National Drug List. Drug list Four (4) Tier Drug Plan

Transcription

1 National Drug List Drug list Four () Tier Drug Plan Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company (Anthem) prescription drug benefits include medications on the Anthem National Drug List. Your coverage has limitations and exclusions. For example, provider administered drugs are not covered under your prescription benefit and drugs used for cosmetic purposes may not be covered. Always refer to your Certificate or Evidence of Coverage for details about what s covered and what s not. Then if you have additional questions, call Customer Service at the number on your member ID card. 955CAMENABC

2 Anthem Blue Cross Drug List Your prescription drug benefit includes coverage for medications that you ll find on the Anthem National Drug List. You can often find more savings when your doctor prescribes medicine that in our National Drug List. Here are some commonly asked questions and answers about how the National Drug List works with your prescription drug plan. Q. What is a Drug List? A. The Anthem National Drug List, also called a formulary, has drugs on it that are approved by the U.S. Food and Drug Administration (FDA). This includes brand-name and generic drugs, reviewed and recommended for their quality and for how well they work. The review is done by the National Pharmacy and Therapeutics (P&T) Process. The P&T process involves an independent group of practicing doctors and pharmacists in charge of the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs. They choose the top drugs for our list based on their safety, how they work and their value. Drugs on our list are reviewed from time to time. Sometimes this results in drugs being added or removed. So now and then, it s a good idea to check the status of any drugs you may be taking. You can see the list by going to anthem.com/ca. Also, we will always try to notify you of any changes to the formulary that impact you. Q. How do we determine the tier of a drug? A. Medications on the Anthem National Drug List are grouped into tiers. Drugs on the lowest tier have the lowest cost share, which is what you pay. Drugs on the highest tier cost you more. Several factors determine what tier a drug is placed in, including: }} Clinical considerations. }} Cost of the drug in comparison to other drugs used for the same type of treatment. }} Availability of over-the-counter options. Q. Is this list a complete listing of all covered drugs under the Anthem National Drug List? A. Yes, this is a complete listing of all covered drugs. Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). We cover contraceptives for members enrolled in a California plan according to state regulations.

3 For more information about your drug plan, you can do the following: }} Go to anthem.com/ca }} Call Customer Service at the number on your ID card }} Speech and hearing impaired (TDD/TTY users) should call , Monday Friday, 8:0 a.m. 5 p.m. ET Tier definitions Tier drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions. Tier drugs have a medium cost share. These may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs. Tier drugs have a higher cost share than Tier. Tier drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier may also include drugs that were recently approved by the FDA. Tier drugs have a higher cost share than Tier. Tier drugs have the highest cost share. They may cost more than others used to treat the same condition. Tier may also include drugs that were recently approved by the FDA or drugs that are used to treat complex, chronic conditions and may need special handling.

4 Anthem National Formulary Four-Tier Table of Contents ANALGESICS... 6 ANESTHETICS... ANTIARTHRITICS... ANTIASTHMATICS... 6 ANTIBIOTICS... 9 ANTICOAGULANTS... 0 ANTIDOTES... ANTIFUNGALS... ANTIHISTAMINE AND DECONGESTANT COMBINATION... ANTIHISTAMINES... ANTIHYPERGLYCEMICS... ANTIINFECTIVES... 8 ANTIINFECTIVES/MISCELLANEOUS... 7 ANTINEOPLASTICS... 8 ANTI-OBESITY DRUGS... ANTIPARKINSON DRUGS... ANTIPLATELET DRUGS... 5 ANTIVIRALS... 6 AUTONOMIC DRUGS... 9 BIOLOGICALS... 5 BLOOD CARDIAC DRUGS... 6 CARDIOVASCULAR... 6 CNS DRUGS... 7 COLONY STIMULATING FACTORS CONTRACEPTIVES COUGH/COLD PREPARATIONS DIAGNOSTIC... 8 DIURETICS... 8 EENT PREPS ELECT/CALORIC/HO GASTROINTESTINAL HERBALS HORMONES IMMUNOSUPPRESANT... MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG... MUSCLE RELAXANTS... 5 PRE-NATAL VITAMINS... 6 PSYCHOTHERAPEUTIC DRUGS... 9 SEDATIVE/HYPNOTICS... 6 SKIN PREPS... 6 SMOKING DETERRENTS... 7 THYROID PREPS... 7 UNCLASSIFIED DRUG PRODUCTS... 8 VITAMINS... 5

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6 Anthem National Formulary Four-Tier ANALGESICS ABSTRAL SUBLINGUAL acetaminophen-codeine oral acetaminophen-codeine oral tablet 00-5 mg acetaminophen-codeine oral tablet 00-0 mg, mg ACTIQ BUCCAL LOZENGE ON A HANDLE ALFENTA INJECTION alfentanil injection ALLZITAL ORAL PA; QL QL PA; QL almotriptan malate oral tablet QL ALSUMA PEN INJECTOR AMERGE ORAL ascomp with codeine oral capsule ASTRAMORPH-PF INJECTION ST; QL ST; QL AXERT ORAL ST; QL BELBUCA BUCCAL FILM belladonna alkaloids-opium rectal suppository belladonna-opium rectal suppository BUPAP ORAL PA; QL 6 BUPRENEX INJECTION buprenorphine hcl injection buprenorphine hcl injection syringe butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-co d oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen-caf f oral capsule butalbital-acetaminophen-caf f oral tablet butalbital-aspirin-caffeine oral capsule butorphanol tartrate injection butorphanol tartrate nasal spray,non-aerosol BUTRANS TRANSDERMAL PATCH WEEKLY CAFERGOT ORAL CAMBIA ORAL POWDER IN PACKET capacet oral capsule CAPITAL WITH CODEINE ORAL carisoprodol-asa-codeine oral tablet choline,magnesium salicylate oral liquid clonidine (pf) epidural codeine sulfate oral tablet codeine-butalbital-asa-caff oral capsule CONZIP ORAL,ER BIPHASE HR 7-8 QL QL QL QL QL QL Effective //6

7 CONZIP ORAL,ER BIPHASE HR 5-75 D.H.E.5 INJECTION DEMEROL (PF) INJECTION 00 MG/ ML, 5 MG/0.5 ML, 50 MG/ML, 75 MG/.5 ML demerol (pf) injection 00 mg/ml DEMEROL (PF) INJECTION DEMEROL INJECTION DEMEROL ORAL diclofenac potassium oral tablet diflunisal oral tablet dihydrocode-acetaminophencaff oral capsule dihydrocodeine-aspirin-caff oral capsule dihydroergotamine injection dihydroergotamine nasal spray,non-aerosol DILAUDID (PF) INJECTION DILAUDID ORAL LIQUID DILAUDID ORAL DILAUDID-HP (PF) INJECTION QL PA QL PA QL diskets oral tablet,soluble QL DOLOPHINE ORAL DURACLON (PF) EPIDURAL DURAGESIC TRANSDERMAL PATCH 7 HOUR QL ST; QL 7 duramorph (pf) injection ELMIRON ORAL EMBEDA ORAL,ORAL ONLY,EXT.REL PELL PA; QL endocet oral tablet QL endodan oral tablet ERGOMAR SUBLINGUAL ESGIC ORAL ESGIC ORAL EXALGO ER ORAL EXTENDED RELEASE HR fentanyl citrate (pf) injection fentanyl citrate (pf) intravenous syringe fentanyl citrate buccal lozenge on a handle fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 7 HOUR 7.5 MCG/HOUR, 6.5 MCG/HOUR, 87.5 MCG/HOUR FENTORA BUCCAL, EFFERVESCENT FIORICET ORAL FIORICET WITH CODEINE ORAL FIORINAL ORAL FIORINAL-CODEINE # ORAL ST; QL PA; QL QL QL PA; QL QL FROVA ORAL ST; QL frovatriptan oral tablet QL Effective //6

8 HYCET ORAL hydrocodone-acetaminophen oral 0-5 mg/5 ml(5 ml),.5-67 mg/5 ml, 5-6 mg/7.5ml(7.5ml) HYDROCODONE-ACET AMINOPHEN ORAL MG/5 ML hydrocodone-acetaminophen oral tablet 0-00 mg, 0-5 mg, 5-00 mg, 5-5 mg, mg, mg hydrocodone-acetaminophen oral tablet.5-5 mg hydrocodone-ibuprofen oral tablet 0-00 mg, mg hydrocodone-ibuprofen oral tablet 5-00 mg hydromorphone (pf) injection hydromorphone injection HYDROMORPHONE INJECTION 0.5 MG/0.5 ML hydromorphone injection syringe mg/ml, mg/ml, mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release hr hydromorphone rectal suppository HYSINGLA ER ORAL,ORAL ONLY,EXT.REL. HR IBUDONE ORAL 0-00 MG IBUDONE ORAL 5-00 MG ibuprofen-oxycodone oral tablet QL QL QL QL QL QL PA; QL QL QL 8 IMITREX NASAL SPRAY,NON-AEROSOL IMITREX ORAL IMITREX STATDOSE KIT REFILL CARTRIDGE IMITREX STATDOSE PEN PEN INJECTOR IMITREX INFUMORPH P/F INJECTION IONSYS TRANSDERMAL SYSTEM,TRANSDERMA L PCA isometh-dichloral-acetamino phn oral capsule isomethepten-caf-acetaminop hen oral tablet KADIAN ORAL,EXTEND.REL EASE PELLETS ST; QL ST; QL ST; QL ST; QL ST; QL ST; QL ketorolac injection cartridge QL ketorolac injection QL ketorolac injection syringe QL ketorolac intramuscular ketorolac intramuscular syringe QL QL ketorolac oral tablet QL LAZANDA NASAL SPRAY,NON-AEROSOL levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet PA; QL QL lorcet hd oral tablet QL lorcet plus oral tablet QL lortab 0-5 oral tablet QL lortab 5-5 oral tablet QL lortab oral tablet QL Effective //6

9 LORTAB ELIXIR ORAL margesic oral capsule marten-tab oral tablet QL MAXALT ORAL QL MAXALT-MLT ORAL,DISINTEGRATI NG mefenamic acid oral capsule meperidine (pf) injection meperidine injection cartridge meperidine oral meperidine oral tablet QL methadone injection QL methadone intensol oral concentrate QL methadone oral concentrate QL methadone oral QL methadone oral tablet QL methadone oral tablet,soluble QL methadose oral concentrate QL methadose oral tablet,soluble QL migergot rectal suppository MIGRANAL NASAL SPRAY,NON-AEROSOL morphine (pf) in dextrose 5 % intravenous morphine (pf) injection morphine (pf) intravenous patient control.analgesia soln 50 mg/0 ml morphine (pf) intravenous patient control.analgesia soln 0 mg/0 ml morphine concentrate oral morphine injection morphine injection syringe QL QL QL 9 MORPHINE PEN INJECTOR morphine intravenous cartridge 0 mg/ml, 5 mg/ml, mg/ml, mg/ml MORPHINE CARTRIDGE 8 MG/ML morphine intravenous pt controlled analgesia syring morphine intravenous 0 mg/ml, 00 mg/ ml, 5 mg/ml, 50 mg/0 ml, 50 mg/ml MORPHINE MG/ML, 8 MG/ML MORPHINE 0 MG/ML, 8 MG/ML morphine intravenous syringe mg/ml, mg/ml morphine oral capsule, er multiphase hr morphine oral capsule,extend.release pellets morphine oral 0 mg/5 ml morphine oral 0 mg/5 ml QL QL QL QL QL morphine oral tablet QL morphine oral tablet extended release morphine rectal suppository 0 mg, 0 mg, 5 mg morphine rectal suppository 0 mg MS CONTIN ORAL EXTENDED RELEASE nalbuphine injection QL QL QL naratriptan oral tablet QL nodolor oral capsule Effective //6

10 NORCO ORAL QL NUCYNTA ER ORAL EXTENDED RELEASE HR NUCYNTA ORAL OFIRMEV OPANA ER ORAL,ORAL ONLY,EXT.REL. HR OPANA INJECTION ST; QL QL ST; QL OPANA ORAL QL OXAYDO ORAL, ORAL ONLY oxycodone oral capsule oxycodone oral concentrate oxycodone oral oxycodone oral tablet OXYCODONE ORAL,ORAL ONLY,EXT.REL. HR oxycodone-acetaminophen oral tablet QL QL oxycodone-aspirin oral tablet QL OXYCONTIN ORAL,ORAL ONLY,EXT.REL. HR QL oxymorphone oral tablet QL oxymorphone oral tablet extended release hr pentazocine-naloxone oral tablet PERCOCET ORAL PONSTEL ORAL PRIALT INTRATHECAL PRIMLEV ORAL PRODRIN ORAL QL QL QL 0 RELPAX ORAL QL reprexain oral tablet 0-00 mg,.5-00 mg reprexain oral tablet 5-00 mg RIMSO-50 INTRAVESICAL QL rizatriptan oral tablet QL rizatriptan oral tablet,disintegrating ROXICODONE ORAL SPRIX NASAL SPRAY,NON-AEROSOL SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL sufenta intravenous SUFENTANIL CITRATE sumatriptan nasal spray,non-aerosol sumatriptan succinate oral tablet sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous sumatriptan succinate subcutaneous syringe SUMAVEL DOSEPRO NEEDLE-FREE INJECTOR SYNALGOS-DC ORAL TALWIN INJECTION tencon oral tablet TRAMADOL ORAL,ER BIPHASE HR 7-8 QL PA; QL QL QL QL QL QL QL ST; QL QL Effective //6

11 TRAMADOL ORAL,ER BIPHASE HR 5-75 QL tramadol oral tablet QL tramadol oral tablet extended release hr tramadol oral tablet, er multiphase hr tramadol-acetaminophen oral tablet TREXIMET ORAL QL QL QL ST; QL TREZIX ORAL QL TYLENOL-CODEINE # ORAL TYLENOL-CODEINE # ORAL ULTIVA RECON ULTRACET ORAL ULTRAM ER ORAL EXTENDED RELEASE HR QL QL QL QL ULTRAM ORAL QL VANATOL LQ ORAL verdrocet oral tablet vicodin es oral tablet QL vicodin hp oral tablet QL vicodin oral tablet QL VICOPROFEN ORAL XARTEMIS XR ORAL TAB,ORAL ONLY,IR - ER, BIPHASE XODOL 0/00 ORAL XODOL 5/00 ORAL XODOL 7.5/00 ORAL xylon 0 oral tablet QL ST; QL QL QL QL zamicet oral QL zebutal oral capsule ZECUITY TRANSDERMAL PATCH, IONTOPHORETIC ZEMBRACE SYMTOUCH PEN INJECTOR ST; QL ST; QL ZIPSOR ORAL ST ZOHYDRO ER ORAL, ORAL ONLY, ER HR PA; QL zolmitriptan oral tablet QL zolmitriptan oral tablet,disintegrating ZOMIG NASAL SPRAY,NON-AEROSOL QL ST; QL ZOMIG ORAL ST; QL ZOMIG ZMT ORAL,DISINTEGRATI NG ANESTHETICS AMIDATE AMIDATE ARTICADENT DENTAL INJECTION CARTRIDGE BREVITAL INJECTION RECON BUCALSEP MUCOUS MEMBRANE AEROSOL,SPRAY BUCALSEP MUCOUS MEMBRANE bupivacaine (pf) injection bupivacaine injection bupivacaine-dextrose-water( pf) injection bupivacaine-epinephrine (pf) injection ST; QL Effective //6

12 BUPIVACAINE-EPINEPH RINE BITART INJECTION CARTRIDGE bupivacaine-epinephrine injection CARBOCAINE (PF) INJECTION 0 MG/ML ( %), 0 MG/ML ( %) carbocaine (pf) injection 5 mg/ml (.5 %) CARBOCAINE INJECTION CETACAINE TOPICAL AEROSOL,SPRAY CITANEST FORTE DENTAL INJECTION CARTRIDGE CITANEST PLAIN DENTAL INJECTION CARTRIDGE cocaine topical compound 7 inhalation gas DIPRIVAN EMULSION EMLA TOPICAL ethyl chloride topical aerosol,spray etomidate intravenous EXPAREL (PF) LOCAL INFILTRATION forane inhalation liquid glydo mucous membrane jelly in applicator isoflurane inhalation liquid IV INFUSION CPI KIT KETALAR INJECTION KETAMINE IN 0.9 % SOD CHLORIDE ketamine injection LDO PLUS TOPICAL GEL lidocaine (pf) in d7.5w intrathecal lidocaine (pf) injection 0 mg/ml ( %), 5 mg/ml (.5 %), 0 mg/ml ( %), 5 mg/ml (0.5 %) LIDOCAINE (PF) INJECTION 0 MG/ML ( %) lidocaine hcl injection lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine viscous mucous membrane lidocaine-epinephrine (pf) injection LIDOCAINE-EPINEPHRI NE BIT INJECTION CARTRIDGE lidocaine-epinephrine injection lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit LIDOCAINE-TETRACAI NE TOPICAL LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED LIVIXIL PAK TOPICAL KIT Effective //6

13 LP LITE PAK TOPICAL KIT lta pre-attached laryngotracheal MARCAINE (PF) INJECTION 0.5 % (.5 MG/ML), 0.5 % (5 MG/ML) marcaine (pf) injection 0.75 % (7.5 mg/ml) MARCAINE INJECTION MARCAINE SPINAL (PF) INJECTION MARCAINE-EPINEPHRI NE (PF) INJECTION MARCAINE-EPINEPHRI NE INJECTION MEPIVACAINE (PF) INJECTION CARTRIDGE midazolam (pf) injection cartridge midazolam (pf) injection midazolam (pf) injection syringe mg/ ml ( mg/ml) MIDAZOLAM (PF) INJECTION 5 MG/ML midazolam injection NAROPIN (PF) INJECTION NESACAINE INJECTION NESACAINE-MPF INJECTION PAIN EASE TOPICAL AEROSOL,SPRAY phenazopyridine oral tablet PLIAGLIS TOPICAL polocaine injection % (0 mg/ml) POLOCAINE INJECTION % polocaine-mpf injection PONTOCAINE TOPICAL propofol intravenous emulsion PROPOVEN (PF) EMULSION PYRIDIUM ORAL relador pak plus topical kit relador pak topical kit ropivacaine (pf) injection SENSORCAINE INJECTION 0.5 % (.5 MG/ML) sensorcaine injection 0.5 % (5 mg/ml) sensorcaine/epinephrine injection SENSORCAINE-MPF INJECTION SENSORCAINE-MPF SPINAL INJECTION SENSORCAINE-MPF/EPI NEPHRINE INJECTION sevoflurane inhalation liquid sojourn inhalation liquid SPRAY AND STRETCH TOPICAL AEROSOL,SPRAY SUPRANE INHALATION LIQUID SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING terrell inhalation liquid tetracaine hcl (pf) injection Effective //6

14 ULTANE INHALATION LIQUID xylocaine dental-epinephrine injection cartridge XYLOCAINE INJECTION XYLOCAINE-EPINEPHR INE INJECTION XYLOCAINE-MPF INJECTION XYLOCAINE-MPF/EPIN EPHRINE INJECTION ZINGO INTRADERMAL PEN INJECTOR ANTIARTHRITICS allopurinol oral tablet aloprim intravenous recon soln ANAPROX DS ORAL ARAVA ORAL ARTHROTEC 50 ORAL,IR,DELAYED REL,BIPHASIC ARTHROTEC 75 ORAL,IR,DELAYED REL,BIPHASIC CALDOLOR RECON CELEBREX ORAL ST ST ST; QL celecoxib oral capsule ST; QL COLCHICINE ORAL COLCHICINE ORAL colchicine-probenecid oral tablet COLCRYS ORAL COMFORT PAC-IBUPROFEN KIT PA; QL PA; QL PA; QL COMFORT PAC-MELOXICAM KIT COMFORT PAC-NAPROXEN KIT CUPRIMINE ORAL DAYPRO ORAL DEPEN TITRATABS ORAL diclofenac sodium oral tablet extended release hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic DISALCID ORAL QL ST DUEXIS ORAL ST; QL DYLOJECT EC-NAPROSYN ORAL,DELAYED RELEASE (DR/EC) ELITEK RECON ENBREL RECON ENBREL ENBREL SURECLICK PEN INJECTOR etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release hr EUFLEXXA INTRA-ARTICULAR FELDENE ORAL FENOPROFEN ORAL ; QL ; QL ; QL ST Effective //6

15 fenoprofen oral tablet flurbiprofen oral tablet GEL-ONE INTRA-ARTICULAR GENVISC 850 INTRA-ARTICULAR HUMIRA PEDIATRIC CROHN'S START KIT HUMIRA PEN CROHN'S-UC-HS START PEN INJECTOR KIT HUMIRA PEN PSORIASIS STARTER PEN INJECTOR KIT HUMIRA PEN PEN INJECTOR KIT HUMIRA KIT HYALGAN INTRA-ARTICULAR HYALGAN INTRA-ARTICULAR ibuprofen oral suspension ibuprofen oral tablet INDOCIN ORAL INDOCIN RECTAL SUPPOSITORY indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets hr ; QL ; QL ; QL ; QL ; QL ST ST KINERET KRYSTEXXA leflunomide oral tablet meclofenamate oral capsule meloxicam oral suspension QL meloxicam oral tablet QL MITIGARE ORAL MOBIC ORAL PA; QL QL MOBIC ORAL QL MONOVISC INTRA-ARTICULAR nabumetone oral tablet NALFON ORAL NAPRELAN CR ORAL, ER MULTIPHASE HR NAPROSYN ORAL naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet naproxen sodium oral tablet, er multiphase hr ORENCIA (WITH MALTOSE) RECON ORENCIA ORTHOVISC INTRA-ARTICULAR ST ; QL OTEZLA ORAL ; QL 5 Effective //6

16 OTEZLA STARTER ORAL S,DOSE PACK OTREXUP (PF) AUTO-INJECTOR oxaprozin oral tablet piroxicam oral capsule probenecid oral tablet RASUVO (PF) AUTO-INJECTOR RHEUMATREX ORAL S,DOSE PACK RIDAURA ORAL salsalate oral tablet SIMPONI ARIA SIMPONI PEN INJECTOR SIMPONI sulindac oral tablet SUPARTZ FX INTRA-ARTICULAR SYNVISC INTRA-ARTICULAR SYNVISC-ONE INTRA-ARTICULAR TIVORBEX ORAL tolmetin oral capsule tolmetin oral tablet TREPADONE (WITH BROMELAIN) ORAL ; QL ; QL ; QL ; QL ; QL ST; QL ULORIC ORAL ST VIMOVO ORAL,IR,DELAYED REL,BIPHASIC VIVLODEX ORAL VOLTAREN-XR ORAL EXTENDED RELEASE HR XELJANZ ORAL XELJANZ XR ORAL EXTENDED RELEASE HR ZORVOLEX ORAL ZYLOPRIM ORAL ANTIASTHMATICS ACCOLATE ORAL acetylcysteine ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER AEROSPAN INHALATION HFA AEROSOL INHALER albuterol sulfate inhalation for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release hr ALVESCO INHALATION HFA AEROSOL INHALER aminophylline intravenous 50 mg/0 ml AMINOPHYLLINE 500 MG/0 ML ST; QL QL ; QL ST; QL QL QL QL QL 6 Effective //6

17 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE ARCAPTA NEOHALER INHALATION, W/INHALATION DEVICE ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (0 DOSES), 0 MCG (0 DOSES), 0 MCG (0 DOSES), 0 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (7 DOSES), 0 MCG ( DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER BREO ELLIPTA INHALATION BLISTER WITH DEVICE BROVANA INHALATION FOR NEBULIZATION budesonide inhalation suspension for nebulization CINQAIR COMBIVENT RESPIMAT INHALATION MIST cromolyn inhalation for nebulization cromolyn oral concentrate QL QL QL QL QL QL QL QL QL QL DALIRESP ORAL DULERA INHALATION HFA AEROSOL INHALER ELIXOPHYLLIN ORAL ELIXIR FLOVENT DISKUS INHALATION BLISTER WITH DEVICE FLOVENT HFA INHALATION HFA AEROSOL INHALER FORADIL AEROLIZER INHALATION, W/INHALATION DEVICE GASTROCROM ORAL CONCENTRATE INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE ipratropium bromide inhalation ipratropium-albuterol inhalation for nebulization levalbuterol hcl inhalation for nebulization metaproterenol oral syrup metaproterenol oral tablet montelukast oral granules in packet QL QL QL QL QL QL QL QL montelukast oral tablet QL montelukast oral tablet,chewable NUCALA RECON PERFOROMIST INHALATION FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL INHALER QL QL QL 7 Effective //6

18 PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED PROVENTIL HFA INHALATION HFA AEROSOL INHALER PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED PULMICORT INHALATION FOR NEBULIZATION QVAR INHALATION AEROSOL SEEBRI NEOHALER INHALATION, W/INHALATION DEVICE SEREVENT DISKUS INHALATION BLISTER WITH DEVICE SINGULAIR ORAL GRANULES IN PACKET SINGULAIR ORAL SINGULAIR ORAL,CHEWABLE SPIRIVA RESPIMAT INHALATION MIST SPIRIVA WITH HANDIHALER INHALATION, W/INHALATION DEVICE STIOLTO RESPIMAT INHALATION MIST STRIVERDI RESPIMAT INHALATION MIST SYMBICORT INHALATION HFA AEROSOL INHALER terbutaline oral tablet terbutaline subcutaneous QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL 8 THEO- ORAL,EXTENDED RELEASE HR theochron oral tablet extended release hr theophylline in dextrose 5 % intravenous parenteral theophylline oral elixir theophylline oral theophylline oral tablet extended release theophylline oral tablet extended release hr TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED UTIBRON NEOHALER INHALATION, W/INHALATION DEVICE VENTOLIN HFA INHALATION HFA AEROSOL INHALER VOSPIRE ER ORAL EXTENDED RELEASE HR XOLAIR RECON XOPENEX CONCENTRATE INHALATION FOR NEBULIZATION XOPENEX HFA INHALATION HFA AEROSOL INHALER XOPENEX INHALATION FOR NEBULIZATION zafirlukast oral tablet ZYFLO CR ORAL, ER MULTIPHASE HR ZYFLO ORAL QL QL QL QL QL QL Effective //6

19 ANTIBIOTICS ACTICLATE ORAL ST ADOXA ORAL ST amikacin injection amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet AMOXICILLIN ORAL, ER MULTIPHASE HR amoxicillin oral tablet,chewable amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous recon soln AUGMENTIN ES-600 ORAL FOR RECONSTITUTION AUGMENTIN ORAL FOR RECONSTITUTION 5-.5 MG/5 ML AUGMENTIN ORAL FOR RECONSTITUTION MG/5 ML 9 AUGMENTIN ORAL AUGMENTIN XR ORAL EXTENDED RELEASE HR AVAR LS TOPICAL CLEANSER AVAR LS TOPICAL FOAM AVAR LS TOPICAL PADS, MEDICATED PA avar topical cleanser PA AVAR TOPICAL FOAM PA AVAR TOPICAL PADS, MEDICATED AVAR-E GREEN TOPICAL AVAR-E LS TOPICAL AVAR-E TOPICAL AVELOX ABC PACK ORAL AVELOX IN NACL (ISO-OSMOTIC) PIGGYBACK PA QL AVELOX ORAL QL AVIDOXY DK KIT avidoxy oral tablet AVYCAZ RECON AZACTAM IN DEXTROSE (ISO-OSM) PIGGYBACK AZACTAM INJECTION RECON AZASITE OPHTHALMIC DROPS azithromycin intravenous recon soln azithromycin oral packet QL Effective //6

20 azithromycin oral suspension for reconstitution QL azithromycin oral tablet QL aztreonam injection recon soln azuphen mb oral capsule baciim intramuscular recon soln bacitracin intramuscular recon soln bacitracin ophthalmic ointment bacitracin-polymyxin b ophthalmic ointment BACTRIM DS ORAL BACTRIM ORAL BACTROBAN NASAL NASAL OINTMENT BACTROBAN TOPICAL BENZAMYCIN TOPICAL GEL BENZAMYCINPAK TOPICAL GEL BENZODOX 0 KIT, CLEANSER ER AND BENZODOX 60 KIT, CLEANSER ER AND BESIVANCE OPHTHALMIC DROPS, BETHKIS INHALATION FOR NEBULIZATION BIAXIN ORAL FOR RECONSTITUTION BIAXIN ORAL BICILLIN C-R ST BICILLIN L-A BLEPH-0 OPHTHALMIC DROPS BLEPHAMIDE OPHTHALMIC DROPS, BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT bp 0- topical cleanser CAPASTAT INJECTION RECON CAYSTON INHALATION FOR NEBULIZATION CEDAX ORAL CEDAX ORAL FOR RECONSTITUTION cefaclor oral capsule cefaclor oral suspension for reconstitution cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml CEFAZOLIN IN DEXTROSE (ISO-OS) PIGGYBACK GRAM/00 ML cefazolin injection recon soln cefazolin intravenous recon soln cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet 0 Effective //6

21 CEFEPIME IN DEXTROSE 5 % PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln cefixime oral suspension for reconstitution CEFOTAN INJECTION RECON cefotaxime injection recon soln CEFOTETAN IN DEXTROSE, ISO-OSM PIGGYBACK cefotetan injection recon soln cefotetan intravenous recon soln cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet CEFTAZIDIME IN D5W PIGGYBACK ceftazidime injection recon soln ceftibuten oral capsule ceftibuten oral suspension for reconstitution CEFTIN ORAL FOR RECONSTITUTION CEFTIN ORAL ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln gram, 0 gram, gram, 50 mg, 500 mg CEFTRIAXONE INJECTION RECON 00 GRAM ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln cefuroxime sodium intravenous recon soln CENTANY AT TOPICAL OINTMENT KIT CENTANY TOPICAL OINTMENT cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet CETRAXAL OTIC DROPPERETTE chloramphenicol sod succinate intravenous recon soln CILOXAN OPHTHALMIC DROPS CILOXAN OPHTHALMIC OINTMENT CIPRO HC OTIC DROPS, CIPRO IN D5W PIGGYBACK CIPRO ORAL,MICROCA PSULE RECON QL CIPRO ORAL QL CIPRO XR ORAL, ER MULTIPHASE HR CIPRODEX OTIC DROPS, QL Effective //6

22 ciprofloxacin (mixture) oral tablet, er multiphase hr ciprofloxacin hcl ophthalmic drops QL ciprofloxacin hcl oral tablet QL ciprofloxacin hcl otic dropperette ciprofloxacin in 5 % dextrose intravenous piggyback ciprofloxacin lactate intravenous ciprofloxacin oral suspension,microcapsule recon CLAFORAN IN DEXTROSE(ISO-OSM) PIGGYBACK CLAFORAN INJECTION RECON CLAFORAN RECON clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr cleansing wash topical cleanser CLEOCIN IN 5 % DEXTROSE PIGGYBACK CLEOCIN INJECTION CLEOCIN CLEOCIN ORAL CLEOCIN ORAL RECON CLEOCIN T TOPICAL GEL QL CLEOCIN T TOPICAL LOTION CLEOCIN T TOPICAL CLEOCIN T TOPICAL SWAB CLEOCIN VAGINAL CLEOCIN VAGINAL SUPPOSITORY CLIN SINGLE USE INJECTION KIT CLINDACIN ETZ TOPICAL KIT clindacin etz topical swab clindacin p topical swab CLINDACIN PAC TOPICAL KIT CLINDAGEL TOPICAL GEL clindamycin hcl oral capsule clindamycin in 5 % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection clindamycin phosphate intravenous clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical clindamycin phosphate topical swab clindamycin phosphate vaginal cream ST ST ST Effective //6

23 CLINDESSE VAGINAL,EXTENDED RELEASE colistin (colistimethate na) injection recon soln COLY-MYCIN M PARENTERAL INJECTION RECON COLY-MYCIN S OTIC DROPS, CORTISPORIN TOPICAL CORTISPORIN TOPICAL OINTMENT CORTISPORIN-TC OTIC DROPS, CUBICIN RECON CYCLOSERINE ORAL DALVANCE DAPSONE ORAL demeclocycline oral tablet dicloxacillin oral capsule DIFICID ORAL DORIBAX RECON DORYX ORAL,DELAYED RELEASE (DR/EC) doxy-00 intravenous recon soln doxycycline hyclate intravenous recon soln doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) ST ST doxycycline monohydrate oral capsule DOXYCYCLINE MONOHYDRATE ORAL,IR - DELAY REL,BIPHASE doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet e.e.s. 00 oral tablet E.E.S. GRANULES ORAL FOR RECONSTITUTION ery pads topical swab erygel topical gel ERYPED 00 ORAL FOR RECONSTITUTION ERYPED 00 ORAL FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 50 mg, mg ERY-TAB ORAL,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet ERYTHROCIN RECON erythromycin ethylsuccinate oral tablet erythromycin ophthalmic ointment erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin with ethanol topical gel ST Effective //6

24 erythromycin with ethanol topical erythromycin with ethanol topical swab erythromycin-benzoyl peroxide topical gel ethambutol oral tablet EVOCLIN TOPICAL FOAM FACTIVE ORAL FLAGYL ER ORAL EXTENDED RELEASE FLAGYL ORAL FLAGYL ORAL FORTAZ IN DEXTROSE 5 % PIGGYBACK FORTAZ INJECTION RECON FORTAZ RECON FURADANTIN ORAL gatifloxacin ophthalmic drops gentak ophthalmic ointment gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 00 MG/50 ML, 0 MG/00 ML gentamicin injection gentamicin ophthalmic drops gentamicin ophthalmic ointment gentamicin sulfate (ped) (pf) injection QL gentamicin sulfate (pf) intravenous 00 mg/0 ml GENTAMICIN SULFATE (PF) 60 MG/6 ML gentamicin topical cream gentamicin topical ointment HIPREX ORAL hyolev mb oral tablet hyophen oral tablet ILOTYCIN OPHTHALMIC OINTMENT imipenem-cilastatin intravenous recon soln INDIOMIN MB ORAL INVANZ INJECTION RECON INVANZ RECON isoniazid injection isoniazid oral isoniazid oral tablet KEFLEX ORAL KETEK ORAL KITABIS PAK INHALATION FOR NEBULIZATION LEVAQUIN ORAL levofloxacin in d5w intravenous piggyback levofloxacin intravenous levofloxacin ophthalmic drops LEVOFLOXACIN ORAL QL QL levofloxacin oral tablet QL Effective //6

25 LINCOCIN INJECTION lincomycin injection linezolid intravenous parenteral linezolid oral suspension for reconstitution PA; QL linezolid oral tablet PA; QL linezolid-0.9% sodium chloride intravenous parenteral MACROBID ORAL MACRODANTIN ORAL MAXIPIME INJECTION RECON MAXIPIME RECON MAXITROL OPHTHALMIC DROPS, MAXITROL OPHTHALMIC OINTMENT MEFOXIN IN DEXTROSE (ISO-OSM) PIGGYBACK meropenem intravenous recon soln MEROPENEM-0.9% SODIUM CHLORIDE PIGGYBACK MERREM RECON methenamine hippurate oral tablet methenamine mandelate oral tablet methen-sod phos-meth blue-hyos oral tablet metro i.v. intravenous piggyback METROGEL VAGINAL VAGINAL GEL metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule metronidazole oral tablet metronidazole vaginal gel MINOCIN RECON MINOCIN ORAL ST ST minocycline oral capsule ST minocycline oral tablet ST minocycline oral tablet extended release hr mondoxyne nl oral capsule MONODOX ORAL MONUROL ORAL PACKET MORGIDOX X00 KIT MORGIDOX X00 KIT morgidox oral capsule MOXATAG ORAL, ER MULTIPHASE HR MOXEZA OPHTHALMIC DROPS, VISCOUS ST ST moxifloxacin oral tablet QL MOXIFLOXACIN-SOD.A CE,SUL-WATER PIGGYBACK mupirocin calcium topical cream mupirocin topical ointment MYAMBUTOL ORAL MYCOBUTIN ORAL 5 Effective //6

26 nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln nafcillin intravenous recon soln neomycin oral tablet neomycin-bacitracin-poly-hc ophthalmic ointment neomycin-bacitracin-polymy xin ophthalmic ointment neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neomycin-polymyxin-gramic idin ophthalmic drops neomycin-polymyxin-hc ophthalmic drops,suspension neomycin-polymyxin-hc otic drops,suspension neomycin-polymyxin-hc otic neo-polycin hc ophthalmic ointment neo-polycin ophthalmic ointment NEOSPORIN (NEO-POLYM-GRAMICI D) OPHTHALMIC DROPS NEO-SYNALAR KIT TOPICAL NEO-SYNALAR TOPICAL nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension NUVESSA VAGINAL GEL OCUFLOX OPHTHALMIC DROPS ofloxacin ophthalmic drops ofloxacin oral tablet QL ofloxacin otic drops ORACEA ORAL,IR - DELAY REL,BIPHASE ORBACTIV RECON OTIPRIO INTRATYMPANIC oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln oxacillin intravenous recon soln PASER ORAL GRANULES DR FOR SUSP IN PACKET PCE ORAL, PARTICLES/CRYSTALS PENICILLIN G POT IN DEXTROSE PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral tablet pfizerpen-g injection recon soln phosphasal oral tablet piperacillin-tazobactam intravenous recon soln 6 Effective //6

27 PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED PLEXION TOPICAL CLEANSER PLEXION TOPICAL PLEXION TOPICAL LOTION polycin ophthalmic ointment polymyxin b sulfate injection recon soln polymyxin b sulf-trimethoprim ophthalmic drops POLYTRIM OPHTHALMIC DROPS PRED-G OPHTHALMIC DROPS, PRED-G S.O.P. OPHTHALMIC OINTMENT PRIFTIN ORAL PRIMAXIN IV RECON PRIMSOL ORAL pyrazinamide oral tablet rifabutin oral capsule RIFADIN RECON RIFADIN ORAL RIFAMATE ORAL rifampin intravenous recon soln rifampin oral capsule RIFATER ORAL ROSANIL TOPICAL CLEANSER QL PA 7 rosula cleansing cloths topical pads, medicated ROSULA TOPICAL CLEANSER SILVADENE TOPICAL silver sulfadiazine topical cream SIRTURO ORAL SIVEXTRO RECON SIVEXTRO ORAL SOLODYN ORAL EXTENDED RELEASE HR SPECTRACEF ORAL ss 0- topical cleanser ssd topical cream sss 0-5 topical cream sss 0-5 topical foam STREPTOMYCIN RECON sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment sulfacetamide sodium-sulfur topical cleanser 0- %, % sulfacetamide sodium-sulfur topical cleanser 0-5 % (w/w), 9- %, 9-.5 % sulfacetamide sodium-sulfur topical cream 0- % sulfacetamide sodium-sulfur topical cream 0-5 % (w/w), % sulfacetamide sodium-sulfur topical foam sulfacetamide sodium-sulfur topical lotion PA; QL ST PA PA Effective //6

28 sulfacetamide sodium-sulfur topical pads, medicated sulfacetamide sodium-sulfur topical suspension 0-5 % sulfacetamide sodium-sulfur topical suspension 8- % sulfacetamide sod-sulfur-urea topical cleanser sulfacetamide-prednisolone ophthalmic drops sulfacetamide-sulfur-cleansr topical kit sulfacleanse 8- topical suspension sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream sulfadiazine oral tablet sulfamethoxazole-trimethopri m intravenous sulfamethoxazole-trimethopri m oral suspension sulfamethoxazole-trimethopri m oral tablet SULFAMYLON TOPICAL SULFAMYLON TOPICAL PACKET sulfatrim oral suspension SUMADAN TOPICAL CLEANSER SUMADAN TOPICAL KIT SUMADAN XLT TOPICAL COMBO PACK,CLEANSER AND SUMAXIN CP TOPICAL KIT SUMAXIN TOPICAL CLEANSER SUMAXIN TOPICAL PADS, MEDICATED PA PA PA PA PA PA PA PA PA 8 SUMAXIN TS TOPICAL SUPRAX ORAL SUPRAX ORAL FOR RECONSTITUTION SUPRAX ORAL,CHEWABLE SYNERCID RECON TAZICEF INJECTION RECON TAZICEF RECON TEFLARO RECON tetracycline oral capsule THALOMID ORAL thermazene topical cream TOBI INHALATION FOR NEBULIZATION TOBI PODHALER INHALATION TOBI PODHALER INHALATION, W/INHALATION DEVICE TOBRADEX OPHTHALMIC DROPS, TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST OPHTHALMIC DROPS, tobramycin in 0.5 % nacl inhalation for nebulization tobramycin in 0.9 % nacl intravenous piggyback PA PA; QL Effective //6

29 tobramycin ophthalmic drops tobramycin sulfate injection recon soln tobramycin sulfate injection tobramycin-dexamethasone ophthalmic drops,suspension TOBREX OPHTHALMIC DROPS TOBREX OPHTHALMIC OINTMENT TRECATOR ORAL trimethoprim oral tablet TYGACIL RECON UNASYN INJECTION RECON ur n-c oral tablet uramit mb oral capsule URELLE ORAL uretron d-s oral tablet URIBEL ORAL urimar-t oral tablet urin ds oral tablet uro-blue oral tablet urogesic-blue oral tablet uro-l oral tablet urolet mb oral tablet uro-mp oral capsule urophen mb oral tablet uryl oral tablet ustell oral capsule UTA ORAL utira-c oral tablet VANCOCIN ORAL VANCOMYCIN IN D5W PIGGYBACK VANCOMYCIN IN DEXTROSE ISO-OSM PIGGYBACK vancomycin intravenous recon soln,000 mg, 0 gram, 5 gram, 500 mg VANCOMYCIN RECON 750 MG vancomycin oral capsule vandazole vaginal gel VIBATIV RECON VIBRAMYCIN ORAL VIBRAMYCIN ORAL FOR RECONSTITUTION VIBRAMYCIN ORAL SYRUP VIGAMOX OPHTHALMIC DROPS XIFAXAN ORAL ST PA; QL zencia topical cleanser PA ZERBAXA RECON ZINACEF IN STERILE WATER PIGGYBACK ZINACEF INJECTION RECON ZINACEF RECON ZITHROMAX RECON ZITHROMAX ORAL PACKET ZITHROMAX ORAL FOR RECONSTITUTION QL QL 9 Effective //6

30 ZITHROMAX ORAL ZITHROMAX TRI-PAK ORAL ZITHROMAX Z-PAK ORAL ZMAX ORAL,EXTENDE D REL RECON ZOSYN IN DEXTROSE (ISO-OSM) PIGGYBACK ZOSYN RECON ZYLET OPHTHALMIC DROPS, ZYMAXID OPHTHALMIC DROPS ZYVOX PARENTERAL ZYVOX ORAL FOR RECONSTITUTION QL QL QL QL PA; QL ZYVOX ORAL PA; QL ANTICOAGULANTS ACD ACD-A ANGIOMAX RECON ANTICOAG CITRATE PHOS DEXTROSE ARGATROBAN IN 0.9 % SOD CHLOR PARENTERAL ARGATROBAN IN 0.9 % SOD CHLOR ARGATROBAN IN NACL (ISO-OS) 0 ARGATROBAN ARIXTRA BIVALIRUDIN RECON COUMADIN ORAL ELIQUIS ORAL QL enoxaparin subcutaneous enoxaparin subcutaneous syringe fondaparinux subcutaneous syringe FRAGMIN FRAGMIN hep flush-0 (pf) intravenous heparin (porcine) in 5 % dex intravenous parenteral heparin (porcine) in nacl (pf) intravenous parenteral heparin (porcine) injection cartridge heparin (porcine) injection heparin flush intravenous kit heparin flush(porcine)-0.9nacl intravenous kit heparin lock flush (porcine) intravenous heparin lock flush (porcine) intravenous syringe heparin lock flush intravenous Effective //6

31 heparin lock flush intravenous syringe heparin lock intravenous heparin lockflush(porcine)(pf) intravenous syringe HEPARIN(PORCINE) IN 0.5% NACL PARENTERAL,500 UNIT/50 ML heparin(porcine) in 0.5% nacl intravenous parenteral 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection heparin, porcine (pf) injection syringe heparin, porcine (pf) intravenous heparin, porcine (pf) intravenous syringe IPRIVASK RECON jantoven oral tablet LOVENOX LOVENOX monoject prefill (pf) intravenous syringe monoject prefill advanced (pf) intravenous syringe PRADAXA ORAL SAVAYSA ORAL SODIUM CITRATE QL QL TRICITRASOL INJECTION CONCENTRATE warfarin oral tablet XARELTO ORAL XARELTO ORAL S,DOSE PACK ANTIDOTES EVZIO INJECTION AUTO-INJECTOR MOVANTIK ORAL naloxone injection naloxone injection syringe naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL RELISTOR RELISTOR REVIA ORAL ANTIFUNGALS ABELCET AMBISOME FOR RECONSTITUTION amphotericin b injection recon soln ANCOBON ORAL CANCIDAS RECON CICLODAN KIT TOPICAL COMBO PACK CICLODAN KIT TOPICAL ciclodan topical cream QL PA; QL PA Effective //6

32 ciclodan topical ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical ciclopirox topical suspension ciclopirox-ure-camph-mentheuc topical clotrimazole mucous membrane troche clotrimazole topical cream clotrimazole topical clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion CNL 8 NAIL TOPICAL KIT CRESEMBA RECON CRESEMBA ORAL DIFLUCAN ORAL FOR RECONSTITUTION DIFLUCAN ORAL econazole topical cream ECOZA TOPICAL FOAM ERAXIS(WATER DILUENT) RECON ERTACZO TOPICAL EXELDERM TOPICAL EXELDERM TOPICAL EXODERM TOPICAL LOTION EXTINA TOPICAL FOAM PA fluconazole in dextrose(iso-o) intravenous piggyback FLUCONAZOLE IN NACL (ISO-OSM) PIGGYBACK 00 MG/50 ML fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/00 ml fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet GRIS-PEG (ULTRAMICROSIZE) ORAL GYNAZOLE- VAGINAL itraconazole oral capsule PA JUBLIA TOPICAL WITH APPLICATOR KERYDIN TOPICAL WITH APPLICATOR ketoconazole oral tablet ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo LAMISIL ORAL GRANULES IN PACKET LAMISIL ORAL LOPROX TOPICAL SHAMPOO LOTRISONE TOPICAL Effective //6

33 LUZU TOPICAL MENTAX TOPICAL miconazole- vaginal suppository MYCAMINE RECON NAFTIFINE TOPICAL % naftifine topical cream % NAFTIN TOPICAL NAFTIN TOPICAL GEL NATACYN OPHTHALMIC DROPS, NIZORAL TOPICAL SHAMPOO NOXAFIL NOXAFIL ORAL NOXAFIL ORAL,DELAYED RELEASE (DR/EC) nyamyc topical powder NYATA TOPICAL COMBO PACK,GEL AND POWDER nystatin oral powder nystatin oral suspension nystatin oral tablet nystatin topical cream nystatin topical ointment nystatin topical powder nystatin-triamcinolone topical cream nystatin-triamcinolone topical ointment nystop topical powder ONMEL ORAL ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL oxiconazole topical cream OXISTAT TOPICAL OXISTAT TOPICAL LOTION PEDIADERM AF TOPICAL PENLAC TOPICAL SPORANOX ORAL SPORANOX ORAL SPORANOX PULSEPAK ORAL TERAZOL VAGINAL TERAZOL 7 VAGINAL terbinafine hcl oral tablet terconazole vaginal cream terconazole vaginal suppository PA PA PA TRIACETIN LIQUID QL TRIPLE DYE TOPICAL SWAB VFEND IV VFEND ORAL FOR RECONSTITUTION VFEND ORAL voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet VUSION TOPICAL OINTMENT XOLEGEL TOPICAL GEL Effective //6

34 ANTIHISTAMINE AND DECONGESTANT COMBINATION ALLEGRA-D HOUR ORAL EXTENDED RELEASE HR centergy oral drops CLARINEX-D HOUR ORAL, ER MULTIPHASE HR promethazine vc oral syrup promethazine-phenylephrine oral syrup SEMPREX-D ORAL ANTIHISTAMINES arbinoxa oral liquid arbinoxa oral tablet ST; QL ST; QL ST azelastine ophthalmic drops QL BEPREVE OPHTHALMIC DROPS carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet ST; QL cetirizine oral QL CLARINEX ORAL SYRUP CLARINEX ORAL clemastine oral tablet CYPROHEPTADINE ORAL SYRUP cyproheptadine oral tablet ST; QL ST; QL desloratadine oral tablet QL desloratadine oral tablet,disintegrating diphenhydramine hcl injection diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule QL diphenhydramine hcl oral elixir ELESTAT OPHTHALMIC DROPS EMADINE OPHTHALMIC DROPS ST; QL ST; QL epinastine ophthalmic drops QL hydroxyzine hcl intramuscular HYDROXYZINE HCL ORAL hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule KARBINAL ER ORAL,EXTENDE D REL HR LASTACAFT OPHTHALMIC DROPS ST; QL levocetirizine oral QL levocetirizine oral tablet QL olopatadine ophthalmic drops ST; QL PATADAY OPHTHALMIC DROPS PATANOL OPHTHALMIC DROPS PAZEO OPHTHALMIC DROPS PHENERGAN INJECTION promethazine injection promethazine oral syrup promethazine oral tablet VISTARIL ORAL XYZAL ORAL ST; QL ST; QL ST; QL ST; QL XYZAL ORAL ST; QL ANTIHYPERGLYCEMIC S acarbose oral tablet ACTOPLUS MET ORAL QL Effective //6

35 ACTOPLUS MET XR ORAL, ER MULTIPHASE HR QL ACTOS ORAL QL AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE ALOGLIPTIN ORAL ALOGLIPTIN-METFOR MIN ORAL ALOGLIPTIN-PIOGLITA ZONE ORAL AMARYL ORAL APIDRA SOLOSTAR INSULIN PEN APIDRA AVANDAMET ORAL AVANDIA ORAL BYDUREON PEN INJECTOR BYDUREON,EXTENDE D REL RECON BYETTA PEN INJECTOR PA; QL ST; QL ST; QL ST; QL ST ST ST; QL ST; QL ST ST; QL ST; QL chlorpropamide oral tablet PA CYCLOSET ORAL DUETACT ORAL FARXIGA ORAL FORTAMET ORAL EXTENDED RELEASE HR QL ST; QL glimepiride oral tablet glipizide oral tablet glipizide oral tablet extended release hr glipizide-metformin oral tablet GLUCOPHAGE ORAL GLUCOPHAGE XR ORAL EXTENDED RELEASE HR GLUCOTROL ORAL GLUCOTROL XL ORAL EXTENDED RELEASE HR GLUCOVANCE ORAL GLUMETZA ORAL,ER GAST.RETENTION HR glyburide micronized oral tablet glyburide oral tablet glyburide-metformin oral tablet GLYNASE ORAL GLYSET ORAL GLYXAMBI ORAL HUMALOG KWIKPEN INSULIN PEN HUMALOG MIX KWIKPEN INSULIN PEN HUMALOG MIX ST ST; QL 5 Effective //6

36 HUMALOG MIX 75-5 KWIKPEN INSULIN PEN HUMALOG MIX 75-5 HUMALOG CARTRIDGE HUMALOG HUMULIN 70/0 KWIKPEN INSULIN PEN HUMULIN 70/0 HUMULIN N KWIKPEN INSULIN PEN HUMULIN N HUMULIN R INJECTION HUMULIN R U-500 (CONC) KWIKPEN INSULIN PEN HUMULIN R U-500 (CONCENTRATED) INVOKAMET ORAL INVOKANA ORAL JANUMET ORAL JANUMET XR ORAL, ER MULTIPHASE HR JANUVIA ORAL ST; QL ST; QL ST; QL ST; QL ST; QL JARDIANCE ORAL JENTADUETO ORAL ST; QL ST; QL KAZANO ORAL ST; QL KOMBIGLYZE XR ORAL, ER MULTIPHASE HR KORLYM ORAL LANTUS SOLOSTAR INSULIN PEN LANTUS LEVEMIR FLEXTOUCH INSULIN PEN LEVEMIR metformin oral tablet metformin oral tablet extended release hr metformin oral tablet extended release hr metformin oral tablet,er gast.retention hr nateglinide oral tablet ST; QL ST NESINA ORAL ST; QL NOVOLIN 70/0 NOVOLIN N NOVOLIN R INJECTION NOVOLOG FLEXPEN INSULIN PEN NOVOLOG MIX 70-0 FLEXPEN INSULIN PEN 6 Effective //6

37 NOVOLOG MIX 70-0 NOVOLOG PENFILL CARTRIDGE NOVOLOG ONGLYZA ORAL.5 MG ONGLYZA ORAL 5 MG ST; DO ST; QL OSENI ORAL ST; QL pioglitazone oral tablet QL pioglitazone-glimepiride oral tablet pioglitazone-metformin oral tablet PRANDIN ORAL PRECOSE ORAL repaglinide oral tablet repaglinide-metformin oral tablet RIOMET ORAL STARLIX ORAL SYMLINPEN 0 PEN INJECTOR SYMLINPEN 60 PEN INJECTOR SYNJARDY ORAL TANZEUM PEN INJECTOR 0 MG/0.5 ML TANZEUM PEN INJECTOR 50 MG/0.5 ML tolazamide oral tablet tolbutamide oral tablet QL QL ST; QL ST; QL ST 7 TOUJEO SOLOSTAR INSULIN PEN TRADJENTA ORAL TRESIBA FLEXTOUCH U-00 INSULIN PEN TRESIBA FLEXTOUCH U-00 INSULIN PEN TRULICITY PEN INJECTOR VICTOZA -PAK PEN INJECTOR VICTOZA -PAK PEN INJECTOR XIGDUO XR ORAL, IR - ER, BIPHASIC HR ANTIINFECTIVES/MISC ELLANEOUS ALBENZA ORAL ALINIA ORAL FOR RECONSTITUTION ALINIA ORAL atovaquone oral suspension atovaquone-proguanil oral tablet BILTRICIDE ORAL chloroquine phosphate oral tablet COARTEM ORAL DARAPRIM ORAL EMVERM ORAL,CHEWABLE fem ph vaginal gel formadon topical ST; DO ST ST ST; QL ST; QL ST; QL ST; QL PA; QL Effective //6

38 formadon topical with applicator formaldehyde topical with applicator GLUTARALDEHYDE glycine irrigation glycine urologic irrigation hydroxychloroquine oral tablet ivermectin oral tablet MALARONE ORAL MALARONE PEDIATRIC ORAL mefloquine oral tablet MEPRON ORAL NEBUPENT INHALATION RECON paromomycin oral capsule PENTAM INJECTION RECON PLAQUENIL ORAL PRIMAQUINE ORAL QUALAQUIN ORAL PA; QL quinine sulfate oral capsule PA; QL RELAGARD VAGINAL GEL STROMECTOL ORAL TINDAMAX ORAL tinidazole oral tablet ANTIINFECTIVES ARESTIN DENTAL CARTRIDGE AVC VAGINAL VAGINAL ANTINEOPLASTICS ABRAXANE FOR RECONSTITUTION ACTIMMUNE ADCETRIS RECON adrucil intravenous AFINITOR DISPERZ ORAL FOR AFINITOR ORAL ALECENSA ORAL ALFERON N INJECTION ALIMTA RECON ALKERAN RECON ALKERAN ORAL ; QL PA PA PA PA anastrozole oral tablet PA; QL ARIMIDEX ORAL AROMASIN ORAL ARRANON ARZERRA AVASTIN azacitidine injection recon soln PA; QL PA; QL PA PA QL 8 Effective //6

39 BELEODAQ RECON BENDEKA PA bexarotene oral capsule PA; QL bicalutamide oral tablet BICNU RECON bleomycin injection recon soln BLINCYTO KIT PA BOSULIF ORAL PA; QL BUSULFEX CAMPATH CAMPTOSAR capecitabine oral tablet PA; QL CAPRELSA ORAL CARAC TOPICAL carboplatin intravenous recon soln carboplatin intravenous CASODEX ORAL cisplatin intravenous cladribine intravenous CLOLAR COMETRIQ ORAL COSMEGEN RECON PA; QL PA; QL 9 COTELLIC ORAL cyclophosphamide intravenous recon soln CYCLOPHOSPHAMIDE ORAL CYRAMZA cytarabine (pf) injection cytarabine injection dacarbazine intravenous recon soln DACOGEN RECON DARZALEX daunorubicin intravenous recon soln daunorubicin intravenous decitabine intravenous recon soln DEPOCYT (PF) INTRATHECAL PA; QL PA diclofenac sodium topical gel PA; QL DOCEFREZ RECON docetaxel intravenous DOXIL doxorubicin intravenous recon soln doxorubicin intravenous doxorubicin, peg-liposomal intravenous suspension EFUDEX TOPICAL PA Effective //6

40 ELIGARD ELLENCE PA; QL EMCYT ORAL PA EMPLICITI RECON epirubicin intravenous recon soln epirubicin intravenous ERBITUX ERIVEDGE ORAL ERWINAZE INJECTION RECON ETOPOPHOS RECON etoposide intravenous etoposide oral capsule PA PA; QL PA exemestane oral tablet PA; QL FARESTON ORAL FARYDAK ORAL FASLODEX QL PA; QL FEMARA ORAL PA; QL FIRMAGON KIT W DILUENT RECON floxuridine injection recon soln fludarabine intravenous recon soln fludarabine intravenous PA 0 FLUOROPLEX TOPICAL fluorouracil intravenous FLUOROURACIL TOPICAL 0.5 % fluorouracil topical cream 5 % fluorouracil topical flutamide oral capsule FOLOTYN GAZYVA gemcitabine intravenous recon soln gemcitabine intravenous GEMZAR RECON GILOTRIF ORAL GLEEVEC ORAL GLEOSTINE ORAL GLIADEL WAFER IMPLANT WAFER HALAVEN HERCEPTIN RECON HEXALEN ORAL HYCAMTIN RECON HYCAMTIN ORAL HYDREA ORAL PA PA PA; QL PA; QL PA PA PA PA PA Effective //6

41 hydroxyurea oral capsule IBRANCE ORAL PA; QL ICLUSIG ORAL PA; QL IDAMYCIN PFS idarubicin intravenous IFEX RECON ifosfamide intravenous recon soln ifosfamide intravenous ifosfamide-mesna intravenous kit imatinib oral tablet PA; QL IMBRUVICA ORAL IMLYGIC INJECTION PA; QL INLYTA ORAL PA; QL INTRON A INJECTION RECON INTRON A INJECTION IRESSA ORAL PA; QL irinotecan intravenous ISTODAX RECON IXEMPRA RECON JAKAFI ORAL PA; QL JEVTANA KADCYLA RECON PA KEYTRUDA RECON KEYTRUDA KYPROLIS RECON LENVIMA ORAL PA PA PA PA; QL letrozole oral tablet PA; QL LEUKERAN ORAL leuprolide subcutaneous kit PA LEVULAN TOPICAL lipodox 50 intravenous suspension lipodox intravenous suspension LONSURF ORAL LUPRON DEPOT ( MONTH) KIT LUPRON DEPOT ( MONTH) KIT LUPRON DEPOT (6 MONTH) KIT LUPRON DEPOT KIT LYNPARZA ORAL LYSODREN ORAL MARQIBO KIT MATULANE ORAL PA PA PA PA; QL PA PA; QL QL Effective //6

42 megestrol oral tablet MEKINIST ORAL melphalan hcl intravenous recon soln mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection methotrexate sodium injection methotrexate sodium oral tablet mitomycin intravenous recon soln mitoxantrone intravenous concentrate MUSTARGEN INJECTION RECON MYLERAN ORAL NAVELBINE NEXAVAR ORAL NILANDRON ORAL NINLARO ORAL NIPENT RECON ODOMZO ORAL ONCASPAR INJECTION ONIVYDE DISPERSION OPDIVO oxaliplatin intravenous recon soln PA; QL PA; QL QL PA; QL PA; QL PA PA oxaliplatin intravenous paclitaxel intravenous concentrate PANRETIN TOPICAL GEL PERJETA PHOTOFRIN RECON PA PICATO TOPICAL GEL PA; QL POMALYST ORAL PORTRAZZA PROLEUKIN RECON PROVENGE PURIXAN ORAL REVLIMID ORAL RITUXAN CONCENTRATE SOLARAZE TOPICAL GEL SOLTAMOX ORAL SPRYCEL ORAL STIVARGA ORAL SUTENT ORAL SYLATRON KIT SYLVANT RECON PA; QL PA PA; QL PA PA; QL PA; QL PA; QL PA; QL Effective //6