farmacopea 2022 de emblemhealth

Farmacopea 2022de EmblemHealth LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTOS PLANES 22329, V15

Esta farmacopea se actualizó el 05/01/2022. Para obtener información más reciente o para hacer otras preguntas, comuníquese con EmblemHealth Medicare HMO al 877-344-7364 (los usuarios de TTY deben llamar al 711), de lunes a domingos, de 8 am a 8 pm, o visite emblemhealth.com/medicare.

Lista de medicamentos cubiertos para: • EmblemHealth VIP Dual (HMO D-SNP)

• EmblemHealth VIP Dual Select (HMO D-SNP)

• EmblemHealth VIP Solutions (HMO D-SNP)

• EmblemHealth VIP Dual Reserve (HMO D-SNP)

https://emblemhealth.com/medicare

Nota para los miembros existentes: Esta farmacopea se ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún se incluyan los medicamentos que usted toma. Cuando esta lista de medicamentos (farmacopea) se refiera a “nosotros”, “nos” o “nuestro”, significa Health Insurance Plan of Greater New York (HIP). Cuando se refiere a “plan” o a “nuestro plan”, significa EmblemHealth VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP) y VIP Dual Reserve (HMO D-SNP).

El presente documento incluye una lista de medicamentos (farmacopea) para nuestro plan que se encuentra vigente a partir de 05/01/2022. Para obtener una farmacopea actualizada, comuníquese con nosotros. Nuestra información de contacto, junto con la última fecha en que hemos actualizado la farmacopea, aparece en la portada y en la contratapa.

Para poder utilizar sus beneficios de medicamentos con receta, por lo general, deberá usar farmacias de la red. Los beneficios, la farmacopea, la red de farmacias o los copagos y el coseguro pueden cambiar a partir del 1.° de enero de 2023 y periódicamente durante el año.

¿Qué es la Farmacopea de EmblemHealth VIP Dual (HMO D-SNP), EmblemHealth VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP), VIP Dual Reserve (HMO D-SNP)? La farmacopea es una lista de medicamentos cubiertos seleccionados por nuestro plan en colaboración con un equipo de proveedores de atención médica que representa las terapias con receta que se consideran una parte necesaria de un programa de tratamiento de calidad. Por lo general, nuestro plan cubre los medicamentos que se encuentran incluidos en nuestra farmacopea, siempre que el medicamento sea médicamente necesario, la receta se llene en una farmacia de la red y se respeten las demás reglas del plan. Para obtener más información sobre cómo llenar sus medicamentos con receta, consulte su Evidencia de Cobertura.

¿Puede cambiar la farmacopea (lista de medicamentos)? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1.° de enero, pero nuestro plan puede agregar o quitar medicamentos de la lista de medicamentos durante el año o agregar nuevas restricciones. Debemos seguirlas reglas de Medicare al hacer estos cambios.

Cambios que pueden afectarle este año: En los casos que figuran a continuación, usted se verá afectado por los cambios de cobertura durante el año:

• Nuevos medicamentos genéricos. Podemos eliminar de inmediato un medicamento de marcaincluido en nuestra lista de medicamentos si lo reemplazamos por un nuevo medicamento genéricocon las mismas o menos restricciones. Además, al agregar el nuevo medicamento genérico, podemosdecidir mantener el medicamento de marca en nuestra lista de medicamentos o agregar nuevasrestricciones. Si actualmente está tomando ese medicamento de marca, es posible que no leinformemos con anticipación antes de hacer ese cambio, pero luego le brindaremos informaciónsobre los cambios específicos que hemos realizado.

Si realizamos dicho cambio, usted o el profesional autorizado para recetar pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El aviso que le proporcionamos también incluirá información sobre cómo solicitar una excepción, además, puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción ala Farmacopea de EmblemHealth VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP) y VIP Dual Reserve (HMO D-SNP)?”.

• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos (FDA)considera que un medicamento de nuestra farmacopea no es seguro o el fabricante del medicamento loretira del mercado, inmediatamente lo eliminaremos de nuestra farmacopea y notificaremos alos miembros que toman el medicamento.

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Otros cambios. Es posible que hagamos otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico nuevo para reemplazar un medicamento de marca actualmente incluido en la farmacopea o agregar nuevas restricciones al medicamento de marca. Podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca actualmente incluido en la farmacopea o agregar nuevas restricciones al medicamento de marca. También podemos hacer cambios basados en nuevas pautas clínicas. Si eliminamos medicamentos de nuestra farmacopea, si agregamos límites de cantidad o restricciones de tratamiento escalonado o autorización previa a un medicamento, debemos notificar a los miembros afectados el cambio por lo menos 30 días antes de que el cambio entre en vigencia, o en el momento en que el miembro solicite un relleno del medicamento, en cuyo momento el miembro recibirá un suministro para un mes del medicamento.

o Si realizamos estos otros cambios, usted o el profesional autorizado para recetar puedensolicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca parausted. El aviso que le proporcionamos también incluirá información sobre cómo solicitaruna excepción, además, puede encontrar información en la sección a continuación titulada“Farmacopea de EmblemHealth VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIPSolutions (HMO D-SNP) y VIP Dual Reserve (HMO D-SNP)”.

Cambios que no lo afectarán si actualmente está tomando el medicamento. Generalmente, si usted está tomando un medicamento de nuestra farmacopea 2022 que estaba cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2022, excepto como se describió anteriormente. Esto significa que estos medicamentos permanecerán disponibles con el mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el resto del año de cobertura. No obtendrá un aviso directo este año sobre los cambios que no lo afectan. Sin embargo, el 1.º de enero del próximo año, esos cambios lo afectarían y es importante que controle la lista de medicamentos del nuevo año del beneficio para ver los cambios en los medicamentos.

La farmacopea adjunta tendrá vigencia a partir del 05/01/2022. Para obtener la información másactualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y la contratapa.

Nota: En caso de un cambio en la farmacopea que no sea por mantenimiento a mitad del año, dicho cambio se agregará a una lista exhaustiva de cambios que se han producido desde la impresión dela farmacopea. La lista de cambios se incluye con el folleto de la farmacopea que se envía por correo a los nuevos miembros con su kit de bienvenida. Los miembros existentes pueden ver la farmacopea actualizada al visitarnos en nuestro sitio web en emblemhealth.com/medicare. La farmacopea publicada en nuestro sitio web se actualiza de forma mensual.

¿Cómo debo usar la farmacopea? Existen dos formas de encontrar su medicamento dentro de la farmacopea:

Afección médica La farmacopea comienza en la página 1. Los medicamentos de esta farmacopea se agrupan en categorías, según el tipo de afección médica que suelen tratar. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca están enumerados en la categoría “Lípidos/Cardiovascular hipertensivo”. Si conoce para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego, busque su medicamento en el nombre de la categoría.

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http://emblemhealth.com/medicare

Lista por orden alfabético Si no está seguro de la categoría en la que debe buscar, busque su medicamento en el Índice que comienza en la página 95. El Índice le brinda una lista por orden alfabético de todos los medicamentos incluidos en el presente documento. Los medicamentos de marca y los medicamentos genéricos están enumerados en el Índice. Busque en el Índice y encuentre su medicamento. Al lado de su medicamento, verá el número de página donde puede encontrar la información de la cobertura. Vaya a la página enumerada en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Nuestro plan cubre los medicamentos de marca y los medicamentos genéricos. Un medicamento genérico está aprobado por la FDA al contener el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

¿Existen algunas restricciones en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales sobre la cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: Nuestro plan le exige a usted o a su médico que obtenga una autorizaciónprevia para determinados medicamentos. Esto significa que deberá obtener aprobación de nuestroplan antes de llenar sus medicamentos con receta. Si no obtiene la aprobación, es posible quenuestro plan no cubra el medicamento.

• Límites de cantidad: Para determinados medicamentos, nuestro plan limita la cantidad del medicamentoque cubriremos. Por ejemplo, nuestro plan proporciona 30 comprimidos por receta de JANUVIA®. Estopuede ser además del suministro estándar de uno o tres meses.

• Tratamiento escalonado: En algunos casos, nuestro plan le exige que pruebe primero determinadosmedicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección.Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su afección médica, es posible quenuestro plan no cubra el Medicamento B a menos que primero pruebe el Medicamento A. Siel Medicamento A no funciona para usted, entonces su plan cubrirá el Medicamento B.

Puede averiguar si su medicamento tiene algún requisito o límite adicional buscando en la farmacopea que comienza en la página 1. Además, puede obtener más información sobre las restricciones que se aplican a los medicamentos cubiertos específicos al visitar nuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y tratamiento escalonado. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la última fecha en que hemos actualizado la farmacopea, aparece en la portada y en la contratapa.

Puede solicitara nuestro planque haga una excepción sobre estas restricciones o límites, opara obtener una lista de otros medicamentos similares que puedan tratar suafección médica. Vea la sección “¿Cómo solicito una excepción a la Farmacopea de EmblemHealth VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP) y VIP Dual Reserve (HMO D-SNP)?”, en lapágina v para obtenerinformación sobre cómo solicitar una excepción.

¿Qué sucede si mi medicamento no aparece en la Farmacopea? Si su medicamento no está incluido en la presente farmacopea (lista de medicamentos cubiertos), debería comunicarse

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primero con el Servicio de atención al cliente y consultar si su medicamento está cubierto.

Si sabe que nuestro plan no cubre su medicamento, tiene dos opciones: • Puede solicitar al Servicio de atención al cliente una lista de los medicamentos similares que están

cubiertos por nuestro plan. Cuando reciba esa lista, muéstresela a su médico y pídale que recete unmedicamento similar que esté cubierto por nuestro plan.

• Puede solicitarque hagamos una excepción y cubramos su medicamento. Consulte a continuación paraobtener más información sobre cómo puede solicitar una excepción.

¿Cómo solicito una excepción a la Farmacopea de EmblemHealth VIP Dual (HMO DSNP), EmblemHealth VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP), VIP Dual Reserve (HMO D-SNP)? Puede solicitarnos que hagamos una excepción sobre nuestras reglas de cobertura. Existen variostipos de excepcionesque puede solicitarnos que hagamos. • Puede solicitarnos que cubramos un medicamento incluso si no está en nuestra farmacopea.

• Puede solicitarnos que eximamos las restricciones o los límites de cobertura sobre su medicamento.Por ejemplo, para determinadosmedicamentos, nuestro plan limita la cantidad del medicamento quecubriremos. Si un medicamento tiene un límite de cantidad, puede solicitarnos querenunciemos aeselímite y cubramos un monto mayor.

Generalmente, nuestro plan solamente aprobará su solicitud de excepción si los medicamentos alternativos incluidos en la farmacopea del plan o las restricciones de uso adicionales no son tan eficaces para tratar su afección o le producen efectos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción de la farmacopea o de restricción de utilización. Cuando solicite una excepción de la farmacopea o de restricción de utilización, debe enviar una declaración del profesional autorizado para recetar o médico que apoye su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas de haber recibido la declaración de apoyo del profesional autorizado para recetar. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que esperar una decisión durante 72 horas podría perjudicar gravemente su salud. Si se otorga la solicitud para acelerar el proceso, debemos brindarle una decisión a más tardar 24 horas después de recibir la declaración de apoyo de su médico u otro profesional autorizado para recetar.

¿Qué debo hacer antes de hablar con mi médico sobre cambiar los medicamentoso solicitar una excepción?Como un miembro nuevo o que continúa en nuestro plan, es posible que esté tomando medicamentos que no están en la farmacopea. También es posible que esté tomando un medicamento que está en nuestra farmacopea, pero que su posibilidad de obtenerlo sea limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes de que pueda llenar una receta. Debe hablar con su médico para decidir si debe cambiarse a un medicamento más adecuado que nosotros cubramos o solicitar una excepción de la farmacopea para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción adecuado para usted, es posible que cubramos sus medicamentos en determinados casos durante los primeros 90 días en que usted es miembro de nuestro plan.

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Para cada uno de sus medicamentos que no están cubiertos en nuestra farmacopea o si su capacidad para obtener los medicamentos se encuentra limitada, cubriremos un suministro temporal de 30 días. Si su receta médica fue hecha por pocos días, permitiremos varios rellenos hasta un máximo de un suministro de 30 días del medicamento. Luego de su primer suministro de 30 días, no pagaremos por estos medicamentos, incluso si hace menos de 90 días que usted es miembro del plan.

Si usted es residente de un centro de cuidados a largo plazo y necesita un medicamento que no está en nuestra farmacopea o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento mientras solicita una excepción a la farmacopea.

Si es un miembro actual de nuestro plan y experimenta algún cambio en el nivel de atención, como por ejemplo, ser admitido o dado de alta en un centro de cuidados a largo plazo, se le permitirá una renovación temporal por una única vez de sus medicamentos, según sea necesario, para ayudarle en la transición a su nuevo nivel de atención.

Para más información Para obtener información más detallada sobre la cobertura de medicamentos con receta de la farmacopea de EmblemHealth VIP Dual (HMO D-SNP), VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP) y VIP Dual Reserve (HMO D-SNP), revise su Evidencia de Cobertura y otros materiales del plan.

Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la última fecha en que hemos actualizado la farmacopea, aparece en la portada y en la contratapa.

Si tiene alguna pregunta en general sobre la cobertura de medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los siete días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

Farmacopea de EmblemHealth VIP Dual (HMO D-SNP), EmblemHealth VIP Dual Select (HMO D-SNP), VIP Solutions (HMO D-SNP), VIP Dual Reserve (HMO D-SNP) La farmacopea que comienza en la página 1 proporciona información sobre la cobertura de los medicamentos cubiertos por nuestro plan. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice que comienza en la página 95.

La primera columna del cuadro enumera el nombre del medicamento. Los medicamentos de marca se encuentran escritos con mayúsculas (p. ej., SYNTHROID) y los medicamentos genéricos se encuentran escritos en cursiva minúscula (p. ej., Levothyroxine).

La información en la columna Requisitos/límites le informa si nuestro plan tiene algún requisito especial para la cobertura de su medicamento.

A continuación, aparece una lista de abreviaturas que pueden aparecer en las páginas siguientes dentro de la columna Requisitos/límites que le informa si hay algún requisito especial de cobertura para su medicamento.

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http://www.medicare.gov

Lista de abreviaturas

AP B/D: Este medicamento con receta puede estar cubierto por la Parte B o D de Medicare según las circunstancias. Es posible que se deba presentar la información que describa el uso y el entorno de la regulación del medicamento para tomar una determinación.

DL: Disponibilidad limitada. Esta receta solamente puede estar disponible en determinadas farmacias. Para obtener más información, llame al Servicio de atención al cliente.

MPC: Medicamento pedido por correo. Este medicamento con receta está disponible a través de nuestro servicio de pedido por correo, así como también a través de nuestras farmacias de venta al detalle de la red. Considere usar los pedidos por correo para sus medicamentos a largo plazo (de mantenimiento) (como, por ejemplo, los medicamentos para la presión arterial alta). Las farmacias de venta al detalle de la red pueden ser más adecuadas para medicamentos con receta a corto plazo (como, por ejemplo, los antibióticos).

AP: Autorización previa. El plan le exige a usted o a su médico que obtenga una autorización previa para determinados medicamentos. Esto significa que deberá obtener aprobación antes de llenar sus medicamentos con receta. Si no obtiene la aprobación, es posible que no cubramos el medicamento.

LC: Límite de cantidad. Para determinados medicamentos, el plan limita la cantidad del medicamento que cubriremos.

TE: Tratamiento escalonado. En algunos casos, el plan le exige que pruebe primero determinados medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su afección médica, es posible que el plan no cubra el Medicamento B a menos que primero pruebe el Medicamento A. Si el Medicamento A no funciona para usted, entonces cubriremos el Medicamento B.

SDL: Suministro diario limitado. Para determinados medicamentos, el plan limita el suministro diario que cubriremos por un mes por vez.

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Y0026_126476 Accepted 8/29/16 EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

10-9124 5/21

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EmblemHealth: • Provides free aids and services to people with disabilities to communicate effectively with us,

such as:– Qualified sign language interpreters– Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

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If you need these services, contact 1-877-411-3625.

If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call 1-877-411-3625. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or byphone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department isavailable to help you. You can also file a civil rights complaint with the U.S. Department of Health andHuman Services, Office of Civil Rights electronically through the Office of Civil Rights ComplaintPortal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Departmentof Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building,Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services).

Complaint forms are available at hhs.gov/ocr/office/file/index.html.

Y0026_126477 NM

https://hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on

what the symbols and abbreviations on this table mean by going to page v.

This drug list was last updated on 04/13/2022.

1

Drug Name Drug Tier Requirements/Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET INTRAVENOUS SUSPENSION 1 B/D PA; MO

AMBISOME INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

1 B/D PA; MO

amphotericin b injection recon soln 1 B/D PA; MO

caspofungin intravenous recon soln 50 mg 1

caspofungin intravenous recon soln 70 mg 1

clotrimazole mucous membrane troche 1 MO

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml

1 B/D PA; MO

fluconazole in nacl (iso-osm) intravenous


1 B/D PA

fluconazole oral suspension for reconstitution 1 MO

fluconazole oral tablet 1 MO

flucytosine oral capsule 1 MO

griseofulvin microsize oral suspension 1 MO

griseofulvin microsize oral tablet 1 MO

griseofulvin ultramicrosize oral tablet 1 MO

itraconazole oral capsule 1 MO; QL (120 per 30 days)

ketoconazole oral tablet 1 MO

NOXAFIL ORAL SUSPENSION 1 MO

nystatin oral suspension 1 MO

nystatin oral tablet 1 MO

posaconazole oral tablet,delayed release (dr/ec) 1 PA; MO

terbinafine hcl oral tablet 1 MO; QL (90 per 365 days)

TOLSURA ORAL CAPSULE, SOLID

DISPERSION

1 PA; MO; QL (120 per 30 days)

voriconazole intravenous recon soln 1 B/D PA; MO

voriconazole oral suspension for reconstitution 1 MO

voriconazole oral tablet 1 MO

ANTIVIRALS

abacavir oral solution 1 MO; QL (960 per 30 days)




2


abacavir oral tablet 1 MO; QL (60 per 30 days)

abacavir-lamivudine oral tablet 1 MO; QL (30 per 30 days)

abacavir-lamivudine-zidovudine oral tablet 1 MO; QL (60 per 30 days)

acyclovir oral capsule 1 MO

acyclovir oral suspension 200 mg/5 ml 1 MO

acyclovir oral tablet 1 MO

acyclovir sodium intravenous solution 1 B/D PA; MO

adefovir oral tablet 1 MO

amantadine hcl oral capsule 1 MO

amantadine hcl oral solution 1 MO

amantadine hcl oral tablet 1 MO

APTIVUS ORAL CAPSULE 1 MO; QL (120 per 30 days)

atazanavir oral capsule 150 mg, 200 mg 1 MO; QL (60 per 30 days)

atazanavir oral capsule 300 mg 1 MO; QL (30 per 30 days)

BARACLUDE ORAL SOLUTION 1 MO

BIKTARVY ORAL TABLET 1 MO; QL (30 per 30 days)

CABENUVA INTRAMUSCULAR

SUSPENSION,EXTENDED RELEASE

1 MO

cidofovir intravenous solution 1 B/D PA; MO

CIMDUO ORAL TABLET 1 MO; QL (30 per 30 days)

COMPLERA ORAL TABLET 1 MO; QL (30 per 30 days)

DELSTRIGO ORAL TABLET 1 MO; QL (30 per 30 days)

DESCOVY ORAL TABLET 200-25 MG 1 MO; QL (30 per 30 days)

DOVATO ORAL TABLET 1 MO; QL (30 per 30 days)

EDURANT ORAL TABLET 1 MO; QL (30 per 30 days)

efavirenz oral capsule 200 mg 1 MO; QL (90 per 30 days)

efavirenz oral capsule 50 mg 1 MO; QL (360 per 30 days)

efavirenz oral tablet 1 MO; QL (30 per 30 days)

efavirenz-emtricitabin-tenofov oral tablet 1 MO; QL (30 per 30 days)

efavirenz-lamivu-tenofov disop oral tablet 1 MO; QL (30 per 30 days)

emtricitabine oral capsule 1 MO; QL (30 per 30 days)

emtricitabine-tenofovir (tdf) oral tablet 1 MO; QL (30 per 30 days)

EMTRIVA ORAL CAPSULE 1 MO; QL (30 per 30 days)




3


EMTRIVA ORAL SOLUTION 1 MO; QL (680 per 28 days)

entecavir oral tablet 1 MO; QL (30 per 30 days)

EPCLUSA ORAL PELLETS IN PACKET 1 PA; MO; QL (28 per 28 days)

EPCLUSA ORAL TABLET 200-50 MG 1 PA; MO; QL (30 per 30 days)

EPCLUSA ORAL TABLET 400-100 MG 1 PA; MO; QL (28 per 28 days)

EPIVIR HBV ORAL SOLUTION 1 MO

etravirine oral tablet 1 MO; QL (60 per 30 days)

EVOTAZ ORAL TABLET 1 MO; QL (30 per 30 days)

famciclovir oral tablet 125 mg 1 MO

famciclovir oral tablet 250 mg 1 MO; QL (60 per 30 days)

famciclovir oral tablet 500 mg 1 MO; QL (21 per 7 days)

fosamprenavir oral tablet 1 MO; QL (120 per 30 days)

FUZEON SUBCUTANEOUS RECON SOLN 1 MO; QL (60 per 30 days)

ganciclovir sodium intravenous recon soln 1 B/D PA; MO

GENVOYA ORAL TABLET 1 MO; QL (30 per 30 days)

HARVONI ORAL PELLETS IN PACKET 1 PA; MO; QL (28 per 28 days)

HARVONI ORAL TABLET 45-200 MG 1 PA; MO; QL (30 per 30 days)

HARVONI ORAL TABLET 90-400 MG 1 PA; MO; QL (28 per 28 days)

INTELENCE ORAL TABLET 100 MG, 200 MG 1 MO; QL (60 per 30 days)

INTELENCE ORAL TABLET 25 MG 1 MO; QL (120 per 30 days)

INVIRASE ORAL TABLET 1 MO; QL (120 per 30 days)

ISENTRESS HD ORAL TABLET 1 MO; QL (60 per 30 days)

ISENTRESS ORAL POWDER IN PACKET 1 MO; QL (180 per 30 days)

ISENTRESS ORAL TABLET 1 MO; QL (60 per 30 days)

ISENTRESS ORAL TABLET,CHEWABLE 1 MO; QL (180 per 30 days)

JULUCA ORAL TABLET 1 MO; QL (30 per 30 days)

KALETRA ORAL TABLET 100-25 MG 1 MO; QL (300 per 30 days)

KALETRA ORAL TABLET 200-50 MG 1 MO; QL (120 per 30 days)

lamivudine oral solution 1 MO; QL (900 per 30 days)

lamivudine oral tablet 100 mg, 300 mg 1 MO; QL (30 per 30 days)

lamivudine oral tablet 150 mg 1 MO; QL (60 per 30 days)

lamivudine-zidovudine oral tablet 1 MO; QL (60 per 30 days)




4


LEXIVA ORAL SUSPENSION 1 MO; QL (1575 per 28 days)

lopinavir-ritonavir oral solution 1 MO; QL (480 per 30 days)

lopinavir-ritonavir oral tablet 100-25 mg 1 MO; QL (300 per 30 days)

lopinavir-ritonavir oral tablet 200-50 mg 1 MO; QL (120 per 30 days)

maraviroc oral tablet 150 mg 1 MO; QL (60 per 30 days)

maraviroc oral tablet 300 mg 1 MO; QL (120 per 30 days)

MOLNUPIRAVIR ORAL CAPSULE 1 QL (40 per 180 days)

nevirapine oral suspension 1 QL (1200 per 30 days)

nevirapine oral tablet 1 MO; QL (60 per 30 days)

nevirapine oral tablet extended release 24 hr 100

mg

1 MO; QL (90 per 30 days)

nevirapine oral tablet extended release 24 hr 400

mg


NORVIR ORAL POWDER IN PACKET 1 MO; QL (360 per 30 days)

NORVIR ORAL SOLUTION 1 MO; QL (480 per 30 days)

ODEFSEY ORAL TABLET 1 MO; QL (30 per 30 days)

oseltamivir oral capsule 30 mg 1 MO; QL (84 per 180 days)

oseltamivir oral capsule 45 mg, 75 mg 1 MO; QL (42 per 180 days)

oseltamivir oral suspension for reconstitution 1 MO

PAXLOVID (EUA) ORAL TABLET 1 QL (30 per 180 days)

PIFELTRO ORAL TABLET 1 MO; QL (30 per 30 days)

PREVYMIS INTRAVENOUS SOLUTION 1 PA

PREVYMIS ORAL TABLET 1 PA; MO

PREZCOBIX ORAL TABLET 1 MO; QL (30 per 30 days)

PREZISTA ORAL SUSPENSION 1 MO; QL (400 per 30 days)

PREZISTA ORAL TABLET 150 MG 1 MO; QL (180 per 30 days)


PREZISTA ORAL TABLET 75 MG 1 MO


RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE


RETROVIR INTRAVENOUS SOLUTION 1 MO

REYATAZ ORAL POWDER IN PACKET 1 MO; QL (180 per 30 days)




5


ribavirin oral capsule 1

ribavirin oral tablet 200 mg 1 MO

rimantadine oral tablet 1 MO

ritonavir oral tablet 1 MO; QL (360 per 30 days)

RUKOBIA ORAL TABLET EXTENDED

RELEASE 12 HR


SELZENTRY ORAL SOLUTION 1 MO; QL (1840 per 30 days)

SELZENTRY ORAL TABLET 150 MG 1 MO; QL (60 per 30 days)




stavudine oral capsule 1 MO; QL (60 per 30 days)

STRIBILD ORAL TABLET 1 MO; QL (30 per 30 days)

SYMTUZA ORAL TABLET 1 MO; QL (30 per 30 days)

SYNAGIS INTRAMUSCULAR SOLUTION 1 PA; MO

TEMIXYS ORAL TABLET 1 MO; QL (30 per 30 days)

tenofovir disoproxil fumarate oral tablet 1 MO; QL (30 per 30 days)

TIVICAY ORAL TABLET 10 MG 1 MO; QL (60 per 30 days)

TIVICAY ORAL TABLET 25 MG, 50 MG 1 MO; QL (60 per 30 days)

TIVICAY PD ORAL TABLET FOR

SUSPENSION


TRIUMEQ ORAL TABLET 1 MO; QL (30 per 30 days)

TROGARZO INTRAVENOUS SOLUTION 1 PA; MO

TYBOST ORAL TABLET 1 MO; QL (30 per 30 days)

valacyclovir oral tablet 1 MO

valganciclovir oral recon soln 1 MO

valganciclovir oral tablet 1 MO

VEKLURY INTRAVENOUS RECON SOLN 1

VIRACEPT ORAL TABLET 250 MG 1 MO; QL (270 per 30 days)

VIRACEPT ORAL TABLET 625 MG 1 MO; QL (120 per 30 days)

VIREAD ORAL POWDER 1 MO; QL (240 per 30 days)

VIREAD ORAL TABLET 150 MG, 200 MG, 250

MG





6


VOSEVI ORAL TABLET 1 PA; MO; QL (28 per 28 days)

XOFLUZA ORAL TABLET 20 MG, 40 MG 1 MO; QL (2 per 180 days)

XOFLUZA ORAL TABLET 80 MG 1 MO; QL (1 per 180 days)

zidovudine oral capsule 1 MO; QL (180 per 30 days)

zidovudine oral syrup 1 MO; QL (1680 per 28 days)

zidovudine oral tablet 1 MO; QL (60 per 30 days)

CEPHALOSPORINS

cefaclor oral capsule 1 MO

cefaclor oral tablet extended release 12 hr 1 MO

cefadroxil oral capsule 1 MO

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1 MO

cefadroxil oral tablet 1 MO

cefazolin in dextrose (iso-osm) intravenous

piggyback 1 gram/50 ml, 2 gram/50 ml

1 MO

cefazolin injection recon soln 1 gram, 500 mg 1 MO

cefazolin injection recon soln 10 gram, 100 gram,

300 g

1

cefazolin intravenous recon soln 1

cefdinir oral capsule 1 MO

cefdinir oral suspension for reconstitution 1 MO

cefepime in dextrose (iso-osm) intravenous

piggyback

1

CEFEPIME IN DEXTROSE 5 %

INTRAVENOUS PIGGYBACK

1 MO

cefepime injection recon soln 1 MO

cefixime oral capsule 1 MO

cefixime oral suspension for reconstitution 1 MO

CEFOTETAN IN DEXTROSE (ISO-OSM)


1

cefotetan injection recon soln 1

cefoxitin in dextrose (iso-osm) intravenous

piggyback

1 B/D PA

cefoxitin intravenous recon soln 1 gram, 2 gram 1 B/D PA; MO




7


cefoxitin intravenous recon soln 10 gram 1 B/D PA

cefpodoxime oral suspension for reconstitution 1 MO

cefpodoxime oral tablet 1 MO

cefprozil oral suspension for reconstitution 1 MO

cefprozil oral tablet 1 MO

CEFTAZIDIME IN D5W INTRAVENOUS

PIGGYBACK

1

ceftazidime injection recon soln 1 gram, 2 gram 1 MO

ceftazidime injection recon soln 6 gram 1

ceftriaxone in dextrose (iso-osm) intravenous

piggyback

1 MO

ceftriaxone injection recon soln 1 gram, 2 gram,

250 mg, 500 mg

1 MO

ceftriaxone injection recon soln 10 gram 1

CEFTRIAXONE INJECTION RECON SOLN

100 GRAM

1

ceftriaxone intravenous recon soln 1 MO

cefuroxime axetil oral tablet 1 MO

cefuroxime sodium injection recon soln 750 mg 1 B/D PA; MO

cefuroxime sodium intravenous recon soln 1.5

gram

1 B/D PA; MO

cefuroxime sodium intravenous recon soln 7.5

gram

1 B/D PA

cephalexin oral capsule 1 MO

cephalexin oral suspension for reconstitution 1 MO

cephalexin oral tablet 1 MO

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5 ML

1

SUPRAX ORAL TABLET,CHEWABLE 1 MO

TEFLARO INTRAVENOUS RECON SOLN 1 B/D PA; MO

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous recon soln 1 B/D PA; MO

azithromycin oral packet 1 MO

azithromycin oral suspension for reconstitution 1 MO




8


azithromycin oral tablet 250 mg (6 pack), 500 mg

(3 pack)

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 MO

clarithromycin oral suspension for reconstitution 1 MO

clarithromycin oral tablet 1 MO

clarithromycin oral tablet extended release 24 hr 1 MO

erythrocin (as stearate) oral tablet 250 mg 1 MO

ERYTHROCIN INTRAVENOUS RECON SOLN

500 MG

1 B/D PA; MO

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml

1 MO

erythromycin ethylsuccinate oral tablet 1

erythromycin oral capsule,delayed release(dr/ec) 1 MO

erythromycin oral tablet 1 MO

MISCELLANEOUS ANTIINFECTIVES

albendazole oral tablet 1 MO

amikacin injection solution 1,000 mg/4 ml 1 B/D PA; MO

amikacin injection solution 500 mg/2 ml 1 MO

ARIKAYCE INHALATION SUSPENSION FOR

NEBULIZATION

1 PA; QL (236 per 28 days)

atovaquone oral suspension 1 MO

atovaquone-proguanil oral tablet 1 MO

aztreonam injection recon soln 1 MO

bacitracin intramuscular recon soln 1

CAYSTON INHALATION SOLUTION FOR

NEBULIZATION

1 MO; LA; QL (84 per 28 days)

chloramphenicol sod succinate intravenous recon

soln

1 B/D PA

chloroquine phosphate oral tablet 1 MO

clindamycin hcl oral capsule 1 MO

clindamycin pediatric oral recon soln 1 MO

clindamycin phosphate injection solution 1 B/D PA; MO

clindamycin phosphate intravenous solution 600

mg/4 ml

1 B/D PA; MO




9


COARTEM ORAL TABLET 1 MO

colistin (colistimethate na) injection recon soln 1 B/D PA; MO

dapsone oral tablet 1 MO

daptomycin intravenous recon soln 500 mg 1 MO

ertapenem injection recon soln 1 MO

ethambutol oral tablet 1 MO

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50

ml

1 MO

GENTAMICIN IN NACL (ISO-OSM)

INTRAVENOUS PIGGYBACK 100 MG/50 ML

1 MO

GENTAMICIN IN NACL (ISO-OSM)

INTRAVENOUS PIGGYBACK 120 MG/100 ML

1

gentamicin in nacl (iso-osm) intravenous


1

gentamicin injection solution 40 mg/ml 1 MO

hydroxychloroquine oral tablet 200 mg 1 MO

imipenem-cilastatin intravenous recon soln 1 B/D PA; MO

isoniazid injection solution 1

isoniazid oral solution 1 MO

isoniazid oral tablet 1 MO

ivermectin oral tablet 1 MO

linezolid in dextrose 5% intravenous piggyback 1 PA

linezolid oral suspension for reconstitution 1 PA; MO

linezolid oral tablet 1 PA; MO

linezolid-0.9% sodium chloride intravenous

parenteral solution

1 PA

mefloquine oral tablet 1 MO

meropenem intravenous recon soln 1 MO

MEROPENEM-0.9% SODIUM CHLORIDE


1

metro i.v. intravenous piggyback 1 MO

metronidazole in nacl (iso-osm) intravenous

piggyback

1 MO

metronidazole oral capsule 1 MO




10


metronidazole oral tablet 1 MO

neomycin oral tablet 1 MO

paromomycin oral capsule 1 MO

PASER ORAL GRANULES DR FOR SUSP IN

PACKET

1 MO

pentamidine inhalation recon soln 1 B/D PA; MO

pentamidine injection recon soln 1 B/D PA; MO

polymyxin b sulfate injection recon soln 1 MO

PRETOMANID ORAL TABLET 1 PA

PRIFTIN ORAL TABLET 1 MO

primaquine oral tablet 1 MO

pyrazinamide oral tablet 1 MO

pyrimethamine oral tablet 1 PA; MO

quinine sulfate oral capsule 1 PA; MO

rifabutin oral capsule 1 MO

rifampin intravenous recon soln 1 MO

rifampin oral capsule 1 MO

SIRTURO ORAL TABLET 1 PA; LA

STREPTOMYCIN INTRAMUSCULAR RECON

SOLN

1 MO

SYNERCID INTRAVENOUS RECON SOLN 1 B/D PA

tigecycline intravenous recon soln 1 MO

tinidazole oral tablet 1 MO

TOBI PODHALER INHALATION CAPSULE,

W/INHALATION DEVICE


tobramycin in 0.225 % nacl inhalation solution for

nebulization

1 B/D PA; MO

tobramycin sulfate injection recon soln 1

tobramycin sulfate injection solution 1 MO

TRECATOR ORAL TABLET 1 MO

VANCOMYCIN IN 0.9 % SODIUM CHL


1 B/D PA

VANCOMYCIN IN DEXTROSE 5 %


1 B/D PA




11


VANCOMYCIN INJECTION RECON SOLN 1

vancomycin intravenous recon soln 1,000 mg, 500

mg, 750 mg

1 MO

vancomycin intravenous recon soln 10 gram, 5

gram

1

vancomycin oral capsule 1 MO

XIFAXAN ORAL TABLET 550 MG 1 MO

PENICILLINS

amoxicillin oral capsule 1 MO

amoxicillin oral suspension for reconstitution 1 MO

amoxicillin oral tablet 1 MO

amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO

amoxicillin-pot clavulanate oral suspension for

reconstitution

1 MO

amoxicillin-pot clavulanate oral tablet 1 MO

amoxicillin-pot clavulanate oral tablet extended

release 12 hr

1 MO

amoxicillin-pot clavulanate oral tablet,chewable 1 MO

ampicillin oral capsule 500 mg 1 MO

ampicillin sodium injection recon soln 1 gram, 10

gram, 125 mg, 250 mg, 500 mg

1 B/D PA; MO

ampicillin sodium injection recon soln 2 gram 1 MO

ampicillin sodium intravenous recon soln 1 B/D PA

ampicillin-sulbactam injection recon soln 1.5

gram, 3 gram

1 MO

ampicillin-sulbactam injection recon soln 15 gram 1

ampicillin-sulbactam intravenous recon soln 1

BICILLIN C-R INTRAMUSCULAR SYRINGE 1 MO

BICILLIN L-A INTRAMUSCULAR SYRINGE 1 MO

dicloxacillin oral capsule 1 MO

nafcillin in dextrose (iso-osm) intravenous

piggyback

1 B/D PA

nafcillin injection recon soln 1 gram, 2 gram 1 B/D PA; MO

nafcillin injection recon soln 10 gram 1 B/D PA




12


nafcillin intravenous recon soln 2 gram 1 B/D PA; MO

oxacillin in dextrose (iso-osm) intravenous

piggyback 1 gram/50 ml

1

oxacillin in dextrose (iso-osm) intravenous

piggyback 2 gram/50 ml

1 MO

oxacillin injection recon soln 1 gram 1

oxacillin injection recon soln 10 gram 1

oxacillin injection recon soln 2 gram 1 MO

penicillin g potassium injection recon soln 20

million unit

1 B/D PA; MO

penicillin g potassium injection recon soln 5

million unit

1 MO

penicillin g procaine intramuscular syringe 1.2

million unit/2 ml

1 MO

penicillin g procaine intramuscular syringe

600,000 unit/ml

1 B/D PA; MO

penicillin g sodium injection recon soln 1 B/D PA; MO

penicillin v potassium oral recon soln 1 MO

penicillin v potassium oral tablet 1 MO

PIPERACILLIN-TAZOBACTAM

INTRAVENOUS RECON SOLN 13.5 GRAM

1

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram

1 MO

piperacillin-tazobactam intravenous recon soln

40.5 gram

1

QUINOLONES

ciprofloxacin hcl oral tablet 1 MO

ciprofloxacin in 5 % dextrose intravenous


1 MO

levofloxacin in d5w intravenous piggyback 250

mg/50 ml

1

levofloxacin in d5w intravenous piggyback 500

mg/100 ml, 750 mg/150 ml

1 MO

levofloxacin intravenous solution 1 B/D PA; MO

levofloxacin oral solution 1 MO

levofloxacin oral tablet 1 MO




13


moxifloxacin oral tablet 1 MO

MOXIFLOXACIN-SOD.ACE,SUL-WATER


1 B/D PA

moxifloxacin-sod.chloride(iso) intravenous

piggyback

1 B/D PA; MO

ofloxacin oral tablet 300 mg, 400 mg 1 MO

SULFA'S / RELATED AGENTS

sulfadiazine oral tablet 1 MO

sulfamethoxazole-trimethoprim intravenous

solution

1 B/D PA; MO

sulfamethoxazole-trimethoprim oral suspension 1 MO

sulfamethoxazole-trimethoprim oral tablet 1 MO

TETRACYCLINES

demeclocycline oral tablet 1 MO

doxy-100 intravenous recon soln 1 MO

doxycycline hyclate intravenous recon soln 1

doxycycline hyclate oral capsule 1 MO

doxycycline hyclate oral tablet 100 mg, 20 mg 1 MO

doxycycline hyclate oral tablet,delayed release

(dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

1 MO

doxycycline monohydrate oral capsule 100 mg, 50

mg

1 MO

doxycycline monohydrate oral capsule 150 mg, 75

mg

1 MO

doxycycline monohydrate oral tablet 100 mg, 50

mg

1 MO

doxycycline monohydrate oral tablet 150 mg, 75

mg

1 MO

minocycline oral capsule 1 MO

minocycline oral tablet 1 MO

minocycline oral tablet extended release 24 hr 135

mg, 45 mg, 90 mg

1 MO

tetracycline oral capsule 1 MO

URINARY TRACT AGENTS

methenamine hippurate oral tablet 1 MO




14


methenamine mandelate oral tablet 1 gram 1 MO

nitrofurantoin macrocrystal oral capsule 1 MO

nitrofurantoin monohyd/m-cryst oral capsule 1 MO

trimethoprim oral tablet 1 MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

dexrazoxane hcl intravenous recon soln 1 B/D PA; MO

ELITEK INTRAVENOUS RECON SOLN 1 B/D PA; MO

leucovorin calcium injection recon soln 100 mg,

200 mg, 350 mg, 50 mg

1 B/D PA; MO

leucovorin calcium injection recon soln 500 mg 1 B/D PA

leucovorin calcium oral tablet 1 MO

levoleucovorin calcium intravenous recon soln 50

mg

1 B/D PA; MO

levoleucovorin calcium intravenous solution 1 B/D PA

mesna intravenous solution 1 B/D PA; MO

MESNEX ORAL TABLET 1 MO

XGEVA SUBCUTANEOUS SOLUTION 1 B/D PA; MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone oral tablet 250 mg 1 MO; QL (120 per 30 days)

abiraterone oral tablet 500 mg 1 MO; QL (60 per 30 days)

ABRAXANE INTRAVENOUS SUSPENSION

FOR RECONSTITUTION

1 B/D PA; MO

AFINITOR DISPERZ ORAL TABLET FOR

SUSPENSION

1 PA; MO

AFINITOR ORAL TABLET 10 MG 1 PA; MO; QL (30 per 30 days)

ALECENSA ORAL CAPSULE 1 PA; MO; QL (240 per 30 days)

ALIMTA INTRAVENOUS RECON SOLN 1 B/D PA; MO

ALIQOPA INTRAVENOUS RECON SOLN 1 PA

ALUNBRIG ORAL TABLET 180 MG, 90 MG 1 PA; QL (30 per 30 days)

ALUNBRIG ORAL TABLET 30 MG 1 PA; QL (180 per 30 days)

ALUNBRIG ORAL TABLETS,DOSE PACK 1 PA; QL (30 per 30 days)

anastrozole oral tablet 1 MO; QL (30 per 30 days)




15


ASTAGRAF XL ORAL CAPSULE,EXTENDED

RELEASE 24HR

1 B/D PA; MO

AYVAKIT ORAL TABLET 1 PA; QL (30 per 30 days)

azacitidine injection recon soln 1 MO

AZASAN ORAL TABLET 1 B/D PA; MO

azathioprine oral tablet 100 mg, 75 mg 1 B/D PA; MO

azathioprine oral tablet 50 mg 1 B/D PA; MO

azathioprine sodium injection recon soln 1

BALVERSA ORAL TABLET 1 PA; LA

BAVENCIO INTRAVENOUS SOLUTION 1 PA

BELEODAQ INTRAVENOUS RECON SOLN 1 B/D PA

BENDEKA INTRAVENOUS SOLUTION 1 PA; MO

BESPONSA INTRAVENOUS RECON SOLN 1 PA; MO

bexarotene oral capsule 1 PA; MO

bicalutamide oral tablet 1 MO; QL (30 per 30 days)

bleomycin injection recon soln 1 B/D PA; MO

BOSULIF ORAL TABLET 100 MG 1 PA; MO; QL (90 per 30 days)

BOSULIF ORAL TABLET 400 MG, 500 MG 1 PA; MO; QL (30 per 30 days)

BRAFTOVI ORAL CAPSULE 75 MG 1 PA; MO; LA; QL (180 per 30 days)

BRUKINSA ORAL CAPSULE 1 PA; LA; QL (120 per 30 days)

CABOMETYX ORAL TABLET 1 PA; MO; LA; QL (30 per 30 days)

CALQUENCE ORAL CAPSULE 1 PA; LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 100 MG 1 LA; QL (60 per 30 days)

CAPRELSA ORAL TABLET 300 MG 1 LA; QL (30 per 30 days)

carboplatin intravenous solution 1 B/D PA; MO

carmustine intravenous recon soln 1 B/D PA; MO

cisplatin intravenous solution 1 B/D PA; MO

cladribine intravenous solution 1 B/D PA; MO

clofarabine intravenous solution 1 B/D PA

COMETRIQ ORAL CAPSULE 1 PA; MO

COPIKTRA ORAL CAPSULE 1 PA; LA; QL (60 per 30 days)

COTELLIC ORAL TABLET 1 PA; MO; LA; QL (63 per 28 days)

cyclophosphamide oral capsule 1 B/D PA; MO




16


cyclosporine intravenous solution 1

cyclosporine modified oral capsule 1 B/D PA; MO

cyclosporine modified oral solution 1 B/D PA

cyclosporine oral capsule 1 B/D PA; MO

CYRAMZA INTRAVENOUS SOLUTION 1 PA; MO

cytarabine (pf) injection solution 100 mg/5 ml (20

mg/ml)

1 B/D PA; MO

cytarabine (pf) injection solution 20 mg/ml 1 B/D PA

cytarabine injection solution 1 B/D PA; MO

dacarbazine intravenous recon soln 1 B/D PA; MO

DARZALEX INTRAVENOUS SOLUTION 1 PA; MO

daunorubicin intravenous solution 1 B/D PA

DAURISMO ORAL TABLET 100 MG 1 PA; MO; QL (30 per 30 days)

DAURISMO ORAL TABLET 25 MG 1 PA; MO; QL (60 per 30 days)

decitabine intravenous recon soln 1 MO

doxorubicin intravenous recon soln 50 mg 1 B/D PA; MO

doxorubicin intravenous solution 10 mg/5 ml, 20

mg/10 ml, 50 mg/25 ml

1 B/D PA; MO

doxorubicin intravenous solution 2 mg/ml 1 B/D PA

doxorubicin, peg-liposomal intravenous

suspension

1 B/D PA; MO

DROXIA ORAL CAPSULE 1 MO

ELIGARD (3 MONTH) SUBCUTANEOUS

SYRINGE

1 PA; MO


SYRINGE

1 PA; MO


SYRINGE

1 PA; MO

ELIGARD SUBCUTANEOUS SYRINGE 1 PA; MO

EMCYT ORAL CAPSULE 1 MO

EMPLICITI INTRAVENOUS RECON SOLN 1 PA; MO

ENSPRYNG SUBCUTANEOUS SYRINGE 1 PA; MO

ENVARSUS XR ORAL TABLET EXTENDED

RELEASE 24 HR

1 B/D PA; MO




17


epirubicin intravenous solution 200 mg/100 ml 1 B/D PA; MO

ERIVEDGE ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

ERLEADA ORAL TABLET 1 MO; QL (120 per 30 days)

erlotinib oral tablet 100 mg, 150 mg 1 PA; MO; QL (30 per 30 days)

erlotinib oral tablet 25 mg 1 PA; MO; QL (90 per 30 days)

etoposide intravenous solution 1 B/D PA; MO

everolimus (antineoplastic) oral tablet 1 PA; MO; QL (30 per 30 days)

everolimus (antineoplastic) oral tablet for

suspension

1 PA; MO

everolimus (immunosuppressive) oral tablet 1 B/D PA; MO

exemestane oral tablet 1 MO

EXKIVITY ORAL CAPSULE 1 PA; LA

FARYDAK ORAL CAPSULE 10 MG 1 PA; MO; QL (12 per 21 days)

FARYDAK ORAL CAPSULE 15 MG, 20 MG 1 PA; MO; QL (6 per 21 days)

FASLODEX INTRAMUSCULAR SYRINGE 1 B/D PA; MO

fludarabine intravenous recon soln 1 B/D PA; MO

fludarabine intravenous solution 1 B/D PA

fluorouracil intravenous solution 1 gram/20 ml,

500 mg/10 ml

1 B/D PA; MO

fluorouracil intravenous solution 2.5 gram/50 ml,

5 gram/100 ml

1 B/D PA

flutamide oral capsule 1 MO

FOTIVDA ORAL CAPSULE 1 PA; LA; QL (21 per 28 days)

fulvestrant intramuscular syringe 1 B/D PA; MO

GAVRETO ORAL CAPSULE 1 PA; MO; LA; QL (120 per 30 days)

GAZYVA INTRAVENOUS SOLUTION 1 B/D PA; MO

gemcitabine intravenous recon soln 1 gram, 200

mg

1 B/D PA; MO

gemcitabine intravenous recon soln 2 gram 1 B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml

(38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200

mg/5.26 ml (38 mg/ml)

1 B/D PA; MO

gengraf oral capsule 1 B/D PA; MO

gengraf oral solution 1 B/D PA; MO




18


GILOTRIF ORAL TABLET 1 PA; MO; QL (30 per 30 days)

hydroxyurea oral capsule 1 MO

IBRANCE ORAL CAPSULE 1 PA; MO; QL (21 per 28 days)

IBRANCE ORAL TABLET 1 PA; MO; QL (21 per 28 days)

ICLUSIG ORAL TABLET 10 MG, 30 MG, 45

MG


ICLUSIG ORAL TABLET 15 MG 1 PA; QL (60 per 30 days)

idarubicin intravenous solution 1 B/D PA; MO

IDHIFA ORAL TABLET 1 PA; MO; LA; QL (30 per 30 days)

ifosfamide intravenous recon soln 1 B/D PA; MO

ifosfamide intravenous solution 1 gram/20 ml 1 B/D PA; MO

ifosfamide intravenous solution 3 gram/60 ml 1 B/D PA

imatinib oral tablet 100 mg 1 PA; MO; QL (90 per 30 days)

imatinib oral tablet 400 mg 1 PA; MO; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 1 PA; QL (30 per 30 days)

IMBRUVICA ORAL TABLET 1 PA; QL (30 per 30 days)

IMFINZI INTRAVENOUS SOLUTION 1 PA; MO

INLYTA ORAL TABLET 1 MG 1 PA; MO; QL (180 per 30 days)

INLYTA ORAL TABLET 5 MG 1 PA; MO; QL (120 per 30 days)

INQOVI ORAL TABLET 1 PA; MO; QL (5 per 28 days)

INREBIC ORAL CAPSULE 1 PA; MO; QL (120 per 30 days)

IRESSA ORAL TABLET 1 PA; MO; QL (30 per 30 days)

irinotecan intravenous solution 100 mg/5 ml, 40

mg/2 ml

1 B/D PA; MO

irinotecan intravenous solution 500 mg/25 ml 1 B/D PA

ISTODAX INTRAVENOUS RECON SOLN 1 B/D PA; MO

JAKAFI ORAL TABLET 1 PA; MO; QL (60 per 30 days)

KADCYLA INTRAVENOUS RECON SOLN 1 PA; MO

KANJINTI INTRAVENOUS RECON SOLN 1 PA; MO

KEYTRUDA INTRAVENOUS SOLUTION 1 PA

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG



400 MG/DAY(200 MG X 2)-2.5 MG





19



600 MG/DAY(200 MG X 3)-2.5 MG


KISQALI ORAL TABLET 200 MG/DAY (200

MG X 1)



MG X 2)



MG X 3)


KOSELUGO ORAL CAPSULE 1 PA; LA

KYPROLIS INTRAVENOUS RECON SOLN 1 PA

LANREOTIDE SUBCUTANEOUS SYRINGE 1 B/D PA

lapatinib oral tablet 1 PA; MO; QL (180 per 30 days)

LENVIMA ORAL CAPSULE 1 PA; MO

letrozole oral tablet 1 MO; QL (30 per 30 days)

LEUKERAN ORAL TABLET 1 MO

leuprolide subcutaneous kit 1 PA; MO

LONSURF ORAL TABLET 1 PA; MO

LORBRENA ORAL TABLET 1 PA; MO

LUMAKRAS ORAL TABLET 1 PA; MO; QL (240 per 30 days)

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT

1 PA; MO



1 PA; MO



1 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG

1 PA; MO

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 7.5 MG

1 PA; MO

LUPRON DEPOT-PED (3 MONTH)


1 PA; MO

LUPRON DEPOT-PED INTRAMUSCULAR KIT 1 PA; MO

LYNPARZA ORAL TABLET 1 PA; MO; QL (120 per 30 days)

LYSODREN ORAL TABLET 1

MATULANE ORAL CAPSULE 1




20


megestrol oral suspension 400 mg/10 ml (10 ml) 1 PA

megestrol oral suspension 400 mg/10 ml (40

mg/ml), 625 mg/5 ml (125 mg/ml)

1 PA; MO

megestrol oral tablet 1 PA; MO

MEKINIST ORAL TABLET 0.5 MG 1 PA; MO; QL (90 per 30 days)

MEKINIST ORAL TABLET 2 MG 1 PA; MO; QL (30 per 30 days)

MEKTOVI ORAL TABLET 1 PA; MO; LA; QL (180 per 30 days)

melphalan hcl intravenous recon soln 1 B/D PA

mercaptopurine oral tablet 1 MO

methotrexate sodium (pf) injection recon soln 1 B/D PA

methotrexate sodium (pf) injection solution 1 B/D PA; MO

methotrexate sodium injection solution 1 B/D PA

methotrexate sodium oral tablet 1 B/D PA; MO

mitomycin intravenous recon soln 1 B/D PA; MO

mitoxantrone intravenous concentrate 1 B/D PA; MO

MVASI INTRAVENOUS SOLUTION 1 PA; MO

mycophenolate mofetil (hcl) intravenous recon

soln

1

mycophenolate mofetil oral capsule 1 B/D PA; MO

mycophenolate mofetil oral suspension for

reconstitution

1 B/D PA; MO

mycophenolate mofetil oral tablet 1 B/D PA; MO

mycophenolate sodium oral tablet,delayed release

(dr/ec)

1 B/D PA; MO

MYLOTARG INTRAVENOUS RECON SOLN 1 PA; MO

NERLYNX ORAL TABLET 1 PA; MO; LA; QL (180 per 30 days)

NEXAVAR ORAL TABLET 1 PA; MO; LA; QL (120 per 30 days)

nilutamide oral tablet 1 MO; QL (30 per 30 days)

NINLARO ORAL CAPSULE 2.3 MG 1 PA; MO; QL (6 per 28 days)

NINLARO ORAL CAPSULE 3 MG 1 PA; MO; QL (4 per 28 days)

NINLARO ORAL CAPSULE 4 MG 1 PA; MO; QL (3 per 28 days)

NUBEQA ORAL TABLET 1 PA; MO; LA; QL (120 per 30 days)

NULOJIX INTRAVENOUS RECON SOLN 1 MO




21


octreotide acetate injection solution 1,000 mcg/ml,

500 mcg/ml

1 PA; MO

octreotide acetate injection solution 100 mcg/ml,

200 mcg/ml, 50 mcg/ml

1 PA; MO

octreotide acetate injection syringe 100 mcg/ml (1

ml), 50 mcg/ml (1 ml)

1 PA; MO

octreotide acetate injection syringe 500 mcg/ml (1

ml)

1 PA; MO

ODOMZO ORAL CAPSULE 1 PA; MO; LA; QL (30 per 30 days)

ONUREG ORAL TABLET 1 PA; MO; QL (14 per 28 days)

OPDIVO INTRAVENOUS SOLUTION 100

MG/10 ML, 120 MG/12 ML, 40 MG/4 ML

1 PA; MO

ORGOVYX ORAL TABLET 1 PA; LA

oxaliplatin intravenous recon soln 100 mg 1 B/D PA; MO

oxaliplatin intravenous recon soln 50 mg 1 B/D PA

oxaliplatin intravenous solution 100 mg/20 ml, 50

mg/10 ml (5 mg/ml)

1 B/D PA; MO

oxaliplatin intravenous solution 200 mg/40 ml 1 B/D PA

paclitaxel intravenous concentrate 1 B/D PA; MO

PEMAZYRE ORAL TABLET 1 PA; LA; QL (14 per 21 days)

PERJETA INTRAVENOUS SOLUTION 1 PA; MO

PIQRAY ORAL TABLET 200 MG/DAY (200

MG X 1)


PIQRAY ORAL TABLET 250 MG/DAY (200

MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)


POMALYST ORAL CAPSULE 1 PA; MO; LA

PORTRAZZA INTRAVENOUS SOLUTION 1 PA; MO

POTELIGEO INTRAVENOUS SOLUTION 1 PA

PROGRAF ORAL GRANULES IN PACKET 1 B/D PA; MO

PURIXAN ORAL SUSPENSION 1

QINLOCK ORAL TABLET 1 PA; LA; QL (90 per 30 days)

RETEVMO ORAL CAPSULE 40 MG 1 PA; MO; LA; QL (60 per 30 days)

RETEVMO ORAL CAPSULE 80 MG 1 PA; MO; LA; QL (120 per 30 days)

REVLIMID ORAL CAPSULE 1 PA; MO; LA; QL (28 per 28 days)

REZUROCK ORAL TABLET 1 PA; QL (30 per 30 days)




22


ROZLYTREK ORAL CAPSULE 100 MG 1 PA; MO; QL (180 per 30 days)

ROZLYTREK ORAL CAPSULE 200 MG 1 PA; MO; QL (90 per 30 days)

RUBRACA ORAL TABLET 1 PA; MO; LA; QL (120 per 30 days)

RUXIENCE INTRAVENOUS SOLUTION 1 PA; MO

RYBREVANT INTRAVENOUS SOLUTION 1 PA; MO

RYDAPT ORAL CAPSULE 1 PA; MO

RYLAZE INTRAMUSCULAR SOLUTION 1 PA

SANDIMMUNE ORAL SOLUTION 1 B/D PA; MO

SAPHNELO INTRAVENOUS SOLUTION 1 PA

SCEMBLIX ORAL TABLET 1 PA; MO

SIGNIFOR SUBCUTANEOUS SOLUTION 1 PA

SIMULECT INTRAVENOUS RECON SOLN 10

MG

1

SIMULECT INTRAVENOUS RECON SOLN 20

MG

1 MO

sirolimus oral solution 1 B/D PA; MO

sirolimus oral tablet 1 B/D PA; MO

SOLTAMOX ORAL SOLUTION 1 MO

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE 120 MG/0.5 ML, 90 MG/0.3 ML

1 B/D PA; MO

SOMATULINE DEPOT SUBCUTANEOUS

SYRINGE 60 MG/0.2 ML

1 MO

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50

MG, 80 MG


SPRYCEL ORAL TABLET 20 MG 1 PA; MO; QL (90 per 30 days)

SPRYCEL ORAL TABLET 70 MG 1 PA; MO; QL (60 per 30 days)

STIVARGA ORAL TABLET 1 PA; MO; QL (84 per 28 days)

sunitinib oral capsule 1 PA; MO; QL (30 per 30 days)

SUTENT ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

SYNRIBO SUBCUTANEOUS RECON SOLN 1 B/D PA

TABLOID ORAL TABLET 1 MO

TABRECTA ORAL TABLET 1 PA; MO; QL (112 per 28 days)

tacrolimus oral capsule 0.5 mg, 1 mg 1 B/D PA; MO

tacrolimus oral capsule 5 mg 1 B/D PA; MO




23


TAFINLAR ORAL CAPSULE 1 PA; MO; QL (120 per 30 days)

TAGRISSO ORAL TABLET 1 PA; MO; LA; QL (30 per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG 1 PA; MO; QL (90 per 30 days)

TALZENNA ORAL CAPSULE 0.5 MG, 0.75

MG, 1 MG


tamoxifen oral tablet 1 MO

TARGRETIN TOPICAL GEL 1 PA; MO; QL (60 per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG 1 PA; MO; QL (112 per 28 days)

TASIGNA ORAL CAPSULE 50 MG 1 PA; MO; QL (120 per 30 days)

TAZVERIK ORAL TABLET 1 PA; LA; QL (240 per 30 days)

TECENTRIQ INTRAVENOUS SOLUTION 1 PA; MO

TEPMETKO ORAL TABLET 1 PA; LA; QL (60 per 30 days)

THALOMID ORAL CAPSULE 100 MG, 50 MG 1 PA; MO; QL (30 per 30 days)

THALOMID ORAL CAPSULE 150 MG, 200 MG 1 PA; MO; QL (60 per 30 days)

thiotepa injection recon soln 15 mg 1 PA; MO

TIBSOVO ORAL TABLET 1 PA; QL (60 per 30 days)

TIVDAK INTRAVENOUS RECON SOLN 1 PA; MO

toposar intravenous solution 1 B/D PA; MO

topotecan intravenous recon soln 1 B/D PA; MO

topotecan intravenous solution 4 mg/4 ml (1

mg/ml)

1 B/D PA; MO

toremifene oral tablet 1 MO; QL (30 per 30 days)

TRAZIMERA INTRAVENOUS RECON SOLN 1 PA; MO

TREANDA INTRAVENOUS RECON SOLN 1 B/D PA; MO

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION

1 B/D PA; MO

tretinoin (antineoplastic) oral capsule 1 MO

TRUSELTIQ ORAL CAPSULE 1 PA; LA; QL (21 per 28 days)

TUKYSA ORAL TABLET 1 PA; LA; QL (120 per 30 days)

TURALIO ORAL CAPSULE 1 PA; LA; QL (120 per 30 days)

UKONIQ ORAL TABLET 1 PA; QL (120 per 30 days)

VELCADE INJECTION RECON SOLN 1 B/D PA; MO

VENCLEXTA ORAL TABLET 10 MG 1 PA; LA; QL (60 per 30 days)




24




VENCLEXTA STARTING PACK ORAL

TABLETS,DOSE PACK

1 PA; LA; QL (42 per 180 days)

VERZENIO ORAL TABLET 1 PA; MO; LA; QL (60 per 30 days)

vinblastine intravenous solution 1 B/D PA; MO

vincasar pfs intravenous solution 1 B/D PA; MO

vincristine intravenous solution 1 B/D PA; MO

vinorelbine intravenous solution 1 B/D PA; MO

VITRAKVI ORAL CAPSULE 100 MG 1 PA; MO; LA; QL (60 per 30 days)

VITRAKVI ORAL CAPSULE 25 MG 1 PA; MO; LA; QL (180 per 30 days)

VITRAKVI ORAL SOLUTION 1 PA; MO; LA; QL (300 per 30 days)

VIZIMPRO ORAL TABLET 1 PA; MO; QL (30 per 30 days)

VOTRIENT ORAL TABLET 1 PA; MO; QL (120 per 30 days)

WELIREG ORAL TABLET 1 PA; LA

XALKORI ORAL CAPSULE 1 PA; MO; QL (60 per 30 days)

XATMEP ORAL SOLUTION 1 PA; MO

XERMELO ORAL TABLET 1 PA; QL (84 per 28 days)

XOSPATA ORAL TABLET 1 PA; LA; QL (90 per 30 days)

XPOVIO ORAL TABLET 100 MG/WEEK (50

MG X 2), 40 MG/WEEK (40 MG X 1), 40MG

TWICE WEEK (40 MG X 2), 60 MG/WEEK (60

MG X 1), 60MG TWICE WEEK (120

MG/WEEK), 80 MG/WEEK (40 MG X 2), 80MG

TWICE WEEK (160 MG/WEEK)

1 PA; LA

XTANDI ORAL CAPSULE 1 MO; QL (120 per 30 days)

XTANDI ORAL TABLET 40 MG 1 MO; QL (120 per 30 days)

XTANDI ORAL TABLET 80 MG 1 MO; QL (60 per 30 days)

YERVOY INTRAVENOUS SOLUTION 1 PA; MO

YONDELIS INTRAVENOUS RECON SOLN 1 PA

YONSA ORAL TABLET 1 MO; QL (120 per 30 days)

ZALTRAP INTRAVENOUS SOLUTION 1 PA; MO

ZEJULA ORAL CAPSULE 1 PA; LA; QL (90 per 30 days)

ZELBORAF ORAL TABLET 1 PA; MO; QL (240 per 30 days)




25


ZIRABEV INTRAVENOUS SOLUTION 1 PA; MO

ZOLINZA ORAL CAPSULE 1 PA; MO; QL (120 per 30 days)

ZORTRESS ORAL TABLET 1 MG 1 B/D PA; MO

ZYDELIG ORAL TABLET 1 PA; MO; QL (60 per 30 days)

ZYKADIA ORAL TABLET 1 PA; MO; QL (90 per 30 days)

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET 1 PA; MO

BANZEL ORAL SUSPENSION 1 PA; MO

BANZEL ORAL TABLET 1 PA; MO

BRIVIACT INTRAVENOUS SOLUTION 1 PA

BRIVIACT ORAL SOLUTION 1 PA; MO

BRIVIACT ORAL TABLET 1 PA; MO

carbamazepine oral capsule, er multiphase 12 hr 1 MO

carbamazepine oral suspension 100 mg/5 ml 1 MO

carbamazepine oral suspension 200 mg/10 ml 1

carbamazepine oral tablet 1 MO

carbamazepine oral tablet extended release 12 hr 1 MO

carbamazepine oral tablet,chewable 1 MO

CELONTIN ORAL CAPSULE 300 MG 1 MO

clobazam oral suspension 1 PA; MO

clobazam oral tablet 1 PA; MO

clonazepam oral tablet 1 MO

clonazepam oral tablet,disintegrating 1 MO

DIACOMIT ORAL CAPSULE 1 PA

DIACOMIT ORAL POWDER IN PACKET 1 PA

diazepam rectal kit 2.5 mg 1 MO

DILANTIN 30 MG ORAL CAPSULE 1 MO

divalproex oral capsule, delayed release sprinkle 1

divalproex oral tablet extended release 24 hr 1 MO

divalproex oral tablet,delayed release (dr/ec) 1 MO

EPIDIOLEX ORAL SOLUTION 1 PA; MO; LA




26


epitol oral tablet 1 MO

EPRONTIA ORAL SOLUTION 1 MO

ethosuximide oral capsule 1 MO

ethosuximide oral solution 1 MO

felbamate oral suspension 1 MO

felbamate oral tablet 1 MO

FINTEPLA ORAL SOLUTION 1 PA; LA

fosphenytoin injection solution 1 B/D PA; MO

FYCOMPA ORAL SUSPENSION 1 PA; MO

FYCOMPA ORAL TABLET 10 MG, 12 MG, 4

MG, 6 MG, 8 MG

1 PA; MO

FYCOMPA ORAL TABLET 2 MG 1 PA; MO

gabapentin oral capsule 100 mg 1 MO; QL (180 per 30 days)

gabapentin oral capsule 300 mg, 400 mg 1 MO; QL (270 per 30 days)

gabapentin oral solution 250 mg/5 ml 1 MO; QL (2160 per 30 days)

gabapentin oral solution 250 mg/5 ml (5 ml), 300

mg/6 ml (6 ml)

1 QL (2160 per 30 days)

gabapentin oral tablet 600 mg 1 MO; QL (180 per 30 days)

gabapentin oral tablet 800 mg 1 MO; QL (120 per 30 days)

lamotrigine oral tablet 1 MO

lamotrigine oral tablet disintegrating, dose pk 25

mg(14)-50 mg (14)-100 mg (7)

1 MO

lamotrigine oral tablet extended release 24hr 1 MO

lamotrigine oral tablet, chewable dispersible 1 MO

lamotrigine oral tablet,disintegrating 1 MO

lamotrigine oral tablets,dose pack 1 MO

levetiracetam in nacl (iso-osm) intravenous

piggyback 1,000 mg/100 ml, 500 mg/100 ml

1 MO

levetiracetam in nacl (iso-osm) intravenous

piggyback 1,500 mg/100 ml

1

levetiracetam intravenous solution 1 MO

levetiracetam oral solution 100 mg/ml 1 MO

levetiracetam oral solution 500 mg/5 ml (5 ml) 1

levetiracetam oral tablet 1 MO




27


levetiracetam oral tablet extended release 24 hr 1 MO

NAYZILAM NASAL SPRAY,NON-AEROSOL 1 PA; MO; QL (10 per 30 days)

oxcarbazepine oral suspension 1 MO

oxcarbazepine oral tablet 1 MO

phenobarbital oral elixir 1 PA; MO

phenobarbital oral tablet 100 mg, 15 mg, 30 mg,

60 mg

1 PA

phenobarbital oral tablet 16.2 mg, 32.4 mg, 64.8

mg, 97.2 mg

1 PA; MO

phenytoin oral suspension 100 mg/4 ml 1

phenytoin oral suspension 125 mg/5 ml 1 MO

phenytoin oral tablet,chewable 1 MO

phenytoin sodium extended release oral capsule 1 MO

phenytoin sodium intravenous solution 1 B/D PA

pregabalin oral capsule 100 mg, 150 mg, 200 mg,

25 mg, 50 mg, 75 mg


pregabalin oral capsule 225 mg, 300 mg 1 MO; QL (60 per 30 days)

pregabalin oral solution 1 MO; QL (900 per 30 days)

primidone oral tablet 1 MO

roweepra oral tablet 500 mg 1 MO

rufinamide oral suspension 1 PA; MO

rufinamide oral tablet 1 PA; MO

SPRITAM ORAL TABLET FOR SUSPENSION 1 MO

SYMPAZAN ORAL FILM 10 MG, 20 MG 1 PA; MO

SYMPAZAN ORAL FILM 5 MG 1 PA; MO

tiagabine oral tablet 1 MO

topiramate oral capsule, sprinkle 1 MO

topiramate oral capsule,sprinkle,er 24hr 1 MO

topiramate oral tablet 1 MO

valproate sodium intravenous solution 1 B/D PA; MO

valproic acid (as sodium salt) oral solution 250

mg/5 ml

1 MO

valproic acid (as sodium salt) oral solution 250

mg/5 ml (5 ml), 500 mg/10 ml (10 ml)

1




28


valproic acid oral capsule 1 MO

VALTOCO NASAL SPRAY,NON-AEROSOL 1 PA; MO

vigabatrin oral powder in packet 1 PA; MO; LA

vigabatrin oral tablet 1 PA; MO; LA

VIMPAT INTRAVENOUS SOLUTION 1 PA; MO

VIMPAT ORAL SOLUTION 1 PA; MO

VIMPAT ORAL TABLET 1 PA; MO

XCOPRI MAINTENANCE PACK ORAL

TABLET 250MG/DAY(150 MG X1-100MG X1),

350 MG/DAY (200 MG X1-150MG X1)

1 MO

XCOPRI ORAL TABLET 1 MO

XCOPRI TITRATION PACK ORAL

TABLETS,DOSE PACK 12.5 MG (14)- 25 MG

(14)

1 MO

XCOPRI TITRATION PACK ORAL

TABLETS,DOSE PACK 150 MG (14)- 200 MG

(14), 50 MG (14)- 100 MG (14)

1 MO

zonisamide oral capsule 1 PA; MO

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE 1 PA; MO; LA

benztropine injection solution 1 B/D PA; MO

benztropine oral tablet 1 MO

bromocriptine oral capsule 1 MO

bromocriptine oral tablet 1 MO

carbidopa oral tablet 1 MO

carbidopa-levodopa oral tablet 1 MO

carbidopa-levodopa oral tablet extended release 1 MO

carbidopa-levodopa oral tablet,disintegrating 1 MO

carbidopa-levodopa-entacapone oral tablet 1 MO

entacapone oral tablet 1 MO

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MO

pramipexole oral tablet 1 MO

pramipexole oral tablet extended release 24 hr 1 MO

rasagiline oral tablet 1 MO




29


ropinirole oral tablet 1 MO

ropinirole oral tablet extended release 24 hr 1 MO

selegiline hcl oral capsule 1 MO

selegiline hcl oral tablet 1 MO

tolcapone oral tablet 1

trihexyphenidyl oral elixir 1 MO

trihexyphenidyl oral tablet 1 MO

MIGRAINE / CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR


AJOVY AUTOINJECTOR SUBCUTANEOUS

AUTO-INJECTOR

1 PA; MO; QL (1.5 per 30 days)

AJOVY SUBCUTANEOUS SYRINGE 1 PA; MO; QL (1.5 per 30 days)

dihydroergotamine injection solution 1

dihydroergotamine nasal spray,non-aerosol 1 PA

EMGALITY SUBCUTANEOUS PEN

INJECTOR


EMGALITY SUBCUTANEOUS SYRINGE 120

MG/ML


EMGALITY SUBCUTANEOUS SYRINGE 300

MG/3 ML (100 MG/ML X 3)


migergot rectal suppository 1 MO

naratriptan oral tablet 1 MO; QL (18 per 28 days)

NURTEC ODT ORAL

TABLET,DISINTEGRATING


rizatriptan oral tablet 1 MO; QL (36 per 30 days)

rizatriptan oral tablet,disintegrating 1 MO; QL (36 per 30 days)

sumatriptan nasal spray,non-aerosol 20

mg/actuation


sumatriptan nasal spray,non-aerosol 5

mg/actuation


sumatriptan succinate oral tablet 1 MO; QL (9 per 30 days)

sumatriptan succinate subcutaneous cartridge 1 MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous pen injector 1 MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous solution 1 MO; QL (10 per 30 days)




30


UBRELVY ORAL TABLET 1 PA; QL (16 per 30 days)

zolmitriptan oral tablet 1 MO; QL (12 per 30 days)

zolmitriptan oral tablet,disintegrating 1 MO; QL (12 per 30 days)

MISCELLANEOUS NEUROLOGICAL THERAPY

AUBAGIO ORAL TABLET 1 MO

dalfampridine oral tablet extended release 12 hr 1 PA; MO; QL (60 per 30 days)

dimethyl fumarate oral capsule,delayed

release(dr/ec)

1 MO

donepezil oral tablet 1 MO; QL (30 per 30 days)

donepezil oral tablet,disintegrating 1 MO; QL (30 per 30 days)

EVRYSDI ORAL RECON SOLN 1 PA; MO; LA

galantamine oral solution 1 MO

galantamine oral tablet 1 MO

GILENYA ORAL CAPSULE 0.5 MG 1 MO

glatiramer subcutaneous syringe 1

glatopa subcutaneous syringe 1 MO

INGREZZA INITIATION PACK ORAL

CAPSULE,DOSE PACK

1 PA; LA; QL (28 per 180 days)

INGREZZA ORAL CAPSULE 1 PA; LA; QL (30 per 30 days)

KEVEYIS ORAL TABLET 1 PA

MAVENCLAD (10 TABLET PACK) ORAL

TABLET

1 MO


TABLET

1 MO


TABLET

1 MO


TABLET

1 MO


TABLET

1 MO


TABLET

1 MO


TABLET

1 MO

MAYZENT ORAL TABLET 0.25 MG, 2 MG 1 MO




31


MAYZENT STARTER(FOR 2MG MAINT)

ORAL TABLETS,DOSE PACK

1 MO

memantine oral capsule,sprinkle,er 24hr 1 MO

memantine oral solution 1 MO

memantine oral tablet 1 MO

MEMANTINE ORAL TABLETS,DOSE PACK 1 MO

NUEDEXTA ORAL CAPSULE 1 PA; MO; QL (60 per 30 days)

RADICAVA INTRAVENOUS SOLUTION 1 PA

rivastigmine tartrate oral capsule 1.5 mg 1 MO; QL (240 per 30 days)

rivastigmine tartrate oral capsule 3 mg 1 MO; QL (120 per 30 days)

rivastigmine tartrate oral capsule 4.5 mg, 6 mg 1 MO; QL (60 per 30 days)

rivastigmine transdermal patch 24 hour 1 MO; QL (30 per 30 days)

TEGSEDI SUBCUTANEOUS SYRINGE 1 PA; MO

tetrabenazine oral tablet 1 PA; MO

TYSABRI INTRAVENOUS SOLUTION 1 PA; MO

VUMERITY ORAL CAPSULE,DELAYED

RELEASE(DR/EC)

1 MO

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral tablet 10 mg, 20 mg 1 MO

cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA; MO

dantrolene oral capsule 1 MO

metaxalone oral tablet 1 PA; MO

pyridostigmine bromide oral tablet 60 mg 1 MO

pyridostigmine bromide oral tablet extended

release

1 MO

regonol injection solution 1 B/D PA

tizanidine oral capsule 1 MO

tizanidine oral tablet 1 MO

NARCOTIC ANALGESICS

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg


acetaminophen-codeine oral tablet 300-60 mg 1 MO; QL (180 per 30 days)

buprenorphine hcl injection solution 1 B/D PA; MO




32


buprenorphine hcl injection syringe 1 B/D PA

buprenorphine hcl sublingual tablet 1 MO

butalbital-acetaminop-caf-cod oral capsule 1 PA; MO; QL (360 per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg 1 PA; MO; QL (360 per 30 days)

butalbital-acetaminophen-caff oral capsule 1 PA; MO; QL (360 per 30 days)

butalbital-acetaminophen-caff oral tablet 1 PA; MO; QL (360 per 30 days)

butalbital-aspirin-caffeine oral capsule 1 PA; MO; QL (180 per 30 days)

butalbital-aspirin-caffeine oral tablet 1 PA; QL (180 per 30 days)

codeine sulfate oral tablet 1 MO; QL (180 per 30 days)

endocet oral tablet 1 MO; QL (360 per 30 days)

fentanyl citrate buccal lozenge on a handle 1,200

mcg


fentanyl citrate buccal lozenge on a handle 1,600

mcg


fentanyl citrate buccal lozenge on a handle 200

mcg



mcg



mcg



mcg


fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


hydrocodone-acetaminophen oral solution 7.5-325

mg/15 ml


hydrocodone-acetaminophen oral tablet 10-300

mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg,

7.5-325 mg


hydrocodone-ibuprofen oral tablet 1 MO; QL (50 per 30 days)

hydromorphone (pf) injection solution 10 (mg/ml)

(5 ml), 10 mg/ml

1 B/D PA; QL (120 per 30 days)

hydromorphone injection solution 1 mg/ml 1 B/D PA; QL (50 per 30 days)

hydromorphone oral liquid 1 MO; QL (1500 per 30 days)

hydromorphone oral tablet 1 MO; QL (180 per 30 days)

methadone injection solution 1 B/D PA; QL (1200 per 30 days)




33


methadone intensol oral concentrate 1 MO; QL (160 per 30 days)

methadone oral concentrate 1 QL (160 per 30 days)

methadone oral solution 10 mg/5 ml 1 PA; MO; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 1 PA; MO; QL (1200 per 30 days)

methadone oral tablet 10 mg 1 PA; MO; QL (120 per 30 days)

methadone oral tablet 5 mg 1 PA; MO; QL (240 per 30 days)

methadose oral concentrate 1 MO; QL (160 per 30 days)

morphine (pf) injection solution 0.5 mg/ml 1 B/D PA; QL (1200 per 30 days)

morphine (pf) injection solution 1 mg/ml 1 B/D PA; MO; QL (600 per 30 days)

morphine concentrate oral solution 1 MO; QL (300 per 30 days)

MORPHINE INTRAVENOUS SYRINGE 10

MG/ML


MORPHINE INTRAVENOUS SYRINGE 8

MG/ML


morphine oral capsule, er multiphase 24 hr 120

mg


morphine oral capsule, er multiphase 24 hr 30 mg,

45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets 10

mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg


morphine oral solution 1 MO; QL (900 per 30 days)

morphine oral tablet 1 MO; QL (180 per 30 days)

morphine oral tablet extended release 100 mg 1 PA; MO; QL (60 per 30 days)

morphine oral tablet extended release 15 mg, 30

mg, 60 mg


morphine oral tablet extended release 200 mg 1 PA; MO; QL (30 per 30 days)

oxycodone oral capsule 1 MO; QL (360 per 30 days)

oxycodone oral concentrate 1 MO; QL (180 per 30 days)

oxycodone oral solution 1 MO; QL (1200 per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg 1 MO; QL (180 per 30 days)

oxycodone oral tablet 30 mg 1 MO; QL (134 per 30 days)

oxycodone oral tablet 5 mg 1 MO; QL (360 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg





34


oxymorphone oral tablet 10 mg 1 MO; QL (200 per 30 days)

oxymorphone oral tablet 5 mg 1 MO; QL (180 per 30 days)

oxymorphone oral tablet extended release 12 hr 10

mg, 15 mg, 20 mg, 5 mg, 7.5 mg



mg



mg


NON-NARCOTIC ANALGESICS

buprenorphine-naloxone sublingual film 12-3 mg 1 MO; QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg,

4-1 mg, 8-2 mg


buprenorphine-naloxone sublingual tablet 1 MO; QL (90 per 30 days)

butorphanol injection solution 1 mg/ml 1 MO; QL (857 per 30 days)

butorphanol injection solution 2 mg/ml 1 MO; QL (214 per 30 days)

butorphanol nasal spray,non-aerosol 1 MO; QL (5 per 30 days)

celecoxib oral capsule 1 MO

DICLOFENAC EPOLAMINE TRANSDERMAL

PATCH 12 HOUR

1 PA

diclofenac potassium oral tablet 50 mg 1 MO

diclofenac sodium oral tablet extended release 24

hr

1 MO

diclofenac sodium oral tablet,delayed release

(dr/ec)

1 MO

diclofenac sodium topical drops 1 MO; QL (600 per 30 days)

diclofenac sodium topical gel 1 % 1 MO; QL (1000 per 30 days)

diclofenac-misoprostol oral tablet, ir, delayed

release, biphasic

1 MO

diflunisal oral tablet 1 MO

ec-naproxen oral tablet,delayed release (dr/ec)

375 mg

1

ec-naproxen oral tablet,delayed release (dr/ec)

500 mg

1 MO

etodolac oral capsule 1 MO

etodolac oral tablet 1 MO




35


etodolac oral tablet extended release 24 hr 1 MO

fenoprofen oral tablet 1 MO

flurbiprofen oral tablet 100 mg 1 MO

ibu oral tablet 1 MO

ibuprofen oral suspension 1 MO

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO

indomethacin oral capsule 1 MO

indomethacin oral capsule, extended release 1 MO

ketoprofen oral capsule 50 mg, 75 mg 1

KLOXXADO NASAL SPRAY,NON-AEROSOL 1 MO

LUCEMYRA ORAL TABLET 1 PA; MO

meloxicam oral tablet 1 MO

nabumetone oral tablet 1 MO

nalbuphine injection solution 10 mg/ml 1 B/D PA; MO; QL (200 per 30 days)

nalbuphine injection solution 20 mg/ml 1 B/D PA; MO; QL (100 per 30 days)

naloxone injection solution 1 MO

naloxone injection syringe 1 MO

naloxone nasal spray,non-aerosol 1 MO

naltrexone oral tablet 1 MO

naproxen oral suspension 1 MO

naproxen oral tablet 1 MO

naproxen oral tablet,delayed release (dr/ec) 375

mg

1 MO

naproxen oral tablet,delayed release (dr/ec) 500

mg

1

NARCAN NASAL SPRAY,NON-AEROSOL 1 MO

oxaprozin oral tablet 1 MO

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP

1 PA; MO

piroxicam oral capsule 1 MO

sulindac oral tablet 1 MO

tolmetin oral capsule 1 MO

tolmetin oral tablet 600 mg 1 MO




36


tramadol oral tablet 50 mg 1 MO; QL (240 per 30 days)

tramadol oral tablet extended release 24 hr 1 MO; QL (30 per 30 days)

tramadol oral tablet, er multiphase 24 hr 1 MO; QL (30 per 30 days)

tramadol-acetaminophen oral tablet 1 MO; QL (240 per 30 days)

VIVITROL INTRAMUSCULAR SUSPENSION,

EXTENDED RELEASE RECON

1 MO

ZIMHI INJECTION SYRINGE 1

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION, EXTENDED RELEASE RECON

1 MO

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION, EXTENDED RELEASE

SYRINGE

1 MO

alprazolam oral tablet 1 MO

alprazolam oral tablet extended release 24 hr 1 PA; MO

alprazolam oral tablet,disintegrating 1 MO

amitriptyline oral tablet 1 PA; MO

amoxapine oral tablet 1 MO

aripiprazole oral solution 1 MO

aripiprazole oral tablet 1 MO; QL (30 per 30 days)

aripiprazole oral tablet,disintegrating 1 MO; QL (60 per 30 days)

ARISTADA INITIO INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING

1 MO

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED RELEASE SYRINGE

1 MO

armodafinil oral tablet 150 mg, 200 mg, 250 mg 1 PA; MO; QL (30 per 30 days)

armodafinil oral tablet 50 mg 1 PA; MO; QL (90 per 30 days)

asenapine maleate sublingual tablet 1 MO; QL (60 per 30 days)

atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40

mg


atomoxetine oral capsule 100 mg, 60 mg, 80 mg 1 MO; QL (30 per 30 days)

bupropion hcl oral tablet 1 MO

bupropion hcl oral tablet extended release 24 hr

150 mg, 300 mg

1 MO

bupropion hcl oral tablet sustained-release 12 hr 1 MO




37


buspirone oral tablet 1 MO

CAPLYTA ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

chlorpromazine injection solution 1 MO

chlorpromazine oral concentrate 1 MO

chlorpromazine oral tablet 1 MO

citalopram oral solution 1 MO

citalopram oral tablet 1 MO

clomipramine oral capsule 1 PA; MO

clonidine hcl oral tablet extended release 12 hr 1 MO; QL (120 per 30 days)

clorazepate dipotassium oral tablet 1 PA; MO

clozapine oral tablet 1

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 25 mg

1

clozapine oral tablet,disintegrating 150 mg, 200

mg

1

desipramine oral tablet 1 MO

desvenlafaxine succinate oral tablet extended

release 24 hr

1 MO

dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 20 mg, 5 mg


dexmethylphenidate oral capsule,er biphasic 50-

50 30 mg, 40 mg


dexmethylphenidate oral tablet 10 mg 1 MO; QL (60 per 30 days)

dexmethylphenidate oral tablet 2.5 mg, 5 mg 1 MO; QL (120 per 30 days)

dextroamphetamine sulfate oral capsule, extended

release 10 mg, 5 mg


dextroamphetamine sulfate oral capsule, extended

release 15 mg


dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1 MO; QL (180 per 30 days)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr


dextroamphetamine-amphetamine oral tablet 1 MO; QL (90 per 30 days)

diazepam intensol oral concentrate 1 PA; MO

diazepam oral concentrate 1 PA

diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA; MO




38


diazepam oral tablet 1 PA; MO

doxepin oral capsule 1 PA; MO

doxepin oral concentrate 1 PA; MO

DRIZALMA SPRINKLE ORAL CAPSULE,

DELAYED REL SPRINKLE

1 PA; MO

duloxetine oral capsule,delayed release(dr/ec) 1 MO

EMSAM TRANSDERMAL PATCH 24 HOUR 1 PA; MO; QL (30 per 30 days)

ergoloid oral tablet 1 MO

escitalopram oxalate oral solution 1 MO

escitalopram oxalate oral tablet 1 MO

eszopiclone oral tablet 1 MO; QL (30 per 30 days)

FANAPT ORAL TABLET 1 MO; QL (60 per 30 days)

FANAPT ORAL TABLETS,DOSE PACK 1 MO; QL (8 per 28 days)

FETZIMA ORAL CAPSULE, EXTENDED

RELEASE 24HR DOSE PACK


FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR


fluoxetine (pmdd) oral tablet 1

fluoxetine oral capsule 1 MO

fluoxetine oral capsule,delayed release(dr/ec) 1 MO

fluoxetine oral solution 1 MO

fluoxetine oral tablet 10 mg, 20 mg 1 MO

fluoxetine oral tablet 60 mg 1 MO

fluphenazine decanoate injection solution 1 MO

fluphenazine hcl injection solution 1 MO

fluphenazine hcl oral concentrate 1 MO

fluphenazine hcl oral elixir 1 MO

fluphenazine hcl oral tablet 1 MO

fluvoxamine oral capsule,extended release 24hr 1 MO

fluvoxamine oral tablet 1 MO

GEODON INTRAMUSCULAR RECON SOLN 1 MO

guanfacine oral tablet extended release 24 hr 1 MO; QL (30 per 30 days)

haloperidol decanoate intramuscular solution 100

mg/ml, 100 mg/ml (1 ml), 50 mg/ml

1 MO




39


haloperidol decanoate intramuscular solution 50

mg/ml(1ml)

1

haloperidol lactate injection solution 1 MO

haloperidol lactate oral concentrate 1 MO

haloperidol oral tablet 1 MO

HETLIOZ LQ ORAL SUSPENSION 1 PA; MO

HETLIOZ ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

imipramine hcl oral tablet 1 PA; MO

imipramine pamoate oral capsule 1 PA; MO

INVEGA HAFYERA INTRAMUSCULAR

SYRINGE

1 MO

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234

MG/1.5 ML

1 MO

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML

1 MO

LATUDA ORAL TABLET 1 MO

lithium carbonate oral capsule 1 MO

lithium carbonate oral tablet 1 MO

lithium carbonate oral tablet extended release 1 MO

lithium citrate oral solution 8 meq/5 ml 1 MO

lorazepam intensol oral concentrate 1 PA

lorazepam oral concentrate 1 PA; MO

lorazepam oral tablet 1 PA; MO

loxapine succinate oral capsule 1 MO

maprotiline oral tablet 1 MO

MARPLAN ORAL TABLET 1 MO

methamphetamine oral tablet 1 PA; MO; QL (150 per 30 days)

methylphenidate hcl oral capsule, er biphasic 30-

70 10 mg, 20 mg, 30 mg


methylphenidate hcl oral capsule, er biphasic 30-

70 40 mg, 50 mg, 60 mg


methylphenidate hcl oral capsule,er biphasic 50-

50 10 mg





40



50 20 mg



50 30 mg


methylphenidate hcl oral solution 1 MO

methylphenidate hcl oral tablet 10 mg, 5 mg 1 MO; QL (180 per 30 days)

methylphenidate hcl oral tablet 20 mg 1 MO; QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 1 MO; QL (90 per 30 days)

methylphenidate hcl oral tablet extended release

24hr 18 mg



24hr 18 mg (bx rating)

1 QL (120 per 30 days)


24hr 36 mg






24hr 54 mg





mirtazapine oral tablet 1 MO

mirtazapine oral tablet,disintegrating 30 mg, 45

mg

1 MO

modafinil oral tablet 100 mg 1 PA; MO; QL (30 per 30 days)

modafinil oral tablet 200 mg 1 PA; MO; QL (60 per 30 days)

molindone oral tablet 1 MO

nefazodone oral tablet 1 MO

nortriptyline oral capsule 1 MO

nortriptyline oral solution 1 MO

NUPLAZID ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

NUPLAZID ORAL TABLET 1 PA; MO; QL (30 per 30 days)

olanzapine intramuscular recon soln 1 MO

olanzapine oral tablet 1 MO

olanzapine oral tablet,disintegrating 1 MO

olanzapine-fluoxetine oral capsule 1 MO




41


oxazepam oral capsule 1 PA; MO

paliperidone oral tablet extended release 24hr 1.5

mg, 3 mg, 9 mg


paliperidone oral tablet extended release 24hr 6

mg


paroxetine hcl oral suspension 1 MO

paroxetine hcl oral tablet 1 MO

paroxetine hcl oral tablet extended release 24 hr 1 MO

paroxetine mesylate(menop.sym) oral capsule 1 MO

PAXIL ORAL SUSPENSION 1 MO

perphenazine oral tablet 1 MO

perphenazine-amitriptyline oral tablet 1 PA; MO

phenelzine oral tablet 1 MO

pimozide oral tablet 1 MO

protriptyline oral tablet 1 MO

quetiapine oral tablet 1 MO

quetiapine oral tablet extended release 24 hr 1 MO

ramelteon oral tablet 1 MO; QL (30 per 30 days)

REXULTI ORAL TABLET 1 MO

RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 12.5

MG/2 ML, 25 MG/2 ML

1 MO

RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 37.5

MG/2 ML, 50 MG/2 ML

1 MO

risperidone oral solution 1 MO

risperidone oral tablet 1 MO

risperidone oral tablet,disintegrating 1 MO

SECUADO TRANSDERMAL PATCH 24 HOUR 1 PA; MO; QL (30 per 30 days)

sertraline oral concentrate 1 MO

sertraline oral tablet 1 MO

temazepam oral capsule 1 MO

thioridazine oral tablet 1 MO

thiothixene oral capsule 1 MO




42


tranylcypromine oral tablet 1 MO

trazodone oral tablet 1 MO

trifluoperazine oral tablet 1 MO

trimipramine oral capsule 1 PA; MO

TRINTELLIX ORAL TABLET 1 MO

venlafaxine oral capsule,extended release 24hr 1 MO

venlafaxine oral tablet 1 MO

venlafaxine oral tablet extended release 24hr 150

mg, 37.5 mg, 75 mg

1 MO

venlafaxine oral tablet extended release 24hr 225

mg

1 MO

VERSACLOZ ORAL SUSPENSION 1

VIIBRYD ORAL TABLET 1 MO

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)


VRAYLAR ORAL CAPSULE 1.5 MG 1 PA; MO; QL (120 per 30 days)

VRAYLAR ORAL CAPSULE 3 MG 1 PA; MO; QL (60 per 30 days)

VRAYLAR ORAL CAPSULE 4.5 MG 1 PA; MO; QL (40 per 30 days)

VRAYLAR ORAL CAPSULE 6 MG 1 PA; MO; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK 1 PA; MO; QL (7 per 180 days)

XYREM ORAL SOLUTION 1 PA; LA; QL (540 per 30 days)

ziprasidone hcl oral capsule 1 MO

ziprasidone mesylate intramuscular recon soln 1 MO

zolpidem oral tablet 1 MO; QL (30 per 30 days)

zolpidem oral tablet, extended release multiphase 1 MO; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION

1 MO

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone intravenous solution 1 B/D PA; MO

amiodarone oral tablet 100 mg, 400 mg 1

amiodarone oral tablet 200 mg 1 MO

dofetilide oral capsule 1 MO




43


flecainide oral tablet 1 MO

lidocaine (pf) intravenous solution 1

mexiletine oral capsule 1 MO

MULTAQ ORAL TABLET 1 MO; QL (60 per 30 days)

pacerone oral tablet 100 mg, 200 mg, 400 mg 1 MO

procainamide injection solution 1

propafenone oral capsule,extended release 12 hr 1 MO

propafenone oral tablet 1 MO

quinidine gluconate oral tablet extended release 1 MO

quinidine sulfate oral tablet 1 MO

sorine oral tablet 120 mg, 160 mg, 80 mg 1 MO

sorine oral tablet 240 mg 1

sotalol af oral tablet 1

sotalol oral tablet 1 MO

ANTIHYPERTENSIVE THERAPY

acebutolol oral capsule 1 MO

aliskiren oral tablet 1 MO

amiloride oral tablet 1 MO

amiloride-hydrochlorothiazide oral tablet 1 MO

amlodipine oral tablet 1 MO

amlodipine-benazepril oral capsule 1 MO

amlodipine-olmesartan oral tablet 1 MO

amlodipine-valsartan oral tablet 1 MO

amlodipine-valsartan-hydrochlorothiazide oral

tablet

1 MO

atenolol oral tablet 1 MO

atenolol-chlorthalidone oral tablet 1 MO

benazepril oral tablet 1 MO; QL (60 per 30 days)

benazepril-hydrochlorothiazide oral tablet 1 MO

betaxolol oral tablet 1 MO

bisoprolol fumarate oral tablet 1 MO

bisoprolol-hydrochlorothiazide oral tablet 1 MO

bumetanide injection solution 1 MO




44


bumetanide oral tablet 1 MO

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 5

MG


BYSTOLIC ORAL TABLET 20 MG 1 MO; QL (60 per 30 days)

candesartan oral tablet 1 MO

candesartan-hydrochlorothiazide oral tablet 1 MO

captopril oral tablet 1 MO

captopril-hydrochlorothiazide oral tablet 1 MO

cartia xt oral capsule,extended release 24hr 1 MO

carvedilol oral tablet 1 MO

carvedilol phosphate oral capsule, er multiphase

24 hr

1 ST; MO

chlorothiazide sodium intravenous recon soln 1 MO

chlorthalidone oral tablet 25 mg, 50 mg 1 MO

clonidine hcl oral tablet 1 MO

clonidine transdermal patch weekly 1 MO

DEMSER ORAL CAPSULE 1 PA; MO

diltiazem hcl intravenous recon soln 1 B/D PA

diltiazem hcl intravenous solution 1 B/D PA

diltiazem hcl oral capsule,ext.rel 24h degradable 1 MO

diltiazem hcl oral capsule,extended release 12 hr 1 MO

diltiazem hcl oral capsule,extended release 24 hr 1 MO

diltiazem hcl oral capsule,extended release 24hr 1 MO

diltiazem hcl oral tablet 1 MO

diltiazem hcl oral tablet extended release 24 hr 1

dilt-xr oral capsule, extended release 24h

degradable

1 MO

doxazosin oral tablet 1 mg, 2 mg, 4 mg 1 MO; QL (30 per 30 days)

doxazosin oral tablet 8 mg 1 MO; QL (60 per 30 days)

enalapril maleate oral tablet 1 MO

enalapril-hydrochlorothiazide oral tablet 1 MO

eplerenone oral tablet 1 MO

felodipine oral tablet extended release 24 hr 1 MO




45


fosinopril oral tablet 1 MO

fosinopril-hydrochlorothiazide oral tablet 1 MO

furosemide injection syringe 1 B/D PA; MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1 MO

furosemide oral tablet 1 MO

hydralazine injection solution 1 B/D PA; MO

hydralazine oral tablet 1 MO

hydrochlorothiazide oral capsule 1 MO

hydrochlorothiazide oral tablet 1 MO

indapamide oral tablet 1 MO

irbesartan oral tablet 1 MO

irbesartan-hydrochlorothiazide oral tablet 1 MO

isradipine oral capsule 1 MO

KERENDIA ORAL TABLET 1 PA; QL (30 per 30 days)

labetalol intravenous solution 1 B/D PA

labetalol intravenous syringe 20 mg/4 ml (5

mg/ml)

1 B/D PA

labetalol oral tablet 1 MO

lisinopril oral tablet 1 MO

lisinopril-hydrochlorothiazide oral tablet 1 MO

losartan oral tablet 100 mg 1 MO; QL (45 per 30 days)

losartan oral tablet 25 mg, 50 mg 1 MO; QL (60 per 30 days)

losartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

matzim la oral tablet extended release 24 hr 1 MO

methyldopa-hydrochlorothiazide oral tablet 1 PA; MO

metolazone oral tablet 1 MO

metoprolol succinate oral tablet extended release

24 hr

1 MO

metoprolol tartrate intravenous solution 1 B/D PA

metoprolol tartrate oral tablet 1 MO

metoprolol tartrate-hydrochlorothiazide oral

tablet

1 MO

metyrosine oral capsule 1 PA; MO




46


minoxidil oral tablet 1 MO

moexipril oral tablet 1 MO

nadolol oral tablet 1 MO

nebivolol oral tablet 10 mg, 2.5 mg, 5 mg 1 QL (30 per 30 days)

nebivolol oral tablet 20 mg 1 QL (60 per 30 days)

nicardipine intravenous solution 1

nicardipine oral capsule 1 MO

nifedipine oral tablet extended release 1 MO

nifedipine oral tablet extended release 24hr 1 MO

nimodipine oral capsule 1 MO

olmesartan oral tablet 1 MO; QL (30 per 30 days)

olmesartan-amlodipine-hydrochlorothiazide oral

tablet

1 MO

olmesartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

perindopril erbumine oral tablet 1 MO

phenoxybenzamine oral capsule 1 PA; MO

pindolol oral tablet 1 MO

prazosin oral capsule 1 MO

propranolol intravenous solution 1 B/D PA

propranolol oral capsule,extended release 24 hr 1 MO

propranolol oral solution 1 MO

propranolol oral tablet 1 MO

propranolol-hydrochlorothiazide oral tablet 1 MO

quinapril oral tablet 1 MO

quinapril-hydrochlorothiazide oral tablet 1 MO

ramipril oral capsule 1 MO

spironolactone oral tablet 1 MO

spironolactone-hydrochlorothiazide oral tablet 1 MO

taztia xt oral capsule,extended release 24 hr 1 MO

TEKTURNA HCT ORAL TABLET 1 MO

telmisartan oral tablet 1 MO

telmisartan-hydrochlorothiazide oral tablet 1 MO

terazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO; QL (30 per 30 days)




47


terazosin oral capsule 10 mg 1 MO; QL (60 per 30 days)

tiadylt er oral capsule,extended release 24 hr 1 MO

timolol maleate oral tablet 1 MO

torsemide oral tablet 1 MO

trandolapril oral tablet 1 MO

trandolapril-verapamil oral tablet, ir - er, biphasic

24hr

1 MO

treprostinil sodium injection solution 1 B/D PA; MO

triamterene-hydrochlorothiazide oral capsule

37.5-25 mg

1 MO

triamterene-hydrochlorothiazide oral tablet 1 MO

UPTRAVI INTRAVENOUS RECON SOLN 1 PA; LA; QL (60 per 30 days)

UPTRAVI ORAL TABLET 1 PA; MO; LA; QL (60 per 30 days)

UPTRAVI ORAL TABLETS,DOSE PACK 1 PA; MO; LA

valsartan oral tablet 160 mg, 40 mg, 80 mg 1 MO; QL (60 per 30 days)

valsartan oral tablet 320 mg 1 MO; QL (30 per 30 days)

valsartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days)

verapamil intravenous solution 1 B/D PA

verapamil intravenous syringe 1 B/D PA

verapamil oral capsule, 24 hr er pellet ct 1 MO

verapamil oral capsule, extended release pellets

24 hr

1 MO

verapamil oral tablet 1 MO

verapamil oral tablet extended release 1 MO

COAGULATION THERAPY

aspirin-dipyridamole oral capsule, er multiphase

12 hr

1 MO

BRILINTA ORAL TABLET 1 MO

cilostazol oral tablet 1 MO

clopidogrel oral tablet 300 mg 1 MO; QL (1 per 30 days)

clopidogrel oral tablet 75 mg 1 MO

ELIQUIS DVT-PE TREAT 30D START ORAL

TABLETS,DOSE PACK

1 MO

ELIQUIS ORAL TABLET 1 MO




48


enoxaparin subcutaneous solution 1 MO; QL (180 per 30 days)

enoxaparin subcutaneous syringe 100 mg/ml, 150

mg/ml


enoxaparin subcutaneous syringe 120 mg/0.8 ml,

80 mg/0.8 ml


enoxaparin subcutaneous syringe 30 mg/0.3 ml 1 MO; QL (18 per 30 days)



fondaparinux subcutaneous syringe 10 mg/0.8 ml 1 MO; QL (24 per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 1 MO; QL (15 per 30 days)

fondaparinux subcutaneous syringe 5 mg/0.4 ml 1 MO; QL (12 per 30 days)

fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 1 MO; QL (18 per 30 days)

FRAGMIN SUBCUTANEOUS SOLUTION 1 MO; QL (30 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 10,000

ANTI-XA UNIT/ML



ANTI-XA UNIT/0.5 ML



ANTI-XA UNIT/0.6 ML



ANTI-XA UNIT/0.72 ML

1 MO; QL (21.6 per 30 days)


ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA

UNIT/0.2 ML



ANTI-XA UNIT/0.3 ML


heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml (40

unit/ml)

1

heparin (porcine) in 5 % dex intravenous

parenteral solution 25,000 unit/250 ml(100

unit/ml), 25,000 unit/500 ml (50 unit/ml)

1 MO

heparin (porcine) in nacl (pf) intravenous

parenteral solution

1

heparin (porcine) injection cartridge 1 MO

heparin (porcine) injection solution 1 B/D PA; MO




49


HEPARIN(PORCINE) IN 0.45% NACL

INTRAVENOUS PARENTERAL SOLUTION

12,500 UNIT/250 ML

1

heparin(porcine) in 0.45% nacl intravenous

parenteral solution 25,000 unit/250 ml, 25,000

unit/500 ml

1 MO

heparin, porcine (pf) injection solution 1,000

unit/ml

1

heparin, porcine (pf) injection solution 5,000

unit/0.5 ml

1 MO

heparin, porcine (pf) injection syringe 5,000

unit/0.5 ml

1 MO

jantoven oral tablet 1 MO

MULPLETA ORAL TABLET 1 PA; MO; QL (7 per 14 days)

pentoxifylline oral tablet extended release 1 MO

PRADAXA ORAL CAPSULE 1 MO

prasugrel oral tablet 1 MO

PROMACTA ORAL POWDER IN PACKET 1 PA; MO; LA

PROMACTA ORAL TABLET 1 PA; MO; LA

warfarin oral tablet 1 MO

XARELTO DVT-PE TREAT 30D START ORAL

TABLETS,DOSE PACK

1 MO

XARELTO ORAL SUSPENSION FOR

RECONSTITUTION

1 MO

XARELTO ORAL TABLET 1 MO

LIPID/CHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin oral tablet 1 MO; QL (30 per 30 days)

atorvastatin oral tablet 1 MO; QL (45 per 30 days)

cholestyramine (with sugar) oral powder 1 MO

cholestyramine (with sugar) oral powder in packet 1 MO

cholestyramine light oral powder 1

cholestyramine light oral powder in packet 1

cholestyramine-aspartame oral powder in packet 1

colesevelam oral powder in packet 1 MO

colesevelam oral tablet 1 MO




50


colestipol oral granules 1 MO

colestipol oral packet 1 MO

colestipol oral tablet 1 MO

ezetimibe oral tablet 1 MO; QL (30 per 30 days)

ezetimibe-simvastatin oral tablet 1 MO; QL (30 per 30 days)

fenofibrate micronized oral capsule 130 mg, 134

mg, 200 mg, 43 mg, 67 mg

1 MO

fenofibrate nanocrystallized oral tablet 145 mg, 48

mg

1 MO

fenofibrate oral tablet 160 mg, 54 mg 1 MO

fenofibric acid (choline) oral capsule,delayed

release(dr/ec)

1 MO

fenofibric acid oral tablet 1 MO

gemfibrozil oral tablet 1 MO

icosapent ethyl oral capsule 1 MO; QL (120 per 30 days)

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30

MG, 5 MG

1 PA; MO; LA

lovastatin oral tablet 10 mg, 20 mg 1 MO; QL (45 per 30 days)

lovastatin oral tablet 40 mg 1 MO; QL (60 per 30 days)

niacin oral tablet extended release 24 hr 1 MO

omega-3 acid ethyl esters oral capsule 1 MO

PRALUENT SUBCUTANEOUS PEN

INJECTOR 150 MG/ML


PRALUENT SUBCUTANEOUS PEN

INJECTOR 75 MG/ML


pravastatin oral tablet 1 MO; QL (45 per 30 days)

prevalite oral powder 1 MO

prevalite oral powder in packet 1 MO

REPATHA PUSHTRONEX SUBCUTANEOUS

WEARABLE INJECTOR

1 PA; QL (3.5 per 28 days)

REPATHA SUBCUTANEOUS SYRINGE 1 PA; QL (3 per 28 days)

REPATHA SURECLICK SUBCUTANEOUS

PEN INJECTOR


rosuvastatin oral tablet 1 MO; QL (30 per 30 days)

simvastatin oral tablet 1 MO; QL (30 per 30 days)




51


VASCEPA ORAL CAPSULE 0.5 GRAM 1 MO; QL (240 per 30 days)

VASCEPA ORAL CAPSULE 1 GRAM 1 MO; QL (120 per 30 days)

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL SOLUTION 1 PA

CORLANOR ORAL TABLET 1 PA; MO

digitek oral tablet 125 mcg (0.125 mg) 1 MO

digitek oral tablet 250 mcg (0.25 mg) 1 PA; MO

digox oral tablet 125 mcg (0.125 mg) 1 MO

digox oral tablet 250 mcg (0.25 mg) 1 PA; MO

digoxin injection solution 1

digoxin oral solution 1 PA; MO

digoxin oral tablet 125 mcg (0.125 mg) 1 MO

digoxin oral tablet 250 mcg (0.25 mg) 1 PA; MO

digoxin oral tablet 62.5 mcg (0.0625 mg) 1 MO; QL (30 per 30 days)

ENTRESTO ORAL TABLET 1 MO

LANOXIN ORAL TABLET 125 MCG (0.125

MG), 62.5 MCG (0.0625 MG)

1 MO

LANOXIN ORAL TABLET 250 MCG (0.25 MG) 1 PA; MO

ranolazine oral tablet extended release 12 hr 1 MO

VECAMYL ORAL TABLET 1

VYNDAMAX ORAL CAPSULE 1 PA; MO; QL (30 per 30 days)

VYNDAQEL ORAL CAPSULE 1 PA; MO; QL (120 per 30 days)

NITRATES

isosorbide dinitrate oral tablet 1 MO

isosorbide mononitrate oral tablet 1 MO

isosorbide mononitrate oral tablet extended

release 24 hr

1 MO

nitro-bid transdermal ointment 1 MO

nitroglycerin intravenous solution 1 B/D PA

nitroglycerin sublingual tablet 1 MO

nitroglycerin transdermal patch 24 hour 1 MO

nitroglycerin translingual spray,non-aerosol 1 MO

DERMATOLOGICALS/TOPICAL THERAPY




52


ANTIPSORIATIC / ANTISEBORRHEIC

acitretin oral capsule 1 MO

calcipotriene scalp solution 1 MO; QL (60 per 30 days)

calcipotriene topical cream 1 MO; QL (120 per 30 days)

calcipotriene topical ointment 1 MO; QL (120 per 30 days)

calcipotriene-betamethasone topical ointment 1 MO

calcitriol topical ointment 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS

SYRINGE


COSENTYX (2 PENS) SUBCUTANEOUS PEN

INJECTOR


COSENTYX SUBCUTANEOUS PEN

INJECTOR


COSENTYX SUBCUTANEOUS SYRINGE 150

MG/ML


COSENTYX SUBCUTANEOUS SYRINGE 75

MG/0.5 ML


selenium sulfide topical lotion 1 MO

SKYRIZI SUBCUTANEOUS PEN INJECTOR 1 PA; MO; QL (2 per 30 days)

SKYRIZI SUBCUTANEOUS SYRINGE 150

MG/ML


SKYRIZI SUBCUTANEOUS SYRINGE KIT 1 PA; MO; QL (1 per 84 days)

STELARA SUBCUTANEOUS SOLUTION 1 PA; MO; QL (1 per 84 days)

STELARA SUBCUTANEOUS SYRINGE 45

MG/0.5 ML


STELARA SUBCUTANEOUS SYRINGE 90

MG/ML


MISCELLANEOUS DERMATOLOGICALS

ammonium lactate topical cream 1 MO

ammonium lactate topical lotion 1 MO

diclofenac sodium topical gel 3 % 1 PA; MO; QL (100 per 30 days)

DUPIXENT SUBCUTANEOUS PEN INJECTOR 1 PA; MO

DUPIXENT SUBCUTANEOUS SYRINGE 1 PA; MO

fluorouracil topical cream 5 % 1 MO

fluorouracil topical solution 1 MO




53


imiquimod topical cream in packet 5 % 1 MO

lidocaine (pf) injection solution 1

lidocaine hcl injection solution 1

lidocaine hcl laryngotracheal solution 1 MO

lidocaine hcl mucous membrane jelly 1 MO

lidocaine hcl mucous membrane jelly in applicator 1 MO

lidocaine hcl mucous membrane solution 2 % 1

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

1 MO

lidocaine topical adhesive patch,medicated 5 % 1 PA; MO; QL (90 per 30 days)

lidocaine topical ointment 1 MO; QL (50 per 30 days)

lidocaine viscous mucous membrane solution 1 MO

lidocaine-prilocaine topical cream 1 MO; QL (30 per 30 days)

methoxsalen oral capsule, liquid-filled, rapid

release

1 MO

PANRETIN TOPICAL GEL 1 PA; MO

pimecrolimus topical cream 1 ST; MO

podofilox topical solution 1 MO

REGRANEX TOPICAL GEL 1 PA; MO; QL (30 per 30 days)

SANTYL TOPICAL OINTMENT 1 MO

silver sulfadiazine topical cream 1 MO

ssd topical cream 1 MO

tacrolimus topical ointment 1 MO

VALCHLOR TOPICAL GEL 1 PA; MO

THERAPY FOR ACNE

adapalene topical cream 1 PA; MO

adapalene topical gel 1 PA; MO

adapalene topical gel with pump 1 PA; MO

adapalene topical solution 1 PA

amnesteem oral capsule 1

claravis oral capsule 1

clindamycin phosphate topical foam 1

clindamycin phosphate topical gel 1 MO




54


clindamycin phosphate topical gel, once daily 1 MO

clindamycin phosphate topical lotion 1 MO

clindamycin phosphate topical solution 1 MO

clindamycin phosphate topical swab 1 MO

clindamycin-benzoyl peroxide topical gel 1 MO

clindamycin-benzoyl peroxide topical gel with

pump 1-5 %

1 MO

ery pads topical swab 1 MO

erythromycin with ethanol topical gel 1 MO

erythromycin with ethanol topical solution 1 MO

erythromycin-benzoyl peroxide topical gel 1 MO

metronidazole topical cream 1 MO

metronidazole topical gel 1 MO

metronidazole topical gel with pump 1 MO

metronidazole topical lotion 1 MO

tazarotene topical cream 1 MO

tretinoin microspheres topical gel 1 PA; MO

tretinoin microspheres topical gel with pump 1 PA; MO

tretinoin topical cream 1 PA; MO

tretinoin topical gel 0.01 %, 0.025 % 1 PA; MO

TOPICAL ANTIBACTERIALS

gentamicin topical cream 1 MO

gentamicin topical ointment 1 MO

mupirocin topical ointment 1 MO

sulfacetamide sodium (acne) topical suspension 1 MO

SULFAMYLON TOPICAL CREAM 1 MO

TOPICAL ANTIFUNGALS

ciclopirox topical cream 1 MO

ciclopirox topical gel 1 MO

ciclopirox topical shampoo 1 MO

ciclopirox topical solution 1 MO

ciclopirox topical suspension 1 MO

clotrimazole topical cream 1 MO




55


clotrimazole-betamethasone topical cream 1 MO

clotrimazole-betamethasone topical lotion 1 MO

econazole topical cream 1 MO

ketoconazole topical cream 1 MO

ketoconazole topical shampoo 1 MO

nyamyc topical powder 1 MO

nystatin topical cream 1 MO

nystatin topical ointment 1 MO

nystatin topical powder 1

nystatin-triamcinolone topical cream 1 MO

nystatin-triamcinolone topical ointment 1 MO

nystop topical powder 1 MO

TOPICAL ANTIVIRALS

acyclovir topical ointment 1 MO

DENAVIR TOPICAL CREAM 1 MO; QL (5 per 30 days)

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 % 1 MO

ala-cort topical cream 2.5 % 1

alclometasone topical cream 1 MO

alclometasone topical ointment 1 MO

amcinonide topical cream 1 MO

amcinonide topical lotion 1 MO

amcinonide topical ointment 1

betamethasone dipropionate topical cream 1 MO

betamethasone dipropionate topical lotion 1 MO

betamethasone dipropionate topical ointment 1 MO

betamethasone valerate topical cream 1 MO

betamethasone valerate topical foam 1 MO

betamethasone valerate topical lotion 1 MO

betamethasone valerate topical ointment 1 MO

betamethasone, augmented topical cream 1 MO

betamethasone, augmented topical gel 1 MO




56


betamethasone, augmented topical lotion 1 MO

desoximetasone topical cream 1 MO

desoximetasone topical gel 1 MO

desoximetasone topical ointment 1 MO

fluocinolone and shower cap scalp oil 1 MO

fluocinolone topical oil 1 MO

fluocinolone topical ointment 1 MO

fluocinolone topical solution 1 MO

fluticasone propionate topical cream 1 MO

fluticasone propionate topical lotion 1 MO

fluticasone propionate topical ointment 1 MO

hydrocortisone butyrate topical cream 1 MO

hydrocortisone butyrate topical ointment 1 MO

hydrocortisone butyrate topical solution 1 MO

hydrocortisone butyr-emollient topical cream 1 MO

hydrocortisone topical cream 1 %, 2.5 % 1 MO

hydrocortisone topical lotion 2.5 % 1 MO

hydrocortisone topical ointment 2.5 % 1 MO

hydrocortisone valerate topical cream 1 MO

hydrocortisone valerate topical ointment 1 MO

mometasone topical cream 1 MO

mometasone topical ointment 1 MO

mometasone topical solution 1 MO

prednicarbate topical ointment 1 MO

triamcinolone acetonide topical aerosol 1 MO

triamcinolone acetonide topical cream 1 MO

triamcinolone acetonide topical lotion 1 MO

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

1 MO

triderm topical cream 0.1 % 1 MO

TOPICAL SCABICIDES / PEDICULICIDES

lindane topical shampoo 1 MO

malathion topical lotion 1 MO




57


permethrin topical cream 1 MO

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

neomycin-polymyxin b gu irrigation solution 1 MO

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec) 1 MO

anagrelide oral capsule 1 MO

ARALAST NP INTRAVENOUS RECON SOLN 1 B/D PA; MO; LA

AURYXIA ORAL TABLET 1 PA; MO

cevimeline oral capsule 1 MO

CHEMET ORAL CAPSULE 1

CLINIMIX 4.25%/D5W SULFITE FREE


1 B/D PA

CLINIMIX E 2.75%/D5W SULFITE FREE


1 B/D PA

d10 %-0.45 % sodium chloride intravenous

parenteral solution

1 MO

d2.5 %-0.45 % sodium chloride intravenous

parenteral solution

1 B/D PA

d5 % and 0.9 % sodium chloride intravenous

parenteral solution

1 MO

d5 %-0.45 % sodium chloride intravenous

parenteral solution

1 MO

deferasirox oral tablet, dispersible 1 MO

deferiprone oral tablet 1 PA; MO

dextrose 10 % and 0.2 % nacl intravenous

parenteral solution

1 B/D PA

dextrose 10 % in water (d10w) intravenous

parenteral solution

1 B/D PA


syringe

1 B/D PA


parenteral solution

1 MO


piggyback

1 B/D PA; MO




58


dextrose 5 %-lactated ringers intravenous

parenteral solution

1 B/D PA; MO

dextrose 5%-0.2 % sod chloride intravenous

parenteral solution

1

dextrose 5%-0.3 % sod.chloride intravenous

parenteral solution

1 B/D PA


parenteral solution

1 B/D PA; MO


syringe

1 B/D PA; MO


parenteral solution

1 B/D PA

disulfiram oral tablet 250 mg 1 MO

disulfiram oral tablet 500 mg 1

droxidopa oral capsule 1 PA; MO

EMPAVELI SUBCUTANEOUS SOLUTION 1 B/D PA

ENDARI ORAL POWDER IN PACKET 1 PA; MO; LA; QL (180 per 30 days)

FERRIPROX (2 TIMES A DAY) ORAL

TABLET

1 PA

FERRIPROX ORAL TABLET 1 PA

INCRELEX SUBCUTANEOUS SOLUTION 1 B/D PA; MO; LA

lanthanum oral tablet,chewable 1 MO

levocarnitine (with sugar) oral solution 1 B/D PA; MO

levocarnitine oral solution 100 mg/ml 1 B/D PA; MO

levocarnitine oral tablet 1 B/D PA; MO

midodrine oral tablet 1 MO

NORTHERA ORAL CAPSULE 1 PA; MO

pilocarpine hcl oral tablet 1 MO

RAVICTI ORAL LIQUID 1 PA; MO

riluzole oral tablet 1 MO

risedronate oral tablet 30 mg 1 MO

sevelamer carbonate oral powder in packet 1 MO

sevelamer carbonate oral tablet 1 MO

sodium chloride 0.9 % intravenous parenteral

solution

1 MO




59


sodium chloride 0.9 % intravenous piggyback 1 MO

sodium chloride irrigation solution 1 MO

sodium polystyrene sulfonate oral powder 1 MO

sps (with sorbitol) oral suspension 1 MO

sps (with sorbitol) rectal enema 1

TAVNEOS ORAL CAPSULE 1 PA; LA

trientine oral capsule 1 PA; MO

zoledronic acid-mannitol-water intravenous


1 MO

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended

release 12 hr

1 MO

CHANTIX CONTINUING MONTH BOX ORAL

TABLET

1 MO

CHANTIX ORAL TABLET 1 MO

CHANTIX STARTING MONTH BOX ORAL

TABLETS,DOSE PACK

1 MO

NICOTROL INHALATION CARTRIDGE 1 MO

NICOTROL NS NASAL SPRAY,NON-

AEROSOL

1 MO

varenicline oral tablet 1 MO

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal spray, aerosol 1 MO; QL (60 per 30 days)

azelastine nasal spray,non-aerosol 1 MO; QL (60 per 30 days)

chlorhexidine gluconate mucous membrane

mouthwash

1 MO

denta 5000 plus dental cream 1 MO

dentagel dental gel 1 MO

ipratropium bromide nasal spray,non-aerosol 21

mcg (0.03 %)


ipratropium bromide nasal spray,non-aerosol 42

mcg (0.06 %)


olopatadine nasal spray,non-aerosol 1 MO; QL (30.5 per 30 days)




60


periogard mucous membrane mouthwash 1 MO

sf 5000 plus dental cream 1 MO

sf dental gel 1 MO

triamcinolone acetonide dental paste 1 MO

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution 1 MO

fluocinolone acetonide oil otic (ear) drops 1 MO

hydrocortisone-acetic acid otic (ear) drops 1 MO

ofloxacin otic (ear) drops 1 MO

OTIC STEROID / ANTIBIOTIC

ciprofloxacin-dexamethasone otic (ear)

drops,suspension

1 MO

neomycin-polymyxin-hc otic (ear)

drops,suspension

1 MO

neomycin-polymyxin-hc otic (ear) solution 1 MO

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR INJECTION GEL 1 PA; MO

dexamethasone intensol oral drops 1 MO

dexamethasone oral elixir 1 MO

dexamethasone oral solution 1 MO

dexamethasone oral tablet 1 MO

dexamethasone sodium phos (pf) injection solution 1 MO

dexamethasone sodium phosphate injection

solution

1 B/D PA; MO

dexamethasone sodium phosphate injection

syringe

1 B/D PA; MO

fludrocortisone oral tablet 1 MO

HEMADY ORAL TABLET 1 PA; MO

hydrocortisone oral tablet 1 MO

KENALOG INJECTION SUSPENSION 1 MO

methylprednisolone acetate injection suspension 1 B/D PA; MO

methylprednisolone oral tablet 1 MO




61


methylprednisolone oral tablets,dose pack 1 MO

methylprednisolone sodium succ injection recon

soln 125 mg, 40 mg

1 B/D PA; MO

methylprednisolone sodium succ intravenous

recon soln 1,000 mg

1 B/D PA; MO

millipred oral tablet 1 MO

prednisolone oral solution 1 MO

prednisolone sodium phosphate oral solution 10

mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4

mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7

mg/5 ml)

1 MO

prednisolone sodium phosphate oral solution 15

mg/5 ml (5 ml)

1

prednisolone sodium phosphate oral

tablet,disintegrating

1 MO

prednisone intensol oral concentrate 1 MO

prednisone oral solution 1 MO

prednisone oral tablet 1 MO

prednisone oral tablets,dose pack 1 MO

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION

RECON SOLN 1,000 MG/8 ML, 250 MG/2 ML,

500 MG/4 ML

1 B/D PA; MO

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION

RECON SOLN 100 MG/2 ML

1 MO

triamcinolone acetonide injection suspension 40

mg/ml

1 MO

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1 MO

propylthiouracil oral tablet 1 MO

DIABETES THERAPY

acarbose oral tablet 1 MO

alcohol pads topical pads, medicated 1 MO

BASAGLAR KWIKPEN U-100 INSULIN

SUBCUTANEOUS PEN

1 MO

BYDUREON BCISE SUBCUTANEOUS AUTO-

INJECTOR





62


BYETTA SUBCUTANEOUS PEN INJECTOR

10 MCG/DOSE(250 MCG/ML) 2.4 ML


BYETTA SUBCUTANEOUS PEN INJECTOR 5

MCG/DOSE (250 MCG/ML) 1.2 ML


CYCLOSET ORAL TABLET 1 ST; MO

diazoxide oral suspension 1 MO

FARXIGA ORAL TABLET 1 MO; QL (30 per 30 days)

FIASP FLEXTOUCH U-100 INSULIN

SUBCUTANEOUS PEN

1 MO

FIASP PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE

1 MO

FIASP U-100 INSULIN SUBCUTANEOUS

SOLUTION

1 MO

GAUZE PADS 2 X 2 1 MO

glimepiride oral tablet 1 MO

glipizide oral tablet 1 MO

glipizide oral tablet extended release 24hr 1 MO

glipizide-metformin oral tablet 2.5-250 mg, 2.5-

500 mg


glipizide-metformin oral tablet 5-500 mg 1 MO; QL (120 per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON

SOLN

1 MO

GLUCAGON (HCL) EMERGENCY KIT

INJECTION RECON SOLN

1

GLUCAGON EMERGENCY KIT (HUMAN)

INJECTION RECON SOLN

1 MO

glyburide micronized oral tablet 1 ST; MO

glyburide oral tablet 1 ST; MO

glyburide-metformin oral tablet 1 ST; MO

GVOKE HYPOPEN 1-PACK SUBCUTANEOUS

AUTO-INJECTOR

1 MO

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS

AUTO-INJECTOR

1 MO

GVOKE PFS 1-PACK SUBCUTANEOUS

SYRINGE

1 MO




63


GVOKE PFS 2-PACK SUBCUTANEOUS

SYRINGE

1 MO

GVOKE SUBCUTANEOUS SOLUTION 1

JANUMET ORAL TABLET 1 MO; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER

MULTIPHASE 24 HR


JANUVIA ORAL TABLET 1 MO; QL (30 per 30 days)

JARDIANCE ORAL TABLET 1 MO

KOMBIGLYZE XR ORAL TABLET, ER

MULTIPHASE 24 HR


LANTUS SOLOSTAR U-100 INSULIN

SUBCUTANEOUS PEN

1 MO

LANTUS U-100 INSULIN SUBCUTANEOUS

SOLUTION

1 MO

LEVEMIR FLEXTOUCH U-100 INSULN

SUBCUTANEOUS INSULIN PEN

1 MO

LEVEMIR U-100 INSULIN SUBCUTANEOUS

SOLUTION

1 MO

metformin oral tablet 1 MO

metformin oral tablet extended release 24 hr 500

mg


metformin oral tablet extended release 24 hr 750

mg


nateglinide oral tablet 1 MO

NOVOFINE NEEDLE 1 MO

NOVOLIN 70/30 U-100 INSULIN

SUBCUTANEOUS SUSPENSION

1 MO

NOVOLIN 70-30 FLEXPEN U-100


1 MO

NOVOLIN N FLEXPEN SUBCUTANEOUS

INSULIN PEN

1 MO

NOVOLIN N NPH U-100 INSULIN

SUBCUTANEOUS SUSPENSION

1 MO

NOVOLIN R FLEXPEN SUBCUTANEOUS

INSULIN PEN

1 MO

NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION

1 MO




64


NOVOLOG FLEXPEN U-100 INSULIN

SUBCUTANEOUS PEN

1 MO

NOVOLOG MIX 70-30 U-100 INSULN

SUBCUTANEOUS SOLUTION

1 MO

NOVOLOG MIX 70-30FLEXPEN U-100


1 MO

NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE

1 MO

NOVOLOG U-100 INSULIN ASPART

SUBCUTANEOUS SOLUTION

1 MO

NOVOTWIST NEEDLE 1 MO

ONGLYZA ORAL TABLET 1 MO; QL (30 per 30 days)

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG(2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1

MG/DOSE (2 MG/1.5 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1

MG/DOSE (4 MG/3 ML)


pioglitazone oral tablet 1 MO

pioglitazone-glimepiride oral tablet 1 MO; QL (30 per 30 days)

pioglitazone-metformin oral tablet 1 MO; QL (90 per 30 days)

repaglinide oral tablet 0.5 mg 1 MO; QL (930 per 30 days)

repaglinide oral tablet 1 mg 1 MO; QL (480 per 30 days)

repaglinide oral tablet 2 mg 1 MO; QL (240 per 30 days)

RYBELSUS ORAL TABLET 1 MO; QL (30 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS PEN

INJECTOR

1 MO

SYMLINPEN 60 SUBCUTANEOUS PEN

INJECTOR

1 MO

SYNJARDY ORAL TABLET 1 MO; QL (60 per 30 days)

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG


SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG


TOUJEO MAX U-300 SOLOSTAR


1 MO




65


TOUJEO SOLOSTAR U-300 INSULIN

SUBCUTANEOUS PEN

1 MO

TRESIBA FLEXTOUCH U-100


1 MO

TRESIBA FLEXTOUCH U-200


1 MO

TRESIBA U-100 INSULIN SUBCUTANEOUS

SOLUTION

1 MO

TRULICITY SUBCUTANEOUS PEN

INJECTOR 0.75 MG/0.5 ML


TRULICITY SUBCUTANEOUS PEN

INJECTOR 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5

MG/0.5 ML


VICTOZA 2-PAK SUBCUTANEOUS PEN

INJECTOR


VICTOZA 3-PAK SUBCUTANEOUS PEN

INJECTOR


XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-

500 MG


XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG


MISCELLANEOUS HORMONES

ALDURAZYME INTRAVENOUS SOLUTION 1 MO

cabergoline oral tablet 1 MO; QL (20 per 30 days)

calcitonin (salmon) injection solution 1 B/D PA; MO

calcitonin (salmon) nasal spray,non-aerosol 1 MO

calcitriol intravenous solution 1 mcg/ml 1

calcitriol oral capsule 1 B/D PA; MO

calcitriol oral solution 1 B/D PA

CEREZYME INTRAVENOUS RECON SOLN

400 UNIT

1 MO

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR RECON SOLN

1 PA; MO

cinacalcet oral tablet 30 mg 1 B/D PA; MO; QL (60 per 30 days)





66



danazol oral capsule 1 MO

desmopressin injection solution 1 MO

desmopressin nasal spray with pump 1 MO

desmopressin nasal spray,non-aerosol 10

mcg/spray (0.1 ml)

1

desmopressin oral tablet 1 MO

ELAPRASE INTRAVENOUS SOLUTION 1 MO

ELELYSO INTRAVENOUS RECON SOLN 1 MO

FABRAZYME INTRAVENOUS RECON SOLN 1 PA; MO

GALAFOLD ORAL CAPSULE 1 PA; MO; QL (15 per 30 days)

JYNARQUE ORAL TABLET 1 PA; LA

JYNARQUE ORAL TABLETS, SEQUENTIAL 1 PA; LA; QL (56 per 28 days)

KORLYM ORAL TABLET 1 PA

KUVAN ORAL TABLET,SOLUBLE 1 PA; MO

methyltestosterone oral capsule 1 MO

MIACALCIN INJECTION SOLUTION 1 B/D PA; MO

miglustat oral capsule 1 PA; MO; LA

NAGLAZYME INTRAVENOUS SOLUTION 1 MO

NATPARA SUBCUTANEOUS CARTRIDGE 1 PA; MO; LA

NEXVIAZYME INTRAVENOUS RECON

SOLN

1 PA; MO

NOVAREL INTRAMUSCULAR RECON SOLN

10,000 UNIT

1 PA; MO

ORILISSA ORAL TABLET 1 PA; MO

oxandrolone oral tablet 10 mg 1 MO

oxandrolone oral tablet 2.5 mg 1 MO

pamidronate intravenous solution 1 B/D PA; MO

PARICALCITOL HEMODIALYSIS PORT

INJECTION SOLUTION

1 B/D PA

paricalcitol intravenous solution 2 mcg/ml 1 B/D PA

paricalcitol intravenous solution 5 mcg/ml 1 B/D PA; MO

paricalcitol oral capsule 1 B/D PA; MO

PREGNYL INTRAMUSCULAR RECON SOLN 1 PA; MO




67


sapropterin oral tablet,soluble 1 PA; MO

SOMAVERT SUBCUTANEOUS RECON SOLN 1 B/D PA; MO

SYNAREL NASAL SPRAY,NON-AEROSOL 1 MO

testosterone cypionate intramuscular oil 100

mg/ml, 200 mg/ml, 200 mg/ml (1 ml)

1 MO

testosterone enanthate intramuscular oil 1 MO

testosterone transdermal gel in metered-dose

pump 20.25 mg/1.25 gram (1.62 %)

1 MO

testosterone transdermal gel in packet 1.62 %

(20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)

1 MO

TOLVAPTAN ORAL TABLET 15 MG 1 PA; MO

tolvaptan oral tablet 30 mg 1 PA; MO; QL (60 per 30 days)

VPRIV INTRAVENOUS RECON SOLN 1 MO

zoledronic acid intravenous solution 1 B/D PA; MO

zoledronic acid-mannitol-water intravenous


1 B/D PA; MO

THYROID HORMONES

levothyroxine oral tablet 1 MO

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

1 MO

liothyronine intravenous solution 1 MO

liothyronine oral tablet 1 MO

SYNTHROID ORAL TABLET 1 MO

unithroid oral tablet 1 MO

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

atropine injection solution 0.4 mg/ml 1

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1

dicyclomine oral capsule 1 MO

dicyclomine oral solution 1 MO

dicyclomine oral tablet 1 MO

glycopyrrolate injection solution 1 MO

glycopyrrolate oral tablet 1 mg, 2 mg 1 MO




68


loperamide oral capsule 1 MO

methscopolamine oral tablet 1 MO

MISCELLANEOUS GASTROINTESTINAL AGENTS

alosetron oral tablet 1 PA; MO; QL (60 per 30 days)

aprepitant oral capsule 1 B/D PA; MO

aprepitant oral capsule,dose pack 1 B/D PA; MO

balsalazide oral capsule 1 MO

betaine oral powder 1

budesonide oral capsule, delayed, extended

release

1 MO

budesonide oral tablet,delayed and ext.release 1 QL (30 per 30 days)

CHOLBAM ORAL CAPSULE 1 PA

compro rectal suppository 1 MO

constulose oral solution 1 MO

cromolyn oral concentrate 1 MO

CYSTADANE ORAL POWDER 1

dronabinol oral capsule 1 B/D PA; MO

EMEND ORAL SUSPENSION FOR

RECONSTITUTION

1 B/D PA

enulose oral solution 1 MO

GATTEX 30-VIAL SUBCUTANEOUS KIT 1 PA; MO

GATTEX ONE-VIAL SUBCUTANEOUS KIT 1 PA; MO

gavilyte-c oral recon soln 1 MO

gavilyte-g oral recon soln 1 MO

gavilyte-n oral recon soln 1 MO

generlac oral solution 1 MO

granisetron (pf) intravenous solution 1 mg/ml (1

ml)

1 MO

granisetron hcl intravenous solution 1 MO

granisetron hcl oral tablet 1 B/D PA; MO

hydrocortisone rectal enema 1 MO

hydrocortisone topical cream with perineal

applicator

1 MO




69


lactulose oral solution 10 gram/15 ml 1 MO

lactulose oral solution 10 gram/15 ml (15 ml), 20

gram/30 ml

1

LINZESS ORAL CAPSULE 1 MO; QL (30 per 30 days)

LIVMARLI ORAL SOLUTION 1 PA; LA

LUBIPROSTONE ORAL CAPSULE 1 ST; MO; QL (60 per 30 days)

meclizine oral tablet 12.5 mg, 25 mg 1 MO

mesalamine oral capsule (with del rel tablets) 1 MO

mesalamine oral capsule,extended release 24hr 1 MO

mesalamine oral tablet,delayed release (dr/ec) 1.2

gram

1 MO

mesalamine rectal enema 1 MO

mesalamine rectal suppository 1 MO

mesalamine with cleansing wipe rectal enema kit 1 MO

metoclopramide hcl injection solution 1 B/D PA; MO

metoclopramide hcl injection syringe 1 B/D PA

metoclopramide hcl oral solution 1 MO

metoclopramide hcl oral tablet 1 MO

MOVANTIK ORAL TABLET 1 MO

MOVIPREP ORAL POWDER IN PACKET 1 MO

ondansetron hcl (pf) injection solution 1 MO

ondansetron hcl (pf) injection syringe 1 MO

ondansetron hcl intravenous solution 1 MO

ondansetron hcl oral solution 1 B/D PA; MO

ondansetron hcl oral tablet 24 mg 1 B/D PA

ondansetron hcl oral tablet 4 mg, 8 mg 1 B/D PA; MO

ondansetron oral tablet,disintegrating 1 B/D PA; MO

PANCREAZE ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT,

16,800-56,800- 98,400 UNIT, 2,600-8,800- 15,200

UNIT, 21,000-54,700- 83,900 UNIT, 37,000-

97,300- 149,900 UNIT, 4,200-14,200- 24,600

UNIT

1 MO

peg 3350-electrolytes oral recon soln 236-22.74-

6.74 -5.86 gram

1 MO




70


peg-electrolyte oral recon soln 1 MO

prochlorperazine edisylate injection solution 10

mg/2 ml (5 mg/ml)

1 MO

prochlorperazine maleate oral tablet 1 MO

prochlorperazine rectal suppository 1 MO

procto-pak topical cream with perineal applicator 1 MO

proctosol hc topical cream with perineal

applicator

1 MO

proctozone-hc topical cream with perineal

applicator

1 MO

RECTIV RECTAL OINTMENT 1 MO; QL (30 per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION 1 MO

RELISTOR SUBCUTANEOUS SYRINGE 1 MO

REMICADE INTRAVENOUS RECON SOLN 1 PA; MO

SANCUSO TRANSDERMAL PATCH WEEKLY 1 MO; QL (2 per 15 days)

scopolamine base transdermal patch 3 day 1 MO; QL (10 per 30 days)

sulfasalazine oral tablet 1 MO

sulfasalazine oral tablet,delayed release (dr/ec) 1 MO

TRULANCE ORAL TABLET 1 MO; QL (30 per 30 days)

ursodiol oral capsule 300 mg 1 MO

ursodiol oral tablet 1 MO

VARUBI ORAL TABLET 1 B/D PA

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT, 20,000-63,000-

84,000 UNIT, 25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT, 40,000-126,000-

168,000 UNIT, 5,000-17,000- 24,000 UNIT

1 MO

ULCER THERAPY

amoxicillin-clarithromycin-lansoprazole oral

combo pack

1 MO

cimetidine hcl oral solution 1 MO

cimetidine oral tablet 1 MO

esomeprazole sodium intravenous recon soln 40

mg

1 B/D PA




71


famotidine (pf) intravenous solution 1 MO

famotidine (pf)-nacl (iso-osm) intravenous

piggyback

1 B/D PA; MO

famotidine intravenous solution 1 B/D PA; MO

famotidine oral suspension 1 MO

famotidine oral tablet 20 mg, 40 mg 1 MO

lansoprazole oral capsule,delayed release(dr/ec) 1 MO

misoprostol oral tablet 1 MO

nizatidine oral capsule 1

nizatidine oral solution 1 MO

omeprazole oral capsule,delayed release(dr/ec) 1 MO

pantoprazole oral tablet,delayed release (dr/ec) 1 MO

sucralfate oral suspension 1 MO

sucralfate oral tablet 1 MO

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE SUBCUTANEOUS SOLUTION 1 PA; MO

ARCALYST SUBCUTANEOUS RECON SOLN 1 PA; MO

AVONEX INTRAMUSCULAR PEN INJECTOR

KIT

1 MO

AVONEX INTRAMUSCULAR SYRINGE KIT 1 MO

BESREMI SUBCUTANEOUS SYRINGE 1 PA; LA

BETASERON SUBCUTANEOUS KIT 1 MO

EGRIFTA SV SUBCUTANEOUS RECON SOLN 1 PA; MO

EXTAVIA SUBCUTANEOUS KIT 1 MO

EXTAVIA SUBCUTANEOUS RECON SOLN 1

GRANIX SUBCUTANEOUS SOLUTION 1 PA; MO

GRANIX SUBCUTANEOUS SYRINGE 1 PA; MO

INTRON A INJECTION RECON SOLN 1 B/D PA; MO

LEUKINE INJECTION RECON SOLN 1 PA; MO

MOZOBIL SUBCUTANEOUS SOLUTION 1 B/D PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS

PEN INJECTOR

1 PA; MO




72


PEGASYS SUBCUTANEOUS SOLUTION 1 MO; QL (4 per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE 1 MO; QL (2 per 28 days)

PLEGRIDY INTRAMUSCULAR SYRINGE 1 MO

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 1 MO

PLEGRIDY SUBCUTANEOUS SYRINGE 1 MO

PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML



UNIT/2 ML

1 B/D PA; MO


UNIT/ML



UNIT/ML


REBIF (WITH ALBUMIN) SUBCUTANEOUS

SYRINGE

1 MO

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR

1 MO

REBIF TITRATION PACK SUBCUTANEOUS

SYRINGE

1 MO

RETACRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML



UNIT/2 ML



UNIT/ML



UNIT/ML


ZARXIO INJECTION SYRINGE 1 PA; MO

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON

SOLN

1 MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SUSPENSION

1 MO

ADACEL(TDAP ADOLESN/ADULT)(PF)

INTRAMUSCULAR SYRINGE

1 MO




73


BCG VACCINE, LIVE (PF) PERCUTANEOUS


1 MO

BEXSERO INTRAMUSCULAR SYRINGE 1 MO

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION

1 MO

BOOSTRIX TDAP INTRAMUSCULAR

SYRINGE

1 MO

DAPTACEL (DTAP PEDIATRIC) (PF)


1 MO

DENGVAXIA (PF) SUBCUTANEOUS


1

ENGERIX-B (PF) INTRAMUSCULAR

SUSPENSION

1 B/D PA; MO

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

1 B/D PA; MO

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE

1 B/D PA; MO

fomepizole intravenous solution 1 B/D PA

GAMMAGARD LIQUID INJECTION

SOLUTION

1 PA; MO

GAMMAGARD S-D (IGA < 1 MCG/ML)

INTRAVENOUS RECON SOLN

1 B/D PA; MO

GAMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %)

1 PA; MO

GAMUNEX-C INJECTION SOLUTION 10

GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10

%), 20 GRAM/200 ML (10 %), 40 GRAM/400

ML (10 %), 5 GRAM/50 ML (10 %)

1 B/D PA; MO

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION

1 MO

GARDASIL 9 (PF) INTRAMUSCULAR

SYRINGE

1 MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1 MO

HIBERIX (PF) INTRAMUSCULAR RECON

SOLN

1 MO

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN

1




74


INFANRIX (DTAP) (PF) INTRAMUSCULAR

SYRINGE

1 MO

IPOL INJECTION SUSPENSION 1

IXIARO (PF) INTRAMUSCULAR SYRINGE 1

KINRIX (PF) INTRAMUSCULAR

SUSPENSION

1

KINRIX (PF) INTRAMUSCULAR SYRINGE 1 MO

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

1 MO

MENQUADFI (PF) INTRAMUSCULAR

SOLUTION

1 MO

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT

1 MO

M-M-R II (PF) SUBCUTANEOUS RECON

SOLN

1 MO

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 1 MO

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION

1

PREHEVBRIO (PF) INTRAMUSCULAR

SUSPENSION

1 B/D PA

PROQUAD (PF) SUBCUTANEOUS


1

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION

1

QUADRACEL (PF) INTRAMUSCULAR

SYRINGE

1

RABAVERT (PF) INTRAMUSCULAR


1 MO

RECOMBIVAX HB (PF) INTRAMUSCULAR

SUSPENSION

1 B/D PA; MO


SYRINGE 10 MCG/ML

1 B/D PA; MO


SYRINGE 5 MCG/0.5 ML

1 B/D PA

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION

1

ROTATEQ VACCINE ORAL SOLUTION 1 MO




75


SHINGRIX (PF) INTRAMUSCULAR


1 MO

STAMARIL (PF) SUBCUTANEOUS


1

TDVAX INTRAMUSCULAR SUSPENSION 1 B/D PA; MO

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION

1 B/D PA; MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE 1 MO

TETANUS,DIPHTHERIA TOX PED(PF)


1 MO

TICOVAC INTRAMUSCULAR SYRINGE 1

TRUMENBA INTRAMUSCULAR SYRINGE 1 MO

TWINRIX (PF) INTRAMUSCULAR SYRINGE 1 MO

TYPHIM VI INTRAMUSCULAR SOLUTION 1

TYPHIM VI INTRAMUSCULAR SYRINGE 1 MO

VAQTA (PF) INTRAMUSCULAR

SUSPENSION

1 MO

VAQTA (PF) INTRAMUSCULAR SYRINGE 1 MO

VARIVAX (PF) SUBCUTANEOUS


1

VARIZIG INTRAMUSCULAR SOLUTION 1 MO

YF-VAX (PF) SUBCUTANEOUS SUSPENSION

FOR RECONSTITUTION

1

MISCELLANEOUS SUPPLIES

MISCELLANEOUS SUPPLIES

INSULIN PEN NEEDLE 1 MO

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1

ML, 1/2 ML

1 MO

NEEDLES, INSULIN DISP., SAFETY 1 MO

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 1 MO

allopurinol sodium intravenous recon soln 1 B/D PA

febuxostat oral tablet 1 ST; MO




76


MITIGARE ORAL CAPSULE 1 MO

probenecid oral tablet 1 MO

probenecid-colchicine oral tablet 1 MO

OSTEOPOROSIS THERAPY

alendronate oral solution 1 MO; QL (375 per 30 days)

alendronate oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg 1 MO; QL (5 per 30 days)

FORTEO SUBCUTANEOUS PEN INJECTOR 20

MCG/DOSE (600MCG/2.4ML)


ibandronate oral tablet 1 MO; QL (1 per 30 days)

PROLIA SUBCUTANEOUS SYRINGE 1 PA; MO; QL (1 per 180 days)

raloxifene oral tablet 1 MO

risedronate oral tablet 150 mg, 35 mg, 35 mg (12

pack), 35 mg (4 pack), 5 mg

1 MO

risedronate oral tablet,delayed release (dr/ec) 1 MO

TYMLOS SUBCUTANEOUS PEN INJECTOR 1 MO; QL (1.56 per 30 days)

OTHER RHEUMATOLOGICALS

BENLYSTA INTRAVENOUS RECON SOLN

120 MG

1 B/D PA; MO

BENLYSTA INTRAVENOUS RECON SOLN

400 MG

1 MO

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR

1 PA; MO

BENLYSTA SUBCUTANEOUS SYRINGE 1 PA; MO

ENBREL MINI SUBCUTANEOUS

CARTRIDGE


ENBREL SUBCUTANEOUS RECON SOLN 1 PA; MO; QL (8 per 28 days)

ENBREL SUBCUTANEOUS SOLUTION 1 PA; MO; QL (8 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5 ML (0.5)


ENBREL SUBCUTANEOUS SYRINGE 50

MG/ML (1 ML)


ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR





77


HUMIRA PEN CROHNS-UC-HS START

SUBCUTANEOUS INJECTOR KIT


HUMIRA PEN PSOR-UVEITS-ADOL HS



HUMIRA PEN SUBCUTANEOUS INJECTOR

KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT 40

MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8

ML


HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8

ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS



HUMIRA(CF) PEN PEDIATRIC UC

SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA(CF) PEN PSOR-UV-ADOL HS



HUMIRA(CF) SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML


HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE

KIT 10 MG/0.1 ML, 20 MG/0.2 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML


leflunomide oral tablet 1 MO; QL (30 per 30 days)

ORENCIA CLICKJECT SUBCUTANEOUS

AUTO-INJECTOR


ORENCIA SUBCUTANEOUS SYRINGE 125

MG/ML


ORENCIA SUBCUTANEOUS SYRINGE 50

MG/0.4 ML


ORENCIA SUBCUTANEOUS SYRINGE 87.5

MG/0.7 ML


OTEZLA ORAL TABLET 1 PA; MO; QL (60 per 30 days)




78


OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47)


penicillamine oral capsule 1 PA; MO

penicillamine oral tablet 1 PA; MO

RINVOQ ORAL TABLET EXTENDED

RELEASE 24 HR 15 MG, 30 MG


XELJANZ ORAL SOLUTION 1 PA; MO

XELJANZ ORAL TABLET 1 PA; MO; QL (60 per 30 days)

XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HR


OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

camila oral tablet 1 MO

COMBIPATCH TRANSDERMAL PATCH

SEMIWEEKLY

1 MO

CRINONE VAGINAL GEL 1 PA; MO

DEPO-SUBQ PROVERA 104

SUBCUTANEOUS SYRINGE

1 MO

errin oral tablet 1 MO

estradiol oral tablet 1 PA; MO

estradiol transdermal patch semiweekly 1 MO

estradiol transdermal patch weekly 0.025 mg/24

hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24

hr

1 MO

estradiol transdermal patch weekly 0.06 mg/24 hr,

0.1 mg/24 hr

1

estradiol vaginal cream 1 MO

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

1 MO

heather oral tablet 1 MO

hydroxyprogesterone caproate intramuscular oil 1 PA

jencycla oral tablet 1 MO

jinteli oral tablet 1 MO

lyza oral tablet 1

medroxyprogesterone intramuscular suspension 1 MO; QL (1 per 90 days)




79


medroxyprogesterone intramuscular syringe 1 MO; QL (1 per 90 days)

medroxyprogesterone oral tablet 1 MO

norethindrone (contraceptive) oral tablet 1

norethindrone acetate oral tablet 1 MO

PREMARIN INJECTION RECON SOLN 1 B/D PA

PREMARIN VAGINAL CREAM 1 MO

progesterone micronized oral capsule 1 MO

MISCELLANEOUS OB/GYN

CLEOCIN VAGINAL SUPPOSITORY 1 MO

clindamycin phosphate vaginal cream 1 MO

metronidazole vaginal gel 1 MO

miconazole-3 vaginal suppository 1 MO

ORIAHNN ORAL CAPSULE, SEQUENTIAL 1 PA; MO

terconazole vaginal cream 1 MO

terconazole vaginal suppository 1 MO

tranexamic acid oral tablet 1 MO

vandazole vaginal gel 1 MO

ORAL CONTRACEPTIVES / RELATED AGENTS

altavera (28) oral tablet 1 MO

alyacen 1/35 (28) oral tablet 1 MO

alyacen 7/7/7 (28) oral tablet 1 MO

amethia oral tablets,dose pack,3 month 1 MO

amethyst (28) oral tablet 1 MO

apri oral tablet 1 MO

aranelle (28) oral tablet 1 MO

ashlyna oral tablets,dose pack,3 month 1 MO

aubra eq oral tablet 1 MO

aubra oral tablet 1

aviane oral tablet 1 MO

azurette (28) oral tablet 1 MO

balziva (28) oral tablet 1 MO

blisovi 24 fe oral tablet 1 MO




80


blisovi fe 1.5/30 (28) oral tablet 1 MO

blisovi fe 1/20 (28) oral tablet 1 MO

briellyn oral tablet 1 MO

camrese lo oral tablets,dose pack,3 month 1 MO

camrese oral tablets,dose pack,3 month 1 MO

caziant (28) oral tablet 1 MO

chateal (28) oral tablet 1

cryselle (28) oral tablet 1 MO

cyclafem 1/35 (28) oral tablet 1 MO

cyclafem 7/7/7 (28) oral tablet 1 MO

dasetta 1/35 (28) oral tablet 1 MO

dasetta 7/7/7 (28) oral tablet 1 MO

daysee oral tablets,dose pack,3 month 1 MO

desog-e.estradiol/e.estradiol oral tablet 1

drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-

0.451 mg (24) (4)

1

drospirenone-ethinyl estradiol oral tablet 3-0.02

mg

1 MO

drospirenone-ethinyl estradiol oral tablet 3-0.03

mg

1

elinest oral tablet 1 MO

ELLA ORAL TABLET 1

emoquette oral tablet 1 MO

enpresse oral tablet 1 MO

enskyce oral tablet 1 MO

estarylla oral tablet 1 MO

falmina (28) oral tablet 1 MO

introvale oral tablets,dose pack,3 month 1 MO

jolessa oral tablets,dose pack,3 month 1 MO

junel 1.5/30 (21) oral tablet 1 MO

junel 1/20 (21) oral tablet 1 MO

junel fe 1.5/30 (28) oral tablet 1 MO

junel fe 1/20 (28) oral tablet 1 MO




81


junel fe 24 oral tablet 1 MO

kariva (28) oral tablet 1 MO

kelnor 1/35 (28) oral tablet 1 MO

kurvelo (28) oral tablet 1 MO

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),

0.15 mg-30 mcg (84)/10 mcg (7)

1

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

1 MO

larissia oral tablet 1 MO

layolis fe oral tablet,chewable 1 MO

lessina oral tablet 1 MO

levonest (28) oral tablet 1 MO

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg

1 MO

levonorgestrel-ethinyl estrad oral tablet 0.15-0.03

mg, 90-20 mcg (28)

1

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

1 MO

levonorg-eth estrad triphasic oral tablet 1

levora-28 oral tablet 1 MO

loryna (28) oral tablet 1 MO

low-ogestrel (28) oral tablet 1 MO

lutera (28) oral tablet 1 MO

marlissa (28) oral tablet 1 MO

microgestin 1.5/30 (21) oral tablet 1 MO

microgestin 1/20 (21) oral tablet 1 MO

microgestin fe 1.5/30 (28) oral tablet 1 MO

microgestin fe 1/20 (28) oral tablet 1 MO

mono-linyah oral tablet 1 MO

necon 0.5/35 (28) oral tablet 1 MO

nikki (28) oral tablet 1 MO

noreth-ethinyl estradiol-iron oral tablet,chewable 1




82


norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-25 mcg

1

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-35 mcg (28)

1 MO

nortrel 0.5/35 (28) oral tablet 1 MO

nortrel 1/35 (21) oral tablet 1 MO

nortrel 1/35 (28) oral tablet 1 MO

nortrel 7/7/7 (28) oral tablet 1 MO

nylia 1/35 (28) oral tablet 1 MO

nylia 7/7/7 (28) oral tablet 1 MO

ocella oral tablet 1 MO

orsythia oral tablet 1 MO

philith oral tablet 1 MO

pimtrea (28) oral tablet 1 MO

pirmella oral tablet 1 MO

portia 28 oral tablet 1 MO

previfem oral tablet 1 MO

reclipsen (28) oral tablet 1 MO

sprintec (28) oral tablet 1 MO

sronyx oral tablet 1 MO

syeda oral tablet 1 MO

tilia fe oral tablet 1 MO

tri-estarylla oral tablet 1 MO

tri-legest fe oral tablet 1 MO

tri-linyah oral tablet 1 MO

tri-sprintec (28) oral tablet 1 MO

trivora (28) oral tablet 1 MO

TYBLUME ORAL TABLET,CHEWABLE 1 MO

velivet triphasic regimen (28) oral tablet 1 MO

viorele (28) oral tablet 1 MO

wera (28) oral tablet 1 MO

wymzya fe oral tablet,chewable 1 MO

zovia 1-35 (28) oral tablet 1 MO




83


OXYTOCICS

methylergonovine oral tablet 1

OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac ophthalmic (eye) ointment 1 MO

AZASITE OPHTHALMIC (EYE) DROPS 1 MO

bacitracin ophthalmic (eye) ointment 1 MO

bacitracin-polymyxin b ophthalmic (eye) ointment 1 MO

BESIVANCE OPHTHALMIC (EYE)

DROPS,SUSPENSION

1 MO

ciprofloxacin hcl ophthalmic (eye) drops 1 MO

erythromycin ophthalmic (eye) ointment 1 MO

gatifloxacin ophthalmic (eye) drops 1 MO

gentak ophthalmic (eye) ointment 1 MO

gentamicin ophthalmic (eye) drops 1 MO

levofloxacin ophthalmic (eye) drops 0.5 % 1 MO

moxifloxacin ophthalmic (eye) drops 1 MO

moxifloxacin ophthalmic (eye) drops, viscous 1

NATACYN OPHTHALMIC (EYE)

DROPS,SUSPENSION

1

neomycin-bacitracin-polymyxin ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin-gramicidin ophthalmic (eye)

drops

1 MO

neo-polycin ophthalmic (eye) ointment 1 MO

ofloxacin ophthalmic (eye) drops 1 MO

polycin ophthalmic (eye) ointment 1 MO

polymyxin b sulf-trimethoprim ophthalmic (eye)

drops

1 MO

tobramycin ophthalmic (eye) drops 1 MO

ANTIVIRALS

trifluridine ophthalmic (eye) drops 1 MO

ZIRGAN OPHTHALMIC (EYE) GEL 1 MO




84


BETA-BLOCKERS

betaxolol ophthalmic (eye) drops 1 MO

BETIMOL OPHTHALMIC (EYE) DROPS 1 MO

carteolol ophthalmic (eye) drops 1 MO

levobunolol ophthalmic (eye) drops 0.5 % 1 MO

timolol maleate ophthalmic (eye) drops (timoptic

generic)

1 MO

timolol maleate ophthalmic (eye) gel forming

solution (timoptic generic)

1 MO

MISCELLANEOUS OPHTHALMOLOGICS

azelastine ophthalmic (eye) drops 1 MO

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)

OINTMENT

1 MO

cromolyn ophthalmic (eye) drops 1 MO

CYSTARAN OPHTHALMIC (EYE) DROPS 1

epinastine ophthalmic (eye) drops 1 MO

olopatadine ophthalmic (eye) drops 0.1 % 1 MO

olopatadine ophthalmic (eye) drops 0.2 % 1 MO

OXERVATE OPHTHALMIC (EYE) DROPS 1 PA; MO; QL (112 per 365 days)

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

1 MO

RESTASIS MULTIDOSE OPHTHALMIC (EYE)

DROPS


RESTASIS OPHTHALMIC (EYE)

DROPPERETTE


sulfacetamide sodium ophthalmic (eye) drops 1 MO

sulfacetamide sodium ophthalmic (eye) ointment 1 MO

sulfacetamide-prednisolone ophthalmic (eye)

drops

1 MO

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

diclofenac sodium ophthalmic (eye) drops 1 MO

flurbiprofen sodium ophthalmic (eye) drops 1 MO

ILEVRO OPHTHALMIC (EYE)

DROPS,SUSPENSION

1 MO

ketorolac ophthalmic (eye) drops 1 MO




85


PROLENSA OPHTHALMIC (EYE) DROPS 1 MO

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule, extended release 1 MO

acetazolamide oral tablet 1 MO

acetazolamide sodium injection recon soln 1 MO

methazolamide oral tablet 1 MO

OTHER GLAUCOMA DRUGS

brimonidine-timolol ophthalmic (eye) drops 1 MO

COMBIGAN OPHTHALMIC (EYE) DROPS 1 MO

dorzolamide ophthalmic (eye) drops 1 MO

dorzolamide-timolol ophthalmic (eye) drops 1 MO

latanoprost ophthalmic (eye) drops 1 MO

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%


RHOPRESSA OPHTHALMIC (EYE) DROPS 1 MO

ROCKLATAN OPHTHALMIC (EYE) DROPS 1 MO

travoprost ophthalmic (eye) drops 1 MO; QL (2.5 per 30 days)

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

drops,suspension

1 MO

neomycin-polymyxin b-dexameth ophthalmic (eye)

ointment

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

drops,suspension

1 MO

neo-polycin hc ophthalmic (eye) ointment 1 MO

tobramycin-dexamethasone ophthalmic (eye)

drops,suspension

1 MO

STEROIDS

dexamethasone sodium phosphate ophthalmic

(eye) drops

1 MO

fluorometholone ophthalmic (eye)

drops,suspension

1 MO




86


prednisolone acetate ophthalmic (eye)

drops,suspension

1 MO

prednisolone sodium phosphate ophthalmic (eye)

drops

1 MO

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

1 MO

apraclonidine ophthalmic (eye) drops 1 MO

brimonidine ophthalmic (eye) drops 0.15 % 1

brimonidine ophthalmic (eye) drops 0.2 % 1 MO

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

cetirizine oral solution 1 mg/ml 1 MO

clemastine oral tablet 2.68 mg 1 PA; MO

cyproheptadine oral syrup 1 PA; MO

cyproheptadine oral tablet 1 PA; MO

desloratadine oral tablet 1 MO

desloratadine oral tablet,disintegrating 1 MO

diphenhydramine hcl injection solution 50 mg/ml 1 MO

diphenhydramine hcl injection syringe 1 B/D PA; MO

EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.3 ML (MANUFACTURED BY

MYLAN SPECIALTY)


epinephrine injection auto-injector 0.3 mg/0.3 ml

(manufactured by mylan specialty)


hydroxyzine hcl intramuscular solution 1 B/D PA; MO

hydroxyzine hcl oral solution 1 MO

hydroxyzine hcl oral tablet 1 MO

levocetirizine oral solution 1 MO

levocetirizine oral tablet 1 MO; QL (30 per 30 days)

promethazine oral tablet 1 PA; MO

PULMONARY AGENTS

acetylcysteine solution 1 B/D PA; MO

ADEMPAS ORAL TABLET 1 PA; MO; LA; QL (90 per 30 days)




87


ADVAIR HFA AEROSOL INHALER 1 MO; QL (24 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90

mcg/actuation


albuterol sulfate inhalation hfa aerosol inhaler 90

mcg/actuation (nda020503)


albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3

ml (0.083 %)

1 B/D PA; MO; QL (360 per 30 days)

albuterol sulfate inhalation solution for

nebulization 2.5 mg/0.5 ml, 5 mg/ml


albuterol sulfate oral syrup 1 MO

albuterol sulfate oral tablet 1 MO

albuterol sulfate oral tablet extended release 12 hr 1 MO

alyq oral tablet 1 PA; QL (60 per 30 days)

ambrisentan oral tablet 1 PA; MO; LA; QL (30 per 30 days)

ANORO ELLIPTA INHALATION BLISTER

WITH DEVICE


ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE


ASMANEX HFA AEROSOL INHALER 1 MO; QL (26 per 30 days)

ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED 110

MCG/ ACTUATION (30), 220 MCG/

ACTUATION (120), 220 MCG/ ACTUATION

(30), 220 MCG/ ACTUATION (60)


ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED 220

MCG/ ACTUATION (14)


ATROVENT HFA AEROSOL INHALER 1 MO; QL (26 per 30 days)

BEVESPI AEROSPHERE HFA AEROSOL

INHALER


bosentan oral tablet 1 PA; MO; LA; QL (60 per 30 days)

BREO ELLIPTA INHALATION BLISTER

WITH DEVICE


budesonide inhalation suspension for nebulization

0.25 mg/2 ml, 0.5 mg/2 ml





88


budesonide inhalation suspension for nebulization

1 mg/2 ml

1 B/D PA; MO

CINRYZE INTRAVENOUS RECON SOLN 1 PA; MO

COMBIVENT RESPIMAT INHALATION MIST 1 MO; QL (8 per 30 days)

cromolyn inhalation solution for nebulization 1 B/D PA; MO; QL (240 per 30 days)

DALIRESP ORAL TABLET 1 MO

DULERA INHALATION HFA AEROSOL

INHALER


ESBRIET ORAL CAPSULE 1 PA; MO

ESBRIET ORAL TABLET 1 PA; MO

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 50

MCG/ACTUATION


FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 250 MCG/ACTUATION


FLOVENT HFA AEROSOL INHALER 110

MCG/ACTUATION



MCG/ACTUATION



MCG/ACTUATION


flunisolide nasal spray,non-aerosol 1 MO; QL (50 per 30 days)

fluticasone propionate nasal spray,suspension 1 MO; QL (16 per 30 days)

fluticasone propion-salmeterol inhalation blister

with device


formoterol fumarate inhalation solution for

nebulization


icatibant subcutaneous syringe 1 PA; MO

ipratropium bromide inhalation solution 1 B/D PA; MO; QL (315 per 30 days)

ipratropium-albuterol inhalation solution for

nebulization


KALYDECO ORAL GRANULES IN PACKET 1 PA; MO; QL (60 per 30 days)

KALYDECO ORAL TABLET 1 PA; MO; QL (60 per 30 days)

levalbuterol hcl inhalation solution for

nebulization 0.31 mg/3 ml, 0.63 mg/3 ml

1 B/D PA; MO




89


levalbuterol hcl inhalation solution for

nebulization 1.25 mg/0.5 ml, 1.25 mg/3 ml


metaproterenol oral syrup 1 MO

mometasone nasal spray,non-aerosol 1 MO; QL (51 per 30 days)

montelukast oral granules in packet 1 MO

montelukast oral tablet 1 MO

montelukast oral tablet,chewable 1 MO

OFEV ORAL CAPSULE 1 PA; MO; QL (60 per 30 days)

OPSUMIT ORAL TABLET 1 PA; MO; LA; QL (30 per 30 days)

ORKAMBI ORAL GRANULES IN PACKET 1 PA; MO

ORKAMBI ORAL TABLET 1 PA; MO

ORLADEYO ORAL CAPSULE 1 PA; LA; QL (30 per 30 days)

PERFOROMIST INHALATION SOLUTION

FOR NEBULIZATION


PULMOZYME INHALATION SOLUTION 1 B/D PA; MO

sajazir subcutaneous syringe 1 PA

SEREVENT DISKUS INHALATION BLISTER

WITH DEVICE


sildenafil (pulmonary arterial hypertension) oral

tablet


SPIRIVA RESPIMAT INHALATION MIST 1 MO; QL (4 per 30 days)

SPIRIVA WITH HANDIHALER INHALATION

CAPSULE, W/INHALATION DEVICE


STIOLTO RESPIMAT INHALATION MIST 1 MO; QL (4 per 30 days)

SYMBICORT HFA AEROSOL INHALER 1 MO; QL (20 per 30 days)

SYMDEKO ORAL TABLETS, SEQUENTIAL

100-150 MG (D)/ 150 MG (N)

1 PA; MO; LA; QL (56 per 28 days)

SYMDEKO ORAL TABLETS, SEQUENTIAL

50-75 MG (D)/ 75 MG (N)


tadalafil (pulmonary arterial hypertension) oral

tablet 20 mg


terbutaline oral tablet 1 MO

terbutaline subcutaneous solution 1 MO

theophylline oral elixir 1 MO

theophylline oral solution 1 MO




90


theophylline oral tablet extended release 12 hr 300

mg, 450 mg

1 MO

theophylline oral tablet extended release 24 hr 1 MO

TRACLEER ORAL TABLET FOR

SUSPENSION


TRELEGY ELLIPTA INHALATION BLISTER

WITH DEVICE


TRIKAFTA ORAL TABLETS, SEQUENTIAL 1 PA; MO; QL (84 per 28 days)

VENTOLIN HFA AEROSOL INHALER 1 MO; QL (36 per 30 days)

wixela inhub inhalation blister with device 1 QL (60 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN 1 PA; MO; LA; QL (6 per 28 days)

XOLAIR SUBCUTANEOUS SYRINGE 150

MG/ML


XOLAIR SUBCUTANEOUS SYRINGE 75

MG/0.5 ML


zafirlukast oral tablet 1 MO

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

flavoxate oral tablet 1 MO

GELNIQUE TRANSDERMAL GEL IN PACKET 1 ST; MO; QL (30 per 30 days)

MYRBETRIQ ORAL

SUSPENSION,EXTENDED REL RECON

1

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HR

1 MO

oxybutynin chloride oral syrup 1 MO

oxybutynin chloride oral tablet 1 MO

oxybutynin chloride oral tablet extended release

24hr 10 mg, 15 mg


oxybutynin chloride oral tablet extended release

24hr 5 mg


solifenacin oral tablet 1 MO; QL (30 per 30 days)

tolterodine oral capsule,extended release 24hr 1 MO; QL (30 per 30 days)

tolterodine oral tablet 1 MO; QL (60 per 30 days)

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HR

1 MO




91


trospium oral capsule,extended release 24hr 1 MO; QL (30 per 30 days)

trospium oral tablet 1 MO; QL (60 per 30 days)

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin oral tablet extended release 24 hr 1 MO; QL (30 per 30 days)

dutasteride oral capsule 1 MO; QL (30 per 30 days)

dutasteride-tamsulosin oral capsule, er multiphase

24 hr


finasteride oral tablet 5 mg 1 MO

tamsulosin oral capsule 1 MO

MISCELLANEOUS UROLOGICALS

bethanechol chloride oral tablet 1 MO

CYSTAGON ORAL CAPSULE 1 LA

ELMIRON ORAL CAPSULE 1 MO

potassium citrate oral tablet extended release 1 MO

tadalafil oral tablet 2.5 mg, 5 mg 1 PA; MO; QL (30 per 30 days)

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate(phosphat bind) oral capsule 1 MO

calcium acetate(phosphat bind) oral tablet 1 MO

klor-con 10 oral tablet extended release 1 MO

klor-con 8 oral tablet extended release 1 MO

klor-con m15 oral tablet,er particles/crystals 1 MO

klor-con m20 oral tablet,er particles/crystals 1 MO

klor-con oral packet 1 MO

lactated ringers intravenous parenteral solution 1 MO

magnesium sulfate injection solution 1 B/D PA; MO

magnesium sulfate injection syringe 1 B/D PA

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution

1 B/D PA

potassium chloride in 0.9%nacl intravenous

parenteral solution 20 meq/l, 40 meq/l

1 B/D PA

potassium chloride in 5 % dex intravenous

parenteral solution 20 meq/l

1 B/D PA




92


potassium chloride in lr-d5 intravenous parenteral

solution 20 meq/l

1 B/D PA

potassium chloride in water intravenous

piggyback 10 meq/100 ml, 10 meq/50 ml, 20

meq/100 ml, 20 meq/50 ml, 40 meq/100 ml

1

potassium chloride intravenous solution 1

potassium chloride oral capsule, extended release 1 MO

potassium chloride oral liquid 1 MO

potassium chloride oral packet 1 MO

potassium chloride oral tablet extended release 10

meq, 8 meq

1 MO

potassium chloride oral tablet extended release 20

meq

1

potassium chloride oral tablet,er particles/crystals

10 meq

1 MO

potassium chloride oral tablet,er particles/crystals

20 meq

1

potassium chloride-0.45 % nacl intravenous

parenteral solution

1

potassium chloride-d5-0.2%nacl intravenous

parenteral solution 20 meq/l

1 B/D PA

potassium chloride-d5-0.9%nacl intravenous

parenteral solution

1 B/D PA

ringer's intravenous parenteral solution 1 B/D PA

sodium chloride 0.45 % intravenous parenteral

solution

1 MO

sodium chloride 3 % hypertonic intravenous

parenteral solution

1

sodium chloride 5 % hypertonic intravenous

parenteral solution

1 MO

sodium chloride intravenous parenteral solution 1

MISCELLANEOUS NUTRITION PRODUCTS

AMINOSYN II 15 % INTRAVENOUS

PARENTERAL SOLUTION

1 B/D PA

CLINIMIX 5%/D15W SULFITE FREE


1 B/D PA




93


CLINIMIX 4.25%/D10W SULFITE FREE


1 B/D PA

CLINIMIX 5%-D20W SULFITE FREE


1 B/D PA

CLINIMIX 6%-D5W (SULFITE-FREE)


1 B/D PA

CLINIMIX 8%-D10W(SULFITE-FREE)


1 B/D PA

CLINIMIX 8%-D14W(SULFITE-FREE)


1 B/D PA



1 B/D PA



1 B/D PA

CLINIMIX E 5%/D15W SULFITE FREE


1 B/D PA

CLINIMIX E 5%/D20W SULFITE FREE


1 B/D PA

CLINIMIX E 8%-D10W SULFITEFREE


1 B/D PA

CLINIMIX E 8%-D14W SULFITEFREE


1 B/D PA

DOJOLVI ORAL LIQUID 1 PA; MO; LA

electrolyte-48 in d5w intravenous parenteral

solution

1 B/D PA

intralipid intravenous emulsion 20 % 1 B/D PA

INTRALIPID INTRAVENOUS EMULSION 30

%

1 B/D PA

ISOLYTE S PH 7.4 INTRAVENOUS

PARENTERAL SOLUTION

1

ISOLYTE-P IN 5 % DEXTROSE


1

ISOLYTE-S INTRAVENOUS PARENTERAL

SOLUTION

1

PLASMA-LYTE 148 INTRAVENOUS

PARENTERAL SOLUTION

1 B/D PA

PLASMA-LYTE A INTRAVENOUS

PARENTERAL SOLUTION

1 B/D PA




94


PLENAMINE INTRAVENOUS PARENTERAL

SOLUTION

1 B/D PA

premasol 10 % intravenous parenteral solution 1 B/D PA

PROCALAMINE 3% INTRAVENOUS

PARENTERAL SOLUTION

1 B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL

SOLUTION

1 B/D PA

travasol 10 % intravenous parenteral solution 1 B/D PA

TROPHAMINE 10 % INTRAVENOUS

PARENTERAL SOLUTION

1 B/D PA

VITAMINS / HEMATINICS

fluoride (sodium) oral tablet 1 MO

fluoride (sodium) oral tablet,chewable 1 mg (2.2

mg sod. fluoride)

1 MO

prenatal vitamin oral tablet 1 MO




95

Index

A abacavir .................................. 1

abacavir-lamivudine ............... 2

abacavir-lamivudine-

zidovudine .......................... 2

ABELCET .............................. 1

ABILIFY MAINTENA ........ 35

abiraterone ............................ 14

ABRAXANE ........................ 14

acamprosate .......................... 56

acarbose ................................ 60

acebutolol ............................. 42

acetaminophen-codeine ........ 31

acetazolamide ................. 83, 84

acetazolamide sodium .......... 84

acetic acid ............................. 59

acetylcysteine ....................... 85

acitretin ................................. 51

ACTHAR ............................. 59

ACTHIB (PF) ....................... 72

ACTIMMUNE ..................... 70

acyclovir ........................... 2, 54

acyclovir sodium .................... 2

ADACEL(TDAP

ADOLESN/ADULT)(PF) 72

adapalene .............................. 53

adefovir................................... 2

ADEMPAS ........................... 85

ADVAIR HFA ..................... 85

AFINITOR ........................... 14

AFINITOR DISPERZ .......... 14

AIMOVIG AUTOINJECTOR

.......................................... 28

AJOVY AUTOINJECTOR .. 28

AJOVY SYRINGE .............. 28

ak-poly-bac ........................... 82

ala-cort .................................. 54

albendazole ............................. 8

albuterol sulfate .............. 85, 86

alclometasone ....................... 54

alcohol pads .......................... 61

ALDURAZYME .................. 64

ALECENSA ......................... 14

alendronate ........................... 75

alfuzosin ............................... 89

ALIMTA .............................. 14

ALIQOPA ............................ 14

aliskiren ................................ 42

allopurinol ............................ 75

allopurinol sodium ................ 75

alosetron ............................... 67

ALPHAGAN P ..................... 85

alprazolam ............................ 35

altavera (28) .......................... 78

ALUNBRIG ......................... 14

alyacen 1/35 (28) .................. 78

alyacen 7/7/7 (28) ................. 78

alyq ....................................... 86

amantadine hcl ........................ 2

AMBISOME .......................... 1

ambrisentan .......................... 86

amcinonide ........................... 54

amethia ................................. 78

amethyst (28) ........................ 78

amikacin ................................. 8

amiloride ............................... 42

amiloride-hydrochlorothiazide

.......................................... 42

AMINOSYN II 15 % ........... 91

amiodarone ........................... 42

amitriptyline ......................... 35

amlodipine ............................ 42

amlodipine-atorvastatin ........ 48

amlodipine-benazepril .......... 42

amlodipine-olmesartan ......... 42

amlodipine-valsartan ............ 43

amlodipine-valsartan-

hydrochlorothiazide .......... 43

ammonium lactate ................ 52

amnesteem ............................ 53

amoxapine ............................ 35

amoxicil-clarithromy-lansopraz

.......................................... 70

amoxicillin ............................ 11

amoxicillin-pot clavulanate .. 11

amphotericin b ........................ 1

ampicillin .............................. 11

ampicillin sodium ................. 11

ampicillin-sulbactam ............ 11

anagrelide ............................. 56

anastrozole ............................ 14

ANORO ELLIPTA ............... 86

APOKYN ............................. 28

apraclonidine ........................ 85

aprepitant .............................. 67

apri ........................................ 78

APTIOM ............................... 24

APTIVUS ............................... 2

ARALAST NP ...................... 56

aranelle (28) .......................... 78

ARCALYST ......................... 70

ARIKAYCE ........................... 8

aripiprazole ..................... 35, 36

ARISTADA .......................... 36

ARISTADA INITIO ............. 36

armodafinil ........................... 36

ARNUITY ELLIPTA ........... 86

asenapine maleate ................. 36

ashlyna .................................. 78

ASMANEX HFA ................. 86

ASMANEX TWISTHALER 86

aspirin-dipyridamole ............. 47

ASTAGRAF XL ................... 14

atazanavir ................................ 2

atenolol ................................. 43

atenolol-chlorthalidone ......... 43

atomoxetine .......................... 36

atorvastatin ........................... 49

atovaquone .............................. 8

atovaquone-proguanil ............. 8

atropine ................................. 66

ATROVENT HFA ................ 86

AUBAGIO ............................ 29

aubra ..................................... 78

aubra eq ................................ 78

AURYXIA ............................ 56

aviane .................................... 78

AVONEX ............................. 70

AYVAKIT ............................ 14

azacitidine ............................. 14

AZASAN .............................. 14

AZASITE ............................. 82

azathioprine .......................... 14

azathioprine sodium .............. 14

azelastine ........................ 58, 83




96

azithromycin ........................... 7

aztreonam ............................... 8

azurette (28).......................... 78

B bacitracin .......................... 8, 82

bacitracin-polymyxin b ........ 82

baclofen ................................ 31

balsalazide ............................ 67

BALVERSA ......................... 14

balziva (28) ........................... 78

BANZEL .............................. 24

BARACLUDE ....................... 2

BASAGLAR KWIKPEN U-

100 INSULIN ................... 61

BAVENCIO ......................... 15

BCG VACCINE, LIVE (PF) 72

BELEODAQ ........................ 15

benazepril ............................. 43

benazepril-hydrochlorothiazide

.......................................... 43

BENDEKA ........................... 15

BENLYSTA ......................... 75

benztropine ........................... 28

BESIVANCE ....................... 82

BESPONSA ......................... 15

BESREMI ............................ 70

betaine .................................. 67

betamethasone dipropionate 54,

55

betamethasone valerate ........ 55

betamethasone, augmented... 55

BETASERON ...................... 70

betaxolol ......................... 43, 82

bethanechol chloride ............ 90

BETIMOL ............................ 82

BEVESPI AEROSPHERE ... 86

bexarotene ............................ 15

BEXSERO ............................ 72

bicalutamide ......................... 15

BICILLIN C-R ..................... 11

BICILLIN L-A ..................... 11

BIKTARVY ........................... 2

bisoprolol fumarate .............. 43

bisoprolol-hydrochlorothiazide

.......................................... 43

bleomycin ............................. 15

BLEPHAMIDE S.O.P. ......... 83

blisovi 24 fe .......................... 79

blisovi fe 1.5/30 (28) ............ 79

blisovi fe 1/20 (28) ............... 79

BOOSTRIX TDAP ............... 72

bosentan ................................ 86

BOSULIF ............................. 15

BRAFTOVI .......................... 15

BREO ELLIPTA .................. 86

briellyn .................................. 79

BRILINTA ........................... 47

brimonidine .......................... 85

brimonidine-timolol .............. 84

BRIVIACT ........................... 24

bromocriptine ....................... 28

BRUKINSA .......................... 15

budesonide ...................... 67, 86

bumetanide ........................... 43

buprenorphine hcl ................. 31

buprenorphine-naloxone ....... 33

bupropion hcl ........................ 36

bupropion hcl (smoking deter)

.......................................... 58

buspirone .............................. 36

butalbital-acetaminop-caf-cod

.......................................... 31

butalbital-acetaminophen ..... 31

butalbital-acetaminophen-caff

.......................................... 31

butalbital-aspirin-caffeine .... 31

butorphanol ........................... 33

BYDUREON BCISE ........... 61

BYETTA .............................. 61

BYSTOLIC .......................... 43

C CABENUVA .......................... 2

cabergoline ........................... 64

CABOMETYX ..................... 15

calcipotriene ......................... 51

calcipotriene-betamethasone 51

calcitonin (salmon) ............... 64

calcitriol .......................... 51, 64

calcium acetate(phosphat bind)

.......................................... 90

CALQUENCE ...................... 15

camila ................................... 77

camrese ................................. 79

camrese lo ............................. 79

candesartan ........................... 43

candesartan-


CAPLYTA ............................ 36

CAPRELSA .......................... 15

captopril ................................ 43

captopril-hydrochlorothiazide

.......................................... 43

carbamazepine ................ 24, 25

carbidopa .............................. 28

carbidopa-levodopa .............. 28

carbidopa-levodopa-

entacapone ........................ 28

carboplatin ............................ 15

carmustine ............................. 15

carteolol ................................ 83

cartia xt ................................. 43

carvedilol .............................. 43

carvedilol phosphate ............. 43

caspofungin ............................. 1

CAYSTON ............................. 8

caziant (28) ........................... 79

cefaclor ................................... 6

cefadroxil ................................ 6

cefazolin ................................. 6

cefazolin in dextrose (iso-osm)

............................................ 6

cefdinir .................................... 6

cefepime ................................. 6

cefepime in dextrose (iso-osm)

............................................ 6

CEFEPIME IN DEXTROSE 5

% ......................................... 6

cefixime .................................. 6

cefotetan ................................. 6

CEFOTETAN IN DEXTROSE

(ISO-OSM) ......................... 6

cefoxitin .................................. 6

cefoxitin in dextrose (iso-osm)

............................................ 6

cefpodoxime ........................... 6

cefprozil .................................. 6

ceftazidime ............................. 7

CEFTAZIDIME IN D5W ....... 7

ceftriaxone .............................. 7

CEFTRIAXONE .................... 7

ceftriaxone in dextrose (iso-

osm) .................................... 7

cefuroxime axetil .................... 7




97

cefuroxime sodium ................. 7

celecoxib............................... 33

CELONTIN .......................... 25

cephalexin............................... 7

CEREZYME ........................ 64

cetirizine ............................... 85

cevimeline ............................ 56

CHANTIX ............................ 58

CHANTIX CONTINUING

MONTH BOX .................. 58

CHANTIX STARTING

MONTH BOX .................. 58

chateal (28) ........................... 79

CHEMET ............................. 56

chloramphenicol sod succinate

............................................ 8

chlorhexidine gluconate ....... 58

chloroquine phosphate............ 8

chlorothiazide sodium .......... 43

chlorpromazine ..................... 36

chlorthalidone ....................... 43

CHOLBAM .......................... 67

cholestyramine (with sugar) . 49

cholestyramine light ............. 49

cholestyramine-aspartame .... 49

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 65

ciclopirox .............................. 54

cidofovir ................................. 2

cilostazol............................... 47

CIMDUO ................................ 2

cimetidine ............................. 70

cimetidine hcl ....................... 70

cinacalcet .............................. 65

CINRYZE ............................ 86

ciprofloxacin hcl ............. 12, 82

ciprofloxacin in 5 % dextrose

.......................................... 12

ciprofloxacin-dexamethasone

.......................................... 59

cisplatin ................................ 15

citalopram ............................. 36

cladribine .............................. 15

claravis ................................. 53

clarithromycin ........................ 7

clemastine ............................. 85

CLEOCIN ............................ 78

clindamycin hcl ...................... 8

clindamycin pediatric ............. 8

clindamycin phosphate .... 8, 53,

78

clindamycin-benzoyl peroxide

.......................................... 53

CLINIMIX 5%/D15W

SULFITE FREE ............... 91

CLINIMIX 4.25%/D10W

SULFITE FREE ............... 91

CLINIMIX 4.25%/D5W

SULFITE FREE ............... 56

CLINIMIX 5%-D20W

SULFITE FREE ............... 91

CLINIMIX 6%-D5W

(SULFITE-FREE) ............ 91

CLINIMIX 8%-

D10W(SULFITE-FREE).. 91

CLINIMIX 8%-

D14W(SULFITE-FREE).. 91

CLINIMIX E 2.75%/D5W

SULFITE FREE ............... 56


SULFITE FREE ............... 92


SULFITE FREE ............... 92

CLINIMIX E 5%/D15W

SULFITE FREE ............... 92

CLINIMIX E 5%/D20W

SULFITE FREE ............... 92

CLINIMIX E 8%-D10W

SULFITEFREE ................ 92

CLINIMIX E 8%-D14W

SULFITEFREE ................ 92

clobazam ............................... 25

clofarabine ............................ 15

clomipramine ........................ 36

clonazepam ........................... 25

clonidine ............................... 43

clonidine hcl ................... 36, 43

clopidogrel ............................ 47

clorazepate dipotassium ....... 36

clotrimazole ...................... 1, 54

clotrimazole-betamethasone . 54

clozapine ............................... 36

COARTEM ............................ 8

codeine sulfate ...................... 31

colesevelam .......................... 49

colestipol ............................... 49

colistin (colistimethate na) ..... 8

COMBIGAN ........................ 84

COMBIPATCH .................... 77

COMBIVENT RESPIMAT .. 86

COMETRIQ ......................... 15

COMPLERA .......................... 2

compro .................................. 67

constulose ............................. 67

COPIKTRA .......................... 15

CORLANOR ........................ 50

COSENTYX ......................... 51

COSENTYX (2 SYRINGES)

.......................................... 51

COSENTYX PEN ................ 51

COSENTYX PEN (2 PENS) 51

COTELLIC ........................... 15

CRINONE ............................ 77

cromolyn ................... 67, 83, 86

cryselle (28) .......................... 79

cyclafem 1/35 (28) ................ 79

cyclafem 7/7/7 (28) ............... 79

cyclobenzaprine .................... 31

cyclophosphamide ................ 15

CYCLOSET ......................... 61

cyclosporine .......................... 15

cyclosporine modified .......... 15

cyproheptadine ..................... 85

CYRAMZA .......................... 15

CYSTADANE ...................... 67

CYSTAGON ........................ 90

CYSTARAN ......................... 83

cytarabine ............................. 15

cytarabine (pf) ...................... 15

D d10 %-0.45 % sodium chloride

.......................................... 56

d2.5 %-0.45 % sodium

chloride ............................. 56

d5 % and 0.9 % sodium

chloride ............................. 56

d5 %-0.45 % sodium chloride

.......................................... 56

dacarbazine ........................... 16

dalfampridine ........................ 29

DALIRESP ........................... 86

danazol .................................. 65

dantrolene ............................. 31




98

dapsone ................................... 8

DAPTACEL (DTAP

PEDIATRIC) (PF) ........... 72

daptomycin ............................. 8

DARZALEX ........................ 16

dasetta 1/35 (28) ................... 79

dasetta 7/7/7 (28) .................. 79

daunorubicin ......................... 16

DAURISMO......................... 16

daysee ................................... 79

decitabine ............................. 16

deferasirox ............................ 56

deferiprone ........................... 56

DELSTRIGO .......................... 2

demeclocycline ..................... 13

DEMSER .............................. 43

DENAVIR ............................ 54

DENGVAXIA (PF) .............. 72

denta 5000 plus..................... 58

dentagel ................................ 59

DEPO-SUBQ PROVERA 104

.......................................... 77

DESCOVY ............................. 2

desipramine .......................... 36

desloratadine......................... 85

desmopressin ........................ 65

desog-e.estradiol/e.estradiol . 79

desoximetasone .................... 55

desvenlafaxine succinate ...... 36

dexamethasone ..................... 59

dexamethasone intensol........ 59

dexamethasone sodium phos

(pf) .................................... 59

dexamethasone sodium

phosphate .................... 59, 84

dexmethylphenidate ....... 36, 37

dexrazoxane hcl .................... 13

dextroamphetamine sulfate .. 37

dextroamphetamine-

amphetamine .................... 37

dextrose 10 % and 0.2 % nacl

.......................................... 56

dextrose 10 % in water (d10w)

.......................................... 57


.......................................... 57

dextrose 5 % in water (d5w) 57

dextrose 5 %-lactated ringers57

dextrose 5%-0.2 % sod

chloride ............................. 57

dextrose 5%-0.3 %

sod.chloride ...................... 57


.......................................... 57


.......................................... 57

DIACOMIT .......................... 25

diazepam ......................... 25, 37

diazepam intensol ................. 37

diazoxide .............................. 61

DICLOFENAC EPOLAMINE

.......................................... 33

diclofenac potassium ............ 34

diclofenac sodium ..... 34, 52, 83

diclofenac-misoprostol ......... 34

dicloxacillin .......................... 11

dicyclomine .................... 66, 67

diflunisal ............................... 34

digitek ................................... 50

digox ..................................... 50

digoxin .................................. 50

dihydroergotamine ................ 28

DILANTIN 30 MG .............. 25

diltiazem hcl ................... 43, 44

dilt-xr .................................... 44

dimethyl fumarate ................. 29

diphenhydramine hcl ............ 85

disulfiram .............................. 57

divalproex ............................. 25

dofetilide ............................... 42

DOJOLVI ............................. 92

donepezil .............................. 29

dorzolamide .......................... 84

dorzolamide-timolol ............. 84

DOVATO ............................... 2

doxazosin .............................. 44

doxepin ................................. 37

doxorubicin ........................... 16

doxorubicin, peg-liposomal .. 16

doxy-100 ............................... 13

doxycycline hyclate .............. 13

doxycycline monohydrate .... 13

DRIZALMA SPRINKLE ..... 37

dronabinol ............................. 67

drospirenone-e.estradiol-lm.fa

.......................................... 79

drospirenone-ethinyl estradiol

.......................................... 79

DROXIA ............................... 16

droxidopa .............................. 57

DULERA .............................. 87

duloxetine ............................. 37

DUPIXENT PEN .................. 52

DUPIXENT SYRINGE ........ 52

dutasteride ............................. 89

dutasteride-tamsulosin .......... 89

E ec-naproxen .......................... 34

econazole .............................. 54

EDURANT ............................. 2

efavirenz ................................. 2

efavirenz-emtricitabin-tenofov

............................................ 2

efavirenz-lamivu-tenofov disop

............................................ 2

EGRIFTA SV ....................... 70

ELAPRASE .......................... 65

electrolyte-48 in d5w ............ 92

ELELYSO ............................ 65

ELIGARD ............................. 16

ELIGARD (3 MONTH) ....... 16



elinest .................................... 79

ELIQUIS ............................... 47

ELIQUIS DVT-PE TREAT

30D START ...................... 47

ELITEK ................................ 13

ELLA .................................... 79

ELMIRON ............................ 90

EMCYT ................................ 16

EMEND ................................ 67

EMGALITY PEN ................. 28

EMGALITY SYRINGE ....... 29

emoquette ............................. 79

EMPAVELI .......................... 57

EMPLICITI .......................... 16

EMSAM ............................... 37

emtricitabine ........................... 2

emtricitabine-tenofovir (tdf) ... 2

EMTRIVA .............................. 2

enalapril maleate ................... 44

enalapril-hydrochlorothiazide

.......................................... 44




99

ENBREL ........................ 75, 76

ENBREL MINI .................... 75

ENBREL SURECLICK ....... 76

ENDARI ............................... 57

endocet ................................. 31

ENGERIX-B (PF) ................ 72

ENGERIX-B PEDIATRIC

(PF) ................................... 72

enoxaparin ............................ 47

enpresse ................................ 79

enskyce ................................. 79

ENSPRYNG ......................... 16

entacapone ............................ 28

entecavir ................................. 3

ENTRESTO ......................... 50

enulose .................................. 67

ENVARSUS XR .................. 16

EPCLUSA .............................. 3

EPIDIOLEX ......................... 25

epinastine .............................. 83

epinephrine ........................... 85

EPINEPHRINE .................... 85

epirubicin .............................. 16

epitol ..................................... 25

EPIVIR HBV.......................... 3

eplerenone ............................ 44

EPRONTIA .......................... 25

ergoloid................................. 37

ERIVEDGE .......................... 16

ERLEADA ........................... 16

erlotinib ................................ 16

errin ...................................... 77

ertapenem ............................... 8

ery pads ................................ 53

ERYTHROCIN ...................... 8

erythrocin (as stearate) ........... 8

erythromycin .................... 8, 82

erythromycin ethylsuccinate .. 8

erythromycin with ethanol ... 53

erythromycin-benzoyl peroxide

.......................................... 53

ESBRIET .............................. 87

escitalopram oxalate ............. 37

esomeprazole sodium ........... 70

estarylla ................................ 79

estradiol ................................ 77

estradiol valerate .................. 77

eszopiclone ........................... 37

ethambutol .............................. 8

ethosuximide ........................ 25

etodolac ................................ 34

etoposide ............................... 16

etravirine ................................. 3

everolimus (antineoplastic) .. 16

everolimus

(immunosuppressive) ....... 16

EVOTAZ ................................ 3

EVRYSDI ............................. 29

exemestane ........................... 17

EXKIVITY ........................... 17

EXTAVIA ............................ 70

ezetimibe .............................. 49

ezetimibe-simvastatin ........... 49

F FABRAZYME ..................... 65

falmina (28) .......................... 79

famciclovir .............................. 3

famotidine ............................. 70

famotidine (pf) ...................... 70

famotidine (pf)-nacl (iso-osm)

.......................................... 70

FANAPT .............................. 37

FARXIGA ............................ 61

FARYDAK ........................... 17

FASLODEX ......................... 17

febuxostat ............................. 75

felbamate .............................. 25

felodipine .............................. 44

fenofibrate ............................ 49

fenofibrate micronized ......... 49

fenofibrate nanocrystallized . 49

fenofibric acid ....................... 49

fenofibric acid (choline) ....... 49

fenoprofen ............................ 34

fentanyl ................................. 32

fentanyl citrate ................ 31, 32

FERRIPROX ........................ 57

FERRIPROX (2 TIMES A

DAY) ................................ 57

FETZIMA ............................. 37

FIASP FLEXTOUCH U-100

INSULIN .......................... 61

FIASP PENFILL U-100

INSULIN .......................... 61

FIASP U-100 INSULIN ....... 61

finasteride ............................. 89

FINTEPLA ........................... 25

flavoxate ............................... 89

flecainide .............................. 42

FLOVENT DISKUS ............ 87

FLOVENT HFA ................... 87

fluconazole ............................. 1

fluconazole in nacl (iso-osm) . 1

flucytosine .............................. 1

fludarabine ............................ 17

fludrocortisone ...................... 59

flunisolide ............................. 87

fluocinolone .......................... 55

fluocinolone acetonide oil .... 59

fluocinolone and shower cap 55

fluoride (sodium) .................. 93

fluorometholone ................... 84

fluorouracil ..................... 17, 52

fluoxetine ........................ 37, 38

fluoxetine (pmdd) ................. 37

fluphenazine decanoate ........ 38

fluphenazine hcl .................... 38

flurbiprofen ........................... 34

flurbiprofen sodium .............. 83

flutamide ............................... 17

fluticasone propionate .... 55, 87

fluticasone propion-salmeterol

.......................................... 87

fluvoxamine .......................... 38

fomepizole ............................ 72

fondaparinux ......................... 47

formoterol fumarate .............. 87

FORTEO ............................... 75

fosamprenavir ......................... 3

fosinopril ............................... 44

fosinopril-hydrochlorothiazide

.......................................... 44

fosphenytoin ......................... 25

FOTIVDA ............................. 17

FRAGMIN ............................ 47

fulvestrant ............................. 17

furosemide ............................ 44

FUZEON ................................ 3

FYCOMPA ........................... 25

G gabapentin ....................... 25, 26

GALAFOLD ......................... 65

galantamine ........................... 29

GAMMAGARD LIQUID .... 72




100

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 72

GAMUNEX-C ..................... 72

ganciclovir sodium ................. 3

GARDASIL 9 (PF) .............. 72

gatifloxacin ........................... 82

GATTEX 30-VIAL .............. 67

GATTEX ONE-VIAL .......... 67

GAUZE PAD ....................... 61

gavilyte-c .............................. 67

gavilyte-g .............................. 67

gavilyte-n .............................. 67

GAVRETO ........................... 17

GAZYVA ............................. 17

GELNIQUE .......................... 89

gemcitabine .......................... 17

gemfibrozil ........................... 49

generlac ................................ 67

gengraf .................................. 17

gentak ................................... 82

gentamicin .................. 9, 53, 82

gentamicin in nacl (iso-osm) .. 9

GENTAMICIN IN NACL

(ISO-OSM) ......................... 9

GENVOYA ............................ 3

GEODON ............................. 38

GILENYA ............................ 29

GILOTRIF ............................ 17

glatiramer ............................. 29

glatopa .................................. 29

glimepiride ........................... 61

glipizide ................................ 61

glipizide-metformin .............. 61

GLUCAGEN HYPOKIT ..... 61

GLUCAGON (HCL)

EMERGENCY KIT ......... 61

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 61

glyburide............................... 61

glyburide micronized............ 61

glyburide-metformin ............ 61

glycopyrrolate....................... 67

granisetron (pf) ..................... 67

granisetron hcl ...................... 67

GRANIX .............................. 70

griseofulvin microsize ............ 1

griseofulvin ultramicrosize ..... 1

guanfacine ............................ 38

GVOKE ................................ 62

GVOKE HYPOPEN 1-PACK

.......................................... 61

GVOKE HYPOPEN 2-PACK

.......................................... 62

GVOKE PFS 1-PACK

SYRINGE ......................... 62

GVOKE PFS 2-PACK

SYRINGE ......................... 62

H haloperidol ............................ 38

haloperidol decanoate ........... 38

haloperidol lactate ................ 38

HARVONI .............................. 3

HAVRIX (PF) ...................... 73

heather .................................. 77

HEMADY ............................ 60

heparin (porcine) .................. 48

heparin (porcine) in 5 % dex 48

heparin (porcine) in nacl (pf) 48

heparin(porcine) in 0.45% nacl

.......................................... 48

HEPARIN(PORCINE) IN

0.45% NACL .................... 48

heparin, porcine (pf) ............. 48

HETLIOZ ............................. 38

HETLIOZ LQ ....................... 38

HIBERIX (PF) ...................... 73

HUMIRA .............................. 76

HUMIRA PEN ..................... 76

HUMIRA PEN CROHNS-UC-

HS START ....................... 76

HUMIRA PEN PSOR-

UVEITS-ADOL HS ......... 76

HUMIRA(CF) ...................... 76

HUMIRA(CF) PEDI

CROHNS STARTER ....... 76

HUMIRA(CF) PEN .............. 76

HUMIRA(CF) PEN

CROHNS-UC-HS ............ 76

HUMIRA(CF) PEN

PEDIATRIC UC ............... 76

HUMIRA(CF) PEN PSOR-

UV-ADOL HS .................. 76

hydralazine ........................... 44

hydrochlorothiazide .............. 44

hydrocodone-acetaminophen 32

hydrocodone-ibuprofen ........ 32

hydrocortisone .......... 55, 60, 68

hydrocortisone butyrate ........ 55

hydrocortisone butyr-emollient

.......................................... 55

hydrocortisone valerate ........ 55

hydrocortisone-acetic acid .... 59

hydromorphone ..................... 32

hydromorphone (pf) .............. 32

hydroxychloroquine ................ 9

hydroxyprogesterone caproate

.......................................... 77

hydroxyurea .......................... 17

hydroxyzine hcl .................... 85

I ibandronate ........................... 75

IBRANCE ............................. 17

ibu ......................................... 34

ibuprofen ............................... 34

icatibant ................................ 87

ICLUSIG .............................. 17

icosapent ethyl ...................... 49

idarubicin .............................. 17

IDHIFA ................................. 17

ifosfamide ....................... 17, 18

ILEVRO ............................... 83

imatinib ................................. 18

IMBRUVICA ....................... 18

IMFINZI ............................... 18

imipenem-cilastatin ................ 9

imipramine hcl ...................... 38

imipramine pamoate ............. 38

imiquimod ............................. 52

IMOVAX RABIES VACCINE

(PF) ................................... 73

INCRELEX .......................... 57

indapamide ........................... 44

indomethacin ........................ 34

INFANRIX (DTAP) (PF) ..... 73

INGREZZA .......................... 30

INGREZZA INITIATION

PACK ............................... 30

INLYTA ............................... 18

INQOVI ................................ 18

INREBIC .............................. 18

INSULIN PEN NEEDLE ..... 74

INSULIN SYRINGE (DISP)

U-100 ................................ 74

INTELENCE .......................... 3




101

intralipid ............................... 92

INTRALIPID ....................... 92

INTRON A ........................... 71

introvale ................................ 79

INVEGA HAFYERA ........... 38

INVEGA SUSTENNA ......... 38

INVIRASE ............................. 3

IPOL ..................................... 73

ipratropium bromide ....... 59, 87

ipratropium-albuterol ........... 87

irbesartan .............................. 44

irbesartan-hydrochlorothiazide

.......................................... 44

IRESSA ................................ 18

irinotecan .............................. 18

ISENTRESS ........................... 3

ISENTRESS HD .................... 3

ISOLYTE S PH 7.4 .............. 92

ISOLYTE-P IN 5 %

DEXTROSE ..................... 92

ISOLYTE-S .......................... 92

isoniazid ................................. 9

isosorbide dinitrate ............... 50

isosorbide mononitrate ... 50, 51

isradipine .............................. 44

ISTODAX ............................ 18

itraconazole ............................ 1

ivermectin ............................... 9

IXIARO (PF) ........................ 73

J JAKAFI ................................ 18

jantoven ................................ 48

JANUMET ........................... 62

JANUMET XR ..................... 62

JANUVIA ............................ 62

JARDIANCE ........................ 62

jencycla................................. 77

jinteli .................................... 77

jolessa ................................... 79

JULUCA ................................ 3

junel 1.5/30 (21) ................... 79

junel 1/20 (21) ...................... 79

junel fe 1.5/30 (28) ............... 79

junel fe 1/20 (28) .................. 79

junel fe 24 ............................. 80

JUXTAPID ........................... 49

JYNARQUE ......................... 65

K KADCYLA .......................... 18

KALETRA ............................. 3

KALYDECO ........................ 87

KANJINTI ............................ 18

kariva (28) ............................ 80

kelnor 1/35 (28) .................... 80

KENALOG ........................... 60

KERENDIA .......................... 44

ketoconazole ..................... 1, 54

ketoprofen ............................. 34

ketorolac ............................... 83

KEVEYIS ............................. 30

KEYTRUDA ........................ 18

KINRIX (PF) ........................ 73

KISQALI .............................. 18

KISQALI FEMARA CO-

PACK ............................... 18

klor-con ................................ 90

klor-con 10 ........................... 90

klor-con 8 ............................. 90

klor-con m15 ........................ 90

klor-con m20 ........................ 90

KLOXXADO ....................... 34

KOMBIGLYZE XR ............. 62

KORLYM ............................. 65

KOSELUGO ........................ 18

kurvelo (28) .......................... 80

KUVAN ................................ 65

KYPROLIS .......................... 18

L l norgest/e.estradiol-e.estrad . 80

labetalol ................................ 44

lactated ringers ..................... 90

lactulose ................................ 68

lamivudine .............................. 3

lamivudine-zidovudine ........... 3

lamotrigine ............................ 26

LANOXIN ............................ 50

LANREOTIDE ..................... 18

lansoprazole .......................... 70

lanthanum ............................. 57

LANTUS SOLOSTAR U-100

INSULIN .......................... 62

LANTUS U-100 INSULIN .. 62

lapatinib ................................ 18

larissia ................................... 80

latanoprost ............................ 84

LATUDA .............................. 38

layolis fe ............................... 80

leflunomide ........................... 76

LENVIMA ............................ 19

lessina ................................... 80

letrozole ................................ 19

leucovorin calcium ............... 14

LEUKERAN ......................... 19

LEUKINE ............................. 71

leuprolide .............................. 19

levalbuterol hcl ..................... 87

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 62

LEVEMIR U-100 INSULIN 62

levetiracetam ......................... 26

levetiracetam in nacl (iso-osm)

.......................................... 26

levobunolol ........................... 83

levocarnitine ......................... 57

levocarnitine (with sugar) ..... 57

levocetirizine ........................ 85

levofloxacin .................... 12, 82

levofloxacin in d5w .............. 12

levoleucovorin calcium ........ 14

levonest (28) ......................... 80

levonorgestrel-ethinyl estrad 80

levonorg-eth estrad triphasic 80

levora-28 ............................... 80

levothyroxine ........................ 66

levoxyl .................................. 66

LEXIVA ................................. 3

lidocaine ............................... 52

lidocaine (pf) .................. 42, 52

lidocaine hcl .......................... 52

lidocaine viscous .................. 52

lidocaine-prilocaine .............. 52

lindane .................................. 56

linezolid .................................. 9

linezolid in dextrose 5% ......... 9

linezolid-0.9% sodium chloride

............................................ 9

LINZESS .............................. 68

liothyronine ........................... 66

lisinopril ................................ 44

lisinopril-hydrochlorothiazide

.......................................... 44

lithium carbonate .................. 38

lithium citrate ........................ 38




102

LIVMARLI .......................... 68

LONSURF ............................ 19

loperamide ............................ 67

lopinavir-ritonavir .............. 3, 4

lorazepam ............................. 39

lorazepam intensol................ 39

LORBRENA ........................ 19

loryna (28) ............................ 80

losartan ................................. 44

losartan-hydrochlorothiazide 44

lovastatin .............................. 49

low-ogestrel (28) .................. 80

loxapine succinate ................ 39

LUBIPROSTONE ................ 68

LUCEMYRA ....................... 34

LUMAKRAS ....................... 19

LUMIGAN ........................... 84

LUPRON DEPOT ................ 19

LUPRON DEPOT (3

MONTH) .......................... 19

LUPRON DEPOT (4

MONTH) .......................... 19

LUPRON DEPOT (6

MONTH) .......................... 19

LUPRON DEPOT-PED ....... 19

LUPRON DEPOT-PED (3

MONTH) .......................... 19

lutera (28) ............................. 80

LYNPARZA......................... 19

LYSODREN......................... 19

lyza ....................................... 78

M magnesium sulfate ................ 90

malathion .............................. 56

maprotiline ........................... 39

maraviroc ................................ 4

marlissa (28) ......................... 80

MARPLAN .......................... 39

MATULANE ....................... 19

matzim la .............................. 45

MAVENCLAD (10 TABLET

PACK) .............................. 30

MAVENCLAD (4 TABLET

PACK) .............................. 30

MAVENCLAD (5 TABLET

PACK) .............................. 30

MAVENCLAD (6 TABLET

PACK) .............................. 30

MAVENCLAD (7 TABLET

PACK) .............................. 30

MAVENCLAD (8 TABLET

PACK) .............................. 30

MAVENCLAD (9 TABLET

PACK) .............................. 30

MAYZENT .......................... 30

MAYZENT STARTER(FOR

2MG MAINT) .................. 30

meclizine .............................. 68

medroxyprogesterone ........... 78

mefloquine .............................. 9

megestrol .............................. 19

MEKINIST ........................... 19

MEKTOVI ............................ 19

meloxicam ............................ 34

melphalan hcl ....................... 19

memantine ............................ 30

MEMANTINE ...................... 30

MENACTRA (PF) ............... 73

MENQUADFI (PF) .............. 73

MENVEO A-C-Y-W-135-DIP

(PF) ................................... 73

mercaptopurine ..................... 19

meropenem ............................. 9

MEROPENEM-0.9%

SODIUM CHLORIDE ....... 9

mesalamine ........................... 68

mesalamine with cleansing

wipe .................................. 68

mesna .................................... 14

MESNEX .............................. 14

metaproterenol ...................... 87

metaxalone ............................ 31

metformin ............................. 62

methadone ............................ 32

methadone intensol ............... 32

methadose ............................. 32

methamphetamine ................ 39

methazolamide ...................... 84

methenamine hippurate ........ 13

methenamine mandelate ....... 13

methimazole ......................... 60

methotrexate sodium ...... 19, 20

methotrexate sodium (pf) ..... 19

methoxsalen .......................... 52

methscopolamine .................. 67

methyldopa-


methylergonovine ................. 81

methylphenidate hcl .............. 39

methylprednisolone .............. 60

methylprednisolone acetate .. 60

methylprednisolone sodium

succ ................................... 60

methyltestosterone ................ 65

metoclopramide hcl .............. 68

metolazone ............................ 45

metoprolol succinate ............. 45

metoprolol tartrate ................ 45

metoprolol tartrate-


metro i.v. ................................. 9

metronidazole ............. 9, 53, 78

metronidazole in nacl (iso-

osm) .................................... 9

metyrosine ............................ 45

mexiletine ............................. 42

MIACALCIN ....................... 65

miconazole-3 ........................ 78

microgestin 1.5/30 (21) ........ 80

microgestin 1/20 (21) ........... 80

microgestin fe 1.5/30 (28) .... 80

microgestin fe 1/20 (28) ....... 80

midodrine .............................. 57

migergot ................................ 29

miglustat ............................... 65

millipred ............................... 60

minocycline .......................... 13

minoxidil ............................... 45

mirtazapine ........................... 39

misoprostol ........................... 70

MITIGARE ........................... 75

mitomycin ............................. 20

mitoxantrone ......................... 20

M-M-R II (PF) ...................... 73

modafinil ............................... 40

moexipril ............................... 45

molindone ............................. 40

MOLNUPIRAVIR ................. 4

mometasone .................... 55, 87

mono-linyah .......................... 80

montelukast ........................... 87

morphine ......................... 32, 33

MORPHINE ......................... 32




103

morphine (pf)........................ 32

morphine concentrate ........... 32

MOVANTIK ........................ 68

MOVIPREP .......................... 68

moxifloxacin................... 12, 82

MOXIFLOXACIN-

SOD.ACE,SUL-WATER . 12

moxifloxacin-sod.chloride(iso)

.......................................... 12

MOZOBIL ............................ 71

MULPLETA......................... 48

MULTAQ ............................. 42

mupirocin ............................. 53

MVASI ................................. 20

mycophenolate mofetil ......... 20

mycophenolate mofetil (hcl) 20

mycophenolate sodium ......... 20

MYLOTARG ....................... 20

MYRBETRIQ ...................... 89

N nabumetone .......................... 34

nadolol .................................. 45

nafcillin................................. 11

nafcillin in dextrose (iso-osm)

.......................................... 11

NAGLAZYME..................... 65

nalbuphine ............................ 34

naloxone ............................... 34

naltrexone ............................. 35

naproxen ............................... 35

naratriptan............................. 29

NARCAN ............................. 35

NATACYN .......................... 82

nateglinide ............................ 62

NATPARA ........................... 65

NAYZILAM ........................ 26

nebivolol ............................... 45

necon 0.5/35 (28).................. 80

NEEDLES, INSULIN

DISP.,SAFETY ................ 74

nefazodone ........................... 40

neomycin ................................ 9

neomycin-bacitracin-poly-hc 84

neomycin-bacitracin-

polymyxin ........................ 82

neomycin-polymyxin b gu ... 56

neomycin-polymyxin b-

dexameth .......................... 84

neomycin-polymyxin-

gramicidin ......................... 82

neomycin-polymyxin-hc 59, 84

neo-polycin ........................... 82

neo-polycin hc ...................... 84

NERLYNX ........................... 20

NEUPRO .............................. 28

nevirapine ............................... 4

NEXAVAR .......................... 20

NEXVIAZYME ................... 65

niacin .................................... 49

nicardipine ............................ 45

NICOTROL .......................... 58

NICOTROL NS .................... 58

nifedipine .............................. 45

nikki (28) .............................. 80

nilutamide ............................. 20

nimodipine ............................ 45

NINLARO ............................ 20

nitro-bid ................................ 51

nitrofurantoin macrocrystal .. 13

nitrofurantoin monohyd/m-

cryst .................................. 13

nitroglycerin ......................... 51

nizatidine .............................. 70

NORDITROPIN FLEXPRO 71

noreth-ethinyl estradiol-iron . 80

norethindrone (contraceptive)

.......................................... 78

norethindrone acetate ........... 78

norgestimate-ethinyl estradiol

.................................... 80, 81

NORTHERA ........................ 57

nortrel 0.5/35 (28) ................. 81

nortrel 1/35 (21) .................... 81

nortrel 1/35 (28) .................... 81

nortrel 7/7/7 (28) .................. 81

nortriptyline .......................... 40

NORVIR ................................. 4

NOVAREL ........................... 65

NOVOFINE .......................... 62

NOVOLIN 70/30 U-100

INSULIN .......................... 62

NOVOLIN 70-30 FLEXPEN

U-100 ................................ 62

NOVOLIN N FLEXPEN ..... 62

NOVOLIN N NPH U-100

INSULIN .......................... 62

NOVOLIN R FLEXPEN ...... 63

NOVOLIN R REGULAR U-

100 INSULN .................... 63

NOVOLOG FLEXPEN U-100

INSULIN .......................... 63

NOVOLOG MIX 70-30 U-100

INSULN ........................... 63

NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 63

NOVOLOG PENFILL U-100

INSULIN .......................... 63

NOVOLOG U-100 INSULIN

ASPART ........................... 63

NOVOTWIST ...................... 63

NOXAFIL ............................... 1

NUBEQA ............................. 20

NUEDEXTA ........................ 30

NULOJIX ............................. 20

NUPLAZID .......................... 40

NURTEC ODT ..................... 29

nyamyc ................................. 54

nylia 1/35 (28) ...................... 81

nylia 7/7/7 (28) ..................... 81

nystatin ............................. 1, 54

nystatin-triamcinolone .......... 54

nystop ................................... 54

O ocella ..................................... 81

octreotide acetate .................. 20

ODEFSEY .............................. 4

ODOMZO ............................. 20

OFEV .................................... 88

ofloxacin ................... 12, 59, 82

olanzapine ............................. 40

olanzapine-fluoxetine ........... 40

olmesartan ............................. 45

olmesartan-amlodipine-


olmesartan-


olopatadine ..................... 59, 83

omega-3 acid ethyl esters ..... 49

omeprazole ........................... 70

ondansetron ........................... 68

ondansetron hcl ..................... 68

ondansetron hcl (pf) .............. 68

ONGLYZA ........................... 63

ONUREG ............................. 20




104

OPDIVO ............................... 20

OPSUMIT ............................ 88

ORENCIA ...................... 76, 77

ORENCIA CLICKJECT ...... 76

ORGOVYX .......................... 20

ORIAHNN ........................... 78

ORILISSA ............................ 65

ORKAMBI ........................... 88

ORLADEYO ........................ 88

orsythia ................................. 81

oseltamivir .............................. 4

OTEZLA .............................. 77

OTEZLA STARTER ........... 77

oxacillin ................................ 11

oxacillin in dextrose(iso-osm)

.......................................... 11

oxaliplatin ....................... 20, 21

oxandrolone .......................... 65

oxaprozin .............................. 35

oxazepam .............................. 40

oxcarbazepine ....................... 26

OXERVATE ........................ 83

oxybutynin chloride.............. 89

oxycodone ............................ 33

oxycodone-acetaminophen ... 33

oxymorphone ........................ 33

OZEMPIC ............................ 63

P pacerone ............................... 42

paclitaxel .............................. 21

paliperidone .......................... 40

pamidronate .......................... 65

PANCREAZE ...................... 69

PANRETIN .......................... 52

pantoprazole ......................... 70

paricalcitol ............................ 66

PARICALCITOL ................. 65

paromomycin .......................... 9

paroxetine hcl ....................... 40

paroxetine

mesylate(menop.sym) ...... 40

PASER ................................... 9

PAXIL .................................. 40

PAXLOVID (EUA)................ 4

PEDIARIX (PF) ................... 73

PEDVAX HIB (PF) .............. 73

peg 3350-electrolytes ........... 69

PEGASYS ............................ 71

peg-electrolyte ...................... 69

PEMAZYRE ........................ 21

penicillamine ........................ 77

penicillin g potassium ........... 12

penicillin g procaine ............. 12

penicillin g sodium ............... 12

penicillin v potassium ........... 12

PENNSAID .......................... 35

pentamidine ...................... 9, 10

pentoxifylline ........................ 48

PERFOROMIST .................. 88

perindopril erbumine ............ 45

periogard ............................... 59

PERJETA ............................. 21

permethrin ............................ 56

perphenazine ......................... 40

perphenazine-amitriptyline ... 40

phenelzine ............................. 40

phenobarbital ........................ 26

phenoxybenzamine ............... 45

phenytoin .............................. 26

phenytoin sodium ................. 26

phenytoin sodium extended .. 26

philith .................................... 81

PIFELTRO ............................. 4

pilocarpine hcl ................ 57, 83

pimecrolimus ........................ 52

pimozide ............................... 40

pimtrea (28) .......................... 81

pindolol ................................. 45

pioglitazone .......................... 63

pioglitazone-glimepiride ...... 63

pioglitazone-metformin ........ 63

piperacillin-tazobactam ........ 12

PIPERACILLIN-

TAZOBACTAM .............. 12

PIQRAY ............................... 21

pirmella ................................. 81

piroxicam .............................. 35

PLASMA-LYTE 148 ........... 92

PLASMA-LYTE A .............. 92

PLEGRIDY .......................... 71

PLENAMINE ....................... 92

podofilox .............................. 52

polycin .................................. 82

polymyxin b sulfate .............. 10

polymyxin b sulf-trimethoprim

.......................................... 82

POMALYST ......................... 21

portia 28 ................................ 81

PORTRAZZA ....................... 21

posaconazole ........................... 1

potassium chlorid-d5-

0.45%nacl ......................... 90

potassium chloride .......... 90, 91

potassium chloride in 0.9%nacl

.......................................... 90

potassium chloride in 5 % dex

.......................................... 90

potassium chloride in lr-d5 ... 90

potassium chloride in water .. 90

potassium chloride-0.45 % nacl

.......................................... 91

potassium chloride-d5-

0.2%nacl ........................... 91

potassium chloride-d5-

0.9%nacl ........................... 91

potassium citrate ................... 90

POTELIGEO ........................ 21

PRADAXA ........................... 48

PRALUENT PEN ................. 49

pramipexole .......................... 28

prasugrel ............................... 48

pravastatin ............................. 49

prazosin ................................. 45

prednicarbate ........................ 55

prednisolone ......................... 60

prednisolone acetate ............. 84

prednisolone sodium phosphate

.................................... 60, 84

prednisone ............................. 60

prednisone intensol ............... 60

pregabalin ....................... 26, 27

PREGNYL ............................ 66

PREHEVBRIO (PF) ............. 73

PREMARIN ......................... 78

premasol 10 % ...................... 92

prenatal vitamin oral tablet ... 93

PRETOMANID .................... 10

prevalite .......................... 49, 50

previfem ................................ 81

PREVYMIS ............................ 4

PREZCOBIX .......................... 4

PREZISTA ............................. 4

PRIFTIN ............................... 10

primaquine ............................ 10




105

primidone ............................. 27

probenecid ............................ 75

probenecid-colchicine .......... 75

procainamide ........................ 42

PROCALAMINE 3% ........... 92

prochlorperazine ................... 69

prochlorperazine edisylate.... 69

prochlorperazine maleate oral

.......................................... 69

PROCRIT ............................. 71

procto-pak............................. 69

proctosol hc .......................... 69

proctozone-hc ....................... 69

progesterone micronized ...... 78

PROGRAF ........................... 21

PROLENSA ......................... 83

PROLIA ............................... 75

PROMACTA ........................ 48

promethazine ........................ 85

propafenone .......................... 42

propranolol ........................... 45

propranolol-


propylthiouracil .................... 60

PROQUAD (PF) .................. 73

PROSOL 20 % ..................... 92

protriptyline .......................... 40

PULMOZYME .................... 88

PURIXAN ............................ 21

pyrazinamide ........................ 10

pyridostigmine bromide ....... 31

pyrimethamine ...................... 10

Q QINLOCK ............................ 21

QUADRACEL (PF) ............. 73

quetiapine ............................. 40

quinapril ............................... 45

quinapril-hydrochlorothiazide

.......................................... 46

quinidine gluconate .............. 42

quinidine sulfate ................... 42

quinine sulfate ...................... 10

R RABAVERT (PF) ................ 73

RADICAVA ......................... 30

raloxifene .............................. 75

ramelteon .............................. 40

ramipril ................................. 46

ranolazine ............................. 50

rasagiline .............................. 28

RAVICTI .............................. 58

REBIF (WITH ALBUMIN) . 71

REBIF REBIDOSE .............. 71

REBIF TITRATION PACK . 71

reclipsen (28) ........................ 81

RECOMBIVAX HB (PF) ... 73,

74

RECTIV ................................ 69

regonol .................................. 31

REGRANEX ........................ 52

RELENZA DISKHALER ...... 4

RELISTOR ........................... 69

REMICADE ......................... 69

repaglinide ............................ 63

REPATHA ............................ 50

REPATHA PUSHTRONEX 50

REPATHA SURECLICK .... 50

RESTASIS ............................ 83

RESTASIS MULTIDOSE ... 83

RETACRIT .......................... 71

RETEVMO ........................... 21

RETROVIR ............................ 4

REVLIMID .......................... 21

REXULTI ............................. 40

REYATAZ ............................. 4

REZUROCK ........................ 21

RHOPRESSA ....................... 84

ribavirin .................................. 4

rifabutin ................................ 10

rifampin ................................ 10

riluzole .................................. 58

rimantadine ............................. 4

ringer's .................................. 91

RINVOQ .............................. 77

risedronate ...................... 58, 75

RISPERDAL CONSTA . 40, 41

risperidone ............................ 41

ritonavir .................................. 5

rivastigmine .......................... 30

rivastigmine tartrate .............. 30

rizatriptan .............................. 29

ROCKLATAN ..................... 84

ropinirole .............................. 28

rosuvastatin ........................... 50

ROTARIX ............................ 74

ROTATEQ VACCINE ......... 74

roweepra ............................... 27

ROZLYTREK ...................... 21

RUBRACA ........................... 21

rufinamide ............................. 27

RUKOBIA .............................. 5

RUXIENCE .......................... 21

RYBELSUS .......................... 63

RYBREVANT ...................... 21

RYDAPT .............................. 21

RYLAZE .............................. 21

S sajazir .................................... 88

SANCUSO ........................... 69

SANDIMMUNE ................... 21

SANTYL .............................. 52

SAPHNELO ......................... 21

sapropterin ............................ 66

SCEMBLIX .......................... 21

scopolamine base .................. 69

SECUADO ........................... 41

selegiline hcl ......................... 28

selenium sulfide .................... 51

SELZENTRY ......................... 5

SEREVENT DISKUS .......... 88

sertraline ............................... 41

sevelamer carbonate ............. 58

sf 59

sf 5000 plus ........................... 59

SHINGRIX (PF) ................... 74

SIGNIFOR ............................ 21

sildenafil (pulmonary arterial

hypertension) .................... 88

silver sulfadiazine ................. 52

SIMULECT .................... 21, 22

simvastatin ............................ 50

sirolimus ............................... 22

SIRTURO ............................. 10

SKYRIZI .............................. 51

sodium chloride .............. 58, 91

sodium chloride 0.45 % ........ 91

sodium chloride 0.9 % .......... 58

sodium chloride 3 %

hypertonic ......................... 91

sodium chloride 5 %

hypertonic ......................... 91

sodium polystyrene sulfonate

.......................................... 58

solifenacin ............................. 89




106

SOLTAMOX ........................ 22

SOLU-CORTEF ACT-O-

VIAL (PF) ........................ 60

SOMATULINE DEPOT ...... 22

SOMAVERT ........................ 66

sorine .................................... 42

sotalol ................................... 42

sotalol af ............................... 42

SPIRIVA RESPIMAT ......... 88

SPIRIVA WITH

HANDIHALER ................ 88

spironolactone ...................... 46

spironolactone-


sprintec (28).......................... 81

SPRITAM ............................ 27

SPRYCEL ............................ 22

sps (with sorbitol) ................. 58

sronyx ................................... 81

ssd ......................................... 52

STAMARIL (PF) ................. 74

stavudine................................. 5

STELARA ............................ 51

STIOLTO RESPIMAT ........ 88

STIVARGA .......................... 22

STREPTOMYCIN ............... 10

STRIBILD .............................. 5

sucralfate .............................. 70

sulfacetamide sodium ........... 83

sulfacetamide sodium (acne) 53

sulfacetamide-prednisolone .. 83

sulfadiazine........................... 12

sulfamethoxazole-trimethoprim

.......................................... 13

SULFAMYLON .................. 54

sulfasalazine ......................... 69

sulindac................................. 35

sumatriptan ........................... 29

sumatriptan succinate ........... 29

sunitinib ................................ 22

SUPRAX ................................ 7

SUTENT .............................. 22

syeda ..................................... 81

SYMBICORT ...................... 88

SYMDEKO .......................... 88

SYMLINPEN 120 ................ 63

SYMLINPEN 60 .................. 63

SYMPAZAN ........................ 27

SYMTUZA ............................. 5

SYNAGIS ............................... 5

SYNAREL ............................ 66

SYNERCID .......................... 10

SYNJARDY ......................... 63

SYNJARDY XR ............. 63, 64

SYNRIBO ............................ 22

SYNTHROID ....................... 66

T TABLOID ............................ 22

TABRECTA ......................... 22

tacrolimus ....................... 22, 52

tadalafil ................................. 90

tadalafil (pulm. hypertension)

.......................................... 88

TAFINLAR .......................... 22

TAGRISSO .......................... 22

TALZENNA ......................... 22

tamoxifen .............................. 22

tamsulosin ............................. 90

TARGRETIN ....................... 22

TASIGNA ............................ 22

TAVNEOS ........................... 58

tazarotene .............................. 53

taztia xt ................................. 46

TAZVERIK .......................... 22

TDVAX ................................ 74

TECENTRIQ ........................ 22

TEFLARO .............................. 7

TEGSEDI ............................. 30

TEKTURNA HCT ............... 46

telmisartan ............................ 46

telmisartan-


temazepam ............................ 41

TEMIXYS .............................. 5

TENIVAC (PF) .................... 74

tenofovir disoproxil fumarate . 5

TEPMETKO ......................... 22

terazosin ................................ 46

terbinafine hcl ......................... 1

terbutaline ............................. 88

terconazole ............................ 78

testosterone ........................... 66

testosterone cypionate .......... 66

testosterone enanthate ........... 66

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 74

tetrabenazine ......................... 30

tetracycline ........................... 13

THALOMID ................... 22, 23

theophylline .......................... 88

thioridazine ........................... 41

thiotepa ................................. 23

thiothixene ............................ 41

tiadylt er ................................ 46

tiagabine ............................... 27

TIBSOVO ............................. 23

TICOVAC ............................ 74

tigecycline ............................. 10

tilia fe .................................... 81

timolol maleate ............... 46, 83

tinidazole .............................. 10

TIVDAK ............................... 23

TIVICAY ................................ 5

TIVICAY PD .......................... 5

tizanidine .............................. 31

TOBI PODHALER .............. 10

tobramycin ............................ 82

tobramycin in 0.225 % nacl .. 10

tobramycin sulfate ................ 10

tobramycin-dexamethasone .. 84

tolcapone ............................... 28

tolmetin ................................. 35

TOLSURA .............................. 1

tolterodine ............................. 89

tolvaptan ............................... 66

TOLVAPTAN ...................... 66

topiramate ............................. 27

toposar .................................. 23

topotecan ............................... 23

toremifene ............................. 23

torsemide .............................. 46

TOUJEO MAX U-300

SOLOSTAR ..................... 64

TOUJEO SOLOSTAR U-300

INSULIN .......................... 64

TOVIAZ ............................... 89

TRACLEER ......................... 88

tramadol ................................ 35

tramadol-acetaminophen ...... 35

trandolapril ........................... 46

trandolapril-verapamil .......... 46

tranexamic acid ..................... 78

tranylcypromine .................... 41

travasol 10 % ........................ 92




107

travoprost .............................. 84

TRAZIMERA....................... 23

trazodone .............................. 41

TREANDA ........................... 23

TRECATOR ......................... 10

TRELEGY ELLIPTA .......... 88

TRELSTAR .......................... 23

treprostinil sodium................ 46

TRESIBA FLEXTOUCH U-

100 .................................... 64

TRESIBA FLEXTOUCH U-

200 .................................... 64

TRESIBA U-100 INSULIN . 64

tretinoin (antineoplastic) ...... 23

tretinoin microspheres .......... 53

tretinoin topical .................... 53

triamcinolone acetonide 55, 56,

59, 60

triamterene-


triderm .................................. 56

trientine................................. 58

tri-estarylla ........................... 81

trifluoperazine ...................... 41

trifluridine............................. 82

trihexyphenidyl .................... 28

TRIKAFTA .......................... 88

tri-legest fe............................ 81

tri-linyah ............................... 81

trimethoprim ......................... 13

trimipramine ......................... 41

TRINTELLIX....................... 41

tri-sprintec (28) ..................... 81

TRIUMEQ .............................. 5

trivora (28)............................ 81

TROGARZO .......................... 5

TROPHAMINE 10 % .......... 92

trospium ................................ 89

TRULANCE......................... 69

TRULICITY ......................... 64

TRUMENBA ....................... 74

TRUSELTIQ ........................ 23

TUKYSA .............................. 23

TURALIO ............................ 23

TWINRIX (PF) .................... 74

TYBLUME .......................... 81

TYBOST ................................ 5

TYMLOS ............................. 75

TYPHIM VI ......................... 74

TYSABRI ............................. 30

U UBRELVY ........................... 29

UKONIQ .............................. 23

unithroid ............................... 66

UPTRAVI ............................. 46

ursodiol ................................. 69

V valacyclovir ............................ 5

VALCHLOR ........................ 52

valganciclovir ......................... 5

valproate sodium .................. 27

valproic acid ......................... 27

valproic acid (as sodium salt)

.......................................... 27

valsartan ................................ 46

valsartan-hydrochlorothiazide

.......................................... 46

VALTOCO ........................... 27

vancomycin .......................... 10

VANCOMYCIN .................. 10

VANCOMYCIN IN 0.9 %

SODIUM CHL ................. 10

VANCOMYCIN IN

DEXTROSE 5 % .............. 10

vandazole .............................. 78

VAQTA (PF) ........................ 74

varenicline ............................ 58

VARIVAX (PF) ................... 74

VARIZIG .............................. 74

VARUBI ............................... 69

VASCEPA ............................ 50

VECAMYL .......................... 50

VEKLURY ............................. 5

VELCADE ........................... 23

velivet triphasic regimen (28)

.......................................... 81

VENCLEXTA ...................... 23

VENCLEXTA STARTING

PACK ............................... 23

venlafaxine ........................... 41

VENTOLIN HFA ................. 89

verapamil .............................. 46

VERSACLOZ ...................... 41

VERZENIO .......................... 23

VICTOZA 2-PAK ................ 64

VICTOZA 3-PAK ................ 64

vigabatrin .............................. 27

VIIBRYD ............................. 41

VIMPAT ............................... 27

vinblastine ............................. 23

vincasar pfs ........................... 23

vincristine ............................. 23

vinorelbine ............................ 23

viorele (28) ........................... 81

VIRACEPT ............................. 5

VIREAD ................................. 5

VITRAKVI ........................... 23

VIVITROL ........................... 35

VIZIMPRO ........................... 23

voriconazole ........................... 1

VOSEVI ................................. 5

VOTRIENT .......................... 23

VPRIV .................................. 66

VRAYLAR ........................... 41

VUMERITY ......................... 30

VYNDAMAX ...................... 50

VYNDAQEL ........................ 50

W warfarin ................................. 48

WELIREG ............................ 24

wera (28) ............................... 81

wixela inhub ......................... 89

wymzya fe ............................ 81

X XALKORI ............................ 24

XARELTO ........................... 48

XARELTO DVT-PE TREAT

30D START ...................... 48

XATMEP .............................. 24

XCOPRI ............................... 27

XCOPRI MAINTENANCE

PACK ............................... 27

XCOPRI TITRATION PACK

.......................................... 27

XELJANZ ............................. 77

XELJANZ XR ...................... 77

XERMELO ........................... 24

XGEVA ................................ 14

XIFAXAN ............................ 10

XIGDUO XR ........................ 64

XOFLUZA ............................. 5

XOLAIR ............................... 89

XOSPATA ............................ 24

XPOVIO ............................... 24




108

XTANDI............................... 24

XYREM ............................... 41

Y YERVOY ............................. 24

YF-VAX (PF) ....................... 74

YONDELIS .......................... 24

YONSA ................................ 24

Z zafirlukast ............................. 89

ZALTRAP ............................ 24

ZARXIO ............................... 71

ZEJULA ............................... 24

ZELBORAF ......................... 24

ZENPEP ............................... 69

zidovudine .......................... 5, 6

ZIMHI .................................. 35

ziprasidone hcl ...................... 41

ziprasidone mesylate ............ 42

ZIRABEV ............................. 24

ZIRGAN ............................... 82

zoledronic acid ..................... 66

zoledronic acid-mannitol-water

.................................... 58, 66

ZOLINZA ............................. 24

zolmitriptan ........................... 29

zolpidem ............................... 42

zonisamide ............................ 28

ZORTRESS .......................... 24

zovia 1-35 (28) ..................... 81

ZYDELIG ............................. 24

ZYKADIA ............................ 24

ZYPREXA RELPREVV ...... 42

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