Medicare PPO BlueSM SaverRx (PPO) SM 2018 … to existing members: This formulary has changed since...

Medicare PPO BlueSM SaverRx (PPO)Medicare PPO BlueSM ValueRx (PPO)Medicare PPO BlueSM PlusRx (PPO)

2018 FORMULARY(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN18151, Version 15This formulary was updated on 07/01/2018. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. H2230_1748 Accepted 09022017

http://medicare.bluecrossma.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 Blue Cross Blue Shield of Massachusetts. When it refers to “plan” or “our plan,” it means Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx, and Medicare PPO Blue PlusRx. This document includes a list of the drugs (formulary) for our plan which is current as of 7/01/2018. 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/co-insurance may change on 01/1/2019, and from time to time during the year.

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What is the Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO) and Medicare PPO Blue PlusRx (PPO) Formulary?A formulary is a list of covered drugs selected by Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx 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. Our plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx 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?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 7/01/2018. To get updated information about the drugs covered by our plans, please contact us. Our contact information appears on the front and back cover pages. Our contact information appears on the front and back cover pages.

If we have a mid-year non-maintenance formulary change, we will provide a notice in the monthly Explanation of Benefits and on our website, www.bluecrossma.com/medicare. You may ask for a copy of the most recent formulary by contacting us. Our contact information appears on the front and back cover pages.


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How do I use the Formulary?There are two ways to find your drug within the formulary:• Medical Condition. The formulary begins on page 9. 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 9. 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 103. 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?Our plans cover 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.

3

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: Our plans require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug.

Quantity Limits: For certain drugs, our plans limit the amount of the drug that our plans will cover. For example, our plans provide up to 30 capsules per 30 days per prescription for Omeprazole 10 mg capsules. This may be in addition to a standard one-month or three-month supply.

Morphine Equivalent Dosing: For certain drugs or combinations of drugs, there may be a safety limit applied to prevent opioid overutilization. The limit on these medications may be cumulative with other similar medications that you may be taking in the same class. A dosage adjustment by your physician or an exception may be required if you exceed the safety limit.

Step Therapy: In some cases, our plans require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plans 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 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online 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 our plan 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 Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx formulary?” on page 4 for information about how to request an exception.

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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 Member Service and ask if your drug is covered.

If you learn that Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx do not cover your drug, you have two options:• You can ask Member Services for a list of similar drugs that are covered by our plans.

When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plans.

• You can ask our plans to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO) and Medicare PPO Blue PlusRx (PPO) Formulary?You can ask our plans 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 your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug 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 the specialty 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, our plans limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx 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, tiering or utilization restriction exception. When you request a formulary, tiering 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.

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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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91-day have Pharmacy confirm if this should say 91-day transition supply and may be up to a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If 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 (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you change your level of care, such as a move from a hospital to a home setting, 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 up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan’s exception process.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that might be covered under Medicare Part B.

For more informationFor more detailed information about your Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx or Medicare PPO Blue PlusRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plans, 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 call 1-877-486-2048. Or, visit www.medicare.gov.

https://www.medicare.gov

6

Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx and Medicare PPO Blue PlusRx FormularyThe formulary that begins on page 9 provides coverage information about the drugs covered by Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx, and Medicare PPO Blue PlusRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 103.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AMOXIL®´) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug.

The abbreviations you may see in the formulary (list of covered drugs) include: Quantity Limits (QL): To help ensure that the quantity and dosage of your medications remains consistent with manufacturer, clinical, and Food and Drug Administration (FDA) recommendations, we maintain a list of medications subject to QL. When you fill a prescription for a medication subject to QL, your prescription is reviewed for:

• Dose Consolidation. Dose consolidation checks to see whether you’re taking two or more daily doses of medicine that could be replaced with one daily dose providing the same total amount of medication.

• Recommended Monthly Dosing Level. This process checks to see that your monthly dosage of medication is consistent with both the manufacturer’s and the FDA’s monthly dosing recommendations and clinical information. Your doctor can also apply for an exception to QL guidelines when medically necessary.

• Mail Order (MO): These prescription drugs are available through mail-order.

Home Infusion (HI): This prescription drug may be covered under our medical benefit. For more information, call Member Services at 1-800-200-4255, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY users should call 711. Our contact information appears on the front and back cover pages.

Medical Benefit (MB): These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmacies or mail-order service.*

Prior Authorization (PA): These prescription drugs require prior authorization from the plan.

Step Therapy (ST): These prescription drugs require you to first try another drug to treat your medical condition.

* Coverage for diabetic test strips and blood glucose monitors at a participating retail or mail order pharmacy is limited to those listed on our formulary and provided at no cost to you. There is no coverage for other brand test strips and blood glucose monitors that are not listed on our formulary when purchased at a retail or mail order pharmacy.

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Limited Pharmacy Availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at 1-800-200-4255, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY users should call 711. Our contact information appears on the front and back cover pages.

Medicare Part B or D (B/D): This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

How much will I pay for my Medicare Advantage plan’s covered drugs?Your Medicare prescription drug costs: The amount you pay depends on which drug tier your drug is in under our plan. You can find out which drug tier your drug is in by looking in the formulary included in this booklet. See the next page for the copayment/co-insurance amount for each type of drug.

If you qualify for extra help with your drug costs, your costs for your drugs may be different than those described on the next page. Please refer to the plan Summary of Benefits or your Evidence of Coverage or call Member Service to find out what your costs are.

Your costs for drugs and supplies covered under your plan’s medical benefit: You will find some drugs and supplies listed in the formulary drug list with a “MB” note in the tier column. These drugs and supplies covered under your plan’s medical benefit are available through network retail pharmacies or mail-order service. However, they do not qualify for exception requests, extra help on drug costs, transition fills, or accumulate toward your total out-of-pocket costs to bring you through the coverage gap faster like drugs covered under your Medicare prescription drug benefit.

8

Explanation of Tiers and Copayments/Co-insurance: Initial Coverage Stage

Plans Drug Tier Annual Deductible

30-day supply at a preferred network retail pharmacy

30-day supply at a standard network retail pharmacy

90-day supply at a network mail-order pharmacy

Medicare PPO Blue SaverRx (PPO)

Tier 1: Preferred Generic Drugs $0 for Tier 1 and Tier 2

$5 $10 $5

Tier 2: Generic Drugs $11 $16 $22

Tier 3: Preferred Brand Drugs$405

for Tiers 3, 4, and 5

$42 $47 $84

Tier 4: Non-Preferred Brand Drugs $95 $100 $190

Tier 5: Specialty Tier Drugs 25% 25% 25%

Medicare PPO Blue ValueRx (PPO)


$3 $8 $3




$42 $47 $84



Medicare PPO Blue PlusRx (PPO)


$1 $6 $1




$42 $47 $84



ANTI - INFECTIVES: ANTIFUNGALAGENTSDrug Name Tier Requirements/

LimitsAMBISOME 5 B/D PA, MO, HIamphotericin b 2 B/D PA, MO, HICANCIDAS 5 B/D PA, MO, HIcaspofungin 5 B/D PA, HIclotrimazole mucous 2 MOmembrane

CRESEMBA 5 HIINTRAVENOUS

CRESEMBA ORAL 5 MOfluconazole 2 MOfluconazole in 2 HIdextrose(iso-o)

fluconazole in nacl 2 MO, HI(iso-osm) intravenouspiggyback 200mg/100 ml

fluconazole in nacl 2 HI(iso-osm) intravenouspiggyback 400mg/200 ml

flucytosine 5 MOgriseofulvin microsize 2 MOgriseofulvinultramicrosize

2 MO

itraconazole 2 MO, QL (120 per30 days)

ketoconazole oral 2 MOMYCAMINE 5 MO, HINOXAFIL 3 HIINTRAVENOUS

NOXAFIL ORAL 5 MOnystatin oralsuspension

2 MO

nystatin oral tablet 2 MO

ANTI - INFECTIVES: ANTIFUNGALAGENTS (continued)Drug Name Tier Requirements/

Limitsterbinafine hcl oral 2 MO, QL (30 per

30 days)voriconazole 2 MO, HIintravenous

voriconazole oral 5 MO

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7. 9

ANTI - INFECTIVES: ANTIVIRALSDrug Name Tier Requirements/

Limitsabacavir 2 MOabacavir-lamivudine 5 MOabacavir-lamivudine- 5 MOzidovudine

acyclovir oral capsule 2 MOacyclovir oralsuspension 200 mg/5ml

2 MO

acyclovir oral tablet 2 MOacyclovir sodiumintravenous recon

2 B/D PA, HI

soln 500 mgacyclovir sodiumintravenous solution

2 B/D PA, MO, HI

adefovir 5 MOamantadine hcl 2 MOAPTIVUS ORAL 5 MOCAPSULE

APTIVUS ORAL 5SOLUTION

atazanavir oral 2 MOcapsule 150 mg, 200mg

atazanavir oral 5 MOcapsule 300 mg

ATRIPLA 5 MOBARACLUDE ORAL 3 MOSOLUTION

BIKTARVY 5 MOcidofovir 5 B/D PA, MO, HICIMDUO 5 MOCOMPLERA 5 MOCRIXIVAN ORAL 3 MOCAPSULE 200 MG,400 MG

ANTI - INFECTIVES: ANTIVIRALS(continued)Drug Name Tier Requirements/

LimitsDAKLINZA ORALTABLET 30 MG

5 PA, MO, QL (90per 30 days)

DAKLINZA ORALTABLET 60 MG, 90MG


DESCOVY 5 MOdidanosine oral 2 MOcapsule,delayedrelease(dr/ec) 200mg, 250 mg, 400 mg

EDURANT 5 MOefavirenz oral capsule200 mg

5 MO

efavirenz oral capsule50 mg

2 MO

efavirenz oral tablet 5 MOEMTRIVA 3 MOentecavir 5 MOEPCLUSA 5 PA, MO, QL (28

per 28 days)EPIVIR HBV ORAL 3 MOSOLUTION

EVOTAZ 5 MOfamciclovir 2 MOfosamprenavir 5 MOFUZEON 5 MOSUBCUTANEOUSRECON SOLN

ganciclovir sodiumintravenous recon

2 B/D PA, MO, HI

solnganciclovir sodiumintravenous solution

2 B/D PA, MO, HI

GENVOYA 5 MOHARVONI 5 PA, MO, QL (28

per 28 days)

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7.10


LimitsINTELENCE ORAL 5 MOTABLET 100 MG,200 MG

INTELENCE ORAL 3 MOTABLET 25 MG

INVIRASE 5 MOISENTRESS HD 5 MOISENTRESS ORAL 5 MOPOWDER INPACKET

ISENTRESS ORAL 5 MOTABLET

ISENTRESS ORAL 5 MOTABLET,CHEWABLE100 MG

ISENTRESS ORAL 3 MOTABLET,CHEWABLE25 MG

JULUCA 5 MOKALETRA ORAL 3 MOTABLET 100-25 MG

KALETRA ORAL 5 MOTABLET 200-50 MG

lamivudine 2 MOlamivudine-zidovudine 2 MOLEXIVA ORAL 3 MOSUSPENSION

lopinavir-ritonavir 2 MOMAVYRET 5 PA, MO, QL (90

per 30 days)moderiba 2 MO


Limitsmoderiba dose packoral tablets,dose

2 MO

pack 200 mg (28)-400 mg (28), 400-400mg (28)-mg (28),600-400 mg (28)-mg(28)

moderiba dose packoral tablets,dose

2

pack 400 mg (7)- 400mg (7)


5

pack 600 mg (7)- 600mg (7)


5 MO

pack 600-600 mg(28)-mg (28)

nevirapine oral tablet 2 MOnevirapine oral tabletextended release 24

2 MO

hrNORVIR ORAL 3CAPSULE

NORVIR ORAL 3 MOPOWDER INPACKET

NORVIR ORAL 3 MOSOLUTION

NORVIR ORAL 3 MOTABLET

ODEFSEY 5 MOOLYSIO 5 PA, MO, QL (30

per 30 days)oseltamivir oralcapsule 30 mg

2 MO, QL (84 per180 days)



Limitsoseltamivir oralcapsule 45 mg, 75


mgoseltamivir oralsuspension forreconstitution


PREVYMIS 5 HIINTRAVENOUS

PREVYMIS ORAL 5 MOPREZCOBIX 5 MOPREZISTA ORAL 5 MOSUSPENSION

PREZISTA ORAL 3 MOTABLET 150 MG, 75MG

PREZISTA ORAL 5 MOTABLET 600 MG,800 MG

RELENZADISKHALER


RESCRIPTOR 3 MORETROVIRINTRAVENOUS

3 MO, HI

REYATAZ ORAL 5 MOCAPSULE 150 MG,200 MG, 300 MG

REYATAZ ORAL 5 MOPOWDER INPACKET

ribasphere oralcapsule

2 MO

ribasphere oral tablet200 mg, 400 mg

2 MO

ribasphere oral tablet600 mg

5 MO


Limitsribasphere ribapakoral tablets,dose

2 MO

pack 200 mg (28)-400 mg (28)

ribasphere ribapakoral tablets,dose

2

pack 200 mg (7)- 400mg (7)


5

pack 400 mg (7)- 400mg (7), 600 mg (7)-400 mg (7), 600 mg(7)- 600 mg (7)


5 MO

pack 400-400 mg(28)-mg (28),600-400 mg (28)-mg(28), 600-600 mg(28)-mg (28)

ribavirin oral capsule 2 MOribavirin oral tablet 2 MO200 mg

rimantadine 2 MOritonavir 2 MOSELZENTRY 3 MOSOVALDI 5 PA, MO, QL (30

per 30 days)stavudine oral capsule 2 MOSTRIBILD 5 MOSUSTIVA ORAL 5 MOCAPSULE 200 MG

SUSTIVA ORAL 5 MOTABLET

SYMFI 5 MOSYMFI LO 5 MO



LimitsSYNAGIS 5 MO, LATECHNIVIE 5 PA, MO, QL (60

per 30 days)tenofovir disoproxilfumarate

5 MO

TIVICAY ORALTABLET 10 MG

3 MO

TIVICAY ORALTABLET 25 MG, 50MG

5 MO

TRIUMEQ 5 MOTROGARZO 5 MOTRUVADA 5 MOTYBOST 3 MOvalacyclovir 2 MOvalganciclovir oralrecon soln

5 MO

valganciclovir oraltablet

5 MO

VEMLIDY 5 MOVIDEX 2 GRAMPEDIATRIC

3 MO

VIDEX 4 GRAMPEDIATRIC

3 MO

VIDEX EC ORALCAPSULE,DELAYEDRELEASE(DR/EC)125 MG

3 MO

VIEKIRA PAK 5 PA, MO, QL(112 per 28days)

VIEKIRA XR 5 PA, MO, QL (84per 28 days)

VIRACEPT ORALTABLET

5 MO


LimitsVIRAMUNE ORALSUSPENSION

3 MO

VIREAD 5 MOVOSEVI 5 PA, MO, QL (30

per 30 days)ZEPATIER 5 PA, MO, QL (30

per 30 days)ZERIT ORAL RECONSOLN

3 MO

ZIAGEN ORALSOLUTION

3 MO

zidovudine 2 MO


ANTI - INFECTIVES:CEPHALOSPORINSDrug Name Tier Requirements/

Limitscefaclor oral capsule 2 MOcefaclor oralsuspension forreconstitution 125mg/5 ml, 250 mg/5 ml

2 MO

cefaclor oralsuspension forreconstitution 375mg/5 ml

2

cefaclor oral tabletextended release 12hr

2 MO

cefadroxil oral capsule 2 MOcefadroxil oralsuspension forreconstitution 250mg/5 ml, 500 mg/5 ml

2 MO

cefadroxil oral tablet 2 MOcefazolin in dextrose(iso-os) intravenouspiggyback 1 gram/50ml, 2 gram/50 ml

2 MO, HI

cefazolin injectionrecon soln 1 gram,500 mg

2 MO, HI

cefazolin injectionrecon soln 10 gram

2 HI

cefazolin injectionrecon soln 100 gram,20 gram, 300 g

2 HI

cefazolin intravenous 2 HIcefdinir 2 MOcefepime 2 MO, HIcefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50ml

2

ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefepime in dextrose,iso-osm intravenouspiggyback 2gram/100 ml

2 MO

cefixime 2 MOcefotaxime injectionrecon soln 1 gram, 2gram, 500 mg

2 HI

cefotaxime injectionrecon soln 10 gram

2 HI

cefotetan injection 2 HIcefotetan intravenous 2 HIcefoxitin in dextrose,iso-osm

2

cefoxitin intravenousrecon soln 1 gram, 2gram

2 MO, HI

cefoxitin intravenousrecon soln 10 gram

2 HI

cefpodoxime 2 MOcefprozil 2 MOceftazidime injectionrecon soln 1 gram, 2gram

2 MO, HI

ceftazidime injectionrecon soln 6 gram

2 HI

ceftriaxone indextrose,iso-os

2 MO

ceftriaxone injectionrecon soln 1 gram, 2gram, 250 mg, 500mg

2 MO, HI

ceftriaxone injectionrecon soln 10 gram

2 HI

ceftriaxoneintravenous

2 MO, HI


ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefuroxime axetil oral 2 MOtablet

cefuroxime sodium 2 MO, HIinjection recon soln750 mg

cefuroxime sodium 2 MO, HIintravenous reconsoln 1.5 gram

cefuroxime sodium 2 HIintravenous reconsoln 7.5 gram

cephalexin 2 MOSUPRAX ORAL 3 MOCAPSULE

SUPRAX ORAL 3 MOTABLET,CHEWABLE

TEFLARO 5 MO, HIZERBAXA 5 HI

ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDESDrug Name Tier Requirements/

Limitsazithromycinintravenous

2 MO, HI

azithromycin oral 2 MOclarithromycin oralsuspension forreconstitution

2 MO

clarithromycin oraltablet

2 MO

clarithromycin oraltablet extended

2 MO

release 24 hrDIFICID 5 MOe.e.s. 400 oral tablet 2 MOery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

2 MO

ERY-TAB ORAL 3 MOTABLET,DELAYEDRELEASE (DR/EC)500 MG

erythrocin (asstearate) oral tablet250 mg

2 MO

ERYTHROCININTRAVENOUS

3 MO, HI

RECON SOLN 500MG

erythromycinethylsuccinate oralsuspension forreconstitution

2 MO

erythromycinethylsuccinate oraltablet

2 MO

erythromycin oralcapsule,delayedrelease(dr/ec)

2 MO


ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDES (continued)Drug Name Tier Requirements/

Limitserythromycin oraltablet

2 MO

ANTI - INFECTIVES:MISCELLANEOUS ANTDrug Name Tier

ALBENZA 3ALINIA ORAL 3SUSPENSION FORRECONSTITUTION

ALINIA ORAL TABLET 5amikacin injection 2solution 1,000 mg/4ml

amikacin injection 2solution 500 mg/2 ml

atovaquone 5atovaquone-proguanil 2AZACTAM 3AZACTAM IN 3DEXTROSE (ISO-OSM)

aztreonam injection 2recon soln 1 gram

aztreonam injection 2recon soln 2 gram

baciim 2bacitracin 2intramuscular

BENZNIDAZOLE 3BETHKIS 5CAPASTAT 3CAYSTON 5chloramphenicol sod 2succinate

chloroquine 2phosphate

cleocin intravenous 2solution 300 mg/2 ml

clindamycin hcl 2

IINFECTIVESRequirements/Limits

MOMO

MOMO, HI

MO, HI

MOMOMO, HIHI

MO, HI

MO, HI

MO

B/D PA, MOHIMO, LAHI

MO

MO


ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVES(continued)Drug Name Tier Requirements/

Limitsclindamycin in 5 %dextrose

2 MO, HI

clindamycin palmitatehcl

2 MO

clindamycin pediatric 2 MOclindamycinphosphate injection

2 MO, HI

clindamycinphosphateintravenous solution300 mg/2 ml, 900mg/6 ml

2 HI

clindamycinphosphateintravenous solution600 mg/4 ml

2 HI

COARTEM 3 MOcolistin (colistimethatena)

2 MO, HI

CYCLOSERINE 3 MODALVANCE 3 MO, HIdapsone oral 2 MOdaptomycin 5 MO, HIDARAPRIM 5DORIPENEMINTRAVENOUSRECON SOLN 250MG

3 HI

DORIPENEMINTRAVENOUSRECON SOLN 500MG

3 HI

EMVERM 5 MOethambutol 2 MO


Limitsgentamicin in nacl(iso-osm) intravenouspiggyback 100mg/100 ml, 60 mg/50ml, 80 mg/50 ml

2 MO, HI

gentamicin in nacl(iso-osm) intravenouspiggyback 70 mg/50ml, 90 mg/100 ml

2 HI

gentamicin in nacl(iso-osm) intravenouspiggyback 80 mg/100ml

2 HI

gentamicin injectionsolution 20 mg/2 ml

2 MO, HI

gentamicin injectionsolution 40 mg/ml

2 MO, HI

gentamicin sulfate(ped) (pf)

2 MO

gentamicin sulfate (pf)intravenous solution100 mg/10 ml

2 MO, HI

hydroxychloroquine 2 MOimipenem-cilastatin 2 MO, HIIMPAVIDO 3 MOINVANZ INJECTION 3 MO, HIINVANZINTRAVENOUS

3 HI

isoniazid injection 2isoniazid oral 2 MOivermectin 2 MOlincomycin 2 HIlinezolid 5 MOlinezolid in dextrose5%

5 HI



Limitslinezolid-0.9% sodiumchloride

5

mefloquine 2 MOmeropenem 2 MO, HImetro i.v. 2 MO, HImetronidazole in nacl(iso-os)

2 MO, HI

metronidazole oral 2 MONEBUPENT 3 B/D PA, MOneomycin 2 MOORBACTIV 5 MO, HIparomomycin 2 MOPASER 3 MOPENTAM 4 MO, HIpolymyxin b sulfate 2 MO, HIpraziquantel 2 MOPRIFTIN 3 MOPRIMAQUINE 4 MOpyrazinamide 2 MOquinine sulfate 2 MOrifabutin 2 MOrifampin intravenous 2 MO, HIrifampin oral 2 MORIFATER 4 MOSIRTURO 5 MO, LASIVEXTROINTRAVENOUS

5 HI

SIVEXTRO ORAL 5 MOSTREPTOMYCIN 3 MOSYNERCID 5 HItigecycline 5 HI


Limitstinidazole 2 MOTOBI PODHALERINHALATIONCAPSULE

5

TOBI PODHALERINHALATIONCAPSULE, W/INHALATIONDEVICE

5 MO

tobramycin in 0.225 %nacl

5 B/D PA, MO

tobramycin sulfateinjection recon soln

2 HI

tobramycin sulfateinjection solution

2 MO, HI

TRECATOR 3 MOTYGACIL 5 MO, HIXIFAXAN ORALTABLET 550 MG

5 MO


ANTI - INFECTIVES: PENICILLINSDrug Name Tier Requirements/

Limitsamoxicillin oralcapsule

2 MO

amoxicillin oralsuspension forreconstitution

2 MO

amoxicillin oral tablet 2 MOamoxicillin oral tablet,chewable 125 mg,250 mg

2 MO

amoxicillin-potclavulanate oralsuspension forreconstitution

2 MO

amoxicillin-potclavulanate oraltablet

2 MO

amoxicillin-potclavulanate oraltablet extendedrelease 12 hr

2 MO

amoxicillin-potclavulanate oraltablet,chewable

2 MO

ampicillin oral capsule 2 MOampicillin sodiuminjection recon soln 1gram, 10 gram, 125mg

2 MO, HI

ampicillin sodiuminjection recon soln 2gram, 250 mg, 500mg

2 MO, HI

ampicillin sodiumintravenous

2 HI

ampicillin-sulbactaminjection recon soln1.5 gram, 3 gram

2 MO, HI

ampicillin-sulbactaminjection recon soln15 gram

2 HI

ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsampicillin-sulbactamintravenous reconsoln 1.5 gram

2 HI

ampicillin-sulbactamintravenous reconsoln 3 gram

2 MO, HI

BICILLIN L-A 4 MOdicloxacillin 2 MOnafcillin in dextroseiso-osm intravenouspiggyback 1 gram/50ml

2 HI

nafcillin in dextroseiso-osm intravenouspiggyback 2gram/100 ml

2 MO, HI

nafcillin injection reconsoln 1 gram

2 MO, HI


5 MO, HI


2 MO, HI

nafcillin intravenousrecon soln 1 gram

2 MO, HI

nafcillin intravenousrecon soln 2 gram

2 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50ml

2 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50ml

5 MO, HI

oxacillin injectionrecon soln 1 gram

2 HI

oxacillin injectionrecon soln 10 gram

5 HI


ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsoxacillin injectionrecon soln 2 gram

2 MO, HI

penicillin g potassiuminjection recon soln20 million unit

2 MO, HI

penicillin g potassiuminjection recon soln 5million unit

2 MO, HI

penicillin g procaineintramuscular syringe1.2 million unit/2 ml

2 MO

penicillin g procaineintramuscular syringe600,000 unit/ml

2

penicillin g sodium 2 MO, HIpenicillin v potassium 2 MOpfizerpen-g 2 HIpiperacillin-tazobactam

2 MO, HI

intravenous reconsoln 2.25 gram,3.375 gram, 4.5gram, 40.5 gram

ANTI - INFECTIVES: QUINOLONESDrug Name Tier Requirements/

LimitsBAXDELA 5 HIINTRAVENOUS

BAXDELA ORAL 5 MOciprofloxacin 2ciprofloxacin (mixture)oral tablet, er

2 MO

multiphase 24 hrciprofloxacin hcl oral 2 MOciprofloxacin in 5 %dextrose intravenous

2 MO, HI

piggyback 200mg/100 ml

ciprofloxacin in 5 %dextrose intravenous

2 MO, HI

piggyback 400mg/200 ml

ciprofloxacin lactateintravenous solution

2 HI

400 mg/40 mllevofloxacin in d5w 2 HIintravenouspiggyback 250 mg/50ml

levofloxacin in d5w 2 MO, HIintravenouspiggyback 500mg/100 ml, 750mg/150 ml

levofloxacin 2 MO, HIintravenous

levofloxacin oral 2 MOmoxifloxacin in nacl 2 HI(iso-osm)

moxifloxacin oral 2 MOofloxacin oral tablet 2300 mg

ofloxacin oral tablet 2 MO400 mg


ANTI - INFECTIVES: SULFA'S /RELATED AGENTSDrug Name Tier Requirements/

Limitssulfadiazine 2 MOsulfamethoxazole-trimethoprimintravenous

2 MO, HI

sulfamethoxazole-trimethoprim oral

2 MO

sulfatrim 2 MO

ANTI - INFECTIVES:TETRACYCLINESDrug Name Tier Requirements/

Limitscoremino oral tabletextended release 24hr

2

demeclocycline 2 MOdoxy-100 2 MO, HIdoxycycline hyclateoral capsule

2 MO

doxycycline hyclateoral tablet 100 mg,150 mg, 20 mg, 75mg

2 MO

doxycycline hyclateoral tablet 50 mg

2

doxycycline hyclateoral tablet,delayedrelease (dr/ec)

2 MO

doxycyclinemonohydrate oralcapsule

2 MO

doxycyclinemonohydrate oralsuspension forreconstitution

2 MO

doxycyclinemonohydrate oraltablet

2 MO

minocycline oralcapsule

2 MO

minocycline oral tablet 2 MOminocycline oral tabletextended release 24hr 115 mg, 65 mg

5 MO

minocycline oral tabletextended release 24hr 135 mg, 45 mg, 90mg

2 MO

mondoxyne nl 2 MOmorgidox 2 MO


ANTI - INFECTIVES:TETRACYCLINES (continued)Drug Name Tier Requirements/

Limitsokebo oral capsule 75 2 MOmg

soloxide 2tetracycline 2 MO

ANTI - INFECTIVES: URINARYTRACT AGENTSDrug Name Tier Requirements/

Limitsmethenamine 2 MOhippurate

methenamine 2 MOmandelate

nitrofurantoin 2 MOnitrofurantoin 2 MOmacrocrystal

nitrofurantoin 2 MOmonohyd/m-cryst

trimethoprim 2 MO

ANTI - INFECTIVES: VANCOMYCINDrug Name Tier Requirements/

LimitsVANCOMYCIN IN 3 MOD5W INTRAVENOUSPIGGYBACK 1GRAM/200 ML(BRAND)

VANCOMYCIN IN 3D5W INTRAVENOUSPIGGYBACK 500MG/100 ML, 750MG/150 ML (BRAND)

VANCOMYCIN IN 3DEXTROSE ISO-OSM (BRAND)

VANCOMYCIN 3INJECTION(BRAND)

vancomycinintravenous recon

2 MO, HI

soln 1,000 mg, 10gram, 500 mg

vancomycinintravenous recon

2 MO, HI

soln 5 gram, 750 mgvancomycin oralcapsule

5 MO

VIBATIV 3INTRAVENOUSRECON SOLN 750MG


ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS:ADJUNCTIVE AGENTSDrug Name Tier Requirements/

Limitsamifostine crystalline 5 MOdexrazoxane hcl 5 HIintravenous reconsoln 250 mg

dexrazoxane hcl 5 MO, HIintravenous reconsoln 500 mg

ELITEK 5 MO, HIKEPIVANCE 5 MO, HIleucovorin calcium 2 MO, HIinjection recon soln100 mg, 350 mg

leucovorin calcium 2 MO, HIinjection recon soln200 mg, 50 mg

leucovorin calcium 2 HIinjection recon soln500 mg

leucovorin calcium 2 MOoral

LEVOLEUCOVORIN 5 HIINTRAVENOUSRECON SOLN 175MG (BRAND)

levoleucovorin 5 HIintravenous reconsoln 50 mg

levoleucovorin 5 HIintravenous solution

mesna 2 MO, HIMESNEX ORAL 5 MOVISTOGARD 5 MOXGEVA 5 PA, MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSDrug Name Tier Requirements/

LimitsABRAXANE 5 MO, HIadriamycinintravenous solution

2 HI

10 mg/5 ml, 2 mg/ml,50 mg/25 ml

adriamycinintravenous solution

2 HI

20 mg/10 mladrucil intravenoussolution 2.5 gram/50ml

2 B/D PA, HI

adrucil intravenoussolution 5 gram/100ml

2 B/D PA, MO, HI

adrucil intravenoussolution 500 mg/10ml

2 B/D PA, MO, HI

AFINITOR 5 MOAFINITOR DISPERZ 5 MOALECENSA 5 MOALIMTA 3 MOINTRAVENOUSRECON SOLN 100MG

ALIMTAINTRAVENOUS

5 MO, HI

RECON SOLN 500MG

ALIQOPA 5 MO, HI, LAALUNBRIG 5 MOanastrozole 2 MOARRANON 5 HIARZERRA 5 B/D PA, MO, HIASTAGRAF XL 4 B/D PA, MOAVASTIN 5 MO, HIazacitidine 5 MO, HI


ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS(continued)Drug Name Tier Requirements/

Limitsazathioprine 2 B/D PA, MOazathioprine sodium 2 B/D PA, HIBAVENCIO 5 MO, HI, LABELEODAQ 5 MO, HIBENDEKA 5 MOBESPONSA 5 MO, HIbexarotene 5 MObicalutamide 2 MOBICNU 5 MO, HIbleomycin injectionrecon soln 15 unit

2 B/D PA, MO, HI

bleomycin injectionrecon soln 30 unit

2 B/D PA, MO, HI

BLINCYTOINTRAVENOUS KIT

3 B/D PA, MO

BORTEZOMIB 5 MO, HIBOSULIF 5 MObusulfan 5 HICABOMETYX 5 MO, LACALQUENCE 5 MO, LAcapecitabine MB MOCAPRELSA 5 MO, LAcarboplatinintravenous solution

2 MO, HI

CELLCEPTINTRAVENOUS

3 B/D PA, MO, HI

cisplatin 2 MO, HIcladribine 5 B/D PA, MO, HIclofarabine 5 HICOMETRIQ 5 MOCOTELLIC 5 MO, LA


Limitscyclophosphamideintravenous

2 MO

cyclophosphamideoral capsule

2 B/D PA, MO

cyclosporineintravenous

2 B/D PA, HI

cyclosporine modified 2 B/D PA, MOcyclosporine oralcapsule

2 B/D PA, MO

CYRAMZA 5 B/D PA, MO, HIcytarabine 2 B/D PA, MO, HIcytarabine (pf)injection solution 100mg/5 ml (20 mg/ml)

2 B/D PA, MO, HI

cytarabine (pf)injection solution 2gram/20 ml (100 mg/ml)

2 B/D PA, MO, HI

cytarabine (pf)injection solution 20mg/ml

2 B/D PA, HI

dacarbazineintravenous reconsoln 100 mg

2 MO, HI

dacarbazineintravenous reconsoln 200 mg

2 MO, HI

dactinomycin 5 HIDARZALEX 5 MO, HI, LAdaunorubicinintravenous solution

2 HI

decitabine 5 MO, HIdocetaxel intravenoussolution 160 mg/16ml (10 mg/ml)

5 HI



Limitsdocetaxel intravenoussolution 160 mg/8 ml(20 mg/ml), 20 mg/ml(1 ml), 80 mg/8 ml(10 mg/ml)

5 MO, HI

docetaxel intravenoussolution 20 mg/2 ml(10 mg/ml)

5 HI

DOCETAXELINTRAVENOUSSOLUTION 20 MG/ML (BRAND)

5 HI

docetaxel intravenoussolution 80 mg/4 ml(20 mg/ml)

5 MO, HI

doxorubicinintravenous reconsoln 10 mg

2 HI

doxorubicinintravenous reconsoln 50 mg

2 MO, HI

doxorubicinintravenous solution10 mg/5 ml, 2 mg/ml,20 mg/10 ml

2 MO, HI

doxorubicinintravenous solution50 mg/25 ml

2 MO, HI

doxorubicin, peg-liposomal

5 MO, HI

ELIGARD 3 MOELIGARD (3 MONTH) 3 MOELIGARD (4 MONTH) 3 MOELIGARD (6 MONTH) 3 MOEMCYT 3 MOEMPLICITI 5 B/D PA, MO, HIENVARSUS XR 4 B/D PA, MO


Limitsepirubicin intravenoussolution 200 mg/100ml

2 MO, HI

epirubicin intravenoussolution 50 mg/25 ml

2 MO, HI

ERBITUXINTRAVENOUSSOLUTION 100MG/50 ML

5 MO, HI

ERBITUXINTRAVENOUSSOLUTION 200MG/100 ML

5 MO, HI

ERIVEDGE 5 MOERLEADA 5 MOERWINAZE 5 MO, HIETOPOPHOS 3 MO, HIetoposide intravenous 2 MO, HIetoposide oral MB MOexemestane 2 MOFARESTON 5 MOFARYDAK 5 MOFASLODEX 5 MOFIRMAGON KIT WDILUENT SYRINGESUBCUTANEOUSRECON SOLN 120MG

5 MO

FIRMAGON KIT WDILUENT SYRINGESUBCUTANEOUSRECON SOLN 80MG

3 MO

floxuridine 2 B/D PA



Limitsfludarabineintravenous reconsoln

2 MO, HI

fludarabineintravenous solution

2 HI

fluorouracilintravenous solution1 gram/20 ml, 2.5gram/50 ml, 500mg/10 ml

2 B/D PA, MO, HI

fluorouracilintravenous solution5 gram/100 ml

2 B/D PA, MO, HI

flutamide 2 MOFOLOTYNINTRAVENOUSSOLUTION 20 MG/ML (1 ML)

3 MO, HI

FOLOTYNINTRAVENOUSSOLUTION 40 MG/2ML (20 MG/ML)

5 MO, HI

GAZYVA 3 MOgemcitabineintravenous reconsoln 1 gram

2 MO, HI

gemcitabineintravenous reconsoln 2 gram

2 HI

gemcitabineintravenous reconsoln 200 mg

2 MO, HI

gemcitabineintravenous solution1 gram/26.3 ml (38mg/ml), 200 mg/5.26ml (38 mg/ml)

2 MO, HI


Limitsgemcitabineintravenous solution2 gram/52.6 ml (38mg/ml)

2 HI

gengraf oral capsule100 mg, 25 mg

2 B/D PA, MO

gengraf oral solution 2 B/D PA, MOGILOTRIF 5 MOGLEOSTINE 3 MOHALAVEN 5 MO, HIHERCEPTIN 5 MO, HIHEXALEN 5 MOHYCAMTIN ORAL MB MOhydroxyurea 2 MOIBRANCE 5 PA, MOICLUSIG ORALTABLET 15 MG

5

ICLUSIG ORALTABLET 45 MG

5 MO

idarubicin 2 HIIDHIFA 5 MO, LAifosfamide intravenousrecon soln 1 gram

2 MO, HI

ifosfamide intravenousrecon soln 3 gram

2 MO, HI

ifosfamide intravenoussolution

2 HI

imatinib 5 MOIMBRUVICA 5 PA, MOIMFINZI 5 MO, HI, LAINLYTA 5 MOIRESSA 5 MO



Limitsirinotecan intravenoussolution 100 mg/5 ml

2 MO, HI

irinotecan intravenoussolution 40 mg/2 ml

2 MO, HI

irinotecan intravenoussolution 500 mg/25ml

2 HI

ISTODAX 5 MO, HIIXEMPRA 5 MO, HIJAKAFI 5 PA, MOJEVTANA 5 MO, HIKADCYLA 5 MO, HIKEYTRUDAINTRAVENOUSSOLUTION

5 MO, HI

KISQALI 5 PA, MOKISQALI FEMARACO-PACK

5 PA, MO

KYPROLIS 5 MO, HILARTRUVO 5 MO, HI, LALENVIMA 5 MOletrozole 2 MOLEUKERAN 3 MOleuprolidesubcutaneous kit

2 MO

LONSURF 5 MOLUPRON DEPOT 5 MOLUPRON DEPOT (3MONTH)

5 MO

LUPRON DEPOT (4MONTH)

5 MO

LUPRON DEPOT (6MONTH)

5 MO


LimitsLUPRON DEPOT-PED

5 MO

LUPRON DEPOT-PED (3 MONTH)

5 MO

LYNPARZA 5 MOLYSODREN 3 MOMATULANE 5 MOmegestrol oralsuspension 400mg/10 ml (10 ml)

2 PA

megestrol oralsuspension 400mg/10 ml (40 mg/ml),625 mg/5 ml

2 PA, MO

megestrol oral tablet 2 PA, MOMEKINIST 5 MOmelphalan 2 B/D PA, MOmelphalan hcl 5 HImercaptopurine 2 MOmethotrexate sodium(pf) injection reconsoln

2 B/D PA, HI

methotrexate sodium(pf) injection solution

2 B/D PA, MO, HI

methotrexate sodiuminjection

2 B/D PA, MO, HI

methotrexate sodiumoral

2 B/D PA, MO

mitomycin intravenousrecon soln 20 mg, 5mg

2 MO, HI

mitomycin intravenousrecon soln 40 mg

5 MO, HI

mitoxantrone 2 MO, HIMUSTARGEN 3 MO, HI



Limitsmycophenolate mofetilhcl

2 B/D PA, HI

mycophenolate mofetiloral capsule

2 B/D PA, MO

mycophenolate mofetiloral suspension forreconstitution

5 B/D PA, MO

mycophenolate mofetiloral tablet

2 B/D PA, MO

mycophenolatesodium oral tablet,delayed release (dr/ec)

2 B/D PA, MO

MYLERAN MB MOMYLOTARG 5 MO, HI, LANERLYNX 5 PA, MO, LANEXAVAR 5 MO, LAnilutamide 5 MONINLARO 5 MONULOJIX 5 B/D PA, MO, HIoctreotide acetateinjection solution1,000 mcg/ml, 500mcg/ml

5 MO

octreotide acetateinjection solution 100mcg/ml, 200 mcg/ml,50 mcg/ml

2 MO

octreotide acetateinjection syringe 100mcg/ml (1 ml), 50mcg/ml (1 ml)

2 MO

octreotide acetateinjection syringe 500mcg/ml (1 ml)

5 MO

ODOMZO 5 MO, LA


LimitsONCASPAR 5 MOONIVYDE 5 MOOPDIVOINTRAVENOUSSOLUTION 100MG/10 ML, 40 MG/4ML

5 MO, HI

OPDIVOINTRAVENOUSSOLUTION 240MG/24 ML

5 MO, HI

oxaliplatin intravenousrecon soln 100 mg

2 MO, HI

oxaliplatin intravenousrecon soln 50 mg

2 HI

oxaliplatin intravenoussolution 100 mg/20ml

2 MO, HI

oxaliplatin intravenoussolution 50 mg/10 ml(5 mg/ml)

2 MO, HI

paclitaxel 2 MO, HIPERJETA 5 MO, HIPOMALYST 5 PA, MO, LAPORTRAZZA 5 B/D PA, MOPROGRAFINTRAVENOUS

3 B/D PA, MO, HI

PURIXAN 5 MORAPAMUNE ORALSOLUTION

5 B/D PA, MO

REVLIMID 5 PA, MO, LARITUXAN 5 PA, MO, HIRITUXAN HYCELA 5 MOROMIDEPSIN 5RUBRACA 5 MO, LA



LimitsRYDAPT 5 MOSANDOSTATIN LARDEPOTINTRAMUSCULARSUSPENSION,EXTENDED RELRECON

5 MO

SIGNIFOR 5 MOSIGNIFOR LAR 5 MOSIMULECTINTRAVENOUSRECON SOLN 10MG

3 B/D PA, HI

SIMULECTINTRAVENOUSRECON SOLN 20MG

3 B/D PA, MO, HI

sirolimus oral tablet0.5 mg, 1 mg

2 B/D PA, MO

sirolimus oral tablet 2mg

5 B/D PA, MO

SOLTAMOX 4 MOSOMATULINEDEPOT

5 MO

SPRYCEL 5 MOSTIVARGA 5 MOSUTENT 5 MOSYLVANT 5 MO, HISYNRIBO 5 MOTABLOID 3 MOtacrolimus oral 2 B/D PA, MOTAFINLAR 5 MOTAGRISSO 5 MO, LAtamoxifen 2 MOTARCEVA 5 MO


LimitsTARGRETIN 1% GEL 5 MOTASIGNA 5 MOTECENTRIQ 5 MO, HI, LATEMODARINTRAVENOUS

3 MO

TEMODAR ORAL MB MOtemozolomide MB MOTHALOMID 5 MOthiotepa 5 MOtoposar 2 MO, HItopotecan intravenousrecon soln

5 HI

topotecan intravenoussolution

5 MO, HI

TORISEL 5 MO, HITREANDAINTRAVENOUSRECON SOLN

5 MO, HI

TRELSTAR 5 MOtretinoin(chemotherapy)

5 MO

TRISENOXINTRAVENOUSSOLUTION 2 MG/ML

5 MO, HI

TYKERB 5 MO, LAUNITUXIN 5 MOVALSTAR 3 MOVANTAS 3 MOVECTIBIXINTRAVENOUSSOLUTION 100MG/5 ML (20 MG/ML)

5 B/D PA, MO, HI



LimitsVECTIBIXINTRAVENOUSSOLUTION 400MG/20 ML (20 MG/ML)

5 B/D PA, MO, HI

VELCADE 5 MO, HIVENCLEXTA ORALTABLET 10 MG, 50MG

3 MO, LA

VENCLEXTA ORALTABLET 100 MG

5 MO, LA

VENCLEXTASTARTING PACK

5 MO, LA

VERZENIO 5 MO, LAvinblastineintravenous solution

2 B/D PA, MO, HI

vincasar pfsintravenous solution1 mg/ml

2 B/D PA, HI

vincasar pfsintravenous solution2 mg/2 ml

2 B/D PA, MO, HI

vincristine intravenoussolution 1 mg/ml

2 B/D PA, MO, HI

vincristine intravenoussolution 2 mg/2 ml

2 B/D PA, MO, HI

vinorelbineintravenous solution10 mg/ml

2 MO, HI

vinorelbineintravenous solution50 mg/5 ml

2 MO, HI

VOTRIENT 5 MOVYXEOS 5 B/D PA, MO, HIXALKORI 5 MOXATMEP 5 B/D PA, MO


LimitsXELODA MB MOXERMELO 5 MO, LAXTANDI 5 PA, MOYERVOYINTRAVENOUSSOLUTION 200MG/40 ML (5 MG/ML)

5 MO, HI

YERVOYINTRAVENOUSSOLUTION 50MG/10 ML (5 MG/ML)

5 MO, HI

YONDELIS 5 MO, HIZALTRAPINTRAVENOUSSOLUTION 100MG/4 ML (25 MG/ML)

5 MO, HI

ZALTRAPINTRAVENOUSSOLUTION 200MG/8 ML (25 MG/ML)

5 MO, HI

ZANOSAR 3 MO, HIZEJULA 5 MO, LAZELBORAF 5 MOZOLADEX 3 MOZOLINZA 5 MOZORTRESS 5 B/D PA, MOZYDELIG 5 MOZYKADIA 5 MOZYTIGA 5 PA, MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTSDrug Name Tier Requirements/

LimitsAPTIOM ORAL 3 MOTABLET 200 MG,400 MG, 800 MG

APTIOM ORAL 5 MOTABLET 600 MG

BANZEL ORAL 3 MOSUSPENSION

BANZEL ORAL 3 MOTABLET 200 MG

BANZEL ORAL 5 MOTABLET 400 MG

BRIVIACT 3 HIINTRAVENOUS

BRIVIACT ORAL 5 MOcarbamazepine oralcapsule, ermultiphase 12 hr

2 MO

carbamazepine oralsuspension 100 mg/5ml

2 MO

carbamazepine oraltablet

1 MO

carbamazepine oraltablet extended

2 MO

release 12 hrcarbamazepine oraltablet,chewable

1 MO

CELONTIN ORAL 3 MOCAPSULE 300 MG

clonazepam oral tablet 2 PA, MOclonazepam oraltablet,disintegrating

2 PA, MO

DIASTAT 4 MODIASTAT ACUDIAL 4 MOdiazepam rectal 2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTS (continued)Drug Name Tier Requirements/

LimitsDILANTIN 30 MG 3 MOdivalproex oralcapsule, delayed relsprinkle

2 MO

divalproex oral tabletextended release 24

2 MO

hrdivalproex oral tablet,delayed release (dr/ec)

1 MO

epitol 1 MOethosuximide 2 MOfelbamate oral 5 MOsuspension

felbamate oral tablet 2 MOfosphenytoin injectionsolution 100 mg pe/2ml

2 MO, HI

fosphenytoin injectionsolution 500 mgpe/10 ml

2 MO, HI

FYCOMPA ORAL 5 MOSUSPENSION

FYCOMPA ORAL 4 MOTABLET

gabapentin oralcapsule

1 MO

gabapentin oralsolution 250 mg/5 ml

2 MO

gabapentin oralsolution 250 mg/5 ml(5 ml), 300 mg/6 ml(6 ml)

2

gabapentin oral tablet600 mg, 800 mg

1 MO



LimitsGABITRIL ORALTABLET 12 MG, 16MG

3 MO

lamotrigine oral tablet 1 MOlamotrigine oral tabletdisintegrating, dosepk

2 MO

lamotrigine oral tabletextended release24hr

2 MO

lamotrigine oral tablet,chewable dispersible

2 MO

lamotrigine oral tablet,disintegrating

2 MO

lamotrigine oraltablets,dose pack

2 MO

levetiracetam in nacl(iso-os) intravenouspiggyback 1,000mg/100 ml, 1,500mg/100 ml

2 HI

levetiracetam in nacl(iso-os) intravenouspiggyback 500mg/100 ml

2 MO, HI

levetiracetamintravenous

2 MO, HI

levetiracetam oralsolution 100 mg/ml

2 MO

levetiracetam oralsolution 500 mg/5 ml(5 ml)

2

levetiracetam oraltablet

2 MO

levetiracetam oraltablet extendedrelease 24 hr

2 MO


LimitsLYRICA 4 PA, MOONFI ORALSUSPENSION

4 PA, MO

ONFI ORAL TABLET10 MG, 20 MG

4 PA, MO

oxcarbazepine 2 MOOXTELLAR XR 4 MOPEGANONE 3 MOphenobarbital 2 PA, MOphenobarbital sodiuminjection solution 130mg/ml

2 MO

phenobarbital sodiuminjection solution 65mg/ml

2

phenytoin oralsuspension 100 mg/4ml

2

phenytoin oralsuspension 125 mg/5ml

2 MO

phenytoin oral tablet,chewable

2 MO

phenytoin sodiumextended

2 MO

phenytoin sodiumintravenous solution

2 MO, HI

phenytoin sodiumintravenous syringe

2 HI

primidone 2 MOQUDEXY XR 4 PA, MOroweepra 2 MOroweepra xr 2SABRIL ORALTABLET

5 MO, LA



LimitsSPRITAM 4 MOtiagabine 2 MOtopiramate oralcapsule, sprinkle

2 PA, MO

topiramate oral tablet 1 PA, MOTROKENDI XR ORALCAPSULE,EXTENDED

4 PA, MO

RELEASE 24HR 100MG, 25 MG, 50 MG

TROKENDI XR ORALCAPSULE,EXTENDED

5 PA, MO

RELEASE 24HR 200MG

valproate sodium 2 MO, HIvalproic acid 2 MOvalproic acid (assodium salt) oralsolution 250 mg/5 ml

2 MO

valproic acid (assodium salt) oralsolution 250 mg/5 ml(5 ml), 500 mg/10 ml(10 ml)

2

vigabatrin 5 MO, LAVIMPAT 3 HIINTRAVENOUS

VIMPAT ORAL 3 MOSOLUTION

VIMPAT ORAL 3 MOTABLET

zonisamide 2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTSDrug Name Tier Requirements/

LimitsAPOKYN 5 MO, LAbenztropine injection 2 MO, HIbenztropine oral 1 MObromocriptine 2 MOcarbidopa 2 MOcarbidopa-levodopa 2 MOoral tablet

carbidopa-levodopa 2 MOoral tablet extendedrelease

carbidopa-levodopa 2 MOoral tablet,disintegrating

carbidopa-levodopa- 2 MOentacapone

entacapone 2 MONEUPRO 4 MOpramipexole oral 2 MOtablet

pramipexole oral 2 MOtablet extendedrelease 24 hr

rasagiline 2 MOropinirole oral tablet 2 MOropinirole oral tablet 2 MOextended release 24hr

selegiline hcl 2 MOtolcapone 5 MOtrihexyphenidyl oral 2 MOelixir

trihexyphenidyl oral 1 MOtablet

ZELAPAR 4 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPYDrug Name Tier Requirements/

Limitsalmotriptan malateoral tablet 12.5 mg


almotriptan malateoral tablet 6.25 mg


dihydroergotamineinjection

2 MO

dihydroergotaminenasal


eletriptan 2 MO, QL (12 per30 days)

ergotamine-caffeine 2 MOfrovatriptan 2 MO, QL (27 per

30 days)migergot 2 MOnaratriptan 2 MO, QL (9 per

30 days)rizatriptan oral tablet 2 MO, QL (18 per

30 days)rizatriptan oral tablet,disintegrating


sumatriptan nasalspray,non-aerosol 20mg/actuation


sumatriptan nasalspray,non-aerosol 5mg/actuation


sumatriptan succinateoral


sumatriptan succinatesubcutaneouscartridge


sumatriptan succinatesubcutaneous peninjector


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPY(continued)Drug Name Tier Requirements/

Limitssumatriptan succinatesubcutaneoussolution


sumatriptan-naproxen 2 MOzolmitriptan oral tablet2.5 mg


zolmitriptan oral tablet5 mg


zolmitriptan oral tablet,disintegrating 2.5 mg


zolmitriptan oral tablet,disintegrating 5 mg


ZOMIG NASAL 3 MO, QL (18 per30 days)


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPYDrug Name Tier Requirements/

LimitsAMPYRA 5 PA, MO, LA, QL

(60 per 30days)

AUBAGIO 5 PA, MOAUSTEDO 5 MO, LAdonepezil oral tablet10 mg, 5 mg

1 MO

donepezil oral tablet23 mg

2 MO

donepezil oral tablet,disintegrating

1 MO

galantamine oralcapsule,ext rel.pellets 24 hr

2 MO

galantamine oralsolution

2 MO

galantamine oraltablet

2 MO

GILENYA ORALCAPSULE 0.5 MG

5 PA, MO

glatiramersubcutaneoussyringe 20 mg/ml


glatiramersubcutaneoussyringe 40 mg/ml


glatopa subcutaneoussyringe 20 mg/ml


glatopa subcutaneoussyringe 40 mg/ml


HORIZANT 4 MOINGREZZA 5 MO, LAKEVEYIS 5 MOLEMTRADA 3 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

Limitsmemantine oral 2 MOcapsule,sprinkle,er24hr

memantine oral 2 PA, MOsolution

memantine oral tablet 2 PA, MONUEDEXTA 3 PA, MOOCREVUS 5 MORADICAVA 5 MO, HIrivastigmine tartrate 2 MOrivastigminetransdermal

2 MO

TECFIDERA 5 PA, MO, LAtetrabenazine 5 MOTYSABRI 5 PA, MO, HI, LA


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPYDrug Name Tier Requirements/

Limitsanectine 2baclofen oral tablet 10 2 MOmg, 20 mg

carisoprodol 2 PA, MOcarisoprodol-asa-codeine

2 PA, MO

carisoprodol-aspirin 2 PA, MOchlorzoxazone oral 2 PAtablet 250 mg

chlorzoxazone oral 2 PA, MOtablet 500 mg

cyclobenzaprine oraltablet

2 PA, MO

dantrolene 2 MOmeprobamate 2 MOMESTINON ORAL 5 MOSYRUP

metaxall 2 PAmetaxalone 2 PA, MOmethocarbamol 2 PA, HIinjection

methocarbamol oral 2 PA, MOneostigminemethylsulfateintravenous solution

2 MO

0.5 mg/mlneostigminemethylsulfateintravenous solution

2

1 mg/mlorphenadrine citrateinjection

2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPY (continued)Drug Name Tier Requirements/

Limitsorphenadrine citrateoral tablet extended

2 PA, MO

releasepyridostigminebromide oral tablet

2 MO

pyridostigminebromide oral tablet

2 MO

extended releaseregonol 2revonto 2tizanidine 2 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICSDrug Name Tier Requirements/

Limitsacetaminophen-caff-dihydrocod oralcapsule

2 MO

acetaminophen-codeine oral solution120 mg-12 mg /5 ml(5 ml), 300 mg-30 mg/12.5 ml

2

acetaminophen-codeine oral solution120-12 mg/5 ml

2 MO

acetaminophen-codeine oral tablet

2 MO

ascomp with codeine 2 PA, MObuprenorphine hclinjection solution

2 MO, HI

buprenorphine hclinjection syringe

2 HI

buprenorphine hclsublingual

2 MO

butalbital compoundw/codeine

2 PA, MO

butalbital-acetaminop-caf-cod

2 PA, MO

butalbital-acetaminophen

2 PA, MO

butalbital-acetaminophen-cafforal capsule

2 PA, MO

butalbital-acetaminophen-cafforal tablet 50-325-40mg

2 PA, MO

butalbital-aspirin-caffeine oral capsule

2 PA, MO

butalbital-aspirin-caffeine oral tablet

2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICS (continued)Drug Name Tier Requirements/

Limitscapacet 2 PA, MOcodeine sulfate oraltablet

2 MO

codeine-butalbital-asa-caff

2 PA

demerol (pf) injectionsolution 100 mg/ml

2 B/D PA, MO

duramorph (pf)injection solution 0.5mg/ml

2 MO, HI

duramorph (pf)injection solution 1mg/ml

2 HI

endocet oral tablet10-325 mg, 2.5-325mg, 5-325 mg,7.5-325 mg

2 MO

fentanyl citrate (pf)injection

2 MO

fentanyl citrate (pf)intravenous syringe100 mcg/2 ml (50mcg/ml)

2

fentanyl citrate buccallozenge on a handle

5 PA, MO

fentanyl transdermalpatch

2 MO

hydrocodone-acetaminophen oralsolution 7.5-325mg/15 ml

2 MO

hydrocodone-acetaminophen oraltablet 10-300 mg,10-325 mg, 2.5-325mg, 5-300 mg, 5-325mg, 7.5-300 mg,7.5-325 mg

2 MO



Limitshydrocodone-ibuprofen oral tablet10-200 mg, 5-200mg, 7.5-200 mg

2 MO

hydromorphone (pf) 2 MOhydromorphoneinjection solution 1mg/ml

2

hydromorphoneinjection solution 2mg/ml, 4 mg/ml

2 MO

hydromorphoneinjection syringe 1mg/ml, 2 mg/ml

2

hydromorphoneinjection syringe 4mg/ml

2 MO

hydromorphone oralliquid

2 MO

hydromorphone oraltablet

2 MO

hydromorphone oraltablet extendedrelease 24 hr 12 mg,8 mg

2 MO

hydromorphone oraltablet extendedrelease 24 hr 16 mg,32 mg

5 MO

ibuprofen-oxycodone 2 MOlevorphanol tartrate 2 MOlorcet (hydrocodone) 2 MOlorcet hd 2 MOlorcet plus oral tablet7.5-325 mg

2 MO


Limitsmeperidine (pf)injection solution 100mg/ml, 50 mg/ml

2 B/D PA, MO

meperidine (pf)injection solution 25mg/ml

2 B/D PA

meperidine injectioncartridge

2 B/D PA

meperidine oral 2 MOmethadone injectionsolution

2 HI

methadone intensol 2 MOmethadone oralconcentrate

2 MO

methadone oralsolution

2 MO

methadone oral tablet 2 MOmethadose oralconcentrate

2 MO

morphine (pf) injectionsolution 0.5 mg/ml

2

morphine (pf) injectionsolution 1 mg/ml

2 MO

morphine (pf)intravenous patientcontrol.analgesiasoln 150 mg/30 ml

2 B/D PA, MO

morphine (pf)intravenous patientcontrol.analgesiasoln 30 mg/30 ml

2 B/D PA

morphine concentrateoral solution

2 MO



LimitsMORPHINEINJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND)

3

morphine injectionsolution 8 mg/ml

2

morphine injectionsyringe 10 mg/ml, 2mg/ml, 4 mg/ml

2 MO

morphine injectionsyringe 5 mg/ml, 8mg/ml

2

morphine intravenouscartridge 10 mg/ml, 2mg/ml, 4 mg/ml

2

MORPHINEINTRAVENOUSCARTRIDGE 8 MG/ML (BRAND)

3

morphine intravenoussolution 10 mg/ml

2 MO

MORPHINEINTRAVENOUSSOLUTION 4 MG/ML, 8 MG/ML(BRAND)

3 MO

MORPHINEINTRAVENOUSSYRINGE 10 MG/ML, 8 MG/ML(BRAND)

3

morphine intravenoussyringe 2 mg/ml, 4mg/ml

2

morphine oralcapsule, ermultiphase 24 hr

2 MO


Limitsmorphine oralcapsule,extend.release pellets

2 MO

morphine oral solution 2 MOmorphine oral tablet 2 MOmorphine oral tabletextended release

2 MO

oxycodone oralcapsule

2 MO

oxycodone oralconcentrate

2 MO

oxycodone oralsolution

2 MO

oxycodone oral tablet 2 MOOXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 20 MG, 40 MG,80 MG (BRAND)

3 MO

OXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 15MG, 30 MG, 60 MG(BRAND)

3

oxycodone-acetaminophen oraltablet 10-325 mg,2.5-325 mg, 5-325mg, 7.5-325 mg

2 MO

oxycodone-aspirin 2 MOOXYCONTIN ORALTABLET,ORAL ONLY,EXT.REL.12 HR

3 MO

oxymorphone oraltablet

2 MO



Limitsoxymorphone oraltablet extended

2 MO

release 12 hrpanlor(acetam-caff-dihydrocod)

2

phrenilin forte(withcaffeine)

2 PA

tencon oral tablet 2 PA, MO50-325 mg

vicodin 2 MOvicodin es 2 MOvicodin hp 2 MOxylon 10 2zebutal oral capsule50-325-40 mg

2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICSDrug Name Tier Requirements/

Limitsbuprenorphine-naloxone

2 MO

butorphanol tartrateinjection

2 MO, HI

butorphanol tartratenasal

2 MO

celecoxib 2 PA, MO, QL (60per 30 days)

clonidine (pf) epiduralsolution 5,000

2

mcg/10 mldiclofenac potassium 2 MOdiclofenac sodium oral 2 MOtablet extendedrelease 24 hr

diclofenac sodium oral 2 MOtablet,delayedrelease (dr/ec)

diclofenac sodium 2 MOtopical drops

diclofenac sodium 2 MOtopical gel 1 %

diclofenac-misoprostoloral tablet,ir,delayedrel,biphasic

2 MO

diflunisal 2 MODUROLANE MB MOetodolac oral capsule 2 MOetodolac oral tablet 2 MOetodolac oral tablet 2 MOextended release 24hr

EUFLEXXA MB MOfenoprofen oral tablet 2 MOflurbiprofen 2 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICS (continued)Drug Name Tier Requirements/

LimitsGEL-ONE MB MOGELSYN-3 MB MOGENVISC 850 MB MOHYALGAN MB MOHYMOVIS MBibu 1 MOibuprofen lysine (pf) 2ibuprofen oralsuspension

2 MO

ibuprofen oral tablet400 mg, 600 mg, 800mg

1 MO

indomethacin oralcapsule

2 MO

indomethacin oralcapsule, extendedrelease

2 MO

indomethacin sodium 2ketoprofen oralcapsule

2 MO

ketoprofen oralcapsule,ext rel.pellets 24 hr 200 mg

2 MO

ketorolac injectioncartridge 15 mg/ml

2

ketorolac injectioncartridge 30 mg/ml

2 MO

ketorolac injectionsolution 15 mg/ml, 30mg/ml (1 ml)

2 MO

ketorolac injectionsyringe

2

ketorolacintramuscularcartridge

2 MO


Limitsketorolacintramuscularsolution

2 MO

ketorolacintramuscular syringe

2

ketorolac oral 2 MOmeclofenamate 2 MOmefenamic acid 2 MOmeloxicam oralsuspension

2 MO

meloxicam oral tablet 1 MO, QL (30 per30 days)

MONOVISC MB MOnabumetone 2 MOnalbuphine 2 MO, HInaloxone 2 MOnaltrexone 2 MOnaproxen oralsuspension

2 MO

naproxen oral tablet 1 MOnaproxen oral tablet,delayed release (dr/ec)

1 MO

naproxen sodium oraltablet 275 mg, 550mg

1 MO

naproxen sodium oraltablet, er multiphase24 hr

1 MO

ORTHOVISC MB MOoxaprozin 2 MOpentazocine-naloxone 2 MOpiroxicam 2 MOprofeno 2



Limitssalsalate 1 MOSUBOXONE 3 MOsulindac 1 MOSUPARTZ FX MB MOSYNVISC MB MOSYNVISC-ONE MB MOtolmetin 2 MOtramadol oral tablet 2 MOtramadol oral tablet 2 MOextended release 24hr

tramadol oral tablet, er 2 MOmultiphase 24 hr

tramadol- 2 MOacetaminophen

VISCO-3 MB MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGSDrug Name Tier Requirements/

LimitsABILIFY MAINTENA 5 MOADASUVE 4alprazolam intensol 2 PA, MOalprazolam oral tablet 2 PA, MOalprazolam oral tabletextended release 24

2 PA, MO

hralprazolam oral tablet,disintegrating

2 PA, MO

amitriptyline 2 PA, MOamitriptyline-chlordiazepoxide

2 PA, MO

amoxapine 2 MOaripiprazole oralsolution

2 MO

aripiprazole oral tablet10 mg, 15 mg, 2 mg,5 mg

2 MO

aripiprazole oral tablet20 mg, 30 mg

5 MO

aripiprazole oraltablet,disintegrating

5 MO

ARISTADA 5 MOarmodafinil 2 PA, MOatomoxetine oralcapsule 10 mg, 100mg, 18 mg, 25 mg,80 mg


atomoxetine oralcapsule 40 mg, 60


mgbupropion hcl oraltablet

1 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGS(continued)Drug Name Tier Requirements/

Limitsbupropion hcl oraltablet extendedrelease 12 hr

2 MO

bupropion hcl oraltablet extendedrelease 24 hr

2 MO

buspirone 2 MOchlordiazepoxide hcl 2 PA, MOchlorpromazineinjection

2 MO, HI

chlorpromazine oral 2 MOcitalopram oralsolution

2 MO

citalopram oral tablet 1 MOclomipramine 2 PA, MOclonidine hcl oraltablet extendedrelease 12 hr

2 MO

clorazepatedipotassium

2 PA, MO

clozapine oral tablet 2 MOclozapine oral tablet,disintegrating 100mg, 12.5 mg, 25 mg

2

CLOZAPINE ORALTABLET,DISINTEGRATING150 MG, 200 MG(BRAND)

4

desipramine 2 MOdesvenlafaxinesuccinate oral tabletextended release 24hr

2 MO


Limitsdexmethylphenidateoral capsule,erbiphasic 50-50 10mg, 20 mg, 30 mg,40 mg, 5 mg


dexmethylphenidateoral capsule,erbiphasic 50-50 15mg, 25 mg, 35 mg


dexmethylphenidateoral tablet

2 MO

dextroamphetamineoral capsule,extended release

2 MO

dextroamphetamineoral solution

2 MO

dextroamphetamineoral tablet

2 MO

dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr 10 mg,15 mg, 25 mg, 5 mg


dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr 20 mg,30 mg


dextroamphetamine-amphetamine oraltablet

2 MO

diazepam injectionsolution

2 PA

diazepam injectionsyringe

2 PA, MO

diazepam intensol 2 PA, MO



Limitsdiazepam oralconcentrate

2 PA, MO

diazepam oral solution5 mg/5 ml (1 mg/ml)

2 PA, MO

diazepam oral tablet 2 PA, MOdoxepin oral 2 PA, MOduloxetine oralcapsule,delayedrelease (dr/ec)

2 MO

EMSAM 5 ST, MOergoloid 2 MOescitalopram oxalateoral solution

2 MO

escitalopram oxalateoral tablet

1 MO

estazolam 2 PA, MOeszopiclone 2 MO, QL (30 per

30 days)FANAPT ORALTABLET 1 MG, 2MG, 4 MG

4 MO

FANAPT ORALTABLET 10 MG, 12MG, 6 MG, 8 MG

5 MO

FANAPT ORALTABLETS,DOSEPACK

4 MO

FAZACLO ORALTABLET,DISINTEGRATING150 MG, 200 MG

4

FETZIMA 4 ST, MOflumazenil 2 MOfluoxetine oral capsule 1 MO


Limitsfluoxetine oralcapsule,delayedrelease(dr/ec)

2 MO

fluoxetine oral solution 2 MOfluoxetine oral tablet 2 MOfluphenazinedecanoate

2 MO

fluphenazine hcl 2 MOflurazepam 2 PA, MOfluvoxamine oralcapsule,extendedrelease 24hr

2 MO

fluvoxamine oral tablet 2 MOFORFIVO XL 4 MOGEODONINTRAMUSCULAR

3 MO

guanfacine oral tabletextended release 24hr

2 MO

guanidine 2 MOhaloperidol 1 MOhaloperidol decanoate 2 MOhaloperidol lactateinjection

2 MO

haloperidol lactateintramuscular

2

haloperidol lactate oral 2 MOHETLIOZ 5 PA, MO, QL (30

per 30 days)imipramine hcl 2 PA, MOimipramine pamoate 2 PA, MO



LimitsINVEGA SUSTENNAINTRAMUSCULARSYRINGE 117MG/0.75 ML, 156MG/ML, 234 MG/1.5ML, 78 MG/0.5 ML

5 MO

INVEGA SUSTENNAINTRAMUSCULARSYRINGE 39MG/0.25 ML

4 MO

INVEGA TRINZA 5 MOKHEDEZLA 4 ST, MOLATUDA ORALTABLET 120 MG

5 MO

LATUDA ORALTABLET 20 MG, 40MG, 60 MG, 80 MG

4 MO

lithium carbonate oralcapsule

1 MO

lithium carbonate oraltablet

1 MO

lithium carbonate oraltablet extendedrelease

1 MO

lithium citrate oralsolution 8 meq/5 ml

2 MO

lorazepam injectionsolution

2 PA, MO

lorazepam injectionsyringe

2 PA

lorazepam intensol 2 PA, MOlorazepam oral 2 PA, MOloxapine succinate 2 MOmaprotiline 2 MOMARPLAN 3 MO


Limitsmetadate er oral tabletextended release


methamphetamine 2 PA, MOmethylphenidate hcloral capsule, erbiphasic 30-70 10mg, 20 mg


methylphenidate hcloral capsule, erbiphasic 30-70 30mg, 40 mg, 50 mg,60 mg


methylphenidate hcloral capsule,erbiphasic 50-50 10mg, 20 mg


methylphenidate hcloral capsule,erbiphasic 50-50 30mg, 40 mg, 60 mg


methylphenidate hcloral solution

2 MO

methylphenidate hcloral tablet

2 MO

methylphenidate hcloral tablet extendedrelease 10 mg


methylphenidate hcloral tablet extendedrelease 20 mg


methylphenidate hcloral tablet extendedrelease 24hr 18 mg,27 mg, 54 mg


methylphenidate hcloral tablet extendedrelease 24hr 36 mg




Limitsmethylphenidate hcloral tablet,chewable

2 MO

midazolam (pf)injection

2

midazolam injection 2midazolam oral syrup2 mg/ml

2 MO

mirtazapine oral tablet 1 MOmirtazapine oraltablet,disintegrating

2 MO

modafinil 2 PA, MOnefazodone 2 MOnortriptyline 2 MONUPLAZID 5 MOolanzapineintramuscular reconsoln

2 MO

olanzapine oral tablet 2 MOolanzapine oral tablet,disintegrating

2 MO

olanzapine-fluoxetine 2 MOoxazepam 2 PA, MOpaliperidone oraltablet extendedrelease 24hr 1.5 mg,3 mg, 6 mg

2 MO

paliperidone oraltablet extendedrelease 24hr 9 mg

5 MO

paroxetine hcl oraltablet

1 MO

paroxetine hcl oraltablet extendedrelease 24 hr

2 MO


Limitsparoxetine mesylate(menop.sym)

2 MO

PAXIL ORALSUSPENSION

4 MO

pentobarbital sodiuminjection solution

2

perphenazine 2 MOperphenazine-amitriptyline

2 PA, MO

phenelzine 2 MOpimozide 2 MOprocentra 2 MOprotriptyline 2 MOquetiapine oral tablet 2 MOquetiapine oral tabletextended release 24hr

2 MO

REXULTI 5 MORISPERDAL CONSTAINTRAMUSCULARSYRINGE 12.5 MG/2ML, 25 MG/2 ML

3 MO

RISPERDAL CONSTAINTRAMUSCULARSYRINGE 37.5 MG/2ML, 50 MG/2 ML

5 MO

risperidone oralsolution

2 MO

risperidone oral tablet 1 MOrisperidone oral tablet,disintegrating

2 MO

SAPHRIS (BLACKCHERRY)

4 MO

seconal sodium 2 PA



Limitssertraline oralconcentrate

2 MO

sertraline oral tablet 1 MOtemazepam 2 PA, MOthioridazine 2 MOthiothixene 1 MOtranylcypromine 2 MOtrazodone 1 MOtriazolam 2 PA, MOtrifluoperazine 2 MOtrimipramine 2 PA, MOTRINTELLIX 4 ST, MOvenlafaxine oralcapsule,extendedrelease 24hr

2 MO

venlafaxine oral tablet 2 MOvenlafaxine oral tabletextended release24hr 150 mg, 37.5mg, 75 mg

2 MO

VENLAFAXINE ORALTABLET EXTENDEDRELEASE 24HR 225MG (BRAND)

4 MO

VERSACLOZ 5VIIBRYD ORALTABLET

4 ST, MO

VIIBRYD ORALTABLETS,DOSEPACK 10 MG (7)- 20MG (23)

4 ST, MO

VRAYLAR ORALCAPSULE

5 MO


LimitsVRAYLAR ORALCAPSULE,DOSEPACK

4 MO

XYREM 5 PA, MO, LAzaleplon 2 MO, QL (30 per

30 days)zenzedi oral tablet 10mg, 5 mg

2 MO

ZENZEDI ORALTABLET 15 MG, 2.5MG, 20 MG, 30 MG,7.5 MG (BRAND)

4 MO

ziprasidone hcl 2 MOzolpidem oral tablet 2 MO, QL (30 per

30 days)zolpidem oral tablet,ext releasemultiphase


zolpidem sublingual 2 MO, QL (30 per30 days)

ZYPREXARELPREVV

4 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIARRHYTHMIC AGENTSDrug Name Tier Requirements/

Limitsadenosine 2amiodaroneintravenous solution

2 B/D PA, MO, HI

amiodaroneintravenous syringe

2 B/D PA, HI

amiodarone oral 2 MOdisopyramidephosphate oralcapsule

2 MO

dofetilide 2 MOflecainide 2 MOibutilide fumarate 2 MOlidocaine (pf) in d7.5w 2 MOlidocaine (pf)intravenous solution

2 MO, HI

lidocaine (pf)intravenous syringe

2 HI

lidocaine in 5 % 2dextrose (pf)intravenousparenteral solution 4mg/ml (0.4 %), 8 mg/ml (0.8 %)

mexiletine 2 MOMULTAQ 4 MOpacerone oral tablet100 mg, 200 mg, 400

2 MO

mgprocainamide injectionsolution 100 mg/ml

2 MO, HI

procainamide injectionsolution 500 mg/ml

2 HI

propafenone oralcapsule,extendedrelease 12 hr

2 MO

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIARRHYTHMIC AGENTS(continued)Drug Name Tier Requirements/

Limitspropafenone oraltablet

2 MO

quinidine gluconateinjection

2 MO, HI

quinidine gluconateoral tablet extended

2 MO

releasequinidine sulfate oraltablet

2 MO

sorine oral tablet 120 2 MOmg, 160 mg, 80 mg

sorine oral tablet 240 2mg

sotalol af 2 MOsotalol oral 2 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIHYPERTENSIVE THERAPYDrug Name Tier Requirements/

Limitsacebutolol 1 MOafeditab cr oral tabletextended release

1 MO

amiloride 1 MOamiloride-hydrochlorothiazide

1 MO

amlodipine 1 MOamlodipine-benazepril 1 MOamlodipine-olmesartan

1 MO

amlodipine-valsartan 1 MOamlodipine-valsartan-hcthiazid

1 MO

atenolol 1 MOatenolol-chlorthalidone 1 MObenazepril 1 MObenazepril-hydrochlorothiazide

1 MO

betaxolol oral 1 MObisoprolol fumarate 1 MObisoprolol-hydrochlorothiazide

1 MO

bumetanide injection 2 MO, HIbumetanide oral 1 MOcandesartan 1 MOcandesartan-hydrochlorothiazid

1 MO

captopril 1 MOcaptopril-hydrochlorothiazide

1 MO

cartia xt oral capsule,extended release24hr

1 MO

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIHYPERTENSIVETHERAPY (continued)Drug Name Tier Requirements/

Limitscarvedilol 1 MOcarvedilol phosphateoral capsule, ermultiphase 24 hr

1 MO

chlorothiazide 1 MOchlorothiazide sodium 2 MO, HIchlorthalidone oraltablet 25 mg, 50 mg

1 MO

clonidine (pf) epiduralsolution 1,000mcg/10 ml (100 mcg/ml)

2

clonidine hcl oraltablet

1 MO

clonidine transdermal 2 MODEMSER 5 MOdiltiazem hclintravenous

2 HI

diltiazem hcl oralcapsule, extendedrelease

1 MO

diltiazem hcl oralcapsule,ext releasedegradable

1 MO

diltiazem hcl oralcapsule,extendedrelease 12 hr

1 MO

diltiazem hcl oralcapsule,extendedrelease 24hr

1 MO

diltiazem hcl oraltablet

1 MO

diltiazem hcl oraltablet extendedrelease 24 hr

1 MO



Limitsdilt-xr oral capsule,extrelease degradable

1 MO

doxazosin 1 MOenalapril maleate 1 MOenalaprilat intravenoussolution

2

enalapril-hydrochlorothiazide

1 MO

eplerenone 1 MOepoprostenol (glycine) 2 B/D PA, MOeprosartan 1 MOesmolol intravenoussolution

2

ethacrynate sodium 5 HIethacrynic acid 5 MOfelodipine oral tabletextended release 24hr

1 MO

fosinopril 1 MOfosinopril-hydrochlorothiazide

1 MO

furosemide injection 2 MO, HIfurosemide oralsolution 10 mg/ml, 40mg/5 ml (8 mg/ml)

1 MO

furosemide oral tablet 1 MOguanfacine oral tablet 1 MOhydralazine injection 2 MO, HIhydralazine oral 1 MOhydrochlorothiazide 1 MOindapamide 1 MOirbesartan 1 MO


Limitsirbesartan-hydrochlorothiazide

1 MO

isradipine 1 MOlabetalol intravenoussolution

2 MO, HI

labetalol intravenoussyringe 20 mg/4 ml (5mg/ml)

2 HI

labetalol oral 1 MOlisinopril 1 MOlisinopril-hydrochlorothiazide

1 MO

losartan 1 MOlosartan-hydrochlorothiazide

1 MO

mannitol 20 % 2mannitol 25 %intravenous solution

2 MO

matzim la oral tabletextended release 24hr

1 MO

methyclothiazide 1 MOmethyldopa 1 MOmethyldopa-hydrochlorothiazide

1 MO

methyldopate 2 HImetolazone 1 MOmetoprolol succinateoral tablet extendedrelease 24 hr

1 MO

metoprolol ta-hydrochlorothiaz

1 MO

metoprolol tartrateintravenous solution

2 MO, HI



Limitsmetoprolol tartrateintravenous syringe

2

metoprolol tartrate oraltablet

1 MO

minoxidil oral 1 MOmoexipril 1 MOmoexipril-hydrochlorothiazide

1 MO

nadolol 1 MOnadolol-bendroflumethiazide

1 MO

nicardipineintravenous solution

2 HI

nicardipine oral 1 MOnifedipine oral capsule 1 MOnifedipine oral tabletextended release

1 MO

nifedipine oral tabletextended release24hr

1 MO

nimodipine 1 MOnisoldipine oral tabletextended release 24hr

1 MO

olmesartan 1 MOolmesartan-amlodipin-hcthiazid

1 MO

olmesartan-hydrochlorothiazide

1 MO

ORENITRAM ORALTABLET EXTENDEDRELEASE 0.125 MG

3 PA, MO


LimitsORENITRAM ORALTABLET EXTENDEDRELEASE 0.25 MG,1 MG, 2.5 MG, 5 MG

5 PA, MO

osmitrol 15 % 2osmitrol 20 % 2perindopril erbumine 1 MOphenoxybenzamine 5 MOphentolamine injectionrecon soln

2

pindolol 1 MOprazosin 1 MOpropranololintravenous

2 HI

propranolol oralcapsule,extendedrelease 24 hr

1 MO

propranolol oralsolution

1 MO

propranolol oral tablet 1 MOpropranolol-hydrochlorothiazid

1 MO

quinapril 1 MOquinapril-hydrochlorothiazide

1 MO

ramipril 1 MOREMODULIN 5 PA, MO, HI, LAspironolactone 1 MOspironolacton-hydrochlorothiaz

1 MO

taztia xt oral capsule,extended release

1 MO

TEKTURNA 3 MOTEKTURNA HCT 3 MO



Limitstelmisartan 1 MOtelmisartan-amlodipine 1 MOtelmisartan-hydrochlorothiazid

1 MO

terazosin 1 MOtimolol maleate oral 1 MOtorsemide oral 1 MOtrandolapril 1 MOtrandolapril-verapamiloral tablet, ir - er,biphasic 24hr

1 MO

triamterene-hydrochlorothiazid

1 MO

UPTRAVI 5 PA, MO, LAvalsartan 1 MOvalsartan-hydrochlorothiazide

1 MO

veletri 2 B/D PA, MOverapamil intravenoussolution

2 MO, HI

verapamil intravenoussyringe

2 HI

verapamil oralcapsule, 24 hr erpellet ct

1 MO

verapamil oralcapsule,ext rel.pellets 24 hr

1 MO

verapamil oral tablet 1 MOverapamil oral tabletextended release

1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: CARDIACGLYCOSIDESDrug Name Tier Requirements/

Limitsdigitek 1 MOdigox 1 MOdigoxin injectionsolution

2 MO, HI

digoxin oral solution50 mcg/ml

2 MO

digoxin oral tablet 1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:COAGULATION THERAPYDrug Name Tier Requirements/

Limitsaminocaproic acidintravenous

2 MO

aspirin-dipyridamoleoral capsule, ermultiphase 12 hr

2 MO

BEVYXXA 3 QL (43 per 180days)

BRILINTA 4 MOcilostazol 2 MOclopidogrel 1 MOdipyridamoleintravenous

2

dipyridamole oral 2 MOELIQUIS 3 MOenoxaparinsubcutaneoussolution


enoxaparinsubcutaneoussyringe 100 mg/ml,150 mg/ml


enoxaparinsubcutaneoussyringe 120 mg/0.8ml, 80 mg/0.8 ml


enoxaparinsubcutaneoussyringe 30 mg/0.3 ml






fondaparinuxsubcutaneoussyringe 10 mg/0.8 ml


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsfondaparinuxsubcutaneoussyringe 2.5 mg/0.5 ml


fondaparinuxsubcutaneoussyringe 5 mg/0.4 ml


fondaparinuxsubcutaneoussyringe 7.5 mg/0.6 ml


hep flush-10 (pf) MB MOheparin (porcine) in5 % dex intravenous

2 HI

parenteral solution12,500 unit/250 ml

heparin (porcine) in5 % dex intravenous

2 HI

parenteral solution20,000 unit/500 ml(40 unit/ml)

heparin (porcine) in5 % dex intravenous

2 MO, HI

parenteral solution25,000 unit/250 ml(100 unit/ml), 25,000unit/500 ml (50 unit/ml)

heparin (porcine) innacl (pf)

2

heparin (porcine)injection cartridge

2 MO, HI

heparin (porcine)injection solution

2 MO, HI

heparin (porcine)injection syringe5,000 unit/ml

2 MO, HI

heparin flush(porcine)-0.9nacl

MB MO

heparin lock flush MB MO


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsheparin lock flush(porcine) intravenoussolution

MB MO

heparin lockflush(porcine)(pf)

MB MO

heparin(porcine) in0.45% naclintravenousparenteral solution25,000 unit/250 ml,25,000 unit/500 ml

2 MO

heparin, porcine (pf)injection

2 MO

heparin, porcine (pf)intravenous syringe 1unit/ml

MB

heparin, porcine (pf)intravenous syringe10 unit/ml, 100 unit/ml

MB MO

jantoven 1 MONPLATE 3 MOpentoxifylline oraltablet extendedrelease

2 MO

PRADAXA 4 MOprasugrel 2 MOPRAXBIND 5PROMACTA 5 MO, LAprotamine 2tranexamic acidintravenous

2 MO, HI

warfarin 1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: LIPID/CHOLESTEROL LOWERINGAGENTSDrug Name Tier Requirements/

Limitsamlodipine-atorvastatin

1 MO

atorvastatin 1 MO, QL (30 per30 days)

cholestyramine (withsugar)

1 MO

cholestyramine light 1 MOcolesevelam 2 MOcolestipol 1 MOezetimibe 1 MO, QL (30 per

30 days)ezetimibe-simvastatin 1 MO, QL (30 per

30 days)fenofibrate micronized 1 MOfenofibratenanocrystallized

1 MO

FENOFIBRATE ORALCAPSULE (BRAND)

3 MO

fenofibrate oral tablet 1 MOfenofibric acid 1 MOfenofibric acid(choline) oralcapsule,delayedrelease(dr/ec)

1 MO

fluvastatin oralcapsule 20 mg


fluvastatin oralcapsule 40 mg


fluvastatin oral tabletextended release 24hr


gemfibrozil 1 MOJUXTAPID 5 PA, MO, LAKYNAMRO 5 PA, MO, LA


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: LIPID/CHOLESTEROLLOWERING AGENTS (continued)Drug Name Tier Requirements/

Limitslovastatin oral tablet10 mg


lovastatin oral tablet20 mg, 40 mg


niacin oral tablet 2 MOextended release 24hr

omega-3 acid ethyl 2 MOesters

PRALUENT PENSUBCUTANEOUSPEN INJECTOR 150


MG/MLPRALUENT PENSUBCUTANEOUSPEN INJECTOR 75


MG/MLpravastatin 1 MO, QL (30 per

30 days)prevalite 1 MOREPATHA 5 PA, MO, QL (3

per 30 days)REPATHAPUSHTRONEX

5 PA, MO, QL (3.5per 30 days)

REPATHASURECLICK


rosuvastatin 1 MO, QL (30 per30 days)

simvastatin 1 MO, QL (30 per30 days)

triklo 2 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:MISCELLANEOUSCARDIOVASCULAR AGENTSDrug Name Tier Requirements/

Limitscardioplegic soln 2CORLANOR 3 PA, MOdobutamine 2 B/D PAdobutamine in d5wintravenous

2 B/D PA, MO

parenteral solution1,000 mg/250 ml(4,000 mcg/ml)

dobutamine in d5wintravenous

2 B/D PA

parenteral solution250 mg/250 ml (1mg/ml), 500 mg/250ml (2,000 mcg/ml)

dopamine in 5 %dextrose intravenous

2 B/D PA

solution 200 mg/250ml (800 mcg/ml), 400mg/250 ml (1,600mcg/ml), 400 mg/500ml (800 mcg/ml), 800mg/500 ml (1,600mcg/ml)

dopamine in 5 %dextrose intravenous

2 B/D PA, MO

solution 800 mg/250ml (3,200 mcg/ml)

dopamine intravenoussolution 200 mg/5 ml(40 mg/ml), 800mg/10 ml (80 mg/ml),800 mg/5 ml (160mg/ml)

2 B/D PA

dopamine intravenoussolution 400 mg/10ml (40 mg/ml), 400mg/5 ml (80 mg/ml)

2 B/D PA, MO


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: MISCELLANEOUSCARDIOVASCULAR AGENTS(continued)Drug Name Tier Requirements/

LimitsENTRESTO 3 PA, MO, QL (60

per 30 days)isoproterenol hcl 2milrinone 2 B/D PA, MOmilrinone in 5 %dextrose

2 B/D PA, MO

norepinephrinebitartrate

2

RANEXA 3 MOsodium nitroprusside 2VECAMYL 5

CARDIOVASCULAR,HYPERTENSION / LIPIDS: NITRATESDrug Name Tier Requirements/

Limitsisosorbide dinitrateoral tablet

2 MO

isosorbide dinitrateoral tablet extendedrelease

2

isosorbidemononitrate oraltablet

1 MO

isosorbidemononitrate oraltablet extendedrelease 24 hr

1 MO

nitro-bid 2 MOnitroglycerin in 5 %dextrose intravenoussolution 100 mg/250ml (400 mcg/ml), 200mg/500 ml (400 mcg/ml), 50 mg/250 ml(200 mcg/ml), 50mg/500 ml (100 mcg/ml)

2 B/D PA

nitroglycerin in 5 %dextrose intravenoussolution 25 mg/250ml (100 mcg/ml)

2 B/D PA, MO

nitroglycerinintravenous

2 B/D PA, HI

nitroglycerin oralcapsule, extendedrelease

2

nitroglycerinsublingual

2 MO

nitroglycerintransdermal patch 24hour

2 MO

nitroglycerintranslingual spray,non-aerosol

2 MO


DERMATOLOGICALS/TOPICALTHERAPY: ANTIPSORIATIC /ANTISEBORRHEICDrug Name Tier Requirements/

Limitsacitretin oral capsule10 mg

2 MO

acitretin oral capsule17.5 mg, 25 mg

5 MO

calcipotriene 2 MOcalcipotriene-betamethasone

2 MO

calcitrene 2 MOcalcitriol topical 2 MOCOSENTYX 5 PA, MOCOSENTYX (2SYRINGES)

5 PA, MO

COSENTYX PEN 5 PA, MOCOSENTYX PEN (2PENS)

5 PA, MO

selenium sulfide 2 MOtopical lotion

STELARAINTRAVENOUS

5 PA, MO, HI

STELARASUBCUTANEOUS

5 PA, MO

DERMATOLOGICALS/TOPICALTHERAPY: BURN THERAPYDrug Name Tier Requirements/

Limitssilver sulfadiazine 2 MOssd 2 MO

DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALSDrug Name Tier Requirements/

Limitsammonium lactate 2 MOCONDYLOX 3 MOTOPICAL GEL

diclofenac sodium 5 MOtopical gel 3 %

doxepin topical 2 MODUPIXENT 5 PA, MOFLUOROURACIL 5 MOTOPICAL CREAM0.5 % (BRAND)

fluorouracil topicalcream 5 %

2 MO

fluorouracil topicalsolution

2 MO

imiquimod 2 MOmethoxsalen 5 MOPANRETIN 5 MOpodofilox 2 MOprudoxin 2 MOREGRANEX 5 MOtacrolimus topical 2 PA, MOUVADEX 3VALCHLOR 5 MO


DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNEDrug Name Tier Requirements/

Limitsadapalene topical 2 PA, MOcream

adapalene topical gel 2 PA, MOadapalene topical gelwith pump

2 PA, MO

adapalene-benzoylperoxide

2 PA, MO

amnesteem 2 MOavita topical cream 2 PA, MOclaravis 2 MOclindacin etz topicalswab

2 MO

clindacin p 2 MOclindamycinphosphate topical

2 MO

clindamycin-benzoylperoxide

2 MO

clindamycin-tretinoin 2 PA, MOdapsone topical 2 MOery pads 2 MOerygel 2 MOerythromycin withethanol

2 MO

erythromycin-benzoylperoxide

2 MO

FABIOR 4 MOisotretinoin 2metronidazole topical 2 MOmyorisan oral capsule10 mg, 20 mg, 40 mg

2 MO

myorisan oral capsule30 mg

2

neuac 2 MOrosadan topical cream 2 MO

DERMATOLOGICALS/TOPICALHERAPY: THERAPY FOR ACNE

continued)rug Name Tier Requirements/

Limitssadan topical gel 2 MOzarotene 2 PA, MO

AZORAC TOPICALCREAM 0.05 %

4 PA, MO

AZORAC TOPICALGEL

4 PA, MO

etinoin microspheres 2 PA, MOetinoin topical 2 PA, MOenatane 2 MO

T(D

rotaT

T

trtrz


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICSDrug Name Tier Requirements/

Limitsbupivacaine 2 MObupivacaine (pf)injection solution0.25 % (2.5 mg/ml),0.5 % (5 mg/ml)

2 MO

bupivacaine (pf)injection solution0.75 % (7.5 mg/ml)

2

bupivacaine-epinephrine (pf)

2

bupivacaine-epinephrine injectionsolution0.25 %-1:200,000

2

bupivacaine-epinephrine injectionsolution0.5 %-1:200,000

2 MO

carbocaine (pf)injection solution 15mg/ml (1.5 %)

2

chloroprocaine (pf) 2glydo 2 MOlidocaine (pf) injectionsolution 10 mg/ml(1 %), 20 mg/ml(2 %), 40 mg/ml(4 %)

2 MO

lidocaine (pf) injectionsolution 15 mg/ml(1.5 %)

2 HI

lidocaine (pf) injectionsolution 5 mg/ml(0.5 %)

2 MO, HI

lidocaine hcl injectionsolution 10 mg/ml(1 %), 5 mg/ml(0.5 %)

2 MO, HI

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICS(continued)Drug Name Tier Requirements/

Limitslidocaine hcl injectionsolution 20 mg/ml(2 %)

2 MO, HI

lidocaine hcllaryngotracheal

2 MO

lidocaine hcl mucousmembrane jelly

2 MO

lidocaine hcl mucousmembrane jelly inapplicator

2 MO

lidocaine hcl mucousmembrane solution4 % (40 mg/ml)

2 MO

lidocaine topicaladhesive patch,medicated

2 PA, MO

lidocaine topicalointment

2 MO

lidocaine viscous 2 MOlidocaine-epinephrineinjection solution0.5 %-1:200,000,1.5 %-1:200,000,2 %-1:200,000

2

lidocaine-epinephrineinjection solution1 %-1:100,000,2 %-1:100,000

2 MO

lidocaine-prilocainetopical cream

2 MO

marcaine (pf) injectionsolution 0.75 % (7.5mg/ml)

2

polocaine injectionsolution 1 % (10 mg/ml)

2

polocaine-mpf 2


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICS(continued)Drug Name Tier Requirements/

Limitsropivacaine (pf)injection solution

2

sensorcaine injectionsolution 0.5 % (5 mg/ml)

2 MO

sensorcaine/epinephrine

2

sensorcaine-mpfinjection solution0.5 % (5 mg/ml)

2

xylocaine dental-epinephrine

2

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALANTIBACTERIALSDrug Name Tier Requirements/

Limitsgentamicin topical 2 MOmafenide acetate 2 MOmupirocin 2 MOmupirocin calcium 2 MOsulfacetamide sodium 2 MO(acne)

SULFAMYLON 3 MOTOPICAL CREAM

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIFUNGALSDrug Name Tier Requirements/

Limitsciclodan 2 MOciclopirox 2 MOclotrimazole topical 2 MOclotrimazole- 2 MObetamethasone

econazole 2 MOketoconazole topical 2 MOLUZU 4 MOnaftifine 2 MOnyamyc 2 MOnystatin topical 2 MOnystatin-triamcinolone 2 MOnystop 2 MOoxiconazole 2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIVIRALSDrug Name Tier Requirements/

Limitsacyclovir topical 2 MODENAVIR 3 MOZOVIRAX TOPICAL 5 MOCREAM


DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDSDrug Name Tier Requirements/

Limitsala-cort topical cream 2 MOalclometasone 2 MOamcinonide topicalcream

2 MO

amcinonide topicallotion

2 MO

amcinonide topicalointment

2

apexicon e 2 MObetamethasonedipropionate

2 MO

betamethasonevalerate

2 MO

betamethasone,augmented

2 MO

clobetasol 2 MOclobetasol-emollient 2 MOclodan 2 MOdesonide 2 MOdesoximetasone 2 MOdiflorasone 2 MOfluocinolone 2 MOfluocinolone andshower cap

2 MO

fluocinonide 2 MOfluocinonide-e 2 MOfluocinonide-emollient 2flurandrenolide 2 MOfluticasone topical 2 MOhalobetasolpropionate

2 MO

hydrocortisonebutyrate

2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDS (continued)Drug Name Tier Requirements/

Limitshydrocortisone butyr-emollient

2 MO

hydrocortisone topicalcream 1 %, 2.5 %

2 MO

hydrocortisone topicallotion 2.5 %

2 MO

hydrocortisone topicalointment 1 %, 2.5 %

2 MO

hydrocortisonevalerate

2 MO

hydrocortisone-minoil-wht pet

2 MO

mometasone topical 2 MOnolix topical cream 2nolix topical lotion 2 MOprednicarbate 2 MOtriamcinoloneacetonide topicalaerosol

2 MO

triamcinoloneacetonide topicalcream

2 MO

triamcinoloneacetonide topicallotion

2 MO

triamcinoloneacetonide topicalointment 0.025 %,0.1 %, 0.5 %

2 MO

trianex 2 MOtriderm topical cream0.1 %

2 MO

triderm topical cream0.5 %

2


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ENZYMESDrug Name Tier Requirements/

LimitsSANTYL 3 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL SCABICIDES /PEDICULICIDESDrug Name Tier Requirements/

Limitslindane topicalshampoo

2 MO

malathion 2 MOpermethrin topical 2 MOcream

DIAGNOSTICS / MISCELLANEOUSAGENTS: ANTIDOTESDrug Name Tier Requirements/

Limitsacetylcysteineintravenous

2 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: IRRIGATING SOLUTIONSDrug Name Tier Requirements/

Limitslactated ringersirrigation

2 MO

neomycin-polymyxin b 2 MOgu

ringer's irrigation 2 MOSORBITOL 3IRRIGATION

tis-u-sol pentalyte 2 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsacamprosate oraltablet,delayedrelease (dr/ec)

2 MO

acetic acid irrigation 2 MOADAGEN 5 MOalendronate oral tablet40 mg


anagrelide 2 MOARALAST NPINTRAVENOUS

5 PA, MO, HI, LA

RECON SOLN 1,000MG

ARALAST NPINTRAVENOUS

5 PA, MO, HI, LA

RECON SOLN 500MG

bacteriostatic water MB(parabens)

bd pre-filled normalsaline

MB MO

BUPHENYL ORAL 5 MOTABLET

bupivacaine-dextrose-water(pf)

2

caffeine citrate 2intravenous

caffeine citrate oral 2 MOCARBAGLU 5 MO, LAcevimeline 2 MOCHEMET 3 MOCLINIMIX 4.25%/D5WSULFIT FREE

4 B/D PA, HI

CLINIMIX E 2.75%/D10W SUL FREE

4 B/D PA, HI


DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUS AGENTS(continued)Drug Name Tier Requirements/

LimitsCLINIMIX E 2.75%/D5W SULF FREE

4 B/D PA, HI

CLINIMIX N9G20E2.75%-D10W(SF)

4 B/D PA, HI

d10 %-0.45 % sodiumchloride

2 HI

d2.5 %-0.45 % sodiumchloride

2 HI

d5 % and 0.9 %sodium chloride

2 MO, HI

d5 %-0.45 % sodiumchloride

2 MO, HI

deferoxamine 2 MOdextrose 10 % and0.2 % nacl

2 HI

dextrose 10 % inwater (d10w)

2 MO, HI


2


2


2


2

dextrose 5 % in water(d5w) intravenousparenteral solution

2 MO, HI

dextrose 5 % in water(d5w) intravenouspiggyback

2 MO, HI

dextrose 5 %-lactatedringers

2 MO, HI

dextrose 5%-0.2 %sod chloride

2 HI


Limitsdextrose 5%-0.3 %sod.chloride

2 HI

dextrose 50 % inwater (d50w)intravenousparenteral solution

2 MO

dextrose 50 % inwater (d50w)intravenous syringe

2


2 MO

dextrose with sodiumchloride

2 HI

disulfiram 2 MOetidronate disodium 2 MOEXJADE 5 MO, LAFERRIPROX ORALSOLUTION

5

FERRIPROX ORALTABLET

5 MO

GLASSIA 5 PA, MO, HI, LAINCRELEX 5 PA, MO, LAJADENU 5 MOJADENU SPRINKLE 5 MOkionex 2 MOkionex (with sorbitol) 2 MOlanthanum oral tablet,chewable

2 MO

levocarnitine (withsugar)

2 MO

levocarnitine oraltablet

2 MO

lmd 10 % in 0.9 %sodium chlor

2



Limitslmd 10 % in 5 %dextrose

2

midodrine 2 MOmonoject 0.9%sodium chloride

MB

monoject prefilladvanced ns

MB MO

monoject prefill salineflush

MB

normal saline flush MB MONORTHERA 5 MOORFADIN ORALCAPSULE 10 MG, 2MG, 5 MG

5 LA

ORFADIN ORALCAPSULE 20 MG

5 MO

ORFADIN ORALSUSPENSION

5 MO, LA

pilocarpine hcl oral 2 MOPROLASTIN-CINTRAVENOUSRECON SOLN

5 PA, HI, LA

PROLASTIN-CINTRAVENOUSSOLUTION

5 PA, MO, HI, LA

RAVICTI 5 MOriluzole 2 MOrisedronate oral tablet30 mg


sevelamer carbonateoral powder in packet

5 MO

sevelamer carbonateoral tablet

2 MO

sodium benzoate-sodphenylacet

2


Limitssodium chlor 0.9%bacteriostat

MB

sodium chloride 0.9 %injection solution

MB

sodium chloride 0.9 %injection syringe

MB MO

sodium chloride 0.9 %intravenousparenteral solution

2 MO, HI

sodium chloride 0.9 %intravenouspiggyback

2 MO, HI

sodium chlorideirrigation

2 MO

sodium phenylbutyrate 5 MOsodium polystyrene(sorb free)

2 MO

sodium polystyrenesulfonate oral

2 MO

sodium polystyrenesulfonate rectalenema 30 gram/120ml

2

sps (with sorbitol) oral 2 MOsps (with sorbitol)rectal

2

SYPRINE 5 MOsyrex sodium chloride0.9 %

MB

THIOLA 5 MOtrientine 5 MOVELTASSA 4 MOwater for inject,bacteriostat

MB



Limitswater for irrigation,sterile

2 MO

XURIDEN 5 MOzoledronic acid-mannitol-water

2 MO, HI

DIAGNOSTICS / MISCELLANEOUSAGENTS: SMOKING DETERRENTSDrug Name Tier Requirements/

Limitsbupropion hcl(smoking deter) oraltablet extendedrelease

2 MO

CHANTIX 3 MOCHANTIXCONTINUINGMONTH BOX

3 MO

CHANTIX STARTINGMONTH BOX

3 MO

NICOTROL 3 MONICOTROL NS 3 MO

EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsazelastine nasal 2 MO, QL (60 per

30 days)chlorhexidinegluconate mucousmembrane

2 MO

denta 5000 plus 2 MOdentagel 2 MOipratropium bromidenasal spray,non-aerosol 0.03 %


ipratropium bromidenasal spray,non-aerosol 42 mcg(0.06 %)


olopatadine nasal 2 MO, QL (30.5per 30 days)

oralone 2 MOparoex oral rinse 2 MOperiogard 2 MOsf 2 MOsf 5000 plus 2 MOtriamcinoloneacetonide dental

2 MO


EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSOTIC PREPARATIONSDrug Name Tier Requirements/

Limitsacetic acid otic (ear) 2 MOciprofloxacin hcl otic(ear)

2 MO

floxin otic (ear) drops 2fluocinolone acetonide 2 MOoil

hydrocortisone-aceticacid

2 MO

ofloxacin otic (ear) 2 MO

EAR, NOSE / THROATMEDICATIONS: OTIC STEROID /ANTIBIOTICDrug Name Tier Requirements/

LimitsCIPRODEX 3 MOneomycin-polymyxin-hc otic (ear)

2 MO

ENDOCRINE/DIABETES: ADRENALHORMONESDrug Name Tier Requirements/

Limitsa-hydrocort 2 MObetamethasone acet, 2 MOsod phos

cortisone 2 MOdecadron 2deltasone oral tablet20 mg

2 B/D PA, MO

dexamethasone 2 MOintensol

dexamethasone oral 2 MOelixir

dexamethasone oral 2 MOsolution

dexamethasone oral 1 MOtablet

dexamethasone 2 MOsodium phos (pf)

dexamethasone 2 MO, HIsodium phosphateinjection solution 10mg/ml

dexamethasone 2 MOsodium phosphateinjection solution 4mg/ml

dexamethasone 2 MOsodium phosphateinjection syringe

fludrocortisone 2 MOhydrocortisone oral 2 MOmethylprednisolone 2 MOacetate

methylprednisoloneoral tablet

1 B/D PA, MO

methylprednisoloneoral tablets,dose

1 MO

pack


ENDOCRINE/DIABETES: ADRENALHORMONES (continued)Drug Name Tier Requirements/

Limitsmethylprednisolonesodium succ injectionrecon soln 125 mg,40 mg

2 MO, HI

methylprednisolonesodium succintravenous

2 MO, HI

millipred dp 1 MOmillipred oral tablet 1 B/D PA, MOprednisolone oralsolution 15 mg/5 ml

2 MO

prednisolone sodiumphosphate oralsolution 10 mg/5 ml,15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml(5 mg/ml), 5 mgbase/5 ml (6.7 mg/5ml)

2 MO

prednisolone sodiumphosphate oral tablet,disintegrating

2 B/D PA, MO

prednisone intensol 2 B/D PA, MOprednisone oralsolution

2 MO

prednisone oral tablet 1 B/D PA, MOprednisone oraltablets,dose pack

1 MO

RAYOS 5 B/D PA, MOtriamcinoloneacetonide injection

2 MO

veripred 20 2 MO

ENDOCRINE/DIABETES:ANTITHYROID AGENTSDrug Name Tier Requirements/

Limitsmethimazole oraltablet 10 mg, 5 mg

2 MO

propylthiouracil 1 MO


ENDOCRINE/DIABETES: DIABETESTHERAPYDrug Name Tier Requirements/

Limitsacarbose 1 MOACCU-CHEK AVIVAPLUS TEST STRIP

MB MO, QL (300 per30 days)

ACCU-CHEK BLOODGLUCOSE METERS

MB QL (1 per 365days)

ACCU-CHEKCOMPACT PLUSTEST STRIP


ACCU-CHEK GUIDETEST STRIP


ACCU-CHEKSMARTVIEW TESTSTRIP


ACCUTRENDGLUCOSE TESTSTRIP


ALCOHOL PADS 3 MOAVANDIA ORAL 4 MOTABLET 2 MG, 4 MG

BYDUREON 3 MO, QL (4 per28 days)

BYDUREON BCISE 3 MO, QL (3.4 per30 days)

BYETTASUBCUTANEOUSPEN INJECTOR 10

3 MO, QL (2.4 per30 days)

MCG/DOSE(250MCG/ML) 2.4 ML

BYETTASUBCUTANEOUSPEN INJECTOR 5


MCG/DOSE (250MCG/ML) 1.2 ML

chlorpropamide 1 MOCYCLOSET 4 MOFARXIGA 3 MOGAUZE PADS 2 X 2 3 MO

ENDOCRINE/DIABETES: DIABETESERAPY (continued)

ug Name Tier Requirements/Limits

mepiride 1 MOpizide oral tablet 1 MOpizide oral tabletxtended release

1 MO

4hrpizide-metformin 1 MOUCAGEN 3 MOYPOKITUCAGON 3 MOMERGENCY KITUMAN)buride 1 MOburide micronized 1 MOburide-metformin 1 MOYXAMBI 4 MOMALOG JUNIOR 3 MO

WIKPEN U-100MALOG KWIKPEN 3 MOSULINMALOG MIX 50-50 3 MOSULN U-100MALOG MIX 50-50 3 MO

WIKPENMALOG MIX 75-25 3 MO

WIKPENMALOG MIX 75-25 3 MO-100)INSULNMALOG U-100 3 MOSULINMULIN 70/30

-100 INSULIN3 MO

MULIN 70/30-100 KWIKPEN

3 MO

MULIN N NPH 3 MOSULIN KWIKPEN

THDr

gligliglie2

gliGLH

GLE(H

glyglyglyGLHUK

HUIN

HUIN

HUK

HUK

HU(U

HUIN

HUU

HUU

HUIN


ENDOCRINE/DIABETES: DIABETESTHERAPY (continued)Drug Name Tier Requirements/

LimitsHUMULIN N NPHU-100 INSULIN

3 MO

HUMULIN RREGULAR U-100INSULN

3 MO

HUMULIN R U-500(CONC) INSULIN

3 MO

INPEN (FORHUMALOG)

3 QL (1 per 365days)

INSULIN PENNEEDLE

3 MO

INSULIN SYRINGE(DISP) U-100 0.3 ML

3 MO

INSULIN SYRINGE(DISP) U-100 1 ML

3 MO

INSULIN SYRINGE(DISP) U-100 1/2 ML

3 MO

INVOKAMET 4 MOINVOKAMET XR 4 MOINVOKANA 3 MOJANUMET 3 MOJANUMET XR 3 MOJANUVIA 3 MOJARDIANCE 3 MOKOMBIGLYZE XR 3 MOLANTUS SOLOSTARU-100 INSULIN

3 MO

LANTUS U-100INSULIN

3 MO

metformin oral tablet 1 MOmetformin oral tabletextended release(osm) 24hr

1 MO

metformin oral tabletextended release 24hr

1 MO


Limitsmetformin oral tablet,er gast.retention 24hr

1 MO

miglitol 1 MOnateglinide 1 MONEEDLES, INSULINDISP.,SAFETY

3 MO

ONETOUCH BLOODGLUCOSE METERS

MB QL (1 per 365days)

ONETOUCH ULTRABLUE TEST STRIP


ONETOUCH VERIOTEST STRIP


ONGLYZA 3 MOOZEMPICSUBCUTANEOUSPEN INJECTOR 0.25MG OR 0.5 MG(2MG/1.5 ML)

4 ST, MO, QL (1.5per 28 days)

OZEMPICSUBCUTANEOUSPEN INJECTOR 1MG/0.75 ML (2MG/1.5 ML)

4 ST, MO, QL (3per 28 days)

pioglitazone 1 MOpioglitazone-glimepiride

1 MO

pioglitazone-metformin

1 MO

PROGLYCEM 3 MOrepaglinide 1 MOrepaglinide-metformin 1 MOSYMLINPEN 120 5 MOSYMLINPEN 60 5 MOSYNJARDY 4 MOSYNJARDY XR 4 MO



Limitstolazamide 1 MOtolbutamide 1 MOTOUJEO MAX 3 MOSOLOSTAR

TOUJEO SOLOSTAR 3 MOU-300 INSULIN

TRULICITY 3 MO, QL (2 per28 days)

XIGDUO XR 4 MO

ENDOCRINE/DIABETES:MISCELLANEOUS HORMONESDrug Name Tier Requirements/

LimitsALDURAZYME 5 MO, HIANADROL-50 5 PA, MOcabergoline 2 MOcalcitonin (salmon) 2 MOcalcitriol intravenous 2 MO, HIsolution 1 mcg/ml

calcitriol oral capsule 1 MOcalcitriol oral solution 2 MOCERDELGA 5 MOCEREZYMEINTRAVENOUS

5 PA, MO, HI

RECON SOLN 400UNIT

CHORIONICGONADOTROPIN,HUMAN

3 PA, MO

clomiphene citrate 2 MOdanazol 2 MOdesmopressininjection

2 MO, HI

desmopressin nasalsolution

2

desmopressin nasalspray with pump

2 MO

desmopressin nasalspray,non-aerosol

2 MO

desmopressin oral 2 MOdoxercalciferol 2intravenous

doxercalciferol oral 2 MOELELYSO 5 MO, HIFABRAZYMEINTRAVENOUS

5 MO, HI

RECON SOLN 35MG


ENDOCRINE/DIABETES:MISCELLANEOUS HORMONES(continued)Drug Name Tier Requirements/

LimitsFABRAZYMEINTRAVENOUSRECON SOLN 5 MG

3 MO, HI

JYNARQUE 5 MOKANUMA 5 MO, HIKORLYM 5 PA, MOKUVAN 5 MOMETHITEST 3 MOmethyltestosteroneoral capsule

5 MO

MIACALCININJECTION

4 MO

miglustat 5 MOMYALEPT 5 MO, LANAGLAZYME 5 MO, HI, LANATPARA 5 PA, MO, LANOVAREL 3 PA, MOoxandrolone oraltablet 10 mg

5 PA, MO

oxandrolone oraltablet 2.5 mg

2 PA, MO

pamidronateintravenous reconsoln

2 MO, HI

pamidronateintravenous solution

2 MO, HI

PARICALCITOLHEMODIALYSISPORT INJECTION

3

paricalcitolintravenous

2 HI

PARICALCITOLINTRAVENOUSSOLUTION 2 MCG/ML (BRAND)

3 HI


LimitsPARICALCITOLINTRAVENOUSSOLUTION 5 MCG/ML (BRAND)

3 MO, HI

paricalcitol oral 2 MOPARSABIV 5 MOSAMSCA 5 MOSENSIPAR ORALTABLET 30 MG

3 MO

SENSIPAR ORALTABLET 60 MG, 90MG

5 MO

SOMAVERT 5 MOSTIMATE 3 MOSTRENSIQ 5 MO, LASYNAREL 5 MOtestosterone cypionate 2 MOtestosteroneenanthate

2 MO

testosteronetransdermal gel(generic)

2 MO

testosteronetransdermal gel inmetered-dose pump12.5 mg/ 1.25 gram(1 %) (Androgelgeneric)

2 MO

testosteronetransdermal gel inpacket (Androgelgeneric)

2 MO

testosteronetransdermal solutionin metered pump w/app (Axiron generic)

2 MO



LimitsVIMIZIM 3 MOZAVESCA 5 MO, LAzoledronic acid 2 MO, HIintravenous solution

ZOMETAINTRAVENOUS

5 MO, HI

PIGGYBACK

ENDOCRINE/DIABETES: THYROIDHORMONESDrug Name Tier Requirements/

Limitslevothyroxineintravenous recon

2 MO

soln 200 mcg, 500mcg

levothyroxine oral 1 MOlevoxyl oral tablet 100mcg, 112 mcg, 125mcg, 137 mcg, 150mcg, 175 mcg, 200mcg, 25 mcg, 50mcg, 75 mcg, 88 mcg

1 MO

liothyronineintravenous

2 MO, HI

liothyronine oral 2 MOnp thyroid 2 MOthyroid (pork) oraltablet 30 mg, 60 mg

2

thyroid (pork) oraltablet 90 mg

2 MO

unithroid 1 MO

GASTROENTEROLOGY:ANTIDIARRHEALS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsatropine injectionsyringe 0.05 mg/ml,0.1 mg/ml

2

chlordiazepoxide-clidinium

2

CUVPOSA 4 MOdicyclomineintramuscular

2 MO

dicyclomine oralcapsule

2 MO

dicyclomine oralsolution

2 MO

dicyclomine oral tablet 2 MOdiphenoxylate-atropine

2 MO

glycopyrrolateinjection

2 MO

glycopyrrolate oraltablet 1 mg, 2 mg

2 MO

loperamide oralcapsule

2 MO

methscopolamine 2 MOMYTESI 3 MOopium tincture 2 MOparegoric 2 MOpropantheline 2 MO


GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTSDrug Name Tier Requirements/

Limitsalosetron 5 MO, QL (60 per

30 days)AMITIZA 3 MO, QL (60 per

30 days)aprepitant 2 B/D PA, MObalsalazide 2 MObudesonide oral 5 MOcapsule,delayed,extend.release

CHOLBAM 5 MOCIMZIA 5 PA, MO, QL (3

per 28 days)CIMZIA POWDER 5 PA, MO, QL (1FOR RECONST per 28 days)

CIMZIA STARTER KIT 5 PA, MO, QL (3per 28 days)

CINVANTI 3 HIcolocort 2 MOcompro 2 MOconstulose 2 MOCREON ORAL 3 MOCAPSULE,DELAYEDRELEASE(DR/EC)12,000-38,000 -60,000UNIT,24,000-76,000 -120,000UNIT, 3,000-9,500-15,000 UNIT,6,000-19,000 -30,000UNIT

CREON ORAL 5 MOCAPSULE,DELAYEDRELEASE(DR/EC)36,000-114,000-180,000 UNIT

cromolyn oral 2 MO

GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTS(continued)Drug Name Tier Requirements/

LimitsCYSTADANE 5 MOdimenhydrinateinjection solution

2 MO

DIPENTUM 5 MOdronabinol oralcapsule 10 mg

5 B/D PA, MO

dronabinol oralcapsule 2.5 mg, 5 mg

2 B/D PA, MO

droperidol injectionsolution

2 MO

EMEND(FOSAPREPITANT)

3 MO, HI

EMEND ORALSUSPENSION FOR

3 B/D PA, MO

RECONSTITUTIONENTYVIO 3 MOenulose 2 MOGATTEX 30-VIAL 5 PA, MOGATTEX ONE-VIAL 5 PA, MOgavilyte-c 2 MOgavilyte-g 2 MOgavilyte-n 2 MOgenerlac 2 MOgranisetron (pf)intravenous solution

2 MO, HI

1 mg/ml (1 ml)granisetron (pf)intravenous solution

2 HI

100 mcg/mlgranisetron hclintravenous

2 MO, HI

granisetron hcl oral 2 B/D PA, MOhydrocortisone rectal 2 MO



Limitshydrocortisone topicalcream with perinealapplicator

2 MO

hydrocortisone-pramoxine rectalcream 1-1 %

2 MO

INFLECTRA 5 PA, MO, HIlactulose 2 MOLINZESS 3 MO, QL (30 per

30 days)meclizine oral tablet12.5 mg, 25 mg

2 MO

mesalamine oraltablet,delayedrelease (dr/ec) 1.2gram

2 MO

mesalamine rectal 2 MOmetoclopramide hclinjection solution

2 MO, HI

metoclopramide hclinjection syringe

2 HI

metoclopramide hcloral solution

2 MO

metoclopramide hcloral tablet

1 MO

metoclopramide hcloral tablet,disintegrating

2 MO

OCALIVA 5 MO, LA, QL (30per 30 days)

ondansetron hcl (pf) 2 MO, HIondansetron hclintravenous

2 MO

ondansetron hcl oralsolution

2 B/D PA, MO


Limitsondansetron hcl oraltablet 24 mg

2 B/D PA

ondansetron hcl oraltablet 4 mg, 8 mg

2 B/D PA, MO

ondansetron oraltablet,disintegrating

2 B/D PA, MO

OSMOPREP 4 MOpalonosetronintravenous solution0.25 mg/5 ml

2 MO

peg 3350-electrolytesoral recon soln236-22.74-6.74 -5.86gram

2 MO

peg 3350-electrolytesoral recon soln240-22.72-6.72 -5.84gram

2

peg-electrolyte 2PENTASA ORALCAPSULE,EXTENDEDRELEASE 250 MG

3 MO

PENTASA ORALCAPSULE,EXTENDEDRELEASE 500 MG

5 MO

polyethylene glycol3350

2 MO

prochlorperazine 2 MOprochlorperazineedisylate injectionsolution 10 mg/2 ml(5 mg/ml)

2 MO

prochlorperazinemaleate oral

1 MO



Limitsprocto-med hc 2 MOprocto-pak 2 MOproctosol hc topical 2 MOproctozone-hc 2 MORECTIV 4 MORELISTOR ORAL 5 MORELISTORSUBCUTANEOUSSOLUTION

5 MO

RELISTORSUBCUTANEOUSSYRINGE

5 MO

REMICADE 5 PA, MO, HIRENFLEXIS 5 PA, MO, HIscopolamine base 2 MOSUCRAID 5 MOsulfasalazine oraltablet

2 MO

sulfasalazine oraltablet,delayedrelease (dr/ec)

2 MO

SYNDROS 5 B/D PA, MOtrilyte with flavorpackets

2 MO

trimethobenzamideoral

2 B/D PA, MO

UCERIS ORAL 5 MOUCERIS RECTAL 4 MOursodiol 2 MOVARUBIINTRAVENOUS

3

VARUBI ORAL 3 B/D PA, MO


LimitsZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)10,000-32,000 -42,000UNIT,10,000-34,000 -55,000UNIT,15,000-51,000 -82,000UNIT, 20,000-63,000-84,000 UNIT,25,000-85,000-136,000 UNIT,3,000-10,000- 16,000UNIT,5,000-17,000 -27,000UNIT

3 MO

ZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)15,000-47,000 -63,000UNIT

3

ZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)25,000-79,000-105,000 UNIT,40,000-126,000-168,000 UNIT,5,000-17,000- 24,000UNIT

5 MO

ZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)3,000-10,000 -14,000-UNIT

3


GASTROENTEROLOGY: ULCERTHERAPYDrug Name Tier Requirements/

Limitsamoxicil-clarithromy-lansopraz

2 MO

CARAFATE ORAL 3 MOSUSPENSION

cimetidine 2 MOcimetidine hcl oral 2 MOesomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 20 mg


esomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 40 mg


esomeprazole sodiumintravenous recon

2 HI

soln 20 mgesomeprazole sodiumintravenous recon

2 MO, HI

soln 40 mgfamotidine (pf) 2 MO, HIfamotidine (pf)-nacl(iso-os)

2 MO, HI

famotidine intravenous 2 MO, HIsolution

famotidine oral 2 MOsuspension

famotidine oral tablet 1 MO20 mg, 40 mg

lansoprazole oralcapsule,delayedrelease(dr/ec) 15 mg


lansoprazole oralcapsule,delayedrelease(dr/ec) 30 mg


lansoprazole oraltablet,disintegrat,delay rel

2 MO

GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitsmisoprostol 2 MOnizatidine 2 MOomeppi oral capsule20-1.1 mg-gram


omeppi oral capsule40-1.1 mg-gram


omeprazole oralcapsule,delayedrelease(dr/ec) 10 mg


omeprazole oralcapsule,delayedrelease(dr/ec) 20 mg,40 mg


omeprazole-sodiumbicarbonate oralcapsule 20-1.1 mg-


gramomeprazole-sodiumbicarbonate oralcapsule 40-1.1 mg-


gramomeprazole-sodiumbicarbonate oralpacket 20-1,680 mg


omeprazole-sodiumbicarbonate oralpacket 40-1,680 mg


pantoprazoleintravenous

2 MO, HI

pantoprazole oraltablet,delayedrelease (dr/ec) 20 mg


pantoprazole oraltablet,delayedrelease (dr/ec) 40 mg


rabeprazole oraltablet,delayedrelease (dr/ec)



GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitsranitidine hcl injectionsolution 25 mg/ml

2 MO, HI

ranitidine hcl injectionsolution 50 mg/2 ml(25 mg/ml)

2 MO, HI

ranitidine hcl oral 1 MOcapsule

ranitidine hcl oral 2 MOsyrup

ranitidine hcl oral 1 MOtablet 150 mg, 300mg

sucralfate oral tablet 2 MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGSDrug Name Tier Requirements/

LimitsACTIMMUNE 5 PA, MOARCALYST 5 MOAVONEX (WITHALBUMIN)


AVONEXINTRAMUSCULARPEN INJECTOR KIT


AVONEXINTRAMUSCULARSYRINGE KIT


GRANIX 5 MOHUMATROPE 5 PA, MOILARIS (PF)SUBCUTANEOUS

5 PA, MO, LA

SOLUTIONINTRON AINJECTION RECON

3 PA, MO

SOLN 10 MILLIONUNIT (1 ML)

INTRON AINJECTION RECON

5 PA, MO

SOLN 18 MILLIONUNIT (1 ML), 50MILLION UNIT (1ML)

INTRON AINJECTION

3 PA, MO

SOLUTIONLEUKINE INJECTIONRECON SOLN

5 MO, HI

MOZOBIL 5 MONEULASTA 5 MO, QL (1.2 per

30 days)NEUPOGENINJECTIONSOLUTION 300


MCG/ML


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsNEUPOGENINJECTIONSOLUTION 480MCG/1.6 ML


NEUPOGENINJECTIONSYRINGE 300MCG/0.5 ML


NEUPOGENINJECTIONSYRINGE 480MCG/0.8 ML


OMNITROPE 5 PA, MOPEGASYSPROCLICK


PEGASYSSUBCUTANEOUSSOLUTION


PEGASYSSUBCUTANEOUSSYRINGE


PEGINTRONSUBCUTANEOUSKIT 50 MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 125MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 63MCG/0.5 ML- 94MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSSYRINGE 125MCG/0.5 ML



LimitsPLEGRIDYSUBCUTANEOUSSYRINGE 63MCG/0.5 ML- 94MCG/0.5 ML


PROCRIT INJECTIONSOLUTION 10,000UNIT/ML, 2,000UNIT/ML, 20,000UNIT/2 ML, 3,000UNIT/ML, 4,000UNIT/ML


PROCRIT INJECTIONSOLUTION 20,000UNIT/ML


PROCRIT INJECTIONSOLUTION 40,000UNIT/ML


PROLEUKIN 5 PA, MO, HIREBIF (WITHALBUMIN)


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR 22MCG/0.5 ML, 44MCG/0.5 ML


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR8.8MCG/0.2ML-22MCG/0.5ML (6)


REBIF TITRATIONPACK


SEROSTIMSUBCUTANEOUSRECON SOLN 4 MG,5 MG, 6 MG

5 PA, MO

SYLATRON 5 MO



LimitsZARXIO INJECTIONSYRINGE 300MCG/0.5 ML


ZARXIO INJECTIONSYRINGE 480MCG/0.8 ML


ZORBTIVE 5 PA, MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALSDrug Name Tier Requirements/

LimitsACTHIB (PF) 3 MOADACEL(TDAPADOLESN/ADULT)(PF)

3 MO

AFLURIA 2017-2018 MBAFLURIA 2017-2018 MB MO(PF)

AFLURIA QUAD2017-2018

MB

AFLURIA QUAD2017-2018 (PF)

MB

BCG VACCINE, LIVE(PF)

3 MO

BEXSERO 3 MOBOOSTRIX TDAP 3 MOBOTOX 4 PA, MODAPTACEL (DTAPPEDIATRIC) (PF)

3 MO

DYSPORT 4 PA, MOENGERIX-B (PF) 3 B/D PA, MOENGERIX-BPEDIATRIC (PF)INTRAMUSCULAR

3 B/D PA, MO

SYRINGEFLUAD 2017-2018 (65YR UP)(PF)

MB MO

FLUARIX QUAD2017-2018 (PF)

MB MO

FLUBLOK 2017-2018 MB MO(PF)

FLUBLOK QUAD2017-2018 (PF)

MB

FLUCELVAX QUAD2017-2018

MB


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALS (continued)Drug Name Tier Requirements/

LimitsFLUCELVAX QUAD2017-2018 (PF)

MB MO

FLULAVAL QUAD2017-2018

MB

FLULAVAL QUAD2017-2018 (PF)

MB MO

FLUMIST QUAD2017-2018

MB

FLUVIRIN 2017-2018 MBFLUVIRIN 2017-2018(PF)

MB MO

FLUZONE HIGH-DOSE 2017-18 (PF)

MB MO

FLUZONEINTRADERM QUAD2017-18

MB

FLUZONE QUAD2017-2018

MB

FLUZONE QUAD2017-2018 (PF)INTRAMUSCULARSUSPENSION

MB

FLUZONE QUAD2017-2018 (PF)INTRAMUSCULARSYRINGE

MB MO

FLUZONE QUADPEDI 2017-18 (PF)

MB

fomepizole 2 HIGAMASTAN S/D 3 MOGAMMAGARDLIQUID

5 PA, MO, HI

GAMMAGARD S-D(IGA < 1 MCG/ML)

5 PA, MO, HI


LimitsGAMUNEX-CINJECTIONSOLUTION 1GRAM/10 ML (10 %)

5 PA, MO, HI

GAMUNEX-CINJECTIONSOLUTION 10GRAM/100 ML(10 %), 2.5 GRAM/25ML (10 %), 20GRAM/200 ML(10 %), 40GRAM/400 ML(10 %), 5 GRAM/50ML (10 %)

5 PA, MO, HI

GARDASIL 9 (PF) 3 MOGRASTEK 4 MOHAVRIX (PF)INTRAMUSCULARSUSPENSION

3 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 1,440ELISA UNIT/ML

3 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 720 ELISAUNIT/0.5 ML

3

HIBERIX (PF) 3 MOHYPERRAB (PF) 3HYPERRAB S/D (PF) 3IMOVAX RABIESVACCINE (PF)

3 MO

INFANRIX (DTAP)(PF)

3 MO

IPOL 3 MO



LimitsIXIARO (PF) 3 MOKINRIX (PF)INTRAMUSCULARSUSPENSION

3

KINRIX (PF)INTRAMUSCULARSYRINGE

3 MO

MENACTRA (PF)INTRAMUSCULARSOLUTION

3 MO

MENVEO A-C-Y-W-135-DIP (PF)

3 MO

M-M-R II (PF) 3 MOORALAIRSUBLINGUALTABLET 300 INDXREACTIVITY

3 MO

PEDIARIX (PF) 3 MOPEDVAX HIB (PF) 3 MOPENTACEL (PF) 3 MOPNEUMOVAX 23 MB MOPREVNAR 13 (PF) MB MOPROQUAD (PF) 3 MOQUADRACEL (PF) 3 MORABAVERT (PF) 3 MORAGWITEK 4RECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION

3 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 10 MCG/ML

3 B/D PA, MO


LimitsRECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 5 MCG/0.5ML

3 B/D PA

ROTARIX 3ROTATEQ VACCINE 3 MOSHINGRIX (PF) 3 MOSTAMARIL (PF) 3TENIVAC (PF) 3 MOTETANUS,DIPHTHERIA TOXPED(PF)

3 MO

TETANUS-DIPHTHERIATOXOIDS-TD

3 MO

TICE BCG 3 MOTRUMENBA 3 MOTWINRIX (PF)INTRAMUSCULARSYRINGE

3 MO

TYPHIM VIINTRAMUSCULARSOLUTION

3

TYPHIM VIINTRAMUSCULARSYRINGE

3 MO

VAQTA (PF) 3 MOVARIVAX (PF) 3 MOVARIZIGINTRAMUSCULARSOLUTION

5 MO



LimitsXEOMININTRAMUSCULAR

4 PA, MO

RECON SOLN 100UNIT, 50 UNIT

XEOMININTRAMUSCULAR

5 PA, MO

RECON SOLN 200UNIT

YF-VAX (PF) 3 MOZINPLAVA 5 PA, MO, HIZOSTAVAX (PF) 3 MO

MUSCULOSKELETAL /RHEUMATOLOGY: GOUT THERAPYDrug Name Tier Requirements/

Limitsallopurinol 1 MOallopurinol sodium 2 HIaloprim 2 HICOLCHICINE ORAL 3 MOTABLET

COLCRYS 3 MOKRYSTEXXA 4 MOprobenecid 2 MOprobenecid-colchicine 2 MOULORIC 4 MOZURAMPIC 4 MO

MUSCULOSKELETAL /RHEUMATOLOGY: OSTEOPOROSISTHERAPYDrug Name Tier Requirements/

Limitsalendronate oralsolution


alendronate oral tablet10 mg, 5 mg


alendronate oral tablet35 mg, 70 mg


FORTEO 5 PA, MO, QL (2.4per 28 days)

ibandronate 2 MOintravenous

ibandronate oral 2 MO, QL (1 per30 days)

PROLIA 4 PA, MOraloxifene 2 MOrisedronate oral tablet150 mg


risedronate oral tablet35 mg, 35 mg (12pack), 35 mg (4pack)


risedronate oral tablet5 mg


risedronate oral tablet,delayed release (dr/ec)


TYMLOS 5 PA, MO, QL(1.56 per 30days)


MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALSDrug Name Tier Requirements/

LimitsACTEMRAINTRAVENOUS

5 PA, MO, HI

ACTEMRASUBCUTANEOUS

5 PA, MO

BENLYSTAINTRAVENOUS

5 MO, HI

BENLYSTA 5 MOSUBCUTANEOUS

CUPRIMINE 5 MODEPEN TITRATABS 5 MOENBREL MINI 5 PA, MO, QL (8

per 28 days)ENBRELSUBCUTANEOUSRECON SOLN


ENBRELSUBCUTANEOUSSYRINGE


ENBREL SURECLICK 5 PA, MO, QL (8per 28 days)

HUMIRA PEDIATRICCROHN'S START


HUMIRA PEN 5 PA, MO, QL (6per 30 days)

HUMIRA PENCROHN'S-UC-HSSTART


HUMIRA PENPSORIASIS-UVEITIS


HUMIRASUBCUTANEOUSSYRINGE KIT 10


MG/0.1 ML, 10MG/0.2 ML, 20MG/0.4 ML, 40MG/0.4 ML, 40MG/0.8 ML

MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsHUMIRASUBCUTANEOUSSYRINGE KIT 20


MG/0.2 MLKEVZARASUBCUTANEOUS

5 PA, MO

SYRINGEKINERET 5 PA, MOleflunomide 2 MO, QL (30 per

30 days)ORENCIA 5 PA, MOORENCIA (WITHMALTOSE)

5 PA, MO, HI

ORENCIACLICKJECT

5 PA, MO

OTEZLA 5 PA, MO, QL (60per 30 days)

OTEZLA STARTERORAL TABLETS,DOSE PACK 10 MG


(4)-20 MG (4)-30 MG(47)

RIDAURA 5 MOSIMPONI ARIA 5 PA, MO, HISIMPONISUBCUTANEOUSPEN INJECTOR 100


MG/MLSIMPONISUBCUTANEOUSPEN INJECTOR 50


MG/0.5 MLSIMPONISUBCUTANEOUSSYRINGE 100 MG/ML



MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsSIMPONISUBCUTANEOUSSYRINGE 50 MG/0.5ML


OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINSDrug Name Tier Requirements/

Limitsamabelz 2 MOcamila 2 MOdeblitane 2 MOerrin 2 MOESTRACE VAGINAL 3 MOestradiol 2 MOestradiol valerateintramuscular oil 20mg/ml, 40 mg/ml

2 MO

estradiol-norethindrone acet

2 MO

estropipate 2 MOfyavolv 2 MOheather 2 MOhydroxyprogesteronecaproate

5 MO

jencycla 2 MOjevantique lo 2 MOjinteli 2 MOjolivette 2 MOlopreeza 2 MOlyza 2 MOMAKENA 5 MOMAKENA (PF) 5 MOmedroxyprogesterone 2 MOmimvey 2 MOmimvey lo 2 MOnora-be 2 MOnorethindrone(contraceptive)

2 MO

norethindrone acetate 2 MO


OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINS(continued)Drug Name Tier Requirements/

Limitsnorethindrone ac-eth 2 MOestradiol oral tablet0.5-2.5 mg-mcg, 1-5mg-mcg

norlyda 2 MOnorlyroc 2PREMARIN 4 MO, HIINJECTION

progesterone 2 MOprogesterone in oil 2 MOprogesterone 2 MOmicronized

sharobel 2 MOtulana 2yuvafem 2 MO

OBSTETRICS / GYNECOLOGY:MISCELLANEOUS OB/GYNDrug Name Tier Requirements/

LimitsCLEOCIN VAGINAL 3 MOSUPPOSITORY

clindamycinphosphate vaginal

2 MO

GYNAZOLE-1 4 MOLUPANETA PACK (1MONTH)

5 MO

LUPANETA PACK (3MONTH)

5 MO

metronidazole vaginal 2 MOmiconazole-3 vaginalsuppository

2 MO

terconazole 2 MOtranexamic acid oral 2 MOvandazole 2 MOxulane 2 MO


OBSTETRICS / GYNECOLOGY:ORAL CONTRACEPTIVES /RELATED AGENTSDrug Name Tier Requirements/

Limitsaltavera (28) 2 MOalyacen 1/35 (28) 2 MOalyacen 7/7/7 (28) 2 MOamethia 2 MOamethia lo 2 MOamethyst 2 MOapri 2 MOaranelle (28) 2 MOashlyna 2 MOaubra 2 MOaviane 2 MOazurette (28) 2 MObalziva (28) 2 MObekyree (28) 2 MOblisovi 24 fe 2 MOblisovi fe 1.5/30 (28) 2 MOblisovi fe 1/20 (28) 2 MObriellyn 2 MOcamrese 2 MOcamrese lo 2 MOcaziant (28) 2 MOchateal 2 MOcryselle (28) 2 MOcyclafem 1/35 (28) 2 MOcyclafem 7/7/7 (28) 2 MOcyred 2 MOdasetta 1/35 (28) 2 MOdasetta 7/7/7 (28) 2 MOdaysee 2 MOdelyla (28) 2

OBSTETRICS / GYNECOLOGY: ORALCONTRACEPTIVES / RELATEDAGENTS (continued)Drug Name Tier Requirements/

Limitsdesog-e.estradiol/e.estradiol

2 MO

desogestrel-ethinylestradiol

2

drospirenone-e.estradiol-lm.fa

2 MO

drospirenone-ethinylestradiol

2 MO

elinest 2 MOELLA 3emoquette 2 MOenpresse 2 MOenskyce 2 MOestarylla 2 MOethynodiol diac-ethestradiol

2

falmina (28) 2 MOfayosim 2 MOfemynor 2 MOgianvi (28) 2 MOintrovale 2 MOisibloom 2 MOjolessa 2 MOjuleber 2 MOjunel 1.5/30 (21) 2 MOjunel 1/20 (21) 2 MOjunel fe 1.5/30 (28) 2 MOjunel fe 1/20 (28) 2 MOjunel fe 24 2 MOkaitlib fe 2 MOkariva (28) 2 MOkelnor 1/35 (28) 2 MO



Limitskelnor 1-50 2 MOkimidess (28) 2 MOkurvelo 2 MOl norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month0.10 mg-20 mcg(84)/10 mcg (7), 0.15mg-30 mcg (84)/10mcg (7)

2 MO

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month0.15 mg-20 mcg/0.15 mg-25 mcg

2

larin 1.5/30 (21) 2 MOlarin 1/20 (21) 2 MOlarin 24 fe 2 MOlarin fe 1.5/30 (28) 2 MOlarin fe 1/20 (28) 2 MOlarissia 2 MOlayolis fe 2 MOleena 28 2 MOlessina 2 MOlevonest (28) 2 MOlevonorgestrel-ethinylestrad

2 MO

levonorg-eth estradtriphasic

2 MO

levora-28 2 MOlillow 2 MOloryna (28) 2 MOlow-ogestrel (28) 2 MOlutera (28) 2 MO


Limitsmarlissa 2 MOmelodetta 24 fe 2 MOmibelas 24 fe 2 MOmicrogestin 1.5/30(21)

2 MO

microgestin 1/20 (21) 2 MOmicrogestin fe 1.5/30(28)

2 MO

microgestin fe 1/20(28)

2 MO

mili 2mono-linyah 2 MOmononessa (28) 2 MOmyzilra 2 MOnecon 0.5/35 (28) 2 MOnecon 7/7/7 (28) 2 MOnikki (28) 2 MOnoreth-ethinylestradiol-iron

2 MO

norethindrone ac-ethestradiol oral tablet1-20 mg-mcg

2 MO

norethindrone-e.estradiol-iron

2 MO

norgestimate-ethinylestradiol

2 MO

nortrel 0.5/35 (28) 2 MOnortrel 1/35 (21) 2 MOnortrel 1/35 (28) 2 MOnortrel 7/7/7 (28) 2 MOocella 2 MOogestrel (28) 2 MOorsythia 2 MO



Limitsphilith 2 MOpimtrea (28) 2 MOpirmella 2 MOportia 2 MOprevifem 2 MOquasense 2 MOrajani 2 MOreclipsen (28) 2 MOrivelsa 2 MOsetlakin 2 MOsprintec (28) 2 MOsronyx 2 MOsyeda 2 MOtarina fe 1/20 (28) 2 MOtilia fe 2 MOtri femynor 2 MOtri-estarylla 2 MOtri-legest fe 2 MOtri-linyah 2 MOtri-lo-estarylla 2 MOtri-lo-marzia 2 MOtri-lo-sprintec 2 MOtri-mili 2trinessa (28) 2 MOtrinessa lo 2 MOtri-previfem (28) 2 MOtri-sprintec (28) 2 MOtrivora (28) 2 MOtri-vylibra 2tydemy 2 MO


Limitsvelivet triphasicregimen (28)

2 MO

vestura (28) 2 MOvienva 2 MOviorele (28) 2 MOvyfemla (28) 2 MOvylibra 2wera (28) 2 MOwymzya fe 2 MOzarah 2 MOzenchent (28) 2 MOzovia 1/35e (28) 2 MOzovia 1/50e (28) 2 MO

OBSTETRICS / GYNECOLOGY:OXYTOCICSDrug Name Tier Requirements/

Limitsmethergine 2methylergonovineinjection

2

methylergonovine oral 2 MOoxytocin injectionsolution

2 MO


OPHTHALMOLOGY: ANTIBIOTICSDrug Name Tier Requirements/

Limitsak-poly-bac 2 MObacitracin ophthalmic(eye)

2 MO

bacitracin-polymyxin bophthalmic (eye)

2 MO

ciprofloxacin hclophthalmic (eye)

2 MO

erythromycinophthalmic (eye)

1 MO

gatifloxacin 2 MOgentak ophthalmic(eye) ointment

1 MO

gentamicin ophthalmic(eye) drops

1 MO

levofloxacin 2 MOophthalmic (eye)

moxifloxacin 2 MOophthalmic (eye)

NATACYN 3 MOneomycin-bacitracin-polymyxin

2 MO

neomycin-polymyxin-gramicidin

2 MO

neo-polycin 2 MOofloxacin ophthalmic(eye)

2 MO

polycin 2 MOpolymyxin b sulf-trimethoprim

1 MO

tobramycin 1 MO

OPHTHALMOLOGY: ANTIVIRALSDrug Name Tier Requirements/

Limitstrifluridine 2 MOZIRGAN 4 MO

OPHTHALMOLOGY: BETA-BLOCKERSDrug Name Tier Requirements/

Limitsbetaxolol ophthalmic(eye)

2 MO

carteolol 1 MOlevobunolol 1 MOophthalmic (eye)drops 0.5 %

metipranolol 2timolol maleate 1 MOophthalmic (eye)drops

timolol maleate 2 MOophthalmic (eye)drops, once daily

timolol maleate 1 MOophthalmic (eye) gelforming solution

OPHTHALMOLOGY:CHOLINESTERASE INHIBITORMIOTICSDrug Name Tier Requirements/

LimitsPHOSPHOLINE 3 MOIODIDE


OPHTHALMOLOGY: CYCLOPLEGICMYDRIATICSDrug Name Tier Requirements/

Limitsatropine ophthalmic(eye) drops

2 MO

OPHTHALMOLOGY: DIRECT ACTINGMIOTICSDrug Name Tier Requirements/

Limitspilocarpine hclophthalmic (eye)drops 1 %, 2 %, 4 %

1 MO

OPHTHALMOLOGY:MISCELLANEOUSOPHTHALMOLOGICSDrug Name Tier Requirements/

Limitsazelastine ophthalmic(eye)

2 MO

balanced salt 2bss 2 MOcromolyn ophthalmic(eye)

2 MO

CYSTARAN 5 MOepinastine 2 MOLACRISERT 3 MOolopatadineophthalmic (eye)

2 MO

RESTASIS 3 MO, QL (60 per30 days)

RESTASISMULTIDOSE


OPHTHALMOLOGY: NON-STEROIDAL ANTI-INFLAMMATORYAGENTSDrug Name Tier Requirements/

Limitsbromfenac 2 MOdiclofenac sodium 2 MOophthalmic (eye)

flurbiprofen sodium 2 MOketorolac ophthalmic(eye)

2 MO

OPHTHALMOLOGY: ORAL DRUGSFOR GLAUCOMADrug Name Tier Requirements/

Limitsacetazolamide oral 2 MOcapsule, extendedrelease

acetazolamide oral 2 MOtablet

acetazolamide sodium 2 MO, HImethazolamide 2 MO

OPHTHALMOLOGY: OTHERGLAUCOMA DRUGSDrug Name Tier Requirements/

Limitsbimatoprostophthalmic (eye)

2 MO

dorzolamide 2 MOdorzolamide-timolol 2 MOlatanoprost 2 MOmiostat 2TRAVATAN Z 3 MO


OPHTHALMOLOGY: STEROID-ANTIBIOTIC COMBINATIONSDrug Name Tier Requirements/

Limitsneomycin-bacitracin-poly-hc

2 MO

neomycin-polymyxinb-dexameth

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

2 MO

neo-polycin hc 2 MOtobramycin-dexamethasone

2 MO

OPHTHALMOLOGY: STEROIDSDrug Name Tier Requirements/

Limitsdexamethasone 2 MOsodium phosphateophthalmic (eye)

fluorometholone 2 MOFML S.O.P. 3 MOPRED MILD 3 MOprednisolone acetate 2 MOprednisolone sodiumphosphateophthalmic (eye)

2 MO

OPHTHALMOLOGY: STEROID-SULFONAMIDE COMBINATIONSDrug Name Tier Requirements/

LimitsBLEPHAMIDE 4 MOBLEPHAMIDE S.O.P. 4 MOsulfacetamide- 2 MOprednisolone

OPHTHALMOLOGY:SULFONAMIDESDrug Name Tier Requirements/

Limitssulfacetamide sodium 1 MOophthalmic (eye)drops

sulfacetamide sodium 2 MOophthalmic (eye)ointment

OPHTHALMOLOGY:SYMPATHOMIMETICSDrug Name Tier Requirements/

Limitsapraclonidine 2 MObrimonidine 1 MO


RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTSDrug Name Tier Requirements/

Limitsadrenalin injection 2carbinoxaminemaleate oral liquid

2 MO

carbinoxaminemaleate oral tablet 4mg

2 MO

carbinoxaminemaleate oral tablet 6mg

2

cetirizine oral solution1 mg/ml

2 MO

clemastine oral tablet2.68 mg

2 MO

cyproheptadine 2 MOdesloratadine oraltablet

2 MO

desloratadine oraltablet,disintegrating

2 MO

diphenhydramine hclinjection solution 50mg/ml

2 MO, HI

diphenhydramine hclinjection syringe

2 MO, HI

diphenhydramine hcloral elixir

2 PA

EPINEPHRINEINJECTION AUTO-INJECTOR 0.15MG/0.15 ML, 0.3MG/0.3 ML(ADRENACLICK)

4 MO

EPINEPHRINEINJECTION AUTO-INJECTOR 0.15MG/0.3 ML, 0.3MG/0.3 ML (EPIPEN)

3 MO

EPIPEN 3 MO

RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTS (continued)Drug Name Tier Requirements/

LimitsEPIPEN 2-PAK 3 MOEPIPEN JR 3 MOEPIPEN JR 2-PAK 3 MOhydroxyzine hclintramuscular

2 MO

hydroxyzine hcl oralsolution 10 mg/5 ml

2 PA, MO

hydroxyzine hcl oraltablet

2 PA, MO

hydroxyzine pamoate 2 PA, MOlevocetirizine oralsolution

2 MO

levocetirizine oraltablet

2 MO

phenadoz 2 MOphenergan rectal 2promethazine injectionsolution

2 MO

promethazine oral 2 PA, MOpromethazine rectalsuppository 12.5 mg,25 mg

2 MO

promethazine rectalsuppository 50 mg

2

promethegan 2 MO


RESPIRATORY AND ALLERGY:PULMONARY AGENTSDrug Name Tier Requirements/

Limitsacetylcysteine 2 B/D PA, MOADCIRCA 5 PA, MOADEMPAS 5 PA, MO, LAADVAIR DISKUS 4 PA, MO, QL (60

per 30 days)ADVAIR HFA 4 PA, MO, QL (24

per 30 days)albuterol sulfateinhalation solution for

2 B/D PA, MO

nebulizationalbuterol sulfate oral 2 MOsyrup

albuterol sulfate oral 2 MOtablet

albuterol sulfate oral 2 MOtablet extendedrelease 12 hr

aminophyllineintravenous solution

2 HI

250 mg/10 mlaminophyllineintravenous solution

2 HI

500 mg/20 mlANORO ELLIPTA 3 MO, QL (60 per

30 days)ARCAPTANEOHALER


ARNUITY ELLIPTAINHALATIONBLISTER WITH


DEVICE 100 MCG/ACTUATION, 200MCG/ACTUATION

ARNUITY ELLIPTAINHALATIONBLISTER WITH


DEVICE 50 MCG/ACTUATION

RESPIRATORY AND ALLERGY:PULMONARY AGENTS (continued)Drug Name Tier Requirements/

LimitsATROVENT HFA 3 MO, QL (38.7

per 30 days)BEVESPIAEROSPHERE

3 MO, QL (10.7per 30 days)

BROVANA 3 B/D PA, MObudesonide inhalation 2 B/D PA, MOCINRYZE 5 MO, HICOMBIVENTRESPIMAT


cromolyn inhalation 2 B/D PA, MODALIRESP 3 MODULERA 3 MO, QL (26 per

30 days)ESBRIET 5 PA, MOFASENRA 5 PA, MOFIRAZYR 5 MOFLOVENT DISKUS 3 MO, QL (120 per

30 days)FLOVENT HFAAEROSOL INHALER110 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER220 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER44 MCG/ACTUATION

3 MO, QL (21.2per 30 days)

flunisolide nasal spray,non-aerosol 25 mcg(0.025 %)


fluticasone nasal 2 MO, QL (32 per30 days)

HYPER-SAL MB MO



LimitsINCRUSE ELLIPTA 3 MO, QL (30 per

30 days)ipratropium bromideinhalation

2 B/D PA, MO

ipratropium-albuterol 2 B/D PA, MOKALYDECO 5 PA, MOLETAIRIS 5 PA, MO, LAlevalbuterol hcl 2 B/D PA, MOmetaproterenol 2 MOmometasone nasal 2 MO, QL (34 per

30 days)montelukast 2 MOnebusal inhalationsolution fornebulization 3 %

MB MO

NEBUSALINHALATIONSOLUTION FORNEBULIZATION 6 %(BRAND)

MB MO

NUCALA 5 PA, MO, LAOFEV 5 PA, MOOPSUMIT 5 PA, MO, LAORKAMBI 5 PA, MO, QL

(112 per 28days)

PROAIR HFA 3 MO, QL (25.5per 30 days)

PROAIR RESPICLICK 3 MO, QL (3 per30 days)

pulmosal MB MOPULMOZYME 5 B/D PA, MOREVATIO ORALSUSPENSION FORRECONSTITUTION

5 PA, MO

RUCONEST 5 MO, HI


LimitsSEREVENT DISKUS 3 MO, QL (60 per

30 days)sildenafil (pulmonaryarterial hypertension)intravenous solution10 mg/12.5 ml

5 PA, HI

sildenafil (pulmonaryarterial hypertension)oral tablet 20 mg

2 PA, MO

sodium chlorideinhalation

MB MO

SPIRIVA RESPIMAT 3 MO, QL (4 per30 days)

SPIRIVA WITHHANDIHALER


STIOLTO RESPIMAT 3 MO, QL (4 per30 days)

STRIVERDIRESPIMAT


SYMBICORT 3 MO, QL (20.4per 30 days)

terbutaline 2 MOtheophylline indextrose 5 %intravenousparenteral solution200 mg/100 ml, 200mg/50 ml, 400mg/250 ml, 400mg/500 ml, 800mg/250 ml

2

theophylline oral elixir 2theophylline oralsolution

2 MO

theophylline oral tabletextended release 12hr

2 MO



Limitstheophylline oral tabletextended release 24hr

2 MO

TRACLEER 5 PA, MO, LATYVASO 5 B/D PA, MOTYVASOINSTITUTIONALSTART KIT

5 B/D PA

TYVASO REFILL KIT 5 B/D PA, MOTYVASO STARTERKIT

5 B/D PA, MO

VENTAVIS 5 B/D PA, MOXOLAIR 5 PA, MO, LAzafirlukast 2 MOzileuton oral tablet,extended release12hr mphase

5 MO

UROLOGICALS:ANTICHOLINERGICS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsdarifenacin oral tabletextended release 24hr

2 MO

flavoxate 2 MOoxybutynin chlorideoral syrup

2 MO

oxybutynin chlorideoral tablet

2 MO

oxybutynin chlorideoral tablet extendedrelease 24hr

2 MO

tolterodine oralcapsule,extendedrelease 24hr

2 MO

tolterodine oral tablet 2 MOtrospium oral capsule,extended release24hr

2 MO

trospium oral tablet 2 MO


UROLOGICALS: BENIGNPROSTATIC HYPERPLASIA(BPH)THERAPYDrug Name Tier Requirements/

Limitsalfuzosin oral tablet 2 MOextended release 24hr

dutasteride 2 MOdutasteride-tamsulosin 2 MOoral capsule, ermultiphase 24 hr

finasteride oral tablet 2 MO5 mg

tamsulosin oral 1 MOcapsule,extendedrelease 24hr

UROLOGICALS: CHOLINERGICSTIMULANTSDrug Name Tier Requirements/

Limitsbethanechol chloride 2 MO

UROLOGICALS: MISCELLANEOUSUROLOGICALSDrug Name Tier Requirements/

Limitsalprostadil 2 MOCIALIS ORALTABLET 2.5 MG, 5MG


CYSTAGON 3 MO, LAELMIRON 3 MOglycine urologic 2glycine urologicsolution

2

potassium citrate oraltablet extended

2 MO

releasePROCYSBI 5 MO

VITAMINS, HEMATINICS /ELECTROLYTES: BLOODDERIVATIVESDrug Name Tier Requirements/

Limitsalbumin, human 25 % 2albuminar 25 % 2 MOalbuminar 5 % 2alburx (human) 25 % 2 MOalburx (human) 5 % 2albutein 25 % 2albutein 5 % 2buminate 5 % 2plasbumin 25 % 2 MOplasbumin 5 % 2


VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTESDrug Name Tier Requirements/

Limitscalcium acetate oral 2 MOcapsule

calcium acetate oral 2 MOtablet 667 mg

calcium chloride 2calcium gluconateintravenous

2 MO

effer-k oral tablet, 1 MOeffervescent 25 meq

eliphos 2 MOGLYCOPHOS 3k-effervescent 1 MOklor-con 10 oral tablet 1 MOextended release

klor-con 20 meqpacket

1 MO

klor-con 8 oral tablet 1 MOextended release

klor-con m10 oral 1 MOtablet,er particles/crystals



klor-con sprinkle oralcapsule, extendedrelease

1 MO

klor-con/ef 1 MOk-tab oral tablet 1 MOextended release 8meq

lactated ringersintravenous

2 MO, HI

VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTES(continued)Drug Name Tier Requirements/

Limitsmagnesium chlorideinjection

2 MO

magnesium sulfate inwater intravenous

2

parenteral solutionmagnesium sulfate inwater intravenous

2

piggyback 2 gram/50ml (4 %), 4 gram/50ml (8 %)

magnesium sulfate inwater intravenous

2 MO

piggyback 4gram/100 ml (4 %)

magnesium sulfateinjection solution

2 MO, HI

magnesium sulfateinjection syringe

2 HI

NORMOSOL-R 4NORMOSOL-R IN 4 HI5 % DEXTROSE

potassium acetateintravenous solution

2

2 meq/mlpotassium bicarb andchloride

1 MO

potassium bicarb-citricacid

1 MO

potassium chlorid-d5-0.45%nacl

2 HI

intravenousparenteral solution 10meq/l, 30 meq/l, 40meq/l



Limitspotassium chlorid-d5-0.45%naclintravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride in0.9%nacl intravenousparenteral solution 20meq/l, 40 meq/l

2 HI

potassium chloride in5 % dex intravenousparenteral solution 20meq/l, 40 meq/l

2 HI

potassium chloride in5 % dex intravenousparenteral solution 30meq/l

2 HI

potassium chloride inlr-d5 intravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride inlr-d5 intravenousparenteral solution 40meq/l

2 HI

potassium chloride inwater intravenouspiggyback 10meq/100 ml

2 MO, HI

potassium chloride inwater intravenouspiggyback 10 meq/50ml

2 MO, HI

potassium chloride inwater intravenouspiggyback 20meq/100 ml, 40meq/100 ml

2 HI


Limitspotassium chloride inwater intravenouspiggyback 20 meq/50ml, 30 meq/100 ml

2 HI

potassium chlorideintravenous

2 MO, HI

potassium chlorideoral capsule,extended release

1 MO

potassium chlorideoral liquid

2 MO

potassium chlorideoral packet

2 MO

potassium chlorideoral tablet extendedrelease

1 MO

potassium chlorideoral tablet,erparticles/crystals

1 MO

potassiumchloride-0.45 % nacl

2 HI

potassium chloride-d5-0.2%naclintravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride-d5-0.2%naclintravenousparenteral solution 30meq/l, 40 meq/l

2 HI


2 HI



Limitspotassium chloride-d5-0.9%naclintravenousparenteral solution 20meq/l

2 MO, HI


2 HI

potassium phosphatem-/d-basic

2

ringer's intravenous 2 HIsodium acetate 2sodium bicarbonateintravenous solution

2 MO

sodium bicarbonateintravenous syringe10 meq/10 ml(8.4 %), 7.5 % (0.9meq/ml)

2 MO

sodium bicarbonateintravenous syringe4.2 % (0.5 meq/ml),8.4 % (1 meq/ml)

2

sodium chloride0.45 % intravenousparenteral solution

2 MO, HI

sodium chloride0.45 % intravenouspiggyback

2 HI

sodium chloride 3 % 2 MO, HIsodium chloride 5 % 2 HIsodium chlorideintravenousparenteral solution2.5 meq/ml

2 MO, HI


Limitssodium chlorideintravenousparenteral solution 4meq/ml

2 MO, HI

sodium lactateintravenous

2 HI

sodium phosphate 2 MO


VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTSDrug Name Tier Requirements/

LimitsAMINOSYN 10 % 4 B/D PA, HIAMINOSYN 7 %WITH

4 B/D PA, HI

ELECTROLYTESAMINOSYN 8.5 % 4 B/D PA, HIAMINOSYN 8.5 %-ELECTROLYTES

4 B/D PA, HI

AMINOSYN II 10 % 4 B/D PA, HIAMINOSYN II 15 % 4 B/D PA, HIAMINOSYN II 7 % 4 B/D PA, HIAMINOSYN II 8.5 % 4 B/D PA, HIAMINOSYN II 8.5 %-ELECTROLYTES

4 B/D PA, HI

AMINOSYN M 3.5 % 4 B/D PA, HIAMINOSYN-HBC 7% 4 B/D PA, HIAMINOSYN-PF 10 % 4 B/D PA, HIAMINOSYN-PF 7 %(SULFITE-FREE)

4 B/D PA, HI

AMINOSYN-RF 5.2 % 4 B/D PA, HICLINIMIX 5%/D15WSULFITE FREE

4 B/D PA, HI

CLINIMIX 5%/D25WSULFITE-FREE

4 B/D PA, HI

CLINIMIX 2.75%/D5WSULFIT FREE

4 B/D PA, HI

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA, HI

CLINIMIX 4.25%-D20W SULF-FREE

4 B/D PA, HI

CLINIMIX 4.25%-D25W SULF-FREE

4 B/D PA, HI

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA, HI

VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

LimitsCLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA, HI

CLINIMIX E 4.25%/D25W SUL FREE

4 B/D PA, HI

CLINIMIX E 4.25%/D5W SULF FREE

4 B/D PA, HI

CLINIMIX E 5%/D15WSULFIT FREE

4 B/D PA, HI


4 B/D PA, HI


4 B/D PA, HI

CLINIMIX N14G30E4.25%-D15W SF

4 B/D PA, HI

CLINIMIX N9G15E2.75%-D7.5W SF

4 B/D PA, HI

cysteine (l-cysteine)intravenous solution

2 B/D PA

electrolyte-48 in d5w 2FREAMINE HBC6.9 %

4 B/D PA, HI

freamine iii 10 % 2 B/D PAHEPATAMINE 8% 4 B/D PA, HIhetastarch 6 % in 20.9 % nacl

intralipid intravenousemulsion 20 %

2 B/D PA, HI

INTRALIPIDINTRAVENOUS

4 B/D PA, HI

EMULSION 30 %NEPHRAMINE 5.4 % 4 B/D PA, HINORMOSOL-M IN 4 HI5 % DEXTROSE

NORMOSOL-R PH 4 HI7.4


VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

Limitsplasmanate 2plenamine 2 B/D PA, HIpremasol 10 % 2 B/D PA, MO, HIPREMASOL 6 % 4 B/D PA, HIPROCALAMINE 3% 4 B/D PA, HIPROSOL 20 % 4 B/D PA, MO, HISMOFLIPID 4 B/D PA, HItravasol 10 % 2 B/D PA, MO, HITROPHAMINE 10 % 4 B/D PA, MO, HITROPHAMINE 6% 4 B/D PA, HI

VITAMINS, HEMATINICS /ELECTROLYTES: VITAMINS /HEMATINICSDrug Name Tier Requirements/

Limitsfluoride (sodium) oraldrops

2 MO

fluoride (sodium) oraltablet

2 MO

fluoride (sodium) oraltablet,chewable 0.25mg(0.55 mg sod.fluoride), 0.5 mg (1.1mg sodium fluorid)

2 MO

fluoritab oral tablet,chewable 0.5 mg (1.1mg sodium fluorid)

2 MO

ludent fluoride oraltablet,chewable 0.25mg(0.55 mg sod.fluoride), 0.5 mg (1.1mg sodium fluorid)

2 MO

multi-vit with fluoride-iron

2 MO

multivitamin withfluoride

2 MO

multi-vitamin withfluoride oral drops

2 MO

multivitamins withfluoride

2 MO

multivit-fluor (vit eacetate)

2 MO

mvc-fluoride 2 MOprenatal vitamin oraltablet

2 MO

tri-vitamin with fluoride 2 MOvitamins a,c,d andfluoride

2


Index of DrugsAa-hydrocort. . . . . . . . . . . . . . . . . . . . . . . . . . . 66abacavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10abacavir-lamivudine. . . . . . . . . . . . . . . . . . . . 10abacavir-lamivudine-zidovudine. . . . . . . . . . 10ABILIFY MAINTENA. . . . . . . . . . . . . . . . . . . 42ABRAXANE. . . . . . . . . . . . . . . . . . . . . . . . . . 23acamprosate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

acarbose. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68ACCU-CHEK AVIVA PLUS TEST STRIP. . . . 68ACCU-CHEK BLOOD GLUCOSE METERS. 68ACCU-CHEK COMPACT PLUS TEST STRIP 68ACCU-CHEK GUIDE TEST STRIP. . . . . . . . 68ACCU-CHEK SMARTVIEW TEST STRIP. . . 68ACCUTREND GLUCOSE TEST STRIP. . . . 68acebutolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49acetaminophen-caff-dihydrocod oral capsule 37acetaminophen-codeine oral solution 120 mg-12mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml. . . 37

acetaminophen-codeine oral solution 120-12mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

acetaminophen-codeine oral tablet. . . . . . . . 37acetazolamide oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

acetazolamide oral tablet. . . . . . . . . . . . . . . . 90acetazolamide sodium. . . . . . . . . . . . . . . . . . 90acetic acid irrigation. . . . . . . . . . . . . . . . . . . . 62acetic acid otic (ear). . . . . . . . . . . . . . . . . . . . 66acetylcysteine. . . . . . . . . . . . . . . . . . . . . . . . . 93acetylcysteine intravenous. . . . . . . . . . . . . . . 62acitretin oral capsule 10 mg. . . . . . . . . . . . . . 57acitretin oral capsule 17.5 mg, 25 mg. . . . . . 57ACTEMRA INTRAVENOUS. . . . . . . . . . . . . . 83ACTEMRA SUBCUTANEOUS. . . . . . . . . . . . 83ACTHIB (PF). . . . . . . . . . . . . . . . . . . . . . . . . 79ACTIMMUNE. . . . . . . . . . . . . . . . . . . . . . . . . 77acyclovir oral capsule. . . . . . . . . . . . . . . . . . 10acyclovir oral suspension 200 mg/5 ml. . . . . 10acyclovir oral tablet. . . . . . . . . . . . . . . . . . . . 10

acyclovir sodium intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

acyclovir sodium intravenous solution. . . . . . 10acyclovir topical. . . . . . . . . . . . . . . . . . . . . . . 60ADACEL(TDAP ADOLESN/ADULT)(PF). . . . 79ADAGEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62adapalene topical cream. . . . . . . . . . . . . . . . 58adapalene topical gel. . . . . . . . . . . . . . . . . . . 58adapalene topical gel with pump. . . . . . . . . . 58adapalene-benzoyl peroxide. . . . . . . . . . . . . 58ADASUVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 42ADCIRCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93adefovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ADEMPAS. . . . . . . . . . . . . . . . . . . . . . . . . . . 93adenosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48adrenalin injection. . . . . . . . . . . . . . . . . . . . . 92adriamycin intravenous solution 10 mg/5 ml, 2mg/ml, 50 mg/25 ml. . . . . . . . . . . . . . . . . . . 23

adriamycin intravenous solution 20 mg/10 ml 23adrucil intravenous solution 2.5 gram/50 ml. 23adrucil intravenous solution 5 gram/100 ml. . 23adrucil intravenous solution 500 mg/10 ml. . 23ADVAIR DISKUS. . . . . . . . . . . . . . . . . . . . . . 93ADVAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 93afeditab cr oral tablet extended release. . . . . 49AFINITOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23AFINITOR DISPERZ. . . . . . . . . . . . . . . . . . . 23AFLURIA 2017-2018. . . . . . . . . . . . . . . . . . . 79AFLURIA 2017-2018 (PF). . . . . . . . . . . . . . . 79AFLURIA QUAD 2017-2018. . . . . . . . . . . . . 79AFLURIA QUAD 2017-2018 (PF). . . . . . . . . 79ak-poly-bac. . . . . . . . . . . . . . . . . . . . . . . . . . 89ala-cort topical cream. . . . . . . . . . . . . . . . . . 61ALBENZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16albumin, human 25 %. . . . . . . . . . . . . . . . . . 96albuminar 25 %. . . . . . . . . . . . . . . . . . . . . . . 96albuminar 5 %. . . . . . . . . . . . . . . . . . . . . . . . 96alburx (human) 25 %. . . . . . . . . . . . . . . . . . . 96alburx (human) 5 %. . . . . . . . . . . . . . . . . . . . 96albutein 25 %. . . . . . . . . . . . . . . . . . . . . . . . . 96albutein 5 %. . . . . . . . . . . . . . . . . . . . . . . . . . 96

103

albuterol sulfate inhalation solution fornebulization. . . . . . . . . . . . . . . . . . . . . . . . . . 93

albuterol sulfate oral syrup. . . . . . . . . . . . . . . 93albuterol sulfate oral tablet. . . . . . . . . . . . . . . 93albuterol sulfate oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

alclometasone. . . . . . . . . . . . . . . . . . . . . . . . 61ALCOHOL PADS. . . . . . . . . . . . . . . . . . . . . . 68ALDURAZYME. . . . . . . . . . . . . . . . . . . . . . . . 70ALECENSA. . . . . . . . . . . . . . . . . . . . . . . . . . 23alendronate oral solution. . . . . . . . . . . . . . . . 82alendronate oral tablet 10 mg, 5 mg. . . . . . . 82alendronate oral tablet 35 mg, 70 mg. . . . . . 82alendronate oral tablet 40 mg. . . . . . . . . . . . 62alfuzosin oral tablet extended release 24 hr. 96ALIMTA INTRAVENOUS RECON SOLN 100MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

ALIMTA INTRAVENOUS RECON SOLN 500MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

ALINIA ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 16

ALINIA ORAL TABLET. . . . . . . . . . . . . . . . . . 16ALIQOPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23allopurinol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82allopurinol sodium. . . . . . . . . . . . . . . . . . . . . 82almotriptan malate oral tablet 12.5 mg. . . . . 34almotriptan malate oral tablet 6.25 mg. . . . . 34aloprim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82alosetron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73alprazolam intensol. . . . . . . . . . . . . . . . . . . . 42alprazolam oral tablet. . . . . . . . . . . . . . . . . . 42alprazolam oral tablet extended release 24 hr 42alprazolam oral tablet,disintegrating. . . . . . . 42alprostadil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96altavera (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86ALUNBRIG. . . . . . . . . . . . . . . . . . . . . . . . . . . 23alyacen 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 86alyacen 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . 86amabelz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84amantadine hcl. . . . . . . . . . . . . . . . . . . . . . . 10AMBISOME. . . . . . . . . . . . . . . . . . . . . . . . . . . 9amcinonide topical cream. . . . . . . . . . . . . . . 61amcinonide topical lotion. . . . . . . . . . . . . . . . 61

amcinonide topical ointment. . . . . . . . . . . . . 61amethia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86amethia lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 86amethyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86amifostine crystalline. . . . . . . . . . . . . . . . . . . 23amikacin injection solution 1,000 mg/4 ml. . . 16amikacin injection solution 500 mg/2 ml. . . . 16amiloride. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49amiloride-hydrochlorothiazide. . . . . . . . . . . . 49aminocaproic acid intravenous. . . . . . . . . . . 53aminophylline intravenous solution 250 mg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

aminophylline intravenous solution 500 mg/20ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

AMINOSYN 10 %. . . . . . . . . . . . . . . . . . . . 100AMINOSYN 7 % WITH ELECTROLYTES. . 100AMINOSYN 8.5 %. . . . . . . . . . . . . . . . . . . . 100AMINOSYN 8.5 %-ELECTROLYTES. . . . . 100AMINOSYN II 10 %. . . . . . . . . . . . . . . . . . . 100AMINOSYN II 15 %. . . . . . . . . . . . . . . . . . . 100AMINOSYN II 7 %. . . . . . . . . . . . . . . . . . . . 100AMINOSYN II 8.5 %. . . . . . . . . . . . . . . . . . 100AMINOSYN II 8.5 %-ELECTROLYTES. . . . 100AMINOSYN M 3.5 %. . . . . . . . . . . . . . . . . . 100AMINOSYN-HBC 7%. . . . . . . . . . . . . . . . . . 100AMINOSYN-PF 10 %. . . . . . . . . . . . . . . . . . 100AMINOSYN-PF 7 % (SULFITE-FREE). . . . 100AMINOSYN-RF 5.2 %. . . . . . . . . . . . . . . . . 100amiodarone intravenous solution. . . . . . . . . . 48amiodarone intravenous syringe. . . . . . . . . . 48amiodarone oral. . . . . . . . . . . . . . . . . . . . . . . 48AMITIZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73amitriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . 42amitriptyline-chlordiazepoxide. . . . . . . . . . . . 42amlodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 49amlodipine-atorvastatin. . . . . . . . . . . . . . . . . 54amlodipine-benazepril. . . . . . . . . . . . . . . . . . 49amlodipine-olmesartan. . . . . . . . . . . . . . . . . 49amlodipine-valsartan. . . . . . . . . . . . . . . . . . . 49amlodipine-valsartan-hcthiazid. . . . . . . . . . . 49ammonium lactate. . . . . . . . . . . . . . . . . . . . . 57amnesteem. . . . . . . . . . . . . . . . . . . . . . . . . . 58

104

amoxapine. . . . . . . . . . . . . . . . . . . . . . . . . . . 42amoxicil-clarithromy-lansopraz. . . . . . . . . . . 76amoxicillin oral capsule. . . . . . . . . . . . . . . . . 19amoxicillin oral suspension for reconstitution 19amoxicillin oral tablet. . . . . . . . . . . . . . . . . . . 19amoxicillin oral tablet,chewable 125 mg, 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

amoxicillin-pot clavulanate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 19

amoxicillin-pot clavulanate oral tablet. . . . . . 19amoxicillin-pot clavulanate oral tablet extendedrelease 12 hr. . . . . . . . . . . . . . . . . . . . . . . . 19

amoxicillin-pot clavulanate oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 19

amphotericin b. . . . . . . . . . . . . . . . . . . . . . . . . 9ampicillin oral capsule. . . . . . . . . . . . . . . . . . 19ampicillin sodium injection recon soln 1 gram,10 gram, 125 mg. . . . . . . . . . . . . . . . . . . . . 19

ampicillin sodium injection recon soln 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 19

ampicillin sodium intravenous. . . . . . . . . . . . 19ampicillin-sulbactam injection recon soln 1.5gram, 3 gram. . . . . . . . . . . . . . . . . . . . . . . . 19

ampicillin-sulbactam injection recon soln 15gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ampicillin-sulbactam intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

ampicillin-sulbactam intravenous recon soln 3gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

AMPYRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ANADROL-50. . . . . . . . . . . . . . . . . . . . . . . . 70anagrelide. . . . . . . . . . . . . . . . . . . . . . . . . . . 62anastrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . 23anectine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36ANORO ELLIPTA. . . . . . . . . . . . . . . . . . . . . 93apexicon e. . . . . . . . . . . . . . . . . . . . . . . . . . . 61APOKYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33apraclonidine. . . . . . . . . . . . . . . . . . . . . . . . . 91aprepitant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73apri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86APTIOM ORAL TABLET 200 MG, 400 MG, 800MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

APTIOM ORAL TABLET 600 MG. . . . . . . . . 31APTIVUS ORAL CAPSULE. . . . . . . . . . . . . . 10

APTIVUS ORAL SOLUTION. . . . . . . . . . . . . 10ARALAST NP INTRAVENOUS RECON SOLN1,000 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 62

ARALAST NP INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

aranelle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86ARCALYST. . . . . . . . . . . . . . . . . . . . . . . . . . . 77ARCAPTA NEOHALER. . . . . . . . . . . . . . . . . 93aripiprazole oral solution. . . . . . . . . . . . . . . . 42aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

aripiprazole oral tablet 20 mg, 30 mg. . . . . . 42aripiprazole oral tablet,disintegrating. . . . . . . 42ARISTADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 42armodafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . 42ARNUITY ELLIPTA INHALATION BLISTERWITH DEVICE 100 MCG/ACTUATION, 200MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 93

ARNUITY ELLIPTA INHALATION BLISTERWITH DEVICE 50 MCG/ACTUATION. . . . . 93

ARRANON. . . . . . . . . . . . . . . . . . . . . . . . . . . 23ARZERRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 23ascomp with codeine. . . . . . . . . . . . . . . . . . . 37ashlyna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86aspirin-dipyridamole oral capsule, er multiphase12 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

ASTAGRAF XL. . . . . . . . . . . . . . . . . . . . . . . 23atazanavir oral capsule 150 mg, 200 mg. . . . 10atazanavir oral capsule 300 mg. . . . . . . . . . . 10atenolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49atenolol-chlorthalidone. . . . . . . . . . . . . . . . . . 49atomoxetine oral capsule 10 mg, 100 mg, 18mg, 25 mg, 80 mg. . . . . . . . . . . . . . . . . . . . 42

atomoxetine oral capsule 40 mg, 60 mg. . . . 42atorvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 54atovaquone. . . . . . . . . . . . . . . . . . . . . . . . . . 16atovaquone-proguanil. . . . . . . . . . . . . . . . . . 16ATRIPLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10atropine injection syringe 0.05 mg/ml, 0.1mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

atropine ophthalmic (eye) drops. . . . . . . . . . 90ATROVENT HFA. . . . . . . . . . . . . . . . . . . . . . 93AUBAGIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35aubra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

105

AUSTEDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 35AVANDIA ORAL TABLET 2 MG, 4 MG. . . . . 68AVASTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23aviane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86avita topical cream. . . . . . . . . . . . . . . . . . . . . 58AVONEX (WITH ALBUMIN). . . . . . . . . . . . . . 77AVONEX INTRAMUSCULAR PEN INJECTORKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

AVONEX INTRAMUSCULAR SYRINGE KIT. 77azacitidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 23AZACTAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 16AZACTAM IN DEXTROSE (ISO-OSM). . . . . 16azathioprine. . . . . . . . . . . . . . . . . . . . . . . . . . 24azathioprine sodium. . . . . . . . . . . . . . . . . . . . 24azelastine nasal. . . . . . . . . . . . . . . . . . . . . . . 65azelastine ophthalmic (eye). . . . . . . . . . . . . . 90azithromycin intravenous. . . . . . . . . . . . . . . . 15azithromycin oral. . . . . . . . . . . . . . . . . . . . . . 15aztreonam injection recon soln 1 gram. . . . . 16aztreonam injection recon soln 2 gram. . . . . 16azurette (28). . . . . . . . . . . . . . . . . . . . . . . . . 86

Bbaciim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16bacitracin intramuscular. . . . . . . . . . . . . . . . . 16bacitracin ophthalmic (eye). . . . . . . . . . . . . . 89bacitracin-polymyxin b ophthalmic (eye). . . . 89baclofen oral tablet 10 mg, 20 mg. . . . . . . . . 36bacteriostatic water(parabens). . . . . . . . . . . 62balanced salt. . . . . . . . . . . . . . . . . . . . . . . . . 90balsalazide. . . . . . . . . . . . . . . . . . . . . . . . . . . 73balziva (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86BANZEL ORAL SUSPENSION. . . . . . . . . . . 31BANZEL ORAL TABLET 200 MG. . . . . . . . . 31BANZEL ORAL TABLET 400 MG. . . . . . . . . 31BARACLUDE ORAL SOLUTION. . . . . . . . . . 10BAVENCIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 24BAXDELA INTRAVENOUS. . . . . . . . . . . . . . 20BAXDELA ORAL. . . . . . . . . . . . . . . . . . . . . . 20BCG VACCINE, LIVE (PF). . . . . . . . . . . . . . 79bd pre-filled normal saline. . . . . . . . . . . . . . . 62bekyree (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86

BELEODAQ. . . . . . . . . . . . . . . . . . . . . . . . . . 24benazepril. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49benazepril-hydrochlorothiazide. . . . . . . . . . . 49BENDEKA. . . . . . . . . . . . . . . . . . . . . . . . . . . 24BENLYSTA INTRAVENOUS. . . . . . . . . . . . . 83BENLYSTA SUBCUTANEOUS. . . . . . . . . . . 83BENZNIDAZOLE. . . . . . . . . . . . . . . . . . . . . . 16benztropine injection. . . . . . . . . . . . . . . . . . . 33benztropine oral. . . . . . . . . . . . . . . . . . . . . . . 33BESPONSA. . . . . . . . . . . . . . . . . . . . . . . . . . 24betamethasone acet,sod phos. . . . . . . . . . . . 66betamethasone dipropionate. . . . . . . . . . . . . 61betamethasone valerate. . . . . . . . . . . . . . . . 61betamethasone, augmented. . . . . . . . . . . . . 61betaxolol ophthalmic (eye). . . . . . . . . . . . . . . 89betaxolol oral. . . . . . . . . . . . . . . . . . . . . . . . . 49bethanechol chloride. . . . . . . . . . . . . . . . . . . 96BETHKIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16BEVESPI AEROSPHERE. . . . . . . . . . . . . . . 93BEVYXXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 53bexarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 24BEXSERO. . . . . . . . . . . . . . . . . . . . . . . . . . . 79bicalutamide. . . . . . . . . . . . . . . . . . . . . . . . . . 24BICILLIN L-A. . . . . . . . . . . . . . . . . . . . . . . . . 19BICNU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24BIKTARVY. . . . . . . . . . . . . . . . . . . . . . . . . . . 10bimatoprost ophthalmic (eye). . . . . . . . . . . . 90bisoprolol fumarate. . . . . . . . . . . . . . . . . . . . 49bisoprolol-hydrochlorothiazide. . . . . . . . . . . . 49bleomycin injection recon soln 15 unit. . . . . . 24bleomycin injection recon soln 30 unit. . . . . . 24BLEPHAMIDE. . . . . . . . . . . . . . . . . . . . . . . . 91BLEPHAMIDE S.O.P.. . . . . . . . . . . . . . . . . . 91BLINCYTO INTRAVENOUS KIT. . . . . . . . . . 24blisovi 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 86blisovi fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . 86blisovi fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 86BOOSTRIX TDAP. . . . . . . . . . . . . . . . . . . . . 79BORTEZOMIB. . . . . . . . . . . . . . . . . . . . . . . . 24BOSULIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24BOTOX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79briellyn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

106

BRILINTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53brimonidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 91BRIVIACT INTRAVENOUS. . . . . . . . . . . . . . 31BRIVIACT ORAL. . . . . . . . . . . . . . . . . . . . . . 31bromfenac. . . . . . . . . . . . . . . . . . . . . . . . . . . 90bromocriptine. . . . . . . . . . . . . . . . . . . . . . . . . 33BROVANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 93bss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90budesonide inhalation. . . . . . . . . . . . . . . . . . 93budesonide oralcapsule,delayed,extend.release. . . . . . . . . . 73

bumetanide injection. . . . . . . . . . . . . . . . . . . 49bumetanide oral. . . . . . . . . . . . . . . . . . . . . . . 49buminate 5 %. . . . . . . . . . . . . . . . . . . . . . . . . 96BUPHENYL ORAL TABLET. . . . . . . . . . . . . . 62bupivacaine. . . . . . . . . . . . . . . . . . . . . . . . . . 59bupivacaine (pf) injection solution 0.25 % (2.5mg/ml), 0.5 % (5 mg/ml). . . . . . . . . . . . . . . . 59

bupivacaine (pf) injection solution 0.75 % (7.5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

bupivacaine-dextrose-water(pf). . . . . . . . . . . 62bupivacaine-epinephrine (pf). . . . . . . . . . . . . 59bupivacaine-epinephrine injection solution0.25 %-1:200,000. . . . . . . . . . . . . . . . . . . . . 59

bupivacaine-epinephrine injection solution0.5 %-1:200,000. . . . . . . . . . . . . . . . . . . . . . 59

buprenorphine hcl injection solution. . . . . . . 37buprenorphine hcl injection syringe. . . . . . . . 37buprenorphine hcl sublingual. . . . . . . . . . . . . 37buprenorphine-naloxone. . . . . . . . . . . . . . . . 40bupropion hcl (smoking deter) oral tabletextended release. . . . . . . . . . . . . . . . . . . . . 65

bupropion hcl oral tablet. . . . . . . . . . . . . . . . 42bupropion hcl oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

bupropion hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

buspirone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43busulfan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24butalbital compound w/codeine. . . . . . . . . . . 37butalbital-acetaminop-caf-cod. . . . . . . . . . . . 37butalbital-acetaminophen. . . . . . . . . . . . . . . . 37butalbital-acetaminophen-caff oral capsule. . 37

butalbital-acetaminophen-caff oral tablet50-325-40 mg. . . . . . . . . . . . . . . . . . . . . . . . 37

butalbital-aspirin-caffeine oral capsule. . . . . 37butalbital-aspirin-caffeine oral tablet. . . . . . . 37butorphanol tartrate injection. . . . . . . . . . . . . 40butorphanol tartrate nasal. . . . . . . . . . . . . . . 40BYDUREON. . . . . . . . . . . . . . . . . . . . . . . . . . 68BYDUREON BCISE. . . . . . . . . . . . . . . . . . . . 68BYETTA SUBCUTANEOUS PEN INJECTOR 10MCG/DOSE(250 MCG/ML) 2.4 ML. . . . . . . 68

BYETTA SUBCUTANEOUS PEN INJECTOR 5MCG/DOSE (250 MCG/ML) 1.2 ML. . . . . . . 68

Ccabergoline. . . . . . . . . . . . . . . . . . . . . . . . . . . 70CABOMETYX. . . . . . . . . . . . . . . . . . . . . . . . . 24caffeine citrate intravenous. . . . . . . . . . . . . . 62caffeine citrate oral. . . . . . . . . . . . . . . . . . . . 62calcipotriene. . . . . . . . . . . . . . . . . . . . . . . . . . 57calcipotriene-betamethasone. . . . . . . . . . . . . 57calcitonin (salmon). . . . . . . . . . . . . . . . . . . . . 70calcitrene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57calcitriol intravenous solution 1 mcg/ml. . . . . 70calcitriol oral capsule. . . . . . . . . . . . . . . . . . . 70calcitriol oral solution. . . . . . . . . . . . . . . . . . . 70calcitriol topical. . . . . . . . . . . . . . . . . . . . . . . 57calcium acetate oral capsule. . . . . . . . . . . . . 97calcium acetate oral tablet 667 mg. . . . . . . . 97calcium chloride. . . . . . . . . . . . . . . . . . . . . . . 97calcium gluconate intravenous. . . . . . . . . . . 97CALQUENCE. . . . . . . . . . . . . . . . . . . . . . . . . 24camila. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84camrese. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86camrese lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 86CANCIDAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9candesartan. . . . . . . . . . . . . . . . . . . . . . . . . . 49candesartan-hydrochlorothiazid. . . . . . . . . . . 49capacet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37CAPASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . 16capecitabine. . . . . . . . . . . . . . . . . . . . . . . . . . 24CAPRELSA. . . . . . . . . . . . . . . . . . . . . . . . . . 24captopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

107

captopril-hydrochlorothiazide. . . . . . . . . . . . . 49CARAFATE ORAL SUSPENSION. . . . . . . . . 76CARBAGLU. . . . . . . . . . . . . . . . . . . . . . . . . . 62carbamazepine oral capsule, er multiphase 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

carbamazepine oral suspension 100 mg/5 ml 31carbamazepine oral tablet. . . . . . . . . . . . . . . 31carbamazepine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

carbamazepine oral tablet,chewable. . . . . . . 31carbidopa. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33carbidopa-levodopa oral tablet. . . . . . . . . . . 33carbidopa-levodopa oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

carbidopa-levodopa oral tablet,disintegrating 33carbidopa-levodopa-entacapone. . . . . . . . . . 33carbinoxamine maleate oral liquid. . . . . . . . . 92carbinoxamine maleate oral tablet 4 mg. . . . 92carbinoxamine maleate oral tablet 6 mg. . . . 92carbocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

carboplatin intravenous solution. . . . . . . . . . 24cardioplegic soln. . . . . . . . . . . . . . . . . . . . . . 55carisoprodol. . . . . . . . . . . . . . . . . . . . . . . . . . 36carisoprodol-asa-codeine. . . . . . . . . . . . . . . 36carisoprodol-aspirin. . . . . . . . . . . . . . . . . . . . 36carteolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89cartia xt oral capsule,extended release 24hr. 49carvedilol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49carvedilol phosphate oral capsule, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

caspofungin. . . . . . . . . . . . . . . . . . . . . . . . . . . 9CAYSTON. . . . . . . . . . . . . . . . . . . . . . . . . . . 16caziant (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86cefaclor oral capsule. . . . . . . . . . . . . . . . . . . 14cefaclor oral suspension for reconstitution 125mg/5 ml, 250 mg/5 ml. . . . . . . . . . . . . . . . . . 14

cefaclor oral suspension for reconstitution 375mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

cefaclor oral tablet extended release 12 hr. . 14cefadroxil oral capsule. . . . . . . . . . . . . . . . . . 14cefadroxil oral suspension for reconstitution 250mg/5 ml, 500 mg/5 ml. . . . . . . . . . . . . . . . . . 14

cefadroxil oral tablet. . . . . . . . . . . . . . . . . . . . 14cefazolin in dextrose (iso-os) intravenouspiggyback 1 gram/50 ml, 2 gram/50 ml. . . . 14

cefazolin injection recon soln 1 gram, 500 mg 14cefazolin injection recon soln 10 gram. . . . . . 14cefazolin injection recon soln 100 gram, 20gram, 300 g. . . . . . . . . . . . . . . . . . . . . . . . . 14

cefazolin intravenous. . . . . . . . . . . . . . . . . . . 14cefdinir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14cefepime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14cefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 14

cefepime in dextrose,iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 14

cefixime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14cefotaxime injection recon soln 1 gram, 2 gram,500 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

cefotaxime injection recon soln 10 gram. . . . 14cefotetan injection. . . . . . . . . . . . . . . . . . . . . 14cefotetan intravenous. . . . . . . . . . . . . . . . . . 14cefoxitin in dextrose, iso-osm. . . . . . . . . . . . 14cefoxitin intravenous recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

cefoxitin intravenous recon soln 10 gram. . . 14cefpodoxime. . . . . . . . . . . . . . . . . . . . . . . . . . 14cefprozil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14ceftazidime injection recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

ceftazidime injection recon soln 6 gram. . . . . 14ceftriaxone in dextrose,iso-os. . . . . . . . . . . . 14ceftriaxone injection recon soln 1 gram, 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 14

ceftriaxone injection recon soln 10 gram. . . . 14ceftriaxone intravenous. . . . . . . . . . . . . . . . . 14cefuroxime axetil oral tablet. . . . . . . . . . . . . . 15cefuroxime sodium injection recon soln 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

cefuroxime sodium intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

cefuroxime sodium intravenous recon soln 7.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

celecoxib. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40CELLCEPT INTRAVENOUS. . . . . . . . . . . . . 24CELONTIN ORAL CAPSULE 300 MG. . . . . 31

108

cephalexin. . . . . . . . . . . . . . . . . . . . . . . . . . . 15CERDELGA. . . . . . . . . . . . . . . . . . . . . . . . . . 70CEREZYME INTRAVENOUS RECON SOLN400 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 70

cetirizine oral solution 1 mg/ml. . . . . . . . . . . 92cevimeline. . . . . . . . . . . . . . . . . . . . . . . . . . . 62CHANTIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65CHANTIX CONTINUING MONTH BOX. . . . 65CHANTIX STARTING MONTH BOX. . . . . . . 65chateal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86CHEMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62chloramphenicol sod succinate. . . . . . . . . . . 16chlordiazepoxide hcl. . . . . . . . . . . . . . . . . . . 43chlordiazepoxide-clidinium. . . . . . . . . . . . . . . 72chlorhexidine gluconate mucous membrane. 65chloroprocaine (pf). . . . . . . . . . . . . . . . . . . . . 59chloroquine phosphate. . . . . . . . . . . . . . . . . 16chlorothiazide. . . . . . . . . . . . . . . . . . . . . . . . . 49chlorothiazide sodium. . . . . . . . . . . . . . . . . . 49chlorpromazine injection. . . . . . . . . . . . . . . . 43chlorpromazine oral. . . . . . . . . . . . . . . . . . . . 43chlorpropamide. . . . . . . . . . . . . . . . . . . . . . . 68chlorthalidone oral tablet 25 mg, 50 mg. . . . . 49chlorzoxazone oral tablet 250 mg. . . . . . . . . 36chlorzoxazone oral tablet 500 mg. . . . . . . . . 36CHOLBAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 73cholestyramine (with sugar). . . . . . . . . . . . . . 54cholestyramine light. . . . . . . . . . . . . . . . . . . . 54CHORIONIC GONADOTROPIN, HUMAN. . 70CIALIS ORAL TABLET 2.5 MG, 5 MG. . . . . . 96ciclodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ciclopirox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60cidofovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cilostazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53CIMDUO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cimetidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76cimetidine hcl oral. . . . . . . . . . . . . . . . . . . . . 76CIMZIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73CIMZIA POWDER FOR RECONST. . . . . . . . 73CIMZIA STARTER KIT. . . . . . . . . . . . . . . . . . 73CINRYZE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93CINVANTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

CIPRODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 66ciprofloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . 20ciprofloxacin (mixture) oral tablet, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

ciprofloxacin hcl ophthalmic (eye). . . . . . . . . 89ciprofloxacin hcl oral. . . . . . . . . . . . . . . . . . . 20ciprofloxacin hcl otic (ear). . . . . . . . . . . . . . . 66ciprofloxacin in 5 % dextrose intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . 20

ciprofloxacin in 5 % dextrose intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . 20

ciprofloxacin lactate intravenous solution 400mg/40 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 20

cisplatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24citalopram oral solution. . . . . . . . . . . . . . . . . 43citalopram oral tablet. . . . . . . . . . . . . . . . . . . 43cladribine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24claravis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58clarithromycin oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 15

clarithromycin oral tablet. . . . . . . . . . . . . . . . 15clarithromycin oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

clemastine oral tablet 2.68 mg. . . . . . . . . . . . 92cleocin intravenous solution 300 mg/2 ml. . . 16CLEOCIN VAGINAL SUPPOSITORY. . . . . . 85clindacin etz topical swab. . . . . . . . . . . . . . . 58clindacin p. . . . . . . . . . . . . . . . . . . . . . . . . . . 58clindamycin hcl. . . . . . . . . . . . . . . . . . . . . . . 16clindamycin in 5 % dextrose. . . . . . . . . . . . . 17clindamycin palmitate hcl. . . . . . . . . . . . . . . . 17clindamycin pediatric. . . . . . . . . . . . . . . . . . . 17clindamycin phosphate injection. . . . . . . . . . 17clindamycin phosphate intravenous solution 300mg/2 ml, 900 mg/6 ml. . . . . . . . . . . . . . . . . . 17

clindamycin phosphate intravenous solution 600mg/4 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

clindamycin phosphate topical. . . . . . . . . . . . 58clindamycin phosphate vaginal. . . . . . . . . . . 85clindamycin-benzoyl peroxide. . . . . . . . . . . . 58clindamycin-tretinoin. . . . . . . . . . . . . . . . . . . 58CLINIMIX 5%/D15W SULFITE FREE. . . . . 100CLINIMIX 5%/D25W SULFITE-FREE. . . . 100

109

CLINIMIX 2.75%/D5W SULFIT FREE. . . . . 100CLINIMIX 4.25%-D20W SULF-FREE. . . . . 100CLINIMIX 4.25%-D25W SULF-FREE. . . . . 100CLINIMIX 4.25%/D10W SULF FREE. . . . . 100CLINIMIX 4.25%/D5W SULFIT FREE. . . . . . 62CLINIMIX 5%-D20W(SULFITE-FREE). . . . 100CLINIMIX E 2.75%/D10W SUL FREE. . . . . . 62CLINIMIX E 2.75%/D5W SULF FREE. . . . . . 63CLINIMIX E 4.25%/D10W SUL FREE. . . . . 100CLINIMIX E 4.25%/D25W SUL FREE. . . . . 100CLINIMIX E 4.25%/D5W SULF FREE. . . . . 100CLINIMIX E 5%/D15W SULFIT FREE. . . . . 100CLINIMIX E 5%/D20W SULFIT FREE. . . . . 100CLINIMIX E 5%/D25W SULFIT FREE. . . . . 100CLINIMIX N14G30E 4.25%-D15W SF. . . . . 100CLINIMIX N9G15E 2.75%-D7.5W SF. . . . . 100CLINIMIX N9G20E 2.75%-D10W(SF). . . . . . 63clobetasol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61clobetasol-emollient. . . . . . . . . . . . . . . . . . . . 61clodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61clofarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . 24clomiphene citrate. . . . . . . . . . . . . . . . . . . . . 70clomipramine. . . . . . . . . . . . . . . . . . . . . . . . . 43clonazepam oral tablet. . . . . . . . . . . . . . . . . . 31clonazepam oral tablet,disintegrating. . . . . . 31clonidine (pf) epidural solution 1,000 mcg/10 ml(100 mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . 49

clonidine (pf) epidural solution 5,000 mcg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

clonidine hcl oral tablet. . . . . . . . . . . . . . . . . 49clonidine hcl oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

clonidine transdermal. . . . . . . . . . . . . . . . . . . 49clopidogrel. . . . . . . . . . . . . . . . . . . . . . . . . . . 53clorazepate dipotassium. . . . . . . . . . . . . . . . 43clotrimazole mucous membrane. . . . . . . . . . . 9clotrimazole topical. . . . . . . . . . . . . . . . . . . . 60clotrimazole-betamethasone. . . . . . . . . . . . . 60clozapine oral tablet. . . . . . . . . . . . . . . . . . . . 43clozapine oral tablet,disintegrating 100 mg, 12.5mg, 25 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 43

CLOZAPINE ORAL TABLET,DISINTEGRATING150 MG, 200 MG (BRAND). . . . . . . . . . . . . 43

COARTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . 17codeine sulfate oral tablet. . . . . . . . . . . . . . . 37codeine-butalbital-asa-caff. . . . . . . . . . . . . . . 37COLCHICINE ORAL TABLET. . . . . . . . . . . . 82COLCRYS. . . . . . . . . . . . . . . . . . . . . . . . . . . 82colesevelam. . . . . . . . . . . . . . . . . . . . . . . . . . 54colestipol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54colistin (colistimethate na). . . . . . . . . . . . . . . 17colocort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73COMBIVENT RESPIMAT. . . . . . . . . . . . . . . . 93COMETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . . 24COMPLERA. . . . . . . . . . . . . . . . . . . . . . . . . . 10compro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73CONDYLOX TOPICAL GEL. . . . . . . . . . . . . 57constulose. . . . . . . . . . . . . . . . . . . . . . . . . . . 73coremino oral tablet extended release 24 hr. 21CORLANOR. . . . . . . . . . . . . . . . . . . . . . . . . . 55cortisone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66COSENTYX. . . . . . . . . . . . . . . . . . . . . . . . . . 57COSENTYX (2 SYRINGES). . . . . . . . . . . . . 57COSENTYX PEN. . . . . . . . . . . . . . . . . . . . . . 57COSENTYX PEN (2 PENS). . . . . . . . . . . . . 57COTELLIC. . . . . . . . . . . . . . . . . . . . . . . . . . . 24CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,24,000-76,000 -120,000 UNIT, 3,000-9,500-15,000 UNIT, 6,000-19,000 -30,000 UNIT. . 73

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 36,000-114,000- 180,000 UNIT. . . 73

CRESEMBA INTRAVENOUS. . . . . . . . . . . . . 9CRESEMBA ORAL. . . . . . . . . . . . . . . . . . . . . 9CRIXIVAN ORAL CAPSULE 200 MG, 400MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

cromolyn inhalation. . . . . . . . . . . . . . . . . . . . 93cromolyn ophthalmic (eye). . . . . . . . . . . . . . . 90cromolyn oral. . . . . . . . . . . . . . . . . . . . . . . . . 73cryselle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86CUPRIMINE. . . . . . . . . . . . . . . . . . . . . . . . . . 83CUVPOSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 72cyclafem 1/35 (28). . . . . . . . . . . . . . . . . . . . . 86cyclafem 7/7/7 (28). . . . . . . . . . . . . . . . . . . . 86cyclobenzaprine oral tablet. . . . . . . . . . . . . . 36cyclophosphamide intravenous. . . . . . . . . . . 24

110

cyclophosphamide oral capsule. . . . . . . . . . . 24CYCLOSERINE. . . . . . . . . . . . . . . . . . . . . . . 17CYCLOSET. . . . . . . . . . . . . . . . . . . . . . . . . . 68cyclosporine intravenous. . . . . . . . . . . . . . . . 24cyclosporine modified. . . . . . . . . . . . . . . . . . 24cyclosporine oral capsule. . . . . . . . . . . . . . . 24cyproheptadine. . . . . . . . . . . . . . . . . . . . . . . . 92CYRAMZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 24cyred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86CYSTADANE. . . . . . . . . . . . . . . . . . . . . . . . . 73CYSTAGON. . . . . . . . . . . . . . . . . . . . . . . . . . 96CYSTARAN. . . . . . . . . . . . . . . . . . . . . . . . . . 90cysteine (l-cysteine) intravenous solution. . 100cytarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24cytarabine (pf) injection solution 100 mg/5 ml(20 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 24

cytarabine (pf) injection solution 2 gram/20 ml(100 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 24

cytarabine (pf) injection solution 20 mg/ml. . 24

Dd10 %-0.45 % sodium chloride. . . . . . . . . . . 63d2.5 %-0.45 % sodium chloride. . . . . . . . . . . 63d5 % and 0.9 % sodium chloride. . . . . . . . . . 63d5 %-0.45 % sodium chloride. . . . . . . . . . . . 63dacarbazine intravenous recon soln 100 mg. 24dacarbazine intravenous recon soln 200 mg. 24dactinomycin. . . . . . . . . . . . . . . . . . . . . . . . . 24DAKLINZA ORAL TABLET 30 MG. . . . . . . . . 10DAKLINZA ORAL TABLET 60 MG, 90 MG. . 10DALIRESP. . . . . . . . . . . . . . . . . . . . . . . . . . . 93DALVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 17danazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70dantrolene. . . . . . . . . . . . . . . . . . . . . . . . . . . 36dapsone oral. . . . . . . . . . . . . . . . . . . . . . . . . 17dapsone topical. . . . . . . . . . . . . . . . . . . . . . . 58DAPTACEL (DTAP PEDIATRIC) (PF). . . . . . 79daptomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 17DARAPRIM. . . . . . . . . . . . . . . . . . . . . . . . . . 17darifenacin oral tablet extended release 24 hr 95DARZALEX. . . . . . . . . . . . . . . . . . . . . . . . . . 24dasetta 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 86

dasetta 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 86daunorubicin intravenous solution. . . . . . . . . 24daysee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86deblitane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84decadron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66decitabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24deferoxamine. . . . . . . . . . . . . . . . . . . . . . . . . 63deltasone oral tablet 20 mg. . . . . . . . . . . . . . 66delyla (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 86demeclocycline. . . . . . . . . . . . . . . . . . . . . . . . 21demerol (pf) injection solution 100 mg/ml. . . 37DEMSER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49DENAVIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60denta 5000 plus. . . . . . . . . . . . . . . . . . . . . . . 65dentagel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65DEPEN TITRATABS. . . . . . . . . . . . . . . . . . . 83DESCOVY. . . . . . . . . . . . . . . . . . . . . . . . . . . 10desipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 43desloratadine oral tablet. . . . . . . . . . . . . . . . 92desloratadine oral tablet,disintegrating. . . . . 92desmopressin injection. . . . . . . . . . . . . . . . . 70desmopressin nasal solution. . . . . . . . . . . . . 70desmopressin nasal spray with pump. . . . . . 70desmopressin nasal spray,non-aerosol. . . . . 70desmopressin oral. . . . . . . . . . . . . . . . . . . . . 70desog-e.estradiol/e.estradiol. . . . . . . . . . . . . 86desogestrel-ethinyl estradiol. . . . . . . . . . . . . 86desonide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61desoximetasone. . . . . . . . . . . . . . . . . . . . . . . 61desvenlafaxine succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 43

dexamethasone intensol. . . . . . . . . . . . . . . . 66dexamethasone oral elixir. . . . . . . . . . . . . . . 66dexamethasone oral solution. . . . . . . . . . . . . 66dexamethasone oral tablet. . . . . . . . . . . . . . 66dexamethasone sodium phos (pf). . . . . . . . . 66dexamethasone sodium phosphate injectionsolution 10 mg/ml. . . . . . . . . . . . . . . . . . . . . 66

dexamethasone sodium phosphate injectionsolution 4 mg/ml. . . . . . . . . . . . . . . . . . . . . . 66

dexamethasone sodium phosphate injectionsyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

111

dexamethasone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

dexmethylphenidate oral capsule,er biphasic50-50 10 mg, 20 mg, 30 mg, 40 mg, 5 mg. . 43

dexmethylphenidate oral capsule,er biphasic50-50 15 mg, 25 mg, 35 mg. . . . . . . . . . . . . 43

dexmethylphenidate oral tablet. . . . . . . . . . . 43dexrazoxane hcl intravenous recon soln 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

dexrazoxane hcl intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

dextroamphetamine oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

dextroamphetamine oral solution. . . . . . . . . . 43dextroamphetamine oral tablet. . . . . . . . . . . 43dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 25 mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 30 mg. . . . . 43

dextroamphetamine-amphetamine oral tablet 43dextrose 10 % and 0.2 % nacl. . . . . . . . . . . . 63dextrose 10 % in water (d10w). . . . . . . . . . . 63dextrose 20 % in water (d20w). . . . . . . . . . . 63dextrose 25 % in water (d25w). . . . . . . . . . . 63dextrose 30 % in water (d30w). . . . . . . . . . . 63dextrose 40 % in water (d40w). . . . . . . . . . . 63dextrose 5 % in water (d5w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 63

dextrose 5 % in water (d5w) intravenouspiggyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 63

dextrose 5 %-lactated ringers. . . . . . . . . . . . 63dextrose 5%-0.2 % sod chloride. . . . . . . . . . 63dextrose 5%-0.3 % sod.chloride. . . . . . . . . . 63dextrose 50 % in water (d50w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 63

dextrose 50 % in water (d50w) intravenoussyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

dextrose 70 % in water (d70w). . . . . . . . . . . 63dextrose with sodium chloride. . . . . . . . . . . . 63DIASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31DIASTAT ACUDIAL. . . . . . . . . . . . . . . . . . . . 31diazepam injection solution. . . . . . . . . . . . . . 43diazepam injection syringe. . . . . . . . . . . . . . 43

diazepam intensol. . . . . . . . . . . . . . . . . . . . . 43diazepam oral concentrate. . . . . . . . . . . . . . 44diazepam oral solution 5 mg/5 ml (1 mg/ml). 44diazepam oral tablet. . . . . . . . . . . . . . . . . . . 44diazepam rectal. . . . . . . . . . . . . . . . . . . . . . . 31diclofenac potassium. . . . . . . . . . . . . . . . . . . 40diclofenac sodium ophthalmic (eye). . . . . . . 90diclofenac sodium oral tablet extended release24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

diclofenac sodium oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

diclofenac sodium topical drops. . . . . . . . . . . 40diclofenac sodium topical gel 1 %. . . . . . . . . 40diclofenac sodium topical gel 3 %. . . . . . . . . 57diclofenac-misoprostol oral tablet,ir,delayedrel,biphasic. . . . . . . . . . . . . . . . . . . . . . . . . . 40

dicloxacillin. . . . . . . . . . . . . . . . . . . . . . . . . . . 19dicyclomine intramuscular. . . . . . . . . . . . . . . 72dicyclomine oral capsule. . . . . . . . . . . . . . . . 72dicyclomine oral solution. . . . . . . . . . . . . . . . 72dicyclomine oral tablet. . . . . . . . . . . . . . . . . . 72didanosine oral capsule,delayed release(dr/ec)200 mg, 250 mg, 400 mg. . . . . . . . . . . . . . . 10

DIFICID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15diflorasone. . . . . . . . . . . . . . . . . . . . . . . . . . . 61diflunisal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40digitek. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52digox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52digoxin injection solution. . . . . . . . . . . . . . . . 52digoxin oral solution 50 mcg/ml. . . . . . . . . . . 52digoxin oral tablet. . . . . . . . . . . . . . . . . . . . . . 52dihydroergotamine injection. . . . . . . . . . . . . . 34dihydroergotamine nasal. . . . . . . . . . . . . . . . 34DILANTIN 30 MG. . . . . . . . . . . . . . . . . . . . . . 31dilt-xr oral capsule,ext release degradable. . 50diltiazem hcl intravenous. . . . . . . . . . . . . . . . 49diltiazem hcl oral capsule, extended release. 49diltiazem hcl oral capsule,ext releasedegradable. . . . . . . . . . . . . . . . . . . . . . . . . . 49

diltiazem hcl oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

diltiazem hcl oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

112

diltiazem hcl oral tablet. . . . . . . . . . . . . . . . . 49diltiazem hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

dimenhydrinate injection solution. . . . . . . . . . 73DIPENTUM. . . . . . . . . . . . . . . . . . . . . . . . . . 73diphenhydramine hcl injection solution 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

diphenhydramine hcl injection syringe. . . . . . 92diphenhydramine hcl oral elixir. . . . . . . . . . . 92diphenoxylate-atropine. . . . . . . . . . . . . . . . . 72dipyridamole intravenous. . . . . . . . . . . . . . . . 53dipyridamole oral. . . . . . . . . . . . . . . . . . . . . . 53disopyramide phosphate oral capsule. . . . . . 48disulfiram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63divalproex oral capsule, delayed rel sprinkle. 31divalproex oral tablet extended release 24 hr 31divalproex oral tablet,delayed release (dr/ec) 31dobutamine. . . . . . . . . . . . . . . . . . . . . . . . . . 55dobutamine in d5w intravenous parenteralsolution 1,000 mg/250 ml (4,000 mcg/ml). . 55

dobutamine in d5w intravenous parenteralsolution 250 mg/250 ml (1 mg/ml), 500 mg/250ml (2,000 mcg/ml). . . . . . . . . . . . . . . . . . . . 55

docetaxel intravenous solution 160 mg/16 ml(10 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 24

docetaxel intravenous solution 160 mg/8 ml (20mg/ml), 20 mg/ml (1 ml), 80 mg/8 ml (10mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

docetaxel intravenous solution 20 mg/2 ml (10mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

DOCETAXEL INTRAVENOUS SOLUTION 20MG/ML (BRAND). . . . . . . . . . . . . . . . . . . . . 25

docetaxel intravenous solution 80 mg/4 ml (20mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

dofetilide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48donepezil oral tablet 10 mg, 5 mg. . . . . . . . . 35donepezil oral tablet 23 mg. . . . . . . . . . . . . . 35donepezil oral tablet,disintegrating. . . . . . . . 35dopamine in 5 % dextrose intravenous solution200 mg/250 ml (800 mcg/ml), 400 mg/250 ml(1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml),800 mg/500 ml (1,600 mcg/ml). . . . . . . . . . 55

dopamine in 5 % dextrose intravenous solution800 mg/250 ml (3,200 mcg/ml). . . . . . . . . . 55

dopamine intravenous solution 200 mg/5 ml (40mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml(160 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 55

dopamine intravenous solution 400 mg/10 ml(40 mg/ml), 400 mg/5 ml (80 mg/ml). . . . . . 55

DORIPENEM INTRAVENOUS RECON SOLN250 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

DORIPENEM INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

dorzolamide. . . . . . . . . . . . . . . . . . . . . . . . . . 90dorzolamide-timolol. . . . . . . . . . . . . . . . . . . . 90doxazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50doxepin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 44doxepin topical. . . . . . . . . . . . . . . . . . . . . . . . 57doxercalciferol intravenous. . . . . . . . . . . . . . 70doxercalciferol oral. . . . . . . . . . . . . . . . . . . . . 70doxorubicin intravenous recon soln 10 mg. . 25doxorubicin intravenous recon soln 50 mg. . 25doxorubicin intravenous solution 10 mg/5 ml, 2mg/ml, 20 mg/10 ml. . . . . . . . . . . . . . . . . . . 25

doxorubicin intravenous solution 50 mg/25 ml 25doxorubicin, peg-liposomal. . . . . . . . . . . . . . 25doxy-100. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21doxycycline hyclate oral capsule. . . . . . . . . . 21doxycycline hyclate oral tablet 100 mg, 150 mg,20 mg, 75 mg. . . . . . . . . . . . . . . . . . . . . . . . 21

doxycycline hyclate oral tablet 50 mg. . . . . . 21doxycycline hyclate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

doxycycline monohydrate oral capsule. . . . . 21doxycycline monohydrate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 21

doxycycline monohydrate oral tablet. . . . . . . 21dronabinol oral capsule 10 mg. . . . . . . . . . . . 73dronabinol oral capsule 2.5 mg, 5 mg. . . . . . 73droperidol injection solution. . . . . . . . . . . . . . 73drospirenone-e.estradiol-lm.fa. . . . . . . . . . . . 86drospirenone-ethinyl estradiol. . . . . . . . . . . . 86DULERA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93duloxetine oral capsule,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

DUPIXENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 57duramorph (pf) injection solution 0.5 mg/ml. . 37duramorph (pf) injection solution 1 mg/ml. . . 37

113

DUROLANE. . . . . . . . . . . . . . . . . . . . . . . . . . 40dutasteride. . . . . . . . . . . . . . . . . . . . . . . . . . . 96dutasteride-tamsulosin oral capsule, ermultiphase 24 hr. . . . . . . . . . . . . . . . . . . . . . 96

DYSPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Ee.e.s. 400 oral tablet. . . . . . . . . . . . . . . . . . . 15econazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60EDURANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 10efavirenz oral capsule 200 mg. . . . . . . . . . . . 10efavirenz oral capsule 50 mg. . . . . . . . . . . . . 10efavirenz oral tablet. . . . . . . . . . . . . . . . . . . . 10effer-k oral tablet, effervescent 25 meq. . . . . 97electrolyte-48 in d5w. . . . . . . . . . . . . . . . . . 100ELELYSO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70eletriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ELIGARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ELIGARD (3 MONTH). . . . . . . . . . . . . . . . . . 25ELIGARD (4 MONTH). . . . . . . . . . . . . . . . . . 25ELIGARD (6 MONTH). . . . . . . . . . . . . . . . . . 25elinest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86eliphos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97ELIQUIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ELITEK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ELLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ELMIRON. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96EMCYT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25EMEND (FOSAPREPITANT). . . . . . . . . . . . . 73EMEND ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 73

emoquette. . . . . . . . . . . . . . . . . . . . . . . . . . . 86EMPLICITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 25EMSAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44EMTRIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10EMVERM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17enalapril maleate. . . . . . . . . . . . . . . . . . . . . . 50enalapril-hydrochlorothiazide. . . . . . . . . . . . . 50enalaprilat intravenous solution. . . . . . . . . . . 50ENBREL MINI. . . . . . . . . . . . . . . . . . . . . . . . 83ENBREL SUBCUTANEOUS RECON SOLN. 83ENBREL SUBCUTANEOUS SYRINGE. . . . . 83

ENBREL SURECLICK. . . . . . . . . . . . . . . . . . 83endocet oral tablet 10-325 mg, 2.5-325 mg,5-325 mg, 7.5-325 mg. . . . . . . . . . . . . . . . . 37

ENGERIX-B (PF). . . . . . . . . . . . . . . . . . . . . . 79ENGERIX-B PEDIATRIC (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 79

enoxaparin subcutaneous solution. . . . . . . . 53enoxaparin subcutaneous syringe 100 mg/ml,150 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 53

enoxaparin subcutaneous syringe 120 mg/0.8ml, 80 mg/0.8 ml. . . . . . . . . . . . . . . . . . . . . . 53

enoxaparin subcutaneous syringe 30 mg/0.3ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53



enpresse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86enskyce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86entacapone. . . . . . . . . . . . . . . . . . . . . . . . . . 33entecavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ENTRESTO. . . . . . . . . . . . . . . . . . . . . . . . . . 56ENTYVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73enulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73ENVARSUS XR. . . . . . . . . . . . . . . . . . . . . . . 25EPCLUSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 10epinastine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90EPINEPHRINE INJECTION AUTO-INJECTOR0.15 MG/0.15 ML, 0.3 MG/0.3 ML(ADRENACLICK). . . . . . . . . . . . . . . . . . . . . 92

EPINEPHRINE INJECTION AUTO-INJECTOR0.15 MG/0.3 ML, 0.3 MG/0.3 ML (EPIPEN). 92

EPIPEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92EPIPEN 2-PAK. . . . . . . . . . . . . . . . . . . . . . . 92EPIPEN JR. . . . . . . . . . . . . . . . . . . . . . . . . . 92EPIPEN JR 2-PAK. . . . . . . . . . . . . . . . . . . . . 92epirubicin intravenous solution 200 mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

epirubicin intravenous solution 50 mg/25 ml. 25epitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31EPIVIR HBV ORAL SOLUTION. . . . . . . . . . . 10eplerenone. . . . . . . . . . . . . . . . . . . . . . . . . . . 50epoprostenol (glycine). . . . . . . . . . . . . . . . . . 50eprosartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 50

114

ERBITUX INTRAVENOUS SOLUTION 100MG/50 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 25

ERBITUX INTRAVENOUS SOLUTION 200MG/100 ML. . . . . . . . . . . . . . . . . . . . . . . . . 25

ergoloid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ergotamine-caffeine. . . . . . . . . . . . . . . . . . . . 34ERIVEDGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 25ERLEADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25errin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84ERWINAZE. . . . . . . . . . . . . . . . . . . . . . . . . . 25ery pads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ery-tab oral tablet,delayed release (dr/ec) 250mg, 333 mg. . . . . . . . . . . . . . . . . . . . . . . . . 15

ERY-TAB ORAL TABLET,DELAYED RELEASE(DR/EC) 500 MG. . . . . . . . . . . . . . . . . . . . . 15

erygel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58erythrocin (as stearate) oral tablet 250 mg. . 15ERYTHROCIN INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

erythromycin ethylsuccinate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 15

erythromycin ethylsuccinate oral tablet. . . . . 15erythromycin ophthalmic (eye). . . . . . . . . . . . 89erythromycin oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 15

erythromycin oral tablet. . . . . . . . . . . . . . . . . 16erythromycin with ethanol. . . . . . . . . . . . . . . 58erythromycin-benzoyl peroxide. . . . . . . . . . . 58ESBRIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93escitalopram oxalate oral solution. . . . . . . . . 44escitalopram oxalate oral tablet. . . . . . . . . . . 44esmolol intravenous solution. . . . . . . . . . . . . 50esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 20 mg. . . . . . . . . . . . . . . . . . 76

esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 40 mg. . . . . . . . . . . . . . . . . . 76

esomeprazole sodium intravenous recon soln20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

esomeprazole sodium intravenous recon soln40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86estazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ESTRACE VAGINAL. . . . . . . . . . . . . . . . . . . 84estradiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

estradiol valerate intramuscular oil 20 mg/ml, 40mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

estradiol-norethindrone acet. . . . . . . . . . . . . 84estropipate. . . . . . . . . . . . . . . . . . . . . . . . . . . 84eszopiclone. . . . . . . . . . . . . . . . . . . . . . . . . . 44ethacrynate sodium. . . . . . . . . . . . . . . . . . . . 50ethacrynic acid. . . . . . . . . . . . . . . . . . . . . . . . 50ethambutol. . . . . . . . . . . . . . . . . . . . . . . . . . . 17ethosuximide. . . . . . . . . . . . . . . . . . . . . . . . . 31ethynodiol diac-eth estradiol. . . . . . . . . . . . . 86etidronate disodium. . . . . . . . . . . . . . . . . . . . 63etodolac oral capsule. . . . . . . . . . . . . . . . . . . 40etodolac oral tablet. . . . . . . . . . . . . . . . . . . . 40etodolac oral tablet extended release 24 hr. . 40ETOPOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 25etoposide intravenous. . . . . . . . . . . . . . . . . . 25etoposide oral. . . . . . . . . . . . . . . . . . . . . . . . 25EUFLEXXA. . . . . . . . . . . . . . . . . . . . . . . . . . 40EVOTAZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10exemestane. . . . . . . . . . . . . . . . . . . . . . . . . . 25EXJADE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63ezetimibe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ezetimibe-simvastatin. . . . . . . . . . . . . . . . . . 54

FFABIOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58FABRAZYME INTRAVENOUS RECON SOLN35 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

FABRAZYME INTRAVENOUS RECON SOLN 5MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

falmina (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86famciclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 10famotidine (pf). . . . . . . . . . . . . . . . . . . . . . . . 76famotidine (pf)-nacl (iso-os). . . . . . . . . . . . . 76famotidine intravenous solution. . . . . . . . . . . 76famotidine oral suspension. . . . . . . . . . . . . . 76famotidine oral tablet 20 mg, 40 mg. . . . . . . 76FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG. 44FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG,8 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

FANAPT ORAL TABLETS,DOSE PACK. . . . 44FARESTON. . . . . . . . . . . . . . . . . . . . . . . . . . 25FARXIGA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

115

FARYDAK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25FASENRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 93FASLODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 25fayosim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86FAZACLO ORAL TABLET,DISINTEGRATING150 MG, 200 MG. . . . . . . . . . . . . . . . . . . . . 44

felbamate oral suspension. . . . . . . . . . . . . . . 31felbamate oral tablet. . . . . . . . . . . . . . . . . . . 31felodipine oral tablet extended release 24 hr. 50femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86fenofibrate micronized. . . . . . . . . . . . . . . . . . 54fenofibrate nanocrystallized. . . . . . . . . . . . . . 54FENOFIBRATE ORAL CAPSULE (BRAND). 54fenofibrate oral tablet. . . . . . . . . . . . . . . . . . . 54fenofibric acid. . . . . . . . . . . . . . . . . . . . . . . . . 54fenofibric acid (choline) oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 54

fenoprofen oral tablet. . . . . . . . . . . . . . . . . . . 40fentanyl citrate (pf) injection. . . . . . . . . . . . . . 37fentanyl citrate (pf) intravenous syringe 100mcg/2 ml (50 mcg/ml). . . . . . . . . . . . . . . . . . 37

fentanyl citrate buccal lozenge on a handle. . 37fentanyl transdermal patch. . . . . . . . . . . . . . 37FERRIPROX ORAL SOLUTION. . . . . . . . . . 63FERRIPROX ORAL TABLET. . . . . . . . . . . . . 63FETZIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44finasteride oral tablet 5 mg. . . . . . . . . . . . . . 96FIRAZYR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93FIRMAGON KIT W DILUENT SYRINGESUBCUTANEOUS RECON SOLN 120 MG. 25

FIRMAGON KIT W DILUENT SYRINGESUBCUTANEOUS RECON SOLN 80 MG. . 25

flavoxate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95flecainide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48FLOVENT DISKUS. . . . . . . . . . . . . . . . . . . . 93FLOVENT HFA AEROSOL INHALER 110MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 93

FLOVENT HFA AEROSOL INHALER 220MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 93

FLOVENT HFA AEROSOL INHALER 44MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 93

floxin otic (ear) drops. . . . . . . . . . . . . . . . . . . 66floxuridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

FLUAD 2017-2018 (65 YR UP)(PF). . . . . . . 79FLUARIX QUAD 2017-2018 (PF). . . . . . . . . 79FLUBLOK 2017-2018 (PF). . . . . . . . . . . . . . 79FLUBLOK QUAD 2017-2018 (PF). . . . . . . . . 79FLUCELVAX QUAD 2017-2018. . . . . . . . . . . 79FLUCELVAX QUAD 2017-2018 (PF). . . . . . . 80fluconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9fluconazole in dextrose(iso-o). . . . . . . . . . . . . 9fluconazole in nacl (iso-osm) intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . . 9

fluconazole in nacl (iso-osm) intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . . 9

flucytosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9fludarabine intravenous recon soln. . . . . . . . 26fludarabine intravenous solution. . . . . . . . . . 26fludrocortisone. . . . . . . . . . . . . . . . . . . . . . . . 66FLULAVAL QUAD 2017-2018. . . . . . . . . . . . 80FLULAVAL QUAD 2017-2018 (PF). . . . . . . . 80flumazenil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44FLUMIST QUAD 2017-2018. . . . . . . . . . . . . 80flunisolide nasal spray,non-aerosol 25 mcg(0.025 %). . . . . . . . . . . . . . . . . . . . . . . . . . . 93

fluocinolone. . . . . . . . . . . . . . . . . . . . . . . . . . 61fluocinolone acetonide oil. . . . . . . . . . . . . . . 66fluocinolone and shower cap. . . . . . . . . . . . . 61fluocinonide. . . . . . . . . . . . . . . . . . . . . . . . . . 61fluocinonide-e. . . . . . . . . . . . . . . . . . . . . . . . 61fluocinonide-emollient. . . . . . . . . . . . . . . . . . 61fluoride (sodium) oral drops. . . . . . . . . . . . . 101fluoride (sodium) oral tablet. . . . . . . . . . . . . 101fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodiumfluorid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

fluoritab oral tablet,chewable 0.5 mg (1.1 mgsodium fluorid). . . . . . . . . . . . . . . . . . . . . . 101

fluorometholone. . . . . . . . . . . . . . . . . . . . . . . 91fluorouracil intravenous solution 1 gram/20 ml,2.5 gram/50 ml, 500 mg/10 ml. . . . . . . . . . . 26

fluorouracil intravenous solution 5 gram/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

FLUOROURACIL TOPICAL CREAM 0.5 %(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

fluorouracil topical cream 5 %. . . . . . . . . . . . 57fluorouracil topical solution. . . . . . . . . . . . . . 57

116

fluoxetine oral capsule. . . . . . . . . . . . . . . . . . 44fluoxetine oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 44

fluoxetine oral solution. . . . . . . . . . . . . . . . . . 44fluoxetine oral tablet. . . . . . . . . . . . . . . . . . . . 44fluphenazine decanoate. . . . . . . . . . . . . . . . . 44fluphenazine hcl. . . . . . . . . . . . . . . . . . . . . . . 44flurandrenolide. . . . . . . . . . . . . . . . . . . . . . . . 61flurazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . 44flurbiprofen. . . . . . . . . . . . . . . . . . . . . . . . . . . 40flurbiprofen sodium. . . . . . . . . . . . . . . . . . . . 90flutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26fluticasone nasal. . . . . . . . . . . . . . . . . . . . . . 93fluticasone topical. . . . . . . . . . . . . . . . . . . . . 61fluvastatin oral capsule 20 mg. . . . . . . . . . . . 54fluvastatin oral capsule 40 mg. . . . . . . . . . . . 54fluvastatin oral tablet extended release 24 hr 54FLUVIRIN 2017-2018. . . . . . . . . . . . . . . . . . 80FLUVIRIN 2017-2018 (PF). . . . . . . . . . . . . . 80fluvoxamine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

fluvoxamine oral tablet. . . . . . . . . . . . . . . . . . 44FLUZONE HIGH-DOSE 2017-18 (PF). . . . . 80FLUZONE INTRADERM QUAD 2017-18. . . 80FLUZONE QUAD 2017-2018. . . . . . . . . . . . 80FLUZONE QUAD 2017-2018 (PF)INTRAMUSCULAR SUSPENSION. . . . . . . 80

FLUZONE QUAD 2017-2018 (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 80

FLUZONE QUAD PEDI 2017-18 (PF). . . . . . 80FML S.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . 91FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML). . . . . . . . . . . . . . . . . . . . . . . . . . . 26

FOLOTYN INTRAVENOUS SOLUTION 40MG/2 ML (20 MG/ML). . . . . . . . . . . . . . . . . 26

fomepizole. . . . . . . . . . . . . . . . . . . . . . . . . . . 80fondaparinux subcutaneous syringe 10 mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 2.5 mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 5 mg/0.4ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 7.5 mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FORFIVO XL. . . . . . . . . . . . . . . . . . . . . . . . . 44FORTEO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82fosamprenavir. . . . . . . . . . . . . . . . . . . . . . . . . 10fosinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50fosinopril-hydrochlorothiazide. . . . . . . . . . . . 50fosphenytoin injection solution 100 mg pe/2ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

fosphenytoin injection solution 500 mg pe/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

FREAMINE HBC 6.9 %. . . . . . . . . . . . . . . . 100freamine iii 10 %. . . . . . . . . . . . . . . . . . . . . 100frovatriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 34furosemide injection. . . . . . . . . . . . . . . . . . . . 50furosemide oral solution 10 mg/ml, 40 mg/5 ml(8 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . 50

furosemide oral tablet. . . . . . . . . . . . . . . . . . 50FUZEON SUBCUTANEOUS RECON SOLN 10fyavolv. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84FYCOMPA ORAL SUSPENSION. . . . . . . . . 31FYCOMPA ORAL TABLET. . . . . . . . . . . . . . . 31

Ggabapentin oral capsule. . . . . . . . . . . . . . . . . 31gabapentin oral solution 250 mg/5 ml. . . . . . 31gabapentin oral solution 250 mg/5 ml (5 ml), 300mg/6 ml (6 ml). . . . . . . . . . . . . . . . . . . . . . . 31

gabapentin oral tablet 600 mg, 800 mg. . . . . 31GABITRIL ORAL TABLET 12 MG, 16 MG. . . 32galantamine oral capsule,ext rel. pellets 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

galantamine oral solution. . . . . . . . . . . . . . . . 35galantamine oral tablet. . . . . . . . . . . . . . . . . 35GAMASTAN S/D. . . . . . . . . . . . . . . . . . . . . . 80GAMMAGARD LIQUID. . . . . . . . . . . . . . . . . 80GAMMAGARD S-D (IGA < 1 MCG/ML). . . . . 80GAMUNEX-C INJECTION SOLUTION 1GRAM/10 ML (10 %). . . . . . . . . . . . . . . . . . 80

GAMUNEX-C INJECTION SOLUTION 10GRAM/100 ML (10 %), 2.5 GRAM/25 ML(10 %), 20 GRAM/200 ML (10 %), 40GRAM/400 ML (10 %), 5 GRAM/50 ML (10%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

ganciclovir sodium intravenous recon soln. . 10ganciclovir sodium intravenous solution. . . . 10

117

GARDASIL 9 (PF). . . . . . . . . . . . . . . . . . . . . 80gatifloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 89GATTEX 30-VIAL. . . . . . . . . . . . . . . . . . . . . . 73GATTEX ONE-VIAL. . . . . . . . . . . . . . . . . . . . 73GAUZE PADS 2 X 2. . . . . . . . . . . . . . . . . . . 68gavilyte-c. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73gavilyte-g. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73gavilyte-n. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73GAZYVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26GEL-ONE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41GELSYN-3. . . . . . . . . . . . . . . . . . . . . . . . . . . 41gemcitabine intravenous recon soln 1 gram. 26gemcitabine intravenous recon soln 2 gram. 26gemcitabine intravenous recon soln 200 mg. 26gemcitabine intravenous solution 1 gram/26.3ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml). 26

gemcitabine intravenous solution 2 gram/52.6ml (38 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . 26

gemfibrozil. . . . . . . . . . . . . . . . . . . . . . . . . . . 54generlac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73gengraf oral capsule 100 mg, 25 mg. . . . . . . 26gengraf oral solution. . . . . . . . . . . . . . . . . . . 26gentak ophthalmic (eye) ointment. . . . . . . . . 89gentamicin in nacl (iso-osm) intravenouspiggyback 100 mg/100 ml, 60 mg/50 ml, 80mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 17

gentamicin in nacl (iso-osm) intravenouspiggyback 70 mg/50 ml, 90 mg/100 ml. . . . 17

gentamicin in nacl (iso-osm) intravenouspiggyback 80 mg/100 ml. . . . . . . . . . . . . . . 17

gentamicin injection solution 20 mg/2 ml. . . . 17gentamicin injection solution 40 mg/ml. . . . . 17gentamicin ophthalmic (eye) drops. . . . . . . . 89gentamicin sulfate (ped) (pf). . . . . . . . . . . . . 17gentamicin sulfate (pf) intravenous solution 100mg/10 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 17

gentamicin topical. . . . . . . . . . . . . . . . . . . . . 60GENVISC 850. . . . . . . . . . . . . . . . . . . . . . . . 41GENVOYA. . . . . . . . . . . . . . . . . . . . . . . . . . . 10GEODON INTRAMUSCULAR. . . . . . . . . . . . 44gianvi (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 86GILENYA ORAL CAPSULE 0.5 MG. . . . . . . 35GILOTRIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

GLASSIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63glatiramer subcutaneous syringe 20 mg/ml. . 35glatiramer subcutaneous syringe 40 mg/ml. . 35glatopa subcutaneous syringe 20 mg/ml. . . . 35glatopa subcutaneous syringe 40 mg/ml. . . . 35GLEOSTINE. . . . . . . . . . . . . . . . . . . . . . . . . . 26glimepiride. . . . . . . . . . . . . . . . . . . . . . . . . . . 68glipizide oral tablet. . . . . . . . . . . . . . . . . . . . . 68glipizide oral tablet extended release 24hr. . 68glipizide-metformin. . . . . . . . . . . . . . . . . . . . . 68GLUCAGEN HYPOKIT. . . . . . . . . . . . . . . . . 68GLUCAGON EMERGENCY KIT (HUMAN). . 68glyburide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68glyburide micronized. . . . . . . . . . . . . . . . . . . 68glyburide-metformin. . . . . . . . . . . . . . . . . . . . 68glycine urologic. . . . . . . . . . . . . . . . . . . . . . . 96glycine urologic solution. . . . . . . . . . . . . . . . . 96GLYCOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 97glycopyrrolate injection. . . . . . . . . . . . . . . . . 72glycopyrrolate oral tablet 1 mg, 2 mg. . . . . . . 72glydo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59GLYXAMBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 68granisetron (pf) intravenous solution 1 mg/ml (1ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

granisetron (pf) intravenous solution 100mcg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

granisetron hcl intravenous. . . . . . . . . . . . . . 73granisetron hcl oral. . . . . . . . . . . . . . . . . . . . 73GRANIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77GRASTEK. . . . . . . . . . . . . . . . . . . . . . . . . . . 80griseofulvin microsize. . . . . . . . . . . . . . . . . . . 9griseofulvin ultramicrosize. . . . . . . . . . . . . . . . 9guanfacine oral tablet. . . . . . . . . . . . . . . . . . 50guanfacine oral tablet extended release 24 hr 44guanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44GYNAZOLE-1. . . . . . . . . . . . . . . . . . . . . . . . 85

HHALAVEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26halobetasol propionate. . . . . . . . . . . . . . . . . 61haloperidol. . . . . . . . . . . . . . . . . . . . . . . . . . . 44haloperidol decanoate. . . . . . . . . . . . . . . . . . 44

118

haloperidol lactate injection. . . . . . . . . . . . . . 44haloperidol lactate intramuscular. . . . . . . . . . 44haloperidol lactate oral. . . . . . . . . . . . . . . . . . 44HARVONI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10HAVRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 80

HAVRIX (PF) INTRAMUSCULAR SYRINGE1,440 ELISA UNIT/ML. . . . . . . . . . . . . . . . . 80

HAVRIX (PF) INTRAMUSCULAR SYRINGE720 ELISA UNIT/0.5 ML. . . . . . . . . . . . . . . . 80

heather. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84hep flush-10 (pf). . . . . . . . . . . . . . . . . . . . . . . 53heparin (porcine) in 5 % dex intravenousparenteral solution 12,500 unit/250 ml. . . . . 53

heparin (porcine) in 5 % dex intravenousparenteral solution 20,000 unit/500 ml (40unit/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

heparin (porcine) in 5 % dex intravenousparenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml). . . . . . . 53

heparin (porcine) in nacl (pf). . . . . . . . . . . . . 53heparin (porcine) injection cartridge. . . . . . . 53heparin (porcine) injection solution. . . . . . . . 53heparin (porcine) injection syringe 5,000unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

heparin flush(porcine)-0.9nacl. . . . . . . . . . . . 53heparin lock flush. . . . . . . . . . . . . . . . . . . . . . 53heparin lock flush (porcine) intravenoussolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin lockflush(porcine)(pf). . . . . . . . . . . . 54heparin(porcine) in 0.45% nacl intravenousparenteral solution 25,000 unit/250 ml, 25,000unit/500 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin, porcine (pf) injection. . . . . . . . . . . . 54heparin, porcine (pf) intravenous syringe 1unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 54

HEPATAMINE 8%. . . . . . . . . . . . . . . . . . . . 100HERCEPTIN. . . . . . . . . . . . . . . . . . . . . . . . . 26hetastarch 6 % in 0.9 % nacl. . . . . . . . . . . . 100HETLIOZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44HEXALEN. . . . . . . . . . . . . . . . . . . . . . . . . . . 26HIBERIX (PF). . . . . . . . . . . . . . . . . . . . . . . . 80HORIZANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 35

HUMALOG JUNIOR KWIKPEN U-100. . . . . 68HUMALOG KWIKPEN INSULIN. . . . . . . . . . 68HUMALOG MIX 50-50 INSULN U-100. . . . . 68HUMALOG MIX 50-50 KWIKPEN. . . . . . . . . 68HUMALOG MIX 75-25 KWIKPEN. . . . . . . . . 68HUMALOG MIX 75-25(U-100)INSULN. . . . . 68HUMALOG U-100 INSULIN. . . . . . . . . . . . . . 68HUMATROPE. . . . . . . . . . . . . . . . . . . . . . . . . 77HUMIRA PEDIATRIC CROHN'S START. . . . 83HUMIRA PEN. . . . . . . . . . . . . . . . . . . . . . . . 83HUMIRA PEN CROHN'S-UC-HS START. . . 83HUMIRA PEN PSORIASIS-UVEITIS. . . . . . . 83HUMIRA SUBCUTANEOUS SYRINGE KIT 10MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.4 ML, 40MG/0.4 ML, 40 MG/0.8 ML. . . . . . . . . . . . . . 83

HUMIRA SUBCUTANEOUS SYRINGE KIT 20MG/0.2 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 83

HUMULIN 70/30 U-100 INSULIN. . . . . . . . . 68HUMULIN 70/30 U-100 KWIKPEN. . . . . . . . 68HUMULIN N NPH INSULIN KWIKPEN. . . . . 68HUMULIN N NPH U-100 INSULIN. . . . . . . . 69HUMULIN R REGULAR U-100 INSULN. . . . 69HUMULIN R U-500 (CONC) INSULIN. . . . . . 69HYALGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 41HYCAMTIN ORAL. . . . . . . . . . . . . . . . . . . . . 26hydralazine injection. . . . . . . . . . . . . . . . . . . 50hydralazine oral. . . . . . . . . . . . . . . . . . . . . . . 50hydrochlorothiazide. . . . . . . . . . . . . . . . . . . . 50hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml. . . . . . . . . . . . . . . . . . . . . 37

hydrocodone-acetaminophen oral tablet 10-300mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325mg, 7.5-300 mg, 7.5-325 mg. . . . . . . . . . . . 37

hydrocodone-ibuprofen oral tablet 10-200 mg,5-200 mg, 7.5-200 mg. . . . . . . . . . . . . . . . . 38

hydrocortisone butyr-emollient. . . . . . . . . . . . 61hydrocortisone butyrate. . . . . . . . . . . . . . . . . 61hydrocortisone oral. . . . . . . . . . . . . . . . . . . . 66hydrocortisone rectal. . . . . . . . . . . . . . . . . . . 73hydrocortisone topical cream 1 %, 2.5 %. . . 61hydrocortisone topical cream with perinealapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 74

hydrocortisone topical lotion 2.5 %. . . . . . . . 61

119

hydrocortisone topical ointment 1 %, 2.5 %. . 61hydrocortisone valerate. . . . . . . . . . . . . . . . . 61hydrocortisone-acetic acid. . . . . . . . . . . . . . . 66hydrocortisone-min oil-wht pet. . . . . . . . . . . . 61hydrocortisone-pramoxine rectal cream 1-1%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

hydromorphone (pf). . . . . . . . . . . . . . . . . . . . 38hydromorphone injection solution 1 mg/ml. . 38hydromorphone injection solution 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone injection syringe 1 mg/ml, 2mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone injection syringe 4 mg/ml. . . 38hydromorphone oral liquid. . . . . . . . . . . . . . . 38hydromorphone oral tablet. . . . . . . . . . . . . . . 38hydromorphone oral tablet extended release 24hr 12 mg, 8 mg. . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone oral tablet extended release 24hr 16 mg, 32 mg. . . . . . . . . . . . . . . . . . . . . . 38

hydroxychloroquine. . . . . . . . . . . . . . . . . . . . 17hydroxyprogesterone caproate. . . . . . . . . . . 84hydroxyurea. . . . . . . . . . . . . . . . . . . . . . . . . . 26hydroxyzine hcl intramuscular. . . . . . . . . . . . 92hydroxyzine hcl oral solution 10 mg/5 ml. . . . 92hydroxyzine hcl oral tablet. . . . . . . . . . . . . . . 92hydroxyzine pamoate. . . . . . . . . . . . . . . . . . . 92HYMOVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41HYPER-SAL. . . . . . . . . . . . . . . . . . . . . . . . . 93HYPERRAB (PF). . . . . . . . . . . . . . . . . . . . . . 80HYPERRAB S/D (PF). . . . . . . . . . . . . . . . . . 80

Iibandronate intravenous. . . . . . . . . . . . . . . . 82ibandronate oral. . . . . . . . . . . . . . . . . . . . . . . 82IBRANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ibu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ibuprofen lysine (pf). . . . . . . . . . . . . . . . . . . . 41ibuprofen oral suspension. . . . . . . . . . . . . . . 41ibuprofen oral tablet 400 mg, 600 mg, 800mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ibuprofen-oxycodone. . . . . . . . . . . . . . . . . . . 38ibutilide fumarate. . . . . . . . . . . . . . . . . . . . . . 48ICLUSIG ORAL TABLET 15 MG. . . . . . . . . . 26

ICLUSIG ORAL TABLET 45 MG. . . . . . . . . . 26idarubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26IDHIFA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ifosfamide intravenous recon soln 1 gram. . . 26ifosfamide intravenous recon soln 3 gram. . . 26ifosfamide intravenous solution. . . . . . . . . . . 26ILARIS (PF) SUBCUTANEOUS SOLUTION. 77imatinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26IMBRUVICA. . . . . . . . . . . . . . . . . . . . . . . . . . 26IMFINZI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26imipenem-cilastatin. . . . . . . . . . . . . . . . . . . . 17imipramine hcl. . . . . . . . . . . . . . . . . . . . . . . . 44imipramine pamoate. . . . . . . . . . . . . . . . . . . 44imiquimod. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57IMOVAX RABIES VACCINE (PF). . . . . . . . . 80IMPAVIDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 17INCRELEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 63INCRUSE ELLIPTA. . . . . . . . . . . . . . . . . . . . 94indapamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 50indomethacin oral capsule. . . . . . . . . . . . . . . 41indomethacin oral capsule, extended release 41indomethacin sodium. . . . . . . . . . . . . . . . . . . 41INFANRIX (DTAP) (PF). . . . . . . . . . . . . . . . . 80INFLECTRA. . . . . . . . . . . . . . . . . . . . . . . . . . 74INGREZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 35INLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26INPEN (FOR HUMALOG). . . . . . . . . . . . . . . 69INSULIN PEN NEEDLE. . . . . . . . . . . . . . . . . 69INSULIN SYRINGE (DISP) U-100 0.3 ML. . . 69INSULIN SYRINGE (DISP) U-100 1 ML. . . . 69INSULIN SYRINGE (DISP) U-100 1/2 ML. . . 69INTELENCE ORAL TABLET 100 MG, 200MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

INTELENCE ORAL TABLET 25 MG. . . . . . . 11intralipid intravenous emulsion 20 %. . . . . . 100INTRALIPID INTRAVENOUS EMULSION 30%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

INTRON A INJECTION RECON SOLN 10MILLION UNIT (1 ML). . . . . . . . . . . . . . . . . 77

INTRON A INJECTION RECON SOLN 18MILLION UNIT (1 ML), 50 MILLION UNIT (1ML). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

INTRON A INJECTION SOLUTION. . . . . . . . 77

120

introvale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86INVANZ INJECTION. . . . . . . . . . . . . . . . . . . 17INVANZ INTRAVENOUS. . . . . . . . . . . . . . . . 17INVEGA SUSTENNA INTRAMUSCULARSYRINGE 117 MG/0.75 ML, 156 MG/ML, 234MG/1.5 ML, 78 MG/0.5 ML. . . . . . . . . . . . . . 45

INVEGA SUSTENNA INTRAMUSCULARSYRINGE 39 MG/0.25 ML. . . . . . . . . . . . . . 45

INVEGA TRINZA. . . . . . . . . . . . . . . . . . . . . . 45INVIRASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11INVOKAMET. . . . . . . . . . . . . . . . . . . . . . . . . 69INVOKAMET XR. . . . . . . . . . . . . . . . . . . . . . 69INVOKANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 69IPOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80ipratropium bromide inhalation. . . . . . . . . . . 94ipratropium bromide nasal spray,non-aerosol0.03 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

ipratropium bromide nasal spray,non-aerosol 42mcg (0.06 %). . . . . . . . . . . . . . . . . . . . . . . . 65

ipratropium-albuterol. . . . . . . . . . . . . . . . . . . 94irbesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50irbesartan-hydrochlorothiazide. . . . . . . . . . . 50IRESSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26irinotecan intravenous solution 100 mg/5 ml. 27irinotecan intravenous solution 40 mg/2 ml. . 27irinotecan intravenous solution 500 mg/25 ml 27ISENTRESS HD. . . . . . . . . . . . . . . . . . . . . . 11ISENTRESS ORAL POWDER IN PACKET. . 11ISENTRESS ORAL TABLET. . . . . . . . . . . . . 11ISENTRESS ORAL TABLET,CHEWABLE 100MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ISENTRESS ORAL TABLET,CHEWABLE 25MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

isibloom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86isoniazid injection. . . . . . . . . . . . . . . . . . . . . . 17isoniazid oral. . . . . . . . . . . . . . . . . . . . . . . . . 17isoproterenol hcl. . . . . . . . . . . . . . . . . . . . . . 56isosorbide dinitrate oral tablet. . . . . . . . . . . . 56isosorbide dinitrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

isosorbide mononitrate oral tablet. . . . . . . . . 56isosorbide mononitrate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 56

isotretinoin. . . . . . . . . . . . . . . . . . . . . . . . . . . 58

isradipine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ISTODAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27itraconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 9ivermectin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17IXEMPRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27IXIARO (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 81

JJADENU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63JADENU SPRINKLE. . . . . . . . . . . . . . . . . . . 63JAKAFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27jantoven. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JANUMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69JANUMET XR. . . . . . . . . . . . . . . . . . . . . . . . 69JANUVIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69JARDIANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 69jencycla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84jevantique lo. . . . . . . . . . . . . . . . . . . . . . . . . . 84JEVTANA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27jinteli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84jolessa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86jolivette. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84juleber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86JULUCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11junel 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 86junel 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . 86junel fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 86junel fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . 86junel fe 24. . . . . . . . . . . . . . . . . . . . . . . . . . . 86JUXTAPID. . . . . . . . . . . . . . . . . . . . . . . . . . . 54JYNARQUE. . . . . . . . . . . . . . . . . . . . . . . . . . 71

Kk-effervescent. . . . . . . . . . . . . . . . . . . . . . . . 97k-tab oral tablet extended release 8 meq. . . 97KADCYLA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27kaitlib fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86KALETRA ORAL TABLET 100-25 MG. . . . . . 11KALETRA ORAL TABLET 200-50 MG. . . . . . 11KALYDECO. . . . . . . . . . . . . . . . . . . . . . . . . . 94KANUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71kariva (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 86

121

kelnor 1-50. . . . . . . . . . . . . . . . . . . . . . . . . . . 87kelnor 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 86KEPIVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 23ketoconazole oral. . . . . . . . . . . . . . . . . . . . . . . 9ketoconazole topical. . . . . . . . . . . . . . . . . . . 60ketoprofen oral capsule. . . . . . . . . . . . . . . . . 41ketoprofen oral capsule,ext rel. pellets 24 hr 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ketorolac injection cartridge 15 mg/ml. . . . . . 41ketorolac injection cartridge 30 mg/ml. . . . . . 41ketorolac injection solution 15 mg/ml, 30 mg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ketorolac injection syringe. . . . . . . . . . . . . . . 41ketorolac intramuscular cartridge. . . . . . . . . . 41ketorolac intramuscular solution. . . . . . . . . . 41ketorolac intramuscular syringe. . . . . . . . . . . 41ketorolac ophthalmic (eye). . . . . . . . . . . . . . . 90ketorolac oral. . . . . . . . . . . . . . . . . . . . . . . . . 41KEVEYIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35KEVZARA SUBCUTANEOUS SYRINGE. . . 83KEYTRUDA INTRAVENOUS SOLUTION. . . 27KHEDEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . 45kimidess (28). . . . . . . . . . . . . . . . . . . . . . . . . 87KINERET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83KINRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 81

KINRIX (PF) INTRAMUSCULAR SYRINGE. 81kionex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63kionex (with sorbitol). . . . . . . . . . . . . . . . . . . 63KISQALI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27KISQALI FEMARA CO-PACK. . . . . . . . . . . . 27klor-con 10 oral tablet extended release. . . . 97klor-con 20 meq packet. . . . . . . . . . . . . . . . . 97klor-con 8 oral tablet extended release. . . . . 97klor-con m10 oral tablet,er particles/crystals. 97klor-con m15 oral tablet,er particles/crystals. 97klor-con m20 oral tablet,er particles/crystals. 97klor-con sprinkle oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

klor-con/ef. . . . . . . . . . . . . . . . . . . . . . . . . . . 97KOMBIGLYZE XR. . . . . . . . . . . . . . . . . . . . . 69KORLYM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71KRYSTEXXA. . . . . . . . . . . . . . . . . . . . . . . . . 82

kurvelo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87KUVAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71KYNAMRO. . . . . . . . . . . . . . . . . . . . . . . . . . . 54KYPROLIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Ll norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),0.15 mg-30 mcg (84)/10 mcg (7). . . . . . . . . 87

l norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.15 mg-20 mcg/ 0.15 mg-25mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

labetalol intravenous solution. . . . . . . . . . . . 50labetalol intravenous syringe 20 mg/4 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

labetalol oral. . . . . . . . . . . . . . . . . . . . . . . . . 50LACRISERT. . . . . . . . . . . . . . . . . . . . . . . . . . 90lactated ringers intravenous. . . . . . . . . . . . . . 97lactated ringers irrigation. . . . . . . . . . . . . . . . 62lactulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74lamivudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 11lamivudine-zidovudine. . . . . . . . . . . . . . . . . . 11lamotrigine oral tablet. . . . . . . . . . . . . . . . . . 32lamotrigine oral tablet disintegrating, dose pk 32lamotrigine oral tablet extended release 24hr 32lamotrigine oral tablet, chewable dispersible. 32lamotrigine oral tablet,disintegrating. . . . . . . 32lamotrigine oral tablets,dose pack. . . . . . . . . 32lansoprazole oral capsule,delayed release(dr/ec) 15 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 76

lansoprazole oral capsule,delayed release(dr/ec) 30 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 76

lansoprazole oral tablet,disintegrat, delay rel 76lanthanum oral tablet,chewable. . . . . . . . . . . 63LANTUS SOLOSTAR U-100 INSULIN. . . . . 69LANTUS U-100 INSULIN. . . . . . . . . . . . . . . . 69larin 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 87larin 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . . 87larin 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87larin fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 87larin fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . . 87larissia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87LARTRUVO. . . . . . . . . . . . . . . . . . . . . . . . . . 27

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latanoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . 90LATUDA ORAL TABLET 120 MG. . . . . . . . . 45LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG,80 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

layolis fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87leena 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87leflunomide. . . . . . . . . . . . . . . . . . . . . . . . . . . 83LEMTRADA. . . . . . . . . . . . . . . . . . . . . . . . . . 35LENVIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27lessina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87LETAIRIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94letrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27leucovorin calcium injection recon soln 100 mg,350 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

leucovorin calcium injection recon soln 200 mg,50 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

leucovorin calcium injection recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

leucovorin calcium oral. . . . . . . . . . . . . . . . . 23LEUKERAN. . . . . . . . . . . . . . . . . . . . . . . . . . 27LEUKINE INJECTION RECON SOLN. . . . . . 77leuprolide subcutaneous kit. . . . . . . . . . . . . . 27levalbuterol hcl. . . . . . . . . . . . . . . . . . . . . . . . 94levetiracetam in nacl (iso-os) intravenouspiggyback 1,000 mg/100 ml, 1,500 mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml. . . . . . . . . . . . . . 32

levetiracetam intravenous. . . . . . . . . . . . . . . 32levetiracetam oral solution 100 mg/ml. . . . . . 32levetiracetam oral solution 500 mg/5 ml (5ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

levetiracetam oral tablet. . . . . . . . . . . . . . . . . 32levetiracetam oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

levobunolol ophthalmic (eye) drops 0.5 %. . . 89levocarnitine (with sugar). . . . . . . . . . . . . . . . 63levocarnitine oral tablet. . . . . . . . . . . . . . . . . 63levocetirizine oral solution. . . . . . . . . . . . . . . 92levocetirizine oral tablet. . . . . . . . . . . . . . . . . 92levofloxacin in d5w intravenous piggyback 250mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 20

levofloxacin in d5w intravenous piggyback 500mg/100 ml, 750 mg/150 ml. . . . . . . . . . . . . . 20

levofloxacin intravenous. . . . . . . . . . . . . . . . 20levofloxacin ophthalmic (eye). . . . . . . . . . . . 89levofloxacin oral. . . . . . . . . . . . . . . . . . . . . . . 20LEVOLEUCOVORIN INTRAVENOUS RECONSOLN 175 MG (BRAND). . . . . . . . . . . . . . . 23

levoleucovorin intravenous recon soln 50 mg 23levoleucovorin intravenous solution. . . . . . . . 23levonest (28). . . . . . . . . . . . . . . . . . . . . . . . . 87levonorg-eth estrad triphasic. . . . . . . . . . . . . 87levonorgestrel-ethinyl estrad. . . . . . . . . . . . . 87levora-28. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87levorphanol tartrate. . . . . . . . . . . . . . . . . . . . 38levothyroxine intravenous recon soln 200 mcg,500 mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

levothyroxine oral. . . . . . . . . . . . . . . . . . . . . . 72levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,137 mcg, 150 mcg, 175 mcg, 200 mcg, 25mcg, 50 mcg, 75 mcg, 88 mcg. . . . . . . . . . . 72

LEXIVA ORAL SUSPENSION. . . . . . . . . . . . 11lidocaine (pf) in d7.5w. . . . . . . . . . . . . . . . . . 48lidocaine (pf) injection solution 10 mg/ml (1 %),20 mg/ml (2 %), 40 mg/ml (4 %). . . . . . . . . 59

lidocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine (pf) injection solution 5 mg/ml (0.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine (pf) intravenous solution. . . . . . . . . 48lidocaine (pf) intravenous syringe. . . . . . . . . 48lidocaine hcl injection solution 10 mg/ml (1 %), 5mg/ml (0.5 %). . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine hcl injection solution 20 mg/ml (2%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine hcl laryngotracheal. . . . . . . . . . . . . 59lidocaine hcl mucous membrane jelly. . . . . . 59lidocaine hcl mucous membrane jelly inapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine hcl mucous membrane solution 4 %(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine in 5 % dextrose (pf) intravenousparenteral solution 4 mg/ml (0.4 %), 8 mg/ml(0.8 %). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

lidocaine topical adhesive patch,medicated. 59lidocaine topical ointment. . . . . . . . . . . . . . . 59lidocaine viscous. . . . . . . . . . . . . . . . . . . . . . 59

123

lidocaine-epinephrine injection solution0.5 %-1:200,000, 1.5 %-1:200,000, 2 %-1:200,000. . . . . . . . . . . . . . . . . . . . . . . . . . . 59

lidocaine-epinephrine injection solution1 %-1:100,000, 2 %-1:100,000. . . . . . . . . . 59

lidocaine-prilocaine topical cream. . . . . . . . . 59lillow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87lincomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 17lindane topical shampoo. . . . . . . . . . . . . . . . 62linezolid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17linezolid in dextrose 5%. . . . . . . . . . . . . . . . . 17linezolid-0.9% sodium chloride. . . . . . . . . . . 18LINZESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74liothyronine intravenous. . . . . . . . . . . . . . . . . 72liothyronine oral. . . . . . . . . . . . . . . . . . . . . . . 72lisinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50lisinopril-hydrochlorothiazide. . . . . . . . . . . . . 50lithium carbonate oral capsule. . . . . . . . . . . . 45lithium carbonate oral tablet. . . . . . . . . . . . . . 45lithium carbonate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

lithium citrate oral solution 8 meq/5 ml. . . . . 45lmd 10 % in 0.9 % sodium chlor. . . . . . . . . . . 63lmd 10 % in 5 % dextrose. . . . . . . . . . . . . . . 64LONSURF. . . . . . . . . . . . . . . . . . . . . . . . . . . 27loperamide oral capsule. . . . . . . . . . . . . . . . . 72lopinavir-ritonavir. . . . . . . . . . . . . . . . . . . . . . 11lopreeza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84lorazepam injection solution. . . . . . . . . . . . . 45lorazepam injection syringe. . . . . . . . . . . . . . 45lorazepam intensol. . . . . . . . . . . . . . . . . . . . . 45lorazepam oral. . . . . . . . . . . . . . . . . . . . . . . . 45lorcet (hydrocodone). . . . . . . . . . . . . . . . . . . 38lorcet hd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38lorcet plus oral tablet 7.5-325 mg. . . . . . . . . 38loryna (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 87losartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50losartan-hydrochlorothiazide. . . . . . . . . . . . . 50lovastatin oral tablet 10 mg. . . . . . . . . . . . . . 55lovastatin oral tablet 20 mg, 40 mg. . . . . . . . 55low-ogestrel (28). . . . . . . . . . . . . . . . . . . . . . 87loxapine succinate. . . . . . . . . . . . . . . . . . . . . 45

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodiumfluorid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

LUPANETA PACK (1 MONTH). . . . . . . . . . . 85LUPANETA PACK (3 MONTH). . . . . . . . . . . 85LUPRON DEPOT. . . . . . . . . . . . . . . . . . . . . . 27LUPRON DEPOT (3 MONTH). . . . . . . . . . . . 27LUPRON DEPOT (4 MONTH). . . . . . . . . . . . 27LUPRON DEPOT (6 MONTH). . . . . . . . . . . . 27LUPRON DEPOT-PED. . . . . . . . . . . . . . . . . 27LUPRON DEPOT-PED (3 MONTH). . . . . . . 27lutera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 87LUZU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60LYNPARZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27LYRICA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32LYSODREN. . . . . . . . . . . . . . . . . . . . . . . . . . 27lyza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

MM-M-R II (PF). . . . . . . . . . . . . . . . . . . . . . . . . 81mafenide acetate. . . . . . . . . . . . . . . . . . . . . . 60magnesium chloride injection. . . . . . . . . . . . 97magnesium sulfate in water intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 97

magnesium sulfate in water intravenouspiggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

magnesium sulfate in water intravenouspiggyback 4 gram/100 ml (4 %). . . . . . . . . . 97

magnesium sulfate injection solution. . . . . . . 97magnesium sulfate injection syringe. . . . . . . 97MAKENA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84MAKENA (PF). . . . . . . . . . . . . . . . . . . . . . . . 84malathion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62mannitol 20 %. . . . . . . . . . . . . . . . . . . . . . . . 50mannitol 25 % intravenous solution. . . . . . . . 50maprotiline. . . . . . . . . . . . . . . . . . . . . . . . . . . 45marcaine (pf) injection solution 0.75 % (7.5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

marlissa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87MARPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 45MATULANE. . . . . . . . . . . . . . . . . . . . . . . . . . 27matzim la oral tablet extended release 24 hr. 50

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MAVYRET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11meclizine oral tablet 12.5 mg, 25 mg. . . . . . . 74meclofenamate. . . . . . . . . . . . . . . . . . . . . . . . 41medroxyprogesterone. . . . . . . . . . . . . . . . . . 84mefenamic acid. . . . . . . . . . . . . . . . . . . . . . . 41mefloquine. . . . . . . . . . . . . . . . . . . . . . . . . . . 18megestrol oral suspension 400 mg/10 ml (10ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

megestrol oral suspension 400 mg/10 ml (40mg/ml), 625 mg/5 ml. . . . . . . . . . . . . . . . . . 27

megestrol oral tablet. . . . . . . . . . . . . . . . . . . 27MEKINIST. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27melodetta 24 fe. . . . . . . . . . . . . . . . . . . . . . . 87meloxicam oral suspension. . . . . . . . . . . . . . 41meloxicam oral tablet. . . . . . . . . . . . . . . . . . . 41melphalan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27melphalan hcl. . . . . . . . . . . . . . . . . . . . . . . . . 27memantine oral capsule,sprinkle,er 24hr. . . . 35memantine oral solution. . . . . . . . . . . . . . . . . 35memantine oral tablet. . . . . . . . . . . . . . . . . . 35MENACTRA (PF) INTRAMUSCULARSOLUTION. . . . . . . . . . . . . . . . . . . . . . . . . . 81

MENVEO A-C-Y-W-135-DIP (PF). . . . . . . . . 81meperidine (pf) injection solution 100 mg/ml, 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

meperidine (pf) injection solution 25 mg/ml. . 38meperidine injection cartridge. . . . . . . . . . . . 38meperidine oral. . . . . . . . . . . . . . . . . . . . . . . 38meprobamate. . . . . . . . . . . . . . . . . . . . . . . . . 36mercaptopurine. . . . . . . . . . . . . . . . . . . . . . . 27meropenem. . . . . . . . . . . . . . . . . . . . . . . . . . 18mesalamine oral tablet,delayed release (dr/ec)1.2 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

mesalamine rectal. . . . . . . . . . . . . . . . . . . . . 74mesna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23MESNEX ORAL. . . . . . . . . . . . . . . . . . . . . . . 23MESTINON ORAL SYRUP. . . . . . . . . . . . . . 36metadate er oral tablet extended release. . . 45metaproterenol. . . . . . . . . . . . . . . . . . . . . . . . 94metaxall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36metaxalone. . . . . . . . . . . . . . . . . . . . . . . . . . . 36metformin oral tablet. . . . . . . . . . . . . . . . . . . 69

metformin oral tablet extended release (osm)24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

metformin oral tablet extended release 24 hr 69metformin oral tablet,er gast.retention 24 hr. 69methadone injection solution. . . . . . . . . . . . . 38methadone intensol. . . . . . . . . . . . . . . . . . . . 38methadone oral concentrate. . . . . . . . . . . . . 38methadone oral solution. . . . . . . . . . . . . . . . 38methadone oral tablet. . . . . . . . . . . . . . . . . . 38methadose oral concentrate. . . . . . . . . . . . . 38methamphetamine. . . . . . . . . . . . . . . . . . . . . 45methazolamide. . . . . . . . . . . . . . . . . . . . . . . . 90methenamine hippurate. . . . . . . . . . . . . . . . . 22methenamine mandelate. . . . . . . . . . . . . . . . 22methergine. . . . . . . . . . . . . . . . . . . . . . . . . . . 88methimazole oral tablet 10 mg, 5 mg. . . . . . . 67METHITEST. . . . . . . . . . . . . . . . . . . . . . . . . . 71methocarbamol injection. . . . . . . . . . . . . . . . 36methocarbamol oral. . . . . . . . . . . . . . . . . . . . 36methotrexate sodium (pf) injection recon soln 27methotrexate sodium (pf) injection solution. . 27methotrexate sodium injection. . . . . . . . . . . . 27methotrexate sodium oral. . . . . . . . . . . . . . . 27methoxsalen. . . . . . . . . . . . . . . . . . . . . . . . . . 57methscopolamine. . . . . . . . . . . . . . . . . . . . . . 72methyclothiazide. . . . . . . . . . . . . . . . . . . . . . 50methyldopa. . . . . . . . . . . . . . . . . . . . . . . . . . . 50methyldopa-hydrochlorothiazide. . . . . . . . . . 50methyldopate. . . . . . . . . . . . . . . . . . . . . . . . . 50methylergonovine injection. . . . . . . . . . . . . . 88methylergonovine oral. . . . . . . . . . . . . . . . . . 88methylphenidate hcl oral capsule, er biphasic30-70 10 mg, 20 mg. . . . . . . . . . . . . . . . . . . 45

methylphenidate hcl oral capsule, er biphasic30-70 30 mg, 40 mg, 50 mg, 60 mg. . . . . . . 45

methylphenidate hcl oral capsule,er biphasic50-50 10 mg, 20 mg. . . . . . . . . . . . . . . . . . . 45

methylphenidate hcl oral capsule,er biphasic50-50 30 mg, 40 mg, 60 mg. . . . . . . . . . . . . 45

methylphenidate hcl oral solution. . . . . . . . . 45methylphenidate hcl oral tablet. . . . . . . . . . . 45methylphenidate hcl oral tablet extendedrelease 10 mg. . . . . . . . . . . . . . . . . . . . . . . 45

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methylphenidate hcl oral tablet extendedrelease 20 mg. . . . . . . . . . . . . . . . . . . . . . . 45

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg, 27 mg, 54 mg. . . . . . . 45

methylphenidate hcl oral tablet extendedrelease 24hr 36 mg. . . . . . . . . . . . . . . . . . . 45

methylphenidate hcl oral tablet,chewable. . . 46methylprednisolone acetate. . . . . . . . . . . . . . 66methylprednisolone oral tablet. . . . . . . . . . . . 66methylprednisolone oral tablets,dose pack. . 66methylprednisolone sodium succ injection reconsoln 125 mg, 40 mg. . . . . . . . . . . . . . . . . . . 67

methylprednisolone sodium succ intravenous 67methyltestosterone oral capsule. . . . . . . . . . 71metipranolol. . . . . . . . . . . . . . . . . . . . . . . . . . 89metoclopramide hcl injection solution. . . . . . 74metoclopramide hcl injection syringe. . . . . . . 74metoclopramide hcl oral solution. . . . . . . . . . 74metoclopramide hcl oral tablet. . . . . . . . . . . . 74metoclopramide hcl oral tablet,disintegrating 74metolazone. . . . . . . . . . . . . . . . . . . . . . . . . . . 50metoprolol succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 50

metoprolol ta-hydrochlorothiaz. . . . . . . . . . . 50metoprolol tartrate intravenous solution. . . . . 50metoprolol tartrate intravenous syringe. . . . . 51metoprolol tartrate oral tablet. . . . . . . . . . . . . 51metro i.v.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18metronidazole in nacl (iso-os). . . . . . . . . . . . 18metronidazole oral. . . . . . . . . . . . . . . . . . . . . 18metronidazole topical. . . . . . . . . . . . . . . . . . . 58metronidazole vaginal. . . . . . . . . . . . . . . . . . 85mexiletine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48MIACALCIN INJECTION. . . . . . . . . . . . . . . . 71mibelas 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . 87miconazole-3 vaginal suppository. . . . . . . . . 85microgestin 1.5/30 (21). . . . . . . . . . . . . . . . . 87microgestin 1/20 (21). . . . . . . . . . . . . . . . . . . 87microgestin fe 1.5/30 (28). . . . . . . . . . . . . . . 87microgestin fe 1/20 (28). . . . . . . . . . . . . . . . . 87midazolam (pf) injection. . . . . . . . . . . . . . . . . 46midazolam injection. . . . . . . . . . . . . . . . . . . . 46midazolam oral syrup 2 mg/ml. . . . . . . . . . . . 46

midodrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64migergot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34miglitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69miglustat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87millipred dp. . . . . . . . . . . . . . . . . . . . . . . . . . 67millipred oral tablet. . . . . . . . . . . . . . . . . . . . . 67milrinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56milrinone in 5 % dextrose. . . . . . . . . . . . . . . 56mimvey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84mimvey lo. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84minocycline oral capsule. . . . . . . . . . . . . . . . 21minocycline oral tablet. . . . . . . . . . . . . . . . . . 21minocycline oral tablet extended release 24 hr115 mg, 65 mg. . . . . . . . . . . . . . . . . . . . . . . 21

minocycline oral tablet extended release 24 hr135 mg, 45 mg, 90 mg. . . . . . . . . . . . . . . . . 21

minoxidil oral. . . . . . . . . . . . . . . . . . . . . . . . . 51miostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90mirtazapine oral tablet. . . . . . . . . . . . . . . . . . 46mirtazapine oral tablet,disintegrating. . . . . . . 46misoprostol. . . . . . . . . . . . . . . . . . . . . . . . . . . 76mitomycin intravenous recon soln 20 mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

mitomycin intravenous recon soln 40 mg. . . 27mitoxantrone. . . . . . . . . . . . . . . . . . . . . . . . . 27modafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46moderiba. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11moderiba dose pack oral tablets,dose pack 200mg (28)- 400 mg (28), 400-400 mg (28)-mg(28), 600-400 mg (28)-mg (28). . . . . . . . . . . 11

moderiba dose pack oral tablets,dose pack 400mg (7)- 400 mg (7). . . . . . . . . . . . . . . . . . . . 11

moderiba dose pack oral tablets,dose pack 600mg (7)- 600 mg (7). . . . . . . . . . . . . . . . . . . . 11

moderiba dose pack oral tablets,dose pack600-600 mg (28)-mg (28). . . . . . . . . . . . . . . 11

moexipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51moexipril-hydrochlorothiazide. . . . . . . . . . . . 51mometasone nasal. . . . . . . . . . . . . . . . . . . . 94mometasone topical. . . . . . . . . . . . . . . . . . . . 61mondoxyne nl. . . . . . . . . . . . . . . . . . . . . . . . 21mono-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . 87

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monoject 0.9% sodium chloride. . . . . . . . . . . 64monoject prefill advanced ns. . . . . . . . . . . . . 64monoject prefill saline flush. . . . . . . . . . . . . . 64mononessa (28). . . . . . . . . . . . . . . . . . . . . . . 87MONOVISC. . . . . . . . . . . . . . . . . . . . . . . . . . 41montelukast. . . . . . . . . . . . . . . . . . . . . . . . . . 94morgidox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21morphine (pf) injection solution 0.5 mg/ml. . . 38morphine (pf) injection solution 1 mg/ml. . . . 38morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml. . . . . . . . . . . . 38

morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml. . . . . . . . . . . . . 38

morphine concentrate oral solution. . . . . . . . 38MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine injection solution 8 mg/ml. . . . . . . 39morphine injection syringe 10 mg/ml, 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine injection syringe 5 mg/ml, 8 mg/ml 39morphine intravenous cartridge 10 mg/ml, 2 mg/ml, 4 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 39

MORPHINE INTRAVENOUS CARTRIDGE 8MG/ML (BRAND). . . . . . . . . . . . . . . . . . . . . 39

morphine intravenous solution 10 mg/ml. . . . 39MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 39

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 39

morphine intravenous syringe 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine oral capsule, er multiphase 24 hr. . 39morphine oral capsule,extend.release pellets 39morphine oral solution. . . . . . . . . . . . . . . . . . 39morphine oral tablet. . . . . . . . . . . . . . . . . . . . 39morphine oral tablet extended release. . . . . 39moxifloxacin in nacl (iso-osm). . . . . . . . . . . . 20moxifloxacin ophthalmic (eye). . . . . . . . . . . . 89moxifloxacin oral. . . . . . . . . . . . . . . . . . . . . . 20MOZOBIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77MULTAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48multi-vit with fluoride-iron. . . . . . . . . . . . . . . 101multi-vitamin with fluoride oral drops. . . . . . 101

multivit-fluor (vit e acetate). . . . . . . . . . . . . . 101multivitamin with fluoride. . . . . . . . . . . . . . . 101multivitamins with fluoride. . . . . . . . . . . . . . 101mupirocin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60mupirocin calcium. . . . . . . . . . . . . . . . . . . . . 60MUSTARGEN. . . . . . . . . . . . . . . . . . . . . . . . . 27mvc-fluoride. . . . . . . . . . . . . . . . . . . . . . . . . 101MYALEPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71MYCAMINE. . . . . . . . . . . . . . . . . . . . . . . . . . . 9mycophenolate mofetil hcl. . . . . . . . . . . . . . . 28mycophenolate mofetil oral capsule. . . . . . . 28mycophenolate mofetil oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 28

mycophenolate mofetil oral tablet. . . . . . . . . 28mycophenolate sodium oral tablet,delayedrelease (dr/ec). . . . . . . . . . . . . . . . . . . . . . . 28

MYLERAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 28MYLOTARG. . . . . . . . . . . . . . . . . . . . . . . . . . 28myorisan oral capsule 10 mg, 20 mg, 40 mg. 58myorisan oral capsule 30 mg. . . . . . . . . . . . . 58MYTESI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72myzilra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Nnabumetone. . . . . . . . . . . . . . . . . . . . . . . . . . 41nadolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51nadolol-bendroflumethiazide. . . . . . . . . . . . . 51nafcillin in dextrose iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 19

nafcillin in dextrose iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 19

nafcillin injection recon soln 1 gram. . . . . . . . 19nafcillin injection recon soln 10 gram. . . . . . . 19nafcillin injection recon soln 2 gram. . . . . . . . 19nafcillin intravenous recon soln 1 gram. . . . . 19nafcillin intravenous recon soln 2 gram. . . . . 19naftifine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60NAGLAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 71nalbuphine. . . . . . . . . . . . . . . . . . . . . . . . . . . 41naloxone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41naltrexone. . . . . . . . . . . . . . . . . . . . . . . . . . . 41naproxen oral suspension. . . . . . . . . . . . . . . 41naproxen oral tablet. . . . . . . . . . . . . . . . . . . . 41

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naproxen oral tablet,delayed release (dr/ec). 41naproxen sodium oral tablet 275 mg, 550 mg 41naproxen sodium oral tablet, er multiphase 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

naratriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 34NATACYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89nateglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 69NATPARA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71NEBUPENT. . . . . . . . . . . . . . . . . . . . . . . . . . 18nebusal inhalation solution for nebulization 3%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

NEBUSAL INHALATION SOLUTION FORNEBULIZATION 6 % (BRAND). . . . . . . . . . 94

necon 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . . 87necon 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . . 87NEEDLES, INSULIN DISP.,SAFETY. . . . . . . 69nefazodone. . . . . . . . . . . . . . . . . . . . . . . . . . 46neo-polycin. . . . . . . . . . . . . . . . . . . . . . . . . . 89neo-polycin hc. . . . . . . . . . . . . . . . . . . . . . . . 91neomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18neomycin-bacitracin-poly-hc. . . . . . . . . . . . . 91neomycin-bacitracin-polymyxin. . . . . . . . . . . 89neomycin-polymyxin b gu. . . . . . . . . . . . . . . 62neomycin-polymyxin b-dexameth. . . . . . . . . 91neomycin-polymyxin-gramicidin. . . . . . . . . . . 89neomycin-polymyxin-hc ophthalmic (eye). . . 91neomycin-polymyxin-hc otic (ear). . . . . . . . . 66neostigmine methylsulfate intravenous solution0.5 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 36

neostigmine methylsulfate intravenous solution1 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

NEPHRAMINE 5.4 %. . . . . . . . . . . . . . . . . . 100NERLYNX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28neuac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58NEULASTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 77NEUPOGEN INJECTION SOLUTION 300MCG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

NEUPOGEN INJECTION SOLUTION 480MCG/1.6 ML. . . . . . . . . . . . . . . . . . . . . . . . . 78

NEUPOGEN INJECTION SYRINGE 300MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 78

NEUPOGEN INJECTION SYRINGE 480MCG/0.8 ML. . . . . . . . . . . . . . . . . . . . . . . . . 78

NEUPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

nevirapine oral tablet. . . . . . . . . . . . . . . . . . . 11nevirapine oral tablet extended release 24 hr 11NEXAVAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28niacin oral tablet extended release 24 hr. . . . 55nicardipine intravenous solution. . . . . . . . . . 51nicardipine oral. . . . . . . . . . . . . . . . . . . . . . . 51NICOTROL. . . . . . . . . . . . . . . . . . . . . . . . . . . 65NICOTROL NS. . . . . . . . . . . . . . . . . . . . . . . 65nifedipine oral capsule. . . . . . . . . . . . . . . . . . 51nifedipine oral tablet extended release. . . . . 51nifedipine oral tablet extended release 24hr. 51nikki (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 87nilutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28nimodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 51NINLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28nisoldipine oral tablet extended release 24 hr 51nitro-bid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56nitrofurantoin. . . . . . . . . . . . . . . . . . . . . . . . . 22nitrofurantoin macrocrystal. . . . . . . . . . . . . . 22nitrofurantoin monohyd/m-cryst. . . . . . . . . . . 22nitroglycerin in 5 % dextrose intravenoussolution 100 mg/250 ml (400 mcg/ml), 200mg/500 ml (400 mcg/ml), 50 mg/250 ml (200mcg/ml), 50 mg/500 ml (100 mcg/ml). . . . . . 56

nitroglycerin in 5 % dextrose intravenoussolution 25 mg/250 ml (100 mcg/ml). . . . . . 56

nitroglycerin intravenous. . . . . . . . . . . . . . . . 56nitroglycerin oral capsule, extended release. 56nitroglycerin sublingual. . . . . . . . . . . . . . . . . 56nitroglycerin transdermal patch 24 hour. . . . . 56nitroglycerin translingual spray,non-aerosol. 56nizatidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76nolix topical cream. . . . . . . . . . . . . . . . . . . . . 61nolix topical lotion. . . . . . . . . . . . . . . . . . . . . 61nora-be. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84norepinephrine bitartrate. . . . . . . . . . . . . . . . 56noreth-ethinyl estradiol-iron. . . . . . . . . . . . . . 87norethindrone (contraceptive). . . . . . . . . . . . 84norethindrone ac-eth estradiol oral tablet 0.5-2.5mg-mcg, 1-5 mg-mcg. . . . . . . . . . . . . . . . . . 85

norethindrone ac-eth estradiol oral tablet 1-20mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

norethindrone acetate. . . . . . . . . . . . . . . . . . 84

128

norethindrone-e.estradiol-iron. . . . . . . . . . . . 87norgestimate-ethinyl estradiol. . . . . . . . . . . . 87norlyda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85norlyroc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85normal saline flush. . . . . . . . . . . . . . . . . . . . . 64NORMOSOL-M IN 5 % DEXTROSE. . . . . . 100NORMOSOL-R. . . . . . . . . . . . . . . . . . . . . . . 97NORMOSOL-R IN 5 % DEXTROSE. . . . . . . 97NORMOSOL-R PH 7.4. . . . . . . . . . . . . . . . 100NORTHERA. . . . . . . . . . . . . . . . . . . . . . . . . . 64nortrel 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . 87nortrel 1/35 (21). . . . . . . . . . . . . . . . . . . . . . . 87nortrel 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 87nortrel 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 87nortriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 46NORVIR ORAL CAPSULE. . . . . . . . . . . . . . . 11NORVIR ORAL POWDER IN PACKET. . . . . 11NORVIR ORAL SOLUTION. . . . . . . . . . . . . . 11NORVIR ORAL TABLET. . . . . . . . . . . . . . . . . 11NOVAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 71NOXAFIL INTRAVENOUS. . . . . . . . . . . . . . . . 9NOXAFIL ORAL. . . . . . . . . . . . . . . . . . . . . . . . 9np thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72NPLATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54NUCALA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94NUEDEXTA. . . . . . . . . . . . . . . . . . . . . . . . . . 35NULOJIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28NUPLAZID. . . . . . . . . . . . . . . . . . . . . . . . . . . 46nyamyc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60nystatin oral suspension. . . . . . . . . . . . . . . . . 9nystatin oral tablet. . . . . . . . . . . . . . . . . . . . . . 9nystatin topical. . . . . . . . . . . . . . . . . . . . . . . . 60nystatin-triamcinolone. . . . . . . . . . . . . . . . . . 60nystop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

OOCALIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74ocella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87OCREVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . 35octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml. . . . . . . . . . . . . . . . . . . . . . . 28

octreotide acetate injection solution 100 mcg/ml,200 mcg/ml, 50 mcg/ml. . . . . . . . . . . . . . . . 28

octreotide acetate injection syringe 100 mcg/ml(1 ml), 50 mcg/ml (1 ml). . . . . . . . . . . . . . . . 28

octreotide acetate injection syringe 500 mcg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

ODEFSEY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ODOMZO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28OFEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94ofloxacin ophthalmic (eye). . . . . . . . . . . . . . . 89ofloxacin oral tablet 300 mg. . . . . . . . . . . . . . 20ofloxacin oral tablet 400 mg. . . . . . . . . . . . . . 20ofloxacin otic (ear). . . . . . . . . . . . . . . . . . . . . 66ogestrel (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87okebo oral capsule 75 mg. . . . . . . . . . . . . . . 22olanzapine intramuscular recon soln. . . . . . . 46olanzapine oral tablet. . . . . . . . . . . . . . . . . . . 46olanzapine oral tablet,disintegrating. . . . . . . 46olanzapine-fluoxetine. . . . . . . . . . . . . . . . . . . 46olmesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 51olmesartan-amlodipin-hcthiazid. . . . . . . . . . . 51olmesartan-hydrochlorothiazide. . . . . . . . . . . 51olopatadine nasal. . . . . . . . . . . . . . . . . . . . . . 65olopatadine ophthalmic (eye). . . . . . . . . . . . . 90OLYSIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11omega-3 acid ethyl esters. . . . . . . . . . . . . . . 55omeppi oral capsule 20-1.1 mg-gram. . . . . . 76omeppi oral capsule 40-1.1 mg-gram. . . . . . 76omeprazole oral capsule,delayed release(dr/ec)10 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

omeprazole oral capsule,delayed release(dr/ec)20 mg, 40 mg. . . . . . . . . . . . . . . . . . . . . . . . 76

omeprazole-sodium bicarbonate oral capsule20-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 76

omeprazole-sodium bicarbonate oral capsule40-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 76

omeprazole-sodium bicarbonate oral packet20-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 76

omeprazole-sodium bicarbonate oral packet40-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 76

OMNITROPE. . . . . . . . . . . . . . . . . . . . . . . . . 78ONCASPAR. . . . . . . . . . . . . . . . . . . . . . . . . . 28ondansetron hcl (pf). . . . . . . . . . . . . . . . . . . . 74ondansetron hcl intravenous. . . . . . . . . . . . . 74

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ondansetron hcl oral solution. . . . . . . . . . . . . 74ondansetron hcl oral tablet 24 mg. . . . . . . . . 74ondansetron hcl oral tablet 4 mg, 8 mg. . . . . 74ondansetron oral tablet,disintegrating. . . . . . 74ONETOUCH BLOOD GLUCOSE METERS. 69ONETOUCH ULTRA BLUE TEST STRIP. . . 69ONETOUCH VERIO TEST STRIP. . . . . . . . . 69ONFI ORAL SUSPENSION. . . . . . . . . . . . . . 32ONFI ORAL TABLET 10 MG, 20 MG. . . . . . . 32ONGLYZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 69ONIVYDE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28OPDIVO INTRAVENOUS SOLUTION 100MG/10 ML, 40 MG/4 ML. . . . . . . . . . . . . . . . 28

OPDIVO INTRAVENOUS SOLUTION 240MG/24 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 28

opium tincture. . . . . . . . . . . . . . . . . . . . . . . . 72OPSUMIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94ORALAIR SUBLINGUAL TABLET 300 INDXREACTIVITY. . . . . . . . . . . . . . . . . . . . . . . . . 81

oralone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65ORBACTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 18ORENCIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83ORENCIA (WITH MALTOSE). . . . . . . . . . . . 83ORENCIA CLICKJECT. . . . . . . . . . . . . . . . . 83ORENITRAM ORAL TABLET EXTENDEDRELEASE 0.125 MG. . . . . . . . . . . . . . . . . . 51

ORENITRAM ORAL TABLET EXTENDEDRELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG. 51

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

ORFADIN ORAL CAPSULE 20 MG. . . . . . . . 64ORFADIN ORAL SUSPENSION. . . . . . . . . . 64ORKAMBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94orphenadrine citrate injection. . . . . . . . . . . . . 36orphenadrine citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

orsythia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87ORTHOVISC. . . . . . . . . . . . . . . . . . . . . . . . . 41oseltamivir oral capsule 30 mg. . . . . . . . . . . 11oseltamivir oral capsule 45 mg, 75 mg. . . . . 12oseltamivir oral suspension for reconstitution 12osmitrol 15 %. . . . . . . . . . . . . . . . . . . . . . . . . 51osmitrol 20 %. . . . . . . . . . . . . . . . . . . . . . . . . 51

OSMOPREP. . . . . . . . . . . . . . . . . . . . . . . . . . 74OTEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83OTEZLA STARTER ORAL TABLETS,DOSEPACK 10 MG (4)-20 MG (4)-30 MG (47). . . 83

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 19

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50 ml. . . . . . . . . . . . . . . . 19

oxacillin injection recon soln 1 gram. . . . . . . 19oxacillin injection recon soln 10 gram. . . . . . 19oxacillin injection recon soln 2 gram. . . . . . . 20oxaliplatin intravenous recon soln 100 mg. . . 28oxaliplatin intravenous recon soln 50 mg. . . . 28oxaliplatin intravenous solution 100 mg/20 ml 28oxaliplatin intravenous solution 50 mg/10 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

oxandrolone oral tablet 10 mg. . . . . . . . . . . . 71oxandrolone oral tablet 2.5 mg. . . . . . . . . . . 71oxaprozin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41oxazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46oxcarbazepine. . . . . . . . . . . . . . . . . . . . . . . . 32oxiconazole. . . . . . . . . . . . . . . . . . . . . . . . . . 60OXTELLAR XR. . . . . . . . . . . . . . . . . . . . . . . 32oxybutynin chloride oral syrup. . . . . . . . . . . . 95oxybutynin chloride oral tablet. . . . . . . . . . . . 95oxybutynin chloride oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

oxycodone oral capsule. . . . . . . . . . . . . . . . . 39oxycodone oral concentrate. . . . . . . . . . . . . . 39oxycodone oral solution. . . . . . . . . . . . . . . . . 39oxycodone oral tablet. . . . . . . . . . . . . . . . . . . 39OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg. . . . 39

oxycodone-aspirin. . . . . . . . . . . . . . . . . . . . . 39OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR. . . . . . . . . . . . . . . . . . . . . . . . . . 39

oxymorphone oral tablet. . . . . . . . . . . . . . . . 39

130

oxymorphone oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxytocin injection solution. . . . . . . . . . . . . . . 88OZEMPIC SUBCUTANEOUS PEN INJECTOR0.25 MG OR 0.5 MG(2 MG/1.5 ML). . . . . . . 69

OZEMPIC SUBCUTANEOUS PEN INJECTOR1 MG/0.75 ML (2 MG/1.5 ML). . . . . . . . . . . 69

Ppacerone oral tablet 100 mg, 200 mg, 400mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

paclitaxel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28paliperidone oral tablet extended release 24hr1.5 mg, 3 mg, 6 mg. . . . . . . . . . . . . . . . . . . 46

paliperidone oral tablet extended release 24hr 9mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

palonosetron intravenous solution 0.25 mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

pamidronate intravenous recon soln. . . . . . . 71pamidronate intravenous solution. . . . . . . . . 71panlor(acetam-caff-dihydrocod). . . . . . . . . . . 40PANRETIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 57pantoprazole intravenous. . . . . . . . . . . . . . . 76pantoprazole oral tablet,delayed release (dr/ec)20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

pantoprazole oral tablet,delayed release (dr/ec)40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

paregoric. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72PARICALCITOL HEMODIALYSIS PORTINJECTION. . . . . . . . . . . . . . . . . . . . . . . . . . 71

paricalcitol intravenous. . . . . . . . . . . . . . . . . 71PARICALCITOL INTRAVENOUS SOLUTION 2MCG/ML (BRAND). . . . . . . . . . . . . . . . . . . . 71

PARICALCITOL INTRAVENOUS SOLUTION 5MCG/ML (BRAND). . . . . . . . . . . . . . . . . . . . 71

paricalcitol oral. . . . . . . . . . . . . . . . . . . . . . . . 71paroex oral rinse. . . . . . . . . . . . . . . . . . . . . . 65paromomycin. . . . . . . . . . . . . . . . . . . . . . . . . 18paroxetine hcl oral tablet. . . . . . . . . . . . . . . . 46paroxetine hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

paroxetine mesylate(menop.sym). . . . . . . . . 46PARSABIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 71PASER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

PAXIL ORAL SUSPENSION. . . . . . . . . . . . . 46PEDIARIX (PF). . . . . . . . . . . . . . . . . . . . . . . 81PEDVAX HIB (PF). . . . . . . . . . . . . . . . . . . . . 81peg 3350-electrolytes oral recon soln236-22.74-6.74 -5.86 gram. . . . . . . . . . . . . 74

peg 3350-electrolytes oral recon soln240-22.72-6.72 -5.84 gram. . . . . . . . . . . . . 74

peg-electrolyte. . . . . . . . . . . . . . . . . . . . . . . . 74PEGANONE. . . . . . . . . . . . . . . . . . . . . . . . . . 32PEGASYS PROCLICK. . . . . . . . . . . . . . . . . 78PEGASYS SUBCUTANEOUS SOLUTION. . 78PEGASYS SUBCUTANEOUS SYRINGE. . . 78PEGINTRON SUBCUTANEOUS KIT 50MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 78

penicillin g potassium injection recon soln 20million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 20

penicillin g potassium injection recon soln 5million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 20

penicillin g procaine intramuscular syringe 1.2million unit/2 ml. . . . . . . . . . . . . . . . . . . . . . 20

penicillin g procaine intramuscular syringe600,000 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 20

penicillin g sodium. . . . . . . . . . . . . . . . . . . . . 20penicillin v potassium. . . . . . . . . . . . . . . . . . . 20PENTACEL (PF). . . . . . . . . . . . . . . . . . . . . . 81PENTAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PENTASA ORAL CAPSULE, EXTENDEDRELEASE 250 MG. . . . . . . . . . . . . . . . . . . . 74

PENTASA ORAL CAPSULE, EXTENDEDRELEASE 500 MG. . . . . . . . . . . . . . . . . . . . 74

pentazocine-naloxone. . . . . . . . . . . . . . . . . . 41pentobarbital sodium injection solution. . . . . 46pentoxifylline oral tablet extended release. . . 54perindopril erbumine. . . . . . . . . . . . . . . . . . . 51periogard. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65PERJETA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28permethrin topical cream. . . . . . . . . . . . . . . . 62perphenazine. . . . . . . . . . . . . . . . . . . . . . . . . 46perphenazine-amitriptyline. . . . . . . . . . . . . . . 46pfizerpen-g. . . . . . . . . . . . . . . . . . . . . . . . . . . 20phenadoz. . . . . . . . . . . . . . . . . . . . . . . . . . . . 92phenelzine. . . . . . . . . . . . . . . . . . . . . . . . . . . 46phenergan rectal. . . . . . . . . . . . . . . . . . . . . . 92phenobarbital. . . . . . . . . . . . . . . . . . . . . . . . . 32

131

phenobarbital sodium injection solution 130mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

phenobarbital sodium injection solution 65mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

phenoxybenzamine. . . . . . . . . . . . . . . . . . . . 51phentolamine injection recon soln. . . . . . . . . 51phenytoin oral suspension 100 mg/4 ml. . . . 32phenytoin oral suspension 125 mg/5 ml. . . . 32phenytoin oral tablet,chewable. . . . . . . . . . . 32phenytoin sodium extended. . . . . . . . . . . . . . 32phenytoin sodium intravenous solution. . . . . 32phenytoin sodium intravenous syringe. . . . . 32philith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PHOSPHOLINE IODIDE. . . . . . . . . . . . . . . . 89phrenilin forte(with caffeine). . . . . . . . . . . . . . 40pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,4 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

pilocarpine hcl oral. . . . . . . . . . . . . . . . . . . . . 64pimozide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46pimtrea (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88pindolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51pioglitazone. . . . . . . . . . . . . . . . . . . . . . . . . . 69pioglitazone-glimepiride. . . . . . . . . . . . . . . . . 69pioglitazone-metformin. . . . . . . . . . . . . . . . . 69piperacillin-tazobactam intravenous recon soln2.25 gram, 3.375 gram, 4.5 gram, 40.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

pirmella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88piroxicam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41plasbumin 25 %. . . . . . . . . . . . . . . . . . . . . . . 96plasbumin 5 %. . . . . . . . . . . . . . . . . . . . . . . . 96plasmanate. . . . . . . . . . . . . . . . . . . . . . . . . . 101PLEGRIDY SUBCUTANEOUS PEN INJECTOR125 MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . 78

PLEGRIDY SUBCUTANEOUS PEN INJECTOR63 MCG/0.5 ML- 94 MCG/0.5 ML. . . . . . . . 78

PLEGRIDY SUBCUTANEOUS SYRINGE 125MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 78

PLEGRIDY SUBCUTANEOUS SYRINGE 63MCG/0.5 ML- 94 MCG/0.5 ML. . . . . . . . . . . 78

plenamine. . . . . . . . . . . . . . . . . . . . . . . . . . . 101PNEUMOVAX 23. . . . . . . . . . . . . . . . . . . . . . 81podofilox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57polocaine injection solution 1 % (10 mg/ml). 59

polocaine-mpf. . . . . . . . . . . . . . . . . . . . . . . . 59polycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89polyethylene glycol 3350. . . . . . . . . . . . . . . . 74polymyxin b sulf-trimethoprim. . . . . . . . . . . . 89polymyxin b sulfate. . . . . . . . . . . . . . . . . . . . 18POMALYST. . . . . . . . . . . . . . . . . . . . . . . . . . 28portia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PORTRAZZA. . . . . . . . . . . . . . . . . . . . . . . . . 28potassium acetate intravenous solution 2meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

potassium bicarb and chloride. . . . . . . . . . . . 97potassium bicarb-citric acid. . . . . . . . . . . . . . 97potassium chlorid-d5-0.45%nacl intravenousparenteral solution 10 meq/l, 30 meq/l, 40meq/l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

potassium chlorid-d5-0.45%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 98

potassium chloride in 0.9%nacl intravenousparenteral solution 20 meq/l, 40 meq/l. . . . . 98

potassium chloride in 5 % dex intravenousparenteral solution 20 meq/l, 40 meq/l. . . . . 98

potassium chloride in 5 % dex intravenousparenteral solution 30 meq/l. . . . . . . . . . . . . 98

potassium chloride in lr-d5 intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 98

potassium chloride in lr-d5 intravenousparenteral solution 40 meq/l. . . . . . . . . . . . . 98

potassium chloride in water intravenouspiggyback 10 meq/100 ml. . . . . . . . . . . . . . 98

potassium chloride in water intravenouspiggyback 10 meq/50 ml. . . . . . . . . . . . . . . 98

potassium chloride in water intravenouspiggyback 20 meq/100 ml, 40 meq/100 ml. 98

potassium chloride in water intravenouspiggyback 20 meq/50 ml, 30 meq/100 ml. . 98

potassium chloride intravenous. . . . . . . . . . . 98potassium chloride oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

potassium chloride oral liquid. . . . . . . . . . . . 98potassium chloride oral packet. . . . . . . . . . . 98potassium chloride oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

potassium chloride oral tablet,erparticles/crystals. . . . . . . . . . . . . . . . . . . . . . 98

potassium chloride-0.45 % nacl. . . . . . . . . . . 98

132

potassium chloride-d5-0.2%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 98

potassium chloride-d5-0.2%nacl intravenousparenteral solution 30 meq/l, 40 meq/l. . . . . 98




potassium citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

potassium phosphate m-/d-basic. . . . . . . . . . 99PRADAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 54PRALUENT PEN SUBCUTANEOUS PENINJECTOR 150 MG/ML. . . . . . . . . . . . . . . . 55

PRALUENT PEN SUBCUTANEOUS PENINJECTOR 75 MG/ML. . . . . . . . . . . . . . . . . 55

pramipexole oral tablet. . . . . . . . . . . . . . . . . 33pramipexole oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

prasugrel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54pravastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 55PRAXBIND. . . . . . . . . . . . . . . . . . . . . . . . . . . 54praziquantel. . . . . . . . . . . . . . . . . . . . . . . . . . 18prazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51PRED MILD. . . . . . . . . . . . . . . . . . . . . . . . . . 91prednicarbate. . . . . . . . . . . . . . . . . . . . . . . . . 61prednisolone acetate. . . . . . . . . . . . . . . . . . . 91prednisolone oral solution 15 mg/5 ml. . . . . . 67prednisolone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

prednisolone sodium phosphate oral solution 10mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml(6.7 mg/5 ml). . . . . . . . . . . . . . . . . . . . . . . . 67

prednisolone sodium phosphate oraltablet,disintegrating. . . . . . . . . . . . . . . . . . . . 67

prednisone intensol. . . . . . . . . . . . . . . . . . . . 67prednisone oral solution. . . . . . . . . . . . . . . . . 67prednisone oral tablet. . . . . . . . . . . . . . . . . . 67prednisone oral tablets,dose pack. . . . . . . . . 67PREMARIN INJECTION. . . . . . . . . . . . . . . . 85premasol 10 %. . . . . . . . . . . . . . . . . . . . . . . 101PREMASOL 6 %. . . . . . . . . . . . . . . . . . . . . 101

prenatal vitamin oral tablet. . . . . . . . . . . . . . 101prevalite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55previfem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PREVNAR 13 (PF). . . . . . . . . . . . . . . . . . . . 81PREVYMIS INTRAVENOUS. . . . . . . . . . . . . 12PREVYMIS ORAL. . . . . . . . . . . . . . . . . . . . . 12PREZCOBIX. . . . . . . . . . . . . . . . . . . . . . . . . 12PREZISTA ORAL SUSPENSION. . . . . . . . . 12PREZISTA ORAL TABLET 150 MG, 75 MG. 12PREZISTA ORAL TABLET 600 MG, 800 MG 12PRIFTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PRIMAQUINE. . . . . . . . . . . . . . . . . . . . . . . . 18primidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32PROAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 94PROAIR RESPICLICK. . . . . . . . . . . . . . . . . . 94probenecid. . . . . . . . . . . . . . . . . . . . . . . . . . . 82probenecid-colchicine. . . . . . . . . . . . . . . . . . 82procainamide injection solution 100 mg/ml. . 48procainamide injection solution 500 mg/ml. . 48PROCALAMINE 3%. . . . . . . . . . . . . . . . . . 101procentra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46prochlorperazine. . . . . . . . . . . . . . . . . . . . . . 74prochlorperazine edisylate injection solution 10mg/2 ml (5 mg/ml). . . . . . . . . . . . . . . . . . . . 74

prochlorperazine maleate oral. . . . . . . . . . . . 74PROCRIT INJECTION SOLUTION 10,000UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,3,000 UNIT/ML, 4,000 UNIT/ML. . . . . . . . . 78

PROCRIT INJECTION SOLUTION 20,000UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

PROCRIT INJECTION SOLUTION 40,000UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

procto-med hc. . . . . . . . . . . . . . . . . . . . . . . . 75procto-pak. . . . . . . . . . . . . . . . . . . . . . . . . . . 75proctosol hc topical. . . . . . . . . . . . . . . . . . . . 75proctozone-hc. . . . . . . . . . . . . . . . . . . . . . . . 75PROCYSBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 96profeno. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41progesterone. . . . . . . . . . . . . . . . . . . . . . . . . 85progesterone in oil. . . . . . . . . . . . . . . . . . . . . 85progesterone micronized. . . . . . . . . . . . . . . . 85PROGLYCEM. . . . . . . . . . . . . . . . . . . . . . . . . 69PROGRAF INTRAVENOUS. . . . . . . . . . . . . 28

133

PROLASTIN-C INTRAVENOUS RECONSOLN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

PROLASTIN-C INTRAVENOUS SOLUTION 64PROLEUKIN. . . . . . . . . . . . . . . . . . . . . . . . . 78PROLIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82PROMACTA. . . . . . . . . . . . . . . . . . . . . . . . . . 54promethazine injection solution. . . . . . . . . . . 92promethazine oral. . . . . . . . . . . . . . . . . . . . . 92promethazine rectal suppository 12.5 mg, 25mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

promethazine rectal suppository 50 mg. . . . . 92promethegan. . . . . . . . . . . . . . . . . . . . . . . . . 92propafenone oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

propafenone oral tablet. . . . . . . . . . . . . . . . . 48propantheline. . . . . . . . . . . . . . . . . . . . . . . . . 72propranolol intravenous. . . . . . . . . . . . . . . . . 51propranolol oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

propranolol oral solution. . . . . . . . . . . . . . . . 51propranolol oral tablet. . . . . . . . . . . . . . . . . . 51propranolol-hydrochlorothiazid. . . . . . . . . . . 51propylthiouracil. . . . . . . . . . . . . . . . . . . . . . . . 67PROQUAD (PF). . . . . . . . . . . . . . . . . . . . . . . 81PROSOL 20 %. . . . . . . . . . . . . . . . . . . . . . . 101protamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54protriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 46prudoxin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57pulmosal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94PULMOZYME. . . . . . . . . . . . . . . . . . . . . . . . 94PURIXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28pyrazinamide. . . . . . . . . . . . . . . . . . . . . . . . . 18pyridostigmine bromide oral tablet. . . . . . . . . 36pyridostigmine bromide oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

QQUADRACEL (PF). . . . . . . . . . . . . . . . . . . . . 81quasense. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88QUDEXY XR. . . . . . . . . . . . . . . . . . . . . . . . . 32quetiapine oral tablet. . . . . . . . . . . . . . . . . . . 46quetiapine oral tablet extended release 24 hr 46quinapril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

quinapril-hydrochlorothiazide. . . . . . . . . . . . . 51quinidine gluconate injection. . . . . . . . . . . . . 48quinidine gluconate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

quinidine sulfate oral tablet. . . . . . . . . . . . . . 48quinine sulfate. . . . . . . . . . . . . . . . . . . . . . . . 18

RRABAVERT (PF). . . . . . . . . . . . . . . . . . . . . . 81rabeprazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

RADICAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 35RAGWITEK. . . . . . . . . . . . . . . . . . . . . . . . . . 81rajani. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88raloxifene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82ramipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51RANEXA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56ranitidine hcl injection solution 25 mg/ml. . . . 77ranitidine hcl injection solution 50 mg/2 ml (25mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

ranitidine hcl oral capsule. . . . . . . . . . . . . . . 77ranitidine hcl oral syrup. . . . . . . . . . . . . . . . . 77ranitidine hcl oral tablet 150 mg, 300 mg. . . . 77RAPAMUNE ORAL SOLUTION. . . . . . . . . . . 28rasagiline. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33RAVICTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64RAYOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67REBIF (WITH ALBUMIN). . . . . . . . . . . . . . . . 78REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 22 MCG/0.5 ML, 44 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML(6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

REBIF TITRATION PACK. . . . . . . . . . . . . . . 78reclipsen (28). . . . . . . . . . . . . . . . . . . . . . . . . 88RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 81

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 10 MCG/ML. . . . . . . . . . . . . . . . . 81

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 5 MCG/0.5 ML. . . . . . . . . . . . . . . 81

RECTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75regonol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

134

REGRANEX. . . . . . . . . . . . . . . . . . . . . . . . . . 57RELENZA DISKHALER. . . . . . . . . . . . . . . . . 12RELISTOR ORAL. . . . . . . . . . . . . . . . . . . . . 75RELISTOR SUBCUTANEOUS SOLUTION. . 75RELISTOR SUBCUTANEOUS SYRINGE. . . 75REMICADE. . . . . . . . . . . . . . . . . . . . . . . . . . 75REMODULIN. . . . . . . . . . . . . . . . . . . . . . . . . 51RENFLEXIS. . . . . . . . . . . . . . . . . . . . . . . . . . 75repaglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 69repaglinide-metformin. . . . . . . . . . . . . . . . . . 69REPATHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55REPATHA PUSHTRONEX. . . . . . . . . . . . . . . 55REPATHA SURECLICK. . . . . . . . . . . . . . . . . 55RESCRIPTOR. . . . . . . . . . . . . . . . . . . . . . . . 12RESTASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 90RESTASIS MULTIDOSE. . . . . . . . . . . . . . . . 90RETROVIR INTRAVENOUS. . . . . . . . . . . . . 12REVATIO ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 94

REVLIMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 28revonto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36REXULTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46REYATAZ ORAL CAPSULE 150 MG, 200 MG,300 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

REYATAZ ORAL POWDER IN PACKET. . . . 12ribasphere oral capsule. . . . . . . . . . . . . . . . . 12ribasphere oral tablet 200 mg, 400 mg. . . . . 12ribasphere oral tablet 600 mg. . . . . . . . . . . . 12ribasphere ribapak oral tablets,dose pack 200mg (28)- 400 mg (28). . . . . . . . . . . . . . . . . . 12

ribasphere ribapak oral tablets,dose pack 200mg (7)- 400 mg (7). . . . . . . . . . . . . . . . . . . . 12

ribasphere ribapak oral tablets,dose pack 400mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7),600 mg (7)- 600 mg (7). . . . . . . . . . . . . . . . 12

ribasphere ribapak oral tablets,dose pack400-400 mg (28)-mg (28), 600-400 mg (28)-mg(28), 600-600 mg (28)-mg (28). . . . . . . . . . . 12

ribavirin oral capsule. . . . . . . . . . . . . . . . . . . 12ribavirin oral tablet 200 mg. . . . . . . . . . . . . . 12RIDAURA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83rifabutin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18rifampin intravenous. . . . . . . . . . . . . . . . . . . 18

rifampin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 18RIFATER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18riluzole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64rimantadine. . . . . . . . . . . . . . . . . . . . . . . . . . 12ringer's intravenous. . . . . . . . . . . . . . . . . . . . 99ringer's irrigation. . . . . . . . . . . . . . . . . . . . . . 62risedronate oral tablet 150 mg. . . . . . . . . . . . 82risedronate oral tablet 30 mg. . . . . . . . . . . . . 64risedronate oral tablet 35 mg, 35 mg (12 pack),35 mg (4 pack). . . . . . . . . . . . . . . . . . . . . . . 82

risedronate oral tablet 5 mg. . . . . . . . . . . . . . 82risedronate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

RISPERDAL CONSTA INTRAMUSCULARSYRINGE 12.5 MG/2 ML, 25 MG/2 ML. . . . 46

RISPERDAL CONSTA INTRAMUSCULARSYRINGE 37.5 MG/2 ML, 50 MG/2 ML. . . . 46

risperidone oral solution. . . . . . . . . . . . . . . . . 46risperidone oral tablet. . . . . . . . . . . . . . . . . . 46risperidone oral tablet,disintegrating. . . . . . . 46ritonavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12RITUXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28RITUXAN HYCELA. . . . . . . . . . . . . . . . . . . . 28rivastigmine tartrate. . . . . . . . . . . . . . . . . . . . 35rivastigmine transdermal. . . . . . . . . . . . . . . . 35rivelsa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88rizatriptan oral tablet. . . . . . . . . . . . . . . . . . . 34rizatriptan oral tablet,disintegrating. . . . . . . . 34ROMIDEPSIN. . . . . . . . . . . . . . . . . . . . . . . . 28ropinirole oral tablet. . . . . . . . . . . . . . . . . . . . 33ropinirole oral tablet extended release 24 hr. 33ropivacaine (pf) injection solution. . . . . . . . . 60rosadan topical cream. . . . . . . . . . . . . . . . . . 58rosadan topical gel. . . . . . . . . . . . . . . . . . . . . 58rosuvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . 55ROTARIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81ROTATEQ VACCINE. . . . . . . . . . . . . . . . . . . 81roweepra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32roweepra xr. . . . . . . . . . . . . . . . . . . . . . . . . . 32RUBRACA. . . . . . . . . . . . . . . . . . . . . . . . . . . 28RUCONEST. . . . . . . . . . . . . . . . . . . . . . . . . . 94RYDAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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SSABRIL ORAL TABLET. . . . . . . . . . . . . . . . . 32salsalate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42SAMSCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71SANDOSTATIN LAR DEPOTINTRAMUSCULAR SUSPENSION,EXTENDED REL RECON. . . . . . . . . . . . . . 29

SANTYL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62SAPHRIS (BLACK CHERRY). . . . . . . . . . . . 46scopolamine base. . . . . . . . . . . . . . . . . . . . . 75seconal sodium. . . . . . . . . . . . . . . . . . . . . . . 46selegiline hcl. . . . . . . . . . . . . . . . . . . . . . . . . 33selenium sulfide topical lotion. . . . . . . . . . . . 57SELZENTRY. . . . . . . . . . . . . . . . . . . . . . . . . . 12SENSIPAR ORAL TABLET 30 MG. . . . . . . . 71SENSIPAR ORAL TABLET 60 MG, 90 MG. . 71sensorcaine injection solution 0.5 % (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

sensorcaine-mpf injection solution 0.5 % (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

sensorcaine/epinephrine. . . . . . . . . . . . . . . . 60SEREVENT DISKUS. . . . . . . . . . . . . . . . . . . 94SEROSTIM SUBCUTANEOUS RECON SOLN4 MG, 5 MG, 6 MG. . . . . . . . . . . . . . . . . . . . 78

sertraline oral concentrate. . . . . . . . . . . . . . . 47sertraline oral tablet. . . . . . . . . . . . . . . . . . . . 47setlakin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88sevelamer carbonate oral powder in packet. 64sevelamer carbonate oral tablet. . . . . . . . . . 64sf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65sf 5000 plus. . . . . . . . . . . . . . . . . . . . . . . . . . 65sharobel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85SHINGRIX (PF). . . . . . . . . . . . . . . . . . . . . . . 81SIGNIFOR. . . . . . . . . . . . . . . . . . . . . . . . . . . 29SIGNIFOR LAR. . . . . . . . . . . . . . . . . . . . . . . 29sildenafil (pulmonary arterial hypertension)intravenous solution 10 mg/12.5 ml. . . . . . . 94

sildenafil (pulmonary arterial hypertension) oraltablet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 94

silver sulfadiazine. . . . . . . . . . . . . . . . . . . . . 57SIMPONI ARIA. . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS PEN INJECTOR100 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS PEN INJECTOR50 MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS SYRINGE 100MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS SYRINGE 50MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 84

SIMULECT INTRAVENOUS RECON SOLN 10MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

SIMULECT INTRAVENOUS RECON SOLN 20MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

simvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 55sirolimus oral tablet 0.5 mg, 1 mg. . . . . . . . . 29sirolimus oral tablet 2 mg. . . . . . . . . . . . . . . . 29SIRTURO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18SIVEXTRO INTRAVENOUS. . . . . . . . . . . . . 18SIVEXTRO ORAL. . . . . . . . . . . . . . . . . . . . . 18SMOFLIPID. . . . . . . . . . . . . . . . . . . . . . . . . 101sodium acetate. . . . . . . . . . . . . . . . . . . . . . . 99sodium benzoate-sod phenylacet. . . . . . . . . 64sodium bicarbonate intravenous solution. . . 99sodium bicarbonate intravenous syringe 10meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml). . . . 99

sodium bicarbonate intravenous syringe 4.2 %(0.5 meq/ml), 8.4 % (1 meq/ml). . . . . . . . . . 99

sodium chlor 0.9% bacteriostat. . . . . . . . . . . 64sodium chloride 0.45 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chloride 0.45 % intravenouspiggyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chloride 0.9 % injection solution. . . . 64sodium chloride 0.9 % injection syringe. . . . . 64sodium chloride 0.9 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

sodium chloride 0.9 % intravenous piggyback 64sodium chloride 3 %. . . . . . . . . . . . . . . . . . . 99sodium chloride 5 %. . . . . . . . . . . . . . . . . . . 99sodium chloride inhalation. . . . . . . . . . . . . . . 94sodium chloride intravenous parenteral solution2.5 meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chloride intravenous parenteral solution4 meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chloride irrigation. . . . . . . . . . . . . . . . 64

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sodium lactate intravenous. . . . . . . . . . . . . . 99sodium nitroprusside. . . . . . . . . . . . . . . . . . . 56sodium phenylbutyrate. . . . . . . . . . . . . . . . . . 64sodium phosphate. . . . . . . . . . . . . . . . . . . . . 99sodium polystyrene (sorb free). . . . . . . . . . . 64sodium polystyrene sulfonate oral. . . . . . . . . 64sodium polystyrene sulfonate rectal enema 30gram/120 ml. . . . . . . . . . . . . . . . . . . . . . . . . 64

soloxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22SOLTAMOX. . . . . . . . . . . . . . . . . . . . . . . . . . 29SOMATULINE DEPOT. . . . . . . . . . . . . . . . . . 29SOMAVERT. . . . . . . . . . . . . . . . . . . . . . . . . . 71SORBITOL IRRIGATION. . . . . . . . . . . . . . . . 62sorine oral tablet 120 mg, 160 mg, 80 mg. . . 48sorine oral tablet 240 mg. . . . . . . . . . . . . . . . 48sotalol af. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48sotalol oral. . . . . . . . . . . . . . . . . . . . . . . . . . . 48SOVALDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12SPIRIVA RESPIMAT. . . . . . . . . . . . . . . . . . . 94SPIRIVA WITH HANDIHALER. . . . . . . . . . . . 94spironolacton-hydrochlorothiaz. . . . . . . . . . . 51spironolactone. . . . . . . . . . . . . . . . . . . . . . . . 51sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88SPRITAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33SPRYCEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29sps (with sorbitol) oral. . . . . . . . . . . . . . . . . . 64sps (with sorbitol) rectal. . . . . . . . . . . . . . . . . 64sronyx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88ssd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57STAMARIL (PF). . . . . . . . . . . . . . . . . . . . . . . 81stavudine oral capsule. . . . . . . . . . . . . . . . . . 12STELARA INTRAVENOUS. . . . . . . . . . . . . . 57STELARA SUBCUTANEOUS. . . . . . . . . . . . 57STIMATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71STIOLTO RESPIMAT. . . . . . . . . . . . . . . . . . . 94STIVARGA. . . . . . . . . . . . . . . . . . . . . . . . . . . 29STRENSIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 71STREPTOMYCIN. . . . . . . . . . . . . . . . . . . . . . 18STRIBILD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12STRIVERDI RESPIMAT. . . . . . . . . . . . . . . . . 94SUBOXONE. . . . . . . . . . . . . . . . . . . . . . . . . . 42SUCRAID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

sucralfate oral tablet. . . . . . . . . . . . . . . . . . . 77sulfacetamide sodium (acne). . . . . . . . . . . . . 60sulfacetamide sodium ophthalmic (eye)drops. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

sulfacetamide sodium ophthalmic (eye)ointment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

sulfacetamide-prednisolone. . . . . . . . . . . . . . 91sulfadiazine. . . . . . . . . . . . . . . . . . . . . . . . . . 21sulfamethoxazole-trimethoprim intravenous. 21sulfamethoxazole-trimethoprim oral. . . . . . . . 21SULFAMYLON TOPICAL CREAM. . . . . . . . 60sulfasalazine oral tablet. . . . . . . . . . . . . . . . . 75sulfasalazine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

sulfatrim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21sulindac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42sumatriptan nasal spray,non-aerosol 20mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan nasal spray,non-aerosol 5mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate oral. . . . . . . . . . . . . . . 34sumatriptan succinate subcutaneouscartridge. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate subcutaneous peninjector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate subcutaneous solution 34sumatriptan-naproxen. . . . . . . . . . . . . . . . . . 34SUPARTZ FX. . . . . . . . . . . . . . . . . . . . . . . . . 42SUPRAX ORAL CAPSULE. . . . . . . . . . . . . . 15SUPRAX ORAL TABLET,CHEWABLE. . . . . 15SUSTIVA ORAL CAPSULE 200 MG. . . . . . . 12SUSTIVA ORAL TABLET. . . . . . . . . . . . . . . . 12SUTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29syeda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88SYLATRON. . . . . . . . . . . . . . . . . . . . . . . . . . 78SYLVANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29SYMBICORT. . . . . . . . . . . . . . . . . . . . . . . . . 94SYMFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYMFI LO. . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYMLINPEN 120. . . . . . . . . . . . . . . . . . . . . . 69SYMLINPEN 60. . . . . . . . . . . . . . . . . . . . . . . 69SYNAGIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13SYNAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 71

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SYNDROS. . . . . . . . . . . . . . . . . . . . . . . . . . . 75SYNERCID. . . . . . . . . . . . . . . . . . . . . . . . . . . 18SYNJARDY. . . . . . . . . . . . . . . . . . . . . . . . . . . 69SYNJARDY XR. . . . . . . . . . . . . . . . . . . . . . . 69SYNRIBO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29SYNVISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42SYNVISC-ONE. . . . . . . . . . . . . . . . . . . . . . . 42SYPRINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64syrex sodium chloride 0.9 %. . . . . . . . . . . . . 64

TTABLOID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29tacrolimus oral. . . . . . . . . . . . . . . . . . . . . . . . 29tacrolimus topical. . . . . . . . . . . . . . . . . . . . . . 57TAFINLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 29TAGRISSO. . . . . . . . . . . . . . . . . . . . . . . . . . . 29tamoxifen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29tamsulosin oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

TARCEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29TARGRETIN 1% GEL. . . . . . . . . . . . . . . . . . 29tarina fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 88TASIGNA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29tazarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 58TAZORAC TOPICAL CREAM 0.05 %. . . . . . 58TAZORAC TOPICAL GEL. . . . . . . . . . . . . . . 58taztia xt oral capsule, extended release. . . . 51TECENTRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 29TECFIDERA. . . . . . . . . . . . . . . . . . . . . . . . . . 35TECHNIVIE. . . . . . . . . . . . . . . . . . . . . . . . . . 13TEFLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15TEKTURNA. . . . . . . . . . . . . . . . . . . . . . . . . . 51TEKTURNA HCT. . . . . . . . . . . . . . . . . . . . . . 51telmisartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 52telmisartan-amlodipine. . . . . . . . . . . . . . . . . . 52telmisartan-hydrochlorothiazid. . . . . . . . . . . . 52temazepam. . . . . . . . . . . . . . . . . . . . . . . . . . 47TEMODAR INTRAVENOUS. . . . . . . . . . . . . 29TEMODAR ORAL. . . . . . . . . . . . . . . . . . . . . 29temozolomide. . . . . . . . . . . . . . . . . . . . . . . . . 29tencon oral tablet 50-325 mg. . . . . . . . . . . . . 40TENIVAC (PF). . . . . . . . . . . . . . . . . . . . . . . . 81

tenofovir disoproxil fumarate. . . . . . . . . . . . . 13terazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52terbinafine hcl oral. . . . . . . . . . . . . . . . . . . . . . 9terbutaline. . . . . . . . . . . . . . . . . . . . . . . . . . . 94terconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 85testosterone cypionate. . . . . . . . . . . . . . . . . . 71testosterone enanthate. . . . . . . . . . . . . . . . . 71testosterone transdermal gel (generic). . . . . 71testosterone transdermal gel in metered-dosepump 12.5 mg/ 1.25 gram (1 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

testosterone transdermal gel in packet(Androgel generic). . . . . . . . . . . . . . . . . . . . 71

testosterone transdermal solution in meteredpump w/app (Axiron generic). . . . . . . . . . . . 71

TETANUS,DIPHTHERIA TOX PED(PF). . . . 81TETANUS-DIPHTHERIA TOXOIDS-TD. . . . 81tetrabenazine. . . . . . . . . . . . . . . . . . . . . . . . . 35tetracycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 22THALOMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 29theophylline in dextrose 5 % intravenousparenteral solution 200 mg/100 ml, 200 mg/50ml, 400 mg/250 ml, 400 mg/500 ml, 800mg/250 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 94

theophylline oral elixir. . . . . . . . . . . . . . . . . . 94theophylline oral solution. . . . . . . . . . . . . . . . 94theophylline oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

theophylline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

THIOLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64thioridazine. . . . . . . . . . . . . . . . . . . . . . . . . . . 47thiotepa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29thiothixene. . . . . . . . . . . . . . . . . . . . . . . . . . . 47thyroid (pork) oral tablet 30 mg, 60 mg. . . . . 72thyroid (pork) oral tablet 90 mg. . . . . . . . . . . 72tiagabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33TICE BCG. . . . . . . . . . . . . . . . . . . . . . . . . . . 81tigecycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 18tilia fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88timolol maleate ophthalmic (eye) drops. . . . . 89timolol maleate ophthalmic (eye) drops, oncedaily. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

138

timolol maleate ophthalmic (eye) gel formingsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

timolol maleate oral. . . . . . . . . . . . . . . . . . . . 52tinidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18tis-u-sol pentalyte. . . . . . . . . . . . . . . . . . . . . . 62TIVICAY ORAL TABLET 10 MG. . . . . . . . . . 13TIVICAY ORAL TABLET 25 MG, 50 MG. . . . 13tizanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36TOBI PODHALER INHALATION CAPSULE. 18TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 18

tobramycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 89tobramycin in 0.225 % nacl. . . . . . . . . . . . . . 18tobramycin sulfate injection recon soln. . . . . 18tobramycin sulfate injection solution. . . . . . . 18tobramycin-dexamethasone. . . . . . . . . . . . . 91tolazamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 70tolbutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 70tolcapone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33tolmetin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42tolterodine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

tolterodine oral tablet. . . . . . . . . . . . . . . . . . . 95topiramate oral capsule, sprinkle. . . . . . . . . . 33topiramate oral tablet. . . . . . . . . . . . . . . . . . . 33toposar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29topotecan intravenous recon soln. . . . . . . . . 29topotecan intravenous solution. . . . . . . . . . . 29TORISEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29torsemide oral. . . . . . . . . . . . . . . . . . . . . . . . 52TOUJEO MAX SOLOSTAR. . . . . . . . . . . . . . 70TOUJEO SOLOSTAR U-300 INSULIN. . . . . 70TRACLEER. . . . . . . . . . . . . . . . . . . . . . . . . . 95tramadol oral tablet. . . . . . . . . . . . . . . . . . . . 42tramadol oral tablet extended release 24 hr. 42tramadol oral tablet, er multiphase 24 hr. . . . 42tramadol-acetaminophen. . . . . . . . . . . . . . . . 42trandolapril. . . . . . . . . . . . . . . . . . . . . . . . . . . 52trandolapril-verapamil oral tablet, ir - er, biphasic24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

tranexamic acid intravenous. . . . . . . . . . . . . 54tranexamic acid oral. . . . . . . . . . . . . . . . . . . . 85tranylcypromine. . . . . . . . . . . . . . . . . . . . . . . 47

travasol 10 %. . . . . . . . . . . . . . . . . . . . . . . . 101TRAVATAN Z. . . . . . . . . . . . . . . . . . . . . . . . . 90trazodone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47TREANDA INTRAVENOUS RECON SOLN. 29TRECATOR. . . . . . . . . . . . . . . . . . . . . . . . . . 18TRELSTAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 29tretinoin (chemotherapy). . . . . . . . . . . . . . . . 29tretinoin microspheres. . . . . . . . . . . . . . . . . . 58tretinoin topical. . . . . . . . . . . . . . . . . . . . . . . . 58tri femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-legest fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-marzia. . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-sprintec. . . . . . . . . . . . . . . . . . . . . . . . . 88tri-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-previfem (28). . . . . . . . . . . . . . . . . . . . . . . 88tri-sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . 88tri-vitamin with fluoride. . . . . . . . . . . . . . . . . 101tri-vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88triamcinolone acetonide dental. . . . . . . . . . . 65triamcinolone acetonide injection. . . . . . . . . . 67triamcinolone acetonide topical aerosol. . . . . 61triamcinolone acetonide topical cream. . . . . 61triamcinolone acetonide topical lotion. . . . . . 61triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %. . . . . . . . . . . . . . . . . 61

triamterene-hydrochlorothiazid. . . . . . . . . . . 52trianex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61triazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47triderm topical cream 0.1 %. . . . . . . . . . . . . . 61triderm topical cream 0.5 %. . . . . . . . . . . . . . 61trientine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64trifluoperazine. . . . . . . . . . . . . . . . . . . . . . . . . 47trifluridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89trihexyphenidyl oral elixir. . . . . . . . . . . . . . . . 33trihexyphenidyl oral tablet. . . . . . . . . . . . . . . 33triklo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55trilyte with flavor packets. . . . . . . . . . . . . . . . 75trimethobenzamide oral. . . . . . . . . . . . . . . . . 75trimethoprim. . . . . . . . . . . . . . . . . . . . . . . . . . 22

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trimipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 47trinessa (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88trinessa lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 88TRINTELLIX. . . . . . . . . . . . . . . . . . . . . . . . . . 47TRISENOX INTRAVENOUS SOLUTION 2MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

TRIUMEQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13trivora (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88TROGARZO. . . . . . . . . . . . . . . . . . . . . . . . . . 13TROKENDI XR ORAL CAPSULE,EXTENDEDRELEASE 24HR 100 MG, 25 MG, 50 MG. . 33

TROKENDI XR ORAL CAPSULE,EXTENDEDRELEASE 24HR 200 MG. . . . . . . . . . . . . . . 33

TROPHAMINE 10 %. . . . . . . . . . . . . . . . . . 101TROPHAMINE 6%. . . . . . . . . . . . . . . . . . . . 101trospium oral capsule,extended release 24hr 95trospium oral tablet. . . . . . . . . . . . . . . . . . . . 95TRULICITY. . . . . . . . . . . . . . . . . . . . . . . . . . . 70TRUMENBA. . . . . . . . . . . . . . . . . . . . . . . . . . 81TRUVADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 13tulana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85TWINRIX (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 81

TYBOST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13tydemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88TYGACIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18TYKERB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29TYMLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82TYPHIM VI INTRAMUSCULAR SOLUTION. 81TYPHIM VI INTRAMUSCULAR SYRINGE. . 81TYSABRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35TYVASO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95TYVASO INSTITUTIONAL START KIT. . . . . 95TYVASO REFILL KIT. . . . . . . . . . . . . . . . . . . 95TYVASO STARTER KIT. . . . . . . . . . . . . . . . . 95

UUCERIS ORAL. . . . . . . . . . . . . . . . . . . . . . . 75UCERIS RECTAL. . . . . . . . . . . . . . . . . . . . . 75ULORIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82unithroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72UNITUXIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 29UPTRAVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

ursodiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75UVADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Vvalacyclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 13VALCHLOR. . . . . . . . . . . . . . . . . . . . . . . . . . 57valganciclovir oral recon soln. . . . . . . . . . . . . 13valganciclovir oral tablet. . . . . . . . . . . . . . . . 13valproate sodium. . . . . . . . . . . . . . . . . . . . . . 33valproic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 33valproic acid (as sodium salt) oral solution 250mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

valproic acid (as sodium salt) oral solution 250mg/5 ml (5 ml), 500 mg/10 ml (10 ml). . . . . 33

valsartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52valsartan-hydrochlorothiazide. . . . . . . . . . . . 52VALSTAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 1 GRAM/200 ML (BRAND). . 22

VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 500 MG/100 ML, 750 MG/150ML (BRAND). . . . . . . . . . . . . . . . . . . . . . . . 22

VANCOMYCIN IN DEXTROSE ISO-OSM(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

VANCOMYCIN INJECTION (BRAND). . . . . . 22vancomycin intravenous recon soln 1,000 mg,10 gram, 500 mg. . . . . . . . . . . . . . . . . . . . . 22

vancomycin intravenous recon soln 5 gram, 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

vancomycin oral capsule. . . . . . . . . . . . . . . . 22vandazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85VANTAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29VAQTA (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 81VARIVAX (PF). . . . . . . . . . . . . . . . . . . . . . . . 81VARIZIG INTRAMUSCULAR SOLUTION. . . 81VARUBI INTRAVENOUS. . . . . . . . . . . . . . . . 75VARUBI ORAL. . . . . . . . . . . . . . . . . . . . . . . . 75VECAMYL. . . . . . . . . . . . . . . . . . . . . . . . . . . 56VECTIBIX INTRAVENOUS SOLUTION 100MG/5 ML (20 MG/ML). . . . . . . . . . . . . . . . . 29

VECTIBIX INTRAVENOUS SOLUTION 400MG/20 ML (20 MG/ML). . . . . . . . . . . . . . . . 30

VELCADE. . . . . . . . . . . . . . . . . . . . . . . . . . . 30veletri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

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velivet triphasic regimen (28). . . . . . . . . . . . . 88VELTASSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 64VEMLIDY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13VENCLEXTA ORAL TABLET 10 MG, 50 MG 30VENCLEXTA ORAL TABLET 100 MG. . . . . . 30VENCLEXTA STARTING PACK. . . . . . . . . . 30venlafaxine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

venlafaxine oral tablet. . . . . . . . . . . . . . . . . . 47venlafaxine oral tablet extended release 24hr150 mg, 37.5 mg, 75 mg. . . . . . . . . . . . . . . 47

VENLAFAXINE ORAL TABLET EXTENDEDRELEASE 24HR 225 MG (BRAND). . . . . . . 47

VENTAVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 95verapamil intravenous solution. . . . . . . . . . . 52verapamil intravenous syringe. . . . . . . . . . . . 52verapamil oral capsule, 24 hr er pellet ct. . . . 52verapamil oral capsule,ext rel. pellets 24 hr. . 52verapamil oral tablet. . . . . . . . . . . . . . . . . . . 52verapamil oral tablet extended release. . . . . 52veripred 20. . . . . . . . . . . . . . . . . . . . . . . . . . . 67VERSACLOZ. . . . . . . . . . . . . . . . . . . . . . . . . 47VERZENIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 30vestura (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88VIBATIV INTRAVENOUS RECON SOLN 750MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

vicodin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40vicodin es. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40vicodin hp. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40VIDEX 2 GRAM PEDIATRIC. . . . . . . . . . . . . 13VIDEX 4 GRAM PEDIATRIC. . . . . . . . . . . . . 13VIDEX EC ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 125 MG. . . . . . . . . . . . . 13

VIEKIRA PAK. . . . . . . . . . . . . . . . . . . . . . . . . 13VIEKIRA XR. . . . . . . . . . . . . . . . . . . . . . . . . . 13vienva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88vigabatrin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33VIIBRYD ORAL TABLET. . . . . . . . . . . . . . . . 47VIIBRYD ORAL TABLETS,DOSE PACK 10 MG(7)- 20 MG (23). . . . . . . . . . . . . . . . . . . . . . 47

VIMIZIM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72VIMPAT INTRAVENOUS. . . . . . . . . . . . . . . . 33VIMPAT ORAL SOLUTION. . . . . . . . . . . . . . 33

VIMPAT ORAL TABLET. . . . . . . . . . . . . . . . . 33vinblastine intravenous solution. . . . . . . . . . . 30vincasar pfs intravenous solution 1 mg/ml. . . 30vincasar pfs intravenous solution 2 mg/2 ml. 30vincristine intravenous solution 1 mg/ml. . . . 30vincristine intravenous solution 2 mg/2 ml. . . 30vinorelbine intravenous solution 10 mg/ml. . . 30vinorelbine intravenous solution 50 mg/5 ml. 30viorele (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88VIRACEPT ORAL TABLET. . . . . . . . . . . . . . 13VIRAMUNE ORAL SUSPENSION. . . . . . . . . 13VIREAD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13VISCO-3. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42VISTOGARD. . . . . . . . . . . . . . . . . . . . . . . . . 23vitamins a,c,d and fluoride. . . . . . . . . . . . . . 101voriconazole intravenous. . . . . . . . . . . . . . . . . 9voriconazole oral. . . . . . . . . . . . . . . . . . . . . . . 9VOSEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13VOTRIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 30VRAYLAR ORAL CAPSULE. . . . . . . . . . . . . 47VRAYLAR ORAL CAPSULE,DOSE PACK. . 47vyfemla (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88VYXEOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Wwarfarin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54water for inject, bacteriostat. . . . . . . . . . . . . . 64water for irrigation, sterile. . . . . . . . . . . . . . . 65wera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 88wymzya fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 88

XXALKORI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30XATMEP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30XELODA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30XEOMIN INTRAMUSCULAR RECON SOLN100 UNIT, 50 UNIT. . . . . . . . . . . . . . . . . . . . 82

XEOMIN INTRAMUSCULAR RECON SOLN200 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 82

XERMELO. . . . . . . . . . . . . . . . . . . . . . . . . . . 30XGEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

141

XIFAXAN ORAL TABLET 550 MG. . . . . . . . . 18XIGDUO XR. . . . . . . . . . . . . . . . . . . . . . . . . . 70XOLAIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95XTANDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30xulane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85XURIDEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65xylocaine dental-epinephrine. . . . . . . . . . . . . 60xylon 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40XYREM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

YYERVOY INTRAVENOUS SOLUTION 200MG/40 ML (5 MG/ML). . . . . . . . . . . . . . . . . 30

YERVOY INTRAVENOUS SOLUTION 50MG/10 ML (5 MG/ML). . . . . . . . . . . . . . . . . 30

YF-VAX (PF). . . . . . . . . . . . . . . . . . . . . . . . . 82YONDELIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 30yuvafem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Zzafirlukast. . . . . . . . . . . . . . . . . . . . . . . . . . . . 95zaleplon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ZALTRAP INTRAVENOUS SOLUTION 100MG/4 ML (25 MG/ML). . . . . . . . . . . . . . . . . 30

ZALTRAP INTRAVENOUS SOLUTION 200MG/8 ML (25 MG/ML). . . . . . . . . . . . . . . . . 30

ZANOSAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 30zarah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88ZARXIO INJECTION SYRINGE 300 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

ZARXIO INJECTION SYRINGE 480 MCG/0.8ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

ZAVESCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72zebutal oral capsule 50-325-40 mg. . . . . . . . 40ZEJULA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZELAPAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZELBORAF. . . . . . . . . . . . . . . . . . . . . . . . . . . 30zenatane. . . . . . . . . . . . . . . . . . . . . . . . . . . . 58zenchent (28). . . . . . . . . . . . . . . . . . . . . . . . . 88

ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 10,000-32,000 -42,000UNIT, 10,000-34,000 -55,000 UNIT,15,000-51,000 -82,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-85,000- 136,000 UNIT,3,000-10,000- 16,000 UNIT,5,000-17,000 -27,000 UNIT. . . . . . . . . . . . . 75

ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 15,000-47,000 -63,000UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 25,000-79,000- 105,000UNIT, 40,000-126,000- 168,000 UNIT,5,000-17,000- 24,000 UNIT. . . . . . . . . . . . . 75

ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 3,000-10,000 -14,000-UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

zenzedi oral tablet 10 mg, 5 mg. . . . . . . . . . . 47ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20MG, 30 MG, 7.5 MG (BRAND). . . . . . . . . . . 47

ZEPATIER. . . . . . . . . . . . . . . . . . . . . . . . . . . 13ZERBAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 15ZERIT ORAL RECON SOLN. . . . . . . . . . . . . 13ZIAGEN ORAL SOLUTION. . . . . . . . . . . . . . 13zidovudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 13zileuton oral tablet,extended release 12hrmphase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

ZINPLAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 82ziprasidone hcl. . . . . . . . . . . . . . . . . . . . . . . . 47ZIRGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89ZOLADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 30zoledronic acid intravenous solution. . . . . . . 72zoledronic acid-mannitol-water. . . . . . . . . . . 65ZOLINZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30zolmitriptan oral tablet 2.5 mg. . . . . . . . . . . . 34zolmitriptan oral tablet 5 mg. . . . . . . . . . . . . . 34zolmitriptan oral tablet,disintegrating 2.5 mg. 34zolmitriptan oral tablet,disintegrating 5 mg. . 34zolpidem oral tablet. . . . . . . . . . . . . . . . . . . . 47zolpidem oral tablet,ext release multiphase. . 47zolpidem sublingual. . . . . . . . . . . . . . . . . . . . 47ZOMETA INTRAVENOUS PIGGYBACK. . . . 72ZOMIG NASAL. . . . . . . . . . . . . . . . . . . . . . . 34zonisamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZORBTIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 79

142

ZORTRESS. . . . . . . . . . . . . . . . . . . . . . . . . . 30ZOSTAVAX (PF). . . . . . . . . . . . . . . . . . . . . . 82zovia 1/35e (28). . . . . . . . . . . . . . . . . . . . . . . 88zovia 1/50e (28). . . . . . . . . . . . . . . . . . . . . . . 88ZOVIRAX TOPICAL CREAM. . . . . . . . . . . . . 60ZURAMPIC. . . . . . . . . . . . . . . . . . . . . . . . . . 82ZYDELIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYKADIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYPREXA RELPREVV. . . . . . . . . . . . . . . . . 47ZYTIGA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

143

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Nondiscrimination NoticeBlue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

Blue Cross Blue Shield of Massachusetts provides:• Free aids and services to people with disabilities to communicate effectively with us, such as

qualified sign language interpreters and written information in other formats (large print or other formats).

• Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Laureen Corey, Medicare Advantage Appeals and Grievance Manager.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Laureen Corey, Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from February 15 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through February 14, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711).

If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at www.hhs.gov.

mailto:MedicareAdvantageRXAppeals%40bcbsma.com?subject=

https://www.hhs.gov

Translation ResourcesProficiency of Language Assistance Services

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

Chinese/繁體中文: 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 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/االعربية: ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255

.(هاتف الصم والبكم: 711)

Mon-Khmer, Cambodian/ : 1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Translation Resources Proficiency of Language Assistance Services

143

English: ATT ENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711)

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).Hindi/1-800-200-4255 (TTY: 711)

Mon-Khmer, Cambodian/ : 1-800-200-4255 (TTY: 711).

Arabic/خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 4255-200-800-1 (رقم :ةيبرعلا ھاتف الصم والبكم: 711).ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن

Chinese/繁體中文: 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 1-800-200-4255 (TTY: 711)..

Gujarati/ : 1-800-200-4255 (TTY: 711)

This formulary was updated on 7/1/2018. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

The Formulary may change at any time. You will receive notice when necessary.

®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of the medications listed are the property of their respective manufacturers. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

175305-7 55-0652-18 (7/18)


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