-INFECTIVES · TIER 03 NON-PREFERRED terbinafine HCL QL Baxdela terbinafine hydrochlorideQL Cipro...

Atrium Health

Table of Contents

Analgesics - Drugs for Pain............................................................................................................................................ 3Analgesics - Drugs for Pain and Inflammation................................................................................................................4Anesthetics..................................................................................................................................................................... 5Anti-Addiction / Substance Abuse Treatment Agents..................................................................................................... 6Antibacterials.................................................................................................................................................................. 6Anticoagulants................................................................................................................................................................ 9Anticonvulsants - Drugs for Seizures..............................................................................................................................9Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.......................................................................... 10Antidepressants............................................................................................................................................................ 10Antiemetics - Drugs for Nausea and Vomiting.............................................................................................................. 11Antifungals.................................................................................................................................................................... 12Antigout Agents.............................................................................................................................................................13Anti-inflammatory Agents..............................................................................................................................................13Antimigraine Agents......................................................................................................................................................13Antimyasthenic Agents................................................................................................................................................. 13Antimycobacterials........................................................................................................................................................13Antineoplastics - Drugs for Cancer............................................................................................................................... 14Antiparasitics.................................................................................................................................................................16Antiparkinson Agents.................................................................................................................................................... 17Antiplatelets.................................................................................................................................................................. 17Antipsychotics - Drugs for Mood Disorders...................................................................................................................17Antivirals....................................................................................................................................................................... 18Anxiolytics - Drugs for Anxiety...................................................................................................................................... 19Bipolar Agents - Drugs for Mood Disorders.................................................................................................................. 20Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......................................................... 20Cardiovascular Agents - Drugs for Heart and Circulation Conditions........................................................................... 21Central Nervous System Agents - Drugs for Attention Deficit Disorder....................................................................... 25Central Nervous System Agents - Drugs for Multiple Sclerosis....................................................................................25Central Nervous System Agents - Miscellaneous.........................................................................................................26Dental and Oral Agents - Drugs for Mouth and Throat Conditions............................................................................... 26Dermatological Agents - Drugs for Skin Conditions......................................................................................................27Diabetes - Antidiabetic Agents......................................................................................................................................30Diabetes - Glucose Monitoring......................................................................................................................................31Diabetes - Glycemic Agents..........................................................................................................................................32Diabetes - Insulins........................................................................................................................................................ 33Electrolytes / Minerals / Metals / Vitamins.................................................................................................................... 33Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer........................................................................................... 35Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions............................................................ 35Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment......................................................... 37Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.................................................................. 37Genitourinary Agents - Drugs for Prostate Conditions..................................................................................................38Hormonal Agents - Adrenal...........................................................................................................................................38Hormonal Agents - Men's Health.................................................................................................................................. 39Hormonal Agents - Osteoporosis..................................................................................................................................39Hormonal Agents - Pituitary.......................................................................................................................................... 39Hormonal Agents - Prostaglandins............................................................................................................................... 40Hormonal Agents - Sex Hormones and Birth Control ................................................................................................... 40Hormonal Agents - Thyroid........................................................................................................................................... 44Immunological Agents - Drugs for Immune System Stimulation or Suppression..........................................................44Inflammatory Bowel Disease Agents............................................................................................................................ 45Metabolic Bone Disease Agents - Drugs for Osteoporosis...........................................................................................45Metabolic Bone Disease Agents - Other.......................................................................................................................46Miscellaneous Therapeutic Agents............................................................................................................................... 46Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...................................................................... 50

1

Ophthalmic Agents - Drugs for Glaucoma.................................................................................................................... 51Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions.....................................................................................52Otic Agents - Drugs for Ear Conditions.........................................................................................................................52Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold................................................................... 53Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...............................................54Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis................................................................................55Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension................................................................56Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................................. 56Sleep Disorder Agents.................................................................................................................................................. 56

2

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

acetaminophen-codeine TIER 01 QL

acetaminophen-codeine #2

TIER 01 QL


TIER 01 QL


TIER 01 QL

ACTIQ TIER 03 PA; QL

apap-caff-dihydrocodeine

TIER 01 QL

ascomp-codeine TIER 01

BELBUCA TIER 02 PA; QL

BUPRENEX TIER 03

buprenorphine hcl injection

TIER 01

buprenorphine transdermal

TIER 01 PA; QL

butalbital-acetaminophen TIER 01

butalbital-apap-caff-cod TIER 01

butalbital-apap-caffeine TIER 01

butalbital-asa-caff-codeine

TIER 01

butalbital-aspirin-caffeine TIER 01

butorphanol tartrate injection

TIER 01

butorphanol tartrate nasal

TIER 01 QL

BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

TIER 03 PA; QL

carisoprodol-aspirin-codeine

TIER 01

codeine sulfate TIER 01 QL

DEMEROL TIER 03

DILAUDID INJECTION TIER 03

DOLOPHINE TIER 03 PA

duramorph TIER 01

duraxin TIER 01

endocet TIER 01 QL

ESGIC TIER 03

fentanyl TIER 01 PA; QL


fentanyl citrate buccal lozenge on a handle

TIER 01 PA; QL

FIORINAL TIER 03

FIORINAL/CODEINE #3 TIER 03

hydrocodone bitartrate er TIER 01 PA; QL

hydrocodone-acetaminophen

TIER 01 QL

hydrocodone-ibuprofen TIER 01 QL

hydromorphone hcl er TIER 01 PA; QL

HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML

TIER 03

hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml

TIER 01

hydromorphone hcl oral TIER 01 QL

hydromorphone hcl pf TIER 01

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION

TIER 03

hydromorphone hcl solution 1 mg/ml injection

TIER 01

HYDROMORPHONE HCL-NACL INJECTION

TIER 03

HYSINGLA ER TIER 02 PA; QL

INFUMORPH 200 TIER 03

INFUMORPH 500 TIER 03

levorphanol tartrate oral TIER 01 QL

lorcet TIER 01 QL

lorcet hd TIER 01 QL

LORTAB TIER 03 QL

MEDROX-RX TIER 03

meperidine hcl injection TIER 01

meperidine hcl oral TIER 01 QL

methadone hcl injection TIER 01

methadone hcl intensol TIER 01

methadone hcl oral concentrate

TIER 01

methadone hcl oral solution

TIER 01

methadone hcl oral tablet TIER 01 PA

methadone hcl oral tablet soluble

TIER 01

TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY

3


methadose oral concentrate 10 mg/ml

TIER 01

methadose oral tablet soluble

TIER 01

methadose sugar-free TIER 01

mitigo TIER 01

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

TIER 01 QL

morphine sulfate (pf) injection

TIER 01

morphine sulfate er TIER 01 PA; QL

morphine sulfate er beads

TIER 01 PA; QL

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

TIER 03

morphine sulfate injection solution 2 mg/ml, 4 mg/ml, 5 mg/ml

TIER 01

morphine sulfate intramuscular

TIER 01

morphine sulfate oral TIER 01 QL

MORPHINE SULFATE-NACL INJECTION

TIER 03

nalbuphine hcl injection TIER 01

oxycodone hcl oral capsule

TIER 01 QL

oxycodone hcl oral concentrate 100 mg/5ml

TIER 01 QL

oxycodone hcl oral solution

TIER 01 QL

oxycodone hcl oral tablet TIER 01 QL

oxycodone-acetaminophen

TIER 01 QL

oxycodone-aspirin TIER 01 QL

OXYCONTIN TIER 02 PA; QL

oxymorphone hcl TIER 01 QL

oxymorphone hcl er TIER 01 PA; QL

pentazocine-naloxone hcl

TIER 01 QL

PROBUPHINE IMPLANT KIT

TIER 03


tencon TIER 01

tramadol hcl er (biphasic) TIER 01 QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

TIER 01 PA; QL

tramadol hcl er oral tablet extended release 24 hour

TIER 01 QL

tramadol hcl ir TIER 01 QL

tramadol-acetaminophen TIER 01 QL

TREZIX TIER 03 QL

XTAMPZA ER TIER 02 PA; QL

ZEBUTAL TIER 03

Analgesics - Drugs for Pain and Inflammation

celecoxib oral TIER 01

DAYPRO TIER 03

DICLOFENAC EPOLAMINE

TIER 03

diclofenac potassium TIER 01

diclofenac sodium er TIER 01

diclofenac sodium oral TIER 01

diclofenac sodium transdermal gel 1 %

TIER 01

diclofenac sodium transdermal solution

TIER 01 PA

diclofenac-misoprostol TIER 01

DICLOFONO TIER 03

diflunisal oral TIER 01

EC-NAPROSYN TIER 03

ec-naproxen TIER 01

etodolac TIER 01

etodolac er TIER 01

FELDENE TIER 03

fenoprofen calcium oral TIER 01

fenortho TIER 01

flurbiprofen oral TIER 01

ibu TIER 01

ibuprofen oral suspension

TIER 01

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

TIER 01


4


INDOCIN ORAL TIER 03 ST

indomethacin er TIER 01

indomethacin oral capsule 25 mg, 50 mg

TIER 01

ketoprofen er TIER 01

ketoprofen oral TIER 01

ketorolac tromethamine injection solution 15 mg/ml

TIER 01

ketorolac tromethamine intramuscular

TIER 01

ketorolac tromethamine oral

TIER 01

KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION

TIER 03

ketorolac tromethamine solution 30 mg/ml injection

TIER 01

LODINE TIER 03

meclofenamate sodium oral

TIER 01

mefenamic acid oral TIER 01

meloxicam oral TIER 01

nabumetone oral TIER 01

naproxen dr TIER 01

naproxen oral TIER 01

naproxen sodium er TIER 01

naproxen sodium oral tablet 275 mg, 550 mg

TIER 01

naproxen-esomeprazole TIER 01 PA

oxaprozin TIER 01

piroxicam oral TIER 01

sulindac oral TIER 01

tolmetin sodium TIER 01

Anesthetics

ARTICADENT DENTAL TIER 03

bupivacaine fisiopharma TIER 01

bupivacaine hcl (pf) TIER 01

bupivacaine hcl injection solution 0.25 %, 0.5 %

TIER 01

bupivacaine-epinephrine TIER 01


bupivacaine-epinephrine (pf)

TIER 01

CARBOCAINE TIER 03

CARBOCAINE PRESERVATIVE-FREE

TIER 03

chloroprocaine hcl (pf) TIER 01

CITANEST FORTE DENTAL

TIER 03

CITANEST PLAIN DENTAL

TIER 03

COCAINE HCL NASAL TIER 03

D-CARE 100X TIER 03

ethyl chloride TIER 01

EXPAREL TIER 03

GEBAUERS PAIN EASE TIER 03

GEBAUERS SPRAY AND STRETCH

TIER 03

glydo TIER 01

L.E.T. TIER 03

lidocaine external ointment

TIER 01

lidocaine external patch 5 %

TIER 01

lidocaine hcl (pf) TIER 01

lidocaine hcl external solution

TIER 01

lidocaine hcl injection solution 0.5 %

TIER 01

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

lidocaine hcl solution 1 % injection

TIER 01

LIDOCAINE HCL SOLUTION 1 % INJECTION

TIER 03

lidocaine hcl solution 2 % injection

TIER 01

LIDOCAINE HCL SOLUTION 2 % INJECTION

TIER 03

lidocaine hcl urethral/mucosal

TIER 01


5


LIDOCAINE IN DEXTROSE

TIER 03

lidocaine-epinephrine injection

TIER 01

lidocaine-prilocaine external cream

TIER 01

LIDOCAINE-SODIUM BICARBONATE

TIER 03

LIDO-EPINEPHRINE-TETRACAINE

TIER 03

MARCAINE TIER 03

MARCAINE PRESERVATIVE FREE

TIER 03

MARCAINE/EPINEPHRINE

TIER 03

MARCAINE/EPINEPHRINE PF

TIER 03

NAROPIN TIER 03

NESACAINE TIER 03

NESACAINE-MPF TIER 03

ORABLOC TIER 03

polocaine TIER 01

polocaine-mpf TIER 01

PREPIV SUPPLY TIER 03

ropivacaine hcl injection solution 10 mg/ml, 2 mg/ml, 5 mg/ml, 7.5 mg/ml

TIER 01

sensorcaine TIER 01

sensorcaine/epinephrine TIER 01

sensorcaine-mpf TIER 01

sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

TIER 01

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %

TIER 03

tetracaine hcl injection TIER 01

VENIPUNCTURE PX1 PHLEBOTOMY

TIER 03

XYLOCAINE TIER 03


xylocaine dental TIER 01

XYLOCAINE/EPINEPHRINE

TIER 03

XYLOCAINE-MPF TIER 03

XYLOCAINE-MPF/EPINEPHRINE

TIER 03

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium TIER 01

ANTABUSE TIER 03

BUNAVAIL TIER 03 QL

buprenorphine hcl sublingual

TIER 01 QL

buprenorphine hcl-naloxone hcl

TIER 01 QL

bupropion hcl er (smoking det)

TIER 01 QL

CHANTIX TIER 03 QL

CHANTIX CONTINUING MONTH PAK

TIER 03 QL

CHANTIX STARTING MONTH PAK

TIER 03 QL

disulfiram oral TIER 01

EVZIO TIER 03 ST

LUCEMYRA TIER 03 ST; QL

naloxone hcl injection solution

TIER 01

naloxone hcl injection solution cartridge

TIER 01

naloxone hcl injection solution prefilled syringe

TIER 01

naltrexone hcl oral TIER 01

NARCAN TIER 02

NICOTROL TIER 03 QL

NICOTROL NS TIER 03 QL

SUBLOCADE SPECIALTY

VIVITROL SPECIALTY

ZUBSOLV TIER 02 QL

Antibacterials

AEMCOLO TIER 03 PA

ALTABAX TIER 03


6


amikacin sulfate injection TIER 01

amoxicillin TIER 01

amoxicillin-potassium clavulanate er

TIER 01

amoxicillin-potassium clavulanate oral

TIER 01

ampicillin TIER 01

ampicillin sodium injection

TIER 01

ampicillin-sulbactam sodium injection

TIER 01

ARIKAYCE SPECIALTY

AUGMENTIN TIER 03

AUGMENTIN ES-600 TIER 03

avidoxy TIER 01

AZACTAM TIER 03

azithromycin oral TIER 01

aztreonam TIER 01

baciim TIER 01

bacitracin intramuscular TIER 01

BACTRIM TIER 03

BACTRIM DS TIER 03

BAXDELA ORAL TIER 03

benzalkonium chloride external solution

TIER 01

BICILLIN C-R TIER 03

BICILLIN C-R 900/300 TIER 03

BICILLIN L-A TIER 03

cefaclor TIER 01

cefaclor er TIER 01

cefadroxil TIER 01

cefazolin sodium injection

TIER 01

cefdinir TIER 01

cefditoren pivoxil TIER 01

cefepime hcl injection TIER 01

cefixime TIER 01

CEFOTAN TIER 03

cefotaxime sodium TIER 01

cefotetan disodium TIER 01

cefoxitin sodium injection TIER 01


cefpodoxime proxetil TIER 01

cefprozil TIER 01

ceftazidime injection TIER 01

ceftriaxone sodium injection

TIER 01

cefuroxime axetil TIER 01

cefuroxime sodium injection

TIER 01

CENTANY TIER 03

cephalexin TIER 01

CIPRO TIER 03

ciprofloxacin hcl oral TIER 01

clarithromycin er TIER 01

clarithromycin oral TIER 01

CLEOCIN ORAL TIER 03

CLEOCIN PHOSPHATE TIER 03

CLEOCIN VAGINAL CREAM

TIER 03

CLEOCIN VAGINAL SUPPOSITORY

TIER 02

clindamycin hcl oral TIER 01

clindamycin palmitate hcl TIER 01

clindamycin phosphate injection

TIER 01

clindamycin phosphate vaginal

TIER 01

CLINDESSE TIER 03

colistimethate sodium (cba)

TIER 01

COLY-MYCIN M TIER 03

coremino TIER 01

demeclocycline hcl TIER 01

dicloxacillin sodium TIER 01

DIFICID TIER 03

doxycycline hyclate oral capsule

TIER 01

doxycycline hyclate oral tablet

TIER 01

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

TIER 01


7


doxycycline monohydrate oral

TIER 01

E.E.S. 400 TIER 03

E.E.S. GRANULES TIER 03

ertapenem sodium TIER 01

ERYPED 200 TIER 03

ERYPED 400 TIER 03

ERY-TAB TIER 03

ERYTHROCIN STEARATE

TIER 03

erythromycin base TIER 01

erythromycin ethylsuccinate oral

TIER 01

erythromycin oral TIER 01

FIRVANQ TIER 03

FLAGYL TIER 03

FORTAZ INJECTION TIER 03

gentamicin sulfate external

TIER 01

gentamicin sulfate injection

TIER 01

HIPREX TIER 03

hydrogen peroxide TIER 01

INVANZ TIER 03

iodine tincture external tincture 2 %

TIER 01

KEFLEX TIER 03

levofloxacin oral TIER 01

LINCOCIN TIER 03

lincomycin hcl injection TIER 01

linezolid oral TIER 01 QL

MACROBID TIER 03

MACRODANTIN TIER 03

mafenide acetate external

TIER 01

methenamine hippurate TIER 01

metronidazole oral TIER 01

metronidazole vaginal TIER 01

minocycline hcl er oral tablet extended release 24 hour

TIER 01

minocycline hcl oral TIER 01


mondoxyne nl TIER 01

MONUROL TIER 03

morgidox oral TIER 01

moxifloxacin hcl oral TIER 01

mupirocin calcium TIER 01

mupirocin external TIER 01

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

TIER 01

neomycin sulfate oral TIER 01

nitrofurantoin TIER 01

nitrofurantoin macrocrystal oral

TIER 01

nitrofurantoin monohydrate macrocrystals

TIER 01

NUZYRA ORAL TIER 03

ofloxacin oral TIER 01

oxacillin sodium injection TIER 01

paromomycin sulfate oral TIER 01

penicillin g potassium TIER 01

penicillin g procaine TIER 01

penicillin g sodium TIER 01

penicillin v potassium TIER 01

PFIZERPEN TIER 03

polymyxin b sulfate injection

TIER 01

PRIMSOL TIER 03

SEYSARA TIER 03 ST

silver sulfadiazine external

TIER 01

SOLOSEC TIER 03

ssd TIER 01

streptomycin sulfate intramuscular

TIER 01

sulfadiazine oral TIER 01

sulfamethoxazole-trimethoprim oral

TIER 01

SULFAMYLON EXTERNAL PACKET

TIER 03

sulfatrim pediatric TIER 01

SUPRAX TIER 03


8


tazicef injection TIER 01

tetracycline hcl oral TIER 01

tinidazole oral TIER 01

tobramycin sulfate injection

TIER 01

trimethoprim oral TIER 01

UNASYN INJECTION TIER 03

VANCOCIN TIER 03

VANCOCIN HCL TIER 03

vancomycin hcl oral TIER 01

vandazole TIER 01

VIBRAMYCIN TIER 03 ST

XENLETA ORAL TIER 03

XEPI TIER 03

XIFAXAN TIER 03 PA

XIMINO TIER 03

ZITHROMAX ORAL TIER 03

ZITHROMAX TRI-PAK TIER 03

ZITHROMAX Z-PAK TIER 03

ZYVOX ORAL SUSPENSION RECONSTITUTED

TIER 03 QL

Anticoagulants

acd formula a TIER 01

acd-a noclot-50 TIER 01

anticoagulant cit dext soln a

TIER 01

anticoagulant sodium citrate

TIER 01

ARIXTRA SPECIALTY

ELIQUIS TIER 02

ELIQUIS DVT/PE STARTER PACK

TIER 02

enoxaparin sodium SPECIALTY

fondaparinux sodium SPECIALTY

FRAGMIN SPECIALTY

heparin sodium (porcine) TIER 01

heparin sodium (porcine) pf

TIER 01

jantoven PREVENT

LOVENOX SPECIALTY


PRADAXA TIER 02

SAVAYSA TIER 03

SODIUM CITRATE IN VITRO

TIER 03

TRICITRASOL TIER 03

warfarin sodium oral PREVENT

XARELTO TIER 02

XARELTO STARTER PACK

TIER 02

Anticonvulsants - Drugs for Seizures

BANZEL TIER 03 PA

BRIVIACT ORAL TIER 03 ST

carbamazepine er oral capsule extended release 12 hour

PREVENT

carbamazepine er oral tablet extended release 12 hour 100 mg

TIER 01

carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg

PREVENT

carbamazepine oral PREVENT

CELONTIN TIER 03

CEREBYX TIER 03

clobazam TIER 01 PA

DIACOMIT SPECIALTY PA

DIASTAT ACUDIAL TIER 03 QL

DIASTAT PEDIATRIC TIER 03 QL

diazepam rectal TIER 01 QL

DILANTIN ORAL CAPSULE 30 MG

TIER 02

divalproex sodium er TIER 01

divalproex sodium oral TIER 01

EPIDIOLEX SPECIALTY PA

epitol PREVENT

ethosuximide oral TIER 01

felbamate TIER 01

fosphenytoin sodium TIER 01

FYCOMPA TIER 03

gabapentin oral TIER 01

GABITRIL TIER 03


9


LAMICTAL XR ORAL KIT

TIER 03

lamotrigine er TIER 01

lamotrigine oral TIER 01

lamotrigine starter kit-blue

TIER 01

lamotrigine starter kit-green

TIER 01

lamotrigine starter kit-orange

TIER 01

levetiracetam er TIER 01

levetiracetam oral TIER 01

NAYZILAM TIER 03 QL

NEMBUTAL TIER 03

oxcarbazepine TIER 01

PEGANONE TIER 03

pentobarbital sodium injection

TIER 01

phenobarbital oral TIER 01

phenobarbital sodium injection

TIER 01

PHENYTEK TIER 02

phenytoin infatabs PREVENT

phenytoin oral PREVENT

phenytoin sodium extended

PREVENT

phenytoin sodium injection

TIER 01

primidone oral TIER 01

roweepra TIER 01

roweepra xr TIER 01

subvenite TIER 01

subvenite starter kit-blue TIER 01

subvenite starter kit-green

TIER 01

subvenite starter kit-orange

TIER 01

SYMPAZAN TIER 03 PA

tiagabine hcl TIER 01

topiramate er TIER 01

topiramate oral TIER 01

TROKENDI XR TIER 03 ST


valproic acid oral capsule TIER 01

valproic acid oral solution PREVENT

VALTOCO 10 MG DOSE TIER 03 QL




vigabatrin SPECIALTY PA

vigadrone SPECIALTY PA

VIMPAT ORAL TIER 03

ZARONTIN TIER 02

zonisamide oral TIER 01

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT TIER 03

donepezil hcl TIER 01

EXELON TIER 03

galantamine hydrobromide

TIER 01

galantamine hydrobromide er

TIER 01

memantine hcl er TIER 01

memantine hcl oral TIER 01

NAMENDA TIER 03

NAMENDA TITRATION PAK

TIER 03

NAMENDA XR TIER 03

NAMENDA XR TITRATION PACK

TIER 03

NAMZARIC TIER 02

RAZADYNE TIER 03

RAZADYNE ER TIER 03

rivastigmine TIER 01

rivastigmine tartrate TIER 01

Antidepressants

amitriptyline hcl oral PREVENT

amoxapine TIER 01

APLENZIN TIER 03 ST

bupropion hcl er (sr) TIER 01


10


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

TIER 01

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

TIER 02

bupropion hcl oral TIER 01

chlordiazepoxide-amitriptyline

TIER 01

citalopram hydrobromide PREVENT

clomipramine hcl oral TIER 01

desipramine hcl oral TIER 01

DESVENLAFAXINE ER TIER 03 ST; QL

desvenlafaxine succinate er

TIER 01

doxepin hcl oral capsule TIER 01

doxepin hcl oral concentrate

TIER 01

DRIZALMA SPRINKLE TIER 03

duloxetine hcl oral PREVENT

EMSAM TIER 03

escitalopram oxalate PREVENT

FETZIMA TIER 03 ST; QL

FETZIMA TITRATION TIER 03 ST; QL

fluoxetine hcl (pmdd) TIER 01

fluoxetine hcl oral capsule

PREVENT

fluoxetine hcl oral capsule delayed release

PREVENT

fluoxetine hcl oral solution

PREVENT

fluoxetine hcl oral tablet TIER 01

fluvoxamine maleate TIER 01

fluvoxamine maleate er TIER 01

FORFIVO XL TIER 03

imipramine hcl oral TIER 01

imipramine pamoate TIER 01

maprotiline hcl TIER 01

MARPLAN TIER 03

mirtazapine oral TIER 01

NARDIL TIER 03


nefazodone hcl TIER 01

NORPRAMIN TIER 03

nortriptyline hcl oral TIER 01

olanzapine-fluoxetine hcl TIER 01

PARNATE TIER 03

paroxetine hcl PREVENT

paroxetine hcl er TIER 01

paroxetine mesylate TIER 01 QL

PAXIL ORAL SUSPENSION

TIER 02 ST

perphenazine-amitriptyline

TIER 01

PEXEVA TIER 03

phenelzine sulfate oral TIER 01

protriptyline hcl TIER 01

REMERON TIER 03

REMERON SOLTAB TIER 03

SARAFEM TIER 03

sertraline hcl oral PREVENT

SPRAVATO (56 MG DOSE)

SPECIALTY PA

SPRAVATO (84 MG DOSE)

SPECIALTY PA

SYMBYAX TIER 03

tranylcypromine sulfate TIER 01

trazodone hcl oral TIER 01

trimipramine maleate oral

TIER 01

TRINTELLIX TIER 03 ST; QL

venlafaxine hcl PREVENT

venlafaxine hcl er PREVENT

VIIBRYD TIER 03

VIIBRYD STARTER PACK

TIER 03

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL TIER 03 QL

ANZEMET TIER 03 QL

aprepitant TIER 01 QL

BONJESTA TIER 03 PA; QL


11


compro TIER 01

DICLEGIS TIER 03 PA; QL

dimenhydrinate injection TIER 01

doxylamine-pyridoxine TIER 01 PA; QL

dronabinol TIER 01 PA; QL

droperidol injection TIER 01

EMEND ORAL TIER 03 QL

EMEND TRI-PACK TIER 03 QL

granisetron hcl oral TIER 01 QL

MARINOL TIER 03 PA; QL

meclizine hcl oral tablet TIER 01

metoclopramide hcl injection

TIER 01

metoclopramide hcl oral TIER 01

ondansetron hcl injection TIER 01

ondansetron hcl oral solution

TIER 01 QL

ondansetron hcl oral tablet 24 mg

TIER 01 QL

ondansetron hcl oral tablet 4 mg, 8 mg

TIER 01

ondansetron odt TIER 01

perphenazine oral TIER 01

prochlorperazine TIER 01

prochlorperazine edisylate injection

TIER 01

prochlorperazine maleate oral

TIER 01

REGLAN TIER 03

scopolamine TIER 01

SUSTOL TIER 03 QL

SYNDROS TIER 03 PA; QL

TIGAN TIER 03

TRANSDERM SCOP (1.5 MG)

TIER 03

TRANSDERM-SCOP (1.5 MG)

TIER 03

trimethobenzamide hcl oral

TIER 01

VARUBI (180 MG DOSE)

TIER 03 QL


Antifungals

ANCOBON TIER 03

BIO-STATIN ORAL CAPSULE

TIER 03

ciclodan TIER 01

ciclopirox TIER 01

ciclopirox olamine external

TIER 01

clotrimazole external TIER 01

clotrimazole mouth/throat TIER 01

clotrimazole-betamethasone

TIER 01

CRESEMBA ORAL SPECIALTY

DIFLUCAN TIER 03

econazole nitrate external

TIER 01

exoderm external lotion TIER 01

fluconazole oral TIER 01

flucytosine oral TIER 01

griseofulvin microsize oral

TIER 01

griseofulvin ultramicrosize

TIER 01

GYNAZOLE-1 TIER 03

itraconazole oral TIER 01 PA

KERYDIN TIER 03 PA

ketoconazole external TIER 01

ketoconazole oral TIER 01

ketodan external foam TIER 01

LOPROX EXTERNAL CREAM

TIER 03

LOPROX EXTERNAL SHAMPOO

TIER 03

LOPROX EXTERNAL SUSPENSION

TIER 03

miconazole 3 vaginal suppository

TIER 01

naftifine hcl TIER 01

NAFTIN TIER 03

NOXAFIL ORAL SPECIALTY

nyamyc TIER 01

nystatin external TIER 01


12


nystatin mouth/throat TIER 01

nystatin oral TIER 01

nystatin-triamcinolone TIER 01

nystop TIER 01

oxiconazole nitrate TIER 01

posaconazole SPECIALTY

SPORANOX TIER 03 PA

SPORANOX PULSEPAK TIER 03 PA

terbinafine hcl oral TIER 01 QL

terconazole TIER 01

VFEND ORAL SUSPENSION RECONSTITUTED

SPECIALTY

voriconazole oral SPECIALTY

Antigout Agents

allopurinol oral TIER 01

colchicine oral tablet TIER 01

colchicine-probenecid TIER 01

COLCRYS TIER 02

febuxostat TIER 01 ST

probenecid TIER 01

ULORIC TIER 03 ST

ZYLOPRIM TIER 03

Anti-inflammatory Agents

EMFLAZA SPECIALTY PA

Antimigraine Agents

AIMOVIG SPECIALTY PA

almotriptan malate TIER 01 QL

AMERGE TIER 03 QL

CAFERGOT TIER 03

D.H.E. 45 TIER 03

dihydroergotamine mesylate injection

TIER 01

dihydroergotamine mesylate nasal

TIER 01 QL

eletriptan hydrobromide TIER 01 QL

EMGALITY SPECIALTY PA

EMGALITY (300 MG DOSE)

SPECIALTY PA

ERGOMAR TIER 03


ergotamine-caffeine TIER 01

frovatriptan succinate TIER 01 QL

MIGERGOT TIER 03

MIGRANAL TIER 03 QL

naratriptan hcl TIER 01 QL

NURTEC TIER 02 PA

rizatriptan benzoate TIER 01 QL

sumatriptan nasal TIER 01 QL

sumatriptan succinate oral

TIER 01 QL

sumatriptan succinate refill

TIER 01 QL

sumatriptan succinate subcutaneous

TIER 01 QL

sumatriptan-naproxen sodium

TIER 01 QL

zolmitriptan oral TIER 01 QL

ZOMIG NASAL TIER 03 ST; QL

Antimyasthenic Agents

GUANIDINE HCL TIER 03

MESTINON ORAL SOLUTION

TIER 03

MESTINON ORAL TABLET EXTENDED RELEASE

TIER 03

pyridostigmine bromide er

TIER 01

pyridostigmine bromide oral

TIER 01

Antimycobacterials

CAPASTAT SULFATE TIER 03

cycloserine oral TIER 01

dapsone oral TIER 01

ethambutol hcl oral TIER 01

isoniazid injection TIER 01

isoniazid oral TIER 01

MYAMBUTOL TIER 03

MYCOBUTIN TIER 03

PASER TIER 03

PRETOMANID TIER 03

PRIFTIN TIER 03


13


pyrazinamide oral TIER 01

rifabutin TIER 01

RIFADIN ORAL TIER 03

rifampin oral TIER 01

SIRTURO TIER 03

TRECATOR TIER 03

Antineoplastics - Drugs for Cancer

abiraterone acetate SPECIALTY PA

AFINITOR DISPERZ SPECIALTY PA

AFINITOR ORAL TABLET 10 MG

SPECIALTY PA

ALECENSA SPECIALTY PA

ALKERAN ORAL SPECIALTY

ALUNBRIG SPECIALTY PA

anastrozole oral TIER 01

AROMASIN SPECIALTY

AYVAKIT SPECIALTY PA

azacitidine SPECIALTY

BALVERSA SPECIALTY PA

bexarotene SPECIALTY PA

bicalutamide TIER 01

bleomycin sulfate SPECIALTY

BOSULIF SPECIALTY PA

BRAFTOVI SPECIALTY PA

BRUKINSA SPECIALTY PA

CABOMETYX SPECIALTY PA

CALQUENCE SPECIALTY PA

capecitabine SPECIALTY PA

CAPRELSA SPECIALTY PA

CASODEX TIER 03

COMETRIQ (100 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

COPIKTRA SPECIALTY PA

COTELLIC SPECIALTY PA

cyclophosphamide injection

SPECIALTY


cyclophosphamide oral SPECIALTY

cytarabine SPECIALTY

cytarabine (pf) SPECIALTY

DAURISMO SPECIALTY PA

DROXIA TIER 03

EMCYT SPECIALTY

ERIVEDGE SPECIALTY PA

erlotinib hcl SPECIALTY PA

ERWINAZE SPECIALTY

etoposide oral SPECIALTY

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

SPECIALTY PA

exemestane SPECIALTY

FARESTON SPECIALTY

FARYDAK SPECIALTY PA

FASLODEX SPECIALTY

FEMARA TIER 03

floxuridine injection SPECIALTY

flutamide TIER 01

fulvestrant SPECIALTY

GILOTRIF SPECIALTY PA

GLEOSTINE SPECIALTY

HERCEPTIN HYLECTA SPECIALTY PA

HYCAMTIN ORAL SPECIALTY

HYDREA TIER 03

hydroxyurea oral TIER 01

IBRANCE SPECIALTY PA

ICLUSIG SPECIALTY PA

IDHIFA SPECIALTY PA

imatinib mesylate SPECIALTY PA

IMBRUVICA SPECIALTY PA

IMLYGIC SPECIALTY

INLYTA SPECIALTY PA

INREBIC SPECIALTY PA

IRESSA SPECIALTY PA

JAKAFI SPECIALTY PA

KISQALI (200 MG DOSE)

SPECIALTY PA


SPECIALTY PA


14



SPECIALTY PA

KISQALI FEMARA (400 MG DOSE)

SPECIALTY PA

KISQALI FEMARA (600 MG DOSE)

SPECIALTY PA

KISQALI FEMARA(200 MG DOSE)

SPECIALTY PA

KOSELUGO SPECIALTY PA

LENVIMA (10 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

letrozole oral TIER 01

leucovorin calcium injection

TIER 01

leucovorin calcium oral TIER 01

LEUKERAN SPECIALTY

LONSURF SPECIALTY PA

LORBRENA SPECIALTY PA

LYNPARZA SPECIALTY PA

LYSODREN SPECIALTY

MATULANE SPECIALTY

MEKINIST SPECIALTY PA

MEKTOVI SPECIALTY PA

melphalan SPECIALTY

mercaptopurine oral TIER 01

MESNEX ORAL SPECIALTY

MYLERAN SPECIALTY

NERLYNX SPECIALTY PA

NEXAVAR SPECIALTY PA


NILANDRON SPECIALTY

nilutamide SPECIALTY

NINLARO SPECIALTY PA

NUBEQA SPECIALTY PA

ODOMZO SPECIALTY PA

ONCASPAR SPECIALTY

PANRETIN SPECIALTY

PIQRAY (200 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

POMALYST SPECIALTY PA

PURIXAN SPECIALTY

QINLOCK SPECIALTY PA

REVLIMID SPECIALTY PA

RITUXAN HYCELA SPECIALTY PA

ROZLYTREK SPECIALTY PA

RUBRACA SPECIALTY PA

RYDAPT SPECIALTY PA

SIKLOS TIER 03 PA

SOLTAMOX TIER 03

SPRYCEL SPECIALTY PA

STIVARGA SPECIALTY PA

SUTENT SPECIALTY PA

SYNRIBO SPECIALTY PA

TABLOID SPECIALTY

TAFINLAR SPECIALTY PA

TAGRISSO SPECIALTY PA

TALZENNA SPECIALTY PA

tamoxifen citrate oral TIER 01

TARCEVA SPECIALTY PA

TARGRETIN EXTERNAL

SPECIALTY PA

TASIGNA SPECIALTY PA

TEMODAR ORAL SPECIALTY PA

temozolomide SPECIALTY PA

TEPADINA SPECIALTY

THALOMID SPECIALTY PA


15


thiotepa injection SPECIALTY

TIBSOVO SPECIALTY PA

toremifene citrate SPECIALTY

tretinoin oral SPECIALTY

TUKYSA SPECIALTY PA

TURALIO SPECIALTY PA

TYKERB SPECIALTY PA

VALCHLOR SPECIALTY PA

valrubicin SPECIALTY

VALSTAR SPECIALTY

VELCADE SPECIALTY PA

VENCLEXTA SPECIALTY PA

VENCLEXTA STARTING PACK

SPECIALTY PA

VERZENIO SPECIALTY PA

VIDAZA SPECIALTY

VITRAKVI SPECIALTY PA

VIZIMPRO SPECIALTY PA

VOTRIENT SPECIALTY PA

XALKORI SPECIALTY PA

XELODA SPECIALTY PA

XOSPATA SPECIALTY PA

XPOVIO (100 MG ONCE WEEKLY)

SPECIALTY PA


SPECIALTY PA

XPOVIO (40 MG TWICE WEEKLY)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

XTANDI SPECIALTY PA

ZEJULA SPECIALTY PA

ZELBORAF SPECIALTY PA

ZOLINZA SPECIALTY PA

ZYDELIG SPECIALTY PA

ZYKADIA SPECIALTY PA


Antiparasitics

albendazole oral TIER 01 PA

ALINIA TIER 02

ARAKODA TIER 03

atovaquone oral TIER 01

atovaquone-proguanil hcl TIER 01

BENZNIDAZOLE TIER 03

BILTRICIDE TIER 03

chloroquine phosphate oral

TIER 01

COARTEM TIER 03

crotan TIER 01

DARAPRIM SPECIALTY PA

EGATEN TIER 03

ELIMITE TIER 03

EMVERM TIER 02

hydroxychloroquine sulfate oral

TIER 01

IMPAVIDO TIER 03

ivermectin oral TIER 01

KRINTAFEL TIER 03

lindane TIER 01

MALARONE TIER 03

malathion TIER 01

mefloquine hcl TIER 01

MEPRON TIER 03

NEBUPENT TIER 03

OVIDE TIER 03

PENTAM TIER 03

pentamidine isethionate TIER 01

permethrin external TIER 01

PLAQUENIL TIER 02

praziquantel oral TIER 01

primaquine phosphate TIER 01

pyrimethamine oral SPECIALTY PA

PYRIMETHAMINE-LEUCOVORIN

TIER 03

QUALAQUIN TIER 03 PA

quinine sulfate oral TIER 01 PA

SKLICE TIER 03


16


spinosad TIER 01

STROMECTOL TIER 03

sulfurated lime TIER 01

Antiparkinson Agents

amantadine hcl oral TIER 01

APOKYN SPECIALTY PA

AZILECT TIER 03

benztropine mesylate TIER 01

bromocriptine mesylate oral

TIER 01

carbidopa oral TIER 01

carbidopa-levodopa TIER 01

carbidopa-levodopa er TIER 01

carbidopa-levodopa-entacapone

TIER 01

COGENTIN TIER 03

COMTAN TIER 03

DUOPA TIER 03 PA

entacapone TIER 01

INBRIJA SPECIALTY PA

MIRAPEX TIER 03

MIRAPEX ER TIER 03

NEUPRO TIER 03 ST

NOURIANZ TIER 03 PA

PARLODEL TIER 03

pramipexole dihydrochloride

TIER 01

pramipexole dihydrochloride er

TIER 01

rasagiline mesylate oral TIER 01

REQUIP XL TIER 03

ropinirole hcl TIER 01

ropinirole hcl er TIER 01

RYTARY TIER 03 ST

selegiline hcl oral TIER 01

SINEMET TIER 03

STALEVO 100 TIER 03

STALEVO 125 TIER 03

STALEVO 150 TIER 03

STALEVO 200 TIER 03


STALEVO 50 TIER 03

STALEVO 75 TIER 03

TASMAR TIER 03

tolcapone TIER 01

trihexyphenidyl hcl TIER 01

XADAGO SPECIALTY ST

ZELAPAR TIER 03

Antiplatelets

AGGRENOX TIER 03

aspirin-dipyridamole er TIER 01

BRILINTA TIER 02

CABLIVI SPECIALTY PA

cilostazol TIER 01

clopidogrel bisulfate oral PREVENT

dipyridamole oral TIER 01

EFFIENT TIER 03

prasugrel hcl TIER 01

ZONTIVITY TIER 03

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA TIER 03

ADASUVE TIER 03 PA

aripiprazole TIER 01

ARISTADA TIER 03

ARISTADA INITIO TIER 03

CAPLYTA TIER 03 ST; QL

chlorpromazine hcl injection

TIER 01

chlorpromazine hcl oral TIER 01

clozapine TIER 01

CLOZARIL TIER 03

FANAPT TIER 03 ST; QL

FANAPT TITRATION PACK

TIER 03 ST; QL

fluphenazine decanoate injection

TIER 01

fluphenazine hcl TIER 01

GEODON INTRAMUSCULAR

TIER 03

HALDOL TIER 03


17


HALDOL DECANOATE TIER 03

haloperidol decanoate intramuscular

TIER 01

haloperidol lactate TIER 01

haloperidol oral TIER 01

INVEGA TIER 03

INVEGA SUSTENNA TIER 03

INVEGA TRINZA TIER 03

LATUDA TIER 03

loxapine succinate TIER 01

molindone hcl TIER 01

NUPLAZID TIER 03 PA

olanzapine TIER 01

paliperidone er TIER 01

PERSERIS TIER 03

pimozide TIER 01

quetiapine fumarate TIER 01

quetiapine fumarate er TIER 01

REXULTI TIER 03

RISPERDAL CONSTA TIER 03

risperidone TIER 01

SAPHRIS TIER 02

thioridazine hcl oral TIER 01

thiothixene TIER 01

trifluoperazine hcl TIER 01

VERSACLOZ TIER 03

VRAYLAR TIER 03 ST; QL

ziprasidone hcl TIER 01

ziprasidone mesylate TIER 01

ZYPREXA RELPREVV TIER 03

ZYPREXA ZYDIS TIER 03

Antivirals

abacavir sulfate TIER 01

abacavir sulfate-lamivudine

TIER 01

abacavir-lamivudine-zidovudine

TIER 01

acyclovir external TIER 01

acyclovir oral TIER 01

adefovir dipivoxil SPECIALTY


APTIVUS TIER 02

atazanavir sulfate TIER 01

BARACLUDE ORAL SOLUTION

SPECIALTY QL

BIKTARVY TIER 03

CIMDUO TIER 02

COMBIVIR TIER 03

COMPLERA TIER 02

CRIXIVAN TIER 02

DELSTRIGO TIER 03

DESCOVY TIER 03 PA

didanosine TIER 01

DOVATO TIER 02

EDURANT TIER 02

efavirenz TIER 01

EMTRIVA TIER 02

entecavir SPECIALTY QL

EPCLUSA SPECIALTY PA; QL

EPIVIR TIER 03

EPIVIR HBV SPECIALTY

EPZICOM TIER 03

EVOTAZ TIER 02

famciclovir oral TIER 01

FAVIPIRAVIR TIER 03

fosamprenavir calcium TIER 01

FUZEON SPECIALTY

GENVOYA TIER 03

HARVONI SPECIALTY PA; QL

HEPSERA SPECIALTY

INTELENCE TIER 02

INTRON A SPECIALTY PA

INVIRASE TIER 02

ISENTRESS TIER 02

ISENTRESS HD TIER 02

JULUCA TIER 02

KALETRA ORAL SOLUTION

TIER 03

KALETRA ORAL TABLET

TIER 02

lamivudine oral solution TIER 01


18


lamivudine oral tablet 100 mg

SPECIALTY

lamivudine oral tablet 150 mg, 300 mg

TIER 01

lamivudine-zidovudine TIER 01

LEXIVA ORAL SUSPENSION

TIER 02

LEXIVA ORAL TABLET TIER 03

lopinavir-ritonavir TIER 01

MAVYRET SPECIALTY PA; QL

nevirapine TIER 01

nevirapine er TIER 01

NORVIR ORAL PACKET TIER 02

NORVIR ORAL SOLUTION

TIER 02

NORVIR ORAL TABLET TIER 03

ODEFSEY TIER 03

oseltamivir phosphate oral

TIER 01 QL

PEGASYS SPECIALTY PA

PEGASYS PROCLICK SPECIALTY PA

PEGINTRON SPECIALTY PA

PIFELTRO TIER 03

PREVYMIS ORAL SPECIALTY

PREZCOBIX TIER 02

PREZISTA TIER 02

RELENZA DISKHALER TIER 03 QL

RETROVIR ORAL TIER 03

REYATAZ ORAL CAPSULE

TIER 03

REYATAZ ORAL PACKET

TIER 02

ribavirin inhalation TIER 01

ribavirin oral SPECIALTY

rimantadine hcl TIER 01

ritonavir TIER 01

SELZENTRY TIER 02 PA

SITAVIG TIER 03

SOVALDI SPECIALTY PA; QL

stavudine TIER 01

STRIBILD TIER 03


SUSTIVA TIER 03

SYMFI TIER 02

SYMFI LO TIER 02

SYMTUZA TIER 03

tenofovir disoproxil fumarate

TIER 01

TIVICAY TIER 02

TIVICAY PD TIER 02

TRIUMEQ TIER 02

TRIZIVIR TIER 03

TRUVADA TIER 02

TYBOST TIER 02

valacyclovir hcl oral TIER 01

valganciclovir hcl TIER 01

VEMLIDY SPECIALTY

VIEKIRA PAK SPECIALTY PA; QL

VIRACEPT TIER 02

VIRAMUNE TIER 03

VIRAMUNE XR TIER 03

VIRAZOLE TIER 03

VIREAD ORAL POWDER

TIER 02

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

TIER 02

VIREAD ORAL TABLET 300 MG

TIER 03

VOSEVI SPECIALTY PA; QL

XOFLUZA (40 MG DOSE)

TIER 03 QL

XOFLUZA (80 MG DOSE)

TIER 03 QL

ZEPATIER SPECIALTY PA

ZIAGEN TIER 03

zidovudine TIER 01

Anxiolytics - Drugs for Anxiety

alprazolam er TIER 01 QL

alprazolam intensol TIER 01 QL

alprazolam oral TIER 01 QL

alprazolam xr TIER 01 QL


19


ATIVAN INJECTION TIER 03

buspirone hcl oral TIER 01

chlordiazepoxide hcl TIER 01 QL

clonazepam oral TIER 01 QL

clorazepate dipotassium TIER 01 QL

diazepam intensol TIER 01

diazepam intramuscular TIER 01

diazepam oral TIER 01

diazepam solution 5 mg/ml injection

TIER 01

DIAZEPAM SOLUTION 5 MG/ML INJECTION

TIER 03

DORAL TIER 03 QL

estazolam TIER 01 QL

HALCION TIER 03 QL

hydroxyzine hcl intramuscular

TIER 01

hydroxyzine hcl oral TIER 01

hydroxyzine pamoate oral

TIER 01

lorazepam injection TIER 01

lorazepam intensol TIER 01 QL

lorazepam oral concentrate 2 mg/ml

TIER 01 QL

lorazepam oral tablet TIER 01 QL

meprobamate TIER 01

oxazepam TIER 01 QL

quazepam TIER 01 QL

TRANXENE-T TIER 03 QL

triazolam TIER 01 QL

VISTARIL TIER 03

Bipolar Agents - Drugs for Mood Disorders

EQUETRO TIER 03

lithium TIER 01

lithium carbonate er TIER 01

lithium carbonate oral TIER 01

LITHOBID TIER 02


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

ADVATE SPECIALTY

ADYNOVATE SPECIALTY

AFSTYLA SPECIALTY

AGRYLIN TIER 03

ALPHANATE/VWF COMPLEX/HUMAN

SPECIALTY

ALPHANINE SD SPECIALTY

ALPROLIX SPECIALTY

AMICAR SPECIALTY

aminocaproic acid oral SPECIALTY

anagrelide hcl TIER 01

ARANESP (ALBUMIN FREE)

SPECIALTY PA

ASTRINGYN TIER 03

BENEFIX SPECIALTY

COAGADEX SPECIALTY

CORIFACT SPECIALTY

DOPTELET SPECIALTY PA

ELOCTATE SPECIALTY

FEIBA SPECIALTY

FIBRYGA SPECIALTY

HEMLIBRA SPECIALTY

HEMOFIL M SPECIALTY

HUMATE-P SPECIALTY

IDELVION SPECIALTY

IXINITY SPECIALTY

JIVI SPECIALTY

KCENTRA TIER 03

KOATE SPECIALTY

KOATE-DVI SPECIALTY

KOGENATE FS SPECIALTY

KOVALTRY SPECIALTY

LEUKINE SPECIALTY PA

LYSTEDA TIER 03

MIRCERA SPECIALTY PA

MONONINE SPECIALTY

MOZOBIL SPECIALTY PA


20


MULPLETA SPECIALTY PA

NEULASTA SPECIALTY PA

NEULASTA ONPRO SPECIALTY PA

NIVESTYM SPECIALTY PA

NOVOEIGHT SPECIALTY

NOVOSEVEN RT SPECIALTY

NPLATE SPECIALTY PA

NUWIQ SPECIALTY

OBIZUR SPECIALTY

PROFILNINE SPECIALTY

PROFILNINE SD SPECIALTY

PROMACTA SPECIALTY PA

REBINYN SPECIALTY

REBLOZYL SPECIALTY PA

RECOMBINATE SPECIALTY

RECOTHROM TIER 03

RECOTHROM SPRAY KIT

TIER 03

RETACRIT SPECIALTY PA

RIASTAP SPECIALTY

RIXUBIS SPECIALTY

TAVALISSE SPECIALTY PA

THROMBIN-JMI TIER 03

THROMBIN-JMI EPISTAXIS

TIER 03

THROMBOGEN TIER 03

tranexamic acid oral TIER 01

TRETTEN SPECIALTY

UDENYCA SPECIALTY PA

VONVENDI SPECIALTY

WILATE SPECIALTY

XYNTHA SPECIALTY

XYNTHA SOLOFUSE SPECIALTY

ZARXIO SPECIALTY PA

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL TIER 03

ACCURETIC TIER 03

acebutolol hcl oral TIER 01


acetazolamide sodium TIER 01

ALDACTAZIDE TIER 03

ALDACTONE TIER 03

aliskiren fumarate TIER 01

alprostadil injection TIER 01

amiloride hcl oral TIER 01

amiloride-hydrochlorothiazide

TIER 01

amiodarone hcl oral TIER 01

amlodipine besylate oral PREVENT

amlodipine besylate-benazepril hcl

PREVENT

amlodipine besylate-valsartan

PREVENT

amlodipine-atorvastatin TIER 01

amlodipine-olmesartan PREVENT

amlodipine-valsartan-hctz

PREVENT

ATACAND HCT TIER 03

atenolol oral PREVENT

atenolol-chlorthalidone TIER 01

atorvastatin calcium oral PREVENT

AVALIDE TIER 03

benazepril hcl oral PREVENT

benazepril-hydrochlorothiazide

PREVENT

BETAPACE AF TIER 03

betaxolol hcl oral TIER 01

BIDIL TIER 03

bisoprolol fumarate TIER 01

bisoprolol-hydrochlorothiazide

TIER 01

bumetanide TIER 01

BUMEX TIER 03

BYSTOLIC TIER 02

CADUET TIER 03

CALAN SR TIER 03

candesartan cilexetil PREVENT

candesartan cilexetil-hctz PREVENT

captopril oral TIER 01


21


captopril-hydrochlorothiazide

TIER 01

CARDIZEM TIER 03

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

TIER 03

CARDURA TIER 03

CAROSPIR TIER 03

cartia xt PREVENT

carvedilol PREVENT

carvedilol phosphate er TIER 01

CATAPRES TIER 03

chlorthalidone TIER 01

cholestyramine light TIER 01

cholestyramine oral TIER 01

clonidine TIER 01

clonidine hcl oral TIER 01

colesevelam hcl TIER 01

colestipol hcl TIER 01

CORLANOR TIER 03 PA

DEMSER TIER 03

DIBENZYLINE TIER 03

digitek TIER 01

digox TIER 01

digoxin injection TIER 01

digoxin oral TIER 01

DILATRATE-SR TIER 03

diltiazem hcl er beads PREVENT

diltiazem hcl er coated beads

PREVENT

diltiazem hcl er oral capsule extended release 12 hour

PREVENT

diltiazem hcl oral PREVENT

dilt-xr PREVENT

disopyramide phosphate TIER 01

DIURIL TIER 03

dofetilide TIER 01

doxazosin mesylate oral TIER 01

DYRENIUM TIER 03


EDARBI TIER 03 ST

EDARBYCLOR TIER 03 ST

EDECRIN TIER 03

enalapril maleate oral PREVENT

enalapril-hydrochlorothiazide

PREVENT

ENTRESTO TIER 02

EPHEDRINE SULFATE (PRESSORS)

TIER 03

epinephrine pf TIER 01

epinephrine solution prefilled syringe 1 mg/10ml injection

TIER 01

EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION

TIER 03

eplerenone TIER 01

ethacrynic acid TIER 01

EZALLOR SPRINKLE TIER 03 ST

ezetimibe TIER 01

ezetimibe-simvastatin TIER 01

felodipine er PREVENT

fenofibrate micronized PREVENT

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

PREVENT

fenofibrate oral capsule 150 mg, 50 mg

TIER 01

fenofibrate oral tablet PREVENT

fenofibric acid TIER 01

FIBRICOR ORAL TABLET 105 MG

TIER 03 ST

FIBRICOR ORAL TABLET 35 MG

TIER 03

flecainide acetate TIER 01

FLOLIPID TIER 03 ST

fluvastatin sodium PREVENT

fluvastatin sodium er PREVENT

fosinopril sodium PREVENT

fosinopril sodium-hctz PREVENT

furosemide injection TIER 01

furosemide oral TIER 01


22


gemfibrozil oral PREVENT

GONITRO TIER 03

guanfacine hcl TIER 01

HEMANGEOL TIER 03

hydralazine hcl injection TIER 01

hydralazine hcl oral TIER 01

hydrochlorothiazide oral PREVENT

indapamide TIER 01

INSPRA TIER 03

irbesartan PREVENT

irbesartan-hydrochlorothiazide

PREVENT

isoproterenol hcl injection

TIER 01

ISORDIL TITRADOSE TIER 03

isosorbide dinitrate TIER 01

isosorbide mononitrate TIER 01

isosorbide mononitrate er

TIER 01

isradipine PREVENT

ISUPREL TIER 03

JUXTAPID SPECIALTY PA

labetalol hcl oral TIER 01

LANOXIN TIER 02

LANOXIN PEDIATRIC TIER 02

LIPOFEN TIER 03

lisinopril oral PREVENT

lisinopril-hydrochlorothiazide

PREVENT

LIVALO TIER 03 ST

LOPID TIER 03

LOPRESSOR TIER 03

LOPRESSOR HCT TIER 03

losartan potassium oral PREVENT

losartan potassium-hctz PREVENT

LOTENSIN TIER 03

LOTENSIN HCT TIER 03

lovastatin PREVENT

matzim la PREVENT

MAXZIDE TIER 03


MAXZIDE-25 TIER 03

methyldopa TIER 01

methyldopa-hydrochlorothiazide

TIER 01

metolazone TIER 01

metoprolol succinate er PREVENT

metoprolol tartrate oral PREVENT

metoprolol-hydrochlorothiazide

TIER 01

metyrosine TIER 01

mexiletine hcl oral TIER 01

midodrine hcl TIER 01

MINIPRESS TIER 03

minitran TIER 01

minoxidil oral TIER 01

moexipril hcl PREVENT

MULTAQ TIER 03

nadolol oral TIER 01

niacin (antihyperlipidemic)

TIER 01

niacin er (antihyperlipidemic)

TIER 01

niacor TIER 01

nicardipine hcl oral TIER 01

nifedipine er PREVENT

nifedipine er osmotic release

PREVENT

nifedipine oral TIER 01

nimodipine oral TIER 01

nisoldipine er TIER 01

NITRO-BID TIER 03

NITRO-DUR TIER 03

nitroglycerin sublingual TIER 01

nitroglycerin transdermal TIER 01

nitroglycerin translingual TIER 01

NITROLINGUAL TIER 03

NITROMIST TIER 03

nitro-time oral capsule extended release 2.5 mg

TIER 01

NORPACE TIER 03

NORPACE CR TIER 02


23


NORTHERA SPECIALTY PA

NYMALIZE TIER 03

olmesartan medoxomil oral

PREVENT

olmesartan medoxomil-hctz

PREVENT

olmesartan-amlodipine-hctz

PREVENT

omega-3-acid ethyl esters

TIER 01 PA

PACERONE ORAL TABLET 100 MG, 400 MG

TIER 03

pacerone oral tablet 200 mg

TIER 01

pentoxifylline er TIER 01

perindopril erbumine TIER 01

phenoxybenzamine hcl oral

TIER 01

phentolamine mesylate injection

TIER 01

pindolol TIER 01

PRALUENT TIER 02 PA

pravastatin sodium PREVENT

prazosin hcl oral TIER 01

PRESTALIA TIER 03

prevalite TIER 01

procainamide hcl injection

TIER 01

PROCARDIA TIER 03

PROCARDIA XL TIER 03

propafenone hcl TIER 01

propafenone hcl er TIER 01

propranolol hcl er PREVENT

propranolol hcl oral solution

TIER 01

propranolol hcl oral tablet PREVENT

propranolol-hctz TIER 01

PROSTIN VR TIER 03

quinapril hcl PREVENT

quinapril-hydrochlorothiazide

PREVENT

quinidine gluconate er TIER 01


quinidine sulfate TIER 01

ramipril PREVENT

ranolazine er TIER 01

RECTIV TIER 03

REPATHA TIER 02 PA

REPATHA PUSHTRONEX SYSTEM

TIER 02 PA

REPATHA SURECLICK TIER 02 PA

rosuvastatin calcium PREVENT

RYTHMOL SR TIER 03

simvastatin oral PREVENT

sorine TIER 01

sotalol hcl (af) TIER 01

sotalol hcl oral TIER 01

SOTYLIZE TIER 03

spironolactone oral TIER 01

spironolactone-hctz TIER 01

SULAR TIER 03

TARKA TIER 03

taztia xt PREVENT

TEKTURNA TIER 02

TEKTURNA HCT TIER 02 ST

telmisartan PREVENT

telmisartan-amlodipine TIER 01

telmisartan-hctz PREVENT

TENORETIC 100 TIER 03

TENORETIC 50 TIER 03

tiadylt er PREVENT

TIAZAC TIER 03

timolol maleate oral TIER 01

torsemide TIER 01

trandolapril PREVENT

trandolapril-verapamil hcl er

TIER 01

triamterene oral TIER 01

triamterene-hctz TIER 01

TRILIPIX TIER 03

TWYNSTA TIER 03

valsartan PREVENT


24


valsartan-hydrochlorothiazide

PREVENT

VASCEPA TIER 03 PA

VASERETIC TIER 03

VECAMYL TIER 03

verapamil hcl er PREVENT

verapamil hcl oral PREVENT

VERELAN TIER 03

VERELAN PM TIER 03

VYNDAMAX SPECIALTY PA

VYNDAQEL SPECIALTY PA

ZIAC TIER 03

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADZENYS ER TIER 03 PA

ADZENYS XR-ODT TIER 03 ST; QL

AMPHETAMINE ER TIER 03 PA

amphetamine sulfate TIER 01 PA

amphetamine-dextroamphetamine

TIER 01 PA

amphetamine-dextroamphetamine er

TIER 01 PA

APTENSIO XR TIER 03 ST; QL

atomoxetine hcl TIER 01

clonidine hcl er TIER 01

COTEMPLA XR-ODT TIER 03 ST; QL

DAYTRANA TIER 03 ST; QL

dexmethylphenidate hcl TIER 01 PA

dexmethylphenidate hcl er

TIER 01 PA

dextroamphetamine sulfate

TIER 01 PA

dextroamphetamine sulfate er

TIER 01 PA

DYANAVEL XR TIER 03 ST; QL

EVEKEO ODT TIER 03 PA

guanfacine hcl er TIER 01

JORNAY PM TIER 03 ST; QL

KAPVAY TIER 03 ST

metadate er TIER 01 PA


methamphetamine hcl TIER 01 PA

METHYLIN TIER 03 ST; QL

methylphenidate hcl er TIER 01 PA

methylphenidate hcl er (cd)

TIER 01 PA

methylphenidate hcl er (la)

TIER 01 PA

methylphenidate hcl oral TIER 01 PA

MYDAYIS TIER 03 ST; QL

PROCENTRA TIER 03 ST; QL

QUILLICHEW ER TIER 03 ST; QL

QUILLIVANT XR TIER 03 ST; QL

relexxii TIER 01 PA

VYVANSE TIER 02 PA

ZENZEDI ORAL TABLET 10 MG, 5 MG

TIER 03 PA

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

TIER 03 ST; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA SPECIALTY PA

AUBAGIO SPECIALTY PA; QL

AVONEX PEN SPECIALTY PA; QL

AVONEX PREFILLED SPECIALTY PA; QL

BAFIERTAM SPECIALTY PA

BETASERON SPECIALTY PA; QL

COPAXONE SPECIALTY PA; QL

dalfampridine er SPECIALTY PA

dimethyl fumarate oral SPECIALTY PA; QL

GILENYA SPECIALTY PA; QL

glatiramer acetate SPECIALTY PA; QL

glatopa SPECIALTY PA; QL

MAVENCLAD (10 TABS) SPECIALTY PA







25



MAYZENT SPECIALTY PA

MAYZENT STARTER PACK

SPECIALTY PA

REBIF SPECIALTY PA; QL

REBIF REBIDOSE SPECIALTY PA; QL

REBIF REBIDOSE TITRATION PACK

SPECIALTY PA; QL

REBIF TITRATION PACK

SPECIALTY PA; QL

TECFIDERA SPECIALTY PA; QL

VUMERITY SPECIALTY PA

VUMERITY (STARTER) SPECIALTY PA

Central Nervous System Agents - Miscellaneous

ADDYI TIER 03 PA

ANECTINE TIER 03

AUSTEDO SPECIALTY PA

benzphetamine hcl TIER 01 PA

caffeine citrate oral TIER 01

CAFFEINE-SODIUM BENZOATE

TIER 03

CONTRAVE TIER 02 PA

diethylpropion hcl er TIER 01 PA

diethylpropion hcl oral TIER 01 PA

GRALISE TIER 03 ST; QL

HORIZANT TIER 03 PA; QL

INGREZZA SPECIALTY PA

LOMAIRA TIER 03 PA

LYRICA CR TIER 03 ST; QL

NUEDEXTA TIER 03 PA

phendimetrazine tartrate TIER 01 PA

phendimetrazine tartrate er

TIER 01 PA

phentermine hcl oral TIER 01 PA

pregabalin oral TIER 01 QL

QSYMIA TIER 03 PA

QUELICIN TIER 03

RILUTEK SPECIALTY PA

riluzole SPECIALTY PA


SAVELLA TIER 03 ST; QL

SAVELLA TITRATION PACK

TIER 03 ST; QL

SAXENDA SPECIALTY PA

SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

succinylcholine chloride solution 20 mg/ml injection

TIER 01

SUCCINYLCHOLINE CHLORIDE SOLUTION 20 MG/ML INJECTION

TIER 03

TEGSEDI SPECIALTY PA

tetrabenazine SPECIALTY PA

TIGLUTIK SPECIALTY PA

VYLEESI TIER 03 PA

XENICAL TIER 03 PA

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

cavarest TIER 01

cevimeline hcl TIER 01

chlorhexidine gluconate mouth/throat

TIER 01

clinpro 5000 TIER 01

DEBACTEROL TIER 03

denta 5000 plus TIER 01

dentagel TIER 01

easygel TIER 01

EVOXAC TIER 03

fluoridex TIER 01

fluoridex daily renewal TIER 01

fluoridex enhanced whitening

TIER 01

fluoridex sensitivity relief TIER 01

lidocaine hcl mouth/throat

TIER 01

lidocaine viscous hcl TIER 01

MI PASTE TIER 03

MI PASTE PLUS TIER 03


26


NAFRINSE DAILY ACIDULATED

TIER 03

NAFRINSE DAILY/NEUTRAL

TIER 03

NAFRINSE WEEKLY TIER 03

neutral sodium fluoride TIER 01

oralone TIER 01

paroex TIER 01

PERIDEX TIER 03

periogard TIER 01

pilocarpine hcl oral TIER 01

PREVIDENT 5000 BOOSTER PLUS

TIER 03

PREVIDENT 5000 DRY MOUTH

TIER 03

PREVIDENT 5000 ENAMEL PROTECT

TIER 03

PREVIDENT 5000 ORTHO DEFENSE

TIER 03

PREVIDENT 5000 PLUS TIER 03

PREVIDENT 5000 SENSITIVE

TIER 03

PREVIDENT DENTAL TIER 03

prevident mouth/throat TIER 01

REMESENSE TIER 03

SALAGEN TIER 03

sf TIER 01

sf 5000 plus TIER 01

sodium fluoride 5000 plus

TIER 01

sodium fluoride 5000 ppm

TIER 01

sodium fluoride 5000 sensitive

TIER 01

sodium fluoride dental TIER 01

TOPEX TOPICAL ANESTHETIC

TIER 03

triamcinolone acetonide mouth/throat

TIER 01

Dermatological Agents - Drugs for Skin Conditions

ABSORICA LD TIER 03 PA


acitretin TIER 01

ACTICOAT EXTERNAL SHEET 16"X16"

TIER 03

ACZONE EXTERNAL GEL 7.5 %

TIER 02

adapalene external cream

TIER 01 PA

adapalene external gel TIER 01 PA

ADAPALENE EXTERNAL SOLUTION

TIER 03 PA

adapalene-benzoyl peroxide

TIER 01

ala-cort TIER 01

alclometasone dipropionate

TIER 01

ALCOHOL PREP PADS EXTERNAL 70 %

TIER 03

ALTRENO TIER 03 PA

amcinonide TIER 01

ammonium lactate external

TIER 01

amnesteem TIER 01 PA

AMNIOCORE HUMAN TISSUE EXTERNAL DISK

TIER 03

AMNIOCORE HUMAN TISSUE EXTERNAL SHEET 2 CM X 12 CM , 6 CM X 16 CM , 6 CM X 9 CM , 9 CM X 20 CM

TIER 03

AMZEEQ TIER 03

ARIDA TIER 03

ATRALIN TIER 03 PA

avita TIER 01 PA

AZADROX TIER 03

azelaic acid external TIER 01

AZELEX TIER 03

balsam peru-castor oil TIER 01

benzoyl peroxide-erythromycin

TIER 01

beser external lotion TIER 01

betamethasone dipropionate aug

TIER 01


27


betamethasone dipropionate external

TIER 01

betamethasone valerate external

TIER 01

BIAFINE TIER 03

BIONECT EXTERNAL CREAM

TIER 03

BIOSTEP AG EXTERNAL SHEET 4"X4"

TIER 03

BPCO TIER 03

calcipotriene external cream

TIER 01

calcipotriene external ointment

TIER 01

calcipotriene external solution

TIER 01

calcipotriene-betameth diprop

TIER 01 QL

CALCITRENE TIER 03

calcitriol external TIER 01

CARAC TIER 03

claravis TIER 01 PA

CLEOCIN-T EXTERNAL LOTION

TIER 03

clindacin etz external swab

TIER 01

clindacin-p TIER 01

clindamycin phosphate-benzoyl peroxide

TIER 01

clindamycin phosphate external

TIER 01

clindamycin-tretinoin TIER 01

clobetasol prop emollient base

TIER 01

clobetasol propionate e TIER 01

clobetasol propionate emulsion

TIER 01

clobetasol propionate external

TIER 01

clocortolone pivalate TIER 01

clodan external shampoo TIER 01

coal tar external TIER 01

CONDYLOX TIER 03


CORTISPORIN TIER 03

CUTIVATE TIER 03

dapsone external gel 5 %

TIER 01

DERMA-SMOOTHE/FS BODY

TIER 03

DERMA-SMOOTHE/FS SCALP

TIER 03

DERMULCERA TIER 03

desonide external TIER 01

DESOWEN TIER 03

desoximetasone external TIER 01

diclofenac sodium transdermal gel 3 %

TIER 01 ST; QL

diflorasone diacetate TIER 01

DIPROLENE TIER 03

DIPROLENE AF TIER 03

DOVONEX TIER 03

doxepin hcl external TIER 01

doxycycline TIER 01

DRYSOL TIER 03

DUPIXENT SPECIALTY PA

DURAFIBER TIER 03

EFUDEX TIER 03

EPIDUO FORTE TIER 03

EPIFOAM TIER 03

ery TIER 01

ERYGEL TIER 03

erythromycin external TIER 01

EUCRISA TIER 02 ST

EVOCLIN TIER 03

FINACEA EXTERNAL FOAM

TIER 03 ST

fluocinolone acetonide body

TIER 01

fluocinolone acetonide external

TIER 01

fluocinolone acetonide scalp

TIER 01

fluocinonide emulsified base

TIER 01

fluocinonide external TIER 01


28


FLUOROPLEX TIER 03

FLUOROURACIL EXTERNAL CREAM 0.5 %

TIER 02

fluorouracil external cream 5 %

TIER 01

fluorouracil external solution

TIER 01

flurandrenolide TIER 01

fluticasone propionate external

TIER 01

GORDOFILM TIER 03

halcinonide TIER 01

halobetasol propionate external cream

TIER 01

halobetasol propionate external ointment

TIER 01

hydrocortisone butyr lipo base

TIER 01

hydrocortisone butyrate TIER 01

hydrocortisone external cream 1 %, 2.5 %

TIER 01

hydrocortisone external lotion 2.5 %

TIER 01

hydrocortisone external ointment 1 %, 2.5 %

TIER 01

hydrocortisone valerate TIER 01

imiquimod external TIER 01

isotretinoin oral TIER 01 PA

KERAMATRIX REPLICINE 5CMX5CM

TIER 03

KLARON TIER 03

lactic acid e TIER 01

lactic acid external TIER 01

LEVULAN KERASTICK TIER 03

LUXIQ TIER 03

methoxsalen rapid TIER 01

METROCREAM TIER 03

METROLOTION TIER 03

metronidazole external TIER 01

MICROCYN EXTERNAL LIQUID 0.023 %

TIER 03

MIRVASO TIER 02


mometasone furoate external

TIER 01

myorisan TIER 01 PA

NEO-SYNALAR EXTERNAL CREAM

TIER 03

neuac external gel TIER 01

nolix TIER 01

NORMLGEL AG TIER 03

NOVACHOR TIER 03

NUCEL INJECTION INJECTABLE 2.5 ML

TIER 03

NUSHIELD EXTERNAL DISK

TIER 03

OLUX TIER 03

OLUX-E TIER 03

ONEXTON TIER 03

OSTEOCONDUCTIVE MATRIX PLUS

TIER 03

OXSORALEN ULTRA TIER 03

PICATO TIER 03 ST

pimecrolimus TIER 01

podofilox external TIER 01

PRAMOSONE EXTERNAL CREAM 1-1 %

TIER 02

PRAMOSONE EXTERNAL LOTION

TIER 03

prednicarbate TIER 01

PROTOPIC TIER 03

PYROGALLIC ACID TIER 03

QBREXZA TIER 03 QL

RADIAPLEXRX TIER 03

REGENECARE TIER 03

REGRANEX TIER 03 PA

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

TIER 02 PA

RHOFADE TIER 03

rosadan external cream TIER 01

rosadan external gel TIER 01

SANTYL TIER 03

SCENESSE SPECIALTY PA


29


selenium sulfide external lotion

TIER 01

SERNIVO TIER 03

SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2"X3"

TIER 03

SOOLANTRA TIER 02

SORIATANE TIER 03

sulfacetamide sodium (acne)

TIER 01

SYNALAR TIER 03

TACLONEX EXTERNAL SUSPENSION

TIER 03 QL

tacrolimus external ointment

TIER 01

tazarotene external TIER 01

TAZORAC EXTERNAL CREAM 0.05 %

TIER 03

TAZORAC EXTERNAL GEL

TIER 03

TEMOVATE TIER 03

TEXACORT TIER 03

THERAHONEY EXTERNAL SHEET

TIER 03

TOLAK TIER 03

TOPICORT EXTERNAL CREAM 0.25 %

TIER 03

TOPICORT EXTERNAL GEL

TIER 03

TOPICORT EXTERNAL OINTMENT

TIER 03

tovet external foam TIER 01

tretinoin external TIER 01 PA

tretinoin microsphere TIER 01 PA

tretinoin microsphere pump

TIER 01 PA

triamcinolone acetonide external

TIER 01

trianex TIER 01

TRI-CHLOR TIER 03

triderm TIER 01

TRIDESILON TIER 03

vashe cleansing TIER 01


VENELEX TIER 03

XALIX TIER 03

XERAC AC TIER 03

XEROFORM OIL EMULSION 2"X2"

TIER 03

XEROFORM OIL EMULSION GAUZE

TIER 03

XEROFORM OIL EMULSION STRIP

TIER 03

XEROFORM OIL ROLL 4"X9'

TIER 03

XEROFORM PETROLAT GAUZE 1"X8"

TIER 03

XEROFORM PETROLAT GAUZE 5"X9"

TIER 03

XEROFORM PETROLAT PATCH 2"X2"

TIER 03

XEROFORM PETROLAT PATCH 4"X4"

TIER 03

XEROFORM PETROLATUM ROLL 4"X9'

TIER 03

zenatane TIER 01 PA

Diabetes - Antidiabetic Agents

acarbose oral TIER 01

ACTOPLUS MET TIER 03

ACTOS TIER 03

AMARYL TIER 03

AVANDIA TIER 03 ST

BYDUREON TIER 02 ST; QL

BYDUREON BCISE AUTOINJECTOR

TIER 02 ST; QL

BYETTA 10 MCG PEN TIER 02 ST; QL

BYETTA 5 MCG PEN TIER 02 ST; QL

CYCLOSET TIER 03 ST

DUETACT TIER 03

FARXIGA TIER 02 ST

glimepiride PREVENT

glipizide er PREVENT


30


glipizide ir PREVENT

glipizide xl PREVENT

glipizide-metformin hcl PREVENT

GLUCOTROL TIER 03

GLUCOTROL XL TIER 03

glyburide micronized PREVENT

glyburide oral PREVENT

glyburide-metformin PREVENT

GLYNASE TIER 03

GLYSET TIER 03

GLYXAMBI TIER 02 ST

JANUMET TIER 02 ST

JANUMET XR TIER 02 ST

JANUVIA TIER 02 ST

JARDIANCE TIER 02 ST

JENTADUETO TIER 02 ST

JENTADUETO XR TIER 02 ST

metformin hcl er PREVENT

metformin hcl oral solution

TIER 01

metformin hcl oral tablet PREVENT

miglitol TIER 01

nateglinide TIER 01

OZEMPIC TIER 02 ST; QL

pioglitazone hcl PREVENT

pioglitazone hcl-glimepiride

TIER 01

pioglitazone hcl-metformin hcl

PREVENT

PRECOSE TIER 03

repaglinide PREVENT

RIOMET TIER 03 ST

RIOMET ER TIER 03 ST

RYBELSUS TIER 02 ST; QL

SOLIQUA TIER 02 ST; QL

STARLIX TIER 03

SYMLINPEN 120 TIER 03 PA

SYMLINPEN 60 TIER 03 PA

SYNJARDY TIER 02 ST

SYNJARDY XR TIER 02 ST


tolbutamide TIER 01

TRADJENTA TIER 02 ST

TRIJARDY XR TIER 02 ST

TRULICITY TIER 02 ST; QL

VICTOZA TIER 02 ST; QL

XIGDUO XR TIER 02 ST

XULTOPHY TIER 03 ST; QL

Diabetes - Glucose Monitoring

ACCU-CHEK FASTCLIX LANCET KIT

TIER 02

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

TIER 02

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

TIER 02

AUTOLET LANCING DEVICE

TIER 03

BLUESTAR TIER 03

CARETOUCH LANCING/EJECTOR

TIER 03

CEQUR SIMPLICITY 2U PREVENT

CEQUR SIMPLICITY INSERTER

TIER 03

CEQUR SIMPLICITY STARTER

TIER 03

CHEMSTRIP UGK TIER 03

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

TIER 02

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

TIER 02

DIATHRIVE LANCING DEVICE

TIER 03

ENLITE GLUCOSE SENSOR

TIER 03

EVERSENSE SENSOR/HOLDER

TIER 03


31


EVERSENSE SMART TRANSMITTER

TIER 03

FREESTYLE LIBRE 14 DAY READER

PREVENT

FREESTYLE LIBRE 14 DAY SENSOR

PREVENT

FREESTYLE LIBRE 2 READER SYSTM

PREVENT

FREESTYLE LIBRE 2 SENSOR SYSTM

PREVENT

GENTEEL LANCING KIT (BLUE)

TIER 03

GOJJI LANCING DEVICE/CLEAR CAP

TIER 03

GUARDIAN CONNECT TRANSMITTER

TIER 03

GUARDIAN LINK 3 TRANSMITTER

TIER 03

GUARDIAN REAL-TIME SYSTEM

TIER 03

GUARDIAN SENSOR (3) TIER 03

INPEN 100-BLUE-LILLY TIER 03

INPEN 100-BLUE-NOVO TIER 03

INPEN 100-GRAY-LILLY TIER 03

INPEN 100-GREY-NOVO

TIER 03

INPEN 100-PINK-LILLY TIER 03

INPEN 100-PINK-NOVO TIER 03

KETONE TEST TIER 03

KETOSTIX TIER 03

LANCETS TIER 02

LANCETS TIER 03

LANCETS KIT TIER 03

MICROLET NEXT LANCING DEVICE

TIER 03

MINIMED GUARDIAN SENSOR 3

TIER 03

NOVOPEN ECHO TIER 03

OMNIPOD DASH SYSTEM

TIER 03

OMNIPOD STARTER TIER 03

ONETOUCH DELICA LANCING DEV

PREVENT


ONETOUCH DELICA PLUS LANCING

TIER 03

ONETOUCH ULTRA TIER 02

ONETOUCH ULTRA 2 KIT W/DEVICE

TIER 02

ONETOUCH ULTRA MINI KIT W/DEVICE

TIER 02

ONETOUCH VERIO KIT W/DEVICE

PREVENT

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

PREVENT

ONETOUCH VERIO IN VITRO SOLUTION HIGH

TIER 03

ONETOUCH VERIO TEST STRIPS

PREVENT

ONETOUCH VERIO IQ SYSTEM

PREVENT

ONETOUCH VERIO REFLECT KIT W/DEVICE

PREVENT

ONETOUCH VERIO REFLECT KIT W/DEVICE

TIER 03

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

TIER 02

PARADIGM REAL-TIME STARTER

TIER 03

SOF-SENSOR TIER 03

SURESTEP PRO HIGH GLUCOSE

TIER 03

SURESTEP PRO LOW GLUCOSE

TIER 03

SURESTEP PRO NORMAL GLUCOSE

TIER 03

VIVAGUARD LANCING DEVICE

TIER 03

Diabetes - Glycemic Agents

BAQSIMI ONE PACK TIER 02

BAQSIMI TWO PACK TIER 02

diazoxide oral TIER 01

GLUCAGEN HYPOKIT TIER 03 ST


32


GLUCAGON EMERGENCY KIT

TIER 02

GVOKE HYPOPEN 1-PACK

TIER 02

GVOKE HYPOPEN 2-PACK

TIER 02

GVOKE PFS TIER 02

PROGLYCEM TIER 03

Diabetes - Insulins

AFREZZA TIER 03 PA

BD AUTOSHIELD DUO PEN NEEDLES

PREVENT

BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML

TIER 02

BD ULTRA-FINE INSULIN SYRINGES

PREVENT

BD ULTRA-FINE PEN NEEDLES

PREVENT

BD ULTRA-FINE PEN NEEDLES

TIER 02

BD VEO INSULIN SYR U/F 1/2UNIT

PREVENT

DROPLET MICRON TIER 02

HUMALOG KWIKPEN PREVENT

HUMALOG MIX 50/50 KWIKPEN

PREVENT

HUMALOG MIX 50/50 VIAL

PREVENT

HUMALOG MIX 75/25 KWIKPEN

PREVENT

HUMALOG MIX 75/25 VIAL

PREVENT

HUMALOG U-100 JUNIOR KWIKPEN

PREVENT

HUMALOG VIAL PREVENT

HUMULIN 70/30 KWIKPEN

PREVENT

HUMULIN 70/30 VIAL PREVENT

HUMULIN N KWIKPEN PREVENT

HUMULIN N VIAL PREVENT


HUMULIN R U-500 KWIKPEN

TIER 02

HUMULIN R U-500 VIAL TIER 02

HUMULIN R VIAL PREVENT

INSULIN LISPRO PROT & LISPRO

PREVENT

INSULIN PEN NEEDLES TIER 02

INSULIN SYRINGES TIER 02

LANTUS SOLOSTAR PREVENT

LANTUS U-100 VIAL PREVENT

LEVEMIR U-100 FLEXTOUCH

PREVENT

LEVEMIR U-100 VIAL PREVENT

MAXICOMFORT SYR 27G X 1/2"

TIER 02

NOVOFINE AUTOCOVER PEN NEEDLE

TIER 02

NOVOFINE PEN NEEDLE

TIER 02

NOVOFINE PLUS PEN NEEDLE

TIER 02

NOVOTWIST PEN NEEDLE

TIER 02

TOUJEO MAX SOLOSTAR

TIER 02

TOUJEO SOLOSTAR TIER 02

Electrolytes / Minerals / Metals / Vitamins

AQUASOL A TIER 03

ARGININE HCL INJECTION

TIER 03

CALCIFOL TIER 03

CARBAGLU SPECIALTY

CHEMET TIER 03

clovique SPECIALTY PA

cyanocobalamin injection solution 1000 mcg/ml

TIER 01

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

TIER 03

deferasirox SPECIALTY PA

deferasirox granules SPECIALTY PA


33


dehydrated alcohol TIER 01

DEXPANTHENOL INJECTION

TIER 03

DRISDOL TIER 03

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

TIER 03

effer-k oral tablet effervescent 25 meq

TIER 01

ergocalciferol oral capsule

TIER 01

EXJADE SPECIALTY PA

FERRIPROX SPECIALTY PA

FERRIPROX TWICE-A-DAY

SPECIALTY PA

FLUORABON TIER 02

fluoritab TIER 01

FLURA-DROPS TIER 02

folic acid injection TIER 01

folic acid oral tablet 1 mg TIER 01

GALZIN TIER 03

GLUTATHIONE INJECTION SOLUTION 200 MG/ML

TIER 03

GLYCINE INJECTION TIER 03

hematinic/folic acid TIER 01

hemocyte-f TIER 01

hydroxocobalamin acetate

TIER 01

iodine strong oral TIER 01

JADENU SPECIALTY PA

JADENU SPRINKLE SPECIALTY PA

JYNARQUE SPECIALTY QL

kionex TIER 01

klor-con TIER 01

klor-con 10 TIER 01

klor-con m10 TIER 01

KLOR-CON M15 TIER 03

klor-con m20 TIER 01

klor-con sprinkle TIER 01

klor-con/ef TIER 01


K-PHOS TIER 03

K-PHOS-NEUTRAL TIER 03

k-prime TIER 01

LEVOCARNITINE INJECTION

TIER 03

levocarnitine oral solution

TIER 01

levocarnitine oral tablet TIER 01

levocarnitine sf TIER 01

LIPO TIER 03

LIPO-C TIER 03

LOKELMA TIER 03

ludent TIER 01

LYSINE HCL INJECTION

TIER 03

MAGNEBIND 400 TIER 03

magnesium chloride injection

TIER 01

magnesium sulfate solution 50 % injection

TIER 01

MAGNESIUM SULFATE SOLUTION 50 % INJECTION

TIER 03

MEPHYTON TIER 03

METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED

TIER 03

n-acetyl-l-cysteine oral TIER 01

nafrinse TIER 01

nafrinse drops TIER 01

NASCOBAL TIER 03

NEOKE ALCAR TIER 03

ORACIT TIER 03

phospha 250 neutral TIER 01

phosphorous TIER 01

phospho-trin 250 neutral TIER 01

phytonadione injection TIER 01

phytonadione oral TIER 01

pot bicarb-pot chloride TIER 01

potassium bicarbonate oral

TIER 01


34


potassium chloride crys er

TIER 01

potassium chloride er TIER 01

potassium chloride oral TIER 01

potassium citrate er TIER 01

prenatal oral tablet 27-1 mg

PREVENT

PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION

TIER 03

pyridoxine hcl solution 100 mg/ml injection

TIER 01

saline bacteriostatic TIER 01

SALINE-PHENOL TIER 03

SAMSCA SPECIALTY QL

sod citrate-citric acid TIER 01

sodium chloride (pf) TIER 01

sodium chloride bacteriostatic

TIER 01

sodium chloride injection TIER 01

sodium fluoride oral TIER 01

sodium polystyrene sulfonate

TIER 01

sps TIER 01

TAURINE INJECTION TIER 03

thiamine hcl injection TIER 01

tolvaptan SPECIALTY QL

TRI-AMINO TIER 03

trientine hcl SPECIALTY PA

TRIFERIC HEMODIALYSIS PACKET

TIER 03

UROCIT-K 10 TIER 03

UROCIT-K 15 TIER 03

UROCIT-K 5 TIER 03

VELTASSA TIER 03

virt-phos 250 neutral TIER 01

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

TIER 01

vitamin k1 injection TIER 01


Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

CARAFATE ORAL SUSPENSION

TIER 03

cimetidine hcl TIER 01

cimetidine oral TIER 01

CYTOTEC TIER 03

DEXILANT TIER 02

esomeprazole magnesium

TIER 01

famotidine oral suspension reconstituted

TIER 01

famotidine oral tablet 20 mg, 40 mg

TIER 01

FIRST-LANSOPRAZOLE

TIER 03 ST

FIRST-OMEPRAZOLE TIER 03 ST

lansoprazole oral TIER 01

misoprostol oral TIER 01

NEXIUM ORAL PACKET TIER 03

nizatidine TIER 01

omeprazole oral capsule delayed release

TIER 01

OMEPRAZOLE+SYRSPEND SF ALKA

TIER 03 ST

pantoprazole sodium oral packet

TIER 01 ST; QL

pantoprazole sodium oral tablet delayed release

TIER 01

PRILOSEC TIER 03 ST; QL

PROTONIX ORAL PACKET

TIER 03 ST; QL

rabeprazole sodium oral tablet delayed release

TIER 01

sucralfate oral TIER 01

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL TIER 03

alosetron hcl TIER 01 PA

amoxicill-clarithro-lansopraz

TIER 01


35


ANASPAZ TIER 03

ATROPEN TIER 03

atropine sulfate injection solution 8 mg/20ml

TIER 01

atropine sulfate injection solution prefilled syringe

TIER 01

BENTYL TIER 03

cascara sagrada oral fluid extract

TIER 01

CHENODAL SPECIALTY PA

chlordiazepoxide-clidinium

TIER 01

CLENPIQ TIER 03

constulose TIER 01

cromolyn sodium oral TIER 01

CUVPOSA TIER 03

dicyclomine hcl intramuscular

TIER 01

dicyclomine hcl oral TIER 01

diphenoxylate-atropine TIER 01

ed-spaz TIER 01

ENTEREG TIER 03

enulose TIER 01

GASTROCROM TIER 03

GATTEX SPECIALTY PA

gavilyte-c TIER 01

gavilyte-g TIER 01

gavilyte-h TIER 01

gavilyte-n with flavor pack

TIER 01

generlac TIER 01

glycopyrrolate injection solution

TIER 01

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

glycopyrrolate oral tablet 1 mg, 2 mg

TIER 01

glycopyrrolate pf TIER 01

GLYRX-PF TIER 03

HELIDAC THERAPY TIER 03

hyoscyamine sulfate oral TIER 01


hyoscyamine sulfate sl TIER 01

hyoscyamine sulfate sublingual

TIER 01

hyosyne TIER 01

lactulose TIER 01

lactulose encephalopathy

TIER 01

LINZESS TIER 02 ST; QL

LOMOTIL TIER 03

loperamide hcl oral capsule

TIER 01

methscopolamine bromide oral

TIER 01

mineral oil heavy oral TIER 01

MOTEGRITY TIER 03 ST; QL

MYTESI TIER 03 QL

nulev TIER 01

OMECLAMOX-PAK TIER 02

oscimin TIER 01

OSMOPREP TIER 03

peg 3350-kcl-na bicarb-nacl

TIER 01

peg-3350/electrolytes TIER 01

peg-prep TIER 01

phenobarbital-belladonna alk

TIER 01

PLENVU TIER 03

propantheline bromide oral

TIER 01

PYLERA TIER 02

RESTORA RX TIER 03

SEROSTIM SPECIALTY PA

sodium bicarbonate oral powder

TIER 01

SUPREP BOWEL PREP KIT

TIER 03

SYMPROIC SPECIALTY ST; QL

TALICIA TIER 03

trilyte TIER 01

URSO 250 TIER 03

URSO FORTE TIER 03

ursodiol oral TIER 01


36


VIBERZI TIER 03 PA

XERMELO SPECIALTY PA

ZELNORM TIER 03

ZORBTIVE SPECIALTY PA

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

BRINEURA SPECIALTY PA

BUPHENYL SPECIALTY

CERDELGA SPECIALTY PA

CHOLBAM SPECIALTY PA

CREON TIER 02

CRYSVITA SPECIALTY PA

CYSTADANE SPECIALTY

CYSTAGON SPECIALTY

GALAFOLD SPECIALTY PA

KUVAN SPECIALTY PA

miglustat SPECIALTY PA

MYALEPT SPECIALTY PA

nitisinone SPECIALTY PA

NITYR SPECIALTY PA

OCALIVA SPECIALTY PA

ORFADIN SPECIALTY PA

PALYNZIQ SPECIALTY PA

PROCYSBI SPECIALTY PA

RAVICTI SPECIALTY PA

REVCOVI SPECIALTY PA

sodium phenylbutyrate oral

SPECIALTY

STRENSIQ SPECIALTY PA

SUCRAID SPECIALTY

XURIDEN SPECIALTY PA

ZAVESCA SPECIALTY PA

ZENPEP TIER 02

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA TIER 03


bethanechol chloride oral TIER 01

calcium acetate (phos binder)

TIER 01

calcium acetate oral tablet 667 mg

TIER 01

CUPRIMINE SPECIALTY PA

darifenacin hydrobromide er

TIER 01

DEPEN TITRATABS SPECIALTY

DETROL TIER 03

DETROL LA TIER 03

DITROPAN XL TIER 03

ELMIRON TIER 02

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

TIER 03

flavoxate hcl TIER 01

FOSRENOL TIER 03

GELNIQUE TIER 03 ST

INTRAROSA TIER 03

lanthanum carbonate TIER 01

LITHOSTAT TIER 03

MUSE TIER 03 QL

MYRBETRIQ TIER 02

oxybutynin chloride er TIER 01

oxybutynin chloride oral TIER 01

OXYTROL TIER 03 ST; QL

penicillamine oral capsule

SPECIALTY PA

penicillamine oral tablet SPECIALTY

phenazo oral tablet 200 mg

TIER 01

phenazopyridine hcl oral tablet 100 mg, 200 mg

TIER 01

PHOSLYRA TIER 03

RIMSO-50 TIER 03

sevelamer carbonate TIER 01

sevelamer hcl TIER 01

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

TIER 01 QL


37


solifenacin succinate TIER 01

tadalafil oral TIER 01 QL

THIOLA SPECIALTY

THIOLA EC SPECIALTY

tolterodine tartrate TIER 01

tolterodine tartrate er TIER 01

TOVIAZ TIER 03

trospium chloride TIER 01

trospium chloride er TIER 01

uretron d/s TIER 01

urin ds TIER 01

utrona-c TIER 01

vardenafil hcl oral TIER 01 QL

VELPHORO TIER 03

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er TIER 01

CARDURA XL TIER 03 ST

dutasteride oral TIER 01

dutasteride-tamsulosin hcl

TIER 01

finasteride oral tablet 5 mg

TIER 01

JALYN TIER 03

PROSCAR TIER 03

RAPAFLO TIER 03

silodosin TIER 01

tamsulosin hcl PREVENT

terazosin hcl TIER 01

Hormonal Agents - Adrenal

betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml

TIER 01

CELESTONE SOLUSPAN

TIER 03

cortisone acetate oral TIER 01

DEPO-MEDROL TIER 03

DEXAMETHASONE (LA) TIER 03

dexamethasone intensol TIER 01


dexamethasone oral TIER 01

dexamethasone sod phosphate pf

TIER 01

dexamethasone sodium phosphate injection

TIER 01

DEXONTO 0.4% TIER 03

fludrocortisone acetate oral

TIER 01

hydrocortisone oral TIER 01

KENALOG INJECTION SUSPENSION 10 MG/ML

TIER 03

KENALOG-80 TIER 03

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

TIER 03

MEDROL ORAL TABLET 2 MG

TIER 02

MEDROL ORAL TABLET THERAPY PACK

TIER 03

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML

TIER 03

methylprednisolone acetate suspension 40 mg/ml injection

TIER 01

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION

TIER 03

methylprednisolone acetate suspension 80 mg/ml injection

TIER 01

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION

TIER 03

methylprednisolone oral TIER 01

methylprednisolone sodium succ

TIER 01

METHYLPREDNISOLONE-BUPIVACAINE

TIER 03

MILLIPRED TIER 02


38


MILLIPRED DP 12-DAY TIER 03

ORAPRED ODT TIER 03

PEDIAPRED TIER 03

prednisolone oral solution

TIER 01

prednisolone sodium phosphate oral

TIER 01

prednisone intensol TIER 01

prednisone oral TIER 01

SOLU-CORTEF TIER 03

SOLU-MEDROL TIER 03

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION

TIER 03

triamcinolone acetonide suspension 40 mg/ml injection

TIER 01

TRIAMCINOLONE DIACETATE INJECTION SUSPENSION 80 MG/ML

TIER 03

TRIAMCINOLONE-BUPIVACAINE

TIER 03

Hormonal Agents - Men's Health

ANADROL-50 TIER 03 PA

ANDRODERM TIER 02 PA

danazol oral TIER 01

METHITEST TIER 03 PA

methyltestosterone oral TIER 01 PA

NATESTO TIER 03 PA

oxandrolone oral TIER 01 PA; QL

testosterone cypionate intramuscular

TIER 01 PA

testosterone enanthate intramuscular

TIER 01 PA

testosterone transdermal TIER 01 PA

XYOSTED TIER 03 PA

Hormonal Agents - Osteoporosis

EVISTA TIER 03

OSPHENA TIER 03


raloxifene hcl TIER 01

Hormonal Agents - Pituitary

ACTHAR SPECIALTY PA

cabergoline TIER 01

chorionic gonadotropin intramuscular

SPECIALTY

clomiphene citrate oral TIER 01

DDAVP TIER 03

DDAVP RHINAL TUBE TIER 02

desmopressin ace spray refrig

TIER 01

desmopressin acetate injection

TIER 01

desmopressin acetate oral

TIER 01

desmopressin acetate spray

TIER 01

EGRIFTA SV SPECIALTY PA; QL

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 45 MG

SPECIALTY PA; QL

ELIGARD SUBCUTANEOUS KIT 30 MG

SPECIALTY PA

ELIGARD SUBCUTANEOUS KIT 7.5 MG

SPECIALTY QL

FIRMAGON SPECIALTY PA; QL

FIRMAGON (240 MG DOSE)

SPECIALTY PA; QL

FOLLISTIM AQ SPECIALTY

ganirelix acetate SPECIALTY

INCRELEX SPECIALTY PA

leuprolide acetate injection

SPECIALTY

LEUPROLIDE ACETATE-BUPIVACAINE

TIER 03

LUPANETA PACK SPECIALTY PA; QL

LUPRON DEPOT (1-MONTH)

SPECIALTY

LUPRON DEPOT (3-MONTH)

SPECIALTY PA


39


LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

SPECIALTY PA

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

SPECIALTY PA

LUPRON DEPOT-PED (1-MONTH)

SPECIALTY PA

LUPRON DEPOT-PED (3-MONTH)

SPECIALTY PA

MENOPUR SPECIALTY

NOCDURNA TIER 03

NORDITROPIN FLEXPRO

SPECIALTY PA

novarel intramuscular solution reconstituted 10000 unit

SPECIALTY

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

SPECIALTY

NUTROPIN AQ NUSPIN 10

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

octreotide acetate SPECIALTY PA

ORILISSA TIER 02 PA

OVIDREL SPECIALTY

oxytocin injection TIER 01

PITOCIN TIER 03

pregnyl SPECIALTY

SIGNIFOR SPECIALTY PA

SIGNIFOR LAR SPECIALTY PA

SOMATULINE DEPOT SPECIALTY PA

SOMAVERT SPECIALTY PA

STIMATE SPECIALTY

SUPPRELIN LA SPECIALTY PA; QL

SYNAREL SPECIALTY

TRELSTAR MIXJECT SPECIALTY PA; QL


TRIPTODUR SPECIALTY PA; QL

VANTAS SPECIALTY PA; QL

ZOLADEX SPECIALTY QL

Hormonal Agents - Prostaglandins

KORLYM SPECIALTY PA

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA TIER 03

afirmelle TIER 01

ALORA TIER 03

altavera TIER 01

alyacen 1/35 TIER 01

alyacen 7/7/7 TIER 01

amabelz TIER 01

amethia TIER 01 QL

amethia lo TIER 01 QL

amethyst TIER 01

ANGELIQ TIER 03

apri TIER 01

aranelle TIER 01

ashlyna TIER 01 QL

aubra TIER 01

aubra eq TIER 01

aurovela 1.5/30 TIER 01

aurovela 1/20 TIER 01

aurovela 24 fe TIER 01

aurovela fe 1.5/30 TIER 01

aurovela fe 1/20 TIER 01

aviane TIER 01

AYGESTIN TIER 03

ayuna TIER 01

azurette TIER 01

balziva TIER 01

bekyree TIER 01

BIJUVA TIER 03

blisovi 24 fe TIER 01

blisovi fe 1.5/30 TIER 01

blisovi fe 1/20 TIER 01


40


briellyn TIER 01

camila TIER 01

camrese TIER 01 QL

camrese lo TIER 01 QL

caziant TIER 01

charlotte 24 fe TIER 01

chateal TIER 01

chateal eq TIER 01

CLIMARA PRO TIER 02

COMBIPATCH TIER 03

CRINONE TIER 03

cryselle-28 TIER 01

cyclafem 1/35 TIER 01

cyclafem 7/7/7 TIER 01

cyred TIER 01

cyred eq TIER 01

dasetta 1/35 TIER 01

dasetta 7/7/7 TIER 01

daysee TIER 01 QL

deblitane TIER 01

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

TIER 03

delyla TIER 01

DEPO-ESTRADIOL TIER 03

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

TIER 03 QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

TIER 03

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

TIER 03 QL

DEPO-SUBQ PROVERA 104

TIER 03 QL

desogestrel-ethinyl estradiol

TIER 01

DIVIGEL TIER 03

dotti TIER 01


drospiren-eth estrad-levomefol

TIER 01

drospirenone-ethinyl estradiol

TIER 01

DUAVEE TIER 02

ELESTRIN TIER 03

elinest TIER 01

ELLA TIER 03

eluryng TIER 01

emoquette TIER 01

ENDOMETRIN TIER 02

enpresse-28 TIER 01

enskyce TIER 01

errin TIER 01

estarylla TIER 01

estradiol oral TIER 01

estradiol transdermal TIER 01

estradiol vaginal TIER 01

estradiol valerate intramuscular

TIER 01

estradiol-norethindrone acet

TIER 01

ESTRING TIER 03 QL

ESTROGEL TIER 03

ESTROSTEP FE TIER 03

ethynodiol diac-eth estradiol

TIER 01

etonogestrel-ethinyl estradiol

TIER 01

EVAMIST TIER 03

falmina TIER 01

fayosim TIER 01 QL

FEMHRT LOW DOSE TIER 03

FEMRING TIER 03 QL

femynor TIER 01

fyavolv TIER 01

gianvi TIER 01

hailey 1.5/30 TIER 01

hailey 24 fe TIER 01

hailey fe 1.5/30 TIER 01

hailey fe 1/20 TIER 01


41


heather TIER 01

hydroxyprogesterone caproate intramuscular oil

SPECIALTY

hydroxyprogesterone caproate intramuscular solution

SPECIALTY PA

IMVEXXY MAINTENANCE PACK

TIER 03

IMVEXXY STARTER PACK

TIER 03

incassia TIER 01

introvale TIER 01 QL

isibloom TIER 01

jaimiess TIER 01 QL

jasmiel TIER 01

jencycla TIER 01

jinteli TIER 01

jolessa TIER 01 QL

juleber TIER 01

junel 1.5/30 TIER 01

junel 1/20 TIER 01

junel fe 1.5/30 TIER 01

junel fe 1/20 TIER 01

junel fe 24 TIER 01

kaitlib fe TIER 01

kalliga TIER 01

kariva TIER 01

kelnor 1/35 TIER 01

kelnor 1/50 TIER 01

kurvelo TIER 01

larin 1.5/30 TIER 01

larin 1/20 TIER 01

larin 24 fe TIER 01

larin fe 1.5/30 TIER 01

larin fe 1/20 TIER 01

larissia TIER 01

layolis fe TIER 01

leena TIER 01

lessina TIER 01

levonest TIER 01


levonorgest-eth est & eth est

TIER 01 QL

levonorgest-eth estrad 91-day

TIER 01 QL

levonorgestrel-ethinyl estrad

TIER 01

levonorg-eth estrad triphasic

TIER 01

levora 0.15/30 (28) TIER 01

lillow TIER 01

lojaimiess TIER 01 QL

lopreeza TIER 01

loryna TIER 01

LOSEASONIQUE TIER 03 QL

low-ogestrel TIER 01

lo-zumandimine TIER 01

lutera TIER 01

lyza TIER 01

MAKENA SPECIALTY

marlissa TIER 01

medroxyprogesterone acetate intramuscular

TIER 01 QL

medroxyprogesterone acetate oral

TIER 01

megestrol acetate oral TIER 01

melodetta 24 fe TIER 01

MENEST TIER 02

MENOSTAR TIER 03

mibelas 24 fe TIER 01

microgestin 1.5/30 TIER 01

microgestin 1/20 TIER 01

microgestin fe 1.5/30 TIER 01

microgestin fe 1/20 TIER 01

mili TIER 01

mimvey TIER 01

MINIVELLE TIER 03

MIRCETTE TIER 03

mono-linyah TIER 01

NATAZIA TIER 02

necon 0.5/35 (28) TIER 01

nikki TIER 01


42


nora-be TIER 01

norethin ace-eth estrad-fe

TIER 01

norethindrone acetate oral

TIER 01

norethindrone acet-ethinyl est

TIER 01

norethindrone oral TIER 01

norethindrone-eth estradiol

TIER 01

norethin-eth estradiol-fe TIER 01

norgestimate-eth estradiol

TIER 01

norgestimate-ethinyl estradiol triphasic

TIER 01

norlyda TIER 01

norlyroc TIER 01

nortrel 0.5/35 (28) TIER 01

nortrel 1/35 (21) TIER 01

nortrel 1/35 (28) TIER 01

nortrel 7/7/7 TIER 01

NUVARING TIER 03

ocella TIER 01

orsythia TIER 01

philith TIER 01

pimtrea TIER 01

pirmella 1/35 TIER 01

pirmella 7/7/7 TIER 01

portia-28 TIER 01

PREFEST TIER 03

PREMARIN INJECTION TIER 03

PREMARIN ORAL TIER 02

PREMARIN VAGINAL TIER 02

PREMPHASE TIER 02

PREMPRO TIER 02

previfem TIER 01

progesterone intramuscular

TIER 01

progesterone micronized oral

TIER 01

PROVERA TIER 03

QUARTETTE TIER 03 QL


reclipsen TIER 01

rivelsa TIER 01 QL

setlakin TIER 01 QL

sharobel TIER 01

simliya TIER 01

simpesse TIER 01 QL

sprintec 28 TIER 01

sronyx TIER 01

syeda TIER 01

tarina 24 fe TIER 01

tarina fe 1/20 TIER 01

tarina fe 1/20 eq TIER 01

tilia fe TIER 01

tri femynor TIER 01

tri-estarylla TIER 01

tri-legest fe TIER 01

tri-linyah TIER 01

tri-lo-estarylla TIER 01

tri-lo-marzia TIER 01

tri-lo-mili TIER 01

tri-lo-sprintec TIER 01

tri-mili TIER 01

tri-previfem TIER 01

tri-sprintec TIER 01

trivora (28) TIER 01

tri-vylibra TIER 01

tri-vylibra lo TIER 01

tulana TIER 01

tydemy TIER 01

velivet TIER 01

vienva TIER 01

viorele TIER 01

volnea TIER 01

vyfemla TIER 01

vylibra TIER 01

wera TIER 01

wymzya fe TIER 01

xulane TIER 01

yuvafem TIER 01


43


zarah TIER 01

zovia 1/35e (28) TIER 01

zumandimine TIER 01

Hormonal Agents - Thyroid

ARMOUR THYROID TIER 03 ST

euthyrox PREVENT

levo-t PREVENT

levothyroxine sodium oral

PREVENT

levoxyl PREVENT

liothyronine sodium oral TIER 01

methimazole oral PREVENT

NATURE-THROID TIER 03 ST

np thyroid TIER 01

propylthiouracil oral TIER 01

TAPAZOLE TIER 03

unithroid PREVENT

WESTHROID TIER 03 ST

WP THYROID TIER 03 ST

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN SPECIALTY PA

ACTEMRA SUBCUTANEOUS

SPECIALTY PA

ACTIMMUNE SPECIALTY PA

ALFERON N SPECIALTY

ARCALYST SPECIALTY PA

ASTAGRAF XL TIER 02

AZASAN TIER 03

azathioprine oral TIER 01

azathioprine sodium TIER 01

BENLYSTA SUBCUTANEOUS

SPECIALTY PA

CELLCEPT SPECIALTY

CIMZIA SPECIALTY PA

CIMZIA PREFILLED KIT SPECIALTY PA

CIMZIA STARTER KIT SPECIALTY PA


CUVITRU SPECIALTY PA

cyclosporine modified TIER 01

cyclosporine oral TIER 01

ENBREL SPECIALTY PA

ENBREL MINI SPECIALTY PA

ENBREL SURECLICK SPECIALTY PA

ENSPRYNG TIER 03

ENVARSUS XR TIER 02

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

SPECIALTY PA

FIRAZYR SPECIALTY PA

GAMASTAN SPECIALTY PA

GAMMAGARD SPECIALTY PA

GAMMAKED SPECIALTY PA

GAMUNEX-C SPECIALTY PA

gengraf TIER 01

HIZENTRA SPECIALTY PA

HUMIRA SPECIALTY PA

HUMIRA PEDIATRIC CROHNS START

SPECIALTY PA

HUMIRA PEN SPECIALTY PA

HUMIRA PEN-CD/UC/HS STARTER

SPECIALTY PA

HUMIRA PEN-PS/UV/ADOL HS START

SPECIALTY PA

HYPERRHO S/D SPECIALTY

HYQVIA SPECIALTY PA

icatibant acetate SPECIALTY PA

ILARIS SPECIALTY PA

ILUMYA SPECIALTY PA

IMURAN TIER 03

KALBITOR SPECIALTY PA

KEVZARA SPECIALTY PA

KINERET SPECIALTY PA

leflunomide oral TIER 01

methotrexate (anti-rheumatic)

TIER 01

methotrexate oral TIER 01

methotrexate sodium TIER 01

methotrexate sodium (pf) TIER 01


44


MICRHOGAM ULTRA-FILTERED PLUS

SPECIALTY

mycophenolate mofetil SPECIALTY

mycophenolate sodium SPECIALTY

MYFORTIC SPECIALTY

NEORAL TIER 02

ORENCIA CLICKJECT SPECIALTY PA

ORENCIA SUBCUTANEOUS

SPECIALTY PA

OTEZLA SPECIALTY PA

OTREXUP SPECIALTY PA

PROGRAF ORAL TIER 02

RAPAMUNE SPECIALTY

RASUVO SPECIALTY PA

RHOGAM ULTRA-FILTERED PLUS

SPECIALTY

RHOPHYLAC TIER 02

RIDAURA SPECIALTY

RINVOQ SPECIALTY PA

SANDIMMUNE ORAL TIER 02

SILIQ SPECIALTY PA

SIMPONI SPECIALTY PA

sirolimus oral SPECIALTY

SKYRIZI (150 MG DOSE)

SPECIALTY PA

STELARA SUBCUTANEOUS

SPECIALTY PA

SYNAGIS SPECIALTY PA

tacrolimus oral TIER 01

TAKHZYRO SPECIALTY PA

TALTZ SPECIALTY PA

TICE BCG SPECIALTY

TREMFYA SPECIALTY PA

TREXALL TIER 03

WINRHO SDF SPECIALTY

XATMEP SPECIALTY

XELJANZ SPECIALTY PA

XELJANZ XR SPECIALTY PA

XEMBIFY SPECIALTY PA

ZORTRESS SPECIALTY PA


Inflammatory Bowel Disease Agents

ANALPRAM-HC EXTERNAL CREAM

TIER 03

ANUSOL-HC EXTERNAL

TIER 03

APRISO TIER 02

AZULFIDINE TIER 03

AZULFIDINE EN-TABS TIER 03

balsalazide disodium TIER 01

budesonide er TIER 01

budesonide oral TIER 01

CORTENEMA TIER 03

CORTIFOAM TIER 03

ENTOCORT EC TIER 03

hydrocortisone (perianal) TIER 01

hydrocortisone ace-pramoxine external cream 1-1 %

TIER 01

hydrocortisone rectal TIER 01

mesalamine er TIER 01

mesalamine oral TIER 01

mesalamine rectal TIER 01

mesalamine-cleanser TIER 01

PENTASA TIER 03

PROCTOFOAM HC TIER 02

procto-med hc TIER 01

procto-pak TIER 01

proctosol hc TIER 01

proctozone-hc TIER 01

ROWASA TIER 03

SFROWASA TIER 02

sulfasalazine oral TIER 01

UCERIS RECTAL TIER 03

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 35 MG

TIER 03 QL

ACTONEL ORAL TABLET 30 MG, 5 MG

TIER 03


45


alendronate sodium oral solution

TIER 01

alendronate sodium oral tablet 10 mg, 5 mg

PREVENT

alendronate sodium oral tablet 35 mg, 70 mg

PREVENT QL

ATELVIA TIER 03 QL

BINOSTO TIER 03 QL

BONIVA ORAL TIER 03 QL

calcitonin (salmon) TIER 01 QL

EVENITY SPECIALTY PA

FORTEO SPECIALTY PA

FOSAMAX TIER 03 QL

FOSAMAX PLUS D TIER 03 QL

ibandronate sodium oral PREVENT QL

MIACALCIN INJECTION TIER 03

PROLIA SPECIALTY PA

RAYALDEE TIER 03

risedronate sodium oral tablet 150 mg, 35 mg

TIER 01 QL

risedronate sodium oral tablet 30 mg, 5 mg

TIER 01

risedronate sodium oral tablet delayed release

TIER 01 QL

TYMLOS SPECIALTY PA

XGEVA SPECIALTY PA

Metabolic Bone Disease Agents - Other

calcitriol oral TIER 01

cinacalcet hcl SPECIALTY PA

doxercalciferol oral TIER 01

NATPARA SPECIALTY PA

paricalcitol oral SPECIALTY

ROCALTROL TIER 03

ZEMPLAR ORAL SPECIALTY

Miscellaneous Therapeutic Agents

ACCU-CHEK TENDER 1 INFUSION

TIER 03

ACTIFOAM COLLAGEN SPONGE

TIER 03


AEROGEAR ACTION ASTHMA KIT

TIER 03

AIRS PEDIATRIC AEROSOL MASK

TIER 03

ALCOHOL PREP PADS PAD

TIER 03

ALCOHOL PREP PADS PAD 70 %

TIER 03

ALL FLOW 1000 PFT FILTER DEVICE

TIER 03

ALPHA-LIPOIC ACID INJECTION

TIER 03

AMD FOAM DRESSING TIER 03

AMD FOAM DRESSING TOPSHEET

TIER 03

AMPHADASE TIER 03

arnica flower TIER 01

ARTISS TIER 03

ASTHMAPACK III TIER 03

AURA PORTANEB TIER 03

AVITENE TIER 03

AVITENE FLOUR TIER 03

BACTERIOSTATIC WATER(BENZ ALC)

TIER 03

bal in oil TIER 01

BENTLEY THE BEAR PED NEBULIZER

TIER 03

BIOGUARD GAUZE SPONGES PAD 4"X4"

TIER 03

BIOGUARD ISLAND DRESSINGS

TIER 03

BIOGUARD NON-ADHERENT DRESSING

TIER 03

BOTOX SPECIALTY PA

BREATHE EASE LARGE

TIER 02

BREATHE EASE MEDIUM

TIER 02

BREATHE EASE NEB MASK/CHILD

TIER 03

BREATHE EASE NEB MASK/INFANT

TIER 03

BREATHE EASE SMALL TIER 02

BREATHERITE TIER 02


46


BREATHERITE VALVED MDI CHAMBER

TIER 03

CALCIUM DISODIUM VERSENATE

TIER 03

CAPTAIN EAGLE PED NEBULIZER

TIER 03

CARETOUCH 2 CPAP HOSE HANGER

TIER 03

CARETOUCH CPAP & BIPAP HOSE

TIER 03

CARETOUCH CPAP MASK WIPES

TIER 03

CARETOUCH CPAP PRE-WASH SOLN

TIER 03

CARETOUCH CPAP TUBE BRUSH

TIER 03

CARETOUCH UNIVERSL CPAP FILTER

TIER 03

CEFALY KIT TIER 03

CHEMOPLUS LATEX GLOVES

TIER 03

CHEMOPLUS NEOPRENE GLOVE

TIER 03

CHLORHEXIDINE GLUCONATE SOLUTION 20 %

TIER 03

CLEVER CHOICE HOLDING CHAMBER

TIER 02

CLEVER CHOICE TENS UNIT

TIER 03

CLEVER CHOICE WHIS AIR PED NEB

TIER 03

CLEVER CHOICE WHISPER AIRE NEB

TIER 03

COAGUCHEK XS SYSTEM

TIER 03

COATAMAX PATCH TIER 03

COMP A-I-R NEBULIZER

TIER 03

COMPACT SPACE CHAMBER/LG MASK

TIER 02

COMPACT SPACE CHAMBER/MED MASK

TIER 02


COMPACT SPACE CHAMBER/SM MASK

TIER 02

CONCEPTION KIT TIER 03

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

TIER 03

CURITY AMD ANTIMICROBIAL STRIP

TIER 03

CURITY IODOFORM PACKING STRIP

TIER 03

CYTOTINE ORAL POWDER

TIER 03

deferoxamine mesylate TIER 01

DEFLUX TIER 03

DENTAL NEEDLE TIER 03

DESFERAL TIER 03

DOVER URETHRAL CATHETER

TIER 03

DUODOTE TIER 03

DYSPORT SPECIALTY PA

EASIVENT TIER 02

EMBRACE SEIZURE MONITORING SYS

TIER 03

EMJOI TENS TIER 03

ENDARI SPECIALTY PA

ENDO AVITENE TIER 03

ENEMA BOTTLE TIER 03

ENTRISTAR PEG ENTERAL CONNECT

TIER 03

EPISIL TIER 03

ergoloid mesylates oral TIER 01

EROS-CTD TIER 03

EXACTA-MED ORAL SYRINGE 5ML

TIER 03

EXCILON AMD DRAIN SPONGES

TIER 03

FACE MASK EARLOOP-STYLE

TIER 03

FACE MASK RESP N-100 PART

TIER 03

FACE MASK RESPIRATOR R-95 PART

TIER 03


47


FLEXICHAMBER ADULT MASK/SMALL

TIER 02

FLEXICHAMBER CHILD MASK/LARGE

TIER 02

FLEXICHAMBER CHILD MASK/SMALL

TIER 02

FLYP NEBULIZER TIER 03

FORA D40G GLUCOSE/PRESSURE

TIER 03

formaldehyde external solution 37 %

TIER 01

GAMMACORE TIER 03

GAMMACORE SAPPHIRE 31-DAY

TIER 03

GAMMACORE SAPPHIRE REFILL KIT

TIER 03

GELFILM EXTERNAL TIER 03

GEL-FLOW NT TIER 03

GELFOAM TIER 03

GELFOAM COMPRESSED SIZE 100

TIER 03

GELFOAM DENTAL PACK SIZE 4

TIER 03

GELFOAM SPONGE TIER 03

GELFOAM SPONGE SIZE 100

TIER 03


TIER 03


TIER 03

GELX TIER 03

GIVLAARI SPECIALTY PA

glutaraldehyde external TIER 01

HISTOACRYL TIER 03

HYLENEX TIER 03

INFED TIER 03

INSPIREASE RESERVOIR BAGS

TIER 02

INSTAT TIER 03

INSUFLON TIER 03

INTERCEED TIER 03

INTERCEED (TC7) TIER 03


IV ADMINISTRATION SET

TIER 03

IV EXTENSION SET TIER 03

J-TIP KIT W/VIAL ADAPTERS

TIER 03

KANGAROO BALLOON 20FR/3.5CM

TIER 03

KANGAROO GASTROSTOMY TUBE

TIER 03

KANGAROO GRAVITY FEEDING BAG

TIER 03

KANGAROO JOEY ENTERAL PUMP

TIER 03

KANGAROO MULTI-FUNCTIONAL PORT

TIER 03

KANGAROO STOMA MEASURING DEV

TIER 03

KARAYA GUM POWDER

TIER 03

KENDALL SCD EXPRESS FOOT CUFF

TIER 03

KERLIX AMD ANTIMICROBIAL

TIER 03

KERLIX AMD SUPER SPONGES

TIER 03

LATEX GLOVES MEDIUM

TIER 03

LOOP TIER 03

MASK VORTEX TIER 02

MEDICAL COMPRESSION STOCKINGS

TIER 03

methergine TIER 01

methylergonovine maleate

TIER 01

MICROAIR VIBRATING MESH NEBUL

TIER 03

MICROCHAMBER DEVICE

TIER 02

MICRONEB TIER 03

MONARCH ETNS SYSTEM

TIER 03

MUCOTROL TIER 03

MUGARD TIER 03


48


MYOBLOC SPECIALTY PA

NEB-RITE4 TIER 03

NEBULIZER PED FROG TIER 03

NEBULIZER PED FROG KIT

TIER 03

NEBULIZER SYSTEM ALL-IN-ONE

TIER 03

NEOKE RA LIPOIC TIER 03

NERIVIO TIER 03

NEXAVIR TIER 03

NITRILE GLOVES LARGE

TIER 03

NORDIPEN 5 INJECTION DEVICE

TIER 03

NORM-JECT LUER SLIP SYRINGE

TIER 03

NOZIN NASAL SANITIZER POPSWAB

TIER 03

NS-2 ELECTRIC PATCH POUCH

TIER 03

OMNIPOD DASH 5 PACK PODS

TIER 03

ONE FLOW SPIROMETER DEVICE

TIER 03

ORAMAGICRX TIER 03

ORAPEUTIC TIER 03

PAIN RELIEF WITH TENS S2000

TIER 03

PANDA MASK LARGE TIER 02

PANDA MASK MEDIUM TIER 02

PANDA MASK SMALL TIER 02

PARI ALTERA NEBULIZER HANDSET

TIER 03

PARI MASK SET TIER 03

PARI TREK S COMBO PACK

TIER 03

PEDIATRIC PANDA MASK

TIER 02

PENTETATE CALCIUM TRISODIUM

TIER 03

PENTETATE ZINC TRISODIUM

TIER 03

PHOTREXA VISCOUS TIER 03


PHOTREXA-PHOTREXA VISCOUS KIT

TIER 03

pocket spacer TIER 01

POLYTOZA PATCH TIER 03

POWDER FREE NITRILE GLOVES SM

TIER 03

pralidoxime chloride intramuscular

TIER 01

PRO COMFORT SPACER ADULT

TIER 02

PRO COMFORT SPACER CHILD

TIER 02

PRO COMFORT SPACER INFANT

TIER 02

PRO COMFORT TENS UNIT

TIER 03

PROCARE SPACER/ADULT MASK

TIER 02

PROCARE SPACER/CHILD MASK

TIER 02

PROVENT SLEEP APNEA THERAPY

TIER 03

PROVENT SR SLEEP APNEA THERAPY

TIER 03

RADIOGARDASE SPECIALTY

RAPPORT RLS TIER 03

RAPPORT VTD TIER 03

RUSCH FLOCATH QUICK 16FR

TIER 03

RUZURGI SPECIALTY PA

SALICEPT TIER 03

SAVI TIER 03

SHARPS CONTAINER TIER 03

SIDESTREAM ADULT FACE MASK

TIER 03

SIDESTREAM PEDIATRIC FACE MASK

TIER 03

sodium saccharin powder

TIER 01

SOLESTA SPECIALTY

SPARKY THE DOG PED NEBULIZER

TIER 03


49


sterile water for injection injection

TIER 01

SURGICEL FIBRILLAR TIER 03

SURGICEL NU-KNIT TIER 03

SYRINGE AVITENE TIER 03

SYRINGE LUER LOCK 30 ML

TIER 03

SYRINGE LUER SLIP 1 ML

TIER 03

SYRINGE PRECISEDOSE DISPENSER

TIER 03

TACHOSIL TIER 03

TELFA AMD ISLAND DRESSING

TIER 03

TELFA AMD NON-ADHERENT

TIER 03

THROMBI-GEL 10 TIER 03



THROMBI-PAD TIER 03

TISSEEL TIER 03

TRUZONE PEAK FLOW METER

TIER 03

ULTRAFOAM SPONGE 2X6.25X7CM

TIER 03


TIER 03


TIER 03

ULTRAFOAM SPONGE 8X25X1CM

TIER 03


TIER 03

VAPRO PLUS CATHETER 12FR/8"

TIER 03

VAPRO PLUS CATHETER 14FR/8"

TIER 03

VISTOGARD TIER 03

VITRASE TIER 03

VORTEX HOLDING CHAMBER/MASK

TIER 03

XEOMIN SPECIALTY PA

XIAFLEX SPECIALTY PA


ZEWA DIGITAL TENS UNIT

TIER 03

ZEWA TENS/EMS COMBO UNIT

TIER 03

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR TIER 03

ACULAR LS TIER 03

ALOMIDE TIER 03

AZASITE TIER 03

azelastine hcl ophthalmic TIER 01

BACIGUENT OPHTHALMIC OINTMENT 500 UNIT/GM

TIER 02

bacitracin ophthalmic TIER 01

BEPREVE TIER 03 ST

BESIVANCE TIER 03

BETADINE OPHTHALMIC PREP

TIER 03

BLEPH-10 TIER 03

bromfenac sodium (once-daily)

TIER 01 QL

CILOXAN TIER 03

ciprofloxacin hcl ophthalmic

TIER 01

cromolyn sodium ophthalmic

TIER 01

dexamethasone sodium phosphate ophthalmic

TIER 01

diclofenac sodium ophthalmic

TIER 01

epinastine hcl TIER 01

erythromycin ophthalmic TIER 01

FLAREX TIER 03

fluorometholone TIER 01

flurbiprofen sodium TIER 01

FML TIER 02

FML FORTE TIER 03

FML LIQUIFILM TIER 03

gatifloxacin ophthalmic TIER 01


50


gentak TIER 01

gentamicin sulfate ophthalmic

TIER 01

INVELTYS TIER 03

ketorolac tromethamine ophthalmic

TIER 01

levofloxacin ophthalmic TIER 01

LOTEMAX SM TIER 03

loteprednol etabonate TIER 01

MAXIDEX TIER 03

MITOSOL TIER 03

MOXEZA TIER 02

moxifloxacin hcl (2x day) TIER 01

moxifloxacin hcl ophthalmic

TIER 01

NATACYN TIER 02

OCUFLOX TIER 03

ofloxacin ophthalmic TIER 01

olopatadine hcl ophthalmic

TIER 01

OZURDEX SPECIALTY

POVIDONE-IODINE OPHTHALMIC

TIER 03

PRED MILD TIER 03

prednisolone acetate ophthalmic

TIER 01

prednisolone sodium phosphate ophthalmic

TIER 01

PROLENSA TIER 02 QL

sulfacetamide sodium ophthalmic

TIER 01

tobramycin ophthalmic TIER 01

TOBREX TIER 03

trifluridine TIER 01

ZIRGAN TIER 03

ZYMAXID TIER 03

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er TIER 01

acetazolamide oral TIER 01


ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

TIER 02

apraclonidine hcl TIER 01

AZOPT TIER 02

betaxolol hcl ophthalmic TIER 01

BETIMOL TIER 03

BETOPTIC-S TIER 03

bimatoprost ophthalmic TIER 01 QL

brimonidine tartrate ophthalmic

PREVENT

carteolol hcl TIER 01

COMBIGAN TIER 02

dorzolamide hcl solution 2 % ophthalmic

TIER 01

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC

TIER 03

dorzolamide hcl-timolol mal

TIER 01

dorzolamide hcl-timolol mal pf

TIER 01

IOPIDINE TIER 03

ISOPTO CARPINE TIER 03

ISTALOL TIER 03

KEVEYIS SPECIALTY PA

latanoprost ophthalmic PREVENT

levobunolol hcl TIER 01

LUMIGAN TIER 02 QL

methazolamide oral TIER 01

PHOSPHOLINE IODIDE TIER 02

pilocarpine hcl ophthalmic

TIER 01

RHOPRESSA TIER 02

ROCKLATAN TIER 02 QL

SIMBRINZA TIER 02

timolol maleate ophthalmic

PREVENT

TRAVATAN Z TIER 03 QL

travoprost (bak free) TIER 01 QL

TRUSOPT TIER 03

XELPROS TIER 03 ST; QL


51


Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac TIER 01

AKTEN TIER 03

ALCAINE TIER 03

altacaine TIER 01

altafrin TIER 01

atropine sulfate ophthalmic ointment

TIER 01

atropine sulfate ophthalmic solution 1 %

TIER 01

bacitracin-polymyxin b ophthalmic

TIER 01

bacitra-neomycin-polymyxin-hc

TIER 01

BLEPHAMIDE TIER 03

BLEPHAMIDE S.O.P. TIER 03

CYCLOGYL TIER 03

CYCLOMYDRIL TIER 03

cyclopentolate hcl ophthalmic

TIER 01

CYSTARAN SPECIALTY PA

EYLEA SPECIALTY

homatropaire TIER 01

ISOPTO ATROPINE TIER 03

LACRISERT TIER 03

LASTACAFT TIER 03 ST

LUCENTIS SPECIALTY

MAXITROL TIER 03

MEMBRANEBLUE TIER 03

neomycin-bacitracin zn-polymyx

TIER 01

neomycin-polymyxin-dexameth ophthalmic ointment

TIER 01

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

TIER 01

neomycin-polymyxin-gramicidin

TIER 01


neomycin-polymyxin-hc ophthalmic

TIER 01

neo-polycin TIER 01

neo-polycin hc TIER 01

OXERVATE SPECIALTY PA; QL

phenylephrine hcl ophthalmic

TIER 01

polycin TIER 01

polymyxin b-trimethoprim TIER 01

POLYTRIM TIER 03

PRED-G TIER 03

PRED-G S.O.P. TIER 03

proparacaine hcl ophthalmic

TIER 01

RESTASIS TIER 02 PA

RESTASIS MULTIDOSE TIER 02 PA

sulfacetamide-prednisolone ophthalmic solution

TIER 01

tetracaine hcl ophthalmic TIER 01

TOBRADEX OPHTHALMIC OINTMENT

TIER 03

TOBRADEX ST TIER 03

tobramycin-dexamethasone

TIER 01

TROPICAMIDE-CYCLOPENTOLATE-PE

TIER 03

VISIONBLUE TIER 03

XIIDRA TIER 02 PA

ZYLET TIER 03

Otic Agents - Drugs for Ear Conditions

acetic acid otic TIER 01

CETRAXAL TIER 03

CIPRO HC TIER 03

CIPRODEX TIER 03

ciprofloxacin hcl otic TIER 01

ciprofloxacin-dexamethasone

TIER 01

cortic-nd TIER 01

DERMOTIC TIER 03


52


exotic-hc TIER 01

flac TIER 01

fluocinolone acetonide otic

TIER 01

hydrocortisone-acetic acid

TIER 01

neomycin-polymyxin-hc otic

TIER 01

ofloxacin otic TIER 01

OTICIN HC NR TIER 03

PRAMOTIC TIER 03

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

azelastine hcl nasal TIER 01 QL

azelastine-fluticasone TIER 01

BECONASE AQ TIER 03 QL

benzonatate TIER 01

bromfed dm TIER 01

brompheniramine tannate

TIER 01

carbinoxamine maleate TIER 01

cetirizine hcl oral solution TIER 01

clemastine fumarate oral tablet 2.68 mg

TIER 01

CUROSURF TIER 03

cyproheptadine hcl oral TIER 01

desloratadine TIER 01

dexchlorpheniramine maleate oral

TIER 01

diphen oral elixir TIER 01

diphenhydramine hcl injection

TIER 01

diphenhydramine hcl oral elixir

TIER 01

DYMISTA TIER 02

FASENRA SPECIALTY

FASENRA PEN SPECIALTY

flunisolide nasal TIER 01 QL

fluticasone propionate nasal

TIER 01


guaiatussin ac TIER 01 PA; QL

guaifenesin ac TIER 01 PA; QL

hydrocodone polst-chlorphen polst er susp

TIER 01 PA; QL

hydrocodone-homatropine

TIER 01 PA; QL

hydromet TIER 01 PA; QL

HYPERSAL TIER 03

INFASURF TIER 03

ipratropium bromide nasal

TIER 01

levocetirizine dihydrochloride oral

TIER 01

maxi-tuss ac TIER 01 PA; QL

mometasone furoate nasal

TIER 01 QL

nebusal inhalation nebulization solution 3 %

TIER 01

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

TIER 03

NUCALA SPECIALTY QL

olopatadine hcl nasal TIER 01 QL

OMNARIS TIER 03 QL

PATANASE TIER 03 QL

PHENERGAN TIER 03

promethazine hcl injection

TIER 01

promethazine hcl oral TIER 01

promethazine hcl rectal TIER 01

promethazine-codeine TIER 01 PA; QL

promethazine-dm TIER 01

promethazine-phenyleph-codeine

TIER 01 PA; QL

promethazine-phenylephrine

TIER 01

promethegan TIER 01

pseudoephedrine-bromphen-dm

TIER 01

pulmosal TIER 01

QNASL TIER 03 QL

QNASL CHILDRENS TIER 03 QL

RYCLORA TIER 03


53


ryvent TIER 01

SINUVA TIER 03

sodium chloride inhalation

TIER 01

SURVANTA TIER 03

TESSALON PERLES TIER 03

virtussin ac w/alc TIER 01 PA; QL

XOLAIR SPECIALTY

ZETONNA TIER 03 QL

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

ACCOLATE TIER 03

acetylcysteine inhalation TIER 01

ADRENALIN INJECTION TIER 03

ADVAIR DISKUS TIER 02 QL

ADVAIR HFA TIER 02 QL

AIRDUO DIGIHALER TIER 03 QL

albuterol sulfate er TIER 01

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

PREVENT QL

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

TIER 01 QL

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

PREVENT QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml

TIER 01 QL

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml

TIER 01

albuterol sulfate oral TIER 01

ANORO ELLIPTA PREVENT QL

ARCAPTA NEOHALER TIER 03 ST


ARMONAIR DIGIHALER TIER 03 QL

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT

PREVENT QL

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT

TIER 02 QL

ATROVENT HFA PREVENT QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML

TIER 03

BREO ELLIPTA PREVENT QL

BROVANA TIER 03 QL

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

PREVENT QL

budesonide inhalation suspension 1 mg/2ml

TIER 01 QL

COMBIVENT RESPIMAT

TIER 02 QL

cromolyn sodium inhalation

TIER 01

DALIRESP TIER 03 PA

difil-g forte TIER 01

ELIXOPHYLLIN TIER 02

epinephrine injection solution

TIER 01

epinephrine injection solution auto-injector

TIER 01

EPIPEN 2-PAK TIER 03 ST

ESBRIET SPECIALTY PA

FLOVENT DISKUS TIER 02 QL

FLOVENT HFA PREVENT QL

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

TIER 01 QL


54


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

PREVENT QL

INCRUSE ELLIPTA PREVENT QL

ipratropium bromide inhalation

TIER 01 QL

ipratropium-albuterol TIER 01 QL

levalbuterol hcl inhalation TIER 01 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

TIER 03 QL

LONHALA MAGNAIR REFILL KIT

TIER 03 QL

LONHALA MAGNAIR STARTER KIT

TIER 03 QL

metaproterenol sulfate oral

TIER 01

montelukast sodium oral TIER 01

OFEV SPECIALTY PA

PERFOROMIST TIER 03 QL

PROAIR DIGIHALER TIER 03 QL

PROAIR HFA TIER 02 QL

PROAIR RESPICLICK PREVENT QL

PROVENTIL HFA TIER 03 QL

PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION

PREVENT QL

PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION

TIER 02 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT

PREVENT QL

SCLEROSOL INTRAPLEURAL

TIER 03


SEREVENT DISKUS TIER 02 QL

SPIRIVA HANDIHALER TIER 02 QL

SPIRIVA RESPIMAT TIER 02 QL

STERILE TALC POWDER

TIER 03

STERITALC TIER 03

STIOLTO RESPIMAT TIER 02 QL

STRIVERDI RESPIMAT TIER 02 ST; QL

SYMBICORT PREVENT QL

SYMJEPI TIER 03

terbutaline sulfate injection

TIER 01

terbutaline sulfate oral TIER 01

THEO-24 TIER 02

theophylline TIER 01

theophylline er TIER 01

TRELEGY ELLIPTA TIER 02 QL

VENTOLIN HFA TIER 02 QL

wixela inhub TIER 01 QL

XOPENEX TIER 03 QL

XOPENEX CONCENTRATE

TIER 03 QL

XOPENEX HFA TIER 03 QL

YUPELRI TIER 03 QL

zafirlukast TIER 01

zileuton er TIER 01 ST

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS SPECIALTY

CAYSTON SPECIALTY PA

KALYDECO SPECIALTY PA

ORKAMBI SPECIALTY PA; QL

PULMOZYME SPECIALTY PA

SYMDEKO SPECIALTY PA; QL

TOBI PODHALER SPECIALTY QL

tobramycin inhalation SPECIALTY

TRIKAFTA SPECIALTY PA; QL


55


Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADEMPAS SPECIALTY PA

alyq SPECIALTY PA

ambrisentan SPECIALTY PA

bosentan SPECIALTY PA

OPSUMIT SPECIALTY PA

ORENITRAM SPECIALTY PA

REVATIO ORAL SUSPENSION RECONSTITUTED

SPECIALTY PA

sildenafil citrate oral suspension reconstituted

SPECIALTY PA

sildenafil citrate oral tablet 20 mg

SPECIALTY PA

tadalafil (pah) SPECIALTY PA

TRACLEER 32 MG SPECIALTY PA

treprostinil SPECIALTY PA

TYVASO SPECIALTY PA

TYVASO REFILL SPECIALTY PA

TYVASO STARTER SPECIALTY PA

UPTRAVI SPECIALTY PA

VENTAVIS SPECIALTY PA

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral TIER 01

carisoprodol oral TIER 01

carisoprodol-aspirin oral tablet 200-325 mg

TIER 01

chlorzoxazone TIER 01

cyclobenzaprine hcl er TIER 01

cyclobenzaprine hcl oral TIER 01

DANTRIUM ORAL TIER 03

dantrolene sodium oral TIER 01

FEXMID TIER 03

LORZONE TIER 03

metaxalone TIER 01

methocarbamol injection TIER 01


methocarbamol oral TIER 01

orphenadrine citrate er TIER 01

orphenadrine citrate injection

TIER 01

orphenadrine-asa-caffeine

TIER 01

ROBAXIN TIER 03

ROBAXIN-750 TIER 03

tizanidine hcl oral TIER 01

Sleep Disorder Agents

armodafinil TIER 01 PA; QL

BELSOMRA TIER 03 ST; QL

doxepin hcl oral tablet TIER 01 QL

eszopiclone TIER 01 QL

flurazepam hcl TIER 01 PA; QL

HETLIOZ SPECIALTY PA

modafinil TIER 01 PA; QL

ramelteon TIER 01 QL

ROZEREM TIER 03 QL

SECONAL TIER 03

SILENOR TIER 03 QL

SUNOSI TIER 02 PA; QL

temazepam TIER 01 QL

WAKIX SPECIALTY PA

XYREM SPECIALTY PA; QL

zaleplon TIER 01 QL

zolpidem tartrate TIER 01 QL

zolpidem tartrate er TIER 01 QL

ZOLPIMIST TIER 03 ST; QL


56

Index of Drugs

abacavir sulfate.............................18abacavir sulfate-lamivudine.......... 18abacavir-lamivudine-zidovudine... 18ABILIFY MAINTENA.....................17abiraterone acetate.......................14ABSORICA LD..............................27acamprosate calcium......................6acarbose.......................................30ACCOLATE.................................. 54ACCU-CHEK FASTCLIX LANCET KIT.................................31ACCU-CHEK MULTICLIX LANCET DEVICE KIT...................31ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...................31ACCU-CHEK TENDER 1 INFUSION.....................................46ACCUPRIL....................................21ACCURETIC.................................21acd formula a..................................9acd-a noclot-50...............................9acebutolol hcl ................................21acetaminophen-codeine................. 3acetaminophen-codeine #2............ 3acetaminophen-codeine #3............ 3acetaminophen-codeine #4............ 3acetazolamide...............................51acetazolamide er.......................... 51acetazolamide sodium..................21acetic acid.....................................52acetylcysteine............................... 54acitretin......................................... 27ACTEMRA.................................... 44ACTEMRA ACTPEN.....................44ACTHAR.......................................39ACTICOAT....................................27ACTIFOAM COLLAGEN SPONGE...................................... 46ACTIGALL.................................... 35ACTIMMUNE................................44ACTIQ.............................................3ACTIVELLA.................................. 40ACTONEL.....................................45ACTOPLUS MET..........................30ACTOS......................................... 30ACULAR....................................... 50ACULAR LS..................................50acyclovir ........................................18ACZONE.......................................27adapalene.....................................27ADAPALENE................................ 27adapalene-benzoyl peroxide.........27ADASUVE.....................................17ADDYI...........................................26adefovir dipivoxil ........................... 18ADEMPAS.................................... 56

ADRENALIN................................. 54ADVAIR DISKUS..........................54ADVAIR HFA................................ 54ADVATE....................................... 20ADYNOVATE................................20ADZENYS ER...............................25ADZENYS XR-ODT......................25AEMCOLO......................................6AEROGEAR ACTION ASTHMA KIT................................................ 46AFINITOR.....................................14AFINITOR DISPERZ.................... 14afirmelle........................................ 40AFREZZA..................................... 33AFSTYLA......................................20AGGRENOX.................................17AGRYLIN......................................20AIMOVIG...................................... 13AIRDUO DIGIHALER................... 54AIRS PEDIATRIC AEROSOL MASK............................................46ak-poly-bac................................... 52AKTEN..........................................52AKYNZEO.....................................11ala-cort ..........................................27albendazole.................................. 16albuterol sulfate............................ 54albuterol sulfate er........................ 54albuterol sulfate hfa...................... 54ALBUTEROL SULFATE HFA.......54ALCAINE...................................... 52alclometasone dipropionate..........27ALCOHOL PREP PADS.........27, 46ALDACTAZIDE.............................21ALDACTONE................................21ALECENSA...................................14alendronate sodium...................... 46ALFERON N................................. 44alfuzosin hcl er..............................38ALINIA.......................................... 16aliskiren fumarate......................... 21ALKERAN.....................................14ALL FLOW 1000 PFT FILTER......46allopurinol..................................... 13almotriptan malate........................ 13ALOMIDE......................................50ALORA..........................................40alosetron hcl ................................. 35ALPHAGAN P...............................51ALPHA-LIPOIC ACID................... 46ALPHANATE/VWF COMPLEX/HUMAN......................20ALPHANINE SD........................... 20alprazolam.................................... 19alprazolam er................................19alprazolam intensol.......................19

alprazolam xr................................ 19ALPROLIX.................................... 20alprostadil ..................................... 21ALTABAX........................................6altacaine....................................... 52altafrin...........................................52altavera.........................................40ALTRENO.....................................27ALUNBRIG................................... 14alyacen 1/35................................. 40alyacen 7/7/7................................ 40alyq............................................... 56amabelz........................................ 40amantadine hcl............................. 17AMARYL.......................................30ambrisentan..................................56amcinonide................................... 27AMD FOAM DRESSING...............46AMD FOAM DRESSING TOPSHEET.................................. 46AMERGE...................................... 13amethia.........................................40amethia lo..................................... 40amethyst....................................... 40AMICAR........................................20amikacin sulfate..............................7amiloride hcl ..................................21amiloride-hydrochlorothiazide.......21aminocaproic acid.........................20amiodarone hcl............................. 21amitriptyline hcl .............................10amlodipine besylate......................21amlodipine besylate-benazepril hcl ................................................. 21amlodipine besylate-valsartan...... 21amlodipine-atorvastatin.................21amlodipine-olmesartan................. 21amlodipine-valsartan-hctz.............21ammonium lactate........................ 27amnesteem...................................27AMNIOCORE HUMAN TISSUE... 27amoxapine.................................... 10amoxicill-clarithro-lansopraz......... 35amoxicillin....................................... 7amoxicillin-potassium clavulanate.. 7amoxicillin-potassium clavulanate er.....................................................7AMPHADASE............................... 46AMPHETAMINE ER..................... 25amphetamine sulfate.................... 25amphetamine-dextroamphetamine......................25amphetamine-dextroamphetamine er..................25ampicillin.........................................7ampicillin sodium............................ 7

57

ampicillin-sulbactam sodium...........7AMPYRA.......................................25AMZEEQ.......................................27ANADROL-50............................... 39anagrelide hcl............................... 20ANALPRAM-HC............................45ANASPAZ.....................................36anastrozole................................... 14ANCOBON....................................12ANDRODERM.............................. 39ANECTINE....................................26ANGELIQ......................................40ANORO ELLIPTA......................... 54ANTABUSE.................................... 6anticoagulant cit dext soln a........... 9anticoagulant sodium citrate...........9ANUSOL-HC.................................45ANZEMET.....................................11apap-caff-dihydrocodeine............... 3APLENZIN.................................... 10APOKYN.......................................17apraclonidine hcl...........................51aprepitant......................................11apri ................................................40APRISO........................................ 45APTENSIO XR..............................25APTIVUS...................................... 18AQUASOL A.................................33ARAKODA.................................... 16aranelle.........................................40ARANESP (ALBUMIN FREE).......20ARCALYST...................................44ARCAPTA NEOHALER................54ARGININE HCL............................ 33ARICEPT...................................... 10ARIDA...........................................27ARIKAYCE......................................7aripiprazole................................... 17ARISTADA....................................17ARISTADA INITIO........................ 17ARIXTRA........................................ 9armodafinil .................................... 56ARMONAIR DIGIHALER..............54ARMOUR THYROID.....................44arnica flower................................. 46ARNUITY ELLIPTA.......................54AROMASIN...................................14ARTICADENT DENTAL..................5ARTISS.........................................46ascomp-codeine............................. 3ashlyna......................................... 40aspirin-dipyridamole er................. 17ASTAGRAF XL.............................44ASTHMAPACK III .........................46ASTRINGYN.................................20ATACAND HCT............................ 21atazanavir sulfate..........................18

ATELVIA.......................................46atenolol ......................................... 21atenolol-chlorthalidone..................21ATIVAN.........................................20atomoxetine hcl.............................25atorvastatin calcium......................21atovaquone...................................16atovaquone-proguanil hcl ............. 16ATRALIN.......................................27ATROPEN.................................... 36atropine sulfate....................... 36, 52ATROVENT HFA..........................54AUBAGIO..................................... 25aubra.............................................40aubra eq........................................40AUGMENTIN.................................. 7AUGMENTIN ES-600..................... 7AURA PORTANEB.......................46aurovela 1.5/30.............................40aurovela 1/20................................40aurovela 24 fe...............................40aurovela fe 1.5/30.........................40aurovela fe 1/20............................40AURYXIA......................................37AUSTEDO.................................... 26AUTOLET LANCING DEVICE......31AUVI-Q......................................... 54AVALIDE.......................................21AVANDIA......................................30aviane........................................... 40avidoxy............................................7avita.............................................. 27AVITENE...................................... 46AVITENE FLOUR......................... 46AVONEX PEN.............................. 25AVONEX PREFILLED.................. 25AYGESTIN....................................40ayuna............................................40AYVAKIT.......................................14azacitidine.....................................14AZACTAM.......................................7AZADROX.................................... 27AZASAN....................................... 44AZASITE.......................................50azathioprine.................................. 44azathioprine sodium......................44azelaic acid...................................27azelastine hcl..........................50, 53azelastine-fluticasone................... 53AZELEX........................................27AZILECT.......................................17azithromycin....................................7AZOPT..........................................51aztreonam.......................................7AZULFIDINE.................................45AZULFIDINE EN-TABS................ 45azurette.........................................40

BACIGUENT.................................50baciim............................................. 7bacitracin.................................. 7, 50bacitracin-polymyxin b.................. 52bacitra-neomycin-polymyxin-hc.... 52baclofen........................................ 56BACTERIOSTATIC WATER(BENZ ALC).....................46BACTRIM........................................7BACTRIM DS..................................7BAFIERTAM................................. 25bal in oil .........................................46balsalazide disodium.................... 45balsam peru-castor oil .................. 27BALVERSA...................................14balziva...........................................40BANZEL..........................................9BAQSIMI ONE PACK................... 32BAQSIMI TWO PACK...................32BARACLUDE................................18BAXDELA....................................... 7BD AUTOSHIELD DUO PEN NEEDLES.....................................33BD ULTRA-FINE INSULIN SYRINGES................................... 33BD ULTRA-FINE PEN NEEDLES 33BD VEO INSULIN SYR U/F 1/2UNIT........................................ 33BECONASE AQ............................53bekyree.........................................40BELBUCA.......................................3BELSOMRA..................................56benazepril hcl ................................21benazepril-hydrochlorothiazide.....21BENEFIX...................................... 20BENLYSTA...................................44BENTLEY THE BEAR PED NEBULIZER..................................46BENTYL........................................36benzalkonium chloride....................7BENZNIDAZOLE.......................... 16benzonatate..................................53benzoyl peroxide-erythromycin.....27benzphetamine hcl ........................26benztropine mesylate....................17BEPREVE.....................................50beser.............................................27BESIVANCE................................. 50BETADINE OPHTHALMIC PREP 50betamethasone dipropionate........ 28betamethasone dipropionate aug. 27betamethasone sod phos & acet.. 38betamethasone valerate............... 28BETAPACE AF.............................21BETASERON................................25betaxolol hcl ............................21, 51bethanechol chloride.....................37

58

BETHKIS...................................... 55BETIMOL......................................51BETOPTIC-S................................ 51bexarotene....................................14BIAFINE........................................28bicalutamide..................................14BICILLIN C-R..................................7BICILLIN C-R 900/300....................7BICILLIN L-A...................................7BIDIL.............................................21BIJUVA......................................... 40BIKTARVY....................................18BILTRICIDE..................................16bimatoprost...................................51BINOSTO......................................46BIOGUARD GAUZE SPONGES.. 46BIOGUARD ISLAND DRESSINGS.................................46BIOGUARD NON-ADHERENT DRESSING...................................46BIONECT......................................28BIO-STATIN..................................12BIOSTEP AG................................28bisoprolol fumarate....................... 21bisoprolol-hydrochlorothiazide......21bleomycin sulfate..........................14BLEPH-10.....................................50BLEPHAMIDE...............................52BLEPHAMIDE S.O.P....................52blisovi 24 fe...................................40blisovi fe 1.5/30.............................40blisovi fe 1/20................................40BLUESTAR...................................31BONIVA........................................ 46BONJESTA...................................11bosentan.......................................56BOSULIF...................................... 14BOTOX......................................... 46BPCO............................................28BRAFTOVI....................................14BREATHE EASE LARGE.............46BREATHE EASE MEDIUM...........46BREATHE EASE NEB MASK/CHILD................................46BREATHE EASE NEB MASK/INFANT..............................46BREATHE EASE SMALL............. 46BREATHERITE.............................46BREATHERITE VALVED MDI CHAMBER....................................47BREO ELLIPTA............................ 54briellyn.......................................... 41BRILINTA......................................17brimonidine tartrate.......................51BRINEURA................................... 37BRIVIACT....................................... 9bromfed dm...................................53

bromfenac sodium (once-daily).... 50bromocriptine mesylate.................17brompheniramine tannate.............53BROVANA.................................... 54BRUKINSA................................... 14budesonide............................. 45, 54budesonide er...............................45bumetanide...................................21BUMEX.........................................21BUNAVAIL......................................6BUPHENYL.................................. 37bupivacaine fisiopharma.................5bupivacaine hcl...............................5bupivacaine hcl (pf) .........................5bupivacaine-epinephrine.................5bupivacaine-epinephrine (pf) .......... 5BUPRENEX....................................3buprenorphine.................................3buprenorphine hcl.......................3, 6buprenorphine hcl-naloxone hcl ......6bupropion hcl................................ 11bupropion hcl er (smoking det)....... 6bupropion hcl er (sr)......................10bupropion hcl er (xl) ......................11BUPROPION HCL ER (XL).......... 11buspirone hcl................................ 20butalbital-acetaminophen................3butalbital-apap-caff-cod.................. 3butalbital-apap-caffeine.................. 3butalbital-asa-caff-codeine..............3butalbital-aspirin-caffeine................3butorphanol tartrate........................ 3BUTRANS.......................................3BYDUREON................................. 30BYDUREON BCISE AUTOINJECTOR..........................30BYETTA 10 MCG PEN.................30BYETTA 5 MCG PEN...................30BYSTOLIC....................................21cabergoline................................... 39CABLIVI........................................17CABOMETYX............................... 14CADUET.......................................21CAFERGOT..................................13caffeine citrate.............................. 26CAFFEINE-SODIUM BENZOATE.................................. 26CALAN SR....................................21CALCIFOL.................................... 33calcipotriene..................................28calcipotriene-betameth diprop...... 28calcitonin (salmon)........................46CALCITRENE...............................28calcitriol ...................................28, 46calcium acetate.............................37calcium acetate (phos binder).......37

CALCIUM DISODIUM VERSENATE................................47CALQUENCE............................... 14camila........................................... 41camrese........................................41camrese lo.................................... 41candesartan cilexetil ..................... 21candesartan cilexetil-hctz............. 21CAPASTAT SULFATE..................13capecitabine..................................14CAPLYTA..................................... 17CAPRELSA...................................14CAPTAIN EAGLE PED NEBULIZER..................................47captopril ........................................ 21captopril-hydrochlorothiazide........22CARAC......................................... 28CARAFATE...................................35CARBAGLU..................................33carbamazepine............................... 9carbamazepine er...........................9carbidopa......................................17carbidopa-levodopa...................... 17carbidopa-levodopa er..................17carbidopa-levodopa-entacapone.. 17carbinoxamine maleate.................53CARBOCAINE................................5CARBOCAINE PRESERVATIVE-FREE................. 5CARDIZEM...................................22CARDIZEM LA..............................22CARDURA....................................22CARDURA XL...............................38CARETOUCH 2 CPAP HOSE HANGER...................................... 47CARETOUCH CPAP & BIPAP HOSE............................................47CARETOUCH CPAP MASK WIPES.......................................... 47CARETOUCH CPAP PRE-WASH SOLN................................ 47CARETOUCH CPAP TUBE BRUSH......................................... 47CARETOUCH LANCING/EJECTOR....................31CARETOUCH UNIVERSL CPAP FILTER......................................... 47carisoprodol.................................. 56carisoprodol-aspirin...................... 56carisoprodol-aspirin-codeine...........3CAROSPIR...................................22carteolol hcl ...................................51cartia xt......................................... 22carvedilol .......................................22carvedilol phosphate er.................22cascara sagrada........................... 36CASODEX.................................... 14

59

CATAPRES.................................. 22cavarest........................................ 26CAYSTON.................................... 55caziant.......................................... 41cefaclor........................................... 7cefaclor er.......................................7cefadroxil ........................................ 7CEFALY KIT................................. 47cefazolin sodium.............................7cefdinir ............................................ 7cefditoren pivoxil .............................7cefepime hcl....................................7cefixime...........................................7CEFOTAN.......................................7cefotaxime sodium..........................7cefotetan disodium..........................7cefoxitin sodium..............................7cefpodoxime proxetil .......................7cefprozil .......................................... 7ceftazidime......................................7ceftriaxone sodium..........................7cefuroxime axetil .............................7cefuroxime sodium..........................7celecoxib.........................................4CELESTONE SOLUSPAN........... 38CELLCEPT................................... 44CELONTIN......................................9CENTANY.......................................7cephalexin.......................................7CEQUR SIMPLICITY 2U.............. 31CEQUR SIMPLICITY INSERTER.31CEQUR SIMPLICITY STARTER..31CERDELGA..................................37CEREBYX.......................................9cetirizine hcl..................................53CETRAXAL...................................52cevimeline hcl............................... 26CHANTIX........................................6CHANTIX CONTINUING MONTH PAK.................................. 6CHANTIX STARTING MONTH PAK.................................................6charlotte 24 fe...............................41chateal.......................................... 41chateal eq..................................... 41CHEMET.......................................33CHEMOPLUS LATEX GLOVES...47CHEMOPLUS NEOPRENE GLOVE......................................... 47CHEMSTRIP UGK........................31CHENODAL..................................36chlordiazepoxide hcl..................... 20chlordiazepoxide-amitriptyline...... 11chlordiazepoxide-clidinium............36chlorhexidine gluconate................26CHLORHEXIDINE GLUCONATE.47chloroprocaine hcl (pf) .................... 5

chloroquine phosphate................. 16chlorpromazine hcl ........................17chlorthalidone............................... 22chlorzoxazone...............................56CHOLBAM....................................37cholestyramine..............................22cholestyramine light......................22chorionic gonadotropin................. 39ciclodan.........................................12ciclopirox.......................................12ciclopirox olamine......................... 12cilostazol.......................................17CILOXAN......................................50CIMDUO....................................... 18cimetidine......................................35cimetidine hcl................................35CIMZIA..........................................44CIMZIA PREFILLED KIT.............. 44CIMZIA STARTER KIT................. 44cinacalcet hcl ................................ 46CIPRO............................................ 7CIPRO HC.................................... 52CIPRODEX...................................52ciprofloxacin hcl .................. 7, 50, 52ciprofloxacin-dexamethasone.......52citalopram hydrobromide.............. 11CITANEST FORTE DENTAL..........5CITANEST PLAIN DENTAL........... 5claravis..........................................28clarithromycin..................................7clarithromycin er............................. 7clemastine fumarate..................... 53CLENPIQ......................................36CLEOCIN........................................7CLEOCIN PHOSPHATE.................7CLEOCIN-T.................................. 28CLEVER CHOICE HOLDING CHAMBER....................................47CLEVER CHOICE TENS UNIT.... 47CLEVER CHOICE WHIS AIR PED NEB......................................47CLEVER CHOICE WHISPER AIRE NEB.....................................47CLIMARA PRO.............................41clindacin etz..................................28clindacin-p.....................................28clindamycin hcl ............................... 7clindamycin palmitate hcl ................7clindamycin phosphate............. 7, 28clindamycin phosphate-benzoyl peroxide........................................28clindamycin-tretinoin.....................28CLINDESSE................................... 7clinpro 5000.................................. 26clobazam........................................ 9clobetasol prop emollient base..... 28clobetasol propionate....................28

clobetasol propionate e.................28clobetasol propionate emulsion.... 28clocortolone pivalate.....................28clodan........................................... 28clomiphene citrate.........................39clomipramine hcl...........................11clonazepam.................................. 20clonidine........................................22clonidine hcl ..................................22clonidine hcl er..............................25clopidogrel bisulfate......................17clorazepate dipotassium...............20clotrimazole...................................12clotrimazole-betamethasone.........12clovique.........................................33clozapine.......................................17CLOZARIL.................................... 17COAGADEX................................. 20COAGUCHEK XS SYSTEM.........47coal tar..........................................28COARTEM....................................16COATAMAX PATCH.................... 47COCAINE HCL............................... 5codeine sulfate................................3COGENTIN...................................17colchicine......................................13colchicine-probenecid...................13COLCRYS.................................... 13colesevelam hcl............................ 22colestipol hcl ................................. 22colistimethate sodium (cba)............7COLY-MYCIN M............................. 7COMBIGAN.................................. 51COMBIPATCH..............................41COMBIVENT RESPIMAT.............54COMBIVIR....................................18COMETRIQ (100 MG DAILY DOSE).......................................... 14COMETRIQ (140 MG DAILY DOSE).......................................... 14COMETRIQ (60 MG DAILY DOSE).......................................... 14COMP A-I-R NEBULIZER............ 47COMPACT SPACE CHAMBER/LG MASK...................47COMPACT SPACE CHAMBER/MED MASK................47COMPACT SPACE CHAMBER/SM MASK.................. 47COMPLERA..................................18compro..........................................12COMTAN...................................... 17CONCEPTION KIT....................... 47CONDYLOX..................................28constulose.....................................36CONTRAVE..................................26COPAXONE................................. 25

60

COPIKTRA................................... 14coremino.........................................7CORIFACT................................... 20CORLANOR................................. 22CORTENEMA...............................45cortic-nd........................................52CORTIFOAM................................ 45cortisone acetate.......................... 38CORTISPORIN.............................28COTELLIC.................................... 14COTEMPLA XR-ODT................... 25CREON.........................................37CRESEMBA..................................12CRINONE..................................... 41CRIXIVAN.....................................18cromolyn sodium...............36, 50, 54crotan............................................16cryselle-28.................................... 41CRYSVITA....................................37CUPRIMINE..................................37CURITY AMD ANTIMICROBIAL SPNGE......................................... 47CURITY AMD ANTIMICROBIAL STRIP........................................... 47CURITY IODOFORM PACKING STRIP........................................... 47CUROSURF................................. 53CUTIVATE....................................28CUVITRU......................................44CUVPOSA.................................... 36cyanocobalamin............................33CYANOCOBALAMIN....................33cyclafem 1/35................................41cyclafem 7/7/7...............................41cyclobenzaprine hcl ...................... 56cyclobenzaprine hcl er..................56CYCLOGYL.................................. 52CYCLOMYDRIL............................52cyclopentolate hcl ......................... 52cyclophosphamide........................14cycloserine....................................13CYCLOSET.................................. 30cyclosporine..................................44cyclosporine modified................... 44cyproheptadine hcl........................53cyred.............................................41cyred eq........................................41CYSTADANE................................37CYSTAGON..................................37CYSTARAN.................................. 52cytarabine..................................... 14cytarabine (pf)...............................14CYTOTEC.....................................35CYTOTINE....................................47D.H.E. 45...................................... 13dalfampridine er............................25DALIRESP....................................54

danazol......................................... 39DANTRIUM...................................56dantrolene sodium........................ 56dapsone..................................13, 28DARAPRIM...................................16darifenacin hydrobromide er.........37dasetta 1/35..................................41dasetta 7/7/7.................................41DAURISMO.................................. 14DAYPRO.........................................4daysee.......................................... 41DAYTRANA.................................. 25D-CARE 100X.................................5DDAVP......................................... 39DDAVP RHINAL TUBE.................39DEBACTEROL............................. 26deblitane....................................... 41deferasirox....................................33deferasirox granules..................... 33deferoxamine mesylate.................47DEFLUX........................................47dehydrated alcohol....................... 34DELESTROGEN...........................41DELSTRIGO.................................18delyla............................................ 41demeclocycline hcl ..........................7DEMEROL......................................3DEMSER...................................... 22denta 5000 plus............................ 26dentagel........................................26DENTAL NEEDLE........................ 47DEPEN TITRATABS.....................37DEPO-ESTRADIOL......................41DEPO-MEDROL...........................38DEPO-PROVERA.........................41DEPO-SUBQ PROVERA 104.......41DERMA-SMOOTHE/FS BODY.....28DERMA-SMOOTHE/FS SCALP...28DERMOTIC...................................52DERMULCERA.............................28DESCOVY.................................... 18DESFERAL...................................47desipramine hcl.............................11desloratadine................................ 53desmopressin ace spray refrig......39desmopressin acetate...................39desmopressin acetate spray.........39desogestrel-ethinyl estradiol .........41desonide....................................... 28DESOWEN................................... 28desoximetasone............................28DESVENLAFAXINE ER................11desvenlafaxine succinate er......... 11DETROL....................................... 37DETROL LA..................................37dexamethasone............................ 38DEXAMETHASONE (LA)............. 38

dexamethasone intensol...............38dexamethasone sod phosphate pf...................................................38dexamethasone sodium phosphate...............................38, 50dexchlorpheniramine maleate.......53DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)................................. 31DEXILANT.................................... 35dexmethylphenidate hcl ................25dexmethylphenidate hcl er............25DEXONTO 0.4%...........................38DEXPANTHENOL........................ 34dextroamphetamine sulfate.......... 25dextroamphetamine sulfate er...... 25DIACOMIT...................................... 9DIASTAT ACUDIAL........................9DIASTAT PEDIATRIC.................... 9DIATHRIVE LANCING DEVICE... 31diazepam.................................. 9, 20DIAZEPAM................................... 20diazepam intensol.........................20diazoxide.......................................32DIBENZYLINE.............................. 22DICLEGIS.....................................12DICLOFENAC EPOLAMINE...........4diclofenac potassium...................... 4diclofenac sodium...............4, 28, 50diclofenac sodium er.......................4diclofenac-misoprostol ....................4DICLOFONO.................................. 4dicloxacillin sodium.........................7dicyclomine hcl............................. 36didanosine.................................... 18diethylpropion hcl..........................26diethylpropion hcl er......................26DIFICID...........................................7difil-g forte.....................................54diflorasone diacetate.....................28DIFLUCAN....................................12diflunisal..........................................4digitek........................................... 22digox............................................. 22digoxin.......................................... 22dihydroergotamine mesylate.........13DILANTIN....................................... 9DILATRATE-SR............................22DILAUDID.......................................3diltiazem hcl..................................22diltiazem hcl er..............................22diltiazem hcl er beads...................22diltiazem hcl er coated beads....... 22dilt-xr.............................................22dimenhydrinate............................. 12

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dimethyl fumarate......................... 25diphen...........................................53diphenhydramine hcl.....................53diphenoxylate-atropine................. 36DIPROLENE.................................28DIPROLENE AF........................... 28dipyridamole................................. 17disopyramide phosphate...............22disulfiram........................................ 6DITROPAN XL..............................37DIURIL..........................................22divalproex sodium...........................9divalproex sodium er.......................9DIVIGEL........................................41dofetilide....................................... 22DOLOPHINE...................................3donepezil hcl .................................10DOPTELET...................................20DORAL......................................... 20dorzolamide hcl.............................51DORZOLAMIDE HCL................... 51dorzolamide hcl-timolol mal.......... 51dorzolamide hcl-timolol mal pf...... 51dotti ...............................................41DOVATO.......................................18DOVER URETHRAL CATHETER.................................. 47DOVONEX....................................28doxazosin mesylate...................... 22doxepin hcl ........................11, 28, 56doxercalciferol ...............................46doxycycline................................... 28doxycycline hyclate.........................7doxycycline monohydrate............... 8doxylamine-pyridoxine..................12DRISDOL......................................34DRIZALMA SPRINKLE.................11dronabinol.....................................12droperidol......................................12DROPLET MICRON..................... 33drospiren-eth estrad-levomefol.....41drospirenone-ethinyl estradiol .......41DROXIA........................................14DRYSOL.......................................28DUAVEE.......................................41DUETACT.....................................30duloxetine hcl................................11DUODOTE....................................47DUOPA.........................................17DUPIXENT....................................28DURAFIBER.................................28duramorph...................................... 3duraxin............................................3dutasteride....................................38dutasteride-tamsulosin hcl............38DYANAVEL XR.............................25DYMISTA......................................53

DYRENIUM...................................22DYSPORT.................................... 47E.E.S. 400.......................................8E.E.S. GRANULES.........................8EASIVENT....................................47easygel......................................... 26EC-NAPROSYN............................. 4ec-naproxen....................................4econazole nitrate.......................... 12EDARBI........................................ 22EDARBYCLOR.............................22EDECRIN......................................22ed-spaz.........................................36EDURANT.................................... 18efavirenz....................................... 18EFFER-K...................................... 34effer-k............................................34EFFIENT.......................................17EFUDEX....................................... 28EGATEN.......................................16EGRIFTA SV................................ 39ELESTRIN.................................... 41eletriptan hydrobromide................13ELIGARD......................................39ELIMITE........................................16elinest........................................... 41ELIQUIS..........................................9ELIQUIS DVT/PE STARTER PACK..............................................9ELIXOPHYLLIN............................ 54ELLA.............................................41ELMIRON..................................... 37ELOCTATE...................................20eluryng..........................................41EMBRACE SEIZURE MONITORING SYS...................... 47EMCYT......................................... 14EMEND.........................................12EMEND TRI-PACK.......................12EMFLAZA..................................... 13EMGALITY....................................13EMGALITY (300 MG DOSE)........ 13EMJOI TENS................................ 47emoquette.....................................41EMSAM.........................................11EMTRIVA......................................18EMVERM......................................16ENABLEX..................................... 37enalapril maleate.......................... 22enalapril-hydrochlorothiazide........22ENBREL....................................... 44ENBREL MINI...............................44ENBREL SURECLICK..................44ENDARI........................................ 47ENDO AVITENE...........................47endocet...........................................3ENDOMETRIN..............................41

ENEMA BOTTLE..........................47ENLITE GLUCOSE SENSOR...... 31enoxaparin sodium......................... 9enpresse-28..................................41enskyce.........................................41ENSPRYNG..................................44entacapone...................................17entecavir ....................................... 18ENTEREG.................................... 36ENTOCORT EC............................45ENTRESTO.................................. 22ENTRISTAR PEG ENTERAL CONNECT....................................47enulose......................................... 36ENVARSUS XR............................44EPCLUSA.....................................18EPHEDRINE SULFATE (PRESSORS)............................... 22EPIDIOLEX.....................................9EPIDUO FORTE...........................28EPIFOAM......................................28epinastine hcl................................50epinephrine.............................22, 54EPINEPHRINE............................. 22epinephrine pf...............................22EPIPEN 2-PAK............................. 54EPISIL...........................................47epitol ............................................... 9EPIVIR..........................................18EPIVIR HBV..................................18eplerenone....................................22EPZICOM..................................... 18EQUETRO....................................20ergocalciferol ................................ 34ergoloid mesylates........................47ERGOMAR................................... 13ergotamine-caffeine......................13ERIVEDGE................................... 14erlotinib hcl ....................................14EROS-CTD...................................47errin...............................................41ertapenem sodium..........................8ERWINAZE...................................14ery.................................................28ERYGEL....................................... 28ERYPED 200..................................8ERYPED 400..................................8ERY-TAB........................................ 8ERYTHROCIN STEARATE............8erythromycin....................... 8, 28, 50erythromycin base.......................... 8erythromycin ethylsuccinate........... 8ESBRIET...................................... 54escitalopram oxalate.....................11ESGIC.............................................3esomeprazole magnesium............35estarylla........................................ 41

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estazolam..................................... 20estradiol ........................................ 41estradiol valerate.......................... 41estradiol-norethindrone acet.........41ESTRING......................................41ESTROGEL.................................. 41ESTROSTEP FE.......................... 41eszopiclone...................................56ethacrynic acid..............................22ethambutol hcl .............................. 13ethosuximide...................................9ethyl chloride...................................5ethynodiol diac-eth estradiol .........41etodolac.......................................... 4etodolac er......................................4etonogestrel-ethinyl estradiol ........41etoposide...................................... 14EUCRISA......................................28euthyrox........................................44EVAMIST......................................41EVEKEO ODT.............................. 25EVENITY...................................... 46everolimus.............................. 14, 44EVERSENSE SENSOR/HOLDER.......................31EVERSENSE SMART TRANSMITTER............................ 32EVISTA.........................................39EVOCLIN......................................28EVOTAZ....................................... 18EVOXAC.......................................26EVZIO.............................................6EXACTA-MED ORAL SYRINGE 5ML...............................................47EXCILON AMD DRAIN SPONGES....................................47EXELON....................................... 10exemestane.................................. 14EXJADE........................................34exoderm........................................12exotic-hc....................................... 53EXPAREL....................................... 5EYLEA.......................................... 52EZALLOR SPRINKLE...................22ezetimibe...................................... 22ezetimibe-simvastatin................... 22FACE MASK EARLOOP-STYLE..47FACE MASK RESP N-100 PART.47FACE MASK RESPIRATOR R-95 PART....................................... 47falmina.......................................... 41famciclovir .....................................18famotidine..................................... 35FANAPT........................................17FANAPT TITRATION PACK.........17FARESTON.................................. 14FARXIGA......................................30

FARYDAK.....................................14FASENRA.....................................53FASENRA PEN............................ 53FASLODEX...................................14FAVIPIRAVIR............................... 18fayosim......................................... 41febuxostat..................................... 13FEIBA........................................... 20felbamate........................................9FELDENE....................................... 4felodipine er.................................. 22FEMARA.......................................14FEMHRT LOW DOSE.................. 41FEMRING..................................... 41femynor.........................................41fenofibrate.....................................22fenofibrate micronized.................. 22fenofibric acid................................22fenoprofen calcium......................... 4fenortho...........................................4fentanyl........................................... 3fentanyl citrate................................ 3FERRIPROX.................................34FERRIPROX TWICE-A-DAY........34FETZIMA...................................... 11FETZIMA TITRATION.................. 11FEXMID........................................ 56FIBRICOR.....................................22FIBRYGA......................................20FINACEA...................................... 28finasteride..................................... 38FIORINAL....................................... 3FIORINAL/CODEINE #3.................3FIRAZYR...................................... 44FIRMAGON.................................. 39FIRMAGON (240 MG DOSE).......39FIRST-LANSOPRAZOLE............. 35FIRST-OMEPRAZOLE................. 35FIRVANQ........................................8flac................................................ 53FLAGYL..........................................8FLAREX........................................50flavoxate hcl ..................................37flecainide acetate..........................22FLEXICHAMBER ADULT MASK/SMALL...............................48FLEXICHAMBER CHILD MASK/LARGE.............................. 48FLEXICHAMBER CHILD MASK/SMALL...............................48FLOLIPID......................................22FLOVENT DISKUS.......................54FLOVENT HFA.............................54floxuridine..................................... 14fluconazole....................................12flucytosine.....................................12fludrocortisone acetate................. 38

flunisolide......................................53fluocinolone acetonide............28, 53fluocinolone acetonide body......... 28fluocinolone acetonide scalp.........28fluocinonide...................................28fluocinonide emulsified base.........28FLUORABON............................... 34fluoridex........................................ 26fluoridex daily renewal.................. 26fluoridex enhanced whitening....... 26fluoridex sensitivity relief ...............26fluoritab.........................................34fluorometholone............................50FLUOROPLEX..............................29FLUOROURACIL..........................29fluorouracil .................................... 29fluoxetine hcl .................................11fluoxetine hcl (pmdd).................... 11fluphenazine decanoate................17fluphenazine hcl............................17FLURA-DROPS............................34flurandrenolide..............................29flurazepam hcl.............................. 56flurbiprofen......................................4flurbiprofen sodium....................... 50flutamide....................................... 14fluticasone propionate.............29, 53fluticasone-salmeterol ...................54FLUTICASONE-SALMETEROL... 55fluvastatin sodium.........................22fluvastatin sodium er.....................22fluvoxamine maleate.....................11fluvoxamine maleate er.................11FLYP NEBULIZER........................48FML...............................................50FML FORTE................................. 50FML LIQUIFILM............................50folic acid........................................34FOLLISTIM AQ.............................39fondaparinux sodium...................... 9FORA D40G GLUCOSE/PRESSURE............... 48FORFIVO XL................................ 11formaldehyde................................48FORTAZ......................................... 8FORTEO.......................................46FOSAMAX.................................... 46FOSAMAX PLUS D...................... 46fosamprenavir calcium..................18fosinopril sodium...........................22fosinopril sodium-hctz...................22fosphenytoin sodium.......................9FOSRENOL..................................37FRAGMIN....................................... 9FREESTYLE LIBRE 14 DAY READER.......................................32

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FREESTYLE LIBRE 14 DAY SENSOR.......................................32FREESTYLE LIBRE 2 READER SYSTM......................................... 32FREESTYLE LIBRE 2 SENSOR SYSTM......................................... 32frovatriptan succinate....................13fulvestrant..................................... 14furosemide....................................22FUZEON.......................................18fyavolv...........................................41FYCOMPA......................................9gabapentin......................................9GABITRIL....................................... 9GALAFOLD...................................37galantamine hydrobromide........... 10galantamine hydrobromide er.......10GALZIN.........................................34GAMASTAN..................................44GAMMACORE..............................48GAMMACORE SAPPHIRE 31-DAY.............................................. 48GAMMACORE SAPPHIRE REFILL KIT...................................48GAMMAGARD..............................44GAMMAKED.................................44GAMUNEX-C................................44ganirelix acetate............................39GASTROCROM............................36gatifloxacin....................................50GATTEX....................................... 36gavilyte-c.......................................36gavilyte-g...................................... 36gavilyte-h...................................... 36gavilyte-n with flavor pack.............36GEBAUERS PAIN EASE................5GEBAUERS SPRAY AND STRETCH.......................................5GELFILM...................................... 48GEL-FLOW NT............................. 48GELFOAM.................................... 48GELFOAM COMPRESSED SIZE 100................................................48GELFOAM DENTAL PACK SIZE 4....................................................48GELFOAM SPONGE....................48GELFOAM SPONGE SIZE 100....48GELFOAM SPONGE SIZE 200....48GELFOAM SPONGE SIZE 50......48GELNIQUE................................... 37GELX............................................ 48gemfibrozil .................................... 23generlac........................................36gengraf..........................................44gentak...........................................51gentamicin sulfate.....................8, 51GENTEEL LANCING KIT (BLUE).32

GENVOYA....................................18GEODON......................................17gianvi............................................ 41GILENYA...................................... 25GILOTRIF..................................... 14GIVLAARI..................................... 48glatiramer acetate.........................25glatopa..........................................25GLEOSTINE................................. 14glimepiride.................................... 30glipizide er.....................................30glipizide ir ......................................31glipizide xl ..................................... 31glipizide-metformin hcl ..................31GLUCAGEN HYPOKIT.................32GLUCAGON EMERGENCY KIT.. 33GLUCOTROL............................... 31GLUCOTROL XL..........................31glutaraldehyde.............................. 48GLUTATHIONE............................ 34glyburide....................................... 31glyburide micronized.....................31glyburide-metformin......................31GLYCINE......................................34glycopyrrolate............................... 36GLYCOPYRROLATE................... 36glycopyrrolate pf........................... 36glydo............................................... 5GLYNASE.....................................31GLYRX-PF....................................36GLYSET........................................31GLYXAMBI................................... 31GOJJI LANCING DEVICE/CLEAR CAP...................32GONITRO.....................................23GORDOFILM................................29GRALISE...................................... 26granisetron hcl .............................. 12griseofulvin microsize................... 12griseofulvin ultramicrosize............ 12guaiatussin ac...............................53guaifenesin ac...............................53guanfacine hcl ...............................23guanfacine hcl er.......................... 25GUANIDINE HCL..........................13GUARDIAN CONNECT TRANSMITTER............................ 32GUARDIAN LINK 3 TRANSMITTER............................ 32GUARDIAN REAL-TIME SYSTEM.......................................32GUARDIAN SENSOR (3)............. 32GVOKE HYPOPEN 1-PACK........ 33GVOKE HYPOPEN 2-PACK........ 33GVOKE PFS.................................33GYNAZOLE-1...............................12hailey 1.5/30................................. 41

hailey 24 fe................................... 41hailey fe 1.5/30............................. 41hailey fe 1/20................................ 41halcinonide....................................29HALCION......................................20HALDOL....................................... 17HALDOL DECANOATE................18halobetasol propionate................. 29haloperidol.................................... 18haloperidol decanoate.................. 18haloperidol lactate.........................18HARVONI..................................... 18heather..........................................42HELIDAC THERAPY.................... 36HEMANGEOL...............................23hematinic/folic acid....................... 34HEMLIBRA................................... 20hemocyte-f ....................................34HEMOFIL M..................................20heparin sodium (porcine)................9heparin sodium (porcine) pf............9HEPSERA.....................................18HERCEPTIN HYLECTA............... 14HETLIOZ.......................................56HIPREX.......................................... 8HISTOACRYL...............................48HIZENTRA....................................44homatropaire.................................52HORIZANT................................... 26HUMALOG KWIKPEN..................33HUMALOG MIX 50/50 KWIKPEN.33HUMALOG MIX 50/50 VIAL......... 33HUMALOG MIX 75/25 KWIKPEN.33HUMALOG MIX 75/25 VIAL......... 33HUMALOG U-100 JUNIOR KWIKPEN..................................... 33HUMALOG VIAL...........................33HUMATE-P...................................20HUMIRA........................................44HUMIRA PEDIATRIC CROHNS START..........................................44HUMIRA PEN............................... 44HUMIRA PEN-CD/UC/HS STARTER.....................................44HUMIRA PEN-PS/UV/ADOL HS START..........................................44HUMULIN 70/30 KWIKPEN..........33HUMULIN 70/30 VIAL...................33HUMULIN N KWIKPEN................ 33HUMULIN N VIAL.........................33HUMULIN R U-500 KWIKPEN..... 33HUMULIN R U-500 VIAL.............. 33HUMULIN R VIAL.........................33HYCAMTIN...................................14hydralazine hcl ..............................23HYDREA.......................................14hydrochlorothiazide.......................23

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hydrocodone bitartrate er................3hydrocodone polst-chlorphen polst er susp................................. 53hydrocodone-acetaminophen......... 3hydrocodone-homatropine............53hydrocodone-ibuprofen...................3hydrocortisone.................. 29, 38, 45hydrocortisone (perianal)..............45hydrocortisone ace-pramoxine..... 45hydrocortisone butyr lipo base......29hydrocortisone butyrate................ 29hydrocortisone valerate................ 29hydrocortisone-acetic acid............53hydrogen peroxide..........................8hydromet.......................................53HYDROMORPHONE HCL............. 3hydromorphone hcl.........................3hydromorphone hcl er.....................3hydromorphone hcl pf.....................3HYDROMORPHONE HCL-NACL...3hydroxocobalamin acetate............34hydroxychloroquine sulfate...........16hydroxyprogesterone caproate.....42hydroxyurea..................................14hydroxyzine hcl.............................20hydroxyzine pamoate....................20HYLENEX.....................................48hyoscyamine sulfate..................... 36hyoscyamine sulfate sl ..................36hyosyne........................................ 36HYPERRHO S/D.......................... 44HYPERSAL...................................53HYQVIA........................................ 44HYSINGLA ER................................3ibandronate sodium...................... 46IBRANCE......................................14ibu...................................................4ibuprofen.........................................4icatibant acetate............................44ICLUSIG....................................... 14IDELVION.....................................20IDHIFA..........................................14ILARIS.......................................... 44ILUMYA........................................ 44imatinib mesylate..........................14IMBRUVICA..................................14imipramine hcl...............................11imipramine pamoate..................... 11imiquimod..................................... 29IMLYGIC.......................................14IMPAVIDO.................................... 16IMURAN........................................44IMVEXXY MAINTENANCE PACK............................................42IMVEXXY STARTER PACK......... 42INBRIJA........................................17incassia.........................................42

INCRELEX....................................39INCRUSE ELLIPTA...................... 55indapamide................................... 23INDOCIN.........................................5indomethacin.................................. 5indomethacin er.............................. 5INFASURF....................................53INFED...........................................48INFUMORPH 200...........................3INFUMORPH 500...........................3INGREZZA....................................26INLYTA......................................... 14INPEN 100-BLUE-LILLY...............32INPEN 100-BLUE-NOVO............. 32INPEN 100-GRAY-LILLY..............32INPEN 100-GREY-NOVO.............32INPEN 100-PINK-LILLY................32INPEN 100-PINK-NOVO.............. 32INREBIC....................................... 14INSPIREASE RESERVOIR BAGS............................................48INSPRA........................................ 23INSTAT.........................................48INSUFLON....................................48INSULIN LISPRO PROT & LISPRO.........................................33INSULIN PEN NEEDLES............. 33INSULIN SYRINGES....................33INTELENCE..................................18INTERCEED.................................48INTERCEED (TC7).......................48INTRAROSA.................................37INTRON A.....................................18introvale........................................ 42INVANZ...........................................8INVEGA........................................ 18INVEGA SUSTENNA....................18INVEGA TRINZA.......................... 18INVELTYS.................................... 51INVIRASE.....................................18iodine strong................................. 34iodine tincture................................. 8IOPIDINE......................................51ipratropium bromide................53, 55ipratropium-albuterol .....................55irbesartan......................................23irbesartan-hydrochlorothiazide..... 23IRESSA.........................................14ISENTRESS................................. 18ISENTRESS HD........................... 18isibloom.........................................42isoniazid........................................13isoproterenol hcl ........................... 23ISOPTO ATROPINE.....................52ISOPTO CARPINE....................... 51ISORDIL TITRADOSE..................23isosorbide dinitrate........................23

isosorbide mononitrate................. 23isosorbide mononitrate er............. 23isotretinoin.................................... 29isradipine...................................... 23ISTALOL.......................................51ISUPREL...................................... 23itraconazole.................................. 12IV ADMINISTRATION SET...........48IV EXTENSION SET.....................48ivermectin..................................... 16IXINITY......................................... 20JADENU....................................... 34JADENU SPRINKLE.....................34jaimiess.........................................42JAKAFI..........................................14JALYN...........................................38jantoven.......................................... 9JANUMET.....................................31JANUMET XR...............................31JANUVIA.......................................31JARDIANCE................................. 31jasmiel...........................................42jencycla.........................................42JENTADUETO..............................31JENTADUETO XR........................31jinteli ..............................................42JIVI................................................20jolessa...........................................42JORNAY PM.................................25J-TIP KIT W/VIAL ADAPTERS.....48juleber...........................................42JULUCA........................................18junel 1.5/30................................... 42junel 1/20...................................... 42junel fe 1.5/30............................... 42junel fe 1/20.................................. 42junel fe 24..................................... 42JUXTAPID.................................... 23JYNARQUE.................................. 34kaitlib fe.........................................42KALBITOR....................................44KALETRA..................................... 18kalliga............................................42KALYDECO.................................. 55KANGAROO BALLOON 20FR/3.5CM................................. 48KANGAROO GASTROSTOMY TUBE............................................ 48KANGAROO GRAVITY FEEDING BAG............................. 48KANGAROO JOEY ENTERAL PUMP........................................... 48KANGAROO MULTI-FUNCTIONAL PORT....................48KANGAROO STOMA MEASURING DEV........................48KAPVAY....................................... 25

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KARAYA GUM..............................48kariva............................................ 42KCENTRA.....................................20KEFLEX..........................................8kelnor 1/35....................................42kelnor 1/50....................................42KENALOG.................................... 38KENALOG-80............................... 38KENDALL SCD EXPRESS FOOT CUFF................................. 48KERAMATRIX REPLICINE 5CMX5CM.................................... 29KERLIX AMD ANTIMICROBIAL...48KERLIX AMD SUPER SPONGES....................................48KERYDIN......................................12ketoconazole.................................12ketodan.........................................12KETONE TEST.............................32ketoprofen.......................................5ketoprofen er...................................5ketorolac tromethamine............ 5, 51KETOROLAC TROMETHAMINE... 5KETOSTIX....................................32KEVEYIS...................................... 51KEVZARA.....................................44KINERET...................................... 44kionex........................................... 34KISQALI (200 MG DOSE)............ 14KISQALI (400 MG DOSE)............ 14KISQALI (600 MG DOSE)............ 15KISQALI FEMARA (400 MG DOSE).......................................... 15KISQALI FEMARA (600 MG DOSE).......................................... 15KISQALI FEMARA(200 MG DOSE).......................................... 15KLARON.......................................29klor-con.........................................34klor-con 10....................................34klor-con m10.................................34KLOR-CON M15...........................34klor-con m20.................................34klor-con sprinkle............................34klor-con/ef.....................................34KOATE..........................................20KOATE-DVI.................................. 20KOGENATE FS............................ 20KORLYM.......................................40KOSELUGO..................................15KOVALTRY...................................20K-PHOS........................................34K-PHOS-NEUTRAL......................34k-prime..........................................34KRINTAFEL..................................16kurvelo.......................................... 42KUVAN......................................... 37

L.E.T............................................... 5labetalol hcl ...................................23LACRISERT..................................52lactic acid......................................29lactic acid e...................................29lactulose........................................36lactulose encephalopathy............. 36LAMICTAL XR.............................. 10lamivudine...............................18, 19lamivudine-zidovudine.................. 19lamotrigine.................................... 10lamotrigine er................................10lamotrigine starter kit-blue............ 10lamotrigine starter kit-green..........10lamotrigine starter kit-orange........10LANCETS..................................... 32LANOXIN......................................23LANOXIN PEDIATRIC..................23lansoprazole................................. 35lanthanum carbonate....................37LANTUS SOLOSTAR...................33LANTUS U-100 VIAL....................33larin 1.5/30....................................42larin 1/20.......................................42larin 24 fe......................................42larin fe 1.5/30................................42larin fe 1/20...................................42larissia...........................................42LASTACAFT.................................52latanoprost....................................51LATEX GLOVES MEDIUM...........48LATUDA........................................18layolis fe........................................42leena.............................................42leflunomide................................... 44LENVIMA (10 MG DAILY DOSE). 15LENVIMA (12 MG DAILY DOSE). 15LENVIMA (14 MG DAILY DOSE). 15LENVIMA (18 MG DAILY DOSE). 15LENVIMA (20 MG DAILY DOSE). 15LENVIMA (24 MG DAILY DOSE). 15LENVIMA (4 MG DAILY DOSE)... 15LENVIMA (8 MG DAILY DOSE)... 15lessina...........................................42letrozole........................................ 15leucovorin calcium........................ 15LEUKERAN.................................. 15LEUKINE...................................... 20leuprolide acetate......................... 39LEUPROLIDE ACETATE-BUPIVACAINE..............................39levalbuterol hcl ..............................55LEVALBUTEROL HFA................. 55LEVEMIR U-100 FLEXTOUCH.... 33LEVEMIR U-100 VIAL.................. 33levetiracetam................................ 10levetiracetam er............................ 10

levobunolol hcl ..............................51LEVOCARNITINE.........................34levocarnitine..................................34levocarnitine sf..............................34levocetirizine dihydrochloride........53levofloxacin...............................8, 51levonest........................................ 42levonorgest-eth est & eth est........42levonorgest-eth estrad 91-day......42levonorgestrel-ethinyl estrad.........42levonorg-eth estrad triphasic........ 42levora 0.15/30 (28)........................42levorphanol tartrate.........................3levo-t .............................................44levothyroxine sodium....................44levoxyl...........................................44LEVULAN KERASTICK................29LEXIVA......................................... 19lidocaine..........................................5lidocaine hcl ..............................5, 26LIDOCAINE HCL............................ 5lidocaine hcl (pf) ..............................5lidocaine hcl urethral/mucosal........ 5LIDOCAINE IN DEXTROSE...........6lidocaine viscous hcl.....................26lidocaine-epinephrine......................6lidocaine-prilocaine.........................6LIDOCAINE-SODIUM BICARBONATE..............................6LIDO-EPINEPHRINE-TETRACAINE.................................6lillow..............................................42LINCOCIN.......................................8lincomycin hcl ................................. 8lindane.......................................... 16linezolid...........................................8LINZESS.......................................36liothyronine sodium.......................44LIPO..............................................34LIPO-C..........................................34LIPOFEN...................................... 23lisinopril .........................................23lisinopril-hydrochlorothiazide........ 23lithium........................................... 20lithium carbonate.......................... 20lithium carbonate er...................... 20LITHOBID..................................... 20LITHOSTAT..................................37LIVALO......................................... 23LODINE.......................................... 5lojaimiess......................................42LOKELMA.....................................34LOMAIRA......................................26LOMOTIL......................................36LONHALA MAGNAIR REFILL KIT................................................ 55

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LONHALA MAGNAIR STARTER KIT................................................ 55LONSURF.....................................15LOOP............................................48loperamide hcl.............................. 36LOPID...........................................23lopinavir-ritonavir .......................... 19lopreeza........................................42LOPRESSOR............................... 23LOPRESSOR HCT.......................23LOPROX.......................................12lorazepam.....................................20lorazepam intensol........................20LORBRENA..................................15lorcet...............................................3lorcet hd..........................................3LORTAB......................................... 3loryna............................................42LORZONE.................................... 56losartan potassium........................23losartan potassium-hctz................23LOSEASONIQUE......................... 42LOTEMAX SM.............................. 51LOTENSIN....................................23LOTENSIN HCT........................... 23loteprednol etabonate...................51lovastatin.......................................23LOVENOX...................................... 9low-ogestrel .................................. 42loxapine succinate........................ 18lo-zumandimine............................ 42LUCEMYRA....................................6LUCENTIS....................................52ludent............................................34LUMIGAN..................................... 51LUPANETA PACK........................39LUPRON DEPOT (1-MONTH)......39LUPRON DEPOT (3-MONTH)......39LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..... 40LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..... 40LUPRON DEPOT-PED (1-MONTH)....................................... 40LUPRON DEPOT-PED (3-MONTH)....................................... 40lutera.............................................42LUXIQ...........................................29LYNPARZA...................................15LYRICA CR...................................26LYSINE HCL.................................34LYSODREN..................................15LYSTEDA..................................... 20lyza............................................... 42MACROBID.................................... 8MACRODANTIN.............................8mafenide acetate............................ 8

MAGNEBIND 400.........................34magnesium chloride......................34magnesium sulfate........................34MAGNESIUM SULFATE.............. 34MAKENA.......................................42MALARONE..................................16malathion...................................... 16maprotiline hcl ...............................11MARCAINE.....................................6MARCAINE PRESERVATIVE FREE.............................................. 6MARCAINE/EPINEPHRINE........... 6MARCAINE/EPINEPHRINE PF......6MARINOL..................................... 12marlissa........................................ 42MARPLAN.................................... 11MASK VORTEX............................48MATULANE.................................. 15matzim la...................................... 23MAVENCLAD (10 TABS)..............25MAVENCLAD (4 TABS)................25MAVENCLAD (5 TABS)................25MAVENCLAD (6 TABS)................25MAVENCLAD (7 TABS)................25MAVENCLAD (8 TABS)................25MAVENCLAD (9 TABS)................26MAVYRET.................................... 19MAXICOMFORT SYR 27G X 1/2"............................................... 33MAXIDEX......................................51MAXITROL................................... 52maxi-tuss ac..................................53MAXZIDE......................................23MAXZIDE-25.................................23MAYZENT.....................................26MAYZENT STARTER PACK........26meclizine hcl ................................. 12meclofenamate sodium...................5MEDICAL COMPRESSION STOCKINGS.................................48MEDROL...................................... 38MEDROX-RX..................................3medroxyprogesterone acetate......42mefenamic acid...............................5mefloquine hcl ...............................16megestrol acetate......................... 42MEKINIST.....................................15MEKTOVI......................................15melodetta 24 fe.............................42meloxicam.......................................5melphalan..................................... 15memantine hcl .............................. 10memantine hcl er.......................... 10MEMBRANEBLUE........................52MENEST.......................................42MENOPUR................................... 40MENOSTAR................................. 42

meperidine hcl ................................ 3MEPHYTON................................. 34meprobamate................................20MEPRON......................................16mercaptopurine.............................15mesalamine.................................. 45mesalamine er.............................. 45mesalamine-cleanser....................45MESNEX.......................................15MESTINON...................................13metadate er...................................25metaproterenol sulfate..................55metaxalone................................... 56metformin hcl er............................31metformin hcl ir ............................. 31methadone hcl................................ 3methadone hcl intensol...................3methadose......................................4methadose sugar-free.....................4methamphetamine hcl.................. 25methazolamide............................. 51methenamine hippurate..................8methergine....................................48methimazole................................. 44METHITEST................................. 39methocarbamol.............................56methotrexate.................................44methotrexate (anti-rheumatic).......44methotrexate sodium.................... 44methotrexate sodium (pf)..............44methoxsalen rapid........................ 29methscopolamine bromide............36METHYLCOBALAMIN..................34methyldopa................................... 23methyldopa-hydrochlorothiazide...23methylergonovine maleate............48METHYLIN....................................25methylphenidate hcl ......................25methylphenidate hcl er..................25methylphenidate hcl er (cd).......... 25methylphenidate hcl er (la)........... 25methylprednisolone.......................38METHYLPREDNISOLONE ACETATE..................................... 38methylprednisolone acetate..........38methylprednisolone sodium succ..38METHYLPREDNISOLONE-BUPIVACAINE..............................38methyltestosterone....................... 39metoclopramide hcl.......................12metolazone................................... 23metoprolol succinate er.................23metoprolol tartrate.........................23metoprolol-hydrochlorothiazide.....23METROCREAM............................29METROLOTION........................... 29metronidazole........................... 8, 29

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metyrosine.................................... 23mexiletine hcl................................23MI PASTE.....................................26MI PASTE PLUS...........................26MIACALCIN.................................. 46mibelas 24 fe................................ 42miconazole 3.................................12MICRHOGAM ULTRA-FILTERED PLUS..........................45MICROAIR VIBRATING MESH NEBUL..........................................48MICROCHAMBER........................48MICROCYN.................................. 29microgestin 1.5/30........................ 42microgestin 1/20........................... 42microgestin fe 1.5/30.................... 42microgestin fe 1/20....................... 42MICROLET NEXT LANCING DEVICE........................................ 32MICRONEB.................................. 48midodrine hcl................................ 23MIGERGOT.................................. 13miglitol ...........................................31miglustat....................................... 37MIGRANAL...................................13mili ................................................ 42MILLIPRED...................................38MILLIPRED DP 12-DAY............... 39mimvey......................................... 42mineral oil heavy...........................36MINIMED GUARDIAN SENSOR 3....................................................32MINIPRESS..................................23minitran.........................................23MINIVELLE...................................42minocycline hcl............................... 8minocycline hcl er........................... 8minoxidil ........................................23MIRAPEX......................................17MIRAPEX ER................................17MIRCERA..................................... 20MIRCETTE................................... 42mirtazapine................................... 11MIRVASO..................................... 29misoprostol ................................... 35mitigo.............................................. 4MITOSOL......................................51modafinil ....................................... 56moexipril hcl ..................................23molindone hcl................................18mometasone furoate...............29, 53MONARCH ETNS SYSTEM.........48mondoxyne nl................................. 8mono-linyah.................................. 42MONONINE..................................20montelukast sodium......................55MONUROL..................................... 8

morgidox.........................................8MORPHINE SULFATE................... 4morphine sulfate............................. 4morphine sulfate (concentrate).......4morphine sulfate (pf) .......................4morphine sulfate er.........................4morphine sulfate er beads.............. 4MORPHINE SULFATE-NACL........ 4MOTEGRITY................................ 36MOXEZA.......................................51moxifloxacin hcl ........................ 8, 51moxifloxacin hcl (2x day).............. 51MOZOBIL......................................20MUCOTROL................................. 48MUGARD......................................48MULPLETA...................................21MULTAQ.......................................23mupirocin........................................ 8mupirocin calcium...........................8MUSE........................................... 37MYALEPT.....................................37MYAMBUTOL...............................13MYCOBUTIN................................ 13mycophenolate mofetil ..................45mycophenolate sodium.................45MYDAYIS......................................25MYFORTIC...................................45MYLERAN.................................... 15MYOBLOC....................................49myorisan....................................... 29MYRBETRIQ................................ 37MYTESI........................................ 36nabumetone....................................5n-acetyl-l-cysteine.........................34nadolol .......................................... 23nafcillin sodium............................... 8nafrinse.........................................34NAFRINSE DAILY ACIDULATED 27NAFRINSE DAILY/NEUTRAL...... 27nafrinse drops...............................34NAFRINSE WEEKLY....................27naftifine hcl....................................12NAFTIN.........................................12nalbuphine hcl .................................4naloxone hcl....................................6naltrexone hcl ................................. 6NAMENDA....................................10NAMENDA TITRATION PAK........10NAMENDA XR..............................10NAMENDA XR TITRATION PACK............................................10NAMZARIC...................................10naproxen.........................................5naproxen dr.....................................5naproxen sodium............................ 5naproxen sodium er........................5naproxen-esomeprazole.................5

naratriptan hcl...............................13NARCAN.........................................6NARDIL.........................................11NAROPIN....................................... 6NASCOBAL.................................. 34NATACYN.....................................51NATAZIA.......................................42nateglinide.................................... 31NATESTO.....................................39NATPARA.....................................46NATURE-THROID........................44NAYZILAM....................................10NEB-RITE4...................................49NEBULIZER PED FROG..............49NEBULIZER PED FROG KIT....... 49NEBULIZER SYSTEM ALL-IN-ONE..............................................49NEBUPENT.................................. 16nebusal......................................... 53NEBUSAL.....................................53necon 0.5/35 (28)..........................42nefazodone hcl............................. 11NEMBUTAL.................................. 10NEOKE ALCAR............................ 34NEOKE RA LIPOIC...................... 49neomycin sulfate.............................8neomycin-bacitracin zn-polymyx...52neomycin-polymyxin-dexameth.... 52neomycin-polymyxin-gramicidin....52neomycin-polymyxin-hc.......... 52, 53neo-polycin................................... 52neo-polycin hc...............................52NEORAL.......................................45NEO-SYNALAR............................29NERIVIO.......................................49NERLYNX.....................................15NESACAINE...................................6NESACAINE-MPF.......................... 6neuac............................................29NEULASTA...................................21NEULASTA ONPRO.....................21NEUPRO...................................... 17neutral sodium fluoride................. 27nevirapine..................................... 19nevirapine er.................................19NEXAVAR.....................................15NEXAVIR......................................49NEXIUM........................................35niacin (antihyperlipidemic)............ 23niacin er (antihyperlipidemic)........23niacor............................................23nicardipine hcl...............................23NICOTROL..................................... 6NICOTROL NS............................... 6nifedipine...................................... 23nifedipine er.................................. 23nifedipine er osmotic release........23

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nikki ...............................................42NILANDRON.................................15nilutamide..................................... 15nimodipine.................................... 23NINLARO......................................15nisoldipine er.................................23nitisinone.......................................37NITRILE GLOVES LARGE...........49NITRO-BID................................... 23NITRO-DUR..................................23nitrofurantoin...................................8nitrofurantoin macrocrystal ............. 8nitrofurantoin monohydrate macrocrystals..................................8nitroglycerin.................................. 23NITROLINGUAL........................... 23NITROMIST..................................23nitro-time.......................................23NITYR...........................................37NIVESTYM................................... 21nizatidine.......................................35NOCDURNA.................................40nolix.............................................. 29nora-be......................................... 43NORDIPEN 5 INJECTION DEVICE........................................ 49NORDITROPIN FLEXPRO...........40norethin ace-eth estrad-fe.............43norethindrone................................43norethindrone acetate...................43norethindrone acet-ethinyl est...... 43norethindrone-eth estradiol ...........43norethin-eth estradiol-fe................43norgestimate-eth estradiol ............ 43norgestimate-ethinyl estradiol triphasic........................................ 43norlyda..........................................43norlyroc.........................................43NORM-JECT LUER SLIP SYRINGE......................................49NORMLGEL AG........................... 29NORPACE....................................23NORPACE CR..............................23NORPRAMIN................................11NORTHERA..................................24nortrel 0.5/35 (28)......................... 43nortrel 1/35 (21)............................ 43nortrel 1/35 (28)............................ 43nortrel 7/7/7...................................43nortriptyline hcl..............................11NORVIR........................................19NOURIANZ...................................17NOVACHOR.................................29novarel..........................................40NOVAREL.....................................40NOVOEIGHT................................ 21

NOVOFINE AUTOCOVER PEN NEEDLE....................................... 33NOVOFINE PEN NEEDLE........... 33NOVOFINE PLUS PEN NEEDLE.33NOVOPEN ECHO........................ 32NOVOSEVEN RT......................... 21NOVOTWIST PEN NEEDLE........ 33NOXAFIL...................................... 12NOZIN NASAL SANITIZER POPSWAB....................................49np thyroid......................................44NPLATE........................................21NS-2 ELECTRIC PATCH POUCH.........................................49NUBEQA.......................................15NUCALA....................................... 53NUCEL..........................................29NUEDEXTA.................................. 26nulev............................................. 36NUPLAZID....................................18NURTEC.......................................13NUSHIELD....................................29NUTROPIN AQ NUSPIN 10......... 40NUTROPIN AQ NUSPIN 20......... 40NUTROPIN AQ NUSPIN 5........... 40NUVARING...................................43NUWIQ......................................... 21NUZYRA.........................................8nyamyc......................................... 12NYMALIZE....................................24nystatin................................... 12, 13nystatin-triamcinolone...................13nystop........................................... 13OBIZUR........................................ 21OCALIVA...................................... 37ocella............................................ 43octreotide acetate......................... 40OCUFLOX.................................... 51ODEFSEY.....................................19ODOMZO......................................15OFEV............................................55ofloxacin..............................8, 51, 53olanzapine.................................... 18olanzapine-fluoxetine hcl .............. 11olmesartan medoxomil ..................24olmesartan medoxomil-hctz..........24olmesartan-amlodipine-hctz..........24olopatadine hcl........................51, 53OLUX............................................29OLUX-E........................................ 29OMECLAMOX-PAK......................36omega-3-acid ethyl esters............ 24omeprazole...................................35OMEPRAZOLE+SYRSPEND SF ALKA.............................................35OMNARIS.....................................53OMNIPOD DASH 5 PACK PODS.49

OMNIPOD DASH SYSTEM..........32OMNIPOD STARTER...................32ONCASPAR..................................15ondansetron hcl............................ 12ondansetron odt............................12ONE FLOW SPIROMETER..........49ONETOUCH DELICA LANCING DEV.............................................. 32ONETOUCH DELICA PLUS LANCING......................................32ONETOUCH ULTRA.................... 32ONETOUCH ULTRA 2 KIT W/DEVICE....................................32ONETOUCH ULTRA MINI KIT W/DEVICE....................................32ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..............32ONETOUCH VERIO IQ SYSTEM 32ONETOUCH VERIO KIT W/DEVICE....................................32ONETOUCH VERIO REFLECT....32ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..............32ONEXTON....................................29OPSUMIT..................................... 56ORABLOC...................................... 6ORACIT........................................ 34oralone..........................................27ORAMAGICRX............................. 49ORAPEUTIC.................................49ORAPRED ODT........................... 39ORENCIA..................................... 45ORENCIA CLICKJECT.................45ORENITRAM................................ 56ORFADIN......................................37ORILISSA..................................... 40ORKAMBI..................................... 55orphenadrine citrate......................56orphenadrine citrate er..................56orphenadrine-asa-caffeine............56orsythia......................................... 43oscimin..........................................36oseltamivir phosphate...................19OSMOPREP.................................36OSPHENA.................................... 39OSTEOCONDUCTIVE MATRIX PLUS............................................ 29OTEZLA........................................45OTICIN HC NR............................. 53OTREXUP.................................... 45OVIDE...........................................16OVIDREL......................................40oxacillin sodium.............................. 8oxandrolone..................................39oxaprozin........................................ 5oxazepam..................................... 20oxcarbazepine.............................. 10

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OXERVATE.................................. 52oxiconazole nitrate........................13OXSORALEN ULTRA...................29oxybutynin chloride.......................37oxybutynin chloride er...................37oxycodone hcl.................................4oxycodone-acetaminophen.............4oxycodone-aspirin...........................4OXYCONTIN.................................. 4oxymorphone hcl............................ 4oxymorphone hcl er........................ 4oxytocin.........................................40OXYTROL.....................................37OZEMPIC..................................... 31OZURDEX.................................... 51PACERONE..................................24pacerone.......................................24PAIN RELIEF WITH TENS S2000........................................... 49paliperidone er..............................18PALYNZIQ....................................37PANDA MASK LARGE.................49PANDA MASK MEDIUM...............49PANDA MASK SMALL................. 49PANRETIN....................................15pantoprazole sodium.................... 35PARADIGM REAL-TIME STARTER.....................................32PARI ALTERA NEBULIZER HANDSET.....................................49PARI MASK SET.......................... 49PARI TREK S COMBO PACK......49paricalcitol .....................................46PARLODEL...................................17PARNATE.....................................11paroex...........................................27paromomycin sulfate.......................8paroxetine hcl............................... 11paroxetine hcl er........................... 11paroxetine mesylate......................11PASER..........................................13PATANASE...................................53PAXIL............................................11PEDIAPRED.................................39PEDIATRIC PANDA MASK..........49peg 3350-kcl-na bicarb-nacl......... 36peg-3350/electrolytes................... 36PEGANONE................................. 10PEGASYS.....................................19PEGASYS PROCLICK................. 19PEGINTRON................................ 19peg-prep....................................... 36penicillamine.................................37penicillin g potassium......................8penicillin g procaine........................ 8penicillin g sodium.......................... 8penicillin v potassium......................8

PENTAM.......................................16pentamidine isethionate................16PENTASA.....................................45pentazocine-naloxone hcl...............4PENTETATE CALCIUM TRISODIUM..................................49PENTETATE ZINC TRISODIUM..49pentobarbital sodium.................... 10pentoxifylline er.............................24PERFOROMIST........................... 55PERIDEX......................................27perindopril erbumine.....................24periogard.......................................27permethrin.....................................16perphenazine................................12perphenazine-amitriptyline............11PERSERIS....................................18PEXEVA....................................... 11PFIZERPEN....................................8phenazo........................................37phenazopyridine hcl......................37phendimetrazine tartrate...............26phendimetrazine tartrate er...........26phenelzine sulfate.........................11PHENERGAN...............................53phenobarbital ................................10phenobarbital sodium................... 10phenobarbital-belladonna alk........36phenoxybenzamine hcl .................24phentermine hcl ............................ 26phentolamine mesylate.................24phenylephrine hcl..........................52PHENYTEK.................................. 10phenytoin...................................... 10phenytoin infatabs.........................10phenytoin sodium..........................10phenytoin sodium extended..........10philith............................................ 43PHOSLYRA.................................. 37phospha 250 neutral .....................34PHOSPHOLINE IODIDE.............. 51phosphorous.................................34phospho-trin 250 neutral ...............34PHOTREXA VISCOUS.................49PHOTREXA-PHOTREXA VISCOUS KIT...............................49phytonadione................................ 34PICATO........................................ 29PIFELTRO.................................... 19pilocarpine hcl .........................27, 51pimecrolimus.................................29pimozide....................................... 18pimtrea..........................................43pindolol ......................................... 24pioglitazone hcl.............................31pioglitazone hcl-glimepiride.......... 31pioglitazone hcl-metformin hcl ...... 31

PIQRAY (200 MG DAILY DOSE). 15PIQRAY (250 MG DAILY DOSE). 15PIQRAY (300 MG DAILY DOSE). 15pirmella 1/35................................. 43pirmella 7/7/7................................ 43piroxicam........................................ 5PITOCIN....................................... 40PLAQUENIL..................................16PLENVU....................................... 36pocket spacer............................... 49podofilox....................................... 29polocaine........................................ 6polocaine-mpf................................. 6polycin...........................................52polymyxin b sulfate......................... 8polymyxin b-trimethoprim..............52POLYTOZA PATCH..................... 49POLYTRIM................................... 52POMALYST.................................. 15portia-28........................................43posaconazole................................13pot bicarb-pot chloride.................. 34potassium bicarbonate..................34potassium chloride........................35potassium chloride crys er............35potassium chloride er....................35potassium citrate er...................... 35POVIDONE-IODINE..................... 51POWDER FREE NITRILE GLOVES SM.................................49PRADAXA.......................................9pralidoxime chloride......................49PRALUENT...................................24pramipexole dihydrochloride.........17pramipexole dihydrochloride er.....17PRAMOSONE.............................. 29PRAMOTIC...................................53prasugrel hcl ................................. 17pravastatin sodium........................24praziquantel .................................. 16prazosin hcl...................................24PRECOSE.................................... 31PRED MILD.................................. 51PRED-G........................................52PRED-G S.O.P............................. 52prednicarbate................................29prednisolone................................. 39prednisolone acetate.................... 51prednisolone sodium phosphate................................................ 39, 51prednisone....................................39prednisone intensol.......................39PREFEST..................................... 43pregabalin.....................................26pregnyl..........................................40PREMARIN...................................43PREMPHASE............................... 43

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PREMPRO....................................43prenatal.........................................35PREPIV SUPPLY........................... 6PRESTALIA..................................24PRETOMANID..............................13prevalite........................................ 24PREVIDENT................................. 27prevident.......................................27PREVIDENT 5000 BOOSTER PLUS............................................ 27PREVIDENT 5000 DRY MOUTH. 27PREVIDENT 5000 ENAMEL PROTECT.....................................27PREVIDENT 5000 ORTHO DEFENSE.....................................27PREVIDENT 5000 PLUS..............27PREVIDENT 5000 SENSITIVE.... 27previfem........................................43PREVYMIS................................... 19PREZCOBIX.................................19PREZISTA.................................... 19PRIFTIN........................................13PRILOSEC....................................35primaquine phosphate.................. 16primidone......................................10PRIMSOL........................................8PRO COMFORT SPACER ADULT..........................................49PRO COMFORT SPACER CHILD...........................................49PRO COMFORT SPACER INFANT.........................................49PRO COMFORT TENS UNIT.......49PROAIR DIGIHALER....................55PROAIR HFA................................55PROAIR RESPICLICK..................55probenecid....................................13PROBUPHINE IMPLANT KIT.........4procainamide hcl...........................24PROCARDIA................................ 24PROCARDIA XL...........................24PROCARE SPACER/ADULT MASK............................................49PROCARE SPACER/CHILD MASK............................................49PROCENTRA............................... 25prochlorperazine...........................12prochlorperazine edisylate............12prochlorperazine maleate............. 12PROCTOFOAM HC......................45procto-med hc...............................45procto-pak.....................................45proctosol hc.................................. 45proctozone-hc...............................45PROCYSBI................................... 37PROFILNINE................................ 21PROFILNINE SD.......................... 21

progesterone.................................43progesterone micronized.............. 43PROGLYCEM...............................33PROGRAF....................................45PROLENSA.................................. 51PROLIA.........................................46PROMACTA................................. 21promethazine hcl .......................... 53promethazine-codeine.................. 53promethazine-dm..........................53promethazine-phenyleph-codeine 53promethazine-phenylephrine........ 53promethegan.................................53propafenone hcl ............................24propafenone hcl er........................24propantheline bromide..................36proparacaine hcl ........................... 52propranolol hcl .............................. 24propranolol hcl er..........................24propranolol-hctz............................24propylthiouracil ..............................44PROSCAR....................................38PROSTIN VR................................24PROTONIX...................................35PROTOPIC...................................29protriptyline hcl ..............................11PROVENT SLEEP APNEA THERAPY.....................................49PROVENT SR SLEEP APNEA THERAPY.....................................49PROVENTIL HFA......................... 55PROVERA.................................... 43pseudoephedrine-bromphen-dm.. 53PULMICORT FLEXHALER...........55pulmosal....................................... 53PULMOZYME...............................55PURIXAN......................................15PYLERA........................................36pyrazinamide................................ 14pyridostigmine bromide.................13pyridostigmine bromide er............ 13PYRIDOXINE HCL....................... 35pyridoxine hcl................................35pyrimethamine.............................. 16PYRIMETHAMINE-LEUCOVORIN..............................16PYROGALLIC ACID..................... 29QBREXZA.....................................29QINLOCK......................................15QNASL..........................................53QNASL CHILDRENS....................53QSYMIA........................................26QUALAQUIN.................................16QUARTETTE................................43quazepam.....................................20QUELICIN.....................................26quetiapine fumarate......................18

quetiapine fumarate er..................18QUILLICHEW ER......................... 25QUILLIVANT XR...........................25quinapril hcl ...................................24quinapril-hydrochlorothiazide........24quinidine gluconate er...................24quinidine sulfate............................24quinine sulfate...............................16rabeprazole sodium...................... 35RADIAPLEXRX.............................29RADIOGARDASE.........................49raloxifene hcl.................................39ramelteon......................................56ramipril ..........................................24ranolazine er.................................24RAPAFLO.....................................38RAPAMUNE................................. 45RAPPORT RLS............................ 49RAPPORT VTD............................ 49rasagiline mesylate.......................17RASUVO.......................................45RAVICTI........................................37RAYALDEE...................................46RAZADYNE.................................. 10RAZADYNE ER............................ 10REBIF........................................... 26REBIF REBIDOSE........................26REBIF REBIDOSE TITRATION PACK............................................26REBIF TITRATION PACK............ 26REBINYN......................................21REBLOZYL...................................21reclipsen....................................... 43RECOMBINATE........................... 21RECOTHROM.............................. 21RECOTHROM SPRAY KIT.......... 21RECTIV.........................................24REGENECARE.............................29REGLAN.......................................12REGRANEX..................................29RELENZA DISKHALER................19relexxii ...........................................25REMERON................................... 11REMERON SOLTAB.................... 11REMESENSE............................... 27repaglinide.................................... 31REPATHA.....................................24REPATHA PUSHTRONEX SYSTEM.......................................24REPATHA SURECLICK............... 24REQUIP XL...................................17RESTASIS....................................52RESTASIS MULTIDOSE..............52RESTORA RX.............................. 36RETACRIT....................................21RETIN-A MICRO PUMP...............29RETROVIR................................... 19

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REVATIO......................................56REVCOVI......................................37REVLIMID.....................................15REXULTI.......................................18REYATAZ..................................... 19RHOFADE.................................... 29RHOGAM ULTRA-FILTERED PLUS............................................ 45RHOPHYLAC............................... 45RHOPRESSA............................... 51RIASTAP...................................... 21ribavirin......................................... 19RIDAURA......................................45rifabutin.........................................14RIFADIN....................................... 14rifampin.........................................14RILUTEK.......................................26riluzole.......................................... 26rimantadine hcl............................. 19RIMSO-50.....................................37RINVOQ........................................45RIOMET........................................31RIOMET ER..................................31risedronate sodium....................... 46RISPERDAL CONSTA................. 18risperidone....................................18ritonavir .........................................19RITUXAN HYCELA.......................15rivastigmine...................................10rivastigmine tartrate...................... 10rivelsa........................................... 43RIXUBIS....................................... 21rizatriptan benzoate...................... 13ROBAXIN......................................56ROBAXIN-750.............................. 56ROCALTROL................................46ROCKLATAN................................51ropinirole hcl................................. 17ropinirole hcl er............................. 17ropivacaine hcl................................6rosadan.........................................29rosuvastatin calcium..................... 24ROWASA......................................45roweepra.......................................10roweepra xr...................................10ROZEREM....................................56ROZLYTREK................................ 15RUBRACA.................................... 15RUSCH FLOCATH QUICK 16FR.49RUZURGI..................................... 49RYBELSUS...................................31RYCLORA.................................... 53RYDAPT....................................... 15RYTARY....................................... 17RYTHMOL SR.............................. 24ryvent............................................54SALAGEN.....................................27

SALICEPT.................................... 49saline bacteriostatic...................... 35SALINE-PHENOL.........................35SAMSCA.......................................35SANDIMMUNE............................. 45SANTYL........................................29SAPHRIS......................................18SARAFEM.................................... 11SAVAYSA.......................................9SAVELLA......................................26SAVELLA TITRATION PACK.......26SAVI..............................................49SAXENDA.....................................26SCENESSE.................................. 29SCLEROSOL INTRAPLEURAL....55scopolamine..................................12SECONAL.....................................56selegiline hcl ................................. 17selenium sulfide............................30SELZENTRY.................................19sensorcaine.................................... 6sensorcaine/epinephrine.................6sensorcaine-mpf............................. 6sensorcaine-mpf/epinephrine......... 6SENSORCAINE-MPF/EPINEPHRINE.......................6SEREVENT DISKUS....................55SERNIVO......................................30SEROSTIM...................................36sertraline hcl ................................. 11setlakin..........................................43sevelamer carbonate.................... 37sevelamer hcl ................................37SEYSARA.......................................8sf...................................................27sf 5000 plus.................................. 27SFROWASA................................. 45sharobel........................................43SHARPS CONTAINER.................49SIDESTREAM ADULT FACE MASK............................................49SIDESTREAM PEDIATRIC FACE MASK.................................49SIGNIFOR.................................... 40SIGNIFOR LAR............................ 40SIKLOS.........................................15sildenafil citrate.......................37, 56SILENOR......................................56SILIQ.............................................45silodosin........................................38silver sulfadiazine........................... 8SILVERSEAL HYDROGEL DRESSING...................................30SIMBRINZA.................................. 51simliya...........................................43simpesse.......................................43SIMPONI.......................................45

simvastatin....................................24SINEMET......................................17SINUVA........................................ 54sirolimus........................................45SIRTURO......................................14SITAVIG........................................19SKLICE.........................................16SKYRIZI (150 MG DOSE)............ 45sod citrate-citric acid.....................35sodium bicarbonate...................... 36sodium chloride.......................35, 54sodium chloride (pf) ...................... 35sodium chloride bacteriostatic...... 35SODIUM CITRATE.........................9sodium fluoride....................... 27, 35sodium fluoride 5000 plus.............27sodium fluoride 5000 ppm............ 27sodium fluoride 5000 sensitive..... 27sodium phenylbutyrate..................37sodium polystyrene sulfonate....... 35sodium saccharin..........................49SOF-SENSOR..............................32SOLESTA..................................... 49solifenacin succinate.....................38SOLIQUA......................................31SOLOSEC...................................... 8SOLTAMOX..................................15SOLU-CORTEF............................39SOLU-MEDROL........................... 39SOMATULINE DEPOT.................40SOMAVERT..................................40SOOLANTRA................................30SORIATANE.................................30sorine............................................24sotalol hcl ......................................24sotalol hcl (af) ............................... 24SOTYLIZE.................................... 24SOVALDI...................................... 19SPARKY THE DOG PED NEBULIZER..................................49spinosad....................................... 17SPIRIVA HANDIHALER............... 55SPIRIVA RESPIMAT.................... 55spironolactone.............................. 24spironolactone-hctz.......................24SPORANOX................................. 13SPORANOX PULSEPAK............. 13SPRAVATO (56 MG DOSE).........11SPRAVATO (84 MG DOSE).........11sprintec 28.................................... 43SPRYCEL.....................................15sps................................................ 35sronyx........................................... 43ssd.................................................. 8STALEVO 100.............................. 17STALEVO 125.............................. 17STALEVO 150.............................. 17

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STALEVO 200.............................. 17STALEVO 50................................ 17STALEVO 75................................ 17STARLIX.......................................31stavudine...................................... 19STELARA..................................... 45STERILE TALC POWDER........... 55sterile water for injection...............50STERITALC..................................55STIMATE...................................... 40STIOLTO RESPIMAT...................55STIVARGA....................................15STRENSIQ................................... 37streptomycin sulfate........................8STRIBILD......................................19STRIVERDI RESPIMAT............... 55STROMECTOL.............................17SUBLOCADE..................................6subvenite...................................... 10subvenite starter kit-blue...............10subvenite starter kit-green............ 10subvenite starter kit-orange.......... 10SUCCINYLCHOLINE CHLORIDE................................... 26succinylcholine chloride................26SUCRAID......................................37sucralfate...................................... 35SULAR..........................................24sulfacetamide sodium...................51sulfacetamide sodium (acne)........30sulfacetamide-prednisolone..........52sulfadiazine.....................................8sulfamethoxazole-trimethoprim.......8SULFAMYLON............................... 8sulfasalazine.................................45sulfatrim pediatric............................8sulfurated lime.............................. 17sulindac...........................................5sumatriptan...................................13sumatriptan succinate...................13sumatriptan succinate refill ........... 13sumatriptan-naproxen sodium...... 13SUNOSI........................................56SUPPRELIN LA............................40SUPRAX.........................................8SUPREP BOWEL PREP KIT........36SURESTEP PRO HIGH GLUCOSE.................................... 32SURESTEP PRO LOW GLUCOSE.................................... 32SURESTEP PRO NORMAL GLUCOSE.................................... 32SURGICEL FIBRILLAR................ 50SURGICEL NU-KNIT....................50SURVANTA.................................. 54SUSTIVA...................................... 19SUSTOL....................................... 12

SUTENT....................................... 15syeda............................................ 43SYMBICORT................................ 55SYMBYAX.................................... 11SYMDEKO....................................55SYMFI...........................................19SYMFI LO.....................................19SYMJEPI...................................... 55SYMLINPEN 120..........................31SYMLINPEN 60............................31SYMPAZAN..................................10SYMPROIC...................................36SYMTUZA.....................................19SYNAGIS......................................45SYNALAR.....................................30SYNAREL.....................................40SYNDROS....................................12SYNJARDY...................................31SYNJARDY XR.............................31SYNRIBO......................................15SYRINGE AVITENE..................... 50SYRINGE LUER LOCK................ 50SYRINGE LUER SLIP.................. 50SYRINGE PRECISEDOSE DISPENSER.................................50TABLOID...................................... 15TACHOSIL....................................50TACLONEX.................................. 30tacrolimus............................... 30, 45tadalafil ......................................... 38tadalafil (pah)................................56TAFINLAR.................................... 15TAGRISSO................................... 15TAKHZYRO.................................. 45TALICIA........................................ 36TALTZ...........................................45TALZENNA...................................15tamoxifen citrate........................... 15tamsulosin hcl ...............................38TAPAZOLE...................................44TARCEVA.....................................15TARGRETIN.................................15tarina 24 fe....................................43tarina fe 1/20.................................43tarina fe 1/20 eq............................43TARKA..........................................24TASIGNA......................................15TASMAR.......................................17TAURINE......................................35TAVALISSE.................................. 21tazarotene.....................................30tazicef............................................. 9TAZORAC.....................................30taztia xt ......................................... 24TECFIDERA................................. 26TEGSEDI......................................26TEKTURNA.................................. 24

TEKTURNA HCT..........................24TELFA AMD ISLAND DRESSING...................................50TELFA AMD NON-ADHERENT....50telmisartan.................................... 24telmisartan-amlodipine..................24telmisartan-hctz............................ 24temazepam...................................56TEMODAR....................................15TEMOVATE..................................30temozolomide............................... 15tencon.............................................4tenofovir disoproxil fumarate.........19TENORETIC 100..........................24TENORETIC 50............................24TEPADINA....................................15terazosin hcl ..................................38terbinafine hcl............................... 13terbutaline sulfate......................... 55terconazole................................... 13TESSALON PERLES................... 54testosterone..................................39testosterone cypionate..................39testosterone enanthate.................39tetrabenazine................................26tetracaine hcl............................ 6, 52tetracycline hcl ................................9TEXACORT.................................. 30THALOMID................................... 15THEO-24.......................................55theophylline...................................55theophylline er.............................. 55THERAHONEY.............................30thiamine hcl...................................35THIOLA.........................................38THIOLA EC...................................38thioridazine hcl ..............................18thiotepa.........................................16thiothixene.................................... 18THROMBI-GEL 10........................50THROMBI-GEL 100......................50THROMBI-GEL 40........................50THROMBIN-JMI............................21THROMBIN-JMI EPISTAXIS........21THROMBI-PAD.............................50THROMBOGEN............................21tiadylt er........................................ 24tiagabine hcl ..................................10TIAZAC.........................................24TIBSOVO......................................16TICE BCG.....................................45TIGAN...........................................12TIGLUTIK......................................26tilia fe............................................ 43timolol maleate........................24, 51tinidazole.........................................9TISSEEL.......................................50

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TIVICAY........................................19TIVICAY PD..................................19tizanidine hcl .................................56TOBI PODHALER.........................55TOBRADEX..................................52TOBRADEX ST............................ 52tobramycin.............................. 51, 55tobramycin sulfate...........................9tobramycin-dexamethasone......... 52TOBREX.......................................51TOLAK..........................................30tolbutamide................................... 31tolcapone...................................... 17tolmetin sodium...............................5tolterodine tartrate.........................38tolterodine tartrate er.................... 38tolvaptan....................................... 35TOPEX TOPICAL ANESTHETIC. 27TOPICORT................................... 30topiramate.....................................10topiramate er.................................10toremifene citrate..........................16torsemide......................................24TOUJEO MAX SOLOSTAR..........33TOUJEO SOLOSTAR...................33tovet..............................................30TOVIAZ.........................................38TRACLEER...................................56TRADJENTA.................................31tramadol hcl er................................4tramadol hcl er (biphasic)............... 4tramadol hcl ir ................................. 4tramadol-acetaminophen................4trandolapril ....................................24trandolapril-verapamil hcl er......... 24tranexamic acid.............................21TRANSDERM SCOP (1.5 MG).....12TRANSDERM-SCOP (1.5 MG).... 12TRANXENE-T...............................20tranylcypromine sulfate.................11TRAVATAN Z............................... 51travoprost (bak free)..................... 51trazodone hcl................................ 11TRECATOR..................................14TRELEGY ELLIPTA......................55TRELSTAR MIXJECT...................40TREMFYA.....................................45treprostinil ..................................... 56tretinoin...................................16, 30tretinoin microsphere.................... 30tretinoin microsphere pump.......... 30TRETTEN..................................... 21TREXALL......................................45TREZIX...........................................4tri femynor.....................................43triamcinolone acetonide....27, 30, 39TRIAMCINOLONE ACETONIDE..39

TRIAMCINOLONE DIACETATE...39TRIAMCINOLONE-BUPIVACAINE..............................39TRI-AMINO...................................35triamterene....................................24triamterene-hctz............................24trianex...........................................30triazolam....................................... 20TRI-CHLOR.................................. 30TRICITRASOL................................9triderm...........................................30TRIDESILON................................ 30trientine hcl................................... 35tri-estarylla.................................... 43TRIFERIC..................................... 35trifluoperazine hcl..........................18trifluridine...................................... 51trihexyphenidyl hcl ........................ 17TRIJARDY XR.............................. 31TRIKAFTA.................................... 55tri-legest fe....................................43tri-linyah........................................ 43TRILIPIX....................................... 24tri-lo-estarylla................................ 43tri-lo-marzia...................................43tri-lo-mili ........................................ 43tri-lo-sprintec.................................43trilyte............................................. 36trimethobenzamide hcl ..................12trimethoprim....................................9tri-mili ............................................ 43trimipramine maleate.................... 11TRINTELLIX................................. 11tri-previfem....................................43TRIPTODUR.................................40tri-sprintec.....................................43TRIUMEQ..................................... 19trivora (28).................................... 43tri-vylibra....................................... 43tri-vylibra lo................................... 43TRIZIVIR.......................................19TROKENDI XR............................. 10TROPICAMIDE-CYCLOPENTOLATE-PE..............52trospium chloride.......................... 38trospium chloride er...................... 38TRULICITY................................... 31TRUSOPT.....................................51TRUVADA.....................................19TRUZONE PEAK FLOW METER.50TUKYSA....................................... 16tulana............................................43TURALIO...................................... 16TWYNSTA.................................... 24TYBOST....................................... 19tydemy.......................................... 43TYKERB....................................... 16

TYMLOS.......................................46TYVASO....................................... 56TYVASO REFILL..........................56TYVASO STARTER..................... 56UCERIS........................................ 45UDENYCA.................................... 21ULORIC........................................ 13ULTRAFOAM SPONGE 2X6.25X7CM................................ 50ULTRAFOAM SPONGE 8X12.5X1CM................................ 50ULTRAFOAM SPONGE 8X12.5X3CM................................ 50ULTRAFOAM SPONGE 8X25X1CM................................... 50ULTRAFOAM SPONGE 8X6.25X1CM................................ 50UNASYN.........................................9unithroid........................................44UPTRAVI...................................... 56uretron d/s.....................................38urin ds...........................................38UROCIT-K 10............................... 35UROCIT-K 15............................... 35UROCIT-K 5................................. 35URSO 250.................................... 36URSO FORTE.............................. 36ursodiol ......................................... 36utrona-c.........................................38valacyclovir hcl ..............................19VALCHLOR.................................. 16valganciclovir hcl ...........................19valproic acid..................................10valrubicin.......................................16valsartan....................................... 24valsartan-hydrochlorothiazide.......25VALSTAR..................................... 16VALTOCO 10 MG DOSE..............10VALTOCO 15 MG DOSE..............10VALTOCO 20 MG DOSE..............10VALTOCO 5 MG DOSE................10VANCOCIN.....................................9VANCOCIN HCL.............................9vancomycin hcl ............................... 9vandazole....................................... 9VANTAS....................................... 40VAPRO PLUS CATHETER 12FR/8".........................................50VAPRO PLUS CATHETER 14FR/8".........................................50vardenafil hcl .................................38VARUBI (180 MG DOSE).............12VASCEPA.....................................25VASERETIC................................. 25vashe cleansing............................30VECAMYL.....................................25VELCADE.....................................16

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velivet............................................43VELPHORO..................................38VELTASSA................................... 35VEMLIDY......................................19VENCLEXTA................................ 16VENCLEXTA STARTING PACK.. 16VENELEX..................................... 30VENIPUNCTURE PX1 PHLEBOTOMY...............................6venlafaxine hcl..............................11venlafaxine hcl er..........................11VENTAVIS....................................56VENTOLIN HFA............................55verapamil hcl .................................25verapamil hcl er............................ 25VERELAN.....................................25VERELAN PM...............................25VERSACLOZ................................18VERZENIO................................... 16VFEND..........................................13VIBERZI........................................37VIBRAMYCIN................................. 9VICTOZA...................................... 31VIDAZA.........................................16VIEKIRA PAK............................... 19vienva........................................... 43vigabatrin...................................... 10vigadrone......................................10VIIBRYD....................................... 11VIIBRYD STARTER PACK...........11VIMPAT........................................ 10viorele........................................... 43VIRACEPT....................................19VIRAMUNE...................................19VIRAMUNE XR.............................19VIRAZOLE....................................19VIREAD........................................ 19virt-phos 250 neutral .....................35virtussin ac w/alc...........................54VISIONBLUE................................ 52VISTARIL......................................20VISTOGARD.................................50vitamin d (ergocalciferol) ...............35vitamin k1......................................35VITRAKVI..................................... 16VITRASE...................................... 50VIVAGUARD LANCING DEVICE. 32VIVITROL....................................... 6VIZIMPRO.................................... 16volnea........................................... 43VONVENDI...................................21voriconazole..................................13VORTEX HOLDING CHAMBER/MASK.........................50VOSEVI........................................ 19VOTRIENT....................................16VRAYLAR.....................................18

VUMERITY................................... 26VUMERITY (STARTER)...............26vyfemla......................................... 43VYLEESI.......................................26vylibra........................................... 43VYNDAMAX..................................25VYNDAQEL.................................. 25VYVANSE.....................................25WAKIX.......................................... 56warfarin sodium.............................. 9wera..............................................43WESTHROID................................44WILATE........................................ 21WINRHO SDF...............................45wixela inhub..................................55WP THYROID...............................44wymzya fe.....................................43XADAGO...................................... 17XALIX............................................30XALKORI...................................... 16XARELTO.......................................9XARELTO STARTER PACK.......... 9XATMEP.......................................45XELJANZ......................................45XELJANZ XR................................45XELODA....................................... 16XELPROS.....................................51XEMBIFY......................................45XENICAL...................................... 26XENLETA....................................... 9XEOMIN........................................50XEPI................................................9XERAC AC................................... 30XERMELO.................................... 37XEROFORM OIL EMULSION 2"X2".............................................30XEROFORM OIL EMULSION GAUZE......................................... 30XEROFORM OIL EMULSION STRIP........................................... 30XEROFORM OIL ROLL 4"X9'...... 30XEROFORM PETROLAT GAUZE 1"X8"............................... 30XEROFORM PETROLAT GAUZE 5"X9"............................... 30XEROFORM PETROLAT PATCH 2"X2"................................30XEROFORM PETROLAT PATCH 4"X4"................................30XEROFORM PETROLATUM ROLL 4"X9'................................... 30XGEVA......................................... 46XIAFLEX.......................................50XIFAXAN........................................ 9XIGDUO XR..................................31XIIDRA..........................................52XIMINO...........................................9

XOFLUZA (40 MG DOSE)............19XOFLUZA (80 MG DOSE)............19XOLAIR.........................................54XOPENEX.................................... 55XOPENEX CONCENTRATE........55XOPENEX HFA............................ 55XOSPATA.....................................16XPOVIO (100 MG ONCE WEEKLY)......................................16XPOVIO (40 MG ONCE WEEKLY)......................................16XPOVIO (40 MG TWICE WEEKLY)......................................16XPOVIO (60 MG ONCE WEEKLY)......................................16XPOVIO (60 MG TWICE WEEKLY)......................................16XPOVIO (80 MG ONCE WEEKLY)......................................16XPOVIO (80 MG TWICE WEEKLY)......................................16XTAMPZA ER.................................4XTANDI.........................................16xulane........................................... 43XULTOPHY.................................. 31XURIDEN......................................37XYLOCAINE................................... 6xylocaine dental..............................6XYLOCAINE/EPINEPHRINE..........6XYLOCAINE-MPF.......................... 6XYLOCAINE-MPF/EPINEPHRINE.......................6XYNTHA....................................... 21XYNTHA SOLOFUSE...................21XYOSTED.....................................39XYREM.........................................56YUPELRI...................................... 55yuvafem........................................ 43zafirlukast......................................55zaleplon........................................ 56zarah.............................................44ZARONTIN................................... 10ZARXIO........................................ 21ZAVESCA.....................................37ZEBUTAL........................................4ZEJULA........................................ 16ZELAPAR..................................... 17ZELBORAF...................................16ZELNORM.................................... 37ZEMPLAR.....................................46zenatane.......................................30ZENPEP....................................... 37ZENZEDI...................................... 25ZEPATIER.................................... 19ZETONNA.....................................54ZEWA DIGITAL TENS UNIT........ 50

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ZEWA TENS/EMS COMBO UNIT............................................. 50ZIAC..............................................25ZIAGEN........................................ 19zidovudine.....................................19zileuton er..................................... 55ziprasidone hcl..............................18ziprasidone mesylate....................18ZIRGAN........................................ 51ZITHROMAX...................................9ZITHROMAX TRI-PAK................... 9ZITHROMAX Z-PAK.......................9ZOLADEX.....................................40ZOLINZA.......................................16zolmitriptan................................... 13zolpidem tartrate...........................56zolpidem tartrate er.......................56ZOLPIMIST...................................56ZOMIG..........................................13zonisamide....................................10ZONTIVITY...................................17ZORBTIVE....................................37ZORTRESS.................................. 45zovia 1/35e (28)............................44ZUBSOLV.......................................6zumandimine................................ 44ZYDELIG...................................... 16ZYKADIA...................................... 16ZYLET...........................................52ZYLOPRIM................................... 13ZYMAXID......................................51ZYPREXA RELPREVV.................18ZYPREXA ZYDIS......................... 18ZYVOX............................................9

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-INFECTIVES · TIER 03 NON-PREFERRED terbinafine HCL QL Baxdela terbinafine hydrochlorideQL Cipro...

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Transcript of -INFECTIVES · TIER 03 NON-PREFERRED terbinafine HCL QL Baxdela terbinafine hydrochlorideQL Cipro...