HealthPartners GenericsPlusRx 2018 Formulary (List of covered drugs) For current information on the GenericsPlusRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners
What s the GenericsPlusRx drug list? This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates. Who decides what s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information. How do you use the drug list? The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3. Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost. Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines. The Status can be used to determine how much a medicine will cost you. For exact cost information, Find the status for your medicine. Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Status. Or, Log on to your myhealthpartners account to check your pharmacy benefits. F $ Formulary Low Cost Generics F $$ Formulary High Cost Generics F $$$ Formulary Brands What s a Medicine? medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines. What do the abbreviations in the More details column mean? This column gives special information about the medicine you re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list: Prior Authorization Required PA Step Therapy Required ST Age Edit AE Gender Edit Female GE Female Gender Edit Male GE Male Quantity Limit Smoking Cessation Benefit SC Trial Drug Program TD Weight Loss Benefit WL Oncology Benefit ONC
Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits. What s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance. What s an Age Edit (AE)? An age edit means some medicines are only covered if you re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Quantity Limit ()? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description. What s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to: Side effects High cost High potential for waste Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you ll get the rest of your month supply. If a copay applies to the medicine, you ll pay no more than one copay for each one month supply. What s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category. What s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you re only responsible for your regular generic or brand pharmacy copay or coinsurance. The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (9/15) 2015 HealthPartners
Table of Contents Alcohol Dependency...6 Allergy...6 Alpha-1 Antitrypsin Deficiency... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Anti-Infective...7 Arthritis...15 Asthma & Copd...16 Behavioral Health...18 Birth Control... 23 Bleeding Disorders... 27 Blood Modifier...28 Blood Thinner... 31 Bone Health... 32 Cancer... 33 Corticosteroids... 36 Cough & Cold... 37 Cystic Fibrosis... 37 Dementia... 37 Diabetes...38 Ear Conditions... 41 Enzyme Replacement... 42 Eye Conditions... 42 Gout... 44 Heart Health... 45 Hereditary Angioedema... 51 Idiopathic Pulmonary Fibrosis... 51 Immune Deficiency...52 Immune Suppressant... 53 Kidney Failure...53 Men's Health... 54 Migraine...54 Mouth & Throat...55 Multiple Sclerosis... 56 Muscle Relaxant... 56 Other Conditions... 57 Pain... 58 Parkinson's...61 Pulmonary Hypertension... 62 Seizures / Epilepsy...63 Skin Conditions...65 Sleep Disorders...70 Smoking Cessation... 70 Stomach / Gastrointestinal... 70 Thyroid...73 Urinary & Bladder Health...73 Vaccines... 74 Vitamins And Minerals...78 4
Weight Loss...79 Women's Health...79 5
Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 250, 500 naltrexone oral tablet 50 Allergy Allergy, Eye azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % epinastine ophthalmic (eye) drops 0.05 % olopatadine ophthalmic (eye) drops 0.1 % Allergy, Injection epinephrine injection auto-injector 0.15 /0.15 ml, 0.15 /0.3 ml, 0.3 /0.3 ml Allergy, Other Nasal azelastine nasal aerosol,spray 137 mcg (0.1 %) ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) Allergy, Other Oral GRASTEK SUBLINGUAL TABLET 2,800 BAU $ PA ODACTRA SUBLINGUAL TABLET 12 SQ-HDM $ PA RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT Antihistamines, Oral cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet 4 $ PA hydroxyzine hcl oral solution 10 /5 ml ; AE hydroxyzine hcl oral tablet 10, 25, 50 F$ ; AE hydroxyzine pamoate oral capsule 100, 25, 50 ; AE promethazine oral tablet 12.5, 25, 50 ; AE Corticosteroids, Nasal flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) 6
fluticasone nasal spray,suspension 50 mcg/actuation Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML F$ $ $ $ $ ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG $ Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents naloxone injection syringe 1 /ml NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION Anti-Infective Antibiotics, Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250, 500 $ $ cephalexin oral capsule 250, 500 F$ cephalexin oral suspension for reconstitution 125 /5 ml, 250 /5 ml 7
SUPRAX ORAL CAPSULE 400 MG $ Antibiotics, Macrolides azithromycin oral suspension for reconstitution 100 /5 ml, 200 /5 ml azithromycin oral tablet 250, 500 F$ azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG $ PA Antibiotics, Other clindamycin hcl oral capsule 150, 300 F$ clindamycin hcl oral capsule 75 clindamycin palmitate hcl oral recon soln 75 /5 ml FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML linezolid oral suspension for reconstitution 100 /5 ml $ linezolid oral tablet 600 PA neomycin oral tablet 500 sulfamethoxazole-trimethoprim oral suspension 200-40 /5 ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-160 trimethoprim oral tablet 100 vancomycin intravenous recon soln 1,000, 10 gram, 250, 5 gram, 500 vancomycin oral capsule 125, 250 XIFAXAN ORAL TABLET 200 MG, 550 MG $ PA Antibiotics, Penicillins amoxicillin oral capsule 250, 500 F$ amoxicillin oral suspension for reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 F$ amoxicillin oral tablet,chewable 125, 250 F$ F$ F$ PA 8
amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 /5 ml, 250-62.5 /5 ml, 400-57 /5 ml, 600-42.9 /5 ml amoxicillin-pot clavulanate oral tablet 250-125, 500-125, 875-125 amoxicillin-pot clavulanate oral tablet,chewable 200-28.5, 400-57 ampicillin oral capsule 250, 500 F$ ampicillin oral suspension for reconstitution 125 /5 ml, 250 /5 ml dicloxacillin oral capsule 250, 500 penicillin v potassium oral recon soln 125 /5 ml, 250 /5 ml F$ penicillin v potassium oral tablet 250, 500 F$ Antibiotics, Quinolones CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin oral solution 250 /10 ml $ F$ levofloxacin oral tablet 250, 500, 750 F$ moxifloxacin oral tablet 400 Antibiotics, Tetracyclines demeclocycline oral tablet 150, 300 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 50 minocycline oral capsule 100, 50, 75 tetracycline oral capsule 250, 500 Antifungals clotrimazole mucous membrane troche 10 CRESEMBA ORAL CAPSULE 186 MG $ PA 9
fluconazole oral suspension for reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 200 fluconazole oral tablet 150, 50 F$ griseofulvin microsize oral suspension 125 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA ketoconazole oral tablet 200 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit $ $ terbinafine hcl oral tablet 250 F$ voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) voriconazole oral tablet 200, 50 PA Anti-Infective, Other ALBENZA ORAL TABLET 200 MG $ PA atovaquone oral suspension 750 /5 ml dapsone oral tablet 100, 25 ivermectin oral tablet 3 praziquantel oral tablet 600 rifabutin oral capsule 150 SIVEXTRO ORAL TABLET 200 MG $ PA Antiprotozoals atovaquone-proguanil oral tablet 250-100, 62.5-25 chloroquine phosphate oral tablet 250, 500 hydroxychloroquine oral tablet 200 mefloquine oral tablet 250 metronidazole oral tablet 250, 500 10 PA PA PA
Antiviral, Hepatitis B adefovir oral tablet 10 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) lamivudine oral tablet 100 VEMLIDY ORAL TABLET 25 MG Antiviral, Hepatitis C $ $ $ EPCLUSA ORAL TABLET 400-100 MG $ HARVONI ORAL TABLET 90-400 MG $ INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML $ $ MAVYRET ORAL TABLET 100-40 MG $ OLYSIO ORAL CAPSULE 150 MG $ PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML $ $ $ $ $ REBETOL ORAL SOLUTION 40 MG/ML $ ribavirin oral capsule 200 ribavirin oral tablet 200 VOSEVI ORAL TABLET 400-100-100 MG $ Antiviral, Hiv abacavir oral solution 20 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet 600-300 abacavir-lamivudine-zidovudine oral tablet 300-150-300 11
APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150, 200, 300 ATRIPLA ORAL TABLET 600-200-300 MG BIKTARVY ORAL TABLET 50-200-25 MG COMPLERA ORAL TABLET 200-25-300 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET 200-25 MG didanosine oral capsule,delayed release(dr/ec) 125, 200, 250, 400 EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EVOTAZ ORAL TABLET 300-150 MG fosamprenavir oral tablet 700 $ $ $ $ $ $ $ $ $ $ $ FUZEON SUBCUTANEOUS RECON SOLN 90 MG $ GENVOYA ORAL TABLET 150-150-200-10 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET 50-25 MG KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 lamivudine-zidovudine oral tablet 150-300 LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution 400-100 /5 ml nevirapine oral suspension 50 /5 ml $ $ $ $ $ $ $ $ $ $ $ 12
nevirapine oral tablet 200 nevirapine oral tablet extended release 24 hr 100, 400 NORVIR ORAL SOLUTION 80 MG/ML ODEFSEY ORAL TABLET 200-25-25 MG PREZCOBIX ORAL TABLET 800-150 MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 100 SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 15, 20, 30, 40 STRIBILD ORAL TABLET 150-150-200-300 MG SYMTUZA ORAL TABLET 800-150-200-10 MG tenofovir disoproxil fumarate oral tablet 300 TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG TYBOST ORAL TABLET 150 MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZERIT ORAL RECON SOLN 1 MG/ML zidovudine oral capsule 100 zidovudine oral syrup 10 /ml $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 13
zidovudine oral tablet 300 Antiviral, Other acyclovir oral capsule 200 acyclovir oral suspension 200 /5 ml acyclovir oral tablet 400, 800 amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 famciclovir oral tablet 125, 250, 500 oseltamivir oral capsule 30, 45, 75 oseltamivir oral suspension for reconstitution 6 /ml PREVYMIS ORAL TABLET 240 MG, 480 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 $ $ TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG $ TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML valacyclovir oral tablet 1 gram, 500 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 Tuberculosis $ cycloserine oral capsule 250 PA ethambutol oral tablet 100, 400 isoniazid oral solution 50 /5 ml F$ isoniazid oral tablet 100, 300 F$ PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 $ SIRTURO ORAL TABLET 100 MG $ PA TRECATOR ORAL TABLET 250 MG $ PA Urinary Anti-Infectives MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100, 50 $ ; AE 14
nitrofurantoin monohyd/m-cryst oral capsule 100 ; AE nitrofurantoin oral suspension 25 /5 ml ; AE Arthritis Arthritis, Other DEPEN TITRATABS ORAL TABLET 250 MG $ Disease Modifying Agents ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10, 20 methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML $ $ $ $ $ $ $ $ $ OTEZLA ORAL TABLET 30 MG $ OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML $ $ PA 15
RIDAURA ORAL CAPSULE 3 MG Asthma & Copd Asthma & Copd, Other ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION cromolyn inhalation solution for nebulization 20 /2 ml $ $ DALIRESP ORAL TABLET 250 MCG $ PA DALIRESP ORAL TABLET 500 MCG $ PA ipratropium bromide inhalation solution 0.02 % montelukast oral granules in packet 4 montelukast oral tablet 10 F$ montelukast oral tablet,chewable 4, 5 Bronchodilators, Inhaled albuterol sulfate inhalation solution for nebulization 0.63 /3 ml, 1.25 /3 ml, 2.5 /3 ml (0.083 %), 5 /ml INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Bronchodilators, Oral albuterol sulfate oral syrup 2 /5 ml albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 12 hr 4, 8 theophylline oral tablet extended release 12 hr 100, 200, 300, 450 theophylline oral tablet extended release 24 hr 400 theophylline oral tablet extended release 600 $ $ $ $ 16
Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation ipratropium-albuterol inhalation solution for nebulization 0.5-3 (2.5 base)/3 ml TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, 1 /2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION $ $ $ $ $ $ $ $ $ $ $ PA 17
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION Behavioral Health Antipsychotic $ $ $ $ aripiprazole oral solution 1 /ml AE aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 10, 15 clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet,disintegrating 100, 12.5, 150, 200, 25 FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)- 2MG(2)- 4MG(2)-6MG(2) $ $ AE PA; AE AE PA; AE PA PA fluphenazine hcl oral concentrate 5 /ml F$ AE fluphenazine hcl oral elixir 2.5 /5 ml F$ AE fluphenazine hcl oral tablet 1, 10, 2.5, 5 AE haloperidol lactate oral concentrate 2 /ml AE haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10, 25, 5, 50 $ AE PA; AE NUPLAZID ORAL CAPSULE 34 MG $ NUPLAZID ORAL TABLET 10 MG $ 18
NUPLAZID ORAL TABLET 17 MG $ ; TD olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 10, 15, 20, 5 paliperidone oral tablet extended release 24hr 1.5, 3, 6, 9 perphenazine oral tablet 16, 2, 4, 8 quetiapine oral tablet 100, 200, 25, 300, 400, 50 quetiapine oral tablet extended release 24 hr 150, 200, 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG $ AE PA; AE PA AE AE PA; AE PA risperidone oral solution 1 /ml AE risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5, 1, 2, 3, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG $ AE PA; AE PA SAPHRIS SUBLINGUAL TABLET 2.5 MG $ PA thioridazine oral tablet 10, 100, 25, 50 AE thiothixene oral capsule 1, 10, 2, 5 AE trifluoperazine oral tablet 1, 10, 2, 5 AE VERSACLOZ ORAL SUSPENSION 50 MG/ML $ PA; AE ziprasidone hcl oral capsule 20, 40, 60, 80 Anxiety AE alprazolam oral tablet 0.25, 0.5, 1, 2 F$ alprazolam oral tablet extended release 24 hr 0.5, 1, 2, 3 buspirone oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 25 F$ 19
chlordiazepoxide hcl oral capsule 5 clonazepam oral tablet 0.5, 1, 2 F$ clonazepam oral tablet,disintegrating 0.125, 0.25, 0.5, 1, 2 diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml (1 /ml) diazepam oral tablet 10, 2, 5 F$ diazepam rectal kit 12.5-15-17.5-20, 2.5, 5-7.5-10 lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 F$ Attention Deficit/Hyperactivity Disorder (Adhd) adderall xr oral capsule,extended release 24hr 10, 15, 20, 25, 30, 5 atomoxetine oral capsule 10, 100, 18, 25, 40, 60, 80 dexmethylphenidate oral capsule,er biphasic 50-50 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate oral tablet 10, 2.5, 5 dextroamphetamine oral capsule, extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 dextroamphetamine-amphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 guanfacine oral tablet extended release 24 hr 1, 2, 3, 4 metadate er oral tablet extended release 20 methylphenidate hcl oral capsule, er biphasic 30-70 10, 20, 30, 40, 50, 60 methylphenidate hcl oral capsule,er biphasic 50-50 10, 20, 30, 40, 60 methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet extended release 10, 20 20
methylphenidate hcl oral tablet extended release 24hr 18, 27, 36, 54 QUILLICHEW ER ORAL TABLET,CHEW,IR- ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG QUILLIVANT XR 25 MG/5 ML SUSP 300 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 600 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 750 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 900 MG 5 MG/ML (25 MG/5 ML) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Bipolar Disorder divalproex oral capsule, delayed rel sprinkle 125 divalproex oral tablet extended release 24 hr 500 divalproex oral tablet,delayed release (dr/ec) 125, 250, 500 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release 24 hr 150, 300 bupropion hcl oral tablet sustained-release 12 hr 100, 150, 200 mirtazapine oral tablet 15, 30, 45, 7.5 Depression, Maois phenelzine oral tablet 15 $ $ $ $ $ $ $ 21
tranylcypromine oral tablet 10 Depression, Serotonin Modulators nefazodone oral tablet 100, 150, 200, 250, 50 trazodone oral tablet 100, 150, 300, 50 Depression, Snris desvenlafaxine succinate oral tablet extended release 24 hr 100, 25, 50 duloxetine oral capsule,delayed release(dr/ec) 20, 30, 60 venlafaxine oral capsule,extended release 24hr 150, 37.5, 75 venlafaxine oral tablet 100, 25, 37.5, 50, 75 Depression, Ssris citalopram oral solution 10 /5 ml F$ citalopram oral tablet 10, 20, 40 F$ escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 20, 5 F$ fluoxetine oral capsule 10, 20, 40 F$ fluoxetine oral solution 20 /5 ml (4 /ml) fluvoxamine oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 /ml F$ $ sertraline oral tablet 100, 25, 50 F$ Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral tablet 10, 100, 150, 25, 50, 75 AE clomipramine oral capsule 25, 50, 75 AE desipramine oral tablet 10, 100, 150, 25, 50, 75 doxepin oral capsule 10, 100, 150, 25, 50, 75 22 AE
doxepin oral concentrate 10 /ml AE imipramine hcl oral tablet 10, 25, 50 AE nortriptyline oral capsule 10, 25, 50, 75 nortriptyline oral solution 10 /5 ml Seizures / Epilepsy divalproex oral tablet extended release 24 hr 250 Birth Control Contraceptives, Other NUVARING VAGINAL RING 0.12-0.015 MG/24 HR xulane transdermal patch weekly 150-35 mcg/24 hr Emergency Contraception ELLA ORAL TABLET 30 MG levonorgestrel oral tablet 1.5 my way oral tablet 1.5 next choice one dose oral tablet 1.5 Oral Contraceptives altavera (28) oral tablet 0.15-0.03 alyacen 1/35 (28) oral tablet 1-35 -mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg apri oral tablet 0.15-0.03 aranelle (28) oral tablet 0.5/1/0.5-35 -mcg aubra oral tablet 0.1-20 -mcg aviane oral tablet 0.1-20 -mcg azurette (28) oral tablet 0.15-0.02 x21 /0.01 x 5 balziva (28) oral tablet 0.4-35 -mcg blisovi fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) brevicon (28) oral tablet 0.5-35 -mcg briellyn oral tablet 0.4-35 -mcg $ $ 23
camila oral tablet 0.35 caziant (28) oral tablet 0.1/.125/.15-25 -mcg chateal oral tablet 0.15-0.03 cryselle (28) oral tablet 0.3-30 -mcg cyclafem 1/35 (28) oral tablet 1-35 -mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg dasetta 1/35 (28) oral tablet 1-35 -mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg desogestrel-ethinyl estradiol oral tablet 0.15-0.03 drospirenone-ethinyl estradiol oral tablet 3-0.03 elinest oral tablet 0.3-30 -mcg emoquette oral tablet 0.15-0.03 enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) enskyce oral tablet 0.15-0.03 errin oral tablet 0.35 estarylla oral tablet 0.25-35 -mcg falmina (28) oral tablet 0.1-20 -mcg gianvi (28) oral tablet 3-0.02 gildagia oral tablet 0.4-35 -mcg heather oral tablet 0.35 introvale oral tablets,dose pack,3 month 0.15-30 mcg jencycla oral tablet 0.35 jolessa oral tablets,dose pack,3 month 0.15-30 mcg jolivette oral tablet 0.35 junel 1.5/30 (21) oral tablet 1.5-30 -mcg junel 1/20 (21) oral tablet 1-20 -mcg junel fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) 24
kariva (28) oral tablet 0.15-0.02 x21 /0.01 x 5 kelnor 1/35 (28) oral tablet 1-35 -mcg kurvelo oral tablet 0.15-0.03 larin 1/20 (21) oral tablet 1-20 -mcg larin fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) leena 28 oral tablet 0.5/1/0.5-35 -mcg lessina oral tablet 0.1-20 -mcg levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet 0.1-20 -mcg, 0.15-0.03 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15-30 mcg levora-28 oral tablet 0.15-0.03 loryna (28) oral tablet 3-0.02 low-ogestrel (28) oral tablet 0.3-30 -mcg lutera (28) oral tablet 0.1-20 -mcg lyza oral tablet 0.35 marlissa oral tablet 0.15-0.03 microgestin 1.5/30 (21) oral tablet 1.5-30 mcg microgestin 1/20 (21) oral tablet 1-20 -mcg microgestin fe 1.5/30 (28) oral tablet 1.5-30 mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) mono-linyah oral tablet 0.25-35 -mcg mononessa (28) oral tablet 0.25-35 -mcg myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet 0.5-35 -mcg necon 1/35 (28) oral tablet 1-35 -mcg necon 1/50 (28) oral tablet 1-50 -mcg 25
necon 10/11 (28) oral tablet 0.5-35/1-35 mcg/-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg nora-be oral tablet 0.35 norethindrone (contraceptive) oral tablet 0.35 norethindrone ac-eth estradiol oral tablet 1-20 -mcg norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25-25 mcg, 0.18/0.215/0.25-35 mcg (28), 0.25-35 -mcg norinyl 1/35 (28) oral tablet 1-35 -mcg nortrel 0.5/35 (28) oral tablet 0.5-35 -mcg nortrel 1/35 (21) oral tablet 1-35 -mcg nortrel 1/35 (28) oral tablet 1-35 -mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg ocella oral tablet 3-0.03 ogestrel (28) oral tablet 0.5-50 -mcg orsythia oral tablet 0.1-20 -mcg philith oral tablet 0.4-35 -mcg pimtrea (28) oral tablet 0.15-0.02 x21 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-35 mcg, 1-35 -mcg portia oral tablet 0.15-0.03 previfem oral tablet 0.25-35 -mcg quasense oral tablets,dose pack,3 month 0.15-30 mcg reclipsen (28) oral tablet 0.15-0.03 sprintec (28) oral tablet 0.25-35 -mcg sronyx oral tablet 0.1-20 -mcg syeda oral tablet 3-0.03 tilia fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri-estarylla oral tablet 0.18/0.215/0.25-35 mcg (28) 26
tri-legest fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25-25 mcg trinessa (28) oral tablet 0.18/0.215/0.25-35 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25-25 mcg tri-previfem (28) oral tablet 0.18/0.215/0.25-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25-35 mcg (28) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 -mcg vestura (28) oral tablet 3-0.02 viorele (28) oral tablet 0.15-0.02 x21 /0.01 x 5 vyfemla (28) oral tablet 0.4-35 -mcg wera (28) oral tablet 0.5-35 -mcg zarah oral tablet 3-0.03 zenchent (28) oral tablet 0.4-35 -mcg zovia 1/35e (28) oral tablet 1-35 -mcg zovia 1/50e (28) oral tablet 1-50 -mcg Bleeding Disorders Bleeding Disorders, Hemophilia STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Bleeding Disorders, Other AMICAR ORAL SOLUTION 250 MG/ML (25 %) AMICAR ORAL TABLET 500 MG $ $ $ PA 27
Blood Modifier Blood Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML $ $ $ $ $ ; ONC LEUKINE INJECTION RECON SOLN 250 MCG $ NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG REBINYN INTRAVENOUS RECON SOLN 1,000 (+/- ) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML $ $ $ $ $ $ $ $ $ 28
Clotting Disorders ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/- ) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/- ) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/- ) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/- ) UNIT RANGE ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT BEBULIN INTRAVENOUS RECON SOLN 700 (+/-) UNIT BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT $ $ $ $ $ $ $ $ $ $ $ $ 29
HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,500 UNIT HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 UNIT HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 UNIT HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/- ) UNIT KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 30
OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 % PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 450-450 UNIT, 500-500 UNIT, 900-900 UNIT XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT Blood Thinner Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) $ $ $ $ $ $ $ $ $ $ $ $ $ enoxaparin subcutaneous solution 300 /3 ml enoxaparin subcutaneous syringe 100 /ml, 120 /0.8 ml, 150 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml fondaparinux subcutaneous syringe 10 /0.8 ml, 2.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) PA 31
heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Platelet Inhibitors anagrelide oral capsule 0.5, 1 aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 F$ $ F$ $ $ $ PA clopidogrel oral tablet 75 F$ dipyridamole oral tablet 25, 50, 75 pentoxifylline oral tablet extended release 400 prasugrel oral tablet 10, 5 ZONTIVITY ORAL TABLET 2.08 MG $ PA Bone Health Bone Health, Other etidronate disodium oral tablet 200, 400 Osteoporosis alendronate oral solution 70 /75 ml alendronate oral tablet 10, 35, 5, 70 alendronate oral tablet 40 calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML 32 F$ $
ibandronate oral tablet 150 raloxifene oral tablet 60 TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) Cancer Cancer, Alkylating Agents EMCYT ORAL CAPSULE 140 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG $ $ $ HEXALEN ORAL CAPSULE 50 MG $ ; ONC LEUKERAN ORAL TABLET 2 MG $ MATULANE ORAL CAPSULE 50 MG $ ; ONC melphalan oral tablet 2 MYLERAN ORAL TABLET 2 MG temozolomide oral capsule 100, 140, 180, 20, 250, 5 $ ; ONC VALCHLOR TOPICAL GEL 0.016 % $ ; ONC; Cancer, Antiandrogens bicalutamide oral tablet 50 ERLEADA ORAL TABLET 60 MG $ ; ONC flutamide oral capsule 125 XTANDI ORAL CAPSULE 40 MG $ ; TD; ONC ZYTIGA ORAL TABLET 250 MG, 500 MG $ ; TD; ONC Cancer, Antimetabolites capecitabine oral tablet 150, 500 ; ONC hydroxyurea oral capsule 500 LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG $ ; ONC mercaptopurine oral tablet 50 TABLOID ORAL TABLET 40 MG Cancer, Aromatase Inhibitors $ anastrozole oral tablet 1 F$ exemestane oral tablet 25 letrozole oral tablet 2.5 Cancer, Hdac Inhibitors ZOLINZA ORAL CAPSULE 100 MG $ ; TD; ONC 33
Cancer, Immunosuppressives AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG cyclophosphamide oral capsule 25, 50 methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG Cancer, Interferons SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Cancer, Natural And Semi-Synthetic etoposide oral capsule 50 $ $ $ $ $ $ ; TD; ONC ; TD; ONC ; ONC ; ONC ; ONC ; ONC HYCAMTIN INTRAVENOUS RECON SOLN 4 MG $ ; ONC HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG $ ; ONC Cancer, Other Agents megestrol oral tablet 20, 40 ODOMZO ORAL CAPSULE 200 MG $ ; TD; ONC ZEJULA ORAL CAPSULE 100 MG $ ; TD; ONC Cancer, Retinoids tretinoin (chemotherapy) oral capsule 10 ; ONC Cancer, Serms SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10, 20 Cancer, Signal Transduction Inhibitors $ ALECENSA ORAL CAPSULE 150 MG $ BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG $ ; TD; ONC 34
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG $ ; TD; ONC CAPRELSA ORAL TABLET 100 MG, 300 MG $ ; ONC COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) $ ; TD; ONC COTELLIC ORAL TABLET 20 MG $ ; ONC ERIVEDGE ORAL CAPSULE 150 MG $ ; TD; ONC GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG $ ; ONC IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG $ ; ONC ICLUSIG ORAL TABLET 15 MG, 45 MG $ ; ONC IDHIFA ORAL TABLET 100 MG, 50 MG $ ; ONC imatinib oral tablet 100, 400 ; TD; ONC IMBRUVICA ORAL CAPSULE 140 MG, 70 MG $ ; TD; ONC IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG $ ; TD; ONC INLYTA ORAL TABLET 1 MG, 5 MG $ ; TD; ONC IRESSA ORAL TABLET 250 MG $ ; TD; ONC JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) $ $ $ ; TD; ONC ; ONC ; ONC MEKINIST ORAL TABLET 0.5 MG, 2 MG $ ; ONC NERLYNX ORAL TABLET 40 MG $ ; TD; ONC NEXAVAR ORAL TABLET 200 MG $ ; TD; ONC NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG $ ; ONC RYDAPT ORAL CAPSULE 25 MG $ ; ONC SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG $ ; TD; ONC STIVARGA ORAL TABLET 40 MG $ ; ONC SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG $ ; TD; ONC TAFINLAR ORAL CAPSULE 50 MG, 75 MG $ ; TD; ONC 35
TAGRISSO ORAL TABLET 40 MG, 80 MG $ ; TD; ONC TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG $ ; TD; ONC TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG $ ; TD; ONC TYKERB ORAL TABLET 250 MG $ ; ONC VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG $ ; ONC VOTRIENT ORAL TABLET 200 MG $ ; TD; ONC XALKORI ORAL CAPSULE 200 MG, 250 MG $ ; TD; ONC ZELBORAF ORAL TABLET 240 MG $ ; ONC ZYKADIA ORAL CAPSULE 150 MG $ ; TD; ONC Corticosteroids Corticosteroids, Injectable dexamethasone sodium phosphate injection solution 4 /ml Corticosteroids, Oral DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 4, 6 dexamethasone oral tablet 2 fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 20, 5 MEDROL ORAL TABLET 2 MG methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablets,dose pack 4 MILLIPRED ORAL TABLET 5 MG prednisolone oral solution 15 /5 ml prednisolone sodium phosphate oral solution 15 /5 ml (3 /ml), 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml $ F$ $ $ $ 36
prednisone oral tablet 1, 10, 2.5, 20, 5, 50 F$ prednisone oral tablets,dose pack 10, 5 F$ Cough & Cold Cough & Cold benzonatate oral capsule 100, 200 codeine-guaifenesin oral liquid 10-100 /5 ml ; AE promethazine vc oral syrup 6.25-5 /5 ml F$ promethazine-dm oral syrup 6.25-15 /5 ml F$ Cystic Fibrosis Cystic Fibrosis acetylcysteine solution 100 /ml (10 %), 200 /ml (20 %) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG $ $ KALYDECO ORAL TABLET 150 MG $ ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG $ $ PULMOZYME INHALATION SOLUTION 1 MG/ML $ ; SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N) tobramycin in 0.225 % nacl inhalation solution for nebulization 300 /5 ml Dementia Dementia donepezil oral tablet 10, 5 donepezil oral tablet,disintegrating 10, 5 galantamine oral capsule,ext rel. pellets 24 hr 16, 24, 8 galantamine oral solution 4 /ml galantamine oral tablet 12, 4, 8 memantine oral solution 2 /ml memantine oral tablet 10, 5 $ 37
memantine oral tablets,dose pack 5-10 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 Diabetes Diabetes, Alpha-Glucosidase Inhibitors acarbose oral tablet 100, 25, 50 miglitol oral tablet 100, 25, 50 Diabetes, Biguanides metformin oral tablet 1,000, 500, 850 F$ metformin oral tablet extended release 24 hr 500, 750 Diabetes, Dpp-4 Inhibitor / Biguanide Combinations JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG Diabetes, Dpp-4 Inhibitors TRADJENTA ORAL TABLET 5 MG Diabetes, Glp-1 Agonists BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML) TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) F$ $ $ $ $ $ $ $ $ $ $ $ 38
Diabetes, Intermediate-Acting Insulins HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML Diabetes, Long-Acting Insulins BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML Diabetes, Meglitinides nateglinide oral tablet 120, 60 repaglinide oral tablet 0.5, 1, 2 Diabetes, Other Oral Agents $ $ $ $ $ PA PA CYCLOSET ORAL TABLET 0.8 MG $ PA Diabetes, Pre-Mixed Insulins HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) $ $ $ $ $ $ 39
Diabetes, Rapid-Acting Insulins HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML Diabetes, Rescue Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGEN INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG Diabetes, Sglt2 Inhibitor / Biguanide Combinations INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG Diabetes, Sglt2 Inhibitors INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG Diabetes, Short-Acting Insulins HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 40
Diabetes, Sulfonylurea / Biguanide Combination glipizide-metformin oral tablet 2.5-250, 2.5-500, 5-500 Diabetes, Sulfonylureas glimepiride oral tablet 1, 2, 4 F$ glipizide oral tablet 10, 5 F$ glipizide oral tablet extended release 24hr 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 PA glyburide oral tablet 1.25, 2.5, 5 PA Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone-metformin oral tablet 15-500, 15-850 Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone-glimepiride oral tablet 30-2, 30-4 Diabetes, Thiazolidinediones pioglitazone oral tablet 15, 30, 45 F$ Ear Conditions Anti-Infectives, Ear acetic acid otic (ear) solution 2 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 /ml-unit/ml-% ofloxacin otic (ear) drops 0.3 % Ear Conditions, Other fluocinolone acetonide oil otic (ear) drops 0.01 % $ $ 41
Enzyme Replacement Enzyme Replacement CERDELGA ORAL CAPSULE 84 MG $ CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76,000-120,000 UNIT, 3,000-9,500-15,000 UNIT, 36,000-114,000-180,000 UNIT, 6,000-19,000-30,000 UNIT $ miglustat oral capsule 100 STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML $ SUCRAID ORAL SOLUTION 8,500 UNIT/ML $ Eye Conditions Anti-Infectives, Eye bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 % CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) moxifloxacin ophthalmic (eye) drops 0.5 % neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-10,000 unit/ml- 0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75-10,000 unit-0.025/ml ofloxacin ophthalmic (eye) drops 0.3 % 42 $ $ $ PA
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 /ml sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 % TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % trifluridine ophthalmic (eye) drops 1 % ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % Anti-Inflammatories, Eye bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % Eye Conditions, Other atropine ophthalmic (eye) drops 1 % atropine ophthalmic (eye) ointment 1 % $ $ $ F$ $ $ $ 43