20 Drug Formulary - Kaiser Permanente€¦ · Over-the-Counter (OTC) Drugs A few plans offer...

XB0001338-50-17

Effective August 2020

2020 Drug FormularyFor members covered through large employer groups with a 3-tier in-network pharmacy

benefit or members with an out-of-network pharmacy benefit

Tip: To bring up the search box and search by drug name:

PC: Control + F | Mac: Command + F

Access PPO

Alliance

Alliant Plus

Core

Elect PPO

Omni PPO

Options PPO

All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.

Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.

How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.

How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.

Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.

Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.

Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non-formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug.

Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 30 days prior to the effective date.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:

• Preferred blood glucose strips:

o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required

• Disposable insulin syringes and needles

• Lancing devices and lancets

Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order Pharmacy

PO Box 34383 Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630-4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives Most plans cover Affordable Care Act (ACA) requirements for preventative care medications and contraceptives in full. View our Preventive Medications List (PDF) formulary to see which preventive drugs and contraceptives are covered in full. (This list can also be found on the www.kp.org/wa/formulary webpage.)

Note: If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods on the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out- of- network (OON) benefits, contraceptives will be subject to the OON cost-share.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend

a preferred generic or therapeutically equivalent product. If you and your provider determine that the

preferred contraceptive(s) would be medically inappropriate, your provider must request a

contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be

covered in full.

Excluded Prescription Products for Medications that have Over-The-Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), and fluticasone propionate nasal spray (Flonase).

Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

https://www1.ghc.org/static/pdf/public/formulary/aca-list.pdf

How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.

The most current drug formulary is available at www.kp.org/wa/formulary.

9

Table of Contents

Analgesics - Drugs for Pain and Inflammation ........................................................................ 11

Analgesics - Drugs for Pain .......................................................................................................... 12

Anesthetics ....................................................................................................................................... 14

Anti-Addiction / Substance Abuse Treatment Agents........................................................... 15

Antibacterials .................................................................................................................................... 16

Anticoagulants ................................................................................................................................. 18

Anticonvulsants - Drugs for Seizures ........................................................................................ 19

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 20

Antidepressants ............................................................................................................................... 21

Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 22

Antifungals ........................................................................................................................................ 23

Antigout Agents ............................................................................................................................... 24

Anti-inflammatory Agents ............................................................................................................. 24

Antimigraine Agents ....................................................................................................................... 24

Antimyasthenic Agents .................................................................................................................. 25

Antimycobacterials ......................................................................................................................... 25

Antineoplastics - Drugs for Cancer ............................................................................................ 25

Antiparasitics .................................................................................................................................... 27

Antiparkinson Agents ..................................................................................................................... 28

Antiplatelets ...................................................................................................................................... 29

Antipsychotics - Drugs for Mood Disorders ............................................................................ 29

Antivirals ............................................................................................................................................ 30

Anxiolytics - Drugs for Anxiety .................................................................................................... 32

Bipolar Agents - Drugs for Mood Disorders ............................................................................. 32

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 33

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 33

Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 38

Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 39

Central Nervous System Agents - Miscellaneous .................................................................. 39

Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 40

Dermatological Agents - Drugs for Skin Conditions ............................................................. 40

Diabetes - Antidiabetic Agents .................................................................................................... 47

Diabetes - Glucose Monitoring .................................................................................................... 48

Diabetes - Glycemic Agents ......................................................................................................... 49

Diabetes - Insulins ........................................................................................................................... 49

Electrolytes / Minerals / Metals / Vitamins ................................................................................ 51

10

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 53

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 53

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 55

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 55

Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 56

Hormonal Agents - Adrenal .......................................................................................................... 56

Hormonal Agents - Men's Health ................................................................................................. 58

Hormonal Agents - Osteoporosis ............................................................................................... 58

Hormonal Agents - Pituitary ......................................................................................................... 58

Hormonal Agents - Prostaglandins ............................................................................................ 59

Hormonal Agents - Sex Hormones and Birth Control ........................................................... 59

Hormonal Agents - Thyroid ........................................................................................................... 63

Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 64

Immunological Agents - Drugs for Vaccination ...................................................................... 65

Inflammatory Bowel Disease Agents ......................................................................................... 66

Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 67

Metabolic Bone Disease Agents - Other ................................................................................... 67

Miscellaneous Therapeutic Agents ............................................................................................ 67

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 70

Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 71

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 72

Otic Agents - Drugs for Ear Conditions ..................................................................................... 73

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 73

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 75

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 77

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 77

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 77

Sleep Disorder Agents ................................................................................................................... 78

Index of Drugs .................................................................................................................................. 80

Effective Date: 08/01/2020 11

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ARTHROTEC 3

CELEBREX 3

celecoxib oral 1

DAYPRO 3

DICLOFENAC EPOLAMINE

3

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 %

3

diclofenac sodium transdermal solution

3

diclofenac-misoprostol 3

DICLOFONO 3

diflunisal oral 1

DUEXIS 3 PA; QL

EC-NAPROSYN 3

ec-naproxen 3

etodolac 1

etodolac er 3

FELDENE 3

fenoprofen calcium oral 3

fenortho 3

FLECTOR 3

flurbiprofen oral 1

GABAPENTIN-NAPROXEN CMPD KIT

3

ibu 1

ibuprofen oral suspension 3

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

INDOCIN 3

indomethacin er 1

indomethacin oral capsule 25 mg, 50 mg

1

ketoprofen er 3

Drug Name Drug Tier

Notes

ketoprofen oral 3

ketorolac tromethamine injection

1

ketorolac tromethamine intramuscular

1

ketorolac tromethamine oral

3

LICART 3

LODINE 3

meclofenamate sodium oral

1

mefenamic acid oral 3

meloxicam oral 1

MOBIC 3

nabumetone oral 1

NALFON 3

NAPRELAN 3

NAPROSYN ORAL SUSPENSION

3

naproxen dr 3

naproxen oral 1

naproxen sodium er 3

naproxen sodium oral tablet 275 mg, 550 mg

1

naproxen-esomeprazole 3 PA; QL

oxaprozin 3

PENNSAID 3

piroxicam oral 1

QMIIZ ODT 3

RELAFEN DS 3 PA

REXAPHENAC 3

salsalate oral 1

SPRIX 3

sulindac oral 1

TIVORBEX 3

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet

3


Drug Name Drug Tier

Notes

VIMOVO 3 PA; QL

VIVLODEX 3

VOLTAREN 3

ZIPSOR 3 PA

ZORVOLEX 3 PA

Analgesics - Drugs for Pain

7T GUMMY ES 3

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 400 MCG, 600 MCG, 800 MCG

3 PA; QL

acetaminophen-codeine 1 QL

acetaminophen-codeine #2

1 QL


1 QL


1 QL

ACTIQ 3 PA; QL

ALLZITAL 3

APADAZ 3 QL

apap-caff-dihydrocodeine 3 QL

ARYMO ER 3 ST; QL

ascomp-codeine 3 QL

BELBUCA 3 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

3 QL

BUPAP 3

buprenorphine transdermal

3 PA; QL

butalbital-acetaminophen capsule 50-300 mg oral

3

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

3

butalbital-acetaminophen oral tablet

3

butalbital-apap-caff-cod 3 QL

butalbital-apap-caffeine oral capsule

3

Drug Name Drug Tier

Notes

butalbital-apap-caffeine oral tablet

1

butalbital-asa-caff-codeine

3 QL

butalbital-aspirin-caffeine 1

butorphanol tartrate nasal 3

BUTRANS 3 PA; QL

carisoprodol-aspirin-codeine

3 PA

codeine sulfate 1 QL

CONZIP 3 ST; QL

DILAUDID ORAL 3 QL

DOLOPHINE 3 ST; QL

DURAGESIC-100 3 PA; QL





duraxin 3

DVORAH 3 QL

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

3 PA

endocet 1 QL

ESGIC 3

fentanyl citrate buccal lozenge on a handle

3 PA; QL

FENTANYL CITRATE BUCCAL TABLET

3 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

3 PA; QL


Drug Name Drug Tier

Notes

FENTANYL-BUPIVACAINE-NACL INJECTION

3

FENTORA 3 PA; QL

FIORICET 3

FIORICET/CODEINE 3 QL

FIORINAL 3

FIORINAL/CODEINE #3 3 QL

hydrocodone bitartrate er 3 QL

hydrocodone-acetaminophen oral solution 10-325 mg/15ml

3 QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

3 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 QL

hydrocodone-ibuprofen 3 QL

hydromorphone hcl er 3 ST; QL

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal 1

HYSINGLA ER 3 PA; QL

KADIAN 3 PA; QL

LAZANDA 3 PA; QL

levorphanol tartrate oral 1 PA; QL

lorcet 1 QL

lorcet hd 1 QL

lorcet plus oral tablet 7.5-325 mg

1 QL

LORTAB 3 QL

meperidine hcl oral tablet 3 QL

methadone hcl intensol 1 ST; QL

methadone hcl oral 1 ST; QL

Drug Name Drug Tier

Notes

methadose oral concentrate 10 mg/ml

3 ST; QL

methadose oral tablet soluble

1 ST; QL

methadose sugar-free 3 ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate er beads 3 ST; QL

morphine sulfate er oral capsule extended release 24 hour

3 PA; QL

morphine sulfate er oral tablet extended release

1 ST; QL

morphine sulfate oral 1 QL

morphine sulfate rectal 1

MS CONTIN 3 ST; QL

NALOCET 3 QL

NORCO 3 QL

NUCYNTA 3 PA; QL

NUCYNTA ER 3 ST; QL

OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG

3 QL

OXYCODONE HCL ER 2 ST; QL

oxycodone hcl oral capsule

3 QL

oxycodone hcl oral concentrate 100 mg/5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet 1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

oxycodone-acetaminophen oral tablet 2.5-300 mg

3 QL

oxycodone-aspirin 1 QL

OXYCONTIN 2 ST; QL

oxymorphone hcl 3 QL

oxymorphone hcl er 3 ST; QL


Drug Name Drug Tier

Notes

pentazocine-naloxone hcl 3

PERCOCET 3 QL

PRIMLEV 3 QL

PROLATE 3 QL

ROXICODONE 3 QL

SUBSYS 3 PA; QL

tencon 3

tramadol hcl er (biphasic) 3 ST; QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3 ST; QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

3 ST; QL

tramadol hcl er oral tablet extended release 24 hour

3 ST; QL

tramadol hcl ir 1 QL

tramadol-acetaminophen 1 QL

TREZIX 3 QL

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG

3 QL

ULTRACET 3 QL

ULTRAM 3 QL

VANATOL LQ 3

VANATOL S 3

VTOL LQ 3

XTAMPZA ER 3 ST; QL

ZEBUTAL 3

ZOHYDRO ER 3 PA; QL

Anesthetics

1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %

3

7T LIDO 3

AGONEAZE 3

ANODYNE LPT 3

ASTERO 3

Drug Name Drug Tier

Notes

COCAINE HCL NASAL 3

DERMACINRX EMPRICAINE

3

DERMACINRX PRIZOPAK

3

EHA 3

ethyl chloride 3

FLEXIN 3

GEBAUERS PAIN EASE 3

GEBAUERS SPRAY AND STRETCH

3

GEN7T 3

glydo 1

GOPRELTO 3

LDO PLUS 3

LEVATIO 3

LIDO BDK 3

lidocaine external ointment

3

lidocaine external patch 5 %

1

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %

3

lidocaine hcl external cream 3 %

3

LIDOCAINE HCL EXTERNAL CREAM 4.12 %

3

lidocaine hcl external lotion

3 PA

lidocaine hcl external solution

3

lidocaine hcl injection solution

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

3

lidocaine hcl urethral/mucosal

1


Drug Name Drug Tier

Notes

lidocaine-epinephrine injection solution 1 %-1:100000

3

lidocaine-prilocaine 1

LIDODERM 3

LIDOMAR 3

lidopin external cream 3 %

3

LIDOPRIL 3

LIDOPRIL XR 3

LIDO-PRILO CAINE PACK

3

LIDORX 3 PA

LIDO-SORB 3 PA

LIDOTHOL EXTERNAL PATCH

3

LIDOTRAL 3

LIVIXIL PAK 3

MEDI-PATCH RX 3

NUMBRINO 3

NUVAKAAN 3

NUVAKAAN-II 3

premium lidocaine 3

PRILOLID 3

PRILOVIX 3

PRILOVIX LITE 3

PRILOVIX LITE PLUS 3

PRILOVIX PLUS 3

prilovix ultralite 1

prilovix ultralite plus 1

RELADOR PAK 3

RELADOR PAK PLUS 3

RENOVO 3

SOOTHEE 3

SYNERA 3

VEXATROL 3

XYLOCAINE 3

Drug Name Drug Tier

Notes

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 1 %-1:100000

3

XYLOCAINE-MPF 3

ZERUVIA 3

ZIONODIL 3 PA

ZIONODIL 100 3 PA

ZTLIDO 3

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium 1

ANTABUSE 3

BUNAVAIL 3

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual film

3

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1

bupropion hcl er (smoking det)

1

CHANTIX 2

CHANTIX CONTINUING MONTH PAK

2

CHANTIX STARTING MONTH PAK

2

disulfiram oral 1

EVZIO 3

goodsense nicotine mouth/throat gum

2 PA

LUCEMYRA 3 PA; QL

naloxone hcl injection solution

1

NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR

3

naloxone hcl injection solution cartridge

1

naloxone hcl injection solution prefilled syringe

1


Drug Name Drug Tier

Notes

naltrexone hcl oral 1

NARCAN 1

NICORETTE MOUTH/THROAT GUM 2 MG

2 PA

nicotine polacrilex mouth/throat

2 PA

nicotine step 1 1 PA



SUBOXONE 3

VIVITROL 2 QL

ZUBSOLV 3

Antibacterials

ACTICLATE 3

AEMCOLO 3 PA

ALTABAX 3

amoxicillin 1

amoxicillin-potassium clavulanate er

3

amoxicillin-potassium clavulanate oral

1

ampicillin 1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg

1

ARIKAYCE 3

AUGMENTIN 3

AUGMENTIN ES-600 3

avidoxy 1

azithromycin oral 1

BACTRIM 3

BACTRIM DS 3

BAXDELA ORAL 3 QL

BICILLIN L-A 2

cefaclor 3

cefaclor er 3

cefadroxil 1

Drug Name Drug Tier

Notes

cefazolin sodium injection solution reconstituted 1 gm

1

cefdinir 1

cefditoren pivoxil 3

cefepime hcl injection solution reconstituted 1 gm

3

cefixime 1

cefpodoxime proxetil 3

cefprozil 1

ceftazidime injection solution reconstituted 1 gm

1

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

1

cefuroxime axetil 1

CENTANY 3

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral capsule 750 mg

3

cephalexin oral suspension reconstituted

1

cephalexin oral tablet 3

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

2

CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%)

3

CIPRO ORAL TABLET 3

ciprofloxacin hcl oral 1

clarithromycin er 3

clarithromycin oral 1

CLEOCIN 3

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML

3


Drug Name Drug Tier

Notes

clindamycin hcl oral 1

clindamycin palmitate hcl 1

clindamycin phosphate injection solution 300 mg/2ml

1

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

3

COLY-MYCIN M 3

coremino 3 PA

demeclocycline hcl 3

dicloxacillin sodium 1

DIFICID 3 PA; QL

DORYX 3

DORYX MPC 3

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline hyclate oral tablet delayed release

3

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral suspension reconstituted

3

doxycycline monohydrate oral tablet

1

E.E.S. 400 3

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN STEARATE

3

erythromycin base 3

erythromycin ethylsuccinate oral

3

Drug Name Drug Tier

Notes

erythromycin oral 3

FIRVANQ 2

FLAGYL 3

gentamicin sulfate external

1

gentamicin sulfate injection solution 40 mg/ml

1

HIPREX 3

KEFLEX 3

levofloxacin oral 1

LINCOCIN 3

lincomycin hcl injection 3

linezolid oral suspension reconstituted

1 QL

linezolid oral tablet 1

MACROBID 3

MACRODANTIN 3

mafenide acetate external 3

methenamine hippurate 1

methenamine mandelate oral

3

metronidazole oral capsule

3

metronidazole oral tablet 1

metronidazole vaginal 1

minocycline hcl er oral tablet extended release 24 hour

3 PA

minocycline hcl oral capsule

1

minocycline hcl oral tablet 3

MINOLIRA 3 PA

mondoxyne nl 1

MONUROL 3

morgidox oral 1

moxifloxacin hcl oral 1

mupirocin calcium 1

mupirocin external 1


Drug Name Drug Tier

Notes

neomycin sulfate oral 1

neomycin-polymyxin b gu 3

nitrofurantoin 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

NUVESSA 3

NUZYRA ORAL 3 QL

ofloxacin oral 3

paromomycin sulfate oral 3

penicillin v potassium 1

PRIMSOL 2

SEYSARA 3 PA; QL

SILVADENE 3

silver nitrate external 3

silver sulfadiazine external

1

SIVEXTRO ORAL 2 QL

SOLODYN 3 PA

SOLOSEC 3

ssd 1

streptomycin sulfate intramuscular

3

sulfadiazine oral 3

sulfamethoxazole-trimethoprim oral

1

SULFAMYLON 3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

Drug Name Drug Tier

Notes

SUPRAX ORAL TABLET CHEWABLE

3

TARGADOX 3

tazicef injection solution reconstituted 1 gm

1

tetracycline hcl oral 3

tinidazole oral 3

trimethoprim oral 1

VANCOCIN 3 QL

VANCOCIN HCL 3 QL

vancomycin hcl oral capsule

1 QL

vancomycin hcl oral solution reconstituted

1

vandazole 1

VIBRAMYCIN 3

XENLETA ORAL 3

XEPI 3

XIFAXAN 3 PA; QL

XIMINO 3 PA

ZITHROMAX ORAL 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZYVOX ORAL SUSPENSION RECONSTITUTED

3 QL

ZYVOX ORAL TABLET 3

Anticoagulants

ARIXTRA 3 QL

ELIQUIS 3 PA

ELIQUIS DVT/PE STARTER PACK

3 PA

enoxaparin sodium 1 QL

fondaparinux sodium 1 QL


Drug Name Drug Tier

Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

3

FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML

3 PA

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) pf

1

jantoven 1

LOVENOX 1 QL

PRADAXA 2

SAVAYSA 3 PA

warfarin sodium oral 1

XARELTO 2 PA

XARELTO STARTER PACK

2 PA

Anticonvulsants - Drugs for Seizures

APTIOM 3 PA; QL

BANZEL 3 QL

BRIVIACT ORAL 3 PA

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 2

clobazam 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIACOMIT 3 PA; QL

DIASTAT ACUDIAL 3

Drug Name Drug Tier

Notes

DIASTAT PEDIATRIC 1

diazepam rectal 1

DILANTIN INFATABS 3

DILANTIN ORAL CAPSULE 100 MG

3

DILANTIN ORAL CAPSULE 30 MG

2

DILANTIN ORAL SUSPENSION

3

divalproex sodium er 1

divalproex sodium oral 1

EPIDIOLEX 3 PA; QL

epitol 1

ethosuximide oral 1

felbamate oral suspension

3

felbamate oral tablet 3 QL

FELBATOL ORAL SUSPENSION

3

FELBATOL ORAL TABLET

3 QL

FINTEPLA 3

FYCOMPA 3 ST; QL

gabapentin oral 1

GABITRIL 3

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL 3

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 3

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

3

lamotrigine starter kit-blue 3


Drug Name Drug Tier

Notes

lamotrigine starter kit-green

3

lamotrigine starter kit-orange

3

levetiracetam er 1

levetiracetam oral 1

MYSOLINE 3 QL

NAYZILAM 3 PA; QL

NEMBUTAL 3

NEURONTIN 3

ONFI 3

oxcarbazepine 1

OXTELLAR XR 3

PEGANONE 3

pentobarbital sodium injection

3

phenobarbital oral 1

phenobarbital sodium injection solution 130 mg/ml

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral suspension 125 mg/5ml

1

phenytoin oral tablet chewable

1

phenytoin sodium extended oral capsule 100 mg

1

phenytoin sodium extended oral capsule 200 mg, 300 mg

3

phenytoin sodium injection

1

primidone oral 1 QL

QUDEXY XR 3 PA

roweepra 1

roweepra xr 1

SABRIL ORAL PACKET 3

SABRIL ORAL TABLET 3 PA

SPRITAM 3

Drug Name Drug Tier

Notes

subvenite 1

subvenite starter kit-blue 3

subvenite starter kit-green 3

subvenite starter kit-orange

3

SYMPAZAN 3

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl 3

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 3 PA

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 PA

valproic acid oral 1

VALTOCO 10 MG DOSE 2



VALTOCO 5 MG DOSE 2

vigabatrin oral packet 3

vigabatrin oral tablet 3 PA

vigadrone 3

VIMPAT ORAL 3

XCOPRI 3 PA; QL

XCOPRI (250 MG DAILY DOSE)

3 PA; QL

XCOPRI (350 MG DAILY DOSE)

3 PA; QL

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT 3

donepezil hcl oral tablet 10 mg, 5 mg

1


Drug Name Drug Tier

Notes

donepezil hcl oral tablet 23 mg

3

donepezil hcl oral tablet dispersible

3

EXELON 3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 3 PA

memantine hcl oral solution

3

memantine hcl oral tablet 10 mg, 5 mg

1

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

3

NAMENDA 3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 PA

NAMENDA XR TITRATION PACK

3 PA

NAMZARIC 3

RAZADYNE 3

RAZADYNE ER 3

rivastigmine 3

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN 3

BRISDELLE 3

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

3 ST

Drug Name Drug Tier

Notes

bupropion hcl oral 1

CELEXA 3

chlordiazepoxide-amitriptyline

3

citalopram hydrobromide 1

clomipramine hcl oral 1

CYMBALTA 3

desipramine hcl oral 1

DESVENLAFAXINE ER 3 PA

desvenlafaxine succinate er

3 PA

doxepin hcl oral capsule 1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3

duloxetine hcl oral 1

EFFEXOR XR 3

EMSAM 3

escitalopram oxalate 1

FETZIMA 3 ST

FETZIMA TITRATION 3 PA

fluoxetine hcl (pmdd) 3

fluoxetine hcl oral capsule 1

fluoxetine hcl oral capsule delayed release

3

fluoxetine hcl oral solution 1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

fluvoxamine maleate er 3

FORFIVO XL 3 ST

imipramine hcl oral 1

imipramine pamoate 3

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 3

nefazodone hcl 3


Drug Name Drug Tier

Notes

NORPRAMIN 3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl 3

PAMELOR 3

PARNATE 3

paroxetine hcl 1

paroxetine hcl er 3

paroxetine mesylate 3

PAXIL CR 3

PAXIL ORAL SUSPENSION

2

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA 3

phenelzine sulfate oral 1

PRISTIQ 3 PA

protriptyline hcl 1

PROZAC 3

REMERON 3

REMERON SOLTAB 3

SARAFEM 3

sertraline hcl oral 1

SYMBYAX 3

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral 3

TRINTELLIX 3 ST

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

venlafaxine hcl er oral tablet extended release 24 hour

3

VIIBRYD 3 ST

VIIBRYD STARTER PACK

3 ST

WELLBUTRIN SR 3

Drug Name Drug Tier

Notes

WELLBUTRIN XL 3

ZOLOFT 3

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL 3

ANZEMET 3

aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1

aprepitant oral capsule 40 mg

3

BONJESTA 3 PA

compro 1

DICLEGIS 3 PA

dimenhydrinate injection 1

doxylamine-pyridoxine 3 PA

dronabinol 1

EMEND ORAL 3

EMEND TRI-PACK 3

granisetron hcl oral 3 PA

MARINOL 3

meclizine hcl oral tablet 3

metoclopramide hcl injection

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

3

ondansetron hcl injection 1

ondansetron hcl oral 1

ondansetron odt 1

perphenazine oral 1

prochlorperazine 1

prochlorperazine edisylate injection

1

prochlorperazine maleate oral

1

REGLAN 3


Drug Name Drug Tier

Notes

SANCUSO 3 PA

scopolamine 3

SYNDROS 3

TIGAN 3

TRANSDERM SCOP (1.5 MG)

3

TRANSDERM-SCOP (1.5 MG)

3

trimethobenzamide hcl oral

3

VARUBI (180 MG DOSE) 3 PA

VARUBI ORAL TABLET 90 MG

3 PA

ZOFRAN 3

ZUPLENZ 3

Antifungals

ANCOBON 3 QL

BIO-STATIN ORAL CAPSULE

3

bio-statin oral powder 3

ciclodan 1

ciclopirox external gel 1

ciclopirox external shampoo

3

ciclopirox external solution

1

ciclopirox olamine external

1

clotrimazole external 3

clotrimazole mouth/throat 1

clotrimazole-betamethasone

1

CRESEMBA ORAL 2 PA; QL

DIFLUCAN 3

ECONASIL 3

econazole nitrate external 3

ECOZA 3

ERTACZO 3

EXELDERM 3

exoderm external lotion 3

Drug Name Drug Tier

Notes

EXTINA 3

fluconazole oral 1

flucytosine oral 2 QL

griseofulvin microsize oral 1

griseofulvin ultramicrosize 1

GYNAZOLE-1 3

itraconazole oral 1 PA

JUBLIA 3 PA

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

3

ketoconazole external shampoo

1

ketoconazole oral 1

ketodan external foam 3

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT 0.77 % (SUSP)

3

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LULICONAZOLE 3

LUZU 3

miconazole 3 vaginal suppository

3

MICONAZOLE-ZINC OXIDE-PETROLAT

3

naftifine hcl 3

NAFTIN 3

NOXAFIL ORAL SUSPENSION

3 PA; QL

NOXAFIL ORAL TABLET DELAYED RELEASE

3 PA

nyamyc 1

nystatin external 1

nystatin mouth/throat 1


Drug Name Drug Tier

Notes

nystatin oral 1

nystatin-triamcinolone 1

nystop 1

ORAVIG 3

oxiconazole nitrate 3

OXISTAT 3

posaconazole 3 PA

SPORANOX 3 PA

SPORANOX PULSEPAK 3 PA

terbinafine hcl oral 1

terconazole 3

TOLSURA 3 PA

VFEND 3 PA

voriconazole oral 1 PA

VUSION 3

XOLEGEL 3

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

1

colchicine tablet 0.6 mg oral

1

COLCHICINE TABLET 0.6 MG ORAL (authorized generic)

2

colchicine-probenecid 1

COLCRYS 2

febuxostat 3 PA

GLOPERBA 3

MITIGARE 3

probenecid 1

ULORIC 3 PA

ZYLOPRIM 3

Anti-inflammatory Agents

EMFLAZA 3 PA; QL

Antimigraine Agents

Drug Name Drug Tier

Notes

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

3 PA

AJOVY 3 PA

almotriptan malate 3 ST

AMERGE 3

CAFERGOT 3

CAMBIA 3 PA

D.H.E. 45 3 QL

dihydroergotamine mesylate injection

1 QL

dihydroergotamine mesylate nasal

1

eletriptan hydrobromide 3 ST

EMGALITY 3 PA

EMGALITY (300 MG DOSE)

3 PA

ERGOMAR 2

ergotamine-caffeine 1

FROVA 3 ST

frovatriptan succinate 3 ST

IMITREX 3

IMITREX STATDOSE REFILL

3

IMITREX STATDOSE SYSTEM

3

MAXALT 3

MAXALT-MLT 3

MIGERGOT 2

MIGRANAL 3

naratriptan hcl 1

NURTEC 3 PA

RELPAX 3 ST

REYVOW 3 PA

rizatriptan benzoate 1

sumatriptan nasal 1

sumatriptan succinate oral

1


Drug Name Drug Tier

Notes

sumatriptan succinate refill

1

sumatriptan succinate subcutaneous

1

sumatriptan-naproxen sodium

3 ST

TOSYMRA 3

TREXIMET 3 ST

UBRELVY 3 PA

ZEMBRACE SYMTOUCH 3

zolmitriptan oral 1

ZOMIG 3

ZOMIG ZMT 3

Antimyasthenic Agents

GUANIDINE HCL 3

MESTINON ORAL SOLUTION

2

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

pyridostigmine bromide er 1

pyridostigmine bromide oral

1

Antimycobacterials

cycloserine oral 3

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL 2

MYCOBUTIN 3

PASER 3

PRIFTIN 2

pyrazinamide oral 1

rifabutin 1

RIFADIN ORAL 3

RIFAMATE 3

rifampin oral 1

Drug Name Drug Tier

Notes

RIFATER 3

SIRTURO ORAL TABLET 100 MG

3 PA; QL

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 QL

AFINITOR DISPERZ 2 PA; QL

AFINITOR ORAL TABLET 10 MG

2 PA; QL

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG

3 PA; QL

ALECENSA 3 PA; QL

ALKERAN ORAL 3 QL

ALUNBRIG 3 PA; QL

anastrozole oral 1

ARIMIDEX 3

AROMASIN 3

AYVAKIT 3 PA; QL

BALVERSA 3 PA; QL

bexarotene 3 PA; QL

bicalutamide 1

BOSULIF 3 PA; QL

BRAFTOVI 3 PA; QL

BRUKINSA 3 PA; QL

CABOMETYX 3 PA

CALQUENCE 3 PA; QL

capecitabine 1 QL

CAPRELSA 3 PA; QL

CASODEX 3

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

3 PA; QL

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

3 PA; QL

COMETRIQ (60 MG DAILY DOSE)

3 PA; QL

COPIKTRA 3 PA; QL

COTELLIC 2 PA; QL


Drug Name Drug Tier

Notes

cyclophosphamide oral 1

DAURISMO 3 PA; QL

DROXIA 2

EMCYT 3 QL

ERIVEDGE 3 PA

ERLEADA 3 PA; QL

erlotinib hcl 1 PA

etoposide oral 1 QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

1 PA; QL

exemestane 1

FARESTON 3 PA

FARYDAK 3 PA; QL

FEMARA 3

flutamide 1

GILOTRIF 2 PA; QL

GLEEVEC 3 QL

GLEOSTINE 2

HYCAMTIN ORAL 3 QL

HYDREA 3

hydroxyurea oral 1

IBRANCE 3 PA; QL

ICLUSIG 3 PA; QL

IDHIFA 3 PA; QL

imatinib mesylate 1 QL

IMBRUVICA 2 PA; QL

INLYTA 3 PA; QL

INREBIC 3 PA; QL

IRESSA 2 PA; QL

JAKAFI 3 PA

KISQALI (200 MG DOSE) 3 PA; QL



KISQALI FEMARA (400 MG DOSE)

3 PA; QL

KISQALI FEMARA (600 MG DOSE)

3 PA; QL

KISQALI FEMARA(200 MG DOSE)

3 PA; QL

Drug Name Drug Tier

Notes

KOSELUGO 3 PA; QL

LENVIMA (10 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL


3 PA


3 PA; QL


3 PA; QL


3 PA; QL


3 PA

letrozole oral 1

leucovorin calcium injection solution 100 mg/10ml

3

leucovorin calcium oral 1

LEUKERAN 2

LONSURF 3 PA; QL

LORBRENA 3 PA; QL

LYNPARZA ORAL CAPSULE 50 MG

3 PA; QL

LYSODREN 3 PA

MATULANE 2 QL

MEKINIST 2 PA; QL

MEKTOVI 3 PA; QL

melphalan 1 QL

mercaptopurine oral 1

mesna 1

MESNEX ORAL 2

MYLERAN 2 QL

NERLYNX 3 PA; QL

NEXAVAR 2 PA

NILANDRON 3 PA

nilutamide 3 PA

NINLARO 3 PA; QL


Drug Name Drug Tier

Notes

NUBEQA 3 PA; QL

ODOMZO 3 PA; QL

PANRETIN 3 PA; QL

PEMAZYRE 3 PA; QL

PIQRAY (200 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL

POMALYST 3 PA; QL

PURIXAN 3 PA

QINLOCK 3 PA; QL

RETEVMO 3 PA; QL

REVLIMID 2 PA; QL

ROZLYTREK 3 PA; QL

RUBRACA 3 PA; QL

RYDAPT 2 PA; QL

SIKLOS 3 PA; QL

SOLTAMOX 3

SPRYCEL 2 PA; QL

STIVARGA 2 PA

SUTENT 2 PA; QL

TABLOID 2

TABRECTA 3 PA; QL

TAFINLAR 2 PA; QL

TAGRISSO 2 PA; QL

TALZENNA 3 PA; QL

tamoxifen citrate oral 1

TARCEVA 3 PA

TARGRETIN 3 PA; QL

TASIGNA 3 PA; QL

TAZVERIK 3 PA; QL

TEMODAR ORAL 3 QL

temozolomide 1 QL

THALOMID 2 PA; QL

TIBSOVO 3 PA; QL

toremifene citrate 3 PA

tretinoin oral 1 QL

Drug Name Drug Tier

Notes

TUKYSA 3 PA; QL

TURALIO 3 PA; QL

TYKERB 2 PA; QL

VALCHLOR 3 PA; QL

VENCLEXTA 2 PA; QL

VENCLEXTA STARTING PACK

2 PA; QL

VERZENIO 3 PA; QL

VITRAKVI 3 PA; QL

VIZIMPRO 3 PA; QL

VOTRIENT 2 PA; QL

XALKORI 3 PA; QL

XELODA 3 QL

XOSPATA 3 PA; QL

XPOVIO (100 MG ONCE WEEKLY)

3 PA; QL


3

XPOVIO (40 MG TWICE WEEKLY)

3


3 PA; QL


3


3 PA; QL


3 PA; QL

XTANDI 2 PA; QL

YONSA 3 QL

ZEJULA 3 PA; QL

ZELBORAF 2 PA

ZOLINZA 3 PA; QL

ZYDELIG 2 PA; QL

ZYKADIA 3 PA; QL

ZYTIGA ORAL TABLET 250 MG

3 QL

ZYTIGA ORAL TABLET 500 MG

2 QL

Antiparasitics

albendazole oral 1


Drug Name Drug Tier

Notes

ALBENZA 3

ALINIA 2

atovaquone oral 1

BENZNIDAZOLE 3 QL

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 2

DARAPRIM 3 PA; QL

ELIMITE 3

EMVERM 3

hydroxychloroquine sulfate oral

1

IMPAVIDO 3 PA; QL

ivermectin oral 3

KRINTAFEL 2

lindane 3

malathion 3

MEPRON 3

NATROBA 3

NEBUPENT 3

OVIDE 3

PENTAM 3

pentamidine isethionate 3

permethrin external 1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate 1

pyrimethamine oral 1 PA; QL

QUALAQUIN 3

quinine sulfate oral 3

SKLICE 3

spinosad 3

STROMECTOL 3

Antiparkinson Agents

amantadine hcl oral 1

Drug Name Drug Tier

Notes

APOKYN 3 QL

AZILECT 3 PA

benztropine mesylate 1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa er 1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg

1

carbidopa-levodopa oral tablet dispersible 25-250 mg

3

carbidopa-levodopa-entacapone

1

COGENTIN 3

COMTAN 3

DUOPA 2 PA

entacapone 1

GOCOVRI 3 PA; QL

INBRIJA 3 PA; QL

KYNMOBI TITRATION KIT

3

LODOSYN 3

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

NOURIANZ 3 PA; QL

OSMOLEX ER 3 PA

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

3

rasagiline mesylate oral 1 PA

REQUIP XL 3

ropinirole hcl 1

ropinirole hcl er 3


Drug Name Drug Tier

Notes

RYTARY 3 PA

selegiline hcl oral 1

SINEMET 3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR 3 QL

tolcapone 3 QL

trihexyphenidyl hcl 1

XADAGO 3 PA

ZELAPAR 3 QL

Antiplatelets

AGGRENOX 3

aspirin-dipyridamole er 1

BRILINTA 2

CABLIVI 3 PA; QL

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

DURLAZA 3

EFFIENT 3

PLAVIX 3

prasugrel hcl 1

YOSPRALA 3

ZONTIVITY 3

Antipsychotics - Drugs for Mood Disorders

ABILIFY 3

ABILIFY MAINTENA 2 QL

ABILIFY MYCITE 3

aripiprazole oral solution 1

aripiprazole oral tablet 1

aripiprazole oral tablet dispersible

3

ARISTADA 2 QL

Drug Name Drug Tier

Notes

ARISTADA INITIO 2 QL

CAPLYTA 3 PA; QL

chlorpromazine hcl injection

1

chlorpromazine hcl oral 1

clozapine oral tablet 1

clozapine oral tablet dispersible

3

CLOZARIL 3

FANAPT 3 ST

FANAPT TITRATION PACK

3 ST

fluphenazine decanoate injection

1

fluphenazine hcl 1

GEODON 3

HALDOL 3

HALDOL DECANOATE 3

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1

INVEGA 3 ST

INVEGA SUSTENNA 2

INVEGA TRINZA 2 QL

LATUDA 3 PA

loxapine succinate 1

molindone hcl 3

NUPLAZID 3 PA; QL

olanzapine 1

paliperidone er 3 ST

PERSERIS 2

pimozide 1

quetiapine fumarate 1

quetiapine fumarate er 1

REXULTI 3 PA

RISPERDAL 3

RISPERDAL CONSTA 2


Drug Name Drug Tier

Notes

risperidone oral solution 1

risperidone oral tablet 1

risperidone oral tablet dispersible

3

SAPHRIS 3 ST

SECUADO 3 ST

SEROQUEL 3

SEROQUEL XR 3

thioridazine hcl oral 3

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3

VRAYLAR 3 PA; QL

ziprasidone hcl 1

ziprasidone mesylate 3

ZYPREXA 3

ZYPREXA RELPREVV 2

ZYPREXA ZYDIS 3

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

1 QL

acyclovir external 3

acyclovir oral 1

adefovir dipivoxil 1 QL

APTIVUS ORAL CAPSULE

2 QL

APTIVUS ORAL SOLUTION

3 QL

atazanavir sulfate 1 QL

ATRIPLA 2 QL

BARACLUDE ORAL SOLUTION

2 QL

BARACLUDE ORAL TABLET

3 QL

BIKTARVY 2 QL

CIMDUO 2 QL

Drug Name Drug Tier

Notes

COMBIVIR 3

COMPLERA 2 PA; QL

CRIXIVAN 2

DELSTRIGO 3 PA; QL

DENAVIR 3

DESCOVY 2 QL

didanosine 1

DOVATO 2 QL

EDURANT 2

efavirenz 1

EMTRIVA 2

entecavir 1 QL

EPCLUSA 2 PA; QL

EPIVIR 3

EPIVIR HBV ORAL SOLUTION

2

EPIVIR HBV ORAL TABLET

3

EPZICOM 3 QL

EVOTAZ 3 QL

famciclovir oral 3

fosamprenavir calcium 1 QL

FUZEON 3 QL

GENVOYA 2

HARVONI ORAL PACKET

3

HARVONI ORAL TABLET 2 PA; QL

HEPSERA 3 QL

INTELENCE 2

INTRON A 2 QL

INVIRASE 2

ISENTRESS HD 2

ISENTRESS ORAL PACKET

3

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA 2 QL


Drug Name Drug Tier

Notes

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET 2

lamivudine 1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

2 PA; QL

LEXIVA ORAL SUSPENSION

2 QL

LEXIVA ORAL TABLET 3 QL

lopinavir-ritonavir 1

MAVYRET 3 PA; QL

nevirapine er 1

nevirapine oral suspension

3

nevirapine oral tablet 1

NORVIR ORAL PACKET 2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET 3

ODEFSEY 2 QL

oseltamivir phosphate oral

1

PEGASYS 2 QL

PEGASYS PROCLICK 2 QL

PEGINTRON 2 QL

PIFELTRO 3 PA; QL

PREVYMIS ORAL 2 PA; QL

PREZCOBIX 2 QL

PREZISTA 2

RELENZA DISKHALER 2

RETROVIR ORAL 3

REYATAZ ORAL CAPSULE

3 QL

REYATAZ ORAL PACKET

2

ribavirin inhalation 3

ribavirin oral 1 QL

rimantadine hcl 1

ritonavir 1

Drug Name Drug Tier

Notes

SELZENTRY ORAL SOLUTION

2 QL

SELZENTRY ORAL TABLET 150 MG, 300 MG

2 QL

SELZENTRY ORAL TABLET 25 MG, 75 MG

2

SITAVIG 3

SOFOSBUVIR-VELPATASVIR

2 PA; QL

SOVALDI ORAL PACKET 3

SOVALDI ORAL TABLET 200 MG

2 PA; QL

SOVALDI ORAL TABLET 400 MG

3 PA; QL

stavudine 1

STRIBILD 2 PA; QL

SUSTIVA 3

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

3 QL

SYMFI 1

SYMFI LO 1

SYMTUZA 2 QL

TAMIFLU 2

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 3

TRIUMEQ 2 QL

TRIZIVIR 3 QL

TRUVADA 2 QL

TYBOST 2 PA

valacyclovir hcl oral 1

VALCYTE 3 QL

valganciclovir hcl 1 QL

VALTREX 3

VEMLIDY 3 PA; QL

VIEKIRA PAK 3 PA; QL

VIRACEPT 2


Drug Name Drug Tier

Notes

VIRAMUNE 3

VIRAMUNE XR 3

VIRAZOLE 3

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VIREAD ORAL TABLET 300 MG

3

VOSEVI 2 PA; QL

XERESE 3

XOFLUZA (40 MG DOSE)

3

XOFLUZA (80 MG DOSE)

3

ZEPATIER 3 PA; QL

ZIAGEN 3

zidovudine 1

ZOVIRAX EXTERNAL 3

ZOVIRAX ORAL SUSPENSION

3

Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam intensol 3

alprazolam oral tablet 1

alprazolam oral tablet dispersible

3

alprazolam xr 1

ATIVAN INJECTION SOLUTION 2 MG/ML

3

ATIVAN ORAL 3

buspirone hcl oral 1

chlordiazepoxide hcl 1

clonazepam oral 1

clorazepate dipotassium 1

diazepam intensol 3

diazepam intramuscular 1

diazepam oral concentrate

3

Drug Name Drug Tier

Notes

diazepam oral solution 1

diazepam oral tablet 1

diazepam solution 5 mg/ml injection

1

DIAZEPAM SOLUTION 5 MG/ML INJECTION

3

DORAL 3

estazolam 3

HALCION 3

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

KLONOPIN 3

lorazepam injection solution 2 mg/ml

1

lorazepam intensol 1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 1

meprobamate 3

midazolam hcl (pf) injection solution 10 mg/2ml, 5 mg/ml

1

midazolam hcl injection solution 10 mg/2ml, 5 mg/ml

1

midazolam hcl oral 3

oxazepam 1

quazepam 3

TRANXENE-T 3

triazolam 1

VALIUM 3

VISTARIL 3

XANAX 3

XANAX XR 3

Bipolar Agents - Drugs for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

lithium carbonate oral 1


Drug Name Drug Tier

Notes

LITHOBID 3

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

AGRYLIN 3

AMICAR 3

aminocaproic acid oral 3

anagrelide hcl 1

ARANESP (ALBUMIN FREE)

3 PA

DOPTELET 3 PA; QL

EPOGEN 2 PA

FULPHILA 3 PA; QL

GRANIX 3 QL

HEMLIBRA 2 PA; QL

LEUKINE 2

LYSTEDA 3 QL

MIRCERA 3 PA

MULPLETA 3 PA; QL

NEULASTA 3 PA; QL

NEULASTA ONPRO 3 PA; QL

NEUPOGEN 2 QL

NIVESTYM 3 QL

PROCRIT 2 PA

PROMACTA 3 PA; QL

RETACRIT 3 PA

TAVALISSE 3 PA; QL

tranexamic acid oral 1 QL

UDENYCA 3 PA; QL

ZARXIO 2 QL

ZIEXTENZO 3 PA; QL

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

acetazolamide sodium 3

ALDACTAZIDE ORAL TABLET 25-25 MG

3

Drug Name Drug Tier

Notes

ALDACTAZIDE ORAL TABLET 50-50 MG

2

ALDACTONE 3

aliskiren fumarate 3 ST

alprostadil injection 1

ALTACE 3

ALTOPREV 3

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral tablet 100 mg, 400 mg

3

amiodarone hcl oral tablet 200 mg

1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

3 ST

amlodipine-atorvastatin 3

amlodipine-olmesartan 1

amlodipine-valsartan-hctz 3

ANTARA 3

ATACAND 3

ATACAND HCT 3

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

AVALIDE 3

AVAPRO 3

AZOR 3

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1

BENICAR 3

BENICAR HCT 3

BETAPACE 3

BETAPACE AF 3

betaxolol hcl oral 1


Drug Name Drug Tier

Notes

BIDIL 3

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

BRETYLIUM TOSYLATE 3

bumetanide oral 1

BUMEX 3

BYSTOLIC 3

CADUET 3

CALAN SR 3

candesartan cilexetil 3

candesartan cilexetil-hctz 3

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 3

CATAPRES 3

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorothiazide oral 1

chlorthalidone 1

cholestyramine light packets

1

cholestyramine oral packets

1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 3

COLESTID 3

Drug Name Drug Tier

Notes

COLESTID FLAVORED 3

colestipol hcl 1

CONSENSI 3 PA; QL

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA

COZAAR 3

CRESTOR 3

DEMSER 3

DIBENZYLINE 3

digitek 1

digox 1

digoxin injection 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 3

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

diltiazem hcl er coated beads oral tablet extended release 24 hour

3

diltiazem hcl er oral capsule extended release 12 hour

1

diltiazem hcl oral 1

dilt-xr 1

DIOVAN 3

DIOVAN HCT 3

disopyramide phosphate 1

DIURIL 2

dofetilide 3 PA

doxazosin mesylate oral 1

DUTOPROL 3

DYAZIDE 3

DYRENIUM 3

EDARBI 3 ST


Drug Name Drug Tier

Notes

EDARBYCLOR 3 ST

EDECRIN 3 PA

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 PA

EPANED 3

epinephrine pf 1

eplerenone 1

ethacrynic acid 1 PA

EXFORGE 3 ST

EXFORGE HCT 3

EZALLOR SPRINKLE 3

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized 1

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral capsule 150 mg, 50 mg

3

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg

3

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid oral capsule delayed release

3

fenofibric acid oral tablet 1

FENOGLIDE 3

FIBRICOR 3

flecainide acetate 1

FLOLIPID 3

fluvastatin sodium 3

fluvastatin sodium er 3

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide injection 1

furosemide oral 1

Drug Name Drug Tier

Notes

gemfibrozil oral 1

GONITRO 3

guanfacine hcl 1

HEMANGEOL 3 PA

hydralazine hcl oral 1

hydrochlorothiazide oral 1

HYZAAR 3

indapamide 1

INDERAL LA 3

INDERAL XL 3

INNOPRAN XL 3

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

isoproterenol hcl injection 3

ISORDIL TITRADOSE 3

isosorbide dinitrate 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

isradipine 1

ISUPREL 3

JUXTAPID 3 PA; QL

KAPSPARGO SPRINKLE 3

KATERZIA 3

labetalol hcl oral 1

LANOXIN 3

LANOXIN PEDIATRIC 3

LASIX 3

LESCOL XL 3

LIPITOR 3

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3

LOPID 3


Drug Name Drug Tier

Notes

LOPRESSOR 3

LOPRESSOR HCT 3

losartan potassium oral 1

losartan potassium-hctz 1

LOTENSIN 3

LOTENSIN HCT 3

LOTREL 3

lovastatin 1

LOVAZA 3

matzim la 3

MAXZIDE 3

MAXZIDE-25 3

methyldopa 1

methyldopa-hydrochlorothiazide

3

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral 1

NEXLETOL 3 PA

niacin (antihyperlipidemic) 3

niacin er (antihyperlipidemic)

3

niacor 3

NIASPAN 3

nicardipine hcl oral 1

Drug Name Drug Tier

Notes

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 3

NITRO-BID 2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual 3

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

nitro-time oral capsule extended release 9 mg

1

NORPACE 3

NORPACE CR 2

NORTHERA 3 PA; QL

NORVASC 3

NYMALIZE 3 QL

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

3

omega-3-acid ethyl esters 3

pacerone oral tablet 100 mg, 400 mg

3

pacerone oral tablet 200 mg

1

papaverine hcl injection 1


Drug Name Drug Tier

Notes

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

1

phentolamine mesylate injection

1

pindolol 1

PRALUENT 3 PA; QL

PRAVACHOL 3

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3

prevalite 1

PRINIVIL 3

procainamide hcl injection 1

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 3

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

PROSTIN VR 3

QBRELIS 3

QUESTRAN 3

QUESTRAN LIGHT 3

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate 1

ramipril 1

RANEXA 3 PA

ranolazine er 3 PA

RECTIV 2

REPATHA 3 PA

REPATHA PUSHTRONEX SYSTEM

3 PA

Drug Name Drug Tier

Notes

REPATHA SURECLICK 3 PA

rosuvastatin calcium 1

RYTHMOL SR 3

simvastatin oral 1

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR 3

TARKA 3

taztia xt 3

TEKTURNA 3 ST

TEKTURNA HCT 3 ST

telmisartan 3

telmisartan-amlodipine 3

telmisartan-hctz 3

TENORETIC 100 3

TENORETIC 50 3

TENORMIN 3

tiadylt er 3

TIAZAC 3

TIKOSYN 3 PA

timolol maleate oral 1

TOPROL XL 3

torsemide 1

trandolapril 1

trandolapril-verapamil hcl er

3

triamterene oral 1

triamterene-hctz 1

TRIBENZOR 3

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

TWYNSTA 3


Drug Name Drug Tier

Notes

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA ORAL CAPSULE 0.5 GM

3 PA

VASCEPA ORAL CAPSULE 1 GM

3

VASERETIC 3

VASOTEC 3

VECAMYL 3

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

3

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VYNDAMAX 3 PA; QL

VYNDAQEL 3 PA; QL

VYTORIN 3

WELCHOL 3

ZESTORETIC 3

ZESTRIL 3

ZETIA 3

ZIAC 3

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

3

ZYPITAMAG 3

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3

ADDERALL XR 1 QL

ADHANSIA XR 3 ST; QL

ADZENYS ER 3 PA

Drug Name Drug Tier

Notes

ADZENYS XR-ODT 3 PA

AMPHETAMINE ER 3 PA

amphetamine sulfate 3 PA

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1 QL

APTENSIO XR 3 ST; QL

atomoxetine hcl 1

clonidine hcl er 3

CONCERTA 3 QL

COTEMPLA XR-ODT 3 PA; QL

DAYTRANA 3 ST; QL

DESOXYN 3

DEXEDRINE 3 QL

dexmethylphenidate hcl 1

dexmethylphenidate hcl er

3 ST; QL

dextroamphetamine sulfate er

1 QL

dextroamphetamine sulfate oral solution

3

dextroamphetamine sulfate oral tablet

1

DYANAVEL XR 3 ST

EVEKEO 3 PA

EVEKEO ODT 3 PA

FOCALIN 3

FOCALIN XR 3 ST; QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 ST; QL

KAPVAY 3

metadate er 1 QL

methamphetamine hcl 3

METHYLIN 3

methylphenidate hcl er 1 QL

methylphenidate hcl er (cd)

1 QL


Drug Name Drug Tier

Notes

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg

3 ST; QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg

1 ST; QL

methylphenidate hcl oral solution

3

methylphenidate hcl oral tablet

1

methylphenidate hcl oral tablet chewable

3

MYDAYIS 3 PA; QL

PROCENTRA 3

QUILLICHEW ER 3 PA

QUILLIVANT XR 3 ST; QL

relexxii 1 QL

RITALIN 3

RITALIN LA 3 ST; QL

STRATTERA 3

VYVANSE 3 PA; QL

zenzedi oral tablet 10 mg, 5 mg

1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA; QL

AUBAGIO 3 PA; QL

AVONEX PEN 2 PA; QL

AVONEX PREFILLED 2 PA; QL

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

2 PA; QL

BETASERON 3 PA; QL

COPAXONE 3 PA; QL

dalfampridine er 3 PA; QL

EXTAVIA 1 QL

GILENYA 2 PA; QL

Drug Name Drug Tier

Notes

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml

1 QL

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml

3 QL

glatopa subcutaneous solution prefilled syringe 20 mg/ml

1 QL

glatopa subcutaneous solution prefilled syringe 40 mg/ml

3 QL

MAVENCLAD (10 TABS) 3 PA; QL







MAYZENT 3 PA; QL

MAYZENT STARTER PACK

3 PA; QL

PLEGRIDY 3 PA; QL

PLEGRIDY STARTER PACK

3 PA; QL

REBIF 2 PA; QL

REBIF REBIDOSE 2 PA; QL

REBIF REBIDOSE TITRATION PACK

2 PA; QL

REBIF TITRATION PACK 2 PA; QL

TECFIDERA 3 PA; QL

VUMERITY 3 PA; QL

VUMERITY (STARTER) 3 PA; QL

Central Nervous System Agents - Miscellaneous

AUSTEDO 3 PA; QL

caffeine citrate oral 1

CAFFEINE-SODIUM BENZOATE

3

GRALISE 3

GRALISE STARTER 3

HORIZANT 3


Drug Name Drug Tier

Notes

INGREZZA 3 PA; QL

LIDOTIN 3

LIPRITIN 3

LYRICA 3 QL

LYRICA CR 3 PA

NUEDEXTA 3 PA

pregabalin oral 1 QL

RILUTEK 3 QL

riluzole 1 QL

SAVELLA 3 ST

SAVELLA TITRATION PACK

3 ST

TEGSEDI 3 PA; QL

tetrabenazine 3 PA; QL

TIGLUTIK 3 QL

XENAZINE 3 PA; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

BOCASAL 3

cevimeline hcl 3

chlorhexidine gluconate mouth/throat

1

DEBACTEROL 3

EVOXAC 3

FIRST-MOUTHWASH BLM

3

lidocaine hcl mouth/throat 3

lidocaine viscous hcl 1

MUCOSITISRX 3

NEUTRASAL 3

NUMOISYN MOUTH/THROAT LOZENGE

3

oralone 1

paroex 1

periogard 1

pilocarpine hcl oral tablet 5 mg

1

pilocarpine hcl oral tablet 7.5 mg

3

Drug Name Drug Tier

Notes

SALAGEN 3

SALIVAMAX 3

triamcinolone acetonide mouth/throat

1

XEROSTOMIA RELIEF SPRAY

3

Dermatological Agents - Drugs for Skin Conditions

ABSORICA 3

ABSORICA LD 3

ACANYA 3

acitretin 1 QL

ACZONE 3

adapalene external cream 1

adapalene external gel 1

ADAPALENE EXTERNAL PAD

3

ADAPALENE EXTERNAL SOLUTION

3

adapalene-benzoyl peroxide

3

ADVANCED ALLERGY COLLECTION

3

AKLIEF 3 PA

ALA SCALP 3

ala-cort external cream 1 %

3

ala-cort external cream 2.5 %

1

alclometasone dipropionate

1

ALDARA 3

ALTRENO 3

amcinonide 3

AMELUZ 2 QL

ammonium lactate external

3

amnesteem 1

AMZEEQ 3

ANACAINE 3


Drug Name Drug Tier

Notes

APEXICON E 3

ARAZLO 3

arzol silver nit applicators 3

ATOPADERM 3

ATOPICLAIR 3

ATRALIN 3

avar cleanser 1

AVAR LS CLEANSER 3

AVAR-E EMOLLIENT 3

AVAR-E GREEN 3

AVAR-E LS 3

avita 1

azelaic acid external 1

AZELEX 2

BENSAL HP 3

BENZACLIN 3

BENZACLIN WITH PUMP 3

BENZAMYCIN 3

benzepro foaming cloths 3

BENZIQ 3

BENZIQ LS 3

BENZOYL PEROX-HYDROCORTISONE

3

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %

3

BENZOYL PEROXIDE FORTE- HC

3

benzoyl peroxide-erythromycin

1

beser external lotion 3

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

betamethasone valerate external

1

bp 10-1 3

bp cleansing wash 3

Drug Name Drug Tier

Notes

BRYHALI 3

calcipotriene 1

calcipotriene-betameth diprop external ointment

3

calcipotriene-betameth diprop suspension 0.005-0.064 % external

3

CALCIPOTRIENE-BETAMETH DIPROP SUSPENSION 0.005-0.064 % EXTERNAL

3

calcitrene 1

calcitriol external 3

CAPEX 2

CARAC 2

cem-urea 3

CERACADE 3

ceramax external cream 3

claravis 1

CLEOCIN-T 3

clindacin etz external swab

1

clindacin-p 1

CLINDAGEL 3

clindamycin phos-benzoyl perox external gel 1.2-2.5 %, 1.2-5 %

3

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external foam

3

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

3


Drug Name Drug Tier

Notes

clindamycin phosphate gel 1 % external

1

clindamycin-tretinoin 3

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

3

clobetasol propionate external cream

1

clobetasol propionate external foam

3

clobetasol propionate external gel

1

clobetasol propionate external liquid

3

clobetasol propionate external lotion

1

clobetasol propionate external ointment

1

clobetasol propionate external shampoo

3

clobetasol propionate external solution

1

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 3

clodan external shampoo 3

CLODERM 3

CONDYLOX 2

CORDRAN EXTERNAL CREAM

3

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

2

CORTISPORIN EXTERNAL CREAM

3

CORTISPORIN EXTERNAL OINTMENT

2

Drug Name Drug Tier

Notes

CUTIVATE 3

dapsone external gel 5 % 3

dapsone gel 7.5 % external

3

DAPSONE GEL 7.5 % EXTERNAL

3

DERMA-SMOOTHE/FS BODY

3

DERMA-SMOOTHE/FS SCALP

3

DESONATE 3

desonide external cream 1

desonide external gel 3

desonide external lotion 1

desonide external ointment

1

DESOWEN 3

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

3

desoximetasone external ointment

1

DEXERYL 3

diclofenac sodium transdermal gel 3 %

3

DIFFERIN EXTERNAL CREAM

1

DIFFERIN EXTERNAL GEL 0.3 %

3

DIFFERIN EXTERNAL LOTION

2

diflorasone diacetate 3

DIPROLENE 3

DIPROLENE AF 3

DOVONEX 3

doxepin hcl external 3

doxycycline 3

DRITHO-CREME HP 3


Drug Name Drug Tier

Notes

DRYSOL 2

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR

3

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; QL

EFUDEX 3

ELETONE 3

ELIDEL 1

EMULSION SB 3

ENSTILAR 3

ENTTY SPRAY EMULSION

3

EPICERAM 3

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

ery 3

ERYGEL 3

erythromycin external 1

EUCRISA 3 PA; QL

EVOCLIN 3

FABIOR 3

FINACEA EXTERNAL FOAM

2

FINACEA EXTERNAL GEL

3

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external cream 0.05 %

1

Drug Name Drug Tier

Notes

fluocinonide external cream 0.1 %

3

fluocinonide external gel 1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOPAR 3

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

fluorouracil external solution

1

flurandrenolide 3

fluticasone propionate external cream

1

fluticasone propionate external lotion

3

fluticasone propionate external ointment

3

grafco silver nit applicator 3

halcinonide 3

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

3

halobetasol propionate external ointment

1

HALOG EXTERNAL CREAM

3

HALOG EXTERNAL OINTMENT

3

HPR 3

HPR PLUS 3

HYDRO 40 3

hydrocortisone ace-pramoxine external cream 2.5-1 %

1


Drug Name Drug Tier

Notes

hydrocortisone butyr lipo base

3

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

3

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 1 %

3

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone valerate 1

HYLAGUARD 3

HYLATOPIC PLUS EXTERNAL CREAM

3

HYLATOPIC PLUS EXTERNAL FOAM

3

ILIDERM 3

imiquimod external 1

IMIQUIMOD PUMP 3

IMPOYZ 3 PA

isotretinoin oral 1

KAMDOY 3

KENALOG EXTERNAL 3

KERALAC 3

KERALYT EXTERNAL GEL 6 %

3

KIVIK 3

KLARON 3

lactic acid e 3

lactic acid external 3

LEVULAN KERASTICK 2 QL

LEXETTE 3

Drug Name Drug Tier

Notes

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL

3

LOCOID 3

LOCOID LIPOCREAM 3

LUXIQ 3

methoxsalen rapid 1 QL

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole external cream

1

metronidazole external gel 0.75 %

1

metronidazole external gel 1 %

3

metronidazole external lotion

3

MIMYX 3

MIRVASO 3

mometasone furoate external

1

myorisan 1

NEOCERA 3

NEOSALUS CP 3

NEOSALUS EXTERNAL CREAM

3

NEOSALUS EXTERNAL FOAM

3

NEO-SYNALAR EXTERNAL CREAM

3

neuac external gel 3

NIVATOPIC PLUS 3

nolix 3

NORITATE 3

NOVACORT 3

NUCORT 3

OLUX 3

OLUX-E 3

ONEXTON 3


Drug Name Drug Tier

Notes

ORACEA 3 PA

OVACE PLUS EXTERNAL CREAM

3

OVACE PLUS EXTERNAL FOAM

3

OVACE PLUS EXTERNAL SHAMPOO

3

OVACE PLUS WASH 3

OVACE WASH 3

OXSORALEN ULTRA 3 QL

PANDEL 3

PENLEN 3

PHLAG SPRAY 3

PICATO 2 QL

pimecrolimus cream 1 % external

1

PIMECROLIMUS CREAM 1 % EXTERNAL

2

PLEXION 3

PLEXION CLEANSER 3

PLEXION CLEANSING CLOTH

3

podocon 3

podofilox external 1

PRAMOSONE EXTERNAL CREAM 1-1 %

2

PRAMOSONE EXTERNAL CREAM 1-2.5 %

3

PRAMOSONE EXTERNAL LOTION

2

pramox 3

prednicarbate 3

PRESERA 3

PROTEXA 3

PROTOPIC 3

PRUCLAIR 3

PRUDOXIN 3

PRUMYX 3

Drug Name Drug Tier

Notes

PSORCON 3

PYROGALLIC ACID 3

QBREXZA 3 PA

RESORCINOL-SULFUR 3

RETIN-A 1

RETIN-A MICRO GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

3

RHOFADE 3

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

3

SALEX EXTERNAL SHAMPOO

3

salicylic acid external cream

3

salicylic acid external foam

3

salicylic acid external gel 3

salicylic acid external liquid

3

salicylic acid external lotion

3

salicylic acid external shampoo

3

salicylic acid external solution 26 %

3

salicylic acid wart remover

3

salimez 3

SALIMEZ FORTE 3

SALVAX 3

SANTYL 2

selenium sulfide external lotion

1


Drug Name Drug Tier

Notes

selenium sulfide external shampoo 2.25 %

3

SERNIVO 3

sodium hyaluronate external

3

sodium sulfacetamide 1

sodium sulfacetamide wash liquid 10 % external

3

SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL

3

SOOLANTRA 3

SORIATANE 3 QL

SORILUX 3

sss 10-5 3

sulfacetamide sodium (acne)

1

sulfacetamide sodium external

3

sulfacetamide sodium-sulfur external cream

3

sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external liquid

3

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide sodium-sulfur external lotion 9.8-4.8 %

3

sulfacetamide sodium-sulfur external pad

3

sulfacetamide sodium-sulfur external suspension

3

sulfacetamide-sulfur in urea

1

sulfacleanse 8/4 3

sulfamez wash 3

SUMADAN WASH 3

SUMAXIN 3

Drug Name Drug Tier

Notes

SUMAXIN WASH 3

SUVICORT 3

synalar external cream 1

synalar external ointment 1

SYNALAR EXTERNAL SOLUTION

3

SYNERDERM 3

TACLONEX 3

tacrolimus external ointment

1

tazarotene external 1

TAZORAC EXTERNAL CREAM 0.05 %

2

TAZORAC EXTERNAL CREAM 0.1 %

1

TAZORAC EXTERNAL GEL

2

TEMOVATE 3

TETRIX 3

TEXACORT 3

TOLAK 3

TOPICORT 3

TOPICORT SPRAY 3

tovet external foam 3

tretinoin external cream 1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin external gel 0.05 %

3

tretinoin microsphere 1

tretinoin microsphere pump

1

triamcinolone acetonide external aerosol solution

3

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1


Drug Name Drug Tier

Notes

triamcinolone acetonide external ointment 0.05 %

3

trianex 3

triderm 1

TRIDESILON 3

ULTRAVATE 3

UMECTA MOUSSE 3

URAMAXIN 3

urea external cream 39 %, 41 %, 45 %, 47 %

3

urea external cream 40 % 1

UREA EXTERNAL FOAM 3

urea external suspension 3

urea hydrating 3

urea nail 3

uredeb 3

uremez-40 1

URESOL 3

UTOPIC 3

VANOS 3

VANOXIDE-HC 3

VECTICAL 1

VELTIN 3

VERDESO 3

VEREGEN 3

VIRASAL 3

XALIX 3

XERALUX 3

xurea 3

zaclir cleansing 3

zenatane 1

ZIANA 3

ZITHRANOL 3

ZONALON 3

ZYCLARA 3

ZYCLARA PUMP 3

Diabetes - Antidiabetic Agents

Drug Name Drug Tier

Notes

acarbose oral 1

ACTOPLUS MET 3

ACTOS 3

ADLYXIN 3 PA; QL

ADLYXIN STARTER PACK

3 PA; QL

ALOGLIPTIN BENZOATE 3 PA

ALOGLIPTIN-METFORMIN HCL

3 PA

ALOGLIPTIN-PIOGLITAZONE

3 PA

AMARYL 3

AVANDIA 3

BYDUREON 3 PA; QL

BYDUREON BCISE AUTOINJECTOR

3 PA; QL

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG

3 PA; QL

BYETTA 10 MCG PEN 3 PA; QL

BYETTA 5 MCG PEN 3 PA; QL

CYCLOSET 3 ST

DUETACT 3

FARXIGA 3 PA; QL

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG

3 PA

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG

3

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 3

GLUCOTROL 3

GLUCOTROL XL 3


Drug Name Drug Tier

Notes

GLUMETZA 3 PA

glyburide micronized 3

glyburide oral 1

glyburide-metformin 3

GLYNASE 3

GLYSET 3

GLYXAMBI 3 ST

INVOKAMET 3 PA; QL

INVOKAMET XR 3 PA; QL

INVOKANA 3 PA; QL

JANUMET 3 PA

JANUMET XR 3 PA

JANUVIA 3 PA

JARDIANCE 2 PA; QL

JENTADUETO 3 ST

JENTADUETO XR 3 ST

KAZANO 3 PA

KOMBIGLYZE XR 3 PA

metformin hcl er 1

metformin hcl er (mod) 3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg

3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 500 mg

3

metformin hcl ir 1

miglitol 3

nateglinide 3

NESINA 3 PA

ONGLYZA 3 PA

OSENI 3 PA

OZEMPIC 3 PA; QL

pioglitazone hcl 3

pioglitazone hcl-glimepiride

3

pioglitazone hcl-metformin hcl

3

PRECOSE 3

Drug Name Drug Tier

Notes

QTERN 3 PA; QL

repaglinide 3

RIOMET 2

RIOMET ER 3 PA

RYBELSUS 3 PA

SEGLUROMET 3 PA; QL

SOLIQUA 3 PA; QL

STARLIX 3

STEGLATRO 3 PA; QL

STEGLUJAN 3 PA; QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3 PA; QL

SYNJARDY XR 3 PA; QL

tolbutamide 1

TRADJENTA 3 ST

TRIJARDY XR 3 PA; QL

TRULICITY 3 PA; QL

VICTOZA 3 PA; QL

XIGDUO XR 3 PA; QL

XULTOPHY 3 PA

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO

1

ACCU-CHEK COMPACT PLUS CONTROL

1

ACCU-CHEK FASTCLIX LANCET KIT

1

ACCU-CHEK GUIDE CONTROL

1

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

1

ACCU-CHEK SMARTVIEW CONTROL

1

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

1

AGAMATRIX CONTROL LEVEL 2

1

AGAMATRIX CONTROL LEVEL 4

1


Drug Name Drug Tier

Notes

AUTOLET LANCING DEVICE

1

CARETOUCH CONTROL SOL LEVEL 2

1

CARETOUCH LANCING/EJECTOR

1

CONTOUR CONTROL 1

CONTOUR NEXT CONTROL

1

CONTOUR NEXT TEST 1 PA; QL

DIATHRIVE GLUCOSE CONTROL SOLN

1

DIATHRIVE LANCING DEVICE

1

EASY TRAK II CONTROL 1

EASYMAX 15 LEVEL 2-3 CONTROL

1

EASYMAX CONTROL 1

EASYMAX CONTROL NORMAL/HIGH

1

EMBRACE TALK GLUCOSE CONTROL

1

FORTISCARE CONTROL 1

FREESTYLE TEST 1 PA; QL

GENTEEL LANCING KIT (BLUE)

1

GOJJI CONTROL 1

GOJJI LANCING DEVICE/CLEAR CAP

1

LANCETS 1

LANCETS KIT 1

MICROLET NEXT LANCING DEVICE

1

OMNIPOD DASH SYSTEM

3 PA

OMNIPOD STARTER 3 PA

ONETOUCH DELICA LANCING DEV

1

ONETOUCH DELICA PLUS LANCING

1

Drug Name Drug Tier

Notes

ONETOUCH ULTRA BLUE TEST STRIPS IN VITRO STRIP

1 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

1

ONETOUCH VERIO TEST STRIPS

1 QL

SURESTEP PRO HIGH GLUCOSE

1

SURESTEP PRO LOW GLUCOSE

1

SURESTEP PRO NORMAL GLUCOSE

1

TRUE METRIX LEVEL 1 1



UNISTRIP CONTROL IN VITRO SOLUTION LOW

1

V-GO 20 3 PA

V-GO 30 3 PA

V-GO 40 3 PA

VIVAGUARD INO CONTROL SOLUTION

1

VIVAGUARD LANCING DEVICE

1

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

diazoxide oral 1

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

GLUCAGON EMERGENCY KIT

3

GVOKE HYPOPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML

3 QL

GVOKE PFS 3 QL

PROGLYCEM 2

Diabetes - Insulins


Drug Name Drug Tier

Notes

ADMELOG 3

ADMELOG SOLOSTAR 3

AFREZZA 3 PA

APIDRA SOLOSTAR 3

APIDRA VIAL 3

BASAGLAR KWIKPEN 3 PA

BD AUTOSHIELD DUO PEN NEEDLES

1

BD ULTRA-FINE INSULIN SYRINGES

1

BD ULTRA-FINE PEN NEEDLES

1

BD VEO INSULIN SYR U/F 1/2UNIT

1

FIASP 3

FIASP FLEXTOUCH 3

FIASP PENFILL 3

HUMALOG 2

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 50/50 VIAL

3

HUMALOG MIX 75/25 KWIKPEN

3

HUMALOG MIX 75/25 VIAL

3

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMULIN 70/30 KWIKPEN

1

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 1

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN

1

HUMULIN R U-500 VIAL (CONCENTRATED)

1

HUMULIN R VIAL 1

INSULIN ASP PROT & ASP FLEXPEN

3

Drug Name Drug Tier

Notes

INSULIN ASPART 3

INSULIN ASPART FLEXPEN

3

INSULIN ASPART PENFILL

3

INSULIN ASPART PROT & ASPART

3

INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

2

INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

3

INSULIN LISPRO JUNIOR KWIKPEN

3

INSULIN LISPRO PROT & LISPRO

3

INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS

2

INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS

3

INSULIN PEN NEEDLES 1

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

1

LANTUS SOLOSTAR 2 PA

LANTUS U-100 VIAL 2 PA

LEVEMIR U-100 FLEXTOUCH

2 PA


Drug Name Drug Tier

Notes

LEVEMIR U-100 VIAL 2 PA

LYUMJEV 3

LYUMJEV KWIKPEN 3

MAXICOMFORT SYR 27G X 1/2"

1

NOVOFINE AUTOCOVER PEN NEEDLE

1

NOVOFINE PEN NEEDLE

1

NOVOFINE PLUS PEN NEEDLE

1

NOVOLIN 70/30 RELION 3 ST

NOVOLIN 70/30 VIAL 3 ST

NOVOLIN N RELION 3 ST

NOVOLIN N VIAL 3 ST

NOVOLIN R RELION 3 ST

NOVOLIN R VIAL 3 ST

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 FLEXPEN

3

NOVOLOG MIX 70/30 VIAL

3

NOVOLOG PENFILL 3

NOVOLOG U-100 VIAL 3

NOVOTWIST PEN NEEDLE

1

TOUJEO MAX SOLOSTAR

3 PA

TOUJEO SOLOSTAR 3 PA

TRESIBA 3 PA

TRESIBA FLEXTOUCH 3 PA

Electrolytes / Minerals / Metals / Vitamins

argyle sterile saline 1

argyle sterile water 3

CARBAGLU 3 PA; QL

CARNITOR ORAL 1

CARNITOR SF 1

CHEMET 3

clovique 3 PA; QL

Drug Name Drug Tier

Notes

curity sterile saline 1

cyanocobalamin injection solution 1000 mcg/ml

1

cytra k crystals 1

deferasirox 3 PA; QL

dehydrated alcohol 3

DEXPANTHENOL INJECTION

3

DRISDOL 3

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

3

ergocalciferol oral capsule 1

EXJADE 3 PA; QL

FERRIPROX ORAL SOLUTION

3 PA

FERRIPROX ORAL TABLET

3 PA; QL

FLUORABON 3

fluoritab oral solution 3

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 2.2 (1 f) mg

1

fluoritab oral tablet chewable 1.1 (0.5 f) mg

3

FLURA-DROPS 2

folic acid injection 1

folic acid oral tablet 1 mg 1

FOLVIK-D 3

FOLVITE-D 3

GENICIN VITA-D 3

iodine strong oral 3

JADENU 3 PA; QL

JADENU SPRINKLE 3 PA; QL

JYNARQUE 3 PA; QL

kionex 1

klor-con 1

klor-con 10 1


Drug Name Drug Tier

Notes

klor-con m10 1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

2

klor-con m20 1

klor-con sprinkle 1

klor-con/ef 3

K-PHOS 3

K-PHOS NO 2 3

K-PHOS-NEUTRAL 3

k-prime 3

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

2

levocarnitine oral solution 1

levocarnitine oral tablet 1

levocarnitine sf 1

LOKELMA 3 PA; QL

ludent oral tablet chewable 0.55 (0.25 f) mg

1

ludent oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

3

MAGNESIUM SULFATE INJECTION

3

MEPHYTON 1

MIFEPREX 3

mifepristone 3

nafrinse 1

nafrinse drops 3

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

Drug Name Drug Tier

Notes

phytonadione injection 1

phytonadione oral 1

pot bicarb-pot chloride 3

potassium bicarbonate oral

3

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

potassium citrate-citric acid

1

SAMSCA 3 PA; QL

sod citrate-citric acid 1

sodium chloride (pf) 1

sodium chloride irrigation 1

sodium fluoride oral solution

1

sodium fluoride oral tablet 1.1 (0.5 f) mg

1

sodium fluoride oral tablet 2.2 (1 f) mg

3

sodium fluoride oral tablet chewable

1

sodium polystyrene sulfonate oral

1

sodium polystyrene sulfonate rectal

3

sps 1

sterile water for irrigation 3

SYPRINE 3 PA; QL

taron-crystals 1

tolvaptan 3 PA; QL

tricitrates 1

trientine hcl 3 PA; QL

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

VELTASSA 3 PA

virt-phos 250 neutral 1


Drug Name Drug Tier

Notes

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

water for irrigation, sterile 3

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX 3 ST

ACIPHEX SPRINKLE 3 PA

CARAFATE ORAL SUSPENSION

1

CARAFATE ORAL TABLET

3

cimetidine hcl 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 3 PA

esomeprazole magnesium oral packet

3 PA

ESOMEPRAZOLE STRONTIUM

3 PA

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

FIRST-LANSOPRAZOLE 3

FIRST-OMEPRAZOLE 3

lansoprazole oral capsule delayed release

1

lansoprazole oral tablet delayed release dispersible

3 PA

misoprostol oral 1

NEXIUM ORAL PACKET 3 PA

nizatidine 3

omeprazole oral capsule delayed release

1

OMEPRAZOLE+SYRSPEND SF ALKA

3

omeprazole-sodium bicarbonate oral packet

3 PA

pantoprazole sodium oral 1

Drug Name Drug Tier

Notes

PEPCID 3

PREVACID 3

PREVACID SOLUTAB 3 PA

PRILOSEC 3

PROTONIX ORAL 3

rabeprazole sodium oral tablet delayed release

1 ST

sucralfate oral 1

ZEGERID ORAL PACKET

3 PA

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL 3

alosetron hcl 3 QL

AMITIZA 3 PA; QL

amoxicill-clarithro-lansopraz

3

ANASPAZ 3

belladonna alkaloids-opium

1

BENTYL 3

CHENODAL 3

chlordiazepoxide-clidinium

1

CLENPIQ 3

constulose 1

cromolyn sodium oral 3

CUVPOSA 3

dicyclomine hcl intramuscular

3

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spaz 3

ENTEREG 3

enulose 1

GASTROCROM 3

GATTEX 3 PA; QL

gavilyte-c 1

gavilyte-g 1


Drug Name Drug Tier

Notes

gavilyte-h 3

gavilyte-n with flavor pack 1

generlac 1

GLYCATE 3

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GLYCOPYRROLATE ORAL TABLET 1.5 MG

3

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

2

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

HELIDAC THERAPY 2

hyoscyamine sulfate er 3

hyoscyamine sulfate injection

3

hyoscyamine sulfate oral 3

hyoscyamine sulfate sl 3

hyoscyamine sulfate sublingual

3

hyosyne 3

KRISTALOSE 3

lactulose encephalopathy 1

lactulose oral packet 3

lactulose oral solution 1

LEVBID 3

LEVSIN 3

LEVSIN/SL 3

LIBRAX 3

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

3 PA; QL

LINZESS ORAL CAPSULE 72 MCG

3 PA

LOMOTIL 3

Drug Name Drug Tier

Notes

loperamide hcl oral capsule

1

LOTRONEX 3 QL

methscopolamine bromide oral

3

MOTEGRITY 3 PA

MOTOFEN 3

MOVANTIK 3 PA; QL

MOVIPREP 2

MYTESI 3

nulev 3

NULYTELY WITH FLAVOR PACKS

3

OMECLAMOX-PAK 3

opium 1

oscimin 3

oscimin sr 3

OSMOPREP 3

peg 3350-kcl-na bicarb-nacl

1

peg-3350/electrolytes 1

peg-prep 3

PLENVU 3

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

3

PROBICHEW 3

propantheline bromide oral

1

PYLERA 2

RELISTOR ORAL 3 PA

RELISTOR SUBCUTANEOUS

2

SEROSTIM 3 PA; QL

SUPREP BOWEL PREP KIT

3

SYMAX DUOTAB 3

symax-sl 3

symax-sr 3

SYMPROIC 3 PA


Drug Name Drug Tier

Notes

TALICIA 3

trilyte 1

TRULANCE 3 PA

URSO 250 3

URSO FORTE 3

ursodiol oral 1

VIBERZI 3 PA

XERMELO 3 PA; QL

ZELNORM 3 PA

ZORBTIVE 3 PA; QL

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

BUPHENYL 3 QL

CERDELGA 2 PA; QL

CHOLBAM 3 PA; QL

CREON 2

CRYSVITA 3 PA; QL

CYSTADANE 3

CYSTAGON 2 PA

GALAFOLD 3 PA; QL

KUVAN 3 PA; QL

miglustat 3 PA; QL

MYALEPT 3 PA; QL

nitisinone 3 PA; QL

NITYR 3 PA; QL

OCALIVA 3 PA; QL

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

3 PA; QL

ORFADIN ORAL CAPSULE 20 MG

3 PA

ORFADIN ORAL SUSPENSION

3 PA; QL

PANCREAZE 3

PERTZYE 3

PROCYSBI 3 PA; QL

RAVICTI 3 PA; QL

sodium phenylbutyrate oral

3 QL

Drug Name Drug Tier

Notes

STRENSIQ 3 PA; QL

SUCRAID 3 PA

VIOKACE 3

ZAVESCA 3 PA; QL

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation 1

AURYXIA 3 PA; QL

bethanechol chloride oral 1

calcium acetate (phos binder)

1

calcium acetate oral tablet 667 mg

1

CERVIDIL 2

CUPRIMINE 1 PA; QL

darifenacin hydrobromide er

1

DEPEN TITRATABS 3 PA; QL

DETROL 3

DETROL LA 3

DITROPAN XL 3

ELMIRON 2

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

3

FEM PH 3

flavoxate hcl 1

FOSRENOL ORAL PACKET

3

FOSRENOL ORAL TABLET CHEWABLE

3 QL

GELNIQUE 3 ST

hyophen 3

INTRAROSA 3 PA; QL

lanthanum carbonate 3 QL

LITHOSTAT 3

me/naphos/mb/hyo1 3

MYRBETRIQ 3 ST


Drug Name Drug Tier

Notes

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST

penicillamine oral capsule 1 PA; QL

penicillamine oral tablet 2 PA; QL

PENTOSAN POLYSULFATE SODIUM ORAL

2

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PHOSLYRA 3

phosphasal 3

PREPIDIL 2

PROSTIN E2 2

PYRIDIUM 3

RENACIDIN 3

RENAGEL 3

RENVELA 3

RIMSO-50 3

sevelamer carbonate 1

sevelamer hcl 1

solifenacin succinate 1

THIOLA 3

THIOLA EC 3 PA

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3 ST

trospium chloride 1

trospium chloride er 1

urelle 3

uretron d/s 3

uribel 3

URIMAR-T 3

urin ds 3

URO-458 3

UROGESIC-BLUE 3

Drug Name Drug Tier

Notes

uro-mp 3

URYL 3

ustell 3

uticap 3

utira-c 3

utrona-c 3

VELPHORO 3 PA; QL

VESICARE 3

vilamit mb 3

VILEVEV MB 3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3

dutasteride oral 1

dutasteride-tamsulosin hcl 3

finasteride oral tablet 5 mg

1

FLOMAX 3

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 3

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 3

Hormonal Agents - Adrenal

BETAMETHASONE SODIUM PHOSPHATE INJECTION

3

CORTEF ORAL TABLET 10 MG, 20 MG

3

CORTEF ORAL TABLET 5 MG

2

cortisone acetate oral 1

DECADRON 3


Drug Name Drug Tier

Notes

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

2

DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML

3

DEXABLISS 3

DEXAMETHASONE (LA) 3

dexamethasone intensol 2

dexamethasone oral elixir 1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone oral tablet therapy pack

3

dexamethasone sod phosphate pf injection solution

1

dexamethasone sodium phosphate injection

1

DEXONTO 0.4% 3

DXEVO 11-DAY 3

fludrocortisone acetate oral

1

HIDEX 6-DAY 3

hydrocortisone oral 1

KENALOG INJECTION 3

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

METHYLPREDNISOLONE ACE-LIDO

3

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 40 MG/ML, 80 MG/ML

3

methylprednisolone oral 1

Drug Name Drug Tier

Notes

methylprednisolone sodium succ injection solution reconstituted 125 mg

1

MILLIPRED 3

MILLIPRED DP 12-DAY 3

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48)

3

ORAPRED ODT 3

PEDIAPRED 3

prednisolone oral solution 1

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml

3

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible

3

prednisone intensol 3

prednisone oral 1

RAYOS 3 PA

SOLU-CORTEF 2

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 125 MG

3

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY 3

TAPERDEX 7-DAY 3

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MG/ML

3

triamcinolone acetonide suspension 40 mg/ml injection

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION

3


Drug Name Drug Tier

Notes

TRIAMCINOLONE DIACETATE INJECTION

3

TRIAMCINOLONE DIACETATE PF INJECTION SUSPENSION 80 MG/2ML

3

Hormonal Agents - Men's Health

ANADROL-50 3 QL

ANDRODERM 3 PA; QL

ANDROGEL 3 PA; QL

ANDROGEL PUMP 3 PA; QL

danazol oral 1

DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)

1 PA

FORTESTA 3 PA; QL

JATENZO 3 PA

METHITEST 3 PA

methyltestosterone oral 3 PA

NATESTO 3 PA; QL

oxandrolone oral 3

TESTIM 3 PA; QL

TESTONE CIK 3

TESTOSTERONE CYPIONATE INJECTION

1 PA

testosterone cypionate intramuscular

1 PA

testosterone enanthate intramuscular

1 PA

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

3 PA; QL

testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

1 PA; QL

testosterone transdermal solution

3 PA; QL

VOGELXO 3 PA; QL

Drug Name Drug Tier

Notes

VOGELXO PUMP 3 PA; QL

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3

OSPHENA 3 PA

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA; QL

BYNFEZIA PEN 3 PA; QL

cabergoline 1

DDAVP 3

DDAVP RHINAL TUBE 3

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate spray

1

EGRIFTA 3 QL

EGRIFTA SV 3 QL

ELIGARD 3

GENOTROPIN 3 PA; QL

GENOTROPIN MINIQUICK

3 PA; QL

HUMATROPE 3 PA; QL

INCRELEX 3 PA; QL

ISTURISA 3 PA; QL

leuprolide acetate injection

1

LUPRON DEPOT (1-MONTH)

2

LUPRON DEPOT (3-MONTH)

2

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2


Drug Name Drug Tier

Notes

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2

LUPRON DEPOT-PED (1-MONTH)

2

LUPRON DEPOT-PED (3-MONTH)

2

NOCDURNA 3 PA

NORDITROPIN FLEXPRO

3 PA; QL

NUTROPIN AQ NUSPIN 10

3 PA; QL


3 PA; QL


3 PA; QL

octreotide acetate 1

OMNITROPE 2 PA; QL

ORILISSA 3 PA; QL

SAIZEN 3 PA; QL

SAIZENPREP 3 PA; QL

SANDOSTATIN 3

SANDOSTATIN LAR DEPOT

2 QL

SIGNIFOR 3 PA; QL

SOMATULINE DEPOT 3 PA

SOMAVERT 3 PA; QL

STIMATE 2

SYNAREL 3 QL

ZOMACTON 3 PA; QL

Hormonal Agents - Prostaglandins

KORLYM 3 PA; QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA 3

afirmelle 1

ALORA 3

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

Drug Name Drug Tier

Notes

amabelz 3

amethia 3

amethia lo 3

amethyst 3

ANGELIQ 3

ANNOVERA 3

apri 1

aranelle 1

ashlyna 3

aubra 1

aubra eq 1

aurovela 1.5/30 1

aurovela 1/20 1

aurovela 24 fe 3

aurovela fe 1.5/30 1

aurovela fe 1/20 1

aviane 1

AYGESTIN 3

ayuna 1

azurette 3

BALCOLTRA 3

balziva 1

bekyree 3

BEYAZ 3

BIJUVA 3

blisovi 24 fe 3

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camila 1

camrese 3

camrese lo 3

caziant 1

chateal 1

chateal eq 1

CLIMARA 1


Drug Name Drug Tier

Notes

CLIMARA PRO 3

COMBIPATCH 3

covaryx 3

covaryx hs 3

CRINONE 3

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1

daysee 3

deblitane 1

DELESTROGEN 2

delyla 1

DEPO-ESTRADIOL 2

DEPO-PROVERA 3

DEPO-SUBQ PROVERA 104

3

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

3

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

1

DIVIGEL 3

dotti 3

drospiren-eth estrad-levomefol

3

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

3

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1

DUAVEE 3

eemt 3

eemt hs 3

Drug Name Drug Tier

Notes

ELESTRIN 3

elinest 1

ELLA 2

eluryng 1

emoquette 1

ENDOMETRIN 3

enpresse-28 1

enskyce 1

errin 1

est estrogens-methyltest 3

est estrogens-methyltest ds

3

est estrogens-methyltest hs

3

estarylla 1

ESTRACE 3

estradiol oral 1

estradiol transdermal patch twice weekly

3

estradiol transdermal patch weekly

1

estradiol vaginal 1

estradiol valerate intramuscular

1

estradiol-norethindrone acet

3

ESTRING 2

ESTROGEL 3

ESTROSTEP FE 3

ethynodiol diac-eth estradiol

1

etonogestrel-ethinyl estradiol

1

EVAMIST 3

falmina 1

fayosim 3

FEMHRT LOW DOSE 3

FEMRING 2

femynor 1


Drug Name Drug Tier

Notes

FIRST-PROGESTERONE VGS

3

fyavolv 3

GENERESS FE 3

gianvi 3

hailey 1.5/30 1

hailey 24 fe 3

hailey fe 1.5/30 1

hailey fe 1/20 1

heather 1

hydroxyprogesterone caproate intramuscular oil

1

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia 1

introvale 3

isibloom 1

jaimiess 3

jasmiel 3

jencycla 1

jinteli 3

jolessa 3

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 3

kaitlib fe 3

kalliga 1

kariva 3

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

larin 1.5/30 1

Drug Name Drug Tier

Notes

larin 1/20 1

larin 24 fe 3

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 3

leena 1

lessina 1

levonest 1

levonorgest-eth est & eth est

3

levonorgest-eth estrad 91-day

3

levonorgestrel 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

3

levonorg-eth estrad triphasic

1

levora 0.15/30 (28) 1

LILETTA (52 MG) 3

lillow 1

LO LOESTRIN FE 3

LOESTRIN 1.5/30 (21) 3

LOESTRIN 1/20 (21) 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

lojaimiess 3

lopreeza 3

loryna 3

LOSEASONIQUE 3

low-ogestrel 1

lo-zumandimine 3

lutera 1

lyza 1


Drug Name Drug Tier

Notes

MAKENA INTRAMUSCULAR

3

MAKENA SUBCUTANEOUS

2 QL

marlissa 1

medroxyprogesterone acetate intramuscular

1

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral suspension 625 mg/5ml

3

megestrol acetate oral tablet

1

melodetta 24 fe 3

MENEST 3

MENOSTAR 3

mibelas 24 fe 3

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

mili 1

mimvey 3

MINASTRIN 24 FE 3

MINIVELLE 3

MIRCETTE 3

MIRENA (52 MG) 2

mono-linyah 1

NATAZIA 3

necon 0.5/35 (28) 1

nikki 3

nora-be 1

norethin ace-eth estrad-fe oral tablet

1

norethin ace-eth estrad-fe oral tablet chewable

3

Drug Name Drug Tier

Notes

norethindrone acetate oral

1

norethindrone acet-ethinyl est

1

norethindrone oral 1

norethindrone-eth estradiol

3

norethin-eth estradiol-fe 3

norgestimate-eth estradiol 1

norgestimate-ethinyl estradiol triphasic

1

norlyda 1

norlyroc 1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 1

NUVARING 3

ocella 1

orsythia 1

ORTHO MICRONOR 3

PARAGARD INTRAUTERINE COPPER

2

philith 1

pimtrea 3

pirmella 1/35 1

pirmella 7/7/7 1

PLAN B ONE-STEP 3

portia-28 1

PREFEST 3

PREMARIN ORAL 3 ST

PREMARIN VAGINAL 2

PREMPHASE 3

PREMPRO 3

preventeza 1

previfem 1

progesterone intramuscular

1


Drug Name Drug Tier

Notes

progesterone micronized oral

1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3

reclipsen 1

rivelsa 3

SAFYRAL 3

SEASONIQUE 3

setlakin 3

sharobel 1

simliya 3

simpesse 3

SKYLA 2

SLYND 3

sprintec 28 1

sronyx 1

syeda 1

tarina 24 fe 3

tarina fe 1/20 1

tarina fe 1/20 eq 1

TAYTULLA 3

tilia fe 3

tri femynor 1

tri-estarylla 1

tri-legest fe 3

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem 1

tri-sprintec 1

trivora (28) 1

tri-vylibra 1

Drug Name Drug Tier

Notes

tri-vylibra lo 1

tulana 1

tydemy 3

VAGIFEM 3

velivet 1

vienva 1

viorele 3

VIVELLE-DOT 3

volnea 3

vyfemla 1

vylibra 1

wera 1

wymzya fe 3

xulane 1

YASMIN 28 3

YAZ 3

yuvafem 1

zarah 1

zovia 1/35e (28) 1

zumandimine 1

Hormonal Agents - Thyroid

ARMOUR THYROID 3

CYTOMEL 3

euthyrox 3

levo-t 3

levothyroxine sodium oral 1

levoxyl 3

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3

np thyroid 3

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

TIROSINT 3

TIROSINT-SOL 3


Drug Name Drug Tier

Notes

unithroid 3

WESTHROID 3

WP THYROID 3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 3 PA; QL

ACTEMRA SUBCUTANEOUS

3 PA; QL

ACTIMMUNE 3 QL

ALFERON N 3

ARAVA 3

ARCALYST 3 PA; QL

ASTAGRAF XL 3

AZASAN 3

azathioprine oral 1

BENLYSTA SUBCUTANEOUS

3 PA; QL

BERINERT 2 PA; QL

CELLCEPT 3

CIMZIA 3 PA; QL

CIMZIA PREFILLED KIT 3 PA; QL

CIMZIA STARTER KIT 3 PA; QL

CINRYZE 3 PA; QL

COSENTYX (300 MG DOSE)

2 PA; QL

COSENTYX 150 MG/ML 2 PA; QL

COSENTYX SENSOREADY (300 MG)

2 PA; QL

COSENTYX SENSOREADY PEN

2 PA; QL

CUTAQUIG 3 PA; QL

CUVITRU 2 PA; QL

cyclosporine modified 1

cyclosporine oral 1

ENBREL 2 PA; QL

ENBREL MINI 2 PA; QL

ENBREL SURECLICK 2 PA; QL

ENVARSUS XR 3

Drug Name Drug Tier

Notes

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

3 QL

FIRAZYR 3 PA; QL

gengraf 1

HAEGARDA 3 PA; QL

HEPAGAM B 3

HIZENTRA 2 PA; QL

HUMIRA 2 PA; QL

HUMIRA PEDIATRIC CROHNS START

2 PA; QL

HUMIRA PEN 2 PA; QL

HUMIRA CITRATE FREE 2 PA; QL

HUMIRA PEN-PS/UV/ADOL HS START

2 PA; QL

HYPERHEP B S/D 2

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

3

HYPERRAB INJECTION SOLUTION 900 UNIT/3ML

3 PA

HYPERRAB S/D 3

HYPERTET S/D 3

HYQVIA 2 PA; QL

icatibant acetate 2 QL

IMOGAM RABIES-HT 3

IMURAN 3

KEDRAB 3

KEVZARA 3 PA; QL

KINERET 3 PA; QL

leflunomide oral 1

methotrexate oral 1

methotrexate sodium 1

methotrexate sodium (pf) 1

mycophenolate mofetil 1

mycophenolate sodium 1

MYFORTIC 3

NABI-HB 2

NEORAL 3


Drug Name Drug Tier

Notes

OLUMIANT 3 PA; QL

ORENCIA CLICKJECT 2 PA; QL

ORENCIA SUBCUTANEOUS

2 PA; QL

OTEZLA 2 PA; QL

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

3 PA

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML

3

PROGRAF ORAL 3

RAPAMUNE 3

RASUVO 2

RHOPHYLAC 3

RIDAURA 2 QL

RINVOQ 3 PA; QL

RUCONEST 3 PA; QL

SANDIMMUNE ORAL 3

SILIQ 3 PA; QL

SIMPONI 3 PA; QL

sirolimus oral 1

SKYRIZI (150 MG DOSE) 3 PA; QL

STELARA SUBCUTANEOUS

2 PA; QL

tacrolimus oral 1

TAKHZYRO 3 PA; QL

TALTZ 3 PA; QL

TREMFYA 2 PA; QL

TREXALL 3

VARIZIG 3

XATMEP 3 QL

XELJANZ 2 PA; QL

XELJANZ XR 2 PA; QL

XEMBIFY 3 PA; QL

Drug Name Drug Tier

Notes

ZORTRESS 3 QL

Immunological Agents - Drugs for Vaccination

ACTHIB 2

ADACEL 2

AFLURIA QUADRIVALENT

1

BEXSERO 2

BIOTHRAX 3

BOOSTRIX 2

DAPTACEL 2

DIPHTHERIA-TETANUS TOXOIDS DT

2

ENGERIX-B 2

FLUAD 1

FLUAD QUADRIVALENT 3

FLUARIX QUADRIVALENT

1

FLUBLOK QUADRIVALENT

1

FLUCELVAX QUADRIVALENT

1

FLULAVAL QUADRIVALENT

1

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

1

FLUZONE HIGH-DOSE QUADRIVALENT

1

FLUZONE QUADRIVALENT

1

GARDASIL 9 2

HAVRIX 2

HEPLISAV-B 2

HIBERIX 2

INFANRIX 2

IPOL 2

KINRIX 2

MENACTRA 2


Drug Name Drug Tier

Notes

MENVEO 2

M-M-R II 2

PEDIARIX 2

PEDVAX HIB 2

PENTACEL 2

PNEUMOVAX 23 2

PREVNAR 13 2

PROQUAD 2

QUADRACEL 2

RECOMBIVAX HB 2

ROTARIX 2

ROTATEQ 2

SHINGRIX 2

TDVAX 2

TENIVAC 2

TRUMENBA 2

TWINRIX 3

VAQTA INTRAMUSCULAR SUSPENSION 50 UNIT/ML

2

VARIVAX 2

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

2

Inflammatory Bowel Disease Agents

ANALPRAM-HC 3

anucort-hc 3

ANUSOL-HC EXTERNAL 3

anusol-hc rectal 3

APRISO 3 ST

ASACOL HD 3 ST

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide er 3 PA; QL

budesonide oral 3 PA

Drug Name Drug Tier

Notes

CANASA 3

COLAZAL 3

colocort 1

CORTENEMA 3

CORTIFOAM 2

DELZICOL 3 ST

DIPENTUM 3 ST; QL

ENTOCORT EC 3 PA

hemmorex-hc 3

hydrocortisone (perianal) external cream 1 %

3

hydrocortisone (perianal) external cream 2.5 %

1

hydrocortisone ace-pramoxine external cream 1-1 %

3

hydrocortisone acetate rectal

3

hydrocortisone rectal 1

LIALDA 1 ST

lidocaine-hydrocort (perianal)

3

lidocaine-hydrocortisone ace rectal cream 3-0.5 %

3

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

3

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %

3

mesalamine er 3 ST

mesalamine oral capsule delayed release

3 ST

mesalamine oral tablet delayed release

1 ST

mesalamine rectal 1

mesalamine-cleanser 3

PENTASA 2 ST

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 2


Drug Name Drug Tier

Notes

procto-med hc 1

procto-pak 3

proctosol hc 1

proctozone-hc 1

ROWASA 3

SFROWASA 3

sulfasalazine oral 1

UCERIS ORAL 3 PA; QL

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL 3 ST

alendronate sodium 1

ATELVIA 3 ST

BINOSTO 3

BONIVA ORAL 3

calcitonin (salmon) 3

FORTEO 3 PA; QL

FOSAMAX 3

FOSAMAX PLUS D 3

ibandronate sodium oral 1

MIACALCIN INJECTION 3

RAYALDEE 3 PA

risedronate sodium oral tablet

1 ST

risedronate sodium oral tablet delayed release

3 ST

TERIPARATIDE (RECOMBINANT)

3 PA; QL

TYMLOS 3 PA

Metabolic Bone Disease Agents - Other

calcitriol oral 1

cinacalcet hcl 1 PA

doxercalciferol oral 3

NATPARA 3 PA; QL

paricalcitol oral 3

ROCALTROL 3

SENSIPAR 3 PA

Drug Name Drug Tier

Notes

ZEMPLAR ORAL 3

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS

3

ACREMONIUM 3

ALCOHOL PREP PADS PAD , 70 %

1

ALDER 3

AMERICAN BEECH 3

ANTIVENIN LATRODECTUS MACTANS

3

ARIZONA CYPRESS 3

ASPERGILLUS FUMIGATUS INJECTION

3

AUREOBASIDIUM 3

AUREOBASIDIUM PULLULANS INJECTION

3

AUSTRALIAN PINE 3

BALD CYPRESS 3

BOTRYTIS 3

BREATHE EASE LARGE 2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL 2

BREATHERITE 2

BROME 3

CALCIUM DISODIUM VERSENATE

3

CALIFORNIA PEPPER TREE

3

CANDIDA ALBICANS EXTRACT INJECTION

3

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNU/ML

3

CATTLE EPITHELIUM 3

CAYA 2

CEDAR ELM 3


Drug Name Drug Tier

Notes

CLADOSPORIUM CLADOSPORIOIDES

3

CLADOSPORIUM SPHAEROSPERMUM

3

CLEVER CHOICE HOLDING CHAMBER

2

COMPACT SPACE CHAMBER/LG MASK

2

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

CURVULARIA 3

CYTOTINE ORAL POWDER

3

deferoxamine mesylate injection solution reconstituted 500 mg

1

DESFERAL 3

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

3

DRECHSLERA 3

DUST MITE MIXED ALLERGEN EXT

3

EASIVENT 2

ENDARI 3 PA; QL

EPICOCCUM 3

EPICOCCUMNIGRUM 3

ergoloid mesylates oral 3

FEMCAP 2

FIRDAPSE 3 PA; QL

FIRE ANT 3

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2

FUSARIUM 3

GERMAN COCKROACH 3

Drug Name Drug Tier

Notes

GLUCAGEN DIAGNOSTIC

2

GLUCAGON HCL (DIAGNOSTIC)

2

GRASTEK 3 PA

HACKBERRY 3

HONEY BEE VENOM 3

HONEY BEE VENOM PROTEIN

3

HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10

3

JUNE GRASS POLLEN STANDARDIZED

3

KAPOK 3

MASK VORTEX 2

MELALEUCA 3

methergine 1

methylergonovine maleate

1

MICROCHAMBER DEVICE

2

MIXED ASPERGILLUS 3

MIXED FEATHERS 3

MIXED VESPID VENOM PROTEIN INJECTION

3

mixed vespid venom protein subcutaneous solution reconstituted 1100-1100-1100 mcg

3

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120-120-120 MCG

3

MUCOR 3

ODACTRA 3 PA

OLIVE TREE 3

OMNIPOD 5 PACK 3 PA

OMNIPOD DASH 5 PACK PODS

3 PA


Drug Name Drug Tier

Notes

ORALAIR 3 PA

ORALAIR ADULT SAMPLE KIT

3 PA

ORALAIR ADULT STARTER PACK

3 PA

ORALAIR CHILDRENS SAMPLE KIT

3 PA

ORALAIR CHILDRENS STARTER PACK

3 PA

OXBRYTA 3 PA; QL

PALFORZIA (12 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL

PALFORZIA (300 MG MAINTENANCE)

3 PA; QL

PALFORZIA (300 MG TITRATION)

3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL

PALFORZIA INITIAL ESCALATION

3 PA; QL

PANDA MASK LARGE 2

PANDA MASK MEDIUM 2

PANDA MASK SMALL 2

PEDIATRIC PANDA MASK

2

PENICILLIUM NOTATUM INJECTION

3

Drug Name Drug Tier

Notes

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

3

PERENNIAL RYE GRASS POLLEN

3

PHYSOSTIGMINE SALICYLATE

3

pocket spacer 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2

PRO COMFORT SPACER INFANT

2

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

QUEEN PALM 3

RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10

3

RAGWITEK 3 PA

RED MAPLE 3

RHIZOPUS 3

RUZURGI 3 PA; QL

SACCHAROMYCES CEREVISIAE INJECTION

3

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS

3

SPINY PIGWEED 3

STEMPHYLIUM 3

SWEET GUM 3

SWEET VERNAL GRASS POLLEN

3

TACHOSIL 3

TALL RAGWEED 3

TRICHOPHYTON 3

VENOMIL HONEY BEE VENOM

3


Drug Name Drug Tier

Notes

VENOMIL MIXED VESPID VENOM

3

VENOMIL WASP VENOM

3

VENOMIL WHITE FACED HORNET

3

VENOMIL YELLOW HORNET VENOM

3

VENOMIL YELLOW JACKET VENOM

3

VISTOGARD 3 PA; QL

WASP VENOM PROTEIN 3

WESTERN JUNIPER 3

WHITE BIRCH 3

WHITE FACED HORNET VENOM

3

WHITE MULBERRY 3

WHITE-FACED HORNET VENOM

3

WIDE-SEAL DIAPHRAGM 60

2


2


2


2


2


2


2


2

YELLOW HORNET VENOM PROTEIN

3

YELLOW JACKET VENOM PROTEIN

3

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR 2

ACULAR LS 3

Drug Name Drug Tier

Notes

ACUVAIL 3

ALOCRIL 3

ALOMIDE 2

ALREX 3

AZASITE 3

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1

BEPREVE 3

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

3

BROMSITE 3

CILOXAN OPHTHALMIC OINTMENT

2

CILOXAN OPHTHALMIC SOLUTION

3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

DUREZOL 2

epinastine hcl 3

erythromycin ophthalmic 1

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak 1


Drug Name Drug Tier

Notes

gentamicin sulfate ophthalmic

1

ILEVRO 3

INVELTYS 3

ketorolac tromethamine ophthalmic

1

KLARITY-A 3

KLARITY-B 3

KLARITY-L 3

levofloxacin ophthalmic 3

LOTEMAX 3

LOTEMAX SM 3

loteprednol etabonate 3

MAXIDEX 3

MOXEZA 3

moxifloxacin hcl (2x day) 1

moxifloxacin hcl ophthalmic

1

NATACYN 2

NEVANAC 3

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic solution 0.1 %

1

olopatadine hcl ophthalmic solution 0.2 %

3

PAZEO 3

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 2

PREDNISOL ACE-MOXIFLOX-BROMFEN

3

prednisolone acetate ophthalmic

1

prednisolone acetate p-f 1

prednisolone sodium phosphate ophthalmic

3

PREDNISOLON-MOXIFLOX-NEPAFENAC

3

Drug Name Drug Tier

Notes

PROLENSA 3

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX OPHTHALMIC OINTMENT

2

TOBREX OPHTHALMIC SOLUTION

3

trifluridine 1

VIGAMOX 2

ZERVIATE 3

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P 3

apraclonidine hcl 3

AZOPT 2

betaxolol hcl ophthalmic 1

BETIMOL 3

BETOPTIC-S 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic solution 0.15 %

3

brimonidine tartrate ophthalmic solution 0.2 %

1

BRIMONIDINE-DORZOLAMIDE

3

carteolol hcl 1

COMBIGAN 3

COSOPT 3

COSOPT PF 3

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC

3

dorzolamide hcl solution 2 % ophthalmic

1


Drug Name Drug Tier

Notes

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

3

IOPIDINE 3

ISOPTO CARPINE 3

ISTALOL 3

KEVEYIS 3 PA; QL

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

3

levobunolol hcl 1

LUMIGAN 2

methazolamide oral 1

PHOSPHOLINE IODIDE 3

pilocarpine hcl ophthalmic 1

RHOPRESSA 3 PA

ROCKLATAN 3 PA

SIMBRINZA 3

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.5 % (daily)

3

TIMOLOL-BRIMON-DORZOL-LATANOPR

3

TIMOLOL-BRIMONIDINE-DORZOLAMID

3

TIMOLOL-DORZOLAMID-LATANOPROST

3

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 3

travoprost (bak free) 1

Drug Name Drug Tier

Notes

TRUSOPT 3

VYZULTA 3 PA

XALATAN 3

XELPROS 3

ZIOPTAN 3

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ACUICYN 3

ak-poly-bac 1

AKTEN 3

ALCAINE 3

altacaine 3

altafrin 1

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 %

1

atropine sulfate ophthalmic solution 1 %

1

AVENOVA 3

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

CEQUA 3 PA

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

2 PA

CYSTARAN 3

GELFILM OPHTHALMIC 3

homatropaire 1

HYPOCYN 3

LACRISERT 2


Drug Name Drug Tier

Notes

LASTACAFT 3

MAXITROL 3

neomycin-bacitracin zn-polymyx

3

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin

1

neomycin-polymyxin-hc ophthalmic

3

neo-polycin 3

neo-polycin hc 1

OXERVATE 3 PA; QL

phenylephrine hcl ophthalmic

1

polycin 1

polymyxin b-trimethoprim 1

POLYTRIM 3

PRED-G 2

PRED-G S.O.P. 2

PREDNISOLONE ACETATE-NEPAFENAC

3

PREDNISOLONE ACET-MOXIFLOXACIN

3

PREDNISOLONE-BROMFENAC

3

PREDNISOLONE-GATIFLOXACIN

3

PREDNISOLONE-MOXIFLOXACIN

3

PREDNISOLON-GATIFLOX-BROMFENAC

3

PREDNISOLON-MOXIFLOX-BROMFENAC

3

proparacaine hcl ophthalmic

3

RESTASIS 2 PA

Drug Name Drug Tier

Notes

RESTASIS MULTIDOSE 2 PA

sulfacetamide-prednisolone ophthalmic solution

1

tetracaine hcl ophthalmic 3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX OPHTHALMIC SUSPENSION

3

TOBRADEX ST 3

tobramycin-dexamethasone

1

TROPICAMIDE-CYCLOPENTOLATE-PE

3

TROPICAMIDE-PHENYLEPHRINE

3

TROPIC-PROPARACA-PE-KETOROLAC

3

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3

CIPRO HC 2

CIPRODEX 2

ciprofloxacin hcl otic 3

DERMOTIC 3

flac 3

fluocinolone acetonide otic

3

hydrocortisone-acetic acid 3

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTOVEL 3

PRAMOTIC 3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL 3


Drug Name Drug Tier

Notes

azelastine hcl nasal 1

azelastine-fluticasone 3

BECONASE AQ 3 PA

benzonatate oral capsule 100 mg, 200 mg

1

benzonatate oral capsule 150 mg

3

bromfed dm 3

BROMPHENIRAMINE MALEATE INTRAMUSCULAR

3

brompheniramine tannate 3

carbinoxamine maleate 1

cetirizine hcl oral solution 3

CLARINEX 3

CLARINEX-D 12 HOUR 3

clemastine fumarate oral tablet 2.68 mg

1

CUROSURF 3

cyproheptadine hcl oral 1

DERMACINRX AZENASE PAK

3

desloratadine 1

dexchlorpheniramine maleate oral

3

diphen oral elixir 3

diphenhydramine hcl injection

1

diphenhydramine hcl oral elixir

3

DYMISTA 3

FASENRA PEN 3 PA; QL

flunisolide nasal 1

hydrocodone polst-cpm polst er

3

hydrocodone-homatropine

1

hydromet 1

HYPERSAL 3

INFASURF 3

Drug Name Drug Tier

Notes

ipratropium bromide nasal 1

KARBINAL ER 3

levocetirizine dihydrochloride oral

1

MICLARA LQ 3

mometasone furoate nasal

3 PA

NASONEX 3 PA

nebusal inhalation nebulization solution 3 %

1

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

3

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; QL

olopatadine hcl nasal 3

OMNARIS 3 PA

PATANASE 3

PHENERGAN 3

promethazine hcl injection 3

promethazine hcl oral 1

promethazine hcl rectal 1

promethazine-codeine 3 PA

promethazine-dm 1

promethazine-phenyleph-codeine

3 PA

promethazine-phenylephrine

1

promethegan 1

pseudoephedrine-bromphen-dm oral syrup

3

pulmosal 1

QNASL 3 PA

QNASL CHILDRENS 3 PA

RYCLORA 3


Drug Name Drug Tier

Notes

ryvent 1

SEMPREX-D 3

sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %

1

sodium chloride inhalation nebulization solution 10 %

3

SSKI 2

SURVANTA 2

TESSALON PERLES 3

TUSSICAPS 3

TUXARIN ER 3 PA; QL

TUZISTRA XR 3 PA

XHANCE 3 PA

ZETONNA 3 PA

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation 1

ADVAIR DISKUS 1

ADVAIR HFA 2

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP II 3

ADYPHREN II 3

AIRDUO RESPICLICK 113/14

3 PA


3 PA


3 PA

albuterol sulfate er 3

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1 QL

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

3 QL

Drug Name Drug Tier

Notes

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

3 QL

albuterol sulfate inhalation 1

albuterol sulfate oral 1

ALVESCO 2

ANORO ELLIPTA 3 PA

ARCAPTA NEOHALER 3

ARNUITY ELLIPTA 3 PA

ASMANEX (120 METERED DOSES)

2 ST


2 ST


2 ST


2 ST


2 ST

ASMANEX HFA 2 ST

ATROVENT HFA 2

AUVI-Q 3 PA

BEVESPI AEROSPHERE 3 PA

BREO ELLIPTA 3 PA

BROVANA 3 PA

budesonide inhalation 1

BUDESONIDE-FORMOTEROL FUMARATE

3 PA

COMBIVENT RESPIMAT 2

cromolyn sodium inhalation

1

DALIRESP 3

difil-g forte 3

DUAKLIR PRESSAIR 3 PA

DULERA 3 PA

ELIXOPHYLLIN 3

epinephrine injection solution auto-injector

1


Drug Name Drug Tier

Notes

EPINEPHRINE PROFESSIONAL

3

EPINEPHRINESNAP-EMS

3

EPINEPHRINESNAP-V 3

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

EPISNAP 3

ESBRIET 2 PA; QL

FLOVENT DISKUS 2 PA

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

2 PA

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 PA

INCRUSE ELLIPTA 3 PA

ipratropium bromide inhalation

1

ipratropium-albuterol 1

levalbuterol hcl inhalation 3

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

3 QL

LONHALA MAGNAIR REFILL KIT

3 PA

LONHALA MAGNAIR STARTER KIT

3 PA

metaproterenol sulfate oral

1

Drug Name Drug Tier

Notes

montelukast sodium oral 1

OFEV 2 PA; QL

PERFOROMIST 3

PROAIR DIGIHALER 3 QL

PROAIR HFA 3 QL

PROAIR RESPICLICK 3 QL

PROVENTIL HFA 3 QL

PULMICORT FLEXHALER

3 PA

PULMICORT SUSPENSION

3

QVAR REDIHALER 3 PA

SEEBRI NEOHALER 3 PA

SEREVENT DISKUS 2 ST

SINGULAIR 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 ST

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2 PA

SYMBICORT 3 PA

SYMJEPI 3

terbutaline sulfate injection

3

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

theophylline er 1

TRELEGY ELLIPTA 3 PA

TUDORZA PRESSAIR 3

UTIBRON NEOHALER 3 PA

VENTOLIN HFA 1 QL

XOPENEX 3


Drug Name Drug Tier

Notes

XOPENEX CONCENTRATE

3

XOPENEX HFA 3 QL

YUPELRI 3 PA

zafirlukast 3

zileuton er 3 PA; QL

ZYFLO 3 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS 3 PA; QL

CAYSTON 3 PA; QL

KALYDECO 3 PA; QL

KITABIS PAK 3 PA; QL

ORKAMBI 3 PA; QL

PULMOZYME 2

SYMDEKO 3 PA; QL

TOBI NEBULIZER 3 PA; QL

TOBI PODHALER 3 PA; QL

tobramycin nebulization solution 300 mg/5ml inhalation

1 PA; QL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION

3 PA; QL

TRIKAFTA 3 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA 3 PA; QL

ADEMPAS 3 PA; QL

alyq 3 PA; QL

ambrisentan 1 PA; QL

bosentan 1 PA; QL

LETAIRIS 3 PA; QL

OPSUMIT 2 PA; QL

ORENITRAM 3 PA; QL

REVATIO ORAL SUSPENSION RECONSTITUTED

3 PA; QL

REVATIO ORAL TABLET 3 PA

Drug Name Drug Tier

Notes

sildenafil citrate oral suspension reconstituted

3 PA; QL

sildenafil citrate oral tablet 20 mg

1 PA

tadalafil (pah) 3 PA; QL

TRACLEER 3 PA; QL

TYVASO 2 PA; QL

TYVASO REFILL 2 PA; QL

TYVASO STARTER 2 PA; QL

UPTRAVI 2 PA; QL

VENTAVIS 2 PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX 3 PA; QL

baclofen oral 1

carisoprodol oral 3 PA; QL

carisoprodol-aspirin 3 PA

chlorzoxazone oral tablet 250 mg

3

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg

3 QL

cyclobenzaprine hcl er 3 PA; QL

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1 QL

cyclobenzaprine hcl oral tablet 7.5 mg

3 QL

DANTRIUM ORAL 3

dantrolene sodium oral 1

FEXMID 3 QL

FIRST-BACLOFEN 3

LORZONE 3 QL

metaxalone 3 QL

methocarbamol injection 1

methocarbamol oral 1 QL

NOPIOID-TC KIT 3

NORGESIC FORTE 3 QL

orphenadrine citrate er 1 QL

orphenadrine citrate injection

3


Drug Name Drug Tier

Notes

orphenadrine-asa-caffeine

3 QL

ORPHENGESIC FORTE ORAL TABLET 770-60-50 MG

3 QL

OZOBAX 3

ROBAXIN 3

ROBAXIN-750 3 QL

SKELAXIN 3 QL

SOMA 3 PA; QL

tizanidine hcl oral capsule 3

tizanidine hcl oral tablet 1

VANADOM 3 PA; QL

ZANAFLEX 3

Sleep Disorder Agents

AMBIEN 3

AMBIEN CR 3

AMYTAL SODIUM 3

armodafinil 3 PA

BELSOMRA 3 PA

DAYVIGO 3 PA

doxepin hcl oral tablet 3

EDLUAR 3

eszopiclone 1

flurazepam hcl 1

HETLIOZ 3 PA; QL

INTERMEZZO 3

LUNESTA 3

modafinil 1

NUVIGIL 3 PA

PROVIGIL 3

ramelteon 3

RESTORIL 3

ROZEREM 3

SECONAL 2

SILENOR 3

SUNOSI 3 PA; QL

Drug Name Drug Tier

Notes

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

1

temazepam oral capsule 22.5 mg

3

WAKIX 3 PA; QL

XYREM 3 PA; QL

zaleplon 1

zolpidem tartrate er 3

zolpidem tartrate oral 1

zolpidem tartrate sublingual

3

ZOLPIMIST 3

80

Index of Drugs

1 1ST MEDX-PATCH/

LIDOCAINE ................. 14 7 7T GUMMY ES ................ 12 7T LIDO ........................... 14 A abacavir sulfate ............... 30 abacavir sulfate-lamivudine

.................................... 30 abacavir-lamivudine-

zidovudine ................... 30 ABILIFY ........................... 29 ABILIFY MAINTENA ........ 29 ABILIFY MYCITE ............ 29 abiraterone acetate.......... 25 ABSORICA ...................... 40 ABSORICA LD ................ 40 ABSTRAL ........................ 12 ACACIA ........................... 67 acamprosate calcium ....... 15 ACANYA ......................... 40 acarbose ......................... 47 ACCOLATE ..................... 75 ACCU-CHEK AVIVA

DEVICE ....................... 48 ACCU-CHEK COMPACT

PLUS CONTROL ......... 48 ACCU-CHEK FASTCLIX

LANCET KIT ................ 48 ACCU-CHEK GUIDE

CONTROL ................... 48 ACCU-CHEK MULTICLIX

LANCET DEVICE KIT .. 48 ACCU-CHEK SMARTVIEW

CONTROL ................... 48 ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT .. 48 ACCUPRIL ...................... 33 ACCURETIC ................... 33 acebutolol hcl .................. 33 acetaminophen-codeine .. 12 acetaminophen-codeine #2

.................................... 12 acetaminophen-codeine #3

.................................... 12 acetaminophen-codeine #4

.................................... 12 acetazolamide ................. 71 acetazolamide er ............. 71 acetazolamide sodium ..... 33 acetic acid ................. 55, 73 acetylcysteine .................. 75

ACIPHEX ........................ 53 ACIPHEX SPRINKLE ...... 53 acitretin ........................... 40 ACREMONIUM ............... 67 ACTEMRA....................... 64 ACTEMRA ACTPEN ....... 64 ACTHAR ......................... 58 ACTHIB ........................... 65 ACTICLATE .................... 16 ACTIGALL ....................... 53 ACTIMMUNE .................. 64 ACTIQ ............................. 12 ACTIVELLA ..................... 59 ACTONEL ....................... 67 ACTOPLUS MET ............ 47 ACTOS ............................ 47 ACUICYN ........................ 72 ACULAR ......................... 70 ACULAR LS .................... 70 ACUVAIL ......................... 70 acyclovir .......................... 30 ACZONE ......................... 40 ADACEL .......................... 65 adapalene ....................... 40 ADAPALENE ................... 40 adapalene-benzoyl peroxide

.................................... 40 ADCIRCA ........................ 77 ADDERALL ..................... 38 ADDERALL XR ............... 38 adefovir dipivoxil .............. 30 ADEMPAS....................... 77 ADHANSIA XR ................ 38 ADLYXIN ......................... 47 ADLYXIN STARTER PACK

.................................... 47 ADMELOG ...................... 50 ADMELOG SOLOSTAR .. 50 ADRENALIN .................... 73 ADVAIR DISKUS............. 75 ADVAIR HFA ................... 75 ADVANCED ALLERGY

COLLECTION ............. 40 ADYPHREN .................... 75 ADYPHREN AMP............ 75 ADYPHREN AMP II ......... 75 ADYPHREN II ................. 75 ADZENYS ER ................. 38 ADZENYS XR-ODT ......... 38 AEMCOLO ...................... 16 AFINITOR ....................... 25 AFINITOR DISPERZ ....... 25 afirmelle .......................... 59

AFLURIA QUADRIVALENT .................................... 65

AFREZZA........................ 50 AGAMATRIX CONTROL

LEVEL 2 ...................... 48 AGAMATRIX CONTROL

LEVEL 4 ...................... 48 AGGRENOX ................... 29 AGONEAZE .................... 14 AGRYLIN ........................ 33 AIMOVIG......................... 24 AIRDUO RESPICLICK

113/14 ......................... 75 AIRDUO RESPICLICK

232/14 ......................... 75 AIRDUO RESPICLICK

55/14 ........................... 75 AJOVY ............................ 24 AKLIEF ........................... 40 ak-poly-bac ..................... 72 AKTEN ............................ 72 AKYNZEO ....................... 22 ALA SCALP .................... 40 ala-cort ............................ 40 albendazole ..................... 27 ALBENZA........................ 28 albuterol sulfate ............... 75 albuterol sulfate er ........... 75 albuterol sulfate hfa ......... 75 ALBUTEROL SULFATE

HFA ............................. 75 ALCAINE......................... 72 alclometasone dipropionate

.................................... 40 ALCOHOL PREP PADS .. 67 ALDACTAZIDE ............... 33 ALDACTONE .................. 33 ALDARA ......................... 40 ALDER ............................ 67 ALECENSA ..................... 25 alendronate sodium ......... 67 ALFERON N ................... 64 alfuzosin hcl er ................ 56 ALINIA ............................ 28 aliskiren fumarate ............ 33 ALKERAN ....................... 25 allopurinol........................ 24 ALLZITAL ........................ 12 almotriptan malate ........... 24 ALOCRIL......................... 70 ALOGLIPTIN BENZOATE

.................................... 47

81

ALOGLIPTIN-METFORMIN HCL ............................. 47

ALOGLIPTIN-PIOGLITAZONE .......... 47

ALOMIDE ........................ 70 ALORA ............................ 59 alosetron hcl .................... 53 ALPHAGAN P ................. 71 alprazolam ....................... 32 alprazolam er ................... 32 alprazolam intensol.......... 32 alprazolam xr ................... 32 alprostadil ........................ 33 ALREX ............................ 70 ALTABAX ........................ 16 altacaine .......................... 72 ALTACE .......................... 33 altafrin ............................. 72 altavera ........................... 59 ALTOPREV ..................... 33 ALTRENO ....................... 40 ALUNBRIG ...................... 25 ALVESCO ....................... 75 alyacen 1/35 .................... 59 alyacen 7/7/7 ................... 59 alyq ................................. 77 amabelz ........................... 59 amantadine hcl ................ 28 AMARYL ......................... 47 AMBIEN .......................... 78 AMBIEN CR .................... 78 ambrisentan..................... 77 amcinonide ...................... 40 AMELUZ .......................... 40 AMERGE ......................... 24 AMERICAN BEECH ........ 67 amethia ........................... 59 amethia lo ........................ 59 amethyst .......................... 59 AMICAR .......................... 33 amiloride hcl .................... 33 amiloride-

hydrochlorothiazide ..... 33 aminocaproic acid ........... 33 amiodarone hcl ................ 33 AMITIZA .......................... 53 amitriptyline hcl ................ 21 amlodipine besylate ......... 33 amlodipine besylate-

benazepril hcl .............. 33 amlodipine besylate-

valsartan ...................... 33 amlodipine-atorvastatin ... 33 amlodipine-olmesartan .... 33 amlodipine-valsartan-hctz 33

ammonium lactate ........... 40 amnesteem ..................... 40 amoxapine....................... 21 amoxicill-clarithro-lansopraz

.................................... 53 amoxicillin ....................... 16 amoxicillin-potassium

clavulanate .................. 16 amoxicillin-potassium

clavulanate er .............. 16 AMPHETAMINE ER ........ 38 amphetamine sulfate ....... 38 amphetamine-

dextroamphetamine ..... 38 amphetamine-

dextroamphetamine er . 38 ampicillin ......................... 16 ampicillin sodium ............. 16 AMPYRA ......................... 39 AMRIX ............................. 77 AMYTAL SODIUM ........... 78 AMZEEQ ......................... 40 ANACAINE ...................... 40 ANADROL-50 .................. 58 ANAFRANIL .................... 21 anagrelide hcl .................. 33 ANALPRAM-HC .............. 66 ANASPAZ ....................... 53 anastrozole...................... 25 ANCOBON ...................... 23 ANDRODERM ................. 58 ANDROGEL .................... 58 ANDROGEL PUMP ......... 58 ANGELIQ ........................ 59 ANNOVERA .................... 59 ANODYNE LPT ............... 14 ANORO ELLIPTA ............ 75 ANTABUSE ..................... 15 ANTARA ......................... 33 ANTIVENIN

LATRODECTUS MACTANS ................... 67

anucort-hc ....................... 66 anusol-hc ........................ 66 ANUSOL-HC ................... 66 ANZEMET ....................... 22 APADAZ .......................... 12 apap-caff-dihydrocodeine 12 APEXICON E .................. 41 APIDRA SOLOSTAR ...... 50 APIDRA VIAL .................. 50 APLENZIN....................... 21 APOKYN ......................... 28 apraclonidine hcl ............. 71 aprepitant ........................ 22

apri .................................. 59 APRISO .......................... 66 APTENSIO XR ................ 38 APTIOM .......................... 19 APTIVUS......................... 30 aranelle ........................... 59 ARANESP (ALBUMIN

FREE) ......................... 33 ARAVA ............................ 64 ARAZLO ......................... 41 ARCALYST ..................... 64 ARCAPTA NEOHALER ... 75 argyle sterile saline ......... 51 argyle sterile water .......... 51 ARICEPT ........................ 20 ARIKAYCE ...................... 16 ARIMIDEX ....................... 25 aripiprazole ..................... 29 ARISTADA ...................... 29 ARISTADA INITIO ........... 29 ARIXTRA ........................ 18 ARIZONA CYPRESS ...... 67 armodafinil ...................... 78 ARMOUR THYROID ....... 63 ARNUITY ELLIPTA ......... 75 AROMASIN ..................... 25 ARTHROTEC .................. 11 ARYMO ER ..................... 12 arzol silver nit applicators 41 ASACOL HD ................... 66 ascomp-codeine .............. 12 ashlyna ........................... 59 ASMANEX (120 METERED

DOSES) ...................... 75 ASMANEX (14 METERED




DOSES) ...................... 75 ASMANEX HFA .............. 75 ASPERGILLUS

FUMIGATUS ............... 67 aspirin-dipyridamole er .... 29 ASTAGRAF XL ............... 64 ASTERO ......................... 14 ATACAND ....................... 33 ATACAND HCT............... 33 atazanavir sulfate ............ 30 ATELVIA ......................... 67 atenolol ........................... 33 atenolol-chlorthalidone .... 33 ATIVAN ........................... 32

82

atomoxetine hcl ............... 38 ATOPADERM .................. 41 ATOPICLAIR ................... 41 atorvastatin calcium ......... 33 atovaquone ..................... 28 ATRALIN ......................... 41 ATRIPLA ......................... 30 atropine sulfate ................ 72 ATROPINE SULFATE ..... 72 ATROVENT HFA ............. 75 AUBAGIO ........................ 39 aubra ............................... 59 aubra eq .......................... 59 AUGMENTIN ................... 16 AUGMENTIN ES-600 ...... 16 AUREOBASIDIUM .......... 67 AUREOBASIDIUM

PULLULANS ............... 67 aurovela 1.5/30 ................ 59 aurovela 1/20................... 59 aurovela 24 fe .................. 59 aurovela fe 1.5/30 ............ 59 aurovela fe 1/20 ............... 59 AURYXIA ........................ 55 AUSTEDO ....................... 39 AUSTRALIAN PINE ......... 67 AUTOLET LANCING

DEVICE ....................... 49 AUVI-Q ............................ 75 AVALIDE ......................... 33 AVANDIA ........................ 47 AVAPRO ......................... 33 avar cleanser ................... 41 AVAR LS CLEANSER ..... 41 AVAR-E EMOLLIENT ...... 41 AVAR-E GREEN ............. 41 AVAR-E LS ..................... 41 AVENOVA ....................... 72 aviane.............................. 59 avidoxy ............................ 16 avita ................................ 41 AVODART ....................... 56 AVONEX PEN ................. 39 AVONEX PREFILLED ..... 39 AVONEX VIAL

INTRAMUSCULAR KIT .................................... 39

AYGESTIN ...................... 59 ayuna .............................. 59 AYVAKIT ......................... 25 AZASAN .......................... 64 AZASITE ......................... 70 azathioprine ..................... 64 azelaic acid ..................... 41 azelastine hcl ............. 70, 74

azelastine-fluticasone ...... 74 AZELEX .......................... 41 AZILECT ......................... 28 azithromycin .................... 16 AZOPT ............................ 71 AZOR .............................. 33 AZULFIDINE ................... 66 AZULFIDINE EN-TABS ... 66 azurette ........................... 59 B bacitracin ......................... 70 bacitracin-polymyxin b ..... 72 bacitra-neomycin-

polymyxin-hc ............... 72 baclofen .......................... 77 BACTRIM ........................ 16 BACTRIM DS .................. 16 BALCOLTRA ................... 59 BALD CYPRESS ............. 67 balsalazide disodium ....... 66 BALVERSA ..................... 25 balziva ............................. 59 BANZEL .......................... 19 BAQSIMI ONE PACK ...... 49 BAQSIMI TWO PACK ..... 49 BARACLUDE .................. 30 BASAGLAR KWIKPEN.... 50 BAXDELA ....................... 16 BD AUTOSHIELD DUO

PEN NEEDLES ........... 50 BD ULTRA-FINE INSULIN

SYRINGES .................. 50 BD ULTRA-FINE PEN

NEEDLES ................... 50 BD VEO INSULIN SYR U/F

1/2UNIT ....................... 50 BECONASE AQ .............. 74 bekyree ........................... 59 BELBUCA ....................... 12 belladonna alkaloids-opium

.................................... 53 BELSOMRA .................... 78 benazepril hcl .................. 33 benazepril-

hydrochlorothiazide ..... 33 BENICAR ........................ 33 BENICAR HCT ................ 33 BENLYSTA ..................... 64 BENSAL HP .................... 41 BENTYL .......................... 53 BENZACLIN .................... 41 BENZACLIN WITH PUMP

.................................... 41 BENZAMYCIN ................. 41 benzepro foaming cloths . 41

BENZHYDROCODONE-ACETAMINOPHEN ..... 12

BENZIQ .......................... 41 BENZIQ LS ..................... 41 BENZNIDAZOLE ............. 28 benzonatate .................... 74 BENZOYL PEROX-

HYDROCORTISONE .. 41 BENZOYL PEROXIDE .... 41 BENZOYL PEROXIDE

FORTE- HC ................. 41 benzoyl peroxide-

erythromycin ................ 41 benztropine mesylate ...... 28 BEPREVE ....................... 70 BERINERT ...................... 64 beser ............................... 41 BESIVANCE ................... 70 BETADINE OPHTHALMIC

PREP .......................... 70 betamethasone

dipropionate ................ 41 betamethasone

dipropionate aug ......... 41 BETAMETHASONE

SODIUM PHOSPHATE56 betamethasone valerate .. 41 BETAPACE ..................... 33 BETAPACE AF ............... 33 BETASERON .................. 39 betaxolol hcl .............. 33, 71 bethanechol chloride ....... 55 BETHKIS......................... 77 BETIMOL ........................ 71 BETOPTIC-S .................. 71 BEVESPI AEROSPHERE75 bexarotene ...................... 25 BEXSERO ....................... 65 BEYAZ ............................ 59 bicalutamide .................... 25 BICILLIN L-A ................... 16 BIDIL ............................... 34 BIJUVA ........................... 59 BIKTARVY ...................... 30 BILTRICIDE .................... 28 bimatoprost ..................... 71 BINOSTO ........................ 67 bio-statin ......................... 23 BIO-STATIN .................... 23 BIOTHRAX ...................... 65 bisoprolol fumarate .......... 34 bisoprolol-

hydrochlorothiazide ..... 34 BLEPH-10 ....................... 70 BLEPHAMIDE ................. 72

83

BLEPHAMIDE S.O.P. ...... 72 blisovi 24 fe ..................... 59 blisovi fe 1.5/30 ............... 59 blisovi fe 1/20 .................. 59 BOCASAL ....................... 40 BONIVA ........................... 67 BONJESTA ..................... 22 BOOSTRIX ...................... 65 bosentan ......................... 77 BOSULIF ......................... 25 BOTRYTIS ...................... 67 bp 10-1 ............................ 41 bp cleansing wash ........... 41 BRAFTOVI ...................... 25 BREATHE EASE LARGE 67 BREATHE EASE MEDIUM

.................................... 67 BREATHE EASE SMALL 67 BREATHERITE ............... 67 BREO ELLIPTA ............... 75 BRETYLIUM TOSYLATE 34 briellyn ............................. 59 BRILINTA ........................ 29 brimonidine tartrate.......... 71 BRIMONIDINE-

DORZOLAMIDE .......... 71 BRISDELLE..................... 21 BRIVIACT ........................ 19 BROME ........................... 67 bromfed dm ..................... 74 bromfenac sodium (once-

daily) ............................ 70 bromocriptine mesylate ... 28 BROMPHENIRAMINE

MALEATE .................... 74 brompheniramine tannate 74 BROMSITE ..................... 70 BROVANA ....................... 75 BRUKINSA ...................... 25 BRYHALI ......................... 41 budesonide ................ 66, 75 budesonide er .................. 66 BUDESONIDE-

FORMOTEROL FUMARATE ................. 75

bumetanide ..................... 34 BUMEX ........................... 34 BUNAVAIL ...................... 15 BUPAP ............................ 12 BUPHENYL ..................... 55 buprenorphine ................. 12 buprenorphine hcl ............ 15 buprenorphine hcl-naloxone

hcl ................................ 15 bupropion hcl ................... 21

bupropion hcl er (smoking det) .............................. 15

bupropion hcl er (sr) ........ 21 bupropion hcl er (xl) ......... 21 BUPROPION HCL ER (XL)

.................................... 21 buspirone hcl ................... 32 butalbital-acetaminophen 12 BUTALBITAL-

ACETAMINOPHEN ..... 12 butalbital-apap-caff-cod ... 12 butalbital-apap-caffeine ... 12 butalbital-asa-caff-codeine

.................................... 12 butalbital-aspirin-caffeine . 12 butorphanol tartrate ......... 12 BUTRANS ....................... 12 BYDUREON .................... 47 BYDUREON BCISE

AUTOINJECTOR ........ 47 BYETTA 10 MCG PEN .... 47 BYETTA 5 MCG PEN ...... 47 BYNFEZIA PEN .............. 58 BYSTOLIC ...................... 34 C cabergoline...................... 58 CABLIVI .......................... 29 CABOMETYX .................. 25 CADUET ......................... 34 CAFERGOT .................... 24 caffeine citrate ................. 39 CAFFEINE-SODIUM

BENZOATE ................. 39 CALAN SR ...................... 34 calcipotriene .................... 41 calcipotriene-betameth

diprop .......................... 41 CALCIPOTRIENE-

BETAMETH DIPROP .. 41 calcitonin (salmon) .......... 67 calcitrene ......................... 41 calcitriol ..................... 41, 67 calcium acetate ............... 55 calcium acetate (phos

binder) ......................... 55 CALCIUM DISODIUM

VERSENATE ............... 67 CALIFORNIA PEPPER

TREE........................... 67 CALQUENCE .................. 25 CAMBIA .......................... 24 camila .............................. 59 camrese .......................... 59 camrese lo....................... 59 CANASA ......................... 66

candesartan cilexetil ........ 34 candesartan cilexetil-hctz 34 CANDIDA ALBICANS

EXTRACT ................... 67 capecitabine .................... 25 CAPEX ............................ 41 CAPLYTA........................ 29 CAPRELSA ..................... 25 captopril .......................... 34 captopril-

hydrochlorothiazide ..... 34 CARAC ........................... 41 CARAFATE ..................... 53 CARBAGLU .................... 51 carbamazepine ............... 19 carbamazepine er ........... 19 CARBATROL .................. 19 carbidopa ........................ 28 carbidopa-levodopa ......... 28 carbidopa-levodopa er..... 28 carbidopa-levodopa-

entacapone ................. 28 carbinoxamine maleate ... 74 CARDIZEM ..................... 34 CARDIZEM CD ............... 34 CARDIZEM LA ................ 34 CARDURA ...................... 34 CARDURA XL ................. 56 CARETOUCH CONTROL

SOL LEVEL 2 .............. 49 CARETOUCH

LANCING/EJECTOR ... 49 carisoprodol .................... 77 carisoprodol-aspirin ......... 77 carisoprodol-aspirin-codeine

.................................... 12 CARNITOR ..................... 51 CARNITOR SF ................ 51 CAROSPIR ..................... 34 carteolol hcl ..................... 71 cartia xt ........................... 34 carvedilol ......................... 34 carvedilol phosphate er ... 34 CASODEX ...................... 25 CATAPRES ..................... 34 CATAPRES-TTS-1 .......... 34 CATAPRES-TTS-2 .......... 34 CATAPRES-TTS-3 .......... 34 CATTLE EPITHELIUM .... 67 CAYA .............................. 67 CAYSTON ....................... 77 caziant ............................ 59 CEDAR ELM ................... 67 cefaclor ........................... 16 cefaclor er ....................... 16

84

cefadroxil ......................... 16 cefazolin sodium .............. 16 cefdinir............................. 16 cefditoren pivoxil .............. 16 cefepime hcl .................... 16 cefixime ........................... 16 cefpodoxime proxetil ........ 16 cefprozil ........................... 16 ceftazidime ...................... 16 ceftriaxone sodium .......... 16 cefuroxime axetil ............. 16 CELEBREX ..................... 11 celecoxib ......................... 11 CELEXA .......................... 21 CELLCEPT ...................... 64 CELONTIN ...................... 19 cem-urea ......................... 41 CENTANY ....................... 16 cephalexin ....................... 16 CEQUA ........................... 72 CERACADE .................... 41 ceramax .......................... 41 CERDELGA..................... 55 CERVIDIL ........................ 55 cetirizine hcl..................... 74 CETRAXAL ..................... 73 cevimeline hcl .................. 40 CHANTIX ........................ 15 CHANTIX CONTINUING

MONTH PAK ............... 15 CHANTIX STARTING

MONTH PAK ............... 15 chateal............................. 59 chateal eq ........................ 59 CHEMET ......................... 51 CHENODAL .................... 53 chlordiazepoxide hcl ........ 32 chlordiazepoxide-

amitriptyline ................. 21 chlordiazepoxide-clidinium

.................................... 53 chlorhexidine gluconate ... 40 chloroquine phosphate .... 28 chlorothiazide .................. 34 chlorpromazine hcl .......... 29 chlorthalidone .................. 34 chlorzoxazone ................. 77 CHOLBAM ...................... 55 cholestyramine ................ 34 cholestyramine light ......... 34 ciclodan ........................... 23 ciclopirox ......................... 23 ciclopirox olamine ............ 23 cilostazol ......................... 29 CILOXAN ........................ 70

CIMDUO ......................... 30 cimetidine ........................ 53 cimetidine hcl .................. 53 CIMZIA ............................ 64 CIMZIA PREFILLED KIT . 64 CIMZIA STARTER KIT .... 64 cinacalcet hcl ................... 67 CINRYZE ........................ 64 CIPRO ............................. 16 CIPRO HC....................... 73 CIPRODEX ..................... 73 ciprofloxacin hcl ... 16, 70, 73 citalopram hydrobromide . 21 CLADOSPORIUM

CLADOSPORIOIDES .. 67 CLADOSPORIUM

SPHAEROSPERMUM . 68 claravis ............................ 41 CLARINEX ...................... 74 CLARINEX-D 12 HOUR .. 74 clarithromycin .................. 16 clarithromycin er .............. 16 clemastine fumarate ........ 74 CLENPIQ ........................ 53 CLEOCIN ........................ 16 CLEOCIN PHOSPHATE . 16 CLEOCIN-T ..................... 41 CLEVER CHOICE

HOLDING CHAMBER . 68 CLIMARA ........................ 59 CLIMARA PRO ............... 59 clindacin etz .................... 41 clindacin-p ....................... 41 CLINDAGEL .................... 41 clindamycin hcl ................ 17 clindamycin palmitate hcl . 17 clindamycin phosphate ... 17,

41, 42 CLINDAMYCIN

PHOSPHATE .............. 41 clindamycin phosphate-

benzoyl peroxide ......... 41 clindamycin-tretinoin ........ 42 CLINDESSE .................... 17 clobazam ......................... 19 clobetasol prop emollient

base ............................ 42 clobetasol propionate ...... 42 clobetasol propionate e ... 42 clobetasol propionate

emulsion ...................... 42 CLOBEX ......................... 42 CLOBEX SPRAY............. 42 clocortolone pivalate ........ 42 clodan ............................. 42

CLODERM ...................... 42 clomipramine hcl ............. 21 clonazepam ..................... 32 clonidine .......................... 34 clonidine hcl .................... 34 clonidine hcl er ................ 38 clopidogrel bisulfate ........ 29 clorazepate dipotassium .. 32 clotrimazole ..................... 23 clotrimazole-betamethasone

.................................... 23 clovique ........................... 51 clozapine ......................... 29 CLOZARIL ...................... 29 COARTEM ...................... 28 COCAINE HCL ............... 14 codeine sulfate ................ 12 COGENTIN ..................... 28 COLAZAL........................ 66 colchicine ........................ 24 COLCHICINE .................. 24 colchicine-probenecid ..... 24 COLCRYS ....................... 24 colesevelam hcl............... 34 COLESTID ...................... 34 COLESTID FLAVORED .. 34 colestipol hcl ................... 34 colistimethate sodium (cba)

.................................... 17 colocort ........................... 66 COLY-MYCIN M .............. 17 COMBIGAN .................... 71 COMBIPATCH ................ 59 COMBIVENT RESPIMAT 75 COMBIVIR ...................... 30 COMETRIQ (100 MG

DAILY DOSE) ............. 25 COMETRIQ (140 MG

DAILY DOSE) ............. 25 COMETRIQ (60 MG DAILY

DOSE) ......................... 25 COMPACT SPACE

CHAMBER/LG MASK . 68 COMPACT SPACE

CHAMBER/MED MASK .................................... 68

COMPACT SPACE CHAMBER/SM MASK . 68

COMPLERA .................... 30 compro ............................ 22 COMTAN ........................ 28 CONCERTA .................... 38 CONDYLOX .................... 42 CONSENSI ..................... 34 constulose ....................... 53

85

CONTOUR CONTROL .... 49 CONTOUR NEXT

CONTROL ................... 49 CONTOUR NEXT TEST .. 49 CONZIP ........................... 12 COPAXONE .................... 39 COPIKTRA ...................... 25 CORDRAN ...................... 42 COREG ........................... 34 COREG CR ..................... 34 coremino ......................... 17 CORGARD ...................... 34 CORLANOR .................... 34 CORTEF ......................... 56 CORTENEMA ................. 66 CORTIFOAM ................... 66 cortisone acetate ............. 56 CORTISPORIN ............... 42 COSENTYX (300 MG

DOSE) ......................... 64 COSENTYX 150 MG/ML . 64 COSENTYX

SENSOREADY (300 MG) .................................... 64

COSENTYX SENSOREADY PEN ... 64

COSOPT ......................... 71 COSOPT PF.................... 71 COTELLIC ....................... 25 COTEMPLA XR-ODT ...... 38 covaryx ............................ 59 covaryx hs ....................... 60 COZAAR ......................... 34 CREON ........................... 55 CRESEMBA .................... 23 CRESTOR ....................... 34 CRINONE ........................ 60 CRIXIVAN ....................... 30 cromolyn sodium . 53, 70, 75 crotan .............................. 28 cryselle-28 ....................... 60 CRYSVITA ...................... 55 CUPRIMINE .................... 55 curity sterile saline ........... 51 CUROSURF .................... 74 CURVULARIA ................. 68 CUTAQUIG ..................... 64 CUTIVATE ...................... 42 CUVITRU ........................ 64 CUVPOSA ....................... 53 cyanocobalamin .............. 51 cyclafem 1/35 .................. 60 cyclafem 7/7/7 ................. 60 cyclobenzaprine hcl ......... 77 cyclobenzaprine hcl er ..... 77

CYCLOGYL ..................... 72 CYCLOMYDRIL .............. 72 cyclopentolate hcl ............ 72 cyclophosphamide ........... 26 cycloserine ...................... 25 CYCLOSET ..................... 47 cyclosporine .................... 64 CYCLOSPORINE IN

KLARITY ..................... 72 cyclosporine modified ...... 64 CYMBALTA ..................... 21 cyproheptadine hcl .......... 74 cyred ............................... 60 cyred eq .......................... 60 CYSTADANE .................. 55 CYSTAGON .................... 55 CYSTARAN ..................... 72 CYTOMEL ....................... 63 CYTOTEC ....................... 53 CYTOTINE ...................... 68 cytra k crystals ................ 51 D D.H.E. 45 ........................ 24 dalfampridine er .............. 39 DALIRESP ...................... 75 danazol ........................... 58 DANTRIUM ..................... 77 dantrolene sodium ........... 77 dapsone .................... 25, 42 DAPSONE....................... 42 DAPTACEL ..................... 65 DARAPRIM ..................... 28 darifenacin hydrobromide er

.................................... 55 dasetta 1/35 .................... 60 dasetta 7/7/7 ................... 60 DAURISMO ..................... 26 DAYPRO ......................... 11 daysee ............................ 60 DAYTRANA ..................... 38 DAYVIGO ........................ 78 DDAVP ............................ 58 DDAVP RHINAL TUBE ... 58 DEBACTEROL ................ 40 deblitane ......................... 60 DECADRON .................... 56 deferasirox ...................... 51 deferoxamine mesylate ... 68 dehydrated alcohol .......... 51 DELESTROGEN ............. 60 DELSTRIGO ................... 30 delyla............................... 60 DELZICOL....................... 66 demeclocycline hcl .......... 17 DEMSER ......................... 34

DENAVIR ........................ 30 DEPAKOTE .................... 19 DEPAKOTE ER............... 19 DEPAKOTE SPRINKLES 19 DEPEN TITRATABS ....... 55 DEPO-ESTRADIOL ........ 60 DEPO-MEDROL ............. 57 DEPO-PROVERA ........... 60 DEPO-SUBQ PROVERA

104 .............................. 60 DEPO-TESTOSTERONE 58 DERMACINRX AZENASE

PAK ............................. 74 DERMACINRX

EMPRICAINE .............. 14 DERMACINRX PRIZOPAK

.................................... 14 DERMA-SMOOTHE/FS

BODY .......................... 42 DERMA-SMOOTHE/FS

SCALP ........................ 42 DERMOTIC ..................... 73 DESCOVY ...................... 30 DESFERAL ..................... 68 desipramine hcl ............... 21 desloratadine .................. 74 desmopressin ace spray

refrig ............................ 58 desmopressin acetate ..... 58 desmopressin acetate spray

.................................... 58 desogestrel-ethinyl estradiol

.................................... 60 DESONATE .................... 42 desonide ......................... 42 DESOWEN ..................... 42 desoximetasone .............. 42 DESOXYN ...................... 38 DESVENLAFAXINE ER .. 21 desvenlafaxine succinate er

.................................... 21 DETROL ......................... 55 DETROL LA .................... 55 DEXABLISS .................... 57 dexamethasone............... 57 DEXAMETHASONE (LA) 57 dexamethasone intensol . 57 dexamethasone sod

phosphate pf ............... 57 dexamethasone sodium

phosphate ............. 57, 70 dexchlorpheniramine

maleate ....................... 74 DEXEDRINE ................... 38 DEXERYL ....................... 42

86

DEXILANT ....................... 53 dexmethylphenidate hcl ... 38 dexmethylphenidate hcl er

.................................... 38 DEXONTO 0.4% ............. 57 DEXPANTHENOL ........... 51 dextroamphetamine sulfate

.................................... 38 dextroamphetamine sulfate

er ................................. 38 DIACOMIT ....................... 19 DIASTAT ACUDIAL ......... 19 DIASTAT PEDIATRIC ..... 19 DIATHRIVE GLUCOSE

CONTROL SOLN ........ 49 DIATHRIVE LANCING

DEVICE ....................... 49 diazepam ................... 19, 32 DIAZEPAM ...................... 32 diazepam intensol ........... 32 diazoxide ......................... 49 DIBENZYLINE ................. 34 DICLEGIS ....................... 22 DICLOFENAC EPOLAMINE

.................................... 11 diclofenac potassium ....... 11 diclofenac sodium 11, 42, 70 diclofenac sodium er ........ 11 diclofenac-misoprostol ..... 11 DICLOFONO ................... 11 dicloxacillin sodium .......... 17 dicyclomine hcl ................ 53 didanosine ....................... 30 DIFFERIN ........................ 42 DIFICID ........................... 17 difil-g forte ....................... 75 diflorasone diacetate ....... 42 DIFLUCAN ...................... 23 diflunisal .......................... 11 digitek .............................. 34 digox ............................... 34 digoxin ............................. 34 dihydroergotamine mesylate

.................................... 24 DILANTIN ........................ 19 DILANTIN INFATABS ...... 19 DILATRATE-SR .............. 34 DILAUDID ....................... 12 diltiazem hcl..................... 34 diltiazem hcl er ................ 34 diltiazem hcl er beads ...... 34 diltiazem hcl er coated

beads .......................... 34 dilt-xr ............................... 34 dimenhydrinate ................ 22

DIOVAN .......................... 34 DIOVAN HCT .................. 34 DIPENTUM ..................... 66 diphen ............................. 74 diphenhydramine hcl ....... 74 diphenoxylate-atropine .... 53 DIPHTHERIA-TETANUS

TOXOIDS DT .............. 65 DIPROLENE ................... 42 DIPROLENE AF .............. 42 dipyridamole .................... 29 disopyramide phosphate . 34 disulfiram ......................... 15 DITROPAN XL ................ 55 DIURIL ............................ 34 divalproex sodium ........... 19 divalproex sodium er ....... 19 DIVIGEL .......................... 60 dofetilide .......................... 34 DOG EPITHELIUM .......... 68 DOLOPHINE ................... 12 donepezil hcl ............. 20, 21 DOPTELET ..................... 33 DORAL ............................ 32 DORYX ........................... 17 DORYX MPC .................. 17 dorzolamide hcl ............... 71 DORZOLAMIDE HCL ...... 71 dorzolamide hcl-timolol mal

.................................... 72 dorzolamide hcl-timolol mal

pf ................................. 72 dotti ................................. 60 DOVATO ......................... 30 DOVONEX ...................... 42 doxazosin mesylate ......... 34 doxepin hcl .......... 21, 42, 78 doxercalciferol ................. 67 doxycycline...................... 42 doxycycline hyclate ......... 17 doxycycline monohydrate 17 doxylamine-pyridoxine ..... 22 DRECHSLERA ................ 68 DRISDOL ........................ 51 DRITHO-CREME HP ...... 42 DRIZALMA SPRINKLE.... 21 dronabinol ....................... 22 drospiren-eth estrad-

levomefol ..................... 60 drospirenone-ethinyl

estradiol ....................... 60 DROXIA .......................... 26 DRYSOL ......................... 43 DUAKLIR PRESSAIR ...... 75 DUAVEE ......................... 60

DUETACT ....................... 47 DUEXIS .......................... 11 DULERA ......................... 75 duloxetine hcl .................. 21 DUOPA ........................... 28 DUPIXENT ...................... 43 DURAGESIC-100 ............ 12 DURAGESIC-12.............. 12 DURAGESIC-25.............. 12 DURAGESIC-50.............. 12 DURAGESIC-75.............. 12 duraxin ............................ 12 DUREZOL ....................... 70 DURLAZA ....................... 29 DUST MITE MIXED

ALLERGEN EXT ......... 68 dutasteride ...................... 56 dutasteride-tamsulosin hcl

.................................... 56 DUTOPROL .................... 34 DVORAH......................... 12 DXEVO 11-DAY .............. 57 DYANAVEL XR ............... 38 DYAZIDE ........................ 34 DYMISTA ........................ 74 DYRENIUM ..................... 34 E E.E.S. 400 ....................... 17 E.E.S. GRANULES ......... 17 EASIVENT ...................... 68 EASY TRAK II CONTROL

.................................... 49 EASYMAX 15 LEVEL 2-3

CONTROL................... 49 EASYMAX CONTROL .... 49 EASYMAX CONTROL

NORMAL/HIGH ........... 49 EC-NAPROSYN .............. 11 ec-naproxen .................... 11 ECONASIL ...................... 23 econazole nitrate ............. 23 ECOZA ........................... 23 EDARBI .......................... 34 EDARBYCLOR ............... 34 EDECRIN ........................ 34 EDLUAR ......................... 78 ed-spaz ........................... 53 EDURANT ....................... 30 eemt ................................ 60 eemt hs ........................... 60 efavirenz ......................... 30 effer-k .............................. 51 EFFER-K......................... 51 EFFEXOR XR ................. 21 EFFIENT ......................... 29

87

EFUDEX .......................... 43 EGRIFTA ......................... 58 EGRIFTA SV ................... 58 EHA ................................. 14 ELESTRIN ....................... 60 ELETONE ....................... 43 eletriptan hydrobromide ... 24 ELIDEL ............................ 43 ELIGARD ........................ 58 ELIMITE .......................... 28 elinest .............................. 60 ELIQUIS .......................... 18 ELIQUIS DVT/PE

STARTER PACK ......... 18 ELIXOPHYLLIN ............... 75 ELLA ............................... 60 ELMIRON ........................ 55 eluryng ............................ 60 EMBEDA ......................... 12 EMBRACE TALK

GLUCOSE CONTROL . 49 EMCYT ............................ 26 EMEND ........................... 22 EMEND TRI-PACK .......... 22 EMFLAZA ........................ 24 EMGALITY ...................... 24 EMGALITY (300 MG

DOSE) ......................... 24 emoquette ....................... 60 EMSAM ........................... 21 EMTRIVA ........................ 30 EMULSION SB ................ 43 EMVERM ........................ 28 ENABLEX ........................ 55 enalapril maleate ............. 35 enalapril-

hydrochlorothiazide ..... 35 ENBREL .......................... 64 ENBREL MINI ................. 64 ENBREL SURECLICK ..... 64 ENDARI ........................... 68 endocet ........................... 12 ENDOMETRIN ................ 60 ENGERIX-B..................... 65 enoxaparin sodium .......... 18 enpresse-28 .................... 60 enskyce ........................... 60 ENSTILAR ....................... 43 entacapone ..................... 28 entecavir .......................... 30 ENTEREG ....................... 53 ENTOCORT EC .............. 66 ENTRESTO ..................... 35 ENTTY SPRAY EMULSION

.................................... 43

enulose ........................... 53 ENVARSUS XR .............. 64 EPANED ......................... 35 EPCLUSA ....................... 30 EPICERAM ..................... 43 EPICOCCUM .................. 68 EPICOCCUMNIGRUM .... 68 EPIDIOLEX ..................... 19 EPIDUO .......................... 43 EPIDUO FORTE ............. 43 EPIFOAM ........................ 43 epinastine hcl .................. 70 epinephrine ..................... 75 epinephrine pf ................. 35 EPINEPHRINE

PROFESSIONAL ........ 76 EPINEPHRINESNAP-EMS

.................................... 76 EPINEPHRINESNAP-V ... 76 EPIPEN 2-PAK ................ 76 EPIPEN JR 2-PAK .......... 76 EPISNAP ........................ 76 epitol ............................... 19 EPIVIR ............................ 30 EPIVIR HBV .................... 30 eplerenone ...................... 35 EPOGEN ......................... 33 EPZICOM ........................ 30 EQUETRO ...................... 32 ergocalciferol ................... 51 ergoloid mesylates .......... 68 ERGOMAR...................... 24 ergotamine-caffeine ......... 24 ERIVEDGE...................... 26 ERLEADA ....................... 26 erlotinib hcl ...................... 26 errin ................................. 60 ERTACZO ....................... 23 ery ................................... 43 ERYGEL ......................... 43 ERYPED 200 .................. 17 ERYPED 400 .................. 17 ERY-TAB ........................ 17 ERYTHROCIN STEARATE

.................................... 17 erythromycin ........ 17, 43, 70 erythromycin base ........... 17 erythromycin ethylsuccinate

.................................... 17 ESBRIET ......................... 76 escitalopram oxalate ....... 21 ESGIC ............................. 12 esomeprazole magnesium

.................................... 53

ESOMEPRAZOLE STRONTIUM ............... 53

est estrogens-methyltest . 60 est estrogens-methyltest ds

.................................... 60 est estrogens-methyltest hs

.................................... 60 estarylla .......................... 60 estazolam........................ 32 ESTRACE ....................... 60 estradiol .......................... 60 estradiol valerate ............. 60 estradiol-norethindrone acet

.................................... 60 ESTRING ........................ 60 ESTROGEL .................... 60 ESTROSTEP FE ............. 60 eszopiclone ..................... 78 ethacrynic acid ................ 35 ethambutol hcl ................. 25 ethosuximide ................... 19 ethyl chloride ................... 14 ethynodiol diac-eth estradiol

.................................... 60 etodolac .......................... 11 etodolac er ...................... 11 etonogestrel-ethinyl

estradiol ...................... 60 etoposide ........................ 26 EUCRISA ........................ 43 euthyrox .......................... 63 EVAMIST ........................ 60 EVEKEO ......................... 38 EVEKEO ODT ................. 38 everolimus ................. 26, 64 EVISTA ........................... 58 EVOCLIN ........................ 43 EVOTAZ ......................... 30 EVOXAC ......................... 40 EVZIO ............................. 15 EXELDERM .................... 23 EXELON ......................... 21 exemestane .................... 26 EXFORGE ...................... 35 EXFORGE HCT .............. 35 EXJADE .......................... 51 exoderm .......................... 23 EXTAVIA ......................... 39 EXTINA ........................... 23 EZALLOR SPRINKLE ..... 35 ezetimibe......................... 35 ezetimibe-simvastatin ...... 35 F FABIOR .......................... 43 falmina ............................ 60

88

famciclovir ....................... 30 famotidine ........................ 53 FANAPT .......................... 29 FANAPT TITRATION PACK

.................................... 29 FARESTON ..................... 26 FARXIGA ........................ 47 FARYDAK ....................... 26 FASENRA PEN ............... 74 fayosim ............................ 60 febuxostat ........................ 24 felbamate ........................ 19 FELBATOL ...................... 19 FELDENE ........................ 11 felodipine er ..................... 35 FEM PH ........................... 55 FEMARA ......................... 26 FEMCAP ......................... 68 FEMHRT LOW DOSE ..... 60 FEMRING ........................ 60 femynor ........................... 60 fenofibrate ....................... 35 fenofibrate micronized ..... 35 fenofibric acid .................. 35 FENOGLIDE.................... 35 fenoprofen calcium .......... 11 fenortho ........................... 11 fentanyl ............................ 12 fentanyl citrate ................. 12 FENTANYL CITRATE ..... 12 FENTANYL-BUPIVACAINE-

NACL ........................... 13 FENTORA ....................... 13 FERRIPROX ................... 51 FETZIMA ......................... 21 FETZIMA TITRATION ..... 21 FEXMID ........................... 77 FIASP .............................. 50 FIASP FLEXTOUCH ....... 50 FIASP PENFILL .............. 50 FIBRICOR ....................... 35 FINACEA ......................... 43 finasteride ........................ 56 FINTEPLA ....................... 19 FIORICET ....................... 13 FIORICET/CODEINE ...... 13 FIORINAL ........................ 13 FIORINAL/CODEINE #3 .. 13 FIRAZYR ......................... 64 FIRDAPSE ...................... 68 FIRE ANT ........................ 68 FIRST-BACLOFEN .......... 77 FIRST-LANSOPRAZOLE 53 FIRST-MOUTHWASH BLM

.................................... 40

FIRST-OMEPRAZOLE .... 53 FIRST-PROGESTERONE

VGS ............................ 60 FIRVANQ ........................ 17 flac .................................. 73 FLAGYL .......................... 17 FLAREX .......................... 70 flavoxate hcl .................... 55 flecainide acetate ............ 35 FLECTOR ....................... 11 FLEXICHAMBER ADULT

MASK/SMALL ............. 68 FLEXICHAMBER CHILD

MASK/LARGE ............. 68 FLEXICHAMBER CHILD

MASK/SMALL ............. 68 FLEXIN ........................... 14 FLOLIPID ........................ 35 FLOMAX ......................... 56 FLOVENT DISKUS ......... 76 FLOVENT HFA ............... 76 FLUAD ............................ 65 FLUAD QUADRIVALENT 65 FLUARIX QUADRIVALENT

.................................... 65 FLUBLOK QUADRIVALENT

.................................... 65 FLUCELVAX

QUADRIVALENT ........ 65 fluconazole ...................... 23 flucytosine ....................... 23 fludrocortisone acetate .... 57 FLULAVAL

QUADRIVALENT ........ 65 flunisolide ........................ 74 fluocinolone acetonide .... 43,

73 fluocinolone acetonide body

.................................... 43 fluocinolone acetonide scalp

.................................... 43 fluocinonide ..................... 43 fluocinonide emulsified base

.................................... 43 FLUOPAR ....................... 43 FLUORABON .................. 51 fluoritab ........................... 51 fluorometholone .............. 70 FLUOROPLEX ................ 43 fluorouracil....................... 43 FLUOROURACIL ............ 43 fluoxetine hcl ................... 21 fluoxetine hcl (pmdd) ....... 21 fluphenazine decanoate .. 29 fluphenazine hcl .............. 29

FLURA-DROPS .............. 51 flurandrenolide ................ 43 flurazepam hcl ................. 78 flurbiprofen ...................... 11 flurbiprofen sodium .......... 70 flutamide ......................... 26 fluticasone propionate ..... 43 fluticasone-salmeterol ..... 76 FLUTICASONE-

SALMETEROL ............ 76 fluvastatin sodium ........... 35 fluvastatin sodium er ....... 35 fluvoxamine maleate ....... 21 fluvoxamine maleate er ... 21 FLUZONE HIGH-DOSE .. 65 FLUZONE HIGH-DOSE

QUADRIVALENT ........ 65 FLUZONE

QUADRIVALENT ........ 65 FML ................................. 70 FML FORTE .................... 70 FML LIQUIFILM .............. 70 FOCALIN ........................ 38 FOCALIN XR .................. 38 folic acid .......................... 51 FOLVIK-D ....................... 51 FOLVITE-D ..................... 51 fondaparinux sodium ....... 18 FORFIVO XL ................... 21 FORTAMET .................... 47 FORTEO ......................... 67 FORTESTA ..................... 58 FORTISCARE CONTROL

.................................... 49 FOSAMAX ...................... 67 FOSAMAX PLUS D ......... 67 fosamprenavir calcium .... 30 fosinopril sodium ............. 35 fosinopril sodium-hctz ..... 35 FOSRENOL .................... 55 FRAGMIN ....................... 19 FREESTYLE TEST ......... 49 FROVA ........................... 24 frovatriptan succinate ...... 24 FULPHILA ....................... 33 furosemide ...................... 35 FUSARIUM ..................... 68 FUZEON ......................... 30 fyavolv ............................. 60 FYCOMPA ...................... 19 G gabapentin ...................... 19 GABAPENTIN-NAPROXEN

CMPD KIT ................... 11 GABITRIL........................ 19

89

GALAFOLD ..................... 55 galantamine hydrobromide

.................................... 21 galantamine hydrobromide

er ................................. 21 GARDASIL 9 ................... 65 GASTROCROM .............. 53 gatifloxacin ...................... 70 GATTEX .......................... 53 gavilyte-c ......................... 53 gavilyte-g ......................... 53 gavilyte-h ......................... 54 gavilyte-n with flavor pack 54 GEBAUERS PAIN EASE . 14 GEBAUERS SPRAY AND

STRETCH ................... 14 GELFILM ......................... 72 GELNIQUE ...................... 55 gemfibrozil ....................... 35 GEN7T ............................ 14 GENERESS FE ............... 61 generlac .......................... 54 gengraf ............................ 64 GENICIN VITA-D ............. 51 GENOTROPIN ................ 58 GENOTROPIN MINIQUICK

.................................... 58 gentak ............................. 70 gentamicin sulfate ..... 17, 71 GENTEEL LANCING KIT

(BLUE) ........................ 49 GENVOYA ...................... 30 GEODON ........................ 29 GERMAN COCKROACH. 68 gianvi ............................... 61 GILENYA ......................... 39 GILOTRIF ........................ 26 glatiramer acetate ............ 39 glatopa ............................ 39 GLEEVEC ....................... 26 GLEOSTINE .................... 26 glimepiride ....................... 47 glipizide er ....................... 47 glipizide ir ........................ 47 glipizide xl ........................ 47 glipizide-metformin hcl ..... 47 GLOPERBA..................... 24 GLUCAGEN DIAGNOSTIC

.................................... 68 GLUCAGEN HYPOKIT .... 49 GLUCAGON EMERGENCY

KIT ............................... 49 GLUCAGON HCL

(DIAGNOSTIC) ............ 68 GLUCOTROL .................. 47

GLUCOTROL XL............. 47 GLUMETZA ..................... 48 glyburide ......................... 48 glyburide micronized ....... 48 glyburide-metformin ......... 48 GLYCATE ....................... 54 glycopyrrolate .................. 54 GLYCOPYRROLATE ...... 54 glydo ............................... 14 GLYNASE ....................... 48 GLYSET .......................... 48 GLYXAMBI ...................... 48 GOCOVRI ....................... 28 GOJJI CONTROL ............ 49 GOJJI LANCING

DEVICE/CLEAR CAP .. 49 GOLYTELY ..................... 54 GONITRO ....................... 35 goodsense nicotine ......... 15 GOPRELTO .................... 14 grafco silver nit applicator 43 GRALISE ........................ 39 GRALISE STARTER ....... 39 granisetron hcl ................. 22 GRANIX .......................... 33 GRASTEK ....................... 68 griseofulvin microsize ...... 23 griseofulvin ultramicrosize23 guanfacine hcl ................. 35 guanfacine hcl er ............. 38 GUANIDINE HCL ............ 25 GVOKE HYPOPEN ......... 49 GVOKE PFS ................... 49 GYNAZOLE-1 ................. 23 H HACKBERRY .................. 68 HAEGARDA .................... 64 hailey 1.5/30 .................... 61 hailey 24 fe ...................... 61 hailey fe 1.5/30 ................ 61 hailey fe 1/20 ................... 61 halcinonide ...................... 43 HALCION ........................ 32 HALDOL .......................... 29 HALDOL DECANOATE ... 29 halobetasol propionate .... 43 HALOBETASOL

PROPIONATE ............. 43 HALOG ........................... 43 haloperidol ...................... 29 haloperidol decanoate ..... 29 haloperidol lactate ........... 29 HARVONI ........................ 30 HAVRIX ........................... 65 heather ............................ 61

HELIDAC THERAPY ....... 54 HEMANGEOL ................. 35 HEMLIBRA ...................... 33 hemmorex-hc .................. 66 HEPAGAM B ................... 64 heparin sodium (porcine) . 19 heparin sodium (porcine) pf

.................................... 19 HEPLISAV-B ................... 65 HEPSERA ....................... 30 HETLIOZ ......................... 78 HIBERIX ......................... 65 HIDEX 6-DAY ................. 57 HIPREX .......................... 17 HIZENTRA ...................... 64 homatropaire ................... 72 HONEY BEE VENOM ..... 68 HONEY BEE VENOM

PROTEIN .................... 68 HORIZANT ...................... 39 HORSE EPITHELIUM ..... 68 HPR ................................ 43 HPR PLUS ...................... 43 HUMALOG ...................... 50 HUMALOG KWIKPEN..... 50 HUMALOG MIX 50/50

KWIKPEN ................... 50 HUMALOG MIX 50/50 VIAL

.................................... 50 HUMALOG MIX 75/25

KWIKPEN ................... 50 HUMALOG MIX 75/25 VIAL

.................................... 50 HUMALOG U-100 JUNIOR

KWIKPEN ................... 50 HUMATROPE ................. 58 HUMIRA .......................... 64 HUMIRA PEDIATRIC

CROHNS START ........ 64 HUMIRA PEN ................. 64 HUMIRA PEN-CD/UC/HS

STARTER ................... 64 HUMIRA PEN-PS/UV/ADOL

HS START .................. 64 HUMULIN 70/30 KWIKPEN

.................................... 50 HUMULIN 70/30 VIAL ..... 50 HUMULIN N KWIKPEN ... 50 HUMULIN N VIAL ........... 50 HUMULIN R U-500

KWIKPEN ................... 50 HUMULIN R U-500 VIAL

(CONCENTRATED) .... 50 HUMULIN R VIAL ........... 50 HYCAMTIN ..................... 26

90

hydralazine hcl ................ 35 HYDREA ......................... 26 HYDRO 40 ...................... 43 hydrochlorothiazide ......... 35 hydrocodone bitartrate er 13 hydrocodone polst-cpm

polst er ........................ 74 hydrocodone-

acetaminophen ............ 13 hydrocodone-homatropine

.................................... 74 hydrocodone-ibuprofen .... 13 hydrocortisone ..... 44, 57, 66 hydrocortisone (perianal) . 66 hydrocortisone ace-

pramoxine .............. 43, 66 hydrocortisone acetate .... 66 hydrocortisone butyr lipo

base ............................ 44 hydrocortisone butyrate ... 44 hydrocortisone valerate ... 44 hydrocortisone-acetic acid

.................................... 73 hydromet ......................... 74 hydromorphone hcl .......... 13 hydromorphone hcl er ...... 13 hydroxychloroquine sulfate

.................................... 28 hydroxyprogesterone

caproate ...................... 61 hydroxyurea..................... 26 hydroxyzine hcl ................ 32 hydroxyzine pamoate ...... 32 HYLAGUARD .................. 44 HYLATOPIC PLUS .......... 44 hyophen .......................... 55 hyoscyamine sulfate ........ 54 hyoscyamine sulfate er .... 54 hyoscyamine sulfate sl .... 54 hyosyne ........................... 54 HYPERHEP B S/D .......... 64 HYPERRAB..................... 64 HYPERRAB S/D .............. 64 HYPERSAL ..................... 74 HYPERTET S/D .............. 64 HYPOCYN ...................... 72 HYQVIA ........................... 64 HYSINGLA ER ................ 13 HYZAAR .......................... 35 I ibandronate sodium ......... 67 IBRANCE ........................ 26 ibu ................................... 11 ibuprofen ......................... 11 icatibant acetate .............. 64

ICLUSIG .......................... 26 IDHIFA ............................ 26 ILEVRO ........................... 71 ILIDERM ......................... 44 imatinib mesylate............. 26 IMBRUVICA .................... 26 imipramine hcl ................. 21 imipramine pamoate ........ 21 imiquimod ........................ 44 IMIQUIMOD PUMP ......... 44 IMITREX ......................... 24 IMITREX STATDOSE

REFILL ........................ 24 IMITREX STATDOSE

SYSTEM ..................... 24 IMOGAM RABIES-HT ..... 64 IMPAVIDO....................... 28 IMPOYZ .......................... 44 IMURAN .......................... 64 IMVEXXY MAINTENANCE

PACK .......................... 61 IMVEXXY STARTER PACK

.................................... 61 INBRIJA .......................... 28 incassia ........................... 61 INCRELEX ...................... 58 INCRUSE ELLIPTA ......... 76 indapamide...................... 35 INDERAL LA ................... 35 INDERAL XL ................... 35 INDOCIN ......................... 11 indomethacin ................... 11 indomethacin er ............... 11 INFANRIX ....................... 65 INFASURF ...................... 74 INGREZZA ...................... 40 INLYTA ........................... 26 INNOPRAN XL ................ 35 INREBIC ......................... 26 INSPRA ........................... 35 INSULIN ASP PROT & ASP

FLEXPEN .................... 50 INSULIN ASPART ........... 50 INSULIN ASPART

FLEXPEN .................... 50 INSULIN ASPART PENFILL

.................................... 50 INSULIN ASPART PROT &

ASPART ...................... 50 INSULIN LISPRO ............ 50 INSULIN LISPRO (1 UNIT

DIAL) ........................... 50 INSULIN LISPRO JUNIOR

KWIKPEN .................... 50

INSULIN LISPRO PROT & LISPRO ....................... 50

INSULIN PEN NEEDLES 50 INSULIN SYRINGES ...... 50 INTELENCE .................... 30 INTERMEZZO ................. 78 INTRAROSA ................... 55 INTRON A ....................... 30 introvale .......................... 61 INTUNIV ......................... 38 INVEGA .......................... 29 INVEGA SUSTENNA ...... 29 INVEGA TRINZA ............. 29 INVELTYS ....................... 71 INVIRASE ....................... 30 INVOKAMET ................... 48 INVOKAMET XR ............. 48 INVOKANA ..................... 48 iodine strong ................... 51 IOPIDINE ........................ 72 IPOL ................................ 65 ipratropium bromide .. 74, 76 ipratropium-albuterol ....... 76 irbesartan ........................ 35 irbesartan-

hydrochlorothiazide ..... 35 IRESSA ........................... 26 ISENTRESS .................... 30 ISENTRESS HD .............. 30 isibloom ........................... 61 isoniazid .......................... 25 isoproterenol hcl .............. 35 ISOPTO CARPINE .......... 72 ISORDIL TITRADOSE .... 35 isosorbide dinitrate .......... 35 isosorbide mononitrate .... 35 isosorbide mononitrate er 35 isotretinoin ....................... 44 isradipine......................... 35 ISTALOL ......................... 72 ISTURISA ....................... 58 ISUPREL......................... 35 itraconazole ..................... 23 ivermectin........................ 28 J JADENU ......................... 51 JADENU SPRINKLE ....... 51 jaimiess ........................... 61 JAKAFI ............................ 26 JALYN ............................. 56 jantoven .......................... 19 JANUMET ....................... 48 JANUMET XR ................. 48 JANUVIA ......................... 48 JARDIANCE .................... 48

91

jasmiel ............................. 61 JATENZO ........................ 58 jencycla ........................... 61 JENTADUETO ................ 48 JENTADUETO XR........... 48 jinteli ................................ 61 jolessa ............................. 61 JORNAY PM ................... 38 JUBLIA ............................ 23 juleber ............................. 61 JULUCA .......................... 30 JUNE GRASS POLLEN

STANDARDIZED ......... 68 junel 1.5/30 ...................... 61 junel 1/20 ......................... 61 junel fe 1.5/30 .................. 61 junel fe 1/20 ..................... 61 junel fe 24 ........................ 61 JUXTAPID ....................... 35 JYNARQUE ..................... 51 K KADIAN ........................... 13 kaitlib fe ........................... 61 KALETRA ........................ 31 kalliga .............................. 61 KALYDECO ..................... 77 KAMDOY ......................... 44 KAPOK ............................ 68 KAPSPARGO SPRINKLE35 KAPVAY .......................... 38 KARBINAL ER ................. 74 kariva .............................. 61 KATERZIA ....................... 35 KAZANO ......................... 48 KEDRAB ......................... 64 KEFLEX .......................... 17 kelnor 1/35 ...................... 61 kelnor 1/50 ...................... 61 KENALOG ................. 44, 57 KEPPRA .......................... 19 KEPPRA XR .................... 19 KERALAC ....................... 44 KERALYT ........................ 44 KERYDIN ........................ 23 ketoconazole ................... 23 ketodan ........................... 23 ketoprofen ....................... 11 ketoprofen er ................... 11 ketorolac tromethamine .. 11,

71 KEVEYIS ......................... 72 KEVZARA ....................... 64 KINERET ......................... 64 KINRIX ............................ 65 kionex .............................. 51

KISQALI (200 MG DOSE)26 KISQALI (400 MG DOSE)26 KISQALI (600 MG DOSE)26 KISQALI FEMARA (400 MG

DOSE) ......................... 26 KISQALI FEMARA (600 MG

DOSE) ......................... 26 KISQALI FEMARA(200 MG

DOSE) ......................... 26 KITABIS PAK .................. 77 KIVIK ............................... 44 KLARITY-A...................... 71 KLARITY-B...................... 71 KLARITY-L ...................... 71 KLARON ......................... 44 KLONOPIN...................... 32 klor-con ........................... 51 klor-con 10 ...................... 51 klor-con m10 ................... 52 KLOR-CON M15 ............. 52 klor-con m20 ................... 52 klor-con sprinkle .............. 52 klor-con/ef ....................... 52 KOMBIGLYZE XR ........... 48 KORLYM ......................... 59 KOSELUGO .................... 26 K-PHOS .......................... 52 K-PHOS NO 2 ................. 52 K-PHOS-NEUTRAL ......... 52 k-prime ............................ 52 KRINTAFEL .................... 28 KRISTALOSE .................. 54 K-TAB ............................. 52 kurvelo ............................ 61 KUVAN ............................ 55 KYNMOBI TITRATION KIT

.................................... 28 L labetalol hcl ..................... 35 LACRISERT .................... 72 lactic acid ........................ 44 lactic acid e ..................... 44 lactulose .......................... 54 lactulose encephalopathy 54 LAMICTAL....................... 19 LAMICTAL ODT .............. 19 LAMICTAL STARTER ..... 19 LAMICTAL XR ................. 19 lamivudine ....................... 31 lamivudine-zidovudine ..... 31 lamotrigine....................... 19 lamotrigine er .................. 19 lamotrigine starter kit-blue19 lamotrigine starter kit-green

.................................... 20

lamotrigine starter kit-orange ......................... 20

LANCETS ....................... 49 LANOXIN ........................ 35 LANOXIN PEDIATRIC .... 35 lansoprazole .................... 53 lanthanum carbonate ...... 55 LANTUS SOLOSTAR...... 50 LANTUS U-100 VIAL ...... 50 larin 1.5/30 ...................... 61 larin 1/20 ......................... 61 larin 24 fe ........................ 61 larin fe 1.5/30 .................. 61 larin fe 1/20 ..................... 61 larissia ............................. 61 LASIX .............................. 35 LASTACAFT ................... 73 latanoprost ...................... 72 LATANOPROST-TIMOLOL

MALEATE ................... 72 LATUDA .......................... 29 layolis fe .......................... 61 LAZANDA ....................... 13 LDO PLUS ...................... 14 LEDIPASVIR-

SOFOSBUVIR ............. 31 leena ............................... 61 leflunomide ...................... 64 LENVIMA (10 MG DAILY

DOSE) ......................... 26 LENVIMA (12 MG DAILY







DOSE) ......................... 26 LESCOL XL .................... 35 lessina ............................. 61 LETAIRIS ........................ 77 letrozole .......................... 26 leucovorin calcium ........... 26 LEUKERAN ..................... 26 LEUKINE......................... 33 leuprolide acetate ............ 58 levalbuterol hcl ................ 76 LEVALBUTEROL HFA .... 76 LEVATIO ......................... 14

92

LEVBID ........................... 54 LEVEMIR U-100

FLEXTOUCH ............... 50 LEVEMIR U-100 VIAL ..... 51 levetiracetam ................... 20 levetiracetam er ............... 20 levobunolol hcl ................. 72 levocarnitine .................... 52 levocarnitine sf ................ 52 levocetirizine

dihydrochloride ............ 74 levofloxacin ............... 17, 71 levonest ........................... 61 levonorgest-eth est & eth

est ............................... 61 levonorgest-eth estrad 91-

day .............................. 61 levonorgestrel .................. 61 levonorgestrel-ethinyl estrad

.................................... 61 levonorg-eth estrad triphasic

.................................... 61 levora 0.15/30 (28) .......... 61 levorphanol tartrate.......... 13 levo-t ............................... 63 levothyroxine sodium ....... 63 levoxyl ............................. 63 LEVSIN ........................... 54 LEVSIN/SL ...................... 54 LEVULAN KERASTICK ... 44 LEXAPRO ....................... 21 LEXETTE ........................ 44 LEXIVA ............................ 31 LIALDA ............................ 66 LIBRAX ........................... 54 LICART ........................... 11 LIDO BDK ....................... 14 lidocaine .......................... 14 lidocaine hcl .............. 14, 40 LIDOCAINE HCL ............. 14 lidocaine hcl (pf) .............. 14 lidocaine hcl

urethral/mucosal .......... 14 lidocaine viscous hcl ........ 40 lidocaine-epinephrine ...... 15 lidocaine-hydrocort

(perianal) ..................... 66 lidocaine-hydrocortisone

ace .............................. 66 LIDOCAINE-

HYDROCORTISONE ACE ....................... 44, 66

lidocaine-prilocaine .......... 15 LIDODERM ..................... 15 LIDOMAR ........................ 15

lidopin .............................. 15 LIDOPRIL ........................ 15 LIDOPRIL XR .................. 15 LIDO-PRILO CAINE PACK

.................................... 15 LIDORX ........................... 15 LIDO-SORB .................... 15 LIDOTHOL ...................... 15 LIDOTIN .......................... 40 LIDOTRAL....................... 15 LILETTA (52 MG) ............ 61 lillow ................................ 61 LINCOCIN ....................... 17 lincomycin hcl .................. 17 lindane ............................ 28 linezolid ........................... 17 LINZESS ......................... 54 liothyronine sodium ......... 63 LIPITOR .......................... 35 LIPOFEN ......................... 35 LIPRITIN ......................... 40 lisinopril ........................... 35 lisinopril-hydrochlorothiazide

.................................... 35 lithium .............................. 32 lithium carbonate ............. 32 lithium carbonate er ......... 32 LITHOBID ....................... 33 LITHOSTAT .................... 55 LIVALO ........................... 35 LIVIXIL PAK .................... 15 LO LOESTRIN FE ........... 61 LOCOID .......................... 44 LOCOID LIPOCREAM .... 44 LODINE ........................... 11 LODOSYN....................... 28 LOESTRIN 1.5/30 (21) .... 61 LOESTRIN 1/20 (21) ....... 61 LOESTRIN FE 1.5/30 ...... 61 LOESTRIN FE 1/20 ......... 61 lojaimiess ........................ 61 LOKELMA ....................... 52 LOMOTIL ........................ 54 LONHALA MAGNAIR

REFILL KIT ................. 76 LONHALA MAGNAIR

STARTER KIT ............. 76 LONSURF ....................... 26 loperamide hcl ................. 54 LOPID ............................. 35 lopinavir-ritonavir ............. 31 lopreeza .......................... 61 LOPRESSOR .................. 35 LOPRESSOR HCT .......... 35 LOPROX ......................... 23

lorazepam ....................... 32 lorazepam intensol .......... 32 LORBRENA .................... 26 lorcet ............................... 13 lorcet hd .......................... 13 lorcet plus........................ 13 LORTAB ......................... 13 loryna .............................. 61 LORZONE ....................... 77 losartan potassium .......... 36 losartan potassium-hctz .. 36 LOSEASONIQUE ............ 61 LOTEMAX ....................... 71 LOTEMAX SM ................ 71 LOTENSIN ...................... 36 LOTENSIN HCT .............. 36 loteprednol etabonate ..... 71 LOTREL .......................... 36 LOTRONEX .................... 54 lovastatin ......................... 36 LOVAZA .......................... 36 LOVENOX ....................... 19 low-ogestrel ..................... 61 loxapine succinate ........... 29 lo-zumandimine ............... 61 LUCEMYRA .................... 15 ludent .............................. 52 LULICONAZOLE ............. 23 LUMIGAN........................ 72 LUNESTA ....................... 78 LUPRON DEPOT (1-

MONTH) ...................... 58 LUPRON DEPOT (3-

MONTH) ...................... 58 LUPRON DEPOT (4-

MONTH) INTRAMUSCULAR KIT 30MG .......................... 58

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 58

LUPRON DEPOT-PED (1-MONTH) ...................... 59

LUPRON DEPOT-PED (3-MONTH) ...................... 59

lutera ............................... 61 LUXIQ ............................. 44 LUZU .............................. 23 LYNPARZA ..................... 26 LYRICA ........................... 40 LYRICA CR ..................... 40 LYSODREN .................... 26 LYSTEDA........................ 33 LYUMJEV ....................... 51

93

LYUMJEV KWIKPEN ...... 51 lyza .................................. 61 M MACROBID ..................... 17 MACRODANTIN .............. 17 mafenide acetate ............. 17 MAGNESIUM SULFATE . 52 MAKENA ......................... 61 malathion ......................... 28 maprotiline hcl ................. 21 MARINOL ........................ 22 marlissa ........................... 62 MARPLAN ....................... 21 MASK VORTEX .............. 68 MATULANE ..................... 26 matzim la ......................... 36 MAVENCLAD (10 TABS). 39 MAVENCLAD (4 TABS) .. 39 MAVENCLAD (5 TABS) .. 39 MAVENCLAD (6 TABS) .. 39 MAVENCLAD (7 TABS) .. 39 MAVENCLAD (8 TABS) .. 39 MAVENCLAD (9 TABS) .. 39 MAVYRET ....................... 31 MAXALT .......................... 24 MAXALT-MLT .................. 24 MAXICOMFORT SYR 27G

X 1/2 ............................ 51 MAXIDEX ........................ 71 MAXITROL ...................... 73 MAXZIDE ........................ 36 MAXZIDE-25 ................... 36 MAYZENT ....................... 39 MAYZENT STARTER

PACK .......................... 39 me/naphos/mb/hyo1 ........ 55 meclizine hcl .................... 22 meclofenamate sodium ... 11 MEDI-PATCH RX ............ 15 MEDROL ......................... 57 medroxyprogesterone

acetate ........................ 62 mefenamic acid ............... 11 megestrol acetate ............ 62 MEKINIST ....................... 26 MEKTOVI ........................ 26 MELALEUCA ................... 68 melodetta 24 fe ................ 62 meloxicam ....................... 11 melphalan ........................ 26 memantine hcl ................. 21 memantine hcl er ............. 21 MENACTRA .................... 65 MENEST ......................... 62 MENOSTAR .................... 62

MENVEO ........................ 65 meperidine hcl ................. 13 MEPHYTON .................... 52 meprobamate .................. 32 MEPRON ........................ 28 mercaptopurine ............... 26 mesalamine ..................... 66 mesalamine er ................. 66 mesalamine-cleanser ...... 66 mesna ............................. 26 MESNEX ......................... 26 MESTINON ..................... 25 metadate er ..................... 38 metaproterenol sulfate ..... 76 metaxalone...................... 77 metformin hcl er .............. 48 metformin hcl er (mod) .... 48 metformin hcl er (osm) .... 48 metformin hcl ir ................ 48 methadone hcl ................. 13 methadone hcl intensol ... 13 methadose ...................... 13 methadose sugar-free ..... 13 methamphetamine hcl ..... 38 methazolamide ................ 72 methenamine hippurate ... 17 methenamine mandelate . 17 methergine ...................... 68 methimazole .................... 63 METHITEST .................... 58 methocarbamol ............... 77 methotrexate ................... 64 methotrexate sodium ....... 64 methotrexate sodium (pf) . 64 methoxsalen rapid ........... 44 methscopolamine bromide

.................................... 54 methyldopa...................... 36 methyldopa-

hydrochlorothiazide ..... 36 methylergonovine maleate

.................................... 68 METHYLIN ...................... 38 methylphenidate hcl ........ 39 methylphenidate hcl er .... 38 methylphenidate hcl er (cd)

.................................... 38 methylphenidate hcl er (la)

.................................... 39 methylprednisolone ......... 57 METHYLPREDNISOLONE

ACE-LIDO ................... 57 METHYLPREDNISOLONE

ACETATE .................... 57

methylprednisolone sodium succ............................. 57

methyltestosterone .......... 58 metoclopramide hcl ......... 22 metolazone ..................... 36 metoprolol succinate er ... 36 metoprolol tartrate ........... 36 metoprolol-

hydrochlorothiazide ..... 36 METROCREAM .............. 44 METROGEL .................... 44 METROLOTION .............. 44 metronidazole ........... 17, 44 mexiletine hcl .................. 36 MIACALCIN .................... 67 mibelas 24 fe ................... 62 MICARDIS ...................... 36 MICARDIS HCT .............. 36 MICLARA LQ .................. 74 miconazole 3 ................... 23 MICONAZOLE-ZINC

OXIDE-PETROLAT ..... 23 MICROCHAMBER .......... 68 microgestin 1.5/30 ........... 62 microgestin 1/20 .............. 62 microgestin fe 1.5/30 ....... 62 microgestin fe 1/20 .......... 62 MICROLET NEXT

LANCING DEVICE ...... 49 midazolam hcl ................. 32 midazolam hcl (pf) ........... 32 midodrine hcl ................... 36 MIFEPREX ...................... 52 mifepristone .................... 52 MIGERGOT .................... 24 miglitol ............................. 48 miglustat ......................... 55 MIGRANAL ..................... 24 mili .................................. 62 MILLIPRED ..................... 57 MILLIPRED DP ............... 57 MILLIPRED DP 12-DAY .. 57 mimvey ........................... 62 MIMYX ............................ 44 MINASTRIN 24 FE .......... 62 MINIPRESS .................... 36 minitran ........................... 36 MINIVELLE ..................... 62 minocycline hcl ................ 17 minocycline hcl er ............ 17 MINOLIRA ....................... 17 minoxidil .......................... 36 MIRAPEX ........................ 28 MIRAPEX ER .................. 28 MIRCERA ....................... 33

94

MIRCETTE ...................... 62 MIRENA (52 MG) ............ 62 mirtazapine ...................... 21 MIRVASO ........................ 44 misoprostol ...................... 53 MITIGARE ....................... 24 MIXED ASPERGILLUS ... 68 MIXED FEATHERS ......... 68 mixed vespid venom protein

.................................... 68 MIXED VESPID VENOM

PROTEIN .................... 68 M-M-R II .......................... 65 MOBIC ............................ 11 modafinil .......................... 78 moexipril hcl .................... 36 molindone hcl .................. 29 mometasone furoate .. 44, 74 mondoxyne nl .................. 17 mono-linyah ..................... 62 montelukast sodium ......... 76 MONUROL ...................... 17 morgidox ......................... 17 morphine sulfate .............. 13 morphine sulfate

(concentrate) ............... 13 morphine sulfate er .......... 13 morphine sulfate er beads

.................................... 13 MOTEGRITY ................... 54 MOTOFEN ...................... 54 MOVANTIK ..................... 54 MOVIPREP ..................... 54 MOXEZA ......................... 71 moxifloxacin hcl ......... 17, 71 moxifloxacin hcl (2x day) . 71 MS CONTIN .................... 13 MUCOR ........................... 68 MUCOSITISRX ............... 40 MULPLETA ..................... 33 MULTAQ ......................... 36 mupirocin ......................... 17 mupirocin calcium ............ 17 MYALEPT ....................... 55 MYAMBUTOL .................. 25 MYCOBUTIN ................... 25 mycophenolate mofetil ..... 64 mycophenolate sodium .... 64 MYDAYIS ........................ 39 MYFORTIC ..................... 64 MYLERAN ....................... 26 myorisan .......................... 44 MYRBETRIQ ................... 55 MYSOLINE ...................... 20 MYTESI ........................... 54

N NABI-HB ......................... 64 nabumetone .................... 11 nadolol ............................ 36 nafrinse ........................... 52 nafrinse drops ................. 52 naftifine hcl ...................... 23 NAFTIN ........................... 23 NALFON ......................... 11 NALOCET ....................... 13 naloxone hcl .................... 15 NALOXONE HCL ............ 15 naltrexone hcl .................. 16 NAMENDA ...................... 21 NAMENDA TITRATION

PAK ............................. 21 NAMENDA XR ................ 21 NAMENDA XR TITRATION

PACK .......................... 21 NAMZARIC ..................... 21 NAPRELAN ..................... 11 NAPROSYN .................... 11 naproxen ......................... 11 naproxen dr ..................... 11 naproxen sodium ............. 11 naproxen sodium er ......... 11 naproxen-esomeprazole .. 11 naratriptan hcl ................. 24 NARCAN ......................... 16 NARDIL ........................... 21 NASONEX....................... 74 NATACYN ....................... 71 NATAZIA ......................... 62 nateglinide ....................... 48 NATESTO ....................... 58 NATPARA ....................... 67 NATROBA ....................... 28 NATURE-THROID ........... 63 NAYZILAM ...................... 20 NEBUPENT ..................... 28 nebusal ........................... 74 NEBUSAL ....................... 74 necon 0.5/35 (28) ............ 62 nefazodone hcl ................ 21 NEMBUTAL ..................... 20 NEOCERA ...................... 44 neomycin sulfate ............. 18 neomycin-bacitracin zn-

polymyx ....................... 73 neomycin-polymyxin b gu 18 neomycin-polymyxin-

dexameth .................... 73 neomycin-polymyxin-

gramicidin .................... 73 neomycin-polymyxin-hc ... 73

neo-polycin ...................... 73 neo-polycin hc ................. 73 NEORAL ......................... 64 NEOSALUS .................... 44 NEOSALUS CP............... 44 NEO-SYNALAR .............. 44 NERLYNX ....................... 26 NESINA .......................... 48 neuac .............................. 44 NEULASTA ..................... 33 NEULASTA ONPRO ....... 33 NEUPOGEN ................... 33 NEUPRO......................... 28 NEURONTIN ................... 20 NEUTRASAL .................. 40 NEVANAC ....................... 71 nevirapine ....................... 31 nevirapine er ................... 31 NEXAVAR ....................... 26 NEXIUM .......................... 53 NEXLETOL ..................... 36 niacin (antihyperlipidemic)

.................................... 36 niacin er

(antihyperlipidemic) ..... 36 niacor .............................. 36 NIASPAN ........................ 36 nicardipine hcl ................. 36 NICORETTE ................... 16 nicotine polacrilex ............ 16 nicotine step 1 ................. 16 nicotine step 2 ................. 16 nicotine step 3 ................. 16 nifedipine......................... 36 nifedipine er .................... 36 nifedipine er osmotic

release ........................ 36 nikki ................................. 62 NILANDRON ................... 26 nilutamide........................ 26 nimodipine ....................... 36 NINLARO ........................ 26 nisoldipine er ................... 36 nitisinone ......................... 55 NITRO-BID ...................... 36 NITRO-DUR .................... 36 nitrofurantoin ................... 18 nitrofurantoin macrocrystal

.................................... 18 nitrofurantoin monohydrate

macrocrystals .............. 18 nitroglycerin ..................... 36 NITROLINGUAL .............. 36 NITROMIST .................... 36 NITROSTAT .................... 36

95

nitro-time ......................... 36 NITYR ............................. 55 NIVATOPIC PLUS ........... 44 NIVESTYM ...................... 33 nizatidine ......................... 53 NOCDURNA.................... 59 nolix ................................. 44 NOPIOID-TC KIT ............. 77 nora-be ............................ 62 NORCO ........................... 13 NORDITROPIN FLEXPRO

.................................... 59 norethin ace-eth estrad-fe 62 norethindrone .................. 62 norethindrone acetate ...... 62 norethindrone acet-ethinyl

est ............................... 62 norethindrone-eth estradiol

.................................... 62 norethin-eth estradiol-fe ... 62 NORGESIC FORTE ........ 77 norgestimate-eth estradiol

.................................... 62 norgestimate-ethinyl

estradiol triphasic ......... 62 NORITATE ...................... 44 norlyda ............................ 62 norlyroc ........................... 62 NORPACE ...................... 36 NORPACE CR ................ 36 NORPRAMIN .................. 22 NORTHERA .................... 36 nortrel 0.5/35 (28) ............ 62 nortrel 1/35 (21) ............... 62 nortrel 1/35 (28) ............... 62 nortrel 7/7/7 ..................... 62 nortriptyline hcl ................ 22 NORVASC ...................... 36 NORVIR .......................... 31 NOURIANZ ..................... 28 NOVACORT .................... 44 NOVOFINE AUTOCOVER

PEN NEEDLE .............. 51 NOVOFINE PEN NEEDLE

.................................... 51 NOVOFINE PLUS PEN

NEEDLE ...................... 51 NOVOLIN 70/30 RELION 51 NOVOLIN 70/30 VIAL ...... 51 NOVOLIN N RELION ...... 51 NOVOLIN N VIAL ............ 51 NOVOLIN R RELION ...... 51 NOVOLIN R VIAL ............ 51 NOVOLOG FLEXPEN ..... 51

NOVOLOG MIX 70/30 FLEXPEN .................... 51

NOVOLOG MIX 70/30 VIAL .................................... 51

NOVOLOG PENFILL ....... 51 NOVOLOG U-100 VIAL ... 51 NOVOTWIST PEN

NEEDLE ...................... 51 NOXAFIL ......................... 23 np thyroid ........................ 63 NUBEQA ......................... 27 NUCALA ......................... 74 NUCORT ......................... 44 NUCYNTA ....................... 13 NUCYNTA ER ................. 13 NUEDEXTA ..................... 40 nulev ............................... 54 NULYTELY WITH FLAVOR

PACKS ........................ 54 NUMBRINO ..................... 15 NUMOISYN ..................... 40 NUPLAZID ...................... 29 NURTEC ......................... 24 NUTROPIN AQ NUSPIN 10

.................................... 59 NUTROPIN AQ NUSPIN 20

.................................... 59 NUTROPIN AQ NUSPIN 5

.................................... 59 NUVAKAAN .................... 15 NUVAKAAN-II ................. 15 NUVARING ..................... 62 NUVESSA ....................... 18 NUVIGIL .......................... 78 NUZYRA ......................... 18 nyamyc ............................ 23 NYMALIZE ...................... 36 nystatin ...................... 23, 24 nystatin-triamcinolone ..... 24 nystop ............................. 24 O OCALIVA ........................ 55 ocella............................... 62 octreotide acetate ............ 59 OCUFLOX ....................... 71 ODACTRA....................... 68 ODEFSEY ....................... 31 ODOMZO ........................ 27 OFEV .............................. 76 ofloxacin .............. 18, 71, 73 olanzapine ....................... 29 olanzapine-fluoxetine hcl . 22 OLIVE TREE ................... 68 olmesartan medoxomil .... 36

olmesartan medoxomil-hctz .................................... 36

olmesartan-amlodipine-hctz .................................... 36

olopatadine hcl .......... 71, 74 OLUMIANT ..................... 64 OLUX .............................. 44 OLUX-E .......................... 44 OMECLAMOX-PAK ........ 54 omega-3-acid ethyl esters36 omeprazole ..................... 53 OMEPRAZOLE+SYRSPEN

D SF ALKA .................. 53 omeprazole-sodium

bicarbonate ................. 53 OMNARIS ....................... 74 OMNIPOD 5 PACK ......... 68 OMNIPOD DASH 5 PACK

PODS .......................... 68 OMNIPOD DASH SYSTEM

.................................... 49 OMNIPOD STARTER ..... 49 OMNITROPE .................. 59 ondansetron hcl............... 22 ondansetron odt .............. 22 ONETOUCH DELICA

LANCING DEV ............ 49 ONETOUCH DELICA PLUS

LANCING .................... 49 ONETOUCH ULTRA BLUE

TEST STRIPS ............. 49 ONETOUCH VERIO KIT

W/DEVICE .................. 49 ONEXTON ...................... 44 ONFI ............................... 20 ONGLYZA ....................... 48 opium .............................. 54 OPSUMIT........................ 77 ORACEA ......................... 45 ORACIT .......................... 52 ORALAIR ........................ 68 ORALAIR ADULT SAMPLE

KIT .............................. 69 ORALAIR ADULT

STARTER PACK ......... 69 ORALAIR CHILDRENS

SAMPLE KIT ............... 69 ORALAIR CHILDRENS

STARTER PACK ......... 69 oralone ............................ 40 ORAPRED ODT .............. 57 ORAVIG .......................... 24 ORENCIA........................ 64 ORENCIA CLICKJECT ... 64 ORENITRAM .................. 77

96

ORFADIN ........................ 55 ORILISSA ........................ 59 ORKAMBI ........................ 77 orphenadrine citrate ......... 77 orphenadrine citrate er .... 77 orphenadrine-asa-caffeine

.................................... 78 ORPHENGESIC FORTE . 78 orsythia ............................ 62 ORTHO MICRONOR ....... 62 oscimin ............................ 54 oscimin sr ........................ 54 oseltamivir phosphate ...... 31 OSENI ............................. 48 OSMOLEX ER ................. 28 OSMOPREP.................... 54 OSPHENA ....................... 58 OTEZLA .......................... 65 OTOVEL .......................... 73 OTREXUP ....................... 65 OVACE PLUS ................. 45 OVACE PLUS WASH ...... 45 OVACE WASH ................ 45 OVIDE ............................. 28 oxandrolone .................... 58 oxaprozin ......................... 11 OXAYDO ......................... 13 oxazepam ........................ 32 OXBRYTA ....................... 69 oxcarbazepine ................. 20 OXERVATE ..................... 73 oxiconazole nitrate........... 24 OXISTAT ......................... 24 OXSORALEN ULTRA ..... 45 OXTELLAR XR ................ 20 oxybutynin chloride .......... 56 oxybutynin chloride er ...... 56 oxycodone hcl ................. 13 OXYCODONE HCL ER ... 13 oxycodone-acetaminophen

.................................... 13 oxycodone-aspirin ........... 13 OXYCONTIN ................... 13 oxymorphone hcl ............. 13 oxymorphone hcl er ......... 13 OXYTROL ....................... 56 OZEMPIC ........................ 48 OZOBAX ......................... 78 P pacerone ......................... 36 PALFORZIA (12 MG DAILY

DOSE) ......................... 69 PALFORZIA (120 MG

DAILY DOSE) .............. 69

PALFORZIA (160 MG DAILY DOSE) .............. 69

PALFORZIA (20 MG DAILY DOSE) ......................... 69




PALFORZIA (300 MG MAINTENANCE) ......... 69

PALFORZIA (300 MG TITRATION) ................ 69




PALFORZIA INITIAL ESCALATION .............. 69

paliperidone er ................ 29 PAMELOR....................... 22 PANCREAZE .................. 55 PANDA MASK LARGE .... 69 PANDA MASK MEDIUM . 69 PANDA MASK SMALL .... 69 PANDEL .......................... 45 PANRETIN ...................... 27 pantoprazole sodium ....... 53 papaverine hcl ................. 36 PARAGARD

INTRAUTERINE COPPER ..................... 62

paricalcitol ....................... 67 PARLODEL ..................... 28 PARNATE ....................... 22 paroex ............................. 40 paromomycin sulfate ....... 18 paroxetine hcl .................. 22 paroxetine hcl er .............. 22 paroxetine mesylate ........ 22 PASER ............................ 25 PATANASE ..................... 74 PAXIL .............................. 22 PAXIL CR ........................ 22 PAZEO ............................ 71 PEDIAPRED ................... 57 PEDIARIX ....................... 65 PEDIATRIC PANDA MASK

.................................... 69 PEDVAX HIB ................... 66 peg 3350-kcl-na bicarb-nacl

.................................... 54

peg-3350/electrolytes ...... 54 PEGANONE .................... 20 PEGASYS ....................... 31 PEGASYS PROCLICK .... 31 PEGINTRON ................... 31 peg-prep ......................... 54 PEMAZYRE .................... 27 penicillamine ................... 56 penicillin v potassium ...... 18 PENICILLIUM NOTATUM69 PENLEN ......................... 45 PENNSAID ...................... 11 PENTACEL ..................... 66 PENTAM ......................... 28 pentamidine isethionate .. 28 PENTASA ....................... 66 pentazocine-naloxone hcl 14 pentobarbital sodium ....... 20 PENTOSAN

POLYSULFATE SODIUM .................................... 56

pentoxifylline er ............... 36 PEPCID .......................... 53 PERCOCET .................... 14 PERENNIAL RYE GRASS

POLLEN ...................... 69 PERFOROMIST .............. 76 perindopril erbumine ....... 36 periogard ......................... 40 permethrin ....................... 28 perphenazine .................. 22 perphenazine-amitriptyline

.................................... 22 PERSERIS ...................... 29 PERTZYE ....................... 55 PEXEVA ......................... 22 phenazo .......................... 56 phenazopyridine hcl ........ 56 phenelzine sulfate ........... 22 PHENERGAN ................. 74 phenobarbital .................. 20 phenobarbital sodium ...... 20 phenoxybenzamine hcl.... 37 phentolamine mesylate ... 37 phenylephrine hcl ............ 73 PHENYTEK ..................... 20 phenytoin ........................ 20 phenytoin infatabs ........... 20 phenytoin sodium ............ 20 phenytoin sodium extended

.................................... 20 philith .............................. 62 PHLAG SPRAY ............... 45 PHOSLYRA .................... 56 phospha 250 neutral ....... 52

97

phosphasal ...................... 56 PHOSPHOLINE IODIDE . 72 phosphorous.................... 52 phospho-trin 250 neutral .. 52 PHYSOSTIGMINE

SALICYLATE ............... 69 phytonadione ................... 52 PICATO ........................... 45 PIFELTRO ....................... 31 pilocarpine hcl ........... 40, 72 pimecrolimus ................... 45 PIMECROLIMUS ............. 45 pimozide .......................... 29 pimtrea ............................ 62 pindolol ............................ 37 pioglitazone hcl ................ 48 pioglitazone hcl-glimepiride

.................................... 48 pioglitazone hcl-metformin

hcl ................................ 48 PIQRAY (200 MG DAILY

DOSE) ......................... 27 PIQRAY (250 MG DAILY

DOSE) ......................... 27 PIQRAY (300 MG DAILY

DOSE) ......................... 27 pirmella 1/35 .................... 62 pirmella 7/7/7 ................... 62 piroxicam ......................... 11 PLAN B ONE-STEP ........ 62 PLAQUENIL .................... 28 PLAVIX ............................ 29 PLEGRIDY ...................... 39 PLEGRIDY STARTER

PACK .......................... 39 PLENVU .......................... 54 PLEXION ......................... 45 PLEXION CLEANSER ..... 45 PLEXION CLEANSING

CLOTH ........................ 45 PNEUMOVAX 23 ............ 66 pocket spacer .................. 69 podocon .......................... 45 podofilox .......................... 45 polycin ............................. 73 polymyxin b-trimethoprim. 73 POLYTRIM ...................... 73 POMALYST ..................... 27 portia-28 .......................... 62 posaconazole .................. 24 pot bicarb-pot chloride ..... 52 potassium bicarbonate .... 52 potassium chloride........... 52 potassium chloride crys er

.................................... 52

potassium chloride er ...... 52 potassium citrate er ......... 52 potassium citrate-citric acid

.................................... 52 POVIDONE-IODINE ........ 71 PRADAXA ....................... 19 PRALUENT ..................... 37 pramipexole dihydrochloride

.................................... 28 pramipexole dihydrochloride

er ................................. 28 PRAMOSONE ................. 45 PRAMOTIC ..................... 73 pramox ............................ 45 prasugrel hcl .................... 29 PRAVACHOL .................. 37 pravastatin sodium .......... 37 praziquantel ..................... 28 prazosin hcl ..................... 37 PRECOSE....................... 48 PRED FORTE ................. 71 PRED MILD ..................... 71 PRED-G .......................... 73 PRED-G S.O.P. ............... 73 prednicarbate .................. 45 PREDNISOL ACE-

MOXIFLOX-BROMFEN .................................... 71

prednisolone .................... 57 prednisolone acetate ....... 71 prednisolone acetate p-f .. 71 PREDNISOLONE

ACETATE-NEPAFENAC .................................... 73

PREDNISOLONE ACET-MOXIFLOXACIN ......... 73

prednisolone sodium phosphate ............. 57, 71

PREDNISOLONE-BROMFENAC ............. 73

PREDNISOLONE-GATIFLOXACIN .......... 73

PREDNISOLONE-MOXIFLOXACIN ......... 73

PREDNISOLON-GATIFLOX-BROMFENAC ............. 73

PREDNISOLON-MOXIFLOX-BROMFENAC ............. 73

PREDNISOLON-MOXIFLOX-NEPAFENAC .............. 71

prednisone ...................... 57 prednisone intensol ......... 57

PREFEST ....................... 62 pregabalin ....................... 40 PREMARIN ..................... 62 premium lidocaine ........... 15 PREMPHASE ................. 62 PREMPRO ...................... 62 PREPIDIL........................ 56 PREPOPIK ...................... 54 PRESERA ....................... 45 PRESTALIA .................... 37 PREVACID ...................... 53 PREVACID SOLUTAB .... 53 prevalite .......................... 37 preventeza ...................... 62 previfem .......................... 62 PREVNAR 13 .................. 66 PREVYMIS ..................... 31 PREZCOBIX ................... 31 PREZISTA ...................... 31 PRIFTIN .......................... 25 PRILOLID........................ 15 PRILOSEC ...................... 53 PRILOVIX ....................... 15 PRILOVIX LITE ............... 15 PRILOVIX LITE PLUS ..... 15 PRILOVIX PLUS ............. 15 prilovix ultralite ................ 15 prilovix ultralite plus ......... 15 primaquine phosphate ..... 28 primidone ........................ 20 PRIMLEV ........................ 14 PRIMSOL ........................ 18 PRINIVIL ......................... 37 PRISTIQ ......................... 22 PRO COMFORT SPACER

ADULT ........................ 69 PRO COMFORT SPACER

CHILD ......................... 69 PRO COMFORT SPACER

INFANT ....................... 69 PROAIR DIGIHALER ...... 76 PROAIR HFA .................. 76 PROAIR RESPICLICK .... 76 probenecid ...................... 24 PROBICHEW .................. 54 procainamide hcl ............. 37 PROCARDIA ................... 37 PROCARDIA XL ............. 37 PROCARE

SPACER/ADULT MASK .................................... 69

PROCARE SPACER/CHILD MASK .......................... 69

PROCENTRA ................. 39 prochlorperazine ............. 22

98

prochlorperazine edisylate .................................... 22

prochlorperazine maleate 22 PROCORT ...................... 66 PROCRIT ........................ 33 PROCTOCORT ............... 66 PROCTOFOAM HC ......... 66 procto-med hc ................. 66 procto-pak ....................... 66 proctosol hc ..................... 66 proctozone-hc .................. 67 PROCYSBI ...................... 55 progesterone ................... 62 progesterone micronized . 62 PROGLYCEM ................. 49 PROGRAF ...................... 65 PROLATE ....................... 14 PROLENSA ..................... 71 PROMACTA .................... 33 promethazine hcl ............. 74 promethazine-codeine ..... 74 promethazine-dm ............ 74 promethazine-phenyleph-

codeine ........................ 74 promethazine-

phenylephrine .............. 74 promethegan ................... 74 PROMETRIUM ................ 62 propafenone hcl ............... 37 propafenone hcl er .......... 37 propantheline bromide ..... 54 proparacaine hcl .............. 73 propranolol hcl ................. 37 propranolol hcl er ............. 37 propranolol-hctz ............... 37 propylthiouracil ................ 63 PROQUAD ...................... 66 PROSCAR ...................... 56 PROSTIN E2 ................... 56 PROSTIN VR .................. 37 PROTEXA ....................... 45 PROTONIX ..................... 53 PROTOPIC ..................... 45 protriptyline hcl ................ 22 PROVENTIL HFA ............ 76 PROVERA ....................... 62 PROVIGIL ....................... 78 PROZAC ......................... 22 PRUCLAIR ...................... 45 PRUDOXIN ..................... 45 PRUMYX ......................... 45 pseudoephedrine-

bromphen-dm .............. 74 PSORCON ...................... 45

PULMICORT FLEXHALER .................................... 76

PULMICORT SUSPENSION ............. 76

pulmosal .......................... 74 PULMOZYME ................. 77 PURIXAN ........................ 27 PYLERA .......................... 54 pyrazinamide ................... 25 PYRIDIUM....................... 56 pyridostigmine bromide ... 25 pyridostigmine bromide er25 pyrimethamine ................. 28 PYROGALLIC ACID ........ 45 Q QBRELIS ........................ 37 QBREXZA ....................... 45 QINLOCK ........................ 27 QMIIZ ODT...................... 11 QNASL ............................ 74 QNASL CHILDRENS ...... 74 QTERN ........................... 48 QUADRACEL .................. 66 QUALAQUIN ................... 28 QUARTETTE .................. 63 quazepam ....................... 32 QUDEXY XR ................... 20 QUEEN PALM ................. 69 QUESTRAN .................... 37 QUESTRAN LIGHT ......... 37 quetiapine fumarate ......... 29 quetiapine fumarate er .... 29 QUILLICHEW ER ............ 39 QUILLIVANT XR ............. 39 quinapril hcl ..................... 37 quinapril-

hydrochlorothiazide ..... 37 quinidine gluconate er ..... 37 quinidine sulfate .............. 37 quinine sulfate ................. 28 QVAR REDIHALER ......... 76 R RABBIT EPITHELIUM ..... 69 rabeprazole sodium ......... 53 RAGWITEK ..................... 69 raloxifene hcl ................... 58 ramelteon ........................ 78 ramipril ............................ 37 RANEXA ......................... 37 ranolazine er ................... 37 RAPAFLO ....................... 56 RAPAMUNE .................... 65 rasagiline mesylate .......... 28 RASUVO ......................... 65 RAVICTI .......................... 55

RAYALDEE ..................... 67 RAYOS ........................... 57 RAZADYNE .................... 21 RAZADYNE ER............... 21 REBIF ............................. 39 REBIF REBIDOSE .......... 39 REBIF REBIDOSE

TITRATION PACK ....... 39 REBIF TITRATION PACK39 reclipsen ......................... 63 RECOMBIVAX HB .......... 66 RECTIV ........................... 37 RED MAPLE ................... 69 REGLAN ......................... 22 RELADOR PAK............... 15 RELADOR PAK PLUS .... 15 RELAFEN DS ................. 11 RELENZA DISKHALER .. 31 relexxii ............................. 39 RELISTOR ...................... 54 RELPAX .......................... 24 REMERON ...................... 22 REMERON SOLTAB ....... 22 RENACIDIN .................... 56 RENAGEL ....................... 56 RENOVO ........................ 15 RENVELA ....................... 56 repaglinide ...................... 48 REPATHA ....................... 37 REPATHA PUSHTRONEX

SYSTEM ..................... 37 REPATHA SURECLICK .. 37 REQUIP XL ..................... 28 RESORCINOL-SULFUR . 45 RESTASIS ...................... 73 RESTASIS MULTIDOSE . 73 RESTORIL ...................... 78 RETACRIT ...................... 33 RETEVMO ...................... 27 RETIN-A ......................... 45 RETIN-A MICRO GEL 0.04

%, 0.1 % ...................... 45 RETIN-A MICRO PUMP .. 45 RETROVIR ..................... 31 REVATIO ........................ 77 REVLIMID ....................... 27 REXAPHENAC ............... 11 REXULTI ......................... 29 REYATAZ ....................... 31 REYVOW ........................ 24 RHIZOPUS ..................... 69 RHOFADE ...................... 45 RHOPHYLAC .................. 65 RHOPRESSA ................. 72 ribavirin ........................... 31

99

RIDAURA ........................ 65 rifabutin ........................... 25 RIFADIN .......................... 25 RIFAMATE ...................... 25 rifampin ........................... 25 RIFATER ......................... 25 RILUTEK ......................... 40 riluzole ............................. 40 rimantadine hcl ................ 31 RIMSO-50 ....................... 56 RINVOQ .......................... 65 RIOMET .......................... 48 RIOMET ER .................... 48 risedronate sodium .......... 67 RISPERDAL .................... 29 RISPERDAL CONSTA .... 29 risperidone ...................... 30 RITALIN .......................... 39 RITALIN LA ..................... 39 ritonavir ........................... 31 rivastigmine ..................... 21 rivastigmine tartrate ......... 21 rivelsa .............................. 63 rizatriptan benzoate ......... 24 ROBAXIN ........................ 78 ROBAXIN-750 ................. 78 ROCALTROL .................. 67 ROCKLATAN .................. 72 ropinirole hcl .................... 28 ropinirole hcl er ................ 28 rosadan ........................... 45 ROSADAN ...................... 45 rosuvastatin calcium ........ 37 ROTARIX ........................ 66 ROTATEQ ....................... 66 ROWASA ........................ 67 roweepra ......................... 20 roweepra xr ..................... 20 ROXICODONE ................ 14 ROZEREM ...................... 78 ROZLYTREK ................... 27 RUBRACA ....................... 27 RUCONEST .................... 65 RUZURGI ........................ 69 RYBELSUS ..................... 48 RYCLORA ....................... 74 RYDAPT .......................... 27 RYTARY .......................... 29 RYTHMOL SR ................. 37 ryvent .............................. 75 S SABRIL ........................... 20 SACCHAROMYCES

CEREVISIAE ............... 69 SAFYRAL ........................ 63

SAIZEN ........................... 59 SAIZENPREP ................. 59 SALAGEN ....................... 40 SALEX ............................ 45 salicylic acid .................... 45 salicylic acid wart remover

.................................... 45 salimez ............................ 45 SALIMEZ FORTE ............ 45 SALIVAMAX .................... 40 salsalate .......................... 11 SALVAX .......................... 45 SAMSCA ......................... 52 SANCUSO ...................... 23 SANDIMMUNE ................ 65 SANDOSTATIN ............... 59 SANDOSTATIN LAR

DEPOT ........................ 59 SANTYL .......................... 45 SAPHRIS ........................ 30 SARAFEM ....................... 22 SAVAYSA ....................... 19 SAVELLA ........................ 40 SAVELLA TITRATION

PACK .......................... 40 scopolamine .................... 23 SEASONIQUE ................ 63 SECONAL ....................... 78 SECUADO ...................... 30 SEEBRI NEOHALER ...... 76 SEGLUROMET ............... 48 selegiline hcl .................... 29 selenium sulfide ........ 45, 46 SELZENTRY ................... 31 SEMPREX-D ................... 75 SENSIPAR ...................... 67 SEREVENT DISKUS ....... 76 SERNIVO ........................ 46 SEROQUEL .................... 30 SEROQUEL XR .............. 30 SEROSTIM ..................... 54 sertraline hcl .................... 22 setlakin ............................ 63 sevelamer carbonate ....... 56 sevelamer hcl .................. 56 SEYSARA ....................... 18 SFROWASA .................... 67 sharobel .......................... 63 SHINGRIX ....................... 66 SIGNIFOR ....................... 59 SIKLOS ........................... 27 sildenafil citrate ............... 77 SILENOR ........................ 78 SILIQ ............................... 65 silodosin .......................... 56

SILVADENE .................... 18 silver nitrate ..................... 18 silver sulfadiazine ............ 18 SIMBRINZA .................... 72 simliya ............................. 63 simpesse ......................... 63 SIMPONI ......................... 65 simvastatin ...................... 37 SINEMET ........................ 29 SINGULAIR ..................... 76 sirolimus .......................... 65 SIRTURO ........................ 25 SITAVIG .......................... 31 SIVEXTRO ...................... 18 SKELAXIN ...................... 78 SKLICE ........................... 28 SKYLA ............................ 63 SKYRIZI (150 MG DOSE)65 SLYND ............................ 63 sod citrate-citric acid ....... 52 sodium chloride ......... 52, 75 sodium chloride (pf) ......... 52 sodium fluoride ................ 52 sodium hyaluronate ......... 46 sodium phenylbutyrate .... 55 sodium polystyrene

sulfonate ..................... 52 sodium sulfacetamide ..... 46 sodium sulfacetamide wash

.................................... 46 SODIUM

SULFACETAMIDE WASH ......................... 46

SOFOSBUVIR-VELPATASVIR ............ 31

solifenacin succinate ....... 56 SOLIQUA ........................ 48 SOLODYN ...................... 18 SOLOSEC ....................... 18 SOLTAMOX .................... 27 SOLU-CORTEF .............. 57 SOLU-MEDROL .............. 57 SOMA ............................. 78 SOMATULINE DEPOT .... 59 SOMAVERT .................... 59 SOOLANTRA .................. 46 SOOTHEE ...................... 15 SORIATANE ................... 46 SORILUX ........................ 46 sorine .............................. 37 sotalol hcl ........................ 37 sotalol hcl (af) .................. 37 SOTYLIZE ....................... 37 SOVALDI ........................ 31 spinosad ......................... 28

100

SPINY PIGWEED ............ 69 SPIRIVA HANDIHALER .. 76 SPIRIVA RESPIMAT ....... 76 spironolactone ................. 37 spironolactone-hctz ......... 37 SPORANOX .................... 24 SPORANOX PULSEPAK 24 sprintec 28 ....................... 63 SPRITAM ........................ 20 SPRIX ............................. 11 SPRYCEL ....................... 27 sps .................................. 52 sronyx.............................. 63 ssd .................................. 18 SSKI ................................ 75 sss 10-5 ........................... 46 STALEVO 100 ................. 29 STALEVO 125 ................. 29 STALEVO 150 ................. 29 STALEVO 200 ................. 29 STALEVO 50 ................... 29 STALEVO 75 ................... 29 STARLIX ......................... 48 stavudine ......................... 31 STEGLATRO ................... 48 STEGLUJAN ................... 48 STELARA ........................ 65 STEMPHYLIUM .............. 69 sterile water for irrigation . 52 STIMATE ......................... 59 STIOLTO RESPIMAT ...... 76 STIVARGA ...................... 27 STRATTERA ................... 39 STRENSIQ ...................... 55 streptomycin sulfate ......... 18 STRIBILD ........................ 31 STRIVERDI RESPIMAT .. 76 STROMECTOL ............... 28 SUBOXONE .................... 16 SUBSYS .......................... 14 subvenite ......................... 20 subvenite starter kit-blue . 20 subvenite starter kit-green

.................................... 20 subvenite starter kit-orange

.................................... 20 SUCRAID ........................ 55 sucralfate ......................... 53 SULAR ............................ 37 sulfacetamide sodium 46, 71 sulfacetamide sodium

(acne) .......................... 46 sulfacetamide sodium-sulfur

.................................... 46

sulfacetamide-prednisolone .................................... 73

sulfacetamide-sulfur in urea .................................... 46

sulfacleanse 8/4 .............. 46 sulfadiazine ..................... 18 sulfamethoxazole-

trimethoprim ................ 18 sulfamez wash ................ 46 SULFAMYLON ................ 18 sulfasalazine ................... 67 sulfatrim pediatric ............ 18 sulindac ........................... 11 SUMADAN WASH ........... 46 sumatriptan ..................... 24 sumatriptan succinate 24, 25 sumatriptan succinate refill

.................................... 25 sumatriptan-naproxen

sodium......................... 25 SUMAXIN ........................ 46 SUMAXIN WASH ............ 46 SUNOSI .......................... 78 SUPRAX ......................... 18 SUPREP BOWEL PREP

KIT .............................. 54 SURESTEP PRO HIGH

GLUCOSE ................... 49 SURESTEP PRO LOW

GLUCOSE ................... 49 SURESTEP PRO NORMAL

GLUCOSE ................... 49 SURVANTA ..................... 75 SUSTIVA ......................... 31 SUTENT .......................... 27 SUVICORT...................... 46 SWEET GUM .................. 69 SWEET VERNAL GRASS

POLLEN ...................... 69 syeda .............................. 63 SYLATRON ..................... 31 SYMAX DUOTAB ............ 54 symax-sl .......................... 54 symax-sr ......................... 54 SYMBICORT ................... 76 SYMBYAX ....................... 22 SYMDEKO ...................... 77 SYMFI ............................. 31 SYMFI LO ....................... 31 SYMJEPI ......................... 76 SYMLINPEN 120............. 48 SYMLINPEN 60 .............. 48 SYMPAZAN .................... 20 SYMPROIC ..................... 54 SYMTUZA ....................... 31

synalar ............................ 46 SYNALAR ....................... 46 SYNAREL ....................... 59 SYNDROS ...................... 23 SYNERA ......................... 15 SYNERDERM ................. 46 SYNJARDY ..................... 48 SYNJARDY XR ............... 48 SYNTHROID ................... 63 SYPRINE ........................ 52 T TABLOID......................... 27 TABRECTA ..................... 27 TACHOSIL ...................... 69 TACLONEX ..................... 46 tacrolimus.................. 46, 65 tadalafil (pah) .................. 77 TAFINLAR ....................... 27 TAGRISSO ..................... 27 TAKHZYRO .................... 65 TALICIA .......................... 55 TALL RAGWEED ............ 69 TALTZ ............................. 65 TALZENNA ..................... 27 TAMIFLU......................... 31 tamoxifen citrate .............. 27 tamsulosin hcl ................. 56 TAPAZOLE ..................... 63 TAPERDEX 12-DAY ....... 57 TAPERDEX 6-DAY ......... 57 TAPERDEX 7-DAY ......... 57 TARCEVA ....................... 27 TARGADOX .................... 18 TARGRETIN ................... 27 tarina 24 fe ...................... 63 tarina fe 1/20 ................... 63 tarina fe 1/20 eq .............. 63 TARKA ............................ 37 taron-crystals .................. 52 TASIGNA ........................ 27 TASMAR ......................... 29 TAVALISSE .................... 33 TAYTULLA ...................... 63 tazarotene ....................... 46 tazicef ............................. 18 TAZORAC ....................... 46 taztia xt ........................... 37 TAZVERIK ...................... 27 TDVAX ............................ 66 TECFIDERA .................... 39 TEGRETOL ..................... 20 TEGRETOL-XR............... 20 TEGSEDI ........................ 40 TEKTURNA ..................... 37 TEKTURNA HCT ............ 37

101

telmisartan ....................... 37 telmisartan-amlodipine .... 37 telmisartan-hctz ............... 37 temazepam ..................... 78 TEMODAR ...................... 27 TEMOVATE..................... 46 temozolomide .................. 27 tencon ............................. 14 TENIVAC ......................... 66 tenofovir disoproxil fumarate

.................................... 31 TENORETIC 100 ............. 37 TENORETIC 50 ............... 37 TENORMIN ..................... 37 terazosin hcl .................... 56 terbinafine hcl .................. 24 terbutaline sulfate ............ 76 terconazole ...................... 24 TERIPARATIDE

(RECOMBINANT) ........ 67 TESSALON PERLES ...... 75 TESTIM ........................... 58 TESTONE CIK ................ 58 testosterone .................... 58 testosterone cypionate .... 58 TESTOSTERONE

CYPIONATE ................ 58 testosterone enanthate .... 58 tetrabenazine................... 40 tetracaine hcl ................... 73 tetracycline hcl ................. 18 TETRIX ........................... 46 TEXACORT ..................... 46 THALOMID ...................... 27 THEO-24 ......................... 76 theophylline ..................... 76 theophylline er ................. 76 THIOLA ........................... 56 THIOLA EC ..................... 56 thioridazine hcl ................ 30 thiothixene ....................... 30 tiadylt er ........................... 37 tiagabine hcl .................... 20 TIAZAC ........................... 37 TIBSOVO ........................ 27 TIGAN ............................. 23 TIGLUTIK ........................ 40 TIKOSYN ........................ 37 tilia fe ............................... 63 timolol maleate .......... 37, 72 TIMOLOL-BRIMON-

DORZOL-LATANOPR . 72 TIMOLOL-BRIMONIDINE-

DORZOLAMID ............. 72

TIMOLOL-DORZOLAMID-LATANOPROST .......... 72

TIMOPTIC ....................... 72 TIMOPTIC OCUDOSE .... 72 TIMOPTIC-XE ................. 72 tinidazole ......................... 18 TIROSINT ....................... 63 TIROSINT-SOL ............... 63 TIVICAY .......................... 31 TIVICAY PD .................... 31 TIVORBEX ...................... 11 tizanidine hcl ................... 78 TOBI NEBULIZER ........... 77 TOBI PODHALER ........... 77 TOBRADEX .................... 73 TOBRADEX ST ............... 73 tobramycin................. 71, 77 TOBRAMYCIN ................ 77 tobramycin-dexamethasone

.................................... 73 TOBREX ......................... 71 TOLAK ............................ 46 tolbutamide...................... 48 tolcapone ........................ 29 tolmetin sodium ............... 11 TOLSURA ....................... 24 tolterodine tartrate ........... 56 tolterodine tartrate er ....... 56 tolvaptan ......................... 52 TOPAMAX....................... 20 TOPAMAX SPRINKLE .... 20 TOPICORT...................... 46 TOPICORT SPRAY ......... 46 topiramate ....................... 20 topiramate er ................... 20 TOPROL XL .................... 37 toremifene citrate............. 27 torsemide ........................ 37 TOSYMRA ...................... 25 TOUJEO MAX SOLOSTAR

.................................... 51 TOUJEO SOLOSTAR ..... 51 tovet ................................ 46 TOVIAZ ........................... 56 TRACLEER ..................... 77 TRADJENTA ................... 48 tramadol hcl er ................ 14 TRAMADOL HCL ER ...... 14 tramadol hcl er (biphasic) 14 tramadol hcl ir .................. 14 tramadol-acetaminophen . 14 trandolapril ...................... 37 trandolapril-verapamil hcl er

.................................... 37 tranexamic acid ............... 33

TRANSDERM SCOP (1.5 MG) ............................. 23

TRANSDERM-SCOP (1.5 MG) ............................. 23

TRANXENE-T ................. 32 tranylcypromine sulfate ... 22 TRAVATAN Z .................. 72 travoprost (bak free) ........ 72 trazodone hcl .................. 22 TRECATOR .................... 25 TRELEGY ELLIPTA ........ 76 TREMFYA ....................... 65 TRESIBA......................... 51 TRESIBA FLEXTOUCH .. 51 tretinoin ..................... 27, 46 tretinoin microsphere ....... 46 tretinoin microsphere pump

.................................... 46 TREXALL ........................ 65 TREXIMET ...................... 25 TREZIX ........................... 14 tri femynor ....................... 63 triamcinolone acetonide . 40,

46, 47, 57 TRIAMCINOLONE

ACETONIDE ............... 57 TRIAMCINOLONE

DIACETATE ................ 58 TRIAMCINOLONE

DIACETATE PF .......... 58 triamterene ...................... 37 triamterene-hctz .............. 37 trianex ............................. 47 triazolam ......................... 32 TRIBENZOR ................... 37 TRICHOPHYTON ........... 69 tricitrates ......................... 52 TRICOR .......................... 37 triderm ............................. 47 TRIDESILON .................. 47 trientine hcl ...................... 52 tri-estarylla ...................... 63 trifluoperazine hcl ............ 30 trifluridine ........................ 71 TRIGLIDE ....................... 37 trihexyphenidyl hcl ........... 29 TRIJARDY XR ................ 48 TRIKAFTA ....................... 77 tri-legest fe ...................... 63 TRILEPTAL ..................... 20 tri-linyah .......................... 63 TRILIPIX ......................... 37 tri-lo-estarylla .................. 63 tri-lo-marzia ..................... 63 tri-lo-mili .......................... 63

102

tri-lo-sprintec.................... 63 trilyte ............................... 55 trimethobenzamide hcl .... 23 trimethoprim .................... 18 tri-mili............................... 63 trimipramine maleate ....... 22 TRINTELLIX .................... 22 tri-previfem ...................... 63 tri-sprintec ....................... 63 TRIUMEQ ........................ 31 trivora (28) ....................... 63 tri-vylibra .......................... 63 tri-vylibra lo ...................... 63 TRIZIVIR ......................... 31 TROKENDI XR ................ 20 TROPICAMIDE-

CYCLOPENTOLATE-PE .................................... 73

TROPICAMIDE-PHENYLEPHRINE ...... 73

TROPIC-PROPARACA-PE-KETOROLAC .............. 73

trospium chloride ............. 56 trospium chloride er ......... 56 TRUE METRIX LEVEL 1 . 49 TRUE METRIX LEVEL 2 . 49 TRUE METRIX LEVEL 3 . 49 TRULANCE ..................... 55 TRULICITY ...................... 48 TRUMENBA .................... 66 TRUSOPT ....................... 72 TRUVADA ....................... 31 TUDORZA PRESSAIR .... 76 TUKYSA .......................... 27 tulana .............................. 63 TURALIO ......................... 27 TUSSICAPS .................... 75 TUXARIN ER ................... 75 TUZISTRA XR ................. 75 TWINRIX ......................... 66 TWYNSTA ....................... 37 TYBOST .......................... 31 tydemy ............................. 63 TYKERB .......................... 27 TYLENOL WITH CODEINE

#3 ................................ 14 TYMLOS ......................... 67 TYVASO .......................... 77 TYVASO REFILL ............. 77 TYVASO STARTER ........ 77 U UBRELVY ....................... 25 UCERIS ........................... 67 UDENYCA ....................... 33 ULORIC ........................... 24

ULTRACET ..................... 14 ULTRAM ......................... 14 ULTRAVATE ................... 47 UMECTA MOUSSE ......... 47 UNISTRIP CONTROL ..... 49 unithroid .......................... 63 UPTRAVI ........................ 77 URAMAXIN ..................... 47 urea ................................. 47 UREA .............................. 47 urea hydrating ................. 47 urea nail .......................... 47 uredeb ............................. 47 urelle ............................... 56 uremez-40 ....................... 47 URESOL ......................... 47 uretron d/s ....................... 56 uribel ............................... 56 URIMAR-T....................... 56 urin ds ............................. 56 URO-458 ......................... 56 UROCIT-K 10 .................. 52 UROCIT-K 15 .................. 52 UROCIT-K 5 .................... 52 UROGESIC-BLUE ........... 56 uro-mp ............................. 56 UROXATRAL .................. 56 URSO 250 ....................... 55 URSO FORTE ................. 55 ursodiol ........................... 55 URYL .............................. 56 ustell................................ 56 UTIBRON NEOHALER.... 76 uticap .............................. 56 utira-c .............................. 56 UTOPIC .......................... 47 utrona-c ........................... 56 V VAGIFEM ........................ 63 valacyclovir hcl ................ 31 VALCHLOR ..................... 27 VALCYTE ........................ 31 valganciclovir hcl ............. 31 VALIUM ........................... 32 valproic acid .................... 20 valsartan ......................... 37 valsartan-

hydrochlorothiazide ..... 38 VALTOCO 10 MG DOSE 20 VALTOCO 15 MG DOSE 20 VALTOCO 20 MG DOSE 20 VALTOCO 5 MG DOSE .. 20 VALTREX ........................ 31 VANADOM ...................... 78 VANATOL LQ .................. 14

VANATOL S .................... 14 VANCOCIN ..................... 18 VANCOCIN HCL ............. 18 vancomycin hcl ............... 18 vandazole........................ 18 VANOS ........................... 47 VANOXIDE-HC ............... 47 VAQTA ............................ 66 VARIVAX ........................ 66 VARIZIG ......................... 65 VARUBI .......................... 23 VARUBI (180 MG DOSE) 23 VASCEPA ....................... 38 VASERETIC .................... 38 VASOTEC ....................... 38 VECAMYL ....................... 38 VECTICAL ...................... 47 velivet .............................. 63 VELPHORO .................... 56 VELTASSA ..................... 52 VELTIN ........................... 47 VEMLIDY ........................ 31 VENCLEXTA ................... 27 VENCLEXTA STARTING

PACK .......................... 27 venlafaxine hcl ................ 22 venlafaxine hcl er ............ 22 VENOMIL HONEY BEE

VENOM ....................... 69 VENOMIL MIXED VESPID

VENOM ....................... 70 VENOMIL WASP VENOM

.................................... 70 VENOMIL WHITE FACED

HORNET ..................... 70 VENOMIL YELLOW

HORNET VENOM ....... 70 VENOMIL YELLOW

JACKET VENOM ........ 70 VENTAVIS ...................... 77 VENTOLIN HFA .............. 76 verapamil hcl ................... 38 verapamil hcl er ............... 38 VERDESO ...................... 47 VEREGEN ...................... 47 VERELAN ....................... 38 VERELAN PM ................. 38 VERSACLOZ .................. 30 VERZENIO ...................... 27 VESICARE ...................... 56 VEXATROL ..................... 15 VFEND ............................ 24 V-GO 20 .......................... 49 V-GO 30 .......................... 49 V-GO 40 .......................... 49

103

VIBERZI .......................... 55 VIBRAMYCIN .................. 18 VICTOZA ......................... 48 VIEKIRA PAK .................. 31 vienva .............................. 63 vigabatrin ......................... 20 vigadrone ........................ 20 VIGAMOX ....................... 71 VIIBRYD .......................... 22 VIIBRYD STARTER PACK

.................................... 22 vilamit mb ........................ 56 VILEVEV MB ................... 56 VIMOVO .......................... 12 VIMPAT ........................... 20 VIOKACE ........................ 55 viorele.............................. 63 VIRACEPT ...................... 31 VIRAMUNE ..................... 32 VIRAMUNE XR ............... 32 VIRASAL ......................... 47 VIRAZOLE ...................... 32 VIREAD ........................... 32 virt-phos 250 neutral ........ 52 VISTARIL ........................ 32 VISTOGARD ................... 70 vitamin d (ergocalciferol) . 53 vitamin k1 ........................ 53 VITRAKVI ........................ 27 VIVAGUARD INO

CONTROL SOLUTION 49 VIVAGUARD LANCING

DEVICE ....................... 49 VIVELLE-DOT ................. 63 VIVITROL ........................ 16 VIVLODEX ...................... 12 VIZIMPRO ....................... 27 VOGELXO ....................... 58 VOGELXO PUMP ........... 58 volnea.............................. 63 VOLTAREN ..................... 12 voriconazole .................... 24 VOSEVI ........................... 32 VOTRIENT ...................... 27 VRAYLAR ....................... 30 VTOL LQ ......................... 14 VUMERITY ...................... 39 VUMERITY (STARTER) .. 39 VUSION .......................... 24 vyfemla ............................ 63 vylibra .............................. 63 VYNDAMAX .................... 38 VYNDAQEL ..................... 38 VYTORIN ........................ 38 VYVANSE ....................... 39

VYZULTA ........................ 72 W WAKIX ............................ 78 warfarin sodium ............... 19 WASP VENOM PROTEIN

.................................... 70 water for irrigation, sterile 53 WELCHOL ...................... 38 WELLBUTRIN SR ........... 22 WELLBUTRIN XL ............ 22 wera ................................ 63 WESTERN JUNIPER ...... 70 WESTHROID .................. 63 WHITE BIRCH ................ 70 WHITE FACED HORNET

VENOM ....................... 70 WHITE MULBERRY ........ 70 WHITE-FACED HORNET

VENOM ....................... 70 WIDE-SEAL DIAPHRAGM

60 ................................ 70 WIDE-SEAL DIAPHRAGM







95 ................................ 70 WP THYROID ................. 63 wymzya fe ....................... 63 X XADAGO ......................... 29 XALATAN ........................ 72 XALIX .............................. 47 XALKORI ........................ 27 XANAX ............................ 32 XANAX XR ...................... 32 XARELTO ....................... 19 XARELTO STARTER PACK

.................................... 19 XATMEP ......................... 65 XCOPRI .......................... 20 XCOPRI (250 MG DAILY

DOSE) ......................... 20 XCOPRI (350 MG DAILY

DOSE) ......................... 20 XELJANZ ........................ 65 XELJANZ XR .................. 65

XELODA ......................... 27 XELPROS ....................... 72 XEMBIFY ........................ 65 XENAZINE ...................... 40 XENLETA........................ 18 XEPI ................................ 18 XERALUX ....................... 47 XERESE ......................... 32 XERMELO ...................... 55 XEROSTOMIA RELIEF

SPRAY ........................ 40 XHANCE ......................... 75 XIFAXAN......................... 18 XIGDUO XR .................... 48 XIIDRA ............................ 73 XIMINO ........................... 18 XOFLUZA (40 MG DOSE)

.................................... 32 XOFLUZA (80 MG DOSE)

.................................... 32 XOLEGEL ....................... 24 XOPENEX ....................... 76 XOPENEX

CONCENTRATE ......... 77 XOPENEX HFA............... 77 XOSPATA ....................... 27 XPOVIO (100 MG ONCE

WEEKLY) .................... 27 XPOVIO (40 MG ONCE

WEEKLY) .................... 27 XPOVIO (40 MG TWICE





WEEKLY) .................... 27 XTAMPZA ER ................. 14 XTANDI ........................... 27 xulane ............................. 63 XULTOPHY ..................... 48 xurea ............................... 47 XYLOCAINE ................... 15 XYLOCAINE/EPINEPHRIN

E ................................. 15 XYLOCAINE-MPF ........... 15 XYOSTED ....................... 58 XYREM ........................... 78 Y YASMIN 28 ..................... 63 YAZ ................................. 63

104

YELLOW HORNET VENOM PROTEIN .................... 70

YELLOW JACKET VENOM PROTEIN .................... 70

YONSA ............................ 27 YOSPRALA ..................... 29 YUPELRI ......................... 77 yuvafem ........................... 63 Z zaclir cleansing ................ 47 zafirlukast ........................ 77 zaleplon ........................... 78 ZANAFLEX ...................... 78 zarah ............................... 63 ZARONTIN ...................... 20 ZARXIO ........................... 33 ZAVESCA ....................... 55 ZEBUTAL ........................ 14 ZEGERID ........................ 53 ZEJULA ........................... 27 ZELAPAR ........................ 29 ZELBORAF ..................... 27 ZELNORM ....................... 55 ZEMBRACE SYMTOUCH

.................................... 25 ZEMPLAR ....................... 67 zenatane ......................... 47 ZENPEP .......................... 55 zenzedi ............................ 39 ZENZEDI ......................... 39 ZEPATIER ....................... 32 ZERUVIA ......................... 15

ZERVIATE....................... 71 ZESTORETIC ................. 38 ZESTRIL ......................... 38 ZETIA .............................. 38 ZETONNA ....................... 75 ZIAC ................................ 38 ZIAGEN ........................... 32 ZIANA ............................. 47 zidovudine ....................... 32 ZIEXTENZO .................... 33 zileuton er ....................... 77 ZIONODIL ....................... 15 ZIONODIL 100 ................ 15 ZIOPTAN ........................ 72 ziprasidone hcl ................ 30 ziprasidone mesylate ....... 30 ZIPSOR ........................... 12 ZIRGAN .......................... 71 ZITHRANOL .................... 47 ZITHROMAX ................... 18 ZITHROMAX TRI-PAK .... 18 ZITHROMAX Z-PAK ........ 18 ZOCOR ........................... 38 ZOFRAN ......................... 23 ZOHYDRO ER ................ 14 ZOLINZA ......................... 27 zolmitriptan ...................... 25 ZOLOFT .......................... 22 zolpidem tartrate ............. 78 zolpidem tartrate er ......... 78 ZOLPIMIST ..................... 78 ZOMACTON .................... 59

ZOMIG ............................ 25 ZOMIG ZMT .................... 25 ZONALON ....................... 47 ZONEGRAN .................... 20 zonisamide ...................... 20 ZONTIVITY ..................... 29 ZORBTIVE ...................... 55 ZORTRESS .................... 65 ZORVOLEX .................... 12 ZOSTAVAX ..................... 66 zovia 1/35e (28) .............. 63 ZOVIRAX ........................ 32 ZTLIDO ........................... 15 ZUBSOLV ....................... 16 zumandimine ................... 63 ZUPLENZ........................ 23 ZYCLARA ....................... 47 ZYCLARA PUMP ............ 47 ZYDELIG......................... 27 ZYFLO ............................ 77 ZYKADIA......................... 27 ZYLET ............................. 73 ZYLOPRIM ...................... 24 ZYMAXID ........................ 71 ZYPITAMAG ................... 38 ZYPREXA ....................... 30 ZYPREXA RELPREVV ... 30 ZYPREXA ZYDIS ............ 30 ZYTIGA ........................... 27 ZYVOX ............................ 18

Appendix A: OVER-THE-COUNTER (OTC) MEDICATION

BENEFIT LIST

The medications listed below are covered only for members who have purchased a special benefit offered through Kaiser Permanente

Washington called the Over-the-Counter Pharmacy Benefit.

***Typically, if a generic product is available for a drug, the Brand Name product may not be covered.***

Generic Product Name ***Brand Name*** Forms

ALLERGY COUGH AND COLD

Antihistamines CHLORPHENIRAMINE CHLOR-TRIMETON® Tab, Liquid

CLEMASTINE TAVIST® Tab, Liquid

DIPHENHYDRAMINE BENADRYL® Cap, Liquid

LORATADINE CLARITIN® Tab, Liquid

Decongestants OXYMETAZOLINE NASAL SPRAY AFRIN® Spray

PHENYLEPHRINE NASAL SPRAY NEO-SYNEPHRINE® Spray

PSEUDOEPHEDRINE SUDAFED® Tablet

Antihistamine/Decongestant Combinations TRIPROLIDINE/PSEUDOEPHEDRINE ACTIFED® Tablet

BROMPHENIRAMINE/PSEUDOEPHEDRINE DIMETAPP® Liquid

Expectorants/Cough Agents GUAIFENESIN ROBITUSSIN® Liquid

GUAIFENESIN/DEXTROMETHORPHAN ROBITUSSIN-DM® Liquid

DEXTROMETHORPHAN ROBITUSSIN COUGH® Liquid

DEXTROMETHORPHAN EXTEND RELEASE DELSYM® Liquid

AUTONOMICS AND CNS

Analgesics, Miscellaneous ACETAMINOPHEN TYLENOL® Tab, Chew, Supp,

Liquid

Non-Steroidal Anti-Inflammatories IBUPROFEN MOTRIN®, ADVIL® Tab, Liquid

Salicylates ASPIRIN BAYER®, ASCRIPTIN® Tab, Supp

DERMATOLOGICAL/ TOPICAL AGENTS

Acne/Psoriasis, Topical BENZOYL PEROXIDE 5%, 10% BENZAC® Gel, Wash, Lotion

COAL TAR Solution

Anesthetic Agents, Topical BENZOCAINE HURRICAINE® Gel

PRAMOXINE ANUSOL® Ointment

Antifungals, Topical

CLOTRIMAZOLE 1% LOTRIMIN® Cream, Solution

MICONAZOLE 2% MICATIN®, DESENEX® Cream, Powder

Anti-Infectives, Topical BACITRACIN BACIGUENT® Ointment

BACITRACIN, POLYMIXIN B POLYSPORIN® Ointment

BACITRACIN, NEOMYCIN, POLYMYXIN B NEOSPORIN® Ointment

OATMEAL, COLLOIDAL AVEENO® BATH POWDER Powder

Anti-Itch, Topical CALAMINE CALAMINE Lotion

CAMPHOR/ MENTHOL SARNA® Lotion

CAPSAICIN ZOSTRIX®, ZOSTRIX-HP® Cream

Anti-Virals, Topical DOCOSANOL 10% ABREVA® Cream

Corticosteroids, Topical, Low Potency HYDROCORTISONE 0.5%, 1% CORTIZONE® Cream, Oint,

Lotion

Keratolytics SALICYLIC ACID 17% DUOFILM® Liquid

SALICYLIC ACID 40% MEDIPLAST® Plaster

UREA 10%, 20% UREACIN®, CARMOL® 20 Cream, Lotion

Dermatologics, Miscellaneous ALUMINUM ACETATE BUROWS® Liquid

AMMONIUM LACTATE 12% AMLACTIN® Cream, Lotion

HYDROGEN PEROXIDE HYDROGEN PEROXIDE Liquid

VITAMIN A&D A AND D® OINTMENT Ointment

WITCH HAZEL TUCKS® Solution, Pads

ZINC OXIDE, COD LIVER OIL & LANOLIN DESITIN® Oint, Paste

ZINC OXIDE 20% BALMEX® Ointment

Scabicides PERMETHRIN NIX® Rinse

PYRETHRINS, PIPERONYL BUTOXIDE RID®, R & C® Shampoo

Skin Protectants LANOLIN, HYDROUS LANOLIN Ointment

PETROLATUM, GLYCERIN,BENZYL ALC MOISTUREL® Lotion

PETROLATUM, MINERAL OIL/WAX, ETC. AQUAPHOR®, EUCERIN® Ointment

EYE, EAR, NOSE AND THROAT

Otics CARBAMIDE DEBROX® Solution

Nasal Agents CROMOLYN NASALCROM® Spray

Ophthalmics ARTIFICIAL TEARS HYOPTEARS®, PURALUBE® Drops, Ointment

CARBOXYMETHYLCELLULOSE CELLUVISC®, REFRESH PLUS® Drops

HYDROXYPROPYL METHYLCELLULOSE TEARS NATURALE II® Drops

KETOTIFEN FUMARATE 0.025% ZADITOR® Drops

NAPHAZOLINE/ PHENIRAMINE OPCON-A® Drops

POLYVINYL ALCOHOL, POVIDONE REFRESH® PF Drops

SODIUM CHLORIDE 5% MURO®-128 Drops, Ointment

Throat and Mouth Agents

CETYLPYRIDINIUM CL, BENZYL ALCOHOL CEPACOL® Lozenge

GASTROINTESTINAL AGENTS

Antacids/Adsorbents CHARCOAL, ACTIVATED W/O SORBITOL ACTIDOSE Liquid

ALUMINUM/ MAGNESIUM MAALOX® Tablet, Liquid

ALUMINUM/ MAGNESIUM/ SIMETHICONE MINTOX® PLUS, MI-ACID Tablet, Liquid

ALUM/ MAGN/TRISILIS/ALG AC/SOD BICAR GAVISCON®, GENATON Tablet

ALUMINUM HYDROXIDE ALTERNAGEL®, AMPHOGEL® Liquid

MAGNESIUM OXIDE MAG-OX® Tablet

Antidiarrheals BISMUTH SUBSALICYLATE PEPTO BISMOL® Tablet, Liquid

LOPERAMIDE IMMODIUM® Tablet, Liquid

Antinauseants DIMENHYDRINATE DRAMAMINE® Tablet, Liquid

MECLIZINE BONINE®, ANTIVERT® Tablet

Laxatives/Cathartics BISACODYL DULCOLAX® Tablet, Supp

DOCUSATE SODIUM COLACE® Tablet, Liquid

GLYCERIN GLYCERIN Liquid, Supp

MAGNESIUM CITRATE CITRO-MAG® Liquid

MILK OF MAGNESIA MILK OF MAGNESIA Liquid

MINERAL OIL FLEET® MINERAL OIL Liquid

PSYLLIUM METAMUCIL® Powder

POLYETHYLENE GLYCOL MIRALAX® Powder

SENNA SENOKOT® Tablet, Liquid

Histamine H2 Blockers RANITIDINE ZANTAC® Tablet

Gastrointestinal, Miscellaneous SIMETHICONE MYLICON® Tablet

LACTOBACILLUS BACID® Capsule

SHARK LIVER OIL, COCOA BUTTER, PHENYLEPHRINE

HEMORRHOIDAL SUPPOSITORIES

Supp

Proton Pump Inhibitors OMEPRAZOLE PRILOSEC OTC Tablet

GENITOURINARY

Overactive bladder treatment OXYBUTYNIN OXYTROL® PATCH Patch

HORMONES

Contraceptive LEVONORGESTROL PLAN B ONE STEP Tablet

LIPID LOWERING AGENTS

Non-Prescription Agents NIACIN NIACIN Tablet

NIACIN EXTENDED-RELEASE SLO-NIACIN® Tablet

FISH OILS SEA-OMEGA®-50 Capsule

NUTRITIONALS AND SUPPLEMENTS

Vitamins/Dietary Supplements ACETYLCYSTEINE NAC® Capsule

ASCORBIC ACID (VIT C) Tablet

CYANOCOBALAMIN (VIT B12) Tablet

CHOLECALCIFEROL (VIT D) Tablet

FOLIC ACID Tablet

NIACINAMIDE (VIT B3) Tablet

PRENATAL VITAMINS W/ FOLIC ACID Tablet

PYRIDOXINE (VIT B6) Tablet

THIAMINE (VIT B1) Tablet

VITAMIN A Capsule

VITAMIN B COMPLEX Tablet

VITAMIN B COMPLEX W/C Tablet

VITAMIN E Capsule

Electrolytes, Iron, & Minerals CALCIUM CARBONATE TUMS® Chew tabs, Liquid

CALCIUM CITRATE CAL-CITRATE® Tablet

CALCIUM CITRATE w/VITAMIN D CITRACAL® Tablet

ELECTROLYTE ORAL PEDIALYTE® Liquid

FERROUS GLUCONATE FERGON® Tablet

FERROUS SULFATE FER-IN-SOL® Tablet, Liquid

MAGNESIUM OXIDE URO-MAG® Capsule

SODIUM BICARBONATE Tablet

ZINC SULFATE ZINCATE® Capsule

VAGINAL PREPARATIONS

Vaginal Anti-Infectives POVIDONE-IODINE BETADINE® Douche

Vaginal Antifungals CLOTRIMAZOLE MYCELEX®-7, GYNE-LOTRIMIN®-

3 Cream, Vag tabs

MICONAZOLE MONISTAT® Cream

Miscellaneous LUBRICATING JELLY K-Y JELLY® JELLY

Kaiser Permanente Nondiscrimination Notice and Language Access Services

KAISER PERMANENTE NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:

Provide free aids and services to people with disabilities to help ensure effective communication, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)

Provide free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Kaiser Permanente.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.

Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636

TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711

Electronically: kp.org/wa/feedback

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)

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

For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines

http://www.hhs.gov/ocr/office/file/index.html

LANGUAGE ACCESS SERVICES

English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、お電話にてご連絡ください。

አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد

XB0001444-56-18

20 Drug Formulary - Kaiser Permanente€¦ · Over-the-Counter (OTC) Drugs A few plans offer...

Documents

Transcript of 20 Drug Formulary - Kaiser Permanente€¦ · Over-the-Counter (OTC) Drugs A few plans offer...