H9345_MBR16_03 CMS Approved VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This formulary was updated on 10/01/2016. For more recent information or other questions, please contact VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit Formulary ID: 16511.000, Version 19
VillageCareMAX Full Advantage FIDA Plan 2016 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in VillageCareMAX Full Advantage FIDA Plan. VillageCareMAX Full Advantage FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check VillageCareMAX Full Advantage FIDA Plan s up-to-date List of Covered Drugs online at www.villagecaremax.org or by calling VillageCareMAX Full Advantage FIDA Plan Participant Services at 1-800-469-6292. TTY users should call 711. Limitations and restrictions may apply. For more information, call VillageCareMAX Full Advantage FIDA Plan Participant Services or read the VillageCareMAX Full Advantage FIDA Plan Participant Handbook. There are no copays for any covered drugs. You can get this information for free in other formats, such as large print, braille, or audio. Call 1-800-469-6292 and 711 during hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. You can get this information for free in other languages. Call 1-800-469-6292 and TTY users should call 711 during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. Puede obtener esta información gratis en Español. Llame a Servicios del Participante al 1-800-469-6292 durante las horas de 8:00 am a 8:00pm, 7 días de la semana. Usuarios de TTY llamar al 711. La llamada es gratuita. Lei puo ottenere questi informazioni in Italiano gratuitamente. Chiama il Servizio Partecipanti a 1-800-469-6292 durante il periodo da 8AM a 8PM, 7 giorni alla settimana. TTY utilizzatori dovressi chiamare 711. La chiamata è gratis. Ou ka jwenn enfòmasyon sa a pou gratis nan kreyòl ayisyen. Rele sèvis patisipan nan 1-800- 469-6292 les heures de 8:00 je pou 8:00 pm, 7 jou nan semenn nan. Utilisateurs TTY ta dwe rele 711. Apèl gratis. Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону 1-800-469-6292 с 8:00 утра до 8 вечера, 7 дней в неделю. Пользователи TTY звоните по телефону 711. Звонок бесплатный. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit ii
您可免費獲得到以上的中文資訊, 請致電參與者服務電話 1-800-469-6292, 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽力語言殘障服務專線 (TTY) 用戶請撥打 711 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7일오전 8시에서오후 8시사이에1-800-469-6292 번 (TTY 사용자는 711번 ) 으로문의해주십시오. 통화는무료입니다. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VillageCareMAX Full Advantage FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit iii
Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by VillageCareMAX Full Advantage FIDA Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. VillageCareMAX Full Advantage FIDA Plan will cover all drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a VillageCareMAX Full Advantage FIDA Plan network pharmacy. VillageCareMAX Full Advantage FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at www.villagecaremax.org or call Participant Services at 1-800-469-6292. TTY users should call 711. 2. Does the Drug List ever change? Yes. VillageCareMAX Full Advantage FIDA Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit iv
Decide to require or not require prior approval for a drug. (Prior approval is permission from VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page vi). We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check VillageCareMAX Full Advantage FIDA Plan s up to date Drug List online at You can also call Participant Services to check the current Drug List at 1-800-469-6292. TTY users should call 711. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. VillageCareMAX Full Advantage FIDA Plan may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. VillageCareMAX Full Advantage FIDA Plan will send you a letter when a drug you are taking is removed from the Drug List. Our web site includes the most up-to-date information about our Drug List. You can always check www.villagecaremax.org or call Participant Services if you have any questions. Our phone number is 1-800-469-6292. TTY users should call 711. We are open 7 days a week from 8:00 am to 8:00 pm. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit v
4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Please talk to your doctor if you are taking a medication that the FDA determines to be unsafe. Your doctor can prescribe a different medication to replace the one that is no longer available. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, VillageCareMAX Full Advantage FIDA Plan may not cover the drug. Quantity limits: Sometimes VillageCareMAX Full Advantage FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes VillageCareMAX Full Advantage FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 1. You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new VillageCareMAX Full Advantage FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit vi
is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page I-1. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Participant Services at 1-800-469-6292 and ask about it. If you learn that VillageCareMAX Full Advantage FIDA Plan will not cover the drug, you can do one of these things: If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit vii
Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new VillageCareMAX Full Advantage FIDA Plan Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of VillageCareMAX Full Advantage FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. VillageCareMAX Full Advantage FIDA Plan has a transition process and ensures that continued drug coverage is provided to new and current Part D members. There are times when you may experience a change in your level of care, such as a discharge or admission to a Long Term Care facility or a discharge or admission to a hospital. In these cases, VillageCareMAX Full Advantage FIDA plan will provide you with a one-time emergency supply of a non-formulary medication. Non-formulary drugs include both Part D drugs that are not on a plan s formulary and Part D drugs that are on a plan s formulary but require prior authorization or step therapy under the plan s utilization management rules. Please call Participant Services if you have any questions. You can call 1-800-469-6292 from 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit viii
11. Can you ask for an exception to cover your drug? Yes. You can ask VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask VillageCareMAX Full Advantage FIDA Plan or your IDT to change the rules on your drug. For example, VillageCareMAX Full Advantage FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). VillageCareMAX Full Advantage FIDA Plan covers both brand name drugs and generic drugs. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit ix
15. What are OTC drugs? OTC stands for over-the-counter. VillageCareMAX Full Advantage FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC drugs are covered. OTC drugs are included in Tier 4. 16. Does VillageCareMAX Full Advantage FIDA Plan cover OTC nondrug products? VillageCareMAX Full Advantage FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider. Examples include: OTC diabetic supplies such as gauze pads, alcohol swabs/pads, insulin syringes and needles. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC drugs are covered. You can read the VillageCareMAX Full Advantage FIDA Plan Drug List to see what OTC nondrug products are covered. 17. What is your copay? You will not be charged a copay for drugs on the Drug List. 18. What are drug tiers? In the VillageCareMAX Full Advantage FIDA Plan Formulary, you will see 4 drug tiers included in the formulary list. Tier 1 drugs are generic drugs covered by Medicare Tier 2 drugs are brand name and specialty drugs covered by Medicare Tier 3 drugs are non-part D generic and brand name drugs covered by Medicaid Tier 4 drugs are Over-the-Counter (OTC) drugs covered by Medicaid As a member of our plan, you will pay $0 copayment for drugs in any of these 4 tiers. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit x
List of Covered Drugs The list of covered drugs that begins below on page 1 gives you information about the drugs covered by VillageCareMAX Full Advantage FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., LIPITOR and generic drugs are listed in lower-case italics (e.g., ibuprofen). The information in the necessary actions, restrictions, or limits on use column tells you if VillageCareMAX Full Advantage FIDA Plan has any rules for covering your drug. ABBREVIATION/SYMBOL DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA-HRM Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications You (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Participants age 65 yrs or older are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xi
ABBREVIATION/SYMBOL DESCRIPTION EXPLANATION PA NSO QL ST Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction If you are a new participant or if you have not taken this drug before, you (or your physician) are required to get prior authorization from VillageCareMAX Full Advantage FIDA Plan before you fill your prescription for this drug. Without prior approval, VillageCareMAX Full Advantage FIDA Plan may not cover this drug. VillageCareMAX Full Advantage FIDA Plan limits the amount of this drug that is covered per prescription, or within a specific time frame. Before VillageCareMAX Full Advantage FIDA Plan can provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. OTHER SPECIAL REQUIREMENTS FOR COVERAGE LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Participant Services at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. * Not a Part D Drug This drug is a non-part D drug, or an OTC drug or product covered by Medicaid. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xii
Note: The * next to a drug means the drug is not a Part D drug and are included in tiers 3 and 4. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, VillageCareMAX Full Advantage FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at 1-800-469-6292 or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to appeal a decision. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions. If you have questions, please call VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. TTY users should call 711. The call is free. For more? information, visit xiii
Table of Contents Analgesics... 3 Anesthetics... 15 Anti-Addiction/Substance Abuse Treatment Agents... 15 Antianxiety Agents... 17 Antibacterials... 18 Anticancer Agents... 30 Anticholinergic Agents... 40 Anticonvulsants... 41 Antidementia Agents... 45 Antidepressants... 46 Antidiabetic Agents... 50 Antifungals... 54 Antihistamines... 58 Anti-Infectives (Skin And Mucous Membrane)... 64 Antimigraine Agents... 64 Antimycobacterials... 65 Antinausea Agents... 66 Antiparasite Agents... 68 Antiparkinsonian Agents... 69 Antipsychotic Agents... 70 Antivirals (Systemic)... 74 Blood Products/Modifiers/Volume Expanders... 81 Caloric Agents... 85 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016 1
Cardiovascular Agents... 91 Central Nervous System Agents... 107 Contraceptives... 109 Cough And Cold Products... 118 Dental And Oral Agents... 130 Dermatological Agents... 130 Devices... 139 Disinfectants (For Non-Dermatologic Use)... 140 Enzyme Replacement/Modifiers... 140 Eye, Ear, Nose, Throat Agents... 142 Gastrointestinal Agents... 150 Genitourinary Agents... 164 Heavy Metal Antagonists... 164 Hormonal Agents, Stimulant/Replacement/Modifying... 165 Immunological Agents... 172 Inflammatory Bowel Disease Agents... 181 Irrigating Solutions... 182 Metabolic Bone Disease Agents... 182 Miscellaneous Therapeutic Agents... 184 Ophthalmic Agents... 190 Replacement Preparations... 191 Respiratory Tract Agents... 202 Skeletal Muscle Relaxants... 206 Sleep Disorder Agents... 207 Vasodilating Agents... 208 Vitamins And Minerals... 209 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016 2
Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg rapid tab 160 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen 80 mg/0.8 ml drp infants 80 mg/0.8 ml * acetaminophen-codeine 120 mg-12 mg/5 ml solution 120-12 mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 mg ALLZITAL ORAL TABLET 25-325 MG ascomp with codeine oral capsule 30-50-325-40 mg (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 3
BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule 30-50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325- 40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule 50-325-40 mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule 50-325-40 mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * child pain-fever 160 mg/5 ml a/f,gluten/f,cherry 160 mg/5 ml * (Acetaminophen) (Infants' Tylenol) ST; QL (60 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) QL (240 per 30 days) 4
child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) (Codeine Sulfate) mg, 60 mg cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet 10-325 mg, 2.5- QL (360 per 30 days) (Xolox) 325 mg, 5-325 mg, 7.5-325 mg endodan oral tablet 4.8355-325 mg (Percodan) QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 (Actiq) PA; QL (120 per 30 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour (Duragesic) QL (10 per 30 days) feverall 120 mg suppository QL (30 per 30 days) (Acetaminophen) children's, outer 120 mg * feverall 325 mg suppository junior QL (30 per 30 days) (Acetaminophen) str, outer 325 mg * feverall 650 mg suppository adult, QL (30 per 30 days) (Acetaminophen) outer 650 mg * hydrocodone-acetaminophen oral QL (2700 per 30 days) solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 7.5-325 mg/15 ml (Hycet) hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) 5
hydrocodone-acetaminophen oral QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, 5-325 (Norco) mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet QL (150 per 30 days) 10-200 mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg (Ibudone) hydromorphone (pf) injection solution 10 mg/ml (Dilaudid-HP) hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution 2 (Hydromorphone mg/ml HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 days) junior mapap 160 mg rapid tab 160 QL (30 per 30 days) (Acetaminophen) mg * LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; QL (30 per 30 days) lorcet (hydrocodone) oral tablet 5- QL (360 per 30 days) (Norco) 325 mg lorcet hd oral tablet 10-325 mg (Norco) QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml elixir 160 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) 6
mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Tylenol Arthritis) mg * margesic oral capsule 50-325-40 mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg (Diskets) QL (360 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia (Morphine Sulfate/0.9% syring 50 mg/25 ml (2 mg/ml) Nacl/PF) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml carpuject 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution QL (200 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine concentrate oral syringe 20 mg/ml (Morphine Sulfate) 7
morphine in dextrose 5 % injection pt controlled analgesia syring 100 mg/50 ml (2 mg/ml), 50 mg/25 ml (2 mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml morphine intravenous cartridge 15 mg/ml morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate/D5W) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG, 30 MG morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg (Morphine Sulfate) non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG 8
NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (180 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 15 mg, QL (180 per 30 days) (Roxicodone) 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg (Oxycontin) oxycodone oral tablet,oral QL (120 per 30 days) (Oxycontin) only,ext.rel.12 hr 80 mg (Oxycodone QL (1800 per 30 days) oxycodone-acetaminophen oral HCl/Acetaminophe solution 5-325 mg/5 ml n) oxycodone-acetaminophen oral QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, 5-325 (Xolox) mg, 7.5-325 mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet 10-650 mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet 7.5-500 mg oxycodone-aspirin oral tablet QL (360 per 30 days) (Percodan) 4.8355-325 mg OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg, 5 QL (180 per 30 days) (Opana) mg 9
oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Opana ER) oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg * QL (240 per 30 days) (Acetaminophen) q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * ra jr acetaminophen 160 mg tab QL (30 per 30 days) (Acetaminophen) rapid melts 160 mg * reprexain oral tablet 10-200 mg, 2.5-200 mg, 5-200 mg roxicet oral solution 5-325 mg/5 ml (Ibudone) (Oxycodone HCl/Acetaminophe n) QL (150 per 30 days) QL (1800 per 30 days) silapap infant's drops infant 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * sm arthritis pain er 650 mg caplet QL (180 per 30 days) (Tylenol Arthritis) 650 mg * sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * 10
tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (180 per tencon oral tablet 50-325 mg (Tencon) 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) 37.5-325 mg (includes Vicodin, vicodin es oral tablet 7.5-300 mg (Norco) Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin hp oral tablet 10-300 mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) vicodin oral tablet 5-300 mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) xylon 10 oral tablet 10-200 mg (Ibudone) QL (150 per 30 days) zebutal oral capsule 50-325-40 mg (Esgic) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 11
aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML A/F (OTC) 100 MG/5 ML * cvs ibuprofen 200 mg softgel liquid (Advil) filled,softge 200 mg * diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 100 mg diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac sodium topical gel 3 % (Voltaren) bufferin 325 mg tablet coated 325 choline,magnesium salicylate oral diclofenac potassium oral tablet 50 (Aspirin/Calcium (Choline Sal/Mag (Diclofenac mg * liquid 500 mg/5 ml mg Carbonate/Mag) Salicylate) Potassium) QL (60 per 30 days) 12
diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50-200 (Arthrotec 50) mg-mcg, 75-200 mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Etodolac) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) mg fenoprofen oral capsule 200 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) 13
INFANTS' MOTRIN 50 MG/1.25 ML D/F, BERRY FLAVOR 50 3 $0 MG/1.25 ML * ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior (Advil) strength 100 mg * st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) QL (20 per 30 days) 14
tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 (Xylocaine-MPF) mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) (Xylocaine) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream 2.5-2.5 % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg (Acamprosate Calcium) (Buprenorphine HCl) (Buprenorphine HCl/Naloxone HCl) PA PA; QL (90 per 30 days) PA; QL (90 per 30 days) 15
bupropion hcl sr 150 mg tablet f/c 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NICODERM CQ 14 MG/24HR PATCH 14 MG/24 HR * NICODERM CQ 21 MG/24HR PATCH 21 MG/24 HR * NICODERM CQ 7 MG/24HR PATCH 7 MG/24 HR * nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) 16
nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) PA; QL (90 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) QL (90 per 30 days) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg diazepam injection syringe 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml 17
diazepam oral solution 5 mg/5 ml (1 mg/ml) (Diazepam) diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg (Diastat) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan) ONFI ORAL SUSPENSION 2.5 MG/ML Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 (Gentamicin In ml, 100 mg/50 ml, 60 mg/50 ml, 70 Nacl, Iso-Osm) mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 (Gentamicin mg/ml Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl inhalation solution for nebulization (Tobi) 300 mg/5 ml QL (1200 per 30 days) QL (120 per 30 days) QL (90 per 30 days) PA NSO; QL (480 per 30 days) QL (224 per 28 days) 18
tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml, 80 mg/100 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 mg/5 ml soln 75 mg/5 ml clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin Palmitate) (Cleocin HCl) (Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) (Zyvox) linezolid oral tablet 600 mg (Zyvox) 19
methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (75/25) (Macrodantin) (Macrobid) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) 20
polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl gram/200 ml In Dextrose 5 %) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 1 gram/50 Sodium/Dextrose, ml, 2 gram/50 ml Iso) PA; QL (9 per 30 days) PA 21
cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime injection recon soln 1 gram, 2 gram (Maxipime) cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg (Claforan) (Cefoxitin cefoxitin in dextrose, iso-osm Sodium/Dextrose, intravenous piggyback 2 gram/50 ml Iso) cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram (Cefoxitin Sodium) cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) 22
ceftibuten oral suspension for reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback 50ml galaxycontainer 1 gram/50 ml ceftriaxone 1 gm vial 10's, fliptop,l/f 1 gram ceftriaxone 2 gm piggyback 50ml galaxycontainer 2 gram/50 ml ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 gram, 2 gram cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg, 750 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Cedax) (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Rocephin) (Ceftriaxone Na/Dextrose, Iso) (Ceftin) (Zinacef) (Zinacef) (Keflex) (Cephalexin) (Cephalexin) (Fortaz) 23
TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 mg (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) e.e.s. 400 oral tablet 400 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) ery-tab oral tablet,delayed release (Erythromycin (dr/ec) 250 mg, 500 mg Base) ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet (Erythromycin 250 mg Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (Erythromycin tablet 400 mg Ethylsuccinate) 24
erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 mg meropenem iv 1 gm vial outer, latexfree 1 gram Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Merrem) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Amoxicillin) (Augmentin) LA 25
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg ampicillin 2 gm vial 10's, latex-free 2 gram ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Sodium) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Dicloxacillin Sodium) (Nafcillin Sodium) 26
nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram piperacil-tazobact 40.5 gram p/f, latex-free 40.5 gram (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) (Penicillin G Potassium) (Zosyn) (Zosyn) 27
Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml (Cipro) (Cipro I.V.) (Ciprofloxacin Lactate) (Cipro) ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f, in d5w 400 mg/200 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 (Levaquin) mg/150 ml levofloxacin intravenous solution 25 mg/ml (Levofloxacin) levofloxacin oral solution 250 mg/10 ml (Levaquin) levofloxacin oral tablet 250 mg, 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous solution 400-80 mg/5 Trimethoprim) ml sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension 200-40 mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) 28
sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension 200-40 mg/5 ml Tetracyclines doxy-100 intravenous recon soln 100 mg doxycycline hyclate 100 mg cap 100 mg doxycycline hyclate 100 mg tab 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline mono 100 mg cap 100 mg doxycycline mono 100 mg tablet f/c 100 mg doxycycline mono 50 mg tablet 50 mg doxycycline monohydrate oral capsule 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 150 mg, 75 mg (Azulfidine) (Sulfamethoxazole/ Trimethoprim) (Doxycycline Hyclate) (Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy) (Doryx) (Adoxa) (Avidoxy) (Avidoxy) (Adoxa) (Vibramycin) (Avidoxy) 29
minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous recon soln 10 mg, 20 mg, 50 mg adriamycin intravenous solution 10 mg/5 ml adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Minocin) (Minocycline HCl) (Tetracycline HCl) (Doxorubicin HCl) (Doxorubicin HCl) (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole oral tablet 1 mg (Arimidex) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) 30
AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML (Vidaza) bexarotene oral capsule 75 mg (Targretin) bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 30 (Bleomycin unit Sulfate) bleomycin sulfate 15 unit vial latexfree 15 unit Sulfate) (Bleomycin BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 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) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) 31
COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG (Cyclophosphamid e) (Cyclophosphamid e) (Dactinomycin) (Dacogen) (Doxil) PA NSO; LA; QL (63 per 28 days) ; ST ; ST PA NSO PA NSO; LA QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) 32
EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 500 (Fluorouracil) mg/10 ml flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO PA NSO; QL (30 per 30 days) PA NSO 33
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial suv 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) (Ifex) (Ifosfamide/Mesna ) imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA 15 MG KIT WITH DILUENT 15 MG IXEMPRA INTRAVENOUS RECON SOLN 45 MG PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) 34
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 (Leuprolide mg/0.2 ml Acetate) lipodox 50 intravenous suspension 2 mg/ml (Doxil) lipodox intravenous suspension 2 mg/ml (Doxil) lomustine oral capsule 10 mg, 100 mg, 40 mg (Lomustine) LONSURF ORAL TABLET 15-6.14 MG LONSURF ORAL TABLET 20-8.19 MG PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) 35
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate 50 mg/2 ml vial latexfree, 5's, mdv 25 mg/ml Sodium) (Methotrexate methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium) methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) ; ST 36
NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) 37
STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) TREANDA 25 MG VIAL 25 MG PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO; (vial only) 38
TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 180 MG/2 ML, 45 MG/0.5 ML TRELSTAR 22.5 MG SYRINGE OUTER 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 50 mg/5 ml (Navelbine) VOTRIENT ORAL TABLET 200 MG QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) (capsule: 10mg) ; ST PA NSO PA NSO PA NSO; LA PA NSO; LA PA NSO; QL (120 per 30 days) 39
XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION (Atropine Sulfate) (Atropine Sulfate) (Propantheline Bromide) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) QL (4 per 28 days) 40
Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 41
divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin 500 mg pe/10 ml 10's,sdv,latex-free 500 mg pe/10 ml (Cerebyx) fosphenytoin injection solution 100 mg pe/2 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg ST ST 42
lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution 130 mg/ml, 65 mg/ml Sodium) 43
phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) POTIGA ORAL TABLET 200 MG, QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG QL (270 per 30 days) primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION 1,000 MG days) SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiragen oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) topiramate oral capsule, sprinkle 15 mg, 25 mg (Topamax) topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) ST; QL (120 per 30 days) 44
TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, ST QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG 45
NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG buproban oral tablet extended release 150 mg bupropion hcl (smoking deter) oral tablet extended release 150 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg (Exelon) (Exelon) (Amitriptyline HCl) (Amoxapine) (Wellbutrin SR) (Wellbutrin SR) (Wellbutrin) (Wellbutrin SR) (Wellbutrin XL) (Citalopram Hydrobromide) (Celexa) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) PA NSO-HRM ST QL (30 per 30 days) 46
clomipramine oral capsule 25 mg, PA NSO-HRM (Anafranil) 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 PA NSO-HRM (Doxepin HCl) mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Cymbalta); QL (60 (Duloxetine) release(dr/ec) 20 mg, 60 mg per 30 days) duloxetine oral capsule,delayed (Cymbalta); QL (30 (Duloxetine) release(dr/ec) 30 mg per 30 days) duloxetine oral capsule,delayed (Irenka); QL (30 per 30 (Duloxetine) release(dr/ec) 40 mg days) EMSAM TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 47
fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML (Fluvoxamine Maleate) (Fluvoxamine Maleate) (Tofranil) (Tofranil-Pm) (Maprotiline HCl) (Remeron) (Remeron) (Nefazodone HCl) (Pamelor) (Nortriptyline HCl) (Symbyax) (Paxil) (Paxil CR) PA NSO-HRM PA NSO-HRM 48
perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg (Perphenazine/Ami triptyline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) SILENOR ORAL TABLET 3 MG, 6 MG SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg (Trazodone HCl) trimipramine oral capsule 100 mg, (Trimipramine 25 mg, 50 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 (Effexor XR) mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (Venlafaxine HCl) (Venlafaxine HCl) PA NSO-HRM ST; QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM PA NSO-HRM ST 49
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg CYCLOSET ORAL TABLET 0.8 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG 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 INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG (Precose) QL (90 per 30 days) QL (180 per 30 days) ST ST ST ST ST 50
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG KORLYM ORAL TABLET 300 MG PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (75 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (150 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr 1,000 mg metformin oral tablet extended QL (150 per 30 days) (Fortamet) release 24hr 500 mg miglitol oral tablet 100 mg, 25 mg, QL (90 per 30 days) (Glyset) 50 mg nateglinide oral tablet 120 mg, 60 QL (90 per 30 days) (Starlix) mg pioglitazone oral tablet 15 mg, 30 QL (30 per 30 days) (Actos) mg, 45 mg pioglitazone-glimepiride oral tablet QL (30 per 30 days) (Duetact) 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet QL (90 per 30 days) (Actoplus Met) 15-500 mg, 15-850 mg repaglinide oral tablet 0.5 mg, 1 mg, QL (240 per 30 days) (Prandin) 2 mg repaglinide-metformin oral tablet 1- QL (150 per 30 days) (Prandimet) 500 mg, 2-500 mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML PA; QL (10.8 per 28 days) 51
SYMLINPEN 60 PA; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 12.5- ST 1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA Insulins HUMULIN R U-500 (CONC) QL (24 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U-500 QL (40 per 28 days) (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS QL (40 per 28 days) SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION QL (40 per 28 days) SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 52
NOVOLOG MIX 70-30 FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX 70-30 QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENFILL QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS QL (40 per 28 days) SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (240 per 30 days) 250 mg in HCl) glipizide-metformin oral tablet 2.5- (Glipizide/Metform QL (120 per 30 days) 500 mg, 5-500 mg in HCl) glyburide micronized oral tablet 1.5 PA-HRM; AGE (Max (Glynase) mg, 3 mg, 6 mg 64 Years) glyburide oral tablet 1.25 mg, 2.5 PA-HRM; AGE (Max (Glyburide) mg, 5 mg 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max (Glucovance) 1.25-250 mg, 2.5-500 mg, 5-500 mg 64 Years) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) 53
tolbutamide oral tablet 500 mg (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML aloe vesta 2% antifungal oint 2 % * AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln (Miconazole Nitrate) (Amphotericin B) 50 mg anti-fungal 1% powder 1 % * (Tolnaftate) antifungal 2% cream 2 % * (Nuzole) baza antifungal 2% cream 12's 2 % * (Nuzole) blis-to-sol 1% liquid 1 % * (Tolnaftate) CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Loprox) ciclopirox topical gel 0.77 % (Loprox) ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Penlac) ciclopirox topical suspension 0.77 (Ciclopirox % Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) topical solution 8 % clotrim 1% vaginal cream 1 % * (Gyne-Lotrimin) clotrimazole 1% cream (otc) 1 % * (Lotrimin AF) clotrimazole 1% solution (otc) 1 % (Clotrimazole) * clotrimazole insert 100 mg * (Clotrimazole) clotrimazole mucous membrane (Clotrimazole) troche 10 mg 54
clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Clotrimazole) clotrimazole-7 cream 1 % * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream 1-0.05 % (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion 1-0.05 % methasone Dip) critic-aid clear af 2% oint 12's, w/ (Miconazole antifungal 2 % * Nitrate) cvs 3-day vaginal cream 2 % * (Gyne-Lotrimin) cvs af 1% spray powder 1 % * (Tinactin) cvs miconazole 3 combo pack 3pref applic w/cream 4 % (200 mg)- 2 % (9 gram) * (Miconazole Nitrate) dermafungal 2% ointment 2 % * (Miconazole Nitrate) econazole topical cream 1 % (Econazole Nitrate) elon dual defense 25% solution 25 % * (Undecylenic Acid) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback 400 mg/200 Nacl,Iso-Osm) ml fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml (Fluconazole In Nacl,Iso-Osm) fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml (Diflucan) fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg (Diflucan) fluconazole-nacl 400 mg/200 ml (Fluconazole In 10's,latex-free, p/f 400 mg/200 ml Nacl,Iso-Osm) flucytosine oral capsule 250 mg, 500 mg (Ancobon) fungi cure intensive 1% spray 1 % * (Clotrimazole) FUNGI-NAIL TINCTURE * 55
fungoid-d 1% cream 1 % * (Tinactin) gnp miconazole 3 combo pack 4 % (Miconazole (200 mg)- 2 % (9 gram) * Nitrate) griseofulvin microsize oral tablet (Grifulvin V) 500 mg inzo antifungal 2% cream 2 % * (Nuzole) itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg (Ketoconazole) ketoconazole topical cream 2 % (Ketoconazole) ketoconazole topical shampoo 2 % (Nizoral) lamisil af defens 1% spray pwd 1 % (Tinactin) * lamisil af defense 1% powder 1 % * (Tolnaftate) LAMISIL ANTIFUNGAL 1% SPRAY FOR ATHLETES FOOT 1 % * LAMISIL AT 1% GEL 1 % * micatin 2% antifungal cream 2 % * (Nuzole) miconazole 3 combo pack 3 sup,9gm (Monistat 3) crm w/app 200 mg- 2 % (9 gram) * miconazole 7 100 mg vag supp 100 (Miconazole mg * Nitrate) (Miconazole miconazole nitrate 2% cream 2 % * Nitrate) miconazole-3 vaginal suppository (Miconazole 200 mg Nitrate) MONISTAT 3 COMBO PACK 3 SUPP, 9 GM CREAM 200 MG- 2 % (9 GRAM) * MONISTAT 3 COMBO PACK 4 % (200 MG)- 2 % (9 GRAM) * monistat 7 cream 7 applicators 2 % (Miconazole * Nitrate) myco nail a 25% solution 25 % * (Undecylenic Acid) 56
NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 (Nystatin) unit/gram nystatin oral suspension 100,000 (Nystatin) unit/ml nystatin oral tablet 500,000 unit (Nystatin) nystatin topical cream 100,000 (Nystatin) unit/gram nystatin topical ointment 100,000 (Nystatin) unit/gram nystatin topical powder 100,000 (Nystatin) unit/gram nystatin-triamcinolone topical (Nystatin/Triamcin cream 100,000-0.1 unit/g-% ) nystatin-triamcinolone topical (Nystatin/Triamcin ointment 100,000-0.1 unit/gram-% ) nystop topical powder 100,000 (Nystatin) unit/gram pv foot odor control 1% powder 1 % (Tinactin) * qc 3 day vaginal 4% cream 200 (Miconazole mg/5 gram (4 %) * Nitrate) ra antifungal 1% liquid spray liquid (Tolnaftate) spray 1 % * remedy phytplx antifungal oint 2 % (Miconazole * Nitrate) terbinafine 1% cream 1 % * (Lamisil At) terbinafine hcl oral tablet 250 mg (Lamisil) tolnaftate 1% cream 1 % * (Tinactin) tolnaftate 1% solution 1 % * (Tolnaftate) 57
triple paste af 2% ointment 2 % * (Miconazole Nitrate) voriconazole intravenous solution 200 mg (Vfend IV) voriconazole oral suspension for reconstitution 200 mg/5 ml (40 (Vfend) mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Antihistamines Antihistamines alavert 10 mg odt non-drowsy, mint 10 mg * (Claritin) alavert d-12 allergy-sinus tab 5-120 (Claritin-D 12 mg * Hour) ALLEGRA ALLERGY 180 MG TABLET 180 MG * ALLEGRA ALLERGY 60 MG TABLET 60 MG * aller-chlor 2 mg/5 ml syrup 2 mg/5 (Chlorpheniramine ml * Maleate) aller-chlor 4 mg tablet 4 mg * (Chlor-Trimeton) allerclear d-12hr tablet 5-120 mg * (Claritin-D 12 Hour) allerclear d-24hr er tablet nondrowsy 10-240 mg * Hour) (Claritin-D 24 allergy 4 mg tablet 4 mg * (Chlor-Trimeton) allerhist-1 1.34 mg tablet 1.34 mg * (Clemastine Fumarate) aller-tec d 5-120 mg tablet 5-120 mg * (Zyrtec-D) ambi 60pse-4cpm tablet 4-60 mg * (Chlorpheniramine/ Pseudoephed) aprodine tablet 2.5-60 mg * (Triprolidine/Pseud oephedrine) 58
banophen 25 mg capsule 25 mg * (Zzzquil) banophen 25 mg tablet 25 mg * (Diphenhydramine HCl) banophen allergy 12.5 mg/5 ml a/f 12.5 mg/5 ml * (Zzzquil) benadryl allergy 25 mg ultratb (Diphenhydramine ultratab 25 mg * HCl) cetirizine hcl 1 mg/1 ml soln children, s/f, grape (otc) 1 mg/ml * (Children'S Zyrtec) cetirizine hcl 10 mg tablet indoor & outdoor 10 mg * (Zyrtec) cetirizine hcl 5 mg chew tab children's,outer,u-d 5 mg * (Zyrtec) cetirizine-pse er 5-120 mg tab 5-120 mg * (Zyrtec-D) child allegra allergy 30 mg/5 ml (Fexofenadine suspension 30 mg/5 ml * HCl) CHILD CLARITIN 5 MG/5 ML SOLN A/F,D/F,S/F,GRAPE 5 MG/5 ML * child triaminic cold & allergy 1-2.5 mg/5 ml * (Dimetapp) child wal-tap cold-allergy elx 1-2.5 mg/5 ml * (Dimetapp) CHILD ZYRTEC 1 MG/ML SOLUTION D/F,S/F,GRAPE 1 MG/ML * children's allegra allergy oral tablet 30 mg * CHILDREN'S ZYRTEC 10 MG ODT 10 MG * child's aller-tec 1 mg/ml soln 1 mg/ml * (Children'S Zyrtec) CHILD'S CLARITIN 5 MG TAB CHEW 5 MG * 59
child's wal-dryl 12.5 mg/5 ml a/f,s/f,d/f,bubb gum 12.5 mg/5 ml * child's wal-zyr 10 mg chew tab 10 mg * CLARITIN 10 MG LIQUI-GEL CAP 10 MG * CLARITIN 10 MG REDITABS 10 MG * CLARITIN 10 MG TABLET (OTC) 10 MG * CLARITIN 5 MG REDITABS 5 MG * cold-allergy-sinus oral tablet 2.5-60 mg * compoz 25 mg gelcap 25 mg * cvs allergy 25 mg tablet 25 mg * cvs allergy relief 10 mg sftgl 10 mg * cvs child allergy 10 mg chw tb 24 hr,indoor/outdoor 10 mg * cvs cold & cough nighttime liq 6.25-2.5 mg/5 ml * cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg dailyhist-1 1.34 mg tablet 1.34 mg * dayhist allergy 1.34 mg tablet 12 hr relief 1.34 mg * dimaphen elixir a/f, grape, gluten-f 1-2.5 mg/5 ml * (Zzzquil) (Zyrtec) (Triprolidine/Pseud oephedrine) (Diphenhydramine HCl) (Diphenhydramine HCl) (Zyrtec) (Zyrtec) (Triaminic Nighttime Cold- Cough) (Cyproheptadine HCl) (Cyproheptadine HCl) (Clemastine Fumarate) (Clemastine Fumarate) (Dimetapp) 60
dimetapp cold & congest liquid 6.25-2.5 mg/5 ml * (Triaminic Nighttime Cold- Cough) diphenhist 12.5 mg/5 ml soln 12.5 (Zzzquil) mg/5 ml * diphenhist 25 mg capsule 25 mg * (Zzzquil) diphenhist 25 mg captab captab 25 (Diphenhydramine mg * HCl) diphenhydramine 25 mg capsule (Zzzquil) (otc) 25 mg * diphenhydramine 50 mg capsule (Zzzquil) (otc) 50 mg * diphenhydramine 50 mg tablet 50 (Diphenhydramine mg * HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) (Chlorpheniramine ed chlorped jr syrup 2 mg/5 ml * Maleate) ed-a-hist 4 mg-10 mg tablet 4-10 mg (Chlorpheniramine/ * Phenylephrine) fexofenadine hcl 180 mg tablet (Allegra Allergy) 24hr,original str (otc) 180 mg * fexofenadine hcl 60 mg tablet (Allegra Allergy) indoor/outdoor (otc) 60 mg * hm z-sleep 25 mg softgel 25 mg * (Zzzquil) levocetirizine oral solution 2.5 mg/5 (Xyzal) ml levocetirizine oral tablet 5 mg (Xyzal) loratadine 10 mg tablet 10 mg * (Claritin) fexofenadine hcl 30 mg/5 ml 30 loratadine allergy 5 mg/5 ml d/f, a/f, loratadine-d 12 hour tablet nondrowsy 5-120 mg * (Fexofenadine (Children'S (Claritin-D 12 mg/5 ml * s/f 5 mg/5 ml * HCl) Claritin) Hour) 61
loratadine-d 24hr tablet 10-240 mg * promethazine oral syrup 6.25 mg/5 ml pv nyt-time sleep 25 mg caplet 25 mg * q-dryl 12.5 mg/5 ml liquid a/f 12.5 mg/5 ml * ra sleep aid 50 mg/30 ml liq 50 mg/30 ml * siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * simply sleep 25 mg caplet caplet 25 mg * sleep aid 25 mg tablet 25 mg * sm allergy relief 1.34 mg tab 1.34 mg * sm sinus and allergy tablet maximum strength 4-60 mg * sm z-sleep 50 mg/30 ml liquid berry,gluten-free 50 mg/30 ml * sudogest sinus & allergy tab 4-60 mg * TRIAMINIC NIGHTTIME COLD- COUGH CHILDREN'S, GRAPE 6.25-2.5 MG/5 ML * unisom 50 mg sleepgels softgel 50 mg * wal-act d cold & allergy tab 2.5-60 mg * wal-dryl allergy 25 mg capsule 25 mg * wal-dryl allergy 25 mg minitab minitab, coated 25 mg * (Claritin-D 24 Hour) (Promethazine HCl) (Diphenhydramine HCl) (Zzzquil) (Zzzquil) (Zzzquil) (Diphenhydramine HCl) (Doxylamine Succinate) (Clemastine Fumarate) (Chlorpheniramine/ Pseudoephed) (Zzzquil) (Chlorpheniramine/ Pseudoephed) (Zzzquil) (Triprolidine/Pseud oephedrine) (Zzzquil) (Diphenhydramine HCl) PA-HRM; AGE (Max 64 Years) 62
wal-fex allergy 180 mg tablet 180 (Allegra Allergy) mg * wal-fex allergy 60 mg tablet 60 mg * (Allegra Allergy) wal-finate 4 mg tablet 4 mg * (Chlor-Trimeton) (Chlorpheniramine/ wal-finate-d tablet 4-60 mg * Pseudoephed) wal-itin 10 mg odt non-drowsy 10 (Claritin) mg * wal-itin 10 mg tablet non-drowsy 10 (Claritin) mg * wal-itin 5 mg/5 ml syrup children's, (Children'S grape 5 mg/5 ml * Claritin) (Claritin-D 12 wal-itin d 12 hour tablet 5-120 mg * Hour) wal-itin d 24 hour tablet 10-240 mg (Claritin-D 24 * Hour) (Unisom wal-sleep z 25 mg odt 25 mg * Sleepmelts) wal-sleep z 25 mg softgel 25 mg * (Zzzquil) wal-sleep z 50 mg/30 ml liquid (Zzzquil) berry, a/f, d/f, s/f 50 mg/30 ml * (Doxylamine wal-som 25 mg tablet 25 mg * Succinate) wal-som 50 mg softgel softgel 50 mg (Zzzquil) * wal-tap elixir 1-2.5 mg/5 ml * (Dimetapp) wal-zyr 10 mg tablet 10 mg * (Zyrtec) wal-zyr d tablet 12 hr 5-120 mg * (Zyrtec-D) wal-zyr solution children's, a/f 1 (Children'S Zyrtec) mg/ml * wal-phed pe sinus-allergy tab 4-10 wal-phed sinus and allergy tab 4-60 (Chlorpheniramine/ (Chlorpheniramine/ mg * mg * Phenylephrine) Pseudoephed) 63
ZYRTEC 10 MG LIQUID GELS 10 MG * ZYRTEC 10 MG ODT 10 MG * ZYRTEC 10 MG TABLET INDOOR/OUTDOOR 24 HR (OTC) 10 MG * Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA 10% CREAM 10 % * AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) terconazole vaginal suppository 80 mg (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection QL (30 per 28 days) (D.H.E.45) solution 1 mg/ml dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) QL (8 per 28 days) (Migranal) ERGOMAR SUBLINGUAL QL (40 per 28 days) TABLET 2 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) QL (18 per 28 days) rizatriptan oral tablet 10 mg, 5 mg (Maxalt) QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) (Maxalt Mlt) 10 mg, 5 mg sumatriptan 6 mg/0.5 ml syrng (Sumatriptan QL (4 per 28 days) p/f,dehp/f,pvc/f 6 mg/0.5 ml Succinate) 64
sumatriptan nasal spray,nonaerosol 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml, 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM (Imitrex) (Imitrex) (Sumatriptan Succinate) (Imitrex) (Sumatriptan Succinate) (Sumatriptan Succinate) (Imitrex) (Zomig) (Zomig Zmt) QL (12 per 28 days) QL (18 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (12 per 28 days) QL (12 per 28 days) dapsone oral tablet 100 mg, 25 mg (Dapsone) ethambutol oral tablet 100 mg, 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml (Isoniazid) isoniazid oral tablet 100 mg, 300 mg (Isoniazid) PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg (Pyrazinamide) rifabutin oral capsule 150 mg (Mycobutin) 65
rifampin intravenous recon soln 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET 50-120- 300 MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE 300-0.5 MG (Rifadin) (Rifadin) PA; QL (188 per 168 days) compro rectal suppository 25 mg (Compazine) cvs motion sickness 50 mg tab 50 mg * (Dimenhydrinate) dimenhydrinate injection solution 50 (Dimenhydrinate) mg/ml dramamine 50 mg tablet 50 mg * (Dimenhydrinate) dramamine less drowsy 25 mg tb 25 mg * (Meclizine HCl) driminate 50 mg tablet 50 mg * (Dimenhydrinate) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg (Marinol) EMEND INTRAVENOUS RECON QL (2 per 28 days) SOLN 150 MG EMEND ORAL CAPSULE 125 MG, 80 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) 66
granisetron (pf) intravenous (Granisetron solution 100 mcg/ml HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) granisetron hcl oral tablet 1 mg (Granisetron HCl) meclizine 12.5 mg caplet caplet (otc) 12.5 mg * (Meclizine HCl) meclizine 25 mg tablet (otc) 25 mg * (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Meclizine HCl) motion sickness 25 mg tablet 25 mg * (Meclizine HCl) ondansetron hcl (pf) injection (Ondansetron solution 4 mg/2 ml HCl/PF) ondansetron hcl (pf) injection (Ondansetron syringe 4 mg/2 ml HCl/PF) ondansetron hcl oral solution 4 (Zofran) mg/5 ml ondansetron hcl oral tablet 24 mg, 4 (Zofran) mg, 8 mg ondansetron oral (Zofran Odt) tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 PA-HRM; AGE (Max (Phenergan) mg, 25 mg 64 Years) prochlorperazine edisylate injection (Prochlorperazine solution 10 mg/2 ml (5 mg/ml) Edisylate) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) prochlorperazine rectal suppository 25 mg (Compazine) promethazine oral tablet 12.5 mg, (Promethazine PA-HRM; AGE (Max 25 mg, 50 mg HCl) 64 Years) promethazine rectal suppository PA-HRM; AGE (Max (Phenergan) 12.5 mg, 25 mg, 50 mg 64 Years) promethegan rectal suppository PA-HRM; AGE (Max (Phenergan) 12.5 mg, 25 mg, 50 mg 64 Years) 67
TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) travel sickness 25 mg tab chew 25 mg * (Bonine) wal-dram 50 mg tablet 50 mg * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg (Malarone) chloroquine phosphate oral tablet (Chloroquine 250 mg, 500 mg Phosphate) COARTEM ORAL TABLET 20-120 MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 mg (Plaquenil) ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg (Mefloquine HCl) NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg (Paromomycin Sulfate) QL (10 per 30 days) QL (6 per 21 days) 68
PENTAM INJECTION RECON SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG QL (90 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg (Amantadine HCl) amantadine hcl oral solution 50 mg/5 ml (Amantadine HCl) amantadine hcl oral tablet 100 mg (Amantadine HCl) APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML AZILECT ORAL TABLET 0.5 MG, 1 MG benztropine oral tablet 0.5 mg, 1 (Benztropine mg, 2 mg Mesylate) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg (Cabergoline) carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg (Sinemet CR) carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 (Sinemet CR) mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- (Stalevo 50) 125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg (Comtan) QL (60 per 30 days) PA-HRM; AGE (Max 64 Years) 69
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 (Mirapex) mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg (Requip) ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 (Requip XL) mg, 8 mg selegiline hcl oral capsule 5 mg (Eldepryl) selegiline hcl oral tablet 5 mg (Selegiline HCl) trihexyphenidyl oral elixir 0.4 mg/ml (Trihexyphenidyl trihexyphenidyl oral tablet 2 mg, 5 mg Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG HCl) (Trihexyphenidyl HCl) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml (Abilify) QL (900 per 30 days) 70
aripiprazole oral tablet 10 mg, 15 QL (30 per 30 days) (Abilify) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) QL (60 per 30 days) aripiprazole oral QL (90 per 30 days) (Abilify Discmelt) tablet,disintegrating 10 mg aripiprazole oral QL (60 per 30 days) (Abilify Discmelt) tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution (Chlorpromazine 25 mg/ml HCl) chlorpromazine oral tablet 10 mg, (Chlorpromazine 100 mg, 200 mg, 25 mg, 50 mg HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating ST 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg (Fazaclo) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 ST; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- ST; QL (8 per 28 days) 6MG(2) fluphenazine decanoate injection solution 25 mg/ml (Fluphenazine Decanoate) 71
fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Fluphenazine HCl) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate) (Haloperidol Lactate) (Haloperidol) QL (6 per 28 days) 72
loxapine succinate oral capsule 10 (Loxapine mg, 25 mg, 5 mg, 50 mg Succinate) molindone oral tablet 10 mg (Molindone HCl) QL (240 per 30 days) molindone oral tablet 25 mg (Molindone HCl) QL (270 per 30 days) molindone oral tablet 5 mg (Molindone HCl) QL (120 per 30 days) NUPLAZID ORAL TABLET 17 PA NSO; QL (60 per MG 30 days) olanzapine intramuscular recon soln QL (30 per 30 days) (Zyprexa) 10 mg olanzapine oral tablet 10 mg, 15 QL (30 per 30 days) (Zyprexa) mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating QL (30 per 30 days) (Zyprexa Zydis) 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating QL (31 per 30 days) (Zyprexa Zydis) 20 mg paliperidone oral tablet extended QL (30 per 30 days) (Invega) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended QL (60 per 30 days) (Invega) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg (Perphenazine) pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 QL (90 per 30 days) (Seroquel) mg, 25 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 QL (120 per 30 days) MG REXULTI ORAL TABLET 0.5 MG QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, QL (30 per 30 days) 2 MG, 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) QL (480 per 30 days) 73
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV 405 MG VL KIT W/ DILUENT, OUTER 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG (Risperdal) (Risperdal M-Tab) (Risperdal M-Tab) (Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl) (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral tablet 300 mg (Ziagen) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days) ST; QL (60 per 30 days) PA NSO-HRM ST; QL (540 per 30 days) QL (30 per 30 days) QL (7 per 30 days) QL (60 per 30 days) 74
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET 600-200-300 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 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET 600-300 MG EVOTAZ ORAL TABLET 300-150 MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET 150-150-200-10 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG (Trizivir) (Videx EC) 75
INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION 400-100 MG/5 ML KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg, 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet 150-300 mg (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 mg/5 ml (Viramune) nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 hr 100 mg, 400 mg (Viramune XR) NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET 200-25-25 MG 76
PREZCOBIX ORAL TABLET 800-150 MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg (Zerit) stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET 150-150-200-300 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG 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 77
VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg (Zidovudine) Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS 100 MG/1 ML VIAL 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG QL (84 per 180 days) 78
TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG EPCLUSA ORAL TABLET 400-100 MG HARVONI ORAL TABLET 90-400 MG OLYSIO ORAL CAPSULE 150 MG SOVALDI ORAL TABLET 400 MG TECHNIVIE ORAL TABLET 12.5-75-50 MG VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG- 75 MG -50 MG/250 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG- 50 MG- 33.33 MG-200 MG ZEPATIER ORAL TABLET 50-100 MG Interferons INTRON A 25 MILLION UNIT/2.5 ML 10 MILLION UNIT/ML INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) QL (48 per 180 days) QL (42 per 180 days) QL (540 per 180 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA; QL (84 per 28 days) PA; QL (30 per 30 days) PA NSO PA NSO 79
INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 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 SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous (Acyclovir solution 50 mg/ml Sodium) adefovir oral tablet 10 mg (Hepsera) entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg (Famvir) ganciclovir sodium intravenous recon soln 500 mg (Cytovene) PA NSO PA NSO PA PA PA PA PA NSO; QL (4 per 28 days) 80
ribasphere oral capsule 200 mg (Rebetol) ribasphere oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral tablet 450 mg (Valcyte) VIRAZOLE INHALATION RECON SOLN 6 GRAM Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Arixtra) (Arixtra) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) 81
heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner 25,000 unit/250 ml heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container 25,000 unit/250 ml(100 unit/ml) IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg (Heparin Sodium,Porcine/D5 W) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Heparin Sodium,Porcine/PF ) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5 W) (Coumadin) (Coumadin) PA; QL (24 per 28 days) ST; QL (60 per 30 days) 82
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG PA PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (0.6 per 28 days) 83
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 10,000 UNITS/ML VIAL 4'S, MDV, OUTER 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 mg/ml (25 %) aminocaproic acid oral tablet 1,000 mg, 500 mg anagrelide oral capsule 0.5 mg, 1 mg protamine intravenous solution 10 mg/ml tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) (Aminocaproic Acid) (Aminocaproic Acid) (Agrylin) (Protamine Sulfate) (Tranexamic Acid) PA; QL (12 per 28 days) PA; QL (12 per 28 days) PA; QL (6 per 28 days) PA; QL (30 per 30 days) tranexamic acid oral tablet 650 mg (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors 84
aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg (Aggrenox) BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg (Pletal) clopidogrel oral tablet 300 mg, 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg (Persantine) EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 mg (Pentoxifylline) Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % QL (30 per 30 days) 85
AMINOSYN 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % 86
CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF- FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % 87
CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % cysteine (l-cysteine) intravenous solution 50 mg/ml dex4 glucose 4 gm tablet chew grape flavor 4 gram * dextrose 10 % in water (d10w) intravenous parenteral solution 10 % (Cysteine HCl) (Dextrose) (Dextrose 10 % in Water) 88
dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous solution Water) dextrose 20 % in water (d20w) (Dextrose 20 % in intravenous parenteral solution 20 Water) % dextrose 25 % in water (d25w) (Dextrose 25 % in intravenous syringe Water) dextrose 40 % in water (d40w) (Dextrose 40 % in intravenous parenteral solution 40 Water) % dextrose 5 % in ringers intravenous (Dextrose 5 % In parenteral solution 5 % Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous parenteral solution Water) dextrose 50 % in water (d50w) (Dextrose 50 % in intravenous syringe Water) dextrose 70 % in water (d70w) (Dextrose 70 % in intravenous parenteral solution Water) FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % gluco burst 40% gel 40 % * (Dextrose) glucose 4 gram tablet chew na/f, caffeine free 4 gram * (Dextrose) glucose 40% gel tropical fruit 40 % * (Dextrose) glutose 15 gel 3 pak, outer, u-d 40 % * (Dextrose) 89
HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % HEPATASOL 8 % INTRAVENOUS PARENTERAL SOLUTION 8 % insta-glucose gel 24 gram/31 gram * insta-glucose gel 24 gram/31 gram * INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION 3.31-9.8-3.9 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION 2.36-6.8-3.5 % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % (Dextrose/Dextrin/ Maltose) (Fat Emul/Soy/Mct/Oli v/fish Oil) 90
TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg (Catapres) (Catapres-Tts 1) (Catapres-Tts 1) (Clonidine HCl/Chlorthalidon e) (Cardura) guanfacine oral tablet 1 mg, 2 mg (Tenex) midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG phenylephrine hcl injection solution 10 mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists (Midodrine HCl) (Vazculep) (Minipress) QL (4 per 28 days) QL (8 per 28 days) PA-HRM; AGE (Max 64 Years) PA; QL (180 per 30 days) 91
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG irbesartan oral tablet 150 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10- 25 MG, 40-5-12.5 MG, 40-5-25 MG valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) (Diovan) (Diovan HCT) PA; QL (60 per 30 days) ST 92
Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg (Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydroch lorothiazide) (Vasotec) (Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydroc hlorothiazide) (Zestril) (Zestoretic) moexipril oral tablet 15 mg, 7.5 mg (Moexipril HCl) moexipril-hydrochlorothiazide oral (Moexipril/Hydroc tablet 15-12.5 mg, 15-25 mg, 7.5- hlorothiazide) 12.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Aceon) (Accupril) 93
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml, 500 mg/ml propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg (Accuretic) (Altace) (Mavik) (Cordarone) (Norpace) (Tikosyn) (Tambocor) (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) (Mexiletine HCl) (Cordarone) (Procainamide HCl) (Rythmol SR) (Rythmol) 94
quinidine gluconate oral tablet (Quinidine extended release 324 mg Gluconate) quinidine sulfate oral tablet 200 mg, 300 mg (Quinidine Sulfate) quinidine sulfate oral tablet extended release 300 mg (Quinidine Sulfate) Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg (Sectral) atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg (Tenoretic 50) betaxolol oral tablet 10 mg, 20 mg (Betaxolol HCl) bisoprolol fumarate oral tablet 10 mg, 5 mg (Zebeta) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5- (Ziac) 6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg (Coreg) esmolol intravenous solution 100 mg/10 ml (10 mg/ml) (Brevibloc) labetalol intravenous solution 5 mg/ml (Labetalol HCl) labetalol oral tablet 100 mg, 200 mg, 300 mg (Trandate) metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 (Toprol XL) mg, 25 mg, 50 mg 95
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50 mg, 50-25 mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Lopressor HCT) (Metoprolol Tartrate) (Metoprolol Tartrate) (Lopressor) (Corgard) pindolol oral tablet 10 mg, 5 mg (Pindolol) propranolol intravenous solution 1 mg/ml (Propranolol HCl) propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg (Inderal LA) propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) (Propranolol HCl) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg (Propranolol HCl) propranolol-hydrochlorothiazid (Propranolol/Hydro oral tablet 40-25 mg, 80-25 mg chlorothiazid) sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg (Betapace) sotalol 120 mg tablet 120 mg (Betapace) sotalol af oral tablet 120 mg (Betapace) sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) timolol maleate oral tablet 10 mg, (Timolol Maleate) 20 mg, 5 mg Calcium-Channel Blocking Agents 96
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem 24hr er 180 mg cap 180 mg diltiazem 24hr er 360 mg cap 360 mg diltiazem hcl intravenous recon soln 100 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext release degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule, extended release 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Cardizem LA) (Cardizem CD) (Cardizem CD) (Cardizem CD) (Verapamil HCl) (Verelan Pm) 97
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG (Verelan) (Calan) (Calan SR) digitek oral tablet 125 mcg (Lanoxin) digitek oral tablet 250 mcg (Lanoxin) digox 125 mcg tablet 125 mcg (Lanoxin) ST (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) 98
digox 250 mcg tablet 250 mcg (Lanoxin) digoxin 0.25 mg/ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML (Digoxin) (Digoxin) digoxin oral tablet 125 mcg (Lanoxin) digoxin oral tablet 250 mcg (Lanoxin) dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml) (Dobutamine HCl/D5W) (Dobutamine HCl) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (300 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) 99
dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 800 mg/250 ml (3,200 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) ephedrine sulfate injection solution 50 mg/ml epinephrine hcl (pf) intravenous solution 1 mg/ml (1 ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML ethamolin intravenous solution 5 % FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg (Dopamine HCl/D5W) (Dopamine HCl) (Ephedrine Sulfate) (Epinephrine HCl/PF) (Adrenaclick) (Epinephrine) (Epinephrine) (Ethanolamine Oleate) (Hydralazine HCl) (Hydralazine HCl) 100
LANOXIN ORAL TABLET 187.5 MCG LANOXIN ORAL TABLET 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml norepinephrine bitartrate intravenous solution 1 mg/ml papaverine injection solution 30 mg/ml papaverine oral capsule, extended release 150 mg RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg (Milrinone Lactate/D5W) (Milrinone Lactate) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl) (Adalat CC) (Norvasc) (Lotrel) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days); AGE (Max 64 Years) (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA PA 101
amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-160 mg, 5- (Exforge) 320 mg amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, (Exforge HCT) 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 MG CLEVIPREX INTRAVENOUS EMULSION 50 MG/100 ML felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg (Felodipine) isradipine oral capsule 2.5 mg, 5 mg (Isradipine) nicardipine oral capsule 20 mg, 30 mg (Nicardipine HCl) nifedical xl oral tablet extended release 24hr 30 mg, 60 mg (Procardia XL) nifedipine er 30 mg tablet f/c 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) Diuretics amiloride oral tablet 5 mg (Amiloride HCl) amiloride-hydrochlorothiazide oral (Amiloride/Hydroc tablet 5-50 mg hlorothiazide) bumetanide injection solution 0.25 mg/ml (Bumetanide) bumetanide oral tablet 0.5 mg, 1 mg, 2 mg (Bumetanide) chlorothiazide oral tablet 250 mg, 500 mg (Chlorothiazide) chlorothiazide sodium intravenous recon soln 500 mg (Sodium Diuril) ST 102
chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG furosemide injection solution 10 mg/ml (Furosemide) furosemide injection syringe 10 mg/ml (Furosemide) furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) (Furosemide) furosemide oral tablet 20 mg, 40 mg, 80 mg (Lasix) hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 (Hydrochlorothiazi mg, 25 mg, 50 mg de) indapamide oral tablet 1.25 mg, 2.5 mg (Indapamide) methyclothiazide oral tablet 5 mg (Methyclothiazide) metolazone oral tablet 10 mg, 2.5 mg, 5 mg (Zaroxolyn) torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg (Demadex) triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 50-25 mg (Dyazide) triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 mg (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 (Caduet) mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Lipitor) 103
cholestyramine light oral powder 4 (Cholestyramine/A gram spartame) cholestyramine light oral powder in packet 4 gram (Questran) cholestyramine packet 4 gram (Questran) colestipol hcl granules packet 5 gram (Colestid) colestipol oral granules 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) endur-acin sr 500 mg tablet 500 mg * (Slo-Niacin) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 (Lofibra) mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg (Tricor) fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg (Lofibra) fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 (Trilipix) mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor) niacin 50 mg tablet 50 mg * (Slo-Niacin) niacin 500 mg capsule sa 500 mg * (Niacin) PA PA; QL (4 per 28 days) QL (30 per 30 days) 104
niacin 500 mg tablet 500 mg * (Slo-Niacin) niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg (Niaspan) niacin tr 500 mg caplet caplet 500 mg * (Slo-Niacin) niacinamide 500 mg tablet 500 mg * (Niacinamide) niacor oral tablet 500 mg (Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML PRALUENT SYRINGE SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg (Pravachol) prevalite oral powder 4 gram (Cholestyramine/A spartame) prevalite packet outer 4 gram (Cholestyramine/A spartame) REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Crestor) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg (Zocor) PA; QL (2 per 28 days) PA; QL (2 per 28 days) PA; QL (3.5 per 28 days) PA; QL (3 per 28 days) PA; QL (3 per 28 days) 105
simvastatin oral tablet 80 mg (Zocor) QL (30 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG Renin-Angiotensin- Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) spironolactone oral tablet 100 mg, 25 mg, 50 mg (Aldactone) spironolacton-hydrochlorothiaz oral (Aldactazide) tablet 25-25 mg Vasodilators BIDIL ORAL TABLET 20-37.5 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg (Isochron) isosorbide dinitrate oral tablet extended release 40 mg (Isochron) isosorbide dinitrate sublingual (Isosorbide tablet 2.5 mg, 5 mg Dinitrate) isosorbide mononitrate oral tablet (Isosorbide 10 mg, 20 mg Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg (Imdur) minitran transdermal patch 24 hour QL (30 per 30 days) (Nitro-Dur) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 days) (Nitro-Dur) 0.4 mg/hr minoxidil oral tablet 10 mg, 2.5 mg (Minoxidil) 106
NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml) nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG caffeine citrated intravenous solution 60 mg/3 ml (20 mg/ml) caffeine citrated oral solution 60 mg/3 ml (20 mg/ml) caffeine-sodium benzoate injection solution 250 mg/ml (125 mg/ml caffeine) (Nitroglycerin/D5 W) (Nitroglycerin) (Nitrostat) (Nitro-Dur) (Nitro-Dur) (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) QL (30 per 30 days) QL (60 per 30 days) PA; QL (60 per 30 days) 107
clonidine hcl oral tablet extended release 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg flumazenil intravenous solution 0.1 mg/ml guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml methylphenidate cd 20 mg cap 20 mg methylphenidate cd 40 mg cap 40 mg (Kapvay) (Focalin) (Dexedrine) (Dexedrine) (Adderall XR) (Adderall XR) (Adderall) (Romazicon) (Intuniv) (Lithium Carbonate) (Lithobid) (Lithobid) (Lithium Citrate) (Metadate Cd) (Metadate Cd) QL (60 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 108
methylphenidate oral capsule, er biphasic 30-70 10 mg, 50 mg, 60 mg (Metadate Cd) methylphenidate oral capsule, er biphasic 30-70 30 mg (Metadate Cd) methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg (Metadate Cd) methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml (Methylin) methylphenidate oral tablet 10 mg, 20 mg, 5 mg (Ritalin) methylphenidate oral tablet (Methylphenidate extended release 10 mg, 20 mg HCl) methylphenidate oral tablet extended release 24hr 18 mg, 27 (Concerta) mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg (Concerta) NUEDEXTA ORAL CAPSULE 20-10 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Contraceptives QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) 109
Contraceptives AFTERA 1.5 MG TABLET 1.5 MG * 3 $0 altavera (28) oral tablet 0.15-0.03 mg (Amethyst) alyacen 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (Seasonique) (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) apri oral tablet 0.15-0.03 mg (Desogen) aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) aubra oral tablet 0.1-20 mg-mcg (Amethyst) aviane oral tablet 0.1-20 mg-mcg (Amethyst) azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) balziva (28) oral tablet 0.4-35 mgmcg (Modicon) bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) blisovi fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) QL (6 per 365 days) QL (91 per 84 days) QL (91 per 84 days) 110
briellyn oral tablet 0.4-35 mg-mcg (Modicon) camila oral tablet 0.35 mg (Nor-Q-D) camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) (Seasonique) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg (Desogen) cryselle (28) oral tablet 0.3-30 mgmcg Estradiol) (Norgestrel-Ethinyl cyclafem 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) cyred oral tablet 0.15-0.03 mg (Desogen) dasetta 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (Seasonique) (7) deblitane oral tablet 0.35 mg (Nor-Q-D) delyla (28) oral tablet 0.1-20 mgmcg (Amethyst) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg (Desogen) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg (Yaz) econtra ez 1.5 mg tablet inner 1.5 mg * (Aftera) QL (91 per 84 days) QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) 111
elinest oral tablet 0.3-30 mg-mcg (Norgestrel-Ethinyl Estradiol) ELLA ORAL TABLET 30 MG QL (6 per 365 days) emoquette oral tablet 0.15-0.03 mg (Desogen) enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) enskyce oral tablet 0.15-0.03 mg (Desogen) errin oral tablet 0.35 mg (Nor-Q-D) estarylla oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) fallback solo 1.5 mg tablet inner 1.5 QL (6 per 365 days) (Aftera) mg * falmina (28) oral tablet 0.1-20 mgmcg (Amethyst) gianvi (28) oral tablet 3-0.02 mg (Yaz) gildagia oral tablet 0.4-35 mg-mcg (Modicon) gildess 1.5/30 (21) oral tablet 1.5-30 (Loestrin) mg-mcg gildess 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) gildess fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) gildess fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) heather oral tablet 0.35 mg (Nor-Q-D) introvale oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) jencycla oral tablet 0.35 mg (Nor-Q-D) jolessa oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) jolivette oral tablet 0.35 mg (Nor-Q-D) juleber oral tablet 0.15-0.03 mg (Desogen) junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) 112
junel 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) kelnor 1/35 (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) kurvelo oral tablet 0.15-0.03 mg (Amethyst) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) (Seasonique) larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) larin 1/20 (21) oral tablet 1-20 mgmcg (Loestrin) larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) larin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) larissia oral tablet 0.1-20 mg-mcg (Amethyst) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg (Modicon) lessina oral tablet 0.1-20 mg-mcg (Amethyst) levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) QL (91 per 84 days) 113
levonor-eth estrad 0.15-0.03 outer QL (91 per 84 days) (Amethyst) 0.15-0.03 mg levonorgestrel 1.5 mg tablet (otc) QL (6 per 365 days) (Aftera) 1.5 mg * levonorgestrel oral tablet 0.75 mg (Plan B One-Step) QL (12 per 365 days) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (Amethyst) levonorgestrel-ethinyl estrad oral QL (91 per 84 days) tablets,dose pack,3 month 0.15 mg- 30 mcg (Amethyst) levonorg-eth estrad triphasic oral QL (91 per 84 days) tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) levora-28 oral tablet 0.15-0.03 mg (Amethyst) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) loryna (28) oral tablet 3-0.02 mg (Yaz) low-ogestrel (28) oral tablet 0.3-30 (Norgestrel-Ethinyl mg-mcg Estradiol) lutera (28) oral tablet 0.1-20 mgmcg (Amethyst) lyza oral tablet 0.35 mg (Nor-Q-D) marlissa oral tablet 0.15-0.03 mg (Amethyst) microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg (Loestrin) microgestin 1/20 (21) oral tablet 1-20 mg-mcg (Loestrin) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) (Loestrin Fe) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) (Loestrin Fe) mono-linyah oral tablet 0.25-35 mgmcg (Ortho-Cyclen) 114
mononessa (28) oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) my way 1.5 mg tablet (otc) 1.5 mg * (Aftera) QL (6 per 365 days) myzilra oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg (Modicon) necon 1/35 (28) oral tablet 1-35 mgmcg (Modicon) necon 1/50 (28) oral tablet 1-50 mgmcg (Norinyl 1+50) necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg (Modicon) necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) next choice one dose 1.5 mg tb (otc) QL (6 per 365 days) (Aftera) 1.5 mg * next choice one dose oral tablet 1.5 QL (6 per 365 days) (Plan B One-Step) mg nikki (28) oral tablet 3-0.02 mg (Yaz) nora-be oral tablet 0.35 mg (Nor-Q-D) norethindrone (contraceptive) oral tablet 0.35 mg (Nor-Q-D) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) (Loestrin Fe) norg-ee 0.18-0.215-0.25/0.035 3x28 day regimen 0.18/0.215/0.25 mg-35 (Ortho-Cyclen) mcg (28) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, (Ortho-Cyclen) 0.25-35 mg-mcg norlyroc oral tablet 0.35 mg (Nor-Q-D) 115
nortrel 0.5/35 (28) oral tablet 0.5-35 (Modicon) mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg (Modicon) nortrel 1/35 (28) oral tablet 1-35 mg-mcg (Modicon) nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg (Modicon) NUVARING VAGINAL RING ST; QL (1 per 28 days) 0.12-0.015 MG/24 HR ocella oral tablet 3-0.03 mg (Yaz) ogestrel (28) oral tablet 0.5-50 mgmcg Estradiol) (Norgestrel-Ethinyl opcicon one-step 1.5 mg tablet 1.5 QL (6 per 365 days) (Aftera) mg * option 2 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) orsythia oral tablet 0.1-20 mg-mcg (Amethyst) philith oral tablet 0.4-35 mg-mcg (Modicon) pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg (Modicon) PLAN B ONE-STEP 1.5 MG QL (6 per 365 days) 3 $0 TABLET (OTC) 1.5 MG * portia oral tablet 0.15-0.03 mg (Amethyst) previfem oral tablet 0.25-35 mg-mcg (Ortho-Cyclen) quasense oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) react 1.5 mg tablet 1.5 mg * (Aftera) QL (6 per 365 days) reclipsen (28) oral tablet 0.15-0.03 mg (Desogen) setlakin oral tablets,dose pack,3 (Levonorgestrel- QL (91 per 84 days) month 0.15 mg-30 mcg Ethin Estradiol) sharobel oral tablet 0.35 mg (Nor-Q-D) 116
sprintec (28) oral tablet 0.25-35 mgmcg (Ortho-Cyclen) sronyx oral tablet 0.1-20 mg-mcg (Amethyst) syeda oral tablet 3-0.03 mg (Yaz) tarina fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) (Loestrin Fe) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) (Loestrin Fe) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg (Ortho-Cyclen) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) (Ortho-Cyclen) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10) (Amethyst) velivet triphasic regimen (28) oral tablet 0.1/.125/.15-25 mg-mcg (Desogen) vestura (28) oral tablet 3-0.02 mg (Yaz) vienva oral tablet 0.1-20 mg-mcg (Amethyst) viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x 5 (Mircette) 117
vyfemla (28) oral tablet 0.4-35 mgmcg (Modicon) wera (28) oral tablet 0.5-35 mg-mcg (Modicon) xulane transdermal patch weekly 150-35 mcg/24 hr (Ortho Evra) zarah oral tablet 3-0.03 mg (Yaz) zenchent (28) oral tablet 0.4-35 mgmcg (Modicon) zovia 1/35e (28) oral tablet 1-35 mg-mcg (Demulen 1-50-21) zovia 1/50e (28) oral tablet 1-50 mg-mcg (Demulen 1-50-21) Cough And Cold Products Cough And Cold Products 15dm-5peh-2cpm liquid strawberry 2-5-15 mg/5 ml * 25cpd-200gfn liquid 25-200 mg/5 ml * 30pse-150gfn-15dm liquid 30-15- 150 mg/5 ml * 30pse-3brm-15dm oral liquid 3-30- 15 mg/5 ml * 3brm-15dm-30pse liquid 3-30-15 mg/5 ml * 3brm-30dm-50pse liquid (otc) 3-50- 30 mg/5 ml * 50pse-3brm-30dm oral liquid 3-50- 30 mg/5 ml * actinel pediatric liquid 15-5-50 mg/5 ml * adt robitussin linger cold syr 15 mg/5 ml * adt robitussin peak cld dm max 10-200 mg/5 ml * (Chlorpheniramine/ Phenyleph/Dm) (Vanacof G) (Trispec Pse) (Neo Dm) (Neo Dm) (Neo Dm) (Neo Dm) (Trispec Pse) (Dextromethorphan Hbr) (G-Zyncof) QL (3 per 28 days) 118
adult robitussin peak cold liq nondrowsy 10-100 mg/5 ml * (G-Zyncof) adult wal-tussin dm max liq (G-Zyncof) a/f,cherry menthol 10-200 mg/5 ml * adult wal-tussin dm syrup (Cough Formula a/f,cherry,adult 10-100 mg/5 ml * Dm) (Robitussin adult wal-tussin liquid 100 mg/5 ml Mucus-Chest * Congest) alka-seltzer plus mucus-conges 10- (Guaifenesin/Dextr 200 mg * omethorphan) ambi 10peh-4cpm-20dm tablet 4-10- (Chlorpheniramine/ 20 mg * Phenyleph/Dm) ambi 20dm-4cpm tablet 4-20 mg * (Coricidin Hbp) ambi 40pse-400gfn-20dm tablet 40-20-400 mg * (Poly-Vent Dm) ambi 60pse-4cpm-20dm tablet 4-60- (Chlorpheniramin/ 20 mg * Pseudoephed/Dm) benzonatate 100 mg capsule 100 mg * (Zonatuss) 3 $0 benzonatate 150 mg capsule 150 mg * (Zonatuss) 3 $0 benzonatate 200 mg capsule 200 mg * (Zonatuss) 3 $0 bio-dtuss dmx liquid 1-30-20 mg/5 ml * (Neo Dm) bionel pediatric liquid 15-5-50 mg/5 ml * (Trispec Pse) biospec dmx liquid 15-25 mg/5 ml * (G-Zyncof) bp 8 cough oral suspension a/f, (Guaifenesin/Dm/P grape (otc) 30-15-175 mg/5 ml * seudoephedrine) bpm-pse-dm liquid a/f, cotton candy (otc) 4-20-20 mg/5 ml * (Neo Dm) bromfed dm cough syrup 2-30-10 (Brompheniramine/ mg/5 ml * Pseudoephed/Dm) 3 $0 119
bromphenir-pseudoephed-dm syr (rx) 2-30-10 mg/5 ml * brom-pse-dm cough syrup butter scotch (otc) 2-30-10 mg/5 ml * centergy dm pediatric drops 1-2-3 mg/ml * cheracol d cough formula 10-100 mg/5 ml * cheratussin dac syrup 30-10-100 mg/5 ml * child sudafed pe cough-cold lq 2.5-5 mg/5 ml * child triaminic cgh-congst syr 5-100 mg/5 ml * child wal-tussin 7.5 mg odt 7.5 mg * children's mucinex cough liq a/f 5-100 mg/5 ml * children's silfedrine liq 15 mg/5 ml * childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f 15 mg/5 ml * chl mucinex chest congest liq a/f 100 mg/5 ml * chld triaminic cgh-sor thr sus 160-5 mg/5 ml * codituss dm syrup 8.33-5-10 mg/5 ml * cold multi-symptom day-night pseudoephedrine-free 2-5-10-325 mg * cold relief multi-symp caplet cplt,12 day,12 night 2-5-10-325 mg * (Brompheniramine/ Pseudoephed/Dm) (Brompheniramine/ Pseudoephed/Dm) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Tusnel C) (Dextromethorphan /Phenylephrine) (Cough Formula Dm) (Dextromethorphan Hbr) (G-Zyncof) (Pseudoephedrine HCl) (Pseudoephedrine HCl) (Robitussin Mucus-Chest Congest) (Child Tylenol Plus Cough-Sore) (Pyrilamine/Pe/De xtromethorphan) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pe/Acetaminop hen/chlorph) 120
cold-flu relief d/n softgel 10-5- (Vicks Dayquil- 325mg(d)/ 15-325-6.25mg * Nyquil) (Dcold-flu relief liquid 12.5-30-1,000 Methorphan/Aceta mg/30 ml * min/doxylamn) congestac tablet 60-400 mg * (Poly-Vent Ir) congest-eze 60-400 mg caplet 60-400 mg * (Poly-Vent Ir) (Dcoricidin hbp cold-multi sympt 6.25- Methorphan/Aceta 15-325 mg/15 ml * min/doxylamn) coricidin hbp softgel 10-200 mg * (Guaifenesin/Dextr omethorphan) cough & cold syrup 5-10-100 mg/5 ml * (Maxiphen Dmx) cough & cold tablet 4-30 mg * (Coricidin Hbp) cvs chest cong relief pe tab 10-400 mg * (Maxiphen) cvs chest congest relief dm tb 20-400 mg * (Allfen Dm) cvs child cold-cough day liq 2.5-5 mg/5 ml * cvs child's chest congest liq 100 mg/5 ml * cvs cough & sore throat susp 160-5 mg/5 ml * cvs daytime-nighttime cold-flu multi-symp,twin pack 6.25-5-10-325 mg/15 ml * cvs tussin cgh 15 mg liq gels nondrowsy, liq gels 15 mg * cvs tussin dm cough-chest liq 10-200 mg/5 ml * (Dextromethorphan /Phenylephrine) (Robitussin Mucus-Chest Congest) (Child Tylenol Plus Cough-Sore) (Dm/Pe/Acetamino phen/doxylamine) (Robitussin) (G-Zyncof) 121
daytime cold & cough liquid 1,000-30 mg/30 ml * daytime cold-flu liquid a/f, glutenfree 5-10-325 mg/15 ml * (Triaminic) (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan daytime cough liquid a/f, gluten-free 5 mg/5 ml * Hbr) daytime-nighttime cough liquid (Dextromethorphan 15mg/15ml(d)/ 12.5-30mg/30ml * Hb/Doxylamine) delsym cough+chest cngst dm lq 5-100 mg/5 ml * (G-Zyncof) despec-dm tablet 30-10-200 mg * (Poly-Vent Dm) dextromethorphan er 30 mg/5 ml 30 mg/5 ml * (Delsym) diabetic tussin dm liquid 10-100 mg/5 ml * (G-Zyncof) diabetic tussin dm max-str liq 10-200 mg/5 ml * (G-Zyncof) ed bron gp liquid 5-100 mg/5 ml * (Despec) entre-cough liquid 30-15-175 mg/5 ml * (Trispec Pse) expectorant 100 mg/5 ml syrup 100 mg/5 ml * expectorant dm cough liquid 20-300 mg/5 ml * expectorant max cough-cold 30-15 mg/5 ml * geri-tussin dm syrup 10-100 mg/5 ml * guaifenesin 200 mg tablet (otc) 200 mg * guaifenesin dac oral solution 30-10- 100 mg/5 ml * (Robitussin Mucus-Chest Congest) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Cough Formula Dm) (Allfen) (Tusnel C) 122
guaifenesin er 600 mg tablet 600 mg * head congestion day-night pack 2-5- 10-325 mg * (Mucinex) (Dm Hb/Pe/Acetaminop hen/chlorph) hydrocodone-chlorphen er susp 10- (Tussionex) 3 $0 8 mg/5 ml * hydrocodone-homatropine 5-1.5 mg (Tussigon) 3 $0 tablet 5-1.5 mg * (Hydrocodone hydromet syrup 5-1.5 mg/5 ml * Bit/Homatrop Me- 3 $0 Br) liquibid d-r tablet 10-400 mg * (Maxiphen) lohist-dm syrup 2-5-10 mg/5 ml * (Ala-Hist Dm) 3 $0 lortuss ex liquid 30-10-100 mg/5 ml (Tusnel C) * mar-cof bp liquid 2-30-7.5 mg/5 ml (Bromphenira/Pseu 3 $0 * doephed/codein) mar-cof cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) 3 $0 M-END DM SYRUP 2-15-15 MG/5 ML * mucus dm 600-30 mg tablet 30-600 (Mucinex Dm) mg * mucus dm max tablet 60-1,200 mg * (Mucinex Dm) mucus relief 400 mg tablet d/f 400 (Allfen) mg * nasal-sinus decongest tab 30 mg * (Sudafed 12-Hour) NEO DM SYRUP 3-50-30 MG/5 ML * neo-tuss liquid 30-200 mg/5 ml * (G-Zyncof) mesehist dm oral syrup 2-15-15 nasohist dm pediatric drops 1-2-3 (Chlorpheniramin/ (Chlorpheniramine/ mg/5 ml * mg/ml * Pseudoephed/Dm) Phenyleph/Dm) 123
NEXAFED 30 MG TABLET 30 MG * night time cold med liquid 6.25-30- 15-500 mg/15 ml * NIGHT TIME COLD-FLU RLF SFTGL SFTGL, MULTI- SYMPTOM 6.25-15-325 MG * night time cough & sore throat 12.5-30-1,000 mg/30 ml * nighttime cough liquid gluten-free, cherry 6.25-15 mg/15 ml * nohist-dm liquid 4-10-15 mg/5 ml * pecgen dmx 125-15 mg/5 ml liq 15-125 mg/5 ml * pedia relief cough-cold liquid a/f, cherry 1-15-5 mg/5 ml * pediacare multi-symt cold liq non drowsy, grape 2.5-5 mg/5 ml * phenylhistine dh liquid (otc) 2-30-10 mg/5 ml * poly-tussin liquid 9.375-10 mg/5 ml * promethazine vc-codeine syrup 6.25-5-10 mg/5 ml * promethazine-codeine syrup 6.25-10 mg/5 ml * promethazine-dm syrup 6.25-15 mg/5 ml * pseudoephed 30 mg/5 ml soln 30 mg/5 ml * (Dm/P- Ephed/Acetaminop h/doxylam) (D- Methorphan/Aceta min/doxylamn) (Dextromethorphan Hb/Doxylamine) (Chlorpheniramine/ Phenyleph/Dm) (G-Zyncof) (Chlorpheniramin/ Pseudoephed/Dm) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine) (Promethazine/Phe nyleph/codeine) (Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Pseudoephedrine HCl) 3 $0 3 $0 3 $0 124
pseudoephedrine 30 mg tablet 30 mg * pseudoephedrine 60 mg tablet exstr, non drowsy (otc) 60 mg * pv flu relief therapy liquid daytime 5-10-325 mg/15 ml * pv night-time softgel multisympt.,softgel 6.25-30-15-325 mg * (Sudafed 12-Hour) (Sudafed 12-Hour) (D- Methorphan/Pe/Ac etaminophen) (Dm/P- Ephed/Acetaminop h/doxylam) pv tussin pe liquid 5-100 mg/5 ml * (Despec) q-tapp dm elixir 1-15-5 mg/5 ml * (Brompheniramine/ Pseudoephed/Dm) (Robitussin q-tussin 100 mg/5 ml solution a/f, Mucus-Chest non-drowsy 100 mg/5 ml * Congest) q-tussin dm syrup 10-100 mg/5 ml * (Cough Formula Dm) ra child plus cough-runny nose pseudoephedrine free 1-5-160 mg/5 ml * ra daytime-nighttime softgel cold-flu relief 10-5-325mg(d)/ 15-325- 6.25mg * ra flu formula gelcap 12.5-5-10-325 mg * ra maximum strength flu tablet 2-15-500 mg * ra mucus relief 400 mg tablet 400 mg * ra multi-symptom cold caplet nighttime,cplt 2-5-10-325 mg * ra tussin dm syrup a/f 10-100 mg/5 ml * (Dextromethorphn/ Acetaminoph/Cp) (Vicks Dayquil- Nyquil) (Dm/Pe/Acetamino ph/diphenhydram) (Coricidin Hbp) (Allfen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Cough Formula Dm) 125
ra tussin max strn cough syrup 15 (Dextromethorphan mg/5 ml * Hbr) refenesen 200 mg tablet 200 mg * (Allfen) refenesen pe caplet 10-400 mg * (Maxiphen) relcof c liquid 6.3-100 mg/5 ml * (M-Clear Wc) 3 $0 REZIRA SOLUTION 60-5 MG/5 ML * 3 $0 robafen 100 mg/5 ml syrup 100 mg/5 ml * robafen cough 15 mg liquidgel nondrowsy,liquidgel 15 mg * robafen-dm syrup 10-100 mg/5 ml * robitussin cough-chest-cong dm 10-200 mg * ROBITUSSIN LONG-ACTING LIQ 1-7.5 MG/5 ML * robitussin pediatric cough syp a/f,long-acting 7.5 mg/5 ml * rydex liquid 1.3-10-6.3 mg/5 ml * rynex dm liquid a/f, prof use only 1-2.5-5 mg/5 ml * safetussin dm liquid 10-100 mg/5 ml * scot-tussin 100 mg/5 ml liq 100 mg/5 ml * scot-tussin dm s-f liquid 2-15 mg/5 ml * siltussin sa 100 mg/5 ml syr 100 mg/5 ml * (Robitussin Mucus-Chest Congest) (Robitussin) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Bromphenira/Pseu doephed/codein) (Brompheniram/Ph enylephrine/dm) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) 126
sm adult nasal decongestant lq 15 mg/5 ml * sm childrens plus cold susp grape,multi-symptom 1-2.5-5-160 mg/5 ml * sm cold-cough child elixir 1-15-5 mg/5 ml * sm cough & runny nose liquid 1-5 mg/5 ml * sm cough-head congestion lq 20-10- 66.7 mg/5 ml * sm flu severe cold-congestion maximum strength 4-60-30-1,000 mg * sm mucus relief cough liquid childrens, a/f 5-100 mg/5 ml * sm nite time cold-flu liquid 7.5-60- 30-1,000 mg/30 ml * sm nite time cold-flu rel sfgl softgel 6.25-30-15-325 mg * sm pain reliever cold caplet 2-30- 15-325 mg * sm pedia relief liquid 1-15-5 mg/5 ml * sm severe cold m-s caplet 30-15-500 mg * sm tussin cf syrup 30-10-100 mg/5 ml * sudafed 30 mg tablet nondrowsy,max-str 30 mg * sudogest 30 mg tablet boxed 30 mg * (Pseudoephedrine HCl) (Dm Hb/Pe/Acetaminop hen/chlorph) (Brompheniramine/ Pseudoephed/Dm) (Vicks Children'S Nyquil) (Trispec Pse) (Dm Hb/Pseudoephed/A cetamin/cp) (G-Zyncof) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm/P- Ephed/Acetaminop h/doxylam) (Dm Hb/Pseudoephed/A cetamin/cp) (Chlorpheniramin/ Pseudoephed/Dm) (Dm/Pseudoephed/ Acetaminophen) (Guaifenesin/Dm/P seudoephedrine) (Sudafed 12-Hour) (Sudafed 12-Hour) 127
sudogest 60 mg tablet 60 mg * (Sudafed 12-Hour) suphedrin liquid 15 mg/5 ml * (Pseudoephedrine HCl) suphedrine pe combo pack cplt 5- (Diphenhydram/Pe/ 10-325 mg * Dm/Acetamin/Gg) THERAFLU COLD AND COUGH POWDER 10-20-650 MG * THERAFLU MULTI-SYMP COLD CPLT 5-10-325 MG * TRIAMINIC COUGH-SORE THROAT LQ A/F,CHILDREN'S 160-5 MG/5 ML * triaminic daytime cold-cough (Dextromethorphan children's, cherry 2.5-5 mg/5 ml * /Phenylephrine) tri-dex pe oral syrup 2-10-15 mg/5 (Chlorpheniramine/ ml * Phenyleph/Dm) trymine cg liquid 7.5-225 mg/5 ml * (M-Clear Wc) tusnel diabetic liquid (otc) 10-100 mg/5 ml * (G-Zyncof) TUSNEL LIQUID A/F,A/F,D/F 30-15-200 MG/5 ML * TUSNEL PEDIATRIC LIQUID (RX) 15-5-50 MG/5 ML * TUSSI PRES-B LIQUID 4-10-30 MG/5 ML * tussin cf cough-cold syrup a/f 5-10- 100 mg/5 ml * (Maxiphen Dmx) tussin cold-congestion gelcap liquid (Guaifenesin/Dm/P gelcap 30-10-200 mg * seudoephedrine) tussin dm syrup 15-100 mg/5 ml * (Cough Formula Dm) VANACOF LIQUID 1-30-12.5 MG/5 ML * vicks dayquil cough liquid a/f,8 hr (Dextromethorphan rlf 5 mg/5 ml * Hbr) 128
vicks dayquil liquicaps cold & flu 5-10-325 mg * vicks nature fusion cough liq 5 mg/5 ml * vicks nyquil severe cold-flu 6.25-5- 10-325 mg/15 ml * virdec dm drops 1-3.5-3 mg/ml * (D- Methorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (Dm/Pe/Acetamino phen/doxylamine) (Chlorpheniramine/ Phenyleph/Dm) virtussin ac liquid 10-100 mg/5 ml * (M-Clear Wc) v-r infant non-asa cold drp 15-5-160 (Dm/Pseudoephed/ mg/1.6 ml * Acetaminophen) v-r non-aspirin flu gelcap gelatin (Dm/Pseudoephed/ caplet 30-15-500 mg * Acetaminophen) v-r pedia relief inf drops (Dextromethorphan decongestant + 7.5-2.5 mg/0.8 ml * /Pseudoephed) vr triacting cold-cough liq 1-15-5 (Chlorpheniramin/ mg/5 ml * Pseudoephed/Dm) v-r tussin cf syrup 30-10-100 mg/5 (Guaifenesin/Dm/P ml * seudoephedrine) wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour) wal-phed pe day-night combo pk (Diphenhydram/Pe/ gluten-free 5-10-325 mg * Dm/Acetamin/Gg) wal-tussin cough 15 mg softgel 15 mg * (Robitussin) wal-tussin cough 15 mg/5 ml 15 (Dextromethorphan mg/5 ml * Hbr) wal-tussin cough-cold cf liq pseudoephedrine free 5-10-100 (Maxiphen Dmx) mg/5 ml * zephrex-d 30 mg tablet 30 mg * (Sudafed 12-Hour) ZONATUSS 150 MG CAPSULE 150 MG * 3 $0 129
zyncof 20-400 mg/5 ml liquid 20-400 mg/5 ml * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous membrane mouthwash 0.12 % oralone dental paste 0.1 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % triamcinolone acetonide dental paste 0.1 % (Peridex) (Triamcinolone Acetonide) (Peridex) (Salagen) (Triamcinolone Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg (Soriatane) acne medication 10% lotion 10 % * (Benzoyl Peroxide) ACNE MEDICATION 5% LOTION 5 % * acneclear gel 10 % * (Benzoyl Peroxide) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 days) ALCOHOL PADS TOPICAL PADS, MEDICATED ALCOHOL PREP PADS amlactin 12% lotion 12 % * (Ammonium Lactate) 130
ammonium lactate 12% cream (Ammonium fragrance free (otc) 12 % * Lactate) ammonium lactate 12% lotion (otc) (Ammonium 12 % * Lactate) ammonium lactate topical cream 12 % (Lac-Hydrin) ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE TOPICAL OINTMENT 10 % benzoyl peroxide 10% gel aqueous (otc) 10 % * (Benzoyl Peroxide) benzoyl peroxide 5% gel aqueous (otc) 5 % * (Benzoyl Peroxide) BETADINE 5% SPRAY 5 % * calcipotriene scalp solution 0.005 % (Calcipotriene) calcipotriene topical cream 0.005 % (Dovonex) calcipotriene topical ointment 0.005 % (Calcipotriene) calcitrene topical ointment 0.005 % (Calcipotriene) calcitriol topical ointment 3 mcg/gram (Vectical) CASTELLANI PAINT MODIFIED 1.5 % * CONDYLOX TOPICAL GEL 0.5 % COSENTYX (150 MG/ML) 300 MG DOSE-2 PENS 150 MG/ML COSENTYX (150 MG/ML) 300 MG DOSE-2 SYRINGES 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML PA PA PA 131
COSENTYX SUBCUTANEOUS PA SYRINGE 150 MG/ML cvs skin treatment body lotion 12 % (Ammonium * Lactate) fluorouracil topical cream 0.5 %, 5 (Carac) % fluorouracil topical solution 2 %, 5 (Fluorouracil) % (Ammonium geri-hydrolac 12% lotion 12 % * Lactate) (Ammonium geri-hydrolac 5% lotion 5 % * Lactate) imiquimod topical cream in packet 5 PA NSO; QL (24 per (Aldara) % 30 days) LACTINOL HX CREAM * lobana bath oil * (Mineral Oil) methoxsalen rapid oral capsule 10 (Oxsoralen-Ultra) mg PANRETIN TOPICAL GEL 0.1 % persa-gel 10% 12's,max-strength 10 (Benzoyl Peroxide) % * PICATO TOPICAL GEL 0.015 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) (Podophyllum podocon topical liquid 25 % Resin) podofilox topical solution 0.5 % (Condylox) pv acne pimple 10% gel 10 % * (Benzoyl Peroxide) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM TALTZ AUTOINJECTOR PA SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML potassium hydroxide topical (Potassium solution 5 % Hydroxide) 132
TALTZ SYRINGE PA SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL 0.016 % zenatane oral capsule 10 mg, 20 mg, (Isotretinoin) 30 mg, 40 mg zinc oxide 20% ointment 20 % * (Boudreauxs) ZOVIRAX TOPICAL CREAM 5 % QL (15 per 30 days) Dermatological Antibacterials bacitracin 500 unit/gm ointmnt 500 unit/gram * (Bacitracin) bacitraycin plus 500 unit/gm 500 unit/gram * (Bacitracin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 % (Cleocin T) clindamycin phosphate topical swab 1 % (Cleocin T) cvs triple antibiotic ointment 3.5mg- 400 unit- 5,000 unit/gram * ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % (Neomycin Su/Bacitrac Zn/Poly) (Erythromycin Base/Ethanol) (Erygel) (Erythromycin Base/Ethanol) (Erythromycin Base/Ethanol) 133
gentamicin topical cream 0.1 % (Gentamicin Sulfate) gentamicin topical ointment 0.1 % (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical gel 0.75 %, 1 % (Rosadan) metronidazole topical lotion 0.75 % (Metrolotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation (Neosporin G.U. solution 40 mg-200,000 unit/ml Irrigant) (Neomycin neosporin ointment 3.5mg-400 unit- Su/Bacitrac 5,000 unit/gram * Zn/Poly) rosadan topical cream 0.75 % (Metrocream) selenium sulfide topical lotion 2.5 % (Selenium Sulfide) selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) silver nitrate topical ointment 10 % (Silver Nitrate) silver nitrate topical solution 0.5 %, 10 %, 25 %, 50 % (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % (Silvadene) sulfacetamide sodium (acne) topical suspension 10 % triple antibiotic ointment carton 3.5mg-400 unit- 5,000 unit/gram * (Klaron) (Neomycin Su/Bacitrac Zn/Poly) Dermatological Anti- Inflammatory Agents ala-cort topical cream 1 % (Anusol-HC) ala-scalp topical lotion 2 % (Scalacort) 134
(Alclometasone alclometasone topical cream 0.05 % Dipropionate) alclometasone topical ointment 0.05 (Alclometasone % Dipropionate) aquanil hc 1% lotion 1 % * (Cortizone-10) beta hc 1% lotion 1 % * (Cortizone-10) betamethasone valerate topical (Luxiq) foam 0.12 % betamethasone, augmented topical (Diprolene AF) cream 0.05 % betamethasone, augmented topical (Diprolene) lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) (Clobetasol clobetasol scalp solution 0.05 % Propionate) clobetasol topical foam 0.05 % (Olux) (Clobetasol clobetasol topical gel 0.05 % Propionate) clobetasol topical lotion 0.05 % (Clobex) betamethasone dipropionate topical betamethasone dipropionate topical betamethasone dipropionate topical betamethasone valerate topical betamethasone valerate topical betamethasone valerate topical betamethasone, augmented topical (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone (Betamethasone cream 0.05 % lotion 0.05 % ointment 0.05 % cream 0.1 % lotion 0.1 % ointment 0.1 % gel 0.05 % Dipropionate) Dipropionate) Dipropionate) Valerate) Valerate) Valerate) Dipropionate) 135
clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % (Temovate) clocortolone pivalate topical cream 0.1 % (Cloderm) colocort rectal enema 100 mg/60 ml (Cortenema) cormax scalp solution 0.05 % (Clobetasol Propionate) cortizone-10 1% creme maximum strength 1 % * (Hydrocortisone) CORTIZONE-10 1% LOTION 1 % * cortizone-10 1% ointment 1 % * (Hydrocortisone) dermarest eczema 1% lotion 1 % * (Cortizone-10) desonide topical cream 0.05 % (Desowen) desonide topical ointment 0.05 % (Desonide) desoximetasone topical cream 0.05 %, 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, 0.25 % (Topicort) ELIDEL TOPICAL CREAM 1 % fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel 0.05 % (Fluocinonide) fluocinonide topical ointment 0.05 % (Fluocinonide) fluocinonide topical solution 0.05 % (Fluocinonide) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment 0.005 % (Fluticasone Propionate) halobetasol propionate topical cream 0.05 % (Ultravate) 136
halobetasol propionate topical (Ultravate) ointment 0.05 % hydro skin 1% lotion 1 % * (Cortizone-10) hydrocortisone 0.5% cream (otc) (Hydrocortisone) 0.5 % * hydrocortisone 0.5% ointment 0.5 % (Hydrocortisone) * hydrocortisone 1% cream maximum (Hydrocortisone) strength (otc) 1 % * hydrocortisone 1% cream maximum (Hydrocortisone strength 1 % * Acetate) hydrocortisone 1% lotion (otc) 1 % (Cortizone-10) 3 $0 * hydrocortisone 1% ointment carton (Hydrocortisone) (otc) 1 % * hydrocortisone acet-aloe vera (Hydrocortisone topical gel 2 % Acetate/Aloe V) hydrocortisone buty 0.1% cream 0.1 (Hydrocortisone % Butyrate) hydrocortisone butyrate topical (Locoid) ointment 0.1 % hydrocortisone butyrate topical (Locoid) solution 0.1 % hydrocortisone rectal enema 100 (Cortenema) mg/60 ml hydrocortisone topical cream 1 %, (Anusol-HC) 2.5 % hydrocortisone topical lotion 2.5 % (Scalacort) hydrocortisone topical ointment 1 (Hydrocortisone) %, 2.5 % hydrocortisone butyr-emollient hydrocortisone valerate topical (Hydrocortisone (Hydrocortisone topical cream 0.1 % cream 0.2 % Butyrate) Valerate) 137
hydrocortisone valerate topical ointment 0.2 % (Westcort) mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % (Elocon) neosporin 1% anti-itch cream 1 % * (Hydrocortisone) ONFI ORAL TABLET 10 MG, 20 MG prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) preparation h hc 1% cream 1 % * (Hydrocortisone) procto-med hc topical cream with perineal applicator 2.5 % (Hydrocortisone) procto-pak topical cream with perineal applicator 1 % (Anusol-HC) proctosol hc rectal cream 2.5 % (Hydrocortisone) proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) proctozone-hc topical cream with perineal applicator 2.5 % (Hydrocortisone) recort plus 1% cream 1 % * (Hydrocortisone) tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical (Triamcinolone cream 0.025 %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical (Triamcinolone lotion 0.025 %, 0.1 % Acetonide) triamcinolone acetonide topical (Triamcinolone ointment 0.025 %, 0.1 %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone Acetonide) u-cort topical cream 1-10 % (Hydrocortisone Acetate/Urea) Dermatological Retinoids PA NSO; QL (60 per 30 days) adapalene topical cream 0.1 % (Differin) 138
adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM 0.05 %, 0.1 % tretinoin gel micro 0.04% tube 0.04 PA (Retin-A Micro) % tretinoin gel micro 0.1% tube 0.1 % (Retin-A Micro) PA tretinoin microspheres topical gel PA (Retin-A Micro) with pump 0.04 %, 0.1 % tretinoin topical cream 0.025 %, PA (Retin-A) 0.05 %, 0.1 % tretinoin topical gel 0.01 %, 0.025 PA (Retin-A) %, 0.05 % Scabicides And Pediculicides cvs lice killing shampoo maximum strength 0.33-4 % * (Piperonyl Butoxide/Pyrethrin s) cvs permethrin 1% lotion 1 % * (Nix) malathion topical lotion 0.5 % (Ovide) NIX 1% CREME RINSE LIQUID W/ NIT COMB 1 % * permethrin topical cream 5 % (Elimite) ra lice treatment 1% crm rinse 2x59ml, 2 combs 1 % * (Nix) sm lice treatment permethrin 2's 1 % * (Nix) v-r lice cream rinse 1 % * (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0.3 ML 31GX5/16 0.3 ML 31 GAUGE X 5/16 139
BD INSULIN SYR 0.5 ML 31GX5/16" 0.5 ML 31 GAUGE X 5/16 BD INSULIN SYR 1 ML 31GX5/16" 1 ML 31 GAUGE X 5/16 BD ULTRA-FINE PEN NDL 8MMX31G SHORT 31 GAUGE X 5/16" INSULIN SYRINGE-NEEDLE U- 100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" VGO 40 DISPOSABLE DEVICE Disinfectants (For Non- Dermatologic Use) Disinfectants (For Non- Dermatologic Use) sm iodine tincture * (Iodine) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 140
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 ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG KANUMA INTRAVENOUS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG MYOZYME INTRAVENOUS RECON SOLN 50 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG pancrelipase 5000 oral capsule,delayed release(dr/ec) 5,000-17,000-27,000 unit PULMOZYME INHALATION SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML (Zenpep) PA PA; LA 141
VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68,000-109,000 UNIT, 25,000-85,000-136,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-136,000-218,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC GEL 3.5 % alcaine ophthalmic drops 0.5 % (Proparacaine HCl) altacaine ophthalmic drops 0.5 % (Tetravisc) altamist 0.65% nose spray 0.65 % * (Little Remedies) apraclonidine ophthalmic drops 0.5 % artificial tears 1.4 % drops 1.4 % * artificial tears drops p/f, sterile 0.1-0.3 % * artificial tears eye drops strl 0.1-0.3 % * (Iopidine) (Polyvinyl Alcohol) (Dextran 70/Hypromellose/P F) (Tears Naturale) PA QL (90 per 30 days) 142
artificial tears eye ointment 83-15 % (Genteal Pm) * atropine ophthalmic drops 1 % (Isopto Atropine) atropine ophthalmic ointment 1 % (Atropine Sulfate) atropine-care ophthalmic drops 1 % (Isopto Atropine) ayr saline 0.65% nose drops 0.65 % * (Sodium Chloride) ayr saline 0.65% nose spray 0.65 % * (Little Remedies) azelastine nasal aerosol,spray 137 mcg (0.1 %) (Astepro) azelastine ophthalmic drops 0.05 % (Azelastine HCl) (Dextran bion tears eye drops 0.1-0.3 % * 70/Hypromellose/P F) carteolol ophthalmic drops 1 % (Carteolol HCl) cromolyn ophthalmic drops 4 % (Cromolyn Sodium) cvs artificial tears drops sterile 1- (Glycerin/Propylen 0.3 % * e Glycol) cvs lubricant 0.5% eye drops sterile 0.5 % * (Refresh Tears) cvs lubricant dry eye rlf 1% 1 % * (Carboxymethylcel lulose Sodium) cvs lubricant eye ointment p/f 57.3- (Genteal Pm) 42.5 % * cvs lubricant gel eye drops 0.25-0.3 % * cvs lubricating eye drops dry eye soln 0.5-0.9 % * cvs natural tears drops 0.1-0.3 % * cyclopentolate ophthalmic drops 0.5 %, 1 %, 2 % (Carboxymethylcel l/hypromellose) (Refresh Optive) (Dextran 70/Hypromellose/P F) (Cyclogyl) QL (30 per 25 days) 143
CYSTARAN OPHTHALMIC DROPS 0.44 % deep sea 0.65% nose spray 0.65 % * (Little Remedies) (Oxymetazoline dristan long lasting mist 0.05 % * HCl) epinastine ophthalmic drops 0.05 % (Elestat) (Genteal Mild To eq gentle 0.3% eye drops 0.3 % * Moderate) eq revive plus 0.5% eye drops 0.5 % (Carboxymethylcel * lulose Sodium) flucaine ophthalmic drops 0.25-0.5 (Proparacaine/Fluo % rescein Sod) GENTEAL GEL DROPS 0.25-0.3 % * GENTEAL MILD 0.2% EYE DROPS 0.2 % * GENTEAL MILD-MODERATE EYE DROP P/F, DRY EYE RELIEF 0.3 % * GENTEAL SEVERE 0.3% EYE GEL P/F, STRL, INNER 0.3 % * genteal tears 0.1%-0.3% drop 0.1- (Tears Naturale) 0.3 % * (Isopto homatropaire ophthalmic drops 5 % Homatropine) ipratropium bromide nasal (Atrovent) spray,non-aerosol 0.03 % ipratropium bromide nasal (Atrovent) spray,non-aerosol 0.06 % (Genteal Mild To isopto tears 0.5% eye drops 0.5 % * Moderate) LACRISERT OPHTHALMIC INSERT 5 MG homatropine hbr ophthalmic drops (Isopto 5 % Homatropine) QL (30 per 28 days) QL (15 per 10 days) 144
lubricant 0.5-0.9% eye drops 0.5- (Carboxymethylcel 0.9 % * l/glycerin/pf) lubricant 0.5-0.9% eye drops 0.5- (Refresh Optive) 0.9 % * lubricant 0.6% eye drops 0.6 % * (Propylene Glycol) lubrifresh pm eye ointment 83-15 % (Genteal Pm) * muro-128 2% eye drops 2 % * (Sodium Chloride) muro-128 5% eye drops 5 % * (Sodium Chloride) muro-128 5% eye ointment 5 % * (Sodium Chloride) naphazoline ophthalmic drops 0.1 % (Naphazoline HCl) nasal decongestant 0.05% spray (Afrin) 0.05 % * (Genteal Mild To natural balance tears drops 0.4 % * Moderate) (Genteal Mild To nature's tears drops 0.4 % * Moderate) neo-synephrine 12 hour spray 0.05 (Oxymetazoline % * HCl) ocean 0.65% nasal spray 0.65 % * olopatadine ophthalmic drops 0.1 % (Patanol) PATADAY OPHTHALMIC DROPS 0.2 % phenylephrine hcl ophthalmic drops (Mydfrin) 10 %, 2.5 % proparacaine ophthalmic drops 0.5 (Proparacaine HCl) % pure & gentle eye drops lubricant (Genteal Mild To 0.3 % * Moderate) (Genteal Mild To pv artificial tears 0.4 % * Moderate) pv lubricant 1.4 % eye drops 1.4 % (Polyvinyl * Alcohol) pv pure-gentle eye drops sterile 0.3 (Genteal Mild To % * Moderate) ST 145
REFRESH CELLUVISC 1% EYE DROPS 1 % * REFRESH CLASSIC EYE DROPS U-D,P/F,30X.4ML 1.4-0.6 % * REFRESH LACRI-LUBE OINTMENT 56.8-42.5 % * REFRESH OPTIVE EYE DROPS 0.5-0.9 % * retaine cmc 0.5% eye drops 0.5 % * (Carboxymethylcel lulose Sodium) saline mist 0.65% nose spry 0.65 % * (Little Remedies) sea soft 0.65% nasal mist 0.65 % * (Little Remedies) sm lubricant eye drops strl 0.4-0.3 % * (Systane) sodium chloride 5% eye drop 5 % * (Sodium Chloride) sodium chloride 5% eye oint 5 % * (Sodium Chloride) SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % * SYSTANE GEL EYE DROPS 0.4-0.3 % * tears again 1.4 % drops 1.4 % * (Polyvinyl Alcohol) tears again eye ointment 80-20 % * (Genteal Pm) (Dextran tears naturale free drops u- 70/Hypromellose/P d,36x.9ml,p/f 0.1-0.3 % * F) tetracaine hcl (pf) ophthalmic drops (Tetracaine 0.5 % HCl/PF) ultra fresh pm ointment * (Lanolin/Mineral Oil/Petrolatum) vicks qlearquil 0.05% mist 0.05 % * (Oxymetazoline HCl) vicks sinex 12 hour spray 0.05 % * (Afrin) 146
Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic solution 2 % (Acetic Acid) bacitracin ophthalmic ointment 500 unit/gram (Bacitracin) bacitracin-polymyxin b ophthalmic (Bacitracin/Polymy ointment 500-10,000 unit/gram xin B Sulfate) bleph-10 ophthalmic drops 10 % (Sulfacetamide Sodium) CIPRODEX OTIC DROPS,SUSPENSION 0.3-0.1 % ciprofloxacin hcl ophthalmic drops 0.3 % (Ciloxan) ciprofloxacin hcl otic dropperette 0.2 % (Cetraxal) COLY-MYCIN S OTIC DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML erythromycin ophthalmic ointment 5 mg/gram (0.5 %) (Ilotycin) gatifloxacin ophthalmic drops 0.5 % (Zymaxid) gentak ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) gentamicin ophthalmic drops 0.3 % (Garamycin) gentamicin ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic drops 0.5 % (Levofloxacin) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neomycin Su/Baci ophthalmic ointment 3.5-400-10,000 Zn/Poly/HC) mg-unit/g-1% 147
neomycin-bacitracin-polymyxin ophthalmic ointment 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension 3.5-10,000-10 mgunit-mg/ml neomycin-polymyxin-hc otic drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/mlunit/ml-% neo-polycin hc ophthalmic ointment 3.5-400-10,000 mg-unit/g-1% (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Maxitrol) (Neosporin) (Neomycin/Polymy xin B Sulf/HC) (Neomycin/Polymy xin B Sulf/HC) (Cortisporin) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin neo-polycin ophthalmic ointment Su/Bacitra/Polymy 3.5-400-10,000 mg-unit-unit/g xin) ofloxacin ophthalmic drops 0.3 % (Floxin) ofloxacin otic drops 0.3 % (Floxin) polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml REFRESH OPTIVE ADVANCED DROPS 0.5-1-0.5 % * sulfacetamide sodium ophthalmic drops 10 % (Polytrim) (Sulfacetamide Sodium) 148
sulfacetamide sodium ophthalmic (Sulfacetamide ointment 10 % Sodium) sulfacetamide-prednisolone (Sulfacetamide/Pre ophthalmic drops 10 %-0.23 % dnisolone Sp) (0.25 %) TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION 0.3-0.05 % tobramycin ophthalmic drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic drops,suspension 0.3-0.1 (Tobradex) % trifluridine ophthalmic drops 1 % (Viroptic) VIGAMOX OPHTHALMIC DROPS 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ZYLET OPHTHALMIC DROPS,SUSPENSION 0.3-0.5 % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC DROPS,SUSPENSION 0.2 % bromfenac ophthalmic drops 0.09 % (Bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % DUREZOL OPHTHALMIC DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) (Diclofenac Sodium) (Flunisolide) ST QL (50 per 25 days) 149
fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC DROPS,SUSPENSION 0.3 % ketorolac ophthalmic drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % NEVANAC OPHTHALMIC DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % PROLENSA OPHTHALMIC DROPS 0.07 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % XIIDRA OPHTHALMIC DROPPERETTE 5 % Gastrointestinal Agents Antiflatulents bicarsim forte 125 mg tablet 125 mg * cvs gas relief 125 mg chew tab extra strength 125 mg * (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) (Simethicone) (Gas-X) QL (60 per 30 days) PA; QL (60 per 30 days) 150
cvs gas relief 125 mg softgel softgel 125 mg * (Phazyme) cvs gas relief 80 mg tab chew 80 mg * (Gas-X) gas relief 125 mg chew tablet max str,lactose-free 125 mg * (Gas-X) gas relief 80 mg tablet chew lactosefree 80 mg * (Gas-X) gas-x ultra strength softgel 180 mg * (Phazyme) inf gas rel 20 mg/0.3 ml drop (Simethicone) 20mg/0.3ml, dye free 40 mg/0.6 ml * mi-acid gas 80 mg tab chew 80 mg * (Gas-X) mytab gas 80 mg tablet chew 80 mg * (Gas-X) mytab gas max str 125 mg tab 125 mg * (Gas-X) simethicone 180 mg softgel 180 mg * (Phazyme) v-r anti-gas 166 mg softgel 166 mg * (Phazyme) Antiulcer Agents And Acid Suppressants acid reducer 20 mg tablet maximum strength 20 mg * (Pepcid Ac) amoxicil-clarithromy-lansopraz oral (Prevpac) combo pack 500-500-30 mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Cimetidine) cvs cimetidine 200 mg tablet (otc) 200 mg * (Tagamet Hb) (Rx Product Only) 151
esomeprazole sodium intravenous recon soln 20 mg, 40 mg (Nexium I.V.) famotidine (pf) intravenous solution 20 mg/2 ml (Famotidine) famotidine (pf)-nacl (iso-os) (Famotidine In intravenous piggyback 20 mg/50 ml Nacl,Iso-Osm/PF) famotidine 40 mg/4 ml vial 25's,outer 10 mg/ml (Famotidine) famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) gnp acid reducer 10 mg tablet 10 mg * (Pepcid Ac) lansoprazole dr 15 mg capsule na/f (otc) 15 mg * (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) omeprazole dr 20 mg tablet 20 mg * (Omeprazole) omeprazole mag dr 20.6 mg cap two (Omeprazole 14-days course 20 mg * Magnesium) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg (Prilosec) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) oral capsule 20-1.1 mg-gram pantoprazole intravenous recon soln (Protonix IV) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) PRILOSEC OTC 20.6 MG TABLET OTC 20 MG * pub famotidine 20 mg tablet max strength (otc) 20 mg * (Pepcid Ac) pv acid relief 200 mg tablet 200 mg * (Tagamet Hb) 152
ra omeprazole-bicarb 20-1,100 3x14 day course (otc) 20-1.1 mggram (Zegerid Otc) * ranitidine 150 mg tablet maximum strength (otc) 150 mg * (Zantac) ranitidine 75 mg tablet s/f, sodiumfree 75 mg * (Zantac) ranitidine hcl injection solution 50 (Rx Product Only) (Ranitidine HCl) mg/2 ml (25 mg/ml) ranitidine hcl oral capsule 150 mg, (Rx Product Only) (Ranitidine HCl) 300 mg ranitidine hcl oral syrup 15 mg/ml (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg sucralfate oral suspension 100 mg/ml (Sucralfate) sucralfate oral tablet 1 gram (Carafate) wal-zan 75 mg tablet 75 mg * (Zantac) ZANTAC 150 MG TABLET TWIN PACK(2X45TABS) (OTC) 150 MG * ZANTAC 150 MG TABLET TWIN PK, MAX STRGTH (OTC) 150 MG * ZANTAC 75 MG TABLET 75 MG * Gastrointestinal Agents, Other acid gone antacid liquid 95-358 mg/15 ml * (Gaviscon) almacone liquid 200-200-20 mg/5 (Maalox Maximum ml * almacone-2 liquid 400-400-40 mg/5 ml * Strength) (Maalox Maximum Strength) 153
aluminum hydroxide gel sugar-free 320 mg/5 ml * AMITIZA ORAL CAPSULE 24 MCG, 8 MCG antacid plus x-stren susp 500-450- 40 mg/5 ml * antacid ultra tablet chew 400 mg (1,000 mg) * antacid xtra strength chew tab extra-strength 300 mg (750 mg) * antacid-antigas liquid 200-200-20 mg/5 ml * anti-diarrheal 2 mg caplet caplet 2 mg * bismatrol suspension 262 mg/15 ml * BUPHENYL ORAL TABLET 500 MG calci-chew tablet 500 mg calcium (1,250 mg) * calcium 500 mg chewable tablet tab chew,p/f 500 mg calcium (1,250 mg) * calcium antacid 500 mg chw tab assorted fruit 200 mg calcium (500 mg) * CALCIUM-500 MG TABLET CHEWABLE SOY FREE, YEAST FREE 500-100 MG-UNIT * cal-gest 500 mg tablet chew 200 mg calcium (500 mg) * CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG child soothe 400 mg tab chew 400 mg * (Aluminum Hydroxide) (Maalox Maximum Strength) (Tums) (Tums) (Maalox Maximum Strength) (Imodium A-D) (Pepto-Bismol) (Tums) (Tums) (Tums) (Tums) (Tums) QL (60 per 30 days) 154
children pepto 400 mg tab chew bubble gum, na/f 400 mg * comfort gel max str susp max-str 400-400-40 mg/5 ml * comfort gel suspension regular str, cherry 200-200-20 mg/5 ml * constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml cvs antacid-antigas tab chew 1,000-60 mg * (Tums) (Maalox Maximum Strength) (Maalox Maximum Strength) (Lactulose) (Gastrocrom) (Calcium Carbonate/Simethi cone) cvs anti-diarrheal 2 mg sftgel softgel (Loperamide HCl) 2 mg * cvs anti-diarrheal suspension 262 mg/15 ml * (Pepto-Bismol) cvs loperamide 1 mg/7.5 ml liq mint 1 mg/7.5 ml * (Loperamide HCl) diamode 2 mg tablet outer, f/c 2 mg * (Imodium A-D) dicyclomine oral capsule 10 mg (Bentyl) dicyclomine oral solution 10 mg/5 ml (Dicyclomine HCl) dicyclomine oral tablet 20 mg (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate 2.5-0.025 mg/5 ml HCl/Atropine) diphenoxylate-atropine oral tablet 2.5-0.025 mg (Lomotil) enulose oral solution 10 gram/15 ml (Lactulose) flanax antacid liquid 200-200-20 (Maalox Maximum mg/5 ml * Strength) foaming antacid liquid 95-358 mg/15 ml * (Gaviscon) 155
GATTEX 5 MG 30-VIAL KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gelusil antacid & antigas liq 400-400-40 mg/5 ml * gelusil tablet chewable cool mint 200-200-25 mg * generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0.2 mg/ml glycopyrrolate oral tablet 1 mg, 2 mg imodium a-d 1 mg/7.5 ml liquid mint 1 mg/7.5 ml * IMODIUM A-D 2 MG CAPLET CAPLET 2 MG * kaopectate 262 mg/15 ml susp vanilla flavor 262 mg/15 ml * kionex 15 gm/60 ml suspension 15-19.3 gram/60 ml kionex oral powder (Maalox Maximum Strength) (Almacone) (Lactulose) (Robinul) (Loperamide HCl) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) (Sodium Polystyrene Sulfon/Sorb) lactulose oral solution 10 gram/15 ml (Lactulose) LINZESS ORAL CAPSULE 145 MCG, 290 MCG loperamide 1 mg/5 ml liquid 1 mg/5 ml * (Loperamide HCl) loperamide oral capsule 2 mg (Loperamide HCl) LOTRONEX ORAL TABLET 0.5 MG, 1 MG PA PA QL (30 per 30 days) 156
maalox advanced suspension regular strength 200-200-20 mg/5 ml * MAGNEBIND 300 TABLET 250-300 MG * magnesium 500 mg capsule s/f,na/f 500 mg * magnesium oxide 250 mg tablet 250 mg * magnesium oxide 400 mg tablet s/f,p/f,gluten-free 400 mg * magnesium oxide 500 mg tablet p/f,s/f,lactose-free 500 mg * masanti liquid 400-400-40 mg/5 ml * medi-first pep-t-med tab chew 262 mg * methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg (Maalox Maximum Strength) (Uromag) (Magox 400) (Magox 400) (Magox 400) (Maalox Maximum Strength) (Pepto-Bismol To- Go) (Methscopolamine Bromide) (Metoclopramide HCl) (Metoclopramide HCl) (Reglan) mgo 400 mg tablet 400 mg * (Magox 400) mi acid suspension 200-200-20 (Maalox Maximum mg/5 ml, 400-400-40 mg/5 ml * Strength) mi-acid ds tablet 700-300 mg * (Rolaids) mintox maximum strength susp max (Maalox Maximum str, lemon creme 400-400-40 mg/5 Strength) ml * mintox plus tablet chewable 200- (Almacone) 200-25 mg * 157
mintox suspension mint creme 200- (Maalox Maximum 200-20 mg/5 ml * Strength) MOVANTIK ORAL TABLET 12.5 MG, 25 MG NUTRESTORE ORAL POWDER IN PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG phillips 500 mg caplet 500 mg * (Magox 400) pink bismuth tablet chew 262 mg * (Pepto-Bismol To- Go) ra loperamide 1 mg/7.5 ml susp mint (Loperamide HCl) 1 mg/7.5 ml * ra magnesium 500 mg capsule 500 mg * (Uromag) RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML ri-gel ii suspension 400-400-40 (Maalox Maximum mg/5 ml * Strength) ri-mox suspension 200-200-20 mg/5 (Maalox Maximum ml * Strength) sm foaming antacid tablet chew 80-20 mg * (Gaviscon) sm stomach relief caplet 262 mg * (Bismuth Subsalicylate) sodium bicarb 650 mg tablet 10 gr (Sodium 650 mg * Bicarbonate) QL (30 per 30 days) PA; QL (30 per 30 days) PA PA; QL (90 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 158
sodium polystyrene (sorb free) oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml soothe 262 mg caplet caplet 262 mg * soothe 262 mg/15 ml suspension s/f,cherry 262 mg/15 ml * sps (with sorbitol) oral suspension 15-20 gram/60 ml (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Bismuth Subsalicylate) (Pepto-Bismol) (Sodium Polystyrene Sulfon/Sorb) ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg, 500 mg (Urso) VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives alophen pills 5 mg * (Dulcolax) bisac-evac 10 mg suppository 10 mg (Dulcolax) * bisacodyl 10 mg suppository 10 mg * (Dulcolax) bisacodyl ec 5 mg tablet 5 mg * (Dulcolax) biscolax 10 mg suppository 10 mg * (Dulcolax) BLADDER CONTROL PAD X- LONG 9'S,X-LONG * COLACE 100 MG CAPSULE 100 MG * cvs enema disposable 19-7 gram/118 ml * cvs fiber therapy 500 mg caplt soluble, caplet 500 mg * cvs kids 100 mg mini enema 100 mg/5 ml * (Enema) (Citrucel) (Docusate Sodium) ST; QL (60 per 30 days) 159
cvs purelax powder 14 once-daily (Gavilax) doses 17 gram/dose * cvs purelax powder packet s/f, 10 (Miralax) daily doses 17 gram * cvs senna laxative 8.6 mg tab 8.6 mg (Senokot) * cvs stool softener softgel softgel 240 (Surfak) mg * doc-q-lace 100 mg softgel 100 mg * (Colace) docu liquid 50 mg/5 ml 50 mg/5 ml (Docusate Sodium) * docusate sodium 100 mg tablet (Docusate Sodium) crushable 100 mg * docusate sodium-senna tablet 8.6-50 (Sennosides/Docus mg * ate Sodium) docusol mini-enema outer 283 mg * (Docusate Sodium) dok 100 mg softgel softgel 100 mg * (Colace) dok 100 mg tablet 100 mg * (Docusate Sodium) dulcolax ss 100 mg softgel 100 mg * (Colace) enema disposable 19-7 gram/118 ml (Enema) * enema ready to use latex-free 19-7 (Enema) gram/118 ml * enemeez mini enema 5cc tubes, (Docusate Sodium) outer 283 mg/5 ml * enemeez plus mini enema outer 283- (Docusol Plus) 20 mg/5 ml * (Psyllium Seed eq fiber therapy powder * (With Sugar)) equalactin 500 mg tab chew 500 mg (Calcium * Polycarbophil) fiber tablet unboxed 625 mg * (Fibercon) fiber therapy (psyllium) oral powder (Psyllium Seed) * 160
fiber therapy powder 2 gram/19 gram * (Citrucel) fiber-lax captabs 500mg polycarbophil 625 mg * (Fibercon) fibertab oral tablet 625 mg * (Fibercon) FLEET BISACODYL 10 MG ENEMA 10 MG/30 ML * gavilyte-c oral recon soln 240-22.72-6.72-5.84 gram (Golytely) gavilyte-g oral recon soln 236-22.74-6.74-5.86 gram (Golytely) gavilyte-n oral recon soln 420 gram (Nulytely with Flavor Packs) gentlelax powder 30 once-daily doses 17 gram/dose * (Gavilax) glycolax powder 7 doses (otc) 17 gram/dose * (Gavilax) 3 $0 healthylax powder packet 14x17gm, outer 17 gram * (Miralax) hydrocil instant packet * (Psyllium Seed) KONSYL 6 GM PACKET S/F, GLUTEN-F, OUTER 6 GRAM * konsyl fiber 625 mg caplet caplet, s/f (Fibercon) 625 mg * konsyl psyllium fiber packet orange, (Psyllium Husk gluten free 3.4 gram * (With Sugar)) magic bullet 10 mg suppos 10 mg * (Dulcolax) milk of magnesia suspension 400 (Milk Of mg/5 ml * Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 GRAM natural fiber lax powder * (Psyllium Seed (With Sugar)) 161
oral saline laxative liquid s/f, ginger (Na Phos,M-B/Na lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba) peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram, 240-22.72-6.72-5.84 gram (Golytely) peg-electrolyte soln oral recon soln (Nulytely with 420 gram Flavor Packs) peri-colace tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) phillips' lax liqui-gels 100 mg * (Colace) phosphate oral saline laxative s/f, (Na Phos,M-B/Na ginger lemon 7.2-2.7 gram/15 ml * Phos,Di-Ba) polyethylene glycol 3350 oral (Polyethylene powder 17 gram/dose Glycol 3350) polyethylene glycol 3350 oral (Polyethylene powder in packet 17 gram Glycol 3350) polyethylene glycol 3350 powd 14 once-daily doses (otc) 17 gram/dose (Gavilax) * polyethylene glycol 3350 powd 17 grams pkts,outer (otc) 17 gram * (Miralax) polyethylene glycol 3350 powd outer,s/f (otc) 17 gram * (Miralax) promolaxin 100 mg tablet 100 mg * (Docusate Sodium) pv senna 8.6 mg softgel 8.6 mg * (Sennosides) ra enema twin pack 2 x 4.5oz, rtu 19-7 gram/118 ml * (Enema) ra laxative peg 3350 powder 14 once-daily doses 17 gram/dose * (Gavilax) reguloid powder orange * (Psyllium Seed (With Sugar)) senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml * (Sennosides) senexon tablet 8.6 mg * (Senokot) 162
senna 8.8 mg/5 ml syrup a/f, chocolate 8.8 mg/5 ml * (Sennosides) senna-lax 8.6 mg tablet 8.6 mg * (Senokot) senokot-s tablet 8.6-50 mg * (Sennosides/Docus ate Sodium) silace 50 mg/5 ml liquid 50 mg/5 ml * (Docusate Sodium) silace 60 mg/15 ml syrup 60 mg/15 ml * (Docusate Sodium) sm clearlax powder 14 once-daily doses 17 gram/dose * (Gavilax) sm fiber laxative 500 mg cplt 500 mg * (Citrucel) sm fiber smooth powder * (Psyllium Seed) smoothlax powder packet 10 oncedaily doses 17 gram * (Miralax) trilyte with flavor packets oral recon (Nulytely with soln 420 gram Flavor Packs) Phosphate Binders calcium acetate oral capsule 667 mg (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calphron 667 mg tablet 667 mg * (Calcium Acetate) eliphos oral tablet 667 mg (Calcium Acetate) (Calcium magnebind 400 oral tablet 400-200- Carbonate/Mag 1 mg Carb/Fa) PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG 163
Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg (Oxybutynin Chloride) (Oxybutynin Chloride) (Ditropan XL) (Detrol LA) tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg tamsulosin oral capsule,extended release 24hr 0.4 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg (Trospium Chloride) (Trospium Chloride) (Uroxatral) (Flomax) (Terazosin HCl) (Desferal) 164
DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE ORAL CAPSULE 250 MG Hormonal Agents, Stimulant/Replacement/Modif ying Androgens ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) (Sodium Thiosulfate) androxy oral tablet 10 mg (Fluoxymesterone) danazol oral capsule 100 mg, 200 mg, 50 mg (Danazol) oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) PA; QL (30 per 30 days) PA; QL (150 per 30 days) PA; QL (150 per 30 days) 165
testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) testosterone transdermal gel in metered-dose pump 1.25 gram/ actuation (1 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram) testosterone transdermal gel in packet 1 % (50 mg/5 gram) Estrogens And Antiestrogens amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DUAVEE ORAL TABLET 0.45-20 MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr (Depo- Testosterone) (Testosterone Enanthate) (Testim) (Vogelxo) (Androgel) (Testim) (Activella) (Estrace) (Vivelle-Dot) (Climara) PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA; QL (300 per 30 days) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; QL (8 per 28 days); AGE (Max 64 Years) PA-HRM; QL (4 per 28 days); AGE (Max 64 Years) 166
estradiol valerate intramuscular oil 10 mg/ml, 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG (Delestrogen) (Activella) (Estropipate) mimvey lo oral tablet 0.5-0.1 mg (Activella) mimvey oral tablet 1-0.5 mg (Activella) PREMARIN INJECTION RECON SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 0.625 MG/GRAM PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG raloxifene oral tablet 60 mg (Evista) VAGIFEM VAGINAL TABLET 10 MCG Glucocorticoids/Mineraloco rticoids a-hydrocort injection recon soln 100 (Hydrocortisone mg Sod Succinate) betamethasone acet,sod phos injection suspension 6 mg/ml (Celestone) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (1 per 84 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) QL (18 per 28 days) 167
cortisone oral tablet 25 mg (Cortisone Acetate) dexamethasone oral elixir 0.5 mg/5 (Dexamethasone) ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone injection solution 10 mg/ml, 4 mg/ml Sod Phosphate) fludrocortisone oral tablet 0.1 mg (Fludrocortisone Acetate) hydrocortisone oral tablet 10 mg, 20 (Cortef) mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml (Depo-Medrol) methylprednisolone oral tablet 16 (Medrol) mg, 32 mg, 4 mg, 8 mg methylprednisolone oral (Medrol) tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg (Solu-Medrol) methylprednisolone ss 1 gm vl mdv,latex-free 1,000 mg (Solu-Medrol) prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) (Pediapred) prednisone oral solution 5 mg/5 ml (Prednisone) prednisone oral tablet 1 mg, 2.5 mg, (Prednisone) 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg (Prednisone) prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) (Prednisone) 168
SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection suspension 10 mg/ml, 40 mg/ml Pituitary desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,nonaerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED) (Triamcinolone Acetonide) (Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP) QL (15 per 30 days) QL (15 per 30 days) PA PA QL (1 per 84 days) 169
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.5 ML (FNL) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG SANDOSTATIN LAR 10 MG KIT 10 MG SANDOSTATIN LAR 20 MG KIT 20 MG SANDOSTATIN LAR 30 MG KIT 30 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML (Octreotide Acetate) (Sandostatin) (Octreotide Acetate) PA PA PA PA QL (1 per 28 days) 170
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg MEGACE ES ORAL SUSPENSION 625 MG/5 ML megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg (Hydroxyprogester one Caproate) (Depo-Provera) (Medroxyprogester one Acetate) (Provera) (Megace Es) (Aygestin) (Progesterone) (Prometrium) (Levothyroxine Sodium) (Levoxyl) QL (1 per 360 days) QL (10 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) 171
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg (Cytomel) methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG AUBAGIO ORAL TABLET 14 MG, 7 MG azathioprine oral tablet 50 mg (Imuran) azathioprine sodium injection recon (Azathioprine soln 100 mg Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN 500 MG CIMZIA POWDER FOR PA RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS PA SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution (Sandimmune) 250 mg/5 ml cyclosporine modified oral capsule (Neoral) 100 mg, 25 mg, 50 mg cyclosporine modified oral solution (Neoral) 100 mg/ml PA; QL (28 per 28 days) 172
cyclosporine oral capsule 100 mg, (Sandimmune) 25 mg ENBREL SUBCUTANEOUS PA RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS PA SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAPLEX INTRAVENOUS SOLUTION 5 % gengraf oral capsule 100 mg, 25 (Neoral) mg, 50 mg gengraf oral solution 100 mg/ml (Neoral) HUMIRA PEDIATRIC CROHN'S PA START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PA 173
HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 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 HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 2.5 GRAM/25 ML (10 %) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1.2 ML (150 MG/ML) IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil oral capsule 250 mg (Arava) (Cellcept) PA PA PA PA PA; QL (18.76 per 28 days) 174
mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML RIDAURA ORAL CAPSULE 3 MG sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines (Cellcept) (Cellcept) (Myfortic) (Rapamune) (Hecoria) PA PA PA; LA; QL (15 per 28 days) ; QL (120 per 30 days) 175
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG (TICE STRAIN) VIAL LATEX-FREE, OUTER 50 MG BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5-125 MCG/0.5 ML 176
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B 20 MCG/ML VIAL 10'S,ADULT,P/F,OUTER 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION 20-40-40-20 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE 20-40-40-20 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) ; QL (3 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days) 177
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG- LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML IPOL INJECTION SYRINGE 40-8- 32 UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-2.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG 178
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 10 MCG /0.5 ML (FINAL) MENVEO MENCYW-135 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT QL (2 per 365 days) QL (2 per 365 days) 179
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SUSPENSION 2 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS TOXOID,ADSORBED (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension 2-2 lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT - 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML (Tetanus, Diphtheria Tox,Adult) ; QL (3 per 365 days) ; QL (3 per 365 days) 180
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA 25 UNITS/0.5 ML VIAL SDV, OUTER 25 UNIT/0.5 ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Alosetron HCl) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg (Colazal) budesonide oral capsule,delayed,extend.release 3 mg (Entocort EC) QL (2 per 365 days) QL (1 per 365 days) 181
DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet,delayed release (dr/ec) 800 mg Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 (Asacol Hd) % (Acetic Acid) LACTATED RINGERS IRRIGATION SOLUTION ringers irrigation solution (Ringers Solution) sodium chloride irrigation solution (Sodium Chloride 0.9 % Irrig Solution) sorbitol irrigation solution 3 %, 3.3 % (Sorbitol Solution) sorbitol-mannitol urethral solution (Mannitol/Sorbitol 2.7-0.54 g/100 ml Solution) water for irrigation, sterile (Water For irrigation solution Irrigation,Sterile) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation (Alendronate Sodium) (Fosamax) (Fosamax) (Miacalcin) ST QL (300 per 28 days) QL (4 per 28 days) QL (3.7 per 28 days) 182
calcitriol intravenous solution 1 mcg/ml (Calcitriol) calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 mcg/2 ml (Doxercalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg (Hectorol) FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 PA; QL (2.4 per 28 days) MCG/2.4 ML FORTICAL NASAL SPRAY,NON- AEROSOL 200 UNIT/ACTUATION QL (3.7 per 28 days) ibandronate intravenous solution 3 (Ibandronate QL (3 per 84 days) mg/3 ml Sodium) ibandronate intravenous syringe 3 QL (3 per 84 days) (Boniva) mg/3 ml ibandronate oral tablet 150 mg (Boniva) QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 2 MCG/ML, 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg (Zemplar) PROLIA SUBCUTANEOUS QL (1 per 180 days) SYRINGE 60 MG/ML risedronate oral tablet 150 mg (Actonel) QL (1 per 28 days) 183
risedronate oral tablet 30 mg, 5 mg (Actonel) QL (30 per 28 days) ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML zoledronic acid intravenous solution 4 mg/5 ml (Zometa) zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml zoledronic acid-mannitol-water intravenous solution 5 mg/100 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML allopurinol oral tablet 100 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg anticoag citrate phos dextrose solution 2.63-222 gram-mg/100ml AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG (Zoledronic Acid/Mannitol- Water) (Reclast) (Zyloprim) (Ethyol) (Citrate Phosphate Dextros Soln) QL (100 per 300 days) PA PA ST 184
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG BETASERON SUBCUTANEOUS KIT 0.3 MG bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg (Urecholine) buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg (Buspirone HCl) CERDELGA ORAL CAPSULE 84 MG CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG colchicine oral tablet 0.6 mg (Colcrys) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML CYSTADANE ORAL POWDER 1 GRAM/1.7 ML droperidol injection solution 2.5 mg/ml (Droperidol) dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg (Jalyn) ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML (Ergoloid Mesylates) ST ST PA ST PA QL (30 per 30 days) PA; LA 185
EXTAVIA SUBCUTANEOUS KIT 0.3 MG finasteride oral tablet 5 mg (Proscar) fomepizole intravenous solution 1 gram/ml (Fomepizole) FUSILEV INTRAVENOUS RECON SOLN 50 MG GAUZE PAD TOPICAL BANDAGE 2 X 2 " GILENYA ORAL CAPSULE 0.5 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG guanidine oral tablet 125 mg (Guanidine HCl) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml (Hydroxyzine HCl) hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg (Hydroxyzine HCl) hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg (Vistaril) KEVEYIS ORAL TABLET 50 MG LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML leucovorin calcium 200 mg vial sdv, p/f, latex-free 200 mg leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg (Leucovorin Calcium) (Leucovorin Calcium) (Leucovorin Calcium) ST QL (28 per 28 days) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA NSO; QL (120 per 30 days) PA 186
levocarnitine (with sugar) oral (Levocarnitine solution 100 mg/ml (With Sugar)) levocarnitine oral tablet 330 mg (Carnitor) levoleucovorin intravenous recon soln 50 mg (Fusilev) mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG MINERAL OIL HEAVY * morrhuate sodium intravenous (Sodium solution 5 % Morrhuate) ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORFADIN ORAL SUSPENSION 4 MG/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) OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML, 7.5 MG/0.4 ML PA PA; QL (60 per 30 days) PA; QL (60 per 30 days) 187
PANTILINERS PAD * PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML probenecid oral tablet 500 mg (Probenecid) probenecid-colchicine oral tablet (Colchicine/Proben 500-0.5 mg ecid) PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG pv extra cleansing douche * (Acetic Acid) pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet extended release 180 mg (Mestinon) qc mineral oil heavy * (Mineral Oil) ra feminine care douche * (Acetic Acid) 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 REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) ST ST 188
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REMICADE INTRAVENOUS RECON SOLN 100 MG sb disp douche extra clns v&w * (Acetic Acid) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML STERILE PADS 2" X 2" 2 X 2 " summer's eve dche-xtra clns 12's,extra-cleansing * (Acetic Acid) summer's eve douche-ultra clns 12's,2pk,ultra clns * (Acetic Acid) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG PA QL (60 per 30 days) PA PA PA PA QL (14 per 30 days) 189
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG topical light mineral oil * (Mineral Oil) QL (60 per 30 days) PA NSO; QL (60 per 30 days) TYBOST ORAL TABLET 150 MG QL (30 per 30 days) ULORIC ORAL TABLET 40 MG, QL (30 per 30 days) 80 MG XELJANZ ORAL TABLET 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg (Diamox Sequels) acetazolamide oral tablet 125 mg, 250 mg (Acetazolamide) acetazolamide sodium injection (Acetazolamide recon soln 500 mg Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % (Betaxolol HCl) bimatoprost ophthalmic drops 0.03 % (Bimatoprost) brimonidine ophthalmic drops 0.15 %, 0.2 % (Alphagan P) PA; QL (60 per 30 days) PA; QL (30 per 30 days) ST (drops: 0.15%, 0.20%) 190
COMBIGAN OPHTHALMIC DROPS 0.2-0.5 % dorzolamide ophthalmic drops 2 % (Trusopt) dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml (Cosopt) latanoprost ophthalmic drops 0.005 % (Xalatan) levobunolol ophthalmic drops 0.25 %, 0.5 % (Betagan) LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25 mg, 50 (Neptazane) mg metipranolol ophthalmic drops 0.3 % (Metipranolol) PHOSPHOLINE IODIDE OPHTHALMIC DROPS 0.125 % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA OPHTHALMIC DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic drops 0.25 %, 0.5 % (Timoptic) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % (Timoptic-Xe) TRAVATAN Z OPHTHALMIC DROPS 0.004 % travoprost (benzalkonium) (Travoprost ophthalmic drops 0.004 % (Benzalkonium)) Replacement Preparations Replacement Preparations calcitrate + vit d caplet 315-250 mg-unit * calcitrate 200 mg (950 mg) tab 200 mg (950 mg) * (Citracal-Vitamin D) (Calcium Citrate) QL (2.5 per 25 days) QL (2.5 per 25 days) QL (2.5 per 25 days) 191
calcium 1,000 + d3 caplet 1,000 mg(2,500 mg)-800 unit * calcium 500+d tablet chew 500 mg(1,250mg) -400 unit * calcium 600 + vit d 400 caplet s/f, p/f, caplet 600 mg(1,500mg) -400 unit * calcium 600 + vit d 400 softgl 600 mg(1,500mg) -400 unit * calcium 600 + vit d tablet 600-125 mg-unit * calcium 600 + vitamin d sftgl rapid release, sftgl 600 mg(1,500mg) -500 unit * calcium 600 mg tablet 600 mg (1,500 mg) * calcium 600+d softgel 600 mg calcium- 200 unit * calcium 600-vit d3 200 tablet 600 mg(1,500mg) -200 unit * calcium 600-vit d3 400 tablet 600 mg(1,500mg) -400 unit * calcium carb 1,250 mg/5 ml sus 500 mg/5 ml (1,250 mg/5 ml) * calcium carbonate 648 mg tab 260 mg calcium (648 mg) * calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) calcium citrate - vit d caplet caplet, coated 315-200 mg-unit * (Caltrate 600 Plus D3) (Calcium 600 + Vit D) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Calcium Carbonate/Vitamin D3) (Calcium Carbonate) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Calcium Carbonate) (Calcium Carbonate) (Calcium Chloride) (Calcium Chloride) (Citracal-Vitamin D) 192
calcium citrate-vit d3 caplet s/f, p/f 315-250 mg-unit * calcium gluconate 500 mg tab 45 mg (500 mg) * calcium gluconate intravenous solution 100 mg/ml (10%) calcium with vit d tablet 600-125 mg-unit * CALTRATE 600 + D SOFT CHEW TAB VANILLA CREME 600 MG (1,500 MG)-800 UNIT * CALTRATE 600 PLUS D3 TABLET 600 MG(1,500MG) -800 UNIT * citracal + d maximum caplet 315-250 mg-unit * citrus calcium + d tablet 315-250 mg-unit * cvs calcium + vitamin d3 sftgl absorbable 600 mg(1,500mg) -500 unit * cvs calcium 500 + vit d 200 tb 500 mg(1,250mg) -200 unit * cvs calcium 500 + vit d tablet oyster shell 500 mg(1,250mg) -125 unit * cvs calcium 600-vit d3 800 tab p/f, s/f,gluten-free 600 mg(1,500mg) - 800 unit * cvs magnesium 250 mg tablet 250 mg * (Citracal-Vitamin D) (Calcium Gluconate) (Calcium Gluconate) (Calcium Carbonate/Vitamin D2) (Citracal-Vitamin D) (Citracal-Vitamin D) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Caltrate 600 Plus D3) (Magnesium) cvs pediatric electrolyte soln * (Pedialyte) cvs pediatric electrolyte soln a/f, p/f * (Pedialyte) 193
d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0.2 % dextrose-kcl-nacl intravenous solution 5-0.224-0.225 % effer-k oral tablet, effervescent 25 meq electrolyte-48 in d5w intravenous parenteral solution eql calcium 600 mg + d softgel 600 mg(1,500mg) -100 unit * gnp calcium 500-vit d3 600 tab 500mg (1,250mg) -600 unit * gnp calcium 600+d3+min chew tb p/f,gluten/f,yeast/f 600 mg calcium- 800 unit-40 mg * (Dextrose 10 % and 0.45 % NaCl) (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 10 % and 0.2 % NaCl) (Dextrose 5%- Lactated Ringers) (Dextrose 5 %-0.2 % NaCl) (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Potassium Chloride/D5-0.2%NaCl) (Klor-Con-Ef) (Electrolyte-48 Solution/D5W) (Calcium Carbonate/Vitamin D3) (Caltrate 600 Plus D3) (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) 194
hm calcium 600+d plus tab chew gluten-free 600 mg calcium- 800 unit-40 mg * hm calcium citrate-vit d cplt caplet, gluten-free 315-250 mg-unit * HYPERLYTE CR INTRAVENOUS SOLUTION 25-20-5-5-30-30 MEQ/20 ML IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-H IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION k-effervescent oral tablet, effervescent 25 meq KELP 150 MCG TABLET 150 MCG * KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq (Ca/D3/Mag Ox/Zinc/Cop/Mang /Bor) (Citracal-Vitamin D) (Klor-Con-Ef) (Potassium Chloride) (Potassium Chloride) 195
klor-con m20 oral tablet,er (Potassium particles/crystals 20 meq Chloride) klor-con sprinkle oral capsule, (Potassium extended release 10 meq, 8 meq Chloride) (Calcium liquid calcium 600-vit d3 sfgl 600 Carbonate/Vitamin mg(1,500mg) -400 unit * D3) liquid calcium 600-vit d3 sfgl (Calcium softgel,p/f,gluten-f 600 mg(1,500mg) Carbonate/Vitamin -500 unit * D3) liquid calcium with vitamin d softgel, s/f, p/f 600 mg calcium- 200 (Calcium Carbonate/Vitamin unit * D3) mag delay dr 64 mg tablet 64 mg * (Slow-Mag) mag64 dr 64 mg tablet 64 mg * (Slow-Mag) mag-g 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium 250 mg tablet 250 mg * (Magnesium) (Magnesium magnesium 300 mg capsule 300 mg Oxide/Mag Aa * Chelate) magnesium chloride injection (Magnesium solution 200 mg/ml (20 %) Chloride) magnesium gluc 500 mg tablet 27 mg (500 mg) * (Magonate) magnesium sulf in 0.45% nacl intravenous solution 20 gram/500 ml (40 mg/ml) magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) 196
magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml natural calcium 500 mg tablet 500 mg calcium (1,250 mg) * NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION (Magnesium Sulfate in Water) (Magnesium Sulfate) (Magnesium Sulfate) (Calcium Carbonate) nu-mag 71.5 mg tablet 71.5 mg * (Slow-Mag) NUTRILYTE II INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML NUTRILYTE INTRAVENOUS SOLUTION 25-40.6-5 MEQ/20 ML oysco 500-vit d3 200 tablet 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oysco d tablet 250-125 mg-unit * (Caltrate 600 Plus D3) oysco-500 tablet 500 mg calcium (Calcium (1,250 mg) * Carbonate) oyster shell 250 mg + vit d tb 250- (Caltrate 600 Plus 125 mg-unit * D3) oyster shell 500-vit d3 200 tb 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) oyster shell calcium 500 mg tb (Calcium 500mg elemental ca 500 mg calcium Carbonate) (1,250 mg) * 197
oyster shell calcium tablet 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) oyster shell calcium-vit d tab (Caltrate 600 Plus p/f,s/f,gluten-free 500 mg(1,250mg) D3) -400 unit * oystercal-d 500 mg-400 unit tb 500 (Caltrate 600 Plus mg(1,250mg) -400 unit * D3) pediatric electrolyte solution * (Pedialyte) PHOS-NAK PACKET 280-160-250 MG * phospha 250 neutral oral tablet 250 mg (K-Phos Neutral) PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous (Potassium solution 2 meq/ml, 4 meq/ml Acetate) potassium bicarb and chloride oral (Pot Chloride/Pot tablet, effervescent 25 meq Bicarb/Cit Ac) potassium bicarb-citric acid oral tablet, effervescent 25 meq (Klor-Con-Ef) potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l (Potassium Chloride/D5-0.45nacl) potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l (Potassium Chloride In 0.9%NaCl) 198
potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l (Potassium Chloride In D5w) (Potassium Chloride In Lr-D5) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con) (Klor-Con 10) (Klor-Con 10) (Potassium Chloride) (Potassium Chloride-0.45% NaCl) (Potassium Chloride/D5-0.2%NaCl) (Potassium Chloride/D5-0.3%NaCl) 199
potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) potassium citrate-citric acid oral packet 3,300-1,002 mg potassium cl 10 meq/50 ml sol 10 meq/50 ml potassium cl 20 meq/50 ml sol 20 meq/50 ml potassium cl er 10 meq tablet 10 meq potassium cl er 10 meq tablet f/c 10 meq potassium cl er 20 meq tablet 20 meq (Potassium Chloride/D5-0.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Klor-Con 10) (Potassium Chloride) (Potassium potassium phosphate m-/d-basic Phos,M-Basic-Dintravenous solution 3 mmol/ml Basic) (Ca/D3/Mag ra cal 600-vit d3-min chew tab 600 Ox/Zinc/Cop/Mang mg calcium- 400 unit-40 mg * /Bor) ra hi-cal plus vitamin d tab 500 (Caltrate 600 Plus mg(1,250mg) -200 unit * D3) (Calcium ra oyster shell-vitamin d tab s/f, p/f Carbonate/Vitamin 250 (625)-125 mg-unit * D2) ra pediatric electrolyte soln a/f * (Pedialyte) ra pediatric freezer pops * (Pedialyte) ringers intravenous parenteral solution sm calcium 600-vit d3 800 tab 600 mg(1,500mg) -800 unit * (Ringers Solution) (Caltrate 600 Plus D3) 200
sm pediatric electrolyte soln * (Pedialyte) sodium acetate intravenous solution 2 meq/ml, 4 meq/ml (Sodium Acetate) sodium bicarbonate intravenous (Sodium solution 1 meq/ml (8.4 %) Bicarbonate) sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (Sodium (0.5 meq/ml), 7.5 % (0.9 meq/ml), Bicarbonate) 8.4 % (1 meq/ml) sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution 0.45 % 0.45 %) sodium chloride 0.9 % intravenous (0.9 % Sodium parenteral solution 0.9 % Chloride) sodium chloride 3 % intravenous (Sodium Chloride parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous parenteral solution 167 meq/l sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV 18-18-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION 35-20-5 MEQ/20 ML virt-phos 250 neutral oral tablet 250 mg 3 %) (Sodium Chloride 5 %) (Sodium Chloride) (Sodium Lactate) (Sodium Lactate) (Sodium Phos,M- Basic-D-Basic) (K-Phos Neutral) 201
v-r calcium 400 + d 133 caplet 400-133.3 mg-unit * Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids 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 BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION (Caltrate 600 Plus D3) QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (12 per 28 days) QL (24 per 28 days) 202
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg (Singulair) montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 (Singulair) mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml (Albuterol Sulfate) (Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER) (Ipratropium Bromide) (Ipratropium/Albut erol Sulfate) QL (21.2 per 28 days) QL (17.4 per 25 days) QL (25.8 per 28 days) QL (8 per 30 days) 203
metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theochron oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg (Metaproterenol Sulfate) (Metaproterenol Sulfate) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) 204
theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) (Theophylline/D5 W) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) (Acetadote) QL (2 per 28 days) acetylcysteine solution 100 mg/ml (Acetadote) (10 %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS PA SOLUTION 10 MG/ML cromolyn inhalation solution for (Cromolyn nebulization 20 mg/2 ml Sodium) cromolyn sodium nasal spray 5.2 (Nasalcrom) mg/spray (4 %) * DALIRESP ORAL TABLET 500 QL (30 per 30 days) MCG ESBRIET ORAL CAPSULE 267 PA; QL (270 per 30 MG days) 205
KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET 200-125 MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG sodium chloride 0.9% inhal vl u-d, suv, p/f (rx) 0.9 % * XOLAIR SUBCUTANEOUS RECON SOLN 150 MG (Pulmosal) 3 $0 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg (Baclofen) carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg (Soma) (Parafon Forte DSC) (Fexmid) (Dantrium) metaxall oral tablet 800 mg (Skelaxin) metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg (Skelaxin) (Robaxin) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; LA; QL (1 per 28 days) PA PA; QL (120 per 30 days) PA PA-HRM; QL (120 per 30 days); AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) PA-HRM; AGE (Max 64 Years) 206
revonto intravenous recon soln 20 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Dantrium) (Zanaflex) tizanidine oral tablet 2 mg, 4 mg (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Nuvigil) (Lunesta) HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg (Sonata) PA QL (30 per 30 days) PA-HRM; QL (30 per 30 days); AGE (Max 64 Years) PA LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) 207
zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents (Ambien CR) ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (Flolan) OPSUMIT ORAL TABLET 10 MG PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA; QL (30 per 30 days) 208
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil intravenous solution 10 mg/12.5 ml (Revatio) sildenafil oral tablet 20 mg (Revatio) TRACLEER ORAL TABLET 125 MG, 62.5 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals PA PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (240 per 30 days) PA; QL (200 per 365 days) 209
a thru z advanced formula tab (Multivitamin/Iron/ gluten-free 18-400 mg-mcg * Folic Acid) a thru z advanced formula tab new (Multivitamin with formula * Minerals/Lut) a thru z select 50+ formula tb advanced formula 0.4-300-250 mgmcg-mcg (Biocel) * a thru z select men 50+ tablet 300-600-300 mcg * (Biocel) a thru z select multivit tab 500-300- 250 mcg * (Biocel) a thru z select tablet adults 50+,iron-free 0.4-300-250 mg-mcgmcg * (Biocel) a thru z select tablet new (Multivitamin with formulation * Minerals/Lut) a thru z select women's tablet * (Mv,Fe,Min/Lutein ) abc plus tablet 0.4-300-250 mgmcg-mcg * (Biocel) adult multi gummies 200 mcg * (One-A-Day Vitacraves) adult one daily gummies 200 mcg * (One-A-Day Vitacraves) adults' 50+ daily formula tab 0.4-300-250 mg-mcg-mcg * (Biocel) adults 50+ multivitamin tablet 0.4-300-250 mg-mcg-mcg * (Biocel) adults' daily formula tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) animal chews tablet * (Multivitamin) antioxidant softgel softgel * (Beta-Carotene(A)- Vits C,E/Mins) apatate forte liquid * (Multivitamin with Minerals) 210
b complete tablet * (Vitamin B Complex) b complex capsule * (Vitamin B Complex) b complex formula #1 tablet * (Vitamin B Complex) b complex tablet * (Vitamin B Complex) b-12 500 mcg tablet 500 mcg * (B-12) b-12 dots 500 mcg tablet 500 mcg * (B-12) balance b-100 tablet * (Vitamin B Complex) balance b-50 tablet * (Vitamin B Complex) balance b-50 tablet inner,p/f,gluten/f (Vitamin B * Complex) balanced b-100 tablet * (Vitamin B Complex) balanced b-100 tablet 100 mg * (Vit B Complex 100 No.3/Herbal) balanced b-50 tablet * (Vitamin B Complex) balanced b-50 tablet * (Vitamin B Complex) balanced b-complex caplet p/f,nolactose 400 mcg * (Dialyvite 800) b-complex plus vitamin c cplt caplet * (Vita-Bee with C) b-complex with b12 tablet * (Vitamin B Complex) b-complex with c tablet * (Vita-Bee with C) b-complex with vit c caplet s/f,p/f,gluten-free 400 mcg * (Dialyvite 800) biosupp liquid * (Multivitamin with Minerals) 211
biotin 300 mcg tablet 300 mcg * (Biotin) biovol syrup * (Multivitamin with Minerals) c complex 500 mg tablet sa 500 mg * (Ascorbic Acid) calcidol drops 8,000 unit/ml * (Drisdol) centamin liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) central-vite seniors tablet * (Multivit with Iron- Minerals) (Multivitcentram-care multivit-min liq 9 mg Minerals/Ferrous iron/15 ml * Gluc) centravites 50 plus tablet * (Multivit with Iron- Minerals) centrum complete multivit tab 18-400 mg-mcg * centrum multivit-mineral liq 9 mg iron/15 ml * centrum silver tablet adults 50 + 0.4-300-250 mg-mcg-mcg * century adults 50+ tablet gluten free 0.4-300-250 mg-mcg-mcg * century mature tablet * cerovite liquid 9 mg iron/15 ml * (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) (Biocel) (Biocel) century ultimate women's tab 18-400 mg-mcg * cerovite advanced form tab 18-400 mg-mcg * (Multivitamin with Minerals/Lut) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivit- Minerals/Ferrous Gluc) 212
certavite sr-antioxidant tab 0.4-300- 250 mg-mcg-mcg * certavite-antioxidant liquid 9 mg iron/15 ml * certavite-antioxidant tablet 18-400 mg-mcg * child chew + iron tab chew * (Biocel) (Multivit- Minerals/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Iron) child chew vitamin tablet * (Multivitamin) child ferrous sulfate 15 mg/ml 15 mg iron (75 mg)/ml * (Fer-In-Sol) children's chewable vitamin * (Multivitamin) childrens multivit tab chew * (Multivitamin) complete multi 50+ tablet 500-300- 250 mcg * (Biocel) complete multivitamin tab * (Multivit,Th Iron,Other Min) complete senior tablet * (Multivit with Iron- Minerals) cvs bal b-100 tablet * (Vitamin B Complex) cvs bal b-50 tablet * (Vitamin B Complex) cvs balanced b-150 tablet * (Vitamin B Complex) cvs b-complex-vit c caplet caplet * (Vita-Bee with C) cvs child vit-mineral tab * (Multivit with Iron- Minerals) cvs children's chewable vit * (Multivitamin) cvs childs vit with c tab chew * (Multivitamin) cvs child's vitamin-iron tb * (Multivitamin with Iron) cvs daily gummies complete adult vit (One-A-Day 200 mcg * Vitacraves) 213
cvs daily multiple tablet * (Multivitamin) cvs daily multiple tablet for women * (Multivitamin) cvs daily teen multi-vitamin 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs gummy swirls chewable * (Multivitamin) cvs iron 27 mg tablet 240 mg (27 mg (Fergon) iron) * cvs men's daily gummies p/f, glutenfree 200 mcg * Vitacraves) (One-A-Day cvs men's multi-vit tablet * (Multivitamin) cvs prenatal vitamin tablet * (Prenatal Vit Calc,Iron,Folic) cvs spectravite adult 50+ tabs 0.4-300-250 mg-mcg-mcg * (Biocel) cvs spectravite advanced tab 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) cvs spectravite liquid * (Pediavit) cvs spectravite senior * (Multivitamin with Minerals/Lut) cvs spectravite senior tab * (Multivit with Iron- Minerals) cvs spectravite senior tablet 500-300-250 mcg * (Biocel) cvs spectravite tablet chew * (Multivitamin with cvs spectravite ultra women tb 18-400 mg-mcg * cvs super b complx & c cplt caplet, p/f * cvs vision formula tablet 1,000 unit- 200 mg-60 unit-2 mg * cvs vitamin b-100 complx tb * Iron) (Multivitamin/Iron/ Folic Acid) (Vita-Bee with C) (Vits A,C,E/Lutein/Mine rals) (Vitamin B Complex) 214
cvs vitamin c 1,000 mg tb chw 1,000 (Ascorbic Acid) mg * cvs vitamin d3 1,000 unit sfgl softgel (D3-50) 1,000 unit * cvs women's daily gummies p/f, (One-A-Day gluten-free 200 mcg * Vitacraves) cyanocobalamin 1,000 mcg/ml 25's (Cyanocobalamin 3 $0 1,000 mcg/ml * (Vitamin B-12)) d3 dots 2,000 unit tablet p/f 2,000 (Vitamin D3) unit * (Multivitamin with daily multi vitamin-iron tab * Iron) daily multiple tablet 18-400 mg-mcg (Multivitamin/Iron/ * Folic Acid) daily multiple vitamin tab sugar (Multivitamin) coated * daily value multivitamin tab s/f * (Multivitamin) (Multivitamin with daily vitamin + iron tablet * Iron) daily vitamin formula tablet * (Multivitamin) (Multivitamin with daily vitamin formula tablet * Minerals) daily vitamin tablet p/f,na/f * (Multivitamin) daily vite tablet s/f, p/f * (Multivitamin) daily vite tablet s/f,p/f * (Multivitamin) (Multivitamin with daily vite with iron tablet * Iron) dino-life extra c tab chew * (Multivitamin) (Multivit with Irondino-life iron-zinc tb chew * Minerals) dino-life tablet chewable * (Multivitamin) daily multivitamin-iron tablet 18- daily vit formula + iron tab 18-400 (Multivitamin/Iron/ (Multivitamin/Iron/ 400 mg-mcg * mg-mcg * Folic Acid) Folic Acid) 215
eldertonic elixir 0.5-0.6-7-0.7 mg * (B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) ellis tonic * (Multivitamin with Minerals) (Pedi Mv eq child complete chew tablet 18 mg No.58/Ferrous iron * Fumarate) eq complete multivitamin tab 0.4-300-250 mg-mcg-mcg * (Biocel) eq complete multivitamin tab glutenfree 18-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ eql central-vite select tablet * (Multivitamin with Minerals/Lut) eql century mature tablet 500-300- 250 mcg * (Biocel) eql chewable multi vitamin tab * (Multivitamin) eql child's multivit tab chew with vitamin c * (Multivitamin) eql childs multivit-mineral tb * (Multivit with Iron- Minerals) (Vits eql eye health plus lutein tab 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) eql one daily 50 plus tablet * (Multivitamin with Minerals) eql one daily essential tablet * (Multivitamin) eql one daily maximum tablet 18-0.4 mg * (Tab A Vite) eql one daily men's tablet * (Multivitamin with Minerals) ergocalciferol 8,000 units/ml 8,000 unit/ml * (Drisdol) essentia tablet 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) 216
essential balance tablet * essential daily tablet w/iron & calcium 18-0.4 mg * ferocon capsule 110-0.5 mg * ferretts 325 mg tablet 325 mg (106 mg iron) * ferrex 150 capsule outer, u-d 150 mg iron * ferrex 150 plus capsule 150-50-50 mg * (Mv,Fe,Min/Lutein ) (Tab A Vite) (Iron Fum/Vit C/B12-If/Fa) 3 $0 (Ferrous Fumarate) (Pic 200) (Iron Aspgly,Ps/C/Succi nic Acid) ferrocite tablet 324 mg (106 mg iron) * (Ferrous Fumarate) ferrous fumarate 324 mg tab 324 mg (Ferrous Fumarate) (106 mg iron) * ferrous gluconate 240 mg tab 240mg=27mg elemental 240 mg (27 (Fergon) mg iron) * ferrous gluconate 324 mg tab 324 mg (36 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) * (Fergon) ferrous sulf 220 mg/5 ml elix 220 mg (Ferrous Sulfate) (44 mg iron)/5 ml * ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5 ml * (Ferrous Sulfate) ferrous sulf ec 324 mg tablet 324 mg (Ferrous Sulfate) (65 mg iron) * ferrous sulfate 325 mg tablet red 325 mg (65 mg iron) * (Slow Fe) flintstones complete tablet * (Multivit with Iron- Minerals) flintstones extra c tab chew * (Multivitamin) flintstones tablet chewable * (Multivitamin) 217
flintstones with iron tab chew 18 mg iron * (Pedi Mv No.79/Ferrous Fumarate) folic acid 1 mg tablet (rx) 1 mg * (Folic Acid) 3 $0 folic acid 1,000 mcg tablet p/f,s/f (otc) 1 mg * (Folic Acid) FOLIC ACID 20 MG CAPSULE 20 MG * folic acid 400 mcg tablet s/f,p/f,lactose-free 400 mcg * (Folic Acid) fosfree tablet 175.5-14.5 mg * (Calcium/Multivita min with Iron) geravim liquid * (Pediavit) geriaton liquid * (Pediavit) gnp century mature tablet gluten- (Biocel) free 0.4-300-250 mg-mcg-mcg * gnp century tablet gluten-free 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) gnp one daily essential tablet * (Multivitamin) gs prenatal vitamins tablet 28-800 (Pnv133/Ferrous mg-mcg * Fumarate/Fa) gummi bear multivit tab chew (Multivitamin) multivit & minerals * hair vitamins * healthy eyes caplet caplet 1,000 unit-200 mg-60 unit-2 mg * hemocyte tablet u-u,blister pk 324 mg (106 mg iron) * hi-b complex tablet * hm complete 50+ tablet 0.4-300-250 mg-mcg-mcg * (Multivitamin with Iron) (Vits A,C,E/Lutein/Mine rals) (Ferrous Fumarate) (Vitamin B Complex) (Biocel) 218
hm one daily with iron tablet glutenfree 18-400 mg-mcg * Folic Acid) (Multivitamin/Iron/ hm super vitamin b complex glutenfree 400 mcg * (Dialyvite 800) honey bears chew tab * (Multivitamin) honey bears-iron-zinc tab chew * (Multivit with Iron- Minerals) icaps plus tablet lactose free * (Multivitamin with Minerals) iferex 150 capsule 150 mg iron * (Pic 200) iron 27 mg tablet 236 mg (27 mg iron) * (Fergon) iron 28 mg tablet 256 mg (28 mg iron) * (Fergon) kenwood therapeutic liquid * (Multivitamin,Ther apeutic) life-pack women's p/f,s/f 0.8 mg * (Multivit with Iron- Minerals) LIQUI-E LIQUID 400 UNIT/15 ML * little animals child tb chw * (Multivitamin) little animals-iron tab chew * (Multivitamin with Iron) lysiplex plus liquid * (Pediavit) MACUVITE EYE CARE TABLET 7,160 UNIT-113 MG-100 UNIT * MACUVITE TABLET 5,000-60-30 UNIT-MG-UNIT * mega multivitamin-mineral tab * (Multivitamin with Minerals) mega multivit-chelated min tab * (Multivitamin with Minerals) MEPHYTON 5 MG TABLET 5 MG * 3 $0 219
milltrium senior multivit tab * (Multivitamin with Minerals/Lut) multi complete-iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-day plus iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) multi-delyn with iron liquid 10 mg (Multivitamin/Ferr iron/5 ml * ous Gluconate) multiple vitamin with iron tab * (Multivitamin with Iron) multiple vitamin w-minerals tb * (Multivitamin with Minerals) multiple vitamins tablet one daily * (Multivitamin) multivitamin child tab chew * (Multivitamin) multi-vitamin daily tablet * (Multivitamin) multivitamin-mineral liquid 9 mg iron/15 ml * (Multivit- Minerals/Ferrous Gluc) multivit-fluor 0.5 mg tab chew (Pedi M.Vit No.17 chewable, d/f, s/f 0.5 mg with Fluoride) multivit-iron child tab chew (Multivitamin with children's * Iron) multivit-mineral hp cap * (Multivitamin,Ther and Minerals) multivit-minerals tablet s/f,p/f * (Multivitamin with Minerals) my favorite multiple liquid * (Multivitamin) myvitalife soft-gel capsule * (Multivitamin with Minerals) NASCOBAL 500 MCG NASAL SPRAY 500 MCG/SPRAY * 3 $0 nephplex rx tablet 1-60-300-12.5 mg-mg-mcg-mg * (Vit B Cmplx No3/Fa/C/Biot/Zin c) 3 $0 220
nephron fa tablet 66.6-75-1 mg * (Iron Fum/Doss/Fa/Vit Bcomp,C) 3 $0 nephro-vite rx tablet 1-60-300 mgmg-mcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 niacinamide er 500 mg tablet 500 mg * (Niacinamide) nu-iron 150 capsule 150 mg iron * (Pic 200) ocutabs tablet s/f, w/lutein * (Beta-Carotene(A)- Vits C,E/Mins) oncovite tablet * (Multivitamin,Ther apeutic) one daily complete tablet * (Multivitamin with Minerals) one daily essential tablet * (Multivitamin) one daily multivitamin tab * (Multivitamin) one daily multivitamin tablet * (Multivitamin with Iron) one daily multivitamin tablet 400 mcg * (Quintabs) one daily multivitamin-iron tb 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) one daily plus iron tablet 18-400 (Multivitamin/Iron/ mg-mcg * Folic Acid) one daily tablet * (Multivitamin) one daily tablet * (Multivitamin with Iron) one daily tablet men's formula * (Multivitamin) one daily with minerals tablet * (Multivitamin with Minerals) one-a-day essential tablet * (Multivitamin) one-a-day max formula tab * (Multivitamin with Minerals) one-a-day teen advantage tab 18- (Multivitamin/Iron/ 400 mg-mcg * Folic Acid) 221
one-a-day teen advantage tab 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) pharmacist multi-vite tab * (Multivitamin) pnv prenatal plus multivit tab s/f, (Pnv with gluten-free 27 mg iron- 1 mg Ca,No.72/Iron/Fa) poly-iron 150 mg capsule 150 mg iron * (Pic 200) (Pediatric poly-vita drops 1,500-35-400 unitmg-unit/ml * Multivitamin No.20) poly-vita with iron drops 1,500 unit- (Ped Multivit 400 unit-10 mg/ml * #46/Iron Sulfate) poly-vitamin drops 1,500-35-400 unit-mg-unit/ml * (Pediatric Multivitamin No.20) poly-vitamin tab chew * (Multivitamin) polyvitamin w-iron drops 1,500 (Ped Multivit unit-400 unit-10 mg/ml * #46/Iron Sulfate) (Prenatal Vit prenatal tablet (otc) 27-0.8 mg * No.130/Iron/Fa) (Prenatal prenatal tablet 27 mg iron- 800 mcg Vit#96/Ferrous * Fum/Fa) prenatal tablet 28 mg iron- 800 mcg * prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg prenatal vitamin tablet 28 mg iron- 800 mcg * prenatal vitamins tablet phosphorus free 28 mg iron- 800 mcg * prosight tablet 5,000-60-30 unit-mgunit * pub multivitamin 50 plus tab * (Prenatal Vit/Iron Fumarate/Fa) (Pnv with Ca,No.72/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Prenatal) (A/C/E/Zinc/Sod Selenate/Copper) (Multivitamin with Minerals/Lut) (All Rx Prenatal Vitamins Covered) (All Rx Prenatal Vitamins Covered) 222
pv b-100 complex * (Vitamin B Complex) pv b-50 complex * (Vitamin B Complex) pv kid's gummy bear tab chew chewable * (Multivitamin) pv kid's vit + extra c chew tb * (Multivitamin) pv kid's vit + iron tab chew * (Multivitamin with Iron) pv kid's vit complete tab chew * (Multivitamin) pv kid's vitamins chew tab * (Multivitamin) pv kids vitamins+iron tab chew 15 (Ped Multivit mg iron * #17/Iron Fumarate) pv multivital platinum tablet * (Multivitamin with Minerals/Lut) pv multivital platinum tablet w/lutein & lycopene 500-300-250 (Biocel) mcg * pv prenatal formula tablet 28 mg (Prenatal Vit iron- 800 mcg * pv prenatal formula tablet 28 mg iron- 800 mcg * pv stress 500 plus zinc tab * pyridoxine 100 mg/ml vial 25's 100 mg/ml * qc child complete vit chew tab 18 mg iron * No.131/Iron/Fa) (Prenatal Vit/Iron Fumarate/Fa) (Multivitamin,Stres s Formula/Zn) (Pyridoxine HCl) 3 $0 (Pedi Mv No.67/Ferrous Fumarate) qc children's chewable tablet * (Multivitamin) qc maximum daily multivit tab 18-0.4 mg * (Tab A Vite) qc multi-vite 50 & over tablet (Multivitamin with w/lycopene * Minerals/Lut) 223
qc multi-vite tablet 18-400 mg-mcg (Multivitamin/Iron/ * Folic Acid) qc women's daily multivit tab 18-0.4 (Tab A Vite) mg * (Vitamin B ra balanced b-100 tablet 0.4 mg * Complex/Folic Acid) (Vitamin B ra b-complex tablet p/f * Complex) (Vitamin B ra b-complex tablet p/f * Complex) (Multivitamin with ra central vite select tab p/f * Minerals/Lut) (Multivit with Ironra central-vite select tab p/f * Minerals) ra central-vite senior tablet 0.4-300- (Biocel) 250 mg-mcg-mcg * ra central-vite tablet 0.4-300-250 (Biocel) mg-mcg-mcg * (Multivitamin with ra one daily energy tablet * Minerals) (Multivitamin with ra one daily plus iron tablet * Iron) ra one daily tablet p/f * (Multivitamin) ra therapeutic m multivit tab 18-0.4 (Tab A Vite) mg * ra vitamin b-12 1,000 mcg tab (B-12) timed-release 1,000 mcg * ra central-vite tablet 18-400 mgmcg * ra prenatal tablet 28 mg iron- 800 ra vit b-12 1,000 mcg/ml liq 1,000 (Multivitamin/Iron/ (Prenatal Vit/Iron (Cyanocobalamin mcg * mcg/ml * Folic Acid) Fumarate/Fa) (Vitamin B-12)) 224
ra vitamin c 1,000 mg tab sa w/bioflavonoids 1,000 mg * (Ascorbic Acid) ra vitamin c 500 mg tab chew p/f 500 mg * (Ascorbic Acid) ra vitamin c tr 500 mg caplet caplet,p/f,s/f 500 mg * (Ascorbic Acid) rena-vite rx tablet 1-60-300 mg-mgmcg * 3/Fa/Vit C/Biotin) (Vit B Cmplx 3 $0 scooby-doo one a day tablet * (Multivit with Iron- Minerals) senior tabs 0.4-300-250 mg-mcgmcg * (Biocel) sentry senior multivitamin tab sodium/f,yeast/f 500-300-250 mcg * (Biocel) sentry senior tablet 0.4-300-250 mgmcg-mcg * (Biocel) sentry tablet 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) sm airshield effervescent tab 5,000- (Vit A,C,E/Dietary 1000-30 unit-mg-unit * Supp No.12) sm animal shapes tab chew * (Multivitamin) sm animal shapes tab chew toddlers * (Multivitamin) sm animal shapes w-iron tab (Multivitamin with children's * Iron) (Vits sm antioxidant vitamins tablet 1,000 A,C,E/Lutein/Mine unit-200 mg-60 unit-2 mg * rals) sm b complex with vit c tablet gluten-free * (Vita-Bee with C) sm complete multi-vit-mineral (Multivitamin/Iron/ advanced formula 18-400 mg-mcg * Folic Acid) sm complete senior formula tab * (Multivit with Iron- Minerals) 225
sm complete senior formula tab 0.4-300-250 mg-mcg-mcg * sm hair, skin and nails caplet caplet, gluten-free * sm multivitamin w-iron tab * sm natural balanced b-100 tab 100 mg * sm opti-vitamin tablet 1,000 unit- 200 mg-60 unit-2 mg * sm prenatal vitamins tablet 28 mg iron- 800 mcg * sm super b complex-c caplet caplet * sm therapeutic m tablet 27-0.4 mg * sm vitamin b complex tablet glutenfree 0.4 mg * sm vitamin b-100 complex tab gluten-free 0.4 mg * sm vitamin d3 4,000 unit sftgl softgel, gluten-free 4,000 unit * sodium fluoride oral tablet 1 mg fluoride (2.2 mg) stress b tablet * stress b with zinc tablet * stress formula tablet * (Biocel) (Multivitamin with Minerals) (Multivitamin with Iron) (Vit B Complex 100 Cmb #2/Herbs) (Vits A,C,E/Lutein/Mine rals) (Prenatal) (Vita-Bee with C) (Multivit,Tx,Iron/C alcm/fa/mins) (Vitamin B Complex/Folic Acid) (Vitamin B Complex/Folic Acid) (D3-50) (Pedi M.Vit No.17 with Fluoride) (Vitamin B Complex) (Multivitamin,Stres s Formula/Zn) (Multivitamin,Stres s Formula) 226
stress formula with iron tab * (Iron/Mv,Stress Form) (Vit B stress formula with iron tab 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) stress formula with zinc tab * (Multivitamin,Stres s Formula/Zn) (Vit B stress-c with iron tablet 500 mg-400 Comp/C/Fa/Iron/Vi mcg- 18 mg iron * t E) (Mv-Min/Iron sunvite tablet 18 mg iron-400 mcg- Fum/Fa/K/Lyco/Lu 25 mcg * tn) super b complex-c caplet caplet * (Vita-Bee with C) (Vitamin B super b maxi complex caplet 0.4 mg Complex/Folic * Acid) super b with vit c capsule * (B Complex with Vitamin C) super b-50 complex capsule * (Vitamin B Complex) super b-50 complex plus tab * (Vitamin B Complex) super b-complex folic-vit c tb p/f 400 mcg * (Dialyvite 800) super multiple vit-mineral tab * (Multivit with Iron- Minerals) super multivitamin tablet * (Multivitamin) super quints b-50 tablet 0.4 mg * (Vitamin B Complex/Folic Acid) super quints b-50 tablets * (Vitamin B Complex) super thera vite m tablet * (Multivitamin,Ther and Minerals) 227
superior 35 vit-mineral tab sa * (Multivit with Iron- Minerals) superplex-t tablet * (Vita-Bee with C) support liquid * (Multivitamin with Minerals) support-500 softgel * (B Complex with Vitamin C) 3 $0 sv hair, skin and nails caplet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg * Gluc/Fa/Biotin) tab-a-vite tablet * (Multivitamin) tab-a-vite with iron tablet * (Multivitamin with Iron) tab-a-vite-minerals tablet * (Multivitamin with Minerals) thera m plus tablet 9 mg iron-400 (Multivits,Ca,Mine mcg * rals/iron/fa) thera tablet * (Multivitamin,Ther apeutic) thera-d 2000 tablet 2,000 unit * (Vitamin D3) theradex m tablet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m caplet caplet 27-0.4 mg * (Multivit,Tx,Iron/C alcm/fa/mins) thera-m tablet w/beta carotene 9 mg (Multivits,Ca,Mine iron-400 mcg * rals/iron/fa) therapeutic-m caplet p/f, s/f, caplet 9 (Multivits,Ca,Mine mg iron-400 mcg * rals/iron/fa) thera-tabs tablet * (Multivitamin,Ther apeutic) theratrum compl 50 plus tab * (Multivitamin with Minerals/Lut) theratrum complete 50 plus (Multivit with Ironp/f,caplet * Minerals) thiamine 200 mg/2 ml vial 25's,mdv,outer 100 mg/ml * (Thiamine HCl) 3 $0 228
thiamine 500 mg tablet 500 mg * (Thiamine HCl) total b with vit c caplet * (Vita-Bee with C) totalday multiple tablet sa * (Multivitamin with Minerals) (Vit A tri-vi-sol drops 750 unit-35 mg -400 Palmitate/Vit C/Vit unit/ml * D3) tri-vita drops 1,500-35-400 unit-mgunit/ml * tri-vitamin drops 1,500-35-400 unitmg-unit/ml * ultra b-100 complex tablet * v-c forte capsule 1 mg * vic-forte capsule 1 mg * vision plus lutein vitamin tab * vision vitamins * vision vitamins tablet w/lutein,p/f 1,000 unit-200 mg-60 unit-2 mg * (Pedi Multivit A,C,And D3 No.21) (Pedi Multivit A,C,And D3 No.21) (Vitamin B Complex) (Multivitamin- Minerals No.7/Fa) (Multivitamin- Minerals No.7/Fa) (Multivitamin with Minerals/Lut) (Beta-Carotene(A)- Vits C,E/Mins) (Vits A,C,E/Lutein/Mine rals) 3 $0 3 $0 vit d2 1.25 mg (50,000 unit) 50,000 unit * (Drisdol) 3 $0 VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 MG IRON-1 MG -50 MG-200 MG vitalets tablet chewable child, (Multivitamin with orange,s/f * Iron) vitamin a 10,000 units capsule soluble 10,000 unit * (Vitamin A) 229
vitamin a 25,000 units capsule softgel 25,000 unit * (Vitamin A) vitamin and minerals tablet * (Multivitamin,Ther and Minerals) (Vit B vitamin b complex tablet 500 mg- Comp/C/Fa/Iron/Vi 400 mcg- 18 mg iron * t E) vitamin b complex-vit c cap * (B Complex with Vitamin C) vitamin b complex-vit c tablet * (Vita-Bee with C) vitamin b-12 1,000 mcg tablet 1,000 mcg * (B-12) vitamin b-12 100 mcg tablet 100 mcg * (B-12) vitamin b-12 250 mcg tablet 250 mcg * (B-12) vitamin b12 500 mcg tablet 500 mcg * (B-12) vitamin b-12 tr 1,000 mcg tab (Cyanocobalamin lactose free 1,000 mcg * (Vitamin B-12)) vitamin b12-folic acid tablet 500- (Cyanocobalamin/ 400 mcg * Folic Acid) vitamin b-6 250 mg tablet p/f 250 mg * (Pyridoxine HCl) vitamin b-6 50 mg tablet 50 mg * (Pyridoxine HCl) (Folic Acid/B vitamin b-complex & c caplet p/f,no Cmplx C/Rice lactose,cplt 400-500 mcg-mg * Bran) vitamin c 1,000 mg tablet 1,000 mg * (Ascorbic Acid) vitamin c 1,500 mg tablet sa na/f,s/f,starch/free 1,500 mg * (Ascorbic Acid) vitamin c 250 mg tablet 250 mg * (Ascorbic Acid) vitamin c 250 mg tablet chew 250 mg * (Ascorbic Acid) 230
vitamin c 500 mg tablet chew 500 mg * (Ascorbic Acid) vitamin c 500 mg/5 ml liquid 500 mg/5 ml * (Ascorbic Acid) vitamin d 1,000 unit tablet 1,000 unit * (Vitamin D3) vitamin d3 1,000 unit tablet s/f,p/f 1,000 unit * (Vitamin D3) vitamin d3 1,000 units softgel softgel, p/f, s/f 1,000 unit * (D3-50) vitamin d3 10,000 unit softgel softgel 10,000 unit * (D3-50) vitamin d3 2,000 unit tablet s/f,p/f 2,000 unit * (Vitamin D3) vitamin d3 400 unit tab chew orange, p/f 400 unit * (Vitamin D3) vitamin d3 400 unit tablet s/f,p/f 400 unit * (Vitamin D3) vitamin d3 400 unit/5 ml liq 400 (Cholecalciferol unit/5 ml * (Vitamin D3)) vitamin d3 5,000 unit capsule s/f, p/f 5,000 unit * (D3-50) vitamin d3 5,000 unit/ml drops a/f, p/f,gluten-free 5,000 unit/ml * (Just D) vitamin k 100 mcg tablet p/f, glutenfree 100 mcg * (Phytonadione) vitamins for hair tablet * (Multivitamin) vitrum 50+ senior tablet 500-300- 250 mcg * (Biocel) vitrum senior tablet f/f,p/f * (Multivitamin with Minerals/Lut) v-r natural b-100 tablet * (Vitamin B Complex) yelets tablet 18-400 mg-mcg * (Multivitamin/Iron/ Folic Acid) 231
zoo chews gummie tablet * (Multivitamin) 232
INDEX 3 3 day vaginal... 57 30pse-150gfn-15dm... 118 30pse-3brm-15dm... 118 3-day vaginal... 55 5 50pse-3brm-30dm... 118 8 8-MOP... 130 A a thru z advanced formula... 209, 210 a thru z high potency... 210 a thru z select... 210 a thru z select 50+ formula... 210 a thru z select women's... 210 abacavir... 74 abacavir-lamivudine-zidovudine... 75 abc plus... 210 ABELCET... 54 ABILIFY MAINTENA... 70 ABRAXANE... 30 ABREVA... 64 acamprosate... 15 acarbose... 50 acebutolol... 95 acephen... 3 acetaminophen... 3 acetaminophen-codeine... 3 acetazolamide... 190 acetazolamide sodium... 190 acetic acid... 147, 182 acetylcysteine... 205 acid gone antacid... 153 acid reducer (famotidine)... 151, 152 acid relief (cimetidine)... 152 acitretin... 130 acne medication... 130, 132 ACNE MEDICATION... 130 acne-clear... 130 ACTEMRA... 184 ACTHIB (PF)... 175, 176 ACTIMMUNE... 184 actinel pediatric... 118 acyclovir... 80, 130 acyclovir sodium... 80 ADACEL(TDAP ADOLESN/ADULT)(PF) 176 ADAGEN... 140 adapalene... 138, 139 ADCETRIS... 30 ADCIRCA... 208 adefovir... 80 ADEMPAS... 208 adriamycin... 30 adrucil... 30 adt robitussin peak cld dm max... 118 adult multivitamin gummies 210 adult nasal decongestant... 127 adult one daily gummies... 210 adult robitussin lingering cld 118 adult robitussin peak cold dm... 119 adult wal-tussin... 119 adult wal-tussin dm max... 119 adults 50 plus... 210 adults 50+ daily formula... 210 adults' daily formula... 210 ADVAIR DISKUS... 202 ADVAIR HFA... 202 ADVIL... 11 af 55 afeditab cr... 101 AFINITOR... 30 AFINITOR DISPERZ... 30 AFTERA... 109, 110 a-hydrocort... 167 airshield... 225 AKTEN (PF)... 142 AKYNZEO... 66 ala-cort... 134 ala-scalp... 134 alavert... 58 alavert d-12 allergy-sinus... 58 ALBENZA... 68 albuterol sulfate... 203 alcaine... 142 alclometasone... 135 ALCOHOL PADS... 130 ALCOHOL PREP PADS... 130 ALDURAZYME... 140 ALECENSA... 30 alendronate... 182 alfuzosin... 164 ALIMTA... 30 ALINIA... 68 alka-seltzer plus mucus-conges... 119 ALLEGRA ALLERGY... 58 aller-chlor... 58 allerclear d-12hr... 58 allerclear d-24hr... 58 allergy (chlorpheniramine)... 58 allergy (diphenhydramine)... 60 allergy relief (cetirizine)... 60 allergy relief (clemastine)... 62 allerhist-1... 58 aller-tec d... 58 allopurinol... 184 ALLZITAL... 3 almacone... 153 I-1 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
almacone-2... 153 aloe vesta antifungal (micon). 54 alophen... 159 alosetron... 181 ALPHAGAN P... 190 alprazolam... 17 ALREX... 149 altacaine... 142 altamist... 142 altavera (28)... 110 aluminum hydroxide gel... 154 alyacen 1/35 (28)... 110 alyacen 7/7/7 (28)... 110 amabelz... 166 amantadine hcl... 69 ambi 10peh-4cpm-20dm... 119 ambi 20dm-4cpm... 119 ambi 40pse-400gfn-20dm... 119 ambi 60pse-4cpm... 58 ambi 60pse-4cpm-20dm... 119 AMBISOME... 54 amethia... 110 amethia lo... 110 amifostine crystalline... 184 amiloride... 102 amiloride-hydrochlorothiazide... 102 AMINO ACIDS 15 %... 85 aminocaproic acid... 84 AMINOSYN 10 %... 85 AMINOSYN 3.5 %... 85 AMINOSYN 7 %... 85 AMINOSYN 7 % WITH ELECTROLYTES... 85 AMINOSYN 8.5 %... 85 AMINOSYN 8.5 %- ELECTROLYTES... 86 AMINOSYN II 10 %... 86 AMINOSYN II 15 %... 86 AMINOSYN II 7 %... 86 AMINOSYN II 8.5 %... 86 AMINOSYN II 8.5 %- ELECTROLYTES... 86 AMINOSYN M 3.5 %... 86 AMINOSYN-HBC 7%... 86 AMINOSYN-PF 10 %... 86 AMINOSYN-PF 7 % (SULFITE-FREE)... 86 AMINOSYN-RF 5.2 %... 86 amiodarone... 94 AMITIZA... 154 amitriptyline... 46 amlactin... 130 amlodipine... 101 amlodipine-atorvastatin... 103 amlodipine-benazepril... 101 amlodipine-valsartan... 102 amlodipine-valsartan-hcthiazid... 102 ammonium lactate... 131 amoxapine... 46 amoxicil-clarithromy-lansopraz... 151 amoxicillin... 25 amoxicillin-pot clavulanate... 25, 26 amphotericin b... 54 ampicillin... 26 ampicillin sodium... 26 ampicillin-sulbactam... 26 AMPYRA... 107 ANACAINE... 131 anagrelide... 84 anastrozole... 30 ANDRODERM... 165 ANDROGEL... 165 androxy... 165 animal chews... 210 animal shape vitamins... 225 animal shapes plus iron... 225 antacid anti-gas... 154 antacid anti-gas (ca carb-sim)... 155 antacid extra-strength... 154 antacid plus extra strength... 154 anticoag citrate phos dextrose... 184 anti-diarrheal... 155 anti-diarrheal (loperamide).. 154, 155 antifungal (tolnaftate)... 54, 57 antifungal cream... 54 anti-gas maximum strength.. 151 antioxidant... 210 antioxidant vitamins... 225 apatate forte... 210 APOKYN... 69 apraclonidine... 142 apri... 110 APRISO... 181 aprodine... 58 APTIOM... 41 APTIVUS... 75 aquanil hc... 135 aranelle (28)... 110 ARCALYST... 172 aripiprazole... 70, 71 ARISTADA... 71 armodafinil... 207 arthritis pain relief (acetam)... 10 artificial tears (petro/min)... 143 artificial tears (pf)... 142 artificial tears (polyvin alc).. 142 artificial tears(dext70-hypro) 142 artificial tears(glycerin-peg). 143 artificial tears(hypromellose) 145 ASACOL HD... 181 ascomp with codeine... 3 ascorbic acid (vitamin c)... 215, 230 ashlyna... 110 aspirin... 12 aspirin, buffered... 12 aspirin-dipyridamole... 84, 85 aspir-low... 12 I-2 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
ASSURE ID INSULIN SAFETY... 139 ASTAGRAF XL... 172 atenolol... 95 atenolol-chlorthalidone... 95 atorvastatin... 103 atovaquone... 68 atovaquone-proguanil... 68 ATRIPLA... 75 atropine... 40, 143 atropine-care... 143 ATROVENT HFA... 203 AUBAGIO... 172 aubra... 110 AVASTIN... 31 AVC VAGINAL... 64 aviane... 110 AVONEX... 185 AVONEX (WITH ALBUMIN)... 184 ayr saline... 143 azacitidine... 31 azathioprine... 172 azathioprine sodium... 172 azelastine... 143 AZILECT... 69 azithromycin... 24 AZOPT... 190 AZOR... 102 aztreonam... 25 azurette (28)... 110 B b complete... 211 b complex 1... 211 b complex 100... 226 b complex-vitamin b12... 211 b complex-vitamin c-folic acid... 211, 219, 227 b-100 complex... 223 b-12 dots... 211 b-50 complex... 223 bacitracin... 19, 133, 147 bacitracin-polymyxin b... 147 bacitraycin plus... 133 baclofen... 206 bal b-100... 213 bal b-50... 213 balance b-100... 211 balance b-50... 211 balanced b-100... 211, 224 balanced b-150... 213 balanced b-50... 211 balanced b-50 complex... 211 balsalazide... 181 balziva (28)... 110 banophen... 59 banophen allergy... 59 BANZEL... 41 baza antifungal... 54 BCG VACCINE, LIVE (PF) 176 b-complex... 224 b-complex with vitamin c... 211, 213, 225, 230 BD INSULIN PEN NEEDLE UF SHORT... 140 BD INSULIN SYRINGE ULTRA-FINE... 139, 140 bekyree (28)... 110 BELBUCA... 4 BELEODAQ... 31 BELSOMRA... 207 benadryl allergy... 59 benazepril... 93 benazepril-hydrochlorothiazide... 93 BENDEKA... 31 BENICAR... 92 BENICAR HCT... 91, 92 BENLYSTA... 185 benzonatate... 119 benzoyl peroxide... 131 benztropine... 69 BETADINE... 131 beta-hc... 135 betamethasone acet,sod phos 167 betamethasone dipropionate. 135 betamethasone valerate... 135 betamethasone, augmented.. 135 BETASERON... 185 betaxolol... 95, 190 bethanechol chloride... 185 BETHKIS... 18 bexarotene... 31 BEXSERO (PF)... 176 bicalutamide... 31 bicarsim forte... 150 BICILLIN C-R... 26 BICILLIN L-A... 26 BIDIL... 106 bimatoprost... 190 bio-dtuss dmx... 119 bion tears (pf)... 143 bionel pediatric... 119 biospec dmx... 119 biosupp... 211 biotin... 212 biovol... 212 bisac-evac... 159 bisacodyl... 159 biscolax... 159 bismatrol... 154 bisoprolol fumarate... 95 bisoprolol-hydrochlorothiazide... 95 bleomycin... 31 bleph-10... 147 BLINCYTO... 31 blisovi 24 fe... 110 blisovi fe 1.5/30 (28)... 110 blisovi fe 1/20 (28)... 110 blis-to-sol (tolnaftate)... 54 BOOSTRIX TDAP... 176 BOSULIF... 31 bp 8 cough... 119 BREO ELLIPTA... 202 briellyn... 111 I-3 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
BRILINTA... 85 brimonidine... 190 BRINTELLIX... 46 BRIVIACT... 41 bromfed dm... 119 bromfenac... 149 bromocriptine... 69 brompheniramine-pseudoephdm... 118, 119, 120 budesonide... 181 bufferin... 12 bumetanide... 102 BUPHENYL... 154 buprenorphine hcl... 4, 15 buprenorphine-naloxone... 15 buproban... 46 bupropion hcl... 46 bupropion hcl (smoking deter)... 16, 46 buspirone... 185 butalbital compound w/codeine 4 butalbital-acetaminop-caf-cod. 4 butalbital-acetaminophen... 4 butalbital-acetaminophen-caff. 4 butalbital-aspirin-caffeine... 4 BUTRANS... 4 BYSTOLIC... 95 C c complex... 212 cabergoline... 69 CABOMETYX... 31 ca-d3-mag ox-zinc-cop-mangbor... 194, 195, 200 caffeine citrated... 107 caffeine-sodium benzoate... 107 calci-chew... 154 calcidol... 212 calcipotriene... 131 calcitonin (salmon)... 182 calcitrate... 191 calcitrate-vitamin d... 191 calcitrene... 131 calcitriol... 131, 183 calcium 500 + d... 193 calcium 500 + d (d3)... 193 calcium 600... 192 calcium 600 + d(3)... 192 calcium 600 with vitamin d3 196 calcium acetate... 163 calcium antacid... 154 calcium carbonate... 154, 192 calcium carbonate-vitamin d2... 193 calcium carbonate-vitamin d3... 192, 193, 194, 200 CALCIUM CARBONATE- VITAMIN D3... 154 calcium chloride... 192 calcium citrate-vitamin d3.. 192, 193, 195 calcium gluconate... 193 calcium+d... 202 CALDOLOR... 12 cal-gest antacid... 154 calphron... 163 CALTRATE 600 + D... 193 CALTRATE WITH VITAMIN D3... 193 camila... 111 camrese... 111 camrese lo... 111 CANCIDAS... 54 candesartan... 92 candesartan-hydrochlorothiazid... 92 capacet... 4 CAPASTAT... 65 CAPRELSA... 31 captopril... 93 captopril-hydrochlorothiazide 93 CARAFATE... 151 CARBAGLU... 154 carbamazepine... 41 carbidopa... 69 carbidopa-levodopa... 69 carbidopa-levodopa-entacapone... 69 CARIMUNE NF NANOFILTERED... 172 carisoprodol... 206 carteolol... 143 cartia xt... 96, 97 carvedilol... 95 CASTELLANI PAINT MODIFIED... 131 CAYSTON... 25 caziant (28)... 111 cefaclor... 21 cefadroxil... 21 cefazolin... 22 cefazolin in dextrose (iso-os). 21 cefdinir... 22 cefditoren pivoxil... 22 cefepime... 22 CEFEPIME IN DEXTROSE 5 %... 22 CEFEPIME IN DEXTROSE,ISO-OSM... 22 cefotaxime... 22 cefoxitin... 22 cefoxitin in dextrose, iso-osm 22 cefpodoxime... 22 cefprozil... 22 ceftazidime... 22 ceftibuten... 22, 23 ceftriaxone... 23 ceftriaxone in dextrose,iso-os. 23 cefuroxime axetil... 23 cefuroxime sodium... 23 celecoxib... 12 CELLCEPT INTRAVENOUS... 172 CELONTIN... 41 centamin... 212 centergy dm... 120 central vite with lutein... 224 I-4 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
central-vite... 224 central-vite for seniors... 212 central-vite select... 216, 224 central-vite senior... 224 centram-care... 212 centravites 50 plus... 212 centrum... 212 centrum complete... 212 centrum silver... 212 century... 218 century adults 50+... 212 century mature... 212, 216, 218 century ultimate women's... 212 cephalexin... 23 CEPROTIN (BLUE BAR)... 81 CERDELGA... 185 CEREZYME... 140 cerovite... 212 cerovite advanced formula... 212 certavite senior-antioxidant.. 213 certavite-antioxid (iron gluc) 213 certavite-antioxidant... 213 CERVARIX VACCINE (PF)... 176 cetirizine... 59 cetirizine-pseudoephedrine... 59 CETYLEV... 185 cevimeline... 130 CHANTIX... 16 CHANTIX CONTINUING MONTH BOX... 16 CHANTIX STARTING MONTH BOX... 16 cheracol d... 120 cheratussin dac... 120 chest congestion relief + dm 121 chest congestion relief pe... 121 chewable multi vitamin... 216 child allergy relf(cetirizine)... 60 child complete multivitamin 216 child cough and sore throat.. 121 child mucinex chest congestion... 120 child plus cough and runnynose... 125 child triaminic cold-allergy... 59 child triaminic cough-congest... 120 child triaminic cough-sore thr... 120 child vitamin with minerals.. 213 child wal-tap cold-allergy... 59 child wal-tussin cough relief 120 CHILDREN'S ADVIL... 12 children's allegra allergy... 59 children's aller-tec... 59 children's chest congestion... 121 children's chewable... 223 children's chewable complete... 213 children's chewable vitamin. 213 children's chewable w/minerals... 216 CHILDREN'S CLARITIN... 59 children's cold-cough daytime... 121 children's complete vitamin. 223 children's mapap... 5 children's mucinex cough... 120 children's multivit w/extra c. 216 children's non-aspirin... 4, 5 children's pain reliever... 10 children's pain-fever relief... 4 children's pepto... 155 childrens plus multi-symp cold... 127 children's silfedrine... 120 children's soothe... 154 children's sudafed... 120 children's sudafed pe cough. 120 children's tactinal... 5 children's wal-dryl allergy... 60 children's wal-zyr... 60 CHILDREN'S ZYRTEC ALLERGY... 59 childs chew vite... 213 child's vitamin with iron... 213 child's vitamin with vitamin c... 213 childs/iron... 213 chlophedianol-guaifenesin... 118 chloramphenicol sod succinate... 19 chlordiazepoxide hcl... 17 chlorhexidine gluconate... 130 chloroquine phosphate... 68 chlorothiazide... 102 chlorothiazide sodium... 102 chlorpheniramine-phenyleph-dm... 118 chlorpromazine... 71 chlorthalidone... 103 chlorzoxazone... 206 cholecalciferol (vitamin d3) 215, 231 cholestyramine (with sugar). 104 cholestyramine light... 104 choline,magnesium salicylate 12 ciclopirox... 54 ciclopirox-ure-camph-menth-euc... 54 cilostazol... 85 cimetidine... 151 cimetidine hcl... 151 CIMZIA... 172 CIMZIA POWDER FOR RECONST... 172 CINQAIR... 205 CINRYZE... 83 CIPRODEX... 147 ciprofloxacin... 28 ciprofloxacin hcl... 28, 147 ciprofloxacin in 5 % dextrose 28 ciprofloxacin lactate... 28 citalopram... 46 I-5 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
citracal + d maximum... 193 citrus calcium... 193 clarithromycin... 24 CLARITIN... 60 CLARITIN LIQUI-GEL... 60 CLARITIN REDITABS... 60 clearlax... 163 CLEVIPREX... 102 clindamycin hcl... 19 clindamycin in 5 % dextrose.. 19 clindamycin palmitate hcl... 19 clindamycin pediatric... 19 clindamycin phosphate... 19, 64, 133 CLINIMIX 5%/D15W SULFITE FREE... 87 CLINIMIX 5%/D25W SULFITE-FREE... 87 CLINIMIX 2.75%/D5W SULFIT FREE... 87 CLINIMIX 4.25%/D10W SULF FREE... 87 CLINIMIX 4.25%/D5W SULFIT FREE... 87 CLINIMIX 4.25%-D20W SULF-FREE... 87 CLINIMIX 4.25%-D25W SULF-FREE... 87 CLINIMIX 5%- D20W(SULFITE-FREE)... 87 CLINIMIX E 2.75%/D10W SUL FREE... 87 CLINIMIX E 2.75%/D5W SULF FREE... 88 CLINIMIX E 4.25%/D10W SUL FREE... 88 CLINIMIX E 4.25%/D25W SUL FREE... 88 CLINIMIX E 4.25%/D5W SULF FREE... 88 CLINIMIX E 5%/D15W SULFIT FREE... 88 CLINIMIX E 5%/D20W SULFIT FREE... 88 CLINIMIX E 5%/D25W SULFIT FREE... 88 CLINISOL SF 15 %... 88 clobetasol... 135, 136 clobetasol-emollient... 136 clocortolone pivalate... 136 clomipramine... 47 clonazepam... 17 clonidine... 91 clonidine hcl... 91, 108 clopidogrel... 85 clorazepate dipotassium... 17 clorpres... 91 clotrimazole... 54, 55 clotrimazole-7... 55 clotrimazole-betamethasone... 55 clozapine... 71 COARTEM... 68 codeine sulfate... 5 codituss dm... 120 COLACE... 159 colchicine... 185 cold and cough (diphenhydr-pe)... 60 cold multi-symptom day/night... 120 cold relief m/s day/night... 120 cold-allergy-sinus... 60 cold-flu relief... 121 cold-flu relief, day/night... 121 colestipol... 104 colistin (colistimethate na)... 19 colocort... 136 COLY-MYCIN S... 147 COMBIGAN... 191 COMBIPATCH... 166 COMBIVENT RESPIMAT. 203 COMETRIQ... 31 comfort gel... 155 comfort gel extra strength... 155 COMPLERA... 75 complete 50+... 218 complete multi 50+... 213 complete multivitamin. 213, 216 complete multivitamin-mineral... 216, 225 complete senior... 213, 225, 226 compoz... 60 compro... 66 COMVAX (PF)... 176 CONDYLOX... 131 congestac... 121 congest-eze... 121 constulose... 155 COPAXONE... 185 coricidin hbp... 121 coricidin hbp cold-multi sympt... 121 CORLANOR... 98 cormax... 136 cortisone... 168 cortizone-10... 136 CORTIZONE-10... 136 COSENTYX... 132 COSENTYX (2 SYRINGES)... 131 COSENTYX PEN... 131 COSENTYX PEN (2 PENS) 131 COTELLIC... 32 cough and cold... 121 cough and runny nose... 127 CREON... 141 critic-aid clear af... 55 CRIXIVAN... 75 cromolyn... 143, 155, 205 cryselle (28)... 111 CUBICIN... 19 cyanocobalamin (vitamin b-12)... 211, 215, 224, 230 cyclafem 1/35 (28)... 111 cyclafem 7/7/7 (28)... 111 cyclobenzaprine... 206 I-6 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
cyclopentolate... 143 cyclophosphamide... 32 CYCLOPHOSPHAMIDE... 32 CYCLOSET... 50 cyclosporine... 172, 173 cyclosporine modified... 172 cyproheptadine... 60 CYRAMZA... 32 cyred... 111 CYSTADANE... 185 CYSTARAN... 144 cysteine (l-cysteine)... 88 D d10 %-0.45 % sodium chloride... 194 d2.5 %-0.45 % sodium chloride... 194 d3 dots... 215 d5 % and 0.9 % sodium chloride... 194 d5 %-0.45 % sodium chloride... 194 dactinomycin... 32 daily gummies... 213 daily multiple... 214, 215 daily multi-vitamin... 220 daily multivitamin with iron 215 daily multi-vitamins/iron... 215 daily teen multi-vitamin... 214 daily value... 215 daily vitamin... 215 daily vitamin formula... 215 daily vitamin formula + iron 215 daily vitamin formula-minerals... 215 daily vitamin with iron... 215 daily vites/iron... 215 dailyhist-1... 60 daily-vite... 215 DAKLINZA... 79 DALIRESP... 205 danazol... 165 dantrolene... 206 dapsone... 65 DAPTACEL (DTAP PEDIATRIC) (PF)... 177 daptomycin... 19 DARAPRIM... 68 DARZALEX... 32 dasetta 1/35 (28)... 111 dasetta 7/7/7 (28)... 111 dayhist allergy... 60 daysee... 111 daytime cold and cough... 122 daytime cold-flu... 122 day-time cough... 122 daytime-nighttime... 125 daytime-nighttime cold-flu.. 121 daytime-nighttime cough... 122 deblitane... 111 decitabine... 32 decongestant cough... 127 deep sea nasal... 144 deferoxamine... 164 delsym cough-chest congest dm... 122 delyla (28)... 111 DELZICOL... 182 DEMSER... 98 DEPEN TITRATABS... 165 DEPO-PROVERA... 171 dermafungal... 55 dermarest eczema (hydrocort)... 136 DESCOVY... 75 desipramine... 47 desmopressin... 169 desog-e.estradiol/e.estradiol. 111 desogestrel-ethinyl estradiol 111 desonide... 136 desoximetasone... 136 despec-dm (pseudoeph-dmguaif)... 122 dex4 glucose... 88 dexamethasone... 168 dexamethasone sodium phosphate... 149, 168 dexmethylphenidate... 108 dextroamphetamine... 108 dextroamphetamineamphetamine... 108 dextromethorphan polistirex 122 dextrose 10 % and 0.2 % nacl... 194 dextrose 10 % in water (d10w)... 88, 89 dextrose 20 % in water (d20w)... 89 dextrose 25 % in water (d25w)... 89 dextrose 40 % in water (d40w)... 89 dextrose 5 % in ringers... 89 dextrose 5 % in water (d5w).. 89 dextrose 5 %-lactated ringers194 dextrose 5%-0.2 % sod chloride... 194 dextrose 5%-0.3 % sod.chloride... 194 dextrose 50 % in water (d50w)... 89 dextrose 70 % in water (d70w)... 89 dextrose with sodium chloride... 194 dextrose-kcl-nacl... 194 diabetic tussin dm... 122 diamode... 155 diazepam... 17, 18 diazepam intensol... 17 diclofenac potassium... 12 diclofenac sodium... 12, 149 diclofenac-misoprostol... 13 dicloxacillin... 26 dicyclomine... 155 didanosine... 75 I-7 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
DIFICID... 24 diflunisal... 13 digitek... 98 digox... 98, 99 digoxin... 99 DIGOXIN... 99 dihydroergotamine... 64 DILANTIN... 41 diltiazem hcl... 97 dilt-xr... 97 dimaphen (pe)... 60 dimenhydrinate... 66 dimetapp cold-congestion... 61 dino-life... 215 dino-life with extra c... 215 dino-life with iron-zinc... 215 DIPENTUM... 182 diphenhist... 61 diphenhydramine hcl... 61 diphenoxylate-atropine... 155 dipyridamole... 85 disopyramide phosphate... 94 disulfiram... 16 divalproex... 41, 42 dobutamine... 99 dobutamine in d5w... 99 doc-q-lace... 160 docu... 160 docusate sodium... 160 docusol... 160 dofetilide... 94 dok... 160 donepezil... 45 dopamine... 100 dopamine in 5 % dextrose... 100 dorzolamide... 191 dorzolamide-timolol... 191 douche vinegar and water extra... 189 doxazosin... 91 doxepin... 47 doxercalciferol... 183 doxorubicin, peg-liposomal... 32 doxy-100... 29 doxycycline hyclate... 29 doxycycline monohydrate... 29 dramamine... 66 dramamine less drowsy... 66 driminate... 66 dristan long lasting... 144 dronabinol... 66 droperidol... 185 drospirenone-ethinyl estradiol... 111 DROXIA... 32 DUAVEE... 166 dulcolax stool softener (dss) 160 DULERA... 202 duloxetine... 47 DUREZOL... 149 dutasteride... 185 dutasteride-tamsulosin... 185 DYRENIUM... 103 E e.c. prin... 13 e.e.s. 400... 24 e.e.s. granules... 24 econazole... 55 econtra ez... 111 ed a-hist... 61 ed bron gp... 122 ed chlorped jr... 61 EDURANT... 75 effer-k... 194 EFFIENT... 85 ELAPRASE... 141 eldertonic... 216 electrolyte-48 in d5w... 194 ELIDEL... 136 ELIGARD... 32 ELIGARD (3 MONTH)... 32 ELIGARD (4 MONTH)... 32 ELIGARD (6 MONTH)... 32 elinest... 112 eliphos... 163 ELIQUIS... 81 ELITEK... 141 ELLA... 112 ellis tonic... 216 ELMIRON... 185 elon dual defense... 55 EMCYT... 32 EMEND... 66 emoquette... 112 EMPLICITI... 33 EMSAM... 47 EMTRIVA... 75 EMVERM... 68 enalapril maleate... 93 enalaprilat... 93 enalapril-hydrochlorothiazide 93 ENBREL... 173 ENBREL SURECLICK... 173 endocet... 5 endodan... 5 endur-acin... 104 enema... 160, 162 enema disposable... 159, 160 enemeez... 160 enemeez plus... 160 ENGERIX-B (PF)... 177 ENGERIX-B PEDIATRIC (PF)... 177 enoxaparin... 81 enpresse... 112 enskyce... 112 entacapone... 69 entecavir... 80 entre-cough... 122 ENTRESTO... 92 enulose... 155 ENVARSUS XR... 173 EPCLUSA... 79 ephedrine sulfate... 100 epinastine... 144 epinephrine... 100 I-8 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
epinephrine hcl (pf)... 100 EPIPEN 2-PAK... 100 EPIPEN JR 2-PAK... 100 epitol... 42 EPIVIR HBV... 75 eplerenone... 106 EPOGEN... 83 epoprostenol (glycine)... 208 EPZICOM... 75 eq gentle... 144 equalactin... 160 ergocalciferol (vitamin d2). 216, 229 ergoloid... 185 ERGOMAR... 64 ERIVEDGE... 33 errin... 112 ery pads... 133 ery-tab... 24 ERY-TAB... 24 ERYTHROCIN... 24 erythrocin (as stearate)... 24 erythromycin... 25, 147 erythromycin ethylsuccinate.. 24 erythromycin with ethanol... 133 ESBRIET... 205 escitalopram oxalate... 47 esmolol... 95 esomeprazole sodium... 152 essentia... 216 essential balance with lutein 217 essential daily... 217 estarylla... 112 ESTRACE... 166 estradiol... 166 estradiol valerate... 167 estradiol-norethindrone acet. 167 estropipate... 167 eszopiclone... 207 ethambutol... 65 ethamolin... 100 ethosuximide... 42 etodolac... 13 ETOPOPHOS... 33 etoposide... 33 EVOTAZ... 75 exemestane... 33 EXJADE... 165 EXONDYS 51... 185 expectorant... 122 expectorant dm... 122 expectorant max strength... 122 EXTAVIA... 186 extra cleansing douche... 188 eye health plus lutein... 216 F FABRAZYME... 141 fallback solo... 112 falmina (28)... 112 famciclovir... 80 famotidine... 152 famotidine (pf)... 152 famotidine (pf)-nacl (iso-os) 152 FANAPT... 71 FARESTON... 33 FARYDAK... 33 FASLODEX... 33 felbamate... 42 felodipine... 102 feminine care douche... 188 FEMRING... 167 fenofibrate... 104 fenofibrate micronized... 104 fenofibrate nanocrystallized. 104 fenofibric acid... 104 fenofibric acid (choline)... 104 fenoprofen... 13 fentanyl... 5 fentanyl citrate... 5 ferocon... 217 ferretts... 217 ferrex 150... 217 ferrex 150 plus... 217 FERRIPROX... 165 ferrocite... 217 ferrous fumarate... 217 ferrous gluconate... 217, 219 ferrous sulfate... 213, 217 FETZIMA... 47 feverall... 5 fexofenadine... 61 fiber (calcium polycarbophil)... 160 fiber laxative (methylcellulo)163 fiber smooth... 163 fiber therapy (m-cell/sugar).. 161 fiber therapy (m-cellulose)... 159 fiber therapy (psyllium)... 160 fiber therapy (psyllium/sugar)... 160 fiber-lax... 161 fibertab... 161 finasteride... 186 FIRAZYR... 100 flanax antacid... 155 FLEBOGAMMA DIF... 173 flecainide... 94 FLECTOR... 13 FLEET BISACODYL... 161 flintstones complete (iron)... 217 flintstones multivitamin... 217 flintstones with iron... 218 flintstones/extra c... 217 FLOVENT DISKUS... 202 FLOVENT HFA... 202, 203 floxuridine... 33 flu formula daytime-nighttime... 125 flu relief therapy daytime... 125 flu severe cold-congestion... 127 flucaine... 144 fluconazole... 55 fluconazole in dextrose(iso-o) 55 fluconazole in nacl (iso-osm). 55 flucytosine... 55 fludrocortisone... 168 I-9 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
flumazenil... 108 flunisolide... 149 fluocinonide... 136 fluorometholone... 150 fluorouracil... 33, 132 fluoxetine... 47 fluphenazine decanoate... 71 fluphenazine hcl... 72 flurbiprofen... 13 flurbiprofen sodium... 150 flutamide... 33 fluticasone... 136, 150 fluvoxamine... 48 foaming antacid... 155, 158 folic acid... 218 FOLIC ACID... 218 fomepizole... 186 fondaparinux... 81 foot odor control... 57 FORTEO... 183 FORTICAL... 183 foscarnet... 78 fosfree... 218 fosinopril... 93 fosinopril-hydrochlorothiazide... 93 fosphenytoin... 42 FREAMINE HBC 6.9 %... 89 FREAMINE III 10 %... 89 fungi cure... 55 FUNGI-NAIL... 55 fungoid-d... 56 furosemide... 103 FUSILEV... 186 FUZEON... 75 FYCOMPA... 42 G gabapentin... 42 GABITRIL... 42 galantamine... 45 GAMASTAN S/D... 173 GAMMAGARD LIQUID... 173 GAMMAPLEX... 173 ganciclovir sodium... 80 GARDASIL (PF)... 177 GARDASIL 9 (PF)... 177 gas relief... 151 gas relief extra strength... 150 gas-x ultra-strength... 151 gatifloxacin... 147 GATTEX 30-VIAL... 156 GATTEX ONE-VIAL... 156 GAUZE PAD... 186 gavilyte-c... 161 gavilyte-g... 161 gavilyte-n... 161 GAZYVA... 33 gelusil antacid and anti-gas.. 156 gemfibrozil... 104 generlac... 156 gengraf... 173 GENOTROPIN... 169 GENOTROPIN MINIQUICK... 169 gentak... 147 gentamicin... 18, 134, 147 gentamicin in nacl (iso-osm).. 18 gentamicin sulfate (ped) (pf).. 18 gentamicin sulfate (pf)... 18 GENTEAL MILD TO MODERATE... 144 GENTEAL GEL... 144 GENTEAL MILD... 144 GENTEAL SEVERE... 144 genteal tears... 144 gentlelax... 161 GENVOYA... 75 GEODON... 72 geravim... 218 geriaton... 218 geri-hydrolac... 132 geri-tussin dm... 122 gianvi (28)... 112 gildagia... 112 gildess 1.5/30 (21)... 112 gildess 1/20 (21)... 112 gildess 24 fe... 112 gildess fe 1.5/30 (28)... 112 gildess fe 1/20 (28)... 112 GILENYA... 186 GILOTRIF... 33 GLEOSTINE... 33 glimepiride... 53 glipizide... 53 glipizide-metformin... 53 GLUCAGEN HYPOKIT... 186 GLUCAGON EMERGENCY KIT (HUMAN)... 186 gluco burst... 89 glucose... 89 glucose gel... 89 glutose 15... 89 glyburide... 53 glyburide micronized... 53 glyburide-metformin... 53 glycolax... 161 glycopyrrolate... 156 glydo... 15 GLYXAMBI... 50 granisetron (pf)... 67 granisetron hcl... 67 GRANIX... 83 griseofulvin microsize... 56 guaifenesin... 122, 123 guaifenesin dac... 122 guanfacine... 91, 108 guanidine... 186 gummi bear multivitamin... 218, 223 gummy swirls... 214 H hair vitamins... 218 hair,skin and nails... 226, 228 halobetasol propionate. 136, 137 haloperidol... 72 haloperidol decanoate... 72 I-10 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
haloperidol lactate... 72 HARVONI... 79 HAVRIX (PF)... 177, 178 head congestion day-night... 123 healthy eyes... 218 healthylax... 161 heather... 112 hemocyte... 218 heparin (porcine)... 82 heparin (porcine) in 5 % dex.. 82 heparin (porcine) in nacl (pf). 82 heparin(porcine) in 0.45% nacl... 82 heparin, porcine (pf)... 82 HEPATAMINE 8%... 90 HEPATASOL 8 %... 90 HERCEPTIN... 33 HETLIOZ... 207 HEXALEN... 33 hi-b complex... 218 HIBERIX (PF)... 178 hi-cal plus vit d... 200 homatropaire... 144 homatropine hbr... 144 honey bears... 219 honey bears with iron-zinc... 219 HUMIRA... 174 HUMIRA PEDIATRIC CROHN'S START... 173 HUMIRA PEN... 174 HUMIRA PEN CROHN'S-UC- HS START... 173 HUMIRA PEN PSORIASIS- UVEITIS... 174 HUMULIN R U-500 (CONC) KWIKPEN... 52 HUMULIN R U-500 (CONCENTRATED)... 52 hydralazine... 100 hydrochlorothiazide... 103 hydrocil instant... 161 hydrocodone-acetaminophen 5, 6 hydrocodone-chlorpheniramine... 123 hydrocodone-homatropine... 123 hydrocodone-ibuprofen... 6 hydrocortisone... 137, 168 hydrocortisone acet-aloe vera... 137 hydrocortisone acetate... 137 hydrocortisone butyrate... 137 hydrocortisone butyr-emollient... 137 hydrocortisone valerate 137, 138 hydromet... 123 hydromorphone... 6 hydromorphone (pf)... 6 hydroskin... 137 hydroxychloroquine... 68 hydroxyprogesterone caproate... 171 hydroxyurea... 33 hydroxyzine hcl... 186 hydroxyzine pamoate... 186 HYPERLYTE CR... 195 HYPERRAB S/D (PF)... 174 HYQVIA... 174 HYQVIA IG COMPONENT... 174 HYSINGLA ER... 6 I ibandronate... 183 IBRANCE... 34 ibuprofen... 12, 13, 14 ibuprofen jr strength... 13 icaps plus... 219 ICLUSIG... 34 iferex 150... 219 ifosfamide... 34 ifosfamide-mesna... 34 ILARIS (PF)... 174 ILEVRO... 150 imatinib... 34 IMBRUVICA... 34 imipenem-cilastatin... 25 imipramine hcl... 48 imipramine pamoate... 48 imiquimod... 132 IMLYGIC... 34 imodium a-d... 156 IMODIUM A-D... 156 IMOGAM RABIES-HT (PF)... 174 IMOVAX RABIES VACCINE (PF)... 178 INCRELEX... 169 indapamide... 103 indomethacin... 13 indomethacin sodium... 13 INFANRIX (DTAP) (PF)... 178 infants gas relief... 151 infant's ibuprofen... 13 INFANT'S MOTRIN... 14 infants' non-aspirin cold... 129 INLYTA... 34 insta-glucose... 90 INSULIN SYRINGE-NEEDLE U-100... 140 INTELENCE... 75 INTRALIPID... 90 INTRON A... 79, 80 introvale... 112 INVANZ... 25 INVEGA SUSTENNA... 72 INVEGA TRINZA... 72 INVIRASE... 76 INVOKAMET... 50 INVOKAMET XR... 50 INVOKANA... 50 inzo antifungal... 56 iodine... 140 IONOSOL-B IN D5W... 195 IONOSOL-MB IN D5W... 195 IPOL... 178 ipratropium bromide... 144, 203 ipratropium-albuterol... 203 I-11 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
IPRIVASK... 82 irbesartan... 92 irbesartan-hydrochlorothiazide... 92 IRESSA... 34 iron high potency... 214 ISENTRESS... 76 ISOLYTE M IN 5 % DEXTROSE... 195 ISOLYTE-H IN 5 % DEXTROSE... 195 ISOLYTE-P IN 5 % DEXTROSE... 195 ISOLYTE-S... 195 isoniazid... 65 isopto tears... 144 isosorbide dinitrate... 106 isosorbide mononitrate... 106 isradipine... 102 itraconazole... 56 ivermectin... 68 IXEMPRA... 34 IXIARO (PF)... 178 J JAKAFI... 35 jantoven... 82 JANUMET... 50 JANUMET XR... 50 JANUVIA... 50 JARDIANCE... 50 jencycla... 112 JENTADUETO... 50 JENTADUETO XR... 51 jolessa... 112 jolivette... 112 jr. acetaminophen... 10 juleber... 112 junel 1.5/30 (21)... 112 junel 1/20 (21)... 113 junel fe 1.5/30 (28)... 113 junel fe 1/20 (28)... 113 junel fe 24... 113 junior mapap... 6 JUXTAPID... 104 K KABIVEN... 90 KALETRA... 76 KALYDECO... 206 KANUMA... 141 kaopectate (bismuth subsalicy)... 156 kariva (28)... 113 k-effervescent... 195 kelnor 1/35 (28)... 113 KELP (IODINE)... 195 ketoconazole... 56 ketoprofen... 14 ketorolac... 14, 150 KEVEYIS... 186 KEYTRUDA... 35 kids mini enema... 159 kid's vitamins... 223 kid's vitamins + extra c... 223 kids vitamins + iron... 223 kid's vitamins + iron... 223 kimidess (28)... 113 KINERET... 174 KINRIX (PF)... 178 kionex... 156 kionex (with sorbitol)... 156 KLOR-CON 10... 195 klor-con m10... 195 klor-con m15... 195 klor-con m20... 196 klor-con sprinkle... 196 konsyl (sugar)... 161 konsyl fiber... 161 KONSYL SUGAR-FREE... 161 KORLYM... 51 KRYSTEXXA... 141 kurvelo... 113 KUVAN... 141 KYNAMRO... 104 KYPROLIS... 35 L l norgest/e.estradiol-e.estrad. 113 labetalol... 95 LACRISERT... 144 LACTATED RINGERS... 182 LACTINOL HX... 132 lactulose... 156 LAMICTAL... 42 LAMISIL (AEROSOL)... 56 lamisil af... 56 LAMISIL AT... 56 lamivudine... 76 lamivudine-zidovudine... 76 lamotrigine... 42, 43 LANOXIN... 101 lansoprazole... 152 LANTUS... 52 LANTUS SOLOSTAR... 52 larin 1.5/30 (21)... 113 larin 1/20 (21)... 113 larin 24 fe... 113 larin fe 1.5/30 (28)... 113 larin fe 1/20 (28)... 113 larissia... 113 latanoprost... 191 LATUDA... 72 laxative peg 3350... 162 LAZANDA... 6 leena 28... 113 leflunomide... 174 LEMTRADA... 186 LENVIMA... 35 lessina... 113 LETAIRIS... 208 letrozole... 35 leucovorin calcium... 186 LEUKERAN... 35 LEUKINE... 83 leuprolide... 35 levetiracetam... 43 levobunolol... 191 levocarnitine... 187 I-12 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
levocarnitine (with sugar)... 187 levocetirizine... 61 levofloxacin... 28, 147 levofloxacin in d5w... 28 levoleucovorin... 187 levonest (28)... 113 levonorgestrel... 114 levonorgestrel-ethinyl estrad 114 levonorg-eth estrad triphasic 114 levora-28... 114 levothyroxine... 171 LEXIVA... 76 lice cream rinse... 139 lice killing... 139 lice treatment... 139 lice treatment (permethrin).. 139 lidocaine... 15 lidocaine (pf)... 15, 94 lidocaine hcl... 15 lidocaine in 5 % dextrose (pf) 94 lidocaine viscous... 15 lidocaine-prilocaine... 15 life-pack women's... 219 linezolid... 19 LINZESS... 156 liothyronine... 172 lipodox... 35 lipodox 50... 35 liquibid d-r... 123 liquid calcium with vitamin d... 196 LIQUI-E... 219 lisinopril... 93 lisinopril-hydrochlorothiazide 93 lithium carbonate... 108 lithium citrate... 108 little animals... 219 little animals-iron... 219 LIVALO... 104 lobana bath... 132 lohist-dm... 123 lomedia 24 fe... 114 lomustine... 35 LONSURF... 35 loperamide... 155, 156, 158 loratadine... 61 loratadine-d... 61, 62 lorazepam... 18 lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 lortuss ex... 123 loryna (28)... 114 losartan... 92 losartan-hydrochlorothiazide. 92 LOTEMAX... 150 LOTRONEX... 156 lovastatin... 104 low-ogestrel (28)... 114 loxapine succinate... 73 lubricant dry eye relief... 143 lubricant eye... 143 lubricant eye (cmc-glycer)(pf)... 145 lubricant eye (cmc-glycerin) 145 lubricant eye (pg-peg 400)... 146 lubricant eye (polyv alcohol) 145 lubricant eye (propyl glycol) 145 lubricant eye drops... 143 lubricant gel... 143 lubricating drops... 143 lubrifresh pm... 145 LUMIGAN... 191 LUPRON DEPOT... 36 LUPRON DEPOT (3 MONTH)... 36 LUPRON DEPOT (4 MONTH)... 36 LUPRON DEPOT (6 MONTH)... 36 LUPRON DEPOT-PED... 169 LUPRON DEPOT-PED (3 MONTH)... 169 lutera (28)... 114 LYNPARZA... 36 LYRICA... 43 lysiplex plus... 219 LYSODREN... 36 lyza... 114 M maalox advanced... 157 MACUVITE... 219 MACUVITE EYE CARE... 219 mag 64... 196 mag-delay... 196 mag-g... 196 MAGNEBIND 300... 157 magnebind 400... 163 magnesium... 193, 196 magnesium (oxide/aa chelate)... 196 magnesium chloride... 196 magnesium gluconate... 196 magnesium oxide... 157, 158 magnesium sulf in 0.45% nacl... 196 magnesium sulfate... 197 magnesium sulfate in d5w... 196 magnesium sulfate in water. 196, 197 malathion... 139 mapap (acetaminophen)... 6, 7 mapap arthritis pain... 7 mapap extra strength... 7 maprotiline... 48 mar-cof bp... 123 mar-cof cg... 123 margesic... 7 marlissa... 114 MARPLAN... 48 masanti double strength... 157 MATULANE... 36 matzim la... 97 maximum daily multivitamin... 223 maximum strength flu... 125 I-13 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
meclizine... 67 medroxyprogesterone... 171 mefenamic acid... 14 mefloquine... 68 MEFOXIN IN DEXTROSE (ISO-OSM)... 23 mega multiple/chelated mineral... 219 mega multivitamin with mineral... 219 MEGACE ES... 171 megestrol... 36, 171 MEKINIST... 36 meloxicam... 14 memantine... 45 MENACTRA (PF)... 178 M-END DM... 123 MENEST... 167 MENHIBRIX (PF)... 178 MENOMUNE - A/C/Y/W-135 (PF)... 178 men's daily gummies... 214 men's multi-vitamin... 214 men's one daily... 216 MENVEO A-C-Y-W-135-DIP (PF)... 179 MENVEO MENA COMPONENT (PF)... 179 MENVEO MENCYW-135 COMPNT (PF)... 179 MEPHYTON... 219 mercaptopurine... 36 meropenem... 25 mesalamine... 182 mesehist dm... 123 mesna... 187 MESNEX... 187 MESTINON... 187 MESTINON TIMESPAN... 187 metaproterenol... 204 metaxall... 206 metaxalone... 206 metformin... 51 methadone... 7 methadose... 7 methazolamide... 191 methenamine hippurate... 20 methimazole... 172 methocarbamol... 206 methotrexate sodium... 36 methotrexate sodium (pf)... 36 methoxsalen rapid... 132 methscopolamine... 157 methyclothiazide... 103 methylphenidate... 108, 109 methylprednisolone... 168 methylprednisolone acetate.. 168 methylprednisolone sodium succ... 168 metipranolol... 191 metoclopramide hcl... 157 metolazone... 103 metoprolol succinate... 95 metoprolol ta-hydrochlorothiaz... 96 metoprolol tartrate... 96 metronidazole... 20, 64, 134 metronidazole in nacl (iso-os) 20 mexiletine... 94 mgo... 157 MIACALCIN... 183 mi-acid... 157 mi-acid gas relief... 151 micatin... 56 miconazole 7... 56 miconazole nitrate... 55, 56 miconazole-3... 56 microgestin 1.5/30 (21)... 114 microgestin 1/20 (21)... 114 microgestin fe 1.5/30 (28)... 114 microgestin fe 1/20 (28)... 114 midodrine... 91 miglitol... 51 milk of magnesia... 161 milltrium senior... 220 milrinone... 101 milrinone in 5 % dextrose... 101 mimvey... 167 mimvey lo... 167 mineral oil... 188, 190 MINERAL OIL... 187 mineral oil laxative... 161 minitran... 106 minocycline... 30 minoxidil... 106 mintox... 158 mintox maximum strength... 157 mintox plus... 157 MIRCERA... 83 mirtazapine... 48 misoprostol... 152 mitoxantrone... 36 M-M-R II (PF)... 179 moexipril... 93 moexipril-hydrochlorothiazide... 93 molindone... 73 mometasone... 138 MONISTAT 3... 56 monistat 7... 56 mono-linyah... 114 mononessa (28)... 115 montelukast... 203 morphine... 7, 8 MORPHINE... 8 morphine (pf) in 0.9 % nacl... 7 morphine concentrate... 7 morphine in dextrose 5 %... 8 morrhuate sodium... 187 motion sickness... 66 motion sickness (meclizine)... 67 MOVANTIK... 158 MOVIPREP... 161 MOXEZA... 147 moxifloxacin... 28 MOZOBIL... 83 I-14 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
mucus dm... 123 mucus dm max... 123 mucus relief... 123, 125 mucus relief cough... 127 MULTAQ... 94 multi complete with iron... 220 multi-day with iron... 220 multi-delyn with iron... 220 multiple vitamin-minerals... 220 multiple vitamins... 220 multiple vitamins with iron.. 220 multi-symptom cold night time... 125 multivital platinum... 223 multivitamin 50 plus... 222 multi-vitamin hp/minerals... 220 multivitamin with fluoride... 220 multivitamin with iron. 220, 226 multivitamin with minerals.. 220 multi-vite... 224 multi-vite 50 and over... 223 mupirocin... 134 mupirocin calcium... 134 muro 128... 145 my favorite multiple... 220 my way... 115 myco nail a... 56 mycophenolate mofetil. 174, 175 mycophenolate sodium... 175 MYOZYME... 141 MYRBETRIQ... 164 mytab gas... 151 mytab gas maximum strength... 151 my-vitalife... 220 myzilra... 115 N nabumetone... 14 nadolol... 96 nafcillin... 26, 27 NAGLAZYME... 141 naloxone... 16 naltrexone... 16 NAMENDA XR... 45, 46 NAMZARIC... 46 naphazoline... 145 naproxen... 14 naproxen sodium... 14 naratriptan... 64 NARCAN... 16 nasal and sinus decongestant 123 nasal decongestant (oxymetazl)... 145 NASCOBAL... 220 nasohist dm... 123 NATACYN... 147 nateglinide... 51 NATPARA... 183 natural b-100... 231 natural b-100 complex... 226 natural balance... 145 natural calcium... 197 natural fiber laxative therapy 161 natural tears (pf)... 143 nature's tears (hypromellose) 145 NEBUPENT... 68 necon 0.5/35 (28)... 115 necon 1/35 (28)... 115 necon 1/50 (28)... 115 necon 10/11 (28)... 115 necon 7/7/7 (28)... 115 nefazodone... 48 NEO DM... 123 neomycin... 18 neomycin-bacitracin-poly-hc 147 neomycin-bacitracin-polymyxin... 148 neomycin-polymyxin b gu... 134 neomycin-polymyxin b- dexameth... 148 neomycin-polymyxingramicidin... 148 neomycin-polymyxin-hc... 148 neo-polycin... 148 neo-polycin hc... 148 neosporin (neo-bac-polym).. 134 neosporin anti-itch... 138 neo-synephrine 12 h spr (oxym)... 145 neo-tuss... 123 nephplex rx... 220 NEPHRAMINE 5.4 %... 90 nephron fa... 221 nephro-vite rx... 221 NEULASTA... 83 NEUMEGA... 83 NEUPOGEN... 84 NEUPRO... 70 NEVANAC... 150 nevirapine... 76 NEXAFED... 124 NEXAVAR... 37 next choice one dose... 115 niacin... 104, 105 niacinamide... 105, 221 niacor... 105 nicardipine... 102 NICODERM CQ... 16 nicorelief... 16 nicorette... 16 nicotine... 16, 17 nicotine (polacrilex)... 16, 17 NICOTROL... 17 nifedical xl... 102 nifedipine... 102 night time... 125 night time cold medicine... 124 night time cold-flu... 127 night time cold-flu relief... 127 night time cough-sore throat 124 nighttime cough... 124 nikki (28)... 115 NILANDRON... 37 nilutamide... 37 NINLARO... 37 I-15 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
NITE TIME COLD-FLU RELIEF... 124 NITRO-BID... 107 nitrofurantoin macrocrystal... 20 nitrofurantoin monohyd/m-cryst... 20 nitroglycerin... 107 nitroglycerin in 5 % dextrose 107 NITROSTAT... 107 NIX CREME RINSE... 139 nohist-dm... 124 non-aspirin cold... 127 non-aspirin extra strength.. 8, 10 non-aspirin flu... 129 non-aspirin jr strength... 5 nora-be... 115 NORDITROPIN FLEXPRO 170 norepinephrine bitartrate... 101 norethindrone (contraceptive)... 115 norethindrone acetate... 171 norethindrone ac-eth estradiol... 115 norethindrone-e.estradiol-iron... 115 norgestimate-ethinyl estradiol... 115 norlyroc... 115 NORMOSOL-M IN 5 % DEXTROSE... 197 NORMOSOL-R PH 7.4... 197 nortemp... 8 NORTHERA... 91 nortrel 0.5/35 (28)... 116 nortrel 1/35 (21)... 116 nortrel 1/35 (28)... 116 nortrel 7/7/7 (28)... 116 nortriptyline... 48 NORVIR... 76 NOVOLIN 70/30... 52 NOVOLIN N... 52 NOVOLIN R... 52 NOVOLOG... 53 NOVOLOG FLEXPEN... 52 NOVOLOG MIX 70-30... 53 NOVOLOG MIX 70-30 FLEXPEN... 53 NOVOLOG PENFILL... 53 NOXAFIL... 57 NUCALA... 206 NUCYNTA... 9 NUCYNTA ER... 8 NUEDEXTA... 109 nu-iron... 221 NULOJIX... 175 nu-mag... 197 NUPLAZID... 73 NUTRESTORE... 158 NUTRILIPID... 90 NUTRILYTE... 197 NUTRILYTE II... 197 NUVARING... 116 nyamyc... 57 nystatin... 57 nystatin-triamcinolone... 57 nystop... 57 nyt-time sleep... 62 O OCALIVA... 158 ocean nasal... 145 ocella... 116 OCTAGAM... 175 octreotide acetate... 170 ocutabs... 221 ODEFSEY... 76 ODOMZO... 37 OFEV... 206 ofloxacin... 28, 148 ogestrel (28)... 116 olanzapine... 73 olanzapine-fluoxetine... 48 olopatadine... 145 OLYSIO... 79 omega-3 acid ethyl esters... 105 omeprazole... 152 omeprazole magnesium... 152 omeprazole-sodium bicarbonate... 152, 153 ONCASPAR... 37 oncovite... 221 ondansetron... 67 ondansetron hcl... 67 ondansetron hcl (pf)... 67 one daily... 221, 224 one daily 50 plus... 216 one daily complete... 221 one daily energy... 224 one daily essential 216, 218, 221 one daily maximum (with ca)... 216 one daily multi-vit w-mineral... 221 one daily multivitamin... 221 one daily multivit-iron(folic) 221 one daily plus iron 219, 221, 224 one daily plus minerals... 221 one daily with iron... 221 one-a-day essential... 221 one-a-day maximum formula221 one-a-day teen advantage... 221, 222 ONFI... 18, 138 opcicon one-step... 116 OPDIVO... 37 OPSUMIT... 208 option 2... 116 opti-vitamins... 226 oral saline laxative... 162 oralone... 130 ORENCIA... 175 ORENCIA (WITH MALTOSE)... 175 ORENCIA CLICKJECT... 187 ORENITRAM... 209 ORFADIN... 141, 187 ORKAMBI... 206 I-16 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
orsythia... 116 OTEZLA... 187 OTEZLA STARTER... 187 OTREXUP (PF)... 187 oxacillin... 27 oxacillin in dextrose(iso-osm) 27 oxandrolone... 165 oxcarbazepine... 43 OXTELLAR XR... 43 oxybutynin chloride... 164 oxycodone... 9 oxycodone-acetaminophen... 9 oxycodone-aspirin... 9 OXYCONTIN... 9 oxymorphone... 9, 10 oysco 500/d... 197 oysco d... 197 oysco-500... 197 oyster shell calcium 500... 197 oyster shell calcium-vit d2... 200 oyster shell calcium-vit d3.. 197, 198 oystercal-d... 198 P pacerone... 94 pain relief... 10 pain relief adult... 5 pain reliever jr strength... 10 paliperidone... 73 pancrelipase 5000... 141 PANRETIN... 132 PANTILINERS... 188 pantoprazole... 152 papaverine... 101 paricalcitol... 183 PARICALCITOL... 183 paromomycin... 68 paroxetine hcl... 48 PASER... 65 PATADAY... 145 PAXIL... 48 pecgen dmx... 124 pedia relief... 127 pedia relief cough-cold... 124 pedia relief infant... 129 pediacare multi-symptom cold... 124 PEDIARIX (PF)... 179 pediatric electrolyte... 193, 198, 200, 201 pediatric freezer pops... 200 pediatric multivitamin.. 220, 225 PEDVAX HIB (PF)... 179 peg 3350-electrolytes... 162 PEGANONE... 43 PEGASYS... 80 PEGASYS PROCLICK... 80 peg-electrolyte soln... 162 PEGINTRON... 80 PEN NEEDLE, DIABETIC. 140 penicillin g pot in dextrose... 27 penicillin g potassium... 27 penicillin g procaine... 27 penicillin v potassium... 27 PENTACEL (PF)... 179 PENTAM... 69 pentoxifylline... 85 pep-t-med... 157 peri-colace... 162 PERIKABIVEN... 90 perindopril erbumine... 93 periogard... 130 permethrin... 139 perphenazine... 73 perphenazine-amitriptyline... 49 persa-gel... 132 pfizerpen-g... 27 pharbetol... 10 pharmacist favorite multi-vit 222 phenadoz... 67 phenelzine... 49 phenobarbital... 43 phenobarbital sodium... 43 phenylephrine hcl... 91, 145 phenylhistine dh... 124 phenytoin... 44 phenytoin sodium... 44 phenytoin sodium extended... 44 philith... 116 phillips... 158 phillips liqui-gels... 162 PHOSLYRA... 163 PHOS-NAK... 198 phospha 250 neutral... 198 phosphate laxative... 162 PHOSPHOLINE IODIDE... 191 phytonadione (vitamin k1)... 231 PICATO... 132 pilocarpine hcl... 130, 191 pimozide... 73 pimtrea (28)... 116 pindolol... 96 pink bismuth... 158 pioglitazone... 51 pioglitazone-glimepiride... 51 pioglitazone-metformin... 51 piperacillin-tazobactam... 27 pirmella... 116 piroxicam... 14 PLAN B ONE-STEP... 116 PLASMA-LYTE 148... 198 PLASMA-LYTE A... 198 PLASMA-LYTE-56 IN 5 % DEXTROSE... 198 PLEGRIDY... 188 podocon... 132 podofilox... 132 polyethylene glycol 3350... 162 poly-iron... 222 polymyxin b sulfate... 21 polymyxin b sulf-trimethoprim... 148 poly-tussin... 124 poly-vita... 222 poly-vita (iron)... 222 poly-vitamin... 222 I-17 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
poly-vitamin with iron... 222 poly-vitamins... 222 POMALYST... 37 portia... 116 PORTRAZZA... 37 potassium acetate... 198 potassium bicarb and chloride... 198 potassium bicarb-citric acid. 198 potassium chlorid-d5-0.45%nacl... 198 potassium chloride... 199, 200 potassium chloride in 0.9%nacl... 198 potassium chloride in 5 % dex... 199 potassium chloride in lr-d5.. 199 potassium chloride-0.45 % nacl... 199 potassium chloride-d5-0.2%nacl... 199 potassium chloride-d5-0.3%nacl... 199 potassium chloride-d5-0.9%nacl... 200 potassium citrate... 200 potassium citrate-citric acid. 200 potassium hydroxide... 132 potassium phosphate m-/d-basic... 200 POTIGA... 44 PRADAXA... 82 PRALUENT PEN... 105 PRALUENT SYRINGE... 105 pramipexole... 70 pravastatin... 105 prazosin... 91 prednicarbate... 138 prednisolone acetate... 150 prednisolone sodium phosphate... 150, 168 prednisone... 168 PREMARIN... 167 PREMASOL 10 %... 90 PREMASOL 6 %... 90 PREMPHASE... 167 PREMPRO... 167 prenatal... 218, 222, 226 prenatal formula... 223 prenatal plus (calcium carb). 222 prenatal tablet... 224 prenatal vit#96-ferrous fum-fa... 222 prenatal vitamin... 214, 222 prenatal vitamin plus low iron... 222 prenatal vitamin with minerals... 222 prenatal vit-iron fumarate-fa 222 preparation h hydrocortisone 138 PREVAIL BLADDER CONTROL PAD... 159 prevalite... 105 PREVIDENT 5000 SENSITIVE... 130 previfem... 116 PREZCOBIX... 77 PREZISTA... 77 PRIFTIN... 65 PRILOSEC OTC... 152 PRIMAQUINE... 69 primidone... 44 PRISTIQ... 49 PRIVIGEN... 175 PROAIR HFA... 204 PROAIR RESPICLICK... 204 probenecid... 188 probenecid-colchicine... 188 procainamide... 94 PROCALAMINE 3%... 90 prochlorperazine... 67 prochlorperazine edisylate... 67 prochlorperazine maleate... 67 PROCRIT... 84 procto-med hc... 138 procto-pak... 138 proctosol hc... 138 proctozone-hc... 138 PROCYSBI... 188 progesterone in oil... 171 progesterone micronized... 171 PROGLYCEM... 107 PROGRAF... 175 PROLASTIN-C... 206 PROLENSA... 150 PROLEUKIN... 37 PROLIA... 183 PROMACTA... 84 promethazine... 62, 67 promethazine vc-codeine... 124 promethazine-codeine... 124 promethazine-dm... 124 promethegan... 67 promolaxin... 162 propafenone... 94 propantheline... 40 proparacaine... 145 propranolol... 96 propranolol-hydrochlorothiazid... 96 propylthiouracil... 172 PROQUAD (PF)... 179 prosight... 222 PROSOL 20 %... 90 protamine... 84 protriptyline... 49 pseudoephedrine hcl... 124, 125 PULMOZYME... 141 pure and gentle eye... 145 purelax... 160 PURIXAN... 37 pyrazinamide... 65 pyridostigmine bromide... 188 pyridoxine (vitamin b6)... 223 Q q-dryl... 62 I-18 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
q-pap... 10 q-pap extra strength... 10 q-tapp dm... 125 q-tussin... 125 q-tussin dm... 125 QUADRACEL (PF)... 179 quasense... 116 quetiapine... 73 QUILLIVANT XR... 109 quinapril... 93 quinapril-hydrochlorothiazide 94 quinidine gluconate... 95 quinidine sulfate... 95 quinine sulfate... 69 QVAR... 203 R RABAVERT (PF)... 179 raloxifene... 167 ramipril... 94 RANEXA... 101 ranitidine hcl... 153 RAPAMUNE... 175 RASUVO (PF)... 188 RAVICTI... 158 react... 116 REBIF (WITH ALBUMIN) 188 REBIF REBIDOSE... 188 REBIF TITRATION PACK 189 reclipsen (28)... 116 RECOMBIVAX HB (PF)... 180 recort plus... 138 refenesen... 126 refenesen pe... 126 REFRESH CELLUVISC... 146 REFRESH CLASSIC (PF).. 146 REFRESH LACRI-LUBE... 146 REFRESH OPTIVE... 146 REFRESH OPTIVE ADVANCED... 148 reguloid... 162 relcof c... 126 RELENZA DISKHALER... 78 RELISTOR... 158 remedy phytoplex antifungal. 57 REMICADE... 189 REMODULIN... 209 RENAGEL... 163 rena-vite rx... 225 RENVELA... 163 repaglinide... 51 repaglinide-metformin... 51 REPATHA PUSHTRONEX 105 REPATHA SURECLICK... 105 REPATHA SYRINGE... 105 reprexain... 10 RESCRIPTOR... 77 RESTASIS... 150 retaine cmc... 146 RETROVIR... 77 revive plus... 144 REVLIMID... 37 revonto... 207 REXULTI... 73 REYATAZ... 77 REZIRA... 126 ribasphere... 81 RIDAURA... 175 rifabutin... 65 rifampin... 66 RIFATER... 66 ri-gel ii... 158 riluzole... 109 rimantadine... 78 ri-mox... 158 ringers... 182, 200 risedronate... 183, 184 RISPERDAL CONSTA... 73 risperidone... 73, 74 RITUXAN... 37 rivastigmine... 46 rivastigmine tartrate... 46 rizatriptan... 64 robafen... 126 robafen cough... 126 robafen dm... 126 robitussin cough-chest cong dm... 126 ROBITUSSIN LONG-ACTING... 126 robitussin pediatric... 126 ropinirole... 70 rosadan... 134 rosuvastatin... 105 ROTARIX... 180 ROTATEQ VACCINE... 180 ROWEEPRA... 44 roxicet... 10 ROZEREM... 207 rydex... 126 rynex dm... 126 S SABRIL... 44 safe tussin dm... 126 SAIZEN... 170 SAIZEN CLICK.EASY... 170 saline mist... 146 SANDOSTATIN LAR DEPOT... 170 SANTYL... 132 SAPHRIS (BLACK CHERRY)... 74 SAVELLA... 109 scooby-doo one a day... 225 scot-tussin dm... 126 scot-tussin expectorant... 126 sea soft nasal mist... 146 selegiline hcl... 70 selenium sulfide... 134 SELZENTRY... 77 senexon... 162 senior tabs... 225 senna... 162, 163 senna lax... 163 senna laxative... 160 senna with docusate sodium. 160 senokot-s... 163 I-19 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
SENSIPAR... 189 sentry... 225 sentry senior... 225 SEREVENT DISKUS... 204 SEROSTIM... 170 sertraline... 49 setlakin... 116 sharobel... 116 SIGNIFOR... 189 silace... 163 siladryl sa... 62 silapap... 10 sildenafil... 209 SILENOR... 49 siltussin sa... 126 silver nitrate... 134 silver sulfadiazine... 134 SIMBRINZA... 191 simethicone... 151 simply sleep... 62 SIMPONI... 189 SIMPONI ARIA... 189 simvastatin... 105, 106 sinus and allergy(pseudoephed)... 62 sirolimus... 175 SIRTURO... 66 skin treatment... 132 sleep aid (diphenhydramine).. 62 sleep aid (doxylamine)... 62 smoflipid... 90 smoothlax... 163 sodium acetate... 201 sodium bicarbonate... 158, 201 sodium chloride... 146, 182, 201, 206 sodium chloride 0.45 %... 201 sodium chloride 0.9 %... 201 sodium chloride 3 %... 201 sodium chloride 5 %... 201 sodium fluoride... 226 sodium lactate... 201 sodium phosphate... 201 sodium polystyrene (sorb free)... 159 sodium polystyrene sulfonate... 159 sodium thiosulfate... 165 SOLTAMOX... 37 SOLU-CORTEF (PF)... 169 SOMATULINE DEPOT... 170 SOMAVERT... 171 soothe (bismuth subsalicylate)... 159 soothe regular strength... 159 sorbitol... 182 sorbitol-mannitol... 182 sorine... 96 sotalol... 96 sotalol af... 96 SOVALDI... 79 spectravite... 214 spectravite adult 50+... 214 spectravite advanced formula... 214 spectravite senior... 214 spectravite senior w-lycopene... 214 spectravite ultra women... 214 SPIRIVA RESPIMAT... 204 SPIRIVA WITH HANDIHALER... 204 spironolactone... 106 spironolacton-hydrochlorothiaz... 106 sprintec (28)... 117 SPRITAM... 44 SPRYCEL... 37 sps (with sorbitol)... 159 sronyx... 117 ssd... 134 st joseph aspirin... 14 st. joseph aspirin... 14 stavudine... 77 STELARA... 189 STERILE PADS... 189 STIOLTO RESPIMAT... 40 STIVARGA... 38 stomach relief... 158 stool softener... 160 STRATTERA... 109 STRENSIQ... 141 streptomycin... 18 stress 500 plus zinc... 223 stress b with zinc... 226 stress b-biotin... 226 stress formula... 226 stress formula plus iron... 227 stress formula with iron... 227 stress formula with zinc... 227 STRIBILD... 77 STRIVERDI RESPIMAT... 204 sucralfate... 153 sudafed... 127 sudogest... 127, 128 sudogest sinus and allergy... 62 sulfacetamide sodium... 148, 149 sulfacetamide sodium (acne) 134 sulfacetamide-prednisolone.. 149 sulfadiazine... 28 sulfamethoxazole-trimethoprim... 28 sulfasalazine... 28, 29 sulfatrim... 29 sulindac... 14 sumatriptan... 65 sumatriptan succinate... 64, 65 summer's eve disposable douche... 189 summers eve extra cleansing 189 sunvite... 227 super b complex-vitamin c.. 214, 226, 227 super b maxi complex... 227 super b/c... 227 super b-50 complex... 227 I-20 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
super b-50 complex plus... 227 super multiple... 227 super multivitamin... 227 super quints... 227 super quints b-50... 227 super thera vite m... 227 superior 35... 228 superplex-t... 228 suphedrin... 128 suphedrine pe day-night... 128 suphedrine severe cold max str... 127 support... 228 support-500... 228 SUPPRELIN LA... 171 SUPRAX... 23 SURMONTIL... 49 SUSTIVA... 77 SUTENT... 38 syeda... 117 SYLATRON... 80 SYLVANT... 38 SYMLINPEN 120... 51 SYMLINPEN 60... 52 SYNAGIS... 78 SYNAREL... 189 SYNERCID... 21 SYNJARDY... 52 SYNRIBO... 38 SYPRINE... 165 SYSTANE (PROPYLENE GLYCOL)... 146 SYSTANE GEL... 146 T tab-a-vite... 228 tab-a-vite/iron... 228 tab-a-vite-minerals... 228 TABLOID... 38 tacrolimus... 138, 175 tactinal... 11 tactinal extra strength... 11 TAFINLAR... 38 TAGRISSO... 38 TALTZ AUTOINJECTOR.. 132 TALTZ SYRINGE... 133 TAMIFLU... 78, 79 tamoxifen... 38 tamsulosin... 164 TARCEVA... 38 TARGRETIN... 38 tarina fe 1/20 (28)... 117 TASIGNA... 38 tazicef... 23 TAZORAC... 139 taztia xt... 97 tears again... 146 tears again (pva)... 146 tears naturale free (pf)... 146 TECENTRIQ... 38 TECFIDERA... 189, 190 TECHNIVIE... 79 TEFLARO... 24 telmisartan... 92 telmisartan-hydrochlorothiazid... 92 TEMODAR... 38 tencon... 11 TENIVAC (PF)... 180 terazosin... 164 terbinafine hcl... 57 terbutaline... 204 terconazole... 64 testosterone... 166 testosterone cypionate... 166 testosterone enanthate... 166 TETANUS TOXOID,ADSORBED (PF)... 180 TETANUS,DIPHTHERIA TOX PED(PF)... 180 tetanus-diphtheria toxoids-td 180 tetrabenazine... 109 tetracaine hcl (pf)... 146 tetracycline... 30 THALOMID... 190 the magic bullet... 161 theochron... 204 theophylline... 205 theophylline in dextrose 5 % 205 thera m plus (ferrous fumarat)... 228 thera vitamin... 228 thera-d... 228 theradex m... 228 THERAFLU DAYTIME COLD-COUGH... 128 THERAFLU MULTI- SYMPTOM COLD... 128 thera-m... 228 therapeutic liquid... 219 therapeutic m + beta-carotene... 224 therapeutic-m... 228 therapeutic-m vitamin/minerals... 226 thera-tabs... 228 theratrum complete 50 plus.. 228 theratrum complete 50 plus/lut... 228 thiamine hcl (vitamin b1)... 228, 229 thioridazine... 74 thiotepa... 38 thiothixene... 74 tiagabine... 44 TICE BCG... 176 tilia fe... 117 timolol maleate... 96, 191 TIVICAY... 77 tizanidine... 207 TOBI PODHALER... 18 TOBRADEX... 149 TOBRADEX ST... 149 tobramycin... 149 tobramycin in 0.225 % nacl... 18 tobramycin in 0.9 % nacl... 19 I-21 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
tobramycin sulfate... 19 tobramycin-dexamethasone. 149 TOLAK... 133 tolazamide... 53 tolbutamide... 54 tolmetin... 14, 15 tolnaftate... 57 tolterodine... 164 topiragen... 44 topiramate... 44 toposar... 38 torsemide... 103 total b/c... 229 totalday multiple... 229 TOUJEO SOLOSTAR... 53 TOVIAZ... 164 TPN ELECTROLYTES... 201 TPN ELECTROLYTES II... 201 TRACLEER... 209 TRADJENTA... 52 tramadol... 11 tramadol-acetaminophen... 11 trandolapril... 94 tranexamic acid... 84 TRANSDERM-SCOP... 68 tranylcypromine... 49 TRAVASOL 10 %... 91 TRAVATAN Z... 191 travel sickness (meclizine)... 68 travoprost (benzalkonium)... 191 trazodone... 49 TREANDA... 38, 39 TRECATOR... 66 TRELSTAR... 39 tretinoin... 139 tretinoin (chemotherapy)... 39 tretinoin microspheres... 139 TREXALL... 39 triacting m-sym cold/cough. 129 triamcinolone acetonide... 130, 138, 169 triaminic cold and cough (pe)... 128 TRIAMINIC COLD AND COUGHNT(PE)... 62 TRIAMINIC COUGH-SORE THROAT... 128 triamterene-hydrochlorothiazid... 103 trianex... 138 TRIBENZOR... 92 tri-buffered aspirin... 14 tri-dex pe... 128 tri-estarylla... 117 trifluoperazine... 74 trifluridine... 149 trihexyphenidyl... 70 tri-legest fe... 117 tri-linyah... 117 tri-lo-estarylla... 117 tri-lo-marzia... 117 tri-lo-sprintec... 117 trilyte with flavor packets... 163 trimethoprim... 21 trimipramine... 49 trinessa (28)... 117 TRINTELLIX... 49 triple antibiotic... 133, 134 triple paste af... 58 tri-previfem (28)... 117 tri-sprintec (28)... 117 TRIUMEQ... 77 tri-vi-sol... 229 tri-vita... 229 tri-vitamin... 229 trivora (28)... 117 TROKENDI XR... 45 TROPHAMINE 10 %... 91 TROPHAMINE 6%... 91 trospium... 164 TRULICITY... 52 TRUMENBA... 180 TRUVADA... 77 trymine cg... 128 TUDORZA PRESSAIR... 205 tusnel diabetic... 128 TUSNEL NEW FORMULA 128 TUSNEL PEDIATRIC... 128 TUSSI PRES-B... 128 tussin cf... 127, 129 tussin cf cough-cold... 128 tussin cold-congestion... 128 tussin cough (dm only)... 121 tussin dm... 125, 128 tussin dm cough and chest... 121 tussin maximum strength... 126 tussin pe... 125 TWINRIX (PF)... 180 TYBOST... 190 TYGACIL... 30 TYKERB... 39 TYPHIM VI... 180, 181 TYSABRI... 175 TYVASO... 209 TYVASO REFILL KIT... 209 TYVASO STARTER KIT... 209 TYZEKA... 81 U u-cort... 138 ULORIC... 190 ultra b-100 complex... 229 ultra fresh pm... 146 ultra strength antacid... 154 unisom sleepgels... 62 UNITUXIN... 39 UPTRAVI... 209 ursodiol... 159 V VAGIFEM... 167 valacyclovir... 81 VALCHLOR... 133 valganciclovir... 81 valproate sodium... 45 valproic acid... 45 valproic acid (as sodium salt). 45 I-22 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
valsartan... 92 valsartan-hydrochlorothiazide 92 VALSTAR... 39 valu-tapp dm... 127 VANACOF... 128 vancomycin... 21 vancomycin in dextrose 5 %.. 21 VAQTA (PF)... 181 VARIVAX (PF)... 181 VASCEPA... 106 v-c forte... 229 VELCADE... 39 velivet triphasic regimen (28)... 117 VENCLEXTA... 39 VENCLEXTA STARTING PACK... 39 venlafaxine... 49 VENTOLIN HFA... 205 verapamil... 97, 98 VERSACLOZ... 74 vestura (28)... 117 VGO 40... 140 VIBERZI... 159 vic-forte... 229 vicks dayquil cold-flu relief. 129 vicks dayquil cough... 128 vicks nature fusion cough... 129 vicks nyquil severe cold-flu. 129 vicks qlearquil(oxymetazoline)... 146 vicks sinex 12-hour... 146 vicodin... 11 vicodin es... 11 vicodin hp... 11 VICTOZA 3-PAK... 52 VIDEX 2 GRAM PEDIATRIC... 78 VIDEX 4 GRAM PEDIATRIC... 78 VIEKIRA PAK... 79 VIEKIRA XR... 79 vienva... 117 VIGAMOX... 149 VIIBRYD... 49, 50 VIMIZIM... 142 VIMPAT... 45 vinorelbine... 39 viorele (28)... 117 VIRACEPT... 78 VIRAMUNE XR... 78 VIRAZOLE... 81 virdec dm... 129 VIREAD... 78 virt-phos 250 neutral... 201 virtussin ac... 129 vision... 229 vision formula (with lutein) 214, 229 vision plus lutein... 229 vit b complex-folic acid... 226 VITAFOL FE+ (WITH DOCUSATE)... 229 vitalets... 229 vitamin a... 229, 230 vitamin b complex... 211, 224 vitamin b-100 complex... 214 vitamin b12-folic acid... 230 vitamin b-6... 230 vitamin c... 225, 230, 231 vitamin d3... 226, 231 vitamins and minerals... 230 vitamins b complex... 211, 230 vitamins for hair... 231 VITEKTA... 78 vitrum senior... 231 VOLTAREN... 15 voriconazole... 58 VOTRIENT... 39 VPRIV... 142 VRAYLAR... 74 vyfemla (28)... 118 W wal-act d cold and allergy... 62 wal-dram... 68 wal-dryl allergy... 62 wal-fex allergy... 63 wal-finate... 63 wal-finate-d... 63 wal-itin... 63 wal-itin d... 63 wal-itin d 12 hour... 63 wal-phed... 63, 129 wal-phed pe day-night... 129 wal-phed pe sinus and allergy 63 wal-profen... 15 wal-sleep z... 63 wal-som (diphenhydramine).. 63 wal-som (doxylamine)... 63 wal-tap... 63 wal-tussin cough... 129 wal-tussin cough and cold cf 129 wal-tussin dm... 119 wal-zan 75... 153 wal-zyr (cetirizine)... 63 wal-zyr d... 63 warfarin... 82 water for irrigation, sterile... 182 WELCHOL... 106 wera (28)... 118 womens daily gummies... 215 women's daily multivitamin. 224 X XALKORI... 40 XARELTO... 83 XELJANZ... 190 XELJANZ XR... 190 XIFAXAN... 21 XIIDRA... 150 XOLAIR... 206 XTANDI... 40 xulane... 118 xylon 10... 11 XYREM... 207 Y yelets... 231 I-23 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
YERVOY... 40 YF-VAX (PF)... 181 YONDELIS... 40 Z zafirlukast... 203 zaleplon... 207 ZANTAC... 153 ZANTAC 75... 153 zarah... 118 ZARXIO... 84 ZAVESCA... 142 zebutal... 11 ZELBORAF... 40 ZEMPLAR... 184 zenatane... 133 zenchent (28)... 118 ZENPEP... 142 ZEPATIER... 79 zephrex-d... 129 ZETIA... 106 ZIAGEN... 78 zidovudine... 78 ZINBRYTA... 190 zinc oxide... 133 ziprasidone hcl... 74 ZIRGAN... 149 ZOLADEX... 40 zoledronic acid... 184 zoledronic acid-mannitol-water... 184 ZOLINZA... 40 zolmitriptan... 65 zolpidem... 208 ZOMETA... 184 ZONATUSS... 129 zonisamide... 45 zoo chews... 232 ZORTRESS... 175 ZOSTAVAX (PF)... 181 zovia 1/35e (28)... 118 zovia 1/50e (28)... 118 ZOVIRAX... 133 z-sleep... 61, 62 ZUBSOLV... 17 ZYDELIG... 40 ZYKADIA... 40 ZYLET... 149 zyncof... 130 ZYPREXA RELPREVV... 74 ZYRTEC... 64 ZYTIGA... 40 ZYVOX... 21 I-24 VillageCareMAX Full Advantage FIDA Plan 2016 Formulary Formulary ID:16511.000 Version: 19 Effective: November 01, 2016
This formulary was updated on 10/01/2016. For more recent information or other questions, please contact VillageCareMAX Full Advantage FIDA Plan at 1-800-469-6292, 8:00 am to 8:00 pm, 7 days a week. The call is free. TTY users should call 711. For more information, visit Formulary ID: 16511.000, Version 19