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True Blue Rx | St. Luke’s Health Partners (HMO)

2021 Connected Access Formulary

(List of Covered Drugs)

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

FORMULARY ID: 00021344 V11

This formulary was updated on 02/01/2021. For more recent information or other questions, please contact Blue Cross of Idaho Care Plus, Inc. at 855-479-3661 or, for TTY users, 711, 24 hours a day, seven days a week, or visit bcidaho.com/DrugList.

Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español,

tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 888-494-2583 (TTY: 711).注意：

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H1350_OP21343_C 02/01/2021

Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-596 (09-20)

http://bcidaho.com/DrugList

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 of Idaho Care Plus, Inc. When it refers to “plan” or “our plan,” it means True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Essentials, or True Blue Rx | St. Luke’s Health Partners.

This document includes list of the drugs (formulary) for our plan which is current as of 02/01/2021 For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

02/01/2021

What is the True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Essentials, and True Blue Rx | St. Luke’s Health Partners Formulary?

A formulary is a list of covered drugs selected by our plan 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Essentials, and True Blue Rx | St. Luke’s Health Partners network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

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

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Essentials, and True Blue Rx | St. Luke’s Health Partners’ Formulary?”

Drugs removed from the market. 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.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, 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 30 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 30-day supply of the drug. o If we make these other changes, you or

your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials,

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and True Blue Rx | St. Luke’s Health Partners’ Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

The enclosed formulary is current as of 02/01/2021. To get updated information about the drugs covered by our Plan, please contact us. Our contact information appears on the front and back cover pages We will send you a notice in the event of a mid-year non-maintenance formulary change. The notice will generally be sent 60 days prior to the change. We list any formulary updates on our website along with the most current formulary.

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

Medical Condition The formulary begins on page eight. 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 Medications. If you know what your drug is used for, look for the category name in the list that begins on page eight. 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 in the back of the formulary. The Index provides an alphabetical list of all 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?

We 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.

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

Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 pills per prescription for Januvia. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, we 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, we may not cover Drug B unless you try Drug A

02/01/2021

first. If Drug A does not work for you, we 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 eight. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. 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 us 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 True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials, and True Blue Rx | St. Luke’s Health Partners’ formulary?” on this page for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

You can ask Customer Service for a list ofsimilar drugs that are covered by us. Whenyou receive the list, show it to your doctorand ask him or her to prescribe a similar drugthat is covered by us.

You can ask us to make an exception andcover your drug. See below for informationabout how to request an exception.

How do I request an exception to the True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials, and True Blue Rx | St. Luke’s Health Partners’ Formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is noton our formulary. If approved, this drug willbe covered at a pre-determined cost-sharinglevel, and you would not be able to ask us toprovide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at alower cost-sharing level if this drug is not onthe specialty tier. If approved this wouldlower the amount you must pay for your drug.

You can ask us to waive coverage restrictionsor limits on your drug. For example, forcertain drugs, we limit the amount of the drugthat we will cover. If your drug has a quantitylimit, you can ask us to waive the limit andcover a greater amount.

Generally, we 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,

02/01/2021

we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

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

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

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

When you have a change in your level of care, like admission to a long-term care facility, you may need more medication. Requests for more medication may be denied if you ask for a refill

too soon. If this happens, your pharmacy can ask us to override the denial in order to refill your prescription.

For more information

For more detailed information about your True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials, and True Blue Rx | St. Luke’s Health Partners’ prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials, and True Blue Rx | St. Luke’s Health Partners’, 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 1-877486-2048. Or visit http://www.medicare.gov.

True Blue Rx, True Blue Rx Gem, True Blue Rx Preferred, True Blue Rx Essentials, and True Blue Rx | St. Luke’s Health Partners’ Formulary

The formulary that begins on page eight provides coverage information about the drugs covered by us. If you have trouble finding your drug in the list, turn to the Index in the back of the formulary.

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

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

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http://www.medicare.gov

LEGEND

SYMBOL NAME DESCRIPTION

QL Quantity Limit

Restricts the frequency, amount or dosage of medication for

which you can obtain benefits each time you get a prescription

filled (most often set on a monthly basis).

PA Prior Authorization

The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription.

LA Limited Access

This prescription may be available only at certain pharmacies.

For more information, consult your Pharmacy Directory or call

Customer Service at 1-855-479-3661, 24 hours a day, 7 days a

week TTY/TDD users should call 711.

PA-BvD B vs D Prior

Covered under Medicare B or D. This drug may be covered

under Medicare Part B or D depending upon circumstances.

Information may need to be submitted describing the use and

setting of the drug to make the determination.

NE Non-Extended Day Supply This prescription cannot be filled for more than a 30-day supply.

NM Not Mail Order Not available for Mail Order

ST Step Therapy

The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition.

02/01/2021 7

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

02/01/2021 8

Connected Access (List of Covered Drugs)DRUG NAME DRUG TIER R

EQUIREMENTS / LIMITS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS butalbital-aspirin-caffeine 50-325-40 mg cap 2 PA; QL (180 per 30 days)

celecoxib 2 PA

diclofenac epolamine 4 PA; QL (60 per 30 days) diclofenac potassium 1 diclofenac sodium 1 % gel 2 QL (1000 per 30 days) diclofenac sodium 1.5 % solution 2 QL (300 per 30 days) diclofenac sodium 100 mg tab er 24h 1 diclofenac sodium 25 mg tab dr, 50 mg tab dr, 75 mg tab dr 1 diclofenac-misoprostol 2 diflunisal 1 ec-naproxen 1 etodolac 1 etodolac 400 mg tab er 24h 2 etodolac 500 mg tab er 24h 2 etodolac 600 mg tab er 24h 2 FLECTOR 4 PA; QL (60 per 30 days) flurbiprofen 1 ibu 1 ibuprofen 100 mg/5ml suspension, 400 mg tab, 600 mg tab, 800 mg tab 1 ketoprofen 200 mg cap er 24h 2 ketoprofen 25 mg cap 5 ketoprofen 50 mg cap, 75 mg cap 2 ketorolac tromethamine 10 mg tab, 15 mg/ml solution, 30 mg/ml solution, 60 mg/2ml solution 2 PA

meclofenamate sodium 2 mefenamic acid 2 meloxicam 7.5 mg tab, 15 mg tab 1 nabumetone 1 NALFON 400 MG CAP 4 naproxen 125 mg/5ml suspension, 250 mg tab, 375 mg tab, 375 mg tab dr, 500 mg tab, 500 mg tab dr 1 naproxen sodium 1 oxaprozin 1 piroxicam 1 relafen 1


02/01/2021 9

sulindac 1

tolmetin sodium 2

OPIOID ANALGESICS, LONG-ACTING

BELBUCA 75 MCG, 150 MCG, 300 MCG, 450 MCG, 600 MCG 4 PA; QL (60 per 30 days); NE

BELBUCA 750 MCG, 900 MCG 5 PA; QL (60 per 30 days); NE

buprenorphine 5 mcg/hr patch wk, 10 mcg/hr patch wk, 15 mcg/hr patch wk, 20 mcg/hr patch wk 2 PA; QL (4 per 28 days); NE

buprenorphine 7.5 mcg/hr patch wk 2 PA

fentanyl 12 mcg/hr patch, 25 mcg/hr patch, 37.5 mcg/hr patch, 50 mcg/hr patch, 62.5 mcg/hr patch, 75 mcg/hr patch, 100 mcg/hr patch 2 PA; QL (15 per 30 days); NE

fentanyl 87.5 mcg/hr patch 72hr 5 PA; QL (15 per 30 days); NE

hydromorphone hcl 12 mg tab er 24h 2 PA; QL (30 per 30 days); NE




METHADONE HCL 10 MG/ML SOLUTION 1 QL (20 per 30 days); NE

methadone hcl 5 mg tab, 10 mg tab 1 PA; QL (180 per 30 days); NE

methadone hcl 5 mg/5ml, 10 mg/5ml 1 QL (900 per 30 days); NE

morphine sulfate 10 mg cap er 24h 2 PA; QL (60 per 30 days); NE


morphine sulfate 100 mg tab er 2 PA; QL (60 per 30 days); NE










morphine sulfate beads 120 mg cap er 24h 2 PA; QL (30 per 30 days); NE






oxycodone hcl er 80 mg tb12 deter 5 PA; QL (60 per 30 days); NE

oxycodone hcl er er 10 mg, er 15 mg, er 20 mg, er 30 mg, er 40 mg, er 60 mg 2 PA; QL (60 per 30 days); NE

oxymorphone hcl 10 mg tab er 12h 2 PA; QL (60 per 30 days); NE



02/01/2021 10





oxymorphone hcl 7.5 mg tab er 12h 2 PA; QL (60 per 30 days); NE

tramadol hcl (biphasic) 100 mg tab er 24h 2 PA; QL (30 per 30 days); NE



tramadol hcl 100 mg tab er 24h 2 PA; QL (30 per 30 days); NE



OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 200 MCG SL TAB 5 PA; QL (120 per 30 days); NE

acetaminophen-codeine #2 1 QL (180 per 30 days); NE



acetaminophen-codeine 120-12 mg/5ml solution 1 QL (900 per 30 days); NE

acetaminophen-codeine 300-15 mg tab, 300-60 mg tab, 300-30 mg tab 1 QL (180 per 30 days); NE

ascomp-codeine 2 PA; QL (180 per 30 days); NE

butalbital-apap-caff-cod 50-325-40-30 mg cap 2 PA; QL (180 per 30 days); NE

butalbital-asa-caff-codeine 2 PA; QL (180 per 30 days); NE

butorphanol tartrate 1 mg/ml solution 2 QL (240 per 30 days); NE



codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab 3 QL (180 per 30 days); NE

duramorph 0.5 mg/ml solution 2 QL (180 per 30 days); NE

duramorph 1 mg/ml solution 1 QL (180 per 30 days); NE

endocet 1 QL (180 per 30 days); NE

fentanyl citrate 100 mcg tab, 200 mcg loz handle, 200 mcg tab, 400 mcg tab, 400 mcg loz handle, 600 mcg loz handle, 600 mcg tab, 800 mcg tab, 800 mcg loz handle, 1200 mcg loz handle, 1600 mcg loz handle 5 PA; QL (120 per 30 days); NE

hydrocodone-acetaminophen 2.5-108 mg/5ml, 5217 mg/10ml, 7.5-325 mg/15ml 1 QL (2700 per 30 days); NE

hydrocodone-acetaminophen 5-325 mg tab, 5300 mg tab, 7.5-300 mg tab, 7.5-325 mg tab, 10300 mg tab, 10-325 mg tab 1 QL (180 per 30 days); NE

hydrocodone-ibuprofen 1 QL (50 per 10 days); NE

hydromorphone hcl 1 mg/ml liquid 1 QL (720 per 30 days); NE

hydromorphone hcl 1 mg/ml solution, 2 mg tab, 4 mg tab, 8 mg tab 1 QL (180 per 30 days); NE

hydromorphone hcl 4 mg/ml solution 1 QL (60 per 30 days); NE


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hydromorphone hcl pf 10 mg/ml, 50 mg/5ml, 500 mg/50ml 1 QL (120 per 30 days); NE

hydromorphone hcl pf 2 mg/ml solution 2 QL (180 per 30 days); NE

LAZANDA 5 PA; QL (30 per 30 days); NE

lorcet 1 QL (180 per 30 days); NE

lorcet hd 1 QL (180 per 30 days); NE

meperidine hcl 50 mg tab, 100 mg tab 2 PA; QL (180 per 30 days); NE

morphine sulfate (concentrate) 1 QL (180 per 30 days); NE

morphine sulfate (pf) 0.5 mg/ml solution 2 QL (180 per 30 days); NE

morphine sulfate (pf) 1 mg/ml solution 1 QL (180 per 30 days); NE

morphine sulfate 1 mg/ml solution, 15 mg tab, 30 mg tab 1 QL (180 per 30 days); NE

morphine sulfate 10 mg/5ml, 20 mg/5ml 1 QL (900 per 30 days); NE

nalbuphine hcl 10 mg/ml solution 1 QL (60 per 30 days); NE

nalbuphine hcl 20 mg/ml solution 1 QL (90 per 30 days); NE

NUCYNTA 100 MG TAB 5 QL (181 per 30 days); NE

oxycodone hcl 10 mg/0.5ml, 100 mg/5ml 2 QL (180 per 30 days); NE

oxycodone hcl 5 mg cap, 5 mg tab, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab 1 QL (180 per 30 days); NE

oxycodone hcl 5 mg/5ml solution 1 QL (900 per 30 days); NE

oxycodone-acetaminophen 2.5-325 mg tab, 5-325 mg tab, 7.5-325 mg tab, 10-325 mg tab 1 QL (180 per 30 days); NE

oxycodone-aspirin 1 QL (180 per 30 days); NE

oxycodone-ibuprofen 2 QL (28 per 7 days); NE

oxymorphone hcl 2 QL (180 per 30 days); NE

tramadol hcl 50 mg tab 1 QL (240 per 30 days); NE

tramadol-acetaminophen 1 QL (40 per 5 days); NE

vicodin 1 QL (180 per 30 days); NE

vicodin es 1 QL (180 per 30 days); NE

vicodin hp 1 QL (180 per 30 days); NE

ANESTHETICS

LOCAL ANESTHETICS

glydo 1

lidocaine 5 % ointment 1 PA; QL (150 per 30 days)

lidocaine 5 % patch 2 PA; QL (90 per 30 days)

lidocaine hcl (pf) (pf) 0.5 %, (pf) 1 % 2

lidocaine hcl 1 %, 2 % 2

lidocaine hcl 4 % solution 1 PA; QL (300 per 30 days)

lidocaine hcl urethral/mucosal 1

lidocaine viscous hcl 1

lidocaine-prilocaine 2 QL (30 per 30 days)

NAYZILAM 4


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ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 2

disulfiram 2

OPIOID DEPENDENCE

buprenorphine hcl 2 mg sl tab 2 QL (240 per 30 days); NE

buprenorphine hcl 8 mg sl tab 2 QL (60 per 30 days); NE

buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab 2 QL (360 per 30 days); NE

buprenorphine hcl-naloxone hcl 8-2 mg sl tab 2 QL (90 per 30 days); NE

OPIOID REVERSAL AGENTS

naloxone hcl 0.4 mg/ml solution, 0.4 mg/ml soln cart, 2 mg/2ml soln prsyr, 4 mg/10ml solution 1

naltrexone hcl 2

NARCAN 3

SMOKING CESSATION AGENTS

bupropion hcl (smoking det) 150 mg tab er 12h 1 QL (60 per 30 days)

CHANTIX 0.5 MG TAB 4 PA; QL (60 per 30 days)

CHANTIX 1 MG TAB 4 PA; QL (56 per 28 days)

CHANTIX CONTINUING MONTH PAK 4 PA; QL (56 per 28 days)

CHANTIX STARTING MONTH PAK 4 PA

NICOTROL NS 4 QL (120 per 30 days)

ANTIBACTERIALS

AMINOGLYCOSIDES amikacin sulfate 1

gentamicin in saline 1

gentamicin sulfate 0.1 % cream, 0.1 % ointment, 10 mg/ml solution, 40 mg/ml solution 1 neomycin sulfate 1

paromomycin sulfate 1

streptomycin sulfate 5

tobramycin sulfate 1.2 gm recon soln 5

tobramycin sulfate 1.2 gm/30ml solution 2

tobramycin sulfate 2 gm/50ml, 10 mg/ml, 80 mg/2ml 1

ANTIBACTERIALS, OTHER acetic acid 2 % solution 1

aztreonam 2

chloramphenicol sod succinate 1

CLEOCIN 100 MG SUPPOS 4 clindacin etz 1

clindacin-p 1

clindamycin hcl 1


02/01/2021 13

clindamycin palmitate hcl 1 clindamycin phosphate 1 % swab, 2 % cream, 9 gm/60ml solution, 300 mg/2ml solution, 600 mg/4ml solution, 9000 mg/60ml solution 1 clindamycin phosphate in d5w 1 colistimethate sodium (cba) 2 DALVANCE 5 DAPTOMYCIN , 350 MG RECON SOLN 5 fosfomycin tromethamine 2 LINCOCIN 3 lincomycin hcl 1 linezolid 100 mg/5ml recon susp 5 PA; QL (1800 per 30 days) linezolid 600 mg tab 2 PA; QL (56 per 28 days) linezolid 600 mg/300ml solution 2 methenamine hippurate 2 metronidazole 0.75 % gel (topical) 2 metronidazole 0.75 % gel vaginal 1 metronidazole 0.75 % lotion, 0.75 % cream, 1 % gel 2 metronidazole 250 mg tab, 375 mg cap, 500 mg tab 1 metronidazole in nacl 5-0.79 mg/ml-%, 500-0.79 mg/100ml-% 2 MONUROL 4 neomycin-polymyxin b gu 2 nitrofurantoin 5 nitrofurantoin macrocrystal 2 nitrofurantoin monohyd macro 2 ORBACTIV 5 rosadan 2 SIVEXTRO 200 MG RECON SOLN 5 PA SIVEXTRO 200 MG TAB 5 PA; QL (6 per 30 days) SYNERCID 5 TIGECYCLINE 5 tinidazole 2 trimethoprim 1 vancomycin hcl 1 gm soln, 10 gm soln, 500 mg soln 2


02/01/2021 14

VANCOMYCIN HCL 1.25 GM RECON SOLN, 1.5 GM RECON SOLN, 250 MG RECON SOLN, 500 MG/100ML SOLUTION, 750 MG/150ML SOLUTION, 1000 MG/200ML SOLUTION, 1250 MG/250ML SOLUTION, 1500 MG/300ML SOLUTION, 1750 MG/350ML SOLUTION, 2000 MG/400ML SOLUTION 3 vancomycin hcl 125 mg cap 2 PA vancomycin hcl 250 mg cap 5 PA

VANCOMYCIN HCL IN NACL IN 500-0.9 MG/100ML-%, IN 750-0.9 MG/150ML-% 4 vandazole 1 XIFAXAN 200 MG TAB 4 PA; QL (9 per 3 days)

XIFAXAN 550 MG TAB 5 PA; QL (84 per 28 days)

BETA-LACTAM, CEPHALOSPORINS

AVYCAZ 5 cefaclor 125 mg/5ml recon susp, 250 mg cap, 250 mg/5ml recon susp, 375 mg/5ml recon susp, 500 mg cap 1 cefadroxil 1 gm tab, 250 mg/5ml recon susp, 500 mg/5ml recon susp, 500 mg cap 2 cefazolin sodium 1 gm soln, 10 gm soln, 500 mg soln 2 CEFAZOLIN SODIUM 100 GM SOLN, 300 GM SOLN 4 cefdinir 125 mg/5ml recon susp, 250 mg/5ml recon susp, 300 mg cap 2 cefepime hcl 1 gm soln, 2 gm soln 2 CEFEPIME-DEXTROSE 3 cefixime 100 mg/5ml recon susp, 200 mg/5ml recon susp, 400 mg cap 2 cefotaxime sodium 2 cefotetan disodium 2 cefoxitin sodium 2 CEFOXITIN SODIUM-DEXTROSE 4 cefpodoxime proxetil 50 mg/5ml recon susp, 100 mg/5ml recon susp, 100 mg tab, 200 mg tab 2 cefprozil 125 mg/5ml recon susp, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab 2 ceftazidime 2 ceftriaxone sodium 1 gm soln, 2 gm soln, 10 gm soln, 250 mg soln, 500 mg soln 2 CEFTRIAXONE SODIUM 100 GM RECON SOLN 3 ceftriaxone sodium for inj 1 gm 2 ceftriaxone sodium for inj 2 gm 2


02/01/2021 15

cefuroxime axetil 2

cefuroxime sodium 2

cephalexin 125 mg/5ml recon susp, 250 mg cap, 250 mg/5ml recon susp, 500 mg cap, 750 mg cap 1 FORTAZ 2 SUPRAX 100 MG CHEW TAB, 200 MG CHEW TAB, 500 MG/5ML RECON SUSP 4

tazicef (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) 2

TEFLARO 5 BETA-LACTAM, PENICILLINS amoxicillin 125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg chew tab, 250 mg cap, 400 mg/5ml recon susp, 500 mg cap, 500 mg tab, 875 mg tab 1

amoxicillin-pot clavulanate 1000-62.5 mg tab er 12h 2

amoxicillin-pot clavulanate 200-28.5 mg/5ml recon susp, 200-28.5 mg chew tab, 250-125 mg tab, 250-62.5 mg/5ml recon susp, 400-57 mg chew tab, 400-57 mg/5ml recon susp, 500-125 mg tab, 600-42.9 mg/5ml recon susp, 875-125 mg tab 2

ampicillin 1

ampicillin sodium 1 gm soln, 10 gm soln, 125 mg soln, 250 mg soln, 500 mg soln 1

ampicillin sodium 2 gm recon soln for inj 1

ampicillin sodium 2 gm recon soln for iv 1

ampicillin-sulbactam sodium 2

BICILLIN C-R 4 BICILLIN C-R 900/300 4 BICILLIN L-A 4 dicloxacillin sodium 1

nafcillin sodium 1 gm recon soln for inj 2

nafcillin sodium 1 gm recon soln for iv 5

NAFCILLIN SODIUM 10 GM RECON SOLN 5 nafcillin sodium 2 gm recon soln 2

nafcillin sodium for iv soln 1 gm 5

PENICILLIN G POT IN DEXTROSE 3 penicillin g potassium 1

penicillin g sodium 1

penicillin v potassium 125 mg/5ml recon soln, 250 mg/5ml recon soln, 250 mg tab, 500 mg tab 1

pfizerpen 1


02/01/2021 16

piperacillin sod-tazobactam so 2

CARBAPENEMS ertapenem sodium 2

imipenem-cilastatin 2

meropenem 2

MACROLIDES azithromycin 1 gm packet 2

azithromycin 100 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg tab, 500 mg recon soln, 500 mg tab, 600 mg tab 1

clarithromycin 125 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg tab, 500 mg tab 2

clarithromycin 500 mg tab er 24h 2

DIFICID 200 MG TAB 5 PA e.e.s. 400 1

ery-tab 2

ERYTHROCIN LACTOBIONATE 4 erythrocin stearate 2

erythromycin 250 mg tab dr, 333 mg tab dr, 500 mg tab dr 2

erythromycin base 250 mg cp dr part, 500 mg tab 1

erythromycin base 250 mg tab, 250 mg tab dr, 333 mg tab dr, 500 mg tab dr 2 erythromycin ethylsuccinate 200 mg/5ml recon susp 2

erythromycin ethylsuccinate 400 mg tab 1

erythromycin stearate 2

QUINOLONES ciprofloxacin hcl 0.3 % solution, 100 mg tab, 250 mg tab, 500 mg tab, 750 mg tab 1

ciprofloxacin in d5w 1

levofloxacin 25 mg/ml solution iv 1

levofloxacin 25 mg/ml solution oral 1

levofloxacin 250 mg tab, 500 mg tab, 750 mg tab 1

levofloxacin in d5w 1

moxifloxacin hcl 400 mg tab 2

MOXIFLOXACIN HCL 400 MG/250ML SOLUTION 3

moxifloxacin hcl in nacl 2

ofloxacin 300 mg tab, 400 mg tab 2

SULFONAMIDES sulfacetamide sodium (acne) 2

SULFADIAZINE 4


02/01/2021 17

sulfamethoxazole-trimethoprim 200-40 mg/5ml suspension, 400-80 mg tab, 400-80 mg/5ml solution, 800-160 mg tab 1

TETRACYCLINES

demeclocycline hcl 2

doxy 100 2

doxycycline hyclate 20 mg tab, 50 mg tab dr, 50 mg cap, 75 mg tab dr, 75 mg tab, 100 mg tab, 100 mg tab dr, 100 mg recon soln, 100 mg cap, 150 mg tab, 150 mg tab dr, 200 mg tab dr 2

doxycycline monohydrate 25 mg/5ml recon susp, 50 mg tab, 50 mg cap, 75 mg tab, 75 mg cap, 100 mg cap, 100 mg tab, 150 mg tab, 150 mg cap 2

minocycline hcl 50 mg cap, 75 mg cap, 100 mg cap 1

mondoxyne nl 2

morgidox 2

okebo 2

soloxide 2

tetracycline hcl 2

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT 10 MG TAB, 10 MG/ML SOLUTION 5 PA; QL (600 per 30 days)

BRIVIACT 25 MG TAB 5 PA; QL (240 per 30 days)

BRIVIACT 50 MG TAB 5 PA; QL (120 per 30 days)

BRIVIACT 50 MG/5ML SOLUTION 4 PA

BRIVIACT 75 MG TAB, 100 MG TAB 5 PA; QL (60 per 30 days)

DIACOMIT 250 MG CAP, 250 MG PACKET 5 PA; LA; QL (360 per 30 days); NM

DIACOMIT 500 MG PACKET, 500 MG CAP 5 PA; LA; QL (180 per 30 days); NM

divalproex sodium 1

divalproex sodium 250 mg tab er 24h 1

divalproex sodium 500 mg tab er 24h 1

EPIDIOLEX 5 PA; LA; NM

felbamate 400 mg tab, 600 mg/5ml suspension, 600 mg tab 2

FINTEPLA 5 PA; LA; NM

FYCOMPA 0.5 MG/ML SUSPENSION 4 QL (720 per 30 days)

FYCOMPA 10 MG TAB, 12 MG TAB 5 QL (30 per 30 days)

FYCOMPA 2 MG TAB 4 QL (180 per 30 days)




02/01/2021 18


lamotrigine 100 mg tab er 24h 2


lamotrigine 25 mg tab disp, 50 mg tab disp, 100 mg tab disp, 200 mg tab disp 2




lamotrigine 5 mg chew tab, 25 mg tab, 25 mg chew tab, 100 mg tab, 150 mg tab, 200 mg tab 1


lamotrigine starter kit-blue 2

lamotrigine starter kit-green 2

lamotrigine starter kit-orange 2

levetiracetam 100 mg/ml solution, 250 mg tab, 500 mg tab, 750 mg tab, 1000 mg tab 1

levetiracetam 500 mg tab er 24h 2 QL (180 per 30 days)

levetiracetam 500 mg/5ml solution 2

levetiracetam 750 mg tab er 24h 2 QL (120 per 30 days)

LEVETIRACETAM IN NACL 1000 MG/100ML, 1500 MG/100ML 2

LEVETIRACETAM IN NACL 500 MG/100ML SOLUTION 5

roweepra 1

roweepra xr 500 mg tab er 24h 2 QL (180 per 30 days)

roweepra xr 750 mg tab er 24h 2 QL (120 per 30 days)

SPRITAM 250 MG TAB, 500 MG TAB, 1000 MG TAB 4 PA; QL (60 per 30 days)

SPRITAM 750 MG TAB 4 PA; QL (120 per 30 days)

subvenite 1

subvenite starter kit-blue 2

subvenite starter kit-green 2

subvenite starter kit-orange 2

topiramate 100 mg tab 1 QL (480 per 30 days)

topiramate 15 mg cap, 25 mg cap 1




TROKENDI XR 100 MG CAP ER 24H 5 QL (30 per 30 days)

TROKENDI XR 200 MG CAP ER 24H 5 QL (60 per 30 days)

TROKENDI XR 25 MG CAP ER, 50 MG CAP ER 4 QL (30 per 30 days)

valproate sodium 1

valproic acid 250 mg cap, 250 mg/5ml solution 1

XCOPRI (250 MG DAILY DOSE) 5 QL (56 per 28 days)


02/01/2021 19

XCOPRI (350 MG DAILY DOSE) 5 QL (56 per 28 days)

XCOPRI 14 X 12.5 MG & 14 X 25 MG TAB THPK 4 QL (56 per 365 over time); NE

XCOPRI 150 MG TAB, 200 MG TAB 5 QL (60 per 30 days)

XCOPRI 50 MG TAB, 100 MG TAB 5 QL (30 per 30 days)

XCOPRI COPRI 14 50 MG 14 100 MG TAB THPK, COPRI 14 150 MG 14 200 MG TAB THPK 5 QL (56 per 365 over time); NE

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 4 ethosuximide 250 mg/5ml solution, 250 mg cap 2

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam 10 mg tab 2 PA; QL (120 per 30 days)

clobazam 2.5 mg/ml suspension 2 PA; QL (480 per 30 days)

clobazam 20 mg tab 2 PA; QL (60 per 30 days)

DIASTAT ACUDIAL 4

DIASTAT PEDIATRIC 4 diazepam 2.5 mg gel, 10 mg gel, 20 mg gel 2

gabapentin 100 mg cap 1 QL (1080 per 30 days)

gabapentin 250 mg/5ml, 300 mg/6ml 1 QL (2160 per 30 days)



gabapentin 600 mg tab 1 QL (180 per 30 days)

gabapentin 800 mg tab 1 QL (120 per 30 days)

phenobarbital 100 mg tab 1 PA; QL (120 per 30 days)


phenobarbital 16.2 mg tab 1 PA; QL (741 per 30 days)

phenobarbital 20 mg/5ml elixir 1 PA; QL (3000 per 30 days)






primidone 1

SYMPAZAN 10 MG, 20 MG 5 PA; QL (60 per 30 days)

SYMPAZAN 5 MG FILM 4 PA; QL (30 per 30 days)

tiagabine hcl 2

VALTOCO 10 MG DOSE 4 VALTOCO 15 MG DOSE 4 VALTOCO 20 MG DOSE 4 VALTOCO 5 MG DOSE 4

vigabatrin 5 PA; LA; QL (180 per 30 days); NM

vigadrone 5 PA; LA; QL (180 per 30 days); NM


02/01/2021 20

SODIUM CHANNEL AGENTS APTIOM 5 ST BANZEL 200 MG TAB 5 PA; QL (480 per 30 days)

BANZEL 40 MG/ML SUSPENSION 5 PA; QL (2400 per 30 days) BANZEL 400 MG TAB 5 PA; QL (240 per 30 days) carbamazepine 100 mg cap er 12h 2 carbamazepine 100 mg chew tab, 100 mg/5ml suspension, 200 mg tab 1 carbamazepine 100 mg tab er 12h 2 carbamazepine 200 mg cap er 12h 2 carbamazepine 200 mg tab er 12h 2 carbamazepine 300 mg cap er 12h 2 carbamazepine 400 mg tab er 12h 2 CEREBYX 500 MG PE/10ML SOLUTION 4 DILANTIN 30 MG CAP, 100 MG CAP 4 DILANTIN INFATABS 4 epitol 1 fosphenytoin sodium 2 oxcarbazepine 150 mg tab, 300 mg/5ml suspension, 300 mg tab, 600 mg tab 1 PEGANONE 4 PHENYTEK 4 phenytoin 50 mg chew tab, 100 mg/4ml suspension, 125 mg/5ml suspension 1 phenytoin infatabs 1 phenytoin sodium 1 phenytoin sodium extended 1 rufinamide 5 PA; QL (2400 per 30 days) TEGRETOL 100 MG/5ML SUSPENSION 4 VIMPAT 10 MG/ML, 200 MG/20ML 5 QL (1200 per 30 days) VIMPAT 100 MG TAB 5 QL (120 per 30 days) VIMPAT 150 MG TAB, 200 MG TAB 5 QL (60 per 30 days) VIMPAT 50 MG TAB 4 QL (240 per 30 days) zonisamide 1

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates 2 PA

CHOLINESTERASE INHIBITORS donepezil hcl 1 QL (30 per 30 days) galantamine hydrobromide 16 mg cap er 24h 2 QL (30 per 30 days) galantamine hydrobromide 24 mg cap er 24h 2 QL (30 per 30 days) galantamine hydrobromide 4 mg tab, 8 mg tab, 12 mg tab 2 QL (60 per 30 days)


02/01/2021 21

galantamine hydrobromide 4 mg/ml solution 2 QL (200 per 30 days)

galantamine hydrobromide 8 mg cap er 24h 2 QL (30 per 30 days)

rivastigmine 2 QL (30 per 30 days)

rivastigmine tartrate 2 QL (60 per 30 days)

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

memantine hcl 10 mg tab, 28 5 mg & 21 10 mg tab 2 PA; QL (60 per 30 days)

memantine hcl 14 mg cap er 24h 2 PA; QL (30 per 30 days)

memantine hcl 2 mg/ml, 10 mg/5ml 2 PA; QL (300 per 30 days)



memantine hcl 5 mg tab 2 PA; QL (90 per 30 days)


ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl (sr) 100 mg tab er 12h 1 QL (120 per 30 days)



bupropion hcl (xl) 150 mg tab er 24h 1 QL (90 per 30 days)

bupropion hcl (xl) 300 mg tab er 24h 1 QL (30 per 30 days)

bupropion hcl 100 mg tab 1 QL (135 per 30 days)

bupropion hcl 75 mg tab 1 QL (180 per 30 days)

chlordiazepoxide-amitriptyline 2 PA

maprotiline hcl 25 mg tab 2 QL (270 per 30 days)



mirtazapine 15 mg tab 1 QL (90 per 30 days)

mirtazapine 15 mg tab disp 2 QL (90 per 30 days)





mirtazapine 7.5 mg tab 1 QL (180 per 30 days)

olanzapine-fluoxetine hcl 3-25 mg cap, 6-25 mg cap 2 QL (90 per 30 days)

olanzapine-fluoxetine hcl 6-50 mg cap, 12-25 mg cap, 12-50 mg cap 2 QL (30 per 30 days)

perphenazine-amitriptyline 2 PA

SPRAVATO (56 MG DOSE) 5 PA; QL (16 per 28 days); NM

SPRAVATO (84 MG DOSE) 5 PA; QL (24 per 28 days); NM

ZULRESSO 5 PA; NM

MONOAMINE OXIDASE INHIBITORS


02/01/2021 22

EMSAM 5 PA; QL (30 per 30 days)

MARPLAN 4

phenelzine sulfate 1

tranylcypromine sulfate 2

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide 10 mg tab 1 QL (120 per 30 days)

citalopram hydrobromide 10 mg/5ml solution 1 QL (600 per 30 days)



desvenlafaxine succinate 100 mg tab er 24h 2 QL (120 per 30 days)



escitalopram oxalate 10 mg tab 1 QL (60 per 30 days)



escitalopram oxalate 5 mg/5ml solution 1 QL (600 per 30 days)

FETZIMA 20 MG CAP ER 24H 4 PA; QL (180 per 30 days)

FETZIMA 40 MG CAP ER 24H 4 PA; QL (90 per 30 days)

FETZIMA 80 MG CAP ER, 120 MG CAP ER 4 PA; QL (30 per 30 days)

FETZIMA TITRATION 4 PA

fluoxetine hcl 10 mg tab, 10 mg cap 1 QL (240 per 30 days)

fluoxetine hcl 20 mg cap 1 QL (120 per 30 days)

fluoxetine hcl 20 mg tab 2 QL (120 per 30 days)

fluoxetine hcl 20 mg/5ml solution 1 QL (600 per 30 days)

fluoxetine hcl 40 mg cap 1 QL (60 per 30 days)

FLUOXETINE HCL 60 MG TAB 2 QL (30 per 30 days)

fluvoxamine maleate 100 mg cap er 24h 1 QL (90 per 30 days)

fluvoxamine maleate 100 mg tab 1 QL (90 per 30 days)

fluvoxamine maleate 150 mg cap er 24h 1 QL (60 per 30 days)



nefazodone hcl 100 mg tab 2 QL (180 per 30 days)





paroxetine hcl 10 mg tab 1 QL (180 per 30 days)

paroxetine hcl 12.5 mg tab er 24h 2 QL (180 per 30 days)


paroxetine hcl 25 mg tab er 24h 2 QL (90 per 30 days)


paroxetine hcl 37.5 mg tab er 24h 2 QL (60 per 30 days)


02/01/2021 23


PAXIL 10 MG/5ML SUSPENSION 4 QL (900 per 30 days)

sertraline hcl 100 mg tab 1 QL (60 per 30 days)

sertraline hcl 20 mg/ml conc 1 QL (300 per 30 days)



trazodone hcl 300 mg tab 2

trazodone hcl 50 mg tab, 100 mg tab, 150 mg tab 1

TRINTELLIX 10 MG TAB 4 QL (60 per 30 days)



venlafaxine hcl 100 mg tab 1 QL (113 per 30 days)

venlafaxine hcl 150 mg cap er 24h 1 QL (60 per 30 days)

venlafaxine hcl 150 mg tab er 24h 2 QL (60 per 30 days)



venlafaxine hcl 37.5 mg cap er 24h 1 QL (180 per 30 days)

venlafaxine hcl 37.5 mg tab 1 QL (300 per 30 days)

venlafaxine hcl 37.5 mg tab er 24h 2 QL (180 per 30 days)


venlafaxine hcl 75 mg cap er 24h 1 QL (90 per 30 days)



VIIBRYD 10 MG TAB 4 ST; QL (120 per 30 days)



VIIBRYD STARTER PACK 4 ST

TRICYCLICS

amitriptyline hcl 2 PA

amoxapine 1 PA

clomipramine hcl 2 PA

desipramine hcl 2 PA

doxepin hcl 10 mg cap, 10 mg/ml conc, 25 mg cap, 50 mg cap, 75 mg cap, 100 mg cap, 150 mg cap 2 PA

imipramine hcl 2 PA

imipramine pamoate 2 PA

nortriptyline hcl 10 mg/5ml solution, 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap 1 PA

protriptyline hcl 2 PA

trimipramine maleate 2

ANTIEMETICS

ANTIEMETICS, OTHER


02/01/2021 24

compro 1

meclizine hcl 1

metoclopramide hcl 5 mg/ml solution, 5 mg/5ml solution, 5 mg tab, 10 mg tab, 10 mg/10ml solution 1

perphenazine 1

phenadoz 2 PA

prochlorperazine 1

prochlorperazine edisylate 1

prochlorperazine maleate 1

promethazine hcl 12.5 mg tab, 12.5 mg suppos, 25 mg tab, 25 mg suppos, 50 mg tab 2 PA

promethegan 2 PA

scopolamine 2 QL (10 per 28 days)

TRANSDERM SCOP (1.5 MG) 4 QL (10 per 28 days)

TRANSDERM-SCOP (1.5 MG) 4 QL (10 per 28 days)

trimethobenzamide hcl 2

EMETOGENIC THERAPY ADJUNCTS

ALOXI 4 PA

aprepitant 125 mg cap 2 PA-BvD; QL (5 per 30 days)


aprepitant 80 125 mg cap, 80 125 mg misc 2 PA-BvD; QL (15 per 30 days)


dronabinol 2 PA-BvD; QL (120 per 30 days)

EMEND 125 MG/5ML RECON SUSP 3 PA-BvD; QL (15 per 30 days)

EMEND 150 MG RECON SOLN 3

fosaprepitant dimeglumine 2

granisetron hcl 1 mg tab 2 PA-BvD; QL (30 per 30 days)

granisetron hcl 1 mg/ml solution 2

ondansetron 2 PA-BvD; QL (90 per 30 days)

ondansetron hcl 24 mg tab 2 PA-BvD; QL (30 per 30 days)

ondansetron hcl 4 mg tab, 8 mg tab 2 PA-BvD; QL (90 per 30 days)

ondansetron hcl 4 mg/2ml solution 2

ondansetron hcl 4 mg/5ml solution 2 PA-BvD; QL (450 per 30 days)

palonosetron hcl 0.25 mg/5ml solution 2 PA

SANCUSO 5 PA; QL (4 per 28 days)

ANTIFUNGALS

ANTIFUNGALS ABELCET 4 PA-BvD

AMBISOME 5 PA-BvD

amphotericin b 2 PA-BvD

ciclopirox olamine 0.77 % cream, 0.77 % suspension 1


02/01/2021 25

clotrimazole 1 % cream 2 clotrimazole 1 % solution, 10 mg troche 1 CRESEMBA 5 PA econazole nitrate 1 fluconazole 10 mg/ml recon susp, 40 mg/ml recon susp, 50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab 1 fluconazole in dextrose 200 mg/100ml solution 2 fluconazole in dextrose 400 mg/200ml solution 1 fluconazole in sodium chloride 200-0.9 mg/100ml% solution 2 fluconazole in sodium chloride 400-0.9 mg/200ml% solution 1 flucytosine 250 mg cap 2 flucytosine 500 mg cap 5 griseofulvin microsize 125 mg/5ml suspension, 500 mg tab 2 griseofulvin ultramicrosize 2 itraconazole 100 mg cap 2 PA

ketoconazole 2 % cream 1 QL (120 per 30 days) ketoconazole 2 % foam 2 ketoconazole 2 % shampoo, 200 mg tab 1 ketodan 2 MENTAX 4 micafungin sodium 5 miconazole 3 1 MYCAMINE 5 naftifine hcl 2 NAFTIN 2 % GEL 3 NOXAFIL 300 MG/16.7ML SOLUTION 5 NOXAFIL 40 MG/ML SUSPENSION 5 PA nyamyc 1 nystatin 100000 unit/gm powder, 100000 unit/ml suspension, 100000 unit/gm ointment, 100000 unit/gm cream, 500000 unit tab 1 nystop 1 oxiconazole nitrate 5 QL (60 per 30 days) OXISTAT 1 % LOTION 4 posaconazole 5 PA

terbinafine hcl 1 terconazole 0.4 %, 0.8 % 1 terconazole 80 mg suppos 2 voriconazole 40 mg/ml recon susp, 200 mg recon soln, 200 mg tab 5 PA


02/01/2021 26

voriconazole 50 mg tab 2 PA

ANTIGOUT AGENTS

ANTIGOUT AGENTS

allopurinol 1

colchicine 2

colchicine-probenecid 1

febuxostat 2 ST

probenecid 1

ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS dihydroergotamine mesylate 1 mg/ml solution 2 PA

dihydroergotamine mesylate 4 mg/ml solution 5 QL (8 per 28 days)

migergot 5

PROPHYLACTIC

AIMOVIG (140 MG DOSE) 3 PA; QL (2 per 30 days); NM

AIMOVIG 140 MG/ML SOLN A-INJ 3 PA; QL (1 per 30 days); NM

AIMOVIG 70 MG/ML SOLN A-INJ 3 PA; QL (2 per 30 days); NM

EMGALITY 3 PA; QL (2 per 30 days); NM

EMGALITY (300 MG DOSE) 5 PA; QL (3 per 30 days); NM

SEROTONIN (5-HT) RECEPTOR AGONIST

almotriptan malate 2 QL (9 per 30 days)

eletriptan hydrobromide 2 QL (9 per 30 days)

frovatriptan succinate 2 QL (12 per 30 days)

naratriptan hcl 1 QL (9 per 30 days)

rizatriptan benzoate 2 QL (12 per 30 days)

sumatriptan 2

sumatriptan succinate 25 mg tab, 50 mg tab, 100 mg tab 1 QL (9 per 30 days)

sumatriptan succinate 4 mg/0.5ml soln a-inj, 6 mg/0.5ml soln a-inj, 6 mg/0.5ml solution 2 QL (6 per 30 days)

sumatriptan succinate refill 2 QL (6 per 30 days)

zolmitriptan 2 QL (9 per 30 days)

ZOMIG 2.5 MG, 5 MG 4

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 3

MESTINON 60 MG/5ML SOLUTION 5

pyridostigmine bromide 180 mg tab er 2

pyridostigmine bromide 30 mg tab, 60 mg tab 1

pyridostigmine bromide 60 mg/5ml solution 2


02/01/2021 27

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone 25 mg tab, 100 mg tab 2

rifabutin 2

ANTITUBERCULARS

CAPASTAT SULFATE 4

ethambutol hcl 1

isoniazid 100 mg tab, 300 mg tab 1

isoniazid 50 mg/5ml syrup, 100 mg/ml solution 2

PASER 4

PRIFTIN 4

pyrazinamide 1

rifampin 1

SIRTURO 5 PA; LA

TRECATOR 4

ANTINEOPLASTICS

ALKYLATING AGENTS BICNU 5 PA-BvD; NM

busulfan 2 PA-BvD; NM

BUSULFEX 4 PA-BvD; NM

carmustine 5 PA-BvD; NM

CYCLOPHOSPHAMIDE 1 GM/5ML, 500 MG/2.5ML 5

cyclophosphamide 25 mg cap, 50 mg cap 3 PA-BvD; NM

EVOMELA 5 PA-BvD; NM

GLEOSTINE 4 PA IFEX 3 GM RECON SOLN 4 PA-BvD; NM

ifosfamide 1 gm/20ml solution, 1 gm recon soln, 3 gm/60ml solution 2 PA-BvD; NM

IFOSFAMIDE 3 GM RECON SOLN 4 PA-BvD; NM

LEUKERAN 4 MATULANE 5 LA; NM melphalan hcl 2 PA-BvD; NM

thiotepa 100 mg recon soln 2 PA-BvD

thiotepa 15 mg recon soln 2 PA-BvD; NM

TREANDA 5 PA-BvD; NM

VALCHLOR 5 PA; LA; NM YONDELIS 5 PA-BvD; NM

ZEPZELCA 5 NM ANTIANDROGENS abiraterone acetate 250 mg tab 5 PA; QL (120 per 30 days); NM

bicalutamide 1 QL (30 per 30 days)

ERLEADA 5 PA; LA; NM


02/01/2021 28

flutamide 1

nilutamide 5 QL (30 per 30 days)

NUBEQA 5 PA; LA; QL (120 per 30 days); NM

XTANDI 5 PA; LA; QL (120 per 30 days); NM

YONSA 5 PA; QL (120 per 30 days); NM

ZYTIGA 500 MG TAB 5 PA; LA; QL (60 per 30 days); NM

ANTIANGIOGENIC AGENTS

POMALYST 1 MG CAP 5 PA; LA; QL (120 per 30 days); NM

POMALYST 2 MG CAP 5 PA; LA; QL (60 per 30 days); NM

POMALYST 3 MG CAP, 4 MG CAP 5 PA; LA; QL (30 per 30 days); NM

REVLIMID 10 MG CAP 5 PA; LA; QL (60 per 30 days); NM

REVLIMID 2.5 MG CAP, 15 MG CAP, 20 MG CAP, 25 MG CAP 5 PA; LA; QL (30 per 30 days); NM

REVLIMID 5 MG CAP 5 PA; LA; QL (150 per 30 days); NM

THALOMID 150 MG CAP, 200 MG CAP 5 PA; QL (60 per 30 days); NM THALOMID 50 MG CAP, 100 MG CAP 5 PA; QL (30 per 30 days); NM ANTIESTROGENS/MODIFIERS

EMCYT 4 NM

FASLODEX 5 PA; NM fulvestrant 5 PA; NM

SOLTAMOX 5 tamoxifen citrate 1

toremifene citrate 5 QL (30 per 30 days); NM

ANTIMETABOLITES

ALIMTA 5 PA; NM cladribine 5 PA-BvD; NM

clofarabine 5 PA-BvD; NM

CLOLAR 5 PA-BvD; NM

cytarabine 2 PA-BvD; NM

cytarabine (pf) 2 PA-BvD; NM

DROXIA 4 fluorouracil 1 gm/20ml, 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml 2 PA-BvD; NM

FOLOTYN 5 PA-BvD; NM

gemcitabine hcl 1 gm/26.3ml solution, 1 gm recon soln, 2 gm recon soln, 200 mg recon soln, 200 mg/5.26ml solution 2 PA-BvD; NM

gemcitabine hcl 2 gm/52.6ml solution 5 PA-BvD; NM

hydroxyurea 1

INQOVI 5 PA; LA; QL (5 per 28 days)


02/01/2021 29

mercaptopurine 1

NIPENT 5 PA-BvD; NM

PURIXAN 5 PA; NM

TABLOID 4

ANTINEOPLASTICS, OTHER

adriamycin 2 mg/ml solution, 10 mg recon soln, 50 mg recon soln 2 PA-BvD; NM

ARRANON 5 PA-BvD; NM

arsenic trioxide 5 PA-BvD; NM

AYVAKIT 5 PA; LA; QL (30 per 30 days); NM

azacitidine 5 PA; NM

bleomycin sulfate 2 PA-BvD; NM

BORTEZOMIB 5 PA; NM

BRUKINSA 5 PA; LA; QL (120 per 30 days); NM

carboplatin 2 PA-BvD; NM

cisplatin 2 PA-BvD; NM

dacarbazine 2 PA-BvD; NM

dactinomycin 5 PA-BvD; NM

daunorubicin hcl 20 mg/4ml solution 3 PA-BvD; NM

DAUNORUBICIN HCL 50 MG/10ML SOLUTION 4 PA-BvD; NM

decitabine 5 PA-BvD; NM

dexrazoxane hcl 5 PA-BvD; NM

docetaxel 160 mg/16ml solution 4 PA-BvD; NM

DOCETAXEL 20 MG/ML CONC, 20 MG/2ML SOLUTION, 80 MG/8ML SOLUTION, 160 MG/8ML CONC, 200 MG/10ML CONC 5 PA-BvD; NM

DOCETAXEL 80 MG/4ML CONC 2 PA-BvD; NM

doxorubicin hcl 2 mg/ml solution, 50 mg recon soln 2 PA-BvD; NM

doxorubicin hcl liposomal 5 PA; NM

epirubicin hcl 2 PA-BvD; NM

ERWINAZE 5 PA; LA; NM

fludarabine phosphate 50 mg recon soln 2 PA-BvD; NM

HALAVEN 5 PA; NM

idarubicin hcl 5 PA-BvD; NM

IDHIFA 100 MG TAB 5 PA; LA; QL (30 per 30 days); NM

IDHIFA 50 MG TAB 5 PA; LA; QL (60 per 30 days); NM

IMLYGIC 1000000 UNIT/ML SUSPENSION 4 PA; NM

IMLYGIC 100000000 UNIT/ML SUSPENSION 5 PA; NM

INREBIC 5 PA; LA; QL (120 per 30 days); NM

irinotecan hcl 2 PA-BvD; NM

ISTODAX (OVERFILL) 5 PA; NM


02/01/2021 30

IXEMPRA KIT 5 PA; NM KHAPZORY 5 PA; NM KISQALI FEMARA (400 MG DOSE) 5 PA; QL (70 per 28 days); NM

KISQALI FEMARA (600 MG DOSE) 5 PA; QL (91 per 28 days); NM

KISQALI FEMARA(200 MG DOSE) 5 PA; QL (49 per 28 days); NM

KOSELUGO 5 PA; NM

leucovorin calcium 50 mg soln, 100 mg soln, 200 mg soln, 350 mg soln, 500 mg soln 1 PA-BvD

levoleucovorin calcium 5 PA; NM

levoleucovorin calcium pf 5 PA; NM

LONSURF 5 PA; NM MARQIBO 5 NM mitomycin 40 mg recon soln 5 PA-BvD; NM

mitomycin 5 mg soln, 20 mg soln 2 PA-BvD; NM

mitoxantrone hcl 1 PA-BvD; NM

mutamycin 40 mg recon soln 5 PA-BvD; NM

mutamycin 5 mg soln, 20 mg soln 2 PA-BvD; NM

NINLARO 5 PA; QL (3 per 28 days); NM

ONUREG 5 PA; QL (14 per 28 days)

oxaliplatin 100 mg recon soln 5 PA-BvD; NM

oxaliplatin 200 mg/40ml solution 2 PA-BvD

oxaliplatin 50 mg/10ml solution, 50 mg recon soln, 100 mg/20ml solution 2 PA-BvD; NM

paclitaxel 30 mg/5ml, 100 mg/16.7ml, 150 mg/25ml 2 PA-BvD; NM

paclitaxel 300 mg/50ml conc 2 NM

paraplatin 1000 mg/100ml solution 2 PA-BvD

paraplatin 50 mg/5ml, 150 mg/15ml, 450 mg/45ml, 600 mg/60ml 2 PA-BvD; NM

PHESGO 5 PA; NM PROLEUKIN 5 PA-BvD; NM

QINLOCK 5 PA; QL (90 per 30 days); NM

RETEVMO 40 MG CAP 5 PA; QL (180 per 30 days); NM

RETEVMO 80 MG CAP 5 PA; QL (120 per 30 days); NM

ROMIDEPSIN 10 MG RECON SOLN, 27.5 MG/5.5ML SOLUTION 5 PA; NM

ROZLYTREK 100 MG CAP 5 PA; LA; QL (150 per 30 days); NM

ROZLYTREK 200 MG CAP 5 PA; LA; QL (90 per 30 days); NM

SYNRIBO 5 PA; NM

TABRECTA 5 PA; QL (120 per 30 days); NM

TAXOTERE 5 PA-BvD; NM

TAZVERIK 5 PA; LA; QL (240 per 30 days); NM


02/01/2021 31

TRISENOX 5 PA-BvD; NM

VELCADE 5 PA; NM

vinblastine sulfate 2 PA-BvD; NM

vincasar pfs 2 PA-BvD; NM

vincristine sulfate 2 PA-BvD; NM

vinorelbine tartrate 2 PA-BvD; NM

VYXEOS 5 PA-BvD; NM

XPOVIO (100 MG ONCE WEEKLY) 5 PA; LA; QL (20 per 28 days); NM


XPOVIO (40 MG TWICE WEEKLY) 5 PA; LA; QL (16 per 28 days); NM





ZALTRAP 5 PA; LA; NM

ZANOSAR 5 PA-BvD; NM

ZOLINZA 5 PA; QL (120 per 30 days); NM

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1 QL (30 per 30 days)

exemestane 2 QL (60 per 30 days)

letrozole 1 QL (30 per 30 days)

ENZYME INHIBITORS

ETOPOPHOS 5 PA-BvD; NM

etoposide 2 PA-BvD; NM

GAVRETO 5 PA; LA; QL (120 per 30 days)

toposar 1 gm/50ml, 100 mg/5ml 2 PA-BvD; NM

topotecan hcl 4 mg recon soln, 4 mg/4ml solution 5 PA-BvD; NM

MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TAB 5 PA; NM

AFINITOR DISPERZ 5 PA; NM

ALECENSA 5 PA; LA; QL (240 per 30 days); NM

ALIQOPA 5 PA; LA; NM

ALUNBRIG 180 MG TAB 5 PA; LA; QL (30 per 30 days); NM


ALUNBRIG 90 & 180 MG TAB THPK 5 PA; LA; QL (30 per 180 over time); NM; NE


BALVERSA 3 MG TAB 5 PA; LA; QL (90 per 30 days); NM



BELEODAQ 5 PA; NM

BOSULIF 100 MG TAB 5 PA; QL (120 per 30 days); NM


02/01/2021 32

BOSULIF 400 MG TAB, 500 MG TAB 5 PA; QL (30 per 30 days); NM

BRAFTOVI 5 PA; LA; QL (180 per 30 days); NM

CABOMETYX 5 PA; LA; QL (30 per 30 days); NM

CALQUENCE 5 PA; LA; NM

CAPRELSA 100 MG TAB 5 PA; LA; QL (90 per 30 days); NM

CAPRELSA 300 MG TAB 5 PA; LA; QL (30 per 30 days); NM

COMETRIQ (100 MG DAILY DOSE) 5 PA; LA; QL (56 per 28 days); NM



COPIKTRA 5 PA; LA; QL (60 per 30 days); NM

COTELLIC 5 PA; LA; QL (90 per 30 days); NM

CYRAMZA 5 PA; LA; NM

DAURISMO 100 MG TAB 5 PA; LA; QL (30 per 30 days); NM

DAURISMO 25 MG TAB 5 PA; LA; QL (60 per 30 days); NM

ERIVEDGE 5 PA; LA; QL (30 per 30 days); NM

erlotinib hcl 100 mg tab, 150 mg tab 5 PA; QL (30 per 30 days); NM

erlotinib hcl 25 mg tab 5 PA; QL (90 per 30 days); NM

everolimus 2.5 mg tab, 5 mg tab, 7.5 mg tab 5 PA; NM

FARYDAK 10 MG CAP 5 PA; LA; QL (60 per 30 days); NM

FARYDAK 15 MG CAP, 20 MG CAP 5 PA; LA; QL (30 per 30 days); NM

GILOTRIF 5 PA; LA; QL (30 per 30 days); NM

IBRANCE 5 PA; LA; QL (30 per 30 days); NM

ICLUSIG 15 MG TAB 5 PA; LA; QL (60 per 30 days); NM

ICLUSIG 45 MG TAB 5 PA; LA; QL (30 per 30 days); NM

imatinib mesylate 100 mg tab 5 PA; QL (240 per 30 days); NM

imatinib mesylate 400 mg tab 5 PA; QL (60 per 30 days); NM

IMBRUVICA 140 MG CAP, 140 MG TAB 5 PA; LA; QL (90 per 30 days); NM

IMBRUVICA 70 MG CAP, 280 MG TAB, 420 MG TAB, 560 MG TAB 5 PA; LA; QL (30 per 30 days); NM

INLYTA 1 MG TAB 5 PA; LA; QL (240 per 30 days); NM

INLYTA 5 MG TAB 5 PA; LA; QL (120 per 30 days); NM

IRESSA 5 LA; NM

JAKAFI 10 MG TAB 5 PA; LA; QL (150 per 30 days); NM






02/01/2021 33

KISQALI (200 MG DOSE) 5 PA; QL (21 per 21 days); NM



KYPROLIS 5 PA; LA; NM

lapatinib ditosylate 5 PA; QL (180 per 30 days)

LENVIMA (10 MG DAILY DOSE) 5 PA; LA; QL (30 per 30 days); NM








LORBRENA 100 MG TAB 5 PA; LA; QL (30 per 30 days); NM

LORBRENA 25 MG TAB 5 PA; LA; QL (90 per 30 days); NM

LYNPARZA 5 PA; LA; QL (120 per 30 days); NM

MEKINIST 0.5 MG TAB 5 PA; LA; QL (90 per 30 days); NM

MEKINIST 2 MG TAB 5 PA; LA; QL (30 per 30 days); NM

MEKTOVI 5 PA; LA; QL (180 per 30 days); NM

NERLYNX 5 PA; LA; QL (180 per 30 days); NM

NEXAVAR 5 PA; LA; QL (120 per 30 days); NM

ODOMZO 5 PA; LA; QL (30 per 30 days); NM

PEMAZYRE 5 PA; LA; QL (14 per 21 days); NM

PIQRAY (200 MG DAILY DOSE) 5 PA; QL (28 per 28 days); NM



RUBRACA 200 MG TAB 5 PA; LA; QL (180 per 30 days); NM

RUBRACA 250 MG TAB, 300 MG TAB 5 PA; LA; QL (120 per 30 days); NM

RYDAPT 5 PA; QL (240 per 30 days); NM

SPRYCEL 5 PA; QL (30 per 30 days); NM

STIVARGA 5 PA; LA; QL (120 per 30 days); NM

SUTENT 12.5 MG CAP 5 PA; QL (90 per 30 days); NM

SUTENT 25 MG CAP, 37.5 MG CAP, 50 MG CAP 5 PA; QL (30 per 30 days); NM

TAFINLAR 5 PA; LA; QL (120 per 30 days); NM

TAGRISSO 40 MG TAB 5 PA; LA; QL (60 per 30 days); NM

TAGRISSO 80 MG TAB 5 PA; LA; QL (30 per 30 days); NM


02/01/2021 34

TALZENNA 0.25 MG CAP 5 PA; LA; QL (180 per 30 days); NM

TALZENNA 1 MG CAP 5 PA; LA; QL (60 per 30 days); NM

TASIGNA 5 PA; QL (112 per 28 days); NM

TIBSOVO 5 PA; LA; QL (60 per 30 days); NM

TUKYSA 5 PA; LA; QL (120 per 30 days); NM

TURALIO 5 PA; LA; QL (120 per 30 days); NM

TYKERB 5 PA; LA; QL (180 per 30 days); NM

VENCLEXTA 10 MG TAB 3 PA; LA; QL (60 per 30 days); NM



VENCLEXTA STARTING PACK 5 PA; LA; NM

VERZENIO 5 PA; LA; QL (60 per 30 days); NM

VITRAKVI 100 MG CAP 5 PA; LA; QL (60 per 30 days); NM

VITRAKVI 20 MG/ML SOLUTION 5 PA; LA; QL (300 per 30 days); NM

VITRAKVI 25 MG CAP 5 PA; LA; QL (180 per 30 days); NM

VIZIMPRO 15 MG TAB 5 PA; LA; QL (90 per 30 days); NM

VIZIMPRO 30 MG TAB, 45 MG TAB 5 PA; LA; QL (30 per 30 days); NM

VOTRIENT 5 PA; LA; QL (120 per 30 days); NM

XALKORI 5 PA; LA; QL (60 per 30 days); NM

XOSPATA 5 PA; LA; QL (90 per 30 days); NM

ZEJULA 5 PA; LA; QL (90 per 30 days); NM

ZELBORAF 5 PA; LA; QL (240 per 30 days); NM

ZYDELIG 5 PA; LA; QL (60 per 30 days); NM

ZYKADIA 5 PA; LA; QL (90 per 30 days); NM

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

ARZERRA 5 PA; NM AVASTIN 5 PA; LA; NM BAVENCIO 5 PA; LA; NM BESPONSA 5 PA-BvD; LA; NM

BLENREP 5 PA BLINCYTO 5 PA; NM DARZALEX 5 PA; LA; NM DARZALEX FASPRO 5 PA; NM EMPLICITI 5 PA; LA; NM


02/01/2021 35

ENHERTU 5 PA; NM

ERBITUX 5 PA; NM

GAZYVA 5 PA; LA; NM

HERCEPTIN 150 MG RECON SOLN 5 PA-BvD; NM

HERCEPTIN HYLECTA 5 PA-BvD; NM

IMFINZI 5 PA; LA; NM

KADCYLA 5 PA; NM

KEYTRUDA 5 PA; NM

LIBTAYO 5 PA; LA; NM

LUMOXITI 5 PA; LA; NM

MONJUVI 5 PA

MYLOTARG 5 PA; LA; NM

OPDIVO 5 PA; LA; NM

PADCEV 5 PA; NM

PERJETA 5 PA; NM

POLIVY 140 MG RECON SOLN 5 PA-BvD; NM

POLIVY 30 MG RECON SOLN 5 PA-BvD

POTELIGEO 5 PA-BvD; LA; NM

RITUXAN 5 PA-BvD; LA; NM

RITUXAN HYCELA 5 PA-BvD; LA; NM

SARCLISA 5 PA; NM

SYLVANT 100 MG RECON SOLN 5 PA; LA; NM

TECENTRIQ 1200 MG/20ML SOLUTION 5 PA; LA; QL (20 per 21 days); NM

TECENTRIQ 840 MG/14ML SOLUTION 5 PA; LA; QL (28 per 30 days); NM

VECTIBIX 5 PA; NM

YERVOY 5 PA; NM

RETINOIDS

bexarotene 5 PA; QL (300 per 30 days); NM

PANRETIN 5 NM

TARGRETIN 1 % GEL 5 PA; QL (60 per 30 days); NM

tretinoin 10 mg cap 5

TREATMENT ADJUNCTS

ELITEK 5 PA; NM

leucovorin calcium 5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab 1

mesna 2

MESNEX 400 MG TAB 4

ANTIPARASITICS

ANTHELMINTHICS albendazole 2

ivermectin 3 mg tab 2

praziquantel 2

ANTIPROTOZOALS


02/01/2021 36

ALINIA 500 MG TAB 5 QL (6 per 30 days)

atovaquone 5 PA

atovaquone-proguanil hcl 2

chloroquine phosphate 1

COARTEM 4

DARAPRIM 5

hydroxychloroquine sulfate 1

mefloquine hcl 2

nitazoxanide 5 QL (6 per 30 days)

PENTAM 4

pentamidine isethionate 2

pentamidine isethionate 300 mg recon soln for nebulization 2 PA-BvD

pentamidine isethionate for nebulization soln 300 mg 2 PA-BvD

primaquine phosphate 4

pyrimethamine 5

quinine sulfate 2 PA

ANTIPARKINSON AGENTS

ANTICHOLINERGICS benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab 1 PA

benztropine mesylate 1 mg/ml solution 2 PA

trihexyphenidyl hcl 0.4 mg/ml solution, 2 mg tab, 5 mg tab 1 PA ANTIPARKINSON AGENTS, OTHER amantadine hcl 50 mg/5ml syrup, 100 mg cap, 100 mg tab 1 carbidopa-levodopa-entacapone 2

entacapone 2

tolcapone 5 PA; QL (180 per 30 days)

DOPAMINE AGONISTS

APOKYN 5 PA; LA; NM bromocriptine mesylate 2

NEUPRO 4 QL (30 per 30 days)

pramipexole dihydrochloride 1

pramipexole dihydrochloride 0.375 mg tab er 24h 2




pramipexole dihydrochloride 3 mg tab er 24h 2




02/01/2021 37

ropinirole hcl 1 ropinirole hcl 12 mg tab er 24h 2 ropinirole hcl 2 mg tab er 24h 2 ropinirole hcl 4 mg tab er 24h 2 ropinirole hcl 6 mg tab er 24h 2 ropinirole hcl 8 mg tab er 24h 2 DOPAMINE PRECURSORS AND/OR L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 2 carbidopa-levodopa 10-100 mg tab, 25-100 mg tab, 25-250 mg tab 1 carbidopa-levodopa 25-100 mg tab er 1 carbidopa-levodopa 50-200 mg tab er 1 MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate 2 selegiline hcl 2 ZELAPAR 5

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine hcl 10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab 1 chlorpromazine hcl 25 mg/ml, 50 mg/2ml 3 fluphenazine decanoate 1 fluphenazine hcl 1 mg tab, 2.5 mg/ml solution, 2.5 mg tab, 2.5 mg/5ml elixir, 5 mg tab, 10 mg tab 1 haloperidol 1 haloperidol decanoate 1 haloperidol lactate 1 loxapine succinate 2 molindone hcl 2 pimozide 2 thioridazine hcl 2 thiothixene 1 trifluoperazine hcl 1 2ND GENERATION/ATYPICAL

ABILIFY MAINTENA 5 QL (1 per 28 days)

aripiprazole 1 mg/ml solution 2 QL (900 per 30 days)

aripiprazole 10 mg tab 2 QL (90 per 30 days)

aripiprazole 10 mg tab disp 5 QL (90 per 30 days)


aripiprazole 15 mg tab disp 5 QL (60 per 30 days)


aripiprazole 20 mg tab, 30 mg tab 2 QL (30 per 30 days)


02/01/2021 38


ARISTADA 1064 MG/3.9ML PRSYR 5 QL (3.9 per 60 days); NE

ARISTADA 441 MG/1.6ML PRSYR 5 QL (1.6 per 30 days)



ARISTADA INITIO 5 QL (4.8 per 365 over time); NE

CAPLYTA 5 PA; QL (30 per 30 days)

FANAPT 1 MG TAB 4 QL (720 per 30 days)

FANAPT 10 MG TAB, 12 MG TAB 5 QL (60 per 30 days)





FANAPT TITRATION PACK 4

GEODON 20 MG RECON SOLN 4 QL (6 per 3 days)

INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYR 5 QL (0.75 per 28 days)

INVEGA SUSTENNA 156 MG/ML SUSP PRSYR 5 QL (1 per 28 days)




INVEGA TRINZA 273 MG/0.875ML SUSP PRSYR 5 QL (0.875 per 90 days); NE




NUPLAZID 10 MG TAB, 34 MG CAP 5 PA; LA; QL (30 per 30 days); NM

olanzapine 10 mg recon soln 2 QL (90 per 30 days)

olanzapine 10 mg tab 1 QL (60 per 30 days)

olanzapine 10 mg tab disp 2 QL (60 per 30 days)



olanzapine 2.5 mg tab 1 QL (240 per 30 days)





olanzapine 7.5 mg tab 1 QL (80 per 30 days)

paliperidone 1.5 mg tab er 24h 2 QL (240 per 30 days)

paliperidone 3 mg tab er 24h 2 QL (120 per 30 days)



PERSERIS 5 QL (1 per 28 days)

quetiapine fumarate 100 mg tab 1 QL (240 per 30 days)

quetiapine fumarate 150 mg tab er 24h 2 QL (150 per 30 days)



02/01/2021 39









REXULTI 0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 2 MG TAB 5 QL (60 per 30 days)

REXULTI 3 MG TAB, 4 MG TAB 5 QL (30 per 30 days)

RISPERDAL CONSTA 12.5 MG, 25 MG 4 QL (2 per 28 days)

RISPERDAL CONSTA 37.5 MG, 50 MG 5 QL (2 per 28 days)

risperidone 0.25 mg tab 1 QL (1920 per 30 days)

risperidone 0.25 mg tab disp 2 QL (1920 per 30 days)

risperidone 0.5 mg tab 1 QL (960 per 30 days)

risperidone 0.5 mg tab disp 2 QL (960 per 30 days)

risperidone 1 mg tab disp 2 QL (480 per 30 days)

risperidone 1 mg/ml solution, 1 mg tab 1 QL (480 per 30 days)

risperidone 2 mg tab 1 QL (240 per 30 days)






SAPHRIS 10 MG SL TAB 5 QL (60 per 30 days)

SAPHRIS 2.5 MG SL TAB 4 QL (240 per 30 days)

SAPHRIS 5 MG SL TAB 4 QL (120 per 30 days)

SECUADO 5 QL (30 per 30 days)

VRAYLAR 1.5 & 3 MG CAP THPK 4

VRAYLAR 1.5 MG CAP, 3 MG CAP, 4.5 MG CAP, 6 MG CAP 5 QL (30 per 30 days)

ziprasidone hcl 20 mg cap 2 QL (240 per 30 days)

ziprasidone hcl 40 mg cap 2 QL (120 per 30 days)

ziprasidone hcl 60 mg cap, 80 mg cap 2 QL (60 per 30 days)

ziprasidone mesylate 2 QL (6 per 3 days)

ZYPREXA RELPREVV 210 MG RECON SUSP 4 QL (2 per 28 days)

ZYPREXA RELPREVV 300 MG, 405 MG 5 QL (2 per 28 days)

TREATMENT-RESISTANT

clozapine 100 mg tab, 100 mg tab disp 2 QL (270 per 30 days)

clozapine 12.5 mg tab disp 2 QL (2160 per 30 days)

clozapine 150 mg tab disp 2 QL (180 per 30 days)

clozapine 200 mg tab 2 QL (120 per 30 days)

clozapine 200 mg tab disp 5 QL (120 per 30 days)


02/01/2021 40

clozapine 25 mg tab, 25 mg tab disp 2 QL (1080 per 30 days)

clozapine 50 mg tab 2 QL (540 per 30 days)

VERSACLOZ 4 QL (600 per 30 days)

ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTS

baclofen 20 mg tab 1 QL (120 per 30 days)

baclofen 5 mg tab, 10 mg tab 1 QL (90 per 30 days)

dantrolene sodium 2

tizanidine hcl 2 mg cap, 4 mg cap, 6 mg cap 2

tizanidine hcl 2 mg tab, 4 mg tab 1

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

cidofovir 2 PA-BvD; NM

ganciclovir sodium 500 mg recon soln 2 PA-BvD; NM

valganciclovir hcl 450 mg tab 5 NM

ZIRGAN 4

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 2 PA; NM

BARACLUDE 0.05 MG/ML SOLUTION 5 PA; NM

entecavir 2 PA; NM

lamivudine 100 mg tab 2 NM

VEMLIDY 5 PA; QL (30 per 30 days); NM

ANTI-HEPATITIS C (HCV) AGENTS

EPCLUSA 200-50 MG TAB 5 PA; QL (30 per 30 days)

EPCLUSA 400-100 MG TAB 5 PA; QL (30 per 30 days); NM

HARVONI 5 PA; QL (28 per 28 days); NM

PEGINTRON 5 NM

ribavirin 200 mg cap, 200 mg tab 2 NM

VOSEVI 5 PA; QL (30 per 30 days); NM

ANTIHERPETIC AGENTS

acyclovir 200 mg/5ml suspension, 200 mg cap, 400 mg tab, 800 mg tab 1

acyclovir sodium 1 PA-BvD

famciclovir 125 mg tab, 250 mg tab 2 QL (60 per 30 days)

famciclovir 500 mg tab 2 QL (21 per 7 days)

trifluridine 2

valacyclovir hcl 1 gm tab 2 QL (90 per 30 days)

valacyclovir hcl 500 mg tab 2 QL (60 per 30 days)

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY 5 QL (30 per 30 days); NM

DOVATO 5 QL (30 per 30 days); NM


02/01/2021 41

GENVOYA 5 QL (30 per 30 days); NM

ISENTRESS 100 MG CHEW TAB 4 QL (180 per 30 days); NM

ISENTRESS 100 MG PACKET 5 QL (180 per 30 days); NM

ISENTRESS 25 MG CHEW TAB 3 QL (720 per 30 days); NM

ISENTRESS 400 MG TAB 5 QL (120 per 30 days); NM

ISENTRESS HD 5 QL (60 per 30 days); NM

JULUCA 5 QL (30 per 30 days); NM

STRIBILD 5 QL (30 per 30 days); NM

TIVICAY 10 MG TAB 4 QL (60 per 30 days); NM

TIVICAY 25 MG TAB, 50 MG TAB 5 QL (60 per 30 days); NM

TIVICAY PD 5 QL (180 per 30 days); NM

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

ATRIPLA 5 QL (30 per 30 days); NM

COMPLERA 5 QL (30 per 30 days); NM

DELSTRIGO 5 QL (30 per 30 days); NM

EDURANT 5 QL (30 per 30 days); NM

efavirenz 200 mg cap 2 QL (120 per 30 days); NM

efavirenz 50 mg cap 2 QL (360 per 30 days); NM

efavirenz 600 mg tab 5 QL (30 per 30 days); NM

efavirenz-emtricitab-tenofovir 5 QL (30 per 30 days)

efavirenz-lamivudine-tenofovir 5 QL (30 per 30 days)

INTELENCE 100 MG TAB 5 QL (120 per 30 days); NM



nevirapine 100 mg tab er 24h 2 QL (90 per 30 days); NM

nevirapine 200 mg tab 2 QL (60 per 30 days); NM

nevirapine 400 mg tab er 24h 2 QL (30 per 30 days); NM

nevirapine 50 mg/5ml suspension 2 QL (1200 per 30 days); NM

ODEFSEY 5 QL (30 per 30 days); NM

PIFELTRO 5 QL (30 per 30 days); NM

SYMFI 5 QL (30 per 30 days); NM

SYMFI LO 5 QL (30 per 30 days); NM

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

abacavir sulfate 20 mg/ml solution 2 QL (960 per 30 days); NM

abacavir sulfate 300 mg tab 2 QL (60 per 30 days); NM

abacavir sulfate-lamivudine 2 QL (30 per 30 days); NM

abacavir-lamivudine-zidovudine 5 QL (60 per 30 days); NM

CIMDUO 5 QL (30 per 30 days); NM

DESCOVY 5 QL (30 per 30 days); NM

didanosine 200 mg cap dr 2 QL (60 per 30 days); NM

didanosine 250 mg cap dr, 400 mg cap dr 2 QL (30 per 30 days); NM


02/01/2021 42

emtricitabine 2 QL (30 per 30 days)

emtricitabine-tenofovir df 5 QL (30 per 30 days)

EMTRIVA 10 MG/ML SOLUTION 4 QL (850 per 30 days); NM

EMTRIVA 200 MG CAP 4 QL (30 per 30 days); NM

lamivudine 10 mg/ml solution 2 QL (960 per 30 days); NM

lamivudine 150 mg tab 2 QL (60 per 30 days); NM

lamivudine 300 mg tab 2 QL (30 per 30 days); NM

lamivudine-zidovudine 1 QL (60 per 30 days); NM

RETROVIR 10 MG/ML SOLUTION 4 NM

stavudine 15 mg cap, 20 mg cap 2 QL (120 per 30 days); NM

stavudine 30 mg cap, 40 mg cap 2 QL (60 per 30 days); NM

TEMIXYS 5 QL (30 per 30 days); NM

tenofovir disoproxil fumarate 2 QL (30 per 30 days); NM

TRIUMEQ 5 QL (30 per 30 days); NM

TRUVADA 5 QL (30 per 30 days); NM

VIDEX 4 QL (1200 per 30 days); NM

VIDEX EC 125 MG CAP DR 4 QL (90 per 30 days); NM

VIREAD 150 MG TAB, 200 MG TAB, 250 MG TAB 5 QL (30 per 30 days); NM

VIREAD 40 MG/GM POWDER 5 QL (240 per 30 days); NM

zidovudine 100 mg cap 2 QL (180 per 30 days); NM

zidovudine 300 mg tab 2 QL (60 per 30 days); NM

zidovudine 50 mg/5ml syrup 2 QL (1920 per 30 days); NM

ANTI-HIV AGENTS, OTHER

FUZEON 5 QL (60 per 30 days); NM

RUKOBIA 5 QL (60 per 30 days)

SELZENTRY 150 MG TAB, 300 MG TAB 5 QL (120 per 30 days); NM

SELZENTRY 20 MG/ML SOLUTION 5 QL (1840 per 30 days); NM

SELZENTRY 25 MG TAB 4 QL (120 per 30 days); NM

SELZENTRY 75 MG TAB 4 QL (60 per 30 days); NM

TROGARZO 5 PA; LA; QL (23.94 per 28 days); NM

TYBOST 3 QL (30 per 30 days); NM

ANTI-HIV AGENTS, PROTEASE INHIBITORS (PI)

APTIVUS 100 MG/ML SOLUTION 5 QL (380 per 30 days); NM

APTIVUS 250 MG CAP 5 QL (120 per 30 days); NM

atazanavir sulfate 150 mg cap, 200 mg cap 2 QL (60 per 30 days); NM

atazanavir sulfate 300 mg cap 2 QL (30 per 30 days); NM

CRIXIVAN 200 MG CAP 4 QL (360 per 30 days); NM

CRIXIVAN 400 MG CAP 4 QL (180 per 30 days); NM

EVOTAZ 5 QL (30 per 30 days); NM

fosamprenavir calcium 5 QL (120 per 30 days); NM

INVIRASE 500 MG TAB 5 QL (120 per 30 days); NM

KALETRA 100-25 MG TAB 4 QL (300 per 30 days); NM

KALETRA 200-50 MG TAB 5 QL (120 per 30 days); NM


02/01/2021 43

LEXIVA 50 MG/ML SUSPENSION 4 QL (1800 per 30 days); NM

lopinavir-ritonavir 2 QL (480 per 30 days); NM

NORVIR 100 MG PACKET 4 QL (360 per 30 days); NM

NORVIR 80 MG/ML SOLUTION 3 QL (480 per 30 days); NM

PREZCOBIX 5 QL (30 per 30 days); NM

PREZISTA 100 MG/ML SUSPENSION 5 QL (400 per 30 days); NM

PREZISTA 150 MG TAB 4 QL (180 per 30 days); NM

PREZISTA 600 MG TAB, 800 MG TAB 5 QL (60 per 30 days); NM

PREZISTA 75 MG TAB 4 QL (300 per 30 days); NM

REYATAZ 50 MG PACKET 5 QL (240 per 30 days); NM

ritonavir 2 QL (360 per 30 days); NM

SYMTUZA 5 QL (30 per 30 days); NM

VIRACEPT 250 MG TAB 5 QL (300 per 30 days); NM

VIRACEPT 625 MG TAB 5 QL (120 per 30 days); NM

ANTI-INFLUENZA AGENTS

oseltamivir phosphate 6 mg/ml recon susp, 30 mg cap, 45 mg cap, 75 mg cap 2

RELENZA DISKHALER 4 QL (60 per 180 over time); NE

rimantadine hcl 2

XOFLUZA (40 MG DOSE) 3

XOFLUZA (80 MG DOSE) 3

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 1

hydroxyzine pamoate 2 PA

meprobamate 2 PA

BENZODIAZEPINES

alprazolam 0.25 mg tab disp, 0.5 mg tab disp, 1 mg tab disp 2

alprazolam 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab disp, 2 mg tab 2 QL (120 per 30 days)

alprazolam 0.5 mg tab er 24h 2 QL (120 per 30 days)

alprazolam 1 mg tab er 24h 2 QL (120 per 30 days)



ALPRAZOLAM INTENSOL 3 QL (300 per 30 days)

alprazolam xr 0.5 mg tab er, 2 mg tab er, 3 mg tab er 2 QL (120 per 30 days)

chlordiazepoxide hcl 2 QL (120 per 30 days)

clonazepam 0.125 mg tab disp 2 QL (4800 per 30 days)


clonazepam 0.5 mg tab 1 QL (1200 per 30 days)



02/01/2021 44

clonazepam 1 mg tab 1 QL (600 per 30 days)

clonazepam 1 mg tab disp 2 QL (600 per 30 days)

clonazepam 2 mg tab 1 QL (300 per 30 days)

clonazepam 2 mg tab disp 2 QL (300 per 30 days)

clorazepate dipotassium 2

diazepam 10 mg tab 2 QL (120 per 30 days)



diazepam 5 mg/5ml solution 2 QL (1200 per 30 days)

lorazepam 0.5 mg tab, 1 mg tab 2 QL (90 per 30 days)

lorazepam 1 mg/0.5ml conc, 2 mg tab, 2 mg/ml conc 2 QL (150 per 30 days)

lorazepam intensol 2 QL (150 per 30 days)

oxazepam 2 QL (120 per 30 days)

BIPOLAR AGENTS

MOOD STABILIZERS

LATUDA 20 MG TAB 5 QL (240 per 30 days)


LATUDA 60 MG TAB, 120 MG TAB 5 QL (30 per 30 days)


LITHIUM 3

lithium carbonate 1

lithium carbonate 300 mg tab er 1

lithium carbonate 450 mg tab er 1

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 1 QL (90 per 30 days)

AVANDIA 2 MG TAB 3 PA; QL (120 per 30 days)

AVANDIA 4 MG TAB 3 PA; QL (60 per 30 days)

BYDUREON 2 MG PEN 3 QL (4 per 28 days)

BYDUREON BCISE 3 QL (4 per 28 days)

BYETTA 10 MCG PEN 3 QL (2.4 per 30 days)

BYETTA 5 MCG PEN 3 QL (1.2 per 30 days)

CYCLOSET 4 ST; QL (180 per 30 days)

FARXIGA 3 QL (30 per 30 days)

glimepiride 1 mg tab 1 QL (240 per 30 days)



glipizide 10 mg tab 1 QL (120 per 30 days)

glipizide 10 mg tab er 24h 1 QL (60 per 30 days)

glipizide 2.5 mg tab er 24h 1 QL (240 per 30 days)

glipizide 5 mg tab 1 QL (240 per 30 days)


02/01/2021 45

glipizide 5 mg tab er 24h 1 QL (120 per 30 days)

glipizide xl 10 mg tab er 24h 1 QL (60 per 30 days)

glipizide xl 2.5 mg tab er 24h 1 QL (240 per 30 days)

glipizide xl 5 mg tab er 24h 1 QL (120 per 30 days)

glipizide-metformin hcl 2.5-250 mg tab 1 QL (240 per 30 days)

glipizide-metformin hcl 2.5-500 mg tab, 5-500 mg tab 1 QL (120 per 30 days)

glyburide 1.25 mg tab 1 PA; QL (480 per 30 days)

glyburide 2.5 mg tab 1 PA; QL (240 per 30 days)

glyburide 5 mg tab 1 PA; QL (120 per 30 days)

glyburide micronized 1.5 mg tab 1 PA; QL (240 per 30 days)

glyburide micronized 3 mg tab 1 PA; QL (120 per 30 days)

glyburide micronized 6 mg tab 1 PA; QL (60 per 30 days)

glyburide-metformin 1.25-250 mg tab 1 PA; QL (240 per 30 days)

glyburide-metformin 2.5-500 mg tab, 5-500 mg tab 1 PA; QL (120 per 30 days)

JANUMET 3 QL (60 per 30 days)

JANUMET XR 100-1000 MG TAB ER 24H 3 QL (30 per 30 days)

JANUMET XR 50-500 MG TAB ER, 50-1000 MG TAB ER 3 QL (60 per 30 days)

JANUVIA 100 MG TAB 3 QL (30 per 30 days)



JARDIANCE 3 QL (30 per 30 days)

JENTADUETO 3 QL (60 per 30 days)

JENTADUETO XR 2.5-1000 MG TAB ER 24H 3 QL (60 per 30 days)

JENTADUETO XR 5-1000 MG TAB ER 24H 3 QL (30 per 30 days)

metformin hcl 1000 mg tab 1 QL (60 per 30 days)


metformin hcl 500 mg tab er 24h 1 QL (120 per 30 days)

metformin hcl 750 mg tab er 24h 1 QL (60 per 30 days)


miglitol 2 QL (90 per 30 days)

nateglinide 120 mg tab 1 QL (90 per 30 days)

nateglinide 60 mg tab 1 QL (180 per 30 days)

OZEMPIC (0.25 OR 0.5 MG/DOSE) 3

OZEMPIC (1 MG/DOSE) 3

pioglitazone hcl 15 mg tab 1 QL (90 per 30 days)



pioglitazone hcl-glimepiride 2 QL (30 per 30 days)

pioglitazone hcl-metformin hcl 2 QL (90 per 30 days)

repaglinide 0.5 mg tab 1 QL (960 per 30 days)

repaglinide 1 mg tab 1 QL (480 per 30 days)


02/01/2021 46

repaglinide 2 mg tab 1 QL (240 per 30 days) RYBELSUS 3 MG TAB 3 QL (30 per 180 over time); NE RYBELSUS 7 MG TAB, 14 MG TAB 3 QL (30 per 30 days) SYMLINPEN 120 5 PA; QL (11 per 30 days) SYMLINPEN 60 5 PA; QL (6 per 30 days) SYNJARDY 3 QL (60 per 30 days) SYNJARDY XR 25-1000 MG TAB ER 24H 3 QL (30 per 30 days) SYNJARDY XR 5-1000 MG TAB ER, 10-1000 MG TAB ER, 12.5-1000 MG TAB ER 3 QL (60 per 30 days) tolbutamide 1 QL (180 per 30 days) TRADJENTA 3 QL (30 per 30 days) TRULICITY 3 QL (2 per 28 days) VICTOZA 3 QL (9 per 30 days) XIGDUO XR 2.5-1000 MG TAB ER, 5-1000 MG TAB ER 3 QL (60 per 30 days) XIGDUO XR 5-500 MG TAB ER, 10-500 MG TAB ER, 10-1000 MG TAB ER 3 QL (30 per 30 days) GLYCEMIC AGENTS

diazoxide 2 GLUCAGEN HYPOKIT 4 GLUCAGON EMERGENCY 1 MG KIT 3 PROGLYCEM 4 INSULINS APIDRA 4 ST APIDRA SOLOSTAR 4 ST HUMALOG 3 HUMALOG JUNIOR KWIKPEN 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 KWIKPEN 3 HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 KWIKPEN 3 HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSION 2 HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML SUSP PEN 2 HUMULIN N 100 UNIT/ML SUSPENSION 2 HUMULIN N KWIKPEN 100 UNIT/ML SUSP PEN 2 HUMULIN R 100 UNIT/ML SOLUTION 2 HUMULIN R U-500 (CONCENTRATED) 5 PA HUMULIN R U-500 KWIKPEN 5 PA INSULIN ASP PROT & ASP FLEXPEN 4 ST INSULIN ASPART 4 ST INSULIN ASPART FLEXPEN 4 ST


02/01/2021 47

INSULIN ASPART PENFILL 4 ST

INSULIN ASPART PROT & ASPART 4 ST

INSULIN LISPRO 3

INSULIN LISPRO (1 UNIT DIAL) 3

INSULIN LISPRO JUNIOR KWIKPEN 3

INSULIN LISPRO PROT & LISPRO 3

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXTOUCH 3

NOVOLIN 70/30 (70-30) 100 UNIT/ML SUSPENSION 4 ST

NOVOLIN 70/30 FLEXPEN (70-30) 100 UNIT/ML SUSP PEN 4 ST

NOVOLIN 70/30 FLEXPEN RELION (70-30) 100 UNIT/ML SUSP PEN 4 ST

NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML SUSPENSION 4 ST

NOVOLIN N 100 UNIT/ML SUSPENSION 4 ST

NOVOLIN N FLEXPEN 100 UNIT/ML SUSP PEN 4 ST

NOVOLIN N FLEXPEN RELION 100 UNIT/ML SUSP PEN 4 ST

NOVOLIN N RELION 100 UNIT/ML SUSPENSION 4 ST

NOVOLIN R 100 UNIT/ML SOLUTION 4 ST

NOVOLIN R FLEXPEN 100 UNIT/ML SOLN PEN 4 ST

NOVOLIN R FLEXPEN RELION 100 UNIT/ML SOLN PEN 4 ST

NOVOLIN R RELION 100 UNIT/ML SOLUTION 4 ST

NOVOLOG 4 ST

NOVOLOG FLEXPEN 4 ST

NOVOLOG MIX 70/30 4 ST

NOVOLOG MIX 70/30 FLEXPEN 4 ST

NOVOLOG PENFILL 4 ST

TOUJEO MAX SOLOSTAR 3

TOUJEO SOLOSTAR 3

BLOOD PRODUCTS AND MODIFIERS

ANTICOAGULANTS

ELIQUIS 3 QL (60 per 30 days)

ELIQUIS DVT/PE STARTER PACK 3 QL (74 per 180 over time); NE

enoxaparin sodium 100 mg/ml, 150 mg/ml 2 QL (56 per 28 days)

enoxaparin sodium 120 mg/0.8ml solution 1 QL (44.8 per 28 days)


enoxaparin sodium 300 mg/3ml solution 2 QL (168 per 28 days)


02/01/2021 48




fondaparinux sodium 10 mg/0.8ml solution 5 QL (24 per 30 days)

fondaparinux sodium 2.5 mg/0.5ml solution 2 QL (15 per 30 days)

fondaparinux sodium 5 mg/0.4ml solution 5 QL (12 per 30 days)

fondaparinux sodium 7.5 mg/0.6ml solution 5 QL (18 per 30 days)

HEPARIN (PORCINE) IN NACL (PORCINE)125000.45 UT/250ML-%, (PORCINE)25000-0.45 UT/500ML-% 3 PA-BvD

HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% SOLUTION 3

heparin sod (porcine) in d5w (porcine), (porcine)100 unit/ml solution, (porcine)25000-5 ut/500ml-% solution 1

heparin sodium (porcine) (porcine) 1000 unit/ml, (porcine) 5000 unit/ml, (porcine) 10000 unit/ml, (porcine) 20000 unit/ml 1 PA-BvD

jantoven 1

PRADAXA 4 QL (60 per 30 days)

warfarin sodium 1

XARELTO 10 MG TAB, 20 MG TAB 3 QL (30 per 30 days)

XARELTO 2.5 MG TAB, 15 MG TAB 3 QL (60 per 30 days)

XARELTO STARTER PACK 3

BLOOD PRODUCTS AND MODIFIERS, OTHER

anagrelide hcl 1

ARANESP (ALBUMIN FREE) FREE) 10 MCG/0.4ML SOLN PRSYR, FREE) 25 MCG/0.42ML SOLN PRSYR, FREE) 25 MCG/ML SOLUTION, FREE) 40 MCG/ML SOLUTION, FREE) 40 MCG/0.4ML SOLN PRSYR, FREE) 60 MCG/ML SOLUTION 4 PA; NM

ARANESP (ALBUMIN FREE) FREE) 60 MCG/0.3ML SOLN PRSYR, FREE) 100 MCG/ML SOLUTION, FREE) 100 MCG/0.5ML SOLN PRSYR, FREE) 150 MCG/0.3ML SOLN PRSYR, FREE) 200 MCG/0.4ML SOLN PRSYR, FREE) 200 MCG/ML SOLUTION, FREE) 300 MCG/ML SOLUTION, FREE) 300 MCG/0.6ML SOLN PRSYR, FREE) 500 MCG/ML SOLN PRSYR 5 PA; NM

EPOGEN 4 PA; NM FULPHILA 5 PA; QL (1.2 per 28 days); NM

GRANIX 5 PA; NM

LEUKINE 5 PA; NM MOZOBIL 5 PA; NM


02/01/2021 49

NEULASTA 5 PA; QL (1.2 per 28 days); NM

NEULASTA ONPRO 5 PA; QL (1.2 per 28 days); NM

NEUPOGEN 5 PA; NM

NIVESTYM 5 PA; NM

PROCRIT 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 10000 UNIT/ML, 20000 UNIT/ML 4 PA; NM

PROCRIT 40000 UNIT/ML SOLUTION 5 PA; NM

PROMACTA 12.5 MG PACKET 5 PA; LA; QL (360 per 30 days); NM

PROMACTA 12.5 MG TAB, 25 MG TAB 5 PA; LA; QL (30 per 30 days); NM

PROMACTA 25 MG PACKET 5 PA; LA; QL (180 per 30 days); NM

PROMACTA 50 MG TAB 5 PA; LA; QL (90 per 30 days); NM

PROMACTA 75 MG TAB 5 PA; LA; QL (60 per 30 days); NM

ZARXIO 5 PA; NM

HEMOSTASIS AGENTS

tranexamic acid 650 mg tab, 1000 mg/10ml solution 2

PLATELET MODIFYING AGENTS

aspirin-dipyridamole 25-200 mg cap er 12h 2 ST; QL (60 per 30 days)

BRILINTA 3 QL (60 per 30 days)

cilostazol 1

clopidogrel bisulfate 300 mg tab 1 QL (1 per 30 days)

clopidogrel bisulfate 75 mg tab 1 QL (30 per 30 days)

prasugrel hcl 2 QL (30 per 30 days)

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine 2 QL (4 per 28 days)

clonidine hcl 1

guanfacine hcl 2 PA

midodrine hcl 2

NORTHERA 100 MG CAP 5 PA; LA; QL (540 per 30 days); NM



ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 1

phenoxybenzamine hcl 5

prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS


02/01/2021 50

candesartan cilexetil 1 EDARBI 4 irbesartan 1 losartan potassium 1 olmesartan medoxomil 2 telmisartan 1 valsartan 1 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl 1 captopril 1 enalapril maleate 1 fosinopril sodium 1 lisinopril 1 moexipril hcl 1 perindopril erbumine 1 quinapril hcl 1 ramipril 1 trandolapril 1 ANTIARRHYTHMICS amiodarone hcl 100 mg tab, 200 mg tab, 400 mg tab 1 disopyramide phosphate 2 PA

dofetilide 2 NM

flecainide acetate 1 mexiletine hcl 1 MULTAQ 4 QL (60 per 30 days) pacerone 1 propafenone hcl 1 propafenone hcl 225 mg cap er 12h 2 propafenone hcl 325 mg cap er 12h 2 propafenone hcl 425 mg cap er 12h 2 quinidine gluconate 324 mg tab er 2 quinidine sulfate 1 sorine 1 sotalol hcl 1 sotalol hcl (af) 2 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl 1 atenolol 1 betaxolol hcl 10 mg tab, 20 mg tab 1 bisoprolol fumarate 1 BYSTOLIC 4 carvedilol 1


02/01/2021 51

labetalol hcl 100 mg tab, 200 mg tab, 300 mg tab 1

metoprolol succinate 100 mg tab er 24h 1




metoprolol tartrate 5 mg/5ml solution, 5 mg/5ml soln cart, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab, 100 mg tab 1

nadolol 2

pindolol 1

propranolol hcl 10 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab 1 propranolol hcl 120 mg cap er 24h 2

propranolol hcl 160 mg cap er 24h 2



timolol maleate 5 mg tab, 10 mg tab, 20 mg tab 1

CALCIUM CHANNEL BLOCKING AGENTS, DIHYDROPYRIDINES

afeditab cr 1

amlodipine besylate 1

felodipine 10 mg tab er 24h 1

felodipine 2.5 mg tab er 24h 1

felodipine 5 mg tab er 24h 1

isradipine 2

nicardipine hcl 20 mg cap, 30 mg cap 1

nifedipine 30 mg tab er 24h 1



nifedipineosmotic release 30 mg tab er 24h 1



nimodipine 2

nisoldipine 17 mg tab er 24h 2


nisoldipine 25.5 mg tab er 24h 2




nisoldipine 8.5 mg tab er 24h 2

CALCIUM CHANNEL BLOCKING AGENTS, NONDIHYDROPYRIDINES

CARDIZEM LA 120 MG TAB ER 24H 4 cartia xt 1


02/01/2021 52

diltiazem hcl 120 mg cap er 12h 1




diltiazem hcl 30 mg tab, 60 mg tab, 90 mg tab, 120 mg tab 1 diltiazem hcl 60 mg cap er 12h 1


diltiazem hcl coated beads 180 mg tab er 24h 2





diltiazem hclbeads 120 mg cap er 24h 1






diltiazem hclcoated beads 120 mg cap er 24h 1





dilt-xr 1

matzim la 2

taztia xt 1

tiadylt 120 mg cap er 24h 1






verapamil hcl 100 mg cap er 24h 1


verapamil hcl 120 mg tab er 1








verapamil hcl 40 mg tab, 80 mg tab, 120 mg tab 1


02/01/2021 53

CARDIOVASCULAR AGENTS, OTHER acetazolamide 1 acetazolamide sodium 2 ALDACTAZIDE 50-50 MG TAB 4 aliskiren fumarate 2 amiloride-hydrochlorothiazide 1 amlodipine besy-benazepril hcl 1 amlodipine besylate-valsartan 1 amlodipine-atorvastatin 2 amlodipine-olmesartan 2 amlodipine-valsartan-hctz 2 atenolol-chlorthalidone 1 benazepril-hydrochlorothiazide 1 BIDIL 3 QL (180 per 30 days) bisoprolol-hydrochlorothiazide 1 candesartan cilexetil-hctz 1 captopril-hydrochlorothiazide 1 CORLANOR 5 MG TAB, 7.5 MG TAB 4 PA; QL (60 per 30 days)

CORLANOR 5 MG/5ML SOLUTION 4 PA; QL (560 per 28 days) DEMSER 5 digitek 125 mcg tab 1 digitek 250 mcg tab 1 PA

digox 125 mcg tab 1 digox 250 mcg tab 1 PA

digoxin 0.05 mg/ml solution 2 digoxin 0.25 mg/ml solution 2 PA

digoxin 125 mcg tab 1 digoxin 250 mcg tab 1 PA

DUTOPROL 4 enalapril-hydrochlorothiazide 1 ENTRESTO 3 PA fosinopril sodium-hctz 1 irbesartan-hydrochlorothiazide 1 LANOXIN 250 MCG TAB 4 PA LANOXIN 62.5 MCG TAB, 125 MCG TAB 4 lisinopril-hydrochlorothiazide 1 losartan potassium-hctz 1 metoprolol-hydrochlorothiazide 1 metyrosine 5 nadolol-bendroflumethiazide 2 olmesartan medoxomil-hctz 2 olmesartan-amlodipine-hctz 2 pentoxifylline 400 mg tab er 1 propranolol-hctz 1


02/01/2021 54

quinapril-hydrochlorothiazide 1

ranolazine 1000 mg tab er 12h 2 PA

ranolazine 500 mg tab er 12h 2 PA

spironolactone-hctz 1

TEKTURNA HCT 3 telmisartan-amlodipine 2

telmisartan-hctz 1

trandolapril-verapamil hcl 1-240 mg tab er 2




triamterene-hctz 1

valsartan-hydrochlorothiazide 1

VECAMYL 4 DIURETICS, LOOP bumetanide 0.25 mg/ml solution, 0.5 mg tab, 1 mg tab, 2 mg tab 1

ethacrynate sodium 1

ethacrynic acid 2

furosemide 10 mg/ml solution inj 1

furosemide 10 mg/ml solution oral 1

furosemide 8 mg/ml solution, 20 mg tab, 40 mg tab, 80 mg tab 1

furosemide inj 10 mg/ml 1

torsemide 1

DIURETICS, POTASSIUM-SPARING amiloride hcl 1

eplerenone 2

spironolactone 1

triamterene 2

DIURETICS, THIAZIDE chlorthalidone 1

hydrochlorothiazide 1

indapamide 1

metolazone 2

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate 40 mg tab, 50 mg cap, 120 mg tab, 150 mg cap 2 fenofibrate 48 mg tab, 54 mg tab, 67 mg cap, 134 mg cap, 145 mg tab, 160 mg tab, 200 mg cap 1

fenofibrate micronized 1

fenofibric acid 1

FIBRICOR 35 MG TAB 1 gemfibrozil 1


02/01/2021 55

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 1

fluvastatin sodium 2

fluvastatin sodium 80 mg tab er 24h 2

lovastatin 1

pravastatin sodium 1

rosuvastatin calcium 1

simvastatin 1

DYSLIPIDEMICS, OTHER

cholestyramine light 4 gm packet, 4 gm/dose powder 1

colesevelam hcl 625 mg tab 2

colestipol hcl 1 gm tab, 5 gm packet, 5 gm granules 1

ezetimibe 2

ezetimibe-simvastatin 2 PA; QL (30 per 30 days)

icosapent ethyl 2

JUXTAPID 30 MG CAP, 40 MG CAP, 60 MG CAP 5 PA; LA; QL (30 per 30 days); NM

JUXTAPID 5 MG CAP, 10 MG CAP, 20 MG CAP 5 PA; LA; NM

niacin (antihyperlipidemic) 1

niacin(antihyperlipidemic) 1000 mg tab er 2



niacor 1

omega-3-acid ethyl esters 2

PRALUENT 4 PA; QL (2 per 28 days); NM

prevalite 4 gm packet, 4 gm/dose powder 1

REPATHA 3 PA; QL (3 per 28 days); NM

REPATHA PUSHTRONEX SYSTEM 3 PA; QL (3.5 per 28 days); NM

REPATHA SURECLICK 3 PA; QL (3 per 28 days); NM

VASCEPA 3

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl 10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab 1 hydralazine hcl 20 mg/ml solution 2

minoxidil 1

VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 4

isosorbide dinitrate 5 mg tab, 10 mg tab, 20 mg tab, 30 mg tab 1

isosorbide mononitrate 1

isosorbide mononitrate 120 mg tab er 24h 1


02/01/2021 56



minitran 1

NITRO-BID 3 NITRO-DUR 0.3 MG/HR PATCH, 0.8 MG/HR PATCH 4

nitroglycerin 0.1 mg/hr patch, 0.2 mg/hr patch, 0.4 mg/hr patch, 0.6 mg/hr patch 1

nitroglycerin 0.3 mg sl tab, 0.4 mg sl tab, 0.4 mg/spray solution, 0.6 mg sl tab 2

RECTIV 3 QL (30 per 30 days)

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine-dextroamphet 10 mg cap er 24h 2 PA; QL (30 per 30 days)






amphetamine-dextroamphetamine 30 mg tab 1 PA; QL (60 per 30 days)

amphetamine-dextroamphetamine 5 mg tab, 7.5 mg tab, 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab 1 PA; QL (90 per 30 days)

dextroamphetamine sulfate 10 mg cap er 24h 2 QL (60 per 30 days)

dextroamphetamine sulfate 10 mg tab 1 QL (180 per 30 days)



dextroamphetamine sulfate 5 mg tab 1 QL (90 per 30 days)

dextroamphetamine sulfate 5 mg/5ml solution 1 QL (1920 per 30 days)

procentra 1 QL (1920 per 30 days)

VYVANSE 10 MG CAP, 20 MG CAP, 30 MG CAP, 40 MG CAP, 50 MG CAP, 60 MG CAP, 70 MG CAP 4 PA; QL (30 per 30 days)

zenzedi 10 mg tab 1 QL (180 per 30 days)

zenzedi 5 mg tab 1 QL (90 per 30 days)

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

APTENSIO XR 4 PA; QL (30 per 30 days)

atomoxetine hcl 10 mg cap, 18 mg cap, 25 mg cap, 40 mg cap 2 QL (60 per 30 days)

atomoxetine hcl 60 mg cap, 80 mg cap, 100 mg cap 2 QL (30 per 30 days)

DAYTRANA 4 QL (30 per 30 days)


02/01/2021 57

dexmethylphenidate hcl 1 QL (60 per 30 days)

dexmethylphenidate hcl 10 mg cap er 24h 2 QL (30 per 30 days)








guanfacine hcl 1 mg tab er 24h 2 PA; QL (30 per 30 days)




metadate 20 mg tab er 2 PA; QL (90 per 30 days)

methylphenidate hcl (cd) 10 mg cap er 2 PA; QL (30 per 30 days)






methylphenidate hcl (la) 10 mg cap er 24h 2 PA; QL (30 per 30 days)





methylphenidate hcl (xr) 10 mg cap er 24h 2 PA; QL (30 per 30 days)







methylphenidate hcl 10 mg chew tab 2 PA; QL (180 per 30 days)

methylphenidate hcl 10 mg/5ml solution 2 PA; QL (900 per 30 days)

methylphenidate hcl 18 mg tab er 2 PA; QL (30 per 30 days)

methylphenidate hcl 18 mg tab er 24h 2 PA; QL (30 per 30 days)

methylphenidate hcl 2.5 mg chew tab, 5 mg chew tab 2 PA; QL (90 per 30 days)







02/01/2021 58

methylphenidate hcl 5 mg tab, 10 mg tab, 20 mg tab 1 PA; QL (90 per 30 days)

methylphenidate hcl 5 mg/5ml solution 2 PA; QL (1800 per 30 days)



CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO 5 PA; LA; QL (120 per 30 days); NM

butalbital-acetaminophen 50-325 mg tab 1 PA; QL (180 per 30 days)

butalbital-apap-caffeine 50-325-40 mg tab 1 PA; QL (180 per 30 days)

INGREZZA 40 & 80 MG CAP THPK 5 PA; QL (56 per 365 over time); NM; NE

INGREZZA 40 MG CAP 5 PA; QL (60 per 30 days); NM

INGREZZA 80 MG CAP 5 PA; QL (30 per 30 days); NM

NUEDEXTA 3 PA; QL (60 per 30 days)

riluzole 2 NM

tencon 1 PA; QL (180 per 30 days)

tetrabenazine 12.5 mg tab 5 PA; QL (240 per 30 days); NM

tetrabenazine 25 mg tab 5 PA; QL (120 per 30 days); NM

FIBROMYALGIA AGENTS

DRIZALMA SPRINKLE 20 MG CAP DR 4 QL (180 per 30 days)




duloxetine hcl 20 mg cp dr part 2 QL (180 per 30 days)




pregabalin 100 mg cap 1 QL (180 per 30 days)


pregabalin 20 mg/ml solution 1 QL (900 per 30 days)


pregabalin 225 mg cap, 300 mg cap 1 QL (60 per 30 days)




MULTIPLE SCLEROSIS AGENTS

AUBAGIO 5 PA; LA; QL (30 per 30 days); NM

AVONEX 5 PA; QL (4 per 28 days); NM

AVONEX PEN 5 PA; QL (4 per 28 days); NM

AVONEX PREFILLED 5 PA; QL (4 per 28 days); NM

BETASERON 5 PA; QL (15 per 30 days); NM

COPAXONE 20 MG/ML SOLN PRSYR 5 PA; QL (30 per 30 days); NM

COPAXONE 40 MG/ML SOLN PRSYR 5 PA; QL (12 per 28 days); NM


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dalfampridine 10 mg tab er 12h 5 PA; QL (60 per 30 days); NM

GILENYA 5 PA; QL (30 per 30 days); NM

PLEGRIDY 5 PA; QL (1 per 28 days); NM

PLEGRIDY STARTER PACK 5 PA; QL (1 per 180 over time); NM; NE

TECFIDERA 5 PA; LA; NM TYSABRI 5 PA; LA; NM

DENTAL AND ORAL AGENTS

DENTAL AND ORAL AGENTS cevimeline hcl 2 chlorhexidine gluconate 1 oralone 2 paroex 1 periogard 1 pilocarpine hcl 5 mg tab, 7.5 mg tab 2 triamcinolone acetonide 0.1 % paste 2

DERMATOLOGICAL AGENTS

ACNE AND ROSACEA AGENTS acitretin 10 mg cap, 25 mg cap 2 acitretin 17.5 mg cap 5 adapalene 0.1 % cream, 0.1 % gel, 0.3 % gel 2 amnesteem 2 avita 2 PA; QL (45 per 30 days) azelaic acid 2 AZELEX 4 benzoyl peroxide-erythromycin 2 claravis 10 mg cap, 20 mg cap, 40 mg cap 2 claravis 30 mg cap 4 clindamycin phos-benzoyl perox 1-5 % gel, 1.2-5 % gel 2 clindamycin-tretinoin 2 PA

isotretinoin 2 myorisan 2 neuac 2 tazarotene 2 PA

TAZORAC 0.05 % CREAM, 0.05 % GEL, 0.1 % GEL 4 PA tretinoin 0.01 % gel, 0.025 % gel, 0.025 % cream, 0.05 % cream, 0.05 % gel, 0.1 % cream 2 PA; QL (45 per 30 days) tretinoin microsphere 2 PA; QL (50 per 30 days) tretinoin microsphere pump 2 PA; QL (50 per 30 days) zenatane 2 DERMATITIS AND PRURITUS AGENTS


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ala-cort 1 % cream 2 ala-cort 2.5 % cream 1 alclometasone dipropionate 0.05 % ointment 1 amcinonide 0.1 % cream, 0.1 % lotion 2 ammonium lactate 1 APEXICON E 3 betamethasone dipropionate 0.05 % lotion, 0.05 % cream 1 betamethasone dipropionate aug 0.05 % ointment, 0.05 % gel 1 betamethasone valerate 0.1 % ointment, 0.1 % lotion, 0.1 % cream, 0.12 % foam 1 CAPEX 4 clobetasol propionate 0.05 % foam 2 QL (100 per 30 days) clobetasol propionate 0.05 % lotion, 0.05 % solution, 0.05 % liquid, 0.05 % shampoo, 0.05 % gel 2 clobetasol propionate 0.05 % ointment 2 QL (120 per 30 days) clodan 2 DESONATE 4 desonide 0.05 % cream, 0.05 % ointment, 0.05 % gel 2 desoximetasone 0.05 % ointment, 0.05 % cream, 0.05 % gel, 0.25 % cream, 0.25 % ointment 2 diflorasone diacetate 2 doxepin hcl 5 % cream 5 PA; QL (45 per 30 days) fluocinolone acetonide 0.01 % solution, 0.01 % cream, 0.025 % cream, 0.025 % ointment 2 QL (120 per 30 days) fluocinonide 0.05 % cream, 0.05 % ointment, 0.05 % gel, 0.05 % solution 1 QL (240 per 30 days) fluocinonide 0.1 % cream 2 QL (120 per 30 days) fluocinonide emulsified base 1 QL (240 per 30 days) flurandrenolide 0.05 % cream, 0.05 % lotion 2 fluticasone propionate 0.005 % ointment, 0.05 % cream 1 halcinonide 2 halobetasol propionate 0.05 % ointment, 0.05 % cream 2 HALOG 0.1 % OINTMENT 4 hydrocortisone (perianal) 1 hydrocortisone 1 % cream, 1 % ointment 2 hydrocortisone 2.5 % cream, 2.5 % lotion, 2.5 % ointment 1 hydrocortisone butyrate 0.1 % solution 2


02/01/2021 61

hydrocortisone valerate 0.2 % cream 2 mometasone furoate 0.1 % solution 1 nolix 0.05 % cream, 0.05 % lotion 2 PANDEL 5 pimecrolimus 2 PA; QL (100 per 90 days); NE procto-med hc 1 procto-pak 1 proctosol hc 1 proctozone-hc 1 selenium sulfide 2.5 % lotion 2 tacrolimus 0.03 %, 0.1 % 2 PA; QL (100 per 90 days); NE triamcinolone acetonide 0.025 % ointment, 0.025 % cream, 0.025 % lotion, 0.1 % ointment, 0.1 % lotion, 0.1 % cream, 0.5 % cream, 0.5 % ointment 1 triamcinolone acetonide 0.147 mg/gm aero soln 2 triderm 1 DERMATOLOGICAL AGENTS, OTHER calcipotriene 0.005 % cream, 0.005 % ointment 2 QL (120 per 30 days) calcipotriene 0.005 % solution 2 QL (60 per 30 days) calcipotriene-betameth diprop 0.005-0.064 % ointment 2 QL (400 per 28 days) calcipotriene-betameth diprop 0.005-0.064 % suspension 5 QL (420 per 28 days) calcitrene 2 QL (120 per 30 days) calcitriol 3 mcg/gm ointment 2 QL (800 per 28 days) clotrimazole-betamethasone 1-0.05 % cream 1 clotrimazole-betamethasone 1-0.05 % lotion 2 CORTISPORIN 1 % OINTMENT 4 diclofenac sodium 3 % gel 2 PA; QL (100 per 30 days) fluorouracil 0.5 % cream 5 fluorouracil 2 % solution, 5 % solution, 5 % cream 2 imiquimod 2 methoxsalen rapid 5 NM

nystatin-triamcinolone 2 podofilox 2 SANTYL 4 QL (30 per 30 days) silver sulfadiazine 1 ssd 1 TACLONEX 0.005-0.064 % SUSPENSION 5 QL (420 per 28 days) VEREGEN 5 ZYCLARA 5 ZYCLARA PUMP 5 PEDICULICIDES/SCABICIDES

crotan 2


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ivermectin 0.5 % lotion 2 lindane 2 malathion 2 permethrin 1 SKLICE 4 TOPICAL ANTI-INFECTIVES acyclovir 5 % cream 2 QL (5 per 30 days) acyclovir 5 % ointment 2 QL (30 per 30 days) ACZONE 7.5 % GEL 4 ciclodan 1 ciclopirox 0.77 % gel, 1 % shampoo, 8 % solution 1 clindamycin phosphate 1 % foam 2 clindamycin phosphate 1 % lotion, 1 % gel 1 clindamycin phosphate 1 % solution 1 QL (120 per 30 days) dapsone 5 % gel, 7.5 % gel 2 DENAVIR 4 QL (5 per 30 days) ery 2 erythromycin 2 % gel, 2 % solution 1 erythromycin 2 % pad 2 mupirocin 1 QL (120 per 30 days) mupirocin calcium 1 SULFAMYLON 85 MG/GM CREAM 4

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

AMINOSYN II 3 PA-BvD

AMINOSYN-PF 3 PA-BvD

CARBAGLU 5 PA; LA; NM CLINIMIX E/DEXTROSE (2.75/5) 3 PA-BvD

CLINIMIX E/DEXTROSE (4.25/10) 4 PA-BvD

CLINIMIX E/DEXTROSE (4.25/5) 3 PA-BvD

CLINIMIX E/DEXTROSE (5/15) 3 PA-BvD




CLINIMIX/DEXTROSE (4.25/10) 3 PA-BvD

CLINIMIX/DEXTROSE (4.25/5) 3 PA-BvD

CLINIMIX/DEXTROSE (5/15) 3 PA-BvD





clinisol sf 2 PA-BvD

CLINOLIPID 1 PA-BvD


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FREAMINE HBC 4 PA-BvD

FREAMINE III 3 PA-BvD

hepatamine 2 PA-BvD

INTRALIPID 20 % EMULSION 1 PA-BvD

INTRALIPID 30 % EMULSION 4 PA-BvD

ISOLYTE-P IN D5W 4 ISOLYTE-S 4 ISOLYTE-S PH 7.4 4 kcl in dextrose-nacl in 10-5-0.45 meq/l-%-%, in 205-0.2 meq/l-%-%, in 20-5-0.45 meq/l-%-%, in 20-50.9 meq/l-%-%, in 20-5-0.33 meq/l-%-%, in 30-50.45 meq/l-%-%, in 40-5-0.45 meq/l-%-% 1

KCL IN DEXTROSE-NACL IN 20-5-0.225 MEQ/L-%%, IN 40-5-0.9 MEQ/L-%-% 3

klor-con 10 1

klor-con 8 meq tab er 1

klor-con m10 1

klor-con m15 2

klor-con m20 1

klor-con sprinkle 1

K-TAB 3 magnesium sulfate 50 % solution 1

NEPHRAMINE 3 PA-BvD

NORMOSOL-M IN D5W 3 NORMOSOL-R PH 7.4 4 NUTRILIPID 1 PA-BvD

PLASMA-LYTE 148 4 PLASMA-LYTE A 4 plenamine 2 PA-BvD

potassium chloride 10 meq cap er 1

potassium chloride 10 meq tab er 1

POTASSIUM CHLORIDE 2 MEQ/ML, 10 %, 10 MEQ/100ML, 10 MEQ/50ML, 20 MEQ/100ML, 20 MEQ/50ML, 20 MEQ/15ML (10%), 40 MEQ/15ML (20%), 40 MEQ/100ML 1


potassium chloride 8 meq cap er 1


potassium chloride crys 10 meq tab er 1

potassium chloride crys 20 meq tab er 1

potassium chloride in nacl 1

potassium citrate 10 meq (1080 mg) tab er 2




02/01/2021 64

PREMASOL 10 % SOLUTION 3 PA-BvD

premasol 6 % solution 2 PA-BvD

PROCALAMINE 3 PA-BvD

PROSOL 3 PA-BvD

sodium chloride 0.45 %, 2.5 meq/ml, 3 %, 5 % 1

sodium chloride 0.9 % solution irrigation 2

sodium chloride 0.9 % solution iv 1

sodium chloride irrigation soln 0.9% 2

TRAVASOL 3 PA-BvD

TROPHAMINE 3 PA-BvD

ELECTROLYTE/MINERAL/METAL MODIFIERS

clovique 5 NM

deferasirox 90 mg tab, 125 mg tab sol, 180 mg tab, 250 mg tab sol, 360 mg tab, 500 mg tab sol 5 PA; NM

deferasirox granules 5 PA

deferiprone 5 PA; LA

FERRIPROX 100 MG/ML SOLUTION, 500 MG TAB, 1000 MG TAB 5 PA; LA; NM

FERRIPROX TWICE-A-DAY 5 PA; NM

JADENU 180 MG TAB 5 PA; LA; NM

JADENU SPRINKLE 5 PA; LA; NM

JYNARQUE 15 MG TAB, 30 MG TAB 5 PA; LA; QL (120 per 30 days); NM

SAMSCA 15 MG TAB 5 PA; QL (30 per 30 days); NM

SAMSCA 30 MG TAB 5 PA; QL (60 per 30 days); NM

tolvaptan 15 mg tab 5 PA; QL (30 per 30 days)

tolvaptan 30 mg tab 5 PA; QL (60 per 30 days); NM

trientine hcl 5 NM

PHOSPHATE BINDERS

calcium acetate 1

calcium acetate (phos binder) 1

FOSRENOL 750 MG PACKET, 1000 MG PACKET 5 lanthanum carbonate 5

PHOSLYRA 4 sevelamer carbonate 0.8 gm packet 5 QL (540 per 30 days)

sevelamer carbonate 2.4 gm packet 5 QL (180 per 30 days)

sevelamer carbonate 800 mg tab 2 QL (540 per 30 days)

VELPHORO 5 QL (180 per 30 days)

POTASSIUM BINDERS

kionex 1

sodium polystyrene sulfonate , 15 gm/60ml suspension, 30 gm/120ml suspension, 50 gm/200ml suspension 1

sps 1


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VELTASSA 5 LA; NM VITAMINS DEXTROSE 40 % SOLUTION 3 dextrose 5 %, 10 %, 30 %, 50 %, 70 %, 250 mg/ml 1 dextrose in lactated ringers 2 DEXTROSE-NACL 10-0.2 % SOLUTION 3 dextrose-nacl 2.5-0.45 %, 5-0.45 %, 5-0.9 %, 50.33 %, 5-0.2 %, 5-0.225 %, 10-0.45 % 1 irrigation solutions, physiological 4 KCL-LACTATED RINGERS-D5W 3 lactated ringers 2 lactated ringers solution (irrigation) 2 levocarnitine 1 gm/10ml solution 2 PA-BvD

levocarnitine 330 mg tab 3 PA-BvD

levocarnitine sf 2 PA-BvD

potassium chloride in dextrose 1

GASTROINTESTINAL AGENTS

ANTI-CONSTIPATION AGENTS AMITIZA 3 QL (60 per 30 days) constulose 1 enulose 1 gavilyte-h 1 gavilyte-n with flavor pack 1 generlac 1 KRISTALOSE 20 GM PACKET 4 LACTULOSE 10 GM PACKET 5 lactulose 10 gm/15ml, 20 gm/30ml 1 lactulose encephalopathy 1 LINZESS 3 QL (30 per 30 days) MOVANTIK 3 QL (30 per 30 days) MOVIPREP 4 peg 3350-kcl-na bicarb-nacl 1 peg-3350/electrolytes/ascorbat 2 peg-kcl-nacl-nasulf-na asc-c 2 polyethylene glycol 3350 3350 17 gm/scoop powder, 3350 17 gm packet 1 RELISTOR 12 MG/0.6ML SOLUTION 5 PA; QL (18 per 30 days)

RELISTOR 8 MG/0.4ML SOLUTION 5 PA; QL (12 per 30 days)

SUPREP BOWEL PREP KIT 4 trilyte 1 ANTI-DIARRHEAL AGENTS alosetron hcl 5 PA; QL (60 per 30 days) diphenatol 1


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diphenoxylate-atropine 2.5-0.025 mg/5ml liquid, 2.5-0.025 mg tab 1 loperamide hcl 2 mg cap 1

VIBERZI 5 PA ANTISPASMODICS, GASTROINTESTINAL atropine sulfate 0.25 mg/5ml soln, 0.5 mg/5ml soln, 1 mg/10ml soln 2

chlordiazepoxide-clidinium 2 PA

dicyclomine hcl 10 mg/5ml solution, 10 mg cap, 10 mg/ml solution, 20 mg tab 1 glycopyrrolate 0.2 mg/ml, 0.4 mg/2ml, 1 mg/5ml, 4 mg/20ml 1 glycopyrrolate 1 mg tab, 2 mg tab 2

methscopolamine bromide 2

GASTROINTESTINAL AGENTS, OTHER CHENODAL 5 PA; NM GATTEX 5 PA; LA; NM gavilyte-c 1

gavilyte-g 1

GOLYTELY 227.1 GM RECON SOLN 4 MYALEPT 5 PA; LA; NM peg 3350/electrolytes 1

peg-3350/electrolytes 1

PYLERA 5 ursodiol 2

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 1

cimetidine hcl 1

famotidine 20 mg/2ml solution, 20 mg tab, 40 mg/5ml recon susp, 40 mg tab 1

famotidine 40 mg/4ml, 200 mg/20ml 2

famotidine premixed 2

nizatidine 15 mg/ml solution, 150 mg cap, 300 mg cap 2

ranitidine hcl 15 mg/ml syrup, 75 mg/5ml syrup, 150 mg tab, 150 mg/10ml syrup, 300 mg tab 1 ranitidine hcl 50 mg/2ml solution, 150 mg cap, 150 mg/6ml solution, 300 mg cap, 1000 mg/40ml solution 2

PROTECTANTS CARAFATE 1 GM/10ML SUSPENSION 3

sucralfate 1 gm tab 1

SUCRALFATE 1 GM/10ML SUSPENSION 3

PROTON PUMP INHIBITORS


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DEXILANT 4 ST; QL (30 per 30 days)

esomeprazole magnesium 20 mg cap dr, 40 mg cap dr 2 QL (30 per 30 days)

esomeprazole sodium 2

lansoprazole 15 mg cap dr 2

lansoprazole 30 mg cap dr 2 QL (30 per 30 days)

omeprazole 1

pantoprazole sodium 20 mg tab dr, 40 mg tab dr 1

pantoprazole sodium 40 mg recon soln 2

rabeprazole sodium 2 QL (30 per 30 days)

GENETIC OR ENZYME OR PROTEIN DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

GENETIC OR ENZYME OR PROTEIN DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ALDURAZYME 5 PA; LA; NM ARALAST NP 5 PA; LA; NM CERDELGA 5 PA; NM CEREZYME 5 PA; LA; NM CHOLBAM 5 PA; QL (120 per 30 days); NM

CREON 3

cromolyn sodium 100 mg/5ml conc 2

CYSTADANE 5 LA; NM CYSTARAN 5 LA; NM ELAPRASE 5 PA; LA; NM FABRAZYME 5 PA; LA; NM KANUMA 5 PA; LA; NM KEVEYIS 5 PA; QL (120 per 30 days); NM

KUVAN 5 PA; LA; NM

LUMIZYME 5 PA; LA; NM miglustat 5 PA; LA; NM

NAGLAZYME 5 PA; LA; NM nitisinone 5 PA; NM

ORFADIN 4 MG/ML SUSPENSION, 20 MG CAP 5 PA; LA; NM

PANCREAZE 4 ST

PERTZYE 16000 UNIT CP DR PART 5 ST PERTZYE 4000 DR, 8000 DR, 24000-86250 DR 4 ST PROCYSBI 25 MG CAP DR, 75 MG CAP DR 5 LA; NM PROLASTIN-C 5 PA; LA; NM

RAVICTI 5 PA; LA; QL (525 per 30 days); NM

sapropterin dihydrochloride 5 PA

sodium phenylbutyrate 3 gm/tsp powder, 500 mg tab 5 PA; NM

STRENSIQ 5 PA; LA; NM


02/01/2021 68

SUCRAID 5 LA; NM

VIMIZIM 5 PA; NM

VIOKACE 10440 UNIT TAB 4

VIOKACE 20880 UNIT TAB 5

VPRIV 5 PA; NM

ZEMAIRA 5 PA; LA; NM

ZENPEP 25000-79000 DR, 40000-126000 DR 5 ST

ZENPEP 3000-14000 DR, 5000-24000 DR, 1000032000 DR, 15000-47000 DR, 20000-63000 DR 3 ST

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide 15 mg tab er 24h 2 QL (30 per 30 days)

darifenacin hydrobromide 7.5 mg tab er 24h 2 QL (30 per 30 days)

flavoxate hcl 1

GELNIQUE 4 ST; QL (30 per 30 days)

MYRBETRIQ 4 QL (30 per 30 days)

oxybutynin chloride 10 mg tab er 24h 2 QL (60 per 30 days)


oxybutynin chloride 5 mg tab 1 QL (120 per 30 days)


oxybutynin chloride 5 mg/5ml syrup 1 QL (600 per 30 days)

OXYTROL 4 QL (8 per 28 days)

solifenacin succinate 2 QL (30 per 30 days)

tolterodine tartrate 2 QL (60 per 30 days)

tolterodine tartrate 2 mg cap er 24h 2 QL (30 per 30 days)

tolterodine tartrate 4 mg cap er 24h 2 QL (30 per 30 days)

TOVIAZ 4 QL (30 per 30 days)

trospium chloride 2 QL (60 per 30 days)

trospium chloride 60 mg cap er 24h 2 QL (30 per 30 days)

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl 10 mg tab er 24h 2

dutasteride 2 QL (30 per 30 days)

dutasteride-tamsulosin hcl 2 QL (30 per 30 days)

finasteride 1

silodosin 2

tamsulosin hcl 1

GENITOURINARY AGENTS, OTHER

bethanechol chloride 2

ELMIRON 4

penicillamine 250 mg tab 5

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)


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HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ACTHAR 5 PA; LA; NM

alclometasone dipropionate 0.05 % cream 1 betamethasone dipropionate 0.05 % ointment 1 betamethasone dipropionate aug 0.05 % cream, 0.05 % lotion 1 clobetasol prop emollient base 2 QL (120 per 30 days) clobetasol propionate e 2 QL (120 per 30 days) cortisone acetate 2 decadron 0.5 mg tab, 0.5 mg/5ml elixir, 0.75 mg tab, 4 mg tab, 6 mg tab 1 desonide 0.05 % lotion 2 dexamethasone 0.5 mg tab, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab 1 DEXAMETHASONE INTENSOL 3 dexamethasone sod phosphate pf 10 mg/ml solution 3 dexamethasone sodium phosphate 4 mg/ml, 10 mg/ml, 20 mg/5ml, 100 mg/10ml, 120 mg/30ml 1 fludrocortisone acetate 1 HEMADY 5 hydrocortisone butyrate 0.1 % ointment 2 hydrocortisone valerate 0.2 % ointment 2 KORLYM 5 PA; LA; NM methylprednisolone 1 methylprednisolone acetate 1 methylprednisolone sodium succ 40 mg soln, 125 mg soln, 1000 mg soln 1 MILLIPRED 3 mometasone furoate 0.1 % ointment, 0.1 % cream 1 prednicarbate 1 prednisolone 1 prednisolone sodium phosphate 10 mg/5ml solution, 10 mg tab disp, 15 mg tab disp, 20 mg/5ml solution, 30 mg tab disp 2 prednisolone sodium phosphate 6.7 (5 base) mg/5ml, 15 mg/5ml, 25 mg/5ml 1


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prednisone 1 mg tab, 2.5 mg tab, 5 mg (21) tab thpk, 5 mg (48) tab thpk, 5 mg/5ml solution, 5 mg tab, 10 mg tab, 10 mg (48) tab thpk, 20 mg tab, 50 mg tab 1

PREDNISONE INTENSOL 4 SOLU-CORTEF 250 MG RECON SOLN 4

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

CHORIONIC GONADOTROPIN 3 PA; NM

desmopressin ace spray refrig 2

desmopressin acetate 0.1 mg tab, 0.2 mg tab, 4 mcg/ml solution 2

desmopressin acetate spray 2

GENOTROPIN 5 PA; NM GENOTROPIN MINIQUICK 5 PA; NM HUMATROPE 5 PA; NM INCRELEX 5 PA; LA; NM NORDITROPIN FLEXPRO 5 PA; NM NOVAREL 10000 UNIT RECON SOLN 3 PA; NM NOVAREL 5000 UNIT RECON SOLN 4 PA; NM NUTROPIN AQ NUSPIN 10 5 PA; LA; NM NUTROPIN AQ NUSPIN 20 5 PA; LA; NM NUTROPIN AQ NUSPIN 5 5 PA; LA; NM OMNITROPE 5 MG/1.5ML SOLN CART, 5.8 MG RECON SOLN, 10 MG/1.5ML SOLN CART 5 PA; LA; NM

PREGNYL 3 PA; NM

SAIZEN 5 PA; LA; NM SAIZENPREP 5 PA; LA; NM SEROSTIM 5 PA; LA; NM STIMATE 4 NM ZOMACTON (FOR ZOMA-JET 10) 5 PA; NM ZOMACTON 10 MG RECON SOLN 5 PA; NM ZOMACTON 5 MG RECON SOLN 4 PA; NM ZORBTIVE 5 PA; NM

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PROSTAGLANDINS)

misoprostol 1


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HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS ANADROL-50 5

PA oxandrolone 10 mg tab 2 PA; QL (60 per 30 days)

oxandrolone 2.5 mg tab 2 PA; QL (240 per 30 days)

ANDROGENS

danazol 2 methyltestosterone 5 testosterone 1.62 % gel, 20.25 mg/act (1.62%) gel, 40.5 mg/2.5gm (1.62%) gel 2 PA; QL (150 per 30 days) testosterone 12.5 mg/act (1%) gel, 25 mg/2.5gm (1%) gel, 50 mg/5gm (1%) gel 2 PA; QL (300 per 30 days) testosterone 20.25 mg/1.25gm (1.62%) gel 2 PA; QL (112.5 per 30 days) testosterone cypionate 2 PA testosterone enanthate 2 PA

ESTROGENS ALORA 4 PA; QL (8 per 28 days) alyacen 1/35 2 alyacen 7/7/7 1 amethia 2 amethyst 2 apri 1

aranelle 2 ashlyna 2 aubra 1 aubra eq 1 aurovela 1.5/30 1 aurovela 1/20 1 aurovela 24 fe 1 aurovela fe 1.5/30 1 aurovela fe 1/20 1 aviane 1 ayuna 1 azurette 2 balziva 2 bekyree 2 blisovi 24 fe 1 blisovi fe 1.5/30 1 blisovi fe 1/20 1 briellyn 2 camrese 2 caziant 2 charlotte 24 fe 2


02/01/2021 72

chateal 1 chateal eq 1 cryselle-28 1 cyclafem 1/35 2 cyclafem 7/7/7 1 cyred 1 cyred eq 1 dasetta 1/35 2 dasetta 7/7/7 1 daysee 2 DEPO-ESTRADIOL 4 desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) tab 2 desogestrel-ethinyl estradiol 0.15-30 mg-mcg tab 1 DIVIGEL 0.25 MG/0.25GM GEL, 0.5 MG/0.5GM GEL, 0.75 MG/0.75GM GEL, 1 MG/GM GEL, 1.25 MG/1.25GM GEL 4 PA

drospiren-eth estrad-levomefol 3-0.02-0.451 mg tab 2 drospirenone-ethinyl estradiol 2 ELESTRIN 4 PA elinest 1 emoquette 1 enpresse-28 1 enskyce 1 estarylla 1 estradiol 0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr patch tw 2 PA; QL (8 per 28 days) estradiol 0.025 mg/24hr patch wk, 0.0375 mg/24hr patch wk, 0.05 mg/24hr patch wk, 0.06 mg/24hr patch wk, 0.075 mg/24hr patch wk, 0.1 mg/24hr patch wk 2 PA; QL (4 per 28 days) estradiol 0.1 mg/gm cream, 10 mcg tab 2 estradiol 0.5 mg tab, 1 mg tab, 2 mg tab 1 PA

estradiol valerate 2 ESTRING 4 QL (1 per 90 days); NE ethynodiol diac-eth estradiol 2 EVAMIST 4 PA falmina 1 fayosim 2 FEMRING 4 QL (1 per 90 days); NE femynor 1 fyavolv 1 PA


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gianvi 2

hailey 1.5/30 1

hailey 24 fe 1

hailey fe 1.5/30 1

hailey fe 1/20 1

introvale 2

isibloom 1

jaimiess 2

jasmiel 2

jinteli 1 PA

jolessa 2

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kaitlib fe 2

kalliga 1

kariva 2

kelnor 1/35 2

kelnor 1/50 2

kurvelo 1

larin 1.5/30 1

larin 1/20 1

larin 24 fe 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 2

leena 2

lessina 1

levonest 1

levonorgest-eth est & eth est 2

levonorgest-eth estrad 91-day 0.15-0.03 &0.01 mg tab, 0.15-0.03 mg tab 2

levonorgestrel-ethinyl estrad 90-20 mcg tab 2

levora 0.15/30 (28) 1

lillow 1

loestrin 1.5/30 (21) 1

loestrin 1/20 (21) 1

loestrin fe 1.5/30 1

loestrin fe 1/20 1

loryna 2


02/01/2021 74

low-ogestrel 1 lo-zumandimine 2 lutera 1 marlissa 1 melodetta 24 fe 2 MENEST 0.3 MG TAB, 0.625 MG TAB, 1.25 MG TAB 4 PA

MENOSTAR 4 PA; QL (4 per 28 days) mibelas 24 fe 2 microgestin 1.5/30 1 microgestin 1/20 1 microgestin 24 fe 1 microgestin fe 1.5/30 1 microgestin fe 1/20 1 mili 1 mono-linyah 1 necon 0.5/35 (28) 2 nikki 2 norethin ace-eth estrad-fe 1-20 mg-mcg(24) chew tab 2 norethin ace-eth estrad-fe 1-20 tab, 1.5-30 tab 1 norethindrone acet-ethinyl est 1 norethindrone-eth estradiol 1 PA

norethin-eth estradiol-fe 2 norgestimate-eth estradiol 1 norgestim-eth estrad triphasic 1 nortrel 0.5/35 (28) 2 nortrel 1/35 (21) 2 nortrel 1/35 (28) 2 nortrel 7/7/7 1 ocella 2 ogestrel 1 orsythia 1 philith 2 pimtrea 2 pirmella 1/35 2 pirmella 7/7/7 1 portia-28 1 PREMARIN 0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.9 MG TAB, 1.25 MG TAB 3 PA

PREMARIN 0.625 MG/GM CREAM 3 PREMPHASE 3 PA PREMPRO 3 PA previfem 1


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reclipsen 1

rivelsa 2

setlakin 2

simliya 2

simpesse 2

sprintec 28 1

sronyx 1

syeda 2

tarina 24 fe 1

tarina fe 1/20 1

tarina fe 1/20 eq 1

tilia fe 2

tri femynor 1

tri-estarylla 1

tri-legest fe 2

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem 1

tri-sprintec 1

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

TYBLUME 1 velivet 2

vienva 1

viorele 2

volnea 2

vyfemla 2

vylibra 1

wera 2

wymzya fe 2

xulane 2

yuvafem 2

zarah 2

zovia 1/35 (28) 2

zovia 1/35e (28) 2

zumandimine 2

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS), OTHER


02/01/2021 76

afirmelle 1 altavera 1 amabelz 2 PA

COMBIPATCH 4 PA; QL (8 per 28 days) delyla 1 estradiol-norethindrone acet 2 PA

levonorgestrel-ethinyl estrad 0.1-20 tab, 0.15-30 tab 1 levonorg-eth estrad triphasic 1 lopreeza 2 PA

mimvey 2 PA

PROGESTINS camila 1 CRINONE 4 PA; NM deblitane 1 DEPO-PROVERA 400 MG/ML SUSPENSION 4 DEPO-SUBQ PROVERA 104 4 ELLA 3 errin 1 heather 1 hydroxyprogesterone caproate 1.25 gm/5ml solution 2

PA; QL (25 per 147 over time); NM; NE

hydroxyprogesterone caproate 250 mg/ml oil 5 PA; QL (25 per 147 over time); NM; NE

incassia 1 jencycla 1 lyza 1 medroxyprogesterone acetate 150 mg/ml suspension, 150 mg/ml susp prsyr 2 medroxyprogesterone acetate 2.5 mg tab, 5 mg tab, 10 mg tab 1 megestrol acetate 20 mg tab, 40 mg/ml suspension, 40 mg tab, 400 mg/10ml suspension 2 PA

megestrol acetate 625 mg/5ml suspension 2 PA

nora-be 1 norethindrone 1 norethindrone acetate 2 norlyda 1 norlyroc 1 progesterone micronized 2 sharobel 1 tulana 1 SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS


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DUAVEE 4 PA; QL (30 per 30 days)

raloxifene hcl 2 QL (30 per 30 days)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

euthyrox 1

levo-t 1

LEVOTHYROXINE SODIUM 13 MCG CAP, 25 MCG CAP, 50 MCG CAP, 75 MCG CAP, 88 MCG CAP, 100 MCG CAP, 112 MCG CAP, 125 MCG CAP, 137 MCG CAP, 150 MCG CAP, 175 MCG CAP, 200 MCG CAP 4

levothyroxine sodium 25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab 1

levoxyl 1

liothyronine sodium 5 mcg tab, 25 mcg tab, 50 mcg tab 1

np thyroid 1 PA

SYNTHROID 3

TIROSINT 4

unithroid 1

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

LYSODREN 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 2

ELIGARD 22.5 MG KIT 4 PA; QL (1 per 84 days); NM; NE

ELIGARD 30 MG KIT 4 PA; QL (1 per 112 over time); NM; NE

ELIGARD 45 MG KIT 4 PA; QL (1 per 168 over time); NM; NE

ELIGARD 7.5 MG KIT 4 PA; QL (1 per 28 days); NM

FIRMAGON 4 PA; QL (1 per 28 days); NM

FIRMAGON (240 MG DOSE) 5 PA; QL (4 per 365 over time); NM; NE

leuprolide acetate 2 PA; NM

LUPANETA PACK 11.25 & 5 MG KIT 5 PA; QL (1 per 84 days); NM; NE


02/01/2021 78

LUPANETA PACK 3.75 & 5 MG KIT 5 PA; QL (1 per 28 days); NM

LUPRON DEPOT (1-MONTH) 5 PA; QL (1 per 28 days); NM

LUPRON DEPOT (3-MONTH) 5 PA; QL (1 per 84 days); NM; NE

LUPRON DEPOT (4-MONTH) 5 PA; QL (1 per 112 over time); NM; NE

LUPRON DEPOT (6-MONTH) 5 PA; QL (1 per 168 over time); NM; NE

LUPRON DEPOT-PED (1-MONTH) (1-MONTH) 11.25 MG, (1-MONTH) 15 MG 5 PA; QL (1 per 28 days); NM

octreotide acetate 50 mcg/ml, 100 mcg/ml, 200 mcg/ml, 1000 mcg/ml 2 PA; NM

octreotide acetate 500 mcg/ml solution 5 PA; NM

SIGNIFOR 5 PA; LA; NM

SIGNIFOR LAR 5 PA; LA; QL (1 per 28 days); NM

SOMATULINE DEPOT 5 PA; NM

SOMAVERT 5 PA; LA; NM

SYNAREL 5 PA; NM

TRELSTAR MIXJECT 11.25 MG RECON SUSP 5 PA; QL (1 per 84 days); NM; NE

TRELSTAR MIXJECT 22.5 MG RECON SUSP 5 PA; QL (1 per 168 over time); NM; NE

TRELSTAR MIXJECT 3.75 MG RECON SUSP 5 PA; QL (1 per 28 days); NM

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

CINRYZE 5 PA; LA; NM

icatibant acetate 5 PA; NM

IMMUNOGLOBULINS

ATGAM 5 PA-BvD; NM

GAMUNEX-C 5 PA; NM

HYPERRAB 5 NM

HYPERRAB S/D 3 NM

IMOGAM RABIES-HT 3 NM

KEDRAB 3 NM

OCTAGAM 1 GM/20ML, 2 GM/20ML, 2.5 GM/50ML, 5 GM/100ML, 25 GM/500ML, 30 GM/300ML 5 PA; NM

VARIZIG 3 NM

IMMUNOLOGICAL AGENTS, OTHER

ARCALYST 5 PA; NM


02/01/2021 79

BENLYSTA 120 MG RECON SOLN, 200 MG/ML SOLN A-INJ, 200 MG/ML SOLN PRSYR, 400 MG RECON SOLN 5 PA; NM

COSENTYX 5 PA; LA; QL (8 per 28 days); NM

COSENTYX (300 MG DOSE) 5 PA; LA; QL (8 per 28 days); NM

COSENTYX SENSOREADY (300 MG) 5 PA; LA; QL (8 per 28 days); NM

COSENTYX SENSOREADY PEN 5 PA; LA; QL (8 per 28 days); NM

ILARIS 5 PA; LA; NM

RIDAURA 5 SIMULECT 5 PA-BvD; NM

SKYRIZI (150 MG DOSE) 5 PA; QL (6 per 365 days); NM; NE

STELARA 45 MG/0.5ML SOLN, 90 MG/ML SOLN 5 PA; QL (1 per 28 days); NM

STELARA 45 MG/0.5ML SOLUTION 5 PA; LA; QL (1 per 28 days); NM

SYNAGIS 5 PA; NM

XOLAIR 150 MG RECON SOLN 5 PA; LA; QL (6 per 28 days); NM

IMMUNOSTIMULANTS

ACTIMMUNE 5 PA; LA; NM INTRON A 10000000 SOLN, 18000000 SOLN 4 PA-BvD; NM

INTRON A 6000000 UNIT/ML SOLUTION, 10000000 UNIT/ML SOLUTION, 50000000 UNIT RECON SOLN 5 PA-BvD; NM

PEGASYS 5 NM PEGASYS PROCLICK 5 NM SYLATRON 5 PA; NM IMMUNOSUPPRESSANTS ASTAGRAF XL 4 PA-BvD; NM

AZASAN 4 PA-BvD

azathioprine 1 PA-BvD

AZATHIOPRINE SODIUM 3 PA-BvD

cyclosporine 25 mg cap, 50 mg/ml solution, 100 mg cap 2 PA-BvD; NM

cyclosporine modified 25 mg cap, 50 mg cap, 100 mg/ml solution, 100 mg cap 2 PA-BvD; NM

ENBREL 25 MG RECON SOLN, 50 MG/ML SOLN PRSYR 5 PA; QL (8 per 28 days); NM

ENBREL 25 MG/0.5ML SOLN PRSYR 5 PA; QL (4.08 per 28 days); NM

ENBREL 25 MG/0.5ML SOLUTION 5 PA; QL (4 per 28 days); NM

ENBREL MINI 5 PA; QL (8 per 28 days); NM

ENBREL SURECLICK 5 PA; QL (8 per 28 days); NM

ENTYVIO 5 PA; QL (4 per 56 days); NM; NE

ENVARSUS XR 0.75 MG TAB ER, 1 MG TAB ER 4 PA-BvD; NM

ENVARSUS XR 4 MG TAB ER 24H 5 PA-BvD; NM

everolimus 0.25 mg tab 2 PA-BvD; NM


02/01/2021 80

everolimus 0.5 mg tab, 0.75 mg tab 5 PA-BvD; NM

gengraf 25 mg cap, 100 mg cap, 100 mg/ml solution 2 PA-BvD; NM

HUMIRA 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML 5 PA; QL (2 per 28 days); NM

HUMIRA 40 MG/0.8ML, 40 MG/0.4ML 5 PA; QL (4 per 28 days); NM

HUMIRA 80 MG/0.8ML PEN KIT 5 PA; QL (6 per 365 over time); NE

HUMIRA PEDIATRIC CROHNS START 40 MG/0.8ML, 80 MG/0.8ML 5


HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML & 40MG/0.4ML PREF SY KT 5


HUMIRA PEN 5 PA; QL (4 per 28 days); NM

HUMIRA PEN-CD/UC/HS STARTER 40 MG/0.8ML PEN KIT 5


HUMIRA PEN-CD/UC/HS STARTER 80 MG/0.8ML PEN KIT 5


HUMIRA PEN-PS/UV/ADOL HS START 5 PA; QL (8 per 365 over time); NM; NE

HUMIRA PEN-PSOR/UVEIT STARTER 5 PA; QL (6 per 365 over time); NM; NE

leflunomide 2

methotrexate 1

METHOTREXATE (ANTI-RHEUMATIC) 3

methotrexate sodium (pf) 1

methotrexate sodium 1 gm recon soln, 2.5 mg tab, 50 mg/2ml solution, 250 mg/10ml solution 1

mycophenolate mofetil 200 mg/ml recon susp 5 PA-BvD; NM

mycophenolate mofetil 250 mg cap, 500 mg tab 2 PA-BvD; NM

mycophenolate mofetil hcl 2 PA-BvD; NM

mycophenolate sodium 2 PA-BvD; NM

NULOJIX 5 PA; NM PROGRAF 0.2 MG PACKET, 1 MG PACKET 4 PA-BvD; NM

PROGRAF 5 MG/ML SOLUTION 5 PA-BvD; NM

REMICADE 5 PA; NM

RINVOQ 5 PA; QL (30 per 30 days); NM

sirolimus 0.5 mg tab, 1 mg/ml solution, 1 mg tab 2 PA-BvD; NM

sirolimus 2 mg tab 5 PA-BvD; NM

tacrolimus 0.5 mg cap, 1 mg cap, 5 mg cap 2 PA-BvD; NM

temsirolimus 5 PA; NM

TORISEL 5 PA; NM TREXALL 10 MG TAB, 15 MG TAB 4 XATMEP 4 NM ZORTRESS 5 PA-BvD; NM


02/01/2021 81

VACCINES ACTHIB 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 DAPTACEL 3 DIPHTHERIA-TETANUS TOXOIDS DT 3 ENGERIX-B 3 PA-BvD

GARDASIL 9 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES 3 INFANRIX 3 IPOL 3 IXIARO 3 KINRIX 3 MENACTRA 3 MENVEO 3 M-M-R II 3 PEDIARIX 3 PEDVAX HIB 3 PENTACEL 3 PROQUAD 3 QUADRACEL 3 RABAVERT 3 RECOMBIVAX HB 3 PA-BvD

ROTARIX 3 ROTATEQ 3 SHINGRIX 3 STAMARIL 3 TDVAX 3 TENIVAC 3 TRUMENBA 3 TWINRIX 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES balsalazide disodium 2


02/01/2021 82

mesalamine 0.375 gm cap er 24h 2

mesalamine 1.2 gm tab dr, 4 gm enema, 800 mg tab dr, 1000 mg suppos 2

mesalamine-cleanser 2

PENTASA 250 MG CAP ER 4 PENTASA 500 MG CAP ER 5 sulfasalazine 1

GLUCOCORTICOIDS

budesonide 3 mg cp dr part 2

budesonide 9 mg tab er 24h 5 PA

hydrocortisone 5 mg tab, 10 mg tab, 20 mg tab, 100 mg/60ml enema 1

UCERIS 2 MG/ACT FOAM 4

METABOLIC BONE DISEASE AGENTS

METABOLIC BONE DISEASE AGENTS alendronate sodium 35 mg tab, 70 mg tab 1 QL (4 per 28 days)

alendronate sodium 5 mg tab, 10 mg tab, 40 mg tab 1 QL (30 per 30 days)

alendronate sodium 70 mg/75ml solution 1 QL (300 per 28 days)

calcitonin (salmon) 2 QL (4 per 30 days)

calcitriol 0.25 mcg cap, 0.5 mcg cap 2 PA-BvD

cinacalcet hcl 30 mg tab 2 PA-BvD; QL (60 per 30 days); NM



doxercalciferol 0.5 mcg cap, 1 mcg cap, 2.5 mcg cap, 4 mcg/2ml solution 2 PA-BvD

FORTEO 5 PA; QL (3 per 28 days); NM

FOSAMAX PLUS D 4 ST; QL (4 per 28 days)

ibandronate sodium 150 mg tab 2 QL (1 per 28 days)

ibandronate sodium 3 mg/3ml solution 2 PA-BvD

MIACALCIN 5 PA-BvD

NATPARA 5 PA; QL (2 per 28 days); NM

pamidronate disodium 30 mg recon soln, 30 mg/10ml solution, 90 mg recon soln, 90 mg/10ml solution 2 NM

PAMIDRONATE DISODIUM 6 MG/ML SOLUTION 3 PA-BvD; NM

paricalcitol 1 mcg cap, 2 mcg cap, 2 mcg/ml solution, 4 mcg cap, 5 mcg/ml solution 2 PA-BvD

PROLIA 4 PA; QL (1 per 180 over time); NM; NE


02/01/2021 83

risedronate sodium 150 mg tab 2 ST; QL (1 per 28 days)

risedronate sodium 35 mg tab dr, 35 mg tab 2 ST; QL (4 per 28 days)

risedronate sodium 5 mg tab, 30 mg tab 2 ST; QL (30 per 30 days)

TERIPARATIDE (RECOMBINANT) 5 PA; QL (3 per 28 days); NM

TYMLOS 5 PA; QL (1.56 per 28 days); NM

XGEVA 5 PA; QL (5.1 per 28 days); NM

ZOLEDRONIC ACID 4 MG/100ML SOLUTION 4 PA; NM

zoledronic acid 4 mg/5ml conc 2 PA; NM

zoledronic acid 5 mg/100ml solution 2 PA; NM

MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTS

ALCOHOL SWABS 2

GAUZE STERILE PADS 2" X 2" 2 QL (200 per 30 days)

INSULIN PEN NEEDLE 2 QL (200 per 30 days)

INSULIN SYRINGE (DISP) U-100 0.3 ML 2 QL (200 per 30 days)

INSULIN SYRINGE (DISP) U-100 1 ML 2 QL (200 per 30 days)

INSULIN SYRINGE (DISP) U-100 1/2 ML 2 QL (200 per 30 days)

NEEDLES, INSULIN DISP., SAFETY 2 QL (200 per 30 days)

sterile water for irrigation 2

TRODELVY 5 PA; NM

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER ak-poly-bac 1

ATROPINE SULFATE 1 % SOLUTION, 1 % OINTMENT 3 bacitracin-polymyxin b 1

bacitra-neomycin-polymyxin-hc 2

BLEPHAMIDE 4 BLEPHAMIDE S.O.P. 4 COMBIGAN 3 CORTISPORIN 3.5-10000-0.5 CREAM 4 dorzolamide hcl-timolol mal 2

ISOPTO ATROPINE 3 LACRISERT 4 QL (60 per 30 days)

neomycin-bacitracin zn-polymyx 1

neomycin-polymyxin-dexameth 0.1 % suspension, 3.5-10000-0.1 ointment, 3.5-10000-0.1 suspension 1

neomycin-polymyxin-gramicidin 1

neomycin-polymyxin-hc 3.5-10000-1 suspension 2

neo-polycin 1

neo-polycin hc 2


02/01/2021 84

polycin 1 PRED-G 4 RESTASIS 3 QL (60 per 30 days) RESTASIS MULTIDOSE 3 QL (5.5 per 28 days) ROCKLATAN 3 sulfacetamide-prednisolone 1 TOBRADEX 0.3-0.1 % OINTMENT 3 TOBRADEX ST 3 tobramycin-dexamethasone 2 XIIDRA 3 QL (60 per 30 days) ZYLET 4 OPHTHALMIC ANTI-ALLERGY AGENTS ALOCRIL 4 ALOMIDE 4 azelastine hcl 0.05 % solution 2 BEPREVE 4 cromolyn sodium 4 % solution 1 epinastine hcl 2 LASTACAFT 4 olopatadine hcl 0.1 %, 0.2 % 2 PAZEO 3 OPHTHALMIC ANTI-INFECTIVES bacitracin 500 unit/gm ointment 1 erythromycin 5 mg/gm ointment 1 gatifloxacin 2 gentak 1 gentamicin sulfate 0.3 % solution 1 levofloxacin 0.5 % solution 1 moxifloxacin hcl 0.5 % solution 2 NATACYN 4 ofloxacin ophth soln 0.3% 1 polymyxin b-trimethoprim 1 sulfacetamide sodium 10 % ointment, 10 % solution 1 tobramycin 0.3 % solution 1 OPHTHALMIC ANTI-INFLAMMATORIES ACUVAIL 4 bromfenac sodium (once-daily) 2 dexamethasone sodium phosphate 0.1 % solution 1 diclofenac sodium 0.1 % solution 1 DUREZOL 3 fluorometholone 2 flurbiprofen sodium 1 FML 3


02/01/2021 85

ILEVRO 3 ketorolac tromethamine 0.4 %, 0.5 % 2

prednisolone acetate 1

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTION 3

OPHTHALMIC BETA-ADRENERGIC BLOCKING AGENTS

betaxolol hcl 0.5 % solution 2

BETIMOL 4

BETOPTIC-S 4

carteolol hcl 1

levobunolol hcl 1

timolol maleate 0.25 % gel soln, 0.5 % gel soln 2

timolol maleate 0.25 %, 0.5 % 1

OPHTHALMIC INTRAOCULAR PRESSURE LOWERING AGENTS, OTHER

acetazolamide 500 mg cap er 12h 2

ALPHAGAN P 0.1 % SOLUTION 3

apraclonidine hcl 2

AZOPT 4

brimonidine tartrate 1

dorzolamide hcl 1

IOPIDINE 1 % SOLUTION 4

methazolamide 1

PHOSPHOLINE IODIDE 4

pilocarpine hcl 1 %, 2 %, 4 % 2

RHOPRESSA 3

SIMBRINZA 3

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 2

latanoprost 1

LUMIGAN 3

travoprost (bak free) 2

ZIOPTAN 4

OTIC AGENTS

OTIC AGENTS CIPRO HC 4 CIPRODEX 3 ciprofloxacin-dexamethasone 2

CORTISPORIN-TC 4 flac 2

fluocinolone acetonide 0.01 % oil 2


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hydrocortisone-acetic acid 2

neomycin-polymyxin-hc 1 %, 3.5-10000-1 1

ofloxacin otic soln 0.3% 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTIHISTAMINES

azelastine hcl 0.1 %, 0.15 %, 137 mcg/spray 2 QL (30 per 25 days)

carbinoxamine maleate 4 mg tab, 4 mg/5ml solution 2 PA

cetirizine hcl 1

cetirizine hcl allergy child 1

clemastine fumarate 2 PA

cyproheptadine hcl 2 mg/5ml syrup, 4 mg tab 2 PA

desloratadine 2

diphenhydramine hcl 50 mg/ml solution 2

hydroxyzine hcl 10 mg/5ml syrup, 10 mg tab, 25 mg tab, 25 mg/ml solution, 50 mg/ml solution, 50 mg tab 2 PA

levocetirizine dihydrochloride 5 mg tab 2

olopatadine hcl 0.6 % solution 2 QL (31 per 30 days)

promethazine hcl 6.25 mg/5ml solution, 6.25 mg/5ml syrup, 25 mg/ml solution, 50 mg/ml solution 2 PA

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ARNUITY ELLIPTA 3 QL (30 per 30 days)

ASMANEX (120 METERED DOSES) 3 QL (1 per 30 days)





ASMANEX HFA 3 QL (13 per 30 days)

budesonide 0.25 mg/2ml suspension, 0.5 mg/2ml suspension 2 PA-BvD; QL (120 per 30 days)

budesonide 1 mg/2ml suspension 2 PA-BvD; QL (60 per 30 days)

FLOVENT DISKUS 250 MCG/BLIST AER POW BA 3 QL (240 per 30 days)

FLOVENT DISKUS 50 MCG/BLIST, 100 MCG/BLIST 3 QL (60 per 30 days)

FLOVENT HFA 110 MCG/ACT AEROSOL 3 QL (12 per 30 days)



flunisolide 1 QL (75 per 30 days)

fluticasone propionate 50 mcg/act suspension 1 QL (16 per 30 days)

mometasone furoate 50 mcg/act suspension 2

QVAR REDIHALER 40 MCG/ACT AERO BA 3 QL (11 per 30 days)


02/01/2021 87

QVAR REDIHALER 80 MCG/ACT AERO BA 3 QL (22 per 30 days)

ANTILEUKOTRIENES

montelukast sodium 4 mg chew tab, 5 mg chew tab, 10 mg tab 1 PA

montelukast sodium 4 mg packet 2 PA

zafirlukast 2

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 3 QL (26 per 30 days)

ipratropium bromide 0.02 % solution 1 PA-BvD

ipratropium bromide 0.03 %, 0.06 % 1 QL (30 per 30 days)

SPIRIVA HANDIHALER 3 QL (30 per 30 days)

SPIRIVA RESPIMAT 3 QL (4 per 30 days)

TUDORZA PRESSAIR 3 QL (1 per 30 days)

BRONCHODILATORS, SYMPATHOMIMETIC

albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln 1 PA-BvD; QL (360 per 30 days)

albuterol sulfate 0.63 mg/3ml soln, 1.25 mg/3ml soln 2 PA-BvD; QL (360 per 30 days)

albuterol sulfate 2 mg tab, 4 mg tab 2

albuterol sulfate 2 mg/5ml syrup 1

albuterol sulfate 2.5 mg/0.5ml soln, (5 mg/ml) 0.5% soln 1 PA-BvD; QL (60 per 30 days)

albuterol sulfate 4 mg tab er 12h 2

albuterol sulfate 8 mg tab er 12h 1

albuterol sulfate hfa 2

ARCAPTA NEOHALER 4 QL (30 per 30 days)

BROVANA 5 PA-BvD; QL (120 per 30 days)

epinephrine 0.15 mg/0.3ml soln, 0.3 mg/0.3ml soln 1 QL (2 per 28 days)

levalbuterol hcl 0.31 mg/3ml soln, 1.25 mg/3ml soln, 1.25 mg/0.5ml soln 2 PA-BvD; QL (270 per 30 days)

levalbuterol hcl 0.63 mg/3ml nebu soln 2 PA-BvD; QL (540 per 30 days)

levalbuterol tartrate 2 QL (45 per 30 days)

metaproterenol sulfate 1

PERFOROMIST 5 PA-BvD; QL (120 per 30 days)

PROAIR HFA 3

PROAIR RESPICLICK 3

PROVENTIL HFA 4

SEREVENT DISKUS 3 QL (60 per 30 days)

SYMJEPI 4 QL (2 per 28 days)

terbutaline sulfate 1 mg/ml solution, 2.5 mg tab, 5 mg tab 1

VENTOLIN HFA 3

CYSTIC FIBROSIS AGENTS


02/01/2021 88

BETHKIS 5 PA-BvD; QL (224 per 28 days); NM

CAYSTON 5 PA; LA; NM

KALYDECO 150 MG TAB 5 PA; QL (60 per 30 days); NM

KALYDECO 25 MG PACKET, 50 MG PACKET, 75 MG PACKET 5 PA; QL (56 per 28 days); NM

ORKAMBI 100-125 MG TAB, 200-125 MG TAB 5 PA; QL (120 per 30 days); NM

PULMOZYME 5 PA-BvD; NM

TOBI PODHALER 5 LA; QL (224 per 28 days); NM

tobramycin 300 mg/4ml nebu soln 5 PA-BvD; QL (224 per 28 days)

tobramycin 300 mg/5ml nebu soln 5 PA-BvD; QL (280 per 28 days); NM

MAST CELL STABILIZERS

cromolyn sodium 20 mg/2ml nebu soln 2 PA-BvD; QL (240 per 30 days)

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

aminophylline 1

DALIRESP 4 PA; QL (30 per 30 days)

ELIXOPHYLLIN 4

theophylline 200 mg tab er 12h 1





PULMONARY ANTIHYPERTENSIVES

ADEMPAS 5 PA; LA; NM

alyq 5 PA; QL (60 per 30 days); NM

ambrisentan 5 PA; LA; QL (30 per 30 days); NM

bosentan 5 PA; LA; QL (60 per 30 days); NM

OPSUMIT 5 PA; LA; QL (30 per 30 days); NM

sildenafil citrate 10 mg/12.5ml solution 5 PA; QL (1125 per 30 days); NM

sildenafil citrate 10 mg/ml recon susp 5 PA; QL (224 per 30 days); NM

sildenafil citrate 20 mg tab 2 PA; QL (90 per 30 days); NM

tadalafil (pah) 5 PA; QL (60 per 30 days); NM

TRACLEER 32 MG TAB SOL 5 PA; LA; QL (120 per 30 days); NM

TYVASO 5 PA; QL (81.2 per 30 days); NM; NE

TYVASO REFILL 5 PA; QL (81.2 per 30 days); NM; NE

TYVASO STARTER 5 PA; QL (81.2 per 365 over time); NM; NE

UPTRAVI 200 & 800 MCG TAB THPK 5 PA; LA; NM


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UPTRAVI 200 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB, 1000 MCG TAB, 1200 MCG TAB, 1400 MCG TAB, 1600 MCG TAB 5 PA; LA; QL (60 per 30 days); NM

VENTAVIS 5 PA; QL (270 per 30 days); NM

PULMONARY FIBROSIS AGENTS

ESBRIET 267 MG TAB, 267 MG CAP 5 PA; QL (270 per 30 days); NM

ESBRIET 801 MG TAB 5 PA; QL (90 per 30 days); NM

OFEV 5 PA; QL (60 per 30 days); NM

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine 10 %, 20 % 2 PA-BvD

ADVAIR HFA 3 QL (12 per 30 days)

ANORO ELLIPTA 3 QL (60 per 30 days)

BREO ELLIPTA 4 QL (60 per 30 days)

budesonide-formoterol fumarate 2 QL (11 per 30 days)

COMBIVENT RESPIMAT 4 QL (8 per 30 days)

DULERA 3 QL (13 per 30 days)

fluticasone-salmeterol 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose 2 QL (60 per 30 days)

ipratropium-albuterol 2 PA-BvD; QL (540 per 30 days)

NUCALA 100 MG/ML SOLN PRSYR, 100 MG RECON SOLN, 100 MG/ML SOLN A-INJ 5 PA; LA; NM

promethazine-phenylephrine 2 PA

ribavirin 6 gm recon soln 5 PA

STIOLTO RESPIMAT 3 QL (4 per 30 days)

SYMBICORT 3 QL (11 per 30 days)

TRELEGY ELLIPTA 3 QL (60 per 30 days)

VIRAZOLE 5 PA

wixela inhub 2 QL (60 per 30 days)

SKELETAL MUSCLE RELAXANTS

SKELETAL MUSCLE RELAXANTS

BOTOX 4 PA; NM

carisoprodol 250 mg tab 2 PA

chlorzoxazone 500 mg tab 2 PA

cyclobenzaprine hcl 2 PA

metaxalone 800 mg tab 2 PA

orphenadrine citrate 2 PA

orphenadrine citrate 100 mg tab er 12h 2 PA

XEOMIN 50 UNIT RECON SOLN 4 PA; NM

SLEEP DISORDER AGENTS

SLEEP PROMOTING AGENTS

HETLIOZ 5 PA; LA; QL (30 per 30 days); NM

ramelteon 2 QL (30 per 30 days)

PA; LA; QL (540 per 30 days); XYREM 5 NM


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temazepam 2 QL (30 per 30 days)

triazolam 1 QL (30 per 30 days)

zaleplon 10 mg cap 2 QL (60 per 30 days)

zaleplon 5 mg cap 2 QL (30 per 30 days)

zolpidem tartrate 2 PA; QL (30 per 30 days)

zolpidem tartrate 12.5 mg tab er 2 PA; QL (30 per 30 days)

zolpidem tartrate 6.25 mg tab er 2 PA; QL (30 per 30 days)

WAKEFULNESS PROMOTING AGENTS

armodafinil 150 mg tab, 200 mg tab, 250 mg tab 2 PA; QL (30 per 30 days)

armodafinil 50 mg tab 2 PA; QL (60 per 30 days)

modafinil 100 mg tab 2 PA

modafinil 200 mg tab 2 PA; QL (60 per 30 days)

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INDEX

A

abacavir sulfate................................................... 41 abacavir sulfate-lamivudine .............................. 41 ABELCET ............................................................ 24 ABILIFY................................................................ 37 ABILIFY MAINTENA.......................................... 37 abiraterone acetate ............................................ 27 ABSTRAL ............................................................ 10 acamprosate calcium......................................... 12 acarbose .............................................................. 44 acebutolol hcl ...................................................... 50 acetaminophen ............................................. 10, 11 acetazolamide............................................... 53, 85 acetazolamide sodium....................................... 53 acetic acid...................................................... 12, 86 acetylcysteine ..................................................... 89 acitretin................................................................. 59 ACTHIB ................................................................ 81 ACTIMMUNE ...................................................... 79 ACUVAIL ............................................................. 84 acyclovir ......................................................... 40, 62 acyclovir sodium ................................................. 40 ACZONE .............................................................. 62 ADACEL............................................................... 81 adapalene............................................................ 59 adefovir dipivoxil ................................................. 40 ADEMPAS ........................................................... 88 ADVAIR HFA....................................................... 89 AFINITOR ............................................................ 31 AFINITOR DISPERZ ......................................... 31 AIMOVIG ............................................................. 26 AIMOVIG (140 MG DOSE) ............................... 26 albendazole ......................................................... 35 albuterol sulfate .................................................. 87 alclometasone dipropionate........................ 60, 69 ALCOHOL SWABS............................................ 83 ALDACTAZIDE ................................................... 53

ALDURAZYME ................................................... 67 ALECENSA ......................................................... 31 alendronate sodium ........................................... 82 alfuzosin hcl......................................................... 68 ALIMTA ................................................................ 28 ALINIA.................................................................. 36 ALIQOPA ............................................................. 31 aliskiren fumarate ............................................... 53 allopurinol ............................................................ 26 almotriptan malate.............................................. 26 ALOCRIL ............................................................. 84 ALOMIDE............................................................. 84 ALORA ................................................................. 71 alosetron hcl........................................................ 65 ALOXI................................................................... 24 ALPHAGAN P ..................................................... 85 alprazolam ........................................................... 43 ALPRAZOLAM.................................................... 43 ALPRAZOLAM INTENSOL............................... 43 ALUNBRIG .......................................................... 31 amantadine hcl ................................................... 36 AMBISOME ......................................................... 24 ambrisentan......................................................... 88 amcinonide .......................................................... 60 amikacin sulfate.................................................. 12 amiloride hcl ........................................................ 54 AMINO ACID....................................................... 37 aminophylline ...................................................... 88 AMINOSYN ......................................................... 62 AMINOSYN II...................................................... 62 AMINOSYN-PF................................................... 62 amiodarone hcl ................................................... 50 AMITIZA............................................................... 65 amitriptyline hcl ................................................... 23 amlodipine besylate ..................................... 51, 53 amlodipine besylate-valsartan.......................... 53 amoxapine ........................................................... 23 amoxicillin ............................................................ 15 amphetamine ...................................................... 56

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amphetamine-dextroamphetamine.................. 56 amphotericin b .................................................... 24 ampicillin .............................................................. 15 ampicillin sodium ................................................ 15 ANADROL-50 ..................................................... 71 anagrelide hcl...................................................... 48 anastrozole.......................................................... 31 ANORO ELLIPTA............................................... 89 APEXICON E ...................................................... 60 APIDRA................................................................ 46 APIDRA SOLOSTAR......................................... 46 APOKYN.............................................................. 36 apraclonidine hcl ................................................ 85 aprepitant............................................................. 24 APTENSIO XR.................................................... 56 APTIOM ............................................................... 20 APTIVUS ............................................................. 42 ARALAST NP...................................................... 67 ARANESP (ALBUMIN FREE) .......................... 48 ARCALYST ......................................................... 78 ARCAPTA NEOHALER..................................... 87 aripiprazole.................................................... 37, 38 ARISTADA........................................................... 38 ARISTADA INITIO.............................................. 38 armodafinil ........................................................... 90 ARNUITY ELLIPTA............................................ 86 ARRANON........................................................... 29 arsenic trioxide.................................................... 29 ARZERRA ........................................................... 34 ASMANEX (120 METERED DOSES)............. 86 ASMANEX (14 METERED DOSES) ............... 86 ASMANEX (30 METERED DOSES) ............... 86 ASMANEX (60 METERED DOSES) ............... 86 ASMANEX HFA.................................................. 86 aspirin................................................................... 49 aspirin-dipyridamole........................................... 49 ASTAGRAF XL ................................................... 79 atazanavir sulfate ............................................... 42 atenolol........................................................... 50, 53 ATGAM ................................................................ 78 atomoxetine hcl................................................... 56 atorvastatin calcium ........................................... 55

atovaquone.......................................................... 36 atovaquone-proguanil hcl.................................. 36 ATRIPLA.............................................................. 41 atropine sulfate ................................................... 66 ATROPINE SULFATE ....................................... 83 ATROVENT HFA................................................ 87 AUBAGIO ............................................................ 58 AUSTEDO ........................................................... 58 AVANDIA ............................................................. 44 AVASTIN ............................................................. 34 AVONEX.............................................................. 58 AVONEX PEN..................................................... 58 AVONEX PREFILLED ....................................... 58 AVYCAZ............................................................... 14 AYVAKIT.............................................................. 29 azacitidine............................................................ 29 AZASAN............................................................... 79 azathioprine......................................................... 79 AZATHIOPRINE ................................................. 79 AZATHIOPRINE SODIUM ................................ 79 azelaic acid.......................................................... 59 azelastine hcl ................................................ 84, 86 AZELEX ............................................................... 59 azithromycin ........................................................ 16 AZOPT ................................................................. 85 aztreonam............................................................ 12

B

bacitracin ....................................................... 83, 84 bacitracin-polymyxin b ....................................... 83 baclofen ............................................................... 40 balsalazide disodium ......................................... 81 BALVERSA ......................................................... 31 BANZEL ............................................................... 20 BARACLUDE ...................................................... 40 BAVENCIO.......................................................... 34 BCG VACCINE ................................................... 81 BELBUCA.............................................................. 9 BELEODAQ......................................................... 31 benazepril hcl................................................ 50, 53 BENLYSTA.......................................................... 79

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benzoyl peroxide ................................................ 59 benzoyl peroxide-erythromycin ........................ 59 benztropine mesylate ........................................ 36 BEPREVE............................................................ 84 BESPONSA......................................................... 34 betamethasone valerate.................................... 60 BETASERON...................................................... 58 betaxolol hcl .................................................. 50, 85 bethanechol chloride.......................................... 68 BETHKIS ............................................................. 88 BETIMOL ............................................................. 85 BETOPTIC-S....................................................... 85 bexarotene........................................................... 35 BEXSERO ........................................................... 81 bicalutamide ........................................................ 27 BICILLIN C-R ...................................................... 15 BICILLIN C-R 900/300 ...................................... 15 BICILLIN L-A ....................................................... 15 BICNU .................................................................. 27 BIDIL..................................................................... 53 BIKTARVY........................................................... 40 bimatoprost.......................................................... 85 bisoprolol fumarate ............................................ 50 BLENREP............................................................ 34 bleomycin sulfate................................................ 29 BLEPHAMIDE..................................................... 83 BLEPHAMIDE S.O.P......................................... 83 BLINCYTO........................................................... 34 BOOSTRIX.......................................................... 81 BORTEZOMIB .................................................... 29 bosentan .............................................................. 88 BOSULIF ....................................................... 31, 32 BOTOX................................................................. 89 BRAFTOVI........................................................... 32 BREO ELLIPTA .................................................. 89 BRILINTA............................................................. 49 brimonidine tartrate ............................................ 85 BRIVIACT ............................................................ 17 bromocriptine mesylate ..................................... 36 BROVANA ........................................................... 87 BRUKINSA .......................................................... 29 budesonide.............................................. 82, 86, 89

bumetanide.......................................................... 54 buprenorphine................................................. 9, 12 buprenorphine hcl .............................................. 12 bupropion hcl................................................. 12, 21 buspirone hcl....................................................... 43 busulfan ............................................................... 27 BUSULFEX ......................................................... 27 butalbital-acetaminophen.................................. 58 butalbital-aspirin-caffeine .................................... 8 butorphanol tartrate............................................ 10 BYDUREON ........................................................ 44 BYDUREON BCISE........................................... 44 BYETTA 10 MCG PEN...................................... 44 BYETTA 5 MCG PEN........................................ 44 BYSTOLIC........................................................... 50

C

cabergoline.......................................................... 77 CABOMETYX ..................................................... 32 caffeine................................................................. 58 calcipotriene ........................................................ 61 calcitonin (salmon) ............................................. 82 calcitriol .......................................................... 61, 82 calcium ........................................................... 62, 64 CALCIUM....................................................... 19, 51 CALQUENCE...................................................... 32 candesartan cilexetil .................................... 50, 53 CAPASTAT SULFATE ...................................... 27 CAPEX ................................................................. 60 CAPLYTA ............................................................ 38 CAPRELSA ......................................................... 32 captopril ......................................................... 50, 53 CARAFATE ......................................................... 66 CARBAGLU......................................................... 62 carbamazepine ................................................... 20 carbidopa ....................................................... 36, 37 carbidopa-levodopa ..................................... 36, 37 carbidopa-levodopa-entacapone ..................... 36 carbinoxamine maleate ..................................... 86 carboplatin ........................................................... 29 CARDIZEM.......................................................... 51

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CARDIZEM LA.................................................... 51 carisoprodol......................................................... 89 carmustine ........................................................... 27 carvedilol.............................................................. 50 CAYSTON ........................................................... 88 cefaclor................................................................. 14 cefadroxil ............................................................. 14 cefazolin sodium................................................. 14 CEFAZOLIN SODIUM ....................................... 14 cefdinir.................................................................. 14 cefepime hcl ........................................................ 14 CEFEPIME-DEXTROSE................................... 14 cefixime ................................................................ 14 cefotaxime sodium ............................................. 14 cefotetan disodium ............................................. 14 cefoxitin sodium.................................................. 14 CEFOXITIN SODIUM-DEXTROSE................. 14 cefpodoxime proxetil.......................................... 14 cefprozil................................................................ 14 ceftazidime .......................................................... 14 ceftriaxone sodium ............................................. 14 CEFTRIAXONE SODIUM ................................. 14 cefuroxime axetil................................................. 15 cefuroxime sodium ............................................. 15 celecoxib................................................................ 8 CELONTIN .......................................................... 19 cephalexin ........................................................... 15 CERDELGA......................................................... 67 CEREBYX ........................................................... 20 CEREZYME ........................................................ 67 cetirizine hcl......................................................... 86 cevimeline hcl ..................................................... 59 CHANTIX ............................................................. 12 CHANTIX CONTINUING MONTH PAK.......... 12 CHANTIX STARTING MONTH PAK............... 12 CHENODAL ........................................................ 66 chlordiazepoxide hcl .......................................... 43 chlordiazepoxide-amitriptyline.......................... 21 chlorhexidine gluconate .................................... 59 chloroquine phosphate ...................................... 36 chlorpromazine hcl ............................................. 37 chlorthalidone................................................ 53, 54

chlorzoxazone..................................................... 89 CHOLBAM........................................................... 67 cholestyramine.................................................... 55 cholestyramine light ........................................... 55 CHORIONIC GONADOTROPIN...................... 70 ciclopirox ........................................................ 24, 62 ciclopirox olamine............................................... 24 cidofovir................................................................ 40 cilostazol .............................................................. 49 CIMDUO .............................................................. 41 cimetidine............................................................. 66 cimetidine hcl ...................................................... 66 cinacalcet hcl....................................................... 82 CINRYZE ............................................................. 78 CIPRO .................................................................. 85 CIPRO HC ........................................................... 85 CIPRODEX.......................................................... 85 ciprofloxacin .................................................. 16, 85 ciprofloxacin hcl .................................................. 16 ciprofloxacin in d5w............................................ 16 ciprofloxacin-dexamethasone .......................... 85 cisplatin ................................................................ 29 citalopram hydrobromide................................... 22 cladribine ............................................................. 28 clarithromycin ...................................................... 16 clemastine fumarate........................................... 86 CLEOCIN............................................................. 12 clindamycin hcl ................................................... 12 clindamycin phosphate................................ 13, 62 clindamycin phosphate in d5w ......................... 13 CLINIMIX E/DEXTROSE (2.75/5) ................... 62 CLINIMIX E/DEXTROSE (4.25/10) ................. 62 CLINIMIX E/DEXTROSE (4.25/5) ................... 62 CLINIMIX E/DEXTROSE (5/15)....................... 62 CLINIMIX E/DEXTROSE (5/20)....................... 62 CLINIMIX/DEXTROSE (4.25/10) ..................... 62 CLINIMIX/DEXTROSE (4.25/5) ....................... 62 CLINIMIX/DEXTROSE (5/15)........................... 62 CLINIMIX/DEXTROSE (5/20)........................... 62 CLINOLIPID ........................................................ 62 clobazam ............................................................. 19 clobetasol propionate .................................. 60, 69

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clofarabine ........................................................... 28 CLOLAR............................................................... 28 clomipramine hcl................................................. 23 clonazepam ................................................... 43, 44 clonidine............................................................... 49 clonidine hcl......................................................... 49 clopidogrel bisulfate ........................................... 49 clorazepate dipotassium ................................... 44 clotrimazole ................................................... 25, 61 clozapine........................................................ 39, 40 COARTEM........................................................... 36 codeine sulfate.................................................... 10 colchicine ............................................................. 26 colesevelam hcl .................................................. 55 colestipol hcl........................................................ 55 colistimethate sodium ........................................ 13 COMBIGAN......................................................... 83 COMBIPATCH .................................................... 76 COMBIVENT RESPIMAT ................................. 89 COMETRIQ (100 MG DAILY DOSE).............. 32 COMETRIQ (140 MG DAILY DOSE).............. 32 COMETRIQ (60 MG DAILY DOSE) ................ 32 COMPLERA ........................................................ 41 COPAXONE........................................................ 58 COPIKTRA .......................................................... 32 CORLANOR ........................................................ 53 cortisone acetate ................................................ 69 CORTISPORIN....................................... 61, 83, 85 CORTISPORIN-TC ............................................ 85 COSENTYX......................................................... 79 COSENTYX (300 MG DOSE) .......................... 79 COSENTYX SENSOREADY (300 MG).......... 79 COSENTYX SENSOREADY PEN .................. 79 COTELLIC ........................................................... 32 CREON ................................................................ 67 CRESEMBA ........................................................ 25 CRINONE ............................................................ 76 CRIXIVAN............................................................ 42 cromolyn sodium .................................... 67, 84, 88 cyclobenzaprine hcl ........................................... 89 cyclophosphamide ............................................. 27 CYCLOPHOSPHAMIDE ................................... 27

CYCLOSET ......................................................... 44 cyclosporine ........................................................ 79 cyproheptadine hcl ............................................. 86 CYRAMZA ........................................................... 32 CYSTADANE ...................................................... 67 CYSTARAN......................................................... 67 cytarabine ............................................................ 28

D

dacarbazine......................................................... 29 dactinomycin ....................................................... 29 dalfampridine....................................................... 59 DALIRESP........................................................... 88 DALVANCE ......................................................... 13 danazol................................................................. 71 dantrolene sodium.............................................. 40 dapsone ......................................................... 27, 62 DAPTACEL ......................................................... 81 DAPTOMYCIN .................................................... 13 DARAPRIM ......................................................... 36 darifenacin hydrobromide ................................. 68 DARZALEX ......................................................... 34 DARZALEX FASPRO........................................ 34 daunorubicin hcl ................................................. 29 DAUNORUBICIN HCL....................................... 29 DAURISMO ......................................................... 32 DAYTRANA......................................................... 56 decitabine ............................................................ 29 deferasirox........................................................... 64 DELSTRIGO ....................................................... 41 demeclocycline hcl ............................................. 17 DEMSER ............................................................. 53 DENAVIR............................................................. 62 DEPO-ESTRADIOL ........................................... 72 DEPO-PROVERA .............................................. 76 DEPO-SUBQ PROVERA 104 .......................... 76 DESCOVY ........................................................... 41 desipramine hcl................................................... 23 desloratadine....................................................... 86 desmopressin acetate ....................................... 70 desmopressin acetate spray ............................ 70

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DESONATE......................................................... 60 desonide ........................................................ 60, 69 desoximetasone ................................................. 60 desvenlafaxine.................................................... 22 desvenlafaxine succinate.................................. 22 dexamethasone ............................................ 69, 84 DEXAMETHASONE .......................................... 69 DEXAMETHASONE INTENSOL ..................... 69 dexamethasone sodium phosphate .......... 69, 84 DEXILANT ........................................................... 67 dexmethylphenidate hcl .................................... 57 dexrazoxane hcl ................................................. 29 dextroamphetamine sulfate .............................. 56 dextrose ......................................................... 63, 65 DEXTROSE................................................... 62, 65 dextrose in lactated ringers .............................. 65 DEXTROSE-NACL............................................. 65 DIACOMIT ........................................................... 17 DIASTAT ACUDIAL ........................................... 19 DIASTAT PEDIATRIC ....................................... 19 diazepam ....................................................... 19, 44 diazoxide.............................................................. 46 diclofenac epolamine ........................................... 8 diclofenac potassium ........................................... 8 diclofenac sodium .................................... 8, 61, 84 dicloxacillin sodium ............................................ 15 dicyclomine hcl ................................................... 66 didanosine ........................................................... 41 DIFICID ................................................................ 16 diflorasone diacetate.......................................... 60 diflunisal ................................................................. 8 digoxin.................................................................. 53 dihydroergotamine mesylate ............................ 26 DILANTIN ............................................................ 20 DILANTIN INFATABS........................................ 20 DILATRATE-SR.................................................. 55 diltiazem hcl......................................................... 52 diltiazem hcl coated beads ............................... 52 diphenhydramine hcl.......................................... 86 DIPHTHERIA-TETANUS TOXOIDS ............... 81 DIPHTHERIA-TETANUS TOXOIDS DT......... 81 disopyramide phosphate ................................... 50

disulfiram ............................................................. 12 divalproex sodium .............................................. 17 DIVIGEL............................................................... 72 docetaxel ............................................................. 29 DOCETAXEL ...................................................... 29 dofetilide............................................................... 50 dorzolamide hcl............................................. 83, 85 DOVATO.............................................................. 40 doxazosin mesylate ........................................... 49 doxepin hcl .................................................... 23, 60 doxercalciferol..................................................... 82 doxorubicin hcl.................................................... 29 doxorubicin hcl liposomal .................................. 29 doxycycline hyclate ............................................ 17 DRIZALMA SPRINKLE ..................................... 58 dronabinol............................................................ 24 drospirenone-ethinyl estradiol .......................... 72 DROXIA ............................................................... 28 DUAVEE .............................................................. 77 DULERA .............................................................. 89 duloxetine hcl ...................................................... 58 DUREZOL ........................................................... 84 dutasteride........................................................... 68 dutasteride-tamsulosin hcl ................................ 68 DUTOPROL ........................................................ 53

E

econazole nitrate ................................................ 25 EDARBI................................................................ 50 EDURANT ........................................................... 41 efavirenz .............................................................. 41 ELAPRASE ......................................................... 67 ELESTRIN ........................................................... 72 eletriptan hydrobromide .................................... 26 ELIGARD ............................................................. 77 ELIQUIS............................................................... 47 ELIQUIS DVT/PE STARTER PACK ............... 47 ELITEK................................................................. 35 ELIXOPHYLLIN .................................................. 88 ELLA..................................................................... 76 ELMIRON ............................................................ 68

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EMCYT................................................................. 28 EMEND ................................................................ 24 EMGALITY .......................................................... 26 emollient............................................................... 69 EMPLICITI ........................................................... 34 EMSAM ................................................................ 22 emtricitabine........................................................ 42 EMTRIVA............................................................. 42 enalapril maleate ................................................ 50 ENBREL............................................................... 79 ENBREL MINI ..................................................... 79 ENBREL SURECLICK....................................... 79 ENGERIX-B......................................................... 81 ENHERTU ........................................................... 35 enoxaparin sodium....................................... 47, 48 entacapone.......................................................... 36 entecavir .............................................................. 40 ENTRESTO......................................................... 53 ENTYVIO ............................................................. 79 ENVARSUS XR.................................................. 79 EPCLUSA............................................................ 40 EPIDIOLEX ......................................................... 17 epinephrine.......................................................... 87 epirubicin hcl ....................................................... 29 eplerenone........................................................... 54 EPOGEN ............................................................. 48 ERBITUX ............................................................. 35 ergoloid mesylates ............................................. 20 ERIVEDGE.......................................................... 32 ERLEADA............................................................ 27 erlotinib hcl .......................................................... 32 ertapenem sodium ............................................. 16 ERWINAZE ......................................................... 29 ERYTHROCIN LACTOBIONATE .................... 16 erythromycin base.............................................. 16 erythromycin ethylsuccinate ............................. 16 erythromycin stearate ........................................ 16 ESBRIET ............................................................. 89 escitalopram oxalate.......................................... 22 esomeprazole magnesium................................ 67 esomeprazole sodium ....................................... 67 estradiol ................................................... 72, 74, 76

estradiol valerate ................................................ 72 ESTRING............................................................. 72 ethacrynate sodium............................................ 54 ethacrynic acid.................................................... 54 ethambutol hcl..................................................... 27 ethosuximide ....................................................... 19 etodolac ................................................................. 8 ETOPOPHOS ..................................................... 31 etoposide ............................................................. 31 EVAMIST ............................................................. 72 everolimus ............................................... 32, 79, 80 EVOMELA ........................................................... 27 EVOTAZ............................................................... 42 exemestane......................................................... 31 ezetimibe ............................................................. 55 ezetimibe-simvastatin ........................................ 55

F

FABRAZYME ...................................................... 67 famciclovir............................................................ 40 famotidine ............................................................ 66 FANAPT............................................................... 38 FANAPT TITRATION PACK............................. 38 FARXIGA ............................................................. 44 FARYDAK............................................................ 32 FASLODEX ......................................................... 28 febuxostat ............................................................ 26 felbamate ............................................................. 17 felodipine ............................................................. 51 FEMARA .............................................................. 30 FEMRING ............................................................ 72 fenofibrate............................................................ 54 fenofibrate micronized ....................................... 54 fenofibric acid...................................................... 54 fentanyl............................................................. 9, 10 fentanyl citrate..................................................... 10 FERRIPROX ....................................................... 64 FERRIPROX TWICE-A-DAY............................ 64 FETZIMA ............................................................. 22 FETZIMA TITRATION ....................................... 22 FIBRICOR ........................................................... 54

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finasteride ............................................................ 68 FINTEPLA ........................................................... 17 FIRMAGON ......................................................... 77 FIRMAGON (240 MG DOSE) .......................... 77 flavoxate hcl ........................................................ 68 flecainide acetate ............................................... 50 FLECTOR .............................................................. 8 FLOVENT DISKUS ............................................ 86 FLOVENT HFA ................................................... 86 fluconazole .......................................................... 25 fluconazole in dextrose...................................... 25 flucytosine............................................................ 25 fludarabine phosphate ....................................... 29 fludrocortisone acetate ...................................... 69 fluocinolone acetonide................................. 60, 85 fluocinonide ......................................................... 60 fluocinonide emulsified base ............................ 60 fluorouracil ..................................................... 28, 61 fluoxetine hcl ....................................................... 22 FLUOXETINE HCL ............................................ 22 fluphenazine decanoate .................................... 37 fluphenazine hcl.................................................. 37 flurandrenolide .................................................... 60 flurbiprofen....................................................... 8, 84 flurbiprofen sodium ............................................ 84 flutamide .............................................................. 28 fluticasone propionate ................................. 60, 86 fluticasone-salmeterol........................................ 89 fluvastatin sodium............................................... 55 fluvoxamine maleate.......................................... 22 FML....................................................................... 84 FOLOTYN............................................................ 28 fondaparinux sodium ......................................... 48 FORTAZ............................................................... 15 FORTEO .............................................................. 82 FOSAMAX ........................................................... 82 FOSAMAX PLUS D ........................................... 82 fosamprenavir calcium....................................... 42 fosaprepitant dimeglumine................................ 24 fosinopril sodium........................................... 50, 53 fosphenytoin sodium.......................................... 20 FOSRENOL......................................................... 64

FREAMINE HBC ................................................ 63 FREAMINE III ..................................................... 63 frovatriptan succinate ........................................ 26 FULPHILA ........................................................... 48 fulvestrant ............................................................ 28 furosemide........................................................... 54 FUZEON .............................................................. 42 FYCOMPA..................................................... 17, 18

G

GABA ................................................................... 19 gabapentin........................................................... 19 galantamine hydrobromide ......................... 20, 21 GAMMA-AMINOBUTYRIC ACID..................... 19 GAMUNEX-C ...................................................... 78 ganciclovir sodium.............................................. 40 GARDASIL 9 ....................................................... 81 GATTEX............................................................... 66 GAVRETO ........................................................... 31 GAZYVA .............................................................. 35 GELNIQUE.......................................................... 68 gemcitabine hcl................................................... 28 gemfibrozil ........................................................... 54 GENOTROPIN.................................................... 70 GENOTROPIN MINIQUICK ............................. 70 gentamicin in saline ........................................... 12 gentamicin sulfate ........................................ 12, 84 GENVOYA........................................................... 41 GEODON............................................................. 38 GILENYA ............................................................. 59 GILOTRIF ............................................................ 32 GLEOSTINE........................................................ 27 glimepiride ........................................................... 44 glipizide .......................................................... 44, 45 glipizide-metformin hcl....................................... 45 GLUCAGEN HYPOKIT ..................................... 46 GLUCAGON EMERGENCY............................. 46 GLUCOSE ........................................................... 44 glyburide .............................................................. 45 glyburide micronized.......................................... 45 glyburide-metformin ........................................... 45

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glycopyrrolate...................................................... 66 GOLYTELY ......................................................... 66 granisetron hcl .................................................... 24 GRANIX ............................................................... 48 griseofulvin microsize ........................................ 25 griseofulvin ultramicrosize ................................ 25 guanfacine hcl............................................... 49, 57 GUANIDINE HCL ............................................... 26

H

HALAVEN............................................................ 29 halcinonide .......................................................... 60 halobetasol propionate ...................................... 60 HALOG................................................................. 60 haloperidol ........................................................... 37 haloperidol decanoate ....................................... 37 haloperidol lactate .............................................. 37 HARVONI ............................................................ 40 HAVRIX................................................................ 81 HEMADY ............................................................. 69 HEPARIN (PORCINE) IN NACL ...................... 48 heparin sod (porcine) in d5w ............................ 48 heparin sodium (porcine) .................................. 48 HERCEPTIN ....................................................... 35 HERCEPTIN HYLECTA .................................... 35 HETLIOZ.............................................................. 89 HIBERIX............................................................... 81 HUMALOG .......................................................... 46 HUMALOG JUNIOR KWIKPEN....................... 46 HUMALOG KWIKPEN....................................... 46 HUMALOG MIX 50/50 ....................................... 46 HUMALOG MIX 50/50 KWIKPEN ................... 46 HUMALOG MIX 75/25 ....................................... 46 HUMALOG MIX 75/25 KWIKPEN ................... 46 HUMATROPE ..................................................... 70 HUMIRA............................................................... 80 HUMIRA PEDIATRIC CROHNS START........ 80 HUMIRA PEN ..................................................... 80 HUMIRA PEN-CD/UC/HS STARTER ............. 80 HUMIRA PEN-PS/UV/ADOL HS START ....... 80 HUMULIN 70/30 ................................................. 46

HUMULIN 70/30 KWIKPEN.............................. 46 HUMULIN N ........................................................ 46 HUMULIN N KWIKPEN..................................... 46 HUMULIN R ........................................................ 46 HUMULIN R U-500 (CONCENTRATED) ....... 46 HUMULIN R U-500 KWIKPEN......................... 46 hydralazine hcl.................................................... 55 hydrochlorothiazide ...................................... 53, 54 hydrocodone-acetaminophen........................... 10 hydrocodone-ibuprofen ..................................... 10 hydrocortisone ............................ 60, 61, 69, 82, 86 hydrocortisone butyrate............................... 60, 69 hydrocortisone valerate ............................... 61, 69 hydromorphone hcl .................................. 9, 10, 11 hydroxychloroquine sulfate ............................... 36 hydroxyprogesterone caproate ........................ 76 hydroxyurea......................................................... 28 hydroxyzine hcl ................................................... 86 hydroxyzine pamoate ........................................ 43 HYPERRAB......................................................... 78 HYPERRAB S/D................................................. 78

I

ibandronate sodium ........................................... 82 IBRANCE............................................................. 32 ibuprofen................................................................ 8 icatibant acetate ................................................. 78 ICLUSIG............................................................... 32 idarubicin hcl ....................................................... 29 IDHIFA ................................................................. 29 IFEX...................................................................... 27 ifosfamide ............................................................ 27 IFOSFAMIDE ...................................................... 27 ILARIS.................................................................. 79 ILEVRO................................................................ 85 imatinib mesylate................................................ 32 IMBRUVICA ........................................................ 32 IMFINZI ................................................................ 35 imipenem-cilastatin ............................................ 16 imipramine hcl..................................................... 23 imipramine pamoate .......................................... 23

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imiquimod ............................................................ 61 IMLYGIC .............................................................. 29 IMOGAM RABIES-HT ....................................... 78 IMOVAX RABIES ............................................... 81 INCRELEX........................................................... 70 indapamide.......................................................... 54 INFANRIX ............................................................ 81 INGREZZA .......................................................... 58 INLYTA................................................................. 32 INQOVI................................................................. 28 INREBIC .............................................................. 29 INSULIN ASP PROT & ASP FLEXPEN ......... 46 INSULIN ASPART........................................ 46, 47 INSULIN ASPART FLEXPEN .......................... 46 INSULIN ASPART PENFILL ............................ 47 INSULIN ASPART PROT & ASPART............. 47 INSULIN LISPRO ............................................... 47 INSULIN LISPRO (1 UNIT DIAL) .................... 47 INSULIN LISPRO JUNIOR KWIKPEN ........... 47 INSULIN LISPRO PROT & LISPRO ............... 47 INSULIN SYRINGE............................................ 83 INTELENCE ........................................................ 41 INTRALIPID......................................................... 63 INTRON A ........................................................... 79 INVEGA ............................................................... 38 INVEGA SUSTENNA......................................... 38 INVEGA TRINZA................................................ 38 INVIRASE............................................................ 42 IOPIDINE ............................................................. 85 IPOL ..................................................................... 81 ipratropium bromide ........................................... 87 ipratropium-albuterol.......................................... 89 irbesartan....................................................... 50, 53 irbesartan-hydrochlorothiazide......................... 53 IRESSA................................................................ 32 irinotecan hcl ....................................................... 29 irrigation solutions, physiological ..................... 65 ISENTRESS........................................................ 41 ISENTRESS HD ................................................. 41 ISOLYTE-P IN D5W........................................... 63 ISOLYTE-S.......................................................... 63 ISOLYTE-S PH 7.4 ............................................ 63

isoniazid ............................................................... 27 ISOPTO ATROPINE.......................................... 83 isosorbide dinitrate ............................................. 55 isosorbide mononitrate ................................ 55, 56 isotretinoin ........................................................... 59 isradipine ............................................................. 51 ISTODAX (OVERFILL)...................................... 29 itraconazole ......................................................... 25 ivermectin ...................................................... 35, 62 IXEMPRA KIT ..................................................... 30 IXIARO ................................................................. 81

J

JADENU............................................................... 64 JADENU SPRINKLE.......................................... 64 JAKAFI ................................................................. 32 JANUMET............................................................ 45 JANUMET XR ..................................................... 45 JANUVIA.............................................................. 45 JARDIANCE ........................................................ 45 JENTADUETO .................................................... 45 JENTADUETO XR ............................................. 45 JULUCA ............................................................... 41 JUXTAPID ........................................................... 55 JYNARQUE......................................................... 64

K

KADCYLA............................................................ 35 KALETRA ............................................................ 42 KALYDECO......................................................... 88 KANUMA ............................................................. 67 KCL IN DEXTROSE-NACL .............................. 63 KCL-LACTATED RINGERS-D5W ................... 65 KEDRAB .............................................................. 78 ketoconazole ....................................................... 25 ketoprofen.............................................................. 8 ketorolac tromethamine................................. 8, 85 KEVEYIS ............................................................. 67 KEYTRUDA......................................................... 35 KHAPZORY......................................................... 30

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KINRIX ................................................................. 81 KISQALI (600 MG DOSE) ................................ 33 KORLYM.............................................................. 69 KOSELUGO ........................................................ 30 KRISTALOSE ..................................................... 65 K-TAB................................................................... 63 KUVAN................................................................. 67 KYPROLIS........................................................... 33

L

labetalol hcl ......................................................... 51 LACRISERT ........................................................ 83 lactulose............................................................... 65 LACTULOSE....................................................... 65 lamivudine ............................................... 40, 41, 42 lamivudine-zidovudine ................................. 41, 42 lamotrigine ........................................................... 18 LANOXIN ............................................................. 53 lansoprazole........................................................ 67 lanthanum carbonate ......................................... 64 LANTUS............................................................... 47 LANTUS SOLOSTAR........................................ 47 LASTACAFT ....................................................... 84 latanoprost........................................................... 85 LATUDA............................................................... 44 LAZANDA ............................................................ 11 leflunomide .......................................................... 80 letrozole ............................................................... 31 leucovorin calcium........................................ 30, 35 LEUKERAN ......................................................... 27 LEUKINE ............................................................. 48 leuprolide acetate ............................................... 77 levalbuterol hcl.................................................... 87 levalbuterol tartrate ............................................ 87 LEVEMIR ............................................................. 47 LEVEMIR FLEXTOUCH.................................... 47 levetiracetam....................................................... 18 LEVETIRACETAM ............................................. 18 LEVETIRACETAM IN NACL ............................ 18 levobunolol hcl .................................................... 85 levocarnitine ........................................................ 65

levocetirizine dihydrochloride ........................... 86 levofloxacin.................................................... 16, 84 levofloxacin in d5w ............................................. 16 levoleucovorin calcium ...................................... 30 levothyroxine sodium ......................................... 77 LEVOTHYROXINE SODIUM ........................... 77 LEXIVA................................................................. 43 LIBTAYO.............................................................. 35 lidocaine............................................................... 11 lidocaine hcl......................................................... 11 lidocaine-prilocaine ............................................ 11 LINCOCIN ........................................................... 13 lincomycin hcl...................................................... 13 lindane.................................................................. 62 linezolid ................................................................ 13 LINZESS.............................................................. 65 liothyronine sodium ............................................ 77 lisinopril .......................................................... 50, 53 LITHIUM............................................................... 44 lithium carbonate ................................................ 44 LONSURF ........................................................... 30 LOOP ................................................................... 54 loperamide hcl..................................................... 66 lopinavir-ritonavir ................................................ 43 lorazepam............................................................ 44 LORBRENA......................................................... 33 losartan potassium ....................................... 50, 53 lovastatin.............................................................. 55 loxapine succinate.............................................. 37 LUMIGAN ............................................................ 85 LUMIZYME .......................................................... 67 LUMOXITI............................................................ 35 LUPANETA PACK ....................................... 77, 78 LUPRON DEPOT (1-MONTH) ......................... 78 LUPRON DEPOT (3-MONTH) ......................... 78 LUPRON DEPOT (4-MONTH) ......................... 78 LUPRON DEPOT (6-MONTH) ......................... 78 LUPRON DEPOT-PED (1-MONTH) ............... 78 LYNPARZA ......................................................... 33 LYSODREN......................................................... 77

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M

magnesium.......................................................... 63 magnesium sulfate ............................................. 63 malathion ............................................................. 62 maprotiline hcl..................................................... 21 MARPLAN ........................................................... 22 MARQIBO............................................................ 30 MATULANE......................................................... 27 meclizine hcl........................................................ 24 meclofenamate sodium ....................................... 8 medroxyprogesterone acetate ......................... 76 mefenamic acid..................................................... 8 mefloquine hcl..................................................... 36 megestrol acetate............................................... 76 MEKINIST............................................................ 33 MEKTOVI............................................................. 33 meloxicam ............................................................. 8 melphalan ............................................................ 27 melphalan hcl...................................................... 27 memantine hcl..................................................... 21 MENACTRA ........................................................ 81 MENEST .............................................................. 74 MENOSTAR ........................................................ 74 MENTAX .............................................................. 25 MENVEO ............................................................. 81 meperidine hcl..................................................... 11 meprobamate...................................................... 43 mercaptopurine................................................... 29 meropenem ......................................................... 16 mesalamine ......................................................... 82 mesna................................................................... 35 MESNEX.............................................................. 35 MESTINON ......................................................... 26 metaproterenol sulfate....................................... 87 metaxalone.......................................................... 89 metformin hcl....................................................... 45 methadone hcl ...................................................... 9 METHADONE HCL .............................................. 9 methazolamide ................................................... 85 methenamine hippurate .................................... 13 methimazole........................................................ 78

METHOTREXATE.............................................. 80 METHOTREXATE (ANTI-RHEUMATIC)........ 80 methotrexate sodium ......................................... 80 methoxsalen rapid.............................................. 61 methscopolamine bromide................................ 66 methylphenidate hcl ..................................... 57, 58 methylprednisolone............................................ 69 methylprednisolone acetate.............................. 69 methyltestosterone............................................. 71 metoclopramide hcl............................................ 24 metolazone.......................................................... 54 metoprolol succinate.......................................... 51 metoprolol tartrate .............................................. 51 metronidazole ..................................................... 13 metronidazole in nacl......................................... 13 metyrosine ........................................................... 53 mexiletine hcl ...................................................... 50 MIACALCIN......................................................... 82 micafungin sodium ............................................. 25 midodrine hcl....................................................... 49 miglitol .................................................................. 45 miglustat............................................................... 67 MILLIPRED ......................................................... 69 minocycline hcl ................................................... 17 minoxidil ............................................................... 55 mirtazapine.......................................................... 21 misoprostol ...................................................... 8, 70 mitomycin............................................................. 30 mitoxantrone hcl ................................................. 30 M-M-R II ............................................................... 81 modafinil............................................................... 90 moexipril hcl ........................................................ 50 molindone hcl...................................................... 37 mometasone furoate.............................. 61, 69, 86 MONJUVI............................................................. 35 montelukast sodium ........................................... 87 MONUROL .......................................................... 13 morphine sulfate ............................................. 9, 11 morphine sulfate beads ....................................... 9 MOVANTIK.......................................................... 65 MOVIPREP ......................................................... 65 moxifloxacin hcl ............................................ 16, 84

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MOXIFLOXACIN HCL ....................................... 16 MOZOBIL............................................................. 48 MULTAQ .............................................................. 50 mupirocin ............................................................. 62 MYALEPT............................................................ 66 MYCAMINE ......................................................... 25 mycophenolate mofetil ...................................... 80 mycophenolate mofetil hcl ................................ 80 mycophenolate sodium ..................................... 80 MYLOTARG ........................................................ 35 MYRBETRIQ....................................................... 68

N

nabumetone .......................................................... 8 nadolol............................................................ 51, 53 nafcillin sodium ................................................... 15 NAFCILLIN SODIUM ......................................... 15 naftifine hcl .......................................................... 25 NAFTIN ................................................................ 25 NAGLAZYME...................................................... 67 nalbuphine hcl..................................................... 11 NALFON ................................................................ 8 naloxone hcl ........................................................ 12 naltrexone hcl...................................................... 12 naproxen................................................................ 8 naproxen sodium.................................................. 8 naratriptan hcl ..................................................... 26 NARCAN.............................................................. 12 NATACYN ........................................................... 84 nateglinide ........................................................... 45 NATPARA............................................................ 82 NAYZILAM........................................................... 11 nefazodone hcl ................................................... 22 neomycin sulfate................................................. 12 neomycin-polymyxin-gramicidin....................... 83 NEPHRAMINE .................................................... 63 NERLYNX............................................................ 33 NEULASTA ......................................................... 49 NEULASTA ONPRO.......................................... 49 NEUPOGEN........................................................ 49 NEUPRO ............................................................. 36

nevirapine ............................................................ 41 NEXAVAR ........................................................... 33 niacin .................................................................... 55 niacin (antihyperlipidemic) ................................ 55 nicardipine hcl ..................................................... 51 NICOTROL .......................................................... 12 NICOTROL NS ................................................... 12 nifedipine ............................................................. 51 nilutamide ............................................................ 28 nimodipine ........................................................... 51 NINLARO............................................................. 30 NIPENT ................................................................ 29 nisoldipine............................................................ 51 nitisinone.............................................................. 67 NITRO-BID .......................................................... 56 NITRO-DUR ........................................................ 56 nitrofurantoin ....................................................... 13 nitrofurantoin macrocrystal ............................... 13 nitrofurantoin monohyd macro ......................... 13 nitroglycerin ......................................................... 56 NIVESTYM .......................................................... 49 nizatidine.............................................................. 66 NORDITROPIN FLEXPRO............................... 70 norethindrone acetate........................................ 76 NORMOSOL-M IN D5W ................................... 63 NORMOSOL-R ................................................... 63 NORMOSOL-R PH 7.4...................................... 63 NORTHERA ........................................................ 49 nortriptyline hcl.................................................... 23 NORVIR ............................................................... 43 NOVAREL ........................................................... 70 NOVOLIN 70/30 ................................................. 47 NOVOLIN 70/30 FLEXPEN .............................. 47 NOVOLIN 70/30 FLEXPEN RELION .............. 47 NOVOLIN 70/30 RELION ................................. 47 NOVOLIN N......................................................... 47 NOVOLIN N FLEXPEN ..................................... 47 NOVOLIN N FLEXPEN RELION ..................... 47 NOVOLIN N RELION......................................... 47 NOVOLIN R......................................................... 47 NOVOLIN R FLEXPEN ..................................... 47 NOVOLIN R FLEXPEN RELION ..................... 47

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NOVOLIN R RELION......................................... 47 NOVOLOG .......................................................... 47 NOVOLOG FLEXPEN ....................................... 47 NOVOLOG MIX 70/30 ....................................... 47 NOVOLOG MIX 70/30 FLEXPEN.................... 47 NOVOLOG PENFILL ......................................... 47 NOXAFIL ............................................................. 25 NUBEQA.............................................................. 28 NUCALA .............................................................. 89 NUCYNTA ........................................................... 11 NUEDEXTA......................................................... 58 NULOJIX.............................................................. 80 NUPLAZID........................................................... 38 NUTRILIPID ........................................................ 63 NUTROPIN AQ NUSPIN 10 ............................. 70 NUTROPIN AQ NUSPIN 20 ............................. 70 NUTROPIN AQ NUSPIN 5 ............................... 70 nystatin........................................................... 25, 61 nystatin-triamcinolone........................................ 61

O

OCTAGAM .......................................................... 78 octreotide acetate............................................... 78 ODEFSEY ........................................................... 41 ODOMZO............................................................. 33 OFEV.................................................................... 89 ofloxacin................................................... 16, 84, 86 olanzapine ..................................................... 21, 38 olanzapine-fluoxetine hcl .................................. 21 olmesartan medoxomil ................................ 50, 53 olopatadine hcl.............................................. 84, 86 omega-3-acid ethyl esters ................................ 55 omeprazole.......................................................... 67 OMNITROPE ...................................................... 70 ondansetron ........................................................ 24 ondansetron hcl .................................................. 24 ONUREG ............................................................. 30 OPDIVO ............................................................... 35 OPSUMIT ............................................................ 88 ORBACTIV .......................................................... 13 ORFADIN............................................................. 67

ORKAMBI ............................................................ 88 orphenadrine citrate ........................................... 89 oseltamivir phosphate........................................ 43 oxaliplatin............................................................. 30 oxandrolone......................................................... 71 oxaprozin ............................................................... 8 oxazepam ............................................................ 44 oxcarbazepine..................................................... 20 oxiconazole nitrate ............................................. 25 OXISTAT ............................................................. 25 oxybutynin chloride ............................................ 68 oxycodone hcl ................................................. 9, 11 oxycodone-aspirin .............................................. 11 oxycodone-ibuprofen ......................................... 11 oxymorphone hcl ...................................... 9, 10, 11 OXYTROL ........................................................... 68 OZEMPIC (0.25 OR 0.5 MG/DOSE) ............... 45 OZEMPIC (1 MG/DOSE) .................................. 45

P

paclitaxel.............................................................. 30 PADCEV .............................................................. 35 paliperidone......................................................... 38 palonosetron hcl ................................................. 24 pamidronate disodium ....................................... 82 PAMIDRONATE DISODIUM ............................ 82 PANCREAZE ...................................................... 67 PANDEL............................................................... 61 PANRETIN .......................................................... 35 pantoprazole sodium ......................................... 67 paricalcitol............................................................ 82 paromomycin sulfate.......................................... 12 paroxetine hcl................................................ 22, 23 PASER ................................................................. 27 PAXIL ................................................................... 23 PAZEO ................................................................. 84 PEDIARIX............................................................ 81 PEDVAX HIB....................................................... 81 PEGANONE........................................................ 20 PEGASYS ........................................................... 79 PEGASYS PROCLICK...................................... 79

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PEGINTRON....................................................... 40 PEMAZYRE......................................................... 33 penicillamine ....................................................... 68 PENICILLIN G POT IN DEXTROSE ............... 15 penicillin g potassium ........................................ 15 penicillin g sodium.............................................. 15 penicillin v potassium......................................... 15 PENTACEL ......................................................... 81 PENTAM .............................................................. 36 pentamidine isethionate .................................... 36 PENTASA............................................................ 82 pentoxifylline ....................................................... 53 PERFOROMIST ................................................. 87 perindopril erbumine .......................................... 50 PERJETA............................................................. 35 permethrin ........................................................... 62 perphenazine ................................................ 21, 24 perphenazine-amitriptyline................................ 21 PERSERIS .......................................................... 38 PERTZYE ............................................................ 67 phenelzine sulfate .............................................. 22 phenobarbital ...................................................... 19 phenoxybenzamine hcl...................................... 49 PHENYTEK ......................................................... 20 phenytoin ............................................................. 20 phenytoin sodium ............................................... 20 phenytoin sodium extended.............................. 20 PHESGO ............................................................. 30 PHOSLYRA......................................................... 64 PHOSPHOLINE IODIDE................................... 85 PIFELTRO ........................................................... 41 pilocarpine hcl ............................................... 59, 85 pimecrolimus ....................................................... 61 pimozide............................................................... 37 pindolol................................................................. 51 pioglitazone hcl ................................................... 45 pioglitazone hcl-glimepiride .............................. 45 pioglitazone hcl-metformin hcl.......................... 45 PIQRAY (250 MG DAILY DOSE) .................... 33 piroxicam ............................................................... 8 PLASMA-LYTE 148 ........................................... 63 PLASMA-LYTE A ............................................... 63

PLEGRIDY .......................................................... 59 PLEGRIDY STARTER PACK........................... 59 podofilox............................................................... 61 POLIVY ................................................................ 35 polyethylene glycol 3350................................... 65 polymyxin b-trimethoprim .................................. 84 POMALYST......................................................... 28 posaconazole...................................................... 25 potassium ...................................................... 63, 65 POTASSIUM ........................................... 54, 63, 64 potassium chloride ....................................... 63, 65 POTASSIUM CHLORIDE ................................. 63 potassium chloride in dextrose ........................ 65 potassium chloride in nacl ................................ 63 POTELIGEO ....................................................... 35 PRADAXA ........................................................... 48 PRALUENT ......................................................... 55 pramipexole dihydrochloride ............................ 36 prasugrel hcl........................................................ 49 pravastatin sodium ............................................. 55 praziquantel......................................................... 35 prazosin hcl ......................................................... 49 PRED-G ............................................................... 84 prednicarbate ...................................................... 69 prednisolone............................................ 69, 84, 85 PREDNISOLONE............................................... 85 prednisolone sodium phosphate...................... 69 PREDNISOLONE SODIUM PHOSPHATE.... 85 prednisone........................................................... 70 PREDNISONE .................................................... 70 PREDNISONE INTENSOL ............................... 70 pregabalin............................................................ 58 PREGNYL ........................................................... 70 PREMARIN ......................................................... 74 PREMASOL ........................................................ 64 PREMPHASE ..................................................... 74 PREMPRO .......................................................... 74 PREZCOBIX ....................................................... 43 PREZISTA ........................................................... 43 PRIFTIN ............................................................... 27 primaquine phosphate ....................................... 36 primidone ............................................................. 19

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PROAIR HFA ...................................................... 87 PROAIR RESPICLICK ...................................... 87 probenecid........................................................... 26 PROCALAMINE ................................................. 64 prochlorperazine................................................. 24 prochlorperazine edisylate................................ 24 prochlorperazine maleate ................................. 24 PROCRIT............................................................. 49 PROCYSBI.......................................................... 67 progesterone ....................................................... 76 progesterone micronized................................... 76 PROGLYCEM ..................................................... 46 PROGRAF........................................................... 80 PROLASTIN-C.................................................... 67 PROLEUKIN ....................................................... 30 PROLIA................................................................ 82 PROMACTA ........................................................ 49 promethazine hcl .......................................... 24, 86 propafenone hcl.................................................. 50 propranolol hcl .................................................... 51 propylthiouracil.................................................... 78 PROQUAD .......................................................... 81 PROSOL.............................................................. 64 PROTEASE......................................................... 42 PROTEIN............................................................. 67 protriptyline hcl.................................................... 23 PROVENTIL HFA............................................... 87 PULMOZYME ..................................................... 88 PURIXAN............................................................. 29 PYLERA............................................................... 66 pyrazinamide....................................................... 27 pyridostigmine bromide ..................................... 26 pyrimethamine .................................................... 36

Q

QINLOCK............................................................. 30 QUADRACEL...................................................... 81 quetiapine fumarate ..................................... 38, 39 quinapril hcl ......................................................... 50 quinapril-hydrochlorothiazide ........................... 54 quinidine gluconate ............................................ 50

quinidine sulfate.................................................. 50 quinine sulfate..................................................... 36 QVAR REDIHALER ..................................... 86, 87

R

RABAVERT ......................................................... 81 rabeprazole sodium ........................................... 67 raloxifene hcl ....................................................... 77 ramelteon............................................................. 89 ramipril ................................................................. 50 ranitidine hcl ........................................................ 66 ranolazine ............................................................ 54 rasagiline mesylate ............................................ 37 RAVICTI............................................................... 67 RECOMBIVAX HB ............................................. 81 RECTIV ................................................................ 56 RELENZA DISKHALER .................................... 43 RELISTOR........................................................... 65 REMICADE ......................................................... 80 repaglinide ..................................................... 45, 46 REPATHA............................................................ 55 REPATHA PUSHTRONEX SYSTEM ............. 55 REPATHA SURECLICK.................................... 55 REPLACE...................62, 67, 68, 69, 70, 71, 75, 77 RESTASIS........................................................... 84 RESTASIS MULTIDOSE .................................. 84 RETEVMO........................................................... 30 RETROVIR .......................................................... 42 REVLIMID............................................................ 28 REXULTI.............................................................. 39 REYATAZ ............................................................ 43 RHOPRESSA ..................................................... 85 ribavirin........................................................... 40, 89 RIDAURA............................................................. 79 rifabutin ................................................................ 27 rifampin ................................................................ 27 riluzole .................................................................. 58 RINVOQ............................................................... 80 risedronate sodium ............................................ 83 RISPERDAL........................................................ 39 RISPERDAL CONSTA ...................................... 39

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risperidone........................................................... 39 ritonavir ................................................................ 43 RITUXAN ............................................................. 35 RITUXAN HYCELA............................................ 35 rivastigmine ......................................................... 21 rivastigmine tartrate ........................................... 21 rizatriptan benzoate ........................................... 26 ROCKLATAN ...................................................... 84 ROMIDEPSIN ..................................................... 30 rosuvastatin calcium .......................................... 55 ROTARIX............................................................. 81 ROTATEQ ........................................................... 81 ROZLYTREK....................................................... 30 RUBRACA ........................................................... 33 RUKOBIA............................................................. 42 RYBELSUS ......................................................... 46 RYDAPT .............................................................. 33

S

SAIZEN ................................................................ 70 SAIZENPREP ..................................................... 70 SAMSCA.............................................................. 64 SANCUSO........................................................... 24 SANTYL ............................................................... 61 SAPHRIS ............................................................. 39 sapropterin dihydrochloride .............................. 67 SARCLISA........................................................... 35 scopolamine ........................................................ 24 SECUADO........................................................... 39 selegiline hcl........................................................ 37 selenium............................................................... 61 selenium sulfide.................................................. 61 SELZENTRY ....................................................... 42 SEREVENT DISKUS ......................................... 87 SEROSTIM.......................................................... 70 sertraline hcl........................................................ 23 sevelamer carbonate ......................................... 64 SHINGRIX ........................................................... 81 SIGNIFOR ........................................................... 78 SIGNIFOR LAR .................................................. 78 sildenafil citrate ................................................... 88

silodosin ............................................................... 68 silver sulfadiazine ............................................... 61 SIMBRINZA......................................................... 85 SIMULECT .......................................................... 79 simvastatin........................................................... 55 sirolimus............................................................... 80 SIRTURO............................................................. 27 SIVEXTRO .......................................................... 13 SKLICE ................................................................ 62 SKYRIZI (150 MG DOSE) ................................ 79 SLEEP.................................................................. 89 sodium chloride............................................. 25, 64 sodium phenylbutyrate ...................................... 67 sodium polystyrene sulfonate........................... 64 solifenacin succinate.......................................... 68 SOLTAMOX ........................................................ 28 SOLU-CORTEF .................................................. 70 SOMATULINE DEPOT...................................... 78 SOMAVERT ........................................................ 78 sotalol hcl............................................................. 50 SPIRIVA HANDIHALER .................................... 87 SPIRIVA RESPIMAT ......................................... 87 spironolactone..................................................... 54 SPRAVATO (56 MG DOSE) ............................ 21 SPRAVATO (84 MG DOSE) ............................ 21 SPRITAM............................................................. 18 SPRYCEL............................................................ 33 STAMARIL........................................................... 81 stavudine ............................................................. 42 STELARA ............................................................ 79 STERILE.............................................................. 83 STIMATE ............................................................. 70 STIOLTO RESPIMAT........................................ 89 STIVARGA .......................................................... 33 STRENSIQ .......................................................... 67 streptomycin sulfate ........................................... 12 STRIBILD............................................................. 41 SUCRAID............................................................. 68 sucralfate ............................................................. 66 SUCRALFATE .................................................... 66 sulfacetamide sodium.................................. 16, 84 sulfacetamide sodium (acne) ........................... 16

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SULFADIAZINE.................................................. 16 sulfamethoxazole-trimethoprim ........................ 17 SULFAMYLON ................................................... 62 sulfasalazine ....................................................... 82 sulindac.................................................................. 9 sumatriptan.......................................................... 26 sumatriptan succinate........................................ 26 SUPRAX .............................................................. 15 SUPREP BOWEL PREP KIT ........................... 65 SUTENT............................................................... 33 SYLATRON ......................................................... 79 SYLVANT ............................................................ 35 SYMBICORT....................................................... 89 SYMFI .................................................................. 41 SYMFI LO............................................................ 41 SYMJEPI ............................................................. 87 SYMLINPEN 120................................................ 46 SYMLINPEN 60.................................................. 46 SYMPAZAN......................................................... 19 SYMTUZA ........................................................... 43 SYNAGIS............................................................. 79 SYNAREL............................................................ 78 SYNERCID .......................................................... 13 SYNJARDY ......................................................... 46 SYNJARDY XR................................................... 46 SYNRIBO............................................................. 30 SYNTHROID ....................................................... 77

T

TABLOID ............................................................. 29 TABRECTA ......................................................... 30 TACLONEX ......................................................... 61 tacrolimus ...................................................... 61, 80 tadalafil................................................................. 88 TAFINLAR ........................................................... 33 TAGRISSO.......................................................... 33 TALZENNA.......................................................... 34 tamoxifen citrate ................................................. 28 tamsulosin hcl ..................................................... 68 TARGRETIN ....................................................... 35 TASIGNA ............................................................. 34

TAXOTERE ......................................................... 30 tazarotene............................................................ 59 TAZORAC ........................................................... 59 TAZVERIK ........................................................... 30 TDVAX ................................................................. 81 TECENTRIQ ....................................................... 35 TECFIDERA ........................................................ 59 TEFLARO ............................................................ 15 TEGRETOL ......................................................... 20 TEKTURNA ......................................................... 54 TEKTURNA HCT................................................ 54 telmisartan ..................................................... 50, 54 telmisartan-amlodipine ...................................... 54 temazepam.......................................................... 90 TEMIXYS ............................................................. 42 temsirolimus ........................................................ 80 TENIVAC ............................................................. 81 tenofovir disoproxil fumarate ............................ 42 terazosin hcl ........................................................ 49 terbinafine hcl...................................................... 25 terbutaline sulfate ............................................... 87 TERIPARATIDE (RECOMBINANT) ................ 83 testosterone......................................................... 71 testosterone cypionate ...................................... 71 testosterone enanthate...................................... 71 tetrabenazine ...................................................... 58 tetracycline hcl .................................................... 17 THALOMID .......................................................... 28 theophylline ......................................................... 88 thioridazine hcl.................................................... 37 thiotepa ................................................................ 27 thiothixene ........................................................... 37 thyroid................................................................... 77 THYROID....................................................... 77, 78 tiagabine hcl ........................................................ 19 TIBSOVO............................................................. 34 TIGECYCLINE.................................................... 13 timolol maleate.............................................. 51, 85 tinidazole.............................................................. 13 TIROSINT ............................................................ 77 TIVICAY ............................................................... 41 TIVICAY PD ........................................................ 41

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tizanidine hcl ....................................................... 40 TOBI ..................................................................... 88 TOBI PODHALER .............................................. 88 TOBRADEX......................................................... 84 TOBRADEX ST .................................................. 84 tobramycin ............................................... 12, 84, 88 tobramycin sulfate .............................................. 12 tobramycin-dexamethasone ............................. 84 tolbutamide.......................................................... 46 tolcapone ............................................................. 36 tolmetin sodium..................................................... 9 tolterodine tartrate .............................................. 68 tolvaptan .............................................................. 64 topiramate............................................................ 18 topotecan hcl....................................................... 31 toremifene citrate................................................ 28 TORISEL ............................................................. 80 torsemide ............................................................. 54 TOUJEO MAX SOLOSTAR.............................. 47 TOUJEO SOLOSTAR ....................................... 47 TOVIAZ ................................................................ 68 TRACLEER ......................................................... 88 TRADJENTA ....................................................... 46 tramadol hcl................................................... 10, 11 tramadol-acetaminophen .................................. 11 trandolapril..................................................... 50, 54 trandolapril-verapamil hcl .................................. 54 tranexamic acid................................................... 49 TRANSDERM SCOP (1.5 MG)........................ 24 TRANSDERM-SCOP (1.5 MG)........................ 24 tranylcypromine sulfate ..................................... 22 TRAVASOL ......................................................... 64 travoprost............................................................. 85 trazodone hcl....................................................... 23 TREANDA ........................................................... 27 TRECATOR......................................................... 27 TRELEGY ELLIPTA........................................... 89 TRELSTAR MIXJECT ....................................... 78 tretinoin .......................................................... 35, 59 tretinoin microsphere ......................................... 59 TREXALL............................................................. 80 triamcinolone acetonide .............................. 59, 61

triamterene .......................................................... 54 triazolam .............................................................. 90 trientine hcl .......................................................... 64 trifluoperazine hcl ............................................... 37 trifluridine ............................................................. 40 trihexyphenidyl hcl.............................................. 36 trimethobenzamide hcl ...................................... 24 trimethoprim ........................................................ 13 trimipramine maleate ......................................... 23 TRINTELLIX........................................................ 23 TRISENOX .......................................................... 31 TRIUMEQ ............................................................ 42 TRODELVY ......................................................... 83 TROGARZO ........................................................ 42 TROKENDI XR ................................................... 18 TROPHAMINE .................................................... 64 trospium chloride ................................................ 68 TRULICITY .......................................................... 46 TRUMENBA ........................................................ 81 TRUVADA ........................................................... 42 TUDORZA PRESSAIR...................................... 87 TUKYSA............................................................... 34 TURALIO ............................................................. 34 TWINRIX.............................................................. 81 TYBOST............................................................... 42 TYKERB............................................................... 34 TYMLOS .............................................................. 83 TYPHIM VI........................................................... 81 TYSABRI ............................................................. 59 TYVASO .............................................................. 88 TYVASO REFILL................................................ 88 TYVASO STARTER........................................... 88

U

UCERIS ............................................................... 82 UPTRAVI ....................................................... 88, 89 ursodiol................................................................. 66

V

valacyclovir hcl.................................................... 40

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VALCHLOR ......................................................... 27 valganciclovir hcl ................................................ 40 valproate sodium ................................................ 18 valproic acid ........................................................ 18 valsartan .................................................. 50, 53, 54 valsartan-hydrochlorothiazide .......................... 54 VALTOCO 10 MG DOSE.................................. 19 VALTOCO 15 MG DOSE.................................. 19 VALTOCO 20 MG DOSE.................................. 19 VALTOCO 5 MG DOSE .................................... 19 vancomycin hcl ............................................. 13, 14 VANCOMYCIN HCL .......................................... 14 VANCOMYCIN HCL IN NACL ......................... 14 VAQTA ................................................................. 81 VARIVAX ............................................................. 81 VARIZIG............................................................... 78 VASCEPA............................................................ 55 VECAMYL ........................................................... 54 VECTIBIX ............................................................ 35 VELCADE............................................................ 31 VELPHORO ........................................................ 64 VELTASSA.......................................................... 65 VEMLIDY ............................................................. 40 VENCLEXTA....................................................... 34 VENCLEXTA STARTING PACK ..................... 34 venlafaxine hcl .................................................... 23 VENTAVIS........................................................... 89 VENTOLIN HFA ................................................. 87 verapamil hcl ....................................................... 52 VEREGEN ........................................................... 61 VERSACLOZ ...................................................... 40 VERZENIO .......................................................... 34 VIBERZI ............................................................... 66 VICTOZA ............................................................. 46 VIDEX................................................................... 42 VIDEX EC............................................................ 42 vigabatrin ............................................................. 19 VIIBRYD............................................................... 23 VIIBRYD STARTER PACK............................... 23 VIMIZIM ............................................................... 68 VIMPAT................................................................ 20 vinblastine sulfate............................................... 31

vincristine sulfate................................................ 31 vinorelbine tartrate ............................................. 31 VIOKACE............................................................. 68 VIRACEPT........................................................... 43 VIRAZOLE........................................................... 89 VIREAD................................................................ 42 VITRAKVI ............................................................ 34 VIZIMPRO ........................................................... 34 voriconazole .................................................. 25, 26 VOSEVI................................................................ 40 VOTRIENT .......................................................... 34 VPRIV................................................................... 68 VRAYLAR............................................................ 39 VYVANSE............................................................ 56 VYXEOS .............................................................. 31

W

warfarin sodium .................................................. 48

X

XALKORI ............................................................. 34 XARELTO............................................................ 48 XARELTO STARTER PACK ............................ 48 XATMEP .............................................................. 80 XCOPRI ......................................................... 18, 19 XCOPRI (250 MG DAILY DOSE) .................... 18 XCOPRI (350 MG DAILY DOSE) .................... 19 XEOMIN............................................................... 89 XGEVA................................................................. 83 XIFAXAN ............................................................. 14 XIGDUO XR ........................................................ 46 XIIDRA ................................................................. 84 XOFLUZA ............................................................ 43 XOLAIR................................................................ 79 XOSPATA............................................................ 34 XPOVIO (100 MG ONCE WEEKLY)............... 31 XPOVIO (40 MG ONCE WEEKLY) ................. 31 XPOVIO (40 MG TWICE WEEKLY)................ 31 XPOVIO (60 MG ONCE WEEKLY) ................. 31 XPOVIO (60 MG TWICE WEEKLY)................ 31

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XPOVIO (80 MG ONCE WEEKLY) ................. 31 XPOVIO (80 MG TWICE WEEKLY)................ 31 XTANDI ................................................................ 28 XYREM ................................................................ 90

Y

YERVOY.............................................................. 35 YF-VAX ................................................................ 81 YONDELIS .......................................................... 27 YONSA................................................................. 28

Z

zafirlukast............................................................. 87 zaleplon................................................................ 90 ZALTRAP............................................................. 31 ZANOSAR ........................................................... 31 ZARXIO................................................................ 49 ZEJULA................................................................ 34 ZELAPAR ............................................................ 37 ZELBORAF ......................................................... 34 ZEMAIRA............................................................. 68 ZENPEP............................................................... 68 ZEPZELCA.......................................................... 27 zidovudine ........................................................... 42

ZIOPTAN ............................................................. 85 ziprasidone hcl.................................................... 39 ziprasidone mesylate ......................................... 39 ZIRGAN ............................................................... 40 zoledronic acid.................................................... 83 ZOLEDRONIC ACID.......................................... 83 ZOLINZA.............................................................. 31 zolmitriptan .......................................................... 26 zolpidem tartrate................................................. 90 ZOMACTON........................................................ 70 ZOMACTON (FOR ZOMA-JET 10)................. 70 ZOMIG ................................................................. 26 zonisamide .......................................................... 20 ZORBTIVE........................................................... 70 ZORTRESS......................................................... 80 ZOSTAVAX ......................................................... 81 ZULRESSO ......................................................... 21 ZYCLARA ............................................................ 61 ZYCLARA PUMP ............................................... 61 ZYDELIG ............................................................. 34 ZYKADIA ............................................................. 34 ZYLET .................................................................. 84 ZYPREXA............................................................ 39 ZYPREXA RELPREVV ..................................... 39 ZYTIGA ................................................................ 28

DISCRIMINATION IS AGAINST THE LAW Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc., (collectively referred to as Blue Cross of Idaho) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: • Provides free aids and services to people with

disabilities to communicate effectively with us, such as: Qualified sign language interpreterso Written information in other formats (largeo print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact Blue Cross of Idaho Customer Service Department. Call 1-800-627-1188 (TTY: 711), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho 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 Blue Cross of Idaho’s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone: 1-800-274-4018 Fax: 208-331-7493 Email: grievances&[email protected] TTY: 711 You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal. hhs.gov/ocr/portal/lobby.jsf

, or by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TTY). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian, Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are available to you. Call 1-800-627-1188 (TTY: 711).

Form No. 3-1187 (09-20)

Multi-language Interpreter Services

http://www.hhs.gov/ocr/office/file/index.html

mailto:grievances&[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

3000 East Pine Avenue | Meridian, Idaho | 83642-5995 Mailing Address: PO Box 8406 | Boise, Idaho | 83707-2406

888-494-2583 | TTY 711

This formulary was updated on 02/01/2021. For more recent information or other questions, please contact Blue Cross of Idaho Care Plus, Inc. at 855-479-3661 or, for TTY users, 711, 24 hours a day, seven days a week, or visit bcidaho.com/DrugList.

H1350_OP21343_C 02/01/2021 © 2020 by Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho Care Plus”), an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc. Form No. 16-596 (09-20)

http://bcidaho.com/DrugList

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