2017 Health Choice Utah Formulary Welcome to Our Family! ienvenidos a Nuestra Familia! Updated November 2017
What is the Health Choice Utah Formulary/Preferred Drug List (PDL)? A Formulary / Preferred Drug List (PDL) is a list of drugs chosen by Health Choice Utah and a team of doctors and pharmacists. Health Choice will cover the drugs listed in our PDL as long as they are medically necessary and appropriate. All Health Choice member prescriptions must be filled at a Health Choice network pharmacy, and other plan rules must be followed. What if a drug is not on the Formulary/ PDL? If a drug you want to prescribe for your patient is not on this Formulary / PDL, the prescriber can: Prescribe a similar drug that is Formulary / PDL covered, or Ask Health Choice to make an exception and cover the medically necessary, non-formulary drug through the prior authorization process. Can the Formulary / PDF change? Yes, Health Choice may add or take off drugs during the year. To get the latest information about covered drugs, go to our website at www.healthchoiceutah.com or call Health Choice Member Services at 877-358-8797. Product Selection Criteria The Health Choice Pharmacy & Therapeutics Committee will consider and advise Health Choice on all new-to-market drugs and will continually review and evaluate existing market drugs for formulary/pdl inclusion. The committee s evaluation includes a current literature review. Expert external opinion may also be sought. Formal reviews are prepared that typically address the following information: Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications, warnings and precautions Pharmacokinetics Cost-effectiveness Patient administration and compliance considerations When a new drug is considered for formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion of one or more drugs in a particular therapeutic class in an effort to continually promote the most clinically useful and costeffective agents. The entire formulary / PDL is reviewed and approved annually. Prior authorization (PA) is required for two groups of medications and for two clinical formulary/ PDL override conditions: Medication roups Medications noted with a PA in the formulary / PDL. All unlisted medications. i
Clinical Override Conditions To override a Step Therapy (ST) edit. To override a Quantity Limit (QL) edit. Health Choice anticipates that requests for an unlisted medication will be infrequent and providers will be able to prescribe a formulary / PDL medication for the vast majority of therapeutic needs. Providers are encouraged to use this formulary / PDL when prescribing medications for Health Choice members to avoid unnecessary delays in therapy. Off label drugs may be prior authorized when the use of the drug has proven to be the community standard. Health Choice providers may formally request the Health Choice Pharmacy & Therapeutics Committee consider a medication be considered for addition to the formulary / PDL. The instructions and required submission form(s) which indicate how to submit a formulary / PDL medication consideration request are detailed in the Health Choice Provider Manual. The instructions and materials are also available on the Health Choice website. All the information in the Health Choice formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. Formulary Product Descriptions To assist in understanding which specific strengths and dosage forms are on the formulary, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are on formulary. eneric drugs are identified in lower case type, whereas brand drugs are identified in all caps allopurinol is a generic drug ULORIC is a brand drug The brand name products shown are for reference only; a different brand or a generic version may be dispensed. simvastatin ZOCOR Extended-release and delayed-release products require their own entry. Identified below, both propranolol and propranolol SR are on the formulary. propranolol INDERAL propranolol SR INDERAL LA Dose forms on formulary will be consistent with the category and use where listed. Identified below from Otic group, the otic solution and ophthalmic ointment are on the formulary, and the ophthalmic products and topical cream cannot be assumed to be on formulary unless there are entries for these products in the OPHTHALMIC and DERMATOLOY sections of the formulary. neomycin/polymyxin /hydrocortisone CORTISPORIN ii
eneric Substitution Utah Medicaid health plans are required to utilize a mandatory generic drug substitution policy. eneric substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand name product. To gain FDA approval: 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand name product. 2. The FDA has given the generic an "A" rating compared to the brand name product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand name product. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange ook). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the healthcare practitioner to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the practitioner are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange ook and carry a "" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. It is also recommended that generic substitution not be undertaken for any unrated multisource products that might be considered narrow therapeutic index, or maintenance drugs where it is known that unrated products from different labelers are not bioequivalent. State law or regulations may dictate the ability to practice generic substitution for selected products or categories of drugs. Drug Efficacy Study Implementation Drugs Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. eginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. Utah Medicaid and Health Choice will not pay for DESI "less than fully effective" drug products. iii
Pharmacy enefit Manager (PM) Health Choice Utah uses EnvisionRx to process our prescription drug claims LEEND oldface PA QL ST Indicates generic availability Over-the-Counter Prior Authorization Required Quantity Level Limit Step Therapy through prerequisite drug required Editor Your comments and suggestions regarding the Health Choice Formulary are encouraged. Your input is vital to this clinical formulary s continued success. All responses will be reviewed and considered. Please send comments to: Pharmacy Services Department Health Choice Utah 410 N 44 th Street, Suite 405 Phoenix, AZ 85008 Notice The information contained in this document is proprietary information. The information may not be copied in whole or in part without written permission of Health Choice Utah. Copyright 2013. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Health Choice. These trademarked brand names are included for informational purposes only and are not intended to imply or suggest any affiliation between Health Choice and such third-party pharmaceutical companies. iv
Health Choice Utah Formulary Effective November 1, 2017 Product Reference rand- eneric *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* modafinil oral tablet 100, 200 Provigil PA *Aminoglycosides* ETHKIS INHALATION NEULIZATION SOLUTION 300 M/4ML KITAIS PAK INHALATION NEULIZATION SOLUTION 300 M/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *Analgesics - Anti-Inflammatory* SP celecoxib oral capsule 100, 200, 400, 50 CeleREX PA diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ENREL SUCUTANEOUS SOLUTION PREFILLED SYRINE 25 M/0.5ML ENREL SUCUTANEOUS SOLUTION PREFILLED SYRINE 50 M/ML ENREL SUCUTANEOUS SOLUTION RECONSTITUTED 25 M ENREL SURECLICK SUCUTANEOUS SOLUTION AUTO-INJECTOR 50 M/ML etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 ProFeno flurbiprofen oral tablet 100, 50 HUMIRA PEDIATRIC CROHNS START SUCUTANEOUS PREFILLED SYRINE KIT 40 M/0.8ML ; QL (4.08 ML per 28 days) ; QL (3.92 ML per 28 days) ; QL (8 EA per 28 days) ; QL (3.92 ML per 28 days) ; QL (2 EA per 30 days) 1
Product Reference rand- eneric HUMIRA PEN SUCUTANEOUS PEN- INJECTOR KIT 40 M/0.8ML HUMIRA PEN-CROHNS STARTER SUCUTANEOUS PEN-INJECTOR KIT 40 M/0.8ML HUMIRA PEN-PSORIASIS STARTER SUCUTANEOUS PEN-INJECTOR KIT 40 M/0.8ML HUMIRA SUCUTANEOUS PREFILLED SYRINE KIT 10 M/0.2ML, 20 M/0.4ML, 40 M/0.8ML ibuprofen childrens oral suspension 100 /5ml ibuprofen junior strength oral tablet chewable 100 HyVee Ibuprofen Childrens Advil Junior Strength ibuprofen oral capsule 200 Advil Migraine ibuprofen oral tablet 200 Motrin I ibuprofen oral tablet 400, 600, 800 INDOCIN ORAL SUSPENSION 25 M/5ML INDOCIN RECTAL SUPPOSITORY 50 M indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 infants ibuprofen oral suspension 50 /1.25ml ketoprofen oral capsule 50, 75 Medi-Profen leflunomide oral tablet 10, 20 Arava meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral tablet 220 Flanax Pain Relief naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene RIDAURA ORAL CAPSULE 3 M sm ibuprofen jr oral tablet 100 Advil Junior Strength sulindac oral tablet 150, 200 *Analgesics - Nonnarcotic* ; QL (2 EA per 30 days) ; QL (2 EA per 30 days) ; QL (2 EA per 30 days) ; QL (2 EA per 30 days) acetaminophen er oral tablet extended release 650 Tylenol 8 Hour 2
Product Reference rand- eneric acetaminophen extra strength oral liquid 500 /15ml acetaminophen extra strength oral tablet 500 acetaminophen junior strength oral tablet dispersible 160 Chloraseptic Sore Throat Tylenol Extra Strength acetaminophen oral capsule 500 acetaminophen oral elixir 160 /5ml Medi-Tabs Childrens acetaminophen oral liquid 160 /5ml Little Remedies for Fever acetaminophen oral solution 160 /5ml acetaminophen oral tablet 325 Pharbetol acetaminophen oral tablet chewable 80 Childrens Medi-Tabs adult aspirin ec low strength oral tablet delayed release 81 Ecotrin Low Strength aspirin childrens oral tablet chewable 81 ayer Low Dose aspirin ec oral tablet delayed release 325 ayer Aspirin Regimen aspirin oral tablet 325 ayer Advanced Aspirin Reg St aspirin rectal suppository 300, 600 bayer advanced aspirin ex st oral tablet 500 buffered aspirin oral tablet 325 ufferin butalbital-acetaminophen oral tablet 50-325 butalbital-apap-caffeine oral capsule 50-300- 40 butalbital-apap-caffeine oral capsule 50-325- 40 butalbital-apap-caffeine oral tablet 50-325-40 butalbital-asa-caffeine oral capsule 50-325-40 butalbital-aspirin-caffeine oral tablet 50-325- 40 childrens acetaminophen oral tablet dispersible 80 choline & mag trisalicylate oral tablet 1000, 500, 750 choline-mag trisalicylate oral liquid 500 /5ml diflunisal oral tablet 500 Tencon Fioricet Zebutal Esgic Fiorinal Mapap Childrens feverall adults rectal suppository 650 feverall childrens rectal suppository 120 feverall junior strength rectal suppository 325 3
Product Reference rand- eneric headache formula oral tablet 250-250-65 Excedrin Migraine infants pain reliever oral suspension 80 /0.8ml infants silapap oral solution 100 /ml non-aspirin jr strength oral tablet chewable 160 pain & fever childrens oral suspension 160 /5ml promacet oral tablet 50-650 salsalate oral tablet 500, 750 *Analgesics - Opioid* acetaminophen-codeine #2 oral tablet 300-15 acetaminophen-codeine #3 oral tablet 300-30 acetaminophen-codeine #4 oral tablet 300-60 acetaminophen-codeine oral solution 120-12 /5ml butalbital-apap-caff-cod oral capsule 50-300- 40-30 butalbital-apap-caff-cod oral capsule 50-325- 40-30 butalbital-asa-caff-codeine oral capsule 50-325-40-30 UTRANS TRANSDERMAL PATCH WEEKLY 10 MC/HR, 15 MC/HR, 20 MC/HR, 5 MC/HR, 7.5 MC/HR codeine sulfate oral tablet 30, 60 fentanyl transdermal patch 72 hour 100 mcg/hr Medi-Tabs Junior Strength PediaCare Children Tylenol with Codeine #3 Tylenol with Codeine #4 Fioricet/Codeine Fiorinal/Codeine #3 Duragesic-100 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7 Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) PA Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (15 EA per 30 days) Supply reater than 7; QL (15 EA per 30 days) Supply reater than 7; QL (15 EA per 30 days) fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 Supply reater than 7; QL (15 EA per 30 days) 4
Product Reference rand- eneric hydrocodone-acetaminophen oral solution 10-325 /15ml hydrocodone-acetaminophen oral solution 7.5-325 /15ml hydrocodone-acetaminophen oral tablet 10-300 hydrocodone-acetaminophen oral tablet 10-325 hydrocodone-acetaminophen oral tablet 2.5-325 hydrocodone-acetaminophen oral tablet 5-300 hydrocodone-acetaminophen oral tablet 5-325 hydrocodone-acetaminophen oral tablet 7.5-300 hydrocodone-acetaminophen oral tablet 7.5-325 Zamicet Hycet Supply reater than 7 Supply reater than 7 Vicodin HP QL (180 EA per 30 days) Norco Verdrocet Vicodin Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Lorcet QL (180 EA per 30 days) Vicodin ES Supply reater than 7; QL (180 EA per 30 days) Norco QL (180 EA per 30 days) hydrocodone-ibuprofen oral tablet 10-200 Xylon hydrocodone-ibuprofen oral tablet 5-200 Ibudone hydrocodone-ibuprofen oral tablet 7.5-200 hydromorphone hcl oral liquid 1 /ml Dilaudid hydromorphone hcl oral tablet 2, 4, 8 Dilaudid meperidine hcl oral tablet 100, 50 Demerol methadone hcl oral concentrate 10 /ml Methadose methadone hcl oral solution 10 /5ml, 5 /5ml Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7 Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) methadone hcl oral tablet 10, 5 Dolophine QL (180 EA per 30 days) methadone hcl oral tablet soluble 40 Methadose morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 Supply reater than 7 PA; QL (30 EA per 30 days) 5
Product Reference rand- eneric morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate injection solution 2 /ml, 4 /ml, 8 /ml morphine sulfate intravenous solution 1 /ml, 25 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 oxycodone hcl er oral tablet er 12 hour abusedeterrent 10, 15, 20, 30, 40, 60, 80 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 Kadian PA; QL (90 EA per 30 days) MS Contin QL (90 EA per 30 days) OxyCONTIN oxycodone hcl oral tablet 15, 30, 5 Roxicodone oxycodone-acetaminophen oral tablet 10-325 oxycodone-acetaminophen oral tablet 2.5-325 oxycodone-acetaminophen oral tablet 5-325, 7.5-325 oxycodone-aspirin oral tablet 4.8355-325 oxycodone-ibuprofen oral tablet 5-400 oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 Supply reater than 7 Supply reater than 7 Supply reater than 7 Supply reater than 7; QL (180 EA per 30 days) PA; QL (90 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7 Supply reater than 7 Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Endocet QL (180 EA per 30 days) Percocet Endocet Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7; QL (180 EA per 30 days) QL (90 EA per 30 days) 6
Product Reference rand- eneric oxymorphone hcl oral tablet 10, 5 Opana ROXICET ORAL SOLUTION 5-325 M/5ML tramadol hcl er (biphasic) oral tablet extended release 24 hour 100, 200, 300 tramadol hcl er oral tablet extended release 24 hour 100, 200, 300 tramadol hcl oral tablet 50 Ultram tramadol-acetaminophen oral tablet 37.5-325 *Androgens-Anabolic* Ultracet Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7 Supply reater than 7; QL (180 EA per 30 days) Supply reater than 7 ANDROXY ORAL TALET 10 M PA danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml *Anorectal Agents* Depo-Testosterone PA PA ANALPRAM E RECTAL KIT 2.5-1 & 1 % CORTIFOAM RECTAL FOAM 10 % hydrocortisone ace-pramoxine rectal cream 1-1 % Analpram-HC hydrocortisone rectal enema 100 /60ml Cortenema lidocaine-hydrocortisone ace rectal cream 3-0.5 % lidocaine-hydrocortisone ace rectal kit 2-2 % Ana-Lex lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 % pramoxine hcl rectal foam 1 % Proctofoam PROCTOFOAM HC RECTAL FOAM 1-1 % procto-pak rectal cream 1 % proctozone-hc rectal cream 2.5 % *Antacids* aluminum hydroxide gel oral suspension 320 /5ml antacid calcium extra strength oral tablet chewable 750 Tums Smoothies antacid calcium oral tablet chewable 500 Tums antacid extra strength oral tablet chewable 675-135 Rolaids Extra Strength antacid oral tablet chewable 420 Titralac 7
Product Reference rand- eneric antacid oral tablet chewable 550-110 Rolaids calcium antacid ultra strength oral tablet chewable 1000 Tums Ultra 1000 CHILDRENS SOOTHE ORAL TALET CHEWALE 400 M geri-lanta supreme oral suspension 400-135 /5ml gnp foaming antacid oral suspension 95-358 /15ml heartburn antacid ex st oral tablet chewable 160-105 aviscon Acid one magnesium oxide oral tablet 250, 400 magnesium oxide oral tablet 420 Maox mi-acid oral tablet chewable 700-300 sm foaming antacid oral tablet chewable 80-20 sodium bicarbonate oral tablet 325, 650 tgt antacid oral tablet chewable 1000 Tums Ultra 1000 *Anthelmintics* ALENZA ORAL TALET 200 M ILTRICIDE ORAL TALET 600 M ivermectin oral tablet 3 Stromectol pin-x oral suspension 50 /ml reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide dinitrate sublingual tablet sublingual 2.5, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-ID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.6 /hr nitroglycerin transdermal patch 24 hour 0.4 /hr NITROSTAT SULINUAL TALET SULINUAL 0.3 M, 0.4 M, 0.6 M Nitro-Dur Minitran 8
Product Reference rand- eneric RANEXA ORAL TALET EXTENDED RELEASE 12 HOUR 1000 M, 500 M *Antianxiety Agents* PA hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 *Antiarrhythmics* Vistaril amiodarone hcl oral tablet 100, 200 Pacerone disopyramide phosphate oral capsule 100, 150 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 MULTAQ ORAL TALET 400 M NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 M, 150 M pacerone oral tablet 100, 200 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiasthmatic And ronchodilator Agents* ADVAIR DISKUS INHALATION AEROSOL POWDER REATH ACTIVATED 100-50 MC/DOSE, 250-50 MC/DOSE, 500-50 MC/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 MC/ACT, 230-21 MC/ACT, 45-21 MC/ACT AEROSPAN INHALATION AEROSOL SOLUTION 80 MC/ACT albuterol sulfate er oral tablet extended release 12 hour 4, 8 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml Norpace Tikosyn Rythmol SR VoSpire ER 9
Product Reference rand- eneric albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 220 MC/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 110 MC/INH, 220 MC/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 220 MC/INH ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MC/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml, 1 /2ml COMIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MC/ACT cromolyn sodium inhalation nebulization solution 20 /2ml DULERA INHALATION AEROSOL 100-5 MC/ACT, 200-5 MC/ACT FLOVENT DISKUS INHALATION AEROSOL POWDER REATH ACTIVATED 100 MC/LIST, 250 MC/LIST, 50 MC/LIST FLOVENT HFA INHALATION AEROSOL 110 MC/ACT, 220 MC/ACT, 44 MC/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER REATH ACTIVATED 62.5 MC/INH ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution 0.5-2.5 (3) /3ml metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 Pulmicort montelukast sodium oral packet 4 Singulair montelukast sodium oral tablet 10 Singulair montelukast sodium oral tablet chewable 4, 5 PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 ASE) MC/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER REATH ACTIVATED 180 MC/ACT, 90 MC/ACT QVAR INHALATION AEROSOL SOLUTION 40 MC/ACT, 80 MC/ACT Singulair QL (26 M per 30 days) QL (36 M per 30 days) 10
Product Reference rand- eneric SEREVENT DISKUS INHALATION AEROSOL POWDER REATH ACTIVATED 50 MC/DOSE SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MC/ACT, 2.5 MC/ACT QL (60 EA per 30 days) SYMICORT INHALATION AEROSOL 160-4.5 MC/ACT, 80-4.5 MC/ACT terbutaline sulfate oral tablet 2.5, 5 theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml TUDORZA PRESSAIR INHALATION AEROSOL POWDER REATH ACTIVATED 400 MC/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 ASE) MC/ACT XOPENEX HFA INHALATION AEROSOL 45 MC/ACT Theochron zafirlukast oral tablet 10, 20 Accolate ST *Anticoagulants* QL (10.2 M per 30 days) ELIQUIS ORAL TALET 2.5 M, 5 M QL (60 EA per 30 days) enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml Lovenox QL (20 ML per 10 days) Lovenox QL (20 ML per 10 days) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml SP SP warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 7.5 Jantoven warfarin sodium oral tablet 5, 6 Coumadin XARELTO ORAL TALET 10 M, 15 M, 20 M XARELTO STARTER PACK ORAL TALET THERAPY PACK 15 & 20 M *Antidiabetics* QL (60 EA per 30 days) QL (51 EA per 365 days) acarbose oral tablet 100, 25, 50 Precose 11
Product Reference rand- eneric ACTOPLUS MET XR ORAL TALET EXTENDED RELEASE 24 HOUR 15-1000 M, 30-1000 M APIDRA INJECTION SOLUTION 100 UNIT/ML APIDRA SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML AVANDIA ORAL TALET 2 M, 4 M chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 lucotrol XL glipizide oral tablet 10, 5 lucotrol glipizide-metformin hcl oral tablet 2.5-250, 2.5-500, 5-500 LUCAON EMERENCY INJECTION KIT 1 M glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet 1.25-250 glyburide-metformin oral tablet 2.5-500, 5-500 HUMULIN R U-500 (CONCENTRATED) SUCUTANEOUS SOLUTION 500 UNIT/ML INVOKANA ORAL TALET 100 M, 300 M JANUMET ORAL TALET 50-1000 M, 50-500 M JANUMET XR ORAL TALET EXTENDED RELEASE 24 HOUR 100-1000 M, 50-1000 M, 50-500 M JANUVIA ORAL TALET 100 M, 25 M, 50 M LANTUS SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUCUTANEOUS SOLUTION 100 UNIT/ML metformin hcl er oral tablet extended release 24 hour 500, 750 metformin hcl oral tablet 1000, 500, 850 lynase lucovance lucophage XR lucophage nateglinide oral tablet 120, 60 Starlix QL (60 ML per 30 days) QL (60 ML per 30 days) PA; QL (60 ML per 30 days) PA PA PA QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) 12
Product Reference rand- eneric NOVOLIN 70/30 RELION SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN N SUCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLO FLEXPEN SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLO MIX 70/30 FLEXPEN SUCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLO MIX 70/30 SUCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLO PENFILL SUCUTANEOUS SOLUTION CARTRIDE 100 UNIT/ML NOVOLO SUCUTANEOUS SOLUTION 100 UNIT/ML pioglitazone hcl oral tablet 15, 30, 45 pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet 15-500, 15-850 repaglinide oral tablet 0.5 Actos Duetact Actoplus Met repaglinide oral tablet 1, 2 Prandin TANZEUM SUCUTANEOUS PEN- INJECTOR 30 M, 50 M tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 TOUJEO SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML VICTOZA SUCUTANEOUS SOLUTION PEN-INJECTOR 18 M/3ML *Antidiarrheals* ; QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) QL (60 ML per 30 days) PA QL (21 ML per 30 days) PA bismuth subsalicylate oral tablet chewable 262 diphenoxylate-atropine oral liquid 2.5-0.025 /5ml Pepto-ismol InstaCool diphenoxylate-atropine oral tablet 2.5-0.025 Lomotil 13
Product Reference rand- eneric FULYZAQ ORAL TALET DELAYED RELEASE 125 M IMODIUM A-D ORAL TALET CHEWALE 2 M loperamide a-d oral tablet 2 loperamide hcl oral capsule 2 Imodium A-D loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml Imodium A-D pink bismuth maximum strength oral suspension 525 /15ml PA; QL (60 EA per 30 days) Kaopectate Extra Strength pink bismuth oral suspension 262 /15ml Pepto-ismol soothe oral tablet 262 *Antidotes* naloxone hcl injection solution 0.4 /ml, 1 /ml NARCAN NASAL LIQUID 4 M/0.1ML *Antiemetics* ANZEMET ORAL TALET 100 M, 50 M PA aprepitant oral capsule 125 Emend aprepitant oral capsule 40, 80 Emend QL (6 EA per 30 days) aprepitant oral capsule 80 & 125 Emend Tri-Pack DICLEIS ORAL TALET DELAYED RELEASE 10-10 M dimenhydrinate oral tablet 50 Dramamine dronabinol oral capsule 10, 2.5, 5 Marinol granisetron hcl oral tablet 1 meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy meclizine hcl oral tablet chewable 25 ondansetron hcl injection solution 4 /2ml, 40 /20ml ondansetron hcl oral solution 4 /5ml Zofran QL (360 EA per 365 days) ondansetron hcl oral tablet 24 QL (30 EA per 30 days) ondansetron hcl oral tablet 4, 8 Zofran QL (30 EA per 30 days) ondansetron oral tablet dispersible 4, 8 Zofran ODT QL (30 EA per 30 days) trimethobenzamide hcl oral capsule 300 Tigan *Antifungals* SP fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 Diflucan Diflucan flucytosine oral capsule 250, 500 Ancobon 14
Product Reference rand- eneric griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 ris-pe itraconazole oral capsule 100 Sporanox Pulsepak PA ketoconazole oral tablet 200 NOXAFIL ORAL SUSPENSION 40 M/ML PA nystatin oral tablet 500000 unit SPORANOX ORAL SOLUTION 10 M/ML PA terbinafine hcl oral tablet 250 LamISIL QL (90 EA per 365 days) voriconazole oral suspension reconstituted 40 /ml Vfend voriconazole oral tablet 200, 50 Vfend *Antihistamines* all day allergy oral capsule 10 ZyrTEC Allergy altaryl oral syrup 12.5 /5ml carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 cetirizine hcl oral solution 1 /ml Wal-Zyr Childrens cetirizine hcl oral tablet 10 ZyrTEC Allergy cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 Wal-Zyr Childrens chlorpheniramine maleate er oral tablet extended release 12 Chlor-Trimeton Allergy chlorpheniramine maleate oral tablet 4 Wal-finate clemastine fumarate oral syrup 0.67 /5ml clemastine fumarate oral tablet 1.34 clemastine fumarate oral tablet 2.68 cvs allergy childrens oral tablet chewable 12.5 cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 Dayhist Allergy 12 Hour Relief enadryl Allergy Childrens diphenhydramine hcl oral capsule 25 Wal-Dryl Allergy diphenhydramine hcl oral capsule 50 anophen diphenhydramine hcl oral elixir 12.5 /5ml diphenhydramine hcl oral liquid 12.5 /5ml Scot-Tussin Allergy Relief diphenhydramine hcl oral tablet 25 anophen ed chlorped jr oral syrup 2 /5ml Diabetic Tussin Allergy ED CHLORPED ORAL LIQUID 2 M/ML eq allergy relief childrens oral tablet dispersible 12.5 Wal-Dryl Allergy Rel Childrens 15
Product Reference rand- eneric fexofenadine hcl childrens oral suspension 30 /5ml Allegra Allergy Childrens fexofenadine hcl oral tablet 180 Wal-Fex Allergy fexofenadine hcl oral tablet 60 Allegra Allergy levocetirizine dihydrochloride oral solution 2.5 /5ml Xyzal levocetirizine dihydrochloride oral tablet 5 Xyzal loratadine allergy relief oral tablet dispersible 10 Wal-vert loratadine oral tablet 10 Claritin promethazine hcl injection solution 25 /ml, 50 /ml Phenergan promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 50 Phenergan promethazine hcl rectal suppository 25 Promethegan TRIAMINIC COUH/RUNNY NOSE ORAL STRIP 12.5 M *Antihyperlipidemics* atorvastatin calcium oral tablet 10, 20, 40, 80 Lipitor QL (30 EA per 30 days) cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid ezetimibe oral tablet 10 Zetia fenofibrate micronized oral capsule 134, 200, 67 Lofibra fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 FENOFIRIC ACID ORAL TALET 105 M, 35 M Trilipix Fibricor fluvastatin sodium oral capsule 20 Lescol fluvastatin sodium oral capsule 40 gemfibrozil oral tablet 600 Lopid 16
Product Reference rand- eneric JUXTAPID ORAL CAPSULE 10 M, 30 M, 40 M, 5 M, 60 M JUXTAPID ORAL CAPSULE 20 M PA; QL (30 EA per 30 days) PA; QL (90 EA per 30 days) lovastatin oral tablet 10, 20 QL (30 EA per 30 days) lovastatin oral tablet 40 Mevacor QL (30 EA per 30 days) niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 Niaspan omega-3-acid ethyl esters oral capsule 1 gm Lovaza pravastatin sodium oral tablet 10 QL (30 EA per 30 days) pravastatin sodium oral tablet 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *Antihypertensives* Pravachol QL (30 EA per 30 days) Zocor QL (30 EA per 30 days) amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 amlodipine besy-benazepril hcl oral capsule 2.5-10, 5-40 Lotrel atenolol-chlorthalidone oral tablet 100-25 Tenoretic 100 atenolol-chlorthalidone oral tablet 50-25 Tenoretic 50 benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 bisoprolol-hydrochlorothiazide oral tablet 10-6.25, 2.5-6.25, 5-6.25 captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, 50-25 clonidine hcl oral tablet 0.1, 0.2, 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr clonidine hcl transdermal patch weekly 0.2 /24hr clonidine hcl transdermal patch weekly 0.3 /24hr doxazosin mesylate oral tablet 1, 2, 4, 8 enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 10-25 enalapril-hydrochlorothiazide oral tablet 5-12.5 Ziac Catapres Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 Cardura Vasotec Vaseretic eplerenone oral tablet 25, 50 Inspra 17
Product Reference rand- eneric eprosartan mesylate oral tablet 600 fosinopril sodium oral tablet 10, 20, 40 fosinopril sodium-hctz oral tablet 10-12.5, 20-12.5 guanfacine hcl oral tablet 1, 2 hydralazine hcl oral tablet 10, 100, 25, 50 irbesartan oral tablet 150, 300, 75 Avapro irbesartan-hydrochlorothiazide oral tablet 150-12.5, 300-12.5 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet 100-12.5, 100-25, 50-12.5 methyldopa oral tablet 250, 500 methyldopa-hydrochlorothiazide oral tablet 250-15, 250-25 metoprolol-hydrochlorothiazide oral tablet 100-25, 100-50 metoprolol-hydrochlorothiazide oral tablet 50-25 minoxidil oral tablet 10, 2.5 moexipril hcl oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet 15-12.5, 15-25, 7.5-12.5 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 olmesartan medoxomil oral tablet 20, 40, 5 olmesartan medoxomil-hctz oral tablet 20-12.5, 40-12.5, 40-25 perindopril erbumine oral tablet 2 Avalide Zestril Zestoretic Cozaar Hyzaar Lopressor HCT Corzide enicar enicar HCT perindopril erbumine oral tablet 4, 8 Aceon prazosin hcl oral capsule 1, 2, 5 Minipress propranolol-hctz oral tablet 40-25, 80-25 quinapril hcl oral tablet 10, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet 10-12.5, 20-12.5, 20-25 Accupril Accuretic 18
Product Reference rand- eneric ramipril oral capsule 1.25, 10, 2.5, 5 terazosin hcl oral capsule 1, 10, 2, 5 Altace trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet 160-12.5, 160-25, 320-12.5, 320-25, 80-12.5 *Anti-Infective Agents - Misc.* Diovan Diovan HCT atovaquone oral suspension 750 /5ml Mepron clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml Cleocin Cleocin dapsone oral tablet 100, 25 linezolid oral suspension reconstituted 100 /5ml Zyvox PA linezolid oral tablet 600 Zyvox PA metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl PRIMSOL ORAL SOLUTION 50 M/5ML SIVEXTRO ORAL TALET 200 M sulfamethoxazole-trimethoprim oral suspension 200-40 /5ml sulfamethoxazole-trimethoprim oral tablet 400-80 sulfamethoxazole-trimethoprim oral tablet 800-160 tinidazole oral tablet 250 Sulfatrim Pediatric actrim actrim DS tinidazole oral tablet 500 Tindamax trimethoprim oral tablet 100 vancomycin hcl oral capsule 125, 250 Vancocin HCl XIFAXAN ORAL TALET 200 M, 550 M PA *Antimalarials* atovaquone-proguanil hcl oral tablet 250-100, 62.5-25 chloroquine phosphate oral tablet 250, 500 Malarone COARTEM ORAL TALET 20-120 M hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 19
Product Reference rand- eneric quinine sulfate oral capsule 324 Qualaquin *Antimyasthenic Agents* pyridostigmine bromide er oral tablet extended release 180 Mestinon pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents* pyridostigmine bromide er oral tablet extended release 180 Mestinon pyridostigmine bromide oral tablet 60 Mestinon *Antimycobacterial Agents* ethambutol hcl oral tablet 100, 400 Myambutol ISONARIF ORAL CAPSULE 150-300 M isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 Rifadin SIRTURO ORAL TALET 100 M *Antineoplastics And Adjunctive Therapies* ACTIMMUNE SUCUTANEOUS SOLUTION 2000000 UNIT/0.5ML AFINITOR DISPERZ ORAL TALET SOLULE 2 M, 3 M, 5 M AFINITOR ORAL TALET 10 M, 2.5 M, 5 M, 7.5 M PA PA anastrozole oral tablet 1 Arimidex bexarotene oral capsule 75 Targretin bicalutamide oral tablet 50 Casodex OSULIF ORAL TALET 100 M, 500 M CAPRELSA ORAL TALET 100 M, 300 M SP COMETRIQ (100 M DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 M COMETRIQ (140 M DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 M COMETRIQ (60 M DAILY DOSE) ORAL KIT 20 M COTELLIC ORAL TALET 20 M cyclophosphamide oral capsule 25, 50 ELIARD SUCUTANEOUS KIT 7.5 M SP ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 M etoposide oral capsule 50 SP 20
Product Reference rand- eneric exemestane oral tablet 25 Aromasin FARESTON ORAL TALET 60 M SP flutamide oral capsule 125 ILOTRIF ORAL TALET 20 M, 30 M, 40 M LEOSTINE ORAL CAPSULE 10 M, 100 M, 40 M HEXALEN ORAL CAPSULE 50 M SP hydroxyurea oral capsule 500 Hydrea ICLUSI ORAL TALET 15 M, 45 M INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT JAKAFI ORAL TALET 10 M, 15 M, 20 M, 25 M, 5 M LENVIMA 10 M DAILY DOSE ORAL CAPSULE THERAPY PACK 10 M LENVIMA 14 M DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 M LENVIMA 18 M DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) M LENVIMA 20 M DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) M LENVIMA 24 M DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 M LENVIMA 8 M DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) M letrozole oral tablet 2.5 Femara leucovorin calcium oral tablet 10, 15, 25, 5 LEUKERAN ORAL TALET 2 M leuprolide acetate injection kit 1 /0.2ml SP LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 M, 7.5 M LYSODREN ORAL TALET 500 M MATULANE ORAL CAPSULE 50 M SP megestrol acetate oral suspension 40 /ml megestrol acetate oral tablet 20, 40 melphalan oral tablet 2 Alkeran SP mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 SP ; QL (60 EA per 30 days) PA SP SP SP 21
Product Reference rand- eneric methotrexate sodium (pf) injection solution 50 /2ml methotrexate sodium injection solution 50 /2ml methotrexate sodium injection solution reconstituted 1 gm MYLERAN ORAL TALET 2 M NINLARO ORAL CAPSULE 2.3 M, 3 M, 4 M POMALYST ORAL CAPSULE 1 M, 2 M, 3 M, 4 M STIVARA ORAL TALET 40 M PA SYNRIO SUCUTANEOUS SOLUTION RECONSTITUTED 3.5 M TALOID ORAL TALET 40 M tamoxifen citrate oral tablet 10, 20 TARRETIN ORAL CAPSULE 75 M PA tretinoin oral capsule 10 SP XTANDI ORAL CAPSULE 40 M ZELORAF ORAL TALET 240 M PA ZOLINZA ORAL CAPSULE 100 M PA *Antiparkinson Agents* amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 benztropine mesylate oral tablet 0.5, 1, 2 bromocriptine mesylate oral capsule 5 Parlodel bromocriptine mesylate oral tablet 2.5 Parlodel carbidopa-levodopa er oral tablet extended release 25-100, 50-200 carbidopa-levodopa oral tablet 10-100, 25-100, 25-250 carbidopa-levodopa oral tablet dispersible 10-100, 25-100, 25-250 carbidopa-levodopa-entacapone oral tablet 12.5-50-200 carbidopa-levodopa-entacapone oral tablet 18.75-75-200 carbidopa-levodopa-entacapone oral tablet 25-100-200 carbidopa-levodopa-entacapone oral tablet 31.25-125-200 Sinemet CR Sinemet Stalevo 50 Stalevo 75 Stalevo 100 Stalevo 125 ; QL (21 EA per 28 days) PA ; QL (120 EA per 30 days) 22
Product Reference rand- eneric carbidopa-levodopa-entacapone oral tablet 37.5-150-200 carbidopa-levodopa-entacapone oral tablet 50-200-200 Stalevo 150 Stalevo 200 entacapone oral tablet 200 Comtan pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 Mirapex Requip selegiline hcl oral capsule 5 Eldepryl selegiline hcl oral tablet 5 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 *Antipsychotics/Antimanic Agents* prochlorperazine rectal suppository 25 Compro *Antiretrovirals Adjuvants*** TYOST ORAL TALET 150 M *Antivirals* abacavir sulfate oral solution 20 /ml Ziagen abacavir sulfate oral tablet 300 Ziagen abacavir sulfate-lamivudine oral tablet 600-300 abacavir-lamivudine-zidovudine oral tablet 300-150-300 Epzicom Trizivir acyclovir oral capsule 200 Zovirax acyclovir oral suspension 200 /5ml Zovirax acyclovir oral tablet 400, 800 Zovirax adefovir dipivoxil oral tablet 10 Hepsera APTIVUS ORAL CAPSULE 250 M APTIVUS ORAL SOLUTION 100 M/ML ATRIPLA ORAL TALET 600-200-300 M ARACLUDE ORAL SOLUTION 0.05 M/ML COMPLERA ORAL TALET 200-25-300 M CRIXIVAN ORAL CAPSULE 200 M, 400 M DESCOVY ORAL TALET 200-25 M SP didanosine oral capsule delayed release 125, 200, 250, 400 EDURANT ORAL TALET 25 M EMTRIVA ORAL CAPSULE 200 M EMTRIVA ORAL SOLUTION 10 M/ML Videx EC entecavir oral tablet 0.5, 1 araclude EPIVIR HV ORAL SOLUTION 5 M/ML SP 23
Product Reference rand- eneric EVOTAZ ORAL TALET 300-150 M SP famciclovir oral tablet 125, 250 famciclovir oral tablet 500 Famvir fosamprenavir calcium oral tablet 700 Lexiva FUZEON SUCUTANEOUS SOLUTION RECONSTITUTED 90 M ENVOYA ORAL TALET 150-150-200-10 M INTELENCE ORAL TALET 100 M, 200 M, 25 M INVIRASE ORAL CAPSULE 200 M INVIRASE ORAL TALET 500 M ISENTRESS ORAL TALET 400 M ISENTRESS ORAL TALET CHEWALE 100 M, 25 M KALETRA ORAL TALET 100-25 M, 200-50 M lamivudine oral solution 10 /ml Epivir lamivudine oral tablet 100 Epivir HV SP lamivudine oral tablet 150, 300 Epivir lamivudine-zidovudine oral tablet 150-300 Combivir LEXIVA ORAL SUSPENSION 50 M/ML lopinavir-ritonavir oral solution 400-100 /5ml Kaletra MODERIA ORAL 200 & 400 M MODERIA ORAL 400 & 600 M PA nevirapine er oral tablet extended release 24 hour 100, 400 NEVIRAPINE ORAL SUSPENSION 50 M/5ML Viramune XR Viramune nevirapine oral tablet 200 Viramune NORVIR ORAL CAPSULE 100 M NORVIR ORAL SOLUTION 80 M/ML NORVIR ORAL TALET 100 M ODEFSEY ORAL TALET 200-25-25 M SP oseltamivir phosphate oral capsule 30, 45, 75 PEASYS PROCLICK SUCUTANEOUS SOLUTION 135 MC/0.5ML, 180 MC/0.5ML PEASYS SUCUTANEOUS SOLUTION 180 MC/ML PE-INTRON REDIPEN PAK 4 SUCUTANEOUS KIT 120 MC/0.5ML Tamiflu QL (10 EA per 365 days) SP 24
Product Reference rand- eneric PE-INTRON REDIPEN SUCUTANEOUS KIT 150 MC/0.5ML PE-INTRON REDIPEN SUCUTANEOUS KIT 50 MC/0.5ML, 80 MC/0.5ML PREZCOIX ORAL TALET 800-150 M PREZISTA ORAL TALET 150 M, 600 M, 75 M, 800 M REETOL ORAL SOLUTION 40 M/ML RELENZA DISKHALER INHALATION AEROSOL POWDER REATH ACTIVATED 5 M/LISTER RESCRIPTOR ORAL TALET 100 M, 200 M REYATAZ ORAL CAPSULE 150 M, 200 M, 300 M ribasphere oral capsule 200 ribasphere oral tablet 200 ribasphere oral tablet 400, 600 RIASPHERE RIAPAK ORAL TALET 200 & 400 M RIASPHERE RIAPAK ORAL TALET 400 & 600 M RIASPHERE RIAPAK ORAL TALET 400 M, 600 M SP QL (10 EA per 365 days) PA ribavirin oral capsule 200 Rebetol ribavirin oral tablet 200 Moderiba rimantadine hcl oral tablet 100 Flumadine SELZENTRY ORAL TALET 150 M, 300 M SOVALDI ORAL TALET 400 M stavudine oral capsule 15, 20, 30, 40 Zerit stavudine oral solution reconstituted 1 /ml Zerit STRIILD ORAL TALET 150-150-200-300 M SUSTIVA ORAL CAPSULE 200 M, 50 M SUSTIVA ORAL TALET 600 M TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 M/ML TIVICAY ORAL TALET 50 M SP TRIUMEQ ORAL TALET 600-50-300 M SP TRUVADA ORAL TALET 200-300 M TYZEKA ORAL TALET 600 M valacyclovir hcl oral tablet 1 gm, 500 Valtrex QL (10 ML per 365 days) 25
Product Reference rand- eneric valganciclovir hcl oral solution reconstituted 50 /ml Valcyte valganciclovir hcl oral tablet 450 Valcyte VIDEX ORAL SOLUTION RECONSTITUTED 2 M, 4 M VIRACEPT ORAL TALET 250 M, 625 M VIREAD ORAL TALET 150 M, 200 M, 250 M, 300 M VITEKTA ORAL TALET 150 M, 85 M SP zidovudine oral capsule 100 Retrovir zidovudine oral syrup 50 /5ml Retrovir zidovudine oral tablet 300 *Assorted Classes* CUPRIMINE ORAL CAPSULE 250 M REVLIMID ORAL CAPSULE 10 M, 15 M, 2.5 M, 20 M, 25 M, 5 M sodium polystyrene sulfonate oral suspension 15 gm/60ml sodium polystyrene sulfonate rectal suspension 50 gm/200ml THALOMID ORAL CAPSULE 100 M, 150 M, 200 M, 50 M *eta lockers* Kionex acebutolol hcl oral capsule 200, 400 atenolol oral tablet 100, 25, 50 Tenormin betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10, 5 carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, 50 Coreg Toprol XL metoprolol tartrate oral tablet 100, 50 Lopressor metoprolol tartrate oral tablet 25 nadolol oral tablet 20, 40, 80 Corgard pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 Inderal LA 26
Product Reference rand- eneric sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel lockers* etapace AF Sorine amlodipine besylate oral tablet 10, 2.5, 5 Norvasc QL (30 EA per 30 days) CARDIZEM LA ORAL TALET EXTENDED RELEASE 24 HOUR 120 M QL (30 EA per 30 days) diltiazem hcl er beads oral capsule extended release 24 hour 120, 360, 420 diltiazem hcl er beads oral capsule extended release 24 hour 180, 240, 300 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 300 diltiazem hcl er coated beads oral capsule extended release 24 hour 180, 240, 360 Tiazac QL (30 EA per 30 days) Taztia XT QL (30 EA per 30 days) Cartia XT QL (30 EA per 30 days) Cardizem CD QL (30 EA per 30 days) diltiazem hcl er coated beads oral tablet extended release 24 hour 180, 360, 420 diltiazem hcl er coated beads oral tablet extended release 24 hour 240, 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 Cardizem LA Matzim LA diltiazem hcl oral tablet 120, 30, 60 Cardizem diltiazem hcl oral tablet 90 felodipine er oral tablet extended release 24 hour 10, 2.5, 5 isradipine oral capsule 2.5, 5 nicardipine hcl oral capsule 20, 30 nifedipine er oral tablet extended release 24 hour 30, 90 nifedipine er oral tablet extended release 24 hour 60 nifedipine er osmotic release oral tablet extended release 24 hour 30, 90 nifedipine er osmotic release oral tablet extended release 24 hour 60 Adalat CC Afeditab CR Procardia XL Nifedical XL nifedipine oral capsule 10 Procardia nifedipine oral capsule 20 nimodipine oral capsule 30 27
Product Reference rand- eneric nisoldipine er oral tablet extended release 24 hour 17, 34, 8.5 nisoldipine er oral tablet extended release 24 hour 20, 25.5, 30, 40 verapamil hcl er oral capsule extended release 24 hour 100, 200, 300 Sular Verelan PM QL (30 EA per 30 days) verapamil hcl er oral capsule extended release 24 hour 120, 180, 240, 360 Verelan QL (30 EA per 30 days) verapamil hcl er oral tablet extended release 120, 180 verapamil hcl er oral tablet extended release 240 Calan SR QL (30 EA per 30 days) Isoptin SR QL (30 EA per 30 days) verapamil hcl oral tablet 120, 80 Calan verapamil hcl oral tablet 40 *Cardiotonics* digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg Lanoxin LANOXIN ORAL TALET 187.5 MC, 62.5 MC *Cardiovascular Agents - Misc.* ADCIRCA ORAL TALET 20 M amlodipine-atorvastatin oral tablet 10-10, 10-20, 10-40, 10-80, 5-10, 5-20 Caduet, 5-40, 5-80 amlodipine-atorvastatin oral tablet 2.5-10, 2.5-20, 2.5-40 LETAIRIS ORAL TALET 10 M, 5 M sildenafil citrate oral tablet 20 Revatio PA TRACLEER ORAL TALET 125 M, 62.5 M TYVASO INHALATION SOLUTION 0.6 M/ML TYVASO REFILL INHALATION SOLUTION 0.6 M/ML TYVASO STARTER INHALATION SOLUTION 0.6 M/ML VENTAVIS INHALATION SOLUTION 10 MC/ML, 20 MC/ML *Cephalosporins* cefaclor er oral tablet extended release 12 hour 500 cefaclor oral capsule 250, 500 cefadroxil oral capsule 500 SP cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml 28