Formulary - Simply Healthcare Plans

Transcripción

2016
Formulary
Formulario
List of Covered Drugs
Lista de Medicamentos Cubiertos
PLEASE READ: This document contains information about the drugs we cover in this plan.
This formulary was updated on 8/01/2016. For more recent information or other questions, please contact
Simply Healthcare Plans, Member Services Department toll-free at 1-877-577-0115 / TTY: 711. From October 1 to
February 14, we are open 7 days a week from 8 a.m. – 8 p.m., Eastern. From February 15, we are open Monday
through Friday, 8 a.m. – 8 p.m., or visit mysimplymedicare.com.
FAVOR LEER: Este documento contiene información sobre los medicamentos que cubrimos en este plan.
Este formulario se actualizó el 8/01/2016. Para obtener información más reciente o para preguntas, por favor
llame a Simply Healthcare Plans, Servicios al Afiliado sin cargo al 1-877-577-0115 / TTY: 711. Desde el 1 de octubre
al 14 de febrero, estamos abiertos los 7 días de la semana de 8 a.m. – 8 p.m., hora del este. A partir del 15 de
febrero, estamos abiertos de lunes a viernes de 8 a.m. – 8 p.m., o visite mysimplymedicare.com.
H5471_SHPM01K2256 Accepted
Formulary ID: 16267 Version 18
Simply Healthcare Plans, Inc.
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS
WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Simply Healthcare Plans, Inc.
When it refers to “plan” or “our plan,” it means Simply Healthcare Plans, Inc.
This document includes a list of the drugs (formulary) for our plan which is current as of
August 1, 2016. For an updated formulary, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2017 and from time to
time during the year.
Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid
contract with the State of Florida Agency for Health Care Administration to provide benefits or
arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends
on contract renewal.
This information is available for free in other languages. Please contact our Member Services number
at 1-877-577-0115 for additional information. If you use a TTY device, please call 711. From October
1 to February 14, we are open 7 days a week from 8 a.m. to 8 p.m., Eastern. From February 15 we are
open Monday through Friday, 8 a.m.to 8 p.m. Member Services also has free language interpreter
services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor póngase en contacto
con nuestro departamento de Servicios para Afiliados al 1-877-577-0115 para obtener información
adicional. Si usted usa un dispositivo TTY, por favor llame al 711. Desde el 1 octubre hasta el 14 de
febrero, atendemos los 7 días de la semana de 8 a.m. a 8 p.m., hora del este. A partir del 15 de febrero,
atendemos de lunes a viernes de 8 a.m. a 8 p.m. El Departamento de Servicios para Afiliados también
ofrece servicios de intérprete gratis para las personas que no hablan inglés.
Formulary ID: 16267 Version 18
Effective Date: August 2016.
i
What is the Simply Healthcare Plans, Inc. Formulary?
A formulary is a list of covered drugs selected by Simply Healthcare Plans, Inc. 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. Simply Healthcare Plans, Inc. will generally cover the drugs listed
in our formulary as long as the drug is medically necessary, the prescription is filled at a Simply
Healthcare Plans, Inc. network pharmacy, and other plan rules are followed. For more information on
how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2016 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 formulary, will not affect members who are currently taking the drug. It will remain
available at the same cost-sharing 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 we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move 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, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or 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 take the drug. The enclosed formulary is current as of August 1, 2016. To get updated
information about the drugs covered by Simply Healthcare Plans, Inc., please contact us. Our contact
information appears on the front and back cover pages.
In the event of a mid-year non-maintenance formulary change such as changing a preferred or
non-preferred formulary drug, adding an additional requirement or limit to a drug, remove a dosage
form, or exchanging therapeutic alternatives by adding or deleting a drug or changing a tier as a result
of a therapeutic alternative, we will notify you by providing you with a written notice of the
non-maintenance formulary change.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 2. 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 Agents”. If you know what your drug is
used for, look for the category name in the list that begins on page number 2. Then look under the
category name for your drug.
ii
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 112. 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 first column
of the list.
What are generic drugs?
Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient 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 limits on coverage. These requirements and
limits may include:

Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from
Simply Healthcare Plans, Inc. before you fill your prescriptions. If you don’t get
approval, Simply Healthcare Plans, Inc. may not cover the drug.

Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of
the drug that Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare
Plans, Inc. provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This
may be in addition to a standard one month or three month supply.

Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that
condition. For example, if Drug A and Drug B both treat your medical condition, Simply
Healthcare Plans, Inc. may not cover Drug B unless you try Drug A first. If Drug A does
not work for you, Simply Healthcare Plans, Inc. will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 2. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site.
We have posted on line documents that explain our prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits or for a
list of other, similar drugs that may treat your health condition. See the section, “How do I request an
exception to the Simply Healthcare Plans, Inc.’s formulary?” on page iv for information about how to
request an exception.
iii
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that Simply Healthcare Plans, Inc. does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Simply
Healthcare Plans, Inc. When you receive the list, show it to your doctor and ask him
or her to prescribe a similar drug that is covered by Simply Healthcare Plans, Inc.

You can ask Simply Healthcare Plans, Inc. to make an exception and cover your
drug. See below for information about how to request an exception.
How do I request an exception to the Simply Healthcare Plans, Inc. Formulary?
You can ask Simply Healthcare Plans, Inc. 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,
this drug will be covered at a pre-determined cost-sharing level, and you would 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 this
drug is not on the specialty tier. If approved this would lower the amount you
must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example,
for certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drug that
we will cover. If your drug has a quantity limit, you can ask us to waive the limit
and cover a greater amount.
Generally, Simply Healthcare Plans, Inc. will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction 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 believe 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.
iv
What do I do before I can talk to my doctor about changing my drugs
or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary 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, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when
you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if
you have been a member of the plan less than 90 days.
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 93-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 drugs is limited, but you are past the first 90 days of membership in our plan,
we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days)
while you pursue a formulary exception.
For current members who are changing from one treatment setting to another, for example entering a
long- term care facility from a hospital or being discharged from a hospital to home, the member and
provider will need to utilize our exception and appeals process should the drugs not be on our
formulary. Members entering or being discharged from a long-term care facility will be allowed a onetime 31-day emergency supply of medications for which the member has not already received a
transition supply. In addition, the dispensing pharmacist will need to call the Pharmacy Help Desk to
receive appropriate directions to dispense a prescription required due to a level of care change.
For more information
For more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about Simply Healthcare Plans, Inc., please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call
1-877-486-2048. Or visit http://www.medicare.gov.
v
Simply Healthcare Plans, Inc. Formulary
The formulary below provides coverage information about the drugs covered by Simply Healthcare
Plans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins
on page 112.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10
MG) and generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg).
The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has
any special requirements for coverage of your drug.
vi
List of Abbreviations
B/D
Part B versus D: This prescription drug has a Part B versus D administrative prior
authorization requirement. This drug may be covered under Medicare Part B or D depending
upon the circumstances. Information may need to be submitted describing the use and setting of
the drug to make the determination.
ED
Excluded Drugs: This prescription drug is not normally covered in a Medicare Prescription
Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards
your total drug costs (that is, the amount you pay does not help you qualify for catastrophic
coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not
get any extra help to pay for this drug.
GC
Gap Coverage: We provide additional coverage of this prescription drug in the coverage gap.
Please refer to our Evidence of Coverage for more information about this coverage.
LA
Limited Availability: This prescription may be available only at certain pharmacies. For more
information consult your Provider/Pharmacy Directory or call Member Services at 1-877-5770115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711.
MO
Mail Order Drug. This prescription drug is available through a mail-order service.
PA
Prior Authorization. Simply Healthcare Plans, Inc. requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Simply
Healthcare Plans, Inc. before you fill your prescriptions. If you don't get approval, Simply
Healthcare Plans, Inc. may not cover the drug.
QL
Quantity Limit. For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drug
that Simply Healthcare Plans, Inc. will cover. For example, Simply Healthcare Plans, Inc.
provides 30 tablets per prescription for Celebrex 100mg Capsules. This may be in addition to a
standard one month or three month supply.
ST
Step Therapy. In some cases, Simply Healthcare Plans, Inc requires you to first try certain drugs
to treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc
may not cover drug B unless you try Drug A first. If Drug A does not work for you, Simply
Healthcare Plans, Inc will then cover Drug.
vii
Simply Healthcare Plans, Inc.
Formulario del 2016
(Lista de medicamentos cubiertos)
FAVOR LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Nota a los afiliados existentes: Este formulario ha cambiado desde el año pasado. Por favor revise
este documento para asegurarse de que sigue incluyendo los medicamentos que usted toma.
Cuando esta lista de medicamentos (Formulario) dice “nosotros” o “nuestro”, significa Simply
Healthcare Plans, Inc. Cuando dice “plan” o “nuestro plan”, significa Simply Healthcare Plans, Inc.
Este documento incluye una lista de medicamentos (Formulario) de nuestro plan que esta vigente el
día 1 de agosto del 2016. Para obtener una copia de nuestro formulario más corriente, por favor
comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de actualización
más corriente de nuestro formulario, aparece en la primera y la última página de este documento.
Debe usar las farmacias de la red para tener acceso a su beneficio de medicamentos recetados.
El 1 de enero del 2017 y de vez en cuando durante el año podría haber cambios en los beneficios,
el formulario, la red de farmacias, los copagos o el coseguro.
Simply Healthcare Plans, Inc. es un plan de atención médica coordinada con un contrato Medicare
y un contrato Medicaid con la Agencia de Administración de Cuidado de la Salud (AHCA) del
estado de la Florida para proveer o coordinar los beneficios a ser proporcionados a los afiliados. La
inscripción en Simply Healthcare Plans, Inc. depende de la renovación del contrato.
This information is available for free in other languages. Please contact our Member Services number
at 1-877-577-0115 for additional information. If you use a TTY device, please call 711. From October
1 to February 14, we are open 7 days a week from 8 a.m. – 8 p.m., Eastern. From February 15, we are
open Monday through Friday, 8 a.m. – 8 p.m. Member Services also has free language interpreter
services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor póngase en contacto
con nuestro Departamento de Servicios para Afiliados al 1-877-577-0115 para obtener información
adicional. Si usted usa un dispositivo TTY, por favor llame al 711. Desde el 1 de octubre, hasta el 14
de febrero, atendemos los siete días de la semana de 8 a.m. a 8 p.m., hora del este. A partir del 15 de
febrero atendemos de lunes a viernes 8 a.m. a 8 p.m. El Departamento de Servicios para Afiliados
también ofrece servicios de interprete gratis para las personas que no hablan inglés.
viii
¿Qué es el Formulario de Simply Healthcare Plans, Inc.?
El formulario es una lista de medicamentos cubiertos seleccionados por Simply Healthcare Plans,
Inc. en colaboración con un equipo de proveedores de atención médica, que representa las terapias
farmacológicas consideradas como parte necesaria de un programa de tratamiento de calidad. Por lo
general, Simply Healthcare Plans, Inc. cubrirá los medicamentos incluidos en nuestro formulario
siempre y cuando se necesiten por razones médicas, el medicamento sea surtido en una farmacia de
la red de Simply Healthcare Plans, Inc., y se hayan seguido otras reglas de cobertura. Si desea más
información sobre cómo hacer para que le surtan sus medicamentos recetados, consulte su Evidencia
de Cobertura.
¿Es posible que cambie el formulario (la lista de medicamentos)?
Por lo general, si está tomando un medicamento de nuestro formulario del 2016 que estaba cubierto al
principio del año, no lo descontinuaremos ni reduciremos su cobertura durante el año de cobertura
2016, excepto cuando un medicamento genérico nuevo y menos costoso se ponga a disposición, o
cuando se publique nueva información adversa sobre la seguridad o efectividad de un medicamento.
Otros tipos de cambios en el formulario, como el retiro de un medicamento de nuestro formulario, no
afectará a los afiliados que están tomando actualmente el medicamento. Seguirá estando disponible
con la misma participación de costos para aquellos afiliados que lo están tomando durante el resto del
año de cobertura. Creemos que es importante que usted tenga acceso continuo durante el resto del año
de la cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan,
excepto en los casos en los que pueda ahorrar dinero o podamos garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario o añadimos autorizaciones previas, límites en las
cantidades o restricciones en la terapia por fases en un medicamento, o trasladamos un medicamento a
un nivel con distribución de costos más alta, debemos notificar a los afiliados afectados sobre el cambio
cuando menos con 60 días de anticipación a que entre en vigencia. Alternativamente, daremos
notificación cuando el afiliado solicite la repetición de la receta del medicamento, momento en el cual
el afiliado recibirá un surtido de 60 días del medicamento en cuestión. Si la Administración de
Alimentos y Medicamentos considera que un medicamento en nuestro formulario no es seguro, o el
fabricante del medicamento lo retira del mercado, nosotros eliminaremos inmediatamente dicho
medicamento de nuestro formulario y daremos aviso a los afiliados que lo usan.
El formulario adjunto fue actualizado el 1 de agosto del 2016. Si desea información actualizada de los
medicamentos cubiertos por Simply Healthcare Plans, Inc., pofavor póngase en contacto con nosotros.
Nuestra información de contacto aparece en la portada de este documento.
En caso de que se haga un cambio en el formulario de un medicamento que no sea de mantenimiento a
mitad de año, como el cambio de un medicamento preferido o no preferido del formulario, añadir un
requisito adicional o poner un límite a un medicamento, retirar una forma de dosis, o intercambiar
alternativas terapéuticas agregando o eliminando un medicamento o cambiando un nivel como
resultado de una alternativa terapéutica, se lo notificaremos mediante aviso por escrito del cambio en el
formulario del medicamento que no es de mantenimiento.
ix
¿Cómo uso el formulario?
Hay dos maneras de encontrar su medicamento en el formulario:
Afección
El formulario comienza en la página 2. Los medicamentos en este formulario se agrupan en categorías
en función del tipo de afecciones que tratan habitualmente. Por ejemplo, los medicamentos para tratar
afecciones cardiacas se incluyen en la categoría “Agentes Cardiovasculares”. Si sabe para qué se
usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 2.
Despues busque su medicamento en dicha categoría.
Lista en orden alfabético
Si no sabe a qué categoría corresponde su medicamento, deberá buscarlo en el Índice que comienza
en la página 112. El Índice ofrece una lista alfabética de todos los medicamentos incluidos en este
documento. El Índice incluye tanto los medicamentos de marca como los genéricos. Busque en el
Índice para encontrar su medicamento. Junto al medicamento, verá el número de la página que
contiene la información sobre la cobertura. Vaya a la página indicada en el Índice y encuentre el
nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Simply Healthcare Plans, Inc. cubre medicamentos genéricos y de marca. Un medicamento genérico
esta aprobado por la FDA como un medicamento que tiene el mismo ingrediente activo que el
medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca.
¿Hay restricciones en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura.
Estos requisitos y límites pueden incluir:

Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico
obtengan autorización previa para ciertos medicamentos. Esto significa que necesitará
obtener aprobación de Simply Healthcare Plans, Inc. antes de que pueda surtir sus
recetas. Si no obtiene la aprobación, es posible que Simply Healthcare Plans, Inc. no
cubra el medicamento.

Límites en la Cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc.
limita la cantidad del medicamento que Simply Healthcare Plans, Inc. va a cubrir.
Por ejemplo, Simply Healthcare Plans, Inc. proporciona 30 tabletas por receta del
medicamento LIPITOR EN TABLETAS DE 10 MG. Esto puede ser adicional al
suministro estándar de un mes o tres meses.

Terapia por Fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que
usted pruebe primero ciertos medicamentos para tratar su condición médica antes
de que demos cobertura a otro medicamento para dicha afección. Por ejemplo, si tanto el
Medicamento A como el Medicamento B tratan su condición médica, es posible que
Simply Healthcare Plans, Inc. no cubra el Medicamento B a menos que usted pruebe
primero el Medicamento A. Si el Medicamento A no funciona en su caso, Simply
Healthcare Plans, Inc. cubrirá el Medicamento B.
x
Usted puede consultar el formulario que comienza en la página 2 para determinar si su medicamento
tiene requisitos o límites adicionales. También puede obtener más información sobre las restricciones
que se aplican a medicamentos cubiertos específicos si visita nuestro sitio web.
Tenemos documentos disponibles en nuestro sitio web que explican los requisitos de autorización
previa y terapia por fases. Puede solicitar que le enviemos una copia. Nuestra información de contacto,
junto con la fecha de actualización más corriente de nuestro formulario, aparece en la portada de este
documento.
Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites
o solicitar una lista de otros medicamentos similares que puedan tratar su afeccion. Consulte la sección
“¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?” en la pagina xi
para obtener información sobre cómo solicitar una excepción.
¿Qué sucede si su medicamento no está en el formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos),
debe comunicarse primero con el Departamento de Servicios para Afiliados para confirmar si su
medicamento está cubierto. Si se entera de que Simply Healthcare Plans, Inc. no cubre su
medicamento, usted tiene dos opciones:

Puede comunicarse con el Departamento de Servicios para Afiliados para solicitar
una lista de los medicamentos similares que cubre Simply Healthcare Plans, Inc.
Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento
similar que esté cubierto por Simply Healthcare Plans, Inc.

Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción y cubra
su medicamento. Consulte la sección que sigue para obtener información sobre
cómo solicitar una excepción.
¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.?
Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a nuestras reglas de cobertura.
Hay varios tipos de excepciones que puede pedir.

Puede solicitarnos que cubramos su medicamento aunque no esté incluido en
nuestro formulario. Si es aprobado, este medicamento estará cubierto a un nivel
de costo compartido predeterminado, y no podrá pedirnos que sea cubierto a un
nivel de costo compartido más bajo.

Puede solicitarnos que cubramos un medicamento del formulario a un nivel de
costo compartido mas bajo si dicho medicamento no esta en el nivel de
medicamentos especializados. Si es aprobado, bajaría la cantidad que debe pagar
por su medicamento.

Puede solicitarnos que cancelemos las restricciones o limitaciones en la cobertura
de su medicamento. Por ejemplo, en algunos medicamentos, Simply Healthcare
Plans, Inc. limita la cantidad que tendrá cobertura. Si su medicamento tiene un
límite en la cantidad, puede solicitarnos que cancelemos dicha limitación y
cubramos una mayor cantidad.
xi
Por lo general, Simply Healthcare Plans, Inc. solo aprobará su solicitud para una excepción si los
medicamentos alternativos incluidos en el formulario del plan, el medicamento de nivel más bajo o las
restricciones de uso adicional no son tan eficaces para tratar su afección o pueden ocasionar efectos
médicos adversos.
Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción en
el formulario, el nivel o la limitación en el uso. Cuando solicite una excepción en el formulario, el
nivel o la limitación en el uso, debe presentar una declaración de su médico que respalde su
solicitud. Por lo general, debemos tomar una decisión en un plazo de 72 horas a partir del momento en
el que hayamos recibido la declaración de respaldo de su médico tratante o de quien le receta. Usted
puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que una espera de 72
horas para una decisión puede perjudicar gravemente su salud. Si se concede acelerar su solicitud,
debemos otorgarle una decisión mas tardar 24 horas a partir del momento en que recibamos la
declaración de respaldo de su médico tratante o de quien le receta.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de mis
medicamentos o la solicitud de una excepción?
Si usted es afiliado nuevo o continúa en nuestro plan, podría estar tomando medicamentos que no
están en nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario
pero su capacidad para adquirirlo es limitada. Por ejemplo, podría necesitar una autorización previa de
nuestra parte para poder surtir su receta. Debe hablar con su médico para decidir si debe cambiar a un
medicamento apropiado que nosotros cubramos o solicitar una excepción en el formulario para que
podamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar el
mejor modo de actuar para usted, podríamos cubrir su medicamento en ciertos casos durante los
primeros 90 días de su afiliación a nuestro plan.
Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para adquirir
sus medicamentos es limitada, daremos cobertura a un suministro temporal de 30 días (a menos que
tenga una receta escrita para menos días) cuando vaya a una farmacia de la red. Después de su primer
suministro de 30 días, nosotros no pagaremos estos medicamentos, incluso si usted ha estado afiliado
al plan menos de 90 días.
Si reside en un establecimiento de atención médica prolongada, le permitiremos que surta su receta hasta
que hayamos proporcionado un suministro de transición de 93 días, consistente con el incremento en el
suministro, (a menos que tenga una receta escrita para menos días). Daremos cobertura a más de un
surtido de estos medicamentos durante los primeros 90 días de su afiliación a nuestro plan. Si necesita un
medicamento que no está en nuestro formulario, o si su capacidad para adquirir sus medicamentos es
limitada, pero han pasado los primeros 90 días de su afiliación a nuestro plan, daremos cobertura a un
suministro de emergencia de 31 días de dicho medicamento (a menos que tenga una receta escrita para
menos días) mientras busca una excepción en el formulario.
xii
Para los afiliados actuales que están cambiando de un lugar de tratamiento a otro, por ejemplo, si
después de estar en un hospital ingresan a un establecimiento de atención médica prolongada, o que
regresan a su hogar después de ser dados de alta de un hospital, el afiliado y el proveedor deberán
utilizar nuestro proceso de excepciones y apelaciones en caso de que los medicamentos no estén en
nuestro formulario. Los afiliados que ingresan a un establecimiento de atención médica prolongada, o
que salen de él, tendrán permitido un suministro único de emergencia de 31 días de los medicamentos
para los cuales no hayan recibido aún un suministro de transición. Adicionalmente, el farmacéutico
que surte la receta deberá comunicarse con el Centro de Ayuda para Farmacias con el fin de recibir
instrucciones apropiadas para surtir una receta requerida debido a un cambio en el nivel de la atención.
Si desea más información
Si desea información detallada sobre su cobertura de medicamentos recetados de Simply Healthcare
Plans, Inc., consulte su Evidencia de Cobertura y demás documentos del plan.
Si tiene preguntas sobre Simply Healthcare Plans, Inc., por favor comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha de actualización más corriente de nuestro formulario,
aparece en la portada de este documento.
Si tiene alguna pregunta general sobre la cobertura de medicamentos recetados de Medicare, por favor
comuníquese con Medicare llamando al 1-800-MEDICARE (1-800-633-4227). Se atiende las 24 horas
del día, los 7 días de la semana. Las personas con impedimentos auditivos pueden llamar al 1-877486-2048 o visitar la página http://www.medicare.gov.
Formulario de Simply Healthcare Plans, Inc.
El formulario que se ofrece a continuación proporciona información de cobertura de los medicamentos
cubiertos por Simply Healthcare Plans, Inc. Si tiene dificultades para encontrar su medicamento en la
lista, diríjase al Índice que comienza en la página 112.
En la primera columna del diagrama se incluye el nombre del medicamento. Los medicamentos de
marca están con letras mayúsculas (por ejemplo, LIPITOR 10 MG), y los medicamentos genéricos se
incluyen con letras minúsculas en itálica (por ejemplo, pravastatin sodium 10 mg).
La información en la columna de requisitos y límites indica si Simply Healthcare Plans, Inc. tiene
algún requisito especial para dar cobertura a su medicamento.
xiii
Listado De Abreviaciones
B/D
ED
Parte B o D: Autorización Previa B v D. Dependiendo de las circunstancias, este medicamento
podría tener cobertura bajo la Parte B o la Parte D de Medicare. Puede ser necesario enviar
información sobre el uso del medicamento y la situación específica para tomar una
determinación.
Medicamento Excluido: Este medicamento recetado por lo general no está cubierto en un Plan
de Medicamentos Recetados de Medicare. La cantidad que usted paga cuando le surten una
receta de este medicamento no se toma en cuenta en su costo total de medicamentos (es decir, la
cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe). Además,
si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de
ayuda adicional para pagar por este medicamento.
GC
Brecha en la cobertura. Proporcionamos cobertura adicional de este medicamento recetado
durante la brecha en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener más
información sobre esta cobertura.
LA
Disposición Limitada. Este medicamento recetado solo podría estar disponible en algunas
farmacias. Si desea más información, consulte su Directorio de proveedores/Farmacias o
comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se
atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con
TTY/TDD deben marcar 711.
MO
Pedido por Correo: Este medicamento recetado puede obtenerse mediante pedido por correo.
PA
Autorización Previa: Simply Healthcare Plans, Inc. requiere que usted o su médico obtenga
autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener la
aprobación de Simply Healthcare Plans, Inc. antes de adquirir su medicamento. Si no obtiene
aprobación, Simply Healthcare Plans, Inc. podría no cubrir el medicamento.
QL
Límites en la cantidad: Para ciertos medicamentos, Simply Healthcare Plans, Inc. establece
límites en las cantidades que cubre. Por ejemplo, Simply Healthcare Plans, Inc. proporciona 30
tabletas por receta del medicamento Celebrex en capsulas de 100mg. Esto puede ser adicional al
suministro estándar de un mes o tres meses.
ST
Terapia por fases: En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebe
primero ciertos medicamentos para el tratamiento de su condición médica antes que cubramos
otros medicamentos indicados para ese tratamiento. Por ejemplo, si los medicamentos A y B
están indicados para el tratamiento de su condición médica, es posible que Simply Healthcare
Plans, Inc. no cubra el medicamento B si usted no prueba primero el medicamento A. Si el
medicamento A no es efectivo, entonces Simply Healthcare Plans, Inc. cubrirá el medicamento
B.
xiv
Drug
Drug Name
Tier Requirements/Limits
Analgesics
Analgesics
butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 1
1
QL (240 EA per 30 days)
butalbital/acetaminophen tabs 325mg; 50mg
1
marten-tab tabs 325mg; 50mg
1
tencon tabs 325mg; 50mg
Nonsteroidal Anti-inflammatory Drugs
2
QL (60 EA per 30 days) PA MO
celecoxib caps 100mg
2
2
2
celecoxib caps 50mg
1
MO
diclofenac potassium tabs 50mg
1
MO
diclofenac sodium dr tbec 25mg
1
MO
1
MO
1
MO
diclofenac sodium er tb24 100mg
2
MO
diclofenac sodium/misoprostol tbec 50mg; 200mcg
2
MO
diclofenac sodium/misoprostol tbec 75mg; 200mcg
1
MO
diflunisal tabs 500mg
2
MO
etodolac er tb24 400mg
2
MO
2
MO
1
MO
etodolac caps 200mg
1
MO
etodolac caps 300mg
1
MO
etodolac tabs 400mg
1
MO
etodolac tabs 500mg
1
MO
fenoprofen calcium caps 400mg
1
MO
fenoprofen calcium tabs 600mg
FLECTOR PTCH 1.3%
4
QL (30 EA per 15 days) PA
1
MO
flurbiprofen tabs 100mg
1
MO
flurbiprofen tabs 50mg
1
ibuprofen susp 100mg/5ml
1
MO
ibuprofen tabs 400mg
1
MO
1
MO
2
MO
ketoprofen er cp24 200mg
1
MO
ketoprofen caps 50mg
1
MO
ketoprofen caps 75mg
2
PA
ketorolac tromethamine inj 15mg/ml
2
PA
ketorolac tromethamine inj 300mg/10ml
2
PA
2
PA
2
PA
2
ketorolac tromethamine tabs 10mg
2
MO
meclofenamate sodium caps 100mg
MECLOFENAMATE SODIUM CAPS 50MG
4
MO
You can find information on what the symbols and abbreviations on this table mean by going to page vii.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones encontrados en esta
tabla en la página xiv.
2
Drug
Drug Name
2
MO
mefenamic acid caps 250mg
2
MO
meloxicam susp 7.5mg/5ml
1
MO
meloxicam tabs 15mg
1
MO
meloxicam tabs 7.5mg
1
MO
nabumetone tabs 500mg
1
MO
nabumetone tabs 750mg
1
MO
nalfon caps 400mg
1
MO
naproxen dr tbec 375mg
1
MO
naproxen dr tbec 500mg
1
MO
naproxen kit tabs 500mg
1
MO
naproxen sodium ds tabs 550mg
1
MO
naproxen sodium tabs 275mg
1
MO
naproxen sodium tabs 550mg
1
MO
naproxen susp 125mg/5ml
1
MO
naproxen tabs 250mg
1
MO
naproxen tabs 375mg
1
MO
naproxen tabs 500mg
1
MO
oxaprozin tabs 600mg
2
oxycodone/ibuprofen tabs 400mg; 5mg
1
MO
piroxicam caps 10mg
1
MO
piroxicam caps 20mg
1
MO
sulindac tabs 150mg
1
MO
sulindac tabs 200mg
Opioid Analgesics, Long-acting
2
fentanyl pt72 100mcg/hr
2
2
2
fentanyl pt72 37.5mcg/hr
2
2
2
2
2
hydromorphone hcl er t24a 12mg
2
5
2
1
methadone hcl inj 10mg/ml
1
methadone hcl soln 10mg/5ml
1
methadone hcl soln 5mg/5ml
1
methadone hcl tabs 10mg
1
methadone hcl tabs 5mg
1
methadose tabs 10mg
5
morphine sulfate er cp24 100mg
2
2
2
3
Drug
Drug Name
2
2
2
2
2
2
2
5
2
2
morphine sulfate er tbcr 100mg
2
2
2
2
NUCYNTA ER TB12 100MG
4
4
4
4
4
2
oxycodone hcl er t12a 10mg
2
2
2
2
2
2
OXYCONTIN T12A 10MG
4
OXYCONTIN T12A 15MG
4
OXYCONTIN T12A 20MG
4
OXYCONTIN T12A 30MG
4
OXYCONTIN T12A 40MG
4
OXYCONTIN T12A 60MG
4
OXYCONTIN T12A 80MG
5
2
oxymorphone hydrochloride er tb12 10mg
2
2
2
2
2
2
oxymorphone hydrochloride er tb12 7.5mg
2
tramadol hcl er tb24 100mg
2
2
2
2
2
4
Drug
Drug Name
Opioid Analgesics, Short-acting
ABSTRAL SUBL 100MCG
4
ABSTRAL SUBL 200MCG
5
ABSTRAL SUBL 800MCG
5
1
acetaminophen/codeine #2 tabs 300mg; 15mg
1
1
1
1
1
acetaminophen/codeine phosphate tabs 300mg; 30mg
1
1
1
1
1
1
1
1
1
1
1
QL (5000 ML per 30 days)
acetaminophen/codeine soln 120mg/5ml; 12mg/5ml
1
acetaminophen/codeine tabs 300mg; 15mg
1
acetaminophen/codeine tabs 300mg; 60mg
2
ascomp/codeine caps 325mg; 50mg; 40mg; 30mg
aspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg 2
butalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg; 2
30mg
2
butorphanol tartrate inj 1mg/ml
2
butorphanol tartrate inj 2mg/ml
2
butorphanol tartrate soln 10mg/ml
2
codeine sulfate tabs 15mg
2
2
1
duramorph inj 0.5mg/ml
1
duramorph inj 1mg/ml
1
endocet tabs 325mg; 10mg
1
endocet tabs 325mg; 2.5mg
1
endocet tabs 325mg; 5mg
1
endocet tabs 325mg; 7.5mg
1
endodan tabs 325mg; 4.835mg
5
fentanyl citrate oral transmucosal lpop 1200mcg
5
5
5
5
5
5
Drug
Drug Name
FENTORA TABS 100MCG
5
FENTORA TABS 200MCG
5
FENTORA TABS 400MCG
5
FENTORA TABS 600MCG
5
FENTORA TABS 800MCG
5
1
hydrocodone bitartrate/acetaminophen soln 325mg/15ml;
10mg/15ml
1
hydrocodone bitartrate/acetaminophen soln 325mg/15ml;
7.5mg/15ml
1
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg
1
hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg
1
hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg
1
hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg
hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1
1
hydrocodone/acetaminophen tabs 325mg; 10mg
1
1
hydrocodone/acetaminophen tabs 325mg; 7.5mg
1
1
1
1
QL (150 EA per 30 days) MO
1
hydrocodone/ibuprofen tabs 10mg; 200mg
1
hydrocodone/ibuprofen tabs 5mg; 200mg
1
hydrocodone/ibuprofen tabs 7.5mg; 200mg
1
hydromorphone hcl inj 500mg/50ml
1
hydromorphone hcl liqd 1mg/ml
1
hydromorphone hcl tabs 2mg
1
1
1
ibudone tabs 5mg; 200mg
LAZANDA SOLN 100MCG/ACT
5
LAZANDA SOLN 400MCG/ACT
5
1
lorcet hd tabs 325mg; 10mg
1
lorcet plus tabs 325mg; 7.5mg
1
lorcet tabs 325mg; 5mg
1
lortab tabs 325mg; 10mg
1
lortab tabs 325mg; 5mg
1
lortab tabs 325mg; 7.5mg
2
PA
meperidine hcl tabs 100mg
2
PA
meperidine hcl tabs 50mg
1
morphine sulfate inj 0.5mg/ml
1
morphine sulfate inj 1mg/ml
1
morphine sulfate inj 1mg/ml
1
morphine sulfate soln 100mg/5ml
1
1
6
Drug
Drug Name
1
morphine sulfate tabs 15mg
1
morphine sulfate tabs 30mg
1
nalbuphine hcl inj 10mg/ml
1
nalbuphine hcl inj 20mg/ml
NUCYNTA TABS 100MG
4
NUCYNTA TABS 50MG
4
NUCYNTA TABS 75MG
4
1
oxycodone hcl caps 5mg
2
oxycodone hcl conc 100mg/5ml
1
oxycodone hcl soln 5mg/5ml
1
oxycodone hcl tabs 10mg
1
1
1
1
1
oxycodone hydrochloride caps 5mg
1
oxycodone/acetaminophen tabs 325mg; 10mg
1
oxycodone/acetaminophen tabs 325mg; 2.5mg
1
oxycodone/acetaminophen tabs 325mg; 5mg
1
2
1
oxycodone/aspirin tabs 325mg; 4.835mg
2
oxymorphone hydrochloride tabs 10mg
2
oxymorphone hydrochloride tabs 5mg
1
reprexain tabs 10mg; 200mg
ROXICET SOLN 325MG/5ML; 5MG/5ML
3
1
roxicet tabs 325mg; 5mg
SYNALGOS-DC CAPS 356.4MG; 30MG; 16MG
4
1
tramadol hcl tabs 50mg
tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg 1
1
tramadol hydrochloride tabs 50mg
1
verdrocet tabs 325mg; 2.5mg
1
vicodin es tabs 300mg; 7.5mg
1
vicodin hp tabs 300mg; 10mg
1
vicodin tabs 300mg; 5mg
1
xylon tabs 10mg; 200mg
1
zamicet soln 325mg/15ml; 10mg/15ml
Anesthetics
Local Anesthetics
2
dermacinrx prizopak kit 2.5%; 2.5%
1
glydo gel 2%
2
leva set kit 2.5%; 2.5%
1
lidocaine hcl jelly gel 2%
1
1
1
lidocaine hcl viscous soln 2%
7
Drug
Drug Name
1
lidocaine hcl gel 2%
2
lidocaine hcl inj 0.5%
2
lidocaine hcl inj 1%
2
2
1
lidocaine hcl soln 4%
1
lidocaine pak oint 5%
1
lidocaine viscous soln 2%
2
lidocaine-prilocaine-cream base crea 2.5%; 2.5%
2
lidocaine/prilocaine crea 2.5%; 2.5%
2
lidocaine/prilocaine kit 2.5%; 2.5%
1
lidocaine oint 5%
2
PA
lidocaine ptch 5%
2
livixil pak kit 2.5%; 2.5%
2
lp lite pak kit 2.5%; 2.5%
1
premium lidocaine oint 5%
2
relador pak plus kit 2.5%; 2.5%
2
relador pak kit 2.5%; 2.5%
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
2
MO
acamprosate calcium dr tbec 333mg
2
MO
disulfiram tabs 250mg
2
MO
disulfiram tabs 500mg
Opioid Dependence Treatments
2
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg
2
buprenorphine hcl/naloxone hcl subl 8mg; 2mg
2
buprenorphine hcl subl 2mg
2
buprenorphine hcl subl 8mg
BUTRANS PTWK 10MCG/HR
4
4
4
4
BUTRANS PTWK 7.5MCG/HR
4
2
naltrexone hcl tabs 50mg
SUBOXONE FILM 12MG; 3MG
4
SUBOXONE FILM 2MG; 0.5MG
4
4
4
Opioid Reversal Agents
1
naloxone hcl inj 0.4mg/ml
1
naloxone hcl inj 1mg/ml
1
naloxone hydrochloride inj 1mg/ml
Smoking Cessation Agents
1
buproban tb12 150mg
1
bupropion hcl sr tb12 150mg
1
8
Drug
Drug Name
1
CHANTIX CONTINUING MONTH PAK TABS 1MG
4
CHANTIX STARTING MONTH PAK TABS 0
4
CHANTIX TABS 0.5MG
4
CHANTIX TABS 1MG
4
NICOTROL NS SOLN 10MG/ML
3
Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
5
diclofenac sodium gel 3%
2
MO
tolmetin sodium caps 400mg
2
MO
tolmetin sodium tabs 200mg
2
MO
tolmetin sodium tabs 600mg
Antibacterials
Aminoglycosides
1
amikacin sulfate inj 500mg/2ml
1
garamycin oint 0.3%
1
garamycin soln 0.3%
1
gentak oint 0.3%
1
gentamicin sulfate pediatric inj 10mg/ml
1
gentamicin sulfate pediatric inj 10mg/ml
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9% 1
1
gentamicin sulfate/0.9% sodium chloride inj 1mg/ml; 0.9%
1
gentamicin sulfate/sodium chloride inj 1.2mg/ml; 0.9%
1
gentamicin sulfate crea 0.1%
1
gentamicin sulfate inj 10mg/ml
1
1
1
gentamicin sulfate oint 0.1%
1
gentamicin sulfate oint 0.3%
1
gentamicin sulfate soln 0.3%
1
isotonic gentamicin inj 0.8mg/ml; 0.9%
1
neomycin sulfate tabs 500mg
1
paromomycin sulfate caps 250mg
1
streptomycin sulfate inj 1gm
1
tobramycin sulfate inj 10mg/ml
1
tobramycin sulfate inj 80mg/2ml
1
tobramycin sulfate soln 0.3%
TOBREX OINT 0.3%
4
ZYLET SUSP 0.5%; 0.3%
4
Antibacterials, Other
2
alcohol prep pads pads 70%
ALTABAX OINT 1%
4
9
Drug
Drug Name
1
bacitracin oint 500unit/gm
BACTROBAN NASAL OINT 2%
4
1
chloramphenicol sodium succinate inj 1gm
CLEOCIN SUPP 100MG
4
1
clin single use kit inj 300mg/2ml
1
clindacin etz pledgets swab 1%
1
clindacin-p swab 1%
1
clindamax gel 1%
1
clindamycin hcl caps 150mg
1
1
1
clindamycin palmitate hcl solr 75mg/5ml
1
clindamycin phosphate add-vantage inj 900mg/6ml
1
clindamycin phosphate in d5w inj 300mg/50ml; 5%
1
1
clindamycin phosphate pharmacy bulk package inj 150mg/ml 1
1
clindamycin phosphate crea 2%
1
clindamycin phosphate gel 1%
1
clindamycin phosphate inj 300mg/2ml
1
1
1
1
clindamycin phosphate lotn 1%
1
clindamycin phosphate swab 1%
1
clindamycin inj 900mg/6ml
2
B/D
colistimethate sodium inj 150mg
CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%;
4
5000UNIT/GM
CUBICIN INJ 500MG
5
DALVANCE INJ 500MG
5
2
lansoprazole/amoxicillin/clarithromycin misc 0; 0; 0
LINCOCIN INJ 300MG/ML
3
1
lincomycin hcl inj 300mg/ml
2
linezolid inj 600mg/300ml
2
linezolid susr 100mg/5ml
5
linezolid tabs 600mg
MACRODANTIN CAPS 25MG
4
2
mafenide acetate pack 5%
2
methenamine hippurate tabs 1gm
2
metronidazole in nacl 0.79% inj 500mg/100ml; 0.79%
1
metronidazole vaginal gel 0.75%
1
metronidazole caps 375mg
2
metronidazole crea 0.75%
2
metronidazole gel 0.75%
2
metronidazole gel 1%
10
Drug
Drug Name
2
metronidazole inj 500mg/100ml; 0.79%
2
metronidazole lotn 0.75%
1
metronidazole tabs 250mg
1
metronidazole tabs 500mg
MONUROL PACK 5.631GM
4
1
mupirocin calcium crea 2%
1
mupirocin crea 2%
1
mupirocin oint 2%
neo-polycin hc oint 400unit/gm; 1%; 3.5mg/gm; 10000unit/gm 2
2
neomycin/polymyxin/bacitracin/hydrocortisone oint
400unit/gm; 1%; 0.5%; 10000unit/gm
neomycin/polymyxin/gramicidin soln 0.025mg/ml; 1.75mg/ml; 1
10000unit/ml
2
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;
10000unit/ml
2
nitrofurantoin macrocrystals caps 100mg
2
2
2
nitrofurantoin monohydrate/macrocrystals caps 100mg
2
nitrofurantoin monohydrate caps 100mg
2
nitrofurantoin caps 100mg
2
nitrofurantoin susp 25mg/5ml
ORBACTIV INJ 400MG
5
2
rosadan crea 0.75%
2
rosadan gel 0.75%
1
silver sulfadiazine crea 1%
SIVEXTRO INJ 200MG
5
SIVEXTRO TABS 200MG
5
1
ssd crea 1%
SULFAMYLON CREA 85MG/GM
4
SYNERCID INJ 350MG; 150MG
5
1
thermazene crea 1%
1
trimethoprim tabs 100mg
TYGACIL INJ 50MG
5
5
vancomycin hcl caps 125mg
5
vancomycin hcl caps 250mg
2
vancomycin hcl inj 0.9%; 1gm/200ml
2
vancomycin hcl inj 1000mg
2
vancomycin hcl inj 10gm
2
2
2
vancomycin inj 0.9%; 500mg/100ml
2
vancomycin inj 0.9%; 750mg/150ml
1
vandazole gel 0.75%
XIFAXAN TABS 200MG
4
PA
XIFAXAN TABS 550MG
5
PA
11
Drug
Drug Name
ZYVOX SUSR 100MG/5ML
5
Beta-lactam, Cephalosporins
AVYCAZ INJ 0.5GM; 2GM
5
1
cefaclor caps 250mg
1
cefaclor caps 500mg
1
cefaclor susr 125mg/5ml
1
1
2
cefadroxil caps 500mg
2
cefadroxil susr 250mg/5ml
2
cefadroxil susr 500mg/5ml
2
cefadroxil tabs 1gm
2
cefazolin sodium inj 10gm
2
cefazolin sodium inj 1gm
2
cefazolin sodium inj 500mg
2
cefdinir caps 300mg
2
cefdinir susr 125mg/5ml
2
cefdinir susr 250mg/5ml
2
cefepime inj 1gm/50ml
2
cefepime inj 1gm/50ml; 5%
2
cefepime inj 1gm
2
cefepime inj 2gm/100ml
2
cefepime inj 2gm/50ml; 5%
2
cefepime inj 2gm
2
cefixime susr 100mg/5ml
2
cefixime susr 200mg/5ml
2
cefotaxime sodium inj 10gm
2
2
2
cefotaxime sodium inj 500mg
2
cefoxitin sodium inj 10gm
2
2
cefoxitin sodium inj 1gm; 4%
2
2
cefoxitin sodium inj 2gm; 2.2%
2
cefpodoxime proxetil susr 100mg/5ml
2
cefpodoxime proxetil susr 50mg/5ml
2
cefpodoxime proxetil tabs 100mg
2
cefpodoxime proxetil tabs 200mg
2
cefprozil susr 125mg/5ml
2
cefprozil susr 250mg/5ml
2
cefprozil tabs 250mg
2
cefprozil tabs 500mg
2
ceftazidime inj 1gm
2
ceftazidime inj 2gm
2
ceftazidime inj 6gm
12
Drug Name
ceftriaxone sodium inj 10gm
ceftriaxone sodium inj 250mg
ceftriaxone sodium inj 500mg
cefuroxime axetil tabs 250mg
cefuroxime axetil tabs 500mg
cefuroxime sodium inj 1.5gm
cefuroxime sodium inj 750mg
cephalexin caps 250mg
cephalexin susr 125mg/5ml
cephalexin susr 250mg/5ml
SUPRAX CAPS 400MG
SUPRAX CHEW 100MG
SUPRAX CHEW 200MG
SUPRAX SUSR 500MG/5ML
tazicef inj 1gm
tazicef inj 1gm
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 2gm
tazicef inj 2gm
tazicef inj 6gm
TEFLARO INJ 400MG
TEFLARO INJ 600MG
Beta-lactam, Other
aztreonam inj 1gm
cefotetan inj 10gm
cefotetan inj 1gm
cefotetan inj 2gm
DORIBAX INJ 500MG
imipenem/cilastatin inj 250mg; 250mg
imipenem/cilastatin inj 500mg; 500mg
INVANZ INJ 1GM
meropenem inj 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er tb12 1000mg; 62.5mg
amoxicillin/clavulanate potassium chew 200mg; 28.5mg
amoxicillin/clavulanate potassium chew 400mg; 57mg
amoxicillin/clavulanate potassium susr 200mg/5ml;
28.5mg/5ml
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
4
4
4
4
2
2
2
2
2
2
2
4
4
Requirements/Limits
2
2
2
2
4
2
2
4
2
2
2
2
2
13
Drug
Drug Name
2
62.5mg/5ml
amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml 2
2
42.9mg/5ml
2
amoxicillin/clavulanate potassium tabs 250mg; 125mg
2
2
2
amoxicillin/potassium clavulanate tabs 500mg; 125mg
1
amoxicillin caps 250mg
1
amoxicillin caps 500mg
1
amoxicillin chew 125mg
1
amoxicillin chew 250mg
1
amoxicillin susr 125mg/5ml
1
1
1
1
amoxicillin tabs 500mg
1
amoxicillin tabs 875mg
1
ampicillin sodium inj 10gm
1
1
ampicillin sodium inj 125mg
1
1
2
ampicillin-sulbactam inj 10gm; 5gm
2
ampicillin-sulbactam inj 1gm; 0.5gm
2
ampicillin-sulbactam inj 1gm; 0.5gm
2
2
2
ampicillin/sulbactam inj 2gm; 1gm
1
ampicillin caps 250mg
1
ampicillin caps 500mg
BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML
4
BICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML 4
BICILLIN L-A INJ 1200000UNIT/2ML
4
BICILLIN L-A INJ 2400000UNIT/4ML
4
BICILLIN L-A INJ 600000UNIT/ML
4
1
dicloxacillin sodium caps 250mg
1
dicloxacillin sodium caps 500mg
1
nafcillin sodium inj 10gm
1
1
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
3
DEXTROSE INJ 0; 20000UNIT/ML
3
14
Drug
Drug Name
3
1
penicillin g potassium inj 20000000unit
1
1
1
penicillin g potassium inj 20mu
1
1
penicillin g sodium inj 5000000unit
1
penicillin v potassium solr 125mg/5ml
1
penicillin v potassium solr 250mg/5ml
1
penicillin v potassium tabs 250mg
1
penicillin v potassium tabs 500mg
2
piperacillin sodium/ tazobactam sodium inj 36gm; 4.5gm
2
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm
2
2
2
2
2
piperacillin/tazobactam inj 2gm; 0.25gm
2
2
2
2
2
2
2
2
Macrolides
AKNE-MYCIN OINT 2%
4
AZASITE SOLN 1%
4
1
azithromycin inj 500mg
1
azithromycin inj 500mg
1
azithromycin pack 1gm
1
azithromycin susr 100mg/5ml
1
azithromycin susr 200mg/5ml
1
azithromycin tabs 250mg
1
1
1
2
clarithromycin er tb24 500mg
2
clarithromycin susr 125mg/5ml
2
clarithromycin susr 250mg/5ml
2
clarithromycin tabs 250mg
2
clarithromycin tabs 500mg
DIFICID TABS 200MG
5
QL (20 EA per 10 days) ST
1
e.e.s. 400 tabs 400mg
15
Drug
Drug Name
E.E.S. GRANULES SUSR 200MG/5ML
3
ERY-TAB TBEC 250MG
3
ERY-TAB TBEC 333MG
3
ERY-TAB TBEC 500MG
3
2
ery pads 2%
ERYPED 200 SUSR 200MG/5ML
3
ERYPED 400 SUSR 400MG/5ML
3
ERYTHROCIN LACTOBIONATE INJ 500MG
4
ERYTHROCIN STEARATE TABS 250MG
3
1
erythromycin base tabs 250mg
1
erythromycin base tabs 500mg
1
erythromycin ethylsuccinate tabs 400mg
1
erythromycin cpep 250mg
1
erythromycin gel 2%
1
erythromycin oint 5mg/gm
2
erythromycin pads 2%
1
erythromycin soln 2%
1
ilotycin oint 5mg/gm
1
romycin oint 5mg/gm
Quinolones
AVELOX INJ 400MG/250ML; 0.8%
4
BESIVANCE SUSP 0.6%
4
CILOXAN OINT 0.3%
4
CIPRO HC SUSP 0.2%; 1%
4
CIPRODEX SUSP 0.3%; 0.1%
4
2
ciprofloxacin er tb24 1000mg; 0
2
ciprofloxacin er tb24 500mg; 0
1
ciprofloxacin hcl soln 0.3%
1
ciprofloxacin hcl tabs 100mg
1
1
1
1
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
2
ciprofloxacin inj 400mg/40ml
2
ciprofloxacin susr 250mg/5ml
2
ciprofloxacin susr 500mg/5ml
2
gatifloxacin soln 0.5%
1
levofloxacin in d5w inj 5%; 500mg/100ml
1
levofloxacin in d5w inj 5%; 750mg/150ml
1
levofloxacin inj 25mg/ml
1
levofloxacin soln 0.5%
1
levofloxacin soln 25mg/ml
1
levofloxacin tabs 250mg
1
1
MOXEZA SOLN 0.5%
4
16
Drug
Drug Name
2
moxifloxacin hcl inj 400mg/250ml
2
moxifloxacin hcl tabs 400mg
1
ofloxacin soln 0.3%
1
ofloxacin soln 0.3%
2
ofloxacin tabs 300mg
2
ofloxacin tabs 400mg
VIGAMOX SOLN 0.5%
4
Sulfonamides
BLEPHAMIDE S.O.P. OINT 0.2%; 10%
4
BLEPHAMIDE SUSP 0.2%; 10%
4
2
sodium sulfacetamide lotn 10%
1
sodium sulfacetamide soln 10%
1
sulfacetamide sodium/prednisolone sodium phosphate soln
0.23%; 10%
1
sulfacetamide sodium oint 10%
1
sulfacetamide sodium soln 10%
2
sulfacetamide sodium susp 10%
1
sulfadiazine tabs 500mg
1
sulfamethoxazole/trimethoprim ds tabs 800mg; 160mg
1
sulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml
sulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5ml 1
1
sulfamethoxazole/trimethoprim tabs 400mg; 80mg
1
sulfatrim pediatric susp 200mg/5ml; 40mg/5ml
Tetracyclines
2
avidoxy tabs 100mg
2
demeclocycline hcl tabs 150mg
2
demeclocycline hcl tabs 300mg
2
doxy 100 inj 100mg
2
doxycycline hyclate dr tbec 100mg
2
2
2
2
doxycycline hyclate caps 100mg
2
doxycycline hyclate caps 50mg
2
doxycycline hyclate inj 100mg
2
doxycycline hyclate tabs 100mg
2
doxycycline hyclate tabs 20mg
2
doxycycline monohydrate caps 100mg
2
doxycycline monohydrate caps 50mg
2
doxycycline monohydrate tabs 100mg
2
2
2
2
2
doxycycline caps 100mg
2
17
Drug
Drug Name
2
2
2
doxycycline susr 25mg/5ml
1
minocycline hcl caps 100mg
1
1
2
mondoxyne nl caps 100mg
2
2
2
morgidox 1x100mg caps 100mg
2
morgidox 2x100mg caps 100mg
2
tetracycline hcl caps 250mg
2
tetracycline hcl caps 500mg
2
tetracycline hydrochloride caps 250mg
2
tetracycline hydrochloride caps 500mg
Anticonvulsants
Anticonvulsants, Other
APTIOM TABS 200MG
4
MO
APTIOM TABS 400MG
4
MO
APTIOM TABS 600MG
4
MO
APTIOM TABS 800MG
4
MO
BRIVIACT INJ 50MG/5ML
4
BRIVIACT SOLN 10MG/ML
4
BRIVIACT TABS 100MG
5
BRIVIACT TABS 10MG
4
BRIVIACT TABS 25MG
5
BRIVIACT TABS 50MG
5
BRIVIACT TABS 75MG
5
FYCOMPA TABS 10MG
4
MO
FYCOMPA TABS 12MG
4
MO
FYCOMPA TABS 2MG
4
MO
FYCOMPA TABS 4MG
4
MO
FYCOMPA TABS 6MG
4
MO
FYCOMPA TABS 8MG
4
MO
2
MO
levetiracetam er tb24 500mg
2
MO
levetiracetam er tb24 750mg
2
levetiracetam inj 1000mg/100ml; 750mg/100ml
2
2
2
levetiracetam inj 500mg/5ml
1
MO
levetiracetam soln 100mg/ml
1
MO
levetiracetam tabs 1000mg
1
MO
1
MO
1
MO
1
MO
phenobarbital elix 20mg/5ml
18
Drug
Drug Name
1
MO
phenobarbital tabs 100mg
1
MO
1
MO
phenobarbital tabs 16.2mg
1
MO
1
MO
1
MO
1
MO
1
MO
POTIGA TABS 200MG
5
POTIGA TABS 300MG
4
MO
POTIGA TABS 400MG
4
MO
POTIGA TABS 50MG
4
MO
1
MO
roweepra tabs 500mg
SPRITAM TB3D 1000MG
4
SPRITAM TB3D 250MG
4
SPRITAM TB3D 500MG
4
SPRITAM TB3D 750MG
4
Calcium Channel Modifying Agents
CELONTIN CAPS 300MG
4
MO
2
MO
ethosuximide caps 250mg
2
MO
ethosuximide soln 250mg/5ml
LYRICA CAPS 100MG
3
MO
LYRICA CAPS 150MG
3
MO
LYRICA CAPS 200MG
3
MO
LYRICA CAPS 225MG
3
MO
LYRICA CAPS 25MG
3
MO
LYRICA CAPS 300MG
3
MO
LYRICA CAPS 50MG
3
MO
LYRICA CAPS 75MG
3
MO
LYRICA SOLN 20MG/ML
3
MO
1
MO
zonisamide caps 100mg
1
MO
1
MO
Gamma-aminobutyric Acid (GABA) Augmenting Agents
2
MO
clonazepam odt tbdp 0.125mg
2
MO
2
MO
2
MO
clonazepam odt tbdp 1mg
2
MO
clonazepam odt tbdp 2mg
1
MO
clonazepam tabs 0.5mg
1
MO
clonazepam tabs 1mg
1
MO
clonazepam tabs 2mg
DIASTAT ACUDIAL GEL 10MG
4
DIASTAT ACUDIAL GEL 20MG
4
DIASTAT PEDIATRIC GEL 2.5MG
4
DIAZEPAM GEL 10MG
4
19
Drug
Drug Name
DIAZEPAM GEL 2.5MG
4
DIAZEPAM GEL 20MG
4
1
MO
divalproex sodium dr tbec 125mg
1
MO
1
MO
1
MO
divalproex sodium er tb24 250mg
1
MO
divalproex sodium er tb24 500mg
1
MO
divalproex sodium csdr 125mg
1
MO
gabapentin caps 100mg
1
MO
1
MO
1
MO
gabapentin soln 250mg/5ml
1
MO
gabapentin tabs 600mg
1
MO
gabapentin tabs 800mg
GABITRIL TABS 12MG
4
MO
GABITRIL TABS 16MG
4
MO
ONFI SUSP 2.5MG/ML
4
MO
ONFI TABS 10MG
4
MO
ONFI TABS 20MG
4
MO
1
MO
primidone tabs 250mg
1
MO
primidone tabs 50mg
SABRIL PACK 500MG
5
SABRIL TABS 500MG
5
STAVZOR CPDR 125MG
4
MO
STAVZOR CPDR 250MG
4
MO
STAVZOR CPDR 500MG
4
MO
2
MO
tiagabine hydrochloride tabs 2mg
2
MO
tiagabine hydrochloride tabs 4mg
1
valproate sodium inj 500mg/5ml
1
MO
valproic acid caps 250mg
1
MO
valproic acid syrp 250mg/5ml
Glutamate Reducing Agents
2
MO
felbamate susp 600mg/5ml
2
MO
felbamate tabs 400mg
2
MO
felbamate tabs 600mg
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 4
KIT 0
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT 4
TAKING VALPROATE KIT 0
LAMICTAL STARTER/TAKING VALPROATE KIT 25MG 4
2
MO
lamotrigine er tb24 100mg
2
MO
2
MO
2
MO
2
MO
2
MO
20
Drug
Drug Name
2
MO
lamotrigine odt tbdp 100mg
2
MO
2
MO
2
MO
1
MO
lamotrigine chew 25mg
1
MO
lamotrigine chew 5mg
1
MO
lamotrigine tabs 100mg
1
MO
1
MO
1
MO
1
MO
topiragen tabs 100mg
1
MO
topiragen tabs 200mg
1
MO
topiragen tabs 25mg
1
MO
topiragen tabs 50mg
1
MO
topiramate cpsp 15mg
1
MO
topiramate cpsp 25mg
1
MO
topiramate tabs 100mg
1
MO
1
MO
1
MO
TROKENDI XR CP24 100MG
4
MO
4
MO
4
MO
4
MO
Sodium Channel Agents
BANZEL SUSP 40MG/ML
5
BANZEL TABS 200MG
4
MO
BANZEL TABS 400MG
5
2
MO
carbamazepine er cp12 100mg
2
MO
2
MO
2
MO
carbamazepine er tb12 100mg
2
MO
2
MO
1
MO
carbamazepine chew 100mg
1
MO
carbamazepine susp 100mg/5ml
1
MO
carbamazepine tabs 200mg
CARBATROL CP12 100MG
4
MO
4
MO
4
MO
CEREBYX INJ 500MG PE/10ML
4
DILANTIN INFATABS CHEW 50MG
4
MO
DILANTIN-125 SUSP 125MG/5ML
4
MO
DILANTIN CAPS 100MG
4
MO
DILANTIN CAPS 30MG
4
MO
1
MO
epitol tabs 200mg
21
Drug
Drug Name
EQUETRO CP12 100MG
4
MO
EQUETRO CP12 200MG
4
MO
EQUETRO CP12 300MG
4
MO
2
fosphenytoin sodium inj 100mg pe/2ml
2
fosphenytoin sodium inj 500mg pe/10ml
1
MO
oxcarbazepine susp 300mg/5ml
1
MO
oxcarbazepine tabs 150mg
1
MO
1
MO
PEGANONE TABS 250MG
4
MO
PHENYTEK CAPS 200MG
4
MO
PHENYTEK CAPS 300MG
4
MO
1
MO
phenytoin infatabs chew 50mg
1
MO
phenytoin sodium extended caps 100mg
1
MO
1
MO
1
MO
phenytoin chew 50mg
1
MO
phenytoin susp 125mg/5ml
TEGRETOL-XR TB12 100MG
4
MO
4
MO
4
MO
TEGRETOL SUSP 100MG/5ML
4
MO
TEGRETOL TABS 200MG
4
MO
VIMPAT INJ 200MG/20ML
4
VIMPAT SOLN 10MG/ML
4
MO
VIMPAT TABS 100MG
4
MO
VIMPAT TABS 150MG
4
MO
VIMPAT TABS 200MG
4
MO
VIMPAT TABS 50MG
4
MO
Antidementia Agents
Antidementia Agents, Other
2
PA MO
ergoloid mesylates tabs 1mg
Cholinesterase Inhibitors
1
MO
donepezil hcl tabs 10mg
1
MO
1
MO
1
MO
donepezil hcl tbdp 10mg
1
MO
donepezil hcl tbdp 5mg
EXELON PT24 13.3MG/24HR
3
MO
3
MO
3
MO
2
MO
galantamine hydrobromide cp24 16mg
2
MO
2
MO
2
MO
galantamine hydrobromide soln 4mg/ml
2
MO
galantamine hydrobromide tabs 12mg
22
Drug
Drug Name
2
MO
2
MO
2
MO
rivastigmine tartrate caps 1.5mg
2
MO
rivastigmine tartrate caps 3mg
2
MO
rivastigmine tartrate caps 4.5mg
2
MO
rivastigmine tartrate caps 6mg
2
MO
rivastigmine transdermal system pt24 13.3mg/24hr
2
MO
2
MO
N-methyl-D-aspartate (NMDA) Receptor Antagonist
2
memantine hcl titration pak tabs 0
2
MO
memantine hcl tabs 10mg
2
MO
memantine hcl tabs 5mg
2
MO
memantine hydrochloride soln 2mg/ml
NAMENDA TITRATION PAK TABS 0
3
NAMENDA XR TITRATION PACK CP24 0
4
NAMENDA XR CP24 14MG
4
4
4
NAMENDA XR CP24 7MG
4
NAMENDA SOLN 10MG/5ML
3
MO
NAMENDA TABS 10MG
3
MO
NAMENDA TABS 5MG
3
MO
Antidepressants
Antidepressants, Other
APLENZIN TB24 174MG
4
QL (30 EA per 30 days) ST MO
APLENZIN TB24 348MG
4
APLENZIN TB24 522MG
4
BRINTELLIX TABS 10MG
4
BRINTELLIX TABS 20MG
4
BRINTELLIX TABS 5MG
4
1
MO
bupropion hcl er tb12 100mg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
bupropion hcl xl tb24 150mg
1
MO
bupropion hcl xl tb24 300mg
1
MO
bupropion hcl tabs 100mg
1
MO
bupropion hcl tabs 75mg
FORFIVO XL TB24 450MG
4
2
MO
maprotiline hcl tabs 25mg
2
MO
2
MO
2
MO
mirtazapine odt tbdp 15mg
23
Drug
Drug Name
2
MO
2
MO
1
MO
mirtazapine tabs 15mg
1
MO
1
MO
1
MO
mirtazapine tabs 7.5mg
2
MO
nefazodone hcl tabs 100mg
2
MO
2
MO
2
MO
2
MO
1
MO
trazodone hcl tabs 100mg
1
MO
2
MO
1
MO
TRINTELLIX TABS 10MG
4
TRINTELLIX TABS 20MG
4
TRINTELLIX TABS 5MG
4
Monoamine Oxidase Inhibitors
EMSAM PT24 12MG/24HR
5
EMSAM PT24 6MG/24HR
4
EMSAM PT24 9MG/24HR
4
MARPLAN TABS 10MG
4
MO
1
MO
phenelzine sulfate tabs 15mg
2
MO
tranylcypromine sulfate tabs 10mg
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
1
MO
citalopram hydrobromide soln 10mg/5ml
1
MO
citalopram hydrobromide tabs 10mg
1
MO
1
MO
DESVENLAFAXINE ER TB24 100MG
4
4
4
4
2
duloxetine hcl cpep 20mg
2
2
1
MO
escitalopram oxalate soln 5mg/5ml
1
MO
escitalopram oxalate tabs 10mg
1
MO
1
MO
FETZIMA TITRATION PACK C4PK 0
4
FETZIMA CP24 120MG
4
FETZIMA CP24 20MG
4
FETZIMA CP24 40MG
4
24
Drug
Drug Name
FETZIMA CP24 80MG
4
1
MO
fluoxetine hcl caps 10mg
1
MO
1
MO
1
MO
fluoxetine hcl soln 20mg/5ml
1
MO
fluoxetine hcl tabs 10mg
2
MO
2
MO
1
fluvoxamine maleate er cp24 100mg
1
fluvoxamine maleate er cp24 150mg
1
MO
fluvoxamine maleate tabs 100mg
1
MO
1
MO
2
olanzapine/fluoxetine caps 25mg; 12mg
2
2
2
2
2
MO
paroxetine hcl er tb24 12.5mg
2
MO
paroxetine hcl er tb24 25mg
2
MO
paroxetine hcl er tb24 37.5mg
1
MO
paroxetine hcl tabs 10mg
1
MO
1
MO
1
MO
PAXIL SUSP 10MG/5ML
4
MO
PEXEVA TABS 10MG
4
PEXEVA TABS 20MG
4
PEXEVA TABS 30MG
4
PEXEVA TABS 40MG
4
PRISTIQ TB24 100MG
4
PRISTIQ TB24 25MG
4
PRISTIQ TB24 50MG
4
1
MO
sertraline hcl conc 20mg/ml
1
MO
sertraline hcl tabs 100mg
1
MO
1
MO
1
MO
venlafaxine hcl er cp24 150mg
1
MO
venlafaxine hcl er cp24 37.5mg
1
MO
venlafaxine hcl er cp24 75mg
2
MO
venlafaxine hcl er tb24 150mg
2
MO
2
MO
venlafaxine hcl er tb24 37.5mg
2
MO
1
MO
venlafaxine hcl tabs 100mg
1
MO
25
Drug
Drug Name
1
MO
venlafaxine hcl tabs 37.5mg
1
MO
1
MO
VIIBRYD STARTER PACK KIT 0
4
VIIBRYD KIT 0
4
VIIBRYD TABS 10MG
4
VIIBRYD TABS 20MG
4
VIIBRYD TABS 40MG
4
Tricyclics
2
PA MO
amitriptyline hcl tabs 100mg
2
PA MO
2
PA MO
2
PA MO
2
PA MO
2
PA MO
1
MO
amoxapine tabs 100mg
1
MO
amoxapine tabs 150mg
1
MO
amoxapine tabs 25mg
1
MO
amoxapine tabs 50mg
2
PA MO
chlordiazepoxide/amitriptyline tabs 12.5mg; 5mg
2
PA MO
chlordiazepoxide/amitriptyline tabs 25mg; 10mg
2
PA MO
clomipramine hcl caps 25mg
2
PA MO
2
PA MO
2
MO
desipramine hcl tabs 100mg
2
MO
2
MO
2
MO
2
MO
2
MO
2
PA MO
doxepin hcl caps 100mg
2
PA MO
2
PA MO
2
PA MO
2
PA MO
2
PA MO
2
PA MO
doxepin hcl conc 10mg/ml
2
PA MO
imipramine hcl tabs 10mg
2
PA MO
2
PA MO
2
PA MO
imipramine pamoate caps 100mg
2
PA MO
2
PA MO
2
PA MO
1
MO
nortriptyline hcl caps 10mg
1
MO
26
Drug
Drug Name
1
MO
1
MO
1
MO
nortriptyline hcl soln 10mg/5ml
2
PA MO
perphenazine/amitriptyline tabs 10mg; 2mg
2
PA MO
2
PA MO
2
PA MO
2
PA MO
2
MO
protriptyline hcl tabs 10mg
2
MO
protriptyline hcl tabs 5mg
SURMONTIL CAPS 100MG
4
MO
SURMONTIL CAPS 25MG
4
MO
SURMONTIL CAPS 50MG
4
MO
2
MO
trimipramine maleate caps 100mg
2
MO
2
MO
Antiemetics
Antiemetics, Other
1
meclizine hcl tabs 12.5mg
1
meclizine hcl tabs 25mg
2
PA
phenadoz supp 12.5mg
2
PA
phenadoz supp 25mg
2
PA
phenergan supp 12.5mg
2
PA
phenergan supp 25mg
2
PA
phenergan supp 50mg
2
PA
promethazine hcl plain syrp 6.25mg/5ml
2
PA
promethazine hcl plain syrp 6.25mg/5ml
2
PA
promethazine hcl inj 25mg/ml
2
PA
promethazine hcl inj 50mg/ml
2
PA
promethazine hcl supp 12.5mg
2
PA
promethazine hcl supp 25mg
2
PA
promethazine hcl supp 50mg
2
PA
promethazine hcl syrp 6.25mg/5ml
2
PA
promethazine hcl tabs 12.5mg
2
PA
promethazine hcl tabs 25mg
2
PA
promethazine hcl tabs 50mg
2
PA
promethegan supp 12.5mg
2
PA
promethegan supp 25mg
2
PA
promethegan supp 50mg
TRANSDERM-SCOP PT72 1MG/3DAYS
4
2
PA
trimethobenzamide hcl caps 300mg
Emetogenic Therapy Adjuncts
ALOXI INJ 0.25MG/5ML
4
5
dronabinol caps 10mg
2
dronabinol caps 2.5mg
2
dronabinol caps 5mg
27
Drug
Drug Name
EMEND CAPS 0
3
QL (6 EA per 30 days) B/D
EMEND CAPS 125MG
3
EMEND CAPS 40MG
3
EMEND CAPS 80MG
3
EMEND INJ 150MG
3
2
granisetron hcl inj 1mg/ml
2
granisetron hcl inj 4mg/4ml
2
granisetron hcl tabs 1mg
2
ondansetron hcl inj 40mg/20ml
2
2
2
QL (450 ML per 30 days) B/D
ondansetron hcl soln 4mg/5ml
2
ondansetron hcl tabs 24mg
2
B/D
2
B/D
2
B/D
ondansetron odt tbdp 4mg
2
B/D
ondansetron odt tbdp 8mg
SANCUSO PTCH 3.1MG/24HR
5
Antifungals
Antifungals
ABELCET INJ 5MG/ML
5
B/D
AMBISOME INJ 50MG
5
B/D
2
B/D
amphotericin b inj 50mg
CANCIDAS INJ 70MG
5
1
ciclodan crea 0.77%
1
ciclodan soln 8%
1
ciclopirox nail lacquer soln 8%
1
ciclopirox olamine crea 0.77%
1
ciclopirox gel 0.77%
1
ciclopirox sham 1%
1
ciclopirox susp 0.77%
1
clotrimazole soln 1%
1
clotrimazole troc 10mg
CRESEMBA CAPS 186MG
5
CRESEMBA INJ 372MG
5
1
econazole nitrate crea 1%
EXELDERM CREA 1%
4
ST
EXELDERM SOLN 1%
4
ST
2
fluconazole in dextrose inj 56mg/ml; 200mg/100ml
1
fluconazole in dextrose inj 56mg/ml; 400mg/200ml
2
fluconazole in nacl inj 200mg/100ml; 0.9%
1
fluconazole susr 10mg/ml
1
fluconazole susr 40mg/ml
1
fluconazole tabs 100mg
1
1
28
Drug
Drug Name
1
2
flucytosine caps 250mg
2
flucytosine caps 500mg
2
griseofulvin microsize susp 125mg/5ml
2
griseofulvin microsize tabs 500mg
2
griseofulvin ultramicrosize tabs 125mg
2
griseofulvin ultramicrosize tabs 250mg
2
PA
itraconazole caps 100mg
1
ketoconazole crea 2%
2
ketoconazole foam 2%
1
ketoconazole sham 2%
1
ketoconazole tabs 200mg
2
ketodan foam 2%
MENTAX CREA 1%
4
ST
1
miconazole 3 supp 200mg
MYCAMINE INJ 100MG
5
MYCAMINE INJ 50MG
4
2
naftifine hcl crea 1%
2
naftifine hydrochloride crea 2%
NAFTIN CREA 2%
4
ST
NAFTIN GEL 1%
4
ST
NAFTIN GEL 2%
3
ST
NATACYN SUSP 5%
4
NOXAFIL INJ 300MG/16.7ML
5
PA
NOXAFIL SUSP 40MG/ML
5
PA
NOXAFIL TBEC 100MG
5
PA
1
nyamyc powd 100000unit/gm
2
nystatin/triamcinolone crea 100000unit/gm; 0.1%
2
nystatin/triamcinolone oint 100000unit/gm; 0.1%
1
nystatin crea 100000unit/gm
1
nystatin oint 100000unit/gm
1
nystatin powd 100000unit/gm
1
nystatin susp 100000unit/ml
1
nystatin tabs 500000unit
1
nystop powd 100000unit/gm
ONMEL TABS 200MG
4
PA
2
oxiconazole nitrate crea 1%
OXISTAT CREA 1%
4
ST
OXISTAT LOTN 1%
4
ST
1
pedi-dri powd 100000unit/gm
SPORANOX SOLN 10MG/ML
5
PA
1
terbinafine hcl tabs 250mg
1
terconazole crea 0.4%
1
terconazole crea 0.8%
2
terconazole supp 80mg
2
voriconazole inj 200mg
29
Drug
Drug Name
5
voriconazole susr 40mg/ml
5
voriconazole tabs 200mg
5
voriconazole tabs 50mg
1
zazole crea 0.4%
1
zazole crea 0.8%
2
zazole supp 80mg
Antigout Agents
Antigout Agents
1
MO
allopurinol tabs 100mg
1
MO
allopurinol tabs 300mg
2
colchicine tabs 0.6mg
1
MO
probenecid/colchicine tabs 0.5mg; 500mg
1
MO
probenecid tabs 500mg
ULORIC TABS 40MG
4
ST MO
ULORIC TABS 80MG
4
ST MO
Antimigraine Agents
Ergot Alkaloids
2
dihydroergotamine mesylate inj 1mg/ml
5
dihydroergotamine mesylate soln 4mg/ml
MIGERGOT SUPP 100MG; 2MG
4
Serotonin (5-HT) 1b/1d Receptor Agonists
2
almotriptan malate tabs 12.5mg
2
almotriptan malate tabs 6.25mg
2
almotriptan tabs 12.5mg
2
almotriptan tabs 6.25mg
AXERT TABS 12.5MG
4
AXERT TABS 6.25MG
4
FROVA TABS 2.5MG
4
2
frovatriptan succinate tabs 2.5mg
1
naratriptan hcl tabs 1mg
1
naratriptan hcl tabs 2.5mg
RELPAX TABS 20MG
4
RELPAX TABS 40MG
4
2
rizatriptan benzoate odt tbdp 10mg
2
rizatriptan benzoate odt tbdp 5mg
2
rizatriptan benzoate tabs 10mg
2
rizatriptan benzoate tabs 5mg
2
sumatriptan succinate refill inj 4mg/0.5ml
2
sumatriptan succinate refill inj 6mg/0.5ml
2
sumatriptan succinate inj 4mg/0.5ml
2
2
2
2
1
sumatriptan succinate tabs 100mg
1
30
Drug
Drug Name
1
2
sumatriptan soln 20mg/act
2
sumatriptan soln 5mg/act
2
zolmitriptan odt tbdp 2.5mg
2
zolmitriptan odt tbdp 5mg
2
zolmitriptan tabs 2.5mg
2
zolmitriptan tabs 5mg
ZOMIG NASAL SPRAY SOLN 5MG
4
ZOMIG SOLN 2.5MG
4
Antimyasthenic Agents
Parasympathomimetics
1
guanidine hcl tabs 125mg
MESTINON TIMESPAN TBCR 180MG
4
MESTINON SYRP 60MG/5ML
4
1
pyridostigmine bromide tabs 60mg
2
pyridostigmine bromide tbcr 180mg
Antimycobacterials
Antimycobacterials, Other
2
MO
dapsone tabs 100mg
2
MO
dapsone tabs 25mg
2
rifabutin caps 150mg
Antituberculars
CAPASTAT SULFATE INJ 1GM
4
1
ethambutol hcl tabs 100mg
1
ethambutol hcl tabs 400mg
1
MO
isoniazid tabs 100mg
1
MO
isoniazid tabs 300mg
2
paser pack 4gm
PRIFTIN TABS 150MG
4
1
pyrazinamide tabs 500mg
1
rifampin caps 150mg
1
rifampin caps 300mg
1
rifampin inj 600mg
RIFATER TABS 50MG; 300MG; 120MG
4
SIRTURO TABS 100MG
5
TRECATOR TABS 250MG
4
Antineoplastics
Alkylating Agents
2
B/D
cyclophosphamide caps 25mg
2
B/D
cyclophosphamide caps 50mg
2
B/D
cyclophosphamide tabs 25mg
2
B/D
cyclophosphamide tabs 50mg
GLEOSTINE CAPS 100MG
4
GLEOSTINE CAPS 10MG
4
GLEOSTINE CAPS 40MG
4
GLEOSTINE CAPS 5MG
4
31
Drug
Drug Name
HEXALEN CAPS 50MG
5
PA
LEUKERAN TABS 2MG
4
1
lomustine caps 100mg
1
lomustine caps 10mg
1
lomustine caps 40mg
MATULANE CAPS 50MG
5
MUSTARGEN INJ 10MG
4
2
thiotepa inj 15mg
TREANDA INJ 100MG
5
TREANDA INJ 180MG/2ML
5
TREANDA INJ 45MG/0.5ML
5
VALCHLOR GEL 0.016%
5
PA
Antiandrogens
1
bicalutamide tabs 50mg
1
flutamide caps 125mg
NILANDRON TABS 150MG
5
XTANDI CAPS 40MG
5
PA
ZYTIGA TABS 250MG
5
PA
Antiangiogenic Agents
CAPRELSA TABS 100MG
5
CAPRELSA TABS 300MG
5
PA
REVLIMID CAPS 10MG
5
PA
REVLIMID CAPS 15MG
5
PA
REVLIMID CAPS 2.5MG
5
PA
REVLIMID CAPS 20MG
5
PA
REVLIMID CAPS 25MG
5
PA
REVLIMID CAPS 5MG
5
PA
THALOMID CAPS 100MG
5
PA
THALOMID CAPS 150MG
5
PA
THALOMID CAPS 200MG
5
PA
THALOMID CAPS 50MG
5
PA
Antiestrogens/Modifiers
EMCYT CAPS 140MG
4
FARESTON TABS 60MG
5
FASLODEX INJ 250MG/5ML
5
SOLTAMOX SOLN 10MG/5ML
4
MO
1
MO
tamoxifen citrate tabs 10mg
1
MO
tamoxifen citrate tabs 20mg
Antimetabolites
2
B/D
adrucil inj 2.5gm/50ml
2
B/D
adrucil inj 2.5gm/50ml
2
B/D
adrucil inj 500mg/10ml
2
B/D
adrucil inj 5gm/100ml
2
B/D
cytarabine aqueous inj 100mg/ml
2
B/D
cytarabine aqueous inj 20mg/ml
2
B/D
cytarabine inj 100mg/ml
32
Drug
Drug Name
2
B/D
2
B/D
DROXIA CAPS 200MG
4
MO
DROXIA CAPS 300MG
4
MO
DROXIA CAPS 400MG
4
MO
ELITEK INJ 7.5MG
5
2
B/D
fluorouracil inj 2.5gm/50ml
2
B/D
fluorouracil inj 500mg/10ml
5
gemcitabine hcl inj 1gm
1
hydroxyurea caps 500mg
LONSURF TABS 6.14MG; 15MG
5
PA
LONSURF TABS 8.19MG; 20MG
5
PA
1
mercaptopurine tabs 50mg
PURIXAN SUSP 2000MG/100ML
5
TABLOID TABS 40MG
4
Antineoplastics, Other
2
B/D
adriamycin inj 10mg
2
B/D
adriamycin inj 2mg/ml
2
B/D
adriamycin inj 50mg
ALIMTA INJ 500MG
5
5
amifostine inj 500mg
ARRANON INJ 5MG/ML
5
AZACITIDINE INJ 100MG
5
PA
BELEODAQ INJ 500MG
5
PA
2
carboplatin inj 150mg/15ml
COMETRIQ KIT 0
5
PA
COMETRIQ KIT 0
5
PA
COMETRIQ KIT 20MG
5
PA
COTELLIC TABS 20MG
5
PA
DAUNOXOME INJ 2MG/ML
4
5
PA
decitabine inj 50mg
5
dexrazoxane inj 250mg
5
dexrazoxane inj 500mg
DOCETAXEL INJ 200MG/20ML
5
5
docetaxel inj 80mg/4ml
DOCETAXEL INJ 80MG/8ML
5
DOXIL INJ 2MG/ML
5
B/D
5
B/D
doxorubicin hcl liposome inj 2mg/ml
2
B/D
doxorubicin hcl inj 10mg
2
B/D
doxorubicin hcl inj 2mg/ml
2
B/D
doxorubicin hcl inj 50mg
ERIVEDGE CAPS 150MG
5
PA
ERWINAZE INJ 10000UNIT
5
PA
GILOTRIF TABS 20MG
5
PA
GILOTRIF TABS 30MG
5
PA
GILOTRIF TABS 40MG
5
PA
33
Drug
Drug Name
IBRANCE CAPS 100MG
5
PA
IBRANCE CAPS 125MG
5
PA
IBRANCE CAPS 75MG
5
PA
2
irinotecan hcl inj 100mg/5ml
2
irinotecan inj 100mg/5ml
IXEMPRA KIT INJ 45MG
5
PA
JAKAFI TABS 10MG
5
PA
JAKAFI TABS 15MG
5
PA
JAKAFI TABS 20MG
5
PA
JAKAFI TABS 25MG
5
PA
JAKAFI TABS 5MG
5
PA
JEVTANA INJ 60MG/1.5ML
5
PA
1
leucovorin calcium inj 100mg
1
leucovorin calcium inj 350mg
1
leucovorin calcium tabs 10mg
1
1
1
5
levoleucovorin calcium inj 175mg/17.5ml
5
levoleucovorin inj 175mg/17.5ml
5
B/D
lipodox 50 inj 2mg/ml
5
B/D
lipodox inj 2mg/ml
LYNPARZA CAPS 50MG
5
PA
MEKINIST TABS 0.5MG
5
PA
MEKINIST TABS 2MG
5
PA
MENEST TABS 0.3MG
4
PA MO
MENEST TABS 0.625MG
4
PA MO
MENEST TABS 1.25MG
4
PA MO
MENEST TABS 2.5MG
4
PA MO
2
mesna inj 100mg/ml
MESNEX TABS 400MG
5
2
mitomycin inj 20mg
1
PA
mitoxantrone hcl inj 2mg/ml
NINLARO CAPS 2.3MG
5
NINLARO CAPS 3MG
5
NINLARO CAPS 4MG
5
ODOMZO CAPS 200MG
5
PA
ONCASPAR INJ 750UNIT/ML
5
5
oxaliplatin inj 100mg/20ml
5
oxaliplatin inj 100mg
2
paclitaxel inj 300mg/50ml
POMALYST CAPS 1MG
5
PA
POMALYST CAPS 2MG
5
PA
POMALYST CAPS 3MG
5
PA
POMALYST CAPS 4MG
5
PA
PROLEUKIN INJ 22000000UNIT
5
34
Drug
Drug Name
SYLATRON INJ 200MCG
5
PA
SYLATRON INJ 300MCG
5
PA
SYLATRON INJ 600MCG
5
PA
SYNRIBO INJ 3.5MG
5
PA
TAGRISSO TABS 40MG
5
TAGRISSO TABS 80MG
5
VELCADE INJ 3.5MG
5
PA
VENCLEXTA STARTING PACK TBPK 0
5
PA
VENCLEXTA TABS 100MG
5
VENCLEXTA TABS 10MG
4
VENCLEXTA TABS 50MG
4
2
B/D
vincasar pfs inj 1mg/ml
2
B/D
vincristine sulfate inj 1mg/ml
ZALTRAP INJ 100MG/4ML
5
PA
ZOLINZA CAPS 100MG
5
PA
Antineoplastics
FARYDAK CAPS 10MG
5
FARYDAK CAPS 15MG
5
FARYDAK CAPS 20MG
5
ZYKADIA CAPS 150MG
5
PA
Aromatase Inhibitors, 3rd Generation
1
MO
anastrozole tabs 1mg
2
MO
exemestane tabs 25mg
1
MO
letrozole tabs 2.5mg
Enzyme Inhibitors
2
etoposide inj 100mg/5ml
2
2
2
etoposide inj 1gm/50ml
2
2
toposar inj 100mg/5ml
2
toposar inj 1gm/50ml
2
toposar inj 500mg/25ml
5
topotecan hcl inj 4mg
ZYDELIG TABS 100MG
5
PA
ZYDELIG TABS 150MG
5
PA
Molecular Target Inhibitors
AFINITOR DISPERZ TBSO 2MG
5
PA
5
PA
5
PA
AFINITOR TABS 10MG
5
PA
AFINITOR TABS 2.5MG
5
PA
AFINITOR TABS 5MG
5
PA
AFINITOR TABS 7.5MG
5
PA
ALECENSA CAPS 150MG
5
BOSULIF TABS 100MG
5
PA
35
Drug
Drug Name
BOSULIF TABS 500MG
5
PA
CABOMETYX TABS 20MG
5
PA
CABOMETYX TABS 40MG
5
PA
CABOMETYX TABS 60MG
5
PA
GLEEVEC TABS 100MG
5
PA
GLEEVEC TABS 400MG
5
PA
ICLUSIG TABS 15MG
5
ICLUSIG TABS 45MG
5
PA
5
PA
imatinib mesylate tabs 100mg
5
PA
imatinib mesylate tabs 400mg
IMBRUVICA CAPS 140MG
5
PA
INLYTA TABS 1MG
5
PA
INLYTA TABS 5MG
5
PA
IRESSA TABS 250MG
5
PA
LENVIMA 10MG DAILY DOSE CPPK 10MG
5
PA
LENVIMA 14MG DAILY DOSE CPPK 0
5
PA
5
PA
5
PA
5
PA
5
PA
NEXAVAR TABS 200MG
5
PA
SPRYCEL TABS 100MG
5
PA
SPRYCEL TABS 140MG
5
PA
SPRYCEL TABS 20MG
5
PA
SPRYCEL TABS 50MG
5
PA
SPRYCEL TABS 70MG
5
PA
SPRYCEL TABS 80MG
5
PA
STIVARGA TABS 40MG
5
PA
SUTENT CAPS 12.5MG
5
PA
SUTENT CAPS 25MG
5
PA
SUTENT CAPS 37.5MG
5
PA
SUTENT CAPS 50MG
5
PA
TAFINLAR CAPS 50MG
5
PA
TAFINLAR CAPS 75MG
5
PA
TARCEVA TABS 100MG
5
PA
TARCEVA TABS 150MG
5
PA
TARCEVA TABS 25MG
5
PA
TASIGNA CAPS 150MG
5
PA
TASIGNA CAPS 200MG
5
PA
TYKERB TABS 250MG
5
PA
VOTRIENT TABS 200MG
5
PA
XALKORI CAPS 200MG
5
PA
XALKORI CAPS 250MG
5
PA
ZELBORAF TABS 240MG
5
PA
Monoclonal Antibodies
ARZERRA INJ 1000MG/50ML
5
PA
36
Drug
Drug Name
ARZERRA INJ 100MG/5ML
5
PA
AVASTIN INJ 100MG/4ML
5
PA
AVASTIN INJ 400MG/16ML
5
PA
CYRAMZA INJ 100MG/10ML
5
PA
CYRAMZA INJ 500MG/50ML
5
PA
DARZALEX INJ 100MG/5ML
5
PA
EMPLICITI INJ 300MG
5
PA
EMPLICITI INJ 400MG
5
PA
ERBITUX INJ 100MG/50ML
5
PA
HERCEPTIN INJ 440MG
5
PA
KADCYLA INJ 100MG
5
PA
KEYTRUDA INJ 100MG/4ML
5
PA
KEYTRUDA INJ 50MG
5
PA
OPDIVO INJ 100MG/10ML
5
PA
OPDIVO INJ 40MG/4ML
5
PA
PERJETA INJ 420MG/14ML
5
PA
RITUXAN INJ 500MG/50ML
5
PA
SYLVANT INJ 100MG
5
PA
SYLVANT INJ 400MG
5
PA
TECENTRIQ INJ 1200MG/20ML
5
PA
VECTIBIX INJ 100MG/5ML
5
PA
YERVOY INJ 50MG/10ML
5
PA
Retinoids
5
PA
bexarotene caps 75mg
PANRETIN GEL 0.1%
5
TARGRETIN CAPS 75MG
5
PA
TARGRETIN GEL 1%
5
PA
5
tretinoin caps 10mg
Antiparasitics
Anthelmintics
ALBENZA TABS 200MG
3
BILTRICIDE TABS 600MG
3
2
ivermectin tabs 3mg
Antiprotozoals
ALINIA TABS 500MG
4
2
atovaquone/proguanil hcl tabs 250mg; 100mg
2
atovaquone/proguanil hcl tabs 62.5mg; 25mg
5
atovaquone susp 750mg/5ml
1
MO
chloroquine phosphate tabs 250mg
1
MO
chloroquine phosphate tabs 500mg
COARTEM TABS 20MG; 120MG
4
DARAPRIM TABS 25MG
4
1
MO
hydroxychloroquine sulfate tabs 200mg
2
MO
mefloquine hcl tabs 250mg
NEBUPENT SOLR 300MG
4
B/D
PENTAM 300 INJ 300MG
4
37
Drug
Drug Name
PRIMAQUINE PHOSPHATE TABS 26.3MG
4
2
PA
quinine sulfate caps 324mg
2
tinidazole tabs 250mg
2
tinidazole tabs 500mg
Pediculicides/Scabicides
EURAX CREA 10%
4
EURAX LOTN 10%
4
2
lindane lotn 1%
2
lindane sham 1%
2
malathion lotn 0.5%
1
permethrin crea 5%
SKLICE LOTN 0.5%
4
Antiparkinson Agents
Anticholinergics
2
benztropine mesylate inj 1mg/ml
2
PA MO
benztropine mesylate tabs 0.5mg
2
PA MO
benztropine mesylate tabs 1mg
2
PA MO
benztropine mesylate tabs 2mg
2
PA MO
trihexyphenidyl hcl tabs 2mg
2
PA MO
trihexyphenidyl hcl tabs 5mg
Antiparkinson Agents, Other
2
MO
entacapone tabs 200mg
NEUPRO PT24 1MG/24HR
4
ST MO
4
ST MO
4
ST MO
4
ST MO
4
ST MO
4
ST MO
5
tolcapone tabs 100mg
Dopamine Agonists
APOKYN INJ 10MG/ML
5
PA
2
MO
bromocriptine mesylate caps 5mg
2
MO
bromocriptine mesylate tabs 2.5mg
MIRAPEX ER TB24 0.375MG
4
MO
4
MO
4
MO
MIRAPEX ER TB24 3MG
4
MO
4
MO
2
MO
pramipexole dihydrochloride er tb24 0.375mg
2
MO
2
MO
2
MO
2
MO
pramipexole dihydrochloride er tb24 3mg
2
MO
1
MO
pramipexole dihydrochloride tabs 0.125mg
1
MO
38
Drug
Drug Name
1
MO
1
MO
1
MO
1
MO
pramipexole dihydrochloride tabs 1mg
2
MO
ropinirole er tb24 12mg
2
MO
2
MO
2
MO
2
MO
1
MO
ropinirole hcl tabs 0.25mg
1
MO
ropinirole hcl tabs 0.5mg
1
MO
ropinirole hcl tabs 1mg
1
MO
1
MO
1
MO
1
MO
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
1
MO
carbidopa/levodopa er tbcr 25mg; 100mg
1
MO
carbidopa/levodopa er tbcr 50mg; 200mg
MO
carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg 2
MO
MO
carbidopa/levodopa/entacapone tabs 25mg; 200mg; 100mg 2
2
MO
carbidopa/levodopa/entacapone tabs 31.25mg; 200mg;
125mg
MO
MO
carbidopa/levodopa/entacapone tabs 50mg; 200mg; 200mg 2
1
MO
carbidopa/levodopa tabs 10mg; 100mg
1
MO
1
MO
2
MO
carbidopa tabs 25mg
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TABS 0.5MG
4
MO
AZILECT TABS 1MG
4
MO
2
MO
selegiline hcl caps 5mg
2
MO
selegiline hcl tabs 5mg
ZELAPAR TBDP 1.25MG
4
MO
Antipsychotics
1st Generation/Typical
1
chlorpromazine hcl inj 50mg/2ml
1
MO
chlorpromazine hcl tabs 100mg
1
MO
1
MO
1
MO
1
MO
1
compazine supp 25mg
1
compro supp 25mg
39
Drug
Drug Name
1
fluphenazine decanoate inj 25mg/ml
1
MO
fluphenazine hcl elix 2.5mg/5ml
1
fluphenazine hcl inj 2.5mg/ml
1
MO
fluphenazine hcl tabs 10mg
1
MO
1
MO
fluphenazine hcl tabs 2.5mg
1
MO
1
haloperidol decanoate inj 100mg/ml
1
haloperidol decanoate inj 50mg/ml
1
haloperidol lactate inj 5mg/ml
1
MO
haloperidol conc 2mg/ml
1
MO
haloperidol tabs 0.5mg
1
MO
haloperidol tabs 10mg
1
MO
1
MO
1
MO
1
MO
2
MO
loxapine succinate caps 10mg
2
MO
2
MO
2
MO
2
MO
loxapine caps 10mg
2
MO
loxapine caps 25mg
2
MO
loxapine caps 50mg
2
MO
loxapine caps 5mg
ORAP TABS 1MG
3
MO
ORAP TABS 2MG
3
MO
1
MO
perphenazine tabs 16mg
1
MO
1
MO
1
MO
2
MO
pimozide tabs 1mg
2
MO
pimozide tabs 2mg
1
prochlorperazine edisylate inj 5mg/ml
1
MO
prochlorperazine maleate tabs 10mg
1
MO
prochlorperazine maleate tabs 5mg
1
prochlorperazine supp 25mg
2
PA MO
thioridazine hcl tabs 100mg
2
PA MO
2
PA MO
2
PA MO
1
MO
thiothixene caps 10mg
1
MO
1
MO
1
MO
1
MO
trifluoperazine hcl tabs 10mg
40
Drug
Drug Name
1
MO
1
MO
1
MO
2nd Generation/Atypical
ABILIFY DISCMELT TBDP 10MG
5
ABILIFY DISCMELT TBDP 15MG
5
ABILIFY MAINTENA INJ 300MG
5
ST
5
ST
5
ST
ABILIFY INJ 9.75MG/1.3ML
4
ABILIFY SOLN 1MG/ML
4
QL (900 ML per 30 days) ST MO
5
aripiprazole odt tbdp 10mg
5
aripiprazole odt tbdp 15mg
2
QL (900 ML per 30 days) MO
aripiprazole soln 1mg/ml
2
aripiprazole tabs 10mg
2
2
2
2
2
FANAPT TABS 10MG
5
FANAPT TABS 12MG
5
FANAPT TABS 1MG
4
FANAPT TABS 2MG
4
FANAPT TABS 4MG
4
FANAPT TABS 6MG
5
FANAPT TABS 8MG
5
GEODON INJ 20MG
4
INVEGA SUSTENNA INJ 117MG/0.75ML
5
INVEGA SUSTENNA INJ 156MG/ML
5
5
4
5
INVEGA TRINZA INJ 273MG/0.875ML
5
5
5
5
INVEGA TB24 1.5MG
5
INVEGA TB24 3MG
5
INVEGA TB24 6MG
5
INVEGA TB24 9MG
5
LATUDA TABS 120MG
4
LATUDA TABS 20MG
4
LATUDA TABS 40MG
4
LATUDA TABS 60MG
4
LATUDA TABS 80MG
4
41
Drug
Drug Name
NUPLAZID TABS 17MG
5
2
olanzapine odt tbdp 10mg
2
2
2
2
olanzapine inj 10mg
1
olanzapine tabs 10mg
1
1
olanzapine tabs 2.5mg
1
1
olanzapine tabs 5mg
1
olanzapine tabs 7.5mg
5
paliperidone er tb24 1.5mg
5
paliperidone er tb24 3mg
5
5
1
quetiapine fumarate tabs 100mg
1
1
1
1
1
REXULTI TABS 0.25MG
5
REXULTI TABS 0.5MG
5
REXULTI TABS 1MG
5
REXULTI TABS 2MG
5
REXULTI TABS 3MG
5
REXULTI TABS 4MG
5
RISPERDAL CONSTA INJ 12.5MG
4
RISPERDAL CONSTA INJ 25MG
4
RISPERDAL CONSTA INJ 37.5MG
5
RISPERDAL CONSTA INJ 50MG
5
2
risperidone m-tab tbdp 0.5mg
2
risperidone m-tab tbdp 1mg
2
2
2
2
risperidone odt tbdp 0.25mg
2
risperidone odt tbdp 0.5mg
2
risperidone odt tbdp 1mg
2
2
2
1
risperidone soln 1mg/ml
1
risperidone tabs 0.25mg
1
risperidone tabs 0.5mg
42
Drug
Drug Name
1
risperidone tabs 1mg
1
1
1
SAPHRIS SUBL 10MG
4
SAPHRIS SUBL 2.5MG
4
SAPHRIS SUBL 5MG
4
SEROQUEL XR TB24 150MG
4
4
4
4
4
VRAYLAR CAPS 1.5MG
5
VRAYLAR CAPS 3MG
5
VRAYLAR CAPS 4.5MG
5
VRAYLAR CAPS 6MG
5
VRAYLAR CPPK 0
4
2
ziprasidone hcl caps 20mg
2
2
2
ZYPREXA RELPREVV INJ 210MG
4
5
5
5
5
Antipsychotics
2
MO
molindone hydrochloride tabs 10mg
2
MO
2
MO
Treatment-Resistant
2
clozapine odt tbdp 100mg
2
clozapine odt tbdp 12.5mg
2
2
2
2
clozapine tabs 100mg
2
clozapine tabs 200mg
2
clozapine tabs 25mg
2
clozapine tabs 50mg
VERSACLOZ SUSP 50MG/ML
5
QL (540 ML per 30 days) ST
Antispasticity Agents
Antispasticity Agents
1
MO
baclofen tabs 10mg
1
MO
baclofen tabs 20mg
2
dantrolene sodium caps 100mg
43
Drug
Drug Name
2
2
2
MO
tizanidine hcl caps 2mg
2
MO
2
MO
1
MO
tizanidine hcl tabs 2mg
1
MO
tizanidine hcl tabs 4mg
Antivirals
Anti-cytomegalovirus (CMV) Agents
5
cidofovir inj 75mg/ml
2
B/D
foscavir inj 6000mg/250ml
2
B/D
ganciclovir inj 500mg
5
valganciclovir tabs 450mg
ZIRGAN GEL 0.15%
4
Anti-hepatitis B (HBV) Agents
5
adefovir dipivoxil tabs 10mg
BARACLUDE SOLN 0.05MG/ML
4
QL (630 ML per 30 days) PA MO
5
entecavir tabs 0.5mg
5
entecavir tabs 1mg
INTRON A W/DILUENT INJ 10MU
5
PA
5
PA
5
PA
INTRON A INJ 10MU
5
PA
INTRON A INJ 18MU
5
PA
INTRON A INJ 50MU
5
PA
INTRON A INJ 6000000UNIT/ML
5
PA
TYZEKA TABS 600MG
5
Anti-hepatitis C (HCV) Agents
DAKLINZA TABS 30MG
5
DAKLINZA TABS 60MG
5
HARVONI TABS 90MG; 400MG
5
INCIVEK TABS 375MG
5
MODERIBA 1200 DOSE PACK TABS 600MG
5
MODERIBA 800 DOSE PACK TABS 400MG
5
2
moderiba tabs 200mg
OLYSIO CAPS 150MG
5
PA
PEG-INTRON REDIPEN PAK 4 INJ 120MCG/0.5ML
5
PA
5
PA
5
PA
5
PA
PEG-INTRON REDIPEN INJ 120MCG/0.5ML
5
PA
5
PA
5
PA
5
PA
PEGASYS PROCLICK INJ 135MCG/0.5ML
5
PA
PEGASYS PROCLICK INJ 180MCG/0.5ML
5
PA
44
Drug
Drug Name
PEGASYS INJ 180MCG/0.5ML
5
PA
PEGASYS INJ 180MCG/ML
5
PA
PEGINTRON INJ 120MCG/0.5ML
5
PA
5
PA
5
PA
5
PA
RIBASPHERE RIBAPAK TABS 400MG
5
RIBASPHERE RIBAPAK TABS 600MG
5
2
ribasphere caps 200mg
2
ribasphere tabs 200mg
RIBASPHERE TABS 400MG
4
RIBASPHERE TABS 600MG
5
RIBATAB TABS 400MG
5
2
ribavirin caps 200mg
2
ribavirin tabs 200mg
SOVALDI TABS 400MG
5
PA
TECHNIVIE TABS 12.5MG; 75MG; 50MG
5
VICTRELIS CAPS 200MG
5
VIEKIRA PAK TBPK 250MG; 12.5MG; 75MG; 50MG
5
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ATRIPLA TABS 600MG; 200MG; 300MG
5
GENVOYA TABS 150MG; 150MG; 200MG; 10MG
5
ISENTRESS CHEW 100MG
3
MO
ISENTRESS CHEW 25MG
3
MO
ISENTRESS PACK 100MG
3
MO
ISENTRESS TABS 400MG
5
TIVICAY TABS 50MG
5
VITEKTA TABS 150MG
5
VITEKTA TABS 85MG
5
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA TABS 200MG; 25MG; 300MG
5
EDURANT TABS 25MG
5
INTELENCE TABS 100MG
5
INTELENCE TABS 200MG
5
INTELENCE TABS 25MG
4
MO
2
MO
nevirapine er tb24 100mg
2
MO
nevirapine er tb24 400mg
2
MO
nevirapine susp 50mg/5ml
2
MO
nevirapine tabs 200mg
ODEFSEY TABS 200MG; 25MG; 25MG
5
RESCRIPTOR TABS 100MG
4
MO
RESCRIPTOR TABS 200MG
3
MO
STRIBILD TABS 150MG; 150MG; 200MG; 300MG
5
SUSTIVA CAPS 200MG
4
MO
SUSTIVA CAPS 50MG
4
MO
45
Drug
Drug Name
SUSTIVA TABS 600MG
4
MO
VIRAMUNE XR TB24 100MG
4
MO
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir sulfate/lamivudine/zidovudine tabs 300mg; 150mg; 5
300mg
2
MO
abacavir tabs 300mg
DESCOVY TABS 200MG; 25MG
5
2
MO
didanosine cpdr 125mg
2
MO
2
MO
2
MO
EMTRIVA CAPS 200MG
4
MO
EMTRIVA SOLN 10MG/ML
4
MO
EPZICOM TABS 600MG; 300MG
5
5
lamivudine/zidovudine tabs 150mg; 300mg
2
MO
lamivudine soln 10mg/ml
2
MO
lamivudine tabs 100mg
2
MO
2
MO
RETROVIR IV INFUSION INJ 10MG/ML
4
2
MO
stavudine caps 15mg
2
MO
stavudine caps 20mg
2
MO
stavudine caps 30mg
2
MO
stavudine caps 40mg
2
MO
stavudine solr 1mg/ml
TRIUMEQ TABS 600MG; 50MG; 300MG
5
TRUVADA TABS 100MG; 150MG
5
5
5
5
VIDEX PEDIATRIC SOLR 2GM
4
MO
VIDEX PEDIATRIC SOLR 4GM
4
MO
VIREAD POWD 40MG/GM
5
VIREAD TABS 150MG
5
VIREAD TABS 200MG
5
VIREAD TABS 250MG
5
VIREAD TABS 300MG
5
ZIAGEN SOLN 20MG/ML
4
MO
2
MO
zidovudine caps 100mg
2
MO
zidovudine syrp 50mg/5ml
2
MO
zidovudine tabs 300mg
Anti-HIV Agents, Other
FUZEON INJ 90MG
5
SELZENTRY TABS 150MG
5
SELZENTRY TABS 300MG
5
46
Drug
Drug Name
TYBOST TABS 150MG
3
MO
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAPS 250MG
5
APTIVUS SOLN 100MG/ML
5
CRIXIVAN CAPS 200MG
3
MO
CRIXIVAN CAPS 400MG
3
MO
EVOTAZ TABS 300MG; 150MG
5
INVIRASE CAPS 200MG
5
INVIRASE TABS 500MG
5
KALETRA SOLN 400MG/5ML; 100MG/5ML
5
KALETRA TABS 100MG; 25MG
4
MO
KALETRA TABS 200MG; 50MG
5
LEXIVA SUSP 50MG/ML
4
MO
LEXIVA TABS 700MG
5
NORVIR CAPS 100MG
4
MO
NORVIR SOLN 80MG/ML
4
MO
NORVIR TABS 100MG
4
MO
PREZCOBIX TABS 150MG; 800MG
5
PREZISTA SUSP 100MG/ML
5
PREZISTA TABS 150MG
4
MO
PREZISTA TABS 600MG
5
PREZISTA TABS 75MG
4
MO
PREZISTA TABS 800MG
5
REYATAZ CAPS 150MG
5
REYATAZ CAPS 200MG
5
REYATAZ CAPS 300MG
5
REYATAZ PACK 50MG
5
VIRACEPT TABS 250MG
5
VIRACEPT TABS 625MG
5
Anti-influenza Agents
1
MO
amantadine hcl caps 100mg
1
MO
amantadine hcl syrp 50mg/5ml
1
MO
amantadine hcl tabs 100mg
RELENZA DISKHALER AEPB 5MG/BLISTER
4
2
rimantadine hcl tabs 100mg
TAMIFLU CAPS 30MG
4
TAMIFLU CAPS 45MG
4
TAMIFLU CAPS 75MG
4
Antiherpetic Agents
1
B/D
acyclovir sodium inj 50mg/ml
1
acyclovir caps 200mg
2
acyclovir oint 5%
1
acyclovir susp 200mg/5ml
1
acyclovir tabs 400mg
1
acyclovir tabs 800mg
DENAVIR CREA 1%
4
47
Drug
Drug Name
2
famciclovir tabs 125mg
2
2
2
trifluridine soln 1%
2
valacyclovir hcl tabs 1000mg
2
valacyclovir hcl tabs 500mg
ZOVIRAX CREA 5%
4
Antivirals
ZEPATIER TABS 50MG; 100MG
5
Anxiolytics
Anxiolytics, Other
1
buspirone hcl tabs 10mg
1
1
1
1
buspirone hcl tabs 7.5mg
2
PA
meprobamate tabs 200mg
2
PA
meprobamate tabs 400mg
Benzodiazepines
2
alprazolam er tb24 1mg
2
2
2
alprazolam intensol conc 1mg/ml
2
alprazolam odt tbdp 0.25mg
2
alprazolam odt tbdp 0.5mg
2
alprazolam odt tbdp 1mg
2
alprazolam odt tbdp 2mg
2
alprazolam xr tb24 0.5mg
2
alprazolam xr tb24 1mg
2
2
2
alprazolam tabs 0.25mg
2
alprazolam tabs 0.5mg
2
alprazolam tabs 1mg
2
alprazolam tabs 2mg
2
chlordiazepoxide hcl caps 10mg
2
2
2
clorazepate dipotassium tabs 15mg
2
clorazepate dipotassium tabs 3.75mg
2
clorazepate dipotassium tabs 7.5mg
2
diazepam soln 1mg/ml
2
diazepam tabs 10mg
2
diazepam tabs 2mg
2
diazepam tabs 5mg
2
lorazepam intensol conc 2mg/ml
48
Drug
Drug Name
2
lorazepam conc 2mg/ml
2
2
2
2
lorazepam tabs 0.5mg
2
lorazepam tabs 1mg
2
lorazepam tabs 2mg
1
triazolam tabs 0.125mg
1
triazolam tabs 0.25mg
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitor
2
2
irenka cpep 40mg
Bipolar Agents
Mood Stabilizers
1
MO
lithium carbonate er tbcr 300mg
1
MO
lithium carbonate er tbcr 450mg
1
MO
lithium carbonate caps 150mg
1
MO
1
MO
1
MO
lithium carbonate tabs 300mg
1
MO
lithium soln 8meq/5ml
Blood Glucose Regulators
Antidiabetic Agents
1
MO
acarbose tabs 100mg
1
MO
acarbose tabs 25mg
1
MO
acarbose tabs 50mg
ACTOPLUS MET XR TB24 1000MG; 15MG
3
QL (60 EA per 30 days) MO GC
ACTOPLUS MET XR TB24 1000MG; 30MG
3
AVANDAMET TABS 1000MG; 2MG
3
3
3
AVANDARYL TABS 1MG; 4MG
3
3
3
3
AVANDIA TABS 2MG
3
AVANDIA TABS 4MG
3
AVANDIA TABS 8MG
3
BYDUREON INJ 2MG
3
ST MO
BYDUREON INJ 2MG
3
ST MO
BYETTA INJ 10MCG/0.04ML
4
ST MO
BYETTA INJ 5MCG/0.02ML
4
ST MO
CYCLOSET TABS 0.8MG
4
MO
1
glimepiride tabs 1mg
1
49
Drug
Drug Name
1
1
glipizide er tb24 10mg
1
glipizide er tb24 2.5mg
1
glipizide er tb24 5mg
1
glipizide xl tb24 10mg
1
1
glipizide xl tb24 2.5mg
1
1
1
glipizide/metformin hcl tabs 2.5mg; 250mg
1
glipizide/metformin hcl tabs 2.5mg; 500mg
1
glipizide/metformin hcl tabs 5mg; 500mg
1
glipizide tabs 10mg
1
glipizide tabs 5mg
2
glyburide tabs 1.25mg
2
glyburide tabs 2.5mg
2
glyburide tabs 5mg
GLYSET TABS 100MG
4
MO
GLYSET TABS 25MG
4
MO
GLYSET TABS 50MG
4
MO
INVOKAMET TABS 150MG; 1000MG
3
ST MO
3
ST MO
3
ST MO
3
ST MO
JANUMET XR TB24 1000MG; 100MG
3
3
3
JANUMET TABS 1000MG; 50MG
3
JANUMET TABS 500MG; 50MG
3
JANUVIA TABS 100MG
3
ST MO GC
JANUVIA TABS 25MG
3
ST MO GC
JANUVIA TABS 50MG
3
ST MO GC
JARDIANCE TABS 10MG
3
ST MO
JARDIANCE TABS 25MG
3
ST MO
JENTADUETO TABS 2.5MG; 1000MG
3
3
3
KOMBIGLYZE XR TB24 1000MG; 2.5MG
4
KOMBIGLYZE XR TB24 1000MG; 5MG
4
KOMBIGLYZE XR TB24 500MG; 5MG
4
2
metformin hcl er tb24 1000mg
2
1
1
1
metformin hcl tabs 1000mg
1
50
Drug Name
miglitol tabs 100mg
miglitol tabs 25mg
miglitol tabs 50mg
nateglinide tabs 120mg
nateglinide tabs 60mg
ONGLYZA TABS 2.5MG
ONGLYZA TABS 5MG
pioglitazone hcl-glimepiride tabs 2mg; 30mg
pioglitazone hcl-glimepiride tabs 4mg; 30mg
pioglitazone hcl/metformin hcl tabs 500mg; 15mg
pioglitazone hcl/metformin hcl tabs 850mg; 15mg
pioglitazone hcl tabs 15mg
PRANDIMET TABS 500MG; 1MG
repaglinide/metformin hydrochloride tabs 500mg; 1mg
repaglinide/metformin hydrochloride tabs 500mg; 2mg
repaglinide tabs 0.5mg
repaglinide tabs 1mg
repaglinide tabs 2mg
SYMLINPEN 120 INJ 2700MCG/2.7ML
SYMLINPEN 60 INJ 1500MCG/1.5ML
SYNJARDY TABS 12.5MG; 1000MG
SYNJARDY TABS 12.5MG; 500MG
SYNJARDY TABS 5MG; 1000MG
SYNJARDY TABS 5MG; 500MG
tolazamide tabs 250mg
tolazamide tabs 500mg
tolbutamide tabs 500mg
TRADJENTA TABS 5MG
VICTOZA INJ 18MG/3ML
Glycemic Agents
CLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L;
880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML;
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
Drug
Tier
1
1
1
1
1
1
3
4
2
2
2
2
2
2
2
4
2
2
1
1
1
4
4
3
3
3
3
1
1
1
3
4
Requirements/Limits
MO
MO
MO
MO
MO
ST MO GC
ST MO GC
MO
MO
MO
PA MO
PA MO
ST MO
3
B/D
51
Drug
Drug Name
CLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML;
3
B/D
1035MG/100ML; 575MG/100ML; 20MEQ/1000ML;
15GM/100ML; 515MG/100ML; 240MG/100ML;
300MG/100ML; 365MG/100ML; 290MG/100ML;
200MG/100ML; 280MG/100ML; 340MG/100ML;
250MG/100ML; 210MG/100ML; 90MG/100ML;
20MG/100ML; 290MG/100ML
CLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L;
3
B/D
515MG/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 200MG/100ML;
280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML;
290MG/100ML
CLINIMIX E 2.75%/DEXTROSE 5% INJ 570MG/100ML; 3
B/D
316MG/100ML; 33MG/100ML; 5GM/100ML;
132MG/100ML; 165MG/100ML; 201MG/100ML;
159MG/100ML; 51MG/100ML; 110MG/100ML;
454MG/100ML; 154MG/100ML; 261MG/100ML;
187MG/100ML; 138MG/100ML; 217MG/100ML;
112MG/100ML; 116MG/100ML; 50MG/100ML;
11MG/100ML; 160MG/100ML
B/D
489MG/100ML; 33MG/100ML; 25GM/100ML;
204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 51MG/100ML; 170MG/100ML;
702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML;
77MG/100ML; 179MG/100ML; 77MG/100ML;
17MG/100ML; 247MG/100ML
B/D
489MG/100ML; 33MG/100ML; 5GM/100ML;
204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 51MG/100ML; 170MG/100ML;
702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML;
77MG/100ML; 179MG/100ML; 77MG/100ML;
17MG/100ML; 247MG/100ML
CLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML; 3
B/D
575MG/100ML; 33MG/100ML; 15GM/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML;
290MG/100ML; 51MG/100ML; 200MG/100ML;
826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML;
59MG/100ML; 210MG/100ML; 90MG/100ML;
20MG/100ML; 290MG/100ML
52
Drug
Drug Name
B/D
575MG/100ML; 33MG/100ML; 25GM/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML;
290MG/100ML; 51MG/100ML; 200MG/100ML;
826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML;
59MG/100ML; 210MG/100ML; 90MG/100ML;
20MG/100ML; 290MG/100ML
GLUCAGEN HYPOKIT INJ 1MG
4
GLUCAGON EMERGENCY KIT INJ 1MG
3
IONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%;
4
25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L
KCL 0.15%/D5W/LR INJ 3MEQ/L; 149MEQ/L; 5%;
4
28MEQ/L; 24MEQ/L; 130MEQ/L
1
normosol-r in d5w inj 27meq/l; 98meq/l; 5%; 23meq/l;
3meq/l; 5meq/l; 140meq/l
PROGLYCEM SUSP 50MG/ML
4
MO
Insulins
APIDRA SOLOSTAR INJ 100UNIT/ML
3
MO GC
APIDRA INJ 100UNIT/ML
3
MO GC
HUMALOG KWIKPEN INJ 100UNIT/ML
3
MO
3
MO
3
MO
HUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML;
3
MO GC
50UNIT/ML
HUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML
3
MO GC
HUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML;
3
MO GC
75UNIT/ML
HUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML
3
MO GC
HUMALOG INJ 100UNIT/ML
3
MO
HUMALOG INJ 100UNIT/ML
3
MO
HUMULIN 70/30 KWIKPEN INJ 30UNIT/ML; 70UNIT/ML 3
MO
2
MO
humulin 70/30 inj 30unit/ml; 70unit/ml
HUMULIN N KWIKPEN INJ 100UNIT/ML
3
MO GC
2
MO
humulin n inj 100unit/ml
2
MO
humulin r u-500 (concentrated) inj 500unit/ml
HUMULIN R U-500 KWIKPEN INJ 500UNIT/ML
3
MO
2
MO
humulin r inj 100unit/ml
LANTUS SOLOSTAR INJ 100UNIT/ML
3
MO GC
LANTUS INJ 100UNIT/ML
3
MO GC
LEVEMIR FLEXTOUCH INJ 100UNIT/ML
3
MO
LEVEMIR INJ 100UNIT/ML
3
MO
2
MO
novolin 70/30 relion inj 30unit/ml; 70unit/ml
2
MO
novolin 70/30 inj 30unit/ml; 70unit/ml
2
MO
novolin n relion inj 100unit/ml
2
MO
novolin n inj 100unit/ml
53
Drug
Drug Name
2
MO
novolin r relion inj 100unit/ml
2
MO
novolin r inj 100unit/ml
NOVOLOG FLEXPEN INJ 100UNIT/ML
3
MO GC
NOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ
3
MO GC
30UNIT/ML; 70UNIT/ML
NOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML
3
MO GC
NOVOLOG PENFILL INJ 100UNIT/ML
3
MO
NOVOLOG INJ 100UNIT/ML
3
MO GC
RELION R INJ 100UNIT/ML
3
MO
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN TABS 10MG
3
MO
COUMADIN TABS 1MG
3
MO
COUMADIN TABS 2.5MG
3
MO
COUMADIN TABS 2MG
3
MO
COUMADIN TABS 3MG
3
MO
COUMADIN TABS 4MG
3
MO
COUMADIN TABS 5MG
3
MO
COUMADIN TABS 6MG
3
MO
COUMADIN TABS 7.5MG
3
MO
ELIQUIS TABS 2.5MG
4
ELIQUIS TABS 5MG
4
5
enoxaparin sodium inj 100mg/ml
5
enoxaparin sodium inj 120mg/0.8ml
5
enoxaparin sodium inj 150mg/ml
2
enoxaparin sodium inj 300mg/3ml
2
QL (10.5 ML per 90 days)
2
2
2
5
fondaparinux sodium inj 10mg/0.8ml
2
fondaparinux sodium inj 2.5mg/0.5ml
5
fondaparinux sodium inj 5mg/0.4ml
5
fondaparinux sodium inj 7.5mg/0.6ml
FRAGMIN INJ 10000UNIT/ML
5
FRAGMIN INJ 12500UNIT/0.5ML
5
5
FRAGMIN INJ 18000UNT/0.72ML
5
FRAGMIN INJ 25000UNIT/ML
5
4
4
5
5
1
heparin sodium dcu inj 20000unit/ml
1
heparin sodium/d5w inj 5%; 100unit/ml
1
54
Drug
Drug Name
1
1
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9%
1
heparin sodium/sodium chloride 0.9% premix inj 2unit/ml;
0.9%
1
0.9%
1
0.9%
1
0.9%
1
heparin sodium inj 10000unit/ml
1
1
1
1
MO
jantoven tabs 10mg
1
MO
jantoven tabs 1mg
1
MO
jantoven tabs 2.5mg
1
MO
jantoven tabs 2mg
1
MO
jantoven tabs 3mg
1
MO
jantoven tabs 4mg
1
MO
jantoven tabs 5mg
1
MO
jantoven tabs 6mg
1
MO
jantoven tabs 7.5mg
PRADAXA CAPS 110MG
4
PRADAXA CAPS 150MG
4
PRADAXA CAPS 75MG
4
1
MO
warfarin sodium tabs 10mg
1
MO
1
MO
warfarin sodium tabs 2.5mg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
warfarin sodium tabs 7.5mg
XARELTO STARTER PACK TBPK 0
3
XARELTO TABS 10MG
3
XARELTO TABS 15MG
3
XARELTO TABS 20MG
3
Blood Formation Modifiers
1
MO
anagrelide hydrochloride caps 0.5mg
1
MO
anagrelide hydrochloride caps 1mg
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML
5
PA
ARANESP ALBUMIN FREE INJ 100MCG/ML
5
PA
4
PA
5
PA
55
Drug
Drug Name
5
PA
5
PA
4
PA
4
PA
5
PA
5
PA
4
PA
4
PA
5
PA
4
PA
4
PA
EPOGEN INJ 10000UNIT/ML
4
PA
4
PA
4
PA
4
PA
4
PA
LEUKINE INJ 250MCG
5
PA
MOZOBIL INJ 24MG/1.2ML
5
QL (9.6 ML per 30 days) PA
NEULASTA ONPRO KIT INJ 6MG/0.6ML
5
PA
NEULASTA INJ 6MG/0.6ML
5
PA
NEUMEGA INJ 5MG
5
PA
NEUPOGEN INJ 300MCG/0.5ML
5
PA
NEUPOGEN INJ 300MCG/ML
5
PA
5
PA
5
PA
PROCRIT INJ 10000UNIT/ML
4
PA
5
PA
4
PA
4
PA
5
PA
4
PA
PROMACTA TABS 12.5MG
5
PA
PROMACTA TABS 25MG
5
PA
PROMACTA TABS 50MG
5
PA
PROMACTA TABS 75MG
5
PA
ZARXIO INJ 300MCG/0.5ML
5
PA
ZARXIO INJ 480MCG/0.8ML
5
PA
Coagulants
2
tranexamic acid inj 1000mg/10ml
2
tranexamic acid tabs 650mg
Platelet Modifying Agents
AGGRENOX CP12 25MG; 200MG
4
MO
2
MO
aspirin/dipyridamole cp12 25mg; 200mg
BRILINTA TABS 60MG
4
MO
BRILINTA TABS 90MG
4
MO
1
MO
cilostazol tabs 100mg
56
Drug
Drug Name
1
MO
cilostazol tabs 50mg
1
clopidogrel tabs 300mg
1
MO
clopidogrel tabs 75mg
EFFIENT TABS 10MG
4
MO
EFFIENT TABS 5MG
4
MO
2
PA MO
ticlopidine hcl tabs 250mg
Cardiovascular Agents
Alpha-adrenergic Agonists
2
MO
clonidine hcl ptwk 0.1mg/24hr
2
MO
2
MO
1
MO
clonidine hcl tabs 0.1mg
1
MO
1
MO
CLORPRES TABS 15MG; 0.1MG
4
MO
CLORPRES TABS 15MG; 0.2MG
4
MO
2
PA MO
guanfacine hcl tabs 1mg
2
PA MO
guanfacine hcl tabs 2mg
2
midodrine hcl tabs 10mg
2
midodrine hcl tabs 2.5mg
2
midodrine hcl tabs 5mg
Alpha-adrenergic Blocking Agents
DIBENZYLINE CAPS 10MG
4
2
phenoxybenzamine hydrochloride caps 10mg
1
MO
prazosin hcl caps 1mg
1
MO
1
MO
2
reserpine tabs 0.1mg
2
MO
reserpine tabs 0.25mg
Angiotensin II Receptor Antagonists
BENICAR HCT TABS 12.5MG; 20MG
3
MO
BENICAR HCT TABS 12.5MG; 40MG
3
MO
BENICAR HCT TABS 25MG; 40MG
3
MO
BENICAR TABS 20MG
3
MO
BENICAR TABS 40MG
3
MO
BENICAR TABS 5MG
3
MO
1
MO
candesartan cilexetil tabs 16mg
1
MO
1
MO
1
MO
EDARBI TABS 40MG
4
ST MO
EDARBI TABS 80MG
4
ST MO
ENTRESTO TABS 24MG; 26MG
4
4
4
1
MO
eprosartan mesylate tabs 600mg
57
Drug
Drug Name
1
MO
irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg
1
MO
irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg
1
MO
irbesartan tabs 150mg
1
MO
1
MO
MO
losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg 1
MO
losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg 1
MO
losartan potassium/hydrochlorothiazide tabs 25mg; 100mg 1
1
MO
losartan potassium tabs 100mg
1
MO
1
MO
2
MO
telmisartan/amlodipine tabs 10mg; 40mg
2
MO
2
MO
2
MO
1
MO
telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg
1
MO
telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg
1
MO
telmisartan/hydrochlorothiazide tabs 25mg; 80mg
1
MO
telmisartan tabs 20mg
1
MO
1
MO
1
MO
valsartan/hydrochlorothiazide tabs 12.5mg; 160mg
1
MO
1
MO
1
MO
valsartan/hydrochlorothiazide tabs 25mg; 160mg
1
MO
valsartan/hydrochlorothiazide tabs 25mg; 320mg
1
MO
valsartan tabs 160mg
1
MO
valsartan tabs 320mg
1
MO
valsartan tabs 40mg
1
MO
valsartan tabs 80mg
Angiotensin-converting Enzyme (ACE) Inhibitors
1
MO
benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg
1
MO
1
MO
benazepril hcl/hydrochlorothiazide tabs 20mg; 25mg
1
MO
1
MO
benazepril hcl tabs 10mg
1
MO
1
MO
1
MO
1
MO
captopril/hydrochlorothiazide tabs 25mg; 15mg
1
MO
1
MO
1
MO
1
MO
captopril tabs 100mg
1
MO
captopril tabs 12.5mg
1
MO
captopril tabs 25mg
58
Drug
Drug Name
1
MO
captopril tabs 50mg
1
MO
enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg
1
MO
enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg
1
MO
enalapril maleate tabs 10mg
1
MO
enalapril maleate tabs 2.5mg
1
MO
1
MO
1
MO
fosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg
1
MO
fosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg
1
MO
fosinopril sodium tabs 10mg
1
MO
1
MO
1
MO
lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg
1
MO
lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg
1
MO
lisinopril/hydrochlorothiazide tabs 25mg; 20mg
1
MO
lisinopril tabs 10mg
1
MO
lisinopril tabs 2.5mg
1
MO
1
MO
1
MO
1
MO
lisinopril tabs 5mg
1
MO
moexipril hcl tabs 15mg
1
MO
moexipril hcl tabs 7.5mg
1
MO
moexipril/hydrochlorothiazide tabs 12.5mg; 15mg
1
MO
moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg
1
MO
moexipril/hydrochlorothiazide tabs 25mg; 15mg
1
MO
perindopril erbumine tabs 2mg
1
MO
1
MO
1
MO
quinapril hcl tabs 10mg
1
MO
1
MO
1
MO
1
MO
quinapril/hydrochlorothiazide tabs 12.5mg; 10mg
1
MO
quinapril/hydrochlorothiazide tabs 12.5mg; 20mg
1
MO
quinapril/hydrochlorothiazide tabs 25mg; 20mg
1
MO
ramipril caps 1.25mg
1
MO
ramipril caps 10mg
1
MO
ramipril caps 2.5mg
1
MO
ramipril caps 5mg
2
MO
trandolapril/verapamil hcl er tbcr 1mg; 240mg
2
MO
2
MO
2
MO
2
MO
trandolapril/verapamil hcl tbcr 1mg; 240mg
2
MO
59
Drug
Drug Name
2
MO
2
MO
1
MO
trandolapril tabs 1mg
1
MO
1
MO
Antiarrhythmics
1
MO
amiodarone hcl tabs 100mg
1
MO
1
MO
1
MO
amiodarone hydrochloride tabs 200mg
2
PA MO
disopyramide phosphate caps 100mg
2
PA MO
disopyramide phosphate caps 150mg
1
MO
dofetilide caps 125mcg
1
MO
1
MO
1
MO
flecainide acetate tabs 100mg
1
MO
1
MO
1
MO
mexiletine hcl caps 150mg
1
MO
1
MO
MULTAQ TABS 400MG
4
MO
1
MO
pacerone tabs 100mg
1
MO
pacerone tabs 200mg
1
MO
pacerone tabs 400mg
2
MO
propafenone hcl er cp12 225mg
2
MO
2
MO
1
MO
propafenone hcl tabs 150mg
1
MO
1
MO
2
MO
quinidine gluconate cr tbcr 324mg
2
MO
quinidine gluconate er tbcr 324mg
1
MO
quinidine sulfate er tbcr 300mg
1
MO
quinidine sulfate tabs 200mg
1
MO
quinidine sulfate tabs 300mg
1
MO
sorine tabs 120mg
1
MO
sorine tabs 160mg
1
MO
sorine tabs 240mg
1
MO
sorine tabs 80mg
1
MO
sotalol hcl (af) tabs 120mg
1
MO
sotalol hcl tabs 120mg
1
MO
1
MO
1
MO
1
MO
60
Drug
Drug Name
1
MO
1
MO
1
MO
TIKOSYN CAPS 125MCG
4
MO
TIKOSYN CAPS 250MCG
4
MO
TIKOSYN CAPS 500MCG
4
MO
Beta-adrenergic Blocking Agents
1
MO
acebutolol hcl caps 200mg
1
MO
acebutolol hcl caps 400mg
1
MO
atenolol/chlorthalidone tabs 100mg; 25mg
1
MO
atenolol/chlorthalidone tabs 50mg; 25mg
1
MO
atenolol tabs 100mg
1
MO
atenolol tabs 25mg
1
MO
atenolol tabs 50mg
1
MO
betaxolol hcl tabs 10mg
1
MO
betaxolol hcl tabs 20mg
MO
bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg 1
MO
bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg 1
MO
bisoprolol fumarate/hydrochlorothiazide tabs 5mg; 6.25mg 1
1
MO
bisoprolol fumarate tabs 10mg
1
MO
bisoprolol fumarate tabs 5mg
BYSTOLIC TABS 10MG
3
MO
BYSTOLIC TABS 2.5MG
3
MO
BYSTOLIC TABS 20MG
3
MO
BYSTOLIC TABS 5MG
3
MO
1
MO
carvedilol tabs 12.5mg
1
MO
carvedilol tabs 25mg
1
MO
1
MO
COREG CR CP24 10MG
4
MO
COREG CR CP24 20MG
4
MO
COREG CR CP24 40MG
4
MO
COREG CR CP24 80MG
4
MO
DUTOPROL TB24 12.5MG; 100MG
4
MO
4
MO
4
MO
INDERAL XL CP24 120MG
4
MO
4
MO
4
MO
4
MO
INNOPRAN XL CP24 120MG
4
MO
INNOPRAN XL CP24 80MG
4
MO
1
MO
labetalol hcl tabs 100mg
1
MO
1
MO
LEVATOL TABS 20MG
4
MO
61
Drug
Drug Name
1
MO
metoprolol succinate er tb24 100mg
1
MO
1
MO
1
MO
1
metoprolol tartrate inj 1mg/ml
1
metoprolol tartrate inj 1mg/ml
1
MO
metoprolol tartrate tabs 100mg
1
MO
1
MO
1
MO
metoprolol/hydrochlorothiazide tabs 25mg; 100mg
1
MO
1
MO
2
MO
nadolol/bendroflumethiazide tabs 5mg; 40mg
2
MO
nadolol/bendroflumethiazide tabs 5mg; 80mg
2
MO
nadolol tabs 20mg
2
MO
nadolol tabs 40mg
2
MO
nadolol tabs 80mg
1
MO
pindolol tabs 10mg
1
MO
pindolol tabs 5mg
1
MO
propranolol hcl er cp24 120mg
1
MO
1
MO
1
MO
1
MO
propranolol hcl tabs 10mg
1
MO
1
MO
1
MO
1
MO
1
MO
propranolol/hydrochlorothiazide tabs 25mg; 40mg
1
MO
propranolol/hydrochlorothiazide tabs 25mg; 80mg
1
MO
timolol maleate tabs 10mg
1
MO
1
MO
Calcium Channel Blocking Agents
1
MO
afeditab cr tb24 30mg
1
MO
afeditab cr tb24 60mg
MO
amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg 2
MO
MO
MO
MO
amlodipine besylate/atorvastatin calcium tabs 2.5mg; 10mg 2
MO
MO
2
MO
amlodipine besylate/atorvastatin calcium tabs 5mg; 10mg
2
MO
2
MO
62
Drug
Drug Name
2
MO
1
MO
amlodipine besylate/benazepril hcl caps 10mg; 40mg
1
MO
amlodipine besylate/benazepril hcl caps 5mg; 40mg
1
MO
amlodipine besylate/benazepril hydrochloride caps 10mg;
20mg
1
MO
40mg
1
MO
amlodipine besylate/benazepril hydrochloride caps 2.5mg;
10mg
1
MO
10mg
1
MO
20mg
1
MO
40mg
2
MO
amlodipine besylate/valsartan tabs 10mg; 160mg
2
MO
2
MO
2
MO
1
MO
amlodipine besylate tabs 10mg
1
MO
amlodipine besylate tabs 2.5mg
1
MO
amlodipine besylate tabs 5mg
2
MO
amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg
2
MO
amlodipine/valsartan/hctz tabs 10mg; 25mg; 160mg
2
MO
2
MO
amlodipine/valsartan/hctz tabs 5mg; 12.5mg; 160mg
2
MO
AZOR TABS 10MG; 20MG
3
MO
AZOR TABS 10MG; 40MG
3
MO
AZOR TABS 5MG; 20MG
3
MO
AZOR TABS 5MG; 40MG
3
MO
CARDIZEM LA TB24 120MG
4
MO
1
MO
cartia xt cp24 120mg
1
MO
1
MO
1
MO
1
MO
dilt-xr cp24 120mg
1
MO
dilt-xr cp24 180mg
1
MO
dilt-xr cp24 240mg
1
MO
diltiazem cd cp24 120mg
1
MO
1
MO
1
MO
1
MO
diltiazem hcl cd cp24 360mg
1
MO
diltiazem hcl er cp12 120mg
1
MO
63
Drug
Drug Name
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
2
MO
diltiazem hcl er tb24 180mg
2
MO
2
MO
2
MO
2
MO
2
MO
2
MO
64
Drug
Drug Name
2
MO
2
MO
2
MO
1
MO
diltiazem hcl tabs 120mg
1
MO
1
MO
1
MO
1
MO
felodipine er tb24 10mg
1
MO
felodipine er tb24 2.5mg
1
MO
felodipine er tb24 5mg
2
MO
isradipine caps 2.5mg
2
MO
isradipine caps 5mg
2
MO
matzim la tb24 180mg
2
MO
2
MO
2
MO
2
MO
1
MO
nicardipine hcl caps 20mg
1
MO
nicardipine hcl caps 30mg
1
MO
nifediac cc tb24 60mg
1
MO
nifediac cc tb24 90mg
1
MO
nifedical xl tb24 30mg
1
MO
nifedical xl tb24 60mg
1
MO
nifedipine er tb24 30mg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
2
MO
nimodipine caps 30mg
2
MO
nisoldipine er tb24 25.5mg
2
MO
nisoldipine tb24 17mg
2
MO
2
MO
2
MO
2
MO
2
MO
nisoldipine tb24 8.5mg
65
Drug
Drug Name
1
MO
taztia xt cp24 120mg
1
MO
1
MO
1
MO
1
MO
TRIBENZOR TABS 10MG; 12.5MG; 40MG
3
MO
TRIBENZOR TABS 10MG; 25MG; 40MG
3
MO
3
MO
3
MO
TRIBENZOR TABS 5MG; 25MG; 40MG
3
MO
1
MO
verapamil hcl er cp24 100mg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
verapamil hcl er tbcr 120mg
1
MO
1
MO
1
MO
1
MO
verapamil hcl sr cp24 120mg
1
MO
1
MO
1
MO
1
MO
verapamil hcl sr tbcr 120mg
1
MO
verapamil hcl tabs 120mg
1
MO
1
MO
Cardiovascular Agents, Other
AMTURNIDE TABS 150MG; 5MG; 12.5MG
4
MO
4
MO
AMTURNIDE TABS 300MG; 10MG; 25MG
4
MO
4
MO
AMTURNIDE TABS 300MG; 5MG; 25MG
4
MO
DEMSER CAPS 250MG
4
1
digitek tabs 0.125mg
1
PA MO
digitek tabs 0.25mg
1
PA MO
digoxin soln 0.05mg/ml
1
digoxin tabs 125mcg
1
PA MO
digoxin tabs 250mcg
1
digox tabs 125mcg
1
digox tabs 125mcg
1
PA MO
digox tabs 250mcg
LANOXIN TABS 125MCG
4
LANOXIN TABS 250MCG
4
PA MO
LANOXIN TABS 62.5MCG
4
66
Drug
Drug Name
NORTHERA CAPS 100MG
5
PA
NORTHERA CAPS 200MG
5
PA
NORTHERA CAPS 300MG
5
PA
1
MO
pentoxifylline er tbcr 400mg
PRALUENT INJ 150MG/ML
5
QL (2 ML per 28 days) PA
5
5
5
RANEXA TB12 1000MG
3
PA MO
RANEXA TB12 500MG
3
PA MO
REPATHA SURECLICK INJ 140MG/ML
5
REPATHA INJ 140MG/ML
5
TEKAMLO TABS 150MG; 10MG
4
MO
4
MO
4
MO
4
MO
TEKTURNA HCT TABS 150MG; 12.5MG
4
MO
TEKTURNA HCT TABS 150MG; 25MG
4
MO
TEKTURNA HCT TABS 300MG; 12.5MG
4
MO
TEKTURNA HCT TABS 300MG; 25MG
4
MO
TEKTURNA TABS 150MG
4
MO
TEKTURNA TABS 300MG
4
MO
Diuretics, Carbonic Anhydrase Inhibitors
1
MO
acetazolamide tabs 125mg
1
MO
acetazolamide tabs 250mg
Diuretics, Loop
1
bumetanide inj 0.25mg/ml
1
MO
bumetanide tabs 0.5mg
1
MO
bumetanide tabs 1mg
1
MO
bumetanide tabs 2mg
EDECRIN TABS 25MG
4
MO
1
furosemide inj 10mg/ml
1
furosemide inj 10mg/ml
1
MO
furosemide soln 10mg/ml
1
MO
furosemide soln 8mg/ml
1
MO
furosemide tabs 20mg
1
MO
1
MO
1
MO
torsemide tabs 100mg
1
MO
torsemide tabs 10mg
1
MO
torsemide tabs 20mg
1
MO
torsemide tabs 5mg
Diuretics, Potassium-sparing
ALDACTAZIDE TABS 50MG; 50MG
4
MO
1
MO
amiloride hcl tabs 5mg
1
MO
amiloride/hydrochlorothiazide tabs 5mg; 50mg
67
Drug
Drug Name
DYRENIUM CAPS 0; 100MG
4
MO
DYRENIUM CAPS 50MG
4
MO
2
MO
eplerenone tabs 25mg
2
MO
eplerenone tabs 50mg
1
MO
spironolactone/hydrochlorothiazide tabs 25mg; 25mg
1
MO
spironolactone tabs 100mg
1
MO
1
MO
1
MO
triamterene/hydrochlorothiazide caps 25mg; 37.5mg
1
MO
triamterene/hydrochlorothiazide caps 25mg; 50mg
1
MO
triamterene/hydrochlorothiazide tabs 25mg; 37.5mg
1
MO
triamterene/hydrochlorothiazide tabs 50mg; 75mg
Diuretics, Thiazide
MO
candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg 1
MO
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg 1
MO
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 25mg 1
1
MO
chlorothiazide tabs 250mg
1
MO
chlorothiazide tabs 500mg
1
MO
chlorthalidone tabs 25mg
1
MO
chlorthalidone tabs 50mg
1
MO
hydrochlorothiazide caps 12.5mg
1
MO
hydrochlorothiazide tabs 12.5mg
1
MO
hydrochlorothiazide tabs 25mg
1
MO
hydrochlorothiazide tabs 50mg
1
MO
indapamide tabs 1.25mg
1
MO
indapamide tabs 2.5mg
1
MO
methyclothiazide tabs 5mg
1
MO
metolazone tabs 10mg
1
MO
metolazone tabs 2.5mg
1
MO
metolazone tabs 5mg
Dyslipidemics, Fibric Acid Derivatives
1
MO
fenofibrate micronized caps 134mg
1
MO
1
MO
1
MO
fenofibrate caps 130mg
1
MO
1
MO
1
MO
2
MO
fenofibrate tabs 120mg
1
MO
1
MO
2
MO
1
MO
1
MO
1
MO
fenofibric acid dr cpdr 135mg
1
MO
fenofibric acid dr cpdr 45mg
68
Drug
Drug Name
1
MO
fenofibric acid tabs 105mg
1
fenofibric acid tabs 35mg
1
MO
gemfibrozil tabs 600mg
Dyslipidemics, HMG CoA Reductase Inhibitors
1
MO
atorvastatin calcium tabs 10mg
1
MO
1
MO
1
MO
CRESTOR TABS 10MG
3
ST MO
CRESTOR TABS 20MG
3
ST MO
CRESTOR TABS 40MG
3
ST MO
CRESTOR TABS 5MG
3
ST MO
2
MO
fluvastatin sodium er tb24 80mg
2
MO
fluvastatin caps 20mg
2
MO
fluvastatin caps 40mg
LESCOL XL TB24 80MG
4
ST MO
LIVALO TABS 1MG
4
ST MO
LIVALO TABS 2MG
4
ST MO
LIVALO TABS 4MG
4
ST MO
1
MO
lovastatin tabs 10mg
1
MO
1
MO
1
MO
pravastatin sodium tabs 10mg
1
MO
1
MO
1
MO
1
MO
rosuvastatin calcium tabs 10mg
1
MO
1
MO
1
MO
SIMCOR TB24 1000MG; 20MG
4
MO
3
MO
4
MO
3
MO
4
MO
1
MO
simvastatin tabs 10mg
1
MO
1
MO
1
MO
1
PA MO
Dyslipidemics, Other
1
MO
cholestyramine light pack 4gm
1
MO
cholestyramine light powd 4gm/dose
1
MO
cholestyramine light powd 4gm/dose
1
MO
colestipol hcl gran 5gm
1
MO
colestipol hcl tabs 1gm
69
Drug
Drug Name
JUXTAPID CAPS 10MG
5
JUXTAPID CAPS 20MG
5
JUXTAPID CAPS 30MG
5
JUXTAPID CAPS 40MG
5
JUXTAPID CAPS 5MG
5
JUXTAPID CAPS 60MG
5
KYNAMRO INJ 200MG/ML
5
2
MO
niacin er tbcr 1000mg
2
MO
2
MO
1
niacor tabs 500mg
2
MO
omega-3-acid ethyl esters caps 375mg; 465mg; 1gm
1
MO
prevalite pack 4gm
1
MO
prevalite pack 4gm
1
MO
prevalite pack 4gm
1
MO
prevalite powd 4gm/dose
VASCEPA CAPS 1GM
3
MO
VYTORIN TABS 10MG; 10MG
4
ST MO
4
ST MO
4
ST MO
4
PA MO
ZETIA TABS 10MG
4
MO
Vasodilators, Direct-acting Arterial/Venous
DILATRATE SR CPCR 40MG
4
MO
ISORDIL TITRADOSE TABS 40MG
4
MO
1
MO
isosorbide dinitrate er tbcr 40mg
1
MO
isosorbide dinitrate tabs 10mg
1
MO
1
MO
1
MO
1
MO
isosorbide mononitrate er tb24 120mg
1
MO
1
MO
1
MO
isosorbide mononitrate tabs 10mg
1
MO
isosorbide mononitrate tabs 20mg
1
MO
minitran pt24 0.1mg/hr
1
MO
1
MO
1
MO
NITRO-BID OINT 2%
3
MO
NITRO-DUR PT24 0.3MG/HR
4
MO
NITRO-DUR PT24 0.8MG/HR
4
MO
2
MO
nitroglycerin lingual aers 400mcg/spray
2
MO
nitroglycerin lingual aers 400mcg/spray
2
MO
nitroglycerin lingual soln 0.4mg/spray
1
MO
nitroglycerin transdermal pt24 0.1mg/hr
70
Drug
Drug Name
1
MO
1
MO
1
MO
NITROMIST AERS 400MCG/SPRAY
4
MO
NITROSTAT SUBL 0.3MG
3
MO
3
MO
3
MO
RECTIV OINT 0.4%
3
Vasodilators, Direct-acting Arterial
1
MO
hydralazine hcl tabs 100mg
1
MO
1
MO
1
MO
1
MO
minoxidil tabs 10mg
1
MO
minoxidil tabs 2.5mg
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
2
amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg;
1.25mg; 1.25mg
amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2
2.5mg
2
3.75mg; 3.75mg
amphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 5mg 2
2
6.25mg; 6.25mg
amphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 7.5mg; 2
7.5mg
1
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg;
1.25mg; 1.25mg
1
1.875mg; 1.875mg
amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 2.5mg; 1
2.5mg
1
3.125mg; 3.125mg
1
3.75mg; 3.75mg
amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg 1
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 1
7.5mg
1
dexedrine tabs 10mg
1
dexedrine tabs 5mg
2
dextroamphetamine sulfate er cp24 10mg
2
2
71
Drug
Drug Name
1
dextroamphetamine sulfate soln 5mg/5ml
1
dextroamphetamine sulfate tabs 10mg
1
dextroamphetamine sulfate tabs 5mg
2
methamphetamine hcl tabs 5mg
1
procentra soln 5mg/5ml
1
zenzedi tabs 10mg
1
zenzedi tabs 5mg
Attention Deficit Hyperactivity Disorder Agents, Nonamphetamines
DAYTRANA PTCH 10MG/9HR
4
4
4
4
2
dexmethylphenidate hcl er cp24 10mg
2
2
2
2
2
1
dexmethylphenidate hcl tabs 10mg
1
dexmethylphenidate hcl tabs 2.5mg
1
dexmethylphenidate hcl tabs 5mg
FOCALIN XR CP24 25MG
4
FOCALIN XR CP24 35MG
4
2
MO
guanfacine er tb24 1mg
2
MO
2
MO
2
MO
2
metadate er tbcr 20mg
2
methylphenidate hcl cd cpcr 10mg
2
2
2
2
2
2
methylphenidate hcl er cp24 20mg
2
2
2
methylphenidate hcl er tb24 18mg
2
2
2
2
methylphenidate hcl er tbcr 20mg
2
methylphenidate hcl sr tbcr 20mg
2
methylphenidate hcl chew 10mg
2
methylphenidate hcl chew 2.5mg
72
Drug
Drug Name
2
methylphenidate hcl chew 5mg
1
methylphenidate hcl tabs 10mg
1
1
2
MO
methylphenidate hydrochloride soln 10mg/5ml
2
MO
methylphenidate hydrochloride soln 5mg/5ml
STRATTERA CAPS 100MG
4
STRATTERA CAPS 10MG
4
STRATTERA CAPS 18MG
4
STRATTERA CAPS 25MG
4
STRATTERA CAPS 40MG
4
STRATTERA CAPS 60MG
4
STRATTERA CAPS 80MG
4
Central Nervous System, Other
HETLIOZ CAPS 20MG
5
NUEDEXTA CAPS 20MG; 10MG
3
MO
2
riluzole tabs 50mg
5
PA
tetrabenazine tabs 12.5mg
5
PA
tetrabenazine tabs 25mg
XENAZINE TABS 12.5MG
5
PA
XENAZINE TABS 25MG
5
PA
Fibromyalgia Agents
SAVELLA TITRATION PACK MISC 0
3
SAVELLA TABS 100MG
3
SAVELLA TABS 12.5MG
3
SAVELLA TABS 25MG
3
SAVELLA TABS 50MG
3
Multiple Sclerosis Agents
AMPYRA TB12 10MG
5
AUBAGIO TABS 14MG
5
AUBAGIO TABS 7MG
5
AVONEX PEN INJ 30MCG/0.5ML
5
AVONEX INJ 30MCG/0.5ML
5
AVONEX INJ 30MCG/VIAL
5
BETASERON INJ 0.3MG
5
COPAXONE INJ 40MG/ML
5
EXTAVIA INJ 0.3MG
5
GILENYA CAPS 0.5MG
5
5
glatopa inj 20mg/ml
PLEGRIDY STARTER PACK INJ 0
5
PLEGRIDY STARTER PACK INJ 0
5
PLEGRIDY INJ 125MCG/0.5ML
5
PLEGRIDY INJ 125MCG/0.5ML
5
REBIF REBIDOSE TITRATION PACK INJ 0
5
REBIF REBIDOSE INJ 22MCG/0.5ML
5
REBIF REBIDOSE INJ 44MCG/0.5ML
5
73
Drug
Drug Name
REBIF TITRATION PACK INJ 0
5
REBIF INJ 22MCG/0.5ML
5
REBIF INJ 44MCG/0.5ML
5
TYSABRI INJ 300MG/15ML
5
Dental and Oral Agents
Dental and Oral Agents
2
MO
cevimeline hcl caps 30mg
1
chlorhexidine gluconate oral rinse soln 0.12%
1
chlorhexidine gluconate soln 0.12%
2
oralone pste 0.1%
1
paroex soln 0.12%
1
periogard soln 0.12%
2
MO
pilocarpine hcl tabs 7.5mg
2
MO
pilocarpine hydrochloride tabs 5mg
2
triamcinolone acetonide pste 0.1%
2
triamcinolone acetonide pste 0.1%
2
triamcinolone in orabase pste 0.1%
Dermatological Agents
Dermatological Agents
5
PA
acitretin caps 10mg
5
PA
acitretin caps 17.5mg
5
PA
acitretin caps 25mg
ACZONE GEL 5%
4
2
PA
adapalene pump gel 0.3%
2
PA
adapalene crea 0.1%
2
PA
adapalene gel 0.1%
2
PA
adapalene gel 0.3%
1
ammonium lactate crea 12%
1
ammonium lactate lotn 12%
2
amnesteem caps 10mg
2
amnesteem caps 20mg
2
amnesteem caps 40mg
2
PA
avita crea 0.025%
2
PA
avita gel 0.025%
AZELEX CREA 20%
4
2
QL (400 GM per 28 days)
calcipotriene/betamethasone dipropionate oint 0.064%;
0.005%
2
calcipotriene crea 0.005%
2
calcipotriene oint 0.005%
2
calcipotriene soln 0.005%
2
calcitrene oint 0.005%
2
calcitriol oint 3mcg/gm
2
claravis caps 10mg
2
claravis caps 20mg
CLARAVIS CAPS 30MG
5
2
claravis caps 40mg
74
Drug
Drug Name
2
clindamycin phosphate foam 1%
1
clindamycin phosphate soln 1%
2
clindamycin/benzoyl peroxide gel 5%; 1%
2
clindamycin/benzoyl peroxide gel 5%; 1.2%
2
clindamycin/benzoyl peroxide gel 5%; 1.2%
CONDYLOX GEL 0.5%
4
COSENTYX SENSOREADY PEN INJ 150MG/ML
5
PA
COSENTYX INJ 150MG/ML
5
PA
2
curity gauze pads 2"x2" pads
DESONATE GEL 0.05%
4
2
diclofenac sodium gel 1%
2
diclofenac sodium soln 1.5%
2
doxepin hydrochloride crea 5%
ELIDEL CREA 1%
4
ST
2
erythromycin/benzoyl peroxide gel 5%; 3%
FINACEA GEL 15%
4
2
fluocinolone acetonide soln 0.01%
2
fluorouracil crea 0.5%
2
fluorouracil crea 5%
2
fluorouracil soln 2%
2
fluorouracil soln 5%
2
imiquimod crea 5%
2
klofensaid ii soln 1.5%
5
methoxsalen caps 10mg
2
myorisan caps 10mg
2
myorisan caps 20mg
2
myorisan caps 30mg
2
myorisan caps 40mg
2
neuac kit kit 5%; 1.2%
2
neuac gel 5%; 1.2%
PENNSAID SOLN 2%
4
2
podofilox soln 0.5%
2
prudoxin crea 5%
SANTYL OINT 250UNIT/GM
4
2
selenium sulfide lotn 2.5%
STELARA INJ 45MG/0.5ML
5
PA
STELARA INJ 90MG/ML
5
PA
SYNALAR CREAM KIT KIT 0.025%
3
2
tacrolimus oint 0.03%
2
tacrolimus oint 0.1%
TALTZ INJ 80MG/ML
5
PA
TALTZ INJ 80MG/ML
5
PA
TAZORAC CREA 0.05%
4
QL (100 GM per 30 days) PA
TAZORAC CREA 0.1%
4
TAZORAC GEL 0.05%
4
TAZORAC GEL 0.1%
4
75
Drug
Drug Name
TOLAK CREA 4%
4
2
PA
tretinoin microsphere pump gel 0.04%
2
PA
tretinoin microsphere pump gel 0.1%
2
PA
tretinoin microsphere gel 0.04%
2
PA
tretinoin microsphere gel 0.1%
2
PA
tretinoin crea 0.025%
2
PA
tretinoin crea 0.05%
2
PA
tretinoin crea 0.1%
2
PA
tretinoin gel 0.01%
2
PA
tretinoin gel 0.025%
2
PA
tretinoin gel 0.05%
VEREGEN OINT 15%
4
VOLTAREN GEL 1%
4
2
zenatane caps 10mg
2
zenatane caps 20mg
2
zenatane caps 30mg
2
zenatane caps 40mg
2
zonalon crea 5%
ZYCLARA PUMP CREA 2.5%
4
ZYCLARA PUMP CREA 3.75%
5
ZYCLARA CREA 3.75%
5
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN INJ 250UNIT/ML
5
PA
ALDURAZYME INJ 2.9MG/5ML
5
PA
BUPHENYL TABS 500MG
5
CERDELGA CAPS 84MG
5
PA
CEREZYME INJ 400UNIT
5
PA
CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT
3
MO
3
MO
3
MO
3
MO
3
MO
FABRAZYME INJ 35MG
5
PA
KANUMA INJ 20MG/10ML
5
PA
KUVAN PACK 100MG
5
PA
KUVAN PACK 500MG
5
PA
KUVAN TBSO 100MG
5
PA
LUMIZYME INJ 50MG
5
PA
MYOZYME INJ 50MG
5
PA
NAGLAZYME INJ 1MG/ML
5
PA
PANCREAZE CPEP 17500UNIT; 4200UNIT; 10000UNIT 4
MO
MO
MO
MO
2
MO
pancrelipase cpep 27000unit; 5000unit; 17000unit
76
Drug
Drug Name
PERTZYE CPEP 30250UNIT; 8000UNIT; 28750UNIT
4
MO
PERTZYE CPEP 60500UNIT; 16000UNIT; 57500UNIT
4
MO
RAVICTI LIQD 1.1GM/ML
5
PA
5
sodium phenylbutyrate powd 3gm/tsp
STRENSIQ INJ 40MG/ML
5
PA
STRENSIQ INJ 80MG/0.8ML
5
PA
ULTRESA CPEP 27600UNIT; 13800UNIT; 27600UNIT
4
MO
5
5
VIMIZIM INJ 5MG/5ML
5
PA
VIOKACE TABS 39150UNIT; 10440UNIT; 39150UNIT
4
MO
VIOKACE TABS 78300UNIT; 20880UNIT; 78300UNIT
4
MO
VPRIV INJ 400UNIT
5
PA
ZAVESCA CAPS 100MG
5
PA
ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
1
dicyclomine hcl caps 10mg
1
dicyclomine hcl inj 10mg/ml
1
dicyclomine hcl soln 10mg/5ml
1
dicyclomine hcl tabs 20mg
ENTYVIO INJ 300MG
5
PA
1
glycopyrrolate inj 4mg/20ml
2
glycopyrrolate tabs 1mg
2
glycopyrrolate tabs 2mg
2
methscopolamine bromide tabs 2.5mg
2
methscopolamine bromide tabs 5mg
Gastrointestinal Agents, Other
CHENODAL TABS 250MG
5
CHOLBAM CAPS 250MG
5
PA
CHOLBAM CAPS 50MG
5
1
diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml
1
diphenoxylate/atropine tabs 0.025mg; 2.5mg
GATTEX INJ 5MG
5
PA
1
gavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm
1
lofene tabs 0.025mg; 2.5mg
1
lofene tabs 0.025mg; 2.5mg
1
loperamide hcl caps 2mg
1
metoclopramide hcl inj 5mg/ml
1
metoclopramide hcl soln 5mg/5ml
77
Drug
Drug Name
1
metoclopramide hcl tabs 10mg
1
metoclopramide hcl tabs 5mg
OSMOPREP TABS 0.398GM; 1.102GM
4
1
peg-prep kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm
PYLERA CAPS 140MG; 125MG; 125MG
4
RELISTOR INJ 12MG/0.6ML
4
PA
4
PA
4
PA
1
MO
ursodiol caps 300mg
2
MO
ursodiol tabs 250mg
2
MO
ursodiol tabs 500mg
Histamine2 (H2) Receptor Antagonists
1
MO
cimetidine hcl soln 300mg/5ml
1
cimetidine tabs 200mg
1
MO
1
MO
1
MO
1
famotidine inj 200mg/20ml
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
MO
famotidine susr 40mg/5ml
1
MO
famotidine tabs 20mg
1
MO
famotidine tabs 40mg
2
MO
nizatidine caps 150mg
2
MO
nizatidine caps 300mg
2
MO
nizatidine soln 15mg/ml
2
MO
ranitidine hcl caps 150mg
2
MO
ranitidine hcl caps 300mg
1
MO
ranitidine hcl syrp 15mg/ml
1
MO
ranitidine hcl tabs 150mg
1
MO
ranitidine hcl tabs 300mg
78
Drug
Drug Name
Irritable Bowel Syndrome Agents
2
MO
alosetron hydrochloride tabs 0.5mg
2
MO
alosetron hydrochloride tabs 1mg
AMITIZA CAPS 24MCG
4
AMITIZA CAPS 8MCG
4
LINZESS CAPS 145MCG
4
LINZESS CAPS 290MCG
4
VIBERZI TABS 100MG
5
VIBERZI TABS 75MG
5
Laxatives
1
MO
constulose soln 10gm/15ml
1
MO
enulose soln 10gm/15ml
1
gavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm
1
gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm
gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 11.2gm 1
1
MO
generlac soln 10gm/15ml
GOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM; 5.53GM; 4
21.5GM
KRISTALOSE PACK 10GM
4
MO
KRISTALOSE PACK 20GM
4
MO
1
MO
lactulose soln 10gm/15ml
1
MO
lactulose soln 10gm/15ml
MOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM;
4
2.691GM; 7.5GM
peg 3350/electrolytes solr 240gm; 2.98gm; 6.72gm; 5.84gm; 1
22.72gm
peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm; 5.86gm; 1
22.74gm
1
peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm;
5.72gm; 11.2gm
1
pegylax powd 0
1
polyethylene glycol 3350 powd 0
SUPREP BOWEL PREP SOLN 1.6GM/180ML;
4
3.13GM/180ML; 17.5GM/180ML
1
trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm
Protectants
CARAFATE SUSP 1GM/10ML
4
MO
1
MO
misoprostol tabs 100mcg
1
MO
misoprostol tabs 200mcg
1
MO
sucralfate tabs 1gm
Proton Pump Inhibitors
DEXILANT CPDR 30MG
4
DEXILANT CPDR 60MG
4
2
esomeprazole magnesium cpdr 20mg
2
esomeprazole magnesium cpdr 40mg
2
esomeprazole sodium inj 20mg
79
Drug
Drug Name
2
esomeprazole sodium inj 40mg
2
lansoprazole cpdr 15mg
2
lansoprazole cpdr 30mg
NEXIUM PACK 10MG
3
NEXIUM PACK 2.5MG
3
NEXIUM PACK 20MG
3
NEXIUM PACK 40MG
3
NEXIUM PACK 5MG
3
1
omeprazole cpdr 10mg
1
1
2
pantoprazole sodium inj 40mg
1
pantoprazole sodium tbec 20mg
1
pantoprazole sodium tbec 40mg
Genitourinary Agents
Antispasmodics, Urinary
1
MO
darifenacin er tb24 15mg
1
MO
darifenacin er tb24 7.5mg
1
MO
darifenacin hydrobromide er tb24 15mg
1
MO
darifenacin hydrobromide er tb24 7.5mg
ENABLEX TB24 15MG
3
ST MO
ENABLEX TB24 7.5MG
3
ST MO
1
MO
flavoxate hcl tabs 100mg
GELNIQUE GEL 10%
4
ST MO
MYRBETRIQ TB24 25MG
4
ST MO
MYRBETRIQ TB24 50MG
4
ST MO
2
MO
oxybutynin chloride er tb24 10mg
2
MO
2
MO
1
MO
oxybutynin chloride syrp 5mg/5ml
1
MO
oxybutynin chloride tabs 5mg
OXYTROL PTTW 3.9MG/24HR
4
2
MO
tolterodine tartrate er cp24 2mg
2
MO
tolterodine tartrate er cp24 4mg
2
MO
tolterodine tartrate tabs 1mg
2
MO
tolterodine tartrate tabs 2mg
TOVIAZ TB24 4MG
4
ST MO
TOVIAZ TB24 8MG
4
ST MO
2
MO
trospium chloride er cp24 60mg
2
MO
trospium chloride tabs 20mg
VESICARE TABS 10MG
4
ST MO
VESICARE TABS 5MG
4
ST MO
Benign Prostatic Hypertrophy Agents
2
MO
alfuzosin hcl er tb24 10mg
AVODART CAPS 0.5MG
4
MO
1
MO
doxazosin mesylate tabs 1mg
80
Drug
Drug Name
1
MO
1
MO
1
MO
doxazosin tabs 4mg
2
MO
dutasteride/tamsulosin hcl caps 0.5mg; 0.4mg
2
MO
dutasteride/tamsulosin hydrochloride caps 0.5mg; 0.4mg
2
MO
dutasteride caps 0.5mg
1
MO
finasteride tabs 5mg
JALYN CAPS 0.5MG; 0.4MG
4
MO
RAPAFLO CAPS 4MG
3
MO
RAPAFLO CAPS 8MG
3
MO
1
MO
tamsulosin hcl caps 0.4mg
1
MO
terazosin hcl caps 10mg
1
MO
1
MO
1
MO
Genitourinary Agents, Other
2
bethanechol chloride tabs 10mg
2
2
2
1
QL (4 EA per 30 days) GC ED
cialis tabs 10mg
1
cialis tabs 20mg
ELMIRON CAPS 100MG
4
1
viagra tabs 100mg
1
viagra tabs 25mg
1
viagra tabs 50mg
Phosphate Binders
1
MO
calcium acetate caps 667mg
1
MO
calcium acetate tabs 667mg
1
MO
eliphos tabs 667mg
FOSRENOL CHEW 1000MG
5
FOSRENOL CHEW 500MG
5
FOSRENOL CHEW 750MG
5
FOSRENOL PACK 1000MG
5
FOSRENOL PACK 750MG
5
PHOSLYRA SOLN 667MG/5ML
4
MO
RENVELA PACK 0.8GM
5
RENVELA PACK 2.4GM
5
2
MO
sevelamer carbonate tabs 800mg
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
2
a-hydrocort inj 100mg
1
alclometasone dipropionate crea 0.05%
1
alclometasone dipropionate oint 0.05%
1
alphatrex gel 0.05%
2
amcinonide crea 0.1%
81
Drug
Drug Name
2
amcinonide lotn 0.1%
2
apexicon e crea 0.05%
1
augmented betamethasone dipropionate crea 0.05%
1
augmented betamethasone dipropionate gel 0.05%
1
augmented betamethasone dipropionate lotn 0.05%
1
augmented betamethasone dipropionate oint 0.05%
1
baycadron elix 0.5mg/5ml
1
betamethasone dipropionate crea 0.05%
1
betamethasone dipropionate lotn 0.05%
1
betamethasone dipropionate oint 0.05%
1
betamethasone valerate crea 0.1%
1
betamethasone valerate foam 0.12%
1
betamethasone valerate lotn 0.1%
1
betamethasone valerate oint 0.1%
CAPEX SHAM 0.01%
4
2
clobetasol propionate e crea 0.05%
2
clobetasol propionate emollient crea 0.05%
2
clobetasol propionate foam 0.05%
2
clobetasol propionate gel 0.05%
2
clobetasol propionate liqd 0.05%
2
clobetasol propionate lotn 0.05%
2
clobetasol propionate oint 0.05%
2
clobetasol propionate sham 0.05%
2
clobetasol propionate soln 0.05%
2
clodan sham 0.05%
1
clotrimazole/betamethasone dipropionate crea 0.05%; 1%
2
clotrimazole/betamethasone dipropionate lotn 0.05%; 1%
CORDRAN TAPE TAPE 4MCG/SQCM
4
2
cormax scalp application soln 0.05%
2
cormax oint 0.05%
2
cormax soln 0.05%
2
cortisone acetate tabs 25mg
CORTISPORIN CREA 0.5%; 3.5MG/GM; 10000UNIT/GM 4
1
deltasone tabs 20mg
2
desonide crea 0.05%
2
desonide lotn 0.05%
2
desonide oint 0.05%
2
desoximetasone crea 0.05%
2
desoximetasone crea 0.25%
2
desoximetasone gel 0.05%
2
desoximetasone oint 0.05%
2
desoximetasone oint 0.25%
1
dexamethasone intensol conc 1mg/ml
1
dexamethasone sodium phosphate inj 10mg/ml
1
dexamethasone sodium phosphate inj 120mg/30ml
1
dexamethasone sodium phosphate inj 20mg/5ml
82
Drug
Drug Name
1
dexamethasone elix 0.5mg/5ml
1
dexamethasone tabs 0.5mg
1
1
1
dexamethasone tabs 1mg
1
1
1
2
diflorasone diacetate crea 0.05%
2
diflorasone diacetate oint 0.05%
1
MO
fludrocortisone acetate tabs 0.1mg
2
fluocinolone acetonide ear drops oil 0.01%
2
fluocinolone acetonide crea 0.01%
2
fluocinolone acetonide crea 0.025%
2
fluocinolone acetonide oil 0.01%
2
fluocinolone acetonide oint 0.025%
1
fluocinonide-e crea 0.05%
1
fluocinonide crea 0.1%
1
fluocinonide gel 0.05%
1
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
2
flurandrenolide crea 0.05%
1
fluticasone propionate crea 0.05%
1
fluticasone propionate oint 0.005%
2
halobetasol propionate crea 0.05%
2
halobetasol propionate oint 0.05%
HALOG CREA 0.1%
4
HALOG OINT 0.1%
4
2
hydrocortisone butyrate (lipid) crea 0.1%
2
hydrocortisone butyrate (lipophilic) crea 0.1%
2
hydrocortisone butyrate crea 0.1%
2
hydrocortisone butyrate oint 0.1%
2
hydrocortisone butyrate soln 0.1%
2
hydrocortisone valerate crea 0.2%
2
hydrocortisone valerate oint 0.2%
1
hydrocortisone crea 2.5%
1
hydrocortisone crea 1%
1
hydrocortisone lotn 2.5%
1
hydrocortisone oint 2.5%
1
hydrocortisone tabs 10mg
1
1
2
lokara lotn 0.05%
1
methylprednisolone acetate inj 40mg/ml
1
methylprednisolone acetate inj 80mg/ml
1
methylprednisolone dose pack tbpk 4mg
83
Drug
Drug Name
1
methylprednisolone sodiumsuccinate inj 1000mg
1
1
1
methylprednisolone tabs 16mg
1
1
1
MILLIPRED SOLN 10MG/5ML
4
MILLIPRED TABS 5MG
3
1
mometasone furoate crea 0.1%
1
mometasone furoate oint 0.1%
1
mometasone furoate soln 0.1%
PANDEL CREA 0.1%
4
1
prednicarbate crea 0.1%
1
prednicarbate oint 0.1%
2
prednisolone sodium phosphate odt tbdp 10mg
2
2
1
prednisolone sodium phosphate soln 15mg/5ml
1
1
1
prednisone intensol conc 5mg/ml
1
prednisone soln 5mg/5ml
1
prednisone tabs 10mg
1
prednisone tabs 1mg
1
prednisone tabs 2.5mg
1
1
1
prednisone tabs 5mg
1
procto-med hc crea 2.5%
1
procto-pak crea 1%
1
proctosol hc crea 2.5%
1
proctozone-hc crea 2.5%
2
psorcon crea 0.05%
SOLU-CORTEF INJ 250MG
4
TACLONEX SUSP 0.064%; 0.005%
4
2
triamcinolone acetonide aers 0.147mg/gm
1
triamcinolone acetonide crea 0.025%
1
1
1
triamcinolone acetonide lotn 0.025%
1
triamcinolone acetonide lotn 0.1%
1
triamcinolone acetonide oint 0.025%
1
1
1
triderm crea 0.1%
84
Drug
Drug Name
1
u-cort crea 1%; 10%
VERIPRED 20 SOLN 20MG/5ML
4
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
2
PA
chorionic gonadotropin inj 10000unit
2
desmopressin acetate inj 4mcg/ml
2
MO
desmopressin acetate soln 0.01%
2
MO
desmopressin acetate soln 0.01%
2
MO
desmopressin acetate tabs 0.1mg
2
MO
desmopressin acetate tabs 0.2mg
GENOTROPIN MINIQUICK INJ 0.2MG
4
PA MO
5
PA
5
PA
5
PA
5
PA
5
PA
5
PA
5
PA
GENOTROPIN MINIQUICK INJ 1MG
5
PA
GENOTROPIN MINIQUICK INJ 2MG
5
PA
GENOTROPIN INJ 12MG
5
PA
GENOTROPIN INJ 5MG
5
PA
H.P. ACTHAR INJ 80UNIT/ML
5
PA
HUMATROPE COMBO PACK INJ 5MG
5
PA
HUMATROPE INJ 12MG
5
PA
HUMATROPE INJ 24MG
5
PA
HUMATROPE INJ 5MG
5
PA
HUMATROPE INJ 6MG
5
PA
INCRELEX INJ 40MG/4ML
5
NORDITROPIN FLEXPRO INJ 10MG/1.5ML
5
PA
5
PA
NORDITROPIN FLEXPRO INJ 30MG/3ML
5
PA
5
PA
2
PA
novarel inj 10000unit
NUTROPIN AQ NUSPIN 10 INJ 10MG/2ML
5
PA
5
PA
5
PA
NUTROPIN AQ PEN INJ 10MG/2ML
5
PA
NUTROPIN AQ PEN INJ 20MG/2ML
5
PA
OMNITROPE INJ 10MG/1.5ML
5
PA
OMNITROPE INJ 5.8MG
5
PA
OMNITROPE INJ 5MG/1.5ML
4
PA MO
2
PA
pregnyl w/diluent benzyl alcohol/nacl inj 10000unit
SAIZEN CLICK.EASY INJ 8.8MG
5
PA
SAIZEN INJ 5MG
5
PA
SAIZEN INJ 8.8MG
5
PA
85
Drug
Drug Name
SEROSTIM INJ 4MG
5
PA
SEROSTIM INJ 5MG
5
PA
SEROSTIM INJ 6MG
5
PA
TEV-TROPIN INJ 5MG
5
PA
ZOMACTON INJ 10MG
5
PA
ZOMACTON INJ 5MG
5
PA
ZORBTIVE INJ 8.8MG
5
PA
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM TABS 300MG
5
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
ANADROL-50 TABS 50MG
4
5
oxandrolone tabs 10mg
2
oxandrolone tabs 2.5mg
Androgens
ANDROGEL PUMP GEL 1.62%
3
PA MO
ANDROGEL GEL 20.25MG/1.25GM
3
PA MO
ANDROGEL GEL 40.5MG/2.5GM
3
PA MO
ANDROID CAPS 10MG
4
MO
ANDROXY TABS 10MG
4
MO
2
danazol caps 100mg
2
danazol caps 200mg
2
danazol caps 50mg
METHITEST TABS 10MG
3
MO
2
MO
methyltestosterone caps 10mg
2
PA
testosterone cypionate inj 100mg/ml
2
PA
testosterone cypionate inj 200mg/ml
2
testosterone enanthate inj 200mg/ml
2
PA MO
testosterone pump gel 1%
2
PA MO
testosterone gel 1%
2
PA MO
testosterone gel 25mg/2.5gm
TESTRED CAPS 10MG
4
MO
Estrogens
1
MO
altavera tabs 0.03mg; 0.15mg
2
MO
alyacen 1/35 tabs 35mcg; 1mg
1
MO
alyacen 7/7/7 tabs 0; 0
2
amethia tabs 0; 0
2
MO
amethyst tabs 20mcg; 90mcg
1
MO
apri tabs 0.15mg; 30mcg
2
MO
aranelle tabs 0; 0
2
ashlyna tabs 0; 0
1
MO
aubra tabs 20mcg; 0.1mg
86
Drug
Drug Name
1
MO
aviane tabs 20mcg; 0.1mg
2
MO
azurette tabs 0; 0
2
MO
balziva tabs 35mcg; 0.4mg
2
MO
bekyree tabs 0; 0
1
MO
blisovi 24 fe tabs 20mcg; 75mg; 1mg
1
MO
blisovi fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
1
MO
blisovi fe 1/20 tabs 20mcg; 75mg; 1mg
2
MO
briellyn tabs 35mcg; 0.4mg
2
camrese tabs 0; 0
2
camrese tabs 0; 0
2
MO
caziant tabs 0; 0
1
MO
chateal tabs 0.03mg; 0.15mg
1
MO
1
MO
COMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY
4
PA MO
COMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY
4
PA MO
1
MO
cryselle-28 tabs 30mcg; 0.3mg
2
MO
cyclafem 1/35 tabs 35mcg; 1mg
1
MO
cyclafem 7/7/7 tabs 0; 0
1
MO
cyred tabs 0.15mg; 30mcg
2
MO
dasetta 1/35 tabs 35mcg; 1mg
2
MO
dasetta 1/35 tabs 35mcg; 1mg
1
MO
dasetta 7/7/7 tabs 0; 0
1
MO
dasetta 7/7/7 tabs 0; 0
2
daysee tabs 0; 0
2
daysee tabs 0; 0
DELESTROGEN INJ 10MG/ML
4
1
MO
delyla tabs 20mcg; 0.1mg
DEPO-ESTRADIOL INJ 5MG/ML
4
1
MO
desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg
1
MO
desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg
2
MO
desogestrel/ethinyl estradiol tabs 0; 0
DIVIGEL GEL 0.25MG/0.25GM
4
PA MO
DIVIGEL GEL 0.5MG/0.5GM
4
PA MO
2
MO
drospirenone/ethinyl estradiol tabs 3mg; 0.02mg
2
MO
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg
ELESTRIN GEL 0.06%
4
PA MO
1
MO
elinest tabs 30mcg; 0.3mg
1
MO
emoquette tabs 0.15mg; 30mcg
1
MO
enpresse-28 tabs 0; 0
1
MO
enskyce tabs 0.15mg; 30mcg
1
MO
enskyce tabs 0.15mg; 30mcg
1
MO
estarylla tabs 35mcg; 0.25mg
ESTRACE CREA 0.1MG/GM
4
MO
2
estradiol valerate inj 10mg/ml
2
87
Drug
Drug Name
2
2
PA MO
estradiol/norethindrone acetate tabs 0.5mg; 0.1mg
2
PA MO
estradiol pttw 0.025mg/24hr
2
PA MO
2
PA MO
2
PA MO
2
PA MO
1
PA MO
estradiol tabs 0.5mg
1
PA MO
estradiol tabs 1mg
1
PA MO
estradiol tabs 2mg
ESTRING RING 2MG
4
1
MO
falmina tabs 20mcg; 0.1mg
FEMRING RING 0.05MG/24HR
4
FEMRING RING 0.1MG/24HR
4
1
PA MO
fyavolv tabs 2.5mcg; 0.5mg
1
PA MO
fyavolv tabs 5mcg; 1mg
2
MO
gianvi tabs 3mg; 0.02mg
2
MO
gildagia tabs 35mcg; 0.4mg
1
MO
gildess 1.5/30 tabs 30mcg; 1.5mg
1
MO
gildess 1/20 tabs 20mcg; 1mg
1
MO
1
MO
1
MO
gildess 24 fe tabs 20mcg; 75mg; 1mg
1
MO
gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
1
MO
gildess fe 1/20 tabs 20mcg; 75mg; 1mg
2
introvale tabs 0.03mg; 0.15mg
1
PA MO
jevantique lo tabs 2.5mcg; 0.5mg
1
PA MO
jevantique tabs 5mcg; 1mg
1
PA MO
jinteli tabs 5mcg; 1mg
2
jolessa tabs 0.03mg; 0.15mg
1
MO
juleber tabs 0.15mg; 30mcg
1
MO
junel 1.5/30 tabs 30mcg; 1.5mg
1
MO
junel 1/20 tabs 20mcg; 1mg
1
MO
junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
1
MO
junel fe 1/20 tabs 20mcg; 75mg; 1mg
1
MO
junel fe 24 tabs 20mcg; 75mg; 1mg
2
MO
kaitlib fe chew 25mcg; 75mg; 0.8mg
2
MO
kariva tabs 0; 0
2
MO
kelnor 1/35 tabs 35mcg; 1mg
2
MO
kimidess tabs 0; 0
1
MO
kurvelo tabs 0.03mg; 0.15mg
1
MO
kurvelo tabs 0.03mg; 0.15mg
1
MO
larin 1.5/30 tabs 30mcg; 1.5mg
1
MO
larin 1/20 tabs 20mcg; 1mg
1
MO
larin 24 fe tabs 20mcg; 75mg; 1mg
1
MO
larin 24 fe tabs 20mcg; 75mg; 1mg
88
Drug
Drug Name
1
MO
larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
1
MO
larin fe 1/20 tabs 20mcg; 75mg; 1mg
2
MO
layolis fe chew 25mcg; 75mg; 0.8mg
2
MO
leena tabs 0; 0
1
MO
lessina tabs 20mcg; 0.1mg
1
MO
levonest tabs 0; 0
2
MO
levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg
1
MO
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg
2
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg
2
levonorgestrel/ethinyl estradiol tabs 0; 0
1
MO
levonorgestrel/ethinyl estradiol tabs 0; 0
1
MO
levonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg
1
MO
levora 0.15/30-28 tabs 30mcg; 0.15mg
1
MO
lomedia 24 fe tabs 20mcg; 75mg; 1mg
2
PA MO
lopreeza tabs 0.5mg; 0.1mg
2
MO
loryna tabs 3mg; 0.02mg
1
MO
low-ogestrel tabs 30mcg; 0.3mg
1
MO
lutera tabs 20mcg; 0.1mg
1
MO
marlissa tabs 0.03mg; 0.15mg
MENOSTAR PTWK 14MCG/24HR
4
PA MO
1
MO
microgestin 1.5/30 tabs 30mcg; 1.5mg
1
MO
microgestin 1/20 tabs 20mcg; 1mg
1
MO
microgestin 24 fe tabs 20mcg; 75mg; 1mg
1
MO
microgestin 24 fe tabs 20mcg; 75mg; 1mg
1
MO
microgestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
1
MO
microgestin fe tabs 20mcg; 75mg; 1mg
2
PA MO
mimvey lo tabs 0.5mg; 0.1mg
1
MO
mono-linyah tabs 35mcg; 0.25mg
1
MO
mono-linyah tabs 35mcg; 0.25mg
1
MO
mononessa tabs 35mcg; 0.25mg
1
MO
myzilra tabs 0; 0
2
MO
necon 0.5/35-28 tabs 35mcg; 0.5mg
2
MO
necon 1/35 tabs 35mcg; 1mg
1
MO
necon 7/7/7 tabs 0; 0
2
MO
nikki tabs 3mg; 0.02mg
2
MO
norethindrone & ethinyl estradiol ferrous fumarate chew
25mcg; 75mg; 0.8mg
MO
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 1
20mcg; 75mg; 1mg
MO
norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 1
20mcg; 75mg; 1mg
PA MO
norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg 1
1
MO
norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg
1
PA MO
norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg
1
MO
norgestimate/ethinyl estradiol tabs 0; 0
1
MO
norgestimate/ethinyl estradiol tabs 0; 0
89
Drug
Drug Name
1
MO
norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg
1
MO
norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg
2
MO
nortrel 0.5/35 (28) tabs 35mcg; 0.5mg
2
MO
nortrel 1/35 tabs 35mcg; 1mg
2
MO
nortrel 1/35 tabs 35mcg; 1mg
1
MO
nortrel 7/7/7 tabs 0; 0
2
MO
ocella tabs 3mg; 0.03mg
1
MO
ogestrel tabs 50mcg; 0.5mg
1
MO
orsythia tabs 20mcg; 0.1mg
2
MO
philith tabs 35mcg; 0.4mg
2
MO
philith tabs 35mcg; 0.4mg
2
MO
pimtrea tabs 0; 0
2
MO
pirmella 1/35 tabs 35mcg; 1mg
1
MO
pirmella 7/7/7 tabs 0; 0
1
MO
pirmella 7/7/7 tabs 0; 0
1
MO
portia-28 tabs 0.03mg; 0.15mg
PREMARIN CREA 0.625MG/GM
4
MO
1
MO
previfem tabs 35mcg; 0.25mg
2
quasense tabs 0.03mg; 0.15mg
1
MO
reclipsen tabs 0.15mg; 30mcg
2
setlakin tabs 0.03mg; 0.15mg
1
MO
sprintec 28 tabs 35mcg; 0.25mg
1
MO
sronyx tabs 20mcg; 0.1mg
2
MO
syeda tabs 3mg; 0.03mg
1
MO
tarina fe 1/20 tabs 20mcg; 75mg; 1mg
2
MO
tilia fe tabs 0; 75mg; 1mg
1
MO
tri-estarylla tabs 0; 0
2
MO
tri-legest fe tabs 0; 75mg; 1mg
1
MO
tri-linyah tabs 0; 0
1
MO
tri-linyah tabs 0; 0
1
MO
tri-lo-estarylla tabs 0; 0
1
MO
tri-lo-marzia tabs 0; 0
1
MO
tri-lo-sprintec tabs 0; 0
1
MO
tri-previfem tabs 0; 0
1
MO
tri-sprintec tabs 0; 0
1
MO
trinessa lo tabs 0; 0
1
MO
trinessa tabs 0; 0
1
MO
trivora-28 tabs 0; 0
VAGIFEM TABS 10MCG
4
MO
2
MO
velivet tabs 0; 0
2
MO
vestura tabs 3mg; 0.02mg
1
MO
vienva tabs 20mcg; 0.1mg
2
MO
viorele tabs 0; 0
2
MO
viorele tabs 0; 0
2
MO
vyfemla tabs 35mcg; 0.4mg
2
MO
wera tabs 35mcg; 0.5mg
90
Drug
Drug Name
2
MO
wera tabs 35mcg; 0.5mg
2
MO
wymzya fe chew 35mcg; 0; 0.4mg
2
MO
xulane ptwk 35mcg/24hr; 150mcg/24hr
2
MO
zarah tabs 3mg; 0.03mg
2
MO
zenchent fe chew 35mcg; 0; 0.4mg
2
MO
zenchent tabs 35mcg; 0.4mg
2
MO
zeosa chew 35mcg; 0; 0.4mg
2
MO
zovia 1/35e tabs 35mcg; 1mg
2
MO
zovia 1/50e tabs 50mcg; 1mg
Progesterone Agonists/Antagonists
ELLA TABS 30MG
3
Progestins
1
MO
camila tabs 0.35mg
CRINONE GEL 4%
4
CRINONE GEL 8%
4
1
MO
deblitane tabs 0.35mg
DEPO-PROVERA INJ 400MG/ML
4
DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML
4
1
MO
errin tabs 0.35mg
1
MO
heather tabs 0.35mg
1
MO
jencycla tabs 0.35mg
1
MO
jencycla tabs 0.35mg
1
MO
jolivette tabs 0.35mg
1
MO
lyza tabs 0.35mg
2
medroxyprogesterone acetate inj 150mg/ml
1
MO
medroxyprogesterone acetate tabs 10mg
1
MO
medroxyprogesterone acetate tabs 2.5mg
1
MO
medroxyprogesterone acetate tabs 5mg
2
PA
megestrol acetate susp 40mg/ml
2
PA MO
megestrol acetate susp 625mg/5ml
2
PA
megestrol acetate tabs 20mg
2
PA
megestrol acetate tabs 40mg
1
MO
nora-be tabs 0.35mg
2
MO
norethindrone acetate tabs 5mg
1
MO
norethindrone tabs 0.35mg
1
MO
norlyroc tabs 0.35mg
2
MO
progesterone caps 100mg
2
MO
progesterone caps 200mg
1
MO
sharobel tabs 0.35mg
Selective Estrogen Receptor Modifying Agents
2
MO
raloxifene hydrochloride tabs 60mg
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
1
MO
levo-t tabs 100mcg
1
MO
levo-t tabs 112mcg
1
MO
levo-t tabs 125mcg
91
Drug
Drug Name
1
MO
levo-t tabs 137mcg
1
MO
levo-t tabs 150mcg
1
MO
levo-t tabs 175mcg
1
MO
levo-t tabs 200mcg
1
MO
levo-t tabs 25mcg
1
MO
levo-t tabs 300mcg
1
MO
levo-t tabs 50mcg
1
MO
levo-t tabs 75mcg
1
MO
levo-t tabs 88mcg
2
levothyroxine sodium inj 100mcg
1
MO
levothyroxine sodium tabs 100mcg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
levoxyl tabs 100mcg
1
MO
levoxyl tabs 112mcg
1
MO
levoxyl tabs 125mcg
1
MO
levoxyl tabs 137mcg
1
MO
levoxyl tabs 150mcg
1
MO
levoxyl tabs 175mcg
1
MO
levoxyl tabs 200mcg
1
MO
levoxyl tabs 25mcg
1
MO
levoxyl tabs 50mcg
1
MO
levoxyl tabs 75mcg
1
MO
levoxyl tabs 88mcg
1
MO
liothyronine sodium tabs 25mcg
1
MO
1
MO
SYNTHROID TABS 100MCG
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
MO
92
Drug
Drug Name
3
MO
3
MO
THYROLAR-1/2 TABS 30MG
4
MO
THYROLAR-1/4 TABS 15MG
4
MO
THYROLAR-1 TABS 60MG
4
MO
4
MO
4
MO
TIROSINT CAPS 100MCG
4
MO
4
MO
4
MO
4
MO
TIROSINT CAPS 13MCG
4
MO
4
MO
TIROSINT CAPS 25MCG
4
MO
TIROSINT CAPS 50MCG
4
MO
TIROSINT CAPS 75MCG
4
MO
TIROSINT CAPS 88MCG
4
MO
1
MO
unithroid direct tabs 100mcg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
unithroid tabs 100mcg
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
1
MO
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN TABS 500MG
3
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
3
MO
93
Drug
Drug Name
SENSIPAR TABS 60MG
5
SENSIPAR TABS 90MG
5
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
2
cabergoline tabs 0.5mg
ELIGARD INJ 22.5MG
4
ELIGARD INJ 30MG
4
ELIGARD INJ 45MG
4
ELIGARD INJ 7.5MG
4
FIRMAGON INJ 120MG
5
FIRMAGON INJ 80MG
4
2
leuprolide acetate inj 1mg/0.2ml
LUPANETA PACK KIT 11.25MG; 5MG
5
LUPANETA PACK KIT 3.75MG; 5MG
5
LUPRON DEPOT-PED INJ 11.25MG
5
LUPRON DEPOT-PED INJ 15MG
5
LUPRON DEPOT INJ 22.5MG
5
5
LUPRON DEPOT INJ 30MG
5
LUPRON DEPOT INJ 45MG
5
5
5
PA
octreotide acetate inj 1000mcg/ml
2
PA MO
2
PA MO
5
PA
2
PA MO
SANDOSTATIN LAR DEPOT INJ 10MG
5
PA
5
PA
5
PA
SIGNIFOR LAR INJ 20MG
5
5
5
SIGNIFOR INJ 0.3MG/ML
5
5
5
SOMATULINE DEPOT INJ 120MG/0.5ML
5
PA
5
PA
5
PA
SOMAVERT INJ 10MG
5
PA
SOMAVERT INJ 15MG
5
PA
SOMAVERT INJ 20MG
5
PA
SOMAVERT INJ 25MG
5
PA
SOMAVERT INJ 30MG
5
PA
SYNAREL SOLN 2MG/ML
5
TRELSTAR MIXJECT INJ 11.25MG
5
5
94
Drug
Drug Name
5
TRELSTAR INJ 11.25MG
5
TRELSTAR INJ 3.75MG
5
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
1
MO
methimazole tabs 10mg
1
MO
methimazole tabs 5mg
1
MO
propylthiouracil tabs 50mg
Immunological Agents
Angioedema (HAE) Agents
CINRYZE INJ 500UNIT
5
PA
FIRAZYR INJ 30MG/3ML
5
PA
Immune Suppressants
ASTAGRAF XL CP24 0.5MG
4
B/D MO
ASTAGRAF XL CP24 1MG
4
B/D MO
ASTAGRAF XL CP24 5MG
4
B/D MO
AZASAN TABS 100MG
4
B/D MO
AZASAN TABS 75MG
4
B/D MO
2
B/D
azathioprine inj 100mg
1
B/D MO
azathioprine tabs 50mg
BENLYSTA INJ 120MG
5
PA
BENLYSTA INJ 400MG
5
PA
CELLCEPT SUSR 200MG/ML
5
B/D
CIMZIA INJ 200MG/ML
5
PA
CIMZIA INJ 200MG
5
PA
2
B/D MO
cyclosporine modified caps 100mg
2
B/D MO
2
B/D MO
2
B/D MO
cyclosporine modified soln 100mg/ml
2
B/D MO
cyclosporine caps 100mg
2
B/D MO
cyclosporine caps 25mg
ENBREL SURECLICK INJ 50MG/ML
5
PA
ENBREL INJ 25MG/0.5ML
5
PA
ENBREL INJ 25MG
5
PA
ENBREL INJ 50MG/ML
5
PA
ENVARSUS XR TB24 0.75MG
4
B/D MO
ENVARSUS XR TB24 1MG
4
B/D MO
ENVARSUS XR TB24 4MG
4
B/D MO
2
B/D MO
gengraf caps 100mg
2
B/D MO
gengraf caps 25mg
2
B/D MO
gengraf soln 100mg/ml
2
B/D MO
hecoria caps 0.5mg
2
B/D MO
hecoria caps 1mg
2
B/D MO
hecoria caps 5mg
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
5
PA
PACK INJ 40MG/0.8ML
95
Drug
Drug Name
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
5
PA
PACK INJ 40MG/0.8ML
HUMIRA PEN-CROHNS DISEASESTARTER INJ
5
PA
40MG/0.8ML
HUMIRA PEN-PSORIASIS STARTER INJ 40MG/0.8ML 5
PA
HUMIRA PEN INJ 40MG/0.8ML
5
PA
HUMIRA INJ 10MG/0.2ML
5
PA
5
PA
5
PA
KINERET INJ 100MG/0.67ML
5
PA
1
methotrexate sodium inj 1gm/40ml
1
methotrexate tabs 2.5mg
2
B/D MO
mycophenolate mofetil caps 250mg
2
B/D MO
mycophenolate mofetil susr 200mg/ml
2
B/D MO
mycophenolate mofetil tabs 500mg
2
B/D MO
mycophenolic acid dr tbec 180mg
2
B/D MO
mycophenolic acid dr tbec 360mg
NULOJIX INJ 250MG
5
PA
ORENCIA INJ 125MG/ML
5
PA
ORENCIA INJ 250MG
5
PA
RAPAMUNE SOLN 1MG/ML
5
B/D
REMICADE INJ 100MG
5
PA
RHEUMATREX TABS 2.5MG
4
MO
4
MO
4
MO
4
MO
4
MO
SIMPONI ARIA INJ 50MG/4ML
5
PA
SIMPONI INJ 100MG/ML
5
PA
SIMPONI INJ 100MG/ML
5
PA
SIMPONI INJ 50MG/0.5ML
5
PA
SIMPONI INJ 50MG/0.5ML
5
PA
2
B/D MO
sirolimus tabs 0.5mg
2
B/D MO
sirolimus tabs 1mg
2
B/D MO
sirolimus tabs 2mg
2
B/D MO
tacrolimus caps 0.5mg
2
B/D MO
tacrolimus caps 1mg
2
B/D MO
tacrolimus caps 5mg
TREXALL TABS 10MG
4
TREXALL TABS 15MG
4
ZORTRESS TABS 0.25MG
4
PA MO
ZORTRESS TABS 0.5MG
5
PA
ZORTRESS TABS 0.75MG
5
PA
Immunizing Agents, Passive
ATGAM INJ 50MG/ML
5
BIVIGAM INJ 10GM/100ML
5
B/D
96
Drug
Drug Name
BIVIGAM INJ 5GM/50ML
5
B/D
CARIMUNE NANOFILTERED INJ 6GM
5
PA
FLEBOGAMMA DIF INJ 0.5GM/10ML
5
B/D
FLEBOGAMMA DIF INJ 10%
5
B/D
5
B/D
5
B/D
5
B/D
5
B/D
FLEBOGAMMA DIF INJ 10GM/200ML
5
B/D
FLEBOGAMMA DIF INJ 2.5GM/50ML
5
B/D
5
B/D
5
B/D
FLEBOGAMMA INJ 0.5GM/10ML
5
B/D
GAMASTAN S/D INJ 0
3
PA
GAMMAGARD LIQUID INJ 10GM/100ML
5
PA
5
PA
GAMMAGARD LIQUID INJ 2.5GM/25ML
5
PA
5
PA
5
PA
GAMMAKED INJ 10GM/100ML
5
PA
5
PA
GAMMAKED INJ 2.5GM/25ML
5
PA
5
PA
5
PA
GAMUNEX-C INJ 10GM/100ML
5
PA
5
PA
5
PA
GAMUNEX-C INJ 2.5GM/25ML
5
PA
GAMUNEX-C INJ 2.5GM/25ML
5
PA
5
PA
5
PA
5
PA
5
PA
5
PA
5
PA
HYPERRAB S/D INJ 150UNIT/ML
3
B/D
HYPERRAB S/D INJ 150UNIT/ML
3
B/D
IMOGAM RABIES-HT INJ 150UNIT/ML
3
B/D
IMOGAM RABIES-HT INJ 150UNIT/ML
3
B/D
OCTAGAM INJ 10GM/100ML
5
B/D
5
B/D
5
B/D
OCTAGAM INJ 2.5GM/50ML
5
B/D
5
B/D
5
B/D
5
B/D
97
Drug
Drug Name
5
B/D
PRIVIGEN INJ 10GM/100ML
5
B/D
5
B/D
5
B/D
Immunomodulators
ACTEMRA INJ 200MG/10ML
5
PA
5
5
ACTIMMUNE INJ 2000000UNIT/0.5ML
5
ARCALYST INJ 220MG
5
PA
ILARIS INJ 180MG
5
PA
2
MO
leflunomide tabs 10mg
2
MO
leflunomide tabs 20mg
OTEZLA TABS 30MG
5
PA
OTEZLA TBPK 0
5
RIDAURA CAPS 3MG
5
SYNAGIS INJ 50MG/0.5ML
5
TECFIDERA STARTER PACK MISC 0
5
PA
TECFIDERA CPDR 120MG
5
TECFIDERA CPDR 240MG
5
XELJANZ XR TB24 11MG
5
XELJANZ TABS 5MG
5
PA
Vaccines
ACTHIB INJ 0
3
ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML
3
BCG VACCINE INJ 0
3
BEXSERO INJ 0
3
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
3
5LF/0.5ML
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
3
5LF/0.5ML
CERVARIX INJ 0
3
COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML
3
DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 3
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
3
PEDIATRIC INJ 25LFU/0.5ML; 5LFU/0.5ML
ENGERIX-B INJ 10MCG/0.5ML
3
B/D
ENGERIX-B INJ 10MCG/0.5ML
3
B/D
ENGERIX-B INJ 20MCG/ML
3
B/D
GARDASIL 9 INJ 0
3
GARDASIL 9 INJ 0
3
GARDASIL INJ 0
3
GARDASIL INJ 0
3
HAVRIX INJ 1440ELU/ML
3
HAVRIX INJ 720ELU/0.5ML
3
HYQVIA INJ 10GM/100ML; 800UNIT/5ML
5
PA
98
Drug
Drug Name
HYQVIA INJ 2.5GM/25ML; 200UNT/1.25ML
5
PA
5
PA
5
PA
HYQVIA INJ 5GM/50ML; 400UNIT/2.5ML
5
PA
IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML
3
B/D
INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML;
3
10LFU/0.5ML
IPOL INACTIVATED IPV INJ 0
3
IXIARO INJ 0
3
KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;
3
10LFU/0.5ML
KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;
3
10LFU/0.5ML
M-M-R II INJ 0; 0; 0
3
MENACTRA INJ 0
3
MENHIBRIX INJ 2.5MCG; 5MCG; 5MCG
3
MENOMUNE-A/C/Y/W-135 INJ 0
3
MENVEO INJ 0
3
PEDVAX HIB INJ 7.5MCG/0.5ML
3
PROQUAD INJ 0; 0; 0; 0
3
QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0;
3
5LFU/0.5ML
RABAVERT INJ 0
3
B/D
RECOMBIVAX HB INJ 10MCG/ML
3
B/D
3
B/D
3
B/D
RECOMBIVAX HB INJ 5MCG/0.5ML
3
B/D
ROTARIX SUSR 0
3
ROTATEQ SOLN 0
3
TENIVAC INJ 2LFU; 5LFU
3
TETANUS TOXOID ADSORBED INJ 5LFU
3
B/D
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED INJ
3
2LF/0.5ML; 2LF/0.5ML
TRUMENBA INJ 0
3
TWINRIX INJ 720ELU/ML; 20MCG/ML
3
TYPHIM VI INJ 25MCG/0.5ML
3
TYPHIM VI INJ 25MCG/0.5ML
3
VAQTA INJ 25UNIT/0.5ML
3
VAQTA INJ 50UNIT/ML
3
VARIVAX INJ 1350PFU/0.5ML
3
VARIZIG INJ 125UNIT/1.2ML
3
PA
YF-VAX INJ 0
3
ZOSTAVAX INJ 19400UNT/0.65ML
3
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO CP24 0.375GM
3
MO
99
Drug
Drug Name
ASACOL HD TBEC 800MG
3
2
balsalazide disodium caps 750mg
CANASA SUPP 1000MG
4
DIPENTUM CAPS 250MG
4
MO
LIALDA TBEC 1.2GM
4
2
mesalamine kit 4gm
PENTASA CPCR 250MG
4
MO
PENTASA CPCR 500MG
4
MO
Glucocorticoids
2
budesonide cpep 3mg
1
colocort enem 100mg/60ml
1
hydrocortisone enem 100mg/60ml
UCERIS FOAM 2MG/ACT
4
UCERIS TB24 9MG
5
Sulfonamides
1
MO
sulfasalazine tabs 500mg
1
MO
sulfasalazine tbec 500mg
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
1
MO
alendronate sodium soln 70mg/75ml
1
MO
alendronate sodium tabs 10mg
1
1
1
MO
1
2
QL (3.7 ML per 30 days) MO
calcitonin salmon soln 200unit/act
2
calcitonin-salmon soln 200unit/act
2
MO
calcitriol caps 0.25mcg
2
MO
calcitriol caps 0.5mcg
2
MO
doxercalciferol caps 0.5mcg
5
doxercalciferol caps 1mcg
5
doxercalciferol caps 2.5mcg
2
doxercalciferol inj 4mcg/2ml
2
etidronate disodium tabs 200mg
2
etidronate disodium tabs 400mg
FORTEO INJ 600MCG/2.4ML
5
FORTICAL SOLN 200UNIT/ACT
3
FOSAMAX PLUS D TABS 70MG; 2800UNIT
4
FOSAMAX PLUS D TABS 70MG; 5600UNIT
4
2
ibandronate sodium inj 3mg/3ml
2
MO
ibandronate sodium tabs 150mg
MIACALCIN INJ 200UNIT/ML
4
MIACALCIN SOLN 200UNIT/ACT
4
2
pamidronate disodium inj 30mg/10ml
PAMIDRONATE DISODIUM INJ 6MG/ML
4
2
pamidronate disodium inj 90mg/10ml
100
Drug
Drug Name
2
MO
paricalcitol caps 1mcg
2
MO
2
MO
2
paricalcitol inj 2mcg/ml
2
paricalcitol inj 5mcg/ml
PROLIA INJ 60MG/ML
4
2
risedronate sodium dr tbec 35mg
2
risedronate sodium tabs 150mg
2
2
2
2
2
MO
XGEVA INJ 120MG/1.7ML
5
PA
5
PA
zoledronic acid inj 4mg/100ml
2
PA
2
PA
ZOMETA INJ 4MG/100ML
5
PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
1
argyle sterile water 100ml soln 0
2
bd insulin syringe safetyglide/1ml/29g x 1/2" misc
2
bd insulin syringe ultrafine/0.3ml/31g x 5/16" misc
2
bd insulin syringe ultrafine/0.5ml/30g x 1/2" misc
2
bd insulin syringe ultrafine/1ml/31g x 5/16" misc
2
bd pen needle/ultrafine/29g x 12.7mm misc
BOTOX INJ 100UNIT
4
PA
BOTOX INJ 200UNIT
4
PA
FERRIPROX SOLN 100MG/ML
5
PA
FERRIPROX TABS 500MG
5
PA
2
insupen 33gx4mm misc
1
B/D
intralipid inj 20gm/100ml
KEVEYIS TABS 50MG
5
lactated ringers irrigation soln 3meq/l; 109meq/l; 28meq/l; 2
4meq/l; 130meq/l
2
levocarnitine inj 200mg/ml
2
MO
levocarnitine soln 1gm/10ml
2
MO
levocarnitine tabs 330mg
MYALEPT INJ 11.3MG
5
PA
NATPARA INJ 100MCG
5
NATPARA INJ 25MCG
5
NATPARA INJ 50MCG
5
NATPARA INJ 75MCG
5
1
B/D
nutrilipid inj 20gm/100ml
1
B/D
nutrilipid inj 20gm/100ml
ORFADIN CAPS 10MG
5
101
Drug
Drug Name
ORFADIN CAPS 2MG
5
ORFADIN CAPS 5MG
5
1
sterile water irrigation plastic bottle soln 0
1
sterile water irrigation soln 0
XEOMIN INJ 50UNIT
4
PA
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
2
bimatoprost soln 0.03%
COMBIGAN SOLN 0.2%; 0.5%
4
MO
1
latanoprost soln 0.005%
LUMIGAN SOLN 0.01%
3
QL (2.5 ML per 25 days) ST MO
RESCULA SOLN 0.15%
4
1
travoprost soln 0.004%
Ophthalmic Agents, Other
1
ak-poly-bac oint 500unit/gm; 10000unit/gm
2
MO
atropine sulfate soln 1%
2
MO
atropine-care soln 1%
1
bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm
CYSTARAN SOLN 0.44%
5
2
lacrisert inst 5mg
2
naphazoline hcl soln 0.1%
1
neo-polycin oint 400unit/gm; 3.5mg/gm; 10000unit/gm
1
neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm;
10000unit/gm
1
neomycin/polymyxin/bacitracin zinc oint 400unit/gm;
5mg/gm; 10000unit/gm
1
polycin b oint 500unit/gm; 10000unit/gm
1
polycin oint 500unit/gm; 10000unit/gm
polymyxin b sulfate/trimethoprim sulfate soln 10000unit/ml; 1
0.1%
PROCYSBI CPDR 25MG
5
PA
PROCYSBI CPDR 75MG
5
PA
RESTASIS EMUL 0.05%
4
trimethoprim sulfate/polymyxin b sulfate soln 10000unit/ml; 1
0.1%
Ophthalmic Anti-allergy Agents
ALOCRIL SOLN 2%
4
2
azelastine hcl soln 0.05%
BEPREVE SOLN 1.5%
4
1
cromolyn sodium soln 4%
EMADINE SOLN 0.05%
4
2
epinastine hcl soln 0.05%
LASTACAFT SOLN 0.25%
4
2
olopatadine hcl soln 0.1%
PATADAY SOLN 0.2%
4
PATANOL SOLN 0.1%
4
102
Drug
Drug Name
Ophthalmic Anti-inflammatories
ACUVAIL SOLN 0.45%
4
ALOMIDE SOLN 0.1%
4
ALREX SUSP 0.2%
4
2
bromfenac soln 0.09%
2
2
1
dexamethasone sodium phosphate soln 0.1%
1
diclofenac sodium soln 0.1%
DUREZOL EMUL 0.05%
4
FLAREX SUSP 0.1%
3
2
fluorometholone susp 0.1%
1
flurbiprofen sodium soln 0.03%
FML FORTE SUSP 0.25%
3
FML OINT 0.1%
3
2
ketorolac tromethamine soln 0.4%
2
ketorolac tromethamine soln 0.5%
LOTEMAX GEL 0.5%
4
LOTEMAX OINT 0.5%
4
LOTEMAX SUSP 0.5%
4
MAXIDEX SUSP 0.1%
3
neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/gm; 1
10000unit/gm
neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/ml; 1
10000unit/ml
NEVANAC SUSP 0.1%
4
1
poly-dex oint 0.1%; 3.5mg/gm; 10000unit/gm
PRED MILD SUSP 0.12%
3
PRED-G SUSP 0.3%; 1%
3
1
prednisolone acetate susp 1%
1
prednisolone sodium phosphate soln 1%
TOBRADEX ST SUSP 0.05%; 0.3%
4
TOBRADEX OINT 0.1%; 0.3%
4
2
tobramycin/dexamethasone susp 0.1%; 0.3%
VEXOL SUSP 1%
3
Ophthalmic Antiglaucoma Agents
2
MO
acetazolamide er cp12 500mg
ALPHAGAN P SOLN 0.1%
4
MO
2
apraclonidine soln 0.5%
AZOPT SUSP 1%
4
MO
2
MO
betaxolol hcl soln 0.5%
BETIMOL SOLN 0.25%
4
MO
BETIMOL SOLN 0.5%
4
MO
BETOPTIC-S SUSP 0.25%
4
MO
1
MO
brimonidine tartrate soln 0.15%
1
MO
brimonidine tartrate soln 0.2%
103
Drug
Drug Name
1
MO
carteolol hcl soln 1%
MO
dorzolamide hcl/timolol maleate soln 22.3mg/ml; 6.8mg/ml 2
1
MO
dorzolamide hcl soln 2%
IOPIDINE SOLN 1%
4
ISTALOL SOLN 0.5%
4
MO
1
MO
levobunolol hcl soln 0.5%
1
MO
methazolamide tabs 25mg
1
MO
methazolamide tabs 50mg
1
MO
metipranolol soln 0.3%
PHOSPHOLINE IODIDE SOLR 0.125%
4
MO
2
MO
pilocarpine hcl soln 1%
2
MO
2
MO
PILOPINE HS GEL 4%
4
MO
2
MO
timolol maleate ophthalmic gel forming solg 0.25%
2
MO
timolol maleate ophthalmic gel forming solg 0.5%
1
MO
timolol maleate soln 0.25%
1
MO
timolol maleate soln 0.5%
Otic Agents
Otic Agents
2
acetasol hc soln 2%; 1%
1
acetic acid soln 2%
COLY-MYCIN S SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 4
0.5MG/ML
CORTISPORIN-TC SUSP 3MG/ML; 10MG/ML;
4
3.3MG/ML; 0.5MG/ML
2
hydrocortisone/acetic acid soln 2%; 1%
1
neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/ml
1
neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml;
10000unit/ml
1
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml;
10000unit/ml
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE 3
ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT
3
QL (16 GM per 30 days) ST MO
3
3
ALVESCO AERS 160MCG/ACT
4
QL (12.2 GM per 30 days) MO
ALVESCO AERS 80MCG/ACT
4
ASMANEX HFA AERO 100MCG/ACT
3
QL (26 GM per 30 days) MO
ASMANEX HFA AERO 200MCG/ACT
3
ASMANEX TWISTHALER 120 METERED DOSES AEPB 3
220MCG/INH
104
Drug
Drug Name
220MCG/INH
220MCG/INH
110MCG/INH
220MCG/INH
220MCG/INH
ASMANEX TWISTHALER 7 METERED DOSES AEPB
3
110MCG/INH
BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH
4
BREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH
4
2
QL (120 ML per 30 days) B/D MO
budesonide susp 0.25mg/2ml
2
budesonide susp 0.5mg/2ml
2
budesonide susp 1mg/2ml
2
QL (17.2 GM per 30 days)
budesonide susp 32mcg/act
DULERA AERO 5MCG/ACT; 100MCG/ACT
3
QL (17.6 GM per 30 days) ST MO
DULERA AERO 5MCG/ACT; 200MCG/ACT
3
QL (17.6 GM per 30 days) ST MO
FLOVENT DISKUS AEPB 100MCG/BLIST
4
4
4
FLOVENT HFA AERO 110MCG/ACT
4
4
4
1
flunisolide soln 0.025%
1
fluticasone propionate susp 50mcg/act
2
mometasone furoate susp 50mcg/act
PULMICORT FLEXHALER AEPB 180MCG/ACT
3
PULMICORT FLEXHALER AEPB 90MCG/ACT
3
PULMICORT SUSP 1MG/2ML
4
QVAR AERS 40MCG/ACT
3
QVAR AERS 80MCG/ACT
3
SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT
3
SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT
3
2
triamcinolone acetonide aero 55mcg/act
VERAMYST SUSP 27.5MCG/SPRAY
4
QL (10 GM per 30 days) ST
Antihistamines
2
PA
arbinoxa soln 4mg/5ml
2
PA
arbinoxa tabs 4mg
2
2
2
PA
carbinoxamine maleate soln 4mg/5ml
2
PA
carbinoxamine maleate tabs 4mg
1
cetirizine hcl syrp 1mg/ml
105
Drug
Drug Name
2
PA
cyproheptadine hcl syrp 2mg/5ml
2
PA
cyproheptadine hcl tabs 4mg
2
desloratadine odt tbdp 2.5mg
2
desloratadine odt tbdp 5mg
2
desloratadine tabs 5mg
2
diphenhydramine hcl inj 50mg/ml
2
levocetirizine dihydrochloride tabs 5mg
2
olopatadine hcl soln 0.6%
2
PA
pharbedryl caps 50mg
Antileukotrienes
1
MO
montelukast sodium chew 4mg
1
MO
montelukast sodium chew 5mg
2
MO
montelukast sodium pack 4mg
1
MO
montelukast sodium tabs 10mg
2
MO
zafirlukast tabs 10mg
2
MO
zafirlukast tabs 20mg
ZYFLO CR TB12 600MG
4
MO
Bronchodilators, Anticholinergic
ATROVENT HFA AERS 17MCG/ACT
3
COMBIVENT RESPIMAT AERS 100MCG/ACT;
4
20MCG/ACT
2
ipratropium bromide/albuterol sulfate soln 2.5mg/3ml;
0.5mg/3ml
1
QL (312.5 ML per 30 days) B/D MO
ipratropium bromide soln 0.02%
1
1
SPIRIVA HANDIHALER CAPS 18MCG
3
SPIRIVA RESPIMAT AERS 1.25MCG/ACT
3
SPIRIVA RESPIMAT AERS 2.5MCG/ACT
3
TUDORZA PRESSAIR AEPB 400MCG/ACT
3
TUDORZA PRESSAIR AEPB 400MCG/ACT
3
Bronchodilators, Sympathomimetic
2
adrenaclick inj 0.15mg/0.15ml
2
adrenaclick inj 0.3mg/0.3ml
ADRENALIN INJ 30MG/30ML
4
2
MO
albuterol sulfate er tb12 4mg
1
MO
albuterol sulfate er tb12 8mg
1
albuterol sulfate nebu 0.083%
1
albuterol sulfate nebu 0.5%
2
albuterol sulfate nebu 0.63mg/3ml
2
albuterol sulfate nebu 1.25mg/3ml
1
MO
albuterol sulfate syrp 2mg/5ml
2
MO
albuterol sulfate tabs 2mg
2
MO
albuterol sulfate tabs 4mg
2
MO
albuterol tabs 4mg
ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH
4
106
Drug
Drug Name
ARCAPTA NEOHALER CAPS 75MCG
4
BROVANA NEBU 15MCG/2ML
4
2
epinephrine inj 0.15mg/0.15ml
2
epinephrine inj 0.3mg/0.3ml
EPIPEN 2-PAK INJ 0.3MG/0.3ML
4
EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML
4
FORADIL AEROLIZER CAPS 12MCG
4
2
levalbuterol hcl nebu 0.31mg/3ml
2
2
2
QL (45 EA per 30 days) B/D MO
levalbuterol nebu 1.25mg/0.5ml
1
MO
metaproterenol sulfate syrp 10mg/5ml
PERFOROMIST NEBU 20MCG/2ML
4
PROAIR HFA AERS 108MCG/ACT
3
PROAIR RESPICLICK AEPB 108MCG/ACT
3
PROVENTIL HFA AERS 108MCG/ACT
4
SEREVENT DISKUS AEPB 50MCG/DOSE
4
1
terbutaline sulfate inj 1mg/ml
1
MO
terbutaline sulfate tabs 2.5mg
1
MO
terbutaline sulfate tabs 5mg
VENTOLIN HFA AERS 108MCG/ACT
4
XOPENEX HFA AERO 45MCG/ACT
3
Cystic Fibrosis Agents
CAYSTON SOLR 75MG
5
PA
KALYDECO PACK 50MG
5
PA
KALYDECO PACK 75MG
5
PA
KALYDECO TABS 150MG
5
PA
ORKAMBI TABS 125MG; 200MG
5
PULMOZYME SOLN 1MG/ML
5
PA
TOBI PODHALER CAPS 28MG
5
5
PA
tobramycin nebu 300mg/5ml
Mast Cell Stabilizers
2
B/D MO
cromolyn sodium nebu 20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
1
aminophylline inj 25mg/ml
DALIRESP TABS 500MCG
4
PA MO
ELIXOPHYLLIN ELIX 80MG/15ML
4
MO
LUFYLLIN TABS 200MG
4
MO
LUFYLLIN TABS 400MG
4
MO
1
MO
theochron tb12 100mg
1
MO
1
MO
1
MO
theophylline cr tb12 100mg
1
MO
theophylline cr tb12 200mg
1
MO
theophylline er tb12 100mg
1
MO
107
Drug Name
Pulmonary Antihypertensives
ADCIRCA TABS 20MG
ADEMPAS TABS 0.5MG
ADEMPAS TABS 1.5MG
ADEMPAS TABS 1MG
ADEMPAS TABS 2.5MG
ADEMPAS TABS 2MG
LETAIRIS TABS 10MG
LETAIRIS TABS 5MG
OPSUMIT TABS 10MG
ORENITRAM TBCR 0.125MG
ORENITRAM TBCR 1MG
REVATIO SUSR 10MG/ML
sildenafil inj 10mg/12.5ml
sildenafil tabs 20mg
TRACLEER TABS 125MG
TRACLEER TABS 62.5MG
TYVASO REFILL SOLN 0.6MG/ML
TYVASO STARTER SOLN 0.6MG/ML
TYVASO SOLN 0.6MG/ML
UPTRAVI TABS 1000MCG
UPTRAVI TABS 200MCG
UPTRAVI TABS 400MCG
UPTRAVI TABS 600MCG
UPTRAVI TABS 800MCG
UPTRAVI TBPK 0
VENTAVIS SOLN 10MCG/ML
VENTAVIS SOLN 20MCG/ML
Respiratory Tract Agents, Other
acetylcysteine soln 10%
acetylcysteine soln 20%
ARALAST NP INJ 1000MG
ARALAST NP INJ 500MG
benzonatate caps 100mg
benzonatate caps 200mg
ESBRIET CAPS 267MG
Drug
Tier
1
1
1
1
Requirements/Limits
MO
MO
MO
MO
5
5
5
5
5
5
5
5
5
4
4
5
5
5
5
2
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA MO
PA MO
PA
PA
PA
2
2
5
5
1
1
5
B/D
B/D
PA
PA
GC ED
GC ED
PA
108
Drug
Drug Name
1
QL (180 ML per 30 days) GC ED
hydrocodone bitartrate/homatropine methylbromide syrp
1.5mg/5ml; 5mg/5ml
1
hydrocodone/homatropine syrp 1.5mg/5ml; 5mg/5ml
1
hydromet syrp 1.5mg/5ml; 5mg/5ml
OFEV CAPS 100MG
5
PA
OFEV CAPS 150MG
5
PA
PROLASTIN-C INJ 1000MG
5
PA
2
PA
promethazine vc plain syrp 5mg/5ml; 6.25mg/5ml
1
promethazine vc/codeine syrp 10mg/5ml; 5mg/5ml;
6.25mg/5ml
1
promethazine-dm syrp 15mg/5ml; 6.25mg/5ml
1
promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml
promethazine/dextromethorphan syrp 15mg/5ml; 6.25mg/5ml 1
1
promethazine/phenylephrine/codeine syrp 10mg/5ml;
5mg/5ml; 6.25mg/5ml
2
PA
promethazine/phenylephrine syrp 5mg/5ml; 6.25mg/5ml
TYZINE PEDIATRIC NASAL DROPS SOLN 0.05%
3
TYZINE SOLN 0.1%
3
VIRAZOLE SOLR 6GM
5
XOLAIR INJ 150MG
5
PA
ZEMAIRA INJ 1000MG
5
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
2
PA
carisoprodol tabs 250mg
2
PA
cyclobenzaprine hcl tabs 10mg
2
PA
cyclobenzaprine hcl tabs 5mg
2
PA
cyclobenzaprine hcl tabs 7.5mg
2
PA
soma tabs 250mg
Sleep Disorder Agents
GABA Receptor Modulators
2
temazepam caps 15mg
2
temazepam caps 22.5mg
2
temazepam caps 30mg
2
temazepam caps 7.5mg
2
zaleplon caps 10mg
2
zaleplon caps 5mg
2
zolpidem tartrate er tbcr 12.5mg
2
zolpidem tartrate er tbcr 6.25mg
Sleep Disorders, Other
2
armodafinil tabs 150mg
2
2
2
2
modafinil tabs 100mg
5
modafinil tabs 200mg
NUVIGIL TABS 150MG
4
109
Drug
Drug Name
Tier
NUVIGIL TABS 200MG
4
NUVIGIL TABS 250MG
4
NUVIGIL TABS 50MG
4
ROZEREM TABS 8MG
4
SILENOR TABS 3MG
4
SILENOR TABS 6MG
4
XYREM SOLN 500MG/ML
5
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CARBAGLU TABS 200MG
5
DEPEN TITRATABS TABS 250MG
4
EXJADE TBSO 125MG
5
EXJADE TBSO 250MG
5
EXJADE TBSO 500MG
5
JADENU TABS 180MG
5
JADENU TABS 360MG
5
JADENU TABS 90MG
5
1
kionex powd 0
1
kionex susp 15gm/60ml
SAMSCA TABS 15MG
5
SAMSCA TABS 30MG
5
1
sodium polystyrene sulfonate powd 0
1
1
1
sodium polystyrene sulfonate susp 15gm/60ml
1
sodium polystyrene sulfonate susp 30gm/120ml
SYPRINE CAPS 250MG
5
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L;
4
900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML;
210MG/100ML; 510MG/100ML; 660MG/100ML;
510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML;
30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML;
65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML;
560MG/100ML
AMINOSYN 8.5%/ELECTROLYTES INJ 142MEQ/L;
3
1100MG/100ML; 850MG/100ML; 98MEQ/L;
1100MG/100ML; 260MG/100ML; 620MG/100ML;
380MG/100ML; 30MEQ/L; 65MEQ/L; 750MG/100ML;
44MG/100ML; 680MG/100ML
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
B/D
B/D
110
Drug
Drug Name
Tier
AMINOSYN II 8.5%/ELECTROLYTES INJ 61MEQ/L;
3
844MG/100ML; 865MG/100ML; 595MG/100ML; 86MEQ/L;
627MG/100ML; 425MG/100ML; 255MG/100ML;
146MG/100ML; 253MG/100ML; 30MMOLE/L; 66MEQ/L;
170MG/100ML; 230MG/100ML; 425MG/100ML
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;
3
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML
3
865MG/100ML; 595MG/100ML; 627MG/100ML;
425MG/100ML; 255MG/100ML; 561MG/100ML;
850MG/100ML; 893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML; 450MG/100ML;
33.3MEQ/L; 340MG/100ML; 170MG/100ML;
230MG/100ML; 425MG/100ML
3
1018MG/100ML; 700MG/100ML; 738MG/100ML;
500MG/100ML; 300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML; 172MG/100ML;
298MG/100ML; 722MG/100ML; 530MG/100ML;
45.3MEQ/L; 400MG/100ML; 200MG/100ML;
270MG/100ML; 500MG/100ML
AMINOSYN M INJ 65MEQ/L; 448MG/100ML;
3
140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L;
56MG/100ML; 31MG/100ML; 280MG/100ML
AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML;
3
507MG/100ML; 4MEQ/100ML; 660MG/100ML;
154MG/100ML; 789MG/100ML; 1576MG/100ML;
265MG/100ML; 206MG/100ML; 1.12GM/100ML;
228MG/100ML; 448MG/100ML; 221MG/100ML;
272MG/100ML; 88MG/100ML; 33MG/100ML;
789MG/100ML
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
111
Drug
Drug Name
AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;
3
B/D
861MG/100ML; 370MG/100ML; 576MG/100ML;
270MG/100ML; 220MG/100ML; 534MG/100ML;
831MG/100ML; 475MG/100ML; 125MG/100ML;
10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L;
347MG/100ML; 50MG/100ML; 360MG/100ML;
125MG/100ML; 44MG/100ML; 452MG/100ML
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;
3
B/D
1227MG/100ML; 527MG/100ML; 820MG/100ML;
385MG/100ML; 312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML; 180MG/100ML;
427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML;
44MG/100ML; 673MG/100ML
AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML;
4
B/D
429MG/100ML; 462MG/100ML; 726MG/100ML;
535MG/100ML; 726MG/100ML; 726MG/100ML;
330MG/100ML; 165MG/100ML; 528MG/100ML
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
3
B/D
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML
AMINOSYN INJ 90MEQ/L; 1100MG/100ML;
3
B/D
850MG/100ML; 35MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML; 44MG/100ML;
680MG/100ML
1
argyle sterile saline 100ml soln 0.9%
CLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML; 3
B/D
570MG/100ML; 316MG/100ML; 11MEQ/1000ML;
5GM/100ML; 283MG/100ML; 132MG/100ML;
165MG/100ML; 201MG/100ML; 159MG/100ML;
110MG/100ML; 154MG/100ML; 187MG/100ML;
138MG/100ML; 116MG/100ML; 50MG/100ML;
11MG/100ML; 160MG/100ML
3
B/D
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
112
Drug
Drug Name
Tier
3
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
3
438MG/100ML; 204MG/100ML; 255MG/100ML;
311MG/100ML; 247MG/100ML; 170MG/100ML;
238MG/100ML; 289MG/100ML; 213MG/100ML;
179MG/100ML; 77MG/100ML; 17MG/100ML;
247MG/100ML
CLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L;
3
515MG/100ML; 240MG/100ML; 300MG/100ML;
365MG/100ML; 290MG/100ML; 200MG/100ML;
280MG/100ML; 340MG/100ML; 250MG/100ML;
210MG/100ML; 90MG/100ML; 20MG/100ML;
290MG/100ML
316MG/100ML; 33MG/100ML; 10GM/100ML;
132MG/100ML; 165MG/100ML; 201MG/100ML;
159MG/100ML; 51MG/100ML; 110MG/100ML;
454MG/100ML; 154MG/100ML; 261MG/100ML;
187MG/100ML; 138MG/100ML; 217MG/100ML;
112MG/100ML; 116MG/100ML; 50MG/100ML;
11MG/100ML; 160MG/100ML
489MG/100ML; 33MG/100ML; 10GM/100ML;
204MG/100ML; 255MG/100ML; 311MG/100ML;
247MG/100ML; 51MG/100ML; 170MG/100ML;
702MG/100ML; 238MG/100ML; 261MG/100ML;
289MG/100ML; 213MG/100ML; 297MG/100ML;
77MG/100ML; 179MG/100ML; 77MG/100ML;
17MG/100ML; 247MG/100ML
575MG/100ML; 33MG/100ML; 20GM/100ML;
240MG/100ML; 300MG/100ML; 365MG/100ML;
290MG/100ML; 51MG/100ML; 200MG/100ML;
826MG/100ML; 280MG/100ML; 261MG/100ML;
340MG/100ML; 250MG/100ML; 340MG/100ML;
59MG/100ML; 210MG/100ML; 90MG/100ML;
20MG/100ML; 290MG/100ML
Requirements/Limits
B/D
B/D
B/D
B/D
B/D
B/D
113
Drug
Drug Name
Tier
clinisol sf 15% inj 151meq/l; 2170mg/100ml; 1470mg/100ml; 2
434mg/100ml; 749mg/100ml; 1040mg/100ml; 894mg/100ml;
250mg/100ml; 39mg/100ml; 960mg/100ml
1
curity sterile saline soln 0.9%
1
dextrose 10%/nacl 0.45% inj 10%; 0.45%
1
dextrose 10% flex container inj 10%
1
1
dextrose 10% inj 10%
1
dextrose 2.5%/nacl 0.45% inj 2.5%; 0.45%
1
dextrose 2.5%/sodium chloride 0.45% inj 2.5%; 0.45%
1
dextrose 5% viaflex inj 5%
2
dextrose 5%/lactated ringers inj 2.7meq/l; 109meq/l; 5%;
28meq/l; 4meq/l; 130meq/l
1
1
1
1
1
1
dextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l
1
dextrose 5%/sodium chloride 0.2% inj 5%; 0.2%
1
1
1
dextrose 5% inj 5%
FREAMINE HBC 6.9% INJ 59.3MEQ/L; 400MG/100ML; 4
160MG/100ML; 760MG/100ML; 1370MG/100ML;
410MG/100ML; 250MG/100ML; 320MG/100ML;
90MG/100ML; 880MG/100ML
FREAMINE III INJ 72MEQ/L; 600MG/100ML;
3
240MG/100ML; 590MG/100ML; 770MG/100ML;
620MG/100ML; 450MG/100ML; 480MG/100ML;
10MMOLE/L; 115MG/100ML; 950MG/100ML;
560MG/100ML
FREAMINE III INJ 89MEQ/L; 710MG/100ML;
3
280MG/100ML; 690MG/100ML; 910MG/100ML;
730MG/100ML; 530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML; 1120MG/100ML;
660MG/100ML
Requirements/Limits
B/D
B/D
B/D
B/D
114
Drug
Drug Name
Tier
HEPATAMINE INJ 62MEQ/L; 770MG/100ML;
3
240MG/100ML; 900MG/100ML; 1100MG/100ML;
610MG/100ML; 100MG/100ML; 100MG/100ML;
115MG/100ML; 800MG/100ML; 500MG/100ML;
100MG/100ML; 450MG/100ML; 66MG/100ML;
840MG/100ML
HEPATASOL INJ 0.77GM/100ML; 0.6GM/100ML;
3
0.02GM/100ML; 0.9GM/100ML; 0.24GM/100ML;
0.9GM/100ML; 1.1GM/100ML; 0.61GM/100ML;
0.1GM/100ML; 0.1GM/100ML; 0.115GM/100ML;
0.8GM/100ML; 0.5GM/100ML; 0.45GM/100ML;
0.065GM/100ML; 0.84GM/100ML
1
isolyte-m/dextrose 5% inj 20meq/l; 44meq/l; 5%; 15meq/l;
35meq/l; 38meq/l
ISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 5%; 4
3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L
1
k-sol soln 10%
1
k-sol soln 20%
1
k-tab tbcr 10meq
1
k-tab tbcr 20meq
1
kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45%
1
kcl 0.15%/d5w/ nacl 0.3% inj 5%; 20meq/l; 0.33%
1
1
1
1
1
KCL 0.3%/D5W/NACL 0.9% INJ 5%; 40MEQ/L; 0.9%
4
1
klor-con 10 tbcr 10meq
1
klor-con 8 tbcr 8meq
1
klor-con m10 tbcr 10meq
1
1
1
1
1
1
1
1
1
KLOR-CON M15 TBCR 15MEQ
3
1
1
klor-con sprinkle cpcr 10meq
1
klor-con sprinkle cpcr 8meq
Requirements/Limits
B/D
B/D
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
115
Drug
Drug Name
lactated ringers dextrose 5% viaflex inj 2.7meq/l; 109meq/l; 2
5%; 28meq/l; 4meq/l; 130meq/l
2
lactated ringers viaflex inj 3meq/l; 109meq/l; 28meq/l;
4meq/l; 130meq/l
2
lactated ringers inj 3meq/l; 109meq/l; 28meq/l; 4meq/l;
130meq/l
1
magnesium sulfate inj 50%
1
magnesium sulfate inj 50%
NEPHRAMINE INJ 44MEQ/L; 20MG/100ML;
3
B/D
250MG/100ML; 560MG/100ML; 880MG/100ML;
400MG/100ML; 200MG/100ML; 640MG/100ML
1
normosol-m in d5w inj 16meq/l; 40meq/l; 5%; 3meq/l;
13meq/l; 40meq/l
PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 4
PLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%;
4
2
B/D
plenamine inj 151meq/l; 2170mg/100ml; 1470mg/100ml;
250mg/100ml; 39mg/100ml; 960mg/100ml
1
potassium chloride 0.15% /nacl 0.45% viaflex inj 20meq/l;
0.45%
potassium chloride 0.15% d5w/nacl 0.33% inj 5%; 20meq/l; 1
0.33%
1
potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 5%;
20meq/l; 0.45%
0.45%
1
potassium chloride 0.15% nacl 0.9% inj 20meq/l; 0.9%
potassium chloride 0.15% w/nacl 0.9% viaflex inj 20meq/l; 1
0.9%
1
potassium chloride 0.15%/d5w inj 5%; 20meq/l
1
potassium chloride 0.15%/nacl 0.9% inj 20meq/l; 0.9%
0.45%
potassium chloride 0.224%/d5w/nacl 0.45% inj 5%; 30meq/l; 1
0.45%
potassium chloride 0.224%d5w/nacl 0.45% viaflex inj 5%; 1
30meq/l; 0.45%
1
potassium chloride 0.3%/ nacl 0.9% inj 40meq/l; 0.9%
1
potassium chloride 0.3%/d5w inj 5%; 40meq/l
potassium chloride 0.3%/nacl 0.9%/viaflex inj 40meq/l; 0.9% 1
1
MO
potassium chloride cr tbcr 10meq
116
Drug Name
potassium chloride er cpcr 10meq
potassium chloride er cpcr 8meq
potassium chloride er tbcr 10meq
potassium chloride sr tbcr 8meq
potassium chloride sr tbcr 8meq
potassium chloride inj 10meq/100ml
potassium chloride inj 2meq/ml
potassium chloride soln 10%
potassium chloride soln 20%
potassium citrate er tbcr 1080mg
potassium citrate er tbcr 15meq
potassium citrate er tbcr 540mg
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
PREMASOL INJ 56MEQ/L; 320MG/100ML;
300MG/100ML; 220MG/100ML; 290MG/100ML;
490MG/100ML; 840MG/100ML; 490MG/100ML;
200MG/100ML; 290MG/100ML; 410MG/100ML;
120MG/100ML; 140MG/100ML; 470MG/100ML
Drug
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
Requirements/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D
B/D
117
Drug Name
PROCALAMINE INJ 47MEQ/L; 210MG/100ML;
290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML;
420MG/100ML; 85MG/100ML; 210MG/100ML;
170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML;
200MG/100ML
PROSOL INJ 2.76GM/100ML; 1.96GM/100ML;
600MG/100ML; 1.02GM/100ML; 2.06GM/100ML;
1.18GM/100ML; 1.08GM/100ML; 1.08GM/100ML;
1.35GM/100ML; 760MG/100ML; 1GM/100ML;
1.34GM/100ML; 1.02GM/100ML; 980MG/100ML;
320MG/100ML; 50MG/100ML; 1.44GM/100ML
sodium chloride 0.45% viaflex inj 0.45%
sodium chloride 0.45% inj 0.45%
sodium chloride 0.9% soln 0.9%
sodium chloride pab inj 0.9%
sodium chloride inj 0.9%
sodium chloride inj 2.5meq/ml
sodium chloride inj 3%
sodium chloride inj 5%
sodium chloride soln 0.9%
TRAVASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML;
1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML;
0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML;
1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML;
0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML;
5MEQ/L; 0.025GM/100ML; 0.42GM/100ML;
0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML
Vitamins
ergocalciferol caps 50000unit
folic acid tabs 1mg
vitamin d caps 50000unit
Drug
Tier
3
Requirements/Limits
B/D
3
B/D
1
1
1
1
1
1
1
1
1
3
B/D
3
B/D
1
1
1
MO GC ED
MO GC ED
MO GC ED
118
Drug Name
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
Drug Name Page #
AKNE-MYCIN
46
abacavir
ak-poly-bac
46
abacavir sulfate/lamivudine/zidovudine
ALBENZA
ABELCET
28
albuterol
ABILIFY
41
albuterol
sulfate
ABILIFY DISCMELT
41
albuterol sulfate er
ABILIFY MAINTENA
41
alclometasone
dipropionate
ABSTRAL
5
alcohol
prep pads
8
acamprosate calcium dr
ALDACTAZIDE
49
acarbose
ALDURAZYME
61
acebutolol hcl
ALECENSA
5
acetaminophen/codeine
alendronate
sodium
5
acetaminophen/codeine #2
alfuzosin hcl er
5
ALIMTA
5
ALINIA
5
acetaminophen/codeine phosphate
allopurinol
104
acetasol hc
almotriptan
67
acetazolamide
almotriptan
malate
103
acetazolamide er
ALOCRIL
104
acetic acid
ALOMIDE
108
acetylcysteine
alosetron
hydrochloride
74
acitretin
ALOXI
ACTEMRA
98
ALPHAGAN
P
ACTHIB
98
alphatrex
ACTIMMUNE
98
alprazolam
ACTOPLUS MET XR
49
alprazolam er
ACUVAIL
103
alprazolam
intensol
47
acyclovir
alprazolam
odt
47
acyclovir sodium
alprazolam xr
ACZONE
74
ALREX
ADACEL
98
ALTABAX
ADAGEN
76
altavera
74
adapalene
ALVESCO
74
adapalene pump
alyacen
1/35
ADCIRCA
108
alyacen 7/7/7
44
adefovir dipivoxil
amantadine
hcl
ADEMPAS
108
AMBISOME
106
adrenaclick
amcinonide
ADRENALIN
106
amethia
33
adriamycin
amethyst
32
adrucil
amifostine
ADVAIR DISKUS
104
amikacin sulfate
ADVAIR HFA
104
amiloride hcl
62
afeditab cr
amiloride/hydrochlorothiazide
AFINITOR
35
aminophylline
119
Index
Page #
35
56
81
15
102
37
106
106
106
81
9
67
76
35
100
80
33
37
30
30
30
102
103
79
27
103
81
48
48
48
48
48
103
9
86
104
86
86
47
28
81
86
86
33
9
67
67
107
Drug Name Page #
Drug Name
AMINOSYN
112
APOKYN
AMINOSYN 7%/ELECTROLYTES
110
apraclonidine
AMINOSYN 8.5%/ELECTROLYTES
110
apri
AMINOSYN II
111
APRISO
AMINOSYN II 8.5%/ELECTROLYTES
111
APTIOM
AMINOSYN M
111
APTIVUS
AMINOSYN-HBC
111
ARALAST NP
AMINOSYN-PF
112
aranelle
AMINOSYN-PF 7%
112
ARANESP ALBUMIN FREE
AMINOSYN-RF
112
arbinoxa
60
ARCALYST
amiodarone hcl
60
ARCAPTA NEOHALER
amiodarone hydrochloride
AMITIZA
79
argyle sterile saline 100ml
26
amitriptyline hcl
argyle sterile water 100ml
63
amlodipine besylate
aripiprazole
62
amlodipine besylate/atorvastatin calcium
aripiprazole odt
63
amlodipine besylate/benazepril hcl
armodafinil
63
ARRANON
amlodipine besylate/benazepril
ARZERRA
hydrochloride
63
ASACOL HD
amlodipine besylate/valsartan
63
amlodipine/valsartan/hctz
ascomp/codeine
74
ammonium lactate
ashlyna
74
ASMANEX HFA
amnesteem
26
ASMANEX TWISTHALER 120
amoxapine
14
METERED DOSES
amoxicillin
13
ASMANEX TWISTHALER 14 METERED
amoxicillin/clavulanate potassium
13
DOSES
amoxicillin/clavulanate potassium er
14
amoxicillin/potassium clavulanate
71
DOSES
amphetamine/dextroamphetamine
28
amphotericin b
14
DOSES
ampicillin
14
ampicillin sodium
14
DOSES
ampicillin/sulbactam
14
ampicillin-sulbactam
aspirin/dipyridamole
AMPYRA
73
aspirin-caffeine-dihydrocodeine
AMTURNIDE
66
ASTAGRAF XL
ANADROL-50
86
atenolol
55
anagrelide hydrochloride
atenolol/chlorthalidone
35
ATGAM
anastrozole
ANDROGEL
86
atorvastatin calcium
ANDROGEL PUMP
86
atovaquone
ANDROID
86
atovaquone/proguanil hcl
ANDROXY
86
ATRIPLA
ANORO ELLIPTA
106
atropine sulfate
82
apexicon e
atropine-care
APIDRA
53
ATROVENT HFA
APIDRA SOLOSTAR
53
AUBAGIO
APLENZIN
23
aubra
120
Page #
38
103
86
99
18
47
108
86
55
105
98
107
112
101
41
41
109
33
36
100
5
86
104
104
105
105
105
105
56
5
95
61
61
96
69
37
37
45
102
102
106
73
86
Drug Name Page #
Drug Name
82
BENICAR
augmented betamethasone dipropionate
AVANDAMET
49
BENICAR HCT
AVANDARYL
49
BENLYSTA
AVANDIA
49
benzonatate
AVASTIN
37
benztropine mesylate
AVELOX
16
BEPREVE
87
BESIVANCE
aviane
17
avidoxy
betamethasone dipropionate
74
avita
betamethasone valerate
AVODART
80
BETASERON
AVONEX
73
betaxolol hcl
AVONEX PEN
73
betaxolol hcl
AVYCAZ
12
bethanechol chloride
AXERT
30
BETIMOL
AZACITIDINE
33
BETOPTIC-S
AZASAN
95
bexarotene
AZASITE
15
BEXSERO
95
azathioprine
bicalutamide
102
BICILLIN C-R
azelastine hcl
105
BICILLIN L-A
azelastine hcl
AZELEX
74
BILTRICIDE
AZILECT
39
bimatoprost
15
azithromycin
bisoprolol fumarate
AZOPT
103
bisoprolol fumarate/hydrochlorothiazide
AZOR
63
BIVIGAM
13
BLEPHAMIDE
aztreonam
87
BLEPHAMIDE S.O.P.
azurette
10
bacitracin
blisovi 24 fe
102
bacitracin/polymyxin b
blisovi fe 1.5/30
43
baclofen
blisovi fe 1/20
BACTROBAN NASAL
10
BOOSTRIX
100
BOSULIF
balsalazide disodium
87
BOTOX
balziva
BANZEL
21
BREO ELLIPTA
BARACLUDE
44
briellyn
82
BRILINTA
baycadron
BCG VACCINE
98
brimonidine tartrate
101
BRINTELLIX
bd insulin syringe safetyglide/1ml/29g x
BRIVIACT
1/2"
101
bd insulin syringe ultrafine/0.3ml/31g x
bromfenac
5/16"
bromocriptine mesylate
101
BROVANA
bd insulin syringe ultrafine/0.5ml/30g x 1/2"
101
bd insulin syringe ultrafine/1ml/31g x 5/16"
budesonide
101
bd pen needle/ultrafine/29g x 12.7mm
budesonide
87
bekyree
bumetanide
BELEODAQ
33
BUPHENYL
58
benazepril hcl
buprenorphine hcl
58
benazepril hcl/hydrochlorothiazide
buprenorphine hcl/naloxone hcl
121
Page #
57
57
95
108
38
102
16
82
82
73
61
103
81
103
103
37
98
32
14
14
37
102
61
61
96
17
17
87
87
87
98
35
101
105
87
56
103
23
18
103
38
107
100
105
67
76
8
8
Drug Name Page #
Drug Name
8
CARIMUNE NANOFILTERED
buproban
23
bupropion hcl
carisoprodol
23
bupropion hcl er
carteolol hcl
8
bupropion hcl sr
cartia xt
23
bupropion hcl sr
carvedilol
23
CAYSTON
bupropion hcl xl
48
buspirone hcl
caziant
2
butalbital/acetaminophen
cefaclor
2
butalbital/acetaminophen/caffeine
cefadroxil
5
butalbital/aspirin/caffeine/codeine
cefazolin sodium
5
butorphanol tartrate
cefdinir
BUTRANS
8
cefepime
BYDUREON
49
cefixime
BYETTA
49
cefotaxime sodium
BYSTOLIC
61
cefotetan
94
cabergoline
cefoxitin sodium
CABOMETYX
36
cefpodoxime proxetil
74
calcipotriene
cefprozil
74
calcipotriene/betamethasone dipropionate
ceftazidime
100
calcitonin salmon
ceftriaxone sodium
100
calcitonin-salmon
cefuroxime axetil
74
calcitrene
cefuroxime sodium
74
calcitriol
celecoxib
100
CELLCEPT
calcitriol
81
CELONTIN
calcium acetate
91
camila
cephalexin
87
CERDELGA
camrese
CANASA
100
CEREBYX
CANCIDAS
28
CEREZYME
57
CERVARIX
candesartan cilexetil
68
candesartan cilexetil/hydrochlorothiazide
cetirizine hcl
CAPASTAT SULFATE
31
cevimeline hcl
CAPEX
82
CHANTIX
CAPRELSA
32
CHANTIX CONTINUING MONTH PAK
58
CHANTIX STARTING MONTH PAK
captopril
58
captopril/hydrochlorothiazide
chateal
CARAFATE
79
CHENODAL
CARBAGLU
110
chloramphenicol sodium succinate
21
carbamazepine
chlordiazepoxide hcl
21
carbamazepine er
chlordiazepoxide/amitriptyline
CARBATROL
21
chlorhexidine gluconate
39
carbidopa
chlorhexidine gluconate oral rinse
39
carbidopa/levodopa
chloroquine phosphate
39
carbidopa/levodopa er
chlorothiazide
39
carbidopa/levodopa/entacapone
chlorpromazine hcl
105
carbinoxamine maleate
chlorthalidone
33
CHOLBAM
carboplatin
CARDIZEM LA
63
cholestyramine light
122
Page #
97
109
104
63
61
107
87
12
12
12
12
12
12
12
13
12
12
12
12
13
13
13
2
95
19
13
76
21
76
98
105
74
9
9
9
87
77
10
48
26
74
74
37
68
39
68
77
69
Drug Name Page #
Drug Name
85
CLINIMIX E 4.25%/DEXTROSE 10%
chorionic gonadotropin
81
cialis
28
ciclodan
28
CLINIMIX E 5%/DEXTROSE 15%
ciclopirox
28
ciclopirox nail lacquer
28
ciclopirox olamine
44
cidofovir
clinisol sf 15%
56
cilostazol
clobetasol propionate
CILOXAN
16
clobetasol propionate e
78
cimetidine
clobetasol propionate emollient
78
cimetidine hcl
clodan
CIMZIA
95
clomipramine hcl
CINRYZE
95
clonazepam
CIPRO HC
16
clonazepam odt
CIPRODEX
16
clonidine hcl
16
ciprofloxacin
clopidogrel
16
ciprofloxacin er
clorazepate dipotassium
16
CLORPRES
ciprofloxacin hcl
16
ciprofloxacin i.v.-in d5w
clotrimazole
24
citalopram hydrobromide
clotrimazole/betamethasone dipropionate
74
claravis
clozapine
15
clarithromycin
clozapine odt
15
COARTEM
clarithromycin er
CLEOCIN
10
codeine sulfate
10
clin single use kit
colchicine
10
clindacin etz pledgets
colestipol hcl
10
clindacin-p
colistimethate sodium
10
clindamax
colocort
10
COLY-MYCIN S
clindamycin
10
COMBIGAN
clindamycin hcl
10
COMBIPATCH
clindamycin palmitate hcl
10
COMBIVENT RESPIMAT
clindamycin phosphate
75
COMETRIQ
clindamycin phosphate
10
clindamycin phosphate add-vantage
compazine
10
COMPLERA
clindamycin phosphate in d5w
10
clindamycin phosphate pharmacy bulk
compro
COMVAX
package
75
CONDYLOX
clindamycin/benzoyl peroxide
CLINIMIX 2.75%/DEXTROSE 5%
112
constulose
112
COPAXONE
51
CORDRAN TAPE
113
COREG CR
113
cormax
CLINIMIX 5%/DEXTROSE 15%
52
cormax scalp application
52
cortisone acetate
113
CORTISPORIN
113
CORTISPORIN
52
CORTISPORIN-TC
123
Page #
113
52
52
52
113
53
114
82
82
82
82
26
19
19
57
57
48
57
28
82
43
43
37
5
30
69
10
100
104
102
87
106
33
39
45
39
98
75
79
73
82
61
82
82
82
10
82
104
Drug Name Page #
Drug Name
COSENTYX
75
delyla
COSENTYX SENSOREADY PEN
75
demeclocycline hcl
COTELLIC
33
DEMSER
COUMADIN
54
DENAVIR
CREON
76
DEPEN TITRATABS
CRESEMBA
28
DEPO-ESTRADIOL
CRESTOR
69
DEPO-PROVERA
CRINONE
91
DEPO-SUBQ PROVERA 104
CRIXIVAN
47
dermacinrx prizopak
102
DESCOVY
cromolyn sodium
107
cromolyn sodium
desipramine hcl
87
cryselle-28
desloratadine
CUBICIN
10
desloratadine odt
75
curity gauze pads 2"x2"
desmopressin acetate
114
curity sterile saline
desogestrel/ethinyl estradiol
87
DESONATE
cyclafem 1/35
87
cyclafem 7/7/7
desonide
109
cyclobenzaprine hcl
desoximetasone
31
DESVENLAFAXINE ER
cyclophosphamide
CYCLOSET
49
dexamethasone
95
cyclosporine
dexamethasone intensol
95
cyclosporine modified
dexamethasone sodium phosphate
106
cyproheptadine hcl
dexamethasone sodium phosphate
CYRAMZA
37
dexedrine
87
DEXILANT
cyred
CYSTARAN
102
dexmethylphenidate hcl
32
cytarabine
dexmethylphenidate hcl er
32
cytarabine aqueous
dexrazoxane
DAKLINZA
44
dextroamphetamine sulfate
DALIRESP
107
dextroamphetamine sulfate er
DALVANCE
10
dextrose 10%/nacl 0.45%
86
danazol
dextrose 10%
43
dantrolene sodium
dextrose 10% flex container
31
dapsone
DAPTACEL
98
dextrose 2.5%/nacl 0.45%
DARAPRIM
37
dextrose 2.5%/sodium chloride 0.45%
80
darifenacin er
dextrose 5%
80
darifenacin hydrobromide er
dextrose 5% viaflex
DARZALEX
37
dextrose 5%/lactated ringers
87
dasetta 1/35
87
dasetta 7/7/7
DAUNOXOME
33
87
daysee
DAYTRANA
72
91
deblitane
dextrose 5%/potassium chloride 0.15%
33
decitabine
dextrose 5%/sodium chloride 0.2%
DELESTROGEN
87
82
deltasone
124
Page #
87
17
66
47
110
87
91
91
7
46
26
106
106
85
87
75
82
82
24
83
82
82
103
71
79
72
72
33
72
71
114
114
114
114
114
114
114
114
114
114
114
114
114
114
114
114
114
114
Drug Name Page #
Drug Name
DIASTAT ACUDIAL
19
doxazosin
DIASTAT PEDIATRIC
19
doxazosin mesylate
DIAZEPAM
19
doxepin hcl
48
diazepam
doxepin hydrochloride
DIBENZYLINE
57
doxercalciferol
2
DOXIL
diclofenac potassium
9
diclofenac sodium
doxorubicin hcl
75
diclofenac sodium
doxorubicin hcl liposome
103
diclofenac sodium
doxy 100
2
diclofenac sodium dr
doxycycline
2
diclofenac sodium er
doxycycline hyclate
2
diclofenac sodium/misoprostol
doxycycline hyclate dr
14
dicloxacillin sodium
doxycycline monohydrate
77
dicyclomine hcl
dronabinol
46
didanosine
drospirenone/ethinyl estradiol
DIFICID
15
DROXIA
83
DULERA
diflorasone diacetate
2
diflunisal
duloxetine hcl
66
digitek
duloxetine hcl
66
digox
duramorph
66
DUREZOL
digoxin
30
dihydroergotamine mesylate
dutasteride
DILANTIN
21
dutasteride/tamsulosin hcl
DILANTIN INFATABS
21
dutasteride/tamsulosin hydrochloride
DILANTIN-125
21
DUTOPROL
DILATRATE SR
70
DYRENIUM
63
diltiazem cd
e.e.s. 400
65
E.E.S. GRANULES
diltiazem hcl
63
diltiazem hcl cd
econazole nitrate
63
EDARBI
diltiazem hcl er
63
EDECRIN
dilt-xr
DIPENTUM
100
EDURANT
106
EFFIENT
diphenhydramine hcl
77
ELESTRIN
diphenoxylate/atropine
DIPHTHERIA/TETANUS TOXOIDS
98
ELIDEL
ADSORBED PEDIATRIC
ELIGARD
60
disopyramide phosphate
elinest
8
disulfiram
eliphos
20
ELIQUIS
divalproex sodium
20
ELITEK
divalproex sodium dr
20
ELIXOPHYLLIN
divalproex sodium er
DIVIGEL
87
ELLA
DOCETAXEL
33
ELMIRON
60
EMADINE
dofetilide
22
EMCYT
donepezil hcl
DORIBAX
13
EMEND
104
dorzolamide hcl
emoquette
104
EMPLICITI
dorzolamide hcl/timolol maleate
125
Page #
81
80
26
75
100
33
33
33
17
17
17
17
17
27
87
33
105
24
49
5
103
81
81
81
61
68
15
16
28
57
67
45
57
87
75
94
87
81
54
33
107
91
81
102
32
28
87
37
Drug Name Page #
Drug Name
EMSAM
24
esomeprazole sodium
EMTRIVA
46
estarylla
ENABLEX
80
ESTRACE
59
enalapril maleate
estradiol
59
enalapril maleate/hydrochlorothiazide
estradiol valerate
ENBREL
95
estradiol/norethindrone acetate
ENBREL SURECLICK
95
ESTRING
5
endocet
ethambutol hcl
5
endodan
ethosuximide
ENGERIX-B
98
etidronate disodium
54
enoxaparin sodium
etodolac
87
enpresse-28
etodolac er
87
enskyce
etoposide
38
EURAX
entacapone
44
EVOTAZ
entecavir
ENTRESTO
57
EXELDERM
ENTYVIO
77
EXELON
79
enulose
exemestane
ENVARSUS XR
95
EXJADE
102
EXTAVIA
epinastine hcl
107
FABRAZYME
epinephrine
EPIPEN 2-PAK
107
falmina
EPIPEN-JR 2-PAK
107
famciclovir
21
epitol
famotidine
68
FANAPT
eplerenone
EPOGEN
56
FARESTON
57
FARYDAK
eprosartan mesylate
EPZICOM
46
FASLODEX
EQUETRO
22
felbamate
ERBITUX
37
felodipine er
118
FEMRING
ergocalciferol
22
ergoloid mesylates
fenofibrate
ERIVEDGE
33
fenofibrate micronized
91
errin
fenofibric acid
ERWINAZE
33
fenofibric acid dr
16
ery
fenoprofen calcium
ERYPED 200
16
fentanyl
ERYPED 400
16
fentanyl citrate oral transmucosal
ERY-TAB
16
FENTORA
ERYTHROCIN LACTOBIONATE
16
FERRIPROX
ERYTHROCIN STEARATE
16
FETZIMA
16
FETZIMA TITRATION PACK
erythromycin
16
FINACEA
erythromycin base
16
erythromycin ethylsuccinate
finasteride
75
FIRAZYR
erythromycin/benzoyl peroxide
ESBRIET
108
FIRMAGON
24
FLAREX
escitalopram oxalate
79
esomeprazole magnesium
flavoxate hcl
126
Page #
79
87
87
88
87
88
88
31
19
100
2
2
35
38
47
28
22
35
110
73
76
88
48
78
41
32
35
32
20
65
88
68
68
69
68
2
3
5
6
101
24
24
75
81
95
94
103
80
Drug Name Page #
Drug Name
FLEBOGAMMA
97
FRAGMIN
FLEBOGAMMA DIF
97
FREAMINE HBC 6.9%
60
FREAMINE III
flecainide acetate
FLECTOR
2
FROVA
FLOVENT DISKUS
105
frovatriptan succinate
FLOVENT HFA
105
furosemide
28
FUZEON
fluconazole
28
fluconazole in dextrose
fyavolv
28
FYCOMPA
fluconazole in nacl
29
flucytosine
gabapentin
83
GABITRIL
fludrocortisone acetate
105
flunisolide
galantamine hydrobromide
75
GAMASTAN S/D
fluocinolone acetonide
83
GAMMAGARD LIQUID
fluocinolone acetonide
83
GAMMAKED
fluocinolone acetonide ear drops
83
GAMUNEX-C
fluocinonide
83
fluocinonide-e
ganciclovir
103
fluorometholone
garamycin
33
GARDASIL
fluorouracil
75
GARDASIL 9
fluorouracil
25
fluoxetine hcl
gatifloxacin
40
GATTEX
fluphenazine decanoate
40
fluphenazine hcl
gavilyte-c
83
flurandrenolide
gavilyte-g
2
flurbiprofen
gavilyte-h
103
flurbiprofen sodium
gavilyte-n/flavor pack
32
GELNIQUE
flutamide
83
fluticasone propionate
gemcitabine hcl
105
fluticasone propionate
gemfibrozil
69
fluvastatin
generlac
69
fluvastatin sodium er
gengraf
25
GENOTROPIN
fluvoxamine maleate
25
GENOTROPIN MINIQUICK
fluvoxamine maleate er
FML
103
gentak
FML FORTE
103
gentamicin sulfate
FOCALIN XR
72
gentamicin sulfate pediatric
118
folic acid
gentamicin sulfate/0.9% sodium chloride
54
fondaparinux sodium
gentamicin sulfate/sodium chloride
FORADIL AEROLIZER
107
GENVOYA
FORFIVO XL
23
GEODON
FORTEO
100
gianvi
FORTICAL
100
gildagia
FOSAMAX PLUS D
100
gildess 1.5/30
44
foscavir
gildess 1/20
59
fosinopril sodium
gildess 24 fe
59
fosinopril sodium/hydrochlorothiazide
gildess fe 1.5/30
22
fosphenytoin sodium
gildess fe 1/20
FOSRENOL
81
GILENYA
127
Page #
54
114
114
30
30
67
46
88
18
20
20
22
97
97
97
97
44
9
98
98
16
77
79
79
77
79
80
33
69
79
95
85
85
9
9
9
9
9
45
41
88
88
88
88
88
88
88
73
Drug Name Page #
Drug Name
GILOTRIF
33
HUMALOG MIX 75/25 KWIKPEN
73
HUMATROPE
glatopa
GLEEVEC
36
HUMATROPE COMBO PACK
GLEOSTINE
31
HUMIRA
49
HUMIRA PEDIATRIC CROHNS
glimepiride
50
DISEASE STARTER PACK
glipizide
50
HUMIRA PEN
glipizide er
50
HUMIRA PEN-CROHNS
glipizide xl
50
DISEASESTARTER
glipizide/metformin hcl
GLUCAGEN HYPOKIT
53
HUMIRA PEN-PSORIASIS STARTER
GLUCAGON EMERGENCY KIT
53
humulin 70/30
50
HUMULIN 70/30 KWIKPEN
glyburide
77
glycopyrrolate
humulin n
7
HUMULIN N KWIKPEN
glydo
GLYSET
50
humulin r
GOLYTELY
79
humulin r u-500 (concentrated)
28
HUMULIN R U-500 KWIKPEN
granisetron hcl
29
griseofulvin microsize
hydralazine hcl
29
griseofulvin ultramicrosize
hydrochlorothiazide
72
guanfacine er
hydrocodone bitartrate/acetaminophen
57
guanfacine hcl
hydrocodone bitartrate/homatropine
31
guanidine hcl
methylbromide
H.P. ACTHAR
85
hydrocodone/acetaminophen
83
halobetasol propionate
hydrocodone/homatropine
HALOG
83
hydrocodone/ibuprofen
40
haloperidol
hydrocortisone
40
haloperidol decanoate
hydrocortisone
40
haloperidol lactate
hydrocortisone butyrate
HARVONI
44
hydrocortisone butyrate (lipid)
HAVRIX
98
hydrocortisone butyrate (lipophilic)
91
heather
hydrocortisone valerate
95
hecoria
hydrocortisone/acetic acid
55
heparin sodium
hydromet
54
heparin sodium dcu
hydromorphone hcl
54
heparin sodium/d5w
hydromorphone hcl er
55
heparin sodium/nacl 0.9%
hydroxychloroquine sulfate
55
heparin sodium/sodium chloride 0.9%
hydroxyurea
HYPERRAB S/D
premix
HEPATAMINE
115
HYQVIA
HEPATASOL
115
ibandronate sodium
HERCEPTIN
37
IBRANCE
HETLIOZ
73
ibudone
HEXALEN
32
ibuprofen
HUMALOG
53
ICLUSIG
HUMALOG KWIKPEN
53
ILARIS
HUMALOG MIX 50/50
53
ilotycin
HUMALOG MIX 50/50 KWIKPEN
53
imatinib mesylate
HUMALOG MIX 75/25
53
IMBRUVICA
128
Page #
53
85
85
96
95
96
96
96
53
53
53
53
53
53
53
71
68
6
109
6
109
6
83
100
83
83
83
83
104
109
6
3
37
33
97
98
100
34
6
2
36
98
16
36
36
Drug Name Page #
Drug Name
13
imipenem/cilastatin
itraconazole
26
imipramine hcl
ivermectin
26
IXEMPRA KIT
imipramine pamoate
75
IXIARO
imiquimod
IMOGAM RABIES-HT
97
JADENU
IMOVAX RABIES (H.D.C.V.)
99
JAKAFI
INCIVEK
44
JALYN
INCRELEX
85
jantoven
68
JANUMET
indapamide
INDERAL XL
61
JANUMET XR
INFANRIX
99
JANUVIA
INLYTA
36
JARDIANCE
INNOPRAN XL
61
jencycla
101
JENTADUETO
insupen 33gx4mm
INTELENCE
45
jevantique
101
intralipid
jevantique lo
INTRON A
44
JEVTANA
INTRON A W/DILUENT
44
jinteli
88
introvale
jolessa
INVANZ
13
jolivette
INVEGA
41
juleber
INVEGA SUSTENNA
41
junel 1.5/30
INVEGA TRINZA
41
junel 1/20
INVIRASE
47
junel fe 1.5/30
INVOKAMET
50
junel fe 1/20
IONOSOL-B/DEXTROSE 5%
53
junel fe 24
IOPIDINE
104
JUXTAPID
IPOL INACTIVATED IPV
99
KADCYLA
106
ipratropium bromide
kaitlib fe
106
KALETRA
ipratropium bromide/albuterol sulfate
58
KALYDECO
irbesartan
58
KANUMA
irbesartan/hydrochlorothiazide
49
irenka
kariva
IRESSA
36
kcl 0.075%/d5w/nacl 0.45%
34
irinotecan
kcl 0.15%/d5w/ nacl 0.3%
34
KCL 0.15%/D5W/LR
irinotecan hcl
ISENTRESS
45
kcl 0.15%/d5w/nacl 0.2%
115
isolyte-m/dextrose 5%
kcl 0.15%/d5w/nacl 0.225%
ISOLYTE-P/DEXTROSE 5%
115
kcl 0.15%/d5w/nacl 0.45%
31
isoniazid
kcl 0.15%/d5w/nacl 0.9%
ISORDIL TITRADOSE
70
kcl 0.3%/d5w/nacl 0.45%
70
KCL 0.3%/D5W/NACL 0.9%
isosorbide dinitrate
70
isosorbide dinitrate er
kelnor 1/35
70
isosorbide mononitrate
ketoconazole
70
isosorbide mononitrate er
ketodan
9
isotonic gentamicin
ketoprofen
65
isradipine
ketoprofen er
ISTALOL
104
ketorolac tromethamine
129
Page #
29
37
34
99
110
34
81
55
50
50
50
50
91
50
88
88
34
88
88
91
88
88
88
88
88
88
70
37
88
47
107
76
88
115
115
53
115
115
115
115
115
115
88
29
29
2
2
2
Drug Name Page #
Drug Name
103
ketorolac tromethamine
larin 24 fe
KEVEYIS
101
larin fe 1.5/30
KEYTRUDA
37
larin fe 1/20
88
LASTACAFT
kimidess
KINERET
96
latanoprost
KINRIX
99
LATUDA
110
kionex
layolis fe
75
LAZANDA
klofensaid ii
115
klor-con 10
leena
115
klor-con 8
leflunomide
115
LENVIMA 10MG DAILY DOSE
klor-con m10
KLOR-CON M15
115
115
klor-con m20
115
klor-con sprinkle
KOMBIGLYZE XR
50
KORLYM
86
KRISTALOSE
79
LESCOL XL
115
k-sol
lessina
115
LETAIRIS
k-tab
88
kurvelo
letrozole
KUVAN
76
leucovorin calcium
KYNAMRO
70
LEUKERAN
61
LEUKINE
labetalol hcl
102
lacrisert
leuprolide acetate
116
lactated ringers
leva set
116
lactated ringers dextrose 5% viaflex
levalbuterol
101
lactated ringers irrigation
levalbuterol hcl
116
LEVATOL
lactated ringers viaflex
79
LEVEMIR
lactulose
LAMICTAL STARTER/NOT TAKING
20
LEVEMIR FLEXTOUCH
CARBAMAZEPINE
levetiracetam
LAMICTAL STARTER/TAKING
20
levetiracetam er
CARBAMAZEPINE/NOT TAKING
levobunolol hcl
VALPROATE
levocarnitine
LAMICTAL STARTER/TAKING
20
levocetirizine dihydrochloride
VALPROATE
levofloxacin
46
lamivudine
levofloxacin in d5w
46
lamivudine/zidovudine
levoleucovorin
21
lamotrigine
levoleucovorin calcium
20
lamotrigine er
levonest
21
lamotrigine odt
levonorgestrel and ethinyl estradiol
LANOXIN
66
levonorgestrel/ethinyl estradiol
80
lansoprazole
levora 0.15/30-28
10
lansoprazole/amoxicillin/clarithromycin
levo-t
LANTUS
53
levothyroxine sodium
LANTUS SOLOSTAR
53
levoxyl
88
LEXIVA
larin 1.5/30
88
LIALDA
larin 1/20
130
Page #
88
89
89
102
102
41
89
6
89
98
36
36
36
36
36
36
69
89
108
35
34
32
56
94
7
107
107
61
53
53
18
18
104
101
106
16
16
34
34
89
89
89
89
91
92
92
47
100
Drug Name Page #
Drug Name
8
LUPANETA PACK
lidocaine
8
LUPRON DEPOT
lidocaine hcl
7
LUPRON DEPOT-PED
lidocaine hcl jelly
7
lidocaine hcl viscous
lutera
8
LYNPARZA
lidocaine pak
8
LYRICA
lidocaine viscous
8
LYSODREN
lidocaine/prilocaine
8
lidocaine-prilocaine-cream base
lyza
LINCOCIN
10
MACRODANTIN
10
lincomycin hcl
mafenide acetate
38
lindane
magnesium sulfate
10
linezolid
malathion
LINZESS
79
maprotiline hcl
92
liothyronine sodium
marlissa
34
MARPLAN
lipodox
34
lipodox 50
marten-tab
59
MATULANE
lisinopril
59
lisinopril/hydrochlorothiazide
matzim la
49
MAXIDEX
lithium
49
lithium carbonate
meclizine hcl
49
lithium carbonate er
meclofenamate sodium
LIVALO
69
medroxyprogesterone acetate
8
livixil pak
mefenamic acid
77
lofene
mefloquine hcl
83
lokara
megestrol acetate
89
MEKINIST
lomedia 24 fe
32
lomustine
meloxicam
LONSURF
33
memantine hcl
77
loperamide hcl
memantine hcl titration pak
89
lopreeza
memantine hydrochloride
49
MENACTRA
lorazepam
48
MENEST
lorazepam intensol
6
MENHIBRIX
lorcet
6
MENOMUNE-A/C/Y/W-135
lorcet hd
6
MENOSTAR
lorcet plus
6
MENTAX
lortab
89
MENVEO
loryna
58
losartan potassium
meperidine hcl
58
losartan potassium/hydrochlorothiazide
meprobamate
LOTEMAX
103
mercaptopurine
69
lovastatin
meropenem
89
low-ogestrel
mesalamine
40
loxapine
mesna
40
MESNEX
loxapine succinate
8
MESTINON
lp lite pak
LUFYLLIN
107
MESTINON TIMESPAN
LUMIGAN
102
metadate er
LUMIZYME
76
metaproterenol sulfate
131
Page #
94
94
94
89
34
19
93
91
10
10
116
38
23
89
24
2
32
65
103
27
2
91
3
37
91
34
3
23
23
23
99
34
99
99
89
29
99
6
48
33
13
100
34
34
31
31
72
107
Drug Name Page #
Drug Name
50
metformin hcl
minoxidil
50
MIRAPEX ER
metformin hcl er
3
methadone hcl
mirtazapine
3
methadose
mirtazapine odt
72
methamphetamine hcl
misoprostol
104
methazolamide
mitomycin
10
methenamine hippurate
mitoxantrone hcl
95
M-M-R II
methimazole
METHITEST
86
modafinil
96
methotrexate
moderiba
96
MODERIBA 1200 DOSE PACK
methotrexate sodium
75
MODERIBA 800 DOSE PACK
methoxsalen
77
methscopolamine bromide
moexipril hcl
68
methyclothiazide
moexipril/hydrochlorothiazide
72
methylphenidate hcl
molindone hydrochloride
72
methylphenidate hcl cd
mometasone furoate
72
methylphenidate hcl er
mometasone furoate
72
methylphenidate hcl sr
mondoxyne nl
73
methylphenidate hydrochloride
mono-linyah
84
methylprednisolone
mononessa
83
methylprednisolone acetate
montelukast sodium
83
MONUROL
methylprednisolone dose pack
84
methylprednisolone sodiumsuccinate
morgidox 1x100mg
86
methyltestosterone
morgidox 2x100mg
104
metipranolol
morphine sulfate
77
metoclopramide hcl
morphine sulfate er
68
MOVIPREP
metolazone
62
MOXEZA
metoprolol succinate er
62
metoprolol tartrate
moxifloxacin hcl
62
MOZOBIL
metoprolol/hydrochlorothiazide
10
MULTAQ
metronidazole
10
metronidazole in nacl 0.79%
mupirocin
10
metronidazole vaginal
mupirocin calcium
60
MUSTARGEN
mexiletine hcl
MIACALCIN
100
MYALEPT
29
MYCAMINE
miconazole 3
89
microgestin 1.5/30
mycophenolate mofetil
89
microgestin 1/20
mycophenolic acid dr
89
microgestin 24 fe
myorisan
89
MYOZYME
microgestin fe
89
MYRBETRIQ
microgestin fe 1.5/30
57
midodrine hcl
myzilra
MIGERGOT
30
nabumetone
51
miglitol
nadolol
MILLIPRED
84
nadolol/bendroflumethiazide
89
mimvey lo
nafcillin sodium
70
minitran
naftifine hcl
18
minocycline hcl
naftifine hydrochloride
132
Page #
71
38
24
23
79
34
34
99
109
44
44
44
59
59
43
84
105
18
89
89
106
11
18
18
6
3
79
16
17
56
60
11
11
32
101
29
96
96
75
76
80
89
3
62
62
14
29
29
Drug Name Page #
Drug Name
NAFTIN
29
nevirapine er
NAGLAZYME
76
NEXAVAR
7
NEXIUM
nalbuphine hcl
3
nalfon
niacin er
8
naloxone hcl
niacor
8
naloxone hydrochloride
nicardipine hcl
8
NICOTROL NS
naltrexone hcl
NAMENDA
23
nifediac cc
NAMENDA TITRATION PAK
23
nifedical xl
NAMENDA XR
23
nifedipine er
NAMENDA XR TITRATION PACK
23
nikki
102
NILANDRON
naphazoline hcl
3
naproxen
nimodipine
3
NINLARO
naproxen dr
3
naproxen kit
nisoldipine
3
naproxen sodium
nisoldipine er
3
NITRO-BID
naproxen sodium ds
30
NITRO-DUR
naratriptan hcl
NATACYN
29
nitrofurantoin
51
nateglinide
nitrofurantoin macrocrystals
NATPARA
101
nitrofurantoin monohydrate
NEBUPENT
37
nitrofurantoin monohydrate/macrocrystals
89
necon 0.5/35-28
nitroglycerin lingual
89
necon 1/35
nitroglycerin transdermal
89
NITROMIST
necon 7/7/7
24
NITROSTAT
nefazodone hcl
9
neomycin sulfate
nizatidine
102
neomycin/bacitracin/polymyxin
nora-be
102
NORDITROPIN FLEXPRO
neomycin/polymyxin/bacitracin zinc
11
neomycin/polymyxin/bacitracin/hydrocortis
norethindrone
one
norethindrone & ethinyl estradiol ferrous
103
neomycin/polymyxin/dexamethasone
fumarate
11
neomycin/polymyxin/gramicidin
norethindrone acetate
104
neomycin/polymyxin/hc
norethindrone acetate/ethinyl estradiol
11
neomycin/polymyxin/hydrocortisone
norethindrone acetate/ethinyl
104
neomycin/polymyxin/hydrocortisone
estradiol/ferrous fumarate
102
neo-polycin
norgestimate/ethinyl estradiol
11
neo-polycin hc
norlyroc
NEPHRAMINE
116
normosol-m in d5w
75
neuac
normosol-r in d5w
75
NORTHERA
neuac kit
NEULASTA
56
nortrel 0.5/35 (28)
NEULASTA ONPRO KIT
56
nortrel 1/35
NEUMEGA
56
nortrel 7/7/7
NEUPOGEN
56
nortriptyline hcl
NEUPRO
38
NORVIR
NEVANAC
103
novarel
45
nevirapine
novolin 70/30
133
Page #
45
36
80
70
70
65
9
65
65
65
89
32
65
34
65
65
70
70
11
11
11
11
70
70
71
71
78
91
85
91
89
91
89
89
89
91
116
53
67
90
90
90
26
47
85
53
Drug Name Page #
Drug Name
53
ONGLYZA
novolin 70/30 relion
53
ONMEL
novolin n
53
OPDIVO
novolin n relion
54
OPSUMIT
novolin r
54
novolin r relion
oralone
NOVOLOG
54
ORAP
NOVOLOG FLEXPEN
54
ORBACTIV
NOVOLOG MIX 70/30
54
ORENCIA
NOVOLOG MIX 70/30 PREFILLED
54
ORENITRAM
FLEXPEN
ORFADIN
NOVOLOG PENFILL
54
ORKAMBI
NOXAFIL
29
orsythia
NUCYNTA
7
OSMOPREP
NUCYNTA ER
4
OTEZLA
NUEDEXTA
73
oxaliplatin
NULOJIX
96
oxandrolone
NUPLAZID
42
oxaprozin
101
nutrilipid
oxcarbazepine
NUTROPIN AQ NUSPIN 10
85
oxiconazole nitrate
85
OXISTAT
85
oxybutynin chloride
NUTROPIN AQ PEN
85
oxybutynin chloride er
NUVIGIL
109
oxycodone hcl
29
nyamyc
oxycodone hcl er
29
nystatin
oxycodone hydrochloride
29
nystatin/triamcinolone
oxycodone/acetaminophen
29
nystop
oxycodone/aspirin
90
ocella
oxycodone/ibuprofen
OCTAGAM
97
OXYCONTIN
94
octreotide acetate
oxymorphone hydrochloride
ODEFSEY
45
oxymorphone hydrochloride er
ODOMZO
34
OXYTROL
OFEV
109
pacerone
17
ofloxacin
paclitaxel
90
ogestrel
paliperidone er
42
olanzapine
pamidronate disodium
42
PANCREAZE
olanzapine odt
25
olanzapine/fluoxetine
pancrelipase
102
PANDEL
olopatadine hcl
106
PANRETIN
olopatadine hcl
OLYSIO
44
pantoprazole sodium
70
omega-3-acid ethyl esters
paricalcitol
80
omeprazole
paroex
OMNITROPE
85
paromomycin sulfate
ONCASPAR
34
paroxetine hcl
28
ondansetron hcl
paroxetine hcl er
28
ondansetron odt
paser
ONFI
20
PATADAY
134
Page #
51
29
37
108
74
40
11
96
108
101
107
90
78
98
34
86
3
22
29
29
80
80
7
4
7
7
7
3
4
7
4
80
60
34
42
100
76
76
84
37
80
101
74
9
25
25
31
102
Drug Name Page #
Drug Name
PATANOL
102
pilocarpine hydrochloride
PAXIL
25
PILOPINE HS
29
pedi-dri
pimozide
PEDVAX HIB
99
pimtrea
79
peg 3350/electrolytes
pindolol
79
peg-3350/electrolytes
pioglitazone hcl
79
peg-3350/nacl/na bicarbonate/kcl
pioglitazone hcl/metformin hcl
PEGANONE
22
pioglitazone hcl-glimepiride
PEGASYS
45
piperacillin sodium/ tazobactam sodium
PEGASYS PROCLICK
44
piperacillin sodium/tazobactam sodium
PEGINTRON
45
piperacillin/tazobactam
PEG-INTRON REDIPEN
44
pirmella 1/35
PEG-INTRON REDIPEN PAK 4
44
pirmella 7/7/7
78
peg-prep
piroxicam
79
PLASMA-LYTE-148
pegylax
15
PLASMA-LYTE-56/D5W
penicillin g potassium
PENICILLIN G POTASSIUM IN ISO14
PLEGRIDY
OSMOTIC DEXTROSE
PLEGRIDY STARTER PACK
15
penicillin g sodium
plenamine
15
penicillin v potassium
podofilox
PENNSAID
75
polycin
PENTAM 300
37
polycin b
PENTASA
100
poly-dex
67
pentoxifylline er
polyethylene glycol 3350
PERFOROMIST
107
polymyxin b sulfate/trimethoprim sulfate
59
POMALYST
perindopril erbumine
74
periogard
portia-28
PERJETA
37
potassium chloride
38
permethrin
potassium chloride 0.15% /nacl 0.45%
40
perphenazine
viaflex
27
perphenazine/amitriptyline
potassium chloride 0.15% d5w/nacl 0.33%
PERTZYE
77
PEXEVA
25
106
pharbedryl
viaflex
27
phenadoz
potassium chloride 0.15% nacl 0.9%
24
phenelzine sulfate
potassium chloride 0.15% w/nacl 0.9%
27
phenergan
viaflex
18
phenobarbital
potassium chloride 0.15%/d5w
57
phenoxybenzamine hydrochloride
potassium chloride 0.15%/nacl 0.9%
PHENYTEK
22
22
phenytoin
potassium chloride 0.224%/d5w/nacl 0.45%
22
phenytoin infatabs
potassium chloride 0.224%d5w/nacl 0.45%
22
phenytoin sodium extended
viaflex
90
philith
potassium chloride 0.3%/ nacl 0.9%
PHOSLYRA
81
potassium chloride 0.3%/d5w
PHOSPHOLINE IODIDE
104
potassium chloride 0.3%/nacl 0.9%/viaflex
74
pilocarpine hcl
potassium chloride cr
104
pilocarpine hcl
potassium chloride er
135
Page #
74
104
40
90
62
51
51
51
15
15
15
90
90
3
116
116
73
73
116
75
102
102
103
79
102
34
90
117
116
116
116
116
116
116
116
116
116
116
116
116
116
116
116
117
Drug Name Page #
Drug Name
117
PROGLYCEM
potassium chloride sr
117
PROLASTIN-C
potassium citrate er
POTIGA
19
PROLEUKIN
PRADAXA
55
PROLIA
PRALUENT
67
PROMACTA
38
pramipexole dihydrochloride
promethazine hcl
38
pramipexole dihydrochloride er
promethazine hcl plain
PRANDIMET
51
promethazine vc plain
69
pravastatin sodium
promethazine vc/codeine
57
prazosin hcl
promethazine/codeine
PRED MILD
103
promethazine/dextromethorphan
PRED-G
103
promethazine/phenylephrine
84
prednicarbate
promethazine/phenylephrine/codeine
103
prednisolone acetate
promethazine-dm
84
prednisolone sodium phosphate
promethegan
103
prednisolone sodium phosphate
propafenone hcl
84
prednisolone sodium phosphate odt
propafenone hcl er
84
prednisone
propranolol hcl
84
prednisone intensol
propranolol hcl er
85
pregnyl w/diluent benzyl alcohol/nacl
propranolol/hydrochlorothiazide
PREMARIN
90
propylthiouracil
PREMASOL
117
PROQUAD
8
PROSOL
premium lidocaine
70
prevalite
protriptyline hcl
90
PROVENTIL HFA
previfem
PREZCOBIX
47
prudoxin
PREZISTA
47
psorcon
PRIFTIN
31
PULMICORT
PRIMAQUINE PHOSPHATE
38
PULMICORT FLEXHALER
20
PULMOZYME
primidone
PRISTIQ
25
PURIXAN
PRIVIGEN
98
PYLERA
PROAIR HFA
107
pyrazinamide
PROAIR RESPICLICK
107
pyridostigmine bromide
30
QUADRACEL
probenecid
30
probenecid/colchicine
quasense
PROCALAMINE
118
quetiapine fumarate
72
procentra
quinapril hcl
40
prochlorperazine
quinapril/hydrochlorothiazide
40
prochlorperazine edisylate
quinidine gluconate cr
40
prochlorperazine maleate
quinidine gluconate er
PROCRIT
56
quinidine sulfate
84
procto-med hc
quinidine sulfate er
84
procto-pak
quinine sulfate
84
QVAR
proctosol hc
84
RABAVERT
proctozone-hc
PROCYSBI
102
raloxifene hydrochloride
91
progesterone
ramipril
136
Page #
53
109
34
101
56
27
27
109
109
109
109
109
109
109
27
60
60
62
62
62
95
99
118
27
107
75
84
105
105
107
33
78
31
31
99
90
42
59
59
60
60
60
60
38
105
99
91
59
Drug Name Page #
Drug Name
RANEXA
67
risperidone
78
ranitidine hcl
risperidone m-tab
RAPAFLO
81
risperidone odt
RAPAMUNE
96
RITUXAN
RAVICTI
77
rivastigmine tartrate
REBIF
74
rivastigmine transdermal system
REBIF REBIDOSE
73
rizatriptan benzoate
REBIF REBIDOSE TITRATION PACK
73
rizatriptan benzoate odt
REBIF TITRATION PACK
74
romycin
90
reclipsen
ropinirole er
RECOMBIVAX HB
99
ropinirole hcl
RECTIV
71
rosadan
8
relador pak
rosuvastatin calcium
8
ROTARIX
relador pak plus
RELENZA DISKHALER
47
ROTATEQ
RELION R
54
roweepra
RELISTOR
78
ROXICET
RELPAX
30
ROZEREM
REMICADE
96
SABRIL
RENVELA
81
SAIZEN
51
SAIZEN CLICK.EASY
repaglinide
51
SAMSCA
repaglinide/metformin hydrochloride
REPATHA
67
SANCUSO
REPATHA SURECLICK
67
SANDOSTATIN LAR DEPOT
7
SANTYL
reprexain
RESCRIPTOR
45
SAPHRIS
RESCULA
102
SAVELLA
57
SAVELLA TITRATION PACK
reserpine
RESTASIS
102
selegiline hcl
RETROVIR IV INFUSION
46
selenium sulfide
REVATIO
108
SELZENTRY
REVLIMID
32
SENSIPAR
REXULTI
42
SEREVENT DISKUS
REYATAZ
47
SEROQUEL XR
RHEUMATREX
96
SEROSTIM
45
ribasphere
sertraline hcl
RIBASPHERE RIBAPAK
45
setlakin
RIBATAB
45
sevelamer carbonate
45
ribavirin
sharobel
RIDAURA
98
SIGNIFOR
31
SIGNIFOR LAR
rifabutin
31
rifampin
sildenafil
RIFATER
31
SILENOR
73
riluzole
silver sulfadiazine
47
SIMCOR
rimantadine hcl
101
SIMPONI
risedronate sodium
101
SIMPONI ARIA
risedronate sodium dr
RISPERDAL CONSTA
42
simvastatin
137
Page #
42
42
42
37
23
23
30
30
16
39
39
11
69
99
99
19
7
110
20
85
85
110
28
94
75
43
73
73
39
75
46
93
107
43
86
25
90
81
91
94
94
108
110
11
69
96
96
69
Drug Name Page #
Drug Name
96
sirolimus
sulfamethoxazole/trimethoprim ds
SIRTURO
31
SULFAMYLON
SIVEXTRO
11
sulfasalazine
SKLICE
38
sulfatrim pediatric
118
sodium chloride
sulindac
118
sodium chloride 0.45%
sumatriptan
118
sodium chloride 0.45% viaflex
sumatriptan succinate
118
sodium chloride 0.9%
sumatriptan succinate refill
118
SUPRAX
sodium chloride pab
77
SUPREP BOWEL PREP
sodium phenylbutyrate
110
SURMONTIL
sodium polystyrene sulfonate
17
SUSTIVA
sodium sulfacetamide
SOLTAMOX
32
SUTENT
SOLU-CORTEF
84
syeda
109
SYLATRON
soma
SOMATULINE DEPOT
94
SYLVANT
SOMAVERT
94
SYMBICORT
60
SYMLINPEN 120
sorine
60
SYMLINPEN 60
sotalol hcl
60
SYNAGIS
sotalol hcl (af)
SOVALDI
45
SYNALAR CREAM KIT
SPIRIVA HANDIHALER
106
SYNALGOS-DC
SPIRIVA RESPIMAT
106
SYNAREL
68
SYNERCID
spironolactone
68
SYNJARDY
spironolactone/hydrochlorothiazide
SPORANOX
29
SYNRIBO
90
SYNTHROID
sprintec 28
SPRITAM
19
SYPRINE
SPRYCEL
36
TABLOID
90
TACLONEX
sronyx
11
ssd
tacrolimus
46
stavudine
tacrolimus
STAVZOR
20
TAFINLAR
STELARA
75
TAGRISSO
102
TALTZ
sterile water irrigation
102
TAMIFLU
sterile water irrigation plastic bottle
STIVARGA
36
tamoxifen citrate
STRATTERA
73
tamsulosin hcl
STRENSIQ
77
TARCEVA
9
TARGRETIN
streptomycin sulfate
STRIBILD
45
tarina fe 1/20
SUBOXONE
8
TASIGNA
79
sucralfate
tazicef
17
TAZORAC
sulfacetamide sodium
17
sulfacetamide sodium/prednisolone sodium
taztia xt
TECENTRIQ
phosphate
17
TECFIDERA
sulfadiazine
17
TECFIDERA STARTER PACK
sulfamethoxazole/trimethoprim
138
Page #
17
11
100
17
3
31
30
30
13
79
27
45
36
90
35
37
105
51
51
98
75
7
94
11
51
35
92
110
33
84
75
96
36
35
75
47
32
81
36
37
90
36
13
75
66
37
98
98
Drug Name Page #
Drug Name
TECHNIVIE
45
timolol maleate ophthalmic gel forming
TEFLARO
13
tinidazole
TEGRETOL
22
TIROSINT
TEGRETOL-XR
22
TIVICAY
TEKAMLO
67
tizanidine hcl
TEKTURNA
67
TOBI PODHALER
TEKTURNA HCT
67
TOBRADEX
58
TOBRADEX ST
telmisartan
58
telmisartan/amlodipine
tobramycin
58
telmisartan/hydrochlorothiazide
tobramycin sulfate
109
temazepam
tobramycin/dexamethasone
2
TOBREX
tencon
TENIVAC
99
TOLAK
81
terazosin hcl
tolazamide
29
terbinafine hcl
tolbutamide
107
terbutaline sulfate
tolcapone
29
terconazole
tolmetin sodium
86
testosterone
tolterodine tartrate
86
testosterone cypionate
tolterodine tartrate er
86
testosterone enanthate
topiragen
86
testosterone pump
topiramate
TESTRED
86
toposar
TETANUS TOXOID ADSORBED
99
topotecan hcl
TETANUS/DIPHTHERIA TOXOIDS99
torsemide
ADSORBED
TOVIAZ
73
TRACLEER
tetrabenazine
18
TRADJENTA
tetracycline hcl
18
tetracycline hydrochloride
tramadol hcl
TEV-TROPIN
86
tramadol hcl er
THALOMID
32
tramadol hydrochloride
107
theochron
tramadol hydrochloride/acetaminophen
107
theophylline cr
trandolapril
107
theophylline er
trandolapril/verapamil hcl
11
thermazene
trandolapril/verapamil hcl er
40
thioridazine hcl
tranexamic acid
32
TRANSDERM-SCOP
thiotepa
40
thiothixene
tranylcypromine sulfate
THYROLAR-1
93
TRAVASOL
THYROLAR-1/2
93
travoprost
THYROLAR-1/4
93
trazodone hcl
THYROLAR-2
93
TREANDA
THYROLAR-3
93
TRECATOR
20
TRELSTAR
tiagabine hydrochloride
57
TRELSTAR MIXJECT
ticlopidine hcl
TIKOSYN
61
tretinoin
90
tilia fe
tretinoin
62
timolol maleate
tretinoin microsphere
104
timolol maleate
tretinoin microsphere pump
139
Page #
104
38
93
45
44
107
103
103
107
9
103
9
76
51
51
38
9
80
80
21
21
35
35
67
80
108
51
7
4
7
7
60
59
59
56
27
24
118
102
24
32
31
95
94
37
76
76
76
Drug Name Page #
Drug Name
TREXALL
96
TYZINE PEDIATRIC NASAL DROPS
74
UCERIS
triamcinolone acetonide
84
u-cort
105
ULORIC
74
ULTRESA
triamcinolone in orabase
68
triamterene/hydrochlorothiazide
unithroid
49
triazolam
unithroid direct
TRIBENZOR
66
UPTRAVI
84
triderm
ursodiol
90
VAGIFEM
tri-estarylla
40
trifluoperazine hcl
valacyclovir hcl
48
VALCHLOR
trifluridine
38
trihexyphenidyl hcl
valganciclovir
90
tri-legest fe
valproate sodium
90
tri-linyah
valproic acid
90
tri-lo-estarylla
valsartan
90
tri-lo-marzia
valsartan/hydrochlorothiazide
90
tri-lo-sprintec
vancomycin
79
trilyte
vancomycin hcl
27
trimethobenzamide hcl
vandazole
11
VAQTA
trimethoprim
102
VARIVAX
trimethoprim sulfate/polymyxin b sulfate
27
VARIZIG
trimipramine maleate
90
VASCEPA
trinessa
90
VECTIBIX
trinessa lo
TRINTELLIX
24
VELCADE
90
tri-previfem
velivet
90
VENCLEXTA
tri-sprintec
TRIUMEQ
46
VENCLEXTA STARTING PACK
90
trivora-28
venlafaxine hcl
TROKENDI XR
21
venlafaxine hcl er
TROPHAMINE
118
VENTAVIS
80
VENTOLIN HFA
trospium chloride
80
VERAMYST
trospium chloride er
TRUMENBA
99
verapamil hcl
TRUVADA
46
verapamil hcl er
TUDORZA PRESSAIR
106
verapamil hcl sr
TWINRIX
99
verdrocet
TYBOST
47
VEREGEN
TYGACIL
11
VERIPRED 20
TYKERB
36
VERSACLOZ
TYPHIM VI
99
VESICARE
TYSABRI
74
vestura
TYVASO
108
VEXOL
TYVASO REFILL
108
viagra
TYVASO STARTER
108
VIBERZI
TYZEKA
44
vicodin
TYZINE
109
vicodin es
140
Page #
109
100
85
30
77
93
93
108
78
90
48
32
44
20
20
58
58
11
11
11
99
99
99
70
37
35
90
35
35
25
25
108
107
105
66
66
66
7
76
85
43
80
90
103
81
79
7
7
Drug Name Page #
Drug Name
7
vicodin hp
zafirlukast
VICTOZA
51
zaleplon
VICTRELIS
45
ZALTRAP
VIDEX PEDIATRIC
46
zamicet
VIEKIRA PAK
45
zarah
90
ZARXIO
vienva
VIGAMOX
17
ZAVESCA
VIIBRYD
26
zazole
VIIBRYD STARTER PACK
26
ZELAPAR
VIMIZIM
77
ZELBORAF
VIMPAT
22
ZEMAIRA
35
vincasar pfs
zenatane
35
vincristine sulfate
zenchent
VIOKACE
77
zenchent fe
90
ZENPEP
viorele
VIRACEPT
47
zenzedi
VIRAMUNE XR
46
zeosa
VIRAZOLE
109
ZEPATIER
VIREAD
46
ZETIA
118
ZIAGEN
vitamin d
VITEKTA
45
zidovudine
VOLTAREN
76
ziprasidone hcl
29
ZIRGAN
voriconazole
VOTRIENT
36
zoledronic acid
VPRIV
77
ZOLINZA
VRAYLAR
43
zolmitriptan
90
vyfemla
zolmitriptan odt
VYTORIN
70
zolpidem tartrate er
55
ZOMACTON
warfarin sodium
90
ZOMETA
wera
91
ZOMIG
wymzya fe
XALKORI
36
ZOMIG NASAL SPRAY
XARELTO
55
zonalon
XARELTO STARTER PACK
55
zonisamide
XELJANZ
98
ZORBTIVE
XELJANZ XR
98
ZORTRESS
XENAZINE
73
ZOSTAVAX
XEOMIN
102
zovia 1/35e
XGEVA
101
zovia 1/50e
XIFAXAN
11
ZOVIRAX
XOLAIR
109
ZYCLARA
XOPENEX HFA
107
ZYCLARA PUMP
XTANDI
32
ZYDELIG
91
ZYFLO CR
xulane
7
ZYKADIA
xylon
XYREM
110
ZYLET
YERVOY
37
ZYPREXA RELPREVV
YF-VAX
99
ZYTIGA
141
Page #
106
109
35
7
91
56
77
30
39
36
109
76
91
91
77
72
91
48
70
46
46
43
44
101
35
31
31
109
86
101
31
31
76
19
86
96
99
91
91
48
76
76
35
106
35
9
43
32
Drug Name
ZYVOX
Page #
12
142
This formulary was updated on 8/01/2016. For more recent information or other questions, please contact
Simply Healthcare Plans, Member Services Department toll-free at 1-877-577-0115 / TTY: 711. From October 1 to
February 14, we are open 7 days a week from 8 a.m. – 8 p.m., Eastern. From February 15, we are open Monday
through Friday, 8 a.m. – 8 p.m., or visit mysimplymedicare.com.
Este formulario se actualizó el 8/01/2016. Para obtener información más reciente o para preguntas, por favor
llame a Simply Healthcare Plans, Servicios al Afiliado sin cargo al 1-877-577-0115 / TTY: 711. Desde el 1 de octubre
al 14 de febrero, estamos abiertos los 7 días de la semana de 8 a.m. – 8 p.m., hora del este. A partir del 15 de
febrero, estamos abiertos de lunes a viernes de 8 a.m. – 8 p.m., o visite mysimplymedicare.com.

Formulary - Simply Healthcare Plans

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