E N HANCED FORMULARY January 2017 … N HANCED FORMULARY January 2017 INTRODUCTION ... Ancillary charges do not apply toward your deductible or out -of -pocket maximum. ... etodolac

ENHANCED FORMULARY

January 2017 INTRODUCTION

Foreword

The HometownRx Enhanced Formulary is a useful reference for drug product selection. The goal of the

Drug Formulary is to enhance the physician and pharmacist’s abilities to provide optimal cost effective

drug therapy for patients. Ultimately, specific drug selection for an individual member is dependent on

your prescriber.

The Formulary is a continually reviewed and revised list of drugs, which mirror the prevailing clinical opinion of the Pharmaceutical & Therapeutics and Formulary Committees. Due to this continual review process, the HometownRx Enhanced Formulary may not be a complete list of all covered drug products and is not meant to be comprehensive in nature. Formulary change notices will be provided as necessary.

Benefit Coverage and Limitations The Drug Formulary is a list of covered and preferred drug products for members. The Enhanced Formulary is an open formulary but, HometownRx may impose restrictions or not reimburse for certain drug products. In addition, certain drug products have been excluded from this formulary. If you choose to use an excluded drug product HometownRx may not reimburse for these drug products and may require you to pay 100% of the cost. Furthermore, if you choose to use a drug that is excluded, the cost, does not accumulate towards meeting your annual deductible or out-of-pocket maximums. In addition, certain classes of medication are not covered under your pharmacy benefit. These medication classes include: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hemantinics, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications. An ancillary charge/member paid difference may apply to brand medications when an equivalent generic is available. If a member or provider chooses a brand product over the generic the member may be responsible for their copay plus the cost difference between the brand medication and the generic medication. Ancillary charges do not apply toward your deductible or out-of-pocket maximum. The Drug Formulary applies only to outpatient drugs products provided to members, and does not apply to drug products used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Hometown Rx at 1-844-373-0970.

How to Use the Formulary The Formulary is organized by sections either by drug class or disease state and then by the name of the drug product in alphabetical order. All drug names and strengths listed are included in the formulary. The formulary denotes all drug products by product name, strength and dosage form. Generics are denoted in lower case letters by the ingredient name and the formulary will only denote the proprietary - branded names in capital letters that are covered on the formulary.

LAST REVISED 03/16/2017

ENHANCED FORMULARY


For all products within the Drug Formulary, the tier level is denoted throughout the document using the following symbols in the legend below. See your schedule of Benefits for the cost sharing you will pay for a given tier.

For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These prescribing types include Quantity Limit, Prior Authorization, Step Therapy, Age Limits, Max Fill Limits, and Max Days’ Supply which are denoted throughout the document as described below.

S

ENHANCED FORMULARY


Formulary Drug descriptions* To assist in understanding which specific drug products are covered, examples are noted below. All covered strengths and dosages forms are specified within the Formulary. Preferred Generic Drugs:

Preferred Brand and Non-Preferred Generic Drugs:

Non - Preferred Brand and High Cost Generic Drugs:

Specialty Drugs:

* The examples described in this section are for demonstration purposes only and may not reflect what is actually on formulary.

LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ANSAID 100 MG TABLETflurbiprofen 3

butalbital-asa-caffeine cap 1

celecoxib 100 mg capsule 1QL 30 / 30 DAYS

ST


ST


ST


ST

choline mag trisal liquid 1

diclofenac pot 50 mg tablet 1

diclofenac sod dr 25 mg tab 1



diclofenac sod ec 25 mg tab 1



diclofenac sod er 100 mg tab 1

diclofenac-misoprost 50-0.2 tb 1

diclofenac-misoprost 50-200 tb 1

diclofenac-misoprost 75-0.2 tb 1

diclofenac-misoprost 75-200 tb 1

etodolac 200 mg capsule 1

etodolac 300 mg capsule 1

etodolac 400 mg tablet 1

PAGE 4 LAST UPDATED 03/2017


etodolac 500 mg tablet 1

etodolac er 400 mg tablet 1



fenoprofen 200 mg capsule 1

fenoprofen 400 mg capsule 1

fenoprofen 600 mg tablet 1

fenoprofen calcium 400 mg cap 1

FENORTHO 400 MG CAPSULEfenoprofen calcium 3

flurbiprofen 100 mg tablet 1

flurbiprofen 50 mg tablet 1

ibuprofen 100 mg/5 ml susp 1

ibuprofen 400 mg tablet 1



INDOCIN 25 MG/5 ML SUSPENSIONindomethacin 2

INDOCIN 50 MG SUPPOSITORYindomethacin 2

indomethacin 25 mg capsule 1

indomethacin 50 mg capsule 1

indomethacin er 75 mg capsule 1

ketoprofen 50 mg capsule 1

ketoprofen 75 mg capsule 1

ketoprofen er 200 mg capsule 1

ketorolac 10 mg tablet 1

meclofenamate 100 mg capsule 3 ST

meclofenamate 50 mg capsule 3 ST

mefenamic acid 250 mg capsule 3 ST

meloxicam 15 mg tablet 1

meloxicam 7.5 mg tablet 1



meloxicam 7.5 mg/5 ml susp 1

nabumetone 500 mg tablet 1

nabumetone 750 mg tablet 1

NALFON 400 MG CAPSULEfenoprofen calcium 3

NAPROSYN 250 MG TABLETnaproxen 3

naproxen 125 mg/5 ml suspen 1

naproxen 250 mg tablet 1


naproxen 500 mg kit 1


naproxen dr 375 mg tablet 1

naproxen dr 500 mg tablet 1

naproxen ec 375 mg tablet 1

naproxen ec 500 mg tablet 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

naproxen sodium ds 550 mg tab 1

oxaprozin 600 mg caplet 1

oxaprozin 600 mg tablet 1

piroxicam 10 mg capsule 1

piroxicam 20 mg capsule 1

salsalate 500 mg tablet 1

salsalate 750 mg tablet 1

sulindac 150 mg tablet 1

sulindac 200 mg tablet 1

tolmetin sodium 400 mg cap 1

OPIOID ANALGESICS, LONG-ACTING

AVINZA 120 MG CAPSULEmorphine sulfate 4 ST








DURAGESIC 100 MCG/HR PATCHfentanyl 4




EMBEDA ER 100-4 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA

EMBEDA ER 20-0.8 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA


EMBEDA ER 50-2 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA



EXALGO ER 32 MG TABLEThydromorphone hcl 3 PA

fentanyl 100 mcg/hr patch 1



fentanyl 37.5 mcg/hr patch 4







hydromorphone hcl er 12 mg tab 3 PA




methadone 10 mg/5 ml solution 1

methadone 10 mg/ml oral conc 1

methadone 40 mg tablet dispr 1

methadone 5 mg/5 ml solution 1

methadone hcl 10 mg tablet 1

methadone hcl 5 mg tablet 1

methadone intensol 10 mg/ml 1

METHADOSE 10 MG/ML ORAL CONCmethadone hcl 3

methadose 40 mg tablet dispr 1

morphine sulf er 100 mg tablet 1





morphine sulfate er 120 mg cap 1 ST







NUCYNTA ER 100 MG TABLETtapentadol hcl 3

QL 180 / 30 DAYS

ST

AL1 At least 18 yrs old




QL 180 / 30 DAYS

ST



QL 180 / 30 DAYS

ST



QL 180 / 30 DAYS

ST



QL 180 / 30 DAYS

ST


oxycodone hcl er 10 mg tablet 4QL 60 / 30 DAYS

ST

oxycodone hcl er 15 mg tablet 4QL 60 / 30 day(s)

ST


ST


ST


ST


ST


ST

oxymorphone hcl er 10 mg tab 3 QL 60 / 30 DAYS







oxymorphone hcl er 5 mg tablet 3 QL 60 / 30 DAYS

oxymorphone hcl er 7.5 mg tab 3 QL 60 / 30 DAYS

tramadol er 100 mg tablet 1 ST



tramadol hcl er 100 mg capsule 3

tramadol hcl er 100 mg tablet 1 ST






ZOHYDRO ER 10 MG CAPSULEhydrocodone bitartrate 3 PA






OPIOID ANALGESICS, SHORT-ACTING

acetamin-codein 300-30 mg/12.5 1

acetaminop-codeine 120-12 mg/5 1

acetaminophen-cod #2 tablet 1



asa-butalb-caff-cod #3 capsule 1



ascomp with codeine capsule 1

butalb-acetaminoph-caff-codein 3

butalb-caff-acetaminoph-codein 1

butalbital comp-codeine #3 cap 1

CAPITAL WITH CODEINE SUSPacetaminophen with codeine phosphate 3

carisoprodol cpd-codeine tab 1

carisoprodol-aspirin-codein tb 1

codeine sulfate 15 mg tablet 1



endocet 10-325 mg tablet 1

endocet 2.5-325 mg tablet 1

endocet 5-325 tablet 1

endocet 7.5-325 mg tablet 1

fentanyl cit otfc 1,200 mcg 4 PA

fentanyl cit otfc 1,600 mcg 4 PA

fentanyl citrate otfc 200 mcg 4 PA




hydrocodon-acetamin 7.5-325/15 1

hydrocodon-acetaminoph 2.5-325 1



hydrocodon-acetaminophen 5-300 1

hydrocodon-acetaminophen 5-325 1

hydrocodon-acetaminophn 10-300 1

hydrocodon-acetaminophn 10-325 1

hydrocodone-acetamin 10-325/15 1

hydrocodone-acetamin 2.5-108/5 1



hydrocodone-acetamin 2.5-167/5 1

hydrocodone-acetamin 5-163/7.5 1

hydrocodone-acetamin 5-217/10 1

hydrocodone-ibuprofen 10-200 1

hydrocodone-ibuprofen 2.5-200 1

hydrocodone-ibuprofen 5-200 mg 1

hydrocodone-ibuprofen 7.5-200 1

hydromorphone 1 mg/ml solution 1

hydromorphone 2 mg tablet 1

hydromorphone 3 mg suppos 1


hydromorphone 5 mg/5 ml soln 1


lorcet 5-325 mg tablet 1

lorcet hd 10-325 mg tablet 1

lorcet plus 7.5-325 mg tablet 1

lortab 10 mg-300 mg/15 ml elxr 3

lortab 10-325 mg tablet 3

lortab 5-325 mg tablet 3

lortab 7.5-325 mg tablet 3

meperidine 100 mg tablet 1

meperidine 50 mg tablet 1

meperidine 50 mg/5 ml solution 1

morphine 10 mg/ml carpuject 1

morphine 10 mg/ml syringe 1


morphine 15 mg/ml vial 1

morphine 30 mg/30 ml syringe 1

morphine 300 mg/20 ml vial 1






morphine sulf 10 mg suppos 1

morphine sulf 10 mg/0.7 ml syr 1

morphine sulf 10 mg/5 ml soln 1






morphine sulfate ir 15 mg tab 2

morphine sulfate ir 30 mg tab 2

NUCYNTA 100 MG TABLETtapentadol hcl 3 QL 180 / 30 DAYS



OXAYDO 5 MG TABLEToxycodone hcl 3 ST

OXAYDO 7.5 MG TABLEToxycodone hcl 3 ST

OXECTA 5 MG TABLEToxycodone hcl 3 ST

OXECTA 7.5 MG TABLEToxycodone hcl 3 ST

oxycodon-acetaminophen 2.5-325 1

oxycodon-acetaminophen 7.5-325 1

oxycodone hcl 10 mg tablet 1

oxycodone hcl 100 mg/5 ml soln 1




oxycodone hcl 5 mg capsule 1




oxycodone hcl 5 mg/5 ml soln 1

oxycodone-acetaminophen 10-325 1

oxycodone-acetaminophen 5-325 1

oxycodone-acetaminophn 5-325/5 3

oxycodone-aspirin 4.8355-325 1

oxycodone-ibuprofen 5-400 tab 1

oxymorphone hcl 10 mg tablet 3QL 60 / 30 DAYS

ST

oxymorphone hcl 5 mg tablet 3QL 60 / 30 DAYS

ST

reprexain 10-200 mg tablet 1

REPREXAIN 2.5-200 MG TABLEThydrocodone/ibuprofen 1

REPREXAIN 5-200 MG TABLEThydrocodone/ibuprofen 1

ROXICET 5-325 ORAL SOLUTIONoxycodone hcl/acetaminophen 1

ROXICODONE 30 MG TABLEToxycodone hcl 3

tramadol hcl 50 mg tablet 1

tramadol-acetaminophn 37.5-325 1

verdrocet 2.5-325 mg tablet 3

vicodin 5-300 mg tablet 1

vicodin es 7.5-300 mg tablet 1

vicodin hp 10-300 mg tablet 1

xylon 10-200 mg tablet 1

ZAMICET 10-325 MG/15 ML SOLNhydrocodone bitartrate/acetaminophen 3

ANESTHETICS

LOCAL ANESTHETICS

glydo 2% jelly syringe 1

lidocaine 2% viscous soln 1

lidocaine 5% ointment 3



lidocaine 5% patch 3

lidocaine hcl 2% jelly 1

lidocaine hcl 2% jelly 1

lidocaine hcl 4% solution 1

lidocaine-prilocaine cream 1

LIDOVEX 3.75% CREAMlidocaine 3

XYLOCAINE 4% SOLUTIONlidocaine hcl 3

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calc dr 333 mg tab 3

depade 50 mg tablet 1

naltrexone 50 mg tablet 1

revia 50 mg tablet 3

OPIOID DEPENDENCE TREATMENTS

BUNAVAIL 2.1-0.3 MG FILMbuprenorphine hcl/naloxone hcl 4

QL 1 / 1 day(s)

PA

BUNAVAIL 4.2-0.7 MG FILMbuprenorphine hcl/naloxone hcl 4

QL 2 / 1 day(s)

PA

BUNAVAIL 6.3-1 MG FILMbuprenorphine hcl/naloxone hcl 4

QL 2 / 1 day(s)

PA

BUPRENEX 0.3 MG/ML AMPULbuprenorphine hcl 4

buprenorphin-naloxon 8-2 mg sl 4 PA

buprenorphine 0.3 mg/ml syrn 4

buprenorphine 0.3 mg/ml vial 4

buprenorphine 2 mg tablet sl 4QL 3 / 1 day(s)

PA

buprenorphine 8 mg tablet sl 4QL 3 / 1 day(s)

PA

buprenorphn-naloxn 2-0.5 mg sl 4 PA



SUBOXONE 12 MG-3 MG SL FILMbuprenorphine hcl/naloxone hcl 4

QL 2 / 1 day(s)

PA

SUBOXONE 2 MG-0.5 MG SL FILMbuprenorphine hcl/naloxone hcl 4

QL 1 / 1 day(s)

PA


QL 1 / 1 day(s)

PA


QL 2 / 1 day(s)

PA

ZUBSOLV 1.4-0.36 MG TABLET SLbuprenorphine hcl/naloxone hcl 4

QL 1 / 1 day(s)

PA


QL 1 / 1 day(s)

PA


QL 1 / 1 day(s)

PA


QL 1 / 1 day(s)

PA


QL 2 / 1 day(s)

PA

ANTIBACTERIALS

AMINOGLYCOSIDES

GARAMYCIN 3 MG/GM EYE OINTMENTgentamicin sulfate 3

gentak 0.3 % eye ointment 1

gentamicin 0.1% cream 1

gentamicin 0.1% ointment 1

gentamicin 0.3% eye drops 1

gentamicin 0.3% eye ointment 1

gentamicin 3 mg/gm eye oint 1

gentamicin 3 mg/ml eye drops 1

neomycin 500 mg tablet 1

paromomycin 250 mg capsule 1



tobramycin 0.3% eye drops 1

TOBREX 0.3% EYE OINTMENTtobramycin 2

ANTIBACTERIALS, OTHER

ALTABAX 1% OINTMENTretapamulin 3

bacitracin 500 unit/gm ophth 1

BACTROBAN 2% OINTMENTmupirocin 2 QL 1 / 7 DAYS

CLEOCIN 100 MG VAGINAL OVULEclindamycin phosphate 3

CLEOCIN 2% VAGINAL CREAMclindamycin phosphate 3

CLEOCIN 75 MG/5 ML GRANULESclindamycin palmitate hcl 3

clindacin etz 1% pledget 3

clindacin p 1% pledgets 3

clindamycin 2% vaginal cream 1

clindamycin 75 mg/5 ml soln 1

clindamycin hcl 150 mg capsule 1



clindamycin pediatr 75 mg/5 ml 1

clindamycin ph 1% gel 1

clindamycin ph 1% solution 1

clindamycin phos 1% pledget 1

clindamycin phosp 1% lotion 1

CLINDESSE 2% VAGINAL CREAMclindamycin phosphate 3

erythromycin-benzoyl gel 3

FLAGYL ER 750 MG TABLETmetronidazole 3

FURADANTIN 25 MG/5 ML SUSPnitrofurantoin 3

linezolid 100 mg/5 ml susp 2 PA



linezolid 600 mg tablet 2 PA

methenamine hipp 1 gm tablet 1

methenamine md 1 gm tablet 1

methenamine md 500 mg tablet 1

metronidazole 250 mg tablet 1

metronidazole 375 mg capsule 1

metronidazole 500 mg tablet 1

metronidazole vaginal 0.75% gl 1

mupirocin 2% cream 1 QL 1 / 7 DAYS

mupirocin 2% ointment 1 QL 1 / 7 DAYS

nitrofurantoin 25 mg/5 ml susp 1

nitrofurantoin mcr 100 mg cap 1



nitrofurantoin mono-mcr 100 mg 1

phosphasal tablet 3

PRIMSOL 50 MG/5 ML ORAL SOLNtrimethoprim 3

SIVEXTRO 200 MG TABLETtedizolid phosphate 2 PA

TINDAMAX 500 MG TABLETtinidazole 3

tinidazole 500 mg tablet 1

trimethoprim 100 mg tablet 1

BETA-LACTAM, CEPHALOSPORINS

cefaclor 125 mg/5 ml susp 1

cefaclor 250 mg capsule 1

cefaclor 250 mg/5 ml susp 1

cefaclor 375 mg/5 ml suspen 1

cefaclor 500 mg capsule 1

cefaclor er 500 mg tablet 1

cefadroxil 1 gm tablet 1



cefadroxil 250 mg/5 ml susp 1

cefadroxil 500 mg capsule 1

cefadroxil 500 mg/5 ml susp 1

cefdinir 125 mg/5 ml susp 1

cefdinir 250 mg/5 ml susp 1

cefdinir 300 mg capsule 1

cefixime 100 mg/5 ml susp 3

cefixime 200 mg/5 ml susp 3

cefpodoxime 100 mg tablet 1

cefpodoxime 100 mg/5 ml susp 1

cefpodoxime 200 mg tablet 1

cefpodoxime 50 mg/5 ml susp 1

cefprozil 125 mg/5 ml susp 1

cefprozil 250 mg tablet 1

cefprozil 250 mg/5 ml susp 1

cefprozil 500 mg tablet 1

ceftibuten 180 mg/5 ml susp 3

ceftibuten 400 mg capsule 3

CEFTIN 125 MG/5 ML ORAL SUSPcefuroxime axetil 3

CEFTIN 250 MG/5 ML ORAL SUSPcefuroxime axetil 3

CEFTIN 500 MG TABLETcefuroxime axetil 3

cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

cephalexin 125 mg/5 ml susp 1

cephalexin 250 mg capsule 1

cephalexin 250 mg tablet 1

cephalexin 250 mg/5 ml susp 1


cephalexin 500 mg tablet 1




SUPRAX 100 MG TABLET CHEWABLEcefixime 3

SUPRAX 200 MG TABLET CHEWABLEcefixime 3

SUPRAX 400 MG CAPSULEcefixime 3

SUPRAX 500 MG/5 ML SUSPENSIONcefixime 3

BETA-LACTAM, PENICILLINS

amox-clav 200-28.5 mg tab chew 1

amox-clav 200-28.5 mg/5 ml sus 1

amox-clav 250-125 mg tablet 1


amox-clav 400-57 mg tab chew 1

amox-clav 400-57 mg/5 ml susp 1




amox-clav er 1,000-62.5 mg tab 1

amoxicillin 125 mg tab chew 1

amoxicillin 125 mg/5 ml susp 1


amoxicillin 250 mg capsule 1

amoxicillin 250 mg tab chew 1



amoxicillin 500 mg capsule 1

amoxicillin 500 mg tablet 1

amoxicillin 875 mg tablet 1

ampicillin 125 mg/5 ml susp 1

ampicillin 250 mg capsule 1

ampicillin 250 mg/5 ml susp 1

ampicillin 500 mg capsule 1



AUGMENTIN 125-31.25 MG/5 MLamoxicillin/potassium clavulanate 3

dicloxacillin 250 mg capsule 1

dicloxacillin 500 mg capsule 1

penicillin vk 125 mg/5 ml soln 1

penicillin vk 250 mg tablet 1

penicillin vk 250 mg/5 ml soln 1

penicillin vk 500 mg tablet 1

MACROLIDES

AZASITE 1% EYE DROPSazithromycin 3

azithromycin 1 gm pwd packet 1

azithromycin 100 mg/5 ml susp 1

azithromycin 200 mg/5 ml susp 1 QL 3 / 10 DAYS

azithromycin 250 mg tablet 1 QL 8 / 1 FILL

azithromycin 500 mg tablet 1 QL 10 / 1 FILL

azithromycin 600 mg tablet 1

clarithromycin 125 mg/5 ml sus 1

clarithromycin 250 mg tablet 1

clarithromycin 250 mg/5 ml sus 1

clarithromycin 500 mg tablet 1

clarithromycin er 500 mg tab 1

DIFICID 200 MG TABLETfidaxomicin 2 PA

E.E.S. 200 MG/5 ML GRANULESerythromycin ethylsuccinate 1

E.E.S. 400 FILMTABerythromycin ethylsuccinate 1

ery 2% pads 1

ERY-TAB EC 250 MG TABLETerythromycin base 1





erygel 2% gel 3

ERYTHROCIN 250 MG FILMTABerythromycin stearate 1

erythromycin 0.5% eye ointment 1

erythromycin 2% gel 1

erythromycin 2% pledgets 1

erythromycin 2% solution 1

erythromycin 200 mg/5 ml gran 1

erythromycin 250 mg filmtab 1

erythromycin 500 mg filmtab 1

erythromycin dr 250 mg cap 1

erythromycin ec 250 mg cap 1

erythromycin es 400 mg tab 1

ZITHROMAX 250 MG Z-PAK TABLETazithromycin 3

ZITHROMAX TRI-PAK 500 MG TABazithromycin 3

ZMAX 2 G/60 ML ORAL SUSPENSIONazithromycin 3

QUINOLONES

BESIVANCE 0.6% SUSPbesifloxacin hcl 3

CILOXAN 0.3% OINTMENTciprofloxacin hcl 3

ciprofloxacin 0.2% otic soln 1

ciprofloxacin 0.3% eye drop 1

ciprofloxacin 250 mg/5 ml susp 3

ciprofloxacin 500 mg/5 ml susp 3

ciprofloxacin er 1,000 mg tab 1

ciprofloxacin er 500 mg tablet 1

ciprofloxacin hcl 100 mg tab 1

ciprofloxacin hcl 250 mg tab 1 QL 30 / 1 FILL





gatifloxacin 0.5% eye drops 3

LEVAQUIN 25 MG/ML SOLUTIONlevofloxacin 2

levofloxacin 0.5% eye drops 1

levofloxacin 25 mg/ml solution 1

levofloxacin 250 mg tablet 1

levofloxacin 250 mg/10 ml soln 1


levofloxacin 500 mg/20 ml soln 1


MOXEZA 0.5% EYE DROPSmoxifloxacin hcl 3 ST

moxifloxacin hcl 400 mg tablet 1

ofloxacin 0.3% ear drops 1

ofloxacin 0.3% eye drops 1

ofloxacin 400 mg tablet 1

VIGAMOX 0.5% EYE DROPSmoxifloxacin hcl 2

SULFONAMIDES

BLEPH-10 10% EYE DROPSsulfacetamide sodium 1

KLARON 10% LOTIONsulfacetamide sodium 3

silver sulfadiazine 1% cream 1

sodium sulfacetamide 10% lot 1

sodium sulfacetamide 10% lotn 1

SSD 1% CREAMsilver sulfadiazine 1

sulfacetamide 10% eye drops 1

sulfacetamide 10% eye ointment 1

sulfacetamide sod 10% top susp 1



sulfamethoxazole-tmp ds tablet 1

sulfamethoxazole-tmp ss tablet 1

sulfamethoxazole-tmp susp 1

sulfamethoxazole-tmp susp 1

SULFATRIM PEDIATRIC SUSPENSIONsulfamethoxazole/trimethoprim 1

TETRACYCLINES

DORYX DR 150 MG TABLETdoxycycline hyclate 2

doxycycline 25 mg/5 ml susp 1

doxycycline hyc dr 100 mg tab 3





doxycycline hyclate 100 mg cap 1

doxycycline hyclate 100 mg tab 1

doxycycline hyclate 20 mg tab 1

doxycycline ir-dr 40 mg cap 3 ST

doxycycline mono 100 mg cap 3 ST

doxycycline mono 100 mg tablet 3 ST





doxycycline mono 75 mg capsule 3 ST


dynacin 100 mg tablet 3

dynacin 50 mg tablet 3

minocycline 100 mg capsule 1





minocycline hcl 100 mg tablet 3



tetracycline 250 mg capsule 1

tetracycline 500 mg capsule 1

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT 10 MG TABLETbrivaracetam 3

BRIVIACT 10 MG/ML ORAL SOLNbrivaracetam 3





FYCOMPA 0.5 MG/ML ORAL SUSPperampanel 3

QL 2 / 1 day(s)

ST

FYCOMPA 10 MG TABLETperampanel 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 4 / 1 DAYS

ST


QL 2 / 1 DAYS

ST


QL 2 / 1 DAYS

ST




QL 1 / 1 DAYS

ST

KEPPRA 100 MG/ML ORAL SOLNlevetiracetam 3

levetiracetam 1,000 mg tablet 1

levetiracetam 100 mg/ml soln 1

levetiracetam 250 mg tablet 1


levetiracetam 500 mg/5 ml soln 1


levetiracetam er 500 mg tablet 1

levetiracetam er 750 mg tablet 1

roweepra 500 mg tablet 3

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 300 MG KAPSEALmethsuximide 2

ethosuximide 250 mg capsule 1

ethosuximide 250 mg/5 ml soln 1

zonisamide 100 mg capsule 1



GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

DEPAKOTE DR 125 MG SPRINKLE CPdivalproex sodium 3

divalproex dr 125 mg cap sprnk 1

divalproex sod dr 125 mg tab 1



divalproex sod er 250 mg tab 1

divalproex sod er 500 mg tab 1

gabapentin 100 mg capsule 1

gabapentin 250 mg/5 ml soln 1




gabapentin 300 mg/6 ml soln 1


gabapentin 600 mg tablet 1

gabapentin 800 mg tablet 1

GABITRIL 12 MG TABLETtiagabine hcl 2

GABITRIL 16 MG TABLETtiagabine hcl 2

ONFI 10 MG TABLETclobazam 3 PA

ONFI 2.5 MG/ML SUSPENSIONclobazam 3 PA

ONFI 20 MG TABLETclobazam 3 PA

phenobarbital 100 mg tablet 1


phenobarbital 16.2 mg tablet 1

phenobarbital 20 mg/5 ml elix 1

phenobarbital 20 mg/5 ml soln 1






primidone 250 mg tablet 1

primidone 50 mg tablet 1

SABRIL 500 MG POWDER PACKETvigabatrin 4

SABRIL 500 MG TABLETvigabatrin 4

tiagabine hcl 2 mg tablet 2

tiagabine hcl 4 mg tablet 2

valproic acid 250 mg capsule 1



valproic acid 250 mg/5 ml soln 1

valproic acid 500 mg/10 ml sol 1

GLUTAMATE REDUCING AGENTS

LAMICTAL TAB START KIT (GREEN)lamotrigine 3 AL1 At least 2 yrs old

LAMICTAL TB START KIT (ORANGE)lamotrigine 3 AL1 At least 2 yrs old

LAMICTAL XR START KIT (BLUE)lamotrigine 3 AL1 At least 2 yrs old

LAMICTAL XR START KIT (GREEN)lamotrigine 3 AL1 At least 2 yrs old

LAMICTAL XR START KIT (ORANGE)lamotrigine 3 AL1 At least 2 yrs old

lamotrigine 100 mg tablet 1QL 60 / 30 DAYS






lamotrigine 25 mg disper tab 1 AL1 At least 2 yrs old

lamotrigine 25 mg tablet 1 AL1 At least 2 yrs old

lamotrigine 25 mg tb start kit 1 AL1 At least 2 yrs old

lamotrigine 5 mg disper tablet 1 AL1 At least 2 yrs old

lamotrigine er 100 mg tablet 1 AL1 At least 2 yrs old






lamotrigine odt 100 mg tablet 3 AL1 At least 2 yrs old






lamotrigine odt kit (blue) 3 AL1 At least 2 yrs old

lamotrigine odt kit (green) 3 AL1 At least 2 yrs old

lamotrigine odt kit (orange) 3 AL1 At least 2 yrs old

topiragen 100 mg tablet 1



topiramate 100 mg tablet 1

topiramate 15 mg sprinkle cap 1


topiramate 25 mg sprinkle cap 1



topiramate er 100 mg capsule 3





TROKENDI XR 100 MG CAPSULEtopiramate 3




SODIUM CHANNEL AGENTS

APTIOM 200 MG TABLETeslicarbazepine acetate 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST




QL 2 / 1 DAYS

ST


QL 1 / 1 DAYS

ST

BANZEL 200 MG TABLETrufinamide 2

QL 240 / 30 DAYS

ST


BANZEL 40 MG/ML SUSPENSIONrufinamide 2

ST


BANZEL 400 MG TABLETrufinamide 2

ST


carbamazepine 100 mg tab chew 1

carbamazepine 100 mg/5 ml susp 1

carbamazepine 200 mg tablet 1

carbamazepine er 100 mg cap 1

carbamazepine er 100 mg tablet 1





DILANTIN 30 MG CAPSULEphenytoin sodium extended 2

epitol 200 mg tablet 1

oxcarbazepine 150 mg tablet 1


oxcarbazepine 300 mg/5 ml susp 1


OXTELLAR XR 150 MG TABLEToxcarbazepine 3 ST

OXTELLAR XR 300 MG TABLEToxcarbazepine 3

OXTELLAR XR 600 MG TABLEToxcarbazepine 3



PEGANONE 250 MG TABLETethotoin 2

phenytoin 100 mg/4 ml susp 1

phenytoin 125 mg/5 ml susp 1

phenytoin 50 mg infatab 1

phenytoin 50 mg tablet chew 1

phenytoin sod ext 100 mg cap 1



VIMPAT 10 MG/ML SOLUTIONlacosamide 3 AL1 At least 17 yrs old

VIMPAT 100 MG TABLETlacosamide 3 AL1 At least 17 yrs old




ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS

donepezil hcl 10 mg tablet 1



donepezil hcl odt 10 mg tablet 1

donepezil hcl odt 5 mg tablet 1

galantamine 4 mg/ml oral soln 2

galantamine er 16 mg capsule 1



galantamine hbr 12 mg tablet 1



NAMZARIC 14 MG-10 MG CAPSULEmemantine hcl/donepezil hcl 3






NAMZARIC TITRATION PACKmemantine hcl/donepezil hcl 3

rivastigmine 1.5 mg capsule 1

rivastigmine 13.3 mg/24hr ptch 2

rivastigmine 3 mg capsule 1

rivastigmine 4.5 mg capsule 1

rivastigmine 4.6 mg/24hr patch 2

rivastigmine 6 mg capsule 1

rivastigmine 9.5 mg/24hr patch 2

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine 5-10 mg titration pk 2

memantine hcl 10 mg tablet 1

memantine hcl 2 mg/ml solution 2

memantine hcl 5 mg tablet 1

NAMENDA XR 14 MG CAPSULEmemantine hcl 3 ST




NAMENDA XR TITRATION PACKmemantine hcl 3 ST

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

APLENZIN ER 174 MG TABLETbupropion hbr 3 ST





bupropion hcl 100 mg tablet 1QL 60 / 30 DAYS


bupropion hcl 75 mg tablet 1QL 60 / 30 DAYS


bupropion hcl sr 100 mg tablet 1 AL1 At least 18 yrs old

bupropion hcl sr 150 mg tablet 1

QL 60 / 30 DAYS

PA


bupropion hcl sr 200 mg tab 1QL 60 / 30 DAYS


bupropion hcl sr 200 mg tablet 1QL 60 / 30 DAYS


bupropion hcl xl 150 mg tablet 1

QL 30 / 30 DAYS

ST


bupropion hcl xl 300 mg tablet 1

QL 30 / 30 DAYS

ST


chlordiazepo-amitriptyl 5-12.5 1

chlordiazepox-amitriptyl 10-25 1

mirtazapine 15 mg odt 1QL 30 / 30 DAYS


mirtazapine 15 mg tablet 1QL 30 / 30 DAYS




mirtazapine 30 mg tablet 1QL 30 / 30 DAYS






mirtazapine 45 mg tablet 1 AL1 At least 18 yrs old

mirtazapine 7.5 mg tablet 1 AL1 At least 18 yrs old

olanzapine-fluoxetine 12-25 mg 1 ST





perphen-amitrip 2 mg-10 mg tab 1 AL1 At least 18 yrs old





WELLBUTRIN XL 300 MG TABLETbupropion hcl 3

QL 30 / 30 DAYS


MONOAMINE OXIDASE INHIBITORS

EMSAM 12 MG/24 HOURS PATCHselegiline 3



phenelzine sulfate 15 mg tab 1

tranylcypromine sulf 10 mg tab 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR

BRINTELLIX 10 MG TABLETvortioxetine hydrobromide 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST



citalopram hbr 10 mg tablet 1QL 30 / 30 DAYS


citalopram hbr 10 mg/5 ml soln 1 AL1 At least 18 yrs old





desvenlafaxine fum er 100 mg 3QL 1 / 1 DAYS

ST

desvenlafaxine fum er 50 mg 3QL 1 / 1 DAYS

ST

escitalopram 10 mg tablet 1 QL 1 / 1 DAYS



escitalopram oxalate 5 mg/5 ml 1

FETZIMA 20-40 MG TITRATION PAKlevomilnacipran hcl 3

QL 1 / 1 DAYS

ST

FETZIMA ER 120 MG CAPSULElevomilnacipran hcl 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST

fluoxetine 20 mg/5 ml solution 1 AL1 At least 18 yrs old

fluoxetine dr 90 mg capsule 1

QL 4 / 28 DAYS

ST




fluoxetine hcl 10 mg capsule 1 AL1 At least 18 yrs old

fluoxetine hcl 10 mg tablet 1

QL 30 / 30 DAYS

ST



fluoxetine hcl 20 mg tablet 1QL 30 / 30 DAYS



nefazodone hcl 100 mg tablet 1 AL1 At least 18 yrs old





OLEPTRO ER 150 MG TABLETtrazodone hcl 3

QL 30 / 30 DAYS


OLEPTRO ER 300 MG TABLETtrazodone hcl 3

QL 30 / 30 DAYS


paroxetine cr 12.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine cr 25 mg tablet 1 AL1 At least 18 yrs old

paroxetine cr 37.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 12.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 25 mg tablet 1 AL1 At least 18 yrs old

paroxetine er 37.5 mg tablet 1 AL1 At least 18 yrs old

paroxetine hcl 10 mg tablet 1QL 30 / 30 DAYS










sertraline 20 mg/ml oral conc 1 AL1 At least 18 yrs old

sertraline hcl 100 mg tablet 1 AL1 At least 18 yrs old

sertraline hcl 25 mg tablet 1QL 30 / 30 DAYS


sertraline hcl 50 mg tablet 1QL 60 / 30 DAYS


trazodone 100 mg tablet 1 AL1 At least 18 yrs old




TRINTELLIX 10 MG TABLETvortioxetine hydrobromide 3



venlafaxine hcl 100 mg tablet 1 AL1 At least 18 yrs old


venlafaxine hcl 37.5 mg tablet 1 AL1 At least 18 yrs old



venlafaxine hcl er 150 mg cap 1

QL 30 / 30 DAYS

ST


venlafaxine hcl er 150 mg tab 1QL 30 / 30 DAYS


venlafaxine hcl er 225 mg tab 1



venlafaxine hcl er 37.5 mg tab 1QL 30 / 30 DAYS


venlafaxine hcl er 75 mg cap 1

QL 30 / 30 DAYS

ST


venlafaxine hcl er 75 mg tab 1QL 30 / 30 DAYS


VIIBRYD 10 MG TABLETvilazodone hcl 3 ST

VIIBRYD 10-20 MG STARTER PACKvilazodone hcl 3 ST



TRICYCLICS

amitriptyline hcl 10 mg tab 1






amoxapine 100 mg tablet 1




clomipramine 25 mg capsule 3 ST



desipramine 10 mg tablet 1








doxepin 10 mg capsule 1

doxepin 10 mg/ml oral conc 1






elavil 25 mg tablet 3

imipramine hcl 10 mg tablet 1



imipramine pamoate 100 mg cap 1




nortriptyline 10 mg/5 ml sol 1

nortriptyline hcl 10 mg cap 1




SURMONTIL 100 MG CAPSULEtrimipramine maleate 3

TOFRANIL-PM 150 MG CAPSULEimipramine pamoate 3

trimipramine maleate 100 mg cp 1

trimipramine maleate 25 mg cap 1

trimipramine maleate 50 mg cap 1



ANTIEMETICS

ANTIEMETICS, OTHER

AKYNZEO 300-0.5 MG CAPSULEnetupitant/palonosetron hcl 2 QL 1 / 21 DAYS

COMPAZINE 25 MG SUPPOSITORYprochlorperazine 3

compro 25 mg suppository 1

meclizine 12.5 mg tablet 1

meclizine 25 mg tablet 1

metoclopramide 10 mg tablet 1

metoclopramide 10 mg/10 ml sol 1

metoclopramide 5 mg tablet 1

metoclopramide 5 mg/5 ml soln 1

metoclopramide 5 mg/5 ml soln 1

metoclopramide 5 mg/5 ml syrup 1

perphenazine 16 mg tablet 1




phenadoz 12.5 mg suppository 1

phenadoz 25 mg suppository 1

prochlorperazine 10 mg tab 1

prochlorperazine 25 mg supp 1

prochlorperazine 5 mg tablet 1

promethazine 12.5 mg suppos 1

promethazine 25 mg suppository 1

promethazine 50 mg suppository 1

promethazine 50 mg tablet 1

promethegan 12.5 mg suppos 1

promethegan 25 mg suppository 1

promethegan 50 mg suppository 1



EMETOGENIC THERAPY ADJUNCTS

ANZEMET 100 MG TABLETdolasetron mesylate 3

ANZEMET 50 MG TABLETdolasetron mesylate 3

CESAMET 1 MG CAPSULEnabilone 3 ST

EMEND 125 MG CAPSULEaprepitant 2



EMEND TRIPACKaprepitant 2

granisetron hcl 1 mg tablet 1 QL 2 / 1 FILL

ondansetron 4 mg/5 ml solution 1

ondansetron hcl 24 mg tablet 1

ondansetron hcl 4 mg tablet 1 QL 12 / 30 DAYS

ondansetron hcl 8 mg tablet 1 QL 12 / 30 DAYS

ondansetron odt 4 mg tablet 1 QL 12 / 30 DAYS

ondansetron odt 8 mg tablet 1 QL 12 / 30 DAYS

SANCUSO 3.1 MG/24 HR PATCHgranisetron 3

VARUBI 90 MG TABLETrolapitant hcl 2

ZOFRAN 4 MG/5 ML ORAL SOLNondansetron hcl 3

ANTIFUNGALS

ciclodan 0.77% cream 3

ciclopirox 0.77% cream 1

ciclopirox 0.77% gel 1

ciclopirox 0.77% topical susp 1

ciclopirox 1% shampoo 1



ciclopirox 8% solution 1

clotrimazole 1% cream 1

clotrimazole 1% solution 1

clotrimazole 10 mg troche 1

CRESEMBA 186 MG CAPSULEisavuconazonium sulfate 3 PA

DIFLUCAN 40 MG/ML SUSPENSIONfluconazole 3

econazole nitrate 1% cream 1

ECOZA 1% FOAMeconazole nitrate 3

ERTACZO 2% CREAMsertaconazole nitrate 3

EXELDERM 1% CREAMsulconazole nitrate 3

EXELDERM 1% SOLUTIONsulconazole nitrate 3

fluconazole 10 mg/ml susp 1

fluconazole 100 mg tablet 1

fluconazole 150 mg tablet 1 QL 4 / 1 FILL

fluconazole 200 mg tablet 1 PA

fluconazole 40 mg/ml susp 1

fluconazole 50 mg tablet 1

GRIFULVIN V 500 MG TABLETgriseofulvin, microsize 2

griseofulvin 125 mg/5 ml susp 1

griseofulvin micro 500 mg tab 1

griseofulvin ultra 125 mg tab 1

griseofulvin ultra 250 mg tab 1

gynazole 1 2% cream 2

itraconazole 100 mg capsule 1QL 30 / 1 FILL

PA

ketoconazole 2% cream 1

ketoconazole 2% foam 3



ketoconazole 2% shampoo 1

ketoconazole 200 mg tablet 1

ketodan 2% foam 1

LUZU 1% CREAMluliconazole 3

QL 1 / 28 DAYS

ST

naftifine hcl 1% cream 3

naftifine hcl 2% cream 3

NAFTIN 1% GELnaftifine hcl 3

NAFTIN 2% GELnaftifine hcl 3

NOXAFIL 40 MG/ML SUSPENSIONposaconazole 3 AL1 At least 13 yrs old

NOXAFIL DR 100 MG TABLETposaconazole 3 AL1 At least 13 yrs old

nyamyc 100,000 units/gm powder 1

nystatin 100,000 unit/gm cream 1

nystatin 100,000 unit/gm powd 1

nystatin 100,000 unit/ml susp 1

nystatin 100,000 units/gm oint 1

nystatin 150,000,000 units pwd 1


nystatin 500,000 unit oral tab 1

nystatin 500,000 unit/5 ml sus 1


nystatin-triamcinolone ointm 1

nystop 100,000 units/gm powder 1

ONMEL 200 MG TABLETitraconazole 3

ORAVIG 50 MG BUCCAL TABLETmiconazole 3 ST

oxiconazole nitrate 1% cream 3

OXISTAT 1% LOTIONoxiconazole nitrate 3



pedi-dri topical powder 1

PENLAC 8% SOLUTIONciclopirox 3

SPORANOX 10 MG/ML SOLUTIONitraconazole 3

terbinafine hcl 250 mg tablet 1

terconazole 0.4% cream 1

terconazole 0.8% cream 1

terconazole 80 mg suppository 1

voriconazole 200 mg tablet 2 PA

voriconazole 40 mg/ml susp 2 PA

voriconazole 50 mg tablet 2 PA

XOLEGEL 2% GELketoconazole 3 AL1 At least 12 yrs old

ANTIGOUT AGENTS

allopurinol 100 mg tablet 1

allopurinol 300 mg tablet 1

colchicine 0.6 mg tablet 1 QL 4 / 1 DAYS

probenecid 500 mg tablet 1

probenecid-colchicine tabs 1

ULORIC 40 MG TABLETfebuxostat 2

QL 30 / 30 DAYS


ULORIC 80 MG TABLETfebuxostat 2

QL 30 / 30 DAYS


ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine 1 mg/ml am 4

dihydroergotamine 1 mg/ml vl 4

dihydroergotamine 4 mg/ml spry 2 QL 8 / 30 DAYS

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

almotriptan malate 12.5 mg tab 3QL 6 / 1 FILL

ST



almotriptan malate 6.25 mg tab 3QL 6 / 1 FILL

ST

frovatriptan succ 2.5 mg tab 3 ST

naratriptan 1 mg tablet 1QL 9 / 1 FILL

ST

naratriptan 2.5 mg tablet 1QL 9 / 1 FILL

ST

naratriptan hcl 1 mg tablet 1QL 9 / 1 FILL

ST

naratriptan hcl 2.5 mg tablet 1QL 9 / 1 FILL

ST

RELPAX 20 MG TABLETeletriptan hbr 2

RELPAX 40 MG TABLETeletriptan hbr 2

rizatriptan 10 mg odt 1 QL 9 / 1 FILL

rizatriptan 10 mg tablet 1 QL 9 / 1 FILL

rizatriptan 5 mg odt 1 QL 9 / 1 FILL

rizatriptan 5 mg tablet 1 QL 9 / 1 FILL

sumatriptan 20 mg nasal spray 1 QL 6 / 1 FILL

sumatriptan 4 mg/0.5 ml cart 1

sumatriptan 4 mg/0.5 ml inject 2

sumatriptan 5 mg nasal spray 1 QL 6 / 1 FILL

sumatriptan 6 mg/0.5 ml inject 2 QL 1 / 1 FILL

sumatriptan 6 mg/0.5 ml refill 1

sumatriptan 6 mg/0.5 ml syrng 2

sumatriptan 6 mg/0.5 ml vial 1 QL 2.5 / 1 FILL

sumatriptan succ 100 mg tablet 1 QL 9 / 1 FILL





TREXIMET 85-500 MG TABLETsumatriptan succinate/naproxen sodium 3 ST

zolmitriptan 2.5 mg odt 3QL 6 / 1 FILL

ST

zolmitriptan 2.5 mg tablet 3QL 6 / 1 FILL

ST

zolmitriptan 5 mg odt 3QL 3 / 1 FILL

ST

zolmitriptan 5 mg tablet 3QL 3 / 1 FILL

ST

ZOMIG 2.5 MG NASAL SPRAYzolmitriptan 3 ST

ZOMIG 5 MG NASAL SPRAYzolmitriptan 3 ST

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone 25 mg tablet 1

ANTITUBERCULARS

cycloserine 250 mg capsule 2

ethambutol hcl 100 mg tablet 1

ethambutol hcl 400 mg tablet 1

isoniazid 100 mg tablet 1

isoniazid 300 mg tablet 1

isoniazid 50 mg/5 ml solution 1

pyrazinamide 500 mg tablet 1

rifampin 150 mg capsule 1

rifampin 300 mg capsule 1

RIFATER TABLETrifampin/isoniazid/pyrazinamide 2

SIRTURO 100 MG TABLETbedaquiline fumarate 3 PA



TRECATOR 250 MG TABLETethionamide 2

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLETmelphalan 2

HEXALEN 50 MG CAPSULEaltretamine 2

LEUKERAN 2 MG TABLETchlorambucil 2

MATULANE 50 MG CAPSULEprocarbazine hcl 2

MYLERAN 2 MG TABLETbusulfan 2

temozolomide 100 mg capsule 2






ANTIANDROGENS

bicalutamide 50 mg tablet 1

flutamide 125 mg capsule 1

nilutamide 150 mg tablet 2

XTANDI 40 MG CAPSULEenzalutamide 2

QL 4 / 1 DAYS

ST

ZYTIGA 250 MG TABLETabiraterone acetate 2 PA

ANTIANGIOGENIC AGENTS

POMALYST 1 MG CAPSULEpomalidomide 2

QL 21 / 28 DAYS

PA


QL 21 / 28 DAYS

PA




QL 21 / 28 DAYS

PA


QL 21 / 28 DAYS

PA

REVLIMID 10 MG CAPSULElenalidomide 2


REVLIMID 2.5 MG CAPSULElenalidomide 2




ANTIESTROGENS/MODIFIERS

SOLTAMOX 10 MG/5 ML SOLNtamoxifen citrate 2

tamoxifen 10 mg tablet 1

tamoxifen 20 mg tablet 1

ANTIMETABOLITES

capecitabine 150 mg tablet 2 PA

capecitabine 500 mg tablet 2 PA

fluorouracil 2% topical soln 1

fluorouracil 5% cream 1

fluorouracil 5% top solution 1

HYDREA 500 MG CAPSULEhydroxyurea 3

hydroxyurea 500 mg capsule 1

LONSURF 15 MG-6.14 MG TABLETtrifluridine/tipiracil hcl 2

LONSURF 20 MG-8.19 MG TABLETtrifluridine/tipiracil hcl 2

mercaptopurine 50 mg tablet 1



PURIXAN 20 MG/ML ORAL SUSPmercaptopurine 2

ST

AL1 Up to 5 yrs old

ANTINEOPLASTICS, OTHER

FARYDAK 10 MG CAPSULEpanobinostat lactate 2 PA



leucovorin calcium 10 mg tab 1




LYNPARZA 50 MG CAPSULEolaparib 2 PA

LYSODREN 500 MG TABLETmitotane 2

MESNEX 400 MG TABLETmesna 2

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1 mg tablet 1

exemestane 25 mg tablet 2

letrozole 2.5 mg tablet 1

MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TABLETeverolimus 2

QL 30 / 30 DAYS

PA

AFINITOR 2.5 MG TABLETeverolimus 2

QL 30 / 30 DAYS

PA

AFINITOR 5 MG TABLETeverolimus 2

QL 30 / 30 DAYS

PA

AFINITOR 7.5 MG TABLETeverolimus 2

QL 30 / 30 DAYS

PA

AFINITOR DISPERZ 2 MG TABLETeverolimus 2

QL 30 / 30 DAYS

PA




QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

ALECENSA 150 MG CAPSULEalectinib hcl 2

BOSULIF 100 MG TABLETbosutinib 2 PA

BOSULIF 500 MG TABLETbosutinib 2 PA

CABOMETYX 20 MG TABLETcabozantinib s-malate 2



CAPRELSA 100 MG TABLETvandetanib 2 ST

CAPRELSA 300 MG TABLETvandetanib 2 ST

COMETRIQ 100 MG DAILY-DOSE PKcabozantinib s-malate 2 PA

COMETRIQ 140 MG DAILY-DOSE PKcabozantinib s-malate 2 PA

COMETRIQ 60 MG DAILY-DOSE PACKcabozantinib s-malate 2 PA

COTELLIC 20 MG TABLETcobimetinib fumarate 2

ERIVEDGE 150 MG CAPSULEvismodegib 2 PA

GILOTRIF 20 MG TABLETafatinib dimaleate 2



IBRANCE 100 MG CAPSULEpalbociclib 2 PA





ICLUSIG 15 MG TABLETponatinib hcl 2 PA

ICLUSIG 45 MG TABLETponatinib hcl 2 PA

imatinib mesylate 100 mg tab 2 PA

imatinib mesylate 400 mg tab 2 PA

IMBRUVICA 140 MG CAPSULEibrutinib 2 PA

IRESSA 250 MG TABLETgefitinib 2

QL 2 / 1 DAYS

PA

JAKAFI 10 MG TABLETruxolitinib phosphate 2 PA





LENVIMA 10 MG DAILY DOSElenvatinib mesylate 2 PA






MEKINIST 0.5 MG TABLETtrametinib dimethyl sulfoxide 2 PA



MEKINIST 2 MG TABLETtrametinib dimethyl sulfoxide 2 PA

NEXAVAR 200 MG TABLETsorafenib tosylate 2 PA

NINLARO 2.3 MG CAPSULEixazomib citrate 2

NINLARO 3 MG CAPSULEixazomib citrate 2

NINLARO 4 MG CAPSULEixazomib citrate 2

ODOMZO 200 MG CAPSULEsonidegib phosphate 2

SPRYCEL 100 MG TABLETdasatinib 2 PA






STIVARGA 40 MG TABLETregorafenib 2 PA

SUTENT 12.5 MG CAPSULEsunitinib malate 2 ST

SUTENT 25 MG CAPSULEsunitinib malate 2 ST

SUTENT 37.5 MG CAPSULEsunitinib malate 2 ST

SUTENT 50 MG CAPSULEsunitinib malate 2 ST

TAFINLAR 50 MG CAPSULEdabrafenib mesylate 2 PA

TAFINLAR 75 MG CAPSULEdabrafenib mesylate 2 PA

TAGRISSO 40 MG TABLETosimertinib mesylate 2



TAGRISSO 80 MG TABLETosimertinib mesylate 2

TARCEVA 100 MG TABLETerlotinib hcl 2 PA



TASIGNA 150 MG CAPSULEnilotinib hcl 2 PA

TASIGNA 200 MG CAPSULEnilotinib hcl 2 PA

TYKERB 250 MG TABLETlapatinib ditosylate 2 PA

VENCLEXTA 10 MG TABLETvenetoclax 2



VENCLEXTA STARTING PACKvenetoclax 2

VOTRIENT 200 MG TABLETpazopanib hcl 2

XALKORI 200 MG CAPSULEcrizotinib 2 PA

XALKORI 250 MG CAPSULEcrizotinib 2 PA

ZELBORAF 240 MG TABLETvemurafenib 2 PA

ZYDELIG 100 MG TABLETidelalisib 2 PA

ZYDELIG 150 MG TABLETidelalisib 2 PA

ZYKADIA 150 MG CAPSULEceritinib 2 PA

RETINOIDS

tretinoin 10 mg capsule 1



ANTIPARASITICS

ANTIHELMINTHICS

SKLICE 0.5% LOTIONivermectin 2 ST

ANTIPROTOZOALS

ALINIA 100 MG/5 ML SUSPENSIONnitazoxanide 2

ALINIA 500 MG TABLETnitazoxanide 2

chloroquine ph 250 mg tablet 1

chloroquine ph 500 mg tablet 1

COARTEM TABLETSartemether/lumefantrine 2

DARAPRIM 25 MG TABLETpyrimethamine 4 PA

hydroxychloroquine 200 mg tab 1

mefloquine hcl 250 mg tablet 1

PLAQUENIL 200 MG TABLEThydroxychloroquine sulfate 3

quinine sulfate 324 mg capsule 2 PA

PEDICULICIDES/SCABICIDES

elimite 5% cream 3

ELIMITE 5% CREAMpermethrin 3

lindane 1% shampoo 1

permethrin 5% cream 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mes 0.5 mg tab 1

benztropine mes 1 mg tablet 1

benztropine mes 2 mg tablet 1

trihexyphenidyl 2 mg tablet 1

trihexyphenidyl 2 mg/5 ml elx 1



trihexyphenidyl 5 mg tablet 1

ANTIPARKINSON AGENTS, OTHER

amantadine 100 mg capsule 1

amantadine 100 mg tablet 1

amantadine 100 mg/10 ml soln 1

amantadine 50 mg/5 ml solution 1

carbidopa-levodopa-enta 100 mg 1 ST






DOPAMINE AGONISTS

APOKYN 30 MG/3 ML CARTRIDGEapomorphine hcl 4 PA

bromocriptine 2.5 mg tablet 3

NEUPRO 1 MG/24 HR PATCHrotigotine 3 ST






pramipexole 0.125 mg tablet 1




pramipexole 1 mg tablet 1




pramipexole er 0.375 mg tablet 3 ST



pramipexole er 2.25 mg tablet 3

pramipexole er 3 mg tablet 3 ST

pramipexole er 3.75 mg tablet 3


ropinirole hcl 0.25 mg tablet 1

ropinirole hcl 0.5 mg tablet 1

ropinirole hcl 1 mg tablet 1





ropinirole hcl er 12 mg tablet 1





DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa-levo 10-100 mg odt 1



carbidopa-levo er 25-100 tab 1

carbidopa-levo er 50-200 tab 1

carbidopa-levodopa 10-100 tab 1



DUOPA 4.63 MG-20 MG/ML SUSPENScarbidopa/levodopa 3 PA



SINEMET CR 25-100 TABLETcarbidopa/levodopa 3

SINEMET CR 50-200 TABLETcarbidopa/levodopa 3

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT 0.5 MG TABLETrasagiline mesylate 3 ST

AZILECT 1 MG TABLETrasagiline mesylate 3 ST

selegiline hcl 5 mg capsule 1

selegiline hcl 5 mg tablet 1

ZELAPAR 1.25 MG ODT TABLETselegiline hcl 2 ST

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine 10 mg tablet 1





fluphenazine 1 mg tablet 1


fluphenazine 2.5 mg tablet 1

fluphenazine 2.5 mg/5 ml elix 1


fluphenazine 5 mg/ml conc 1

haloperidol 0.5 mg tablet 1

haloperidol 1 mg tablet 1





haloperidol lac 2 mg/ml conc 1



loxapine 10 mg capsule 1




pimozide 1 mg tablet 2

pimozide 2 mg tablet 2

thioridazine 10 mg tablet 1




thiothixene 1 mg capsule 1




trifluoperazine 1 mg tablet 1




2ND GENERATION/ATYPICAL

ABILIFY DISCMELT 15 MG TABLETaripiprazole 3 QL 30 / 30 DAYS

aripiprazole 1 mg/ml solution 3 QL 30 / 30 DAYS

aripiprazole 10 mg tablet 3 QL 30 / 30 DAYS






aripiprazole odt 10 mg tablet 3 QL 30 / 30 DAYS

aripiprazole odt 15 mg tablet 3 QL 30 / 30 DAYS



FANAPT 1 MG TABLETiloperidone 3 ST







FANAPT TITRATION PACKiloperidone 3 ST

LATUDA 120 MG TABLETlurasidone hcl 3 ST





NUPLAZID 17 MG TABLETpimavanserin tartrate 4

olanzapine 10 mg tablet 1


olanzapine 2.5 mg tablet 1



olanzapine 7.5 mg tablet 1

olanzapine odt 10 mg tablet 1






paliperidone er 1.5 mg tablet 3 ST

paliperidone er 3 mg tablet 3 ST



quetiapine er 150 mg tablet 3 ST





quetiapine fumarate 100 mg tab 1






REXULTI 0.25 MG TABLETbrexpiprazole 3

QL 1 / 1 DAYS

ST

REXULTI 0.5 MG TABLETbrexpiprazole 3

QL 1 / 1 DAYS

ST

REXULTI 1 MG TABLETbrexpiprazole 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST

risperidone 0.25 mg odt 1



risperidone 0.25 mg tablet 1

risperidone 0.5 mg odt 1

risperidone 0.5 mg tablet 1

risperidone 1 mg odt 1

risperidone 1 mg tablet 1

risperidone 1 mg/ml solution 1







SAPHRIS 10 MG TAB SL BLK CHERYasenapine maleate 3

QL 2 / 1 DAYS

ST


SAPHRIS 10 MG TAB SUBLINGUALasenapine maleate 3

QL 2 / 1 DAYS

ST


SAPHRIS 2.5 MG TAB SL BLK CHRYasenapine maleate 3

QL 2 / 1 DAYS

ST


SAPHRIS 5 MG TAB SL BLK CHERRYasenapine maleate 3

QL 2 / 1 DAYS

ST


SAPHRIS 5 MG TABLET SUBLINGUALasenapine maleate 3

QL 2 / 1 DAYS

ST


VRAYLAR 1.5 MG CAPSULEcariprazine hcl 4

VRAYLAR 1.5 MG-3 MG PACKcariprazine hcl 4

VRAYLAR 3 MG CAPSULEcariprazine hcl 4



VRAYLAR 4.5 MG CAPSULEcariprazine hcl 4

VRAYLAR 6 MG CAPSULEcariprazine hcl 4

ziprasidone hcl 20 mg capsule 1 QL 60 / 1 FILL




TREATMENT-RESISTANT

clozapine 100 mg tablet 1




clozapine odt 100 mg tablet 3

clozapine odt 12.5 mg tablet 3




VERSACLOZ 50 MG/ML SUSPENSIONclozapine 3

QL 18 / 1 DAYS

ST

ANTISPASTICITY AGENTS

baclofen 10 mg tablet 1

baclofen 20 mg tablet 1

tizanidine hcl 2 mg tablet 1

tizanidine hcl 4 mg tablet 1

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

valganciclovir 450 mg tablet 2 ST

valganciclovir hcl 50 mg/ml 2 ST



ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 10 mg tab 4

BARACLUDE 0.05 MG/ML SOLUTIONentecavir 2

entecavir 0.5 mg tablet 2

entecavir 1 mg tablet 2

EPIVIR HBV 25 MG/5 ML SOLNlamivudine 2

lamivudine 100 mg tablet 2

lamivudine hbv 100 mg tablet 2

TYZEKA 600 MG TABLETtelbivudine 2

ANTI-HEPATITIS C (HCV) AGENTS

DAKLINZA 30 MG TABLETdaclatasvir dihydrochloride 4

DAKLINZA 60 MG TABLETdaclatasvir dihydrochloride 4

DAKLINZA 90 MG TABLETdaclatasvir dihydrochloride 4 PA

EPCLUSA 400 MG-100 MG TABLETsofosbuvir/velpatasvir 4

HARVONI 90-400 MG TABLETledipasvir/sofosbuvir 4 PA

INTRON A 10 MILLION UNITS VIALinterferon alfa-2b,recomb. 4 PA

INTRON A 18 MILLION UNIT/3 MLinterferon alfa-2b,recomb. 4 PA


INTRON A 25 MILLION UNIT/2.5MLinterferon alfa-2b,recomb. 4 PA


OLYSIO 150 MG CAPSULEsimeprevir sodium 4 PA

PEGASYS 180 MCG/0.5 ML SYRINGEpeginterferon alfa-2a 4 PA



PEGASYS 180 MCG/ML VIALpeginterferon alfa-2a 4 PA

PEGASYS PROCLICK 135 MCG/0.5peginterferon alfa-2a 4 PA

PEGASYS PROCLICK 180 MCG/0.5peginterferon alfa-2a 4 PA

REBETOL 200 MG CAPSULEribavirin 4 PA

REBETOL 40 MG/ML SOLUTIONribavirin 4 PA

ribasphere 200 mg capsule 4 PA

ribasphere 200 mg tablet 4 PA



RIBASPHERE RIBAPAK 200-400 MGribavirin 4 PA




RIBATAB 400-400 MG DOSEPACKribavirin 4 PA



ribavirin 200 mg capsule 4 PA

ribavirin 200 mg tablet 4 PA

SOVALDI 400 MG TABLETsofosbuvir 4 PA

TECHNIVIE DOSE PACKombitasvir/paritaprevir/ritonavir 4

VIEKIRA PAKombitasvir/paritaprevir/ritonavir/dasabuvir sodium 4 PA



ZEPATIER 50-100 MG TABLETelbasvir/grazoprevir 4

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA TABLETelvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 2

ISENTRESS 100 MG POWDER PACKETraltegravir potassium 2

QL 60 / 30 DAYS

ST


ISENTRESS 100 MG TABLET CHEWraltegravir potassium 2

QL 60 / 30 DAYS

ST


ISENTRESS 25 MG TABLET CHEWraltegravir potassium 2

QL 60 / 30 DAYS

ST


ISENTRESS 400 MG TABLETraltegravir potassium 2

QL 60 / 30 DAYS

ST


STRIBILD TABLETelvitegravir/cobicistat/emtricitabine/tenofovir disoproxil 2

TIVICAY 10 MG TABLETdolutegravir sodium 2



VITEKTA 150 MG TABLETelvitegravir 2

QL 1 / 1 DAYS

ST

VITEKTA 85 MG TABLETelvitegravir 2

QL 1 / 1 DAYS

ST

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

ATRIPLA TABLETefavirenz/emtricitabine/tenofovir disoproxil fumarate 2 AL1 At least 18 yrs old

COMPLERA TABLETemtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate 2 PA



EDURANT 25 MG TABLETrilpivirine hcl 2

INTELENCE 100 MG TABLETetravirine 2 ST



nevirapine 200 mg tablet 1

nevirapine 50 mg/5 ml susp 2

nevirapine er 100 mg tablet 3

nevirapine er 400 mg tablet 3

ODEFSEY TABLETemtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate 2

RESCRIPTOR 100 MG TABLETdelavirdine mesylate 2

RESCRIPTOR 200 MG TABLETdelavirdine mesylate 2

SUSTIVA 200 MG CAPSULEefavirenz 2

SUSTIVA 50 MG CAPSULEefavirenz 2

SUSTIVA 600 MG TABLETefavirenz 2

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

abacavir 300 mg tablet 2

abacavir-lamivudine 600-300 mg 2

abacavir-lamivudine-zidov tab 2

DESCOVY 200-25 MG TABLETemtricitabine/tenofovir alafenamide fumarate 2

didanosine dr 125 mg capsule 1




EMTRIVA 10 MG/ML SOLUTIONemtricitabine 2 ST



EMTRIVA 200 MG CAPSULEemtricitabine 2

QL 30 / 30 DAYS

ST

lamivudine 10 mg/ml oral soln 2



lamivudine-zidovudine tablet 2

stavudine 1 mg/ml solution 1

stavudine 15 mg capsule 1




TRUVADA 100 MG-150 MG TABLETemtricitabine/tenofovir disoproxil fumarate 2




VIDEX 2 GM PEDIATRIC SOLNdidanosine 3

VIDEX 4 GM PEDIATRIC SOLNdidanosine 3

VIREAD 150 MG TABLETtenofovir disoproxil fumarate 2




VIREAD POWDERtenofovir disoproxil fumarate 2

ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate 2

zidovudine 100 mg capsule 1



zidovudine 300 mg tablet 1

zidovudine 50 mg/5 ml syrup 1

ANTI-HIV AGENTS, OTHER

FUZEON 90 MG VIALenfuvirtide 3 PA

PREZCOBIX 800 MG-150 MG TABLETdarunavir ethanolate/cobicistat 2 QL 1 / 1 DAYS

SELZENTRY 150 MG TABLETmaraviroc 2 ST

SELZENTRY 300 MG TABLETmaraviroc 2 ST

TRIUMEQ TABLETabacavir sulfate/dolutegravir sodium/lamivudine 2 QL 1 / 1 DAYS

TYBOST 150 MG TABLETcobicistat 2 PA

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 100 MG/ML SOLUTIONtipranavir/vitamin e tpgs 2

APTIVUS 250 MG CAPSULEtipranavir 2

CRIXIVAN 200 MG CAPSULEindinavir sulfate 2

CRIXIVAN 400 MG CAPSULEindinavir sulfate 2

EVOTAZ 300 MG-150 MG TABLETatazanavir sulfate/cobicistat 2 QL 1 / 1 DAYS

INVIRASE 200 MG CAPSULEsaquinavir mesylate 2

INVIRASE 500 MG TABLETsaquinavir mesylate 2

KALETRA 100-25 MG TABLETlopinavir/ritonavir 2

KALETRA 200-50 MG TABLETlopinavir/ritonavir 2

KALETRA 80 MG-20 MG/ML SOLNlopinavir/ritonavir 2

LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium 2 ST



LEXIVA 700 MG TABLETfosamprenavir calcium 2

QL 30 / 30 DAYS

ST

NORVIR 100 MG SOFTGEL CAPritonavir 2

NORVIR 100 MG TABLETritonavir 2

NORVIR 80 MG/ML SOLUTIONritonavir 2

PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate 2 ST

PREZISTA 150 MG TABLETdarunavir ethanolate 2 ST




REYATAZ 150 MG CAPSULEatazanavir sulfate 2

QL 2 / 1 DAYS

ST

REYATAZ 200 MG CAPSULEatazanavir sulfate 2

QL 2 / 1 DAYS

ST

REYATAZ 300 MG CAPSULEatazanavir sulfate 2 ST

REYATAZ 50 MG POWDER PACKETatazanavir sulfate 2 ST

VIRACEPT 250 MG TABLETnelfinavir mesylate 2

VIRACEPT 625 MG TABLETnelfinavir mesylate 2

ANTI-INFLUENZA AGENTS

RELENZA 5 MG DISKHALERzanamivir 2

rimantadine hcl 100 mg tablet 1

TAMIFLU 30 MG CAPSULEoseltamivir phosphate 2




TAMIFLU 6 MG/ML SUSPENSIONoseltamivir phosphate 2


ANTIHERPETIC AGENTS

acyclovir 200 mg capsule 1

acyclovir 200 mg/5 ml susp 1

acyclovir 400 mg tablet 1

acyclovir 5% ointment 2

acyclovir 800 mg tablet 1

ALFERON N 5 MILLION UNITS VIALinterferon alfa-n3 4

famciclovir 125 mg tablet 1

famciclovir 250 mg tablet 1

famciclovir 500 mg tablet 1 QL 21 / 1 FILL

valacyclovir hcl 1 gram tablet 1 QL 30 / 30 DAYS

valacyclovir hcl 500 mg tablet 1 QL 30 / 30 DAYS

ZOVIRAX 5% CREAMacyclovir 2

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 10 mg tablet 1




buspirone hcl 7.5 mg tablet 1

BENZODIAZEPINES

alprazolam 0.25 mg tablet 1

alprazolam 0.5 mg tablet 1

alprazolam 1 mg tablet 1

alprazolam 1 mg/ml oral conc 3

alprazolam 2 mg tablet 1



alprazolam er 0.5 mg tablet 1

alprazolam er 1 mg tablet 1



alprazolam odt 0.25 mg tab 1

alprazolam odt 0.5 mg tab 1

alprazolam odt 1 mg tab 1

alprazolam odt 2 mg tab 1

alprazolam xr 0.5 mg tablet 1

alprazolam xr 1 mg tablet 1



chlordiazepoxide 10 mg capsule 1



clonazepam 0.125 mg dis tab 1

clonazepam 0.25 mg odt 1

clonazepam 0.5 mg dis tablet 1

clonazepam 0.5 mg tablet 1

clonazepam 1 mg dis tablet 1

clonazepam 1 mg tablet 1

clonazepam 2 mg odt 1

clonazepam 2 mg tablet 1

clorazepate 15 mg tablet 1

clorazepate 3.75 mg tablet 1

clorazepate 7.5 mg tablet 1

diazepam 10 mg tablet 1



diazepam 5 mg/5 ml solution 1

diazepam 5 mg/ml oral conc 1



lorazepam 0.5 mg tablet 1

lorazepam 1 mg tablet 1

lorazepam 2 mg tablet 1

lorazepam 2 mg/ml oral concent 1

lorazepam intensol 2 mg/ml 1

oxazepam 10 mg capsule 1



BIPOLAR AGENTS

MOOD STABILIZERS

lithium 8 meq/5 ml solution 1

lithium carbonate 150 mg cap 1


lithium carbonate 300 mg tab 1


lithium carbonate er 300 mg tb 1

lithium carbonate er 450 mg tb 1

LITHOBID ER 300 MG TABLETlithium carbonate 3

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 100 mg tablet 1



ACTOPLUS MET XR 15-1,000 MG TBpioglitazone hcl/metformin hcl 2

QL 30 / 30 DAYS

ST

ACTOPLUS MET XR 30-1,000 MG TBpioglitazone hcl/metformin hcl 2

QL 30 / 30 DAYS

ST

alogliptin 12.5 mg tablet 3 ST

alogliptin 25 mg tablet 3 ST

alogliptin 6.25 mg tablet 3 ST



alogliptin-metformin 12.5-1000 3 ST

alogliptin-metformin 12.5-500 3 ST

AVANDAMET 2 MG-1,000 MG TABrosiglitazone maleate/metformin hcl 3 ST

AVANDIA 2 MG TABLETrosiglitazone maleate 3

QL 30 / 30 DAYS

ST

AVANDIA 4 MG TABLETrosiglitazone maleate 3

QL 30 / 30 DAYS

ST

BYDUREON 2 MG PEN INJECTexenatide microspheres 2 ST

BYDUREON 2 MG VIALexenatide microspheres 2 ST

BYETTA 10 MCG DOSE PEN INJexenatide 2 ST

BYETTA 5 MCG DOSE PEN INJexenatide 2 ST

CYCLOSET 0.8 MG TABLETbromocriptine mesylate 3 PA

FARXIGA 10 MG TABLETdapagliflozin propanediol 3

QL 1 / 1 DAYS

ST

FARXIGA 5 MG TABLETdapagliflozin propanediol 3

QL 1 / 1 DAYS

ST

glimepiride 1 mg tablet 1



glipizide 10 mg tablet 1

glipizide 5 mg tablet 1

glipizide er 10 mg tablet 1

glipizide er 2.5 mg tablet 1

glipizide er 5 mg tablet 1

glipizide xl 10 mg tablet 1

glipizide xl 2.5 mg tablet 1

glipizide xl 5 mg tablet 1



glipizide-metformin 2.5-250 mg 1

glipizide-metformin 2.5-500 mg 1

glipizide-metformin 5-500 mg 1

GLUCOPHAGE 1,000 MG TABLETmetformin hcl 3

glyburid-metformin 1.25-250 mg 1

glyburide 2.5 mg tablet 1

glyburide 5 mg tablet 1

glyburide-metformin 2.5-500 mg 1

glyburide-metformin 5-500 mg 1

GLYXAMBI 10 MG-5 MG TABLETempagliflozin/linagliptin 3

QL 1 / 1 DAYS

ST

GLYXAMBI 25 MG-5 MG TABLETempagliflozin/linagliptin 3

QL 1 / 1 DAYS

ST

INVOKANA 100 MG TABLETcanagliflozin 2 ST

INVOKANA 300 MG TABLETcanagliflozin 2 ST

JANUMET 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST

JANUMET 50-500 MG TABLETsitagliptin phosphate/metformin hcl 2 ST

JANUMET XR 100-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST

JANUMET XR 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST

JANUMET XR 50-500 MG TABLETsitagliptin phosphate/metformin hcl 2 ST

JANUVIA 100 MG TABLETsitagliptin phosphate 2 ST



JARDIANCE 10 MG TABLETempagliflozin 3

QL 1 / 1 DAYS

ST



JARDIANCE 25 MG TABLETempagliflozin 3

QL 1 / 1 DAYS

ST

JENTADUETO 2.5 MG-1000 MG TABlinagliptin/metformin hcl 2

QL 2 / 1 DAYS

ST


QL 2 / 1 DAYS

ST


QL 2 / 1 DAYS

ST

KOMBIGLYZE XR 2.5-1,000 MG TABsaxagliptin hcl/metformin hcl 3 ST

KOMBIGLYZE XR 5-1,000 MG TABsaxagliptin hcl/metformin hcl 3 ST

KOMBIGLYZE XR 5-500 MG TABLETsaxagliptin hcl/metformin hcl 3 ST

metformin er 1,000 mg osm-tab 1

metformin hcl 1,000 mg tablet 1

metformin hcl 500 mg tablet 1

metformin hcl 850 mg tablet 1

metformin hcl er 500 mg osm-tb 1

metformin hcl er 500 mg tablet 1

metformin hcl er 750 mg tablet 1

miglitol 100 mg tablet 3



nateglinide 120 mg tablet 1 ST

nateglinide 60 mg tablet 1 ST

ONGLYZA 2.5 MG TABLETsaxagliptin hcl 3 ST

ONGLYZA 5 MG TABLETsaxagliptin hcl 3 ST

pioglitazone hcl 15 mg tablet 1QL 30 / 30 DAYS

ST




ST


ST

pioglitazone-glimepiride 30-2 1 ST

pioglitazone-glimepiride 30-4 1 ST

pioglitazone-metformin 15-500 1QL 30 / 30 DAYS

ST

pioglitazone-metformin 15-850 1QL 30 / 30 DAYS

ST

PRECOSE 25 MG TABLETacarbose 3

repaglinide 0.5 mg tablet 1 ST

repaglinide 1 mg tablet 1 ST

repaglinide 2 mg tablet 1 ST

RIOMET 500 MG/5 ML SOLUTIONmetformin hcl 3

SYMLINPEN 120 PEN INJECTORpramlintide acetate 2 ST

SYMLINPEN 60 PEN INJECTORpramlintide acetate 2 ST

SYNJARDY 12.5-1,000 MG TABLETempagliflozin/metformin hcl 3

SYNJARDY 12.5-500 MG TABLETempagliflozin/metformin hcl 3

SYNJARDY 5-1,000 MG TABLETempagliflozin/metformin hcl 3

SYNJARDY 5-500 MG TABLETempagliflozin/metformin hcl 3

TRADJENTA 5 MG TABLETlinagliptin 2 ST

TRULICITY 0.75 MG/0.5 ML PENdulaglutide 3

QL 4 / 28 DAYS

ST



TRULICITY 1.5 MG/0.5 ML PENdulaglutide 3

QL 4 / 28 DAYS

ST

VICTOZA 2-PAK 18 MG/3 ML PENliraglutide 2 ST

VICTOZA 3-PAK 18 MG/3 ML PENliraglutide 2 ST

XIGDUO XR 10 MG-1,000 MG TABdapagliflozin propanediol/metformin hcl 3

QL 1 / 1 DAYS

ST

XIGDUO XR 10 MG-500 MG TABLETdapagliflozin propanediol/metformin hcl 3

QL 1 / 1 DAYS

ST

XIGDUO XR 5 MG-1,000 MG TABLETdapagliflozin propanediol/metformin hcl 3

QL 2 / 1 DAYS

ST

XIGDUO XR 5 MG-500 MG TABLETdapagliflozin propanediol/metformin hcl 3

QL 2 / 1 DAYS

ST

GLYCEMIC AGENTS

GLUCAGON 1 MG EMERGENCY KITglucagon,human recombinant 2

INSULINS

APIDRA 100 UNITS/ML VIALinsulin glulisine 3

QL 40 / 28 DAYS

ST

APIDRA SOLOSTAR 100 UNITS/MLinsulin glulisine 3

QL 30 / 28 DAYS

ST

BASAGLAR 100 UNIT/ML KWIKPENinsulin glargine,human recombinant analog 2

HUMALOG 100 UNITS/ML CARTRIDGEinsulin lispro 2 QL 30 / 28 DAYS

HUMALOG 100 UNITS/ML KWIKPENinsulin lispro 2 QL 40 / 28 DAYS

HUMALOG 100 UNITS/ML VIALinsulin lispro 2 QL 40 / 28 DAYS

HUMALOG 200 UNITS/ML KWIKPENinsulin lispro 2

HUMALOG MIX 50-50 KWIKPENinsulin lispro protamine and insulin lispro 2 QL 30 / 28 DAYS



HUMALOG MIX 50-50 VIALinsulin lispro protamine and insulin lispro 2 QL 40 / 28 DAYS

HUMALOG MIX 75-25 KWIKPENinsulin lispro protamine and insulin lispro 2 QL 30 / 28 DAYS

HUMALOG MIX 75-25 VIALinsulin lispro protamine and insulin lispro 2 QL 40 / 28 DAYS

HUMULIN R 500 UNITS/ML KWIKPENinsulin regular, human 2 QL 40 / 28 day(s)

HUMULIN R 500 UNITS/ML VIALinsulin regular, human 2 QL 40 / 28 DAYS

LANTUS 100 UNITS/ML VIALinsulin glargine,human recombinant analog 2 QL 40 / 28 DAYS

LANTUS SOLOSTAR 100 UNITS/MLinsulin glargine,human recombinant analog 2 QL 30 / 28 DAYS

LEVEMIR 100 UNITS/ML VIALinsulin detemir 3

QL 40 / 28 DAYS

ST

LEVEMIR FLEXPEN 100 UNITS/MLinsulin detemir 3

QL 30 / 28 DAYS

ST

LEVEMIR FLEXTOUCH 100 UNITS/MLinsulin detemir 3

QL 30 / 28 DAYS

ST

NOVOLOG 100 UNIT/ML CARTRIDGEinsulin aspart 2 QL 40 / 28 DAYS

NOVOLOG 100 UNIT/ML VIALinsulin aspart 2 QL 40 / 28 DAYS

NOVOLOG 100 UNITS/ML FLEXPENinsulin aspart 2 QL 30 / 28 DAYS

NOVOLOG MIX 70-30 FLEXPEN SYRNinsulin aspart protamine human/insulin aspart 2

NOVOLOG MIX 70-30 VIALinsulin aspart protamine human/insulin aspart 2

TOUJEO SOLOSTAR 300 UNITS/MLinsulin glargine,human recombinant analog 3

QL 7.5 / 30 DAYS

ST

TRESIBA FLEXTOUCH 100 UNITS/MLinsulin degludec 3

TRESIBA FLEXTOUCH 200 UNITS/MLinsulin degludec 3



BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

COUMADIN 3 MG TABLETwarfarin sodium 3

ELIQUIS 2.5 MG TABLETapixaban 2 QL 2 / 1 DAYS

ELIQUIS 5 MG TABLETapixaban 2 QL 2 / 1 DAYS

enoxaparin 100 mg/ml syringe 4 MDS1 14 / 1 DAYS

enoxaparin 120 mg/0.8 ml syr 4 MDS1 14 / 1 DAYS

enoxaparin 150 mg/ml syringe 4 MDS1 14 / 1 DAYS


enoxaparin 300 mg/3 ml vial 4




fondaparinux 10 mg/0.8 ml syr 4 PA

fondaparinux 2.5 mg/0.5 ml syr 4 PA

fondaparinux 5 mg/0.4 ml syr 4 PA

fondaparinux 7.5 mg/0.6 ml syr 4 PA

FRAGMIN 10,000 UNITS/ML SYRINGdalteparin sodium,porcine 4 PA

FRAGMIN 12,500 UNITS/0.5 MLdalteparin sodium,porcine 4 PA



FRAGMIN 2,500 UNITS/0.2 ML SYRdalteparin sodium,porcine 4 PA

FRAGMIN 25,000 UNITS/ML VIALdalteparin sodium,porcine 4 PA





FRAGMIN 95,000 UNITS/3.8 ML VLdalteparin sodium,porcine 4 PA

jantoven 1 mg tablet 1



jantoven 2.5 mg tablet 1





jantoven 7.5 mg tablet 1

PRADAXA 110 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 day(s)

PRADAXA 150 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 DAYS

PRADAXA 75 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 DAYS

warfarin sodium 1 mg tablet 1



warfarin sodium 2.5 mg tablet 1





warfarin sodium 7.5 mg tablet 1

XARELTO 10 MG TABLETrivaroxaban 2



XARELTO STARTER PACKrivaroxaban 2



BLOOD FORMATION MODIFIERS

LEUKINE 250 MCG VIALsargramostim 2

NEULASTA 6 MG/0.6 ML SYRINGEpegfilgrastim 2 PA

NEUPOGEN 300 MCG/0.5 ML SYRfilgrastim 2

NEUPOGEN 300 MCG/ML VIALfilgrastim 2

NEUPOGEN 480 MCG/0.8 ML SYRfilgrastim 2

NEUPOGEN 480 MCG/1.6 ML VIALfilgrastim 2

PROMACTA 12.5 MG TABLETeltrombopag olamine 4 PA

PROMACTA 25 MG TABLETeltrombopag olamine 4 PA



ZARXIO 300 MCG/0.5 ML SYRINGEfilgrastim-sndz 2

ZARXIO 480 MCG/0.8 ML SYRINGEfilgrastim-sndz 2

COAGULANTS

tranexamic acid 650 mg tablet 3 PA

PLATELET MODIFYING AGENTS

aspirin-dipyridam er 25-200 mg 3 ST

clopidogrel 300 mg tablet 1

clopidogrel 75 mg tablet 1

dipyridamole 25 mg tablet 1



EFFIENT 10 MG TABLETprasugrel hcl 2

QL 30 / 1 FILL

PA



EFFIENT 5 MG TABLETprasugrel hcl 2

QL 30 / 1 FILL

PA

ZONTIVITY 2.08 MG TABLETvorapaxar sulfate 3 PA

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine 0.1 mg/day patch 1 QL 4 / 28 DAYS



clonidine hcl 0.1 mg tablet 1



guanfacine 1 mg tablet 1

guanfacine 2 mg tablet 1

methyldopa 250 mg tablet 1

methyldopa 500 mg tablet 1

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 1 mg tab 1 QL 30 / 30 DAYS




prazosin 1 mg capsule 1



terazosin 1 mg capsule 1






ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 16 mg tb 3

candesartan cilexetil 32 mg tb 3

candesartan cilexetil 4 mg tab 3

candesartan cilexetil 8 mg tab 3

irbesartan 150 mg tablet 1



losartan potassium 100 mg tab 1 QL 30 / 30 DAYS



olmesartan medoxomil 20 mg tab 2



telmisartan 20 mg tablet 1



valsartan 160 mg tablet 1




ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACEON 8 MG TABLETperindopril erbumine 3

benazepril hcl 10 mg tablet 1




captopril 100 mg tablet 1

captopril 12.5 mg tablet 1





enalapril maleate 10 mg tab 1

enalapril maleate 2.5 mg tab 1

enalapril maleate 20 mg tab 1

enalapril maleate 5 mg tablet 1

fosinopril sodium 10 mg tab 1



lisinopril 10 mg tablet 1

lisinopril 2.5 mg tablet 1





moexipril hcl 15 mg tablet 1

moexipril hcl 7.5 mg tablet 1

perindopril erbumine 2 mg tab 1



quinapril 10 mg tablet 1




ramipril 1.25 mg capsule 1

ramipril 10 mg capsule 1

ramipril 2.5 mg capsule 1

ramipril 5 mg capsule 1

trandolapril 1 mg tablet 1





ANTIARRHYTHMICS

amiodarone hcl 100 mg tablet 1



CORDARONE 200 MG TABLETamiodarone hcl 3

disopyramide 100 mg capsule 1

disopyramide 150 mg capsule 1

flecainide acetate 100 mg tab 1



mexiletine 150 mg capsule 1



MULTAQ 400 MG TABLETdronedarone hcl 2

QL 2 / 1 DAYS

PA

PACERONE 100 MG TABLETamiodarone hcl 1

pacerone 200 mg tablet 1

PACERONE 400 MG TABLETamiodarone hcl 1

propafenone hcl 150 mg tablet 1

propafenone hcl 225 mg tab 1

propafenone hcl 300 mg tab 1

propafenone hcl er 225 mg cap 1



quinidine sulfate 200 mg tab 1

quinidine sulfate 300 mg tab 1

sorine 120 mg tablet 1






sotalol 120 mg tablet 1




sotalol af 120 mg tablet 1



SOTYLIZE 5 MG/ML ORAL SOLUTIONsotalol hcl 3

QL 3840 / 30 DAYS

ST

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol 200 mg capsule 1

acebutolol 400 mg capsule 1

atenolol 100 mg tablet 1



betaxolol 10 mg tablet 1

betaxolol 20 mg tablet 1

bisoprolol fumarate 10 mg tab 1

bisoprolol fumarate 5 mg tab 1

BYSTOLIC 10 MG TABLETnebivolol hcl 3

BYSTOLIC 2.5 MG TABLETnebivolol hcl 3



carvedilol 12.5 mg tablet 1

carvedilol 25 mg tablet 1



COREG CR 10 MG CAPSULEcarvedilol phosphate 3 ST






labetalol hcl 100 mg tablet 1



LEVATOL 20 MG TABLETpenbutolol sulfate 2

metoprolol succ er 100 mg tab 1




metoprolol tartrate 100 mg tab 1


metoprolol tartrate 37.5 mg tb 1



nadolol 20 mg tablet 1



pindolol 10 mg tablet 1

pindolol 5 mg tablet 1

propranolol 10 mg tablet 1


propranolol 20 mg/5 ml soln 1


propranolol 40 mg/5 ml soln 1



propranolol er 120 mg capsule 1






timolol maleate 10 mg tablet 1



CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC 90 MG TABLETnifedipine 3

afeditab cr 30 mg tablet 1

afeditab cr 60 mg tablet 1

amlodipine besylate 10 mg tab 1

amlodipine besylate 2.5 mg tab 1

amlodipine besylate 5 mg tab 1

CARDIZEM LA 120 MG TABLETdiltiazem hcl 3

cartia xt 120 mg capsule 1




dilt xr 120 mg capsule 1



dilt-cd 120 mg capsule 3



dilt-cd er 300 mg capsule 3

diltia xt 120 mg capsule 3



diltiazem 120 mg tablet 1

diltiazem 12hr er 120 mg cap 1





diltiazem 24hr cd 120 mg cap 1













diltiazem er 120 mg capsule 1




diltiazem er 180 mg tablet 1






diltiazem hcl er 120 mg cap 1








diltzac er 120 mg capsule 3





felodipine er 10 mg tablet 1

felodipine er 2.5 mg tablet 1

felodipine er 5 mg tablet 1

matzim la 180 mg tablet 1





nifedical xl 30 mg tablet 1

nifedical xl 60 mg tablet 1

nifedipine 10 mg capsule 1

nifedipine 20 mg capsule 1

nifedipine er 30 mg tablet 1






nisoldipine er 17 mg tablet 3

nisoldipine er 25.5 mg tablet 3




nisoldipine er 8.5 mg tablet 3

PROCARDIA 10 MG CAPSULEnifedipine 3

PROCARDIA XL 30 MG TABLETnifedipine 3



taztia xt 120 mg capsule 1





TIAZAC ER 420 MG CAPSULEdiltiazem hcl 3

verapamil 120 mg tablet 1

verapamil 360 mg cap pellet 1



verapamil er 120 mg capsule 1

verapamil er 120 mg tablet 1





verapamil er pm 100 mg capsule 1



verapamil sr 120 mg capsule 1



CARDIOVASCULAR AGENTS, OTHER

amiloride hcl-hctz 5-50 mg tab 1

amlod-valsa-hctz 10-160-12.5mg 2

amlod-valsa-hctz 10-160-25 mg 2


amlod-valsa-hctz 5-160-12.5 mg 2


amlodipine-atorvast 10-10 mg 1 QL 30 / 30 DAYS






amlodipine-atorvast 2.5-10 mg 1 QL 30 / 30 DAYS







amlodipine-benazepril 10-20 mg 1


amlodipine-benazepril 2.5-10 1




amlodipine-olmesartan 10-20 mg 2 ST




amlodipine-valsartan 10-160 mg 1QL 30 / 30 DAYS

ST


ST


ST


ST



atenolol-chlorthalidone 100-25 1

atenolol-chlorthalidone 50-25 1

benazepril-hctz 10-12.5 mg tab 1


benazepril-hctz 20-25 mg tab 1


bisoprolol-hctz 10-6.25 mg tab 1

bisoprolol-hctz 2.5-6.25 mg tb 1

bisoprolol-hctz 5-6.25 mg tab 1

candesartan-hctz 16-12.5 mg tb 3

candesartan-hctz 32-12.5 mg tb 3

candesartan-hctz 32-25 mg tab 3 QL 1 / 1 DAYS

captopril-hctz 25-15 mg tablet 1




clorpres 0.1-15 tablet 1



CORLANOR 5 MG TABLETivabradine hcl 3 PA

CORLANOR 7.5 MG TABLETivabradine hcl 3 PA

digitek 125 mcg tablet 1

digitek 250 mcg tablet 1

digox 125 mcg tablet 1

digox 250 mcg tablet 1

digoxin 0.05 mg/ml solution 2

digoxin 0.125 mg tablet 1

digoxin 0.25 mg tablet 1

digoxin 125 mcg tablet 1

digoxin 250 mcg tablet 1



enalapril-hctz 10-25 mg tablet 1

enalapril-hctz 5-12.5 mg tab 1

ENTRESTO 24 MG-26 MG TABLETsacubitril/valsartan 3

QL 2 / 1 DAYS

PA


QL 2 / 1 DAYS

PA


QL 2 / 1 DAYS

PA

fosinopril-hctz 10-12.5 mg tab 1

fosinopril-hctz 20-12.5 mg tab 1

irbesartan-hctz 150-12.5 mg tb 1 QL 30 / 30 DAYS

irbesartan-hctz 300-12.5 mg tb 1 QL 30 / 30 DAYS

lisinopril-hctz 10-12.5 mg tab 1

lisinopril-hctz 20-12.5 mg tab 1

lisinopril-hctz 20-25 mg tab 1

losartan-hctz 100-12.5 mg tab 1 QL 30 / 30 DAYS

losartan-hctz 100-25 mg tab 1 QL 30 / 30 DAYS

losartan-hctz 50-12.5 mg tab 1 QL 30 / 30 DAYS

methyldopa-hctz 250-15 mg tab 1

methyldopa-hctz 250-25 mg tab 1

metoprolol-hctz 100-25 mg tab 1



moexipril-hctz 15-12.5 mg tab 1

moexipril-hctz 15-25 mg tablet 1

moexipril-hctz 7.5-12.5 mg tab 1

nadolol-bendroflu 40-5 mg tab 1

nadolol-bendroflu 80-5 mg tab 1

NORTHERA 100 MG CAPSULEdroxidopa 4 PA





olmesartan-hctz 20-12.5 mg tab 2 QL 30 / 30 DAYS

olmesartan-hctz 40-12.5 mg tab 2 QL 30 / 30 DAYS

olmesartan-hctz 40-25 mg tab 2 QL 30 / 30 DAYS

olmsrtn-amldpn-hctz 20-5-12.5 2 ST


olmsrtn-amldpn-hctz 40-10-25mg 2 ST


olmsrtn-amldpn-hctz 40-5-25 mg 2 ST

pentoxifylline er 400 mg tab 1

propranolol-hctz 40-25 mg tab 1

propranolol-hctz 80-25 mg tab 1

quinapril-hctz 10-12.5 mg tab 1

quinapril-hctz 20-12.5 mg tab 1

quinapril-hctz 20-25 mg tab 1

RANEXA ER 1,000 MG TABLETranolazine 2

RANEXA ER 500 MG TABLETranolazine 2

spironolactone-hctz 25-25 tab 1

TEKTURNA 150 MG TABLETaliskiren hemifumarate 2

QL 30 / 30 DAYS

ST

TEKTURNA 300 MG TABLETaliskiren hemifumarate 2

QL 30 / 30 DAYS

ST

TEKTURNA HCT 150-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide 2 ST

TEKTURNA HCT 150-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide 2 ST

TEKTURNA HCT 300-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide 2 ST



TEKTURNA HCT 300-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide 2 ST

telmisartan-amlodipine 40-10 3 ST

telmisartan-amlodipine 40-5 mg 3 ST

telmisartan-amlodipine 80-10 3 ST

telmisartan-amlodipine 80-5 mg 3 ST

telmisartan-hctz 40-12.5 mg tb 3

telmisartan-hctz 80-12.5 mg tb 3

telmisartan-hctz 80-25 mg tab 3

trandolapr-verapam er 1-240 mg 2QL 30 / 30 DAYS

ST


ST


ST


ST

triamterene-hctz 37.5-25 mg cp 1

triamterene-hctz 37.5-25 mg tb 1

triamterene-hctz 50-25 mg cap 1

triamterene-hctz 75-50 mg tab 1

valsartan-hctz 160-12.5 mg tab 1 QL 30 / 30 DAYS

valsartan-hctz 160-25 mg tab 1 QL 30 / 30 DAYS


valsartan-hctz 320-25 mg tab 1 QL 30 / 30 DAYS


DIURETICS, CARBONIC ANHYDRASE INHIBITORS

KEVEYIS 50 MG TABLETdichlorphenamide 4



DIURETICS, LOOP

bumetanide 0.5 mg tablet 1

bumetanide 1 mg tablet 1

bumetanide 2 mg tablet 1

furosemide 10 mg/ml solution 1

furosemide 20 mg tablet 1


furosemide 40 mg/5 ml soln 1


torsemide 10 mg tablet 1




DIURETICS, POTASSIUM-SPARING

amiloride hcl 5 mg tablet 1

eplerenone 25 mg tablet 1

eplerenone 50 mg tablet 1

spironolactone 100 mg tablet 1



DIURETICS, THIAZIDE

chlorothiazide 250 mg tablet 1

chlorothiazide 500 mg tablet 1

chlorthalidone 25 mg tablet 1

chlorthalidone 50 mg tablet 1

DIURIL 250 MG/5 ML ORAL SUSPchlorothiazide 3

hydrochlorothiazide 12.5 mg cp 1

hydrochlorothiazide 12.5 mg tb 1

hydrochlorothiazide 25 mg tab 1

hydrochlorothiazide 50 mg tab 1



indapamide 1.25 mg tablet 1

indapamide 2.5 mg tablet 1

metolazone 10 mg tablet 1

metolazone 2.5 mg tablet 1

metolazone 5 mg tablet 1

ZAROXOLYN 2.5 MG TABLETmetolazone 3

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibric acid 105 mg tablet 3 ST

fenofibric acid 35 mg tablet 3 ST

fenofibric acid dr 135 mg cap 3 ST

fenofibric acid dr 45 mg cap 3 ST

FENOGLIDE 120 MG TABLETfenofibrate 3

gemfibrozil 600 mg tablet 1

TRICOR 145 MG TABLETfenofibrate nanocrystallized 2

QL 30 / 30 DAYS

ST

TRICOR 48 MG TABLETfenofibrate nanocrystallized 2

QL 30 / 30 DAYS

ST

TRIGLIDE 160 MG TABLETfenofibrate nanocrystallized 3 ST

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin 10 mg tablet 1 QL 1 / 1 DAYS




fluvastatin sodium 20 mg cap 3QL 30 / 30 DAYS

ST

fluvastatin sodium 40 mg cap 3QL 30 / 30 DAYS

ST



lovastatin 10 mg tablet 1



pravastatin sodium 10 mg tab 1 QL 30 / 30 DAYS




rosuvastatin calcium 10 mg tab 1 ST


rosuvastatin calcium 40 mg tab 1


simvastatin 10 mg tablet 1 QL 30 / 30 DAYS





DYSLIPIDEMICS, OTHER

cholestyramine light packet 1

cholestyramine light powder 1

cholestyramine packet 1

cholestyramine powder 1

COLESTID FLAVORED GRANULEScolestipol hcl 3

colestipol hcl 1 gm tablet 1

colestipol hcl granules 1

colestipol hcl granules packet 1

colestipol micronized 1 gm tab 1

JUXTAPID 10 MG CAPSULElomitapide mesylate 4 PA








KYNAMRO 200 MG/ML SYRINGEmipomersen sodium 4 PA

niacin er 1,000 mg tablet 1 ST

niacin er 500 mg tablet 1 ST

niacin er 750 mg tablet 1 ST

niacor 500 mg tablet 1

omega-3 ethyl esters 1 gm cap 3QL 120 / 30 DAYS

ST

PRALUENT 150 MG/ML PENalirocumab 4

PRALUENT 150 MG/ML SYRINGEalirocumab 4

PRALUENT 75 MG/ML PENalirocumab 4

PRALUENT 75 MG/ML SYRINGEalirocumab 4

prevalite packet 1

prevalite powder 1

REPATHA 140 MG/ML SURECLICKevolocumab 4

REPATHA 140 MG/ML SYRINGEevolocumab 4

REPATHA 420 MG/3.5ML PUSHTRONXevolocumab 4

VYTORIN 10-10 MG TABLETezetimibe/simvastatin 2

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST




QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

WELCHOL 3.75G PACKETcolesevelam hcl 2 ST

WELCHOL 625 MG TABLETcolesevelam hcl 2 ST

ZETIA 10 MG TABLETezetimibe 2

QL 30 / 30 DAYS

ST

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine 10 mg tablet 1




minoxidil 10 mg tablet 1

minoxidil 2.5 mg tablet 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 40 MG CAPSULEisosorbide dinitrate 2

IMDUR ER 120 MG TABLETisosorbide mononitrate 3



ISORDIL 40 MG TABLETisosorbide dinitrate 2

isosorbide dn 10 mg tablet 1




isosorbide dn er 40 mg tablet 1

isosorbide mn 10 mg tablet 1



isosorbide mn 20 mg tablet 1

isosorbide mn er 120 mg tab 1

isosorbide mn er 30 mg tablet 1

isosorbide mn er 60 mg tablet 1

minitran 0.1 mg/hr patch 1




NITRO-BID 2% OINTMENTnitroglycerin 2

NITRO-DUR 0.3 MG/HR PATCHnitroglycerin 2

NITRO-DUR 0.8 MG/HR PATCHnitroglycerin 2

nitro-time er 2.5 mg capsule 1

nitro-time er 6.5 mg capsule 1

nitro-time er 9 mg capsule 1

nitroglycerin 0.1 mg/hr patch 1


nitroglycerin 0.3 mg tablet sl 1





nitroglycerin 400 mcg spray 1

nitroglycerin er 2.5 mg cap 1

nitroglycerin er 6.5 mg cap 1

nitroglycerin er 9 mg capsule 1

nitroglycerin lingual 0.4 mg 1

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES


d-amphetamine er 10 mg capsule 1

QL 2 / 1 DAYS

ST

AL1 Up to 18 yrs old



QL 4 / 1 DAYS

ST



QL 2 / 1 DAYS

ST


DEXEDRINE 10 MG TABLETdextroamphetamine sulfate 1

QL 1 / 1 DAYS

ST


DEXEDRINE 5 MG TABLETdextroamphetamine sulfate 1

QL 1 / 1 DAYS

ST


DEXEDRINE SPANSULE 10 MGdextroamphetamine sulfate 1

QL 2 / 1 DAYS

ST



QL 4 / 1 DAYS

ST



QL 2 / 1 DAYS

ST


dextroamp-amphet er 10 mg cap 3

QL 30 / 30 DAYS

ST



QL 30 / 30 DAYS

ST





QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST



QL 30 / 30 DAYS

ST


dextroamp-amphetam 12.5 mg tab 1 AL1 Up to 18 yrs old

dextroamp-amphetam 7.5 mg tab 1 AL1 Up to 18 yrs old

dextroamp-amphetamin 10 mg tab 1 AL1 Up to 18 yrs old




dextroamp-amphetamine 5 mg tab 1 AL1 Up to 18 yrs old

dextroamphetamine 10 mg tab 1

QL 1 / 1 DAYS

ST


dextroamphetamine 5 mg tab 1

QL 1 / 1 DAYS

ST


dextroamphetamine 5 mg/5 ml 1 AL1 Up to 18 yrs old

procentra 5 mg/5 ml solution 1 AL1 Up to 18 yrs old

VYVANSE 10 MG CAPSULElisdexamfetamine dimesylate 3

PA



PA



PA





PA



PA



PA



PA


zenzedi 10 mg tablet 3

QL 4 / 1 days

ST


ZENZEDI 15 MG TABLETdextroamphetamine sulfate 3

QL 3 / 1 DAYS

ST


ZENZEDI 2.5 MG TABLETdextroamphetamine sulfate 3

QL 3 / 1 DAYS

ST



QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST


zenzedi 5 mg tablet 3

QL 4 / 1 days

ST


ZENZEDI 7.5 MG TABLETdextroamphetamine sulfate 3

QL 3 / 1 DAYS

ST




ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

APTENSIO XR 10 MG CAPSULEmethylphenidate hcl 3

QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST


dexmethylphenidate 10 mg tab 1QL 2 / 1 DAYS


dexmethylphenidate 2.5 mg tab 1QL 2 / 1 DAYS


dexmethylphenidate 5 mg tab 1QL 2 / 1 DAYS


dexmethylphenidate er 10 mg cp 3

QL 1 / 1 DAYS

ST





QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST


dexmethylphenidate er 5 mg cap 3

QL 1 / 1 DAYS

ST


FOCALIN XR 25 MG CAPSULEdexmethylphenidate hcl 3

QL 1 / 1 DAYS

ST


FOCALIN XR 35 MG CAPSULEdexmethylphenidate hcl 3

QL 1 / 1 DAYS

ST


guanfacine hcl er 1 mg tablet 1 AL1 Up to 18 yrs old




INTUNIV ER 4 MG TABLETguanfacine hcl 3 AL1 Up to 18 yrs old

metadate er 20 mg tablet 3QL 3 / 1 DAYS


methylphenidate 10 mg chew tab 3 AL1 Up to 18 yrs old

methylphenidate 10 mg tablet 1QL 3 / 1 DAYS




methylphenidate 10 mg/5 ml sol 1 AL1 Up to 18 yrs old

methylphenidate 2.5 mg chew tb 3 AL1 Up to 18 yrs old



methylphenidate 5 mg chew tab 3 AL1 Up to 18 yrs old



methylphenidate 5 mg/5 ml soln 1 AL1 Up to 18 yrs old

methylphenidate cd 10 mg cap 3

QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 1 / 1 DAYS

ST


methylphenidate er 10 mg cap 3

QL 2 / 1 DAYS

ST


methylphenidate er 10 mg tab 3QL 3 / 1 DAYS




methylphenidate er 18 mg tab 3

QL 30 / 30 DAYS

ST


methylphenidate er 20 mg cap 3QL 1 / 1 DAYS



QL 2 / 1 DAYS

ST


methylphenidate er 20 mg tab 3QL 3 / 1 DAYS



QL 30 / 30 DAYS

ST


methylphenidate er 30 mg cap 3QL 1 / 1 DAYS



QL 2 / 1 DAYS

ST



QL 2 / 1 DAYS

ST


methylphenidate er 40 mg cap 3 AL1 Up to 18 yrs old


QL 2 / 1 DAYS

ST



QL 1 / 1 DAYS

ST



QL 30 / 30 DAYS

ST





QL 1 / 1 DAYS

ST


methylphenidate la 20 mg cap 3QL 1 / 1 DAYS


methylphenidate la 30 mg cap 3QL 1 / 1 DAYS


methylphenidate la 40 mg cap 3 AL1 Up to 18 yrs old

methylphenidate sr 20 mg tab 3QL 3 / 1 DAYS


QUILLIVANT XR 25 MG/5 ML SUSPmethylphenidate hcl 3

QL 360 / 30 day(s)

ST


RITALIN LA 10 MG CAPSULEmethylphenidate hcl 3

QL 1 / 1 DAYS

ST


STRATTERA 10 MG CAPSULEatomoxetine hcl 2

QL 30 / 30 DAYS



QL 30 / 30 DAYS



QL 30 / 30 DAYS



QL 30 / 30 DAYS



QL 30 / 30 DAYS



QL 30 / 30 DAYS



QL 30 / 30 DAYS




CENTRAL NERVOUS SYSTEM, OTHER

butalb-acetamin-caff 50-300-40 3

butalb-acetamin-caff 50-325-40 1

butalbit-acetaminophen-caff cp 1

butalbital-acetaminophn 50-325 1

capacet capsule 1

MARGESIC CAPSULEbutalbital/acetaminophen/caffeine 1

MARTEN-TAB 325-50 TABLETbutalbital/acetaminophen 1

NUEDEXTA 20-10 MG CAPSULEdextromethorphan hbr/quinidine sulfate 3 PA

tencon 50-325 mg tablet 1

tetrabenazine 12.5 mg tablet 4

tetrabenazine 25 mg tablet 4

ZEBUTAL 50-325-40 MG CAPSULEbutalbital/acetaminophen/caffeine 1

FIBROMYALGIA AGENTS

duloxetine hcl dr 20 mg cap 1

QL 30 / 30 DAYS

ST



QL 30 / 30 DAYS

ST



QL 30 / 30 DAYS

ST


LYRICA 100 MG CAPSULEpregabalin 3 ST


LYRICA 20 MG/ML ORAL SOLUTIONpregabalin 3 ST









SAVELLA 100 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old

SAVELLA 12.5 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old



SAVELLA TITRATION PACKmilnacipran hcl 2 AL1 At least 18 yrs old

MULTIPLE SCLEROSIS AGENTS

AMPYRA ER 10 MG TABLETdalfampridine 4 PA

AUBAGIO 14 MG TABLETteriflunomide 4 PA

AUBAGIO 7 MG TABLETteriflunomide 4 PA

AVONEX 30 MCG VIAL KITinterferon beta-1a/albumin human 4

AVONEX PEN 30 MCG/0.5 ML KITinterferon beta-1a 4

AVONEX PREFILLED SYR 30 MCG KTinterferon beta-1a 4

BETASERON 0.3 MG KITinterferon beta-1b 4

QL 15 / 1 FILL

PA

EXTAVIA 0.3 MG KITinterferon beta-1b 4 PA

EXTAVIA 0.3 MG VIALinterferon beta-1b 4 PA



GILENYA 0.5 MG CAPSULEfingolimod hcl 4 PA

glatopa 20 mg/ml syringe 4 PA

PLEGRIDY 125 MCG/0.5 ML PENpeginterferon beta-1a 4 PA

PLEGRIDY 125 MCG/0.5 ML SYRINGpeginterferon beta-1a 4 PA

PLEGRIDY PEN INJ STARTER PACKpeginterferon beta-1a 4 PA

PLEGRIDY SYRINGE STARTER PACKpeginterferon beta-1a 4 PA

REBIF 22 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

REBIF 44 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

REBIF REBIDOSE 22 MCG/0.5 MLinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

REBIF REBIDOSE 44 MCG/0.5 MLinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

REBIF REBIDOSE TITRATION PACKinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

REBIF TITRATION PACKinterferon beta-1a/albumin human 4

QL 15 / 30 DAYS

PA

TECFIDERA DR 120 MG CAPSULEdimethyl fumarate 4 PA

TECFIDERA DR 240 MG CAPSULEdimethyl fumarate 4 PA

TECFIDERA STARTER PACKdimethyl fumarate 4 PA

DENTAL AND ORAL AGENTS

EPISIL LIQUIDoral mucositis and stomatitis anti-inflammatory agent comb 2 2

oralone 0.1% paste 1

pilocarpine hcl 5 mg tablet 1



pilocarpine hcl 7.5 mg tablet 1

triamcinolone 0.1% paste 1

DERMATOLOGICAL AGENTS

ABSORICA 10 MG CAPSULEisotretinoin 4 PA


ABSORICA 25 MG CAPSULEisotretinoin 4


ABSORICA 35 MG CAPSULEisotretinoin 4


ACZONE 5% GELdapsone 3

ACZONE 7.5% GEL PUMPdapsone 3

QL 1 / 30 day(s)

ST

adapalene 0.1% cream 2QL 1 / 25 DAYS


adapalene 0.1% gel 2QL 1 / 25 DAYS


adapalene 0.1% lotion 3QL 1 / 25 DAYS


adapalene 0.3% gel 2QL 1 / 25 DAYS


adapalene 0.3% gel pump 2QL 1 / 25 DAYS


ALA-QUIN 3-0.5% CREAMclioquinol/hydrocortisone 3

ALPHAQUIN HP 4% CREAMhydroquinone/sunscreens (oxybenzone/octinoxate) 1

amnesteem 10 mg capsule 4 PA





ANALPRAM HC 1% CREAMhydrocortisone acetate/pramoxine hcl 3

ANALPRAM HC 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl 3

avar cleanser 3

AZELEX 20% CREAMazelaic acid 3

blanche 4% cream 3

calcipotriene 0.005% cream 2

calcipotriene 0.005% ointment 3

calcipotriene 0.005% solution 2

calcitrene 0.005% ointment 3

calcitriol 3 mcg/g ointment 1 PA

claravis 10 mg capsule 4 PA




clind ph-benzoyl perox 1.2-5% 3 ST

clinda-tretinoin 1.2%-0.025% 3

QL 1 / 30 day(s)

ST


clindamycin-benzoyl perox 1-5% 3 ST

clotrimazole-betamethasone crm 1

clotrimazole-betamethasone lot 1

CONDYLOX 0.5% GELpodofilox 3

COSENTYX 150 MG/ML PEN INJECTsecukinumab 4 PA

COSENTYX 150 MG/ML SYRINGEsecukinumab 4 PA



COSENTYX 300 MG DOSE-2 PENSsecukinumab 4 PA

COSENTYX 300 MG DOSE-2 SYRINGEsecukinumab 4 PA

dermazene cream 1

diclofenac sodium 3% gel 3 ST

DRITHOCREME HP 1% CREAManthralin 2

DUAC 1.2-5% GELclindamycin phosphate/benzoyl peroxide 3

ELIDEL 1% CREAMpimecrolimus 2

QL 1 / 10 DAYS

ST

ENSTILAR 0.005%-0.064% FOAMcalcipotriene/betamethasone dipropionate 3 ST

EPIDUO 0.1-2.5% GELadapalene/benzoyl peroxide 3

EPIDUO 0.1-2.5% GEL PUMPadapalene/benzoyl peroxide 3

EPIDUO FORTE 0.3-2.5% GEL PUMPadapalene/benzoyl peroxide 3

QL 45 / 30 DAYS

ST


EPIFOAM FOAMhydrocortisone acetate/pramoxine hcl 3

FABIOR 0.1% FOAMtazarotene 3

FINACEA 15% FOAMazelaic acid 3

FINACEA 15% GELazelaic acid 3

FLECTOR 1.3% PATCHdiclofenac epolamine 3

QL 30 / 30 DAYS


fluorouracil 0.5% cream 1

hydrocort-pramoxine 1%-1% crm 1

hydrocort-pramoxine 2.5%-1% cm 1

hydrocort-pramoxine 2.5-1% crm 1



hydrocortisone-iodoquinol crm 1

hydrocortisone-pramoxine cream 1

hydroquinone 4% cream 1

hydroquinone tr 4% cream 1

imiquimod 5% cream packet 1

lustra 4% cream 3

melquin hp 4% cream 1

melquin-3 solution 1

METROLOTION TOPICAL 0.75%metronidazole 3

metronidazole 0.75% cream 1

metronidazole 0.75% lotion 1

metronidazole top 1% gel pump 1

metronidazole topical 0.75% gl 1

metronidazole topical 1% gel 1

myorisan 10 mg capsule 4 PA




neuac gel 3 ST

obagi elastiderm skin 4% cream 1

obagi nu-derm blender 4% cream 1

obagi nu-derm clear 4% cream 1

OBAGI NU-DERM SUNFADERhydroquinone/sunscreens (oxybenzone/octinoxate) 3

OVACE PLUS 10% CREAMsulfacetamide sodium 3 ST

OVACE PLUS 10% SHAMPOOsulfacetamide sodium 3 ST

OVACE PLUS 10% WASHsulfacetamide sodium 3 ST

OVACE PLUS 9.8% FOAMsulfacetamide sodium 3



OVACE PLUS 9.8% LOTIONsulfacetamide sodium 3 ST

podofilox 0.5% topical soln 1

pramcort 1% cream 3

PRAMOSONE 1% CREAMhydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 1% LOTIONhydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 1% OINTMENThydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 1%-1% CREAMhydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 1%-1% OINTMENThydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 2.5% LOTIONhydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 2.5% OINTMENThydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl 3

PRAMOSONE 2.5%-1% OINTMENThydrocortisone acetate/pramoxine hcl 3

PROCORT 1.85%-1.15% CREAMhydrocortisone acetate/pramoxine hcl 3

PROCTOFOAM-HC 1%-1% FOAMhydrocortisone acetate/pramoxine hcl 3

rosadan 0.75% cream 1

rosanil cleanser lotion 3

seb-prev 10% wash 2 ST

selenium sulfide 2.25% shampoo 1

selenium sulfide 2.5% lotion 1

sod sulfacet-sulfur 10-5% clsr 1

sod sulfacetam 10% clnsng gel 3 ST

sod sulfacetamide 10% shampoo 3 ST

sodium sulf-sulfur cleanser 1

sodium sulf-sulfur cleanser 1



sodium sulfacetamide 10% wash 2 ST

SORILUX 0.005% FOAMcalcipotriene 3

STELARA 45 MG/0.5 ML SYRINGEustekinumab 4 PA

STELARA 90 MG/ML SYRINGEustekinumab 4 PA

tacrolimus 0.03% ointment 2QL 1 / 10 DAYS

ST

tacrolimus 0.1% ointment 2QL 1 / 10 DAYS

ST

TALTZ 80 MG/ML AUTOINJ (2-PK)ixekizumab 4 PA

TALTZ 80 MG/ML AUTOINJ (3-PK)ixekizumab 4 PA

TALTZ 80 MG/ML AUTOINJECTORixekizumab 4 PA

TALTZ 80 MG/ML SYRINGEixekizumab 4 PA

TALTZ 80 MG/ML SYRINGE (2-PK)ixekizumab 4 PA

TALTZ 80 MG/ML SYRINGE (3-PK)ixekizumab 4 PA

TAZORAC 0.05% CREAMtazarotene 3

TAZORAC 0.05% GELtazarotene 3

TAZORAC 0.1% CREAMtazarotene 3

TAZORAC 0.1% GELtazarotene 3

tl hydroquinone 4% cream 1

TOLAK 4% CREAMfluorouracil 3

tretinoin 0.01% gel 1

tretinoin 0.025% cream 1

tretinoin 0.025% gel 1





ULESFIA 5% LOTIONbenzyl alcohol 2

zenatane 10 mg capsule 4 PA




ZITHRANOL 1% SHAMPOOanthralin micronized 3

ZITHRANOL-RR 1.2% CREAManthralin 3

ENZYME REPLACEMENT/MODIFIERS

CERDELGA 84 MG CAPSULEeliglustat tartrate 4 PA

CREON DR 12,000 UNITS CAPSULElipase/protease/amylase 3





KUVAN 100 MG POWDER PACKETsapropterin dihydrochloride 4 PA

KUVAN 100 MG TABLETsapropterin dihydrochloride 4 PA

KUVAN 500 MG POWDER PACKETsapropterin dihydrochloride 4 PA

ORFADIN 10 MG CAPSULEnitisinone 4





ORFADIN 4 MG/ML SUSPENSIONnitisinone 4


PANCREAZE DR 10,500 UNIT CAPlipase/protease/amylase 2




pancrelipase dr 5,000 unit cap 1

PERTZYE DR 16,000 UNITS CAPSlipase/protease/amylase 3

PERTZYE DR 8,000 UNITS CAPSULElipase/protease/amylase 3

RAVICTI 1.1 GRAM/ML LIQUIDglycerol phenylbutyrate 4 PA

STRENSIQ 18 MG/0.45 ML VIALasfotase alfa 4


STRENSIQ 40 MG/ML VIALasfotase alfa 4


VIOKACE 10,440-39,150 UNITS TBlipase/protease/amylase 2

VIOKACE 20,880-78,300 UNITS TBlipase/protease/amylase 2

ZAVESCA 100 MG CAPSULEmiglustat 2

ZENPEP DR 10,000 UNITS CAPSULElipase/protease/amylase 2









GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

BENTYL 20 MG TABLETdicyclomine hcl 3

chlordiazepoxide-clidinium cap 1

dicyclomine 10 mg capsule 1

dicyclomine 10 mg/5 ml soln 1

dicyclomine 20 mg tablet 1

ed-spaz 0.125 mg odt 1

glycopyrrolate 1 mg tablet 1

glycopyrrolate 2 mg tablet 1

hyoscyamine 0.125 mg odt 1

hyoscyamine 0.125 mg tab sl 1

hyoscyamine 0.125 mg/5 ml elix 1

hyoscyamine 0.125 mg/ml drop 1

hyoscyamine 125 mcg/5 ml elix 1

hyoscyamine er 0.375 mg tab 1

hyoscyamine sr 0.375 mg tab 1

hyoscyamine sulf 0.125 mg tab 1

hyosyne 0.125 mg/ml drop 1

hyosyne 125 mcg/5 ml elixir 1

LEVSIN 0.125 MG TABLEThyoscyamine sulfate 3

nulev 0.125 mg chewable melt 3

oscimin 0.125 mg odt 1

oscimin 0.125 mg tablet 1



oscimin sl 0.125 mg tablet 1

oscimin sr 0.375 mg tablet 1

ROBINUL FORTE 2 MG TABLETglycopyrrolate 3

SYMAX DUOTABhyoscyamine sulfate 3

GASTROINTESTINAL AGENTS, OTHER

ACTIGALL 300 MG CAPSULEursodiol 4

CHOLBAM 250 MG CAPSULEcholic acid 4 PA

CHOLBAM 50 MG CAPSULEcholic acid 4 PA

cromolyn 100 mg/5 ml oral conc 1

diphenoxylat-atrop 2.5-0.025/5 1

diphenoxylate-atrop 2.5-0.025 1

FULYZAQ 125 MG DR TABLETcrofelemer 2 PA

GASTROCROM 100 MG/5 ML CONCcromolyn sodium 3

GATTEX 5 MG 30-VIAL KITteduglutide 4 PA

GATTEX 5 MG ONE-VIAL KITteduglutide 4 PA

lansoprazol-amoxicil-clarithro 2

LOMOTIL 2.5-0.025 MG TABLETdiphenoxylate hcl/atropine sulfate 3

loperamide 2 mg capsule 1

MOVANTIK 12.5 MG TABLETnaloxegol oxalate 2 PA

MOVANTIK 25 MG TABLETnaloxegol oxalate 2 PA

MYTESI 125 MG DR TABLETcrofelemer 2

OMECLAMOX-PAK COMBO PACKomeprazole/clarithromycin/amoxicillin trihydrate 2

PYLERA CAPSULEcolloidal bismuth subcitrate/metronidazole/tetracycline hcl 3 AL1 At least 18 yrs old



RELISTOR 12 MG/0.6 ML SYRINGEmethylnaltrexone bromide 3 PA

RELISTOR 12 MG/0.6 ML VIALmethylnaltrexone bromide 3 PA

RELISTOR 8 MG/0.4 ML SYRINGEmethylnaltrexone bromide 3 PA

URSO 250 MG TABLETursodiol 4

URSO FORTE 500 MG TABLETursodiol 4

ursodiol 250 mg tablet 1

ursodiol 300 mg capsule 1

ursodiol 500 mg tablet 1

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 200 mg tablet 1


cimetidine 300 mg/5 ml soln 1



famotidine 20 mg tablet 1

famotidine 40 mg tablet 1

famotidine 40 mg/5 ml susp 1

nizatidine 15 mg/ml solution 1

nizatidine 150 mg capsule 1

nizatidine 300 mg capsule 1

ranitidine 15 mg/ml syrup 1

ranitidine 150 mg capsule 1

ranitidine 150 mg tablet 1

ranitidine 150 mg/10 ml syrup 1

ranitidine 300 mg capsule 1

ranitidine 300 mg tablet 1

ZANTAC 150 MG TABLETranitidine hcl 3



IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 0.5 mg tablet 3

AMITIZA 24 MCG CAPSULESlubiprostone 3

ST


AMITIZA 8 MCG CAPSULElubiprostone 3

ST


LINZESS 145 MCG CAPSULElinaclotide 3

QL 30 / 30 DAYS

PA

LINZESS 290 MCG CAPSULElinaclotide 3

QL 30 / 30 DAYS

PA

LAXATIVES

constulose 10 gm/15 ml soln 1

enulose 10 gm/15 ml solution 1

gavilyte-c solution 1

gavilyte-g solution 1

gavilyte-h and bisacodyl kit 1

gavilyte-n solution 1

generlac 10 gm/15 ml solution 1

KRISTALOSE 10 GM PACKETlactulose 3

KRISTALOSE 20 GM PACKETlactulose 3

lactulose 10 gm/15 ml solution 1

lactulose 20 gm/30 ml solution 1

NULYTELY WITH FLAVOR PACKS SOLsodium chloride/sodium bicarbonate/potassium chloride/peg 3

peg 3350 electrolyte soln 1

peg 3350-electrolyte solution 1

peg-3350 and electrolytes soln 1

peg-3350 with flavor packs sol 1

peg-prep kit 2

polyethylene glycol 3350 powd 1



polyethylene glycol 3350 powd 1

trilyte with flavor packets 1

PROTECTANTS

CARAFATE 1 GM TABLETsucralfate 3

misoprostol 200 mcg tablet 1

sucralfate 1 gm tablet 1

PROTON PUMP INHIBITORS

lansoprazole dr 15 mg capsule 1QL 30 / 30 DAYS

ST

lansoprazole dr 30 mg capsule 1QL 30 / 30 DAYS

ST

omeprazole dr 10 mg capsule 1 QL 30 / 30 DAYS



pantoprazole sod dr 20 mg tab 1 QL 30 / 30 DAYS

pantoprazole sod dr 40 mg tab 1 QL 30 / 30 DAYS

PROTONIX 40 MG SUSPENSIONpantoprazole sodium 2

rabeprazole sod dr 20 mg tab 3 QL 1 / 1 DAYS

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin er 15 mg tablet 2

darifenacin er 7.5 mg tablet 2

GELNIQUE 10% GEL SACHETSoxybutynin chloride 3 QL 30 / 30 DAYS

MYRBETRIQ ER 25 MG TABLETmirabegron 3 ST

MYRBETRIQ ER 50 MG TABLETmirabegron 3 ST

oxybutynin 5 mg tablet 1

oxybutynin 5 mg/5 ml syrup 1



oxybutynin cl er 10 mg tablet 1



OXYTROL 3.9 MG/24HR PATCHoxybutynin 3

tolterodine tart er 2 mg cap 2 QL 30 / 30 DAYS

tolterodine tart er 4 mg cap 2 QL 30 / 30 DAYS

tolterodine tartrate 1 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate 2 mg tab 1 QL 60 / 30 DAYS

TOVIAZ ER 4 MG TABLETfesoterodine fumarate 3

QL 30 / 30 DAYS

ST

TOVIAZ ER 8 MG TABLETfesoterodine fumarate 3

QL 30 / 30 DAYS

ST

VESICARE 10 MG TABLETsolifenacin succinate 2

VESICARE 5 MG TABLETsolifenacin succinate 2

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl er 10 mg tablet 1 ST

CARDURA XL 4 MG TABLETdoxazosin mesylate 3

CARDURA XL 8 MG TABLETdoxazosin mesylate 3

dutasteride 0.5 mg capsule 1 ST

dutasteride-tamsulosin 0.5-0.4 3 ST

finasteride 5 mg tablet 1

RAPAFLO 4 MG CAPSULEsilodosin 3

QL 30 / 30 DAYS

ST

RAPAFLO 8 MG CAPSULEsilodosin 3

QL 30 / 30 DAYS

ST

tamsulosin hcl 0.4 mg capsule 1 QL 30 / 30 DAYS



GENITOURINARY AGENTS, OTHER

bethanechol 10 mg tablet 1




CUPRIMINE 250 MG CAPSULEpenicillamine 4 PA

CYSTAGON 150 MG CAPSULEcysteamine bitartrate 3

CYSTAGON 50 MG CAPSULEcysteamine bitartrate 3

DEPEN 250 MG TITRATABpenicillamine 4 PA

ELMIRON 100 MG CAPSULEpentosan polysulfate sodium 2

phenazopyridine 100 mg tab 1

phenazopyridine 200 mg tab 1

phospha 250 neutral tablet 1

potassium citrate er 10 meq tb 1

potassium citrate er 15 meq tb 1

URECHOLINE 5 MG TABLETbethanechol chloride 3

virt-phos 250 neutral tablet 1

PHOSPHATE BINDERS

calcium acetate 667 mg capsule 1

calcium acetate 667 mg gelcap 1

calcium acetate 667 mg tablet 3

FOSRENOL 1,000 MG POWDER PACKlanthanum carbonate 2

FOSRENOL 1,000 MG TABLET CHEWlanthanum carbonate 2

FOSRENOL 500 MG TABLET CHEWlanthanum carbonate 2

FOSRENOL 750 MG POWDER PACKETlanthanum carbonate 2



FOSRENOL 750 MG TABLET CHEWlanthanum carbonate 2

PHOSLYRA 667 MG/5 ML SOLUTIONcalcium acetate 3

RENAGEL 400 MG TABLETsevelamer hcl 3

RENAGEL 800 MG TABLETsevelamer hcl 3

RENVELA 0.8 GM POWDER PACKETsevelamer carbonate 2 AL1 At least 16 yrs old

RENVELA 2.4 GM POWDER PACKETsevelamer carbonate 2 AL1 At least 16 yrs old

RENVELA 800 MG TABLETsevelamer carbonate 2 AL1 At least 16 yrs old

sevelamer carbonate 800 mg tab 1 AL1 At least 16 yrs old

VELPHORO 500 MG CHEWABLE TABsucroferric oxyhydroxide 3 QL 6 / 1 DAYS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ALA-CORT 1% CREAMhydrocortisone 1

alclometasone dipr 0.05% oint 1

alclometasone dipro 0.05% crm 1

amcinonide 0.1% cream 1

amcinonide 0.1% lotion 1

amcinonide 0.1% ointment 1

anucort-hc 25 mg suppository 1

betamethasone dp 0.05% crm 1

betamethasone dp 0.05% lot 1

betamethasone dp 0.05% oint 1

betamethasone dp aug 0.05% crm 1

betamethasone dp aug 0.05% gel 1

betamethasone dp aug 0.05% lot 1

betamethasone dp aug 0.05% oin 1

betamethasone va 0.1% cream 1

betamethasone va 0.1% lotion 1



betamethasone valer 0.1% ointm 1

betamethasone valer 0.12% foam 1

clobetasol 0.05% cream 1

clobetasol 0.05% gel 1

clobetasol 0.05% ointment 1

clobetasol 0.05% shampoo 1

clobetasol 0.05% solution 1

clobetasol 0.05% topical lotn 1

clobetasol emollient 0.05% crm 1

clobetasol emollnt 0.05% foam 1

clobetasol emulsion 0.05% foam 1

clobetasol prop 0.05% foam 1

clocortolone 0.1% cream pump 3

clocortolone pivalate 0.1% crm 3

CORDRAN 0.05% OINTMENTflurandrenolide 3 QL 2 / 10 DAYS

CORDRAN 4 MCG/SQ CM TAPE LARGEflurandrenolide 3 QL 2 / 10 DAYS

cormax 0.05% solution 1

CORTEF 10 MG TABLEThydrocortisone 3



CUTIVATE 0.05% LOTIONfluticasone propionate 3

DELTASONE 20 MG TABLETprednisone 1

DESONATE 0.05% GELdesonide 3

desonide 0.05% cream 3

desonide 0.05% lotion 3

desonide 0.05% ointment 3

desoximetasone 0.05% cream 1



desoximetasone 0.05% gel 1

desoximetasone 0.05% ointment 1

desoximetasone 0.25% cream 1

desoximetasone 0.25% ointment 1

dexamethasone 0.5 mg tablet 1

dexamethasone 0.5 mg/5 ml elx 1

dexamethasone 0.5 mg/5 ml liq 1


dexamethasone 1 mg tablet 1





dexamethasone intensol 1mg/1ml 1

DEXPAK 10 DAY 1.5 MG TABLETdexamethasone 2



diflorasone 0.05% cream 1

diflorasone 0.05% ointment 1

ELOCON 0.1% LOTIONmometasone furoate 3

fludrocortisone 0.1 mg tablet 1

fluocinolone 0.01% body oil 1

fluocinolone 0.01% cream 1

fluocinolone 0.01% solution 1

fluocinolone 0.025% cream 1

fluocinolone 0.025% ointment 1

fluocinonide 0.05% cream 1

fluocinonide 0.05% gel 1

fluocinonide 0.05% ointment 1



fluocinonide 0.05% solution 1

fluocinonide 0.1% cream 1

fluocinonide-e 0.05% cream 1

fluocinonide-emol 0.05% cream 3

flurandrenolide 0.05% cream 3 QL 2 / 10 day(s)

flurandrenolide 0.05% lotion 3

fluticasone prop 0.005% oint 1

fluticasone prop 0.05% cream 1

fluticasone prop 0.05% lotion 1

grx hicort 25 mg suppository 1

halobetasol prop 0.05% cream 1

halobetasol prop 0.05% ointmnt 1

HALOG 0.1% CREAMhalcinonide 2

HALOG 0.1% OINTMENThalcinonide 2

hemmorex-hc 25 mg suppository 2

hydrocortisone 1% absorbase 1

hydrocortisone 1% cream 1

hydrocortisone 1% cream 1

hydrocortisone 1% ointment 1

hydrocortisone 10 mg tablet 1

hydrocortisone 2.5% cream 1

hydrocortisone 2.5% lotion 1

hydrocortisone 2.5% ointment 1


hydrocortisone 30 mg supp 1


hydrocortisone ac 25 mg supp 1

hydrocortisone buty 0.1% cream 1

hydrocortisone butyr 0.1% oint 1

hydrocortisone butyr 0.1% soln 1



hydrocortisone val 0.2% cream 1

hydrocortisone val 0.2% ointmt 1

KORLYM 300 MG TABLETmifepristone 3 PA

LOCOID 0.1% LOTIONhydrocortisone butyrate 3

MEDROL 2 MG TABLETmethylprednisolone 2

methylprednisolone 16 mg tab 1


methylprednisolone 4 mg dosepk 1

methylprednisolone 4 mg tablet 1


MILLIPRED 10 MG/5 ML SOLUTIONprednisolone sod phosphate 3

millipred 5 mg tablet 3

mometasone furoate 0.1% cream 1

mometasone furoate 0.1% oint 1

mometasone furoate 0.1% soln 1

PANDEL 0.1% CREAMhydrocortisone probutate 3

prednisolone 15 mg/5 ml soln 1


prednisolone 15 mg/5 ml syrup 1


prednisolone odt 10 mg tablet 2



prednisolone sod ph 25 mg/5 ml 1

prednisone 1 mg tablet 1

prednisone 10 mg tab dose pack 1





prednisone 2.5 mg tablet 1


prednisone 5 mg tab dose pack 1



prednisone 5 mg/5 ml solution 1

prednisone 5 mg/ml solution 1


PRELONE 15 MG/5 ML SYRUPprednisolone 1

procto-pak 1% cream 1

triamcinolone 0.025% cream 1

triamcinolone 0.025% lotion 1

triamcinolone 0.025% oint 1


triamcinolone 0.1% lotion 1

triamcinolone 0.1% ointment 1


triamcinolone 0.5% ointment 1

trianex 0.05% ointment 1

triderm 0.1% cream 1

ULTRAVATE 0.05% CREAMhalobetasol propionate 2

ULTRAVATE 0.05% LOTIONhalobetasol propionate 2

ULTRAVATE 0.05% OINTMENThalobetasol propionate 2

VERDESO 0.05% FOAMdesonide 3 ST

VERIPRED 20 20 MG/5 ML SOLNprednisolone sod phosphate 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin 0.01% solution 1 PA



desmopressin 0.01% spray 1 PA

desmopressin 0.1 mg/ml sol 1 PA

desmopressin 0.1 mg/ml spray 1

desmopressin 10 mcg/0.1 ml spr 1

desmopressin acetate 0.1 mg tb 1 PA

desmopressin acetate 0.2 mg tb 1 PA

OMNITROPE 10 MG/1.5 ML CRTGsomatropin 4 PA

OMNITROPE 5 MG/1.5 ML CRTGsomatropin 4 PA

OMNITROPE 5.8 MG VIALsomatropin 4 PA

SAIZEN 5 MG VIALsomatropin 4 PA

SAIZEN 8.8 MG CLICK.EASY CARTGsomatropin 4 PA

SAIZEN 8.8 MG VIALsomatropin 4 PA

SEROSTIM 4 MG VIALsomatropin 4 PA



STIMATE 1.5 MG/ML NASAL SPRAYdesmopressin acetate 3 PA

TEV-TROPIN 5 MG VIALsomatropin 4 PA

ZOMACTON 5 MG VIALsomatropin 4 PA

ZORBTIVE 8.8 MG VIALsomatropin 4 PA

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

ANABOLIC STEROIDS

oxandrolone 10 mg tablet 3

oxandrolone 2.5 mg tablet 3



ANDROGENS

ANDRODERM 2 MG/24HR PATCHtestosterone 3 PA

ANDRODERM 4 MG/24HR PATCHtestosterone 3 PA

ANDROGEL 1.62% GEL PUMPtestosterone 3 PA

ANDROGEL 1.62%(1.25G) GEL PCKTtestosterone 3 PA

ANDROGEL 1.62%(2.5G) GEL PCKTtestosterone 3 PA

AXIRON 30 MG/ACTUATION SOLNtestosterone 3 PA

danazol 100 mg capsule 1



METHITEST 10 MG TABLETmethyltestosterone 2 PA

methyltestosterone 10 mg cap 2 PA

testosteron cyp 1,000 mg/10 ml 1 PA

testosteron cyp 2,000 mg/10 ml 1 PA

testosteron enan 1,000 mg/5 ml 1

testosterone 10 mg gel pump 3 PA

testosterone 12.5 mg/1.25 gram 3 PA

testosterone 25 mg/2.5 gm pkt 3 PA

testosterone 50 mg/5 gram gel 3 PA

testosterone 50 mg/5 gram pkt 3 PA

testosterone cyp 100 mg/ml 1 PA

testosterone cyp 200 mg/ml 1 PA

testosterone enan 200 mg/ml 1

ESTROGENS

altavera-28 tablet 1



alyacen 1-35-28 tablet 1

alyacen 7-7-7-28 tablet 1

amabelz 0.5 mg-0.1 mg tablet 1

amabelz 1 mg-0.5 mg tablet 1

amethia 0.15-0.03-0.01 mg tab 1 MDS1 91 / 1 DAYS

amethia lo tablet 1 MDS1 91 / 1 DAYS

amethyst 90-20 mcg tablet 3

ANGELIQ 0.25 MG-0.5 MG TABLETdrospirenone/estradiol 3 ST

ANGELIQ 0.5 MG-1 MG TABLETdrospirenone/estradiol 3 ST

apri 28 day tablet 1

aranelle 28 tablet 1

ashlyna 0.15-0.03-0.01 mg tab 1

aubra-28 tablet 1

aviane-28 tablet 1

azurette 28 day tablet 1

balziva 28 tablet 1

bekyree 28 day tablet 1

blisovi 24 fe tablet 1

blisovi fe 1-20 tablet 1

blisovi fe 1.5-30 tablet 1

BREVICON 28 TABLETnorethindrone-ethinyl estradiol 1

briellyn tablet 1

camrese 0.15-0.03-0.01 mg tab 1

camrese lo tablet 1 MDS1 91 / 1 DAYS

caziant 28 day tablet 1

chateal-28 tablet 1

CLIMARA PRO PATCHestradiol/levonorgestrel 3

COMBIPATCH 0.05-0.14 MG PTCHestradiol/norethindrone acetate 2



COMBIPATCH 0.05-0.25 MG PTCHestradiol/norethindrone acetate 2

covaryx h.s. tablet 1

covaryx tablet 1

cryselle-28 tablet 1

cyclafem 1-35-28 tablet 1

cyclafem 7-7-7-28 tablet 1

cyred 28 day tablet 1

dasetta 1-35-28 tablet 1

dasetta 7/7/7-28 tablet 1

daysee 0.15-0.03-0.01 mg tab 1 MDS1 91 / 1 DAYS

delyla-28 tablet 1

desogestr-eth estrad eth estra 1

desogestrel-ethinyl estrad tab 1

DIVIGEL 0.25 MG GEL PACKETestradiol 3 ST

DIVIGEL 0.5 MG GEL PACKETestradiol 3 ST

DIVIGEL 1 MG GEL PACKETestradiol 3 ST

drosp-ee-levomef 3-0.02-0.451 3

drospirenone-ee 3-0.02 mg tab 1

drospirenone-ee 3-0.03 mg tab 1

DUAVEE 0.45-20 MG TABLETestrogens, conjugated/bazedoxifene acetate 3 QL 1 / 1 DAYS

eemt ds 1.25-2.5 mg tablet 3

eemt hs 0.625-1.25 mg tablet 3

ELESTRIN 0.06% GELestradiol 3 ST

elinest-28 tablet 1

emoquette 28 day tablet 1

enpresse-28 tablet 1

enskyce 28 tablet 1

estarylla 0.25-0.035 mg tablet 1



ESTRACE 0.01% CREAMestradiol 2

ESTRACE 2 MG TABLETestradiol 3

estradiol 0.025 mg patch 1 QL 8 / 28 DAYS


estradiol 0.0375 mg/day patch 1 QL 4 / 28 DAYS








estradiol 0.5 mg tablet 1

estradiol 1 mg tablet 1

estradiol 2 mg tablet 1

estradiol tds 0.025 mg/day 1 QL 4 / 28 DAYS






estradiol-noreth 0.5-0.1 mg tb 1

estradiol-noreth 1-0.5 mg tab 1

ESTRING 2 MG VAGINAL RINGestradiol 3

ESTROGEL 0.06% GELestradiol 3

estrogen-methyltestos f.s. tab 1



estrogen-methyltestos h.s. tab 1

estrogen-methyltestos h.s. tab 1

estrogen-methyltestosterone tb 1

estropipate 0.625(0.75 mg) tab 1

estropipate 1.25(1.5 mg) tab 1

estropipate 2.5(3 mg) tab 1

EVAMIST 1.53 MG/SPRAYestradiol 3

falmina-28 tablet 1

FEMRING 0.05 MG VAGINAL RINGestradiol acetate 3

FEMRING 0.10 MG VAGINAL RINGestradiol acetate 3

femynor 28 tablet 1

gianvi 3 mg-0.02 mg tablet 1

gildagia 0.4 mg-0.035 mg tab 1

gildess 1 mg-20 mcg tablet 1

gildess 1.5 mg-30 mcg tablet 1

gildess 24 fe 1-0.02 mg tablet 1

gildess fe 1-20 tablet 1

gildess fe 1.5-30 tablet 1

introvale 0.15-0.03 mg tablet 1 MDS1 91 / 1 DAYS

jolessa 0.15 mg-0.03 mg tablet 1

juleber 28 day tablet 1

junel 1 mg-20 mcg tablet 1

junel 1.5 mg-30 mcg tablet 1

junel fe 1 mg-20 mcg tablet 1

junel fe 1.5 mg-30 mcg tablet 1

junel fe 24 tablet 1

kariva 28 day tablet 1

kelnor 1-35 28 tablet 1

kimidess 28 day tablet 1



kurvelo tablet 1

larin 1.5 mg-30 mcg tablet 1

larin 21 1-20 tablet 1

larin 24 fe 1 mg-20 mcg tablet 1

larin fe 1-20 tablet 1

larin fe 1.5-30 tablet 1

larissia-28 tablet 1

leena 28 tablet 1

lessina-28 tablet 1

levonest-28 tablet 1

levono-e estrad 0.10-0.02-0.01 1 MDS1 91 / 1 DAYS

levono-e estrad 0.15-0.03-0.01 1

levonor-eth estra 0.09-0.02 mg 1

levonor-eth estrad 0.1-0.02 mg 1

levonor-eth estrad 0.15-0.03 1 MDS1 91 / 1 DAYS

levonor-eth estrad 0.15-0.03 1 MDS1 91 / 1 DAYS

levonor-eth estrad triphasic 1

levora-28 tablet 1

lomedia 24 fe 1 mg-20 mcg tab 1

lopreeza 0.5 mg-0.1 mg tablet 1

lopreeza 1 mg-0.5 mg tablet 1

loryna 3 mg-0.02 mg tablet 1

low-ogestrel-28 tablet 1

lutera-28 tablet 1

marlissa-28 tablet 1

MENEST 0.3 MG TABLETestrogens,esterified 3






MENOSTAR 14 MCG/DAY PATCHestradiol 3

microgestin 21 1-20 tablet 1

microgestin 21 1.5-30 tab 1

MICROGESTIN 24 FE 1 MG-20 MCGnorethindrone acetate-ethinyl estradiol/ferrous fumarate 3

microgestin fe 1-20 tablet 1

microgestin fe 1.5-30 tab 1

mimvey 1-0.5 mg tablet 1

mimvey lo 0.5-0.1 mg tablet 1

MINIVELLE 0.075 MG PATCHestradiol 3 QL 8 / 28 DAYS

mono-linyah 28 tablet 1

mononessa 28 tablet 1

myzilra-28 tablet 1

NATAZIA 28 TABLETestradiol valerate/dienogest 3

necon 0.5-35-28 tablet 1

necon 1-35-28 tablet 1



necon 7-7-7-28 tablet 1

nikki 3 mg-0.02 mg tablet 1

noret-estr-fe 0.4-0.035(21)-75 1

noreth-estrad-fe 1-0.02(21)-75 1

noreth-estrad-fe 1-0.02(24)-75 1

norethind-eth estrad 1-0.02 mg 1

norg-ee 0.18-0.215-0.25/0.025 1

norg-ee 0.18-0.215-0.25/0.035 1

norg-ethin estra 0.25-0.035 mg 1

NORINYL 1-35 28 TABLETnorethindrone-ethinyl estradiol 1

nortrel 0.5-35-28 tablet 1



nortrel 1-35 21 tablet 1

nortrel 1-35 28 tablet 1

nortrel 7-7-7-28 tablet 1

NUVARING VAGINAL RINGetonogestrel/ethinyl estradiol 3

ocella 3 mg-0.03 mg tablet 1

OGEN 2.5 TABLETestropipate 3

ogestrel tablet 2

orsythia-28 tablet 1

ORTHO EVRA PATCHnorelgestromin/ethinyl estradiol 2

philith 0.4-0.035 mg tablet 1

pimtrea 28 day tablet 1

pirmella 1-35-28 tablet 1

pirmella 7-7-7-28 tablet 1

portia-28 tablet 1

PREFEST TABLETestradiol/norgestimate 2

PREMARIN 0.3 MG TABLETestrogens, conjugated 2





PREMARIN VAGINAL CREAM-APPLestrogens, conjugated 2

PREMPHASE 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2

PREMPRO 0.3 MG-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2

PREMPRO 0.45-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2



PREMPRO 0.625-2.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2

PREMPRO 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2

previfem tablet 1

quasense 0.15-0.03 mg tablet 1

rajani 28 tablet 3

reclipsen 28 day tablet 1

setlakin 0.15 mg-0.03 mg tab 1

sprintec 28 day tablet 1

sronyx 0.10-0.02 mg tablet 1

syeda 28 tablet 1

tarina fe 1-20 tablet 1

tilia fe 28 tablet 1

tri-estarylla tablet 1

tri-legest fe-28 day tablet 1

tri-linyah tablet 1

tri-lo-estarylla tablet 1

tri-lo-marzia tablet 1

tri-lo-sprintec tablet 1

tri-previfem tablet 1

tri-sprintec tablet 1

trinessa lo tablet 1

trinessa tablet 1

trivora-28 tablet 1

velivet 28 day tablet 1

vestura 3 mg-0.02 mg tablet 1

vienva-28 tablet 1

viorele 28 day tablet 1

vyfemla 28 tablet 1

wera 0.5/0.035 mg 28 tablet 1

wymzya fe chewable tablet 1



xulane patch 1

yuvafem 10 mcg vaginal insert 2

zarah tablet 1

zenchent 0.4 mg-35 mcg tablet 1

zenchent fe tablet chewable 1

zeosa chewable tablet 1

zovia 1-35e tablet 1

zovia 1-50e tablet 1

PROGESTINS

AYGESTIN 5 MG TABLETnorethindrone acetate 3

camila 0.35 mg tablet 1

deblitane 0.35 mg tablet 1

errin 0.35 mg tablet 1

heather tablet 1

jencycla 0.35 mg tablet 1

jolivette tablet 1

lyza 0.35 mg tablet 1

medroxyprogesterone 10 mg tab 1

medroxyprogesterone 150 mg/ml 1

medroxyprogesterone 150 mg/ml 1

medroxyprogesterone 2.5 mg tab 1

medroxyprogesterone 5 mg tab 1

megestrol 20 mg tablet 1

nora-be tablet 1

norethindrone 0.35 mg tablet 1

norethindrone 5 mg tablet 1

norlyroc 0.35 mg tablet 1

progesterone 100 mg capsule 1

progesterone 200 mg capsule 1

sharobel 0.35 mg tablet 1



SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl 60 mg tablet 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 120 MG TABLETthyroid,pork 2








CYTOMEL 25 MCG TABLETliothyronine sodium 2



LEVO-T 100 MCG TABLETlevothyroxine sodium 2














levothyroxine 100 mcg tablet 1












LEVOXYL 100 MCG TABLETlevothyroxine sodium 2













liothyronine sod 25 mcg tab 1



NATURE-THROID 113.75 MG TABLETthyroid,pork 1

NATURE-THROID 130 MG TABLETthyroid,pork 1












np thyroid 15 mg tablet 1






SYNTHROID 100 MCG TABLETlevothyroxine sodium 2












THYROLAR-1 STRENGTH TABLETliotrix 2

THYROLAR-1/2 STRENGTH TABliotrix 2

THYROLAR-1/4 STRENGTH TABliotrix 2



UNITHROID 100 MCG TABLETlevothyroxine sodium 2














WESTHROID 130 MG TABLETthyroid,pork 1


WESTHROID 32.5 MG TABLETthyroid,pork 1


WESTHROID 97.5 MG TABLETthyroid,pork 1

WP THYROID 113.75 MG TABLETthyroid,pork 1

WP THYROID 130 MG TABLETthyroid,pork 1






WP THYROID 65 MG TABLETthyroid,pork 1



HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR 30 MG TABLETcinacalcet hcl 4 PA



HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 0.5 mg tablet 1

octreotide 1,000 mcg/5 ml vial 4

octreotide 1,000 mcg/ml vial 4

octreotide 5,000 mcg/5 ml vial 4

octreotide acet 0.05 mg/ml vl 4

octreotide acet 100 mcg/ml amp 4

octreotide acet 100 mcg/ml syr 4

octreotide acet 100 mcg/ml vl 4




octreotide acet 50 mcg/ml vial 4






HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 10 mg tablet 1

methimazole 5 mg tablet 1

propylthiouracil 50 mg tablet 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA (HAE) AGENTS

BERINERT 500 UNIT KITc1 esterase inhibitor 4

RUCONEST 2,100 UNIT VIALc1 esterase inhibitor, recombinant 4

IMMUNE SUPPRESSANTS

ASTAGRAF XL 0.5 MG CAPSULEtacrolimus 3

ASTAGRAF XL 1 MG CAPSULEtacrolimus 3

ASTAGRAF XL 5 MG CAPSULEtacrolimus 3

AZASAN 100 MG TABLETazathioprine 3

AZASAN 75 MG TABLETazathioprine 3

azathioprine 50 mg tablet 1

CIMZIA 200 MG VIAL KITcertolizumab pegol 4 PA

CIMZIA 200 MG/ML STARTER KITcertolizumab pegol 4 PA

CIMZIA 200 MG/ML SYRINGE KITcertolizumab pegol 4 PA

cyclosporine 100 mg capsule 1

cyclosporine 100 mg/ml soln 1

cyclosporine 25 mg capsule 1

cyclosporine modified 100 mg 1





ENBREL 25 MG KITetanercept 4 PA

ENBREL 25 MG/0.5 ML SYRINGEetanercept 4 PA

ENBREL 50 MG/ML SURECLICK SYRetanercept 4 PA

ENBREL 50 MG/ML SYRINGEetanercept 4 PA

gengraf 100 mg capsule 1

gengraf 100 mg/ml solution 1



hecoria 0.5 mg capsule 2

hecoria 1 mg capsule 2

hecoria 5 mg capsule 2

HUMIRA 10 MG/0.2 ML SYRINGEadalimumab 4 PA


HUMIRA 40 MG/0.8 ML PENadalimumab 4 PA


HUMIRA PEDIATRIC CROHN'S STARTadalimumab 4 PA

HUMIRA PEN CROHN-UC-HS STARTERadalimumab 4 PA

HUMIRA PEN PSORIASIS-UVEITISadalimumab 4 PA

IMURAN 50 MG TABLETazathioprine 3

KINERET 100 MG/0.67 ML SYRINGEanakinra 4 PA

methotrexate 2.5 mg tablet 1

methotrexate 250 mg/10 ml vial 1

methotrexate 50 mg/2 ml vial 1

mycophenolate 200 mg/ml susp 3



mycophenolate 250 mg capsule 1

mycophenolate 500 mg tablet 1

mycophenolic acid dr 180 mg tb 2

mycophenolic acid dr 360 mg tb 2

NEORAL 100 MG/ML SOLUTIONcyclosporine, modified 3

ORENCIA 125 MG/ML SYRINGEabatacept 4 PA

ORENCIA CLICKJECT 125 MG/MLabatacept 4 PA

OTREXUP 10 MG/0.4 ML AUTO-INJmethotrexate/pf 4

QL 1.6 / 28 DAYS

ST

OTREXUP 12.5 MG/0.4 ML AUTOINJmethotrexate/pf 4


QL 1.6 / 28 DAYS

ST



QL 1.6 / 28 DAYS

ST



QL 1.6 / 28 DAYS

ST

RAPAMUNE 1 MG/ML ORAL SOLNsirolimus 3 PA

RASUVO 10 MG/0.2 ML AUTOINJmethotrexate/pf 4 ST

RASUVO 12.5 MG/0.25 ML AUTOINJmethotrexate/pf 4 ST



RASUVO 20 MG/0.4 ML AUTOINJmethotrexate/pf 4

QL 1.6 / 28 DAYS

ST








SANDIMMUNE 100 MG/ML SOLNcyclosporine 3

SIMPONI 100 MG/ML PEN INJECTORgolimumab 4 PA

SIMPONI 100 MG/ML SYRINGEgolimumab 4 PA

SIMPONI 50 MG/0.5 ML PEN INJECgolimumab 4 PA

SIMPONI 50 MG/0.5 ML SYRINGEgolimumab 4 PA

sirolimus 0.5 mg tablet 3 PA

sirolimus 1 mg tablet 3 PA

sirolimus 2 mg tablet 3 PA

tacrolimus 0.5 mg capsule 2

tacrolimus 1 mg capsule 2

tacrolimus 5 mg capsule 2

TREXALL 10 MG TABLETmethotrexate sodium 2



TREXALL 7.5 MG TABLETmethotrexate sodium 2

XELJANZ 5 MG TABLETtofacitinib citrate 4 PA

XELJANZ XR 11 MG TABLETtofacitinib citrate 4 PA



ZORTRESS 0.25 MG TABLETeverolimus 2 PA



IMMUNOMODULATORS

ACTEMRA 162 MG/0.9 ML SYRINGEtocilizumab 4 PA

ACTIMMUNE 100 MCG/0.5 ML VIALinterferon gamma-1b,recomb. 4 PA

leflunomide 10 mg tablet 1

leflunomide 20 mg tablet 1

OTEZLA 28 DAY STARTER PACKapremilast 4 PA

OTEZLA 30 MG TABLETapremilast 4 PA

OTEZLA STARTER PACKapremilast 4 PA

RIDAURA 3 MG CAPSULEauranofin 4

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO ER 0.375 GRAM CAPSULEmesalamine 2 QL 120 / 30 DAYS

balsalazide disodium 750 mg cp 3

CANASA 1,000 MG SUPPOSITORYmesalamine 2

DELZICOL DR 400 MG CAPSULEmesalamine 3 ST

DIPENTUM 250 MG CAPSULEolsalazine sodium 3

GIAZO 1.1 GM TABLETbalsalazide disodium 3

LIALDA DR 1.2 GM TABLETmesalamine 3

mesalamine 4 gm/60 ml enema 1



mesalamine 4 gm/60 ml kit 1

mesalamine 800 mg dr tablet 2

PENTASA 250 MG CAPSULEmesalamine 2

PENTASA 500 MG CAPSULEmesalamine 2

GLUCOCORTICOIDS

budesonide ec 3 mg capsule 3

colocort 100 mg enema 1

CORTIFOAM 10% AEROSOLhydrocortisone acetate 2

hydrocortisone 100 mg/60 ml 1

hydrocortisone 2.5% cream 1

procto-med hc 2.5% cream 1

proctosol-hc 2.5% cream 1

proctozone-hc 2.5% cream 1

UCERIS 9 MG ER TABLETbudesonide 3 ST

SULFONAMIDES

sulfasalazine 500 mg tablet 1

sulfasalazine dr 500 mg tab 1

METABOLIC BONE DISEASE AGENTS

alendronate sod 70 mg/75 ml 1

alendronate sodium 10 mg tab 1 QL 30 / 30 DAYS



alendronate sodium 5 mg tablet 1 QL 30 / 30 DAYS


calcitonin-salmon 200 units sp 1

calcitriol 0.25 mcg capsule 1

calcitriol 0.5 mcg capsule 1

calcitriol 1 mcg/ml solution 1



DRISDOL 50,000 UNITS CAPSULEergocalciferol (vitamin d2) 3

FORTEO 600 MCG/2.4 ML PEN INJteriparatide 4 PA

ibandronate sodium 150 mg tab 1

MIACALCIN 200 UNIT NASAL SPRAYcalcitonin,salmon,synthetic 3

NATPARA 100 MCG DOSE CARTRIDGEparathyroid hormone 4 PA




paricalcitol 1 mcg capsule 3



risedronate sod dr 35 mg tab 3 ST

risedronate sodium 150 mg tab 3

risedronate sodium 30 mg tab 3 QL 30 / 30 DAYS

risedronate sodium 35 mg tab 3 QL 4 / 28 DAYS

risedronate sodium 5 mg tablet 3 QL 30 / 30 DAYS

ROCALTROL 1 MCG/ML ORAL SOLNcalcitriol 3

vit d2 1.25 mg (50,000 unit) 1

MISCELLANEOUS THERAPEUTIC AGENTS

insulin syrin 0.5 ml 30gx1/2" 2

insulin syrin 0.5 ml 30gx5/16" 2

insulin syringe 1 ml 30gx1/2" 2

insulin syringe 1 ml 30gx5/16" 2

magellan insul syringe 0.3 ml 2

magellan insul syringe 0.5 ml 2

magellan insulin syr 0.3 ml 2



magellan insulin syr 0.5 ml 2

magellan insulin syringe 1 ml 2

magellan insulin syringe 1 ml 2

monoject 0.5 ml syrn 28gx1/2" 2

monoject 1 ml syrn 28gx1/2" 2

monoject insulin syr 0.3 ml 2

monoject insulin syr 0.5 ml 2

monoject insulin syr 1 ml 2

monoject insulin syr u-100 2

monoject syringe 1 ml 2

MYALEPT 11.3 MG (5 MG/ML) VIALmetreleptin 3 QL 1 / 1 DAYS

pen needles 2

saccharin powder 3

sen-serter 3

sorbitol 70% solution 3

ulticare ins safety 1ml 29x1/2 2

ulticare safety 0.5 ml 29gx1/2 2

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

ak-poly-bac eye ointment 1

atropine 1% eye drops 1

atropine 1% eye ointment 1

bacitracin-polymyxin eye oint 1

BLEPHAMIDE EYE DROPSsulfacetamide sodium/prednisolone acetate 2

BLEPHAMIDE EYE OINTMENTsulfacetamide sodium/prednisolone acetate 2

cyclopentolate 1% eye drops 1

FLUCAINE EYE DROPSproparacaine hcl/fluorescein sodium 1

fluorescein-proparacaine drops 1

homatropaire 5% eye drops 1



homatropine 5% eye drops 1

ISOPTO ATROPINE 1% EYE DROPSatropine sulfate 2

neo-bacit-poly-hc eye ointment 1

neo-polycin eye ointment 1

neo-polycin hc eye ointment 1

neomyc-bacit-polymix eye oint 1

neomyc-polym-gramicid eye drop 1

polycin eye ointment 1

polymyxin b-tmp eye drops 1

PRED-G 1% EYE DROPSgentamicin sulfate/prednisolone acetate 2

PRED-G S.O.P. EYE OINTMENTgentamicin sulfate/prednisolone acetate 2

RESTASIS 0.05% EYE EMULSIONcyclosporine 3

sulf-pred 10-0.23% eye drops 1

sulf-pred 10-0.25% eye drops 1

TOBRADEX EYE OINTMENTtobramycin/dexamethasone 2

TOBRADEX ST EYE DROPStobramycin/dexamethasone 3 ST

tobramycin-dexameth ophth susp 1

tropicamide 0.5% eye drops 1

tropicamide 1% eye drops 1

ZYLET EYE DROPStobramycin/loteprednol etabonate 3

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 2% EYE DROPSnedocromil sodium 3

ALOMIDE 0.1% EYE DROPSlodoxamide tromethamine 3

azelastine hcl 0.05% drops 1

cromolyn 4% eye drops 1

EMADINE 0.05% EYE DROPSemedastine difumarate 3



epinastine hcl 0.05% eye drops 1

LASTACAFT 0.25% EYE DROPSalcaftadine 3 ST

olopatadine hcl 0.1% eye drops 1

PATADAY 0.2% EYE DROPSolopatadine hcl 3

PAZEO 0.7% EYE DROPSolopatadine hcl 3 ST

OPHTHALMIC ANTI-INFLAMMATORIES

ACUVAIL 0.45% OPHTH SOLUTIONketorolac tromethamine/pf 3

ALREX 0.2% EYE DROPSloteprednol etabonate 3

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1

DUREZOL 0.05% EYE DROPSdifluprednate 3

FLAREX 0.1% EYE DROPSfluorometholone acetate 2

fluorometholone 0.1% drops 1

flurbiprofen 0.03% eye drop 1

FML FORTE 0.25% EYE DROPSfluorometholone 3

FML S.O.P. 0.1% OINTMENTfluorometholone 3

ILEVRO 0.3% OPHTH DROPSnepafenac 3

ketorolac 0.4% ophth solution 1

ketorolac 0.5% ophth solution 1

LOTEMAX 0.5% EYE DROPSloteprednol etabonate 2

LOTEMAX 0.5% EYE OINTMENTloteprednol etabonate 2

LOTEMAX 0.5% OPHTHALMIC GELloteprednol etabonate 2

MAXIDEX 0.1% EYE DROPSdexamethasone 2



NEVANAC 0.1% DROPTAINERnepafenac 3

PRED MILD 0.12% EYE DROPSprednisolone acetate 2

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1% DROPSbrimonidine tartrate 2

apraclonidine hcl 0.5% drops 2

AZOPT 1% EYE DROPSbrinzolamide 2

betaxolol hcl 0.5% eye drop 1

BETOPTIC S 0.25% EYE DROPSbetaxolol hcl 2

brimonidine 0.2% eye drop 1

brimonidine tartrate 0.15% drp 1

COMBIGAN 0.2%-0.5% EYE DROPSbrimonidine tartrate/timolol maleate 3

COSOPT PF EYE DROPSdorzolamide hcl/timolol maleate/pf 3

dorzolamide hcl 2% eye drops 1

dorzolamide-timolol eye drops 1

IOPIDINE 1% EYE DROPSapraclonidine hcl 2

levobunolol 0.5% eye drops 1

metipranolol 0.3% eye drops 1

PHOSPHOLINE IODIDE 0.125%echothiophate iodide 2

pilocarpine 1% eye drops 1



SIMBRINZA 1%-0.2% EYE DROPSbrinzolamide/brimonidine tartrate 3

timolol 0.25% eye drops 1



timolol 0.25% gel-solution 1

timolol 0.25% gfs gel-solution 1

timolol 0.5% eye drops 1

timolol 0.5% gel-solution 1

timolol 0.5% gfs gel-solution 1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 0.03% eye drops 3

latanoprost 0.005% eye drops 1

TRAVATAN Z 0.004% EYE DROPtravoprost 2

ZIOPTAN 0.0015% EYE DROPStafluprost/pf 3

OTIC AGENTS

acetasol hc ear drops 1

acetic acid 2% ear solution 1

CIPRO HC OTIC SUSPENSIONciprofloxacin hcl/hydrocortisone 2 ST

CIPRODEX OTIC SUSPENSIONciprofloxacin hcl/dexamethasone 2

ST


fluocinolone oil 0.01% ear drp 1

hydrocortison-acetic acid soln 1

neomycin-polymyxin-hc ear soln 1

neomycin-polymyxin-hc ear susp 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

AEROSPAN 80 MCG INHALERflunisolide 3

QL 17.9 / 30 DAYS

ST

ALVESCO 160 MCG INHALERciclesonide 3

QL 12.2 / 30 DAYS

ST


ALVESCO 80 MCG INHALERciclesonide 3

QL 12.2 / 30 DAYS

ST




ARNUITY ELLIPTA 100 MCG INHfluticasone furoate 3

QL 1 / 1 DAYS

ST

ARNUITY ELLIPTA 200 MCG INHfluticasone furoate 3

QL 1 / 1 DAYS

ST

ASMANEX HFA 100 MCG INHALERmometasone furoate 2

ASMANEX HFA 200 MCG INHALERmometasone furoate 2

ASMANEX TWISTHALER 110 MCG #30mometasone furoate 2 QL 2 / 30 DAYS




ASMANEX TWISTHALR 220 MCG #120mometasone furoate 2 QL 2 / 30 DAYS

BECONASE AQ 0.042% SPRAYbeclomethasone dipropionate 3 QL 50 / 30 DAYS

budesonide 0.25 mg/2 ml susp 1 AL1 Up to 8 yrs old

budesonide 0.5 mg/2 ml susp 1 AL1 Up to 8 yrs old

budesonide 1 mg/2 ml inh susp 1

budesonide 32 mcg nasal spray 3

FLOVENT 100 MCG DISKUSfluticasone propionate 2 QL 120 / 30 DAYS



FLOVENT HFA 110 MCG INHALERfluticasone propionate 2 QL 24 / 30 DAYS

FLOVENT HFA 220 MCG INHALERfluticasone propionate 2 QL 24 / 30 DAYS

FLOVENT HFA 44 MCG INHALERfluticasone propionate 2 QL 21.2 / 30 DAYS



flunisolide 0.025% spray 1 QL 25 / 10 DAYS

fluticasone prop 50 mcg spray 1 QL 32 / 30 DAYS

mometasone furoate 50 mcg spry 1

NASONEX 50 MCG NASAL SPRAYmometasone furoate 2 QL 34 / 30 DAYS

OMNARIS 50 MCG NASAL SPRAYciclesonide 3

QL 12.5 / 30 DAYS

ST


PULMICORT 180 MCG FLEXHALERbudesonide 3 QL 2 / 30 DAYS

PULMICORT 90 MCG FLEXHALERbudesonide 3 QL 2 / 30 DAYS

QNASL 80 MCG NASAL SPRAYbeclomethasone dipropionate 3 ST

QNASL CHILDREN'S 40 MCG SPRAYbeclomethasone dipropionate 3

QVAR 40 MCG ORAL INHALERbeclomethasone dipropionate 2 QL 17.4 / 30 DAYS

QVAR 80 MCG ORAL INHALERbeclomethasone dipropionate 2 QL 17.4 / 30 DAYS

VERAMYST 27.5 MCG NASAL SPRAYfluticasone furoate 3 QL 20 / 30 DAYS

ZETONNA 37 MCG NASAL SPRAYciclesonide 3 ST

ANTIHISTAMINES

arbinoxa 4 mg tablet 1

arbinoxa 4 mg/5 ml liquid 1

azelastine 0.1% (137 mcg) spry 1 QL 60 / 30 DAYS

azelastine 0.15% nasal spray 1 QL 60 / 30 DAYS

carbinoxamine 4 mg/5 ml liquid 1

carbinoxamine maleate 4 mg tab 1

cyproheptadine 4 mg tablet 1

hydroxyzine 10 mg/5 ml soln 1

hydroxyzine 10 mg/5 ml syrup 1



hydroxyzine 50 mg/25 ml syrup 1

hydroxyzine hcl 10 mg tablet 1



hydroxyzine pam 100 mg cap 1



olopatadine 665 mcg nasal spry 3 QL 30.5 / 30 DAYS

promethazine 12.5 mg tablet 1

promethazine 25 mg tablet 1 AL1 At least 2 yrs old

promethazine 6.25 mg/5 ml syrp 1

ANTILEUKOTRIENES

montelukast sod 10 mg tablet 1

montelukast sod 4 mg granules 1

montelukast sod 4 mg tab chew 1

montelukast sod 5 mg tab chew 1

zafirlukast 10 mg tablet 1

zafirlukast 20 mg tablet 1

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT 0.03% SPRAYipratropium bromide 2

ATROVENT 0.06% SPRAYipratropium bromide 2

ATROVENT HFA INHALERipratropium bromide 2 QL 38.7 / 30 DAYS

INCRUSE ELLIPTA 62.5 MCG INHumeclidinium bromide 3

QL 1 / 1 DAYS

ST

ipratropium 0.03% spray 1

ipratropium 0.06% spray 1

ipratropium br 0.02% soln 1

SPIRIVA 18 MCG CP-HANDIHALERtiotropium bromide 2

QL 1 / 1 DAYS

ST



SPIRIVA RESPIMAT 1.25 MCG INHtiotropium bromide 2 ST

SPIRIVA RESPIMAT 2.5 MCG INHtiotropium bromide 2

QL 4 / 30 DAYS

ST

TUDORZA PRESSAIR 400 MCG INHaclidinium bromide 2

QL 1 / 30 DAYS

ST

BRONCHODILATORS, SYMPATHOMIMETIC

ACCUNEB 1.25 MG/3 ML INH SOLNalbuterol sulfate 3

albuterol 2.5 mg/0.5 ml sol 1

albuterol 5 mg/ml solution 1

albuterol sul 0.63 mg/3 ml sol 1

albuterol sul 1.25 mg/3 ml sol 1

albuterol sul 2.5 mg/3 ml soln 1

albuterol sulf 2 mg/5 ml syrup 1

albuterol sulfate 2 mg tab 1

albuterol sulfate 4 mg tab 1

albuterol sulfate er 4 mg tab 1

albuterol sulfate er 8 mg tab 1

ARCAPTA NEOHALER 75 MCG CAPindacaterol maleate 2 ST

BROVANA 15 MCG/2 ML SOLUTIONarformoterol tartrate 2

QL 60 / 1 FILL

PA

epinephrine 0.15 mg auto-injct 1

epinephrine 0.3 mg auto-inject 1

FORADIL AEROLIZER 12 MCG CAPformoterol fumarate 2 QL 120 / 30 DAYS

levalbuterol 0.31 mg/3 ml sol 3 ST



levalbuterol conc 1.25 mg/0.5 3 ST

levalbuterol tar hfa 45mcg inh 3



metaproterenol 10 mg tablet 1

metaproterenol 10 mg/5 ml syr 1

metaproterenol 20 mg tablet 1

PERFOROMIST 20 MCG/2 ML SOLNformoterol fumarate 3

QL 60 / 30 DAYS

PA

PROAIR HFA 90 MCG INHALERalbuterol sulfate 2 QL 8.5 / 15 DAYS

PROAIR RESPICLICK INHAL POWDERalbuterol sulfate 2 QL 2 / 30 DAYS

PROVENTIL HFA 90 MCG INHALERalbuterol sulfate 3 QL 13.4 / 30 DAYS

SEREVENT DISKUS 50 MCGsalmeterol xinafoate 2 QL 120 / 30 DAYS

STRIVERDI RESPIMAT INHAL SPRAYolodaterol hcl 3

QL 1 / 30 DAYS

ST

terbutaline sulfate 2.5 mg tab 1

terbutaline sulfate 5 mg tab 1

VENTOLIN HFA 90 MCG INHALERalbuterol sulfate 2 QL 36 / 30 DAYS

CYSTIC FIBROSIS AGENTS

BETHKIS 300 MG/4 ML AMPULEtobramycin 4

KALYDECO 150 MG TABLETivacaftor 4 PA

KALYDECO 50 MG GRANULES PACKETivacaftor 4

KALYDECO 75 MG GRANULES PACKETivacaftor 4

KITABIS PAK 300 MG/5 MLtobramycin/nebulizer 4 PA

ORKAMBI 100 MG-125 MG TABLETlumacaftor/ivacaftor 4

ORKAMBI 200 MG-125 MG TABLETlumacaftor/ivacaftor 4

QL 4 / 1 DAYS

PA




TOBI PODHALER 28 MG INHALE CAPtobramycin 4 PA

tobramycin 300 mg/5 ml ampule 4

tobramycin pak 300 mg/5 ml 4 PA

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

DALIRESP 500 MCG TABLETroflumilast 3 PA

ELIXOPHYLLIN 80 MG/15 ML ELIXtheophylline anhydrous 1

theochron er 100 mg tablet 1



theophylline 80 mg/15 ml soln 1

theophylline er 100 mg tablet 1


theophylline er 300 mg tab 1


theophylline er 450 mg tab 1


PULMONARY ANTIHYPERTENSIVES

ADCIRCA 20 MG TABLETtadalafil 4 PA

ADEMPAS 0.5 MG TABLETriociguat 4 PA

ADEMPAS 1 MG TABLETriociguat 4 PA


ADEMPAS 2 MG TABLETriociguat 4 PA


LETAIRIS 10 MG TABLETambrisentan 4 PA

LETAIRIS 5 MG TABLETambrisentan 4 PA



OPSUMIT 10 MG TABLETmacitentan 4 PA

ORENITRAM ER 0.125 MG TABLETtreprostinil diolamine 4


ORENITRAM ER 1 MG TABLETtreprostinil diolamine 4


REMODULIN 1 MG/ML VIALtreprostinil sodium 4


REMODULIN 2.5 MG/ML VIALtreprostinil sodium 4


REVATIO 10 MG/ML ORAL SUSPsildenafil citrate 4

sildenafil 20 mg tablet 1 PA

TRACLEER 125 MG TABLETbosentan 4

TRACLEER 62.5 MG TABLETbosentan 4

TYVASO 1.74 MG/2.9 ML SOLUTIONtreprostinil 4

TYVASO INHALATION REFILL KITtreprostinil/nebulizer accessories 4

TYVASO INHALATION STARTER KITtreprostinil/nebulizer and accessories 4 PA

TYVASO INSTITUTIONAL START KITtreprostinil/nebulizer and accessories 4 PA

UPTRAVI 1,000 MCG TABLETselexipag 4






UPTRAVI 200 MCG TABLETselexipag 4

UPTRAVI 200-800 TITRATION PACKselexipag 4




VENTAVIS 10 MCG/1 ML SOLUTIONiloprost tromethamine 4 PA

VENTAVIS 20 MCG/1 ML SOLUTIONiloprost tromethamine 4 PA

RESPIRATORY TRACT AGENTS, OTHER

ADVAIR 100-50 DISKUSfluticasone propionate/salmeterol xinafoate 2

QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

PA

ADVAIR HFA 115-21 MCG INHALERfluticasone propionate/salmeterol xinafoate 2

QL 12 / 30 DAYS

ST


QL 12 / 30 DAYS

ST


QL 12 / 30 DAYS

ST

ANORO ELLIPTA 62.5-25 MCG INHumeclidinium bromide/vilanterol trifenatate 2

QL 60 / 30 DAYS

ST

benzonatate 100 mg capsule 1





BREO ELLIPTA 100-25 MCG INHfluticasone furoate/vilanterol trifenatate 2

QL 60 / 30 DAYS

ST

BREO ELLIPTA 200-25 MCG INHfluticasone furoate/vilanterol trifenatate 2

COMBIVENT RESPIMAT INHAL SPRAYipratropium bromide/albuterol sulfate 2

DULERA 100 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate 2

QL 26 / 30 DAYS

ST


DULERA 200 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate 2

QL 26 / 30 DAYS

ST


ESBRIET 267 MG CAPSULEpirfenidone 4 PA

GRASTEK 2,800 BAU SL TABLETallergenic extract,grass pollen-timothy,standard 3 PA

hydrocod-homatrop 5-1.5 mg tab 1

hydrocodone-chlorphen er susp 1

hydrocodone-homatropine syrup 1

hydromet syrup 1

iprat-albut 0.5-3(2.5) mg/3 ml 1

OFEV 100 MG CAPSULEnintedanib esylate 4 PA

OFEV 150 MG CAPSULEnintedanib esylate 4 PA

ORALAIR 300 IR STARTER PACKgrass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. 3 PA

ORALAIR 300 IR SUBLINGUAL TABgrass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. 3 PA

promethazine vc syrup 1

promethazine vc-codeine syrup 1

promethazine-codeine syrup 1

promethazine-dm solution 1

promethazine-dm syrup 1



promethazine-pe-codeine syrup 1

promethazine-phenylephrine syr 1

PULMOZYME 1 MG/ML AMPULdornase alfa 4 PA

RAGWITEK SUBLINGUAL TABLETallergenic extract-weed pollen-short ragweed 3 PA

SEMPREX-D 8 MG-60 MG CAPSULEpseudoephedrine hcl/acrivastine 3

STIOLTO RESPIMAT INHAL SPRAYtiotropium bromide/olodaterol hcl 3

QL 4 / 30 DAYS

ST

SYMBICORT 160-4.5 MCG INHALERbudesonide/formoterol fumarate 2

QL 20.4 / 30 DAYS

ST


SYMBICORT 80-4.5 MCG INHALERbudesonide/formoterol fumarate 2

QL 20.4 / 30 DAYS

ST


TUSNEL PEDIATRIC LIQUIDguaifenesin/dextromethorphan hbr/pseudoephedrine hcl 3

tussigon 5-1.5 mg tablet 3

SKELETAL MUSCLE RELAXANTS

carisoprodl-aspirin 200-325 mg 1

carisoprodol 250 mg tablet 1

carisoprodol 350 mg tablet 1

carisoprodol compound tab 1

chlorzoxazone 500 mg tablet 1

cyclobenzaprine 10 mg tablet 1

cyclobenzaprine 5 mg tablet 1

LORZONE 375 MG TABLETchlorzoxazone 3 ST

LORZONE 750 MG TABLETchlorzoxazone 3 ST

metaxall 800 mg tablet 2

metaxalone 400 mg tablet 2

metaxalone 800 mg tablet 2



methocarbamol 500 mg tablet 1

methocarbamol 750 mg tablet 1

orphenadrine er 100 mg tablet 1

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

eszopiclone 1 mg tablet 1 QL 1 / 1 DAYS



temazepam 15 mg capsule 1 QL 1 / 1 DAYS

temazepam 22.5 mg capsule 3 QL 15 / 30 DAYS

temazepam 30 mg capsule 1 QL 1 / 1 DAYS

temazepam 7.5 mg capsule 3 QL 15 / 30 DAYS

triazolam 0.125 mg tablet 1 QL 15 / 30 DAYS

triazolam 0.25 mg tablet 1 QL 15 / 30 DAYS

zaleplon 10 mg capsule 1QL 1 / 1 DAYS

ST

zaleplon 5 mg capsule 1QL 1 / 1 DAYS

ST

zolpidem tart er 12.5 mg tab 3QL 15 / 30 DAYS

ST

zolpidem tart er 6.25 mg tab 3QL 15 / 30 DAYS

ST

zolpidem tartrate 10 mg tablet 3 QL 30 / 30 DAYS

zolpidem tartrate 5 mg tablet 3 QL 30 / 30 DAYS

SLEEP DISORDERS, OTHER

armodafinil 150 mg tablet 3QL 30 / fill(s)

PA


PA




PA

armodafinil 50 mg tablet 3QL 30 / FILL

PA

BELSOMRA 15 MG TABLETsuvorexant 3

QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST


QL 1 / 1 DAYS

ST

flurazepam 15 mg capsule 1

flurazepam 30 mg capsule 1

modafinil 100 mg tablet 3QL 30 / 30 DAYS


modafinil 200 mg tablet 3QL 30 / 30 DAYS


XYREM 500 MG/ML ORAL SOLUTIONsodium oxybate 4

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

EXJADE 125 MG TABLETdeferasirox 4



JADENU 180 MG TABLETdeferasirox 4 PA



kionex 15 gm/60 ml suspension 1



sod polystyren sulf 15 g/60 ml 1

sps 15 gm/60 ml suspension 1

SPS 15 GM/60 ML SUSPENSIONsodium polystyrene sulfonate/sorbitol solution 1

ELECTROLYTE/MINERAL REPLACEMENT

calcium-folic acid plus d wfer 1

FOLGARD OS TABLETcalcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron 2

KLOR-CON 25 MEQ PACKETpotassium chloride 3

klor-con m10 tablet 1


KLOR-CON M15 TABLETpotassium chloride 1


klor-con sprinkle er 10 meq cp 1

klor-con sprinkle er 8 meq cap 1

potassium cl 10% (20 meq/15 ml 1


potassium cl 20 meq packet 2


potassium cl 25 meq tab eff 1

potassium cl er 10 meq capsule 1

potassium cl er 10 meq tablet 1




potassium cl er 8 meq capsule 1


tl g-fol os tablet 1

calcium-pnv 28-1-250 mg sftgl 1

CITRANATAL B-CALM COMBO PACKprenatal vitamin no.48/iron,carbonyl,gluconate/folic acid/b6 2



complete natal dha 2

cyanocobalamin 1,000 mcg/ml 1

cyanocobalamin 10,000 mcg/10 1

cyanocobalamin 30,000 mcg/30 1

DIALYVITE 3,000 TABLETfolic acid/vitamin b comp and c/selenium/min aa chel/zinc 1

DUET DHA 400 COMBO PACKprenatal vitamin no.106/sod ferede-iron poly/fa/om3/dha/epa 2

DUET DHA BALANCED (25 MG IRON)prenatal vitamin no.117/sod ferede-iron poly/fa/om3/dha/epa 2

elite ob dha softgel 1

fabb tablet 1

folbee ar tablet 1

folbee plus tablet 1

folbee tablet 1

FOLGARD RX TABLETcyanocobalamin/folic acid/pyridoxine 3

folic acid 1 mg tablet 1

folic acid-vit b6-vit b12 tab 1

folplex 2.2 tablet 1

MEPHYTON 5 MG TABLETphytonadione (vit k1) 2

multi-vit w-fluor 0.25 mg/ml 1



multivit & fluor 0.5 mg/ml drp 1

multivit-fluor 0.25 mg tab chw 1


multivit-fluor 0.25 mg/ml drop 1



multivit-fluor 0.5 mg tab chew 1






multivit-fluor-iron 0.25 mg/ml 1

multivit-fluoride 1 mg tab chw 1

multivit-fluoride 1 mg tab chw 1

multivit-iron-fl 0.25 mg/ml 1



multivit-iron-fluor 0.25 mg/ml 1

MVC-FLUORIDE 0.25 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1

MVC-FLUORIDE 0.5 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1

MVC-FLUORIDE 1 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1

MYNATAL CAPSULEprenatal vitamins with calcium/ferrous fumarate/folic acid 1

mynatal plus captab 1

mynatal-z captab 1

mynephrocaps softgel 1

mynephron capsule 1

NATELLE ONE CAPSULEprenatal vits with calcium #70/ferrous fumarate/fa/dha 2

NEPHRO-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin 1

NICOMIDE TABLETmethyltetrahydrofolate glucosamine/niacinamide/cupric,zn ox 2

niva-plus tablet 1

O-CAL FA TABLETprenatal vitamins with calcium/ferrous fumarate/folic acid 1

OB COMPLETE CAPLETiron,carbonyl/folic acid/multivit with minerals 2

OB COMPLETE ONE SOFTGELpnv no.85/iron carb,aspart.glycinate/folic acid/dha/fish oil 2

OB COMPLETE PETITE SOFTGELprenatal no56/iron carbonyl,asparto glycinate/folic acid/dha 2



OB COMPLETE PREMIER TABLETprenatal vitamins comb #83/iron,carbonyl/iron asparto gly/fa 2

pnv prenatal plus multivit tab 1

pnv-dha + docusate softgel 1

POLY-VI-FLOR 0.25 MG DROPSpediatric multivitamin no.37 with sodium fluoride 2

POLY-VI-FLOR 0.25 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2

POLY-VI-FLOR 0.5 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2

POLY-VI-FLOR 1 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2

POLY-VI-FLOR WITH IRON 0.25 MGpediatric multivit #37/sodium fluoride/iron bisglycinate hcl 2

POLY-VI-FLOR WITH IRON 0.5 MGpediatric multivitamin no.33/sodium fluoride/iron carbonyl 2

PREFERA-OB ONE SOFTGELprenatal vitamin no.19/iron polysac,iron heme/folic acid/dha 2

PRENATA CHEWABLE TABLETprenatal vitamins combo no.37/ferrous fumarate/folic acid 2

PRENATABS FA TABLETprenatal vits with calcium #78/ferrous fumarate/folic acid 1

PRENATABS RX TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid 1

prenatal low iron tablet 1

prenatal plus multivitamin tab 1

prenatal plus tablet 1

prenatal vitamin plus low iron 1

PRENATE CHEWABLE TABLETprenatal vitamins no.112/methyltetrahydrofolate glucosami,fa 2

PRENATE DHA SOFTGELprenatal vitamins no.38/iron fumarate/folate comb no.6/dha 2

PRENATE ELITE TABLETprenatal vitamins combo #36/ferrous fumarate/folate combo #6 2

PRENATE ESSENTIAL SOFTGELprenatal vitamin no.35/iron fumarate/folate comb. no.6/dha 2

preplus ca-fe 27 mg-fa 1 mg tb 1



PREQUE 10 TABLETprenatal vit no.18/iron/folic acid/docusate sod./co-q10/dha 2

rena-vite rx tablet 1

renal caps softgel 1

reno caps softgel 1

se-natal 19 chewable tablet 1

tl gard rx tablet 1

TRI-VI-FLOR 0.25 MG DROPSpediatric multivitamin a,c,and d3 no.38 with sodium fluoride 2

TRI-VI-FLOR 0.5 MG DROPSpediatric multivitamin a,c,and d3 no.38 with sodium fluoride 2

tri-vit-fluor 0.25 mg/ml drop 1

trinatal rx 1 tablet 2

TRINATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid 1

triphrocaps softgel 1

triple-vit w-fluor 0.25 mg/ml 1

trust natal dha 2

vemavite-prx 2 capsule 1

vinacal prenatal tablet 1

vinate one tablet 1

virt-caps (1 mg fa b comp w-c) 1

virt-caps softgel 1

virt-gard tablet 1

virt-vite tablet 1

vit a,c,d-fluoride 0.25 mg/ml 1

VITA-RESPA TABLETcyanocobalamin/folic acid/pyridoxine 3

VITAFOL-OB CAPLETprenatal vitamins comb 10/ferrous fumarate/folic acid 2

VITAFOL-ONE CAPSULEprenatal vitamins no.26/iron polysaccharides/fa/dha 2

vol-care rx tablet 1

vol-plus tablet 1



vp-ch plus softgel 1

vp-heme one softgel 1

vp-vite rx tablet 1

XURIDEN GRANULE PACKETuridine triacetate 4


Index of covered drugsAABACAVIR SULFATE 66,67

ABACAVIR SULFATE/DOLUTEGRAVIR

SODIUM/LAMIVUDINE 68

ABACAVIR SULFATE/LAMIVUDINE 66

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 66

ABATACEPT 154

ABILIFY DISCMELT 58

ABIRATERONE ACETATE 47

ABSORICA 114

ACAMPROSATE CALCIUM 15

ACARBOSE 72,76

ACCUNEB 167

ACEBUTOLOL HCL 86

ACEON 83

ACETAMINOPHEN WITH CODEINE

PHOSPHATE 10,11

ACETIC ACID 163

ACETIC ACID/HYDROCORTISONE 163

ACLIDINIUM BROMIDE 167

ACTEMRA 156

ACTIGALL 123

ACTIMMUNE 156

ACTOPLUS MET XR 72

ACUVAIL 161

ACYCLOVIR 70

ACZONE 114

ADALAT CC 88

ADALIMUMAB 153

ADAPALENE 114

ADAPALENE/BENZOYL PEROXIDE 116

ADCIRCA 169

ADEFOVIR DIPIVOXIL 63

ADEMPAS 169

ADVAIR DISKUS 171

ADVAIR HFA 171

AEROSPAN 163

AFATINIB DIMALEATE 50

AFINITOR 49

AFINITOR DISPERZ 49,50

AKYNZEO 40

ALA-CORT 129

ALA-QUIN 114

ALBUTEROL SULFATE 167,168

ALCAFTADINE 161

ALCLOMETASONE DIPROPIONATE 129

ALECENSA 50

ALECTINIB HCL 50

ALENDRONATE SODIUM 157

ALFERON N 70

ALFUZOSIN HCL 127

ALINIA 54

ALIROCUMAB 100

ALISKIREN HEMIFUMARATE 95

ALISKIREN

HEMIFUMARATE/HYDROCHLOROTHIAZIDE 95,96

ALKERAN 47

ALLERGENIC EXTRACT,GRASS POLLEN-

TIMOTHY,STANDARD 172

ALLERGENIC EXTRACT-WEED POLLEN-SHORT

RAGWEED 173

ALLOPURINOL 44

ALMOTRIPTAN MALATE 44,45

ALOCRIL 160

ALOGLIPTIN BENZOATE 72

ALOGLIPTIN BENZOATE/METFORMIN HCL 73

ALOMIDE 160

ALOSETRON HCL 125

ALPHAGAN P 162

ALPHAQUIN HP 114

ALPRAZOLAM 70,71

ALREX 161

ALTABAX 17

ALTRETAMINE 47

ALVESCO 163

AMANTADINE HCL 55

AMBRISENTAN 169

AMCINONIDE 129

AMILORIDE HCL 97

AMILORIDE HCL/HYDROCHLOROTHIAZIDE 91

AMIODARONE HCL 85


AMITIZA 125

AMITRIPTYLINE HCL 38,39

AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 33

AMLODIPINE BESYLATE 88

AMLODIPINE BESYLATE/ATORVASTATIN

CALCIUM 91,92

AMLODIPINE BESYLATE/BENAZEPRIL HCL 92

AMLODIPINE BESYLATE/OLMESARTAN

MEDOXOMIL 92

AMLODIPINE BESYLATE/VALSARTAN 92

AMLODIPINE

BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE

91

AMOXAPINE 38

AMOXICILLIN 20

AMOXICILLIN/POTASSIUM CLAVULANATE 20,21

AMPICILLIN TRIHYDRATE 20

AMPYRA 112

ANAKINRA 153

ANALPRAM HC 115

ANASTROZOLE 49

ANDRODERM 136

ANDROGEL 136

ANGELIQ 137

ANORO ELLIPTA 171

ANSAID 4

ANTHRALIN 116,120

ANTHRALIN MICRONIZED 120

ANZEMET 41

APIDRA 77

APIDRA SOLOSTAR 77

APIXABAN 79

APLENZIN 32,33

APOKYN 55

APOMORPHINE HCL 55

APRACLONIDINE HCL 162

APREMILAST 156

APREPITANT 41

APRISO 156

APTENSIO XR 106

APTIOM 29,30

APTIVUS 68

ARCAPTA NEOHALER 167

ARFORMOTEROL TARTRATE 167

ARIPIPRAZOLE 58

ARMODAFINIL 174,175

ARMOUR THYROID 146

ARNUITY ELLIPTA 164

ARTEMETHER/LUMEFANTRINE 54

ASENAPINE MALEATE 61

ASFOTASE ALFA 121

ASMANEX 164

ASMANEX HFA 164

ASPIRIN/DIPYRIDAMOLE 81

ASTAGRAF XL 152

ATAZANAVIR SULFATE 69

ATAZANAVIR SULFATE/COBICISTAT 68

ATENOLOL 86

ATENOLOL/CHLORTHALIDONE 93

ATOMOXETINE HCL 110

ATORVASTATIN CALCIUM 98

ATRIPLA 65

ATROPINE SULFATE 159,160

ATROVENT 166

ATROVENT HFA 166

AUBAGIO 112

AUGMENTIN 21

AURANOFIN 156

AVANDAMET 73

AVANDIA 73

AVINZA 6,7

AVONEX 112

AVONEX PEN 112

AXIRON 136

AYGESTIN 145

AZASAN 152

AZASITE 21

AZATHIOPRINE 152,153

AZELAIC ACID 115,116

AZELASTINE HCL 160,165

AZELEX 115

AZILECT 57


AZITHROMYCIN 21,22

AZOPT 162

BBACITRACIN 17

BACITRACIN/POLYMYXIN B SULFATE 159,160

BACLOFEN 62

BACTROBAN 17

BALSALAZIDE DISODIUM 156

BANZEL 30

BARACLUDE 63

BASAGLAR KWIKPEN U-100 77

BECLOMETHASONE DIPROPIONATE 164,165

BECONASE AQ 164

BEDAQUILINE FUMARATE 46

BELSOMRA 175

BENAZEPRIL HCL 83

BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 93

BENTYL 122

BENZONATATE 171

BENZTROPINE MESYLATE 54

BENZYL ALCOHOL 120

BERINERT 152

BESIFLOXACIN HCL 22

BESIVANCE 22

BETAMETHASONE DIPROPIONATE 129

BETAMETHASONE DIPROPIONATE/PROPYLENE

GLYCOL 129

BETAMETHASONE VALERATE 129,130

BETASERON 112

BETAXOLOL HCL 86,162

BETHANECHOL CHLORIDE 128

BETHKIS 168

BETOPTIC S 162

BICALUTAMIDE 47

BIMATOPROST 163

BISACODYL/SODIUM CHLOR/SODIUM

BICARB/POTASSIUM CHL/PEG 3350 125

BISOPROLOL FUMARATE 86

BISOPROLOL

FUMARATE/HYDROCHLOROTHIAZIDE 93

BLEPH-10 23

BLEPHAMIDE 159

BLEPHAMIDE S.O.P. 159

BOSENTAN 170

BOSULIF 50

BOSUTINIB 50

BREO ELLIPTA 172

BREVICON 137

BREXPIPRAZOLE 60

BRIMONIDINE TARTRATE 162

BRIMONIDINE TARTRATE/TIMOLOL MALEATE 162

BRINTELLIX 34

BRINZOLAMIDE 162

BRINZOLAMIDE/BRIMONIDINE TARTRATE 162

BRIVARACETAM 25

BRIVIACT 25

BROMOCRIPTINE MESYLATE 55,73

BROVANA 167

BUDESONIDE 157,164,165

BUDESONIDE/FORMOTEROL FUMARATE 173

BUMETANIDE 97

BUNAVAIL 15

BUPRENEX 15

BUPRENORPHINE HCL 15

BUPRENORPHINE HCL/NALOXONE HCL 15,16

BUPROPION HBR 32,33

BUPROPION HCL 33,34

BUSPIRONE HCL 70

BUSULFAN 47

BUTALBITAL/ACETAMINOPHEN 111

BUTALBITAL/ACETAMINOPHEN/CAFFEINE 111

BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN

E PHOSPHATE 11

BUTALBITAL/ASPIRIN/CAFFEINE 4

BUTOCONAZOLE NITRATE 42

BYDUREON 73

BYDUREON PEN 73

BYETTA 73

BYSTOLIC 86


CC1 ESTERASE INHIBITOR 152

C1 ESTERASE INHIBITOR, RECOMBINANT 152

CABERGOLINE 151

CABOMETYX 50

CABOZANTINIB S-MALATE 50

CALCIPOTRIENE 115,119

CALCIPOTRIENE/BETAMETHASONE

DIPROPIONATE 116

CALCITONIN,SALMON,SYNTHETIC 157,158

CALCITRIOL 115,157,158

CALCIUM ACETATE 128,129

CALCIUM CARB/MAG OXIDE/VITAMIN D3/VIT

B12/FA/VIT B6/BORON 176

CANAGLIFLOZIN 74

CANASA 156

CANDESARTAN CILEXETIL 83

CANDESARTAN

CILEXETIL/HYDROCHLOROTHIAZIDE 93

CAPECITABINE 48

CAPITAL W-CODEINE 11

CAPRELSA 50

CAPTOPRIL 83,84

CAPTOPRIL/HYDROCHLOROTHIAZIDE 93

CARAFATE 126

CARBAMAZEPINE 30

CARBIDOPA/LEVODOPA 56,57

CARBIDOPA/LEVODOPA/ENTACAPONE 55

CARBINOXAMINE MALEATE 165

CARDIZEM LA 88

CARDURA XL 127

CARIPRAZINE HCL 61,62

CARISOPRODOL 173

CARISOPRODOL/ASPIRIN 173

CARISOPRODOL/ASPIRIN/CODEINE

PHOSPHATE 11

CARVEDILOL 86

CARVEDILOL PHOSPHATE 86,87

CEFACLOR 18

CEFADROXIL 18,19

CEFDINIR 19

CEFIXIME 19,20

CEFPODOXIME PROXETIL 19

CEFPROZIL 19

CEFTIBUTEN 19

CEFTIN 19

CEFUROXIME AXETIL 19

CELECOXIB 4

CELONTIN 26

CEPHALEXIN 19

CERDELGA 120

CERITINIB 53

CERTOLIZUMAB PEGOL 152

CESAMET 41

CHLORAMBUCIL 47

CHLORDIAZEPOXIDE HCL 71

CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 122

CHLOROQUINE PHOSPHATE 54

CHLOROTHIAZIDE 97

CHLORPROMAZINE HCL 57

CHLORTHALIDONE 97

CHLORZOXAZONE 173

CHOLBAM 123

CHOLESTYRAMINE (WITH SUGAR) 99

CHOLESTYRAMINE/ASPARTAME 99,100

CHOLIC ACID 123

CHOLINE SALICYLATE/MAGNESIUM SALICYLATE 4

CICLESONIDE 163,165

CICLOPIROX 41,42,44

CICLOPIROX OLAMINE 41

CILOXAN 22

CIMETIDINE 124

CIMETIDINE HCL 124

CIMZIA 152

CINACALCET HCL 151

CIPRO HC 163

CIPRODEX 163

CIPROFLOXACIN 22

CIPROFLOXACIN HCL 22,23

CIPROFLOXACIN HCL/DEXAMETHASONE 163

CIPROFLOXACIN HCL/HYDROCORTISONE 163


CIPROFLOXACIN/CIPROFLOXACIN HCL 22

CITALOPRAM HYDROBROMIDE 35

CITRANATAL B-CALM 176

CLARITHROMYCIN 21

CLEOCIN 17

CLEOCIN PALMITATE 17

CLIMARA PRO 137

CLINDAMYCIN HCL 17

CLINDAMYCIN PALMITATE HCL 17

CLINDAMYCIN PHOSPHATE 17

CLINDAMYCIN PHOSPHATE/BENZOYL

PEROXIDE 115,116,117

CLINDAMYCIN PHOSPHATE/TRETINOIN 115

CLINDESSE 17

CLIOQUINOL/HYDROCORTISONE 114

CLOBAZAM 27

CLOBETASOL PROPIONATE 130

CLOBETASOL PROPIONATE/EMOLLIENT BASE 130

CLOCORTOLONE PIVALATE 130

CLOMIPRAMINE HCL 38

CLONAZEPAM 71

CLONIDINE 82

CLONIDINE HCL 82

CLONIDINE HCL/CHLORTHALIDONE 93

CLOPIDOGREL BISULFATE 81

CLORAZEPATE DIPOTASSIUM 71

CLOTRIMAZOLE 42

CLOTRIMAZOLE/BETAMETHASONE

DIPROPIONATE 115

CLOZAPINE 62

COARTEM 54

COBICISTAT 68

COBIMETINIB FUMARATE 50

CODEINE

PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE10,11

CODEINE SULFATE 11

COLCHICINE 44

COLESEVELAM HCL 101

COLESTID 99

COLESTIPOL HCL 99

COLLOIDAL BISMUTH

SUBCITRATE/METRONIDAZOLE/TETRACYCLINE

HCL 123

COMBIGAN 162

COMBIPATCH 137,138

COMBIVENT RESPIMAT 172

COMETRIQ 50

COMPAZINE 40

COMPLERA 65

CONDYLOX 115

CORDARONE 85

CORDRAN 130

COREG CR 86,87

CORLANOR 93

CORTEF 130

CORTIFOAM 157

COSENTYX (2 SYRINGES) 116

COSENTYX PEN 115

COSENTYX PEN (2 PENS) 116

COSENTYX SYRINGE 115

COSOPT PF 162

COTELLIC 50

COUMADIN 79

CREON 120

CRESEMBA 42

CRIXIVAN 68

CRIZOTINIB 53

CROFELEMER 123

CROMOLYN SODIUM 123,160

CUPRIMINE 128

CUTIVATE 130

CYANOCOBALAMIN (VITAMIN B-12) 177

CYANOCOBALAMIN/FOLIC

ACID/PYRIDOXINE 177,180

CYCLOBENZAPRINE HCL 173

CYCLOPENTOLATE HCL 159

CYCLOSERINE 46

CYCLOSET 73

CYCLOSPORINE 152,155,160

CYCLOSPORINE, MODIFIED 152,153,154

CYPROHEPTADINE HCL 165


CYSTAGON 128

CYSTEAMINE BITARTRATE 128

CYTOMEL 146

DDABIGATRAN ETEXILATE MESYLATE 80

DABRAFENIB MESYLATE 52

DACLATASVIR DIHYDROCHLORIDE 63

DAKLINZA 63

DALFAMPRIDINE 112

DALIRESP 169

DALTEPARIN SODIUM,PORCINE 79,80

DANAZOL 136

DAPAGLIFLOZIN PROPANEDIOL 73

DAPAGLIFLOZIN PROPANEDIOL/METFORMIN

HCL 77

DAPSONE 46,114

DARAPRIM 54

DARIFENACIN HYDROBROMIDE 126

DARUNAVIR ETHANOLATE 69

DARUNAVIR ETHANOLATE/COBICISTAT 68

DASATINIB 52

DEFERASIROX 175

DELAVIRDINE MESYLATE 66

DELTASONE 130

DELZICOL 156

DEPAKOTE SPRINKLE 26

DEPEN 128

DESCOVY 66

DESIPRAMINE HCL 38,39

DESMOPRESSIN ACETATE 134,135

DESMOPRESSIN ACETATE (NON-

REFRIGERATED) 135

DESOGESTREL-ETHINYL

ESTRADIOL 137,138,140,144

DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL

ESTRADIOL 137,138,140,143,144

DESONATE 130

DESONIDE 130,134

DESOXIMETASONE 130,131

DESVENLAFAXINE FUMARATE 35

DEXAMETHASONE 131,161

DEXAMETHASONE SOD PHOSPHATE 161

DEXEDRINE 103

DEXMETHYLPHENIDATE HCL 106,107

DEXPAK 131

DEXTROAMPHETAMINE SULF-

SACCHARATE/AMPHETAMINE SULF-

ASPARTATE 103,104

DEXTROAMPHETAMINE SULFATE 102,103,104,105

DEXTROMETHORPHAN HBR/QUINIDINE

SULFATE 111

DIABETIC SUPPLIES,MISCELL 159

DIALYVITE 3000 177

DIAZEPAM 71

DICHLORPHENAMIDE 96

DICLOFENAC EPOLAMINE 116

DICLOFENAC POTASSIUM 4

DICLOFENAC SODIUM 4,116,161

DICLOFENAC SODIUM/MISOPROSTOL 4

DICLOXACILLIN SODIUM 21

DICYCLOMINE HCL 122

DIDANOSINE 66,67

DIFICID 21

DIFLORASONE DIACETATE 131

DIFLUCAN 42

DIFLUPREDNATE 161

DIGOXIN 93

DIHYDROERGOTAMINE MESYLATE 44

DILANTIN 30

DILATRATE-SR 101

DILTIAZEM HCL 88,89,90,91

DIMETHYL FUMARATE 113

DIPENTUM 156

DIPHENOXYLATE HCL/ATROPINE SULFATE 123

DIPYRIDAMOLE 81

DISOPYRAMIDE PHOSPHATE 85

DIURIL 97

DIVALPROEX SODIUM 26

DIVIGEL 138

DOLASETRON MESYLATE 41

DOLUTEGRAVIR SODIUM 65


DONEPEZIL HCL 31

DORNASE ALFA 173

DORYX 24

DORZOLAMIDE HCL 162

DORZOLAMIDE HCL/TIMOLOL MALEATE 162

DORZOLAMIDE HCL/TIMOLOL MALEATE/PF 162

DOXAZOSIN MESYLATE 82,127

DOXEPIN HCL 39

DOXYCYCLINE HYCLATE 24

DOXYCYCLINE MONOHYDRATE 24

DRISDOL 158

DRITHOCREME HP 116

DRONEDARONE HCL 85

DROSPIRENONE/ESTRADIOL 137

DROSPIRENONE/ETHINYL

ESTRADIOL/LEVOMEFOLATE CALCIUM 138,144

DROXIDOPA 94,95

DUAC 116

DUAVEE 138

DUET DHA 400 177

DUET DHA BALANCED 177

DULAGLUTIDE 76,77

DULERA 172

DULOXETINE HCL 111

DUOPA 56

DURAGESIC 7

DUREZOL 161

DUTASTERIDE 127

DUTASTERIDE/TAMSULOSIN HCL 127

EE.E.S. 200 21

E.E.S. 400 21

ECHOTHIOPHATE IODIDE 162

ECONAZOLE NITRATE 42

ECOZA 42

EDURANT 66

EFAVIRENZ 66

EFAVIRENZ/EMTRICITABINE/TENOFOVIR

DISOPROXIL FUMARATE 65

EFFIENT 81,82

ELBASVIR/GRAZOPREVIR 65

ELESTRIN 138

ELETRIPTAN HBR 45

ELIDEL 116

ELIGLUSTAT TARTRATE 120

ELIMITE 54

ELIQUIS 79

ELIXOPHYLLIN 169

ELMIRON 128

ELOCON 131

ELTROMBOPAG OLAMINE 81

ELVITEGRAVIR 65

ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN

OFOVIR ALAFENAMIDE 65

ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN

OFOVIR DISOPROXIL 65

EMADINE 160

EMBEDA 7

EMEDASTINE DIFUMARATE 160

EMEND 41

EMPAGLIFLOZIN 74,75

EMPAGLIFLOZIN/LINAGLIPTIN 74

EMPAGLIFLOZIN/METFORMIN HCL 76

EMSAM 34

EMTRICITABINE 66,67

EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR

ALAFENAMIDE FUMARATE 66

EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR

DISOPROXIL FUMARATE 65

EMTRICITABINE/TENOFOVIR ALAFENAMIDE

FUMARATE 66

EMTRICITABINE/TENOFOVIR DISOPROXIL

FUMARATE 67

EMTRIVA 66,67

ENALAPRIL MALEATE 84

ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 94

ENBREL 153

ENFUVIRTIDE 68

ENOXAPARIN SODIUM 79

ENSTILAR 116

ENTECAVIR 63


ENTRESTO 94

ENZALUTAMIDE 47

EPCLUSA 63

EPIDUO 116

EPIDUO FORTE 116

EPIFOAM 116

EPINASTINE HCL 161

EPINEPHRINE 167

EPISIL 113

EPIVIR HBV 63

EPLERENONE 97

ERGOCALCIFEROL (VITAMIN D2) 158

ERIVEDGE 50

ERLOTINIB HCL 53

ERTACZO 42

ERY-TAB 21,22

ERYTHROCIN STEARATE 22

ERYTHROMYCIN BASE 21,22

ERYTHROMYCIN BASE/BENZOYL PEROXIDE 17

ERYTHROMYCIN BASE/ETHYL ALCOHOL 21,22

ERYTHROMYCIN ETHYLSUCCINATE 21,22

ERYTHROMYCIN STEARATE 22

ESBRIET 172

ESCITALOPRAM OXALATE 35

ESLICARBAZEPINE ACETATE 29,30

ESTRACE 139

ESTRADIOL 138,139,140,142,145

ESTRADIOL ACETATE 140

ESTRADIOL VALERATE/DIENOGEST 142

ESTRADIOL/LEVONORGESTREL 137

ESTRADIOL/NORETHINDRONE

ACETATE 137,138,139,141,142

ESTRADIOL/NORGESTIMATE 143

ESTRING 139

ESTROGEL 139

ESTROGENS, CONJUGATED 143

ESTROGENS, CONJUGATED/BAZEDOXIFENE

ACETATE 138

ESTROGENS,

CONJUGATED/MEDROXYPROGESTERONE

ACETATE 143,144

ESTROGENS,ESTERIFIED 141

ESTROGENS,ESTERIFIED/METHYLTESTOSTERON

E 138,139,140

ESTROPIPATE 140,143

ESZOPICLONE 174

ETANERCEPT 153

ETHAMBUTOL HCL 46

ETHINYL

ESTRADIOL/DROSPIRENONE 138,140,141,142,143,1

44,145

ETHIONAMIDE 47

ETHOSUXIMIDE 26

ETHOTOIN 31

ETHYNODIOL DIACETATE-ETHINYL

ESTRADIOL 140,145

ETODOLAC 4,5

ETONOGESTREL/ETHINYL ESTRADIOL 143

ETRAVIRINE 66

EVAMIST 140

EVEROLIMUS 49,50,156

EVOLOCUMAB 100

EVOTAZ 68

EXALGO 7

EXELDERM 42

EXEMESTANE 49

EXENATIDE 73

EXENATIDE MICROSPHERES 73

EXJADE 175

EXTAVIA 112

EZETIMIBE 101

EZETIMIBE/SIMVASTATIN 100,101

FFABIOR 116

FAMCICLOVIR 70

FAMOTIDINE 124

FANAPT 59

FARXIGA 73

FARYDAK 49

FEBUXOSTAT 44

FELODIPINE 90


FEMRING 140

FENOFIBRATE 98

FENOFIBRATE NANOCRYSTALLIZED 98

FENOFIBRIC ACID 98

FENOFIBRIC ACID (CHOLINE) 98

FENOGLIDE 98

FENOPROFEN CALCIUM 5,6

FENORTHO 5

FENTANYL 7,8

FENTANYL CITRATE 11

FESOTERODINE FUMARATE 127

FETZIMA 35

FIDAXOMICIN 21

FILGRASTIM 81

FILGRASTIM-SNDZ 81

FINACEA 116

FINASTERIDE 127

FINGOLIMOD HCL 113

FLAGYL ER 17

FLAREX 161

FLECAINIDE ACETATE 85

FLECTOR 116

FLOVENT DISKUS 164

FLOVENT HFA 164

FLUCAINE 159

FLUCONAZOLE 42

FLUDROCORTISONE ACETATE 131

FLUNISOLIDE 163,165

FLUOCINOLONE ACETONIDE 131

FLUOCINOLONE ACETONIDE OIL 163

FLUOCINONIDE 131,132

FLUOCINONIDE/EMOLLIENT BASE 132

FLUOROMETHOLONE 161

FLUOROMETHOLONE ACETATE 161

FLUOROURACIL 48,116,119

FLUOXETINE HCL 35,36

FLUPHENAZINE HCL 57

FLURANDRENOLIDE 130,132

FLURAZEPAM HCL 175

FLURBIPROFEN 4,5

FLURBIPROFEN SODIUM 161

FLUTAMIDE 47

FLUTICASONE FUROATE 164,165

FLUTICASONE FUROATE/VILANTEROL

TRIFENATATE 172

FLUTICASONE PROPIONATE 130,132,164,165

FLUTICASONE PROPIONATE/SALMETEROL

XINAFOATE 171

FLUVASTATIN SODIUM 98

FML FORTE 161

FML S.O.P. 161

FOCALIN XR 107

FOLGARD OS 176

FOLGARD RX 177

FOLIC ACID 177

FOLIC ACID/ARGININE

HCL/CYANOCOBALAMIN/PYRIDOXINE/PEPPER

EXT 177

FOLIC ACID/VITAMIN B COMP AND

C/SELENIUM/MIN AA CHEL/ZINC 177

FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN

C 177

FONDAPARINUX SODIUM 79

FORADIL 167

FORMOTEROL FUMARATE 167,168

FORTEO 158

FOSAMPRENAVIR CALCIUM 68,69

FOSINOPRIL SODIUM 84

FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 94

FOSRENOL 128,129

FRAGMIN 79,80

FROVATRIPTAN SUCCINATE 45

FULYZAQ 123

FURADANTIN 17

FUROSEMIDE 97

FUZEON 68

FYCOMPA 25,26

GGABAPENTIN 26,27

GABITRIL 27

GALANTAMINE HBR 31


GARAMYCIN 16

GASTROCROM 123

GATIFLOXACIN 23

GATTEX 123

GEFITINIB 51

GELNIQUE 126

GEMFIBROZIL 98

GENTAMICIN SULFATE 16

GENTAMICIN SULFATE/PREDNISOLONE

ACETATE 160

GENVOYA 65

GIAZO 156

GILENYA 113

GILOTRIF 50

GLATIRAMER ACETATE 113

GLIMEPIRIDE 73

GLIPIZIDE 73

GLIPIZIDE/METFORMIN HCL 74

GLUCAGON EMERGENCY KIT 77

GLUCAGON,HUMAN RECOMBINANT 77

GLUCOPHAGE 74

GLYBURIDE 74

GLYBURIDE/METFORMIN HCL 74

GLYCEROL PHENYLBUTYRATE 121

GLYCOPYRROLATE 122,123

GLYXAMBI 74

GOLIMUMAB 155

GRANISETRON 41

GRANISETRON HCL 41

GRASS POLLEN-ORCHARD/SWEET

VERNAL/RYE/KENTUCKY/TIMOTHY, STD. 172

GRASTEK 172

GRIFULVIN V 42

GRISEOFULVIN ULTRAMICROSIZE 42

GRISEOFULVIN, MICROSIZE 42

GUAIFENESIN/DEXTROMETHORPHAN

HBR/PSEUDOEPHEDRINE HCL 173

GUANFACINE HCL 82,107

HHALCINONIDE 132

HALOBETASOL PROPIONATE 132,134

HALOG 132

HALOPERIDOL 57

HALOPERIDOL LACTATE 57

HARVONI 63

HEXALEN 47

HOMATROPINE HBR 159,160

HUMALOG 77

HUMALOG KWIKPEN U-100 77

HUMALOG KWIKPEN U-200 77

HUMALOG MIX 50-50 78

HUMALOG MIX 50-50 KWIKPEN 77

HUMALOG MIX 75-25 78

HUMALOG MIX 75-25 KWIKPEN 78

HUMIRA 153

HUMIRA PEDIATRIC CROHN'S 153

HUMIRA PEN 153

HUMIRA PEN CROHN-UC-HS STARTER 153

HUMIRA PEN PSORIASIS-UVEITIS 153

HUMULIN R U-500 78

HUMULIN R U-500 KWIKPEN 78

HYDRALAZINE HCL 101

HYDREA 48

HYDROCHLOROTHIAZIDE 97

HYDROCODONE BITARTRATE 10

HYDROCODONE

BITARTRATE/ACETAMINOPHEN 11,12,14

HYDROCODONE BITARTRATE/HOMATROPINE

METHYLBROMIDE 172,173

HYDROCODONE

POLISTIREX/CHLORPHENIRAMINE POLISTIREX172

HYDROCODONE/IBUPROFEN 12,14

HYDROCORTISONE 129,130,132,134,157

HYDROCORTISONE ACETATE 129,132,157

HYDROCORTISONE ACETATE/PRAMOXINE

HCL 115,116,117,118

HYDROCORTISONE BUTYRATE 132,133

HYDROCORTISONE PROBUTATE 133

HYDROCORTISONE VALERATE 133

HYDROCORTISONE/IODOQUINOL 116,117


HYDROCORTISONE/MINERAL

OIL/PETROLATUM,WHITE 132

HYDROMORPHONE HCL 7,8,12

HYDROQUINONE 115,117,119

HYDROQUINONE MICROSPHERES 117

HYDROQUINONE/SUNSCREENS

(OXYBENZONE/OCTINOXATE) 114,117

HYDROXYCHLOROQUINE SULFATE 54

HYDROXYUREA 48

HYDROXYZINE HCL 165,166

HYDROXYZINE PAMOATE 166

HYOSCYAMINE SULFATE 122,123

IIBANDRONATE SODIUM 158

IBRANCE 50,51

IBRUTINIB 51

IBUPROFEN 5

IBUPROFEN/OXYCODONE HCL 14

ICLUSIG 51

IDELALISIB 53

ILEVRO 161

ILOPERIDONE 59

ILOPROST TROMETHAMINE 171

IMATINIB MESYLATE 51

IMBRUVICA 51

IMDUR 101

IMIPRAMINE HCL 39

IMIPRAMINE PAMOATE 39

IMIQUIMOD 117

IMURAN 153

INCRUSE ELLIPTA 166

INDACATEROL MALEATE 167

INDAPAMIDE 98

INDINAVIR SULFATE 68

INDOCIN 5

INDOMETHACIN 5

INSULIN ASPART 78

INSULIN ASPART PROTAMINE HUMAN/INSULIN

ASPART 78

INSULIN DEGLUDEC 78

INSULIN DETEMIR 78

INSULIN GLARGINE,HUMAN RECOMBINANT

ANALOG 77,78

INSULIN GLULISINE 77

INSULIN LISPRO 77

INSULIN LISPRO PROTAMINE AND INSULIN

LISPRO 77,78

INSULIN REGULAR, HUMAN 78

INTELENCE 66

INTERFERON ALFA-2B,RECOMB. 63

INTERFERON ALFA-N3 70

INTERFERON BETA-1A 112

INTERFERON BETA-1A/ALBUMIN HUMAN 112,113

INTERFERON BETA-1B 112

INTERFERON GAMMA-1B,RECOMB. 156

INTRON A 63

INTUNIV 107

INVIRASE 68

INVOKANA 74

IOPIDINE 162

IPRATROPIUM BROMIDE 166

IPRATROPIUM BROMIDE/ALBUTEROL

SULFATE 172

IRBESARTAN 83

IRBESARTAN/HYDROCHLOROTHIAZIDE 94

IRESSA 51

IRON,CARBONYL/FOLIC ACID/MULTIVIT WITH

MINERALS 178

ISAVUCONAZONIUM SULFATE 42

ISENTRESS 65

ISONIAZID 46

ISOPTO ATROPINE 160

ISORDIL 101

ISOSORBIDE DINITRATE 101

ISOSORBIDE MONONITRATE 101,102

ISOTRETINOIN 114,115,117,120

ITRACONAZOLE 42,43,44

IVABRADINE HCL 93

IVACAFTOR 168

IVERMECTIN 54

IXAZOMIB CITRATE 52


IXEKIZUMAB 119

JJADENU 175

JAKAFI 51

JANUMET 74

JANUMET XR 74

JANUVIA 74

JARDIANCE 74,75

JENTADUETO 75

JUXTAPID 99,100

KKALETRA 68

KALYDECO 168

KEPPRA 26

KETOCONAZOLE 42,43,44

KETOPROFEN 5

KETOROLAC TROMETHAMINE 5,161

KETOROLAC TROMETHAMINE/PF 161

KEVEYIS 96

KINERET 153

KITABIS PAK 168

KLARON 23

KLOR-CON 176

KLOR-CON M15 176

KOMBIGLYZE XR 75

KORLYM 133

KRISTALOSE 125

KUVAN 120

KYNAMRO 100

LLABETALOL HCL 87

LACOSAMIDE 31

LACTULOSE 125

LAMICTAL (GREEN) 28

LAMICTAL (ORANGE) 28

LAMICTAL XR (BLUE) 28

LAMICTAL XR (GREEN) 28

LAMICTAL XR (ORANGE) 28

LAMIVUDINE 63,67

LAMIVUDINE/ZIDOVUDINE 67

LAMOTRIGINE 28,29

LANSOPRAZOLE 126

LANSOPRAZOLE/AMOXICILLIN

TRIHYDRATE/CLARITHROMYCIN 123

LANTHANUM CARBONATE 128,129

LANTUS 78

LANTUS SOLOSTAR 78

LAPATINIB DITOSYLATE 53

LASTACAFT 161

LATANOPROST 163

LATUDA 59

LEDIPASVIR/SOFOSBUVIR 63

LEFLUNOMIDE 156

LENALIDOMIDE 48

LENVATINIB MESYLATE 51

LENVIMA 51

LETAIRIS 169

LETROZOLE 49

LEUCOVORIN CALCIUM 49

LEUKERAN 47

LEUKINE 81

LEVALBUTEROL HCL 167

LEVALBUTEROL TARTRATE 167

LEVAQUIN 23

LEVATOL 87

LEVEMIR 78

LEVEMIR FLEXPEN 78

LEVEMIR FLEXTOUCH 78

LEVETIRACETAM 26

LEVO-T 146,147

LEVOBUNOLOL HCL 162

LEVOFLOXACIN 23

LEVOMILNACIPRAN HCL 35

LEVONORGESTREL-ETHINYL

ESTRADIOL 136,137,138,140,141,142,143,144

LEVONORGESTREL/ETHINYL ESTRADIOL AND

ETHINYL ESTRADIOL 137,138,141

LEVOTHYROXINE SODIUM 146,147,148,149,150

LEVOXYL 147,148


LEVSIN 122

LEXIVA 68,69

LIALDA 156

LIDOCAINE 14,15

LIDOCAINE HCL 14,15

LIDOCAINE/PRILOCAINE 15

LIDOVEX 15

LINACLOTIDE 125

LINAGLIPTIN 76

LINAGLIPTIN/METFORMIN HCL 75

LINDANE 54

LINEZOLID 17,18

LINZESS 125

LIOTHYRONINE SODIUM 146,148

LIOTRIX 149

LIPASE/PROTEASE/AMYLASE 120,121,122

LIRAGLUTIDE 77

LISDEXAMFETAMINE DIMESYLATE 104,105

LISINOPRIL 84

LISINOPRIL/HYDROCHLOROTHIAZIDE 94

LITHIUM CARBONATE 72

LITHIUM CITRATE 72

LITHOBID 72

LOCOID 133

LODOXAMIDE TROMETHAMINE 160

LOMITAPIDE MESYLATE 99,100

LOMOTIL 123

LONSURF 48

LOPERAMIDE HCL 123

LOPINAVIR/RITONAVIR 68

LORAZEPAM 72

LORZONE 173

LOSARTAN POTASSIUM 83

LOSARTAN

POTASSIUM/HYDROCHLOROTHIAZIDE 94

LOTEMAX 161

LOTEPREDNOL ETABONATE 161

LOVASTATIN 99

LOXAPINE SUCCINATE 58

LUBIPROSTONE 125

LULICONAZOLE 43

LUMACAFTOR/IVACAFTOR 168

LURASIDONE HCL 59

LUZU 43

LYNPARZA 49

LYRICA 111,112

LYSODREN 49

MMACITENTAN 170

MARAVIROC 68

MARGESIC 111

MARTEN-TAB 111

MATULANE 47

MAXIDEX 161

MECLIZINE HCL 40

MECLOFENAMATE SODIUM 5

MEDROL 133

MEDROXYPROGESTERONE ACETATE 145

MEFENAMIC ACID 5

MEFLOQUINE HCL 54

MEGESTROL ACETATE 145

MEKINIST 51,52

MELOXICAM 5,6

MELPHALAN 47

MEMANTINE HCL 32

MEMANTINE HCL/DONEPEZIL HCL 31,32

MENEST 141

MENOSTAR 142

MEPERIDINE HCL 12

MEPHYTON 177

MERCAPTOPURINE 48,49

MESALAMINE 156,157

MESALAMINE WITH CLEANSING WIPES 157

MESNA 49

MESNEX 49

METAPROTERENOL SULFATE 168

METAXALONE 173

METFORMIN HCL 74,75,76

METHADONE HCL 8

METHADOSE 8

METHENAMINE HIPPURATE 18


METHENAMINE MANDELATE 18

METHENAMINE/METHYLENE BLUE/SOD

PHOS/P.SALICYLATE/HYOSCYAMINE 18

METHIMAZOLE 152

METHITEST 136

METHOCARBAMOL 174

METHOTREXATE SODIUM 153,155

METHOTREXATE/PF 154,155

METHSUXIMIDE 26

METHYLDOPA 82

METHYLDOPA/HYDROCHLOROTHIAZIDE 94

METHYLNALTREXONE BROMIDE 124

METHYLPHENIDATE HCL 106,107,108,109,110

METHYLPREDNISOLONE 133

METHYLTESTOSTERONE 136

METHYLTETRAHYDROFOLATE

GLUCOSAMINE/NIACINAMIDE/CUPRIC,ZN OX 178

METIPRANOLOL 162

METOCLOPRAMIDE HCL 40

METOLAZONE 98

METOPROLOL SUCCINATE 87

METOPROLOL TARTRATE 87

METOPROLOL

TARTRATE/HYDROCHLOROTHIAZIDE 94

METRELEPTIN 159

METROLOTION 117

METRONIDAZOLE 17,18,117,118

MEXILETINE HCL 85

MIACALCIN 158

MICONAZOLE 43

MICROGESTIN 24 FE 142

MIFEPRISTONE 133

MIGLITOL 75

MIGLUSTAT 121

MILLIPRED 133

MILNACIPRAN HCL 112

MINIVELLE 142

MINOCYCLINE HCL 24,25

MINOXIDIL 101

MIPOMERSEN SODIUM 100

MIRABEGRON 126

MIRTAZAPINE 33,34

MISOPROSTOL 126

MITOTANE 49

MODAFINIL 175

MOEXIPRIL HCL 84

MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 94

MOMETASONE FUROATE 131,133,164,165

MOMETASONE FUROATE/FORMOTEROL

FUMARATE 172

MONTELUKAST SODIUM 166

MORPHINE SULFATE 6,7,8,12,13

MORPHINE SULFATE/NALTREXONE HCL 7

MOVANTIK 123

MOXEZA 23

MOXIFLOXACIN HCL 23

MULTAQ 85

MUPIROCIN 17,18

MUPIROCIN CALCIUM 18

MVC-FLUORIDE 178

MYALEPT 159

MYCOPHENOLATE MOFETIL 153,154

MYCOPHENOLATE SODIUM 154

MYLERAN 47

MYNATAL 178

MYRBETRIQ 126

MYTESI 123

NNABILONE 41

NABUMETONE 6

NADOLOL 87

NADOLOL/BENDROFLUMETHIAZIDE 94

NAFTIFINE HCL 43

NAFTIN 43

NALFON 6

NALOXEGOL OXALATE 123

NALTREXONE HCL 15

NAMENDA XR 32

NAMZARIC 31,32

NAPROSYN 6

NAPROXEN 6


NAPROXEN SODIUM 6

NARATRIPTAN HCL 45

NASONEX 165

NATAZIA 142

NATEGLINIDE 75

NATELLE ONE 178

NATPARA 158

NATURE-THROID 148

NEBIVOLOL HCL 86

NEDOCROMIL SODIUM 160

NEFAZODONE HCL 36

NELFINAVIR MESYLATE 69

NEOMYCIN SULFATE 16

NEOMYCIN SULFATE/BACITRACIN

ZINC/POLYMYXIN B/HYDROCORTISONE 160

NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN

B 160

NEOMYCIN SULFATE/POLYMYXIN B

SULFATE/GRAMICIDIN D 160

NEOMYCIN SULFATE/POLYMYXIN B

SULFATE/HYDROCORTISONE 163

NEORAL 154

NEPAFENAC 161,162

NEPHRO-VITE RX 178

NETUPITANT/PALONOSETRON HCL 40

NEULASTA 81

NEUPOGEN 81

NEUPRO 55

NEVANAC 162

NEVIRAPINE 66

NEXAVAR 52

NIACIN 100

NICOMIDE 178

NIFEDIPINE 88,90

NILOTINIB HCL 53

NILUTAMIDE 47

NINLARO 52

NINTEDANIB ESYLATE 172

NISOLDIPINE 90

NITAZOXANIDE 54

NITISINONE 120,121

NITRO-BID 102

NITRO-DUR 102

NITROFURANTOIN 17,18

NITROFURANTOIN MACROCRYSTAL 18

NITROFURANTOIN

MONOHYDRATE/MACROCRYSTALS 18

NITROGLYCERIN 102

NIZATIDINE 124

NORELGESTROMIN/ETHINYL ESTRADIOL 143,145

NORETHINDRONE 145

NORETHINDRONE ACETATE 145

NORETHINDRONE ACETATE-ETHINYL

ESTRADIOL 140,141,142

NORETHINDRONE ACETATE-ETHINYL

ESTRADIOL/FERROUS

FUMARATE 137,140,141,142,144

NORETHINDRONE-ETHINYL

ESTRADIOL 137,138,140,141,142,143,144,145

NORETHINDRONE-ETHINYL

ESTRADIOL/FERROUS FUMARATE 142,144,145

NORETHINDRONE-MESTRANOL 142

NORGESTIMATE-ETHINYL

ESTRADIOL 138,140,142,144

NORGESTREL-ETHINYL ESTRADIOL 138,141,143

NORINYL 1-35 142

NORTHERA 94,95

NORTRIPTYLINE HCL 39

NORVIR 69

NOVOLOG 78

NOVOLOG FLEXPEN 78

NOVOLOG MIX 70-30 78

NOVOLOG MIX 70-30 FLEXPEN 78

NOXAFIL 43

NU-DERM SUNFADER 117

NUCYNTA 13

NUCYNTA ER 8,9

NUEDEXTA 111

NULYTELY WITH FLAVOR PACKS 125

NUPLAZID 59

NUVARING 143

NYSTATIN 43,44


NYSTATIN/TRIAMCINOLONE ACETONIDE 43

OO-CAL FA 178

OB COMPLETE 178

OB COMPLETE ONE 178

OB COMPLETE PETITE 178

OB COMPLETE PREMIER 179

OCTREOTIDE ACETATE 151

ODEFSEY 66

ODOMZO 52

OFEV 172

OFLOXACIN 23

OGEN 143

OLANZAPINE 59,60

OLANZAPINE/FLUOXETINE HCL 34

OLAPARIB 49

OLEPTRO ER 36

OLMESARTAN MEDOXOMIL 83

OLMESARTAN MEDOXOMIL/AMLODIPINE

BESYLATE/HYDROCHLOROTHIAZIDE 95

OLMESARTAN

MEDOXOMIL/HYDROCHLOROTHIAZIDE 95

OLODATEROL HCL 168

OLOPATADINE HCL 161,166

OLSALAZINE SODIUM 156

OLYSIO 63

OMBITASVIR/PARITAPREVIR/RITONAVIR 64

OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABU

VIR SODIUM 64

OMECLAMOX-PAK 123

OMEGA-3 ACID ETHYL ESTERS 100

OMEPRAZOLE 126

OMEPRAZOLE/CLARITHROMYCIN/AMOXICILLIN

TRIHYDRATE 123

OMNARIS 165

OMNITROPE 135

ONDANSETRON 41

ONDANSETRON HCL 41

ONFI 27

ONGLYZA 75

ONMEL 43

OPSUMIT 170

ORAL MUCOSITIS AND STOMATITIS ANTI-

INFLAMMATORY AGENT COMB 2 113

ORALAIR 172

ORAVIG 43

ORENCIA 154

ORENCIA CLICKJECT 154

ORENITRAM ER 170

ORFADIN 120,121

ORKAMBI 168

ORPHENADRINE CITRATE 174

ORTHO EVRA 143

OSELTAMIVIR PHOSPHATE 69,70

OSIMERTINIB MESYLATE 52,53

OTEZLA 156

OTREXUP 154

OVACE PLUS 117,118

OXANDROLONE 135

OXAPROZIN 6

OXAYDO 13

OXAZEPAM 72

OXCARBAZEPINE 30

OXECTA 13

OXICONAZOLE NITRATE 43

OXISTAT 43

OXTELLAR XR 30

OXYBUTYNIN 127

OXYBUTYNIN CHLORIDE 126,127

OXYCODONE HCL 9,13,14

OXYCODONE HCL/ACETAMINOPHEN 11,13,14

OXYCODONE HCL/ASPIRIN 14

OXYMORPHONE HCL 9,10,14

OXYTROL 127

PPACERONE 85

PALBOCICLIB 50,51

PALIPERIDONE 60

PANCREAZE 121

PANDEL 133


PANOBINOSTAT LACTATE 49

PANTOPRAZOLE SODIUM 126

PARATHYROID HORMONE 158

PARICALCITOL 158

PAROMOMYCIN SULFATE 16

PAROXETINE HCL 36,37

PATADAY 161

PAZEO 161

PAZOPANIB HCL 53

PEDIATRIC MULTIVIT #37/SODIUM

FLUORIDE/IRON BISGLYCINATE HCL 179

PEDIATRIC MULTIVIT WITH A,C,D3 NO.21/SODIUM

FLUORIDE 180

PEDIATRIC MULTIVITAMIN A,C,AND D3 NO.38

WITH SODIUM FLUORIDE 180

PEDIATRIC MULTIVITAMIN COMBINATION

NO.2/SODIUM FLUORIDE 177,178

PEDIATRIC MULTIVITAMIN NO.12 WITH SODIUM

FLUORIDE 178

PEDIATRIC MULTIVITAMIN NO.2/SODIUM

FLUORIDE 177


FLUORIDE 179


FLUORIDE/IRON CARBONYL 179


FLUORIDE 179


FLUORIDE/FERROUS SULFATE 178


FLUORIDE/FERROUS SULFATE 178


FLUORIDE 177,178

PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM

FLUORIDE 177,178

PEG 3350/SOD SULF/SOD BICARB/SOD

CHLORIDE/POTASSIUM CHLORIDE 125

PEGANONE 31

PEGASYS 63,64

PEGASYS PROCLICK 64

PEGFILGRASTIM 81

PEGINTERFERON ALFA-2A 63,64

PEGINTERFERON BETA-1A 113

PEN NEEDLE, DIABETIC 159

PENBUTOLOL SULFATE 87

PENICILLAMINE 128

PENICILLIN V POTASSIUM 21

PENLAC 44

PENTASA 157

PENTOSAN POLYSULFATE SODIUM 128

PENTOXIFYLLINE 95

PERAMPANEL 25,26

PERFOROMIST 168

PERINDOPRIL ERBUMINE 83,84

PERMETHRIN 54

PERPHENAZINE 40

PERPHENAZINE/AMITRIPTYLINE HCL 34

PERTZYE 121

PHENAZOPYRIDINE HCL 128

PHENELZINE SULFATE 34

PHENOBARBITAL 27

PHENYLEPHRINE HCL/PROMETHAZINE

HCL 172,173

PHENYTOIN 31

PHENYTOIN SODIUM EXTENDED 30,31

PHOSLYRA 129

PHOSPHOLINE IODIDE 162

PHYTONADIONE (VIT K1) 177

PILOCARPINE HCL 113,114,162

PIMAVANSERIN TARTRATE 59

PIMECROLIMUS 116

PIMOZIDE 58

PINDOLOL 87

PIOGLITAZONE HCL 75,76

PIOGLITAZONE HCL/GLIMEPIRIDE 76

PIOGLITAZONE HCL/METFORMIN HCL 72,76

PIRFENIDONE 172

PIROXICAM 6

PLAQUENIL 54

PLEGRIDY 113

PLEGRIDY PEN 113


PNV NO.85/IRON

CARB,ASPART.GLYCINATE/FOLIC ACID/DHA/FISH

OIL 178

PODOFILOX 115,118

POLY-VI-FLOR 179

POLY-VI-FLOR WITH IRON 179

POLYETHYLENE GLYCOL 3350 125,126

POLYMYXIN B SULFATE/TRIMETHOPRIM 160

POMALIDOMIDE 47,48

POMALYST 47,48

PONATINIB HCL 51

POSACONAZOLE 43

POTASSIUM CHLORIDE 176

POTASSIUM CHLORIDE/POTASSIUM

BICARBONATE/CITRIC ACID 176

POTASSIUM CITRATE 128

PRADAXA 80

PRALUENT PEN 100

PRALUENT SYRINGE 100

PRAMIPEXOLE DI-HCL 55,56

PRAMLINTIDE ACETATE 76

PRAMOSONE 118

PRASUGREL HCL 81,82

PRAVASTATIN SODIUM 99

PRAZOSIN HCL 82

PRECOSE 76

PRED MILD 162

PRED-G 160

PREDNISOLONE 133,134

PREDNISOLONE ACETATE 162

PREDNISOLONE SOD PHOSPHATE 133,134,162

PREDNISONE 130,133,134

PREFERA-OB ONE 179

PREFEST 143

PREGABALIN 111,112

PRELONE 134

PREMARIN 143

PREMPHASE 143

PREMPRO 143,144

PRENATA 179

PRENATABS FA 179

PRENATABS RX 179

PRENATAL NO56/IRON CARBONYL,ASPARTO

GLYCINATE/FOLIC ACID/DHA 178

PRENATAL VIT NO.18/IRON/FOLIC

ACID/DOCUSATE SOD./CO-Q10/DHA 180

PRENATAL VIT NO.2/IRON BG CHEL,SUCC-

PROT/FOLIC ACID/OMEGA-3 177,180

PRENATAL VIT NO.22/IRON CBN,GLUC/FOLIC

ACID/DOCUSATE SODIUM 180

PRENATAL VIT WITH CALCIUM NO.66/IRON

FUM/FOLIC ACID/DSS/DHA 179,180

PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS

FUMARATE/FOLIC ACID 180

PRENATAL VITAMIN NO.106/SOD FEREDE-IRON

POLY/FA/OM3/DHA/EPA 177

PRENATAL VITAMIN NO.117/SOD FEREDE-IRON

POLY/FA/OM3/DHA/EPA 177

PRENATAL VITAMIN NO.19/IRON POLYSAC,IRON

HEME/FOLIC ACID/DHA 179,181

PRENATAL VITAMIN NO.35/IRON

FUMARATE/FOLATE COMB. NO.6/DHA 179

PRENATAL VITAMIN

NO.48/IRON,CARBONYL,GLUCONATE/FOLIC

ACID/B6 176

PRENATAL VITAMIN NO.7-FERROUS FUMARATE-

FOLIC ACID-DHA 177

PRENATAL VITAMINS COMB

#83/IRON,CARBONYL/IRON ASPARTO GLY/FA 179

PRENATAL VITAMINS COMB 10/FERROUS


PRENATAL VITAMINS COMBO #36/FERROUS

FUMARATE/FOLATE COMBO #6 179

PRENATAL VITAMINS COMBO NO.37/FERROUS


PRENATAL VITAMINS COMBO

NO.59/IRON,CARB/FOLIC ACID/DSS/DHA 181

PRENATAL VITAMINS

NO.112/METHYLTETRAHYDROFOLATE

GLUCOSAMI,FA 179

PRENATAL VITAMINS NO.26/IRON

POLYSACCHARIDES/FA/DHA 180


PRENATAL VITAMINS NO.38/IRON

FUMARATE/FOLATE COMB NO.6/DHA 179

PRENATAL VITAMINS WITH CALCIUM/FERROUS


PRENATAL VITS WITH CALCIUM #70/FERROUS

FUMARATE/FA/DHA 176,178






FUMARATE/FOLIC ACID 178,179,180

PRENATAL VITS WITH CALCIUM

#76/IRON,CARBONYL/FOLIC ACID 179



PRENATAL VITS WITH CALCIUM#118/FERROUS


PRENATE CHEWABLE 179

PRENATE DHA 179

PRENATE ELITE 179

PRENATE ESSENTIAL 179

PREQUE 10 180

PREZCOBIX 68

PREZISTA 69

PRIMIDONE 27

PRIMSOL 18

PROAIR HFA 168

PROAIR RESPICLICK 168

PROBENECID 44

PROBENECID/COLCHICINE 44

PROCARBAZINE HCL 47

PROCARDIA 90

PROCARDIA XL 90

PROCHLORPERAZINE 40

PROCHLORPERAZINE MALEATE 40

PROCORT 118

PROCTOFOAM-HC 118

PROGESTERONE, MICRONIZED 145

PROMACTA 81

PROMETHAZINE HCL 40,166

PROMETHAZINE HCL/CODEINE 172

PROMETHAZINE HCL/DEXTROMETHORPHAN

HBR 172

PROMETHAZINE/PHENYLEPHRINE

HCL/CODEINE 172,173

PROPAFENONE HCL 85

PROPARACAINE HCL/FLUORESCEIN SODIUM 159

PROPRANOLOL HCL 87,88

PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 95

PROPYLTHIOURACIL 152

PROTONIX 126

PROVENTIL HFA 168

PSEUDOEPHEDRINE HCL/ACRIVASTINE 173

PULMICORT FLEXHALER 165

PULMOZYME 173

PURIXAN 49

PYLERA 123

PYRAZINAMIDE 46

PYRIMETHAMINE 54

QQNASL 165

QNASL CHILDREN 165

QUETIAPINE FUMARATE 60

QUILLIVANT XR 110

QUINAPRIL HCL 84

QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 95

QUINIDINE SULFATE 85

QUININE SULFATE 54

QVAR 165

RRABEPRAZOLE SODIUM 126

RAGWITEK 173

RALOXIFENE HCL 146

RALTEGRAVIR POTASSIUM 65

RAMIPRIL 84

RANEXA 95

RANITIDINE HCL 124

RANOLAZINE 95

RAPAFLO 127


RAPAMUNE 154

RASAGILINE MESYLATE 57

RASUVO 154,155

RAVICTI 121

REBETOL 64

REBIF 113

REBIF REBIDOSE 113

REGORAFENIB 52

RELENZA 69

RELISTOR 124

RELPAX 45

REMODULIN 170

RENAGEL 129

RENVELA 129

REPAGLINIDE 76

REPATHA PUSHTRONEX 100

REPATHA SURECLICK 100

REPATHA SYRINGE 100

REPREXAIN 14

RESCRIPTOR 66

RESTASIS 160

RETAPAMULIN 17

REVATIO 170

REVLIMID 48

REXULTI 60

REYATAZ 69

RIBASPHERE RIBAPAK 64

RIBATAB 64

RIBAVIRIN 64

RIDAURA 156

RIFAMPIN 46

RIFAMPIN/ISONIAZID/PYRAZINAMIDE 46

RIFATER 46

RILPIVIRINE HCL 66

RIMANTADINE HCL 69

RIOCIGUAT 169

RIOMET 76

RISEDRONATE SODIUM 158

RISPERIDONE 60,61

RITALIN LA 110

RITONAVIR 69

RIVAROXABAN 80

RIVASTIGMINE 32

RIVASTIGMINE TARTRATE 32

RIZATRIPTAN BENZOATE 45

ROBINUL FORTE 123

ROCALTROL 158

ROFLUMILAST 169

ROLAPITANT HCL 41

ROPINIROLE HCL 56

ROSIGLITAZONE MALEATE 73

ROSIGLITAZONE MALEATE/METFORMIN HCL 73

ROSUVASTATIN CALCIUM 99

ROTIGOTINE 55

ROXICET 14

ROXICODONE 14

RUCONEST 152

RUFINAMIDE 30

RUXOLITINIB PHOSPHATE 51

SSABRIL 27

SACCHARIN 159

SACUBITRIL/VALSARTAN 94

SAIZEN 135

SALMETEROL XINAFOATE 168

SALSALATE 6

SANCUSO 41

SANDIMMUNE 155

SAPHRIS 61

SAPROPTERIN DIHYDROCHLORIDE 120

SAQUINAVIR MESYLATE 68

SARGRAMOSTIM 81

SAVELLA 112

SAXAGLIPTIN HCL 75

SAXAGLIPTIN HCL/METFORMIN HCL 75

SECUKINUMAB 115,116

SELEGILINE 34

SELEGILINE HCL 57

SELENIUM SULFIDE 118

SELEXIPAG 170,171

SELZENTRY 68


SEMPREX-D 173

SENSIPAR 151

SEREVENT DISKUS 168

SEROSTIM 135

SERTACONAZOLE NITRATE 42

SERTRALINE HCL 37

SEVELAMER CARBONATE 129

SEVELAMER HCL 129

SILDENAFIL CITRATE 170

SILODOSIN 127

SILVER SULFADIAZINE 23

SIMBRINZA 162

SIMEPREVIR SODIUM 63

SIMPONI 155

SIMVASTATIN 99

SINEMET CR 57

SIROLIMUS 154,155

SIRTURO 46

SITAGLIPTIN PHOSPHATE 74

SITAGLIPTIN PHOSPHATE/METFORMIN HCL 74

SIVEXTRO 18

SKLICE 54

SODIUM CHLORIDE/SODIUM

BICARBONATE/POTASSIUM

CHLORIDE/PEG 125,126

SODIUM OXYBATE 175

SODIUM PHOSPHATE,DIBASIC/POT

PHOS,MONOB/SOD PHOSPHATE MONO 128

SODIUM POLYSTYRENE SULFONATE 176

SODIUM POLYSTYRENE SULFONATE/SORBITOL

SOLUTION 175,176

SOFOSBUVIR 64

SOFOSBUVIR/VELPATASVIR 63

SOLIFENACIN SUCCINATE 127

SOLTAMOX 48

SOMATROPIN 135

SONIDEGIB PHOSPHATE 52

SORAFENIB TOSYLATE 52

SORBITOL SOLUTION 159

SORILUX 119

SOTALOL HCL 85,86

SOTYLIZE 86

SOVALDI 64

SPIRIVA 166

SPIRIVA RESPIMAT 167

SPIRONOLACTONE 97

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 95

SPORANOX 44

SPRYCEL 52

SPS 176

SSD 23

STAVUDINE 67

STELARA 119

STIMATE 135

STIOLTO RESPIMAT 173

STIVARGA 52

STRATTERA 110

STRENSIQ 121

STRIBILD 65

STRIVERDI RESPIMAT 168

SUBOXONE 16

SUCRALFATE 126

SUCROFERRIC OXYHYDROXIDE 129

SULCONAZOLE NITRATE 42

SULFACETAMIDE SODIUM 23,117,118,119

SULFACETAMIDE SODIUM/PREDNISOLONE

ACETATE 159

SULFACETAMIDE SODIUM/PREDNISOLONE

SODIUM PHOSPHATE 160

SULFACETAMIDE SODIUM/SULFUR 115,118

SULFACETAMIDE SODIUM/SULFUR/UREA 118

SULFAMETHOXAZOLE/TRIMETHOPRIM 24

SULFASALAZINE 157

SULFATRIM 24

SULINDAC 6

SUMATRIPTAN 45

SUMATRIPTAN SUCCINATE 45,46

SUMATRIPTAN SUCCINATE/NAPROXEN

SODIUM 46

SUNITINIB MALATE 52

SUPRAX 20

SURMONTIL 39


SUSTIVA 66

SUTENT 52

SUVOREXANT 175

SYMAX DUOTAB 123

SYMBICORT 173

SYMLINPEN 120 76

SYMLINPEN 60 76

SYNJARDY 76

SYNTHROID 149

SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3

ML 158

SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5

ML 158,159

SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1

ML 159

SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1

ML 158,159

SYRINGE WITH NEEDLE,INSULIN,0.3 ML 159

SYRINGE WITH NEEDLE,INSULIN,0.5 ML 158,159

TTACROLIMUS 119,152,153,155

TADALAFIL 169

TAFINLAR 52

TAFLUPROST/PF 163

TAGRISSO 52,53

TALTZ AUTOINJECTOR 119

TALTZ AUTOINJECTOR (2 PACK) 119

TALTZ AUTOINJECTOR (3 PACK) 119

TALTZ SYRINGE 119

TALTZ SYRINGE (2 PACK) 119

TALTZ SYRINGE (3 PACK) 119

TAMIFLU 69,70

TAMOXIFEN CITRATE 48

TAMSULOSIN HCL 127

TAPENTADOL HCL 8,9,13

TARCEVA 53

TASIGNA 53

TAZAROTENE 116,119

TAZORAC 119

TECFIDERA 113

TECHNIVIE 64

TEDIZOLID PHOSPHATE 18

TEDUGLUTIDE 123

TEKTURNA 95

TEKTURNA HCT 95,96

TELBIVUDINE 63

TELMISARTAN 83

TELMISARTAN/AMLODIPINE BESYLATE 96

TELMISARTAN/HYDROCHLOROTHIAZIDE 96

TEMAZEPAM 174

TEMOZOLOMIDE 47

TENOFOVIR DISOPROXIL FUMARATE 67

TERAZOSIN HCL 82

TERBINAFINE HCL 44

TERBUTALINE SULFATE 168

TERCONAZOLE 44

TERIFLUNOMIDE 112

TERIPARATIDE 158

TESTOSTERONE 136

TESTOSTERONE CYPIONATE 136

TESTOSTERONE ENANTHATE 136

TETRABENAZINE 111

TETRACYCLINE HCL 25

TEV-TROPIN 135

THEOPHYLLINE ANHYDROUS 169

THIORIDAZINE HCL 58

THIOTHIXENE 58

THYROID,PORK 146,148,149,150,151

THYROLAR-1 149

THYROLAR-1/2 149

THYROLAR-1/4 149

THYROLAR-2 149

THYROLAR-3 149

TIAGABINE HCL 27

TIAZAC 91

TIMOLOL MALEATE 88,162,163

TINDAMAX 18

TINIDAZOLE 18

TIOTROPIUM BROMIDE 166,167

TIOTROPIUM BROMIDE/OLODATEROL HCL 173

TIPRANAVIR 68


TIPRANAVIR/VITAMIN E TPGS 68

TIVICAY 65

TIZANIDINE HCL 62

TOBI PODHALER 169

TOBRADEX 160

TOBRADEX ST 160

TOBRAMYCIN 17,168,169

TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 169

TOBRAMYCIN/DEXAMETHASONE 160

TOBRAMYCIN/LOTEPREDNOL ETABONATE 160

TOBRAMYCIN/NEBULIZER 168,169

TOBREX 17

TOCILIZUMAB 156

TOFACITINIB CITRATE 155

TOFRANIL-PM 39

TOLAK 119

TOLMETIN SODIUM 6

TOLTERODINE TARTRATE 127

TOPIRAMATE 29

TORSEMIDE 97

TOUJEO SOLOSTAR 78

TOVIAZ 127

TRACLEER 170

TRADJENTA 76

TRAMADOL HCL 10,14

TRAMADOL HCL/ACETAMINOPHEN 14

TRAMETINIB DIMETHYL SULFOXIDE 51,52

TRANDOLAPRIL 84

TRANDOLAPRIL/VERAPAMIL HCL 96

TRANEXAMIC ACID 81

TRANYLCYPROMINE SULFATE 34

TRAVATAN Z 163

TRAVOPROST 163

TRAZODONE HCL 36,37

TRECATOR 47

TREPROSTINIL 170

TREPROSTINIL DIOLAMINE 170

TREPROSTINIL SODIUM 170

TREPROSTINIL/NEBULIZER ACCESSORIES 170

TREPROSTINIL/NEBULIZER AND

ACCESSORIES 170

TRESIBA FLEXTOUCH U-100 78

TRESIBA FLEXTOUCH U-200 78

TRETINOIN 53,119,120

TREXALL 155

TREXIMET 46

TRI-VI-FLOR 180

TRIAMCINOLONE ACETONIDE 113,114,134

TRIAMTERENE/HYDROCHLOROTHIAZIDE 96

TRIAZOLAM 174

TRICOR 98

TRIFLUOPERAZINE HCL 58

TRIFLURIDINE/TIPIRACIL HCL 48

TRIGLIDE 98

TRIHEXYPHENIDYL HCL 54,55

TRIMETHOPRIM 18

TRIMIPRAMINE MALEATE 39

TRINATE 180

TRINTELLIX 37

TRIUMEQ 68

TROKENDI XR 29

TROPICAMIDE 160

TRULICITY 76,77

TRUVADA 67

TUDORZA PRESSAIR 167

TUSNEL PEDIATRIC 173

TYBOST 68

TYKERB 53

TYVASO 170

TYVASO INSTITUTIONAL START KIT 170

TYVASO REFILL KIT 170

TYVASO STARTER KIT 170

TYZEKA 63

UUCERIS 157

ULESFIA 120

ULORIC 44

ULTRAVATE 134

UMECLIDINIUM BROMIDE 166

UMECLIDINIUM BROMIDE/VILANTEROL

TRIFENATATE 171


UNITHROID 149,150

UPTRAVI 170,171

URECHOLINE 128

URIDINE TRIACETATE 181

URSO 124

URSO FORTE 124

URSODIOL 123,124

USTEKINUMAB 119

VVALACYCLOVIR HCL 70

VALGANCICLOVIR HCL 62

VALPROIC ACID 27

VALPROIC ACID (AS SODIUM SALT) (VALPROATE

SODIUM) 28

VALSARTAN 83

VALSARTAN/HYDROCHLOROTHIAZIDE 96

VANDETANIB 50

VARUBI 41

VELPHORO 129

VEMURAFENIB 53

VENCLEXTA 53

VENCLEXTA STARTING PACK 53

VENETOCLAX 53

VENLAFAXINE HCL 37,38

VENTAVIS 171

VENTOLIN HFA 168

VERAMYST 165

VERAPAMIL HCL 91

VERDESO 134

VERIPRED 20 134

VERSACLOZ 62

VESICARE 127

VICTOZA 2-PAK 77

VICTOZA 3-PAK 77

VIDEX 67

VIEKIRA PAK 64

VIGABATRIN 27

VIGAMOX 23

VIIBRYD 38

VILAZODONE HCL 38

VIMPAT 31

VIOKACE 121

VIRACEPT 69

VIREAD 67

VISMODEGIB 50

VITA-RESPA 180

VITAFOL-OB 180

VITAFOL-ONE 180

VITAMIN B COMPLEX AND VITAMIN C NO.20/FOLIC

ACID 178,180

VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC

ACID/BIOTIN 178,180,181

VITEKTA 65

VORAPAXAR SULFATE 82

VORICONAZOLE 44

VORTIOXETINE HYDROBROMIDE 34,37

VOTRIENT 53

VRAYLAR 61,62

VYTORIN 100,101

VYVANSE 104,105

WWARFARIN SODIUM 79,80

WELCHOL 101

WELLBUTRIN XL 34

WESTHROID 150

WP THYROID 150,151

XXALKORI 53

XARELTO 80

XELJANZ 155

XELJANZ XR 155

XIGDUO XR 77

XOLEGEL 44

XTANDI 47

XURIDEN 181

XYLOCAINE 15

XYREM 175


ZZAFIRLUKAST 166

ZALEPLON 174

ZAMICET 14

ZANAMIVIR 69

ZANTAC 124

ZAROXOLYN 98

ZARXIO 81

ZAVESCA 121

ZEBUTAL 111

ZELAPAR 57

ZELBORAF 53

ZENPEP 121,122

ZENZEDI 105

ZEPATIER 65

ZETIA 101

ZETONNA 165

ZIAGEN 67

ZIDOVUDINE 67,68

ZIOPTAN 163

ZIPRASIDONE HCL 62

ZITHRANOL 120

ZITHRANOL-RR 120

ZITHROMAX 22

ZITHROMAX TRI-PAK 22

ZMAX 22

ZOFRAN 41

ZOHYDRO ER 10

ZOLMITRIPTAN 46

ZOLPIDEM TARTRATE 174

ZOMACTON 135

ZOMIG 46

ZONISAMIDE 26

ZONTIVITY 82

ZORBTIVE 135

ZORTRESS 156

ZOVIRAX 70

ZUBSOLV 16

ZYDELIG 53

ZYKADIA 53

ZYLET 160

ZYTIGA 47


E N HANCED FORMULARY January 2017 … N HANCED FORMULARY January 2017 INTRODUCTION ... Ancillary charges do not apply toward your deductible or out -of -pocket maximum. ... etodolac

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