MAGELLAN Rx STANDARD FORMULARY - Magellan Rx …

Magellan Rx Standard Formulary

Welcome to Magellan Rx Management’s Standard Formulary. A formulary is a list of covered prescription drugs. Please use this formulary drug list when you receive a prescription from your doctor. This formulary list is not intended to imply coverage and may change over time. Please refer to your plan document for detailed information about your drug benefit coverage.

The formulary is organized by categories depending on the type of medical conditions that they are used to treat. Medications are listed as Tier 1 Generic, Tier 2 preferred Brand, and Tier 3 non-preferred Brand. Medications listed as “Specialty Drugs” are used to treat complex medical conditions that require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may apply.

Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug’s safety and efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects appropriate Tier placement based on the drugs’ safety, efficacy and cost- effectiveness. Please note all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.

Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their pharmacy benefit plan. When clinically appropriate, please consider choosing a generic product. If a preferred brand drug from the formulary is prescribed, your copay may be less than if a non-preferred brand drug is prescribed for you.

For the most up-to-date Formulary Drug list visit our website at www.magellanrx.com.

http://www.magellanrx.com/

TIER DESCRIPTION

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered per

prescription, or within a specific time frame.

ST Step Therapy

In some cases, you may be required to first try certain drugs to

treat your medical condition before you move up a “step” to

other drug options.

GL Gender Limit This prescription drug is restricted for a single gender.

AL Age LimitThis prescription drug may only be covered if you meet the

minimum or maximum age limit.

C Custom This drug has unique restrictions.

S Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or

rare conditions. Some examples of the diseases include;

multiple sclerosis, rheumatoid arthritis, hepatitis C, and

hemophilia.

MED Medical Drug

This medication is not on our drug list. Click on the

THERAPEUTIC CLASS or sub class to find covered alternative

medications. If you have questions, please contact member

services.

PR Preventive Medication

Preventive health drugs can help prevent, treat, and manage

several health concerns that can lead to serious illness or

complications in the future. The copays for these products

may vary so check with your plan for further information.

PAGE 2 LAST UPDATED 01/2021

HCRHealth Care Reform

Products

The Affordable Care Act (ACA) requires certain preventive

generic products to be covered at zero dollar copay. This does

not include plans that are grandfathered.

NTINarrow Therapeutic

Indicator

NTI products may have to be monitored by your doctor or

pharmacist more frequently because small changes in doses

can have harmful impacts.

PS Preferred Specialty Preferred Specialty.

PA PA Applies

Your provider is required to get prior authorization before you

fill your prescription, which ensures appropriate use of the

selected drug. Without prior approval, we may not cover this

drug.

B4G Brand For GenericBrand products that would bypass the DAW penalty. The

strategy prefers brands over generics.

HCG High Cost Generic High Cost Generic.

MVB Minimal Value Brand Minimal Value Brand.

MV Minimal Value Generic Minimal Value Generic.

NFD Non-FDA Approved Non-FDA Approved.

BSP Benefit Shift Program Benefit Shift Program.

SBA Select Brand Alternative Select Brand Alternative

PS1 Preferred 1st line

PS2 Preferred 2nd line


PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

CAFERGOT 3 SBA Select BrandAlternative

D.H.E.45 3

QL 10 / 30 days

MED Medical Drug

PA

DIBENZYLINE 3

PR

MVB MINIMALVALUE BRAND

SBA SELECT BRANDALTERNATIVE

dihydroergotamine 1 mg/ml amp 1PA

BSP BENEFIT SHIFTPROGRAM

dihydroergotamine 4 mg/ml spry 1QL 8 / 30 days

PA

ergoloid mesylates 1

ERGOMAR 3

ergotamine-caffeine 1

MIGERGOT 3QL 0.72 / day


MIGRANAL 3

QL 8 / 30 days

PA


phenoxybenzamine hcl 1

HCG

MVGMINIMALVALUEGENERIC



phentolamine mesylate 1 MED Medical Drug

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

alfuzosin hcl er 1QL 1 / day

GL Male

FLOMAX 3QL 2 / day

ST

RAPAFLO 3

QL 1 / day

GL Male

SBA Select BrandAlternative

silodosin 1QL 1 / day

GL Male

tamsulosin hcl 1 QL 2 / day

UROXATRAL 3

QL 1 / day

GL Male


ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

acetaminophen (325mg/32.5ml syr, 500 mg/50 ml syr,650 mg/65 ml bag) 1 MED Medical Drug

ALLZITAL 3

QL 12 / day

HCG

MVB Minimal ValueBrand

BUPAP 1 QL 6 / day

butalbital-acetaminophn 50-300 1

QL 6 / day

HCG




butalbital-acetaminophn 25-325 1 QL 12 / day

butalbital-acetaminophn 50-325 1 QL 6 / day

butalbital-acetaminophen-caffe 1 QL 6 / day

clonidine hcl (1,000 mcg/10 ml vial, 5,000 mcg/10 ml vial) 1 MED Medical Drug

CORICIDIN HBP COLD AND FLU 3

DURACLON 3 MED Medical Drug

ESGIC CAPSULE 1

QL 6 / day

HCG


ESGIC 50-325-40 MG TABLET 3QL 6 / day


FIORICET 3

QL 6 / day

ST


GRALISE 30-DAY STARTER PACK 3 ST

GRALISE ER 300 MG TABLET 3QL 1 / day

ST

GRALISE ER 600 MG TABLET 3QL 3 / day

ST

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 3

QL 3 / day

PA


LYRICA CR 330 MG TABLET 3

QL 2 / day

PA




PHRENILIN FORTE 1 QL 6 / day

PRIALT 3S

MED Medical Drug

TENCON 1 QL 6 / day

VANATOL LQ 3

VTOL LQ 1

ZEBUTAL 1 QL 6 / day

OPIATE AGONISTS

ABSTRAL 3

QL 4 / day

AL At least 18 yrsold

PA


acetamn-caf-dihydrcodein 320.5 1QL 10 / day


acetamin-caf-dihydrocodein 325 1

QL 10 / day


HCG


acetamin-codein 300-30 mg/12.5 1QL 139 / day


acetaminop-codeine 120-12 mg/5 1QL 140 / day




acetaminophen-cod #2 tablet 1QL 22 / day






ACTIQ 3

QL 4 / day


PA


APADAZ 3

QL 12 / day



ARYMO ER 3QL 3 / day

PA

asa-butalb-caffeine-codeine 1QL 6 / day


ASCOMP WITH CODEINE 1QL 6 / day


belladonna-opium 16.2-30 supp 1 QL 2 / day

belladonna-opium 16.2-60 supp 1 QL 1 / day

benzhydrocodone-acetaminophen 1QL 12 / day




butalb-acetaminoph-caff-codein 1 QL 6 / day

butalbital compound-codeine 1QL 6 / day


codeine sulfate 1QL 6 / day


CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 3

QL 1 / day


PA


DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML AMPUL, 50MG/ML CARPUJECT, 50 MG/ML VIAL, 75 MG/1.5 MLAMPUL, 100 MG/2 ML AMPUL)

3

QL 10 / day


MED Medical Drug

DEMEROL 25 MG/ML CARPUJECT 3

QL 20 / day


MED Medical Drug

DEMEROL 75 MG/ML CARPUJECT 3QL 7 / day


DEMEROL 100 MG TABLET 3

QL 5 / day



DEMEROL (100 MG/ML AMPUL, 100 MG/ML CARPUJECT,100 MG/ML VIAL) 3

QL 5 / day


MED Medical Drug



DILAUDID 5 MG/5 ML ORAL LIQUID 3

QL 13 / day



DILAUDID (0.2 MG/ML SYRINGE, 0.5 MG/0.5 ML SYRINGE,1 MG/ML SYRINGE, 2 MG/ML SYRINGE, 4 MG/MLSYRINGE)

3AL At least 18 yrs

oldMED Medical Drug

DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG TABLET) 3

QL 6 / day



DOLOPHINE HCL 3QL 3 / day

PA

DSUVIA 3 MED Medical Drug

DURAGESIC 3QL 0.5 / day

PA

DURAMORPH 10 MG/10 ML AMPUL 1QL 5 / day

MED Medical Drug

DURAMORPH 5 MG/10 ML AMPUL 1QL 10 / day

MED Medical Drug

DVORAH 3

QL 10 / day



ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10-325 MGTABLET) 1

QL 12 / day


HCG



ENDOCET 2.5-325 MG TABLET 1QL 12 / day


EXALGO 3

QL 2 / day

PA


fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 87.5 mcg/hr patch, 100 mcg/hrpatch)

1QL 0.5 / day

PA

fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch) 1

QL 0.5 / day

PA

HCG

fentanyl 100 mcg/2 ml carpujct 1 QL 8 / day

fentanyl citrate otfc 800 mcg 1

QL 4 / day


PA

fentanyl citrate (1,000 mcg/20 ml, 1,250 mcg/25 ml) 1 MED Medical Drug

fentanyl citrate (100 mcg/2 ml syringe, 1,500 mcg/30 mlsyr) 1

QL 8 / day

MED Medical Drug

fentanyl citrate (cit 100 mcg buccal tb, cit 200 mcg buccaltb, cit 400 mcg buccal tb, cit 600 mcg buccal tb, cit 800mcg buccal tb, cit otfc 1,200 mcg, cit otfc 1,600 mcg,citrate otfc 200 mcg, citrate otfc 400 mcg, citrate otfc 600mcg)

1

QL 4 / day


PA

HCG

fentanyl 1,375 mcg/55-0.9%nacl 1QL 15 / day

MED Medical Drug

fentanyl 600 mcg/30ml-0.9%nacl 1QL 19 / day

MED Medical Drug



fentanyl citrate-0.9% nacl (5 mcg/ml-0.9% nacl, 25mcg/2.5ml-0.9%nacl, 50 mcg/5 ml-0.9% nacl, 500mcg/50ml-0.9%nacl, 1,000 mcg/100 ml-ns, 1,000mcg/50-0.9% nacl, 1,100 mcg/55 ml-ns, 1,100 mcg/55-0.9%nacl,1,250 mcg/25 ml-ns, 1,250 mcg/50-0.9%nacl,1,250mcg/125-0.9%nacl, 1,250mcg/250-0.9%nacl,2,500mcg/100-0.9%nacl, 5,000mcg/250-0.9%nacl)

1 MED Medical Drug

fentanyl citrate-0.9% nacl (10 mcg/ml-0.9% nacl,1,000mcg/100-0.9%nacl) 1

QL 38 / day

MED Medical Drug

fentanyl 2 mcg-bupivac 0.1%-ns 1 MED Medical Drug

FENTORA 3

QL 4 / day


PA



FIORINAL WITH CODEINE #3 3

QL 6 / day



hydrocodone bitartrate er 1QL 2 / day

PA

hydrocodone er 10 mg capsule (persion-macoven) 1QL 2 / day

PA


PA


PA




PA


PA

hydrocodone-acetamin 10-325/15 1 AL At least 2 yrsold

hydrocodone-acetaminophen (2.5-108/5, 5-217/10) 1QL 180/day


hydrocodone-acetamn 7.5-325/15 1

QL 180/day


HCG

hydrocodone-acetamin 2.5-325 1QL 20 / day


hydrocodone-acetaminophen (5-300 mg, 7.5-300, 10-300mg) 1

QL 13 / day


HCG

hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg) 1

QL 12 / day


hydrocodone-ibuprofen 10-200 1

QL 5 / day


HCG

hydrocodone-ibuprofen 5-200 mg 1

QL 6 / day


HCG



hydrocodone-ibuprofen 7.5-200 1QL 5 / day


hydromor 5 mcg-bupiva 0.1%-ns 1QL 10 / day

MED Medical Drug

hydromorp 20 mcg-bupiv 0.1%-ns 1QL 3 / day

MED Medical Drug

hydromorph-bupivac-0.9% nacl (10 mcg-bupiva 0.1%-ns,20 mcg-bupi 0.125%-ns) 1 MED Medical Drug

hydromorph-ropiva-0.9% nacl 1QL 6 / day

MED Medical Drug

hydromorphone er 1

QL 2 / day

PA

HCG

hydromorphone hcl 1 mg/ml amp 1QL 13 / day

MED Medical Drug

hydromorphone hcl 4 mg/ml amp 1QL 3 / day

MED Medical Drug

hydromorphone 4 mg/ml carpujct 1

QL 3 / day


MED Medical Drug

hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1

QL 13 / day


HCG

hydromorphone 0.5 mg/0.5 ml 1

QL 50 / day


MED Medical Drug



hydromorphone hcl (1 mg/ml carpujct, 1 mg/ml syringe) 1

QL 13 / day


MED Medical Drug

hydromorphone hcl (2 mg/ml carpujct, 2 mg/ml isecure) 1

QL 6 / day


MED Medical Drug

hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mgtablet) 1

QL 6 / day


hydromorphone hcl (2 mg/ml vial, hcl 2 mg/ml amp, 60mg/30 ml syr) 1

QL 6 / day

MED Medical Drug

hydromorphone 25 mg/25 ml-ns 1 MED Medical Drug

hydromorphone hcl-0.9% nacl (1 mg/5 ml-ns, 12 mg/30ml-ns, 250 mg/250 ml-ns) 1 MED Medical Drug

hydromorphone hcl-0.9% nacl (10 mg/50 ml-ns, 50 mg/50ml-ns) 1

QL 1 / day

MED Medical Drug


QL 25 / day

MED Medical Drug


QL 13 / day

MED Medical Drug

hydromorphone 0.5 mg/50 ml-ns 1QL 5000 / day

MED Medical Drug

hydromorphone 1 mg/50 ml-ns 1QL 50 / day

MED Medical Drug

hydromorphone 2 mg/50 ml-ns 1QL 313 / day

MED Medical Drug



hydromorphone hcl-0.9% nacl (100 mg/50 ml-ns, 200mg/100 ml-ns) 1

QL 6 / day

MED Medical Drug


QL 63 / day

MED Medical Drug

HYSINGLA ER 3QL 1 / day

PA

IBUDONE 10-200 MG TABLET 3

QL 5 / day



IBUDONE 5-200 MG TABLET 1QL 6 / day


KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 50MG CAPSULE, ER 100 MG CAPSULE) 3

QL 2 / day

PA


KADIAN (ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 60MG CAPSULE, ER 80 MG CAPSULE) 3

QL 1 / day

PA


KADIAN ER 200 MG CAPSULE 3QL 1 / day

PA

LAZANDA 3

QL 1 / day


PA


LORCET 1QL 12 / day




LORCET HD 1QL 12 / day


LORCET PLUS 1QL 12 / day


LORTAB 3QL 90 / day


meperidine 10 mg/ml cartrdge 1

QL 50 / day


MED Medical Drug

meperidine 50 mg/5 ml solution 1QL 50 / day


meperidine 100 mg tablet 1QL 5 / day


meperidine 50 mg tablet 1QL 10 / day


meperidine 100 mg/ml vial 1

QL 5 / day


MED Medical Drug


QL 20 / day


MED Medical Drug


QL 10 / day


MED Medical Drug



meperidine 300 mg/30 ml-ns syr 1 MED Medical Drug

meperidine 550 mg/55 ml-ns syr 1QL 50 / day

MED Medical Drug

methadone 10 mg/ml oral conc 1QL 2 / day

PA

methadone 10 mg/5 ml solution 1QL 8 / day

PA

methadone 5 mg/5 ml solution 1QL 18 / day

PA

methadone hcl 10 mg/ml syringe 1

QL 2 / day

MED Medical Drug

PA

methadone hcl (5 mg tablet, 10 mg tablet) 1QL 3 / day

PA

methadone hcl (10 mg/ml vial, 200 mg/20 ml vl) 1QL 2 / day

MED Medical Drug

METHADONE INTENSOL 1QL 2 / day

PA

METHADOSE 10 MG/ML ORAL CONC 3QL 2 / day

PA

MORPHABOND ER 3QL 2 / day

PA

morphine 2 mg/ml carpuject 1

QL 25 / day

MED Medical Drug

PA

HCG



morphine sulfate (5 mg/ml syringe, 5 mg/ml vial) 1

QL 10 / day

MED Medical Drug

PA

morphine sulfate (sulfate 1 mg/ml vial, 10 mg/10 ml vial) 1

QL 50 / day

MED Medical Drug

PA

morphine 10 mg/0.7 ml auto-inj 1

QL 3 / day

MED Medical Drug

PA

morphine sulf 10 mg/5 ml soln 1 QL 25 / day

morphine sulf 100 mg/5 ml conc 1 QL 3 / day

morphine sulf 20 mg/5 ml soln 1 QL 13 / day

morphine sulf 10 mg suppos 1 QL 5 / day

morphine sulfate (10 mg/ml carpuject, 10 mg/ml isecuresyrg, 10 mg/ml syringe, sulfate 10 mg/ml vial, 100 mg/10ml vial)

1

QL 5 / day

MED Medical Drug

PA

morphine sulfate (2 mg/ml isecure syr, 2 mg/ml syringe) 1

QL 25 / day

MED Medical Drug

PA

morphine sulfate (4 mg/ml carpuject, 4 mg/ml isecure syr,4 mg/ml syringe, sulfate 4 mg/ml vial) 1

QL 13 / day

MED Medical Drug

PA

morphine sulfate (8 mg/ml carpuject, 8 mg/ml isecuresyrng, 8 mg/ml syringe, sulfate 8 mg/ml vial) 1

QL 6 / day

MED Medical Drug

PA

morphine sulfate ir 15 mg tab 1QL 3 / day




morphine sulfate ir 30 mg tab 1QL 2 / day


morphine sulfate (1 mg/2 ml syringe, 5 mg/10 ml vial) 1

QL 100 / day

MED Medical Drug

PA

morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mgcap, er 100 mg cap) 1

QL 2 / day

PA

morphine sulfate er (er 30 mg cap, er 45 mg cap) 1QL 1 / day

PA

morphine sulfate er (er 40 mg cap, er 60 mg cap, er 75 mgcap, er 80 mg cap, er 90 mg cap, er 120 mg cap) 1

QL 1 / day

PA

HCG

morphine sulf er 200 mg tablet 1

QL 3 / day

PA

HCG

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet) 1

QL 3 / day

PA

morphine 300 mg/30ml-0.9% nacl 1

QL 5 / day

MED Medical Drug

PA

morphine sulfate-0.9% nacl (150 mg/30 ml-0.9%nacl, 250mg/50 ml-ns, 250mg/250ml-0.9% nacl, 275 mg/55 ml-0.9%nacl)

1MED Medical Drug

PA

morphine 1,000 mg/100 ml-ns 1 MED Medical Drug

morphine sulfate-0.9% nacl (1 mg/ml-0.9% nacl syr, 2mg/2 ml-0.9% nacl, 10 mg/10 ml-ns syrng, 30 mg/30 ml-0.9% nacl, 50 mg/50 ml-0.9% nacl, 100mg/100ml-0.9%nacl)

1

QL 50 / day

MED Medical Drug

PA



morphine sulfate-0.9% nacl (500mg/100ml-0.9% nacl,1,250 mg/250 ml-ns) 1

QL 10 / day

MED Medical Drug

PA

morphine 0.5 mg/0.5ml-0.9%nacl 1

QL 100/ day

MED Medical Drug

PA

morphine 0.5 mg/ml-0.9% nacl 1

QL 100 / day

MED Medical Drug

PA

morphine sulfate-d5w 1MED Medical Drug

PA

MS CONTIN 3

QL 3 / day

PA


NALOCET 3

QL 12 / day



NORCO 3

QL 12 / day



NUCYNTA (50 MG TABLET, 75 MG TABLET) 3QL 6 / day


NUCYNTA 100 MG TABLET 3QL 7 / day




NUCYNTA ER 3

QL 2 / day


PA

OLINVYK (1 MG/ML VIAL, 2 MG/2 ML VIAL, 30 MG/30 MLPCA VIAL) 1 MED Medical Drug

OPANA 3

QL 12 / day



OXAYDO 3QL 8 / day


oxycodone hcl 5 mg capsule 1

QL 8 / day


HCG

oxycodone hcl 100 mg/5 ml conc 1QL 2 / day

HCG

oxycodone hcl 5 mg/5 ml soln 1QL 33 / day

HCG

oxycodone hcl (5 mg tablet, 10 mg tablet, 15 mg tablet,20 mg tablet, 30 mg tablet) 1

QL 8 / day


oxycodone hcl-aspirin 1QL 7 / day


oxycodone hcl-ibuprofen 1QL 4 / day




oxycodon-acetaminophen 2.5-325 1

QL 12 / day


HCG

oxycodone-acetaminophen (oxycodon-acetaminophen2.5-300, oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 5-325, oxycodone-acetaminophen 10-325)

1QL 12 / day


oxymorphone hcl 1QL 12 / day


oxymorphone hcl er (er 5 mg tablet, er 10 mg tab, er 15mg tab, er 20 mg tab, er 30 mg tab, er 40 mg tab) 1

QL 2 / day


PA

HCG

oxymorphone hcl er 7.5 mg tab 1

QL 2 / day


PA

PERCOCET 3

QL 12 / day



PRIMLEV 10-300 MG TABLET 3

QL 3 / day



PRIMLEV 5-300 MG TABLET 3

QL 7 / day





PRIMLEV 7.5-300 MG TABLET 3QL 4 / day


PROLATE 3QL 13 / day


ROXICODONE 3

QL 8 / day



ROXYBOND (15 MG TABLET, 30 MG TABLET) 3 QL 6 / day

ROXYBOND 5 MG TABLET 3 QL 8 / day

SUBSYS 3

QL 12 / day


PA


tramadol hcl 100 mg tablet 1QL 4 / day


tramadol hcl 50 mg tablet 1QL 8 / day


tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er300 mg capsule) 1

QL 1 / day


PA

HCG



tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er300 mg tablet, hcl er 100 mg tablet, hcl er 150 mgcapsule, hcl er 200 mg tablet, hcl er 300 mg tablet)

1

QL 1 / day


PA

tramadol hcl-acetaminophen 1QL 8 / day


TREZIX 3QL 10 / day


TYLENOL-CODEINE NO.3 3QL 12 / day


TYLENOL-CODEINE NO.4 3QL 6 / day


ULTRACET 3QL 8 / day


ULTRAM 3

QL 8 / day



VICODIN 1

QL 13 / day


HCG


VICODIN HP 1

QL 13 / day


HCG




XTAMPZA ER 2QL 2 / day

PA

ZOHYDRO ER 3QL 2 / day

PA

OPIATE PARTIAL AGONISTS

BELBUCA 3

QL 2 / day


PA

BUNAVAIL (2.1-0.3 MG FILM, 6.3-1 MG FILM) 3QL 3 / day

PA

BUNAVAIL 4.2-0.7 MG FILM 3QL 2 / day

PA

BUPRENEX 3QL 17 / day

MED Medical Drug

buprenorphine 1QL 0.144 / day

PA

buprenorphine 0.3 mg/ml crpjct 1 QL 17 / day

buprenorphine hcl (2 mg tablet, 8 mg tablet) 1QL 3 / day

PA

buprenorphine 0.3 mg/ml vial 1QL 17 / day

MED Medical Drug

buprenorphine-naloxone (buprenor-nalox 12-3 mg film,buprenorp-nalox 4-1 mg film) 1

QL 2 / day

PA

buprenorphine-naloxone (bupreno-nalox 2-0.5 mg film,buprenorp-nalox 8-2 mg film, buprenorphin-naloxon 8-2mg, buprenorphn-naloxn 2-0.5 mg)

1QL 3 / day

PA



butorphanol 10 mg/ml spray 1QL 0.3 / day


butorphanol 1 mg/ml vial 1

QL 7 / day


MED Medical Drug

butorphanol tartrate (2 mg/ml vial, 4 mg/2 ml vial) 1

QL 4 / day


MED Medical Drug

BUTRANS 3QL 0.144 / day

PA

nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1QL 5 / day


nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1QL 3 / day


pentazocine-naloxone hcl 1QL 12 / day


SUBLOCADE 100 MG/0.5 ML SYRING 3

QL 0.02 / day

S

MED Medical Drug

PA

SUBLOCADE 300 MG/1.5 ML SYRING 3

QL 0.057 / day

S

MED Medical Drug

PA



SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 3QL 3 / day

PA

SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 3QL 2 / day

PA

TALWIN 3QL 5 / day

MED Medical Drug

ZUBSOLV 2QL 3 / day

PA

ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

ADIPEX-P 37.5 MG CAPSULE 3

QL 2 / day


PA

ADIPEX-P 37.5 MG TABLET 3

QL 2 / day


PA


diethylpropion hcl 1

QL 3 / day


PA

diethylpropion hcl er 1QL 1 / day

PA

LOMAIRA 1

QL 3 / day


PA



phendimetrazine tartrate 1QL 3 / day

PA

phendimetrazine tartrate er 1QL 1 / day

PA

phentermine hcl (15 mg capsule, 30 mg capsule) 1QL 1 / day

PA

phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1

QL 2 / day


PA

QSYMIA 3

QL 1 / day


PA

ANOREXIGENIC AGENTS, MISCELLANEOUS

CONTRAVE 3

QL 4 / day


PA

SELECTIVE SEROTONIN RECEPTOR AGONISTS

BELVIQ 3

QL 2 / day


PA

BELVIQ XR 3

QL 1 / day


PA



ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

ADDERALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET,12.5 MG TABLET, 15 MG TABLET, 20 MG TABLET) 3

QL 3 / day

ST

ADDERALL 30 MG TABLET 3QL 2 / day

ST

ADDERALL XR 3QL 2 / day

ST

ADZENYS ER 3

QL 15 / day

ST


ADZENYS XR-ODT 3

QL 1 / day

ST


amphetamine 3

QL 15 / day

ST


amphetamine sulfate 1 QL 6 / day

benzphetamine hcl 25 mg tablet 1

QL 3 / day


PA

benzphetamine hcl 50 mg tablet 1QL 3 / day

PA

DESOXYN 3

QL 5 / day

ST





DEXEDRINE SPANSULE 10 MG 3QL 5 / day

ST


ST


ST

dextroamphetamine 5 mg/5 ml 1 QL 60 / day

dextroamphetamine 10 mg tab 1 QL 6 / day

dextroamphetamine 5 mg tab 1 QL 2 / day

dextroamphetamine er 10 mg cap 1 QL 5 / day



dextroamphetamine-amphet er 1 QL 2 / day

dextroamp-amphetamin 30 mg tab 1 QL 2 / day

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamin 15 mg tab, dextroamp-amphetamin 20 mgtab, dextroamp-amphetamine 5 mg tab)

1 QL 3 / day

DYANAVEL XR 3

QL 8 / day

ST


EVEKEO 3QL 6 / day

ST

EVEKEO ODT (ODT 5 MG, ODT 10 MG) 3QL 6 / day

ST



EVEKEO ODT 15 MG 3QL 4 / day

ST

EVEKEO ODT 20 MG 3QL 3 / day

ST

methamphetamine hcl 1QL 5 / day

HCG

MYDAYIS 3QL 1 / day

ST

PROCENTRA 3QL 60 / day

ST

REGIMEX 3

QL 3 / day


PA

VYVANSE (10 MG CAPSULE, 10 MG CHEWABLE TABLET,20 MG CAPSULE, 20 MG CHEWABLE TABLET, 30 MGCAPSULE, 30 MG CHEWABLE TABLET, 40 MG CAPSULE, 40MG CHEWABLE TABLET, 50 MG CAPSULE, 50 MGCHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLETABLET, 70 MG CAPSULE)

2 QL 1 / day

ZENZEDI (15 MG TABLET, 30 MG TABLET) 3QL 2 / day

ST

ZENZEDI (2.5 MG TABLET, 20 MG TABLET) 3QL 3 / day

ST

ZENZEDI 10 MG TABLET 1 QL 6 / day

ZENZEDI 5 MG TABLET 1 QL 2 / day

ZENZEDI 7.5 MG TABLET 3QL 8 / day

ST



RESPIRATORY AND CNS STIMULANTS

ADHANSIA XR 3QL 1 / day

ST

APTENSIO XR 3QL 1 / day

ST

caffeine cit 60 mg/3 ml oral 1

HCG


CONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET) 3

QL 2 / day

ST

CONCERTA ER 54 MG TABLET 3QL 1 / day

ST

COTEMPLA XR-ODT 3QL 1 / day

ST

DAYTRANA 3QL 1 / day

ST

dexmethylphenidate 10 mg tab 1 QL 2 / day

dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 QL 3 / day

dexmethylphenidate er 20 mg cp 1 QL 2 / day

dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mgcp)

1 QL 1 / day

DOPRAM 3 MED Medical Drug

doxapram hcl 1 MED Medical Drug

FOCALIN (2.5 MG TABLET, 5 MG TABLET) 3QL 3 / day

ST



FOCALIN 10 MG TABLET 3QL 2 / day

ST

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MGCAPSULE, 40 MG CAPSULE)

3QL 1 / day

ST

FOCALIN XR 20 MG CAPSULE 3QL 2 / day

ST

JORNAY PM 3QL 1 / day

ST

METADATE ER 1 QL 3 / day

METHYLIN 10 MG/5 ML SOLUTION 3QL 30 / day

ST

METHYLIN 5 MG/5 ML SOLUTION 3QL 60 / day

ST

methylphenidate er (er 10 mg cap, er 15 mg cap, er 20 mgcap, er 30 mg cap, er 40 mg cap, er 50 mg cap, er 60 mgcap)

1QL 1 / day

ST

methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mgtab) 1 QL 2 / day

methylphenidate er (er 54 mg tab, er 72 mg tab) 1 QL 1 / day

methylphenidate er 10 mg tab 1 QL 5 / day

methylphenidate er 20 mg tab 1 QL 3 / day

methylphenidate er (la) (10mg cp, 20mg cp, 40mg cp) 1 QL 1 / day

methylphenidate er(la) 30mg cp 1 QL 2 / day

methylphenidate 10 mg/5 ml sol 1 QL 30 / day

methylphenidate 5 mg/5 ml soln 1 QL 60 / day



methylphenidate 2.5 mg chew tb 1

methylphenidate hcl (5 mg chew tab, 10 mg chew tab, 20mg tablet) 1 QL 3 / day

methylphenidate 10 mg tablet 1 QL 5 / day

methylphenidate 5 mg tablet 1 QL 3 / day

methylphenidate cd 30 mg cap 1 QL 2 / day

methylphenidate hcl cd (10 mg cap, 20 mg cap, 40 mgcap, 50 mg cap, 60 mg cap) 1 QL 1 / day

methylphenidate er(cd) 30mg cp 1 QL 2 / day

methylphenidate hcl er (cd) (10mg cp, 20mg cp, 40mg cp,50mg cp, 60mg cp) 1 QL 1 / day

methylphenidate la (10 mg cap, 20 mg cap, 40 mg cap, 60mg cap) 1 QL 1 / day

methylphenidate la 30 mg cap 1 QL 2 / day

QUILLICHEW ER (ER 20 MG CHEW TAB, ER 40 MG CHEWTAB) 3

QL 1 / day

ST


QUILLICHEW ER 30 MG CHEW TAB 3

QL 2 / day

ST


QUILLIVANT XR 3QL 12 / day

ST

RELEXXII 1 QL 1 / day

RITALIN (5 MG TABLET, 20 MG TABLET) 3QL 3 / day

ST

RITALIN 10 MG TABLET 3QL 5 / day

ST



RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 40 MGCAPSULE) 3

QL 1 / day

ST

RITALIN LA 30 MG CAPSULE 3QL 2 / day

ST

WAKEFULNESS-PROMOTING AGENTS

armodafinil 1QL 1 / day

PA

modafinil 1QL 1 / day

PA

NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MGTABLET) 3

QL 1 / day

PA


NUVIGIL 50 MG TABLET 3QL 1 / day

PA

PROVIGIL 3

QL 1 / day

PA


SUNOSI 2

QL 1 / day


PA

WAKIX 3

QL 2 / day

S

PA



ANTI-INFECTIVE AGENTS

ANTHELMINTICS

albendazole 1QL 4 / day

PA

ALBENZA 3

QL 4 / day

PA


BILTRICIDE 3PA


EGATEN 3

EMVERM 2 PA

ivermectin 3 mg tablet 1 PA

praziquantel 1 PA

STROMECTOL 3 PA

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 1

FURADANTIN 3

HIPREX 3

MACROBID 3 SBA Select BrandAlternative

MACRODANTIN 3 SBA Select BrandAlternative

methenamine hippurate 1

methenamine mandelate 1



MONUROL 3

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50mg cap, mcr 100 mg cap) 1

nitrofurantoin mono-macro 1

trimethoprim 1

TRIMPEX 3 QL max 10 days

URIBEL 1

QL 4 / day

HCG


UROGESIC-BLUE 3

ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC 1 QL 0.434 / day

AZASITE 3 QL 0.36/day

BACIGUENT 3 QL 0.434 / day

bacitracin 500 unit/gm ophth 1QL 0.434 / day

HCG

bacitracin-polymyxin 1QL 0.434 / day

HCG

BACTROBAN NASAL 2 PA

BESIVANCE 3 QL 0.767 / day

BLEPH-10 3QL 5 / fill




BLEPHAMIDE 3 QL 5 / fill

BLEPHAMIDE S.O.P. 3 QL 4 / fill

CETRAXAL 3

QL 0.567 / day

ST


CILOXAN (EYE DROPS, OINTMENT) 3 QL 0.767 / day

CIPRO HC 3QL 0.434 / day

ST

CIPRODEX 2QL 0.257 / day

B4G

ciprofloxacin 0.2% otic soln 1 QL 0.567 / day

ciprofloxacin 0.3% eye drop 1 QL 0.767 / day

ciprofloxacin hcl-fluocinolone 1

ciprofloxacin-dexamethasone 1 QL 0.257 / day

COLY-MYCIN S 3 QL 10 / fill

doxycycline hyclate 20 mg tab 1

HCG


erythromycin 0.5% eye ointment 1 QL 0.54 / day

gatifloxacin 1QL 0.36/day

HCG

GENTAK 1 QL 0.54 / day

gentamicin sulfate (0.3% drop, 3 mg/ml drop) 1 QL 2.143 / day

levofloxacin 0.5% eye drops 1 QL 0.767 / day



MAXITROL EYE DROPS 3 QL 5 / fill

MAXITROL EYE OINTMENT 3 QL 4 / fill

MOXEZA 2 QL 0.434 / day

moxifloxacin 0.5% eye drops 1 QL 0.434 / day

NEO-POLYCIN 1 QL 0.124 / day

NEO-POLYCIN HC 1QL 4 / fill

HCG

neomycin-bacitracin-poly-hc 1 QL 4 / fill

neomycin-bacitracin-polymyxin 1 QL 0.124 / day

neomyc-polym-dexameth eye drop 1 QL 5 / fill

neomyc-polym-dexamet eye ointm 1 QL 4 / fill

neomycin-polymyxin-gramicidin 1 QL 1.47 / day

neomycin-poly-hc eye drops 1 QL 10/ fill

neomycin-polymyxin-hc ear susp 1 QL 10 / fill

neomycin-polymyxin-hydrocort 1 QL 10 / fill

OCUFLOX 3 QL 1.47 / day

ofloxacin 0.3% ear drops 1 QL 10 / 30 days

ofloxacin 0.3% eye drops 1 QL 1.47 / day

OTIPRIO 3 MVB MINIMALVALUE BRAND

OTOVEL 3

QL 0.4722 / day

ST





POLYCIN 1 QL 0.434 / day

polymyxin b sul-trimethoprim 1 QL 1.47 / day

POLYTRIM 3 QL 1.47 / day

PRED-G 1% EYE DROPS 3 QL 5 / fill

PRED-G S.O.P. EYE OINTMENT 3 QL 4 / fill

sulfacetamide 10% eye drops 1 QL 5 / fill

sulfacetamide 10% eye ointment 1 QL 4 / fill

sulfacetamide-prednisolone 1 QL 5 / fill

TOBRADEX EYE DROPS 3QL 5 / fill


TOBRADEX EYE OINTMENT 3 QL 4 / fill

TOBRADEX ST 3 QL 5 / fill

tobramycin 0.3% eye drop 1 QL 2.143 / day

tobramycin-dexamethasone 1 QL 5 / fill

TOBREX 0.3% EYE DROP 3 QL 2.143 / day

TOBREX 0.3% EYE OINTMENT 3 QL 0.54 / day

vancomycin 2 mg/0.2 ml syringe 1 MED Medical Drug

VIGAMOX 3

QL 0.434 / day

ST


ZYLET 3QL 5 / fill


ZYMAXID 3 QL 0.36/day



ANTIFUNGALS (EENT)

NATACYN 3 QL 0.767 / day

ANTIVIRALS (EENT)

trifluridine 1

ZIRGAN 3 QL 0.167 / day

EENT ANTI-INFECTIVES, MISCELLANEOUS

acetic acid 2% ear solution 1

BETADINE 5% EYE SOLUTION 3

chlorhexidine 0.12% rinse 1

hydrocortisone-acetic acid 1

PAROEX 1

PERIDEX 3

PERIOGARD 1

povidone iodine 1

ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ACANYA 3

QL 1.667 / day

PA



AKTIPAK 3PA


ALTABAX 3 PA



AMZEEQ 3 QL 1 / day

BACTROBAN 3

BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3

QL 1.667 / day

PA


BENZAMYCIN 3

QL 1.6 / day

PA



CENTANY 3 PA

CLEOCIN 2% VAGINAL CREAM 3MVB MINIMAL

VALUE BRAND


CLEOCIN 100 MG VAGINAL OVULE 2 MVB MINIMALVALUE BRAND

CLEOCIN T 1% GEL 3 QL 75 / 30 days

CLEOCIN T 1% PLEDGETS 3 SBA SELECT BRANDALTERNATIVE

CLEOCIN T (LOION, SOLUION) 3

CLINDACIN ETZ 1% PLEDGET 1 HCG

CLINDACIN P 1 HCG

CLINDAGEL 3

QL 75 / 30 days

PA


clind ph-benzoyl perox 1.2-5% 1 QL 1.5 / day



clind ph-benzoyl pero 1.2-2.5% 3QL 1.667 / day

PA

clindamycin phos-tretinoin 1

QL 2 / day

HCG


clindamycin phosphate 1% foam 1

QL 1.667 / day

HCG


clindamycin ph 1% gel 1 QL 75 / 30 days

clindamycin phosphate 1% gel 1QL 75 / 30 days

PA

clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream) 1

clindamycin ph 1% solution 1 QL 2 / day

clindamycin-benzoyl peroxide (clinda-benzoyl 1-5% pump,clindamycin-benzoyl 1-5%) 1 QL 1.667 / day

CLINDESSE 3

CORTISPORIN CREAM 3 QL 0.25 / day

CORTISPORIN OINTMENT 3 QL 0.5 / day

DUAC 3

QL 1.5 / day

PA


ERY 1

ERYGEL 3 QL 1 / day



erythromycin 2% gel 1 QL 1 / day

erythromycin (pledgets, solution) 1

erythromycin-benzoyl peroxide 1 QL 1.60 / day

EVOCLIN 3

QL 1.667 / day

PA



gentamicin sulfate (cream, ointment) 1

METROCREAM 3 SBA Select BrandAlternative

METROGEL TOPICAL 1% GEL 3

QL 2 / day

ST

PA

METROGEL TOPICAL 1% PUMP 3

QL 1.84 / day

ST

PA

METROGEL-VAGINAL 3MVB MINIMAL

VALUE BRAND


METROLOTION 3

metronidazole (0.75% cream, 0.75% lotion, top 1% gelpump, topical 0.75% gl, topical 1% gel, vaginal 0.75% gl) 1

mupirocin 2% cream 1 QL 2 / day

mupirocin 2% ointment 1 QL 2.5 / day

NEO-SYNALAR 0.5%-0.025% CREAM 3

NEUAC GEL 1 QL 1.5 / day



NORITATE 3

QL 2 / day

PA


NUVESSA 3 MVB MINIMALVALUE BRAND

ONEXTON 1.2%-3.75% GEL 3 QL 1.667 / day

ONEXTON GEL PUMP 3 QL 1.967 / day

ROSADAN (CREAM, GEL) 1

ROSADAN 0.75% CREAM KIT 3 MVB MINIMALVALUE BRAND

ROSADAN 0.75% GEL KIT 3

VANDAZOLE 3

VELTIN 3

QL 2 / day

PA


XEPI 3 PA

ZIANA 3

QL 2 / day

PA


ZILXI 3QL 1 / day

PA

ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)

acyclovir 5% cream 1

QL 0.167 / day


PA



acyclovir 5% ointment 1

DENAVIR 3

QL 0.167 / day


PA

XERESE 3

QL 0.167 / day


PA


ZOVIRAX 5% CREAM 3

QL 0.167 / day


PA


ZOVIRAX 5% OINTMENT 3

QL 30 / fill


PA


LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVC 3 MVB MINIMALVALUE BRAND

BP CLEANSING WASH 1

FEM PH 3

hydrocortisone-iodoquinol 1

iodine (2% mild tincture, 5% strong solution, mild tincture,strong solution) 1



IODOFLEX 3

IODOSORB 3

KLARON 3 QL 4 / day

LUGOL'S 1

SILVADENE 3 ST

silver sulfadiazine 1

sodium sulf-sulfur cleanser 3

sod sulface-sulfur 9-4.5% kit 3

SSD 1

sulfacetamide sodium (sod top susp, sodium lotn) 1 QL 4 / day

SULFAMYLON 8.5% CREAM 3

SCABICIDES AND PEDICULICIDES

CROTAN 1

ELIMITE 3

EURAX (CREAM, LOTION) 3 ST

lindane 1 HCG

malathion 1 HCG

NATROBA 3ST


OVIDE 3 ST

permethrin 1

SKLICE 3 ST

spinosad 1

HCG




ULESFIA 3 ST

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

ALREX 3 QL 0.5 / day

BECONASE AQ 3QL 1.667 / day


DERMOTIC 3

dexamethasone 0.1% eye drop 1 QL 10 / fill

DUREZOL 3 QL 10 / 30 days

FLAC OTIC OIL 1

FLAREX 3 QL 10 / fill

flunisolide 1 QL .834 / day

fluocinolone acetonide oil 1 HCG

fluorometholone 1 QL 10 / fill

fluticasone prop 50 mcg spray 1 QL 0.6 / day

FML 3 QL 10 / fill

FML FORTE 3 QL 10 / fill

FML S.O.P. 3 QL 4 / fill

ILUVIEN 3

QL max 1 per 365days

S

MED Medical Drug

INVELTYS 3 QL 0.4 / day

LOTEMAX 0.5% OPHTHALMIC GEL 3 QL 10 / fill



LOTEMAX 0.5% EYE DROPS 3QL 21 / fill


LOTEMAX 0.5% EYE OINTMENT 3QL 4 / fill


LOTEMAX SM 3 QL 10 / fill

loteprednol etabonate 1 QL 21 / fill

MAXIDEX 3QL 10 / fill


mometasone furoate 50 mcg spry 1 QL 0.567 / day

NASONEX 3QL 0.567 / day


OMNARIS 3 QL 0.434 / day

OMNIPRED 3QL 21 / fill

ST

OZURDEX 3

QL 0.04 / day

S

MED Medical Drug

PRED FORTE 3

QL 21 / fill

ST


PRED MILD 3 QL 21 / fill

prednisolone ac 1% eye drop 1 QL 21 / fill

prednisolone sod 1% eye drop 1 QL 20 / 30 days



QNASL 3 QL 0.4 / day

QNASL CHILDREN 3 QL 0.3 / day

RETISERT 3

QL max 1 per 365days

S

MED Medical Drug

triamcinolone 55 mcg nasal spr 1 QL 0.55 / day

TRIESENCE 3QL 1 / day

MED Medical Drug

XHANCE 3

QL 1.25 / day

ST


YUTIQ 3S

MED Medical Drug

ZETONNA 3 QL 0.22 / day

EENT ANTI-INFLAMMATORY AGENTS, MISC.

CEQUA 3QL 2 / day

PA

RESTASIS 2QL 2 / day

PA

RESTASIS MULTIDOSE 2QL 0.2 / day

PA

XIIDRA 2

QL 2 / day


PA



EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

ACULAR 3 QL 15 / 30 days

ACULAR LS 3 QL 5 / fill

ACUVAIL 3QL 1 / day


bromfenac sodium 1QL 8 / rx

HCG

BROMSITE 3QL 15/ 180 days

PA

diclofenac 0.1% eye drops 1 QL 5 / fill

flurbiprofen sodium 1 QL 3/ fill

ILEVRO 3QL 4 / fill

PA

ketorolac 0.4% ophth solution 1 QL 5 / fill

ketorolac 0.5% ophth solution 1 QL 15 / 30 days

NEVANAC 3QL 3/ fill

PA

PROLENSA 2 QL 3/ fill

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

INTERLEUKIN ANTAGONISTS

DUPIXENT 200 MG/1.14 ML SYRING 3

QL 0.15 / day


S

PS

PA



FASENRA 3

QL 0.04 / day


S

PS

PA


FASENRA PEN 3

QL 0.04 / day


S

PS

PA

NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE) 3

QL 0.04 / day


S

PS

PA

NUCALA 100 MG VIAL 3

QL 0.04 / day


S

PS

PA


LEUKOTRIENE MODIFIERS

ACCOLATE 3QL 2 / day

PR



montelukast sod 4 mg granules 1

QL 1 / day

PR

HCG

montelukast sodium (4 mg tab chew, 5 mg tab chew, 10mg tablet) 1

QL 1 / day

PR

SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MGTABLET CHEW, 10 MG TABLET) 3

QL 1 / day

PR


zafirlukast 1QL 2 / day

PR

zileuton er 1

QL 4 / day

ST

PR

HCG

ZYFLO 3

QL 4 / day

ST

PR

ZYFLO CR 3

QL 4 / day

ST

PR


MAST-CELL STABILIZERS

ALOCRIL 3QL 5 / fill


cromolyn 20 mg/2 ml neb soln 1 PR



cromolyn 4% eye drops 1 QL 10 / fill

cromolyn 100 mg/5 ml oral conc 1

GASTROCROM 3

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA 2QL 2.143 / day

ST

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

ALA-CORT 1

ALA-SCALP 3 MVB Minimal ValueBrand

alclometasone dipro 0.05% crm 1 HCG

alclometasone dipr 0.05% oint 1

amcinonide (cream, lotion) 1

HCG


ANALPRAM HC (CRM SINGLE, LOTION) 3

ANALPRAM HC 1% CREAM 3MVB Minimal Value

Brand


ANALPRAM HC 2.5%-1% CREAM 3MVB Minimal Value

Brand


ANUCORT-HC 1

ANUSOL-HC 2.5% CREAM 3MVB MINIMAL

VALUE BRAND




ANUSOL-HC 25 MG SUPPOSITORY 1

APEXICON E 3 MVB MINIMALVALUE BRAND

BESER 1

betamethasone diprop augmented (crm, gel, lot, oin) 1

betamethasone dipropionate (crm, lot, oint) 1

betamethasone valer 0.12% foam 1 HCG

betamethasone valerate (va cream, va lotion, valer ointm) 1

BRYHALI 3 PA

CAPEX SHAMPOO 3

clobetasol emollient 0.05% crm 1

clobetasol emollnt 0.05% foam 1 HCG

clobetasol emulsion 1 HCG

clobetasol propionate (cream, gel, ointment, shampoo,solution) 1

clobetasol propionate (prop foam, prop spray, topicallotn) 1 HCG

CLOBEX (SHAMPOO, TOPICAL LOTION) 3 ST

CLOBEX 0.05% SPRAY 3ST


clocortolone pivalate 1 HCG

CLODAN 0.05% SHAMPOO 1 HCG

CLODERM 3 ST

COLOCORT 1

CORDRAN 0.025% CREAM 3 QL 4 / day



CORDRAN 0.05% CREAM 3

QL 2 / day



CORDRAN 0.05% LOTION 3

QL 4 / day



CORDRAN 0.05% OINTMENT 3MVB MINIMAL

VALUE BRAND


CORMAX 1

CORTENEMA 3

CORTIFOAM 3 MVB MINIMALVALUE BRAND

CUTIVATE 0.05% CREAM 3

CUTIVATE 0.05% LOTION 3MVB MINIMAL

VALUE BRAND


DERMA-SMOOTHE-FS BODY OIL 3 SBA Select BrandAlternative

DERMA-SMOOTHE-FS SCALP OIL 3

DERMATOP 3

DESONATE 3

desonide (cream, gel, lotion, ointment) 1

DESOWEN (CREAM, LOTION) 3

desoximetasone (cream, ointment) 1 HCG



desoximetasone (0.05% gel, 0.25% cream, 0.25%ointment, 0.25% spray) 1

diflorasone diacetate (cream, ointment) 1 HCG

DIPROLENE 3

ELOCON (CREAM, OINTMENT) 3

EPIFOAM 3

fluocinolone acetonide (0.01% scalp oil, 0.01% solution,0.025% cream, 0.025% ointment) 1 HCG

fluocinolone acetonide (body oil, cream) 1

fluocinonide 0.1% cream 1

HCG


fluocinonide (cream, gel, ointment, solution) 1

fluocinonide-e 1

flurandrenolide 0.05% cream 3

QL 2 / day

HCG


flurandrenolide 0.05% lotion 3

QL 4 / day

HCG


flurandrenolide 0.05% ointment 3

HCG


fluticasone prop 0.05% lotion 1

HCG




fluticasone propionate (0.005% oint, 0.05% cream) 1

halcinonide 1 PA

halobetasol propionate (cream, ointmnt) 1

halobetasol prop 0.05% foam 1 PA

HALOG 0.1% CREAM 3

PA



HALOG (OINTMENT, SOLUTION) 3 PA

hydrocortisone (1% cream, 1% ointment, 2.5% cream,2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1

hydrocortisone 1% absorbase 1

HCG


hydrocortisone acetate (25 mg, 30 mg) 1

hydrocortisone butyrate (lipid crm, lipo cream) 1

HCG


hydrocortisone butyrate (buty cream, butyr lotn, butyroint, butyr soln) 1

hydrocortisone valerate (cream, ointmt) 1

hydrocortisone-pramoxine 1

IMPOYZ 3 QL 4 / day

KENALOG 3 ST

LEXETTE 3PA




lidocaine-hc 3-0.5% cream 1

LOCOID 0.1% CREAM 3MVB MINIMAL

VALUE BRAND


LOCOID (LOTION, SOLUTION) 3 SBA Select BrandAlternative

LUXIQ 3

MICORT HC 2.5% CREAM 3

MICORT-HC 2.5% CREAM 3 MVB MINIMALVALUE BRAND

mometasone furoate (cream, oint, soln) 1

NOLIX 0.05% CREAM 3 QL 8 / day

NOLIX 0.05% LOTION 3 QL 4 / day

OLUX 3 SBA Select BrandAlternative

OLUX-E 3 SBA Select BrandAlternative

ORALONE 1

PANDEL 3

PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1%OINTMENT, 2.5%-1% LOTION, 2.5%-1% OINTMENT) 3

PRAMOSONE E 3

prednicarbate (cream, ointment) 1

PROCORT 3

PROCTO-MED HC 1

PROCTO-PAK 1

PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3



PROCTOFOAM-HC 2

PROCTOSOL-HC 1

PROCTOZONE-HC 1 HCG

PSORCON 3

SANADERMRX 1

SCALACORT 1

SERNIVO 3

SYNALAR (0.01% SOLUTION, 0.025% CREAM) 3

TEMOVATE (CREAM, OINTMENT) 3

TEXACORT 3 MVB Minimal ValueBrand

TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT,0.25% CREAM, 0.25% OINTMENT) 3 SBA Select Brand

Alternative

TOPICORT 0.25% SPRAY 3

PA



TOVET EMOLLIENT 1 HCG

triamcinolone 0.147 mg/g spray 1

HCG


triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.05% ointment, 0.1% cream, 0.1% lotion,0.1% ointment, 0.1% paste, 0.5% cream, 0.5% ointment)

1

TRIANEX 3

TRIDERM 1



TRIDESILON 3

ULTRAVATE 0.05% LOTION 3 MVB Minimal ValueBrand

ULTRAVATE (CREAM, OINTMENT) 3

VANOS 3 MVB MINIMALVALUE BRAND

VANOXIDE-HC 3 QL 0.84 / day

VERDESO 3 MVB Minimal ValueBrand

ANTIANEMIA DRUGS

IRON PREPARATIONS

FERAHEME 3S

MED Medical Drug

FERRLECIT 3S

MED Medical Drug

INFED 1S

MED Medical Drug

INJECTAFER 3S


IRO-PLEX CAPLET 3

MONOFERRIC 3S

MED Medical Drug

SIDEROL 3

sod ferric gluconate complex 1S

MED Medical Drug

TRIFERIC (27.2 MG/5 ML AMPULE, 272 MG POWDERPACKET) 3

S

MED Medical Drug



VENOFER 3S

MED Medical Drug

ANTIARRHYTHMIC AGENTS

CLASS IA ANTIARRHYTHMICS

disopyramide phosphate 1

NORPACE 3

NORPACE CR 100 MG CAPSULE 2

NORPACE CR 150 MG CAPSULE 3

procainamide hcl (1 gram/2 ml vial, 1,000 mg/2 ml vl) 1 MED Medical Drug

quinidine gluc er 324 mg tab 1

quinidine gluc 80 mg/ml vial 1 MED Medical Drug

quinidine sulfate 1

CLASS IB ANTIARRHYTHMICS

lidocaine hcl (1% abboject, 1% syringe, 2% abboject, 2%luer-jet, 2% syringe, 2% vial) 1 MED Medical Drug

lidocaine hcl in 5% dextrose (0.4% in soln, 0.8% in soln) 1 MED Medical Drug

mexiletine hcl 1

XYLOCAINE IV 3 MED Medical Drug

CLASS IC ANTIARRHYTHMICS

flecainide acetate 1

propafenone hcl 1

propafenone hcl er 1

RYTHMOL SR 3



CLASS III ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet) 1

amiodarone hcl (150 mg/3 ml syringe, 150 mg/3 ml vial,450 mg/9 ml vial, 900 mg/18 ml vial) 1 MED Medical Drug

bretylium tosylate 1 MED Medical Drug

CORVERT 3 MED Medical Drug

dofetilide 1 S

ibutilide fumarate 1 MED Medical Drug

MULTAQ 3 PA

NEXTERONE 3 MED Medical Drug

PACERONE 1

TIKOSYN 3

ST

S


CLASS IV ANTIARRHYTHMICS

adenosine (6 mg/2 ml syringe, 6 mg/2 ml vial, 12 mg/4 mlsyringe, 12 mg/4 ml vial) 1 MED Medical Drug

ANTIBACTERIALS

AMINOGLYCOSIDE ANTIBIOTICS

amikacin sulfate 1 MED Medical Drug

ARIKAYCE 3

QL 9 / day

S

PA

BETHKIS 3S

PA



gentamicin sulfate (10 mg/ml vial, 20 mg/2 ml vial, ped20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800mg/20 ml vial)

1 BSP BENEFIT SHIFTPROGRAM

gentamicin sulfate in ns (70 mg/ns 50 ml, 90 mg/ns 100ml) 1 BSP BENEFIT SHIFT

PROGRAM

gentamicin sulfate in ns (iso 100 mg/100 ml, iso 120mg/100 ml, isoton 60 mg/50 ml, isoton 80 mg/100 ml,isoton 80 mg/50 ml, isoton 100 mg/50 ml)

1 MED Medical Drug

gentamicin 0.9mg/3ml-sod citra 1 BSP BENEFIT SHIFTPROGRAM

KITABIS PAK 3S

PA

neomycin sulfate 1

streptomycin sulfate 1 MED Medical Drug

TOBI 3

S

PA


TOBI PODHALER 3S

PA

tobramycin (300 mg/4 ml ampule, pak 300 mg/5 ml) 1S

PA

tobramycin 300 mg/5 ml ampule 1S

PA

tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30ml vial)

1 MED Medical Drug

tobramycin sulfate in ns 1 MED Medical Drug



CHLORAMPHENICOL ANTIBIOTICS

chloramphenicol sod succinate 1 MED Medical Drug

QUINOLONE ANTIBIOTICS

AVELOX 3 QL 21 / fill

AVELOX IV 3 MED Medical Drug

BAXDELA 450 MG TABLET 3QL max 14 days

PA

BAXDELA 300 MG VIAL 3

QL max 14 days

MED Medical Drug

PA

CIPRO 10% SUSPENSION 3 QL 10 / day

CIPRO 5% SUSPENSION 3 QL 7 / day

CIPRO (250 MG TABLET, 500 MG TABLET) 3 QL 2 / day

ciprofloxacin 250 mg/5 ml susp 1 QL 7 / day

ciprofloxacin 500 mg/5 ml susp 1 QL 10 / day

ciprofloxacin er 1,000 mg tab 1 QL 14 / 1 rx

ciprofloxacin er 500 mg tablet 1 QL 28 / fill

ciprofloxacin hcl (100 mg tab, 250 mg tab, 750 mg tab) 1 QL 2 / day

ciprofloxacin hcl 500 mg tab 1 QL 2 / day

ciprofloxacin-d5w 1 MED Medical Drug

FACTIVE 3QL 7 / day

PA

LEVAQUIN 3 QL 30 / fill

levofloxacin 25 mg/ml solution 1



levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet) 1 QL 30 / fill

levofloxacin (500 mg/20 ml vial, 750 mg/30 ml vial) 1 MED Medical Drug

levofloxacin-d5w 1 MED Medical Drug

moxifloxacin 400 mg/250 ml bag 1 MED Medical Drug

moxifloxacin hcl 400 mg tablet 1 QL 21 / fill

ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

AZULFIDINE (500 MG TABLET, ENTAB 500 MG) 3

BACTRIM 3

BACTRIM DS 3

sulfadiazine 1

sulfamethoxazole-tmp ds tablet 1

sulfamethoxazole-trimethoprim (ss tablet, susp) 1

sulfamethoxazole-tmp iv vial 1 MED Medical Drug

sulfasalazine 1

sulfasalazine dr 1

SULFATRIM 1

TETRACYCLINE ANTIBIOTICS

ACTICLATE 3

ST



AVIDOXY 1

COREMINO (ER 90 MG TABLET, ER 135 MG TABLET) 1QL 1 / day

ST



COREMINO ER 45 MG TABLET 1QL 3 / day

ST

demeclocycline hcl 1

DORYX DR 200 MG TABLET 3

QL 7/ rx

ST




ST




ST



DORYX MPC 3ST


DOXY 100 1 MED Medical Drug

doxycycline hyclate (50 mg tablet, hyc dr 80 mg tab,hyclate 50 mg cap, hyclate 100 mg cap, hyclate 100 mgtab)

1

doxycycline hyc dr 200 mg tab 1

QL 7/ rx

ST

HCG




doxycycline hyclate (dr 50 mg tab, dr 100 mg tab) 1 ST

doxycycline hyclate (hyc dr 75 mg tab, hyc dr 150 mg tab,hyclate 75 mg tab, hyclate 150 mg tab) 1

ST

HCG


doxycycline hyclate 100 mg vl 1 MED Medical Drug

doxycycline ir-dr 1

QL 1 / day

HCG


doxycycline mono 150 mg cap 1

QL 30 / fill

HCG


doxycycline monohydrate (25 mg/5 ml susp, mono 50 mgcap, mono 50 mg tablet, mono 100 mg cap, mono 100 mgtablet)

1

doxycycline monohydrate (75 mg capsule, 75 mg tablet,150 mg tablet) 1

HCG


MINOCIN 50 MG PELLETIZED CAP 3

QL 4 / day

ST



MINOCIN 100 MG VIAL 3MED Medical Drug




minocycline er (er 45 mg capsule, er 90 mg capsule) 1

QL 1 / day

PA

HCG


minocycline er 135 mg capsule 1QL 1 / day

PA

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule) 1

minocycline hcl (50 mg tablet, 75 mg tablet, 100 mgtablet) 1

ST

HCG


minocycline er 45 mg tablet 1

QL 3 / day

ST

HCG


minocycline hcl er (er 55 mg tablet, er 65 mg tablet, er 80mg tablet, er 90 mg tablet, er 105 mg tablet, er 115 mgtablet, er 135 mg tablet)

1

QL 1 / day

ST

HCG


MINOLIRA ER 3QL 1 / day

PA

MONDOXYNE NL 100 MG CAPSULE 1

MONDOXYNE NL 75 MG CAPSULE 1

HCG




MONODOX 3

ST



MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

OKEBO 1

ORACEA 3QL 1 / day

PA

SOLODYN 3 QL 1 / day

SOLOXIDE 1

TARGADOX 3

ST



tetracycline hcl 1

VIBRAMYCIN 100 MG CAPSULE 3

ST



VIBRAMYCIN 25 MG/5 ML SUSP 3 ST

VIBRAMYCIN 50 MG/5 ML SYRUP 3ST


XIMINO 3QL 1 / day

PA



ANTIBACTERIALS, MISCELLANEOUS

BACITRACIN ANTIBIOTICS

BACIIM 1 MED Medical Drug

bacitracin 50,000 unit vial 1 MED Medical Drug

CYCLIC LIPOPEPTIDE ANTIBIOTICS

CUBICIN 3MED Medical Drug


CUBICIN RF 3 MED Medical Drug

daptomycin 500 mg vial 1 BSP BENEFIT SHIFTPROGRAM

GLYCOPEPTIDE ANTIBIOTICS

FIRVANQ 3

VANCOCIN HCL 3

vancomycin 1 MED Medical Drug

vancomycin hcl (hcl 125 mg capsule, 250 mg/5 ml soln, hcl250 mg capsule) 1

vancomycin 1 gm vial 1MED Medical Drug




vancomycin hcl (1 gm add-van vial, 1 gram/200 ml bag,hcl 1g/200 ml bag, 1.25 gm/250 ml bag, hcl 1.25 gramvial, 1.5 gram/300 ml bag, hcl 1.5 gram vial, 1.75 gm/350ml bag, 2 gram/400 ml bag, hcl 10 gm vial, hcl 100 gmsmartpak, hcl 250 mg vial, 500 mg add-van vial, 500 mgvial, 500 mg/100 ml bag, 750 mg add-van vial, 750mg/150 ml bag, hcl 750 mg vial)

1 MED Medical Drug

vancomycin hcl 5 gm vial 1 BSP BENEFIT SHIFTPROGRAM

vancomycin hcl-0.9% nacl (vanco 1 gram/150 ml-0.9%,vanco 1 gram/250 ml-0.9%, vanco 1.25 gm/150 ml-0.9%,vanco 1.25 gm/250 ml-0.9%, vanco 1.5 gm/150 ml-0.9%,vanco 1.5 gm/250 ml-0.9%, vanco 1.5 gm/300 ml-0.9%,vanco 1.5 gm/500 ml-0.9%, vanco 1.75 g/250 ml-0.9%,vanco 1.75 gm/500 ml-0.9%, vanco 2 gram/250 ml-0.9%,vanco 2 gram/500 ml-0.9%, vanco 500 mg/100 ml-0.9%,vanco 750 mg/150 ml-0.9%, vanco 750 mg/250 ml-0.9%,vancomycin 1 g/100ml-0.9%, vancomycin 1 g/200ml-0.9%)

1 MED Medical Drug

vancomycin hcl-d5w (vancomycin 1 gram/100 ml-d5w,vancomycin 1 gram/250 ml-d5w, vancomycin 1.25gram/250ml-d5w, vancomycin 1.5 gram/250 ml-d5w,vancomycin 1.5 gram/500 ml-d5w, vancomycin 1.75gram/500ml-d5w, vancomycin 2 gram/500 ml-d5w,vancomycin-d5w 500 mg/100 ml)

1 MED Medical Drug

VIBATIV 3 MED Medical Drug

LINCOMYCIN ANTIBIOTICS

CLEOCIN HCL 3 QL 4 / day

CLEOCIN PEDIATRIC 3 QL 70/ day

CLEOCIN PHOSPHATE (9 G/60 ML VIAL, 150 MG/ML VIAL,300 MG/2 ML VIAL, 300 MG/2ML ADDVAN, 600 MG/4 MLVIAL, 900 MG/6 ML VIAL)

3 MED Medical Drug



CLEOCIN PHOSPHATE (600 MG/4ML, 900 MG/6ML) 3

clindamycin (pediatric) 1 QL 70/ day

clindamycin hcl 1 QL 4 / day

clindamycin phosphate (ph 9 g/60 ml vial, 300 mg/2 mladdvan, ph 300 mg/2 ml vl, 600 mg/4 ml addvan, ph 600mg/4 ml vl, 900 mg/6 ml addvan, ph 900 mg/6 ml vl)

1 MED Medical Drug

clindamycin phosphate-d5w 1 MED Medical Drug

clindamycin-0.9% nacl 1 MED Medical Drug

LINCOCIN 3 MED Medical Drug

lincomycin hcl 1QL 10 / day

MED Medical Drug

OTHER MISC. ANTIBACTERIAL AGENTS

HELIDAC 3 QL max 1 per 365days

PYLERA 2 QL 120 / 365 days

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5 ml susp 1 QL 900 / rx

linezolid 600 mg tablet 1 QL 2 / day

linezolid-0.9% nacl 1 MED Medical Drug

linezolid-d5w 1 MED Medical Drug

SIVEXTRO 200 MG TABLET 3QL 6 / 30 days

PA

SIVEXTRO 200 MG VIAL 3

QL 6 / 30 days

MED Medical Drug

PA



ZYVOX (200 MG/100, 600 MG/300) 3MED Medical Drug

PA

ZYVOX 100 MG/5 ML SUSPENSION 3QL 900 / rx

PA

ZYVOX 600 MG TABLET 3QL 2 / day

PA

PLEUROMUTILINS

XENLETA 600 MG TABLET 3S

PA

XENLETA 150 MG/15 ML VIAL 3S

MED Medical Drug

POLYMYXIN ANTIBIOTICS

colistimethate 1 MED Medical Drug

COLY-MYCIN M PARENTERAL 3 MED Medical Drug

polymyxin b sulfate 1 MED Medical Drug

RIFAMYCIN ANTIBIOTICS

AEMCOLO 3

XIFAXAN 3 PA

STREPTOGRAMIN ANTIBIOTICS

SYNERCID 3 MED Medical Drug

ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

ANASPAZ 3

ANORO ELLIPTA 2QL 2 / day

PR



ATROVENT HFA 3QL 1.29 / day

PR

belladonna-phenobarbital 1

BENTYL 3 MED Medical Drug

BEVESPI AEROSPHERE 3QL 0.357 / day

PA

chlordiazepoxide-clidinium 1

COMBIVENT RESPIMAT 2QL 0.267 / day

PR

CUVPOSA 3

dicyclomine 20 mg/2 ml ampul 1 MED Medical Drug

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mgtablet) 1

dicyclomine 20 mg/2 ml vial 1 MED Medical Drug

DONNATAL (ELIXIR, TABLET) 3

DUAKLIR PRESSAIR 3QL 0.0333 / day

PA

ED-SPAZ 1

GLYCATE 3

glycopyrrolate (0.2 mg/ml syrng, 0.2 mg/ml vial, 0.4 mg/2ml syr, 0.4 mg/2 ml vl, 0.6 mg/3 ml syr, 1 mg/5 ml syrng,1 mg/5 ml vial, 4 mg/20 ml vial)

1 MED Medical Drug

glycopyrrolate (1 mg tablet, 1.5 mg tablet, 2 mg tablet) 1

glycopyrrolate-water 1 MED Medical Drug

GLYRX-PF 0.2 MG/ML VIAL 3 MED Medical Drug

GLYRX-PF 0.4 MG/2 ML VIAL 3



hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab) 1

hyoscyamine sulfate er 1

hyoscyamine sulfate sr 1

HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1

INCRUSE ELLIPTA 3QL 1 / day

PA

ipratropium br 0.02% soln 1QL 12.5 / day

PR

ipratropium-albuterol 1 PR

LEVBID 3 SBA Select BrandAlternative

LEVSIN 0.125 MG TABLET 3

LEVSIN-SL 3

LIBRAX 3 SBA Select BrandAlternative

LONHALA MAGNAIR REFILL 3QL 2 / day

PA

LONHALA MAGNAIR STARTER 3QL 2 / day

PA

methscopolamine bromide 1

NULEV 1

OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1

OSCIMIN SL 1

OSCIMIN SR 1

phenobarbital-belladonna 1



phenobarbital-hyosc-atrop-scop (phenobarb-hyo-atrop-scop elix, phenobarb-hyosc-atrop-scop tab) 1

PHENOHYTRO TABLET 1 HCG

propantheline bromide 1

QBREXZA 3QL 1 / day

PA

SEEBRI NEOHALER 3QL 2 / day

PA

SPIRIVA 2QL 1 / day

PR

SPIRIVA RESPIMAT 2QL 1 / day

PR

STIOLTO RESPIMAT 2QL 0.134 / day

PR

SYMAX 1

SYMAX DUOTAB 3

SYMAX-SL 1

SYMAX-SR 1

TUDORZA PRESSAIR 3

QL 0.04 / day

PR

PA

YUPELRI 3

QL 3 / day


PA



ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

ARIXTRA 3S

PR

fondaparinux sodium 1S

PR

sodium citrate 4% syringe 1

COUMARIN DERIVATIVES

COUMADIN 2PR

NTI

JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET,4 MG TABLET, 5 MG TABLET) 1

PR

NTI

JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET,10 MG TABLET) 1

PR

NTI

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet,3 mg tablet, 4 mg tablet, 5 mg tablet) 1

PR

NTI

warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mgtablet) 1

PR

NTI

DIRECT FACTOR XA INHIBITORS

BEVYXXA 3

QL 1.25 / day


PA

ELIQUIS DVT-PE TREAT START 5MG 2QL 100 / 30 days

PR

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2QL 2 / day

PR



SAVAYSA 3QL 1 / day

PA

XARELTO DVT-PE TREAT START 30D 2 QL 56 / fill

XARELTO (10 MG TABLET, 20 MG TABLET) 2QL 1 / day

PR

XARELTO (2.5 MG TABLET, 15 MG TABLET) 2QL 2 / day

PR

DIRECT THROMBIN INHIBITORS

ANGIOMAX 3 MED Medical Drug

argatroban 1 MED Medical Drug

argatrobn-0.9% nacl 250 mg/250 3 MED Medical Drug

argatroban-0.9% nacl (50 mg/50ml-0.9%nacl, 125mg/125-0.9%nacl) 1 MED Medical Drug

argatroban-sodium chloride 1 MED Medical Drug

bivalirudin rtu 250 mg/50 ml 1 MED Medical Drug

bivalirudin (250 mg add-vant vl, 250 mg vial) 1 MED Medical Drug

bivalirudin-0.9% nacl 1 MED Medical Drug

PRADAXA 2QL 2 / day

PR

HEPARINS

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)

1S

PR

enoxaparin 300 mg/3 ml vial 1S

PR



FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 MLSYR, 7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE,12,500 UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000UNIT/0.72 ML, 95,000 UNIT/3.8 ML VL)

3S

PR

hep-lock flush 100 unit/ml kit 1MED Medical Drug

PR

heparin flush (flush 10 units/ml syr, 20 units/2 ml (10/ml),200 unit/2 ml (100/ml)) 1 BSP BENEFIT SHIFT

PROGRAM

heparin flush (iv flush 1 unit/ml syr, 2 unit/2 ml (1/ml) syr,3 unit/3 ml (1/ml) syr, 5 unit/5 ml (1/ml) syr, 10 unit/10ml (1/ml), 30 units/3 ml (10/ml), 50 units/5 ml (10/ml), 60units/6 ml (10/ml), iv flush 100 units/ml, 300 unit/3 ml(100/ml), 1,000 unit/10 (100/ml))

1PR


heparin lock (10 units/ml, 100 unit/ml) 1 BSP BENEFIT SHIFTPROGRAM

heparin lock (100 unit/10 ml (10/ml), 500 unit/5 ml(100/ml)) 1

PR


heparin 5,000 unit/ml carpujct 1

heparin sodium (5,000 unit/0.5 ml, 5,000 unit/ml syrg,20,000 unit/ml vl) 1 BSP BENEFIT SHIFT

PROGRAM

heparin sodium (sod 1,000 unit/ml vial, 2,000 unit/2 mlvial, sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod10,000 unit/ml vl, 30,000 unit/30 ml vial, 40,000 unit/4 mlvial, 50,000 unit/10 ml vial, 50,000 unit/5 ml vial)

1PR


heparin sodium in 0.45% nacl 1PR


heparin sodium-0.45% nacl (2.5 unit/10 ml-1/2 ns, 3unit/3 ml-1/2 ns, 10 unit/10 ml-1/2 ns, 100 unit/100 ml-1/2 ns, 5,000 unit/1,000-1/2ns)




heparin sodium-0.45% nacl (heparin-12,500 unit/250-1/2,heparin 25,000 unit/250-1/2, heparin 25,000 unit/500-1/2)

1PR


heparin 1,000 unit/1,000 ml-ns 1PR


heparin sodium-0.9% nacl (100 unit/100 ml-ns, 250unit/250 ml-ns, 500 unit/500 ml-ns, 2,000 unit/500 ml-ns,2,500 unit/500 ml-ns, 3,000 unit/500 ml-ns, 4,000unit/1,000 ml-ns, 4,000 unit/500 ml-ns, 5,000 unit/1,000ml-ns, 5,000 unit/5 ml-ns, 5,000 unit/500 ml-ns, 6,000unit/1,000 ml-ns, 10,000 unit/1,000ml-ns, 25,000unit/250 ml-ns, 30,000 unit/1,000-ns)


heparin sodium-0.9% nacl (2,500 unit/5 ml-ns syr, 6,000unit/3 ml-ns syr) 1 MED Medical Drug

heparin sodium-d5w (12,500 unit/250, 20,000 unit/500) 1 BSP BENEFIT SHIFTPROGRAM

heparin sodium-d5w (unit/250, unit/500) 1PR


LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 MLSYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE,150 MG/ML SYRINGE, 300 MG/3 ML VIAL)

3

S

PR


ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS

APTIOM (400 MG TABLET, 600 MG TABLET, 800 MGTABLET) 3

QL 2 / day

PA

APTIOM 200 MG TABLET 3QL 3 / day

PA



BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400MG TABLET) 3 PA

BRIVIACT 10 MG/ML ORAL SOLN 3QL 20 / day

PA

BRIVIACT (10 MG TABLET, 50 MG TABLET) 3QL 4 / day

PA

BRIVIACT 100 MG TABLET 3QL 2 / day

PA


PA


PA

BRIVIACT 50 MG/5 ML VIAL 3

QL 20 / day

MED Medical Drug

PA

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet) 1 NTI

carbamazepine er (er 100 mg cap, er 100 mg tablet, er200 mg cap, er 200 mg tablet, er 300 mg cap, er 400 mgtablet)

1 NTI

CARBATROL 3ST

NTI

DEPACON 3MED Medical Drug

NTI

DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3 NTI

DEPAKOTE 3ST

NTI



DEPAKOTE ER 2ST

NTI

DEPAKOTE SPRINKLE 2ST

NTI

DIACOMIT (250 MG CAPSULE, 250 MG POWDER PACKET,500 MG CAPSULE, 500 MG POWDER PACKET) 3

QL 2 / day

S

PA

divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mgtab, sod dr 250 mg tab, sod dr 500 mg tab) 1 NTI

divalproex sodium er 1 NTI

EPIDIOLEX 3S

PA

EPITOL 1 NTI

EQUETRO 3PR

NTI

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp) 1

FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5ML SUSP) 3 PA

FINTEPLA 3

QL 12 / day

S

PA

FYCOMPA 0.5 MG/ML ORAL SUSP 3 QL 6 / day

FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8MG TABLET, 10 MG TABLET, 12 MG TABLET) 3 QL 1 / day

gabapentin (100 mg capsule, 300 mg capsule, 400 mgcapsule) 1 QL 9 / day



gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 / day

gabapentin 600 mg tablet 1 QL 6 / day

gabapentin 800 mg tablet 1 QL 5 / day

GABITRIL 3

HORIZANT ER 300 MG TABLET 3

QL 4 / day

PA


HORIZANT ER 600 MG TABLET 3

QL 2 / day

PA


KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500MG TABLET, 750 MG TABLET, 1,000 MG TABLET) 3

ST

NTI

KEPPRA 500 MG/5 ML VIAL 3ST

MED Medical Drug

KEPPRA XR 3ST

NTI

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET,25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MGTABLET)

3ST

NTI

LAMICTAL (BLUE) 3ST

NTI

LAMICTAL (GREEN) 3ST

NTI

LAMICTAL (ORANGE) 3ST

NTI

LAMICTAL ODT 3ST

NTI



LAMICTAL ODT (BLUE) 3ST

NTI

LAMICTAL ODT (GREEN) 3ST

NTI

LAMICTAL ODT (ORANGE) 3ST

NTI

LAMICTAL XR 3ST

NTI

LAMICTAL XR (BLUE) 3ST

NTI

LAMICTAL XR (GREEN) 3ST

NTI

LAMICTAL XR (ORANGE) 3ST

NTI

lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mgtablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) 1 NTI

lamotrigine (blue) 1 NTI

lamotrigine (green) 1 NTI

lamotrigine (orange) 1 NTI

lamotrigine er 1 NTI

lamotrigine odt 1 NTI

lamotrigine odt (blue) 1 NTI

lamotrigine odt (green) 1 NTI

lamotrigine odt (orange) 1 NTI

levetiracetam 500 mg/5 ml soln 1QL 946 / 30 days

NTI



levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet) 1 NTI

levetiracetam 500 mg/5 ml vial 1 MED Medical Drug

levetiracetam er 1 NTI

levetiracetam-nacl 1 MED Medical Drug

LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3

QL 2 / day

ST


LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)

3

QL 3 / day

ST


LYRICA 20 MG/ML ORAL SOLUTION 3

QL 30 / day

ST


magnesium sulfate-0.9% nacl (1 g/100 ml-0.9% nacl, 6gm/50 ml-0.9% nacl, 40 g/1000ml-0.9%nacl) 1 MED Medical Drug

magnesium sulfate-d5w (5 gram/100, 6 gram/100, 6gram/50, 40 gram/1000, 40 gram/500) 1 MED Medical Drug

NEURONTIN (100 MG CAPSULE, 300 MG CAPSULE, 400MG CAPSULE) 3

QL 9 / day

ST


NEURONTIN (250 MG/5 ML SOLN, 250 MG/5 MLSOLUTION) 3

QL 72 / day

ST


NEURONTIN 600 MG TABLET 3

QL 6 / day

ST




NEURONTIN 800 MG TABLET 3

QL 5 / day

ST


oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet) 1 NTI

OXTELLAR XR 3 NTI

pregabalin (225 mg capsule, 300 mg capsule) 1 QL 2 / day

pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule) 1 QL 3 / day

pregabalin 20 mg/ml solution 1 QL 30 / day

QUDEXY XR 3 ST

ROWEEPRA 1 NTI

ROWEEPRA XR 1 NTI

rufinamide 1

SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 3

QL 6 / day

S

PA

SPRITAM 3

QL 3 / day


NTI

SUBVENITE 1 NTI

SUBVENITE (BLUE) 1 NTI

SUBVENITE (GREEN) 1 NTI

SUBVENITE (ORANGE) 1 NTI

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3ST

NTI



TEGRETOL XR 3ST

NTI

tiagabine hcl 1

TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP,25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET)

2ST

NTI

topiramate 15 mg sprinkle cap 1 NTI

topiramate (25 mg sprinkle cap, 25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1 NTI

topiramate er 1 NTI

TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5ML SUSP, 600 MG TABLET) 3

ST

NTI

TROKENDI XR 3 ST

valproate sodium 1MED Medical Drug

NTI

valproic acid (250 mg capsule, 250 mg/5 ml soln) 1 NTI

valproic acid 500 mg/10 ml sol 1 NTI

vigabatrin 500 mg powder packt 1

QL 6 / day

S

PS

PA

vigabatrin 500 mg tablet 3

QL 6 / day

S

PA

VIGADRONE 3

QL 6 / day

S

PA



VIMPAT 10 MG/ML SOLUTION 3

VIMPAT (150 MG TABLET, 200 MG TABLET, STARTER KIT) 3 QL 2 / day

VIMPAT (50 MG TABLET, 100 MG TABLET) 3 QL 4 / day

VIMPAT 200 MG/20 ML VIAL 3 MED Medical Drug

XCOPRI (12.5-25 MG PK, 50-100 MG PAK, 150-200 MG PK) 3QL 1 / day

PA

XCOPRI (150 MG TABLET, 200 MG TABLET, 250 MG DAILYDOSE PACK, 350 MG DAILY DOSE PACK) 3

QL 2 / day

PA

XCOPRI (50 MG TABLET, 100 MG TABLET) 3QL 4 / day

PA

ZONEGRAN 2ST

NTI

zonisamide (25 mg capsule, 100 mg capsule) 1 NTI

zonisamide 50 mg capsule 1 NTI

BARBITURATES (ANTICONVULSANTS)

MYSOLINE 3

primidone 1

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 2.5 mg/ml suspension 1S

PA

clobazam (10 mg tablet, 20 mg tablet) 1 PA

clonazepam (2 mg odt, 2 mg tablet) 1 QL 10 / day

clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg distablet, 1 mg odt, 1 mg tablet)

1 QL 3 / day



KLONOPIN (0.5 MG TABLET, 1 MG TABLET) 3

QL 3 / day

ST


KLONOPIN 2 MG TABLET 3

QL 10 / day

ST


NAYZILAM 3 QL 10 / 30 days

ONFI 2.5 MG/ML SUSPENSION 3S

PA

ONFI (10 MG TABLET, 20 MG TABLET) 3 PA

SYMPAZAN 3

QL 2 / day

S

PA

HYDANTOINS

CEREBYX 3 MED Medical Drug

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MGCAPSULE) 2 NTI

DILANTIN-125 1 NTI

fosphenytoin sodium 1 MED Medical Drug

PEGANONE 3

PHENYTEK 2 NTI

phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp) 1 NTI

phenytoin sodium (50 mg/ml ampul, 50 mg/ml syringe, 50mg/ml vial, 100 mg/2 ml vial, 250 mg/5 ml vial) 1

MED Medical Drug

NTI



phenytoin sodium extended 1 NTI

SUCCINIMIDES

CELONTIN 3

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 NTI

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2 NTI

ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN 3

QL 1 / day

ST


bupropion hcl 100 mg tablet 1 QL 5 / day

bupropion hcl 75 mg tablet 1 QL 6 / day

bupropion hcl sr 100 mg tablet 1 QL 4 / day

bupropion hcl sr 150 mg tablet 1QL 2 / day

HCR

bupropion hcl sr 200 mg tablet 1 QL 2 / day

bupropion hcl xl 150 mg tablet 1 QL 3 / day

bupropion hcl xl 300 mg tablet 1 QL 1 / day

bupropion hcl xl 450 mg tablet 1QL 1 / day

ST

FORFIVO XL 3QL 1 / day

ST

mirtazapine 7.5 mg tablet 1 QL 2 / day

mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mgtablet, 45 mg odt, 45 mg tablet) 1 QL 1 / day



REMERON (15 MG SOLTAB, 15 MG TABLET, 30 MGSOLTAB, 30 MG TABLET, 45 MG SOLTAB) 3

QL 1 / day


SPRAVATO 3

QL 8 / 28 days

S

PA

WELLBUTRIN SR (SR 150 MG TABLET, SR 200 MG TABLET) 3QL 2 / day


WELLBUTRIN SR 100 MG TABLET 3QL 4 / day


WELLBUTRIN XL 150 MG TABLET 3QL 3 / day


WELLBUTRIN XL 300 MG TABLET 3QL 1 / day


ZYBAN 3 QL 2 / day

MONOAMINE OXIDASE INHIBITORS

MARPLAN 3 QL 6 / day

NARDIL 3 QL 6 / day

PARNATE 3 QL 6 / day

phenelzine sulfate 1 QL 6 / day

tranylcypromine sulfate 1 QL 6 / day

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE) 3QL 1 / day




CYMBALTA 60 MG CAPSULE 3QL 2 / day


desvenlafaxine er 1

QL 1 / day

HCG


desvenlafaxine succinate er 1 QL 1 / day

DRIZALMA SPRINKLE 3 QL 2 / day

duloxetine hcl (dr 20 mg cap, dr 30 mg cap) 1 QL 1 / day

duloxetine hcl (dr 40 mg cap, dr 60 mg cap) 1 QL 2 / day

EFFEXOR XR (37.5 MG CAPSULE, 150 MG CAPSULE) 3QL 1 / day


EFFEXOR XR 75 MG CAPSULE 3QL 3 / day


FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE,ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MGCAPSULE)

3QL 1 / day

ST

KHEDEZLA 3 QL 1 / day

PRISTIQ 3QL 1 / day


venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mgtablet, 100 mg tablet) 1

venlafaxine hcl 25 mg tablet 1

venlafaxine hcl er (er 37.5 mg cap, er 150 mg cap) 1 QL 1 / day



venlafaxine hcl er 75 mg cap 1 QL 3 / day

venlafaxine hcl er (er 37.5 mg tab, er 75 mg tab, er 150mg tab, er 225 mg tab) 1

QL 1 / day

HCG


SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

BRISDELLE 3

QL 1 / day

ST


CELEXA 3

QL 1 / day

ST


citalopram hbr (10 mg/5 ml soln, 20 mg/10 ml sol) 1 QL 20 / day

citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL 1 / day

escitalopram oxalate 5 mg/5 ml 1 QL 20 / day

escitalopram 20 mg tablet 1 QL 1 / day

escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day

fluoxetine dr 1QL 0.15 / day

HCG

fluoxetine hcl 10 mg capsule 1 QL 1 / day



fluoxetine 20 mg/5 ml solution 1 QL 20 / day

fluoxetine hcl 10 mg tablet 1QL 1.5 / day

HCG



fluoxetine hcl 20 mg tablet 1QL 4 / day

HCG

fluoxetine hcl 60 mg tablet 1QL 1.5 / day

HCG

fluvoxamine maleate (25 mg tab, 50 mg tab) 1 QL 1 / day

fluvoxamine maleate 100 mg tab 1 QL 3 / day

fluvoxamine maleate er 1 QL 2 / day

LEXAPRO (5 MG TABLET, 10 MG TABLET) 3QL 1.5 / day


LEXAPRO 20 MG TABLET 3QL 1 / day


olanzapine-fluoxetine hcl 1

QL 1 / day


PR

paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 QL 2 / day

paroxetine cr 12.5 mg tablet 1 QL 1 / day

paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 QL 2 / day

paroxetine er 12.5 mg tablet 1 QL 1 / day

paroxetine hcl 10 mg tablet 1 QL 1.5 / day

paroxetine hcl 20 mg tablet 1 QL 1 / day



paroxetine mesylate 1 QL 1 / day



PAXIL 10 MG/5 ML SUSPENSION 3QL 42 / day

PA

PAXIL (20 MG TABLET, 40 MG TABLET) 3

QL 1 / day

ST


PAXIL 10 MG TABLET 3

QL 1.5 / day

ST


PAXIL 30 MG TABLET 3

QL 2 / day

ST


PAXIL CR (CR 25 MG TABLET, CR 37.5 MG TABLET) 3

QL 2 / day

ST


PAXIL CR 12.5 MG TABLET 3

QL 1 / day

ST


PEXEVA 3QL 1 / day

PA

PROZAC 10 MG PULVULE 3 SBA Select BrandAlternative

PROZAC 20 MG PULVULE 3QL 4 / day


PROZAC 40 MG PULVULE 3QL 2 / day




SARAFEM 10 MG TABLET 3 QL 1.5 / day

SARAFEM 20 MG TABLET 3 QL 4 / day

sertraline 20 mg/ml oral conc 1 QL 10 / day

sertraline hcl (25 mg tablet, 50 mg tablet) 1 QL 1.5 / day

sertraline hcl 100 mg tablet 1 QL 2 / day

SYMBYAX 3

QL 1 / day


PR

ZOLOFT 20 MG/ML ORAL CONC 3QL 10 / day


ZOLOFT (25 MG TABLET, 50 MG TABLET) 3QL 1.5 / day


ZOLOFT 100 MG TABLET 3QL 2 / day


SEROTONIN MODULATORS

nefazodone hcl 100 mg tablet 1 QL 6 / day



nefazodone hcl 250 mg tablet 1 QL 2.5 / day


trazodone 100 mg tablet 1 QL 4 / day






TRINTELLIX 3QL 1 / day

ST

VIIBRYD 10-20 MG STARTER PACK 3

VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 1 / day

TRICYCLICS, OTHER NOREPI-RU INHIBITORS

amitriptyline hcl 1

amoxapine 1

ANAFRANIL 3 SBA Select BrandAlternative

chlordiazepoxide-amitriptyline 1

clomipramine hcl 1

desipramine hcl 1

doxepin hcl (10 mg capsule, 25 mg capsule, 50 mgcapsule, 100 mg capsule) 1

doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mgcapsule) 1

doxepin hcl (3 mg tablet, 6 mg tablet) 1 QL 1 / day

ELAVIL 3

imipramine hcl 1

imipramine pamoate 1

maprotiline hcl 1

NORPRAMIN 3

nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap) 1



PAMELOR (10 MG CAPSULE, 25 MG CAPSULE, 75 MGCAPSULE) 3

PAMELOR 50 MG CAPSULE 3 SBA Select BrandAlternative

perphenazine-amitriptyline 1

protriptyline hcl 1

SILENOR 3QL 1 / day

B4G

SURMONTIL 3

TOFRANIL (10 MG TABLET, 50 MG TABLET) 3

TOFRANIL 25 MG TABLET 3 SBA Select BrandAlternative

trimipramine maleate 1

ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose 100 mg tablet 1QL 3 / day

PR


PR


PR

GLYSET 3QL 3 / day

PR

miglitol 1QL 3 / day

PR

PRECOSE 100 MG TABLET 3QL 3 / day

PR




PR


PR

AMYLINOMIMETICS

SYMLINPEN 120 2

QL 0.4 / day

PR

PA

SYMLINPEN 60 2

QL 0.2 / day

PR

PA

ANTIDIABETIC AGENTS, MISCELLANEOUS

KORLYM 3S

PA

BIGUANIDES

GLUCOPHAGE 1,000 MG TABLET 3

QL 2.5 / day

ST

PR


GLUCOPHAGE 500 MG TABLET 3

QL 5 / day

ST

PR


GLUCOPHAGE 850 MG TABLET 3

QL 3 / day

ST

PR




GLUCOPHAGE XR 500 MG TAB 3

QL 5 / day

ST

PR


GLUCOPHAGE XR 750 MG TAB 3

QL 3 / day

ST

PR


metformin hcl 500 mg/5 ml soln 1QL 25 / day

PR

metformin hcl 1,000 mg tablet 1QL 2.5 / day

PR

metformin hcl 500 mg tablet 1QL 5 / day

PR

metformin hcl 850 mg tablet 1QL 3 / day

PR

metformin hcl er 500 mg tablet 1

QL 5 / day

COnlyGlucophage ERgenericcovered

PR

metformin hcl er 750 mg tablet 1

QL 3 / day

COnlyGlucophage ERgenericcovered

PR



RIOMET ER 3

QL 20 / day

PR

PA



DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

alogliptin 3

QL 1 / day

PR

PA

alogliptin-metformin 3

QL 2 / day

PR

PA

alogliptin-pioglitazone 3

QL 1 / day

PR

PA

JANUMET 2QL 2 / day

PR

JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2QL 2 / day

PR

JANUMET XR 100-1,000 MG TABLET 2QL 1 / day

PR

JANUVIA 2QL 1 / day

PR

JENTADUETO 2QL 2 / day

PR

JENTADUETO XR 2.5 MG-1,000 MG 2QL 2 / day

PR



JENTADUETO XR 5 MG-1,000 MG TB 2QL 1 / day

PR

KAZANO 3

QL 2 / day

PR

PA

B4G

KOMBIGLYZE XR 3

QL 1 / day

PR

PA

NESINA 3

QL 1 / day

PR

PA

B4G

ONGLYZA 3

QL 1 / day

PR

PA

OSENI 3

QL 1 / day

PR

PA

B4G

TRADJENTA 2QL 1 / day

PR

INCRETIN MIMETICS

ADLYXIN 10-20 MCG STARTER PACK 3QL 14 / 1 rx

PA

ADLYXIN 20 MCG MAINTENANCE PK 3QL 0.22 / day

PA



BYDUREON 2QL 0.15 / day

PR

BYDUREON BCISE 2QL 0.15 / day

PR

BYDUREON PEN 2QL .15 / day

PR

BYETTA 10 MCG DOSE PEN INJ 2QL 0.08 / day

PR

BYETTA 5 MCG DOSE PEN INJ 2QL 0.04 / day

PR

OZEMPIC 0.25-0.5 MG DOSE PEN 2QL 0.067 / day

PR

OZEMPIC 1 MG DOSE PEN 2QL 0.124 / day

PR

RYBELSUS 2QL 1 / day

PA

SAXENDA 3

QL 0.5 / day


PA

TRULICITY 2QL 0.08 / day

PR

VICTOZA 2-PAK 2QL 0.3 / day

PR

VICTOZA 3-PAK 2QL 0.3 / day

PR



MEGLITINIDES

nateglinide 1QL 3 / day

PR

PRANDIN 1 MG TABLET 3QL 4 / day

PR

PRANDIN 2 MG TABLET 3QL 8 / day

PR

repaglinide (0.5 mg tablet, 1 mg tablet) 1QL 4 / day

PR

repaglinide 2 mg tablet 1QL 8 / day

PR

repaglinide-metformin hcl 1QL 5 / day

PR

STARLIX 3QL 3 / day

PR

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

FARXIGA 2QL 1 / day

PR

GLYXAMBI 2QL 1 / day

PR

INVOKAMET 3

QL 2 / day

PR

PA

INVOKAMET XR 3

QL 2 / day

PR

PA



INVOKANA 3

QL 1 / day

PR

PA

JARDIANCE 2QL 1 / day

PR

QTERN 3QL 1 / day

PA

SEGLUROMET 3QL 2 / day

PA

STEGLATRO 3QL 1 / day

PA

STEGLUJAN 3QL 1 / day

PA

SYNJARDY 2 QL 2 / day

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET,12.5-1,000 MG TAB) 2 QL 2 / day

SYNJARDY XR 25-1,000 MG TABLET 2 QL 1 / day

TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 2QL 1 / day

PR

TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 2QL 2 / day

PR

XIGDUO XR (2.5 MG TAB, 5 MG TABLET) 2QL 2 / day

PR

XIGDUO XR (5 MG-500 MG TABLET, 10 MG-1,000 MGTAB, 10 MG-500 MG TABLET) 2

QL 1 / day

PR



SULFONYLUREAS

AMARYL 3 PR

chlorpropamide 100 mg tablet 1 PR

chlorpropamide 250 mg tablet 1QL 3 / day

PR

glimepiride 1 PR

glipizide 1 PR

glipizide er 1 PR

glipizide xl 1 PR

glipizide-metformin (2.5-500 mg, 5-500 mg) 1QL 4 / day

PR

glipizide-metformin 2.5-250 mg 1QL 8 / day

PR

GLUCOTROL 3 PR

GLUCOTROL XL 3 PR

glyburide 1 PR

glyburide micronized 1 PR

glyburid-metformin 1.25-250 mg 1QL 8 / day

PR

glyburide-metformin hcl (2.5-500 mg, 5-500 mg) 1QL 4 / day

PR

GLYNASE 3 PR

tolazamide 250 mg tablet 1QL 4 / day

PR



tolazamide 500 mg tablet 1QL 2 / day

PR

tolbutamide 1QL 6 / day

PR

THIAZOLIDINEDIONES

ACTOPLUS MET 3QL 3 / day

PR

ACTOPLUS MET XR 15-1,000 MG TB 2

QL 3 / day

ST

PR


ACTOPLUS MET XR 30-1,000 MG TB 2

QL 1 / day

ST

PR


ACTOS 3

QL 1 / day

PR


AVANDIA 2 MG TABLET 2

QL 3 / day

PR

PA

AVANDIA 4 MG TABLET 2

QL 2 / day

PR

PA

DUETACT 3QL 1 / day

PR



pioglitazone hcl 1QL 1 / day

PR

pioglitazone-glimepiride 1QL 1 / day

PR

pioglitazone-metformin 1QL 3 / day

PR

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

ANZEMET 3 QL 0.15 / day

granisetron hcl 1 mg tablet 1 QL 6 / 30 days

granisetron hcl (0.1 mg/ml vial, 1 mg/ml vial, 4 mg/4 mlvial) 1

S

MED Medical Drug

ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml amp,hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial, 40 mg/20 ml vial) 1

S


ondansetron 4 mg/5 ml solution 1 QL 20 / day

ondansetron hcl (4 mg tablet, 8 mg tablet) 1

QL 24 / 30 days

CMax allowable-3/day with maxof 24 / 30 days

ondansetron hcl 24 mg tablet 1 QL 3 days

ondansetron hcl-0.9% nacl (8mg/50ml-0.9% nacl,16mg/50ml-0.9%nacl) 1

S


ondansetron hcl-d5w 1S


ondansetron odt 1

QL 24 / 30 days




SANCUSO 3

QL 0.144 / day

PA


ZOFRAN 4 MG/5 ML ORAL SOLN 3QL 20 / day


ZOFRAN (4 MG TABLET, 8 MG TABLET) 3

QL 24 / 30 days



ZUPLENZ 3QL 24 / 30 days


ANTIEMETICS, MISCELLANEOUS

BARHEMSYS 3 MED Medical Drug

CESAMET 3

QL 0.67 / day

S

PA

dronabinol 1 QL 5 / day

MARINOL 3QL 5 / day

PA

scopolamine 1

SYNDROS 3

QL 13 / day


PA

TRANSDERM-SCOP 3 SBA Select BrandAlternative



ANTIHISTAMINES (GI DRUGS)

BONJESTA 3QL 2 / day

PA

COMPAZINE 25 MG SUPPOSITORY 1 PR

COMPAZINE (5 MG TABLET, 10 MG TABLET) 3

COMPRO 1 PR

DICLEGIS 3

QL 4 / day

PA



dimenhydrinate 50 mg/ml vial 1 MED Medical Drug

doxylamine succ-pyridoxine hcl 1QL 4 / day

PA

meclizine hcl (12.5 mg tablet, 25 mg tablet) 1

prochlorperazine 1 PR

prochlorperazine 10 mg/2 ml vl 1MED Medical Drug

PR

prochlorperazine 50 mg/10 ml 1 PR

prochlorperazine maleate 1 PR

TIGAN 300 MG CAPSULE 3

TIGAN 100 MG/ML VIAL 3 MED Medical Drug

trimethobenzamide hcl 1

NEUROKININ-1 RECEPTOR ANTAGONISTS

AKYNZEO 300-0.5 MG CAPSULE 3QL 0.15 / day

PA



aprepitant 125-80-80 mg pack 1QL 3/ fill

HCG

aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day

aprepitant 80 mg capsule 1 QL 0.15 / day

CINVANTI 3S

MED Medical Drug

EMEND TRIPACK 3QL 3/ fill


EMEND (40 MG CAPSULE, 125 MG CAPSULE) 3QL 0.08 / day


EMEND 80 MG CAPSULE 3QL 0.15 / day


EMEND 125 MG POWDER PACKET 3 QL 0.08 / day

EMEND 150 MG VIAL 3

QL 2 / fill

S

MED Medical Drug

fosaprepitant dimeglumine 1

QL 2 / fill

S

MED Medical Drug

VARUBI 90 MG TABLET 3

QL 0.15 / day

S

PA

VARUBI 166.5 MG/92.5 ML VIAL 3

S

MED Medical Drug

PA



ANTIFUNGAL (SYSTEMIC)

ALLYLAMINE ANTIFUNGALS

terbinafine hcl 1

ANTIFUNGALS, MISCELLANEOUS

griseofulvin 125 mg/5 ml susp 1

griseofulvin micro 500 mg tab 1 HCG

griseofulvin ultramicrosize 1 HCG

AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE 3 PA

CRESEMBA 372 MG VIAL 3

S

MED Medical Drug

PA

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/MLSUSPENSION, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET)

3

DIFLUCAN 150 MG TABLET 3 QL 1 / day

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet,100 mg tablet, 200 mg tablet) 1

fluconazole 150 mg tablet 1 QL 1 / day

fluconazole in saline 1 MED Medical Drug

fluconazole-nacl 1 MED Medical Drug

itraconazole (10 mg/ml solution, 100 mg capsule) 1

ketoconazole 200 mg tablet 1

NOXAFIL 40 MG/ML SUSPENSION 3

NOXAFIL DR 100 MG TABLET 3MVB Minimal Value

Brand




NOXAFIL 300 MG/16.7 ML VIAL 3 MED Medical Drug

ONMEL 3 PA

posaconazole dr 100 mg tablet 1

SPORANOX 100 MG CAPSULE 3 PA

SPORANOX 10 MG/ML SOLUTION 3PA


TOLSURA 3S

PA

VFEND 40 MG/ML SUSPENSION 3QL 20 / day

S

VFEND (50 MG TABLET, 200 MG TABLET) 3 QL 4 / day

VFEND IV 3MED Medical Drug

PA

voriconazole 40 mg/ml susp 1QL 20 / day

S

voriconazole (50 mg tablet, 200 mg tablet) 1 QL 4 / day

voriconazole 200 mg vial 1MED Medical Drug

PA

ECHINOCANDIN ANTIFUNGALS

CANCIDAS 3 MED Medical Drug

caspofungin acetate 1 MED Medical Drug

ERAXIS (WATER DILUENT) 3 MED Medical Drug

micafungin 1 MED Medical Drug

MYCAMINE 3 MED Medical Drug



POLYENE ANTIFUNGALS

ABELCET 3 MED Medical Drug

AMBISOME 3 MED Medical Drug

amphotericin b 1 MED Medical Drug

nystatin (100,000 unit/ml susp, 500,000 unit oral tab,500,000 unit/5 ml sus) 1

PYRIMIDINE ANTIFUNGALS

ANCOBON 3

flucytosine 1

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)

naftifine hcl (1% cream, 1% gel, 2% cream) 1

ST

HCG


NAFTIN 2% CREAM 3

ST



NAFTIN 1% GEL 3ST


NAFTIN 2% GEL 3 ST

ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC

TRIPLE DYE 3



AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole (1% solution, 1% topical cream, 10 mgtroche) 1

clotrimazole-betamethasone crm 1

clotrimazole-betamethasone lot 1

ST


HCG

econazole nitrate 1

ECOZA 3ST


ERTACZO 3ST


EXELDERM (CREAM, SOLUTION) 3ST


EXTINA 3ST


GYNAZOLE 1 3 MVB MINIMALVALUE BRAND

JUBLIA 3

QL 0.54 / day


PA

ketoconazole 2% cream 1 QL 2 / day

ketoconazole 2% foam 1ST

HCG



ketoconazole 2% shampoo 1

LOTRISONE 3

luliconazole 1QL 2 / day

PA

LUZU 3

QL 2 / day

PA


miconazole 3 200 mg vag supp 3 GL Female

NIZORAL 3

ORAVIG 3

oxiconazole nitrate 1

ST

HCG


OXISTAT 1% CREAM 3

ST



OXISTAT 1% LOTION 3ST


sulconazole nitrate (cream, soln) 3ST


terconazole 0.4% cream 1QL 1.5 / day

GL Female

terconazole 0.8% cream 1 GL Female



terconazole 80 mg suppository 1

QL 1.5 / day

GL Female

HCG

XOLEGEL 3

ST



HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 8% SOLUTION 1 QL 0.22 / day

ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp,1% shampoo) 1

ciclopirox 8% solution 1 QL 0.22 / day

LOPROX 1% SHAMPOO 3 SBA Select BrandAlternative

LOPROX 0.77% TOPICAL SUSP 3ST


PENLAC 3 QL 0.3 / day

OXABOROLES

KERYDIN 3

QL 0.67 / day


PA

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 1

nystatin (unit/gm cream, unit/gm oint) 1

nystatin 100,000 unit/gm powd 1 QL 1 / day



nystatin-triamcinolone cream 1

nystatin-triamcinolone ointm 1 HCG

NYSTOP 1

ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day

ALPHAGAN P 0.15% EYE DROPS 3QL 0.4 / day


brimonidine 0.2% eye drop 1 QL 0.4 / day

brimonidine tartrate 0.15% drp 1QL 0.4 / day

HCG

COMBIGAN 2 QL 0.334 / day

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

betaxolol hcl 0.5% eye drop 1 QL 0.54 / day

BETIMOL 0.25% EYE DROPS 3 QL 0.286 / day

BETIMOL 0.5% EYE DROPS 3 QL 0.334 / day

BETOPTIC S 3 QL 0.54 / day

carteolol hcl 1 QL 0.334 / day

ISTALOL 3QL 0.286 / day


levobunolol hcl 1 QL 0.4 / day

metipranolol 1 QL 0.334 / day

timolol maleate (drop, maleate drop, maleate drops) 1 QL 0.334 / day



timolol maleate (0.25% gel-solution, 0.25% gfs gel-solution, maleate 0.25% eye drop, 0.5% gel-solution, 0.5%gfs gel-solution)

1 QL 0.286 / day

TIMOPTIC 0.25% EYE DROP 3QL 0.286 / day

ST

TIMOPTIC 0.5% EYE DROP 3QL 0.334 / day

ST

TIMOPTIC 0.25% OCUDOSE DROP 3QL 2 / day

ST

TIMOPTIC 0.5% OCUDOSE DROP 3

QL 2 / day

ST


TIMOPTIC-XE 3QL 0.286 / day

ST

CARBONIC ANHYDRASE INHIBITORS (EENT)

acetazolamide 1

acetazolamide er 1

acetazolamide sodium 1 MED Medical Drug

AZOPT 2 QL 0.334 / day

COSOPT 3

QL 0.334 / day

ST


COSOPT PF 3

QL 2 / day

ST




dorzolamide hcl 1 QL 0.4 / day

dorzolamide-timolol 2%-0.5% 1 QL 2 / day

dorzolamide-timolol eye drops 1 QL 0.334 / day

methazolamide 25 mg tablet 1

methazolamide 50 mg tablet 1 HCG

SIMBRINZA 2 QL 0.4 / day

TRUSOPT 3 QL 0.4 / day

MIOTICS

ISOPTO CARPINE 3 QL 0.54 / day

MIOCHOL-E 3 MED Medical Drug

MIOSTAT 3 MED Medical Drug

PHOSPHOLINE IODIDE 3

pilocarpine hcl (1% drops, 2% drops, 4% drops) 1 QL 0.54 / day

PROSTAGLANDIN ANALOGS

bimatoprost 0.03% eye drops 1QL 0.13 / day

HCG

bimatoprost 0.03% eyelash soln 1

HCG


latanoprost 0.005% eye drops 1 QL 0.13 / day

LATISSE 3 ST

LUMIGAN 2 QL 0.13 / day

TRAVATAN Z 3QL 0.167 / day

ST



travoprost 1 QL 0.167 / day

VYZULTA 3QL 0.25 / day


XALATAN 3

QL 0.13 / day

ST


XELPROS 2 QL 0.1 / day

ZIOPTAN 3 QL 1 / day

RHO KINASE INHIBITORS

RHOPRESSA 3 QL 0.1 / day

ROCKLATAN 3 QL 0.1 / day

ANTIHEMORRHAGIC AGENTS

ANTIHEPARIN AGENTS

protamine sulfate 1 MED Medical Drug

HEMOSTATICS

ADVATE 3S

PA

ADYNOVATE 3S

PA

AFSTYLA 3S

PA

ALPHANATE 3S

PA

ALPHANINE SD 3 S



ALPROLIX 3S

PA

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET,1,000 MG TABLET) 3



aminocaproic acid (0.25 gram/ml, 500 mg tab, 1,000 mgtab) 1

BENEFIX 3S

PA

COAGADEX 3S

PA

CORIFACT 3 S

ELOCTATE 3S

PA

ESPEROCT 3S

PA

FEIBA NF 3S

PA

HELIXATE FS 3S

PA

HEMLIBRA 3

QL 12 / day

S

PA

HEMOFIL M 3S

PA

HUMATE-P 3S

PA



IDELVION 3S

PA

IXINITY 3S

PA

JIVI 3S

PA

KCENTRA 3 MED Medical Drug

KOATE 3S

PA

KOGENATE FS 3S

PA

KOVALTRY 3S

PA

LYSTEDA 3QL 6/ day plus 90/

90 day limitGL Female

MONONINE 3S

PA

NOVOEIGHT 3S

PA

NOVOSEVEN RT 3S

PA

NUWIQ 3S

PA

OBIZUR 3S

PA

PROFILNINE 3S

PA



REBINYN 3S

PA

RECOMBINATE 3S

PA

RIXUBIS 3S

PA

SEVENFACT 3S

PA

tranexamic acid 650 mg tablet 1QL 6 / day

GL Female

tranexamic acid-nacl 1S

MED Medical Drug

TRETTEN 3S

PA

VISTASEAL FIBRIN SEALANT 3 MED Medical Drug

VONVENDI 3S

PA

WILATE 3S

PA

XYNTHA 3S

PA

XYNTHA SOLOFUSE 3S

PA



ANTIHISTAMINE DRUGS

SECOND GENERATION ANTIHISTAMINES

cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 1 QL 10 / day

CLARINEX 0.5 MG/ML (2.5 MG/5) 3

QL 10 / day

PA


CLARINEX 5 MG TABLET 3QL 1 / day


CLARINEX-D 12 HOUR 3QL 2 / day


desloratadine 5 mg tablet 1 QL 1 / day

desloratadine (2.5 mg odt, 5 mg odt) 1

QL 1 / day

HCG


levocetirizine 2.5 mg/5 ml sol 1 QL 30 / day

levocetirizine 5 mg tablet 1 QL 1 / day

QUZYTTIR 3 MED Medical Drug

SEMPREX-D 3QL 4 / day


XYZAL 2.5 MG/5 ML SOLUTION 3 QL 30 / day



ANTIHYPOGLYCEMIC AGENTS

ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS

diazoxide 1

PROGLYCEM 3

GLYCOGENOLYTIC AGENTS

BAQSIMI 2

GLUCAGEN 1 MG HYPOKIT 3 ST

GLUCAGON EMERGENCY KIT 2

GVOKE HYPOPEN 1-PACK 2

GVOKE HYPOPEN 2-PACK 2

GVOKE PFS 1-PACK SYRINGE 2

GVOKE PFS 2-PACK SYRINGE 2

ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE) 3

QL 1 / day

S

PR

PA

JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 3

QL 2 / day

S

PR

PA

LOVAZA 3

QL 4 / day

PR

PA




NEXLETOL 2QL 1 / day

PA

NEXLIZET 2QL 1 / day

PA

niacin er (er 750 mg tablet, er 1,000 mg tablet) 1

QL 2 / day

PR

HCG

niacin er 500 mg tablet 1

QL 3 / day

PR

HCG

NIACOR 3QL 12 / day

PR

NIASPAN ER 1,000 MG TABLET 3

QL 2 / day

ST

PR


NIASPAN ER 500 MG TABLET 3

QL 3 / day

ST

PR

NIASPAN ER 750 MG TABLET 3

QL 2 / day

ST

PR

cvs omega-3 gummy fish 1

omega-3 acid ethyl esters 1QL 4 / day

PR

THEROMEGA SPORT 1



TRIKLO 1QL 4 / day

PR

VASCEPA 0.5 GM CAPSULE 2

QL 4 / day

PR

PA

VASCEPA 1 GM CAPSULE 2

QL 4 / day

PR

PA

B4G

BILE ACID SEQUESTRANTS

cholestyramine powder 1QL 24 / day

PR

cholestyramine packet 1QL 4 / day

PR

cholestyramine light powder 1QL 24 / day

PR

cholestyramine light packet 1QL 4 / day

PR

colesevelam hcl 3.75 g packet 1QL 1 / day

PR

colesevelam 625 mg tablet 1QL 6 / day

PR

COLESTID (FLAVORED GRANULES, GRANULES) 3

QL 30 / day

ST

PR

COLESTID GRANULES PACKET 3

QL 6 / day

ST

PR



COLESTID 1 GM TABLET 3

QL 4 / day

ST

PR

colestipol hcl (granules, granules packet) 1

QL 6 / day

PR

HCG

colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1

QL 4 / day

PR

HCG

PREVALITE POWDER 1QL 24 / day

PR

PREVALITE PACKET 1QL 4 / day

PR

QUESTRAN POWDER 3

QL 24 / day

ST

PR

QUESTRAN PACKET 3QL 4 / day

PR

QUESTRAN LIGHT 3QL 24 / day

PR

WELCHOL 3.75G PACKET 3

QL 1 / day

ST

PR


WELCHOL 625 MG TABLET 3

QL 6 / day

ST

PR



CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe 1QL 1 / day

PR

ezetimibe-simvastatin 1QL 1 / day

PR

VYTORIN 3

QL 1 / day

PR


ZETIA 3

QL 1 / day

PR


FIBRIC ACID DERIVATIVES

ANTARA 30 MG CAPSULE 3

QL 2 / day

PR

PA

ANTARA 90 MG CAPSULE 3

QL 1 / day

PR

PA

fenofibrate (130 mg capsule, 150 mg capsule) 1

QL 1 / day

PR

HCG


fenofibrate (40 mg tablet, 50 mg capsule) 1

QL 2 / day

HCG




fenofibrate (67 mg capsule, 134 mg capsule, 145 mgtablet, 160 mg tablet, 200 mg capsule) 1

QL 1 / day

PR

fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet) 1QL 2 / day

PR

fenofibrate 120 mg tablet 1

QL 1 / day

HCG


fenofibric acid (105 mg tablet, dr 135 mg cap) 1QL 1 / day

PR

fenofibric acid (35 mg tablet, dr 45 mg cap) 1QL 2 / day

PR

FENOGLIDE 120 MG TABLET 3

QL 1 / day

PR



FENOGLIDE 40 MG TABLET 3

QL 2 / day

PR



FIBRICOR 105 MG TABLET 3QL 1 / day

PR

FIBRICOR 35 MG TABLET 3QL 2 / day

PR

gemfibrozil 1QL 2 / day

PR



LIPOFEN 150 MG CAPSULE 3

QL 1 / day

PR

PA


LIPOFEN 50 MG CAPSULE 3

QL 2 / day

PR

PA

LOPID 3QL 2 / day

PR

TRICOR 145 MG TABLET 3

QL 1 / day

ST

PR


TRICOR 48 MG TABLET 3

QL 2 / day

ST

PR


TRIGLIDE 3

QL 1 / day

PR

PA

TRILIPIX DR 135 MG CAPSULE 3QL 1 / day

PR

TRILIPIX DR 45 MG CAPSULE 3QL 2 / day

PR



HMG-COA REDUCTASE INHIBITORS

ALTOPREV 3

QL 1 / day

ST

PR


amlodipine-atorvastatin 1QL 1 / day

PR

atorvastatin calcium (10 mg tablet, 20 mg tablet) 1

QL 1 / day

PR

HCR

atorvastatin calcium (40 mg tablet, 80 mg tablet) 1QL 1 / day

PR

CADUET 3

QL 1 / day

PR



CRESTOR 3

QL 1 / day

ST

PR


EZALLOR SPRINKLE 3

QL 1 / day

ST

PR

FLOLIPID 20 MG/5 ML ORAL SUSP 3

QL 10 / day

ST




FLOLIPID 40 MG/5 ML ORAL SUSP 3QL 5 / day

ST

fluvastatin er 1

QL 1 / day

PR

HCG

fluvastatin sodium 20 mg cap 1

QL 1 / day

PR

HCG

fluvastatin sodium 40 mg cap 1

QL 2 / day

PR

HCG

LESCOL 20 MG CAPSULE 3

QL 1 / day

ST

PR


LESCOL 40 MG CAPSULE 3

QL 2 / day

ST

PR


LESCOL XL 3

QL 1 / day

ST

PR


LIPITOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3

QL 1 / day

ST

PR




LIPITOR 80 MG TABLET 3

ST

PR


LIVALO 2

QL 1 / day

ST

PR

lovastatin (10 mg tablet, 20 mg tablet) 1

QL 1 / day

PR

HCR

lovastatin 40 mg tablet 1

QL 2 / day

PR

HCR

PRAVACHOL 3

QL 1 / day

ST

PR


pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab) 1

QL 1 / day

PR

HCR

pravastatin sodium 80 mg tab 1PR

HCR

rosuvastatin calcium (20 mg tab, 40 mg tab) 1QL 1 / day

PR

rosuvastatin calcium (5 mg tab, 10 mg tab) 1

QL 1 / day

PR

HCR



simvastatin 20 mg/5 ml susp 3

QL 5 / day

ST

PR

simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1

QL 1.5 / day

PR

HCR

simvastatin 5 mg tablet 1

QL 1 / day

PR

HCR

simvastatin 80 mg tablet 1

QL 1 / day

PR

PA

ZOCOR (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3

QL 1.5 / day

ST

PR


ZOCOR 80 MG TABLET 3

QL 1 / day

ST

PR


ZYPITAMAG 3QL 1 / day

ST

PCSK9 INHIBITORS

PRALUENT PEN 3

QL 0.08 / day

S

PS

PA



REPATHA PUSHTRONEX 3

QL 0.13 / day

S

PS

PA

REPATHA SURECLICK 3

QL 0.08 / day

S

PS

PA

REPATHA SYRINGE 3

QL 0.08 / day

S

PS

PA

ANTIMIGRAINE AGENTS

CALCITONIN GENE-RELATED PEPTIDE ANTAG.

AIMOVIG 140 MG/ML AUTOINJECTOR 2

QL 0.04 / day


PA

AIMOVIG 70 MG/ML AUTOINJECTOR 2

QL 2 / 30 days


PA

AIMOVIG AUTOINJECTOR (2 PACK) 2

QL 2/ 30 days


PA

AJOVY AUTOINJECTOR 3

QL 0.057 / day


PA



AJOVY SYRINGE 3

QL 0.057 / day


PA

EMGALITY PEN 2

QL 0.04 / day


PA

EMGALITY 120 MG/ML SYRINGE 2

QL 0.04 / day


PA

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR)) 2

QL 0.1 / day


PA

NURTEC ODT 2

QL 0.54 / day


PA

UBRELVY 2

QL 0.54 / day


PA

SELECTIVE SEROTONIN AGONISTS

almotriptan malate 1QL 0.4 / day

HCG

AMERGE 3

QL 0.6 / day

ST




eletriptan hbr 1 QL 0.4 / day

FROVA 3

QL 0.6 / day

ST



frovatriptan succinate 1QL 0.6 / day

HCG

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PENINJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PENINJECT, 6 MG/0.5 ML VIAL)

3

QL 0.167 / day

ST


IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 3

QL 6 / 30 days

ST


IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3

QL 0.3 / day

ST


MAXALT 3

QL 0.6 / day

ST


MAXALT MLT 3

QL 0.6 / day

ST


naratriptan hcl 1 QL 0.6 / day

ONZETRA XSAIL 3 ST



RELPAX 3

QL 0.4 / day

ST


REYVOW 100 MG TABLET 3

QL 0.3 / day


PA

REYVOW 50 MG TABLET 3

QL 4 / 30 days


PA

rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mgtablet) 1 QL 0.6 / day

sumatriptan 1 QL 6 / 30 days

sumatriptan succ-naproxen sod 1

QL 0.3 / day

HCG


sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)

1 QL 0.167 / day

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet) 1 QL 0.3 / day

SUMAVEL DOSEPRO 3QL 0.134 / day

ST

TOSYMRA 3QL 0.4 / day

ST

TREXIMET 10-60 MG TABLET 3

QL 0.3 / day

ST

PA




TREXIMET 85-500 MG TABLET 3

QL 0.3 / day

ST

PA



ZEMBRACE SYMTOUCH 3QL 0.134 / day

ST

zolmitriptan 1 QL 0.2 / day

zolmitriptan odt 1 QL 0.2 / day

ZOMIG 2.5 MG NASAL SPRAY 3

QL 0.2 / day

ST


ZOMIG 5 MG NASAL SPRAY 3QL 0.2 / day

ST

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3

QL 0.2 / day

ST


ZOMIG ZMT 3

QL 0.2 / day

ST


ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 1



ANTITUBERCULOSIS AGENTS

CAPASTAT SULFATE 3 MED Medical Drug

cycloserine 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet) 1

isoniazid 100 mg/ml vial 1 MED Medical Drug

MYAMBUTOL 3

MYCOBUTIN 3

PASER 3

pretomanid 3

QL 1 / day


PA

PRIFTIN 3 QL 1.25 / day

pyrazinamide 1

rifabutin 1

RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3

RIFADIN IV 600 MG VIAL 3 MED Medical Drug

RIFAMATE 3

rifampin (150 mg capsule, 300 mg capsule) 1

rifampin iv 600 mg vial 1 MED Medical Drug

RIFATER 3

SIRTURO 3 PA

TRECATOR 3



ANTINEOPLASTIC AGENTS

ABRAXANE 3

S

MED Medical Drug

PA

ADCETRIS 3

S

MED Medical Drug

PA

ADRIAMYCIN (10 MG VIAL, 50 MG VIAL, 200 MG/100 MLVIAL) 1

S

MED Medical Drug

ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 50MG/25 ML VIAL) 3

S

MED Medical Drug

ADRUCIL 1S

MED Medical Drug

AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 3

QL 2 / day

S

PA

AFINITOR 2.5 MG TABLET 3

QL 1 / day

S

PA

AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET) 3

QL 1 / day

S

PA

AFINITOR DISPERZ 5 MG TABLET 3

QL 2 / day

S

PA

ALECENSA 3

QL 8 / day


S

PA



ALIMTA 3

S

MED Medical Drug

PA

ALIQOPA 3

S

MED Medical Drug

PA

ALKERAN 2 MG TABLET 3

ALKERAN 50 MG VIAL 3S

MED Medical Drug

ALUNBRIG (90 MG TABLET, 90 MG-180 MG TAB PACK) 3

QL 2 / day


S

PA

ALUNBRIG 180 MG TABLET 3

QL 1 / day


S

PA

ALUNBRIG 30 MG TABLET 3

QL 6 / day


S

PA

anastrozole 1PR

HCR

ARIMIDEX 3ST

PR

AROMASIN 3 PR



ARRANON 3S

MED Medical Drug

arsenic trioxide 1S

MED Medical Drug

ARZERRA 3

S

MED Medical Drug

PA

ASPARLAS 3

S

MED Medical Drug

PA

AVASTIN 3

S

PA


AYVAKIT 3

QL 1 / day

S

PA

azacitidine 1S

MED Medical Drug

BALVERSA 3 MG TABLET 3

QL 3 / day

S

PA


QL 2 / day

S

PA


QL 1 / day

S

PA



BAVENCIO 3

S

MED Medical Drug

PA

bcg (tice strain) 3S

MED Medical Drug

BELEODAQ 3

S

MED Medical Drug

PA

bendamustine hcl 1S

MED Medical Drug

bexarotene 1S

PA

bicalutamide 1

BICNU 3S

MED Medical Drug

BLENREP 3

QL 0.142 / day

S

MED Medical Drug

PA

bleomycin sulfate 1S

MED Medical Drug

BLINCYTO (35 MCG VIAL, 35MCG VL W-STABILIZER) 3S

MED Medical Drug

bortezomib 3

S

MED Medical Drug

PA

BOSULIF (400 MG TABLET, 500 MG TABLET) 3

QL 1 / day

S

PS

PA



BOSULIF 100 MG TABLET 3

QL 4 / day

S

PS

PA

BRAFTOVI 3S

PA

BRUKINSA 3

QL 4 / day

S

PA

busulfan 3S

MED Medical Drug

BUSULFEX 3S

MED Medical Drug

CABOMETYX 3

QL 1 / day

S

PA

CALQUENCE 3

QL 2 / day


S

PA

CAMPATH 3

S

MED Medical Drug

PA

CAMPTOSAR 3S

MED Medical Drug

capecitabine 1S

PA



CAPRELSA 100 MG TABLET 3

QL 2 / day

S

PA

CAPRELSA 300 MG TABLET 3

QL 1 / day

S

PA

CARAC 3PA


carboplatin (50 mg/5 ml vial, 150 mg vial, 150 mg/15 mlvial, 450 mg/45 ml vial, 600 mg/60 ml vial) 1

S

MED Medical Drug

carmustine 1S

MED Medical Drug

CASODEX 3

cisplatin (50 mg vial, 50 mg/50 ml vial, 100 mg/100 mlvial, 200 mg/200 ml vial) 1

S

MED Medical Drug

cladribine 1S

MED Medical Drug

clofarabine 1S

MED Medical Drug

CLOLAR 3S

MED Medical Drug

COMETRIQ 100 MG DAILY-DOSE PK 3

QL 2 / day

S

PA

COMETRIQ 140 MG DAILY-DOSE PK 3

QL 4 / day

S

PA



COMETRIQ 60 MG DAILY-DOSE PACK 3

QL 3 / day

S

PA

COPIKTRA 3S

PA

COSMEGEN 3S

MED Medical Drug

COTELLIC 3

QL 2.5 / day


S

PA

cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA

cyclophosphamide (1 gm vial, 1 gm/5 ml vl, 2 gm vial, 500mg vial, 500 mg/2.5 ml) 1

S

MED Medical Drug

PA

CYRAMZA 3

S

MED Medical Drug

PA

cytarabine 1S

MED Medical Drug

dacarbazine 1S

MED Medical Drug

DACOGEN 3S

MED Medical Drug

dactinomycin 1S

MED Medical Drug



DARZALEX 3

S

MED Medical Drug

PA

DARZALEX FASPRO 3

QL 2.15 / day

S

MED Medical Drug

PA

daunorubicin hcl (20 mg vial, 20 mg/4 ml vial, 50 mg/10ml vial) 1

S

MED Medical Drug

DAURISMO 3

QL 1 / day

S

PA

decitabine 1S

MED Medical Drug

diclofenac sodium 3% gel 1

QL 100 / 30 days

PA

HCG


DOCEFREZ 3S

MED Medical Drug

docetaxel 1S

MED Medical Drug

DOXIL 3S

MED Medical Drug

doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 20 mg/10 mlvial, 50 mg vial, 50 mg/25 ml vial, 150 mg/75 ml vial, 200mg/100 ml vial)

1S

MED Medical Drug



doxorubicin hcl liposome 1S

MED Medical Drug

DROXIA 3

EFUDEX 3

ELLENCE 3S

MED Medical Drug

ELZONRIS 3

S

MED Medical Drug

PA

EMCYT 3 S

ENHERTU 3S

MED Medical Drug

epirubicin hcl (50 mg/25 ml vial, hcl 50 mg vial, 200mg/100 ml vial, hcl 200 mg vial) 1

S

MED Medical Drug

ERBITUX 3

S

MED Medical Drug

PA

ERIVEDGE 3

QL 1 / day

S

PA

ERLEADA 3

QL 4 / day

S

PA

erlotinib hcl 3

QL 1 / day

S

PA

ERWINAZE 3S

MED Medical Drug



ETOPOPHOS 3S

MED Medical Drug

etoposide 50 mg capsule 1 S

etoposide (100 mg/5 ml vial, 500 mg/25 ml vial, 1,000mg/50 ml vial) 1

S

MED Medical Drug

everolimus (5 mg tablet, 7.5 mg tablet) 1

QL 2 / day

S

PA

everolimus 2.5 mg tablet 1

QL 1 / day

S

PA

EVOMELA 3S

MED Medical Drug

exemestane 1PR

HCR

FARYDAK 3S

PA

FASLODEX 3

QL 1.25 / day

S

MED Medical Drug

PA

FEMARA 3PR

PA

floxuridine 1S

MED Medical Drug

fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) 1S

MED Medical Drug



FLUOROPLEX 3

fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5%topical soln) 1

fluorouracil (2.5 gm/50 ml btl, 2.5 gm/50 ml vial, 5gm/100 ml btl, 5 gm/100 ml vial, 500 mg/10 ml vial,1,000 mg/20 ml vl, 2,500 mg/50 ml vl, 5,000 mg/100 ml)

1S

MED Medical Drug

flutamide 1

FOLOTYN 3

S

MED Medical Drug

PA

fulvestrant 1

QL 1.25 / day

S

MED Medical Drug

PA

GAVRETO 3

QL 4 / day

S

PA

GAZYVA 3

S

MED Medical Drug

PA

gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram vial, hcl 1gram/10 ml, hcl 1.5 gram/15 ml, 2 gram/52.6 ml vl, hcl 2gram vial, hcl 2 gram/20 ml, 200 mg/5.26 ml vl, hcl 200mg vial, hcl 200 mg/2 ml vl)

1S

MED Medical Drug

GEMZAR 3S

MED Medical Drug

GILOTRIF 3

QL 1 / day

S

PA



GLEEVEC 100 MG TABLET 3

QL 8 / day

S

PA


GLEEVEC 400 MG TABLET 3

QL 2 / day

S

PA

GLEOSTINE 3

GLIADEL 3 MED Medical Drug

HALAVEN 3

S

MED Medical Drug

PA

HERCEPTIN 3

S

PA


HERCEPTIN HYLECTA 3

S

PA


HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 3S

PA

HYCAMTIN 4 MG VIAL 3

S

MED Medical Drug

PA

HYDREA 3

hydroxyurea 1



IBRANCE (100 MG CAPSULE, 100 MG TABLET) 3

QL 1.25 / day

S

PS

PA


QL 1.667 / day

S

PS

PA


QL 1 / day

S

PS

PA

ICLUSIG 15 MG TABLET 3

QL 2 / day

S

PA

ICLUSIG 45 MG TABLET 3

QL 1 / day

S

PA

IDAMYCIN PFS 3S

MED Medical Drug

idarubicin hcl 1S

MED Medical Drug

IDHIFA 3

QL 1 / day


S

PA

IFEX 3S

MED Medical Drug



ifosfamide (1 gm vial, 1 gm/20 ml vial, 3 gm vial, 3 gm/60ml vial) 1

S

MED Medical Drug

ifosfamide-mesna 1S

MED Medical Drug

imatinib mesylate 100 mg tab 1

QL 8 / day

S

PS

PA

imatinib mesylate 400 mg tab 1

QL 2 / day

S

PS

PA

IMBRUVICA (140 MG CAPSULE, 140 MG TABLET) 3

QL 4 / day

S

PA

IMBRUVICA 70 MG CAPSULE 3

QL 8 / day

S

PA

IMBRUVICA 280 MG TABLET 3

QL 2 / day

S

PA


QL 1.47 / day

S

PA


QL 1 / day

S

PA



IMFINZI 3S

MED Medical Drug

INLYTA 3

QL 4 / day

S

PA

INQOVI 3

QL 0.18 / day

S

PA

INREBIC 3

QL 4 / day

S

PA

IRESSA 3

QL 1 / day

S

PA

irinotecan hcl 1S

MED Medical Drug

ISTODAX 3

S

MED Medical Drug

PA

IXEMPRA 3

S

MED Medical Drug

PA

JAKAFI 3

QL 2 / day

S

PA

JELMYTO 3S

MED Medical Drug



JEVTANA 3

QL 0.15 / day

S

MED Medical Drug

PA

KADCYLA 3

S

MED Medical Drug

PA

KANJINTI 3

S

PS

PA


KEYTRUDA 3

S

MED Medical Drug

PA

KISQALI 200 MG DAILY DOSE 3

QL 1 / day


S

PA


QL 2 / day


S

PA


QL 3 / day


S

PA



KISQALI FEMARA 200 MG CO-PACK 3

QL 2 / day


S

PA


QL 2.5 / day


S

PA


QL 3.334 / day


S

PA

KOSELUGO 3

QL 4 / day

S

PA

KYPROLIS 3

S

MED Medical Drug

PA

lapatinib 3

QL 6 / day

S

PA

LENVIMA 3

QL 3 / day

S

PA

letrozole 1PR

HCR



LEUKERAN 3

LONSURF 15 MG-6.14 MG TABLET 3

QL 2.15 / day

S

PA

LONSURF 20 MG-8.19 MG TABLET 3

QL 3 / day

S

PA

LORBRENA 3

QL 1 / day

S

PA

LUMOXITI 3

S

MED Medical Drug

PA

LYNPARZA 3


S

PA

LYSODREN 3 S

MARQIBO 3

S

MED Medical Drug

PA

MATULANE 3 S

MEKINIST 0.5 MG TABLET 3

QL 4 / day

S

PA

MEKINIST 2 MG TABLET 3

QL 1 / day

S

PA



MEKTOVI 3S

PA

melphalan 1

melphalan hcl 1S

MED Medical Drug

mercaptopurine 1

methotrexate 2.5 mg tablet 1

methotrexate (1 gm vial, 50 mg/2 ml vial, 250 mg/10 mlvial) 1 BSP BENEFIT SHIFT

PROGRAM

methotrexate sodium 1 BSP BENEFIT SHIFTPROGRAM

mitomycin 1S

MED Medical Drug

mitoxantrone hcl 1

S

MED Medical Drug

PA

MONJUVI 3

QL 1.25 / day

S

MED Medical Drug

PA

MUSTARGEN 3S

MED Medical Drug

MUTAMYCIN 1S

MED Medical Drug

MVASI 3

S

PS

PA




MYLERAN 3 S

MYLOTARG 3S

MED Medical Drug

NAVELBINE 3S

MED Medical Drug

NERLYNX 3

QL 6 / day


S

PA

NEXAVAR 3

QL 4 / day

S

PA

NILANDRON 3S


nilutamide 1 S

NINLARO 3

QL 0.124 / day


S

PA

NIPENT 3S

MED Medical Drug

NUBEQA 3

QL 4 / day

S

PS

PA



ODOMZO 3

QL 1 / day

S

PA

OGIVRI 3

S

PA


ONCASPAR 3S

MED Medical Drug

ONUREG 3

QL 0.5 / day

S

PA

OPDIVO 3

S

MED Medical Drug

PA

OTREXUP 3QL 0.08 / day

PA

oxaliplatin (50 mg vial, 50 mg/10 ml vial, 100 mg vial, 100mg/20 ml vial) 1

S

MED Medical Drug

oxaliplatin 200 mg/40 ml vial 1S

MED Medical Drug

paclitaxel 1S

MED Medical Drug

PADCEV 3

S

MED Medical Drug

PA

PANRETIN 3



PARAPLATIN (50 MG/5 ML VIAL, 150 MG/15 ML VIAL, 450MG/45 ML VIAL, 600 MG/60 ML VIAL) 1

S

MED Medical Drug

PARAPLATIN 1,000 MG/100 ML VL 3S

MED Medical Drug

PEMAZYRE 3

QL 0.67 / day

S

PA

PERJETA 3

S

MED Medical Drug

PA

PHOTOFRIN 3S

MED Medical Drug

PICATO 3ST


PIQRAY (250 MG DAILY, 300 MG DAILY) 3

QL 2 / day

S

PA

PIQRAY 200 MG DAILY DOSE 3

QL 1 / day

S

PA

POLIVY 3

QL 1 / day

S

MED Medical Drug

PA

POMALYST 3

QL 1 / day

S

PA



PROLEUKIN 3

S

MED Medical Drug

PA

PURIXAN 3S

PA

QINLOCK 3

QL 3 / day

S

PA

RASUVO 3QL 0.08 / day

PA

RETEVMO 40 MG CAPSULE 3

QL 2 / day

S

PA

RETEVMO 80 MG CAPSULE 3

QL 4 / day

S

PA

REVLIMID 3

QL 1 / day

S

PA

RITUXAN 3

S

PA


RITUXAN HYCELA 3

S

PA


romidepsin (10 mg kit, 10 mg vial, 27.5 mg/5.5 ml vial) 3

S

MED Medical Drug

PA



ROZLYTREK 100 MG CAPSULE 3

QL 5 / day

S

PA

ROZLYTREK 200 MG CAPSULE 3

QL 3 / day

S

PA

RUBRACA 3

QL 2 / day


S

PA

RUXIENCE 3

S

PS

PA


RYDAPT 3

QL 2 / day


S

PA

SIKLOS 3 S

SOLARAZE 3

QL 100 / 30 days

PA



SPRYCEL (100 MG TABLET, 140 MG TABLET) 3

QL 1 / day

S

PA



SPRYCEL (70 MG TABLET, 80 MG TABLET) 3

QL 2 / day

S

PA

SPRYCEL 20 MG TABLET 3

QL 9 / day

S

PA

SPRYCEL 50 MG TABLET 3

QL 3 / day

S

PA

STIVARGA 3

QL 4 / day

S

PA

SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 3

QL 1 / day

S

PA

SUTENT 12.5 MG CAPSULE 3

QL 7 / day

S

PA

SUTENT 25 MG CAPSULE 3

QL 3 / day

S

PA

SYLVANT 3

S

MED Medical Drug

PA

SYNRIBO 3S

PA

TABLOID 3 S



TABRECTA 3

QL 4 / day

S

PA

TAFINLAR 50 MG CAPSULE 3

QL 6 / day

S

PA

TAFINLAR 75 MG CAPSULE 3

QL 4 / day

S

PA

TAGRISSO 3

QL 1 / day


S

PA

TALZENNA 3S

PA

TARCEVA (100 MG TABLET, 150 MG TABLET) 3

QL 1 / day

S

PA

TARCEVA 25 MG TABLET 3

QL 6 / day

S

PA

TARGRETIN 75 MG CAPSULE 3S

PA

TARGRETIN 1% GEL 3S

PA

TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 3

QL 4 / day

S

PA



TASIGNA 50 MG CAPSULE 3

QL 6 / day

S

PA

TAXOTERE 3S

MED Medical Drug

TAZVERIK 3S

PA

TECENTRIQ 3

S

MED Medical Drug

PA

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MGCAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MGCAPSULE)

3S

PA

TEMODAR 100 MG VIAL 3

S

MED Medical Drug

PA

temozolomide 1S

PA

temsirolimus 1

QL 0.29 / day

S

MED Medical Drug

PA

teniposide 1S

MED Medical Drug

TIBSOVO 3S

PA

TOLAK 3 QL 1.47 / day



TOPOSAR 1S

MED Medical Drug

topotecan hcl (1 mg/ml vial, 4 mg vial, 4 mg/4 ml vial) 1S

MED Medical Drug

TORISEL 3

QL 0.29 / day

S

MED Medical Drug

PA

TRAZIMERA 3

S

PS

PA


TREANDA 3

S

MED Medical Drug

PA

tretinoin 10 mg capsule 1QL 90 / 365 days

S

TREXALL 2

TRISENOX 3S

MED Medical Drug

TRODELVY 3

QL 0.58 / day

S

MED Medical Drug

PA

TUKYSA 3

QL 4 / day

S

PA



TURALIO 3

QL 4 / day

S

PA

TYKERB 3

QL 6 / day

S

PA

UNITUXIN 3

S

MED Medical Drug

PA

VALCHLOR 3

QL 3 / day

S

PA

valrubicin 1S

MED Medical Drug

VALSTAR 3S

MED Medical Drug

VECTIBIX 3

S

MED Medical Drug

PA

VELCADE 3

S

MED Medical Drug

PA

VENCLEXTA 3

QL 4 / day

S

PA

VENCLEXTA STARTING PACK 3

QL 1.5 / day

S

PA



VERZENIO 3

QL 2 / day


S

PA

VIDAZA 3S

MED Medical Drug

vinblastine sulfate 1S

MED Medical Drug

VINCASAR PFS 1S

MED Medical Drug

vincristine sulfate 1S

MED Medical Drug

vinorelbine tartrate 1S

MED Medical Drug

VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100MG CAPSULE) 3

QL 2 / day

S

PA

VIZIMPRO 3S

PA

VOTRIENT 3

QL 4 / day

S

PA

XALKORI 3

QL 2 / day

S

PA

XATMEP 3

QL 4 / day

AL Up to 18 yrs old

PA



XELODA 3

QL 4 / day

S

PA

XOSPATA 3

QL 3 / day

S

PA

XPOVIO (40 MG TWICE, 80 MG ONCE) 3

QL 0.574 / day

S

PA

XPOVIO 100 MG ONCE WEEKLY DOSE 3

QL 0.767 / day

S

PA


QL 0.267 / day

S

PA


QL 0.434 / day

S

PA

XPOVIO 60 MG TWICE WEEKLY DOSE 3

QL 0.8 / day

S

PA

XPOVIO 80 MG TWICE WEEKLY DOSE 3

QL 1.25 / day

S

PA

XTANDI 3

QL 4 / day

S

PA



YERVOY 3

S

MED Medical Drug

PA

YONSA 3

QL 4 / day

S

PA

ZALTRAP 3

S

MED Medical Drug

PA

ZANOSAR 3S

MED Medical Drug

ZEJULA 3

QL 3 / day


S

PA

ZELBORAF 3

QL 8 / day

S

PA

ZEPZELCA 3

QL 0.1 / day

S

MED Medical Drug

PA

ZEVALIN 3S

MED Medical Drug

ZIRABEV 3

S

PS

PA




ZOLINZA 3

QL 4 / day

S

PA

ZYDELIG 3

QL 2 / day

S

PA

ZYKADIA (150 MG CAPSULE, 150 MG TABLET) 3

QL 8 / day


S

PA

ZYTIGA 250 MG TABLET 3

QL 4 / day

S

PS

PA

B4G

ZYTIGA 500 MG TABLET 3

QL 2 / day

S

PS

PA

B4G

ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS)

amantadine (50 mg/5 ml solution, 100 mg capsule, 100mg tablet, 100 mg/10 ml soln) 1

GOCOVRI ER 137 MG CAPSULE 3

QL 2 / day

S

PA




GOCOVRI ER 68.5 MG CAPSULE 3

QL 1 / day

S

PA


OSMOLEX ER (ER 129 MG TABLET, ER 193 MG TABLET, ER258 MG TABLET) 3

QL 1 / day

S

PA

OSMOLEX ER 322 MG DAILY DOSE 3

QL 2 / day

S

PA

ANTICHOLINERGIC AGENTS (CNS)

benztropine 2 mg/2 ml ampule 1MED Medical Drug

HCG

benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet) 1

benztropine 2 mg/2 ml vial 1 MED Medical Drug

COGENTIN 3 MED Medical Drug

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mgtablet) 1

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

COMTAN 3

entacapone 1 HCG

ONGENTYS 3

TASMAR 3

tolcapone 1



DOPAMINE PRECURSORS

carbidopa-levodopa (carbidopa-levo 10-100 mg odt,carbidopa-levo 25-100 mg odt, carbidopa-levo 25-250 mgodt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa25-100 tab, carbidopa-levodopa 25-250 tab)

1

carbidopa-levodopa er 1

carbidopa-levodopa-entacapone 1

DUOPA 3

QL 1 / day

S

PA

INBRIJA 3

QL 1 / day

S

PA

RYTARY 3

SINEMET 10-100 3

SINEMET 25-100 3

SINEMET 25-250 3

SINEMET CR 3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

MONOAMINE OXIDASE B INHIBITORS

AZILECT 3



EMSAM 3 QL 1 / day

rasagiline mesylate 1

selegiline hcl (5 mg capsule, 5 mg tablet) 1

XADAGO 3

QL 1 / day


PA

ZELAPAR 3

ANTIPROTOZOALS

AMEBICIDES

paromomycin sulfate 1

ANTIMALARIALS

ARAKODA 3 PA

atovaquone-proguanil hcl 1 PA

chloroquine phosphate 1 PA

COARTEM 3

hydroxychloroquine sulfate 1 PA

KRINTAFEL 3

MALARONE 3 PA

mefloquine hcl 1

PLAQUENIL 3PA


primaquine 1

QUALAQUIN 3QL 42 / 365 days

PA



quinine sulfate 1QL 42 / 365 days

PA

ANTIPROTOZOALS, MISCELLANEOUS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3 PA

atovaquone 1 PA

benznidazole 2QL max 60 days

AL 2 to 12 yrs old

FLAGYL (250 MG TABLET, 375 CAPSULE) 3

FLAGYL 500 MG TABLET 3 SBA Select BrandAlternative

IMPAVIDO 3 S

LAMPIT 120 MG TABLET 3

QL 7.5

AL Up to 17 yrs old

PA

LAMPIT 30 MG TABLET 3

QL 12 / day

AL Up to 17 yrs old

PA

MEPRON 3 PA

METRO IV 3 MED Medical Drug

metronidazole 500 mg/100 ml 1 MED Medical Drug

metronidazole (250 mg tablet, 375 mg capsule, 500 mgtablet) 1

NEBUPENT 3 SBA SELECT BRANDALTERNATIVE

PENTAM 300 3 MED Medical Drug

pentamidine 300 mg vial 1 MED Medical Drug



pentamidine 300 mg inhal powdr 1

SOLOSEC 3QL 1/ fill

GL Female

TINDAMAX 3

tinidazole 1

ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

ADASUVE 3AL At least 18 yrs

oldPR

loxapine 1AL At least 18 yrs

oldPR

molindone hcl 1

ORAP 3

pimozide 1

ATYPICAL ANTIPSYCHOTICS

ABILIFY 3

QL 1 / day

ST


PR


ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER400 MG SYR, ER 400 MG VL) 3

QL 0.04 / day


PR

PA



ABILIFY MYCITE 3

QL 1 / day

ST


PR

PA

aripiprazole 1 mg/ml solution 1

QL 30 / day


PR

aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15mg tablet, 20 mg tablet, 30 mg tablet) 1

QL 1 / day


PR

aripiprazole odt 1

QL 1 / day


PR

ARISTADA ER 1064 MG/3.9 ML SYR 3

QL 0.15 / day


PA

ARISTADA ER 441 MG/1.6 ML SYRN 3

QL 0.07 / day


PA


QL 0.08 / day


PA


QL 0.12 / day


PA



ARISTADA INITIO 3

QL 0.08 / day


PA

CAPLYTA 3

QL 1 / day


PR

PA

clozapine 100 mg tablet 1

QL 9 / day


PR


QL 4 / day


PR


QL 18 / day


PR


QL 3 / day


PR

clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt150 mg tablet, odt 200 mg tablet) 1

QL 3 / day


PR

clozapine odt 100 mg tablet 1

QL 9 / day


PR



CLOZARIL 100 MG TABLET 3

QL 9 / day


PR


QL 4 / day


PR


QL 18 / day


PR


QL 3 / day


PR

FANAPT TITRATION PACK 3

QL 8 / rx

ST


PR

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MGTABLET)

3

QL 2 / day

ST


PR

FAZACLO (12.5 MG ODT, 25 MG ODT, 150 MG ODT, 200MG ODT) 3

QL 3 / day


PR

FAZACLO 100 MG ODT 3

QL 9 / day


PR



GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE, 80 MG CAPSULE) 3

QL 2 / day

ST


PR

GEODON 20 MG/ML VIAL 3ST

PR

INVEGA ER 1.5 MG TABLET 3

QL 8 / day

ST


PR

INVEGA ER 3 MG TABLET 3

QL 4 / day

ST


PR


QL 2 / day

ST


PR


QL 1 / day

ST


PR

INVEGA SUSTENNA 117 MG/0.75 ML 3

QL 0.0333 / day


PR

PA



INVEGA SUSTENNA 156 MG/ML SYRG 3

QL 0.04 / day


PR

PA


QL 0.057 / day


PR

PA


QL 0.0111 / day


PR

PA


QL 0.02 / day


PR

PA

INVEGA TRINZA 273 MG/0.875 ML 3

QL 0.0333 / day


PA


QL 0.057 / day


PA


QL 0.067 / day


PA




QL 0.1 / day


PA

LATUDA 3

QL 1 / day


PR

NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 3

QL 1 / day

S

PA

NUPLAZID 17 MG TABLET 3

QL 2 / day

S

PA

olanzapine (2.5 mg tablet, 5 mg tablet) 1QL 6 / day

PR

olanzapine 10 mg tablet 1QL 3 / day

PR


PR


PR

olanzapine 7.5 mg tablet 1QL 4 / day

PR

olanzapine 10 mg vial 1 PR

olanzapine odt 10 mg tablet 1QL 3 / day

PR


PR




PR


PR

paliperidone er 1.5 mg tablet 1

QL 8 / day


PR

paliperidone er 3 mg tablet 1

QL 4 / day


PR


QL 2 / day


PR


QL 1 / day


PR

PERSERIS 3

QL 0.0333 / day


PR

PA

quetiapine fumarate (25 mg tab, 50 mg tab) 1

QL 6 / day


PR

quetiapine fumarate 100 mg tab 1

QL 3 / day


PR




QL 1.5 / day


PR


QL 1 / day


PR


QL 2 / day


PR

quetiapine er 150 mg tablet 1

QL 5 / day


PR


QL 4 / day


PR


QL 6 / day


PR

quetiapine fumarate er (er 300 mg tablet, er 400 mgtablet) 1

QL 2 / day


PR

REXULTI 3

QL 1 / day


PA



RISPERDAL 1 MG/ML SOLUTION 3

QL 16/day

ST


PR


RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MGTABLET, 2 MG TABLET) 3

QL 8 / day

ST


PR


RISPERDAL 3 MG TABLET 3

QL 5 / day

ST


PR


RISPERDAL 4 MG TABLET 3

QL 4 / day

ST


PR


RISPERDAL CONSTA 3

QL 0.1 / day


PR

PA



risperidone 1 mg/ml solution 1

QL 16/day


PR

risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2mg tablet) 1

QL 8 / day


PR

risperidone 3 mg tablet 1

QL 5 / day


PR

risperidone 4 mg tablet 1

QL 4 / day


PR

risperidone 3 mg odt 1

QL 5 / day


PR

risperidone 4 mg odt 1

QL 4 / day


PR

risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mgodt) 1

QL 8 / day


PR

SAPHRIS 2

QL 2 / day


PR



SECUADO 3QL 1 / day

ST

SEROQUEL (25 MG TABLET, 50 MG TABLET) 3

QL 6 / day

ST


PR


SEROQUEL 100 MG TABLET 3

QL 3 / day

ST


PR



QL 1.5 / day

ST


PR



QL 1 / day

ST


PR



QL 2 / day

ST


PR




SEROQUEL XR SAMPLE KIT 3 AL At least 10 yrsold

SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 3

QL 2 / day

ST


PR


SEROQUEL XR 150 MG TABLET 3

QL 5 / day

ST


PR



QL 4 / day

ST


PR



QL 6 / day

ST


PR


VERSACLOZ 3

QL 20 / day


PR



VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK, 3 MGCAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE) 3

QL 1 / day

ST


ziprasidone hcl 1

QL 2 / day


PR

ziprasidone mesylate 1 PR

ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3

QL 6 / day

ST


PR


ZYPREXA 10 MG TABLET 3

QL 3 / day

ST


PR



QL 2 / day

ST


PR



QL 1 / day

ST


PR




ZYPREXA 7.5 MG TABLET 3

QL 4 / day

ST


PR


ZYPREXA 10 MG VIAL 3

ST


PR


ZYPREXA RELPREVV 3

QL 0.08 / day


PR

PA

ZYPREXA ZYDIS 10 MG TABLET 3

QL 3 / day


PR


QL 2 / day


PR


QL 1 / day


PR


QL 6 / day


PR



BUTYROPHENONES

HALDOL 3MED Medical Drug

PR

HALDOL DECANOATE 100 3

HALDOL DECANOATE 50 3

haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10mg tablet, 20 mg tablet) 1 PR

haloperidol 1 mg tablet 1 PR

haloperidol decanoate (dec 50 mg/ml vial, dec 100 mg/mlamp, dec 100 mg/ml vial, dec 250 mg/5 ml vl, dec 500mg/5 ml vl, decan 50 mg/ml amp)

1 PR

haloperidol decanoate 100 1 PR

haloperidol lac 5 mg/ml ampul 1 PR

haloperidol lac 2 mg/ml conc 1

haloperidol lac 5 mg/ml syring 1

haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl) 1 MED Medical Drug

PHENOTHIAZINES

chlorpromazine hcl (25 mg/ml amp, 25 mg/ml ampule, 50mg/2 ml amp) 1

MED Medical Drug

PR

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1 PR

fluphenazine decanoate 1PR


fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 mlelix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 PR

fluphenazine 2.5 mg/ml vial 1PR




perphenazine 1AL At least 12 yrs

oldPR

thioridazine hcl 1 PR

trifluoperazine hcl 1 PR

THIOXANTHENES

thiothixene 1 PR

ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

FUZEON 3

QL 2 / day

S

PR

RUKOBIA 3S

PR

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET, 150 MG TABLET, 300 MG TABLET) 3

S

PR

HIV INTEGRASE INHIBITOR ANTIRETROVIRALS

DOVATO 3QL 1 / day

S

ISENTRESS 100 MG POWDER PACKET 3 S

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW,400 MG TABLET) 3

S

PR

ISENTRESS HD 3S

PR

JULUCA 3QL 1 / day

S



TIVICAY 3S

PR

TIVICAY PD 3S

PR

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

DELSTRIGO 3S

PR

EDURANT 3S

PR

efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) 1

S

PR

PS

INTELENCE 3S

PR

nevirapine (50 mg/5 ml susp, 200 mg tablet) 1

S

PR

PS

nevirapine er 1

S

PR

PS

PIFELTRO 3S

PR

RESCRIPTOR 3S

PR

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MGTABLET) 3

S

PR



SYMFI 3

S

PS

B4G

SYMFI LO 3

S

PS

B4G

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3S

PR

VIRAMUNE XR 3S

PR

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

abacavir (20 mg/ml solution, 300 mg tablet) 1

S

PR

PS

abacavir-lamivudine 1

S

PR

PS

abacavir-lamivudine-zidovudine 1

S

PR

PS

ATRIPLA 3

ST

S

PR

BIKTARVY 3 S

CIMDUO 3

S

PR

PS



COMBIVIR 3S

PR

COMPLERA 3S

PR

DESCOVY 3

QL 1 / day

S

HCR

didanosine 1

S

PR

PS

emtricitabine 1S

PR

emtricitabine-tenofovir disop 1

S

PR

HCR

PS

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3S

PR

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET) 3

S

PR

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3S

PR

EPZICOM 3S

PR

GENVOYA 3 S

lamivudine 10 mg/ml oral soln 1S

PS



lamivudine (150 mg tablet, 300 mg tablet) 1

S

PR

PS

lamivudine 100 mg tablet 1S

PR

lamivudine hbv 1S

PR

lamivudine-zidovudine 1

S

PR

PS

ODEFSEY 3 S

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3S

PR

RETROVIR 200 MG/20 ML VIAL 3

S

MED Medical Drug

PR

stavudine 1

S

PR

PS

STRIBILD 3S

PR

TEMIXYS 3QL 1 / day

S

tenofovir disoproxil fumarate 1

S

PR

PS

TRIUMEQ 3 S



TRIZIVIR 3S

PR

TRUVADA 3S

PR

VIDEX 3S

PR

VIDEX EC 3S

PR

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, 300 MG TABLET, POWDER) 3

S

PR

ZERIT 3S

PR

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3S

PR

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mgtablet) 1

S

PR

PS

HIV PROTEASE INHIBITOR ANTIRETROVIRALS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3S

PR

atazanavir sulfate 1

S

PR

PS

CRIXIVAN 3S

PR

EVOTAZ 3 S



fosamprenavir calcium 1

S

PR

PS

INVIRASE 3S

PR

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET,200-50 MG TABLET) 3

S

PR

PA

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3S

PR

lopinavir-ritonavir 1

S

PS

PA

NORVIR (80 MG/ML SOLUTION, 100 MG POWDERPACKET, 100 MG TABLET) 3

S

PR

PREZCOBIX 3 S

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET) 3

S

PR

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 3

S

PR

REYATAZ 50 MG POWDER PACKET 3 S

ritonavir 1

S

PR

PS

SYMTUZA 3S

PR



VIRACEPT 3S

PR

ANTITHROMBOTIC AGENTS

ANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI (11 MG KIT, 11 MG VIAL) 3 S

PLATELET-AGGREGATION INHIBITORS

AGGRASTAT (3.75 MG/15 ML VIAL, 5 MG/100 ML VIAL,12.5 MG/250 ML) 3 MED Medical Drug

BRILINTA 2QL 2 / day

PR

cilostazol 1QL 2 / day

PR

clopidogrel 1QL 1 / day

PR

EFFIENT 3

QL 1 / day

PR


eptifibatide (20 mg/10 ml vial, 75 mg/100 ml bag, 75mg/100 ml vial, 200 mg/100 ml vl) 1 MED Medical Drug

INTEGRILIN 3 MED Medical Drug

KENGREAL 3 MED Medical Drug

PLAVIX 3

QL 1 / day

ST

PR




prasugrel hcl 1QL 1 / day

PR

REOPRO 3 MED Medical Drug

ZONTIVITY 3QL 1 / day

PA

PLATELET-REDUCING AGENTS

AGRYLIN 3 QL 4 / day

anagrelide hcl 1 QL 4 / day

THROMBOLYTIC AGENTS

ACTIVASE 3S

MED Medical Drug

CATHFLO ACTIVASE 3S

MED Medical Drug

TNKASE 50 MG KIT 3 MED Medical Drug

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ALLERGENIC EXTRACTS (THERAPEUTIC)

aspergillus fumigatus 3 MED Medical Drug

aureobasidium pullulans 3 MED Medical Drug

botrytis cinerea 3 MED Medical Drug

cladosporium cladosporioides 3 MED Medical Drug

epicoccum nigrum 3 MED Medical Drug

GRASTEK 3QL 1 / day

PA

mixed vespid venom 3,900 mcg 1 MED Medical Drug



mucor plumbeus 3 MED Medical Drug

ODACTRA 3QL 1 / day

PA

ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULTSAMPLE KT, 300 IR STARTER PACK, 300 IR SUBLINGUALTAB)

3S

PA

ORALAIR 100 IR STARTER PACK 3 S

PALFORZIA (3 MG 1), 12 MG 3)) 3

QL 1.5 / day

S

PA

PALFORZIA (40 MG (LEVEL 5), 120 MG (LEVEL 7), 200 MG(LEVEL 9), 300 MG (MAINTENANCE)) 3

QL 31 / 30 days

S

PA

PALFORZIA (80 MG 6), 160 MG 8), 240 MG 10)) 3

QL 2 / day

S

PA

PALFORZIA 6 MG (LEVEL 2) 3

QL 3 / day

S

PA

PALFORZIA INITIAL DOSE PACK 3

QL 0.434 / day

S

PA

PALFORZIA (20 MG 4), 300 MG 11)) 3

QL 15 / 30 days

S

PA

penicillium notatum 3 MED Medical Drug

RAGWITEK 3QL 1 / day

PA



saccharomyces cerevisiae 3 MED Medical Drug

trichophyton mentagrophytes 3 MED Medical Drug

ANTITOXINS AND IMMUNE GLOBULINS

ASCENIV 3

S

MED Medical Drug

PA

BIVIGAM 3

S

PA


CUTAQUIG 3

S

PS

PA

CUVITRU 3S

PA

CYTOGAM 3S

MED Medical Drug

FLEBOGAMMA DIF 3

S

PA


GAMASTAN 3

S

MED Medical Drug

PA

GAMASTAN S-D 3

S

MED Medical Drug

PA

GAMMAGARD LIQUID 3S

PA



GAMMAGARD S-D 3

S

MED Medical Drug

PA

GAMMAKED 3S

PA

GAMMAPLEX (5 GRAM/100 ML VIAL, 5 GRAM/50 MLVIAL, 10 GRAM/100 ML VIAL, 10 GRAM/200 ML VIAL, 20GRAM/200 ML VIAL, 20 GRAM/400 ML VIAL)

3

S

PA


GAMUNEX-C 3S

PA

HEPAGAM B 3S

MED Medical Drug

HIZENTRA (1 GRAM/5 ML SYRINGE, 1 GRAM/5 ML VIAL, 2GRAM/10 ML SYRINGE, 2 GRAM/10 ML VIAL, 4 GRAM/20ML SYRINGE, 4 GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL)

3S

PA

HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 3S

MED Medical Drug

HYPERRAB 3S

MED Medical Drug

HYPERRAB S-D 3S

MED Medical Drug

HYPERRHO S-D 3S

MED Medical Drug

HYPERTET S-D 3S

MED Medical Drug

HYQVIA 3S

PA



HYQVIA IG COMPONENT 3S

PA

IMOGAM RABIES-HT 3S

MED Medical Drug

KEDRAB 3S

MED Medical Drug

MICRHOGAM ULTRA-FILTERED PLUS 3S

MED Medical Drug

NABI-HB 3S

MED Medical Drug

OCTAGAM 3

S

PS

PA


PANZYGA 3

S

MED Medical Drug

PA

PRIVIGEN 3

S

PA


RHOGAM ULTRA-FILTERED PLUS 3S

MED Medical Drug

RHOPHYLAC 3S

MED Medical Drug

VARIZIG 3S

MED Medical Drug



WINRHO SDF 3S

MED Medical Drug

XEMBIFY 3S

PA

TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 2 HCR

BOOSTRIX TDAP (SYRINGE, VIAL) 2 HCR

DAPTACEL DTAP 2 HCR

diphtheria-tetanus toxoids-ped 1

INFANRIX DTAP (SYRINGE, VIAL) 2

tdvax 1 HCR

TENIVAC (SYRINGE, VIAL) 2 HCR

VACCINES

ACTHIB VACCINE WITH DILUENT 2

AFLURIA QUAD 2019-20 (3YR UP) 2AL At least 3 yrs

oldHCR

AFLURIA QUAD 2019-20 (6-35MO) 2AL Up to 3 yrs old

HCR

AFLURIA QUAD 2019-2020 2 HCR

AFLURIA QUAD 2020-2021 2 HCR

AFLURIA QUAD 2020-21 (3YR UP) 2AL At least 3 yrs

oldHCR

AFLURIA QUAD 2020-21 (6-35MO) 2AL Up to 3 yrs old

HCR



bcg vaccine (tice strain) 3 MED Medical Drug

BEXSERO 2

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 2 HCR

ENGERIX-B PEDIATRIC-ADOLESCENT 2 HCR

FLUAD 2019-2020 2AL At least 65 yrs

oldHCR

FLUAD 2020-2021 2AL At least 65 yrs

oldHCR

FLUAD QUAD 2020-2021 2AL At least 65 yrs

oldHCR

FLUARIX QUAD 2019-2020 2 HCR

FLUARIX QUAD 2020-2021 2 HCR

FLUBLOK QUAD 2019-2020 2AL At least 18 yrs

oldHCR

FLUBLOK QUAD 2020-2021 2AL At least 18 yrs

oldHCR

FLUCELVAX QUAD 2019-2020 (2019-2020 SYR, 2019-2020VIAL) 2


HCR

FLUCELVAX QUAD 2020-2021 (2020-2021 SYR, 2020-2021VIAL) 2


HCR

FLULAVAL QUAD 2019-2020 (2019-2020 SYR, 2019-2020VIAL) 2 HCR



FLULAVAL QUAD 2020-2021 2 HCR

FLUMIST QUAD 2019-2020 2AL 2 to 49 yrs old

HCR

FLUMIST QUAD 2020-2021 2AL 2 to 49 yrs old

HCR

FLUZONE HIGH-DOSE 2019-2020 2AL At least 65 yrs

oldHCR

FLUZONE HIGH-DOSE QUAD 2020-21 2AL At least 65 yrs

oldHCR

FLUZONE QUAD 2019-2020 (2019-2020 SYRINGE, 2019-2020 VIAL) 2 HCR

FLUZONE QUAD 2020-2021 (2020-2021 SYRINGE, 2020-2021 VIAL) 2 HCR

FLUZONE QUAD PEDI 2019-2020 2AL Up to 3 yrs old

HCR

GARDASIL 9 (9 SYRINGE, 9 VIAL) 2 HCR

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 MLVIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 2 HCR

HEPLISAV-B 20 MCG/0.5 ML SYRNG 2 HCR

HEPLISAV-B 20 MCG/0.5 ML VIAL 2 HCR

HIBERIX 2

IMOVAX RABIES VACCINE 2

IPOL (SINGLE DOSE SYRINGE, VIAL) 2

IXIARO 2

KINRIX (TIP-LOK SYRINGE, VIAL) 2



M-M-R II VACCINE 2 HCR

MENACTRA 2 HCR

MENQUADFI 2

MENVEO A-C-Y-W-135-DIP 2 HCR

MENVEO MENA COMPONENT 2

MENVEO MENCYW-135 COMPONENT 2

PEDIARIX 2

PEDVAXHIB 2

PENTACEL 2

PENTACEL ACTHIB COMPONENT 3

PENTACEL DTAP-IPV COMPONENT 2

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 2 HCR

PREVNAR 13 2 HCR

PROQUAD 2

QUADRACEL DTAP-IPV 2

RABAVERT 2

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL,10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 2 HCR

ROTARIX 2

ROTATEQ 2

SHINGRIX 2AL At least 50 yrs

oldHCR

SHINGRIX GE ANTIGEN COMPONENT 2AL At least 50 yrs

oldHCR



STAMARIL 2

TRUMENBA 3

TWINRIX 2 HCR

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 2 HCR

VARIVAX VACCINE 2 HCR

VAXCHORA ACTIVE COMPONENT 2

VAXCHORA VACCINE 2

VIVOTIF 2

YF-VAX 2

ZOSTAVAX 2 HCR

ANTIULCER AGENTS AND ACID SUPPRESSANTS

ANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA 3 QL 12 / day

HISTAMINE H2-ANTAGONISTS

cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 mlsoln, 400 mg tablet, 800 mg tablet) 1

famotidine 40 mg/5 ml susp 1 HCG

famotidine 20 mg piggyback 1

MED Medical Drug

HCG


famotidine (20 mg tablet, 40 mg tablet) 1

famotidine (20 mg/2 ml syringe, 20 mg/2 ml vial, 40 mg/4ml vial, 200 mg/20 ml vial, 500 mg/50 ml vial) 1 MED Medical Drug



famotidine-0.9% nacl 1 MED Medical Drug

nizatidine 150 mg capsule 1 QL 2 / day

nizatidine 300 mg capsule 1

nizatidine 15 mg/ml solution 1 HCG

PEPCID (20 MG TABLET, 40 MG TABLET, 40 MG/5 MLORAL SUSP) 3



ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mgtablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mgtablet)

1

ranitidine hcl (hcl 50 mg/2 ml vial, hcl 150 mg/6 ml vl,1,000 mg/40 ml vial) 1 MED Medical Drug

ZANTAC 300 MG TABLET 3 SBA Select BrandAlternative

ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL, 1,000MG/40 ML VIAL) 3

MED Medical Drug


PROSTAGLANDINS

CYTOTEC 3

misoprostol 1

PROTECTANTS

CARAFATE 1 GM/10 ML SUSP 2

CARAFATE 1 GM TABLET 3 SBA Select BrandAlternative

sucralfate (1 gm tablet, 1 gm/10 ml susp) 1

PROTON-PUMP INHIBITORS

ACIPHEX 3

QL 2 / day

ST




ACIPHEX SPRINKLE 3QL 1 / day

ST

DEXILANT 2QL 1 / day

ST

esomeprazole magnesium (dr 20 mg cap, dr 40 mg cap) 1 QL 1 / day

esomeprazole magnesium (dr 10 mg packet, dr 20 mgpacket, dr 40 mg packet) 1

QL 1 / day

HCG

esomeprazole sodium 1 MED Medical Drug

esomeprazole strontium 1

QL 1 / day

ST

HCG


lansoprazol-amoxicil-clarithro 1 QL 112 / 365 days

lansoprazole dr 15 mg capsule 1

lansoprazole (dr 30 mg capsule, odt 15 mg tablet, odt 30mg tablet) 1 QL 1 / day

NEXIUM (DR 20 MG CAPSULE, DR 40 MG CAPSULE) 3

QL 1 / day

ST


NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET, DR 10MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET) 3

QL 1 / day

ST

NEXIUM I.V. 3 MED Medical Drug

OMECLAMOX-PAK 3 QL 80 / 365 days

omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule) 1 QL 1 / day



omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680pkt, 40-1,100 cap, 40-1,680 pkt) 1

ST

HCG


pantoprazole 40 mg suspension 1

pantoprazole sod dr 20 mg tab 1 QL 1 / day

pantoprazole sod dr 40 mg tab 1 QL 2 / day

pantoprazole sodium 40 mg vial 1 MED Medical Drug

PREVACID (15 MG SOLUTAB, DR 15 MG CAPSULE, 30 MGSOLUTAB, DR 30 MG CAPSULE) 3

QL 1 / day

ST


PRILOSEC 3 ST

PROTONIX 40 MG SUSPENSION 3QL 1 / day

ST

PROTONIX DR 20 MG TABLET 3

QL 1 / day

ST


PROTONIX DR 40 MG TABLET 3

QL 2 / day

ST


PROTONIX IV 3 MED Medical Drug

rabeprazole sod dr 20 mg tab 1 QL 2 / day

ZEGERID (20 MG CAPSULE, 40 MG CAPSULE) 3

ST





ZEGERID 20 MG PACKET 3ST


ZEGERID 40 MG PACKET 3

QL 1 / day

ST


ANTIVIRALS (SYSTEMIC)

ADAMANTANE ANTIVIRALS

FLUMADINE 3

rimantadine hcl 1

ANTIVIRALS, MISCELLANEOUS

FOSCAVIR 3 MED Medical Drug

PREVYMIS (240 MG TABLET, 480 MG TABLET) 3


S

PA

PREVYMIS (240 MG/12 ML VIAL, 480 MG/24 ML VIAL) 3


S

MED Medical Drug

PA

XOFLUZA 3 QL 2 / fill

INTERFERON ANTIVIRALS

ALFERON N 3S

MED Medical Drug

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)

3S

PA



PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 3S

PA

PEGASYS PROCLICK 3S

PA

PEGINTRON 3S

PA

SYLATRON 3S

PA

MONOCLONAL ANTIBODY ANTIVIRALS

SYNAGIS 3S

PA

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75mg capsule) 1 QL 20 / 365 days

oseltamivir 6 mg/ml suspension 1 QL 180 / 30 days

RELENZA 3 QL 40 / 365 days

TAMIFLU (30 MG CAPSULE, 45 MG CAPSULE, 75 MGCAPSULE) 3

QL 20 / 365 days

ST

TAMIFLU 6 MG/ML SUSPENSION 3QL 180 / 30 days

ST

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS

acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mgtablet, 800 mg tablet) 1

acyclovir sodium (sodium 1 gm vial, 500 mg/10 ml vial,sodium 500 mg vial, 1,000 mg/20 ml vial) 1 MED Medical Drug

acyclovir sodium-0.9% nacl 1 MED Medical Drug



acyclovir sodium-d5w 1 MED Medical Drug

adefovir dipivoxil 1 S

BARACLUDE 0.05 MG/ML SOLUTION 3

QL 20 / day

S

PA

BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3

QL 1 / day

S

PA

cidofovir 1S

MED Medical Drug

CYTOVENE 3S

MED Medical Drug

entecavir 1QL 1 / day

S

famciclovir 1

ganciclovir 1S

MED Medical Drug

ganciclovir sodium (500 mg vial, 500 mg/10 ml vial) 1S

MED Medical Drug

HEPSERA 3

QL 1 / day

S

PA

MODERIBA 1

QL 6 / day

S

PA

REBETOL 3

QL 30 / day

S

PA



RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1

QL 6 / day

S

PA

RIBASPHERE 400 MG TABLET 3

QL 3 / day

S

PA

RIBASPHERE 600 MG TABLET 3

QL 2 / day

S

PA

RIBASPHERE RIBAPAK 3

QL 2 / day

S

PA

ribavirin (200 mg capsule, 200 mg tablet) 1

QL 6 / day

S

PA

ribavirin 6 gm inhalation vial 1

SITAVIG 3

QL 2 / fill


PA


valacyclovir 1

VALCYTE 50 MG/ML SOLUTION 3 SBA Select BrandAlternative

VALCYTE 450 MG TABLET 3QL 4 / day


valganciclovir hcl 50 mg/ml 1



valganciclovir 450 mg tablet 1 QL 4 / day

VALTREX 3ST


VEMLIDY 3

QL 1 / day


S

PA

VIRAZOLE 3

ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MGTABLET, 800 MG TABLET) 3 SBA Select Brand

Alternative

ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

AMBIEN 3

QL 1 / day

ST



AMBIEN CR 3

QL 1 / day

ST



BELSOMRA 3 ST

buspirone hcl 1

DAYVIGO 3QL 1 / day

ST



dexmedetomidine 200 mcg/2 ml 1 MED Medical Drug

droperidol (5 mg/2 ml ampul, 5 mg/2 ml vial) 1 MED Medical Drug

EDLUAR 3

QL 1 / day

ST


eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day

eszopiclone 3 mg tablet 1QL 1 / day

AL Up to 65 yrs old

HETLIOZ 3

QL 1 / day

S

PA

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl10 mg tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50mg tablet)

1 AL At least 2 yrsold

hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100 mg/2ml vial, 500 mg/10 ml vial) 1


MED Medical Drug

hydroxyzine pam 100 mg cap 1

hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrsold

INTERMEZZO 3

QL 1 / day

ST



LUNESTA (1 MG TABLET, 2 MG TABLET) 3

QL 1 / day

ST




LUNESTA 3 MG TABLET 3

QL 1 / day

ST

AL Up to 65 yrs old


meprobamate 1

PRECEDEX (80 MCG/20 ML VIAL, 200 MCG/2 ML VIAL, 200MCG/50 ML INJECT, 400 MCG/100 ML INJECT, 1,000MCG/250 ML BTL)

3 MED Medical Drug

ramelteon 1 QL 1 / day

ROZEREM 3

QL 1 / day

ST


VISTARIL 3 AL At least 2 yrsold

zaleplon 1 QL 1 / day

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1 QL 1 / day

zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) 1QL 1 / day

HCG

zolpidem tartrate er 1 QL 1 / day

ZOLPIMIST 3QL 0.257 / day


BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

NEMBUTAL SODIUM 3 MED Medical Drug



phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mgtablet, 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet)

1

phenobarbital sodium 1 MED Medical Drug

SECONAL SODIUM 3

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 4 / day

alprazolam 2 mg tablet 1 QL 5 / day

alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 1 / day

alprazolam er 2 mg tablet 1 QL 5 / day

alprazolam er 3 mg tablet 1 QL 3 / day

ALPRAZOLAM INTENSOL 3 QL 10 / day

alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1mg tab) 1 QL 4 / day

alprazolam odt 2 mg tab 1 QL 5 / day

alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 1 / day

alprazolam xr 2 mg tablet 1 QL 5 / day

alprazolam xr 3 mg tablet 1 QL 3 / day

ATIVAN (0.5 MG TABLET, 1 MG TABLET) 3

QL 3 / day



ATIVAN 2 MG TABLET 3

QL 5 / day





ATIVAN (4 MG/ML VIAL, 40 MG/10 ML VIAL) 3 MED Medical Drug

ATIVAN 2 MG/ML VIAL 3MED Medical Drug


chlordiazepoxide 10 mg capsule 1 QL 30 / day



clorazepate 15 mg tablet 1 QL 6 / day

clorazepate 3.75 mg tablet 1 QL 24 / day

clorazepate 7.5 mg tablet 1 QL 12 / day

DIASTAT 3 QL 0.07 / day

DIASTAT ACUDIAL 3 QL 0.07 / day

diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst) 1 QL 0.07 / day

diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5mg/ml oral conc, 10 mg tablet) 1

diazepam (10 mg/2 ml carpuject, 10 mg/2 ml syringe, 50mg/10 ml vial) 1 MED Medical Drug

DORAL 3 QL 1 / day

estazolam 1 QL 1 / day

flurazepam hcl 1 QL 1 / day

HALCION 3QL 2 / day


lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 QL 5 / day

lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day



lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 4 mg/mlcarpuject, 4 mg/ml vial, 40 mg/10 ml vial) 1 MED Medical Drug

lorazepam (2 mg/ml vial, 20 mg/10 ml vial) 1 MED Medical Drug

LORAZEPAM INTENSOL 1 QL 5 / day

lorazepam-0.9% nacl 1 MED Medical Drug

lorazepam-d5w 1 MED Medical Drug

midazolam hcl 2 mg/ml syrup 1

midazolam 55 mg/55 ml-0.9%nacl 1 MED Medical Drug

midazolam 50 mg/50 ml-d5w bag 1 MED Medical Drug

midazolam-0.9% nacl 1 MED Medical Drug

oxazepam 1 QL 4 / day

quazepam 1 QL 1 / day

RESTORIL 3QL 1 / day

ST

temazepam 1 QL 1 / day

TRANXENE T-TAB 3 QL 12 / day

triazolam 0.125 mg tablet 1 QL 1 / day

triazolam 0.25 mg tablet 1 QL 2 / day

VALIUM 3 SBA Select BrandAlternative

VALTOCO 3 QL 10 / 30 days

XANAX (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET) 3QL 4 / day


XANAX 2 MG TABLET 3QL 5 / day




XANAX XR (0.5 MG TABLET, 1 MG TABLET) 3QL 1 / day


XANAX XR 2 MG TABLET 3QL 5 / day


XANAX XR 3 MG TABLET 3QL 3 / day


AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 3 HCR

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1MG TABLET) 3

QL 2 / day

HCR

NICOTROL 3 QL 16/day

NICOTROL NS 3 QL 20 / day

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

ARICEPT 3 AL At least 40 yrsold

bethanechol chloride 1

BLOXIVERZ 3 MED Medical Drug

cevimeline hcl 1

donepezil hcl 1 AL At least 40 yrsold

donepezil hcl odt 1 AL At least 40 yrsold

EVOXAC 3 SBA Select BrandAlternative



EXELON 3 AL At least 40 yrsold

galantamine er 1 AL At least 40 yrsold

galantamine hbr 1 AL At least 40 yrsold

galantamine hydrobromide 1 AL At least 40 yrsold

guanidine hcl 1

MESTINON (60 MG TABLET, 60 MG/5 ML SOLUTION, 180MG TIMESPAN) 3 SBA Select Brand

Alternative

neostigmine methylsulfate (2 mg/2 ml syringe, 4 mg/4 mlsyringe, 5 mg/10 ml vial, 5 mg/5 ml syringe, 10 mg/10 mlvial)

1 MED Medical Drug

physostigmine salicylate 1 MED Medical Drug

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

pyridostigmine br 30 mg tablet 1 HCG

pyridostigmine bromide (60 mg/5 ml soln, br 60 mgtablet) 1

pyridostigmine bromide er 1 HCG

RAZADYNE 3 AL At least 40 yrsold

RAZADYNE ER 3 AL At least 40 yrsold

REGONOL 3 MED Medical Drug

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)


SALAGEN 3



URECHOLINE 3

BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ 2 QL 1 / day

BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol hfa 90 mcg inhaler (par) 1QL 0.6 / day

PR

albuterol hfa 90 mcg inhaler (perrigo) 1QL 0.8 / day

PR

albuterol hfa 90 mcg inhaler (prasco) 3

QL 1.5 / day

PR

PA

albuterol hfa 90 mcg inhaler (teva) 1QL 0.8 / day

PR

albuterol sulfate (2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln,5 mg/ml solution, 100 mg/20 ml soln) 1

QL 18 / day

PR

albuterol sulfate (sulf 2 mg/5 ml syrup, sulfate er 4 mgtab, sulfate er 8 mg tab) 1 PR

albuterol sulfate (2 mg tab, 4 mg tab) 1 PR

albuterol sulfate (0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 1QL 18 / day

PR

albuterol sulfate hfa 1QL 1.5 / day

PR

ARCAPTA NEOHALER 3

QL 1 / day

ST

PR



BROVANA 3QL 4 / day

PR

levalbuterol concentrate 1 PR

levalbuterol hcl 1 PR

levalbuterol tartrate hfa 3

QL 1.5 / day

PR

PA

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20mg tablet) 1 PR

PERFOROMIST 3QL 120 / 30 days

PR

PROAIR DIGIHALER 3

QL 0.8 / day

PR

PA

PROAIR HFA 3

QL 0.8 / day

PR

PA

PROAIR RESPICLICK 3

QL 0.07 / day

PR

PA

PROVENTIL HFA 3

QL 0.6 / day

PR

PA

B4G

SEREVENT DISKUS 2QL 2 / day

PR

STRIVERDI RESPIMAT 2 QL .144 / day



terbutaline sulfate (2.5 mg tab, 5 mg tab) 1PR

HCG

terbutaline sulf 1 mg/ml vial 1 PR

UTIBRON NEOHALER 3QL 2 / day

PA

VENTOLIN HFA 3

QL 1.5 / day

PR

PA

XOPENEX 3PR


XOPENEX CONCENTRATE 3 PR

XOPENEX HFA 3

QL 1.5 / day

PR

PA

B4G

BLOOD DERIVATIVES

ALBUMINEX 3 MED Medical Drug

BLOOD FORMATION, COAGULATION, THROMBOSIS

BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

ADAKVEO 3S

MED Medical Drug

OXBRYTA 3

QL 3 / day

S

PA

TAVALISSE 3S

PA



HEMATOPOIETIC AGENTS

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 MLSYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/MLVIAL, 100 MCG/0.5 ML SYRINGE, 100 MCG/ML VIAL, 150MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)

3

S

PS

PA

DOPTELET 3S

PA

EPOGEN 3S

PA

FULPHILA 3S

PA

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 MLSYRINGE, 300 MCG/ML VIAL, 480 MCG/0.8 ML SAFE SYR,480 MCG/0.8 ML SYRINGE, 480 MCG/1.6 ML VIAL)

3S

PA

LEUKINE 3S

PA

MIRCERA 3S

PA

MOZOBIL 3S

PA

MULPLETA 3

QL 1 / day

S

PA

NEULASTA 3S

PA



NEULASTA ONPRO 3S

PA

NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL,480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 3

S

PA

NIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/ML VIAL,480 MCG/0.8 ML SYRING, 480 MCG/1.6 ML VIAL) 3

S

PA

NPLATE 3

S

MED Medical Drug

PA

PROCRIT 3S

PA

PROMACTA (12.5 MG SUSPEN PACKET, 12.5 MG TABLET,25 MG SUSPENSION PCKT, 25 MG TABLET, 50 MG TABLET,75 MG TABLET)

3S

PA

REBLOZYL 3

S

MED Medical Drug

PA

RETACRIT 3

S

PS

PA

UDENYCA 3S

PA

ZARXIO 3S

PA

ZIEXTENZO 3S

PA



HEMORRHEOLOGIC AGENTS

pentoxifylline 1

CALCIUM-CHANNEL BLOCKING AGENTS

CALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CALAN 3QL 3 / day

PR

CALAN SR 3

QL 1 / day

PR


CARDIZEM 3

QL 4 / day

PR


CARDIZEM CD (300 MG CAPSULE, 360 MG CAPSULE) 3

QL 1 / day

PR


CARDIZEM CD 120 MG CAPSULE 3

QL 4 / day

PR



QL 3 / day

PR



QL 2 / day

PR




CARDIZEM LA (300 MG TABLET, 360 MG TABLET, 420 MGTABLET) 3

QL 1 / day

ST

PR


CARDIZEM LA 120 MG TABLET 3

QL 4 / day

ST

PR


QL 3 / day

ST

PR



QL 2 / day

ST

PR


CARTIA XT 120 MG CAPSULE 1QL 4 / day

PR


PR


PR


PR

DILT XR 120 MG CAPSULE 3QL 4 / day

PR

DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 PR



diltiazem 12hr er 1 PR

diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mgcap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 PR

diltiazem 24hr er 120 mg cap 1QL 4 / day

PR

diltiazem 24hr er 180 mg cap 1QL 3 / day

PR

diltiazem 24h er(cd) 120 mg cp 1QL 4 / day

PR


PR


PR

diltiazem 24hr er (cd) (24h 300 mg cp, 24h 360 mg cp) 1QL 1 / day

PR

diltiazem 24h er(la) 180 mg tb 1QL 3 / day

PR

diltiazem 24h er(la) 240 mg tb 1QL 2 / day

PR

diltiazem 24hr er (la) (24h 300 mg tb, 24h 360 mg tb, 24h420 mg tb) 1

QL 1 / day

PR

diltiazem 24h er(xr) 120 mg cp 1QL 4 / day

PR

diltiazem 24h er(xr) 180 mg cp 1QL 3 / day

PR

diltiazem 24h er(xr) 240 mg cp 1 PR



diltiazem 90 mg tablet 1 PR

diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1QL 4 / day

PR

diltiazem hcl (25 mg/5 ml vial, 50 mg/10 ml vial, 100 mgadd-van vial, 125 mg/25 ml vial) 1

MED Medical Drug

PR

diltiazem hcl-0.7% nacl 1 MED Medical Drug

diltiazem hcl-0.9% nacl 1 MED Medical Drug

diltiazem-d5w 1 MED Medical Drug

MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MGTABLET) 1

QL 1 / day

PR

MATZIM LA 180 MG TABLET 1QL 3 / day

PR

MATZIM LA 240 MG TABLET 1QL 2 / day

PR

TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MGCAPSULE) 1 PR

TAZTIA XT 120 MG CAPSULE 1QL 4 / day

PR

TAZTIA XT 180 MG CAPSULE 1QL 3 / day

PR

TIADYLT ER (ER 240 MG CAPSULE, ER 300 MG CAPSULE,ER 360 MG CAPSULE, ER 420 MG CAPSULE) 1 PR

TIADYLT ER 120 MG CAPSULE 1QL 4 / day

PR

TIADYLT ER 180 MG CAPSULE 1QL 3 / day

PR



TIAZAC (ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER360 MG CAPSULE, ER 420 MG CAPSULE) 3

PR


TIAZAC ER 120 MG CAPSULE 3

QL 4 / day

PR


TIAZAC ER 180 MG CAPSULE 3

QL 3 / day

PR


verapamil er (er 120 mg capsule, er 120 mg tablet, er 180mg capsule, er 180 mg tablet, er 240 mg capsule, er 240mg tablet)

1QL 1 / day

PR

verapamil er pm 1QL 1 / day

PR

verapamil 360 mg cap pellet 1

QL 1 / day

PR

HCG

verapamil 40 mg tablet 1 PR

verapamil hcl (80 mg tablet, 120 mg tablet) 1QL 3 / day

PR

verapamil hcl (5 mg/2 ml ampul, 5 mg/2 ml vial, 10 mg/4ml syringe, 10 mg/4 ml vial) 1

MED Medical Drug

PR

verapamil sr 1QL 1 / day

PR

VERELAN (120 MG CAP PELLET, 180 MG CAP PELLET, 360MG CAP PELLET) 3

QL 1 / day

PR

VERELAN 240 MG CAP PELLET 3

QL 1 / day

PR




VERELAN PM 3

QL 1 / day

PR


DIHYDROPYRIDINES

ADALAT CC 30 MG TABLET 3QL 1 / day

PR

ADALAT CC 60 MG TABLET 3QL 2 / day

PR

ADALAT CC 90 MG TABLET 3 PR

AFEDITAB CR 1QL 1 / day

PR

amlodipine besylate 1QL 1 / day

PR

amlodipine besylate-benazepril 1QL 1 / day

PR

amlodipine-olmesartan 1QL 1 / day

PR

amlodipine-valsartan (5-320 mg, 10-160 mg, 10-320 mg) 1QL 1 / day

PR

amlodipine-valsartan 5-160 mg 1QL 2 / day

PR

amlodipine-valsartan-hctz 1QL 1 / day

PR

AZOR 3

QL 1 / day

PR




CARDENE I.V. 25 MG/10 ML AMPUL 3 MED Medical Drug

CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN,CARDENE-NACL 20 MG/200 ML SOLN, CARDENE-NACL 40MG/200 ML IV)

3MED Medical Drug

PR

CLEVIPREX 3 MED Medical Drug

CONJUPRI 3

QL 1 / day

ST

PR

CONSENSI 3

QL 1 / day

PA


EXFORGE 3

QL 1 / day

ST

PR


EXFORGE HCT 3

QL 1 / day

ST

PR


felodipine er 1QL 1 / day

PR

isradipine 2.5 mg capsule 1QL 2 / day

PR

isradipine 5 mg capsule 1QL 4 / day

PR

KATERZIA 3QL 10 / day

AL Up to 18 yrs old



LOTREL 3

QL 1 / day

ST

PR


nicardipine 20 mg capsule 1 PR

nicardipine 30 mg capsule 1PR

HCG

nicardipine 2.5 mg/ml syringe 1 MED Medical Drug

nicardipine hcl (25 mg/10 ml ampule, 25 mg/10 ml vial) 1MED Medical Drug

PR

nicardipine hcl-0.9% nacl (20mg/200ml-0.9%nacl,40mg/200ml-0.9%nacl) 1

MED Medical Drug

PR

nicardipine hcl-0.9% nacl (0.5 mg/5 ml-ns syr, 1 mg/10 ml-ns syrg) 1 MED Medical Drug

nicardipine hcl-d5w 1MED Medical Drug

PR

nifedipine 1QL 4 / day

PR

nifedipine er (er 30 mg tablet, er 90 mg tablet) 1QL 1 / day

PR

nifedipine er 60 mg tablet 1QL 2 / day

PR

nimodipine 1 PR

nisoldipine 1

QL 1 / day

PR

HCG



NORVASC 3

QL 1 / day

PR


NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 MLSOLUTION) 3

QL 120 / day

PR

NYMALIZE (30 MG/5 ML ORAL SYRNG, 60 MG/10 MLORAL SYRN) 3

QL 60 / day

PR

PROCARDIA 3

QL 4 / day

PR



PROCARDIA XL (30 MG TABLET, 90 MG TABLET) 3

QL 1 / day

PR


PROCARDIA XL 60 MG TABLET 3

QL 2 / day

PR


SULAR 3QL 1 / day

PR

CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

CORLANOR 5 MG/5 ML ORAL SOLN 3QL 15 / day

PA

CORLANOR (5 MG TABLET, 7.5 MG TABLET) 3

QL 2 / day

ST

PA



RANEXA 3

QL 2 / day

ST


ranolazine er 1 QL 2 / day

VYNDAMAX 3

QL 1 / day

S

PA

VYNDAQEL 3

QL 4 / day

S

PA

CARDIOTONIC AGENTS

DIGITEK 1 NTI

DIGOX 1 NTI

digoxin 0.05 mg/ml solution 1NTI

HCG

digoxin (0.25 mg/ml syringe, 500 mcg/2 ml ampule) 1MED Medical Drug

NTI

digoxin (0.125 mg tablet, 0.25 mg tablet, 125 mcg tablet,250 mcg tablet) 1 NTI

LANOXIN 500 MCG/2 ML AMPULE 2MED Medical Drug

NTI

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5MCG TABLET, 250 MCG TABLET) 2 NTI

LANOXIN 500 MCG/2 ML VIAL 3MED Medical Drug

NTI

LANOXIN PEDIATRIC (100 MCG/ML AMPUL, 100 MCG/MLVIAL) 2

MED Medical Drug

NTI



CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 3 PR

CARDURA XL 3

QL 1 / day

ST

PR

doxazosin mesylate 1 PR

MINIPRESS 3 PR

prazosin hcl 1 PR

terazosin hcl 1 PR

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 1 PR

atenolol (25 mg tablet, 50 mg tablet) 1 PR

atenolol 100 mg tablet 1 PR

atenolol-chlorthalidone 1 PR

BETAPACE 3PR


BETAPACE AF 3PR


betaxolol hcl (10 mg tablet, 20 mg tablet) 1 PR

bisoprolol fumarate 1 PR

bisoprolol-hydrochlorothiazide 1 PR

BREVIBLOC (100 MG/10 ML VIAL, 2,000 MG/100 ML BAG,2,500 MG/250 ML BAG) 3 MED Medical Drug



BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2QL 3 / day

PR

BYSTOLIC 2.5 MG TABLET 2QL 1 / day

PR

BYSTOLIC 20 MG TABLET 2QL 2 / day

PR

BYVALSON 2 QL 1 / day

carvedilol 1 PR

carvedilol er (er 10 mg capsule, er 20 mg capsule, er 40mg capsule) 1

QL 2 / day

PR

HCG

carvedilol er 80 mg capsule 1

QL 1 / day

PR

HCG

COREG 3

ST

PR


COREG CR (CR 10 MG CAPSULE, CR 20 MG CAPSULE, CR40 MG CAPSULE) 3

QL 2 / day

ST

PR


COREG CR 80 MG CAPSULE 3

QL 1 / day

ST

PR




CORGARD 3PR


CORZIDE 3 PR

DUTOPROL 3

PR

B4G


esmolol hcl 100 mg/10 ml syrg 1 MED Medical Drug

esmolol hcl 100 mg/10 ml vial 1MED Medical Drug

PR

esmolol hcl-sodium chloride 1 MED Medical Drug

HEMANGEOL 3 S

INDERAL LA 3

ST

PR



INDERAL XL 3

ST

PR


INNOPRAN XL 3

ST

PR


KAPSPARGO SPRINKLE 3

labetalol hcl (20 mg/4 ml crpjt, 20 mg/4 ml syrng) 1MED Medical Drug

PR



labetalol hcl 25 mg/5 ml syr 1 MED Medical Drug

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet) 1 PR

labetalol hcl (20 mg/4 ml vial, 25 mg/5 ml syrng, 50mg/10 ml syrg, 100 mg/20 ml vl, 200 mg/40 ml vl) 1 MED Medical Drug

labetalol hcl-d5w 1 MED Medical Drug

LOPRESSOR 5 MG/5 ML AMPUL 3

MED Medical Drug

PR


LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3PR


LOPRESSOR HCT 3PR


metoprolol succinate 1 PR

metoprolol tartrate (5 mg/5 ml amp, 5 mg/5 ml vial) 1MED Medical Drug

PR

metoprolol 5 mg/5 ml carpuject 1 PR

metoprolol tartrate (25 mg tab, 50 mg tab) 1 PR

metoprolol tartrate (37.5 mg tb, 75 mg tab) 1

metoprolol tartrate 100 mg tab 1 PR

metoprolol-hydrochlorothiazide 1 PR

nadolol 1 PR

nadolol-bendroflu 40-5 mg tab 1 PR

nadolol-bendroflu 80-5 mg tab 1PR

HCG



pindolol 1 PR

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)

1 PR

propranolol 1 mg/ml vial 1MED Medical Drug

PR

propranolol hcl er 1 PR

propranolol-hydrochlorothiazid 1 PR

SORINE 1 PR

sotalol 1 PR

sotalol af 1 PR

sotalol hcl 1 MED Medical Drug

SOTYLIZE 3

TENORETIC 100 3PR


TENORETIC 50 3

PR



TENORMIN 3

ST

PR


timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 PR

TOPROL XL 3PR




ZIAC 3 PR

CELLULAR AND GENE THERAPY

CELLULAR THERAPY

PROVENGE 3

QL 18 / day

S

MED Medical Drug

PA

CENTRAL NERVOUS SYSTEM AGENTS

ANTIMANIC AGENTS

lithium 1 NTI

lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab,600 mg cap) 1 NTI

lithium carbonate er 1 NTI

LITHOBID 3 NTI

CENTRAL NERVOUS SYSTEM AGENTS, MISC.

acamprosate calcium 1

ADDYI 3

QL 1 / day

GL Female

AL 18 to 60 yrs old

PA

atomoxetine hcl 1QL 2 / day


carbidopa 1

flumazenil 1 MED Medical Drug



guanfacine hcl er 1QL 1 / day

PR

INTUNIV 3

QL 1 / day

ST


LODOSYN 3

memantine hcl 2 mg/ml solution 1QL 360 / 30 days


memantine 5-10 mg titration pk 1 AL At least 40 yrsold

memantine hcl 10 mg tablet 1QL 2 / day


memantine hcl 5 mg tablet 1QL 3 / day


memantine hcl er 1 AL At least 40 yrsold

NAMENDA (5 MG TABLET, 5-10 MG TITRATION PK, 10 MGTABLET) 3 AL At least 40 yrs

old

NAMENDA XR TITRATION PACK 3 AL At least 40 yrsold

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE) 3



NAMZARIC (7 MG-10 MG CAPSULE, 14 MG-10 MGCAPSULE, 21 MG-10 MG CAPSULE, 28 MG-10 MGCAPSULE, TITRATION PACK)

3ST




NOURIANZ 3

QL 1 / day

S

PA

NUEDEXTA 2 PA

riluzole 1

STRATTERA 3

QL 2 / day

ST



TIGLUTIK 3 PA

VYLEESI 3

QL 0.08 / day

GL Female

S

PA

XYREM 3

QL 18 / day

S

PA

XYWAV 3

QL 18 / day

S

PA

FIBROMYALGIA AGENTS

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET, TITRATION PACK) 3

QL 2 / day

ST

OPIATE ANTAGONISTS

naloxone 2 mg auto-injector 3 PA



naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2ml syringe, 4 mg/10 ml vial) 1

naltrexone hcl 1

NARCAN 2 QL 2 / 30 days

VIVITROL 3

S

PA


VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO 3

QL 4 / day


S

PA

INGREZZA 40 MG CAPSULE 3

QL 2 / day


S

PA

INGREZZA 80 MG CAPSULE 3

QL 1 / day


S

PA

INGREZZA INITIATION PACK 3

QL 1 / day


S

PA

tetrabenazine 1S

PA



XENAZINE 3

S

PA


CEPHALOSPORIN ANTIBIOTICS

1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mgcapsule, 500 mg/5 ml susp) 1

cefazolin sodium (1 gm add-van vial, 1 gm vial, 10 gm vial,20 gm bulk vial, sod 100 gm bulk bag, sod 300 gm bulkbag, 500 mg vial)

1 MED Medical Drug

cefazolin sodium-0.9% nacl (1 g/10 ml-ns syringe, 2 g/10ml-ns syringe, 2 g/100 ml-0.9% nacl, 2 g/50 ml-0.9% nacl,3 g/100 ml-0.9% nacl)

1 MED Medical Drug

cefazolin sodium-d5w (2 gram/100, 2 gram/50 bag, 3gram/100) 1 MED Medical Drug

cefazolin sodium-dextrose (1 g/50, 2 g/100, 2 g/50) 1 MED Medical Drug

cefazolin sodium-sterile water 1 MED Medical Drug

cefazolin-d5w 1 MED Medical Drug

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mgtablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet,750 mg capsule)

1

KEFLEX 3

2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 mlsusp, 375 mg/5 ml suspen, 500 mg capsule) 1

cefaclor er 1 QL 20 / 30 days

cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 mlsusp, 500 mg tablet) 1



cefuroxime 1

cefuroxime sodium 1 MED Medical Drug

3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

AVYCAZ 3 MED Medical Drug

cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mgcapsule) 1

cefditoren pivoxil 1

cefixime 400 mg capsule 1

cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 1 QL 1200 / 90 days

cefotaxime sodium 1 MED Medical Drug

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet,100 mg/5 ml susp, 200 mg tablet) 1

ceftazidime (1 gm piggyback, 1 gm vial, 2 gm piggyback, 2gm vial, 6 gm vial) 1 MED Medical Drug

ceftriaxone (1 gm add-vant vial, 1 gm piggyback, 1 gmvial, 1 gm-d5w bag, 2 gm add vial, 2 gm piggyback, 2 gmvial, 2 gm-d5w bag, 10 gm vial, 100 gram bulk bag, 250mg vial, 500 mg vial)


CLAFORAN (1 GM ADD-VANTAGE VL, 1 GM VIAL, 2 GMADD-VANTAGE VL, 2 GM VIAL, 10 GM VIAL) 3 MED Medical Drug

FORTAZ 3 MED Medical Drug

SPECTRACEF 3

SUPRAX 400 MG CAPSULE 3 SBA Select BrandAlternative

SUPRAX (100 MG/5 ML SUSPENSION, 200 MG/5 MLSUSPENSION) 3 QL 1200 / 90 days

SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLETCHEWABLE, 500 MG/5 ML SUSPENSION) 3



TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 GMADD-VANTAGE VIAL, 2 GRAM VIAL, 6 GRAM VIAL) 1 MED Medical Drug

4TH GENERATION CEPHALOSPORIN ANTIBIOTICS

cefepime 1 MED Medical Drug

cefepime hcl (1 gm vial, 2 gram vial) 1 MED Medical Drug

cefepime-dextrose 1 MED Medical Drug

MAXIPIME (1 GM ADD-VANTAGE VL, 1 GRAM VIAL, 2 GMADD-VANTAGE VL, 2 GRAM VIAL) 3 MED Medical Drug

5TH GENERATION CEPHALOSPORIN ANTIBIOTICS

TEFLARO 3MED Medical Drug

PA

SIDEROPHORE CEPHALOSPORINS

FETROJA 3 MED Medical Drug

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS 2

QL 2 / day

PR

B4G

ADVAIR HFA 2QL 0.4 / day

PR

AIRDUO DIGIHALER 3

QL 0.04 / day


PA

AIRDUO RESPICLICK 3

QL 0.04 / day


PA



ALVESCO 3

QL 0.434 / day

PR

PA

ARMONAIR DIGIHALER 3QL 0.04 / day

PA

ARMONAIR RESPICLICK 3QL 0.04 / day

PA

ARNUITY ELLIPTA 100 MCG INH 2QL 2 / day

PR


PR


PR

ASMANEX 3

QL 0.04 / day

PR

PA

ASMANEX HFA 3

QL 0.434 / day

PR

PA

BREO ELLIPTA 2QL 2 / day

PR

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp) 1QL 120 / 30 days

PR

budesonide 1 mg/2 ml inh susp 1

QL 120 / 30 days

PR

HCG

budesonide-formoterol 160-4.5 3

QL 0.4 / day

PR

PA



budesonide-formoterol 80-4.5 3QL 0.4 / day

PA

DULERA 3

QL 0.434 / day

PR

PA

FLOVENT 250 MCG DISKUS 2QL 8 / day

PR

FLOVENT DISKUS (50 MCG, 100 MCG) 2QL 4 / day

PR

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCGINHALER) 2

QL 0.8 / day

PR

FLOVENT HFA 44 MCG INHALER 2QL 0.767 / day

PR

fluticasone-salmeterol (55-14, 113-14, 232-14) 1QL 0.04 / day


fluticasone-salmeterol (100-50, 250-50, 500-50) 1QL 2 / day

PR

PULMICORT 3

QL 120 / 30 days

PR


PULMICORT FLEXHALER 2QL 0.07 / day

PR

QVAR REDIHALER 40 MCG 2QL 0.6 / day

PR

QVAR REDIHALER 80 MCG 2QL 0.87 / day

PR



SYMBICORT 2

QL 0.4 / day

PR

B4G

TRELEGY ELLIPTA 2 QL 2 / day

WIXELA INHUB 1QL 2 / day

PR

CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 3

QL 2 / day

S

PA

TRIKAFTA 3

QL 3 / day

S

PA

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO (25 MG GRANULES PACKET, 50 MG GRANULESPACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 3

QL 2 / day

S

PA

ORKAMBI (100-125 MG GRANULE PKT, 150-188 MGGRANULE PKT) 3

QL 2 / day

S

PA

ORKAMBI (100 MG TABLET, 200 MG TABLET) 3

QL 4 / day

S

PA

DENTAL AGENTS

ORAQIX 3 MED Medical Drug



DEPIGMENTING AND PIGMENTING AGENTS

DEPIGMENTING AGENTS

BLANCHE 1

hydroquinone (cream, tr cream) 1

TRI-LUMA 3

PIGMENTING AGENTS

methoxsalen 1

OXSORALEN-ULTRA 3

UVADEX 3S

MED Medical Drug

DEVICES

1st tier unifine pentips 2 PR

1st tier unifine pentips plus 2 PR

1st tier unilet comfortouch 2 PR

2-in-1 lancet device 2 PR

2tek control solution 3

abouttime pen needle 2 PR

accu-chek aviva solution 3

accu-chek (lancet kit, lancets) 2 PR

accu-chek aviva plus meter 3PR

PA

accu-chek compact plus control 3

accu-chek fastclix lancet drum 2 PR

accu-chek fastclix lancing dev 2 PR



accu-chek guide control soln 3

accu-chek guide me glucose mtr 3PR

PA

accu-chek guide monitor system 3PR

PA

accu-chek nano smartview 3PR

PA

accu-chek safe-t-pro 2 PR

accu-chek safe-t-pro plus 2 PR

accu-chek smartview contrl sol 3

accu-chek softclix (lancet kit, lancets) 2 PR

accutrend glucose control 3

acti-lance 2 PR

adjustable lancing device 2 PR

advanced glucose meter 3PR

PA

advanced lancing device 2 PR

advanced travel lancets 2 PR

advocate blood glucose monitor 3PR

PA

advocate control solution (solution high, solution low) 3

advocate duo meter 3PR

PA

advocate lancet 2 PR

advocate lancets 2 PR



advocate lancing device 2 PR

advocate pen needle 2 PR

advocate pen needles 2 PR

advocate rapid-safe 2 PR

advocate redi-code (meter, monitor) 3PR

PA

advocate redi-code duo 3PR

PA

advocate redi-code plus 3PR

PA

advocate redi-code+ ctrl soln 3

agamatrix amp gluc monitor sys 3PR

PA

agamatrix control (high soln, norm-hi soln) 3

agamatrix control solution (2, 4) 3

cvs alkaline batteries 3

alternate site lancets 2 PR

alternate site lancing device 2 PR

aqua lance lancing device 2 PR

assure 4 control solution 3 PA

assure dose 3

assure haemolance plus (18g, 21g, 25g, 28g, blade) 2 PR

assure id duo-shield 2 PR

assure id insulin safety (syr 0.5ml 31gx15/64", syr 1 ml31gx15/64") 2 PR



assure id pen needle 2 PR

assure lance 2 PR

assure lance plus 2 PR

assure platinum glucose meter 3PR

PA

assure prism 3

assure prism multi meter 3PR

PA

auto-lancet mini 2 PR

autolet impression 2 PR

autolet lancing device 2 PR

autolet plus 2 PR

autoshield duo pen needle 2 PR

AVENOVA 3

bd microtainer lancets 2 PR

bd ultra-fine 2 PR

bd ultra-fine ii 2 PR

blood glucose control 3

blood glucose meter 3PR

PA

blood glucose monitoring 3PR

PA

blood lancets 2 PR

blood-glucose control 3



blood-glucose meter 3PR

PA

blunt needle 3

breeze 2 solution 3

bullseye mini safety lancets 2 PR

carefine pen needle 2 PR

carelance ult lancing device 2 PR

careone (lancing device, thin lancet, ultra thin lancet) 2 PR

caresens control solution 3

caresens ultra thin 30g lancet 2 PR

caresens n blood glucose syst 3PR

PA

caresens n voice (n meter, n sys) 3PR

PA

caresens prem lancing device 2 PR

caretouch glucose monitoring 3PR

PA

caretouch insulin syringe (syr 1 ml 28gx5/16", syr 1 ml29gx5/16") 2 PR

caretouch lancing device 2 PR

caretouch pen needle 2 PR

caretouch safety lancets 2 PR

caretouch twist lancet 2 PR

chemstrip bg diary 3 PA

choicedm clarus 3PR

PA



choicedm clarus control soln 3

clever chek blood glucose syst 3PR

PA

clever chek lancets 2 PR

clever choice glucose monitor 3PR

PA

clever choice blood gluc sys 3PR

PA

clever choice control solution (1 sol, 2 sol, 3 sol) 3

clever choice hd glucose syst 3PR

PA

clever choice micro 3PR

PA

clever choice pro glucose mtr 3PR

PA

clever choice talk glucose sys 3PR

PA

clickfine 2 PR

coaguchek lancets 2 PR

color lancets 2 PR

comfort ez 2 PR

comfort ez pen needle 2 PR

comfort lancets 2 PR

contour solution 3

contour (, system) 2 PR



contour next 2 PR

contour next control solution (1 sol, 2 sol) 2

contour next ez meter 2 PR

contour next ez meter system 3 PR

contour next link 2 PR

contour next link 2.4 3 PR

contour next one 3 PR

control ast 3PR

PA

control solution (fora high solution, fora low solution,medpoint solution) 3

cool blood glucose 3PR

PA

cool blood glucose meter 3PR

PA

cool control solution (a solution, b solution) 3

dexcom 2 AL At least 2 yrsold

dexcom g4 ((ped) receiver kit, receiver kit, receiver-share(ped), receiver-share kit, transmitter kit) 2 AL At least 2 yrs

old

dexcom g5 (receiver kit, transmitter kit) 2 AL At least 2 yrsold

dexcom g5-g4 sensor 2 AL At least 2 yrsold

dexcom g6 (receiver, sensor, transmitter) 2 AL At least 2 yrsold

diatrue (1 soln, 2 soln, 3 soln) 3



diatrue plus blood glucose sys 3PR

PA

droplet insulin syringe (0.5 ml 29gx12.5mm(1/2), 0.5 ml30gx12.5mm(1/2), 0.5ml 30gx12.5mm(1/2), ins 0.5ml30gx6mm(1/2), ins 0.5ml 30gx8mm(1/2), ins 0.5ml31gx6mm(1/2), ins 0.5ml 31gx8mm(1/2), ins syr 0.3 ml30gx6mm, ins syr 1 ml 30gx6mm)

2 PR

droplet lancets 2 PR

droplet lancing device 2 PR

droplet micron pen needle 2 PR

droplet pen needle 2 PR

dropsafe pen needle 2 PR

DUROLANE 3

S

PA


e-z ject lancets 2 PR

e-zject lancets 2 PR

easy comfort 2 PR

easy comfort insulin syringe (0.5 ml 32gx5/16", 1 ml32gx5/16") 2 PR

easy comfort pen needle 2 PR

easy comfort pen needles 2 PR

easy glide pen needle 2 PR

easy mini eject lancing device 2 PR

easy plus ii (soln high, soln low) 3



easy plus ii blood glucose sys 3PR

PA

easy step blood glucose meter 3PR

PA

easy step control solution (contrl soln-high, control soln-low, control soln-normal) 3

easy talk (high soln, soln low) 3

easy talk blood glucose meter 3PR

PA

easy touch (button 30g lancets, pressure 30g lancet, pull-top 26g lancet, pull-top 28g lancet, pull-top 30g lancet,pull-top 32g lancet, safety 21g lancets, safety 23g lancets,safety 26g lancets, safety 28g lancets, safety 32g lancets,twist 26g lancets, twist 28g lancets, twist 30g lancets,twist 32g lancets, twist 33g lancets)

2 PR

easy touch control solution 3

easy touch fliplok ndl 25gx5/8 3

easy touch glucose monitor 3PR

PA

easy touch lancing device 2 PR

easy touch pen needle 2 PR

easy touch safety pen needle 2 PR

easy trak (soln high, soln low) 3

easy trak blood glucose meter 3PR

PA

easy trak ii control solution 3

easy twist & cap lancets 2 PR



easy-touch 3PR

PA

easygluco 3PR

PA

easygluco meter 3PR

PA

easygluco meter starter kit 3PR

PA

easygluco plus control normal 3

easymax (low soln, normal soln) 3

easymax 15 (15 1 solution, 15 2 solution) 3

easymax l 3PR

PA

easymax ng (blood sys, system kit) 3PR

PA

easymax v speaking 3PR

PA

easymax v2 3PR

PA

easypoint needle (needle 18g 1", needle 18g 1-1/2",needle 20g 1", needle 20g 1-1/2", needle 21g 1", needle21g 1-1/2", needle 22g 1", needle 22g 1-1/2")

3

eclipse needle (needle 21gx1", needle 22gx1", needle23gx1", needle 25gx1", needle 25gx5/8", needle27gx1/2", needles 21gx1.5")

3

element compact glucose meter 3PR

PA



element compact control soln (soln high, soln normal) 3

element compact v 3PR

PA

element control solution (soln normal, solution high,solution low) 3

element plus 3PR

PA

embrace (blood kit, blood system) 3PR

PA

embrace 30g lancets 2 PR

embrace gluc control soln high 3

embrace evo level 1 ctrl soln 3

embrace evo blood glucose kit 3PR

PA

embrace glucose control soln 3

embrace pro 3

embrace pro blood glucose mtr 3PR

PA

embrace talk (blood mtr, blood sys) 3PR

PA

embrace talk control solution (sol-high(l2), soln-low(l1)) 3

enlite 3

enteral gravity bag set-enfit 3

EPISIL 3

EUFLEXXA 3

S

PS

PA




evencare control solution 3

evencare monitoring system 3PR

PA

evencare g2 blood glucose sys 3PR

PA

evencare g2 control solution 3

evencare g3 control solution 3

evencare g3 blood glucose sys 3PR

PA

evencare mini glucose control 3

evencare mini monitor system 3PR

PA

evencare proview control soln 3

eversense sensor-holder 3

evolution blood glucose meter 3PR

PA

evolution control solution 3

exel hypo needle 30gx0.5" 3

exel mti drawing needle 1

ez smart (high solution, low solution, normal soln) 3

ez smart system kit 3PR

PA

ez smart lancets 2 PR

ez smart plus system kit 3PR

PA



ez-lets 2 PR

ez-vac 3

fifty50 safety seal lancets 2 PR

filter aspirator needle 3

filter needle 1

filter needle 19gx1-1/2" 3

filter needle 5 micron 3

fine 30 universal lancets 2 PR

fingerstix 2 PR

fora control solution 3

fora d10 3 PR

fora d15 glucose-bp monitor 3PR

PA

fora d20 blood glucose system 3PR

PA

fora d40d glucose-bp monitor 3PR

PA

fora d40g glucose-bp monitor 3PR

PA

fora g20 blood glucose system 3PR

PA

fora g30a 3PR

PA

fora gd50 3PR

PA



fora lancets 2 PR

fora lancing device 2 PR

fora premium v10 3PR

PA

fora test n'go voice 3PR

PA

fora tn'g voice 3PR

PA

fora v10 blood glucose system 3PR

PA

fora v10-v12-d10-d20 strp-lnct 3 PA


PA


PA

fora v30a blood glucose system 3PR

PA

foracare gd20 glucose system 3PR

PA

foracare gd40a 3PR

PA

foracare gd40b 3PR

PA

foracare gdh (high soln, low soln, norm soln) 3

foracare lancets 2 PR



fortiscare (soln high, soln low, soln normal) 3

fortiscare blood glucose syst 3PR

PA

freestyle control solution 3

freestyle flash system 3PR

PA

freestyle freedom 3PR

PA

freestyle freedom lite 3PR

PA

freestyle insulinx glucose sys 3PR

PA

freestyle lancets 2 PR

freestyle libre 10 day reader 2 AL At least 18 yrsold

freestyle libre 10 day sensor 2 AL At least 18 yrsold

freestyle libre 14 day reader 2 AL At least 18 yrsold

freestyle libre 14 day sensor 2 AL At least 18 yrsold

freestyle libre 2 reader 2 AL At least 4 yrsold

freestyle libre 2 sensor 2 AL At least 4 yrsold

freestyle lite meter 3PR

PA

freestyle navigator 3



freestyle precision neo meter 3PR

PA

freestyle sidekick ii 3PR

PA

freestyle system 3PR

PA

freestyle unistik 2 2 PR

gdrive 3PR

PA

ge100 blood glucose system 3PR

PA

ge100 control solution normal 3

GEL-ONE 3

S

PA


genteel vacuum lancing device 2 PR

GENVISC 850 3

S

PA


gluco navii glucose monitor kt 3PR

PA

glucocard 01 3PR

PA

glucocard 01 control 3

glucocard expression (, kit) 3PR

PA



glucocard expression cntrl sln 3

glucocard shine (, kit) 3PR

PA

glucocard shine control soln 3

glucocard shine connex meter 3PR

PA

glucocard shine express meter 3PR

PA

glucocard shine xl 3PR

PA

glucocard vital meter kit 3PR

PA

glucocom 2 PR

glucocom blood glucose 3PR

PA

glucocom control solution 3

glucocom lancets 2 PR

glucose control 3

glucose control solution 3

gojji glucose control solution 3

gojji lancet-glucose test strp 3 PA

gojji lancets 2 PR

gojji lancing device 2 PR

gojji multifunctional meter kt 3PR

PA



goodlife ac-302 glucose meter 3PR

PA

harmony control solution 3

healthpro glucose control soln 3

healthpro glucose monitor 3PR

PA

healthwise pen needle 2 PR

healthy accents autolet 2 PR

healthy accents unifine pentip (pentip 4mm 32g, pentip5mm 31g, pentip 6mm 31g, pentip 8mm 31g, pentp12mm 29g)

2 PR

healthy accents unilet lancet 2 PR

HPR PLUS EMOLLIENT FOAM 3

HYALGAN (20 MG/2 ML SYRINGE, 20 MG/2 ML VIAL) 3

S

PA


HYCLODEX 3

HYLATOPICPLUS (CREAM, EMOLLIENT FOAM, LOTION) 3

HYMOVIS 3

S

PA




hypodermic needle (hypo needle,polypropyl hub,hypodermic needle,alum hub, monoject hypo ndl 27gx1-1/2", monoject hypo needle 18x1a, monoject hypo needle19x1, monoject hypo needle 19x1-1/2, monoject hyponeedle 20x1, monoject hypo needle 20x1-1/2, monojecthypo needle 21x1, monoject hypo needle 21x1-1/2,monoject hypodermic needle)

3

hypodermic needle (needle 22x1, needle 22x1.5, needle23x1, needle 25x1, needle 25x1.5, needle 25x5/8, needle26x1.5, needle 27x0.5, needle 30x3/4)

3

hypolance 2 PR

iglucose blood glucose monitor 3PR

PA

incontrol lancing device 2 PR

incontrol pen needle 2 PR

incontrol super thin lancets 2 PR

incontrol ultra thin lancets 2 PR

infinity 3PR

PA

infinity control solution (soln high, soln low, soln normal) 3

infinity voice control soln 3

infinity voice glucose monitor 3PR

PA

inject ease lancets 2 PR

insul-cap 3

insul-eze 3

insulin pen needle 2 PR



insupen 2 PR

integra precisionglide needle 3

invacare lancets 2 PR

jazz wireless 2 3PR

PA

lancets 2 PR

lancets thin 2 PR

lancets ultra thin 2 PR

lancing device (autolet impression lancing dev, cvs lancingdevice, e-z pull & click lancing dev, fifty50 lancing device,ge lancing device, gs lancing device and lancets, invacarelancing device, kro lancing device, kroger lancing device,lancing device, live better advanced lancing, meijerlancing device, ra health care lancing device, relionlancing device, simple diagnstic lancet device, value pluslancing device)

2 PR

lancing system 2 PR

lanzo 2 PR

latex gloves 1

LIDOTREX 2% WOUND GEL 3

lite touch (pen needle 29g, 31gx1/4" pen needle, penneedle 31g) 2 PR

lite touch (28g lancets, 30g lancets, 33g lancets, lancingpen) 2 PR

magellan safety needle 3

magellan safety syringe 3

magni-guide magnifier 3



maxicomfort ii pen needle 2 PR

maxicomfort safety pen needle 2 PR

medisense (h-l solution, h-m-l soln) 3 PA

medisense mid control solution 3

medisense control 3 PA

medisense glucose ketone 3 PA

medisense glucose ketone contr 3

medisense thin lancets 2 PR

medlance plus 2 PR

medlance plus special blade 2 PR

meter-check 3

micro thin lancet 2 PR

micro thin lancets 2 PR

microdot (high-low sol, normal solut) 3

microdot blood glucose system 3PR

PA

microdot insulin pen needle 2 PR

microlet 2 PR

microlet 2 2 PR

microlet next lancing device 2 PR

microtainer lancets 2 PR

mini lancing device 2 PR

mini ultra-thin ii 2 PR



minilink real-time transmitter 3

monoject blood collection 3

monoject enfit syringe (1 ml syringe, 3 ml syringe, 6 mlsyringe, 12 ml syringe, 35 ml syringe, 60 ml syringe) 1

monoject enfit syringe cap 1

monolet lancets 2 PR

monolet thin lancets 2 PR

MONOVISC 3

S

PA


multi-lancet 2 PR

myglucohealth monitoring kit 3PR

PA

myglucohealth control solution 3

myglucohealth lancets 2 PR

nano 2nd gen pen needle 2 PR

needle (needle 18gx1 1/2", needle 30gx1/2") 3

reli on 31g x 1/4" needles 2 PR

nova max blood glucose meter 3PR

PA

nova max glucose control soln 3

nova safety lancets 2 PR

nova sureflex 2 PR

novamax plus glu-ket 3 PA



novofine 32 2 PR

novofine autocover 2 PR

novofine plus 2 PR

novotwist 2 PR

NUMOISYN LOZENGE 3

NUVAIL 3

on call express control soln 3

on call express meter (, system) 3PR

PA

on call lancet 2 PR

on call lancing device 2 PR

on call plus control 3

on call plus lancet 2 PR

on call plus lancing device 2 PR

on call plus meter 3PR

PA

on call vivid control 3

on call vivid meter 3PR

PA

on call vivid pal 3PR

PA

on-the-go 2 PR

onetouch delica (30g lancets, 33g lancets, lancing dev) 2 PR

onetouch delica plus lanc dev 2 PR



onetouch delica plus lancet 2 PR

onetouch lancets 2 PR

onetouch suresoft 2 PR

onetouch ultra control soln 3 PR

onetouch ultra2 3PR

PA

onetouch ultramini 3PR

PA

onetouch verio flex meter 3PR

PA

onetouch verio flex startr kit 3

QL 10 / day

PR

PA

onetouch verio high cntrl soln 3

onetouch verio iq meter 3PR

PA

onetouch verio iq system kit 3PR

PA

onetouch verio meter 3PR

PA

onetouch verio mid cntrl soln 3 PR

onetouch verio reflect kit 3PR

PA

onetouch verio reflect meter 3PR

PA



optumrx (blood meter, blood system) 3PR

PA

optumrx glucose control soln 3

ORAFATE 1 S

ORTHOVISC 3

S

PA


PAIN EASE MEDIUM STREAM SPRAY 3

PAIN EASE MIST SPRAY 3

paradigm real-time 3

paradigm remote control 3



pen needle (fifty50 pen 31g x 3/16" needle, fifty50 pen31g x 5/16" needle, fifty50 pen needle 32g x 1/4", fifty50pen needle 32g x 5/32", gnp clickfine pen ndl 31gx1/4",gnp clickfine pen ndl 31gx5/16, gs pen needle 31g x 1/4",gs pen needle 31g x 5/16", gs pen needle 31g x 5mm, gspen needle 31g x 6mm, gs pen needle 31g x 8mm, gs penneedle 32g x 4mm, gs pen needle 32g x 6mm, kro penneedle 4mm x 32g, kro pen needle 4mm x 33g, kro penneedle 5mm x 31g, kro pen needle 6mm x 31g, kro penneedle 8mm x 31g, kroger pen needles 31g x 5/16", livebetter pen needles 8mm, ms pen needle 6mm 31g, penneedle 4mm 32g, pen needle 5mm 31g, pen needle 6mm31g, pen needle 8mm 31g, pen needle 12mm 29g, penneedle 29g 12mm, pen needle 30g x 5/16", pen needle30g x 8mm, pen needle 31g 5mm, pen needle 31g 6mm,pen needle 31g 8mm, pen needle 31g x 1/4", pen needle31g x 3/16", pen needle 31g x 5/16", pen needle 31g x8mm, pen needle 32g 4mm, pen needle 32g x 1/4", penneedle 32g x 3/16", pen needle 32g x 5/32", pub pen 8mm31g needles, pub pen 12mm 29g needles, pub pen needle6mm 31g, ra pen needle 31gx3/16", ra pen needle31gx5/16", relion mini pen 31g x 1/4" ndl, relion pen 29gneedle, relion pen 31g needle, relion pen needle 29gx1/2",relion pen needle 31gx1/4", relion pen needle 31gx5/16",relion pen needle 32gx5/32", today's hlth pn needle 6mm31g)

2 PR

pen needles 2 PR

pentips 2 PR

pharmacist choice (glucose, mini glu) 3PR

PA

phaseal protector 3

pip 28g lancet 2 PR

pip 30g lancet 2 PR



poly hub needle 30gx1/2" 3

precision control solution 3 PA

precision link direct monit 3PR

PA

precision glucose control 3 PA

precision xtra (, nfrs) 3PR

PA

precision xtr b-ketone strip 3

precision xtra ketone-glucose 3PR

PA

premier blu 3PR

PA

premier compact glucose meter 3PR

PA

premier voice 3PR

PA

premium blood glucose 3PR

PA

premium v10 blood glucose mtr 3PR

PA

pressure activated lancets 2 PR

presto pro 3PR

PA

prevent dropsafe pen needle 2 PR

pro comfort lancet 2 PR



pro comfort lancets 2 PR

pro comfort pen needle 2 PR

pro voice v8 glucose monitor 3PR

PA

pro voice v9 glucose monitor 3PR

PA

prodigy 3PR

PA

prodigy autocode 3PR

PA

prodigy control solution 3

prodigy lancets 2 PR

prodigy lancing device 2 PR

prodigy pocket 3PR

PA

prodigy twist top lancet 2 PR

prodigy voice 3PR

PA

PROTHELIAL 1 S

pure comfort lancets 2 PR

pure comfort pen needle 2 PR

pure comfort safety lancets 2 PR

push button safety lancets 2 PR

quintet blood glucose system 3PR

PA



quintet ac blood glucose meter 3PR

PA

readylance safety lancets 2 PR

refuah plus monitoring system 3PR

PA

refuah plus glucose control 3

REGENECARE 3

reliamed 2 PR

reliamed mini lancing device 2 PR

reliamed safety seal lancets 2 PR

relion all-in-one 3PR

PA

relion confirm 3PR

PA

relion micro (blood glucose sys, system kit) 3PR

PA

relion pen needles 2 PR

relion prime 3PR

PA

relion thin 2 PR

replacement pediatric monitor 3

reveal blood glucose meter 3PR

PA

rightest control solution (soln normal, solution high) 3

rightest gc250s control soln 3



rightest gd500 2 PR

rightest gl300 lancets 2 PR

rightest gm100 system 3PR

PA

rightest gm250s meter 3PR

PA

rightest gm260 meter 3PR

PA

rightest gm300 system 3 PA

rightest gm550 system 3PR

PA

bd safe-clip needl storage dev 3

safety lancets 2 PR

safety pen needle 2 PR

safety seal lancets 2 PR

safety-let 2 PR

safety-lok collection set 3

safetyglide insulin syringe (safetyglid ins 1 ml, saftygld ins0.3 ml, saftygld ins 0.5 ml) 2 PR

safetyglide needle 3

sidekick 3PR

PA

SILVASORB GEL 3

SILVRSTAT 3

single-let 2 PR



smart caresens n 3PR

PA

smart sense 2 PR

smart sense lancets 2 PR

smart sense monitoring system 3PR

PA

smartdiabetes vantage 2 PR

smartest 3

smartest eject 3PR

PA

smartest lancet 2 PR

smartest persona (glucose meter, starter kit) 3PR

PA

smartest pronto (glucose meter, starter kit) 3PR

PA

smartest protege 3PR

PA

smartest smart code 3PR

PA

smartest talking 3PR

PA

sodium hyaluronate 3

S

MED Medical Drug

PA

sof-sensor 3

soft touch 2 PR



solus v2 (, sys kit) 3PR

PA

solus v2 28g lancets 2 PR

solus v2 control solution (solution high, solution low) 3

solus v2 lancets 2 PR

solus v2 lancing device 2 PR

SPRAY AND STRETCH 3

sterilance tl 2 PR

SUPARTZ FX 3

S

PA


super thin lancets 2 PR

sure comfort (pen ndl 29gx1/2", 30g pen needle, 31g penneedle, pen ndl 31gx3/16", pen ndl 32gx1/4", pen ndl32gx5/32")

2 PR

sure comfort lancets 2 PR

sure comfort lancing pen 2 PR

sure-fine pen needles 2 PR

sure-lance 2 PR

sure-pen 2 PR

sure-test easyplus mini meter 3PR

PA

sure-test easyplus mini soln 3

sure-touch 2 PR

sureflex 2 PR



SYNVISC 3

S

PS

PA


SYNVISC-ONE 3

S

PS

PA


td gold blood glucose monitor 3PR

PA

td gold level 1 control sol 3



td gold voice glucose monitor 3PR

PA

techlite insulin syringe (0.3 ml 30gx12mm (1/2), 0.5 ml29gx12mm (1/2), 0.5 ml 30gx12mm (1/2), 0.5 ml30gx8mm (1/2), 0.5 ml 31gx6mm (1/2), 0.5 ml 31gx8mm(1/2))

2 PR

techlite lancets 2 PR

techlite pen needle 2 PR

telcare ultra thin 30g lancets 2 PR

telcare blood glucose monitor 3PR

PA

telcare bgm 3PR

PA



telcare control solution 3

terumo surguard2 (ndl 21gx1 1.5, ndl 22x1-1/2", ndl 23x1-1/2", needle 18gx1", needle 18x1.5, needle 19gx1", needle19x1.5, needle 20gx1", needle 20x1.5, needle 21gx1",needle 22gx1", needle 23gx1", needle 25gx1", needle25x1.5, needle 25x5/8, needle 26x1/2, needle 27x1/2,needle 30x1/2)

3

test n'go blood glucose system 3PR

PA

thin lancets 2 PR

topcare clickfine 2 PR

topcare universal1 lancet 2 PR

topcare universal1 thin lancet 2 PR

TRILURON 3

S

MED Medical Drug

PA

TRIVISC 3

S

PA


true comfort lancet 2 PR

true comfort pen needle 2 PR

true metrix (1 soln, 2 soln, 3 soln) 3

true metrix air glucose meter (glucose meter, humana glumtr, humana meter) 3

PR

PA

true metrix blood glucose mtr 3PR

PA



true metrix go 3PR

PA

true2go blood glucose system 3PR

PA

truecontrol 3

truedraw 2 PR

trueplus lancet 2 PR

trueplus lancets 2 PR

trueplus pen needle 2 PR

trueresult blood glucose systm 3PR

PA

truetrack blood glucose system 3PR

PA

truetrack smart system 3PR

PA

twist lancets 2 PR

ulti-lance (auto-ad, automatic) 2 PR

ulticare pen needle 2 PR

ulticare tb safety 1ml 27gx5/8 3

ultiguard safe pack 2 PR

ultilet basic 2 PR

ultilet classic 2 PR

ultilet lancets 2 PR

ultilet pen needle 2 PR



ultilet safety 2 PR

relion ultima glucose meter 3PR

PA

ultra fine lancets 2 PR

ultra flo pen needle 2 PR

ultra thin 2 PR

ultra thin lancet 2 PR

ultra thin lancets 2 PR

ultra thin plus 2 PR

ultra thin plus lancets 2 PR

ultra-care lancets 2 PR

ultra-fine micro pen needle 2 PR

ultra-fine mini pen needle 2 PR

ultra-fine nano pen needle 2 PR

ultra-fine original pen needle 2 PR

ultra-fine short pen needle 2 PR

ultra-thin ii (pen ndl 29gx1/2", pen ndl 31gx5/16) 2 PR

ultra-thin ii (28g, 30g) 2 PR

ultracare pen needle 2 PR

ultralance 2 PR

ultratlc lancets 2 PR

ultratrak (sol normal, solution) 3

ultratrak blood glucose meter 3PR

PA



ultratrak pro (glucose mtr sys, meter kit) 3PR

PA

ultratrak ultimate cntrl soln 3

ultratrak ultimate glucose mtr 3PR

PA

unifine pentips 2 PR

unifine pentips maxflow 2 PR

pv unifine pentip plus 31gx8mm 2 PR

unifine pentips plus (careone pentp 29gx1/2", careonepentp 31gx1/4", careone pntp 31gx3/16", careone pntp31gx5/16", careone pntp 32gx5/32", heb pntp plus31gx3/16, heb pntp plus 32gx5/32, pentips plus 29gx1/2",pentips plus 31gx1/4", pentips plus 31gx3/16", pentipsplus 31gx5/16", pentips plus 32gx5/32", pentips plus33gx5/32", pub pntp plus 31gx3/16, pv pentip plus31gx5mm, pv pentip plus 31gx6mm, pv pentip plus32gx4mm, pv pentip plus 33gx4mm, shopko pentips 4mm32g, shopko pentips 5mm 31g, shopko pentips 8mm 31g,shopko pntips 12mm 29g, wm pentip plus 4mm 32g, wmpentip plus 5mm 31g, wm pentip plus 6mm 31g, wmpentip plus 8mm 31g)

2 PR

unifine pentips plus maxflow 2 PR

unifine safecontrol 2 PR

unilet comfortouch 2 PR

unilet excelite 2 PR

unilet excelite ii 2 PR

unilet gp lancet 2 PR

unilet lancet 2 PR



unilet lancets 2 PR

unistik 2 2 PR

unistik 2 extra 2 PR

unistik 2 normal 2 PR

unistik 3 (3 1.8 mm lancing devic, 3 comfort lancet, 3gentle 30g lancets, 3 gentle on-the-go 30g, 3 normal 23glancets, 3 safety 21g lancets)

2 PR

unistik 3 comfort 2 PR

unistik 3 extra 2 PR

unistik 3 neonatal 2 PR

unistik czt 2 PR

unistik pro 2 PR

unistik safety 2 PR

unistik touch 2 PR

unistrip (solution high, solution low) 3

universal 1 2 PR

vanishpoint insulin syringe 2 PR

verasens blood glucose meter 3PR

PA

verasens control solution 3

verasens meter starter kit 3PR

PA

verifine pen needle 2 PR

vivaguard ino control solution (soln-l1, l3, soln-l2, soln-l1,2,3) 3



vivaguard ino glucose meter 3PR

PA

vivaguard ino smart gluc meter 3PR

PA

vivaguard lancet 2 PR

vivaguard lancing device 2 PR

wavesense amp 3PR

PA

wavesense control solution 3

wavesense presto system kit 3PR

PA

yale needle 3

DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY

ACTHAR 3S

PA

CORTROSYN 3 MED Medical Drug

cosyntropin 1 MED Medical Drug

DIABETES MELLITUS

accu-chek aviva plus test strp 3

QL 10 / day

PR

PA

accu-chek compact plus strips 3

QL 10 / day

PR

PA



accu-chek guide test strip 3

QL 10 / day

PR

PA

accu-chek smartview test strip 3

QL 10 / day

PR

PA

accutrend glucose test strip 3

QL 10 / day

PR

PA

advanced glucose test strip 3

QL 10 / day

PR

PA

advanced glucose test strips 3

QL 10 / day

PR

PA

advocate redi-code test strip 3

QL 10 / day

PR

PA

advocate redi-code+ 3

QL 10 / day

PR

PA

advocate test strip 3

QL 10 / day

PR

PA

agamatrix amp test strips 3

QL 10 / day

PR

PA



agamatrix presto 3

QL 10 / day

PR

PA

assure 4 test strips 3

QL 10 / day

PR

PA

assure platinum test strips 3

QL 10 / day

PR

PA

assure platinum test strip 3

QL 10 / day

PR

PA

assure prism multi test strips 3

QL 10 / day

PR

PA

blood glucose test strip 3

QL 10 / day

PR

PA

breeze 2 disc test strip 3

QL 10 / day

PR

PA

caresens n test strips 3

QL 10 / day

PR

PA

caretouch test strip 3

QL 10 / day

PR

PA



choicedm clarus test strips 3

QL 10 / day

PR

PA

clever choice micro test strip 3

QL 10 / day

PR

PA

clever choice pro test strip 3

QL 10 / day

PR

PA

clever choice talk test strips 3

QL 10 / day

PR

PA

clever choice test strips 3

QL 10 / day

PR

PA

clever choice voice+ tst strip 3

QL 10 / day

PR

PA

contour next test strip 2QL 10 / day

PR

contour test strip 2QL 10 / day

PR

cool glucose test strip 3

QL 10 / day

PR

PA

dario blood glucose test strip 3

QL 10 / day

PR

PA



diatrue plus test strip 3

QL 10 / day

PR

PA

easy gluco g2 3

QL 10 / day

PR

PA

easy plus ii test strip 3

QL 10 / day

PR

PA

easy step glucose test strips 3

QL 10 / day

PR

PA

easy talk glucose test strip 3

QL 10 / day

PR

PA

easy touch test strip 3

QL 10 / day

PR

PA

easy trak glucose test strip 3

QL 10 / day

PR

PA

easy trak ii test strip 3

QL 10 / day

PR

PA

easygluco plus 3

QL 10 / day

PR

PA



easygluco test strips 3

QL 10 / day

PR

PA

easymax glucose test strips 3

QL 10 / day

PR

PA

easymax 15 glucose test strip 3

QL 10 / day

PR

PA

element compact test strips 3

QL 10 / day

PR

PA

element test strips 3

QL 10 / day

PR

PA

embrace (, glucose) 3

QL 10 / day

PR

PA

embrace evo test strips 3

QL 10 / day

PR

PA

embrace pro test strip 3

QL 10 / day

PR

PA

embrace talk test strip 3

QL 10 / day

PR

PA



evencare glucose tst strips 3

QL 10 / day

PR

PA

evencare g2 test strip 3

QL 10 / day

PR

PA

evencare g3 test strip 3

QL 10 / day

PR

PA

evencare mini glucose test str 3

QL 10 / day

PR

PA

evencare proview test strip 3

QL 10 / day

PR

PA

evolution test strips 3

QL 10 / day

PR

PA

ez smart test strips 3

QL 10 / day

PR

PA

ez smart plus test strips 3

QL 10 / day

PR

PA

fifty50 test strip 3

QL 10 / day

PR

PA



fora 6 connect glucose strip 3

QL 10 / day

PR

PA

fora d15g 3

QL 10 / day

PR

PA

fora d20 glucose test strips 3

QL 10 / day

PR

PA

fora d40-g31 test strips 3

QL 10 / day

PR

PA

fora g20 glucose test strips 3

QL 10 / day

PR

PA

fora g30-premium v10 test strp 3

QL 10 / day

PR

PA

fora gd50 test strips 3

QL 10 / day

PR

PA

fora gtel glucose test strip 3

QL 10 / day

PR

PA

fora test strip 3

QL 10 / day

PR

PA



fora tn'g voice test strips 3

QL 10 / day

PR

PA

fora v10 glucose test strip 3

QL 10 / day

PR

PA

fora v10-v12-d10-d20 strips 3

QL 10 / day

PR

PA

fora v12 glucose test strip 3

QL 10 / day

PR

PA

fora v20 glucose test strips 3

QL 10 / day

PR

PA

fora v30a glucose test strip 3

QL 10 / day

PR

PA

foracare gd20 test strips 3

QL 10 / day

PR

PA

foracare gd40 3

QL 10 / day

PR

PA

fortiscare glucose test strips 3

QL 10 / day

PR

PA



freestyle insulinx (strip nfrs, test strip) 3

QL 10 / day

PR

PA

freestyle insulinx test strips 3

QL 10 / day

PR

PA

freestyle lite test strip 3

QL 10 / day

PR

PA

freestyle precision neo 3

QL 10 / day

PR

PA

freestyle test strips 3

QL 10 / day

PR

PA

ge100 blood glucose test strip 3

QL 10 / day

PR

PA

genstrip 3

QL 10 / day

PR

PA

genultimate test strip 3

QL 10 / day

PR

PA

gluco navii glucose test strip 3

QL 10 / day

PR

PA



glucocard 01 sensor plus 3

QL 10 / day

PR

PA

glucocard expression test strp 3

QL 10 / day

PR

PA

glucocard shine test strips 3

QL 10 / day

PR

PA

glucocard vital test strips 3

QL 10 / day

PR

PA

glucocard vital sensor 3

QL 10 / day

PR

PA

glucocom glucose 3

QL 10 / day

PR

PA

glucose test strip 3

QL 10 / day

PR

PA

gojji blood glucose test strip 3

QL 10 / day

PR

PA

goodlife ac-302 test strip 3

QL 10 / day

PR

PA



harmony glucose test strip 3

QL 10 / day

PR

PA

healthpro glucose test strips 3

QL 10 / day

PR

PA

iglucose test strip 3

QL 10 / day

PR

PA

infinity test strips 3

QL 10 / day

PR

PA

infinity voice test strip 3

QL 10 / day

PR

PA

micro 3

QL 10 / day

PR

PA

microdot test strips 3

QL 10 / day

PR

PA

microdot xtra 3

QL 10 / day

PR

PA

myglucohealth test strips 3

QL 10 / day

PR

PA



neutek 2tek test strips 3

QL 10 / day

PR

PA

nova max glucose test strips 3

QL 10 / day

PR

PA

on call express test strip 3

QL 10 / day

PR

PA

on call plus test strip 3

QL 10 / day

PR

PA

on call vivid test strip 3

QL 10 / day

PR

PA

onetouch ultra blue test strp 3

QL 10 / day

PR

PA

onetouch verio test strip 3

QL 10 / day

PR

PA

optium 3

QL 10 / day

PR

PA

optium ez 3

QL 10 / day

PR

PA



optumrx test strip 3

QL 10 / day

PR

PA

pharmacist choice test strips 3

QL 10 / day

PR

PA

precision pcx 3

QL 10 / day

PR

PA

precision pcx plus 3

QL 10 / day

PR

PA

precision point of care 3

QL 10 / day

PR

PA

precision q-i-d 3

QL 10 / day

PR

PA

precision xtra test strips 3

QL 10 / day

PR

PA

premier test strip 3

QL 10 / day

PR

PA

premium blood glucose test 3

QL 10 / day

PR

PA



premium v10 glucose test strip 3

QL 10 / day

PR

PA

pro voice v8-v9 test strip 3

QL 10 / day

PR

PA

prodigy no coding 3

QL 10 / day

PR

PA

quintet glucose test strips 3

QL 10 / day

PR

PA

quintet ac glucose test strips 3

QL 10 / day

PR

PA

refuah plus test strips 3

QL 10 / day

PR

PA

relion confirm-micro 3

QL 10 / day

PR

PA

relion prime test strips 3

QL 10 / day

PR

PA

reveal test strip 3

QL 10 / day

PR

PA



rightest gs100 test strips 3

QL 10 / day

PR

PA

rightest gs250s test strips 3

QL 10 / day

PR

PA


QL 10 / day

PR

PA


QL 10 / day

PR

PA


QL 10 / day

PR

PA

smart sense test strips 3

QL 10 / day

PR

PA

smartest test 3

QL 10 / day

PR

PA

solus v2 test strips 3

QL 10 / day

PR

PA

sure-test easyplus mini strip 3

QL 10 / day

PR

PA



td gold test strip 3

QL 10 / day

PR

PA

telcare test strips 3

QL 10 / day

PR

PA

test n'go glucose test strip 3

QL 10 / day

PR

PA

test strips 3

QL 10 / day

PR

PA

true metrix glucose test strip 3

QL 10 / day

PR

PA

true metrix pro test strip 3

QL 10 / day

PR

PA

truetest test strips 3

QL 10 / day

PR

PA

truetrack test strip 3

QL 10 / day

PR

PA

ultima (, relion) 3

QL 10 / day

PR

PA



ultratrak test strip 3

QL 10 / day

PR

PA

ultratrak ultimate test strips 3

QL 10 / day

PR

PA

unistrip1 3

QL 10 / day

PR

PA

verasens test strip 3

QL 10 / day

PR

PA

vivaguard ino test strip 3

QL 10 / day

PR

PA

wavesense jazz 3

QL 10 / day

PR

PA

wavesense presto test strips 3

QL 10 / day

PR

PA

OCULAR DISORDERS

TISSUEBLUE 3 MED Medical Drug

PITUITARY FUNCTION

ACTHREL 3

S

MED Medical Drug

PA



MACRILEN 3S

PA

RESPIRATORY FUNCTION

methacholine chloride 1 MED Medical Drug

ROENTGENOGRAPHY AND OTHER IMAGING AGENTS

CERETEC 0.5 MG VIAL 3 MED Medical Drug

CONRAY-43 VIAL 3 MED Medical Drug

DOTAREM 2.5 MMOL/5 ML VIAL 3 MED Medical Drug

OMNIPAQUE 12 MG/ML ORAL SOLN 3

OMNIPAQUE 9 MG/ML ORAL SOLN 3 MED Medical Drug

OPTIRAY 240 (240 MG/ML) SYRN 3 MED Medical Drug

READI-CAT 2 3

TECHNESCAN HDP 3 MED Medical Drug

THYROID FUNCTION

THYROGEN 3

S

PA


URINE AND FECES CONTENTS

azo 3

chek-stix 3 QL 6.66 / day

chemstrip 10 md 3

chemstrip 10 with sg 3

chemstrip 2 gp 3



chemstrip 50b 3

chemstrip 7 3

chemstrip 9 3

combistix reagent 3

hema-combistix 3

ictotest 3

keto-diastix reagent 3

labstix reagent 3

multistix 3

multistix 10 sg 3

multistix 5 3

multistix 7 3

multistix 8 sg 3

multistix 9 3

multistix 9 sg 3

urinary tract infection 3

uristix 4 3

uristix reagent 3

DIURETICS

LOOP DIURETICS

bumetanide (1 mg tablet, 2 mg tablet) 1PR

HCG

bumetanide 0.5 mg tablet 1 PR

DEMADEX 3 PR



EDECRIN 3

PR



ethacrynic acid 1

PR

HCG


furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet) 1 PR

LASIX 3ST

PR

torsemide 1 PR

OSMOTIC DIURETICS

mannitol (5% iv solution, 10% iv solution, 20% iv solution,25% vial) 1 MED Medical Drug

OSMITROL 1 MED Medical Drug

POTASSIUM-SPARING DIURETICS

amiloride hcl 1 PR

amiloride-hydrochlorothiazide 1 PR

DYAZIDE 3

ST

PR


DYRENIUM 3

PR

PA





MAXZIDE 3

ST

PR


MAXZIDE-25 MG 3

ST

PR


triamterene 1PR

PA

triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25mg tb, 50-25 mg cap, 75-50 mg tab) 1 PR

THIAZIDE DIURETICS

chlorothiazide 1 PR

chlorothiazide sodium 1 MED Medical Drug

DIURIL 3 PR

hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 50 mg tab) 1 PR

hydrochlorothiazide 25 mg tab 1 PR

methyclothiazide 1 PR

MICROZIDE 3 PR

SODIUM DIURIL 3 MED Medical Drug

THIAZIDE-LIKE DIURETICS

chlorthalidone 1 PR

indapamide 1 PR

metolazone 1 PR



VASOPRESSIN ANTAGONISTS

JYNARQUE 15 MG TABLET 3

QL 1 / day

S

PA

JYNARQUE (15 MG-15 MG TABLET, 30 MG TABLET, 30MG-15 MG TABLET, 45 MG-15 MG TABLET, 60 MG-30 MGTABLET, 90 MG-30 MG TABLET)

3

QL 2 / day

S

PA

SAMSCA 15 MG TABLET 3

QL 1 / day

S

PA

SAMSCA 30 MG TABLET 3

QL 2 / day

S

PA

tolvaptan 15 mg tablet 1

QL 1 / day

S

PA

tolvaptan 30 mg tablet 1

QL 2 / day

S

PA

DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1 HCG

cabergoline 1

CYCLOSET 3

QL 6 / day

PR

PA



PARLODEL (2.5 MG TABLET, 5 MG CAPSULE) 3

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

APOKYN 3

QL 2 / day

S

PA

KYNMOBI (10 MG FILM, 15 MG FILM, 20 MG FILM, 25 MGFILM, 30 MG FILM) 3

QL 5 / day

S

PA

KYNMOBI TITRATION KIT 3

QL 10 / 30 days

S

PA

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3 PA

pramipexole dihydrochloride 1

pramipexole er 1

REQUIP 3

REQUIP XL 3

ropinirole er 1

ropinirole hcl 1

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS

K-PHOS ORIGINAL 3

ALKALINIZING AGENTS

CYTRA-K CRYSTALS PACKET 1



potassium citrate er 1

UROCIT-K 3

AMMONIA DETOXICANTS

BUPHENYL 500 MG TABLET 3 S

CARBAGLU 3 S

CONSTULOSE 1

ENULOSE 1

GENERLAC 1

KRISTALOSE 1

lactulose 10 gm packet 1

HCG


lactulose (10 gm/15 ml solution, 20 gm/30 ml solution) 1

RAVICTI 3

QL 20 / day

S

PA

sodium phenylbutyrate 500mg tb 1 S

CALORIC AGENTS

ACD-A 30 ML VIAL 1 MED Medical Drug

CLINOLIPID 3 MED Medical Drug

CYCLINEX-1 3

DOJOLVI 3S

PA

EAA 3



GLYCOSADE 60 G POWDER PACKET 3

GLYTACTIN 10 PE COMPLETE 3

GLYTACTIN 15 PE BETTERMILK 3

GLYTACTIN 15 PE COMPLETE 3

GLYTACTIN 20PE BETTERMILK LITE 3

GLYTACTIN BUILD 10 PE 3

GLYTACTIN BUILD 20-20 3

GLYTACTIN BURST 10-10 3

GLYTACTIN BURST 20-20 3

GLYTACTIN RESTORE 10 PE 3

GLYTACTIN RESTORE 10 PE LITE 3

GLYTACTIN RESTORE 5 PE 3

GLYTACTIN RTD 10 PE 3

GLYTACTIN RTD 15 PE 3

GLYTACTIN RTD LITE 15 3

GLYTACTIN SWIRL 15 PE 3

HCY 1 3

HOMINEX-1 3

LANAFLEX 3

OMEGAVEN 3 MED Medical Drug

PHENYLADE GMP DRINK POWDER 3

PHENYLADE GMP MIX-IN POWDER 3

PLENAMINE 1 MED Medical Drug



IRRIGATING SOLUTIONS

DELFLEX-2.5% DEXTROSE 3 MED Medical Drug

RESECTISOL 3 MED Medical Drug

RIMSO-50 3 MED Medical Drug

REPLACEMENT PREPARATIONS

calcium gluconate-0.9% nacl (1 g/50-0.9%, 2 g/50-0.9%) 1 MED Medical Drug

calcium gluconate-nacl 1 MED Medical Drug

dextrose 5%-0.2% nacl-kcl 1 MED Medical Drug




dextrose 5%-1/2ns-kcl 1 MED Medical Drug

dextrose 5%-1/4ns-kcl 1 MED Medical Drug

dextrose 5%-ns-kcl 1 MED Medical Drug

dextrose 5%-potassium chloride 1 MED Medical Drug

EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3

EFFER-K 25 MEQ TABLET EFF 1

K EFFERVESCENT 1

K-TAB ER 3 ST

KLOR-CON 1

KLOR-CON 10 1

KLOR-CON 8 1

KLOR-CON M10 1



KLOR-CON M15 3

KLOR-CON M20 1

KLOR-CON-EF 1

potassium acetate 1 MED Medical Drug

potassium bicarbonate 1

potassium cl 20 meq packet 1 HCG

potassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20% (40 meq/15ml), er 20 meqtablet, 25 meq tab eff)

1

potassium chloride (2 meq/ml conc, 10 meq/100 ml sol,10 meq/5 ml conc, 10 meq/50 ml sol, 20 meq/10 ml conc,20 meq/100 ml sol, 20 meq/50 ml sol, 30 meq/100 ml sol,40 meq/100 ml sol, 40 meq/20 ml conc, 60 meq/30 mlconc)

1 MED Medical Drug

potassium chloride in d5lr 1 MED Medical Drug

potassium chloride proamp 1 MED Medical Drug

potassium chloride-nacl 1 MED Medical Drug

potassium cl-lidocaine-ns 1 MED Medical Drug

potassium ph 30 mmol/250 ml-ns 1 MED Medical Drug

potassium phosphates 1 MED Medical Drug

sodium chloride 0.9% ampule 1 BSP BENEFIT SHIFTPROGRAM

sodium phos 30 mmol/250 ml-ns 1 MED Medical Drug

sodium phosphate-d5w 1 MED Medical Drug

zinc chloride 1 MED Medical Drug



URICOSURIC AGENTS

probenecid 1 QL 4 / day

probenecid-colchicine 1 QL 2 / day

ENZYMES

ADAGEN 3S

MED Medical Drug

ALDURAZYME 3

S

PA


CEREZYME 3

S

PA


ELAPRASE 3

S

PA


ELELYSO 3

S

PS

PA


ELITEK 3S

MED Medical Drug

FABRAZYME 3

S

PA




HYLENEX 3 MED Medical Drug

HYQVIA HY COMPONENT 3S

PA

LUMIZYME 3

S

PA


MEPSEVII 3

S

MED Medical Drug

PA

NAGLAZYME 3

S

PA


PALYNZIQ (10 MG/0.5 ML SYRINGE, 20 MG/ML SYRINGE) 3

QL 2 / day

S

PA

PALYNZIQ 2.5 MG/0.5 ML SYRINGE 3

QL 8 / day

S

PA

REVCOVI 3S

MED Medical Drug

STRENSIQ 3

S

PS

PA

SUCRAID 3S

PA

VIMIZIM 3S

MED Medical Drug



VITRASE 3 MED Medical Drug

VPRIV 3

S

PA


XIAFLEX 3

S

PA


ESTROGENS AND ANTIESTROGENS

ESTROGEN AGONIST-ANTAGONISTS

clomiphene citrate 1 GL Female

EVISTA 3QL 1 / day

PR

FARESTON 3PR


OSPHENA 3 PR

raloxifene hcl 1PR

HCR

SEROPHENE 1 GL Female

SOLTAMOX 3 PR

tamoxifen citrate 1PR

HCR

toremifene citrate 1 PR



ESTROGENS

ACTIVELLA 0.5-0.1 MG TABLET 3

QL 1 / day

GL Female



ACTIVELLA 1 MG-0.5 MG TABLET 3

QL 1 / day

GL Female



ALORA 3

QL 0.29 / day

ST

GL Female

AMABELZ 1QL 1 / day

GL Female

ANGELIQ 3QL 1 / day

GL Female

BIJUVA 3QL 1 / day

GL Female

CLIMARA 3

QL 0.15 / day

ST

GL Female

CLIMARA PRO 2QL 0.15 / day

GL Female

COMBIPATCH 3QL 0.29 / day

GL Female



DELESTROGEN (50 MG/5 ML VIAL, 200 MG/5 ML VIAL) 3ST

GL Female

DELESTROGEN 100 MG/5 ML VIAL 3

ST

GL Female


DEPO-ESTRADIOL 3 GL Female

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75MG GEL PACKET, 1 MG GEL PACKET, 1.25 MG GELPACKET)

2QL 1 / day

GL Female

DOTTI 1QL 0.29 / day

GL Female

DUAVEE 2

ELESTRIN 3 GL Female

ESTRACE 0.01% CREAM 3

QL 4 / day

ST

GL Female

ESTRACE (0.5 MG TABLET, 1 MG TABLET) 3

QL 1 / day

ST

GL Female

ESTRACE 2 MG TABLET 3

QL 1 / day

ST

GL Female


estradiol 0.01% cream 1QL 4 / day

GL Female

estradiol (0.5 mg tablet, 1 mg tablet) 1QL 1 / day

GL Female



estradiol 10 mcg vaginal insrt 1QL 0.643 / day

GL Female

estradiol 2 mg tablet 1QL 1 / day

GL Female

estradiol (once weekly) (0.025 mg patch(1/wk), 0.0375mgpatch(1/wk), 0.05 mg patch (1/wk), 0.06 mg patch (1/wk),0.1 mg patch (1/wk))

1QL 0.15 / day

GL Female

estradiol 0.075 mg patch(1/wk) 1

QL 0.15 / day

GL Female

HCG

estradiol (twice weekly) 1QL 0.29 / day

GL Female

estradiol valerate 1GL Female

HCG

estradiol-norethindrone acetat 1QL 1 / day

GL Female

ESTRING 3QL 90 days

GL Female

ESTROGEL 3QL 1.667 / day

GL Female

EVAMIST 2QL 0.54 / day

GL Female

FEMHRT 3QL 1 / day

GL Female

FEMRING 3

QL 0.02 / day

ST

GL Female



FYAVOLV 1

QL 1 / day

GL Female

HCR

IMVEXXY (4 MCG MAINTENANCE PACK, 4 MCG STARTERPACK, 10 MCG MAINTENANCE PAK, 10 MCG STARTERPACK)

3 QL 1 / day

JEVANTIQUE LO 1

QL 1 / day

GL Female

HCR

JINTELI 1

QL 1 / day

GL Female

HCR

LOPREEZA 1QL 1 / day

GL Female

MENEST (0.625 MG TABLET, 1.25 MG TABLET) 3QL 1 / day

GL Female

MENEST 0.3 MG TABLET 2QL 1 / day

GL Female

MENOSTAR 3QL 0.15 / day

GL Female

MIMVEY 1QL 1 / day

GL Female

MIMVEY LO 1

HCG


MINIVELLE 3

QL 0.29 / day

ST

GL Female



norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg,norethind-eth 0.5-2.5) 1

QL 1 / day

HCR

PREFEST 3QL 1 / day

GL Female

PREMARIN VAGINAL CREAM-APPL 2QL 2 / day

GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET) 2

QL 1 / day

GL Female

PREMARIN 25 MG VIAL 2

PREMPHASE 2QL 1 / day

GL Female

PREMPRO 2QL 1 / day

GL Female

VAGIFEM 3

QL 0.643 / day

GL Female


VIVELLE-DOT 3

QL 0.29 / day

ST

GL Female

YUVAFEM 1QL 0.643 / day

GL Female

EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

ALOMIDE 3QL 10 / fill




azelastine hcl 0.05% drops 1 QL 0.267 / day

azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1 QL 2 / day

azelastine-fluticasone 1QL 0.8 / day

ST

BEPREVE 3QL 0.334 / day

ST

DYMISTA 2QL 0.8 / day

B4G

ELESTAT 3 QL 0.286 / day

EMADINE 3 QL 5 / fill

epinastine hcl 1 QL 0.286 / day

ketotifen fumarate 1 QL 0.167 / day

LASTACAFT 3QL 3 / 30 days

ST

olopatadine hcl (0.1% drops, 0.2% drop) 1 QL 0.286 / day

olopatadine 665 mcg nasal spry 1 QL 31 / 30 days

PATADAY 0.2% EYE DROPS 3QL 0.286 / day

ST

PATANASE 3 QL 31 / 30 days

PATANOL 3QL 0.286 / day

ST

PAZEO 2 QL 0.286 / day

ZERVIATE 3QL 2 / day

ST



EENT DRUGS, MISCELLANEOUS

apraclonidine hcl 1 QL 0.8 / day

BEOVU 3

QL 1 / rx

S

MED Medical Drug

PA

bevacizumab (1 mg/0.04 ml syrng, 1.25 mg/0.05 ml, 2.5mg/0.1 ml syrg) 1

S

MED Medical Drug

PA

CYSTADROPS 3

QL 0.72 / day

S

PA

CYSTARAN 3

QL 1 / day

S

PA

EYLEA 2 MG/0.05 ML SYRINGE 3

QL 0.04 / day

S

PA


IOPIDINE (0.5% DROPS, 1% DROPS) 3 QL 0.8 / day

ipratropium bromide (0.03% spray, 0.06% spray) 1 QL 2 / day

LUCENTIS (0.3 MG/0.05 ML SYRING, 0.3 MG/0.05 MLVIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 3

QL 0.04 / day

S

PA


OXERVATE 3

QL 1 / day

S

PA



TEPEZZA 3S

MED Medical Drug

VISUDYNE 3S

MED Medical Drug

LOCAL ANESTHETICS (EENT)

AKTEN 3

NUMBRINO 3 MED Medical Drug

proparacaine hcl 1

TETCAINE 1

tetracaine hcl (eye drop, steri-unit sol) 1

MYDRIATICS

atropine sulfate (drops, ointment) 1

HOMATROPAIRE 1

homatropine hydrobromide 1

OMIDRIA 3 MED Medical Drug

VASOCONSTRICTORS

ADRENALIN CHLORIDE 3 PA

phenylephrine hcl (2.5% drop, 10% drops) 1

UPNEEQ 3

QL 1 / day


PA

VISINE TOTALITY 3



FIRST GENERATION ANTIHISTAMINES

ETHANOLAMINE DERIVATIVES

carbinoxamine 4 mg/5 ml liquid 1 AL At least 2 yrsold

carbinoxamine maleate 4 mg tab 1 AL At least 6 yrsold

carbinoxamine maleate 6 mg tab 1


HCG


clemastine fumarate 1 AL At least 2 yrsold

diphenhydramine 50 mg/ml crpjt 1

diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 1

diphenhydramine hcl (50 mg/ml syrng, 50 mg/ml vial) 1 BSP BENEFIT SHIFTPROGRAM

diphenhydramine-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM

KARBINAL ER 3 AL At least 2 yrsold

RYVENT 3

ST

HCG


FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp) 1 AL At least 2 yrs

old



PHENOTHIAZINE DERIVATIVES

PHENADOZ 1 AL At least 2 yrsold

PHENERGAN (25 MG/ML AMPUL, 25 MG/ML VIAL, 50MG/ML AMPUL, 50 MG/ML VIAL) 3


MED Medical Drug

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp,12.5 mg suppos, 12.5 mg tablet, 25 mg suppository, 50mg suppository, 50 mg tablet)


promethazine 25 mg tablet 1 AL At least 2 yrsold

promethazine hcl (25 mg/ml ampul, 25 mg/ml vial, 50mg/ml ampul, 50 mg/ml vial) 1



promethazine hcl-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM

promethazine-phenylephrine 1

PROMETHEGAN 1 AL At least 2 yrsold

PROPYLAMINE DERIVATIVES

ABATUSS DMX 1 AL At least 2 yrsold

ALLER-CHLOR 1

CONEX SOLUTION 3

dexchlorpheniramine maleate 1


HCG




RESPA A.R. 3

RYCLORA 3 AL At least 2 yrsold

GASTROINTESTINAL DRUGS

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 1GL Female


APRISO 2 B4G

ASACOL HD 3PA

B4G

balsalazide disodium 1

CANASA 3ST


COLAZAL 3 SBA Select BrandAlternative

DELZICOL 3PA


DIPENTUM 3 PA

LIALDA 3PA


LOTRONEX 3

GL Female


PA

mesalamine 4 gm/60 ml kit 1 HCG



mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 1,000mg supp) 1

mesalamine 800 mg dr tablet 3 PA

mesalamine dr 1

mesalamine er 1

PENTASA 3

ROWASA (4 GM/60 ML ENEMA, 4 GM/60 ML ENEMA KIT) 3

SFROWASA 3

ANTIDIARRHEA AGENTS

diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5,diphenoxylate-atrop 2.5-0.025) 1

LOMOTIL 3

loperamide 2 mg capsule 1

MOTOFEN 3 MVB MINIMALVALUE BRAND

MYTESI 3 S

opium tincture 1 QL 5 / day

paregoric 1

XERMELO 3


S

PA

CATHARTICS AND LAXATIVES

AMITIZA 3

QL 2 / day


PA



CLENPIQ 3 QL 11 / day

COLYTE WITH FLAVOR PACKETS 3

ST



GAVILYTE-C 1 HCR

GAVILYTE-G 1 HCR

GAVILYTE-N 1

HCR

HCG


GOLYTELY PACKET 3QL 1/ fill

ST

GOLYTELY SOLUTION 3QL 134 / day

ST

HYDROCIL INSTANT POWDER 3

KONSYL ORIGINAL FIBER POWDER 3

MOVIPREP 3QL 1/ fill

ST

NULYTELY WITH FLAVOR PACKS 3

QL 134 / day

ST



OSMOPREP 3QL 100 / 30 days

ST



peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution) 1 HCR

peg-3350 and electrolytes 1 HCR

PEG-PREP 1

peg3350-sod sul-nacl-kcl-asb-c 1 HCR

PLENVU 3QL 3/ fill

ST

PREPOPIK 3 QL 2 / fill

SUPREP 3 QL 354 / fill

TRILYTE WITH FLAVOR PACKETS 1 HCR

CHOLELITHOLYTIC AGENTS

ACTIGALL 3

CHENODAL 3 S

URSO 3

URSO FORTE 3

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1

DIGESTANTS

CREON 2

PANCREAZE 3 PA

PERTZYE 3 PA

VIOKACE 3 PA

ZENPEP 2

GI DRUGS, MISCELLANEOUS

CHOLBAM 250 MG CAPSULE 3

QL 7 / day

S

PA



CHOLBAM 50 MG CAPSULE 3

QL 4 / day

S

PA

ENTEREG 3MED Medical Drug

PA

ENTYVIO 3

QL 2/ 30 days

S

PA


GATTEX 3S

PA

HUMIRA(CF) PEDI CROHN 80-40 MG 3

QL 0.22 / day

S

PS

PA

PS1 Preferred 1stline

LINZESS 2QL 1 / day

ST

MOVANTIK 2QL 1 / day

PA

OCALIVA 3

QL 1 / day

S

PA

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 MLSYRINGE, 12 MG/0.6 ML VIAL) 3 PA

RELISTOR 150 MG TABLET 3QL 3 / day

PA



SYMPROIC 2

QL 1 / day


PA

TRULANCE 3

QL 1 / day


PA

VIBERZI 2QL 2 / day

PA

XENICAL 3

PROKINETIC AGENTS

GIMOTI 3

QL 0.334 / day


PA

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol) 1

metoclopramide 10 mg/2 ml syr 1 MED Medical Drug

metoclopramide 10 mg/2 ml vial 1 MED Medical Drug

metoclopramide hcl odt 1

MOTEGRITY 3

QL 1 / day


PA

REGLAN 3

ZELNORM 3

QL 2 / day

AL Up to 65 yrs old

PA



GENERAL ANESTHETICS

BARBITURATES (GENERAL ANESTHETICS)

methohexital-sterile water 1 MED Medical Drug

GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

darifenacin er 1 QL 1 / day

DETROL 3QL 2 / day


DETROL LA 3QL 1 / day


DITROPAN XL 10 MG TABLET 3QL 2 / day


DITROPAN XL 5 MG TABLET 3QL 1 / day


ENABLEX 3QL 1 / day


flavoxate hcl 1

GELNIQUE (GEL PUMP, GEL SACHET) 3QL 1 / day

ST

oxybutynin 5 mg/5 ml syrup 1 QL 20 / day

oxybutynin 5 mg tablet 1 QL 4 / day

oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 QL 2 / day



oxybutynin cl er 5 mg tablet 1 QL 1 / day

OXYTROL 3QL 0.357 / day

ST

solifenacin succinate 1 QL 1 / day

tolterodine tartrate 1 QL 2 / day

tolterodine tartrate er 1 QL 1 / day

TOVIAZ 3 QL 1 / day

trospium chloride 1 QL 2 / day

trospium chloride er 1 QL 1 / day

VESICARE 3QL 1 / day

ST

GOLD COMPOUNDS

RIDAURA 2

GONADOTROPINS AND ANTIGONADOTROPINS

ANTIGONADTROPINS

CETROTIDE 3

GL Female

S

PS

PA

FIRMAGON 3

S

MED Medical Drug

PA

ganirelix acetate 3

GL Female

S

PA



ORIAHNN 2

QL 2 / day


PA

ORILISSA 150 MG TABLET 2

QL 1 / day


PA

ORILISSA 200 MG TABLET 2

QL 2 / day


PA

GONADOTROPINS

chorionic gonad 10,000 unit vl 3S

PA

ELIGARD 3

S

PA


FOLLISTIM AQ 3S

PA

GONAL-F 3

S

PS

PA

GONAL-F RFF 3

GL Female

S

PS

PA

GONAL-F RFF REDI-JECT 3

GL Female

S

PS

PA



leuprolide 2wk 1 mg/0.2 ml kit 1S

PA

leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 1S

PA

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MGKIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 MG 6MO KIT) 3

S

PA


LUPRON DEPOT 11.25 MG 3MO KIT 3

S

PA


LUPRON DEPOT 3.75 MG KIT 3

S

PA


LUPRON DEPO 11.25MG (LUPANETA) 3

S

PA


LUPRON DEPOT 3.75MG (LUPANETA) 3

S

PA


LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG KIT, 15 MGKIT) 3

S

PA


LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT) 3

S

PA




MENOPUR 3

GL Female

S

PA

NOVAREL 3S

PA

OVIDREL 3

S

PS

PA

PREGNYL 3S

PA

SUPPRELIN LA 3

S

PA


SYNAREL 3S

PA

TRELSTAR 3

S

MED Medical Drug

PA

VANTAS 3

S

PA


ZOLADEX 10.8 MG IMPLANT SYRN 3

S

PA


ZOLADEX 3.6 MG IMPLANT SYRN 3

S

PS

PA




HCV ANTIVIRALS

HCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA 3

QL 1 / day

S

PS

PA

HARVONI (33.75-150 MG PELLET PK, 45-200 MG TABLET,90-400 MG TABLET) 3

QL 1 / day

S

PS

PA

HARVONI 45-200 MG PELLET PACKT 3

QL 2 / day

S

PS

PA

ledipasvir-sofosbuvir 3

QL 1 / day

S

PS

PA

sofosbuvir-velpatasvir 3

QL 1 / day

S

PS

PA

SOVALDI 200 MG PELLET PACKET 3

QL 2 / day

S

PS

PA

SOVALDI (150 MG PELLET PACKET, 200 MG TABLET, 400MG TABLET) 3

QL 1 / day

S

PS

PA



VOSEVI 3

QL 1 / day


S

PS

PA

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET 3

QL 3 / day


S

PS

PA

HCV REPLICATION COMPLEX INHIBITORS

DAKLINZA 3

QL 1 / day

S

PA

VIEKIRA PAK 3

QL 4 / day

S

PA

ZEPATIER 3

QL 1 / day

S

PA

HEAVY METAL ANTAGONISTS

BAL IN OIL 3 MED Medical Drug

calcium disodium versenate 1 MED Medical Drug

CHEMET 3



CUPRIMINE 3S

PA

D-PENAMINE 2S

PA

deferasirox (90 mg granule, 90 mg tablet, 125 mg tb forsusp, 180 mg granule, 180 mg tablet, 250 mg tb for susp,360 mg granule, 360 mg tablet, 500 mg tb for susp)

1S

PA

deferiprone 1S

PA

deferoxamine mesylate 1 MED Medical Drug

DEPEN 2

S

PA

B4G


DESFERAL 3 MED Medical Drug

DESFERAL MESYLATE 3 MED Medical Drug

EXJADE 3S

PA

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET,1,000 MG TABLET) 3

S

PA

FERRIPROX (2 TIMES A DAY) 3S

PA

GALZIN 3

JADENU 3S

PA

JADENU SPRINKLE 3S

PA



penicillamine (250 mg capsule, 250 mg tablet) 1S

PA

pentetate calcium trisodium 1 MED Medical Drug

pentetate zinc trisodium 1 MED Medical Drug

trientine hcl 1S

PA

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

A-HYDROCORT 3 MED Medical Drug

ALKINDI SPRINKLE 3 PA

ARISTOSPAN 3 MED Medical Drug

betamethasone acetate-sod phos (6 mg/ml vial, 7 mg/mlvial) 1 MED Medical Drug

betamethasone sod phos-acetate 1 MED Medical Drug

BREZTRI AEROSPHERE 3

QL 0.36/day

PR

PA

budesonide ec 1 HCG

budesonide er 1 PA

CELESTONE 3 MED Medical Drug

CORTEF 3ST


cortisone acetate 1 HCG

DECADRON (0.5 MG TABLET, 0.5 MG/5 ML ELIXIR, 0.75MG TABLET, 4 MG TABLET, 6 MG TABLET) 1



DEPO-MEDROL 3 BSP BENEFIT SHIFTPROGRAM

DEXABLISS 3

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mgtablet, 4 mg tablet, 6 mg tablet)

1

dexamethasone (6 1.5 mg tab, 10 1.5 mg tb, 13 1.5 mg tb) 1

HCG


dexamethasone acetate la 1 BSP BENEFIT SHIFTPROGRAM

dexamethasone acetate-sod phos 1 BSP BENEFIT SHIFTPROGRAM

DEXAMETHASONE INTENSOL 2

dexamethasone sodium phosphate (4 mg/ml syringe, 4mg/ml vial, 10 mg/ml syring, 10 mg/ml vial, 20 mg/5 mlvial, 100 mg/10 ml vl, 120 mg/30 ml vl)


dexamethasone-0.9% nacl 1 BSP BENEFIT SHIFTPROGRAM

DEXPAK 3MVB MINIMAL

VALUE BRAND


DXEVO 3 MVB Minimal ValueBrand

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET, 36 MG TABLET) 3


S

PA

ENTOCORT EC 3

fludrocortisone acetate 1



HEMADY 3 QL 2 / day

HIDEX 1

HCG


hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

INTRAROSA 3

QL 1 / day

ST


KENALOG-10 3 BSP BENEFIT SHIFTPROGRAM

KENALOG-40 3ST


KENALOG-80 3 MED Medical Drug

MEDROL (4 MG DOSEPAK, 4 MG TABLET, 8 MG TABLET,16 MG TABLET, 32 MG TABLET) 3

MEDROL 2 MG TABLET 2

methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab,16 mg tab, 32 mg tab) 1

methylprednisolone acetate (methylprednisolon ac160mg/2ml, methylprednisolone 40 mg/ml vl,methylprednisolone 80 mg/ml vl, methylprednisolone ac50 mg/ml, methylprednisolone ac 80mg/2ml,methylprednisolone ac 100mg/ml)

1 MED Medical Drug

methylprednisolone sodium succ 1 MED Medical Drug

MILLIPRED 3

MILLIPRED DP 3

ORAPRED ODT 3



ORTIKOS 3 PA

PEDIAPRED 3

prednisolone 1

prednisolone sodium phos odt 1

prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5ml soln, 15 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25mg/5 ml)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dosepack, 10 mg tablet, 20 mg tablet, 50 mg tablet)

1

PREDNISONE INTENSOL 3

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O-VL)


SOLU-MEDROL (1 GRAM VIAL, 40 MG VIAL, 125 MG VIAL,500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL) 3 MED Medical Drug

TAPERDEX 3

triamcinolone acet 200 mg/5 ml 1MED Medical Drug


triamcinolone acetonide (40 mg/ml vl, 40mg/ml vl, 50mg/ml vl, 50mg/5ml vl, 100 mg/2 ml, 400 mg/10ml) 1 BSP BENEFIT SHIFT

PROGRAM

triamcinolone diacetate (40 mg/ml, 80 mg/2ml, 80mg/ml) 1 BSP BENEFIT SHIFT

PROGRAM

UCERIS 2 MG RECTAL FOAM 3

UCERIS 9 MG ER TABLET 3 PA

VERIPRED 20 3

ZCORT 3 MVB Minimal ValueBrand



ANDROGENS

ANADROL-50 3 GL Male

ANDRODERM 2

QL 1 / day

GL Male

PA

ANDROGEL (1% (50 MG/5 G) PKT, 1.62% GEL PUMP,1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 3

QL 5 / day

GL Male

PA


ANDROGEL 1% (25 MG/2.5 G) PKT 3

QL 2.5 / day

GL Male

PA


ANDROID 3

GL Male

PA



AVEED 3

S

MED Medical Drug

PA

AXIRON 3

QL 6 / day

GL Male

PA


danazol 1



DEPO-TESTOSTERONE 3GL Male


estrogen-methyltestosterone 1 GL Female

FORTESTA 3

QL 4 / day

GL Male

PA

JATENZO 3GL Male

PA

METHITEST 3

GL Male

PA


methyltestosterone 1

GL Male

HCG


NATESTO 3

QL 3 / day

GL Male


PA


OXANDRIN 3 PA

oxandrolone 1 PA

STRIANT 3GL Male

PA

TESTIM 3

QL 300 / 30 days

GL Male

PA




TESTOPEL 3

GL Male

S

PA



testosterone 50 mg/5 gram gel 1QL 300 / 30 days

GL Male

testosterone (1% (50 mg/5 g) pk, 1.62% (2.5 g) pkt, 1.62%gel pump, 1.62%(1.25 g) pkt, 50 mg/5 gram pkt) 1

QL 5 / day

GL Male

testosterone 10 mg gel pump 1QL 4 / day

GL Male

testosterone 12.5 mg/1.25 gram 1QL 10 / day

GL Male

testosterone 1% (25mg/2.5g) pk 1QL 2.5 / day

GL Male

testosterone 30 mg/1.5 ml pump 1

QL 6 / day

GL Male

PA

HCG

testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100 mg/ml,testosterone 200 mg/ml, testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml, testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)

1 GL Male

testosterone enanthate 1 GL Male

TESTRED 3

GL Male

PA





VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5GEL PACKT) 3

QL 10 / day

PA

XYOSTED 3 PA

CONTRACEPTIVES

AFIRMELLE 1GL Female

HCR

ALTAVERA 1GL Female

HCR

ALYACEN 1GL Female

HCR

AMETHIA 1

QL 91 days

GL Female

HCR

AMETHIA LO 1

QL 91 days

GL Female

HCR

AMETHYST 1

QL 1 / day

GL Female

HCR

ANNOVERA 3

ST

GL Female

HCR

APRI 1GL Female

HCR

ARANELLE 1GL Female

HCR



ASHLYNA 1

QL 91 days

GL Female

HCR

AUBRA 1GL Female

HCR

AUBRA EQ 1GL Female

HCR

AUROVELA 1GL Female

HCR

AUROVELA 24 FE 1GL Female

HCR

AUROVELA FE 1GL Female

HCR

AVIANE 1GL Female

HCR

AYUNA 1GL Female

HCR

AZURETTE 1GL Female

HCR

BALCOLTRA 3 GL Female

BALZIVA 1GL Female

HCR

BEKYREE 1GL Female

HCR

BEYAZ 3

GL Female





BLISOVI 24 FE 1GL Female

HCR

BLISOVI FE 1GL Female

HCR

BRIELLYN 1GL Female

HCR

CAMILA 1GL Female

HCR

CAMRESE 1

QL 91 days

GL Female

HCR

CAMRESE LO 1

QL 91 days

GL Female

HCR

CAZIANT 1GL Female

HCR

CHARLOTTE 24 FE 1GL Female

HCR

CHATEAL 1GL Female

HCR

CHATEAL EQ 1GL Female

HCR

CRYSELLE 1GL Female

HCR

CYCLAFEM 1GL Female

HCR



CYRED 1GL Female

HCR

CYRED EQ 1GL Female

HCR

DASETTA 1GL Female

HCR

DAYSEE 1

QL 91 days

GL Female

HCR

DEBLITANE 1GL Female

HCR

desogestr-eth estrad eth estra 1GL Female

HCR

desogestrel-ethinyl estradiol 1GL Female

HCR

drosp-ee-levomef 3-0.02-0.451 1

GL Female

HCR

HCG

drosp-ee-levomef 3-0.03-0.451 1GL Female

HCR

drospirenone-ethinyl estradiol 1GL Female

HCR

ELINEST 1GL Female

HCR

ELLA 3

QL 1 / day

GL Female

HCR



ELURYNG 1GL Female

HCR

EMOQUETTE 1GL Female

HCR

ENPRESSE 1GL Female

HCR

ENSKYCE 1GL Female

HCR

ERRIN 1GL Female

HCR

ESTARYLLA 1GL Female

HCR

ESTROSTEP FE 3 GL Female

ethynodiol-ethinyl estradiol 1GL Female

HCR

etonogestrel-ethinyl estradiol 1GL Female

HCR

FALMINA 1GL Female

HCR

FAYOSIM 1

QL 91 days

GL Female

HCR

FEMYNOR 1GL Female

HCR

GEMMILY 1GL Female

HCR



GENERESS FE 3ST

GL Female

GIANVI 1GL Female

HCR

HAILEY 1GL Female

HCR

HAILEY 24 FE 1GL Female

HCR

HAILEY FE 1GL Female

HCR

HEATHER 1GL Female

HCR

INCASSIA 1GL Female

HCR

INTROVALE 1

QL 91 days

GL Female

HCR

ISIBLOOM 1GL Female

HCR

JAIMIESS 1

QL 91 days

GL Female

HCR

JASMIEL 1GL Female

HCR

JENCYCLA 1GL Female

HCR



JOLESSA 1

QL 91 days

GL Female

HCR

JOLIVETTE 1GL Female

HCR

JULEBER 1GL Female

HCR

JUNEL 1GL Female

HCR

JUNEL FE 1GL Female

HCR

JUNEL FE 24 1GL Female

HCR

KAITLIB FE 1GL Female

HCR

KALLIGA 1GL Female

HCR

KARIVA 1GL Female

HCR

KELNOR 1-35 1GL Female

HCR

KELNOR 1-50 1GL Female

HCR

KURVELO 1GL Female

HCR

KYLEENA 3

GL Female

S

HCR

PS




LARIN 1GL Female

HCR

LARIN 24 FE 1GL Female

HCR

LARIN FE 1GL Female

HCR

LARISSIA 1GL Female

HCR

LAYOLIS FE 1GL Female

HCR

LEENA 1GL Female

HCR

LESSINA 1GL Female

HCR

LEVONEST 1GL Female

HCR

levonorg-eth estrad eth estrad 1

QL 91 days

GL Female

HCR

levonorgestrel-eth estradiol 1GL Female

HCR

LEVORA-28 1GL Female

HCR

LILETTA 3S

MED Medical Drug

LILLOW 1GL Female

HCR



LO LOESTRIN FE 3GL Female

HCR

LO-ZUMANDIMINE 1GL Female

HCR

LOESTRIN 3

ST

GL Female


LOESTRIN FE 3

ST

GL Female


LOJAIMIESS 1

QL 91 days

GL Female

HCR

LORYNA 1GL Female

HCR

LOSEASONIQUE 3QL 91 days

GL Female

LOW-OGESTREL 1GL Female

HCR

LUTERA 1GL Female

HCR

LYZA 1GL Female

HCR

MARLISSA 1GL Female

HCR

MELODETTA 24 FE 1

GL Female

HCR

HCG



MIBELAS 24 FE 1

GL Female

HCR

HCG

MICROGESTIN 1GL Female

HCR

MICROGESTIN 24 FE 1GL Female

HCR

MICROGESTIN FE 1GL Female

HCR

MILI 1GL Female

HCR

MINASTRIN 24 FE 3GL Female


MIRCETTE 3 GL Female

MIRENA 3

GL Female

S

HCR

PS


MONO-LINYAH 1GL Female

HCR

MONONESSA 1GL Female

HCR

MYZILRA 1GL Female

HCR

NATAZIA 2 GL Female



NECON 1GL Female

HCR

NEXPLANON 3

S

HCR


NIKKI 1GL Female

HCR

NORA-BE 1GL Female

HCR

noreth-estrad-fe 1-0.02(24)-75 1

GL Female

HCR

HCG


norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, noreth-estrad-fe 1-0.02(21)-75, norethin-estra-fe 0.8-0.025 mg)

1GL Female

HCR

norethin-ee 1.5-0.03 mg(21) tb 1GL Female

HCR

norethind-eth estrad 1-0.02 mg 1

QL 1 / day

GL Female

HCR

norethindrone 1GL Female

HCR

norethindrone-eth estradiol-fe 1GL Female

HCR

norgestimate-ethinyl estradiol 1GL Female

HCR



NORLYDA 1GL Female

HCR

NORTREL 1GL Female

HCR

NUVARING 2GL Female

B4G

OCELLA 1GL Female

HCR

OGESTREL 1GL Female

HCR

ORSYTHIA 1GL Female

HCR

ORTHO MICRONOR 3ST

GL Female

ORTHO TRI-CYCLEN 3GL Female


ORTHO TRI-CYCLEN LO 3GL Female


ORTHO-CYCLEN 3ST

GL Female

ORTHO-NOVUM 3ST

GL Female

PARAGARD T 380-A 3

S

HCR




PHILITH 1GL Female

HCR

PIMTREA 1GL Female

HCR

PIRMELLA 1GL Female

HCR

PORTIA 1GL Female

HCR

PREVIFEM 1GL Female

HCR

QUARTETTE 3

GL Female



QUASENSE 1

QL 91 days

GL Female

HCR

RECLIPSEN 1GL Female

HCR

RIVELSA 1

QL 91 days

GL Female

HCR

HCG


SAFYRAL 3ST

GL Female



SEASONIQUE 3

QL 91 days

ST

GL Female

SETLAKIN 1

QL 91 days

GL Female

HCR

SHAROBEL 1GL Female

HCR

SIMLIYA 1GL Female

HCR

SIMPESSE 1

QL 91 days

GL Female

HCR

SKYLA 3

GL Female

S

HCR

PS


SLYND 3 GL Female

SPRINTEC 1GL Female

HCR

SRONYX 1GL Female

HCR

SYEDA 1GL Female

HCR

TARINA 24 FE 1GL Female

HCR



TARINA FE 1GL Female

HCR

TARINA FE 1-20 EQ 1GL Female

HCR

TAYTULLA 3 GL Female

TILIA FE 1GL Female

HCR

TRI FEMYNOR 1GL Female

HCR

TRI-ESTARYLLA 1GL Female

HCR

TRI-LEGEST FE 1GL Female

HCR

TRI-LINYAH 1GL Female

HCR

TRI-LO-ESTARYLLA 1GL Female

HCR

TRI-LO-MARZIA 1GL Female

HCR

TRI-LO-MILI 1GL Female

HCR

TRI-LO-SPRINTEC 1GL Female

HCR

TRI-MILI 1GL Female

HCR

TRI-NORINYL 3 GL Female



TRI-PREVIFEM 1GL Female

HCR

TRI-SPRINTEC 1GL Female

HCR

TRI-VYLIBRA 1GL Female

HCR

TRI-VYLIBRA LO 1GL Female

HCR

TRIVORA-28 1GL Female

HCR

TULANA 1GL Female

HCR

TWIRLA 3

QL 0.124 / day

GL Female

HCR

TYBLUME 1GL Female

HCR

TYDEMY 1GL Female

HCR

VELIVET 1GL Female

HCR

VIENVA 1GL Female

HCR

VIORELE 1GL Female

HCR

VOLNEA 1GL Female

HCR



VYFEMLA 1GL Female

HCR

VYLIBRA 1GL Female

HCR

WERA 1GL Female

HCR

WYMZYA FE 1

GL Female

HCR

HCG

XULANE 3

QL 0.12 / day

GL Female

HCR

YASMIN 28 3

ST

GL Female


YAZ 3GL Female


ZARAH 1GL Female

HCR

ZOVIA 1-35 1GL Female

HCR

ZOVIA 1-35E 1GL Female

HCR

ZUMANDIMINE 1GL Female

HCR



LEPTINS

MYALEPT 3S

PA

PITUITARY

DDAVP (0.01% NASAL SPRAY, 0.1 MG TABLET, 0.2 MGTABLET, 10 MCG/0.1 ML SOLUTION) 3

DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3 MED Medical Drug

desmopressin acetate (0.01% solution, 0.01% spray,acetate 0.1 mg tb, acetate 0.2 mg tb, 10 mcg/0.1 ml spr) 1

desmopressin ac 4 mcg/ml vial 1MED Medical Drug

HCG

desmopressin acetate (ac 4 mcg/ml ampul, 40 mcg/10 mlvial) 1 MED Medical Drug

NOCDURNA 3QL 1 / day

PA

NOCTIVA 3

QL 0.1 / day

PA


NORDITROPIN FLEXPRO 3

S

PS

PA

SEROSTIM 3

QL 1 / day

S

PA

STIMATE 3 S

vasopressin 20 unit/100 ml-ns 1MED Medical Drug

NFDA Non-FDAApproved



vasopressin-0.9% nacl (20 unit/50 ml-ns, 40 unit/100 ml-ns, 50 unit/250 ml-ns, 60 unit/100 ml-ns, 100 unit/100 ml-ns, 100 unit/250 ml-ns)

1 MED Medical Drug

vasopressin-d5w (60 unit/100 ml-d5w, 100 unit/100ml-d5w) 1 MED Medical Drug

ZORBTIVE 3

QL 1 / day

S

PA

PROGESTINS

AYGESTIN 3 GL Female

CRINONE 4% GEL 3 GL Female

CRINONE 8% GEL 3QL 2.5 / day

GL Female

DEPO-PROVERA 150 MG/ML SYRINGE 3QL 90 days

GL Female

DEPO-PROVERA 150 MG/ML VIAL 3 GL Female

DEPO-PROVERA 400 MG/ML VIAL 3

DEPO-SUBQ PROVERA 104 3

QL 90 days

GL Female

HCR

PA

ENDOMETRIN 2QL 3 / day

GL Female

hydroxyprogesterone caproate (hydroxyprogest 250mg/ml vial, hydroxyprogest 1,250 mg/5 ml,hydroxyprogesterone 1.25 g/5ml)

1

GL Female

S

PS

PA




MAKENA 275 MG/1.1 ML AUTOINJCT 3

GL Female

S

PS

PA


MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 3

GL Female

S

PS

PA


medroxyprogesterone 150 mg/ml 1

QL 0.04 / day

GL Female

HCR

medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab) 1 GL Female

MEGACE ES 3 GL Female

megestrol acetate (acet 40 mg/ml susp, acet 400 mg/10ml, 625 mg/5 ml susp) 1

megestrol acetate (20 mg tablet, 40 mg tablet) 1

norethindrone ac (lupaneta) 1 GL Female

norethindrone acetate 1 GL Female

progesterone (100 mg capsule, 200 mg capsule) 1 GL Female

progesterone 500 mg/10 ml vial 1 GL Female

PROMETRIUM 3ST

GL Female

PROVERA 3 GL Female



HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

CATAPRES 3PR


CATAPRES-TTS 1 3

QL 0.15 / day

ST

PR

CATAPRES-TTS 2 3

QL 0.4 / day

ST

PR

CATAPRES-TTS 3 3

QL 0.4 / day

ST

PR

clonidine (0.2 mg/day patch, 0.3 mg/day patch) 1

QL 0.4 / day

PR

HCG

clonidine 0.1 mg/day patch 1

QL 0.15 / day

PR

HCG

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 PR

clonidine hcl er 1QL 4 / day

HCG

guanfacine hcl 1 PR

KAPVAY 3

QL 4 / day

ST




methyldopa 1 PR

methyldopa-hydrochlorothiazide 1 PR

methyldopate hcl 1MED Medical Drug

PR

DIRECT VASODILATORS

BIDIL 3QL 6 / day

PR

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet) 1 PR

hydralazine 20 mg/ml vial 1MED Medical Drug

PR

minoxidil (2.5 mg tablet, 10 mg tablet) 1 PR

NITROPRESS 3 MED Medical Drug

sodium nitroprusside 1 MED Medical Drug

HYPOTENSIVE AGENTS, MISCELLANEOUS

CORLOPAM (10 MG/ML AMPUL, 10 MG/ML VIAL, 20MG/2 ML AMPUL, 20 MG/2 ML VIAL) 3 MED Medical Drug

VECAMYL 3

S

PR

PA

INSULINS

INTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 2QL 90 days

PR

HUMULIN 70/30 KWIKPEN 2QL 90 days

PR



HUMULIN N 2QL 90 days

PR

HUMULIN N KWIKPEN 2QL 90 days

PR

NOVOLIN 70-30 100 UNIT/ML VIAL 2QL 90 days

PR

NOVOLIN 70-30 FLEXPEN 2QL 90 days

PR

NOVOLIN N 100 UNIT/ML VIAL 2QL 90 days

PR

NOVOLIN N FLEXPEN 2QL 90 days

PR

LONG-ACTING INSULINS

BASAGLAR KWIKPEN U-100 3

QL 90 days

PR

PA

LANTUS 2QL 90 days

PR

LANTUS SOLOSTAR 2QL 90 days

PR

LEVEMIR 2QL 90 days

PR

LEVEMIR FLEXTOUCH 2QL 90 days

PR

SEMGLEE 3

QL 90 days

PR

PA



SEMGLEE PEN 3

QL 90 days

PR

PA

SOLIQUA 100-33 2 QL 0.6 / day

TOUJEO MAX SOLOSTAR 2QL 90 days

PR

TOUJEO SOLOSTAR 2QL 90 days

PR

TRESIBA 2QL 90 days

PR

TRESIBA FLEXTOUCH U-100 2QL 90 days

PR

TRESIBA FLEXTOUCH U-200 2QL 90 days

PR

XULTOPHY 100-3.6 3QL 0.5 / day

PA

RAPID-ACTING INSULINS

ADMELOG 3QL 90 days

PA

ADMELOG SOLOSTAR 3QL 90 days

PA

AFREZZA 3QL 90 days

PA

APIDRA 3

QL 90 days

PR

PA



APIDRA SOLOSTAR 3

QL 90 days

PR

PA

FIASP 3QL 90 days

PA

FIASP FLEXTOUCH 3QL 90 days

PA

FIASP PENFILL 3QL 90 days

PA

HUMALOG 100 UNIT/ML CARTRIDGE 2QL 90 days

PR

HUMALOG 100 UNIT/ML VIAL 2

QL 90 days

PR

B4G

HUMALOG JUNIOR KWIKPEN 2

QL 90 days

PR

B4G

HUMALOG KWIKPEN U-100 2

QL 90 days

PR

B4G

HUMALOG KWIKPEN U-200 2QL 90 days

PR

HUMALOG MIX 50-50 2QL 90 days

PR

HUMALOG MIX 50-50 KWIKPEN 2QL 90 days

PR

HUMALOG MIX 75-25 2QL 90 days

PR



HUMALOG MIX 75-25 KWIKPEN 2

QL 90 days

PR

B4G

insulin aspart 2

QL 90 days

PR

PA

insulin aspart flexpen 2

QL 90 days

PR

PA

insulin aspart penfill 2

QL 90 days

PR

PA

insulin aspart prot-insuln asp 2

QL 90 days

PR

PA

insulin lispro 2

QL 90 days

PR

PA

insulin lispro junior kwikpen 2

QL 90 days

PR

PA

insulin lispro kwikpen u-100 2

QL 90 days

PR

PA

insulin lispro protamine mix 2

QL 90 days

PR

PA



LYUMJEV 3

QL 90 days

PR

PA

LYUMJEV KWIKPEN U-100 3

QL 90 days

PR

PA

LYUMJEV KWIKPEN U-200 3

QL 90 days

PR

PA

NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL) 2

QL 90 days

PR

B4G

NOVOLOG FLEXPEN 2

QL 90 days

PR

B4G

NOVOLOG MIX 70-30 2

QL 90 days

PR

B4G

NOVOLOG MIX 70-30 FLEXPEN 2

QL 90 days

PR

B4G

SHORT-ACTING INSULINS

HUMULIN R 2QL 90 days

PR

HUMULIN R U-500 2QL 90 days

PR

HUMULIN R U-500 KWIKPEN 2QL 90 days

PR



MYXREDLIN 3QL 90 days

MED Medical Drug

NOVOLIN R 100 UNIT/ML VIAL 2QL 90 days

PR

NOVOLIN R FLEXPEN 2QL 90 days

PR

ION-REMOVING AGENTS

OTHER ION-REMOVING AGENTS

RADIOGARDASE 3

PHOSPHATE-REMOVING AGENTS

AURYXIA 3

calcium acetate (667 mg capsule, 667 mg gelcap, 667 mgtablet) 1

FOSRENOL (750 MG POWDER PACKET, 1,000 MGPOWDER PACK) 3

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLETCHEW) 3 SBA Select Brand

Alternative

FOSRENOL 1,000 MG TABLET CHEW 3MVB MINIMAL

VALUE BRAND


lanthanum carb 1,000 mg tb chw 1

HCG


lanthanum carbonate (500 mg tab chew, 750 mg tabchew) 1

PHOSLYRA 3



RENAGEL 3ST


RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDERPACKET, 800 MG TABLET) 3

sevelamer 2.4 gm powder packet 1 HCG

sevelamer carbonate (0.8 gm powder packet, carbonate800 mg tab) 1

sevelamer hcl 1

VELPHORO 3

POTASSIUM-REMOVING AGENTS

KIONEX 1

LOKELMA 3 QL 1 / day

sodium polystyrene sulfonate (sod polystyren sulf 15 g/60ml, sodium polystyrene sulf powder, sps 15 gm/60 mlsuspension, sps 30 gm/120 ml enema, sps 50 gm/200 mlenema)

1

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMASUSP) 1

VELTASSA 3 QL 1 / day

LOCAL ANESTHETICS (PARENTERAL)

buffered lidocaine (syring, syrng) 3 MED Medical Drug

lidocaine hcl (40 mg/2 ml (2%) syrg, 50 mg/5 ml (1%) syrg,hcl 50 mg/5 ml syrng, 100 mg/5 ml (2%) syr, 400mg/20ml(2%) syr)

1 MED Medical Drug

lidocaine 5 mg/ml-0.9% nacl 1 MED Medical Drug

ropivacaine 0.5% 1000 mg/200ml 1 MED Medical Drug



ropivacaine 0.5% 500 mg/100 ml 1 MED Medical Drug

MACROLIDE ANTIBIOTICS

ERYTHROMYCIN ANTIBIOTICS

E.E.S. 200 3 SBA Select BrandAlternative

E.E.S. 400 3

ERY-TAB 3

ERYPED 200 2

ERYPED 400 3 SBA Select BrandAlternative

ERYTHROCIN LACTOBIONATE (1 GM ADDVANT VIAL, 500MG ADDVAN VIAL, LACT 500 MG VIAL) 3 MED Medical Drug

ERYTHROCIN STEARATE 3

erythromycin (250 mg filmtab, dr 250 mg cap, dr 250 mgtablet, dr 333 mg tablet, 500 mg filmtab, dr 500 mgtablet)

1

erythromycin ethylsuccinate (200 mg/5 ml susp, 400 mg/5ml susp, es 400 mg tab) 1

OTHER MACROLIDE ANTIBIOTICS

azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1

azithromycin 250 mg tablet 1 QL 6 / 5 days

azithromycin (500 mg add-van vl, i.v. 500 mg vial) 1 MED Medical Drug

clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250mg/5 ml sus, 500 mg tablet) 1

clarithromycin er 1

DIFICID 3 PA



ZITHROMAX 100 MG/5 ML SUSP 3 QL 30 / fill

ZITHROMAX 200 MG/5 ML SUSP 3 QL 60 / fill

ZITHROMAX (1 GM POWDER PACKET, 250 MG Z-PAKTABLET) 3

ZITHROMAX 250 MG TABLET 3 QL 6 / 5 days

ZITHROMAX 500 MG TABLET 3 QL 5 / fill

ZITHROMAX I.V. 500 MG VIAL 3 MED Medical Drug

ZITHROMAX TRI-PAK 3

MISC. BETA-LACTAM ANTIBIOTICS

CARBAPENEM ANTIBIOTICS

doripenem 1 MED Medical Drug

imipenem-cilastatin sodium 1 MED Medical Drug

INVANZ 3BSP BENEFIT SHIFT

PROGRAM


meropenem 1 MED Medical Drug

meropenem-0.9% nacl 1 MED Medical Drug

MERREM 3 MED Medical Drug

PRIMAXIN 3 MED Medical Drug

RECARBRIO 3 MED Medical Drug

CEPHAMYCIN ANTIBIOTICS

CEFOTAN 3 MED Medical Drug

cefotetan 1 MED Medical Drug

cefotetan & dextrose 1 MED Medical Drug



cefoxitin 1 MED Medical Drug

cefoxitin sodium 1 MED Medical Drug

MONOBACTAM ANTIBIOTICS

AZACTAM 3 MED Medical Drug

AZACTAM-ISO-OSMOTIC DEXTROSE 3 MED Medical Drug

aztreonam 1 MED Medical Drug

CAYSTON 3S

PA

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

AVODART 3

QL 1 / day

ST

GL Male


dutasteride 1QL 1 / day

GL Male

dutasteride-tamsulosin 1QL 1 / day

GL Male

finasteride 5 mg tablet 1QL 1 / day

GL Male

JALYN 3

QL 1 / day

GL Male


PROSCAR 3QL 1 / day

GL Male



ALCOHOL DETERRENTS

ANTABUSE 3

disulfiram 1

ANTIDOTES

DUODOTE 3

FUSILEV 3S

MED Medical Drug

KHAPZORY 3S

MED Medical Drug

leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab) 1

leucovorin calcium (cal 100 mg/10 ml vl, cal 500 mg/50 mlvl, calcium 50 mg vial, calcium 100 mg vial, calcium 200mg vial, calcium 350 mg vial, calcium 500 mg vl)

1S

MED Medical Drug

levoleucovorin calcium (50 mg vial, 175 mg vial, 175mg/17.5 ml, 250 mg/25 ml vl) 1

S

MED Medical Drug

methylene blue 1% vial 1 MED Medical Drug

NITHIODOTE 3 MED Medical Drug

pralidoxime chloride 1

PROTOPAM CHLORIDE 3 MED Medical Drug

sodium thiosulfate 1 MED Medical Drug

VISTOGARD 3 S

VORAXAZE 3S

MED Medical Drug



ANTIGOUT AGENTS

allopurinol 100 mg tablet 1 QL 3 / day

allopurinol 300 mg tablet 1 QL 2 / day

allopurinol sodium 1 MED Medical Drug

ALOPRIM 3 MED Medical Drug

colchicine 0.6 mg capsule 1QL 2 / day

ST

colchicine 0.6 mg tablet 1QL 4 / day

ST

COLCRYS 3 QL 4 / day

febuxostat 1QL 1 / day

ST

GLOPERBA 3 PA

KRYSTEXXA 3

QL 0.07 / day

S

MED Medical Drug

PA

MITIGARE 3QL 2 / day

ST

ULORIC 3QL 1 / day

ST

ZYLOPRIM 100 MG TABLET 3 QL 3 / day

ZYLOPRIM 300 MG TABLET 3QL 2 / day




ANTISENSE OLIGONUCLEOTIDES

TEGSEDI 3S

PA

BONE ANABOLIC AGENTS

EVENITY 3

S

MED Medical Drug

PA

EVENITY (2 SYRINGES) 3

S

MED Medical Drug

PA

BONE RESORPTION INHIBITORS

ACTONEL 150 MG TABLET 3QL 0.04 / day

PR

ACTONEL 35 MG TABLET 3QL 0.15 / day

PR

ACTONEL 5 MG TABLET 3QL 1 / day

PR

alendronate sod 70 mg/75 ml 1QL 12.5 / day

PR

alendronate sodium (35 mg tab, 40 mg tab, 70 mg tab) 1QL .15 / day

PR

alendronate sodium (5 mg tablet, 10 mg tab) 1QL 1 / day

PR

ATELVIA 3

QL 0.15 / day

ST

PR



BINOSTO 3QL .15 / day

PR

BONIVA 3 MG/3 ML SYRINGE 3

S

MED Medical Drug

PR

PA

BONIVA 150 MG TABLET 3

QL 0.04 / day

PR


etidronate disodium 1 PR

FOSAMAX 3QL .15 / day

PR

FOSAMAX PLUS D 3QL 0.15 / day

PR

ibandronate 3 mg/3 ml syringe 1S

MED Medical Drug

ibandronate sodium 150 mg tab 1QL 0.04 / day

PR

ibandronate 3 mg/3 ml vial 1

S

MED Medical Drug

PR

pamidronate disodium (30 mg/10 ml vial, disod 30 mgvial, 60 mg/10 ml vial, 90 mg/10 ml vial, disod 90 mg vial) 1

S

MED Medical Drug

PROLIA 3

QL 0.13 / day

S

PA




RECLAST 3

S

MED Medical Drug

PR

risedronate sodium 150 mg tab 1

QL 0.04 / day

PR

HCG

risedronate sodium 30 mg tab 1

risedronate sodium 35 mg tab 1QL 0.15 / day

PR

risedronate sodium 5 mg tablet 1 QL 1 / day

risedronate sodium dr 1 HCG

XGEVA 3

QL 0.07 / day

S

PA


zoledronic acid (4 mg vial, 4 mg/100 ml, 4 mg/5 ml vial, 5mg/100 ml) 1

S

PR


ZOMETA (4 MG/100 ML INJECTION, 4 MG/5 ML VIAL) 3

S

MED Medical Drug

PR

CARBONIC ANHYDRASE INHIBITORS (MISC.)

KEVEYIS 3

QL 4 / day

S

PA



CARIOSTATIC AGENTS

DENTA 5000 PLUS 1

DENTAGEL 1

fluoride 1 HCR

FLUORITAB 1 HCR

FLURA-DROPS 3 HCR

LUDENT FLUORIDE 1 HCR

PREVIDENT 1.1% GEL 3 SBA Select BrandAlternative

PREVIDENT (0.2% RINSE, 5000 BOOSTER PLUS, DENTALRINSE) 3

PREVIDENT 5000 3

PREVIDENT 5000 ENAMEL PROTECT 3

PREVIDENT 5000 ORTHO DEFENSE 3

PREVIDENT 5000 PLUS 3 SBA Select BrandAlternative

PREVIDENT 5000 SENSITIVE 3

SF 1

SF 5000 PLUS 1

sodium fluoride (1.1% cream, 5000 ppm cream, 5000 ppmpaste) 1

sodium fluoride (0.5 mg(1.1 mg), 0.5 mg/ml drop, 1 mg(2.2 mg)) 1 HCR

sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 1 HCR

sodium fluoride sensitive 1



COMPLEMENT INHIBITORS

BERINERT (500 UNIT KIT, 500 UNIT VIAL) 3S

PA

CINRYZE 3S

PA

FIRAZYR 3S

PA

HAEGARDA 3

QL 1.25 / day

S

PA

icatibant 1S

PA

KALBITOR 3

S

PA


RUCONEST 3

QL 0.87 / day

S

PA

SOLIRIS 3

S

PA


TAKHZYRO 3

QL 0.144 / day

S

PA

ULTOMIRIS 3

S

MED Medical Drug

PA



DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 3

QL 0.15 / day

S

PS

PA

PS2 Preferred 2ndline

ACTEMRA 200 MG/10 ML VIAL 3

QL 0.36/day

S

PS

PA




QL 1.5 / day

S

PS

PA




QL 0.15 / day

S

PS

PA





ARAVA 3

AVSOLA 3

QL 10 / 30 days

S

MED Medical Drug

PA

CIMZIA 200 MG VIAL KIT 3

QL 3/ fill

S

PS

PA


CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 3

QL 3/ fill

S

PS

PA


ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 25 MG/0.5ML VIAL, 50 MG/ML SYRINGE) 3

QL 0.29 / day

S

PA

ENBREL MINI 3

QL 0.15 / day

S

PA

ENBREL SURECLICK 3

QL 0.15 / day

S

PA

HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 MLSYRINGE) 3

QL 0.22 / day

S

PS

PA




HUMIRA 10 MG/0.2 ML SYRINGE 3

QL 0.15 / day

S

PS

PA


HUMIRA PEDIATRIC CROHN'S 3

QL 0.22 / day

S

PS

PA


HUMIRA PEN 3

QL 0.22 / day

S

PS

PA


HUMIRA PEN CROHN'S-UC-HS 3

QL 0.22 / day

S

PS

PA


HUMIRA PEN PSOR-UVEITS-ADOL HS 3

QL 0.22 / day

S

PS

PA


HUMIRA(CF) 3

QL 0.22 / day

S

PS

PA




HUMIRA(CF) PEDI CROHN 80MG/0.8 3

QL 0.22 / day

S

PS

PA


HUMIRA(CF) PEN 3

QL 0.22 / day

S

PS

PA


HUMIRA(CF) PEN CROHN'S-UC-HS 3

QL 0.22 / day

S

PS

PA


HUMIRA(CF) PEN PSOR-UV-ADOL HS 3

QL 0.22 / day

S

PS

PA


INFLECTRA 3

QL 0.5 / day

S

PS

PA





KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 MLSYRINGE, 200 MG/1.14 ML PEN INJ, 200 MG/1.14 MLSYRINGE)

3

QL 0.1 / day


S

PA

KINERET 3

QL 10 / day

S

PA

leflunomide 1

OLUMIANT 3

QL 1 / day

S

PA

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE) 3

QL 0.15 / day

S

PS

PA


ORENCIA 250 MG VIAL 3

QL 0.15 / day

S

PS

PA



ORENCIA CLICKJECT 3

QL 0.15 / day

S

PS

PA




OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 3

QL 2 / day

S

PS

PA


REMICADE 3

QL 10 / 30 days

S

MED Medical Drug

PA

RENFLEXIS 3

QL 10 / 30 days

S

PS

PA



RINVOQ 3

QL 1 / day

S

PS

PA


SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 MLSYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/MLSYRINGE)

3

QL 0.04 / day

S

PS

PA




XELJANZ 3

QL 2 / day

S

PS

PA


XELJANZ XR 3

QL 1 / day

S

PS

PA


IMMUNOMODULATORY AGENTS

ACTIMMUNE 3S

PA

AUBAGIO 3

QL 1 / day

S

PR

PA

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 3

QL 0.15 / day

S

PR

PS

PA

AVONEX PEN 3

QL 0.15 / day

S

PR

PS

PA



BAFIERTAM 3

QL 4 / day

S

PA

BETASERON (0.3 MG KIT, 0.3 MG VIAL) 3

QL 0.5 / day

S

PR

PS

PA

COPAXONE 20 MG/ML SYRINGE 3

QL 1 / day

S

PS

PA

B4G

COPAXONE 40 MG/ML SYRINGE 3

QL 0.434 / day

S

PS

PA

B4G

ENSPRYNG 3

QL 0.11 / day

S

PA

EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 3

QL 0.5 / day

S

PR

PA

GILENYA 0.25 MG CAPSULE 3

QL 2 / day

S

PR

PS

PA



GILENYA 0.5 MG CAPSULE 3

QL 1 / day

S

PR

PS

PA

glatiramer 20 mg/ml syringe 3

QL 1 / day

S

PS

PA

glatiramer 40 mg/ml syringe 3

QL 0.434 / day

S

PS

PA

GLATOPA 20 MG/ML SYRINGE 3

QL 1 / day

S

PA

GLATOPA 40 MG/ML SYRINGE 3

QL 0.434 / day

S

PA

KESIMPTA PEN 3

QL 0.057 / day

S

PS

PA

MAYZENT 0.25 MG STARTER PACK 3

QL 2.5 / day

S

PS

PA

MAYZENT 0.25 MG TABLET 3

QL 120 / 30 days

S

PS

PA



MAYZENT 2 MG TABLET 3

QL 1 / day

S

PS

PA

PLEGRIDY 125 MCG/0.5 ML SYRING 3

QL 0.04 / day

S

PS

PA

PLEGRIDY SYRINGE STARTER PACK 3

QL 1/ lifetime

S

PS

PA

PLEGRIDY 125 MCG/0.5 ML PEN 3

QL 0.04 / day

S

PS

PA

PLEGRIDY PEN INJ STARTER PACK 3

QL 1/ lifetime

S

PS

PA

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE) 3

QL 0.22 / day

S

PR

PA

REBIF TITRATION PACK 3

QL 4.2 / 365 days

S

PR

PA



REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 3

QL 0.22 / day

S

PR

PA

REBIF REBIDOSE TITRATION PACK 3

QL 4.2 / 365 days

S

PR

PA

TECFIDERA 3

QL 2 / day

S

PR

PS

PA

B4G

THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 3

QL 2 / day

S

PA

THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 3

QL 1 / day

S

PA

TYSABRI 3

QL 0.6 / day

S

PA


UPLIZNA 3

QL 2 / day

S

MED Medical Drug

PA



VUMERITY 3

QL 4 / day

S

PR

PS

PA

ZEPOSIA (0.23-0.46 MG START PCK, 0.23-0.46-0.92 MGKIT, 0.92 MG CAPSULE) 3

QL 1 / day

S

PA

IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL 0.5 MG CAPSULE 3

QL 15 / day

S

PR

NTI

PA

ASTAGRAF XL 1 MG CAPSULE 3

QL 30 / day

S

PR

NTI

PA

ASTAGRAF XL 5 MG CAPSULE 3

QL 6 / day

S

PR

NTI

PA

ATGAM 3S

MED Medical Drug

AZASAN 100 MG TABLET 3 PR

AZASAN 75 MG TABLET 3PR




azathioprine 1 PR

azathioprine sodium 1 MED Medical Drug

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/MLSYRINGE) 3

S

PA

BENLYSTA 120 MG VIAL 3

QL 0.25 / day

S

PA


BENLYSTA 400 MG VIAL 3

QL 0.334 / day

S

PA


CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500MG TABLET) 3

S

PR

CELLCEPT 500 MG VIAL 3

S

MED Medical Drug

PR

cyclosporine 250 mg/5 ml ampul 1

S

MED Medical Drug

NTI

cyclosporine (25 mg capsule, 100 mg capsule) 1

S

PR

NTI

cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 1

S

PR

NTI



ENVARSUS XR 3

QL 1 / day

S

NTI

PA

everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 1

S

PR

PA

GAMIFANT 3

S

MED Medical Drug

PA

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION) 1

S

PR

NTI

IMURAN 3 PR

MAVENCLAD 3

QL 20 / 30 days

S

PA

mycophenolate 200 mg/ml susp 1 S

mycophenolate mofetil (250 mg capsule, 500 mg tablet) 1S

PR

mycophenolate 500 mg vial 1S

MED Medical Drug

mycophenolic acid 1S

PR

MYFORTIC 3S

PR

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATINCAPSULE, 100 MG/ML SOLUTION) 3

S

PR

NTI



NULOJIX 3

S

MED Medical Drug

PA

PROGRAF 5 MG/ML AMPULE 2

S

MED Medical Drug

NTI

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MGCAPSULE) 2

S

PR

NTI

PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULEPACKET) 2

S

PR

NTI

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/MLORAL SOLN, 2 MG TABLET) 3

S

PR

SANDIMMUNE 50 MG/ML AMPUL 3

S

MED Medical Drug

NTI

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLN) 3

S

PR

NTI

SIMULECT 3 MED Medical Drug

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet) 1

S

PR

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1

S

PR

NTI

THYMOGLOBULIN 3 MED Medical Drug



ZORTRESS 3

S

PR

PA

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

alpha lipoic acid 100 mg cap 1

AMPYRA 3

QL 2 / day

S

PR

PA

ARCALYST 3S

PA

BOTOX 3

S

PA


BOTOX COSMETIC 3

S

PA


CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3 ST

CARNITOR 1 GM/5 ML VIAL 3ST

MED Medical Drug

CARNITOR SF 3ST


CERDELGA 3S

PA

citrus bioflavonoids 3



CYSTADANE 3 S

CYSTAGON 150 MG CAPSULE 3

QL 13 / day

S

PA

CYSTAGON 50 MG CAPSULE 3

QL 40/ day

S

PA

dalfampridine er 1

QL 2 / day

S

PR

PA

DEMSER 3 PR

DYSPORT 3

S

PS

PA


EVRYSDI 3

QL 6.67 / day

S

PA

FIRDAPSE 3

S

PR

PA

GALAFOLD 3S

PA

ILARIS 3

QL 0.08 / day

S

MED Medical Drug

PA



ISTURISA 1 MG TABLET 3

QL 8 / day

S

PA


QL 6 / day

S

PA


QL 2 / day

S

PA

JEUVEAU 3

S

PA


KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500MG POWDER PACKET) 3

S

PA

levocarnitine (1 g/10 ml soln, 330 mg tablet) 1

levocarnitine sf 1

melatonin 3 mg tablet 1

methylene blue powder 3

metyrosine 1 PR

MIDNITE FOR MENOPAUSE 3

MIDNITE MENOPAUSE 3

MIDNITE PM 3

miglustat 1S

PA

MYOBLOC 3

S

MED Medical Drug

PA



NEXAVIR 3 MED Medical Drug

nitisinone 1S

PA

NITYR 3S

PA

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) 3

S

PA

PANHEMATIN 3S

MED Medical Drug

POTABA 3

PROCYSBI DR 25 MG CAPSULE 3

QL 4 / day

S

PA

PROCYSBI DR 75 MG CAPSULE 3

QL 72 / day

S

PA

PROCYSBI (DR 75 MG GRANULE PKT, DR 300 MGGRANULE PKT) 3

S

PA

RUZURGI 3

QL 1 / day

S

PR

PA

sapropterin dihydrochloride (100 mg powder pkt, 100 mgtablet, 500 mg powder pkt) 1

S

PA

THIOLA 3S

PA



THIOLA EC 3S

PA

TYBOST 3 S

XEOMIN 3

S

MED Medical Drug

PA

XURIDEN 3 S

ZAVESCA 3S

PA

PROTECTIVE AGENTS

amifostine 1S

MED Medical Drug

dexrazoxane 1

S

MED Medical Drug

PA

ELMIRON 2QL 3 / day

PA

ETHYOL 3S

MED Medical Drug

mesna 1S

MED Medical Drug

MESNEX 400 MG TABLET 3 S

MESNEX 1 GRAM/10 ML VIAL 3S

MED Medical Drug

ZINECARD 3

S

MED Medical Drug

PA



NONHORMONAL CONTRACEPTIVES

PHEXXI 3

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) 3QL 2 / day


CELEBREX 100 MG CAPSULE 3QL 3 / day


CELEBREX 400 MG CAPSULE 3QL 1 / day


celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day

celecoxib 100 mg capsule 1 QL 3 / day

celecoxib 400 mg capsule 1 QL 1 / day

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

ANAPROX DS 3MVB MINIMAL

VALUE BRAND


ARTHROTEC 50 3ST


ARTHROTEC 75 3ST


CALDOLOR (800 MG/200 ML BAG, 800 MG/8 ML VIAL) 3 MED Medical Drug



CAMBIA 3

QL 1 / day

PA


DAYPRO 3

diclofenac 3

QL 3 / day

ST

HCG


diclofenac epolamine 1QL 2 / day

HCG

diclofenac potassium 1

diclofenac 1.5% topical soln 1

HCG


diclofenac sodium 1% gel 1QL 1000/ 30 days

ST

diclofenac sod dr 25 mg tab 1 HCG

diclofenac sodium (dr 50 mg tab, dr 75 mg tab, ec 25 mgtab, ec 50 mg tab, ec 75 mg tab) 1

diclofenac sodium er 1

diclofenac sodium-misoprostol 1

diflunisal 1

EC-NAPROSYN 3MVB Minimal Value

Brand




ec-naproxen 3MVB Minimal Value

Brand


etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet,500 mg tablet) 1

etodolac er (er 400 mg tablet, er 600 mg tablet) 1

etodolac er 500 mg tablet 1

HCG


FELDENE 3

fenoprofen calcium (200 mg capsule, 400 mg capsule) 1

HCG


fenoprofen 600 mg tablet 1

FENORTHO 3 MVB MINIMALVALUE BRAND

FLECTOR 3QL 2 / day


flurbiprofen 1

IBU 1

ibuprofen 100 mg/5 ml susp 1

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1

ibuprofen lysine 3 MED Medical Drug

INDOCIN 25 MG/5 ML SUSPENSION 3QL 6 / day

PA

INDOCIN 50 MG SUPPOSITORY 3QL 4 / day

PA



indomethacin 25 mg capsule 1

indomethacin 50 mg capsule 1

indomethacin 1 mg vial 1 MED Medical Drug

indomethacin er 1

ketoprofen er 200 mg capsule 1 HCG

ketoprofen (25 mg capsule, 75 mg capsule) 1

ketoprofen 50 mg capsule 1 HCG

ketorolac 30 mg/ml carpuject 1QL 20 / 30 days


ketorolac tromethamine (15 mg/ml carpuject, 15 mg/mlisecure syr, 15 mg/ml vial) 1

QL 40 / 23 days


ketorolac tromethamine (60 mg/2 ml carpuject, 60 mg/2ml vial) 1 QL 20 / 30 days

ketorolac 15.75 mg nasal spray 3QL 5 days

PA

ketorolac 60 mg/2 ml syringe 1 QL 20 / 30 days

ketorolac tromethamine (30 mg/ml isecure syr, 30 mg/mlsyringe) 1

QL 20 / 23 days


ketorolac 10 mg tablet 1 QL 21 / fill

ketorolac 30 mg/ml vial 1QL 20 / 23 days


ketorolac 300 mg/10 ml vial 1QL 20 / 30 days




LICART 3 QL 1 / day

LODINE 3

meclofenamate sodium 1 HCG

mefenamic acid 1

QL 5 / day

HCG


meloxicam 1 QL 1 / day

MOBIC 3

QL 1 / day

ST


nabumetone 1

NALFON 400 MG CAPSULE 3PA


NALFON 600 MG TABLET 3 PA

NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) 3 SBA Select BrandAlternative

NAPRELAN CR 750 MG TABLET 3 QL 1 / day

NAPROSYN 125 MG/5 ML SUSPEN 3MVB MINIMAL

VALUE BRAND


NAPROSYN 500 MG TABLET 3MVB Minimal Value

Brand


naproxen 125 mg/5 ml suspen 1

HCG




naproxen (250 mg tablet, dr 375 mg tablet, dr 500 mgtablet) 1

naproxen (375 mg tablet, 500 mg kit, 500 mg tablet) 1

naproxen sodium (275 mg tab, 550 mg tab) 1

HCG


naproxen sodium cr 1

HCG


naproxen sod er 375 mg tablet 1

naproxen sod er 500 mg tablet 1

HCG


NEOPROFEN 3 MED Medical Drug

oxaprozin 1 HCG

PENNSAID 2% PUMP 3QL 3.8 / day

ST

piroxicam 1 AL Up to 75 yrs old

PROFENO 1

QMIIZ ODT 3

QL 1 / day

AL Up to 18 yrs old


RELAFEN 1 ST

RELAFEN DS 3ST




SPRIX 3

QL 5 days

PA



sulindac 1

tolmetin sodium 400 mg cap 1 HCG

tolmetin sodium (200 mg tab, 600 mg tab) 1

VIVLODEX 10 MG CAPSULE 3

QL 1 / day


PA


VIVLODEX 5 MG CAPSULE 3

QL 1 / day


PA

VOLTAREN 3QL 1000/ 30 days


VOLTAREN-XR 3 SBA Select BrandAlternative

ZIPSOR 3

QL 4 / day

PA


ZORVOLEX 3

QL 3 / day

PA




SALICYLATES

butalbital-aspirin-caffeine (butalb-aspirin-caffe 50-325-40, butalbital-asa-caffeine cap) 1 QL 6 / day

choline mag trisalicylate 1

DURLAZA 3

QL 1 / day

PA


FIORINAL 3QL 6 / day


GOODY'S EXTRA STRENGTH 3

salsalate 1

OXYTOCICS

carboprost tromethamine 3 MED Medical Drug

METHERGINE 1 QL 6 / day

methylergonovine 0.2 mg tablet 1 QL 6 / day

MIFEPREX 3

mifepristone 1

PARATHYROID AND ANTIPARATHYROID AGENTS

ANTIPARATHYROID AGENTS

calcitonin-salmon 1QL 0.13 / day

PR

cinacalcet hcl 1

QL 2 / day

S

PA



MIACALCIN 3S

PR

SENSIPAR (30 MG TABLET, 60 MG TABLET) 3

QL 2 / day

S

PA

SENSIPAR 90 MG TABLET 3

QL 4 / day

S

PA

PARATHYROID AGENTS

FORTEO 3

S

PR

PA

NATPARA 3S

PA

teriparatide 1

S

PR

PA

TYMLOS 3

QL 1.60 / day


S

PA

PENICILLIN ANTIBIOTICS

AMINOPENICILLIN ANTIBIOTICS

amoxicillin (125 mg tab chew, 250 mg tab chew, 250mg/5 ml susp, 500 mg capsule, 500 mg tablet) 1

amoxicillin (125 mg/5 ml susp, 200 mg/5 ml susp, 250 mgcapsule, 400 mg/5 ml susp, 875 mg tablet) 1



amoxicillin-clavulanate pot er 1

amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

1

ampicillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gmadd-vantage vl, 2 gm vial, 10 gm bottle, 10 gm vial, 125mg vial, 250 mg vial, 500 mg vial)

1 MED Medical Drug

ampicillin trihydrate 1

ampicillin-sulbactam (ampicillin-sulb 1.5 g add vial,ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gmvl, ampicillin-sulbactam 3 gm vial, ampicillin-sulbactam 15gm vl)

1 MED Medical Drug

AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML,500-125 TABLET, 875-125 TABLET) 3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

MOXATAG 3

UNASYN 3 MED Medical Drug

EXTENDED-SPECTRUM PENICILLINS

piperacil-tazobact 13.5 gm vl 3 MED Medical Drug

piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl,piperacil-tazo 3.375 gm add vl, piperacil-tazo 4.5 gm addvial, piperacil-tazobact 2.25 gm vl, piperacil-tazobact3.375 gm vl, piperacil-tazobact 4.5 gm vial, piperacil-tazobact 40.5 gram)

1 MED Medical Drug

ZOSYN (2.25 GM/50 ML GALAXY BAG, 2.25 GRAM VIAL,3.375 GM/50 ML GALAXY, 3.375 GRAM VIAL, 4.5 GM/100ML GALAXY BAG, 4.5 GRAM VIAL, 40.5 GRAM BULK VIAL)

3 MED Medical Drug



NATURAL PENICILLIN ANTIBIOTICS

BICILLIN C-R 3

BICILLIN L-A 3

penicillin g potassium 1 MED Medical Drug

penicillin g procaine 1

penicillin g sodium 1 MED Medical Drug

penicillin gk-iso-osm dextrose 1 MED Medical Drug

penicillin v potassium (250 mg tablet, 250 mg/5 ml soln,500 mg tablet) 1

penicillin vk 125 mg/5 ml soln 1

PFIZERPEN 3 MED Medical Drug

PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin 250 mg capsule 1

dicloxacillin 500 mg capsule 1

nafcillin 3 MED Medical Drug

nafcillin sodium (1 gm add-van vial, 1 gm vial, 2 gm add-vant vial, 2 gm vial, 10 gm bulk vial) 1 MED Medical Drug

oxacillin 3 MED Medical Drug

oxacillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gmadd-vantage vl, 2 gm vial, 10 gm vial) 1 MED Medical Drug

PHARMACEUTICAL AIDS

dexrazoxane diluent-sodium lac 1S

MED Medical Drug

diluent for decitabine 1S

MED Medical Drug



DILUENT FOR ELITEK 3S

MED Medical Drug

DILUENT FOR ISTODAX 3S

MED Medical Drug

DILUENT FOR JEVTANA 3S

MED Medical Drug

DILUENT FOR LEFAMULIN(XENLETA) 3S

MED Medical Drug

eucalyptol 1

lumoxiti iv soln stabilizer 3

S

MED Medical Drug

PA

sassafras oil 1

SHINGRIX ADJUVANT COMPONENT 2AL At least 50 yrs

oldHCR

spearmint oil 1

STERILE WATER DILUENT-CABLIVI 1S

MED Medical Drug

sterile water for inject syrng 1S

MED Medical Drug

RADIOACTIVE AGENTS

HICON 3S

MED Medical Drug

METASTRON 3S

MED Medical Drug



QUADRAMET 3S

MED Medical Drug

sodium iodide i-123 1

sodium iodide i-131 1S

MED Medical Drug

XOFIGO 3

S

MED Medical Drug

PA

RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 3

QL 1 / day

ST

PR



ATACAND HCT (32-12.5 MG TAB, 32-25 MG TABLET) 3

QL 1 / day

PR


ATACAND HCT 16-12.5 MG TAB 3

QL 2 / day

PR


AVALIDE 150-12.5 MG TABLET 3

QL 2 / day

PR




AVALIDE 300-12.5 MG TABLET 3

QL 1 / day

PR


AVAPRO 3

QL 1 / day

ST

PR


BENICAR 3

QL 3 / day

PR


BENICAR HCT 3

QL 1 / day

PR


candesartan cilexetil 1QL 1 / day

PR

candesartan-hctz 16-12.5 mg tb 1QL 2 / day

PR

candesartan-hydrochlorothiazid (32-12.5 mg tb, 32-25 mgtab) 1

QL 1 / day

PR

COZAAR (25 MG TABLET, 50 MG TABLET) 3

QL 2 / day

ST

PR


COZAAR 100 MG TABLET 3

QL 1 / day

ST

PR




DIOVAN (40 MG TABLET, 80 MG TABLET, 160 MG TABLET) 3

QL 2 / day

PR


DIOVAN 320 MG TABLET 3

QL 1 / day

PR


DIOVAN HCT (320-12.5 MG TAB, 320-25 MG TABLET) 3

QL 1 / day

PR


DIOVAN HCT (80-12.5 MG TABLET, 160-12.5 MG TAB,160-25 MG TABLET) 3

QL 2 / day

PR


EDARBI 3

QL 1 / day

ST

PR

EDARBYCLOR 3

QL 1 / day

ST

PR

ENTRESTO 2 QL 2 / day

eprosartan mesylate 1QL 1 / day

PR

HYZAAR (100-12.5 TABLET, 100-25 TABLET) 3

QL 1 / day

ST

PR




HYZAAR 50-12.5 TABLET 3

QL 2 / day

ST

PR


irbesartan 1QL 1 / day

PR

irbesartan-hctz 150-12.5 mg tb 1QL 2 / day

PR

irbesartan-hctz 300-12.5 mg tb 1QL 1 / day

PR

losartan potassium (25 mg tab, 50 mg tab) 1QL 2 / day

PR

losartan potassium 100 mg tab 1QL 1 / day

PR

losartan-hctz 50-12.5 mg tab 1QL 2 / day

PR

losartan-hydrochlorothiazide (100-12.5 mg tab, 100-25mg tab) 1

QL 1 / day

PR

MICARDIS 3

QL 1 / day

ST

PR


MICARDIS HCT (40-12.5 MG TABLET, 80-25 MG TABLET) 3

QL 1 / day

ST

PR




MICARDIS HCT 80-12.5 MG TABLET 3

QL 2 / day

ST

PR


olmesartan medoxomil 1QL 3 / day

PR

olmesartan-amlodipine-hctz 1QL 1 / day

PR

olmesartan-hydrochlorothiazide 1QL 1 / day

PR

telmisartan 1QL 1 / day

PR

telmisartan-amlodipine 1QL 1 / day

PR

telmisartan-hctz 80-12.5 mg tb 1QL 2 / day

PR

telmisartan-hydrochlorothiazid (40-12.5 mg tb, 80-25 mgtab) 1

QL 1 / day

PR

TRIBENZOR 3

QL 1 / day

PR


TWYNSTA 3QL 1 / day

PR

valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1QL 2 / day

PR

valsartan 320 mg tablet 1QL 1 / day

PR



valsartan-hydrochlorothiazide (320-12.5 mg tab, 320-25mg tab) 1

QL 1 / day

PR

valsartan-hydrochlorothiazide (80-12.5 mg tab, 160-12.5mg tab, 160-25 mg tab) 1

QL 2 / day

PR

ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

ACCUPRIL 3QL 2 / day

PR

ACCURETIC (10-12.5 MG TABLET, 20-12.5 MG TABLET) 3QL 2 / day

PR

ACCURETIC 20-25 MG TABLET 3QL 1 / day

PR

ALTACE 3

QL 2 / day

ST

PR


benazepril hcl (10 mg tablet, 40 mg tablet) 1QL 2 / day

PR

benazepril hcl 20 mg tablet 1QL 4 / day

PR

benazepril hcl 5 mg tablet 1QL 3 / day

PR

benazepril-hydrochlorothiazide 1

QL 1 / day

PR

HCG

captopril 1

QL 4 / day

PR

HCG



captopril-hydrochlorothiazide 1QL 2 / day

PR

enalapril maleate 1QL 2 / day

PR

enalapril-hctz 10-25 mg tablet 1QL 2 / day

PR

enalapril-hctz 5-12.5 mg tab 1 PR

enalaprilat 1MED Medical Drug

PR

EPANED 3QL 5 / day

PR

fosinopril sodium 1QL 2 / day

PR

fosinopril-hydrochlorothiazide 1QL 2 / day

PR

lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1QL 1 / day

PR

lisinopril (5 mg tablet, 30 mg tablet) 1QL 1 / day

PR

lisinopril 40 mg tablet 1QL 2 / day

PR

lisinopril-hctz 20-25 mg tab 1QL 2 / day

PR

lisinopril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5mg tab) 1

QL 2 / day

PR

LOTENSIN (10 MG TABLET, 40 MG TABLET) 3QL 2 / day

PR



LOTENSIN 20 MG TABLET 3QL 4 / day

PR

LOTENSIN HCT 3QL 1 / day

PR

moexipril hcl 1QL 1 / day

PR

perindopril erbumine 1QL 1 / day

PR

PRESTALIA 3QL 1 / day

ST

PRINIVIL 3

QL 1 / day

ST

PR


QBRELIS 3 QL 40/ day

quinapril hcl 1QL 2 / day

PR

quinapril-hctz 20-25 mg tab 1QL 1 / day

PR

quinapril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5mg tab) 1

QL 2 / day

PR

ramipril 1QL 2 / day

PR

TARKA 3

QL 1 / day

PR




trandolapril 1QL 2 / day

PR

trandolapril-verapamil er 1 PR

VASERETIC 3QL 2 / day

PR

VASOTEC 3

QL 2 / day

PR


ZESTORETIC 3QL 2 / day

PR

ZESTRIL (2.5 MG TABLET, 5 MG TABLET, 10 MG TABLET,20 MG TABLET, 30 MG TABLET) 3

QL 1 / day

ST

PR


ZESTRIL 40 MG TABLET 3

QL 2 / day

ST

PR


MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

ALDACTAZIDE 3 PR

ALDACTONE 3PR


CAROSPIR 2PA




eplerenone 1PR

HCG

INSPRA 25 MG TABLET 3PR


INSPRA 50 MG TABLET 3 PR

spironolactone 1 PR

spironolactone-hctz 1 PR

RENIN INHIBITORS

aliskiren 1QL 1 / day

PR

TEKTURNA 3QL 1 / day

PR

TEKTURNA HCT 3QL 1 / day

PR

RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET) 3

QL 9 / day

S

PA

ESBRIET 801 MG TABLET 3

QL 3 / day

S

PA

OFEV 3

QL 2 / day

S

PA



ANTITUSSIVES

benzonatate (100 mg capsule, perle 100 mg cap) 1 AL At least 10 yrsold

benzonatate (150 mg capsule, 200 mg capsule) 1AL At least 10 yrs

oldHCG

BROMFED DM 1 AL At least 2 yrsold

brompheniramine-pseudoephed-dm 1 AL At least 2 yrsold

codeine-guaifenesin 1QL 60 / day


CORICIDIN HBP COUGH AND COLD 3

guaifenesin-codeine 1QL 60 / day


hydrocod-cpm-pseudoephedrine 1

QL 20 / day


HCG

hydrocodone-chlorpheniramne er 1QL 10 / day


hydrocodone-guaifenesin 1QL 60 / day


hydrocodone-homatropine mbr (soln, syrup) 1QL 30 / day


hydrocodone-homatropine 5-1.5 1

QL 6 / day


HCG



HYDROMET 1QL 30 / day


NEOTUSS PLUS 3

NIVA-HIST DM 1

OBREDON 3

QL 60 / day




promethazine-codeine 1

promethazine-dm 1 AL At least 2 yrsold

promethazine-phenyleph-codeine 1QL 30 / day


TESSALON PERLE 3AL At least 11 yrs

old


TUSNEL CAPLET 3

TUSNEL DM PEDIATRIC DROPS 3

TUSSICAPS 3

QL 6 / day



TUSSIONEX 3

QL 10 / day






TUXARIN ER 3QL 2 / day


TUZISTRA XR 3

QL 20 / day



ZODRYL DAC 50 3

ZODRYL DAC 60 3

ZODRYL DAC 80 3

ZODRYL DEC 50 3

ZODRYL DEC 60 3

ZODRYL DEC 80 3

EXPECTORANTS

GILPHEX TR 3

GILTUSS TR 3

TUSNEL PEDIATRIC DROPS 3

TUSSI-PRES PEDIATRIC LIQUID 3

TUSSLIN PEDIATRIC DROPS 1

MUCOLYTIC AGENTS

acetylcysteine (10% vial, 20% vial) 1

PULMOZYME 3

QL 5 / day

S

PA



PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP 3QL 1 / day

PA

PULMONARY SURFACTANTS

CUROSURF 3

INFASURF 3

SURVANTA 3

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

ARALAST NP 3

S

PA


GLASSIA 3

S

PA


PROLASTIN C 3

S

PA


XOLAIR 150 MG/ML SYRINGE 3

QL 0.15 / day


S

PS

PA




XOLAIR 150 MG VIAL 3

QL 0.22 / day


S

PS

PA


ZEMAIRA 3

S

PA


VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS 3

QL 3 / day

S

PA

ambrisentan 1

QL 1 / day

S

PA

bosentan 3

QL 2 / day

S

PA

epoprostenol sodium 1 S

FLOLAN 3S

PA

LETAIRIS 3

QL 1 / day

S

PA

OPSUMIT 3

QL 1 / day

S

PA



ORENITRAM ER 3

QL 3 / day

S

PA

REMODULIN 3S

PA

TRACLEER (32 MG TABLET FOR SUSP, 62.5 MG TABLET,125 MG TABLET) 3

QL 2 / day

S

PA

treprostinil 1S

PA

TYVASO 3

QL 1 / day

S

PA

TYVASO INSTITUTIONAL START KIT 3

QL 1 / day

S

PA

TYVASO REFILL KIT 3

QL 3 / day

S

PA

TYVASO STARTER KIT 3

QL 3 / day

S

PA

UPTRAVI 200-800 TITRATION PACK 3


S

PA



UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)

3

QL 2 / day


S

PA

VELETRI 3S

PA

VENTAVIS 3

QL 9 / day

S

PA

SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

AMRIX 3

ST



carisoprodol 250 mg tablet 1 HCG

carisoprodol 350 mg tablet 1

carisoprodol compound 1

carisoprodol-aspirin 1

carisoprodol-aspirin-codeine 1 QL 21 / day

chlorzoxazone (375 mg tablet, 500 mg tablet, 750 mgtablet) 1

chlorzoxazone 250 mg tablet 1

HCG


cyclobenzaprine 10 mg tablet 1



cyclobenzaprine 5 mg tablet 1

cyclobenzaprine 7.5 mg tablet 1 HCG

cyclobenzaprine hcl er 1 HCG

FEXMID 3MVB Minimal Value

Brand


LORZONE 3

METAXALL 1

metaxalone 1 HCG

methocarbamol (500 mg tablet, 750 mg tablet) 1

methocarbamol 1,000 mg/10 ml 1 MED Medical Drug

ROBAXIN 500 MG TABLET 3

ROBAXIN 1,000 MG/10 ML VIAL 3 MED Medical Drug

ROBAXIN-750 3 SBA Select BrandAlternative

SKELAXIN 3ST


SOMA 3ST


tizanidine hcl (2 mg capsule, 4 mg capsule, 6 mg capsule) 1 HCG

tizanidine hcl (2 mg tablet, 4 mg tablet) 1

ZANAFLEX (2 MG CAPSULE, 4 MG CAPSULE, 4 MG TABLET,6 MG CAPSULE) 3

ST




DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3

DANTRIUM 20 MG VIAL 3 MED Medical Drug

dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1 HCG

dantrolene sodium 20 mg vial 1 MED Medical Drug

REVONTO 1 MED Medical Drug

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

baclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

OZOBAX 3 PA

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

NORGESIC FORTE 3MVB Minimal Value

Brand


orphenadrine citrate 1 MED Medical Drug

orphenadrine citrate er 1

orphenadrine-aspirin-caffeine 1

ORPHENGESIC FORTE 3 SBA Select BrandAlternative

SKIN AND MUCOUS MEMBRANE AGENTS

ANTIPRURITICS AND LOCAL ANESTHETICS

ANACAINE 3

ANASTIA 3

CETACAINE 3

doxepin 5% cream 1

QL 49 / fill

PA

HCG



ethyl chloride 1

lidocaine 5% patch 1 QL 3 / day

lidocaine 5% ointment 1

lidocaine hcl 3% lotion 1

HCG


lidocaine hcl (3% cream, hcl 4% solution) 1

lidocaine-hc 2.8-0.55% gel 1

lidocaine-prilocaine 1

HCG


lidocaine-tetracaine 3

HCG


LIDODERM 3QL 3 / day


LIDODOSE 2QL 1 / day

PA

LIDOPIN 3% CREAM 1

LIDOPRIL 1

LIDTOPIC MAX 3

NUMBONEX 3

phenazopyridine hcl 1

PLIAGLIS 3 MVB Minimal ValueBrand



PONTOCAINE 3

pramoxine hcl 1

PRE-ATTACHED LTA KIT 3

PRIKAAN 1

HCG


PRIKAAN LITE 1

PRUDOXIN 3

QL 49 / fill

PA


PYRIDIUM 100 MG TABLET 3

PYRIDIUM 200 MG TABLET 3 SBA Select BrandAlternative

RADIAGUARD 3

SYNERA 3 MVB Minimal ValueBrand

WAL-DRYL 2%-0.1% CREAM 1

ZONALON 3QL 30 / fill

PA

ZTLIDO 3QL 3 / day

PA

ASTRINGENTS

DRYSOL 3

CVS MEDICATED PADS 1

XERAC AC 3



CELL STIMULANTS AND PROLIFERANTS

ALTRENO 3QL 1.5 / day

PA

ATRALIN 3QL 1.5 / day

PA

AVITA (CREAM, GEL) 1

KEPIVANCE 3S

MED Medical Drug

REFISSA 3

REGRANEX 3 QL 1 / day

RENOVA 3 MVB Minimal ValueBrand

RENOVA PUMP 3 MVB Minimal ValueBrand

RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%CREAM, 0.1% CREAM) 3

QL 50 / 30 days

PA

RETIN-A MICRO 3

QL 50 / 30 days

PA



RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.1%GEL) 3

QL 50 / 30 days

PA

RETIN-A MICRO PUMP (PUMP 0.06% GEL, PUMP 0.08%GEL) 2

QL 50 / 30 days

AL Up to 25 yrs old

TRETIN-X 0.075% CREAM 3 PA

tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream) 1



tretinoin 0.05% emollient crm 1

tretinoin 0.05% gel 1 QL 1.5 / day

tretinoin microsphere (gel 0.04% pump, gel 0.04% tube,gel 0.1% pump, gel 0.1% tube) 1

QL 1.667 / day

PA

HCG


DETERGENTS

iv sol stabilizer for blincyto 1S

MED Medical Drug

polysorbate 60 1

polysorbate 80 1

triton x-100 3

KERATOLYTIC AGENTS

AVAR CLEANSER 1

AVAR (9.5%-5% FOAM, 9.5-5% CLEANSING PADS) 3

AVAR LS (10%-2% FOAM, 10-2% CLEANSING PADS,CLEANSER) 3

AVAR-E 1

AVAR-E GREEN 1 HCG

AVAR-E LS 3

BENZEFOAM 3 QL 2 / day

BENZEFOAM ULTRA 3 QL 3.334 / day

BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1

BENZEPRO 5.2% EMOLLIENT FOAM 3



benzoyl peroxide (pr 7% wash, 9.8% foam) 1

BP 10-1 1

HCG


BPO (4% GEL, 8% GEL) 3

BPO 6% FOAMING CLOTHS 1 QL 2 / day

PACNEX 1

PLEXION (9.8-4.8% CLEANSER, 9.8-4.8% LOTION) 3 SBA Select BrandAlternative

PLEXION 9.8-4.8% CREAM 3MVB Minimal Value

Brand


PLEXION 9.8-4.8% CLNSING CLOTH 3

pr benzoyl peroxide 1

ROSANIL 1

ROSULA 10%-4.5% WASH 3

ROSULA 10%-5% CLOTHS 1

SALEX 6% SHAMPOO 3MVB Minimal Value

Brand


salicylic acid (foam, gel) 1

HCG


salicylic acid (6% cream, 6% lotion, 6% shampoo, 26%liquid, 27.5% liquid) 1

salicylic acid er 1

HCG




SALIMEZ FORTE 3

SALVAX 3

sod sulfacet-sulfur 10-2% clsr 1

HCG


sod sulfacet-sulfur 10-5% clsr 1

sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8%crm, sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr, sod sulfacetamide-sulfur lotn, sodsulfacetamide-sulfur susp, sodium sulfacet-sulfur wash,sulfacetamide-sulfur 10-2% crm, sulfacetamide-sulfur 10-5% crm)

3

HCG


sod sulfacet-sulfur 10-4% pad 1

sodium sulfacetamide-sulfur (sod sulface-sulfur 9-4.5%wash, sulfacetamide-sulfur 8-4% susp) 3

SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1

SULFACLEANSE 8-4 1

SUMADAN 9%-4.5% WASH 3

SUMAXIN (9%-4% WASH, CLEANSING PADS) 3

SUMAXIN TS 3

ULTRASAL-ER 3 SBA Select BrandAlternative

urea (35% foam, 39% cream, 40% lotion, 45% cream, 45%nail gel) 1

UTOPIC 3 SBA Select BrandAlternative

VIRASAL 3



KERATOPLASTIC AGENTS

DRITHOCREME HP 3

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

ABSORICA 3 PA

ABSORICA LD 3 PA

acitretin (17.5 mg capsule, 25 mg capsule) 1 QL 2 / day

acitretin 10 mg capsule 1 QL 4 / day

ACZONE 5% GEL 3

QL 3 / day

PA


ACZONE 7.5% GEL PUMP 3 QL 3 / day

adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 1 QL 1.5 / day

adapalene 0.1% swab 1QL 1 / day

PA

adapalene (lotion, solution) 1QL 2 / day

PA

adapalene-benzoyl peroxide 1 QL 1.5 / day

AKLIEF 3QL 1.5 / day

PA

ALDARA 3QL 0.434 / day


AMNESTEEM 1 PA

ARAZLO 3 QL 1.5 / day



AVAGE 3 QL 1.47 / day

azelaic acid 3QL 50 / 30 days

PA

AZELEX 3 QL 1.667 / day

calcipotriene 0.005% cream 1QL 2 / day

HCG

calcipotriene (ointment, solution) 1 QL 2 / day

calcipotriene-betamethasone dp 1QL 3 / day

PA

CALCITRENE 1

QL 2 / day

HCG


calcitriol 3 mcg/g ointment 1

QL 3.334 / day

HCG


CLARAVIS 1 PA

CONDYLOX 3

COSENTYX (2 SYRINGES) 3

QL 0.357 / day

S

PA

COSENTYX PEN 3

QL 0.357 / day

S

PA

COSENTYX PEN (2 PENS) 3

QL 0.357 / day

S

PA



COSENTYX SYRINGE 3

QL 0.357 / day

S

PA

dapsone 5% gel 1

QL 3 / day

HCG


dapsone 7.5% gel pump 3 QL 3 / day

DEBACTEROL SWABSTICK 3

DIFFERIN (0.1% CREAM, 0.3% GEL, 0.3% GEL PUMP) 3QL 1.5 / day

PA

DIFFERIN 0.1% LOTION 3QL 1.967 / day

PA

DOVONEX 3

QL 2 / day

PA



DUOBRII 3QL 7 / day

PA

DUPIXENT PEN 3

QL 0.15 / day


S

PS

PA

DUPIXENT 300 MG/2 ML SYRINGE 3

QL 0.15 / day


S

PS

PA



ELIDEL 3

QL 2.5 / day

ST


ENSTILAR 3 QL 2 / day

EPIDUO 3QL 1.5 / day

ST

EPIDUO FORTE 3 QL 1.667 / day

FABIOR 3

QL 3.73 / day

AL Up to 34 yrs old

PA

FINACEA 15% FOAM 3 QL 50 / 30 days

FINACEA 15% GEL 3

QL 50 / 30 days

PA

B4G

finasteride 1 mg tablet 1

FORMADON 1

imiquimod 5% cream packet 1QL 0.434 / day


imiquimod 3.75% cream pump 1

QL 0.25 / day


HCG


isotretinoin 1 PA

ivermectin 1% cream 1 QL 1.5 / day



MIRVASO (GEL, GEL PUMP) 3 QL 1 / day

MYORISAN 1 PA

pimecrolimus 1

QL 2.5 / day

ST


PODOCON-25 3

podofilox 1

PROPECIA 3 ST

PROTOPIC 0.03% OINTMENT 3

QL 2.5 / day

ST


PROTOPIC 0.1% OINTMENT 3

QL 2.5 / day

ST


QUTENZA 3S

MED Medical Drug

RECTIV 3

RHOFADE 3 QL 1.25 / day

SANTYL 3

SILIQ 3


S

PA

SKYRIZI 3

QL 0.07 / day

S

PS

PA




SKYRIZI (2 SYRINGES) KIT 3

QL 0.04 / day

S

PS

PA


SOOLANTRA 3QL 1.5 / day

B4G

SORIATANE 10 MG CAPSULE 3 QL 4 / day

SORIATANE 25 MG CAPSULE 3 QL 2 / day

SORILUX 3

QL 2 / day

PA

B4G



STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90MG/ML SYRINGE) 3

QL 0.08 / day

S

PS

PA


STELARA 130 MG/26 ML VIAL 3

QL 3.73 / day

S

PS

PA





TACLONEX OINTMENT 3

QL 3 / day

PA


TACLONEX 0.005%-0.064% SUSPENS 3QL 4 / day

B4G

tacrolimus (0.03% ointment, 0.1% ointment) 1QL 100 / 30 days

ST

TALTZ AUTOINJECTOR 3

QL 0.15 / day

S

PS

PA


TALTZ AUTOINJECTOR (2 PACK) 3

QL 0.15 / day

S

PS

PA


TALTZ AUTOINJECTOR (3 PACK) 3

QL 0.15 / day

S

PS

PA


TALTZ SYRINGE 3

QL 0.15 / day

S

PS

PA




tazarotene 1 QL 1.47 / day

TAZORAC 0.05% CREAM 3QL 2 / day

PA

TAZORAC 0.1% CREAM 3

QL 2 / day

PA


TAZORAC 0.05% GEL 3QL 3.334 / day

PA

TAZORAC 0.1% GEL 3

QL 3.334 / day

PA


TISSEEL VHSD (2 ML KIT, FROZEN 2 ML SYR, 4 ML KIT,FROZEN 4 ML SYR, 10 ML KIT, FROZEN 10 ML SYR) 3 MED Medical Drug

TREMFYA (100 MG/ML INJECTOR, 100 MG/ML SYRINGE) 3

QL 0.04 / day


S

PS

PA


TRI-CHLOR 3

trichloroacetic acid (20%, 25%, 50%, 75%, 80%, 85%, 90%,100%) 1

VANIQA 3 MVB Minimal ValueBrand

VECTICAL 3QL 3.334 / day

ST



VENELEX OINTMENT 3

VEREGEN 3 MVB MINIMALVALUE BRAND

ZENATANE 1 PA

ZYCLARA 3.75% CREAM 3

QL 56 / 60 days

ST


ZYCLARA 2.5% CREAM PUMP 3

QL 56 / 30 days

ST


ZYCLARA 3.75% CREAM PUMP 3

QL 56 / 60 days

ST



SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

aminophylline 1MED Medical Drug

PR

ELIXOPHYLLIN 3PR

NTI

THEO-24 3PR

NTI

theophylline 80 mg/15 ml soln 1PR

NTI



theophylline (er 400 mg tablet, er 600 mg tablet) 1PR

NTI

theophylline anhydrous 1PR

NTI

theophylline in 5% dextrose 1

MED Medical Drug

PR

NTI

SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS

BYNFEZIA 3

QL 0.6 / day

S

PA

MYCAPSSA 3

QL 4 / day

S

PA

octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/mlamp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100mcg/ml amp, acet 100 mcg/ml syr, acet 100 mcg/ml vl,acet 200 mcg/ml vl, acet 500 mcg/ml amp, acet 500mcg/ml syr, acet 500 mcg/ml vl, 1,000 mcg/5 ml vial,1,000 mcg/ml vial, 5,000 mcg/5 ml vial)

1S

PA

SANDOSTATIN 0.05 MG/ML AMPUL 3

QL 30 / day

S

PA



QL 15 / day

S

PA





QL 3 / day

S

PA


SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MGKT, 30 MG VL) 3

QL 0.04 / day

S

PA


SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 3

QL 0.07 / day

S

PA


SIGNIFOR 3S

PA

SIGNIFOR LAR 3S

PA

SOMATULINE DEPOT 3

QL 0.02 / day

S

PA


SOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN AGONISTS

EGRIFTA 3

QL 2 / day

S

PA



EGRIFTA SV 3

QL 2 / day

S

PA

INCRELEX 3S

PA

SOMATOTROPIN ANTAGONISTS

SOMAVERT 3 S

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS

ADRENALIN 3 MED Medical Drug

AUVI-Q (0.15 MG, 0.3 MG) 3

QL 2 / fill

PA


AUVI-Q 0.1 MG AUTO-INJECTOR 3

QL 2 / fill

PA


epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 4 / fill

epinephrine (0.1 mg/ml syringe, 1 mg/10 ml abbojct, 1mg/ml ampul) 1 MED Medical Drug

epinephrine 30 mg/30 ml vial 1 MED Medical Drug

epinephrine hcl-0.9% nacl (0.16 mg/10 ml-ns, 0.8 mg/50ml-ns) 1 MED Medical Drug

epinephrine 5 mg/250 ml-d5w 1 MED Medical Drug

epinephrine 100 mcg/10 ml-d5w 1 MED Medical Drug

EPINEPHRINESNAP-EMS 3 QL 2 / fill



EPINEPHRINESNAP-V 3 QL 2 / fill

EPIPEN 3QL 4 / fill

PA

EPIPEN 2-PAK 3QL 4 / fill

PA

EPIPEN JR 3QL 4 / fill

PA

EPIPEN JR 2-PAK 3QL 4 / fill

PA

norepinephrine bitar-0.9% nacl (norepineph 0.8 mg/50-0.9% nacl, norepineph 15 mg/250-0.9% nacl, norepinephr0.16 mg/10 ml-ns)

1 MED Medical Drug

norepinephrine bitartrate-d5w (100 mcg/10, 160 mcg/10) 1 MED Medical Drug

NORTHERA 3

QL 84 / 14 days

S

PA

SYMJEPI 3 QL 2 / fill

ALPHA-ADRENERGIC AGONISTS

BIORPHEN 3 MED Medical Drug

LUCEMYRA 3QL 48 tablets/180

daysPA

midodrine hcl 1

phenylephrine hcl-0.9% nacl (1 mg/10 ml-ns, 5 mg/50 ml-ns, 10 mg/250 ml-ns, 100 mcg/10 ml-ns, 200 mcg/2 ml-ns, 200 mg/250 ml-ns, 1,200mcg/10ml-ns)

1 MED Medical Drug

phenylephrine hcl-d5w (8 mg/100, 20 mg/500, 25mg/250, 30 mg/250) 1 MED Medical Drug



phenylephrine hcl-water (0.4mg/10ml-water, 1 mg/10 ml-water) 1 MED Medical Drug

TETRACYCLINE ANTIBIOTICS

AMINOMETHYLCYCLINES

NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150MG-7 DAY WITH LOAD) 3 PA

NUZYRA 100 MG VIAL 3 MED Medical Drug

SEYSARA 3QL 1 / day

PA

GLYCYLCYCLINE ANTIBIOTICS

tigecycline 1 MED Medical Drug

TYGACIL 3 MED Medical Drug

THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

SSKI 3

TAPAZOLE 10 MG TABLET 3

TAPAZOLE 5 MG TABLET 3 SBA Select BrandAlternative

THYROID AGENTS

ARMOUR THYROID 3 ST

CYTOMEL 3 SBA Select BrandAlternative

EUTHYROX 1 NTI



LEVO-T 1 NTI

levothyroxine 1QL 1 / day

NTI

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcgtablet, 150 mcg tablet, 175 mcg tablet)

1 NTI

levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200mcg tablet, 300 mcg tablet) 1 NTI

levothyroxine sodium (100 mcg vial, 200 mcg vial, 500mcg vial) 1

MED Medical Drug

NTI

levothyroxine sodium (100 mcg/5 ml vl, 200 mcg/5 ml vl,500 mcg/5 ml vl) 1

LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET) 1 NTI

LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCGTABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCGTABLET, 175 MCG TABLET, 200 MCG TABLET)

1 NTI

liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1

liothyronine sod 10 mcg/ml vl 1 MED Medical Drug

NATURE-THROID 3

NP THYROID 1

SYNTHROID 3ST

NTI

thyroid (15 mg tablet, 30 mg tablet, 60 mg tablet, 90 mgtablet, 120 mg tablet) 1

THYROLAR-1 3

THYROLAR-1/2 3

THYROLAR-1/4 3



THYROLAR-2 3

THYROLAR-3 3

TIROSINT 3QL 1 / day

NTI

TIROSINT-SOL 3QL 1 / day

NTI

TRIOSTAT 3 MED Medical Drug

UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET, 112 MCG TABLET) 1 NTI

UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCGTABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCGTABLET, 200 MCG TABLET, 300 MCG TABLET)

1 NTI

WESTHROID 3

WP THYROID 3 ST

URINE AND FECES CONTENTS

KETONES

ketone care test strip 3 QL 6.66 / day

ketone test strip 3 QL 6.66 / day

ketostix reagent 3 QL 6.66 / day

trueplus ketone test strip 3 QL 6.66 / day

PH

chemstrip 2 ln 3

nitratest paper 3

PROTEIN

albustix reagent 3



chemstrip micral 3

SUGAR

diastix reagent 3 QL 10 / day

no-stick glucose 3

Uncategorized

Unclassified

CAVERJECT 40 MCG/2 ML AMPUL 3

yohimbine hcl 1

VASODILATING AGENTS

NITRATES AND NITRITES

DILATRATE-SR 3QL 4 / day


GONITRO 3

QL 1.25 / day


PA

ISOCHRON 1 QL 4 / day

ISORDIL 3QL 12 / day


ISORDIL TITRADOSE 3QL 12 / day


isosorbide dinitrate 1 QL 12 / day

isosorbide dinitrate er 1 QL 4 / day



isosorbide mononitrate 1 QL 2 / day

isosorbide mononitrate er 1 QL 2 / day

MINITRAN 1 QL 1 / day

NITRO-BID 2 QL 4 / day

NITRO-DUR 3 QL 1 / day

NITRO-TIME (ER 2.5 MG CAPSULE, ER 6.5 MG CAPSULE) 1 QL 4 / day

nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mgcapsule) 1 QL 4 / day

nitroglycerin 400 mcg spray 1 QL 0.8 / day

nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 QL 6 / day

nitroglycerin 5 mg/ml vial 1 MED Medical Drug

nitroglycerin in d5w 1 MED Medical Drug

nitroglycerin patch 1 QL 1 / day

NITROLINGUAL 3 QL 0.8 / day

NITROMIST 3 QL 0.3 / day

NITROSTAT 3QL 6 / day


PHOSPHODIESTERASE TYPE 5 INHIBITORS

ADCIRCA 3

QL 2 / day

S

PA


ALYQ 1

QL 2 / day

S

PA



CIALIS (10 MG TABLET, 20 MG TABLET) 3

QL 0.2 / day

ST

GL Male


CIALIS (2.5 MG TABLET, 5 MG TABLET) 3

QL 1 / day

ST

GL Male


LEVITRA 3

QL 0.2 / day

GL Male



REVATIO 10 MG/ML ORAL SUSP 3

QL 6 / day


S

PA

REVATIO 20 MG TABLET 3

QL 3 / day


S

PA

REVATIO 10 MG/12.5 ML VIAL 3


S

MED Medical Drug

PA

sildenafil 20 mg tablet (pah) 1

QL 3 / day

S

PA



sildenafil 10 mg/ml oral susp 1

QL 6 / day


S

PA

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mgtablet) 1

QL 0.2 / day

GL Male


sildenafil 10 mg/12.5 ml vial 1


S

MED Medical Drug

PA

STAXYN 3

QL 0.2 / day

GL Male


STENDRA 3QL 0.2 / day

GL Male

tadalafil (2.5 mg tablet, 5 mg tablet) 1QL 1 / day

GL Male

tadalafil 10 mg tablet 1QL 0.2 / day

GL Male

tadalafil 20 mg tablet (ed/bph) 1QL 0.2 / day

GL Male

tadalafil 20 mg tablet (pah) 1

QL 2 / day

S

PA



vardenafil hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet,20 mg tablet) 1

QL 0.2 / day

GL Male


HCG

vardenafil hcl 10 mg odt 1

QL 0.2 / day

GL Male


HCG


VIAGRA 3

QL 0.2 / day

GL Male



VASODILATING AGENTS, MISCELLANEOUS

AGGRENOX 3

QL 2 / day

PR


aspirin-dipyridamole er 1QL 2 / day

PR

CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE20 MCG KIT, 40 MCG VIAL) 3 GL Male

CAVERJECT (10 MCG, 20 MCG) 3

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1QL 4 / day

PR



EDEX 3 GL Male

isoxsuprine 10 mg tablet 1

MUSE 3 GL Male

NATRECOR 3 MED Medical Drug

papaverine hcl 1 MED Medical Drug

VITAMINS

MULTIVITAMIN PREPARATIONS

CADEAU DHA 3 GL Female

INFUVITE PEDIATRIC 1 MED Medical Drug

M.V.I. PEDIATRIC 3 MED Medical Drug

MVW COMPLETE FORMLTN PEDIATRIC 3

MVW COMPLETE FORMUL D3000 SFGL 3

MYNATAL 3GL Female

PR

MYNATAL PLUS 3GL Female

PR

MYNATAL-Z 3GL Female

PR

NEWGEN 3GL Female

PR

OBTREX DHA 3GL Female

PR

ONEVITE 3

PRENA1 CHEW 3GL Female

PR



PRENA1 PEARL 3GL Female

PR

PRENA1 TRUE 3GL Female

PR

PRENATABS RX 3GL Female

PR

prenatal low iron 3GL Female

PR

PRENATAL VITAMIN WITH MINERALS AND FOLIC ACIDGREATER THAN 0.8 MG ORAL TABLET 3

GL Female

PR

prenatal-u 3GL Female

PR

R-NATAL OB 3GL Female

PR

TOBAKIENT 3

TRINATE 3GL Female

PR

TRUST NATAL DHA 3GL Female

PR

VINATE DHA RF 3GL Female

PR

VINATE ONE 3GL Female

PR

VINATE-M 3GL Female

PR

VIRT-C DHA 3



VITATRUE 3GL Female

PR

VITAMIN A

AQUASOL A 3

VITAMIN B COMPLEX

B-12 COMPLIANCE 3

cyanocobalamin injection 1

folic acid 1 mg tablet 1

folic acid (5 mg/ml vial, 50 mg/10 ml vial) 1 MED Medical Drug

hydroxocobalamin 1

METANX 3

NASCOBAL 3

NEPHRONEX-SL 1

pyridoxine 100 mg/ml vial 1 MED Medical Drug

thiamine 200 mg/2 ml vial 1 BSP BENEFIT SHIFTPROGRAM

VITAMIN C

ascorbic acid granules 3

ascorbic acid 500 mg/ml vial 1 MED Medical Drug

VITAMIN D

calcitriol 1 mcg/ml ampul 1 MED Medical Drug

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution) 1

doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 1 S



doxercalciferol 4 mcg/2 ml vl 1S

MED Medical Drug

DRISDOL 3MVB Minimal Value

Brand


HECTOROL 3S

MED Medical Drug

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1 S

paricalcitol (2 mcg/ml vial, 5 mcg/ml vial, 10 mcg/2 mlvial) 1

S

MED Medical Drug

RAYALDEE 3 S

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1MCG/ML ORAL SOLN) 3

vitamin d2 1.25mg(50,000 unit) 1

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3S

PA

ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2ML VIAL) 3

S

MED Medical Drug

PA

VITAMIN E

wheat germ oil 1

VITAMIN K ACTIVITY

MEPHYTON 3 SBA Select BrandAlternative

phytonadione (1 mg/0.5 ml syr, 10 mg/ml ampul) 1 MED Medical Drug

phytonadione 5 mg tablet 1



vitamin k1 1 MED Medical Drug


Index of Covered Drugs

11st tier unifine pentips 2611st tier unifine pentips plus 2611st tier unilet comfortouch 261

22-in-1 lancet device 2612tek 261

AA-HYDROCORT 354abacavir 200abacavir-lamivudine 200abacavir-lamivudine-zidovudine 200ABATUSS DMX 339ABELCET 116ABILIFY 182ABILIFY MAINTENA 182ABILIFY MYCITE 183abouttime pen needle 261ABRAXANE 145ABSORICA 457ABSORICA LD 457ABSTRAL 7acamprosate calcium 251ACANYA 42acarbose 100ACCOLATE 53accu-chek 261accu-chek aviva plus 261,299accu-chek compact plus control 261accu-chek compact plus strips 299accu-chek fastclix lancet drum 261accu-chek fastclix lancing dev 261accu-chek guide control soln 262accu-chek guide me glucose mtr 262accu-chek guide monitor system 262accu-chek guide test strip 300accu-chek nano smartview 262accu-chek safe-t-pro 262

accu-chek safe-t-pro plus 262accu-chek smartview 262,300accu-chek softclix 262ACCUPRIL 437ACCURETIC 437accutrend glucose 262,300ACD-A 323acebutolol hcl 246acetamin-caff-dihydrocodeine 7acetaminophen 5acetaminophen-codeine 7,8acetazolamide 121acetazolamide er 121acetazolamide sodium 121acetic acid 42acetylcysteine 444ACIPHEX 216ACIPHEX SPRINKLE 217acitretin 457ACTEMRA 400ACTEMRA ACTPEN 401ACTHAR 299ACTHIB 211ACTHREL 316acti-lance 262ACTICLATE 67ACTIGALL 343ACTIMMUNE 406ACTIQ 8ACTIVASE 206ACTIVELLA 330ACTONEL 395ACTOPLUS MET 109ACTOPLUS MET XR 109ACTOS 109ACULAR 52ACULAR LS 52ACUVAIL 52acyclovir 46,47,220acyclovir sodium 220acyclovir sodium-0.9% nacl 220

acyclovir sodium-d5w 221ACZONE 457ADACEL TDAP 211ADAGEN 327ADAKVEO 233ADALAT CC 241adapalene 457adapalene-benzoyl peroxide 457ADASUVE 182ADCETRIS 145ADCIRCA 474ADDERALL 30ADDERALL XR 30ADDYI 251adefovir dipivoxil 221ADEMPAS 446adenosine 64ADHANSIA XR 33ADIPEX-P 28adjustable lancing device 262ADLYXIN 104ADMELOG 384ADMELOG SOLOSTAR 384ADRENALIN 468ADRENALIN CHLORIDE 337ADRIAMYCIN 145ADRUCIL 145ADVAIR DISKUS 257ADVAIR HFA 257advanced glucose meter 262advanced glucose test strip 300advanced glucose test strips 300advanced lancing device 262advanced travel lancets 262ADVATE 123advocate blood glucose monitor 262advocate control solution 262advocate duo 262advocate lancet 262advocate lancets 262advocate lancing device 263

advocate pen needle 263advocate pen needles 263advocate rapid-safe 263advocate redi-code 263,300advocate redi-code duo 263advocate redi-code plus 263advocate redi-code+ 300advocate redi-code+ ctrl soln 263advocate test strip 300ADYNOVATE 123ADZENYS ER 30ADZENYS XR-ODT 30AEMCOLO 75AFEDITAB CR 241AFINITOR 145AFINITOR DISPERZ 145AFIRMELLE 361AFLURIA QUAD 2019-20 (3YR UP) 211AFLURIA QUAD 2019-20 (6-35MO) 211AFLURIA QUAD 2019-2020 211AFLURIA QUAD 2020-2021 211AFLURIA QUAD 2020-21 (3YR UP) 211AFLURIA QUAD 2020-21 (6-35MO) 211AFREZZA 384AFSTYLA 123agamatrix amp 263,300agamatrix control 263agamatrix control solution 263agamatrix presto 301AGGRASTAT 205AGGRENOX 477AGRYLIN 206AIMOVIG AUTOINJECTOR 139AIMOVIG AUTOINJECTOR (2 PACK) 139AIRDUO DIGIHALER 257AIRDUO RESPICLICK 257AJOVY AUTOINJECTOR 139AJOVY SYRINGE 140AK-POLY-BAC 38AKLIEF 457AKTEN 337

AKTIPAK 42AKYNZEO 112ALA-CORT 55ALA-SCALP 55albendazole 37ALBENZA 37ALBUMINEX 233albustix reagent 472albuterol hfa 90 mcg inhaler (par) 231albuterol hfa 90 mcg inhaler (perrigo) 231albuterol hfa 90 mcg inhaler (prasco) 231albuterol hfa 90 mcg inhaler (teva) 231albuterol sulfate 231albuterol sulfate hfa 231alclometasone dipropionate 55ALDACTAZIDE 440ALDACTONE 440ALDARA 457ALDURAZYME 327ALECENSA 145alendronate sodium 395ALFERON N 219alfuzosin hcl er 5ALIMTA 146ALINIA 181ALIQOPA 146aliskiren 441alkaline batteries 263ALKERAN 146ALKINDI SPRINKLE 354ALLER-CHLOR 339allopurinol 394allopurinol sodium 394ALLZITAL 5almotriptan malate 140ALOCRIL 54alogliptin 103alogliptin-metformin 103alogliptin-pioglitazone 103ALOMIDE 334ALOPRIM 394

ALORA 330alosetron hcl 340alpha lipoic acid 415ALPHAGAN P 120ALPHANATE 123ALPHANINE SD 123alprazolam 226alprazolam er 226ALPRAZOLAM INTENSOL 226alprazolam odt 226alprazolam xr 226ALPROLIX 124ALREX 49ALTABAX 42ALTACE 437ALTAVERA 361alternate site lancets 263alternate site lancing device 263ALTOPREV 135ALTRENO 453ALUNBRIG 146ALVESCO 258ALYACEN 361ALYQ 474AMABELZ 330amantadine 177AMARYL 108AMBIEN 223AMBIEN CR 223AMBISOME 116ambrisentan 446amcinonide 55AMERGE 140AMETHIA 361AMETHIA LO 361AMETHYST 361AMICAR 124amifostine 419amikacin sulfate 64amiloride hcl 319amiloride-hydrochlorothiazide 319

aminocaproic acid 124aminophylline 465amiodarone hcl 64AMITIZA 341amitriptyline hcl 99amlodipine besylate 241amlodipine besylate-benazepril 241amlodipine-atorvastatin 135amlodipine-olmesartan 241amlodipine-valsartan 241amlodipine-valsartan-hctz 241AMNESTEEM 457amoxapine 99amoxicillin 428amoxicillin-clavulanate pot er 429amoxicillin-clavulanate potass 429amphetamine 30amphetamine sulfate 30amphotericin b 116ampicillin sodium 429ampicillin trihydrate 429ampicillin-sulbactam 429AMPYRA 415AMRIX 448AMZEEQ 43ANACAINE 450ANADROL-50 358ANAFRANIL 99anagrelide hcl 206ANALPRAM HC 55ANAPROX DS 420ANASPAZ 75ANASTIA 450anastrozole 146ANCOBON 116ANDRODERM 358ANDROGEL 358ANDROID 358ANGELIQ 330ANGIOMAX 80ANNOVERA 361

ANORO ELLIPTA 75ANTABUSE 393ANTARA 132ANUCORT-HC 55ANUSOL-HC 55,56ANZEMET 110APADAZ 8APEXICON E 56APIDRA 384APIDRA SOLOSTAR 385APLENZIN 92APOKYN 322apraclonidine hcl 336aprepitant 113APRI 361APRISO 340APTENSIO XR 33APTIOM 82APTIVUS 203aqua lance lancing device 263AQUASOL A 480ARAKODA 180ARALAST NP 445ARANELLE 361ARANESP 234ARAVA 401ARAZLO 457ARCALYST 415ARCAPTA NEOHALER 231argatroban 80argatroban-0.9% nacl 80argatroban-sodium chloride 80ARICEPT 229ARIKAYCE 64ARIMIDEX 146aripiprazole 183aripiprazole odt 183ARISTADA 183ARISTADA INITIO 184ARISTOSPAN 354ARIXTRA 79

armodafinil 36ARMONAIR DIGIHALER 258ARMONAIR RESPICLICK 258ARMOUR THYROID 470ARNUITY ELLIPTA 258AROMASIN 146ARRANON 147arsenic trioxide 147ARTHROTEC 50 420ARTHROTEC 75 420ARYMO ER 8ARZERRA 147asa-butalb-caffeine-codeine 8ASACOL HD 340ASCENIV 208ASCOMP WITH CODEINE 8ascorbic acid 480ASHLYNA 362ASMANEX 258ASMANEX HFA 258ASPARLAS 147aspergillus fumigatus 206aspirin-dipyridamole er 477assure 4 263,301assure dose 263assure haemolance plus 263assure id duo-shield 263assure id insulin safety 263assure id pen needle 264assure lance 264assure lance plus 264assure platinum 264,301assure platinum test strip 301assure prism 264assure prism multi 264,301ASTAGRAF XL 411ATACAND 432ATACAND HCT 432atazanavir sulfate 203ATELVIA 395atenolol 246

atenolol-chlorthalidone 246ATGAM 411ATIVAN 226,227atomoxetine hcl 251atorvastatin calcium 135atovaquone 181atovaquone-proguanil hcl 180ATRALIN 453ATRIPLA 200atropine sulfate 337ATROVENT HFA 76AUBAGIO 406AUBRA 362AUBRA EQ 362AUGMENTIN 429AUGMENTIN ES-600 429AUGMENTIN XR 429aureobasidium pullulans 206AUROVELA 362AUROVELA 24 FE 362AUROVELA FE 362AURYXIA 388AUSTEDO 254auto-lancet mini 264autolet impression 264autolet lancing device 264autolet plus 264autoshield duo pen needle 264AUVI-Q 468AVAGE 458AVALIDE 432,433AVANDIA 109AVAPRO 433AVAR 454AVAR LS 454AVAR-E 454AVAR-E GREEN 454AVAR-E LS 454AVASTIN 147AVC 47AVEED 358

AVELOX 66AVELOX IV 66AVENOVA 264AVIANE 362AVIDOXY 67AVITA 453AVODART 392AVONEX 406AVONEX PEN 406AVSOLA 401AVYCAZ 256AXIRON 358AYGESTIN 379AYUNA 362AYVAKIT 147azacitidine 147AZACTAM 392AZACTAM-ISO-OSMOTIC DEXTROSE 392AZASAN 411AZASITE 38azathioprine 412azathioprine sodium 412azelaic acid 458azelastine hcl 335azelastine-fluticasone 335AZELEX 458AZILECT 179azithromycin 390azo 317AZOPT 121AZOR 241aztreonam 392AZULFIDINE 67AZURETTE 362

BB-12 COMPLIANCE 480BACIGUENT 38BACIIM 72bacitracin 38,72bacitracin-polymyxin 38

baclofen 450BACTRIM 67BACTRIM DS 67BACTROBAN 43BACTROBAN NASAL 38BAFIERTAM 407BAL IN OIL 352BALCOLTRA 362balsalazide disodium 340BALVERSA 147BALZIVA 362BANZEL 83BAQSIMI 128BARACLUDE 221BARHEMSYS 111BASAGLAR KWIKPEN U-100 383BAVENCIO 148BAXDELA 66bcg (tice strain) 148bcg vaccine (tice strain) 212bd microtainer lancets 264bd ultra-fine 264bd ultra-fine ii 264BECONASE AQ 49BEKYREE 362BELBUCA 26BELEODAQ 148belladonna-opium 8belladonna-phenobarbital 76BELSOMRA 223BELVIQ 29BELVIQ XR 29benazepril hcl 437benazepril-hydrochlorothiazide 437bendamustine hcl 148BENEFIX 124BENICAR 433BENICAR HCT 433BENLYSTA 412BENTYL 76BENZACLIN 43

BENZAMYCIN 43BENZEFOAM 454BENZEFOAM ULTRA 454BENZEPRO 454benzhydrocodone-acetaminophen 8benznidazole 181benzonatate 442benzoyl peroxide 455benzphetamine hcl 30benztropine mesylate 178BEOVU 336BEPREVE 335BERINERT 399BESER 56BESIVANCE 38BETADINE 42betamethasone acetate-sod phos 354betamethasone diprop augmented 56betamethasone dipropionate 56betamethasone sod phos-acetate 354betamethasone valerate 56BETAPACE 246BETAPACE AF 246BETASERON 407betaxolol hcl 120,246bethanechol chloride 229BETHKIS 64BETIMOL 120BETOPTIC S 120bevacizumab 336BEVESPI AEROSPHERE 76BEVYXXA 79bexarotene 148BEXSERO 212BEYAZ 362bicalutamide 148BICILLIN C-R 430BICILLIN L-A 430BICNU 148BIDIL 382BIJUVA 330

BIKTARVY 200BILTRICIDE 37bimatoprost 122BINOSTO 396BIORPHEN 469bisoprolol fumarate 246bisoprolol-hydrochlorothiazide 246bivalirudin 80bivalirudin-0.9% nacl 80BIVIGAM 208BLANCHE 261BLENREP 148bleomycin sulfate 148BLEPH-10 38BLEPHAMIDE 39BLEPHAMIDE S.O.P. 39BLINCYTO 148BLISOVI 24 FE 363BLISOVI FE 363blood glucose control 264blood glucose meter 264blood glucose monitoring 264blood glucose test strip 301blood lancets 264blood-glucose control 264blood-glucose meter 265BLOXIVERZ 229blunt needle 265BONIVA 396BONJESTA 112BOOSTRIX TDAP 211bortezomib 148bosentan 446BOSULIF 148,149BOTOX 415BOTOX COSMETIC 415botrytis cinerea 206BP 10-1 455BPO 455BRAFTOVI 149breeze 2 265,301

BREO ELLIPTA 258bretylium tosylate 64BREVIBLOC 246BREZTRI AEROSPHERE 354BRIELLYN 363BRILINTA 205brimonidine tartrate 120BRISDELLE 95BRIVIACT 83BROMFED DM 442bromfenac sodium 52bromocriptine mesylate 321brompheniramine-pseudoephed-dm 442BROMSITE 52BROVANA 232BRUKINSA 149BRYHALI 56budesonide 258budesonide ec 354budesonide er 354budesonide-formoterol fumarate 258,259buffered lidocaine 389bullseye mini safety lancets 265bumetanide 318BUNAVAIL 26BUPAP 5BUPHENYL 323BUPRENEX 26buprenorphine 26buprenorphine hcl 26buprenorphine-naloxone 26bupropion hcl 92bupropion hcl sr 92bupropion xl 92buspirone hcl 223busulfan 149BUSULFEX 149butalb-acetaminoph-caff-codein 9butalbital compound-codeine 9butalbital-acetaminophen 5,6butalbital-acetaminophen-caffe 6

butalbital-aspirin-caffeine 427butorphanol tartrate 27BUTRANS 27BYDUREON 105BYDUREON BCISE 105BYDUREON PEN 105BYETTA 105BYNFEZIA 466BYSTOLIC 247BYVALSON 247

Ccabergoline 321CABLIVI 205CABOMETYX 149CADEAU DHA 478CADUET 135CAFERGOT 4caffeine citrate 33CALAN 236CALAN SR 236calcipotriene 458calcipotriene-betamethasone dp 458calcitonin-salmon 427CALCITRENE 458calcitriol 458,480calcium acetate 388calcium disodium versenate 352calcium gluconate-0.9% nacl 325calcium gluconate-nacl 325CALDOLOR 420CALQUENCE 149CAMBIA 421CAMILA 363CAMPATH 149CAMPTOSAR 149CAMRESE 363CAMRESE LO 363CANASA 340CANCIDAS 115candesartan cilexetil 433

candesartan-hydrochlorothiazid 433CAPASTAT SULFATE 144capecitabine 149CAPEX SHAMPOO 56CAPLYTA 184CAPRELSA 150captopril 437captopril-hydrochlorothiazide 438CARAC 150CARAFATE 216CARBAGLU 323carbamazepine 83carbamazepine er 83CARBATROL 83carbidopa 251carbidopa-levodopa 179carbidopa-levodopa er 179carbidopa-levodopa-entacapone 179carbinoxamine maleate 338carboplatin 150carboprost tromethamine 427CARDENE I.V. 242CARDIZEM 236CARDIZEM CD 236CARDIZEM LA 237CARDURA 246CARDURA XL 246carefine pen needle 265carelance ult lancing device 265careone 265caresens 265caresens n 265,301caresens n voice 265caresens prem lancing device 265caretouch glucose monitoring 265caretouch insulin syringe 265caretouch lancing device 265caretouch pen needle 265caretouch safety lancets 265caretouch test strip 301caretouch twist lancet 265

carisoprodol 448carisoprodol compound 448carisoprodol-aspirin 448carisoprodol-aspirin-codeine 448carmustine 150CARNITOR 415CARNITOR SF 415CAROSPIR 440carteolol hcl 120CARTIA XT 237carvedilol 247carvedilol er 247CASODEX 150caspofungin acetate 115CATAPRES 381CATAPRES-TTS 1 381CATAPRES-TTS 2 381CATAPRES-TTS 3 381CATHFLO ACTIVASE 206CAVERJECT 473,477CAYSTON 392CAZIANT 363cefaclor 255cefaclor er 255cefadroxil 255cefazolin sodium 255cefazolin sodium-0.9% nacl 255cefazolin sodium-d5w 255cefazolin sodium-dextrose 255cefazolin sodium-sterile water 255cefazolin-d5w 255cefdinir 256cefditoren pivoxil 256cefepime 257cefepime hcl 257cefepime-dextrose 257cefixime 256CEFOTAN 391cefotaxime sodium 256cefotetan 391cefotetan & dextrose 391

cefoxitin 392cefoxitin sodium 392cefpodoxime proxetil 256cefprozil 255ceftazidime 256ceftriaxone 256cefuroxime 256cefuroxime sodium 256CELEBREX 420celecoxib 420CELESTONE 354CELEXA 95CELLCEPT 412CELONTIN 92CENTANY 43cephalexin 255CEQUA 51CERDELGA 415CEREBYX 91CERETEC 317CEREZYME 327CESAMET 111CETACAINE 450cetirizine hcl 127CETRAXAL 39CETROTIDE 347cevimeline hcl 229CHANTIX 229CHARLOTTE 24 FE 363CHATEAL 363CHATEAL EQ 363chek-stix 317CHEMET 352chemstrip 317chemstrip 10 with sg 317chemstrip 2 gp 317chemstrip 2 ln 472chemstrip 50b 318chemstrip 7 318chemstrip 9 318chemstrip bg diary 265

chemstrip micral 473CHENODAL 343chloramphenicol sod succinate 66chlordiazepoxide hcl 227chlordiazepoxide-amitriptyline 99chlordiazepoxide-clidinium 76chlorhexidine gluconate 42chloroquine phosphate 180chlorothiazide 320chlorothiazide sodium 320chlorpromazine hcl 197chlorpropamide 108chlorthalidone 320chlorzoxazone 448choicedm clarus 265choicedm clarus control soln 266choicedm clarus test strips 302CHOLBAM 343,344cholestyramine 130cholestyramine light 130choline mag trisalicylate 427chorionic gonadotropin 348CIALIS 475CICLODAN 119ciclopirox 119cidofovir 221cilostazol 205CILOXAN 39CIMDUO 200cimetidine 215CIMZIA 401cinacalcet hcl 427CINRYZE 399CINVANTI 113CIPRO 66CIPRO HC 39CIPRODEX 39ciprofloxacin 66ciprofloxacin er 66ciprofloxacin hcl 39,66ciprofloxacin hcl-fluocinolone 39

ciprofloxacin-d5w 66ciprofloxacin-dexamethasone 39cisplatin 150citalopram hbr 95citrus bioflavonoids 415cladosporium cladosporioides 206cladribine 150CLAFORAN 256CLARAVIS 458CLARINEX 127CLARINEX-D 12 HOUR 127clarithromycin 390clarithromycin er 390CLEANSING WASH 47clemastine fumarate 338CLENPIQ 342CLEOCIN 43CLEOCIN HCL 73CLEOCIN PEDIATRIC 73CLEOCIN PHOSPHATE 73,74CLEOCIN T 43clever chek blood glucose syst 266clever chek lancets 266clever choice 266clever choice blood gluc sys 266clever choice control solution 266clever choice hd glucose syst 266clever choice micro 266clever choice micro test strip 302clever choice pro 266,302clever choice talk 266,302clever choice test strips 302clever choice voice+ tst strip 302CLEVIPREX 242clickfine 266CLIMARA 330CLIMARA PRO 330CLINDACIN ETZ 43CLINDACIN P 43CLINDAGEL 43clindamycin (pediatric) 74

clindamycin hcl 74clindamycin phos-benzoyl perox 43,44clindamycin phos-tretinoin 44clindamycin phosphate 44,74clindamycin phosphate-d5w 74clindamycin-0.9% nacl 74clindamycin-benzoyl peroxide 44CLINDESSE 44CLINOLIPID 323clobazam 90clobetasol emollient 56clobetasol emulsion 56clobetasol propionate 56CLOBEX 56clocortolone pivalate 56CLODAN 56CLODERM 56clofarabine 150CLOLAR 150clomiphene citrate 329clomipramine hcl 99clonazepam 90clonidine 381clonidine hcl 6,381clonidine hcl er 381clopidogrel 205clorazepate dipotassium 227clotrimazole 117clotrimazole-betamethasone 117clozapine 184clozapine odt 184CLOZARIL 185COAGADEX 124coaguchek 266COARTEM 180codeine sulfate 9codeine-guaifenesin 442COGENTIN 178COLAZAL 340colchicine 394COLCRYS 394

colesevelam hcl 130COLESTID 130,131colestipol hcl 131colistimethate 75COLOCORT 56color lancets 266COLY-MYCIN M PARENTERAL 75COLY-MYCIN S 39COLYTE WITH FLAVOR PACKETS 342COMBIGAN 120COMBIPATCH 330combistix reagent 318COMBIVENT RESPIMAT 76COMBIVIR 201COMETRIQ 150,151comfort ez 266comfort ez pen needle 266comfort lancets 266COMPAZINE 112COMPLERA 201COMPRO 112COMTAN 178CONCERTA 33CONDYLOX 458CONEX 339CONJUPRI 242CONRAY-43 317CONSENSI 242CONSTULOSE 323contour 266contour next 267contour next control solution 267contour next ez 267contour next link 267contour next link 2.4 267contour next one 267contour next test strip 302contour test strip 302CONTRAVE 29control ast 267control solution 267

CONZIP 9cool blood glucose 267cool blood glucose meter 267cool control solution 267cool glucose test strip 302COPAXONE 407COPIKTRA 151CORDRAN 56,57COREG 247COREG CR 247COREMINO 67,68CORGARD 248CORICIDIN HBP COLD AND FLU 6CORICIDIN HBP COUGH AND COLD 442CORIFACT 124CORLANOR 244CORLOPAM 382CORMAX 57CORTEF 354CORTENEMA 57CORTIFOAM 57cortisone acetate 354CORTISPORIN 44CORTROSYN 299CORVERT 64CORZIDE 248COSENTYX (2 SYRINGES) 458COSENTYX PEN 458COSENTYX PEN (2 PENS) 458COSENTYX SYRINGE 459COSMEGEN 151COSOPT 121COSOPT PF 121cosyntropin 299COTELLIC 151COTEMPLA XR-ODT 33COUMADIN 79COZAAR 433CREON 343CRESEMBA 114CRESTOR 135

CRINONE 379CRIXIVAN 203cromolyn sodium 54,55CROTAN 48CRYSELLE 363CUBICIN 72CUBICIN RF 72CUPRIMINE 353CUROSURF 445CUTAQUIG 208CUTIVATE 57CUVITRU 208CUVPOSA 76cyanocobalamin injection 480CYCLAFEM 363CYCLINEX-1 323cyclobenzaprine hcl 448,449cyclobenzaprine hcl er 449cyclophosphamide 151cycloserine 144CYCLOSET 321cyclosporine 412cyclosporine modified 412CYMBALTA 93,94cyproheptadine hcl 338CYRAMZA 151CYRED 364CYRED EQ 364CYSTADANE 416CYSTADROPS 336CYSTAGON 416CYSTARAN 336cytarabine 151CYTOGAM 208CYTOMEL 470CYTOTEC 216CYTOVENE 221CYTRA-K 322

DD-PENAMINE 353

D.H.E.45 4dacarbazine 151DACOGEN 151dactinomycin 151DAKLINZA 352dalfampridine er 416DALIRESP 445danazol 358DANTRIUM 450dantrolene sodium 450dapsone 143,459DAPTACEL DTAP 211daptomycin 72darifenacin er 346dario blood glucose test strip 302DARZALEX 152DARZALEX FASPRO 152DASETTA 364daunorubicin hcl 152DAURISMO 152DAYPRO 421DAYSEE 364DAYTRANA 33DAYVIGO 223DDAVP 378DEBACTEROL 459DEBLITANE 364DECADRON 354decitabine 152deferasirox 353deferiprone 353deferoxamine mesylate 353DELESTROGEN 331DELFLEX-2.5% DEXTROSE 325DELSTRIGO 199DELZICOL 340DEMADEX 318demeclocycline hcl 68DEMEROL 9DEMSER 416DENAVIR 47

DENTA 5000 PLUS 398DENTAGEL 398DEPACON 83DEPAKENE 83DEPAKOTE 83DEPAKOTE ER 84DEPAKOTE SPRINKLE 84DEPEN 353DEPO-ESTRADIOL 331DEPO-MEDROL 355DEPO-PROVERA 379DEPO-SUBQ PROVERA 104 379DEPO-TESTOSTERONE 359DERMA-SMOOTHE-FS 57DERMATOP 57DERMOTIC 49DESCOVY 201DESFERAL 353DESFERAL MESYLATE 353desipramine hcl 99desloratadine 127desmopressin acetate 378desogestr-eth estrad eth estra 364desogestrel-ethinyl estradiol 364DESONATE 57desonide 57DESOWEN 57desoximetasone 57,58DESOXYN 30desvenlafaxine er 94desvenlafaxine succinate er 94DETROL 346DETROL LA 346DEXABLISS 355dexamethasone 355dexamethasone acetate la 355dexamethasone acetate-sod phos 355DEXAMETHASONE INTENSOL 355dexamethasone sodium phosphate 49,355dexamethasone-0.9% nacl 355dexchlorpheniramine maleate 339

dexcom 267dexcom g4 267dexcom g5 267dexcom g5-g4 sensor 267dexcom g6 267DEXEDRINE 31DEXILANT 217dexmedetomidine hcl 224dexmethylphenidate hcl 33dexmethylphenidate hcl er 33DEXPAK 355dexrazoxane 419dexrazoxane diluent-sodium lac 430dextroamphetamine sulfate 31dextroamphetamine sulfate er 31dextroamphetamine-amphet er 31dextroamphetamine-amphetamine 31dextrose 5%-0.2% nacl-kcl 325dextrose 5%-0.225% nacl-kcl 325dextrose 5%-0.3% nacl-kcl 325dextrose 5%-0.45% nacl-kcl 325dextrose 5%-1/2ns-kcl 325dextrose 5%-1/4ns-kcl 325dextrose 5%-ns-kcl 325dextrose 5%-potassium chloride 325DIACOMIT 84DIASTAT 227DIASTAT ACUDIAL 227diastix reagent 473diatrue 267diatrue plus 268,303diazepam 227diazoxide 128DIBENZYLINE 4DICLEGIS 112diclofenac 421diclofenac epolamine 421diclofenac potassium 421diclofenac sodium 52,152,421diclofenac sodium er 421diclofenac sodium-misoprostol 421

dicloxacillin sodium 430dicyclomine hcl 76didanosine 201diethylpropion hcl 28diethylpropion hcl er 28DIFFERIN 459DIFICID 390diflorasone diacetate 58DIFLUCAN 114diflunisal 421DIGITEK 245DIGOX 245digoxin 245dihydroergotamine mesylate 4DILANTIN 91DILANTIN-125 91DILATRATE-SR 473DILAUDID 10DILT-XR 237diltiazem 12hr er 238diltiazem 24hr er 238diltiazem 24hr er (cd) 238diltiazem 24hr er (la) 238diltiazem 24hr er (xr) 238diltiazem hcl 239diltiazem hcl-0.7% nacl 239diltiazem hcl-0.9% nacl 239diltiazem-d5w 239diluent for decitabine 430DILUENT FOR ELITEK 431DILUENT FOR ISTODAX 431DILUENT FOR JEVTANA 431DILUENT FOR LEFAMULIN(XENLETA) 431dimenhydrinate 112DIOVAN 434DIOVAN HCT 434DIPENTUM 340diphenhydramine hcl 338diphenhydramine-0.9% nacl 338diphenoxylate-atropine 341diphtheria-tetanus toxoids-ped 211

DIPROLENE 58dipyridamole 477disopyramide phosphate 63disulfiram 393DITROPAN XL 346DIURIL 320divalproex sodium 84divalproex sodium er 84DIVIGEL 331DOCEFREZ 152docetaxel 152dofetilide 64DOJOLVI 323DOLOPHINE HCL 10donepezil hcl 229donepezil hcl odt 229DONNATAL 76DOPRAM 33DOPTELET 234DORAL 227doripenem 391DORYX 68DORYX MPC 68dorzolamide hcl 122dorzolamide-timolol 122DOTAREM 317DOTTI 331DOVATO 198DOVONEX 459doxapram hcl 33doxazosin mesylate 246doxepin hcl 99,450doxercalciferol 480,481DOXIL 152doxorubicin hcl 152doxorubicin hcl liposome 153DOXY 100 68doxycycline hyclate 39,68,69doxycycline ir-dr 69doxycycline monohydrate 69doxylamine succ-pyridoxine hcl 112

DRISDOL 481DRITHOCREME HP 457DRIZALMA SPRINKLE 94dronabinol 111droperidol 224droplet insulin syringe 268droplet lancets 268droplet lancing device 268droplet micron pen needle 268droplet pen needle 268dropsafe pen needle 268drospirenone-eth estra-levomef 364drospirenone-ethinyl estradiol 364DROXIA 153DRYSOL 452DSUVIA 10DUAC 44DUAKLIR PRESSAIR 76DUAVEE 331DUETACT 109DULERA 259duloxetine hcl 94DUOBRII 459DUODOTE 393DUOPA 179DUPIXENT PEN 459DUPIXENT SYRINGE 52,459DURACLON 6DURAGESIC 10DURAMORPH 10DUREZOL 49DURLAZA 427DUROLANE 268dutasteride 392dutasteride-tamsulosin 392DUTOPROL 248DVORAH 10DXEVO 355DYANAVEL XR 31DYAZIDE 319DYMISTA 335

DYRENIUM 319DYSPORT 416

Ee-z ject lancets 268e-zject lancets 268E.E.S. 200 390E.E.S. 400 390EAA 323easy comfort 268easy comfort insulin syringe 268easy comfort pen needle 268easy comfort pen needles 268easy glide pen needle 268easy gluco g2 303easy mini eject lancing device 268easy plus ii 268,269,303easy step 269,303easy step control solution 269easy talk 269,303easy touch 269easy touch control solution 269easy touch fliplock needles 269easy touch glucose monitor 269easy touch lancing device 269easy touch pen needle 269easy touch safety pen needle 269easy touch test strip 303easy trak 269,303easy trak ii control solution 269easy trak ii test strip 303easy twist & cap lancets 269easy-touch 270easygluco 270easygluco meter 270easygluco meter starter kit 270easygluco plus 303easygluco plus control normal 270easygluco test strips 304easymax 270,304easymax 15 270,304

easymax l 270easymax ng 270easymax v speaking 270easymax v2 270easypoint needle 270EC-NAPROSYN 421ec-naproxen 422eclipse needle 270econazole nitrate 117ECOZA 117ED-SPAZ 76EDARBI 434EDARBYCLOR 434EDECRIN 319EDEX 478EDLUAR 224EDURANT 199efavirenz 199EFFER-K 325EFFEXOR XR 94EFFIENT 205EFUDEX 153EGATEN 37EGRIFTA 467EGRIFTA SV 468ELAPRASE 327ELAVIL 99ELELYSO 327element compact 270,304element compact control soln 271element compact v 271element control solution 271element plus 271element test strips 304ELESTAT 335ELESTRIN 331eletriptan hbr 141ELIDEL 460ELIGARD 348ELIMITE 48ELINEST 364

ELIQUIS 79ELITEK 327ELIXOPHYLLIN 465ELLA 364ELLENCE 153ELMIRON 419ELOCON 58ELOCTATE 124ELURYNG 365ELZONRIS 153EMADINE 335embrace 271,304embrace evo 271,304embrace glucose control soln 271embrace pro 271embrace pro blood glucose mtr 271embrace pro test strip 304embrace talk 271embrace talk control solution 271embrace talk test strip 304EMCYT 153EMEND 113EMFLAZA 355EMGALITY PEN 140EMGALITY SYRINGE 140EMOQUETTE 365EMSAM 180emtricitabine 201emtricitabine-tenofovir disop 201EMTRIVA 201EMVERM 37ENABLEX 346enalapril maleate 438enalapril-hydrochlorothiazide 438enalaprilat 438ENBREL 401ENBREL MINI 401ENBREL SURECLICK 401ENDOCET 10,11ENDOMETRIN 379ENGERIX-B ADULT 212

ENGERIX-B PEDIATRIC-ADOLESCENT 212ENHERTU 153enlite 271enoxaparin sodium 80ENPRESSE 365ENSKYCE 365ENSPRYNG 407ENSTILAR 460entacapone 178entecavir 221enteral gravity bag set-enfit 271ENTEREG 344ENTOCORT EC 355ENTRESTO 434ENTYVIO 344ENULOSE 323ENVARSUS XR 413EPANED 438EPCLUSA 351epicoccum nigrum 206EPIDIOLEX 84EPIDUO 460EPIDUO FORTE 460EPIFOAM 58epinastine hcl 335epinephrine 468epinephrine hcl-0.9% nacl 468epinephrine hcl-d5w 468epinephrine-d5w 468EPINEPHRINESNAP-EMS 468EPINEPHRINESNAP-V 469EPIPEN 469EPIPEN 2-PAK 469EPIPEN JR 469EPIPEN JR 2-PAK 469epirubicin hcl 153EPISIL 271EPITOL 84EPIVIR 201EPIVIR HBV 201eplerenone 441

EPOGEN 234epoprostenol sodium 446eprosartan mesylate 434eptifibatide 205EPZICOM 201EQUETRO 84ERAXIS (WATER DILUENT) 115ERBITUX 153ergoloid mesylates 4ERGOMAR 4ergotamine-caffeine 4ERIVEDGE 153ERLEADA 153erlotinib hcl 153ERRIN 365ERTACZO 117ERWINAZE 153ERY 44ERY-TAB 390ERYGEL 44ERYPED 200 390ERYPED 400 390ERYTHROCIN LACTOBIONATE 390ERYTHROCIN STEARATE 390erythromycin 39,45,390erythromycin ethylsuccinate 390erythromycin-benzoyl peroxide 45ESBRIET 441escitalopram oxalate 95ESGIC 6esmolol hcl 248esmolol hcl-sodium chloride 248esomeprazole magnesium 217esomeprazole sodium 217esomeprazole strontium 217ESPEROCT 124ESTARYLLA 365estazolam 227ESTRACE 331estradiol 331,332estradiol (once weekly) 332

estradiol (twice weekly) 332estradiol valerate 332estradiol-norethindrone acetat 332ESTRING 332ESTROGEL 332estrogen-methyltestosterone 359ESTROSTEP FE 365eszopiclone 224ethacrynic acid 319ethambutol hcl 144ethosuximide 92ethyl chloride 451ethynodiol-ethinyl estradiol 365ETHYOL 419etidronate disodium 396etodolac 422etodolac er 422etonogestrel-ethinyl estradiol 365ETOPOPHOS 154etoposide 154eucalyptol 431EUCRISA 55EUFLEXXA 271EURAX 48EUTHYROX 470EVAMIST 332EVEKEO 31EVEKEO ODT 31,32evencare 272,305evencare g2 272,305evencare g3 272,305evencare mini glucose control 272evencare mini glucose test str 305evencare mini monitor system 272evencare proview control soln 272evencare proview test strip 305EVENITY 395EVENITY (2 SYRINGES) 395everolimus 154,413eversense sensor-holder 272EVISTA 329

EVOCLIN 45evolution blood glucose meter 272evolution control solution 272evolution test strips 305EVOMELA 154EVOTAZ 203EVOXAC 229EVRYSDI 416EXALGO 11exel hypodermic needle 272exel mti drawing needle 272EXELDERM 117EXELON 230exemestane 154EXFORGE 242EXFORGE HCT 242EXJADE 353EXTAVIA 407EXTINA 117EYLEA 336ez smart 272,305ez smart lancets 272ez smart plus 272,305ez-lets 273ez-vac 273EZALLOR SPRINKLE 135ezetimibe 132ezetimibe-simvastatin 132

FFABIOR 460FABRAZYME 327FACTIVE 66FALMINA 365famciclovir 221famotidine 215famotidine-0.9% nacl 216FANAPT 185FARESTON 329FARXIGA 106FARYDAK 154

FASENRA 53FASENRA PEN 53FASLODEX 154FAYOSIM 365FAZACLO 185febuxostat 394FEIBA NF 124felbamate 84FELBATOL 84FELDENE 422felodipine er 242FEM PH 47FEMARA 154FEMHRT 332FEMRING 332FEMYNOR 365fenofibrate 132,133fenofibric acid 133FENOGLIDE 133fenoprofen calcium 422FENORTHO 422fentanyl 11fentanyl citrate 11fentanyl citrate-0.9% nacl 11,12fentanyl-bupivacaine-0.9% nacl 12FENTORA 12FERAHEME 62FERRIPROX 353FERRIPROX (2 TIMES A DAY) 353FERRLECIT 62FETROJA 257FETZIMA 94FEXMID 449FIASP 385FIASP FLEXTOUCH 385FIASP PENFILL 385FIBRICOR 133fifty50 safety seal lancets 273fifty50 test strip 305filter aspirator needle 273filter needle 273

FINACEA 460finasteride 392,460fine 30 universal lancets 273fingerstix 273FINTEPLA 84FIORICET 6FIORINAL 427FIORINAL WITH CODEINE #3 12FIRAZYR 399FIRDAPSE 416FIRMAGON 347FIRVANQ 72FLAC OTIC OIL 49FLAGYL 181FLAREX 49flavoxate hcl 346FLEBOGAMMA DIF 208flecainide acetate 63FLECTOR 422FLOLAN 446FLOLIPID 135,136FLOMAX 5FLOVENT DISKUS 259FLOVENT HFA 259floxuridine 154FLUAD 2019-2020 212FLUAD 2020-2021 212FLUAD QUAD 2020-2021 212FLUARIX QUAD 2019-2020 212FLUARIX QUAD 2020-2021 212FLUBLOK QUAD 2019-2020 212FLUBLOK QUAD 2020-2021 212FLUCELVAX QUAD 2019-2020 212FLUCELVAX QUAD 2020-2021 212fluconazole 114fluconazole in saline 114fluconazole-nacl 114flucytosine 116fludarabine phosphate 154fludrocortisone acetate 355FLULAVAL QUAD 2019-2020 212

FLULAVAL QUAD 2020-2021 213FLUMADINE 219flumazenil 251FLUMIST QUAD 2019-2020 213FLUMIST QUAD 2020-2021 213flunisolide 49fluocinolone acetonide 58fluocinolone acetonide oil 49fluocinonide 58fluocinonide-e 58fluoride 398FLUORITAB 398fluorometholone 49FLUOROPLEX 155fluorouracil 155fluoxetine dr 95fluoxetine hcl 95,96fluphenazine decanoate 197fluphenazine hcl 197FLURA-DROPS 398flurandrenolide 58flurazepam hcl 227flurbiprofen 422flurbiprofen sodium 52flutamide 155fluticasone propionate 49,58,59fluticasone-salmeterol 259fluvastatin er 136fluvastatin sodium 136fluvoxamine maleate 96fluvoxamine maleate er 96FLUZONE HIGH-DOSE 2019-2020 213FLUZONE HIGH-DOSE QUAD 2020-21 213FLUZONE QUAD 2019-2020 213FLUZONE QUAD 2020-2021 213FLUZONE QUAD PEDI 2019-2020 213FML 49FML FORTE 49FML S.O.P. 49FOCALIN 33,34FOCALIN XR 34

folic acid 480FOLLISTIM AQ 348FOLOTYN 155fondaparinux sodium 79fora 6 connect glucose strip 306fora control solution 273fora d10 273fora d15 glucose-bp monitor 273fora d15g 306fora d20 273,306fora d40-g31 test strips 306fora d40d glucose-bp monitor 273fora d40g glucose-bp monitor 273fora g20 273,306fora g30-premium v10 test strp 306fora g30a 273fora gd50 273fora gd50 test strips 306fora gtel glucose test strip 306fora lancets 274fora lancing device 274fora premium v10 274fora test n'go voice 274fora test strip 306fora tn'g voice 274fora tn'g voice test strips 307fora v10 274,307fora v10-v12-d10-d20 274,307fora v12 274,307fora v20 274,307fora v30a 274,307foracare gd20 274,307foracare gd40 307foracare gd40a 274foracare gd40b 274foracare gdh 274foracare lancets 274FORFIVO XL 92FORMADON 460FORTAZ 256FORTEO 428

FORTESTA 359fortiscare 275fortiscare blood glucose syst 275fortiscare glucose test strips 307FOSAMAX 396FOSAMAX PLUS D 396fosamprenavir calcium 204fosaprepitant dimeglumine 113FOSCAVIR 219fosfomycin tromethamine 37fosinopril sodium 438fosinopril-hydrochlorothiazide 438fosphenytoin sodium 91FOSRENOL 388FRAGMIN 81freestyle control solution 275freestyle flash system 275freestyle freedom 275freestyle freedom lite 275freestyle insulinx 275,308freestyle insulinx test strips 308freestyle lancets 275freestyle libre 10 day reader 275freestyle libre 10 day sensor 275freestyle libre 14 day reader 275freestyle libre 14 day sensor 275freestyle libre 2 reader 275freestyle libre 2 sensor 275freestyle lite meter 275freestyle lite test strip 308freestyle navigator 275freestyle precision neo 308freestyle precision neo meter 276freestyle sidekick ii 276freestyle system 276freestyle test strips 308freestyle unistik 2 276FROVA 141frovatriptan succinate 141FULPHILA 234fulvestrant 155

FURADANTIN 37furosemide 319FUSILEV 393FUZEON 198FYAVOLV 333FYCOMPA 84

Ggabapentin 84,85GABITRIL 85GALAFOLD 416galantamine er 230galantamine hbr 230galantamine hydrobromide 230GALZIN 353GAMASTAN 208GAMASTAN S-D 208GAMIFANT 413GAMMAGARD LIQUID 208GAMMAGARD S-D 209GAMMAKED 209GAMMAPLEX 209GAMUNEX-C 209ganciclovir 221ganciclovir sodium 221ganirelix acetate 347GARDASIL 9 213GASTROCROM 55gatifloxacin 39GATTEX 344GAVILYTE-C 342GAVILYTE-G 342GAVILYTE-N 342GAVRETO 155GAZYVA 155gdrive 276ge100 blood glucose system 276ge100 blood glucose test strip 308ge100 control solution normal 276GEL-ONE 276GELNIQUE 346

gemcitabine hcl 155gemfibrozil 133GEMMILY 365GEMZAR 155GENERESS FE 366GENERLAC 323GENGRAF 413genstrip 308GENTAK 39gentamicin sulfate 39,45,65gentamicin sulfate in ns 65gentamicin-sodium citrate 65genteel vacuum lancing device 276genultimate test strip 308GENVISC 850 276GENVOYA 201GEODON 186GIANVI 366GILENYA 407,408GILOTRIF 155GILPHEX TR 444GILTUSS TR 444GIMOTI 345GLASSIA 445glatiramer acetate 408GLATOPA 408GLEEVEC 156GLEOSTINE 156GLIADEL 156glimepiride 108glipizide 108glipizide er 108glipizide xl 108glipizide-metformin 108GLOPERBA 394GLUCAGEN 128GLUCAGON EMERGENCY KIT 128gluco navii 276,308glucocard 01 276glucocard 01 control 276glucocard 01 sensor plus 309

glucocard expression 276,277,309glucocard shine 277,309glucocard shine connex meter 277glucocard shine express meter 277glucocard shine xl 277glucocard vital 277,309glucocard vital sensor 309glucocom 277glucocom blood glucose 277glucocom control solution 277glucocom glucose 309glucocom lancets 277GLUCOPHAGE 101GLUCOPHAGE XR 102glucose control 277glucose control solution 277glucose test strip 309GLUCOTROL 108GLUCOTROL XL 108glyburide 108glyburide micronized 108glyburide-metformin hcl 108GLYCATE 76glycopyrrolate 76glycopyrrolate-water 76GLYCOSADE 324GLYNASE 108GLYRX-PF 76GLYSET 100GLYTACTIN 10 PE COMPLETE 324GLYTACTIN 15 PE BETTERMILK 324GLYTACTIN 15 PE COMPLETE 324GLYTACTIN 20PE BETTERMILK LITE 324GLYTACTIN BUILD 10 PE 324GLYTACTIN BUILD 20-20 324GLYTACTIN BURST 10-10 324GLYTACTIN BURST 20-20 324GLYTACTIN RESTORE 10 PE 324GLYTACTIN RESTORE 10 PE LITE 324GLYTACTIN RESTORE 5 PE 324GLYTACTIN RTD 10 PE 324

GLYTACTIN RTD 15 PE 324GLYTACTIN RTD LITE 15 324GLYTACTIN SWIRL 15 PE 324GLYXAMBI 106GOCOVRI 177,178gojji blood glucose test strip 309gojji glucose control solution 277gojji lancet-glucose test strp 277gojji lancets 277gojji lancing device 277gojji multi-functional meter 277GOLYTELY 342GONAL-F 348GONAL-F RFF 348GONAL-F RFF REDI-JECT 348GONITRO 473goodlife ac-302 glucose meter 278goodlife ac-302 test strip 309GOODY'S EXTRA STRENGTH 427GRALISE 6granisetron hcl 110GRANIX 234GRASTEK 206griseofulvin 114griseofulvin ultramicrosize 114guaifenesin-codeine 442guanfacine hcl 381guanfacine hcl er 252guanidine hcl 230GVOKE HYPOPEN 1-PACK 128GVOKE HYPOPEN 2-PACK 128GVOKE PFS 1-PACK SYRINGE 128GVOKE PFS 2-PACK SYRINGE 128GYNAZOLE 1 117

HHAEGARDA 399HAILEY 366HAILEY 24 FE 366HAILEY FE 366HALAVEN 156

halcinonide 59HALCION 227HALDOL 197HALDOL DECANOATE 100 197HALDOL DECANOATE 50 197halobetasol propionate 59HALOG 59haloperidol 197haloperidol decanoate 197haloperidol decanoate 100 197haloperidol lactate 197harmony control solution 278harmony glucose test strip 310HARVONI 351HAVRIX 213HCY 1 324healthpro glucose control soln 278healthpro glucose monitor 278healthpro glucose test strips 310healthwise pen needle 278healthy accents autolet 278healthy accents unifine pentip 278healthy accents unilet lancet 278HEATHER 366HECTOROL 481HELIDAC 74HELIXATE FS 124hema-combistix 318HEMADY 356HEMANGEOL 248HEMLIBRA 124HEMOFIL M 124HEPAGAM B 209heparin flush 81heparin lock 81heparin sodium 81heparin sodium in 0.45% nacl 81heparin sodium-0.45% nacl 81,82heparin sodium-0.9% nacl 82heparin sodium-d5w 82HEPLISAV-B 213

HEPSERA 221HERCEPTIN 156HERCEPTIN HYLECTA 156HETLIOZ 224HIBERIX 213HICON 431HIDEX 356HIPREX 37HIZENTRA 209HOMATROPAIRE 337homatropine hydrobromide 337HOMINEX-1 324HORIZANT 85HPR PLUS 278HUMALOG 385HUMALOG JUNIOR KWIKPEN 385HUMALOG KWIKPEN U-100 385HUMALOG KWIKPEN U-200 385HUMALOG MIX 50-50 385HUMALOG MIX 50-50 KWIKPEN 385HUMALOG MIX 75-25 385HUMALOG MIX 75-25 KWIKPEN 386HUMATE-P 124HUMIRA 401,402HUMIRA PEDIATRIC CROHN'S 402HUMIRA PEN 402HUMIRA PEN CROHN'S-UC-HS 402HUMIRA PEN PSOR-UVEITS-ADOL HS 402HUMIRA(CF) 402HUMIRA(CF) PEDIATRIC CROHN'S 344,403HUMIRA(CF) PEN 403HUMIRA(CF) PEN CROHN'S-UC-HS 403HUMIRA(CF) PEN PSOR-UV-ADOL HS 403HUMULIN 70-30 382HUMULIN 70/30 KWIKPEN 382HUMULIN N 383HUMULIN N KWIKPEN 383HUMULIN R 387HUMULIN R U-500 387HUMULIN R U-500 KWIKPEN 387HYALGAN 278

HYCAMTIN 156HYCLODEX 278hydralazine hcl 382HYDREA 156hydrochlorothiazide 320HYDROCIL INSTANT 342hydrocod-cpm-pseudoephedrine 442hydrocodone bitartrate er 12hydrocodone er 10 mg capsule (persion-macoven) 12hydrocodone er 15 mg capsule (persion-macoven) 12hydrocodone er 30 mg capsule (persion-macoven) 12hydrocodone er 40 mg capsule (persion-macoven) 13hydrocodone er 50 mg capsule (persion-macoven) 13hydrocodone-acetaminophen 13hydrocodone-chlorpheniramne er 442hydrocodone-guaifenesin 442hydrocodone-homatropine mbr 442hydrocodone-ibuprofen 13,14hydrocortisone 59,356hydrocortisone acetate 59hydrocortisone butyrate 59hydrocortisone valerate 59hydrocortisone-acetic acid 42hydrocortisone-iodoquinol 47hydrocortisone-pramoxine 59HYDROMET 443hydromorph-bupivac-0.9% nacl 14hydromorph-ropiva-0.9% nacl 14hydromorphone er 14hydromorphone hcl 14,15hydromorphone hcl-0.9% nacl 15,16hydroquinone 261hydroxocobalamin 480hydroxychloroquine sulfate 180hydroxyprogesterone caproate 379hydroxyurea 156

hydroxyzine hcl 224hydroxyzine pamoate 224HYLATOPICPLUS 278HYLENEX 328HYMOVIS 278hyoscyamine sulfate 77hyoscyamine sulfate er 77hyoscyamine sulfate sr 77HYOSYNE 77HYPERHEP B S-D 209HYPERRAB 209HYPERRAB S-D 209HYPERRHO S-D 209HYPERTET S-D 209hypodermic needle 279hypolance 279HYQVIA 209HYQVIA HY COMPONENT 328HYQVIA IG COMPONENT 210HYSINGLA ER 16HYZAAR 434,435

Iibandronate sodium 396IBRANCE 157IBU 422IBUDONE 16ibuprofen 422ibuprofen lysine 422ibutilide fumarate 64icatibant 399ICLUSIG 157ictotest 318IDAMYCIN PFS 157idarubicin hcl 157IDELVION 125IDHIFA 157IFEX 157ifosfamide 158ifosfamide-mesna 158iglucose blood glucose monitor 279

iglucose test strip 310ILARIS 416ILEVRO 52ILUVIEN 49imatinib mesylate 158IMBRUVICA 158IMFINZI 159imipenem-cilastatin sodium 391imipramine hcl 99imipramine pamoate 99imiquimod 460IMITREX 141IMOGAM RABIES-HT 210IMOVAX RABIES VACCINE 213IMPAVIDO 181IMPOYZ 59IMURAN 413IMVEXXY 333INBRIJA 179INCASSIA 366incontrol lancing device 279incontrol pen needle 279incontrol super thin lancets 279incontrol ultra thin lancets 279INCRELEX 468INCRUSE ELLIPTA 77indapamide 320INDERAL LA 248INDERAL XL 248INDOCIN 422indomethacin 423indomethacin er 423INFANRIX DTAP 211INFASURF 445INFED 62infinity 279infinity control solution 279infinity test strips 310infinity voice control soln 279infinity voice glucose monitor 279infinity voice test strip 310

INFLECTRA 403INFUVITE PEDIATRIC 478INGREZZA 254INGREZZA INITIATION PACK 254inject ease lancets 279INJECTAFER 62INLYTA 159INNOPRAN XL 248INQOVI 159INREBIC 159INSPRA 441insul-cap 279insul-eze 279insulin aspart 386insulin aspart flexpen 386insulin aspart penfill 386insulin aspart prot-insuln asp 386insulin lispro 386insulin lispro junior kwikpen 386insulin lispro kwikpen u-100 386insulin lispro protamine mix 386insulin pen needle 279insupen 280integra precisionglide needle 280INTEGRILIN 205INTELENCE 199INTERMEZZO 224INTRAROSA 356INTRON A 219INTROVALE 366INTUNIV 252invacare lancets 280INVANZ 391INVEGA 186INVEGA SUSTENNA 186,187INVEGA TRINZA 187,188INVELTYS 49INVIRASE 204INVOKAMET 106INVOKAMET XR 106INVOKANA 107

iodine 47IODOFLEX 48IODOSORB 48IOPIDINE 336IPOL 213ipratropium bromide 77,336ipratropium-albuterol 77irbesartan 435irbesartan-hydrochlorothiazide 435IRESSA 159irinotecan hcl 159IRO-PLEX 62ISENTRESS 198ISENTRESS HD 198ISIBLOOM 366ISOCHRON 473isoniazid 144ISOPTO CARPINE 122ISORDIL 473ISORDIL TITRADOSE 473isosorbide dinitrate 473isosorbide dinitrate er 473isosorbide mononitrate 474isosorbide mononitrate er 474isotretinoin 460isoxsuprine hcl 478isradipine 242ISTALOL 120ISTODAX 159ISTURISA 417itraconazole 114iv sol stabilizer for blincyto 454ivermectin 37,460IXEMPRA 159IXIARO 213IXINITY 125

JJADENU 353JADENU SPRINKLE 353JAIMIESS 366

JAKAFI 159JALYN 392JANTOVEN 79JANUMET 103JANUMET XR 103JANUVIA 103JARDIANCE 107JASMIEL 366JATENZO 359jazz wireless 2 280JELMYTO 159JENCYCLA 366JENTADUETO 103JENTADUETO XR 103,104JEUVEAU 417JEVANTIQUE LO 333JEVTANA 160JINTELI 333JIVI 125JOLESSA 367JOLIVETTE 367JORNAY PM 34JUBLIA 117JULEBER 367JULUCA 198JUNEL 367JUNEL FE 367JUNEL FE 24 367JUXTAPID 128JYNARQUE 321

KK EFFERVESCENT 325K-PHOS ORIGINAL 322K-TAB ER 325KADCYLA 160KADIAN 16KAITLIB FE 367KALBITOR 399KALETRA 204KALLIGA 367

KALYDECO 260KANJINTI 160KAPSPARGO SPRINKLE 248KAPVAY 381KARBINAL ER 338KARIVA 367KATERZIA 242KAZANO 104KCENTRA 125KEDRAB 210KEFLEX 255KELNOR 1-35 367KELNOR 1-50 367KENALOG 59KENALOG-10 356KENALOG-40 356KENALOG-80 356KENGREAL 205KEPIVANCE 453KEPPRA 85KEPPRA XR 85KERYDIN 119KESIMPTA PEN 408keto-diastix reagent 318ketoconazole 114,117,118ketone care test strip 472ketone test strip 472ketoprofen 423ketorolac tromethamine 52,423ketostix reagent 472ketotifen fumarate 335KEVEYIS 397KEVZARA 404KEYTRUDA 160KHAPZORY 393KHEDEZLA 94KINERET 404KINRIX 213KIONEX 389KISQALI 160KISQALI FEMARA CO-PACK 161

KITABIS PAK 65KLARON 48KLONOPIN 91KLOR-CON 325KLOR-CON 10 325KLOR-CON 8 325KLOR-CON M10 325KLOR-CON M15 326KLOR-CON M20 326KLOR-CON-EF 326KOATE 125KOGENATE FS 125KOMBIGLYZE XR 104KONSYL 342KORLYM 101KOSELUGO 161KOVALTRY 125KRINTAFEL 180KRISTALOSE 323KRYSTEXXA 394KURVELO 367KUVAN 417KYLEENA 367KYNMOBI 322KYPROLIS 161

Llabetalol hcl 248,249labetalol hcl-d5w 249labstix reagent 318lactulose 323LAMICTAL 85LAMICTAL (BLUE) 85LAMICTAL (GREEN) 85LAMICTAL (ORANGE) 85LAMICTAL ODT 85LAMICTAL ODT (BLUE) 86LAMICTAL ODT (GREEN) 86LAMICTAL ODT (ORANGE) 86LAMICTAL XR 86LAMICTAL XR (BLUE) 86

LAMICTAL XR (GREEN) 86LAMICTAL XR (ORANGE) 86lamivudine 201,202lamivudine hbv 202lamivudine-zidovudine 202lamotrigine 86lamotrigine (blue) 86lamotrigine (green) 86lamotrigine (orange) 86lamotrigine er 86lamotrigine odt 86lamotrigine odt (blue) 86lamotrigine odt (green) 86lamotrigine odt (orange) 86LAMPIT 181LANAFLEX 324lancets 280lancets thin 280lancets ultra thin 280lancing device 280lancing system 280LANOXIN 245LANOXIN PEDIATRIC 245lansoprazol-amoxicil-clarithro 217lansoprazole 217lanthanum carbonate 388LANTUS 383LANTUS SOLOSTAR 383lanzo 280lapatinib 161LARIN 368LARIN 24 FE 368LARIN FE 368LARISSIA 368LASIX 319LASTACAFT 335latanoprost 122latex gloves 280LATISSE 122LATUDA 188LAYOLIS FE 368

LAZANDA 16ledipasvir-sofosbuvir 351LEENA 368leflunomide 404LENVIMA 161LESCOL 136LESCOL XL 136LESSINA 368LETAIRIS 446letrozole 161leucovorin calcium 393LEUKERAN 162LEUKINE 234leuprolide acetate 349levalbuterol concentrate 232levalbuterol hcl 232levalbuterol tartrate hfa 232LEVAQUIN 66LEVBID 77LEVEMIR 383LEVEMIR FLEXTOUCH 383levetiracetam 86,87levetiracetam er 87levetiracetam-nacl 87LEVITRA 475LEVO-T 471levobunolol hcl 120levocarnitine 417levocarnitine sf 417levocetirizine dihydrochloride 127levofloxacin 39,66,67levofloxacin-d5w 67levoleucovorin calcium 393LEVONEST 368levonorg-eth estrad eth estrad 368levonorgestrel-eth estradiol 368LEVORA-28 368levothyroxine 471levothyroxine sodium 471LEVOXYL 471LEVSIN 77

LEVSIN-SL 77LEXAPRO 96LEXETTE 59LEXIVA 204LIALDA 340LIBRAX 77LICART 424lidocaine 451lidocaine hcl 63,389,451lidocaine hcl in 5% dextrose 63lidocaine hcl-0.9% nacl 389lidocaine-hydrocortisone 60,451lidocaine-prilocaine 451lidocaine-tetracaine 451LIDODERM 451LIDODOSE 451LIDOPIN 451LIDOPRIL 451LIDOTREX 280LIDTOPIC MAX 451LILETTA 368LILLOW 368LINCOCIN 74lincomycin hcl 74lindane 48linezolid 74linezolid-0.9% nacl 74linezolid-d5w 74LINZESS 344liothyronine sodium 471LIPITOR 136,137LIPOFEN 134lisinopril 438lisinopril-hydrochlorothiazide 438lite touch 280lithium 251lithium carbonate 251lithium carbonate er 251LITHOBID 251LIVALO 137LO LOESTRIN FE 369

LO-ZUMANDIMINE 369LOCOID 60LODINE 424LODOSYN 252LOESTRIN 369LOESTRIN FE 369LOJAIMIESS 369LOKELMA 389LOMAIRA 28LOMOTIL 341LONHALA MAGNAIR REFILL 77LONHALA MAGNAIR STARTER 77LONSURF 162loperamide 341LOPID 134lopinavir-ritonavir 204LOPREEZA 333LOPRESSOR 249LOPRESSOR HCT 249LOPROX 119lorazepam 227,228LORAZEPAM INTENSOL 228lorazepam-0.9% nacl 228lorazepam-d5w 228LORBRENA 162LORCET 16LORCET HD 17LORCET PLUS 17LORTAB 17LORYNA 369LORZONE 449losartan potassium 435losartan-hydrochlorothiazide 435LOSEASONIQUE 369LOTEMAX 49,50LOTEMAX SM 50LOTENSIN 438,439LOTENSIN HCT 439loteprednol etabonate 50LOTREL 243LOTRISONE 118

LOTRONEX 340lovastatin 137LOVAZA 128LOVENOX 82LOW-OGESTREL 369loxapine 182LUCEMYRA 469LUCENTIS 336LUDENT FLUORIDE 398LUGOL'S 48luliconazole 118LUMIGAN 122LUMIZYME 328LUMOXITI 162lumoxiti iv soln stabilizer 431LUNESTA 224,225LUPRON DEPOT 349LUPRON DEPOT (LUPANETA) 349LUPRON DEPOT-PED 349LUTERA 369LUXIQ 60LUZU 118LYNPARZA 162LYRICA 87LYRICA CR 6LYSODREN 162LYSTEDA 125LYUMJEV 387LYUMJEV KWIKPEN U-100 387LYUMJEV KWIKPEN U-200 387LYZA 369

MM-M-R II VACCINE 214M.V.I. PEDIATRIC 478MACRILEN 317MACROBID 37MACRODANTIN 37magellan safety needle 280magellan safety syringe 280magnesium sulfate-0.9% nacl 87

magnesium sulfate-d5w 87magni-guide magnifier 280MAKENA 380MALARONE 180malathion 48mannitol 319maprotiline hcl 99MARINOL 111MARLISSA 369MARPLAN 93MARQIBO 162MATULANE 162MATZIM LA 239MAVENCLAD 413MAVYRET 352MAXALT 141MAXALT MLT 141maxicomfort ii pen needle 281maxicomfort safety pen needle 281MAXIDEX 50MAXIPIME 257MAXITROL 40MAXZIDE 320MAXZIDE-25 MG 320MAYZENT 408,409meclizine hcl 112meclofenamate sodium 424MEDICATED PADS 452medisense 281medisense control 281medisense glucose ketone 281medisense glucose ketone contr 281medisense thin lancets 281medlance plus 281medlance plus special blade 281MEDROL 356medroxyprogesterone acetate 380mefenamic acid 424mefloquine hcl 180MEGACE ES 380megestrol acetate 380

MEKINIST 162MEKTOVI 163melatonin 417MELODETTA 24 FE 369meloxicam 424melphalan 163melphalan hcl 163memantine hcl 252memantine hcl er 252MENACTRA 214MENEST 333MENOPUR 350MENOSTAR 333MENQUADFI 214MENVEO A-C-Y-W-135-DIP 214MENVEO MENA COMPONENT 214MENVEO MENCYW-135 COMPONENT 214meperidine hcl 17meperidine hcl-0.9% nacl 18MEPHYTON 481meprobamate 225MEPRON 181MEPSEVII 328mercaptopurine 163meropenem 391meropenem-0.9% nacl 391MERREM 391mesalamine 340,341mesalamine dr 341mesalamine er 341mesna 419MESNEX 419MESTINON 230METADATE ER 34METANX 480metaproterenol sulfate 232METASTRON 431METAXALL 449metaxalone 449meter-check 281metformin hcl 102

metformin hcl er 102methacholine chloride 317methadone hcl 18METHADONE INTENSOL 18METHADOSE 18methamphetamine hcl 32methazolamide 122methenamine hippurate 37methenamine mandelate 37METHERGINE 427methimazole 470METHITEST 359methocarbamol 449methohexital-sterile water 346methotrexate 163methotrexate sodium 163methoxsalen 261methscopolamine bromide 77methyclothiazide 320methyldopa 382methyldopa-hydrochlorothiazide 382methyldopate hcl 382methylene blue 393,417methylergonovine maleate 427METHYLIN 34methylphenidate er 34methylphenidate er (la) 34methylphenidate hcl 34,35methylphenidate hcl cd 35methylphenidate hcl er (cd) 35methylphenidate la 35methylprednisolone 356methylprednisolone acetate 356methylprednisolone sodium succ 356methyltestosterone 359metipranolol 120metoclopramide hcl 345metoclopramide hcl odt 345metolazone 320metoprolol succinate 249metoprolol tartrate 249

metoprolol-hydrochlorothiazide 249METRO IV 181METROCREAM 45METROGEL 45METROGEL-VAGINAL 45METROLOTION 45metronidazole 45,181metyrosine 417mexiletine hcl 63MIACALCIN 428MIBELAS 24 FE 370micafungin 115MICARDIS 435MICARDIS HCT 435,436miconazole 3 118MICORT-HC 60MICRHOGAM ULTRA-FILTERED PLUS 210micro 310micro thin lancet 281micro thin lancets 281microdot 281,310microdot insulin pen needle 281microdot xtra 310MICROGESTIN 370MICROGESTIN 24 FE 370MICROGESTIN FE 370microlet 281microlet 2 281microlet next lancing device 281microtainer lancets 281MICROZIDE 320midazolam hcl 228midazolam hcl-0.9% nacl 228midazolam hcl-d5w 228midazolam-0.9% nacl 228MIDNITE FOR MENOPAUSE 417MIDNITE MENOPAUSE 417MIDNITE PM 417midodrine hcl 469MIFEPREX 427mifepristone 427

MIGERGOT 4miglitol 100miglustat 417MIGRANAL 4MILI 370MILLIPRED 356MILLIPRED DP 356MIMVEY 333MIMVEY LO 333MINASTRIN 24 FE 370mini lancing device 281mini ultra-thin ii 281minilink real-time transmitter 282MINIPRESS 246MINITRAN 474MINIVELLE 333MINOCIN 69minocycline er 70minocycline hcl 70minocycline hcl er 70MINOLIRA ER 70minoxidil 382MIOCHOL-E 122MIOSTAT 122MIRAPEX 322MIRAPEX ER 322MIRCERA 234MIRCETTE 370MIRENA 370mirtazapine 92MIRVASO 461misoprostol 216MITIGARE 394mitomycin 163mitoxantrone hcl 163mixed vespid venom protein 206MOBIC 424modafinil 36MODERIBA 221moexipril hcl 439molindone hcl 182

mometasone furoate 50,60MONDOXYNE NL 70MONJUVI 163MONO-LINYAH 370MONODOX 71MONOFERRIC 62monoject blood collection 282monoject enfit syringe 282monoject enfit syringe cap 282monolet lancets 282monolet thin lancets 282MONONESSA 370MONONINE 125MONOVISC 282montelukast sodium 54MONUROL 38MORGIDOX 71MORPHABOND ER 18morphine sulfate 18,19,20morphine sulfate er 20morphine sulfate-0.9% nacl 20,21morphine sulfate-d5w 21MOTEGRITY 345MOTOFEN 341MOVANTIK 344MOVIPREP 342MOXATAG 429MOXEZA 40moxifloxacin 40,67moxifloxacin hcl 67MOZOBIL 234MS CONTIN 21mucor plumbeus 207MULPLETA 234MULTAQ 64multi-lancet 282multistix 318multistix 10 sg 318multistix 5 318multistix 7 318multistix 8 sg 318

multistix 9 318multistix 9 sg 318mupirocin 45MUSE 478MUSTARGEN 163MUTAMYCIN 163MVASI 163MVW COMPLETE FORMLTN PEDIATRIC 478MVW COMPLETE FORMULATION D3000 478MYALEPT 378MYAMBUTOL 144MYCAMINE 115MYCAPSSA 466MYCOBUTIN 144mycophenolate mofetil 413mycophenolic acid 413MYDAYIS 32MYFORTIC 413myglucohealth 282,310myglucohealth control solution 282myglucohealth lancets 282MYLERAN 164MYLOTARG 164MYNATAL 478MYNATAL PLUS 478MYNATAL-Z 478MYOBLOC 417MYORISAN 461MYRBETRIQ 231MYSOLINE 90MYTESI 341MYXREDLIN 388MYZILRA 370

NNABI-HB 210nabumetone 424nadolol 249nadolol-bendroflumethiazide 249nafcillin 430nafcillin sodium 430

naftifine hcl 116NAFTIN 116NAGLAZYME 328nalbuphine hcl 27NALFON 424NALOCET 21naloxone hcl 253,254naltrexone hcl 254NAMENDA 252NAMENDA XR 252NAMZARIC 252nano 2nd gen pen needle 282NAPRELAN 424NAPROSYN 424naproxen 424,425naproxen sodium 425naproxen sodium cr 425naproxen sodium er 425naratriptan hcl 141NARCAN 254NARDIL 93NASCOBAL 480NASONEX 50NATACYN 42NATAZIA 370nateglinide 106NATESTO 359NATPARA 428NATRECOR 478NATROBA 48NATURE-THROID 471NAVELBINE 164NAYZILAM 91NEBUPENT 181NECON 371needle 282needles 282nefazodone hcl 98NEMBUTAL SODIUM 225NEO-POLYCIN 40NEO-POLYCIN HC 40

NEO-SYNALAR 45neomycin sulfate 65neomycin-bacitracin-poly-hc 40neomycin-bacitracin-polymyxin 40neomycin-polymyxin-dexameth 40neomycin-polymyxin-gramicidin 40neomycin-polymyxin-hc 40neomycin-polymyxin-hydrocort 40NEOPROFEN 425NEORAL 413neostigmine methylsulfate 230NEOTUSS PLUS 443NEPHRONEX-SL 480NERLYNX 164NESINA 104NEUAC 45NEULASTA 234NEULASTA ONPRO 235NEUPOGEN 235NEUPRO 322NEURONTIN 87,88neutek 2tek test strips 311NEVANAC 52nevirapine 199nevirapine er 199NEWGEN 478NEXAVAR 164NEXAVIR 418NEXIUM 217NEXIUM I.V. 217NEXLETOL 129NEXLIZET 129NEXPLANON 371NEXTERONE 64niacin er 129NIACOR 129NIASPAN 129nicardipine hcl 243nicardipine hcl-0.9% nacl 243nicardipine hcl-d5w 243NICOTROL 229

NICOTROL NS 229nifedipine 243nifedipine er 243NIKKI 371NILANDRON 164nilutamide 164nimodipine 243NINLARO 164NIPENT 164nisoldipine 243NITHIODOTE 393nitisinone 418nitratest paper 472NITRO-BID 474NITRO-DUR 474NITRO-TIME 474nitrofurantoin 38nitrofurantoin mono-macro 38nitroglycerin 474nitroglycerin in d5w 474nitroglycerin patch 474NITROLINGUAL 474NITROMIST 474NITROPRESS 382NITROSTAT 474NITYR 418NIVA-HIST DM 443NIVESTYM 235nizatidine 216NIZORAL 118no-stick glucose 473NOCDURNA 378NOCTIVA 378NOLIX 60NORA-BE 371NORCO 21NORDITROPIN FLEXPRO 378norepinephrine bitar-0.9% nacl 469norepinephrine bitartrate-d5w 469norethin-eth estra-ferrous fum 371norethindron-ethinyl estradiol 334,371

norethindrone 371norethindrone ac (lupaneta) 380norethindrone acetate 380norethindrone-eth estradiol-fe 371NORGESIC FORTE 450norgestimate-ethinyl estradiol 371NORITATE 46NORLYDA 372NORPACE 63NORPACE CR 63NORPRAMIN 99NORTHERA 469NORTREL 372nortriptyline hcl 99NORVASC 244NORVIR 204NOURIANZ 253nova max blood glucose meter 282nova max glucose control soln 282nova max glucose test strips 311nova safety lancets 282nova sureflex 282novamax plus glu-ket 282NOVAREL 350NOVOEIGHT 125novofine 32 283novofine autocover 283novofine plus 283NOVOLIN 70-30 383NOVOLIN 70-30 FLEXPEN 383NOVOLIN N 383NOVOLIN N FLEXPEN 383NOVOLIN R 388NOVOLIN R FLEXPEN 388NOVOLOG 387NOVOLOG FLEXPEN 387NOVOLOG MIX 70-30 387NOVOLOG MIX 70-30 FLEXPEN 387NOVOSEVEN RT 125novotwist 283NOXAFIL 114,115

NP THYROID 471NPLATE 235NUBEQA 164NUCALA 53NUCYNTA 21NUCYNTA ER 22NUEDEXTA 253NULEV 77NULOJIX 414NULYTELY WITH FLAVOR PACKS 342NUMBONEX 451NUMBRINO 337NUMOISYN 283NUPLAZID 188NURTEC ODT 140NUVAIL 283NUVARING 372NUVESSA 46NUVIGIL 36NUWIQ 125NUZYRA 470NYAMYC 119NYMALIZE 244nystatin 116,119nystatin-triamcinolone 120NYSTOP 120

OOBIZUR 125OBREDON 443OBTREX DHA 478OCALIVA 344OCELLA 372OCTAGAM 210octreotide acetate 466OCUFLOX 40ODACTRA 207ODEFSEY 202ODOMZO 165OFEV 441ofloxacin 40,67

OGESTREL 372OGIVRI 165OKEBO 71olanzapine 188olanzapine odt 188,189olanzapine-fluoxetine hcl 96OLINVYK 22olmesartan medoxomil 436olmesartan-amlodipine-hctz 436olmesartan-hydrochlorothiazide 436olopatadine hcl 335OLUMIANT 404OLUX 60OLUX-E 60OMECLAMOX-PAK 217omega-3 129omega-3 acid ethyl esters 129OMEGAVEN 324omeprazole 217omeprazole-sodium bicarbonate 218OMIDRIA 337OMNARIS 50OMNIPAQUE 317OMNIPRED 50on call express control soln 283on call express meter 283on call express test strip 311on call lancet 283on call lancing device 283on call plus control 283on call plus lancet 283on call plus lancing device 283on call plus meter 283on call plus test strip 311on call vivid control 283on call vivid meter 283on call vivid pal 283on call vivid test strip 311on-the-go 283ONCASPAR 165ondansetron hcl 110

ondansetron hcl-0.9% nacl 110ondansetron hcl-d5w 110ondansetron odt 110onetouch delica 283onetouch delica plus lanc dev 283onetouch delica plus lancet 284onetouch lancets 284onetouch suresoft 284onetouch ultra blue test strp 311onetouch ultra control soln 284onetouch ultra2 284onetouch ultramini 284onetouch verio flex meter 284onetouch verio flex startr kit 284onetouch verio high cntrl soln 284onetouch verio iq meter 284onetouch verio iq system kit 284onetouch verio meter 284onetouch verio mid cntrl soln 284onetouch verio reflect kit 284onetouch verio reflect meter 284onetouch verio test strip 311ONEVITE 478ONEXTON 46ONFI 91ONGENTYS 178ONGLYZA 104ONMEL 115ONUREG 165ONZETRA XSAIL 141OPANA 22OPDIVO 165opium tincture 341OPSUMIT 446OPTIRAY 240 317optium 311optium ez 311optumrx 285,312ORACEA 71ORAFATE 285ORALAIR 207

ORALONE 60ORAP 182ORAPRED ODT 356ORAQIX 260ORAVIG 118ORENCIA 404ORENCIA CLICKJECT 404ORENITRAM ER 447ORFADIN 418ORIAHNN 348ORILISSA 348ORKAMBI 260orphenadrine citrate 450orphenadrine citrate er 450orphenadrine-aspirin-caffeine 450ORPHENGESIC FORTE 450ORSYTHIA 372ORTHO MICRONOR 372ORTHO TRI-CYCLEN 372ORTHO TRI-CYCLEN LO 372ORTHO-CYCLEN 372ORTHO-NOVUM 372ORTHOVISC 285ORTIKOS 357OSCIMIN 77OSCIMIN SL 77OSCIMIN SR 77oseltamivir phosphate 220OSENI 104OSMITROL 319OSMOLEX ER 178OSMOPREP 342OSPHENA 329OTEZLA 405OTIPRIO 40OTOVEL 40OTREXUP 165OVIDE 48OVIDREL 350oxacillin 430oxacillin sodium 430

oxaliplatin 165OXANDRIN 359oxandrolone 359oxaprozin 425OXAYDO 22oxazepam 228OXBRYTA 233oxcarbazepine 88OXERVATE 336oxiconazole nitrate 118OXISTAT 118OXSORALEN-ULTRA 261OXTELLAR XR 88oxybutynin chloride 346oxybutynin chloride er 346,347oxycodone hcl 22oxycodone hcl-aspirin 22oxycodone hcl-ibuprofen 22oxycodone-acetaminophen 23oxymorphone hcl 23oxymorphone hcl er 23OXYTROL 347OZEMPIC 105OZOBAX 450OZURDEX 50

PPACERONE 64paclitaxel 165PACNEX 455PADCEV 165PAIN EASE MEDIUM STREAM SPRAY 285PAIN EASE MIST SPRAY 285PALFORZIA 207paliperidone er 189PALYNZIQ 328PAMELOR 100pamidronate disodium 396PANCREAZE 343PANDEL 60PANHEMATIN 418

PANRETIN 165pantoprazole sodium 218PANZYGA 210papaverine hcl 478paradigm real-time 285paradigm remote control 285PARAGARD T 380-A 372PARAPLATIN 166paregoric 341paricalcitol 481PARLODEL 322PARNATE 93PAROEX 42paromomycin sulfate 180paroxetine cr 96paroxetine er 96paroxetine hcl 96paroxetine mesylate 96PASER 144PATADAY 335PATANASE 335PATANOL 335PAXIL 97PAXIL CR 97PAZEO 335PEDIAPRED 357PEDIARIX 214PEDVAXHIB 214peg 3350-electrolyte 343peg-3350 and electrolytes 343PEG-PREP 343peg3350-sod sul-nacl-kcl-asb-c 343PEGANONE 91PEGASYS 220PEGASYS PROCLICK 220PEGINTRON 220PEMAZYRE 166pen needle 286pen needles 286penicillamine 354penicillin g potassium 430

penicillin g procaine 430penicillin g sodium 430penicillin gk-iso-osm dextrose 430penicillin v potassium 430penicillium notatum 207PENLAC 119PENNSAID 425PENTACEL 214PENTACEL ACTHIB COMPONENT 214PENTACEL DTAP-IPV COMPONENT 214PENTAM 300 181pentamidine isethionate 181,182PENTASA 341pentazocine-naloxone hcl 27pentetate calcium trisodium 354pentetate zinc trisodium 354pentips 286pentoxifylline 236PEPCID 216PERCOCET 23PERFOROMIST 232PERIDEX 42perindopril erbumine 439PERIOGARD 42PERJETA 166permethrin 48perphenazine 198perphenazine-amitriptyline 100PERSERIS 189PERTZYE 343PEXEVA 97PFIZERPEN 430pharmacist choice 286,312phaseal protector 286PHENADOZ 339phenazopyridine hcl 451phendimetrazine tartrate 29phendimetrazine tartrate er 29phenelzine sulfate 93PHENERGAN 339phenobarbital 226

phenobarbital sodium 226phenobarbital-belladonna 77phenobarbital-hyosc-atrop-scop 78PHENOHYTRO 78phenoxybenzamine hcl 4phentermine hcl 29phentolamine mesylate 5PHENYLADE GMP 324PHENYLADE GMP MIX-IN 324phenylephrine hcl 337phenylephrine hcl-0.9% nacl 469phenylephrine hcl-d5w 469phenylephrine hcl-water 470PHENYTEK 91phenytoin 91phenytoin sodium 91phenytoin sodium extended 92PHEXXI 420PHILITH 373PHOSLYRA 388PHOSPHOLINE IODIDE 122PHOTOFRIN 166PHRENILIN FORTE 7physostigmine salicylate 230phytonadione 481PICATO 166PIFELTRO 199pilocarpine hcl 122,230pimecrolimus 461pimozide 182PIMTREA 373pindolol 250pioglitazone hcl 110pioglitazone-glimepiride 110pioglitazone-metformin 110pip lancet 286piperacillin-tazobactam 429PIQRAY 166PIRMELLA 373piroxicam 425PLAQUENIL 180

PLAVIX 205PLEGRIDY 409PLEGRIDY PEN 409PLENAMINE 324PLENVU 343PLEXION 455PLIAGLIS 451PNEUMOVAX 23 214PODOCON-25 461podofilox 461POLIVY 166poly hub needle 287POLYCIN 41polymyxin b sul-trimethoprim 41polymyxin b sulfate 75polysorbate 60 454polysorbate 80 454POLYTRIM 41POMALYST 166PONTOCAINE 452PORTIA 373posaconazole 115POTABA 418potassium acetate 326potassium bicarbonate 326potassium chloride 326potassium chloride in d5lr 326potassium chloride proamp 326potassium chloride-nacl 326potassium citrate er 323potassium cl-lidocaine-ns 326potassium phosphate-0.9% nacl 326potassium phosphates 326povidone iodine 42pr benzoyl peroxide 455PRADAXA 80pralidoxime chloride 393PRALUENT PEN 138pramipexole dihydrochloride 322pramipexole er 322PRAMOSONE 60

PRAMOSONE E 60pramoxine hcl 452PRANDIN 106prasugrel hcl 206PRAVACHOL 137pravastatin sodium 137praziquantel 37prazosin hcl 246PRE-ATTACHED LTA KIT 452PRECEDEX 225precision 287precision glucose control 287precision pcx 312precision pcx plus 312precision point of care 312precision q-i-d 312precision xtra 287,312precision xtra ketone-glucose 287PRECOSE 100,101PRED FORTE 50PRED MILD 50PRED-G 41prednicarbate 60prednisolone 357prednisolone acetate 50prednisolone sodium phos odt 357prednisolone sodium phosphate 50,357prednisone 357PREDNISONE INTENSOL 357PREFEST 334pregabalin 88PREGNYL 350PREMARIN 334premier blu 287premier compact glucose meter 287premier test strip 312premier voice 287premium blood glucose 287premium blood glucose test 312premium v10 287,313PREMPHASE 334

PREMPRO 334PRENA1 CHEW 478PRENA1 PEARL 479PRENA1 TRUE 479PRENATABS RX 479prenatal low iron 479PRENATAL VITAMIN WITH MINERALS AND FOLICACID GREATER THAN 0.8 MG ORAL TABLET 479prenatal-u 479PREPOPIK 343pressure activated lancets 287PRESTALIA 439presto pro 287pretomanid 144PREVACID 218PREVALITE 131prevent dropsafe pen needle 287PREVIDENT 398PREVIDENT 5000 398PREVIDENT 5000 ENAMEL PROTECT 398PREVIDENT 5000 ORTHO DEFENSE 398PREVIDENT 5000 PLUS 398PREVIDENT 5000 SENSITIVE 398PREVIFEM 373PREVNAR 13 214PREVYMIS 219PREZCOBIX 204PREZISTA 204PRIALT 7PRIFTIN 144PRIKAAN 452PRIKAAN LITE 452PRILOSEC 218primaquine 180PRIMAXIN 391primidone 90PRIMLEV 23,24PRINIVIL 439PRISTIQ 94PRIVIGEN 210pro comfort lancet 287

pro comfort lancets 288pro comfort pen needle 288pro voice v8 glucose monitor 288pro voice v8-v9 test strip 313pro voice v9 glucose monitor 288PROAIR DIGIHALER 232PROAIR HFA 232PROAIR RESPICLICK 232probenecid 327probenecid-colchicine 327procainamide hcl 63PROCARDIA 244PROCARDIA XL 244PROCENTRA 32prochlorperazine 112prochlorperazine edisylate 112prochlorperazine maleate 112PROCORT 60PROCRIT 235PROCTO-MED HC 60PROCTO-PAK 60PROCTOCORT 60PROCTOFOAM-HC 61PROCTOSOL-HC 61PROCTOZONE-HC 61PROCYSBI 418prodigy 288prodigy autocode 288prodigy control solution 288prodigy lancets 288prodigy lancing device 288prodigy no coding 313prodigy pocket 288prodigy twist top lancet 288prodigy voice 288PROFENO 425PROFILNINE 125progesterone 380PROGLYCEM 128PROGRAF 414PROLASTIN C 445

PROLATE 24PROLENSA 52PROLEUKIN 167PROLIA 396PROMACTA 235promethazine hcl 339promethazine hcl-0.9% nacl 339promethazine-codeine 443promethazine-dm 443promethazine-phenyleph-codeine 443promethazine-phenylephrine 339PROMETHEGAN 339PROMETRIUM 380propafenone hcl 63propafenone hcl er 63propantheline bromide 78proparacaine hcl 337PROPECIA 461propranolol hcl 250propranolol hcl er 250propranolol-hydrochlorothiazid 250propylthiouracil 470PROQUAD 214PROSCAR 392protamine sulfate 123PROTHELIAL 288PROTONIX 218PROTONIX IV 218PROTOPAM CHLORIDE 393PROTOPIC 461protriptyline hcl 100PROVENGE 251PROVENTIL HFA 232PROVERA 380PROVIGIL 36PROZAC 97PRUDOXIN 452PSORCON 61PULMICORT 259PULMICORT FLEXHALER 259PULMOZYME 444

pure comfort lancets 288pure comfort pen needle 288pure comfort safety lancets 288PURIXAN 167push button safety lancets 288PYLERA 74pyrazinamide 144PYRIDIUM 452pyridostigmine bromide 230pyridostigmine bromide er 230pyridoxine hcl 480

QQBRELIS 439QBREXZA 78QINLOCK 167QMIIZ ODT 425QNASL 51QNASL CHILDREN 51QSYMIA 29QTERN 107QUADRACEL DTAP-IPV 214QUADRAMET 432QUALAQUIN 180QUARTETTE 373QUASENSE 373quazepam 228QUDEXY XR 88QUESTRAN 131QUESTRAN LIGHT 131quetiapine fumarate 189,190quetiapine fumarate er 190QUILLICHEW ER 35QUILLIVANT XR 35quinapril hcl 439quinapril-hydrochlorothiazide 439quinidine gluconate 63quinidine sulfate 63quinine sulfate 181quintet 288,313quintet ac 289,313

QUTENZA 461QUZYTTIR 127QVAR REDIHALER 259

RR-NATAL OB 479RABAVERT 214rabeprazole sodium 218RADIAGUARD 452RADIOGARDASE 388RAGWITEK 207raloxifene hcl 329ramelteon 225ramipril 439RANEXA 245ranitidine hcl 216ranolazine er 245RAPAFLO 5RAPAMUNE 414rasagiline mesylate 180RASUVO 167RAVICTI 323RAYALDEE 481RAZADYNE 230RAZADYNE ER 230READI-CAT 2 317readylance safety lancets 289REBETOL 221REBIF 409REBIF REBIDOSE 410REBINYN 126REBLOZYL 235RECARBRIO 391RECLAST 397RECLIPSEN 373RECOMBINATE 126RECOMBIVAX HB 214RECTIV 461REFISSA 453refuah plus 289,313refuah plus glucose control 289

REGENECARE 289REGIMEX 32REGLAN 345REGONOL 230REGRANEX 453RELAFEN 425RELAFEN DS 425RELENZA 220RELEXXII 35reliamed 289reliamed mini lancing device 289reliamed safety seal lancets 289relion all-in-one 289relion confirm 289relion confirm-micro 313relion micro 289relion pen needles 289relion prime 289relion prime test strips 313relion thin 289RELISTOR 344RELPAX 142REMERON 93REMICADE 405REMODULIN 447RENAGEL 389RENFLEXIS 405RENOVA 453RENOVA PUMP 453RENVELA 389REOPRO 206repaglinide 106repaglinide-metformin hcl 106REPATHA PUSHTRONEX 139REPATHA SURECLICK 139REPATHA SYRINGE 139replacement pediatric monitor 289REQUIP 322REQUIP XL 322RESCRIPTOR 199RESECTISOL 325

RESPA A.R. 340RESTASIS 51RESTASIS MULTIDOSE 51RESTORIL 228RETACRIT 235RETEVMO 167RETIN-A 453RETIN-A MICRO 453RETIN-A MICRO PUMP 453RETISERT 51RETROVIR 202REVATIO 475REVCOVI 328reveal blood glucose meter 289reveal test strip 313REVLIMID 167REVONTO 450REXULTI 190REYATAZ 204REYVOW 142RHOFADE 461RHOGAM ULTRA-FILTERED PLUS 210RHOPHYLAC 210RHOPRESSA 123RIBASPHERE 222RIBASPHERE RIBAPAK 222ribavirin 222RIDAURA 347rifabutin 144RIFADIN 144RIFAMATE 144rifampin 144RIFATER 144rightest control solution 289rightest gc250s control soln 289rightest gd500 290rightest gl300 lancets 290rightest gm100 system 290rightest gm250s meter 290rightest gm260 meter 290rightest gm300 system 290

rightest gm550 system 290rightest gs100 test strips 314rightest gs250s test strips 314rightest gs260 test strips 314rightest gs300 test strips 314rightest gs550 test strips 314riluzole 253rimantadine hcl 219RIMSO-50 325RINVOQ 405RIOMET 103RIOMET ER 103risedronate sodium 397risedronate sodium dr 397RISPERDAL 191RISPERDAL CONSTA 191risperidone 192risperidone odt 192RITALIN 35RITALIN LA 36ritonavir 204RITUXAN 167RITUXAN HYCELA 167rivastigmine 230RIVELSA 373RIXUBIS 126rizatriptan 142ROBAXIN 449ROBAXIN-750 449ROCALTROL 481ROCKLATAN 123romidepsin 167ropinirole er 322ropinirole hcl 322ropivacaine hcl 389,390ROSADAN 46ROSANIL 455ROSULA 455rosuvastatin calcium 137ROTARIX 214ROTATEQ 214

ROWASA 341ROWEEPRA 88ROWEEPRA XR 88ROXICODONE 24ROXYBOND 24ROZEREM 225ROZLYTREK 168RUBRACA 168RUCONEST 399rufinamide 88RUKOBIA 198RUXIENCE 168RUZURGI 418RYBELSUS 105RYCLORA 340RYDAPT 168RYTARY 179RYTHMOL SR 63RYVENT 338

SSABRIL 88saccharomyces cerevisiae 208safe-clip 290safety lancets 290safety pen needle 290safety seal lancets 290safety-let 290safety-lok collection set 290safetyglide insulin syringe 290safetyglide needle 290SAFYRAL 373SALAGEN 230SALEX 455salicylic acid 455salicylic acid er 455SALIMEZ FORTE 456salsalate 427SALVAX 456SAMSCA 321SANADERMRX 61

SANCUSO 111SANDIMMUNE 414SANDOSTATIN 466,467SANDOSTATIN LAR DEPOT 467SANTYL 461SAPHRIS 192sapropterin dihydrochloride 418SARAFEM 98sassafras oil 431SAVAYSA 80SAVELLA 253SAXENDA 105SCALACORT 61scopolamine 111SEASONIQUE 374SECONAL SODIUM 226SECUADO 193SEEBRI NEOHALER 78SEGLUROMET 107selegiline hcl 180SELZENTRY 198SEMGLEE 383SEMGLEE PEN 384SEMPREX-D 127SENSIPAR 428SEREVENT DISKUS 232SERNIVO 61SEROPHENE 329SEROQUEL 193SEROQUEL XR 194SEROSTIM 378sertraline hcl 98SETLAKIN 374sevelamer carbonate 389sevelamer hcl 389SEVENFACT 126SEYSARA 470SF 398SF 5000 PLUS 398SFROWASA 341SHAROBEL 374

SHINGRIX 214SHINGRIX ADJUVANT COMPONENT 431SHINGRIX GE ANTIGEN COMPONENT 214sidekick 290SIDEROL 62SIGNIFOR 467SIGNIFOR LAR 467SIKLOS 168sildenafil 20 mg tablet (pah) 475sildenafil citrate 476SILENOR 100SILIQ 461silodosin 5SILVADENE 48SILVASORB 290silver sulfadiazine 48SILVRSTAT 290SIMBRINZA 122SIMLIYA 374SIMPESSE 374SIMPONI 405SIMPONI ARIA 406SIMULECT 414simvastatin 138SINEMET 10-100 179SINEMET 25-100 179SINEMET 25-250 179SINEMET CR 179single-let 290SINGULAIR 54sirolimus 414SIRTURO 144SITAVIG 222SIVEXTRO 74SKELAXIN 449SKLICE 48SKYLA 374SKYRIZI 461SKYRIZI (2 SYRINGES) KIT 462SLYND 374smart caresens n 291

smart sense 291smart sense lancets 291smart sense monitoring system 291smart sense test strips 314smartdiabetes vantage 291smartest 291smartest eject 291smartest lancet 291smartest persona 291smartest pronto 291smartest protege 291smartest smart code 291smartest talking 291smartest test 314sod ferric gluconate complex 62sodium chloride 326sodium citrate 79SODIUM DIURIL 320sodium fluoride 398sodium fluoride 2.2 mg (fluoride ion 1 mg) oraltablet 398sodium fluoride sensitive 398sodium hyaluronate 291sodium iodide i-123 432sodium iodide i-131 432sodium nitroprusside 382sodium phenylbutyrate 323sodium phosphate-0.9% nacl 326sodium phosphate-d5w 326sodium polystyrene sulfonate 389sodium sulfacetamide-sulfur 48,456sodium thiosulfate 393sof-sensor 291sofosbuvir-velpatasvir 351soft touch 291SOLARAZE 168solifenacin succinate 347SOLIQUA 100-33 384SOLIRIS 399SOLODYN 71SOLOSEC 182

SOLOXIDE 71SOLTAMOX 329SOLU-CORTEF 357SOLU-MEDROL 357solus v2 292solus v2 control solution 292solus v2 lancets 292solus v2 lancing device 292solus v2 test strips 314SOMA 449SOMATULINE DEPOT 467SOMAVERT 468SOOLANTRA 462SORIATANE 462SORILUX 462SORINE 250sotalol 250sotalol af 250sotalol hcl 250SOTYLIZE 250SOVALDI 351spearmint oil 431SPECTRACEF 256spinosad 48SPIRIVA 78SPIRIVA RESPIMAT 78spironolactone 441spironolactone-hctz 441SPORANOX 115SPRAVATO 93SPRAY AND STRETCH 292SPRINTEC 374SPRITAM 88SPRIX 426SPRYCEL 168,169SPS 389SRONYX 374SSD 48SSKI 470SSS 10-5 456STALEVO 100 179

STALEVO 125 179STALEVO 150 179STALEVO 200 179STALEVO 50 179STALEVO 75 179STAMARIL 215STARLIX 106stavudine 202STAXYN 476STEGLATRO 107STEGLUJAN 107STELARA 462STENDRA 476sterilance tl 292STERILE WATER DILUENT-CABLIVI 431STIMATE 378STIOLTO RESPIMAT 78STIVARGA 169STRATTERA 253STRENSIQ 328streptomycin sulfate 65STRIANT 359STRIBILD 202STRIVERDI RESPIMAT 232STROMECTOL 37SUBLOCADE 27SUBOXONE 28SUBSYS 24SUBVENITE 88SUBVENITE (BLUE) 88SUBVENITE (GREEN) 88SUBVENITE (ORANGE) 88SUCRAID 328sucralfate 216SULAR 244sulconazole nitrate 118sulfacetamide sodium 41,48sulfacetamide-prednisolone 41SULFACLEANSE 8-4 456sulfadiazine 67sulfamethoxazole-trimethoprim 67

SULFAMYLON 48sulfasalazine 67sulfasalazine dr 67SULFATRIM 67sulindac 426SUMADAN 456sumatriptan 142sumatriptan succ-naproxen sod 142sumatriptan succinate 142SUMAVEL DOSEPRO 142SUMAXIN 456SUMAXIN TS 456SUNOSI 36SUPARTZ FX 292super thin lancets 292SUPPRELIN LA 350SUPRAX 256SUPREP 343sure comfort 292sure comfort lancets 292sure comfort lancing pen 292sure-fine pen needles 292sure-lance 292sure-pen 292sure-test easyplus mini 292,314sure-touch 292sureflex 292SURMONTIL 100SURVANTA 445SUSTIVA 199SUTENT 169SYEDA 374SYLATRON 220SYLVANT 169SYMAX 78SYMAX DUOTAB 78SYMAX-SL 78SYMAX-SR 78SYMBICORT 260SYMBYAX 98SYMDEKO 260

SYMFI 200SYMFI LO 200SYMJEPI 469SYMLINPEN 120 101SYMLINPEN 60 101SYMPAZAN 91SYMPROIC 345SYMTUZA 204SYNAGIS 220SYNALAR 61SYNAREL 350SYNDROS 111SYNERA 452SYNERCID 75SYNJARDY 107SYNJARDY XR 107SYNRIBO 169SYNTHROID 471SYNVISC 293SYNVISC-ONE 293

TTABLOID 169TABRECTA 170TACLONEX 463tacrolimus 414,463tadalafil 476tadalafil 20 mg tablet (ed/bph) 476tadalafil 20 mg tablet (pah) 476TAFINLAR 170TAGRISSO 170TAKHZYRO 399TALICIA 215TALTZ AUTOINJECTOR 463TALTZ AUTOINJECTOR (2 PACK) 463TALTZ AUTOINJECTOR (3 PACK) 463TALTZ SYRINGE 463TALWIN 28TALZENNA 170TAMIFLU 220tamoxifen citrate 329

tamsulosin hcl 5TAPAZOLE 470TAPERDEX 357TARCEVA 170TARGADOX 71TARGRETIN 170TARINA 24 FE 374TARINA FE 375TARINA FE 1-20 EQ 375TARKA 439TASIGNA 170,171TASMAR 178TAVALISSE 233TAXOTERE 171TAYTULLA 375tazarotene 464TAZICEF 257TAZORAC 464TAZTIA XT 239TAZVERIK 171td gold blood glucose monitor 293td gold level 1 control sol 293td gold level 2 control sol 293td gold level 3 control sol 293td gold test strip 315td gold voice glucose monitor 293tdvax 211TECENTRIQ 171TECFIDERA 410techlite insulin syringe 293techlite lancets 293techlite pen needle 293TECHNESCAN HDP 317TEFLARO 257TEGRETOL 88TEGRETOL XR 89TEGSEDI 395TEKTURNA 441TEKTURNA HCT 441telcare 293,315telcare bgm 293

telcare control solution 294telmisartan 436telmisartan-amlodipine 436telmisartan-hydrochlorothiazid 436temazepam 228TEMIXYS 202TEMODAR 171TEMOVATE 61temozolomide 171temsirolimus 171TENCON 7teniposide 171TENIVAC 211tenofovir disoproxil fumarate 202TENORETIC 100 250TENORETIC 50 250TENORMIN 250TEPEZZA 337terazosin hcl 246terbinafine hcl 114terbutaline sulfate 233terconazole 118,119teriparatide 428terumo surguard2 294TESSALON PERLE 443test n'go 294,315test strips 315TESTIM 359TESTOPEL 360testosterone 360testosterone cypionate 360testosterone enanthate 360TESTRED 360TETCAINE 337tetrabenazine 254tetracaine hcl 337tetracycline hcl 71TEXACORT 61THALOMID 410THEO-24 465theophylline 465,466

theophylline anhydrous 466theophylline in 5% dextrose 466THEROMEGA SPORT 129thiamine hcl 480thin lancets 294THIOLA 418THIOLA EC 419thioridazine hcl 198thiothixene 198THYMOGLOBULIN 414THYROGEN 317thyroid 471THYROLAR-1 471THYROLAR-1/2 471THYROLAR-1/4 471THYROLAR-2 472THYROLAR-3 472TIADYLT ER 239tiagabine hcl 89TIAZAC 240TIBSOVO 171TIGAN 112tigecycline 470TIGLUTIK 253TIKOSYN 64TILIA FE 375timolol maleate 120,121,250TIMOPTIC 121TIMOPTIC OCUDOSE 121TIMOPTIC-XE 121TINDAMAX 182tinidazole 182TIROSINT 472TIROSINT-SOL 472TISSEEL VHSD 464TISSUEBLUE 316TIVICAY 199TIVICAY PD 199tizanidine hcl 449TNKASE 206TOBAKIENT 479

TOBI 65TOBI PODHALER 65TOBRADEX 41TOBRADEX ST 41tobramycin 41,65tobramycin sulfate 65tobramycin sulfate in ns 65tobramycin-dexamethasone 41TOBREX 41TOFRANIL 100TOLAK 171tolazamide 108,109tolbutamide 109tolcapone 178tolmetin sodium 426TOLSURA 115tolterodine tartrate 347tolterodine tartrate er 347tolvaptan 321TOPAMAX 89topcare clickfine 294topcare universal1 lancet 294topcare universal1 thin lancet 294TOPICORT 61topiramate 89topiramate er 89TOPOSAR 172topotecan hcl 172TOPROL XL 250toremifene citrate 329TORISEL 172torsemide 319TOSYMRA 142TOUJEO MAX SOLOSTAR 384TOUJEO SOLOSTAR 384TOVET EMOLLIENT 61TOVIAZ 347TRACLEER 447TRADJENTA 104tramadol hcl 24tramadol hcl er 24,25

tramadol hcl-acetaminophen 25trandolapril 440trandolapril-verapamil er 440tranexamic acid 126tranexamic acid-nacl 126TRANSDERM-SCOP 111TRANXENE T-TAB 228tranylcypromine sulfate 93TRAVATAN Z 122travoprost 123TRAZIMERA 172trazodone hcl 98,99TREANDA 172TRECATOR 144TRELEGY ELLIPTA 260TRELSTAR 350TREMFYA 464treprostinil 447TRESIBA 384TRESIBA FLEXTOUCH U-100 384TRESIBA FLEXTOUCH U-200 384TRETIN-X 453tretinoin 172,453,454tretinoin microsphere 454TRETTEN 126TREXALL 172TREXIMET 142,143TREZIX 25TRI FEMYNOR 375TRI-CHLOR 464TRI-ESTARYLLA 375TRI-LEGEST FE 375TRI-LINYAH 375TRI-LO-ESTARYLLA 375TRI-LO-MARZIA 375TRI-LO-MILI 375TRI-LO-SPRINTEC 375TRI-LUMA 261TRI-MILI 375TRI-NORINYL 375TRI-PREVIFEM 376

TRI-SPRINTEC 376TRI-VYLIBRA 376TRI-VYLIBRA LO 376triamcinolone acetonide 51,61,357triamcinolone diacetate 357triamterene 320triamterene-hydrochlorothiazid 320TRIANEX 61triazolam 228TRIBENZOR 436trichloroacetic acid 464trichophyton mentagrophytes 208TRICOR 134TRIDERM 61TRIDESILON 62trientine hcl 354TRIESENCE 51TRIFERIC 62trifluoperazine hcl 198trifluridine 42TRIGLIDE 134trihexyphenidyl hcl 178TRIJARDY XR 107TRIKAFTA 260TRIKLO 130TRILEPTAL 89TRILIPIX 134TRILURON 294TRILYTE WITH FLAVOR PACKETS 343trimethobenzamide hcl 112trimethoprim 38trimipramine maleate 100TRIMPEX 38TRINATE 479TRINTELLIX 99TRIOSTAT 472TRIPLE DYE 116TRISENOX 172triton x-100 454TRIUMEQ 202TRIVISC 294

TRIVORA-28 376TRIZIVIR 203TRODELVY 172TROKENDI XR 89trospium chloride 347trospium chloride er 347true comfort lancet 294true comfort pen needle 294true metrix 294true metrix air glucose meter 294true metrix blood glucose mtr 294true metrix glucose test strip 315true metrix go 295true metrix pro test strip 315true2go blood glucose system 295truecontrol 295truedraw 295trueplus ketone test strip 472trueplus lancet 295trueplus lancets 295trueplus pen needle 295trueresult blood glucose systm 295truetest test strips 315truetrack blood glucose system 295truetrack smart system 295truetrack test strip 315TRULANCE 345TRULICITY 105TRUMENBA 215TRUSOPT 122TRUST NATAL DHA 479TRUVADA 203TUDORZA PRESSAIR 78TUKYSA 172TULANA 376TURALIO 173TUSNEL 443TUSNEL DM PEDIATRIC 443TUSNEL PEDIATRIC 444TUSSI-PRES PEDIATRIC 444TUSSICAPS 443

TUSSIONEX 443TUSSLIN 444TUXARIN ER 444TUZISTRA XR 444TWINRIX 215TWIRLA 376twist lancets 295TWYNSTA 436TYBLUME 376TYBOST 419TYDEMY 376TYGACIL 470TYKERB 173TYLENOL-CODEINE NO.3 25TYLENOL-CODEINE NO.4 25TYMLOS 428TYPHIM VI 215TYSABRI 410TYVASO 447TYVASO INSTITUTIONAL START KIT 447TYVASO REFILL KIT 447TYVASO STARTER KIT 447

UUBRELVY 140UCERIS 357UDENYCA 235ULESFIA 49ULORIC 394ulti-lance 295ulticare pen needle 295ulticare tb safety syringe 295ultiguard safe pack 295ultilet basic 295ultilet classic 295ultilet lancets 295ultilet pen needle 295ultilet safety 296ultima 296,315ULTOMIRIS 399ultra fine lancets 296

ultra flo pen needle 296ultra thin 296ultra thin lancet 296ultra thin lancets 296ultra thin plus 296ultra thin plus lancets 296ultra-care lancets 296ultra-fine micro pen needle 296ultra-fine mini pen needle 296ultra-fine nano pen needle 296ultra-fine original pen needle 296ultra-fine short pen needle 296ultra-thin ii 296ultracare pen needle 296ULTRACET 25ultralance 296ULTRAM 25ULTRASAL-ER 456ultratlc lancets 296ultratrak 296,316ultratrak pro 297ultratrak ultimate 297,316ULTRAVATE 62UNASYN 429unifine pentips 297unifine pentips maxflow 297unifine pentips plus 297unifine pentips plus maxflow 297unifine safecontrol 297unilet comfortouch 297unilet excelite 297unilet excelite ii 297unilet gp lancet 297unilet lancet 297unilet lancets 298unistik 2 298unistik 2 extra 298unistik 2 normal 298unistik 3 298unistik 3 comfort 298unistik 3 extra 298

unistik 3 neonatal 298unistik czt 298unistik pro 298unistik safety 298unistik touch 298unistrip 298unistrip1 316UNITHROID 472UNITUXIN 173universal 1 298UPLIZNA 410UPNEEQ 337UPTRAVI 447,448urea 456URECHOLINE 231URIBEL 38urinary tract infection 318uristix 4 318uristix reagent 318UROCIT-K 323UROGESIC-BLUE 38UROXATRAL 5URSO 343URSO FORTE 343ursodiol 343UTIBRON NEOHALER 233UTOPIC 456UVADEX 261

VVAGIFEM 334valacyclovir 222VALCHLOR 173VALCYTE 222valganciclovir hcl 222,223VALIUM 228valproate sodium 89valproic acid 89valrubicin 173valsartan 436valsartan-hydrochlorothiazide 437

VALSTAR 173VALTOCO 228VALTREX 223VANATOL LQ 7VANCOCIN HCL 72vancomycin 72vancomycin hcl 41,72,73vancomycin hcl-0.9% nacl 73vancomycin hcl-d5w 73VANDAZOLE 46VANIQA 464vanishpoint insulin syringe 298VANOS 62VANOXIDE-HC 62VANTAS 350VAQTA 215vardenafil hcl 477VARIVAX VACCINE 215VARIZIG 210VARUBI 113VASCEPA 130VASERETIC 440vasopressin-0.9% nacl 378,379vasopressin-d5w 379VASOTEC 440VAXCHORA ACTIVE COMPONENT 215VAXCHORA VACCINE 215VECAMYL 382VECTIBIX 173VECTICAL 464VELCADE 173VELETRI 448VELIVET 376VELPHORO 389VELTASSA 389VELTIN 46VEMLIDY 223VENCLEXTA 173VENCLEXTA STARTING PACK 173VENELEX 465venlafaxine hcl 94

venlafaxine hcl er 94,95VENOFER 63VENTAVIS 448VENTOLIN HFA 233verapamil er 240verapamil er pm 240verapamil hcl 240verapamil sr 240verasens blood glucose meter 298verasens control solution 298verasens meter starter kit 298verasens test strip 316VERDESO 62VEREGEN 465VERELAN 240VERELAN PM 241verifine pen needle 298VERIPRED 20 357VERSACLOZ 194VERZENIO 174VESICARE 347VFEND 115VFEND IV 115VIAGRA 477VIBATIV 73VIBERZI 345VIBRAMYCIN 71VICODIN 25VICODIN HP 25VICTOZA 2-PAK 105VICTOZA 3-PAK 105VIDAZA 174VIDEX 203VIDEX EC 203VIEKIRA PAK 352VIENVA 376vigabatrin 89VIGADRONE 89VIGAMOX 41VIIBRYD 99VIMIZIM 328

VIMPAT 90VINATE DHA RF 479VINATE ONE 479VINATE-M 479vinblastine sulfate 174VINCASAR PFS 174vincristine sulfate 174vinorelbine tartrate 174VIOKACE 343VIORELE 376VIRACEPT 205VIRAMUNE 200VIRAMUNE XR 200VIRASAL 456VIRAZOLE 223VIREAD 203VIRT-C DHA 479VISINE TOTALITY 337VISTARIL 225VISTASEAL FIBRIN SEALANT 126VISTOGARD 393VISUDYNE 337vitamin d2 481vitamin k1 482VITATRUE 480VITRAKVI 174VITRASE 329vivaguard ino control solution 298vivaguard ino glucose meter 299vivaguard ino smart gluc meter 299vivaguard ino test strip 316vivaguard lancet 299vivaguard lancing device 299VIVELLE-DOT 334VIVITROL 254VIVLODEX 426VIVOTIF 215VIZIMPRO 174VOGELXO 361VOLNEA 376VOLTAREN 426

VOLTAREN-XR 426VONVENDI 126VORAXAZE 393voriconazole 115VOSEVI 352VOTRIENT 174VPRIV 329VRAYLAR 195VTOL LQ 7VUMERITY 411VYFEMLA 377VYLEESI 253VYLIBRA 377VYNDAMAX 245VYNDAQEL 245VYTORIN 132VYVANSE 32VYZULTA 123

WWAKIX 36WAL-DRYL 452warfarin sodium 79water 431wavesense amp 299wavesense control solution 299wavesense jazz 316wavesense presto 299,316WELCHOL 131WELLBUTRIN SR 93WELLBUTRIN XL 93WERA 377WESTHROID 472wheat germ oil 481WILATE 126WINRHO SDF 211WIXELA INHUB 260WP THYROID 472WYMZYA FE 377

XXADAGO 180XALATAN 123XALKORI 174XANAX 228XANAX XR 229XARELTO 80XATMEP 174XCOPRI 90XELJANZ 406XELJANZ XR 406XELODA 175XELPROS 123XEMBIFY 211XENAZINE 255XENICAL 345XENLETA 75XEOMIN 419XEPI 46XERAC AC 452XERESE 47XERMELO 341XGEVA 397XHANCE 51XIAFLEX 329XIFAXAN 75XIGDUO XR 107XIIDRA 51XIMINO 71XOFIGO 432XOFLUZA 219XOLAIR 445,446XOLEGEL 119XOPENEX 233XOPENEX CONCENTRATE 233XOPENEX HFA 233XOSPATA 175XPOVIO 175XTAMPZA ER 26XTANDI 175

XULANE 377XULTOPHY 100-3.6 384XURIDEN 419XYLOCAINE IV 63XYNTHA 126XYNTHA SOLOFUSE 126XYOSTED 361XYREM 253XYWAV 253XYZAL 127

Yyale needle 299YASMIN 28 377YAZ 377YERVOY 176YF-VAX 215yohimbine hcl 473YONSA 176YUPELRI 78YUTIQ 51YUVAFEM 334

Zzafirlukast 54zaleplon 225ZALTRAP 176ZANAFLEX 449ZANOSAR 176ZANTAC 216ZARAH 377ZARONTIN 92ZARXIO 235ZAVESCA 419ZCORT 357ZEBUTAL 7ZEGERID 218,219ZEJULA 176ZELAPAR 180ZELBORAF 176ZELNORM 345

ZEMAIRA 446ZEMBRACE SYMTOUCH 143ZEMPLAR 481ZENATANE 465ZENPEP 343ZENZEDI 32ZEPATIER 352ZEPOSIA 411ZEPZELCA 176ZERIT 203ZERVIATE 335ZESTORETIC 440ZESTRIL 440ZETIA 132ZETONNA 51ZEVALIN 176ZIAC 251ZIAGEN 203ZIANA 46zidovudine 203ZIEXTENZO 235zileuton er 54ZILXI 46zinc chloride 326ZINECARD 419ZIOPTAN 123ziprasidone hcl 195ziprasidone mesylate 195ZIPSOR 426ZIRABEV 176ZIRGAN 42ZITHROMAX 391ZITHROMAX TRI-PAK 391ZOCOR 138ZODRYL DAC 50 444ZODRYL DAC 60 444ZODRYL DAC 80 444ZODRYL DEC 50 444ZODRYL DEC 60 444ZODRYL DEC 80 444ZOFRAN 111

ZOHYDRO ER 26ZOLADEX 350zoledronic acid 397ZOLINZA 177zolmitriptan 143zolmitriptan odt 143ZOLOFT 98zolpidem tartrate 225zolpidem tartrate er 225ZOLPIMIST 225ZOMETA 397ZOMIG 143ZOMIG ZMT 143ZONALON 452ZONEGRAN 90zonisamide 90ZONTIVITY 206ZORBTIVE 379ZORTRESS 415ZORVOLEX 426ZOSTAVAX 215ZOSYN 429ZOVIA 1-35 377ZOVIA 1-35E 377ZOVIRAX 47,223ZTLIDO 452ZUBSOLV 28ZUMANDIMINE 377ZUPLENZ 111ZYBAN 93ZYCLARA 465ZYDELIG 177ZYFLO 54ZYFLO CR 54ZYKADIA 177ZYLET 41ZYLOPRIM 394ZYMAXID 41ZYPITAMAG 138ZYPREXA 195,196ZYPREXA RELPREVV 196

ZYPREXA ZYDIS 196ZYTIGA 177ZYVOX 75

MAGELLAN Rx STANDARD FORMULARY - Magellan Rx …

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