Preferred Drug List Select Health PerformRx Pharmacy Services Phone 1.866.610.2773 Fax 1.866.610.2775 Member Services Phone 1.888.276.2020 Providers may request the addition or deletion of a medication to this list. Requests must include the drug name, rationale for inclusion on the list, role in therapy and medications that may be replaced by the addition. Please direct such requests to: Pharmacy and Therapeutics Committee at Select Health PO Box 40849 Charleston, SC 29423 Members may request changes to the list by calling Member Services. For the most current Preferred Drug List (PDL), please use the searchable PDL on our website, www.selecthealthofsc.com.
Status Requirements/Limits Drug Name Status Requirements/Limits Antihistamine Drugs Ethanolamine Derivatives carbinoxamine maleate oral tablet 4 mg clemastine oral tablet diphenhydramine HCl injection solution 50 mg/ml diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule diphenhydramine HCl oral liquid diphenhydramine HCl oral syrup diphenhydramine HCl oral tablet 25 mg Sleep Aid (doxylamine) First Gen. Antihist. Derivatives, Misc. cyproheptadine First Generation Antihistamines carbinoxamine maleate oral tablet 4 mg clemastine oral tablet cyproheptadine diphenhydramine HCl injection solution 50 mg/ml diphenhydramine HCl injection syringe diphenhydramine HCl oral capsule diphenhydramine HCl oral liquid diphenhydramine HCl oral syrup diphenhydramine HCl oral tablet 25 mg Sleep Aid (doxylamine) Phenothiazine Derivatives promethazine injection solution promethazine oral promethazine rectal Promethazine VC Promethazine VC-Codeine = Age Limit = Quantity Limit 1
Piperazine Derivatives hydroxyzine HCl oral solution 10 mg/5 ml hydroxyzine HCl oral tablet hydroxyzine pamoate meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable Propylamine Derivatives Carbaphen CH Centergy Conex oral solution Dimetapp Cold-Allergy (PE) Ed Chlorped D Lodrane D LoHist - D M-End DMX NoHist-DM Rynex PSE Trexbrom Second Generation Antihistamines cetirizine oral solution 1 mg/ml cetirizine oral tablet cetirizine-pseudoephedrine fexofenadine oral suspension fexofenadine oral tablet 180 mg levocetirizine oral tablet loratadine oral solution loratadine oral tablet loratadine oral tablet,disintegrating Loratadine-D oral tablet extended release 12 hr loratadine-pseudoephedrine Anti-Infective Agents 1St Generation Cephalosporin Antibiotics = Age Limit = Quantity Limit 2
cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 2Nd Generation Cephalosporin Antibiotics Specialty cefotetan Specialty cefotetan in dextrose, iso-osm Specialty cefprozil Ceftin oral suspension for reconstitution 250 mg/5 ml cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram Specialty cefuroxime sodium intravenous recon soln 7.5 gram Specialty Zinacef intravenous recon soln 1.5 gram, 750 mg Specialty 3Rd Generation Cephalosporin Antibiotics cefdinir cefotaxime Specialty ceftazidime Specialty ceftriaxone Specialty ceftriaxone in dextrose,iso-os Specialty ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg Specialty Claforan intravenous recon soln Specialty Fortaz in dextrose 5 % Specialty Suprax oral capsule Suprax oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml TAZICEF intravenous Specialty = Age Limit = Quantity Limit 3
4Th Generation Cephalosporin Antibiotics cefepime Specialty cefepime in dextrose 5 % Specialty cefepime in dextrose,iso-osm Specialty Adamantane Antivirals amantadine HCl oral capsule amantadine HCl oral solution rimantadine Allylamine Antifungals terbinafine HCl oral Amebicides metronidazole in NaCl (iso-os) Specialty metronidazole oral tablet Yodoxin Aminoglycoside Antibiotics amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml gentamicin in NaCl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml = Age Limit = Quantity Limit 4 Specialty Specialty gentamicin injection Specialty gentamicin sulfate (PF) Specialty Tobi Podhaler Specialty tobramycin in 0.225 % NaCl Specialty tobramycin sulfate Specialty Aminopenicillin Antibiotics amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet
amoxicillin-pot clavulanate oral tablet,chewable ampicillin ampicillin sodium Specialty ampicillin-sulbactam Specialty Augmentin oral suspension for reconstitution 125-31.25 mg/5 ml Anthelmintics Biltricide Antifungals, Miscellaneous griseofulvin microsize griseofulvin ultramicrosize SSKI Antimalarials atovaquone-proguanil chloroquine phosphate Daraprim Specialty hydroxychloroquine mefloquine primaquine quinidine gluconate oral quinidine sulfate Antimycobacterials, Miscellaneous dapsone oral Antiprotozoals, Miscellaneous atovaquone dapsone oral metronidazole in NaCl (iso-os) Specialty metronidazole oral tablet Nebupent Specialty Pentam Specialty Antituberculosis Agents amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml Specialty = Age Limit = Quantity Limit 5
ciprofloxacin ciprofloxacin (mixture) ciprofloxacin HCl oral tablet 250 mg, 500 mg ciprofloxacin HCl oral tablet 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 ml clarithromycin ethambutol isoniazid oral = Age Limit = Quantity Limit 6 Specialty Levaquin in 5 % dextrose Specialty levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral Mycobutin pyrazinamide rifampin intravenous Specialty rifampin oral Antivirals, Miscellaneous foscarnet Specialty Azole Antifungals fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml fluconazole in NaCl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg itraconazole ketoconazole oral Sporanox oral solution Specialty Specialty Vfend IV Specialty Carbapenem Antibiotics Doribax Specialty Invanz Specialty
meropenem Specialty Primaxin IV intravenous recon soln 250 mg Specialty Cephamycin Antibiotics cefotetan Specialty cefotetan in dextrose, iso-osm Specialty Cyclic Lipopeptide Antibiotics daptomycin Specialty Echinocandin Antifungals caspofungin Specialty Eraxis(Water Diluent) Specialty Mycamine Specialty Erythromycin Antibiotics Ery-Tab Erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin-sulfisoxazole Extended-Spectrum Penicillins piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram Specialty Zosyn in dextrose (iso-osm) Specialty Glycopeptide Antibiotics vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 750 mg/150 ml Specialty vancomycin intravenous Specialty vancomycin oral capsule Vibativ intravenous recon soln 750 mg Specialty Glycylcycline Antibiotics tigecycline Specialty = Age Limit = Quantity Limit 7
Hiv Entry And Fusion Inhibitors Fuzeon subcutaneous recon soln Selzentry oral tablet Hiv Integrase Inhibitor Antiretrovirals Genvoya Isentress HD Isentress oral tablet Isentress oral tablet,chewable Juluca Stribild Hiv Nonnucleoside Rev.Transcrip. Inhib. Edurant efavirenz Intelence oral tablet 100 mg, 200 mg Juluca nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 400 mg Odefsey Rescriptor Viramune XR oral tablet extended release 24 hr 100 mg Hiv Nucleoside, Nucleotide Rt Inhibitors abacavir abacavir-lamivudine Descovy didanosine Emtriva Epivir HBV Genvoya lamivudine oral solution = Age Limit = Quantity Limit 8
lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine Odefsey stavudine Stribild tenofovir disoproxil fumarate Trizivir Truvada Videx 2 gram Pediatric Viread oral tablet 150 mg, 200 mg, 250 mg zidovudine Hiv Protease Inhibitor Antiretrovirals Aptivus atazanavir Crixivan oral capsule 200 mg, 400 mg fosamprenavir Invirase Kaletra oral tablet Lexiva oral suspension lopinavir-ritonavir Norvir oral capsule Norvir oral solution Prezcobix Prezista oral suspension Prezista oral tablet 150 mg, 600 mg, 75 mg, 800 mg ritonavir Viracept oral tablet Interferon Antivirals Alferon N Specialty Intron A injection Specialty Sylatron Specialty Lincomycin Antibiotics = Age Limit = Quantity Limit 9
clindamycin HCl oral capsule 150 mg, 300 mg clindamycin in 5 % dextrose Specialty clindamycin palmitate HCl clindamycin phosphate injection Specialty clindamycin phosphate intravenous solution 900 mg/6 ml Specialty Lincocin Specialty Macrolide Antibiotics Ery-Tab Erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet Monobactam Antibiotics Azactam in dextrose (iso-osm) Specialty aztreonam Specialty Cayston Specialty Monoclonal Antibody Antivirals Synagis Natural Penicillin Antibiotics Bicillin L-A penicillin G potassium Specialty penicillin V potassium Neuraminidase Inhibitor Antivirals oseltamivir Relenza Diskhaler Nucleoside And Nucleotide Antivirals acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet = Age Limit = Quantity Limit 10
adefovir Specialty cidofovir Specialty Cytovene Specialty entecavir Rebetol oral solution Specialty valacyclovir Other Macrolide Antibiotics azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin Zmax Oxazolidinone Antibiotics Zyvox intravenous Specialty Penicillinase-Resistant Penicillins dicloxacillin nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml Specialty nafcillin injection Specialty oxacillin injection Specialty Polyene Antifungals Abelcet Specialty AmBisome Specialty Amphotec Specialty nystatin oral Polymyxin Antibiotics colistin (colistimethate Na) Specialty Quinolone Antibiotics ciprofloxacin ciprofloxacin (mixture) ciprofloxacin HCl oral tablet 250 mg, 500 mg ciprofloxacin HCl oral tablet 750 mg = Age Limit = Quantity Limit 11
ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 ml Specialty Levaquin in 5 % dextrose Specialty levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral ofloxacin oral tablet 400 mg Rifamycin Antibiotics Mycobutin rifampin intravenous Specialty rifampin oral Streptogramin Antibiotics Synercid Specialty Sulfonamide Antibiotics (Systemic) erythromycin-sulfisoxazole sulfadiazine sulfamethoxazole-trimethoprim intravenous Specialty sulfamethoxazole-trimethoprim oral sulfasalazine Tetracycline Antibiotics Doxy-100 Specialty doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet,delayed release (DR/EC) 75 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline Urinary Anti-Infectives nitrofurantoin = Age Limit = Quantity Limit 12
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst trimethoprim Urin DS Antineoplastic Agents Antineoplastic Agents Abraxane Specialty Adcetris Specialty Afinitor Specialty Afinitor Disperz Specialty Alferon N Specialty Alimta Specialty anastrozole Arranon Specialty Arzerra intravenous solution 100 mg/5 ml Specialty Avastin Specialty bexarotene Specialty bicalutamide BiCNU Specialty bleomycin Specialty Bosulif Specialty busulfan Specialty Camptosar intravenous solution 300 mg/15 ml Specialty capecitabine Specialty Caprelsa Specialty carboplatin Specialty cisplatin Specialty cladribine Specialty clofarabine Specialty Cometriq Specialty cyclophosphamide intravenous Specialty cytarabine Specialty = Age Limit = Quantity Limit 13
cytarabine (PF) injection solution Specialty dacarbazine Specialty Dacogen Specialty dactinomycin Specialty daunorubicin intravenous solution Specialty DepoCyt (PF) Specialty Docefrez Specialty docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) = Age Limit = Quantity Limit 14 Specialty Doxil Specialty doxorubicin intravenous solution Specialty Droxia Eligard Specialty Eligard (3 month) Specialty Eligard (4 month) Specialty Eligard (6 month) Specialty Emcyt epirubicin intravenous recon soln 50 mg Specialty epirubicin intravenous solution Specialty Erbitux Specialty Erivedge Specialty Erwinaze Specialty Etopophos Specialty etoposide Specialty exemestane Faslodex Specialty Firmagon kit w diluent syringe Specialty Firmagon subcutaneous recon soln 120 mg Specialty floxuridine Specialty fludarabine Specialty fluorouracil intravenous Specialty flutamide
Folotyn Specialty gemcitabine intravenous recon soln Specialty gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) Specialty Gliadel Wafer Specialty Halaven Specialty Herceptin intravenous recon soln 440 mg Specialty Hexalen Hycamtin oral Specialty hydroxyurea Ibrance Specialty Iclusig Specialty idarubicin Specialty ifosfamide Specialty ifosfamide-mesna intravenous kit 1-1 gram Specialty imatinib Specialty Inlyta Specialty Intron A injection Specialty irinotecan Specialty Ixempra Specialty Jakafi Specialty Jevtana Specialty Kadcyla Specialty Kyprolis intravenous recon soln 60 mg Specialty letrozole Leukeran leuprolide subcutaneous kit Specialty Lupron Depot Specialty Lupron Depot (3 month) Specialty Lupron Depot (4 month) Specialty Lupron Depot (6 Month) Specialty Lupron Depot-Ped Specialty Lupron Depot-Ped (3 month) Specialty = Age Limit = Quantity Limit 15
Lysodren Matulane megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml megestrol oral tablet melphalan melphalan HCl Specialty mercaptopurine methotrexate sodium methotrexate sodium (PF) mitomycin intravenous Specialty mitoxantrone Specialty Mustargen Specialty Myleran Nexavar Specialty nilutamide Specialty Oncaspar Specialty oxaliplatin Specialty paclitaxel Specialty pentostatin Specialty Perjeta Specialty Photofrin Specialty Pomalyst Specialty Proleukin Specialty Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25 mg, 5 mg = Age Limit = Quantity Limit 16 Specialty Rituxan Specialty Rituxan Hycela Specialty romidepsin Specialty Sprycel Specialty Stivarga Specialty Supprelin LA Specialty Sutent Specialty
Sylatron Specialty Synribo Specialty Tabloid tamoxifen Tarceva Specialty Targretin topical Specialty Tasigna Specialty Temodar Specialty teniposide Specialty Theracys Specialty thiotepa Specialty Tice BCG Specialty topotecan Specialty Torisel Specialty Treanda intravenous recon soln Specialty Trelstar Specialty tretinoin (chemotherapy) Specialty Trisenox intravenous solution 10 mg/10 ml Specialty Tykerb Specialty Valstar Specialty Vectibix Specialty Velcade Specialty Vidaza Specialty vinblastine Specialty vincristine Specialty vinorelbine Specialty Votrient Specialty Xalkori Specialty Xtandi Specialty Yervoy Specialty Zaltrap Specialty Zanosar Specialty Zelboraf Specialty = Age Limit = Quantity Limit 17
Zevalin (Y-90) Specialty Zoladex Specialty Zolinza Specialty Zytiga oral tablet 250 mg Specialty Antitoxins,Immune Glob,Toxoids,Vaccines Antitoxins And Immune Globulins Carimune NF Nanofiltered Specialty CytoGam intravenous solution 50 mg/ml Specialty Flebogamma DIF intravenous solution 5 % Specialty GamaAN S/D Specialty Gammagard S/D Specialty Gamunex-C injection solution 1 gram/10 ml (10 %), 10 gram/100 ml (10 %), 2.5 gram/25 ml (10 %), 20 gram/200 ml (10 %), 5 gram/50 ml (10 %) Hizentra subcutaneous solution 1 gram/5 ml (20 %), 2 gram/10 ml (20 %), 4 gram/20 ml (20 %) = Age Limit = Quantity Limit 18 Specialty Specialty MICRhoGAM Ultra-Filtered PLUS Specialty Privigen Specialty RhoGAM Ultra-Filtered PLUS Specialty Rhophylac Specialty WinRho SDF Specialty Toxoids Adacel(Tdap Adolesn/Adult)(PF) Boostrix Tdap Vaccines Afluria 2017-2018 Afluria 2017-2018 (PF) Afluria Quad 2017-2018 Afluria Quad 2017-2018 (PF) Fluarix Quad 2017-2018 (PF) Flucelvax Quad 2017-2018 Flucelvax Quad 2017-2018 (PF) ; ; ; ; ; ; ;
Flulaval Quad 2017-2018 (PF) Fluvirin 2017-2018 Fluvirin 2017-2018 (PF) Fluzone High-Dose 2017-18 (PF) Fluzone Intraderm Quad 2017-18 Fluzone Quad 2017-2018 Fluzone Quad 2017-2018 (PF) Fluzone Quad Pedi 2017-18 (PF) Tice BCG Specialty Autonomic Drugs Alpha- And Beta-Adrenergic Agonists Bromfed DM cetirizine-pseudoephedrine Children's Silfedrine Conex oral solution epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml epinephrine injection solution epinephrine injection syringe 0.1 mg/ml Lodrane D LoHist - D Loratadine-D oral tablet extended release 12 hr loratadine-pseudoephedrine Lortuss EX oral syrup M-End DMX Nasal Decongestant (pseudoeph) oral tablet pseudoephedrine HCl oral tablet 60 mg pseudoephedrine-guaifenesin Rynex PSE Alpha-Adrenergic Agonists Carbaphen CH Centergy clonidine ; ; ; ; ; ; ; ; = Age Limit = Quantity Limit 19
clonidine HCl oral tablet Despec Dimetapp Cold-Allergy (PE) Ed Chlorped D methyldopa methyldopa-hydrochlorothiazide midodrine NoHist-DM Promethazine VC Promethazine VC-Codeine Trexbrom Tussin CF (PE-DM-guaif) Antimuscarinics/Antispasmodics Anoro Ellipta Atrovent HFA chlordiazepoxide-clidinium Combivent Respimat dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine glycopyrrolate oral tablet 1 mg, 2 mg hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml hydrocodone-homatropine oral tablet hyoscyamine sulfate ipratropium bromide inhalation ipratropium-albuterol methscopolamine propantheline Spiriva Respimat Stiolto Respimat Antiparkinsonian Agents = Age Limit = Quantity Limit 20
benztropine oral trihexyphenidyl Autonomic Drugs, Miscellaneous Chantix Chantix Starting Month Box Chantix Starting Month Pak nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal lozenge nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr Nicotrol Nicotrol NS Centrally Acting Skeletal Muscle Relaxnt carisoprodol oral tablet 350 mg carisoprodol-asa-codeine carisoprodol-aspirin chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg methocarbamol oral tizanidine oral tablet Gaba-Derivative Skeletal Muscle Relaxant baclofen Lioresal Specialty Non-Sel. Beta-Adrenergic Blocking Agents carvedilol labetalol oral nadolol nadolol-bendroflumethiazide pindolol propranolol oral ; = Age Limit = Quantity Limit 21
propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Non-Sel.Alpha-1-Adrenergic Blocking Agts doxazosin prazosin terazosin Non-Sel.Alpha-Adrenergic Blocking Agents dihydroergotamine injection dihydroergotamine nasal Ergomar phenoxybenzamine Parasympathomimetic (Cholinergic Agents) bethanechol chloride donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 23 mg donepezil oral tablet,disintegrating Mestinon oral syrup Prostigmin pyridostigmine bromide rivastigmine tartrate Selective Alpha-1-Adrenergic Block.Agent alfuzosin carvedilol labetalol oral tamsulosin Selective Beta-2-Adrenergic Agonists albuterol sulfate inhalation solution for nebulization ; ; ; = Age Limit = Quantity Limit 22
albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr 8 mg Anoro Ellipta Breo Ellipta Combivent Respimat Dulera fluticasone-salmeterol ipratropium-albuterol levalbuterol tartrate Serevent Diskus Stiolto Respimat terbutaline oral Ventolin HFA Selective Beta-Adrenergic Blocking Agent atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg Skeletal Muscle Relaxants, Miscellaneous Botox Specialty Dysport Specialty Myobloc Specialty orphenadrine citrate oral Orphenadrine Compound Xeomin Specialty ; = Age Limit = Quantity Limit 23
Blood Formation, Coagulation, Thrombosis Coumarin Derivatives warfarin Direct Factor Xa Inhibitors Eliquis Xarelto Direct Thrombin Inhibitors Pradaxa Hematopoietic Agents Aranesp (in polysorbate) Specialty Epogen injection solution 10,000 unit/ml, 2,000 unit/ml, 20,000 unit/2 ml, 20,000 unit/ml, 3,000 unit/ml, 4,000 unit/ml = Age Limit = Quantity Limit 24 Specialty Granix Specialty Leukine injection recon soln Specialty Mozobil Specialty Neulasta Specialty Neumega Specialty Neupogen Specialty Nplate Specialty Omontys Specialty Procrit Specialty Promacta Specialty Zarxio Specialty Hemorrheologic Agents pentoxifylline Hemostatics Amicar DDAVP nasal solution desmopressin nasal spray,non-aerosol desmopressin oral Heparins
enoxaparin subcutaneous solution enoxaparin subcutaneous syringe heparin (porcine) in 5 % dex Specialty heparin (porcine) in NaCl (PF) Specialty heparin (porcine) injection solution 1,000 unit/ml, 5,000 unit/ml heparin, porcine (PF) injection syringe heparin, porcine (PF) intravenous solution 25,000 unit/10 ml Iron Preparations Atabex EC Bio-35, Gluten Free Cadeau DHA Centrum Specialist Prenatal Classic Prenatal Daily Prenatal Expecta Prenatal FE C FE C Plus Feraheme Specialty Ferocon Ferrex 28 Ferrlecit Specialty ferrous gluconate oral tablet 324 mg (37.5 mg iron), 324 mg (38 mg iron) ferrous sulfate oral drops ferrous sulfate oral elixir ferrous sulfate oral solution ferrous sulfate oral tablet 325 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (DR/EC) Infed Injectafer Iron Chews = Age Limit = Quantity Limit 25
KPN oral tablet 9 mg iron- 267 mcg Mini Prenatal Multigen Multigen Folic Multigen Plus Multi-Vit with Fluoride-Iron Mynatal oral capsule Mynatal Plus Mynatal-Z Obstetrix DHA Obstetrix EC O-Cal FA O-Cal Prenatal One A Day Women's Prenatal DHA One-A-Day Womens Formula oral tablet 18 mg iron-400 mcg-500 mg Ca One-A-Day Women's Prenatal 1 Perry Prenatal PNV cmb#95-ferrous fumarate-fa Poly-Vi-Flor with Iron Prenatabs Rx Prenatal + DHA oral combo pack 28 mg iron-800 mcg-200 mg Prenatal 19 Prenatal Formula oral tablet 9 mg iron- 267 mcg Prenatal Low Iron Prenatal Multi-DHA (algal oil) Prenatal Multi-DHA oral capsule 27 mg iron-800 mcg-228 mg Prenatal oral tablet 28 mg iron- 800 mcg Prenatal Plus Prenatal Plus (calcium carb) Prenatal Plus DHA oral combo pack Prenatal Vitamin Plus Low Iron = Age Limit = Quantity Limit 26
prenatal vit-iron fum-folic ac prenatal vits96-iron fum-folic ProRenal QD Protect Iron Right Step Prenatal Vitamins Similac Prenatal Slow Release Iron oral tablet extended release 143 mg (45 mg iron), 160 mg (50 mg iron) TriAdvance Trinatal GT Trinatal Rx 1 Trinate Triveen-Duo DHA Tri-Vit with Fluoride and Iron Venofer Vinate GT Vinate One Vinate Ultra Vol-Nate Vol-Tab Rx Wee Care Women's Daily Caplet Women's Prenatal + DHA Platelet-Aggregation Inhibitors aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg aspirin rectal aspirin-dipyridamole butalbital-aspirin-caffeine oral capsule cilostazol clopidogrel dipyridamole oral = Age Limit = Quantity Limit 27
prasugrel ticlopidine Thrombolytic Agents Activase intravenous recon soln 50 mg Specialty aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg aspirin rectal butalbital-aspirin-caffeine oral capsule Cathflo Activase Specialty Cardiovascular Drugs Alpha-Adrenergic Blocking Agents carvedilol doxazosin labetalol oral prazosin terazosin Alpha-Adrenergic Blocking Agt.(Hypoten) doxazosin labetalol oral prazosin terazosin Angiotensin Ii Receptor Antagon.(Hypotn) amlodipine-valsartan irbesartan irbesartan-hydrochlorothiazide losartan losartan-hydrochlorothiazide olmesartan olmesartan-hydrochlorothiazide = Age Limit = Quantity Limit 28
telmisartan valsartan oral tablet 160 mg, 40 mg, 80 mg valsartan oral tablet 320 mg valsartan-hydrochlorothiazide Angiotensin Ii Receptor Antagonists amlodipine-valsartan irbesartan irbesartan-hydrochlorothiazide losartan losartan-hydrochlorothiazide olmesartan olmesartan-hydrochlorothiazide telmisartan valsartan valsartan-hydrochlorothiazide Angiotensin-Convert.Enzyme Inhib(Hypotn) amlodipine-benazepril benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide = Age Limit = Quantity Limit 29
ramipril trandolapril Angiotensin-Converting Enzyme Inhibitors amlodipine-benazepril benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide ramipril trandolapril Antiarrhythmics, Miscellaneous Digox digoxin oral solution 50 mcg/ml magnesium sulfate injection Specialty Antilipemic Agents, Miscellaneous Juxtapid Specialty Kynamro Specialty Niacin Flush Free oral capsule 750 mg niacin oral capsule, extended release 250 mg, 500 mg Beta-Adrenergic Blocking Agents = Age Limit = Quantity Limit 30
atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Beta-Adrenergic Blocking Agt.(Hypoten) atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral = Age Limit = Quantity Limit 31
timolol maleate oral Bile Acid Sequestrants cholestyramine (with sugar) Cholestyramine Light oral powder in packet colestipol Prevalite oral powder WelChol Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet verapamil oral tablet verapamil oral tablet extended release Calcium-Channel Blocking Agents amlodipine amlodipine-benazepril amlodipine-valsartan diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet felodipine Nifediac CC oral tablet extended release 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg, 90 mg verapamil oral tablet verapamil oral tablet extended release = Age Limit = Quantity Limit 32
Calcium-Channel Blocking Agents(Hypoten) diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet verapamil oral tablet verapamil oral tablet extended release Calcium-Channel Blocking Agents, Misc. diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet verapamil oral tablet verapamil oral tablet extended release Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide Cardiotonic Agents Digox digoxin oral solution 50 mcg/ml Central Alpha-Agonists clonidine clonidine HCl oral tablet guanfacine oral tablet guanfacine oral tablet extended release 24 hr methyldopa methyldopa-hydrochlorothiazide Class Ia Antiarrhythmics disopyramide phosphate oral capsule = Age Limit = Quantity Limit 33
quinidine gluconate oral quinidine sulfate Class Ib Antiarrhythmics Dilantin mexiletine phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg Class Ic Antiarrhythmics flecainide propafenone oral tablet Class Ii Antiarrhythmics atenolol atenolol-chlorthalidone bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Class Iii Antiarrhythmics amiodarone oral tablet 200 mg, 400 mg Pacerone oral tablet 100 mg sotalol oral = Age Limit = Quantity Limit 34
Class Iv Antiarrhythmics diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet verapamil oral tablet verapamil oral tablet extended release Dihydropyridines amlodipine amlodipine-benazepril amlodipine-valsartan felodipine Nifediac CC oral tablet extended release 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg, 90 mg Dihydropyridines (Antihypertensive) amlodipine amlodipine-benazepril amlodipine-valsartan felodipine Nifediac CC oral tablet extended release 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg, 90 mg Direct Vasodilators hydralazine oral minoxidil oral Diuretics, Miscellaneous (Hypotensive) Theo-24 = Age Limit = Quantity Limit 35
theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized fenofibrate oral tablet 160 mg, 54 mg gemfibrozil Hmg-Coa Reductase Inhibitors atorvastatin lovastatin pravastatin rosuvastatin simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Hypotensive Agents, Miscellaneous amlodipine amlodipine-benazepril amlodipine-valsartan carvedilol doxazosin felodipine Nifediac CC oral tablet extended release 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg, 90 mg phenoxybenzamine pindolol propranolol oral sotalol oral terazosin timolol maleate oral Loop Diuretics (Hypotensive Agents) = Age Limit = Quantity Limit 36
bumetanide oral furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet torsemide oral Mineralocorticoid (Aldosterone) Antagnts Aldactazide oral tablet 50-50 mg spironolactone spironolacton-hydrochlorothiaz Mineralocorticoid(Aldoster.)Antag(Hyp ot) Aldactazide oral tablet 50-50 mg spironolactone spironolacton-hydrochlorothiaz Nitrates And Nitrites isosorbide dinitrate oral isosorbide mononitrate Nitro-Bid Nitro-Dur transdermal patch 24 hour 0.3 mg/hr, 0.8 mg/hr nitroglycerin oral nitroglycerin transdermal patch 24 hour Pcsk9 Inhibitors Praluent Pen Specialty Repatha Pushtronex Specialty Repatha SureClick Specialty Repatha Syringe Specialty Peripheral Adrenergic Inhibitors reserpine Phosphodiesterase Type 5 Inhibitors Adcirca Specialty cilostazol = Age Limit = Quantity Limit 37
Revatio intravenous Specialty Revatio oral suspension for reconstitution Specialty sildenafil (antihypertensive) oral Potassium-Sparing Diuretics (Hypoten) Aldactazide oral tablet 50-50 mg amiloride amiloride-hydrochlorothiazide spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet Thiazide Diuretics(Hypotensive Agents) Aldactazide oral tablet 50-50 mg amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide Diuril enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyclothiazide methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz moexipril-hydrochlorothiazide nadolol-bendroflumethiazide olmesartan-hydrochlorothiazide propranolol-hydrochlorothiazid = Age Limit = Quantity Limit 38
quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet valsartan-hydrochlorothiazide Thiazide-Like Diuretics(Hypotensive Agt) atenolol-chlorthalidone chlorthalidone oral tablet 25 mg, 50 mg indapamide metolazone Vasodilating Agents, Miscellaneous amlodipine amlodipine-benazepril amlodipine-valsartan aspirin-dipyridamole diltiazem HCl oral capsule,ext.rel 24h degradable diltiazem HCl oral capsule,extended release 12 hr diltiazem HCl oral capsule,extended release 24 hr diltiazem HCl oral capsule,extended release 24hr diltiazem HCl oral tablet dipyridamole oral epoprostenol (glycine) Specialty felodipine Letairis Specialty Nifediac CC oral tablet extended release 60 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr nifedipine oral tablet extended release 30 mg, 90 mg Orenitram Specialty Remodulin Specialty Tracleer Specialty = Age Limit = Quantity Limit 39
Tyvaso Specialty Tyvaso Refill Kit Specialty Tyvaso Starter Kit Specialty Veletri Specialty Ventavis Specialty verapamil oral tablet verapamil oral tablet extended release Cellular And Gene Therapy Cellular And Gene Therapy Provenge Specialty Cellular Therapy Provenge Specialty Central Nervous System Agents Adamantanes (Cns) amantadine HCl oral capsule amantadine HCl oral solution Amphetamines dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg Vyvanse Analgesics And Antipyretics, Misc. acetaminophen oral elixir acetaminophen oral liquid acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet acetaminophen oral tablet,chewable acetaminophen rectal acetaminophen-codeine oral solution 120-12 mg/5 ml acetaminophen-codeine oral tablet = Age Limit = Quantity Limit 40 ;
butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral tablet 50-325- 40 mg Feverall rectal suppository 325 mg, 80 mg gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg isometh-dichloral-acetaminophn Junior Mapap Mapap (acetaminophen) oral capsule Nortemp oral drops oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg Pain Relief oral tablet extended release Prialt Specialty tramadol-acetaminophen Anticholinergic Agents (Cns) benztropine oral trihexyphenidyl Anticonvulsants, Miscellaneous Banzel oral tablet carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable divalproex gabapentin oral capsule = Age Limit = Quantity Limit 41
gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack levetiracetam intravenous Specialty levetiracetam oral solution 100 mg/ml levetiracetam oral tablet magnesium sulfate injection Specialty oxcarbazepine oral tablet Sabril oral tablet Specialty topiramate oral capsule, sprinkle topiramate oral tablet valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml vigabatrin Specialty zonisamide Antidepressants, Miscellaneous bupropion HCl bupropion HCl (smoking deter) mirtazapine Antimanic Agents divalproex lithium carbonate lithium citrate oral solution 8 meq/5 ml valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Antimigraine Agents, Miscellaneous aspirin oral tablet aspirin oral tablet,chewable = Age Limit = Quantity Limit 42
aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg aspirin rectal Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg butalbital-acetaminophen-caff oral tablet 50-325- 40 mg butalbital-aspirin-caffeine oral capsule dihydroergotamine injection dihydroergotamine nasal divalproex Ergomar propranolol oral timolol maleate oral tramadol-acetaminophen valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Antipsychotics, Miscellaneous loxapine succinate pimozide Anxiolytics,Sedatives,And Hypnotics,Misc buspirone droperidol injection solution eszopiclone hydroxyzine HCl oral solution 10 mg/5 ml hydroxyzine HCl oral tablet hydroxyzine pamoate promethazine injection solution promethazine oral promethazine rectal Sleep Aid (doxylamine) = Age Limit = Quantity Limit 43
zaleplon zolpidem oral tablet Atypical Antipsychotics Abilify Maintena Specialty aripiprazole oral solution aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg Aristada Specialty clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg Geodon intramuscular Invega Sustenna Specialty Invega Trinza Specialty Latuda oral tablet 120 mg, 20 mg, 40 mg, 60 mg, 80 mg olanzapine intramuscular olanzapine oral olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg Risperdal Consta Specialty risperidone oral solution 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, 3 mg, 4 mg ziprasidone HCl Zyprexa Relprevv Specialty Barbiturates (Anticonvulsants) = Age Limit = Quantity Limit 44 ; ; ; ; ; ; ; ; ; ; ; ; ; ;
phenobarbital primidone Barbiturates (Anxiolytic, Sedative/Hyp) Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg butalbital-acetaminophen oral tablet 50-325 mg butalbital-acetaminophen-caff oral tablet 50-325- 40 mg butalbital-aspirin-caffeine oral capsule phenobarbital Benzodiazepines (Anticonvulsants) clonazepam clorazepate dipotassium Diazepam Intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet diazepam rectal Lorazepam Intensol lorazepam oral tablet Benzodiazepines (Anxiolytic,Sedativ/Hyp) alprazolam oral tablet amitriptyline-chlordiazepoxide chlordiazepoxide HCl chlordiazepoxide-clidinium clonazepam clorazepate dipotassium Diazepam Intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet diazepam rectal estazolam Lorazepam Intensol = Age Limit = Quantity Limit 45
lorazepam oral tablet midazolam oral syrup 2 mg/ml oxazepam temazepam oral capsule 15 mg, 30 mg triazolam Butyrophenones haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral Central Nervous System Agents, Misc. atomoxetine Austedo Specialty guanfacine oral tablet guanfacine oral tablet extended release 24 hr Ingrezza Specialty memantine oral tablet memantine oral tablets,dose pack riluzole Xenazine Specialty Cyclooxygenase-2 (Cox-2) Inhibitors celecoxib oral capsule 100 mg, 200 mg celecoxib oral capsule 400 mg, 50 mg Dopamine Precursors carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release Ergot-Deriv. Dopamine Receptor Agonists bromocriptine cabergoline Fibromyalgia Agents duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg = Age Limit = Quantity Limit 46
duloxetine oral capsule,delayed release(dr/ec) 60 mg Savella Hydantoins Dilantin phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule 100 mg Monoamine Oxidase B Inhibitors selegiline HCl Monoamine Oxidase Inhibitors phenelzine selegiline HCl tranylcypromine Nonergot-Deriv.Dopamine Receptor Agonist APOKYN Specialty pramipexole oral tablet ropinirole oral tablet Opiate Agonists acetaminophen-codeine oral solution 120-12 mg/5 ml acetaminophen-codeine oral tablet Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg carisoprodol-asa-codeine codeine sulfate oral tablet fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg = Age Limit = Quantity Limit 47
hydromorphone oral liquid hydromorphone oral tablet hydromorphone rectal meperidine oral morphine concentrate oral solution morphine oral solution morphine oral tablet morphine oral tablet extended release oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg oxycodone oral tablet 30 mg oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg Promethazine VC-Codeine tramadol oral tablet tramadol-acetaminophen Opiate Antagonists Evzio naltrexone Narcan nasal spray,non-aerosol 4 mg/actuation Vivitrol Opiate Partial Agonists buprenorphine HCl sublingual buprenorphine-naloxone butorphanol tartrate nasal nalbuphine Other Nonsteroidal Anti-Inflam. Agents diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % diflunisal etodolac oral tablet = Age Limit = Quantity Limit 48 ; ; ;
flurbiprofen oral tablet 50 mg ibuprofen oral suspension ibuprofen oral tablet ibuprofen oral tablet,chewable indomethacin oral capsule Infant's Ibuprofen ketoprofen oral capsule ketorolac oral meclofenamate meloxicam oral tablet nabumetone naproxen naproxen sodium oral capsule naproxen sodium oral tablet piroxicam sulindac Phenothiazines chlorpromazine fluphenazine decanoate fluphenazine HCl injection fluphenazine HCl oral tablet perphenazine perphenazine-amitriptyline prochlorperazine prochlorperazine Edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate thioridazine trifluoperazine Respiratory And Cns Stimulants Butalbital Compound W/Codeine butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg = Age Limit = Quantity Limit 49
butalbital-acetaminophen-caff oral tablet 50-325- 40 mg butalbital-aspirin-caffeine oral capsule caffeine citrate oral dexmethylphenidate methylphenidate HCl oral capsule, ER biphasic 30-70 methylphenidate HCl oral solution 10 mg/5 ml methylphenidate HCl oral tablet methylphenidate HCl oral tablet extended release 20 mg methylphenidate HCl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg Salicylates aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (DR/EC) 325 mg, 81 mg aspirin rectal aspirin-dipyridamole Butalbital Compound W/Codeine butalbital-aspirin-caffeine oral capsule carisoprodol-asa-codeine carisoprodol-aspirin Orphenadrine Compound salsalate Sel.Serotonin,Norepi Reuptake Inhibitor duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg Savella venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet = Age Limit = Quantity Limit 50
Selective Serotonin Agonists rizatriptan sumatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution Selective-Serotonin Reuptake Inhibitors citalopram escitalopram oxalate fluoxetine oral capsule 10 mg, 20 mg fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg fluvoxamine oral tablet olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine HCl oral tablet paroxetine HCl oral tablet extended release 24 hr Paxil oral suspension sertraline oral concentrate sertraline oral tablet 100 mg, 25 mg, 50 mg Serotonin Modulators nefazodone trazodone Succinimides ethosuximide Thioxanthenes thiothixene Tricyclics, Other Norepi-Ru Inhibitors amitriptyline amitriptyline-chlordiazepoxide amoxapine clomipramine ; = Age Limit = Quantity Limit 51
desipramine doxepin oral imipramine HCl maprotiline nortriptyline oral capsule perphenazine-amitriptyline Vesicular Monoamine Transport2 Inhibitor Austedo Specialty Ingrezza Specialty Xenazine Specialty Wakefulness-Promoting Agents modafinil Devices Devices Accu-Chek Aviva Control Soln Accu-Chek FastClix Accu-Chek Guide Glucose Meter Accu-Chek Guide L1-L2 Ctrl Sol Accu-Chek Multiclix Lancet Accu-Chek SmartView Contrl Sol Accu-Chek Soft Dev Lancets Accu-Chek Softclix Lancet Dev Accu-Chek Softclix Lancets Aerochamber MV Euflexxa Specialty Gelclair Gel-One Specialty Gelsyn-3 Specialty GenVisc 850 Specialty heparin (porcine) in NaCl (PF) Specialty Hyalgan Specialty = Age Limit = Quantity Limit 52
Hyper-Sal inhalation solution for nebulization 7 % Insulin Syringe syringe 0.5 ml 29 gauge x 1/2" Lancets,Ultra Thin 26 gauge Monovisc Specialty ORTHOVISC Specialty pen needle, diabetic needle 29 gauge x 1/2" sodium chloride inhalation solution for nebulization 0.9 % Soft Touch Lancets Solesta Specialty Supartz FX Specialty Synvisc Specialty Synvisc-One Specialty Vortex Holding Chamber Diagnostic Agents Adrenocortical Insufficiency Acthar H.P. cosyntropin injection Specialty Diabetes Mellitus Accu-Chek Aviva Plus test strp Accu-Chek Guide Accu-Chek SmartView Test Strip Thyroid Function Thyrogen Specialty Electrolytic, Caloric, And Water Balance Alkalinizing Agents Cytra-2 Oracit potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) Ammonia Detoxicants = Age Limit = Quantity Limit 53
Carbaglu Specialty Enulose lactulose oral solution 10 gram/15 ml Caloric Agents Clinisol SF 15 % Specialty D5 %-0.45 % sodium chloride Specialty dextrose 70 % in water (D70W) Specialty Intralipid intravenous emulsion 20 % Specialty L-Carnitine oral capsule Liposyn III intravenous emulsion 10 %, 30 % Specialty Prosol 20 % Specialty Travasol 10 % Specialty TrophAmine 10 % Specialty Carbonic Anhydrase Inhibitors acetazolamide Diuretics, Miscellaneous Theo-24 theophylline oral tablet extended release 12 hr theophylline oral tablet extended release 24 hr Irrigating Solutions sodium chloride irrigation water for irrigation, sterile Loop Diuretics bumetanide oral furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet torsemide oral Phosphate-Removing Agents calcium acetate oral capsule sevelamer carbonate oral tablet Potassium-Removing Agents Kionex (with sorbitol) = Age Limit = Quantity Limit 54
SPS (with sorbitol) rectal Potassium-Sparing Diuretics Aldactazide oral tablet 50-50 mg amiloride amiloride-hydrochlorothiazide spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet Replacement Preparations Atabex EC Bio-35, Gluten Free Ca-D3-mag-zinc-cop-mang-bor calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500 mg)-800 unit, 600 mg(1,500mg) -400 unit calcium citrate-vitamin D3 oral tablet 315-250 mg-unit Citracal + D3 (calcium phos) oral tablet,chewable 250 mg calcium- 250 unit Citrus Calcium oral tablet 315-250 mg-unit Daily Prenatal Hyper-Sal inhalation solution for nebulization 7 % Klor-Con Klor-Con/EF Mynatal oral capsule Mynatal Plus Mynatal-Z O-Cal FA O-Cal Prenatal One A Day Women's Prenatal DHA One-A-Day Womens Formula oral tablet 18 mg iron-400 mcg-500 mg Ca = Age Limit = Quantity Limit 55
One-A-Day Women's Prenatal 1 Oralyte Oyster Shell Calcium-Vit D3 oral tablet 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit Perry Prenatal potassium chloride oral capsule, extended release 10 meq potassium chloride oral liquid potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet,er particles/crystals Prenatabs Rx Prenatal Formula oral tablet 9 mg iron- 267 mcg Prenatal Low Iron Prenatal Plus Prenatal Plus (calcium carb) Prenatal Vitamin Plus Low Iron prenatal vit-iron fum-folic ac prenatal vits96-iron fum-folic Prosteon Right Step Prenatal Vitamins selenium oral tablet,delayed release (DR/EC) sodium chloride inhalation solution for nebulization 0.9 % TheraCal D4000 TPN Electrolytes Specialty TPN Electrolytes II Specialty TriAdvance Trinatal Rx 1 Trinate Triveen-Duo DHA Upcal D Vinate One = Age Limit = Quantity Limit 56
Vinate Ultra Vol-Nate Vol-Tab Rx VP-GGR-B6 Women's Daily Caplet Thiazide Diuretics Aldactazide oral tablet 50-50 mg amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide Diuril enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyclothiazide methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz moexipril-hydrochlorothiazide nadolol-bendroflumethiazide olmesartan-hydrochlorothiazide propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet valsartan-hydrochlorothiazide Thiazide-Like Diuretics = Age Limit = Quantity Limit 57
atenolol-chlorthalidone chlorthalidone oral tablet 25 mg, 50 mg indapamide metolazone Uricosuric Agents probenecid probenecid-colchicine Vasopressin Antagonists Samsca Specialty Enzymes Enzymes Activase intravenous recon soln 50 mg Specialty Adagen Specialty Aldurazyme Specialty Cathflo Activase Specialty Cerezyme Specialty Elaprase Specialty Elelyso Specialty Elitek Specialty Fabrazyme Specialty Myozyme Specialty Naglazyme Specialty Pulmozyme Specialty Sucraid Specialty Voraxaze Specialty VPRIV Specialty Xiaflex Specialty Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) brimonidine Antiallergic Agents azelastine nasal = Age Limit = Quantity Limit 58