Express Scripts Prescription Information For Concordia Health Plan Medicare Supplement Members - Basic & Plus Plans Express Scripts Preferred Formulary... 2 Express Scripts Preferred List Exclusions... 22 Specialty s. 24 s/supplies Not Covered by the Concordia Health Plan (CHP).... 26
Express Scripts Medicare (PDP) 206 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 6033, v6 This formulary was updated on 08/4/205. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at www.express-scripts.com. Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 4, 205. For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January, 207. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME969 CRP5_000 F0PP4C6A
What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of covered Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or l for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at www.express-scripts.com or contact Customer Service. Express Scripts Medicare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 206 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s formulary, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from our formulary, adds prior authorization, quantity l, and/or step therapy restrictions on a drug, or moves a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug on our formulary is unsafe, or if the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. i
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 70. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the Name column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or l on coverage. These requirements and l may include: Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity L: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or l by looking in the drug list that begins on page. Note: This drug list includes all possible restrictions and l on coverage. The requirements and l may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at www.express-scripts.com or contact Customer Service. You can ask us to make an exception to these restrictions or l. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. ii
What if my drug is not on the formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request a formulary exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level. If your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our Preferred Brand tier instead. If approved, this would lower the amount you must pay for your drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in our Specialty tier. You can ask us to waive coverage restrictions or l on your drug. For example, for certain drugs, Express Scripts Medicare l the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Generally, your request for an exception will only be approved if the alternative drugs that are included in the plan formulary, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii
How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that is not on our formulary, or if your ability to get drugs is limited, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for at least 30 days, or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to provide up to a total of at least a 30-day supply of the medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drug is limited but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency transition supply of that drug (unless you have a prescription written for fewer days) while you pursue an exception. Other times when we will cover at least a temporary 30-day transition supply (or less, if you have a prescription written for fewer days) include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. iv
Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 70. The Name column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. v
Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. s Includes Helpful tips : Generic s 2: Preferred Brand s 3: Non-Preferred Brand s 4: Specialty s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high cost brand-name and generic drugs. Use drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than non-preferred brand drugs. Many non-preferred drugs have lower-cost alternatives in s and 2. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist using the information provided on the front and back covers of this formulary. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at.800.medicare (.800.633.4227), 24 hours a day, 7 days a week. TTY users should call.877.486.2048. Or visit http://www.medicare.gov. vi
Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan l the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vii
Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 PA; MO AMBISOME 4 PA; MO amphotericin b PA; MO CANCIDAS 4 PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG 4 fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral LAMISIL ORAL GRANULES IN PACKET MYCAMINE Name NOXAFIL ORAL nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution PA; MO adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 4 cidofovir 4 PA; MO
Name COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir foscarnet PA; MO FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium HARVONI 4 PA; MO; QL (28 per 28 days) INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET 2 Name ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 00 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET 00-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) nevirapine NORVIR 2
Name OLYSIO 4 PA; MO; QL (28 per 28 days) PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg Name ribasphere ribapak oral tablets,dose pack 400-400 mg (28)-mg (28), 600-400 mg (28)-mg (28), 600-600 mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI 4 PA; MO; QL (28 per 28 days) stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TIVICAY TRIUMEQ TRUVADA TYZEKA valacyclovir ; QL (30 per VALCYTE ORAL RECON SOLN valganciclovir VIDEX 2 GRAM PEDIATRIC 3
Name VIEKIRA PAK 4 PA; MO; QL (2 per 28 days) VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIRAZOLE VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet Name cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram cefdinir cefditoren pivoxil oral tablet 200 mg cefepime cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone injection recon soln 0 gram 4
Name ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln.5 gram, 750 mg cefuroxime sodium intravenous cephalexin FORTAZ INTRAVENOUS RECON SOLN GRAM SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 2 3 MO 3 3 MO TEFLARO 3 MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg Name azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet 5 2 ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml atovaquone
Name atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML aztreonam injection recon soln gram baciim bacitracin intramuscular 2 4 BETHKIS 4 PA; MO; QL (224 per 28 days) BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 days) chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric Name clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE DARAPRIM ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid injection 3 MO 6
Name isoniazid oral ivermectin oral KETEK linezolid intravenous 4 linezolid oral mefloquine meropenem intravenous recon soln 500 mg metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 2 PA; MO; QL (6 per 28 days) neomycin paromomycin PASER PENTAM 3 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin intravenous rifampin oral SIRTURO ; LA STREPTOMYCIN INTRAMUSCULA R SYNERCID 4 Name tinidazole TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.225 % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/00 ml tobramycin sulfate injection solution ; QL (224 per 28 days) 4 PA; MO; QL (280 per 28 days) TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg 7
Name amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N 25-3.25 MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin injection recon soln gram nafcillin injection recon soln 0 gram Name oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml 2 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln 3.375 gram, 4.5 gram 8
Name ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 3.375 GRAM/50 ML QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml levofloxacin intravenous 2 levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS Name sulfadiazine oral sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline oral doxy-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS 9
Name MACRODANTIN ORAL CAPSULE 25 MG methenamine hippurate nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin monohyd/m-cryst nitrofurantoin oral PRIMSOL 3 MO trimethoprim VANCOMYCIN vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg ELITEK INTRAVENOUS RECON SOLN.5 MG FUSILEV 4 4 Name KEPIVANCE 4 leucovorin calcium injection recon soln 00 mg, 350 mg leucovorin calcium oral mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adrucil intravenous solution 500 mg/0 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG 4 PA; MO 4 PA; MO; QL (60 per 4 PA; MO anastrozole ARRANON 4 ARZERRA INTRAVENOUS SOLUTION 00 MG/5 ML 4 PA; MO AVASTIN azacitidine 0
Name azathioprine PA; MO BELEODAQ bicalutamide BICNU 3 MO bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG BUSULFEX 4 CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N 4 PA; MO 4 PA; MO; QL (30 per 4 PA; MO; LA; QL (90 per 30 days) 4 PA; MO; LA; QL (30 per 30 days) 2 PA; MO 4 PA; MO cisplatin cladribine CLOLAR COMETRIQ 4 PA; MO CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous 2 PA; MO PA Name cyclosporine modified cyclosporine oral capsule PA; MO PA; MO cytarabine cytarabine (pf) injection solution 2 gram/20 ml (00 mg/ml) dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution DAUNOXOME decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) doxorubicin intravenous solution 50 mg/25 ml 4 DROXIA EMCYT epirubicin intravenous solution 50 mg/25 ml
Name ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML ERIVEDGE 4 PA; MO; QL (30 per ERWINAZE ETOPOPHOS 3 MO etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE 5 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml 4 PA; MO; QL (2 per 2 days) 4 PA; MO; QL (6 per 2 days) flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) Name gemcitabine intravenous recon soln gram gengraf PA; MO GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEEVEC ORAL TABLET 00 MG GLEEVEC ORAL TABLET 400 MG 4 PA; MO; QL (60 per 4 PA; MO; QL (40 per 4 PA; MO; QL (30 per 4 PA; MO HALAVEN HERCEPTIN HEXALEN hydroxyurea 4 PA; MO; QL (60 per IBRANCE 4 PA; MO; QL (2 per 28 days) ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln gram 4 PA; MO; QL (90 per 4 PA; MO; QL (30 per IMBRUVICA 4 PA; MO; QL (20 per INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG 4 PA; MO 4 PA; MO; QL (20 per 2
Name irinotecan intravenous solution 00 mg/5 ml ISTODAX IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG 4 PA; MO JEVTANA KADCYLA INTRAVENOUS RECON SOLN 00 MG KEYTRUDA INTRAVENOUS RECON SOLN 4 PA; MO; QL (60 per LENVIMA 4 PA; MO letrozole LEUKERAN leuprolide LOMUSTINE LUPRON DEPOT 4 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) 4 PA; MO 4 PA; MO 4 PA; MO Name LUPRON DEPOT- PED INTRAMUSCULA R KIT.25 MG, 5 MG 4 PA; MO LYNPARZA 4 PA; MO LYSODREN MATULANE MEGACE ES megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl 4 mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium oral mitomycin intravenous recon soln 20 mg 4 PA; MO; QL (20 per 4 PA; MO; QL (30 per PA PA; MO PA; MO mitoxantrone MUSTARGEN 3 MO mycophenolate mofetil oral capsule PA; MO 3
Name mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium 4 PA; MO PA; MO PA; MO NEORAL 3 PA; MO NEXAVAR 4 PA; MO; LA; QL (20 per 30 days) NILANDRON NIPENT NULOJIX 4 PA; MO octreotide acetate injection solution,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml ONCASPAR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 00 mg/20 ml paclitaxel PERJETA POMALYST Name PROGRAF INTRAVENOUS 2 PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 2 PA; MO REVLIMID 4 PA; MO; LA RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG (DOSE PACK 2), 2.5 MG (DOSE PACK 6), 2.5 MG (DOSE PACK 20), 2.5 MG (DOSE PACK 8) 3 PA; MO 3 PA RITUXAN 4 PA; MO SANDIMMUNE INTRAVENOUS SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R KIT 3 PA; MO 3 PA; MO 2 PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 PA; MO 4
Name sirolimus oral tablet 0.5 mg, mg sirolimus oral tablet 2 mg PA; MO 4 PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 40 MG SPRYCEL ORAL TABLET 70 MG 4 PA; MO 4 PA; MO; QL (30 per 4 PA; MO; QL (60 per STIVARGA 4 PA; MO; QL (84 per 28 days) SUTENT ORAL CAPSULE 2.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 00 MG 4 PA; MO 4 PA; MO; QL (60 per 4 PA; MO; QL (30 per SYNRIBO TABLOID tacrolimus oral capsule 0.5 mg, mg tacrolimus oral capsule 5 mg PA; MO 4 PA; MO Name TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG tamoxifen TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG 4 PA; MO; QL (80 per 4 PA; MO; QL (20 per 4 PA; MO TARGRETIN TASIGNA ORAL CAPSULE 50 MG TASIGNA ORAL CAPSULE 200 MG 4 PA; MO; QL (30 per 4 PA; MO 4 PA; MO; QL (2 per 28 days) THALOMID 4 PA; MO toposar topotecan intravenous recon soln TORISEL TREANDA INTRAVENOUS RECON SOLN 00 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRELSTAR DEPOT 4 5
Name TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N TRELSTAR INTRAMUSCULA R SYRINGE.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR LA 4 tretinoin (chemotherapy) TRISENOX TYKERB 4 PA; MO; LA; QL (80 per 30 days) VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (20 MG/ML) 4 PA; MO VELCADE vinblastine intravenous solution vincasar pfs intravenous solution mg/ml vincristine intravenous solution mg/ml vinorelbine intravenous solution 50 mg/5 ml VOTRIENT 4 PA; MO; QL (20 per Name XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 4 PA; MO 4 PA; MO; QL (60 per XTANDI 4 PA; MO; QL (20 per YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) ZANOSAR 3 MO ZELBORAF 4 PA; MO; QL (240 per ZOLINZA ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 2 PA; MO 4 PA; MO ZYDELIG 4 PA; MO; QL (90 per ZYKADIA 4 PA; MO; QL (50 per ZYTIGA 4 PA; MO; QL (20 per AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS 6
Name APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 3 MO clonazepam PA; MO diazepam rectal PA; MO DILANTIN 30 MG divalproex epitol ethosuximide felbamate Name fosphenytoin injection solution 00 mg pe/2 ml FYCOMPA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG GRALISE 2 PA; MO GRALISE 30-DAY STARTER PACK lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK,000 MG/00 ML,,500 MG/00 ML 2 PA; MO 2 7
Name LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 500 MG/00 ML levetiracetam intravenous levetiracetam oral solution 00 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA 2 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG 2 PA; MO 2 PA; MO oxcarbazepine PEGANONE phenobarbital oral elixir phenobarbital oral tablet 00 mg phenobarbital oral tablet 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable Name phenytoin sodium extended phenytoin sodium intravenous solution POTIGA primidone SABRIL ; LA TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 8 2 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine
Name bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 24 hr 0.75 mg,.5 mg ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY CAFERGOT dihydroergotamine injection dihydroergotamine nasal migergot ; QL (8 per 28 days) naratriptan ; QL (8 per 28 days) RELPAX ; QL (8 per 28 days) rizatriptan ; QL (36 per 28 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation ; QL (8 per 28 days) Name sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution ; QL (36 per 28 days) ; QL (8 per 28 days) ; QL (6 per 28 days) ; QL (6 per 28 days) zolmitriptan ; QL (8 per 28 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 4 PA; MO; LA AUBAGIO 4 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil EXELON TRANSDERMAL 4 PA; MO; QL (2 per 28 days) galantamine GILENYA 4 PA; MO glatopa 4 PA; MO; QL (30 per NAMENDA ORAL SOLUTION 2 PA; MO NAMENDA XR 2 PA; MO NUEDEXTA 9
Name rivastigmine tartrate TECFIDERA 4 PA; MO TYSABRI 4 PA; MO; LA XENAZINE 4 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen dantrolene LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide oral tablet 2 PA; MO 2 PA tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution 300 mg-30 mg /2.5 ml acetaminophencodeine oral tablet 300-5 mg, 300-30 mg QL (4500 per 30 days) ; QL (360 per Name acetaminophencodeine oral tablet 300-60 mg ; QL (80 per BUPRENEX ; QL (267 per buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg QL (267 per 30 days) ; QL (300 per ; QL (75 per BUTRANS ; QL (4 per 28 days) codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml endocet oral tablet 0-325 mg, 5-325 mg, 7.5-325 mg ; QL (80 per ; QL (4000 per QL (2000 per 30 days) ; QL (360 per endodan ; QL (360 per fentanyl citrate buccal lozenge on a handle,200 mcg fentanyl citrate buccal lozenge on a handle,600 mcg 4 PA; MO; QL (39 per 4 PA; MO; QL (29 per 20
Name fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr fentanyl transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution 7.5-325 mg/5 ml hydrocodoneacetaminophen oral tablet 0-300 mg, 0-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodoneibuprofen oral tablet 7.5-200 mg hydromorphone (pf) injection solution 0 mg/ml 4 PA; MO; QL (20 per 4 PA; MO; QL (6 per 4 PA; MO; QL (77 per 4 PA; MO; QL (58 per ; QL (9 per ; QL (0 per ; QL (5550 per ; QL (360 per ; QL (50 per ; QL (20 per Name hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 2 mg, 8 mg hydromorphone oral tablet extended release 24 hr 6 mg hydromorphone oral tablet extended release 24 hr 32 mg ; QL (500 per ; QL (80 per ; QL (60 per ; QL (60 per ; QL (47 per ibuprofen-oxycodone ; QL (28 per levorphanol tartrate ; QL (20 per lorcet (hydrocodone) ; QL (360 per lorcet hd ; QL (360 per lorcet plus oral tablet 7.5-325 mg ; QL (360 per lortab 0-325 ; QL (360 per lortab 5-325 ; QL (360 per lortab 7.5-325 ; QL (360 per methadone injection QL (60 per 30 days) methadone oral solution 0 mg/5 ml ; QL (600 per 2
Name methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 20 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 0 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 00 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution ; QL (200 per ; QL (20 per ; QL (240 per ; QL (300 per QL (000 per 30 days) QL (500 per 30 days) ; QL (50 per ; QL (60 per ; QL (90 per ; QL (60 per ; QL (75 per ; QL (900 per Name morphine oral tablet ; QL (80 per morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet 0-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg ; QL (60 per ; QL (20 per ; QL (30 per ; QL (00 per ; QL (360 per ; QL (80 per ; QL (200 per ; QL (80 per ; QL (34 per ; QL (360 per ; QL (360 per oxycodone-aspirin ; QL (360 per 22
Name OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 2 hr 30 mg oxymorphone oral tablet extended release 2 hr 40 mg ; QL (90 per ; QL (67 per ; QL (50 per ; QL (200 per ; QL (80 per ; QL (90 per ; QL (67 per ; QL (50 per reprexain ; QL (50 per vicodin es oral tablet 7.5-300 mg vicodin hp oral tablet 0-300 mg ; QL (360 per ; QL (360 per Name vicodin oral tablet 5-300 mg ; QL (360 per zamicet QL (5550 per 30 days) NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet 2-0.5 mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenacmisoprostol PA; MO; QL (360 per PA; MO; QL (90 per ; QL (720 per ; QL (360 per ; QL (5 per 28 days) diflunisal etodolac fenoprofen oral tablet FLECTOR 3 PA; MO; QL (60 per flurbiprofen 23
Name ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate oral mefenamic acid meloxicam oral suspension meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe mg/ml ; QL (30 per ; QL (200 per ; QL (00 per naltrexone oral naproxen naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr oxaprozin Name piroxicam SUBOXONE SUBLINGUAL FILM 2-3 MG SUBOXONE SUBLINGUAL FILM 2-0.5 MG SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG sulindac oral tolmetin oral capsule tolmetin oral tablet 600 mg 2 PA; MO; QL (60 per 2 PA; MO; QL (360 per 2 PA; MO; QL (90 per tramadol oral tablet ; QL (240 per tramadol oral tablet extended release 24 hr 00 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg tramadolacetaminophen VOLTAREN GEL TOPICAL GEL % ; QL (30 per ; QL (30 per ; QL (240 per PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 0 MG 3 MO; QL (90 per 24
Name ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING amitriptyline PA; MO amoxapine amphetamine salt combo aripiprazole oral tablet 0 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 20 MG 4 ; QL (90 per ; QL (60 per ; QL (450 per ; QL (60 per ; QL (30 per ; QL (80 per 3 MO; QL (60 per 3 MO; QL (30 per Name BRINTELLIX ORAL TABLET 5 MG bupropion hcl oral tablet bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 50 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg bupropion hcl oral tablet extended release 24 hr 300 mg 3 MO; QL (20 per buspirone chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (20 per ; QL (90 per ; QL (60 per ; QL (90 per ; QL (60 per ; QL (20 per ; QL (60 per ; QL (30 per clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr 25
Name clorazepate dipotassium clozapine oral tablet 00 mg, 25 mg, 50 mg clozapine oral tablet 200 mg clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg PA; MO desipramine oral dexedrine dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule,extended release 24hr diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml PA; MO diazepam oral tablet PA; MO doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg ; QL (80 per ; QL (20 per Name duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (90 per ; QL (60 per ; QL (60 per ; QL (30 per ; QL (20 per eszopiclone ST; MO; QL (30 per FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG, 8 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLETS,DOSE PACK 3 MO; QL (720 per 3 MO; QL (90 per 3 MO; QL (60 per 3 MO; QL (360 per 3 MO; QL (80 per 3 MO; QL (20 per 3 MO; QL (8 per 28 days) 26
Name FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg 3 2 ST; MO; QL (28 per 28 days) 2 ST; MO; QL (30 per 2 ST; MO; QL (80 per 2 ST; MO; QL (90 per 2 ST; MO; QL (45 per ; QL (240 per ; QL (60 per ; QL (4 per 28 days) ; QL (240 per Name fluoxetine oral tablet 20 mg fluphenazine decanoate fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (90 per ; QL (60 per ; QL (90 per ; QL (360 per ; QL (80 per FORFIVO XL 3 MO; QL (30 per GEODON INTRAMUSCULA R 3 MO guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ 4 PA; MO imipramine hcl PA; MO imipramine pamoate PA; MO 27
Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG 3 MO; QL (240 per 3 MO; QL (20 per 3 MO; QL (60 per 3 MO; QL (4 per 3 MO ; QL (30 per ; QL (240 per ; QL (20 per Name LATUDA ORAL TABLET 60 MG, 80 MG lithium carbonate lithium citrate oral solution 8 meq/5 ml ; QL (60 per lorazepam intensol PA; MO lorazepam oral tablet PA; MO loxapine succinate maprotiline MARPLAN metadate er methamphetamine methylphenidate oral capsule, er biphasic 30-70 0 mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic 50-50 methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr methylphenidate oral tablet,chewable mirtazapine 28
Name modafinil PA; MO nefazodone nortriptyline olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (60 per ; QL (30 per ; QL (240 per ; QL (20 per ; QL (8 per ; QL (60 per ; QL (30 per ; QL (20 per ORAP oxazepam PA; MO paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg ; QL (80 per ; QL (90 per ; QL (60 per Name paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION ; QL (45 per ; QL (80 per ; QL (90 per ; QL (60 per 3 MO perphenazine phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG procentra protriptyline quetiapine oral tablet 00 mg 2 ST; MO; QL (20 per 2 ST; MO; QL (480 per 2 ST; MO; QL (240 per ; QL (240 per 29
Name quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 2.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QL (20 per ; QL (902 per ; QL (8 per ; QL (60 per ; QL (480 per ; QL (480 per ; QL (920 per ; QL (960 per ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per Name risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (920 per ; QL (960 per ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per ROZEREM ; QL (30 per SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG ; QL (60 per ; QL (240 per ; QL (20 per ; QL (6 per 30
Name SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg ; QL (20 per ; QL (8 per ; QL (60 per ; QL (480 per STRATTERA ; QL (60 per ; QL (240 per ; QL (20 per SURMONTIL 3 PA; MO temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone Name trifluoperazine venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg VERSACLOZ 4 LA VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (7)-40 MG (6) ; QL (60 per ; QL (80 per ; QL (90 per ; QL (90 per ; QL (270 per ; QL (80 per ; QL (50 per ; QL (20 per ; QL (60 per ; QL (30 per ; QL (30 per XYREM ; LA zaleplon oral capsule 0 mg zaleplon oral capsule 5 mg ST; MO; QL (60 per ST; MO; QL (30 per 3
Name zenzedi oral tablet 0 mg, 5 mg ZENZEDI ORAL TABLET 5 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg 3 MO ; QL (240 per ; QL (20 per ; QL (80 per ; QL (60 per zolpidem ST; MO; QL (30 per ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 20 MG 4 LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg PA; MO flecainide mexiletine Name pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet sorine oral tablet 20 mg, 60 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 20 mg sotalol oral tablet 60 mg, 240 mg, 80 mg SOTYLIZE 2 32 TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol oral afeditab cr amiloride oral amlodipine amiloridehydrochlorothiazide amlodipinebenazepril
Name atenolol AZOR 2 ST; MO benazepril BENICAR 2 ST; MO BENICAR HCT 2 ST; MO betaxolol oral BIDIL bisoprolol fumarate bumetanide BYSTOLIC candesartan captopril amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol chlorothiazide chlorothiazide sodium Name chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 days) clonidine hcl oral tablet clorpres oral tablet 0.-5 mg, 0.2-5 mg COREG CR DEMSER diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 mg diltiazem hcl oral tablet dilt-xr doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 per ; QL (60 per EDARBI 3 ST; MO EDARBYCLOR 3 ST; MO EDECRIN 33
Name enalapril maleate eplerenone eprosartan felodipine fosinopril furosemide injection furosemide oral solution 0 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan isradipine labetalol intravenous solution labetalol oral lisinopril losartan enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide matzim la Name methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral minoxidil oral moexipril nadolol metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide nicardipine nifedical xl nifedipine oral tablet extended release 24hr nimodipine nisoldipine perindopril erbumine pindolol prazosin oral propranolol intravenous propranolol oral 34
Name quinapril ramipril REMODULIN 4 PA; MO; LA spironolactone taztia xt telmisartan terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg timolol maleate oral torsemide oral trandolapril ; QL (30 per ; QL (60 per TRIBENZOR 2 ST; MO valsartan propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide Name verapamil intravenous solution verapamil oral CARDIAC GLYCOSIDES digitek digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX 3 MO BRILINTA cilostazol clopidogrel dipyridamole oral EFFIENT ELIQUIS enoxaparin fondaparinux subcutaneous syringe 0 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 35
Name heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution jantoven pentoxifylline PRADAXA PROMACTA 4 PA; MO; LA tranexamic acid intravenous warfarin XARELTO ZONTIVITY LIPID/CHOLESTEROL LOWERING AGENTS amlodipineatorvastatin ; QL (30 per atorvastatin ; QL (30 per cholestyramine light oral powder in packet colestipol oral granules colestipol oral tablet Name CRESTOR ; QL (30 per fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet 60 mg, 54 mg fenofibric acid (choline) fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg gemfibrozil oral ; QL (30 per ; QL (60 per JUXTAPID ; LA LIPOFEN 3 MO lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg niacin oral tablet extended release 24 hr ; QL (30 per ; QL (60 per pravastatin ; QL (30 per prevalite oral powder simvastatin ; QL (30 per VASCEPA ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS 36
Name CORLANOR 2 PA; MO RANEXA VECAMYL 4 NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol PA NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 0 mg acitretin oral capsule 7.5 mg, 25 mg calcipotriene calcipotrienebetamethasone calcitriol topical COSENTYX PEN 4 PA; MO Name COSENTYX PEN (2 PENS) selenium sulfide topical suspension STELARA SUBCUTANEOUS SYRINGE BURN THERAPY 4 PA; MO 4 PA; MO silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS 8-MOP ammonium lactate topical CARAC CONDYLOX TOPICAL GEL diclofenac sodium topical gel FLUOROURACIL TOPICAL CREAM 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution PA; MO 4 ST; MO imiquimod methoxsalen rapid PANRETIN podofilox prudoxin REGRANEX 37
Name tacrolimus topical PA; MO UVADEX 3 VALCHLOR ZYCLARA 4 ST; MO THERAPY FOR ACNE adapalene topical cream adapalene topical gel PA; MO PA; MO amnesteem avita topical cream PA; MO AZELEX claravis clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel -5 % ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycinbenzoyl peroxide metronidazole topical cream metronidazole topical gel metronidazole topical lotion myorisan Name neuac TAZORAC 2 PA; MO tretinoin microspheres topical gel with pump PA; MO tretinoin topical PA; MO zenatane TOPICAL ANESTHETICS lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine-prilocaine topical cream 38 PA; MO TOPICAL ANTIBACTERIALS
Name ALTABAX gentamicin topical mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical econazole topical ketoconazole topical cream ketoconazole topical shampoo NAFTIN nyamyc nystatin topical clotrimazolebetamethasone nystatintriamcinolone nystop TOPICAL ANTIVIRALS acyclovir topical DENAVIR XERESE 3 MO ZOVIRAX TOPICAL CREAM 3 MO TOPICAL CORTICOSTEROIDS Name ala-cort topical cream alclometasone amcinonide apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented CAPEX clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clodan CORDRAN TAPE LARGE ROLL cormax topical solution 39
Name desonide desoximetasone diflorasone fluocinolone fluocinonide topical cream 0. % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical halobetasol propionate hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone valerate Name LOCOID TOPICAL LOTION mometasone PANDEL prednicarbate triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0. %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES EURAX 3 MO lindane malathion permethrin topical cream SKLICE DIAGNOSTICS / MISCELLANEOUS AGENTS 40
Name IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg anagrelide ARALAST NP INTRAVENOUS RECON SOLN 500 MG ; QL (30 per ; LA CARBAGLU ; LA cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 0 % and 0.2 % nacl 2 PA Name dextrose 0 % in water (d0w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride disulfiram etidronate disodium EXJADE ; LA FERRIPROX INCRELEX ; LA JADENU kionex oral powder levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet midodrine NORTHERA ORFADIN 4 LA pilocarpine hcl oral 4
Name PROLASTIN-C ; LA RAVICTI RENVELA riluzole risedronate oral tablet 30 mg sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) ; QL (30 per SYPRINE THIOLA water for irrigation, sterile zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS PA; MO buproban CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 3 MO NICOTROL NS 3 MO Name EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 per BACTROBAN NASAL chlorhexidine gluconate mucous membrane ipratropium bromide nasal ; QL (30 per olopatadine ; QL (30.5 per periogard triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S CORTISPORIN-TC 42
Name neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort cortisone DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 25 mg, 40 mg PA; MO millipred oral tablet PA; MO Name prednisolone sodium phosphate oral solution 5 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating PA; MO prednisone intensol PA; MO prednisone oral solution prednisone oral tablet SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML, 250 MG/2 ML SOLU-MEDROL (PF) INJECTION SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM veripred 20 ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg PA; MO propylthiouracil DIABETES THERAPY 43
Name acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ALCOHOL PADS ; QL (90 per ; QL (360 per ; QL (80 per APIDRA 3 ST; MO APIDRA SOLOSTAR 3 ST; MO BYDUREON 2 PA; MO; QL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 PA; MO; QL (2.4 per 2 PA; MO; QL (.2 per CYCLOSET 3 MO; QL (80 per FARXIGA ORAL TABLET 0 MG FARXIGA ORAL TABLET 5 MG GAUZE PADS 2X2 glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg ; QL (30 per ; QL (60 per ; QL (240 per ; QL (20 per ; QL (60 per Name glipizide oral tablet 0 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 0 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet 2.5-250 mg glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) HUMALOG KWIKPEN HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN ; QL (20 per ; QL (240 per ; QL (60 per ; QL (240 per ; QL (20 per ; QL (240 per ; QL (20 per 44
Name HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML (PREFILLED SYRINGE) HUMULIN 70/30 HUMULIN 70/30 KWIKPEN 2 HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U-00 0.3 ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 /2 ML INVOKAMET ; QL (60 per Name INVOKANA ; QL (30 per JANUMET ; QL (60 per JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 MG ; QL (30 per ; QL (60 per JANUVIA ; QL (30 per JENTADUETO 3 ST; MO; QL (60 per KAZANO 3 ST; MO; QL (60 per KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-,000 MG, 5-500 MG LANTUS LANTUS SOLOSTAR ; QL (60 per ; QL (30 per LEVEMIR LEVEMIR FLEXTOUCH 45
Name metformin oral tablet,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr,000 mg nateglinide oral tablet 20 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY ; QL (75 per ; QL (50 per ; QL (90 per ; QL (20 per ; QL (75 per ; QL (75 per ; QL (90 per ; QL (80 per NESINA 3 ST; MO; QL (30 per NOVOFINE 32 NOVOLOG 3 ST; MO NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN NOVOLOG PENFILL 3 ST; MO 3 ST; MO 3 ST; MO 3 ST; MO Name ONGLYZA ; QL (30 per pioglitazone ; QL (30 per pioglitazoneglimepiride pioglitazonemetformin PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet mg repaglinide oral tablet 2 mg ; QL (30 per ; QL (90 per ; QL (960 per ; QL (480 per ; QL (240 per RIOMET ; QL (765 per SYMLINPEN 20 2 PA; MO; QL (8.9 per 30 days) SYMLINPEN 60 2 PA; MO; QL (0.5 per 30 days) tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (20 per ; QL (60 per tolbutamide ; QL (80 per TOUJEO SOLOSTAR TRADJENTA 3 ST; MO; QL (30 per VGO 20 46
Name VGO 30 VGO 40 VICTOZA 3-PAK 2 PA; MO; QL (9 per XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 0-,000 MG XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 0-500 MG, 5-,000 MG, 5-500 MG ; QL (30 per ; QL (60 per MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 4 PA; MO ANDRODERM 2 PA; MO ANDROGEL 2 PA; MO AXIRON 3 PA; MO cabergoline calcitonin (salmon) calcitriol intravenous solution mcg/ml calcitriol oral CERDELGA CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chorionic gonadotropin, human PA; MO Name danazol oral desmopressin injection desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE FABRAZYME INTRAVENOUS RECON SOLN 35 MG FORTESTA 3 PA; MO fortical KORLYM KUVAN ORAL POWDER IN PACKET 500 MG KUVAN ORAL TABLET,SOLUBL E ; LA LUMIZYME MIACALCIN INJECTION 3 MO MYALEPT 4 PA; MO; LA MYOZYME NAGLAZYME ; LA NATPARA 4 PA; MO; LA novarel PA; MO 47
Name oxandrolone oral tablet 0 mg oxandrolone oral tablet 2.5 mg pamidronate intravenous solution 4 PA; MO PA; MO paricalcitol oral SAMSCA 4 PA; MO SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SOMAVERT STIMATE SYNAREL TESTIM 3 PA; MO testosterone cypionate testosterone enanthate ZAVESCA ; LA ZEMPLAR INTRAVENOUS zoledronic acid intravenous solution THYROID HORMONES levothyroxine oral levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg Name liothyronine unithroid oral tablet 00 mcg, 2 mcg, 25 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0. mg/ml diphenoxylateatropine glycopyrrolate injection 48 glycopyrrolate oral loperamide oral capsule MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO 2 PA; MO alosetron ALOXI AMITIZA APRISO 3 MO ASACOL HD balsalazide budesonide oral CHENODAL 4 PA; MO; LA CIMZIA 4 PA; MO
Name CIMZIA POWDER FOR RECONST 4 PA; MO colocort compro constulose CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 6,000-9,000-30,000 UNIT CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 36,000-4,000-80,000 UNIT cromolyn oral CYSTADANE DELZICOL DIPENTUM dronabinol oral capsule 0 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND INTRAVENOUS RECON SOLN 50 MG 4 PA; MO PA; MO EMEND ORAL 2 PA; MO enulose Name GATTEX ONE- VIAL gavilyte-c gavilyte-g gavilyte-n generlac granisetron (pf) intravenous solution 00 mcg/ml granisetron hcl intravenous solution mg/ml ( ml) granisetron hcl oral PA; MO hydrocortisone rectal enema lactulose oral solution 0 gram/5 ml LIALDA LINZESS meclizine oral tablet 2.5 mg, 25 mg mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl oral MOVANTIK MOVIPREP 3 MO ondansetron PA; MO ondansetron hcl (pf) injection solution 49
Name ondansetron hcl (pf) injection syringe ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg peg 3350- electrolytes oral recon soln 236-22.74-6.74-5.86 gram PA; MO PA PA; MO PENTASA polyethylene glycol 3350 oral powder prochlorperazine prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc RECTIV RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 4 PA; MO Name SANCUSO SUCLEAR SUCRAID sulfasalazine oral tablet sulfazine ec SUPREP BOWEL PREP KIT TRANSDERM- SCOP trilyte with flavor packets 3 MO UCERIS ORAL ursodiol VIOKACE ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40,000-36,000-28,000 UNIT ULCER THERAPY 50
Name amoxicilclarithromylansopraz carafate oral suspension ; QL (2 per cimetidine cimetidine hcl oral DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 MG DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 MG esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg esomeprazole sodium 3 MO; QL (30 per 3 MO famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine oral suspension famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 5 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg ; QL (30 per ; QL (30 per misoprostol Name NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 0 MG, 2.5 MG, 20 MG, 5 MG NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 MG ; QL (30 per nizatidine omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule 20-. mggram omeprazole-sodium bicarbonate oral capsule 40-. mggram pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ; QL (30 per ; QL (30 per ; QL (30 per PYLERA rabeprazole 5
Name ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 50 mg, 300 mg sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML 4 PA; MO 3 PA; MO 3 PA; MO Name ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.5 ML, 50 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML 4 PA; MO ARCALYST 4 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 20,000 UNIT/ML EXTAVIA SUBCUTANEOUS KIT 4 PA; MO; QL (4 per 28 days) 4 PA; MO; QL (4 per 28 days) 4 PA; MO; QL (4 per 28 days) 4 PA; MO; QL (5 per 28 days) 3 PA; MO 4 PA; MO 4 PA; MO; QL (5 per 28 days) ILARIS (PF) 4 PA; MO; LA 52
Name INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION RECON SOLN 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE 4 PA; MO NEUMEGA NEUPOGEN 4 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) NORDITROPIN NORDIFLEX 4 PA; MO 4 PA; MO OMNITROPE 4 PA; MO Name PEGASYS ; QL (4 per 28 days) PEGASYS PROCLICK ; QL (4 per 28 days) PEGINTRON ; QL (4 per 28 days) PEGINTRON REDIPEN PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML ; QL (4 per 28 days) 4 PA; MO; QL ( per 28 days) 4 PA; MO; QL ( per 80 days) 4 PA; MO; QL ( per 28 days) 4 PA; MO; QL ( per 80 days) 2 PA; MO 4 PA; MO 53
Name PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 4 PA; MO; QL (6 per 28 days) 4 PA; MO; QL (6 per 28 days) 4 PA; MO; QL (4.2 per 80 days) SYLATRON 4 PA; MO; QL (2 per 28 days) VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION BCG VACCINE, LIVE (PF) BEXSERO (PF) 2 BOOSTRIX TDAP BOTOX 2 PA; MO CERVARIX VACCINE (PF) 2 COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) Name ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE 2 PA; MO 2 PA; MO 2 PA fomepizole GAMASTAN S/D GARDASIL (PF) GARDASIL 9 (PF) GRASTEK 2 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION 2 IPOL IXIARO (PF) 54
Name MENACTRA (PF) INTRAMUSCULA R SOLUTION MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y- W-35-DIP (PF) M-M-R II (PF) PEDVAX HIB (PF) PRIVIGEN 4 PA; MO PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 0 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 2 ROTATEQ VACCINE 2 PA; MO 2 PA; MO 2 PA Name TENIVAC (PF) INTRAMUSCULA R SYRINGE TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD THYMOGLOBULI N TRUMENBA 2 TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) INTRAMUSCULA R SYRINGE 4 PA 2 VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 2 4 55
Name aloprim colchicineprobenecid COLCRYS probenecid ULORIC 2 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 0 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (286 per ; QL (30 per ; QL (4 per 28 days) FORTEO 4 PA; MO; QL (2.4 per 28 days) FOSAMAX PLUS D ibandronate intravenous solution 3 ST; MO; QL (4 per 28 days) PA; MO ibandronate oral ; QL ( per PROLIA 2 PA; MO raloxifene risedronate oral tablet 50 mg risedronate oral tablet 35 mg risedronate oral tablet 35 mg (2 pack) risedronate oral tablet 5 mg ; QL ( per ; QL (4 per 28 days) QL (4 per 28 days) ; QL (30 per Name risedronate oral tablet,delayed release (dr/ec) ; QL (4 per 28 days) OTHER RHEUMATOLOGICALS ACTEMRA 4 PA; MO BENLYSTA INTRAVENOUS RECON SOLN 20 MG CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK HUMIRA CROHN'S DIS START PCK HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML 3 MO 4 PA; MO; QL (8 per 28 days) 4 PA; MO; QL (8 per 28 days) 4 PA; MO; QL (4 per 28 days) 4 PA; MO; QL (4 per 28 days) 4 PA; MO; QL (4.8 per 80 days) 4 PA; MO; QL (0.4 per 28 days) 4 PA; MO; QL (2 per 28 days) 56
Name HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 4 PA; MO; QL (3.2 per 28 days) leflunomide ; QL (30 per ORENCIA 4 PA; MO ORENCIA (WITH MALTOSE) 4 PA; MO OTEZLA 4 PA; MO OTEZLA STARTER 4 PA; MO RIDAURA SAVELLA ORAL TABLET SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 per ; QL (55 per SIMPONI 4 PA; MO SIMPONI ARIA 4 PA; MO XELJANZ 4 PA; MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % 3 MO 3 PA; MO deblitane DEPO-PROVERA INTRAMUSCULA R SOLUTION Name DEPO-SUBQ PROVERA 04 3 MO DUAVEE errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiolnorethindrone acet ; QL (8 per 28 days) ; QL (4 per 28 days) ESTRING 3 MO estropipate jolivette lyza medroxyprogesteron e intramuscular suspension medroxyprogesteron e oral MENEST 3 MO mimvey mimvey lo nora-be norethindrone (contraceptive) 57
Name norethindrone acetate norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, -5 mg-mcg norlyroc PREMARIN ORAL progesterone micronized sharobel MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository NUVARING 3 MO terconazole tranexamic acid oral vandazole xulane ORAL CONTRACEPTIVES / RELATED AGENTS amethia amethyst apri aranelle (28) Name ashlyna aubra aviane balziva (28) briellyn cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) delyla (28) desoge.estradiol/e.estradio l drospirenone-ethinyl estradiol emoquette enpresse falmina (28) gianvi (28) gildagia gildess 24 fe gildess oral tablet.5-30 mg-mcg introvale junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe 24 kariva (28) kelnor /35 (28) 58
Name l norgest&e estradiol-e estrad oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) larin.5/30 (2) larin /20 (2) larin fe leena 28 lessina levonest (28) levonorgestrelethinyl estrad oral tablet 0.-20 mgmcg levonorgestrelethinyl estrad oral tablet 90-20 mcg levonorgestrelethinyl estrad oral tablets,dose pack,3 month levora-28 lomedia 24 fe loryna (28) lutera (28) marlissa microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) Name microgestin fe /20 (28) mononessa (28) necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nikki (28) noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindronee.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia pimtrea (28) pirmella oral tablet -35 mg-mcg portia previfem quasense reclipsen (28) 59
Name sprintec (28) sronyx tarina fe tri-legest fe trinessa (28) tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) vestura (28) vyfemla (28) wymzya fe zenchent (28) zenchent fe zovia /35e (28) zovia /50e (28) OXYTOCICS methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS bacitracin ophthalmic bacitracinpolymyxin b ophthalmic BESIVANCE CILOXAN OPHTHALMIC OINTMENT Name ciprofloxacin hcl ophthalmic erythromycin ophthalmic garamycin ophthalmic drops gatifloxacin gentak ophthalmic ointment gentamicin ophthalmic levofloxacin ophthalmic NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic polymyxin b sulftrimethoprim tobramycin TOBREX OPHTHALMIC OINTMENT ANTIVIRALS trifluridine ZIRGAN 3 MO BETA-BLOCKERS betaxolol ophthalmic carteolol 60
Name levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 3 MO CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops %, 2 %, 4 % MISCELLANEOUS OPHTHALMOLOGICS azelastine ophthalmic BEPREVE cromolyn ophthalmic CYSTARAN epinastine LACRISERT LASTACAFT PATADAY PAZEO RESTASIS ; QL (60 per Name NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ILEVRO ketorolac ophthalmic NEVANAC PROLENSA ORAL DRUGS FOR GLAUCOMA acetazolamide oral acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS bimatoprost COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.0 % SIMBRINZA 3 MO TRAVATAN Z travoprost (benzalkonium) ZIOPTAN (PF) 3 ST; MO 6
Name STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic ZYLET STEROIDS ALREX dexamethasone sodium phosphate ophthalmic fluorometholone FML S.O.P. LOTEMAX prednisolone acetate prednisolone sodium phosphate ophthalmic STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE 3 MO BLEPHAMIDE S.O.P. tobramycindexamethasone sulfacetamideprednisolone SULFONAMIDES 3 MO Name sulfacetamide sodium ophthalmic SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0. % apraclonidine brimonidine IOPIDINE OPHTHALMIC DROPPERETTE VASOCONSTRICTOR DECONGESTANTS 3 MO naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection solution mg/ml (:,000) (ml) cetirizine oral solution mg/ml desloratadine ; QL (30 per diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir epinephrine injection autoinjector PA ; QL (4 per EPIPEN 2-PAK ; QL (4 per 62
Name EPIPEN JR 2-PAK ; QL (4 per hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PA; MO ; QL (30 per promethazine oral PA; MO PULMONARY AGENTS acetylcysteine solution PA; MO ADCIRCA 4 PA; MO; QL (60 per ADEMPAS 4 PA; MO; LA ADVAIR DISKUS ; QL (60 per ADVAIR HFA ; QL (2 per AEROSPAN ; QL (7.8 per albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml PA; MO albuterol sulfate oral aminophylline intravenous solution 250 mg/0 ml ANORO ELLIPTA ; QL (60 per Name ARCAPTA NEOHALER ARNUITY ELLIPTA ; QL (30 per ; QL (30 per ASMANEX HFA ; QL (3 per ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (30 DOSES), 220 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (20 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (30 per ; QL (240 per ; QL (60 per ATROVENT HFA ; QL (25.8 per BREO ELLIPTA ; QL (60 per budesonide inhalation PA; MO budesonide nasal ; QL (7.2 per CINRYZE 4 PA; MO 63
Name COMBIVENT RESPIMAT ; QL (8 per cromolyn inhalation PA; MO DALIRESP 2 PA; MO DULERA ; QL (3 per DYMISTA ; QL (23 per ELIXOPHYLLIN ORAL ELIXIR 80 MG/5 ML 3 MO ESBRIET 4 PA; MO; QL (270 per FIRAZYR 4 PA; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION ; QL (60 per ; QL (240 per ; QL (2 per ; QL (24 per Name FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (0.6 per ; QL (50 per fluticasone nasal ; QL (6 per FORADIL AEROLIZER ipratropium bromide inhalation ipratropiumalbuterol ; QL (60 per PA; MO PA; MO KALBITOR KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET 4 PA; MO; QL (56 per 28 days) 4 PA; MO; QL (60 per LETAIRIS 4 PA; MO; LA levalbuterol hcl inhalation solution for nebulization 0.3 mg/3 ml, 0.63 mg/3 ml,.25 mg/0.5 ml PA; MO metaproterenol oral montelukast NASONEX ; QL (34 per OFEV 4 PA; MO; QL (60 per OPSUMIT 4 PA; MO; LA 64
Name PERFOROMIST 2 PA; MO PROAIR HFA ; QL (7 per PROAIR RESPICLICK PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 80 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION MG/2 ML ; QL (7 per ; QL (2 per ; QL ( per 2 PA; MO PULMOZYME 4 PA; MO QVAR ; QL (7.4 per SEREVENT DISKUS sildenafil intravenous ; QL (60 per 4 PA sildenafil oral PA; MO; QL (90 per SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER ; QL (60 per ; QL (90 per 90 days) Name STRIVERDI RESPIMAT 3 MO; QL (4 per SYMBICORT ; QL (0.2 per terbutaline oral terbutaline subcutaneous THEO-24 3 MO theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 2 hr 65 TRACLEER 4 PA; MO; LA triamcinolone acetonide nasal TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) ; QL (6.5 per ; QL ( per 2 QL ( per 30 days) TYVASO 4 PA; MO
Name XOLAIR 4 PA; MO; LA; QL (6 per 28 days) zafirlukast ZYFLO ZYFLO CR UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS ENABLEX flavoxate MYRBETRIQ oxybutynin chloride oral tolterodine TOVIAZ trospium VESICARE BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART finasteride oral tablet 5 mg JALYN RAPAFLO 2 ST; MO tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS Name CIALIS ORAL TABLET 2.5 MG, 5 MG 2 PA; MO; QL (30 per CYSTAGON ; LA ELMIRON potassium citrate VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule dextrose-kcl-nacl eliphos klor-con 0 klor-con 8 klor-con m5 klor-con m20 K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ k-tab oral tablet extended release 8 meq lactated ringers intravenous magnesium sulfate injection solution magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE 3 MO 2 66
Name potassium chloridd5-0.45%nacl intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid Name potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride- 0.45 % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % sodium chloride 5 % 67
Name sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % 2 PA 2 PA 2 PA 2 PA AMINOSYN II 7 % 2 PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5.2 % 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA Name CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE- FREE) FREAMINE HBC 6.9 % 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA HEPATAMINE 8% 2 PA intralipid intravenous emulsion 20 % INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 PA; MO 2 PA 2 2 2 68
Name NEPHRAMINE 5.4 % NORMOSOL-R PH 7.4 PLASMA-LYTE 48 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE 2 PA 2 2 premasol 0 % PA; MO PREMASOL 6 % 2 PA travasol 0 % PA; MO TROPHAMINE 0 % 2 2 PA; MO TROPHAMINE 6% 2 PA VITAMINS / HEMATINICS prenatal vitamin oral tablet sodium fluoride oral tablet 69
Index 8 8-MOP... 37 A abacavir... abacavir-lamivudinezidovudine... ABELCET... ABILIFY DISCMELT... 24 ABILIFY MAINTENA... 25 ABRAXANE... 0 acamprosate... 4 acarbose... 44 acebutolol... 32 acetaminophen-codeine... 20 acetasol hc... 42 acetazolamide... 6 acetazolamide sodium... 6 acetic acid... 42 acetylcysteine... 63 acitretin... 37 ACTEMRA... 56 ACTHIB (PF)... 54 ACTIMMUNE... 52 acyclovir..., 39 acyclovir sodium... ADACEL(TDAP ADOLESN/ADULT)(PF) 54 ADAGEN... 4 adapalene... 38 ADCIRCA... 63 adefovir... ADEMPAS... 63 adrenalin... 62 adrucil... 0 ADVAIR DISKUS... 63 ADVAIR HFA... 63 AEROSPAN... 63 afeditab cr... 32 AFINITOR... 0 AFINITOR DISPERZ... 0 AGGRENOX... 35 a-hydrocort... 43 AKYNZEO... 48 ala-cort... 39 ALBENZA... 5 albuterol sulfate... 63 alclometasone... 39 ALCOHOL PADS... 44 ALDURAZYME... 47 alendronate... 4, 56 alfuzosin... 66 ALIMTA... 0 ALINIA... 5 allopurinol... 55 aloprim... 56 alosetron... 48 ALOXI... 48 ALPHAGAN P... 62 ALREX... 62 ALTABAX... 39 amantadine hcl... AMBISOME... amcinonide... 39 amethia... 58 amethyst... 58 amifostine crystalline... 0 amikacin... 5 amiloride... 32 amiloride-hydrochlorothiazide... 32 aminophylline... 63 AMINOSYN 7 % WITH ELECTROLYTES... 68 AMINOSYN 8.5 %- ELECTROLYTES... 68 AMINOSYN II 0 %... 68 AMINOSYN II 5 %... 68 AMINOSYN II 7 %... 68 AMINOSYN II 8.5 %... 68 AMINOSYN II 8.5 %- ELECTROLYTES... 68 AMINOSYN M 3.5 %... 68 AMINOSYN-HBC 7%... 68 AMINOSYN-PF 0 %... 68 AMINOSYN-PF 7 % (SULFITE-FREE)... 68 AMINOSYN-RF 5.2 %... 68 amiodarone... 32 AMITIZA... 48 amitriptyline... 25 amlodipine... 32 amlodipine-atorvastatin... 36 amlodipine-benazepril... 32 amlodipine-valsartan... 33 amlodipine-valsartan-hcthiazid... 33 ammonium lactate... 37 amnesteem... 38 amoxapine... 25 amoxicil-clarithromy-lansopraz... 5 amoxicillin... 7 amoxicillin-pot clavulanate... 8 amphetamine salt combo... 25 amphotericin b... ampicillin... 8 ampicillin sodium... 8 ampicillin-sulbactam... 8 AMPYRA... 9 ANADROL-50... 47 anagrelide... 4 anastrozole... 0 ANDRODERM... 47 ANDROGEL... 47 ANORO ELLIPTA... 63 apexicon e... 39 APIDRA... 44 APIDRA SOLOSTAR... 44 APOKYN... 8 apraclonidine... 62 apri... 58 APRISO... 48 APTIOM... 7 APTIVUS... ARALAST NP... 4 aranelle (28)... 58 ARANESP (IN POLYSORBATE)... 52 ARCALYST... 52 70
ARCAPTA NEOHALER... 63 aripiprazole... 25 ARNUITY ELLIPTA... 63 ARRANON... 0 ARZERRA... 0 ASACOL HD... 48 ashlyna... 58 ASMANEX HFA... 63 ASMANEX TWISTHALER 63 atenolol... 33 atenolol-chlorthalidone... 33 atorvastatin... 36 atovaquone... 5 atovaquone-proguanil... 6 ATRIPLA... atropine... 48, 6 ATROVENT HFA... 63 AUBAGIO... 9 aubra... 58 AUGMENTIN... 8 AVASTIN... 0 aviane... 58 avita... 38 AVODART... 66 AVONEX... 52 AVONEX (WITH ALBUMIN)... 52 AXIRON... 47 azacitidine... 0 AZACTAM IN DEXTROSE (ISO-OSM)... 6 azathioprine... azelastine... 42, 6 AZELEX... 38 AZILECT... 8 azithromycin... 5 AZOR... 33 aztreonam... 6 B baciim... 6 bacitracin... 6, 60 bacitracin-polymyxin b... 60 baclofen... 20 BACTROBAN NASAL... 42 balsalazide... 48 balziva (28)... 58 BANZEL... 7 BARACLUDE... BCG VACCINE, LIVE (PF) 54 BELEODAQ... benazepril... 33 benazepril-hydrochlorothiazide... 33 BENICAR... 33 BENICAR HCT... 33 BENLYSTA... 56 benztropine... 8 BEPREVE... 6 BESIVANCE... 60 betamethasone dipropionate. 39 betamethasone valerate... 39 betamethasone, augmented... 39 BETASERON... 52 betaxolol... 33, 60 bethanechol chloride... 66 BETHKIS... 6 BEXSERO (PF)... 54 bicalutamide... BICILLIN C-R... 8 BICILLIN L-A... 8 BICNU... BIDIL... 33 BILTRICIDE... 6 bimatoprost... 6 bisoprolol fumarate... 33 bisoprolol-hydrochlorothiazide... 33 bleomycin... BLEPHAMIDE... 62 BLEPHAMIDE S.O.P.... 62 BOOSTRIX TDAP... 54 BOSULIF... BOTOX... 54 BREO ELLIPTA... 63 briellyn... 58 BRILINTA... 35 brimonidine... 62 BRINTELLIX... 25 bromfenac... 6 bromocriptine... 9 budesonide... 48, 63 bumetanide... 33 BUPRENEX... 20 buprenorphine hcl... 20 buprenorphine-naloxone... 23 buproban... 42 bupropion hcl... 25 buspirone... 25 BUSULFEX... butorphanol tartrate... 23 BUTRANS... 20 BYDUREON... 44 BYETTA... 44 BYSTOLIC... 33 C cabergoline... 47 CAFERGOT... 9 calcipotriene... 37 calcipotriene-betamethasone 37 calcitonin (salmon)... 47 calcitriol... 37, 47 calcium acetate... 66 camila... 57 CANCIDAS... candesartan... 33 candesartan-hydrochlorothiazid... 33 CAPASTAT... 6 CAPEX... 39 CAPRELSA... captopril... 33 captopril-hydrochlorothiazide... 33 CARAC... 37 carafate... 5 CARBAGLU... 4 carbamazepine... 7 carbidopa... 9 carbidopa-levodopa... 9 carbidopa-levodopaentacapone... 9 carboplatin... carteolol... 60 cartia xt... 33 carvedilol... 33 7
CAYSTON... 6 cefaclor... 4 cefadroxil... 4 cefazolin... 4 cefazolin in dextrose (iso-os). 4 cefdinir... 4 cefditoren pivoxil... 4 cefepime... 4 cefixime... 4 cefotaxime... 4 cefotetan... 4 cefoxitin... 4 cefoxitin in dextrose, iso-osm 4 cefpodoxime... 4 cefprozil... 4 ceftazidime... 4 ceftriaxone... 4, 5 cefuroxime axetil... 5 cefuroxime sodium... 5 celecoxib... 23 CELLCEPT... CELLCEPT INTRAVENOUS... CELONTIN... 7 cephalexin... 5 CERDELGA... 47 CEREZYME... 47 CERVARIX VACCINE (PF)... 54 cetirizine... 62 cevimeline... 4 CHANTIX... 42 CHANTIX CONTINUING MONTH BOX... 42 CHANTIX STARTING MONTH BOX... 42 CHEMET... 4 CHENODAL... 48 chloramphenicol sod succinate... 6 chlorhexidine gluconate... 42 chloroquine phosphate... 6 chlorothiazide... 33 chlorothiazide sodium... 33 chlorpromazine... 25 chlorthalidone... 33 cholestyramine light... 36 chorionic gonadotropin, human... 47 CIALIS... 66 ciclopirox... 39 cidofovir... cilostazol... 35 CILOXAN... 60 cimetidine... 5 cimetidine hcl... 5 CIMZIA... 48 CIMZIA POWDER FOR RECONST... 49 CINRYZE... 63 CIPRODEX... 42 ciprofloxacin... 9 ciprofloxacin (mixture)... 9 ciprofloxacin hcl... 9, 60 ciprofloxacin in 5 % dextrose. 9 ciprofloxacin lactate... 9 cisplatin... citalopram... 25 cladribine... claravis... 38 clarithromycin... 5 CLEOCIN... 58 clindamycin hcl... 6 clindamycin in 5 % dextrose.. 6 clindamycin pediatric... 6 clindamycin phosphate... 6, 38, 58 clindamycin-benzoyl peroxide... 38 CLINIMIX 5%/D5W SULFITE FREE... 68 CLINIMIX 5%/D25W SULFITE-FREE... 68 CLINIMIX 2.75%/D5W SULFIT FREE... 68 CLINIMIX 4.25%/D0W SULF FREE... 68 CLINIMIX 4.25%/D5W SULFIT FREE... 4 CLINIMIX 4.25%-D20W SULF-FREE... 68 CLINIMIX 4.25%-D25W SULF-FREE... 68 CLINIMIX 5%- D20W(SULFITE-FREE).. 68 clobetasol... 39 clobetasol-emollient... 39 clodan... 39 CLOLAR... clomipramine... 25 clonazepam... 7 clonidine... 33 clonidine hcl... 25, 33 clopidogrel... 35 clorazepate dipotassium... 26 clorpres... 33 clotrimazole..., 39 clotrimazole-betamethasone. 39 clozapine... 26 COARTEM... 6 codeine sulfate... 20 colchicine-probenecid... 56 COLCRYS... 56 colestipol... 36 colistin (colistimethate na)... 6 colocort... 49 COLY-MYCIN S... 42 COMBIGAN... 6 COMBIVENT RESPIMAT.. 64 COMETRIQ... COMPLERA... 2 compro... 49 COMVAX (PF)... 54 CONDYLOX... 37 constulose... 49 COPAXONE... 9 CORDRAN TAPE LARGE ROLL... 39 COREG CR... 33 CORLANOR... 37 cormax... 39 cortisone... 43 CORTISPORIN-TC... 42 COSENTYX PEN... 37 72
COSENTYX PEN (2 PENS) 37 CREON... 49 CRESEMBA... CRESTOR... 36 CRINONE... 57 CRIXIVAN... 2 cromolyn... 49, 6, 64 cryselle (28)... 58 CUBICIN... 6 CUPRIMINE... 56 cyclafem /35 (28)... 58 cyclafem 7/7/7 (28)... 58 CYCLOPHOSPHAMIDE... CYCLOSET... 44 cyclosporine... cyclosporine modified... CYSTADANE... 49 CYSTAGON... 66 CYSTARAN... 6 cytarabine... cytarabine (pf)... D d0 % & 0.45 % sodium chloride... 4 d2.5 %-0.45 % sodium chloride... 4 d5 % and 0.9 % sodium chloride... 4 d5 %-0.45 % sodium chloride... 4 dacarbazine... DALIRESP... 64 danazol... 47 dantrolene... 20 DAPSONE... 6 DAPTACEL (DTAP PEDIATRIC) (PF)... 54 DARAPRIM... 6 daunorubicin... DAUNOXOME... deblitane... 57 decitabine... delyla (28)... 58 DELZICOL... 49 demeclocycline... 9 DEMSER... 33 DENAVIR... 39 DEPEN TITRATABS... 56 DEPO-MEDROL... 43 DEPO-PROVERA... 57 DEPO-SUBQ PROVERA 04... 57 desipramine... 26 desloratadine... 62 desmopressin... 47 desog-e.estradiol/e.estradiol. 58 desonide... 40 desoximetasone... 40 dexamethasone... 43 dexamethasone intensol... 43 dexamethasone sodium phosphate... 43, 62 dexedrine... 26 DEXILANT... 5 dexmethylphenidate... 26 dexrazoxane hcl... 0 dextroamphetamine... 26 dextroamphetamineamphetamine... 26 dextrose 0 % and 0.2 % nacl... 4 dextrose 0 % in water (d0w)... 4 dextrose 5 % in water (d5w). 4 dextrose 5 %-lactated ringers4 dextrose 5%-0.2 % sod chloride... 4 dextrose 5%-0.3 % sod.chloride... 4 dextrose with sodium chloride... 4 dextrose-kcl-nacl... 66 diazepam... 7, 26 diazepam intensol... 26 diclofenac potassium... 23 diclofenac sodium... 23, 37, 6 diclofenac-misoprostol... 23 dicloxacillin... 8 didanosine... 2 diflorasone... 40 diflunisal... 23 digitek... 35 digoxin... 35 dihydroergotamine... 9 DILANTIN 30 MG... 7 diltiazem hcl... 33 dilt-xr... 33 DIPENTUM... 49 diphenhydramine hcl... 62 diphenoxylate-atropine... 48 dipyridamole... 35 disulfiram... 4 divalproex... 7 DOCEFREZ... docetaxel... donepezil... 9 dorzolamide... 6 dorzolamide-timolol... 6 doxazosin... 33 doxepin... 26 doxercalciferol... 47 doxorubicin... doxy-00... 9 doxycycline hyclate... 9 doxycycline monohydrate... 9 dronabinol... 49 drospirenone-ethinyl estradiol... 58 DROXIA... DUAVEE... 57 DULERA... 64 duloxetine... 26 duramorph (pf)... 20 DYMISTA... 64 E e.e.s. 400... 5 E.E.S. GRANULES... 5 econazole... 39 EDARBI... 33 EDARBYCLOR... 33 EDECRIN... 33 EDURANT... 2 EFFIENT... 35 ELAPRASE... 47 eliphos... 66 73
ELIQUIS... 35 ELITEK... 0 ELIXOPHYLLIN... 64 ELMIRON... 66 EMCYT... EMEND... 49 emoquette... 58 EMSAM... 26 EMTRIVA... 2 ENABLEX... 66 enalapril maleate... 34 enalapril-hydrochlorothiazide... 34 ENBREL... 56 ENBREL SURECLICK... 56 endocet... 20 endodan... 20 ENGERIX-B (PF)... 54 ENGERIX-B PEDIATRIC (PF)... 54 enoxaparin... 35 enpresse... 58 entacapone... 9 entecavir... 2 enulose... 49 epinastine... 6 epinephrine... 62 EPIPEN 2-PAK... 62 EPIPEN JR 2-PAK... 63 epirubicin... epitol... 7 EPIVIR HBV... 2 eplerenone... 34 EPOGEN... 52 eprosartan... 34 EPZICOM... 2 ERAXIS(WATER DILUENT)... ERBITUX... 2 ergoloid... 26 ERIVEDGE... 2 errin... 57 ERWINAZE... 2 ery pads... 38 ery-tab... 5 ERY-TAB... 5 ERYTHROCIN... 5 erythrocin (as stearate)... 5 erythromycin... 5, 60 erythromycin ethylsuccinate... 5 erythromycin with ethanol... 38 erythromycin-benzoyl peroxide... 38 ESBRIET... 64 escitalopram oxalate... 26 esomeprazole magnesium... 5 esomeprazole sodium... 5 ESTRACE... 57 estradiol... 57 estradiol valerate... 57 estradiol-norethindrone acet. 57 ESTRING... 57 estropipate... 57 eszopiclone... 26 ethambutol... 6 ethosuximide... 7 etidronate disodium... 4 etodolac... 23 ETOPOPHOS... 2 etoposide... 2 EURAX... 40 EVOTAZ... 2 EXELON... 9 exemestane... 2 EXJADE... 4 EXTAVIA... 52 F FABRAZYME... 47 falmina (28)... 58 famciclovir... 2 famotidine... 5 famotidine (pf)... 5 famotidine (pf)-nacl (iso-os) 5 FANAPT... 26 FARESTON... 2 FARXIGA... 44 FARYDAK... 2 FASLODEX... 2 FAZACLO... 27 felbamate... 7 felodipine... 34 fenofibrate... 36 fenofibrate micronized... 36 fenofibrate nanocrystallized. 36 fenofibric acid (choline)... 36 fenoprofen... 23 fentanyl... 2 fentanyl citrate... 20, 2 FERRIPROX... 4 FETZIMA... 27 finasteride... 66 FIRAZYR... 64 FIRMAGON KIT W DILUENT SYRINGE... 2 flavoxate... 66 flecainide... 32 FLECTOR... 23 FLOVENT DISKUS... 64 FLOVENT HFA... 64 fluconazole... fluconazole in dextrose(iso-o) flucytosine... fludarabine... 2 fludrocortisone... 43 flunisolide... 64 fluocinolone... 40 fluocinolone acetonide oil... 42 fluocinonide... 40 fluocinonide-e... 40 fluorometholone... 62 fluorouracil... 2, 37 FLUOROURACIL... 37 fluoxetine... 27 fluphenazine decanoate... 27 fluphenazine hcl... 27 flurbiprofen... 23 flurbiprofen sodium... 6 flutamide... 2 fluticasone... 40, 64 fluvastatin... 36 fluvoxamine... 27 FML S.O.P.... 62 FOLOTYN... 2 fomepizole... 54 fondaparinux... 35 74
FORADIL AEROLIZER... 64 FORFIVO XL... 27 FORTAZ... 5 FORTEO... 56 FORTESTA... 47 fortical... 47 FOSAMAX PLUS D... 56 foscarnet... 2 fosinopril... 34 fosinopril-hydrochlorothiazide... 34 fosphenytoin... 7 FREAMINE HBC 6.9 %... 68 furosemide... 34 FUSILEV... 0 FUZEON... 2 FYCOMPA... 7 G gabapentin... 7 GABITRIL... 7 galantamine... 9 GAMASTAN S/D... 54 ganciclovir sodium... 2 garamycin... 60 GARDASIL (PF)... 54 GARDASIL 9 (PF)... 54 gatifloxacin... 60 GATTEX ONE-VIAL... 49 GAUZE PAD... 44 gavilyte-c... 49 gavilyte-g... 49 gavilyte-n... 49 gemcitabine... 2 gemfibrozil... 36 generlac... 49 gengraf... 2 gentak... 60 gentamicin... 6, 39, 60 gentamicin in nacl (iso-osm).. 6 gentamicin sulfate (pf)... 6 GEODON... 27 gianvi (28)... 58 gildagia... 58 gildess... 58 gildess 24 fe... 58 GILENYA... 9 GILOTRIF... 2 glatopa... 9 GLEEVEC... 2 glimepiride... 44 glipizide... 44 glipizide-metformin... 44 GLUCAGEN HYPOKIT... 44 GLUCAGON EMERGENCY KIT (HUMAN)... 44 glycopyrrolate... 48 GRALISE... 7 GRALISE 30-DAY STARTER PACK... 7 granisetron (pf)... 49 granisetron hcl... 49 GRASTEK... 54 griseofulvin microsize... griseofulvin ultramicrosize... guanidine... 27 H HALAVEN... 2 halobetasol propionate... 40 haloperidol... 27 haloperidol decanoate... 27 haloperidol lactate... 27 HARVONI... 2 HAVRIX (PF)... 54 heparin (porcine)... 36 heparin (porcine) in 5 % dex 36 HEPATAMINE 8%... 68 HERCEPTIN... 2 HETLIOZ... 27 HEXALEN... 2 HUMALOG... 45 HUMALOG KWIKPEN... 44 HUMALOG MIX 50-50... 44 HUMALOG MIX 50-50 KWIKPEN... 44 HUMALOG MIX 75-25... 44 HUMALOG MIX 75-25 KWIKPEN... 44 HUMIRA... 56, 57 HUMIRA CROHN'S DIS START PCK... 56 HUMULIN 70/30... 45 HUMULIN 70/30 KWIKPEN... 45 HUMULIN N... 45 HUMULIN N KWIKPEN... 45 HUMULIN R... 45 HUMULIN R U-500... 45 hydralazine... 34 hydrochlorothiazide... 34 hydrocodone-acetaminophen 2 hydrocodone-ibuprofen... 2 hydrocortisone... 40, 43, 49 hydrocortisone butyrate... 40 hydrocortisone butyr-emollient... 40 hydrocortisone valerate... 40 hydrocortisone-acetic acid... 42 hydromorphone... 2 hydromorphone (pf)... 2 hydroxychloroquine... 6 hydroxyurea... 2 hydroxyzine hcl... 63 I ibandronate... 56 IBRANCE... 2 ibuprofen... 24 ibuprofen-oxycodone... 2 ICLUSIG... 2 idarubicin... 2 ifosfamide... 2 ILARIS (PF)... 52 ILEVRO... 6 IMBRUVICA... 2 imipenem-cilastatin... 6 imipramine hcl... 27 imipramine pamoate... 27 imiquimod... 37 IMOVAX RABIES VACCINE (PF)... 54 INCRELEX... 4 indapamide... 34 INFANRIX (DTAP) (PF)... 54 INLYTA... 2 INSULIN PEN NEEDLE... 45 75
INSULIN SYRINGE (DISP) U-00 0.3 ML... 45 INSULIN SYRINGE (DISP) U-00 ML... 45 INSULIN SYRINGE (DISP) U-00 /2 ML... 45 INTELENCE... 2 intralipid... 68 INTRALIPID... 68 INTRON A... 53 introvale... 58 INVANZ... 6 INVEGA... 28 INVEGA SUSTENNA... 28 INVIRASE... 2 INVOKAMET... 45 INVOKANA... 45 IONOSOL-B IN D5W... 68 IONOSOL-MB IN D5W... 68 IOPIDINE... 62 IPOL... 54 ipratropium bromide... 42, 64 ipratropium-albuterol... 64 irbesartan... 34 irbesartan-hydrochlorothiazide... 34 irinotecan... 3 ISENTRESS... 2 ISOLYTE-P IN 5 % DEXTROSE... 68 ISOLYTE-S... 68 isoniazid... 6, 7 isosorbide dinitrate... 37 isosorbide mononitrate... 37 isradipine... 34 ISTODAX... 3 itraconazole... ivermectin... 7 IXEMPRA... 3 IXIARO (PF)... 54 J JADENU... 4 JAKAFI... 3 JALYN... 66 jantoven... 36 JANUMET... 45 JANUMET XR... 45 JANUVIA... 45 JENTADUETO... 45 JEVTANA... 3 jolivette... 57 junel.5/30 (2)... 58 junel /20 (2)... 58 junel fe.5/30 (28)... 58 junel fe /20 (28)... 58 junel fe 24... 58 JUXTAPID... 36 K KADCYLA... 3 KALBITOR... 64 KALETRA... 2 KALYDECO... 64 kariva (28)... 58 KAZANO... 45 kelnor /35 (28)... 58 KEPIVANCE... 0 KETEK... 7 ketoconazole..., 39 ketoprofen... 24 ketorolac... 6 KEYTRUDA... 3 kionex... 4 klor-con 0... 66 klor-con 8... 66 klor-con m5... 66 klor-con m20... 66 KOMBIGLYZE XR... 45 KORLYM... 47 k-tab... 66 K-TAB... 66 KUVAN... 47 L l norgest&e estradiol-e estrad... 59 labetalol... 34 LACRISERT... 6 lactated ringers... 4, 66 lactulose... 49 LAMISIL... lamivudine... 2 lamivudine-zidovudine... 2 lamotrigine... 7 LANOXIN... 35 lansoprazole... 5 LANTUS... 45 LANTUS SOLOSTAR... 45 larin.5/30 (2)... 59 larin /20 (2)... 59 larin fe... 59 LASTACAFT... 6 latanoprost... 6 LATUDA... 28 leena 28... 59 leflunomide... 57 LENVIMA... 3 lessina... 59 LETAIRIS... 64 letrozole... 3 leucovorin calcium... 0 LEUKERAN... 3 LEUKINE... 53 leuprolide... 3 levalbuterol hcl... 64 LEVEMIR... 45 LEVEMIR FLEXTOUCH... 45 levetiracetam... 8 LEVETIRACETAM IN NACL (ISO-OS)... 7, 8 levobunolol... 6 levocarnitine... 4 levocarnitine (with sugar)... 4 levocetirizine... 63 levofloxacin... 9, 60 levofloxacin in d5w... 9 levonest (28)... 59 levonorgestrel-ethinyl estrad 59 levora-28... 59 levorphanol tartrate... 2 levothyroxine... 48 levoxyl... 48 LEXIVA... 2 LIALDA... 49 lidocaine... 38 lidocaine (pf)... 38 lidocaine hcl... 38 76
lidocaine-prilocaine... 38 lindane... 40 linezolid... 7 LINZESS... 49 LIORESAL... 20 liothyronine... 48 LIPOFEN... 36 lisinopril... 34 lisinopril-hydrochlorothiazide... 34 lithium carbonate... 28 lithium citrate... 28 LOCOID... 40 lomedia 24 fe... 59 LOMUSTINE... 3 loperamide... 48 lorazepam... 28 lorazepam intensol... 28 lorcet (hydrocodone)... 2 lorcet hd... 2 lorcet plus... 2 lortab 0-325... 2 lortab 5-325... 2 lortab 7.5-325... 2 loryna (28)... 59 losartan... 34 losartan-hydrochlorothiazide 34 LOTEMAX... 62 lovastatin... 36 loxapine succinate... 28 LUMIGAN... 6 LUMIZYME... 47 LUPRON DEPOT... 3 LUPRON DEPOT (3 MONTH)... 3 LUPRON DEPOT (4 MONTH)... 3 LUPRON DEPOT (6 MONTH)... 3 LUPRON DEPOT-PED... 3 lutera (28)... 59 LYNPARZA... 3 LYRICA... 8 LYSODREN... 3 lyza... 57 M MACRODANTIN... 0 magnesium sulfate... 66 malathion... 40 maprotiline... 28 marlissa... 59 MARPLAN... 28 MATULANE... 3 matzim la... 34 meclizine... 49 meclofenamate... 24 medroxyprogesterone... 57 mefenamic acid... 24 mefloquine... 7 MEGACE ES... 3 megestrol... 3 MEKINIST... 3 meloxicam... 24 melphalan hcl... 3 MENACTRA (PF)... 55 MENEST... 57 MENOMUNE - A/C/Y/W-35 (PF)... 55 MENVEO A-C-Y-W-35-DIP (PF)... 55 mercaptopurine... 3 meropenem... 7 mesalamine with cleansing wipe... 49 mesna... 0 MESNEX... 0 MESTINON... 20 MESTINON TIMESPAN... 20 metadate er... 28 metaproterenol... 64 metformin... 46 methadone... 2, 22 methamphetamine... 28 methazolamide... 6 methenamine hippurate... 0 methimazole... 43 methotrexate sodium... 3 methotrexate sodium (pf)... 3 methoxsalen rapid... 37 methyclothiazide... 34 methyldopa... 34 methylergonovine... 60 methylphenidate... 28 methylprednisolone... 43 methylprednisolone acetate.. 43 methylprednisolone sodium succ... 43 metipranolol... 6 metoclopramide hcl... 49 metolazone... 34 metoprolol succinate... 34 metoprolol ta-hydrochlorothiaz... 34 metoprolol tartrate... 34 metronidazole... 7, 38, 58 metronidazole in nacl (iso-os) 7 mexiletine... 32 MIACALCIN... 47 miconazole-3... 58 microgestin.5/30 (2)... 59 microgestin /20 (2)... 59 microgestin fe.5/30 (28)... 59 microgestin fe /20 (28)... 59 midodrine... 4 migergot... 9 millipred... 43 mimvey... 57 mimvey lo... 57 minocycline... 9 minoxidil... 34 mirtazapine... 28 misoprostol... 5 mitomycin... 3 mitoxantrone... 3 M-M-R II (PF)... 55 modafinil... 29 moderiba... 2 moderiba dose pack... 2 moexipril... 34 moexipril-hydrochlorothiazide... 34 mometasone... 40 mononessa (28)... 59 montelukast... 64 morphine... 22 77
morphine concentrate... 22 MOVANTIK... 49 MOVIPREP... 49 moxifloxacin... 9 MOZOBIL... 53 mupirocin... 39 mupirocin calcium... 39 MUSTARGEN... 3 MYALEPT... 47 MYCAMINE... mycophenolate mofetil... 3, 4 mycophenolate sodium... 4 myorisan... 38 MYOZYME... 47 MYRBETRIQ... 66 N nabumetone... 24 nadolol... 34 nadolol-bendroflumethiazide 34 nafcillin... 8 nafcillin in dextrose iso-osm.. 8 NAFTIN... 39 NAGLAZYME... 47 nalbuphine... 24 naloxone... 24 naltrexone... 24 NAMENDA... 9 NAMENDA XR... 9 naphazoline... 62 naproxen... 24 naproxen sodium... 24 naratriptan... 9 NASONEX... 64 NATACYN... 60 nateglinide... 46 NATPARA... 47 NEBUPENT... 7 necon 0.5/35 (28)... 59 necon /35 (28)... 59 necon /50 (28)... 59 necon 0/ (28)... 59 necon 7/7/7 (28)... 59 NEEDLES, INSULIN DISP.,SAFETY... 46 nefazodone... 29 neomycin... 7 neomycin-bacitracin-poly-hc 62 neomycin-bacitracinpolymyxin... 60 neomycin-polymyxin b gu... 4 neomycin-polymyxin b- dexameth... 62 neomycin-polymyxingramicidin... 60 neomycin-polymyxin-hc 43, 62 NEORAL... 4 NEPHRAMINE 5.4 %... 69 NESINA... 46 neuac... 38 NEULASTA... 53 NEUMEGA... 53 NEUPOGEN... 53 NEUPRO... 9 NEVANAC... 6 nevirapine... 2 NEXAVAR... 4 NEXIUM PACKET... 5 niacin... 36 nicardipine... 34 NICOTROL... 42 NICOTROL NS... 42 nifedical xl... 34 nifedipine... 34 nikki (28)... 59 NILANDRON... 4 nimodipine... 34 NIPENT... 4 nisoldipine... 34 nitro-bid... 37 nitrofurantoin... 0 nitrofurantoin macrocrystal.. 0 nitrofurantoin monohyd/mcryst... 0 nitroglycerin... 37 NITROSTAT... 37 nizatidine... 5 nora-be... 57 NORDITROPIN FLEXPRO 53 NORDITROPIN NORDIFLEX... 53 noreth-ethinyl estradiol-iron. 59 norethindrone (contraceptive)... 57 norethindrone acetate... 58 norethindrone ac-eth estradiol... 58 norethindrone-e.estradiol-iron... 59 norlyroc... 58 NORMOSOL-R IN 5 % DEXTROSE... 66 NORMOSOL-R PH 7.4... 69 NORTHERA... 4 nortrel 0.5/35 (28)... 59 nortrel /35 (2)... 59 nortrel /35 (28)... 59 nortrel 7/7/7 (28)... 59 nortriptyline... 29 NORVIR... 2 novarel... 47 NOVOFINE 32... 46 NOVOLOG... 46 NOVOLOG FLEXPEN... 46 NOVOLOG MIX 70-30... 46 NOVOLOG MIX 70-30 FLEXPEN... 46 NOVOLOG PENFILL... 46 NOXAFIL... NUEDEXTA... 9 NULOJIX... 4 NUVARING... 58 nyamyc... 39 nystatin..., 39 nystatin-triamcinolone... 39 nystop... 39 O ocella... 59 octreotide acetate... 4 OFEV... 64 ofloxacin... 9, 42, 60 ogestrel (28)... 59 olanzapine... 29 olanzapine-fluoxetine... 29 olopatadine... 42 OLYSIO... 3 78
omeprazole... 5 omeprazole-sodium bicarbonate... 5 OMNITROPE... 53 ONCASPAR... 4 ondansetron... 49 ondansetron hcl... 50 ondansetron hcl (pf)... 49, 50 ONFI... 8 ONGLYZA... 46 OPDIVO... 4 OPSUMIT... 64 ORAP... 29 ORENCIA... 57 ORENCIA (WITH MALTOSE)... 57 ORFADIN... 4 orsythia... 59 OTEZLA... 57 OTEZLA STARTER... 57 oxacillin... 8 oxacillin in dextrose(iso-osm) 8 oxaliplatin... 4 oxandrolone... 48 oxaprozin... 24 oxazepam... 29 oxcarbazepine... 8 oxybutynin chloride... 66 oxycodone... 22 oxycodone-acetaminophen... 22 oxycodone-aspirin... 22 OXYCONTIN... 23 oxymorphone... 23 P pacerone... 32 paclitaxel... 4 pamidronate... 48 PANDEL... 40 PANRETIN... 37 pantoprazole... 5 paricalcitol... 48 paromomycin... 7 paroxetine hcl... 29 PASER... 7 PATADAY... 6 PAXIL... 29 PAZEO... 6 PEDVAX HIB (PF)... 55 peg 3350-electrolytes... 50 PEGANONE... 8 PEGASYS... 53 PEGASYS PROCLICK... 53 PEGINTRON... 53 PEGINTRON REDIPEN... 53 PENICILLIN G POT IN DEXTROSE... 8 penicillin g potassium... 8 penicillin g procaine... 8 penicillin g sodium... 8 penicillin v potassium... 8 PENTAM... 7 PENTASA... 50 pentoxifylline... 36 PERFOROMIST... 65 perindopril erbumine... 34 periogard... 42 PERJETA... 4 permethrin... 40 perphenazine... 29 phenelzine... 29 phenobarbital... 8 phenytoin... 8 phenytoin sodium... 8 phenytoin sodium extended.. 8 PHOSPHOLINE IODIDE... 6 pilocarpine hcl... 4, 6 pimtrea (28)... 59 pindolol... 34 pioglitazone... 46 pioglitazone-glimepiride... 46 pioglitazone-metformin... 46 piperacillin-tazobactam... 8 pirmella... 59 piroxicam... 24 PLASMA-LYTE 48... 69 PLASMA-LYTE A... 69 PLASMA-LYTE-56 IN 5 % DEXTROSE... 69 PLEGRIDY... 53 podofilox... 37 polyethylene glycol 3350... 50 polymyxin b sulfate... 7 polymyxin b sulf-trimethoprim... 60 POMALYST... 4 portia... 59 potassium chlorid-d5-0.45%nacl... 67 potassium chloride... 67 potassium chloride in 0.9%nacl... 67 potassium chloride in 5 % dex... 67 potassium chloride in lr-d5... 67 potassium chloride-0.45 % nacl... 67 potassium chloride-d5-0.2%nacl... 67 potassium chloride-d5-0.3%nacl... 67 potassium chloride-d5-0.9%nacl... 67 potassium citrate... 66 POTIGA... 8 PRADAXA... 36 pramipexole... 9 pravastatin... 36 prazosin... 34 prednicarbate... 40 prednisolone acetate... 62 prednisolone sodium phosphate... 43, 62 prednisone... 43 prednisone intensol... 43 PREMARIN... 58 premasol 0 %... 69 PREMASOL 6 %... 69 prenatal vitamin oral tablet... 69 prevalite... 36 previfem... 59 PREZCOBIX... 3 PREZISTA... 3 PRIFTIN... 7 PRIMAQUINE... 7 primidone... 8 79
PRIMSOL... 0 PRISTIQ... 29 PRIVIGEN... 55 PROAIR HFA... 65 PROAIR RESPICLICK... 65 probenecid... 56 procainamide... 32 procentra... 29 prochlorperazine... 50 prochlorperazine edisylate... 50 prochlorperazine maleate... 50 PROCRIT... 53 procto-pak... 50 proctosol hc... 50 proctozone-hc... 50 progesterone micronized... 58 PROGLYCEM... 46 PROGRAF... 4 PROLASTIN-C... 42 PROLENSA... 6 PROLEUKIN... 54 PROLIA... 56 PROMACTA... 36 promethazine... 63 propafenone... 32 propranolol... 34 propranolol-hydrochlorothiazid... 35 propylthiouracil... 43 PROQUAD (PF)... 55 protriptyline... 29 prudoxin... 37 PULMICORT... 65 PULMICORT FLEXHALER... 65 PULMOZYME... 65 PURIXAN... 4 PYLERA... 5 pyrazinamide... 7 pyridostigmine bromide... 20 Q QUADRACEL (PF)... 55 quasense... 59 quetiapine... 29, 30 quinapril... 35 quinapril-hydrochlorothiazide... 35 quinidine gluconate... 32 quinidine sulfate... 32 quinine sulfate... 7 QVAR... 65 R RABAVERT (PF)... 55 rabeprazole... 5 RAGWITEK... 55 raloxifene... 56 ramipril... 35 RANEXA... 37 ranitidine hcl... 52 RAPAFLO... 66 RAPAMUNE... 4 RAVICTI... 42 REBETOL... 3 REBIF (WITH ALBUMIN). 54 REBIF REBIDOSE... 54 REBIF TITRATION PACK. 54 reclipsen (28)... 59 RECOMBIVAX HB (PF)... 55 RECTIV... 50 REGRANEX... 37 RELENZA DISKHALER... 3 RELISTOR... 50 RELPAX... 9 REMICADE... 50 REMODULIN... 35 RENVELA... 42 repaglinide... 46 reprexain... 23 RESCRIPTOR... 3 RESTASIS... 6 RETROVIR... 3 REVLIMID... 4 REYATAZ... 3 RHEUMATREX... 4 ribasphere... 3 ribasphere ribapak... 3 ribavirin... 3 RIDAURA... 57 rifabutin... 7 rifampin... 7 riluzole... 42 rimantadine... 3 ringers... 4, 67 RIOMET... 46 risedronate... 42, 56 RISPERDAL CONSTA... 30 risperidone... 30 RITUXAN... 4 rivastigmine tartrate... 20 rizatriptan... 9 ropinirole... 9 ROTARIX... 55 ROTATEQ VACCINE... 55 ROZEREM... 30 S SABRIL... 8 SAMSCA... 48 SANCUSO... 50 SANDIMMUNE... 4 SANDOSTATIN LAR DEPOT... 4 SANTYL... 40 SAPHRIS (BLACK CHERRY)... 30 SAVELLA... 57 selegiline hcl... 9 selenium sulfide... 37 SELZENTRY... 3 SENSIPAR... 48 SEREVENT DISKUS... 65 SEROQUEL XR... 30, 3 sertraline... 3 sharobel... 58 SIGNIFOR... 4 sildenafil... 65 silver sulfadiazine... 37 SIMBRINZA... 6 SIMPONI... 57 SIMPONI ARIA... 57 SIMULECT... 4 simvastatin... 36 sirolimus... 5 SIRTURO... 7 SKLICE... 40 sodium chloride... 42, 68 80
sodium chloride 0.45 %... 67 sodium chloride 0.9 %... 42 sodium chloride 3 %... 67 sodium chloride 5 %... 67 sodium fluoride... 69 sodium lactate... 68 sodium phenylbutyrate... 42 sodium polystyrene (sorb free)... 42 SOLTAMOX... 5 SOLU-CORTEF (PF)... 43 SOLU-MEDROL... 43 SOLU-MEDROL (PF)... 43 SOMATULINE DEPOT... 5 SOMAVERT... 48 sorine... 32 sotalol... 32 sotalol af... 32 SOTYLIZE... 32 SOVALDI... 3 SPIRIVA RESPIMAT... 65 SPIRIVA WITH HANDIHALER... 65 spironolactone... 35 spironolacton-hydrochlorothiaz... 35 SPORANOX... sprintec (28)... 60 SPRYCEL... 5 sronyx... 60 ssd... 37 stavudine... 3 STELARA... 37 STIMATE... 48 STIVARGA... 5 STRATTERA... 3 STREPTOMYCIN... 7 STRIBILD... 3 STRIVERDI RESPIMAT... 65 SUBOXONE... 24 SUCLEAR... 50 SUCRAID... 50 sucralfate... 52 sulfacetamide sodium... 62 sulfacetamide sodium (acne) 39 sulfacetamide-prednisolone.. 62 sulfadiazine... 9 sulfamethoxazole-trimethoprim... 9 SULFAMYLON... 39 sulfasalazine... 50 sulfazine ec... 50 sulindac... 24 sumatriptan... 9 sumatriptan succinate... 9 SUPRAX... 5 SUPREP BOWEL PREP KIT... 50 SURMONTIL... 3 SUSTIVA... 3 SUTENT... 5 SYLATRON... 54 SYLVANT... 5 SYMBICORT... 65 SYMLINPEN 20... 46 SYMLINPEN 60... 46 SYNAGIS... 3 SYNAREL... 48 SYNERCID... 7 SYNRIBO... 5 SYPRINE... 42 T TABLOID... 5 tacrolimus... 5, 38 TAFINLAR... 5 TAMIFLU... 3 tamoxifen... 5 tamsulosin... 66 TARCEVA... 5 TARGRETIN... 5 tarina fe... 60 TASIGNA... 5 TAZORAC... 38 taztia xt... 35 TECFIDERA... 20 TEFLARO... 5 TEGRETOL XR... 8 telmisartan... 35 telmisartan-amlodipine... 35 telmisartan-hydrochlorothiazid... 35 temazepam... 3 TENIVAC (PF)... 55 terazosin... 35 terbinafine hcl... terbutaline... 65 terconazole... 58 TESTIM... 48 testosterone cypionate... 48 testosterone enanthate... 48 TETANUS,DIPHTHERIA TOX PED(PF)... 55 TETANUS-DIPHTHERIA TOXOIDS-TD... 55 tetracycline... 9 THALOMID... 5 THEO-24... 65 theophylline... 65 THIOLA... 42 thioridazine... 3 thiothixene... 3 THYMOGLOBULIN... 55 tiagabine... 8 TIKOSYN... 32 timolol maleate... 35, 6 tinidazole... 7 TIVICAY... 3 tizanidine... 20 TOBI PODHALER... 7 tobramycin... 60 tobramycin in 0.225 % nacl... 7 tobramycin in 0.9 % nacl... 7 tobramycin sulfate... 7 tobramycin-dexamethasone.. 62 TOBREX... 60 tolazamide... 46 tolbutamide... 46 tolcapone... 9 tolmetin... 24 tolterodine... 66 topiramate... 8 toposar... 5 topotecan... 5 TORISEL... 5 8
torsemide... 35 TOUJEO SOLOSTAR... 46 TOVIAZ... 66 TRACLEER... 65 TRADJENTA... 46 tramadol... 24 tramadol-acetaminophen... 24 trandolapril... 35 trandolapril-verapamil... 35 tranexamic acid... 36, 58 TRANSDERM-SCOP... 50 tranylcypromine... 3 travasol 0 %... 69 TRAVATAN Z... 6 travoprost (benzalkonium)... 6 trazodone... 3 TREANDA... 5 TRECATOR... 7 TRELSTAR... 6 TRELSTAR DEPOT... 5 TRELSTAR LA... 6 tretinoin... 38 tretinoin (chemotherapy)... 6 tretinoin microspheres... 38 triamcinolone acetonide 40, 42, 65 triamterene-hydrochlorothiazid... 35 trianex... 40 TRIBENZOR... 35 triderm... 40 trifluoperazine... 3 trifluridine... 60 tri-legest fe... 60 trilyte with flavor packets... 50 trimethoprim... 0 trinessa (28)... 60 tri-previfem (28)... 60 TRISENOX... 6 tri-sprintec (28)... 60 TRIUMEQ... 3 trivora (28)... 60 TROPHAMINE 0 %... 69 TROPHAMINE 6%... 69 trospium... 66 TRUMENBA... 55 TRUVADA... 3 TUDORZA PRESSAIR... 65 TWINRIX (PF)... 55 TYGACIL... 7 TYKERB... 6 TYPHIM VI... 55 TYSABRI... 20 TYVASO... 65 TYZEKA... 3 TYZINE... 42 U UCERIS... 50 ULORIC... 56 unithroid... 48 ursodiol... 50 UVADEX... 38 V valacyclovir... 3 VALCHLOR... 38 VALCYTE... 3 valganciclovir... 3 valproate sodium... 8 valproic acid... 8 valproic acid (as sodium salt)... 8 valsartan... 35 valsartan-hydrochlorothiazide... 35 vancomycin... 0 vandazole... 58 VAQTA (PF)... 55 VARIVAX (PF)... 55 VARIZIG... 55 VASCEPA... 36 VECAMYL... 37 VECTIBIX... 6 VELCADE... 6 velivet triphasic regimen (28)... 60 venlafaxine... 3 verapamil... 35 veripred 20... 43 VERSACLOZ... 3 VESICARE... 66 vestura (28)... 60 VGO 20... 46 VGO 30... 47 VGO 40... 47 VIBRAMYCIN... 9 vicodin... 23 vicodin es... 23 vicodin hp... 23 VICTOZA 3-PAK... 47 VIDEX 2 GRAM PEDIATRIC... 3 VIEKIRA PAK... 4 VIIBRYD... 3 VIMPAT... 8 vinblastine... 6 vincasar pfs... 6 vincristine... 6 vinorelbine... 6 VIOKACE... 50 VIRACEPT... 4 VIRAMUNE XR... 4 VIRAZOLE... 4 VIREAD... 4 VITEKTA... 4 VOLTAREN GEL... 24 voriconazole... VOTRIENT... 6 vyfemla (28)... 60 W warfarin... 36 water for irrigation, sterile... 42 wymzya fe... 60 X XALKORI... 6 XARELTO... 36 XELJANZ... 57 XENAZINE... 20 XERESE... 39 XGEVA... 0 XIFAXAN... 7 XIGDUO XR... 47 XOLAIR... 66 XTANDI... 6 xulane... 58 XYREM... 3 82
Y YERVOY... 6 YF-VAX (PF)... 55 Z zafirlukast... 66 zaleplon... 3 ZALTRAP... 6 zamicet... 23 ZANOSAR... 6 ZAVESCA... 48 ZELBORAF... 6 ZEMPLAR... 48 zenatane... 38 zenchent (28)... 60 zenchent fe... 60 ZENPEP... 50 zenzedi... 32 ZENZEDI... 32 ZETIA... 36 ZIAGEN... 4 zidovudine... 4 ZIOPTAN (PF)... 6 ziprasidone hcl... 32 ZIRGAN... 60 ZMAX... 5 zoledronic acid... 48 zoledronic acid-mannitol-water... 42 ZOLINZA... 6 zolmitriptan... 9 zolpidem... 32 zonisamide... 8 ZONTIVITY... 36 ZORTRESS... 6 ZOSTAVAX (PF)... 55 ZOSYN IN DEXTROSE (ISO- OSM)... 9 zovia /35e (28)... 60 zovia /50e (28)... 60 ZOVIRAX... 39 ZYCLARA... 38 ZYDELIG... 6 ZYFLO... 66 ZYFLO CR... 66 ZYKADIA... 6 ZYLET... 62 ZYPREXA RELPREVV... 32 ZYTIGA... 6 ZYVOX... 7 83
With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most out of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 08/4/205. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at www.express-scripts.com. Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. 205 Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0PP4C6A