KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2018...Generic and Brand (Preferred and Non Preferred)...

HIX 2018 BCBSKC KS eff dte 08-01-2018.docx

KANSAS ACA MEMBER

PRESCRIPTION DRUG LIST

2018

HIX 2018 BCBSKC KS eff dte 08-01-2018.docx

Table of Contents

ANTI - INFECTIVES ........................................................................................................................................ 4

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 13

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 18

CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 35

DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 43

DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 52

EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 54

ENDOCRINE/DIABETES .............................................................................................................................. 55

GASTROENTEROLOGY .............................................................................................................................. 72

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 79

MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 82

OBSTETRICS & GYNECOLOGY ................................................................................................................ 84

OPHTHALMOLOGY ..................................................................................................................................... 89

RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 93

UROLOGICALS .............................................................................................................................................. 98

VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 99

Index ................................................................................................................................................................ 108

3

Please see the benefit schedule in your member certificate for member cost sharing associated with

Generic and Brand (Preferred and Non Preferred) drugs.

List of Abbreviations for Prescription Drugs

Drug Category:

1: Generic Drug and Generic Specialty Drug

2: Preferred Drug and Non Preferred Generic Drug

3: Non Preferred Drug and Preferred Specialty Drug

4: Non Preferred Specialty Drug

5: Zero Cost Share Preventive Drug

6: Medical Service Drugs

7: Infertility Drug

ACA*: Affordable Care Act is a zero cost share preventive drug.

M: Maintenance drug.

MSD: Medical Service Drug. This drug is only covered under the medical benefit.

OTC*: Over the Counter drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.

This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we

may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

S: Specialty drug.

SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat

your medical condition, we may not cover Drug B unless you try Drug A first.

*Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two

tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day

treatment regimen when prescribed by an in-network health care provider without prior authorization.

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not

affiliated companies.

4

Drug Name Drug

Category

Requirements

/ Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

AMBISOME 6 MSD

amphotericin b 6 MSD

ANCOBON 3

CANCIDAS 6 MSD

caspofungin 6 MSD

clotrimazole 1

CRESEMBA

INTRAVENOUS

6 MSD

CRESEMBA ORAL 2

DIFLUCAN ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3

DIFLUCAN ORAL

TABLET 100 MG,

200 MG, 50 MG

3

DIFLUCAN ORAL

TABLET 150 MG

3 QL

ERAXIS(WATER

DILUENT)

6 MSD

fluconazole in

dextrose(iso-o)

6 MSD

fluconazole in nacl

(iso-osm)

6 MSD

fluconazole oral

suspension for

reconstitution

1

fluconazole oral

tablet 100 mg, 200

mg, 50 mg

1

fluconazole oral

tablet 150 mg

1 QL

flucytosine 1

Drug Name Drug

Category

Requirements

/ Limits

griseofulvin

microsize

1

griseofulvin

ultramicrosize

1

itraconazole 1 QL

ketoconazole 1

NOXAFIL 2

nystatin 1

ONMEL 3 QL

ORAVIG 3

SPORANOX 2

SPORANOX

PULSEPAK

3 QL

terbinafine hcl 1

VFEND 3

VFEND IV 6 MSD

voriconazole

intravenous

6 MSD

voriconazole oral 1

ANTIVIRALS

abacavir 1 S; QL

abacavir-lamivudine 1 S; QL

abacavir-

lamivudine-

zidovudine

1 S; QL

acyclovir 1

adefovir 1

amantadine hcl 1 M

APTIVUS 3 S; QL

atazanavir 1 S

ATRIPLA 3 S; QL

BARACLUDE

ORAL SOLUTION

2



5

Drug Name Drug

Category

Requirements

/ Limits

BARACLUDE

ORAL TABLET

3

BIKTARVY 3 S

cidofovir 6 MSD

CIMDUO 4 S

COMBIVIR 4 S; QL

COMPLERA 3 S; QL

CRIXIVAN 3 S; QL

CYTOVENE 6 MSD

DAKLINZA 4 PA; ST; S;

SLA

DESCOVY 3 S

didanosine 1 S; QL

EDURANT 3 S; QL

efavirenz 1 S; QL

EMTRIVA 3 S; QL

entecavir 1

EPCLUSA 3 PA; S; SLA

EPIVIR 4 S; QL

EPIVIR HBV

ORAL SOLUTION

2

EPIVIR HBV

ORAL TABLET

3 QL

EPZICOM 4 S; QL

EVOTAZ 4 S; QL

famciclovir 1 QL

FLUMADINE 3

fosamprenavir 1 S; QL

FOSCAVIR 6 MSD

FUZEON 3 S; QL

GANCICLOVIR 6 MSD

ganciclovir sodium 6 MSD

GENVOYA 3 S

Drug Name Drug

Category

Requirements

/ Limits

HARVONI 3 PA; S; SLA;

QL

HEPSERA 3

INTELENCE 3 S; QL

INVIRASE 3 S; QL

ISENTRESS 3 S; QL

ISENTRESS HD 3 S

JULUCA 4 S

KALETRA ORAL

SOLUTION

4 S; QL

KALETRA ORAL

TABLET

3 S; QL

lamivudine oral

solution

1 S; QL

lamivudine oral

tablet 100 mg

1 QL

lamivudine oral

tablet 150 mg, 300

mg

1 S; QL

lamivudine-

zidovudine

1 S; QL

LEXIVA ORAL

SUSPENSION

3 S; QL

LEXIVA ORAL

TABLET

4 S; QL

lopinavir-ritonavir 1 S; QL

MAVYRET 3 S

nevirapine 1 S; QL

NORVIR ORAL

CAPSULE

3 S; QL

NORVIR ORAL

POWDER IN

PACKET

3 S

NORVIR ORAL

SOLUTION

3 S; QL



6

Drug Name Drug

Category

Requirements

/ Limits

NORVIR ORAL

TABLET

4 S; QL

ODEFSEY 3 S

oseltamivir 1 QL

PREVYMIS

INTRAVENOUS

6 MSD

PREVYMIS ORAL 2

PREZCOBIX 4 S

PREZISTA 3 S; QL

RELENZA

DISKHALER

2 QL

RESCRIPTOR 3 S; QL

RETROVIR

INTRAVENOUS

6 MSD

RETROVIR ORAL 4 S; QL

REYATAZ ORAL

CAPSULE

4 S

REYATAZ ORAL

POWDER IN

PACKET

3 S

ribavirin 1 S; SLA

rimantadine 1

ritonavir 1 S; QL

SELZENTRY

ORAL SOLUTION

3 PA; S

SELZENTRY

ORAL TABLET

150 MG, 300 MG

3 PA; S; QL

SELZENTRY

ORAL TABLET 25

MG, 75 MG

3 PA; S

SOVALDI 4 PA; ST; S;

SLA; QL

stavudine 1 S; QL

STRIBILD 3 S; QL

Drug Name Drug

Category

Requirements

/ Limits

SUSTIVA 4 S; QL

SYMFI 4 S

SYMFI LO 4 S

SYNAGIS 6 MSD

TAMIFLU 2 QL

TECHNIVIE 3 PA; S; SLA

tenofovir disoproxil

fumarate

1 S; QL

TIVICAY ORAL

TABLET 10 MG, 25

MG

3 S

TIVICAY ORAL

TABLET 50 MG

3 S; QL

TRIUMEQ 3 S; QL

TRIZIVIR 4 S; QL

TROGARZO 6 MSD

TRUVADA ORAL

TABLET 100-150

MG, 133-200 MG,

167-250 MG

3 S

TRUVADA ORAL

TABLET 200-300

MG

3 S; QL

TYBOST 4 S; QL

valacyclovir 1 QL

VALCYTE 3

valganciclovir 1

VALTREX 3 ST; QL

VEMLIDY 2

VIDEX 2 GRAM

PEDIATRIC

3 S; QL

VIDEX EC 4 S; QL

VIEKIRA PAK 3 PA; S; SLA;

QL

VIEKIRA XR 3 PA; S; SLA



7

Drug Name Drug

Category

Requirements

/ Limits

VIRACEPT 3 S; QL

VIRAMUNE 4 S; QL

VIRAMUNE XR 4 S; QL

VIRAZOLE 4 S; SLA

VIREAD ORAL

POWDER

3 S; QL

VIREAD ORAL

TABLET 150 MG,

200 MG, 250 MG

3 S; QL

VIREAD ORAL

TABLET 300 MG

4 S; QL

VOSEVI 3 S; SLA

ZEPATIER 4 PA; ST; S;

SLA

ZERIT 4 S; QL

ZIAGEN 4 S; QL

zidovudine 1 S; QL

ZOVIRAX 3

CEPHALOSPORINS

AVYCAZ 6 MSD

cefaclor 1

cefadroxil 1

cefazolin 6 MSD

CEFAZOLIN IN

0.9% SOD

CHLORIDE

6 MSD

cefazolin in dextrose

(iso-os) intravenous

piggyback 1 gram/50

ml, 2 gram/50 ml

6 MSD

CEFAZOLIN IN

DEXTROSE (ISO-

OS)

INTRAVENOUS

PIGGYBACK 2

GRAM/100 ML

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

CEFAZOLIN IN

DEXTROSE 5 %

6 MSD

CEFAZOLIN IN

STERILE WATER

6 MSD

cefdinir 1

cefditoren pivoxil 1

cefepime 6 MSD

cefepime in

dextrose,iso-osm

6 MSD

cefixime 1

CEFOTAN 6 MSD

cefotaxime 6 MSD

cefotetan 6 MSD

cefoxitin 6 MSD

cefpodoxime 1

cefprozil 1

ceftriaxone in

dextrose,iso-os

6 MSD

ceftriaxone injection

recon soln 1 gram,

10 gram, 2 gram,

250 mg, 500 mg

6 MSD

CEFTRIAXONE

INJECTION

RECON SOLN 100

GRAM

6 MSD

cefuroxime axetil 1

cefuroxime sodium 6 MSD

cephalexin 1

CLAFORAN 6 MSD

DAXBIA 3

KEFLEX 3

MAXIPIME 6 MSD

SPECTRACEF 3



8

Drug Name Drug

Category

Requirements

/ Limits

SUPRAX 3

TAZICEF 6 MSD

TEFLARO 6 MSD

ERYTHROMYCINS & OTHER

MACROLIDES

azithromycin

intravenous

6 MSD

azithromycin oral 1

clarithromycin 1

DIFICID 3

e.e.s. 400 1

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3

ery-tab oral

tablet,delayed

release (dr/ec) 250

mg, 333 mg

1

ERY-TAB ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 500 MG

3

erythrocin (as

stearate)

1

erythromycin 1

erythromycin

ethylsuccinate

1

ZITHROMAX

INTRAVENOUS

6 MSD

ZITHROMAX

ORAL

3

ZITHROMAX TRI-

PAK

3

ZITHROMAX Z-

PAK

3

Drug Name Drug

Category

Requirements

/ Limits

MISCELLANEOUS

ANTIINFECTIVES

ALBENZA 2 QL

ALINIA 2 QL

amikacin 6 MSD

atovaquone 1

atovaquone-

proguanil

1 QL

BENZNIDAZOLE 2

BETHKIS 6 MSD

BILTRICIDE 2

CAPASTAT 6 MSD

CAYSTON 3 S; SLA; QL

chloramphenicol sod

succinate

6 MSD

chloroquine

phosphate

1

CLEOCIN HCL 3

CLEOCIN IN 5 %

DEXTROSE

6 MSD

CLEOCIN

INJECTION

6 MSD

cleocin intravenous

solution 300 mg/2 ml

6 MSD

CLEOCIN

INTRAVENOUS

SOLUTION 600

MG/4 ML, 900

MG/6 ML

6 MSD

CLEOCIN

PEDIATRIC

3

CLIN SINGLE USE 6 MSD

clindamycin hcl 1

CLINDAMYCIN IN

0.9 % SOD CHLOR

6 MSD



9

Drug Name Drug

Category

Requirements

/ Limits

clindamycin in 5 %

dextrose

6 MSD

clindamycin

palmitate hcl

1

clindamycin

pediatric

1

clindamycin

phosphate

6 MSD

COARTEM 2 QL

colistin

(colistimethate na)

1

COLY-MYCIN M

PARENTERAL

3

CUBICIN 6 MSD

CUBICIN RF 6 MSD

CYCLOSERINE 3

dapsone 1 M

daptomycin 6 MSD

DARAPRIM 2 PA; SLA

DORIPENEM 6 MSD

EMVERM 2 QL

ethambutol 1

FLAGYL 3

gentamicin 6 MSD

gentamicin in nacl

(iso-osm)

intravenous

piggyback 100

mg/100 ml, 60 mg/50

ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50

ml, 90 mg/100 ml

1

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 100

MG/50 ML

2

Drug Name Drug

Category

Requirements

/ Limits

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 120

MG/100 ML

3

gentamicin sulfate

(ped) (pf)

1

gentamicin sulfate

(pf) intravenous

solution 100 mg/10

ml

1

GENTAMICIN

SULFATE (PF)

INTRAVENOUS

SOLUTION 60

MG/6 ML

3

GENTAMICIN-

SODIUM CITRATE

6 MSD

hydroxychloroquine 1 M

imipenem-cilastatin 6 MSD

IMPAVIDO 3 S; QL

INVANZ 6 MSD

isoniazid 1

ivermectin 1 QL

KITABIS PAK 3 S; SLA

LINCOCIN 6 MSD

lincomycin 6 MSD

linezolid 1 PA

linezolid in dextrose

5%

6 MSD

MALARONE 3 QL

MALARONE

PEDIATRIC

3 QL

mefloquine 1 QL

MEPRON 3

meropenem 6 MSD



10

Drug Name Drug

Category

Requirements

/ Limits

MEROPENEM-

0.9% SODIUM

CHLORIDE

6 MSD

MERREM 6 MSD

metro i.v. 6 MSD

metronidazole 1

metronidazole in

nacl (iso-os)

6 MSD

MYAMBUTOL 3

MYCOBUTIN 3

NEBUPENT 2 QL

neomycin 1

paromomycin 1

PASER 3

PLAQUENIL 3 ST; M

polymyxin b sulfate 6 MSD

praziquantel 1

PRIFTIN 2

PRIMAQUINE 2 M; QL

PRIMAXIN IV 6 MSD

pyrazinamide 1

QUALAQUIN 3 QL

quinine sulfate 1 QL

rifabutin 1

RIFADIN

INTRAVENOUS

6 MSD

RIFADIN ORAL 3

RIFAMATE 3

rifampin intravenous 6 MSD

rifampin oral 1

RIFATER 3

RIMSO-50 3

SIRTURO 2 SLA

Drug Name Drug

Category

Requirements

/ Limits

SIVEXTRO 3 PA

SOLOSEC 3

STREPTOMYCIN 6 MSD

STROMECTOL 3 QL

SYNERCID 6 MSD

tigecycline 6

TINDAMAX 3 QL

tinidazole 1 QL

TOBI 3 ST; QL

TOBI PODHALER 2 QL

tobramycin in 0.225

% nacl

1 QL

tobramycin sulfate 6 MSD

TOBRAMYCIN

WITH NEBULIZER

4 S

TRECATOR 3

TYGACIL 6 MSD

VABOMERE 6 MSD

XIFAXAN 2

ZYVOX

INTRAVENOUS

6 MSD

ZYVOX ORAL 3 PA

PENICILLINS

amoxicillin 1

amoxicillin-pot

clavulanate

1

ampicillin 1

ampicillin sodium 6 MSD

ampicillin-sulbactam 6 MSD

AUGMENTIN ES-

600

3



11

Drug Name Drug

Category

Requirements

/ Limits

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 125-31.25 MG/5

ML

2

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 250-62.5 MG/5

ML

3

AUGMENTIN

ORAL TABLET

3

AUGMENTIN XR 3

BICILLIN C-R 6 MSD

dicloxacillin 1

MOXATAG 3

nafcillin 6 MSD

oxacillin 6 MSD

oxacillin in

dextrose(iso-osm)

6 MSD

penicillin g

potassium

6 MSD

penicillin v

potassium

1

pfizerpen-g 6 MSD

PIPERACILLIN-

TAZOBACTAM

INTRAVENOUS

RECON SOLN 13.5

GRAM

6 MSD

piperacillin-

tazobactam

intravenous recon

soln 2.25 gram,

3.375 gram, 4.5

gram, 40.5 gram

6 MSD

UNASYN 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

QUINOLONES

AVELOX 3

AVELOX IN NACL

(ISO-OSMOTIC)

6 MSD

BAXDELA

INTRAVENOUS

6 MSD

BAXDELA ORAL 3

CIPRO 3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin

(mixture)

1

ciprofloxacin hcl 1

FACTIVE 3

LEVAQUIN 3

levofloxacin in d5w 6 MSD

levofloxacin

intravenous

6 MSD

levofloxacin oral 1

moxifloxacin 1

moxifloxacin in nacl

(iso-osm)

6 MSD

ofloxacin 1

SULFA'S & RELATED AGENTS

BACTRIM 3

BACTRIM DS 3

sulfadiazine 1

sulfamethoxazole-

trimethoprim

intravenous

6

sulfamethoxazole-

trimethoprim oral

1

sulfatrim 1

TETRACYCLINES



12

Drug Name Drug

Category

Requirements

/ Limits

ACTICLATE 3 ST

avidoxy 1

coremino 1

demeclocycline 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate 1

doxycycline

monohydrate oral

capsule

1

DOXYCYCLINE

MONOHYDRATE

ORAL

CAPSULE,IR -

DELAY

REL,BIPHASE

3 ST

doxycycline

monohydrate oral

suspension for

reconstitution

1

doxycycline

monohydrate oral

tablet

1

MINOCIN 3 ST

minocycline 1

mondoxyne nl 1

MONODOX 3 ST

morgidox 1

ORACEA 2 ST

SOLODYN 2 ST

soloxide 1

TARGADOX 3 ST

tetracycline 1

VIBRAMYCIN 3 ST

XIMINO 3 ST

Drug Name Drug

Category

Requirements

/ Limits

URINARY TRACT AGENTS

FURADANTIN 3

HIPREX 3

MACROBID 3

MACRODANTIN 3

methenamine

hippurate

1

methenamine

mandelate

1

MONUROL 3

nitrofurantoin 1

nitrofurantoin

macrocrystal

1

nitrofurantoin

monohyd/m-cryst

1

PRIMSOL 3

trimethoprim 1

TRIMPEX 3

VANCOMYCIN

FIRVANQ 3

VANCOCIN 3

VANCOMYCIN IN

0.9 % SODIUM

CHL

6 MSD

VANCOMYCIN IN

DEXTROSE 5 %

6 MSD

VANCOMYCIN

INJECTION

6 MSD

vancomycin

intravenous

6 MSD

vancomycin oral 1

VIBATIV 6 MSD



13

Drug Name Drug

Category

Requirements

/ Limits

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT

DRUGS

ADJUNCTIVE AGENTS

amifostine

crystalline

6 MSD

dexrazoxane hcl 6 MSD

ELITEK 6 MSD

ETHYOL 6 MSD

FUSILEV 6 MSD

KEPIVANCE 6 MSD

leucovorin calcium

injection

1 S

leucovorin calcium

oral

1

LEVOLEUCOVORI

N INTRAVENOUS

RECON SOLN 175

MG

6 MSD

levoleucovorin

intravenous recon

soln 50 mg

6 MSD

levoleucovorin

intravenous solution

6 MSD

mesna 6 MSD

MESNEX

INTRAVENOUS

6 MSD

MESNEX ORAL 2

TOTECT 6 MSD

VISTOGARD 2 SLA

VORAXAZE 6 MSD

XGEVA 6 MSD

ZINECARD (AS

HCL)

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT DRUGS

ABRAXANE 6 MSD

ADCETRIS 6 MSD

adriamycin 6 MSD

adrucil 6 MSD

AFINITOR 3 S; QL

AFINITOR

DISPERZ

3 S; QL

ALECENSA 3 S; SLA

ALIQOPA 6 MSD

ALKERAN

INTRAVENOUS

6 MSD

ALKERAN ORAL 3

ALUNBRIG 4 S

anastrozole 1

ARIMIDEX 3

AROMASIN 4 S

ARRANON 6 MSD

ARZERRA 6 MSD

ASTAGRAF XL 3 ST

AVASTIN 6 MSD

azacitidine 6 MSD

AZASAN 3

azathioprine 1

BAVENCIO 6 MSD

BELEODAQ 6 MSD

BENDEKA 6 MSD

BESPONSA 2

bexarotene 1 S

bicalutamide 1

BICNU 6 MSD



14

Drug Name Drug

Category

Requirements

/ Limits

bleomycin 6 MSD

BLINCYTO 6 MSD

BORTEZOMIB 6 MSD

BOSULIF 3 S; SLA

busulfan 6 MSD

BUSULFEX 6 MSD

CABOMETYX 3 S

CALQUENCE 3 SLA

CAMPTOSAR 6 MSD

capecitabine 1 S

CAPRELSA 2 S; SLA; QL

carboplatin 6 MSD

CASODEX 3

CELLCEPT 3

CELLCEPT

INTRAVENOUS

6 MSD

cisplatin 6 MSD

cladribine 6 MSD

clofarabine 6 MSD

CLOLAR 6 MSD

COMETRIQ 3 SLA; QL

COSMEGEN 6 MSD

COTELLIC 3 S; SLA

cyclophosphamide

intravenous

6 MSD

cyclophosphamide

oral

1

cyclosporine

intravenous

1 S

cyclosporine

modified

1

cyclosporine oral 1

CYRAMZA 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

cytarabine 6 MSD

cytarabine (pf) 6 MSD

dacarbazine 6 MSD

DACOGEN 6 MSD

dactinomycin 6 MSD

DARZALEX 6 MSD

daunorubicin 6 MSD

decitabine 6 MSD

DOCEFREZ 6 MSD

docetaxel


160 mg/16 ml (10

mg/ml), 160 mg/8 ml

(20 mg/ml), 20 mg/2

ml (10 mg/ml), 20

mg/ml (1 ml), 80

mg/4 ml (20 mg/ml),

80 mg/8 ml (10

mg/ml)

6 MSD

DOCETAXEL

INTRAVENOUS

SOLUTION 20

MG/ML

6 MSD

DOXIL 6 MSD

doxorubicin 6 MSD

doxorubicin, peg-

liposomal

6 MSD

DROXIA 3 S

ELIGARD 3 S

ELIGARD (3

MONTH)

3 S

ELIGARD (4

MONTH)

3 S

ELIGARD (6

MONTH)

3 S

ELLENCE 6 MSD



15

Drug Name Drug

Category

Requirements

/ Limits

EMCYT 3 S

EMPLICITI 6 MSD

ENVARSUS XR 3 ST

epirubicin 6 MSD

ERBITUX 6 MSD

ERIVEDGE 3 S; SLA

ERLEADA 2

ERWINAZE 6 MSD

etoposide

intravenous

6 MSD

etoposide oral 1 S

EVOMELA 6 MSD

exemestane 1 S

FARESTON 3 S

FARYDAK 4 S

FASLODEX 6 MSD

FEMARA 3

FIRMAGON KIT W

DILUENT

SYRINGE

3 S; SLA

floxuridine 6 MSD

fludarabine 6 MSD

fluorouracil 6 MSD

flutamide 1

FOLOTYN 6 MSD

GAZYVA 6 MSD

gemcitabine

intravenous recon

soln

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

gemcitabine


1 gram/26.3 ml (38

mg/ml), 2 gram/52.6

ml (38 mg/ml), 200

mg/5.26 ml (38

mg/ml)

6 MSD

GEMCITABINE

INTRAVENOUS

SOLUTION 100

MG/ML

6 MSD

GEMZAR 6 MSD

gengraf 1

GILOTRIF 3 S

GLEEVEC 4 S; QL

GLEOSTINE 3 S

GLIADEL WAFER 6

HALAVEN 6 MSD

HERCEPTIN 6 MSD

HEXALEN 3 S

HYCAMTIN

INTRAVENOUS

6 MSD

HYCAMTIN ORAL 3 S

HYDREA 3

hydroxyurea 1

IBRANCE 3 S

ICLUSIG 2 SLA

IDAMYCIN PFS 6 MSD

idarubicin 6 MSD

IDHIFA 3 S

IFEX 6 MSD

ifosfamide 6 MSD

ifosfamide-mesna 6 MSD

imatinib 1 S; QL



16

Drug Name Drug

Category

Requirements

/ Limits

IMBRUVICA 2 SLA

IMFINZI 6 MSD

IMLYGIC 6 MSD

IMURAN 3

INLYTA 3 S; SLA; QL

IRESSA 3 S; SLA

irinotecan 6 MSD

ISTODAX 6 MSD

IXEMPRA 6 MSD

JAKAFI 3 S; SLA; QL

JEVTANA 6 MSD

KADCYLA 6 MSD

KISQALI 4 S

KISQALI FEMARA

CO-PACK

4 S

KYMRIAH 6 MSD

KYPROLIS 6 MSD

LARTRUVO 6 MSD

LENVIMA 3 S

letrozole 1

LEUKERAN 2

leuprolide 1 S

lipodox 6 MSD

lipodox 50 6 MSD

LONSURF 3 S

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

11.25 MG

3 S

Drug Name Drug

Category

Requirements

/ Limits

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

22.5 MG

4 S

LUPRON DEPOT

(4 MONTH)

4 S

LUPRON DEPOT

(6 MONTH)

4 S

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

3.75 MG

3 S

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

7.5 MG

4 S

LUPRON DEPOT-

PED

3 S

LYNPARZA 3 S; SLA

LYSODREN 3 S

MARQIBO 6 MSD

MATULANE 2 SLA

MEGACE ES 3

megestrol oral

suspension

1

megestrol oral tablet 1 S

MEKINIST 3 S

melphalan 1

melphalan hcl 6 MSD

mercaptopurine 1

methotrexate sodium 1

methotrexate sodium

(pf)

1

mitomycin 6 MSD

mitoxantrone 6 MSD



17

Drug Name Drug

Category

Requirements

/ Limits

MUSTARGEN 6 MSD

MUTAMYCIN 6 MSD

mycophenolate

mofetil

1

mycophenolate

mofetil hcl

6 MSD

mycophenolate

sodium

1

MYFORTIC 3

MYLERAN 3 S

MYLOTARG 6 MSD

NAVELBINE 6 MSD

NEORAL 3

NERLYNX 3 S

NEXAVAR 3 S; QL

NILANDRON 4 S

nilutamide 1 S

NINLARO 3 S; SLA

NIPENT 6 MSD

NULOJIX 6 MSD

octreotide acetate 1 S; SLA

ODOMZO 4 S

ONCASPAR 6 MSD

ONIVYDE 6 MSD

OPDIVO 6 MSD

oxaliplatin 6 MSD

paclitaxel 6 MSD

PERJETA 6 MSD

PORTRAZZA 6 MSD

PROGRAF 3

PURIXAN 2 SLA

RAPAMUNE

ORAL SOLUTION

2

Drug Name Drug

Category

Requirements

/ Limits

RAPAMUNE

ORAL TABLET

3

RITUXAN 6 MSD

RITUXAN

HYCELA

6 MSD

ROMIDEPSIN 6 MSD

RUBRACA 2 PA; SLA

RYDAPT 3 S

SANDIMMUNE

INTRAVENOUS

4 S

SANDIMMUNE

ORAL CAPSULE

3

SANDIMMUNE

ORAL SOLUTION

2

SANDOSTATIN 4 S; SLA

SANDOSTATIN

LAR DEPOT

6 MSD

SIGNIFOR 6 MSD

SIGNIFOR LAR 6 MSD

SIKLOS 4

SIMULECT 6 MSD

sirolimus 1

SOLTAMOX 3

SOMATULINE

DEPOT

3 S; SLA

SPRYCEL 3 S; QL

STIVARGA 3 S

SUPPRELIN LA 6 MSD

SUTENT 3 S; QL

SYLVANT 6 MSD

SYNRIBO 6 MSD

TABLOID 3 S

tacrolimus 1



18

Drug Name Drug

Category

Requirements

/ Limits

TAFINLAR 3 S

TAGRISSO 3 S

tamoxifen 1

TARCEVA 3 S; QL

TARGRETIN

ORAL

4 S

TARGRETIN

TOPICAL

2

TASIGNA 3 S; QL

TAXOTERE 6 MSD

TECENTRIQ 6 MSD

TEMODAR 4 S

temozolomide 1 S

TENIPOSIDE 6 MSD

TEPADINA 6 MSD

THALOMID 3 S

thiotepa 6 MSD

toposar 6 MSD

topotecan 6 MSD

TORISEL 6 MSD

TREANDA 6 MSD

TRELSTAR 6 MSD

tretinoin

(chemotherapy)

1 S

TREXALL 3

TRIPTODUR 6 MSD

TRISENOX 6 MSD

TYKERB 3 S; QL

UNITUXIN 6 MSD

VANTAS 6 MSD

VECTIBIX 6 MSD

VELCADE 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

VENCLEXTA 2 SLA

VERZENIO 3 S

VIDAZA 6 MSD

vinblastine 6 MSD

vincasar pfs 6 MSD

vincristine 6 MSD

vinorelbine 6 MSD

VOTRIENT 3 S; QL

VYXEOS 6 MSD

XALKORI 3 S; QL

XATMEP 4 ST; S

XELODA 4 S

XERMELO 2 PA; SLA

XTANDI 3 S; QL

YERVOY 6 MSD

YONDELIS 6 MSD

YONSA 3

ZALTRAP 6 MSD

ZANOSAR 6 MSD

ZEJULA 2 SLA

ZELBORAF 3 S; QL

ZEVALIN (Y-90) 6 MSD

ZOLADEX 6 MSD

ZOLINZA 3 S; QL

ZORTRESS 2

ZYDELIG 2 SLA

ZYKADIA 3 S; SLA

ZYTIGA 3 S; QL

AUTONOMIC & CNS DRUGS,

NEUROLOGY & PSYCH

ANTICONVULSANTS



19

Drug Name Drug

Category

Requirements

/ Limits

APTIOM 3

BANZEL 2

BRIVIACT 3 ST

carbamazepine 1

CARBATROL 3

CELONTIN 2

clonazepam 1

DEPACON 6 MSD

DEPAKENE 3 ST

DEPAKOTE 3 ST

DEPAKOTE ER 3 ST

DEPAKOTE

SPRINKLES

3 ST

DIASTAT 3

DIASTAT

ACUDIAL

3

diazepam 1

DILANTIN 2

DILANTIN

EXTENDED

3

DILANTIN

INFATABS

3

DILANTIN-125 3

divalproex 1

epitol 1

EQUETRO 3

ethosuximide 1

felbamate 1

FELBATOL 3

fosphenytoin 6 MSD

FYCOMPA 2

gabapentin 1

GABITRIL 3

Drug Name Drug

Category

Requirements

/ Limits

GRALISE 2 ST; QL

GRALISE 30-DAY

STARTER PACK

2 ST; QL

KEPPRA

INTRAVENOUS

6 MSD

KEPPRA ORAL 3 ST

KEPPRA XR 3 ST

KLONOPIN 3

LAMICTAL 3 ST

LAMICTAL ODT 3 ST

LAMICTAL ODT

STARTER (BLUE)

3 ST

LAMICTAL ODT

STARTER

(GREEN)

3 ST

LAMICTAL ODT

STARTER

(ORANGE)

3 ST

LAMICTAL

STARTER (BLUE)

KIT

3 ST

LAMICTAL

STARTER

(GREEN) KIT

3 ST

LAMICTAL

STARTER

(ORANGE) KIT

3 ST

LAMICTAL XR 3 ST

LAMICTAL XR

STARTER (BLUE)

3 ST

LAMICTAL XR

STARTER

(GREEN)

3 ST

LAMICTAL XR

STARTER

(ORANGE)

3 ST

lamotrigine 1



20

Drug Name Drug

Category

Requirements

/ Limits

levetiracetam in nacl

(iso-os)

6 MSD

levetiracetam

intravenous

6 MSD

levetiracetam oral 1

LYRICA CR 3 ST

LYRICA ORAL

CAPSULE

2 ST

LYRICA ORAL

SOLUTION

2

MYSOLINE 3

NEURONTIN 3 ST

ONFI 2

oxcarbazepine 1

OXTELLAR XR 3 ST

PEGANONE 2

PHENYTEK 3

phenytoin 1

phenytoin sodium

extended

1

primidone 1

QUDEXY XR 2 ST

roweepra 1

roweepra xr 1

SABRIL 3 PA; S; SLA

subvenite 1

subvenite starter

(blue) kit

1

subvenite starter

(green) kit

1

subvenite starter

(orange) kit

1

TEGRETOL 3

TEGRETOL XR 3

Drug Name Drug

Category

Requirements

/ Limits

tiagabine 1

TOPAMAX 3 ST

topiramate oral

capsule, sprinkle

1 PA

TOPIRAMATE

ORAL

CAPSULE,SPRINK

LE,ER 24HR

3 ST

topiramate oral

tablet

1 PA

TRILEPTAL 3 ST

TROKENDI XR 3 ST

valproate sodium 6 MSD

valproic acid 1

valproic acid (as

sodium salt)

1

vigabatrin 1 PA; S; SLA

VIMPAT 2

ZARONTIN 3

ZONEGRAN ORAL

CAPSULE 100 MG

3 PA

ZONEGRAN ORAL

CAPSULE 25 MG

3

zonisamide 1 PA

ANTIPARKINSONISM AGENTS

APOKYN 3 S; SLA

AZILECT 3 M

benztropine 1

bromocriptine 1

carbidopa 1 M

carbidopa-levodopa 1 M

carbidopa-levodopa-

entacapone

1 M

COMTAN 3 M



21

Drug Name Drug

Category

Requirements

/ Limits

DUOPA 6 MSD

entacapone 1 M

GOCOVRI 3 PA; SLA

LODOSYN 3 M

MIRAPEX 3 M

MIRAPEX ER 3 M

NEUPRO 3 M

OSMOLEX ER 3 PA; M

PARLODEL 3

pramipexole 1 M

rasagiline 1 M

REQUIP 3 M

REQUIP XL 3 M

ropinirole 1 M

RYTARY 3 M

selegiline hcl 1 M

SINEMET 3 M

SINEMET CR 3 M

STALEVO 100 3 M

STALEVO 125 3 M

STALEVO 150 3 M

STALEVO 200 3 M

STALEVO 50 3 M

STALEVO 75 3 M

TASMAR 3 M

tolcapone 1 M

trihexyphenidyl 1

XADAGO 3 M

ZELAPAR 3 M

MIGRAINE & CLUSTER

HEADACHE THERAPY

Drug Name Drug

Category

Requirements

/ Limits

AIMOVIG

AUTOINJECTOR

2

AIMOVIG

AUTOINJECTOR

(2 PACK)

2

almotriptan malate 1 QL

AMERGE 3 ST; QL

AXERT 3 ST; QL

CAFERGOT 3

D.H.E.45 3

dihydroergotamine

injection

1

dihydroergotamine

nasal

1 QL

eletriptan 1 QL

ERGOMAR 3

ergotamine-caffeine 1

frovatriptan 1 QL

IMITREX 3 ST; QL

IMITREX

STATDOSE KIT

REFILL

3 ST; QL

IMITREX

STATDOSE PEN

3 ST; QL

isometh-dichloral-

acetaminophn

1

isomethepten-caf-

acetaminophen

1

MAXALT 3 ST; QL

MAXALT-MLT 3 ST; QL

migergot 1

MIGRANAL 3 QL

naratriptan 1 QL

ONZETRA XSAIL 3 QL



22

Drug Name Drug

Category

Requirements

/ Limits

PRODRIN 3

RELPAX 3 ST; QL

rizatriptan 1 QL

sumatriptan 1 QL

sumatriptan

succinate

1 QL

sumatriptan-

naproxen

1 QL

SUMAVEL

DOSEPRO

3 ST; QL

TREXIMET 3 ST; QL

ZEMBRACE

SYMTOUCH

3 QL

zolmitriptan 1 QL

ZOMIG NASAL 2 QL

ZOMIG ORAL 3 ST; QL

ZOMIG ZMT 3 ST; QL

MISCELLANEOUS

NEUROLOGICAL THERAPY

AMPYRA 3 PA; S; SLA;

QL

ARICEPT 3 ST; M

AUSTEDO 3 PA; SLA

donepezil oral tablet

10 mg, 5 mg

1 M

donepezil oral tablet

23 mg

1 ST; M

donepezil oral

tablet,disintegrating

1 M

EXELON 3 ST; M; QL

EXONDYS 51 6 MSD

galantamine oral

capsule,ext rel.

pellets 24 hr

1 M; QL

Drug Name Drug

Category

Requirements

/ Limits

galantamine oral

solution

1 M; QL

galantamine oral

tablet 12 mg

1 M

galantamine oral

tablet 4 mg, 8 mg

1 M; QL

HORIZANT 3 ST; QL

INGREZZA 3 PA; SLA

KEVEYIS 3 PA; SLA

memantine oral

capsule,sprinkle,er

24hr

1 M; QL

memantine oral

solution

1 M

memantine oral

tablet

1 M

MEMANTINE

ORAL

TABLETS,DOSE

PACK

3 M; QL

NAMENDA 3 ST; M

NAMENDA

TITRATION PAK

3 M; QL

NAMENDA XR

ORAL

CAP,SPRINKLE,ER

24HR DOSE PACK

2 M; QL

NAMENDA XR

ORAL

CAPSULE,SPRINK

LE,ER 24HR

2 ST; M; QL

NAMZARIC 2 ST

NUEDEXTA 2 PA

RADICAVA 6 MSD

RAZADYNE ER 3 ST; M; QL

RAZADYNE ORAL

TABLET 12 MG

3 ST; M



23

Drug Name Drug

Category

Requirements

/ Limits

RAZADYNE ORAL

TABLET 4 MG, 8

MG

3 ST; M; QL

rivastigmine 1 M; QL

rivastigmine tartrate 1 M; QL

tetrabenazine 1 PA

TYSABRI 6 MSD

XENAZINE 3 PA; ST

MUSCLE RELAXANTS &

ANTISPASMODIC THERAPY

AMRIX 3 ST

baclofen oral tablet

10 mg, 20 mg

1 M

BACLOFEN ORAL

TABLET 5 MG

3 M

BRIDION 6 MSD

carisoprodol 1

carisoprodol-asa-

codeine

1

carisoprodol-aspirin 1

chlorzoxazone 1

cyclobenzaprine 1

CYCLOTENS

REFILL

3

CYCLOTENS

STARTER

3

DANTRIUM 3 M

dantrolene 1 M

FEXMID 3 ST

LORZONE 3 ST

meprobamate 1

MESTINON ORAL

SYRUP

2 M

Drug Name Drug

Category

Requirements

/ Limits

MESTINON ORAL

TABLET

3 M

MESTINON

TIMESPAN

3 M

metaxall 1

metaxalone 1

methocarbamol

injection

6 MSD

methocarbamol oral 1

orphenadrine citrate 1

pyridostigmine

bromide

1 M

ROBAXIN

INJECTION

6 MSD

ROBAXIN ORAL 3

ROBAXIN-750 3

SKELAXIN 3

SOMA 3

tizanidine 1

ZANAFLEX 3

NARCOTIC ANALGESICS

ABSTRAL 3 ST; QL

acetaminophen-caff-

dihydrocod oral

capsule

1

ACETAMINOPHE

N-CAFF-

DIHYDROCOD

ORAL TABLET

3

acetaminophen-

codeine

1

ACTIQ 3 ST; QL

ALLZITAL 3 ST

ARYMO ER 3 ST; QL

ascomp with codeine 1



24

Drug Name Drug

Category

Requirements

/ Limits

BELBUCA 3 PA

BUPAP 3 ST

BUPRENEX 6 MSD

BUPRENORPHINE 3 ST

buprenorphine hcl

injection

6 MSD

buprenorphine hcl

sublingual

1

butalbital compound

w/codeine

1

butalbital-

acetaminop-caf-cod

1

butalbital-

acetaminophen

1

butalbital-

acetaminophen-caff

1

butalbital-aspirin-

caffeine

1

BUTRANS 3 ST

capacet 1

CAPITAL WITH

CODEINE

3

codeine sulfate 1

DEMEROL 3

DEMEROL (PF) 6 MSD

DILAUDID

INJECTION

6 MSD

DILAUDID ORAL 3

diskets 1

DOLOPHINE 3

DURAGESIC 3

EMBEDA 3 ST; QL

endocet 1

ESGIC 3 ST

Drug Name Drug

Category

Requirements

/ Limits

EXALGO ER 3 ST; QL

fentanyl 1

FENTANYL (PF)-

BUPIVACAINE-

NACL

6 MSD

fentanyl citrate 1 ST; QL

fentanyl citrate (pf)

intravenous syringe

100 mcg/2 ml (50

mcg/ml)

6 MSD

FENTANYL

CITRATE (PF)

INTRAVENOUS

SYRINGE 50

MCG/ML

6 MSD

FENTANYL

CITRATE (PF)-

0.9%NACL

INTRAVENOUS

SOLUTION 10

MCG/ML, 20

MCG/ML

6 MSD

fentanyl citrate (pf)-

0.9%nacl


5 mcg/ml

6 MSD

FENTANYL-

ROPIVACAINE-

NACL (PF)

6 MSD

FENTORA 3 ST; QL

FIORICET 3 ST

FIORINAL 3 ST

FIORINAL-

CODEINE #3

3

hydrocodone-

acetaminophen

1

hydrocodone-

ibuprofen

1



25

Drug Name Drug

Category

Requirements

/ Limits

HYDROMORPHO

NE IN 0.9 % NACL

INJECTION

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PATIENT

CONTROL.ANALG

ESIA SOLN

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PREFILLED PUMP

RESERVOIR

6 MSD

hydromorphone in

0.9 % nacl

intravenous pt

controlled analgesia

syring 15 mg/30 ml

(0.5 mg/ml)

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

PT CONTROLLED

ANALGESIA

SYRING 5 MG/25

ML (0.2 MG/ML), 6

MG/30 ML (0.2

MG/ML)

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

SOLUTION

6 MSD

HYDROMORPHO

NE IN 0.9 % NACL

INTRAVENOUS

SYRINGE

6 MSD

hydromorphone

injection solution

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

HYDROMORPHO

NE INJECTION

SYRINGE 0.5

MG/0.5 ML

6 MSD

hydromorphone

injection syringe 1

mg/ml, 2 mg/ml, 4

mg/ml

6 MSD

HYDROMORPHO

NE

INTRAVENOUS

6 MSD

hydromorphone oral

liquid

1

hydromorphone oral

tablet

1

hydromorphone oral

tablet extended

release 24 hr

1 QL

hydromorphone

rectal

1

HYSINGLA ER 2 ST; QL

IBUDONE 3

ibuprofen-oxycodone 1

KADIAN 3 ST; QL

LAZANDA 3 ST; QL

levorphanol tartrate 1

lorcet (hydrocodone) 1

lorcet hd 1

lorcet plus 1

LORTAB ELIXIR 3

meperidine 1

methadone 1

methadose 1

MORPHABOND

ER

3 ST; QL

morphine (pf) 6 MSD



26

Drug Name Drug

Category

Requirements

/ Limits

MORPHINE (PF)

IN 0.9 % NACL

INTRAVENOUS

SOLUTION

6 MSD

morphine (pf) in 0.9

% nacl intravenous

syringe 0.5 mg/ml, 2

mg/2 ml (1 mg/ml)

6 MSD

MORPHINE (PF)

IN 0.9 % NACL

INTRAVENOUS

SYRINGE 5 MG/5

ML (1 MG/ML)

6 MSD

morphine

concentrate

1

MORPHINE IN 0.9

% SODIUM

CHLOR

6 MSD

morphine injection 6 MSD

MORPHINE

INTRAMUSCULA

R

6 MSD

morphine

intravenous

cartridge 10 mg/ml,

2 mg/ml, 4 mg/ml

6 MSD

MORPHINE

INTRAVENOUS

CARTRIDGE 8

MG/ML

6 MSD

morphine

intravenous pt

controlled analgesia

syring

6 MSD

morphine


10 mg/ml, 100 mg/4

ml, 25 mg/ml, 250

mg/10 ml, 50 mg/ml

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

MORPHINE

INTRAVENOUS

SOLUTION 4

MG/ML, 8 MG/ML

6 MSD

MORPHINE

INTRAVENOUS

SYRINGE 10

MG/ML, 8 MG/ML

6 MSD

morphine

intravenous syringe

2 mg/ml, 4 mg/ml

6 MSD

morphine oral

capsule, er

multiphase 24 hr

1 QL

morphine oral

capsule,extend.relea

se pellets

1 QL

morphine oral

solution

1

morphine oral tablet 1

morphine oral tablet

extended release

1 QL

morphine rectal 1

MS CONTIN 3 ST; QL

NALOCET 3

NORCO 3

OPANA 3

OXAYDO 3

oxycodone oral

capsule

1

oxycodone oral

concentrate

1

oxycodone oral

solution

1

oxycodone oral

tablet

1



27

Drug Name Drug

Category

Requirements

/ Limits

OXYCODONE

ORAL

TABLET,ORAL

ONLY,EXT.REL.12

HR

3 ST; QL

oxycodone-

acetaminophen

1

oxycodone-aspirin 1

OXYCONTIN 2 ST; QL

oxymorphone oral

tablet

1

oxymorphone oral

tablet extended

release 12 hr

1 QL

panlor(acetam-caff-

dihydrocod)

1

PERCOCET 3

phrenilin forte(with

caffeine)

1

PRIMLEV 3

PROBUPHINE 6 MSD

ROXICODONE 3

ROXYBOND 3

SUBLOCADE 6 MSD

SUBSYS 3 ST; QL

tencon 1

TREZIX 3

TYLENOL-

CODEINE #3

3

TYLENOL-

CODEINE #4

3

VANATOL LQ 3 ST

VANATOL S 3 ST

verdrocet 1

vicodin 1

Drug Name Drug

Category

Requirements

/ Limits

vicodin es 1

vicodin hp 1

XTAMPZA ER 3 ST; QL

xylon 10 1

zebutal 1

ZOHYDRO ER 3 ST; QL

NON-NARCOTIC ANALGESICS

ANAPROX DS 3 ST; M

ARTHROTEC 50 3 ST; M

ARTHROTEC 75 3 ST; M

aspirin 5 ACA; OTC

aspir-trin 5 ACA; OTC

bayer aspirin 5 ACA; OTC

BUNAVAIL 3 QL

buprenorphine-

naloxone

1 QL

butorphanol tartrate

injection

6 MSD

butorphanol tartrate

nasal

1 QL

CAMBIA 3 ST; QL

CELEBREX 3 ST; M; QL

celecoxib 1 ST; M; QL

choline,magnesium

salicylate

1

CONZIP 3 ST; QL

DAYPRO 3 ST; M

DICLO GEL 3 ST; M

DICLO GEL-

XRYLIX SHEET

3 ST; M

diclofenac potassium 1

diclofenac sodium

oral

1 M



28

Drug Name Drug

Category

Requirements

/ Limits

diclofenac sodium

topical drops

1 M; QL

diclofenac sodium

topical gel

1 ST; M; QL

diclofenac-

misoprostol

1 M

DICLOPAK 3 ST; M

DICLOPR 3 ST; M

diflunisal 1 M

DISALCID 3

DITHOL 3 ST; M

DUEXIS 3 ST; M; QL

e.c. prin 5 ACA; OTC

EC-NAPROSYN 3 ST; M

ecotrin 5 ACA; OTC

etodolac 1 M

EUFLEXXA 6 MSD

EVZIO INJECTION

AUTO-INJECTOR

0.4 MG/0.4 ML

3 ST; QL

EVZIO INJECTION

AUTO-INJECTOR

2 MG/0.4 ML

3 ST

FELDENE 3 ST; M

FENOPROFEN

ORAL CAPSULE

3 ST; M

fenoprofen oral

tablet

1 M

FENORTHO 3 ST; M

FLECTOR 2 ST; QL

flurbiprofen 1 M

FROTEK 3 ST; M

ibu 1 M

ibuprofen 1 M

Drug Name Drug

Category

Requirements

/ Limits

INDOCIN 3 ST

indomethacin 1

ketoprofen 1 M

ketorolac injection 6 MSD

ketorolac

intramuscular

6 MSD

ketorolac oral 1 QL

LEXIXRYL 3 ST; M

lite coat aspirin 5 ACA; OTC

LODINE 3 ST; M

LUCEMYRA 3

meclofenamate 1 M

mefenamic acid 1

meloxicam oral

suspension

1 M

meloxicam oral

tablet 15 mg

1 M

meloxicam oral

tablet 7.5 mg

1 M; QL

MOBIC ORAL

TABLET 15 MG

3 ST; M

MOBIC ORAL

TABLET 7.5 MG

3 ST; M; QL

nabumetone 1 M

nalbuphine 6 MSD

NALFON 3 ST; M

naloxone 1

naltrexone 1

NAPRELAN CR 3 ST; M

NAPROSYN 3 ST; M

naproxen 1 M

naproxen sodium 1 M

NARCAN 2



29

Drug Name Drug

Category

Requirements

/ Limits

NUCYNTA 2 QL

NUCYNTA ER 2 ST; QL

oxaprozin 1 M

PENNSAID 3 ST; M; QL

pentazocine-

naloxone

1

piroxicam 1 M

profeno 1 M

READYSHARP

KETOROLAC

6 MSD

salsalate 1

SPRIX 3 ST; SLA; QL

SUBOXONE 2 QL

sulindac 1 M

TALWIN 6 MSD

TIVORBEX 3 ST; M

tolmetin 1 M

TORONOVA II

SUIK

6 MSD

TORONOVA SUIK 6 MSD

TRAMADOL

ORAL

CAPSULE,ER

BIPHASE 24 HR

17-83

3 ST; QL

TRAMADOL

ORAL

CAPSULE,ER

BIPHASE 24 HR

25-75

3 ST; QL

tramadol oral tablet 1 QL

tramadol oral tablet

extended release 24

hr

1 ST; QL

tramadol oral tablet,

er multiphase 24 hr

1 ST; QL

Drug Name Drug

Category

Requirements

/ Limits

tramadol-

acetaminophen

1 QL

ULTRACET 3 QL

ULTRAM 3 QL

VIMOVO 3 ST; M; QL

VIVITROL 6 MSD

VIVLODEX 3 ST; M

VOLTAREN 3 ST; M; QL

VOLTAREN-XR 3 ST; M

ZIPSOR 3 ST; QL

ZORVOLEX 3 ST; M; QL

ZUBSOLV 2 QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY 3 ST; QL

ABILIFY

MAINTENA

6 MSD

ADASUVE 3

ADDERALL 3 ST; QL

ADDERALL XR 3 ST; QL

ADDYI 3 PA

ADZENYS ER 3 ST

ADZENYS XR-

ODT

3 ST

alprazolam 1

alprazolam intensol 1

AMBIEN 3 ST; QL

AMBIEN CR 3 ST; QL

amitriptyline 1

amitriptyline-

chlordiazepoxide

1

amoxapine 1

ANAFRANIL 3



30

Drug Name Drug

Category

Requirements

/ Limits

APLENZIN 3 ST; M; QL

APTENSIO XR 3 ST

aripiprazole oral

solution

1

aripiprazole oral

tablet

1 QL

aripiprazole oral


1 QL

ARISTADA 6 MSD

armodafinil 1 PA; QL

ATIVAN

INJECTION

6 MSD

ATIVAN ORAL 3

atomoxetine 1 QL

BELSOMRA 3 ST

BRISDELLE 2 ST; M; QL

bupropion hcl oral

tablet

1 M

bupropion hcl oral

tablet extended

release 12 hr

1 M; QL

bupropion hcl oral

tablet extended

release 24 hr 150 mg

1 M

bupropion hcl oral

tablet extended

release 24 hr 300 mg

1 M; QL

buspirone 1 M

CELEXA 3 ST; M; QL

chlordiazepoxide hcl 1

chlorpromazine 1

citalopram 1 M

clomipramine 1

clonidine hcl 1 QL

Drug Name Drug

Category

Requirements

/ Limits

clorazepate

dipotassium

1

clozapine oral tablet 1

clozapine oral


100 mg, 12.5 mg, 25

mg

1

CLOZAPINE

ORAL

TABLET,DISINTE

GRATING 150 MG,

200 MG

3

CLOZARIL 3

CONCERTA 3 ST; QL

COTEMPLA XR-

ODT

3 ST

CYMBALTA 3 ST; M; QL

DAYTRANA 2 ST; QL

desipramine 1

DESOXYN 3 QL

DESVENLAFAXIN

E

3 ST; M; QL

DESVENLAFAXIN

E FUMARATE

3 ST; M

desvenlafaxine

succinate oral tablet

extended release 24

hr 100 mg, 50 mg

1 M; QL

desvenlafaxine

succinate oral tablet

extended release 24

hr 25 mg

1 M

DEXEDRINE

SPANSULE

3 ST; QL

dexmethylphenidate 1 QL

dextroamphetamine 1 QL



31

Drug Name Drug

Category

Requirements

/ Limits

dextroamphetamine-

amphetamine

1 QL

diazepam injection 6 MSD

diazepam intensol 1

diazepam oral 1

DORAL 3

doxepin 1

duloxetine oral

capsule,delayed

release(dr/ec) 20

mg, 30 mg, 60 mg

1 M; QL

duloxetine oral

capsule,delayed

release(dr/ec) 40 mg

1 M

DYANAVEL XR 3 ST

EDLUAR 3 ST; QL

EFFEXOR XR 3 ST; M; QL

EMSAM 3 M; QL

ergoloid 1 M

escitalopram oxalate 1 M

estazolam 1

eszopiclone 1 QL

EVEKEO 2 PA

FANAPT 3 QL

FAZACLO 3

FETZIMA 2 ST; M; QL

flumazenil 6 MSD

fluoxetine oral

capsule 10 mg, 40

mg

1 M; QL

fluoxetine oral

capsule 20 mg

1 M

fluoxetine oral

capsule,delayed

release(dr/ec)

1 M; QL

Drug Name Drug

Category

Requirements

/ Limits

fluoxetine oral

solution

1 M

fluoxetine oral tablet

10 mg

1 M; QL


20 mg

1 M


60 mg

1

fluphenazine

decanoate

6 MSD

fluphenazine hcl 1

flurazepam 1

fluvoxamine 1 M; QL

FOCALIN 3 QL

FOCALIN XR 3 ST; QL

FORFIVO XL 3 ST; M; QL

GEODON

INTRAMUSCULA

R

6 MSD

GEODON ORAL 3 QL

guanfacine 1 QL

guanidine 1

HALCION 3

HALDOL 3

HALDOL

DECANOATE

3

haloperidol 1

haloperidol

decanoate

1

haloperidol lactate 1

HETLIOZ 4 S; SLA; QL

imipramine hcl 1

imipramine pamoate 1

INTERMEZZO 3 ST; QL



32

Drug Name Drug

Category

Requirements

/ Limits

INTUNIV ER 3 ST; QL

INVEGA 3 QL

KAPVAY 3 ST; QL

KHEDEZLA 3 ST; M; QL

LATUDA 2 QL

LEXAPRO 3 ST; M; QL

lithium carbonate 1

lithium citrate 1

LITHOBID 3

LORAZEPAM IN

0.9% SOD

CHLORIDE

6 MSD

LORAZEPAM IN

DEXTROSE 5 %

6 MSD

lorazepam injection 6 MSD

lorazepam intensol 1

lorazepam oral 1

loxapine succinate 1

LUNESTA 3 ST; QL

maprotiline 1

MARPLAN 3 M

metadate er 1

methamphetamine 1 QL

METHYLIN 3 QL

methylphenidate hcl

oral capsule, er

biphasic 30-70

1

methylphenidate hcl

oral capsule,er

biphasic 50-50

1

methylphenidate hcl

oral solution

1 QL

methylphenidate hcl

oral tablet

1 QL

Drug Name Drug

Category

Requirements

/ Limits

methylphenidate hcl

oral tablet extended

release

1

methylphenidate hcl

oral tablet extended

release 24hr 18 mg,

27 mg, 36 mg, 54 mg

1 QL

METHYLPHENID

ATE HCL ORAL

TABLET

EXTENDED

RELEASE 24HR 72

MG

3 ST

methylphenidate hcl

oral tablet,chewable

1 QL

midazolam 6 MSD

midazolam (pf) in

0.9 % nacl

6 MSD

MIDAZOLAM IN

0.9 % SOD

CHLORID

6 MSD

MIDAZOLAM IN

DEXTROSE 5 %

6 MSD

mirtazapine 1 QL

modafinil 1 PA; QL

MYDAYIS 2 ST

NARDIL 3 M

nefazodone 1 M

NORPRAMIN 3

nortriptyline 1

NUPLAZID 4 S; SLA

NUVIGIL 3 PA; QL

olanzapine

intramuscular

6 MSD

olanzapine oral

tablet 10 mg, 15 mg,

2.5 mg, 5 mg, 7.5 mg

1 QL



33

Drug Name Drug

Category

Requirements

/ Limits

olanzapine oral

tablet 20 mg

1

olanzapine oral


1 QL

olanzapine-

fluoxetine

1

ORAP 3

oxazepam 1

paliperidone 1 QL

PAMELOR 3

PARNATE 3 M

paroxetine hcl 1 M; QL

paroxetine

mesylate(menop.sym

)

1 M; QL

PAXIL CR 3 ST; M; QL

PAXIL ORAL

SUSPENSION

3 ST; M

PAXIL ORAL

TABLET

3 ST; M; QL

perphenazine 1

perphenazine-

amitriptyline

1

PEXEVA 3 ST; M; QL

phenelzine 1 M

pimozide 1

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

100 MG, 50 MG

3 ST; M; QL

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

25 MG

3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

procentra 1 QL

protriptyline 1

PROVIGIL 3 ST; QL

PROZAC ORAL

CAPSULE 10 MG,

40 MG

3 ST; M; QL

PROZAC ORAL

CAPSULE 20 MG

3 ST; M

quazepam 1

quetiapine oral

tablet 100 mg, 25

mg, 50 mg

1 PA; QL

quetiapine oral

tablet 200 mg, 300

mg, 400 mg

1 QL

quetiapine oral

tablet extended

release 24 hr

1 QL

QUILLICHEW ER 2 ST

QUILLIVANT XR 2 ST; QL

REMERON 3 QL

REMERON

SOLTAB

3 QL

RESTORIL 3

REXULTI 3

RISPERDAL ORAL

SOLUTION

3

RISPERDAL ORAL

TABLET

3 QL

risperidone oral

solution

1

risperidone oral

tablet

1 QL

risperidone oral


1 QL

RITALIN 3 QL



34

Drug Name Drug

Category

Requirements

/ Limits

RITALIN LA 3 ST

ROZEREM 2 ST; QL

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 10 MG, 5

MG

3 QL

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 2.5 MG

3

SARAFEM ORAL

TABLET 10 MG

3 ST; M; QL

SARAFEM ORAL

TABLET 20 MG

3 ST; M

SEROQUEL ORAL

TABLET 100 MG,

25 MG, 50 MG

3 PA; QL

SEROQUEL ORAL

TABLET 200 MG,

300 MG, 400 MG

3 ST; QL

SEROQUEL XR 3 ST; QL

sertraline oral

concentrate

1 M

sertraline oral tablet 1 M; QL

SILENOR 3 ST; QL

SONATA 3 ST; QL

STRATTERA 3 ST; QL

SURMONTIL 3

SYMBYAX 3

temazepam 1

thioridazine 1

thiothixene 1

TOFRANIL 3

TRANXENE T-

TAB

3

Drug Name Drug

Category

Requirements

/ Limits

tranylcypromine 1 M

trazodone 1

triazolam 1

trifluoperazine 1

trimipramine 1

TRINTELLIX 3 ST; QL

VALIUM 3 ST

venlafaxine oral

capsule,extended

release 24hr 150 mg

1 M

venlafaxine oral

capsule,extended

release 24hr 37.5

mg, 75 mg

1 M; QL

venlafaxine oral

tablet

1 M; QL

venlafaxine oral

tablet extended

release 24hr

1 ST; M; QL

VERSACLOZ 3

VIIBRYD ORAL

TABLET

2 ST; M; QL

VIIBRYD ORAL

TABLETS,DOSE

PACK

2 ST; QL

VRAYLAR 3

VYVANSE 2 ST; QL

WELLBUTRIN SR 3 ST; M; QL

WELLBUTRIN XL 3 ST; M; QL

XANAX 3 ST

XANAX XR 3 ST

XYREM 3 PA; S; SLA;

QL

zaleplon 1 QL



35

Drug Name Drug

Category

Requirements

/ Limits

zenzedi oral tablet

10 mg, 5 mg

1 QL

ZENZEDI ORAL

TABLET 15 MG

3 QL

ZENZEDI ORAL

TABLET 2.5 MG,

20 MG, 30 MG, 7.5

MG

3

ziprasidone hcl 1 QL

ZOLOFT ORAL

CONCENTRATE

3 ST; M

ZOLOFT ORAL

TABLET

3 ST; M; QL

zolpidem 1 QL

ZOLPIMIST 3 ST

ZYPREXA

INTRAMUSCULA

R

6 MSD

ZYPREXA ORAL

TABLET 10 MG, 15

MG, 2.5 MG, 5 MG,

7.5 MG

3 QL

ZYPREXA ORAL

TABLET 20 MG

3

ZYPREXA ZYDIS 3 QL

CARDIOVASCULAR,

HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone 1 M

BETAPACE 3 M

BETAPACE AF 3 M

disopyramide

phosphate

1 M

dofetilide 1

flecainide 1 M

mexiletine 1 M

Drug Name Drug

Category

Requirements

/ Limits

MULTAQ 3 M

NORPACE 3 M

NORPACE CR 3 M

pacerone 1 M

procainamide 6 MSD

propafenone 1 M

quinidine gluconate 1 M

quinidine sulfate 1 M

RYTHMOL SR 3 M

sotalol 1 M

sotalol af 1 M

SOTYLIZE 2 M

TIKOSYN 3 ST

ANTIHYPERTENSIVE THERAPY

ACCUPRIL 3 M

ACCURETIC 3 M

acebutolol 1 M

ADALAT CC 3 ST; M

afeditab cr 1 M

ALDACTAZIDE 3 M

ALDACTONE 3 M

ALTACE 3 M

amiloride 1 M

amiloride-

hydrochlorothiazide

1 M

amlodipine 1 M

amlodipine-

benazepril

1 M

amlodipine-

olmesartan

1 M

amlodipine-

valsartan

1 M



36

Drug Name Drug

Category

Requirements

/ Limits

amlodipine-

valsartan-hcthiazid

1 M

ATACAND 3 ST; M

ATACAND HCT 3 ST; M

atenolol 1 M

atenolol-

chlorthalidone

1 M

AVALIDE 3 ST; M

AVAPRO 3 ST; M

AZOR 3 ST; M

benazepril 1 M

benazepril-

hydrochlorothiazide

1 M

BENICAR 3 ST; M

BENICAR HCT 3 ST; M

betaxolol 1 M

BIDIL 3 M

bisoprolol fumarate 1 M

bisoprolol-

hydrochlorothiazide

1 M

BREVIBLOC 6 MSD

BREVIBLOC IN

NACL (ISO-OSM)

6 MSD

bumetanide 1 M

BYSTOLIC 2 ST; M

BYVALSON 2 ST; M

CALAN 3 ST; M

CALAN SR 3 ST; M

candesartan 1 M

candesartan-

hydrochlorothiazid

1 M

captopril 1 M

Drug Name Drug

Category

Requirements

/ Limits

captopril-

hydrochlorothiazide

1 M

CARDIZEM 3 M

CARDIZEM CD 3 M

CARDIZEM LA 3 M

CARDURA 3 ST; M; QL

CARDURA XL 3 ST; M; QL

CAROSPIR 3 ST; M

cartia xt 1 M

carvedilol 1 M

carvedilol phosphate 1 M

CATAPRES 3 M

CATAPRES-TTS-1 3 M; QL



chlorothiazide 1 M

chlorothiazide

sodium

6 MSD

chlorthalidone 1 M

clonidine 1 M; QL

clonidine hcl 1 M

COREG 3 ST; M

COREG CR 3 ST; M

CORGARD 3 ST; M

CORZIDE 3 ST; M

COZAAR 3 ST; M

DEMADEX 3 M

DEMSER 2

DIBENZYLINE 3

diltiazem 1 M

dilt-xr 1 M

DIOVAN 3 ST; M



37

Drug Name Drug

Category

Requirements

/ Limits

DIOVAN HCT 3 ST; M

DIURIL 3 M

DIURIL IV 6 MSD

doxazosin 1 M; QL

DUTOPROL 3 ST; M

DYAZIDE 3 M

DYRENIUM 3 M

EDARBI 2 ST; M

EDARBYCLOR 2 ST; M

EDECRIN 3 M

enalapril maleate 1 M

enalaprilat 6 MSD

enalapril-

hydrochlorothiazide

1 M

EPANED 3 M

eplerenone 1 M

epoprostenol

(glycine)

6 MSD

eprosartan 1 M

esmolol 6 MSD

ethacrynate sodium 6 MSD

ethacrynic acid 1 M

EXFORGE 3 ST; M

EXFORGE HCT 3 ST; M

felodipine 1 M

FLOLAN 6 MSD

fosinopril 1 M

fosinopril-

hydrochlorothiazide

1 M

FUROSEMIDE IN

0.9 % NACL

6 MSD

furosemide injection 6 MSD

furosemide oral 1 M

Drug Name Drug

Category

Requirements

/ Limits

guanfacine 1 M

HEMANGEOL 3 SLA

hydralazine injection 6 MSD

hydralazine oral 1 M

hydrochlorothiazide 1 M

HYZAAR 3 ST; M

indapamide 1 M

INDERAL LA 3 ST; M

INDERAL XL 3 ST; M

INNOPRAN XL 3 ST; M

INSPRA 3 M

irbesartan 1 M

irbesartan-

hydrochlorothiazide

1 M

isradipine 1 M

labetalol


6 MSD

labetalol

intravenous syringe

20 mg/4 ml (5

mg/ml), 25 mg/5 ml

(5 mg/ml)

6 MSD

LABETALOL

INTRAVENOUS

SYRINGE 50

MG/10 ML (5

MG/ML)

6 MSD

labetalol oral 1 M

LASIX 3 M

LEVATOL 3 ST; M

lisinopril 1 M

lisinopril-

hydrochlorothiazide

1 M

LOPRESSOR 3 ST; M

losartan 1 M



38

Drug Name Drug

Category

Requirements

/ Limits

losartan-

hydrochlorothiazide

1 M

LOTENSIN 3 M

LOTENSIN HCT 3 M

LOTREL 3 ST; M

matzim la 1 M

MAXZIDE 3 M

MAXZIDE-25MG 3 M

methyclothiazide 1 M

methyldopa 1 M

methyldopa-

hydrochlorothiazide

1 M

methyldopate 6 MSD

metolazone 1 M

metoprolol succinate 1 M

METOPROLOL

SU-

HYDROCHLOROT

HIAZ

3 ST; M

metoprolol ta-

hydrochlorothiaz

1 M

metoprolol tartrate

intravenous

6 MSD

metoprolol tartrate

oral

1 M

MICARDIS 3 ST; M

MICARDIS HCT 3 ST; M

MICROZIDE 3 M

MINIPRESS 3 M

minoxidil 1 M

moexipril 1 M

moexipril-

hydrochlorothiazide

1 M

nadolol 1 M

Drug Name Drug

Category

Requirements

/ Limits

nadolol-

bendroflumethiazide

1 M

nicardipine 1 M

nifedipine 1 M

nimodipine 1

nisoldipine 1 M

NORVASC 3 ST; M

NYMALIZE 3

olmesartan 1 M

olmesartan-

amlodipin-hcthiazid

1 M

olmesartan-

hydrochlorothiazide

1 M

ORENITRAM 4 PA; S; SLA

perindopril

erbumine

1 M

phenoxybenzamine 1

phentolamine 6 MSD

pindolol 1 M

prazosin 1 M

PRESTALIA 3 ST; M

PRINIVIL 3 M

PROCARDIA 3 ST; M

PROCARDIA XL 3 ST; M

propranolol 1 M

propranolol-

hydrochlorothiazid

1 M

QBRELIS 3 M

quinapril 1 M

quinapril-

hydrochlorothiazide

1 M

ramipril 1 M

REMODULIN 6 MSD



39

Drug Name Drug

Category

Requirements

/ Limits

SODIUM

EDECRIN

6 MSD

spironolactone 1 M

spironolacton-

hydrochlorothiaz

1 M

SULAR 3 ST; M

TARKA 3 M

taztia xt 1 M

TEKTURNA 2 M

TEKTURNA HCT 2 M

telmisartan 1 M

telmisartan-

amlodipine

1 M

telmisartan-

hydrochlorothiazid

1 M

TENORETIC 100 3 ST; M

TENORETIC 50 3 ST; M

TENORMIN 3 ST; M

terazosin 1 M; QL

TIAZAC 3 M

timolol maleate 1 M

TOPROL XL 3 ST; M

torsemide 1 M

trandolapril 1 M

trandolapril-

verapamil

1 M

triamterene-

hydrochlorothiazid

1 M

TRIBENZOR 3 ST; M

TWYNSTA 3 ST; M

UPTRAVI 3 PA; S; SLA

valsartan 1 M

Drug Name Drug

Category

Requirements

/ Limits

valsartan-

hydrochlorothiazide

1 M

VASERETIC 3 M

VASOTEC 3 M

veletri 6 MSD

verapamil 1 M

VERELAN 3 ST; M

VERELAN PM 3 ST; M

ZESTORETIC 3 M

ZESTRIL 3 M

ZIAC 3 ST; M

CARDIAC GLYCOSIDES

digitek 1 M

digox 1 M

digoxin injection 6 MSD

digoxin oral 1 M

LANOXIN

INJECTION

6 MSD

LANOXIN ORAL 3 M

LANOXIN

PEDIATRIC

6 MSD

COAGULATION THERAPY

ADVATE 6 MSD

ADYNOVATE 6 MSD

AFSTYLA 6 MSD

ALPHANATE 6 MSD

ALPHANINE SD 6 MSD

ALPROLIX 6 MSD

AMICAR 2

ANDEXXA 6 MSD

ANGIOMAX 6 MSD

ARGATROBAN 6 MSD



40

Drug Name Drug

Category

Requirements

/ Limits

ARGATROBAN IN

0.9 % SOD CHLOR

6 MSD

ARGATROBAN IN

NACL (ISO-OS)

6 MSD

ARIXTRA 3

BEBULIN 6 MSD

BENEFIX 6 MSD

BEVYXXA 3 QL

bivalirudin 6 MSD

BIVALIRUDIN-0.9

% SODIUM

CHLOR

6 MSD

CEPROTIN (BLUE

BAR)

6 MSD

CEPROTIN

(GREEN BAR)

6 MSD

COAGADEX 6 MSD

CORIFACT 6 MSD

COUMADIN 3

DEFITELIO 6 MSD

DOPTELET 3 PA

ELIQUIS 2 PA

ELOCTATE 6 MSD

enoxaparin

subcutaneous

solution

6 MSD

enoxaparin

subcutaneous

syringe

1

FEIBA NF 6 MSD

FIBRYGA 6 MSD

fondaparinux 1

FRAGMIN 2

HELIXATE FS 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

HEMLIBRA 6 MSD

HEMOFIL M HIGH 6 MSD

HEMOFIL M LOW 6 MSD

HEMOFIL M MID 6 MSD

HEMOFIL M

SUPER HIGH

6 MSD

hep flush-10 (pf) 1

heparin (porcine) 1

HEPARIN

(PORCINE) IN

0.9% NACL

6 MSD

heparin (porcine) in

5 % dex

6 MSD

heparin (porcine) in

nacl (pf)

1

heparin

flush(porcine)-

0.9nacl

6 MSD

heparin lock flush 1

heparin lock flush

(porcine)

1

heparin

lockflush(porcine)(pf

)

1

HEPARIN(PORCIN

E) IN 0.45% NACL

6 MSD

heparin, porcine (pf) 1

HUMATE-P 6 MSD

IDELVION 6 MSD

IPRIVASK 6 MSD

IXINITY 6 MSD

jantoven 1

KOATE 6 MSD

KOGENATE FS 6 MSD

KOVALTRY 6 MSD



41

Drug Name Drug

Category

Requirements

/ Limits

LOVENOX

SUBCUTANEOUS

SOLUTION

6 MSD

LOVENOX

SUBCUTANEOUS

SYRINGE

3 ST

MEPHYTON 2

MONOCLATE-P 6 MSD

MONONINE 6 MSD

NOVOEIGHT 6 MSD

NOVOSEVEN RT 6 MSD

NPLATE 6 MSD

NUWIQ 6 MSD

OBIZUR 6 MSD

pentoxifylline 1 M

phytonadione

(vitamin k1)

1

PRADAXA 3 PA; M

PRAXBIND 6 MSD

PROFILNINE 6 MSD

PROMACTA 2 PA

REBINYN 6 MSD

RECOMBINATE 6 MSD

RIASTAP 6 MSD

RIXUBIS 6 MSD

SAVAYSA 3 PA

TAVALISSE 3 PA

tranexamic acid 6 MSD

TRETTEN 6 MSD

VONVENDI 6 MSD

warfarin 1

WILATE 6 MSD

XARELTO 2 PA

Drug Name Drug

Category

Requirements

/ Limits

XYNTHA 6 MSD

XYNTHA

SOLOFUSE

6 MSD

LIPID/CHOLESTEROL LOWERING

AGENTS

ALTOPREV 3 ST; M; QL

amlodipine-

atorvastatin

1 M; QL

ANTARA 3 ST; M; QL

atorvastatin oral

tablet 10 mg, 20 mg

5 M; ACA; QL

atorvastatin oral

tablet 40 mg, 80 mg

1 M; QL

CADUET 3 ST; M; QL

cholestyramine (with

sugar)

1 M

cholestyramine light 1 M

colesevelam 1 M

COLESTID 3 ST; M

COLESTID

FLAVORED

3 ST; M

colestipol 1 M

CRESTOR 3 ST; M; QL

ezetimibe 1 ST; M

ezetimibe-

simvastatin

1 M; QL

fenofibrate

micronized

1 M; QL

fenofibrate

nanocrystallized

1 M; QL

FENOFIBRATE

ORAL CAPSULE

3 ST; M; QL

fenofibrate oral

tablet

1 M; QL

fenofibric acid 1 M; QL



42

Drug Name Drug

Category

Requirements

/ Limits

fenofibric acid

(choline)

1 M; QL

FENOGLIDE 3 ST; M; QL

FIBRICOR 3 ST; M; QL

FLOLIPID 3 ST; M

fluvastatin 5 M; ACA; QL

gemfibrozil 1 M; QL

JUXTAPID ORAL

CAPSULE 10 MG,

20 MG, 5 MG

3 PA; S; QL

JUXTAPID ORAL

CAPSULE 30 MG,

40 MG, 60 MG

3 PA; S

KYNAMRO 4 PA; S; SLA;

QL

LESCOL XL 3 ST; M; QL

LIPITOR 3 ST; M; QL

LIPOFEN 2 ST; M; QL

LIVALO 2 ST; M; QL

LOPID 3 M; QL

lovastatin 5 M; ACA; QL

LOVAZA 3 PA; M

niacin 1 M

NIACOR 3 M

NIASPAN

EXTENDED-

RELEASE

3 M

omega-3 acid ethyl

esters

1 PA; M

PRALUENT PEN 3 PA; S; SLA

PRAVACHOL 3 ST; M; QL

pravastatin 5 M; ACA; QL

prevalite 1 M

QUESTRAN 3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

QUESTRAN

LIGHT

3 ST; M

REPATHA

PUSHTRONEX

3 PA; S; SLA

REPATHA

SURECLICK

3 PA; S; SLA

REPATHA

SYRINGE

3 PA; S; SLA

rosuvastatin oral

tablet 10 mg, 5 mg

5 M; ACA; QL

rosuvastatin oral

tablet 20 mg, 40 mg

1 M; QL

simvastatin oral

tablet 10 mg, 20 mg,

40 mg, 5 mg

5 M; ACA; QL

simvastatin oral

tablet 80 mg

1 M; QL

TRICOR 3 ST; M; QL

TRIGLIDE 3 ST; M; QL

triklo 1 PA; M

TRILIPIX 3 ST; M; QL

VASCEPA 2 PA; M

VYTORIN 10-10 3 ST; M; QL




WELCHOL ORAL

POWDER IN

PACKET

2 ST; M

WELCHOL ORAL

TABLET

3 ST; M

ZETIA 3 ST; M

ZOCOR 3 ST; M; QL

MISCELLANEOUS

CARDIOVASCULAR AGENTS



43

Drug Name Drug

Category

Requirements

/ Limits

CORLANOR 2 PA; M

ENTRESTO 2 PA; M

GIAPREZA 6 MSD

NIPRIDE RTU 6 MSD

RANEXA 2 M

VECAMYL 3 SLA

NITRATES

DILATRATE-SR 2 M

GONITRO 3

ISOCHRON 3 M

ISORDIL 3 M

ISORDIL

TITRADOSE

3 M

isosorbide dinitrate 1 M

isosorbide

mononitrate

1 M

MINITRAN 3 M

nitro-bid 1 M

NITRO-DUR 3 M

nitroglycerin oral 1 M

nitroglycerin

sublingual

1

nitroglycerin

transdermal

1 M

nitroglycerin

translingual

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

nitro-time 1 M

DERMATOLOGICALS/TOPICA

L THERAPY

Drug Name Drug

Category

Requirements

/ Limits

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin 1

ANALPRAM-HC 3 ST

calcipotriene 1 QL

calcipotriene-

betamethasone

1 QL

calcitrene 1 QL

calcitriol 1 QL

COAL TAR 2

COSENTYX 3 ST; S; SLA;

QL

COSENTYX (2

SYRINGES)

3 ST; S; SLA;

QL

COSENTYX PEN 3 ST; S; SLA;

QL

COSENTYX PEN

(2 PENS)

3 ST; S; SLA;

QL

DOVONEX 3 QL

drithocreme hp 1

ENSTILAR 2

EPIFOAM 3 ST

hydrocortisone-

pramoxine

1

OVACE 3

OVACE PLUS

SHAMPOO

3

OVACE PLUS

TOPICAL

CLEANSER

3

OVACE PLUS

TOPICAL CREAM

3 ST

OVACE PLUS

TOPICAL FOAM

3



44

Drug Name Drug

Category

Requirements

/ Limits

OVACE PLUS

TOPICAL LOTION

3 ST

OVACE PLUS

WASH

3

PRAMOSONE 3 ST

PRAMOSONE E 3 ST

seb-prev 1

selenium sulfide 1

SELRX 3

SILIQ 4 ST; S

SORIATANE 3

SORILUX 3 QL

STELARA 6 MSD

sulfacetamide

sodium

1

TACLONEX

TOPICAL

OINTMENT

3 QL

TACLONEX

TOPICAL

SUSPENSION

2

TALTZ

AUTOINJECTOR

4 ST; S; SLA

TALTZ

AUTOINJECTOR

(2 PACK)

4 ST; S; SLA

TALTZ

AUTOINJECTOR

(3 PACK)

4 ST; S; SLA

TALTZ SYRINGE 4 ST; S; SLA

TERSI FOAM 3

TREMFYA 3 PA; ST; S

VECTICAL 3 QL

ZITHRANOL 3

BURN THERAPY

Drug Name Drug

Category

Requirements

/ Limits

SILVADENE 3

silver sulfadiazine 1

ssd 1

KERATOLYTICS

BENSAL HP 3

INOVA 4-1 3 ST

KERALYT RX 3

PODOCON 3

SALEX 3

salicylic acid 1

salimez 1

SALIMEZ FORTE 3

SALKERA 3

salvax 1

SALVAX DUO

PLUS

3

ULTRASAL-ER 3

VIRASAL 3

MISCELLANEOUS

DERMATOLOGICALS

ALEVICYN PLUS 3

AMELUZ 6 MSD

ATOPADERM 3

ATOPICLAIR 3

ATRAPRO CP 3

ATRAPRO

HYDROGEL

3

avo cream 1

BIAFINE

EMULSION

3

CARAC 2

celacyn 1



45

Drug Name Drug

Category

Requirements

/ Limits

CONDYLOX 3

CORTANE-B 3

DEXERYL 3

diclofenac sodium 1 PA

doxepin 1

DUPIXENT 3 PA; S

EFUDEX 3

eletone 1

ELIDEL 2 ST; QL

EPICERAM 3

ESKATA 3

EUCRISA 3 PA; ST; QL

FLUOROPLEX 3

FLUOROURACIL

TOPICAL CREAM

0.5 %

3 ST

fluorouracil topical

cream 5 %

1

fluorouracil topical

solution

1

hpr 1

hpr plus 1

hpr plus hydrogel 1

HPR PLUS-MB

HYDROGEL

3

HYDRO 35 3

HYDRO 40 3

HYLATOPIC 3

HYLATOPICPLUS 3

KERAFOAM 3

KERALAC 3

LEVICYN

ANTIPRURITIC

3

Drug Name Drug

Category

Requirements

/ Limits

LEVICYN

ANTIPRURITIC SG

3

LEVULAN 6 MSD

LOUTREX 3

LOYON 3

luxamend 1

methoxsalen 1

METOPIC 3

NEOCERA 3

NEOSALUS 3

nivatopic plus 1

NUTRASEB 3

OXSORALEN

ULTRA

3

PANRETIN 3

PICATO 2 QL

podofilox 1

PRESERA 3

PROMISEB 3

PROTOPIC 3 ST; QL

pruclair 1

prudoxin 1

prumyx 1

prutect 1

QUTENZA 6 MSD

REGRANEX 2 QL

RESTIZAN 3

silver nitrate 1

silver nitrate

applicators

1

SOLARAZE 3 PA

sonafine 1



46

Drug Name Drug

Category

Requirements

/ Limits

sp antipruritic 1

sp scar management 1

tacrolimus 1 ST; QL

TOLAK 3

umecta 1

urea 1

urea nail stick 1

UTOPIC 3

VALCHLOR 3 S; SLA

VEREGEN 3

XCLAIR 3

ZONALON 3

THERAPY FOR ACNE

ABSORICA 2 QL

ACANYA 2 ST; QL

ACZONE 3 ST

adapalene topical

cream

1 QL

adapalene topical

gel

1 QL

adapalene topical

gel with pump

1 QL

ADAPALENE

TOPICAL LOTION

3 ST; QL

adapalene-benzoyl

peroxide

1 QL

AKTIPAK 3 ST

amnesteem 1 QL

ATRALIN 3 QL

AVAR LS 3 ST

avar topical cleanser 1

AVAR TOPICAL

FOAM

3 ST

Drug Name Drug

Category

Requirements

/ Limits

AVAR TOPICAL

PADS,

MEDICATED

3 ST

AVAR-E GREEN 3 ST

AVAR-E LS 3 ST

avita topical cream 1 QL

AVITA TOPICAL

GEL

3 QL

AZELEX 3 ST; QL

BENZACLIN 3 ST

BENZACLIN

PUMP

3 ST; QL

BENZAMYCIN 3 ST

BENZEFOAM 3 ST

BENZEFOAM

ULTRA

3 ST

benzepro 1

benzoyl peroxide 1

bp 10-1 1

bpo 1

claravis 1 QL

cleansing wash 1

CLEOCIN T 3 ST

CLINDACIN ETZ 3 ST

clindacin p 1

CLINDACIN PAC 3 ST

CLINDAGEL 3 ST

clindamycin

phosphate

1

clindamycin-benzoyl

peroxide topical gel

1.2 %(1 % base) -5

%

1 QL



47

Drug Name Drug

Category

Requirements

/ Limits

clindamycin-benzoyl


1-5 %

1

clindamycin-benzoyl


with pump

1 QL

clindamycin-

tretinoin

1

dapsone 1

DIFFERIN 3 ST; QL

DUAC 3 ST; QL

EPIDUO 3 ST; QL

EPIDUO FORTE 2 ST

ery pads 1

erygel 1

erythromycin with

ethanol

1

erythromycin-

benzoyl peroxide

1

EVOCLIN 3 ST

FABIOR 3 PA; QL

FINACEA 2 ST

INOVA 3 ST

isotretinoin 1 QL

METROCREAM 3 ST

METROGEL 3 ST

METROLOTION 3 ST

metronidazole 1

MIRVASO 2

neuac 1 QL

NEUAC KIT 3 ST

NORITATE 3 ST

NUOX 3 ST

Drug Name Drug

Category

Requirements

/ Limits

ONEXTON 2 ST; QL

PLEXION 3 ST

PLEXION

CLEANSING

CLOTHS

3 ST

RETIN-A MICRO 3

RETIN-A MICRO

PUMP

3

RETIN-A TOPICAL

CREAM 0.025 %

3 QL

RETIN-A TOPICAL

CREAM 0.05 %, 0.1

%

3

RETIN-A TOPICAL

GEL 0.01 %

3

RETIN-A TOPICAL

GEL 0.025 %

3 QL

RHOFADE 3

rosadan topical

cream

1

rosadan topical gel 1

ROSADAN

TOPICAL KIT,

CLEANSER AND

GEL

3 ST

ROSADAN

TOPICAL

KIT,CLEANSER

AND CREAM

3 ST

ROSANIL 3 ST

ROSULA 3 ST

rosula cleansing

cloths

1

SOOLANTRA 2 ST

sss 10-5 1

sulfacetamide

sodium-sulfur

1



48

Drug Name Drug

Category

Requirements

/ Limits

sulfacetamide sod-

sulfur-urea

1

sulfacleanse 8-4 1

SUMADAN 3 ST

SUMAXIN 3 ST

SUMAXIN TS 3 ST

tazarotene 1 PA; QL

TAZORAC

TOPICAL CREAM

0.05 %

2 PA; QL

TAZORAC

TOPICAL CREAM

0.1 %

3 PA; QL

TAZORAC

TOPICAL GEL

2 PA; QL

tretinoin

microspheres

1

tretinoin topical

cream 0.025 %

1 QL

tretinoin topical

cream 0.05 %, 0.1 %

1

tretinoin topical gel

0.01 %

1

tretinoin topical gel

0.025 %, 0.05 %

1 QL

TRETIN-X 3

TRETIN-X CREAM

KIT

3

VANOXIDE-HC 3 ST

VELTIN 3 ST

zenatane 1 QL

ZIANA 3 ST

TOPICAL ANESTHETICS

AGONEAZE 3

ANASTIA 3

Drug Name Drug

Category

Requirements

/ Limits

ANODYNE LPT 3

ASTERO 3

BUCALSEP 3

DERMACINRX

EMPRICAINE

3

DOLOTRANZ 3

ethyl chloride 1

glydo 1

LDO PLUS 3

LEVA SET 3

lidocaine (pf)

injection solution

6 MSD

LIDOCAINE (PF)

INJECTION

SYRINGE

6 MSD

lidocaine hcl

injection solution

6 MSD

lidocaine hcl

injection syringe 10

mg/ml (1 %)

6 MSD

LIDOCAINE HCL

INJECTION

SYRINGE 100

MG/5 ML (2 %), 30

MG/3 ML (1%), 50

MG/5 ML (1 %)

6 MSD

lidocaine hcl

laryngotracheal

1

lidocaine hcl mucous

membrane

1

lidocaine hcl topical

cream 3 %

1

LIDOCAINE HCL

TOPICAL CREAM

3.88 %

3

lidocaine hcl topical

lotion

1



49

Drug Name Drug

Category

Requirements

/ Limits

lidocaine hcl-

hydrocortison ac

1

lidocaine topical

adhesive

patch,medicated

1 PA

lidocaine topical

ointment

1

lidocaine viscous 1

lidocaine-prilocaine 1

LIDOCAINE-

TETRACAINE

3 ST

LIDODERM 3 PA; ST

LIDOPAC 3

lidopin topical

cream 3 %

1

LIDOPIN TOPICAL

CREAM 3.25 %

3

LIDO-PRILO

CAINE PACK

3

LIDORX 3

LIDOTRAL 3

lidozion 1

LIDTOPIC MAX 3

LIPROZONEPAK 3

lta pre-attached 1

MEDOLOR PAK 3

NUMBONEX 3

P-CARE X (PF) 6 MSD

PLIAGLIS 3

PRILOLID 3

READYSHARP

LIDOCAINE (PF)

6 MSD

relador pak 1

relador pak plus 1

Drug Name Drug

Category

Requirements

/ Limits

SYNERA 3

TRANZAREL 3

XYLOCAINE 6 MSD

XYLOCAINE-MPF 6 MSD

ZINGO 6 MSD

TOPICAL ANTIBACTERIALS

ALTABAX 3

BACTROBAN 3

CENTANY 3

CENTANY AT 3

CORTISPORIN 3

gentamicin 1

hydrocortisone-

iodoquinol-aloe

1

iodoquinol-hc 1

KLARON 3 ST

lugols 1

mafenide acetate 1

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 3

NEO-SYNALAR

KIT

3

SILVRSTAT 3

sulfacetamide

sodium (acne)

1

SULFAMYLON

TOPICAL CREAM

2

SULFAMYLON

TOPICAL PACKET

3

TOPICAL ANTIFUNGALS

ciclodan 1



50

Drug Name Drug

Category

Requirements

/ Limits

CICLODAN KIT

TOPICAL COMBO

PACK

3

CICLODAN KIT

TOPICAL

SOLUTION

3 ST

ciclopirox 1

clotrimazole-

betamethasone

1

econazole 1

ECOZA 3

ERTACZO 3

EXELDERM 3

EXODERM 3

EXTINA 3

JUBLIA 3 ST; QL

KERYDIN 3 ST; QL

ketoconazole 1

LOPROX 3

LOPROX (AS

OLAMINE)

3

LOPROX KIT 3

LOTRISONE 3

LUZU 3 QL

naftifine 1

NAFTIN 3

NIZORAL 3

nyamyc 1

nystatin 1

nystatin-

triamcinolone

1

nystop 1

oxiconazole 1

Drug Name Drug

Category

Requirements

/ Limits

OXISTAT 3

PENLAC 3 ST

TRIACETIN 2

TRIPLE DYE 3

VUSION 3

XOLEGEL 3

TOPICAL ANTIVIRALS

acyclovir 1 QL

DENAVIR 3

XERESE 3

ZOVIRAX

TOPICAL CREAM

2 QL

ZOVIRAX

TOPICAL

OINTMENT

3 QL

TOPICAL CORTICOSTEROIDS

ala-cort 1

ALA-SCALP 3 ST

alclometasone 1

amcinonide 1

apexicon e 1 QL

AQUA GLYCOLIC

HC

3 ST

betamethasone

dipropionate

1

betamethasone

valerate

1

betamethasone,

augmented

1

CAPEX 3 ST; QL

clobetasol 1

clobetasol-emollient 1

CLOBEX 3 ST



51

Drug Name Drug

Category

Requirements

/ Limits

CLOCORTOLONE

PIVALATE

3 ST; QL

clodan 1

CLODAN KIT 3 ST

CLODERM 3 ST; QL

CORDRAN 3 ST

CORDRAN TAPE

LARGE ROLL

3 ST

cormax 1

CUTIVATE 3 ST

DERMA-

SMOOTHE/FS

BODY OIL

3 ST; QL

DERMA-

SMOOTHE/FS

SCALP OIL

3 ST; QL

DERMATOP 3 ST

DESONATE 3 ST

desonide 1 QL

DESOWEN 3 ST; QL

desoximetasone 1 QL

diflorasone 1 QL

DIPROLENE 3 ST

ELLZIA PAK 3

ELOCON 3 ST

fluocinolone 1 QL

fluocinolone and

shower cap

1 QL

fluocinonide 1

fluocinonide-

emollient

1

flurandrenolide 1

fluticasone 1

Drug Name Drug

Category

Requirements

/ Limits

halobetasol

propionate

1 QL

HALOG 3 ST

hydrocortisone 1

hydrocortisone

butyrate

1

hydrocortisone

butyr-emollient

1

hydrocortisone

valerate

1

hydrocortisone-min

oil-wht pet

1

IMPOYZ 3 ST

KENALOG 3 ST

LOCOID 3 ST

LOCOID

LIPOCREAM

3 ST

LUXIQ 3 ST

mometasone 1

nolix 1

OLUX 3 ST

OLUX-E 3 ST

PANDEL 3 ST

prednicarbate 1

PSORCON 3 ST; QL

scalacort 1

SERNIVO 3 ST

SYNALAR 3 ST; QL

SYNALAR

CREAM KIT

3 ST

SYNALAR

OINTMENT KIT

3 ST

SYNALAR TS 3 ST

TEMOVATE 3 ST



52

Drug Name Drug

Category

Requirements

/ Limits

TEXACORT 3 ST

TOPICORT

TOPICAL CREAM

3 ST; QL

TOPICORT

TOPICAL GEL

3 ST; QL

TOPICORT

TOPICAL

OINTMENT

3 ST; QL

TOPICORT

TOPICAL

SPRAY,NON-

AEROSOL

3 ST

triamcinolone

acetonide

1

trianex 1

triderm 1

TRIDESILON 3 ST; QL

ULTRAVATE

TOPICAL CREAM

3 ST; QL

ULTRAVATE

TOPICAL LOTION

3 ST

ULTRAVATE

TOPICAL

OINTMENT

3 ST; QL

ULTRAVATE X 3 ST

VANOS 3 ST

VERDESO 3 ST

TOPICAL ENZYMES

SANTYL 2

TOPICAL SCABICIDES /

PEDICULICIDES

ELIMITE 3

EURAX 3

lindane 1

malathion 1

Drug Name Drug

Category

Requirements

/ Limits

NATROBA 3 QL

OVIDE 3

permethrin 1

SKLICE 3

spinosad 1 QL

ULESFIA 3

DIAGNOSTICS &

MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers 1

PHYSIOLYTE 3

PHYSIOSOL

IRRIGATION

3

ringer's 1

SORBITOL-

MANNITOL

3

tis-u-sol pentalyte 1

VASHE WOUND

THERAPY

6 MSD


acamprosate 1

ACTONEL 3 ST; QL

ADAGEN 6 MSD

AGRYLIN 3 M

alendronate 1 M; QL

AMMONUL 6 MSD

AMPHADASE 6 MSD

anagrelide 1 M

ANTABUSE 3

ARALAST NP 6 MSD

BUPHENYL 3

caffeine citrate 1



53

Drug Name Drug

Category

Requirements

/ Limits

CARBAGLU 3 PA; S; SLA

CARNITOR 3 M

CARNITOR

(SUGAR-FREE)

3 M

cevimeline 1 M

disulfiram 1

ENDARI 3 SLA

etidronate disodium 1 M

EVOXAC 3 M

FERRLECIT 6 MSD

GLASSIA 6 MSD

ic green 6 MSD

INCRELEX 3 PA; S; SLA

indocyanine green 6 MSD

INFASURF 6

KIT FOR TC 99M-

SESTAMIBI NO.1

6 MSD

KIT PREP OF TC-

99M-

MEBROFENIN

6 MSD

KIT PREP OF TC-

99M-SOD PYROPH

6 MSD

levocarnitine 1 M

levocarnitine (with

sugar)

1 M

LIPOCHOL PLUS 3

LITHOSTAT 3

METOPIRONE 3 SLA

midodrine 1

NITYR 2 SLA

NORTHERA 4 PA; S; SLA

NUTRESTORE 3

ORFADIN 2 SLA

Drug Name Drug

Category

Requirements

/ Limits

pilocarpine hcl 1

PROLASTIN-C 6 MSD

RAVICTI 3 S; SLA

RECLAST 6 MSD

RILUTEK 3

riluzole 1

risedronate 1 QL

SALAGEN

(PILOCARPINE)

3

sodium benzoate-sod

phenylacet

6 MSD

sodium chlor 0.9%

bacteriostat

6 MSD

sodium chloride 0.9

%

6 MSD

sodium ferric

gluconat-sucrose

6 MSD

sodium

phenylbutyrate

1

SOLIRIS 6 MSD

SURVANTA 6 MSD

THALLOUS

CHLORIDE TL-201

6

THIOLA 3 SLA

water for irrigation,

sterile

1

XURIDEN 2 SLA

ZEMAIRA 6 MSD

zoledronic acid-

mannitol-water

6 MSD

SMOKING DETERRENTS

bupropion hcl

(smoking deter)

5 M; ACA

CHANTIX 5 ACA



54

Drug Name Drug

Category

Requirements

/ Limits

CHANTIX

CONTINUING

MONTH BOX

5 ACA

CHANTIX

STARTING

MONTH BOX

5 ACA

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

14 MG/24 HR, 7

MG/24 HR

5 ACA; OTC

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

21 MG/24 HR

5 M; ACA; OTC

nicorelief 5 ACA; OTC

NICORETTE

BUCCAL GUM 2

MG

5 ACA; OTC

nicorette buccal gum

4 mg

5 ACA; OTC

NICORETTE

BUCCAL

LOZENGE

5 ACA; OTC

NICORETTE

BUCCAL MINI

LOZENGE

5 ACA; OTC

nicotine (polacrilex) 5 ACA; OTC

nicotine transdermal

patch 24 hour 14

mg/24 hr, 7 mg/24

hr

5 ACA; OTC


patch 24 hour 21

mg/24 hr

5 M; ACA; OTC


patch, td daily,

sequential

5 ACA; OTC

NICOTROL 5 ACA

Drug Name Drug

Category

Requirements

/ Limits

NICOTROL NS 5 ACA

quit 2 buccal gum 5 ACA; OTC

QUIT 2 BUCCAL

LOZENGE

5 ACA; OTC

quit 4 buccal gum 5 ACA; OTC

QUIT 4 BUCCAL

LOZENGE

5 ACA; OTC

stop smoking aid 5 ACA; OTC

ZYBAN 5 M; ACA

EAR, NOSE & THROAT

MEDICATIONS


ARESTIN 6 MSD

ASTEPRO 3

azelastine nasal

aerosol,spray

1 QL

azelastine nasal

spray,non-aerosol

1

BACTROBAN

NASAL

3

chlorhexidine

gluconate

1

CLINPRO 5000 3 M

DEBACTEROL 3

denta 5000 plus 1 M

dentagel 1 M

EPISIL 3

FLUORIDEX

DAILY DEFENSE

3 M

GELCLAIR 3

ipratropium bromide 1 QL

MUGARD 3

olopatadine 1 QL



55

Drug Name Drug

Category

Requirements

/ Limits

oralone 1

ORAMAGICRX 3

paroex oral rinse 1

PATANASE 3 QL

PERIDEX 3

periogard 1

pilocarpine hcl 1

PREVIDENT 3 M

PREVIDENT 5000

BOOSTER PLUS

3 M

PREVIDENT 5000

DRY MOUTH

3 M

PREVIDENT 5000

ENAMEL

PROTECT

3 M

PREVIDENT 5000

PLUS

3 M

PREVIDENT 5000

SENSITIVE

3 M

Q-CARE RX Q4 3

SALAGEN

(PILOCARPINE)

3

sf 1 M

sf 5000 plus 1 M

triamcinolone

acetonide

1

TYZINE 3

MISCELLANEOUS OTIC

PREPARATIONS

acetic acid 1

CETRAXAL 3 ST

ciprofloxacin hcl 1

DERMOTIC OIL 3

Drug Name Drug

Category

Requirements

/ Limits

fluocinolone

acetonide oil

1

hydrocortisone-

acetic acid

1

ofloxacin 1

OTIPRIO 3

OTIC STEROID / ANTIBIOTIC

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

neomycin-

polymyxin-hc

1

OTOVEL 2

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. 6 MSD

betamethasone

acet,sod phos

6 MSD

BETAMETHASON

E SOD PHOSPH-

WATER

6 MSD

CELESTONE

SOLUSPAN

6 MSD

CORTEF 3 M

cortisone 1

CORTROSYN 6 MSD

cosyntropin 6 MSD

decadron 1

deltasone 1

dexamethasone 1

DEXAMETHASON

E ACE-NACL,ISO-

OSM

3



56

Drug Name Drug

Category

Requirements

/ Limits

dexamethasone

intensol

1

dexamethasone

sodium phos (pf)

6 MSD

dexamethasone

sodium phosphate

6 MSD

DEXPAK 10 DAY 3 ST

DEXPAK 13 DAY 3 ST

DEXPAK 6 DAY 3 ST

EMFLAZA 3 PA; ST; SLA

fludrocortisone 1 M

hydrocortisone 1 M

KENALOG 6 MSD

MEDROL 3

MEDROL (PAK) 3

methylprednisolone 1

millipred 1

millipred dp 1

ORAPRED ODT 3

P-CARE K40 6 MSD

P-CARE K80 6 MSD

POD-CARE 100K 6 MSD

prednisolone 1

prednisolone sodium

phosphate

1

prednisone 1

prednisone intensol 1

PRO-C-DURE 5 6 MSD

PRO-C-DURE 6 6 MSD

RAYOS 3 ST

READYSHARP

DEXAMETHASON

E

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

READYSHARP

TRIAMCINOLONE

6 MSD

TAPERDEX 3 ST

triamcinolone

acetonide

6 MSD

veripred 20 1

ANTITHYROID AGENTS

methimazole 1 M

propylthiouracil 1 M

SSKI 3 M

TAPAZOLE 3 M

BLOOD GLUCOSE MONITORING

DEVICES & SUPPLIES

ACCU-CHEK

AVIVA PLUS

TEST STRP

3 ST; OTC

ACCU-CHEK

COMPACT PLUS

TEST

3 ST; OTC

ACCU-CHEK

GUIDE

3 ST; OTC

ACCU-CHEK

SMARTVIEW

TEST STRIP

3 ST; OTC

ACCUTREND

GLUCOSE

3 ST; OTC

ADVANCED

GLUC METER

TEST STRIP

3 ST; OTC

ADVOCATE REDI-

CODE

3 ST; OTC

ADVOCATE TEST

STRIPS

3 ST; OTC

AGAMATRIX

AMP TEST STRIPS

3 ST; OTC

ASSURE 4 STRIPS 3 ST; OTC



57

Drug Name Drug

Category

Requirements

/ Limits

ASSURE

PLATINUM

3 ST; OTC

ASSURE PRISM

MULTI STRIP

3 ST; OTC

BIONIME

RIGHTEST TEST

STRIPS

3 ST; OTC

BLOOD GLUCOSE

TEST

3 ST; OTC

BREEZE 2 TEST

STRIPS

3 ST; OTC

CARESENS N

TEST STRIPS

3 ST; OTC

CARETOUCH

TEST STRIP

3 ST; OTC

CLEVER CHOICE

MICRO TEST

STRIP

3 ST; OTC

CLEVER CHOICE

PRO

3 ST; OTC

CLEVER CHOICE

TALK TEST

3 ST; OTC

CLEVER CHOICE

TEST STRIPS

3 ST; OTC

CLEVER CHOICE

VOICE+ TEST

3 ST; OTC

CONTOUR NEXT

TEST STRIPS

3 ST; OTC

CONTOUR TEST

STRIPS

3 ST; OTC

COOL GLUCOSE

TEST STRIP

3 ST; OTC

DIATRUE PLUS

TEST STRIP

3 ST; OTC

EASY PLUS II

TEST

3 ST; OTC

EASY STEP 3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

EASY TALK

GLUCOSE TEST

3 ST; OTC

EASY TOUCH

TEST STRIP

3 ST; OTC

EASY TRAK

GLUCOSE TEST

3 ST; OTC

EASYGLUCO

PLUS

3 ST; OTC

EASYGLUCO

TEST

3 ST; OTC

EASYMAX 3 ST; OTC

ELEMENT

COMPACT TEST

STRIPS

3 ST; OTC

ELEMENT TEST

STRIPS

3 ST; OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

EMBRACE EVO

TEST STRIPS

3 ST; OTC

EMBRACE PRO

TEST STRIPS

3 ST; OTC

EVENCARE G2 3 ST; OTC

EVENCARE G3

TEST

3 ST; OTC

EVENCARE MINI

GLUCOSE TEST

STR

3 ST; OTC

EVOLUTION TEST

STRIPS

3 ST; OTC

EZ SMART PLUS

TEST

3 ST; OTC

EZ SMART TEST 3 ST; OTC

FIFTY50 TEST

STRIP

3 ST; OTC

FORA D15G 3 ST; OTC



58

Drug Name Drug

Category

Requirements

/ Limits

FORA D20 3 ST; OTC

FORA D40-G31

TEST STRIPS

3 ST; OTC

FORA G20 3 ST; OTC

FORA G30-

PREMIUM V10

TEST STRP

3 ST; OTC

FORA GD50 TEST

STRIPS

3 ST; OTC

FORA TEST STRIP 3 ST; OTC

FORA TN'G VOICE

TEST STRIPS

3 ST; OTC

FORA V10 3 ST; OTC

FORA V10-V12-

D10-D20 STRIPS

3 ST; OTC

FORA V12

GLUCOSE

3 ST; OTC

FORA V20 3 ST; OTC

FORACARE GD20 3 ST; OTC

FORACARE GD40 3 ST; OTC

FORTISCARE

GLUCOSE TEST

STRIPS

3 ST; OTC

FREESTYLE

INSULINX

3 ST; OTC

FREESTYLE

INSULINX TEST

STRIPS

3 ST; OTC

FREESTYLE LITE

STRIPS

3 ST; OTC

FREESTYLE

PRECISION NEO

STRIPS

3 ST; OTC

FREESTYLE TEST 3 ST; OTC

GE100 BLOOD

GLUCOSE TEST

STRIP

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

GENSTRIP TEST

STRIP

3 ST; OTC

GLUCO NAVII

TEST STRIP

3 ST; OTC

GLUCOCARD 01

SENSOR PLUS

3 ST; OTC

GLUCOCARD

EXPRESSION

3 ST; OTC

GLUCOCARD

SHINE TEST

STRIPS

3 ST; OTC

GLUCOCARD

VITAL SENSOR

3 ST; OTC

GLUCOCARD

VITAL TEST

STRIPS

3 ST; OTC

GLUCOCOM

GLUCOSE

3 ST; OTC

GM100 3 ST; OTC

HEALTHPRO

TEST STRIPS

3 ST; OTC

IGLUCOSE TEST

STRIP

3 ST; OTC

INFINITY TEST

STRIPS

3 ST; OTC

INFINITY VOICE

TEST STRIP

3 ST; OTC

MICRO BLOOD

GLUCOSE

3 ST; OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

MYGLUCOHEALT

H

3 ST; OTC

NEUTEK 2TEK

TEST STRIPS

3 ST; OTC

NOVA MAX

GLUCOSE TEST

3 ST; OTC



59

Drug Name Drug

Category

Requirements

/ Limits

ON CALL

EXPRESS TEST

STRIP

3 ST; OTC

ON CALL PLUS

TEST STRIP

3 ST; OTC

ON CALL VIVID

TEST STRIP

3 ST; OTC

ONETOUCH

ULTRA BLUE

TEST STRIP

2 ST; OTC

ONETOUCH

VERIO

2 ST; OTC

OPTIUM EZ 3 ST; OTC

OPTIUM TEST 3 ST; OTC

OPTUMRX 3 ST; OTC

PHARMACIST

CHOICE

3 ST; OTC

PRECISION PCX

PLUS TEST

3 ST; OTC

PRECISION PCX

TEST

3 ST; OTC

PRECISION POINT

OF CARE TEST

3 ST; OTC

PRECISION Q-I-D

TEST

3 ST; OTC

PRECISION XTRA

TEST

3 ST; OTC

PREMIER TEST

STRIP

3 ST; OTC

PREMIUM V10 3 ST; OTC

PRODIGY NO

CODING

3 ST; OTC

QUINTET AC 3 ST; OTC

REFUAH PLUS 3 ST; OTC

RELION

CONFIRM-MICRO

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

RELION PRIME

TEST STRIPS

3 ST; OTC

REVEAL TEST

STRIP

3 ST; OTC

RIGHTEST GS550

TEST STRIPS

3 ST; OTC

SMART SENSE

TEST STRIPS

3 ST; OTC

SMARTEST TEST 3 ST; OTC

SOLUS V2 TEST

STRIPS

3 ST; OTC

SURE-TEST

EASYPLUS MINI

3 ST; OTC

TELCARE TEST

STRIPS

3 ST; OTC

TEST N'GO TEST 3 ST; OTC

TRUE METRIX

GLUCOSE TEST

STRIP

3 ST; OTC

TRUETEST TEST

STRIPS

3 ST; OTC

TRUETRACK

TEST

3 ST; OTC

ULTIMA TEST

STRIPS

3 ST; OTC

ULTRATRAK 3 ST; OTC

ULTRATRAK

ULTIMATE

3 ST; OTC

UNISTRIP1 TEST

STRIP

3 ST; OTC

VERASENS TEST

STRIP

3 ST; OTC

WAVESENSE

JAZZ

3 ST; OTC

WAVESENSE

PRESTO

3 ST; OTC



60

Drug Name Drug

Category

Requirements

/ Limits

DIABETES, SUPPLIES, & DURABLE

MEDICAL EQUIPMENT

GLUCAGEN

DIAGNOSTIC KIT

2

GLUCAGON HCL 3

INSULIN

SYRINGE-

NEEDLE U-100

2 M

GLUCOSE ELEVATING AGENTS

GLUCAGEN

HYPOKIT

2

GLUCAGON

EMERGENCY KIT

(HUMAN)

2

PROGLYCEM 2 M

INSULIN

SYRINGES/MISCELLANEOUS

DURABLE MEDICAL EQU

2TEK

GLUCOSE/BLOOD

PRESSURE

3 OTC

ACCU-CHEK

AVIVA PLUS

METER

3 ST; OTC

ACCU-CHEK

COMPACT PLUS

CONTROL

3 OTC

ACCU-CHEK

GUIDE GLUCOSE

METER

3 ST; OTC

ACCU-CHEK

GUIDE L1-L2

CTRL SOL

3 OTC

ACCU-CHEK

NANO

3 ST; OTC

ACCU-CHEK

SMARTVIEW

CONTRL SOL

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

ACCUTREND

GLUCOSE

CONTROL

3 OTC

ADVANCED

GLUCOSE METER

3 ST; OTC

ADVOCATE

BLOOD GLUCOSE

MONITOR

3 ST; OTC

ADVOCATE DUO 3 ST; OTC

ADVOCATE LOW

CONTROL

3 OTC

ADVOCATE REDI-

CODE DUO

METER

3 ST; OTC

ADVOCATE REDI-

CODE GLU

MONITOR

3 ST; OTC

ADVOCATE REDI-

CODE+ CTRL

LOW

3 OTC

AGAMATRIX

AMP GLUC

MONITOR SYS

3 ST; OTC

AGAMATRIX

CONTROL HIGH

3 OTC

ASSURE 4

CONTROL

SOLUTION

3 OTC

ASSURE DOSE

NORMAL

CONTROL

3 OTC

ASSURE

PLATINUM

3 ST; OTC

ASSURE PRISM

CONTROL 1-2

SOLN

3 OTC

ASSURE PRISM

MULTI METER

3 ST; OTC



61

Drug Name Drug

Category

Requirements

/ Limits

AUTOJECT 2

INJECTION

DEVICE

2 OTC

AUTOPEN 1 TO 21

UNITS

2 OTC

AUTOSOFT 30 6 MSD

AUTOSOFT 90 6 MSD

BIONIME

RIGHTEST GM300

SYSTEM

3 ST; OTC

BLOOD GLUCOSE

CONTROL,

NORMAL

3 OTC

BLOOD-GLUCOSE

METER

3 ST; OTC

BREEZE 2

CONTROL

SOLUTION,HIGH

3 OTC

CARESENS

CONTROL A

NORMAL

3 OTC

CARESENS N 3 ST; OTC

CARESENS N

VOICE

3 ST; OTC

CARETOUCH

GLUCOSE

MONITORING

3 ST; OTC

CLEVER CHEK

BLOOD GLUCOSE

3 ST; OTC

CLEVER CHOICE

GLUCOSE

MONITOR

3 ST; OTC

CLEVER CHOICE

LEVEL 2

CONTROL

3 OTC

CLEVER CHOICE

MICRO

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

CLEVER CHOICE

PRO

3 ST; OTC

CLEVER CHOICE

TALK GLUCOSE

SYS

3 ST; OTC

CONTOUR

CONTROL

SOLUTION, NML

3 OTC

CONTOUR LINK 3 ST; OTC

CONTOUR NEXT

EZ METER

3 ST; OTC

CONTOUR NEXT

LEV 2 CONTROL

SOL

3 OTC

CONTOUR NEXT

LINK

3 OTC

CONTOUR NEXT

LINK 2.4

3 OTC

CONTOUR NEXT

METER

3 ST; OTC

CONTOUR NEXT

ONE METER

3 ST; OTC

COOL BLOOD

GLUCOSE METER

3 ST; OTC

COOL CONTROL

A SOLUTION

3 OTC

DEXCOM G6

RECEIVER

6 MSD

DIATRUE

CONTROL SOLN

NORMAL

3 OTC

DIATRUE PLUS

BLOOD GLUCOSE

MET

3 ST; OTC

EASY PLUS II

BLOOD GLUCOSE

MET

3 ST; OTC



62

Drug Name Drug

Category

Requirements

/ Limits

EASY STEP

BLOOD GLUCOSE

METER

3 ST; OTC

EASY TALK

BLOOD GLUCOSE

METER

3 ST; OTC

EASY TOUCH

GLUCOSE

MONITOR

3 ST; OTC

EASY TRAK LOW

CONTROL

3 OTC

EASYGLUCO

MONITORING

SYSTEM

3 ST; OTC

EASYGLUCO

PLUS NORMAL

CONTROL

3 OTC

EASYMAX L

BLOOD GLUCOSE

METER

3 ST; OTC

EASYMAX LOW

CONTROL

3 OTC

EASYMAX NG 3 ST; OTC

EASYMAX

NORMAL

CONTROL

3 OTC

EASYMAX V

SPEAKING

GLUCOSE SYS

3 ST; OTC

EASYMAX V2

BLOOD GLUCOSE

METER

3 ST; OTC

ELEMENT

COMPACT

GLUCOSE METER

3 ST; OTC

ELEMENT

COMPACT

NORMAL

CONTROL

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

ELEMENT

COMPACT V

GLUCOSE MTR

3 ST; OTC

ELEMENT

NORMAL

CONTROL

3 OTC

ELEMENT PLUS

BLOOD GLUCOSE

KIT

3 ST; OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

EMBRACE EVO

LEVEL 1

3 OTC

EMBRACE

GLUCOSE

CONTROL LOW

3 OTC

EMBRACE PRO

GLUCOSE METER

3 ST; OTC

EVENCARE G2 3 ST; OTC

EVENCARE G3

GLUCOSE METER

3 ST; OTC

EVENCARE MINI

MONITOR

SYSTEM

3 ST; OTC

EVOLUTION

BLOOD GLUCOSE

METER

3 ST; OTC

EVOLUTION

NORMAL

CONTROL

3 OTC

EZ SMART PLUS

SYSTEM

3 ST; OTC

EZ SMART

SYSTEM

3 ST; OTC

FORA D10 3 OTC

FORA D20 3 ST; OTC

FORA G20 3 ST; OTC



63

Drug Name Drug

Category

Requirements

/ Limits

FORA G30A 3 ST; OTC

FORA GD50

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

FORA NORMAL

CONTROL

3 OTC

FORA PREMIUM

V10 GLUCOSE

METER

3 ST; OTC

FORA TEST N'GO

VOICE METER

3 ST; OTC

FORA TN'G VOICE

METER

3 ST; OTC

FORA V10 3 ST; OTC

FORA V12 BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

FORA V20 3 ST; OTC

FORA V30A 3 ST; OTC

FORACARE GD20

GLUCOSE METER

3 ST; OTC

FORACARE

GD40A GLUCOSE

METER

3 ST; OTC

FORACARE

GD40B GLUCOSE

METER

3 ST; OTC

FORACARE GDH

LOW CONTROL

3 OTC

FORTISCARE

BLOOD GLUCOSE

SYST

3 ST; OTC

FORTISCARE

NORMAL

3 OTC

FREESTYLE

CONTROL

3 OTC

FREESTYLE

FLASH SYSTEM

3 ST; OTC

Drug Name Drug

Category

Requirements

/ Limits

FREESTYLE

FREEDOM

3 ST; OTC

FREESTYLE

FREEDOM LITE

3 ST; OTC

FREESTYLE

INSULINX

3 ST; OTC

FREESTYLE

LIBRE READER

6

FREESTYLE

LIBRE SENSOR

6 MSD

FREESTYLE LITE

METER

3 ST; OTC

FREESTYLE

PRECISION NEO

METER

3 ST; OTC

FREESTYLE

SIDEKICK II

3 ST; OTC

FREESTYLE

SYSTEM KIT

3 ST; OTC

GE100 BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

GE100 CONTROL

SOLUTION

NORMAL

3 OTC

GLUCO NAVII

GLUCOSE

MONITOR

3 ST; OTC

GLUCOCARD 01

METER

3 ST; OTC

GLUCOCARD 01

NORMAL

CONTROL

3 OTC

GLUCOCARD

EXPRESSION

3 ST; OTC

GLUCOCARD

SHINE METER

3 ST; OTC



64

Drug Name Drug

Category

Requirements

/ Limits

GLUCOCARD

SHINE XL METER

3 ST; OTC

GLUCOCARD

VITAL

3 ST; OTC

GLUCOCOM

BLOOD GLUCOSE

3 ST; OTC

GLUCOCOM

CONTROL

NORMAL

3 OTC

GLUCOSE

CONTROL

3 OTC

GM100 3 ST; OTC

HEALTHPRO

GLUCOSE

MONITOR

3 ST; OTC

HEALTHPRO

HIGH-LOW

CONTROL

3 OTC

HUMAPEN

LUXURA HD

2

IGLUCOSE

BLOOD GLUCOSE

MONITOR

3 ST; OTC

INFINITY

CONTROL

SOLUTION NORM

3 OTC

INFINITY

STARTER KIT

3 ST; OTC

INFINITY VOICE

CTRL SOLN-LVL 2

3 OTC

INFINITY VOICE

GLUCOSE

MONITOR

3 ST; OTC

JAZZ WIRELESS 2

METER KIT

3 ST; OTC

LANCETS 2 OTC

LANCING DEVICE 2 OTC

MEDISENSE 3 OTC

Drug Name Drug

Category

Requirements

/ Limits

MEDISENSE

GLUCOSE

KETONE

3 OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

MYGLUCOHEALT

H

3 ST; OTC

MYGLUCOHEALT

H CONTROL

SOLUTION

3 OTC

NOVA MAX

BLOOD GLUCOSE

METER

3 ST; OTC

NOVA MAX

GLUCOSE

CONTROL

3 OTC

NOVAMAX PLUS

GLU-KET

3 OTC

NOVOPEN ECHO 3

ON CALL

EXPRESS

CONTROL

3 OTC

ON CALL

EXPRESS METER

3 ST; OTC

ON CALL PLUS

CONTROL

3 OTC

ON CALL PLUS

METER

3 ST; OTC

ON CALL VIVID

CONTROL

3 OTC

ON CALL VIVID

METER

3 ST; OTC

ON CALL VIVID

PAL METER

3 ST; OTC

ONETOUCH

ULTRA CONTROL

2 OTC



65

Drug Name Drug

Category

Requirements

/ Limits

ONETOUCH

ULTRA2

2 ST; OTC

ONETOUCH

ULTRAMINI

2 ST; OTC

ONETOUCH

VERIO FLEX

2 ST; OTC

ONETOUCH

VERIO IQ METER

2 ST; OTC

ONETOUCH

VERIO SYSTEM

2 ST; OTC

OPTUMRX 3 ST; OTC

PEN NEEDLE 2 M; OTC

PHARMACIST

CHOICE

GLUCOSE SYS

3 ST; OTC

PRECISION XTRA

MONITOR

2 ST; OTC

PREMIER BLU

GLUCOSE METER

3 ST; OTC

PREMIER VOICE

GLUCOSE METER

3 ST; OTC

PREMIUM BLOOD

GLUCOSE

MONITOR

3 ST; OTC

PREMIUM V10 3 ST; OTC

PRESTO PRO

BLOOD GLUCOSE

METER

3 ST; OTC

PRODIGY

AUTOCODE

METER

3 ST; OTC

PRODIGY

AUTOCODE

MONITOR SYST

3 ST; OTC

PRODIGY

CONTROL

SOLUTION, LOW

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

PRODIGY

CONTROL

SOLUTION,HIGH

3 OTC

PRODIGY

POCKET METER

3 ST; OTC

PRODIGY VOICE

GLUCOSE METER

3 ST; OTC

QUINTET BLOOD

GLUCOSE METER

3 ST; OTC

REFUAH PLUS

GLUCOSE

CONTROL

3 OTC

REFUAH PLUS

GLUCOSE

MONITOR

3 ST; OTC

RELION ALL-IN-

ONE METER

3 ST; OTC

RELION CONFIRM 3 ST; OTC

RELION MICRO

GLUCOSE

MONITOR

3 ST; OTC

RELION PRIME

METER

3 ST; OTC

REVEAL BLOOD

GLUCOSE METER

3 ST; OTC

RIGHTEST

CONTROL

SOLUTION HIGH

3 OTC

RIGHTEST GM550

SYSTEM

3 ST; OTC

SIDEKICK BLOOD

GLUCOSE

SYSTEM

3 OTC

SMART SENSE

MONITORING

SYSTEM

3 ST; OTC

SMARTEST

CONTROL

3 OTC



66

Drug Name Drug

Category

Requirements

/ Limits

SMARTEST EJECT 3 ST; OTC

SMARTEST

PERSONA

STARTER

3 ST; OTC

SMARTEST

PRONTO

STARTER

3 ST; OTC

SMARTEST

PROTEGE

3 ST; OTC

SNAP INSULIN

PUMP

CONTROLLER

2

SOLUS V2

AUDIBLE METER

3 ST; OTC

SOLUS V2

CONTROL

SOLUTION,HIGH

3 OTC

SURE-TEST

EASYPLUS MINI

METER

3 ST; OTC

TELCARE BGM 3 ST; OTC

TELCARE BLOOD

GLUCOSE KIT

3 ST; OTC

TELCARE

CONTROL

3 OTC

TEST N'GO

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

TRUE METRIX

AIR GLUCOSE

METER

3 ST; OTC

TRUE METRIX

GLUCOSE METER

3 ST; OTC

TRUE METRIX GO

GLUCOSE METER

3 ST; OTC

TRUE METRIX

LEVEL 1

3 OTC

Drug Name Drug

Category

Requirements

/ Limits

TRUE2GO BLOOD

GLUCOSE

SYSTEM

3 ST; OTC

TRUECONTROL

LEVEL 0

3 OTC

TRUERESULT

BLOOD GLUCOSE

SYSTM

3 ST; OTC

TRUETRACK

BLOOD GLUCOSE

SYSTEM

3 ST; OTC

TRUETRACK

SMART SYSTEM

3 ST; OTC

TRUSTEEL

INFUSION SET 32"

6 MSD

ULTIMA

MONITOR

3 ST; OTC

ULTRATRAK

GLUCOSE METER

3 ST; OTC

ULTRATRAK

ULTIMATE

3 ST; OTC

UNISTRIP LOW

CONTROL

3 OTC

VARISOFT

INFUSION SET 43"

6 MSD

VERASENS

BLOOD GLUCOSE

METER

3 ST; OTC

VGO 20 6 MSD

VGO 30 6 MSD

VGO 40 6 MSD

WAVESENSE AMP 3 ST; OTC

WAVESENSE

CONTROL

SOLUTION

3 OTC

WAVESENSE

PRESTO

3 ST; OTC



67

Drug Name Drug

Category

Requirements

/ Limits

INSULIN THERAPY

ADMELOG

SOLOSTAR U-100

INSULIN

3 M

ADMELOG U-100

INSULIN LISPRO

3 M

AFREZZA

INHALATION

CARTRIDGE

WITH INHALER 12

UNIT, 4 UNIT (90)/

8 UNIT (90), 4

UNIT/8 UNIT/ 12

UNIT (60), 8 UNIT

3 M

AFREZZA

INHALATION

CARTRIDGE

WITH INHALER 4

UNIT, 4 UNIT (60)/

8 UNIT (30)

3 M; QL

APIDRA

SOLOSTAR U-100

INSULIN

3 ST; M

APIDRA U-100

INSULIN

3 ST; M

BASAGLAR

KWIKPEN U-100

INSULIN

3 M

FIASP

FLEXTOUCH U-

100 INSULIN

3 ST; M

FIASP U-100

INSULIN

3 ST; M

HUMALOG

JUNIOR KWIKPEN

U-100

2 M

HUMALOG

KWIKPEN

INSULIN

2 M

Drug Name Drug

Category

Requirements

/ Limits

HUMALOG MIX

50-50 INSULN U-

100

2 M

HUMALOG MIX

50-50 KWIKPEN

2 M

HUMALOG MIX

75-25 KWIKPEN

2 M

HUMALOG MIX

75-25(U-

100)INSULN

2 M

HUMALOG U-100

INSULIN

2 M

HUMULIN 70/30

U-100 INSULIN

2 M; QL

HUMULIN 70/30

U-100 KWIKPEN

2 M; QL

HUMULIN N NPH

INSULIN

KWIKPEN

2 M

HUMULIN N NPH

U-100 INSULIN

2 M; QL

HUMULIN R

REGULAR U-100

INSULN

2 M; QL

HUMULIN R U-500

(CONC) INSULIN

2 M; QL

HUMULIN R U-500

(CONC) KWIKPEN

2 M

LANTUS

SOLOSTAR U-100

INSULIN

2 M

LANTUS U-100

INSULIN

2 M

LEVEMIR

FLEXTOUCH U-

100 INSULN

2 M

LEVEMIR U-100

INSULIN

2 M



68

Drug Name Drug

Category

Requirements

/ Limits

NOVOLOG

FLEXPEN U-100

INSULIN

3 ST; M

NOVOLOG MIX

70-30 U-100

INSULN

3 ST; M

NOVOLOG MIX

70-30FLEXPEN U-

100

3 ST; M

NOVOLOG

PENFILL U-100

INSULIN

3 ST; M

NOVOLOG U-100

INSULIN ASPART

3 ST; M

RELION NOVOLIN

70/30

3 ST; M; QL

RELION NOVOLIN

N

3 ST; M; QL

RELION NOVOLIN

R

3 ST; M; QL

SOLIQUA 100/33 2 ST; M

TOUJEO MAX

SOLOSTAR

2 M

TOUJEO

SOLOSTAR U-300

INSULIN

2 M

TRESIBA

FLEXTOUCH U-

100

2 M

TRESIBA

FLEXTOUCH U-

200

2 M

XULTOPHY

100/3.6

2 ST; M

MISCELLANEOUS HORMONES

ALDURAZYME 6 MSD

ANADROL-50 3

ANDRODERM 2 PA

Drug Name Drug

Category

Requirements

/ Limits

ANDROGEL

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP

2 PA

ANDROGEL

TRANSDERMAL

GEL IN PACKET 1

% (25

MG/2.5GRAM), 1

% (50 MG/5

GRAM)

3 PA; ST

ANDROGEL

TRANSDERMAL

GEL IN PACKET

1.62 % (20.25

MG/1.25 GRAM),

1.62 % (40.5

MG/2.5 GRAM)

2 PA

ANDROID 3 ST

AVEED 6 MSD

AXIRON 3 PA

BRAVELLE 7 ST

BRINEURA 6 MSD

cabergoline 1 M; QL

calcitonin (salmon) 1 M

calcitriol 1 M

CERDELGA 3 S; SLA

CEREZYME 6 MSD

CETROTIDE 7

CHORIONIC

GONADOTROPIN,

HUMAN

7

clomiphene citrate 7

CRYSVITA 2

danazol 1

DDAVP 3 M



69

Drug Name Drug

Category

Requirements

/ Limits

DEPO-

TESTOSTERONE

3 PA

desmopressin 1 M

doxercalciferol

intravenous

6 MSD

doxercalciferol oral 1 M

ELAPRASE 6 MSD

ELELYSO 6 MSD

FABRAZYME 6 MSD

FOLLISTIM AQ 7 ST

FORTESTA 3 ST

GANIRELIX 7 ST; S

GONAL-F 7

GONAL-F RFF 7

GONAL-F RFF

REDI-JECT

7

HECTOROL 6 MSD

JYNARQUE 4 PA; S

KANUMA 6 MSD

KORLYM 3 PA; SLA

KUVAN 3 PA; S; SLA

LUMIZYME 6 MSD

MENOPUR 7

MEPSEVII 6 MSD

METHITEST 2

methyltestosterone 1

MIACALCIN 6 MSD

miglustat 1 S

MYALEPT 3 PA; S; SLA

NAGLAZYME 6 MSD

NATESTO 3 ST

NATPARA 3 PA; S; SLA

Drug Name Drug

Category

Requirements

/ Limits

NOCTIVA 3 M

NOVAREL 7

OVIDREL 7

OXANDRIN 3

oxandrolone 1

PALYNZIQ 3 PA

pamidronate 6 MSD

PARICALCITOL

HEMODIALYSIS

PORT INJECTION

6 MSD

paricalcitol

intravenous

6 MSD

paricalcitol oral 1 M

PREGNYL 7

RAYALDEE 3 M

ROCALTROL 3 M

SAMSCA 3 PA; S; QL

SENSIPAR 2 PA

serophene 7

SOMAVERT 3 S; SLA

STIMATE 2

STRENSIQ 2 SLA

STRIANT 3 PA

SYNAREL 2

TESTIM 3 ST

testosterone

cypionate

1 PA

testosterone

enanthate

1 PA

testosterone

transdermal gel

1



70

Drug Name Drug

Category

Requirements

/ Limits

TESTOSTERONE

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP 10 MG/0.5

GRAM

/ACTUATION

3 ST

testosterone

transdermal gel in

metered-dose pump

12.5 mg/ 1.25 gram

(1 %)

1

testosterone

transdermal gel in

packet

1

testosterone

transdermal solution

in metered pump

w/app

1

TESTRED 3 ST

VASOPRESSIN IN

0.9 % NACL

INTRAVENOUS

SOLUTION 40

UNIT/100 ML(0.4

UNIT/ML)

6 MSD

vasopressin in 0.9

% nacl intravenous

solution 60 unit/100

ml (0.6 unit/ml)

6 MSD

VASOPRESSIN IN

DEXTROSE 5 %

6 MSD

VASOSTRICT 6 MSD

VIMIZIM 6 MSD

VOGELXO 3 ST

VPRIV 6 MSD

ZAVESCA 3 S

ZEMPLAR

INTRAVENOUS

6 MSD

Drug Name Drug

Category

Requirements

/ Limits

ZEMPLAR ORAL 3 M

zoledronic acid 6 MSD

ZOLEDRONIC AC-

MANNITOL-

0.9NACL

6 MSD

ZOMETA 6 MSD

NON-INSULIN HYPOGLYCEMIC

AGENTS

acarbose 1 M

ACTOPLUS MET 3 ST; M; QL

ACTOPLUS MET

XR

3 ST; M; QL

ACTOS 3 ST; M; QL

ADLYXIN 3 ST; M

ALOGLIPTIN 3 ST; M; QL

ALOGLIPTIN-

METFORMIN

3 ST; M; QL

ALOGLIPTIN-

PIOGLITAZONE

3 M; QL

AMARYL 3 M

AVANDIA 3 ST; M; QL

BYDUREON

BCISE

2 ST; M

BYDUREON

SUBCUTANEOUS

PEN INJECTOR

2 ST; M

BYDUREON

SUBCUTANEOUS

SUSPENSION,EXT

ENDED REL

RECON

2 ST; M; QL

BYETTA 2 ST; M; QL

chlorpropamide 1 M

CYCLOSET 3 M; QL

DM2 3 M



71

Drug Name Drug

Category

Requirements

/ Limits

DUETACT 3 ST; M; QL

FARXIGA 2 ST; M; QL

FORTAMET 3 ST; M

glimepiride 1 M

glipizide 1 M

glipizide-metformin 1 M

GLUCOPHAGE 3 ST; M

GLUCOPHAGE XR 3 ST; M

GLUCOTROL 3 M

GLUCOTROL XL 3 M

GLUCOVANCE 3 M

GLUMETZA 3 ST; M; QL

glyburide 1 M

glyburide

micronized

1 M

glyburide-metformin 1 M

GLYNASE 3 M

GLYSET 3 M

GLYXAMBI 2 M

INVOKAMET 2 ST; M; QL

INVOKAMET XR 2 ST; M; QL

INVOKANA 2 ST; M; QL

JANUMET 2 ST; M; QL

JANUMET XR 2 ST; M; QL

JANUVIA 2 ST; M; QL

JARDIANCE 2 ST; M; QL

JENTADUETO 2 ST; M; QL

JENTADUETO XR 2 ST; M

KAZANO 3 ST; M; QL

KOMBIGLYZE XR 3 ST; M; QL

metformin oral

tablet

1 M

Drug Name Drug

Category

Requirements

/ Limits

metformin oral

tablet extended

release 24 hr

1 M

metformin oral

tablet extended

release 24hr

1 ST; M

metformin oral

tablet,er

gast.retention 24 hr

1 M; QL

miglitol 1 M

nateglinide 1 M

NESINA 3 ST; M; QL

ONGLYZA 3 ST; M; QL

OSENI 3 M; QL

OZEMPIC 3 M

pioglitazone 1 M; QL

pioglitazone-

glimepiride

1 M; QL

pioglitazone-

metformin

1 M; QL

PRANDIN 3 M

PRECOSE 3 M

QTERN 3 M

repaglinide 1 M

repaglinide-

metformin

1 M; QL

RIOMET 3 ST; M; QL

SEGLUROMET 2 ST; M

STARLIX 3 M

STEGLATRO 2 ST; M

STEGLUJAN 3 M

SYMLINPEN 120 2 ST; M; QL

SYMLINPEN 60 2 ST; M; QL

SYNJARDY 2 ST; M



72

Drug Name Drug

Category

Requirements

/ Limits

SYNJARDY XR 2 ST; M

TANZEUM 3 ST; M; QL

tolazamide 1 M

tolbutamide 1 M

TRADJENTA 2 ST; QL

TRULICITY 2 ST; M; QL

VICTOZA 2-PAK 3 ST; M; QL

VICTOZA 3-PAK 3 ST; M; QL

XIGDUO XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 10-1,000 MG,

10-500 MG, 5-1,000

MG, 5-500 MG

2 ST; M; QL

XIGDUO XR

ORAL TABLET, IR

- ER, BIPHASIC

24HR 2.5-1,000 MG

2 ST; M

THYROID HORMONES

ARMOUR

THYROID

2 M

CYTOMEL 3 ST; M

LEVO-T 3 M

LEVOTHYROXINE

INTRAVENOUS

RECON SOLN 100

MCG

6 MSD

levothyroxine

intravenous recon

soln 200 mcg, 500

mcg

6 MSD

levothyroxine oral 1 M

levoxyl 1 M

liothyronine 1 M

nature-throid 1 M

np thyroid 1 M

Drug Name Drug

Category

Requirements

/ Limits

SYNTHROID 3 M

thyroid (pork) 1 M

THYROLAR-1 3 M

THYROLAR-1/2 3 M

THYROLAR-1/4 3 M

THYROLAR-2 3 M

THYROLAR-3 3 M

TIROSINT 3 M

unithroid 1 M

westhroid 1 M

WP THYROID 3 M

GASTROENTEROLOGY

ANTIDIARRHEALS &

ANTISPASMODICS

anaspaz 1

atropine 6 MSD

atropine in 0.9 %

sod chloride

intravenous syringe

0.8 mg/2 ml (0.4

mg/ml)

6 MSD

ATROPINE IN 0.9

% SOD CHLORIDE

INTRAVENOUS

SYRINGE 1 MG/2.5

ML (0.4 MG/ML), 2

MG/5 ML (0.4

MG/ML)

6 MSD

belladonna

alkaloids-opium

1

belladonna-opium 1

BENTYL 6 MSD

chlordiazepoxide-

clidinium

1

CUVPOSA 3



73

Drug Name Drug

Category

Requirements

/ Limits

dicyclomine

intramuscular

6 MSD

dicyclomine oral 1

diphenoxylate-

atropine

1

DONNATAL 3

ed-spaz 1

glycopyrrolate

injection

6 MSD

GLYCOPYRROLA

TE

INTRAVENOUS

6 MSD

glycopyrrolate oral 1

hyoscyamine sulfate 1

hyosyne 1

LEVBID 3

LEVSIN

INJECTION

6 MSD

LEVSIN ORAL 3

LEVSIN/SL 3

LIBRAX (WITH

CLIDINIUM)

3 ST

LOMOTIL 3

methscopolamine 1

MOTOFEN 3

MYTESI 3

NULEV 3

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenobarb-hyoscy-

atropine-scop

1

Drug Name Drug

Category

Requirements

/ Limits

phenohytro 1

propantheline 1

ROBINUL FORTE 3

ROBINUL

INJECTION

6 MSD

ROBINUL ORAL 3

SYMAX DUOTAB 3

symax fastabs 1

symax-sl 1

symax-sr 1

MISCELLANEOUS

GASTROINTESTINAL AGENTS

ACTIGALL 3 M

AKYNZEO

(FOSNETUPITANT

)

6 MSD

AKYNZEO

(NETUPITANT)

2 QL

alophen 5 ACA; OTC

alosetron 1

ALOXI 6 MSD

AMITIZA 2

ANALPRAM-HC 3

ANALPRAM-HC

SINGLES

3

anucort-hc 1

ANUSOL-HC 3 ST

ANZEMET 3 QL

aprepitant 1 QL

APRISO 2 M

ASACOL HD 3 ST; M

AURYXIA 3

AZULFIDINE 3 M



74

Drug Name Drug

Category

Requirements

/ Limits

AZULFIDINE EN-

TABS

3 M

balsalazide 1

bisacodyl 5 ACA; OTC

bisa-lax 5 ACA; OTC

BONJESTA 3

budesonide 1

calcium acetate 1

CANASA 2

CESAMET 3 QL

CHENODAL 2 PA; SLA

CHOLBAM 2 PA; SLA

CIMZIA 4 PA; ST; S;

SLA

CIMZIA POWDER

FOR RECONST

4 PA; ST; S;

SLA

CINVANTI 6 MSD

citrate of magnesia 5 ACA; OTC

citroma 5 ACA; OTC

clearlax 5 ACA; OTC

CLENPIQ 5 ACA

COLAZAL 3

colocort 1

COLYTE WITH

FLAVOR PACKS

3

COMPAZINE 3

compro 1

constulose 1

CORTENEMA 3

CORTIFOAM 2

CREON 2

cromolyn 1

CYSTADANE 2 SLA

Drug Name Drug

Category

Requirements

/ Limits

DELZICOL 3 ST; M

DICLEGIS 3

DIPENTUM 3 ST; M

dronabinol 1

ducodyl 5 ACA; OTC

eliphos 1

EMEND

(FOSAPREPITANT

)

6 MSD

EMEND ORAL

CAPSULE

3 QL

EMEND ORAL

CAPSULE,DOSE

PACK

3 QL

EMEND ORAL

SUSPENSION FOR

RECONSTITUTIO

N

2

ENTOCORT EC 3

ENTYVIO 6 MSD

enulose 1

fleet laxative 5 ACA; OTC

FOSRENOL 3 ST

GASTROCROM 3

GATTEX 30-VIAL 4 S; SLA

gavilax 5 ACA; OTC

gavilyte-c 5 ACA

gavilyte-g 5 ACA

gavilyte-n 5 ACA

generlac 1

gentle laxative 5 ACA; OTC

gentlelax 5 ACA; OTC

GIALAX 5 ACA

GIAZO 3



75

Drug Name Drug

Category

Requirements

/ Limits

glycolax 5 ACA; OTC

GOLYTELY ORAL

POWDER IN

PACKET

5 ACA

GOLYTELY ORAL

RECON SOLN

3

granisetron hcl 1 QL

healthylax 5 ACA; OTC

hemmorex-hc 1

hydrocortisone 1

hydrocortisone

acetate

1

hydrocortisone-

pramoxine

1

INFLECTRA 6 MSD

kionex 1

kionex (with

sorbitol)

1

KRISTALOSE 3 M

lactulose 1

lanthanum 1

laxaclear 5 ACA; OTC

laxative (bisacodyl) 5 ACA; OTC

laxative feminine 5 ACA; OTC

laxative peg 3350 5 ACA; OTC

LIALDA 3 M

lidocaine hcl-

hydrocortison ac

1

LINZESS 2

LOTRONEX 3

MAGNEBIND 400 3

magnesium citrate 5 ACA; OTC

MARINOL 3

Drug Name Drug

Category

Requirements

/ Limits

mesalamine oral

tablet,delayed

release (dr/ec) 1.2

gram

1 M

MESALAMINE

ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 800 MG

3 ST; M

mesalamine rectal 1

mesalamine with

cleansing wipe

1

metoclopramide hcl

injection

6 MSD

metoclopramide hcl

oral

1

MICORT-HC 3 ST

milk of magnesia 5 ACA; OTC

milk of magnesia

concentrated

5 ACA; OTC

miralax 5 ACA; OTC

MOVANTIK 2

MOVIPREP 5 ACA

natura-lax 5 ACA; OTC

NULYTELY WITH

FLAVOR PACKS

3

OCALIVA 3 PA; S; SLA

ondansetron 1 QL

ondansetron hcl (pf) 6 MSD

ondansetron hcl

intravenous

6 MSD

ondansetron hcl oral 1 QL

oral saline laxative 5 ACA; OTC

OSMOPREP 5 ACA



76

Drug Name Drug

Category

Requirements

/ Limits

PALONOSETRON

INTRAVENOUS

SOLUTION 0.25

MG/2 ML

6 MSD

palonosetron


0.25 mg/5 ml

6 MSD

PANCREAZE 3 ST

peg 3350-

electrolytes

5 ACA

peg3350 5 ACA; OTC

peg-electrolyte soln 5 ACA

PENTASA 2 M

PERTZYE 3 ST

PHOSLYRA 2

phosphate laxative 5 ACA; OTC

powderlax 5 ACA; OTC

pramcort 1

PREPOPIK 5 ACA

prochlorperazine 1

prochlorperazine

edisylate

6 MSD

prochlorperazine

maleate

1

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 3

procto-med hc 1

proctosol hc 1

proctozone-hc 1

purelax 5 ACA; OTC

RECTIV 2

REGLAN 3

RELISTOR ORAL 3

Drug Name Drug

Category

Requirements

/ Limits

RELISTOR

SUBCUTANEOUS

2

REMICADE 6 MSD

RENAGEL 3 ST

RENFLEXIS 6 PA; ST; MSD

RENVELA 3

ROWASA 3

SANCUSO 2 QL

scopolamine base 1

sevelamer carbonate 1

SFROWASA 3

smoothlax 5 ACA; OTC

sodium polystyrene

(sorb free)

1

sodium polystyrene

sulfonate oral

1

sodium polystyrene

sulfonate rectal

enema 30 gram/120

ml

1

SODIUM

POLYSTYRENE

SULFONATE

RECTAL ENEMA

50 GRAM/200 ML

3

SOLESTA 6 MSD

sps (with sorbitol) 1

SUCRAID 3 S; SLA

sulfasalazine 1 M

SUPREP BOWEL

PREP KIT

5 ACA

SUSTOL 6 MSD

SYMPROIC 3

SYNDROS 3



77

Drug Name Drug

Category

Requirements

/ Limits

TIGAN

INTRAMUSCULA

R

6 MSD

TIGAN ORAL 3

TRANSDERM-

SCOP

3

trilyte with flavor

packets

5 ACA

trimethobenzamide 1

TRULANCE 3 ST

UCERIS ORAL 2

UCERIS RECTAL 3

URSO 250 3 M

URSO FORTE 3 M

ursodiol 1 M

VARUBI

INTRAVENOUS

6 MSD

VARUBI ORAL 2

VELPHORO 2

VELTASSA 3 S; SLA

VIBERZI 2

VIOKACE 2

woman's laxative 5 ACA; OTC

women's gentle

laxative(bisac)

5 ACA; OTC

women's laxative

(bisacodyl)

5 ACA; OTC

ZENPEP 2

ZOFRAN 3 QL

ZOFRAN ODT 3 QL

ZUPLENZ 3 QL

ULCER THERAPY

ACIPHEX 3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

ACIPHEX

SPRINKLE

3 ST; M; QL

amoxicil-

clarithromy-

lansopraz

1

CARAFATE ORAL

SUSPENSION

2 M

CARAFATE ORAL

TABLET

3 M

cimetidine 1 M

cimetidine hcl 1 M

CYTOTEC 3 M

DEXILANT 3 ST; M; QL

ESOMEP-EZS 3 ST; M

esomeprazole

magnesium oral

capsule,delayed


1 M; QL

esomeprazole

magnesium oral

capsule,delayed


1 M

esomeprazole

sodium

6 MSD

ESOMEPRAZOLE

STRONTIUM

3 ST; M

famotidine (pf) 6 MSD

famotidine (pf)-nacl

(iso-os)

6 MSD

FAMOTIDINE IN

0.9 % NACL

6 MSD

famotidine

intravenous

6 MSD

famotidine oral 1 M

lansoprazole oral

capsule,delayed


1 M; QL



78

Drug Name Drug

Category

Requirements

/ Limits

lansoprazole oral

capsule,delayed


1 M

lansoprazole oral

tablet,disintegrat,

delay rel 15 mg

1 M; QL

lansoprazole oral

tablet,disintegrat,

delay rel 30 mg

1 M

misoprostol 1 M

NEXIUM IV 6 MSD

NEXIUM ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

20 MG

3 ST; M; QL

NEXIUM ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

40 MG

3 ST; M

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 10 MG,

2.5 MG, 20 MG, 5

MG

2 ST; M; QL

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 40 MG

2 ST; M

nizatidine 1 M

OMECLAMOX-

PAK

3 QL

omeppi oral capsule

20-1.1 mg-gram

1 ST; M; QL

omeppi oral capsule

40-1.1 mg-gram

1 ST; M

Drug Name Drug

Category

Requirements

/ Limits

omeprazole oral

capsule,delayed


1 M; QL

omeprazole oral

capsule,delayed

release(dr/ec) 20

mg, 40 mg

1 M

omeprazole-sodium

bicarbonate oral

capsule 20-1.1 mg-

gram

1 ST; M; QL

omeprazole-sodium

bicarbonate oral

capsule 40-1.1 mg-

gram

1 ST; M

omeprazole-sodium

bicarbonate oral

packet 20-1,680 mg

1 ST; QL

omeprazole-sodium

bicarbonate oral

packet 40-1,680 mg

1 ST

pantoprazole oral

tablet,delayed

release (dr/ec) 20

mg

1 M; QL

pantoprazole oral

tablet,delayed

release (dr/ec) 40

mg

1 M

PEPCID 3 M

PREVACID ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

15 MG

3 ST; M; QL

PREVACID ORAL

CAPSULE,DELAY

ED

RELEASE(DR/EC)

30 MG

3 ST; M



79

Drug Name Drug

Category

Requirements

/ Limits

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 15 MG

3 ST; M; QL

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 30 MG

3 ST; M

PRILOSEC 3 ST; M; QL

PROTONIX ORAL

GRANULES DR

FOR SUSP IN

PACKET

3 ST; M

PROTONIX ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 20 MG

3 ST; M; QL

PROTONIX ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 40 MG

3 ST; M

PYLERA 2

rabeprazole 1 M

ranitidine hcl

injection

6 MSD

ranitidine hcl oral 1 M

sucralfate 1 M

ZANTAC

INJECTION

6 MSD

ZANTAC ORAL 3 M

ZEGERID ORAL

CAPSULE 20-1.1

MG-GRAM

3 ST; M; QL

ZEGERID ORAL

CAPSULE 40-1.1

MG-GRAM

3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

ZEGERID ORAL

PACKET 20-1,680

MG

3 ST; QL

ZEGERID ORAL

PACKET 40-1,680

MG

3 ST

IMMUNOLOGY, VACCINES &

BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN

POLYSORBATE)

6 MSD

EPOGEN 6 MSD

GRANIX 6 MSD

LEUKINE 6 MSD

MIRCERA 6 MSD

MOZOBIL 6 MSD

NEULASTA 6 MSD

NEUPOGEN 6 MSD

PROCRIT 6 MSD

ZARXIO 6 MSD

GROWTH HORMONES

EGRIFTA 3 PA; S

GENOTROPIN 3 PA; S

GENOTROPIN

MINIQUICK

3 PA; S

HUMATROPE 3 PA; S

NORDITROPIN

FLEXPRO

3 PA; S

NUTROPIN AQ

NUSPIN

4 PA; ST; S

OMNITROPE 4 PA; ST; S

SAIZEN 4 PA; ST; S

SAIZEN

SAIZENPREP

4 PA; ST; S



80

Drug Name Drug

Category

Requirements

/ Limits

SEROSTIM 3 PA; S

ZOMACTON 4 PA; ST; S

ZORBTIVE 4 PA; S; SLA

INTERFERONS

AUBAGIO 4 PA; S; SLA;

QL

AVONEX 3 PA; S; QL

AVONEX (WITH

ALBUMIN)

3 PA; S; QL

BETASERON 3 PA; ST; S; QL

COPAXONE

SUBCUTANEOUS

SYRINGE 20

MG/ML

4 ST; S; QL

COPAXONE

SUBCUTANEOUS

SYRINGE 40

MG/ML

3 PA; S; QL

EXTAVIA 3 PA; S; QL

GILENYA 3 PA; S; SLA

glatiramer 1 PA; S; QL

glatopa

subcutaneous

syringe 20 mg/ml

1 PA; S; QL

glatopa

subcutaneous

syringe 40 mg/ml

1 S; QL

LEMTRADA 6 MSD

moderiba 1 ST; S; SLA

moderiba dose pack 1 ST; S; SLA

OCREVUS 6 MSD

PEGASYS 3 PA; S; SLA;

QL

PEGASYS

PROCLICK

3 PA; S; SLA;

QL

Drug Name Drug

Category

Requirements

/ Limits

PEGINTRON 4 PA; S; SLA;

QL

PLEGRIDY 3 ST; S; QL

POMALYST 3 S; QL

REBETOL 4 ST; S; SLA

REBIF (WITH

ALBUMIN)

3 PA; S; QL

REBIF REBIDOSE 3 PA; S; QL

REBIF TITRATION

PACK

3 PA; S; QL

REVLIMID 3 S

ribasphere 1 ST; S; SLA

ribasphere ribapak 1 ST; S; SLA

ribavirin 1 S; SLA

SYLATRON 3 PA; S; SLA;

QL

TECFIDERA 3 PA; S; SLA;

QL

INTERLEUKINS

ACTIMMUNE 3 S; SLA

ALDARA 3 QL

ALFERON N 6 MSD

ARCALYST 3 PA; ST; S;

SLA

ILARIS (PF) 6 MSD

imiquimod 1 QL

INTRON A 3 S; SLA

KINERET 3 PA; ST; SLA;

QL

PROLEUKIN 6 MSD

ZYCLARA 3 ST; QL

VACCINES & MISCELLANEOUS

IMMUNOLOGICALS

ACTHIB (PF) 6 MSD



81

Drug Name Drug

Category

Requirements

/ Limits

ADACEL(TDAP

ADOLESN/ADULT

)(PF)

6 MSD

ATGAM 6 MSD

BCG VACCINE,

LIVE (PF)

6 MSD

BEXSERO 6 MSD

BIVIGAM 6 MSD

BOOSTRIX TDAP 6 MSD

BOTOX 6 MSD

CARIMUNE NF

NANOFILTERED

6 MSD

CUVITRU 6 MSD

DAPTACEL (DTAP

PEDIATRIC) (PF)

6 MSD

DYSPORT 6 MSD

ENGERIX-B (PF) 6 MSD

ENGERIX-B

PEDIATRIC (PF)

6 MSD

FLEBOGAMMA

DIF

6 MSD

GAMASTAN S/D 6 MSD

GAMMAGARD

LIQUID

6 MSD

GAMMAGARD S-

D (IGA < 1

MCG/ML)

6 MSD

GAMMAKED 6 MSD

GAMMAPLEX 6 MSD

GAMMAPLEX

(WITH SORBITOL)

6 MSD

GAMUNEX-C 6 MSD

HAVRIX (PF) 6 MSD

HEPAGAM B 6 MSD

HEPLISAV-B 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

HIBERIX (PF) 6 MSD

HIZENTRA 6 MSD

HYPERHEP B S/D 6 MSD

HYPERHEP B S-D

NEONATAL

6 MSD

HYPERRAB (PF) 6 MSD

HYPERRAB S/D

(PF)

6 MSD

HYPERTET S/D

(PF)

6 MSD

HYQVIA 6 MSD

IMOGAM RABIES-

HT (PF)

6 MSD

INFANRIX (DTAP)

(PF)

6 MSD

KINRIX (PF) 6 MSD

MENACTRA (PF) 6 MSD

MENVEO A-C-Y-

W-135-DIP (PF)

6 MSD

M-M-R II (PF) 6 MSD

MYOBLOC 6 MSD

NABI-HB 6 MSD

OCTAGAM 6 MSD

PEDIARIX (PF) 6 MSD

PENTACEL

ACTHIB

COMPONENT (PF)

6 MSD

PNEUMOVAX 23 6 MSD

PRIVIGEN 6 MSD

PROQUAD (PF) 6 MSD

PROVENGE 6 MSD

QUADRACEL (PF) 6 MSD

RABAVERT (PF) 6 MSD



82

Drug Name Drug

Category

Requirements

/ Limits

RECOMBIVAX HB

(PF)

6 MSD

ROTARIX 6 MSD

ROTATEQ

VACCINE

6 MSD

SHINGRIX (PF) 6 MSD

TENIVAC (PF) 6 MSD

TETANUS,DIPHTH

ERIA TOX

PED(PF)

6 MSD

TETANUS-

DIPHTHERIA

TOXOIDS-TD

6 MSD

THYMOGLOBULI

N

6 MSD

TICE BCG 6 MSD

TWINRIX (PF) 6 MSD

TYPHIM VI 6 MSD

VAQTA (PF) 6 MSD

VARIZIG 6 MSD

VAXCHORA

VACCINE

6 MSD

VIVOTIF 6 MSD

XEOMIN 6 MSD

YF-VAX (PF) 6 MSD

ZINPLAVA 6 MSD

MUSCULOSKELETAL &

RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 M

COLCHICINE 3 ST

COLCRYS 2

DUZALLO 3 ST

KRYSTEXXA 6 MSD

Drug Name Drug

Category

Requirements

/ Limits

MITIGARE 2

probenecid 1 M

probenecid-

colchicine

1 M

ULORIC 2 ST; M

ZURAMPIC 3 ST; M

ZYLOPRIM 3 M

OSTEOPOROSIS THERAPY

ACTONEL 3 ST; M; QL

alendronate 1 M; QL

ATELVIA 3 ST; M; QL

BINOSTO 3 ST; M; QL

BONIVA

INTRAVENOUS

6 MSD

BONIVA ORAL 3 ST; M; QL

EVISTA 3 PA; M

FORTEO 4 PA; ST; S;

SLA; QL

FOSAMAX 3 ST; M; QL

FOSAMAX PLUS

D

3 ST; M; QL

ibandronate

intravenous

6 MSD

ibandronate oral 1 M; QL

PROLIA 6 MSD

raloxifene 1 PA; M

risedronate 1 M; QL

TYMLOS 3 S

OTHER RHEUMATOLOGICALS

ACTEMRA

INTRAVENOUS

6 MSD

ACTEMRA

SUBCUTANEOUS

3 PA; ST; S;

SLA; QL



83

Drug Name Drug

Category

Requirements

/ Limits

ARAVA 3 QL

BENLYSTA

INTRAVENOUS

6 MSD

BENLYSTA

SUBCUTANEOUS

3 S; SLA

CUPRIMINE 3 ST; M

DEPEN

TITRATABS

2 M

ENBREL 3 PA; ST; S; QL

ENBREL MINI 3 PA; ST; S; QL

ENBREL

SURECLICK

3 PA; ST; S; QL

HUMIRA 3 PA; ST; S; QL

HUMIRA

PEDIATRIC

CROHN'S START

SUBCUTANEOUS

SYRINGE KIT 40

MG/0.8 ML, 80

MG/0.8 ML-40

MG/0.4 ML

3 PA; ST; S; QL

HUMIRA

PEDIATRIC

CROHN'S START

SUBCUTANEOUS

SYRINGE KIT 80

MG/0.8 ML

3 PA; ST; S

HUMIRA PEN 3 PA; ST; S; QL

HUMIRA PEN

CROHN'S-UC-HS

START

3 PA; ST; S; QL

HUMIRA PEN

PSORIASIS-

UVEITIS

3 PA; ST; S; QL

KEVZARA

SUBCUTANEOUS

PEN INJECTOR

4 ST

Drug Name Drug

Category

Requirements

/ Limits

KEVZARA

SUBCUTANEOUS

SYRINGE

4 ST; S

leflunomide 1 QL

OLUMIANT 3 ST

ORENCIA 4 PA; ST; S

ORENCIA (WITH

MALTOSE)

6 MSD

ORENCIA

CLICKJECT

4 PA; ST; S

OTEZLA 3 ST; S; SLA;

QL

OTEZLA

STARTER

3 ST; S; SLA;

QL

OTREXUP (PF) 3 S; QL

RASUVO (PF) 3 S; QL

RIDAURA 2 M

SAVELLA ORAL

TABLET

2 ST; M; QL

SAVELLA ORAL

TABLETS,DOSE

PACK

2 ST; QL

SIMPONI ARIA 6 MSD

SIMPONI

SUBCUTANEOUS

PEN INJECTOR

100 MG/ML

3 PA; ST; S; QL

SIMPONI

SUBCUTANEOUS

PEN INJECTOR 50

MG/0.5 ML

4 PA; ST; S; QL

SIMPONI

SUBCUTANEOUS

SYRINGE 100

MG/ML

3 PA; ST; S; QL



84

Drug Name Drug

Category

Requirements

/ Limits

SIMPONI

SUBCUTANEOUS

SYRINGE 50

MG/0.5 ML

4 PA; ST; S; QL

XELJANZ ORAL

TABLET 10 MG

3 ST; QL

XELJANZ ORAL

TABLET 5 MG

3 ST; S; QL

XELJANZ XR 3 ST; S; QL

OBSTETRICS &

GYNECOLOGY

DIAPHRAGMS AND OTHER NON-

ORAL CONTRACEPTIVES

CAYA

CONTOURED

5 ACA

FC2 FEMALE

CONDOM

5 ACA; OTC

FEMCAP 5 ACA

KYLEENA 6 MSD

LILETTA 6 MSD

MIRENA 6 MSD

PARAGARD T

380A

6 MSD

SKYLA 6 MSD

WIDE-SEAL

DIAPHRAGM

5 ACA

ESTROGENS & PROGESTINS

ACTIVELLA 3 M

ALORA 3 M; QL

amabelz 1 M

ANGELIQ 3 M

AYGESTIN 3 M

camila 5 M; ACA

CLIMARA 3 M; QL

Drug Name Drug

Category

Requirements

/ Limits

CLIMARA PRO 3 M; QL

COMBIPATCH 2 M

covaryx 1

covaryx h.s. 1

CRINONE

VAGINAL GEL 4

%

2

CRINONE

VAGINAL GEL 8

%

7

deblitane 5 M; ACA

DELESTROGEN 3

DEPO-ESTRADIOL 2

DEPO-PROVERA 5 ACA; QL

DEPO-SUBQ

PROVERA 104

5 ACA; QL

DIVIGEL 2 M; QL

DUAVEE 2

eemt 1

eemt hs 1

ELESTRIN 3 M; QL

ENDOMETRIN 7 ST

errin 5 M; ACA

ESTRACE 3 M

estradiol oral 1 M

estradiol

transdermal

1 M; QL

estradiol vaginal 1 M

estradiol valerate 1

estradiol-

norethindrone acet

1 M

ESTRING 2 M

ESTROGEL 3 ST; M; QL



85

Drug Name Drug

Category

Requirements

/ Limits

estrogens-

methyltestosterone

1

estropipate 1 M

EVAMIST 3 QL

FEMHRT LOW

DOSE

3 M

FEMRING 3 ST; M

fyavolv 1 M

heather 5 M; ACA

hydroxyprogesterone

caproate

6 MSD

IMVEXXY 3

jencycla 5 M; ACA

jevantique lo 1 M

jinteli 1 M

jolivette 5 M; ACA

lopreeza 1 M

lyza 5 M; ACA

MAKENA 6 MSD

MAKENA (PF) 6 MSD

medroxyprogesteron

e intramuscular

5 ACA; QL

medroxyprogesteron

e oral

1 M

MENEST 3 M

MENOSTAR 3 M; QL

mimvey 1 M

mimvey lo 1 M

MINIVELLE 2 M; QL

nora-be 5 M; ACA

norethindrone

(contraceptive)

5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

norethindrone

acetate

1 M

norethindrone ac-eth

estradiol

1 M

norlyda 5 M; ACA

norlyroc 5 M; ACA

ORTHO

MICRONOR

5 ST; M; ACA

PREFEST 3 M

PREMARIN 2 M

PREMPHASE 2 M

PREMPRO 2 M

progesterone 7

progesterone

micronized

1 M

PROMETRIUM 3 M

PROVERA 3 M

sharobel 5 M; ACA

tulana 5 M; ACA

VAGIFEM 3 M

VIVELLE-DOT 3 M; QL

yuvafem 1 M

MISCELLANEOUS OB/GYN

AVC VAGINAL 3

CLEOCIN 3

clindamycin

phosphate

1

CLINDESSE 3

CONCEPTROL 5 ACA; OTC

fem ph 1

GYNAZOLE-1 3

gynol ii 5 ACA; OTC

INTRAROSA 3



86

Drug Name Drug

Category

Requirements

/ Limits

isoxsuprine 1 M

LUPANETA PACK

(1 MONTH)

3

LUPANETA PACK

(3 MONTH)

3

LYSTEDA 3

METROGEL

VAGINAL

3

metronidazole 1

MIFEPREX 4 S; SLA

NEXPLANON 6 MSD

NUVARING 5 M; ACA

NUVESSA 3

OSPHENA 3

RELAGARD 3

terconazole 1

TODAY

CONTRACEPTIVE

SPONGE

5 ACA; OTC

tranexamic acid 1

vaginal

contraceptive foam

5 ACA; OTC

vandazole 1

VCF

CONTRACEPTIVE

FILM

5 ACA; OTC

VCF

CONTRACEPTIVE

GEL

5 ACA; OTC

xulane 5 M; ACA

ORAL CONTRACEPTIVES &

RELATED AGENTS

AFTERA 5 ACA; OTC;

QL

altavera (28) 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

alyacen 1/35 (28) 5 M; ACA

alyacen 7/7/7 (28) 5 M; ACA

amethia 5 M; ACA

amethia lo 5 M; ACA

amethyst 5 M; ACA

apri 5 M; ACA

aranelle (28) 5 M; ACA

ashlyna 5 M; ACA

aubra 5 M; ACA

aviane 5 M; ACA

azurette (28) 5 M; ACA

BALCOLTRA 5 M; ACA

balziva (28) 5 M; ACA

bekyree (28) 5 M; ACA

BEYAZ 5 ST; M; ACA

blisovi 24 fe 5 M; ACA

blisovi fe 1.5/30 (28) 5 M; ACA

blisovi fe 1/20 (28) 5 M; ACA

BREVICON (28) 5 ST; M; ACA

briellyn 5 M; ACA

camrese 5 M; ACA

camrese lo 5 M; ACA

caziant (28) 5 M; ACA

chateal 5 M; ACA

cryselle (28) 5 M; ACA

cyclafem 1/35 (28) 5 M; ACA

cyclafem 7/7/7 (28) 5 M; ACA

CYCLESSA (28) 5 ST; M; ACA

cyred 5 M; ACA

dasetta 1/35 (28) 5 M; ACA

dasetta 7/7/7 (28) 5 M; ACA



87

Drug Name Drug

Category

Requirements

/ Limits

daysee 5 M; ACA

delyla (28) 5 M; ACA

desog-

e.estradiol/e.estradio

l

5 M; ACA

desogestrel-ethinyl

estradiol

5 M; ACA

drospirenone-

e.estradiol-lm.fa

5 M; ACA

drospirenone-ethinyl

estradiol

5 M; ACA

econtra ez 5 ACA; OTC;

QL

econtra one-step 5 ACA; OTC;

QL

elinest 5 M; ACA

ELLA 5 ACA; QL

emoquette 5 M; ACA

enpresse 5 M; ACA

enskyce 5 M; ACA

estarylla 5 M; ACA

ESTROSTEP FE-28 5 ST; M; ACA

ethynodiol diac-eth

estradiol

5 M; ACA

falmina (28) 5 M; ACA

fayosim 5 M; ACA

femynor 5 M; ACA

GENERESS FE 5 ST; M; ACA

gianvi (28) 5 M; ACA

introvale 5 M; ACA

isibloom 5 M; ACA

jolessa 5 M; ACA

juleber 5 M; ACA

junel 1.5/30 (21) 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

junel 1/20 (21) 5 M; ACA

junel fe 1.5/30 (28) 5 M; ACA

junel fe 1/20 (28) 5 M; ACA

junel fe 24 5 M; ACA

kaitlib fe 5 M; ACA

kariva (28) 5 M; ACA

kelnor 1/35 (28) 5 M; ACA

kelnor 1-50 5 M; ACA

kimidess (28) 5 M; ACA

kurvelo 5 M; ACA

l norgest/e.estradiol-

e.estrad

5 M; ACA

larin 1.5/30 (21) 5 M; ACA

larin 1/20 (21) 5 M; ACA

larin 24 fe 5 M; ACA

larin fe 1.5/30 (28) 5 M; ACA

larin fe 1/20 (28) 5 M; ACA

larissia 5 M; ACA

layolis fe 5 M; ACA

leena 28 5 M; ACA

lessina 5 M; ACA

levonest (28) 5 M; ACA

levonorgestrel-

ethinyl estrad

5 M; ACA

levonorg-eth estrad

triphasic

5 M; ACA

levora-28 5 M; ACA

lillow 5 M; ACA

LO LOESTRIN FE 5 ST; M; ACA

LOESTRIN 1.5/30

(21)

5 ST; M; ACA

LOESTRIN 1/20

(21)

5 ST; M; ACA



88

Drug Name Drug

Category

Requirements

/ Limits

LOESTRIN FE

1.5/30 (28-DAY)

5 ST; M; ACA

LOESTRIN FE 1/20

(28-DAY)

5 ST; M; ACA

loryna (28) 5 M; ACA

LOSEASONIQUE 5 ST; M; ACA

low-ogestrel (28) 5 M; ACA

lutera (28) 5 M; ACA

marlissa 5 M; ACA

melodetta 24 fe 5 M; ACA

mibelas 24 fe 5 M; ACA

microgestin 1.5/30

(21)

5 M; ACA

microgestin 1/20

(21)

5 M; ACA

MICROGESTIN 24

FE

5 ST; M; ACA

microgestin fe 1.5/30

(28)

5 M; ACA

microgestin fe 1/20

(28)

5 M; ACA

mili 5 M; ACA

MINASTRIN 24 FE 5 ST; M; ACA

MIRCETTE (28) 5 ST; M; ACA

mono-linyah 5 M; ACA

mononessa (28) 5 M; ACA

my choice 5 ACA; OTC;

QL

my way 5 ACA; OTC;

QL

myzilra 5 M; ACA

NATAZIA 5 ST; M; ACA

necon 0.5/35 (28) 5 M; ACA

necon 7/7/7 (28) 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

nikki (28) 5 M; ACA

noreth-ethinyl

estradiol-iron

5 M; ACA

norethindrone ac-eth

estradiol

5 M; ACA

norethindrone-

e.estradiol-iron

5 M; ACA

norgestimate-ethinyl

estradiol

5 M; ACA

nortrel 0.5/35 (28) 5 M; ACA

nortrel 1/35 (21) 5 M; ACA

nortrel 1/35 (28) 5 M; ACA

nortrel 7/7/7 (28) 5 M; ACA

ocella 5 M; ACA

ogestrel (28) 5 M; ACA

opcicon one-step 5 ACA; OTC;

QL

option-2 5 ACA; OTC;

QL

orsythia 5 M; ACA

ORTHO TRI-

CYCLEN (28)

5 ST; M; ACA

ORTHO TRI-

CYCLEN LO (28)

5 ST; M; ACA

ORTHO-CYCLEN

(28)

5 M; ACA

ORTHO-NOVUM

1/35 (28)

5 ST; M; ACA

ORTHO-NOVUM

7/7/7 (28)

5 M; ACA

philith 5 M; ACA

pimtrea (28) 5 M; ACA

pirmella 5 M; ACA

PLAN B ONE-STEP 5 ACA; OTC;

QL



89

Drug Name Drug

Category

Requirements

/ Limits

portia 5 M; ACA

previfem 5 M; ACA

QUARTETTE 5 ST; M; ACA

quasense 5 M; ACA

rajani 5 M; ACA

reclipsen (28) 5 M; ACA

rivelsa 5 M; ACA

SAFYRAL 5 ST; M; ACA

SEASONIQUE 5 ST; M; ACA

setlakin 5 M; ACA

sprintec (28) 5 M; ACA

sronyx 5 M; ACA

syeda 5 M; ACA

TAKE ACTION 5 ACA; OTC;

QL

tarina fe 1/20 (28) 5 M; ACA

TAYTULLA 5 ST; M; ACA

tilia fe 5 M; ACA

tri femynor 5 M; ACA

tri-estarylla 5 M; ACA

tri-legest fe 5 M; ACA

tri-linyah 5 M; ACA

tri-lo-estarylla 5 M; ACA

tri-lo-marzia 5 M; ACA

tri-lo-sprintec 5 M; ACA

tri-mili 5 M; ACA

trinessa (28) 5 M; ACA

trinessa lo 5 M; ACA

TRI-NORINYL (28) 5 ST; M; ACA

tri-previfem (28) 5 M; ACA

tri-sprintec (28) 5 M; ACA

trivora (28) 5 M; ACA

Drug Name Drug

Category

Requirements

/ Limits

tri-vylibra 5 M; ACA

tydemy 5 M; ACA

velivet triphasic

regimen (28)

5 M; ACA

vienva 5 M; ACA

viorele (28) 5 M; ACA

vyfemla (28) 5 M; ACA

vylibra 5 M; ACA

wera (28) 5 M; ACA

wymzya fe 5 M; ACA

YASMIN (28) 5 ST; M; ACA

YAZ (28) 5 ST; M; ACA

zarah 5 M; ACA

zenchent (28) 5 M; ACA

zovia 1/35e (28) 5 M; ACA

OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac 1

AZASITE 2

bacitracin 1

bacitracin-

polymyxin b

1

BESIVANCE 3

BETADINE

OPHTHALMIC

PREP

3

CEFUROXIME

(PF) IN 0.9% NACL

6 MSD

CILOXAN 3

ciprofloxacin hcl 1

erythromycin 1

gatifloxacin 1

gentak 1



90

Drug Name Drug

Category

Requirements

/ Limits

gentamicin 1

levofloxacin 1

MOXEZA 2

moxifloxacin 1

MOXIFLOXACIN

(PF)-BSS NO.2

6 MSD

MOXIFLOXACIN

IN NACL,ISO-

O(PF)

6 MSD

NATACYN 2

neomycin-

bacitracin-

polymyxin

1 M

neomycin-

polymyxin-

gramicidin

1

neo-polycin 1 M

OCUFLOX 3

ofloxacin 1

polycin 1

polymyxin b sulf-

trimethoprim

1

POLYTRIM 3

tobramycin 1

TOBREX 3

VIGAMOX 3

ZYMAXID 3

ANTIVIRALS

trifluridine 1

VIROPTIC 3

ZIRGAN 3

BETA-BLOCKERS

BETAGAN 3 M

betaxolol 1 M

Drug Name Drug

Category

Requirements

/ Limits

BETIMOL 3 M

BETOPTIC S 3 M

carteolol 1 M

ISTALOL 3 ST; M

levobunolol 1 M

metipranolol 1 M

timolol maleate 1 M

TIMOPTIC 3 M

TIMOPTIC

OCUDOSE (PF)

3 ST; M

TIMOPTIC-XE 3 M

CHOLINESTERASE INHIBITOR

MIOTICS

PHOSPHOLINE

IODIDE

2 M

CYCLOPLEGIC MYDRIATICS

atropine 1 M

ATROPINE IN 0.9

% SOD CHLORIDE

3 M

CYCLOGYL 3 M

cyclopentolate 1 M

homatropaire 1 M

homatropine hbr 1 M

MYDRIACYL 3 M

PAREMYD 3

tropicamide 1 M

DIRECT ACTING MIOTICS

ISOPTO CARPINE 3 M

MIOCHOL-E 3

pilocarpine hcl 1 M

MISCELLANEOUS

OPHTHALMOLOGICS

acuicyn 1



91

Drug Name Drug

Category

Requirements

/ Limits

AKTEN (PF) 3

ALOCRIL 3 ST

ALOMIDE 3 ST

altacaine 1

altafluor 1

azelastine 1

BEPREVE 2 ST

BEVACIZUMAB 6 MSD

cromolyn 1

CYSTARAN 2 PA; SLA

ELESTAT 3 ST

EMADINE 3 ST

epinastine 1

EYLEA 6 MSD

flucaine 1

fluorescein-

proparacaine

1

JETREA (PF) 6 MSD

LACRISERT 3

LASTACAFT 3 ST

LIDOCAN-

PHENYLEPH-BSS

NO.2(PF)

6 MSD

LUCENTIS 6 MSD

LUXTURNA 6 MSD

MACUGEN 6 MSD

olopatadine 1

OMIDRIA 6 MSD

PATADAY 3 ST

PATANOL 3 ST

PAZEO 2 ST

Drug Name Drug

Category

Requirements

/ Limits

PHOTREXA

CROSS-LINKING

KIT

6 MSD

PHOTREXA

VISCOUS

6 MSD

PREDNISOLON-

GATIFLOX-

BROMFENAC

3

proparacaine 1

RESTASIS 2 PA; M; QL

RESTASIS

MULTIDOSE

2 PA; M; QL

tetcaine 1

tetracaine hcl 1

TETRACAINE

HCL (PF)

3

TETRAVISC 3

TETRAVISC

FORTE

3

VISUDYNE 6 MSD

VITRASE 6 MSD

XIIDRA 2 M; QL

NON-STEROIDAL ANTI-

INFLAMMATORY AGENTS

ACULAR 3

ACULAR LS 3

ACUVAIL (PF) 3 ST

bromfenac 1

BROMSITE 3

diclofenac sodium 1 QL

flurbiprofen sodium 1

ILEVRO 2

ketorolac 1

NEVANAC 3 ST



92

Drug Name Drug

Category

Requirements

/ Limits

PROLENSA 2

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1 M

acetazolamide

sodium

6 MSD

methazolamide 1 M

NEPTAZANE 3 M

OTHER GLAUCOMA DRUGS

AZOPT 3 M

bimatoprost 1 ST; M

COMBIGAN 2 M

COSOPT 3 M

COSOPT (PF) 3 M

dorzolamide 1 M

dorzolamide-timolol 1 M

latanoprost 1 ST; M

LUMIGAN 2 ST; M

MITOSOL 3

SIMBRINZA 3 M

TRAVATAN Z 2 ST; M

TRUSOPT 3 M

VYZULTA 3 M

XALATAN 3 ST; M

ZIOPTAN (PF) 3 ST; M

STEROID-ANTIBIOTIC

COMBINATIONS

GATIFLOXACIN-

DEXAMETHASON

E

3

MAXITROL 3

neomycin-

bacitracin-poly-hc

1

Drug Name Drug

Category

Requirements

/ Limits

neomycin-polymyxin

b-dexameth

1

neomycin-

polymyxin-hc

1

neo-polycin hc 1

PRED-G 3

PRED-G S.O.P. 3

PREDNISOLONE-

GATIFLOXACIN

3

TOBRADEX

OPHTHALMIC

(EYE)

DROPS,SUSPENSI

ON

3

TOBRADEX

OPHTHALMIC

(EYE) OINTMENT

2

TOBRADEX ST 2

tobramycin-

dexamethasone

1

ZYLET 2

STEROIDS

ALREX 2 ST

dexamethasone

sodium phosphate

1

DUREZOL 3

FLAREX 3

fluorometholone 1

FML FORTE 3

FML LIQUIFILM 3

FML S.O.P. 3

ILUVIEN 6 MSD

LOTEMAX 2

MAXIDEX 3

OMNIPRED 3



93

Drug Name Drug

Category

Requirements

/ Limits

OZURDEX 6 MSD

PRED FORTE 3

PRED MILD 3

prednisolone acetate 1

PREDNISOLONE

ACETATE (PF)

3

prednisolone sodium

phosphate

1

RETISERT 6 MSD

STEROID-SULFONAMIDE

COMBINATIONS

BLEPHAMIDE 3

BLEPHAMIDE

S.O.P.

3

sulfacetamide-

prednisolone

1

SULFONAMIDES

BLEPH-10 3

sulfacetamide

sodium

1

SYMPATHOMIMETICS

ALPHAGAN P

OPHTHALMIC

(EYE) DROPS 0.1

%

2 M

ALPHAGAN P

OPHTHALMIC

(EYE) DROPS 0.15

%

3 M

apraclonidine 1 M

brimonidine 1 M

IOPIDINE 3 M

VASOCONSTRICTOR

DECONGESTANTS

CYCLOMYDRIL 3 M

Drug Name Drug

Category

Requirements

/ Limits

phenylephrine hcl 1

RESPIRATORY, ALLERGY,

COUGH & COLD

ANTIHISTAMINE &

ANTIALLERGENIC AGENTS

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP

II

3

ADYPHREN II 3

AUVI-Q

INJECTION AUTO-

INJECTOR 0.1

MG/0.1 ML

3 ST

AUVI-Q

INJECTION AUTO-

INJECTOR 0.15

MG/0.15 ML, 0.3

MG/0.3 ML

3 ST; QL

carbinoxamine

maleate

1

cetirizine 1

CLARINEX ORAL

SYRUP

3

CLARINEX ORAL

TABLET

3 QL

clemastine 1

cyproheptadine 1

desloratadine 1 QL

diphenhydramine hcl 6 MSD

EPINEPHRINE

INJECTION AUTO-

INJECTOR 0.15

MG/0.15 ML, 0.3

MG/0.3 ML

3 ST; QL



94

Drug Name Drug

Category

Requirements

/ Limits

EPINEPHRINE

INJECTION AUTO-

INJECTOR 0.15

MG/0.3 ML

2 ST; QL

EPINEPHRINESNA

P-V

3

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

EPISNAP 6 MSD

hydroxyzine hcl 1

hydroxyzine

pamoate

1

KARBINAL ER 3

phenadoz 1

PHENERGAN

INJECTION

6 MSD

phenergan rectal 1

promethazine

injection

6 MSD

promethazine oral 1

promethazine rectal 1

promethegan 1

RYVENT 3

VISTARIL 3

COUGH & COLD THERAPY

benzonatate 1

BROMFED DM 3

brompheniramine-

pseudoeph-dm

1

CAPCOF 3

centergy 1

cheratussin ac 1

CLARINEX-D 12

HOUR

3 QL

Drug Name Drug

Category

Requirements

/ Limits

codeine-guaifenesin 1

CODITUSSIN AC 3

CODITUSSIN DAC 3

g tussin ac 1

guaiatussin ac 1

guaifenesin ac 1

guaifenesin dac 1

HISTEX-AC 3

hydrocodone-

chlorpheniramine

1

hydrocodone-cpm-

pseudoephed

1

hydrocodone-

homatropine

1

hydromet 1

lortuss ex 1

MAR-COF CG 3

m-clear wc 1

M-END PE 3

NINJACOF-XG 3

OBREDON 3 ST

POLY-TUSSIN AC 3

promethazine vc-

codeine

1

promethazine-

codeine

1

promethazine-dm 1

promethazine-

phenylephrine

1

PRO-RED AC (W/

DEXCHLORPHENI

R)

3

RESPA-AR 3

robafen ac 1



95

Drug Name Drug

Category

Requirements

/ Limits

rydex 1

SEMPREX-D 3

TESSALON

PERLES

3

tusnel c 1

TUSNEL

PEDIATRIC

3

TUSSICAPS 3 ST

tussigon 1

TUSSIONEX

PENNKINETIC ER

3

TUZISTRA XR 3 ST

virtussin ac 1

virtussin dac 1

VITUZ 3 ST

ZODRYL AC 25 3

ZODRYL AC 30 3

ZODRYL AC 35 3

ZODRYL AC 40 3

ZODRYL AC 50 3

ZODRYL AC 60 3

ZODRYL AC 80 3

ZODRYL DAC 25 3

ZODRYL DAC 30 3

ZODRYL DAC 35 3

ZODRYL DAC 40 3

ZODRYL DAC 50 3

ZODRYL DAC 60 3

ZODRYL DAC 80 3

ZODRYL DEC 25 3

ZODRYL DEC 30 3

ZODRYL DEC 35 3

Drug Name Drug

Category

Requirements

/ Limits

ZODRYL DEC 40 3

ZODRYL DEC 50 3

ZODRYL DEC 60 3

ZODRYL DEC 80 3

Z-TUSS AC 3

PULMONARY AGENTS

ACCOLATE 3 M; QL

acetylcysteine 1

ADCIRCA 3 PA; ST; S; QL

ADEMPAS 3 PA; S; SLA

ADRENALIN 3

ADVAIR DISKUS 2 ST; M; QL

ADVAIR HFA 2 ST; M; QL

AEROSPAN 3 M

AIRDUO

RESPICLICK

3 ST; M; QL

albuterol sulfate

inhalation

1

albuterol sulfate oral 1 M

ALVESCO 3 ST; M; QL

ANORO ELLIPTA 2 M; QL

ARCAPTA

NEOHALER

2 M; QL

ARMONAIR

RESPICLICK

2 M; QL

ARNUITY

ELLIPTA

2 M

ASMANEX HFA 2 M

ASMANEX

TWISTHALER

2 M; QL

ATROVENT HFA 2 M; QL

BECONASE AQ 3 ST; QL

BERINERT 6 MSD



96

Drug Name Drug

Category

Requirements

/ Limits

BEVESPI

AEROSPHERE

2 M

BREO ELLIPTA 2 ST; M; QL

BROVANA 3 M; QL

budesonide

inhalation

1 M; QL

budesonide nasal 1 QL

CINQAIR 6 MSD

CINRYZE 6 MSD

COMBIVENT

RESPIMAT

2 QL

cromolyn 1 M

CUROSURF 3

DALIRESP ORAL

TABLET 250 MCG

2 PA

DALIRESP ORAL

TABLET 500 MCG

2 PA; QL

DULERA 2 ST; M; QL

DYMISTA 2 ST; QL

ELIXOPHYLLIN 3 M

ESBRIET ORAL

CAPSULE

3 PA; S; SLA;

QL

ESBRIET ORAL

TABLET

3 PA; S; SLA

FASENRA 6 MSD

FIRAZYR 3 PA; S; SLA

FLOVENT DISKUS 2 M; QL

FLOVENT HFA 2 M; QL

flunisolide 1 QL

fluticasone 1 QL

FLUTICASONE-

SALMETEROL

2 ST; M; QL

HAEGARDA 6 PA; MSD

HYPER-SAL 3

Drug Name Drug

Category

Requirements

/ Limits

INCRUSE

ELLIPTA

2 M

ipratropium bromide 1 M

ipratropium-

albuterol

1 QL

KALBITOR 6 MSD

KALYDECO 3 PA; S; SLA

LETAIRIS 3 PA; ST; S

levalbuterol hcl 1

LEVALBUTEROL

TARTRATE

3 ST

LONHALA

MAGNAIR REFILL

3 M

LONHALA

MAGNAIR

STARTER

3 M

metaproterenol 1 M

mometasone 1 QL

montelukast oral

granules in packet

1 M

montelukast oral

tablet

1 M; QL

montelukast oral

tablet,chewable

1 M; QL

NASONEX 3 ST; QL

nebusal inhalation

solution for

nebulization 3 %

1

NEBUSAL

INHALATION

SOLUTION FOR

NEBULIZATION 6

%

3

NUCALA 6 MSD

OFEV 3 PA; S; SLA;

QL



97

Drug Name Drug

Category

Requirements

/ Limits

OMNARIS 3 ST; QL

OPSUMIT 3 PA; S

ORKAMBI 3 S; SLA

PERFOROMIST 2 M; QL

PROAIR HFA 2 QL

PROAIR

RESPICLICK

2

PROVENTIL HFA 3 ST; QL

PULMICORT 3 ST; M; QL

PULMICORT

FLEXHALER

2 M; QL

pulmosal 1

PULMOZYME 2

QNASL NASAL

HFA AEROSOL

INHALER 40

MCG/ACTUATION

2 ST

QNASL NASAL

HFA AEROSOL

INHALER 80

MCG/ACTUATION

2 ST; QL

QVAR

REDIHALER

2 M

REVATIO

INTRAVENOUS

4 PA; S

REVATIO ORAL 4 PA; ST; S; QL

RUCONEST 6 MSD

SEEBRI

NEOHALER

3 M

SEREVENT

DISKUS

2 M; QL

sildenafil

(antihypertensive)

1 PA; S; QL

SINGULAIR ORAL

GRANULES IN

PACKET

3 ST; M

Drug Name Drug

Category

Requirements

/ Limits

SINGULAIR ORAL

TABLET

3 ST; M; QL

SINGULAIR ORAL

TABLET,CHEWAB

LE

3 ST; M; QL

sodium chloride 1

SPIRIVA

RESPIMAT

2 M

SPIRIVA WITH

HANDIHALER

2 M; QL

STIOLTO

RESPIMAT

2 M

STRIVERDI

RESPIMAT

2 M

SURFAXIN 6

SYMBICORT 2 ST; M; QL

terbutaline oral 1 M

terbutaline

subcutaneous

1

THEO-24 3 M

theochron 1 M

theophylline 1 M

TICALAST 3 ST

TRACLEER 3 PA; S; SLA

TRELEGY

ELLIPTA

2 M

TUDORZA

PRESSAIR

2 M; QL

TYVASO 6 MSD

TYVASO REFILL

KIT

6 MSD

TYVASO

STARTER KIT

6 MSD

UTIBRON

NEOHALER

3 M



98

Drug Name Drug

Category

Requirements

/ Limits

VENTAVIS 3 ST; S

VENTOLIN HFA 2 QL

XHANCE 3 ST

XOLAIR 6 MSD

XOPENEX 3

XOPENEX

CONCENTRATE

3

XOPENEX HFA 3 ST

zafirlukast 1 M; QL

ZETONNA 3 ST; QL

zileuton 1 M; QL

ZYFLO 3 ST; M

ZYFLO CR 3 ST; M; QL

UROLOGICALS

ANTICHOLINERGICS &

ANTISPASMODICS

darifenacin 1 M

DETROL 3 ST; M

DETROL LA 3 ST; M

DITROPAN XL 3 ST; M

ENABLEX 3 ST; M

flavoxate 1 M

GELNIQUE

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP

2 ST

GELNIQUE

TRANSDERMAL

GEL IN PACKET

2 ST; M; QL

MYRBETRIQ 2 ST; M

oxybutynin chloride 1 M

OXYTROL 3 ST; M; QL

tolterodine 1 M

Drug Name Drug

Category

Requirements

/ Limits

TOVIAZ 2 ST; M

trospium 1 M

VESICARE 2 ST; M

BENIGN PROSTATIC

HYPERPLASIA (BPH) THERAPY

alfuzosin 1 M

AVODART 3 ST; M

CIALIS 2 ST; QL

dutasteride 1 ST; M

dutasteride-

tamsulosin

1 ST; M

finasteride 1 M

FLOMAX 3 ST; M

JALYN 3 ST; M

PROSCAR 3 ST; M

RAPAFLO 2 ST; M

tamsulosin 1 M

UROXATRAL 3 ST; M

CHOLINERGIC STIMULANTS

bethanechol chloride 1

URECHOLINE 3

MISCELLANEOUS UROLOGICALS

azuphen mb 1

CYSTAGON 2 PA; SLA

cytra k crystals 1

cytra-2 1

cytra-3 1

cytra-k 1

ELMIRON 2

hyolev mb 1

hyophen 1

INDIOMIN MB 3



99

Drug Name Drug

Category

Requirements

/ Limits

K-PHOS NO 2 3

K-PHOS

ORIGINAL

2

methen-sod phos-

meth blue-hyos

1

ORACIT 3

phosphasal 1

pot,sodium citrate-

citric acid

1

potassium citrate 1 M

potassium citrate-

citric acid

1

PROCYSBI 4 PA; ST; S;

SLA

SHOHL'S

MODIFIED

3

sodium citrate-citric

acid

1

tricitrates 1

URELLE 3

uretron d-s 1

URIBEL 3

urimar-t 1

urin ds 1

uro-458 1

UROCIT-K 10 3 M

UROCIT-K 15 3 M

UROCIT-K 5 3 M

urogesic-blue 1

uro-mp 1

urophen mb 1

UROQID-ACID

NO.2

3

uryl 1

Drug Name Drug

Category

Requirements

/ Limits

ustell 1

UTA 3

utira-c 1

virtrate-2 1

virtrate-3 1

virtrate-k 1

URINARY ANESTHETICS

phenazopyridine 1

PYRIDIUM 3

VITAMINS, HEMATINICS &

ELECTROLYTES

ELECTROLYTES

calcium 500 + d 5 ACA; OTC

calcium 500 with d 5 ACA; OTC

calcium 600 + d(3) 5 ACA; OTC

calcium 600 with

vitamin d3

5 ACA; OTC

calcium carb and

citrate-vitd3

5 ACA; OTC

calcium carbonate-

vitamin d3

5 ACA; OTC

calcium citrate + d 5 ACA; OTC

calcium citrate-

vitamin d2

5 ACA; OTC

calcium citrate-

vitamin d3

5 ACA; OTC

calcium gluconate in

0.9% nacl


1 gram/100 ml

6 MSD



100

Drug Name Drug

Category

Requirements

/ Limits

CALCIUM

GLUCONATE IN

0.9% NACL

INTRAVENOUS

SOLUTION 1

GRAM/50 ML, 2

GRAM/100 ML, 2

GRAM/50 ML, 3

GRAM/100 ML

6 MSD

CALCIUM

GLUCONATE IN

0.9% NACL

INTRAVENOUS

SYRINGE

6 MSD

CALCIUM

GLUCONATE IN

D5W

6 MSD

citrus calcium 5 ACA; OTC

hi-cal plus vit d 5 ACA; OTC

k-phos-neutral 1

lugols 1

oysco 500/d 5 ACA; OTC

oyster shell + d3 5 ACA; OTC

oyster shell calcium-

vit d3

5 ACA; OTC

oystercal-d 5 ACA; OTC

phospha 250 neutral 1

phosphorous 1

POTABA 3 M

sodium chloride 6 MSD

sodium chloride 0.45

%

6 MSD

sodium chloride 3 % 6 MSD

sodium chloride 5 % 6 MSD

strong iodine 1

virt-phos 250 neutral 1

Drug Name Drug

Category

Requirements

/ Limits

MISCELLANEOUS VITAMINS,

HEMATINICS, & ELECTROLYTES

FORTAVIT 3

ISOLYTE-S 6 MSD

VITAMINS & HEMATINICS

ACTIVE FE 3

ANIMI-3 WITH

VITAMIN D

3

ATABEX EC 3

b complex-vitamin

b12

5 ACA; OTC

b complex-vitamin c-

folic acid

5 ACA; OTC

B-12

COMPLIANCE

6 MSD

BACMIN 3

balanced b-100 5 ACA; OTC

balanced b-100

complex

5 ACA; OTC

balanced b-50 5 ACA; OTC

bal-care dha 1

BAL-CARE DHA

ESSENTIAL

3

b-complex with

vitamin c oral tablet

5 ACA; OTC

b-complex with

vitamin c oral tablet

400-500 mcg-mg

1 OTC

BIFERA RX 3

CADEAU DHA 3

calcium pnv 1

calcium-folic acid-

vitamin d

1

centratex 1



101

Drug Name Drug

Category

Requirements

/ Limits

cholecalciferol

(vitamin d3)

5 ACA; OTC

ciferex 1 M

CITRANATAL

(DUAL-IRON)

3

CITRANATAL 90

DHA (ALGAL OIL)

3

CITRANATAL

ASSURE

3

CITRANATAL B-

CALM (FE GLUC)

3

CITRANATAL

BLOOM

3

CITRANATAL

DHA (ALGAL OIL)

3

CITRANATAL

HARMONY (IRON

FUM)

3

classic prenatal 5 ACA; OTC

c-nate dha 1

complete natal dha 1

completenate 1

complex b-100 1 OTC

CONCEPT DHA 3

CONCEPT OB 3

corvita 1

corvita 150 1

CORVITE 3

CORVITE 150 3

CORVITE FE 3

CORVITE FREE 3

cyanocobalamin

(vitamin b-12)

1

delta d3 5 ACA; OTC

Drug Name Drug

Category

Requirements

/ Limits

dialyvite 1

DIALYVITE 3000 3

DIALYVITE 5000 3

dialyvite 800 5 ACA; OTC

DIALYVITE 800

WITH IRON

3

DIALYVITE

SUPREME D

3

dothelle dha 1

DRISDOL 3

DUET DHA

BALANCED

3

DUET DHA WITH

OMEGA-3

3

d-vi-sol 5 ACA; OTC

ENBRACE HR 3

ergocalciferol

(vitamin d2) oral

capsule

1

ergocalciferol

(vitamin d2) oral

tablet

5 ACA; OTC

ESCAVITE 3

ESCAVITE D 3 M

ESCAVITE LQ 3 M

EXTRA-VIRT

PLUS DHA

3

FERIVA 21-7

TABLET

3

ferocon 1

FERRALET 90

DUAL-IRON

DELIVERY

3

ferraplus 90 1

ferrocite plus 1



102

Drug Name Drug

Category

Requirements

/ Limits

FLORIVA 3 M

FLORIVA

(FLUORIDE-

VITAMIN D3)

5 M; ACA

FLORIVA PLUS 3 M

FLORIVA PLUS

(WITH BIOTIN)

3 M

FLUORABON 5 M; ACA

fluoride (sodium)

oral drops

5 M; ACA

fluoride (sodium)


0.25 mg(0.55 mg

sod. fluoride), 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA

fluoride (sodium)


1 mg (2.2 mg sod.

fluoride)

1 M

fluoritab oral

tablet,chewable 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA

fluoritab oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M

FLURA-DROPS 5 M; ACA

folbee 1

folbee plus 1

FOLET ONE 3

FOLGARD OS 3

FOLGARD RX 3

folic acid oral tablet

1 mg

1 M

folic acid oral tablet

400 mcg, 800 mcg

5 M; ACA; OTC

Drug Name Drug

Category

Requirements

/ Limits

folic acid-vit b6-vit

b12

1

folivane-f 1

folivane-ob 1

folivane-plus 1

folplex 2.2 1

foltabs 800 1 OTC

FOLTRATE 3

full spectrum b-

vitamin c

5 ACA; OTC

FUSION PLUS 3

FUSION

SPRINKLES

3

hematinic plus

vit/minerals

1

hematinic/folic acid 1

hematogen 1

hematogen fa 1

hematogen forte 1

HEMATRON-AF 3

hemenatal ob 1

hemenatal ob + dha 1

hemetab 1

HEMOCYTE-F 3

HEMOCYTE-PLUS 3

ICAR-C PLUS 3

INFUVITE ADULT 6 MSD

INFUVITE

PEDIATRIC

6 MSD

INJECTAFER 6 MSD

INTEGRA F 3

INTEGRA PLUS 3

IROSPAN 24/6 3



103

Drug Name Drug

Category

Requirements

/ Limits

kobee 1 OTC

KOSHER

PRENATAL PLUS

IRON

3

kpn 1 OTC

ludent fluoride oral

tablet,chewable 0.25

mg(0.55 mg sod.

fluoride), 0.5 mg

(1.1 mg sodium

fluorid)

5 M; ACA

ludent fluoride oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M

m.v.i. adult 6 MSD

MARNATAL-F 3

MAXFE (FOLATE-

DOCUSATE)

3

multigen folic 1

multigen plus 1

multi-vit with

fluoride-iron

5 ACA

multi-vitamin with

fluoride oral drops

5 ACA

multi-vitamin with

fluoride oral


mg, 0.5 mg

5 ACA

multi-vitamin with

fluoride oral

tablet,chewable 1

mg

1

multivitamins with

fluoride oral


mg, 0.5 mg

5 ACA

Drug Name Drug

Category

Requirements

/ Limits

multivitamins with

fluoride oral

tablet,chewable 1

mg

1

mvc-fluoride oral


mg, 0.5 mg

5 ACA

mvc-fluoride oral

tablet,chewable 1

mg

1

mynatal 1

mynatal advance 1

mynatal plus 1

mynatal-z 1

mynate 90 plus 1

mynephrocaps 1

mynephron 1

NATACHEW (FE

BIS-GLYCINATE)

3

natural b-100

complex

5 ACA; OTC

NEEVODHA

(WITH ALGAL

OIL)

3

nephplex rx 1

NEPHROCAPS 3

NEPHROCAPS QT 3

NEPHRON FA 3

nephro-vite rx 1

NESTABS 3

NESTABS ABC 3

NESTABS DHA 3

NESTABS ONE 3

NEURIN-SL 3

newgen 1



104

Drug Name Drug

Category

Requirements

/ Limits

NEXAVIR 3

NIVA-PLUS 3

NUTRICAP 3

OB COMPLETE

GOLD

3

OB COMPLETE

ONE

3

OB COMPLETE

PETITE

3

OB COMPLETE

PREMIER

3

OB COMPLETE

WITH DHA

3

obstetrix dha 1

OBSTETRIX EC 3

OBSTETRIX ONE 3

OBTREX DHA 3

O-CAL FA 3

O-CAL

PRENATAL

3

one daily prenatal 5 ACA; OTC

ortho d 1 M

ORTHO DF 3 M

oyster shell calcium-

vit d2

5 ACA; OTC

perry prenatal 5 ACA; OTC

PHYSICIANS EZ

USE B-12

6 MSD

pnv 29-1 1

pnv ob+dha 1

pnv-dha 1

pnv-dha + docusate 1

pnv-ferrous

fumarate-docu-fa

1

Drug Name Drug

Category

Requirements

/ Limits

pnv-omega 1

pnv-select 1

pnv-vp-u 1

POLY-VI-FLOR 3

POLY-VI-FLOR

WITH IRON

3

pr natal 400 1

pr natal 400 ec 1

pr natal 430 1

pr natal 430 ec 1

PREFERA-OB 3

PREFERA-OB ONE 3

PREFERA-OB

PLUS DHA

3

prena1 chew 1

prena1 pearl 1

prena1 true 1

prenaissance 1

prenaissance plus 1

PRENATA 3

prenatabs fa 1

prenatabs rx 1

prenatal 5 ACA; OTC

prenatal complete 5 ACA; OTC

prenatal formula 5 ACA; OTC

prenatal multi-dha

(algal oil)

1 OTC

prenatal one daily 5 ACA; OTC

prenatal plus 1

prenatal plus

(calcium carb)

1

PRENATAL PLUS

DHA

3



105

Drug Name Drug

Category

Requirements

/ Limits

prenatal vitamin 5 ACA; OTC

prenatal vitamin

plus low iron

1

prenatal vitamin

with minerals

5 ACA; OTC

prenatal vits96-iron

fum-folic

5 ACA; OTC

prenatal-u 1

PRENATE AM 3

PRENATE

CHEWABLE

3

PRENATE DHA

(FERR ASP

GLYCIN)

3

PRENATE ELITE

(IRON ASP GLYC)

3

PRENATE

ENHANCE

3

PRENATE

ESSENTIAL(IRON-

ASP-GL)

3

PRENATE MINI

(FERR ASP

GLYCIN)

3

PRENATE PIXIE 3

PRENATE

RESTORE

3

PRENATE STAR 3

preplus 1

pretab 1

PRIMACARE 3

PROFERRIN-

FORTE

3

PROTECT IRON 3

PROVIDA DHA 3

PROVIDA OB 3

Drug Name Drug

Category

Requirements

/ Limits

PURALOR CI 3 M

PUREFE OB PLUS 3

PUREFE PLUS 3

purevit dualfe plus 1

QUFLORA 3 M

QUFLORA FE 3 M

QUFLORA FE

(FERROUS

SULFATE)

5 M; ACA

QUFLORA

PEDIATRIC

3 M

QUFLORA

PEDIATRIC

DROPS

3 M

relnate dha 1

renal caps 1

rena-vite 5 ACA; OTC

rena-vite rx 1

reno caps 1

risacal-d 5 ACA; OTC

R-NATAL OB 3

SELECT-OB 3

SELECT-OB

(FOLIC ACID)

3

SELECT-OB +

DHA

3

se-natal 19 1

se-natal 19 (with

docusate)

1

se-tan plus 1

stress formula 5 ACA; OTC

stress formula with

iron

1 OTC



106

Drug Name Drug

Category

Requirements

/ Limits

stress formula with

iron(sulf)

1 OTC

STROVITE FORTE 3

STROVITE ONE 3

super b complex-

vitamin c

1 OTC

super b maxi

complex

1 OTC

super b-50 complex

plus

1 OTC

super quints 1 OTC

super quints b-50 5 ACA; OTC

superplex-t 1 OTC

SUPERVITE 3

TANDEM PLUS 3

taron forte 1

taron-c dha 1

taron-prex prenatal-

dha

1

THRIVITE RX 3

thrivite-19 1

tl gard rx 1

tl g-fol os 1

tl icon 1

total b/c 1 OTC

TRICARE 3

tricon 1

TRIFERIC 6 MSD

trigels-f forte 1

trinatal rx 1 1

trinate 1

triphrocaps 1

TRISTART DHA 3

Drug Name Drug

Category

Requirements

/ Limits

triveen-duo dha 1

TRI-VI-FLOR 3

tri-vitamin with

fluoride

5 ACA

trust natal dha 1

UDAMIN SP 3

ultra b-100 complex 1 OTC

v-c forte 1

VENOFER 6 MSD

vic-forte 1

vinate care 1

VINATE DHA RF 3

vinate ii 1

vinate m 1

vinate one 1

virt-advance 1

virt-c dha 1

VIRT-CAPS 3

virt-gard 1

virt-nate 1

virt-nate dha 1

virt-pn 1

virt-pn dha 1

virt-pn plus 1

VIRTPREX 3

virt-select 1

virt-vite 1

virt-vite gt 1

VIRT-VITE PLUS 3 M

vit 3 1

VITAFOL 3



107

Drug Name Drug

Category

Requirements

/ Limits

VITAFOL FE+

(WITH

DOCUSATE)

3

VITAFOL

GUMMIES

3

VITAFOL NANO 3

VITAFOL ULTRA 3

VITAFOL-OB 3

VITAFOL-

OB+DHA

3

VITAFOL-ONE 3

vitajoy daily d 5 ACA; OTC

VITAL-D RX 3

VITAMED MD

ONE RX

3

VITAMEDMD

REDICHEW RX

3

vitamin b complex 5 ACA; OTC

vitamin b complex-

folic acid

5 ACA; OTC

vitamin d3 5 ACA; OTC

Drug Name Drug

Category

Requirements

/ Limits

vitamins a,c,d and

fluoride

5 ACA

VITAPEARL 3

VITA-RESPA 3

VITATRUE 3

vol-nate 1

vol-plus 1

vol-tab rx 1

vp-ch plus 1

vp-ch-pnv 1

vp-ggr-b6 1

vp-heme ob 1

vp-heme one 1

VP-PNV-DHA 3

vp-vite rx 1

zatean-pn dha 1

zatean-pn plus 1

zavara 1 M

zingiber 1



108

Index 2 2TEK GLUCOSE/BLOOD

PRESSURE ...................... 59

A abacavir .................................. 3

abacavir-lamivudine ............... 3

abacavir-lamivudine-

zidovudine .......................... 3

ABILIFY .............................. 28

ABILIFY MAINTENA ........ 28

ABRAXANE ........................ 12

ABSORICA .......................... 45

ABSTRAL ............................ 22

acamprosate .......................... 51

ACANYA ............................. 45

acarbose ................................ 69

ACCOLATE......................... 94

ACCU-CHEK AVIVA PLUS

METER ............................ 59

ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 55

ACCU-CHEK COMPACT

PLUS CONTROL ............ 59

ACCU-CHEK COMPACT

PLUS TEST ..................... 55

ACCU-CHEK GUIDE ......... 55

ACCU-CHEK GUIDE

GLUCOSE METER ......... 59

ACCU-CHEK GUIDE L1-L2

CTRL SOL ....................... 59

ACCU-CHEK NANO .......... 59

ACCU-CHEK SMARTVIEW

CONTRL SOL ................. 59

ACCU-CHEK SMARTVIEW

TEST STRIP .................... 55

ACCUPRIL .......................... 34

ACCURETIC ....................... 34

ACCUTREND GLUCOSE .. 55

ACCUTREND GLUCOSE

CONTROL ....................... 59

acebutolol ............................. 34

acetaminophen-caff-

dihydrocod ........................ 22

ACETAMINOPHEN-CAFF-

DIHYDROCOD ............... 22

acetaminophen-codeine ........ 22

acetazolamide ....................... 91

acetazolamide sodium .......... 91

acetic acid ............................. 54

acetylcysteine ....................... 94

ACIPHEX ............................. 76

ACIPHEX SPRINKLE ........ 76

acitretin ................................. 42

ACTEMRA .......................... 81

ACTHAR H.P. ..................... 54

ACTHIB (PF) ....................... 79

ACTICLATE ........................ 11

ACTIGALL .......................... 72

ACTIMMUNE ..................... 79

ACTIQ .................................. 22

ACTIVE FE .......................... 99

ACTIVELLA........................ 83

ACTONEL ..................... 51, 81

ACTOPLUS MET ................ 69

ACTOPLUS MET XR ......... 69

ACTOS ................................. 69

acuicyn.................................. 89

ACULAR.............................. 90

ACULAR LS ........................ 90

ACUVAIL (PF) .................... 90

acyclovir ........................... 3, 49

ACZONE .............................. 45

ADACEL(TDAP

ADOLESN/ADULT)(PF) 80

ADAGEN ............................. 51

ADALAT CC ....................... 34

adapalene .............................. 45

ADAPALENE ...................... 45

adapalene-benzoyl peroxide . 45

ADASUVE ........................... 28

ADCETRIS .......................... 12

ADCIRCA ............................ 94

ADDERALL ........................ 28

ADDERALL XR .................. 28

ADDYI ................................. 28

adefovir ................................... 3

ADEMPAS ........................... 94

ADLYXIN ............................ 69

ADMELOG SOLOSTAR U-

100 INSULIN ................... 66

ADMELOG U-100 INSULIN

LISPRO ............................ 66

ADRENALIN ....................... 94

adriamycin ............................ 12

adrucil ................................... 12

ADVAIR DISKUS ............... 94

ADVAIR HFA ...................... 94

ADVANCED GLUC METER

TEST STRIP ..................... 55

ADVANCED GLUCOSE

METER ............................. 59

ADVATE .............................. 38

ADVOCATE BLOOD

GLUCOSE MONITOR .... 59

ADVOCATE DUO .............. 59

ADVOCATE LOW

CONTROL ....................... 59

ADVOCATE REDI-CODE .. 55

ADVOCATE REDI-CODE

DUO METER ................... 59

ADVOCATE REDI-CODE

GLU MONITOR .............. 59

ADVOCATE REDI-CODE+

CTRL LOW ...................... 59

ADVOCATE TEST STRIPS 55

ADYNOVATE ..................... 38

ADYPHREN ........................ 92

ADYPHREN AMP ............... 92

ADYPHREN AMP II ........... 92

ADYPHREN II ..................... 92

ADZENYS ER ..................... 28

ADZENYS XR-ODT ........... 28

AEROSPAN ......................... 94

afeditab cr ............................. 34

AFINITOR ........................... 12

AFINITOR DISPERZ .......... 12

AFREZZA ............................ 66

AFSTYLA ............................ 38

AFTERA ............................... 85

AGAMATRIX AMP GLUC

MONITOR SYS ............... 59

AGAMATRIX AMP TEST

STRIPS ............................. 55

AGAMATRIX CONTROL

HIGH ................................ 59

AGONEAZE ........................ 47

AGRYLIN ............................ 51

AIMOVIG AUTOINJECTOR

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

AIMOVIG AUTOINJECTOR

(2 PACK) .......................... 20



109

AIRDUO RESPICLICK ...... 94

ak-poly-bac ........................... 88

AKTEN (PF) ........................ 90

AKTIPAK ............................ 45

AKYNZEO

(FOSNETUPITANT) ....... 72

AKYNZEO (NETUPITANT)

.......................................... 72

ala-cort .................................. 49

ALA-SCALP ........................ 49

ALBENZA ............................. 7

albuterol sulfate .................... 94

alclometasone ....................... 49

ALDACTAZIDE .................. 34

ALDACTONE ..................... 34

ALDARA ............................. 79

ALDURAZYME .................. 67

ALECENSA ......................... 12

alendronate ..................... 51, 81

ALEVICYN PLUS ............... 43

ALFERON N........................ 79

alfuzosin ............................... 97

ALINIA .................................. 7

ALIQOPA ............................ 12

ALKERAN ........................... 12

allopurinol ............................ 81

ALLZITAL........................... 22

almotriptan malate ................ 20

ALOCRIL ............................ 90

ALOGLIPTIN ...................... 69

ALOGLIPTIN-METFORMIN

.......................................... 69

ALOGLIPTIN-

PIOGLITAZONE ............. 69

ALOMIDE ........................... 90

alophen ................................. 72

ALORA ................................ 83

alosetron ............................... 72

ALOXI ................................. 72

ALPHAGAN P ..................... 92

ALPHANATE ...................... 38

ALPHANINE SD ................. 38

alprazolam ............................ 28

alprazolam intensol .............. 28

ALPROLIX .......................... 38

ALREX ................................ 91

ALTABAX ........................... 48

altacaine ................................ 90

ALTACE .............................. 34

altafluor ................................ 90

altavera (28) .......................... 85

ALTOPREV ......................... 40

ALUNBRIG ......................... 12

ALVESCO............................ 94

alyacen 1/35 (28) .................. 85

alyacen 7/7/7 (28) ................. 85

amabelz ................................. 83

amantadine hcl ........................ 3

AMARYL ............................. 69

AMBIEN .............................. 28

AMBIEN CR ........................ 28

AMBISOME .......................... 3

amcinonide ........................... 49

AMELUZ ............................. 43

AMERGE ............................. 20

amethia ................................. 85

amethia lo ............................. 85

amethyst................................ 85

AMICAR .............................. 38

amifostine crystalline ........... 12

amikacin ................................. 7

amiloride ............................... 34

amiloride-hydrochlorothiazide

.......................................... 34

amiodarone ........................... 34

AMITIZA ............................. 72

amitriptyline ......................... 28

amitriptyline-chlordiazepoxide

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

amlodipine ............................ 34

amlodipine-atorvastatin ........ 40

amlodipine-benazepril .......... 34

amlodipine-olmesartan ......... 34

amlodipine-valsartan ............ 34

amlodipine-valsartan-hcthiazid

.......................................... 35

AMMONUL ......................... 51

amnesteem ............................ 45

amoxapine ............................ 28

amoxicil-clarithromy-lansopraz

.......................................... 76

amoxicillin .............................. 9

amoxicillin-pot clavulanate .... 9

AMPHADASE ..................... 51

amphotericin b ........................ 3

ampicillin ................................ 9

ampicillin sodium ................... 9

ampicillin-sulbactam .............. 9

AMPYRA ............................. 21

AMRIX ................................. 22

ANADROL-50 ..................... 67

ANAFRANIL ....................... 28

anagrelide ............................. 51

ANALPRAM-HC ........... 42, 72

ANALPRAM-HC SINGLES72

ANAPROX DS ..................... 26

anaspaz ................................. 71

ANASTIA ............................. 47

anastrozole ............................ 12

ANCOBON ............................ 3

ANDEXXA .......................... 38

ANDRODERM .................... 67

ANDROGEL ........................ 67

ANDROID ............................ 67

ANGELIQ ............................ 83

ANGIOMAX ........................ 38

ANIMI-3 WITH VITAMIN D

.......................................... 99

ANODYNE LPT .................. 47

ANORO ELLIPTA ............... 94

ANTABUSE ......................... 51

ANTARA ............................. 40

anucort-hc ............................. 72

ANUSOL-HC ....................... 72

ANZEMET ........................... 72

apexicon e ............................. 49

APIDRA SOLOSTAR U-100

INSULIN .......................... 66

APIDRA U-100 INSULIN ... 66

APLENZIN ........................... 29

APOKYN ............................. 19

apraclonidine ........................ 92

aprepitant .............................. 72

apri ........................................ 85

APRISO ................................ 72

APTENSIO XR .................... 29

APTIOM ............................... 18

APTIVUS ............................... 3

AQUA GLYCOLIC HC ....... 49

ARALAST NP ...................... 51

aranelle (28) .......................... 85

ARANESP (IN

POLYSORBATE) ............ 78

ARAVA ................................ 82



110

ARCALYST ......................... 79

ARCAPTA NEOHALER ..... 94

ARESTIN ............................. 53

ARGATROBAN .................. 38

ARGATROBAN IN 0.9 %

SOD CHLOR ................... 39

ARGATROBAN IN NACL

(ISO-OS) .......................... 39

ARICEPT ............................. 21

ARIMIDEX .......................... 12

aripiprazole ........................... 29

ARISTADA .......................... 29

ARIXTRA ............................ 39

armodafinil ........................... 29

ARMONAIR RESPICLICK 94

ARMOUR THYROID ......... 71

ARNUITY ELLIPTA ........... 94

AROMASIN......................... 12

ARRANON .......................... 12

ARTHROTEC 50 ................. 26

ARTHROTEC 75 ................. 26

ARYMO ER ......................... 22

ARZERRA ........................... 12

ASACOL HD ....................... 72

ascomp with codeine ............ 22

ashlyna .................................. 85

ASMANEX HFA ................. 94

ASMANEX TWISTHALER 94

aspirin ................................... 26

aspir-trin ............................... 26

ASSURE 4 CONTROL

SOLUTION ...................... 59

ASSURE 4 STRIPS ............. 55

ASSURE DOSE NORMAL

CONTROL ....................... 59

ASSURE PLATINUM ... 56, 59

ASSURE PRISM CONTROL

1-2 SOLN ......................... 59

ASSURE PRISM MULTI

METER ............................ 59

ASSURE PRISM MULTI

STRIP ............................... 56

ASTAGRAF XL .................. 12

ASTEPRO ............................ 53

ASTERO .............................. 47

ATABEX EC........................ 99

ATACAND .......................... 35

ATACAND HCT ................. 35

atazanavir................................ 3

ATELVIA ............................. 81

atenolol ................................. 35

atenolol-chlorthalidone ......... 35

ATGAM ............................... 80

ATIVAN ............................... 29

atomoxetine .......................... 29

ATOPADERM ..................... 43

ATOPICLAIR ...................... 43

atorvastatin ........................... 40

atovaquone.............................. 7

atovaquone-proguanil ............. 7

ATRALIN ............................ 45

ATRAPRO CP ..................... 43

ATRAPRO HYDROGEL .... 43

ATRIPLA ............................... 3

atropine ........................... 71, 89

atropine in 0.9 % sod chloride

.......................................... 71

ATROPINE IN 0.9 % SOD

CHLORIDE ................ 71, 89

ATROVENT HFA ............... 94

AUBAGIO............................ 79

aubra ..................................... 85

AUGMENTIN ...................... 10

AUGMENTIN ES-600 ........... 9

AUGMENTIN XR ............... 10

AURYXIA............................ 72

AUSTEDO ........................... 21

AUTOJECT 2 INJECTION

DEVICE ........................... 60

AUTOPEN 1 TO 21 UNITS 60

AUTOSOFT 30 .................... 60

AUTOSOFT 90 .................... 60

AUVI-Q ................................ 92

AVALIDE ............................ 35

AVANDIA ........................... 69

AVAPRO.............................. 35

avar ....................................... 45

AVAR ................................... 45

AVAR LS ............................. 45

AVAR-E GREEN................. 45

AVAR-E LS ......................... 45

AVASTIN ............................ 12

AVC VAGINAL .................. 84

AVEED ................................ 67

AVELOX.............................. 10

AVELOX IN NACL (ISO-

OSMOTIC) ....................... 10

aviane .................................... 85

avidoxy ................................. 11

avita ...................................... 45

AVITA .................................. 45

avo cream .............................. 43

AVODART ........................... 97

AVONEX ............................. 79

AVONEX (WITH ALBUMIN)

.......................................... 79

AVYCAZ ............................... 6

AXERT ................................. 20

AXIRON ............................... 67

AYGESTIN .......................... 83

azacitidine ............................. 12

AZASAN .............................. 12

AZASITE ............................. 88

azathioprine .......................... 12

azelastine ........................ 53, 90

AZELEX ............................... 45

AZILECT ............................. 19

azithromycin ........................... 7

AZOPT ................................. 91

AZOR ................................... 35

AZULFIDINE ...................... 72

AZULFIDINE EN-TABS .... 73

azuphen mb ........................... 97

azurette (28) .......................... 85

B b complex-vitamin b12 ......... 99

b complex-vitamin c-folic acid

.......................................... 99

B-12 COMPLIANCE ........... 99

bacitracin .............................. 88

bacitracin-polymyxin b ......... 88

baclofen ................................ 22

BACLOFEN ......................... 22

BACMIN .............................. 99

BACTRIM ............................ 10

BACTRIM DS ...................... 10

BACTROBAN ..................... 48

BACTROBAN NASAL ....... 53

balanced b-100 ...................... 99

balanced b-100 complex ....... 99

balanced b-50 ........................ 99

bal-care dha .......................... 99



111

BAL-CARE DHA

ESSENTIAL..................... 99

BALCOLTRA ...................... 85

balsalazide ............................ 73

balziva (28) ........................... 85

BANZEL .............................. 18

BARACLUDE ................... 3, 4

BASAGLAR KWIKPEN U-

100 INSULIN ................... 66

BAVENCIO ......................... 12

BAXDELA ........................... 10

bayer aspirin ......................... 26

BCG VACCINE, LIVE (PF) 80

b-complex with vitamin c ..... 99

BEBULIN ............................ 39

BECONASE AQ .................. 94

bekyree (28).......................... 85

BELBUCA ........................... 23

BELEODAQ ........................ 12

belladonna alkaloids-opium . 71

belladonna-opium ................. 71

BELSOMRA ........................ 29

benazepril ............................. 35

benazepril-hydrochlorothiazide

.......................................... 35

BENDEKA ........................... 12

BENEFIX ............................. 39

BENICAR ............................ 35

BENICAR HCT ................... 35

BENLYSTA ......................... 82

BENSAL HP ........................ 43

BENTYL .............................. 71

BENZACLIN ....................... 45

BENZACLIN PUMP ........... 45

BENZAMYCIN ................... 45

BENZEFOAM ..................... 45

BENZEFOAM ULTRA ....... 45

benzepro ............................... 45

BENZNIDAZOLE ................. 7

benzonatate ........................... 93

benzoyl peroxide .................. 45

benztropine ........................... 19

BEPREVE ............................ 90

BERINERT .......................... 94

BESIVANCE ....................... 88

BESPONSA ......................... 12

BETADINE OPHTHALMIC

PREP ................................ 88

BETAGAN ........................... 89

betamethasone acet,sod phos 54

betamethasone dipropionate . 49

BETAMETHASONE SOD

PHOSPH-WATER ........... 54

betamethasone valerate......... 49

betamethasone, augmented ... 49

BETAPACE ......................... 34

BETAPACE AF ................... 34

BETASERON ...................... 79

betaxolol ......................... 35, 89

bethanechol chloride ............. 97

BETHKIS ............................... 7

BETIMOL ............................ 89

BETOPTIC S ........................ 89

BEVACIZUMAB ................. 90

BEVESPI AEROSPHERE ... 95

BEVYXXA .......................... 39

bexarotene ............................ 12

BEXSERO ............................ 80

BEYAZ ................................. 85

BIAFINE EMULSION......... 43

bicalutamide ......................... 12

BICILLIN C-R ..................... 10

BICNU.................................. 12

BIDIL ................................... 35

BIFERA RX ......................... 99

BIKTARVY ........................... 4

BILTRICIDE .......................... 7

bimatoprost ........................... 91

BINOSTO ............................. 81

BIONIME RIGHTEST

GM300 SYSTEM ............. 60

BIONIME RIGHTEST TEST

STRIPS ............................. 56

bisacodyl ............................... 73

bisa-lax ................................. 73

bisoprolol fumarate............... 35

bisoprolol-hydrochlorothiazide

.......................................... 35

bivalirudin ............................ 39

BIVALIRUDIN-0.9 %

SODIUM CHLOR ............ 39

BIVIGAM ............................ 80

bleomycin ............................. 13

BLEPH-10 ............................ 92

BLEPHAMIDE .................... 92

BLEPHAMIDE S.O.P. ......... 92

BLINCYTO .......................... 13

blisovi 24 fe .......................... 85

blisovi fe 1.5/30 (28) ............ 85

blisovi fe 1/20 (28) ............... 85

BLOOD GLUCOSE

CONTROL, NORMAL .... 60

BLOOD GLUCOSE TEST .. 56

BLOOD-GLUCOSE METER

.......................................... 60

BONIVA ............................... 81

BONJESTA .......................... 73

BOOSTRIX TDAP ............... 80

BORTEZOMIB .................... 13

BOSULIF ............................. 13

BOTOX ................................ 80

bp 10-1 .................................. 45

bpo ........................................ 45

BRAVELLE ......................... 67

BREEZE 2 CONTROL

SOLUTION,HIGH ........... 60

BREEZE 2 TEST STRIPS ... 56

BREO ELLIPTA .................. 95

BREVIBLOC ....................... 35

BREVIBLOC IN NACL (ISO-

OSM) ................................ 35

BREVICON (28) .................. 85

BRIDION ............................. 22

briellyn .................................. 85

brimonidine ........................... 92

BRINEURA .......................... 67

BRISDELLE ......................... 29

BRIVIACT ........................... 18

BROMFED DM ................... 93

bromfenac ............................. 90

bromocriptine ....................... 19

brompheniramine-pseudoeph-

dm ..................................... 93

BROMSITE .......................... 90

BROVANA .......................... 95

BUCALSEP .......................... 47

budesonide ...................... 73, 95

bumetanide ........................... 35

BUNAVAIL ......................... 26

BUPAP ................................. 23

BUPHENYL ......................... 51

BUPRENEX ......................... 23

BUPRENORPHINE ............. 23

buprenorphine hcl ................. 23



112

buprenorphine-naloxone....... 26

bupropion hcl........................ 29

bupropion hcl (smoking deter)

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

buspirone .............................. 29

busulfan ................................ 13

BUSULFEX ......................... 13

butalbital compound w/codeine

.......................................... 23

butalbital-acetaminop-caf-cod

.......................................... 23

butalbital-acetaminophen ..... 23

butalbital-acetaminophen-caff

.......................................... 23

butalbital-aspirin-caffeine .... 23

butorphanol tartrate .............. 26

BUTRANS ........................... 23

BYDUREON ........................ 69

BYDUREON BCISE ........... 69

BYETTA .............................. 69

BYSTOLIC .......................... 35

BYVALSON ........................ 35

C cabergoline ........................... 67

CABOMETYX .................... 13

CADEAU DHA.................... 99

CADUET .............................. 40

CAFERGOT ......................... 20

caffeine citrate ...................... 51

CALAN ................................ 35

CALAN SR .......................... 35

calcipotriene ......................... 42

calcipotriene-betamethasone 42

calcitonin (salmon) ............... 67

calcitrene .............................. 42

calcitriol .......................... 42, 67

calcium 500 + d .................... 98

calcium 500 with d ............... 98

calcium 600 + d(3) ............... 98

calcium 600 with vitamin d3 98

calcium acetate ..................... 73

calcium carb and citrate-vitd3

.......................................... 98

calcium carbonate-vitamin d3

.......................................... 98

calcium citrate + d ................ 98

calcium citrate-vitamin d2 .... 98

calcium citrate-vitamin d3 .... 98

calcium gluconate in 0.9% nacl

.......................................... 98

CALCIUM GLUCONATE IN

0.9% NACL ...................... 99

CALCIUM GLUCONATE IN

D5W ................................. 99

calcium pnv .......................... 99

calcium-folic acid-vitamin d 99

CALQUENCE ...................... 13

CAMBIA .............................. 26

camila ................................... 83

CAMPTOSAR ..................... 13

camrese ................................. 85

camrese lo ............................. 85

CANASA.............................. 73

CANCIDAS............................ 3

candesartan ........................... 35

candesartan-hydrochlorothiazid

.......................................... 35

capacet .................................. 23

CAPASTAT ........................... 7

CAPCOF .............................. 93

capecitabine .......................... 13

CAPEX ................................. 49

CAPITAL WITH CODEINE

.......................................... 23

CAPRELSA.......................... 13

captopril ................................ 35

captopril-hydrochlorothiazide

.......................................... 35

CARAC ................................ 43

CARAFATE ......................... 76

CARBAGLU ........................ 52

carbamazepine ...................... 18

CARBATROL ...................... 18

carbidopa .............................. 19

carbidopa-levodopa .............. 19

carbidopa-levodopa-

entacapone ........................ 19

carbinoxamine maleate ......... 92

carboplatin ............................ 13

CARDIZEM ......................... 35

CARDIZEM CD .................. 35

CARDIZEM LA ................... 35

CARDURA .......................... 35

CARDURA XL .................... 35

CARESENS CONTROL A

NORMAL ......................... 60

CARESENS N ...................... 60

CARESENS N TEST STRIPS

.......................................... 56

CARESENS N VOICE ......... 60

CARETOUCH GLUCOSE

MONITORING ................ 60

CARETOUCH TEST STRIP

.......................................... 56

CARIMUNE NF

NANOFILTERED ............ 80

carisoprodol .......................... 22

carisoprodol-asa-codeine ...... 22

carisoprodol-aspirin .............. 22

CARNITOR .......................... 52

CARNITOR (SUGAR-FREE)

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

CAROSPIR ........................... 35

carteolol ................................ 89

cartia xt ................................. 35

carvedilol .............................. 35

carvedilol phosphate ............. 35

CASODEX ........................... 13

caspofungin ............................. 3

CATAPRES .......................... 35

CATAPRES-TTS-1 .............. 35

CATAPRES-TTS-2 .............. 35

CATAPRES-TTS-3 .............. 35

CAYA CONTOURED ......... 83

CAYSTON ............................. 7

caziant (28) ........................... 85

cefaclor ................................... 6

cefadroxil ................................ 6

cefazolin ................................. 6

CEFAZOLIN IN 0.9% SOD

CHLORIDE ........................ 6

cefazolin in dextrose (iso-os) .. 6

CEFAZOLIN IN DEXTROSE

(ISO-OS) ............................. 6

CEFAZOLIN IN DEXTROSE

5 % ...................................... 6

CEFAZOLIN IN STERILE

WATER .............................. 6

cefdinir .................................... 6

cefditoren pivoxil .................... 6

cefepime ................................. 6

cefepime in dextrose,iso-osm . 6

cefixime .................................. 6

CEFOTAN .............................. 6



113

cefotaxime .............................. 6

cefotetan ................................. 6

cefoxitin .................................. 6

cefpodoxime ........................... 6

cefprozil .................................. 6

ceftriaxone .............................. 6

CEFTRIAXONE .................... 6

ceftriaxone in dextrose,iso-os . 6

CEFUROXIME (PF) IN 0.9%

NACL ............................... 88

cefuroxime axetil .................... 6

cefuroxime sodium ................. 6

celacyn .................................. 43

CELEBREX ......................... 26

celecoxib............................... 26

CELESTONE SOLUSPAN . 54

CELEXA .............................. 29

CELLCEPT .......................... 13

CELLCEPT INTRAVENOUS

.......................................... 13

CELONTIN .......................... 18

CENTANY ........................... 48

CENTANY AT .................... 48

centergy ................................ 93

centratex ............................... 99

cephalexin............................... 6

CEPROTIN (BLUE BAR) ... 39

CEPROTIN (GREEN BAR) 39

CERDELGA......................... 67

CEREZYME ........................ 67

CESAMET ........................... 73

cetirizine ............................... 92

CETRAXAL......................... 54

CETROTIDE ........................ 67

cevimeline ............................ 52

CHANTIX ............................ 52

CHANTIX CONTINUING

MONTH BOX .................. 53

CHANTIX STARTING

MONTH BOX .................. 53

chateal................................... 85

CHENODAL ........................ 73

cheratussin ac ....................... 93

chloramphenicol sod succinate

............................................ 7

chlordiazepoxide hcl ............ 29

chlordiazepoxide-clidinium .. 71

chlorhexidine gluconate ....... 53

chloroquine phosphate ............ 7

chlorothiazide ....................... 35

chlorothiazide sodium .......... 35

chlorpromazine ..................... 29

chlorpropamide ..................... 69

chlorthalidone ....................... 35

chlorzoxazone ....................... 22

CHOLBAM .......................... 73

cholecalciferol (vitamin d3) 100

cholestyramine (with sugar) . 40

cholestyramine light ............. 40

choline,magnesium salicylate

.......................................... 26

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 67

CIALIS ................................. 97

ciclodan ................................ 48

CICLODAN KIT .................. 49

ciclopirox .............................. 49

cidofovir ................................. 4

ciferex ................................. 100

CILOXAN ............................ 88

CIMDUO ................................ 4

cimetidine ............................. 76

cimetidine hcl ....................... 76

CIMZIA ................................ 73

CIMZIA POWDER FOR

RECONST ........................ 73

CINQAIR ............................. 95

CINRYZE ............................. 95

CINVANTI ........................... 73

CIPRO .................................. 10

CIPRO HC ............................ 54

CIPRO XR ............................ 10

CIPRODEX .......................... 54

ciprofloxacin ......................... 10

ciprofloxacin (mixture) ......... 10

ciprofloxacin hcl ....... 10, 54, 88

cisplatin ................................ 13

citalopram ............................. 29

CITRANATAL (DUAL-

IRON) ............................. 100

CITRANATAL 90 DHA

(ALGAL OIL) ................ 100

CITRANATAL ASSURE .. 100

CITRANATAL B-CALM (FE

GLUC) ............................ 100

CITRANATAL BLOOM ... 100

CITRANATAL DHA

(ALGAL OIL) ................ 100

CITRANATAL HARMONY

(IRON FUM) .................. 100

citrate of magnesia ................ 73

citroma .................................. 73

citrus calcium ........................ 99

cladribine .............................. 13

CLAFORAN ........................... 6

claravis .................................. 45

CLARINEX .......................... 92

CLARINEX-D 12 HOUR .... 93

clarithromycin ......................... 7

classic prenatal .................... 100

cleansing wash ...................... 45

clearlax ................................. 73

clemastine ............................. 92

CLENPIQ ............................. 73

cleocin ..................................... 7

CLEOCIN ......................... 7, 84

CLEOCIN HCL ...................... 7

CLEOCIN IN 5 %

DEXTROSE ....................... 7

CLEOCIN PEDIATRIC ......... 7

CLEOCIN T ......................... 45

CLEVER CHEK BLOOD

GLUCOSE ........................ 60

CLEVER CHOICE


CLEVER CHOICE LEVEL 2

CONTROL ....................... 60

CLEVER CHOICE MICRO . 60

CLEVER CHOICE MICRO

TEST STRIP ..................... 56

CLEVER CHOICE PRO 56, 60

CLEVER CHOICE TALK

GLUCOSE SYS ............... 60

CLEVER CHOICE TALK

TEST ................................. 56

CLEVER CHOICE TEST

STRIPS ............................. 56

CLEVER CHOICE VOICE+

TEST ................................. 56

CLIMARA ............................ 83

CLIMARA PRO ................... 83

CLIN SINGLE USE ............... 7

CLINDACIN ETZ ................ 45



114

clindacin p ............................ 45

CLINDACIN PAC ............... 45

CLINDAGEL ....................... 45

clindamycin hcl ...................... 7

CLINDAMYCIN IN 0.9 %

SOD CHLOR ..................... 7

clindamycin in 5 % dextrose .. 8

clindamycin palmitate hcl ...... 8

clindamycin pediatric ............. 8

clindamycin phosphate .... 8, 45,

84

clindamycin-benzoyl peroxide

.................................... 45, 46

clindamycin-tretinoin ........... 46

CLINDESSE ........................ 84

CLINPRO 5000 .................... 53

clobetasol .............................. 49

clobetasol-emollient ............. 49

CLOBEX .............................. 49

CLOCORTOLONE

PIVALATE ...................... 50

clodan ................................... 50

CLODAN KIT...................... 50

CLODERM .......................... 50

clofarabine ............................ 13

CLOLAR .............................. 13

clomiphene citrate ................ 67

clomipramine ........................ 29

clonazepam ........................... 18

clonidine ............................... 35

clonidine hcl ................... 29, 35

clorazepate dipotassium ....... 29

clotrimazole ............................ 3

clotrimazole-betamethasone . 49

clozapine............................... 29

CLOZAPINE ........................ 29

CLOZARIL .......................... 29

c-nate dha ........................... 100

COAGADEX ....................... 39

COAL TAR .......................... 42

COARTEM ............................ 8

codeine sulfate ...................... 23

codeine-guaifenesin .............. 93

CODITUSSIN AC ............... 93

CODITUSSIN DAC ............. 93

COLAZAL ........................... 73

COLCHICINE ...................... 81

COLCRYS ........................... 81

colesevelam .......................... 40

COLESTID ........................... 40

COLESTID FLAVORED .... 40

colestipol .............................. 40

colistin (colistimethate na) ..... 8

colocort ................................. 73

COLY-MYCIN M

PARENTERAL .................. 8

COLY-MYCIN S ................. 54

COLYTE WITH FLAVOR

PACKS ............................. 73

COMBIGAN ........................ 91

COMBIPATCH .................... 83

COMBIVENT RESPIMAT . 95

COMBIVIR ............................ 4

COMETRIQ ......................... 13

COMPAZINE ....................... 73

COMPLERA .......................... 4

complete natal dha .............. 100

completenate ....................... 100

complex b-100 .................... 100

compro .................................. 73

COMTAN ............................. 19

CONCEPT DHA ................ 100

CONCEPT OB ................... 100

CONCEPTROL .................... 84

CONCERTA ........................ 29

CONDYLOX........................ 44

constulose ............................. 73

CONTOUR CONTROL

SOLUTION, NML ........... 60

CONTOUR LINK ................ 60

CONTOUR NEXT EZ

METER ............................ 60

CONTOUR NEXT LEV 2

CONTROL SOL............... 60

CONTOUR NEXT LINK .... 60

CONTOUR NEXT LINK 2.4

.......................................... 60

CONTOUR NEXT METER 60

CONTOUR NEXT ONE

METER ............................ 60

CONTOUR NEXT TEST

STRIPS ............................. 56

CONTOUR TEST STRIPS .. 56

CONZIP................................ 26

COOL BLOOD GLUCOSE

METER ............................ 60

COOL CONTROL A

SOLUTION ...................... 60

COOL GLUCOSE TEST

STRIP ............................... 56

COPAXONE ........................ 79

CORDRAN ........................... 50

CORDRAN TAPE LARGE

ROLL ................................ 50

COREG ................................. 35

COREG CR .......................... 35

coremino ............................... 11

CORGARD ........................... 35

CORIFACT .......................... 39

CORLANOR ........................ 42

cormax .................................. 50

CORTANE-B ....................... 44

CORTEF ............................... 54

CORTENEMA ..................... 73

CORTIFOAM ....................... 73

cortisone ............................... 54

CORTISPORIN .................... 48

CORTROSYN ...................... 54

corvita ................................. 100

corvita 150 .......................... 100

CORVITE ........................... 100

CORVITE 150 .................... 100

CORVITE FE ..................... 100

CORVITE FREE ................ 100

CORZIDE ............................. 35

COSENTYX ......................... 42

COSENTYX (2 SYRINGES)

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

COSENTYX PEN ................ 42

COSENTYX PEN (2 PENS) 42

COSMEGEN ........................ 13

COSOPT ............................... 91

COSOPT (PF) ....................... 91

cosyntropin ........................... 54

COTELLIC ........................... 13

COTEMPLA XR-ODT ........ 29

COUMADIN ........................ 39

covaryx ................................. 83

covaryx h.s. ........................... 83

COZAAR .............................. 35

CREON ................................. 73

CRESEMBA ........................... 3

CRESTOR ............................ 40

CRINONE ............................ 83



115

CRIXIVAN ............................ 4

cromolyn................... 73, 90, 95

cryselle (28) .......................... 85

CRYSVITA .......................... 67

CUBICIN ............................... 8

CUBICIN RF ......................... 8

CUPRIMINE ........................ 82

CUROSURF ......................... 95

CUTIVATE .......................... 50

CUVITRU ............................ 80

CUVPOSA ........................... 71

cyanocobalamin (vitamin b-12)

........................................ 100

cyclafem 1/35 (28) ............... 85

cyclafem 7/7/7 (28) .............. 85

CYCLESSA (28) .................. 85

cyclobenzaprine .................... 22

CYCLOGYL ........................ 89

CYCLOMYDRIL ................ 92

cyclopentolate....................... 89

cyclophosphamide ................ 13

CYCLOSERINE .................... 8

CYCLOSET ......................... 69

cyclosporine ......................... 13

cyclosporine modified .......... 13

CYCLOTENS REFILL ........ 22

CYCLOTENS STARTER ... 22

CYMBALTA ....................... 29

cyproheptadine ..................... 92

CYRAMZA .......................... 13

cyred ..................................... 85

CYSTADANE ...................... 73

CYSTAGON ........................ 97

CYSTARAN ........................ 90

cytarabine ............................. 13

cytarabine (pf) ...................... 13

CYTOMEL .......................... 71

CYTOTEC ........................... 76

CYTOVENE .......................... 4

cytra k crystals ...................... 97

cytra-2................................... 97

cytra-3................................... 97

cytra-k................................... 97

D D.H.E.45 ............................... 20

dacarbazine ........................... 13

DACOGEN .......................... 13

dactinomycin ........................ 13

DAKLINZA ........................... 4

DALIRESP ........................... 95

danazol.................................. 67

DANTRIUM ........................ 22

dantrolene ............................. 22

dapsone ............................. 8, 46

DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 80

daptomycin ............................. 8

DARAPRIM ........................... 8

darifenacin ............................ 97

DARZALEX ........................ 13

dasetta 1/35 (28) ................... 85

dasetta 7/7/7 (28) .................. 85

daunorubicin ......................... 13

DAXBIA ................................ 6

DAYPRO.............................. 26

daysee ................................... 86

DAYTRANA........................ 29

DDAVP ................................ 67

DEBACTEROL.................... 53

deblitane ............................... 83

decadron ............................... 54

decitabine.............................. 13

DEFITELIO.......................... 39

DELESTROGEN ................. 83

delta d3 ............................... 100

deltasone ............................... 54

delyla (28)............................. 86

DELZICOL .......................... 73

DEMADEX .......................... 35

demeclocycline ..................... 11

DEMEROL ........................... 23

DEMEROL (PF) .................. 23

DEMSER .............................. 35

DENAVIR ............................ 49

denta 5000 plus ..................... 53

dentagel ................................ 53

DEPACON ........................... 18

DEPAKENE ......................... 18

DEPAKOTE ......................... 18

DEPAKOTE ER ................... 18

DEPAKOTE SPRINKLES... 18

DEPEN TITRATABS .......... 82

DEPO-ESTRADIOL ............ 83

DEPO-PROVERA................ 83

DEPO-SUBQ PROVERA 104

.......................................... 83

DEPO-TESTOSTERONE .... 68

DERMACINRX

EMPRICAINE .................. 47

DERMA-SMOOTHE/FS

BODY OIL ....................... 50

DERMA-SMOOTHE/FS

SCALP OIL ...................... 50

DERMATOP ........................ 50

DERMOTIC OIL .................. 54

DESCOVY ............................. 4

desipramine ........................... 29

desloratadine ......................... 92

desmopressin ........................ 68

desog-e.estradiol/e.estradiol . 86

desogestrel-ethinyl estradiol . 86

DESONATE ......................... 50

desonide ................................ 50

DESOWEN ........................... 50

desoximetasone ..................... 50

DESOXYN ........................... 29

DESVENLAFAXINE .......... 29

DESVENLAFAXINE

FUMARATE .................... 29

desvenlafaxine succinate ...... 29

DETROL .............................. 97

DETROL LA ........................ 97

dexamethasone ..................... 54

DEXAMETHASONE ACE-

NACL,ISO-OSM .............. 54

dexamethasone intensol ........ 55

dexamethasone sodium phos

(pf) .................................... 55

dexamethasone sodium

phosphate .................... 55, 91

DEXCOM G6 RECEIVER .. 60

DEXEDRINE SPANSULE .. 29

DEXERYL ........................... 44

DEXILANT .......................... 76

dexmethylphenidate .............. 29

DEXPAK 10 DAY ............... 55

DEXPAK 13 DAY ............... 55

DEXPAK 6 DAY ................. 55

dexrazoxane hcl .................... 12

dextroamphetamine .............. 29

dextroamphetamine-

amphetamine ..................... 30

dialyvite .............................. 100

DIALYVITE 3000 .............. 100



116

DIALYVITE 5000 ............. 100

dialyvite 800 ....................... 100

DIALYVITE 800 WITH IRON

........................................ 100

DIALYVITE SUPREME D

........................................ 100

DIASTAT ............................. 18

DIASTAT ACUDIAL .......... 18

DIATRUE CONTROL SOLN

NORMAL ........................ 60

DIATRUE PLUS BLOOD

GLUCOSE MET .............. 60

DIATRUE PLUS TEST STRIP

.......................................... 56

diazepam......................... 18, 30

diazepam intensol ................. 30

DIBENZYLINE ................... 35

DICLEGIS ............................ 73

DICLO GEL ......................... 26

DICLO GEL-XRYLIX

SHEET ............................. 26

diclofenac potassium ............ 26

diclofenac sodium ... 26, 27, 44,

90

diclofenac-misoprostol ......... 27

DICLOPAK .......................... 27

DICLOPR ............................. 27

dicloxacillin .......................... 10

dicyclomine .......................... 72

didanosine............................... 4

DIFFERIN ............................ 46

DIFICID ................................. 7

diflorasone ............................ 50

DIFLUCAN ............................ 3

diflunisal ............................... 27

digitek ................................... 38

digox ..................................... 38

digoxin .................................. 38

dihydroergotamine ............... 20

DILANTIN ........................... 18

DILANTIN EXTENDED .... 18

DILANTIN INFATABS ...... 18

DILANTIN-125 ................... 18

DILATRATE-SR ................. 42

DILAUDID .......................... 23

diltiazem ............................... 35

dilt-xr .................................... 35

DIOVAN .............................. 35

DIOVAN HCT ..................... 36

DIPENTUM ......................... 73

diphenhydramine hcl ............ 92

diphenoxylate-atropine ......... 72

DIPROLENE ........................ 50

DISALCID ........................... 27

diskets ................................... 23

disopyramide phosphate ....... 34

disulfiram.............................. 52

DITHOL ............................... 27

DITROPAN XL ................... 97

DIURIL ................................ 36

DIURIL IV ........................... 36

divalproex ............................. 18

DIVIGEL .............................. 83

DM2...................................... 69

DOCEFREZ ......................... 13

docetaxel ............................... 13

DOCETAXEL ...................... 13

dofetilide ............................... 34

DOLOPHINE ....................... 23

DOLOTRANZ...................... 47

donepezil .............................. 21

DONNATAL ........................ 72

DOPTELET .......................... 39

DORAL ................................ 30

DORIPENEM ......................... 8

DORYX ................................ 11

DORYX MPC ...................... 11

dorzolamide .......................... 91

dorzolamide-timolol ............. 91

dothelle dha ........................ 100

DOVONEX .......................... 42

doxazosin .............................. 36

doxepin ........................... 30, 44

doxercalciferol ...................... 68

DOXIL.................................. 13

doxorubicin ........................... 13

doxorubicin, peg-liposomal .. 13

doxycycline hyclate .............. 11

doxycycline monohydrate .... 11

DOXYCYCLINE

MONOHYDRATE ........... 11

DRISDOL ........................... 100

drithocreme hp ...................... 42

dronabinol ............................. 73

drospirenone-e.estradiol-lm.fa

.......................................... 86

drospirenone-ethinyl estradiol

.......................................... 86

DROXIA ............................... 13

DUAC ................................... 46

DUAVEE .............................. 83

ducodyl ................................. 73

DUET DHA BALANCED . 100

DUET DHA WITH OMEGA-3

........................................ 100

DUETACT ........................... 70

DUEXIS ............................... 27

DULERA .............................. 95

duloxetine ............................. 30

DUOPA ................................ 20

DUPIXENT .......................... 44

DURAGESIC ....................... 23

DUREZOL ........................... 91

dutasteride ............................. 97

dutasteride-tamsulosin .......... 97

DUTOPROL ......................... 36

DUZALLO ........................... 81

d-vi-sol ................................ 100

DYANAVEL XR ................. 30

DYAZIDE ............................ 36

DYMISTA ............................ 95

DYRENIUM ......................... 36

DYSPORT ............................ 80

E e.c. prin ................................. 27

e.e.s. 400 ................................. 7

E.E.S. GRANULES ................ 7

EASY PLUS II BLOOD

GLUCOSE MET .............. 60

EASY PLUS II TEST ........... 56

EASY STEP ......................... 56

EASY STEP BLOOD


EASY TALK BLOOD


EASY TALK GLUCOSE

TEST ................................. 56

EASY TOUCH GLUCOSE

MONITOR ....................... 61

EASY TOUCH TEST STRIP

.......................................... 56

EASY TRAK GLUCOSE

TEST ................................. 56



117

EASY TRAK LOW

CONTROL ....................... 61

EASYGLUCO

MONITORING SYSTEM 61

EASYGLUCO PLUS ........... 56

EASYGLUCO PLUS

NORMAL CONTROL ..... 61

EASYGLUCO TEST ........... 56

EASYMAX .......................... 56

EASYMAX L BLOOD


EASYMAX LOW CONTROL

.......................................... 61

EASYMAX NG ................... 61

EASYMAX NORMAL

CONTROL ....................... 61

EASYMAX V SPEAKING

GLUCOSE SYS ............... 61

EASYMAX V2 BLOOD


EC-NAPROSYN .................. 27

econazole .............................. 49

econtra ez.............................. 86

econtra one-step.................... 86

ecotrin ................................... 27

ECOZA ................................ 49

EDARBI ............................... 36

EDARBYCLOR ................... 36

EDECRIN ............................ 36

EDLUAR .............................. 30

ed-spaz .................................. 72

EDURANT ............................. 4

eemt ...................................... 83

eemt hs.................................. 83

efavirenz ................................. 4

EFFEXOR XR ..................... 30

EFUDEX .............................. 44

EGRIFTA ............................. 78

ELAPRASE .......................... 68

ELELYSO ............................ 68

ELEMENT COMPACT


ELEMENT COMPACT

NORMAL CONTROL ..... 61

ELEMENT COMPACT TEST

STRIPS ............................. 56

ELEMENT COMPACT V

GLUCOSE MTR .............. 61

ELEMENT NORMAL

CONTROL ....................... 61

ELEMENT PLUS BLOOD

GLUCOSE KIT ................ 61

ELEMENT TEST STRIPS ... 56

ELESTAT ............................. 90

ELESTRIN ........................... 83

eletone .................................. 44

eletriptan ............................... 20

ELIDEL ................................ 44

ELIGARD ............................ 13

ELIGARD (3 MONTH) ....... 13



ELIMITE .............................. 51

elinest.................................... 86

eliphos .................................. 73

ELIQUIS .............................. 39

ELITEK ................................ 12

ELIXOPHYLLIN ................. 95

ELLA .................................... 86

ELLENCE ............................ 13

ELLZIA PAK ....................... 50

ELMIRON ............................ 97

ELOCON .............................. 50

ELOCTATE ......................... 39

EMADINE............................ 90

EMBEDA ............................. 23

EMBRACE BLOOD

GLUCOSE SYSTEM . 56, 61

EMBRACE EVO LEVEL 1 . 61

EMBRACE EVO TEST

STRIPS ............................. 56

EMBRACE GLUCOSE

CONTROL LOW ............. 61

EMBRACE PRO GLUCOSE

METER ............................ 61

EMBRACE PRO TEST

STRIPS ............................. 56

EMCYT ................................ 14

EMEND ................................ 73

EMEND (FOSAPREPITANT)

.......................................... 73

EMFLAZA ........................... 55

emoquette ............................. 86

EMPLICITI .......................... 14

EMSAM ............................... 30

EMTRIVA .............................. 4

EMVERM ............................... 8

ENABLEX ........................... 97

enalapril maleate ................... 36

enalaprilat ............................. 36

enalapril-hydrochlorothiazide

.......................................... 36

ENBRACE HR ................... 100

ENBREL ............................... 82

ENBREL MINI .................... 82

ENBREL SURECLICK ....... 82

ENDARI ............................... 52

endocet .................................. 23

ENDOMETRIN .................... 83

ENGERIX-B (PF) ................ 80

ENGERIX-B PEDIATRIC

(PF) ................................... 80

enoxaparin ............................ 39

enpresse ................................ 86

enskyce ................................. 86

ENSTILAR ........................... 42

entacapone ............................ 20

entecavir ................................. 4

ENTOCORT EC ................... 73

ENTRESTO .......................... 42

ENTYVIO ............................ 73

enulose .................................. 73

ENVARSUS XR .................. 14

EPANED .............................. 36

EPCLUSA .............................. 4

EPICERAM .......................... 44

EPIDUO ............................... 46

EPIDUO FORTE .................. 46

EPIFOAM ............................. 42

epinastine .............................. 90

EPINEPHRINE .............. 92, 93

EPINEPHRINESNAP-V ...... 93

EPIPEN 2-PAK .................... 93

EPIPEN JR 2-PAK ............... 93

epirubicin .............................. 14

EPISIL .................................. 53

EPISNAP .............................. 93

epitol ..................................... 18

EPIVIR ................................... 4

EPIVIR HBV .......................... 4

eplerenone ............................. 36

EPOGEN .............................. 78

epoprostenol (glycine) .......... 36

eprosartan ............................. 36



118

EPZICOM .............................. 4

EQUETRO ........................... 18

ERAXIS(WATER DILUENT)

............................................ 3

ERBITUX ............................ 14

ergocalciferol (vitamin d2) . 100

ergoloid................................. 30

ERGOMAR .......................... 20

ergotamine-caffeine .............. 20

ERIVEDGE .......................... 14

ERLEADA ........................... 14

errin ...................................... 83

ERTACZO ........................... 49

ERWINAZE ......................... 14

ery pads ................................ 46

erygel .................................... 46

ERYPED 200 ......................... 7

ERYPED 400 ......................... 7

ery-tab..................................... 7

ERY-TAB .............................. 7

erythrocin (as stearate) ........... 7

erythromycin .................... 7, 88

erythromycin ethylsuccinate .. 7

erythromycin with ethanol ... 46

erythromycin-benzoyl peroxide

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

ESBRIET .............................. 95

ESCAVITE ........................ 100

ESCAVITE D ..................... 100

ESCAVITE LQ .................. 100

escitalopram oxalate ............. 30

ESGIC .................................. 23

ESKATA .............................. 44

esmolol ................................. 36

ESOMEP-EZS ...................... 76

esomeprazole magnesium .... 76

esomeprazole sodium ........... 76

ESOMEPRAZOLE

STRONTIUM .................. 76

estarylla ................................ 86

estazolam .............................. 30

ESTRACE ............................ 83

estradiol ................................ 83

estradiol valerate .................. 83

estradiol-norethindrone acet . 83

ESTRING ............................. 83

ESTROGEL ......................... 83

estrogens-methyltestosterone 84

estropipate ............................ 84

ESTROSTEP FE-28 ............. 86

eszopiclone ........................... 30

ethacrynate sodium ............... 36

ethacrynic acid ...................... 36

ethambutol .............................. 8

ethosuximide ........................ 18

ethyl chloride ........................ 47

ethynodiol diac-eth estradiol 86

ETHYOL .............................. 12

etidronate disodium .............. 52

etodolac ................................ 27

etoposide ............................... 14

EUCRISA ............................. 44

EUFLEXXA ......................... 27

EURAX ................................ 51

EVAMIST ............................ 84

EVEKEO .............................. 30

EVENCARE G2 ............. 56, 61

EVENCARE G3 GLUCOSE

METER ............................ 61

EVENCARE G3 TEST ........ 56

EVENCARE MINI

GLUCOSE TEST STR ..... 56

EVENCARE MINI

MONITOR SYSTEM....... 61

EVISTA ................................ 81

EVOCLIN ............................ 46

EVOLUTION BLOOD


EVOLUTION NORMAL

CONTROL ....................... 61

EVOLUTION TEST STRIPS

.......................................... 56

EVOMELA .......................... 14

EVOTAZ ................................ 4

EVOXAC ............................. 52

EVZIO .................................. 27

EXALGO ER ....................... 23

EXELDERM ........................ 49

EXELON .............................. 21

exemestane ........................... 14

EXFORGE............................ 36

EXFORGE HCT................... 36

EXODERM .......................... 49

EXONDYS 51 ...................... 21

EXTAVIA ............................ 79

EXTINA ............................... 49

EXTRA-VIRT PLUS DHA 100

EYLEA ................................. 90

EZ SMART PLUS SYSTEM

.......................................... 61

EZ SMART PLUS TEST ..... 56

EZ SMART SYSTEM .......... 61

EZ SMART TEST ................ 56

ezetimibe ............................... 40

ezetimibe-simvastatin ........... 40

F FABIOR ............................... 46

FABRAZYME ..................... 68

FACTIVE ............................. 10

falmina (28) .......................... 86

famciclovir .............................. 4

famotidine ............................. 76

famotidine (pf) ...................... 76

famotidine (pf)-nacl (iso-os) 76

FAMOTIDINE IN 0.9 %

NACL ............................... 76

FANAPT ............................... 30

FARESTON ......................... 14

FARXIGA ............................ 70

FARYDAK ........................... 14

FASENRA ............................ 95

FASLODEX ......................... 14

fayosim ................................. 86

FAZACLO ............................ 30

FC2 FEMALE CONDOM ... 83

FEIBA NF ............................ 39

felbamate .............................. 18

FELBATOL .......................... 18

FELDENE ............................ 27

felodipine .............................. 36

fem ph ................................... 84

FEMARA ............................. 14

FEMCAP .............................. 83

FEMHRT LOW DOSE ........ 84

FEMRING ............................ 84

femynor ................................. 86

fenofibrate ............................. 40

FENOFIBRATE ................... 40

fenofibrate micronized .......... 40

fenofibrate nanocrystallized . 40

fenofibric acid ....................... 40

fenofibric acid (choline) ....... 41

FENOGLIDE ........................ 41

fenoprofen ............................. 27



119

FENOPROFEN .................... 27

FENORTHO......................... 27

fentanyl ................................. 23

FENTANYL (PF)-

BUPIVACAINE-NACL... 23

fentanyl citrate ...................... 23

fentanyl citrate (pf) ............... 23

FENTANYL CITRATE (PF)

.......................................... 23

fentanyl citrate (pf)-0.9%nacl

.......................................... 23

FENTANYL CITRATE (PF)-

0.9%NACL ....................... 23

FENTANYL-

ROPIVACAINE-NACL

(PF) ................................... 23

FENTORA ........................... 23

FERIVA 21-7 TABLET ..... 100

ferocon ................................ 100

FERRALET 90 DUAL-IRON

DELIVERY .................... 100

ferraplus 90 ......................... 100

FERRLECIT......................... 52

ferrocite plus ....................... 100

FETZIMA ............................ 30

FEXMID .............................. 22

FIASP FLEXTOUCH U-100

INSULIN .......................... 66

FIASP U-100 INSULIN ....... 66

FIBRICOR ........................... 41

FIBRYGA ............................ 39

FIFTY50 TEST STRIP ........ 56

FINACEA ............................ 46

finasteride ............................. 97

FIORICET ............................ 23

FIORINAL ........................... 23

FIORINAL-CODEINE #3 ... 23

FIRAZYR ............................. 95

FIRMAGON KIT W

DILUENT SYRINGE ...... 14

FIRVANQ ............................ 11

FLAGYL ................................ 8

FLAREX .............................. 91

flavoxate ............................... 97

FLEBOGAMMA DIF .......... 80

flecainide .............................. 34

FLECTOR ............................ 27

fleet laxative ......................... 73

FLOLAN .............................. 36

FLOLIPID ............................ 41

FLOMAX ............................. 97

FLORIVA ........................... 101

FLORIVA (FLUORIDE-

VITAMIN D3) ............... 101

FLORIVA PLUS ................ 101

FLORIVA PLUS (WITH

BIOTIN) ......................... 101

FLOVENT DISKUS ............ 95

FLOVENT HFA ................... 95

floxuridine ............................ 14

flucaine ................................. 90

fluconazole ............................. 3

fluconazole in dextrose(iso-o) 3

fluconazole in nacl (iso-osm) . 3

flucytosine .............................. 3

fludarabine ............................ 14

fludrocortisone...................... 55

FLUMADINE ........................ 4

flumazenil ............................. 30

flunisolide ............................. 95

fluocinolone .......................... 50

fluocinolone acetonide oil .... 54

fluocinolone and shower cap 50

fluocinonide .......................... 50

fluocinonide-emollient ......... 50

FLUORABON.................... 101

fluorescein-proparacaine ...... 90

fluoride (sodium) ................ 101

FLUORIDEX DAILY

DEFENSE ........................ 53

fluoritab .............................. 101

fluorometholone ................... 91

FLUOROPLEX .................... 44

fluorouracil ..................... 14, 44

FLUOROURACIL ............... 44

fluoxetine .............................. 30

fluphenazine decanoate ........ 30

fluphenazine hcl ................... 30

FLURA-DROPS ................. 101

flurandrenolide ..................... 50

flurazepam ............................ 30

flurbiprofen ........................... 27

flurbiprofen sodium .............. 90

flutamide ............................... 14

fluticasone ...................... 50, 95

FLUTICASONE-

SALMETEROL ................ 95

fluvastatin ............................. 41

fluvoxamine .......................... 30

FML FORTE ........................ 91

FML LIQUIFILM ................ 91

FML S.O.P. ........................... 91

FOCALIN ............................. 30

FOCALIN XR ...................... 30

folbee .................................. 101

folbee plus .......................... 101

FOLET ONE ...................... 101

FOLGARD OS ................... 101

FOLGARD RX ................... 101

folic acid ............................. 101

folic acid-vit b6-vit b12 ...... 101

folivane-f ............................ 101

folivane-ob .......................... 101

folivane-plus ....................... 101

FOLLISTIM AQ .................. 68

FOLOTYN ........................... 14

folplex 2.2 ........................... 101

foltabs 800 .......................... 101

FOLTRATE ........................ 101

fondaparinux ......................... 39

FORA D10 ............................ 61

FORA D15G ......................... 56

FORA D20 ...................... 57, 61

FORA D40-G31 TEST

STRIPS ............................. 57

FORA G20 ...................... 57, 61

FORA G30A ......................... 62

FORA G30-PREMIUM V10

TEST STRP ...................... 57

FORA GD50 BLOOD

GLUCOSE SYSTEM ....... 62

FORA GD50 TEST STRIPS 57

FORA NORMAL CONTROL

.......................................... 62

FORA PREMIUM V10


FORA TEST N'GO VOICE

METER ............................. 62

FORA TEST STRIP ............. 57

FORA TN'G VOICE METER

.......................................... 62

FORA TN'G VOICE TEST

STRIPS ............................. 57



120

FORA V10 ..................... 57, 62

FORA V10-V12-D10-D20

STRIPS ............................. 57

FORA V12 BLOOD


FORA V12 GLUCOSE ........ 57

FORA V20 ..................... 57, 62

FORA V30A ........................ 62

FORACARE GD20 .............. 57

FORACARE GD20


FORACARE GD40 .............. 57

FORACARE GD40A


FORACARE GD40B


FORACARE GDH LOW

CONTROL ....................... 62

FORFIVO XL ...................... 30

FORTAMET ........................ 70

FORTAVIT .......................... 99

FORTEO .............................. 81

FORTESTA .......................... 68

FORTISCARE BLOOD

GLUCOSE SYST ............. 62

FORTISCARE GLUCOSE

TEST STRIPS .................. 57

FORTISCARE NORMAL ... 62

FOSAMAX .......................... 81

FOSAMAX PLUS D ............ 81

fosamprenavir ......................... 4

FOSCAVIR ............................ 4

fosinopril .............................. 36

fosinopril-hydrochlorothiazide

.......................................... 36

fosphenytoin ......................... 18

FOSRENOL ......................... 73

FRAGMIN ........................... 39

FREESTYLE CONTROL .... 62

FREESTYLE FLASH

SYSTEM .......................... 62

FREESTYLE FREEDOM ... 62

FREESTYLE FREEDOM

LITE ................................. 62

FREESTYLE INSULINX ... 57,

62

FREESTYLE INSULINX

TEST STRIPS .................. 57

FREESTYLE LIBRE

READER .......................... 62

FREESTYLE LIBRE

SENSOR ........................... 62

FREESTYLE LITE METER 62

FREESTYLE LITE STRIPS 57

FREESTYLE PRECISION

NEO METER ................... 62

FREESTYLE PRECISION

NEO STRIPS .................... 57

FREESTYLE SIDEKICK II 62

FREESTYLE SYSTEM KIT 62

FREESTYLE TEST ............. 57

FROTEK .............................. 27

frovatriptan ........................... 20

full spectrum b-vitamin c ... 101

FURADANTIN .................... 11

furosemide ............................ 36

FUROSEMIDE IN 0.9 %

NACL ............................... 36

FUSILEV.............................. 12

FUSION PLUS ................... 101

FUSION SPRINKLES ....... 101

FUZEON ................................ 4

fyavolv .................................. 84

FYCOMPA ........................... 18

G g tussin ac ............................. 93

gabapentin ............................ 18

GABITRIL ........................... 18

galantamine .......................... 21

GAMASTAN S/D ................ 80

GAMMAGARD LIQUID .... 80

GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 80

GAMMAKED ...................... 80

GAMMAPLEX .................... 80

GAMMAPLEX (WITH

SORBITOL) ..................... 80

GAMUNEX-C...................... 80

GANCICLOVIR .................... 4

ganciclovir sodium ................. 4

GANIRELIX ........................ 68

GASTROCROM .................. 73

gatifloxacin ........................... 88

GATIFLOXACIN-

DEXAMETHASONE ...... 91

GATTEX 30-VIAL .............. 73

gavilax .................................. 73

gavilyte-c .............................. 73

gavilyte-g .............................. 73

gavilyte-n .............................. 73

GAZYVA ............................. 14

GE100 BLOOD GLUCOSE

SYSTEM .......................... 62

GE100 BLOOD GLUCOSE

TEST STRIP ..................... 57

GE100 CONTROL

SOLUTION NORMAL .... 62

GELCLAIR .......................... 53

GELNIQUE .......................... 97

gemcitabine ........................... 14

GEMCITABINE ................... 14

gemfibrozil ........................... 41

GEMZAR ............................. 14

GENERESS FE .................... 86

generlac ................................. 73

gengraf .................................. 14

GENOTROPIN ..................... 78

GENOTROPIN MINIQUICK

.......................................... 78

GENSTRIP TEST STRIP ..... 57

gentak ................................... 88

gentamicin .................. 8, 48, 89

gentamicin in nacl (iso-osm) .. 8

GENTAMICIN IN NACL

(ISO-OSM) ......................... 8

gentamicin sulfate (ped) (pf) .. 8

gentamicin sulfate (pf) ............ 8

GENTAMICIN SULFATE

(PF) ..................................... 8

GENTAMICIN-SODIUM

CITRATE ........................... 8

gentle laxative ....................... 73

gentlelax ............................... 73

GENVOYA ............................ 4

GEODON ............................. 30

GIALAX ............................... 73

gianvi (28) ............................ 86

GIAPREZA .......................... 42

GIAZO .................................. 73

GILENYA ............................ 79

GILOTRIF ............................ 14

GLASSIA ............................. 52

glatiramer .............................. 79

glatopa .................................. 79



121

GLEEVEC ............................ 14

GLEOSTINE ........................ 14

GLIADEL WAFER.............. 14

glimepiride ........................... 70

glipizide ................................ 70

glipizide-metformin .............. 70

GLUCAGEN DIAGNOSTIC

KIT ................................... 59

GLUCAGEN HYPOKIT ..... 59

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 59

GLUCAGON HCL .............. 59

GLUCO NAVII GLUCOSE

MONITOR ....................... 62

GLUCO NAVII TEST STRIP

.......................................... 57

GLUCOCARD 01 METER . 62

GLUCOCARD 01 NORMAL

CONTROL ....................... 62

GLUCOCARD 01 SENSOR

PLUS ................................ 57

GLUCOCARD EXPRESSION

.................................... 57, 62

GLUCOCARD SHINE

METER ............................ 62

GLUCOCARD SHINE TEST

STRIPS ............................. 57

GLUCOCARD SHINE XL

METER ............................ 63

GLUCOCARD VITAL ........ 63

GLUCOCARD VITAL

SENSOR .......................... 57

GLUCOCARD VITAL TEST

STRIPS ............................. 57

GLUCOCOM BLOOD

GLUCOSE ....................... 63

GLUCOCOM CONTROL

NORMAL ........................ 63

GLUCOCOM GLUCOSE ... 57

GLUCOPHAGE ................... 70

GLUCOPHAGE XR ............ 70

GLUCOSE CONTROL........ 63

GLUCOTROL ...................... 70

GLUCOTROL XL ............... 70

GLUCOVANCE .................. 70

GLUMETZA ........................ 70

glyburide............................... 70

glyburide micronized............ 70

glyburide-metformin ............ 70

glycolax ................................ 74

glycopyrrolate ....................... 72

GLYCOPYRROLATE ......... 72

glydo ..................................... 47

GLYNASE ........................... 70

GLYSET ............................... 70

GLYXAMBI ........................ 70

GM100............................ 57, 63

GOCOVRI ............................ 20

GOLYTELY ......................... 74

GONAL-F ............................ 68

GONAL-F RFF .................... 68

GONAL-F RFF REDI-JECT 68

GONITRO ............................ 42

GRALISE ............................. 18

GRALISE 30-DAY STARTER

PACK ............................... 18

granisetron hcl ...................... 74

GRANIX .............................. 78

griseofulvin microsize ............ 3

griseofulvin ultramicrosize ..... 3

guaiatussin ac ....................... 93

guaifenesin ac ....................... 93

guaifenesin dac ..................... 93

guanfacine ...................... 30, 36

guanidine .............................. 30

GYNAZOLE-1 ..................... 84

gynol ii .................................. 84

H HAEGARDA........................ 95

HALAVEN ........................... 14

HALCION ............................ 30

HALDOL.............................. 30

HALDOL DECANOATE .... 30

halobetasol propionate .......... 50

HALOG ................................ 50

haloperidol ............................ 30

haloperidol decanoate ........... 30

haloperidol lactate ................ 30

HARVONI.............................. 4

HAVRIX (PF) ...................... 80

HEALTHPRO GLUCOSE

MONITOR ....................... 63

HEALTHPRO HIGH-LOW

CONTROL ....................... 63

HEALTHPRO TEST STRIPS

.......................................... 57

healthylax ............................. 74

heather .................................. 84

HECTOROL ......................... 68

HELIXATE FS ..................... 39

HEMANGEOL ..................... 36

hematinic plus vit/minerals . 101

hematinic/folic acid ............ 101

hematogen ........................... 101

hematogen fa ...................... 101

hematogen forte .................. 101

HEMATRON-AF ............... 101

hemenatal ob ....................... 101

hemenatal ob + dha ............. 101

hemetab ............................... 101

HEMLIBRA ......................... 39

hemmorex-hc ........................ 74

HEMOCYTE-F .................. 101

HEMOCYTE-PLUS ........... 101

HEMOFIL M HIGH ............. 39

HEMOFIL M LOW .............. 39

HEMOFIL M MID ............... 39

HEMOFIL M SUPER HIGH39

hep flush-10 (pf) ................... 39

HEPAGAM B ....................... 80

heparin (porcine) .................. 39

HEPARIN (PORCINE) IN

0.9% NACL ...................... 39

heparin (porcine) in 5 % dex 39

heparin (porcine) in nacl (pf) 39

heparin flush(porcine)-0.9nacl

.......................................... 39

heparin lock flush ................. 39

heparin lock flush (porcine) .. 39

heparin lockflush(porcine)(pf)

.......................................... 39

HEPARIN(PORCINE) IN

0.45% NACL .................... 39

heparin, porcine (pf) ............. 39

HEPLISAV-B ....................... 80

HEPSERA .............................. 4

HERCEPTIN ........................ 14

HETLIOZ ............................. 30

HEXALEN ........................... 14

HIBERIX (PF) ...................... 80

hi-cal plus vit d ..................... 99

HIPREX ................................ 11

HISTEX-AC ......................... 93

HIZENTRA .......................... 80



122

homatropaire......................... 89

homatropine hbr ................... 89

HORIZANT ......................... 21

hpr ........................................ 44

hpr plus ................................. 44

hpr plus hydrogel .................. 44

HPR PLUS-MB HYDROGEL

.......................................... 44

HUMALOG JUNIOR

KWIKPEN U-100 ............ 66

HUMALOG KWIKPEN

INSULIN .......................... 66

HUMALOG MIX 50-50

INSULN U-100 ................ 66

HUMALOG MIX 50-50

KWIKPEN ....................... 66

HUMALOG MIX 75-25

KWIKPEN ....................... 66

HUMALOG MIX 75-25(U-

100)INSULN .................... 66

HUMALOG U-100 INSULIN

.......................................... 66

HUMAPEN LUXURA HD .. 63

HUMATE-P ......................... 39

HUMATROPE ..................... 78

HUMIRA .............................. 82

HUMIRA PEDIATRIC

CROHN'S START ........... 82

HUMIRA PEN ..................... 82

HUMIRA PEN CROHN'S-

UC-HS START ................ 82

HUMIRA PEN PSORIASIS-

UVEITIS .......................... 82

HUMULIN 70/30 U-100

INSULIN .......................... 66

HUMULIN 70/30 U-100

KWIKPEN ....................... 66

HUMULIN N NPH INSULIN

KWIKPEN ....................... 66

HUMULIN N NPH U-100

INSULIN .......................... 66

HUMULIN R REGULAR U-

100 INSULN .................... 66

HUMULIN R U-500 (CONC)

INSULIN .......................... 66

HUMULIN R U-500 (CONC)

KWIKPEN ....................... 66

HYCAMTIN ........................ 14

hydralazine ........................... 36

HYDREA ............................. 14

HYDRO 35 ........................... 44

HYDRO 40 ........................... 44

hydrochlorothiazide .............. 36

hydrocodone-acetaminophen 23

hydrocodone-chlorpheniramine

.......................................... 93

hydrocodone-cpm-

pseudoephed ..................... 93

hydrocodone-homatropine .... 93

hydrocodone-ibuprofen ........ 23

hydrocortisone .......... 50, 55, 74

hydrocortisone acetate .......... 74

hydrocortisone butyrate ........ 50

hydrocortisone butyr-emollient

.......................................... 50

hydrocortisone valerate ........ 50

hydrocortisone-acetic acid .... 54

hydrocortisone-iodoquinol-aloe

.......................................... 48

hydrocortisone-min oil-wht pet

.......................................... 50

hydrocortisone-pramoxine... 42,

74

hydromet ............................... 93

hydromorphone .................... 24

HYDROMORPHONE ......... 24

hydromorphone in 0.9 % nacl

.......................................... 24

HYDROMORPHONE IN 0.9

% NACL ........................... 24

hydroxychloroquine................ 8

hydroxyprogesterone caproate

.......................................... 84

hydroxyurea .......................... 14

hydroxyzine hcl .................... 93

hydroxyzine pamoate ........... 93

HYLATOPIC ....................... 44

HYLATOPICPLUS.............. 44

hyolev mb ............................. 97

hyophen ................................ 97

hyoscyamine sulfate ............. 72

hyosyne ................................. 72

HYPERHEP B S/D .............. 80

HYPERHEP B S-D

NEONATAL .................... 80

HYPERRAB (PF)................. 80

HYPERRAB S/D (PF) ......... 80

HYPER-SAL ........................ 95

HYPERTET S/D (PF) .......... 80

HYQVIA .............................. 80

HYSINGLA ER .................... 24

HYZAAR ............................. 36

I ibandronate ........................... 81

IBRANCE ............................. 14

ibu ......................................... 27

IBUDONE ............................ 24

ibuprofen ............................... 27

ibuprofen-oxycodone ............ 24

ic green ................................. 52

ICAR-C PLUS .................... 101

ICLUSIG .............................. 14

IDAMYCIN PFS .................. 14

idarubicin .............................. 14

IDELVION ........................... 39

IDHIFA ................................. 14

IFEX ..................................... 14

ifosfamide ............................. 14

ifosfamide-mesna ................. 14

IGLUCOSE BLOOD


IGLUCOSE TEST STRIP .... 57

ILARIS (PF) ......................... 79

ILEVRO ............................... 90

ILUVIEN .............................. 91

imatinib ................................. 14

IMBRUVICA ....................... 15

IMFINZI ............................... 15

imipenem-cilastatin ................ 8

imipramine hcl ...................... 30

imipramine pamoate ............. 30

imiquimod ............................. 79

IMITREX ............................. 20

IMITREX STATDOSE KIT

REFILL ............................. 20

IMITREX STATDOSE PEN 20

IMLYGIC ............................. 15

IMOGAM RABIES-HT (PF)

.......................................... 80

IMPAVIDO ............................ 8

IMPOYZ ............................... 50

IMURAN .............................. 15

IMVEXXY ........................... 84

INCRELEX .......................... 52



123

INCRUSE ELLIPTA ........... 95

indapamide ........................... 36

INDERAL LA ...................... 36

INDERAL XL ...................... 36

INDIOMIN MB.................... 97

INDOCIN ............................. 27

indocyanine green ................ 52

indomethacin ........................ 27

INFANRIX (DTAP) (PF) .... 80

INFASURF .......................... 52

INFINITY CONTROL

SOLUTION NORM ......... 63

INFINITY STARTER KIT .. 63

INFINITY TEST STRIPS .... 57

INFINITY VOICE CTRL

SOLN-LVL 2 ................... 63

INFINITY VOICE GLUCOSE

MONITOR ....................... 63

INFINITY VOICE TEST

STRIP ............................... 57

INFLECTRA ........................ 74

INFUVITE ADULT ........... 101

INFUVITE PEDIATRIC.... 101

INGREZZA .......................... 21

INJECTAFER .................... 101

INLYTA ............................... 15

INNOPRAN XL ................... 36

INOVA ................................. 46

INOVA 4-1 ........................... 43

INSPRA ................................ 36

INSULIN SYRINGE-

NEEDLE U-100 ............... 59

INTEGRA F ....................... 101

INTEGRA PLUS ............... 101

INTELENCE .......................... 4

INTERMEZZO .................... 30

INTRAROSA ....................... 84

INTRON A ........................... 79

introvale ................................ 86

INTUNIV ER ....................... 31

INVANZ................................. 8

INVEGA............................... 31

INVIRASE ............................. 4

INVOKAMET ...................... 70

INVOKAMET XR ............... 70

INVOKANA ........................ 70

iodoquinol-hc ....................... 48

IOPIDINE............................. 92

ipratropium bromide ....... 53, 95

ipratropium-albuterol............ 95

IPRIVASK............................ 39

irbesartan .............................. 36

irbesartan-hydrochlorothiazide

.......................................... 36

IRESSA ................................ 15

irinotecan .............................. 15

IROSPAN 24/6 ................... 101

ISENTRESS ........................... 4

ISENTRESS HD .................... 4

isibloom ................................ 86

ISOCHRON.......................... 42

ISOLYTE-S .......................... 99

isometh-dichloral-

acetaminophn.................... 20

isomethepten-caf-

acetaminophen .................. 20

isoniazid.................................. 8

ISOPTO CARPINE .............. 89

ISORDIL .............................. 42

ISORDIL TITRADOSE ....... 42

isosorbide dinitrate ............... 42

isosorbide mononitrate ......... 42

isotretinoin ............................ 46

isoxsuprine............................ 85

isradipine .............................. 36

ISTALOL ............................. 89

ISTODAX ............................ 15

itraconazole ............................ 3

ivermectin ............................... 8

IXEMPRA ............................ 15

IXINITY ............................... 39

J JAKAFI ................................ 15

JALYN ................................. 97

jantoven ................................ 39

JANUMET ........................... 70

JANUMET XR ..................... 70

JANUVIA ............................. 70

JARDIANCE ........................ 70

JAZZ WIRELESS 2 METER

KIT ................................... 63

jencycla ................................. 84

JENTADUETO .................... 70

JENTADUETO XR .............. 70

JETREA (PF) ....................... 90

jevantique lo ......................... 84

JEVTANA ............................ 15

jinteli ..................................... 84

jolessa ................................... 86

jolivette ................................. 84

JUBLIA ................................ 49

juleber ................................... 86

JULUCA ................................. 4

junel 1.5/30 (21) ................... 86

junel 1/20 (21) ...................... 86

junel fe 1.5/30 (28) ............... 86

junel fe 1/20 (28) .................. 86

junel fe 24 ............................. 86

JUXTAPID ........................... 41

JYNARQUE ......................... 68

K KADCYLA ........................... 15

KADIAN .............................. 24

kaitlib fe ................................ 86

KALBITOR .......................... 95

KALETRA ............................. 4

KALYDECO ........................ 95

KANUMA ............................ 68

KAPVAY ............................. 31

KARBINAL ER ................... 93

kariva (28) ............................ 86

KAZANO ............................. 70

KEFLEX ................................. 6

kelnor 1/35 (28) .................... 86

kelnor 1-50 ............................ 86

KENALOG ..................... 50, 55

KEPIVANCE ....................... 12

KEPPRA ............................... 18

KEPPRA XR ........................ 18

KERAFOAM ........................ 44

KERALAC ........................... 44

KERALYT RX ..................... 43

KERYDIN ............................ 49

ketoconazole ..................... 3, 49

ketoprofen ............................. 27

ketorolac ......................... 27, 90

KEVEYIS ............................. 21

KEVZARA ........................... 82

KHEDEZLA ......................... 31

kimidess (28) ........................ 86

KINERET ............................. 79

KINRIX (PF) ........................ 80

kionex ................................... 74

kionex (with sorbitol) ........... 74



124

KISQALI .............................. 15

KISQALI FEMARA CO-

PACK ............................... 15

KIT FOR TC 99M-

SESTAMIBI NO.1 ........... 52

KIT PREP OF TC-99M-

MEBROFENIN ................ 52

KIT PREP OF TC-99M-SOD

PYROPH .......................... 52

KITABIS PAK ....................... 8

KLARON ............................. 48

KLONOPIN ......................... 18

KOATE ................................ 39

kobee .................................. 102

KOGENATE FS ................... 39

KOMBIGLYZE XR ............. 70

KORLYM ............................ 68

KOSHER PRENATAL PLUS

IRON .............................. 102

KOVALTRY ........................ 39

K-PHOS NO 2 ...................... 98

K-PHOS ORIGINAL ........... 98

k-phos-neutral....................... 99

kpn ...................................... 102

KRISTALOSE ..................... 74

KRYSTEXXA ...................... 81

kurvelo .................................. 86

KUVAN ............................... 68

KYLEENA ........................... 83

KYMRIAH ........................... 15

KYNAMRO ......................... 41

KYPROLIS .......................... 15

L l norgest/e.estradiol-e.estrad . 86

labetalol ................................ 36

LABETALOL ...................... 36

LACRISERT ........................ 90

lactated ringers ..................... 51

lactulose ................................ 74

LAMICTAL ......................... 18

LAMICTAL ODT ................ 18

LAMICTAL ODT STARTER

(BLUE) ............................. 18


(GREEN) .......................... 18


(ORANGE)....................... 18

LAMICTAL STARTER

(BLUE) KIT ..................... 18

LAMICTAL STARTER

(GREEN) KIT .................. 18

LAMICTAL STARTER

(ORANGE) KIT ............... 18

LAMICTAL XR ................... 18

LAMICTAL XR STARTER

(BLUE) ............................. 18

LAMICTAL XR STARTER

(GREEN) .......................... 18

LAMICTAL XR STARTER

(ORANGE) ....................... 18

lamivudine .............................. 4

lamivudine-zidovudine ........... 4

lamotrigine............................ 18

LANCETS ............................ 63

LANCING DEVICE ............ 63

LANOXIN ............................ 38

LANOXIN PEDIATRIC ...... 38

lansoprazole .................... 76, 77

lanthanum ............................. 74

LANTUS SOLOSTAR U-100

INSULIN .......................... 66

LANTUS U-100 INSULIN .. 66

larin 1.5/30 (21) .................... 86

larin 1/20 (21) ....................... 86

larin 24 fe.............................. 86

larin fe 1.5/30 (28) ................ 86

larin fe 1/20 (28) ................... 86

larissia ................................... 86

LARTRUVO ........................ 15

LASIX .................................. 36

LASTACAFT ....................... 90

latanoprost ............................ 91

LATUDA.............................. 31

laxaclear................................ 74

laxative (bisacodyl) .............. 74

laxative feminine .................. 74

laxative peg 3350.................. 74

layolis fe ............................... 86

LAZANDA ........................... 24

LDO PLUS ........................... 47

leena 28................................. 86

leflunomide ........................... 82

LEMTRADA ........................ 79

LENVIMA............................ 15

LESCOL XL......................... 41

lessina ................................... 86

LETAIRIS ............................ 95

letrozole ................................ 15

leucovorin calcium ............... 12

LEUKERAN ......................... 15

LEUKINE ............................. 78

leuprolide .............................. 15

LEVA SET ........................... 47

levalbuterol hcl ..................... 95

LEVALBUTEROL

TARTRATE ..................... 95

LEVAQUIN ......................... 10

LEVATOL ............................ 36

LEVBID ............................... 72

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 66

LEVEMIR U-100 INSULIN 66

levetiracetam ......................... 19

levetiracetam in nacl (iso-os) 19

LEVICYN ANTIPRURITIC 44

LEVICYN ANTIPRURITIC

SG ..................................... 44

levobunolol ........................... 89

levocarnitine ......................... 52

levocarnitine (with sugar) ..... 52

levofloxacin .................... 10, 89

levofloxacin in d5w .............. 10

levoleucovorin ...................... 12

LEVOLEUCOVORIN ......... 12

levonest (28) ......................... 86

levonorgestrel-ethinyl estrad 86

levonorg-eth estrad triphasic 86

levora-28 ............................... 86

levorphanol tartrate ............... 24

LEVO-T ................................ 71

levothyroxine ........................ 71

LEVOTHYROXINE ............ 71

levoxyl .................................. 71

LEVSIN ................................ 72

LEVSIN/SL .......................... 72

LEVULAN ........................... 44

LEXAPRO ............................ 31

LEXIVA ................................. 4

LEXIXRYL .......................... 27

LIALDA ............................... 74

LIBRAX (WITH

CLIDINIUM) ................... 72

lidocaine ............................... 48



125

lidocaine (pf) ........................ 47

LIDOCAINE (PF) ................ 47

lidocaine hcl ......................... 47

LIDOCAINE HCL ............... 47

lidocaine hcl-hydrocortison ac

.................................... 48, 74

lidocaine viscous .................. 48

lidocaine-prilocaine .............. 48

LIDOCAINE-TETRACAINE

.......................................... 48

LIDOCAN-PHENYLEPH-

BSS NO.2(PF) .................. 90

LIDODERM ......................... 48

LIDOPAC ............................ 48

lidopin .................................. 48

LIDOPIN .............................. 48

LIDO-PRILO CAINE PACK

.......................................... 48

LIDORX ............................... 48

LIDOTRAL .......................... 48

lidozion ................................. 48

LIDTOPIC MAX ................. 48

LILETTA ............................. 83

lillow .................................... 86

LINCOCIN ............................. 8

lincomycin .............................. 8

lindane .................................. 51

linezolid .................................. 8

linezolid in dextrose 5% ......... 8

LINZESS .............................. 74

liothyronine .......................... 71

LIPITOR .............................. 41

LIPOCHOL PLUS ............... 52

lipodox .................................. 15

lipodox 50 ............................. 15

LIPOFEN ............................. 41

LIPROZONEPAK ................ 48

lisinopril ............................... 36

lisinopril-hydrochlorothiazide

.......................................... 36

lite coat aspirin ..................... 27

lithium carbonate .................. 31

lithium citrate ....................... 31

LITHOBID ........................... 31

LITHOSTAT ........................ 52

LIVALO ............................... 41

LO LOESTRIN FE .............. 86

LOCOID ............................... 50

LOCOID LIPOCREAM ....... 50

LODINE ............................... 27

LODOSYN ........................... 20

LOESTRIN 1.5/30 (21) ........ 86

LOESTRIN 1/20 (21) ........... 86

LOESTRIN FE 1.5/30 (28-

DAY) ................................ 87

LOESTRIN FE 1/20 (28-DAY)

.......................................... 87

LOMOTIL ............................ 72

LONHALA MAGNAIR

REFILL ............................ 95

LONHALA MAGNAIR

STARTER ........................ 95

LONSURF ............................ 15

LOPID .................................. 41

lopinavir-ritonavir .................. 4

lopreeza ................................ 84

LOPRESSOR ....................... 36

LOPROX .............................. 49

LOPROX (AS OLAMINE) .. 49

LOPROX KIT ...................... 49

lorazepam ............................. 31

LORAZEPAM IN 0.9% SOD

CHLORIDE ...................... 31

LORAZEPAM IN

DEXTROSE 5 % .............. 31

lorazepam intensol ................ 31

lorcet (hydrocodone) ............ 24

lorcet hd ................................ 24

lorcet plus ............................. 24

LORTAB ELIXIR ................ 24

lortuss ex............................... 93

loryna (28) ............................ 87

LORZONE ........................... 22

losartan ................................. 36

losartan-hydrochlorothiazide 37

LOSEASONIQUE................ 87

LOTEMAX .......................... 91

LOTENSIN .......................... 37

LOTENSIN HCT ................. 37

LOTREL ............................... 37

LOTRISONE ........................ 49

LOTRONEX ........................ 74

LOUTREX ........................... 44

lovastatin .............................. 41

LOVAZA.............................. 41

LOVENOX ........................... 40

low-ogestrel (28) .................. 87

loxapine succinate ................ 31

LOYON ................................ 44

lta pre-attached ..................... 48

LUCEMYRA ........................ 27

LUCENTIS ........................... 90

ludent fluoride .................... 102

lugols .............................. 48, 99

LUMIGAN ........................... 91

LUMIZYME ......................... 68

LUNESTA ............................ 31

LUPANETA PACK (1

MONTH) .......................... 85

LUPANETA PACK (3

MONTH) .......................... 85

LUPRON DEPOT ................ 15

LUPRON DEPOT (3

MONTH) .......................... 15

LUPRON DEPOT (4

MONTH) .......................... 15

LUPRON DEPOT (6

MONTH) .......................... 15

LUPRON DEPOT-PED ....... 15

lutera (28) ............................. 87

luxamend .............................. 44

LUXIQ .................................. 50

LUXTURNA ........................ 90

LUZU ................................... 49

LYNPARZA ......................... 15

LYRICA ............................... 19

LYRICA CR ......................... 19

LYSODREN ......................... 15

LYSTEDA ............................ 85

lyza ....................................... 84

M m.v.i. adult .......................... 102

MACROBID ......................... 11

MACRODANTIN ................ 11

MACUGEN .......................... 90

mafenide acetate ................... 48

MAGNEBIND 400 ............... 74

magnesium citrate ................. 74

MAKENA ............................. 84

MAKENA (PF) .................... 84

MALARONE ......................... 8

MALARONE PEDIATRIC .... 8

malathion .............................. 51

maprotiline ............................ 31



126

MAR-COF CG ..................... 93

MARINOL ........................... 74

marlissa................................. 87

MARNATAL-F .................. 102

MARPLAN .......................... 31

MARQIBO ........................... 15

MATULANE ....................... 15

matzim la .............................. 37

MAVYRET ............................ 4

MAXALT ............................. 20

MAXALT-MLT ................... 20

MAXFE (FOLATE-

DOCUSATE) ................. 102

MAXIDEX ........................... 91

MAXIPIME ............................ 6

MAXITROL ......................... 91

MAXZIDE ........................... 37

MAXZIDE-25MG ................ 37

m-clear wc ............................ 93

meclofenamate ..................... 27

MEDISENSE ....................... 63

MEDISENSE GLUCOSE

KETONE .......................... 63

MEDOLOR PAK ................. 48

MEDROL ............................. 55

MEDROL (PAK) ................. 55

medroxyprogesterone ........... 84

mefenamic acid .................... 27

mefloquine .............................. 8

MEGACE ES ....................... 15

megestrol .............................. 15

MEKINIST ........................... 15

melodetta 24 fe ..................... 87

meloxicam ............................ 27

melphalan ............................. 15

melphalan hcl ....................... 15

memantine ............................ 21

MEMANTINE ..................... 21

MENACTRA (PF) ............... 80

M-END PE ........................... 93

MENEST .............................. 84

MENOPUR .......................... 68

MENOSTAR ........................ 84

MENVEO A-C-Y-W-135-DIP

(PF) ................................... 80

meperidine ............................ 24

MEPHYTON ........................ 40

meprobamate ........................ 22

MEPRON ............................... 8

MEPSEVII............................ 68

mercaptopurine ..................... 15

meropenem ............................. 8

MEROPENEM-0.9%

SODIUM CHLORIDE ....... 9

MERREM ............................... 9

mesalamine ........................... 74

MESALAMINE ................... 74

mesalamine with cleansing

wipe .................................. 74

mesna .................................... 12

MESNEX.............................. 12

MESTINON ......................... 22

MESTINON TIMESPAN .... 22

metadate er ........................... 31

metaproterenol ...................... 95

metaxall ................................ 22

metaxalone............................ 22

metformin ............................. 70

methadone ............................ 24

methadose ............................. 24

methamphetamine ................ 31

methazolamide ...................... 91

methenamine hippurate ........ 11

methenamine mandelate ....... 11

methen-sod phos-meth blue-

hyos .................................. 98

methimazole ......................... 55

METHITEST ........................ 68

methocarbamol ..................... 22

methotrexate sodium ............ 15

methotrexate sodium (pf) ..... 15

methoxsalen .......................... 44

methscopolamine .................. 72

methyclothiazide .................. 37

methyldopa ........................... 37

methyldopa-

hydrochlorothiazide .......... 37

methyldopate ........................ 37

METHYLIN ......................... 31

methylphenidate hcl ............. 31

METHYLPHENIDATE HCL

.......................................... 31

methylprednisolone .............. 55

methyltestosterone ................ 68

metipranolol.......................... 89

metoclopramide hcl .............. 74

metolazone ............................ 37

METOPIC ............................. 44

METOPIRONE .................... 52

metoprolol succinate ............. 37

METOPROLOL SU-

HYDROCHLOROTHIAZ 37

metoprolol ta-hydrochlorothiaz

.......................................... 37

metoprolol tartrate ................ 37

metro i.v. ................................. 9

METROCREAM .................. 46

METROGEL ........................ 46

METROGEL VAGINAL ..... 85

METROLOTION ................. 46

metronidazole ............. 9, 46, 85

metronidazole in nacl (iso-os) 9

mexiletine ............................. 34

MIACALCIN ....................... 68

mibelas 24 fe ......................... 87

MICARDIS ........................... 37

MICARDIS HCT .................. 37

MICORT-HC ........................ 74

MICRO BLOOD GLUCOSE

.......................................... 57

MICRODOT BLOOD

GLUCOSE SYSTEM . 57, 63

microgestin 1.5/30 (21) ........ 87

microgestin 1/20 (21) ........... 87

MICROGESTIN 24 FE ........ 87

microgestin fe 1.5/30 (28) .... 87

microgestin fe 1/20 (28) ....... 87

MICROZIDE ........................ 37

midazolam ............................ 31

midazolam (pf) in 0.9 % nacl

.......................................... 31

MIDAZOLAM IN 0.9 % SOD

CHLORID ........................ 31

MIDAZOLAM IN

DEXTROSE 5 % .............. 31

midodrine .............................. 52

MIFEPREX .......................... 85

migergot ................................ 20

miglitol ................................. 70

miglustat ............................... 68

MIGRANAL ......................... 20

mili ........................................ 87

milk of magnesia .................. 74



127

milk of magnesia concentrated

.......................................... 74

millipred ............................... 55

millipred dp .......................... 55

mimvey ................................. 84

mimvey lo ............................. 84

MINASTRIN 24 FE ............. 87

MINIPRESS ......................... 37

MINITRAN .......................... 42

MINIVELLE ........................ 84

MINOCIN ............................ 11

minocycline .......................... 11

minoxidil .............................. 37

MIOCHOL-E ....................... 89

miralax .................................. 74

MIRAPEX ............................ 20

MIRAPEX ER ...................... 20

MIRCERA ............................ 78

MIRCETTE (28) .................. 87

MIRENA .............................. 83

mirtazapine ........................... 31

MIRVASO ........................... 46

misoprostol ........................... 77

MITIGARE .......................... 81

mitomycin ............................ 15

MITOSOL ............................ 91

mitoxantrone ........................ 15

M-M-R II (PF) ...................... 80

MOBIC ................................. 27

modafinil .............................. 31

moderiba ............................... 79

moderiba dose pack .............. 79

moexipril .............................. 37

moexipril-hydrochlorothiazide

.......................................... 37

mometasone .................... 50, 95

mondoxyne nl ....................... 11

MONOCLATE-P ................. 40

MONODOX ......................... 11

mono-linyah ......................... 87

mononessa (28) .................... 87

MONONINE ........................ 40

montelukast .......................... 95

MONUROL .......................... 11

morgidox .............................. 11

MORPHABOND ER ........... 24

morphine............................... 25

MORPHINE ......................... 25

morphine (pf) ........................ 24

morphine (pf) in 0.9 % nacl .. 25

MORPHINE (PF) IN 0.9 %

NACL ............................... 25

morphine concentrate ........... 25

MORPHINE IN 0.9 %

SODIUM CHLOR ............ 25

MOTOFEN ........................... 72

MOVANTIK ........................ 74

MOVIPREP .......................... 74

MOXATAG.......................... 10

MOXEZA ............................. 89

moxifloxacin ................... 10, 89

MOXIFLOXACIN (PF)-BSS

NO.2 ................................. 89

moxifloxacin in nacl (iso-osm)

.......................................... 10

MOXIFLOXACIN IN

NACL,ISO-O(PF) ............ 89

MOZOBIL ............................ 78

MS CONTIN ........................ 25

MUGARD ............................ 53

MULTAQ ............................. 34

multigen folic ..................... 102

multigen plus ...................... 102

multi-vit with fluoride-iron 102

multi-vitamin with fluoride 102

multivitamins with fluoride 102

mupirocin.............................. 48

mupirocin calcium ................ 48

MUSTARGEN ..................... 16

MUTAMYCIN ..................... 16

mvc-fluoride ....................... 102

my choice ............................. 87

my way ................................. 87

MYALEPT ........................... 68

MYAMBUTOL ...................... 9

MYCOBUTIN ........................ 9

mycophenolate mofetil ......... 16

mycophenolate mofetil hcl ... 16

mycophenolate sodium ......... 16

MYDAYIS ........................... 31

MYDRIACYL ...................... 89

MYFORTIC ......................... 16

MYGLUCOHEALTH .... 57, 63

MYGLUCOHEALTH

CONTROL SOLUTION .. 63

MYLERAN .......................... 16

MYLOTARG ....................... 16

mynatal ............................... 102

mynatal advance ................. 102

mynatal plus ........................ 102

mynatal-z ............................ 102

mynate 90 plus .................... 102

mynephrocaps ..................... 102

mynephron .......................... 102

MYOBLOC .......................... 80

MYRBETRIQ ....................... 97

MYSOLINE ......................... 19

MYTESI ............................... 72

myzilra .................................. 87

N NABI-HB ............................. 80

nabumetone ........................... 27

nadolol .................................. 37

nadolol-bendroflumethiazide 37

nafcillin ................................. 10

naftifine ................................. 49

NAFTIN ............................... 49

NAGLAZYME ..................... 68

nalbuphine ............................ 27

NALFON .............................. 27

NALOCET ........................... 25

naloxone ............................... 27

naltrexone ............................. 27

NAMENDA .......................... 21

NAMENDA TITRATION

PAK .................................. 21

NAMENDA XR ................... 21

NAMZARIC ......................... 21

NAPRELAN CR .................. 27

NAPROSYN ......................... 27

naproxen ............................... 27

naproxen sodium .................. 27

naratriptan ............................. 20

NARCAN ............................. 27

NARDIL ............................... 31

NASONEX ........................... 95

NATACHEW (FE BIS-

GLYCINATE) ................ 102

NATACYN ........................... 89

NATAZIA ............................ 87

nateglinide ............................ 70

NATESTO ............................ 68

NATPARA ........................... 68

NATROBA ........................... 51



128

natural b-100 complex ........ 102

natura-lax .............................. 74

nature-throid ......................... 71

NAVELBINE ....................... 16

NEBUPENT ........................... 9

nebusal .................................. 95

NEBUSAL ........................... 95

necon 0.5/35 (28).................. 87

necon 7/7/7 (28) ................... 87

NEEVODHA (WITH ALGAL

OIL) ................................ 102

nefazodone ........................... 31

NEOCERA ........................... 44

neomycin ................................ 9

neomycin-bacitracin-poly-hc 91

neomycin-bacitracin-

polymyxin ........................ 89

neomycin-polymyxin b-

dexameth .......................... 91

neomycin-polymyxin-

gramicidin......................... 89

neomycin-polymyxin-hc 54, 91

neo-polycin ........................... 89

neo-polycin hc ...................... 91

NEORAL .............................. 16

NEOSALUS ......................... 44

NEO-SYNALAR ................. 48

NEO-SYNALAR KIT .......... 48

nephplex rx ......................... 102

NEPHROCAPS .................. 102

NEPHROCAPS QT............ 102

NEPHRON FA ................... 102

nephro-vite rx ..................... 102

NEPTAZANE ...................... 91

NERLYNX ........................... 16

NESINA ............................... 70

NESTABS .......................... 102

NESTABS ABC ................. 102

NESTABS DHA ................ 102

NESTABS ONE ................. 102

neuac..................................... 46

NEUAC KIT ........................ 46

NEULASTA ......................... 78

NEUPOGEN ........................ 78

NEUPRO .............................. 20

NEURIN-SL ....................... 102

NEURONTIN....................... 19

NEUTEK 2TEK TEST

STRIPS ............................. 57

NEVANAC .......................... 90

nevirapine ............................... 4

newgen................................ 102

NEXAVAR .......................... 16

NEXAVIR .......................... 103

NEXIUM .............................. 77

NEXIUM IV ......................... 77

NEXIUM PACKET ............. 77

NEXPLANON...................... 85

niacin .................................... 41

NIACOR ............................... 41

NIASPAN EXTENDED-

RELEASE ........................ 41

nicardipine ............................ 37

NICODERM CQ .................. 53

nicorelief ............................... 53

nicorette ................................ 53

NICORETTE ........................ 53

nicotine ................................. 53

nicotine (polacrilex) ............. 53

NICOTROL .......................... 53

NICOTROL NS .................... 53

nifedipine .............................. 37

nikki (28) .............................. 87

NILANDRON ...................... 16

nilutamide ............................. 16

nimodipine ............................ 37

NINJACOF-XG.................... 93

NINLARO ............................ 16

NIPENT ................................ 16

NIPRIDE RTU ..................... 42

nisoldipine ............................ 37

nitro-bid ................................ 42

NITRO-DUR ........................ 42

nitrofurantoin ........................ 11

nitrofurantoin macrocrystal .. 11

nitrofurantoin monohyd/m-

cryst .................................. 11

nitroglycerin ......................... 42

NITROLINGUAL ................ 42

NITROMIST ........................ 42

NITROSTAT ........................ 42

nitro-time .............................. 42

NITYR .................................. 52

NIVA-PLUS ....................... 103

nivatopic plus ....................... 44

nizatidine .............................. 77

NIZORAL ............................. 49

NOCTIVA ............................ 68

nolix ...................................... 50

nora-be .................................. 84

NORCO ................................ 25

NORDITROPIN FLEXPRO 78

noreth-ethinyl estradiol-iron . 87

norethindrone (contraceptive)

.......................................... 84

norethindrone acetate ............ 84

norethindrone ac-eth estradiol

.................................... 84, 87

norethindrone-e.estradiol-iron

.......................................... 87

norgestimate-ethinyl estradiol

.......................................... 87

NORITATE .......................... 46

norlyda .................................. 84

norlyroc ................................. 84

NORPACE ........................... 34

NORPACE CR ..................... 34

NORPRAMIN ...................... 31

NORTHERA ........................ 52

nortrel 0.5/35 (28) ................. 87

nortrel 1/35 (21) .................... 87

nortrel 1/35 (28) .................... 87

nortrel 7/7/7 (28) ................... 87

nortriptyline .......................... 31

NORVASC ........................... 37

NORVIR ............................. 4, 5

NOVA MAX BLOOD


NOVA MAX GLUCOSE

CONTROL ....................... 63

NOVA MAX GLUCOSE

TEST ................................. 57

NOVAMAX PLUS GLU-KET

.......................................... 63

NOVAREL ........................... 68

NOVOEIGHT ....................... 40

NOVOLOG FLEXPEN U-100

INSULIN .......................... 67

NOVOLOG MIX 70-30 U-100

INSULN ........................... 67

NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 67



129

NOVOLOG PENFILL U-100

INSULIN .......................... 67

NOVOLOG U-100 INSULIN

ASPART .......................... 67

NOVOPEN ECHO ............... 63

NOVOSEVEN RT ............... 40

NOXAFIL .............................. 3

np thyroid ............................. 71

NPLATE .............................. 40

NUCALA ............................. 95

NUCYNTA .......................... 28

NUCYNTA ER .................... 28

NUEDEXTA ........................ 21

NULEV ................................ 72

NULOJIX ............................. 16

NULYTELY WITH FLAVOR

PACKS ............................. 74

NUMBONEX ....................... 48

NUOX .................................. 46

NUPLAZID .......................... 31

NUTRASEB ......................... 44

NUTRESTORE .................... 52

NUTRICAP ........................ 103

NUTROPIN AQ NUSPIN ... 78

NUVARING......................... 85

NUVESSA ........................... 85

NUVIGIL ............................. 31

NUWIQ ................................ 40

nyamyc ................................. 49

NYMALIZE ......................... 37

nystatin ............................. 3, 49

nystatin-triamcinolone .......... 49

nystop ................................... 49

O OB COMPLETE GOLD .... 103

OB COMPLETE ONE ....... 103

OB COMPLETE PETITE .. 103

OB COMPLETE PREMIER

........................................ 103

OB COMPLETE WITH DHA

........................................ 103

OBIZUR ............................... 40

OBREDON .......................... 93

obstetrix dha ....................... 103

OBSTETRIX EC ................ 103

OBSTETRIX ONE ............. 103

OBTREX DHA .................. 103

O-CAL FA ......................... 103

O-CAL PRENATAL .......... 103

OCALIVA ............................ 74

ocella .................................... 87

OCREVUS ........................... 79

OCTAGAM .......................... 80

octreotide acetate .................. 16

OCUFLOX ........................... 89

ODEFSEY .............................. 5

ODOMZO ............................ 16

OFEV.................................... 95

ofloxacin ................... 10, 54, 89

ogestrel (28) .......................... 87

olanzapine ....................... 31, 32

olanzapine-fluoxetine ........... 32

olmesartan ............................ 37

olmesartan-amlodipin-

hcthiazid ........................... 37

olmesartan-

hydrochlorothiazide .......... 37

olopatadine ..................... 53, 90

OLUMIANT ......................... 82

OLUX ................................... 50

OLUX-E ............................... 50

OMECLAMOX-PAK .......... 77

omega-3 acid ethyl esters ..... 41

omeppi .................................. 77

omeprazole ........................... 77

omeprazole-sodium

bicarbonate ....................... 77

OMIDRIA ............................ 90

OMNARIS............................ 96

OMNIPRED ......................... 91

OMNITROPE ....................... 78

ON CALL EXPRESS

CONTROL ....................... 63

ON CALL EXPRESS METER

.......................................... 63

ON CALL EXPRESS TEST

STRIP ............................... 58

ON CALL PLUS CONTROL

.......................................... 63

ON CALL PLUS METER ... 63

ON CALL PLUS TEST STRIP

.......................................... 58

ON CALL VIVID CONTROL

.......................................... 63

ON CALL VIVID METER .. 63

ON CALL VIVID PAL

METER ............................. 63

ON CALL VIVID TEST

STRIP ............................... 58

ONCASPAR ......................... 16

ondansetron ........................... 74

ondansetron hcl ..................... 74

ondansetron hcl (pf) .............. 74

one daily prenatal ............... 103

ONETOUCH ULTRA BLUE

TEST STRIP ..................... 58

ONETOUCH ULTRA

CONTROL ....................... 63

ONETOUCH ULTRA2 ........ 64

ONETOUCH ULTRAMINI . 64

ONETOUCH VERIO ........... 58

ONETOUCH VERIO FLEX 64

ONETOUCH VERIO IQ

METER ............................. 64

ONETOUCH VERIO

SYSTEM .......................... 64

ONEXTON ........................... 46

ONFI ..................................... 19

ONGLYZA ........................... 70

ONIVYDE ............................ 16

ONMEL .................................. 3

ONZETRA XSAIL ............... 20

OPANA ................................ 25

opcicon one-step ................... 87

OPDIVO ............................... 16

opium tincture ....................... 72

OPSUMIT ............................. 96

option-2 ................................. 87

OPTIUM EZ ......................... 58

OPTIUM TEST .................... 58

OPTUMRX ..................... 58, 64

ORACEA .............................. 11

ORACIT ............................... 98

oral saline laxative ................ 74

oralone .................................. 54

ORAMAGICRX ................... 54

ORAP ................................... 32

ORAPRED ODT .................. 55

ORAVIG ................................. 3

ORENCIA ............................ 82

ORENCIA (WITH

MALTOSE) ...................... 82

ORENCIA CLICKJECT ...... 82



130

ORENITRAM ...................... 37

ORFADIN ............................ 52

ORKAMBI ........................... 96

orphenadrine citrate .............. 22

orsythia ................................. 87

ortho d ................................ 103

ORTHO DF ........................ 103

ORTHO MICRONOR.......... 84

ORTHO TRI-CYCLEN (28) 87

ORTHO TRI-CYCLEN LO

(28) ................................... 87

ORTHO-CYCLEN (28) ....... 87

ORTHO-NOVUM 1/35 (28) 87

ORTHO-NOVUM 7/7/7 (28)

.......................................... 87

oscimin ................................. 72

oscimin sl ............................. 72

oscimin sr ............................. 72

oseltamivir .............................. 5

OSENI .................................. 70

OSMOLEX ER .................... 20

OSMOPREP ......................... 74

OSPHENA ........................... 85

OTEZLA .............................. 82

OTEZLA STARTER ........... 82

OTIPRIO .............................. 54

OTOVEL .............................. 54

OTREXUP (PF) ................... 82

OVACE ................................ 42

OVACE PLUS ............... 42, 43

OVACE PLUS SHAMPOO . 42

OVACE PLUS WASH......... 43

OVIDE ................................. 51

OVIDREL ............................ 68

oxacillin ................................ 10

oxacillin in dextrose(iso-osm)

.......................................... 10

oxaliplatin ............................. 16

OXANDRIN......................... 68

oxandrolone .......................... 68

oxaprozin .............................. 28

OXAYDO ............................ 25

oxazepam .............................. 32

oxcarbazepine ....................... 19

oxiconazole........................... 49

OXISTAT ............................. 49

OXSORALEN ULTRA ....... 44

OXTELLAR XR .................. 19

oxybutynin chloride .............. 97

oxycodone ............................ 25

OXYCODONE ..................... 26

oxycodone-acetaminophen ... 26

oxycodone-aspirin ................ 26

OXYCONTIN ...................... 26

oxymorphone ........................ 26

OXYTROL ........................... 97

oysco 500/d........................... 99

oyster shell + d3 ................... 99

oyster shell calcium-vit d2 . 103

oyster shell calcium-vit d3 ... 99

oystercal-d ............................ 99

OZEMPIC ............................ 70

OZURDEX ........................... 92

P pacerone................................ 34

paclitaxel .............................. 16

paliperidone .......................... 32

palonosetron ......................... 75

PALONOSETRON .............. 75

PALYNZIQ .......................... 68

PAMELOR ........................... 32

pamidronate .......................... 68

PANCREAZE ...................... 75

PANDEL .............................. 50

panlor(acetam-caff-

dihydrocod) ...................... 26

PANRETIN .......................... 44

pantoprazole ......................... 77

PARAGARD T 380A ........... 83

paregoric ............................... 72

PAREMYD .......................... 89

paricalcitol ............................ 68

PARICALCITOL ................. 68

PARLODEL ......................... 20

PARNATE............................ 32

paroex oral rinse ................... 54

paromomycin .......................... 9

paroxetine hcl ....................... 32

paroxetine

mesylate(menop.sym)....... 32

PASER.................................... 9

PATADAY ........................... 90

PATANASE ......................... 54

PATANOL ........................... 90

PAXIL .................................. 32

PAXIL CR ............................ 32

PAZEO ................................. 90

P-CARE K40 ........................ 55

P-CARE K80 ........................ 55

P-CARE X (PF) .................... 48

PEDIARIX (PF) ................... 80

peg 3350-electrolytes ............ 75

peg3350 ................................ 75

PEGANONE ......................... 19

PEGASYS ............................ 79

PEGASYS PROCLICK ........ 79

peg-electrolyte soln .............. 75

PEGINTRON ....................... 79

PEN NEEDLE ...................... 64

penicillin g potassium ........... 10

penicillin v potassium ........... 10

PENLAC ............................... 49

PENNSAID .......................... 28

PENTACEL ACTHIB

COMPONENT (PF) ......... 80

PENTASA ............................ 75

pentazocine-naloxone ........... 28

pentoxifylline ........................ 40

PEPCID ................................ 77

PERCOCET .......................... 26

PERFOROMIST ................... 96

PERIDEX ............................. 54

perindopril erbumine ............ 37

periogard ............................... 54

PERJETA ............................. 16

permethrin ............................. 51

perphenazine ......................... 32

perphenazine-amitriptyline ... 32

perry prenatal ...................... 103

PERTZYE ............................. 75

PEXEVA .............................. 32

pfizerpen-g ............................ 10

PHARMACIST CHOICE .... 58

PHARMACIST CHOICE

GLUCOSE SYS ............... 64

phenadoz ............................... 93

phenazopyridine ................... 98

phenelzine ............................. 32

phenergan ............................. 93

PHENERGAN ...................... 93

phenobarb-hyoscy-atropine-

scop ................................... 72

phenohytro ............................ 72

phenoxybenzamine ............... 37



131

phentolamine ........................ 37

phenylephrine hcl ................. 92

PHENYTEK ......................... 19

phenytoin .............................. 19

phenytoin sodium extended .. 19

philith ................................... 87

PHOSLYRA ......................... 75

phospha 250 neutral ............. 99

phosphasal ............................ 98

phosphate laxative ................ 75

PHOSPHOLINE IODIDE .... 89

phosphorous ......................... 99

PHOTREXA CROSS-

LINKING KIT.................. 90

PHOTREXA VISCOUS ...... 90

phrenilin forte(with caffeine) 26

PHYSICIANS EZ USE B-12

........................................ 103

PHYSIOLYTE ..................... 51

PHYSIOSOL IRRIGATION 51

phytonadione (vitamin k1) ... 40

PICATO ............................... 44

pilocarpine hcl .......... 52, 54, 89

pimozide ............................... 32

pimtrea (28) .......................... 87

pindolol ................................ 37

pioglitazone .......................... 70

pioglitazone-glimepiride ...... 70

pioglitazone-metformin ........ 70

piperacillin-tazobactam ........ 10

PIPERACILLIN-

TAZOBACTAM .............. 10

pirmella................................. 87

piroxicam .............................. 28

PLAN B ONE-STEP ............ 87

PLAQUENIL ......................... 9

PLEGRIDY .......................... 79

PLEXION ............................. 46

PLEXION CLEANSING

CLOTHS .......................... 46

PLIAGLIS ............................ 48

PNEUMOVAX 23 ............... 80

pnv 29-1 ............................. 103

pnv ob+dha ......................... 103

pnv-dha ............................... 103

pnv-dha + docusate ............ 103

pnv-ferrous fumarate-docu-fa

........................................ 103

pnv-omega .......................... 103

pnv-select............................ 103

pnv-vp-u ............................. 103

POD-CARE 100K ................ 55

PODOCON ........................... 43

podofilox .............................. 44

polycin .................................. 89

polymyxin b sulfate ................ 9

polymyxin b sulf-trimethoprim

.......................................... 89

POLYTRIM.......................... 89

POLY-TUSSIN AC .............. 93

POLY-VI-FLOR ................ 103

POLY-VI-FLOR WITH IRON

........................................ 103

POMALYST ........................ 79

portia ..................................... 88

PORTRAZZA ...................... 16

pot,sodium citrate-citric acid 98

POTABA .............................. 99

potassium citrate ................... 98

potassium citrate-citric acid .. 98

powderlax ............................. 75

pr natal 400 ......................... 103

pr natal 400 ec .................... 103

pr natal 430 ......................... 103

pr natal 430 ec .................... 103

PRADAXA ........................... 40

PRALUENT PEN................. 41

pramcort................................ 75

pramipexole .......................... 20

PRAMOSONE ..................... 43

PRAMOSONE E .................. 43

PRANDIN ............................ 70

PRAVACHOL ..................... 41

pravastatin ............................ 41

PRAXBIND.......................... 40

praziquantel ............................ 9

prazosin ................................ 37

PRECISION PCX PLUS TEST

.......................................... 58

PRECISION PCX TEST ...... 58

PRECISION POINT OF

CARE TEST ..................... 58

PRECISION Q-I-D TEST .... 58

PRECISION XTRA

MONITOR ....................... 64

PRECISION XTRA TEST ... 58

PRECOSE ............................. 70

PRED FORTE ...................... 92

PRED MILD ......................... 92

PRED-G ................................ 91

PRED-G S.O.P. .................... 91

prednicarbate ........................ 50

prednisolone ......................... 55

prednisolone acetate ............. 92

PREDNISOLONE ACETATE

(PF) ................................... 92

prednisolone sodium phosphate

.................................... 55, 92

PREDNISOLONE-

GATIFLOXACIN ............ 91

PREDNISOLON-GATIFLOX-

BROMFENAC ................. 90

prednisone ............................. 55

prednisone intensol ............... 55

PREFERA-OB .................... 103

PREFERA-OB ONE .......... 103

PREFERA-OB PLUS DHA

........................................ 103

PREFEST ............................. 84

PREGNYL ............................ 68

PREMARIN ......................... 84

PREMIER BLU GLUCOSE

METER ............................. 64

PREMIER TEST STRIP ...... 58

PREMIER VOICE GLUCOSE

METER ............................. 64

PREMIUM BLOOD


PREMIUM V10 .............. 58, 64

PREMPHASE ....................... 84

PREMPRO ........................... 84

prena1 chew ........................ 103

prena1 pearl ........................ 103

prena1 true .......................... 103

prenaissance ........................ 103

prenaissance plus ................ 103

PRENATA .......................... 103

prenatabs fa ......................... 103

prenatabs rx ........................ 103

prenatal ............................... 103

prenatal complete ................ 103

prenatal formula .................. 103

prenatal multi-dha (algal oil)

........................................ 103



132

prenatal one daily ............... 103

prenatal plus ....................... 103

prenatal plus (calcium carb)103

PRENATAL PLUS DHA... 103

prenatal vitamin .................. 104

prenatal vitamin plus low iron

........................................ 104

prenatal vitamin with minerals

........................................ 104

prenatal vits96-iron fum-folic

........................................ 104

prenatal-u ............................ 104

PRENATE AM .................. 104

PRENATE CHEWABLE ... 104

PRENATE DHA (FERR ASP

GLYCIN) ....................... 104

PRENATE ELITE (IRON ASP

GLYC) ............................ 104

PRENATE ENHANCE ...... 104

PRENATE

ESSENTIAL(IRON-ASP-

GL) ................................. 104

PRENATE MINI (FERR ASP

GLYCIN) ....................... 104

PRENATE PIXIE ............... 104

PRENATE RESTORE ....... 104

PRENATE STAR ............... 104

preplus ................................ 104

PREPOPIK ........................... 75

PRESERA ............................ 44

PRESTALIA ........................ 37

PRESTO PRO BLOOD


pretab .................................. 104

PREVACID .......................... 77

PREVACID SOLUTAB ...... 78

prevalite ................................ 41

PREVIDENT ........................ 54

PREVIDENT 5000 BOOSTER

PLUS ................................ 54

PREVIDENT 5000 DRY

MOUTH ........................... 54

PREVIDENT 5000 ENAMEL

PROTECT ........................ 54

PREVIDENT 5000 PLUS .... 54

PREVIDENT 5000

SENSITIVE ...................... 54

previfem ............................... 88

PREVYMIS ............................ 5

PREZCOBIX .......................... 5

PREZISTA ............................. 5

PRIFTIN ................................. 9

PRILOLID ............................ 48

PRILOSEC ........................... 78

PRIMACARE ..................... 104

PRIMAQUINE ....................... 9

PRIMAXIN IV ....................... 9

primidone.............................. 19

PRIMLEV ............................ 26

PRIMSOL ............................. 11

PRINIVIL ............................. 37

PRISTIQ ............................... 32

PRIVIGEN ........................... 80

PROAIR HFA ...................... 96

PROAIR RESPICLICK ....... 96

probenecid ............................ 81

probenecid-colchicine .......... 81

PROBUPHINE ..................... 26

procainamide ........................ 34

PROCARDIA ....................... 37

PROCARDIA XL................. 37

PRO-C-DURE 5 ................... 55

PRO-C-DURE 6 ................... 55

procentra ............................... 32

prochlorperazine ................... 75

prochlorperazine edisylate .... 75

prochlorperazine maleate ..... 75

PROCORT............................ 75

PROCRIT ............................. 78

PROCTOCORT.................... 75

PROCTOFOAM HC ............ 75

procto-med hc ....................... 75

proctosol hc .......................... 75

proctozone-hc ....................... 75

PROCYSBI .......................... 98

PRODIGY AUTOCODE

METER ............................ 64

PRODIGY AUTOCODE

MONITOR SYST............. 64

PRODIGY CONTROL

SOLUTION, LOW ........... 64

PRODIGY CONTROL


PRODIGY NO CODING ..... 58

PRODIGY POCKET METER

.......................................... 64

PRODIGY VOICE GLUCOSE

METER ............................. 64

PRODRIN ............................. 21

profeno .................................. 28

PROFERRIN-FORTE ........ 104

PROFILNINE ....................... 40

progesterone ......................... 84

progesterone micronized ...... 84

PROGLYCEM ..................... 59

PROGRAF ............................ 16

PROLASTIN-C .................... 52

PROLENSA ......................... 91

PROLEUKIN ....................... 79

PROLIA ................................ 81

PROMACTA ........................ 40

promethazine ........................ 93

promethazine vc-codeine ...... 93

promethazine-codeine ........... 93

promethazine-dm .................. 93

promethazine-phenylephrine 93

promethegan ......................... 93

PROMETRIUM ................... 84

PROMISEB .......................... 44

propafenone .......................... 34

propantheline ........................ 72

proparacaine ......................... 90

propranolol ........................... 37

propranolol-hydrochlorothiazid

.......................................... 37

propylthiouracil .................... 55

PROQUAD (PF) ................... 80

PRO-RED AC (W/

DEXCHLORPHENIR) ..... 93

PROSCAR ............................ 97

PROTECT IRON ................ 104

PROTONIX .......................... 78

PROTOPIC ........................... 44

protriptyline .......................... 32

PROVENGE ......................... 80

PROVENTIL HFA ............... 96

PROVERA ........................... 84

PROVIDA DHA ................. 104

PROVIDA OB .................... 104

PROVIGIL ........................... 32

PROZAC .............................. 32

pruclair .................................. 44

prudoxin ................................ 44

prumyx .................................. 44



133

prutect ................................... 44

PSORCON ........................... 50

PULMICORT ....................... 96

PULMICORT FLEXHALER

.......................................... 96

pulmosal ............................... 96

PULMOZYME .................... 96

PURALOR CI .................... 104

PUREFE OB PLUS ............ 104

PUREFE PLUS .................. 104

purelax .................................. 75

purevit dualfe plus .............. 104

PURIXAN ............................ 16

PYLERA .............................. 78

pyrazinamide .......................... 9

PYRIDIUM .......................... 98

pyridostigmine bromide ....... 22

Q QBRELIS ............................. 37

Q-CARE RX Q4 .................. 54

QNASL ................................ 96

QTERN ................................ 70

QUADRACEL (PF) ............. 80

QUALAQUIN ........................ 9

QUARTETTE ...................... 88

quasense ............................... 88

quazepam .............................. 32

QUDEXY XR ...................... 19

QUESTRAN......................... 41

QUESTRAN LIGHT............ 41

quetiapine ............................. 32

QUFLORA ......................... 104

QUFLORA FE ................... 104

QUFLORA FE (FERROUS

SULFATE) ..................... 104

QUFLORA PEDIATRIC ... 104

QUFLORA PEDIATRIC

DROPS ........................... 104

QUILLICHEW ER ............... 32

QUILLIVANT XR ............... 32

quinapril ............................... 37

quinapril-hydrochlorothiazide

.......................................... 37

quinidine gluconate .............. 34

quinidine sulfate ................... 34

quinine sulfate ........................ 9

QUINTET AC ...................... 58

QUINTET BLOOD


quit 2 ..................................... 53

QUIT 2 ................................. 53

quit 4 ..................................... 53

QUIT 4 ................................. 53

QUTENZA ........................... 44

QVAR REDIHALER ........... 96

R RABAVERT (PF) ................ 80

rabeprazole ........................... 78

RADICAVA ......................... 21

rajani ..................................... 88

raloxifene .............................. 81

ramipril ................................. 37

RANEXA ............................. 42

ranitidine hcl ......................... 78

RAPAFLO ............................ 97

RAPAMUNE........................ 16

rasagiline .............................. 20

RASUVO (PF) ..................... 82

RAVICTI .............................. 52

RAYALDEE ........................ 68

RAYOS ................................ 55

RAZADYNE .................. 21, 22

RAZADYNE ER .................. 21

READYSHARP

DEXAMETHASONE ...... 55

READYSHARP

KETOROLAC .................. 28

READYSHARP LIDOCAINE

(PF) ................................... 48

READYSHARP

TRIAMCINOLONE ......... 55

REBETOL ............................ 79

REBIF (WITH ALBUMIN) . 79

REBIF REBIDOSE .............. 79

REBIF TITRATION PACK . 79

REBINYN ............................ 40

RECLAST ............................ 52

reclipsen (28) ........................ 88

RECOMBINATE ................. 40

RECOMBIVAX HB (PF) .... 81

RECTIV................................ 75

REFUAH PLUS ................... 58

REFUAH PLUS GLUCOSE

CONTROL ....................... 64

REFUAH PLUS GLUCOSE

MONITOR ....................... 64

REGLAN .............................. 75

REGRANEX ........................ 44

relador pak ............................ 48

relador pak plus .................... 48

RELAGARD ........................ 85

RELENZA DISKHALER ...... 5

RELION ALL-IN-ONE

METER ............................. 64

RELION CONFIRM ............ 64

RELION CONFIRM-MICRO

.......................................... 58

RELION MICRO GLUCOSE

MONITOR ....................... 64

RELION NOVOLIN 70/30 .. 67

RELION NOVOLIN N ........ 67

RELION NOVOLIN R ......... 67

RELION PRIME METER .... 64

RELION PRIME TEST

STRIPS ............................. 58

RELISTOR ........................... 75

relnate dha .......................... 104

RELPAX ............................... 21

REMERON ........................... 32

REMERON SOLTAB .......... 32

REMICADE ......................... 75

REMODULIN ...................... 37

RENAGEL ........................... 75

renal caps ............................ 104

rena-vite .............................. 104

rena-vite rx .......................... 104

RENFLEXIS ......................... 75

reno caps ............................. 104

RENVELA ........................... 75

repaglinide ............................ 70

repaglinide-metformin .......... 70

REPATHA PUSHTRONEX 41

REPATHA SURECLICK .... 41

REPATHA SYRINGE ......... 41

REQUIP ................................ 20

REQUIP XL ......................... 20

RESCRIPTOR ........................ 5

RESPA-AR ........................... 93

RESTASIS ............................ 90

RESTASIS MULTIDOSE .... 90

RESTIZAN ........................... 44

RESTORIL ........................... 32



134

RETIN-A .............................. 46

RETIN-A MICRO ................ 46

RETIN-A MICRO PUMP .... 46

RETISERT ........................... 92

RETROVIR ............................ 5

REVATIO ............................ 96

REVEAL BLOOD GLUCOSE

METER ............................ 64

REVEAL TEST STRIP ........ 58

REVLIMID .......................... 79

REXULTI ............................. 32

REYATAZ ............................. 5

RHOFADE ........................... 46

RIASTAP ............................. 40

ribasphere ............................. 79

ribasphere ribapak ................ 79

ribavirin ............................ 5, 79

RIDAURA ............................ 82

rifabutin .................................. 9

RIFADIN ................................ 9

RIFAMATE ........................... 9

rifampin .................................. 9

RIFATER ............................... 9

RIGHTEST CONTROL

SOLUTION HIGH ........... 64

RIGHTEST GM550 SYSTEM

.......................................... 64

RIGHTEST GS550 TEST

STRIPS ............................. 58

RILUTEK ............................. 52

riluzole .................................. 52

rimantadine ............................. 5

RIMSO-50 .............................. 9

ringer's .................................. 51

RIOMET .............................. 70

risacal-d .............................. 104

risedronate ...................... 52, 81

RISPERDAL ........................ 32

risperidone ............................ 32

RITALIN .............................. 32

RITALIN LA........................ 33

ritonavir .................................. 5

RITUXAN ............................ 16

RITUXAN HYCELA ........... 16

rivastigmine .......................... 22

rivastigmine tartrate.............. 22

rivelsa ................................... 88

RIXUBIS .............................. 40

rizatriptan.............................. 21

R-NATAL OB .................... 104

robafen ac ............................. 93

ROBAXIN ............................ 22

ROBAXIN-750 .................... 22

ROBINUL ............................ 72

ROBINUL FORTE............... 72

ROCALTROL ...................... 68

ROMIDEPSIN...................... 16

ropinirole .............................. 20

rosadan.................................. 46

ROSADAN ........................... 46

ROSANIL ............................. 46

ROSULA .............................. 46

rosula cleansing cloths.......... 46

rosuvastatin ........................... 41

ROTARIX ............................ 81

ROTATEQ VACCINE......... 81

ROWASA ............................. 75

roweepra ............................... 19

roweepra xr ........................... 19

ROXICODONE.................... 26

ROXYBOND ....................... 26

ROZEREM ........................... 33

RUBRACA ........................... 16

RUCONEST ......................... 96

RYDAPT .............................. 16

rydex ..................................... 94

RYTARY.............................. 20

RYTHMOL SR .................... 34

RYVENT .............................. 93

S SABRIL ................................ 19

SAFYRAL ............................ 88

SAIZEN ................................ 78

SAIZEN SAIZENPREP ....... 78

SALAGEN (PILOCARPINE)

.................................... 52, 54

SALEX ................................. 43

salicylic acid ......................... 43

salimez .................................. 43

SALIMEZ FORTE ............... 43

SALKERA............................ 43

salsalate ................................ 28

salvax .................................... 43

SALVAX DUO PLUS ......... 43

SAMSCA ............................. 68

SANCUSO ........................... 75

SANDIMMUNE ................... 16

SANDOSTATIN .................. 16

SANDOSTATIN LAR

DEPOT ............................. 16

SANTYL .............................. 51

SAPHRIS (BLACK

CHERRY) ......................... 33

SARAFEM ........................... 33

SAVAYSA ........................... 40

SAVELLA ............................ 82

scalacort ................................ 50

scopolamine base .................. 75

SEASONIQUE ..................... 88

seb-prev ................................ 43

SEEBRI NEOHALER .......... 96

SEGLUROMET ................... 70

SELECT-OB ....................... 104

SELECT-OB (FOLIC ACID)

........................................ 104

SELECT-OB + DHA .......... 104

selegiline hcl ......................... 20

selenium sulfide .................... 43

SELRX ................................. 43

SELZENTRY ......................... 5

SEMPREX-D ....................... 94

se-natal 19 ........................... 104

se-natal 19 (with docusate) . 104

SENSIPAR ........................... 68

SEREVENT DISKUS .......... 96

SERNIVO ............................. 50

serophene .............................. 68

SEROQUEL ......................... 33

SEROQUEL XR ................... 33

SEROSTIM .......................... 79

sertraline ............................... 33

se-tan plus ........................... 104

setlakin .................................. 88

sevelamer carbonate ............. 75

sf 54

sf 5000 plus ........................... 54

SFROWASA ........................ 75

sharobel ................................. 84

SHINGRIX (PF) ................... 81

SHOHL'S MODIFIED ......... 98

SIDEKICK BLOOD


SIGNIFOR ............................ 16

SIGNIFOR LAR ................... 16



135

SIKLOS ................................ 16

sildenafil (antihypertensive) . 96

SILENOR ............................. 33

SILIQ .................................... 43

SILVADENE ....................... 43

silver nitrate .......................... 44

silver nitrate applicators ....... 44

silver sulfadiazine ................. 43

SILVRSTAT ........................ 48

SIMBRINZA ........................ 91

SIMPONI ....................... 82, 83

SIMPONI ARIA ................... 82

SIMULECT .......................... 16

simvastatin ............................ 41

SINEMET ............................ 20

SINEMET CR ...................... 20

SINGULAIR ........................ 96

sirolimus ............................... 16

SIRTURO ............................... 9

SIVEXTRO ............................ 9

SKELAXIN .......................... 22

SKLICE ................................ 51

SKYLA ................................ 83

SMART SENSE

MONITORING SYSTEM 64

SMART SENSE TEST

STRIPS ............................. 58

SMARTEST CONTROL ..... 64

SMARTEST EJECT ............ 65

SMARTEST PERSONA

STARTER ........................ 65

SMARTEST PRONTO

STARTER ........................ 65

SMARTEST PROTEGE ...... 65

SMARTEST TEST .............. 58

smoothlax ............................. 75

SNAP INSULIN PUMP

CONTROLLER ............... 65

sodium benzoate-sod

phenylacet......................... 52

sodium chlor 0.9% bacteriostat

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

sodium chloride .............. 96, 99

sodium chloride 0.45 % ........ 99

sodium chloride 0.9 % .......... 52

sodium chloride 3 % ............. 99

sodium chloride 5 % ............. 99

sodium citrate-citric acid ...... 98

SODIUM EDECRIN ............ 38

sodium ferric gluconat-sucrose

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

sodium phenylbutyrate ......... 52

sodium polystyrene (sorb free)

.......................................... 75

sodium polystyrene sulfonate

.......................................... 75

SODIUM POLYSTYRENE

SULFONATE ................... 75

SOLARAZE ......................... 44

SOLESTA ............................ 75

SOLIQUA 100/33 ................ 67

SOLIRIS ............................... 52

SOLODYN ........................... 11

SOLOSEC .............................. 9

soloxide ................................ 11

SOLTAMOX ........................ 16

SOLUS V2 AUDIBLE

METER ............................ 65

SOLUS V2 CONTROL


SOLUS V2 TEST STRIPS ... 58

SOMA .................................. 22

SOMATULINE DEPOT ...... 16

SOMAVERT ........................ 68

sonafine ................................ 44

SONATA .............................. 33

SOOLANTRA ...................... 46

SORBITOL-MANNITOL .... 51

SORIATANE ....................... 43

SORILUX ............................. 43

sotalol ................................... 34

sotalol af ............................... 34

SOTYLIZE ........................... 34

SOVALDI .............................. 5

sp antipruritic ........................ 45

sp scar management .............. 45

SPECTRACEF ....................... 6

spinosad ................................ 51

SPIRIVA RESPIMAT .......... 96

SPIRIVA WITH

HANDIHALER ................ 96

spironolactone ...................... 38

spironolacton-hydrochlorothiaz

.......................................... 38

SPORANOX .......................... 3

SPORANOX PULSEPAK ..... 3

sprintec (28) .......................... 88

SPRIX ................................... 28

SPRYCEL ............................. 16

sps (with sorbitol) ................. 75

sronyx ................................... 88

ssd ......................................... 43

SSKI ..................................... 55

sss 10-5 ................................. 46

STALEVO 100 ..................... 20

STALEVO 125 ..................... 20

STALEVO 150 ..................... 20

STALEVO 200 ..................... 20

STALEVO 50 ....................... 20

STALEVO 75 ....................... 20

STARLIX ............................. 70

stavudine ................................. 5

STEGLATRO ....................... 70

STEGLUJAN ....................... 70

STELARA ............................ 43

STIMATE ............................. 68

STIOLTO RESPIMAT ......... 96

STIVARGA .......................... 16

stop smoking aid ................... 53

STRATTERA ....................... 33

STRENSIQ ........................... 68

STREPTOMYCIN ................. 9

stress formula ...................... 104

stress formula with iron ...... 104

stress formula with iron(sulf)

........................................ 105

STRIANT ............................. 68

STRIBILD .............................. 5

STRIVERDI RESPIMAT .... 96

STROMECTOL ..................... 9

strong iodine ......................... 99

STROVITE FORTE ........... 105

STROVITE ONE ................ 105

SUBLOCADE ...................... 26

SUBOXONE ........................ 28

SUBSYS ............................... 26

subvenite ............................... 19

subvenite starter (blue) kit .... 19

subvenite starter (green) kit .. 19

subvenite starter (orange) kit 19

SUCRAID ............................. 75

sucralfate ............................... 78

SULAR ................................. 38

sulfacetamide sodium ..... 43, 92



136

sulfacetamide sodium (acne) 48

sulfacetamide sodium-sulfur 46

sulfacetamide sod-sulfur-urea

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

sulfacetamide-prednisolone .. 92

sulfacleanse 8-4 .................... 47

sulfadiazine........................... 10

sulfamethoxazole-trimethoprim

.......................................... 10

SULFAMYLON .................. 48

sulfasalazine ......................... 75

sulfatrim ............................... 10

sulindac................................. 28

SUMADAN .......................... 47

sumatriptan ........................... 21

sumatriptan succinate ........... 21

sumatriptan-naproxen ........... 21

SUMAVEL DOSEPRO ....... 21

SUMAXIN ........................... 47

SUMAXIN TS...................... 47

super b complex-vitamin c . 105

super b maxi complex ........ 105

super b-50 complex plus .... 105

super quints ........................ 105

super quints b-50 ................ 105

superplex-t .......................... 105

SUPERVITE ...................... 105

SUPPRELIN LA .................. 16

SUPRAX ................................ 7

SUPREP BOWEL PREP KIT

.......................................... 75

SURE-TEST EASYPLUS

MINI ................................. 58

SURE-TEST EASYPLUS

MINI METER .................. 65

SURFAXIN .......................... 96

SURMONTIL ...................... 33

SURVANTA ........................ 52

SUSTIVA ............................... 5

SUSTOL ............................... 75

SUTENT .............................. 16

syeda ..................................... 88

SYLATRON......................... 79

SYLVANT ........................... 16

SYMAX DUOTAB .............. 72

symax fastabs ....................... 72

symax-sl ............................... 72

symax-sr ............................... 72

SYMBICORT ....................... 96

SYMBYAX .......................... 33

SYMFI .................................... 5

SYMFI LO ............................. 5

SYMLINPEN 120 ................ 70

SYMLINPEN 60 .................. 70

SYMPROIC ......................... 75

SYNAGIS ............................... 5

SYNALAR ........................... 50

SYNALAR CREAM KIT .... 50

SYNALAR OINTMENT KIT

.......................................... 50

SYNALAR TS ..................... 50

SYNAREL............................ 68

SYNDROS ........................... 75

SYNERA .............................. 48

SYNERCID ............................ 9

SYNJARDY ......................... 70

SYNJARDY XR................... 71

SYNRIBO ............................ 16

SYNTHROID ....................... 71

T TABLOID ............................ 16

TACLONEX ........................ 43

tacrolimus ....................... 16, 45

TAFINLAR .......................... 17

TAGRISSO .......................... 17

TAKE ACTION ................... 88

TALTZ AUTOINJECTOR .. 43

TALTZ AUTOINJECTOR (2

PACK) .............................. 43

TALTZ AUTOINJECTOR (3

PACK) .............................. 43

TALTZ SYRINGE ............... 43

TALWIN .............................. 28

TAMIFLU .............................. 5

tamoxifen .............................. 17

tamsulosin ............................. 97

TANDEM PLUS ................ 105

TANZEUM .......................... 71

TAPAZOLE ......................... 55

TAPERDEX ......................... 55

TARCEVA ........................... 17

TARGADOX........................ 11

TARGRETIN ....................... 17

tarina fe 1/20 (28) ................. 88

TARKA ................................ 38

taron forte ........................... 105

taron-c dha .......................... 105

taron-prex prenatal-dha ...... 105

TASIGNA ............................. 17

TASMAR ............................. 20

TAVALISSE ........................ 40

TAXOTERE ......................... 17

TAYTULLA ......................... 88

tazarotene .............................. 47

TAZICEF ................................ 7

TAZORAC ........................... 47

taztia xt ................................. 38

TECENTRIQ ........................ 17

TECFIDERA ........................ 79

TECHNIVIE ........................... 5

TEFLARO .............................. 7

TEGRETOL ......................... 19

TEGRETOL XR ................... 19

TEKTURNA ......................... 38

TEKTURNA HCT ................ 38

TELCARE BGM .................. 65

TELCARE BLOOD

GLUCOSE KIT ................ 65

TELCARE CONTROL ........ 65

TELCARE TEST STRIPS ... 58

telmisartan ............................ 38

telmisartan-amlodipine ......... 38

telmisartan-hydrochlorothiazid

.......................................... 38

temazepam ............................ 33

TEMODAR .......................... 17

TEMOVATE ........................ 50

temozolomide ....................... 17

tencon ................................... 26

TENIPOSIDE ....................... 17

TENIVAC (PF) .................... 81

tenofovir disoproxil fumarate . 5

TENORETIC 100 ................. 38

TENORETIC 50 ................... 38

TENORMIN ......................... 38

TEPADINA .......................... 17

terazosin ................................ 38

terbinafine hcl ......................... 3

terbutaline ............................. 96

terconazole ............................ 85

TERSI FOAM ...................... 43

TESSALON PERLES .......... 94

TEST N'GO BLOOD




137

TEST N'GO TEST ............... 58

TESTIM ............................... 68

testosterone ..................... 68, 69

TESTOSTERONE ............... 69

testosterone cypionate .......... 68

testosterone enanthate .......... 68

TESTRED ............................ 69

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 81

TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 81

tetcaine ................................. 90

tetrabenazine......................... 22

tetracaine hcl ........................ 90

TETRACAINE HCL (PF) .... 90

tetracycline ........................... 11

TETRAVISC ........................ 90

TETRAVISC FORTE .......... 90

TEXACORT......................... 51

THALLOUS CHLORIDE TL-

201 .................................... 52

THALOMID......................... 17

THEO-24 .............................. 96

theochron .............................. 96

theophylline .......................... 96

THIOLA ............................... 52

thioridazine ........................... 33

thiotepa ................................. 17

thiothixene ............................ 33

THRIVITE RX ................... 105

thrivite-19 ........................... 105

THYMOGLOBULIN ........... 81

thyroid (pork) ....................... 71

THYROLAR-1 ..................... 71

THYROLAR-1/2 .................. 71

THYROLAR-1/4 .................. 71

THYROLAR-2 ..................... 71

THYROLAR-3 ..................... 71

tiagabine ............................... 19

TIAZAC ............................... 38

TICALAST .......................... 96

TICE BCG ............................ 81

TIGAN ................................. 76

tigecycline .............................. 9

TIKOSYN ............................ 34

tilia fe.................................... 88

timolol maleate ............... 38, 89

TIMOPTIC ........................... 89

TIMOPTIC OCUDOSE (PF)

.......................................... 89

TIMOPTIC-XE .................... 89

TINDAMAX .......................... 9

tinidazole ................................ 9

TIROSINT ............................ 71

tis-u-sol pentalyte ................. 51

TIVICAY................................ 5

TIVORBEX .......................... 28

tizanidine .............................. 22

tl gard rx ............................. 105

tl g-fol os ............................ 105

tl icon .................................. 105

TOBI ....................................... 9

TOBI PODHALER ................ 9

TOBRADEX ........................ 91

TOBRADEX ST................... 91

tobramycin ............................ 89

tobramycin in 0.225 % nacl .... 9

tobramycin sulfate .................. 9

TOBRAMYCIN WITH

NEBULIZER ...................... 9

tobramycin-dexamethasone .. 91

TOBREX .............................. 89

TODAY CONTRACEPTIVE

SPONGE .......................... 85

TOFRANIL .......................... 33

TOLAK ................................ 45

tolazamide ............................ 71

tolbutamide ........................... 71

tolcapone .............................. 20

tolmetin ................................. 28

tolterodine ............................. 97

TOPAMAX .......................... 19

TOPICORT .......................... 51

topiramate ............................. 19

TOPIRAMATE .................... 19

toposar .................................. 17

topotecan .............................. 17

TOPROL XL ........................ 38

TORISEL.............................. 17

TORONOVA II SUIK.......... 28

TORONOVA SUIK ............. 28

torsemide .............................. 38

total b/c ............................... 105

TOTECT ............................... 12

TOUJEO MAX SOLOSTAR

.......................................... 67

TOUJEO SOLOSTAR U-300

INSULIN .......................... 67

TOVIAZ ............................... 97

TRACLEER ......................... 96

TRADJENTA ....................... 71

tramadol ................................ 28

TRAMADOL ....................... 28

tramadol-acetaminophen ...... 28

trandolapril ........................... 38

trandolapril-verapamil .......... 38

tranexamic acid ............... 40, 85

TRANSDERM-SCOP .......... 76

TRANXENE T-TAB ............ 33

tranylcypromine .................... 33

TRANZAREL ...................... 48

TRAVATAN Z ..................... 91

trazodone .............................. 33

TREANDA ........................... 17

TRECATOR ........................... 9

TRELEGY ELLIPTA ........... 96

TRELSTAR .......................... 17

TREMFYA ........................... 43

TRESIBA FLEXTOUCH U-

100 .................................... 67

TRESIBA FLEXTOUCH U-

200 .................................... 67

tretinoin ................................. 47

tretinoin (chemotherapy) ...... 17

tretinoin microspheres .......... 47

TRETIN-X ............................ 47

TRETIN-X CREAM KIT ..... 47

TRETTEN ............................ 40

TREXALL ............................ 17

TREXIMET .......................... 21

TREZIX ................................ 26

tri femynor ............................ 88

TRIACETIN ......................... 49

triamcinolone acetonide . 51, 54,

55

triamterene-hydrochlorothiazid

.......................................... 38

trianex ................................... 51

triazolam ............................... 33

TRIBENZOR ........................ 38

TRICARE ........................... 105

tricitrates ............................... 98

tricon ................................... 105

TRICOR ............................... 41



138

triderm .................................. 51

TRIDESILON ...................... 51

tri-estarylla ........................... 88

TRIFERIC .......................... 105

trifluoperazine ...................... 33

trifluridine............................. 89

trigels-f forte ....................... 105

TRIGLIDE ........................... 41

trihexyphenidyl .................... 20

triklo ..................................... 41

tri-legest fe............................ 88

TRILEPTAL......................... 19

tri-linyah ............................... 88

TRILIPIX ............................. 41

tri-lo-estarylla ....................... 88

tri-lo-marzia .......................... 88

tri-lo-sprintec ........................ 88

trilyte with flavor packets ..... 76

trimethobenzamide ............... 76

trimethoprim ......................... 11

tri-mili .................................. 88

trimipramine ......................... 33

TRIMPEX ............................ 11

trinatal rx 1 ......................... 105

trinate .................................. 105

trinessa (28) .......................... 88

trinessa lo.............................. 88

TRI-NORINYL (28) ............ 88

TRINTELLIX....................... 33

triphrocaps .......................... 105

TRIPLE DYE ....................... 49

tri-previfem (28) ................... 88

TRIPTODUR ....................... 17

TRISENOX .......................... 17

tri-sprintec (28) ..................... 88

TRISTART DHA ............... 105

TRIUMEQ .............................. 5

triveen-duo dha ................... 105

TRI-VI-FLOR .................... 105

tri-vitamin with fluoride ..... 105

trivora (28)............................ 88

tri-vylibra .............................. 88

TRIZIVIR ............................... 5

TROGARZO .......................... 5

TROKENDI XR ................... 19

tropicamide ........................... 89

trospium ................................ 97

TRUE METRIX AIR


TRUE METRIX GLUCOSE

METER ............................ 65

TRUE METRIX GLUCOSE

TEST STRIP..................... 58

TRUE METRIX GO


TRUE METRIX LEVEL 1 ... 65

TRUE2GO BLOOD


TRUECONTROL LEVEL 0 65

TRUERESULT BLOOD

GLUCOSE SYSTM ......... 65

TRUETEST TEST STRIPS . 58

TRUETRACK BLOOD


TRUETRACK SMART

SYSTEM .......................... 65

TRUETRACK TEST ........... 58

TRULANCE ......................... 76

TRULICITY ......................... 71

TRUSOPT ............................ 91

trust natal dha ..................... 105

TRUSTEEL INFUSION SET

32 ...................................... 65

TRUVADA ............................ 5

TUDORZA PRESSAIR ....... 96

tulana .................................... 84

tusnel c .................................. 94

TUSNEL PEDIATRIC ......... 94

TUSSICAPS ......................... 94

tussigon ................................. 94

TUSSIONEX PENNKINETIC

ER ..................................... 94

TUZISTRA XR .................... 94

TWINRIX (PF)..................... 81

TWYNSTA .......................... 38

TYBOST ................................ 5

tydemy .................................. 88

TYGACIL .............................. 9

TYKERB .............................. 17

TYLENOL-CODEINE #3 .... 26

TYLENOL-CODEINE #4 .... 26

TYMLOS.............................. 81

TYPHIM VI ......................... 81

TYSABRI ............................. 22

TYVASO .............................. 96

TYVASO REFILL KIT ........ 96

TYVASO STARTER KIT ... 96

TYZINE ................................ 54

U UCERIS ................................ 76

UDAMIN SP ...................... 105

ULESFIA .............................. 51

ULORIC ............................... 81

ULTIMA MONITOR ........... 65

ULTIMA TEST STRIPS ...... 58

ultra b-100 complex ............ 105

ULTRACET ......................... 28

ULTRAM ............................. 28

ULTRASAL-ER ................... 43

ULTRATRAK ...................... 58

ULTRATRAK GLUCOSE

METER ............................. 65

ULTRATRAK ULTIMATE 58,

65

ULTRAVATE ...................... 51

ULTRAVATE X .................. 51

umecta ................................... 45

UNASYN ............................. 10

UNISTRIP LOW CONTROL

.......................................... 65

UNISTRIP1 TEST STRIP .... 58

unithroid ............................... 71

UNITUXIN ........................... 17

UPTRAVI ............................. 38

urea ....................................... 45

urea nail stick ........................ 45

URECHOLINE ..................... 97

URELLE ............................... 98

uretron d-s ............................. 98

URIBEL ................................ 98

urimar-t ................................. 98

urin ds ................................... 98

uro-458 ................................. 98

UROCIT-K 10 ...................... 98

UROCIT-K 15 ...................... 98

UROCIT-K 5 ........................ 98

urogesic-blue ........................ 98

uro-mp .................................. 98

urophen mb ........................... 98

UROQID-ACID NO.2 .......... 98

UROXATRAL ..................... 97

URSO 250 ............................ 76

URSO FORTE ...................... 76



139

ursodiol ................................. 76

uryl ....................................... 98

ustell ..................................... 98

UTA ...................................... 98

UTIBRON NEOHALER...... 96

utira-c ................................... 98

UTOPIC ............................... 45

V VABOMERE ......................... 9

VAGIFEM ............................ 84

vaginal contraceptive foam .. 85

valacyclovir ............................ 5

VALCHLOR ........................ 45

VALCYTE ............................. 5

valganciclovir ......................... 5

VALIUM .............................. 33

valproate sodium .................. 19

valproic acid ......................... 19

valproic acid (as sodium salt)

.......................................... 19

valsartan ............................... 38

valsartan-hydrochlorothiazide

.......................................... 38

VALTREX ............................. 5

VANATOL LQ .................... 26

VANATOL S ....................... 26

VANCOCIN ......................... 11

vancomycin .......................... 11

VANCOMYCIN .................. 11

VANCOMYCIN IN 0.9 %

SODIUM CHL ................. 11

VANCOMYCIN IN

DEXTROSE 5 % .............. 11

vandazole .............................. 85

VANOS ................................ 51

VANOXIDE-HC .................. 47

VANTAS .............................. 17

VAQTA (PF) ........................ 81

VARISOFT INFUSION SET

43 ...................................... 65

VARIZIG ............................. 81

VARUBI .............................. 76

VASCEPA ............................ 41

VASERETIC ........................ 38

VASHE WOUND THERAPY

.......................................... 51

vasopressin in 0.9 % nacl .... 69

VASOPRESSIN IN 0.9 %

NACL ............................... 69

VASOPRESSIN IN

DEXTROSE 5 % .............. 69

VASOSTRICT ..................... 69

VASOTEC............................ 38

VAXCHORA VACCINE..... 81

v-c forte .............................. 105

VCF CONTRACEPTIVE

FILM ................................ 85

VCF CONTRACEPTIVE GEL

.......................................... 85

VECAMYL .......................... 42

VECTIBIX ........................... 17

VECTICAL .......................... 43

VELCADE ........................... 17

veletri .................................... 38

velivet triphasic regimen (28)

.......................................... 88

VELPHORO ......................... 76

VELTASSA.......................... 76

VELTIN................................ 47

VEMLIDY.............................. 5

VENCLEXTA ...................... 17

venlafaxine ........................... 33

VENOFER.......................... 105

VENTAVIS .......................... 97

VENTOLIN HFA ................. 97

verapamil .............................. 38

VERASENS BLOOD


VERASENS TEST STRIP ... 58

VERDESO............................ 51

verdrocet ............................... 26

VEREGEN ........................... 45

VERELAN ........................... 38

VERELAN PM..................... 38

veripred 20 ............................ 55

VERSACLOZ ...................... 33

VERZENIO .......................... 17

VESICARE .......................... 97

VFEND ................................... 3

VFEND IV ............................. 3

VGO 20 ................................ 65

VGO 30 ................................ 65

VGO 40 ................................ 65

VIBATIV.............................. 11

VIBERZI .............................. 76

VIBRAMYCIN .................... 11

vic-forte .............................. 105

vicodin .................................. 26

vicodin es .............................. 26

vicodin hp ............................. 26

VICTOZA 2-PAK ................ 71

VICTOZA 3-PAK ................ 71

VIDAZA ............................... 17

VIDEX 2 GRAM PEDIATRIC

............................................ 5

VIDEX EC .............................. 5

VIEKIRA PAK ....................... 5

VIEKIRA XR ......................... 5

vienva ................................... 88

vigabatrin .............................. 19

VIGAMOX ........................... 89

VIIBRYD ............................. 33

VIMIZIM .............................. 69

VIMOVO .............................. 28

VIMPAT ............................... 19

vinate care ........................... 105

VINATE DHA RF .............. 105

vinate ii ............................... 105

vinate m .............................. 105

vinate one ............................ 105

vinblastine ............................. 17

vincasar pfs ........................... 17

vincristine ............................. 17

vinorelbine ............................ 17

VIOKACE ............................ 76

viorele (28) ........................... 88

VIRACEPT ............................. 6

VIRAMUNE ........................... 6

VIRAMUNE XR .................... 6

VIRASAL ............................. 43

VIRAZOLE ............................ 6

VIREAD ................................. 6

VIROPTIC ............................ 89

virt-advance ........................ 105

virt-c dha ............................. 105

VIRT-CAPS ....................... 105

virt-gard .............................. 105

virt-nate ............................... 105

virt-nate dha ........................ 105

virt-phos 250 neutral ............. 99

virt-pn ................................. 105

virt-pn dha .......................... 105

virt-pn plus .......................... 105



140

VIRTPREX ........................ 105

virtrate-2 ............................... 98

virtrate-3 ............................... 98

virtrate-k ............................... 98

virt-select ............................ 105

virtussin ac............................ 94

virtussin dac.......................... 94

virt-vite ............................... 105

virt-vite gt ........................... 105

VIRT-VITE PLUS ............. 105

VISTARIL ............................ 93

VISTOGARD ....................... 12

VISUDYNE ......................... 90

vit 3 ..................................... 105

VITAFOL ........................... 105

VITAFOL FE+ (WITH

DOCUSATE) ................. 106

VITAFOL GUMMIES ....... 106

VITAFOL NANO .............. 106

VITAFOL ULTRA ............ 106

VITAFOL-OB .................... 106

VITAFOL-OB+DHA ......... 106

VITAFOL-ONE ................. 106

vitajoy daily d ..................... 106

VITAL-D RX ..................... 106

VITAMED MD ONE RX .. 106

VITAMEDMD REDICHEW

RX .................................. 106

vitamin b complex .............. 106

vitamin b complex-folic acid

........................................ 106

vitamin d3 ........................... 106

vitamins a,c,d and fluoride . 106

VITAPEARL ...................... 106

VITA-RESPA..................... 106

VITATRUE ........................ 106

VITRASE ............................. 90

VITUZ .................................. 94

VIVELLE-DOT ................... 84

VIVITROL ........................... 28

VIVLODEX ......................... 28

VIVOTIF .............................. 81

VOGELXO........................... 69

vol-nate ............................... 106

vol-plus ............................... 106

vol-tab rx ............................ 106

VOLTAREN ........................ 28

VOLTAREN-XR ................. 28

VONVENDI ......................... 40

VORAXAZE ........................ 12

voriconazole ........................... 3

VOSEVI ................................. 6

VOTRIENT .......................... 17

vp-ch plus ........................... 106

vp-ch-pnv............................ 106

vp-ggr-b6 ............................ 106

vp-heme ob ......................... 106

vp-heme one ....................... 106

VP-PNV-DHA.................... 106

VPRIV .................................. 69

vp-vite rx ............................ 106

VRAYLAR ........................... 33

VUSION ............................... 49

vyfemla (28) ......................... 88

vylibra ................................... 88

VYTORIN 10-10 .................. 41

VYTORIN 10-20 .................. 41

VYTORIN 10-40 .................. 41

VYTORIN 10-80 .................. 41

VYVANSE ........................... 33

VYXEOS .............................. 17

VYZULTA ........................... 91

W warfarin ................................ 40

water for irrigation, sterile .... 52

WAVESENSE AMP ............ 65

WAVESENSE CONTROL

SOLUTION ...................... 65

WAVESENSE JAZZ ........... 58

WAVESENSE PRESTO 58, 65

WELCHOL .......................... 41

WELLBUTRIN SR .............. 33

WELLBUTRIN XL .............. 33

wera (28)............................... 88

westhroid .............................. 71

WIDE-SEAL DIAPHRAGM

.......................................... 83

WILATE ............................... 40

woman's laxative .................. 76

women's gentle laxative(bisac)

.......................................... 76

women's laxative (bisacodyl)76

WP THYROID ..................... 71

wymzya fe ............................ 88

X XADAGO ............................. 20

XALATAN ........................... 91

XALKORI ............................ 17

XANAX ................................ 33

XANAX XR ......................... 33

XARELTO ........................... 40

XATMEP .............................. 17

XCLAIR ............................... 45

XELJANZ ............................. 83

XELJANZ XR ...................... 83

XELODA .............................. 17

XENAZINE .......................... 22

XEOMIN .............................. 81

XERESE ............................... 49

XERMELO ........................... 17

XGEVA ................................ 12

XHANCE ............................. 97

XIFAXAN .............................. 9

XIGDUO XR ........................ 71

XIIDRA ................................ 90

XIMINO ............................... 11

XOLAIR ............................... 97

XOLEGEL ............................ 49

XOPENEX ........................... 97

XOPENEX CONCENTRATE

.......................................... 97

XOPENEX HFA .................. 97

XTAMPZA ER ..................... 26

XTANDI ............................... 17

xulane ................................... 85

XULTOPHY 100/3.6 ........... 67

XURIDEN ............................ 52

XYLOCAINE ....................... 48

XYLOCAINE-MPF ............. 48

xylon 10 ................................ 26

XYNTHA ............................. 40

XYNTHA SOLOFUSE ........ 40

XYREM ................................ 33

Y YASMIN (28) ....................... 88

YAZ (28) .............................. 88

YERVOY ............................. 17

YF-VAX (PF) ....................... 81

YONDELIS .......................... 17

YONSA ................................ 17

yuvafem ................................ 84

Z zafirlukast ............................. 97

zaleplon ................................. 33



141

ZALTRAP ............................ 17

ZANAFLEX ......................... 22

ZANOSAR ........................... 17

ZANTAC .............................. 78

zarah ..................................... 88

ZARONTIN ......................... 19

ZARXIO ............................... 78

zatean-pn dha...................... 106

zatean-pn plus ..................... 106

zavara ................................. 106

ZAVESCA ........................... 69

zebutal .................................. 26

ZEGERID ............................. 78

ZEJULA ............................... 17

ZELAPAR ............................ 20

ZELBORAF ......................... 17

ZEMAIRA ............................ 52

ZEMBRACE SYMTOUCH . 21

ZEMPLAR ........................... 69

zenatane ................................ 47

zenchent (28) ........................ 88

ZENPEP ............................... 76

zenzedi .................................. 34

ZENZEDI ............................. 34

ZEPATIER ............................. 6

ZERIT..................................... 6

ZESTORETIC ...................... 38

ZESTRIL .............................. 38

ZETIA .................................. 41

ZETONNA ........................... 97

ZEVALIN (Y-90) ................. 17

ZIAC .................................... 38

ZIAGEN ................................. 6

ZIANA ................................. 47

zidovudine .............................. 6

zileuton ................................. 97

ZINECARD (AS HCL) ........ 12

zingiber ............................... 106

ZINGO.................................. 48

ZINPLAVA .......................... 81

ZIOPTAN (PF) ..................... 91

ziprasidone hcl ...................... 34

ZIPSOR ................................ 28

ZIRGAN ............................... 89

ZITHRANOL ....................... 43

ZITHROMAX ........................ 7

ZITHROMAX TRI-PAK ....... 7

ZITHROMAX Z-PAK ........... 7

ZOCOR ................................ 41

ZODRYL AC 25 .................. 94

ZODRYL AC 30 .................. 94

ZODRYL AC 35 .................. 94

ZODRYL AC 40 .................. 94

ZODRYL AC 50 .................. 94

ZODRYL AC 60 .................. 94

ZODRYL AC 80 .................. 94

ZODRYL DAC 25 ............... 94

ZODRYL DAC 30 ............... 94

ZODRYL DAC 35 ............... 94

ZODRYL DAC 40 ............... 94

ZODRYL DAC 50 ............... 94

ZODRYL DAC 60 ............... 94

ZODRYL DAC 80 ............... 94

ZODRYL DEC 25 ................ 94

ZODRYL DEC 30 ................ 94

ZODRYL DEC 35 ................ 94

ZODRYL DEC 40 ................ 94

ZODRYL DEC 50 ................ 94

ZODRYL DEC 60 ................ 94

ZODRYL DEC 80 ................ 94

ZOFRAN .............................. 76

ZOFRAN ODT ..................... 76

ZOHYDRO ER .................... 26

ZOLADEX ........................... 17

zoledronic acid ..................... 69

zoledronic acid-mannitol-water

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

ZOLEDRONIC AC-

MANNITOL-0.9NACL .... 69

ZOLINZA ............................. 17

zolmitriptan ........................... 21

ZOLOFT ............................... 34

zolpidem ............................... 34

ZOLPIMIST ......................... 34

ZOMACTON ....................... 79

ZOMETA ............................. 69

ZOMIG ................................. 21

ZOMIG ZMT ........................ 21

ZONALON ........................... 45

ZONEGRAN ........................ 19

zonisamide ............................ 19

ZORBTIVE .......................... 79

ZORTRESS .......................... 17

ZORVOLEX ......................... 28

zovia 1/35e (28) .................... 88

ZOVIRAX ........................ 6, 49

Z-TUSS AC .......................... 94

ZUBSOLV ............................ 28

ZUPLENZ ............................ 76

ZURAMPIC ......................... 81

ZYBAN ................................ 53

ZYCLARA ........................... 79

ZYDELIG ............................. 17

ZYFLO ................................. 97

ZYFLO CR ........................... 97

ZYKADIA ............................ 17

ZYLET ................................. 91

ZYLOPRIM .......................... 81

ZYMAXID ........................... 89

ZYPREXA ............................ 34

ZYPREXA ZYDIS ............... 34

ZYTIGA ............................... 17

ZYVOX .................................. 9

Insured/CP-10.14.2016

Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC:

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

○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic

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

as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected]. If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您，或是您正在協助的對象，有關於 Blue KC方面的問題，您有權利免費以您的母語得到幫

助和訊息。洽詢一位翻譯員，請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

Insured/CP-10.14.2016

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한

도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기

위해서는 1-844-395-7126 로 전화하십시오. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126. Arabic:

الضرورية بلغتك من دون اية تكلفة. ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص .7126-395-844-1. للتحدث مع مترجم اتصل بـ

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126. Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126. Laotian: ຖ້ າທ່ ານ, ຫຼື ຄົນ ◌່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫືຼ ອ, ມ ◌ໍ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ◌ິ ສດ ◌່ ທຈະໄດ້ຮັບການຊ່ ວຍເຫືຼ ອແລະ◌ໍ ຂ້ ມູ ນຂ່ າວສານ ◌່ ທເປັ ນພາສາຂອງທ່ ານໍ ◌່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126. Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe. Persian:

زبان خود را به طور ، داشته باشيد حق اين را داريد که کمکو اطالعات به Blue KC اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد .تماس حاصل نماييد 7126-395-844-1.رايگان دريافت نماييد

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126. For TTY services, please call 1-816-842-5607.

KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2018...Generic and Brand (Preferred and Non Preferred)...

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Transcript of KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2018...Generic and Brand (Preferred and Non Preferred)...