LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT ...

LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalbital/aspirin/caffeine 50-325-40 capsule 1 PTD PART DPRODUCTS

celecoxib (50 mg capsule, 100 mg capsule, 200 mgcapsule) 1

C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

celecoxib 400 mg capsule 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75mg tablet dr, 100 mg tab er 24h) 1

C State PDL Class

PTD PART DPRODUCTS

diflunisal 1C State PDL Class

PTD PART DPRODUCTS

etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet,600 mg tab er 24h)

1C State PDL Class

PTD PART DPRODUCTS

fenoprofen calcium (400 mg capsule, 600 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

fenoprofen calcium 200 mg capsule 1 C State PDL Class

FENORTHO 1

flurbiprofen 1C State PDL Class

PTD PART DPRODUCTS

IBU 1C State PDL Class

PTD PART DPRODUCTS

PAGE 1 LAST UPDATED 11/2021

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mgtablet, 800 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

INDOCIN (25 MG/5 ML SUSPENSION, 50 MGSUPPOSITORY) 1

C State PDL Class

PTD PART DPRODUCTS

indomethacin (25 mg capsule, 50 mg capsule, 75 mgcapsule er) 1

C State PDL Class

PTD PART DPRODUCTS

indomethacin, submicronized 1 C State PDL Class

ketoprofen (50 mg capsule, 75 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

ketorolac tromethamine 10 mg tablet 1

QL 20 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

mefenamic acid 1 PTD PART DPRODUCTS

meloxicam 1C State PDL Class

PTD PART DPRODUCTS

nabumetone 1C State PDL Class

PTD PART DPRODUCTS

NALFON 400 MG CAPSULE 1 PTD PART DPRODUCTS

naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mgtablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) 1

C State PDL Class

PTD PART DPRODUCTS

naproxen sodium (275 mg tablet, 550 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS



oxaprozin 600 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

piroxicam 1C State PDL Class

PTD PART DPRODUCTS

salsalate 1C State PDL Class

PTD PART DPRODUCTS

sulindac 1C State PDL Class

PTD PART DPRODUCTS

TIVORBEX 1 PTD PART DPRODUCTS

OPIOID ANALGESICS, LONG-ACTING

BUTRANS 1

C State RebateClass

DC LONG ACTINGOPIOIDS

PA

PTD PART DPRODUCTS

fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72,50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hrpatch td72)

1

C State RebateClass


PA

PTD PART DPRODUCTS

morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mgtablet er, 100 mg tablet er, 200 mg tablet er) 1

C State RebateClass


PA

PTD PART DPRODUCTS



tramadol hcl (100 mg tab er 24h, 200 mg tab er 24h, 300mg tab er 24h) 1

C State RebateClass


PA

PTD PART DPRODUCTS

XTAMPZA ER 1

C State RebateClass


PA

PTD PART DPRODUCTS

OPIOID ANALGESICS, SHORT-ACTING

acetaminophen with codeine phosphate (120-12mg/5solution, 300mg-15mg tablet, 300mg-30mg tablet,300mg-60mg tablet, 300mg/12.5 solution)

1

C State PDL Class

DC SHORT ACTINGOPIOIDS

PTD PART DPRODUCTS

ASCOMP WITH CODEINE 1

C State PDL Class


PTD PART DPRODUCTS

butalbital/acetaminophen/caffeine/codeine phosphate 1

C State PDL Class


PTD PART DPRODUCTS

codeine phosphate/butalbital/aspirin/caffeine 1C State PDL Class

PTD PART DPRODUCTS

ENDOCET 1

C State PDL Class


PTD PART DPRODUCTS



hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 2.5-108/5 solution,hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet,hydrocodone/acetaminophen 7.5-325 mg tablet,hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution,hydrocodone/acetaminophen 10mg-300mg tablet,hydrocodone/acetaminophen 10mg-325mg tablet)

1

C State PDL Class


PTD PART DPRODUCTS

hydrocodone/ibuprofen 1

C State PDL Class


PTD PART DPRODUCTS

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mgsupp.rect, 4 mg tablet, 8 mg tablet) 1

C State PDL Class


PTD PART DPRODUCTS

ibuprofen/oxycodone hcl 1

C State PDL Class


PTD PART DPRODUCTS

meperidine hcl 50 mg tablet 1

C State PDL Class


PTD PART DPRODUCTS



morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10mg/5 ml solution, 15 mg tablet, 20 mg supp.rect, 20 mg/5ml solution, 30 mg supp.rect, 30 mg tablet, 100 mg/5mlsolution)

1

C State PDL Class


PTD PART DPRODUCTS

morphine sulfate (4 mg/ml vial, 8 mg/ml vial, 10 mg/mlvial, 25 mg/ml vial, 50 mg/ml vial) 1


PTD PART DPRODUCTS

morphine sulfate/pf 30 mg/30ml pca vial 1DC SHORT ACTING

OPIOIDS

PTD PART DPRODUCTS

oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tablet, 15 mg tablet, 20 mg tablet, 20mg/ml oral conc, 30 mg tablet)

1

C State PDL Class


PTD PART DPRODUCTS

oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet, hcl/acetaminophen 5 mg-325mg tablet,hcl/acetaminophen 7.5-325 mg tablet,hcl/acetaminophen 10mg-325mg tablet)

1

C State PDL Class


PTD PART DPRODUCTS

pentazocine hcl/naloxone hcl 1DC SHORT ACTING

OPIOIDS

PTD PART DPRODUCTS

PRIMLEV 1DC SHORT ACTING

OPIOIDS

PTD PART DPRODUCTS

tramadol hcl 50 mg tablet 1

C State PDL Class


PTD PART DPRODUCTS



ANESTHETICS

LOCAL ANESTHETICS

AGONEAZE 1

ANASTIA 1 PA

ANODYNE LPT 1 PTD PART DPRODUCTS

DERMACINRX EMPRICAINE 1 PTD PART DPRODUCTS

DERMACINRX PRIZOPAK 1 PTD PART DPRODUCTS

LEVA SET 1 PTD PART DPRODUCTS

LIDO-K 1C State PDL Class

PA

LIDO-PRILO CAINE PACK 1 PTD PART DPRODUCTS

LIDO-SORB 1C State PDL Class

PA

lidocaine (5 % adh. patch, 5 % oint. (g)) 1

C State PDL Class

PA

PTD PART DPRODUCTS

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml)) 1

QL 60 / 30 days

C State PDL Class

PTD PART DPRODUCTS

lidocaine hcl 3 % lotion 1

C State PDL Class

PA

PTD PART DPRODUCTS



lidocaine hcl 2 % solution 1

QL 100 / 30 days

C State PDL Class

PTD PART DPRODUCTS

lidocaine hcl 4 % solution 1C State PDL Class

PTD PART DPRODUCTS

lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g),lidocaine/prilocaine 2.5 kit) 1

QL 30 / 30 days

C State PDL Class

PTD PART DPRODUCTS

LIDOPRIL 1 PTD PART DPRODUCTS

LIDOPRIL XR 1 PTD PART DPRODUCTS

LIDOZION 1C State PDL Class

PA

LIPROZONEPAK 1 PTD PART DPRODUCTS

LIVIXIL PAK 1 PTD PART DPRODUCTS

MEDOLOR PAK 1 PTD PART DPRODUCTS

NUMBONEX 1 PA

PRILOLID 1 PTD PART DPRODUCTS

RELADOR PAK 1 PTD PART DPRODUCTS

RELADOR PAK PLUS 1 PTD PART DPRODUCTS

ZIONODIL 1C State PDL Class

PA



ZIONODIL-100 1C State PDL Class

PA

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 1

QL 180 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

disulfiram 1C State PDL Class

PTD PART DPRODUCTS

naltrexone hcl 1C State Rebate

Class

PTD PART DPRODUCTS

VIVITROL 1C State Rebate

Class

PTD PART DPRODUCTS

OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1

C State RebateClass

PA

PTD PART DPRODUCTS

buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mgtab subl, /naloxone 8 mg-2 mg tab subl) 1

C State RebateClass

PTD PART DPRODUCTS

SUBOXONE 1C State Rebate

Class

PTD PART DPRODUCTS



OPIOID REVERSAL AGENTS

naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1mg/ml syringe) 1

C State RebateClass

PTD PART DPRODUCTS

NARCAN 1C State Rebate

Class

PTD PART DPRODUCTS

SMOKING CESSATION AGENTS

bupropion hcl 150 mg tab er 12h 1

AL At least 18 yrsold

C State PDL Class

DC NicotineReplacement

QPD 2 per day

PTD PART DPRODUCTS

bupropion hcl 150 mg tab sr 12h 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1MG TABLET, STARTING MONTH BOX) 1

QL 360 / 180 DAYS


C State PDL Class


PTD PART DPRODUCTS

famotidine 20 mg tablet 1C State PDL Class

PTD PART DPRODUCTS



NICOTROL 1


C State PDL Class


PTD PART DPRODUCTS

NICOTROL NS 1


C State PDL Class


PTD PART DPRODUCTS

ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate 1000mg/4ml vial 1 PTD PART DPRODUCTS

GENTAK 1C State PDL Class

PTD PART DPRODUCTS

gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 %drops) 1

C State PDL Class

PTD PART DPRODUCTS

gentamicin sulfate 40 mg/ml vial 1 PTD PART DPRODUCTS

neomycin sulfate 1C State PDL Class

PTD PART DPRODUCTS

tobramycin 0.3 % drops 1C State PDL Class

PTD PART DPRODUCTS



tobramycin sulfate (1.2 g vial, 40 mg/ml vial) 1 PTD PART DPRODUCTS

TOBREX 0.3% EYE OINTMENT 1

QL 3.5 / 7 DAYS

C State PDL Class

PTD PART DPRODUCTS

ANTIBACTERIALS, OTHER

bacitracin 500 unit/g oint. (g) 1

QL 3.5 / 7 days

C State PDL Class

PTD PART DPRODUCTS

CENTANY 1 PTD PART DPRODUCTS

CLEOCIN 100 MG VAGINAL OVULE 1C State PDL Class

PTD PART DPRODUCTS

CLEOCIN PHOS 150 MG/ML VIAL 1 PTD PART DPRODUCTS

CLINDACIN ETZ 1% PLEDGET 1 PTD PART DPRODUCTS

CLINDACIN P 1 PTD PART DPRODUCTS

clindamycin hcl 1 PTD PART DPRODUCTS

clindamycin palmitate hcl 1 PTD PART DPRODUCTS

clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 %med. swab, 1 % solution, 2 % cream/appl) 1

C State PDL Class

PTD PART DPRODUCTS

colistin (as colistimethate sodium) 1 PTD PART DPRODUCTS



lincomycin hcl 1 PTD PART DPRODUCTS

linezolid (100 mg/5ml susp recon, 600 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

metronidazole 0.75 % gel w/appl 1C State PDL Class

PTD PART DPRODUCTS

metronidazole (250 mg tablet, 500 mg tablet) 1 PTD PART DPRODUCTS

mupirocin 1C State PDL Class

PTD PART DPRODUCTS

mupirocin calcium 1C State PDL Class

PTD PART DPRODUCTS

nitrofurantoin 1 PTD PART DPRODUCTS

nitrofurantoin macrocrystal 1 PTD PART DPRODUCTS

nitrofurantoin monohydrate/macrocrystals 1 PTD PART DPRODUCTS

NUVESSA 1 PTD PART DPRODUCTS

ORBACTIV 1 PTD PART DPRODUCTS

trimethoprim 1 PTD PART DPRODUCTS

VANCOCIN HCL 1C Supplemental

PTD PART DPRODUCTS



vancomycin hcl (125 mg capsule, 250 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial,100 g bulkbaginj, 500 mg vial, 500 mg vial port, 750 mgvial, 750 mg vial port)

1C Supplemental

PTD PART DPRODUCTS

vancomycin hcl in water for injection (peg-400, nada)(vancomycin/water inj 1g/200ml piggyback,vancomycin/water inj 500mg/0.1l piggyback)

1 C Supplemental

vancomycin in 0.9 % sodium chloride (vancomycin/0.9 %1.25 g/250 plast. bag, vancomycin/0.9 % 1.5g/250mlplast. bag, vancomycin/0.9 % 1.5g/500ml plast. bag,vancomycin/0.9 % 1.75 g/500 plast. bag, vancomycin/0.9% 1.75g/250 plast. bag, vancomycin/0.9 % 1g/200mlfroz.piggy, vancomycin/0.9 % 1g/250ml plast. bag,vancomycin/0.9 % 2 g/500 ml plast. bag, vancomycin/0.9% 500mg/0.1l froz.piggy, vancomycin/0.9 % 750 mg/250plast. bag, vancomycin/0.9 % 750mg/.15l froz.piggy,vancomycin/0.9 % 750mg/.15l plast. bag)

1C Supplemental

PTD PART DPRODUCTS

vancomycin in 5 % dextrose in water (in 5 % 1 g/100 mlplast. bag, in 5 % 1.25 g/250 plast. bag, in 5 % 1.5g/250mlplast. bag, in 5 % 1.5g/500ml plast. bag, in 5 % 1g/200mlfroz.piggy, in 5 % 1g/250ml plast. bag, in 5 % 500mg/0.1lfroz.piggy, in 5 % 750mg/.15l froz.piggy)

1C Supplemental

PTD PART DPRODUCTS

VANDAZOLE 1C State PDL Class

PTD PART DPRODUCTS

ZYVOX 600 MG TABLET 1 PTD PART DPRODUCTS

BETA-LACTAM, CEPHALOSPORINS

cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250mg/5ml susp recon, 375 mg/5ml susp recon, 500 mgcapsule, 500 mg tab er 12h)

1C State PDL Class

PTD PART DPRODUCTS



cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mgcapsule, 500 mg/5ml susp recon) 1

C State PDL Class

PTD PART DPRODUCTS

cefazolin sodium in 0.9 % nacl 3 g/100 ml piggyback 1 PTD PART DPRODUCTS

cefazolin sodium/dextrose 5 % in water 1 PTD PART DPRODUCTS

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon,300 mg capsule) 1

C State PDL Class

PTD PART DPRODUCTS

cefixime 400 mg capsule 1

QL 1 / 30 days

C State PDL Class

PTD PART DPRODUCTS

cefixime (100 mg/5ml susp recon, 200 mg/5ml susprecon) 1

C State PDL Class

PTD PART DPRODUCTS

cefotaxime sodium 1 g vial 1 PTD PART DPRODUCTS

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mgtablet, 100 mg/5ml susp recon, 200 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250mg/5ml susp recon, 500 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

ceftriaxone sodium (250 mg vial, 500 mg vial) 1 PTD PART DPRODUCTS

cefuroxime axetil 1C State PDL Class

PTD PART DPRODUCTS

cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500mg tablet, 750 mg capsule)

1C State PDL Class

PTD PART DPRODUCTS



SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLETCHEWABLE, 500 MG/5 ML SUSPENSION) 1

C State PDL Class

PTD PART DPRODUCTS

BETA-LACTAM, OTHER

VABOMERE 1 PTD PART DPRODUCTS

BETA-LACTAM, PENICILLINS

amoxicillin (125 mg tab chew, 125 mg/5ml susp recon,200 mg/5ml susp recon, 250 mg capsule, 250 mg tabchew, 250 mg/5ml susp recon, 400 mg/5ml susp recon,500 mg capsule, 500 mg tablet, 875 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

amoxicillin/potassium clavulanate (amoxicillin/potassium200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mgtab chew, amoxicillin/potassium 250-125 mg tablet,amoxicillin/potassium 250-62.5/5 susp recon,amoxicillin/potassium 400-57mg tab chew,amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet,amoxicillin/potassium 600-42.9/5 susp recon,amoxicillin/potassium 875-125 mg tablet,amoxicillin/potassium 1000-62.5 tab er 12h)

1C State PDL Class

PTD PART DPRODUCTS

ampicillin sodium 10 g vial 1 PTD PART DPRODUCTS

ampicillin trihydrate 1C State PDL Class

PTD PART DPRODUCTS

AUGMENTIN 125-31.25 MG/5 ML 1C State PDL Class

PTD PART DPRODUCTS

BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS) 1 PTD PART DPRODUCTS

dicloxacillin sodium 1C State PDL Class

PTD PART DPRODUCTS



penicillin v potassium (125 mg/5ml soln recon, 250 mgtablet, 250 mg/5ml soln recon, 500 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

piperacillin sodium/tazobactam sodium(sodium/tazobactam 2.25 g vial, sodium/tazobactam3.375 g vial, sodium/tazobactam 4.5 g vial)

1 PTD PART DPRODUCTS

MACROLIDES

azithromycin (1 g packet, 100 mg/5ml susp recon, 200mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mgtablet)

1C State PDL Class

PTD PART DPRODUCTS

azithromycin 500 mg vial 1 PTD PART DPRODUCTS

clarithromycin (125 mg/5ml susp recon, 250 mg tablet,250 mg/5ml susp recon, 500 mg tab er 24h, 500 mgtablet)

1C State PDL Class

PTD PART DPRODUCTS

ERYTHROCIN LACT 500 MG VIAL 1 PTD PART DPRODUCTS

erythromycin base 5 mg/gram oint. (g) 1C State PDL Class

PTD PART DPRODUCTS

erythromycin base in ethanol 2 % solution 1C State PDL Class

PTD PART DPRODUCTS

ZITHROMAX 1 GM POWDER PACKET 1 PTD PART DPRODUCTS

QUINOLONES

CETRAXAL 1 PTD PART DPRODUCTS

CILOXAN 0.3% OINTMENT 1C State PDL Class

PTD PART DPRODUCTS



ciprofloxacin hcl (0.2 % droperette, 0.3 % drops, 100 mgtablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

levofloxacin (250 mg tablet, 250mg/10ml solution, 500mg tablet, 750 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

levofloxacin 25 mg/ml vial 1 PTD PART DPRODUCTS

MOXEZA 1 PTD PART DPRODUCTS

moxifloxacin hcl 0.5 % drops 1C State PDL Class

PTD PART DPRODUCTS

moxifloxacin hcl 0.5 % drops visc 1 C State PDL Class

ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

SULFONAMIDES

AVC 1C State Rebate

Class

PTD PART DPRODUCTS

silver sulfadiazine 1C State PDL Class

PTD PART DPRODUCTS

SSD 1C State PDL Class

PTD PART DPRODUCTS

sulfacetamide sodium (10 % drops, 10 % oint. (g)) 1C State PDL Class

PTD PART DPRODUCTS



sulfadiazine 1C State PDL Class

PTD PART DPRODUCTS

sulfamethoxazole/trimethoprim(sulfamethoxazole/trimethoprim 200-40mg/5 oral susp,sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)

1C State PDL Class

PTD PART DPRODUCTS

SULFATRIM 1C State PDL Class

PTD PART DPRODUCTS

TETRACYCLINES

demeclocycline hcl 1

C State PDL Class

PA

PTD PART DPRODUCTS

doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mgcapsule, 100 mg tablet, 100 mg tablet dr) 1

C State PDL Class

PTD PART DPRODUCTS

doxycycline hyclate 200 mg tablet dr 1 PTD PART DPRODUCTS

doxycycline monohydrate (50 mg capsule, 100 mgcapsule) 1

C State PDL Class

PTD PART DPRODUCTS

doxycycline monohydrate 100 mg tablet 1 PTD PART DPRODUCTS

MINOCIN 100 MG VIAL 1 PTD PART DPRODUCTS

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule) 1

C State PDL Class

PTD PART DPRODUCTS

MONDOXYNE NL 100 MG CAPSULE 1C State PDL Class

PTD PART DPRODUCTS



MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1C State PDL Class

PTD PART DPRODUCTS

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

levetiracetam (100 mg/ml solution, 250 mg tablet, 500mg tab er 24h, 500 mg tablet, 500 mg/5ml solution, 750mg tab er 24h, 750 mg tablet, 1000 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

levetiracetam 500 mg/5ml vial 1 PTD PART DPRODUCTS

ROWEEPRA 1C State PDL Class

PTD PART DPRODUCTS

ROWEEPRA XR 1C State PDL Class

PTD PART DPRODUCTS

CALCIUM CHANNEL MODIFYING AGENTS

ethosuximide (250 mg capsule, 250 mg/5ml solution) 1C State PDL Class

PTD PART DPRODUCTS

zonisamide 1C State PDL Class

PTD PART DPRODUCTS

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam (2.5 mg/ml oral susp, 10 mg tablet, 20 mgtablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1

QL 2 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS



divalproex sodium (125 mg cap dr spr, 125 mg tablet dr,250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h,500 mg tablet dr)

1C State PDL Class

PTD PART DPRODUCTS

gabapentin (100 mg capsule, 250 mg/5ml solution, 300mg capsule, 300 mg/6ml solution, 400 mg capsule, 600mg tablet, 800 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mgtablet, 97.2mg tablet, 100 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

primidone 1C State PDL Class

PTD PART DPRODUCTS

tiagabine hcl 1

C State PDL Class

PA

PTD PART DPRODUCTS

valproic acid 1C State PDL Class

PTD PART DPRODUCTS

valproic acid (as sodium salt) (valproate sodium) (250mg/5ml solution, 500mg/10ml solution) 1

C State PDL Class

PTD PART DPRODUCTS

valproic acid (as sodium salt) 500 mg/5ml vial 1 PTD PART DPRODUCTS

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5mloral susp) 1

C State PDL Class

PTD PART DPRODUCTS



LAMICTAL XR (BLUE) 1 PTD PART DPRODUCTS

LAMICTAL XR (GREEN) 1 PTD PART DPRODUCTS

LAMICTAL XR (ORANGE) 1 PTD PART DPRODUCTS

lamotrigine (25(21)-50 tb rd dspk, 25(42)-100 tab ds pk,25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tabds pk, 50(42)-100 tb rd dspk)


lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tabrapdis, 25 mg tablet, 25 mg tb chw dsp, 50 mg tab er 24,50 mg tab rapdis, 100 mg tab er 24, 100 mg tab rapdis,100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mgtab rapdis, 200 mg tablet, 250 mg tab er 24, 300 mg taber 24)

1C State PDL Class

PTD PART DPRODUCTS

SUBVENITE 1C State PDL Class

PTD PART DPRODUCTS

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mgtablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

TROKENDI XR 1 PTD PART DPRODUCTS

SODIUM CHANNEL AGENTS

BANZEL 40 MG/ML SUSPENSION 1PA

PTD PART DPRODUCTS

BANZEL (200 MG TABLET, 400 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS

carbamazepine 200mg/10ml oral susp 1 C State PDL Class



carbamazepine (100 mg cpmp 12hr, 100 mg tab chew,100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp12hr, 400 mg tab er 12h)

1C State PDL Class

PTD PART DPRODUCTS

DILANTIN 30 MG CAPSULE 1 PTD PART DPRODUCTS

EPITOL 1C State PDL Class

PTD PART DPRODUCTS

oxcarbazepine (150 mg tablet, 300 mg tablet, 300mg/5ml oral susp, 600 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

OXTELLAR XR 1 PTD PART DPRODUCTS

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125mg/5ml oral susp) 1

C State PDL Class

PTD PART DPRODUCTS

phenytoin sodium extended 1C State PDL Class

PTD PART DPRODUCTS

rufinamide 40 mg/ml oral susp 1

C State PDL Class

PA

PTD PART DPRODUCTS

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MGTABLET, 150 MG TABLET, 200 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS

VIMPAT 200 MG/20 ML VIAL 1PA

PTD PART DPRODUCTS



ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 1 PTD PART DPRODUCTS

CHOLINESTERASE INHIBITORS

donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tabrapdis, 10 mg tablet, 23 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mgcap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel,24 mg cap24h pel)

1

C State PDL Class

PA

PTD PART DPRODUCTS

rivastigmine 1

C State PDL Class

PA

PTD PART DPRODUCTS

rivastigmine tartrate 1

C State PDL Class

PA

PTD PART DPRODUCTS

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (5 mg-10 mg tab ds pk, 7 mg cap spr 24,14 mg cap spr 24, 21 mg cap spr 24, 28 mg cap spr 24) 1

PA

PTD PART DPRODUCTS

memantine hcl (2 mg/ml solution, 5 mg tablet, 10 mgtablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

NAMENDA XR TITRATION PACK 1PA

PTD PART DPRODUCTS



ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

bupropion hcl (75 mg tablet, 100 mg tablet) 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

bupropion hcl (100 mg tab sr 12h, 200 mg tab sr 12h) 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

mirtazapine (7.5 mg tablet, 15 mg tab rapdis, 15 mgtablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis,45 mg tablet)

1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

WELLBUTRIN XL 1 QPD 5.0 per day

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN ANDNOREPINEPHRINE REUPTAKE INHIBITOR

citalopram hydrobromide (10 mg/5 ml solution, 20mg/10ml solution) 1

AL 6.0 to 12.0 yrsold

C State PDL Class

QPD 20.0 per day

PTD PART DPRODUCTS



citalopram hydrobromide (20 mg tablet, 40 mg tablet) 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

citalopram hydrobromide 10 mg tablet 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

escitalopram oxalate (10 mg tablet, 20 mg tablet) 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

escitalopram oxalate 5 mg tablet 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

fluoxetine hcl (10 mg capsule, 40 mg capsule) 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

fluoxetine hcl 20 mg capsule 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS



fluoxetine hcl 20 mg/5 ml solution 1


C State PDL Class

QPD 20.0 per day

PTD PART DPRODUCTS

fluvoxamine maleate 100 mg tablet 1


C State PDL Class

QPD 3.0 per day

PTD PART DPRODUCTS



C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS



C State PDL Class

QPD 6.0 per day

PTD PART DPRODUCTS

maprotiline hcl 1


C State PDL Class

PTD PART DPRODUCTS

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet) 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS



paroxetine hcl 40 mg tablet 1

QL 45 / 30 days


C State PDL Class

QPD 1.5 per day

PTD PART DPRODUCTS

sertraline hcl 20 mg/ml oral conc 1


C State PDL Class

QPD 10.0 per day

PTD PART DPRODUCTS

sertraline hcl (25 mg tablet, 100 mg tablet) 1


C State PDL Class

QPD 3.0 per day

PTD PART DPRODUCTS

sertraline hcl 50 mg tablet 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

trazodone hcl 100 mg tablet 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS



C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS




QL 30 / 30 DAYS


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS



C State PDL Class

QPD 3.0 per day

PTD PART DPRODUCTS

venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tablet, 50mg tablet, 75 mg cap er 24h, 100 mg tablet) 1


C State PDL Class

QPD 3.0 per day

PTD PART DPRODUCTS

venlafaxine hcl 150 mg cap er 24h 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

venlafaxine hcl 25 mg tablet 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

venlafaxine hcl 75 mg tablet 1


C State PDL Class

QPD 5.0 per day

PTD PART DPRODUCTS



TRICYCLICS

amitriptyline hcl 1


C State PDL Class

PTD PART DPRODUCTS

amoxapine 1


C State PDL Class

PTD PART DPRODUCTS

clomipramine hcl 1


C State PDL Class

PTD PART DPRODUCTS

desipramine hcl 1


C State PDL Class

PTD PART DPRODUCTS

doxepin hcl (10 mg capsule, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule) 1

QL 90 / 30 DAYS


C State PDL Class

QPD 3.0 per day

PTD PART DPRODUCTS

doxepin hcl 150 mg capsule 1

QL 90 / 30 DAYS


C State PDL Class

PTD PART DPRODUCTS



doxepin hcl 10 mg/ml oral conc 1

QL 180 / 30 DAYS


C State PDL Class

PTD PART DPRODUCTS

imipramine hcl 1


C State PDL Class

PTD PART DPRODUCTS

imipramine pamoate 1


C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25mg capsule, 50 mg capsule, 75 mg capsule) 1


C State PDL Class

PTD PART DPRODUCTS

protriptyline hcl 1


C State PDL Class

PTD PART DPRODUCTS

trimipramine maleate 1


C State PDL Class

PTD PART DPRODUCTS



ANTIEMETICS

ANTIEMETICS, OTHER

COMPRO 1C State PDL Class

PTD PART DPRODUCTS

meclizine hcl 1 PTD PART DPRODUCTS

metoclopramide hcl (5 mg tab rapdis, 5 mg tablet, 5 mg/5ml solution, 10 mg tab rapdis, 10 mg tablet, 10 mg/10mlsolution)

1C State PDL Class

PTD PART DPRODUCTS

metoclopramide hcl (5 mg/ml vial, 10 mg/2 ml syringe) 1 PTD PART DPRODUCTS

perphenazine 1


C State PDL Class

PTD PART DPRODUCTS

PHENADOZ 1C State PDL Class

PTD PART DPRODUCTS

prochlorperazine 1C State PDL Class

PTD PART DPRODUCTS

prochlorperazine maleate 1C State PDL Class

PTD PART DPRODUCTS

promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50mg supp.rect) 1

C State PDL Class

PTD PART DPRODUCTS

PROMETHEGAN 1C State PDL Class

PTD PART DPRODUCTS



TIGAN 100 MG/ML VIAL 1 PTD PART DPRODUCTS

trimethobenzamide hcl 1 PTD PART DPRODUCTS

EMETOGENIC THERAPY ADJUNCTS

aprepitant 125mg-80mg cap ds pk 1

QL 6 / 21 DAYS

C State PDL Class

PTD PART DPRODUCTS

aprepitant (40 mg capsule, 80 mg capsule, 125 mgcapsule) 1

QL 6 / 21 days

C State PDL Class

PA

PTD PART DPRODUCTS

dronabinol 1 PTD PART DPRODUCTS

granisetron hcl (1 mg tablet, 1 mg/ml vial, 1 mg/ml(1)vial) 1

C State PDL Class

PA

PTD PART DPRODUCTS

granisetron hcl/pf 1PA

PTD PART DPRODUCTS

ondansetron 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

ondansetron hcl (2 mg/ml vial, 4 mg/5 ml solution) 1 PTD PART DPRODUCTS

ondansetron hcl (4 mg tablet, 8 mg tablet) 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS



ondansetron hcl 24 mg tablet 1

C State PDL Class

PA

PTD PART DPRODUCTS

ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4mg/2 ml syringe, hcl/pf 4 mg/2 ml vial) 1 PTD PART D

PRODUCTS

ANTIFUNGALS

CICLODAN (0.77% CREAM, 8% SOLUTION) 1C State PDL Class

PTD PART DPRODUCTS

ciclopirox 8 % solution 1C State PDL Class

PTD PART DPRODUCTS

ciclopirox olamine 0.77 % cream (g) 1C State PDL Class

PTD PART DPRODUCTS

clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) 1C State PDL Class

PTD PART DPRODUCTS

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon) 1

C State PDL Class

QPD 20.0 per day

PTD PART DPRODUCTS

fluconazole (50 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet) 1

C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

griseofulvin, microsize (125 mg/5ml oral susp, 500 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS

ketoconazole (2 % cream (g), 2 % shampoo) 1C State PDL Class

PTD PART DPRODUCTS



miconazole nitrate 1C State PDL Class

PTD PART DPRODUCTS

NATACYN 1C State PDL Class

PTD PART DPRODUCTS

NYAMYC 1C State PDL Class

PTD PART DPRODUCTS

nystatin (500k unit tablet, 100000/g cream (g), 100000/goint. (g), 100000/g powder, 100000/ml oral susp) 1

C State PDL Class

PTD PART DPRODUCTS

NYSTOP 1C State PDL Class

PTD PART DPRODUCTS

terbinafine hcl 1

QL 90 / 365 Days

C State PDL Class

PTD PART DPRODUCTS

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mgsupp.vag) 1 PTD PART D

PRODUCTS

ANTIGOUT AGENTS

allopurinol 1C State PDL Class

PTD PART DPRODUCTS

colchicine 0.6 mg tablet 1

C State PDL Class

PA

PTD PART DPRODUCTS

febuxostat 1

C State PDL Class

PA

PTD PART DPRODUCTS



probenecid 1C State PDL Class

PTD PART DPRODUCTS

probenecid/colchicine 1 PTD PART DPRODUCTS

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

CAFERGOT 1PA

PTD PART DPRODUCTS

ergotamine tartrate/caffeine 1C State PDL Class

PTD PART DPRODUCTS

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

IMITREX (5 MG NASAL SPRAY, 20 MG NASAL SPRAY) 1

C State RebateClass

QPD 0.2 per day

PTD PART DPRODUCTS

naratriptan hcl 1

QL 9 / 30 days

C State RebateClass

PTD PART DPRODUCTS

rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mgtab rapdis, 10 mg tablet) 1

C State RebateClass

QPD 0.3 per day

PTD PART DPRODUCTS

sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5mlpen injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr) 1

C State RebateClass

QPD 0.067 per day

PTD PART DPRODUCTS



sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet) 1

C State RebateClass

QPD 0.3 per day

PTD PART DPRODUCTS

sumatriptan succinate 6 mg/0.5ml vial 1QPD 0.067 per day

PTD PART DPRODUCTS

zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tabrapdis, 5 mg tablet) 1

C State RebateClass

QPD 0.3 per day

PTD PART DPRODUCTS

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 1

ST

C State RebateClass

PA

QPD 0.2 per day

PTD PART DPRODUCTS

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1 PTD PART DPRODUCTS

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS



ANTITUBERCULARS

ethambutol hcl 1C State PDL Class

PTD PART DPRODUCTS

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS

pyrazinamide 1C State PDL Class

PTD PART DPRODUCTS

RIFAMATE 1 PTD PART DPRODUCTS

rifampin (150 mg capsule, 300 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLET 1

C State PDL Class

PA

PTD PART DPRODUCTS

PTBPART BELIGIBLEPRODUCTS

cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PTD PART DPRODUCTS

GLEOSTINE 1 PTD PART DPRODUCTS

LEUKERAN 1 PTD PART DPRODUCTS

MATULANE 1C State PDL Class

PTD PART DPRODUCTS



temozolomide 1

PA

PTD PART DPRODUCTS


ANTIANDROGENS

bicalutamide 1 PTD PART DPRODUCTS

flutamide 1C State PDL Class

PTD PART DPRODUCTS

nilutamide 1 PTD PART DPRODUCTS

ZYTIGA 500 MG TABLET 1PA

PTD PART DPRODUCTS

ANTIANGIOGENIC AGENTS

REVLIMID 1

C State PDL Class

PA

PTD PART DPRODUCTS

THALOMID 1

C State PDL Class

PA

PTD PART DPRODUCTS

ANTIESTROGENS/MODIFIERS

SOLTAMOX 1 PTD PART DPRODUCTS

tamoxifen citrate 1C State PDL Class

PTD PART DPRODUCTS



toremifene citrate 1

C State PDL Class

PA

PTD PART DPRODUCTS

ANTIMETABOLITES

fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1 PTD PART DPRODUCTS

hydroxyurea 1C State PDL Class

PTD PART DPRODUCTS

mercaptopurine 1C State PDL Class

PTD PART DPRODUCTS

TABLOID 1PA

PTD PART DPRODUCTS

ANTINEOPLASTICS, OTHER

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mgtablet, 25 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

SYLATRON 1

C State PDL Class

PA

PTD PART DPRODUCTS

ZOLINZA 1

C State PDL Class

PA

PTD PART DPRODUCTS



AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1

C State PDL Class

PA

PTD PART DPRODUCTS

exemestane 1

C State PDL Class

PA

PTD PART DPRODUCTS

letrozole 1 PTD PART DPRODUCTS

ENZYME INHIBITORS

etoposide 50 mg capsule 1

C State PDL Class

PA

PTD PART DPRODUCTS


MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TABLET 1

C State PDL Class

PA

PTD PART DPRODUCTS

AFINITOR DISPERZ 1

C State PDL Class

PA

PTD PART DPRODUCTS

ALECENSA 1PA

PTD PART DPRODUCTS



CAPRELSA 1

C State PDL Class

PA

PTD PART DPRODUCTS

COTELLIC 1PA

PTD PART DPRODUCTS

ERIVEDGE 1PA

PTD PART DPRODUCTS

erlotinib hcl 1

C State PDL Class

PA

PTD PART DPRODUCTS

everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

GLEEVEC 1

C State PDL Class

PA

PTD PART DPRODUCTS

ICLUSIG (15 MG TABLET, 45 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS

IMBRUVICA 140 MG CAPSULE 1

C State PDL Class

PA

PTD PART DPRODUCTS

INLYTA 1

C State PDL Class

PA

PTD PART DPRODUCTS



IRESSA 1

C State PDL Class

PA

PTD PART DPRODUCTS

JAKAFI 1

C State PDL Class

PA

PTD PART DPRODUCTS

lapatinib ditosylate 1

C State PDL Class

PA

PTD PART DPRODUCTS

NEXAVAR 1

C State PDL Class

PA

PTD PART DPRODUCTS

SUTENT 1

C State PDL Class

PA

PTD PART DPRODUCTS

TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 1

C State PDL Class

PA

PTD PART DPRODUCTS

TYKERB 1PA

PTD PART DPRODUCTS

VOTRIENT 1

C State RebateClass

PA

PTD PART DPRODUCTS



XALKORI 1

C State PDL Class

PA

PTD PART DPRODUCTS

ZELBORAF 1

C State PDL Class

PA

PTD PART DPRODUCTS

MONOCLONAL ANTIBODIES

AVASTIN 1

C State RebateClass

PA

PTD PART DPRODUCTS

HERCEPTIN 1PA

PTD PART DPRODUCTS

RITUXAN 1

C State RebateClass

PA

PTD PART DPRODUCTS

RITUXAN HYCELA 1

C State RebateClass

PA

PTD PART DPRODUCTS

RETINOIDS

bexarotene 1

C State PDL Class

PA

PTD PART DPRODUCTS



tretinoin 10 mg capsule 1

AL Up to 26 yrs old

C State PDL Class

PTD PART DPRODUCTS

ANTIPARASITICS

ANTIHELMINTHICS

albendazole 1

C State PDL Class

PA

PTD PART DPRODUCTS

EMVERM 1 PTD PART DPRODUCTS

ivermectin (0.5 % lotion, 3 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

praziquantel 1C State PDL Class

PTD PART DPRODUCTS

SKLICE 1PA

PTD PART DPRODUCTS

ANTIPROTOZOALS

ALINIA 100 MG/5 ML SUSPENSION 1 PTD PART DPRODUCTS

atovaquone/proguanil hcl 1C State PDL Class

PTD PART DPRODUCTS

chloroquine phosphate 1C State PDL Class

PTD PART DPRODUCTS



COARTEM 1 PTD PART DPRODUCTS

hydroxychloroquine sulfate 200 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

primaquine phosphate 1C State PDL Class

PTD PART DPRODUCTS

quinine sulfate 1C State PDL Class

PTD PART DPRODUCTS

PEDICULICIDES/SCABICIDES

EURAX (CREAM, LOTION) 1C State PDL Class

PTD PART DPRODUCTS

lindane 1 PTD PART DPRODUCTS

malathion 1 PTD PART DPRODUCTS

permethrin 1C State PDL Class

PTD PART DPRODUCTS

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) 1 PTD PART DPRODUCTS

benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml solution, 5 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS



ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5 ml solution, 100 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

entacapone 1C State PDL Class

PTD PART DPRODUCTS

STALEVO 125 1 PTD PART DPRODUCTS



DOPAMINE AGONISTS

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 4.5mg tab er 24h)

1C State PDL Class

PTD PART DPRODUCTS

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet,2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa/levodopa (carbidopa/levodopa 10mg-100mgtablet, carbidopa/levodopa 25mg-100mg tablet,carbidopa/levodopa 25mg-100mg tablet er,carbidopa/levodopa 25mg-250mg tablet,carbidopa/levodopa 50mg-200mg tablet er)

1C State PDL Class

PTD PART DPRODUCTS



ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25 mg/mlampul, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1


C State PDL Class

PTD PART DPRODUCTS

fluphenazine decanoate 1


C State PDL Class

PTD PART DPRODUCTS

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5mlelixir, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1


C State PDL Class

PTD PART DPRODUCTS

haloperidol 1


C State PDL Class

PTD PART DPRODUCTS

haloperidol decanoate (50 mg/ml ampul, 50 mg/ml vial,100 mg/ml ampul, 100 mg/ml vial) 1


C State PDL Class

PTD PART DPRODUCTS

haloperidol lactate 2 mg/ml oral conc 1


C State PDL Class

PTD PART DPRODUCTS

loxapine succinate 1


C State PDL Class

PTD PART DPRODUCTS



molindone hcl 1 PTD PART DPRODUCTS

pimozide 1


C State PDL Class

PTD PART DPRODUCTS

thioridazine hcl 1


C State PDL Class

PTD PART DPRODUCTS

thiothixene 1


C State PDL Class

PTD PART DPRODUCTS

trifluoperazine hcl 1


C State PDL Class

PTD PART DPRODUCTS

2ND GENERATION/ATYPICAL

ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER400 MG SYR, ER 400 MG VL) 1

QL 1 / 30 days


C State RebateClass

PTD PART DPRODUCTS

aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15mg tablet, 20 mg tablet, 30 mg tablet) 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS



ARISTADA ER 1064 MG/3.9 ML SYR 1

QL 3.9 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS

ARISTADA ER 441 MG/1.6 ML SYRN 1

QL 1.6 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 2.4 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 3.2 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS

INVEGA SUSTENNA 117 MG/0.75 ML 1

QL 0.75 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS



INVEGA SUSTENNA 156 MG/ML SYRG 1

QL 1 / 30 days


C State RebateClass

PTD PART DPRODUCTS


QL 1.5 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 0.25 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 0.5 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS

INVEGA TRINZA 273 MG/0.875 ML 1

QL 0.875 / 84DAYS


C State RebateClass

PTD PART DPRODUCTS




QL 1.315 / 84DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 1.75 / 84 DAYS


C State RebateClass

PTD PART DPRODUCTS


QL 2.625 / 84DAYS


C State RebateClass

PTD PART DPRODUCTS

LATUDA 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tabrapdis, 20 mg tablet)

1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS



olanzapine (5 mg tab rapdis, 10 mg tab rapdis) 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mgtablet, 200 mg tablet, 300 mg tablet, 400 mg tablet) 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS

RISPERDAL CONSTA 1

QL 2 / 30 DAYS


C State RebateClass

PTD PART DPRODUCTS

risperidone 1 mg/ml solution 1


C State RebateClass

QPD 8 per day

PTD PART DPRODUCTS

risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, 2mg tab rapdis, 2 mg tablet, 3 mg tab rapdis, 3 mg tablet,4 mg tab rapdis, 4 mg tablet)

1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS



ziprasidone hcl 1


C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

TREATMENT-RESISTANT

clozapine 25 mg tablet 1

QL 150 / 30 DAYS


C State RebateClass

QPD 5.0 per day

PTD PART DPRODUCTS

clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 50 mgtablet, 100 mg tab rapdis, 100 mg tablet, 150 mg tabrapdis, 200 mg tab rapdis, 200 mg tablet)

1


C State RebateClass

QPD 5.0 per day

PTD PART DPRODUCTS

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir 1

C State PDL Class

PA

PTD PART DPRODUCTS

FOSCAVIR 6,000 MG/250 ML BTTL 1

C State PDL Class

PA

PTD PART DPRODUCTS



FOSCAVIR 6,000 MG/250 ML BAG 1C State PDL Class

PA

ganciclovir sodium 500 mg vial 1

C State PDL Class

PA

PTD PART DPRODUCTS

valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 1

C State RebateClass

PA

PTD PART DPRODUCTS

BARACLUDE 0.05 MG/ML SOLUTION 1

C State PDL Class

PA

PTD PART DPRODUCTS

entecavir 1

C State PDL Class

PA

PTD PART DPRODUCTS

EPIVIR HBV 25 MG/5 ML SOLN 1

C State PDL Class

PA

PTD PART DPRODUCTS

lamivudine 100 mg tablet 1C State PDL Class

PTD PART DPRODUCTS



ANTI-HEPATITIS C (HCV) AGENTS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)

1

C State PDL Class

PA

PTD PART DPRODUCTS

MAVYRET 100-40 MG TABLET 1

C State RebateClass

PA

PTD PART DPRODUCTS

PEGASYS PROCLICK 1

C State RebateClass

PA

PTD PART DPRODUCTS

RIBASPHERE 200 MG CAPSULE 1 PTD PART DPRODUCTS

ribavirin (200 mg capsule, 200 mg tablet) 1

C State RebateClass

PA

PTD PART DPRODUCTS

sofosbuvir/velpatasvir 1

C State RebateClass

PA

PTD PART DPRODUCTS

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA 1C State PDL Class

PTD PART DPRODUCTS

ISENTRESS (25 MG TABLET CHEW, 100 MG POWDERPACKET, 100 MG TABLET CHEW, 400 MG TABLET) 1

C State PDL Class

PTD PART DPRODUCTS



ISENTRESS HD 1C State PDL Class

PTD PART DPRODUCTS

STRIBILD 1C State PDL Class

PTD PART DPRODUCTS

TIVICAY 1C State PDL Class

PTD PART DPRODUCTS

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA 1C State PDL Class

PTD PART DPRODUCTS

COMPLERA 1C State PDL Class

PTD PART DPRODUCTS

EDURANT 1C State PDL Class

PTD PART DPRODUCTS

efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

INTELENCE 1C State PDL Class

PTD PART DPRODUCTS

nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200mg tablet, 400 mg tab er 24h) 1

C State PDL Class

PTD PART DPRODUCTS

ODEFSEY 1C State PDL Class

PTD PART DPRODUCTS



RESCRIPTOR 1C State PDL Class

PTD PART DPRODUCTS

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASEINHIBITORS (NRTI)

abacavir sulfate (20 mg/ml solution, 300 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

abacavir sulfate/lamivudine 1C State PDL Class

PTD PART DPRODUCTS

abacavir sulfate/lamivudine/zidovudine 1C State PDL Class

PTD PART DPRODUCTS

DESCOVY 1C State PDL Class

PTD PART DPRODUCTS

didanosine 1C State PDL Class

PTD PART DPRODUCTS

emtricitabine 1C State PDL Class

PTD PART DPRODUCTS

EMTRIVA 200 MG CAPSULE 1 PTD PART DPRODUCTS

EMTRIVA 10 MG/ML SOLUTION 1C State PDL Class

PTD PART DPRODUCTS

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS



lamivudine/zidovudine 1C State PDL Class

PTD PART DPRODUCTS

stavudine 1C State PDL Class

PTD PART DPRODUCTS

tenofovir disoproxil fumarate 1C State PDL Class

PTD PART DPRODUCTS

TRUVADA 1C State PDL Class

PTD PART DPRODUCTS

VIDEX 1C State PDL Class

PTD PART DPRODUCTS

VIDEX EC 125 MG CAPSULE 1C State PDL Class

PTD PART DPRODUCTS

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER) 1

C State PDL Class

PTD PART DPRODUCTS

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS

ANTI-HIV AGENTS, OTHER

FUZEON 1

QL 1 / 30 DAYS

C State PDL Class

PA

PTD PART DPRODUCTS

PREZCOBIX 1C State PDL Class

PTD PART DPRODUCTS



SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MGTABLET, 300 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS

TRIUMEQ 1C State PDL Class

PTD PART DPRODUCTS

TYBOST 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 1C State PDL Class

PTD PART DPRODUCTS

atazanavir sulfate 1C State PDL Class

PTD PART DPRODUCTS

CRIXIVAN 1C State PDL Class

PTD PART DPRODUCTS

EVOTAZ 1C State PDL Class

PTD PART DPRODUCTS

fosamprenavir calcium 1C State PDL Class

PTD PART DPRODUCTS

INVIRASE 1C State PDL Class

PTD PART DPRODUCTS

KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 1C State PDL Class

PTD PART DPRODUCTS



LEXIVA 50 MG/ML SUSPENSION 1C State PDL Class

PTD PART DPRODUCTS

lopinavir/ritonavir 400-100/5 solution 1C State PDL Class

PTD PART DPRODUCTS

NORVIR 80 MG/ML SOLUTION 1C State PDL Class

PTD PART DPRODUCTS

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET) 1

C State PDL Class

PTD PART DPRODUCTS

REYATAZ 50 MG POWDER PACKET 1C State PDL Class

PTD PART DPRODUCTS

ritonavir 1C State PDL Class

PTD PART DPRODUCTS

VIRACEPT 1C State PDL Class

PTD PART DPRODUCTS

ANTI-INFLUENZA AGENTS

oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75mg capsule) 1

QL 20 / 270 DAYS

C State PDL Class

PTD PART DPRODUCTS

oseltamivir phosphate 6 mg/ml susp recon 1C State PDL Class

PTD PART DPRODUCTS

RELENZA 1

QL 40 / 270 DAYS

C State PDL Class

PTD PART DPRODUCTS



rimantadine hcl 1C State PDL Class

PTD PART DPRODUCTS

ANTIHERPETIC AGENTS

acyclovir (5 % oint. (g), 200 mg capsule, 200 mg/5ml oralsusp, 400 mg tablet, 800 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

acyclovir sodium (50 mg/ml vial, 500 mg vial) 1 PTD PART DPRODUCTS

ALFERON N 1

C State PDL Class

PA

PTD PART DPRODUCTS

famciclovir 1

C State PDL Class

PA

PTD PART DPRODUCTS

SITAVIG 1 PTD PART DPRODUCTS

trifluridine 1C State PDL Class

PTD PART DPRODUCTS

valacyclovir hcl 1C State PDL Class

PTD PART DPRODUCTS

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl (10 mg tablet, 15 mg tablet) 1

QL 4 / DAY


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS



buspirone hcl (5 mg tablet, 7.5 mg tablet) 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

buspirone hcl 30 mg tablet 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS

BENZODIAZEPINES

alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h, 2 mg taber 24h, 3 mg tab er 24h) 1


C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1


C State PDL Class

QPD 4 per day

PTD PART DPRODUCTS

alprazolam (2 mg tab rapdis, 2 mg tablet) 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

ALPRAZOLAM INTENSOL 1

QL 60 / 15 DAYS


C State PDL Class

PTD PART DPRODUCTS



chlordiazepoxide hcl 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

clonazepam (2 mg tab rapdis, 2 mg tablet) 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mgtablet)

1


C State PDL Class

QPD 4 per day

PTD PART DPRODUCTS

clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet) 1


C State PDL Class

QPD 4 per day

PTD PART DPRODUCTS

clorazepate dipotassium 15 mg tablet 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

diazepam 5 mg/ml oral conc 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS



diazepam 5 mg/5 ml solution 1

QL 300 / 30 DAYS


C State PDL Class

PTD PART DPRODUCTS

diazepam (5 mg/ml cartridge, 5 mg/ml syringe, 5 mg/mlvial) 1 PTD PART D

PRODUCTS

diazepam (2 mg tablet, 5 mg tablet, 10 mg tablet) 1


C State PDL Class

QPD 4 per day

PTD PART DPRODUCTS

lorazepam (0.5 mg tablet, 1 mg tablet) 1


C State PDL Class

QPD 4 per day

PTD PART DPRODUCTS

lorazepam (2 mg tablet, 2 mg/ml oral conc) 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

LORAZEPAM INTENSOL 1


C State PDL Class

QPD 2 per day

PTD PART DPRODUCTS

oxazepam 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS



BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO 1C State PDL Class

PTD PART DPRODUCTS

lithium carbonate (150 mg capsule, 300 mg capsule, 300mg tablet, 300 mg tablet er, 450 mg tablet er, 600 mgcapsule)

1


C State PDL Class

PTD PART DPRODUCTS

lithium citrate 1


C State PDL Class

PTD PART DPRODUCTS

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 1C State PDL Class

PTD PART DPRODUCTS

ACTOPLUS MET XR 1C State Rebate

Class

PTD PART DPRODUCTS

BYDUREON PEN 1

C State RebateClass

PA

PTD PART DPRODUCTS

BYETTA 1

C State RebateClass

PA

PTD PART DPRODUCTS



FARXIGA 1

C State RebateClass

PA

PTD PART DPRODUCTS

glimepiride 1C State PDL Class

PTD PART DPRODUCTS

glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10mg tab er 24, 10 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

glyburide 1C State PDL Class

PTD PART DPRODUCTS

glyburide,micronized 1C State PDL Class

PTD PART DPRODUCTS

glyburide/metformin hcl 1C State Rebate

Class

PTD PART DPRODUCTS

GLYXAMBI 1

C State RebateClass

PA

PTD PART DPRODUCTS

INVOKAMET 1

C State RebateClass

PA

PTD PART DPRODUCTS

INVOKANA 1

C State RebateClass

PA

PTD PART DPRODUCTS



JANUMET 1

C State RebateClass

PA

PTD PART DPRODUCTS

JANUMET XR 1

C State RebateClass

PA

PTD PART DPRODUCTS

JANUVIA 1

C State RebateClass

PA

PTD PART DPRODUCTS

JARDIANCE 1

C State RebateClass

PA

PTD PART DPRODUCTS

JENTADUETO 1

C State RebateClass

PA

PTD PART DPRODUCTS

JENTADUETO XR 1PA

PTD PART DPRODUCTS

KAZANO 1PA

PTD PART DPRODUCTS

KOMBIGLYZE XR 1

C State RebateClass

PA

PTD PART DPRODUCTS



metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mgtab er 24h, 850 mg tablet, 1000 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

nateglinide 1C State PDL Class

PTD PART DPRODUCTS

NESINA 1PA

PTD PART DPRODUCTS

ONGLYZA 1

C State RebateClass

PA

PTD PART DPRODUCTS

OSENI 1PA

PTD PART DPRODUCTS

pioglitazone hcl 1C State PDL Class

PTD PART DPRODUCTS

pioglitazone hcl/metformin hcl 1C State Rebate

Class

PTD PART DPRODUCTS

repaglinide 1C State PDL Class

PTD PART DPRODUCTS

SYMLINPEN 120 1

C State RebateClass

PA

PTD PART DPRODUCTS

SYMLINPEN 60 1

C State RebateClass

PA

PTD PART DPRODUCTS



SYNJARDY 1

C State RebateClass

PA

PTD PART DPRODUCTS

TRADJENTA 1

C State RebateClass

PA

PTD PART DPRODUCTS

TRULICITY (0.75 MG/0.5 ML PEN, 1.5 MG/0.5 ML PEN) 1

C State RebateClass

PA

PTD PART DPRODUCTS

VICTOZA 2-PAK 1

C State RebateClass

PA

PTD PART DPRODUCTS

VICTOZA 3-PAK 1

C State RebateClass

PA

PTD PART DPRODUCTS

XIGDUO XR (5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET) 1

C State RebateClass

PA

PTD PART DPRODUCTS

GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 1C State PDL Class

PTD PART DPRODUCTS



GLUCAGON 1 MG EMERGENCY KIT 1

QL 1 / 30 days

C State PDL Class

PTD PART DPRODUCTS

PROGLYCEM 1 PTD PART DPRODUCTS

INSULINS

HUMALOG 100 UNIT/ML CARTRIDGE 1C State Rebate

Class

PTD PART DPRODUCTS

HUMULIN R U-500 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMULIN R U-500 KWIKPEN 1

C State RebateClass

PA

PTD PART DPRODUCTS

insulin aspart (100/ml (3) insuln pen, 100/ml cartridge,100/ml vial) 1 PTD PART D

PRODUCTS

insulin aspart protamine human/insulin aspart (artprot/insuln 70-30/ml insuln pen, art prot/insuln 70-30/mlvial)


insulin lispro (100/ml ins pen hf, 100/ml insuln pen,100/ml vial) 1 PTD PART D

PRODUCTS

insulin lispro protamine and insulin lispro 1 PTD PART DPRODUCTS

LANTUS 1C State Rebate

Class

PTD PART DPRODUCTS



LANTUS SOLOSTAR 1C State Rebate

Class

PTD PART DPRODUCTS

LEVEMIR 1C State Rebate

Class

PTD PART DPRODUCTS

LEVEMIR FLEXTOUCH 1C State Rebate

Class

PTD PART DPRODUCTS

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 1

C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS

enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4mlsyringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100mg/ml syringe, 120mg/.8ml syringe, 150 mg/ml syringe,300mg/3ml vial)

1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

heparin sodium,porcine 1C State Rebate

Class

PTD PART DPRODUCTS

heparin sod,pork in 0.45% nacl 12500/250 iv soln 1C State PDL Class

PTD PART DPRODUCTS

heparin sodium,porcine in 0.45 % sodium chloride (in25000/250 iv soln, in 25000/500 iv soln) 1

C State RebateClass

PTD PART DPRODUCTS



heparin sodium,porcine in 0.9 % sodium chloride(sod,porcine/0.9 % 2500/250ml iv soln, sod,porcine/0.9 %2500/500ml iv soln, sod,porcine/0.9 % 30k/1000ml iv soln,sod,porcine/0.9 % 4k/1000 ml iv soln, sod,porcine/0.9 %5000/500ml iv soln, sod,porcine/0.9 % 5k/1000 ml iv soln)

1C State Rebate

Class

PTD PART DPRODUCTS

heparin sod,porcine/0.9 % nacl 100/ml kit 1 C State RebateClass

heparin sodium,porcine in 0.9 % sodium chloride/pf 1C State Rebate

Class

PTD PART DPRODUCTS

heparin sodium,porcine/dextrose 5 % in water 1C State Rebate

Class

PTD PART DPRODUCTS

heparin sodium,porcine/pf (sodium,porcine/pf 1 unit/mlsyringe, sodium,porcine/pf 10 unit/ml syringe,sodium,porcine/pf 200/2 ml syringe, sodium,porcine/pf300/3 ml syringe, sodium,porcine/pf 500/5 ml syringe,sodium,porcine/pf 5000/0.5ml cartridge,sodium,porcine/pf 5000/0.5ml vial)

1C State PDL Class

PTD PART DPRODUCTS

heparin sodium,porcine/pf (sodium,porcine/pf 10 unit/mlvial, sodium,porcine/pf 100/ml (1) syringe,sodium,porcine/pf 1000/10 ml syringe)

1 C State PDL Class

heparin sodium,porcine/pf (sodium,porcine/pf 1000/mlvial, sodium,porcine/pf 5000/0.5ml syringe,sodium,porcine/pf 5000/ml syringe)

1C State Rebate

Class

PTD PART DPRODUCTS

heparin sodium,porcine/pf 100/ml (1) vial 1 C State RebateClass

JANTOVEN 1C State Rebate

Class

PTD PART DPRODUCTS



PRADAXA 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

warfarin sodium 1C State Rebate

Class

PTD PART DPRODUCTS

XARELTO DVT-PE TREAT START 30D 1

QL 51 / 30 days

C State RebateClass

PTD PART DPRODUCTS

XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

BLOOD FORMATION MODIFIERS

anagrelide hcl 1 PTD PART DPRODUCTS

NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL,480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 1

C State RebateClass

PA

PTD PART DPRODUCTS

NPLATE (250 MCG VIAL, 500 MCG VIAL) 1

C State RebateClass

PA

PTD PART DPRODUCTS

PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET) 1

C State RebateClass

PA

PTD PART DPRODUCTS



COAGULANTS

aminocaproic acid (500 mg tablet, 1000 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

PLATELET MODIFYING AGENTS

BRILINTA 1

C State PDL Class

PA

PTD PART DPRODUCTS

cilostazol 1C State PDL Class

PTD PART DPRODUCTS

clopidogrel bisulfate 1C State PDL Class

PTD PART DPRODUCTS

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine 1

QL 4 / 28 DAYS


C State RebateClass

PTD PART DPRODUCTS

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1


C State RebateClass

PTD PART DPRODUCTS



guanfacine hcl (1 mg tablet, 2 mg tablet) 1


C State RebateClass

PTD PART DPRODUCTS

methyldopa 1C State PDL Class

PTD PART DPRODUCTS

midodrine hcl 1 PTD PART DPRODUCTS

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 1C State Rebate

Class

PTD PART DPRODUCTS

prazosin hcl 1C State Rebate

Class

PTD PART DPRODUCTS

terazosin hcl 1C State Rebate

Class

PTD PART DPRODUCTS

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 1 PTD PART DPRODUCTS

irbesartan 1C State PDL Class

PTD PART DPRODUCTS

losartan potassium 1C State PDL Class

PTD PART DPRODUCTS



olmesartan medoxomil 1 PTD PART DPRODUCTS

valsartan 1C State PDL Class

PTD PART DPRODUCTS

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl 1C State PDL Class

PTD PART DPRODUCTS

captopril 1C State PDL Class

PTD PART DPRODUCTS

enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mgtablet, 20 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

EPANED 1C State PDL Class

PTD PART DPRODUCTS

fosinopril sodium 1C State PDL Class

PTD PART DPRODUCTS

lisinopril 1C State PDL Class

PTD PART DPRODUCTS

moexipril hcl 1C State PDL Class

PTD PART DPRODUCTS

perindopril erbumine 1C State PDL Class

PTD PART DPRODUCTS

quinapril hcl 1C State PDL Class

PTD PART DPRODUCTS



ramipril 1C State PDL Class

PTD PART DPRODUCTS

trandolapril 1C State PDL Class

PTD PART DPRODUCTS

ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

disopyramide phosphate 1C State PDL Class

PTD PART DPRODUCTS

dofetilide 1

C State PDL Class

PA

PTD PART DPRODUCTS

flecainide acetate 1C State PDL Class

PTD PART DPRODUCTS

mexiletine hcl 1C State PDL Class

PTD PART DPRODUCTS

MULTAQ 1

C State PDL Class

PA

PTD PART DPRODUCTS

NORPACE CR 1C State PDL Class

PTD PART DPRODUCTS

PACERONE (100 MG TABLET, 200 MG TABLET) 1C State PDL Class

PTD PART DPRODUCTS



propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225mg tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg caper 12h)

1C State PDL Class

PTD PART DPRODUCTS

quinidine gluconate 1C State PDL Class

PTD PART DPRODUCTS

quinidine sulfate 1C State PDL Class

PTD PART DPRODUCTS

SORINE 1C State PDL Class

PTD PART DPRODUCTS

SOTALOL AF 1C State PDL Class

PTD PART DPRODUCTS

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet,240 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

sotalol hcl 150mg/10ml vial 1 PTD PART DPRODUCTS

BETA-ADRENERGIC BLOCKING AGENTS

atenolol 1C State PDL Class

PTD PART DPRODUCTS

bisoprolol fumarate 1C State PDL Class

PTD PART DPRODUCTS

carvedilol 1C State PDL Class

PTD PART DPRODUCTS

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS



metoprolol succinate 1C State PDL Class

PTD PART DPRODUCTS

metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mgtablet, 75 mg tablet, 100 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

nadolol 1C State PDL Class

PTD PART DPRODUCTS

propranolol hcl (120 mg cap sa 24h, 160 mg cap sa 24h) 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

propranolol hcl (60 mg cap sa 24h, 80 mg cap sa 24h) 1

QL 30 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsolution, 40 mg tablet, 40mg/5ml solution, 60 mg tablet,80 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

propranolol hcl 1 mg/ml vial 1 PTD PART DPRODUCTS

CALCIUM CHANNEL BLOCKING AGENTS

amlodipine besylate 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

CARTIA XT (120 MG CAPSULE, 240 MG CAPSULE, 300 MGCAPSULE) 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS



CARTIA XT 180 MG CAPSULE 1C State PDL Class

PTD PART DPRODUCTS

DILT-XR 1C State PDL Class

PTD PART DPRODUCTS

diltiazem hcl (120 mg cap er 24h, 180 mg cap er 24h, 240mg cap er 24h, 300 mg cap er 24h, 360 mg cap er 24h) 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

diltiazem hcl (120 mg cap er deg, 180 mg cap er deg, 240mg cap er deg) 1 C State PDL Class

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mgtablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er12h, 120 mg cap sa 24h, 120 mg tablet, 180 mg cap sa24h, 240 mg cap sa 24h, 300 mg cap sa 24h, 360 mg capsa 24h, 420 mg cap sa 24h)

1C State PDL Class

PTD PART DPRODUCTS

felodipine 1C State PDL Class

PTD PART DPRODUCTS

nifedipine (10 mg capsule, 20 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tab er24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er) 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

TAZTIA XT 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

TIADYLT ER 1C State PDL Class

PTD PART DPRODUCTS



verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

verapamil hcl (120 mg cap24h pel, 120 mg tablet er, 180mg cap24h pel, 180 mg tablet er, 240 mg cap24h pel, 240mg tablet er)

1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

CARDIOVASCULAR AGENTS, OTHER

ALDACTAZIDE 50-50 TABLET 1C State PDL Class

PTD PART DPRODUCTS

atenolol/chlorthalidone 1C State PDL Class

PTD PART DPRODUCTS

benazepril/hydrochlorothiazide 5-6.25mg tablet 1 PTD PART DPRODUCTS

bisoprolol fumarate/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

captopril/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

DIGITEK 1C State PDL Class

PTD PART DPRODUCTS

DIGOX 1C State PDL Class

PTD PART DPRODUCTS

digoxin 250 mcg/ml ampul 1 PTD PART DPRODUCTS

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcgtablet) 1

C State PDL Class

PTD PART DPRODUCTS



enalapril maleate/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

ENTRESTO 1

C State PDL Class

PA

PTD PART DPRODUCTS

fosinopril sodium/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET) 1C State PDL Class

PTD PART DPRODUCTS

LANOXIN PEDIATRIC (100 MCG/ML AMPUL, 100 MCG/MLVIAL) 1 PTD PART D

PRODUCTS

lisinopril/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

losartan potassium/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

metoprolol tartrate/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

olmesartan medoxomil/hydrochlorothiazide 1 PTD PART DPRODUCTS

pentoxifylline 1 PTD PART DPRODUCTS

propranolol hcl/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS



quinapril hcl/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

ranolazine 1

C State PDL Class

PA

PTD PART DPRODUCTS

spironolactone/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

triamterene/hydrochlorothiazide(triamterene/hydrochlorothiazid 37.5-25 mg capsule,triamterene/hydrochlorothiazid 37.5-25 mg tablet,triamterene/hydrochlorothiazid 75 mg-50mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

valsartan/hydrochlorothiazide 1C State PDL Class

PTD PART DPRODUCTS

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tablet, 250 mg tablet, 500 mgcapsule er) 1

C State PDL Class

PTD PART DPRODUCTS

DIURETICS, LOOP

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40mg/5ml solution, 80 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

furosemide (10 mg/ml syringe, 10 mg/ml vial) 1 PTD PART DPRODUCTS

torsemide 1C State PDL Class

PTD PART DPRODUCTS



DIURETICS, POTASSIUM-SPARING

amiloride hcl 1 PTD PART DPRODUCTS

eplerenone 1

C State PDL Class

PA

PTD PART DPRODUCTS

spironolactone 1C State PDL Class

PTD PART DPRODUCTS

DIURETICS, THIAZIDE

chlorthalidone 1C State PDL Class

PTD PART DPRODUCTS

DIURIL 1C State PDL Class

PTD PART DPRODUCTS

hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25mg tablet, 50 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

indapamide 1C State PDL Class

PTD PART DPRODUCTS

metolazone 1C State PDL Class

PTD PART DPRODUCTS

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate (54 mg tablet, 160 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS



fenofibrate nanocrystallized 1C State PDL Class

PTD PART DPRODUCTS

fenofibrate,micronized (67 mg capsule, 134 mg capsule,200 mg capsule) 1

C State PDL Class

PTD PART DPRODUCTS

fenofibric acid 1C State PDL Class

PTD PART DPRODUCTS

FIBRICOR 1 PTD PART DPRODUCTS

gemfibrozil 1C State PDL Class

PTD PART DPRODUCTS

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 1

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

lovastatin 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

pravastatin sodium 1

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

rosuvastatin calcium 1

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS



simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40mg tablet, 80 mg tablet) 1

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1C State PDL Class

PTD PART DPRODUCTS

cholestyramine/aspartame (cholestyramine/aspartame 4g powd pack, cholestyramine/aspartame 4 g powder) 1

C State PDL Class

PTD PART DPRODUCTS

colestipol hcl 1 g tablet 1C State PDL Class

PTD PART DPRODUCTS

ezetimibe 1C State Rebate

Class

PTD PART DPRODUCTS

NIACOR 1 PTD PART DPRODUCTS

PREVALITE (PACKET, POWDER) 1C State PDL Class

PTD PART DPRODUCTS

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

minoxidil 1C State PDL Class

PTD PART DPRODUCTS



VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 1C State PDL Class

PTD PART DPRODUCTS

isosorbide dinitrate 1C State PDL Class

PTD PART DPRODUCTS

isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1

C State PDL Class

PTD PART DPRODUCTS

MINITRAN 1C State PDL Class

PTD PART DPRODUCTS

NITRO-BID 1C State PDL Class

PTD PART DPRODUCTS

NITRO-DUR (0.3 MG/HR PATCH, 0.8 MG/HR PATCH) 1C State PDL Class

PTD PART DPRODUCTS

NITRO-TIME 1

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,0.3 mg tab subl, 0.4 mg tab subl, 0.4mg/hr patch td24,0.6 mg tab subl, 0.6mg/hr patch td24, 2.5 mg capsule er,6.5 mg capsule er, 9 mg capsule er)

1C State PDL Class

PTD PART DPRODUCTS

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

ADDERALL 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS



ADDERALL XR 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mgtablet, dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)

1


C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

dextroamphetamine sulfate (15 mg tablet, 20 mg tablet,30 mg tablet) 1


QPD 2.0 per day

dextroamphetamine sulfate (5 mg tablet, 10 mg tablet) 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)

1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS



clonidine hcl 0.1 mg tab er 12h 1


C State RebateClass

QPD 4 per day

PTD PART DPRODUCTS

CONCERTA 1


C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

DAYTRANA 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10mg tablet) 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS

FOCALIN XR 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS



guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mgtab er 24h, 4 mg tab er 24h) 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

METHYLIN 1


C State RebateClass

QPD 10 per day

PTD PART DPRODUCTS

methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 30 mg cpbp 30-70, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 60 mg cpbp 30-70)

1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet) 1


C State RebateClass

QPD 3 per day

PTD PART DPRODUCTS

RITALIN LA (20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE) 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS



RITALIN LA 10 MG CAPSULE 1


C State RebateClass

QPD 1 per day

PTD PART DPRODUCTS

CENTRAL NERVOUS SYSTEM, OTHER

butalbital/acetaminophen/caffeine(butalb/acetaminophen/caffeine 50-300-40 capsule,butalb/acetaminophen/caffeine 50-325-40 capsule)


butalb/acetaminophen/caffeine 50-325-40 tablet 1C State PDL Class

PTD PART DPRODUCTS

ESGIC CAPSULE 1 PTD PART DPRODUCTS

HORIZANT 1

C State PDL Class

PA

PTD PART DPRODUCTS

OFIRMEV 1

ZEBUTAL 1 PTD PART DPRODUCTS

FIBROMYALGIA AGENTS

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) 1


C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

duloxetine hcl 60 mg capsule dr 1


C State PDL Class

QPD 2.0 per day

PTD PART DPRODUCTS



pregabalin (20 mg/ml solution, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule,200 mg capsule, 225 mg capsule, 300 mg capsule)

1

C State PDL Class

PA

PTD PART DPRODUCTS

MULTIPLE SCLEROSIS AGENTS

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 1

C State RebateClass

PA

PTD PART DPRODUCTS

AVONEX PEN 30 MCG/0.5 ML KIT 1

C State RebateClass

PA

PTD PART DPRODUCTS

BETASERON 0.3 MG KIT 1

C State RebateClass

PA

PTD PART DPRODUCTS

COPAXONE 20 MG/ML SYRINGE 1

C State RebateClass

PA

PTD PART DPRODUCTS

EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 1PA

PTD PART DPRODUCTS

GILENYA 0.5 MG CAPSULE 1

C State RebateClass

PA

PTD PART DPRODUCTS



glatiramer acetate 40 mg/ml syringe 1PA

PTD PART DPRODUCTS

GLATOPA 40 MG/ML SYRINGE 1

C State RebateClass

PA

PTD PART DPRODUCTS

REBIF 1PA

PTD PART DPRODUCTS

REBIF REBIDOSE 1

C State RebateClass

PA

PTD PART DPRODUCTS

DENTAL AND ORAL AGENTS

BOCASAL 1

CAPHOSOL 1 PTD PART DPRODUCTS

chlorhexidine gluconate 1 PTD PART DPRODUCTS

NEUTRASAL 1 PTD PART DPRODUCTS

NUMOISYN LIQUID 1

ORALONE 1C State PDL Class

PTD PART DPRODUCTS

PAROEX 1 PTD PART DPRODUCTS

PERIOGARD 1 PTD PART DPRODUCTS



pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 PTD PART DPRODUCTS

PREVIDENT (0.2%, DENTAL) 1C State PDL Class

PTD PART DPRODUCTS

SALIVAMAX 1

triamcinolone acetonide 0.1 % paste (g) 1C State PDL Class

PTD PART DPRODUCTS

DERMATOLOGICAL AGENTS

acitretin 1 PTD PART DPRODUCTS

adapalene 0.1 % lotion 1

ammonium lactate (12 % cream (g), 12 % lotion) 1 PTD PART DPRODUCTS

AMNESTEEM 1PA

PTD PART DPRODUCTS

ANUSOL-HC 2.5% CREAM 1C State PDL Class

PTD PART DPRODUCTS

AVITA (CREAM, GEL) 1

AL Up to 26 yrs old

CState RebateClass - AHCCCStemp ok

PTD PART DPRODUCTS

BENZEPRO 7% CREAMY WASH 1

BENZEPRO 6% FOAMING CLOTHS 1 C State PDL Class

benzoyl peroxide 7 % cleanser 1C State PDL Class

PTD PART DPRODUCTS



benzoyl peroxide 9.8 % foam 1

benzoyl peroxide microspheres 1

BPO 1 C State PDL Class

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005% solution) 1 PTD PART D

PRODUCTS

CARAC 1 PTD PART DPRODUCTS

CLARAVIS 1PA

PTD PART DPRODUCTS

clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1C State PDL Class

PTD PART DPRODUCTS

clotrimazole/betamethasone dip 1 %-0.05 % cream (g) 1C State PDL Class

PTD PART DPRODUCTS

CORTISPORIN OINTMENT 1C State PDL Class

PTD PART DPRODUCTS

DRITHOCREME HP 1 PTD PART DPRODUCTS

DRYSOL 1C State PDL Class

PTD PART DPRODUCTS

ELIDEL 1PA

PTD PART DPRODUCTS

EPIFOAM 1 PTD PART DPRODUCTS

fluocinonide 0.05 % cream (g) 1C State PDL Class

PTD PART DPRODUCTS



FLUOROPLEX 1 PTD PART DPRODUCTS

fluorouracil 0.5 % cream (g) 1 PTD PART DPRODUCTS

imiquimod 5 % cream pack 1


C Supplemental

QPD 0.434 per day

PTD PART DPRODUCTS

isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule) 1

PA

PTD PART DPRODUCTS

KERALYT SCALP COMPLETE KIT 1

methoxsalen 10 mg cap lq rap 1 PTD PART DPRODUCTS

metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75% lotion) 1

C State PDL Class

PTD PART DPRODUCTS

MYORISAN 1PA

PTD PART DPRODUCTS

NATROBA 1

C State PDL Class

PA

PTD PART DPRODUCTS

NORITATE 1 PTD PART DPRODUCTS

PACNEX 1 C State PDL Class

PHARMABASE BARRIER 1 PTD PART DPRODUCTS



PRAMOSONE (1% LOTION, 1%-1% CREAM, 2.5%-1%LOTION) 1 PTD PART D

PRODUCTS

REGRANEX 1 PTD PART DPRODUCTS

RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%CREAM, 0.1% CREAM) 1

AL Up to 26 yrs old

C State PDL Class

PTD PART DPRODUCTS

ROSADAN (CREAM, GEL) 1C State PDL Class

PTD PART DPRODUCTS

salicylic acid (6 % cream (g), 6 % foam, 28.5 % sol-filmer) 1 C State PDL Class

salicylic acid (6 % crm er (g), 6 % gel (gram), 6 % lotion, 6% lotion er, 6 % shampoo, 26 % liquid, 27.5 % liq-film) 1

C State PDL Class

PTD PART DPRODUCTS

SALIMEZ 1

SALIMEZ FORTE 1 PTD PART DPRODUCTS

selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1C State PDL Class

PTD PART DPRODUCTS

selenium sulfide 2.3 % shampoo 1 C State PDL Class

SORILUX 1 PTD PART DPRODUCTS

spinosad 1

C State PDL Class

PA

PTD PART DPRODUCTS

tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 PTD PART DPRODUCTS



TOLAK 1 PTD PART DPRODUCTS

tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 %gel (gram), 0.05 % cream (g), 0.1 % cream (g)) 1

AL Up to 26 yrs old

CState RebateClass - AHCCCStemp ok

PTD PART DPRODUCTS

ZENATANE 1PA

PTD PART DPRODUCTS

zinc oxide 20 % oint. (g) 1

zinc oxide 25 % paste (g) 1 PTD PART DPRODUCTS

ENZYME REPLACEMENT/MODIFIERS

CERDELGA 1

C State PDL Class

PA

PTD PART DPRODUCTS

CEREZYME 1

C State PDL Class

PA

PTD PART DPRODUCTS

CREON 1

C State RebateClass

QPD 16 per day

PTD PART DPRODUCTS

ELAPRASE 1

C State PDL Class

PA

PTD PART DPRODUCTS



ELELYSO 1

C State PDL Class

PA

PTD PART DPRODUCTS

miglustat 1

C State RebateClass

PA

PTD PART DPRODUCTS

SUCRAID 1PA

PTD PART DPRODUCTS

VPRIV 1

C State PDL Class

PA

PTD PART DPRODUCTS

ZENPEP (DR 10,000 UNIT CAPSULE, DR 15,000 UNITCAPSULE, DR 20,000 UNIT CAPSULE, DR 25,000 UNITCAPSULE, DR 40,000 UNIT CAPSULE)

1

QL 500 / 30 days

C State RebateClass

QPD 16 per day

PTD PART DPRODUCTS

ZENPEP (DR 3,000 UNIT CAPSULE, DR 5,000 UNITCAPSULE) 1

C State RebateClass

QPD 16 per day

PTD PART DPRODUCTS

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

CUVPOSA 1C State PDL Class

PTD PART DPRODUCTS



dicyclomine hcl (10 mg/ml ampul, 10 mg/ml vial) 1 PTD PART DPRODUCTS

dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

ED-SPAZ 1 C State PDL Class

glycopyrrolate (1 mg tablet, 2 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

glycopyrrolate 0.2 mg/ml vial 1 PTD PART DPRODUCTS

hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tabsubl, 0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er12h, 125mcg/5ml elixir)

1C State PDL Class

PTD PART DPRODUCTS

HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1 C State PDL Class

NULEV 1 C State PDL Class

OSCIMIN 1 C State PDL Class

OSCIMIN SL 1 C State PDL Class

OSCIMIN SR 1 C State PDL Class

propantheline bromide 1C State PDL Class

PTD PART DPRODUCTS

SYMAX DUOTAB 1

SYMAX-SR 1

GASTROINTESTINAL AGENTS, OTHER

cromolyn sodium 20 mg/ml oral conc 1 PTD PART DPRODUCTS

diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine 2.5-.025mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS



loperamide hcl 1C State PDL Class

PTD PART DPRODUCTS

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

famotidine (40 mg tablet, 40mg/5ml susp recon) 1C State PDL Class

PTD PART DPRODUCTS

nizatidine (150 mg capsule, 150mg/10ml solution, 300 mgcapsule) 1 PTD PART D

PRODUCTS

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 300 mgcapsule, 300 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

ranitidine hcl 150 mg tablet 1 C State PDL Class

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 1 PTD PART DPRODUCTS

AMITIZA 1

C State PDL Class

PA

PTD PART DPRODUCTS

LINZESS 1

C State PDL Class

PA

PTD PART DPRODUCTS

lubiprostone 1PA

PTD PART DPRODUCTS



LAXATIVES

CONSTULOSE 1C State PDL Class

PTD PART DPRODUCTS

ENULOSE 1C State PDL Class

PTD PART DPRODUCTS

GAVILYTE-C 1 PTD PART DPRODUCTS

GAVILYTE-G 1C State PDL Class

PTD PART DPRODUCTS

GAVILYTE-N 1 PTD PART DPRODUCTS

GENERLAC 1C State PDL Class

PTD PART DPRODUCTS

KRISTALOSE 1 PTD PART DPRODUCTS

lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1C State PDL Class

PTD PART DPRODUCTS

peg 3350/sod sulf/sod bicarb/sod chloride/potassiumchloride 1

C State PDL Class

PTD PART DPRODUCTS

sodium chloride/sodium bicarbonate/potassiumchloride/peg 1 PTD PART D

PRODUCTS

TRILYTE WITH FLAVOR PACKETS 1 PTD PART DPRODUCTS



PROTECTANTS

misoprostol 1 PTD PART DPRODUCTS

sucralfate 1 g tablet 1C State PDL Class

PTD PART DPRODUCTS

PROTON PUMP INHIBITORS

esomeprazole magnesium (20 mg capsule dr, 40 mgcapsule dr) 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

esomeprazole magnesium (10 mg suspdr pkt, 20 mgsuspdr pkt, 40 mg suspdr pkt) 1

AL Up to 18 yrs old

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

lansoprazole (15 mg capsule dr, 30 mg capsule dr) 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1

AL Up to 18 yrs old

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

omeprazole 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS



pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1C State PDL Class

PTD PART DPRODUCTS

PROTONIX 40 MG SUSPENSION 1

AL Up to 18 yrs old

QPD 1.0 per day

PTD PART DPRODUCTS

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

DETROL 1C State Rebate

Class

PTD PART DPRODUCTS

DETROL LA 1C State Rebate

Class

PTD PART DPRODUCTS

oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5ml syrup, 10 mg tab er 24, 15 mg tab er 24) 1

C State RebateClass

PTD PART DPRODUCTS

TOVIAZ 1C State Rebate

Class

PTD PART DPRODUCTS

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl 1C State PDL Class

PTD PART DPRODUCTS

dutasteride 1C State PDL Class

PTD PART DPRODUCTS



finasteride 5 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

tamsulosin hcl 1C State PDL Class

PTD PART DPRODUCTS

GENITOURINARY AGENTS, OTHER

bethanechol chloride 1 PTD PART DPRODUCTS

citric acid/sodium citrate 1C Supplemental

PTD PART DPRODUCTS

ELMIRON 1

C State PDL Class

PA

PTD PART DPRODUCTS

K-PHOS NO.2 1 PTD PART DPRODUCTS

ORACIT 1 PTD PART DPRODUCTS

penicillamine 250 mg capsule 1C State PDL Class

PTD PART DPRODUCTS

phenazopyridine hcl 1C State PDL Class

PTD PART DPRODUCTS

potassium citrate 1 PTD PART DPRODUCTS

potassium citrate/citric acid 1 PTD PART DPRODUCTS

sodium/potassium/potassium citrate/sodium citrate/citac 1 PTD PART D

PRODUCTS



TRICITRATES 1 PTD PART DPRODUCTS

VIRTRATE-2 1 PTD PART DPRODUCTS

VIRTRATE-3 1 PTD PART DPRODUCTS

VIRTRATE-K 1 PTD PART DPRODUCTS

PHOSPHATE BINDERS

calcium acetate 1C State Rebate

Class

PTD PART DPRODUCTS

sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack,800 mg tablet) 1

C State RebateClass

PTD PART DPRODUCTS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

A-HYDROCORT 1C State PDL Class

PTD PART DPRODUCTS

ADV ALLERGY COLLECTION KIT 1

ALA-CORT 1C State PDL Class

PTD PART DPRODUCTS

ALA-SCALP 1C State PDL Class

PTD PART DPRODUCTS

ARISTOSPAN 1C State PDL Class

PTD PART DPRODUCTS



betamethasone dipropionate 0.05 % lotion 1C State PDL Class

PTD PART DPRODUCTS

betamethasone/propylene glyc 0.05 % cream (g) 1C State PDL Class

PTD PART DPRODUCTS

betamethasone valerate (0.1 % cream (g), 0.1 % lotion) 1C State PDL Class

PTD PART DPRODUCTS

betamethasone valerate 0.1 % oint. (g) 1 PTD PART DPRODUCTS

clobetasol propionate 0.05 % cream (g) 1

QL 100 / 30 days

C State PDL Class

PTD PART DPRODUCTS

clobetasol propionate 0.05 % gel (gram) 1

QL 118 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

clobetasol propionate (0.05 % oint. (g), 0.05 % solution) 1

QL 100 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

clobetasol propionate/emoll 0.05 % cream (g) 1

QL 100 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

CORMAX 1C State PDL Class

PTD PART DPRODUCTS

cortisone acetate 1 PTD PART DPRODUCTS



DECADRON 1 PTD PART DPRODUCTS

DEPO-MEDROL 20 MG/ML VIAL 1C State PDL Class

PTD PART DPRODUCTS

DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 1C State PDL Class

PTD PART DPRODUCTS

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mgtablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

DEXAMETHASONE INTENSOL 1C State PDL Class

PTD PART DPRODUCTS

DEXPAK 1 PTD PART DPRODUCTS

fludrocortisone acetate 1C State PDL Class

PTD PART DPRODUCTS

fluocinonide (0.05 % oint. (g), 0.05 % solution, 0.1 %cream (g)) 1

C State PDL Class

PTD PART DPRODUCTS

fluticasone propionate (0.005 % oint. (g), 0.05 % cream(g)) 1

C State PDL Class

PTD PART DPRODUCTS

halcinonide 1 PTD PART DPRODUCTS

halobetasol propionate 0.05 % cream (g) 1

QL 100 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

halobetasol propionate 0.05 % oint. (g) 1

QL 100 / 30 days

C State PDL Class

PTD PART DPRODUCTS



hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint.(g), 2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 %oint. (g))

1C State PDL Class

PTD PART DPRODUCTS

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 PTD PART DPRODUCTS

KENALOG-10 1C State PDL Class

PTD PART DPRODUCTS

KORLYM 1PA

PTD PART DPRODUCTS

MEDROL 2 MG TABLET 1 PTD PART DPRODUCTS

methylprednisolone (4 mg tab ds pk, 4 mg tablet, 8 mgtablet, 16 mg tablet, 32 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

methylprednisolone acetate (40 mg/ml vial, 80 mg/mlvial) 1

C State PDL Class

PTD PART DPRODUCTS

methylprednisolone sodium succinate 1C State PDL Class

PTD PART DPRODUCTS

MILLIPRED 1C State PDL Class

PTD PART DPRODUCTS

MILLIPRED DP 1C State PDL Class

PTD PART DPRODUCTS

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1% solution) 1

C State PDL Class

PTD PART DPRODUCTS

NOLIX 0.05% LOTION 1 PTD PART DPRODUCTS



prednisolone 1C State PDL Class

PTD PART DPRODUCTS

prednisolone sodium phosphate (5 mg/5 ml solution, 10mg tab rapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5 mlsolution, 30 mg tab rapdis)

1C State PDL Class

PTD PART DPRODUCTS

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5mg tablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mgtablet, 20 mg tablet, 50 mg tablet)

1C State PDL Class

PTD PART DPRODUCTS

PREDNISONE INTENSOL 1C State PDL Class

PTD PART DPRODUCTS

PROCTO-MED HC 1 PTD PART DPRODUCTS

PROCTO-PAK 1 PTD PART DPRODUCTS

PROCTOCORT 1% CREAM 1

PROCTOSOL-HC 1 PTD PART DPRODUCTS

PROCTOZONE-HC 1 PTD PART DPRODUCTS

RAYOS 1 PTD PART DPRODUCTS

SCALACORT 1C State PDL Class

PTD PART DPRODUCTS

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O-VL)

1C State PDL Class

PTD PART DPRODUCTS

SOLU-MEDROL 2,000 MG VIAL 1C State PDL Class

PTD PART DPRODUCTS



TAPERDEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 1 PTD PART DPRODUCTS

TOVET EMOLLIENT 1 PTD PART DPRODUCTS

triamcinolone acetonide (0.025 % cream (g), 0.025 %lotion, 0.025 % oint. (g), 0.05 % oint. (g), 0.1 % cream (g),0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint.(g), 10 mg/ml vial, 40 mg/ml vial)

1C State PDL Class

PTD PART DPRODUCTS

TRIANEX 1C State PDL Class

PTD PART DPRODUCTS

TRIDERM 1C State PDL Class

PTD PART DPRODUCTS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

DDAVP 10 MCG/0.1 ML SOLUTION 1C State PDL Class

PTD PART DPRODUCTS

desmopressin acetate (0.1 mg tablet, 0.2 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial,10/spray spray/pump) 1

C State PDL Class

PTD PART DPRODUCTS

desmopressin acetate (non-refrigerated) 1C State PDL Class

PTD PART DPRODUCTS



GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG,MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MG CARTRIDGE)

1

C State RebateClass

PA

PTD PART DPRODUCTS

INCRELEX 1

C State PDL Class

PA

PTD PART DPRODUCTS

NORDITROPIN FLEXPRO 1

C State RebateClass

PA

PTD PART DPRODUCTS

STIMATE 1

C State PDL Class

PA

PTD PART DPRODUCTS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEXHORMONES/MODIFIERS)

ANDROGENS

ANDRODERM 1

C State PDL Class

PA

PTD PART DPRODUCTS

ANDROGEL (1% (25 MG/2.5 G) PKT, 1% (50 MG/5 G) PKT,1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G)GEL PCKT)

1

C State PDL Class

PA

PTD PART DPRODUCTS

danazol 1C State PDL Class

PTD PART DPRODUCTS



NATESTO 1 PTD PART DPRODUCTS

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1

C State PDL Class

PA

PTD PART DPRODUCTS

testosterone enanthate 200 mg/ml vial 1

C State PDL Class

PA

PTD PART DPRODUCTS

ESTROGENS

AFIRMELLE 1 PTD PART DPRODUCTS

ALORA 1C State PDL Class

PTD PART DPRODUCTS

ALTAVERA 1 PTD PART DPRODUCTS

ALYACEN 1 PTD PART DPRODUCTS

AMABELZ 1 PTD PART DPRODUCTS

AMETHIA 1 PTD PART DPRODUCTS

AMETHIA LO 1 PTD PART DPRODUCTS

AMETHYST 1 PTD PART DPRODUCTS

APRI 1 PTD PART DPRODUCTS

ARANELLE 1 PTD PART DPRODUCTS



AUBRA 1 PTD PART DPRODUCTS

AUBRA EQ 1 PTD PART DPRODUCTS

AUROVELA 1C State PDL Class

PTD PART DPRODUCTS

AUROVELA 24 FE 1 PTD PART DPRODUCTS

AUROVELA FE 1 PTD PART DPRODUCTS

AVIANE 1 PTD PART DPRODUCTS

AYUNA 1 PTD PART DPRODUCTS

AZURETTE 1C State PDL Class

PTD PART DPRODUCTS

BALZIVA 1 PTD PART DPRODUCTS

BEKYREE 1 PTD PART DPRODUCTS

BLISOVI 24 FE 1 PTD PART DPRODUCTS

BLISOVI FE 1 PTD PART DPRODUCTS

BRIELLYN 1 PTD PART DPRODUCTS

CAMRESE 1 PTD PART DPRODUCTS

CAMRESE LO 1 PTD PART DPRODUCTS



CHATEAL 1 PTD PART DPRODUCTS

CHATEAL EQ 1 PTD PART DPRODUCTS

CLIMARA PRO 1 PTD PART DPRODUCTS

COMBIPATCH 1 PTD PART DPRODUCTS

CRYSELLE 1 PTD PART DPRODUCTS

CYCLAFEM 7-7-7-28 TABLET 1 PTD PART DPRODUCTS

CYRED 1 PTD PART DPRODUCTS

DASETTA 1 PTD PART DPRODUCTS

desogestrel-ethinyl estradiol 1C State PDL Class

PTD PART DPRODUCTS

desogestrel-ethinyl estradiol/ethinyl estradiol 1 PTD PART DPRODUCTS

ELINEST 1 PTD PART DPRODUCTS

ENPRESSE 1 PTD PART DPRODUCTS

ENSKYCE 1 PTD PART DPRODUCTS

ESTARYLLA 1 PTD PART DPRODUCTS



estradiol (0.01 % cream/appl, .025mg/24h patch tdsw,.025mg/24h patch tdwk, .0375mg/24 patch tdsw,.0375mg/24 patch tdwk, 0.05mg/24h patch tdsw,0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk, 0.5 mgtablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet)

1C State PDL Class

PTD PART DPRODUCTS

estradiol/norethindrone acetate 1 PTD PART DPRODUCTS

ESTRING 1C State PDL Class

PTD PART DPRODUCTS

ethinyl estradiol/drospirenone 0.02-3(28) tablet 1 PTD PART DPRODUCTS

ethinyl estradiol/drospirenone 0.03mg-3mg tablet 1C State PDL Class

PTD PART DPRODUCTS

ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 1 PTD PART DPRODUCTS

ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 1C State PDL Class

PTD PART DPRODUCTS

FALMINA 1 PTD PART DPRODUCTS

FEMRING 1

C State PDL Class

PA

PTD PART DPRODUCTS

FEMYNOR 1 PTD PART DPRODUCTS

FYAVOLV 1C State PDL Class

PTD PART DPRODUCTS



GIANVI 1 PTD PART DPRODUCTS

HAILEY 1 PTD PART DPRODUCTS

HAILEY 24 FE 1 PTD PART DPRODUCTS

HAILEY FE 1 PTD PART DPRODUCTS

INTROVALE 1 PTD PART DPRODUCTS

ISIBLOOM 1 PTD PART DPRODUCTS

JAIMIESS 1 PTD PART DPRODUCTS

JASMIEL 1 PTD PART DPRODUCTS

JINTELI 1 PTD PART DPRODUCTS

JULEBER 1 PTD PART DPRODUCTS

JUNEL 1 PTD PART DPRODUCTS

JUNEL FE 1 PTD PART DPRODUCTS

JUNEL FE 24 1 PTD PART DPRODUCTS

KAITLIB FE 1C State PDL Class

PTD PART DPRODUCTS

KARIVA 1 PTD PART DPRODUCTS

KELNOR 1-35 1 PTD PART DPRODUCTS



KELNOR 1-50 1 PTD PART DPRODUCTS

KURVELO 1 PTD PART DPRODUCTS

LARIN 1 PTD PART DPRODUCTS

LARIN 24 FE 1 PTD PART DPRODUCTS

LARIN FE 1 PTD PART DPRODUCTS

LARISSIA 1 PTD PART DPRODUCTS

LESSINA 1 PTD PART DPRODUCTS

LEVONEST 1 PTD PART DPRODUCTS

levonorgestrel/ethinyl estradiol(levonorgestrel/ethin.estradiol 0.1-0.02mg tablet,levonorgestrel/ethin.estradiol 0.15-0.03 tablet,levonorgestrel/ethin.estradiol 0.15-0.03 tbdspk 3mo,levonorgestrel/ethin.estradiol 6-5-10 tablet,levonorgestrel/ethin.estradiol 90-20 mcg tablet)


LEVORA-28 1 PTD PART DPRODUCTS

LILLOW 1 PTD PART DPRODUCTS

LO-ZUMANDIMINE 1 PTD PART DPRODUCTS

LOPREEZA 1 PTD PART DPRODUCTS

LORYNA 1 PTD PART DPRODUCTS

LOW-OGESTREL 1 PTD PART DPRODUCTS



LUTERA 1 PTD PART DPRODUCTS

MARLISSA 1 PTD PART DPRODUCTS

MELODETTA 24 FE 1 PTD PART DPRODUCTS

MENEST 1C State PDL Class

PTD PART DPRODUCTS

MENOSTAR 1C State PDL Class

PTD PART DPRODUCTS

MICROGESTIN 1 PTD PART DPRODUCTS

MICROGESTIN FE 1 PTD PART DPRODUCTS

MILI 1 PTD PART DPRODUCTS

MIMVEY 1 PTD PART DPRODUCTS

NECON 1 PTD PART DPRODUCTS

NIKKI 1C State PDL Class

PTD PART DPRODUCTS

norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet,1mg-20mcg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

norethindrone acetate-ethinyl estradiol (1mg-5mcgtablet, 1.5-0.03mg tablet) 1 PTD PART D

PRODUCTS

norethindrone-e.estradiol-iron 1mg-20(24) capsule 1C State PDL Class

PTD PART DPRODUCTS



norethindrone acetate-ethinyl estradiol/ferrous fumarate(1mg-20(21) tablet, 1mg-20(24) tab chew, 1.5-30(21)tablet)


norethindrone-ethinyl estradiol/ferrous fumarate 1 PTD PART DPRODUCTS

norgestimate-ethinyl estradiol (0.25-0.035 tablet, 7daysx328 tablet, 7daysx3 lo tablet) 1 PTD PART D

PRODUCTS

NORTREL 1 PTD PART DPRODUCTS

NUVARING 1C State PDL Class

PTD PART DPRODUCTS

ORSYTHIA 1 PTD PART DPRODUCTS

PHILITH 1 PTD PART DPRODUCTS

PIMTREA 1 PTD PART DPRODUCTS

PIRMELLA 1-35 28 TABLET 1 PTD PART DPRODUCTS

PIRMELLA 7-7-7-28 TABLET 1C State PDL Class

PTD PART DPRODUCTS

PORTIA 1 PTD PART DPRODUCTS

PREMARIN VAGINAL CREAM-APPL 1

C State PDL Class

PA

PTD PART DPRODUCTS

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET) 1

C State PDL Class

PTD PART DPRODUCTS



PREMPHASE 1 PTD PART DPRODUCTS

PREMPRO 1C State PDL Class

PTD PART DPRODUCTS

RECLIPSEN 1 PTD PART DPRODUCTS

SETLAKIN 1 PTD PART DPRODUCTS

SIMLIYA 1 PTD PART DPRODUCTS

SIMPESSE 1 PTD PART DPRODUCTS

SPRINTEC 1 PTD PART DPRODUCTS

SRONYX 1 PTD PART DPRODUCTS

SYEDA 1 PTD PART DPRODUCTS

TARINA 24 FE 1 PTD PART DPRODUCTS

TARINA FE 1 PTD PART DPRODUCTS

TARINA FE 1-20 EQ 1 PTD PART DPRODUCTS

TRI FEMYNOR 1 PTD PART DPRODUCTS

TRI-ESTARYLLA 1 PTD PART DPRODUCTS

TRI-LEGEST FE 1 PTD PART DPRODUCTS

TRI-LO-ESTARYLLA 1 PTD PART DPRODUCTS



TRI-LO-MARZIA 1 PTD PART DPRODUCTS

TRI-LO-MILI 1 PTD PART DPRODUCTS

TRI-LO-SPRINTEC 1 PTD PART DPRODUCTS

TRI-MILI 1 PTD PART DPRODUCTS

TRI-PREVIFEM 1 PTD PART DPRODUCTS

TRI-SPRINTEC 1 PTD PART DPRODUCTS

TRI-VYLIBRA 1 PTD PART DPRODUCTS

TRI-VYLIBRA LO 1 PTD PART DPRODUCTS

TRIVORA-28 1 PTD PART DPRODUCTS

VELIVET 1 PTD PART DPRODUCTS

VIENVA 1 PTD PART DPRODUCTS

VIORELE 1 PTD PART DPRODUCTS

VOLNEA 1 PTD PART DPRODUCTS

VYFEMLA 1C State PDL Class

PTD PART DPRODUCTS

VYLIBRA 1 PTD PART DPRODUCTS

WERA 1 PTD PART DPRODUCTS



XULANE 1C State PDL Class

PTD PART DPRODUCTS

YUVAFEM 1C State PDL Class

PTD PART DPRODUCTS

ZARAH 1 PTD PART DPRODUCTS

ZOVIA 1-35 1 PTD PART DPRODUCTS

ZOVIA 1-35E 1 PTD PART DPRODUCTS

ZUMANDIMINE 1 PTD PART DPRODUCTS

PROGESTINS

CAMILA 1C State PDL Class

PTD PART DPRODUCTS

DEBLITANE 1 PTD PART DPRODUCTS

ERRIN 1 PTD PART DPRODUCTS

HEATHER 1 PTD PART DPRODUCTS

JENCYCLA 1 PTD PART DPRODUCTS

KYLEENA 1C Supplemental

PTD PART DPRODUCTS

LILETTA 1C Supplemental

PTD PART DPRODUCTS



MAKENA 1,250 MG/5 ML VIAL 1

C State RebateClass

PA

PTD PART DPRODUCTS

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet,10 mg tablet, 150 mg/ml syringe, 150 mg/ml vial) 1

C State PDL Class

PTD PART DPRODUCTS

megestrol acetate (20 mg tablet, 40 mg tablet,400mg/10ml oral susp) 1 PTD PART D

PRODUCTS

MIRENA 1C Supplemental

PTD PART DPRODUCTS

NEXPLANON 1C Supplemental

PTD PART DPRODUCTS

norethindrone 1C State PDL Class

PTD PART DPRODUCTS

norethindrone acetate 1C State PDL Class

PTD PART DPRODUCTS

NORLYDA 1 PTD PART DPRODUCTS

progesterone, micronized 1C State PDL Class

PTD PART DPRODUCTS

SHAROBEL 1 PTD PART DPRODUCTS

SKYLA 1C Supplemental

PTD PART DPRODUCTS



SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

raloxifene hcl 1C State PDL Class

PTD PART DPRODUCTS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID (180 MG TABLET, 240 MG TABLET,300 MG TABLET) 1

C State PDL Class

PTD PART DPRODUCTS

LEVO-T 1

QL 30 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

levothyroxine sodium 50 mcg capsule 1C State PDL Class

PTD PART DPRODUCTS

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcgtablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

1

QL 30 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

LEVOXYL 1QL 30 / 30 DAYS

PTD PART DPRODUCTS

liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcgtablet) 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

NATURE-THROID (16.25 MG TABLET, 48.75 MG TABLET,81.25 MG TABLET, 97.5 MG TABLET, 113.75 MG TABLET,146.25 MG TABLET, 162.5 MG TABLET, 195 MG TABLET,260 MG TABLET, 325 MG TABLET)

1

NATURE-THROID (32.5 MG TABLET, 65 MG TABLET, 130MG TABLET) 1 PTD PART D

PRODUCTS



NP THYROID 1C State PDL Class

PTD PART DPRODUCTS

THYROID 1C State PDL Class

PTD PART DPRODUCTS

thyroid,pork 1C State PDL Class

PTD PART DPRODUCTS

TIROSINT (13 MCG CAPSULE, 25 MCG CAPSULE, 50 MCGCAPSULE, 75 MCG CAPSULE, 88 MCG CAPSULE, 100 MCGCAPSULE, 112 MCG CAPSULE, 125 MCG CAPSULE, 137MCG CAPSULE, 150 MCG CAPSULE)


UNITHROID 1

QL 30 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

WESTHROID (32.5 MG TABLET, 65 MG TABLET, 130 MGTABLET) 1 PTD PART D

PRODUCTS

WESTHROID (97.5 MG TABLET, 195 MG TABLET) 1

WP THYROID (16.25 MG TABLET, 48.75 MG TABLET, 81.25MG TABLET, 97.5 MG TABLET, 113.75 MG TABLET) 1

WP THYROID (32.5 MG TABLET, 65 MG TABLET, 130 MGTABLET) 1 PTD PART D

PRODUCTS

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

cinacalcet hcl 1

C State PDL Class

PA

PTD PART DPRODUCTS



HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 1 PTD PART DPRODUCTS

ELIGARD 1PA

PTD PART DPRODUCTS

FIRMAGON (2 X 120 MG KIT, 80 MG KIT) 1PA

PTD PART DPRODUCTS

leuprolide acetate 1 mg/0.2ml kit 1

C State PDL Class

PA

PTD PART DPRODUCTS

LUPRON DEPOT (7.5 MG KIT, 11.25 MG 3MO KIT, 22.5 MG3MO KIT) 1

C State PDL Class

PA

PTD PART DPRODUCTS

LUPRON DEPOT (DEPOT 3.75 MG KIT, DEPOT-4 MONTHKIT, DEPOT 45 MG 6MO KIT) 1

PA

PTD PART DPRODUCTS

LUPRON DEPO 11.25MG (LUPANETA) 1

C State PDL Class

PA

PTD PART DPRODUCTS

LUPRON DEPOT 3.75MG (LUPANETA) 1PA

PTD PART DPRODUCTS

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25MG KIT, 15 MG KIT, 30 MG 3MO KIT) 1

C State PDL Class

PA

PTD PART DPRODUCTS



octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe,50 mcg/ml vial, 100 mcg/ml ampul, 100 mcg/ml syringe,100 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul,500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)

1PA

PTD PART DPRODUCTS

SANDOSTATIN LAR DEPOT 1PA

PTD PART DPRODUCTS

SOMATULINE DEPOT 1PA

PTD PART DPRODUCTS

SYNAREL 1PA

PTD PART DPRODUCTS

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 1C State PDL Class

PTD PART DPRODUCTS

propylthiouracil 1C State PDL Class

PTD PART DPRODUCTS

IMMUNOLOGICAL AGENTS

IMMUNE SUPPRESSANTS

ASTAGRAF XL 1

C State PDL Class

PA

PTD PART DPRODUCTS

AZASAN 1 PTD PART DPRODUCTS

azathioprine 50 mg tablet 1C State PDL Class

PTD PART DPRODUCTS



cyclosporine 250 mg/5ml ampul 1 PTD PART DPRODUCTS

cyclosporine (25 mg capsule, 100 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS

cyclosporine, modified (25 mg capsule, 50 mg capsule,100 mg capsule, 100 mg/ml solution) 1

C State PDL Class

PTD PART DPRODUCTS

ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE) 1

C State RebateClass

PA

PTD PART DPRODUCTS

ENBREL MINI 1

C State RebateClass

PA

PTD PART DPRODUCTS

ENBREL SURECLICK 1

C State RebateClass

PA

PTD PART DPRODUCTS

everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 1

C State PDL Class

PA

PTD PART DPRODUCTS

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION) 1

C State PDL Class

PTD PART DPRODUCTS

HUMIRA 40 MG/0.8 ML SYRINGE 1

C State RebateClass

PA

PTD PART DPRODUCTS



HUMIRA PEN 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA PEN CROHN'S-UC-HS 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA PEN PSOR-UVEITS-ADOL HS 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) 20 MG/0.2 ML SYRING 1

C State RebateClass

PA

PTD PART DPRODUCTS

methotrexate sodium 2.5 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

mycophenolate mofetil (200 mg/ml susp recon, 250 mgcapsule, 500 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

SANDIMMUNE 100 MG/ML SOLN 1C State PDL Class

PTD PART DPRODUCTS

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1C State PDL Class

PTD PART DPRODUCTS



TREXALL 1 PTD PART DPRODUCTS

XELJANZ 5 MG TABLET 1

C State RebateClass

PA

PTD PART DPRODUCTS

IMMUNIZING AGENTS, PASSIVE

FLEBOGAMMA DIF 1

C State RebateClass

PA

PTD PART DPRODUCTS

GAMMAGARD LIQUID 1

C State RebateClass

PA

PTD PART DPRODUCTS

GAMMAGARD S-D 1

C State RebateClass

PA

PTD PART DPRODUCTS

GAMMAKED 1

C State RebateClass

PA

PTD PART DPRODUCTS

GAMUNEX-C 1

C State RebateClass

PA

PTD PART DPRODUCTS



HIZENTRA (1 GRAM/5 ML VIAL, 2 GRAM/10 ML VIAL, 4GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL) 1

C State RebateClass

PA

PTD PART DPRODUCTS

PRIVIGEN 1

C State RebateClass

PA

PTD PART DPRODUCTS

IMMUNOMODULATORS

ACTIMMUNE 1

C State PDL Class

PA

PTD PART DPRODUCTS

leflunomide 1C State PDL Class

PTD PART DPRODUCTS

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 1

C State RebateClass

PA

PTD PART DPRODUCTS

SYNAGIS 1

C Supplemental

PA

PTD PART DPRODUCTS

VACCINES

ADACEL TDAP (SYRINGE, VIAL) 1C vaccine

PTD PART DPRODUCTS

BOOSTRIX TDAP (SYRINGE, VIAL) 1C vaccine

PTD PART DPRODUCTS



DAPTACEL DTAP 1C vaccine

PTD PART DPRODUCTS

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 1C vaccine

PTD PART DPRODUCTS

ENGERIX-B PEDIATRIC-ADOLESCENT 1C vaccine

PTD PART DPRODUCTS

HAVRIX 1C vaccine

PTD PART DPRODUCTS

INFANRIX DTAP (SYRINGE, VIAL) 1C vaccine

PTD PART DPRODUCTS

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 1

C vaccine


PREVNAR 13 1

C vaccine


RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL,10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 1

C vaccine

PTD PART DPRODUCTS

SHINGRIX 1C vaccine

PTD PART DPRODUCTS

SHINGRIX ADJUVANT COMPONENT 1


C vaccine

PTD PART DPRODUCTS



SHINGRIX GE ANTIGEN COMPONENT 1C vaccine

PTD PART DPRODUCTS

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 MLVIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 1 PTD PART D

PRODUCTS

ZOSTAVAX 1C vaccine

PTD PART DPRODUCTS

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

CANASA 1

C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

DELZICOL 1

C State PDL Class

QPD 6.0 per day

PTD PART DPRODUCTS

LIALDA 1

C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

PENTASA 1

C State PDL Class

QPD 9.0 per day

PTD PART DPRODUCTS



SFROWASA 1

C State PDL Class

QPD 60.0 per day

PTD PART DPRODUCTS

GLUCOCORTICOIDS

budesonide 3 mg capdr - er 1C State PDL Class

PTD PART DPRODUCTS

COLOCORT 1C State PDL Class

PTD PART DPRODUCTS

CORTIFOAM 1C State PDL Class

PTD PART DPRODUCTS

hydrocortisone 100mg/60ml enema 1C State PDL Class

PTD PART DPRODUCTS

SULFONAMIDES

sulfasalazine (500 mg tablet, 500 mg tablet dr) 1

C State PDL Class

QPD 8.0 per day

PTD PART DPRODUCTS

METABOLIC BONE DISEASE AGENTS

alendronate sodium (5 mg tablet, 10 mg tablet, 35 mgtablet, 70 mg tablet, 70 mg/75ml solution) 1

C State PDL Class

PTD PART DPRODUCTS

calcitonin,salmon,synthetic 200/spray spray/pump 1C State PDL Class

PTD PART DPRODUCTS

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlampul, 1 mcg/ml solution) 1 PTD PART D

PRODUCTS



FORTEO 1

C State PDL Class

PA

PTD PART DPRODUCTS

ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial,150 mg tablet) 1

C State PDL Class

PTD PART DPRODUCTS

PROLIA 1

C State PDL Class

PA

PTD PART DPRODUCTS

teriparatide 1

C State PDL Class

PA

PTD PART DPRODUCTS

MISCELLANEOUS THERAPEUTIC AGENTS

compressor, for nebulizer 1

diaphragms, contoured 1 C State PDL Class

diaphragms, wide seal 1 C State PDL Class

DUROLANE 1 PA

EUFLEXXA 1

PA

PTD PART DPRODUCTS


flash glucose scanning reader 1


C Supplemental

PA




flash glucose sensor 1


C Supplemental

PA

QPD 0.1 per day


GELSYN-3 1

PA


inhaler, assist devices 1QL 2 / 365 DAYS

C State PDL Class

inhaler,assist device,accesory each 1QL 2 / 365 DAYS

C State PDL Class

inhaler,assist device with large mask 1

QL 2 / 365 DAYS

C State PDL Class

PTD PART DPRODUCTS

inhaler,assist device with medium mask 1

QL 2 / 365 DAYS

C State PDL Class

PTD PART DPRODUCTS

inhaler,assist device with small mask 1

QL 2 / 365 DAYS

C State PDL Class

PTD PART DPRODUCTS

LIDO BDK 1

METHERGINE 1C State PDL Class

PTD PART DPRODUCTS



methylergonovine maleate 0.2 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

mucus clearing device 1

nebulizer 1 PTD PART DPRODUCTS

nebulizer accessories each 1 C State PDL Class

nebulizer accessories kit 1

nebulizer and compressor 1

PARAGARD T 380-A 1C Supplemental

PTD PART DPRODUCTS

peak flow meter/inhaler, assist devices 1

pen needle, diabetic 1 PTD PART DPRODUCTS

spirometers and accessories 1

syringe with needle, insulin, safety, 0.3 ml (29 g x1/2" dispsyrin, 30 gx5/16" disp syrin) 1 PTD PART D

PRODUCTS

syringe with needle, insulin, safety, 0.5 ml (29 g x1/2" dispsyrin, 30 gx5/16" disp syrin) 1 PTD PART D

PRODUCTS

syringe with needle, insulin, safety, 1 ml 1 PTD PART DPRODUCTS

syringe with needle,disposable,insulin 1 ml (syringe dispsyrin, syringe 28gx1/2" disp syrin, syringe 29 g x1/2" dispsyrin, syringe 30 gx5/16" disp syrin)


syringe with needle,insulin,0.3 ml 1 PTD PART DPRODUCTS

syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin,ml 29 g x1/2" disp syrin, ml 30 gx5/16" disp syrin) 1 PTD PART D

PRODUCTS

syringe,safety with needle,1 ml (25gx1" syringe, 25gx5/8"disp syrin) 1 PTD PART D

PRODUCTS



OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

AK-POLY-BAC 1C State PDL Class

PTD PART DPRODUCTS

atropine sulfate (1 % drops, 1 % oint. (g)) 1C State PDL Class

PTD PART DPRODUCTS

bacitracin/polymyxin b sulfate 1C State PDL Class

PTD PART DPRODUCTS

BLEPHAMIDE 1C State PDL Class

PTD PART DPRODUCTS

BLEPHAMIDE S.O.P. 1C State PDL Class

PTD PART DPRODUCTS

cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1C State PDL Class

PTD PART DPRODUCTS

HOMATROPAIRE 1C State PDL Class

PTD PART DPRODUCTS

homatropine hbr 1C State PDL Class

PTD PART DPRODUCTS

NEO-POLYCIN 1C State PDL Class

PTD PART DPRODUCTS

NEO-POLYCIN HC 1C State PDL Class

PTD PART DPRODUCTS



neomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone 1

C State PDL Class

PTD PART DPRODUCTS

neomycin sulfate/bacitracin/polymyxin b 1C State PDL Class

PTD PART DPRODUCTS

neomycin sulfate/polymyxin b sulfate/gramicidin d 1C State PDL Class

PTD PART DPRODUCTS

neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1 PTD PART DPRODUCTS

neomycin/polymyxin b sulfate/dexamethasone(neomycin/polymyxin b/dexametha 0.1 % drops susp,neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g))

1C State PDL Class

PTD PART DPRODUCTS

phenylephrine hcl (2.5 % drops, 10 % drops) 1 PTD PART DPRODUCTS

POLYCIN 1C State PDL Class

PTD PART DPRODUCTS

polymyxin b sulfate/trimethoprim 1C State PDL Class

PTD PART DPRODUCTS

PRED-G (1% DROPS, S.O.P. OINTMENT) 1C State PDL Class

PTD PART DPRODUCTS

RESTASIS 1

C State PDL Class

PA

PTD PART DPRODUCTS

sulfacetamide sodium/prednisolone sodium phosphate 1C State PDL Class

PTD PART DPRODUCTS



TOBRADEX EYE OINTMENT 1C State PDL Class

PTD PART DPRODUCTS

TOBRADEX ST 1C State PDL Class

PTD PART DPRODUCTS

tobramycin/dexamethasone 1C State PDL Class

PTD PART DPRODUCTS

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOMIDE 1 PTD PART DPRODUCTS

azelastine hcl 0.05 % drops 1C State PDL Class

PTD PART DPRODUCTS

cromolyn sodium 4 % drops 1C State PDL Class

PTD PART DPRODUCTS

epinastine hcl 1 PTD PART DPRODUCTS

olopatadine hcl (0.1 % drops, 0.2 % drops) 1 PTD PART DPRODUCTS

PAZEO 1 PTD PART DPRODUCTS

OPHTHALMIC ANTI-INFLAMMATORIES

ACUVAIL 1 PTD PART DPRODUCTS

bromfenac sodium 1 PTD PART DPRODUCTS

BROMSITE 1 PTD PART DPRODUCTS



dexamethasone sodium phosphate 0.1 % drops 1C State PDL Class

PTD PART DPRODUCTS

diclofenac sodium 0.1 % drops 1C State PDL Class

PTD PART DPRODUCTS

fluorometholone 1C State PDL Class

PTD PART DPRODUCTS

flurbiprofen sodium 1C State PDL Class

PTD PART DPRODUCTS

FML FORTE 1 PTD PART DPRODUCTS

FML S.O.P. 1C State PDL Class

PTD PART DPRODUCTS

ketorolac tromethamine 0.4 % drops 1C State PDL Class

PTD PART DPRODUCTS

ketorolac tromethamine 0.5 % drops 1 PTD PART DPRODUCTS

MAXIDEX 1C State PDL Class

PTD PART DPRODUCTS

PRED MILD 1C State PDL Class

PTD PART DPRODUCTS

prednisolone acetate 1C State PDL Class

PTD PART DPRODUCTS

prednisolone sodium phosphate 1 % drops 1C State PDL Class

PTD PART DPRODUCTS



PROLENSA 1 PTD PART DPRODUCTS

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1% DROPS 1 PTD PART DPRODUCTS

apraclonidine hcl 1 PTD PART DPRODUCTS

AZOPT 1

C State PDL Class

PA

PTD PART DPRODUCTS

betaxolol hcl 0.5 % drops 1C State PDL Class

PTD PART DPRODUCTS

BETIMOL 1 PTD PART DPRODUCTS

BETOPTIC S 1C State PDL Class

PTD PART DPRODUCTS

brimonidine tartrate 1 PTD PART DPRODUCTS

carteolol hcl 1C State PDL Class

PTD PART DPRODUCTS

dorzolamide hcl 1C State PDL Class

PTD PART DPRODUCTS

dorzolamide hcl/timolol maleate 1C State PDL Class

PTD PART DPRODUCTS

IOPIDINE 1 PTD PART DPRODUCTS



levobunolol hcl 1C State PDL Class

PTD PART DPRODUCTS

methazolamide 1C State PDL Class

PTD PART DPRODUCTS

metipranolol 1C State PDL Class

PTD PART DPRODUCTS

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1C State PDL Class

PTD PART DPRODUCTS

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % dropdaily, 0.5 % drops, 0.5 % sol-gel) 1

C State PDL Class

PTD PART DPRODUCTS

TIMOPTIC OCUDOSE 1 PTD PART DPRODUCTS

TIMOPTIC-XE 1 PTD PART DPRODUCTS

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

latanoprost 1

QL 2.5 / 30 days

C State PDL Class

PTD PART DPRODUCTS

travoprost 1

C State PDL Class

PA

PTD PART DPRODUCTS

ZIOPTAN 1

C State PDL Class

PA

PTD PART DPRODUCTS



OTIC AGENTS

acetic acid 2 % solution 1C State PDL Class

PTD PART DPRODUCTS

CIPRODEX 1C State Rebate

Class

PTD PART DPRODUCTS

fluocinolone acetonide oil 1 PTD PART DPRODUCTS

hydrocortisone/acetic acid 1C State PDL Class

PTD PART DPRODUCTS

neomycin sulfate/polymyxin b sulfate/hydrocortisone(neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp,neomycin/polymyxin b/hydrocort 3.5-10k-1 solution)

1C State PDL Class

PTD PART DPRODUCTS

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ASMANEX 1C State Rebate

Class

PTD PART DPRODUCTS

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb) 1

AL Up to 4 yrs old

C State RebateClass

PTD PART DPRODUCTS


FLOVENT DISKUS 1C State Rebate

Class

PTD PART DPRODUCTS



FLOVENT HFA 1C State Rebate

Class

PTD PART DPRODUCTS

flunisolide 1C State PDL Class

PTD PART DPRODUCTS

fluticasone propionate 50 mcg spray susp 1C State PDL Class

PTD PART DPRODUCTS

OMNARIS 1 PTD PART DPRODUCTS

PULMICORT FLEXHALER 1C State Rebate

Class

PTD PART DPRODUCTS

QNASL 1 PTD PART DPRODUCTS

QNASL CHILDREN 1 PTD PART DPRODUCTS

triamcinolone acetonide 55 mcg spray 1 C State PDL Class

ZETONNA 1 PTD PART DPRODUCTS

ANTIHISTAMINES

azelastine hcl (137 mcg spray/pump, 205.5 mcgspray/pump) 1

C State PDL Class

PTD PART DPRODUCTS

cetirizine hcl 1 mg/ml solution 1

C State PDL Class

QPD 5 per day

PTD PART DPRODUCTS

clemastine fumarate 2.68 mg tablet 1C State PDL Class

PTD PART DPRODUCTS



cyproheptadine hcl 1C State PDL Class

PTD PART DPRODUCTS

DIPHEN 12.5 MG/5 ML ELIXIR 1C State PDL Class

PTD PART DPRODUCTS

DIPHEN 12.5 MG/5 ML SOLUTION 1 C State PDL Class

diphenhydramine hcl 12.5mg/5ml elixir 1 C State PDL Class

diphenhydramine hcl 50 mg/ml syringe 1 PTD PART DPRODUCTS

hydroxyzine hcl (10 mg/5 ml solution, 50 mg/25mlsolution) 1

QL 300 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

hydroxyzine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1

QL 240 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

hydroxyzine pamoate (50 mg capsule, 100 mg capsule) 1

QL 120 / 30 DAYS

C State PDL Class

PTD PART DPRODUCTS

hydroxyzine pamoate 25 mg capsule 1

QL 120 / 30 DAYS

C State PDL Class

QPD 4.0 per day

PTD PART DPRODUCTS

PHENERGAN (25 MG/ML VIAL, 50 MG/ML VIAL) 1 PTD PART DPRODUCTS

promethazine hcl (6.25mg/5ml syrup, 25 mg/ml ampul,50 mg/ml ampul) 1 PTD PART D

PRODUCTS



promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet) 1

C State PDL Class

PTD PART DPRODUCTS

ANTILEUKOTRIENES

montelukast sodium 4 mg gran pack 1

AL Up to 3 yrs old

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

montelukast sodium (4 mg tab chew, 5 mg tab chew, 10mg tablet) 1

C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 1C State Rebate

Class

PTD PART DPRODUCTS

ipratropium bromide 0.2 mg/ml solution 1

C State RebateClass

PTD PART DPRODUCTS


ipratropium bromide (21 mcg spray, 42 mcg spray) 1C State PDL Class

PTD PART DPRODUCTS

SPIRIVA 1C State Rebate

Class

PTD PART DPRODUCTS



TUDORZA PRESSAIR 1C State Rebate

Class

PTD PART DPRODUCTS

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol sulfate 2 mg/5 ml syrup 1C State Rebate

Class

PTD PART DPRODUCTS

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 5 mg/mlsolution)

1

C State RebateClass

PTD PART DPRODUCTS


epinephrine (0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1

QL 2 / 30 DAYS

C State RebateClass

PTD PART DPRODUCTS

isoproterenol hcl 1 PTD PART DPRODUCTS

ISUPREL 1 MG/5 ML AMPUL 1 PTD PART DPRODUCTS

PROAIR HFA 1C State Rebate

Class

PTD PART DPRODUCTS

SEREVENT DISKUS 1


C State RebateClass

PA

PTD PART DPRODUCTS



CYSTIC FIBROSIS AGENTS

BETHKIS 1

C State RebateClass

PA

PTD PART DPRODUCTS


KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULESPACKET, 150 MG TABLET) 1

PA

PTD PART DPRODUCTS

KITABIS PAK 1

C State RebateClass

PA

PTD PART DPRODUCTS


PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

THEO-24 1 PTD PART DPRODUCTS

theophylline anhydrous (100 mg tab er 12h, 200 mg tab er12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)


PULMONARY ANTIHYPERTENSIVES

ADCIRCA 1

C State RebateClass

PA

PTD PART DPRODUCTS

LETAIRIS 1

C State RebateClass

PA

PTD PART DPRODUCTS



REVATIO 10 MG/ML ORAL SUSP 1

AL Up to 12 yrs old

C State RebateClass

PTD PART DPRODUCTS

sildenafil citrate 20 mg tablet 1

C State RebateClass

PA

PTD PART DPRODUCTS

TRACLEER (62.5 MG TABLET, 125 MG TABLET) 1

C State RebateClass

PA

PTD PART DPRODUCTS

VELETRI 1PA

PTD PART DPRODUCTS

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine 1

C Supplemental

PTD PART DPRODUCTS


ADVAIR DISKUS 1

ST

C State RebateClass

PTD PART DPRODUCTS

ADVAIR HFA 1

ST


C State RebateClass

PTD PART DPRODUCTS



ANORO ELLIPTA 1PA

PTD PART DPRODUCTS

ARALAST NP 1

C State PDL Class

PA

PTD PART DPRODUCTS

benzonatate (100 mg capsule, 150 mg capsule, 200 mgcapsule) 1

C State PDL Class

PTD PART DPRODUCTS

BROMFED DM 1C State PDL Class

PTD PART DPRODUCTS

brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 1

C State PDL Class

PTD PART DPRODUCTS

COMBIVENT RESPIMAT 1C State Rebate

Class

PTD PART DPRODUCTS

cromolyn sodium 20 mg/2 ml ampul-neb 1

C State PDL Class

PTD PART DPRODUCTS


DULERA (100 MCG INHALER, 200 MCG INHALER) 1C State Rebate

Class

PTD PART DPRODUCTS

hydrocodone bitartrate/homatropine methylbromide(bit/homatrop 5 mg-1.5mg tablet, bit/homatrop 5-1.5mg/5 syrup)

1

QL 240 / 12 DAYS


C State PDL Class

PTD PART DPRODUCTS



HYDROMET 1

QL 240 / 12 DAYS


C State PDL Class

PTD PART DPRODUCTS

ipratropium bromide/albuterol sulfate 1

C State RebateClass

PTD PART DPRODUCTS


phenylephrine hcl/promethazine hcl 1C State PDL Class

PTD PART DPRODUCTS

PROLASTIN C 1,000 MG VIAL 1PA

PTD PART DPRODUCTS

promethazine hcl/codeine 6.25-10/5 syrup 1


C State PDL Class

QPD 20.0 per day

PTD PART DPRODUCTS

promethazine hcl/dextromethorphan hbr 1

C State PDL Class

QPD 16.0 per day

PTD PART DPRODUCTS

PULMOZYME 1

C State PDL Class

PA

PTD PART DPRODUCTS




STIOLTO RESPIMAT 1

C State RebateClass

PA

PTD PART DPRODUCTS

SYMBICORT 1

ST

C State RebateClass

PTD PART DPRODUCTS

TUZISTRA XR 1

ZEMAIRA 1PA

PTD PART DPRODUCTS

SKELETAL MUSCLE RELAXANTS

baclofen (10 mg tablet, 20 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

dantrolene sodium (25 mg capsule, 50 mg capsule, 100mg capsule) 1

C State PDL Class

PTD PART DPRODUCTS

METAXALL 1 PTD PART DPRODUCTS

metaxalone 1 PTD PART DPRODUCTS

methocarbamol (500 mg tablet, 750 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

orphenadrine citrate 100 mg tablet er 1 PTD PART DPRODUCTS



tizanidine hcl (2 mg tablet, 4 mg tablet) 1C State PDL Class

PTD PART DPRODUCTS

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

eszopiclone 1


C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

temazepam (15 mg capsule, 30 mg capsule) 1


C State PDL Class

QPD 1.0 per day

PTD PART DPRODUCTS

zolpidem tartrate 10 mg tablet 1


C State RebateClass

QPD 1.0 per day

PTD PART DPRODUCTS

zolpidem tartrate 5 mg tablet 1


C State RebateClass

QPD 2 per day

PTD PART DPRODUCTS



SLEEP DISORDERS, OTHER

ROZEREM 1

QL 30 / 30 Days

ST


C State RebateClass

PTD PART DPRODUCTS

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

CHROMAGEN 1

KIONEX 1C State PDL Class

PTD PART DPRODUCTS

NIFEREX 1

sodium polystyrene sulfonate (15 g/60 ml oral susp,powder) 1

C State PDL Class

PTD PART DPRODUCTS

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMASUSP) 1 PTD PART D

PRODUCTS

ELECTROLYTE/MINERAL REPLACEMENT

0.9 % sodium chloride (0.9 % 0.9 % cartridge, 0.9 % 0.9 %syringe) 1 PTD PART D

PRODUCTS

CORVITE 150 1

EFFER-K (20 TABLET EFF, 25 TABLET EFF) 1 PTD PART DPRODUCTS

EFFER-K 10 MEQ TABLET EFF 1

fluoride (sodium) 0.5 mg/ml drops 1 C State PDL Class



fluoride (sodium) (0.25(0.55) tab chew, 0.5(1.1)mg tabchew, 1mg(2.2mg) tab chew) 1

C State PDL Class

PTD PART DPRODUCTS

FLUORITAB 1C State PDL Class

PTD PART DPRODUCTS

FLURA-DROPS 1 PTD PART DPRODUCTS

HEMATOGEN 1

HEMATOGEN FA 1

HEMATOGEN FORTE 1

K-TAB ER 8 MEQ TABLET 1 PTD PART DPRODUCTS

KLOR-CON 1 PTD PART DPRODUCTS

KLOR-CON 10 1 PTD PART DPRODUCTS

KLOR-CON 8 1 PTD PART DPRODUCTS

KLOR-CON M10 1 PTD PART DPRODUCTS



KLOR-CON-EF 1 PTD PART DPRODUCTS

LUDENT FLUORIDE 1C State PDL Class

PTD PART DPRODUCTS

NEPHRON FA 1



NUFERA 1

potassium chloride (2 meq/ml ampul, 2 meq/ml vial, 8meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meqtab er prt, 20 meq tablet er, 20meq/15ml liquid,40meq/15ml liquid)


potassium chloride in water for injection, sterile (in10meq/0.1l piggyback, in 10meq/50ml piggyback, in20meq/0.1l piggyback, in 20meq/50ml piggyback, in40meq/0.1l piggyback)


TRICON 1 PTD PART DPRODUCTS

TRIGELS-F FORTE 1

BACMIN 1 PTD PART DPRODUCTS

BAL-CARE DHA 1 PTD PART DPRODUCTS

C-NATE DHA 1 PTD PART DPRODUCTS

CARNITOR 1 GM/5 ML VIAL 1 PTD PART DPRODUCTS

CITRANATAL B-CALM 1 PTD PART DPRODUCTS

COMPLETE NATAL DHA 1 PTD PART DPRODUCTS

CONCEPT DHA 1 PTD PART DPRODUCTS

CONCEPT OB 1 PTD PART DPRODUCTS

cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1C Supplemental

PTD PART DPRODUCTS



DIALYVITE 1

DUET DHA 400 1 PTD PART DPRODUCTS

DUET DHA BALANCED 1 PTD PART DPRODUCTS

ELITE-OB 1 PTD PART DPRODUCTS

ergocalciferol (vitamin d2) 1 PTD PART DPRODUCTS

folic acid 1 mg tablet 1

FOLIVANE-OB 1 PTD PART DPRODUCTS

FORTAVIT 1 PTD PART DPRODUCTS

KOSHER PRENATAL PLUS IRON 1 PTD PART DPRODUCTS

levocarnitine 330 mg tablet 1 PTD PART DPRODUCTS

levocarnitine (with sugar) 1 PTD PART DPRODUCTS

MARNATAL-F 1 PTD PART DPRODUCTS

multivitamin combination no.51/ferrous fumarate/folicacid 1 PTD PART D

PRODUCTS

MVC-FLUORIDE 1 PTD PART DPRODUCTS

MYNATAL 1 PTD PART DPRODUCTS

MYNATAL PLUS 1 PTD PART DPRODUCTS

MYNATAL-Z 1 PTD PART DPRODUCTS



MYNEPHROCAPS 1

MYNEPHRON 1

NATACHEW 1 PTD PART DPRODUCTS

NEEVODHA 1 PTD PART DPRODUCTS

NESTABS 1 PTD PART DPRODUCTS

NESTABS ABC 1 PTD PART DPRODUCTS

NESTABS DHA 1 PTD PART DPRODUCTS

NEWGEN 1 PTD PART DPRODUCTS

NICADAN 1

NICAZEL 1 PTD PART DPRODUCTS

NICAZEL FORTE 1

NIVA-PLUS 1 PTD PART DPRODUCTS

O-CAL FA 1 PTD PART DPRODUCTS

O-CAL PRENATAL 1 PTD PART DPRODUCTS

OB COMPLETE 1 PTD PART DPRODUCTS

OB COMPLETE ONE 1 PTD PART DPRODUCTS

OB COMPLETE PETITE 1 PTD PART DPRODUCTS

OB COMPLETE PREMIER 1 PTD PART DPRODUCTS



OB COMPLETE WITH DHA 1 PTD PART DPRODUCTS

pediatric multivit with a,c,d3 no.21/sodium fluoride 1 PTD PART DPRODUCTS

pediatric multivitamin no.2/sodium fluoride 1

pediatric multivitamins no.17 with sodium fluoride 1 PTD PART DPRODUCTS

PNV 29-1 1 PTD PART DPRODUCTS

pnv no.72/ferrous fumarate/folic acid/omega-3/dha 1 PTD PART DPRODUCTS

PNV-OMEGA 1 PTD PART DPRODUCTS

PR NATAL 400 1 PTD PART DPRODUCTS

PR NATAL 400 EC 1 PTD PART DPRODUCTS

PR NATAL 430 1 PTD PART DPRODUCTS

PR NATAL 430 EC 1 PTD PART DPRODUCTS

PRENA1 CHEW 1 PTD PART DPRODUCTS

PRENA1 PEARL 1 PTD PART DPRODUCTS

PRENA1 TRUE 1 PTD PART DPRODUCTS

PRENATA 1 PTD PART DPRODUCTS

PRENATABS FA 1 PTD PART DPRODUCTS

PRENATABS RX 1 PTD PART DPRODUCTS



prenatal vits with calcium no.115/iron fumarate/folic acid 1

prenatal vits with calcium no.72/ferrous fumarate/folicacid 1 PTD PART D

PRODUCTS

prenatal vits with calcium no.72/iron,carbonyl/folic acid 1 PTD PART DPRODUCTS

PRENATE AM 1 PTD PART DPRODUCTS

PRENATE CHEWABLE 1 PTD PART DPRODUCTS

PRENATE DHA 1 PTD PART DPRODUCTS

PRENATE ELITE 1 PTD PART DPRODUCTS

PRENATE ENHANCE 1 PTD PART DPRODUCTS

PRENATE ESSENTIAL 1 PTD PART DPRODUCTS

PRENATE MINI 1 PTD PART DPRODUCTS

PRENATE PIXIE 1 PTD PART DPRODUCTS

PRENATE RESTORE 1 PTD PART DPRODUCTS

PRENATE STAR 1 PTD PART DPRODUCTS

PREPLUS 1 PTD PART DPRODUCTS

PRETAB 1 PTD PART DPRODUCTS

PRIMACARE 1 PTD PART DPRODUCTS

PROVIDA OB 1 PTD PART DPRODUCTS



PUREFE OB PLUS 1 PTD PART DPRODUCTS

pyridoxine hcl (vitamin b6) 1 PTD PART DPRODUCTS

QUFLORA (0.125 MG GUMMIES, PED 0.25 MG CHEW TAB,PED 0.25 MG/ML DROP, PED 0.5 MG CHEW TAB, PED 0.5MG/ML DROP, PED 1 MG CHEW TAB)


R-NATAL OB 1 PTD PART DPRODUCTS

RENA-VITE RX 1 PTD PART DPRODUCTS

RENAL CAPS 1

RENO CAPS 1

REQ49+ 1

SE-NATAL 19 1 PTD PART DPRODUCTS

SE-NATAL-19 1 PTD PART DPRODUCTS

SELECT-OB 1 PTD PART DPRODUCTS

SELECT-OB + DHA 1 PTD PART DPRODUCTS

STROVITE ONE 1 PTD PART DPRODUCTS

SUPERVITE 1

TARON-C DHA 1 PTD PART DPRODUCTS

thiamine hcl 1 PTD PART DPRODUCTS

THRIVITE RX 1 PTD PART DPRODUCTS



TRICARE 1 PTD PART DPRODUCTS

TRINATAL RX 1 1 PTD PART DPRODUCTS

TRINATE 1 PTD PART DPRODUCTS

TRIPHROCAPS 1

TRISTART DHA 1 PTD PART DPRODUCTS

TRIVEEN-DUO DHA 1 PTD PART DPRODUCTS

VIC-FORTE 1 PTD PART DPRODUCTS

VIRT-C DHA 1 PTD PART DPRODUCTS

VIRT-CAPS 1 PTD PART DPRODUCTS

VIRT-NATE DHA 1 PTD PART DPRODUCTS

VIRT-PN DHA 1 PTD PART DPRODUCTS

VIRT-PN PLUS 1 PTD PART DPRODUCTS

VITAFOL GUMMIES 1 PTD PART DPRODUCTS

VITAFOL NANO 1 PTD PART DPRODUCTS

VITAFOL ULTRA 1 PTD PART DPRODUCTS

VITAFOL-OB 1 PTD PART DPRODUCTS

VITAFOL-OB+DHA 1 PTD PART DPRODUCTS



VITAFOL-ONE 1 PTD PART DPRODUCTS

VITAL-D RX 1

VITAMEDMD ONE RX 1 PTD PART DPRODUCTS

VITAMEDMD REDICHEW RX 1 PTD PART DPRODUCTS

VITAPEARL 1 PTD PART DPRODUCTS

VITATRUE 1 PTD PART DPRODUCTS

VP-PNV-DHA 1 PTD PART DPRODUCTS

VP-VITE RX 1

ZATEAN-PN DHA 1 PTD PART DPRODUCTS

ZATEAN-PN PLUS 1 PTD PART DPRODUCTS

Uncategorized

Unclassified

AFLURIA QUAD 2020-2021 1

C vaccine

PTD PART DPRODUCTS


AFLURIA QUAD 2020-21 (3YR UP) 1

C vaccine

PTD PART DPRODUCTS




AFLURIA QUAD 2020-21 (6-35MO) 1

C vaccine

PTD PART DPRODUCTS


AFLURIA QUAD 2021-2022 1

C Vaccine


AFLURIA QUAD 2021-22 (3YR UP) 1

C Vaccine


AFLURIA QUAD 2021-22 (6-35MO) 1

C Vaccine


AIMOVIG AUTOINJECTOR 1PA

PTD PART DPRODUCTS

AJOVY AUTOINJECTOR 1

QL 1.5 / 30 days

C State RebateClass

PA

QPD 0.057 per day

PTD PART DPRODUCTS

AJOVY SYRINGE 1

C State RebateClass

PA

QPD 0.057 per day

PTD PART DPRODUCTS



ARISTADA INITIO 1

QL 4.8 / 365 DAYS


C State RebateClass

PTD PART DPRODUCTS

AVSOLA 1

C State RebateClass

PA

PTD PART DPRODUCTS

baclofen 5 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

BIKTARVY 1

C State PDL Class

QPD 1 per day

PTD PART DPRODUCTS

butalbital/aspirin/caffeine 50-325-40 tablet 1C State PDL Class

PTD PART DPRODUCTS

CYCLOSPORINE IN KLARITY 1

DULERA 50 MCG-5 MCG INHALER 1C State Rebate

Class

PTD PART DPRODUCTS

ELIQUIS DVT-PE TREAT START 5MG 1

QL 80 / 365 days

C State RebateClass

PTD PART DPRODUCTS

EMGALITY PEN 1

C State RebateClass

PA

PTD PART DPRODUCTS



EMGALITY 120 MG/ML SYRINGE 1

C State RebateClass

PA

PTD PART DPRODUCTS

ENBREL 25 MG/0.5 ML VIAL 1

C State RebateClass

PA

PTD PART DPRODUCTS

FLORIVA PLUS 1 PTD PART DPRODUCTS

FLUAD 2020-2021 1

C vaccine


FLUAD QUAD 2020-2021 1

C vaccine


FLUAD QUAD 2021-2022 1

C Vaccine


FLUARIX QUAD 2020-2021 1

C vaccine


FLUARIX QUAD 2021-2022 1

C Vaccine


FLUBLOK QUAD 2020-2021 1

C vaccine




FLUBLOK QUAD 2021-2022 1

C Vaccine


FLUCELVAX QUAD 2020-2021 (2020-2021 SYR, 2020-2021VIAL) 1

C vaccine


FLUCELVAX QUAD 2021-2022 (2021-2022 SYR, 2021-2022VIAL) 1

C Vaccine


FLULAVAL QUAD 2020-2021 1

C vaccine

PTD PART DPRODUCTS


FLULAVAL QUAD 2021-2022 1

C Vaccine


FLUMIST QUAD 2020-2021 1

C vaccine


FLUZONE HIGH-DOSE QUAD 2020-21 1

C vaccine

PTD PART DPRODUCTS


FLUZONE HIGH-DOSE QUAD 2021-22 1

C Vaccine




FLUZONE QUAD 2020-2021 (2020-2021 SYRINGE, 2020-2021 VIAL) 1

C vaccine

PTD PART DPRODUCTS


FLUZONE QUAD 2021-2022 (2021-2022 SYRINGE, 2021-2022 VIAL) 1

C Vaccine


FULPHILA 1

C State RebateClass

PA

PTD PART DPRODUCTS

ganciclovir sodium 500mg/10ml vial 1

C State PDL Class

PA

PTD PART DPRODUCTS

GILENYA 0.25 MG CAPSULE 1

C State RebateClass

PA

PTD PART DPRODUCTS

glycopyrrolate 1.5 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

heparin sodium,porcine in 0.9 % sodium chloride(sod,porcine/0.9 % 2500/5 ml syringe, sod,porcine/0.9 %6000/3 ml syringe)

1C State Rebate

Class

PTD PART DPRODUCTS

HIZENTRA (1 GRAM/5 ML SYRINGE, 2 GRAM/10 MLSYRINGE, 4 GRAM/20 ML SYRINGE) 1

C State RebateClass

PA

PTD PART DPRODUCTS



HUMIRA(CF) (10 MG/0.1 ML SYRING, 40 MG/0.4 MLSYRING) 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) PEDIATRIC CROHN'S 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) PEN 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) PEN CROHN'S-UC-HS 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) PEN PEDIATRIC UC 1

C State RebateClass

PA

PTD PART DPRODUCTS

HUMIRA(CF) PEN PSOR-UV-ADOL HS 1

C State RebateClass

PA

PTD PART DPRODUCTS

ICLUSIG (10 MG TABLET, 30 MG TABLET) 1PA

PTD PART DPRODUCTS

IMBRUVICA (70 MG CAPSULE, 140 MG TABLET, 280 MGTABLET, 420 MG TABLET, 560 MG TABLET) 1

C State PDL Class

PA

PTD PART DPRODUCTS



JANSSEN COVID-19 VACCINE (EUA) 1

QLmax quantity 2fills per lifetimecovid vaccine


C vaccine


KENALOG-80 1

C State PDL Class

PA

PTD PART DPRODUCTS

ketoprofen 25 mg capsule 1C State PDL Class

PTD PART DPRODUCTS

MAKENA 275 MG/1.1 ML AUTOINJCT 1

C State RebateClass

PA

PTD PART DPRODUCTS

MODERNA COVID-19 VACCINE (EUA) 1

QL max quantity 3per lifetime


C vaccine


NESTABS ONE 1 PTD PART DPRODUCTS

NIVESTYM (300 MCG/0.5 ML SYRING, 480 MCG/0.8 MLSYRING) 1

C State RebateClass

PA

PTD PART DPRODUCTS



NPLATE 125 MCG VIAL 1

C State RebateClass

PA

PTD PART DPRODUCTS

NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE) 1

PA

PTD PART DPRODUCTS

NYVEPRIA 1

C State RebateClass

PA

PTD PART DPRODUCTS

oxycodone hcl/acetaminophen 2.5-300 mg tablet 1 C State PDL Class

PERSERIS (ER 90 MG SYRINGE KIT, ER 120 MG SYRINGEKIT) 1 PTD PART D

PRODUCTS

PERSERIS ER 90 MG POWDER SYRNG 1

PFIZER COVID (12Y UP) VAC(EUA) 1




PFIZER COVID (5-11Y) VAC (EUA) 1

QLmax quantity 2fills per lifetimecovid vaccine

AL 5 to 11 yrs old


PFIZER COVID-19 VACCINE (EUA) 1



C vaccine




PIFELTRO 1C State PDL Class

PTD PART DPRODUCTS

prednisolone acetate/pf 1 C State PDL Class

PREVNAR 20 1


C Vaccine


RETACRIT 1

C State RebateClass

PA

PTD PART DPRODUCTS

SPRAVATO 1

C State PDL Class

PA

PTD PART DPRODUCTS

SUBLOCADE 1

C State RebateClass

PA

PTD PART DPRODUCTS

syringe,safety with needle,1ml 23gx1" disp syrin 1 PTD PART DPRODUCTS

TASIGNA 50 MG CAPSULE 1

C State PDL Class

PA

PTD PART DPRODUCTS

testosterone cypionate 50 mg/ml vial 1C State PDL Class

PA



tramadol hcl 100 mg tablet 1C State PDL Class

PTD PART DPRODUCTS

triamcinolone diacetate in 0.9 % sodium chloride 1 C State PDL Class

triamcinolone diacetate in 0.9 % sodium chloride/pf 1 C State PDL Class

TRIJARDY XR 1

C State RebateClass

PA

PTD PART DPRODUCTS

TRULICITY (3 MG/0.5 ML PEN, 4.5 MG/0.5 ML PEN) 1

C State RebateClass

PA

PTD PART DPRODUCTS

UBRELVY 1PA

PTD PART DPRODUCTS

UDENYCA 1

C State RebateClass

PA

PTD PART DPRODUCTS

vancomycin hcl 50 mg/ml soln recon 1C State PDL Class

PTD PART DPRODUCTS

vancomycin hcl (1.25 g vial, 1.5 g vial, 250 mg vial) 1C Supplemental

PTD PART DPRODUCTS

vancomycin hcl in sterile water 1 C Supplemental



vancomycin hcl in water for injection (peg-400, nada)(vancomycin/water inj 1.5g/300ml piggyback,vancomycin/water inj 2 g/400 ml piggyback)

1 C Supplemental

vancomycin/0.9 % sod chloride 1.5g/300ml plast. bag 1 C Supplemental

vancomycin hcl in 5 % dextrose 1.75 g/500 plast. bag 1 C Supplemental

XALIX 1

XARELTO 2.5 MG TABLET 1

C State RebateClass

QPD 2.0 per day

PTD PART DPRODUCTS

XELJANZ 10 MG TABLET 1

C State RebateClass

PA

PTD PART DPRODUCTS

XIGDUO XR 2.5 MG-1,000 MG TAB 1

C State RebateClass

PA

PTD PART DPRODUCTS


Index of Covered Drugs

00.9 % sodium chloride 157

AA-HYDROCORT 107abacavir sulfate 58abacavir sulfate/lamivudine 58abacavir sulfate/lamivudine/zidovudine 58ABILIFY MAINTENA 49acamprosate calcium 9acarbose 66acetaminophen with codeine phosphate 4acetazolamide 84acetic acid 146acetylcysteine 152acitretin 95ACTIMMUNE 133ACTOPLUS MET XR 66ACUVAIL 142acyclovir 62acyclovir sodium 62ADACEL TDAP 133adapalene 95ADCIRCA 151ADDERALL 88ADDERALL XR 89adefovir dipivoxil 55ADV ALLERGY COLLECTION KIT 107ADVAIR DISKUS 152ADVAIR HFA 152AFINITOR 41AFINITOR DISPERZ 41AFIRMELLE 114AFLURIA QUAD 2020-2021 166AFLURIA QUAD 2020-21 (3YR UP) 166AFLURIA QUAD 2020-21 (6-35MO) 167AFLURIA QUAD 2021-2022 167AFLURIA QUAD 2021-22 (3YR UP) 167AFLURIA QUAD 2021-22 (6-35MO) 167AGONEAZE 7

AIMOVIG AUTOINJECTOR 167AJOVY AUTOINJECTOR 167AJOVY SYRINGE 167AK-POLY-BAC 140ALA-CORT 107ALA-SCALP 107albendazole 45albuterol sulfate 150ALDACTAZIDE 82ALECENSA 41alendronate sodium 136ALFERON N 62alfuzosin hcl 105ALINIA 45ALKERAN 38allopurinol 35ALOMIDE 142ALORA 114alosetron hcl 102ALPHAGAN P 144alprazolam 63ALPRAZOLAM INTENSOL 63ALTAVERA 114ALYACEN 114AMABELZ 114amantadine hcl 47AMETHIA 114AMETHIA LO 114AMETHYST 114amikacin sulfate 11amiloride hcl 85aminocaproic acid 75amiodarone hcl 78AMITIZA 102amitriptyline hcl 30amlodipine besylate 80ammonium lactate 95AMNESTEEM 95amoxapine 30amoxicillin 16amoxicillin/potassium clavulanate 16

ampicillin sodium 16ampicillin trihydrate 16anagrelide hcl 74ANASTIA 7anastrozole 41ANDRODERM 113ANDROGEL 113ANODYNE LPT 7ANORO ELLIPTA 153ANUSOL-HC 95apraclonidine hcl 144aprepitant 33APRI 114APRISO 135APTIVUS 60ARALAST NP 153ARANELLE 114aripiprazole 49ARISTADA 50ARISTADA INITIO 168ARISTOSPAN 107ARMOUR THYROID 126ASCOMP WITH CODEINE 4ASMANEX 146ASTAGRAF XL 129atazanavir sulfate 60atenolol 79atenolol/chlorthalidone 82atomoxetine hcl 89atorvastatin calcium 86atovaquone/proguanil hcl 45ATRIPLA 57atropine sulfate 140ATROVENT HFA 149AUBRA 115AUBRA EQ 115AUGMENTIN 16AUROVELA 115AUROVELA 24 FE 115AUROVELA FE 115AVASTIN 44

AVC 18AVIANE 115AVITA 95AVONEX 93AVONEX PEN 93AVSOLA 168AYUNA 115AZASAN 129azathioprine 129azelastine hcl 142,147azithromycin 17AZOPT 144AZURETTE 115

Bbacitracin 12bacitracin/polymyxin b sulfate 140baclofen 155,168BACMIN 159BAL-CARE DHA 159BALZIVA 115BANZEL 22BARACLUDE 55BEKYREE 115benazepril hcl 77benazepril hcl/hydrochlorothiazide 82BENZEPRO 95benzonatate 153benzoyl peroxide 95,96benzoyl peroxide microspheres 96benztropine mesylate 46betamethasone dipropionate 108betamethasone dipropionate/propyleneglycol 108betamethasone valerate 108BETASERON 93betaxolol hcl 144bethanechol chloride 106BETHKIS 151BETIMOL 144BETOPTIC S 144

bexarotene 44bicalutamide 39BICILLIN L-A 16BIKTARVY 168bisoprolol fumarate 79bisoprolol fumarate/hydrochlorothiazide 82BLEPHAMIDE 140BLEPHAMIDE S.O.P. 140BLISOVI 24 FE 115BLISOVI FE 115BOCASAL 94BOOSTRIX TDAP 133BPO 96BRIELLYN 115BRILINTA 75brimonidine tartrate 144BROMFED DM 153bromfenac sodium 142bromocriptine mesylate 47brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 153BROMSITE 142budesonide 136,146bumetanide 84buprenorphine hcl 9buprenorphine hcl/naloxone hcl 9bupropion hcl 10,25buspirone hcl 62,63butalbital/acetaminophen/caffeine 92butalbital/acetaminophen/caffeine/codeinephosphate 4butalbital/aspirin/caffeine 1,168BUTRANS 3BYDUREON PEN 66BYETTA 66

CC-NATE DHA 159cabergoline 128CAFERGOT 36calcipotriene 96

calcitonin,salmon,synthetic 136calcitriol 136calcium acetate 107CAMILA 124CAMRESE 115CAMRESE LO 115CANASA 135candesartan cilexetil 76CAPHOSOL 94CAPRELSA 42captopril 77captopril/hydrochlorothiazide 82CARAC 96carbamazepine 22,23carbidopa/levodopa 47CARNITOR 159carteolol hcl 144CARTIA XT 80,81carvedilol 79cefaclor 14cefadroxil 15cefazolin sodium in 0.9 % sodium chloride 15cefazolin sodium/dextrose 5 % in water 15cefdinir 15cefixime 15cefotaxime sodium 15cefpodoxime proxetil 15cefprozil 15ceftriaxone sodium 15cefuroxime axetil 15celecoxib 1CENTANY 12cephalexin 15CERDELGA 99CEREZYME 99cetirizine hcl 147CETRAXAL 17CHANTIX 10CHATEAL 116CHATEAL EQ 116chlordiazepoxide hcl 64

chlorhexidine gluconate 94chloroquine phosphate 45chlorpromazine hcl 48chlorthalidone 85cholestyramine (with sugar) 87cholestyramine/aspartame 87CHROMAGEN 157CICLODAN 34ciclopirox 34ciclopirox olamine 34cidofovir 54cilostazol 75CILOXAN 17cinacalcet hcl 127CIPRODEX 146ciprofloxacin hcl 18citalopram hydrobromide 25,26CITRANATAL B-CALM 159citric acid/sodium citrate 106CLARAVIS 96clarithromycin 17clemastine fumarate 147CLEOCIN 12CLEOCIN PHOSPHATE 12CLIMARA PRO 116CLINDACIN ETZ 12CLINDACIN P 12clindamycin hcl 12clindamycin palmitate hcl 12clindamycin phosphate 12clindamycin phosphate/benzoyl peroxide 96clobazam 20clobetasol propionate 108clobetasol propionate/emollient base 108clomipramine hcl 30clonazepam 64clonidine 75clonidine hcl 75,90clopidogrel bisulfate 75clorazepate dipotassium 64clotrimazole 34

clotrimazole/betamethasone dipropionate 96clozapine 54COARTEM 46codeine phosphate/butalbital/aspirin/caffeine 4colchicine 35colestipol hcl 87colistin (as colistimethate sodium) 12COLOCORT 136COMBIPATCH 116COMBIVENT RESPIMAT 153COMPLERA 57COMPLETE NATAL DHA 159compressor, for nebulizer 137COMPRO 32CONCEPT DHA 159CONCEPT OB 159CONCERTA 90CONSTULOSE 103COPAXONE 93CORMAX 108CORTIFOAM 136cortisone acetate 108CORTISPORIN 96CORVITE 150 157COTELLIC 42CREON 99CRIXIVAN 60cromolyn sodium 101,142,153CRYSELLE 116CUVPOSA 100cyanocobalamin (vitamin b-12) 159CYCLAFEM 116cyclobenzaprine hcl 155cyclopentolate hcl 140cyclophosphamide 38cyclosporine 130CYCLOSPORINE IN KLARITY 168cyclosporine, modified 130cyproheptadine hcl 148CYRED 116

Ddanazol 113dantrolene sodium 155dapsone 37DAPTACEL DTAP 134DASETTA 116DAYTRANA 90DDAVP 112DEBLITANE 124DECADRON 109DELZICOL 135demeclocycline hcl 19DEPO-MEDROL 109DERMA-SMOOTHE-FS 109DERMACINRX EMPRICAINE 7DERMACINRX PRIZOPAK 7DESCOVY 58desipramine hcl 30desmopressin acetate 112desmopressin acetate (non-refrigerated) 112desogestrel-ethinyl estradiol 116desogestrel-ethinyl estradiol/ethinyl estradiol 116DETROL 105DETROL LA 105dexamethasone 109DEXAMETHASONE INTENSOL 109dexamethasone sodium phosphate 143dexmethylphenidate hcl 90DEXPAK 109dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate 89dextroamphetamine sulfate 89DIALYVITE 160diaphragms, contoured 137diaphragms, wide seal 137diazepam 20,64,65diclofenac sodium 1,143dicloxacillin sodium 16dicyclomine hcl 101didanosine 58

diflunisal 1DIGITEK 82DIGOX 82digoxin 82DILANTIN 23DILATRATE-SR 88DILT-XR 81diltiazem hcl 81DIPHEN 148diphenhydramine hcl 148diphenoxylate hcl/atropine sulfate 101dipyridamole 75disopyramide phosphate 78disulfiram 9DIURIL 85divalproex sodium 21dofetilide 78donepezil hcl 24dorzolamide hcl 144dorzolamide hcl/timolol maleate 144doxazosin mesylate 76doxepin hcl 30,31doxycycline hyclate 19doxycycline monohydrate 19DRITHOCREME HP 96dronabinol 33DRYSOL 96DUET DHA 400 160DUET DHA BALANCED 160DULERA 153,168duloxetine hcl 92DUROLANE 137dutasteride 105

EED-SPAZ 101EDURANT 57efavirenz 57EFFER-K 157ELAPRASE 99ELELYSO 100

ELIDEL 96ELIGARD 128ELINEST 116ELIQUIS 72,168ELITE-OB 160ELMIRON 106EMGALITY PEN 168EMGALITY SYRINGE 169emtricitabine 58EMTRIVA 58EMVERM 45enalapril maleate 77enalapril maleate/hydrochlorothiazide 83ENBREL 130,169ENBREL MINI 130ENBREL SURECLICK 130ENDOCET 4ENGERIX-B ADULT 134ENGERIX-B PEDIATRIC-ADOLESCENT 134enoxaparin sodium 72ENPRESSE 116ENSKYCE 116entacapone 47entecavir 55ENTRESTO 83ENULOSE 103EPANED 77EPIFOAM 96epinastine hcl 142epinephrine 150EPITOL 23EPIVIR HBV 55eplerenone 85EQUETRO 66ergocalciferol (vitamin d2) 160ergoloid mesylates 24ergotamine tartrate/caffeine 36ERIVEDGE 42erlotinib hcl 42ERRIN 124ERYTHROCIN LACTOBIONATE 17

erythromycin base 17erythromycin base in ethanol 17escitalopram oxalate 26ESGIC 92esomeprazole magnesium 104ESTARYLLA 116estradiol 117estradiol/norethindrone acetate 117ESTRING 117eszopiclone 156ethambutol hcl 38ethinyl estradiol/drospirenone 117ethosuximide 20ethynodiol diacetate-ethinyl estradiol 117etodolac 1etoposide 41EUFLEXXA 137EURAX 46everolimus 42,130EVOTAZ 60exemestane 41EXTAVIA 93ezetimibe 87

FFALMINA 117famciclovir 62famotidine 10,102FARXIGA 67febuxostat 35felbamate 21felodipine 81FEMRING 117FEMYNOR 117fenofibrate 85fenofibrate nanocrystallized 86fenofibrate,micronized 86fenofibric acid 86fenoprofen calcium 1FENORTHO 1fentanyl 3

FIBRICOR 86finasteride 106FIRMAGON 128flash glucose scanning reader 137flash glucose sensor 138FLEBOGAMMA DIF 132flecainide acetate 78FLORIVA PLUS 169FLOVENT DISKUS 146FLOVENT HFA 147FLUAD 2020-2021 169FLUAD QUAD 2020-2021 169FLUAD QUAD 2021-2022 169FLUARIX QUAD 2020-2021 169FLUARIX QUAD 2021-2022 169FLUBLOK QUAD 2020-2021 169FLUBLOK QUAD 2021-2022 170FLUCELVAX QUAD 2020-2021 170FLUCELVAX QUAD 2021-2022 170fluconazole 34fludrocortisone acetate 109FLULAVAL QUAD 2020-2021 170FLULAVAL QUAD 2021-2022 170FLUMIST QUAD 2020-2021 170flunisolide 147fluocinolone acetonide oil 146fluocinonide 96,109fluoride (sodium) 157,158FLUORITAB 158fluorometholone 143FLUOROPLEX 97fluorouracil 40,97fluoxetine hcl 26,27fluphenazine decanoate 48fluphenazine hcl 48FLURA-DROPS 158flurbiprofen 1flurbiprofen sodium 143flutamide 39fluticasone propionate 109,147fluvoxamine maleate 27

FLUZONE HIGH-DOSE QUAD 2020-21 170FLUZONE HIGH-DOSE QUAD 2021-22 170FLUZONE QUAD 2020-2021 171FLUZONE QUAD 2021-2022 171FML FORTE 143FML S.O.P. 143FOCALIN XR 90folic acid 160FOLIVANE-OB 160FORTAVIT 160FORTEO 137fosamprenavir calcium 60FOSCAVIR 54,55fosinopril sodium 77fosinopril sodium/hydrochlorothiazide 83FULPHILA 171furosemide 84FUZEON 59FYAVOLV 117

Ggabapentin 21galantamine hbr 24GAMMAGARD LIQUID 132GAMMAGARD S-D 132GAMMAKED 132GAMUNEX-C 132ganciclovir sodium 55,171GAVILYTE-C 103GAVILYTE-G 103GAVILYTE-N 103GELSYN-3 138gemfibrozil 86GENERLAC 103GENGRAF 130GENOTROPIN 113GENTAK 11gentamicin sulfate 11GENVOYA 56GIANVI 118GILENYA 93,171

glatiramer acetate 94GLATOPA 94GLEEVEC 42GLEOSTINE 38glimepiride 67glipizide 67GLUCAGEN 70GLUCAGON EMERGENCY KIT 71glyburide 67glyburide,micronized 67glyburide/metformin hcl 67glycopyrrolate 101,171GLYXAMBI 67GRALISE 21granisetron hcl 33granisetron hcl/pf 33griseofulvin, microsize 34guanfacine hcl 76,91

HHAILEY 118HAILEY 24 FE 118HAILEY FE 118halcinonide 109halobetasol propionate 109haloperidol 48haloperidol decanoate 48haloperidol lactate 48HAVRIX 134HEATHER 124HEMATOGEN 158HEMATOGEN FA 158HEMATOGEN FORTE 158heparin sodium,porcine 72heparin sodium,porcine in 0.45 % sodiumchloride 72heparin sodium,porcine in 0.9 % sodiumchloride 73,171heparin sodium,porcine in 0.9 % sodiumchloride/pf 73heparin sodium,porcine/dextrose 5 % in water 73

heparin sodium,porcine/pf 73HERCEPTIN 44HIZENTRA 133,171HOMATROPAIRE 140homatropine hbr 140HORIZANT 92HUMALOG 71HUMIRA 130HUMIRA PEN 131HUMIRA PEN CROHN'S-UC-HS 131HUMIRA PEN PSOR-UVEITS-ADOL HS 131HUMIRA(CF) 131,172HUMIRA(CF) PEDIATRIC CROHN'S 172HUMIRA(CF) PEN 172HUMIRA(CF) PEN CROHN'S-UC-HS 172HUMIRA(CF) PEN PEDIATRIC UC 172HUMIRA(CF) PEN PSOR-UV-ADOL HS 172HUMULIN R U-500 71HUMULIN R U-500 KWIKPEN 71hydralazine hcl 87hydrochlorothiazide 85hydrocodone bitartrate/acetaminophen 5hydrocodone bitartrate/homatropinemethylbromide 153hydrocodone/ibuprofen 5hydrocortisone 110,136hydrocortisone/acetic acid 146HYDROMET 154hydromorphone hcl 5hydroxychloroquine sulfate 46hydroxyurea 40hydroxyzine hcl 148hydroxyzine pamoate 148hyoscyamine sulfate 101HYOSYNE 101

Iibandronate sodium 137IBU 1ibuprofen 2ibuprofen/oxycodone hcl 5

ICLUSIG 42,172IMBRUVICA 42,172imipramine hcl 31imipramine pamoate 31imiquimod 97IMITREX 36INCRELEX 113indapamide 85INDOCIN 2indomethacin 2indomethacin, submicronized 2INFANRIX DTAP 134inhaler, assist devices 138inhaler, assist devices, accessories 138inhaler,assist device with large mask 138inhaler,assist device with medium mask 138inhaler,assist device with small mask 138INLYTA 42insulin aspart 71insulin aspart protamine human/insulin aspart 71insulin lispro 71insulin lispro protamine and insulin lispro 71INTELENCE 57INTRON A 56INTROVALE 118INVEGA SUSTENNA 50,51INVEGA TRINZA 51,52INVIRASE 60INVOKAMET 67INVOKANA 67IOPIDINE 144ipratropium bromide 149ipratropium bromide/albuterol sulfate 154irbesartan 76IRESSA 43ISENTRESS 56ISENTRESS HD 57ISIBLOOM 118isoniazid 38isoproterenol hcl 150isosorbide dinitrate 88

isosorbide mononitrate 88isotretinoin 97ISUPREL 150ivermectin 45

JJAIMIESS 118JAKAFI 43JANSSEN COVID-19 VACCINE (EUA) 173JANTOVEN 73JANUMET 68JANUMET XR 68JANUVIA 68JARDIANCE 68JASMIEL 118JENCYCLA 124JENTADUETO 68JENTADUETO XR 68JINTELI 118JULEBER 118JUNEL 118JUNEL FE 118JUNEL FE 24 118

KK-PHOS NO.2 106K-TAB ER 158KAITLIB FE 118KALETRA 60KALYDECO 151KARIVA 118KAZANO 68KELNOR 1-35 118KELNOR 1-50 119KENALOG-10 110KENALOG-80 173KERALYT SCALP 97ketoconazole 34ketoprofen 2,173ketorolac tromethamine 2,143KIONEX 157

KITABIS PAK 151KLOR-CON 158KLOR-CON 10 158KLOR-CON 8 158KLOR-CON M10 158KLOR-CON M15 158KLOR-CON M20 158KLOR-CON-EF 158KOMBIGLYZE XR 68KORLYM 110KOSHER PRENATAL PLUS IRON 160KRISTALOSE 103KURVELO 119KYLEENA 124

Llabetalol hcl 79lactulose 103LAMICTAL XR (BLUE) 22LAMICTAL XR (GREEN) 22LAMICTAL XR (ORANGE) 22lamivudine 55,58lamivudine/zidovudine 59lamotrigine 22LANOXIN 83LANOXIN PEDIATRIC 83lansoprazole 104LANTUS 71LANTUS SOLOSTAR 72lapatinib ditosylate 43LARIN 119LARIN 24 FE 119LARIN FE 119LARISSIA 119latanoprost 145LATUDA 52leflunomide 133LESSINA 119LETAIRIS 151letrozole 41leucovorin calcium 40

LEUKERAN 38leuprolide acetate 128LEVA SET 7LEVEMIR 72LEVEMIR FLEXTOUCH 72levetiracetam 20LEVO-T 126levobunolol hcl 145levocarnitine 160levocarnitine (with sugar) 160levofloxacin 18LEVONEST 119levonorgestrel/ethinyl estradiol 119LEVORA-28 119levothyroxine sodium 126LEVOXYL 126LEXIVA 61LIALDA 135LIDO BDK 138LIDO-K 7LIDO-PRILO CAINE PACK 7LIDO-SORB 7lidocaine 7lidocaine hcl 7,8lidocaine/prilocaine 8LIDOPRIL 8LIDOPRIL XR 8LIDOZION 8LILETTA 124LILLOW 119lincomycin hcl 13lindane 46linezolid 13LINZESS 102liothyronine sodium 126LIPROZONEPAK 8lisinopril 77lisinopril/hydrochlorothiazide 83lithium carbonate 66lithium citrate 66LIVIXIL PAK 8

LO-ZUMANDIMINE 119loperamide hcl 102lopinavir/ritonavir 61LOPREEZA 119lorazepam 65LORAZEPAM INTENSOL 65LORYNA 119losartan potassium 76losartan potassium/hydrochlorothiazide 83lovastatin 86LOW-OGESTREL 119loxapine succinate 48lubiprostone 102LUDENT FLUORIDE 158LUPRON DEPOT 128LUPRON DEPOT (LUPANETA) 128LUPRON DEPOT-PED 128LUTERA 120

MMAKENA 125,173malathion 46maprotiline hcl 27MARLISSA 120MARNATAL-F 160MATULANE 38MAVYRET 56MAXIDEX 143meclizine hcl 32MEDOLOR PAK 8MEDROL 110medroxyprogesterone acetate 125mefenamic acid 2megestrol acetate 125MELODETTA 24 FE 120meloxicam 2memantine hcl 24MENEST 120MENOSTAR 120meperidine hcl 5mercaptopurine 40

METAXALL 155metaxalone 155metformin hcl 69methazolamide 145METHERGINE 138methimazole 129methocarbamol 155methotrexate sodium 131methoxsalen 97methyldopa 76methylergonovine maleate 139METHYLIN 91methylphenidate hcl 91methylprednisolone 110methylprednisolone acetate 110methylprednisolone sodium succinate 110metipranolol 145metoclopramide hcl 32metolazone 85metoprolol succinate 80metoprolol tartrate 80metoprolol tartrate/hydrochlorothiazide 83metronidazole 13,97mexiletine hcl 78miconazole nitrate 35MICROGESTIN 120MICROGESTIN FE 120midodrine hcl 76miglustat 100MILI 120MILLIPRED 110MILLIPRED DP 110MIMVEY 120MINITRAN 88MINOCIN 19minocycline hcl 19minoxidil 87MIRENA 125mirtazapine 25misoprostol 104MODERNA COVID-19 VACCINE (EUA) 173

moexipril hcl 77molindone hcl 49mometasone furoate 110MONDOXYNE NL 19montelukast sodium 149MORGIDOX 20morphine sulfate 3,6morphine sulfate/pf 6MOXEZA 18moxifloxacin hcl 18mucus clearing device 139MULTAQ 78multivitamin combination no.51/ferrousfumarate/folic acid 160mupirocin 13mupirocin calcium 13MVC-FLUORIDE 160mycophenolate mofetil 131MYNATAL 160MYNATAL PLUS 160MYNATAL-Z 160MYNEPHROCAPS 161MYNEPHRON 161MYORISAN 97

Nnabumetone 2nadolol 80NALFON 2naloxone hcl 10naltrexone hcl 9NAMENDA XR 24naproxen 2naproxen sodium 2naratriptan hcl 36NARCAN 10NATACHEW 161NATACYN 35nateglinide 69NATESTO 114NATROBA 97

NATURE-THROID 126nebulizer 139nebulizer accessories 139nebulizer and compressor 139NECON 120NEEVODHA 161NEO-POLYCIN 140NEO-POLYCIN HC 140neomycin sulfate 11neomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone 141neomycin sulfate/bacitracin/polymyxin b 141neomycin sulfate/polymyxin b sulfate/gramicidind 141neomycin sulfate/polymyxin bsulfate/hydrocortisone 141,146neomycin/polymyxin bsulfate/dexamethasone 141NEPHRON FA 158NESINA 69NESTABS 161NESTABS ABC 161NESTABS DHA 161NESTABS ONE 173NEUPOGEN 74NEUTRASAL 94nevirapine 57NEWGEN 161NEXAVAR 43NEXPLANON 125NIACOR 87NICADAN 161NICAZEL 161NICAZEL FORTE 161NICOTROL 11NICOTROL NS 11nifedipine 81NIFEREX 157NIKKI 120nilutamide 39NITRO-BID 88

NITRO-DUR 88NITRO-TIME 88nitrofurantoin 13nitrofurantoin macrocrystal 13nitrofurantoin monohydrate/macrocrystals 13nitroglycerin 88NIVA-PLUS 161NIVESTYM 173nizatidine 102NOLIX 110NORDITROPIN FLEXPRO 113norethindrone 125norethindrone acetate 125norethindrone acetate-ethinyl estradiol 120norethindrone acetate-ethinyl estradiol/ferrousfumarate 120,121norethindrone-ethinyl estradiol/ferrousfumarate 121norgestimate-ethinyl estradiol 121NORITATE 97NORLYDA 125NORPACE CR 78NORTREL 121nortriptyline hcl 31NORVIR 61NP THYROID 127NPLATE 74,174NUCALA 174NUFERA 159NULEV 101NUMBONEX 8NUMOISYN 94NUVARING 121NUVESSA 13NYAMYC 35nystatin 35NYSTOP 35NYVEPRIA 174

OO-CAL FA 161

O-CAL PRENATAL 161OB COMPLETE 161OB COMPLETE ONE 161OB COMPLETE PETITE 161OB COMPLETE PREMIER 161OB COMPLETE WITH DHA 162octreotide acetate 129ODEFSEY 57OFIRMEV 92ofloxacin 18olanzapine 52,53olmesartan medoxomil 77olmesartan medoxomil/hydrochlorothiazide 83olopatadine hcl 142omeprazole 104OMNARIS 147ondansetron 33ondansetron hcl 33,34ondansetron hcl/pf 34ONGLYZA 69ORACIT 106ORALONE 94ORBACTIV 13orphenadrine citrate 155ORSYTHIA 121OSCIMIN 101OSCIMIN SL 101OSCIMIN SR 101oseltamivir phosphate 61OSENI 69OTEZLA 133oxaprozin 3oxazepam 65oxcarbazepine 23OXTELLAR XR 23oxybutynin chloride 105oxycodone hcl 6oxycodone hcl/acetaminophen 6,174

PPACERONE 78

PACNEX 97pantoprazole sodium 105PARAGARD T 380-A 139PAROEX 94paroxetine hcl 27,28PAZEO 142peak flow meter/inhaler, assist devices 139pediatric multivit with a,c,d3 no.21/sodiumfluoride 162pediatric multivitamin no.2/sodium fluoride 162pediatric multivitamins no.17 with sodiumfluoride 162peg 3350/sod sulf/sod bicarb/sodchloride/potassium chloride 103PEGASYS PROCLICK 56pen needle, diabetic 139penicillamine 106penicillin v potassium 17PENTASA 135pentazocine hcl/naloxone hcl 6pentoxifylline 83perindopril erbumine 77PERIOGARD 94permethrin 46perphenazine 32PERSERIS 174PFIZER COVID (12Y UP) VAC(EUA) 174PFIZER COVID (5-11Y) VAC (EUA) 174PFIZER COVID-19 VACCINE (EUA) 174PHARMABASE BARRIER 97PHENADOZ 32phenazopyridine hcl 106PHENERGAN 148phenobarbital 21phenylephrine hcl 141phenylephrine hcl/promethazine hcl 154phenytoin 23phenytoin sodium extended 23PHILITH 121PIFELTRO 175pilocarpine hcl 95,145

pimozide 49PIMTREA 121pioglitazone hcl 69pioglitazone hcl/metformin hcl 69piperacillin sodium/tazobactam sodium 17PIRMELLA 121piroxicam 3PNEUMOVAX 23 134PNV 29-1 162pnv no.72/ferrous fumarate/folic acid/omega-3/dha 162PNV-OMEGA 162POLYCIN 141polymyxin b sulfate/trimethoprim 141PORTIA 121potassium chloride 159potassium chloride in water for injection,sterile 159potassium citrate 106potassium citrate/citric acid 106PR NATAL 400 162PR NATAL 400 EC 162PR NATAL 430 162PR NATAL 430 EC 162PRADAXA 74pramipexole di-hcl 47PRAMOSONE 98pravastatin sodium 86praziquantel 45prazosin hcl 76PRED MILD 143PRED-G 141prednisolone 111prednisolone acetate 143prednisolone acetate/pf 175prednisolone sodium phosphate 111,143prednisone 111PREDNISONE INTENSOL 111pregabalin 93PREMARIN 121PREMPHASE 122

PREMPRO 122PRENA1 CHEW 162PRENA1 PEARL 162PRENA1 TRUE 162PRENATA 162PRENATABS FA 162PRENATABS RX 162prenatal vits with calcium no.115/ironfumarate/folic acid 163prenatal vits with calcium no.72/ferrousfumarate/folic acid 163prenatal vits with calciumno.72/iron,carbonyl/folic acid 163PRENATE AM 163PRENATE CHEWABLE 163PRENATE DHA 163PRENATE ELITE 163PRENATE ENHANCE 163PRENATE ESSENTIAL 163PRENATE MINI 163PRENATE PIXIE 163PRENATE RESTORE 163PRENATE STAR 163PREPLUS 163PRETAB 163PREVALITE 87PREVIDENT 95PREVNAR 13 134PREVNAR 20 175PREZCOBIX 59PREZISTA 61PRILOLID 8PRIMACARE 163primaquine phosphate 46primidone 21PRIMLEV 6PRIVIGEN 133PROAIR HFA 150probenecid 36probenecid/colchicine 36prochlorperazine 32

prochlorperazine maleate 32PROCTO-MED HC 111PROCTO-PAK 111PROCTOCORT 111PROCTOSOL-HC 111PROCTOZONE-HC 111progesterone, micronized 125PROGLYCEM 71PROLASTIN C 154PROLENSA 144PROLIA 137PROMACTA 74promethazine hcl 32,148,149promethazine hcl/codeine 154promethazine hcl/dextromethorphan hbr 154PROMETHEGAN 32propafenone hcl 79propantheline bromide 101propranolol hcl 80propranolol hcl/hydrochlorothiazide 83propylthiouracil 129PROTONIX 105protriptyline hcl 31PROVIDA OB 163PULMICORT FLEXHALER 147PULMOZYME 154PUREFE OB PLUS 164pyrazinamide 38pyridostigmine bromide 37pyridoxine hcl (vitamin b6) 164

QQNASL 147QNASL CHILDREN 147quetiapine fumarate 53QUFLORA 164quinapril hcl 77quinapril hcl/hydrochlorothiazide 84quinidine gluconate 79quinidine sulfate 79quinine sulfate 46

RR-NATAL OB 164raloxifene hcl 126ramipril 78ranitidine hcl 102ranolazine 84RAYOS 111REBIF 94REBIF REBIDOSE 94RECLIPSEN 122RECOMBIVAX HB 134REGRANEX 98RELADOR PAK 8RELADOR PAK PLUS 8RELENZA 61RENA-VITE RX 164RENAL CAPS 164RENO CAPS 164repaglinide 69REQ49+ 164RESCRIPTOR 58RESTASIS 141RETACRIT 175RETIN-A 98REVATIO 152REVLIMID 39REYATAZ 61RIBASPHERE 56ribavirin 56RIFAMATE 38rifampin 38rimantadine hcl 62RISPERDAL CONSTA 53risperidone 53RITALIN LA 91,92ritonavir 61RITUXAN 44RITUXAN HYCELA 44rivastigmine 24rivastigmine tartrate 24

rizatriptan benzoate 36ropinirole hcl 47ROSADAN 98rosuvastatin calcium 86ROWEEPRA 20ROWEEPRA XR 20ROZEREM 157rufinamide 23

Ssalicylic acid 98SALIMEZ 98SALIMEZ FORTE 98SALIVAMAX 95salsalate 3SANDIMMUNE 131SANDOSTATIN LAR DEPOT 129SCALACORT 111SE-NATAL 19 164SE-NATAL-19 164SELECT-OB 164SELECT-OB + DHA 164selenium sulfide 98SELZENTRY 60SEREVENT DISKUS 150sertraline hcl 28SETLAKIN 122sevelamer carbonate 107SFROWASA 136SHAROBEL 125SHINGRIX 134SHINGRIX ADJUVANT COMPONENT 134SHINGRIX GE ANTIGEN COMPONENT 135sildenafil citrate 152silver sulfadiazine 18SIMLIYA 122SIMPESSE 122simvastatin 87sirolimus 131SITAVIG 62SKLICE 45

SKYLA 125sodium chloride/sodium bicarbonate/potassiumchloride/peg 103sodium polystyrene sulfonate 157sodium/potassium/potassium citrate/sodiumcitrate/cit ac 106sofosbuvir/velpatasvir 56SOLTAMOX 39SOLU-CORTEF 111SOLU-MEDROL 111SOMATULINE DEPOT 129SORILUX 98SORINE 79SOTALOL AF 79sotalol hcl 79spinosad 98SPIRIVA 149spirometers and accessories 139spironolactone 85spironolactone/hydrochlorothiazide 84SPRAVATO 175SPRINTEC 122SPS 157SRONYX 122SSD 18STALEVO 125 47STALEVO 50 47STALEVO 75 47stavudine 59STIMATE 113STIOLTO RESPIMAT 155STRIBILD 57STROVITE ONE 164SUBLOCADE 175SUBOXONE 9SUBVENITE 22SUCRAID 100sucralfate 104sulfacetamide sodium 18sulfacetamide sodium/prednisolone sodiumphosphate 141

sulfadiazine 19sulfamethoxazole/trimethoprim 19sulfasalazine 136SULFATRIM 19sulindac 3sumatriptan succinate 36,37SUPERVITE 164SUPRAX 16SUTENT 43SYEDA 122SYLATRON 40SYMAX DUOTAB 101SYMAX-SR 101SYMBICORT 155SYMLINPEN 120 69SYMLINPEN 60 69SYNAGIS 133SYNAREL 129SYNJARDY 70syringe with needle, insulin, safety, 0.3 ml 139syringe with needle, insulin, safety, 0.5 ml 139syringe with needle, insulin, safety, 1 ml 139syringe with needle,disposable,insulin 1 ml 139syringe with needle,insulin,0.3 ml 139syringe with needle,insulin,0.5 ml 139syringe,safety with needle,1 ml 139,175

TTABLOID 40tacrolimus 98,131tamoxifen citrate 39tamsulosin hcl 106TAPERDEX 112TARINA 24 FE 122TARINA FE 122TARINA FE 1-20 EQ 122TARON-C DHA 164TASIGNA 43,175TAZTIA XT 81temazepam 156temozolomide 39

tenofovir disoproxil fumarate 59terazosin hcl 76terbinafine hcl 35terconazole 35teriparatide 137testosterone cypionate 114,175testosterone enanthate 114THALOMID 39THEO-24 151theophylline anhydrous 151thiamine hcl 164thioridazine hcl 49thiothixene 49THRIVITE RX 164THYROID 127thyroid,pork 127TIADYLT ER 81tiagabine hcl 21TIGAN 33timolol maleate 145TIMOPTIC OCUDOSE 145TIMOPTIC-XE 145TIROSINT 127TIVICAY 57TIVORBEX 3tizanidine hcl 156TOBRADEX 142TOBRADEX ST 142tobramycin 11tobramycin sulfate 12tobramycin/dexamethasone 142TOBREX 12TOLAK 99topiramate 22toremifene citrate 40torsemide 84TOVET EMOLLIENT 112TOVIAZ 105TRACLEER 152TRADJENTA 70tramadol hcl 4,6,176

trandolapril 78travoprost 145trazodone hcl 28,29tretinoin 45,99TREXALL 132TRI FEMYNOR 122TRI-ESTARYLLA 122TRI-LEGEST FE 122TRI-LO-ESTARYLLA 122TRI-LO-MARZIA 123TRI-LO-MILI 123TRI-LO-SPRINTEC 123TRI-MILI 123TRI-PREVIFEM 123TRI-SPRINTEC 123TRI-VYLIBRA 123TRI-VYLIBRA LO 123triamcinolone acetonide 95,112,147triamcinolone diacetate in 0.9 % sodiumchloride 176triamcinolone diacetate in 0.9 % sodiumchloride/pf 176triamterene/hydrochlorothiazide 84TRIANEX 112TRICARE 165TRICITRATES 107TRICON 159TRIDERM 112trifluoperazine hcl 49trifluridine 62TRIGELS-F FORTE 159trihexyphenidyl hcl 46TRIJARDY XR 176TRILYTE WITH FLAVOR PACKETS 103trimethobenzamide hcl 33trimethoprim 13trimipramine maleate 31TRINATAL RX 1 165TRINATE 165TRIPHROCAPS 165TRISTART DHA 165

TRIUMEQ 60TRIVEEN-DUO DHA 165TRIVORA-28 123TROKENDI XR 22TRULICITY 70,176TRUVADA 59TUDORZA PRESSAIR 150TUZISTRA XR 155TYBOST 60TYKERB 43

UUBRELVY 176UDENYCA 176UNITHROID 127ursodiol 102

VVABOMERE 16valacyclovir hcl 62valganciclovir hcl 55valproic acid 21valproic acid (as sodium salt) (valproatesodium) 21valsartan 77valsartan/hydrochlorothiazide 84VANCOCIN HCL 13vancomycin hcl 14,176vancomycin hcl in sterile water 176vancomycin hcl in water for injection (peg-400,nada) 14,177vancomycin in 0.9 % sodium chloride 14,177vancomycin in 5 % dextrose in water 14,177VANDAZOLE 14VAQTA 135VELETRI 152VELIVET 123venlafaxine hcl 29verapamil hcl 82VIC-FORTE 165VICTOZA 2-PAK 70

VICTOZA 3-PAK 70VIDEX 59VIDEX EC 59VIENVA 123VIMPAT 23VIORELE 123VIRACEPT 61VIREAD 59VIRT-C DHA 165VIRT-CAPS 165VIRT-NATE DHA 165VIRT-PN DHA 165VIRT-PN PLUS 165VIRTRATE-2 107VIRTRATE-3 107VIRTRATE-K 107VITAFOL GUMMIES 165VITAFOL NANO 165VITAFOL ULTRA 165VITAFOL-OB 165VITAFOL-OB+DHA 165VITAFOL-ONE 166VITAL-D RX 166VITAMEDMD ONE RX 166VITAMEDMD REDICHEW RX 166VITAPEARL 166VITATRUE 166VIVITROL 9VOLNEA 123VOTRIENT 43VP-PNV-DHA 166VP-VITE RX 166VPRIV 100VYFEMLA 123VYLIBRA 123VYVANSE 89

Wwarfarin sodium 74WELLBUTRIN XL 25WERA 123

WESTHROID 127WP THYROID 127

XXALIX 177XALKORI 44XARELTO 74,177XELJANZ 132,177XIGDUO XR 70,177XTAMPZA ER 4XULANE 124

YYUVAFEM 124

ZZARAH 124ZATEAN-PN DHA 166ZATEAN-PN PLUS 166ZEBUTAL 92ZELBORAF 44ZEMAIRA 155ZENATANE 99ZENPEP 100ZETONNA 147zidovudine 59zinc oxide 99ZIONODIL 8ZIONODIL-100 9ZIOPTAN 145ziprasidone hcl 54ZITHROMAX 17ZOLINZA 40zolmitriptan 37zolpidem tartrate 156ZOMIG 37zonisamide 20ZOSTAVAX 135ZOVIA 1-35 124ZOVIA 1-35E 124ZUMANDIMINE 124

ZYTIGA 39ZYVOX 14

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