Magellan Rx Medicare Basic (PDP) 2020 Formu lary

Magellan Rx Medicare Basic (PDP)

2020 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary File 20075, Version 28

This formulary was updated on 11/24/2020. For more recent information or other questions, please contact Magellan Rx Medicare Customer Service at 1-800-424-5870 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit https://medicare.magellanrx.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Magellan Rx Medicare. When it refers to “plan” or “our plan,” it means Magellan Rx Medicare Basic (PDP).

This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

S4607_CLFMCM_2020_C

What is the Magellan Rx Medicare Basic (PDP) Formulary? A formulary is a list of covered drugs selected by Magellan Rx Medicare Basic (PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Magellan Rx Medicare Basic (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Magellan Rx Medicare Basic (PDP) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep thebrand name drug on our Drug List, but immediately move it to a different cost-sharing tier or addnew restrictions. If you are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Magellan Rx Medicare Basic (PDP)Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. Forinstance, we may add a generic drug that is not new to market to replace a brand name drug currentlyon the formulary or add new restrictions to the brand name drug or move it to a different cost-sharingtier. Or we may make changes based on new clinical guidelines. If we remove drugs from ourformulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or movea drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 daysbefore the change becomes effective, or at the time the member requests a refill of the drug, at whichtime the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Magellan Rx Medicare Basic (PDP)Formulary?”

I

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of December 1, 2020. To get updated information about the drugs covered by Magellan Rx Medicare Basic (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (such as adding prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, removing drugs from our formulary, or moving a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the information. The updated formulary will be available on our website or by calling Customer Service. Our contact information appears on the front and back cover pages of this document.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 87. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Magellan Rx Medicare Basic (PDP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

II

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Magellan Rx Medicare Basic (PDP) requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from Magellan RxMedicare Basic (PDP) before you fill your prescriptions. If you don’t get approval, Magellan RxMedicare Basic (PDP) may not cover the drug.

• Quantity Limits: For certain drugs, Magellan Rx Medicare Basic (PDP) limits the amount of thedrug that Magellan Rx Medicare Basic (PDP) will cover. For example, Magellan Rx Medicare Basic(PDP) provides 60 per prescription for PRADAXA. This may be in addition to a standard one-monthor three-month supply.

• Step Therapy: In some cases, Magellan Rx Medicare Basic (PDP) requires you to first try certaindrugs to treat your medical condition before we will cover another drug for that condition. Forexample, if Drug A and Drug B both treat your medical condition, Magellan Rx Medicare Basic(PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MagellanRx Medicare Basic (PDP) will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Magellan Rx Medicare Basic (PDP) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Magellan Rx Medicare Basic (PDP) formulary?” on page IV for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Magellan Rx Medicare Basic (PDP) does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Magellan Rx MedicareBasic (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Magellan Rx Medicare Basic (PDP).

• You can ask Magellan Rx Medicare Basic (PDP) to make an exception and cover your drug. Seebelow for information about how to request an exception.

III

How do I request an exception to the Magellan Rx Medicare Basic (PDP) Formulary? You can ask Magellan Rx Medicare Basic (PDP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on thespecialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Magellan Rx Medicare Basic (PDP) limits the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Magellan Rx Medicare Basic (PDP) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

IV

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Magellan Rx Management, a properly licensed affiliate of Magellan Health, Inc. (Magellan) implements and maintains an appropriate medication transition process consistent with Centers for Medicare and Medicaid Services (CMS) requirement for members whose current prescribed Part D drugs are not on Magellan’s formulary. Magellan Rx Management (Magellan) implements and maintains an appropriate transition process in compliance with CMS rules and guidance. Transition supplies are available to members whose current drug therapy may not be covered by the plan, or that are on the formulary but subject to prior authorization (PA), step therapy (ST), or quantity limit (QL) edits based on Magellan’s utilization management program. Transition supplies will allow members sufficient time to work with their medical provider to switch to a therapeutically appropriate formulary alternative or to request a coverage determination should the medication be medically necessary. Enrollees experiencing a level of care change may access a refill upon admission or discharge to a long term care facility. Enrollees in need of a one-time Transition Fill, or who are prescribed a Non-Formulary Drug as a result of a level of care change, can be placed in transition via a National Council for Prescription Drug Plans (NCPDP) pharmacy submission clarification code (SCC) via manual override at the pharmacy or by contacting Magellan Call Center for an override.

For more information For more detailed information about your Magellan Rx Medicare Basic (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Magellan Rx Medicare Basic (PDP), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call1-877-486-2048. Or, visit http://www.medicare.gov.

Magellan Rx Medicare Basic (PDP)’s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Magellan Rx Medicare Basic (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 87. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANOXIN) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the Requirements/Limits column tells you if Magellan Rx Medicare Basic (PDP) has any special requirements for coverage of your drug.

V

LEGEND

TIER NAME

1 PREFERRED GENERIC

2 GENERIC

3 PREFERRED BRAND

4 NON-PREFERRED DRUG

5 SPECIALTY TIER

SYMBOL NAME DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that iscovered per prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get priorauthorization before you fill your prescription for thisdrug. Without prior approval, we may not cover thisdrug.

ST Step TherapyIn some cases, you may be required to first try certaindrugs to treat your medical condition before we willcover another drug for that condition.

1

MAGELLAN RX MANAGEMENT PDP (20075) (List of Covered Drugs)

DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib (50 mg cap, 100 mg cap, 200 mgcap, 400 mg cap)

4 QL (60 PER 30 DAYS)

diclofenac potassium 50 mg tab 3

diclofenac sodium (25 mg tab dr, 50 mg tab dr,75 mg tab dr)

3

diclofenac sodium 1 % gel 4 QL (1000 PER 30 DAYS)

ibu (400 mg tab, 600 mg tab, 800 mg tab) 1

ibuprofen (100 mg/5ml suspension, 400 mgtab, 600 mg tab, 800 mg tab)

1

indomethacin (25 mg cap, 50 mg cap) 4

ketorolac tromethamine 10 mg tab 4 QL (20 PER 30 OVER TIME)

meloxicam (7.5 mg tab, 15 mg tab) 1

nabumetone (500 mg tab, 750 mg tab) 2

naproxen (125 mg/5ml suspension, 250 mgtab)

2

naproxen (375 mg tab, 500 mg tab) 1

OPIOID ANALGESICS, LONG-ACTINGEMBEDA (20-0.8 MG CAP ER, 30-1.2 MGCAP ER, 50-2 MG CAP ER, 60-2.4 MG CAPER, 80-3.2 MG CAP ER, 100-4 MG CAP ER)


fentanyl (12 mcg/hr patch 72hr, 25 mcg/hrpatch 72hr, 37.5 mcg/hr patch 72hr, 50 mcg/hrpatch 72hr, 62.5 mcg/hr patch 72hr, 75 mcg/hrpatch 72hr, 100 mcg/hr patch 72hr)


fentanyl 87.5 mcg/hr patch 72hr 5 QL (10 PER 30 DAYS)

methadone hcl (5 mg/5ml solution, 10 mg/5mlsolution)


methadone hcl 10 mg tab 3 QL (180 PER 30 DAYS)

methadone hcl 5 mg tab 3 QL (90 PER 30 DAYS)

You can find information on what the symbols and abbreviationson this table mean by going to page 1.

2


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

morphine sulfate er (er 10 mg cap er 24h, er20 mg cap er 24h, er 30 mg cap er 24h, er 40mg cap er 24h, er 50 mg cap er 24h, er 60 mgcap er 24h, er 80 mg cap er 24h)


morphine sulfate er (er 15 mg tab er, er 30 mgtab er, er 60 mg tab er, er 100 mg tab er)


morphine sulfate er 100 mg cap er 24h 5 QL (30 PER 30 DAYS)

morphine sulfate er 200 mg tab er 4 QL (60 PER 30 DAYS)

tramadol hcl er (biphasic) (er (biphasic) 100mg tab er 24h, er (biphasic) 200 mg tab er24h, er (biphasic) 300 mg tab er 24h)


tramadol hcl er (er 100 mg tab er 24h, er 100mg cap er 24h, er 150 mg cap er 24h, er 200mg tab er 24h, er 200 mg cap er 24h, er 300mg cap er 24h, er 300 mg tab er 24h)


OPIOID ANALGESICS, SHORT-ACTINGacetaminophen-codeine 120-12 mg/5mlsolution

2 QL (2700 PER 30 DAYS)

acetaminophen-codeine 300-15 mg tab 2 QL (180 PER 30 DAYS)



butalbital-apap-caff-cod (50-325-40-30 mgcap, 50-300-40-30 mg cap)


butalbital-asa-caff-codeine 50-325-40-30 mgcap


butorphanol tartrate 10 mg/ml solution 2 QL (60 PER 30 DAYS)

codeine sulfate (15 mg tab, 30 mg tab, 60 mgtab)


duramorph (0.5 mg/ml solution, 1 mg/mlsolution)

2

fentanyl citrate (200 mcg loz handle, 400 mcgloz handle, 600 mcg loz handle, 800 mcg lozhandle, 1200 mcg loz handle, 1600 mcg lozhandle)

5 PA, QL (120 PER 30 DAYS)

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

3 QL (2700 PER 30 DAYS)


3


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

hydrocodone-acetaminophen (5-325 mg tab,5-300 mg tab, 7.5-300 mg tab, 7.5-325 mgtab, 10-300 mg tab, 10-325 mg tab)


hydromorphone hcl (2 mg tab, 4 mg tab, 8 mgtab)


hydromorphone hcl 1 mg/ml liquid 4 QL (1800 PER 30 DAYS)

hydromorphone hcl pf (10 mg/ml solution, 50mg/5ml solution, 500 mg/50ml solution)

4

morphine sulfate (15 mg tab, 30 mg tab) 3 QL (180 PER 30 DAYS)

morphine sulfate (2 mg/ml solution, 4 mg/mlsolution, 8 mg/ml solution, 10 mg/ml solution)

4

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


morphine sulfate (pf) ((pf) 0.5 mg/ml solution,(pf) 1 mg/ml solution, (pf) 2 mg/ml solution,(pf) 4 mg/ml solution, (pf) 5 mg/ml solution,(pf) 8 mg/ml solution, (pf) 10 mg/ml solution,(pf) 15 mg/ml solution)

4

morphine sulfate 10 mg/5ml solution 4 QL (1800 PER 30 DAYS)

morphine sulfate 20 mg/5ml solution 4 QL (900 PER 30 DAYS)

oxycodone hcl (5 mg cap, 5 mg tab, 10 mgtab, 15 mg tab, 20 mg tab, 30 mg tab)


oxycodone hcl 100 mg/5ml conc 4 QL (180 PER 30 DAYS)

oxycodone hcl 5 mg/5ml solution 3 QL (2700 PER 30 DAYS)

oxycodone-acetaminophen (5-325 mg tab,7.5-325 mg tab, 10-325 mg tab)


oxycodone-acetaminophen 2.5-325 mg tab 3 QL (120 PER 30 DAYS)

oxycodone-aspirin 4.8355-325 mg tab 3 QL (360 PER 30 DAYS)

oxycodone-ibuprofen 5-400 mg tab 3 QL (120 PER 30 DAYS)

tramadol hcl 100 mg tab 2 QL (120 PER 30 DAYS)

tramadol hcl 50 mg tab 2 QL (240 PER 30 DAYS)


4


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANESTHETICS

LOCAL ANESTHETICSlidocaine 5 % patch 4 PA

lidocaine hcl 4 % solution 2 PA, QL (50 PER 30 DAYS)

lidocaine-prilocaine 2.5-2.5 % cream 4 PA, QL (30 PER 30 DAYS)

lidocaine-prilocaine cream 2.5-2.5 % 4 PA, QL (30 PER 30 DAYS)

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVINGacamprosate calcium 333 mg tab dr 2

disulfiram (250 mg tab, 500 mg tab) 2

VIVITROL 380 MG RECON SUSP 5

OPIOID DEPENDENCE TREATMENTSbuprenorphine hcl 2 mg sl tab 2 QL (360 PER 30 DAYS)

buprenorphine hcl 8 mg sl tab 2 QL (90 PER 30 DAYS)

buprenorphine hcl-naloxone hcl 12-3 mg film 4 QL (60 PER 30 DAYS)

buprenorphine hcl-naloxone hcl 2-0.5 mg film 4 QL (360 PER 30 DAYS)

buprenorphine hcl-naloxone hcl 2-0.5 mg sltab




buprenorphine hcl-naloxone hcl 8-2 mg sl tab 2 QL (90 PER 30 DAYS)

naltrexone hcl 50 mg tab 2

OPIOID REVERSAL AGENTSnaloxone hcl (0.4 mg/ml solution, 0.4 mg/mlsoln cart, 2 mg/2ml soln prsyr, 4 mg/10mlsolution)

2

NARCAN 4 MG/0.1ML LIQUID 4


5


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

SMOKING CESSATION AGENTSbupropion hcl er (smoking det) tab er 12h 150mg


CHANTIX (0.5 MG TAB, 1 MG TAB) 3 QL (504 PER 365 OVER TIME)

CHANTIX CONTINUING MONTH PAK 1 MGTAB

3 QL (504 PER 365 OVER TIME)

CHANTIX STARTING MONTH PAK 3 QL (504 PER 365 OVER TIME)

NICOTROL NS 10 MG/ML SOLUTION 3 QL (360 PER 365 OVER TIME)

ANTI-INFLAMMATORY AGENTS

GLUCOCORTICOIDStriamcinolone acetonide 0.147 mg/gm aerosoln

4

ANTIBACTERIALS

AMINOGLYCOSIDESamikacin sulfate (1 gm/4ml solution, 500mg/2ml solution)

2

gentamicin in saline (0.8-0.9 mg/ml-%solution, 0.9-0.9 mg/ml-% solution, 1-0.9mg/ml-% solution, 1.2-0.9 mg/ml-% solution,1.4-0.9 mg/ml-% solution, 1.6-0.9 mg/ml-%solution, 2-0.9 mg/ml-% solution)

2

gentamicin sulfate (0.1 % cream, 0.1 %ointment, 40 mg/ml solution)

2

gentamicin sulfate 0.3 % solution 1

neomycin sulfate 500 mg tab 2

paromomycin sulfate 250 mg cap 4

streptomycin sulfate 1 gm recon soln 4

tobramycin 0.3 % solution 1

tobramycin sulfate (1.2 gm/30ml solution, 1.2gm recon soln, 2 gm/50ml solution, 10 mg/mlsolution, 80 mg/2ml solution)

2

TOBREX 0.3 % OINTMENT 4


6


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANTIBACTERIALS, OTHERbacitracin 500 unit/gm ointment 2

BACTROBAN NASAL 2 % OINTMENT 4

clindamycin hcl (75 mg cap, 150 mg cap, 300mg cap)

2

clindamycin palmitate hcl 75 mg/5ml reconsoln

2

clindamycin phosphate (1 % lotion, 1 % gel, 2% cream)

4

clindamycin phosphate (1 % solution, 1 %swab, 9 gm/60ml solution, 300 mg/2mlsolution, 600 mg/4ml solution, 900 mg/6mlsolution, 9000 mg/60ml solution)

2

clindamycin phosphate in d5w ( 600 mg/50mlsolution, 900 mg/50ml solution)

4

clindamycin phosphate in d5w 300 mg/50mlsolution

2

colistimethate sodium (cba) 150 mg recon soln 4

daptomycin (350 mg recon soln, 500 mg reconsoln)

5

linezolid 100 mg/5ml recon susp 5 QL (1800 PER 28 DAYS)

linezolid 600 mg tab 4 QL (56 PER 28 DAYS)

linezolid 600 mg/300ml solution 5

methenamine hippurate tab 1 gm 4

metronidazole (250 mg tab, 375 mg cap, 500mg tab)

3

metronidazole in nacl (5-0.79 mg/ml-%solution, 500-0.79 mg/100ml-% solution)

3

mupirocin 2 % ointment 2

nitrofurantoin 25 mg/5ml suspension 4 QL (7200 PER 365 OVER TIME)

nitrofurantoin macrocrystal 100 mg cap 3 QL (360 PER 365 OVER TIME)



nitrofurantoin monohyd macro 100 mg cap 3 QL (180 PER 365 OVER TIME)


7


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

polymyxin b sulfate 500000 unit recon soln 2

silver sulfadiazine 1 % cream 2

ssd 1 % cream 2

trimethoprim 100 mg tab 2

vancomycin hcl (1 gm recon soln, 1.25 gmrecon soln, 1.5 gm recon soln, 5 gm reconsoln, 10 gm recon soln, 100 gm recon soln,125 mg cap, 250 mg cap, 250 mg/5ml reconsoln, 250 mg recon soln, 500 mg recon soln,750 mg recon soln)

4

vandazole 0.75 % gel 2

BETA-LACTAM, CEPHALOSPORINScefaclor (250 mg cap, 500 mg cap) 4

cefadroxil (1 gm tab, 250 mg/5ml recon susp,500 mg/5ml recon susp, 500 mg cap)

2

cefazolin sodium (1 gm recon soln, 10 gmrecon soln, 20 gm recon soln, 500 mg reconsoln)

2

cefdinir (125 mg/5ml recon susp, 250 mg/5mlrecon susp, 300 mg cap)

3

cefepime hcl (1 gm recon soln, 2 gm reconsoln)

4

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

4

cefixime 400 mg cap 3

cefotetan disodium (1 gm recon soln, 2 gmrecon soln)

2

cefoxitin sodium (1 gm recon soln, 2 gm reconsoln, 10 gm recon soln)

2

cefpodoxime proxetil (50 mg/5ml recon susp,100 mg/5ml recon susp, 100 mg tab, 200 mgtab)

4

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

2

ceftazidime (1 gm recon soln, 2 gm reconsoln, 6 gm recon soln)

2


8


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ceftriaxone sodium (1 gm recon soln, 2 gmrecon soln, 10 gm recon soln, 250 mg reconsoln, 500 mg recon soln)

4

cefuroxime axetil (250 mg tab, 500 mg tab) 3

cefuroxime sodium (1.5 gm recon soln, 7.5 gmrecon soln, 750 mg recon soln)

3

cephalexin (125 mg/5ml recon susp, 250 mgcap, 250 mg tab, 250 mg/5ml recon susp, 500mg tab, 500 mg cap, 750 mg cap)

2

SUPRAX (100 MG CHEW TAB, 200 MGCHEW TAB, 400 MG CAP)

3

SUPRAX 500 MG/5ML RECON SUSP 5

TEFLARO (400 MG RECON SOLN, 600 MGRECON SOLN)

5

BETA-LACTAM, OTHERaztreonam 1 gm recon soln 4

imipenem-cilastatin (250 mg recon soln, 500mg recon soln)

4

meropenem (1 gm recon soln, 500 mg reconsoln)

2

BETA-LACTAM, PENICILLINSamoxicillin (125 mg chew tab, 125 mg/5mlrecon susp, 200 mg/5ml recon susp, 250mg/5ml recon susp, 250 mg chew tab, 250 mgcap, 400 mg/5ml recon susp, 500 mg cap, 500mg tab, 875 mg tab)

2

amoxicillin-pot clavulanate (200-28.5 mg/5mlrecon susp, 200-28.5 mg chew tab, 250-125mg tab, 250-62.5 mg/5ml recon susp, 400-57mg chew tab, 400-57 mg/5ml recon susp, 500-125 mg tab, 600-42.9 mg/5ml recon susp,875-125 mg tab)

4

amoxicillin-pot clavulanate er 1000-62.5 mgtab er 12h

4

ampicillin 500 mg cap 2

ampicillin sodium (1 gm recon soln, 2 gmrecon soln, 10 gm recon soln)

2


9


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ampicillin sodium 125 mg recon soln 4

ampicillin-sulbactam sodium (1.5 (1-0.5) gmrecon soln, 3 (2-1) gm recon soln, 15 (10-5)gm recon soln)

2

AUGMENTIN 125-31.25 MG/5ML RECONSUSP

5

BICILLIN C-R 1200000 UNIT/2MLSUSPENSION

4

BICILLIN C-R 900/300 900000-300000UNIT/2ML SUSPENSION

4

BICILLIN L-A (600000 UNIT/MLSUSPENSION, 1200000 UNIT/2MLSUSPENSION, 2400000 UNIT/4MLSUSPENSION)

4

dicloxacillin sodium (250 mg cap, 500 mg cap) 2

nafcillin sodium (1 gm recon soln, 2 gm reconsoln)

4

nafcillin sodium 10 gm recon soln 5

penicillin g pot in dextrose (20000 unit/mlsolution, 40000 unit/ml solution, 60000 unit/mlsolution)

4

penicillin g potassium (5000000 recon soln,20000000 recon soln)

4

penicillin g sodium 5000000 unit recon soln 5

penicillin v potassium (125 mg/5ml recon soln,250 mg/5ml recon soln)

1

penicillin v potassium (250 mg tab, 500 mgtab)

2

piperacillin sod-tazobactam so (d-tazobactam2.25 (2-0.25) gm recon ln, d-tazobactam 3.375(3-0.375) gm recon ln, d-tazobactam 4.5 (4-0.5) gm recon ln, d-tazobactam 40.5 (36-4.5)gm recon ln)

4

MACROLIDESazithromycin (1 gm packet, 100 mg/5ml reconsusp, 200 mg/5ml recon susp, 250 mg tab,500 mg recon soln, 500 mg tab, 600 mg tab)

2


10


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

clarithromycin (125 mg/5ml recon susp, 250mg/5ml recon susp, 250 mg tab, 500 mg tab)

4

clarithromycin er 500 mg tab er 24h 4

DIFICID 200 MG TAB 5

ERYTHROCIN LACTOBIONATE 500 MGRECON SOLN

4

ERYTHROCIN STEARATE 250 MG TAB 4

erythromycin (2 % gel, 2 % solution, 5 mg/gmointment)

2

erythromycin (250 mg tab dr, 333 mg tab dr,500 mg tab dr)

3

erythromycin base (250 mg tab dr, 333 mg tabdr, 500 mg tab dr)

3

erythromycin base (250 mg tab, 250 mg cp drpart, 500 mg tab)

4

erythromycin ethylsuccinate (200 mg/5mlrecon susp, 400 mg tab)

4

QUINOLONESBAXDELA (300 MG RECON SOLN, 450 MGTAB)

5

BESIVANCE 0.6 % SUSPENSION 4

ciprofloxacin 500 mg/5ml (10%) recon susp 2

ciprofloxacin hcl (0.3 % solution, 100 mg tab,250 mg tab, 500 mg tab, 750 mg tab)

2

ciprofloxacin in d5w (200 mg/100ml solution,400 mg/200ml solution)

2

gatifloxacin 0.5 % solution 2

levofloxacin (0.5 % solution, 250 mg tab, 500mg tab, 750 mg tab)

4

levofloxacin 25 mg/ml oral solution 4

levofloxacin 25 mg/ml solution inj 4

levofloxacin in d5w ( 250 mg/50ml solution,500 mg/100ml solution, 750 mg/150mlsolution)

4


11


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

moxifloxacin hcl 0.5 % solution 4

ofloxacin (300 mg tab, 400 mg tab) 4

ofloxacin 0.3 % ophthalmic solution 4

ofloxacin 0.3 % otic solution 4

SULFONAMIDESsulfadiazine 500 mg tab 4

sulfamethoxazole-trimethoprim (200-40mg/5ml suspension, 400-80 mg tab, 800-160mg tab)

2

sulfatrim pediatric 200-40 mg/5ml suspension 2

TETRACYCLINESdemeclocycline hcl (150 mg tab, 300 mg tab) 4

doxy 100 100 mg recon soln 4

doxycycline hyclate (20 mg tab, 50 mg cap, 75mg tab, 100 mg tab, 100 mg cap, 150 mg tab)

3

doxycycline monohydrate (25 mg/5ml reconsusp, 50 mg tab, 50 mg cap, 75 mg tab, 75 mgcap, 100 mg cap, 100 mg tab, 150 mg tab,150 mg cap)

3

minocycline hcl (50 mg cap, 75 mg cap, 100mg cap)

2

tetracycline hcl (250 mg cap, 500 mg cap) 4

ANTICONVULSANTS

ANTICONVULSANTS, OTHERAPTIOM (200 MG TAB, 400 MG TAB, 600 MGTAB, 800 MG TAB)

5

BRIVIACT (10 MG TAB, 10 MG/MLSOLUTION, 25 MG TAB, 50 MG TAB, 75 MGTAB, 100 MG TAB)

5 PA - FOR NEW STARTS ONLY

EPIDIOLEX 100 MG/ML SOLUTION 5 PA - FOR NEW STARTS ONLY

FINTEPLA 2.2 MG/ML SOLUTION 5 PA - FOR NEW STARTS ONLY

FYCOMPA (0.5 MG/ML SUSPENSION, 2 MGTAB, 8 MG TAB)

4


12


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

FYCOMPA (4 MG TAB, 6 MG TAB, 10 MGTAB, 12 MG TAB)

5

levetiracetam (100 mg/ml solution, 250 mgtab, 500 mg tab, 750 mg tab, 1000 mg tab)

3

levetiracetam er (er 500 mg tab er 24h, er 750mg tab er 24h)

4

NAYZILAM 5 MG/0.1ML SOLUTION 5

SPRITAM (250 MG TAB, 500 MG TAB, 750MG TAB, 1000 MG TAB)

4

XCOPRI (14 X 12.5 MG & 14 X 25 MG TABTHPK, 50 MG TAB, 100 MG TAB, 150 MGTAB)


XCOPRI (14 X 50 MG & 14 X100 MG TABTHPK, 14 X 150 MG & 14 X200 MG TABTHPK, 200 MG TAB)


XCOPRI (250 MG DAILY DOSE) 50 & 200MG TAB THPK


XCOPRI (350 MG DAILY DOSE) 150 & 200MG TAB THPK


CALCIUM CHANNEL MODIFYING AGENTSCELONTIN 300 MG CAP 4

ethosuximide (250 mg/5ml solution, 250 mgcap)

2

pregabalin (25 mg cap, 50 mg cap, 75 mg cap,100 mg cap, 150 mg cap, 200 mg cap, 225 mgcap)


pregabalin 20 mg/ml solution 3 QL (900 PER 30 DAYS)

pregabalin 300 mg cap 3 QL (60 PER 30 DAYS)

zonisamide (25 mg cap, 50 mg cap, 100 mgcap)

2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTSclobazam (2.5 mg/ml suspension, 10 mg tab,20 mg tab)


clonazepam (0.125 mg tab disp, 0.25 mg tabdisp, 0.5 mg tab, 0.5 mg tab disp, 1 mg tab, 1mg tab disp)



13


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

clonazepam (2 mg tab, 2 mg tab disp) 4 QL (300 PER 30 DAYS)

DIASTAT ACUDIAL (10 MG GEL, 20 MGGEL)

4

DIASTAT PEDIATRIC 2.5 MG GEL 4

diazepam (2.5 mg gel, 10 mg gel, 20 mg gel) 4

divalproex sodium (125 mg tab dr, 250 mg tabdr, 500 mg tab dr)

3

divalproex sodium 125 mg dr sprinkle cap 3

divalproex sodium er (er 250 mg tab er 24h, er500 mg tab er 24h)

3

gabapentin (100 mg cap, 300 mg cap) 2 QL (360 PER 30 DAYS)

gabapentin (250 mg/5ml solution, 300 mg/6mlsolution)

2 QL (2160 PER 30 DAYS)

gabapentin 400 mg cap 2 QL (270 PER 30 DAYS)

gabapentin 600 mg tab 2 QL (180 PER 30 DAYS)

gabapentin 800 mg tab 2 QL (150 PER 30 DAYS)

phenobarbital (15 mg tab, 16.2 mg tab, 20mg/5ml elixir, 20 mg/5ml solution, 30 mg tab,32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mgtab, 100 mg tab)

4

primidone (50 mg tab, 250 mg tab) 2

SYMPAZAN (10 MG FILM, 20 MG FILM) 5 PA - FOR NEW STARTS ONLY

SYMPAZAN 5 MG FILM 4 PA - FOR NEW STARTS ONLY

tiagabine hcl (2 mg tab, 4 mg tab, 12 mg tab,16 mg tab)

4

valproate sodium 250 mg/5ml solution 2

valproic acid (250 mg cap, 250 mg/5mlsolution)

2

VALTOCO 10 MG DOSE 10 MG/0.1MLLIQUID


VALTOCO 15 MG DOSE 7.5 MG/0.1ML LIQDTHPK


VALTOCO 20 MG DOSE 10 MG/0.1ML LIQDTHPK



14


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

VALTOCO 5 MG DOSE 5 MG/0.1ML LIQUID 5 QL (10 PER 30 DAYS)

vigabatrin (500 mg tab, 500 mg packet) 5 PA - FOR NEW STARTS ONLY

vigadrone 500 mg packet 5 PA - FOR NEW STARTS ONLY

GLUTAMATE REDUCING AGENTSfelbamate (400 mg tab, 600 mg tab) 4

felbamate 600 mg/5ml suspension 5

lamotrigine (5 mg chew tab, 25 mg tab, 25 mgchew tab, 100 mg tab, 150 mg tab, 200 mgtab)

2

topiramate (15 mg cap sprink, 25 mg capsprink, 25 mg tab, 50 mg tab, 100 mg tab, 200mg tab)

2

SODIUM CHANNEL AGENTSBANZEL (40 MG/ML SUSPENSION, 200 MGTAB, 400 MG TAB)


carbamazepine (100 mg chew tab, 100mg/5ml suspension, 200 mg tab)

4

carbamazepine er (er 100 mg tab er 12h, er100 mg cap er 12h, er 200 mg tab er 12h, er200 mg cap er 12h, er 300 mg cap er 12h, er400 mg tab er 12h)

4

DILANTIN 30 MG CAP 4

oxcarbazepine (150 mg tab, 300 mg tab, 600mg tab)

3

oxcarbazepine 300 mg/5ml suspension 4

PEGANONE 250 MG TAB 4

phenytoin (50 mg chew tab, 100 mg/4mlsuspension, 125 mg/5ml suspension)

2

phenytoin infatabs 50 mg chew tab 2

phenytoin sodium extended (100 mg cap, 200mg cap, 300 mg cap)

4

VIMPAT (10 MG/ML SOLUTION, 50 MG TAB,100 MG TAB, 150 MG TAB, 200 MG TAB)

4


15


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHERergoloid mesylates 1 mg tab 4

CHOLINESTERASE INHIBITORSdonepezil hcl (5 mg tab, 5 mg tab disp, 10 mgtab disp, 10 mg tab)

2

galantamine hydrobromide (4 mg tab, 4 mg/mlsolution, 8 mg tab, 12 mg tab)

4

galantamine hydrobromide er (er 8 mg cap er24h, er 16 mg cap er 24h, er 24 mg cap er24h)

4

rivastigmine (4.6 mg/24hr patch 24hr, 9.5mg/24hr patch 24hr, 13.3 mg/24hr patch 24hr)

4

rivastigmine tartrate (1.5 mg cap, 3 mg cap,4.5 mg cap, 6 mg cap)

4

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine hcl (2 mg/ml solution, 10 mg/5mlsolution)

4

memantine hcl (5 mg tab, 10 mg tab) 3

memantine hcl 5-10 mg titration pack 4

memantine hcl er (er 7 mg cap er 24h, er 14mg cap er 24h, er 21 mg cap er 24h, er 28 mgcap er 24h)


ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHERbupropion hcl (75 mg tab, 100 mg tab) 3

bupropion hcl er (sr) (er (sr) 100 mg tab er12h, er (sr) 150 mg tab er 12h, er (sr) 200 mgtab er 12h)


bupropion hcl er (xl) 150 mg tab er 24h 3 QL (90 PER 30 DAYS)

bupropion hcl er (xl) 300 mg tab er 24h 3 QL (30 PER 30 DAYS)


16


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

mirtazapine (7.5 mg tab, 15 mg tab disp, 15mg tab, 30 mg tab, 30 mg tab disp, 45 mg tab,45 mg tab disp)

2

MONOAMINE OXIDASE INHIBITORSEMSAM (6 MG/24HR PATCH 24HR, 9MG/24HR PATCH 24HR, 12 MG/24HRPATCH 24HR)

5 ST, QL (30 PER 30 DAYS)

MARPLAN 10 MG TAB 4

phenelzine sulfate 15 mg tab 2

tranylcypromine sulfate 10 mg tab 4

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONINAND NOREPINEPHRINE REUPTAKE INHIBITOR

citalopram hydrobromide (10 mg tab, 20 mgtab, 40 mg tab)

1

citalopram hydrobromide 10 mg/5ml solution 2

desvenlafaxine succinate er (er 25 mg tab er24h, er 50 mg tab er 24h, er 100 mg tab er24h)


DRIZALMA SPRINKLE (20 MG CAP DR, 60MG CAP DR)


DRIZALMA SPRINKLE (30 MG CAP DR, 40MG CAP DR)


duloxetine hcl (20 mg cp dr part, 60 mg cp drpart)


duloxetine hcl (30 mg cp dr part, 40 mg cp drpart)


escitalopram oxalate (5 mg/5ml solution, 5 mgtab, 10 mg tab, 20 mg tab)

2

FETZIMA (20 MG CAP ER 24H, 40 MG CAPER 24H, 80 MG CAP ER 24H, 120 MG CAPER 24H)


FETZIMA 20 & 40 MG TITRATION PACK 4 ST, QL (56 PER 365 OVER TIME)

fluoxetine hcl (10 mg cap, 20 mg cap, 40 mgcap)

1

fluoxetine hcl (10 mg tab, 20 mg/5ml solution,20 mg tab, 60 mg tab)

2


17


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

fluoxetine hcl 90 mg cap dr 2 QL (4 PER 28 DAYS)

fluvoxamine maleate (25 mg tab, 50 mg tab,100 mg tab)

4

maprotiline hcl (25 mg tab, 50 mg tab, 75 mgtab)

2

nefazodone hcl (50 mg tab, 100 mg tab, 150mg tab, 200 mg tab, 250 mg tab)

4

paroxetine hcl (10 mg tab, 20 mg tab, 30 mgtab, 40 mg tab)

2

PAXIL 10 MG/5ML SUSPENSION 4

sertraline hcl (25 mg tab, 50 mg tab, 100 mgtab)

1

sertraline hcl 20 mg/ml conc 2

trazodone hcl (50 mg tab, 100 mg tab, 150 mgtab, 300 mg tab)

2

TRINTELLIX (5 MG TAB, 10 MG TAB, 20 MGTAB)


venlafaxine hcl (25 mg tab, 37.5 mg tab, 50mg tab, 75 mg tab, 100 mg tab)

3

venlafaxine hcl er (er 37.5 mg cap er 24h, er75 mg cap er 24h, er 150 mg cap er 24h)

3

venlafaxine hcl er (er 37.5 mg tab er 24h, er75 mg tab er 24h, er 150 mg tab er 24h, er225 mg tab er 24h)

4

VIIBRYD (10 MG TAB, 20 MG TAB, 40 MGTAB)


VIIBRYD STARTER PACK 10 & 20 MG KIT 4 QL (60 PER 365 OVER TIME)

TRICYCLICSamitriptyline hcl (10 mg tab, 25 mg tab, 50 mgtab, 75 mg tab, 100 mg tab, 150 mg tab)

4

amoxapine (25 mg tab, 50 mg tab, 100 mgtab, 150 mg tab)

2

chlordiazepoxide-amitriptyline (5-12.5 mg tab,10-25 mg tab)

4

clomipramine hcl (25 mg cap, 50 mg cap, 75mg cap)

4


18


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

desipramine hcl (10 mg tab, 25 mg tab, 50 mgtab, 75 mg tab, 100 mg tab, 150 mg tab)

4

doxepin hcl (10 mg cap, 10 mg/ml conc, 25mg cap, 50 mg cap, 75 mg cap, 100 mg cap,150 mg cap)

4

imipramine hcl (10 mg tab, 25 mg tab, 50 mgtab)

4

nortriptyline hcl (10 mg cap, 25 mg cap, 50 mgcap, 75 mg cap)

2

nortriptyline hcl 10 mg/5ml solution 4

perphenazine-amitriptyline (2-10 mg tab, 2-25mg tab, 4-50 mg tab, 4-25 mg tab, 4-10 mgtab)

4

protriptyline hcl (5 mg tab, 10 mg tab) 2

trimipramine maleate (25 mg cap, 50 mg cap,100 mg cap)

4

ANTIEMETICS

ANTIEMETICS, OTHERcompro 25 mg suppos 2

meclizine hcl (12.5 mg tab, 25 mg tab) 2

prochlorperazine 25 mg suppos 2

prochlorperazine maleate (5 mg tab, 10 mgtab)

1

promethazine hcl (6.25 mg/5ml solution, 6.25mg/5ml syrup, 12.5 mg tab, 12.5 mg suppos,25 mg tab, 25 mg suppos, 50 mg suppos, 50mg tab)

4

PROMETHEGAN 50 MG SUPPOS 4

scopolamine 1 mg/3days patch 72hr 3

TRANSDERM SCOP (1.5 MG) 1 MG/3DAYSPATCH 72HR

4

TRANSDERM-SCOP (1.5 MG) 1 MG/3DAYSPATCH 72HR

4


19


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

EMETOGENIC THERAPY ADJUNCTSaprepitant 125 mg cap 2 PA - Part B vs D Determination, QL

(2 PER 30 OVER TIME)

aprepitant 40 mg cap 2 PA - Part B vs D Determination, QL(1 PER 30 OVER TIME)

aprepitant 80 & 125 mg cap 2 PA - Part B vs D Determination, QL(6 PER 30 OVER TIME)

aprepitant 80 mg cap 2 PA - Part B vs D Determination, QL(8 PER 30 OVER TIME)

dronabinol (2.5 mg cap, 5 mg cap, 10 mg cap) 4 PA, QL (60 PER 30 OVER TIME)

EMEND 125 MG/5ML RECON SUSP 4 PA - Part B vs D Determination, QL(6 PER 30 OVER TIME)

granisetron hcl 1 mg tab 2 PA - Part B vs D Determination, QL(30 PER 30 OVER TIME)

ondansetron (4 mg tab disp, 8 mg tab disp) 4 PA - Part B vs D Determination

ondansetron hcl (4 mg tab, 8 mg tab) 3 PA - Part B vs D Determination

ondansetron hcl 24 mg tab 3 PA - Part B vs D Determination, QL(14 PER 28 OVER TIME)

ondansetron hcl 4 mg/5ml solution 3 PA - Part B vs D Determination, QL(450 PER 30 DAYS)

ANTIFUNGALS

ABELCET 5 MG/ML SUSPENSION 5 PA - Part B vs D Determination

AMBISOME 50 MG RECON SUSP 5 PA - Part B vs D Determination

amphotericin b 50 mg recon soln 4 PA - Part B vs D Determination

caspofungin acetate (50 mg recon soln, 70 mgrecon soln)

5

ciclopirox (0.77 % gel, 1 % shampoo) 2

ciclopirox 8 % solution 2 PA

ciclopirox olamine (0.77 % cream, 0.77 %suspension)

2

clotrimazole (1 % solution, 1 % cream, 10 mgtroche)

2

clotrimazole-betamethasone (1-0.05 % cream,1-0.05 % lotion)

3


20


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

fluconazole (10 mg/ml recon susp, 40 mg/mlrecon susp, 50 mg tab, 100 mg tab, 150 mgtab, 200 mg tab)

2

fluconazole in dextrose (200 mg/100mlsolution, 400 mg/200ml solution)

2

fluconazole in sodium chloride (100-0.9mg/50ml-% solution, 200-0.9 mg/100ml-%solution, 400-0.9 mg/200ml-% solution)

2

flucytosine (250 mg cap, 500 mg cap) 5

griseofulvin microsize 125 mg/5ml suspension 2

griseofulvin microsize 500 mg tab 4

griseofulvin ultramicrosize (125 mg tab, 250mg tab)

4

itraconazole 10 mg/ml solution 5 PA

itraconazole 100 mg cap 4 PA

ketoconazole (2 % cream, 2 % shampoo, 200mg tab)

4

MICONAZOLE 3 200 MG SUPPOS 3

NATACYN 5 % SUSPENSION 4

NOXAFIL 40 MG/ML SUSPENSION 5

nyamyc 100000 unit/gm powder 3

nystatin (100000 unit/gm powder, 100000unit/ml suspension, 100000 unit/gm ointment,100000 unit/gm cream, 500000 unit tab)

3

nystop 100000 unit/gm powder 3

posaconazole 100 mg tab dr 5

terbinafine hcl 250 mg tab 2 QL (90 PER 180 OVER TIME)

terconazole (0.4 % cream, 0.8 % cream, 80mg suppos)

2

voriconazole (40 mg/ml recon susp, 50 mgtab, 200 mg recon soln, 200 mg tab)

5

ANTIGOUT AGENTS

allopurinol (100 mg tab, 300 mg tab) 2


21


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

colchicine (0.6 mg tab, 0.6 mg cap) 3

colchicine-probenecid 0.5-500 mg tab 2

febuxostat (40 mg tab, 80 mg tab) 3 ST

probenecid 500 mg tab 2

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDSdihydroergotamine mesylate 4 mg/ml solution 5 PA, QL (8 PER 30 OVER TIME)

ergotamine-caffeine 1-100 mg tab 2

PROPHYLACTICAIMOVIG (140 MG DOSE) 70 MG/ML SOLNA-INJ


AIMOVIG 140 MG/ML SOLN A-INJ 4 PA, QL (1 PER 30 DAYS)

AIMOVIG 70 MG/ML SOLN A-INJ 4 PA, QL (2 PER 30 DAYS)

timolol maleate (5 mg tab, 10 mg tab, 20 mgtab)

2

UBRELVY (50 MG TAB, 100 MG TAB) 5 PA, QL (10 PER 30 OVER TIME)

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTSrizatriptan benzoate (5 mg tab disp, 10 mg tabdisp)


rizatriptan benzoate (5 mg tab, 10 mg tab) 3 QL (18 PER 30 OVER TIME)

sumatriptan (5 mg/act solution, 20 mg/actsolution)


sumatriptan succinate (25 mg tab, 50 mg tab,100 mg tab)


sumatriptan succinate (6 mg/0.5ml soln a-inj, 6mg/0.5ml soln prsyr, 6 mg/0.5ml solution)


sumatriptan succinate 4 mg/0.5ml soln a-inj 4 QL (8 PER 30 OVER TIME)

sumatriptan succinate refill 4 mg/0.5ml solncart


sumatriptan succinate refill 6 mg/0.5ml solncart



22


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICSguanidine hcl 125 mg tab 4

pyridostigmine bromide 60 mg tab 3

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHERdapsone (25 mg tab, 100 mg tab) 2

rifabutin 150 mg cap 4

ANTITUBERCULARSethambutol hcl (100 mg tab, 400 mg tab) 2

isoniazid (100 mg tab, 300 mg tab) 2

isoniazid 50 mg/5ml syrup 4

PASER 4 GM PACKET 4

PRIFTIN 150 MG TAB 4

pyrazinamide 500 mg tab 2

rifampin (150 mg cap, 300 mg cap) 2

rifampin 600 mg recon soln 4

RIFATER 50-120-300 MG TAB 4

SIRTURO (20 MG TAB, 100 MG TAB) 5

TRECATOR 250 MG TAB 4

ANTINEOPLASTICS

ALKYLATING AGENTScyclophosphamide (25 mg cap, 50 mg cap) 2 PA - Part B vs D Determination

GLEOSTINE (10 MG CAP, 40 MG CAP, 100MG CAP)

4

LEUKERAN 2 MG TAB 5

MATULANE 50 MG CAP 5


23


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

VALCHLOR 0.016 % GEL 5 PA - FOR NEW STARTS ONLY

ANTIANDROGENSabiraterone acetate 250 mg tab 5 PA - FOR NEW STARTS ONLY

bicalutamide 50 mg tab 3

ERLEADA 60 MG TAB 5 PA - FOR NEW STARTS ONLY

flutamide 125 mg cap 2

nilutamide 150 mg tab 5

NUBEQA 300 MG TAB 5 PA - FOR NEW STARTS ONLY

XTANDI 40 MG CAP 5 PA - FOR NEW STARTS ONLY

YONSA 125 MG TAB 5 PA - FOR NEW STARTS ONLY

ZYTIGA 500 MG TAB 5 PA - FOR NEW STARTS ONLY

ANTIANGIOGENIC AGENTSGAVRETO 100 MG CAP 5 PA - FOR NEW STARTS ONLY

POMALYST (1 MG CAP, 2 MG CAP, 3 MGCAP, 4 MG CAP)


QINLOCK 50 MG TAB 5 PA - FOR NEW STARTS ONLY

REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MGCAP, 15 MG CAP, 20 MG CAP, 25 MG CAP)


TABRECTA (150 MG TAB, 200 MG TAB) 5 PA - FOR NEW STARTS ONLY

THALOMID (50 MG CAP, 100 MG CAP, 150MG CAP, 200 MG CAP)


ANTIESTROGENS/MODIFIERSEMCYT 140 MG CAP 5

SOLTAMOX 10 MG/5ML SOLUTION 5

tamoxifen citrate (10 mg tab, 20 mg tab) 2

toremifene citrate 60 mg tab 5

ANTIMETABOLITESDROXIA (200 MG CAP, 300 MG CAP, 400MG CAP)

4

fluorouracil (2 % solution, 5 % solution) 4


24


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

fluorouracil 0.5 % cream 5

fluorouracil 5 % cream 3

hydroxyurea 500 mg cap 2

LONSURF 15-6.14 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (100 PER 28 DAYS)

LONSURF 20-8.19 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (80 PER 28 DAYS)

mercaptopurine 50 mg tab 3

PURIXAN 2000 MG/100ML SUSPENSION 5

TABLOID 40 MG TAB 4

ANTINEOPLASTICS, OTHERADCETRIS 50 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY

COPIKTRA (15 MG CAP, 25 MG CAP) 5 PA - FOR NEW STARTS ONLY

COTELLIC 20 MG TAB 5 PA - FOR NEW STARTS ONLY

DAURISMO (25 MG TAB, 100 MG TAB) 5 PA - FOR NEW STARTS ONLY

ELZONRIS 1000 MCG/ML SOLUTION 5 PA - FOR NEW STARTS ONLY

ENHERTU 100 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY

FARYDAK (10 MG CAP, 15 MG CAP, 20 MGCAP)

5 PA - FOR NEW STARTS ONLY,QL (6 PER 21 OVER TIME)

IBRANCE (75 MG CAP, 75 MG TAB, 100 MGCAP, 100 MG TAB, 125 MG CAP, 125 MGTAB)


INREBIC 100 MG CAP 5 PA - FOR NEW STARTS ONLY

KISQALI FEMARA 200 MG CO-PACK 5 PA - FOR NEW STARTS ONLY,QL (91 PER 28 DAYS)



leucovorin calcium (5 mg tab, 10 mg tab, 15mg tab, 25 mg tab)

2

LORBRENA (25 MG TAB, 100 MG TAB) 5 PA - FOR NEW STARTS ONLY

LYNPARZA (100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY


25


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

NERLYNX 40 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (180 PER 30 DAYS)

NINLARO (2.3 MG CAP, 3 MG CAP, 4 MGCAP)


ONTRUZANT (150 MG RECON SOLN, 420MG RECON SOLN)


PADCEV (20 MG RECON SOLN, 30 MGRECON SOLN)


PEMAZYRE (4.5 MG TAB, 9 MG TAB, 13.5MG TAB)

5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

PIQRAY (200 MG DAILY DOSE) 200 MG TABTHPK


PIQRAY (250 MG DAILY DOSE) 200 & 50MG TAB THPK


PIQRAY (300 MG DAILY DOSE) 2 X 150 MGTAB THPK


RETEVMO (40 MG CAP, 80 MG CAP) 5 PA - FOR NEW STARTS ONLY

ROZLYTREK (100 MG CAP, 200 MG CAP) 5 PA - FOR NEW STARTS ONLY

RUBRACA (200 MG TAB, 250 MG TAB, 300MG TAB)


RYDAPT 25 MG CAP 5 PA - FOR NEW STARTS ONLY,QL (240 PER 30 DAYS)

SARCLISA (100 MG/5ML SOLUTION, 500MG/25ML SOLUTION)


SYLATRON (200 MCG KIT, 300 MCG KIT,600 MCG KIT)


SYNRIBO 3.5 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY

TALZENNA (0.25 MG CAP, 1 MG CAP) 5 PA - FOR NEW STARTS ONLY

TAZVERIK 200 MG TAB 5 PA - FOR NEW STARTS ONLY

thiotepa (15 mg recon soln, 100 mg reconsoln)

5

TRODELVY 180 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY

TUKYSA (50 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY

VERZENIO (50 MG TAB, 100 MG TAB, 150MG TAB, 200 MG TAB)



26


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

VITRAKVI (20 MG/ML SOLUTION, 25 MGCAP, 100 MG CAP)


XPOVIO (100 MG ONCE WEEKLY) 20 MGTAB THPK




XPOVIO (40 MG TWICE WEEKLY) 20 MGTAB THPK










ZEJULA 100 MG CAP 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

ZOLINZA 100 MG CAP 5 PA - FOR NEW STARTS ONLY

AROMATASE INHIBITORS, 3RD GENERATIONanastrozole 1 mg tab 4

exemestane 25 mg tab 4

letrozole 2.5 mg tab 2

ENZYME INHIBITORSBALVERSA (3 MG TAB, 4 MG TAB, 5 MGTAB)


ZYDELIG (100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY

MOLECULAR TARGET INHIBITORSAFINITOR (2.5 MG TAB, 5 MG TAB, 7.5 MGTAB, 10 MG TAB)


AFINITOR DISPERZ (2 MG TAB SOL, 3 MGTAB SOL, 5 MG TAB SOL)


ALECENSA 150 MG CAP 5 PA - FOR NEW STARTS ONLY,QL (240 PER 30 DAYS)


27


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ALUNBRIG (90 MG TAB, 180 MG TAB) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

ALUNBRIG 30 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (120 PER 30 DAYS)

ALUNBRIG 90 & 180 MG TAB THPK 5 PA - FOR NEW STARTS ONLY,QL (60 PER 365 OVER TIME)

AYVAKIT (100 MG TAB, 200 MG TAB, 300MG TAB)


BOSULIF (100 MG TAB, 400 MG TAB, 500MG TAB)


BRAFTOVI (50 MG CAP, 75 MG CAP) 5 PA - FOR NEW STARTS ONLY

BRUKINSA 80 MG CAP 5 PA - FOR NEW STARTS ONLY

CABOMETYX (20 MG TAB, 40 MG TAB, 60MG TAB)


CALQUENCE 100 MG CAP 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

CAPRELSA 100 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

CAPRELSA 300 MG TAB 5 PA - FOR NEW STARTS ONLY

COMETRIQ 100 MG DAILY-DOSE PACK 5 PA - FOR NEW STARTS ONLY



ERIVEDGE 150 MG CAP 5 PA - FOR NEW STARTS ONLY

erlotinib hcl (100 mg tab, 150 mg tab) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

erlotinib hcl 25 mg tab 5 PA - FOR NEW STARTS ONLY,QL (90 PER 30 DAYS)

everolimus (2.5 mg tab, 5 mg tab, 7.5 mg tab) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

GILOTRIF (20 MG TAB, 30 MG TAB, 40 MGTAB)


ICLUSIG 15 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

ICLUSIG 45 MG TAB 5 PA - FOR NEW STARTS ONLY

IDHIFA (50 MG TAB, 100 MG TAB) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)


28


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

imatinib mesylate (100 mg tab, 400 mg tab) 5 PA - FOR NEW STARTS ONLY

IMBRUVICA (70 MG CAP, 140 MG CAP, 140MG TAB, 280 MG TAB, 420 MG TAB, 560 MGTAB)


INLYTA (1 MG TAB, 5 MG TAB) 5 PA - FOR NEW STARTS ONLY

INQOVI 35-100 MG TAB 5 PA - FOR NEW STARTS ONLY

IRESSA 250 MG TAB 5 PA - FOR NEW STARTS ONLY

JAKAFI (5 MG TAB, 10 MG TAB, 15 MG TAB,20 MG TAB, 25 MG TAB)


KISQALI 200 MG DAILY DOSE 5 PA - FOR NEW STARTS ONLY,QL (63 PER 28 OVER TIME)



KOSELUGO (10 MG CAP, 25 MG CAP) 5 PA - FOR NEW STARTS ONLY

lapatinib ditosylate 250 mg tab 5 PA - FOR NEW STARTS ONLY

LENVIMA DAILY DOSE 10 MG THERAPYPACK
















MEKINIST (0.5 MG TAB, 2 MG TAB) 5 PA - FOR NEW STARTS ONLY

MEKTOVI 15 MG TAB 5 PA - FOR NEW STARTS ONLY


29


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

NEXAVAR 200 MG TAB 5 PA - FOR NEW STARTS ONLY

ODOMZO 200 MG CAP 5 PA - FOR NEW STARTS ONLY

SPRYCEL (20 MG TAB, 50 MG TAB, 70 MGTAB, 80 MG TAB, 100 MG TAB, 140 MGTAB)


STIVARGA 40 MG TAB 5 PA - FOR NEW STARTS ONLY

SUTENT (12.5 MG CAP, 25 MG CAP, 37.5MG CAP, 50 MG CAP)


TAFINLAR (50 MG CAP, 75 MG CAP) 5 PA - FOR NEW STARTS ONLY

TAGRISSO (40 MG TAB, 80 MG TAB) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

TASIGNA (50 MG CAP, 150 MG CAP, 200MG CAP)


TIBSOVO 250 MG TAB 5 PA - FOR NEW STARTS ONLY,QL (60 PER 30 DAYS)

TURALIO 200 MG CAP 5 PA - FOR NEW STARTS ONLY

TYKERB 250 MG TAB 5 PA - FOR NEW STARTS ONLY

VENCLEXTA (10 MG TAB, 50 MG TAB) 3 PA - FOR NEW STARTS ONLY

VENCLEXTA 100 MG TAB 5 PA - FOR NEW STARTS ONLY

VENCLEXTA STARTING THERAPY PACK 5 PA - FOR NEW STARTS ONLY

VIZIMPRO (15 MG TAB, 30 MG TAB, 45 MGTAB)


VOTRIENT 200 MG TAB 5 PA - FOR NEW STARTS ONLY

XALKORI (200 MG CAP, 250 MG CAP) 5 PA - FOR NEW STARTS ONLY

XOSPATA 40 MG TAB 5 PA - FOR NEW STARTS ONLY

ZELBORAF 240 MG TAB 5 PA - FOR NEW STARTS ONLY

ZYKADIA (150 MG CAP, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY

RETINOIDSbexarotene 75 mg cap 5 PA - FOR NEW STARTS ONLY

PANRETIN 0.1 % GEL 5

TARGRETIN 1 % GEL 5 PA - FOR NEW STARTS ONLY

tretinoin 10 mg cap 5


30


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TREATMENT ADJUNCTSMESNEX 400 MG TAB 5

ANTIPARASITICS

ANTHELMINTICSalbendazole 200 mg tab 5

ivermectin 3 mg tab 2

ANTIPROTOZOALSatovaquone 750 mg/5ml suspension 5

atovaquone-proguanil hcl (62.5-25 mg tab,250-100 mg tab)

2

chloroquine phosphate (250 mg tab, 500 mgtab)

2

COARTEM 20-120 MG TAB 4

hydroxychloroquine sulfate 200 mg tab 3

mefloquine hcl 250 mg tab 2

NEBUPENT 300 MG RECON SOLN 4 PA - Part B vs D Determination

PENTAM 300 MG RECON SOLN 4

pentamidine isethionate 300 mg recon soln 4 PA - Part B vs D Determination

primaquine phosphate 26.3 mg tab 2

quinine sulfate 324 mg cap 4 PA

tinidazole (250 mg tab, 500 mg tab) 2

PEDICULICIDES/SCABICIDESlindane 1 % shampoo 4

malathion 0.5 % lotion 4

permethrin 5 % cream 3

ANTIPARKINSON AGENTS

ANTICHOLINERGICSbenztropine mesylate (0.5 mg tab, 1 mg tab, 2mg tab)

4


31


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

trihexyphenidyl hcl (2 mg tab, 5 mg tab) 2

ANTIPARKINSON AGENTS, OTHERentacapone 200 mg tab 3

tolcapone 100 mg tab 5

DOPAMINE AGONISTSAPOKYN 30 MG/3ML SOLN CART 5 PA, QL (90 PER 30 DAYS)

bromocriptine mesylate (2.5 mg tab, 5 mg cap) 4

NEUPRO (1 MG/24HR PATCH 24HR, 2MG/24HR PATCH 24HR, 3 MG/24HR PATCH24HR, 4 MG/24HR PATCH 24HR, 6MG/24HR PATCH 24HR, 8 MG/24HR PATCH24HR)

4 ST

pramipexole dihydrochloride (0.125 mg tab,0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mgtab, 1.5 mg tab)

4

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

2

DOPAMINE PRECURSORS/L- AMINO ACID DECARBOXYLASE INHIBITORScarbidopa-levodopa (10-100 mg tab disp, 10-100 mg tab, 25-100 mg tab, 25-100 mg tabdisp, 25-250 mg tab disp, 25-250 mg tab)

2

carbidopa-levodopa er (er 25-100 mg tab er,er 50-200 mg tab er)

3

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline mesylate (0.5 mg tab, 1 mg tab) 4

selegiline hcl (5 mg tab, 5 mg cap) 3

ANTIPSYCHOTICS

1ST GENERATION/TYPICALchlorpromazine hcl (10 mg tab, 25 mg tab, 50mg tab, 100 mg tab, 200 mg tab)

4

fluphenazine decanoate 25 mg/ml solution 4


32


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

fluphenazine hcl (1 mg tab, 2.5 mg/ml solution,2.5 mg tab, 2.5 mg/5ml elixir, 5 mg/ml conc, 5mg tab, 10 mg tab)

4

haloperidol (0.5 mg tab, 1 mg tab, 2 mg tab, 5mg tab, 10 mg tab, 20 mg tab)

2

haloperidol decanoate (50 mg/ml solution, 100mg/ml solution)

4

haloperidol lactate (2 mg/ml conc, 5 mg/mlsolution)

2

loxapine succinate (5 mg cap, 10 mg cap, 25mg cap, 50 mg cap)

2

molindone hcl (5 mg tab, 10 mg tab, 25 mgtab)

4

perphenazine (2 mg tab, 4 mg tab, 8 mg tab,16 mg tab)

4

pimozide (1 mg tab, 2 mg tab) 4

thioridazine hcl (10 mg tab, 25 mg tab, 50 mgtab, 100 mg tab)

4

thiothixene (1 mg cap, 2 mg cap, 5 mg cap, 10mg cap)

4

trifluoperazine hcl (1 mg tab, 2 mg tab, 5 mgtab, 10 mg tab)

4

2ND GENERATION/ATYPICALABILIFY MAINTENA (300 MG PRSYR, 300MG SRER, 400 MG PRSYR, 400 MG SRER)

5

aripiprazole (10 mg tab disp, 15 mg tab disp) 5 QL (60 PER 30 DAYS)

aripiprazole (10 mg tab, 15 mg tab, 20 mg tab,30 mg tab)


aripiprazole (2 mg tab, 5 mg tab) 4 QL (60 PER 30 DAYS)

aripiprazole 1 mg/ml solution 4 QL (750 PER 30 DAYS)

ARISTADA (441 MG/1.6ML PRSYR, 662MG/2.4ML PRSYR, 882 MG/3.2ML PRSYR,1064 MG/3.9ML PRSYR)

5

ARISTADA INITIO 675 MG/2.4ML PRSYR 5

CAPLYTA 42 MG CAP 5 ST, QL (30 PER 30 DAYS)


33


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

FANAPT (1 MG TAB, 2 MG TAB, 4 MG TAB) 4 ST, QL (60 PER 30 DAYS)

FANAPT (6 MG TAB, 8 MG TAB, 10 MG TAB,12 MG TAB)


FANAPT TITRATION PACK 4 ST, QL (8 PER 180 OVER TIME)

INVEGA SUSTENNA (78 MG/0.5ML SUSPPRSYR, 117 MG/0.75ML SUSP PRSYR, 156MG/ML SUSP PRSYR, 234 MG/1.5ML SUSPPRSYR)

5

INVEGA SUSTENNA 39 MG/0.25ML SUSPPRSYR

4

INVEGA TRINZA (273 MG/0.875ML SUSPPRSYR, 410 MG/1.315ML SUSP PRSYR, 546MG/1.75ML SUSP PRSYR, 819 MG/2.625MLSUSP PRSYR)

5

LATUDA (20 MG TAB, 40 MG TAB, 60 MGTAB, 120 MG TAB)


LATUDA 80 MG TAB 5 QL (60 PER 30 DAYS)

NUPLAZID (10 MG TAB, 34 MG CAP) 5 PA - FOR NEW STARTS ONLY,QL (30 PER 30 DAYS)

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


olanzapine (5 mg tab disp, 10 mg tab disp, 15mg tab disp, 20 mg tab disp)


olanzapine 10 mg recon soln 4

paliperidone er (er 1.5 mg tab er 24h, er 3 mgtab er 24h)


paliperidone er 6 mg tab er 24h 4 QL (60 PER 30 DAYS)

paliperidone er 9 mg tab er 24h 5 QL (30 PER 30 DAYS)

PERSERIS (90 MG PRSYR, 120 MG PRSYR) 5

quetiapine fumarate (25 mg tab, 50 mg tab,100 mg tab, 200 mg tab)


quetiapine fumarate (300 mg tab, 400 mg tab) 4 QL (60 PER 30 DAYS)

quetiapine fumarate er (er 50 mg tab er 24h,er 150 mg tab er 24h, er 300 mg tab er 24h, er400 mg tab er 24h)


quetiapine fumarate er 200 mg tab er 24h 4 QL (90 PER 30 DAYS)


34


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

REXULTI (0.25 MG TAB, 0.5 MG TAB, 1 MGTAB, 2 MG TAB, 3 MG TAB, 4 MG TAB)


RISPERDAL CONSTA (12.5 MG, 25 MG) 4

RISPERDAL CONSTA (37.5 MG, 50 MG) 5

risperidone (0.25 mg tab disp, 0.5 mg tab disp,1 mg tab disp, 2 mg tab disp, 3 mg tab disp, 4mg tab disp)


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


risperidone 1 mg/ml solution 2 QL (240 PER 30 DAYS)

risperidone m-tab (0.5 mg tab disp, 1 mg tabdisp, 2 mg tab disp, 3 mg tab disp, 4 mg tabdisp)


SAPHRIS (2.5 MG SL TAB, 5 MG SL TAB, 10MG SL TAB)


SECUADO (3.8 MG/24HR PATCH 24HR, 5.7MG/24HR PATCH 24HR, 7.6 MG/24HRPATCH 24HR)


VRAYLAR (1.5 MG CAP, 3 MG CAP, 4.5 MGCAP, 6 MG CAP)


VRAYLAR 1.5 & 3 MG CAP THPK 4 ST, QL (14 PER 365 OVER TIME)

ziprasidone hcl (20 mg cap, 40 mg cap, 60 mgcap, 80 mg cap)


ziprasidone mesylate 20 mg recon soln 4

ZYPREXA RELPREVV 210 MG RECONSUSP

4

TREATMENT-RESISTANTclozapine (25 mg tab disp, 100 mg tab disp) 4 QL (270 PER 30 DAYS)

clozapine (25 mg tab, 100 mg tab) 3 QL (270 PER 30 DAYS)

clozapine 12.5 mg tab disp 4 QL (90 PER 30 DAYS)

clozapine 150 mg tab disp 4 QL (180 PER 30 DAYS)

clozapine 200 mg tab 3 QL (120 PER 30 DAYS)

clozapine 200 mg tab disp 5 QL (120 PER 30 DAYS)

clozapine 50 mg tab 3 QL (180 PER 30 DAYS)


35


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

VERSACLOZ 50 MG/ML SUSPENSION 5 QL (540 PER 30 DAYS)

ANTISPASTICITY AGENTS

baclofen (10 mg tab, 20 mg tab) 4

dantrolene sodium (25 mg cap, 50 mg cap,100 mg cap)

2

tizanidine hcl (2 mg tab, 4 mg tab) 2

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTSPREVYMIS (240 MG TAB, 480 MG TAB) 5

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

5

ZIRGAN 0.15 % GEL 4

ANTI-HEPATITIS B (HBV) AGENTSadefovir dipivoxil 10 mg tab 5

BARACLUDE 0.05 MG/ML SOLUTION 5 QL (600 PER 30 DAYS)

entecavir (0.5 mg tab, 1 mg tab) 4 QL (30 PER 30 DAYS)

EPIVIR HBV 5 MG/ML SOLUTION 4

INTRON A (6000000 UNIT/ML SOLUTION,10000000 UNIT/ML SOLUTION, 10000000UNIT RECON SOLN, 18000000 UNITRECON SOLN, 50000000 UNIT RECONSOLN)


lamivudine 100 mg tab 3

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTSEPCLUSA 200-50 MG TAB 5 PA, QL (168 PER 365 OVER

TIME)

EPCLUSA 400-100 MG TAB 5 PA, QL (84 PER 365 OVER TIME)

ledipasvir-sofosbuvir 90-400 mg tab 5 PA, QL (168 PER 365 OVERTIME)

MAVYRET 100-40 MG TAB 5 PA, QL (336 PER 365 OVERTIME)


36


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

sofosbuvir-velpatasvir 400-100 mg tab 5 PA, QL (84 PER 365 OVER TIME)

ANTI-HEPATITIS C (HCV) AGENTS, OTHERPEGASYS (180 MCG/0.5ML SOLUTION, 180MCG/ML SOLUTION)

5 PA

PEGASYS PROCLICK (135 MCG/0.5MLSOLUTION, 180 MCG/0.5ML SOLUTION)

5 PA

ribavirin (200 mg cap, 200 mg tab) 2

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)BIKTARVY 50-200-25 MG TAB 5 QL (30 PER 30 DAYS)

DOVATO 50-300 MG TAB 5 QL (30 PER 30 DAYS)

GENVOYA 150-150-200-10 MG TAB 5 QL (30 PER 30 DAYS)

ISENTRESS (100 MG PACKET, 100 MGCHEW TAB, 400 MG TAB)

5

ISENTRESS 25 MG CHEW TAB 3

ISENTRESS HD 600 MG TAB 5

JULUCA 50-25 MG TAB 5 QL (30 PER 30 DAYS)

STRIBILD 150-150-200-300 MG TAB 5 QL (30 PER 30 DAYS)

TIVICAY (25 MG TAB, 50 MG TAB) 5

TIVICAY 10 MG TAB 4

TIVICAY PD 5 MG TAB SOL 4

TRIUMEQ 600-50-300 MG TAB 5 QL (30 PER 30 DAYS)

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASEINHIBITORS (NNRTI)

ATRIPLA 600-200-300 MG TAB 5 QL (30 PER 30 DAYS)

COMPLERA 200-25-300 MG TAB 5 QL (30 PER 30 DAYS)

EDURANT 25 MG TAB 5

efavirenz (200 mg cap, 600 mg tab) 5

efavirenz 50 mg cap 2

efavirenz-emtricitab-tenofovir 600-200-300 mgtab


efavirenz-lamivudine-tenofovir (400-300-300mg tab, 600-300-300 mg tab)



37


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

INTELENCE (100 MG TAB, 200 MG TAB) 5

INTELENCE 25 MG TAB 4

nevirapine 200 mg tab 2

nevirapine 50 mg/5ml suspension 4

nevirapine er (er 100 mg tab er 24h, er 400mg tab er 24h)

4

ODEFSEY 200-25-25 MG TAB 5 QL (30 PER 30 DAYS)

PIFELTRO 100 MG TAB 5 QL (30 PER 30 DAYS)

RESCRIPTOR 200 MG TAB 4

SYMFI 600-300-300 MG TAB 5 QL (30 PER 30 DAYS)

SYMFI LO 400-300-300 MG TAB 5 QL (30 PER 30 DAYS)

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSETRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate (20 mg/ml solution, 300 mgtab)

4

abacavir sulfate-lamivudine 600-300 mg tab 4 QL (30 PER 30 DAYS)

abacavir-lamivudine-zidovudine 300-150-300mg tab


CIMDUO 300-300 MG TAB 5 QL (30 PER 30 DAYS)

DESCOVY 200-25 MG TAB 5 QL (30 PER 30 DAYS)

didanosine (200 mg cap dr, 250 mg cap dr,400 mg cap dr)

2

emtricitabine 200 mg cap 4

emtricitabine-tenofovir df 200-300 mg tab 5 QL (30 PER 30 DAYS)

EMTRIVA 10 MG/ML SOLUTION 4

lamivudine (150 mg tab, 300 mg tab) 4

lamivudine 10 mg/ml solution 2

lamivudine-zidovudine 150-300 mg tab 4 QL (60 PER 30 DAYS)

stavudine (15 mg cap, 20 mg cap, 30 mg cap,40 mg cap)

2

tenofovir disoproxil fumarate 300 mg tab 4


38


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

TRUVADA (100-150 MG TAB, 133-200 MGTAB, 167-250 MG TAB, 200-300 MG TAB)


VIDEX (2 GM RECON SOLN, 4 GM RECONSOLN)

4

VIDEX EC 125 MG CAP DR 4

VIREAD (40 MG/GM POWDER, 150 MG TAB,200 MG TAB, 250 MG TAB)

5

zidovudine (50 mg/5ml syrup, 100 mg cap,300 mg tab)

2

ANTI-HIV AGENTS, OTHERDELSTRIGO 100-300-300 MG TAB 5 QL (30 PER 30 DAYS)

FUZEON 90 MG RECON SOLN 5 QL (60 PER 30 DAYS)

RUKOBIA 600 MG TAB ER 12H 5

SELZENTRY (20 MG/ML SOLUTION, 75 MGTAB, 150 MG TAB, 300 MG TAB)

5

SELZENTRY 25 MG TAB 4

TYBOST 150 MG TAB 3

ANTI-HIV AGENTS, PROTEASE INHIBITORSAPTIVUS (100 MG/ML SOLUTION, 250 MGCAP)

5

atazanavir sulfate (150 mg cap, 200 mg cap,300 mg cap)

5

CRIXIVAN (200 MG CAP, 400 MG CAP) 3

EVOTAZ 300-150 MG TAB 5 QL (30 PER 30 DAYS)

fosamprenavir calcium 700 mg tab 5

INVIRASE 500 MG TAB 5

KALETRA 100-25 MG TAB 4

KALETRA 200-50 MG TAB 5

LEXIVA 50 MG/ML SUSPENSION 4

lopinavir-ritonavir 400-100 mg/5ml solution 5

NORVIR (80 MG/ML SOLUTION, 100 MGPACKET)

4


39


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

PREZCOBIX 800-150 MG TAB 5 QL (30 PER 30 DAYS)

PREZISTA (100 MG/ML SUSPENSION, 600MG TAB, 800 MG TAB)

5

PREZISTA (75 MG TAB, 150 MG TAB) 4

REYATAZ 50 MG PACKET 5

ritonavir 100 mg tab 2

SYMTUZA 800-150-200-10 MG TAB 5 QL (30 PER 30 DAYS)

VIRACEPT (250 MG TAB, 625 MG TAB) 5

ANTI-INFLUENZA AGENTSamantadine hcl (50 mg/5ml syrup, 100 mgcap, 100 mg tab)

4

oseltamivir phosphate 30 mg cap 2 QL (168 PER 365 OVER TIME)


oseltamivir phosphate 6 mg/ml recon susp 3 QL (1080 PER 365 OVER TIME)


rimantadine hcl 100 mg tab 2

XOFLUZA (40 MG DOSE) 2 X 20 MG TABTHPK

3

XOFLUZA (80 MG DOSE) 2 X 40 MG TABTHPK

3

ANTIHERPETIC AGENTSacyclovir (200 mg cap, 400 mg tab, 800 mgtab)

2

acyclovir (5 % ointment, 200 mg/5mlsuspension)

4

acyclovir sodium 50 mg/ml solution 4 PA - Part B vs D Determination

trifluridine 1 % solution 2

valacyclovir hcl (1 gm tab, 500 mg tab) 3 QL (120 PER 30 DAYS)


40


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ANXIOLYTICS

ANXIOLYTICS, OTHERbuspirone hcl (5 mg tab, 7.5 mg tab, 10 mgtab, 15 mg tab, 30 mg tab)

2

hydroxyzine pamoate (25 mg cap, 50 mg cap,100 mg cap)

4

BENZODIAZEPINESalprazolam (0.25 mg tab, 0.5 mg tab, 1 mgtab)


alprazolam 2 mg tab 4 QL (150 PER 30 DAYS)

alprazolam er (er 0.5 mg tab er 24h, er 1 mgtab er 24h)


alprazolam er 2 mg tab er 24h 4 QL (150 PER 30 DAYS)

alprazolam er 3 mg tab er 24h 4 QL (90 PER 30 DAYS)

alprazolam xr (0.5 mg tab er 24h, 1 mg tab er24h)


alprazolam xr 2 mg tab er 24h 4 QL (150 PER 30 DAYS)

alprazolam xr 3 mg tab er 24h 4 QL (90 PER 30 DAYS)

chlordiazepoxide hcl 10 mg cap 2 QL (900 PER 30 DAYS)



clorazepate dipotassium 15 mg tab 3 QL (180 PER 30 DAYS)

clorazepate dipotassium 3.75 mg tab 3 QL (720 PER 30 DAYS)

clorazepate dipotassium 7.5 mg tab 3 QL (360 PER 30 DAYS)

diazepam (5 mg/5ml solution, 5 mg/ml conc) 2

diazepam 10 mg tab 2 QL (120 PER 30 DAYS)



diazepam intensol 5 mg/ml conc 2

lorazepam (0.5 mg tab, 1 mg tab) 2 QL (90 PER 30 DAYS)


41


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

lorazepam 2 mg tab 2 QL (150 PER 30 DAYS)

lorazepam 2 mg/ml conc 2

lorazepam intensol 2 mg/ml conc 2

temazepam (15 mg cap, 30 mg cap) 4 QL (30 PER 30 DAYS)

BIPOLAR AGENTS

MOOD STABILIZERSEQUETRO (100 MG CAP ER 12H, 200 MGCAP ER 12H, 300 MG CAP ER 12H)

4

lithium 8 meq/5ml solution 2

lithium carbonate (150 mg cap, 300 mg cap,300 mg tab, 600 mg cap)

2

lithium carbonate er (er 300 mg tab er, er 450mg tab er)

2

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTSacarbose (25 mg tab, 50 mg tab, 100 mg tab) 2

glimepiride 1 mg tab 1 QL (240 PER 30 DAYS)



glipizide 10 mg tab 1 QL (120 PER 30 DAYS)

glipizide 5 mg tab 1 QL (240 PER 30 DAYS)

glipizide er 10 mg tab er 24h 1 QL (60 PER 30 DAYS)

glipizide er 2.5 mg tab er 24h 1 QL (240 PER 30 DAYS)

glipizide er 5 mg tab er 24h 1 QL (120 PER 30 DAYS)

glipizide xl 10 mg tab er 24h 1 QL (60 PER 30 DAYS)

glipizide xl 2.5 mg tab er 24h 1 QL (240 PER 30 DAYS)

glipizide xl 5 mg tab er 24h 1 QL (120 PER 30 DAYS)

glipizide-metformin hcl (2.5-500 mg tab, 5-500mg tab)



42


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

glipizide-metformin hcl 2.5-250 mg tab 2 QL (240 PER 30 DAYS)

glyburide-metformin (2.5-500 mg tab, 5-500mg tab)


glyburide-metformin 1.25-250 mg tab 2 QL (240 PER 30 DAYS)

INVOKAMET (50-1000 MG TAB, 150-1000MG TAB, 150-500 MG TAB)


INVOKAMET 50-500 MG TAB 3 ST, QL (120 PER 30 DAYS)

INVOKAMET XR (50-1000 MG TAB ER 24H,50-500 MG TAB ER 24H, 150-1000 MG TABER 24H, 150-500 MG TAB ER 24H)


INVOKANA 100 MG TAB 3 ST, QL (90 PER 30 DAYS)

INVOKANA 300 MG TAB 3 ST, QL (30 PER 30 DAYS)

JANUMET (50-1000 MG TAB, 50-500 MGTAB)


JANUMET XR (50-500 MG TAB ER 24H, 50-1000 MG TAB ER 24H)


JANUMET XR 100-1000 MG TAB ER 24H 3 ST, QL (30 PER 30 DAYS)

JANUVIA (25 MG TAB, 50 MG TAB, 100 MGTAB)

3 ST

JARDIANCE 10 MG TAB 3 ST, QL (60 PER 30 DAYS)

JARDIANCE 25 MG TAB 3 ST, QL (30 PER 30 DAYS)

JENTADUETO (2.5-850 MG TAB, 2.5-1000MG TAB, 2.5-500 MG TAB)


JENTADUETO XR 2.5-1000 MG TAB ER 24H 3 ST, QL (60 PER 30 DAYS)

JENTADUETO XR 5-1000 MG TAB ER 24H 3 ST, QL (30 PER 30 DAYS)

metformin hcl 1000 mg tab 1 QL (60 PER 30 DAYS)



metformin hcl er 500 mg tab er 24h 2 QL (120 PER 30 DAYS)

metformin hcl er 750 mg tab er 24h 2 QL (60 PER 30 DAYS)

nateglinide (60 mg tab, 120 mg tab) 2

pioglitazone hcl 15 mg tab 1 QL (60 PER 30 DAYS)



43


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS


repaglinide (0.5 mg tab, 1 mg tab, 2 mg tab) 2

SYNJARDY (5-1000 MG TAB, 12.5-1000 MGTAB)


SYNJARDY (5-500 MG TAB, 12.5-500 MGTAB)


SYNJARDY XR (10-1000 MG TAB ER 24H,25-1000 MG TAB ER 24H)


SYNJARDY XR (5-1000 MG TAB ER 24H,12.5-1000 MG TAB ER 24H)


TRADJENTA 5 MG TAB 3 ST

TRIJARDY XR (5-2.5-1000 MG TAB ER 24H,10-5-1000 MG TAB ER 24H, 12.5-2.5-1000MG TAB ER 24H, 25-5-1000 MG TAB ER24H)

3 ST

TRULICITY (0.75 MG/0.5ML SOLN PEN, 1.5MG/0.5ML SOLN PEN, 3 MG/0.5ML SOLNPEN, 4.5 MG/0.5ML SOLN PEN)


VICTOZA 18 MG/3ML SOLN PEN 3 ST, QL (9 PER 30 DAYS)

GLYCEMIC AGENTSGLUCAGEN HYPOKIT 1 MG RECON SOLN 4

glucagon emergency 1 mg kit 3

PROGLYCEM 50 MG/ML SUSPENSION 5

INSULINSHUMALOG (100 UNIT/ML SOLUTION, 100UNIT/ML SOLN CART)

3

HUMALOG JUNIOR KWIKPEN 100 UNIT/MLSOLN PEN

3

HUMALOG KWIKPEN (100 UNIT/ML SOLNPEN, 200 UNIT/ML SOLN PEN)

3

HUMALOG MIX 50/50 (50-50) 100 UNIT/MLSUSPENSION

3

HUMALOG MIX 50/50 KWIKPEN (50-50) 100UNIT/ML SUSP PEN

3

HUMALOG MIX 75/25 (75-25) 100 UNIT/MLSUSPENSION

3


44


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

HUMALOG MIX 75/25 KWIKPEN (75-25) 100UNIT/ML SUSP PEN

3

HUMULIN 70/30 (70-30) 100 UNIT/MLSUSPENSION

3

HUMULIN 70/30 KWIKPEN (70-30) 100UNIT/ML SUSP PEN

3

HUMULIN N 100 UNIT/ML SUSPENSION 3

HUMULIN N KWIKPEN 100 UNIT/ML SUSPPEN

3

HUMULIN R 100 UNIT/ML SOLUTION 3

HUMULIN R U-500 (CONCENTRATED) 500UNIT/ML SOLUTION

5 PA - Part B vs D Determination

HUMULIN R U-500 KWIKPEN 500 UNIT/MLSOLN PEN

5

insulin lispro (1 unit dial) 100 unit/ml soln pen 3

insulin lispro 100 unit/ml solution 3

insulin lispro junior kwikpen 100 unit/ml solnpen

3

insulin lispro prot & lispro (75-25) 100 unit/mlsusp pen

3

LANTUS 100 UNIT/ML SOLUTION 3

LANTUS SOLOSTAR 100 UNIT/ML SOLNPEN

3

TOUJEO MAX SOLOSTAR 300 UNIT/MLSOLN PEN

3

TOUJEO SOLOSTAR 300 UNIT/ML SOLNPEN

3

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTSELIQUIS 2.5 MG TAB 3 QL (60 PER 30 DAYS)

ELIQUIS 5 MG TAB 3 QL (90 PER 30 DAYS)

ELIQUIS DVT/PE STARTER PACK 5 MGTAB THPK



45


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

enoxaparin sodium (100 mg/ml solution, 150mg/ml solution)


enoxaparin sodium (80 mg/0.8ml solution, 120mg/0.8ml solution)


enoxaparin sodium 30 mg/0.3ml solution 4 QL (10.5 PER 90 OVER TIME)

enoxaparin sodium 40 mg/0.4ml solution 4 QL (14 PER 90 OVER TIME)

enoxaparin sodium 60 mg/0.6ml solution 4 QL (21 PER 90 OVER TIME)

fondaparinux sodium 10 mg/0.8ml solution 5 PA, QL (28 PER 90 OVER TIME)

fondaparinux sodium 2.5 mg/0.5ml solution 4 PA, QL (17.5 PER 90 OVER TIME)

fondaparinux sodium 5 mg/0.4ml solution 5 PA, QL (14 PER 90 OVER TIME)

fondaparinux sodium 7.5 mg/0.6ml solution 5 PA, QL (21 PER 90 OVER TIME)

heparin sodium (porcine) ((porcine) 1000unit/ml solution, (porcine) 5000 unit/mlsolution, (porcine) 10000 unit/ml solution,(porcine) 20000 unit/ml solution)

2

heparin sodium (porcine) pf ((porcine) 5000unit/0.5ml solution, (porcine) 5000 unit/mlsolution)

2

PRADAXA (75 MG CAP, 110 MG CAP, 150MG CAP)


warfarin sodium (1 mg tab, 2 mg tab, 2.5 mgtab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab,7.5 mg tab, 10 mg tab)

1

XARELTO (10 MG TAB, 20 MG TAB) 3 QL (30 PER 30 DAYS)

XARELTO (2.5 MG TAB, 15 MG TAB) 3 QL (60 PER 30 DAYS)

XARELTO STARTER PACK 3 QL (102 PER 365 OVER TIME)

BLOOD FORMATION MODIFIERSanagrelide hcl (0.5 mg cap, 1 mg cap) 2

ARANESP (ALBUMIN FREE) (FREE) 10MCG/0.4ML SOLN PRSYR, FREE) 25MCG/0.42ML SOLN PRSYR, FREE) 25MCG/ML SOLUTION, FREE) 40 MCG/MLSOLUTION, FREE) 40 MCG/0.4ML SOLNPRSYR, FREE) 60 MCG/0.3ML SOLNPRSYR)

4 PA


46


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ARANESP (ALBUMIN FREE) (FREE) 60MCG/ML SOLUTION, FREE) 100 MCG/MLSOLUTION, FREE) 100 MCG/0.5ML SOLNPRSYR, FREE) 150 MCG/0.3ML SOLNPRSYR, FREE) 200 MCG/0.4ML SOLNPRSYR, FREE) 200 MCG/ML SOLUTION,FREE) 300 MCG/ML SOLUTION, FREE) 300MCG/0.6ML SOLN PRSYR, FREE) 500MCG/ML SOLN PRSYR)

5 PA

NEULASTA 6 MG/0.6ML SOLN PRSYR 5 PA

NEULASTA ONPRO 6 MG/0.6ML PREF SYKT

5 PA

NEUPOGEN (300 MCG/ML SOLUTION, 300MCG/0.5ML SOLN PRSYR, 480 MCG/1.6MLSOLUTION, 480 MCG/0.8ML SOLN PRSYR)

5

PROMACTA (12.5 MG TAB, 25 MG TAB, 50MG TAB, 75 MG TAB)

5 PA

RETACRIT (2000 UNIT/ML SOLUTION, 3000UNIT/ML SOLUTION, 4000 UNIT/MLSOLUTION, 10000 UNIT/ML SOLUTION,40000 UNIT/ML SOLUTION)

4 PA

UDENYCA 6 MG/0.6ML SOLN PRSYR 5 PA

HEMOSTASIS AGENTStranexamic acid 650 mg tab 3

PLATELET MODIFYING AGENTSaspirin-dipyridamole er 25-200 mg cap er 12h 4

BRILINTA (60 MG TAB, 90 MG TAB) 3

cilostazol (50 mg tab, 100 mg tab) 2

clopidogrel bisulfate 75 mg tab 2

prasugrel hcl (5 mg tab, 10 mg tab) 4

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTSclonidine (0.1 mg/24hr patch wk, 0.2 mg/24hrpatch wk, 0.3 mg/24hr patch wk)

4


47


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

clonidine hcl (0.1 mg tab, 0.2 mg tab, 0.3 mgtab)

2

guanfacine hcl (1 mg tab, 2 mg tab) 4

methyldopa (250 mg tab, 500 mg tab) 4

methyldopa-hydrochlorothiazide (250-15 mgtab, 250-25 mg tab)

4

midodrine hcl (2.5 mg tab, 5 mg tab, 10 mgtab)

3

ALPHA-ADRENERGIC BLOCKING AGENTSphenoxybenzamine hcl 10 mg cap 4

prazosin hcl (1 mg cap, 2 mg cap, 5 mg cap) 2

ANGIOTENSIN II RECEPTOR ANTAGONISTSirbesartan (75 mg tab, 150 mg tab, 300 mgtab)

2

irbesartan-hydrochlorothiazide (150-12.5 mgtab, 300-12.5 mg tab)

2

losartan potassium (25 mg tab, 50 mg tab, 100mg tab)

1

losartan potassium-hctz (50-12.5 mg tab, 100-12.5 mg tab, 100-25 mg tab)

2

olmesartan medoxomil (5 mg tab, 20 mg tab,40 mg tab)

2

olmesartan medoxomil-hctz (20-12.5 mg tab,40-12.5 mg tab, 40-25 mg tab)

2

telmisartan (20 mg tab, 40 mg tab, 80 mg tab) 4

valsartan (40 mg tab, 80 mg tab, 160 mg tab,320 mg tab)

2

valsartan-hydrochlorothiazide (80-12.5 mg tab,160-25 mg tab, 160-12.5 mg tab, 320-12.5 mgtab, 320-25 mg tab)

2

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril hcl (5 mg tab, 10 mg tab, 20 mgtab, 40 mg tab)

1

enalapril maleate (2.5 mg tab, 5 mg tab, 10mg tab, 20 mg tab)

2


48


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

enalapril-hydrochlorothiazide (5-12.5 mg tab,10-25 mg tab)

2

fosinopril sodium (10 mg tab, 20 mg tab, 40mg tab)

2

lisinopril (2.5 mg tab, 5 mg tab, 10 mg tab, 20mg tab, 30 mg tab, 40 mg tab)

1

lisinopril-hydrochlorothiazide (10-12.5 mg tab,20-12.5 mg tab, 20-25 mg tab)

2

quinapril hcl (5 mg tab, 10 mg tab, 20 mg tab,40 mg tab)

1

quinapril-hydrochlorothiazide (10-12.5 mg tab,20-25 mg tab, 20-12.5 mg tab)

2

ramipril (1.25 mg cap, 2.5 mg cap, 5 mg cap,10 mg cap)

1

ANTIARRHYTHMICSamiodarone hcl (100 mg tab, 200 mg tab, 400mg tab)

4

dofetilide (125 mcg cap, 250 mcg cap, 500mcg cap)

4

flecainide acetate (50 mg tab, 100 mg tab, 150mg tab)

3

mexiletine hcl (150 mg cap, 200 mg cap, 250mg cap)

4

propafenone hcl (150 mg tab, 225 mg tab, 300mg tab)

3

quinidine sulfate (200 mg tab, 300 mg tab) 2

sotalol hcl (80 mg tab, 120 mg tab, 160 mgtab, 240 mg tab)

2

sotalol hcl (af) ((af) 80 mg tab, (af) 120 mg tab,(af) 160 mg tab)

2

BETA-ADRENERGIC BLOCKING AGENTSatenolol (25 mg tab, 50 mg tab, 100 mg tab) 1

atenolol-chlorthalidone (50-25 mg tab, 100-25mg tab)

4

bisoprolol fumarate (5 mg tab, 10 mg tab) 2


49


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

BYSTOLIC (2.5 MG TAB, 5 MG TAB, 10 MGTAB, 20 MG TAB)

3

carvedilol (3.125 mg tab, 6.25 mg tab, 12.5 mgtab, 25 mg tab)

1

carvedilol phosphate er (er 10 mg cap er 24h,er 20 mg cap er 24h, er 40 mg cap er 24h, er80 mg cap er 24h)

4

labetalol hcl (100 mg tab, 200 mg tab, 300 mgtab)

3

metoprolol succinate er (er 25 mg tab er 24h,er 50 mg tab er 24h, er 100 mg tab er 24h, er200 mg tab er 24h)

2

metoprolol tartrate (25 mg tab, 50 mg tab, 100mg tab)

1

propranolol hcl (10 mg tab, 20 mg tab, 20mg/5ml solution, 40 mg/5ml solution, 40 mgtab, 60 mg tab, 80 mg tab)

4

propranolol hcl er (er 60 mg cap er 24h, er 80mg cap er 24h, er 120 mg cap er 24h, er 160mg cap er 24h)

4

propranolol-hctz (40-25 mg tab, 80-25 mg tab) 4

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besy-benazepril hcl (2.5-10 mgcap, 5-20 mg cap, 5-10 mg cap, 5-40 mg cap,10-40 mg cap, 10-20 mg cap)

4

amlodipine besylate (2.5 mg tab, 5 mg tab, 10mg tab)

1

cartia xt (120 mg cap er 24h, 180 mg cap er24h, 240 mg cap er 24h, 300 mg cap er 24h)

3

dilt-xr (120 mg cap er 24h, 180 mg cap er 24h,240 mg cap er 24h)

4

diltiazem cd (120 mg cap er 24h, 180 mg caper 24h, 240 mg cap er 24h, 300 mg cap er24h)

3

diltiazem hcl (30 mg tab, 60 mg tab, 90 mgtab, 120 mg tab)

2


50


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

diltiazem hcl er (er 60 mg cap er 12h, er 90mg cap er 12h, er 120 mg cap er 12h, er 120mg cap er 24h, er 180 mg cap er 24h, er 240mg cap er 24h)

3

diltiazem hcl er beads (er beads 120 mg caper 24h, er beads 180 mg cap er 24h, er beads240 mg cap er 24h, er beads 300 mg cap er24h, er beads 360 mg cap er 24h, er beads420 mg cap er 24h)

3

diltiazem hcl er coated beads (er beads 120mg cap er 24h, er beads 180 mg cap er 24h,er beads 240 mg cap er 24h, er beads 300 mgcap er 24h, er beads 360 mg cap er 24h)

3

felodipine er (er 2.5 mg tab er 24h, er 5 mg taber 24h, er 10 mg tab er 24h)

3

nifedipine er (er 30 mg tab er 24h, er 60 mgtab er 24h, er 90 mg tab er 24h)

3

nifedipine er osmotic release (er 30 mg tab er24h, er 60 mg tab er 24h, er 90 mg tab er 24h)

3

nimodipine 30 mg cap 5

verapamil hcl (40 mg tab, 80 mg tab, 120 mgtab)

1

verapamil hcl er (er 100 mg cap er 24h, er 120mg tab er, er 120 mg cap er 24h, er 180 mgtab er, er 180 mg cap er 24h, er 200 mg caper 24h, er 240 mg cap er 24h, er 240 mg taber, er 300 mg cap er 24h, er 360 mg cap er24h)

4

CARDIOVASCULAR AGENTS, OTHERaliskiren fumarate (150 mg tab, 300 mg tab) 4 ST, QL (30 PER 30 DAYS)

CORLANOR (5 MG TAB, 7.5 MG TAB) 4 PA, QL (60 PER 30 DAYS)

CORLANOR 5 MG/5ML SOLUTION 4 PA, QL (4501 PER 30 DAYS)

DEMSER 250 MG CAP 5

digitek 125 mcg tab 2 QL (30 PER 30 DAYS)

digitek 250 mcg tab 4

digox 125 mcg tab 3 QL (30 PER 30 DAYS)

digox 250 mcg tab 3


51


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

digoxin (0.05 mg/ml solution, 250 mcg tab) 3

digoxin 125 mcg tab 3 QL (30 PER 30 DAYS)

ENTRESTO (24-26 MG TAB, 49-51 MG TAB,97-103 MG TAB)


LANOXIN 62.5 MCG TAB 4 QL (60 PER 30 DAYS)

metyrosine 250 mg cap 5

NORTHERA (100 MG CAP, 200 MG CAP,300 MG CAP)

5 PA

pentoxifylline er 400 mg tab er 4

ranolazine er (er 500 mg tab er 12h, er 1000mg tab er 12h)

4

REPATHA 140 MG/ML SOLN PRSYR 4 PA, QL (3 PER 28 DAYS)

REPATHA PUSHTRONEX SYSTEM 420MG/3.5ML SOLN CART

4 PA, QL (3.5 PER 28 DAYS)

REPATHA SURECLICK 140 MG/ML SOLN A-INJ


DIURETICS, LOOPbumetanide (0.25 mg/ml solution, 0.5 mg tab,1 mg tab, 2 mg tab)

3

furosemide (20 mg tab, 40 mg tab, 80 mg tab) 1

furosemide (8 mg/ml solution, 10 mg/mlsolution)

2

torsemide (5 mg tab, 10 mg tab, 20 mg tab,100 mg tab)

2

DIURETICS, POTASSIUM-SPARINGamiloride hcl 5 mg tab 2

amiloride-hydrochlorothiazide 5-50 mg tab 2

spironolactone (25 mg tab, 50 mg tab, 100 mgtab)

2

triamterene-hctz (37.5-25 mg cap, 37.5-25 mgtab, 75-50 mg tab)

2


52


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

DIURETICS, THIAZIDEchlorothiazide (250 mg tab, 500 mg tab) 2

chlorthalidone (25 mg tab, 50 mg tab) 4

hydrochlorothiazide (12.5 mg tab, 12.5 mgcap, 25 mg tab, 50 mg tab)

1

indapamide (1.25 mg tab, 2.5 mg tab) 2

methyclothiazide 5 mg tab 2

metolazone (2.5 mg tab, 5 mg tab, 10 mg tab) 3

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVESfenofibrate (40 mg tab, 48 mg tab, 54 mg tab,120 mg tab, 145 mg tab, 160 mg tab)

3

gemfibrozil 600 mg tab 2

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORSatorvastatin calcium (10 mg tab, 20 mg tab, 40mg tab, 80 mg tab)

1

lovastatin (10 mg tab, 20 mg tab, 40 mg tab) 2

pravastatin sodium (10 mg tab, 20 mg tab, 40mg tab, 80 mg tab)

2

rosuvastatin calcium (5 mg tab, 10 mg tab, 20mg tab, 40 mg tab)

2

simvastatin (5 mg tab, 10 mg tab, 20 mg tab,40 mg tab)

1

simvastatin 80 mg tab 1 PA

DYSLIPIDEMICS, OTHERcholestyramine (4 gm/dose powder, 4 gmpacket)

3

cholestyramine light (4 gm packet, 4 gm/dosepowder)

3

colestipol hcl (1 gm tab, 5 gm packet, 5 gmgranules)

2

ezetimibe 10 mg tab 4

ezetimibe-simvastatin (10-20 mg tab, 10-40mg tab, 10-10 mg tab)

2


53


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ezetimibe-simvastatin 10-80 mg tab 2 PA

NIACOR 500 MG TAB 3

omega-3-acid ethyl esters 1 gm cap 4

triklo 1 gm cap 4

VASCEPA (0.5 GM CAP, 1 GM CAP) 4

VASODILATORS, DIRECT-ACTING ARTERIALhydralazine hcl (10 mg tab, 25 mg tab, 50 mgtab, 100 mg tab)

2

minoxidil (2.5 mg tab, 10 mg tab) 4

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUSisosorbide dinitrate (5 mg tab, 10 mg tab, 20mg tab, 30 mg tab)

3

isosorbide dinitrate er 40 mg tab er 3

isosorbide mononitrate (10 mg tab, 20 mg tab) 2

isosorbide mononitrate er (er 30 mg tab er24h, er 60 mg tab er 24h, er 120 mg tab er24h)

2

NITRO-BID 2 % OINTMENT 4

nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hrpatch 24hr, 0.3 mg sl tab, 0.4 mg/hr patch24hr, 0.4 mg sl tab, 0.6 mg/hr patch 24hr, 0.6mg sl tab)

3

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINESdextroamphetamine sulfate 10 mg tab 3 PA, QL (180 PER 30 DAYS)

dextroamphetamine sulfate 5 mg tab 3 PA, QL (90 PER 30 DAYS)

dextroamphetamine-amphetamine (5 mg tab,7.5 mg tab, 10 mg tab, 12.5 mg tab, 15 mgtab, 20 mg tab, 30 mg tab)


dextroamphetamine-amphetamine er (5 mgcap er 24h, 10 mg cap er 24h, 15 mg cap er24h, 20 mg cap er 24h, 25 mg cap er 24h, 30mg cap er 24h)



54


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl (18 mg cap, 25 mg cap, 40mg cap, 60 mg cap, 80 mg cap, 100 mg cap)


atomoxetine hcl 10 mg cap 2 QL (60 PER 30 DAYS)

guanfacine hcl er (er 1 mg tab er 24h, er 2 mgtab er 24h, er 3 mg tab er 24h, er 4 mg tab er24h)

4

methylphenidate hcl (2.5 mg chew tab, 5 mgchew tab)


methylphenidate hcl (5 mg tab, 10 mg tab, 20mg tab)


methylphenidate hcl (5 mg/5ml solution, 10mg/5ml solution)

4 PA

methylphenidate hcl 10 mg chew tab 4 PA, QL (180 PER 30 DAYS)

methylphenidate hcl er (er 18 mg tab er, er 18mg tab er 24h, er 27 mg tab er, er 27 mg taber 24h, er 54 mg tab er 24h, er 54 mg tab er,er 72 mg tab er)


methylphenidate hcl er (er 36 mg tab er, er 36mg tab er 24h)


CENTRAL NERVOUS SYSTEM, OTHERbutalbital-acetaminophen (25-325 mg tab, 50-300 mg tab, 50-325 mg tab, 50-300 mg cap)


butalbital-apap 50-325 mg tab 4 QL (180 PER 30 DAYS)

butalbital-apap-caffeine (50-300-40 mg cap,50-325-40 mg cap, 50-325-40 mg tab)


butalbital-asa-caffeine 50-325-40 mg cap 4 QL (180 PER 30 DAYS)

butalbital-aspirin-caffeine (50-325-40 mg tab,50-325-40 mg cap)


INGREZZA 40 & 80 MG CAP THPK 5 PA, QL (56 PER 365 OVER TIME)

INGREZZA 40 MG CAP 5 PA, QL (60 PER 30 DAYS)

INGREZZA 80 MG CAP 5 PA, QL (30 PER 30 DAYS)

NUEDEXTA 20-10 MG CAP 4 PA


55


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

riluzole 50 mg tab 2 PA

tetrabenazine (12.5 mg tab, 25 mg tab) 5 PA

MULTIPLE SCLEROSIS AGENTSAUBAGIO (7 MG TAB, 14 MG TAB) 4 PA, QL (30 PER 30 DAYS)

AVONEX 30 MCG KIT 5 PA, QL (4 PER 28 DAYS)

AVONEX PEN 30 MCG/0.5ML AUT-IJ KIT 5 PA, QL (4 PER 28 DAYS)

AVONEX PREFILLED 30 MCG/0.5ML PREFSY KT


BETASERON 0.3 MG KIT 5 PA, QL (15 PER 30 DAYS)

dalfampridine er 10 mg tab er 12h 3 PA, QL (60 PER 30 DAYS)

dimethyl fumarate (120 mg cap dr, 240 mgcap dr)


dimethyl fumarate starter pack 120 & 240 mgmisc

5 PA, QL (120 PER 365 OVERTIME)

GILENYA 0.5 MG CAP 5 PA, QL (30 PER 30 DAYS)

glatiramer acetate 20 mg/ml soln prsyr 5 PA, QL (30 PER 30 DAYS)

glatiramer acetate 40 mg/ml soln prsyr 5 PA, QL (12 PER 28 DAYS)

TECFIDERA 120 & 240 MG MISC 5 PA, QL (120 PER 365 OVERTIME)

ZEPOSIA 0.92 MG CAP 5 PA, QL (30 PER 30 DAYS)

ZEPOSIA 7-DAY STARTER PACK 4 X0.23MG & 3 X 0.46MG CAP THPK

5 PA

ZEPOSIA STARTER KIT 0.23MG & 0.46MG &0.92MG CAP THPK

5 PA

DENTAL AND ORAL AGENTS

chlorhexidine gluconate 0.12 % solution 2

lidocaine viscous hcl 2 % solution 1

pilocarpine hcl (5 mg tab, 7.5 mg tab) 3

triamcinolone acetonide 0.1 % paste 2


56


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

DERMATOLOGICAL AGENTS

acitretin (10 mg cap, 25 mg cap) 4

acitretin 17.5 mg cap 5

ammonium lactate (12 % lotion, 12 % cream) 3

azelaic acid 15 % gel 4

calcipotriene (0.005 % cream, 0.005 %ointment)


calcipotriene 0.005 % solution 2 QL (60 PER 30 DAYS)

COSENTYX (300 MG DOSE) 150 MG/MLSOLN PRSYR

5 PA

COSENTYX 150 MG/ML SOLN PRSYR 5 PA

COSENTYX SENSOREADY (300 MG) 150MG/ML SOLN A-INJ

5 PA

COSENTYX SENSOREADY PEN 150 MG/MLSOLN A-INJ

5 PA

imiquimod 5 % cream 4

isotretinoin (10 mg cap, 20 mg cap, 30 mgcap, 40 mg cap)

4 PA

metronidazole (0.75 % gel, 0.75 % cream) 2

metronidazole (0.75 % lotion, 1 % gel) 4

MIRVASO 0.33 % GEL 4 PA

podofilox 0.5 % solution 2

RECTIV 0.4 % OINTMENT 4

SANTYL 250 UNIT/GM OINTMENT 4

selenium sulfide 2.5 % lotion 2

STELARA (45 MG/0.5ML SOLN PRSYR, 45MG/0.5ML SOLUTION)

5 PA, QL (0.5 PER 28 OVER TIME)

STELARA 90 MG/ML SOLN PRSYR 5 PA, QL (1 PER 28 OVER TIME)

tacrolimus (0.03 % ointment, 0.1 % ointment) 4

tazarotene 0.1 % cream 4

tretinoin (0.025 % cream, 0.05 % cream, 0.1% cream)

2 PA


57


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENTaminosyn ii/electrolytes 8.5 % solution 2 PA - Part B vs D Determination

AMINOSYN/ELECTROLYTES 7 %SOLUTION


AMINOSYN/ELECTROLYTES 8.5 %SOLUTION


CARBAGLU 200 MG TAB 5

dextrose (5 % solution, 10 % solution, 50 %solution, 70 % solution)

2

dextrose-nacl (2.5-0.45 % solution, 5-0.45 %solution, 5-0.9 % solution, 5-0.3 % solution, 5-0.33 % solution, 5-0.2 % solution, 5-0.225 %solution, 10-0.2 % solution, 10-0.45 %solution, 10-0.225 % solution)

2

dextrose-sodium chloride 5-0.3 % solution 2

glucose 5 % solution 2

IONOSOL-MB IN D5W SOLUTION 4

ISOLYTE-P IN D5W SOLUTION 4

ISOLYTE-S SOLUTION 4

ISOLYTE-S PH 7.4 SOLUTION 4

kcl in dextrose-nacl ( 10-5-0.45 meq/l-%-%solution, 20-5-0.2 meq/l-%-% solution, 20-5-0.45 meq/l-%-% solution, 20-5-0.33 meq/l-%-% solution, 20-5-0.9 meq/l-%-% solution, 20-5-0.225 meq/l-%-% solution, 30-5-0.45 meq/l-%-% solution, 40-5-0.45 meq/l-%-% solution, 40-5-0.9 meq/l-%-% solution)

2

kcl-lactated ringers-d5w 20 meq/l solution 2

LOZI-FLUR 2.2 (1 F) MG LOZENGE 3

ludent (0.55 (0.25 f) mg chew tab, 1.1 (0.5 f)mg chew tab, 2.2 (1 f) mg chew tab)

3

magnesium sulfate 50 % solution 2

magnesium sulfate 50 % syringe 2


58


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

NORMOSOL-M IN D5W SOLUTION 4

NORMOSOL-R SOLUTION 4

NORMOSOL-R IN D5W SOLUTION 4

NORMOSOL-R PH 7.4 SOLUTION 4

PLASMA-LYTE 148 SOLUTION 4

PLASMA-LYTE A SOLUTION 4

potassium chloride (0.4 meq/ml solution, 2meq/ml solution, 10 meq/100ml solution, 10meq/50ml solution, 20 meq/100ml solution, 20meq/50ml solution, 40 meq/100ml solution)

4

potassium chloride crys er (crys er 10 tab er,crys er 20 tab er)

4

potassium chloride er (er 8 cap er, er 8 tab er,er 10 cap er, er 10 tab er, er 20 tab er)

4

potassium chloride solution 20 meq/15ml(10%)

4

potassium chloride solution 40 meq/15ml(20%)

4

potassium citrate er (er 5 (540 mg) tab er, er10 (1080 mg) tab er, er 15 (1620 mg) tab er)

4

PROCALAMINE 3 % SOLUTION 4 PA - Part B vs D Determination

sodium chloride (0.45 % solution, 0.9 %solution, 3 % solution, 4 meq/ml solution, 5 %solution)

2

sodium fluoride (0.55 (0.25 f) mg chew tab, 1.1(0.5 f) mg chew tab)

3

sodium fluoride 2.2 mg (fluoride ion 1 mg) oraltablet

3

sodium lactate 5 meq/ml solution 2

ELECTROLYTE/MINERAL/METAL MODIFIERSdeferasirox (90 mg tab, 180 mg tab, 360 mgtab)

5 PA

deferasirox granules (granules 90 mg packet,granules 180 mg packet, granules 360 mgpacket)

5 PA


59


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

penicillamine 250 mg tab 5

sodium polystyrene sulfonate powder 2

sodium polystyrene sulfonate 15 gm/60mlsuspension

2

sps 15 gm/60ml suspension 2

trientine hcl 250 mg cap 5 PA

PHOSPHATE BINDERSAURYXIA 1 GM 210 MG(FE) TAB 5 PA

calcium acetate (phos binder) (binder) 667 mgtab, binder) 667 mg cap)

3

sevelamer carbonate (0.8 gm packet, 2.4 gmpacket)

5

sevelamer carbonate 800 mg tab 4

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINALdicyclomine hcl (10 mg cap, 20 mg tab) 1

dicyclomine hcl 10 mg/5ml solution 2

glycopyrrolate (1 mg tab, 2 mg tab) 3

methscopolamine bromide (2.5 mg tab, 5 mgtab)

4

GASTROINTESTINAL AGENTS, OTHERCHENODAL 250 MG TAB 5

CHOLBAM (50 MG CAP, 250 MG CAP) 5 PA

cromolyn sodium 100 mg/5ml conc 2

diphenoxylate-atropine 2.5-0.025 mg tab 2

loperamide hcl 2 mg cap 2

metoclopramide hcl (5 mg tab, 10 mg tab) 1

metoclopramide hcl (5 mg/5ml solution, 10mg/10ml solution)

2

RELISTOR 12 MG/0.6ML SOLUTION 5 ST, QL (18 PER 30 DAYS)


60


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

RELISTOR 150 MG TAB 5 ST, QL (90 PER 30 DAYS)

RELISTOR 8 MG/0.4ML SOLUTION 5 ST, QL (12 PER 30 DAYS)

ursodiol (250 mg tab, 500 mg tab) 3

HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine (200 mg tab, 300 mg tab, 400 mgtab, 800 mg tab)

2

cimetidine hcl 300 mg/5ml solution 2

famotidine (20 mg tab, 40 mg/5ml recon susp,40 mg tab)

4

IRRITABLE BOWEL SYNDROME AGENTSalosetron hcl (0.5 mg tab, 1 mg tab) 5 PA

AMITIZA (8 MCG CAP, 24 MCG CAP) 3 QL (60 PER 30 DAYS)

LINZESS (72 MCG CAP, 145 MCG CAP, 290MCG CAP)


LAXATIVESconstulose 10 gm/15ml solution 2

enulose 10 gm/15ml solution 4

GAVILYTE-C 240 GM RECON SOLN 2

gavilyte-g 236 gm recon soln 2

gavilyte-n with flavor pack 420 gm recon soln 2

generlac 10 gm/15ml solution 4

lactulose (10 gm/15ml solution, 20 gm/30mlsolution)

2

peg 3350-kcl-na bicarb-nacl 420 gm reconsoln

4

peg 3350/electrolytes 240 gm recon soln 4

peg-3350/electrolytes 236 gm recon soln 4

polyethylene glycol 3350 (3350granules,3350powder, 335017gm/scooppowder,335017gmpacket)

2

SUPREP BOWEL PREP KIT 17.5-3.13-1.6GM/177ML SOLUTION

3


61


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

trilyte 420 gm recon soln 2

PROTECTANTSmisoprostol (100 mcg tab, 200 mcg tab) 2

sucralfate 1 gm tab 4

PROTON PUMP INHIBITORSDEXILANT CAP DR 30 MG 4 QL (30 PER 30 DAYS)

DEXILANT CAP DR 60 MG 4 QL (30 PER 30 DAYS)

esomeprazole magnesium (20 mg cap dr, 40mg cap dr)


lansoprazole (15 mg cap dr, 30 mg cap dr) 4 QL (60 PER 30 DAYS)

omeprazole (10 mg cap dr, 20 mg cap dr, 40mg cap dr)


pantoprazole sodium (20 mg tab dr, 40 mg tabdr)


GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

CREON (3000-9500 CP DR PART, 6000 CPDR PART, 12000 CP DR PART, 24000-76000CP DR PART, 36000 CP DR PART)

3

CYSTAGON (50 MG CAP, 150 MG CAP) 4

KUVAN (100 MG PACKET, 100 MG TABSOL, 500 MG PACKET)

5 PA

miglustat 100 mg cap 5 PA

nitisinone (2 mg cap, 5 mg cap, 10 mg cap) 5

ORFADIN (4 MG/ML SUSPENSION, 20 MGCAP)

5

sapropterin dihydrochloride (100 mg tab sol,100 mg packet, 500 mg packet)

5 PA

sodium phenylbutyrate 3 gm/tsp powder 5

ZENPEP (3000-14000 CP DR PART, 5000-24000 CP DR PART, 10000-32000 CP DRPART, 15000-47000 CP DR PART, 20000-63000 CP DR PART, 25000-79000 CP DRPART, 40000-126000 CP DR PART)

3


62


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

GENITOURINARY AGENTS

ANTISPASMODICS, URINARYflavoxate hcl 100 mg tab 2

MYRBETRIQ (25 MG TAB ER 24H, 50 MGTAB ER 24H)

3

oxybutynin chloride (5 mg tab, 5 mg/5mlsyrup)

4

oxybutynin chloride er (er 5 mg tab er 24h, er10 mg tab er 24h, er 15 mg tab er 24h)

4

solifenacin succinate (5 mg tab, 10 mg tab) 3

BENIGN PROSTATIC HYPERTROPHY AGENTSalfuzosin hcl er 10 mg tab er 24h 2

doxazosin mesylate (1 mg tab, 2 mg tab, 4 mgtab, 8 mg tab)

2

finasteride 5 mg tab 2

tamsulosin hcl 0.4 mg cap 2

terazosin hcl (1 mg cap, 2 mg cap, 5 mg cap,10 mg cap)

2

GENITOURINARY AGENTS, OTHERbethanechol chloride (5 mg tab, 10 mg tab, 25mg tab, 50 mg tab)

3

ELMIRON 100 MG CAP 4

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ala-cort 2.5 % cream 1

amcinonide (0.1 % cream, 0.1 % ointment, 0.1% lotion)

4

betamethasone dipropionate (0.05 % lotion,0.05 % cream, 0.05 % ointment)

3

betamethasone dipropionate aug (0.05 %cream, 0.05 % lotion, 0.05 % ointment, 0.05 %gel)

4


63


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

betamethasone valerate (0.1 % ointment, 0.1% lotion, 0.1 % cream)

3

betamethasone valerate 0.12 % foam 3 QL (100 PER 30 DAYS)

cortisone acetate 25 mg tab 2

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

2

DEXAMETHASONE INTENSOL 1 MG/MLCONC

3

fludrocortisone acetate 0.1 mg tab 2

hydrocortisone (2.5 % cream, 2.5 % ointment) 1

hydrocortisone (2.5 % lotion, 5 mg tab, 10 mgtab, 20 mg tab)

2

hydrocortisone butyrate 0.1 % lotion 2

methylprednisolone (4 mg tab thpk, 4 mg tab,8 mg tab, 16 mg tab, 32 mg tab)

2

mometasone furoate (0.1 % ointment, 0.1 %solution, 0.1 % cream)

3

prednisolone (15 mg/5ml syrup, 15 mg/5mlsolution)

2

prednisolone sodium phosphate (6.7 (5 base)mg/5ml solution, 10 mg/5ml solution, 15mg/5ml solution, 20 mg/5ml solution, 25mg/5ml solution)

2

prednisone (1 mg tab, 2.5 mg tab, 5 mg (21)tab thpk, 5 mg (48) tab thpk, 5 mg/5mlsolution, 5 mg tab, 10 mg (21) tab thpk, 10 mgtab, 10 mg (48) tab thpk, 20 mg tab, 50 mgtab)

2

PREDNISONE INTENSOL 5 MG/ML CONC 3

triamcinolone acetonide (0.025 % cream, 0.1% cream, 0.5 % cream)

1

triamcinolone acetonide (0.025 % ointment,0.025 % lotion, 0.1 % ointment, 0.1 % lotion,0.5 % ointment)

2

triamcinolone acetonide 0.147 mg/gm aerosoln

4


64


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

triderm 0.1 % cream 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace spray refrig 0.01 % solution 4

desmopressin acetate (0.1 mg tab, 0.2 mgtab)

3

desmopressin acetate spray 0.01 % solution 4

GENOTROPIN (5 MG RECON SOLN, 12 MGRECON SOLN)

5 PA

GENOTROPIN MINIQUICK (0.4 MG RECONSOLN, 0.6 MG RECON SOLN, 0.8 MGRECON SOLN, 1 MG RECON SOLN, 1.2 MGRECON SOLN, 1.4 MG RECON SOLN, 1.6MG RECON SOLN, 1.8 MG RECON SOLN, 2MG RECON SOLN)

5 PA

GENOTROPIN MINIQUICK 0.2 MG RECONSOLN

4 PA

INCRELEX 40 MG/4ML SOLUTION 5 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING(PROSTAGLANDINS)

KORLYM 300 MG TAB 5 PA, QL (120 PER 30 DAYS)

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

ANABOLIC STEROIDSANADROL-50 50 MG TAB 5 PA

oxandrolone 10 mg tab 5 PA, QL (60 PER 30 DAYS)

oxandrolone 2.5 mg tab 4 PA, QL (240 PER 30 DAYS)

ANDROGENSANDRODERM (2 MG/24HR PATCH 24HR, 4MG/24HR PATCH 24HR)

3 PA

danazol (50 mg cap, 100 mg cap) 2

danazol 200 mg cap 4


65


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

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

3 PA

testosterone cypionate (100 mg/ml solution,200 mg/ml solution)

3 PA

testosterone enanthate 200 mg/ml solution 4 PA

ESTROGENSaltavera 0.15-30 mg-mcg tab 2

alyacen 1/35 1-35 mg-mcg tab 2

apri 0.15-30 mg-mcg tab 2

aranelle 0.5/1/0.5-35 mg-mcg tab 2

aubra 0.1-20 mg-mcg tab 2

aubra eq 0.1-20 mg-mcg tab 2

aviane 0.1-20 mg-mcg tab 2

blisovi 24 fe 1-20 mg-mcg(24) tab 2

blisovi fe 1.5/30 1.5-30 mg-mcg tab 2

briellyn 0.4-35 mg-mcg tab 2

caziant 0.1/0.125/0.15 -0.025 mg tab 2

cryselle-28 0.3-30 mg-mcg tab 2

cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg tab 2

delyla 0.1-20 mg-mcg tab 2

desogestrel-ethinyl estradiol (0.15-0.02/0.01mg (21/5) tab, 0.15-30 mg-mcg tab)

2

drospirenone-ethinyl estradiol (3-0.03 mg tab,3-0.02 mg tab)

2

emoquette 0.15-30 mg-mcg tab 2

enpresse-28 50-30/75-40/ 125-30 mcg tab 2

enskyce 0.15-30 mg-mcg tab 2


66


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

estradiol (0.025 mg/24hr patch wk, 0.025mg/24hr patch tw, 0.0375 mg/24hr patch wk,0.0375 mg/24hr patch tw, 0.05 mg/24hr patchtw, 0.05 mg/24hr patch wk, 0.06 mg/24hrpatch wk, 0.075 mg/24hr patch tw, 0.075mg/24hr patch wk, 0.1 mg/24hr patch tw, 0.1mg/24hr patch wk, 0.5 mg tab, 1 mg tab, 2 mgtab, 10 mcg tab)

4

estradiol 0.1 mg/gm cream 2

estradiol valerate (20 mg/ml oil, 40 mg/ml oil) 2

estradiol-norethindrone acet (0.5-0.1 mg tab,1-0.5 mg tab)

4

ethynodiol diac-eth estradiol (1-50 tab, 1-35tab)

2

falmina 0.1-20 mg-mcg tab 2

femynor 0.25-35 mg-mcg tab 2

fyavolv (0.5-2.5 tab, 1-5 tab) 4

gianvi 3-0.02 mg tab 2

jinteli 1-5 mg-mcg tab 4

juleber 0.15-30 mg-mcg tab 2

junel 1.5/30 1.5-30 mg-mcg tab 2

junel 1/20 1-20 mg-mcg tab 2

junel fe 1/20 1-20 mg-mcg tab 2

kaitlib fe 0.8-25 mg-mcg chew tab 2

kelnor 1/35 1-35 mg-mcg tab 2

kelnor 1/50 1-50 mg-mcg tab 2

kurvelo 0.15-30 mg-mcg tab 2

larin 1/20 1-20 mg-mcg tab 2

larin fe 1.5/30 1.5-30 mg-mcg tab 2

larin fe 1/20 1-20 mg-mcg tab 2

leena 0.5/1/0.5-35 mg-mcg tab 2

lessina 0.1-20 mg-mcg tab 2

levonest 50-30/75-40/ 125-30 mcg tab 2


67


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

levonorg-eth estrad triphasic 50-30/75-40/125-30 mcg tab

2

levonorgest-eth estrad 91-day (0.1-0.02 &0.01 mg tab, 0.15-0.03 &0.01 mg tab)


levonorgestrel-ethinyl estrad (0.1-20 mg-mcgtab, 0.15-30 mg-mcg tab, 90-20 mcg tab)

2

levora 0.15/30 (28) 0.15-30 mg-mcg tab 2

loryna 3-0.02 mg tab 2

marlissa 0.15-30 mg-mcg tab 2

microgestin 1.5/30 1.5-30 mg-mcg tab 2

microgestin fe 1.5/30 1.5-30 mg-mcg tab 2

microgestin fe 1/20 1-20 mg-mcg tab 2

mimvey 1-0.5 mg tab 4

mimvey lo 0.5-0.1 mg tab 4

mononessa 0.25-35 mg-mcg tab 2

necon 0.5/35 (28) 0.5-35 mg-mcg tab 2

nikki 3-0.02 mg tab 2

norethin ace-eth estrad-fe 1-20 mg-mcg(24)tab

2

norethin-eth estradiol-fe (0.4-35 chew tab, 0.8-25 chew tab)

2

norethindrone acet-ethinyl est 1-20 mg-mcgtab

2

norethindrone-eth estradiol (0.5-2.5 tab, 1-5tab)

4

norgestim-eth estrad triphasic(0.18/0.215/0.25 mg-25 mcg tab,0.18/0.215/0.25 mg-35 mcg tab)

2

norgestimate-eth estradiol 0.25-35 mg-mcgtab

2

nortrel 1/35 (21) 1-35 mg-mcg tab 2

nortrel 1/35 (28) 1-35 mg-mcg tab 2

nortrel 7/7/7 0.5/0.75/1-35 mg-mcg tab 2


68


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

OGESTREL 0.5-50 MG-MCG TAB 3

orsythia 0.1-20 mg-mcg tab 2

pimtrea 0.15-0.02/0.01 mg (21/5) tab 2

pirmella 1/35 1-35 mg-mcg tab 2

PREMARIN (0.3 MG TAB, 0.45 MG TAB,0.625 MG TAB, 0.625 MG/GM CREAM, 0.9MG TAB, 1.25 MG TAB)

3

PREMPHASE 0.625-5 MG TAB 4

PREMPRO (0.3-1.5 MG TAB, 0.45-1.5 MGTAB, 0.625-5 MG TAB, 0.625-2.5 MG TAB)

4

previfem 0.25-35 mg-mcg tab 2

reclipsen 0.15-30 mg-mcg tab 2

sprintec 28 0.25-35 mg-mcg tab 2

tarina fe 1/20 1-20 mg-mcg tab 2

tarina fe 1/20 eq 1-20 mg-mcg tab 2

tri-legest fe 1-20/1-30/1-35 mg-mcg tab 2

tri-sprintec 0.18/0.215/0.25 mg-35 mcg tab 2

trivora (28) 50-30/75-40/ 125-30 mcg tab 2

vyfemla 0.4-35 mg-mcg tab 2

wymzya fe 0.4-35 mg-mcg chew tab 2

PROGESTINScamila 0.35 mg tab 2

CRINONE (4 % GEL, 8 % GEL) 4 PA

deblitane 0.35 mg tab 2

DEPO-PROVERA 400 MG/ML SUSPENSION 4 QL (10 PER 28 DAYS)

errin 0.35 mg tab 2

jolivette 0.35 mg tab 2

lyza 0.35 mg tab 2

medroxyprogesterone acetate (150 mg/mlsuspension, 150 mg/ml susp prsyr)


medroxyprogesterone acetate (2.5 mg tab, 5mg tab, 10 mg tab)

2


69


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

megestrol acetate (20 mg tab, 40 mg/mlsuspension, 40 mg tab, 400 mg/10mlsuspension, 625 mg/5ml suspension)


nora-be 0.35 mg tab 2

norethindrone 0.35 mg tab 2

norethindrone acetate 5 mg tab 2

norlyroc 0.35 mg tab 2

progesterone micronized (100 mg cap, 200mg cap)

2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSOSPHENA 60 MG TAB 3 PA, QL (30 PER 30 DAYS)

raloxifene hcl 60 mg tab 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

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

2

levoxyl (25 mcg tab, 50 mcg tab, 75 mcg tab,88 mcg tab, 100 mcg tab, 112 mcg tab, 125mcg tab, 137 mcg tab, 150 mcg tab, 175 mcgtab, 200 mcg tab)

4

liothyronine sodium (5 mcg tab, 25 mcg tab,50 mcg tab)

3

SYNTHROID (25 MCG TAB, 50 MCG TAB, 75MCG TAB, 88 MCG TAB, 100 MCG TAB, 112MCG TAB, 125 MCG TAB, 137 MCG TAB,150 MCG TAB, 175 MCG TAB, 200 MCGTAB, 300 MCG TAB)

4

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

LYSODREN 500 MG TAB 5

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 0.5 mg tab 2


70


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

FIRMAGON (240 MG DOSE) 120 MG/VIALRECON SOLN


FIRMAGON 80 MG RECON SOLN 4 PA - FOR NEW STARTS ONLY,QL (1 PER 28 OVER TIME)

leuprolide acetate 1 mg/0.2ml kit 5 PA - FOR NEW STARTS ONLY

LUPRON DEPOT (1-MONTH) ((1-MONTH)7.5 MG KIT, (1-MONTH) 3.75 MG KIT)


LUPRON DEPOT (3-MONTH) ((3-MONTH)11.25 MG KIT, (3-MONTH) 22.5 MG KIT)


LUPRON DEPOT (4-MONTH) 30 MG KIT 5 PA - FOR NEW STARTS ONLY,QL (1 PER 112 OVER TIME)

LUPRON DEPOT (6-MONTH) 45 MG KIT 5 PA - FOR NEW STARTS ONLY,QL (1 PER 168 OVER TIME)

octreotide acetate (50 mcg/ml solution, 100mcg/ml solution, 200 mcg/ml solution)

2 PA

octreotide acetate (500 mcg/ml solution, 1000mcg/ml solution)

5 PA

SIGNIFOR (0.3 MG/ML SOLUTION, 0.6MG/ML SOLUTION, 0.9 MG/ML SOLUTION)


SOMATULINE DEPOT (60 MG/0.2MLSOLUTION, 90 MG/0.3ML SOLUTION)

5 PA

SOMATULINE DEPOT 120 MG/0.5MLSOLUTION


SOMAVERT (10 MG RECON SOLN, 15 MGRECON SOLN, 20 MG RECON SOLN, 25 MGRECON SOLN, 30 MG RECON SOLN)

5 PA

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTSmethimazole (5 mg tab, 10 mg tab) 2

propylthiouracil 50 mg tab 2

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTSHAEGARDA (2000 RECON SOLN, 3000RECON SOLN)

5 PA


71


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

icatibant acetate 30 mg/3ml solution 5 PA

IMMUNE SUPPRESSANTSACTEMRA (80 MG/4ML SOLUTION, 162MG/0.9ML SOLN PRSYR, 200 MG/10MLSOLUTION, 400 MG/20ML SOLUTION)

5 PA

ACTEMRA ACTPEN 162 MG/0.9ML SOLN A-INJ

5 PA

azathioprine 50 mg tab 3 PA - Part B vs D Determination

BENLYSTA (200 MG/ML SOLN A-INJ, 200MG/ML SOLN PRSYR)

5 PA

cyclosporine (25 mg cap, 100 mg cap) 4 PA - Part B vs D Determination

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


ENBREL (25 MG RECON SOLN, 25MG/0.5ML SOLUTION, 25 MG/0.5ML SOLNPRSYR, 50 MG/ML SOLN PRSYR)

5 PA

ENBREL MINI 50 MG/ML SOLN CART 5 PA

ENBREL SURECLICK 50 MG/ML SOLN A-INJ

5 PA

everolimus (0.25 mg tab, 0.5 mg tab, 0.75 mgtab)


HUMIRA (10 MG/0.1ML PREF SY KT, 10MG/0.2ML PREF SY KT, 20 MG/0.2ML PREFSY KT, 20 MG/0.4ML PREF SY KT, 40MG/0.8ML PREF SY KT, 40 MG/0.4ML PREFSY KT)

5 PA

HUMIRA PEDIATRIC CROHNS START (40MG/0.8ML PREF SY KT, 80 MG/0.8ML &40MG/0.4ML PREF SY KT, 80 MG/0.8MLPREF SY KT)

5 PA

HUMIRA PEN (PEN 40 MG/0.8ML PEN KIT,PEN 40 MG/0.4ML PEN KIT)

5 PA

HUMIRA PEN-CD/UC/HS STARTER (PEN-CD/UC/HS 40 MG/0.8ML PEN KIT, PEN-CD/UC/HS 80 MG/0.8ML PEN KIT)

5 PA

HUMIRA PEN-PS/UV/ADOL HS START 40MG/0.8ML PEN KIT

5 PA


72


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

HUMIRA PEN-PSOR/UVEIT STARTER 80MG/0.8ML & 40MG/0.4ML PEN KIT

5 PA

methotrexate 2.5 mg tab 3

methotrexate sodium (50 mg/2ml solution, 250mg/10ml solution)

2

methotrexate sodium (pf) solution 2

methotrexate sodium 2.5 mg tab 3

mycophenolate mofetil (250 mg cap, 500 mgtab)


mycophenolate mofetil 200 mg/ml recon susp 5 PA - Part B vs D Determination

mycophenolate sodium (180 mg tab dr, 360mg tab dr)


PROGRAF (0.2 MG PACKET, 1 MGPACKET)


RASUVO 10 MG/0.2ML SOLN A-INJ 4 PA, QL (0.8 PER 28 DAYS)

RASUVO 12.5 MG/0.25ML SOLN A-INJ 4 PA, QL (1 PER 28 DAYS)


RASUVO 17.5 MG/0.35ML SOLN A-INJ 4 PA, QL (1.4 PER 28 DAYS)



RASUVO 25 MG/0.5ML SOLN A-INJ 4 PA, QL (2 PER 28 DAYS)



SANDIMMUNE 100 MG/ML SOLUTION 4 PA - Part B vs D Determination

sirolimus (0.5 mg tab, 1 mg tab) 4 PA - Part B vs D Determination

sirolimus (1 mg/ml solution, 2 mg tab) 5 PA - Part B vs D Determination

tacrolimus (0.5 mg cap, 1 mg cap, 5 mg cap) 4 PA - Part B vs D Determination

XATMEP 2.5 MG/ML SOLUTION 4

ZORTRESS 1 MG TAB 5 PA - Part B vs D Determination

IMMUNIZING AGENTS, PASSIVEGAMUNEX-C SOLUTION 5 PA


73


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

OCTAGAM 1 GM/20ML SOLUTION 5 PA

OCTAGAM 2 GM/20ML SOLUTION 5 PA

PRIVIGEN (5 GM/50ML SOLUTION, 10GM/100ML SOLUTION, 20 GM/200MLSOLUTION, 40 GM/400ML SOLUTION)

5 PA

IMMUNOMODULATORSACTIMMUNE 2000000 UNIT/0.5MLSOLUTION


ARCALYST 220 MG RECON SOLN 5 PA

leflunomide (10 mg tab, 20 mg tab) 3

XELJANZ (5 MG TAB, 10 MG TAB) 5 PA, QL (60 PER 30 DAYS)

XELJANZ XR (11 MG TAB ER 24H, 22 MGTAB ER 24H)


VACCINESACTHIB 10 MCG/0.5 RECON SOLN 3

ADACEL 5-2-15.5 LF-MCG/0.5 SUSPENSION 3

bcg vaccine injectable 3

BEXSERO SUSP PRSYR 3

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5SUSPENSION

3

DAPTACEL 23-15-5 SUSPENSION 3

diphtheria-tetanus toxoids dt 25-5 lfu/0.5mlsuspension

2

ENGERIX-B 10 MCG/0.5ML SYRINGE 3 PA - Part B vs D Determination

ENGERIX-B 20 MCG/ML SUSPENSION 3 PA - Part B vs D Determination

GARDASIL 9 SUSP PRSYR 4

GARDASIL 9 SUSPENSION 4

HAVRIX (720 U/0.5ML SUSPENSION, 1440U/ML SUSPENSION)

3

HIBERIX 10 MCG RECON SOLN 3

IMOVAX RABIES 2.5 UNIT/ML INJECTABLE 4 PA - Part B vs D Determination

INFANRIX 25-58-10 SUSPENSION 3


74


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

IPOL 40-8-32 INJECTABLE 3

IXIARO SUSPENSION 3

KINRIX 25-25-10 PREFILLED SYRINGE 3

KINRIX INJECTABLE SUSPENSION 3

M-M-R II RECON SOLN 3

MENACTRA 4MCG/0.5ML INJECTABLE 3

MENVEO RECON SOLN 3

PEDIARIX SUSPENSION 4

PEDVAX HIB 7.5 MCG/0.5ML SUSPENSION 3

PROQUAD 3-4.3-3 INJECTABLE 3

QUADRACEL SUSPENSION 3

RABAVERT 2.5 UNIT RECON SUSP 4 PA - Part B vs D Determination

RABAVERT 2.5 UNIT RECONSUSPRABAVERT 2.5 UNIT RECON SUSP


RECOMBIVAX HB (5 MCG/0.5MLSUSPENSION, 10 MCG/ML SUSPENSION,40 MCG/ML SUSPENSION)


ROTARIX 10E6/ML RECON SUSP 3

ROTATEQ SOLUTION 3

SHINGRIX 50 MCG/0.5ML RECON SUSP 3

TDVAX 2-2 LF/0.5ML SUSPENSION 3

TENIVAC 5-2 LFU INJECTABLE 3

tetanus-diphtheria toxoids td 2-2 lf/0.5mlsuspension

3

TRUMENBA SUSP PRSYR 3

TWINRIX (720-20 ELU-MCG/MLSUSPENSION, 720-20 ELU-MCG/ML SUSPPRSYR)

3

TYPHIM VI 25 MCG/0.5ML SOLUTION 3

VAQTA (25 UNIT/0.5ML SUSPENSION, 50UNIT/ML SUSPENSION)

3

VARIVAX 1350 PFU/0.5ML INJECTABLE 3


75


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

VARIZIG 125 UNIT/1.2ML SOLUTION 5 PA

YF-VAX INJECTABLE 3

ZOSTAVAX 19400 UNT/0.65ML RECONSUSP

4

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATESAPRISO 0.375 GM CAP ER 24H 3

balsalazide disodium 750 mg cap 4

DIPENTUM 250 MG CAP 5

mesalamine 1000 mg suppos 5

mesalamine 4 gm enema 4

mesalamine er 0.375 gm cap er 24h 3

mesalamine-cleanser 4 gm kit 4

GLUCOCORTICOIDSbudesonide 3 mg cp dr part 4

budesonide er 9 mg tab er 24h 5

colocort 100 mg/60ml enema 2

hydrocortisone (perianal) 2.5 % cream 2

hydrocortisone 100 mg/60ml enema 2

procto-med hc 2.5 % cream 2

procto-pak 1 % cream 2

proctosol hc 2.5 % cream 2

proctozone-hc 2.5 % cream 2

SULFONAMIDESsulfasalazine (500 mg tab dr, 500 mg tab) 2

METABOLIC BONE DISEASE AGENTS

alendronate sodium (5 mg tab, 10 mg tab, 35mg tab, 40 mg tab)

1


76


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

alendronate sodium 70 mg tab 1 QL (4 PER 28 DAYS)

alendronate sodium 70 mg/75ml solution 2

calcitonin (salmon) 200 unit/act solution 3 QL (3.7 PER 30 DAYS)

calcitriol (0.25 mcg cap, 0.5 mcg cap, 1mcg/ml solution)

2

cinacalcet hcl (60 mg tab, 90 mg tab) 5 PA - Part B vs D Determination

cinacalcet hcl 30 mg tab 4 PA - Part B vs D Determination

doxercalciferol (0.5 mcg cap, 1 mcg cap, 2.5mcg cap)

4

ibandronate sodium 150 mg tab 3 QL (1 PER 28 DAYS)

NATPARA (25 MCG CARTRIDGE, 50 MCGCARTRIDGE, 75 MCG CARTRIDGE, 100MCG CARTRIDGE)


paricalcitol (1 mcg cap, 2 mcg cap, 4 mcg cap) 4

PROLIA 60 MG/ML SOLN PRSYR 4 QL (2 PER 365 OVER TIME)

TYMLOS 3120 MCG/1.56ML SOLN PEN 5 PA

XGEVA 120 MG/1.7ML SOLUTION 5 PA

MISCELLANEOUS THERAPEUTIC AGENTS

AMINOSYN II 10 % SOLUTION 4 PA - Part B vs D Determination

AMINOSYN-HBC 7 % SOLUTION 4 PA - Part B vs D Determination

AMINOSYN-PF (7 % SOLUTION, 10 %SOLUTION)


AMINOSYN-RF 5.2 % SOLUTION 4 PA - Part B vs D Determination

FREAMINE HBC 6.9 % SOLUTION 4 PA - Part B vs D Determination

gauze pads & dressings - pads 2 x 2 3

HEPATAMINE 8 % SOLUTION 4 PA - Part B vs D Determination

insulin pen needle 3 QL (200 PER 30 DAYS)

insulin syringe (disp) u-100 0.3 ml 3 QL (200 PER 30 DAYS)

insulin syringe (disp) u-100 0.5 ml 3 QL (200 PER 30 DAYS)

insulin syringe (disp) u-100 1 ml 3 QL (200 PER 30 DAYS)

INTRALIPID (20 % EMULSION, 30 %EMULSION)



77


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

isopropyl alcohol 0.7 ml/ml medicated pad 3

levocarnitine (1 gm/10ml solution, 330 mg tab) 2

MYALEPT 11.3 MG RECON SOLN 5 PA

needles, insulin disp., safety 3 QL (200 PER 30 DAYS)

NEPHRAMINE 5.4 % SOLUTION 4 PA - Part B vs D Determination

NUTRILIPID 20 % EMULSION 4 PA - Part B vs D Determination

premasol (6 % solution, 10 % solution) 4 PA - Part B vs D Determination

prenatal vitamin with minerals and folic acidgreater than 0.8 mg oral tablet

2

PROSOL 20 % SOLUTION 4 PA - Part B vs D Determination

TRAVASOL 10 % SOLUTION 4 PA - Part B vs D Determination

TROPHAMINE 10 % SOLUTION 4 PA - Part B vs D Determination

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHERak-poly-bac 500-10000 unit/gm ointment 2

atropine sulfate 1 % solution 2

bacitracin-polymyxin b 500-10000 unit/gmointment

2

CYSTARAN 0.44 % SOLUTION 5 PA, QL (60 PER 28 OVER TIME)

neo-polycin 3.5-400-10000 ointment 2

neomycin-bacitracin zn-polymyx (3.5-400-10000ointment, 5-400-10000ointment)

2

neomycin-polymyxin-gramicidin 1.75-10000-.025 solution

2

polymyxin b-trimethoprim 10000-0.1 unit/ml-%solution

1

proparacaine hcl 0.5 % solution 2

RESTASIS 0.05 % EMULSION 3

RESTASIS MULTIDOSE 0.05 % EMULSION 3

XIIDRA 5 % SOLUTION 4 QL (60 PER 30 DAYS)


78


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine hcl 0.05 % solution 2

cromolyn sodium 4 % solution 1

epinastine hcl 0.05 % solution 2

olopatadine hcl (0.1 % solution, 0.2 %solution)

4

PAZEO 0.7 % SOLUTION 3

OPHTHALMIC ANTI-INFLAMMATORIESbacitra-neomycin-polymyxin-hc 1 % ointment 2

BLEPHAMIDE 10-0.2 % SUSPENSION 4

BLEPHAMIDE S.O.P. 10-0.2 % OINTMENT 4

dexamethasone sodium phosphate 0.1 %solution

2

diclofenac sodium 0.1 % solution 2

DUREZOL 0.05 % EMULSION 4

flurbiprofen sodium 0.03 % solution 2

FML FORTE 0.25 % SUSPENSION 4

ILEVRO 0.3 % SUSPENSION 4 QL (6 PER 30 OVER TIME)

ketorolac tromethamine (0.4 % solution, 0.5 %solution)

2

neomycin-polymyxin-dexameth 3.5-10000-0.1ointment

2

neomycin-polymyxin-dexameth 3.5-10000-0.1suspension

1

prednisolone acetate 1 % suspension 3

prednisolone sodium phosphate 1 % solution 3

sulfacetamide sodium 10 % solution 4

sulfacetamide-prednisolone 10-0.23 %solution

2

TOBRADEX 0.3-0.1 % OINTMENT 4

TOBRADEX ST 0.3-0.05 % SUSPENSION 4


79


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

tobramycin-dexamethasone 0.3-0.1 %suspension

3

ZYLET 0.5-0.3 % SUSPENSION 4

OPHTHALMIC ANTIGLAUCOMA AGENTSacetazolamide (125 mg tab, 250 mg tab) 3

acetazolamide er 500 mg cap er 12h 4

apraclonidine hcl 0.5 % solution 2

AZOPT 1 % SUSPENSION 4

betaxolol hcl 0.5 % solution 2

BETIMOL (0.25 % SOLUTION, 0.5 %SOLUTION)

4

brimonidine tartrate (0.15 % solution, 0.2 %solution)

3

carteolol hcl 1 % solution 2

dorzolamide hcl 2 % solution 2

dorzolamide hcl-timolol mal 22.3-6.8 mg/mlsolution

2

levobunolol hcl 0.5 % solution 2

methazolamide (25 mg tab, 50 mg tab) 4

PHOSPHOLINE IODIDE 0.125 % RECONSOLN

4

pilocarpine hcl (1 % solution, 2 % solution, 4% solution)

3

SIMBRINZA 1-0.2 % SUSPENSION 4

timolol maleate (0.25 % gel f soln, 0.5 % gel fsoln, 0.5 % (daily) solution)

4

timolol maleate (0.25 % solution, 0.5 %solution)

1

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost 0.03 % solution 2 QL (5 PER 30 DAYS)

COMBIGAN 0.2-0.5 % SOLUTION 3

latanoprost 0.005 % solution 1 QL (2.5 PER 25 DAYS)


80


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

LUMIGAN 0.01 % SOLUTION 3 QL (2.5 PER 25 DAYS)

travoprost (bak free) 0.004 % solution 3 QL (2.5 PER 25 DAYS)

OTIC AGENTS

acetic acid 2 % solution 2

ciprofloxacin hcl 0.2 % solution 2

ciprofloxacin-dexamethasone 0.3-0.1 %suspension

4

hydrocortisone-acetic acid 1-2 % solution 2

neomycin-polymyxin-hc (1 % solution, 3.5-10000-1 suspension, 3.5-10000-1 solution)

4

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDSARNUITY ELLIPTA (50 MCG/ACT AER POWBA, 100 MCG/ACT AER POW BA, 200MCG/ACT AER POW BA)


budesonide (0.25 mg/2ml suspension, 0.5mg/2ml suspension, 1 mg/2ml suspension)

4 PA - Part B vs D Determination, QL(120 PER 30 DAYS)

FLOVENT DISKUS (50 MCG/BLIST AERPOW BA, 100 MCG/BLIST AER POW BA)


FLOVENT DISKUS 250 MCG/BLIST AERPOW BA


FLOVENT HFA (110 MCG/ACT AEROSOL,220 MCG/ACT AEROSOL)


FLOVENT HFA 44 MCG/ACT AEROSOL 3 QL (21.2 PER 30 DAYS)

flunisolide 25 mcg/act (0.025%) solution, nasal 2 QL (50 PER 30 DAYS)

fluticasone propionate nasal susp 50 mcg/act 3

QVAR REDIHALER (40 MCG/ACT AERO BA,80 MCG/ACT AERO BA)

4 ST, QL (21.2 PER 30 DAYS)

ANTIHISTAMINESazelastine hcl (0.1 % solution, 0.15 % solution,137 mcg/spray solution)



81


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

cetirizine hcl (1 mg/ml solution, 5 mg/5mlsolution)

2

cyproheptadine hcl 4 mg tab 4

hydroxyzine hcl (10 mg/5ml syrup, 10 mg tab,25 mg tab, 50 mg tab)

4

levocetirizine dihydrochloride 5 mg tab 2

olopatadine hcl 0.6 % solution 4 QL (30.5 PER 30 DAYS)

ANTILEUKOTRIENESmontelukast sodium (4 mg chew tab, 5 mgchew tab, 10 mg tab)

2

montelukast sodium 4 mg packet 4

zafirlukast (10 mg tab, 20 mg tab) 4

BRONCHODILATORS, ANTICHOLINERGICATROVENT HFA 17 MCG/ACT AERO SOLN 4 QL (25.8 PER 30 DAYS)

COMBIVENT RESPIMAT 20-100 MCG/ACTAERO SOLN


ipratropium bromide (0.03 % solution, 0.06 %solution)

2

ipratropium bromide 0.02 % solution 2 PA - Part B vs D Determination, QL(312.5 PER 30 DAYS)

ipratropium-albuterol 0.5-2.5 (3) mg/3mlsolution


SPIRIVA HANDIHALER 18 MCG CAP 3 QL (30 PER 30 DAYS)

SPIRIVA RESPIMAT (1.25 MCG/ACT AEROSOLN, 2.5 MCG/ACT AERO SOLN)


BRONCHODILATORS, SYMPATHOMIMETICalbuterol sulfate (0.63 mg/3ml nebu soln, 1.25mg/3ml nebu soln)


albuterol sulfate (2 mg tab, 2 mg/5ml syrup, 4mg tab)

4

albuterol sulfate (2.5 mg/0.5ml nebu soln, (5mg/ml) 0.5% nebu soln)


albuterol sulfate (2.5 mg/3ml) 0.083% nebusoln



82


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

albuterol sulfate hfa 108 (90 base) mcg/actaero soln


albuterol sulfate hfa 108 (90 base) mcg/actaero soln (nda021457)


epinephrine (0.15 mg/0.3ml soln a-inj, 0.15mg/0.15ml soln a-inj)

3

epinephrine 0.3 mg/0.3ml soln a-inj(nda019430)

3

epinephrine 0.3 mg/0.3ml soln a-inj(nda020800)

3

levalbuterol hcl 0.31 mg/3ml nebu soln 2 PA - Part B vs D Determination, QL(540 PER 30 DAYS)


levalbuterol hcl 1.25 mg/0.5ml nebu soln 4 PA - Part B vs D Determination, QL(90 PER 30 DAYS)


metaproterenol sulfate (10 mg/5ml syrup, 10mg tab, 20 mg tab)

4

PROAIR DIGIHALER 108 MCG/ACT AERPOW BA


PROAIR HFA 108 (90 BASE) MCG/ACTAERO SOLN


PROAIR RESPICLICK 108 (90 BASE)MCG/ACT AER POW BA


SEREVENT DISKUS 50 MCG/DOSE AERPOW BA


terbutaline sulfate (2.5 mg tab, 5 mg tab) 4

XOPENEX (0.31 MG/3ML NEBU SOLN, 0.63MG/3ML NEBU SOLN)


XOPENEX 1.25 MG/3ML NEBU SOLN 4 PA - Part B vs D Determination, QL(270 PER 30 DAYS)

XOPENEX CONCENTRATE 1.25 MG/0.5MLNEBU SOLN



83


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

CYSTIC FIBROSIS AGENTSBETHKIS 300 MG/4ML NEBU SOLN 5 PA - Part B vs D Determination

CAYSTON 75 MG RECON SOLN 5 PA

KALYDECO (25 MG PACKET, 50 MGPACKET, 75 MG PACKET, 150 MG TAB)

5 PA

ORKAMBI (100-125 MG PACKET, 150-188MG PACKET)


ORKAMBI (100-125 MG TAB, 200-125 MGTAB)


PULMOZYME 1 MG/ML SOLUTION 5 PA

tobramycin (300 mg/4ml nebu soln, 300mg/5ml nebu soln)


MAST CELL STABILIZERScromolyn sodium 20 mg/2ml nebu soln 4 PA - Part B vs D Determination

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASEDALIRESP (250 MCG TAB, 500 MCG TAB) 4 PA

theophylline er (er 300 mg tab er 12h, er 400mg tab er 24h, er 450 mg tab er 12h, er 600mg tab er 24h)

2

PULMONARY ANTIHYPERTENSIVESADEMPAS (0.5 MG TAB, 1 MG TAB, 1.5 MGTAB, 2 MG TAB, 2.5 MG TAB)


ambrisentan (5 mg tab, 10 mg tab) 5 PA, QL (30 PER 30 DAYS)

ORENITRAM (0.25 MG TAB ER, 1 MG TABER, 2.5 MG TAB ER, 5 MG TAB ER)

5 PA

ORENITRAM 0.125 MG TAB ER 4 PA

sildenafil citrate 10 mg/ml recon susp 5 PA

sildenafil citrate 20 mg tab 3 PA, QL (90 PER 30 DAYS)

tadalafil (pah) 20 mg tab 4 PA, QL (60 PER 30 DAYS)

VENTAVIS (10 MCG/ML SOLUTION, 20MCG/ML SOLUTION)



84


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

PULMONARY FIBROSIS AGENTSESBRIET (267 MG TAB, 801 MG TAB) 5 PA

RESPIRATORY TRACT AGENTS, OTHERacetylcysteine (10 % solution, 20 % solution) 2 PA - Part B vs D Determination

ADVAIR DISKUS (100-50 MCG/DOSE AERPOW BA, 250-50 MCG/DOSE AER POW BA,500-50 MCG/DOSE AER POW BA)


ADVAIR HFA (45-21 MCG/ACT AEROSOL,115-21 MCG/ACT AEROSOL, 230-21MCG/ACT AEROSOL)


ANORO ELLIPTA 62.5-25 MCG/INH AERPOW BA


ARALAST NP (500 MG RECON SOLN, 1000MG RECON SOLN)

5 PA

BREO ELLIPTA (100-25 MCG/INH AER POWBA, 200-25 MCG/INH AER POW BA)


ESBRIET 267 MG CAP 5 PA

FASENRA 30 MG/ML SOLN PRSYR 5 PA

FASENRA PEN 30 MG/ML SOLN A-INJ 5 PA

fluticasone-salmeterol (100-50 mcg/dose aerpow ba, 250-50 mcg/dose aer pow ba, 500-50mcg/dose aer pow ba)


fluticasone-salmeterol (55-14 mcg/act aer powba, 113-14 mcg/act aer pow ba, 232-14mcg/act aer pow ba)


NUCALA (100 MG/ML SOLN PRSYR, 100MG RECON SOLN, 100 MG/ML SOLN A-INJ)


OFEV (100 MG CAP, 150 MG CAP) 5 PA

PROLASTIN-C (1000 MG/20ML SOLUTION,1000 MG RECON SOLN)

5 PA

STIOLTO RESPIMAT 2.5-2.5 MCG/ACTAERO SOLN


SYMBICORT 160-4.5 MCG/ACT AEROSOL 3 QL (12 PER 30 DAYS)

SYMBICORT 80-4.5 MCG/ACT AEROSOL 3 QL (13.8 PER 30 DAYS)

wixela inhub (100-50 mcg/dose aer pow ba,250-50 mcg/dose aer pow ba, 500-50mcg/dose aer pow ba)



85


DRUG NAME DRUGTIER

REQUIREMENTS/LIMITS

XOLAIR (75 MG/0.5ML SOLN PRSYR, 150MG RECON SOLN, 150 MG/ML SOLNPRSYR)

5 PA

SKELETAL MUSCLE RELAXANTS

chlorzoxazone 500 mg tab 4

cyclobenzaprine hcl (5 mg tab, 10 mg tab) 4

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORSzaleplon 10 mg cap 4 QL (60 PER 30 DAYS)

zaleplon 5 mg cap 4 QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg tab, 10 mg tab) 4 QL (30 PER 30 DAYS)

SLEEP DISORDERS, OTHERBELSOMRA (5 MG TAB, 10 MG TAB, 15 MGTAB, 20 MG TAB)


HETLIOZ 20 MG CAP 5 PA, QL (30 PER 30 DAYS)

modafinil (100 mg tab, 200 mg tab) 3 PA, QL (30 PER 30 DAYS)

XYREM 500 MG/ML SOLUTION 5 PA, QL (540 PER 30 DAYS)


86

Alphabetical Listing

Aabacavir sulfate 38abacavir sulfate-lamivudine 38abacavir-lamivudine-zidovudine 38ABELCET 20ABILIFY MAINTENA 33abiraterone acetate 24acamprosate calcium 5acarbose 42acetaminophen-codeine 3acetaminophen-codeine 300-15 mg tab 3acetaminophen-codeine 300-30 mg tab 3acetaminophen-codeine 300-60 mg tab 3acetazolamide 80acetazolamide er 80acetic acid 81acetylcysteine 85acitretin 57ACTEMRA 72ACTEMRA ACTPEN 72ACTHIB 10 MCG/0.5 RECON SOLN 74ACTIMMUNE 74acyclovir 40acyclovir sodium 40ADACEL 74ADCETRIS 25adefovir dipivoxil 36ADEMPAS 84ADVAIR DISKUS 85ADVAIR HFA 85AFINITOR 27AFINITOR DISPERZ 27AIMOVIG 22AIMOVIG (140 MG DOSE) 22ak-poly-bac 78ala-cort 63albendazole 31albuterol sulfate 82albuterol sulfate hfa 83

albuterol sulfate hfa 108 (90 base) mcg/actaero soln (nda021457) 83ALECENSA 27alendronate sodium 76,77alfuzosin hcl er 63aliskiren fumarate 51allopurinol 21alosetron hcl 61alprazolam 41alprazolam er 41alprazolam xr 41altavera 66ALUNBRIG 28alyacen 1/35 66amantadine hcl 40AMBISOME 20ambrisentan 84amcinonide 63amikacin sulfate 6amiloride hcl 52amiloride-hydrochlorothiazide 52AMINOSYN II 77aminosyn ii/electrolytes 58AMINOSYN-HBC 77AMINOSYN-PF 77AMINOSYN-RF 77AMINOSYN/ELECTROLYTES 58amiodarone hcl 49AMITIZA 61amitriptyline hcl 18amlodipine besy-benazepril hcl 50amlodipine besylate 50ammonium lactate 57amoxapine 18amoxicillin 9amoxicillin-pot clavulanate 9amoxicillin-pot clavulanate er 9amphotericin b 20ampicillin 9ampicillin sodium 9,10ampicillin-sulbactam sodium 10

87

ANADROL-50 65anagrelide hcl 46anastrozole 27ANDRODERM 65ANORO ELLIPTA 85APOKYN 32apraclonidine hcl 80aprepitant 20apri 66APRISO 76APTIOM 12APTIVUS 39ARALAST NP 85aranelle 66ARANESP (ALBUMIN FREE) 46,47ARCALYST 74aripiprazole 33ARISTADA 33ARISTADA INITIO 33ARNUITY ELLIPTA 81aspirin-dipyridamole er 47atazanavir sulfate 39atenolol 49atenolol-chlorthalidone 49atomoxetine hcl 55atorvastatin calcium 53atovaquone 31atovaquone-proguanil hcl 31ATRIPLA 37atropine sulfate 78ATROVENT HFA 82AUBAGIO 56aubra 66aubra eq 66AUGMENTIN 10AURYXIA 60aviane 66AVONEX 56AVONEX PEN 56AVONEX PREFILLED 56AYVAKIT 28

azathioprine 72azelaic acid 57azelastine hcl 79,81azithromycin 10AZOPT 80aztreonam 9

Bbacitra-neomycin-polymyxin-hc 79bacitracin 7bacitracin-polymyxin b 78baclofen 36BACTROBAN NASAL 7balsalazide disodium 76BALVERSA 27BANZEL 15BARACLUDE 36BAXDELA 11bcg vaccine 74BELSOMRA 86benazepril hcl 48BENLYSTA 72benztropine mesylate 31BESIVANCE 11betamethasone dipropionate 63betamethasone dipropionate aug 63betamethasone valerate 64BETASERON 56betaxolol hcl 80bethanechol chloride 63BETHKIS 84BETIMOL 80bexarotene 30BEXSERO 74bicalutamide 24BICILLIN C-R 10BICILLIN C-R 900/300 10BICILLIN L-A 10BIKTARVY 37bimatoprost 80bisoprolol fumarate 49

88

BLEPHAMIDE 79BLEPHAMIDE S.O.P. 79blisovi 24 fe 66blisovi fe 1.5/30 66BOOSTRIX 74BOSULIF 28BRAFTOVI 28BREO ELLIPTA 85briellyn 66BRILINTA 47brimonidine tartrate 80BRIVIACT 12bromocriptine mesylate 32BRUKINSA 28budesonide 76,81budesonide er 76bumetanide 52buprenorphine hcl 5buprenorphine hcl-naloxone hcl 5bupropion hcl 16bupropion hcl er (smoking det) tab er 12h 150mg 6bupropion hcl er (sr) 16bupropion hcl er (xl) 16buspirone hcl 41butalbital-acetaminophen 55butalbital-apap 55butalbital-apap-caff-cod 3butalbital-apap-caffeine 55butalbital-asa-caff-codeine 3butalbital-asa-caffeine 55butalbital-aspirin-caffeine 55butorphanol tartrate 3BYSTOLIC 50

Ccabergoline 70CABOMETYX 28calcipotriene 57calcitonin (salmon) 77calcitriol 77

calcium acetate (phos binder) 60CALQUENCE 28camila 69CAPLYTA 33CAPRELSA 28CARBAGLU 58carbamazepine 15carbamazepine er 15carbidopa-levodopa 32carbidopa-levodopa er 32carteolol hcl 80cartia xt 50carvedilol 50carvedilol phosphate er 50caspofungin acetate 20CAYSTON 84caziant 66cefaclor 8cefadroxil 8cefazolin sodium 8cefdinir 8cefepime hcl 8cefixime 8cefotetan disodium 8cefoxitin sodium 8cefpodoxime proxetil 8cefprozil 8ceftazidime 8ceftriaxone sodium 9cefuroxime axetil 9cefuroxime sodium 9celecoxib 2CELONTIN 13cephalexin 9cetirizine hcl 82CHANTIX 6CHANTIX CONTINUING MONTH PAK 6CHANTIX STARTING MONTH PAK 6CHENODAL 60chlordiazepoxide hcl 41chlordiazepoxide-amitriptyline 18

89

chlorhexidine gluconate 56chloroquine phosphate 31chlorothiazide 53chlorpromazine hcl 32chlorthalidone 53chlorzoxazone 86CHOLBAM 60cholestyramine 53cholestyramine light 53ciclopirox 20ciclopirox olamine 20cilostazol 47CIMDUO 38cimetidine 61cimetidine hcl 61cinacalcet hcl 77ciprofloxacin 11ciprofloxacin hcl 11,81ciprofloxacin in d5w 11ciprofloxacin-dexamethasone 81citalopram hydrobromide 17clarithromycin 11clarithromycin er 11clindamycin hcl 7clindamycin palmitate hcl 7clindamycin phosphate 7clindamycin phosphate in d5w 7clobazam 13clomipramine hcl 18clonazepam 13,14clonidine 47clonidine hcl 48clopidogrel bisulfate 47clorazepate dipotassium 41clotrimazole 20clotrimazole-betamethasone 20clozapine 35COARTEM 31codeine sulfate 3colchicine 22colchicine-probenecid 22

colestipol hcl 53colistimethate sodium (cba) 7colocort 76COMBIGAN 80COMBIVENT RESPIMAT 82COMETRIQ 100 MG DAILY-DOSE PACK 28COMETRIQ 140 MG DAILY-DOSE PACK 28COMETRIQ 60 MG DAILY-DOSE PACK 28COMPLERA 37compro 19constulose 61COPIKTRA 25CORLANOR 51cortisone acetate 64COSENTYX 57COSENTYX (300 MG DOSE) 57COSENTYX SENSOREADY (300 MG) 57COSENTYX SENSOREADY PEN 57COTELLIC 25CREON 62CRINONE 69CRIXIVAN 39cromolyn sodium 60,79,84cryselle-28 66cyclafem 7/7/7 66cyclobenzaprine hcl 86cyclophosphamide 23cyclosporine 72cyclosporine modified 72cyproheptadine hcl 82CYSTAGON 62CYSTARAN 78

Ddalfampridine er 56DALIRESP 84danazol 65dantrolene sodium 36dapsone 23DAPTACEL 74daptomycin 7

90

DAURISMO 25deblitane 69deferasirox 59deferasirox granules 59DELSTRIGO 39delyla 66demeclocycline hcl 12DEMSER 51DEPO-PROVERA 69DESCOVY 38desipramine hcl 19desmopressin ace spray refrig 65desmopressin acetate 65desmopressin acetate spray 65desogestrel-ethinyl estradiol 66desvenlafaxine succinate er 17dexamethasone 64DEXAMETHASONE INTENSOL 64dexamethasone sodium phosphate 79DEXILANT CAP DR 30 MG 62DEXILANT CAP DR 60 MG 62dextroamphetamine sulfate 54dextroamphetamine-amphetamine (5 mg tab,7.5 mg tab, 10 mg tab, 12.5 mg tab, 15 mgtab, 20 mg tab, 30 mg tab) 54dextroamphetamine-amphetamine er (5 mgcap er 24h, 10 mg cap er 24h, 15 mg cap er24h, 20 mg cap er 24h, 25 mg cap er 24h, 30mg cap er 24h) 54dextrose 58dextrose-nacl 58dextrose-sodium chloride 58DIASTAT ACUDIAL 14DIASTAT PEDIATRIC 14diazepam 14,41diazepam intensol 41diclofenac potassium 2diclofenac sodium 2,79dicloxacillin sodium 10dicyclomine hcl 60didanosine 38

DIFICID 11digitek 51digox 51digoxin 52dihydroergotamine mesylate 22DILANTIN 15dilt-xr 50diltiazem cd 50diltiazem hcl 50diltiazem hcl er 51diltiazem hcl er beads 51diltiazem hcl er coated beads 51dimethyl fumarate 56dimethyl fumarate starter pack 56DIPENTUM 76diphenoxylate-atropine 60diphtheria-tetanus toxoids dt 74disulfiram 5divalproex sodium 14divalproex sodium 125 mg dr sprinkle cap 14divalproex sodium er 14dofetilide 49donepezil hcl 16dorzolamide hcl 80dorzolamide hcl-timolol mal 80DOVATO 37doxazosin mesylate 63doxepin hcl 19doxercalciferol 77doxy 100 12doxycycline hyclate 12doxycycline monohydrate 12DRIZALMA SPRINKLE 17dronabinol 20drospirenone-ethinyl estradiol 66DROXIA 24duloxetine hcl 17duramorph 3DUREZOL 79

91

EEDURANT 37efavirenz 37efavirenz-emtricitab-tenofovir 37efavirenz-lamivudine-tenofovir 37ELIQUIS 45ELIQUIS DVT/PE STARTER PACK 45ELMIRON 63ELZONRIS 25EMBEDA 2EMCYT 24EMEND 20emoquette 66EMSAM 17emtricitabine 38emtricitabine-tenofovir df 38EMTRIVA 38enalapril maleate 48enalapril-hydrochlorothiazide 49ENBREL 72ENBREL MINI 72ENBREL SURECLICK 72ENGERIX-B 74ENGERIX-B 10 MCG/0.5ML SYRINGE 74ENHERTU 25enoxaparin sodium 46enpresse-28 66enskyce 66entacapone 32entecavir 36ENTRESTO 52enulose 61EPCLUSA 36EPIDIOLEX 12epinastine hcl 79epinephrine 83epinephrine 0.3 mg/0.3ml soln a-inj(nda019430) 83epinephrine 0.3 mg/0.3ml soln a-inj(nda020800) 83

EPIVIR HBV 36EQUETRO 42ergoloid mesylates 16ergotamine-caffeine 22ERIVEDGE 28ERLEADA 24erlotinib hcl 28errin 69ERYTHROCIN LACTOBIONATE 11ERYTHROCIN STEARATE 11erythromycin 11erythromycin base 11erythromycin ethylsuccinate 11ESBRIET 85escitalopram oxalate 17esomeprazole magnesium 62estradiol 67estradiol valerate 67estradiol-norethindrone acet 67ethambutol hcl 23ethosuximide 13ethynodiol diac-eth estradiol 67everolimus 28,72EVOTAZ 39exemestane 27ezetimibe 53ezetimibe-simvastatin 53,54

Ffalmina 67famotidine 61FANAPT 34FANAPT TITRATION PACK 34FARYDAK 25FASENRA 85FASENRA PEN 85febuxostat 22felbamate 15felodipine er 51femynor 67fenofibrate 53

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fentanyl 2fentanyl citrate 3FETZIMA 17FETZIMA 20 & 40 MG TITRATION PACK 17finasteride 63FINTEPLA 12FIRMAGON 71FIRMAGON (240 MG DOSE) 71flavoxate hcl 63flecainide acetate 49FLOVENT DISKUS 81FLOVENT HFA 81fluconazole 21fluconazole in dextrose 21fluconazole in sodium chloride 21flucytosine 21fludrocortisone acetate 64flunisolide 25 mcg/act (0.025%) solution,nasal 81fluorouracil 24,25fluoxetine hcl 17,18fluphenazine decanoate 32fluphenazine hcl 33flurbiprofen sodium 79flutamide 24fluticasone propionate nasal susp 50 mcg/act

81fluticasone-salmeterol 85fluvoxamine maleate 18FML FORTE 79fondaparinux sodium 46fosamprenavir calcium 39fosinopril sodium 49FREAMINE HBC 77furosemide 52FUZEON 39fyavolv 67FYCOMPA 12,13

Ggabapentin 14

galantamine hydrobromide 16galantamine hydrobromide er 16GAMUNEX-C SOLUTION 73GARDASIL 9 SUSP PRSYR 74GARDASIL 9 SUSPENSION 74gatifloxacin 11gauze pads & dressings - pads 2 x 2 77GAVILYTE-C 61gavilyte-g 61gavilyte-n with flavor pack 61GAVRETO 24gemfibrozil 53generlac 61GENOTROPIN 65GENOTROPIN MINIQUICK 65gentamicin in saline 6gentamicin sulfate 6GENVOYA 37gianvi 67GILENYA 56GILOTRIF 28glatiramer acetate 56GLEOSTINE 23glimepiride 42glipizide 42glipizide er 42glipizide xl 42glipizide-metformin hcl 42,43GLUCAGEN HYPOKIT 44glucagon emergency 44glucose 58glyburide-metformin 43glycopyrrolate 60granisetron hcl 20griseofulvin microsize 21griseofulvin ultramicrosize 21guanfacine hcl 48guanfacine hcl er 55guanidine hcl 23

93

HHAEGARDA 71haloperidol 33haloperidol decanoate 33haloperidol lactate 33HAVRIX 74heparin sodium (porcine) 46heparin sodium (porcine) pf 46HEPATAMINE 77HETLIOZ 86HIBERIX 74HUMALOG 44HUMALOG JUNIOR KWIKPEN 44HUMALOG KWIKPEN 44HUMALOG MIX 50/50 44HUMALOG MIX 50/50 KWIKPEN 44HUMALOG MIX 75/25 44HUMALOG MIX 75/25 KWIKPEN 45HUMIRA 72HUMIRA PEDIATRIC CROHNS START 72HUMIRA PEN 72HUMIRA PEN-CD/UC/HS STARTER 72HUMIRA PEN-PS/UV/ADOL HS START 72HUMIRA PEN-PSOR/UVEIT STARTER 73HUMULIN 70/30 45HUMULIN 70/30 KWIKPEN 45HUMULIN N 45HUMULIN N KWIKPEN 45HUMULIN R 45HUMULIN R U-500 (CONCENTRATED) 45HUMULIN R U-500 KWIKPEN 45hydralazine hcl 54hydrochlorothiazide 53hydrocodone-acetaminophen 3,4hydrocortisone 64,76hydrocortisone (perianal) 76hydrocortisone butyrate 64hydrocortisone-acetic acid 81hydromorphone hcl 4hydromorphone hcl pf 4

hydroxychloroquine sulfate 31hydroxyurea 25hydroxyzine hcl 82hydroxyzine pamoate 41

Iibandronate sodium 77IBRANCE 25ibu 2ibuprofen 2icatibant acetate 72ICLUSIG 28IDHIFA 28ILEVRO 79imatinib mesylate 29IMBRUVICA 29imipenem-cilastatin 9imipramine hcl 19imiquimod 57IMOVAX RABIES 74INCRELEX 65indapamide 53indomethacin 2INFANRIX 74INGREZZA 55INLYTA 29INQOVI 29INREBIC 25insulin lispro 45insulin lispro (1 unit dial) 45insulin lispro junior kwikpen 45insulin lispro prot & lispro 45insulin pen needle 77insulin syringe (disp) u-100 0.3 ml 77insulin syringe (disp) u-100 0.5 ml 77insulin syringe (disp) u-100 1 ml 77INTELENCE 38INTRALIPID 77INTRON A 36INVEGA SUSTENNA 34INVEGA TRINZA 34

94

INVIRASE 39INVOKAMET 43INVOKAMET XR 43INVOKANA 43IONOSOL-MB IN D5W 58IPOL 40-8-32 INJECTABLE 75ipratropium bromide 82ipratropium-albuterol 82irbesartan 48irbesartan-hydrochlorothiazide 48IRESSA 29ISENTRESS 37ISENTRESS HD 37ISOLYTE-P IN D5W 58ISOLYTE-S 58ISOLYTE-S PH 7.4 58isoniazid 23isopropyl alcohol 0.7 ml/ml medicated pad 78isosorbide dinitrate 54isosorbide dinitrate er 54isosorbide mononitrate 54isosorbide mononitrate er 54isotretinoin 57itraconazole 21ivermectin 31IXIARO 75

JJAKAFI 29JANUMET 43JANUMET XR 43JANUVIA 43JARDIANCE 43JENTADUETO 43JENTADUETO XR 43jinteli 67jolivette 69juleber 67JULUCA 37junel 1.5/30 67junel 1/20 67

junel fe 1/20 67

Kkaitlib fe 67KALETRA 39KALYDECO 84kcl in dextrose-nacl 58kcl-lactated ringers-d5w 58kelnor 1/35 67kelnor 1/50 67ketoconazole 21ketorolac tromethamine 2,79KINRIX 25-25-10 PREFILLED SYRINGE 75KINRIX INJECTABLE SUSPENSION 75KISQALI 200 MG DAILY DOSE 29KISQALI 400 MG DAILY DOSE 29KISQALI 600 MG DAILY DOSE 29KISQALI FEMARA 200 MG CO-PACK 25KISQALI FEMARA 400 MG CO-PACK 25KISQALI FEMARA 600 MG CO-PACK 25KORLYM 65KOSELUGO 29kurvelo 67KUVAN 62

Llabetalol hcl 50lactulose 61lamivudine 36,38lamivudine-zidovudine 38lamotrigine 15LANOXIN 52lansoprazole 62LANTUS 45LANTUS SOLOSTAR 45lapatinib ditosylate 29larin 1/20 67larin fe 1.5/30 67larin fe 1/20 67latanoprost 80LATUDA 34

95

ledipasvir-sofosbuvir 36leena 67leflunomide 74LENVIMA DAILY DOSE 10 MG THERAPYPACK 29LENVIMA DAILY DOSE 12 MG THERAPYPACK 29LENVIMA DAILY DOSE 14 MG THERAPYPACK 29LENVIMA DAILY DOSE 18 MG THERAPYPACK 29LENVIMA DAILY DOSE 20 MG THERAPYPACK 29LENVIMA DAILY DOSE 24 MG THERAPYPACK 29LENVIMA DAILY DOSE 4 MG THERAPYPACK 29LENVIMA DAILY DOSE 8 MG THERAPYPACK 29lessina 67letrozole 27leucovorin calcium 25LEUKERAN 23leuprolide acetate 71levalbuterol hcl 83levetiracetam 13levetiracetam er 13levobunolol hcl 80levocarnitine 78levocetirizine dihydrochloride 82levofloxacin 11levofloxacin 25 mg/ml oral solution 11levofloxacin 25 mg/ml solution inj 11levofloxacin in d5w 11levonest 67levonorg-eth estrad triphasic 68levonorgest-eth estrad 91-day 68levonorgestrel-ethinyl estrad 68levora 0.15/30 (28) 68levothyroxine sodium 70levoxyl 70

LEXIVA 39lidocaine 5lidocaine hcl 5lidocaine viscous hcl 56lidocaine-prilocaine 5lidocaine-prilocaine cream 2.5-2.5 % 5lindane 31linezolid 7LINZESS 61liothyronine sodium 70lisinopril 49lisinopril-hydrochlorothiazide 49lithium 42lithium carbonate 42lithium carbonate er 42LONSURF 25loperamide hcl 60lopinavir-ritonavir 39lorazepam 41,42lorazepam intensol 42LORBRENA 25loryna 68losartan potassium 48losartan potassium-hctz 48lovastatin 53loxapine succinate 33LOZI-FLUR 58ludent 58LUMIGAN 81LUPRON DEPOT (1-MONTH) 71LUPRON DEPOT (3-MONTH) 71LUPRON DEPOT (4-MONTH) 71LUPRON DEPOT (6-MONTH) 71LYNPARZA 25LYSODREN 70lyza 69

MM-M-R II 75magnesium sulfate 58magnesium sulfate 50 % syringe 58

96

malathion 31maprotiline hcl 18marlissa 68MARPLAN 17MATULANE 23MAVYRET 36meclizine hcl 19medroxyprogesterone acetate 69mefloquine hcl 31megestrol acetate 70MEKINIST 29MEKTOVI 29meloxicam 2memantine hcl 16memantine hcl 5-10 mg titration pack 16memantine hcl er 16MENACTRA 4MCG/0.5ML INJECTABLE 75MENVEO 75mercaptopurine 25meropenem 9mesalamine 76mesalamine er 76mesalamine-cleanser 76MESNEX 31metaproterenol sulfate 83metformin hcl 43metformin hcl er 43methadone hcl 2methazolamide 80methenamine hippurate tab 1 gm 7methimazole 71methotrexate 73methotrexate sodium 73methotrexate sodium (pf) solution 73methscopolamine bromide 60methyclothiazide 53methyldopa 48methyldopa-hydrochlorothiazide 48methylphenidate hcl 55methylphenidate hcl er 55methylprednisolone 64

metoclopramide hcl 60metolazone 53metoprolol succinate er 50metoprolol tartrate 50metronidazole 7,57metronidazole in nacl 7metyrosine 52mexiletine hcl 49MICONAZOLE 3 21microgestin 1.5/30 68microgestin fe 1.5/30 68microgestin fe 1/20 68midodrine hcl 48miglustat 62mimvey 68mimvey lo 68minocycline hcl 12minoxidil 54mirtazapine 17MIRVASO 57misoprostol 62modafinil 86molindone hcl 33mometasone furoate 64mononessa 68montelukast sodium 82morphine sulfate 4morphine sulfate (concentrate) 4morphine sulfate (pf) 4morphine sulfate er 3moxifloxacin hcl 12mupirocin 7MYALEPT 78mycophenolate mofetil 73mycophenolate sodium 73MYRBETRIQ 63

Nnabumetone 2nafcillin sodium 10naloxone hcl 5

97

naltrexone hcl 5naproxen 2NARCAN 5NATACYN 21nateglinide 43NATPARA 77NAYZILAM 13NEBUPENT 31necon 0.5/35 (28) 68needles, insulin disp., safety 78nefazodone hcl 18neo-polycin 78neomycin sulfate 6neomycin-bacitracin zn-polymyx 78neomycin-polymyxin-dexameth 79neomycin-polymyxin-gramicidin 78neomycin-polymyxin-hc 81NEPHRAMINE 78NERLYNX 26NEULASTA 47NEULASTA ONPRO 47NEUPOGEN 47NEUPRO 32nevirapine 38nevirapine er 38NEXAVAR 30NIACOR 54NICOTROL NS 6nifedipine er 51nifedipine er osmotic release 51nikki 68nilutamide 24nimodipine 51NINLARO 26nitisinone 62NITRO-BID 54nitrofurantoin 7nitrofurantoin macrocrystal 7nitrofurantoin monohyd macro 7nitroglycerin 54nora-be 70

norethin ace-eth estrad-fe 68norethin-eth estradiol-fe 68norethindrone 70norethindrone acet-ethinyl est 68norethindrone acetate 70norethindrone-eth estradiol 68norgestim-eth estrad triphasic 68norgestimate-eth estradiol 68norlyroc 70NORMOSOL-M IN D5W 59NORMOSOL-R 59NORMOSOL-R IN D5W 59NORMOSOL-R PH 7.4 59NORTHERA 52nortrel 1/35 (21) 68nortrel 1/35 (28) 68nortrel 7/7/7 68nortriptyline hcl 19NORVIR 39NOXAFIL 21NUBEQA 24NUCALA 85NUEDEXTA 55NUPLAZID 34NUTRILIPID 78nyamyc 21nystatin 21nystop 21

OOCTAGAM 1 GM/20ML SOLUTION 74OCTAGAM 2 GM/20ML SOLUTION 74octreotide acetate 71ODEFSEY 38ODOMZO 30OFEV 85ofloxacin 12ofloxacin 0.3 % ophthalmic solution 12ofloxacin 0.3 % otic solution 12OGESTREL 69olanzapine 34

98

olmesartan medoxomil 48olmesartan medoxomil-hctz 48olopatadine hcl 79,82omega-3-acid ethyl esters 54omeprazole 62ondansetron 20ondansetron hcl 20ONTRUZANT 26ORENITRAM 84ORFADIN 62ORKAMBI 84orsythia 69oseltamivir phosphate 40OSPHENA 70oxandrolone 65oxcarbazepine 15oxybutynin chloride 63oxybutynin chloride er 63oxycodone hcl 4oxycodone-acetaminophen 4oxycodone-aspirin 4oxycodone-ibuprofen 4

PPADCEV 26paliperidone er 34PANRETIN 30pantoprazole sodium 62paricalcitol 77paromomycin sulfate 6paroxetine hcl 18PASER 23PAXIL 18PAZEO 79PEDIARIX 75PEDVAX HIB 75peg 3350-kcl-na bicarb-nacl 61peg 3350/electrolytes 61peg-3350/electrolytes 61PEGANONE 15PEGASYS 37

PEGASYS PROCLICK 37PEMAZYRE 26penicillamine 60penicillin g pot in dextrose 10penicillin g potassium 10penicillin g sodium 10penicillin v potassium 10PENTAM 31pentamidine isethionate 31pentoxifylline er 52permethrin 31perphenazine 33perphenazine-amitriptyline 19PERSERIS 34phenelzine sulfate 17phenobarbital 14phenoxybenzamine hcl 48phenytoin 15phenytoin infatabs 15phenytoin sodium extended 15PHOSPHOLINE IODIDE 80PIFELTRO 38pilocarpine hcl 56,80pimozide 33pimtrea 69pioglitazone hcl 43,44piperacillin sod-tazobactam so 10PIQRAY (200 MG DAILY DOSE) 26PIQRAY (250 MG DAILY DOSE) 26PIQRAY (300 MG DAILY DOSE) 26pirmella 1/35 69PLASMA-LYTE 148 59PLASMA-LYTE A 59podofilox 57polyethylene glycol 3350 61polymyxin b sulfate 8polymyxin b-trimethoprim 78POMALYST 24posaconazole 21potassium chloride 59potassium chloride crys er 59

99

potassium chloride er 59potassium chloride solution 20 meq/15ml(10%) 59potassium chloride solution 40 meq/15ml(20%) 59potassium citrate er 59PRADAXA 46pramipexole dihydrochloride 32prasugrel hcl 47pravastatin sodium 53prazosin hcl 48prednisolone 64prednisolone acetate 79prednisolone sodium phosphate 64,79prednisone 64PREDNISONE INTENSOL 64pregabalin 13PREMARIN 69premasol 78PREMPHASE 69PREMPRO 69prenatal vitamin with minerals and folic acidgreater than 0.8 mg oral tablet 78previfem 69PREVYMIS 36PREZCOBIX 40PREZISTA 40PRIFTIN 23primaquine phosphate 31primidone 14PRIVIGEN 74PROAIR DIGIHALER 83PROAIR HFA 83PROAIR RESPICLICK 83probenecid 22PROCALAMINE 59prochlorperazine 19prochlorperazine maleate 19procto-med hc 76procto-pak 76proctosol hc 76

proctozone-hc 76progesterone micronized 70PROGLYCEM 44PROGRAF 73PROLASTIN-C 85PROLIA 77PROMACTA 47promethazine hcl 19PROMETHEGAN 19propafenone hcl 49proparacaine hcl 78propranolol hcl 50propranolol hcl er 50propranolol-hctz 50propylthiouracil 71PROQUAD 3-4.3-3 INJECTABLE 75PROSOL 78protriptyline hcl 19PULMOZYME 84PURIXAN 25pyrazinamide 23pyridostigmine bromide 23

QQINLOCK 24QUADRACEL 75quetiapine fumarate 34quetiapine fumarate er 34quinapril hcl 49quinapril-hydrochlorothiazide 49quinidine sulfate 49quinine sulfate 31QVAR REDIHALER 81

RRABAVERT 2.5 UNIT RECON SUSP 75RABAVERT 2.5 UNIT RECONSUSPRABAVERT 2.5 UNIT RECON SUSP75raloxifene hcl 70ramipril 49ranolazine er 52

100

rasagiline mesylate 32RASUVO 73reclipsen 69RECOMBIVAX HB 75RECTIV 57RELISTOR 60,61repaglinide 44REPATHA 52REPATHA PUSHTRONEX SYSTEM 52REPATHA SURECLICK 52RESCRIPTOR 38RESTASIS 78RESTASIS MULTIDOSE 78RETACRIT 47RETEVMO 26REVLIMID 24REXULTI 35REYATAZ 40ribavirin 37rifabutin 23rifampin 23RIFATER 23riluzole 56rimantadine hcl 40RISPERDAL CONSTA 35risperidone 35risperidone m-tab 35ritonavir 40rivastigmine 16rivastigmine tartrate 16rizatriptan benzoate 22ropinirole hcl 32rosuvastatin calcium 53ROTARIX 10E6/ML RECON SUSP 75ROTATEQ 75ROZLYTREK 26RUBRACA 26RUKOBIA 39RYDAPT 26

SSANDIMMUNE 73SANTYL 57SAPHRIS 35sapropterin dihydrochloride 62SARCLISA 26scopolamine 19SECUADO 35selegiline hcl 32selenium sulfide 57SELZENTRY 39SEREVENT DISKUS 83sertraline hcl 18sevelamer carbonate 60SHINGRIX 75SIGNIFOR 71sildenafil citrate 84silver sulfadiazine 8SIMBRINZA 80simvastatin 53sirolimus 73SIRTURO 23sodium chloride 59sodium fluoride 59sodium fluoride 2.2 mg (fluoride ion 1 mg) oraltablet 59sodium lactate 59sodium phenylbutyrate 62sodium polystyrene sulfonate 60sodium polystyrene sulfonate 15 gm/60mlsuspension 60sofosbuvir-velpatasvir 37solifenacin succinate 63SOLTAMOX 24SOMATULINE DEPOT 71SOMAVERT 71sotalol hcl 49sotalol hcl (af) 49SPIRIVA HANDIHALER 82SPIRIVA RESPIMAT 82

101

spironolactone 52sprintec 28 69SPRITAM 13SPRYCEL 30sps 60ssd 8stavudine 38STELARA 57STIOLTO RESPIMAT 85STIVARGA 30streptomycin sulfate 6STRIBILD 37sucralfate 62sulfacetamide sodium 79sulfacetamide-prednisolone 79sulfadiazine 12sulfamethoxazole-trimethoprim 12sulfasalazine 76sulfatrim pediatric 12sumatriptan 22sumatriptan succinate 22sumatriptan succinate refill 22SUPRAX 9SUPREP BOWEL PREP KIT 61SUTENT 30SYLATRON 26SYMBICORT 85SYMFI 38SYMFI LO 38SYMPAZAN 14SYMTUZA 40SYNJARDY 44SYNJARDY XR 44SYNRIBO 26SYNTHROID 70

TTABLOID 25TABRECTA 24tacrolimus 57,73tadalafil (pah) 84

TAFINLAR 30TAGRISSO 30TALZENNA 26tamoxifen citrate 24tamsulosin hcl 63TARGRETIN 30tarina fe 1/20 69tarina fe 1/20 eq 69TASIGNA 30tazarotene 57TAZVERIK 26TDVAX 75TECFIDERA 56TEFLARO 9telmisartan 48temazepam 42TENIVAC 75tenofovir disoproxil fumarate 38terazosin hcl 63terbinafine hcl 21terbutaline sulfate 83terconazole 21testosterone 66testosterone cypionate 66testosterone enanthate 66tetanus-diphtheria toxoids td 75tetrabenazine 56tetracycline hcl 12THALOMID 24theophylline er 84thioridazine hcl 33thiotepa 26thiothixene 33tiagabine hcl 14TIBSOVO 30timolol maleate 22,80tinidazole 31TIVICAY 37TIVICAY PD 37tizanidine hcl 36TOBRADEX 79

102

TOBRADEX ST 79tobramycin 6,84tobramycin sulfate 6tobramycin-dexamethasone 80TOBREX 6tolcapone 32topiramate 15toremifene citrate 24torsemide 52TOUJEO MAX SOLOSTAR 45TOUJEO SOLOSTAR 45TRADJENTA 44tramadol hcl 4tramadol hcl er 3tramadol hcl er (biphasic) 3tranexamic acid 47TRANSDERM SCOP (1.5 MG) 19TRANSDERM-SCOP (1.5 MG) 19tranylcypromine sulfate 17TRAVASOL 78travoprost (bak free) 81trazodone hcl 18TRECATOR 23tretinoin 30,57tri-legest fe 69tri-sprintec 69triamcinolone acetonide 6,56,64triamterene-hctz 52triderm 65trientine hcl 60trifluoperazine hcl 33trifluridine 40trihexyphenidyl hcl 32TRIJARDY XR 44triklo 54trilyte 62trimethoprim 8trimipramine maleate 19TRINTELLIX 18TRIUMEQ 37trivora (28) 69

TRODELVY 26TROPHAMINE 78TRULICITY 44TRUMENBA 75TRUVADA 39TUKYSA 26TURALIO 30TWINRIX 75TYBOST 39TYKERB 30TYMLOS 77TYPHIM VI 75

UUBRELVY 22UDENYCA 47ursodiol 61

Vvalacyclovir hcl 40VALCHLOR 24valganciclovir hcl 36valproate sodium 14valproic acid 14valsartan 48valsartan-hydrochlorothiazide 48VALTOCO 10 MG DOSE 14VALTOCO 15 MG DOSE 14VALTOCO 20 MG DOSE 14VALTOCO 5 MG DOSE 15vancomycin hcl 8vandazole 8VAQTA 75VARIVAX 75VARIZIG 76VASCEPA 54VENCLEXTA 30VENCLEXTA STARTING THERAPY PACK30venlafaxine hcl 18venlafaxine hcl er 18VENTAVIS 84

103

verapamil hcl 51verapamil hcl er 51VERSACLOZ 36VERZENIO 26VICTOZA 44VIDEX 39VIDEX EC 39vigabatrin 15vigadrone 15VIIBRYD 18VIIBRYD STARTER PACK 18VIMPAT 15VIRACEPT 40VIREAD 39VITRAKVI 27VIVITROL 5VIZIMPRO 30voriconazole 21VOTRIENT 30VRAYLAR 35vyfemla 69

Wwarfarin sodium 46wixela inhub 85wymzya fe 69

XXALKORI 30XARELTO 46XARELTO STARTER PACK 46XATMEP 73XCOPRI 13XCOPRI (250 MG DAILY DOSE) 13XCOPRI (350 MG DAILY DOSE) 13XELJANZ 74XELJANZ XR 74XGEVA 77XIIDRA 78XOFLUZA (40 MG DOSE) 40XOFLUZA (80 MG DOSE) 40

XOLAIR 86XOPENEX 83XOPENEX CONCENTRATE 83XOSPATA 30XPOVIO (100 MG ONCE WEEKLY) 27XPOVIO (40 MG ONCE WEEKLY) 27XPOVIO (40 MG TWICE WEEKLY) 27XPOVIO (60 MG ONCE WEEKLY) 27XPOVIO (60 MG TWICE WEEKLY) 27XPOVIO (80 MG ONCE WEEKLY) 27XPOVIO (80 MG TWICE WEEKLY) 27XTANDI 24XYREM 86

YYF-VAX INJECTABLE 76YONSA 24

Zzafirlukast 82zaleplon 86ZEJULA 27ZELBORAF 30ZENPEP 62ZEPOSIA 56ZEPOSIA 7-DAY STARTER PACK 56ZEPOSIA STARTER KIT 56zidovudine 39ziprasidone hcl 35ziprasidone mesylate 35ZIRGAN 36ZOLINZA 27zolpidem tartrate 86zonisamide 13ZORTRESS 73ZOSTAVAX 76ZYDELIG 27ZYKADIA 30ZYLET 80ZYPREXA RELPREVV 35ZYTIGA 24

104

Discrimination is against the law

Magellan* follows the law. We treat all people equally. We do not discriminate against anyone

based on:

• Race

• Color

• National origin

• Age

• Disability

• Sex

We provide free help and services to people with disabilities. We want you to be able to

communicate with us easily. We offer:

• Qualified sign language interpreters

• Written information in many formats. These may include:

o Large print

o Audio

o Accessible electronic formats

o Other formats

We also provide free language services to people whose first language is not English. We offer:

• Qualified interpreters

• Information that is written in other languages

Contact us at 800-424-5870 if you need any of these services.

If you believe we have not provided these services or discriminated in another way, you can file

a grievance with:

Civil Rights Coordinator,

Corporate Compliance Department

Magellan Health

8621 Robert Fulton Drive

Columbia, MD 21046

Phone: 800-424-7721

Email: [email protected]

You can file a grievance in one of two ways:

• By mail

• By email

The civil rights coordinator is available if you need help with any of this.

You can also file a complaint with the U.S. Department of Health and Human Services Office for

Civil Rights. You may do this online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Or you may

do this by mail or phone.

U.S. Department of Health and Human Services

200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019

TDD: 800-537-7697

Complaint forms are available online. You may find them at

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

*Magellan refers to all applicable subsidiaries and affiliates of Magellan Health, Inc. including but not

limited to Magellan Healthcare, Inc., National Imaging Associates, Inc., Magellan Rx Management, LLC

and Magellan Complete Care.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia linguística. Llame al 1-800-424-5870 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-424-5870（TTY：711）。

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услугиперевода. Звоните 1-800-424-5870 (телетайп: 711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-800-424-5870 (TTY: 711)번으로 전화해 주십시오.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-424-5870 (TTY: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-424-5870 (TTY: 711).

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposésgratuitement. Appelez le 1-800-424-5870 (ATS: 711).

אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט אויפמערקזאם :.1-800-424-5870 (TTY: 711)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-424-5870 (TTY: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-424-5870 (TTY: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-424-5870 (TTY: 711).

This formulary was updated on 11/24/2020. For more recent information or other questions, please contact Magellan Rx Medicare Customer Service at 1-800-424-5870 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit https://medicare.magellanrx.com.

Magellan Rx Medicare Basic (PDP) 2020 Formu lary

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