Analgesic Anti-inflammatory or Antipyretic

Analgesic Anti-inflammatory or

Antipyretic(blank)

flurbiprofen 100 mg tablet N 1 90 30flurbiprofen 50 mg tablet N 1 90 30

ibuprofen 100 mg chewable tablet N 1 60 30ibuprofen 100 mg tablet N 1 60 30ibuprofen 100 mg/5 mL oral suspension N 1 60 30

ibuprofen 200 mg capsule N 1 60 30ibuprofen 200 mg tablet N 1 60 30ibuprofen 400 mg tablet N 1 60 30

ibuprofen 50 mg/1.25 mL oral drops suspension N 1 60 30

ibuprofen 600 mg tablet N 1 60 30ibuprofen 800 mg tablet N 1 60 30naproxen 125 mg/5 mL oral suspension N 1 1 30

naproxen 250 mg tablet N 1 60 30naproxen 375 mg tablet N 1 60 30naproxen 500 mg tablet N 1 60 30

naproxen sodium 220 mg capsule N 1 60 30naproxen sodium 220 mg tablet N 1 60 30naproxen sodium 275 mg tablet N 1 60 30

naproxen sodium 550 mg tablet N 1 60 30

Anorectal PreparationsAnorectal - Glucocorticoids

hydrocortisone 1 % topical cream with perineal

applicator N1 90 30

hydrocortisone 2.5 % topical cream with perineal

applicator N1 90 30

Anti-Infective AgentsAntifungals

fluconazole 10 mg/mL oral suspension N 1 30 30fluconazole 100 mg tablet N 1 30 30fluconazole 150 mg tablet N 1 30 30fluconazole 200 mg tablet N 1 30 30

fluconazole 40 mg/mL oral suspension N 1 30 30

fluconazole 50 mg tablet N 1 30 30griseofulvin microsize 125 mg/5 mL oral suspension N 1 30 30griseofulvin microsize 500 mg tablet N 1 30 30griseofulvin ultramicrosize 125 mg tablet N 1 30 30griseofulvin ultramicrosize 250 mg tablet N 1 30 30

nystatin 150 million unit oral powder N 1 480 30nystatin 500 000 unit tablet N 1 480 30nystatin 500 million unit oral powder N 1 480 30

MSN Formulary P/A Tier Quantity Days Supply

page 1 of 30


Antiparasitics

Atovaquone 750 Mg/5ML Oral Susp N 1 30 30hydroxychloroquine 200 mg tablet N 1 60 30

Primaquine 26.3 Mg Tablet N 1 14 30

Antiprotozoal-Antibacterial Agents

metronidazole 250 mg tablet N 1 56 14metronidazole 375 mg capsule N 1 56 14metronidazole 500 mg tablet N 1 56 14

Antitubercular Agents

Cycloserine 250 Mg Capsule N 1 120 30Dapsone 100 Mg Tablet N 1 30 30Dapsone 25 Mg Tablet N 1 120 30ethambutol 100 mg tablet N 1 30 30

ethambutol 400 mg tablet N 1 30 30

isoniazid 100 mg tablet N 1 30 30isoniazid 300 mg tablet N 1 30 30pyrazinamide 500 mg tablet N 1 30 30

Rifabutin 150 Mg Capsule N 1 60 30Rifamate 300-150 Mg Capsule N 1 60 30rifampin 150 mg capsule N 1 30 30

rifampin 300 mg capsule N 1 30 30Rifampin 600 Mg Vial N 1 30 30Rifater 120-50-300 Tablet N 1 180 30

Trecator 250 Mg Tablet N 1 120 30

Cephalosporin Antibiotics

cefaclor 125 mg/5 mL oral suspension N 1 42 14cefaclor 250 mg capsule N 1 42 14

cefaclor 375 mg/5 mL oral suspension N 1 42 14cefaclor 500 mg capsule N 1 42 14Cefadroxil 1 G Tablet N 1 14 30

Cefadroxil 250 Mg/5ML Susp Recon N 1 1 30

Cefadroxil 500 Mg Capsule N 1 14 30

Cefadroxil 500 Mg/5ML Susp Recon N 1 1 30Cefdinir 125 Mg/5ML Susp Recon N 1 1 30Cefdinir 250 Mg/5ML Susp Recon N 1 1 30

Cefdinir 300 Mg Capsule N 1 28 30

cefixime 100 mg/5 mL oral suspension N 1 14 14cefixime 200 mg/5 mL oral suspension N 1 14 14Ceftin 125 Mg/5ML Susp Recon N 3 1 30Ceftin 250 Mg/5ML Susp Recon N 3 1 30Cefuroxime 250 Mg Tablet N 1 20 30Cefuroxime 500 Mg Tablet N 1 40 30

Cefuroxime Sodium 1.5 G Vial N 1 30 30Cefuroxime Sodium 7.5 G Vial N 1 1 30

Cefuroxime Sodium 750 Mg Vial N 1 30 30

page 2 of 30


cephalexin 250 mg capsule N 1 56 14cephalexin 500 mg capsule N 1 56 14cephalexin 750 mg capsule N 1 56 14

Fluoroquinolone Antibiotics and Combinations

ciprofloxacin 250 mg tablet N 1 28 14

ciprofloxacin 500 mg tablet N 1 28 14ciprofloxacin 750 mg tablet N 1 28 14ofloxacin 300 mg tablet N 1 3 30

Folate Antagonist Antibiotics

sulfamethoxazole 200 mg-trimethoprim 40 mg/5 mL

oral suspension N1 56 14

sulfamethoxazole 400 mg-trimethoprim 80 mg tablet N 1 56 14

sulfamethoxazole 800 mg-trimethoprim 160 mg tablet N1 56 14

trimethoprim 100 mg tablet N 1 42 14Glycopeptide Antibiotics

Vancomycin Hcl 10 G Vial N 1 1 30

Vancomycin Hcl 125 Mg Capsule N 1 120 30Vancomycin Hcl 5 G Vial N 1 1 30Vancomycin Hcl 750 Mg Vial N 1 1 30

Hepatitis C antivirals

Daklinza 30 Mg Tablet N 4 30 30Daklinza 60 Mg Tablet N 4 30 30

Daklinza 90 Mg Tablet N 4 30 30

Epclusa 400-100 Mg Tablet N 4 30 30

Harvoni 90-400 MG Tablet N 3 30 30Incivek 375 Mg Tablet N 4 30 30

Incivek 376 Mg Tablet N 4 30 30Mavyret 100-40 Mg Tablet N 4 30 30Olysio 150 Mg Capsule N 4 30 30

Pegasys 180 Mcg/0.5ML Syringe N 4 4 30

Pegasys 180 Mcg/ML Vial N 4 4 30

Ribavirin 200 Mg Capsule N 4 180 30Ribavirin 200 Mg Tablet N 4 180 30Ribavirin 400 Mg Tablet N 4 90 30

Ribavirin 600 Mg Tablet N 4 60 30

SovaldiÂ 400 Mg Tablet N 3 30 30Technivie 12.5-75-50 Mg Tablet N 4 30 30Viekira Pak 12.5-75-50 &250 Mg Tab Pak N 3 4 30Vosevi 400-100-100 Mg Tablet N 4 30 30Zepatier 50-100 Mg Tablet N 4 30 30

Herpes Antiviral Agents

acyclovir 200 mg capsule N 1 90 30acyclovir 200 mg/5 mL oral suspension N 1 90 30

acyclovir 400 mg tablet N 1 90 30

page 3 of 30


acyclovir 800 mg tablet N 1 90 30Valacyclovir Hcl 1000 Mg Tablet N 1 60 30Valacyclovir Hcl 500 Mg Tablet N 1 60 30

Influenza Antiviral Agents

Oseltamivir Phosphate 30 Mg Capsule N 1 10 30

Oseltamivir Phosphate 45 Mg Capsule N 1 10 30Oseltamivir Phosphate 75 Mg Capsule N 1 10 30Tamiflu 6 Mg/ML Susp Recon N 3 1 30

Lincosamide Antibiotics

clindamycin 150 mg capsule N 1 120 30clindamycin 300 mg capsule N 1 120 30

Macrolide Antibiotics and Combinations

azithromycin 250 mg tablet N 1 6 5

azithromycin 500 mg tablet N 1 6 5

azithromycin 600 mg tablet N 1 6 5clarithromycin 125 mg/5 mL oral suspension N 1 1 30clarithromycin 250 mg tablet N 1 28 30

clarithromycin 250 mg/5 mL oral suspension N 1 1 30clarithromycin 500 mg tablet N 1 28 30

Penicillin Antibiotics

amoxicillin 125 mg/5 mL oral suspension N 1 56 14amoxicillin 200 mg/5 mL oral suspension N 1 56 14amoxicillin 250 mg capsule N 1 56 14

amoxicillin 250 mg/5 mL oral suspension N 1 56 14

amoxicillin 250 mg-potassium clavulanate 125 mg

tablet N1 28 14

amoxicillin 400 mg/5 mL oral suspension N 1 56 14

amoxicillin 500 mg capsule N 1 56 14amoxicillin 500 mg tablet N 1 56 14amoxicillin 500 mg-potassium clavulanate 125 mg

tablet N1 28 14

amoxicillin 875 mg tablet N 1 56 14

amoxicillin 875 mg-potassium clavulanate 125 mg

tablet N1 28 14

ampicillin 250 mg capsule N 1 56 14

ampicillin 500 mg capsule N 1 56 14

Bicillin L-A 1.2Mm/2 ML Syringe N 3 2 30Bicillin L-A 2.4Mm/4ML Syringe N 3 2 30dicloxacillin 250 mg capsule N 1 56 14dicloxacillin 500 mg capsule N 1 56 14Penicillin G Potassium 20Mm Unit Vial N 4 14 30Penicillin G Procaine 600000/ML Syringe N 4 14 30

Penicillin G Sodium 5Mm Unit Vial N 4 14 30penicillin V potassium 125 mg/5 mL oral solution N 1 56 14

penicillin V potassium 250 mg tablet N 1 56 14

page 4 of 30


penicillin V potassium 250 mg/5 mL oral solution N 1 56 14penicillin V potassium 500 mg tablet N 1 56 14

Tetracycline Antibiotics and Combinations

doxycycline hyclate 100 mg tablet N 2 28 14


doxycycline hyclate 75 mg tablet N 2 28 14doxycycline monohydrate 100 mg capsule N 1 28 14doxycycline monohydrate 100 mg tablet N 1 28 14

doxycycline monohydrate 150 mg capsule N 1 28 14doxycycline monohydrate 150 mg tablet N 1 28 14doxycycline monohydrate 50 mg capsule N 1 28 14doxycycline monohydrate 50 mg tablet N 1 28 14doxycycline monohydrate 75 mg capsule N 1 28 14

doxycycline monohydrate 75 mg tablet N 1 28 14

Minocycline Hcl 100 Mg Capsule N 1 60 30Minocycline Hcl 50 Mg Capsule N 1 60 30Minocycline Hcl 75 Mg Capsule N 1 60 30

AntineoplasticsAlkylating Agents

busulfan 60 mg/10 mL intravenous solution Y 4 2 15

cyclophosphamide 1 gram intravenous solution Y 4 2 15

cyclophosphamide 2 gram intravenous solution Y 4 2 15

cyclophosphamide 500 mg intravenous solution Y 4 2 15dacarbazine 200 mg intravenous solution Y 4 2 15temozolomide 100 mg capsule Y 4 45 15

temozolomide 140 mg capsule Y 4 45 15temozolomide 180 mg capsule Y 4 45 15temozolomide 20 mg capsule Y 4 45 15

temozolomide 250 mg capsule Y 4 45 15temozolomide 5 mg capsule Y 4 45 15

Antimetabolites

azacitidine 100 mg solution for injection Y 4 2 15

capecitabine 150 mg tablet Y 4 15 15capecitabine 500 mg tablet Y 4 15 15cladribine 10 mg/10 mL intravenous solution Y 4 2 15clofarabine 20 mg/20 mL intravenous solution Y 4 2 15decitabine 50 mg intravenous solution Y 4 2 15

fludarabine 50 mg intravenous solution Y 4 2 15fludarabine 50 mg/2 mL intravenous solution Y 4 2 15fluorouracil 1 gram/20 mL intravenous solution Y 4 2 15fluorouracil 2.5 gram/50 mL intravenous solution Y 4 2 15

fluorouracil 5 gram/100 mL intravenous solution Y 4 2 15

fluorouracil 500 mg/10 mL intravenous solution Y 4 2 15gemcitabine 1 gram intravenous solution Y 4 2 15

page 5 of 30


gemcitabine 1 gram/26.3 mL (38 mg/mL) intravenous

solution Y4 2 15

gemcitabine 2 gram intravenous solution Y 4 2 15

gemcitabine 2 gram/52.6 mL (38 mg/mL) intravenous

solution Y4 2 15

gemcitabine 200 mg intravenous solution Y 4 2 15gemcitabine 200 mg/5.26 mL (38 mg/mL) intravenous

solution Y4 2 15

mercaptopurine 50 mg tablet N 4 15 15methotrexate sodium 2.5 mg tablet N 4 15 15methotrexate sodium 25 mg/mL injection solution N 4 2 15

Chemotherapy Rescue-Antidote Agents

amifostine crystalline 500 mg intravenous solution N 4 2 15

dexrazoxane HCl 250 mg intravenous solution N 4 2 15

dexrazoxane HCl 500 mg intravenous solution N 4 2 15leucovorin calcium 100 mg solution for injection N 4 2 15leucovorin calcium 200 mg solution for injection N 4 2 15

leucovorin calcium 25 mg tablet N 4 15 15leucovorin calcium 350 mg solution for injection N 4 2 15leucovorin calcium 5 mg tablet N 4 15 15

leucovorin calcium 50 mg solution for injection N 4 2 15

levoleucovorin 50 mg intravenous powder for solution N4 2 15

mesna 100 mg/mL intravenous solution N 4 2 15

(blank)

anastrozole 1 mg tablet Y 4 15 15bexarotene 75 mg capsule Y 4 45 15

bleomycin 15 unit solution for injection Y 4 2 15bleomycin 30 unit solution for injection Y 4 2 15carboplatin 10 mg/mL intravenous solution Y 4 2 15

daunorubicin 20 mg intravenous solution Y 4 2 15

daunorubicin 5 mg/mL intravenous solution Y 4 2 15

docetaxel 10 mg/mL intravenous solution Y 4 2 15docetaxel 160 mg/8 mL (20 mg/mL) intravenous

solution Y4 2 15

docetaxel 20 mg/mL intravenous solution Y 4 2 15

doxorubicin 10 mg intravenous solution Y 4 2 15doxorubicin 10 mg/5 mL intravenous solution Y 4 2 15doxorubicin 2 mg/mL intravenous solution Y 4 2 15doxorubicin 20 mg/10 mL intravenous solution Y 4 2 15doxorubicin 50 mg intravenous solution Y 4 2 15doxorubicin 50 mg/25 mL intravenous solution Y 4 2 15

epirubicin 200 mg/100 mL intravenous solution Y 4 2 15epirubicin 50 mg/25 mL intravenous solution Y 4 2 15

etoposide 20 mg/mL intravenous solution Y 4 2 15

page 6 of 30


exemestane 25 mg tablet N 4 15 15idarubicin 1 mg/mL intravenous solution Y 4 2 15irinotecan 100 mg/5 mL intravenous solution Y 4 2 15

irinotecan 40 mg/2 mL intravenous solution Y 4 2 15

letrozole 2.5 mg tablet Y 4 15 15

leuprolide 1 mg/0.2 mL subcutaneous kit N 4 1 15megestrol 20 mg tablet Y 4 1 30megestrol 40 mg tablet Y 4 1 30

mitomycin 20 mg intravenous solution Y 4 2 15mitomycin 40 mg intravenous solution Y 4 2 15mitoxantrone 2 mg/mL concentrate intravenous Y 4 2 15oxaliplatin 100 mg intravenous solution Y 4 2 15oxaliplatin 100 mg/20 mL intravenous solution Y 4 2 15

oxaliplatin 50 mg intravenous solution Y 4 2 15

oxaliplatin 50 mg/10 mL (5 mg/mL) intravenous

solution Y4 2 15

tamoxifen 10 mg tablet Y 4 15 15

tamoxifen 20 mg tablet Y 4 15 15topotecan 4 mg intravenous solution Y 4 2 15

topotecan 4 mg/4 mL (1 mg/mL) intravenous solution Y4 2 15

tretinoin (chemotherapy) 10 mg capsule Y 4 45 15vincristine 1 mg/mL intravenous solution Y 4 2 15

vincristine 2 mg/2 mL intravenous solution Y 4 2 15

vinorelbine 10 mg/mL intravenous solution Y 4 2 15

vinorelbine 50 mg/5 mL intravenous solution Y 4 2 15Xofigo 1 100 kBq/mL(30microcurie/mL) intravenous

solution Y4 2 15

Cardiovascular Therapy AgentsAngina Therapy

isosorbide dinitrate 10 mg tablet N 1 120 30isosorbide dinitrate 20 mg tablet N 1 120 30

isosorbide dinitrate 5 mg tablet N 1 120 30Isosorbide Mononitrate 10 Mg Tablet N 1 60 30Isosorbide Mononitrate 120 Mg Tab ER 24H N 1 30 30Isosorbide Mononitrate 20 Mg Tablet N 1 60 30Isosorbide Mononitrate 30 Mg Tab ER 24H N 1 30 30

Isosorbide Mononitrate 60 Mg Tab ER 24H N 1 30 30nitroglycerin 0.3 mg sublingual tablet N 1 100 30nitroglycerin 0.4 mg sublingual tablet N 1 100 30nitroglycerin 0.6 mg sublingual tablet N 1 100 30

Antiarrhythmics

amiodarone 100 mg tablet N 1 30 30amiodarone 200 mg tablet N 1 30 30

page 7 of 30


amiodarone 400 mg tablet N 1 30 30disopyramide phosphate 100 mg capsule N 1 120 30disopyramide phosphate 150 mg capsule N 1 120 30

flecainide 100 mg tablet N 1 30 30

flecainide 150 mg tablet N 1 30 30

flecainide 50 mg tablet N 1 30 30Mexiletine Hcl 150 Mg Capsule N 1 90 30Mexiletine Hcl 200 Mg Capsule N 1 90 30

Mexiletine Hcl 250 Mg Capsule N 1 90 30

quinidine gluconate ER 324 mg tablet extended release N1 90 30

sotalol 120 mg tablet N 1 30 30sotalol 160 mg tablet N 1 30 30

sotalol 240 mg tablet N 1 30 30

sotalol 80 mg tablet N 1 30 30Sotalol AF 120 mg tablet N 1 30 30Sotalol AF 160 mg tablet N 1 30 30

Sotalol AF 80 mg tablet N 1 30 30Antihyperlipidemics

Atorvastatin Calcium 10 Mg Tablet N 1 30 30

Atorvastatin Calcium 20 Mg Tablet N 1 30 30Atorvastatin Calcium 40 Mg Tablet N 1 30 30Atorvastatin Calcium 80 Mg Tablet N 1 30 30

Cholestyramine 4 G Powd Pack N 1 30 30

Cholestyramine Light 4 G Powd Pack N 1 30 30

Colestipol Hcl 1 G Tablet N 1 60 30Colestipol Hcl 5 G Packet N 1 30 30

Fenofibrate 120 Mg Tablet N 1 30 30Fenofibrate 130 Mg Capsule N 1 30 30Fenofibrate 134 Mg Capsule N 1 30 30

Fenofibrate 145Mg Tablet N 1 30 30

Fenofibrate 150 Mg Capsule N 1 30 30

Fenofibrate 160 Mg Tablet N 1 30 30Fenofibrate 200 Mg Capsule N 1 30 30Fenofibrate 40 Mg Tablet N 1 30 30

Fenofibrate 43 Mg Capsule N 1 30 30

Fenofibrate 48 Mg Tablet N 1 30 30Fenofibrate 50 Mg Capsule N 1 30 30Fenofibrate 54 Mg Tablet N 1 30 30Fenofibrate 67 Mg Capsule N 1 30 30Fenofibric Acid 105 Mg Tablet N 1 30 30Fenofibric Acid 135 Mg Capsule DR N 1 30 30

Fenofibric Acid 35 Mg Tablet N 1 30 30Fenofibric Acid 45 Mg Capsule DR N 1 30 30

gemfibrozil 600 mg tablet N 1 90 30

page 8 of 30


lovastatin 10 mg tablet N 1 30 30lovastatin 20 mg tablet N 1 30 30lovastatin 40 mg tablet N 1 30 30

Niacin 1000 Mg Tablet ER N 1 30 30

Niacin 250 Mg Capsule ER N 1 30 30

Niacin 250 Mg Tablet N 1 30 30Niacin 250 Mg Tablet ER N 1 30 30Niacin 50 Mg Tablet N 1 30 30

Niacin 500 Mg Capsule ER N 1 30 30Niacin 500 Mg Tablet N 1 30 30Niacin 500 Mg Tablet ER N 1 30 30Niacin 750 Mg Tablet ER N 1 30 30Niacin ER 1000 Mg Tab ER 24H N 1 30 30

Niacin ER 500 Mg Tab ER 24H N 1 30 30

Niacin ER 750 Mg Tab ER 24H N 1 30 30Niacin Flush Free 400(500Mg) Capsule N 1 30 30Niacin Flush-Free 400(500Mg) Capsule N 1 30 30

Niacin Inositol 400(500Mg) Capsule N 1 30 30Pravastatin Sodium 10 Mg Tablet N 1 30 30Pravastatin Sodium 20 Mg Tablet N 1 30 30

Pravastatin Sodium 40 Mg Tablet N 1 30 30Pravastatin Sodium 80 Mg Tablet N 1 30 30Rosuvastatin Calcium 10 Mg Tablet N 1 30 30

Rosuvastatin Calcium 20 Mg Tablet N 1 30 30

Rosuvastatin Calcium 40 Mg Tablet N 1 30 30

Rosuvastatin Calcium 5 Mg Tablet N 1 30 30simvastatin 10 mg tablet N 1 30 30

simvastatin 20 mg tablet N 1 30 30simvastatin 40 mg tablet N 1 30 30simvastatin 5 mg tablet N 1 30 30

simvastatin 80 mg tablet N 1 30 30

Welchol 3.75 G Powd Pack N 3 30 30

Welchol 625 Mg Tablet N 3 180 30Antihypertensive Therapy Combinations

atenolol 100 mg-chlorthalidone 25 mg tablet N 1 30 30

atenolol 50 mg-chlorthalidone 25 mg tablet N 1 30 30

Bisoprolol Fumarate 10 Mg Tablet N 1 30 30Bisoprolol Fumarate 5 Mg Tablet N 1 30 30Bisoprolol-Hydrochlorothiazide 10-6.25Mg Tablet N 1 30 30Bisoprolol-Hydrochlorothiazide 2.5-6.25Mg Tablet N 1 30 30Bisoprolol-Hydrochlorothiazide 5-6.25Mg Tablet N 1 30 30Captopril-Hydrochlorothiazide 25 Mg-15Mg Tablet N 1 30 30

Captopril-Hydrochlorothiazide 25 Mg-25Mg Tablet N 1 30 30Captopril-Hydrochlorothiazide 50 Mg-15Mg Tablet N 1 30 30

Captopril-Hydrochlorothiazide 50 Mg-25Mg Tablet N 1 30 30

page 9 of 30


Enalapril-Hydrochlorothiazide 10 Mg-25Mg Tablet N 1 30 30Enalapril-Hydrochlorothiazide 5Mg-12.5Mg Tablet N 1 30 30Irbesartan/Hydrochlorothiazide 150-12.5Mg Tablet N 1 30 30

Irbesartan/Hydrochlorothiazide 300-12.5Mg Tablet N 1 30 30

Propranolol/Hydrochlorothiazid 40 Mg-25Mg Tablet N 1 30 30

Propranolol/Hydrochlorothiazid 80 Mg-25Mg Tablet N 1 30 30Quinapril/Hydrochlorothiazide 10-12.5Mg Tablet N 1 30 30Quinapril/Hydrochlorothiazide 20 Mg-25Mg N 1 30 30

Quinapril/Hydrochlorothiazide 20-12.5 Mg N 1 30 30Beta Adrenergic Blockers

Acebutolol Hcl 200 Mg Capsule N 1 30 30Acebutolol Hcl 400 Mg Capsule N 1 30 30atenolol 100 mg tablet N 1 60 30

atenolol 25 mg tablet N 1 60 30

atenolol 50 mg tablet N 1 60 30Carvedilol 12.5 Mg Tablet N 1 60 30Carvedilol 25 Mg Tablet N 1 60 30

Carvedilol 3.125 Mg Tablet N 1 60 30Carvedilol 6.25 Mg Tablet N 1 60 30Labetalol HCl 100 Mg Tablet N 1 60 30

Labetalol HCl 200 Mg Tablet N 1 60 30Labetalol HCl 300 Mg Tablet N 1 60 30metoprolol succinate ER 100 mg tablet extended

release 24 hr N1 60 30

metoprolol succinate ER 200 mg tablet extended

release 24 hr N1 60 30

metoprolol succinate ER 25 mg tablet extended release

24 hr N1 60 30

metoprolol succinate ER 50 mg tablet extended release

24 hr N1 60 30

metoprolol tartrate 100 mg tablet N 1 90 30

metoprolol tartrate 25 mg tablet N 1 90 30

metoprolol tartrate 37.5 mg tablet N 1 90 30metoprolol tartrate 50 mg tablet N 1 90 30metoprolol tartrate 75 mg tablet N 1 90 30

Nebivolol Hcl 10 Mg Tablet N 1 30 30

Nebivolol Hcl 2.5 Mg Tablet N 1 30 30Nebivolol Hcl 20 Mg Tablet N 1 30 30Nebivolol Hcl 5 Mg Tablet N 1 30 30Pindolol 10 Mg Tablet N 1 30 30Pindolol 5 Mg Tablet N 1 30 30propranolol 10 mg tablet N 1 120 30

propranolol 20 mg tablet N 1 120 30propranolol 40 mg tablet N 1 120 30

propranolol 60 mg tablet N 1 120 30

page 10 of 30


propranolol 80 mg tablet N 1 120 30Calcium Channel Blockers and Combinations

amlodipine 10 mg tablet N 1 30 30

amlodipine 2.5 mg tablet N 1 30 30

amlodipine 5 mg tablet N 1 30 30

diltiazem 120 mg tablet N 1 90 30diltiazem 30 mg tablet N 1 90 30diltiazem 60 mg tablet N 1 90 30

diltiazem 90 mg tablet N 1 90 30diltiazem ER 120 mg capsule extended release N 1 30 30diltiazem ER 120 mg capsule extended release 12 hr N 1 30 30diltiazem ER 180 mg capsule extended release N 1 30 30diltiazem ER 180 mg tablet extended release 24 hr N 1 30 30

diltiazem ER 240 mg capsule extended release N 1 30 30

diltiazem ER 240 mg tablet extended release 24 hr N 1 30 30diltiazem ER 300 mg capsule extended release N 1 30 30diltiazem ER 300 mg tablet extended release 24 hr N 1 30 30

diltiazem ER 360 mg capsule extended release N 1 30 30diltiazem ER 360 mg tablet extended release 24 hr N 1 30 30diltiazem ER 420 mg capsule extended release N 1 30 30

diltiazem ER 420 mg tablet extended release 24 hr N 1 30 30diltiazem ER 60 mg capsule extended release 12 hr N 1 30 30diltiazem ER 90 mg capsule extended release 12 hr N 1 30 30

felodipine ER 10 mg tablet extended release 24 hr N 1 30 30

felodipine ER 2.5 mg tablet extended release 24 hr N 1 30 30

felodipine ER 5 mg tablet extended release 24 hr N 1 30 30Isradipine 2.5 Mg Capsule N 1 60 30

Isradipine 5 Mg Capsule N 1 60 30Nifedipine 10 Mg Capsule N 1 90 30Nifedipine 20 Mg Capsule N 1 90 30

nifedipine ER 30 mg tablet extended release N 1 30 30

nifedipine ER 30 mg tablet extended release 24 hr N 1 30 30

nifedipine ER 60 mg tablet extended release N 1 30 30nifedipine ER 60 mg tablet extended release 24 hr N 1 30 30nifedipine ER 90 mg tablet extended release N 1 30 30

nifedipine ER 90 mg tablet extended release 24 hr N 1 30 30

verapamil 120 mg tablet N 1 90 30verapamil 80 mg tablet N 1 90 30verapamil ER (SR) 120 mg tablet extended release N 1 60 30verapamil ER (SR) 180 mg tablet extended release N 1 60 30verapamil ER (SR) 240 mg tablet extended release N 1 60 30

Cardiac Inotropes

digoxin 125 mcg tablet N 1 30 30digoxin 250 mcg tablet N 1 30 30

Cardiac Sympathomimetics

page 11 of 30


phenylephrine 10 mg/mL injection solution N 1 1 30Central Alpha-2 Receptor Agonists

clonidine HCl 0.1 mg tablet N 1 120 30



Guanfacine Hcl 1 Mg Tablet N 1 30 30Guanfacine Hcl 2 Mg Tablet N 1 30 30Guanfacine Hcl ER 1 Mg Tab ER 24H N 1 30 30

Guanfacine Hcl ER 2 Mg Tab ER 24H N 1 30 30Guanfacine Hcl ER 3 Mg Tab ER 24H N 1 30 30Guanfacine Hcl ER 4 Mg Tab ER 24H N 1 30 30methyldopa 250 mg tablet N 1 90 30methyldopa 500 mg tablet N 1 90 30

Methyldopa-Hydrochlorothiazide 250Mg-15Mg Tablet N1 90 30

Methyldopa-Hydrochlorothiazide 250Mg-25Mg Tablet N1 90 30

Diuretics

Acetazolamide 125 Mg Tablet N 1 120 30acetazolamide 250 mg tablet N 1 90 30

Acetazolamide 500 Mg Capsule ER N 1 60 30Amiloride Hcl 5 Mg Tablet N 1 30 30Amiloride/Hydrochlorothiazide 5 Mg-50 Mg Tablet N 1 30 30

Bumetanide 0.5 Mg Tablet N 1 30 30

Bumetanide 1 Mg Tablet N 1 30 30

Bumetanide 2 Mg Tablet N 1 30 30Chlorthalidone 25 Mg Tablet N 1 30 30

Chlorthalidone 50 Mg Tablet N 1 30 30Eplerenone 25 Mg Tablet N 1 30 30Eplerenone 50 Mg Tablet N 1 30 30

furosemide 10 mg/mL oral solution N 1 60 30

furosemide 20 mg tablet N 1 60 30

furosemide 40 mg tablet N 1 60 30furosemide 80 mg tablet N 1 60 30hydrochlorothiazide 12.5 mg capsule N 1 60 30

hydrochlorothiazide 12.5 mg tablet N 1 60 30

hydrochlorothiazide 25 mg tablet N 1 60 30hydrochlorothiazide 50 mg tablet N 1 60 30Metolazone 10 Mg Tablet N 1 30 30Metolazone 2.5 Mg Tablet N 1 30 30Metolazone 5 Mg Tablet N 1 30 30Spironolact/Hydrochlorothiazide 25 Mg-25Mg Tablet N 1 30 30

spironolactone 100 mg tablet N 1 60 30spironolactone 25 mg tablet N 1 60 30

spironolactone 50 mg tablet N 1 60 30

page 12 of 30


Torsemide 10 Mg Tablet N 1 30 30Torsemide 100 Mg Tablet N 1 30 30Torsemide 20 Mg Tablet N 1 30 30

Torsemide 5 Mg Tablet N 1 30 30

triamterene 37.5 mg-hydrochlorothiazide 25 mg capsule N1 60 30

triamterene 37.5 mg-hydrochlorothiazide 25 mg tablet N1 60 30

triamterene 75 mg-hydrochlorothiazide 50 mg tablet N 1 60 30Peripheral Alpha-1 Receptor Blockers

Alfuzosin HCl ER 10 Mg Tab ER 24H N 1 30 30doxazosin 1 mg tablet N 1 30 30doxazosin 2 mg tablet N 1 30 30

doxazosin 4 mg tablet N 1 30 30

doxazosin 8 mg tablet N 1 30 30prazosin 1 mg capsule N 1 60 30prazosin 2 mg capsule N 1 60 30

prazosin 5 mg capsule N 1 60 30Terazosin HCl 1 Mg Capsule N 1 60 30Terazosin HCl 10 Mg Capsule N 1 60 30

Terazosin HCl 2 Mg Capsule N 1 60 30Terazosin HCl 5 Mg Capsule N 1 60 30Renin-Angiotensin-Aldosterone System (RAAS) Blocking

Agents

Amlodipine Besylate/Valsartan 10Mg-160Mg Tablet N 1 30 30

Amlodipine Besylate/Valsartan 10Mg-320Mg Tablet N 1 30 30Amlodipine Besylate/Valsartan 5 Mg-160Mg Tablet N 1 30 30

Amlodipine Besylate/Valsartan 5 Mg-320Mg Tablet N 1 30 30

Amlodipine Besylate-Benazepril 10 Mg-20Mg Capsule N1 30 30

Amlodipine Besylate-Benazepril 10 Mg-40Mg Capsule N1 30 30

Amlodipine Besylate-Benazepril 2.5Mg-10Mg Capsule N1 30 30

Amlodipine Besylate-Benazepril 5 Mg-10 Mg Capsule N 1 30 30

Amlodipine Besylate-Benazepril 5 Mg-20 Mg Capsule N 1 30 30

Amlodipine Besylate-Benazepril 5 Mg-40 Mg Capsule N 1 30 30benazepril 10 mg tablet N 1 60 30benazepril 10 mg-hydrochlorothiazide 12.5 mg tablet N 1 60 30benazepril 20 mg tablet N 1 60 30benazepril 20 mg-hydrochlorothiazide 12.5 mg tablet N 1 60 30benazepril 20 mg-hydrochlorothiazide 25 mg tablet N 1 60 30

benazepril 40 mg tablet N 1 60 30benazepril 5 mg tablet N 1 60 30

benazepril 5 mg-hydrochlorothiazide 6.25 mg tablet N 1 60 30

page 13 of 30


Captopril 100 Mg Tablet N 1 90 30Captopril 12.5 Mg Tablet N 1 90 30Captopril 25 Mg Tablet N 1 90 30

Captopril 50 Mg Tablet N 1 90 30

enalapril maleate 10 mg tablet N 1 60 30

enalapril maleate 2.5 mg tablet N 1 60 30enalapril maleate 20 mg tablet N 1 60 30enalapril maleate 5 mg tablet N 1 60 30

Fosinopril Sodium 10 Mg Tablet N 1 60 30Fosinopril Sodium 20 Mg Tablet N 1 60 30Fosinopril Sodium 40 Mg Tablet N 1 60 30Fosinopril-Hydrochlorothiazide 10-12.5Mg Tablet N 1 60 30Fosinopril-Hydrochlorothiazide 20-12.5 Mg Tablet N 1 60 30

Irbesartan 150 Mg Tablet N 1 30 30

Irbesartan 300 Mg Tablet N 1 30 30Irbesartan 75 Mg Tablet N 1 30 30lisinopril 10 mg tablet N 1 30 30

lisinopril 10 mg-hydrochlorothiazide 12.5 mg tablet N 1 30 30lisinopril 2.5 mg tablet N 1 30 30lisinopril 20 mg tablet N 1 30 30

lisinopril 20 mg-hydrochlorothiazide 12.5 mg tablet N 1 30 30lisinopril 20 mg-hydrochlorothiazide 25 mg tablet N 1 30 30lisinopril 30 mg tablet N 1 30 30

lisinopril 40 mg tablet N 1 30 30

lisinopril 5 mg tablet N 1 30 30

losartan 100 mg tablet N 1 30 30losartan 100 mg-hydrochlorothiazide 12.5 mg tablet N 1 30 30

losartan 100 mg-hydrochlorothiazide 25 mg tablet N 1 30 30losartan 25 mg tablet N 1 30 30losartan 50 mg tablet N 1 30 30

losartan 50 mg-hydrochlorothiazide 12.5 mg tablet N 1 30 30

Moexipril Hcl 15 Mg Tablet N 1 30 30

Moexipril Hcl 7.5 Mg Tablet N 1 30 30Perindopril Erbumine 2 Mg Tablet N 1 30 30Perindopril Erbumine 4 Mg Tablet N 1 30 30

Perindopril Erbumine 8 Mg Tablet N 1 30 30

Quinapril HCl 10 Mg Tablet N 1 60 30Quinapril HCl 20 Mg Tablet N 1 60 30Quinapril HCl 40 Mg Tablet N 1 60 30Quinapril HCl 5 Mg Tablet N 1 60 30Ramipril 1.25 Mg Capsule N 1 30 30Ramipril 10 Mg Capsule N 1 60 30

Ramipril 2.5 Mg Capsule N 1 30 30Ramipril 5 Mg Capsule N 1 30 30

Telmisartan 20 Mg Tablet N 1 30 30

page 14 of 30


Telmisartan 40 Mg Tablet N 1 30 30Telmisartan 80 Mg Tablet N 1 30 30Telmisartan/Hydrochlorothiazide 40-12.5 Mg Tablet N 1 30 30

Telmisartan/Hydrochlorothiazide 80 Mg-25Mg Tablet N1 30 30

Telmisartan/Hydrochlorothiazide 80-12.5Mg Tablet N 1 30 30Trandolapril 1 Mg Tablet N 1 30 30Trandolapril 2 Mg Tablet N 1 30 30

Trandolapril 4 Mg Tablet N 1 30 30Valsartan 160 Mg Tablet N 1 30 30Valsartan 320 Mg Tablet N 1 30 30Valsartan 40 Mg Tablet N 1 30 30Valsartan 80 Mg Tablet N 1 30 30

Valsartan/Hydrochlorothiazide 160-12.5Mg Tablet N 1 30 30

Valsartan/Hydrochlorothiazide 160-25Mg Tablet N 1 30 30Valsartan/Hydrochlorothiazide 320-12.5Mg Tablet N 1 30 30Valsartan/Hydrochlorothiazide 320Mg-25Mg Tablet N 1 30 30

Valsartan/Hydrochlorothiazide 80-12.5Mg Tablet N 1 30 30Vasodilators

hydralazine 10 mg tablet N 1 120 30

hydralazine 100 mg tablet N 1 120 30hydralazine 25 mg tablet N 1 120 30hydralazine 50 mg tablet N 1 120 30

minoxidil 10 mg tablet N 1 60 30

minoxidil 2.5 mg tablet N 1 60 30

Central Nervous System AgentsAntianxiety Agents

alprazolam 0.25 mg tablet Y 1 30 30

alprazolam 0.5 mg tablet Y 1 30 30alprazolam 1 mg tablet Y 1 30 30alprazolam 2 mg tablet Y 1 30 30buspirone 10 mg tablet Y 1 30 30

buspirone 15 mg tablet Y 1 30 30buspirone 30 mg tablet N 1 30 30buspirone 5 mg tablet Y 1 30 30buspirone 7.5 mg tablet Y 1 30 30lorazepam 0.5 mg tablet Y 1 30 30

lorazepam 1 mg tablet Y 1 30 30lorazepam 2 mg tablet Y 1 30 30lorazepam 2 mg/mL oral concentrate N 3 1 30

Anticonvulsant

carbamazepine 200 mg tablet N 1 90 30

clonazepam 0.125 mg disintegrating tablet Y 1 90 30clonazepam 0.25 mg disintegrating tablet Y 1 90 30

page 15 of 30


clonazepam 0.5 mg disintegrating tablet Y 1 90 30clonazepam 0.5 mg tablet Y 1 90 30clonazepam 1 mg disintegrating tablet Y 1 90 30

clonazepam 1 mg tablet Y 1 90 30

clonazepam 2 mg disintegrating tablet Y 1 90 30

clonazepam 2 mg tablet Y 1 90 30divalproex 125 mg tablet delayed release N 2 60 30divalproex 250 mg tablet delayed release N 2 60 30

divalproex 500 mg tablet delayed release N 2 60 30gabapentin 100 mg capsule N 1 90 30gabapentin 250 mg/5 mL (5 mL) oral solution N 1 90 30gabapentin 250 mg/5 mL oral solution N 1 90 30gabapentin 300 mg capsule N 1 90 30

gabapentin 300 mg/6 mL (6 mL) oral solution N 1 90 30

gabapentin 400 mg capsule N 1 90 30gabapentin 600 mg tablet N 1 90 30gabapentin 800 mg tablet N 1 90 30

lamotrigine 100 mg tablet N 1 60 30lamotrigine 150 mg tablet N 1 60 30lamotrigine 200 mg tablet N 1 60 30

lamotrigine 25 mg tablet N 1 60 30levetiracetam 1 000 mg tablet N 1 30 30levetiracetam 250 mg tablet N 1 30 30

levetiracetam 500 mg tablet N 1 30 30

levetiracetam 750 mg tablet N 1 30 30

phenobarbital 16.2 mg tablet N 1 120 30phenobarbital 32.4 mg tablet N 1 120 30

phenobarbital 64.8 mg tablet N 1 120 30phenobarbital 97.2 mg tablet N 1 120 30phenytoin 100 mg/4 mL oral suspension N 1 480 30

phenytoin 125 mg/5 mL oral suspension N 1 480 30

phenytoin 50 mg chewable tablet N 1 120 30

phenytoin sodium extended 100 mg capsule N 1 120 30phenytoin sodium extended 200 mg capsule N 1 120 30phenytoin sodium extended 300 mg capsule N 1 120 30

topiramate 100 mg tablet N 1 60 30

topiramate 200 mg tablet N 1 60 30topiramate 25 mg tablet N 1 60 30topiramate 50 mg tablet N 1 60 30valproic acid 250 mg capsule N 1 90 30

Antidepressants

amitriptyline 10 mg tablet Y 1 30 30

amitriptyline 100 mg tablet Y 1 30 30amitriptyline 150 mg tablet Y 1 30 30

amitriptyline 25 mg tablet Y 1 30 30

page 16 of 30


amitriptyline 50 mg tablet Y 1 30 30amitriptyline 75 mg tablet Y 1 30 30bupropion HCl 100 mg tablet Y 1 30 30

bupropion HCl 75 mg tablet Y 1 30 30

bupropion HCl SR 100 mg tablet 12 hr sustained-release Y2 30 30

bupropion HCl SR 200 mg tablet 12 hr sustained-release Y2 60 30

bupropion HCl XL 300 mg 24 hr tablet extended release Y3 30 30

citalopram 10 mg tablet Y 1 60 30citalopram 10 mg/5 mL oral solution Y 1 60 30citalopram 20 mg tablet Y 1 60 30

citalopram 40 mg tablet Y 1 60 30

doxepin 10 mg capsule Y 1 30 30doxepin 100 mg capsule Y 1 30 30doxepin 150 mg capsule N 1 30 30

doxepin 25 mg capsule Y 1 30 30doxepin 50 mg capsule Y 1 30 30fluoxetine 10 mg tablet N 1 60 30

fluoxetine 20 mg tablet N 1 60 30fluoxetine 20 mg/5 mL (4 mg/mL) oral solution Y 2 60 30fluoxetine 40 mg capsule N 1 60 30

sertraline 100 mg tablet Y 1 60 30

sertraline 20 mg/mL oral concentrate Y 1 60 30

sertraline 25 mg tablet Y 1 60 30sertraline 50 mg tablet Y 1 60 30

trazodone 100 mg tablet N 1 30 30trazodone 150 mg tablet N 1 30 30trazodone 300 mg tablet Y 1 30 30

trazodone 50 mg tablet N 1 30 30

venlafaxine 100 mg tablet Y 1 60 30

venlafaxine 25 mg tablet Y 1 60 30venlafaxine 37.5 mg tablet Y 1 60 30venlafaxine 50 mg tablet Y 1 60 30

venlafaxine 75 mg tablet Y 1 60 30

venlafaxine ER 150 mg capsule extended release 24 hr Y2 30 30

venlafaxine ER 37.5 mg capsule extended release 24 hr Y2 30 30

venlafaxine ER 75 mg capsule extended release 24 hr Y 2 30 30Antiparkinson Therapy

benztropine 0.5 mg tablet N 1 60 30benztropine 1 mg tablet N 1 60 30

benztropine 2 mg tablet N 1 60 30

page 17 of 30


carbidopa 10 mg-levodopa 100 mg tablet N 1 120 30carbidopa 25 mg-levodopa 100 mg tablet N 1 120 30carbidopa 25 mg-levodopa 250 mg tablet N 1 120 30

trihexyphenidyl 0.4 mg/mL oral elixir N 1 120 30

trihexyphenidyl 2 mg tablet N 1 120 30

trihexyphenidyl 5 mg tablet N 1 120 30Attention Deficit-Hyperact Disorder (ADHD) Therapy

clonidine HCl ER 0.1 mg tablet extended release 12 hr N 1 120 30

Migraine Therapy

sumatriptan 100 mg tablet N 2 12 30sumatriptan 25 mg tablet N 2 12 30sumatriptan 50 mg tablet N 2 12 30sumatriptan 6 mg/0.5 mL subcutaneous solution N 4 2 30

sumatriptan 6 mg/0.5 mL subcutaneous syringe N 4 2 30

Sedative-Hypnotics

lorazepam 2 mg/mL injection solution N 4 1 30lorazepam 2 mg/mL injection syringe N 4 10 30

lorazepam 4 mg/mL injection solution N 4 1 30lorazepam 4 mg/mL injection syringe N 4 10 30

Chemicals-Pharmaceutical Adjuvants(blank)

gemfibrozil (bulk) powder N 1 90 30glyburide (bulk) powder N 1 90 30hydroxychloroquine sulfate (bulk) powder N 1 60 30

prazosin HCl (bulk) powder N 1 60 30prochlorperazine maleate (bulk) powder N 1 100 30sulfacetamide sodium (bulk) powder N 1 1 14

terbutaline sulfate (bulk) powder N 1 90 30

Contraceptives(blank)

medroxyprogesterone 150 mg/mL intramuscular

suspension N4 1 15

medroxyprogesterone 150 mg/mL intramuscular

syringe N4 1 15

DermatologicalDermatological - Anti-infectives

3-Day Vaginal Cream 2 % Cream/Appl N 1 1 30Antifungal Cream 2 % Cream (G) N 1 1 30Bacitracin 500 Unit/G Oint. (G) N 1 1 30

Bacitraycin Plus 500 Unit/G Oint. (G) N 1 1 30Baza Antifungal 2 % Cream (G) N 1 1 30Blis-To-Sol 1 % Solution N 1 1 30

page 18 of 30


Centany 2 % Oint. (G) N 1 1 30Clotrimazole 1 % Cream (G) N 1 1 30Clotrimazole 1 % Solution N 1 1 30

Clotrimazole 10 Mg Troche N 1 1 30

Clotrimazole-Betamethasone 1 %-0.05 % Cream (G) N 1 1 30

Clotrimazole-Betamethasone 1 %-0.05 % Lotion N 1 1 30Inzo Antifungal 2 % Cream (G) N 1 1 30Ketoconazole 2 % Cream (G) N 1 1 30

Ketoconazole 2 % Shampoo N 1 1 30Ketoconazole 200 Mg Tablet N 1 1 30Lice Cream Rinse 1 % Liquid N 1 1 30Lice Treatment 1 % Liquid N 1 1 30Licide 1 %-0.2 % Spray N 1 1 30

Malathion 0.5 % Lotion N 1 1 30

Micatin 2 % Cream (G) N 1 1 30Miranel Af 2 % Cream (G) N 1 1 30Mupirocin 2 % Oint. (G) N 1 1 30

Neosporin 3.5-400-5K Oint. (G) N 1 1 30Nix 1 % Liquid N 1 1 30Nizoral A-D 1 % Shampoo N 1 1 30

nystatin 100 000 unit/gram topical cream N 1 480 30nystatin 100 000 unit/gram topical ointment N 1 480 30nystatin 100 000 unit/gram topical powder N 1 480 30

Permethrin 1 % Liquid N 1 1 30

Permethrin 5 % Cream (G) N 1 1 30

Polysporin 500-10K/G Oint. (G) N 1 1 30Rid 4-.33-.5% Kit N 1 1 30

Selenium Sulfide 2.5 % Lotion N 1 1 30Silver Sulfadiazine 1 % Cream (G) N 1 1 30Spinosad 0.9 % Suspension N 1 1 30

Ssd 1 % Cream (G) N 1 1 30

Sulfadiazine 500 Mg Tablet N 1 1 30

Triple Antibiotic 3.5-400-5K Oint. (G) N 1 1 30

Dermatological - Antineoplastic or Premalignant Lesions

fluorouracil 0.5 % topical cream Y 4 2 15

fluorouracil 2 % topical solution Y 4 2 15fluorouracil 5 % topical cream Y 4 2 15fluorouracil 5 % topical solution Y 4 2 15

Dermatological - Glucocorticoids and Combinations

fluticasone 0.005 % topical ointment N 1 1 30fluticasone 0.05 % lotion N 1 1 30

fluticasone 0.05 % topical cream N 1 1 30hydrocortisone 0.5 % topical cream N 1 90 30

hydrocortisone 0.5 % topical ointment N 1 90 30

page 19 of 30


hydrocortisone 1 % lotion N 1 90 30hydrocortisone 1 % topical cream N 1 90 30hydrocortisone 1 % topical ointment N 1 90 30

hydrocortisone 2.5 % lotion N 1 90 30

hydrocortisone 2.5 % topical cream N 1 90 30

hydrocortisone 2.5 % topical ointment N 1 90 30triamcinolone acetonide 0.025 % topical cream N 1 1 30triamcinolone acetonide 0.1 % topical cream N 1 1 30

triamcinolone acetonide 0.5 % topical cream N 1 1 30Vaginal Anti-infectives

Clotrimazole 1 % Cream/Appl N 1 1 30Clotrimazole-7 1 % Cream/Appl N 1 1 30Miconazole 3 200 Mg Supp.Vag N 1 1 30

Miconazole 7 100 Mg Supp.Vag N 1 1 30

Miconazole 7 2 % Cream/Appl N 1 1 30Miconazole Nitrate 2 % Cream/Appl N 1 1 30Monistat 3 4 % Crm/Pf App N 1 1 30

Monistat 7 2 % Cream/Appl N 1 1 30(blank)

metronidazole 0.75 % topical gel N 1 1 10

metronidazole 1 % topical gel N 1 1 10sulfacetamide sodium 10 % shampoo N 1 1 14sulfacetamide sodium 10 % topical cleanser N 1 1 14

sulfacetamide sodium 10 % topical cleanser gel N 1 1 14

Diagnostic Agents(blank)

True Metrix Glucose Test Strip N 3 100 30Truetest Test Strips N 3 100 30

Electrolyte Balance-Nutritional

Products(blank)

potassium chloride 20 mEq/15 mL oral liquid N 1 480 30potassium chloride 40 mEq/15 mL oral liquid N 1 480 30

potassium chloride ER 10 mEq capsule extended release N1 90 30

potassium chloride ER 10 mEq tablet extended release N1 90 30

potassium chloride ER 10 mEq tablet extended

release(part/cryst) N1 90 30

potassium chloride ER 20 mEq tablet extended release N1 90 30

potassium chloride ER 20 mEq tablet extended

release(part/cryst) N1 90 30

page 20 of 30


potassium chloride ER 8 mEq capsule extended release N1 90 30

potassium chloride ER 8 mEq tablet extended release N 1 90 30

EndocrineCorticosteroids

dexamethasone 0.5 mg tablet N 1 90 30dexamethasone 0.5 mg/5 mL oral elixir N 1 90 30dexamethasone 0.75 mg tablet N 1 90 30dexamethasone 1.5 mg tablet N 1 90 30dexamethasone 4 mg tablet N 1 90 30dexamethasone 6 mg tablet N 1 90 30fludrocortisone 0.1 mg tablet N 1 60 30hydrocortisone 10 mg tablet N 1 90 30

hydrocortisone 20 mg tablet N 1 90 30hydrocortisone 5 mg tablet N 1 90 30

Methylprednisolone 16 Mg Tablet N 1 90 30Methylprednisolone 2 G Vial N 1 1 30Methylprednisolone 2 Mg Tablet N 1 60 30

Methylprednisolone 32 Mg Tablet N 1 60 30Methylprednisolone 4 Mg Tab Ds Pk N 1 1 30

Methylprednisolone 4 Mg Tablet N 1 30 30

Methylprednisolone 40 Mg/ML Vial N 1 1 30

Methylprednisolone 8 Mg Tablet N 1 30 30Methylprednisolone Acetate 20 Mg/ML Vial N 1 1 30Methylprednisolone Acetate 40 Mg/ML Vial N 1 1 30

Methylprednisolone Acetate 80 Mg/ML Vial N 1 1 30Methylprednisolone Sodium Succ 1000 Mg Vial N 1 1 30Methylprednisolone Sodium Succ 125 Mg Vial N 1 1 30

Methylprednisolone Sodium Succ 40 Mg Vial N 1 1 30prednisone 1 mg tablet N 1 120 30prednisone 10 mg tablet N 1 120 30prednisone 2.5 mg tablet N 1 120 30

prednisone 20 mg tablet N 1 120 30prednisone 5 mg tablet N 1 120 30

Hyperglycemic Agents and Combinations

glucagon HCl 1 mg solution for injection N 2 1 30Injectable Antidiabetic Agents

Apidra 100/ML Vial N 3 1 30Humalog 100/ML Vial N 3 2 30Humalog Mix 50-50 50-50/ML Vial N 3 2 30Humalog Mix 75-25 75-25/ML Vial N 3 2 30

Humulin 70-30 70-30/ML Vial N 3 2 30

Humulin N 100/ML Vial N 3 2 30Humulin R U-100 100 unit/mL injection solution N 2 40 30

page 21 of 30


Lantus 100/ML Vial N 3 2 30Levemir 100/ML Vial N 3 2 30Novolin 70-30 70-30/ML Vial N 3 2 30

Novolin N 100/ML Vial N 3 2 30

Novolin R 100 unit/mL injection solution N 2 40 30

Novolog 100/ML Vial N 3 2 30Novolog Mix 70-30 70-30/ML Vial N 3 2 30Sub-Q Insulin Device 40 Unit Each N 1 1 30

Syringe And Needle Insulin 1ML Disp Syrin N 1 100 30Syringe And Needle Insulin 1ML 28Gx1/2 Disp Syrin N 1 100 30

Syringe And Needle Insulin 1ML 31Gx15/64 Disp Syrin N1 30

Syringe-Needle Insulin 0.5 ML 31Gx15/64 Disp Syrin N 1 30

Oral Antidiabetic Agents

Acarbose 100 Mg Tablet N 1 90 30Acarbose 25 Mg Tablet N 1 90 30Acarbose 50 Mg Tablet N 1 90 30

Alogliptin 12.5 Mg Tablet N 1 30 30Alogliptin 25 Mg Tablet N 1 30 30Alogliptin 6.25 Mg Tablet N 1 30 30

Alogliptin-Metformin 12.5-1000 Tablet N 1 60 30Alogliptin-Metformin 12.5-500Mg Tablet N 1 60 30Alogliptin-Pioglitazone 12.5-15 Mg Tablet N 1 30 30

Alogliptin-Pioglitazone 12.5-30 Mg Tablet N 1 30 30

Alogliptin-Pioglitazone 12.5-45 Mg Tablet N 1 30 30

Alogliptin-Pioglitazone 25 Mg-15Mg Tablet N 1 30 30Alogliptin-Pioglitazone 25 Mg-30Mg Tablet N 1 30 30

Alogliptin-Pioglitazone 25 Mg-45Mg Tablet N 1 30 30Avandia 2 Mg Tablet N 3 120 30Avandia 4 Mg Tablet N 3 60 30

Avandia 8 Mg Tablet N 3 30 30

Bydureon 2 Mg Vial N 3 4 30

Bydureon Pen 2Mg/0.65ML Pen Injctr N 3 4 30Byetta 10Mcg/0.04 Pen Injctr N 3 1 30Byetta 5Mcg/0.02 Pen Injctr N 3 1 30

Glimepiride 1 Mg Tablet N 1 30 30

Glimepiride 2 Mg Tablet N 1 30 30Glimepiride 4 Mg Tablet N 1 60 30glipizide 10 mg tablet N 1 120 30glipizide 5 mg tablet N 1 120 30glipizide ER 10 mg tablet extended release 24 hr N 1 60 30glipizide ER 2.5 mg tablet extended release 24 hr N 1 60 30

glipizide ER 5 mg tablet extended release 24 hr N 1 60 30Glipizide-Metformin 2.5-250 Mg Tablet N 1 60 30

Glipizide-Metformin 2.5-500 Mg Tablet N 1 60 30

page 22 of 30


Glipizide-Metformin 5 Mg-500 Mg Tablet N 1 60 30glyburide 1.25 mg tablet N 1 90 30glyburide 2.5 mg tablet N 1 90 30

Glyburide-Metformin HCl 1.25-250Mg Tablet N 1 60 30

Glyburide-Metformin HCl 2.5-500 Mg Tablet N 1 120 30

Glyburide-Metformin HCl 5 Mg-500Mg Tablet N 1 60 30Invokamet 150-1000Mg Tablet N 3 60 30Invokamet 150-500 Mg Tablet N 3 60 30

Invokamet 50-1000 Mg Tablet N 3 60 30Invokamet 50Mg-500Mg Tablet N 3 60 30Invokamet XR 150-1000Mg Tab Bp 24H N 3 30 30Invokamet XR 150-500 Mg Tab Bp 24H N 3 30 30Invokamet XR 50-1000 Mg Tab Bp 24H N 3 30 30

Invokamet XR 50Mg-500Mg Tab Bp 24H N 3 30 30

Invokana 100 Mg Tablet N 3 30 30Invokana 300 Mg Tablet N 3 30 30metformin 1 000 mg tablet N 1 90 30

metformin 500 mg tablet N 1 90 30metformin 850 mg tablet N 1 90 30Metformin HCl ER 500 Mg Tab ER 24H N 1 120 30

Metformin HCl ER 750 Mg Tab ER 24H N 1 90 30Miglitol 100 Mg Tablet N 1 180 30Miglitol 25 Mg Tablet N 1 180 30

Miglitol 50 Mg Tablet N 1 180 30

Nateglinide 120 Mg Tablet N 1 90 30

Nateglinide 60 Mg Tablet N 1 90 30Pioglitazone Hcl 15 Mg Tablet N 1 30 30

Pioglitazone Hcl 30 Mg Tablet N 1 30 30Pioglitazone Hcl 45 Mg Tablet N 1 30 30Repaglinide 0.5 Mg Tablet N 1 90 30

Repaglinide 1 Mg Tablet N 1 90 30

Repaglinide 2 Mg Tablet N 1 180 30

Tolazamide 250 Mg Tablet N 1 30 30Tolazamide 500 Mg Tablet N 1 30 30Tolbutamide 500 Mg Tablet N 1 30 30

Progestins

medroxyprogesterone 10 mg tablet N 4 1 15medroxyprogesterone 2.5 mg tablet N 4 1 15medroxyprogesterone 5 mg tablet N 4 1 15

Thyroid Therapy

Armour Thyroid 120 Mg Tablet N 3 30 30Armour Thyroid 15 Mg Tablet N 3 30 30

Armour Thyroid 180 Mg Tablet N 3 30 30Armour Thyroid 240 Mg Tablet N 3 30 30

Armour Thyroid 30 Mg Tablet N 3 30 30

page 23 of 30


Armour Thyroid 300 Mg Tablet N 3 30 30Armour Thyroid 60 Mg Tablet N 3 30 30Armour Thyroid 90 Mg Tablet N 3 30 30

levothyroxine 100 mcg intravenous solution N 1 30 30

levothyroxine 100 mcg tablet N 1 30 30

levothyroxine 112 mcg tablet N 1 30 30levothyroxine 125 mcg tablet N 1 30 30levothyroxine 137 mcg tablet N 1 30 30

levothyroxine 150 mcg tablet N 1 30 30levothyroxine 175 mcg tablet N 1 30 30levothyroxine 200 mcg tablet N 1 30 30levothyroxine 25 mcg tablet N 1 30 30levothyroxine 300 mcg tablet N 1 30 30

levothyroxine 50 mcg tablet N 1 30 30

levothyroxine 75 mcg tablet N 1 30 30levothyroxine 88 mcg tablet N 1 30 30liothyronine 10 mcg/mL intravenous solution N 1 30 30

liothyronine 25 mcg tablet N 1 30 30Liothyronine 5 Mcg Tablet N 1 30 30liothyronine 50 mcg tablet N 1 30 30

methimazole 10 mg tablet N 1 90 30methimazole 5 mg tablet N 1 90 30Nature-Throid 113.75 Mg Tablet N 3 30 30

Nature-Throid 130 Mg Tablet N 3 30 30

Nature-Throid 146.25 Mg Tablet N 3 30 30

Nature-Throid 16.25 Mg Tablet N 3 30 30Nature-Throid 162.5 Mg Tablet N 3 30 30

Nature-Throid 195 Mg Tablet N 3 30 30Nature-Throid 260 Mg Tablet N 3 30 30Nature-Throid 32.5 Mg Tablet N 3 30 30

Nature-Throid 325 Mg Tablet N 3 30 30

Nature-Throid 48.75 Mg Tablet N 3 30 30

Nature-Throid 65 Mg Tablet N 3 30 30Nature-Throid 81.25 Mg Tablet N 3 30 30Nature-Throid 97.5 Mg Tablet N 3 30 30

Np Thyroid 120 120 Mg Tablet N 3 30 30

Np Thyroid 15 Mg Tablet N 3 30 30Np Thyroid 30 Mg Tablet N 3 30 30Np Thyroid 60 Mg Tablet N 3 30 30Np Thyroid 90 Mg Tablet N 3 30 30propylthiouracil 50 mg tablet N 1 90 30

Gastrointestinal Therapy AgentsInflammatory Bowel Agents

hydrocortisone 100 mg/60 mL enema N 1 90 30

page 24 of 30


mesalamine 4 gram/60 mL enema N 1 180 30mesalamine 800 mg tablet delayed release N 2 180 30sulfasalazine 500 mg tablet N 1 90 30

Laxatives

peg 3350 240 gram-electrolytes 22.72 gram-6.72 g-5.84

g powdr for soln N1 4000 30

peg 3350-electrolytes 236 gram-22.74 gram-6.74 gram-

5.86 gram solution N1 4000 30

peg-electrolyte solution 420 gram oral solution N 1 4000 30(blank)

metoclopramide 5 mg/5 mL oral solution N 1 90 30prochlorperazine maleate 10 mg tablet N 1 100 30prochlorperazine maleate 5 mg tablet N 1 100 30

Genitourinary Therapy(blank)

bethanechol chloride 10 mg tablet N 1 90 30bethanechol chloride 25 mg tablet N 1 90 30bethanechol chloride 5 mg tablet N 1 90 30

bethanechol chloride 50 mg tablet N 1 90 30nitrofurantoin macrocrystal 100 mg capsule N 1 42 14

nitrofurantoin macrocrystal 50 mg capsule N 1 42 14

oxybutynin chloride 5 mg tablet N 1 60 30

oxybutynin chloride 5 mg/5 mL syrup N 1 60 30

Gout and Hyperuricemia Therapy(blank)

allopurinol 100 mg tablet N 1 90 30

allopurinol 300 mg tablet N 1 90 30colchicine 0.6 mg capsule N 3 30 30

colchicine 0.6 mg tablet N 3 30 30

Hematological AgentsAnticoagulants

enoxaparin 100 mg/mL subcutaneous syringe N 4 10 30enoxaparin 120 mg/0.8 mL subcutaneous syringe N 4 10 30

enoxaparin 150 mg/mL subcutaneous syringe N 4 10 30enoxaparin 30 mg/0.3 mL subcutaneous syringe N 4 10 30enoxaparin 40 mg/0.4 mL subcutaneous syringe N 4 10 30enoxaparin 60 mg/0.6 mL subcutaneous syringe N 4 10 30enoxaparin 80 mg/0.8 mL subcutaneous syringe N 4 10 30Heparin Flush 10 Unit/ML Syringe N 4 1 30

Heparin Flush 10 Unit/ML Vial N 4 1 30

Heparin Flush 100/ML (1) Syringe N 4 1 30Heparin Flush 1000/10 ML Syringe N 4 1 30Heparin Flush 500/5 ML Syringe N 4 1 30

page 25 of 30


Heparin Sodium 1000/ML Vial N 4 1 30Heparin Sodium 10000/ML Vial N 4 1 30Heparin Sodium 20000/ML Vial N 4 1 30

Heparin Sodium 5000/0.5ML Syringe N 4 1 30

Heparin Sodium 5000/0.5ML Vial N 4 1 30

Heparin Sodium 5000/ML Vial N 4 1 30warfarin 1 mg tablet N 1 90 30warfarin 10 mg tablet N 1 90 30

warfarin 2 mg tablet N 1 90 30warfarin 2.5 mg tablet N 1 90 30warfarin 3 mg tablet N 1 90 30warfarin 4 mg tablet N 1 90 30warfarin 5 mg tablet N 1 90 30

warfarin 6 mg tablet N 1 90 30

warfarin 7.5 mg tablet N 1 90 30Antiplatelet Agents

Anagrelide Hcl 0.5 Mg Capsule N 1 120 30

Anagrelide Hcl 1 Mg Capsule N 1 60 30Aspirin-Dipyridamole ER 25Mg-200Mg CPMP 12Hr N 1 60 30Cilostazol 100 Mg Tablet N 1 60 30

Cilostazol 50 Mg Tablet N 1 60 30Dipyridamole 25 Mg Tablet N 1 480 30Dipyridamole 50 Mg Tablet N 1 240 30

Dipyridamole 75 Mg Tablet N 1 120 30

(blank)

clopidogrel 300 mg tablet N 1 30 30clopidogrel 75 mg tablet N 1 30 30

Immune ModulatorsImmunosuppressants

Azathioprine 50 Mg Tablet N 1 120 30Cyclosporine 100 Mg Capsule N 1 180 30Cyclosporine 100 Mg/ML Solution N 1 180 30

Cyclosporine 25 Mg Capsule N 1 180 30Cyclosporine Modified 100 Mg Capsule N 1 180 30Cyclosporine Modified 25 Mg Capsule N 1 180 30Cyclosporine Modified 50 Mg Capsule N 1 180 30Envarsus XR 0.75 Mg Tab ER 24H N 1 240 30

Envarsus XR 1 Mg Tab ER 24H N 1 240 30Envarsus XR 4 Mg Tab ER 24H N 1 240 30Mycophenolate Mofetil 200 Mg/ML Susp Recon N 4 2 30Mycophenolate Mofetil 250 Mg Capsule N 4 240 30

Mycophenolate Mofetil 500 Mg Tablet N 4 240 30

Mycophenolate Mofetil 500 Mg Vial N 4 14 30Mycophenolic Acid 180 Mg Tablet DR N 4 240 30

page 26 of 30


Mycophenolic Acid 360 Mg Tablet DR N 4 120 30Sirolimus 0.5 Mg Tablet N 1 240 30Sirolimus 1 Mg Tablet N 1 240 30

Sirolimus 2 Mg Tablet N 1 240 30

Tacrolimus 0.5 Mg Capsule N 1 240 30

Tacrolimus 1 Mg Capsule N 1 240 30Tacrolimus 5 Mg Capsule N 1 240 30Zortress 0.25 Mg Tablet N 3 60 30

Zortress 0.5 Mg Tablet N 3 60 30Zortress 0.75 Mg Tablet N 3 60 30

Locomotor SystemNeuromuscular Therapy Agents

neostigmine methylsulfate 0.5 mg/mL intravenous

solution N1 90 30

neostigmine methylsulfate 1 mg/mL intravenous

solution N1 90 30

pyridostigmine bromide 60 mg tablet N 1 90 30

Medical Supplies and Durable Medical

Equipment (DME)(blank)

Accu-Chek FastClix N 1 100 30

Accu-Chek FastClix kit N 1 100 30Accu-Chek Multiclix Lancet N 1 100 30

Accu-Chek Multiclix Lancet kit N 1 100 30Accu-Chek Softclix Lancets N 1 100 30Acti-Lance Lancets 17 gauge N 1 100 30

Acti-Lance Lancets 23 gauge N 1 100 30Acti-Lance Lancets 28 gauge N 1 100 30

Advanced Travel Lancets 28 gauge N 1 100 30

Advanced Travel Lancets 30 gauge N 1 100 30FreeStyle Lancets 28 gauge N 1 100 30

lancets N 1 100 30Lancets Super Thin N 1 100 30

lancets 21 gauge N 1 100 30lancets 26 gauge N 1 100 30lancets 28 gauge N 1 100 30lancets 30 gauge N 1 100 30lancets 33 gauge N 1 100 30Lancets Thin N 1 100 30

Lancets Thin 23 gauge N 1 100 30

Lancets Thin 28 gauge N 1 100 30Lancets Ultra Thin N 1 100 30Lancets Ultra Thin 26 gauge N 1 100 30

page 27 of 30


True Metrix Air Glucose Meter N 4 1 730True Metrix Air Glucose Meter kit N 4 1 730True Metrix Glucose Meter N 4 1 730

True Metrix Go Glucose Meter N 4 1 730

TRUEplus Lancets 26 gauge N 1 100 30

TRUEplus Lancets 28 gauge N 1 100 30TRUEplus Lancets 30 gauge N 1 100 30TRUEplus Lancets 33 gauge N 1 100 30

Trueresult Blood Glucose System N 4 1 730Trueresult Blood Glucose System kit N 4 1 730Truetrack Blood Glucose System kit N 4 1 730

Mouth-Throat-Dental - Preparations(blank)


nystatin 100 000 unit/mL oral suspension N 1 480 30

Ophthalmic AgentsOphthalmic - Anti-infectives

ofloxacin 0.3 % eye drops N 1 3 30sulfacetamide sodium 10 % eye drops N 1 1 14sulfacetamide sodium 10 % eye ointment N 1 1 14

Ophthalmic - Anti-inflammatory

prednisolone acetate 1 % eye drops suspension N 1 1 30

Ophthalmic - Intraocular Pressure Reducing Agents

brimonidine 0.15 % eye drops N 1 1 30brimonidine 0.2 % eye drops N 1 1 30

carteolol 1 % eye drops N 1 1 30dorzolamide 22.3 mg-timolol 6.8 mg/mL eye drops N 1 1 30

timolol maleate 0.25 % eye drops N 1 1 30

timolol maleate 0.25 % eye gel forming solution N 1 1 30timolol maleate 0.5 % eye drops N 1 1 30

timolol maleate 0.5 % eye gel forming solution N 1 1 30travoprost (benzalkonium) 0.004 % eye drops N 1 1 30

(blank)

phenylephrine 10 % eye drops N 1 1 30phenylephrine 2.5 % eye drops N 1 1 30

Otic(blank)

Carbamoxide Ear Drops 6.5 % N 1 1 30Ear Drops Otc 6.5 % N 1 1 30

Ear Wax Removal Drops 6.5 % N 1 1 30hydrocortisone-acetic acid 1 %-2 % ear drops N 2 1 30ofloxacin 0.3 % ear drops N 1 3 30

page 28 of 30


Respiratory Therapy AgentsAsthma/COPD Therapy Agents

Aerospan 80 Mcg HFA Aer Ad N 3 2 30

albuterol sulfate 0.63 mg/3 mL solution for nebulization N1 300 30

albuterol sulfate 1.25 mg/3 mL solution for nebulization N1 300 30

albuterol sulfate 2 mg tablet N 1 90 30albuterol sulfate 2 mg/5 mL syrup N 1 1 30albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for

nebulization N1 300 30

albuterol sulfate 4 mg tablet N 1 90 30albuterol sulfate concentrate 2.5 mg/0.5 mL solution for

nebulization N1 300 30

albuterol sulfate concentrate 5 mg/mL(0.5 %) solution

for nebulization N1 300 30

Alvesco 160 Mcg HFA Aer Ad N 3 2 30Alvesco 80 Mcg HFA Aer Ad N 3 2 30

Anoro Ellipta 62.5-25Mcg Blst W/Dev N 3 1 30Arcapta Neohaler 75 Mcg Cap W/Dev N 3 60 30

Asmanex 110 Mcg(7) Inhalation N 3 1 30

Asmanex 110Mcg(30) Inhalation N 3 1 30

Asmanex 220Mcg 120 Inhalation N 3 1 30Asmanex 220Mcg(14) Inhalation N 3 1 30Asmanex 220Mcg(30) Inhalation N 3 1 30

Asmanex 220Mcg(60) Inhalation N 3 1 30Asmanex Hfa 100 Mcg Inhalation N 3 1 30Asmanex Hfa 200 Mcg Inhalation N 3 1 30

Atrovent HFA 17Mcg HFA Aer Ad N 3 1 30Breo Ellipta 100-25Mcg Blst W/Dev N 3 1 30Breo Ellipta 200-25 Mcg Blst W/Dev N 3 1 30Budesonide 0.25Mg/2ML Ampul-Neb N 1 1 30

Budesonide 0.5 Mg/2ML Ampul-Neb N 1 1 30Budesonide 32Mcg Spray/Pump N 1 1 30Combivent Respimat 20-100 Mcg Mist Inhal N 3 1 30Cromolyn Sodium 20 Mg/2 ML Ampul-Neb N 1 1 30Cromolyn Sodium 5.2 Mg Spray/Pump N 1 1 30

Dulera 100-5 Mcg Inhalation N 3 1 30Dulera 200-5 Mcg Inhalation N 3 1 30Flunisolide 25 Mcg Spray N 3 1 30Glycopyrrolate 1 Mg Tablet N 1 90 30

Glycopyrrolate 2 Mg Tablet N 1 90 30

Incruse Ellipta 62.5 Mcg Blst W/Dev N 3 1 30Ipratropium Bromide 0.2 Mg/ML Solution N 1 1 30

page 29 of 30


Ipratropium Bromide 21 Mcg Spray N 1 1 30Ipratropium Bromide 42 Mcg Spray N 1 1 30Ipratropium-Albuterol 0.5-3Mg/3 Ampul-Neb N 1 1 30

Levalbuterol Tartrate HFA 45 Mcg HFA Aer Ad N 1 1 30

Metaproterenol Sulfate 10 Mg Tablet N 1 120 30

Metaproterenol Sulfate 10 Mg/5 ML Syrup N 1 3 30Metaproterenol Sulfate 20 Mg Tablet N 1 120 30Montelukast Sodium 10 Mg Tablet N 1 30 30

Montelukast Sodium 4 Mg Gran Pack N 1 30 30Montelukast Sodium 4 Mg Tab Chew N 1 30 30Montelukast Sodium 5 Mg Tab Chew N 1 30 30Proair HFA 90 Mcg HFA Aer Ad N 3 1 30Proair Respiclick 90 Mcg Aer Pow Ba N 3 1 30

Proventil HFA 90 Mcg HFA Aer Ad N 3 1 30

Pulmicort Flexhaler 180 Mcg Aer Pow Ba N 3 1 30Pulmicort Flexhaler 90 Mcg Aer Pow Ba N 3 1 30Qvar 40 Mcg Aer W/Adap N 3 2 30

Qvar 80 Mcg Aer W/Adap N 3 2 30Stiolto Respimat 2.5 Mcg Mist Inhal N 3 1 30Striverdi Respimat 2.5 Mcg Mist Inhal N 3 1 30

Symbicort 160-4.5Mcg HFA Aer Ad N 3 1 30Symbicort 80-4.5 Mcg HFA Aer Ad N 3 1 30terbutaline 1 mg/mL subcutaneous solution N 1 90 30

terbutaline 2.5 mg tablet N 1 90 30

terbutaline 5 mg tablet N 1 90 30

theophylline ER 100 mg tablet extended release 12 hr N 1 120 30theophylline ER 200 mg tablet extended release 12 hr N 1 120 30

theophylline ER 300 mg tablet extended release 12 hr N 1 120 30theophylline ER 400 mg tablet extended release 24 hr N 1 120 30theophylline ER 450 mg tablet extended release 12 hr N 1 120 30

theophylline ER 600 mg tablet extended release 24 hr N 1 120 30

Ventolin HFA 90 Mcg HFA Aer Ad N 3 1 30

Xopenex HFA 45 Mcg HFA Aer Ad N 3 1 30Zafirlukast 10 Mg Tablet N 1 60 30Zafirlukast 20 Mg Tablet N 1 60 30

Nasal Antiallergy

Nasal Allergy Symptom Control 5.2 mg/spray (4 %)

spray N1 1 30

Nasal Corticosteroids

fluticasone 50 mcg/actuation nasal spray suspension N 1 1 30Triamcinolone Acetonide 55 Mcg Spray N 3 1 30

Vaginal ProductsVaginal Anti-infectives

metronidazole 0.75 % vaginal gel N 1 75 30

page 30 of 30

Analgesic Anti-inflammatory or Antipyretic

Documents

Transcript of Analgesic Anti-inflammatory or Antipyretic