University of Utah Health Employee Plan Preferred Drug List

University of Utah Employee PlanPreferred Drug List

How to use the Preferred Drug List The Preferred Drug List (PDL) (also known as a Formulary) is a list of prescription drugs covered under your plan. This contains the covered drugs, doses, and dosage forms. This list is not a complete list and additional prescription drugs may be covered. Please note that the PDL is subject to change as new prescription drugs become available, drug categories are reviewed, and as we strive to provide the most effective and valuable therapies available for our members. Your pharmacy benefit has four prescription drug tiers. The tier is identified in the second column on the Preferred Drug List below. These tiers determine your out of pocket responsibility and correspond to the copays and/or coinsurance shown on your benefit summary. In most cases, the prescription drugs on the lower tiers will cost less.

Tier 1: Preferred Generics

Tier 2: Non-Preferred Generics/Preferred Brands Tier 3: Non-Preferred Brands Tier 4: Specialty (Most specialty drugs require PA and must be filled at the Plan’s designated Specialty Pharmacy) Please note that prescription drugs covered under the Preventive Drug List* have no cost to members and are defined below under PRESCRIPTION DRUGS WITH ENHANCED BENEFITS. If you have any questions about the PDL or your pharmacy benefits, please contact Pharmacy Customer Service at the number listed on the back of your ID Card. Pharmacy Customer Service is available 24 hours/7 days a week/365 days a year. You can also view additional information by logging into the pharmacy member portal. If you need assistance in registering for the portal, please contact Pharmacy Customer Service. The pharmacy member portal provides information such as how to find a pharmacy; look up prescription drug information like benefit tier, limits, and drug interactions; shop for best price of a prescription drug at different pharmacies; check the status of a prescription; print your prescription drug fill history; and how to set up mail order. HOW PRESCRIPTION DRUGS ARE CHOSEN FOR THE PDL Prescription drugs approved by the United States (U.S.) Food and Drug Administration (FDA) are reviewed and considered for the PDL by the Pharmacy & Therapeutics (P&T) Committee utilizing the following criteria:

a) The prescription drug is effective and medically necessary for the treatment, maintenance, and/or prevention of a specific medical condition

b) The PDL does not have other alternatives or similar prescription drugs that could be used in its place c) The prescription drug shows a positive therapeutic outcome d) The prescription drug shows safety for medical use

As the FDA approves new prescription drugs, they are reviewed within 180 days against similar drugs available on the PDL before being considered for inclusion. New prescription drugs with an FDA designation of 1P (FDA priority review – potential therapeutic gain) will automatically be reviewed for consideration for the Preferred Drug List. New prescription drugs with an FDA designation of 1S (FDA standard review – no therapeutic gain) may not be reviewed for consideration until a provider/member requests or the next therapeutic class review is done. In addition, therapeutic classes are reviewed on a regular basis to ensure the Preferred Drug List includes the most effective and valuable prescription drugs. Members will receive notices related to drug formulary changes at the point of sale when filling a prescription that is impacted by modifications to the PDL. Network pharmacies are required to inform the member of these messages regarding updates or changes to the program which may impact a member. In addition, members whose prescription drugs have been removed from the PDL or have a negative change such as increased tier or new limits will receive written communication of change.

PRESCRIPTION DRUGS WITH ENHANCED BENEFITS *PREVENTIVE DRUG (PREV) Certain prescription drugs are considered preventive under the Affordable Care Act (ACA). ACA preventive drugs are covered at 100 percent by the Plan (no patient responsibility); although limits may apply. Drugs available under this benefit are listed as PREV under Limits & Restrictions. For more information about your preventive drug benefits, please contact Pharmacy Customer Service at the number listed on the back of your ID Card.

Preventive Drug Benefits Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk

Birth control as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV

Immunizations — doses, recommended ages, and recommended populations vary

Folic acid supplements for women who may become pregnant

Bowel prep for colorectal cancer screening

Smoking cessation medications

Statin preventive medication for adults 40 to 75 at high risk

Breast cancer risk reduction medications

Fluoride supplements for children without fluoride in their water source

INSULIN PRESCRIPTION PRICING CAP INFORMATION FOR UTAH RESIDENTS ONLY

LIMITED FERTILITY BENEFIT WITH LIFETIME PLAN MAXIMUM Medications used to treat or enhance fertility are covered up to a $3,000 Lifetime Plan Maximum. This means the Plan will pay up to $3,000. Once this maximum is reached, the Plan will not pay any additional amounts for the Lifetime of the coverage. Please refer to the Preferred Drug List (PDL) for drugs that are covered under this Plan Benefit. The PDL also provides the Benefit Tiers for covered drugs.

PRESCRIPTION DRUG LIMITS & REQUIREMENTS AGE Some prescription drugs have a minimum or maximum age limit requirement under the Plan. Only members within those limits are able to fill those prescription drugs. PRIOR AUTHORIZATION (PA) To ensure appropriate utilization, some generic and brand prescription drugs and all specialty drugs require Prior Authorization to be eligible for coverage under the member’s prescription drug benefit. The P&T Committee establishes the PA criteria. In order for a member to receive coverage for a prescription drug requiring PA, the member or member’s provider should contact Pharmacy Customer Service at the number listed on the back of your ID Card. Your provider will be required to complete a PA form and provide clinical documentation to show why this prescription drug is needed for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include your diagnosis and previous therapies that have failed in the letter. If a PA is not received or if the

RAPID-ACTING INSULIN PRODUCTS There is at least one rapid-acting insulin product listed on your formulary at the lowest cost tier (Tier 1), regardless of whether you have met your deductible. LONG-ACTING (BASAL) INSULIN PRODUCTS There is at least one long-acting (basal) preferred insulin product listed on your formulary with a maximum out of pocket cost set at or below the Utah state cap of $28 for the current year, regardless of whether you have met your deductible. Please refer to your plan documents for information on other prescription drugs with enhanced benefits.

prescription drug is filled prior to approval, the cost of the prescription drug will be full member responsibility. In addition, PAs cannot be backdated. QUANTITY LIMIT (QL) Quantity Limit is a program that ensures members do not receive a prescription for a quantity that exceeds recommended Plan or safety limits. Limits are set because some prescription drugs have the potential to be abused, misused, shared, or have a manufacturer’s limit on the recommended maximum dose. Quantity limits are based on FDA approved dosing, current medical practices, evidence-based clinical guidelines, and peer-reviewed medical literature related to a particular prescription drug. Prior Authorization is required for any quantities that exceed Plan limits. STEP THERAPY (ST) Step Therapy is a program for prescription drugs that are taken on a regular basis to treat an ongoing medical condition. The program is developed around effectiveness, safety, and value. In ST, the covered prescription drugs are arranged in a series of “steps”. The program typically starts with generic prescription drugs as the “first step.” These generics are rigorously tested and approved by the FDA and allow you to have safe, effective treatment with prescription drug that is more affordable. More expensive brand-name prescription drugs are usually considered in the “second step”. Step Therapy is developed under the guidance and direction of the P&T Committee. They review the most current research on thousands of drugs tested and approved by the FDA for safety and efficacy. The first time you submit a prescription that is not for a first-step drug, your pharmacist will receive a message to tell you that the Plan requires ST. This means if you don’t want to pay full price for your prescription drug, your doctor needs to write a new prescription for a “first-step” drug. With ST, if you’ve already tried and failed the “first-step” drug, can’t take the “first-step” drug (because of an allergy, etc.), and/or your provider can show medical necessity for the second step products, your provider can submit a request for Prior Authorization review.

ADDITIONAL POLICIES AND PROCESSES BRAND-GENERIC CHARGE (Ancillary Charge) A Brand-Generic Charge is applied to your cost if you receive a brand name prescription drug, regardless of reason or medical necessity, if your provider prescribes a brand name drug when a generic is available. A Brand-Generic Charge is the difference between the cost of the generic and the cost of the brand name prescription drug. This penalty is in addition to the regular cost sharing outlined in your benefits summary. The Brand-Generic Charge does not apply towards Deductibles or Out-of-Pocket Maximum.

MAIL ORDER Mail order is a 90 day supply of a generic or brand name prescription drug (Tier 1, 2, and 3) that is mailed directly to you through a designated Mail Order Pharmacy. Not all prescription drugs are available through Mail Order. Contact Pharmacy Customer Service at the number listed on the back of your ID card or visit the website for more information. MANDATORY GENERIC The Plan mandates generic prescription drugs wherever available. If a brand-name prescription drug is requested when a generic is available, the generic will be available without a Prior Authorization. If brand is still desired, PA will be required, even if not indicated on the PDL below. If brand is approved through the PA process, the Brand-Generic charge will still be applied. NON-FORMULARY (not covered) OR EXCEPTON REQUESTS FOR PRESCRIPTION DRUGS For prescription drugs that are not covered by the Plan (non-formulary), you or your provider may submit an exception request. Your provider will be required to complete a formulary exception form and provide clinical documentation to show why this prescription drug is needed/required for treatment of your disease state or medical condition. A letter of medical necessity is also recommended. Your provider should also include your diagnosis and previous therapies that have been tried and failed in the letter. If an exception request approval is not received or the prescription drug is filled prior to approval, the cost of the prescription drug will be full member responsibility. Contact Pharmacy Customer Service at the number listed on the back of your ID card for more information. Please note certain classes of drugs like Proton Pump Inhibitors, H2 Blockers, and branded Nasal Steroids are excluded for all members under the plan.

OFF-LABEL USE OF PRESCRIPTION DRUGS The FDA requires that prescription drugs used in the U.S. be safe and effective. The label information of a prescription drug outlines use for "approved" doses and specific conditions or disease states. The use of a prescription drug for a disease state or condition not listed on the label, or in a dose or therapy not listed on the label, is considered to be a "non-approved" or "off-label" use of the prescription drug. Off-label use of a prescription drug is not covered unless it meets the Plan’s off-label use policy. A Prior Authorization is required when a prescription drug is used outside of its FDA indication, dosage, or treatment. Coverage will be reviewed under the off-label use policy and subject to the same conditions and limitations as any other prescription drug. Therapies deemed investigational or experimental are not a covered benefit.

PAPER CLAIMS FILING LIMITS Point-of-sale claims are generally submitted electronically at the time of dispensing. However, there may be mitigating reasons that require a claim to be submitted via a paper claim after being dispensed. The timely filing limit for paper claims submission is within 365 days from the date of service for all original claims. Paper claims will be reimbursed based on what the contractual discount would have been if claim had processed through the system, so member will be responsible for any difference in paid cost. SPECIALTY PHARMACY The Plan requires that all prescription drugs noted as Specialty must be filled through the Plan’s designated Specialty Pharmacies. These drugs are usually listed on Tier 4, but certain generics of brand name specialty products may be placed in a lower tier and still be considered specialty. In cases where prescription drugs are available only through a limited distribution source from the manufacturer, these prescription drugs will be directed by the Plan to another designated specialty pharmacy.

LEGEND

TIER DESCRIPTION

1 Preferred Generics

2Preferred Brands/Non-

Preferred Generics

3 Non-Preferred Brands

4 Specialty

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered per

prescription, or within a specific time frame.

PA Prior Authorization

You (or your physician) are required to get prior authorization before

you fill your prescription for this drug. Without prior approval, we may

not cover this drug.

ST Step Therapy

In some cases, you may be required to first try certain drugs to treat

your medical condition before we will cover another drug for that

condition.

GL Gender Limit This prescription drug may only be covered for a single gender.

AL1 Age LimitThis prescription drug may only be covered if you meet the minimum

or maximum age limit.

MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.

MDS1 Max Days Supply There is a limit on the amount of this drug that is covered.

S Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or rare

conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis

C, and hemophilia.

PREV Preventative

Certain medications are considered preventive under the Affordable

Care Act (ACA). ACA preventive drugs are covered at 100 percent

(no patient responsibility), although limits may apply. For more

information about your preventive drug benefits, please contact

Pharmacy Customer Service at the number listed on the back of your

ID Card.

FB Fertility BenefitPlease check your Summary Plan Description to see if this benefit

applies.

PAGE 1 LAST UPDATED 04/2022

LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS

clonidine hcl er 0.1 mg tab er 12h 1 QL 60 / 30 DAYS

guanfacine hcl er 1 mg tab er 24h 1 QL 30 / 30 DAYS




ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR

atomoxetine hcl 10 mg cap 1 QL 60 / 30 DAYS







AMPHETAMINE MIXTURES

amphetamine-dextroamphet er 10 mg cap er 24h 1 QL 60 / 30 DAYS






amphetamine-dextroamphetamine 10 mg tab 1 QL 90 / 30 DAYS

amphetamine-dextroamphetamine 12.5 mg tab 1 QL 90 / 30 DAYS







amphetamine-dextroamphetamine 7.5 mg tab 1 QL 90 / 30 DAYS

AMPHETAMINES

ADZENYS ER 1.25 MG/ML SUSPamphetamine 3 PA

ADZENYS XR-ODT 12.5 MG TAB ER DISPamphetamine 3

QL 60 / 30 DAYS

PA

AL1 At least 6 yrs old


QL 60 / 30 DAYS

PA



QL 60 / 30 DAYS

PA



QL 60 / 30 DAYS

PA



QL 60 / 30 DAYS

PA



QL 60 / 30 DAYS

PA


AMPHETAMINE ER 1.25 MG/ML SUSPamphetamine 3 PA

amphetamine sulfate 10 mg tab 2 QL 30 / 30 DAYS

amphetamine sulfate 5 mg tab 2 QL 30 / 30 DAYS



dextroamphetamine sulfate 10 mg tab 1QL 90 / 30 DAYS

PA

dextroamphetamine sulfate 5 mg tab 1QL 90 / 30 DAYS

PA

dextroamphetamine sulfate 5 mg/5ml solution 1 QL 2700 / 30 DAYS

dextroamphetamine sulfate er 10 mg cap er 24h 1 QL 60 / 30 DAYS



DYANAVEL XR 2.5 MG/ML SUSPamphetamine 3

QL 1080 / 30 DAYS

PA

VYVANSE 10 MG CAPlisdexamfetamine dimesylate 2 QL 30 / 30 day(s)

VYVANSE 10 MG CHEW TABlisdexamfetamine dimesylate 2 QL 30 / 30 day(s)














ANALEPTICS

caffeine citrate 20 mg/ml solution 1

caffeine citrate 60 mg/3ml solution 1

caffeine citrate 60 mg/3ml solution 1

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)

SUNOSI 150 MG TABsolriamfetol hcl 3 PA

SUNOSI 75 MG TABsolriamfetol hcl 3 PA

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS

WAKIX 17.8 MG TABpitolisant hcl 4

PA

S Specialty Drug

WAKIX 4.45 MG TABpitolisant hcl 4

PA

S Specialty Drug

STIMULANTS - MISC.

armodafinil 150 mg tab 1 QL 30 / 30 DAYS




DAYTRANA 10 MG/9HR PATCHmethylphenidate 3

QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

dexmethylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS



dexmethylphenidate hcl 2.5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl 5 mg tab 1 QL 90 / 30 DAYS

dexmethylphenidate hcl er 10 mg cap er 24h 1 QL 60 / 30 DAYS








metadate er 20 mg tab er 2 QL 60 / 30 DAYS

METHYLIN 10 MG/5ML SOLUTIONmethylphenidate hcl 3 QL 2700 / 30 DAYS

METHYLIN 5 MG/5ML SOLUTIONmethylphenidate hcl 3 QL 1080 / 30 DAYS

methylphenidate hcl 10 mg chew tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg tab 1 QL 90 / 30 DAYS

methylphenidate hcl 10 mg/5ml solution 1 QL 1350 / 30 DAYS

methylphenidate hcl 2.5 mg chew tab 1 QL 90 / 30 DAYS


methylphenidate hcl 5 mg chew tab 1 QL 90 / 30 DAYS


methylphenidate hcl 5 mg/5ml solution 1 QL 2700 / 30 DAYS

methylphenidate hcl er (cd) 10 mg cap er 2 QL 60 / 30 DAYS








methylphenidate hcl er (la) 10 mg cap er 24h 2 QL 60 / 30 DAYS





methylphenidate hcl er 10 mg tab er 2 QL 60 / 30 DAYS


METHYLPHENIDATE HCL ER 18 MG TAB ER 24Hmethylphenidate hcl 2 QL 30 / 30 DAYS



methylphenidate hcl er 27 mg tab er 24h 2 QL 30 / 30 DAYS

methylphenidate hcl er 36 mg tab er 2 QL 2 / 1 day(s)

methylphenidate hcl er 36 mg tab er 24h 2 QL 2 / 1 day(s)


methylphenidate hcl er 54 mg tab er 24h 2 QL 30 / 30 DAYS

METHYLPHENIDATE HCL ER 72 MG TAB ERmethylphenidate hcl 2 QL 30 / 30 DAYS

modafinil 100 mg tab 1 QL 30 / 30 DAYS

modafinil 200 mg tab 1 QL 30 / 30 DAYS

QUILLICHEW ER 20 MG CHERmethylphenidate hcl 3

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 30 / 30 DAYS

PA



QUILLIVANT XR 25 MG/5ML SRERmethylphenidate hcl 3

QL 360 / 30 DAYS

AL1 Up to 8 yrs old

ALTERNATIVE MEDICINES

ALTERNATIVE MEDICINE - CI'S

CITRUS BERGAMOT 250 MG/0.25GM POWDERcitrus bergamot 3 AL1 Up to 8 yrs old

ALTERNATIVE MEDICINE - RE'S

RED YEAST RICE 500 MG/0.5GM POWDERred yeast rice extract 3 AL1 Up to 8 yrs old

AMINOGLYCOSIDES

gentamicin sulfate 40 mg/ml solution 3

neomycin sulfate 500 mg tab 1

paromomycin sulfate 250 mg cap 1

TOBI PODHALER 28 MG CAPtobramycin 4

PA

S Specialty Drug

tobramycin 300 mg/5ml nebu soln 4PA

S Specialty Drug

ANALGESICS - ANTI-INFLAMMATORY

ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA 10 MG/0.1ML PREF SY KTadalimumab 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



HUMIRA PEDIATRIC CROHNS START 40 MG/0.8ML PREFSY KTadalimumab

4PA

S Specialty Drug

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML &40MG/0.4ML PREF SY KTadalimumab

4PA

S Specialty Drug

HUMIRA PEDIATRIC CROHNS START 80 MG/0.8ML PREFSY KTadalimumab

4PA

S Specialty Drug

HUMIRA PEN 40 MG/0.4ML PEN KITadalimumab 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

HUMIRA PEN-CD/UC/HS STARTER 40 MG/0.8ML PEN KITadalimumab 4

PA

S Specialty Drug

HUMIRA PEN-CD/UC/HS STARTER 80 MG/0.8ML PEN KITadalimumab 4

PA

S Specialty Drug

HUMIRA PEN-PEDIATRIC UC START 80 MG/0.8ML PEN KITadalimumab 4

PA

S Specialty Drug

HUMIRA PEN-PS/UV/ADOL HS START 40 MG/0.8ML PENKITadalimumab

4PA

S Specialty Drug

HUMIRA PEN-PSOR/UVEIT STARTER 80 MG/0.8ML &40MG/0.4ML PEN KITadalimumab

4PA

S Specialty Drug

SIMPONI 100 MG/ML SOLN A-INJgolimumab 4

PA

S Specialty Drug

SIMPONI 100 MG/ML SOLN PRSYRgolimumab 4

PA

S Specialty Drug

SIMPONI 50 MG/0.5ML SOLN A-INJgolimumab 4

PA

S Specialty Drug

SIMPONI 50 MG/0.5ML SOLN PRSYRgolimumab 4

PA

S Specialty Drug



ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS

OLUMIANT 1 MG TABbaricitinib 4

PA

S Specialty Drug

OLUMIANT 2 MG TABbaricitinib 4

PA

S Specialty Drug

RINVOQ 15 MG TAB ER 24Hupadacitinib 4

PA

S Specialty Drug

XELJANZ 1 MG/ML SOLUTIONtofacitinib citrate 4

PA

S Specialty Drug

XELJANZ 10 MG TABtofacitinib citrate 4

PA

S Specialty Drug

XELJANZ 5 MG TABtofacitinib citrate 4

PA

S Specialty Drug

XELJANZ XR 11 MG TAB ER 24Htofacitinib citrate 4

PA

S Specialty Drug

XELJANZ XR 22 MG TAB ER 24Htofacitinib citrate 4

PA

S Specialty Drug

ANTIRHEUMATIC ANTIMETABOLITES

OTREXUP 10 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic) 3 PA

OTREXUP 12.5 MG/0.4ML SOLN A-INJmethotrexate (antirheumatic) 3 PA








RASUVO 10 MG/0.2ML SOLN A-INJmethotrexate (antirheumatic) 2

RASUVO 12.5 MG/0.25ML SOLN A-INJmethotrexate (antirheumatic) 2








REDITREX 10 MG/0.4ML SOLN PRSYRmethotrexate (antirheumatic) 3 PA

REDITREX 12.5 MG/0.05ML SOLN PRSYRmethotrexate (antirheumatic) 3 PA





REDITREX 25 MG/ML SOLN PRSYRmethotrexate (antirheumatic) 3 PA


CYCLOOXYGENASE 2 (COX-2) INHIBITORS

celecoxib 100 mg cap 1

celecoxib 200 mg cap 1 QL 60 / 30 DAYS



celecoxib 400 mg cap 1 QL 60 / 30 DAYS

celecoxib 50 mg cap 1

GOLD COMPOUNDS

RIDAURA 3 MG CAPauranofin 3 PA

INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)

KINERET 100 MG/0.67ML SOLN PRSYRanakinra 4

PA

S Specialty Drug

INTERLEUKIN-1BETA BLOCKERS

ILARIS 150 MG/ML SOLUTIONcanakinumab 4

PA

S Specialty Drug

INTERLEUKIN-6 RECEPTOR INHIBITORS

ACTEMRA 162 MG/0.9ML SOLN PRSYRtocilizumab 4

PA

S Specialty Drug

ACTEMRA ACTPEN 162 MG/0.9ML SOLN A-INJtocilizumab 4

PA

S Specialty Drug

NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS

diclofenac-misoprostol 50-0.2 mg tab dr 1

diclofenac-misoprostol 75-0.2 mg tab dr 1

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

cataflam 50 mg tab 1

diclofenac potassium 50 mg tab 1

diclofenac sodium 25 mg tab dr 1



diclofenac sodium er 100 mg tab er 24h 1

ec-naproxen 375 mg tab dr 1

ec-naproxen 500 mg tab dr 1

etodolac 200 mg cap 1

etodolac 300 mg cap 1



etodolac 400 mg tab 1

etodolac 500 mg tab 1

etodolac er 400 mg tab er 24h 1



FENOPROFEN CALCIUM 200 MG CAPfenoprofen calcium 1

FENOPROFEN CALCIUM 400 MG CAPfenoprofen calcium 1

fenoprofen calcium 600 mg tab 1

flurbiprofen 100 mg tab 1

FLURBIPROFEN 50 MG TABflurbiprofen 1

flurbiprofen 50 mg tab 1

ibu 400 mg tab 1

ibu 600 mg tab 1

ibu 800 mg tab 1

ibuprofen 100 mg/5ml suspension 1

ibuprofen 400 mg tab 1



indomethacin 25 mg cap 1 QL 120 / 30 DAYS

indomethacin 50 mg cap 1

indomethacin er 75 mg cap er 1

KETOPROFEN 50 MG CAPketoprofen 1

KETOPROFEN 75 MG CAPketoprofen 1

KETOPROFEN ER 200 MG CAP ER 24Hketoprofen 2

ketorolac tromethamine 10 mg tab 1

QL 20 / 0 DAYS

MFL 1 / 30 day(s)

MDS1 5 / 1 day(s)



ketorolac tromethamine 60 mg/2ml solution 1 QL 4 / 28 DAYS

MECLOFENAMATE SODIUM 100 MG CAPmeclofenamate sodium 1

MECLOFENAMATE SODIUM 50 MG CAPmeclofenamate sodium 1

mefenamic acid 250 mg cap 2

meloxicam 15 mg tab 1 QL 30 / 30 DAYS

meloxicam 7.5 mg tab 1 QL 30 / 30 DAYS

nabumetone 500 mg tab 1

nabumetone 750 mg tab 1

naproxen 125 mg/5ml suspension 1

naproxen 250 mg tab 1


naproxen 375 mg tab dr 1


naproxen 500 mg tab dr 1

naproxen sodium 275 mg tab 1

naproxen sodium 550 mg tab 1

oxaprozin 600 mg tab 1

piroxicam 10 mg cap 1

piroxicam 20 mg cap 1

relafen 500 mg tab 1

relafen 750 mg tab 1

sulindac 150 mg tab 1

sulindac 200 mg tab 1

TOLMETIN SODIUM 200 MG TABtolmetin sodium 1

TOLMETIN SODIUM 400 MG CAPtolmetin sodium 1

TOLMETIN SODIUM 600 MG TABtolmetin sodium 1



PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

OTEZLA 10 & 20 & 30 MG TAB THPKapremilast 4

PA

S Specialty Drug

OTEZLA 30 MG TABapremilast 4

PA

S Specialty Drug

PYRIMIDINE SYNTHESIS INHIBITORS

leflunomide 10 mg tab 1 QL 30 / 30 DAYS

leflunomide 20 mg tab 1 QL 30 / 30 DAYS

SELECTIVE COSTIMULATION MODULATORS

ORENCIA 125 MG/ML SOLN PRSYRabatacept 4

PA

S Specialty Drug

ORENCIA 50 MG/0.4ML SOLN PRSYRabatacept 4

PA

S Specialty Drug

ORENCIA 87.5 MG/0.7ML SOLN PRSYRabatacept 4

PA

S Specialty Drug

ORENCIA CLICKJECT 125 MG/ML SOLN A-INJabatacept 4

PA

S Specialty Drug

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

ENBREL 25 MG RECON SOLNetanercept 4

PA

S Specialty Drug

ENBREL 25 MG/0.5ML SOLN PRSYRetanercept 4

PA

S Specialty Drug

ENBREL 25 MG/0.5ML SOLUTIONetanercept 4

PA

S Specialty Drug

ENBREL 50 MG/ML SOLN PRSYRetanercept 4

PA

S Specialty Drug

ENBREL MINI 50 MG/ML SOLN CARTetanercept 4

PA

S Specialty Drug

ENBREL SURECLICK 50 MG/ML SOLN A-INJetanercept 4

PA

S Specialty Drug



ANALGESICS - NONNARCOTIC

ANALGESICS-SEDATIVES

bac 50-325-40 mg tab 1

butalbital-acetaminophen 50-325 mg tab 1

butalbital-apap 50-325 mg tab 1

butalbital-apap-caffeine 50-325-40 mg cap 1

butalbital-apap-caffeine 50-325-40 mg tab 1

butalbital-aspirin-caffeine 50-325-40 mg cap 1

esgic 50-325-40 mg cap 1

TENCON 50-325 MG TABbutalbital-acetaminophen 1

zebutal 50-325-40 mg cap 1

SALICYLATE COMBINATIONS

choline-mag trisalicylate 500 mg/5ml liquid 1 AL1 Up to 8 yrs old

CHOLINE-MAG TRISALICYLATE 500 MG/5ML LIQUIDcholine & mag salicylate 1 AL1 Up to 8 yrs old

SALICYLATES

diflunisal 500 mg tab 1

salsalate 500 mg tab 1

salsalate 750 mg tab 1

ANALGESICS - OPIOID

CODEINE COMBINATIONS

acetaminophen-codeine #2 300-15 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

acetaminophen-codeine #3 300-30 mg tab 1 QL 240 / 30 DAYS

acetaminophen-codeine #4 300-60 mg tab 1 QL 180 / 30 DAYS

acetaminophen-codeine 120-12 mg/5ml solution 1

QL 450 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



acetaminophen-codeine 300-15 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

acetaminophen-codeine 300-30 mg tab 1 QL 240 / 30 DAYS

acetaminophen-codeine 300-60 mg tab 1 QL 180 / 30 DAYS

ascomp-codeine 50-325-40-30 mg cap 2 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-300-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-apap-caff-cod 50-325-40-30 mg cap 1 QL 180 / 30 DAYS

butalbital-asa-caff-codeine 50-325-40-30 mg cap 2 QL 180 / 30 DAYS

DIHYDROCODEINE COMBINATIONS

APAP-CAFF-DIHYDROCODEINE 320.5-30-16 MG CAPacetaminophen-caff-dihydrocod 1 QL 120 / 30 DAYS

HYDROCODONE COMBINATIONS

hydrocodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

hydrocodone-acetaminophen 2.5-325 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydrocodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)


QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)


QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydrocodone-acetaminophen 7.5-325 mg/15ml solution 1

QL 450 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



hydrocodone-ibuprofen 10-200 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

HYDROCODONE-IBUPROFEN 5-200 MG TABhydrocodone-ibuprofen 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydrocodone-ibuprofen 5-200 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydrocodone-ibuprofen 7.5-200 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

ibudone 5-200 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

lorcet 5-325 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

lorcet hd 10-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

lorcet plus 7.5-325 mg tab 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

LORTAB 10-300 MG/15ML ELIXIRhydrocodone-acetaminophen 3

QL 450 / 30 DAYS

AL1 Up to 8 yrs old

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

OPIOID AGONISTS

ABSTRAL 100 MCG SL TABfentanyl citrate 3

QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY




QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

ARYMO ER 15 MG TBER DETERmorphine sulfate 3

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

CODEINE SULFATE 15 MG TABcodeine sulfate 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



codeine sulfate 30 mg tab 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

codeine sulfate 60 mg tab 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

fentanyl 100 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA

fentanyl 37.5 mcg/hr patch 72hr 1QL 15 / 30 DAYS

PA


PA


PA


PA


PA

FENTANYL CITRATE 100 MCG TABfentanyl citrate 2

QL 112 / 28 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



fentanyl citrate 1600 mcg loz handle 2

QL 30 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 112 / 28 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 112 / 28 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 112 / 28 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY




QL 112 / 28 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydrocodone bitartrate er 10 mg cap er 12h 2 PA

HYDROCODONE BITARTRATE ER 10 MG CAP ER 12Hhydrocodone bitartrate 2 PA

hydrocodone bitartrate er 100 mg tb24 deter 2 PA
















hydromorphone hcl 1 mg/ml liquid 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



hydromorphone hcl 1 mg/ml solution 1 QL 120 / 30 DAYS

hydromorphone hcl 2 mg tab 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

hydromorphone hcl er 12 mg tab er 24h 2QL 30 / 30 DAYS

PA


PA


PA


PA

LAZANDA 100 MCG/ACT SOLUTIONfentanyl citrate 3

QL 5 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 5 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 5 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



methadone hcl 10 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 10 MG/5ML SOLUTIONmethadone hcl 1

QL 240 / 30 DAYS

PA

methadone hcl 10 mg/5ml solution 1QL 240 / 30 DAYS

PA

methadone hcl 10 mg/ml conc 1QL 60 / 30 DAYS

PA

METHADONE HCL 10 MG/ML SOLUTIONmethadone hcl 1

QL 240 / 30 DAYS

PA

methadone hcl 10 mg/ml solution 1QL 240 / 30 DAYS

PA

methadone hcl 40 mg tab sol 1QL 30 / 30 DAYS

PA

methadone hcl 5 mg tab 1QL 60 / 30 DAYS

PA

METHADONE HCL 5 MG/5ML SOLUTIONmethadone hcl 1

QL 240 / 30 DAYS

PA

methadone hcl 5 mg/5ml solution 1QL 240 / 30 DAYS

PA

methadone hcl intensol 10 mg/ml conc 1QL 60 / 30 DAYS

PA

METHADOSE 10 MG/ML CONCmethadone hcl 1

QL 60 / 30 DAYS

PA

METHADOSE SUGAR-FREE 10 MG/ML CONCmethadone hcl 1

QL 60 / 30 DAYS

PA

morphine sulfate (concentrate) 100 mg/5ml solution 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



morphine sulfate (concentrate) 20 mg/ml solution 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

morphine sulfate 10 mg/5ml solution 1

QL 480 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

MORPHINE SULFATE 15 MG TABmorphine sulfate 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

morphine sulfate 15 mg tab 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

MORPHINE SULFATE 20 MG/5ML SOLUTIONmorphine sulfate 1

QL 480 / 30 day(s)

AL1 Up to 8 yrs old

MFL 1 / 60 day(s)

MDS1 7 / 1 day(s)

morphine sulfate 20 mg/5ml solution 1

QL 480 / 30 day(s)

AL1 Up to 8 yrs old

MFL 1 / 60 day(s)

MDS1 7 / 1 day(s)

MORPHINE SULFATE 30 MG TABmorphine sulfate 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

morphine sulfate 30 mg tab 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

morphine sulfate er 10 mg cap er 24h 2QL 60 / 30 DAYS

PA

MORPHINE SULFATE ER 10 MG CAP ER 24Hmorphine sulfate 2

QL 60 / 30 day(s)

PA




PA


QL 60 / 30 day(s)

PA

morphine sulfate er 100 mg tab er 1QL 60 / 30 DAYS

PA


PA


PA


QL 60 / 30 day(s)

PA


PA


PA


QL 60 / 30 day(s)

PA


PA


PA


QL 60 / 30 day(s)

PA


PA


QL 60 / 30 day(s)

PA


PA




PA


QL 60 / 30 day(s)

PA

MORPHINE SULFATE ER BEADS 120 MG CAP ER 24Hmorphine sulfate beads 2

QL 30 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

NUCYNTA 100 MG TABtapentadol hcl 3

QL 90 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

NUCYNTA ER 100 MG TAB ER 12Htapentadol hcl 3

QL 60 / 30 DAYS

PA




QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

oxycodone hcl 10 mg tab 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone hcl 100 mg/5ml conc 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone hcl 5 mg cap 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone hcl 5 mg/5ml solution 1

QL 1800 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



OXYCODONE HCL ER 10 MG TB12 DETERoxycodone hcl 1

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

OXYCONTIN 10 MG TB12 DETERoxycodone hcl 3

QL 60 / 30 DAYS

PA


QL 60 / 30 day(s)

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 day(s)

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 day(s)

PA


QL 60 / 30 DAYS

PA

oxymorphone hcl 10 mg tab 1

QL 90 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



oxymorphone hcl 5 mg tab 1

QL 60 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

OXYMORPHONE HCL ER 10 MG TAB ER 12Hoxymorphone hcl 1

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

OXYMORPHONE HCL ER 7.5 MG TAB ER 12Hoxymorphone hcl 1

QL 60 / 30 DAYS

PA

SUBSYS 100 MCG LIQUIDfentanyl 3

QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

SUBSYS 1200 (600 X 2) MCG LIQUIDfentanyl 3

QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)

SUBSYS 1600 (800 X 2) MCG LIQUIDfentanyl 3

QL 30 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 day(s)




QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY


QL 120 / 30 DAYS

PA

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

tramadol hcl 50 mg tab 1 QL 240 / 30 DAYS

tramadol hcl er (biphasic) 100 mg tab er 24h 1QL 30 / 30 day(s)

PA

TRAMADOL HCL ER (BIPHASIC) 100 MG TAB ER 24Htramadol hcl 1

QL 30 / 30 day(s)

PA


PA


QL 30 / 30 day(s)

PA


PA


QL 30 / 30 day(s)

PA

TRAMADOL HCL ER 100 MG CAP ER 24Htramadol hcl 1

QL 30 / 30 DAYS

PA

tramadol hcl er 100 mg tab er 24h 1QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA




QL 30 / 30 DAYS

PA


PA


QL 30 / 30 DAYS

PA


PA

ZOHYDRO ER 10 MG CAP ER 12Hhydrocodone bitartrate 3

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

OPIOID COMBINATIONS

oxycodone-acetaminophen 10-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone-acetaminophen 2.5-325 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone-acetaminophen 5-325 mg tab 1

QL 240 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY



oxycodone-acetaminophen 7.5-325 mg tab 1

QL 180 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

OXYCODONE-ASPIRIN 4.8355-325 MG TABoxycodone-aspirin 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

oxycodone-aspirin 4.8355-325 mg tab 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

OXYCODONE-IBUPROFEN 5-400 MG TABoxycodone-ibuprofen 1

QL 120 / 30 DAYS

MFL 1 / 60 DAYS

MDS1 7 / 1 DAY

OPIOID PARTIAL AGONISTS

BELBUCA 150 MCG FILMbuprenorphine hcl 3

QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST


QL 60 / 30 day(s)

ST

BUNAVAIL 2.1-0.3 MG FILMbuprenorphine hcl-naloxone hcl dihydrate 3 QL 30 / 30 DAYS

BUNAVAIL 4.2-0.7 MG FILMbuprenorphine hcl-naloxone hcl dihydrate 3 QL 30 / 30 DAYS



BUNAVAIL 6.3-1 MG FILMbuprenorphine hcl-naloxone hcl dihydrate 3 QL 60 / 30 DAYS

buprenorphine 10 mcg/hr patch wk 2 QL 4 / 28 DAYS




buprenorphine 7.5 mcg/hr patch wk 2 QL 4 / 28 DAYS

buprenorphine hcl 2 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl 8 mg sl tab 1 QL 90 / 30 DAYS

buprenorphine hcl-naloxone hcl 12-3 mg film 1 QL 60 / 30 DAYS

buprenorphine hcl-naloxone hcl 2-0.5 mg film 1

buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab 1 QL 90 / 30 DAYS



buprenorphine hcl-naloxone hcl 8-2 mg sl tab 1 QL 90 / 30 DAYS

butorphanol tartrate 10 mg/ml solution 1QL 2.5 / 30 DAYS

MDS1 7 / 1 day(s)

pentazocine-naloxone hcl 50-0.5 mg tab 1 QL 120 / 30 DAYS

SUBLOCADE 100 MG/0.5ML SOLN PRSYRbuprenorphine 3 S Specialty Drug

SUBLOCADE 300 MG/1.5ML SOLN PRSYRbuprenorphine 3 S Specialty Drug

ZUBSOLV 1.4-0.36 MG SL TABbuprenorphine hcl-naloxone hcl dihydrate 3 QL 60 / 30 DAYS







TRAMADOL COMBINATIONS

tramadol-acetaminophen 37.5-325 mg tab 1 QL 120 / 30 DAYS

ANDROGENS-ANABOLIC

ANABOLIC STEROIDS

oxandrolone 10 mg tab 1QL 60 / 30 DAYS

PA

oxandrolone 2.5 mg tab 1QL 120 / 30 DAYS

PA

ANDROGENS

danazol 100 mg cap 2

danazol 200 mg cap 2

danazol 50 mg cap 2

DEPO-TESTOSTERONE 100 MG/ML SOLUTIONtestosterone cypionate 2

DEPO-TESTOSTERONE 200 MG/ML SOLUTIONtestosterone cypionate 2

methyltestosterone 10 mg cap 2 PA

NATESTO 5.5 MG/ACT GELtestosterone 3

QL 21.96 / 30 DAYS

PA

testosterone 1.62 % gel 1 QL 150 / 30 DAYS

testosterone 10 mg/act (2%) gel 1

TESTOSTERONE 12.5 MG/ACT (1%) GELtestosterone 1 PA

testosterone 12.5 mg/act (1%) gel 1

testosterone 20.25 mg/1.25gm (1.62%) gel 1 QL 37.5 / 30 DAYS

testosterone 20.25 mg/act (1.62%) gel 1 QL 150 / 30 DAYS

TESTOSTERONE 25 MG/2.5GM (1%) GELtestosterone 1

testosterone 25 mg/2.5gm (1%) gel 1

testosterone 30 mg/act solution 2 QL 180 / 30 DAYS



TESTOSTERONE 50 MG/5GM (1%) GELtestosterone 1 PA

testosterone 50 mg/5gm (1%) gel 1

TESTOSTERONE CYPIONATE 100 MG/ML SOLUTIONtestosterone cypionate 1

testosterone cypionate 100 mg/ml solution 1

TESTOSTERONE CYPIONATE 200 MG/ML SOLUTIONtestosterone cypionate 1

testosterone cypionate 200 mg/ml solution 1

TESTOSTERONE ENANTHATE 200 MG/ML SOLUTIONtestosterone enanthate 1

testosterone enanthate 200 mg/ml solution 1

ANORECTAL AND RELATED PRODUCTS

INTRARECTAL STEROIDS

colocort 100 mg/60ml enema 1

CORTIFOAM 10 % FOAMhydrocortisone acetate (intrarectal) 3

hydrocortisone 100 mg/60ml enema 1

UCERIS 2 MG/ACT FOAMbudesonide (intrarectal) 3 QL 133.6 / 30 day(s)

RECTAL ANESTHETIC/STEROIDS

ANALPRAM-HC 2.5-1 % LOTIONhydrocortisone acetate w/ pramoxine 3

hydrocort-pramoxine (perianal) 2.5-1 % cream 1

hydrocortisone ace-pramoxine 1-1 % cream 1

lidocaine-hydrocort (perianal) 3-0.5 % cream 1

lidocort 3-0.5 % cream 1

PROCTOFOAM HC 1-1 % FOAMhydrocortisone acetate w/ pramoxine 2

RECTAL STEROIDS

anucort-hc 25 mg suppos 2

ANUSOL-HC 2.5 % CREAMhydrocortisone (rectal) 1

anusol-hc 25 mg suppos 2



hemmorex-hc 25 mg suppos 2

hemmorex-hc 30 mg suppos 2

hydrocortisone (perianal) 1 % cream 1

hydrocortisone (perianal) 2.5 % cream 1

hydrocortisone acetate 25 mg suppos 2

hydrocortisone acetate 30 mg suppos 2

procto-med hc 2.5 % cream 1

procto-pak 1 % cream 1

proctosol hc 2.5 % cream 1

proctozone-hc 2.5 % cream 1

ANTHELMINTICS

albendazole 200 mg tab 2

QL 120 / 30 DAYS

PA

MFL 1 / 365 DAYS

EMVERM 100 MG CHEW TABmebendazole 3

QL 6 / 3 DAYS

PA

ivermectin 3 mg tab 1

QL 6 / 1 day(s)

MFL 1 / 365 DAYS

MDS1 2 / 1 day(s)

praziquantel 600 mg tab 2

ANTI-INFECTIVE AGENTS - MISC.

IMPAVIDO 50 MG CAPmiltefosine 3

QL 84 / 28 DAYS

PA

metronidazole 250 mg tab 1

metronidazole 375 mg cap 1

metronidazole 500 mg tab 1

pentamidine isethionate 300 mg recon soln 1

tinidazole 250 mg tab 1

tinidazole 500 mg tab 1

TRIMETHOPRIM 100 MG TABtrimethoprim 1



trimethoprim 100 mg tab 1

XIFAXAN 200 MG TABrifaximin 3

QL 9 / 30 DAYS

PA

XIFAXAN 550 MG TABrifaximin 3

QL 90 / 30 DAYS

PA

ANTI-INFECTIVE MISC. - COMBINATIONS

sulfamethoxazole-trimethoprim 200-40 mg/5ml suspension 1

sulfamethoxazole-trimethoprim 400-80 mg tab 1

sulfamethoxazole-trimethoprim 400-80 mg/5ml solution 1

sulfamethoxazole-trimethoprim 800-160 mg tab 1

sulfatrim pediatric 200-40 mg/5ml suspension 1

ANTIPROTOZOAL AGENTS

ALINIA 100 MG/5ML RECON SUSPnitazoxanide 3 PA

atovaquone 750 mg/5ml suspension 2

LAMPIT 120 MG TABnifurtimox 3

LAMPIT 30 MG TABnifurtimox 3

nitazoxanide 500 mg tab 2QL 20 / 10 day(s)

PA

GLYCOPEPTIDES

vancomycin hcl 125 mg cap 2 QL 56 / 14 DAYS

vancomycin hcl 250 mg cap 2 QL 56 / 14 DAYS

LEPROSTATICS

dapsone 100 mg tab 1

dapsone 25 mg tab 1

LINCOSAMIDES

clindamycin hcl 150 mg cap 1





clindamycin palmitate hcl 75 mg/5ml recon soln 1

MONOBACTAMS

CAYSTON 75 MG RECON SOLNaztreonam lysine 4

PA

S Specialty Drug

OXAZOLIDINONES

linezolid 100 mg/5ml recon susp 1

linezolid 600 mg tab 1 QL 56 / 28 DAYS

linezolid 600 mg/300ml solution 4PA

S Specialty Drug

URINARY ANTI-INFECTIVES

fosfomycin tromethamine 3 gm packet 2

methenamine hippurate 1 gm tab 1

nitrofurantoin 25 mg/5ml suspension 1 AL1 Up to 8 yrs old

nitrofurantoin macrocrystal 100 mg cap 1



nitrofurantoin monohyd macro 100 mg cap 1

URINARY ANTISEPTIC-ANTISPASMODIC &/OR ANALGESICS

uribel 118 mg cap 2

uro-mp 118 mg cap 2

vilamit mb 118 mg cap 2

ANTIANGINAL AGENTS

ANTIANGINALS-OTHER

ranolazine er 1000 mg tab er 12h 2 QL 60 / 30 DAYS

ranolazine er 500 mg tab er 12h 2 QL 60 / 30 DAYS

NITRATES

isosorbide dinitrate 10 mg tab 1






ISOSORBIDE DINITRATE ER 40 MG TAB ERisosorbide dinitrate 1

isosorbide mononitrate 10 mg tab 1

isosorbide mononitrate 20 mg tab 1

isosorbide mononitrate er 120 mg tab er 24h 1



minitran 0.1 mg/hr patch 24hr 1




NITRO-BID 2 % OINTMENTnitroglycerin 1

NITRO-DUR 0.3 MG/HR PATCH 24HRnitroglycerin 3

NITRO-DUR 0.8 MG/HR PATCH 24HRnitroglycerin 3

NITRO-TIME 2.5 MG CAP ERnitroglycerin 1

NITRO-TIME 6.5 MG CAP ERnitroglycerin 1

NITRO-TIME 9 MG CAP ERnitroglycerin 1

nitroglycerin 0.1 mg/hr patch 24hr 1


nitroglycerin 0.3 mg sl tab 1

nitroglycerin 0.4 mg sl tab 1 QL 30 / 30 DAYS


nitroglycerin 0.4 mg/spray solution 2

nitroglycerin 0.6 mg sl tab 1 QL 30 / 30 DAYS




nitroglycerin er 2.5 mg cap er 1

nitroglycerin er 6.5 mg cap er 1

nitroglycerin er 9 mg cap er 1

NITROMIST 400 MCG/SPRAY AERO SOLNnitroglycerin 3

ANTIANXIETY AGENTS

ANTIANXIETY AGENTS - MISC.

buspirone hcl 10 mg tab 1




buspirone hcl 7.5 mg tab 1

hydroxyzine hcl 10 mg tab 1

hydroxyzine hcl 10 mg/5ml syrup 1



HYDROXYZINE PAMOATE 100 MG CAPhydroxyzine pamoate 1

hydroxyzine pamoate 25 mg cap 1

hydroxyzine pamoate 50 mg cap 1

meprobamate 200 mg tab 1

meprobamate 400 mg tab 1

BENZODIAZEPINES

alprazolam 0.25 mg tab 1 QL 90 / 30 DAYS

alprazolam 0.25 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 0.5 mg tab 1 QL 5 / 1 day(s)

alprazolam 0.5 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 1 mg tab 1 QL 5 / 1 day(s)

alprazolam 1 mg tab disp 1 QL 90 / 30 DAYS

alprazolam 2 mg tab 1 QL 90 / 30 DAYS



alprazolam 2 mg tab disp 1 QL 90 / 30 DAYS

alprazolam er 0.5 mg tab er 24h 1 QL 90 / 30 DAYS

alprazolam er 1 mg tab er 24h 1 QL 90 / 30 DAYS



ALPRAZOLAM INTENSOL 1 MG/ML CONCalprazolam 1 AL1 Up to 8 yrs old

alprazolam xr 0.5 mg tab er 24h 1 QL 90 / 30 DAYS

alprazolam xr 1 mg tab er 24h 1 QL 90 / 30 DAYS



chlordiazepoxide hcl 10 mg cap 1



clorazepate dipotassium 15 mg tab 1

clorazepate dipotassium 3.75 mg tab 1

clorazepate dipotassium 7.5 mg tab 1

diazepam 10 mg tab 1 QL 60 / 30 DAYS

DIAZEPAM 10 MG/2ML SOLN A-INJdiazepam 1



diazepam 5 mg/5ml solution 1QL 500 / 30 day(s)

AL1 Up to 8 yrs old

diazepam 5 mg/ml conc 1 AL1 Up to 8 yrs old

DIAZEPAM 5 MG/ML SOLUTIONdiazepam 1

diazepam 5 mg/ml solution 1

diazepam intensol 5 mg/ml conc 1 AL1 Up to 8 yrs old



lorazepam 0.5 mg tab 1 QL 5 / 1 day(s)

lorazepam 1 mg tab 1 QL 5 / 1 day(s)

lorazepam 2 mg tab 1 QL 90 / 30 DAYS

lorazepam 2 mg/ml solution 1

lorazepam 4 mg/ml solution 1

oxazepam 10 mg cap 1 QL 90 / 30 day(s)



ANTIARRHYTHMICS

ANTIARRHYTHMICS TYPE I-A

disopyramide phosphate 100 mg cap 1

disopyramide phosphate 150 mg cap 1

NORPACE 100 MG CAPdisopyramide phosphate 3

NORPACE 150 MG CAPdisopyramide phosphate 3

NORPACE CR 100 MG CAP ER 12Hdisopyramide phosphate 2

NORPACE CR 150 MG CAP ER 12Hdisopyramide phosphate 2

quinidine gluconate er 324 mg tab er 1

QUINIDINE SULFATE 200 MG TABquinidine sulfate 1

quinidine sulfate 200 mg tab 1

QUINIDINE SULFATE 300 MG TABquinidine sulfate 1

quinidine sulfate 300 mg tab 1

ANTIARRHYTHMICS TYPE I-B

mexiletine hcl 150 mg cap 1





ANTIARRHYTHMICS TYPE I-C

flecainide acetate 100 mg tab 1



propafenone hcl 150 mg tab 1



propafenone hcl er 225 mg cap er 12h 1



ANTIARRHYTHMICS TYPE III

amiodarone hcl 100 mg tab 1



dofetilide 125 mcg cap 2



MULTAQ 400 MG TABdronedarone hcl 2 QL 60 / 30 DAYS

pacerone 100 mg tab 1



ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ADRENERGIC COMBINATIONS

ANORO ELLIPTA 62.5-25 MCG/INH AER POW BAumeclidinium-vilanterol 2 QL 14 / 7 DAYS

BREO ELLIPTA 100-25 MCG/INH AER POW BAfluticasone furoate-vilanterol 3

QL 28 / 14 DAYS

ST

BREO ELLIPTA 200-25 MCG/INH AER POW BAfluticasone furoate-vilanterol 3

QL 28 / 14 DAYS

ST

BREZTRI AEROSPHERE 160-9-4.8 MCG/ACT AEROSOLbudesonide-glycopyrrolate-formoterol fumarate 3 PA



COMBIVENT RESPIMAT 20-100 MCG/ACT AERO SOLNipratropium-albuterol 2 QL 4 / 30 DAYS

DULERA 100-5 MCG/ACT AEROSOLmometasone furoate-formoterol fumarate dihydrate 2 QL 13 / 30 day(s)



fluticasone-salmeterol 100-50 mcg/act aer pow ba 2 QL 60 / 30 day(s)

FLUTICASONE-SALMETEROL 113-14 MCG/ACT AER POWBAfluticasone-salmeterol

1 QL 1 / 30 DAYS


1 QL 1 / 30 DAYS




1 QL 1 / 30 DAYS

ipratropium-albuterol 0.5-2.5 (3) mg/3ml solution 1

STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLNtiotropium bromide-olodaterol hcl 2 QL 4 / 30 DAYS

SYMBICORT 160-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate 2 QL 10.2 / 30 DAYS

SYMBICORT 80-4.5 MCG/ACT AEROSOLbudesonide-formoterol fumarate dihydrate 2 QL 10.2 / 30 DAYS

TRELEGY ELLIPTA 100-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol 2 QL 2 / 1 day(s)

TRELEGY ELLIPTA 200-62.5-25 MCG/INH AER POW BAfluticasone-umeclidinium-vilanterol 2 QL 2 / 1 day(s)

wixela inhub 100-50 mcg/act aer pow ba 2 QL 60 / 30 day(s)





ANTI-IGE MONOCLONAL ANTIBODIES

XOLAIR 150 MG RECON SOLNomalizumab 4

PA

S Specialty Drug

XOLAIR 150 MG/ML SOLN PRSYRomalizumab 4

PA

S Specialty Drug

XOLAIR 75 MG/0.5ML SOLN PRSYRomalizumab 4

PA

S Specialty Drug

ANTI-INFLAMMATORY AGENTS

cromolyn sodium 20 mg/2ml nebu soln 1 QL 240 / 30 DAYS

BETA ADRENERGICS

albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate (5 mg/ml) 0.5% nebu soln 1

albuterol sulfate 0.63 mg/3ml nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate 1.25 mg/3ml nebu soln 1 QL 360 / 30 DAYS

albuterol sulfate 2 mg tab 2

albuterol sulfate 2 mg/5ml syrup 1

albuterol sulfate 2.5 mg/0.5ml nebu soln 1

albuterol sulfate 4 mg tab 2 QL 120 / 30 DAYS

ALBUTEROL SULFATE ER 4 MG TAB ER 12Halbuterol sulfate 1

ALBUTEROL SULFATE ER 8 MG TAB ER 12Halbuterol sulfate 1

albuterol sulfate hfa 108 (90 base) mcg/act aero soln 1 QL 18 / 15 day(s)

ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT AEROSOLNalbuterol sulfate

1 QL 18 / 15 day(s)

ARCAPTA NEOHALER 75 MCG CAPindacaterol maleate 3 QL 30 / 30 DAYS

arformoterol tartrate 15 mcg/2ml nebu soln 2 PA

formoterol fumarate 20 mcg/2ml nebu soln 2 PA



levalbuterol hcl 0.31 mg/3ml nebu soln 1 QL 270 / 30 DAYS

levalbuterol hcl 0.63 mg/3ml nebu soln 1 QL 270 / 30 day(s)

levalbuterol hcl 1.25 mg/0.5ml nebu soln 1

levalbuterol hcl 1.25 mg/3ml nebu soln 1 QL 270 / 30 DAYS

LEVALBUTEROL TARTRATE 45 MCG/ACT AEROSOLlevalbuterol tartrate 1 QL 30 / 30 DAYS

METAPROTERENOL SULFATE 10 MG TABmetaproterenol sulfate 1

METAPROTERENOL SULFATE 10 MG/5ML SYRUPmetaproterenol sulfate 1 AL1 Up to 8 yrs old

METAPROTERENOL SULFATE 20 MG TABmetaproterenol sulfate 1

SEREVENT DISKUS 50 MCG/DOSE AER POW BAsalmeterol xinafoate 2 QL 28 / 14 DAYS

STRIVERDI RESPIMAT 2.5 MCG/ACT AERO SOLNolodaterol hcl 3 QL 4 / 30 DAYS

terbutaline sulfate 2.5 mg tab 1 QL 90 / 30 DAYS

terbutaline sulfate 5 mg tab 1

XOPENEX 0.31 MG/3ML NEBU SOLNlevalbuterol hcl 3 QL 270 / 30 DAYS

XOPENEX 0.63 MG/3ML NEBU SOLNlevalbuterol hcl 3 QL 270 / 30 day(s)

XOPENEX 1.25 MG/3ML NEBU SOLNlevalbuterol hcl 3 QL 270 / 30 DAYS

BRONCHODILATORS - ANTICHOLINERGICS

ATROVENT HFA 17 MCG/ACT AERO SOLNipratropium bromide hfa 2 QL 25.8 / 28 DAYS

INCRUSE ELLIPTA 62.5 MCG/INH AER POW BAumeclidinium bromide 2 QL 30 / 30 DAYS

ipratropium bromide 0.02 % solution 1

SPIRIVA HANDIHALER 18 MCG CAPtiotropium bromide monohydrate 2 QL 30 / 30 DAYS

SPIRIVA RESPIMAT 1.25 MCG/ACT AERO SOLNtiotropium bromide monohydrate 2 QL 4 / 30 DAYS

SPIRIVA RESPIMAT 2.5 MCG/ACT AERO SOLNtiotropium bromide monohydrate 2 QL 4 / 30 DAYS



YUPELRI 175 MCG/3ML SOLUTIONrevefenacin 3

QL 90 / 30 DAYS

PA

INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)

FASENRA 30 MG/ML SOLN PRSYRbenralizumab 4

PA

S Specialty Drug

FASENRA PEN 30 MG/ML SOLN A-INJbenralizumab 4

PA

S Specialty Drug

NUCALA 100 MG RECON SOLNmepolizumab 4

PA

S Specialty Drug

NUCALA 100 MG/ML SOLN A-INJmepolizumab 4

PA

S Specialty Drug

NUCALA 100 MG/ML SOLN PRSYRmepolizumab 4

PA

S Specialty Drug

LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast sodium 10 mg tab 1 QL 30 / 30 DAYS

montelukast sodium 4 mg chew tab 1 QL 30 / 30 DAYS

montelukast sodium 4 mg packet 1QL 30 / 30 DAYS

AL1 Up to 4 yrs old

montelukast sodium 5 mg chew tab 1 QL 30 / 30 DAYS

zafirlukast 10 mg tab 1 QL 60 / 30 DAYS

zafirlukast 20 mg tab 1 QL 60 / 30 DAYS

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

DALIRESP 250 MCG TABroflumilast 3

QL 30 / 30 day(s)

PA

DALIRESP 500 MCG TABroflumilast 3

QL 30 / 30 DAYS

PA

STEROID INHALANTS

ARNUITY ELLIPTA 100 MCG/ACT AER POW BAfluticasone furoate (inhalation) 2 QL 1 / 1 day(s)





ASMANEX (120 METERED DOSES) 220 MCG/INH AER POWBAmometasone furoate (inhalation)

3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST


3QL 1 / 30 day(s)

ST

ASMANEX HFA 100 MCG/ACT AEROSOLmometasone furoate (inhalation) 3

QL 13 / 30 day(s)

ST


QL 13 / 30 day(s)

ST


QL 13 / 30 day(s)

ST

budesonide 0.25 mg/2ml suspension 1 QL 120 / 30 DAYS

budesonide 0.5 mg/2ml suspension 1 QL 120 / 30 DAYS

budesonide 1 mg/2ml suspension 1

FLOVENT DISKUS 100 MCG/BLIST AER POW BAfluticasone propionate (inhalation) 2 QL 28 / 14 DAYS





FLOVENT HFA 110 MCG/ACT AEROSOLfluticasone propionate hfa 2 QL 12 / 30 DAYS

FLOVENT HFA 220 MCG/ACT AEROSOLfluticasone propionate hfa 2 QL 12 / 30 DAYS

FLOVENT HFA 44 MCG/ACT AEROSOLfluticasone propionate hfa 2 QL 10.6 / 30 DAYS

PULMICORT FLEXHALER 180 MCG/ACT AER POW BAbudesonide (inhalation) 2 QL 2 / 30 DAYS

PULMICORT FLEXHALER 90 MCG/ACT AER POW BAbudesonide (inhalation) 2 QL 2 / 30 DAYS

QVAR 40 MCG/ACT AERO SOLNbeclomethasone dipropionate 2 QL 34.8 / 30 DAYS

QVAR 80 MCG/ACT AERO SOLNbeclomethasone dipropionate 2 QL 18 / 30 DAYS

QVAR REDIHALER 40 MCG/ACT AERO BAbeclomethasone dipropionate hfa 2 QL 10.6 / 30 DAYS

QVAR REDIHALER 80 MCG/ACT AERO BAbeclomethasone dipropionate hfa 2 QL 10.6 / 30 DAYS

THYMIC STROMAL LYMPHOPOIETIN (TSLP) ANTAGONISTS

TEZSPIRE 210 MG/1.91ML SOLN PRSYRtezepelumab-ekko 4

PA

S Specialty Drug

XANTHINES

ELIXOPHYLLIN 80 MG/15ML ELIXIRtheophylline 1 AL1 Up to 8 yrs old

THEO-24 100 MG CAP ER 24Htheophylline 2




theophylline 80 mg/15ml solution 1 AL1 Up to 8 yrs old

theophylline er 100 mg tab er 12h 1





THEOPHYLLINE ER 300 MG TAB ER 12Htheophylline 1



THEOPHYLLINE ER 450 MG TAB ER 12Htheophylline 1


ANTICOAGULANTS

COUMARIN ANTICOAGULANTS

jantoven 1 mg tab 1

jantoven 10 mg tab 1

jantoven 2 mg tab 1

jantoven 2.5 mg tab 1

jantoven 3 mg tab 1

jantoven 4 mg tab 1

jantoven 5 mg tab 1

jantoven 6 mg tab 1

jantoven 7.5 mg tab 1

warfarin sodium 1 mg tab 1



warfarin sodium 2.5 mg tab 1





warfarin sodium 7.5 mg tab 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS 2.5 MG TABapixaban 2 QL 2 / 1 day(s)

ELIQUIS 5 MG TABapixaban 2 QL 2.5 / 1 day(s)



ELIQUIS DVT/PE STARTER PACK 5 MG TAB THPKapixaban 2 QL 2.5 / 1 day(s)

SAVAYSA 15 MG TABedoxaban tosylate 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

XARELTO 1 MG/ML RECON SUSPrivaroxaban 2 AL1 Up to 8 yrs old

XARELTO 10 MG TABrivaroxaban 2 QL 30 / 30 DAYS

XARELTO 15 MG TABrivaroxaban 2 QL 42 / 30 day(s)

XARELTO 2.5 MG TABrivaroxaban 2 QL 60 / 30 DAYS

XARELTO 20 MG TABrivaroxaban 2 QL 30 / 30 DAYS

XARELTO STARTER PACK 15 & 20 MG TAB THPKrivaroxaban 2 QL 51 / 30 DAYS

HEPARINS AND HEPARINOID-LIKE AGENTS

HEPARIN (PORCINE) IN NACL 1000-0.9 UNIT/L-%SOLUTIONheparin (porcine) in sodium chloride

1

heparin (porcine) in nacl 1000-0.9 ut/500ml-% solution 1

HEPARIN (PORCINE) IN NACL 12500-0.45 UT/250ML-%SOLUTIONheparin (porcine) in sodium chloride

1

heparin (porcine) in nacl 2000-0.9 unit/l-% solution 1


1


1


1




1


1

HEPARIN LOCK FLUSH 1 UNIT/ML SOLUTIONheparin sodium (porcine) lock flush 1

heparin lock flush 10 unit/ml solution 1

HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML SOLUTIONheparin sod (porcine) in d5w 1

HEPARIN SOD (PORCINE) IN D5W 25000-5 UT/500ML-%SOLUTIONheparin sod (porcine) in d5w

1

HEPARIN SOD (PORCINE) IN D5W 40-5 UNIT/ML-%SOLUTIONheparin sod (porcine) in d5w

1

heparin sodium (porcine) 1000 unit/ml solution 1



heparin sodium (porcine) pf 5000 unit/0.5ml solution 1

heparin sodium flush 100-0.9 unit/ml-% kit 1

heparin sodium lock flush 100 unit/ml solution 1

sash kit 100-0.9 unit/ml-% kit 1

LOW MOLECULAR WEIGHT HEPARINS

enoxaparin sodium 100 mg/ml soln prsyr 2 QL 2 / 1 day(s)

enoxaparin sodium 120 mg/0.8ml soln prsyr 2 QL 1.6 / 1 day(s)

enoxaparin sodium 150 mg/ml soln prsyr 2 QL 2 / 1 day(s)


enoxaparin sodium 300 mg/3ml solution 2 QL 3 / 1 day(s)






FRAGMIN 10000 UNIT/ML SOLN PRSYRdalteparin sodium 3 QL 2 / 1 day(s)

FRAGMIN 12500 UNIT/0.5ML SOLN PRSYRdalteparin sodium 3 QL 1 / 1 day(s)

FRAGMIN 15000 UNIT/0.6ML SOLN PRSYRdalteparin sodium 3 QL 1.2 / 1 day(s)

FRAGMIN 18000 UNT/0.72ML SOLN PRSYRdalteparin sodium 3 QL 1.44 / 1 day(s)




FRAGMIN 95000 UNIT/3.8ML SOLUTIONdalteparin sodium 3 QL 7.6 / 1 day(s)

SYNTHETIC HEPARINOID-LIKE AGENTS

fondaparinux sodium 10 mg/0.8ml solution 2 QL 0.8 / 1 day(s)

fondaparinux sodium 2.5 mg/0.5ml solution 2 QL 0.5 / 1 day(s)

fondaparinux sodium 5 mg/0.4ml solution 2 QL 0.4 / 1 day(s)

fondaparinux sodium 7.5 mg/0.6ml solution 2 QL 0.6 / 1 day(s)

THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE

PRADAXA 110 MG CAPdabigatran etexilate mesylate 2 QL 60 / 30 DAYS



ANTICONVULSANTS

AMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA 0.5 MG/ML SUSPENSIONperampanel 3

QL 30 / 30 day(s)

ST

FYCOMPA 10 MG TABperampanel 3

QL 30 / 30 DAYS

ST




QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

ANTICONVULSANTS - BENZODIAZEPINES

clobazam 10 mg tab 1

clobazam 2.5 mg/ml suspension 1

clobazam 20 mg tab 1

clonazepam 0.125 mg tab disp 1 QL 90 / 30 DAYS


clonazepam 0.5 mg tab 1 QL 90 / 30 DAYS


clonazepam 1 mg tab 1 QL 90 / 30 DAYS

clonazepam 1 mg tab disp 1 QL 90 / 30 DAYS

clonazepam 2 mg tab 1 QL 90 / 30 DAYS

clonazepam 2 mg tab disp 1 QL 90 / 30 DAYS

DIAZEPAM 10 MG GELdiazepam (anticonvulsant) 2

DIAZEPAM 2.5 MG GELdiazepam (anticonvulsant) 2

DIAZEPAM 20 MG GELdiazepam (anticonvulsant) 2

NAYZILAM 5 MG/0.1ML SOLUTIONmidazolam (anticonvulsant) 3 PA



VALTOCO 10 MG DOSE 10 MG/0.1ML LIQUIDdiazepam (anticonvulsant) 3 PA

VALTOCO 15 MG DOSE 7.5 MG/0.1ML LIQD THPKdiazepam (anticonvulsant) 3 PA

VALTOCO 20 MG DOSE 10 MG/0.1ML LIQD THPKdiazepam (anticonvulsant) 3 PA

VALTOCO 5 MG DOSE 5 MG/0.1ML LIQUIDdiazepam (anticonvulsant) 3 PA

ANTICONVULSANTS - MISC.

APTIOM 200 MG TABeslicarbazepine acetate 3 QL 30 / 30 DAYS




BRIVIACT 10 MG TABbrivaracetam 3 ST

BRIVIACT 10 MG/ML SOLUTIONbrivaracetam 3 ST





carbamazepine 100 mg chew tab 1

carbamazepine 100 mg/5ml suspension 1

carbamazepine 200 mg tab 1

carbamazepine er 100 mg cap er 12h 1

carbamazepine er 100 mg tab er 12h 1







CARBATROL 100 MG CAP ER 12Hcarbamazepine 3



EPIDIOLEX 100 MG/ML SOLUTIONcannabidiol 4

PA

S Specialty Drug

epitol 200 mg tab 1

EPRONTIA 25 MG/ML SOLUTIONtopiramate 2

QL 16 / 1 day(s)

AL1 Up to 8 yrs old

gabapentin 100 mg cap 1 QL 360 / 30 DAYS

gabapentin 250 mg/5ml solution 1 QL 2160 / 30 DAYS


gabapentin 300 mg/6ml solution 1 QL 2160 / 30 DAYS


gabapentin 600 mg tab 1 QL 180 / 30 DAYS

gabapentin 800 mg tab 1 QL 120 / 30 DAYS

KEPPRA 100 MG/ML SOLUTIONlevetiracetam 3

KEPPRA 1000 MG TABlevetiracetam 3




KEPPRA XR 500 MG TAB ER 24Hlevetiracetam 3 QL 180 / 30 DAYS



KEPPRA XR 750 MG TAB ER 24Hlevetiracetam 3 QL 120 / 30 DAYS

lacosamide 100 mg tab 2QL 60 / 30 day(s)

ST


ST


ST


ST

LAMICTAL 100 MG TABlamotrigine 3



LAMICTAL 25 MG CHEW TABlamotrigine 3


LAMICTAL 5 MG CHEW TABlamotrigine 3

LAMICTAL STARTER 35 X 25 MG KITlamotrigine 3

LAMICTAL STARTER 42 X 25 MG & 7 X 100 MG KITlamotrigine 3

LAMICTAL STARTER 84 X 25 MG & 14X100 MG KITlamotrigine 3

LAMICTAL XR 100 MG TAB ER 24Hlamotrigine 3 QL 30 / 30 DAYS


LAMICTAL XR 21 X 25 MG & 7 X 50 MG KITlamotrigine 3

LAMICTAL XR 25 & 50 & 100 MG KITlamotrigine 3






LAMICTAL XR 50 & 100 & 200 MG KITlamotrigine 3


lamotrigine 100 mg tab 1



lamotrigine 25 mg chew tab 1


lamotrigine 5 mg chew tab 1

lamotrigine er 100 mg tab er 24h 1 QL 30 / 30 DAYS






lamotrigine starter kit-blue 35 x 25 mg kit 1

lamotrigine starter kit-green 84 x 25 mg & 14x100 mg kit 1

lamotrigine starter kit-orange 42 x 25 mg & 7 x 100 mg kit 1

levetiracetam 100 mg/ml solution 1

levetiracetam 1000 mg tab 1




levetiracetam er 500 mg tab er 24h 1 QL 180 / 30 DAYS



levetiracetam er 750 mg tab er 24h 1 QL 120 / 30 DAYS

LYRICA 20 MG/ML SOLUTIONpregabalin 3

QL 900 / 30 DAYS

PA

NEURONTIN 100 MG CAPgabapentin 3 QL 360 / 30 DAYS

NEURONTIN 250 MG/5ML SOLUTIONgabapentin 3 QL 2160 / 30 DAYS



NEURONTIN 600 MG TABgabapentin 3 QL 180 / 30 DAYS

NEURONTIN 800 MG TABgabapentin 3 QL 120 / 30 DAYS

oxcarbazepine 150 mg tab 1


oxcarbazepine 300 mg/5ml suspension 1


OXTELLAR XR 150 MG TAB ER 24Hoxcarbazepine 3

QL 120 / 30 DAYS

PA


QL 120 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

pregabalin 100 mg cap 1 QL 120 / 30 DAYS


pregabalin 20 mg/ml solution 1 QL 900 / 30 day(s)









primidone 250 mg tab 1

primidone 50 mg tab 1

roweepra 1000 mg tab 3



roweepra xr 500 mg tab er 24h 3 QL 180 / 30 DAYS

roweepra xr 750 mg tab er 24h 3 QL 120 / 30 DAYS

rufinamide 200 mg tab 2QL 240 / 30 day(s)

PA

rufinamide 40 mg/ml suspension 2 PA

rufinamide 400 mg tab 2QL 240 / 30 day(s)

PA

SPRITAM 1000 MG TABlevetiracetam 3

QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

subvenite 100 mg tab 1




subvenite starter kit-blue 35 x 25 mg kit 3

subvenite starter kit-green 84 x 25 mg & 14x100 mg kit 3



subvenite starter kit-orange 42 x 25 mg & 7 x 100 mg kit 3

TEGRETOL 100 MG/5ML SUSPENSIONcarbamazepine 3 PA

TEGRETOL 200 MG TABcarbamazepine 3 PA

TEGRETOL-XR 100 MG TAB ER 12Hcarbamazepine 3 PA



TOPAMAX 100 MG TABtopiramate 3 QL 120 / 30 DAYS




TOPAMAX SPRINKLE 15 MG CAP SPRINKtopiramate 3

TOPAMAX SPRINKLE 25 MG CAP SPRINKtopiramate 3

topiramate 100 mg tab 1 QL 120 / 30 DAYS

topiramate 15 mg cap sprink 1


topiramate 25 mg cap sprink 1



topiramate er 100 mg cp24 sprnk 2QL 120 / 30 DAYS

PA


PA


PA




PA


PA

TRILEPTAL 150 MG TABoxcarbazepine 3


TRILEPTAL 300 MG/5ML SUSPENSIONoxcarbazepine 3


VIMPAT 10 MG/ML SOLUTIONlacosamide 3

QL 1200 / 30 DAYS

ST

VIMPAT 100 MG TABlacosamide 3

QL 60 / 30 day(s)

PA


QL 60 / 30 day(s)

PA


QL 60 / 30 day(s)

PA


QL 60 / 30 day(s)

PA

ZONEGRAN 100 MG CAPzonisamide 3

ZONEGRAN 25 MG CAPzonisamide 3

zonisamide 100 mg cap 1



CARBAMATES

felbamate 400 mg tab 1

felbamate 600 mg tab 1



felbamate 600 mg/5ml suspension 1

FELBATOL 400 MG TABfelbamate 3

FELBATOL 600 MG TABfelbamate 3

FELBATOL 600 MG/5ML SUSPENSIONfelbamate 3

XCOPRI (250 MG DAILY DOSE) 100 & 150 MG TAB THPKcenobamate 3

QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST

XCOPRI 100 MG TABcenobamate 3

QL 1 / 1 day(s)

ST

XCOPRI 14 X 12.5 MG & 14 X 25 MG TAB THPKcenobamate 3

QL 1 / 1 day(s)

ST

XCOPRI 14 X 150 MG & 14 X200 MG TAB THPKcenobamate 3

QL 1 / 1 day(s)

ST

XCOPRI 14 X 50 MG & 14 X100 MG TAB THPKcenobamate 3

QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST

GABA MODULATORS

GABITRIL 12 MG TABtiagabine hcl 3





tiagabine hcl 12 mg tab 1




vigabatrin 500 mg tab 2 PA

HYDANTOINS

DILANTIN 100 MG CAPphenytoin sodium extended 3

DILANTIN 30 MG CAPphenytoin sodium extended 3

DILANTIN INFATABS 50 MG CHEW TABphenytoin 3

PEGANONE 250 MG TABethotoin 2

PHENYTEK 200 MG CAPphenytoin sodium extended 3

PHENYTEK 300 MG CAPphenytoin sodium extended 3

phenytoin 100 mg/4ml suspension 1

phenytoin 125 mg/5ml suspension 1

phenytoin 50 mg chew tab 1

phenytoin infatabs 50 mg chew tab 1

phenytoin sodium extended 100 mg cap 1



SUCCINIMIDES

CELONTIN 300 MG CAPmethsuximide 2

ethosuximide 250 mg cap 1

ethosuximide 250 mg/5ml solution 1



VALPROIC ACID

DEPAKENE 250 MG CAPvalproic acid 3

DEPAKENE 250 MG/5ML SOLUTIONvalproate sodium 3

DEPAKOTE 125 MG TAB DRdivalproex sodium 3



DEPAKOTE ER 250 MG TAB ER 24Hdivalproex sodium 3

DEPAKOTE ER 500 MG TAB ER 24Hdivalproex sodium 3

DEPAKOTE SPRINKLES 125 MG CAP DRdivalproex sodium 3

divalproex sodium 125 mg cap dr 1

divalproex sodium 125 mg tab dr 1



divalproex sodium er 250 mg tab er 24h 1

divalproex sodium er 500 mg tab er 24h 1

valproate sodium 250 mg/5ml solution 1

valproic acid 250 mg cap 1

valproic acid 250 mg/5ml solution 1

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine 15 mg tab 1 QL 30 / 30 DAYS

mirtazapine 15 mg tab disp 1 QL 30 / 30 DAYS







mirtazapine 7.5 mg tab 1 QL 30 / 30 DAYS

ANTIDEPRESSANTS - MISC.

bupropion hcl 100 mg tab 1 QL 60 / 30 DAYS

bupropion hcl 75 mg tab 1 QL 180 / 30 DAYS

bupropion hcl er (sr) 100 mg tab er 12h 1 QL 60 / 30 DAYS



bupropion hcl er (xl) 150 mg tab er 24h 1 QL 90 / 30 DAYS

bupropion hcl er (xl) 300 mg tab er 24h 1 QL 60 / 30 DAYS

FORFIVO XL 450 MG TAB ER 24Hbupropion hcl 3

QL 30 / 30 DAYS

ST

MAPROTILINE HCL 25 MG TABmaprotiline hcl 1 QL 270 / 30 DAYS

MAPROTILINE HCL 50 MG TABmaprotiline hcl 1 QL 135 / 30 DAYS

MAPROTILINE HCL 75 MG TABmaprotiline hcl 1

MONOAMINE OXIDASE INHIBITORS (MAOIS)

EMSAM 12 MG/24HR PATCH 24HRselegiline 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

MARPLAN 10 MG TABisocarboxazid 3

phenelzine sulfate 15 mg tab 1

tranylcypromine sulfate 10 mg tab 1



N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS

SPRAVATO (56 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl 3

QL 16 / 28 DAYS

PA

SPRAVATO (84 MG DOSE) 28 MG/DEVICE SOLN THPKesketamine hcl 3

QL 16 / 28 DAYS

PA

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

citalopram hydrobromide 10 mg tab 1 QL 30 / 30 DAYS

citalopram hydrobromide 10 mg/5ml solution 1 QL 600 / 30 DAYS



escitalopram oxalate 10 mg tab 1 QL 60 / 30 DAYS



escitalopram oxalate 5 mg/5ml solution 1 QL 620 / 30 DAYS

fluoxetine hcl 10 mg cap 1 QL 90 / 30 DAYS

fluoxetine hcl 10 mg tab 1 QL 90 / 30 DAYS



fluoxetine hcl 20 mg/5ml solution 1 QL 600 / 30 DAYS


FLUOXETINE HCL 60 MG TABfluoxetine hcl 2 QL 30 / 30 DAYS


FLUOXETINE HCL 90 MG CAP DRfluoxetine hcl 1 QL 4 / 28 DAYS

fluvoxamine maleate 100 mg tab 1 QL 90 / 30 DAYS





fluvoxamine maleate er 100 mg cap er 24h 1

fluvoxamine maleate er 150 mg cap er 24h 1

paroxetine hcl 10 mg tab 1 QL 90 / 30 DAYS

paroxetine hcl 10 mg/5ml suspension 2QL 900 / 30 day(s)

AL1 Up to 8 yrs old




paroxetine hcl er 12.5 mg tab er 24h 1 QL 60 / 30 DAYS

paroxetine hcl er 25 mg tab er 24h 1 QL 60 / 30 DAYS

paroxetine hcl er 37.5 mg tab er 24h 1 QL 60 / 30 DAYS

sertraline hcl 100 mg tab 1 QL 60 / 30 DAYS

sertraline hcl 20 mg/ml conc 1 QL 300 / 30 DAYS



SEROTONIN MODULATORS

NEFAZODONE HCL 100 MG TABnefazodone hcl 1 QL 180 / 30 DAYS





trazodone hcl 100 mg tab 1





TRINTELLIX 10 MG TABvortioxetine hbr 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

VIIBRYD 10 MG TABvilazodone hcl 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

VIIBRYD STARTER PACK 10 & 20 MG KITvilazodone hcl 3

QL 30 / 30 DAYS

ST

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

DESVENLAFAXINE ER 100 MG TAB ER 24Hdesvenlafaxine 1 QL 30 / 30 DAYS

DESVENLAFAXINE ER 50 MG TAB ER 24Hdesvenlafaxine 1 QL 30 / 30 DAYS

desvenlafaxine succinate er 100 mg tab er 24h 1 QL 30 / 30 DAYS



duloxetine hcl 20 mg cp dr part 1 QL 180 / 30 DAYS



EFFEXOR XR 150 MG CAP ER 24Hvenlafaxine hcl 3 QL 60 / 30 DAYS

EFFEXOR XR 37.5 MG CAP ER 24Hvenlafaxine hcl 3

EFFEXOR XR 75 MG CAP ER 24Hvenlafaxine hcl 3



FETZIMA 120 MG CAP ER 24Hlevomilnacipran hcl 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

FETZIMA TITRATION 20 & 40 MG CP24 THPKlevomilnacipran hcl 3

QL 30 / 30 DAYS

ST

KHEDEZLA 100 MG TAB ER 24Hdesvenlafaxine 3 QL 30 / 30 DAYS

KHEDEZLA 50 MG TAB ER 24Hdesvenlafaxine 3 QL 30 / 30 DAYS

venlafaxine hcl 100 mg tab 1 QL 30 / 30 DAYS


venlafaxine hcl 37.5 mg tab 1 QL 90 / 30 DAYS



venlafaxine hcl er 150 mg cap er 24h 1 QL 60 / 30 DAYS

venlafaxine hcl er 37.5 mg cap er 24h 1

venlafaxine hcl er 75 mg cap er 24h 1

TRICYCLIC AGENTS

amitriptyline hcl 10 mg tab 1








AMOXAPINE 100 MG TABamoxapine 1




clomipramine hcl 25 mg cap 1



desipramine hcl 10 mg tab 1






doxepin hcl 10 mg cap 1

doxepin hcl 10 mg/ml conc 1 AL1 Up to 8 yrs old


DOXEPIN HCL 150 MG CAPdoxepin hcl 1




imipramine hcl 10 mg tab 1



imipramine pamoate 100 mg cap 1






NORPRAMIN 10 MG TABdesipramine hcl 3

NORPRAMIN 25 MG TABdesipramine hcl 3

nortriptyline hcl 10 mg cap 1

NORTRIPTYLINE HCL 10 MG/5ML SOLUTIONnortriptyline hcl 1

nortriptyline hcl 10 mg/5ml solution 1




protriptyline hcl 10 mg tab 1

protriptyline hcl 5 mg tab 1

trimipramine maleate 100 mg cap 1



ANTIDIABETICS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose 100 mg tab 1 QL 90 / 30 DAYS



miglitol 100 mg tab 1



ANTIDIABETIC - AMYLIN ANALOGS

SYMLINPEN 120 2700 MCG/2.7ML SOLN PENpramlintide acetate 3

QL 10 / 30 DAYS

PA

SYMLINPEN 60 1500 MCG/1.5ML SOLN PENpramlintide acetate 3

QL 10 / 30 DAYS

PA



BIGUANIDES

metformin hcl 1000 mg tab 1 QL 90 / 30 DAYS


metformin hcl 500 mg/5ml solution 2PA

AL1 0 to 8 yrs old


metformin hcl er 500 mg tab er 24h 1 QL 150 / 30 DAYS

metformin hcl er 750 mg tab er 24h 1 QL 90 / 30 DAYS

DIABETIC OTHER

BAQSIMI ONE PACK 3 MG/DOSE POWDERglucagon 2 QL 2 / 60 day(s)

BAQSIMI TWO PACK 3 MG/DOSE POWDERglucagon 2 QL 2 / 60 day(s)

diazoxide 50 mg/ml suspension 2 AL1 Up to 8 yrs old

GLUCAGEN HYPOKIT 1 MG RECON SOLNglucagon hcl (rdna) 2 QL 2 / 60 day(s)

glucagon emergency 1 mg kit 2 QL 2 / 60 day(s)

GLUCAGON EMERGENCY 1 MG KITglucagon (rdna) 2 QL 2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 0.5 MG/0.1ML SOLN A-INJglucagon 2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 1-PACK 1 MG/0.2ML SOLN A-INJglucagon 2 QL 0.4 / 60 day(s)

GVOKE HYPOPEN 2-PACK 0.5 MG/0.1ML SOLN A-INJglucagon 2 QL 0.2 / 60 day(s)

GVOKE HYPOPEN 2-PACK 1 MG/0.2ML SOLN A-INJglucagon 2 QL 0.4 / 60 day(s)

GVOKE KIT 1 MG/0.2ML SOLUTIONglucagon 2 QL 2 / 60 day(s)

GVOKE PFS 0.5 MG/0.1ML SOLN PRSYRglucagon 2 QL 0.2 / 60 day(s)

GVOKE PFS 1 MG/0.2ML SOLN PRSYRglucagon 2 QL 0.4 / 60 day(s)



DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

ALOGLIPTIN BENZOATE 12.5 MG TABalogliptin benzoate 3

QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 25 MG TABalogliptin benzoate 3

QL 30 / 30 DAYS

ST

ALOGLIPTIN BENZOATE 6.25 MG TABalogliptin benzoate 3

QL 30 / 30 DAYS

ST

JANUVIA 100 MG TABsitagliptin phosphate 2

QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST


QL 1 / 1 day(s)

ST

ONGLYZA 2.5 MG TABsaxagliptin hcl 3

QL 1 / 1 day(s)

ST

ONGLYZA 5 MG TABsaxagliptin hcl 3

QL 1 / 1 day(s)

ST

TRADJENTA 5 MG TABlinagliptin 2

QL 1 / 1 day(s)

ST

DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS

JANUMET 50-1000 MG TABsitagliptin-metformin hcl 2

QL 2 / 1 day(s)

ST

JANUMET 50-500 MG TABsitagliptin-metformin hcl 2

QL 2 / 1 day(s)

ST

JANUMET XR 100-1000 MG TAB ER 24Hsitagliptin-metformin hcl 2

QL 1 / 1 day(s)

ST


QL 2 / 1 day(s)

ST


QL 30 / 30 DAYS

ST



JENTADUETO 2.5-1000 MG TABlinagliptin-metformin hcl 2

QL 2 / 1 day(s)

ST


QL 2 / 1 day(s)

ST


QL 2 / 1 day(s)

ST

JENTADUETO XR 2.5-1000 MG TAB ER 24Hlinagliptin-metformin hcl 2

QL 2 / 1 day(s)

ST

JENTADUETO XR 5-1000 MG TAB ER 24Hlinagliptin-metformin hcl 2

QL 1 / 1 day(s)

ST

KOMBIGLYZE XR 2.5-1000 MG TAB ER 24Hsaxagliptin-metformin hcl 3

QL 2 / 1 day(s)

ST

KOMBIGLYZE XR 5-1000 MG TAB ER 24Hsaxagliptin-metformin hcl 3

QL 1 / 1 day(s)

ST

KOMBIGLYZE XR 5-500 MG TAB ER 24Hsaxagliptin-metformin hcl 3

QL 1 / 1 day(s)

ST

DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES

CYCLOSET 0.8 MG TABbromocriptine mesylate (diabetes) 3 PA

HUMAN INSULIN

BASAGLAR KWIKPEN 100 UNIT/ML SOLN PENinsulin glargine 2 QL 2 / 1 day(s)

HUMALOG 100 UNIT/ML SOLN CARTinsulin lispro 1 QL 2 / 1 day(s)

HUMALOG 100 UNIT/ML SOLUTIONinsulin lispro 1 QL 2 / 1 day(s)

HUMALOG JUNIOR KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro 1 QL 2 / 1 day(s)

HUMALOG KWIKPEN 100 UNIT/ML SOLN PENinsulin lispro 1 QL 2 / 1 day(s)

HUMALOG KWIKPEN 200 UNIT/ML SOLN PENinsulin lispro 1 QL 1 / 1 day(s)



HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro 1 QL 2 / 1 day(s)

HUMALOG MIX 50/50 KWIKPEN (50-50) 100 UNIT/ML SUSPPENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMALOG MIX 75/25 (75-25) 100 UNIT/ML SUSPENSIONinsulin lispro protamine & lispro 1 QL 2 / 1 day(s)

HUMALOG MIX 75/25 KWIKPEN (75-25) 100 UNIT/ML SUSPPENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSIONinsulin nph isophane & reg (human) 1 QL 2 / 1 day(s)

HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML SUSP PENinsulin nph isophane & reg (human) 1 QL 2 / 1 day(s)

HUMULIN N 100 UNIT/ML SUSPENSIONinsulin nph (human) (isophane) 1 QL 2 / 1 day(s)

HUMULIN N KWIKPEN 100 UNIT/ML SUSP PENinsulin nph (human) (isophane) 1 QL 2 / 1 day(s)

HUMULIN R 100 UNIT/ML SOLUTIONinsulin regular (human) 1 QL 2 / 1 day(s)

HUMULIN R U-500 (CONCENTRATED) 500 UNIT/MLSOLUTIONinsulin regular (human)

1 QL 2 / 1 day(s)

HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PENinsulin regular (human) 1 QL 1 / 1 day(s)

INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SOLN PENinsulin lispro 1 QL 2 / 1 day(s)

INSULIN LISPRO 100 UNIT/ML SOLUTIONinsulin lispro 1 QL 2 / 1 day(s)

INSULIN LISPRO JUNIOR KWIKPEN 100 UNIT/ML SOLNPENinsulin lispro

1 QL 2 / 1 day(s)

INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/MLSUSP PENinsulin lispro protamine & lispro

1 QL 2 / 1 day(s)

LANTUS 100 UNIT/ML SOLUTIONinsulin glargine 3

QL 2 / 1 day(s)

PA

LANTUS SOLOSTAR 100 UNIT/ML SOLN PENinsulin glargine 3

QL 2 / 1 day(s)

PA



LEVEMIR 100 UNIT/ML SOLUTIONinsulin detemir 3

QL 2 / 1 day(s)

PA

LEVEMIR FLEXTOUCH 100 UNIT/ML SOLN PENinsulin detemir 3

QL 2 / 1 day(s)

PA

TRESIBA 100 UNIT/ML SOLUTIONinsulin degludec 3

QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PENinsulin degludec 3

QL 2 / 1 day(s)

PA

TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PENinsulin degludec 3

QL 0.9 / 1 day(s)

PA

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

BYDUREON 2 MG PENexenatide 2

QL 4 / 28 DAYS

ST

BYDUREON 2 MG SRERexenatide 2

QL 4 / 28 DAYS

ST

BYDUREON BCISE 2 MG/0.85ML A-INJexenatide 2

QL 3.4 / 28 day(s)

ST

OZEMPIC (0.25 OR 0.5 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide 2

QL 1.5 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 2 MG/1.5ML SOLN PENsemaglutide 2

QL 3 / 28 day(s)

ST

OZEMPIC (1 MG/DOSE) 4 MG/3ML SOLN PENsemaglutide 2

QL 3 / 28 day(s)

ST

OZEMPIC (2 MG/DOSE) 8 MG/3ML SOLN PENsemaglutide 2

QL 3 / 28 day(s)

ST

RYBELSUS 14 MG TABsemaglutide 2

QL 30 / 30 day(s)

ST


QL 30 / 30 day(s)

ST




QL 30 / 30 day(s)

ST

TRULICITY 0.75 MG/0.5ML SOLN PENdulaglutide 2

QL 2 / 28 day(s)

ST


QL 2 / 28 day(s)

ST

TRULICITY 3 MG/0.5ML SOLN PENdulaglutide 2

QL 2 / 28 day(s)

ST


QL 2 / 28 day(s)

ST

VICTOZA 18 MG/3ML SOLN PENliraglutide 2

QL 9 / 30 DAYS

ST

INSULIN-INCRETIN MIMETIC COMBINATIONS

SOLIQUA 100-33 UNT-MCG/ML SOLN PENinsulin glargine-lixisenatide 2

QL 0.6 / 1 day(s)

ST

XULTOPHY 100-3.6 UNIT-MG/ML SOLN PENinsulin degludec-liraglutide 3

QL 0.5 / 1 day(s)

PA

MEGLITINIDE ANALOGUES

nateglinide 120 mg tab 1 QL 90 / 30 DAYS

nateglinide 60 mg tab 1 QL 90 / 30 DAYS

repaglinide 0.5 mg tab 1 QL 240 / 30 DAYS

repaglinide 1 mg tab 1 QL 240 / 30 DAYS

repaglinide 2 mg tab 1 QL 120 / 30 DAYS

PROGESTERONE RECEPTOR ANTAGONISTS

KORLYM 300 MG TABmifepristone (hyperglycemia) 4

PA

S Specialty Drug

SGLT2 INHIBITOR - DPP-4 INHIBITOR - BIGUANIDE COMB

TRIJARDY XR 10-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin 2

QL 1 / 1 day(s)

ST



TRIJARDY XR 12.5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin 2

QL 2 / 1 day(s)

ST

TRIJARDY XR 25-5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin 2

QL 1 / 1 day(s)

ST

TRIJARDY XR 5-2.5-1000 MG TAB ER 24Hempagliflozin-linagliptin-metformin 2

QL 2 / 1 day(s)

ST

SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI 10-5 MG TABempagliflozin-linagliptin 2

QL 30 / 30 DAYS

ST

GLYXAMBI 25-5 MG TABempagliflozin-linagliptin 2

QL 30 / 30 DAYS

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA 10 MG TABdapagliflozin propanediol 2

QL 30 / 30 days

ST

FARXIGA 5 MG TABdapagliflozin propanediol 2

QL 30 / 30 days

ST

JARDIANCE 10 MG TABempagliflozin 2

QL 30 / 30 DAYS

ST

JARDIANCE 25 MG TABempagliflozin 2

QL 30 / 30 DAYS

ST

SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB

SYNJARDY 12.5-1000 MG TABempagliflozin-metformin hcl 2

QL 60 / 30 DAYS

ST

SYNJARDY 12.5-500 MG TABempagliflozin-metformin hcl 2

QL 60 / 30 DAYS

ST

SYNJARDY 5-1000 MG TABempagliflozin-metformin hcl 2

QL 60 / 30 DAYS

ST

SYNJARDY 5-500 MG TABempagliflozin-metformin hcl 2

QL 60 / 30 DAYS

ST



SYNJARDY XR 10-1000 MG TAB ER 24Hempagliflozin-metformin hcl 2

QL 60 / 30 days

ST

SYNJARDY XR 12.5-1000 MG TAB ER 24Hempagliflozin-metformin hcl 2

QL 60 / 30 days

ST


QL 60 / 30 days

ST


QL 60 / 30 days

ST

XIGDUO XR 10-1000 MG TAB ER 24Hdapagliflozin-metformin hcl 2

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

XIGDUO XR 2.5-1000 MG TAB ER 24Hdapagliflozin-metformin hcl 2

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

SULFONYLUREA-BIGUANIDE COMBINATIONS

glipizide-metformin hcl 2.5-250 mg tab 1

glipizide-metformin hcl 2.5-500 mg tab 1

glipizide-metformin hcl 5-500 mg tab 1

glyburide-metformin 1.25-250 mg tab 1

glyburide-metformin 2.5-500 mg tab 1

glyburide-metformin 5-500 mg tab 1

SULFONYLUREAS

glimepiride 1 mg tab 1 QL 60 / 30 DAYS





glipizide 10 mg tab 1 QL 120 / 30 DAYS

glipizide 5 mg tab 1 QL 240 / 30 DAYS

glipizide er 10 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide er 2.5 mg tab er 24h 1 QL 240 / 30 DAYS

glipizide er 5 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide xl 10 mg tab er 24h 1 QL 60 / 30 DAYS

glipizide xl 2.5 mg tab er 24h 1 QL 240 / 30 DAYS

glipizide xl 5 mg tab er 24h 1 QL 60 / 30 DAYS

glyburide 1.25 mg tab 1 QL 480 / 30 DAYS

glyburide 2.5 mg tab 1 QL 240 / 30 DAYS

glyburide 5 mg tab 1 QL 120 / 30 DAYS

glyburide micronized 1.5 mg tab 1 QL 120 / 30 DAYS

glyburide micronized 3 mg tab 1 QL 60 / 30 DAYS

glyburide micronized 6 mg tab 1 QL 30 / 30 DAYS

TOLAZAMIDE 250 MG TABtolazamide 1

TOLAZAMIDE 500 MG TABtolazamide 1

TOLBUTAMIDE 500 MG TABtolbutamide 1

THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS

pioglitazone hcl-metformin hcl 15-500 mg tab 1 QL 90 / 30 DAYS

pioglitazone hcl-metformin hcl 15-850 mg tab 1 QL 90 / 30 DAYS

THIAZOLIDINEDIONES

pioglitazone hcl 15 mg tab 1 QL 30 / 30 DAYS





ANTIDIARRHEAL/PROBIOTIC AGENTS

ANTIDIARRHEAL - CHLORIDE CHANNEL ANTAGONISTS

MYTESI 125 MG TAB DRcrofelemer 3 PA

ANTIPERISTALTIC AGENTS

diphenoxylate-atropine 2.5-0.025 mg tab 1 QL 80 / 10 DAYS

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML LIQUIDdiphenoxylate w/ atropine 1

loperamide hcl 2 mg cap 1

MOTOFEN 1-0.025 MG TABdifenoxin w/ atropine 3 QL 16 / 30 day(s)

opium 10 mg/ml (1%) tincture 1 MDS1 7 / 1 day(s)

PAREGORIC 2 MG/5ML TINCTUREparegoric 1 AL1 Up to 8 yrs old

ANTIDOTES AND SPECIFIC ANTAGONISTS

ANTIDOTES - CHELATING AGENTS

CHEMET 100 MG CAPsuccimer 3 PA

deferasirox 125 mg tab sol 4PA

S Specialty Drug

deferasirox 180 mg packet 4PA

S Specialty Drug

deferasirox 180 mg tab 4PA

S Specialty Drug


S Specialty Drug


S Specialty Drug


S Specialty Drug


S Specialty Drug




S Specialty Drug


S Specialty Drug

deferasirox granules 180 mg packet 4PA

S Specialty Drug


S Specialty Drug


S Specialty Drug

deferiprone 1000 mg tab 4PA

S Specialty Drug

deferiprone 500 mg tab 4PA

S Specialty Drug

FERRIPROX 100 MG/ML SOLUTIONdeferiprone 4

PA

S Specialty Drug

FERRIPROX 1000 MG TABdeferiprone 4

PA

S Specialty Drug

FERRIPROX TWICE-A-DAY 1000 MG TABdeferiprone 4

PA

S Specialty Drug

CETYLEV 2.5 GM EFFER TABacetylcysteine (antidote) 3

CETYLEV 500 MG EFFER TABacetylcysteine (antidote) 3

RADIOGARDASE 0.5 GM CAPprussian blue insoluble (ferric hexacyanoferrate ii) 2

OPIOID ANTAGONISTS

KLOXXADO 8 MG/0.1ML LIQUIDnaloxone hcl 1 QL 2 / 30 day(s)

NALOXONE HCL 0.4 MG/ML SOLN CARTnaloxone hcl 1 QL 2 / 30 day(s)



naloxone hcl 0.4 mg/ml solution 1 QL 2 / 30 day(s)

naloxone hcl 2 mg/2ml soln prsyr 1 QL 4 / 30 day(s)

naloxone hcl 4 mg/0.1ml liquid 1 QL 2 / 30 day(s)

naloxone hcl 4 mg/10ml solution 1 QL 10 / 30 day(s)

naltrexone hcl 50 mg tab 1 QL 60 / 30 DAYS

NARCAN 4 MG/0.1ML LIQUIDnaloxone hcl 1 QL 2 / 30 day(s)

VIVITROL 380 MG RECON SUSPnaltrexone 4

QL 1 / 0 DAYS

MFL 1 / 28 DAYS

S Specialty Drug

ZIMHI 5 MG/0.5ML SOLN PRSYRnaloxone hcl 2 QL 1 / 30 day(s)

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

granisetron hcl 1 mg tab 2 QL 14 / 30 DAYS

ondansetron 4 mg tab disp 1 QL 180 / 30 DAYS

ondansetron 8 mg tab disp 1 QL 180 / 30 DAYS

ondansetron hcl 4 mg tab 1 QL 180 / 30 DAYS

ondansetron hcl 4 mg/5ml solution 1 QL 100 / 30 DAYS

ondansetron hcl 8 mg tab 1 QL 180 / 30 DAYS

SANCUSO 3.1 MG/24HR PATCHgranisetron 3

QL 1 / 7 DAYS

PA

SUSTOL 10 MG/0.4ML PRSYRgranisetron 3

PA

S Specialty Drug

ZUPLENZ 4 MG FILMondansetron 3 PA

ZUPLENZ 8 MG FILMondansetron 3 PA



ANTIEMETIC COMBINATIONS

AKYNZEO 300-0.5 MG CAPnetupitant-palonosetron 3

QL 1 / 0 day(s)

PA

ANTIEMETICS - ANTICHOLINERGIC

meclizine hcl 12.5 mg tab 1

meclizine hcl 25 mg tab 1

scopolamine 1 mg/3days patch 72hr 1 QL 10 / 30 DAYS

trimethobenzamide hcl 300 mg cap 1

ANTIEMETICS - MISCELLANEOUS

dronabinol 10 mg cap 2 QL 60 / 30 DAYS

dronabinol 2.5 mg cap 2 QL 60 / 30 DAYS

dronabinol 5 mg cap 2 QL 60 / 30 DAYS

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant 125 mg cap 1 QL 1 / 21 day(s)

aprepitant 80 & 125 mg cap 1 QL 3 / 21 day(s)

aprepitant 80 & 125 mg misc 1 QL 3 / 21 day(s)

aprepitant 80 mg cap 1 QL 2 / 21 day(s)

VARUBI (180 MG DOSE) 2 X 90 MG TAB THPKrolapitant hcl 3 PA

ANTIFUNGALS

ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (TRITERPENOIDS)

BREXAFEMME 150 MG TABibrexafungerp citrate 3

QL 4 / 30 day(s)

ST

GL Female


flucytosine 250 mg cap 1

flucytosine 500 mg cap 1

griseofulvin microsize 125 mg/5ml suspension 1

griseofulvin microsize 500 mg tab 2 QL 30 / 30 DAYS



griseofulvin ultramicrosize 125 mg tab 2 QL 30 / 30 DAYS

griseofulvin ultramicrosize 250 mg tab 2 QL 30 / 30 DAYS

nystatin 500000 unit tab 1

terbinafine hcl 250 mg tab 1 QL 30 / 30 DAYS

IMIDAZOLES

ketoconazole 200 mg tab 1

TRIAZOLES

CRESEMBA 186 MG CAPisavuconazonium sulfate 4

PA

S Specialty Drug

fluconazole 10 mg/ml recon susp 1

fluconazole 100 mg tab 1

fluconazole 150 mg tab 1 QL 180 / 30 DAYS


fluconazole 40 mg/ml recon susp 1


itraconazole 100 mg cap 1

NOXAFIL 40 MG/ML SUSPENSIONposaconazole 4

PA

S Specialty Drug

posaconazole 100 mg tab dr 4 PA

voriconazole 200 mg tab 2 QL 60 / 30 DAYS

voriconazole 40 mg/ml recon susp 1 AL1 Up to 8 yrs old

voriconazole 50 mg tab 1 QL 120 / 30 DAYS

ANTIHISTAMINES

ANTIHISTAMINES - ETHANOLAMINES

carbinoxamine maleate 4 mg tab 1

CARBINOXAMINE MALEATE 4 MG/5ML SOLUTIONcarbinoxamine maleate 1

carbinoxamine maleate 4 mg/5ml solution 1

CLEMASTINE FUMARATE 2.68 MG TABclemastine fumarate 1



di-phen 12.5 mg/5ml elixir 1

PA

AL1 Up to 8 yrs old

S Specialty Drug

ANTIHISTAMINES - NON-SEDATING

cetirizine hcl 1 mg/ml solution 1

cetirizine hcl 5 mg/5ml solution 1

desloratadine 5 mg tab 1 QL 30 / 30 DAYS

DESLORATADINE 5 MG TAB DISPdesloratadine 1 QL 30 / 30 DAYS

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 300 / 30 DAYS

levocetirizine dihydrochloride 5 mg tab 1 QL 30 / 30 DAYS

ANTIHISTAMINES - PHENOTHIAZINES

phenadoz 12.5 mg suppos 1

phenadoz 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 12.5 mg suppos 1

promethazine hcl 12.5 mg tab 1

promethazine hcl 25 mg suppos 1 QL 30 / 30 DAYS

promethazine hcl 25 mg tab 1

promethazine hcl 50 mg suppos 1

promethazine hcl 50 mg tab 1

promethazine hcl 6.25 mg/5ml solution 1

promethazine hcl 6.25 mg/5ml syrup 1

promethegan 12.5 mg suppos 1

promethegan 25 mg suppos 1 QL 30 / 30 DAYS

ANTIHISTAMINES - PIPERIDINES

cyproheptadine hcl 2 mg/5ml syrup 1

cyproheptadine hcl 4 mg tab 1



ANTIHYPERLIPIDEMICS

ACL INHIB-INTESTINAL CHOLESTEROL ABSORPTION INHIB COMB

NEXLIZET 180-10 MG TABbempedoic acid-ezetimibe 3 PA

ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS

NEXLETOL 180 MG TABbempedoic acid 3 PA

ANTIHYPERLIPIDEMICS - MISC.

icosapent ethyl 1 gm cap 2QL 4 / 1 day(s)

PA

omega-3-acid ethyl esters 1 gm cap 1

triklo 1 gm cap 1

VASCEPA 0.5 GM CAPicosapent ethyl 3

QL 120 / 30 DAYS

PA

BILE ACID SEQUESTRANTS

cholestyramine 4 gm packet 1

cholestyramine 4 gm/dose powder 1

cholestyramine light 4 gm packet 1

cholestyramine light 4 gm/dose powder 1

colesevelam hcl 3.75 gm packet 2QL 30 / 30 DAYS

AL1 Up to 8 yrs old

colesevelam hcl 625 mg tab 2 QL 180 / 30 DAYS

colestipol hcl 1 gm tab 1

colestipol hcl 5 gm granules 1

colestipol hcl 5 gm packet 1

prevalite 4 gm packet 1

prevalite 4 gm/dose powder 1

FIBRIC ACID DERIVATIVES

fenofibrate 134 mg cap 1 QL 30 / 30 DAYS

fenofibrate 145 mg tab 1 QL 30 / 30 DAYS









fenofibrate micronized 130 mg cap 1 QL 30 / 30 DAYS





FENOFIBRIC ACID 105 MG TABfenofibric acid 1 QL 30 / 30 DAYS

fenofibric acid 135 mg cap dr 1 QL 30 / 30 DAYS

FENOFIBRIC ACID 35 MG TABfenofibric acid 1 QL 30 / 30 DAYS

fenofibric acid 45 mg cap dr 1 QL 30 / 30 DAYS

gemfibrozil 600 mg tab 1

HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 10 mg tab 1QL 30 / 30 DAYS

PREV Preventative

atorvastatin calcium 20 mg tab 1QL 30 / 30 DAYS

PREV Preventative

atorvastatin calcium 40 mg tab 1 QL 30 / 30 DAYS

atorvastatin calcium 80 mg tab 1 QL 30 / 30 DAYS

fluvastatin sodium 20 mg cap 1QL 30 / 30 DAYS

PREV Preventative

fluvastatin sodium 40 mg cap 1QL 60 / 30 DAYS

PREV Preventative



fluvastatin sodium er 80 mg tab er 24h 1QL 30 / 30 DAYS

PREV Preventative

lovastatin 10 mg tab 1QL 30 / 30 DAYS

PREV Preventative


PREV Preventative


PREV Preventative

pravastatin sodium 10 mg tab 1QL 30 / 30 DAYS

PREV Preventative


PREV Preventative


PREV Preventative


PREV Preventative

rosuvastatin calcium 10 mg tab 1QL 30 / 30 DAYS

PREV Preventative

rosuvastatin calcium 20 mg tab 1 QL 30 / 30 DAYS

rosuvastatin calcium 40 mg tab 1 QL 30 / 30 DAYS

rosuvastatin calcium 5 mg tab 1QL 30 / 30 DAYS

PREV Preventative

simvastatin 10 mg tab 1QL 30 / 30 DAYS

PREV Preventative


PREV Preventative


PREV Preventative


PREV Preventative



simvastatin 80 mg tab 1 QL 30 / 30 DAYS

INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB

EZETIMIBE-ROSUVASTATIN 10-10 MG TABezetimibe-rosuvastatin calcium 1 QL 1 / 1 day(s)




ezetimibe-simvastatin 10-10 mg tab 1 QL 30 / 30 DAYS




INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe 10 mg tab 1 QL 30 / 30 DAYS

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS

JUXTAPID 10 MG CAPlomitapide mesylate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



NICOTINIC ACID DERIVATIVES

niacin er (antihyperlipidemic) 1000 mg tab er 1



NIACOR 500 MG TABniacin (antihyperlipidemic) 3

PCSK9 INHIBITORS

REPATHA 140 MG/ML SOLN PRSYRevolocumab 2 ST

REPATHA PUSHTRONEX SYSTEM 420 MG/3.5ML SOLNCARTevolocumab

2 ST

REPATHA SURECLICK 140 MG/ML SOLN A-INJevolocumab 2 ST

SMALL INTERFERING RNA (SIRNA) PCSK9 INHIBITORS

LEQVIO 284 MG/1.5ML SOLN PRSYRinclisiran sodium 4

PA

S Specialty Drug

ANTIHYPERTENSIVES

ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besy-benazepril hcl 10-20 mg cap 1


amlodipine besy-benazepril hcl 2.5-10 mg cap 1 QL 30 / 30 DAYS




TRANDOLAPRIL-VERAPAMIL HCL ER 1-240 MG TAB ERtrandolapril-verapamil hcl 1 QL 30 / 30 DAYS

trandolapril-verapamil hcl er 2-180 mg tab er 1 QL 30 / 30 DAYS



TRANDOLAPRIL-VERAPAMIL HCL ER 2-240 MG TAB ERtrandolapril-verapamil hcl 1 QL 30 / 30 day(s)





ACE INHIBITORS

benazepril hcl 10 mg tab 1




captopril 100 mg tab 1

captopril 12.5 mg tab 1



enalapril maleate 1 mg/ml solution 2 AL1 Up to 8 yrs old

enalapril maleate 10 mg tab 1

enalapril maleate 2.5 mg tab 1



fosinopril sodium 10 mg tab 1



lisinopril 10 mg tab 1

lisinopril 2.5 mg tab 1





moexipril hcl 15 mg tab 1

moexipril hcl 7.5 mg tab 1

perindopril erbumine 2 mg tab 1





QBRELIS 1 MG/ML SOLUTIONlisinopril 2 AL1 Up to 8 yrs old

quinapril hcl 10 mg tab 1




ramipril 1.25 mg cap 1 QL 30 / 30 DAYS

ramipril 10 mg cap 1 QL 60 / 30 DAYS

ramipril 2.5 mg cap 1 QL 30 / 30 DAYS

ramipril 5 mg cap 1 QL 30 / 30 DAYS

trandolapril 1 mg tab 1 QL 30 / 30 DAYS



ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE

benazepril-hydrochlorothiazide 10-12.5 mg tab 1


benazepril-hydrochlorothiazide 20-25 mg tab 1


BENAZEPRIL-HYDROCHLOROTHIAZIDE 5-6.25 MG TABbenazepril & hydrochlorothiazide 1

CAPTOPRIL-HYDROCHLOROTHIAZIDE 25-15 MG TABcaptopril & hydrochlorothiazide 1




enalapril-hydrochlorothiazide 10-25 mg tab 1

enalapril-hydrochlorothiazide 5-12.5 mg tab 1



fosinopril sodium-hctz 10-12.5 mg tab 1

fosinopril sodium-hctz 20-12.5 mg tab 1

lisinopril-hydrochlorothiazide 10-12.5 mg tab 1

lisinopril-hydrochlorothiazide 20-12.5 mg tab 1

lisinopril-hydrochlorothiazide 20-25 mg tab 1

moexipril-hydrochlorothiazide 15-12.5 mg tab 1

moexipril-hydrochlorothiazide 15-25 mg tab 1

moexipril-hydrochlorothiazide 7.5-12.5 mg tab 1

quinapril-hydrochlorothiazide 10-12.5 mg tab 1

quinapril-hydrochlorothiazide 20-12.5 mg tab 1

quinapril-hydrochlorothiazide 20-25 mg tab 1

ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE COMB

METHYLDOPA-HYDROCHLOROTHIAZIDE 250-15 MG TABmethyldopa & hydrochlorothiazide 1

METHYLDOPA-HYDROCHLOROTHIAZIDE 250-25 MG TABmethyldopa & hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES

amlodipine-valsartan-hctz 10-160-12.5 mg tab 1 QL 30 / 30 day(s)

amlodipine-valsartan-hctz 10-160-25 mg tab 1 QL 30 / 30 day(s)


amlodipine-valsartan-hctz 5-160-12.5 mg tab 1 QL 30 / 30 day(s)


olmesartan-amlodipine-hctz 20-5-12.5 mg tab 1 QL 30 / 30 DAYS


olmesartan-amlodipine-hctz 40-10-25 mg tab 1 QL 30 / 30 DAYS


olmesartan-amlodipine-hctz 40-5-25 mg tab 1 QL 30 / 30 DAYS

ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB

amlodipine besylate-valsartan 10-160 mg tab 1



amlodipine besylate-valsartan 10-320 mg tab 1

amlodipine besylate-valsartan 5-160 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate-valsartan 5-320 mg tab 1 QL 30 / 30 DAYS

amlodipine-olmesartan 10-20 mg tab 1




telmisartan-amlodipine 40-10 mg tab 1 QL 30 / 30 DAYS




ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE

candesartan cilexetil-hctz 16-12.5 mg tab 1

candesartan cilexetil-hctz 32-12.5 mg tab 1

candesartan cilexetil-hctz 32-25 mg tab 1

irbesartan-hydrochlorothiazide 150-12.5 mg tab 1

irbesartan-hydrochlorothiazide 300-12.5 mg tab 1

losartan potassium-hctz 100-12.5 mg tab 1

losartan potassium-hctz 100-25 mg tab 1

losartan potassium-hctz 50-12.5 mg tab 1

olmesartan medoxomil-hctz 20-12.5 mg tab 1 QL 30 / 30 DAYS

olmesartan medoxomil-hctz 40-12.5 mg tab 1 QL 30 / 30 DAYS

olmesartan medoxomil-hctz 40-25 mg tab 1

telmisartan-hctz 40-12.5 mg tab 1 QL 30 / 30 DAYS

telmisartan-hctz 80-12.5 mg tab 1

telmisartan-hctz 80-25 mg tab 1 QL 30 / 30 DAYS

valsartan-hydrochlorothiazide 160-12.5 mg tab 1

valsartan-hydrochlorothiazide 160-25 mg tab 1




valsartan-hydrochlorothiazide 320-25 mg tab 1


ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan cilexetil 16 mg tab 1 QL 30 / 30 DAYS




EPROSARTAN MESYLATE 600 MG TABeprosartan mesylate 1 QL 30 / 30 DAYS

irbesartan 150 mg tab 1 QL 30 / 30 DAYS



losartan potassium 100 mg tab 1 QL 60 / 30 DAYS



olmesartan medoxomil 20 mg tab 1



telmisartan 20 mg tab 1



valsartan 160 mg tab 1 QL 30 / 30 DAYS






ANTIADRENERGICS - CENTRALLY ACTING

clonidine 0.1 mg/24hr patch wk 1



clonidine hcl 0.1 mg tab 1



guanfacine hcl 1 mg tab 1

guanfacine hcl 2 mg tab 1

METHYLDOPA 250 MG TABmethyldopa 1

methyldopa 250 mg tab 1

METHYLDOPA 500 MG TABmethyldopa 1

methyldopa 500 mg tab 1

ANTIADRENERGICS - PERIPHERALLY ACTING

doxazosin mesylate 1 mg tab 1 QL 30 / 30 DAYS




prazosin hcl 1 mg cap 1



terazosin hcl 1 mg cap 1 QL 30 / 30 DAYS




ANTIHYPERTENSIVES - MISC.

VECAMYL 2.5 MG TABmecamylamine hcl 3 PA



BETA BLOCKER & DIURETIC COMBINATIONS

atenolol-chlorthalidone 100-25 mg tab 1

atenolol-chlorthalidone 50-25 mg tab 1

bisoprolol-hydrochlorothiazide 10-6.25 mg tab 1

bisoprolol-hydrochlorothiazide 2.5-6.25 mg tab 1

bisoprolol-hydrochlorothiazide 5-6.25 mg tab 1

DUTOPROL 100-12.5 MG TAB ER 24Hmetoprolol & hydrochlorothiazide 3 QL 120 / 30 DAYS

DUTOPROL 25-12.5 MG TAB ER 24Hmetoprolol & hydrochlorothiazide 3

DUTOPROL 50-12.5 MG TAB ER 24Hmetoprolol & hydrochlorothiazide 3

metoprolol-hydrochlorothiazide 100-25 mg tab 1

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MG TABmetoprolol & hydrochlorothiazide 1

metoprolol-hydrochlorothiazide 50-25 mg tab 1

NADOLOL-BENDROFLUMETHIAZIDE 40-5 MG TABnadolol & bendroflumethiazide 1

PROPRANOLOL-HCTZ 40-25 MG TABpropranolol & hydrochlorothiazide 1

PROPRANOLOL-HCTZ 80-25 MG TABpropranolol & hydrochlorothiazide 1

DIRECT RENIN INHIBITORS

aliskiren fumarate 150 mg tab 2

aliskiren fumarate 300 mg tab 2

DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB

TEKTURNA HCT 150-12.5 MG TABaliskiren-hydrochlorothiazide 3 QL 30 / 30 DAYS

TEKTURNA HCT 150-25 MG TABaliskiren-hydrochlorothiazide 3 QL 30 / 30 DAYS

TEKTURNA HCT 300-12.5 MG TABaliskiren-hydrochlorothiazide 3 QL 30 / 30 DAYS

TEKTURNA HCT 300-25 MG TABaliskiren-hydrochlorothiazide 3 QL 30 / 30 DAYS



SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

eplerenone 25 mg tab 1 QL 60 / 30 DAYS

eplerenone 50 mg tab 1 QL 60 / 30 DAYS

VASODILATORS

hydralazine hcl 10 mg tab 1




minoxidil 10 mg tab 1

minoxidil 2.5 mg tab 1

ANTIMALARIALS

ANTIMALARIAL COMBINATIONS

atovaquone-proguanil hcl 250-100 mg tab 1

atovaquone-proguanil hcl 62.5-25 mg tab 1

COARTEM 20-120 MG TABartemether-lumefantrine 2

chloroquine phosphate 250 mg tab 1

CHLOROQUINE PHOSPHATE 500 MG TABchloroquine phosphate 1

chloroquine phosphate 500 mg tab 1

HYDROXYCHLOROQUINE SULFATE 100 MG TABhydroxychloroquine sulfate 1

hydroxychloroquine sulfate 200 mg tab 1



mefloquine hcl 250 mg tab 1

PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG TABprimaquine phosphate 2

primaquine phosphate 26.3 (15 base) mg tab 2

quinine sulfate 324 mg cap 1



ANTIMYASTHENIC/CHOLINERGIC AGENTS

GUANIDINE HCL 125 MG TABguanidine hcl 1

pyridostigmine bromide 60 mg tab 1

pyridostigmine bromide er 180 mg tab er 1

RUZURGI 10 MG TABamifampridine 4

PA

S Specialty Drug

ANTIMYCOBACTERIAL AGENTS

ANTI TB COMBINATIONS

RIFAMATE 150-300 MG CAPisoniazid & rifampin 3

RIFATER 50-120-300 MG TABisoniazid-rifampin w/ pyrazinamide 3

CYCLOSERINE 250 MG CAPcycloserine 2

cycloserine 250 mg cap 2

ethambutol hcl 100 mg tab 1

ethambutol hcl 400 mg tab 1

ISONIAZID 100 MG TABisoniazid 1

isoniazid 100 mg tab 1

ISONIAZID 100 MG/ML SOLUTIONisoniazid 1

isoniazid 300 mg tab 1

ISONIAZID 50 MG/5ML SYRUPisoniazid 1

PASER 4 GM PACKETaminosalicylic acid 3 AL1 Up to 8 yrs old

PRETOMANID 200 MG TABpretomanid 3

PRIFTIN 150 MG TABrifapentine 3

pyrazinamide 500 mg tab 1

rifabutin 150 mg cap 1



rifampin 150 mg cap 1

rifampin 300 mg cap 1

SIRTURO 100 MG TABbedaquiline fumarate 4

PA

S Specialty Drug

SIRTURO 20 MG TABbedaquiline fumarate 4

PA

S Specialty Drug

TRECATOR 250 MG TABethionamide 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

ALKYLATING AGENTS

HEXALEN 50 MG CAPaltretamine 4

PA

S Specialty Drug

MYLERAN 2 MG TABbusulfan 4

PA

S Specialty Drug

ANDROGEN BIOSYNTHESIS INHIBITORS

abiraterone acetate 250 mg tab 2

ANTIADRENALS

LYSODREN 500 MG TABmitotane 4

PA

S Specialty Drug

ANTIANDROGENS

bicalutamide 50 mg tab 1

ERLEADA 60 MG TABapalutamide 4

PA

S Specialty Drug

FLUTAMIDE 125 MG CAPflutamide 1

flutamide 125 mg cap 1

nilutamide 150 mg tab 2QL 60 / 30 DAYS

PA

XTANDI 40 MG CAPenzalutamide 4

PA

S Specialty Drug



XTANDI 40 MG TABenzalutamide 4

PA

S Specialty Drug

XTANDI 80 MG TABenzalutamide 4

PA

S Specialty Drug

ANTIESTROGENS

SOLTAMOX 10 MG/5ML SOLUTIONtamoxifen citrate 3 PA

tamoxifen citrate 10 mg tab 1 PREV Preventative

tamoxifen citrate 20 mg tab 1 PREV Preventative

toremifene citrate 60 mg tab 2

ANTIMETABOLITES

capecitabine 150 mg tab 2

capecitabine 500 mg tab 2

mercaptopurine 50 mg tab 1

methotrexate 2.5 mg tab 1

methotrexate sodium (pf) 1 gm/40ml solution 1

methotrexate sodium (pf) 250 mg/10ml solution 1

methotrexate sodium (pf) 50 mg/2ml solution 1

methotrexate sodium 1 gm recon soln 1

methotrexate sodium 2.5 mg tab 1

METHOTREXATE SODIUM 250 MG/10ML SOLUTIONmethotrexate sodium 1

methotrexate sodium 50 mg/2ml solution 1

PURIXAN 2000 MG/100ML SUSPENSIONmercaptopurine 4

PA

S Specialty Drug

TABLOID 40 MG TABthioguanine 4

PA

S Specialty Drug

ANTINEOPLASTIC - ALK INHIBITORS

ALECENSA 150 MG CAPalectinib hcl 4

PA

S Specialty Drug



XALKORI 200 MG CAPcrizotinib 4

PA

S Specialty Drug

XALKORI 250 MG CAPcrizotinib 4

PA

S Specialty Drug

ZYKADIA 150 MG CAPceritinib 4

PA

S Specialty Drug

ANTINEOPLASTIC - ANTI-HER2 AGENTS

TUKYSA 150 MG TABtucatinib 4

PA

S Specialty Drug

TUKYSA 50 MG TABtucatinib 4

PA

S Specialty Drug

ANTINEOPLASTIC - BCL-2 INHIBITORS

VENCLEXTA 10 MG TABvenetoclax 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

VENCLEXTA STARTING PACK 10 & 50 & 100 MG TAB THPKvenetoclax 4

PA

S Specialty Drug

ANTINEOPLASTIC - BCR-ABL KINASE INHIBITORS

BOSULIF 100 MG TABbosutinib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ICLUSIG 10 MG TABponatinib hcl 4

PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

imatinib mesylate 100 mg tab 2 QL 90 / 30 DAYS

imatinib mesylate 400 mg tab 2 QL 60 / 30 DAYS

SCEMBLIX 20 MG TABasciminib hcl 4

PA

S Specialty Drug

SCEMBLIX 40 MG TABasciminib hcl 4

PA

S Specialty Drug

SPRYCEL 100 MG TABdasatinib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

TASIGNA 150 MG CAPnilotinib hcl 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



ANTINEOPLASTIC - BRAF KINASE INHIBITORS

BRAFTOVI 50 MG CAPencorafenib 4

PA

S Specialty Drug

BRAFTOVI 75 MG CAPencorafenib 4

PA

S Specialty Drug

TAFINLAR 50 MG CAPdabrafenib mesylate 4

PA

S Specialty Drug

TAFINLAR 75 MG CAPdabrafenib mesylate 4

PA

S Specialty Drug

ZELBORAF 240 MG TABvemurafenib 4

PA

S Specialty Drug

ANTINEOPLASTIC - BTK INHIBITORS

BRUKINSA 80 MG CAPzanubrutinib 4

PA

S Specialty Drug

CALQUENCE 100 MG CAPacalabrutinib 4

PA

S Specialty Drug

IMBRUVICA 140 MG CAPibrutinib 4

PA

S Specialty Drug

IMBRUVICA 420 MG TABibrutinib 4

PA

S Specialty Drug

IMBRUVICA 560 MG TABibrutinib 4

PA

S Specialty Drug

IMBRUVICA 70 MG CAPibrutinib 4

PA

S Specialty Drug

ANTINEOPLASTIC - EGFR INHIBITORS

erlotinib hcl 100 mg tab 4 PA





EXKIVITY 40 MG CAPmobocertinib succinate 4

PA

S Specialty Drug

GILOTRIF 20 MG TABafatinib dimaleate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

TAGRISSO 40 MG TABosimertinib mesylate 4

PA

S Specialty Drug

TAGRISSO 80 MG TABosimertinib mesylate 4

PA

S Specialty Drug

VIZIMPRO 15 MG TABdacomitinib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTINEOPLASTIC - FGFR KINASE INHIBITORS

BALVERSA 3 MG TABerdafitinib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

PEMAZYRE 13.5 MG TABpemigatinib 4

PA

S Specialty Drug

PEMAZYRE 4.5 MG TABpemigatinib 4

PA

S Specialty Drug



PEMAZYRE 9 MG TABpemigatinib 4

PA

S Specialty Drug

TRUSELTIQ (100MG DAILY DOSE) 100 MG CAP THPKinfigratinib phosphate 4

PA

S Specialty Drug

TRUSELTIQ (125MG DAILY DOSE) 100 & 25 MG CAP THPKinfigratinib phosphate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

ERIVEDGE 150 MG CAPvismodegib 4

PA

S Specialty Drug

ODOMZO 200 MG CAPsonidegib phosphate 4

PA

S Specialty Drug

ANTINEOPLASTIC - HIF-2-ALPHA INHIBITORS

WELIREG 40 MG TABbelzutifan 4

PA

S Specialty Drug

ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS

FARYDAK 10 MG CAPpanobinostat lactate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ZOLINZA 100 MG CAPvorinostat 4

PA

S Specialty Drug



ANTINEOPLASTIC - IMMUNOMODULATORS

POMALYST 1 MG CAPpomalidomide 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTINEOPLASTIC - KRAS INHIBITORS

LUMAKRAS 120 MG TABsotorasib 4

PA

S Specialty Drug

ANTINEOPLASTIC - MEK INHIBITORS

COTELLIC 20 MG TABcobimetinib fumarate 4

PA

S Specialty Drug

KOSELUGO 10 MG CAPselumetinib sulfate 4

PA

S Specialty Drug

KOSELUGO 25 MG CAPselumetinib sulfate 4

PA

S Specialty Drug

MEKINIST 0.5 MG TABtrametinib dimethyl sulfoxide 4

PA

S Specialty Drug

MEKINIST 2 MG TABtrametinib dimethyl sulfoxide 4

PA

S Specialty Drug

MEKTOVI 15 MG TABbinimetinib 4

PA

S Specialty Drug

ANTINEOPLASTIC - MET INHIBITORS

TABRECTA 150 MG TABcapmatinib hcl 4

PA

S Specialty Drug

TABRECTA 200 MG TABcapmatinib hcl 4

PA

S Specialty Drug



TEPMETKO 225 MG TABtepotinib hcl 4

PA

S Specialty Drug

ANTINEOPLASTIC - METHYLTRANSFERASE INHIBITORS

TAZVERIK 200 MG TABtazemetostat hbr 4

PA

S Specialty Drug

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

everolimus 10 mg tab 4PA

S Specialty Drug

everolimus 2 mg tab sol 4PA

S Specialty Drug

everolimus 2.5 mg tab 4PA

S Specialty Drug


S Specialty Drug

everolimus 5 mg tab 4PA

S Specialty Drug


S Specialty Drug

everolimus 7.5 mg tab 4PA

S Specialty Drug

ANTINEOPLASTIC - MULTIKINASE INHIBITORS

CABOMETYX 20 MG TABcabozantinib s-malate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

CAPRELSA 100 MG TABvandetanib 4

PA

S Specialty Drug



CAPRELSA 300 MG TABvandetanib 4

PA

S Specialty Drug

COMETRIQ (100 MG DAILY DOSE) 80 & 20 MG KITcabozantinib s-malate 4

PA

S Specialty Drug

COMETRIQ (140 MG DAILY DOSE) 3 X 20 MG & 80 MG KITcabozantinib s-malate 4

PA

S Specialty Drug

COMETRIQ (60 MG DAILY DOSE) 20 MG KITcabozantinib s-malate 4

PA

S Specialty Drug

FOTIVDA 0.89 MG CAPtivozanib hcl 4

PA

S Specialty Drug

FOTIVDA 1.34 MG CAPtivozanib hcl 4

PA

S Specialty Drug

lapatinib ditosylate 250 mg tab 4PA

S Specialty Drug

NERLYNX 40 MG TABneratinib maleate 4

PA

S Specialty Drug

NEXAVAR 200 MG TABsorafenib tosylate 4

PA

S Specialty Drug

QINLOCK 50 MG TABripretinib 4

PA

S Specialty Drug

STIVARGA 40 MG TABregorafenib 4

PA

S Specialty Drug

sunitinib malate 12.5 mg cap 4PA

S Specialty Drug

sunitinib malate 25 mg cap 4PA

S Specialty Drug

sunitinib malate 37.5 mg cap 4PA

S Specialty Drug

sunitinib malate 50 mg cap 4PA

S Specialty Drug



TURALIO 200 MG CAPpexidartinib hcl 4

PA

S Specialty Drug

UKONIQ 200 MG TABumbralisib tosylate 4

PA

S Specialty Drug

VOTRIENT 200 MG TABpazopanib hcl 4

PA

S Specialty Drug

ANTINEOPLASTIC - PDGFR-ALPHA INHIBITORS

AYVAKIT 100 MG TABavapritinib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTINEOPLASTIC - RET INHIBITORS

GAVRETO 100 MG CAPpralsetinib 4

PA

S Specialty Drug

RETEVMO 40 MG CAPselpercatinib 4

PA

S Specialty Drug

RETEVMO 80 MG CAPselpercatinib 4

PA

S Specialty Drug

ANTINEOPLASTIC - TROPOMYOSIN RECEPTOR KINASE INHIBITORS

ROZLYTREK 100 MG CAPentrectinib 4

PA

S Specialty Drug

ROZLYTREK 200 MG CAPentrectinib 4

PA

S Specialty Drug



ANTINEOPLASTIC - XPO1 INHIBITORS

XPOVIO (100 MG ONCE WEEKLY) 20 MG TAB THPKselinexor 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

XPOVIO (40 MG TWICE WEEKLY) 20 MG TAB THPKselinexor 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTINEOPLASTIC COMBINATIONS

INQOVI 35-100 MG TABdecitabine-cedazuridine 4

PA

S Specialty Drug

LONSURF 15-6.14 MG TABtrifluridine-tipiracil 4

PA

S Specialty Drug



LONSURF 20-8.19 MG TABtrifluridine-tipiracil 4

PA

S Specialty Drug

ANTINEOPLASTICS MISC.

hydroxyurea 500 mg cap 1

INTRON A 10000000 UNIT RECON SOLNinterferon alfa-2b 4

PA

S Specialty Drug

INTRON A 10000000 UNIT/ML SOLUTIONinterferon alfa-2b 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

INTRON A 6000000 UNIT/ML SOLUTIONinterferon alfa-2b 4

PA

S Specialty Drug

MATULANE 50 MG CAPprocarbazine hcl 4

PA

S Specialty Drug

AROMATASE INHIBITORS

anastrozole 1 mg tab 1GL Female

PREV Preventative

exemestane 25 mg tab 1 GL Female

letrozole 2.5 mg tab 1 GL Female

CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS

IBRANCE 100 MG CAPpalbociclib 4

PA

S Specialty Drug

IBRANCE 100 MG TABpalbociclib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug

VERZENIO 100 MG TABabemaciclib 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ESTROGENS-ANTINEOPLASTIC

EMCYT 140 MG CAPestramustine phosphate sodium 4

PA

S Specialty Drug

FOLIC ACID ANTAGONISTS RESCUE AGENTS

leucovorin calcium 10 mg tab 2




IMIDAZOTETRAZINES

temozolomide 100 mg cap 2 QL 2 / 1 day(s)








JANUS ASSOCIATED KINASE (JAK) INHIBITORS

JAKAFI 10 MG TABruxolitinib phosphate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

LHRH ANALOGS

ELIGARD 22.5 MG KITleuprolide acetate (3 month) 4

PA

S Specialty Drug

ELIGARD 30 MG KITleuprolide acetate (4 month) 4

PA

S Specialty Drug

ELIGARD 45 MG KITleuprolide acetate (6 month) 4

PA

S Specialty Drug

ELIGARD 7.5 MG KITleuprolide acetate 4

PA

S Specialty Drug

leuprolide acetate 1 mg/0.2ml kit 4PA

S Specialty Drug

LUPRON DEPOT (1-MONTH) 3.75 MG KITleuprolide acetate 4

PA

S Specialty Drug

LUPRON DEPOT (1-MONTH) 7.5 MG KITleuprolide acetate 4

PA

S Specialty Drug

LUPRON DEPOT (3-MONTH) 11.25 MG KITleuprolide acetate (3 month) 4

PA

S Specialty Drug

LUPRON DEPOT (3-MONTH) 22.5 MG KITleuprolide acetate (3 month) 4

PA

S Specialty Drug



LUPRON DEPOT (4-MONTH) 30 MG KITleuprolide acetate (4 month) 4

PA

S Specialty Drug

LUPRON DEPOT (6-MONTH) 45 MG KITleuprolide acetate (6 month) 4

PA

S Specialty Drug

VANTAS 50 MG KIThistrelin acetate 4

PA

S Specialty Drug

ZOLADEX 10.8 MG IMPLANTgoserelin acetate 4

PA

S Specialty Drug

ZOLADEX 3.6 MG IMPLANTgoserelin acetate 4

PA

S Specialty Drug

MITOTIC INHIBITORS

ETOPOSIDE 50 MG CAPetoposide 4

PA

S Specialty Drug

NITROGEN MUSTARDS AND RELATED ANALOGUES

ALKERAN 2 MG TABmelphalan 4

PA

S Specialty Drug

CYCLOPHOSPHAMIDE 25 MG CAPcyclophosphamide 1

cyclophosphamide 25 mg cap 1

CYCLOPHOSPHAMIDE 50 MG CAPcyclophosphamide 1

cyclophosphamide 50 mg cap 1

LEUKERAN 2 MG TABchlorambucil 4

PA

S Specialty Drug

melphalan 2 mg tab 1

NITROSOUREAS

GLEOSTINE 10 MG CAPlomustine 4

PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug

PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS

COPIKTRA 15 MG CAPduvelisib 4

PA

S Specialty Drug

COPIKTRA 25 MG CAPduvelisib 4

PA

S Specialty Drug

PIQRAY (200 MG DAILY DOSE) 200 MG TAB THPKalpelisib 4

PA

S Specialty Drug

PIQRAY (250 MG DAILY DOSE) 200 & 50 MG TAB THPKalpelisib 4

PA

S Specialty Drug

PIQRAY (300 MG DAILY DOSE) 2 X 150 MG TAB THPKalpelisib 4

PA

S Specialty Drug

ZYDELIG 100 MG TABidelalisib 4

PA

S Specialty Drug

ZYDELIG 150 MG TABidelalisib 4

PA

S Specialty Drug

POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS

LYNPARZA 100 MG TABolaparib 4

PA

S Specialty Drug

LYNPARZA 150 MG TABolaparib 4

PA

S Specialty Drug

TALZENNA 0.25 MG CAPtalazoparib tosylate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

TALZENNA 1 MG CAPtalazoparib tosylate 4

PA

S Specialty Drug



PROGESTINS-ANTINEOPLASTIC

HYDROXYPROGESTERONE CAPROATE 1.25 GM/5MLSOLUTIONhydroxyprogesterone caproate (antineoplastic)

4PA

S Specialty Drug

megestrol acetate 20 mg tab 1

megestrol acetate 40 mg tab 1

megestrol acetate 40 mg/ml suspension 1

megestrol acetate 400 mg/10ml suspension 1

RETINOIDS

tretinoin 10 mg cap 1

SELECTIVE RETINOID X RECEPTOR AGONISTS

bexarotene 75 mg cap 2PA

S Specialty Drug

TARGRETIN 75 MG CAPbexarotene 4

PA

S Specialty Drug

TOPOISOMERASE I INHIBITORS

HYCAMTIN 0.25 MG CAPtopotecan hcl 4

PA

S Specialty Drug

HYCAMTIN 1 MG CAPtopotecan hcl 4

PA

S Specialty Drug

URINARY TRACT PROTECTIVE AGENTS

MESNEX 400 MG TABmesna 3 PA

VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS

INLYTA 1 MG TABaxitinib 4

PA

S Specialty Drug

INLYTA 5 MG TABaxitinib 4

PA

S Specialty Drug

LENVIMA (10 MG DAILY DOSE) 10 MG CAP THPKlenvatinib mesylate 4

PA

S Specialty Drug



LENVIMA (14 MG DAILY DOSE) 10 & 4 MG CAP THPKlenvatinib mesylate 4

PA

S Specialty Drug

LENVIMA (18 MG DAILY DOSE) 10 MG & 2 X 4 MG CAPTHPKlenvatinib mesylate

4PA

S Specialty Drug

LENVIMA (20 MG DAILY DOSE) 2 X 10 MG CAP THPKlenvatinib mesylate 4

PA

S Specialty Drug

LENVIMA (24 MG DAILY DOSE) 2 X 10 MG & 4 MG CAPTHPKlenvatinib mesylate

4PA

S Specialty Drug

LENVIMA (8 MG DAILY DOSE) 2 X 4 MG CAP THPKlenvatinib mesylate 4

PA

S Specialty Drug

ANTIPARKINSON AND RELATED THERAPY AGENTS

ANTIPARKINSON ANTICHOLINERGICS

benztropine mesylate 0.5 mg tab 1

benztropine mesylate 1 mg tab 1

benztropine mesylate 1 mg/ml solution 1

benztropine mesylate 2 mg tab 1

TRIHEXYPHENIDYL HCL 0.4 MG/ML SOLUTIONtrihexyphenidyl hcl 1 AL1 Up to 8 yrs old

trihexyphenidyl hcl 0.4 mg/ml solution 1 AL1 Up to 8 yrs old

trihexyphenidyl hcl 2 mg tab 1

trihexyphenidyl hcl 5 mg tab 1

ANTIPARKINSON DOPAMINERGICS

amantadine hcl 100 mg cap 1

amantadine hcl 100 mg tab 1

amantadine hcl 50 mg/5ml solution 1

amantadine hcl 50 mg/5ml syrup 1

bromocriptine mesylate 2.5 mg tab 1

bromocriptine mesylate 5 mg cap 1



ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

ELDEPRYL 5 MG CAPselegiline hcl 3

rasagiline mesylate 0.5 mg tab 2 QL 30 / 30 DAYS

rasagiline mesylate 1 mg tab 2 QL 30 / 30 DAYS

selegiline hcl 5 mg cap 1

selegiline hcl 5 mg tab 1

ZELAPAR 1.25 MG TAB DISPselegiline hcl 3 PA

CENTRAL/PERIPHERAL COMT INHIBITORS

tolcapone 100 mg tab 2 PA

DECARBOXYLASE INHIBITORS

carbidopa 25 mg tab 1

LODOSYN 25 MG TABcarbidopa 3

LEVODOPA COMBINATIONS

carbidopa-levodopa 10-100 mg tab 1

carbidopa-levodopa 10-100 mg tab disp 1

CARBIDOPA-LEVODOPA 10-100 MG TAB DISPcarbidopa-levodopa 1







carbidopa-levodopa er 25-100 mg tab er 1

carbidopa-levodopa er 50-200 mg tab er 1

CARBIDOPA-LEVODOPA-ENTACAPONE 12.5-50-200 MGTABcarbidopa-levodopa-entacapone

1



carbidopa-levodopa-entacapone 12.5-50-200 mg tab 1


1


carbidopa-levodopa-entacapone 25-100-200 mg tab 1



1


carbidopa-levodopa-entacapone 50-200-200 mg tab 1

DUOPA 4.63-20 MG/ML SUSPENSIONcarbidopa-levodopa 4

PA

S Specialty Drug

RYTARY 23.75-95 MG CAP ERcarbidopa-levodopa 3 QL 120 / 30 DAYS




NONERGOLINE DOPAMINE RECEPTOR AGONISTS

apomorphine hcl 30 mg/3ml soln cart 4PA

S Specialty Drug

KYNMOBI 10 MG FILMapomorphine hydrochloride 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug

KYNMOBI TITRATION KIT 10/15/20/25/30 MG KITapomorphine hydrochloride 4

PA

S Specialty Drug

NEUPRO 1 MG/24HR PATCH 24HRrotigotine 3 PA






pramipexole dihydrochloride 0.125 mg tab 1 QL 90 / 30 DAYS




pramipexole dihydrochloride 1 mg tab 1 QL 90 / 30 DAYS


pramipexole dihydrochloride er 0.375 mg tab er 24h 2 QL 30 / 30 DAYS




pramipexole dihydrochloride er 3 mg tab er 24h 2 QL 30 / 30 DAYS



ropinirole hcl 0.25 mg tab 1



ropinirole hcl 0.5 mg tab 1

ropinirole hcl 1 mg tab 1





ropinirole hcl er 12 mg tab er 24h 1 QL 30 / 30 DAYS





PERIPHERAL COMT INHIBITORS

entacapone 200 mg tab 1 QL 270 / 30 DAYS

ONGENTYS 25 MG CAPopicapone 3 PA

ONGENTYS 50 MG CAPopicapone 3 PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ANTIMANIC AGENTS

LITHIUM 8 MEQ/5ML SOLUTIONlithium 1 AL1 Up to 8 yrs old

LITHIUM CARBONATE 150 MG CAPlithium carbonate 1

lithium carbonate 150 mg cap 1



lithium carbonate 300 mg tab 1





lithium carbonate er 300 mg tab er 1

lithium carbonate er 450 mg tab er 1

LITHOBID 300 MG TAB ERlithium carbonate 3

ANTIPSYCHOTICS - MISC.

CAPLYTA 42 MG CAPlumateperone tosylate 3 ST

EQUETRO 100 MG CAP ER 12Hcarbamazepine (antipsychotic) 3 QL 480 / 30 DAYS



LATUDA 120 MG TABlurasidone hcl 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

VRAYLAR 1.5 & 3 MG CAP THPKcariprazine hcl 3

QL 30 / 30 DAYS

ST

VRAYLAR 1.5 MG CAPcariprazine hcl 3

QL 30 / 30 DAYS

ST

VRAYLAR 3 MG CAPcariprazine hcl 3

QL 30 / 30 DAYS

ST

VRAYLAR 4.5 MG CAPcariprazine hcl 3

QL 30 / 30 DAYS

ST



VRAYLAR 6 MG CAPcariprazine hcl 3

QL 30 / 30 DAYS

ST

ziprasidone hcl 20 mg cap 1 QL 240 / 30 DAYS




BENZISOXAZOLES

FANAPT 1 MG TABiloperidone 3

QL 60 / 30 DAYS

ST


QL 90 / 30 DAYS

ST


QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

ST


QL 60 / 30 DAYS

ST

FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TABiloperidone 3

QL 60 / 30 DAYS

ST

INVEGA HAFYERA 1092 MG/3.5ML SUSP PRSYRpaliperidone palmitate 3 ST

INVEGA HAFYERA 1560 MG/5ML SUSP PRSYRpaliperidone palmitate 3 ST

INVEGA SUSTENNA 117 MG/0.75ML SUSP PRSYRpaliperidone palmitate 3 ST

INVEGA SUSTENNA 156 MG/ML SUSP PRSYRpaliperidone palmitate 3 ST






INVEGA TRINZA 273 MG/0.88ML SUSP PRSYRpaliperidone palmitate 3 ST




paliperidone er 1.5 mg tab er 24h 2QL 30 / 30 DAYS

ST

paliperidone er 3 mg tab er 24h 2QL 30 / 30 DAYS

ST


ST


ST

RISPERDAL CONSTA 12.5 MG SRERrisperidone microspheres 3 ST

RISPERDAL CONSTA 25 MG SRERrisperidone microspheres 3 ST

RISPERDAL CONSTA 37.5 MG SRERrisperidone microspheres 3 ST

RISPERDAL CONSTA 50 MG SRERrisperidone microspheres 3 ST

risperidone 0.25 mg tab 1 QL 60 / 30 DAYS

RISPERIDONE 0.25 MG TAB DISPrisperidone 1 QL 1920 / 30 DAYS

risperidone 0.5 mg tab 1 QL 60 / 30 DAYS



risperidone 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone 1 mg tab 1 QL 480 / 30 DAYS

risperidone 1 mg tab disp 1 QL 60 / 30 DAYS

risperidone 1 mg/ml solution 1 AL1 Up to 8 yrs old







risperidone m-tab 0.5 mg tab disp 1 QL 960 / 30 DAYS

risperidone m-tab 1 mg tab disp 1 QL 60 / 30 DAYS

risperidone m-tab 2 mg tab disp 1 QL 60 / 30 DAYS

BUTYROPHENONES

HALDOL 5 MG/ML SOLUTIONhaloperidol lactate 3

haloperidol 0.5 mg tab 1

haloperidol 1 mg tab 1





haloperidol decanoate 100 mg/ml solution 1

haloperidol decanoate 50 mg/ml solution 1

haloperidol lactate 2 mg/ml conc 1

haloperidol lactate 5 mg/ml solution 1

DIBENZO-OXEPINO PYRROLES

asenapine maleate 10 mg sl tab 2 ST



asenapine maleate 2.5 mg sl tab 2 ST

asenapine maleate 5 mg sl tab 2 ST

DIBENZODIAZEPINES

clozapine 100 mg tab 1 QL 120 / 30 DAYS

clozapine 100 mg tab disp 1

CLOZAPINE 12.5 MG TAB DISPclozapine 1 QL 2160 / 30 DAYS

CLOZAPINE 150 MG TAB DISPclozapine 1 QL 180 / 30 DAYS


CLOZAPINE 200 MG TAB DISPclozapine 1 QL 120 / 30 DAYS


clozapine 25 mg tab disp 1 QL 1080 / 30 DAYS


VERSACLOZ 50 MG/ML SUSPENSIONclozapine 3 PA

DIBENZOTHIAZEPINES

quetiapine fumarate 100 mg tab 1 QL 90 / 30 DAYS






quetiapine fumarate er 150 mg tab er 24h 1 QL 60 / 30 DAYS







DIBENZOXAZEPINES

loxapine succinate 10 mg cap 1




DIHYDROINDOLONES

MOLINDONE HCL 10 MG TABmolindone hcl 1



PHENOTHIAZINES

chlorpromazine hcl 10 mg tab 1





fluphenazine decanoate 25 mg/ml solution 1

fluphenazine hcl 1 mg tab 1


fluphenazine hcl 2.5 mg tab 1

FLUPHENAZINE HCL 2.5 MG/5ML ELIXIRfluphenazine hcl 1 AL1 Up to 8 yrs old

FLUPHENAZINE HCL 2.5 MG/ML SOLUTIONfluphenazine hcl 1


FLUPHENAZINE HCL 5 MG/ML CONCfluphenazine hcl 1 AL1 Up to 8 yrs old

perphenazine 16 mg tab 1






prochlorperazine 25 mg suppos 1 QL 30 / 30 DAYS

prochlorperazine maleate 10 mg tab 1

prochlorperazine maleate 5 mg tab 1

thioridazine hcl 10 mg tab 1




trifluoperazine hcl 1 mg tab 1




QUINOLINONE DERIVATIVES

ABILIFY MAINTENA 300 MG PRSYRaripiprazole 3 ST

ABILIFY MAINTENA 300 MG SRERaripiprazole 3 ST

ABILIFY MAINTENA 400 MG PRSYRaripiprazole 3 ST

ABILIFY MAINTENA 400 MG SRERaripiprazole 3 ST

aripiprazole 1 mg/ml solution 2 QL 30 / 30 DAYS

aripiprazole 10 mg tab 1 QL 30 / 30 DAYS

aripiprazole 10 mg tab disp 1 QL 30 / 30 DAYS


aripiprazole 15 mg tab disp 1 QL 30 / 30 DAYS

aripiprazole 2 mg tab 1 QL 60 / 30 day(s)






REXULTI 0.25 MG TABbrexpiprazole 3

QL 30 / 30 DAYS

ST

REXULTI 0.5 MG TABbrexpiprazole 3

QL 30 / 30 DAYS

ST

REXULTI 1 MG TABbrexpiprazole 3

QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST


QL 30 / 30 DAYS

ST

THIENBENZODIAZEPINES

olanzapine 10 mg tab 1 QL 30 / 30 DAYS

olanzapine 10 mg tab disp 1 QL 30 / 30 DAYS



olanzapine 2.5 mg tab 1 QL 30 / 30 DAYS





olanzapine 7.5 mg tab 1 QL 30 / 30 DAYS

ZYPREXA RELPREVV 210 MG RECON SUSPolanzapine pamoate 3 ST





THIOXANTHENES

thiothixene 1 mg cap 1




ANTISEPTICS & DISINFECTANTS

formadon 10 % solution 1

FORMALDEHYDE 10 % SOLUTIONformaldehyde 3

formaldehyde 10 % solution 1

FORMALDEHYDE 37 % SOLUTIONformaldehyde 3

CHLORINE ANTISEPTICS

BENZALKONIUM CHLORIDE SOLUTIONbenzalkonium chloride 3

BENZALKONIUM CHLORIDE 50 % SOLUTIONbenzalkonium chloride 3

IODINE ANTISEPTICS

IODOFLEX 0.9 % PADcadexomer iodine 3

IODOSORB 0.9 % GELcadexomer iodine 3

ANTIVIRALS

ANTIRETROVIRAL COMBINATIONS

abacavir sulfate-lamivudine 600-300 mg tab 1 QL 30 / 30 DAYS

abacavir-lamivudine-zidovudine 300-150-300 mg tab 2 QL 60 / 30 DAYS

BIKTARVY 30-120-15 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate 4

QL 30 / 30 day(s)

S Specialty Drug

BIKTARVY 50-200-25 MG TABbictegravir-emtricitabine-tenofovir alafenamide fumarate 4

QL 30 / 30 DAYS

S Specialty Drug



CIMDUO 300-300 MG TABlamivudine-tenofovir disoproxil fumarate 4 S Specialty Drug

COMPLERA 200-25-300 MG TABemtricitabine-rilpivirine-tenofovir disoproxil fumarate 4

QL 30 / 30 DAYS

S Specialty Drug

DESCOVY 120-15 MG TABemtricitabine-tenofovir alafenamide fumarate 4

QL 1 / 1 day(s)

PA

S Specialty Drug

DESCOVY 200-25 MG TABemtricitabine-tenofovir alafenamide fumarate 4

QL 30 / 30 DAYS

PA

S Specialty Drug

DOVATO 50-300 MG TABdolutegravir sodium-lamivudine 4

PA

S Specialty Drug

efavirenz-emtricitab-tenofovir 600-200-300 mg tab 4

efavirenz-lamivudine-tenofovir 400-300-300 mg tab 4 S Specialty Drug

efavirenz-lamivudine-tenofovir 600-300-300 mg tab 4 S Specialty Drug

emtricitabine-tenofovir df 100-150 mg tab 4QL 30 / 30 day(s)

S Specialty Drug


S Specialty Drug


S Specialty Drug


PREV Preventative

EVOTAZ 300-150 MG TABatazanavir sulfate-cobicistat 4

QL 30 / 30 DAYS

S Specialty Drug

GENVOYA 150-150-200-10 MG TABelvitegravir-cobicistat-emtricitabine-tenofovir alafenamide 4

QL 30 / 30 DAYS

S Specialty Drug

JULUCA 50-25 MG TABdolutegravir sodium-rilpivirine hcl 4 S Specialty Drug

KALETRA 400-100 MG/5ML SOLUTIONlopinavir-ritonavir 4

PA

S Specialty Drug



lamivudine-zidovudine 150-300 mg tab 1 QL 60 / 30 DAYS

lopinavir-ritonavir 100-25 mg tab 4 S Specialty Drug

lopinavir-ritonavir 200-50 mg tab 4 S Specialty Drug

lopinavir-ritonavir 400-100 mg/5ml solution 1

ODEFSEY 200-25-25 MG TABemtricitabine-rilpivirine-tenofovir alafenamide fumarate 4

QL 30 / 30 DAYS

S Specialty Drug

PREZCOBIX 800-150 MG TABdarunavir-cobicistat 4

QL 30 / 30 DAYS

S Specialty Drug

STRIBILD 150-150-200-300 MG TABelvitegravir-cobicistat-emtricitabine-tenofovir df 4

QL 30 / 30 DAYS

S Specialty Drug

SYMTUZA 800-150-200-10 MG TABdarunavir-cobicistat-emtricitabine-tenofovir alafenamide 4 S Specialty Drug

TEMIXYS 300-300 MG TABlamivudine-tenofovir disoproxil fumarate 4 S Specialty Drug

TRIUMEQ 600-50-300 MG TABabacavir-dolutegravir-lamivudine 4

QL 30 / 30 DAYS

S Specialty Drug

TRIUMEQ PD 60-5-30 MG TAB SOLabacavir-dolutegravir-lamivudine 4

QL 1 / 1 day(s)

S Specialty Drug

ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR)

maraviroc 150 mg tab 4PA

S Specialty Drug

maraviroc 300 mg tab 4PA

S Specialty Drug

SELZENTRY 20 MG/ML SOLUTIONmaraviroc 4

PA

S Specialty Drug

SELZENTRY 25 MG TABmaraviroc 4

PA

S Specialty Drug

SELZENTRY 75 MG TABmaraviroc 4

PA

S Specialty Drug



ANTIRETROVIRALS - FUSION INHIBITORS

FUZEON 90 MG RECON SOLNenfuvirtide 4

PA

S Specialty Drug

ANTIRETROVIRALS - GP120-DIRECTED ATTACHMENT INHIBITOR

RUKOBIA 600 MG TAB ER 12Hfostemsavir tromethamine 4

PA

S Specialty Drug

ANTIRETROVIRALS - INTEGRASE INHIBITORS

ISENTRESS 100 MG CHEW TABraltegravir potassium 4

QL 180 / 30 DAYS

S Specialty Drug

ISENTRESS 100 MG PACKETraltegravir potassium 4

QL 240 / 30 DAYS

S Specialty Drug

ISENTRESS 25 MG CHEW TABraltegravir potassium 4

QL 720 / 30 DAYS

S Specialty Drug

ISENTRESS 400 MG TABraltegravir potassium 4

QL 60 / 30 DAYS

S Specialty Drug

ISENTRESS HD 600 MG TABraltegravir potassium 4

QL 60 / 30 DAYS

S Specialty Drug

TIVICAY 10 MG TABdolutegravir sodium 4

QL 30 / 30 DAYS

S Specialty Drug


QL 30 / 30 DAYS

S Specialty Drug


QL 60 / 30 DAYS

S Specialty Drug

TIVICAY PD 5 MG TAB SOLdolutegravir sodium 4

PA

S Specialty Drug

ANTIRETROVIRALS - PROTEASE INHIBITORS

APTIVUS 100 MG/ML SOLUTIONtipranavir 4

QL 300 / 30 DAYS

AL1 Up to 8 yrs old

S Specialty Drug



APTIVUS 250 MG CAPtipranavir 4

QL 120 / 30 DAYS

S Specialty Drug

atazanavir sulfate 150 mg cap 2

atazanavir sulfate 200 mg cap 2 QL 60 / 30 DAYS

atazanavir sulfate 300 mg cap 2 QL 30 / 30 DAYS

CRIXIVAN 200 MG CAPindinavir sulfate 4

QL 360 / 30 DAYS

S Specialty Drug

CRIXIVAN 400 MG CAPindinavir sulfate 4

QL 180 / 30 DAYS

S Specialty Drug

fosamprenavir calcium 700 mg tab 4QL 120 / 30 DAYS

S Specialty Drug

INVIRASE 200 MG CAPsaquinavir mesylate 4

QL 300 / 30 DAYS

S Specialty Drug

INVIRASE 500 MG TABsaquinavir mesylate 4

QL 120 / 30 DAYS

S Specialty Drug

LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium 4

QL 1800 / 30 DAYS

S Specialty Drug

LEXIVA 700 MG TABfosamprenavir calcium 4

QL 120 / 30 DAYS

S Specialty Drug

NORVIR 100 MG CAPritonavir 4

QL 360 / 30 DAYS

S Specialty Drug

NORVIR 80 MG/ML SOLUTIONritonavir 4

QL 480 / 30 DAYS

AL1 Up to 8 yrs old

S Specialty Drug

PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate 4

QL 400 / 30 day(s)

S Specialty Drug

PREZISTA 150 MG TABdarunavir ethanolate 4

QL 180 / 30 day(s)

S Specialty Drug

PREZISTA 600 MG TABdarunavir 4

QL 60 / 30 day(s)

S Specialty Drug



PREZISTA 75 MG TABdarunavir ethanolate 4

QL 300 / 30 day(s)

S Specialty Drug

PREZISTA 800 MG TABdarunavir 4 S Specialty Drug

REYATAZ 50 MG PACKETatazanavir sulfate 4

AL1 Up to 8 yrs old

S Specialty Drug

ritonavir 100 mg tab 1

VIRACEPT 250 MG TABnelfinavir mesylate 4 S Specialty Drug

VIRACEPT 625 MG TABnelfinavir mesylate 4 S Specialty Drug

ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES

EDURANT 25 MG TABrilpivirine hcl 4

QL 30 / 30 DAYS

S Specialty Drug

efavirenz 200 mg cap 4 S Specialty Drug

efavirenz 50 mg cap 4 S Specialty Drug

efavirenz 600 mg tab 4 S Specialty Drug

etravirine 100 mg tab 4QL 120 / 30 day(s)

S Specialty Drug

etravirine 200 mg tab 4QL 60 / 30 day(s)

S Specialty Drug

INTELENCE 25 MG TABetravirine 4

QL 120 / 30 DAYS

S Specialty Drug

nevirapine 200 mg tab 1 QL 60 / 30 DAYS

NEVIRAPINE 50 MG/5ML SUSPENSIONnevirapine 1

QL 1200 / 30 day(s)

AL1 Up to 8 yrs old

nevirapine er 100 mg tab er 24h 1 QL 90 / 30 DAYS

NEVIRAPINE ER 100 MG TAB ER 24Hnevirapine 1 QL 90 / 30 DAYS

nevirapine er 400 mg tab er 24h 1 QL 30 / 30 DAYS



PIFELTRO 100 MG TABdoravirine 4 S Specialty Drug

RESCRIPTOR 100 MG TABdelavirdine mesylate 4

QL 360 / 30 DAYS

S Specialty Drug

RESCRIPTOR 200 MG TABdelavirdine mesylate 4

QL 180 / 30 DAYS

S Specialty Drug

SUSTIVA 200 MG CAPefavirenz 4

QL 120 / 30 DAYS

S Specialty Drug

SUSTIVA 50 MG CAPefavirenz 4

QL 360 / 30 DAYS

S Specialty Drug

SUSTIVA 600 MG TABefavirenz 4

QL 30 / 30 DAYS

S Specialty Drug

ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES

abacavir sulfate 20 mg/ml solution 1 AL1 Up to 8 yrs old

abacavir sulfate 300 mg tab 1 QL 60 / 30 DAYS

DIDANOSINE 200 MG CAP DRdidanosine 4

QL 60 / 30 DAYS

S Specialty Drug

didanosine 200 mg cap dr 4QL 60 / 30 DAYS

S Specialty Drug


QL 30 / 30 DAYS

S Specialty Drug


S Specialty Drug


QL 30 / 30 DAYS

S Specialty Drug


S Specialty Drug

VIDEX 2 GM RECON SOLNdidanosine 4

QL 120 / 30 DAYS

S Specialty Drug



VIDEX 4 GM RECON SOLNdidanosine 4

QL 120 / 30 DAYS

S Specialty Drug

ZIAGEN 300 MG TABabacavir sulfate 4

QL 60 / 30 DAYS

S Specialty Drug

ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES

emtricitabine 200 mg cap 2

EMTRIVA 10 MG/ML SOLUTIONemtricitabine 4

QL 850 / 30 DAYS

S Specialty Drug

lamivudine 10 mg/ml solution 1

lamivudine 150 mg tab 1 QL 60 / 30 DAYS

lamivudine 300 mg tab 1 QL 30 / 30 DAYS

ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES

RETROVIR 10 MG/ML SOLUTIONzidovudine 4 S Specialty Drug

STAVUDINE 15 MG CAPstavudine 1 QL 120 / 30 DAYS

stavudine 15 mg cap 1 QL 120 / 30 DAYS







ZERIT 1 MG/ML RECON SOLNstavudine 4 S Specialty Drug

zidovudine 100 mg cap 1 QL 180 / 30 DAYS

zidovudine 300 mg tab 1 QL 60 / 30 DAYS

zidovudine 50 mg/5ml syrup 1 QL 1920 / 30 DAYS



ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES

tenofovir disoproxil fumarate 300 mg tab 4 S Specialty Drug

VIREAD 150 MG TABtenofovir disoproxil fumarate 4

QL 30 / 30 DAYS

S Specialty Drug


QL 30 / 30 DAYS

S Specialty Drug


QL 30 / 30 DAYS

S Specialty Drug

VIREAD 40 MG/GM POWDERtenofovir disoproxil fumarate 4

AL1 Up to 8 yrs old

S Specialty Drug

ANTIRETROVIRALS ADJUVANTS

TYBOST 150 MG TABcobicistat 4

PA

S Specialty Drug

ANTIVIRAL COMBINATIONS

PAXLOVID 20 X 150 MG & 10 X 100MG TAB THPKnirmatrelvir-ritonavir 2 QL 30 / 180 day(s)

CMV AGENTS

LIVTENCITY 200 MG TABmaribavir 4

PA

S Specialty Drug

valganciclovir hcl 450 mg tab 2

valganciclovir hcl 50 mg/ml recon soln 2 AL1 Up to 8 yrs old

HEPATITIS B AGENTS

adefovir dipivoxil 10 mg tab 4PA

S Specialty Drug

BARACLUDE 0.05 MG/ML SOLUTIONentecavir 4

PA

S Specialty Drug

entecavir 0.5 mg tab 1 QL 30 / 30 DAYS

entecavir 1 mg tab 1 QL 30 / 30 DAYS

lamivudine 100 mg tab 1



HEPATITIS C AGENT - COMBINATIONS

LEDIPASVIR-SOFOSBUVIR 90-400 MG TABledipasvir-sofosbuvir 4

PA

S Specialty Drug

MAVYRET 100-40 MG TABglecaprevir-pibrentasvir 4

PA

S Specialty Drug

MAVYRET 50-20 MG PACKETglecaprevir-pibrentasvir 4

PA

S Specialty Drug

SOFOSBUVIR-VELPATASVIR 400-100 MG TABsofosbuvir-velpatasvir 4

PA

S Specialty Drug

HEPATITIS C AGENTS

MODERIBA (1200 MG PACK) 600 MG TAB THPKribavirin (hepatitis c) 3 PA

MODERIBA (600 MG PACK) 200 & 400 MG TAB THPKribavirin (hepatitis c) 3 PA

MODERIBA (800 MG PACK) 400 MG TAB THPKribavirin (hepatitis c) 3 PA

moderiba 200 mg tab 3

PEGASYS 180 MCG/0.5ML SOLN PRSYRpeginterferon alfa-2a 4

PA

S Specialty Drug

PEGASYS PROCLICK 135 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a 4

PA

S Specialty Drug

PEGASYS PROCLICK 180 MCG/0.5ML SOLN A-INJpeginterferon alfa-2a 4

PA

S Specialty Drug

PEGINTRON 50 MCG/0.5ML KITpeginterferon alfa-2b 4

PA

S Specialty Drug

REBETOL 40 MG/ML SOLUTIONribavirin (hepatitis c) 3 PA

ribasphere 200 mg cap 3

ribasphere 200 mg tab 3

RIBASPHERE 400 MG TABribavirin (hepatitis c) 3 PA



RIBASPHERE 600 MG TABribavirin (hepatitis c) 3 PA

RIBASPHERE RIBAPAK (1000 PACK) 400 & 600 MG TABTHPKribavirin (hepatitis c)

3 PA

RIBASPHERE RIBAPAK (1200 PACK) 600 MG TAB THPKribavirin (hepatitis c) 3 PA

RIBASPHERE RIBAPAK (600 PACK) 200 & 400 MG TABTHPKribavirin (hepatitis c)

3 PA

RIBASPHERE RIBAPAK (800 PACK) 400 MG TAB THPKribavirin (hepatitis c) 3 PA

ribavirin 200 mg cap 1

ribavirin 200 mg tab 1

HERPES AGENTS - PURINE ANALOGUES

acyclovir 200 mg cap 1

acyclovir 200 mg/5ml suspension 1

acyclovir 400 mg tab 1

acyclovir 800 mg tab 1

acyclovir sodium 50 mg/ml solution 1

SITAVIG 50 MG TABacyclovir 3 ST

valacyclovir hcl 1 gm tab 1

valacyclovir hcl 500 mg tab 1

HERPES AGENTS - THYMIDINE ANALOGUES

famciclovir 125 mg tab 1 QL 60 / 30 DAYS



INFLUENZA AGENTS

RIMANTADINE HCL 100 MG TABrimantadine hydrochloride 1

MISC. ANTIVIRALS

MOLNUPIRAVIR 200 MG CAPmolnupiravir 2 QL 40 / 180 day(s)



NEURAMINIDASE INHIBITORS

oseltamivir phosphate 30 mg cap 1QL 10 / 0 DAYS

MFL 1 / 180 DAYS


MFL 1 / 180 DAYS

oseltamivir phosphate 6 mg/ml recon susp 1QL 180 / 5 DAYS

MFL 1 / 180 DAYS


MFL 1 / 180 DAYS

RELENZA DISKHALER 5 MG/BLISTER AER POW BAzanamivir 2 QL 20 / 10 DAYS

PA ENDONUCLEASE INHIBITORS

XOFLUZA (40 MG DOSE) 1 X 40 MG TAB THPKbaloxavir marboxil 3

QL 1 / 0 day(s)

MFL 1 / 180 day(s)


QL 2 / 0 DAYS

MFL 1 / 180 DAYS


QL 1 / 0 day(s)

MFL 1 / 180 day(s)


QL 2 / 0 DAYS

MFL 1 / 180 DAYS

BETA BLOCKERS

ALPHA-BETA BLOCKERS

carvedilol 12.5 mg tab 1 QL 4 / 1 day(s)

carvedilol 25 mg tab 1 QL 4 / 1 day(s)



carvedilol phosphate er 10 mg cap er 24h 2 QL 30 / 30 DAYS






labetalol hcl 100 mg tab 1



BETA BLOCKERS CARDIO-SELECTIVE

acebutolol hcl 200 mg cap 1

acebutolol hcl 400 mg cap 1

atenolol 100 mg tab 1



betaxolol hcl 10 mg tab 1

betaxolol hcl 20 mg tab 1

bisoprolol fumarate 10 mg tab 1

bisoprolol fumarate 5 mg tab 1

metoprolol succinate er 100 mg tab er 24h 1 QL 60 / 30 DAYS




metoprolol tartrate 100 mg tab 1


metoprolol tartrate 37.5 mg tab 1



nebivolol hcl 10 mg tab 2 QL 60 / 30 day(s)

nebivolol hcl 2.5 mg tab 2 QL 60 / 30 day(s)





BETA BLOCKERS NON-SELECTIVE

INDERAL XL 120 MG CAP ER 24Hpropranolol hcl sustained-release beads 3

INDERAL XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads 3

INNOPRAN XL 120 MG CAP ER 24Hpropranolol hcl sustained-release beads 3

INNOPRAN XL 80 MG CAP ER 24Hpropranolol hcl sustained-release beads 3

nadolol 20 mg tab 1

nadolol 40 mg tab 1

nadolol 80 mg tab 1

pindolol 10 mg tab 1

pindolol 5 mg tab 1

propranolol hcl 10 mg tab 1


propranolol hcl 20 mg/5ml solution 1 AL1 Up to 8 yrs old


PROPRANOLOL HCL 40 MG/5ML SOLUTIONpropranolol hcl 1 AL1 Up to 8 yrs old



propranolol hcl er 120 mg cap er 24h 1




sorine 120 mg tab 1

sorine 160 mg tab 1

sorine 240 mg tab 1

sorine 80 mg tab 1

sotalol hcl (af) 120 mg tab 1





sotalol hcl 120 mg tab 1




SOTYLIZE 5 MG/ML SOLUTIONsotalol hcl 4

QL 1920 / 30 day(s)

PA

TIMOLOL MALEATE 10 MG TABtimolol maleate 1

TIMOLOL MALEATE 20 MG TABtimolol maleate 1

timolol maleate 20 mg tab 1

timolol maleate 5 mg tab 1

CALCIUM CHANNEL BLOCKERS

afeditab cr 30 mg tab er 24h 1

afeditab cr 60 mg tab er 24h 1

amlodipine besylate 10 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate 2.5 mg tab 1 QL 30 / 30 DAYS

amlodipine besylate 5 mg tab 1 QL 30 / 30 DAYS

cartia xt 120 mg cap er 24h 1




dilt-xr 120 mg cap er 24h 1



diltiazem cd 120 mg cap er 24h 1






diltiazem hcl 120 mg tab 1




diltiazem hcl er 120 mg cap er 12h 1






diltiazem hcl er beads 120 mg cap er 24h 1






diltiazem hcl er coated beads 120 mg cap er 24h 1


diltiazem hcl er coated beads 180 mg tab er 24h 1








felodipine er 10 mg tab er 24h 1

felodipine er 2.5 mg tab er 24h 1

felodipine er 5 mg tab er 24h 1

isradipine 2.5 mg cap 1



isradipine 5 mg cap 1

KATERZIA 1 MG/ML SUSPENSIONamlodipine benzoate 3 AL1 Up to 8 yrs old

matzim la 180 mg tab er 24h 1





nicardipine hcl 20 mg cap 1

nicardipine hcl 30 mg cap 1

nifedipine 10 mg cap 1

nifedipine 20 mg cap 1

nifedipine er 30 mg tab er 24h 1



nifedipine er osmotic release 30 mg tab er 24h 1



nimodipine 30 mg cap 1

nisoldipine er 17 mg tab er 24h 1

NISOLDIPINE ER 20 MG TAB ER 24Hnisoldipine 1

NISOLDIPINE ER 25.5 MG TAB ER 24Hnisoldipine 1


nisoldipine er 34 mg tab er 24h 1


nisoldipine er 8.5 mg tab er 24h 1

taztia xt 120 mg cap er 24h 1







tiadylt er 120 mg cap er 24h 1






verapamil hcl 120 mg tab 1



verapamil hcl er 120 mg cap er 24h 1

verapamil hcl er 120 mg tab er 1





CARDIOTONICS

CARDIAC GLYCOSIDES

digitek 125 mcg tab 1

digitek 250 mcg tab 1

digox 125 mcg tab 1

digox 250 mcg tab 1

DIGOXIN 0.05 MG/ML SOLUTIONdigoxin 1

digoxin 0.05 mg/ml solution 1

digoxin 125 mcg tab 1

digoxin 250 mcg tab 1



CARDIOVASCULAR AGENTS - MISC.

CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB

amlodipine-atorvastatin 10-10 mg tab 1 QL 30 / 30 day(s)




amlodipine-atorvastatin 2.5-10 mg tab 1 QL 30 / 30 day(s)

AMLODIPINE-ATORVASTATIN 2.5-10 MG TABamlodipine besylate-atorvastatin calcium 1 QL 30 / 30 day(s)







NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB

ENTRESTO 24-26 MG TABsacubitril-valsartan 2 QL 60 / 30 DAYS



NITRATE & VASODILATOR COMBINATIONS

BIDIL 20-37.5 MG TABisosorbide dinitrate-hydralazine hcl 2

PERIPHERAL VASODILATORS

ISOXSUPRINE HCL 10 MG TABisoxsuprine hcl 1

isoxsuprine hcl 10 mg tab 1

ISOXSUPRINE HCL 20 MG TABisoxsuprine hcl 1



isoxsuprine hcl 20 mg tab 1

PROSTAGLANDIN VASODILATORS

ORENITRAM 0.125 MG TAB ERtreprostinil diolamine 4

PA

S Specialty Drug


PA

S Specialty Drug

ORENITRAM 1 MG TAB ERtreprostinil diolamine 4

PA

S Specialty Drug


PA

S Specialty Drug

ORENITRAM 5 MG TAB ERtreprostinil diolamine 4

PA

S Specialty Drug

PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)

ADEMPAS 0.5 MG TABriociguat 4

PA

S Specialty Drug

ADEMPAS 1 MG TABriociguat 4

PA

S Specialty Drug


PA

S Specialty Drug

ADEMPAS 2 MG TABriociguat 4

PA

S Specialty Drug


PA

S Specialty Drug

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

ambrisentan 10 mg tab 4PA

S Specialty Drug

ambrisentan 5 mg tab 4PA

S Specialty Drug

bosentan 125 mg tab 2 PA



bosentan 62.5 mg tab 2 PA

OPSUMIT 10 MG TABmacitentan 4

PA

S Specialty Drug

TRACLEER 32 MG TAB SOLbosentan 4

PA

S Specialty Drug

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

sildenafil citrate 10 mg/ml recon susp 2 PA

sildenafil citrate 20 mg tab 1 PA

tadalafil (pah) 20 mg tab 2 PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

UPTRAVI 1000 MCG TABselexipag 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

UPTRAVI 200 & 800 MCG TAB THPKselexipag 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS

CIALIS 5 MG TABtadalafil 3 PA

sildenafil citrate 100 mg tab 1 QL 6 / 30 day(s)



STENDRA 100 MG TABavanafil 2 QL 6 / 30 day(s)



tadalafil 10 mg tab 1 PA

tadalafil 2.5 mg tab 1 PA



vardenafil hcl 10 mg tab 1 QL 6 / 30 day(s)

vardenafil hcl 10 mg tab disp 1 QL 6 / 30 day(s)

vardenafil hcl 2.5 mg tab 1 QL 6 / 30 day(s)



SINUS NODE INHIBITORS

CORLANOR 5 MG TABivabradine hcl 2 QL 60 / 30 day(s)

CORLANOR 7.5 MG TABivabradine hcl 2 QL 60 / 30 day(s)

CEPHALOSPORINS

CEPHALOSPORINS - 1ST GENERATION

CEFADROXIL 1 GM TABcefadroxil 1



cefadroxil 1 gm tab 1

cefadroxil 250 mg/5ml recon susp 1

cefadroxil 500 mg cap 1

cefadroxil 500 mg/5ml recon susp 1

cephalexin 125 mg/5ml recon susp 1

cephalexin 250 mg cap 1

CEPHALEXIN 250 MG TABcephalexin 1

cephalexin 250 mg/5ml recon susp 1


CEPHALEXIN 500 MG TABcephalexin 1

CEPHALEXIN 750 MG CAPcephalexin 1


CEPHALOSPORINS - 2ND GENERATION

CEFACLOR 125 MG/5ML RECON SUSPcefaclor 1 AL1 Up to 8 yrs old

CEFACLOR 250 MG CAPcefaclor 1 QL 30 / 10 DAYS

cefaclor 250 mg cap 1 QL 30 / 10 DAYS



CEFACLOR 500 MG CAPcefaclor 1 QL 30 / 10 DAYS

cefaclor 500 mg cap 1 QL 30 / 10 DAYS

CEFACLOR ER 500 MG TAB ER 12Hcefaclor monohydrate 1 QL 20 / 10 DAYS

cefprozil 125 mg/5ml recon susp 1

cefprozil 250 mg tab 1

cefprozil 250 mg/5ml recon susp 1

cefprozil 500 mg tab 1



cefuroxime axetil 250 mg tab 1

cefuroxime axetil 500 mg tab 1

CEPHALOSPORINS - 3RD GENERATION

cefdinir 125 mg/5ml recon susp 1

cefdinir 250 mg/5ml recon susp 1

cefdinir 300 mg cap 1

CEFDITOREN PIVOXIL 200 MG TABcefditoren pivoxil 1

CEFDITOREN PIVOXIL 400 MG TABcefditoren pivoxil 1

cefixime 100 mg/5ml recon susp 2

cefixime 200 mg/5ml recon susp 2 AL1 Up to 8 yrs old

cefixime 400 mg cap 2 QL 14 / 30 DAYS

cefpodoxime proxetil 100 mg tab 1

cefpodoxime proxetil 100 mg/5ml recon susp 1 AL1 Up to 8 yrs old

cefpodoxime proxetil 200 mg tab 1

cefpodoxime proxetil 50 mg/5ml recon susp 1 AL1 Up to 8 yrs old

SUPRAX 100 MG CHEW TABcefixime 3

SUPRAX 200 MG CHEW TABcefixime 3

SUPRAX 400 MG CAPcefixime 3

SUPRAX 500 MG/5ML RECON SUSPcefixime 3 AL1 Up to 8 yrs old

CHEMICALS

BASES

SODIUM HYDROXIDE 10 % SOLUTIONsodium hydroxide 3



CONTRACEPTIVES

BIPHASIC CONTRACEPTIVES - ORAL

azurette 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

bekyree 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

kariva 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

kimidess 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

LO LOESTRIN FE 1 MG-10 MCG / 10 MCG TABnorethindrone acetate-ethinyl estradiol-fe fum (biphasic) 3 QL 30 / 30 day(s)

MIRCETTE 0.15-0.02/0.01 MG (21/5) TABdesogestrel-ethinyl estradiol (biphasic) 3

pimtrea 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

simliya 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

viorele 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

volnea 0.15-0.02/0.01 mg (21/5) tab 1 PREV Preventative

COMBINATION CONTRACEPTIVES - ORAL

afirmelle 0.1-20 mg-mcg tab 1 PREV Preventative

altavera 0.15-30 mg-mcg tab 1 PREV Preventative

alyacen 1/35 1-35 mg-mcg tab 1 PREV Preventative

apri 0.15-30 mg-mcg tab 1 PREV Preventative

aubra 0.1-20 mg-mcg tab 1 PREV Preventative

aubra eq 0.1-20 mg-mcg tab 1 PREV Preventative

aurovela 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

aurovela 1/20 1-20 mg-mcg tab 1 PREV Preventative

aurovela 24 fe 1-20 mg-mcg(24) tab 1 PREV Preventative

aurovela fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

aurovela fe 1/20 1-20 mg-mcg tab 1 PREV Preventative



aviane 0.1-20 mg-mcg tab 1 PREV Preventative

ayuna 0.15-30 mg-mcg tab 1 PREV Preventative

BALCOLTRA 0.1-20 MG-MCG(21) TABlevonorgestrel-ethinyl estradiol-ferrous bisglycinate 3

balziva 0.4-35 mg-mcg tab 1 PREV Preventative

BEYAZ 3-0.02-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium 3 QL 28 / 28 DAYS

blisovi 24 fe 1-20 mg-mcg(24) tab 1 PREV Preventative

blisovi fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

blisovi fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

briellyn 0.4-35 mg-mcg tab 1 PREV Preventative

charlotte 24 fe 1-20 mg-mcg(24) chew tab 1 PREV Preventative

chateal 0.15-30 mg-mcg tab 1 PREV Preventative

chateal eq 0.15-30 mg-mcg tab 1 PREV Preventative

cryselle-28 0.3-30 mg-mcg tab 1 PREV Preventative

cyclafem 1/35 1-35 mg-mcg tab 1 PREV Preventative

cyred 0.15-30 mg-mcg tab 1 PREV Preventative

cyred eq 0.15-30 mg-mcg tab 1 PREV Preventative

dasetta 1/35 1-35 mg-mcg tab 1 PREV Preventative

delyla 0.1-20 mg-mcg tab 1 PREV Preventative

desogestrel-ethinyl estradiol 0.15-30 mg-mcg tab 1 PREV Preventative

drospiren-eth estrad-levomefol 3-0.02-0.451 mg tab 3 QL 28 / 28 DAYS

drospiren-eth estrad-levomefol 3-0.03-0.451 mg tab 1QL 30 / 30 DAYS

PREV Preventative

drospirenone-ethinyl estradiol 3-0.02 mg tab 1 PREV Preventative

drospirenone-ethinyl estradiol 3-0.03 mg tab 1 PREV Preventative

elinest 0.3-30 mg-mcg tab 1 PREV Preventative



emoquette 0.15-30 mg-mcg tab 1 PREV Preventative

enskyce 0.15-30 mg-mcg tab 1 PREV Preventative

estarylla 0.25-35 mg-mcg tab 1 PREV Preventative

ethynodiol diac-eth estradiol 1-35 mg-mcg tab 1 PREV Preventative

ethynodiol diac-eth estradiol 1-50 mg-mcg tab 1 PREV Preventative

falmina 0.1-20 mg-mcg tab 1 PREV Preventative

femynor 0.25-35 mg-mcg tab 1 PREV Preventative

gemmily 1-20 mg-mcg(24) cap 2

GENERESS FE 0.8-25 MG-MCG CHEW TABnorethindrone & ethinyl estradiol-fe 3

gianvi 3-0.02 mg tab 1 PREV Preventative

hailey 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

hailey 24 fe 1-20 mg-mcg(24) tab 1 PREV Preventative

hailey fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

hailey fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

isibloom 0.15-30 mg-mcg tab 1 PREV Preventative

jasmiel 3-0.02 mg tab 1 PREV Preventative

juleber 0.15-30 mg-mcg tab 1 PREV Preventative

junel 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

junel 1/20 1-20 mg-mcg tab 1 PREV Preventative

junel fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

junel fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

junel fe 24 1-20 mg-mcg(24) tab 1 PREV Preventative

kaitlib fe 0.8-25 mg-mcg chew tab 1 PREV Preventative

kalliga 0.15-30 mg-mcg tab 1 PREV Preventative

kelnor 1/35 1-35 mg-mcg tab 1 PREV Preventative



kelnor 1/50 1-50 mg-mcg tab 1 PREV Preventative

kurvelo 0.15-30 mg-mcg tab 1 PREV Preventative

larin 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

larin 1/20 1-20 mg-mcg tab 1 PREV Preventative

larin 24 fe 1-20 mg-mcg(24) tab 1 PREV Preventative

larin fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

larin fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

larissia 0.1-20 mg-mcg tab 1 PREV Preventative

layolis fe 0.8-25 mg-mcg chew tab 1 PREV Preventative

lessina 0.1-20 mg-mcg tab 1 PREV Preventative

levonorgestrel-ethinyl estrad 0.1-20 mg-mcg tab 1 PREV Preventative

levonorgestrel-ethinyl estrad 0.15-30 mg-mcg tab 1 PREV Preventative

levora 0.15/30 (28) 0.15-30 mg-mcg tab 1 PREV Preventative

lillow 0.15-30 mg-mcg tab 1 PREV Preventative

lo-zumandimine 3-0.02 mg tab 1 PREV Preventative

loestrin 1.5/30 (21) 1.5-30 mg-mcg tab 1 PREV Preventative

loestrin 1/20 (21) 1-20 mg-mcg tab 1 PREV Preventative

loestrin fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

loestrin fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

loryna 3-0.02 mg tab 1 PREV Preventative

low-ogestrel 0.3-30 mg-mcg tab 1 PREV Preventative

lutera 0.1-20 mg-mcg tab 1 PREV Preventative

marlissa 0.15-30 mg-mcg tab 1 PREV Preventative

melodetta 24 fe 1-20 mg-mcg(24) chew tab 1 PREV Preventative

merzee 1-20 mg-mcg(24) cap 2

mibelas 24 fe 1-20 mg-mcg(24) chew tab 1 PREV Preventative



microgestin 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

microgestin 1/20 1-20 mg-mcg tab 1 PREV Preventative

microgestin 24 fe 1-20 mg-mcg tab 1 PREV Preventative

microgestin fe 1.5/30 1.5-30 mg-mcg tab 1 PREV Preventative

microgestin fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

mili 0.25-35 mg-mcg tab 1 PREV Preventative

MINASTRIN 24 FE 1-20 MG-MCG(24) CHEW TABnorethin acet & estrad-fe 3

mono-linyah 0.25-35 mg-mcg tab 1 PREV Preventative

mononessa 0.25-35 mg-mcg tab 1 PREV Preventative

necon 0.5/35 (28) 0.5-35 mg-mcg tab 1 PREV Preventative

NEXTSTELLIS 3-14.2 MG TABdrospirenone-estetrol 3

nikki 3-0.02 mg tab 1 PREV Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg tab 1 PREV Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) cap 2

norethin ace-eth estrad-fe 1-20 mg-mcg(24) chew tab 1 PREV Preventative

norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab 1 PREV Preventative

norethin ace-eth estrad-fe 1.5-30 mg-mcg tab 1 PREV Preventative

norethin-eth estradiol-fe 0.4-35 mg-mcg chew tab 1 PREV Preventative

norethin-eth estradiol-fe 0.8-25 mg-mcg chew tab 1 PREV Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg tab 1 PREV Preventative

norethindrone acet-ethinyl est 1-20 mg-mcg(24) chew tab 1 PREV Preventative

norethindrone acet-ethinyl est 1.5-30 mg-mcg tab 1 PREV Preventative

norgestimate-eth estradiol 0.25-35 mg-mcg tab 1 PREV Preventative

nortrel 0.5/35 (28) 0.5-35 mg-mcg tab 1 PREV Preventative

nortrel 1/35 (21) 1-35 mg-mcg tab 1 PREV Preventative



nortrel 1/35 (28) 1-35 mg-mcg tab 1 PREV Preventative

nylia 1/35 1-35 mg-mcg tab 1 PREV Preventative

nymyo 0.25-35 mg-mcg tab 1 PREV Preventative

ocella 3-0.03 mg tab 1 PREV Preventative

OGESTREL 0.5-50 MG-MCG TABnorgestrel & ethinyl estradiol 2 PREV Preventative

orsythia 0.1-20 mg-mcg tab 1 PREV Preventative

ORTHO-CYCLEN (28) 0.25-35 MG-MCG TABnorgestimate-ethinyl estradiol 3

ORTHO-NOVUM 1/35 (28) 1-35 MG-MCG TABnorethindrone & eth estradiol 3

philith 0.4-35 mg-mcg tab 1 PREV Preventative

pirmella 1/35 1-35 mg-mcg tab 1 PREV Preventative

portia-28 0.15-30 mg-mcg tab 1 PREV Preventative

previfem 0.25-35 mg-mcg tab 1 PREV Preventative

rajani 3-0.02-0.451 mg tab 3 QL 28 / 28 DAYS

reclipsen 0.15-30 mg-mcg tab 1 PREV Preventative

SAFYRAL 3-0.03-0.451 MG TABdrospirenone-ethinyl estradiol-levomefolate calcium 3 QL 30 / 30 DAYS

sprintec 28 0.25-35 mg-mcg tab 1 PREV Preventative

sronyx 0.1-20 mg-mcg tab 1 PREV Preventative

syeda 3-0.03 mg tab 1 PREV Preventative

tarina 24 fe 1-20 mg-mcg(24) tab 1 PREV Preventative

tarina fe 1/20 1-20 mg-mcg tab 1 PREV Preventative

tarina fe 1/20 eq 1-20 mg-mcg tab 1 PREV Preventative

taysofy 1-20 mg-mcg(24) cap 2

TAYTULLA 1-20 MG-MCG(24) CAPnorethin acet & estrad-fe 3

TYBLUME 0.1-20 MG-MCG CHEW TABlevonorgestrel & eth estradiol 1 PREV Preventative



tydemy 3-0.03-0.451 mg tab 1QL 30 / 30 DAYS

PREV Preventative

vestura 3-0.02 mg tab 1 PREV Preventative

vienva 0.1-20 mg-mcg tab 1 PREV Preventative

vyfemla 0.4-35 mg-mcg tab 1 PREV Preventative

vylibra 0.25-35 mg-mcg tab 1 PREV Preventative

wera 0.5-35 mg-mcg tab 1 PREV Preventative

wymzya fe 0.4-35 mg-mcg chew tab 1 PREV Preventative

YASMIN 28 3-0.03 MG TABdrospirenone-ethinyl estradiol 3

YAZ 3-0.02 MG TABdrospirenone-ethinyl estradiol 3

zarah 3-0.03 mg tab 1 PREV Preventative

zenchent 0.4-35 mg-mcg tab 1 PREV Preventative

zovia 1/35 (28) 1-35 mg-mcg tab 1 PREV Preventative

zovia 1/35e (28) 1-35 mg-mcg tab 1 PREV Preventative

zumandimine 3-0.03 mg tab 1 PREV Preventative

COMBINATION CONTRACEPTIVES - TRANSDERMAL

TWIRLA 120-30 MCG/24HR PATCH WKlevonorgestrel-ethinyl estradiol 2

QL 3 / 21 day(s)

PREV Preventative

xulane 150-35 mcg/24hr patch wk 1QL 3 / 21 day(s)

PREV Preventative

zafemy 150-35 mcg/24hr patch wk 1QL 3 / 21 day(s)

PREV Preventative

COMBINATION CONTRACEPTIVES - VAGINAL

ANNOVERA 0.013-0.15 MG/24HR RINGsegesterone acetate-ethinyl estradiol 2

QL 1 / 365 day(s)

PREV Preventative

eluryng 0.12-0.015 mg/24hr ring 1QL 1 / 28 DAYS

PREV Preventative



etonogestrel-ethinyl estradiol 0.12-0.015 mg/24hr ring 1QL 1 / 28 DAYS

PREV Preventative

CONTINUOUS CONTRACEPTIVES - ORAL

amethyst 90-20 mcg tab 1 PREV Preventative

dolishale 90-20 mcg tab 1 PREV Preventative

levonorgestrel-ethinyl estrad 90-20 mcg tab 1 PREV Preventative

COPPER CONTRACEPTIVES - IUD

PARAGARD INTRAUTERINE COPPER IUDcopper (iud) 2 PREV Preventative

EMERGENCY CONTRACEPTIVES

ELLA 30 MG TABulipristal acetate 2

QL 1 / 30 DAYS

PREV Preventative

EXTENDED-CYCLE CONTRACEPTIVES - ORAL

amethia 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

amethia lo 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

ashlyna 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

camrese 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

camrese lo 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

daysee 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

fayosim 42-21-21-7 days tab 1 PREV Preventative

iclevia 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative

introvale 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative



jaimiess 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

jolessa 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative

levonorgest-eth est & eth est 42-21-21-7 days tab 1 PREV Preventative

levonorgest-eth estrad 91-day 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

levonorgest-eth estrad 91-day 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

levonorgest-eth estrad 91-day 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative

lojaimiess 0.1-0.02 & 0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

LOSEASONIQUE 0.1-0.02 & 0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day) 3

QUARTETTE 42-21-21-7 DAYS TABlevonorgestrel-ethinyl estradiol (91-day) 3

quasense 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative

rivelsa 42-21-21-7 days tab 1 PREV Preventative

SEASONIQUE 0.15-0.03 &0.01 MG TABlevonorgestrel-ethinyl estradiol (91-day) 3 QL 91 / 91 DAYS

setlakin 0.15-0.03 mg tab 1QL 91 / 91 DAYS

PREV Preventative

simpesse 0.15-0.03 &0.01 mg tab 1QL 91 / 91 DAYS

PREV Preventative

FOUR PHASE CONTRACEPTIVES - ORAL

NATAZIA 3/2-2/2-3/1 MG TABestradiol valerate-dienogest 3 QL 28 / 28 DAYS



PROGESTIN CONTRACEPTIVES - IMPLANTS

NEXPLANON 68 MG IMPLANTetonogestrel 2 PREV Preventative

PROGESTIN CONTRACEPTIVES - INJECTABLE

DEPO-PROVERA 150 MG/ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive) 3

DEPO-PROVERA 150 MG/ML SUSPENSIONmedroxyprogesterone acetate (contraceptive) 3

DEPO-SUBQ PROVERA 104 104 MG/0.65ML SUSP PRSYRmedroxyprogesterone acetate (contraceptive) 2 PREV Preventative

medroxyprogesterone acetate 150 mg/ml susp prsyr 1 PREV Preventative

medroxyprogesterone acetate 150 mg/ml suspension 1 PREV Preventative

PROGESTIN CONTRACEPTIVES - IUD

KYLEENA 19.5 MG IUDlevonorgestrel (iud) 2 PREV Preventative

LILETTA (52 MG) 20.1 MCG/DAY IUDlevonorgestrel (iud) 2 PREV Preventative

MIRENA (52 MG) 20 MCG/DAY IUDlevonorgestrel (iud) 2 PREV Preventative

SKYLA 13.5 MG IUDlevonorgestrel (iud) 2 PREV Preventative

PROGESTIN CONTRACEPTIVES - ORAL

camila 0.35 mg tab 1 PREV Preventative

deblitane 0.35 mg tab 1 PREV Preventative

errin 0.35 mg tab 1 PREV Preventative

heather 0.35 mg tab 1 PREV Preventative

incassia 0.35 mg tab 1 PREV Preventative

jencycla 0.35 mg tab 1 PREV Preventative

jolivette 0.35 mg tab 1 PREV Preventative

lyleq 0.35 mg tab 1 PREV Preventative

lyza 0.35 mg tab 1 PREV Preventative



nora-be 0.35 mg tab 1 PREV Preventative

norethindrone 0.35 mg tab 1 PREV Preventative

norlyda 0.35 mg tab 1 PREV Preventative

norlyroc 0.35 mg tab 1 PREV Preventative

ORTHO MICRONOR 0.35 MG TABnorethindrone (contraceptive) 3

sharobel 0.35 mg tab 1 PREV Preventative

SLYND 4 MG TABdrospirenone 3

tulana 0.35 mg tab 1 PREV Preventative

TRIPHASIC CONTRACEPTIVES - ORAL

alyacen 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

aranelle 0.5/1/0.5-35 mg-mcg tab 1 PREV Preventative

caziant 0.1/0.125/0.15 -0.025 mg tab 1 PREV Preventative

cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

dasetta 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

enpresse-28 50-30/75-40/ 125-30 mcg tab 1 PREV Preventative

ESTROSTEP FE 1-20/1-30/1-35 MG-MCG TABnorethindrone acetate-ethinyl estradiol-fe 3

leena 0.5/1/0.5-35 mg-mcg tab 1 PREV Preventative

levonest 50-30/75-40/ 125-30 mcg tab 1 PREV Preventative

levonorg-eth estrad triphasic 50-30/75-40/ 125-30 mcg tab 1 PREV Preventative

myzilra 50-30/75-40/ 125-30 mcg tab 1 PREV Preventative

necon 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

nortrel 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

nylia 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative



ORTHO TRI-CYCLEN (28) 0.18/0.215/0.25 MG-35 MCG TABnorgestimate-ethinyl estradiol (triphasic) 3

ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 MG-25 MCG TABnorgestimate-ethinyl estradiol (triphasic) 3

ORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1-35 MG-MCG TABnorethindrone-eth estradiol (triphasic) 3

pirmella 7/7/7 0.5/0.75/1-35 mg-mcg tab 1 PREV Preventative

tilia fe 1-20/1-30/1-35 mg-mcg tab 1 PREV Preventative

tri femynor 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-estarylla 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-legest fe 1-20/1-30/1-35 mg-mcg tab 1 PREV Preventative

tri-linyah 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

tri-lo-mili 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

tri-mili 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

TRI-NORINYL (28) 0.5/1/0.5-35 MG-MCG TABnorethindrone-eth estradiol (triphasic) 3

tri-nymyo 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-previfem 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-sprintec 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-vylibra 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

tri-vylibra lo 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

trinessa (28) 0.18/0.215/0.25 mg-35 mcg tab 1 PREV Preventative

trinessa lo 0.18/0.215/0.25 mg-25 mcg tab 1 PREV Preventative

trivora (28) 50-30/75-40/ 125-30 mcg tab 1 PREV Preventative

velivet 0.1/0.125/0.15 -0.025 mg tab 1 PREV Preventative



CORTICOSTEROIDS

GLUCOCORTICOSTEROIDS

ALKINDI SPRINKLE 0.5 MG CAP SPRINKhydrocortisone 3

QL 2 / 1 day(s)

AL1 Up to 8 yrs old

ALKINDI SPRINKLE 1 MG CAP SPRINKhydrocortisone 3

QL 2 / 1 day(s)

AL1 Up to 8 yrs old


QL 2 / 1 day(s)

AL1 Up to 8 yrs old


QL 2 / 1 day(s)

AL1 Up to 8 yrs old

budesonide 3 mg cp dr part 2 QL 90 / 30 DAYS

budesonide er 9 mg tab er 24h 2

CORTISONE ACETATE 25 MG TABcortisone acetate 1

decadron 0.5 mg tab 1

decadron 0.5 mg/5ml elixir 1

decadron 0.75 mg tab 1

decadron 4 mg tab 1

decadron 6 mg tab 1

DEXAMETHASONE 0.5 MG TABdexamethasone 1

dexamethasone 0.5 mg tab 1

dexamethasone 0.5 mg/5ml elixir 1

DEXAMETHASONE 0.5 MG/5ML SOLUTIONdexamethasone 1

DEXAMETHASONE 0.75 MG TABdexamethasone 1


DEXAMETHASONE 1 MG TABdexamethasone 1


DEXAMETHASONE 2 MG TABdexamethasone 1



dexamethasone 4 mg tab 1

dexamethasone 6 mg tab 1

hydrocortisone 10 mg tab 1



MEDROL 2 MG TABmethylprednisolone 3

methylprednisolone 16 mg tab 1



methylprednisolone 4 mg tab thpk 1


methylprednisolone sodium succ 125 mg recon soln 1

PREDNISOLONE 15 MG/5ML SOLUTIONprednisolone 1

prednisolone 15 mg/5ml syrup 1

prednisolone sodium phosphate 10 mg/5ml solution 1

prednisolone sodium phosphate 15 mg/5ml solution 1

prednisolone sodium phosphate 20 mg/5ml solution 1 AL1 Up to 8 yrs old

PREDNISOLONE SODIUM PHOSPHATE 25 MG/5MLSOLUTIONprednisolone sodium phosphate

1 AL1 Up to 8 yrs old

prednisolone sodium phosphate 6.7 (5 base) mg/5ml solution 1

prednisone 1 mg tab 1

prednisone 10 mg (21) tab thpk 1



prednisone 2.5 mg tab 1







PREDNISONE 5 MG/5ML SOLUTIONprednisone 1


PREDNISONE INTENSOL 5 MG/ML CONCprednisone 1 AL1 Up to 8 yrs old

MINERALOCORTICOIDS

fludrocortisone acetate 0.1 mg tab 1

COUGH/COLD/ALLERGY

ANTITUSSIVE - NONNARCOTIC

benzonatate 100 mg cap 1



ANTITUSSIVE - OPIOID

HYCODAN 5-1.5 MG/5ML SOLUTIONhydrocodone bitartrate-homatropine methylbromide 1

QL 30 / 1 day(s)

MFL 1 / 60 day(s)

MDS1 7 / 1 day(s)

hydrocodone bit-homatrop mbr 5-1.5 mg tab 1 QL 6 / 1 day(s)

hydrocodone bit-homatrop mbr 5-1.5 mg/5ml solution 1

QL 30 / 1 day(s)

MFL 1 / 60 day(s)

MDS1 7 / 1 day(s)

hydromet 5-1.5 mg/5ml solution 1

QL 30 / 1 day(s)

MFL 1 / 60 day(s)

MDS1 7 / 1 day(s)

tussigon 5-1.5 mg tab 1 QL 6 / 1 day(s)

ANTITUSSIVE-EXPECTORANT

cheratussin ac 100-10 mg/5ml syrup 1

g tussin ac 100-10 mg/5ml solution 1

guaiatussin ac 100-10 mg/5ml syrup 1

guaifenesin ac 100-10 mg/5ml syrup 1

guaifenesin-codeine 100-10 mg/5ml solution 1



maxi-tuss ac 100-10 mg/5ml solution 1

robafen ac 100-10 mg/5ml solution 1

virtussin a/c 100-10 mg/5ml solution 1

virtussin ac w/alc 100-10 mg/5ml liquid 1

DECONGESTANT & ANTIHISTAMINE

promethazine vc 6.25-5 mg/5ml syrup 1

promethazine vc plain 6.25-5 mg/5ml solution 1

promethazine-phenylephrine 6.25-5 mg/5ml syrup 3

IODINE EXPECTORANTS

SSKI 1 GM/ML SOLUTIONpotassium iodide (expectorant) 3 AL1 Up to 8 yrs old

MISC. RESPIRATORY INHALANTS

HYPERSAL 3.5 % NEBU SOLNsodium chloride (inhalant) 3

NEBUSAL 6 % NEBU SOLNsodium chloride (inhalant) 3

sodium chloride 0.9 % nebu soln 1

sodium chloride 10 % nebu soln 1



MUCOLYTICS

acetylcysteine 10 % solution 1

acetylcysteine 20 % solution 1

NON-NARC ANTITUSSIVE-ANTIHISTAMINE

PROMETHAZINE-DM 6.25-15 MG/5ML SOLUTIONpromethazine-dm 1

promethazine-dm 6.25-15 mg/5ml syrup 1

NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE

bromfed dm 30-2-10 mg/5ml syrup 1

pseudoeph-bromphen-dm 30-2-10 mg/5ml syrup 1



OPIOID ANTITUSSIVE-ANTIHISTAMINE

hydrocod polst-cpm polst er 10-8 mg/5ml susp 1QL 50 / 5 DAYS

MFL 3 / 180 DAYS

promethazine-codeine 6.25-10 mg/5ml solution 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS

promethazine-codeine 6.25-10 mg/5ml syrup 1QL 150 / 5 DAYS

MFL 3 / 180 DAYS

TUZISTRA XR 14.7-2.8 MG/5ML SUSPcodeine polistirex-chlorpheniramine polistirex 3

QL 100 / 5 DAYS

AL1 Up to 8 yrs old

MFL 3 / 180 DAYS

OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE

promethazine vc/codeine 6.25-5-10 mg/5ml syrup 1 QL 120 / 30 DAYS

promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syrup 1 QL 120 / 30 DAYS

PSEUDOEPH-CHLORPHEN-HYDROCOD 60-4-5 MG/5MLSOLUTIONpseudoephed-cpm w/ hydrocod

1QL 150 / 30 DAYS

AL1 Up to 8 yrs old

pseudoeph-chlorphen-hydrocod 60-4-5 mg/5ml solution 1QL 150 / 30 DAYS

AL1 Up to 8 yrs old

DERMATOLOGICALS

ACNE ANTIBIOTICS

clindacin etz 1 % swab 1

clindacin-p 1 % swab 1

clindamycin phosphate 1 % foam 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % gel 1

clindamycin phosphate 1 % lotion 1

clindamycin phosphate 1 % solution 1

clindamycin phosphate 1 % swab 1

dapsone 5 % gel 1

dapsone 7.5 % gel 1



erythromycin 2 % gel 1

erythromycin 2 % pad 1

erythromycin 2 % solution 1

sulfacetamide sodium (acne) 10 % lotion 1

ACNE COMBINATIONS

adapalene-benzoyl peroxide 0.1-2.5 % gel 1 QL 90 / 30 DAYS

avar cleanser 10-5 % liquid 1

avar-e emollient 10-5 % cream 1

avar-e green 10-5 % cream 1

benzoyl peroxide-erythromycin 5-3 % gel 2

clindamycin phos-benzoyl perox 1-5 % gel 2

clindamycin phos-benzoyl perox 1.2-2.5 % gel 1 QL 50 / 30 DAYS

clindamycin phos-benzoyl perox 1.2-5 % gel 1

neuac 1.2-5 % gel 1

rosanil cleanser 10-5 % liquid 1

sss 10-5 10-5 % cream 1

sulfacetamide sodium-sulfur 10-2 % liquid 1

sulfacetamide sodium-sulfur 10-5 % cream 1

sulfacetamide sodium-sulfur 10-5 % liquid 1

sulfacetamide sodium-sulfur 8-4 % suspension 1

sulfacleanse 8/4 8-4 % suspension 1

ACNE PRODUCTS

accutane 10 mg cap 2 QL 60 / 30 DAYS




adapalene 0.1 % cream 1

adapalene 0.1 % gel 1

adapalene 0.3 % gel 1



amnesteem 10 mg cap 2 QL 60 / 30 DAYS



AZELEX 20 % CREAMazelaic acid (acne) 3

QL 50 / 30 DAYS

ST

claravis 10 mg cap 2 QL 60 / 30 DAYS




isotretinoin 10 mg cap 2 QL 60 / 30 DAYS




myorisan 10 mg cap 2 QL 60 / 30 DAYS




tretinoin 0.01 % gel 1 QL 45 / 30 DAYS

tretinoin 0.025 % cream 1 QL 45 / 30 DAYS

tretinoin 0.025 % gel 1 QL 45 / 30 DAYS


tretinoin 0.05 % gel 1


tretinoin microsphere 0.04 % gel 1

tretinoin microsphere 0.1 % gel 1

tretinoin microsphere pump 0.04 % gel 1



tretinoin microsphere pump 0.1 % gel 1

zenatane 10 mg cap 2 QL 60 / 30 DAYS




AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS

VEREGEN 15 % OINTMENTsinecatechins 3 PA

ANTI-INFLAMMATORY AGENTS - TOPICAL

DICLOFENAC EPOLAMINE 1.3 % PATCHdiclofenac epolamine 2

QL 60 / 30 DAYS

PA

diclofenac sodium 1 % gel 1 QL 500 / 30 DAYS

diclofenac sodium 1.5 % solution 1 QL 150 / 30 DAYS

klofensaid ii 1.5 % solution 1 QL 150 / 30 DAYS

ANTIBIOTIC STEROID COMBINATIONS - TOPICAL

CORTISPORIN 1 % OINTMENTbacitracin-polymyxin-neomycin hc 3

CORTISPORIN 3.5-10000-0.5 CREAMneomycin-polymyxin-hc 3

NEO-SYNALAR 0.5-0.025 % CREAMneomycin sulfate-fluocinolone acetonide 3

NEO-SYNALAR 0.5-0.025 % KITneomycin-fluocinolone & emollient 3

ANTIBIOTICS - TOPICAL

ALTABAX 1 % OINTMENTretapamulin 3

gentamicin sulfate 0.1 % cream 1

gentamicin sulfate 0.1 % ointment 1

mupirocin 2 % ointment 1



ANTIFUNGALS - TOPICAL

ciclodan 0.77 % cream 1

ciclodan 8 % solution 1

ciclopirox 0.77 % gel 1

ciclopirox 1 % shampoo 1

ciclopirox 8 % solution 1

ciclopirox olamine 0.77 % cream 1

ciclopirox olamine 0.77 % suspension 1

NAFTIFINE HCL 1 % CREAMnaftifine hcl 3 PA

naftifine hcl 1 % cream 3 PA

naftifine hcl 1 % gel 1

naftifine hcl 2 % cream 2 PA

NAFTIN 2 % GELnaftifine hcl 3 PA

nyamyc 100000 unit/gm powder 1

nystatin 100000 unit/gm cream 1

nystatin 100000 unit/gm ointment 1

nystatin 100000 unit/gm powder 1

nystop 100000 unit/gm powder 1

ANTIFUNGALS - TOPICAL COMBINATIONS

ALA-QUIN 3-0.5 % CREAMclioquinol-hc 3

clotrimazole-betamethasone 1-0.05 % cream 1

clotrimazole-betamethasone 1-0.05 % lotion 1

corti-sav 1-1 % cream 1

dermazene 1-1 % cream 1

EXODERM 25-1 % LOTIONsodium thiosulfate-salicylic acid 1

hydrocortisone-iodoquinol 1-1 % cream 1

MICONAZOLE-ZINC OXIDE-PETROLAT 0.25-15-81.35 %OINTMENTmiconazole-zinc oxide-white petrolatum

2QL 50 / 30 DAYS

PA



nystatin-triamcinolone 100000-0.1 unit/gm-% cream 1

nystatin-triamcinolone 100000-0.1 unit/gm-% ointment 1

RECURA CREAMantifungal combination products, misc. 3

VUSION 0.25-15-81.35 % OINTMENTmiconazole-zinc oxide-white petrolatum 2

QL 50 / 30 DAYS

PA

ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL

VALCHLOR 0.016 % GELmechlorethamine hcl (topical) 4

PA

S Specialty Drug

ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL

FLUOROPLEX 1 % CREAMfluorouracil (topical) 3 PA

FLUOROURACIL 0.5 % CREAMfluorouracil (topical) 1 PA

fluorouracil 5 % cream 1

TOLAK 4 % CREAMfluorouracil (topical) 3

ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL NSAID'S

diclofenac sodium 3 % gel 1 QL 500 / 30 DAYS

ANTINEOPLASTIC RETINOIDS - TOPICAL

PANRETIN 0.1 % GELalitretinoin 4

PA

S Specialty Drug

ANTIPRURITICS - TOPICAL

DOXEPIN HCL 5 % CREAMdoxepin hcl (antipruritic) 3 PA

ANTIPSORIATICS

calcipotriene 0.005 % cream 1 QL 120 / 30 DAYS

CALCIPOTRIENE 0.005 % FOAMcalcipotriene 3

calcipotriene 0.005 % ointment 2

calcipotriene 0.005 % solution 1 QL 60 / 30 DAYS



calcitrene 0.005 % ointment 1

CALCITRIOL 3 MCG/GM OINTMENTcalcitriol (topical) 2

DRITHO-CREME HP 1 % CREAManthralin 2

SORILUX 0.005 % FOAMcalcipotriene 3

tazarotene 0.1 % cream 2

TAZORAC 0.05 % CREAMtazarotene 3 PA

TAZORAC 0.05 % GELtazarotene 3 PA

TAZORAC 0.1 % GELtazarotene 3 PA

ZITHRANOL 1 % SHAMPOOanthralin 3

ANTIPSORIATICS - SYSTEMIC

acitretin 10 mg cap 2 QL 30 / 30 DAYS

acitretin 17.5 mg cap 2 QL 30 / 30 DAYS

acitretin 25 mg cap 2 QL 30 / 30 DAYS

COSENTYX (300 MG DOSE) 150 MG/ML SOLN PRSYRsecukinumab 4

PA

S Specialty Drug

COSENTYX 150 MG/ML SOLN PRSYRsecukinumab 4

PA

S Specialty Drug

COSENTYX 75 MG/0.5ML SOLN PRSYRsecukinumab 4

PA

S Specialty Drug

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

4PA

S Specialty Drug

COSENTYX SENSOREADY PEN 150 MG/ML SOLN A-INJsecukinumab 4

PA

S Specialty Drug

METHOXSALEN RAPID 10 MG CAPmethoxsalen rapid 2 PA



methoxsalen rapid 10 mg cap 2 PA

SKYRIZI (150 MG DOSE) 75 MG/0.83ML PREF SY KTrisankizumab-rzaa 4

PA

S Specialty Drug

SKYRIZI 150 MG/ML SOLN PRSYRrisankizumab-rzaa 4

PA

S Specialty Drug

SKYRIZI PEN 150 MG/ML SOLN A-INJrisankizumab-rzaa 4

PA

S Specialty Drug

STELARA 45 MG/0.5ML SOLN PRSYRustekinumab 4

PA

S Specialty Drug

STELARA 45 MG/0.5ML SOLUTIONustekinumab 4

PA

S Specialty Drug

STELARA 90 MG/ML SOLN PRSYRustekinumab 4

PA

S Specialty Drug

TALTZ 80 MG/ML SOLN A-INJixekizumab 4

PA

S Specialty Drug

TALTZ 80 MG/ML SOLN PRSYRixekizumab 4

PA

S Specialty Drug

TREMFYA 100 MG/ML SOLN PENguselkumab 4

PA

S Specialty Drug

TREMFYA 100 MG/ML SOLN PRSYRguselkumab 4

PA

S Specialty Drug

ANTISEBORRHEIC COMBINATIONS

SODIUM SULFACETAMIDE-BAKUCHIOL 10 % LIQUIDsulfacetamide sodium in bakuchiol vehicle 1

ANTISEBORRHEIC PRODUCTS

OVACE PLUS 10 % CREAMsulfacetamide sodium 3

OVACE PLUS 9.8 % FOAMsulfacetamide sodium 3

OVACE PLUS 9.8 % LOTIONsulfacetamide sodium 3



seb-prev wash 10 % liquid 1

selenium sulfide 2.25 % shampoo 1

selenium sulfide 2.5 % lotion 1

sodium sulfacetamide 10 % shampoo 1

sodium sulfacetamide wash 10 % liquid 1

sodium sulfacetamide wash 10 % liquid 1

sulfacetamide sodium 10 % (cleans) gel 1

sulfacetamide sodium 10 % liquid 1

ANTIVIRAL TOPICAL COMBINATIONS

XERESE 5-1 % CREAMacyclovir-hydrocortisone 3

QL 5 / 30 DAYS

PA

ANTIVIRALS - TOPICAL

acyclovir 5 % ointment 1 QL 30 / 30 DAYS

DENAVIR 1 % CREAMpenciclovir 3

QL 5 / 30 DAYS

PA

ATOPIC DERMATITIS - MONOCLONAL ANTIBODIES

DUPIXENT 100 MG/0.67ML SOLN PRSYRdupilumab 4

PA

S Specialty Drug

DUPIXENT 200 MG/1.14ML SOLN PENdupilumab 4

PA

S Specialty Drug

DUPIXENT 200 MG/1.14ML SOLN PRSYRdupilumab 4

PA

S Specialty Drug

DUPIXENT 300 MG/2ML SOLN PENdupilumab 4

PA

S Specialty Drug

DUPIXENT 300 MG/2ML SOLN PRSYRdupilumab 4

PA

S Specialty Drug

BURN PRODUCTS

silver sulfadiazine 1 % cream 1

ssd 1 % cream 1



SULFAMYLON 85 MG/GM CREAMmafenide acetate 3

CAUTERIZING AGENT COMBINATIONS

ARZOL SILVER NIT APPLICATORS 75-25 % MISCsilver nitrate-potassium nitrate 1

grafco silver nit applicator 75-25 % misc 1

CAUTERIZING AGENTS

SILVER NITRATE 0.5 % SOLUTIONsilver nitrate 1

SILVER NITRATE 10 % OINTMENTsilver nitrate 1

SILVER NITRATE 10 % SOLUTIONsilver nitrate 1



CORTICOSTEROIDS - TOPICAL

ala-cort 1 % cream 1

ala-cort 2.5 % cream 1

alclometasone dipropionate 0.05 % cream 1

alclometasone dipropionate 0.05 % ointment 1

AMCINONIDE 0.1 % CREAMamcinonide 2

AMCINONIDE 0.1 % LOTIONamcinonide 1

AMCINONIDE 0.1 % OINTMENTamcinonide 1

beser 0.05 % lotion 2

betamethasone dipropionate 0.05 % cream 1

betamethasone dipropionate 0.05 % lotion 1

betamethasone dipropionate 0.05 % ointment 1

betamethasone dipropionate aug 0.05 % cream 1

betamethasone dipropionate aug 0.05 % lotion 1



betamethasone dipropionate aug 0.05 % ointment 1

betamethasone valerate 0.1 % cream 1

betamethasone valerate 0.1 % lotion 1

betamethasone valerate 0.1 % ointment 1

betamethasone valerate 0.12 % foam 1

CAPEX 0.01 % SHAMPOOfluocinolone acetonide 2

clobetasol prop emollient base 0.05 % cream 1

clobetasol propionate 0.05 % cream 1

clobetasol propionate 0.05 % foam 1

clobetasol propionate 0.05 % gel 1

clobetasol propionate 0.05 % liquid 1

clobetasol propionate 0.05 % lotion 2

clobetasol propionate 0.05 % ointment 1

clobetasol propionate 0.05 % shampoo 1

clobetasol propionate 0.05 % solution 1

clobetasol propionate e 0.05 % cream 1

clobetasol propionate emulsion 0.05 % foam 1

CLOCORTOLONE PIVALATE 0.1 % CREAMclocortolone pivalate 1

clocortolone pivalate 0.1 % cream 1

CLOCORTOLONE PIVALATE PUMP 0.1 % CREAMclocortolone pivalate 1

clodan 0.05 % shampoo 1

CORDRAN 4 MCG/SQCM TAPEflurandrenolide 3 QL 1 / 30 DAYS

desonide 0.05 % cream 1

desonide 0.05 % lotion 1

desonide 0.05 % ointment 1

desoximetasone 0.05 % cream 1

desoximetasone 0.05 % gel 1

desoximetasone 0.05 % ointment 1



desoximetasone 0.25 % cream 1

desoximetasone 0.25 % ointment 1

DIFLORASONE DIACETATE 0.05 % CREAMdiflorasone diacetate 2

diflorasone diacetate 0.05 % ointment 2

fluocinolone acetonide 0.01 % cream 1

fluocinolone acetonide 0.01 % solution 1

fluocinolone acetonide 0.025 % cream 1

fluocinolone acetonide 0.025 % ointment 1

fluocinolone acetonide body 0.01 % oil 1

fluocinolone acetonide scalp 0.01 % oil 1

fluocinonide 0.05 % cream 1

fluocinonide 0.05 % gel 1

fluocinonide 0.05 % ointment 1

fluocinonide 0.05 % solution 1

fluocinonide 0.1 % cream 2

fluocinonide emulsified base 0.05 % cream 1

flurandrenolide 0.05 % cream 2

flurandrenolide 0.05 % lotion 2

fluticasone propionate 0.005 % ointment 1

fluticasone propionate 0.05 % cream 1

fluticasone propionate 0.05 % lotion 2

halobetasol propionate 0.05 % cream 1

halobetasol propionate 0.05 % ointment 1

hydrocortisone 1 % cream 1

hydrocortisone 1 % ointment 1

hydrocortisone 2.5 % cream 1

hydrocortisone 2.5 % lotion 1

hydrocortisone 2.5 % ointment 1

hydrocortisone butyr lipo base 0.1 % cream 2

HYDROCORTISONE BUTYRATE 0.1 % CREAMhydrocortisone butyrate 1



hydrocortisone butyrate 0.1 % cream 1

hydrocortisone butyrate 0.1 % ointment 1

HYDROCORTISONE BUTYRATE 0.1 % SOLUTIONhydrocortisone butyrate 2

hydrocortisone butyrate 0.1 % solution 2

hydrocortisone in absorbase 1 % ointment 1

hydrocortisone valerate 0.2 % cream 1

hydrocortisone valerate 0.2 % ointment 1

mometasone furoate 0.1 % cream 1

mometasone furoate 0.1 % ointment 1

mometasone furoate 0.1 % solution 1

nolix 0.05 % cream 2

nolix 0.05 % lotion 2

PREDNICARBATE 0.1 % CREAMprednicarbate 1

PREDNICARBATE 0.1 % OINTMENTprednicarbate 1

TEXACORT 2.5 % SOLUTIONhydrocortisone (topical) 3

tovet 0.05 % foam 1

triamcinolone acetonide 0.025 % cream 1

triamcinolone acetonide 0.025 % lotion 1

triamcinolone acetonide 0.025 % ointment 1


triamcinolone acetonide 0.1 % lotion 1


triamcinolone acetonide 0.147 mg/gm aero soln 2



triderm 0.1 % cream 1

triderm 0.5 % cream 1



EMOLLIENT/KERATOLYTIC AGENTS

CEM-UREA 45 % SOLUTIONurea 1

rea lo 40 40 % cream 1

urea 40 % cream 1

urea nail 45 % gel 1

uremez-40 40 % cream 1

EMOLLIENTS

ammonium lactate 12 % cream 1

ammonium lactate 12 % lotion 1

ENZYMES - TOPICAL

SANTYL 250 UNIT/GM OINTMENTcollagenase 2 QL 30 / 30 DAYS

IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL

clotrimazole 1 % cream 1

clotrimazole 1 % solution 1

econazole nitrate 1 % cream 1

ECOZA 1 % FOAMeconazole nitrate 3 QL 70 / 30 DAYS

ERTACZO 2 % CREAMsertaconazole nitrate 3 PA

EXELDERM 1 % CREAMsulconazole nitrate 3

EXELDERM 1 % SOLUTIONsulconazole nitrate 3

ketoconazole 2 % cream 1

ketoconazole 2 % foam 1

ketoconazole 2 % shampoo 1

ketodan 2 % foam 1

oxiconazole nitrate 1 % cream 2 PA

OXISTAT 1 % LOTIONoxiconazole nitrate 3 PA

XOLEGEL 2 % GELketoconazole (topical) 3



IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL

imiquimod 5 % cream 1

ZYCLARA PUMP 2.5 % CREAMimiquimod 3

QL 56 / 28 DAYS

PA

KERATOLYTIC AND/OR ANTIMITOTIC COMBINATIONS

SALVAX DUO PLUS 6 & 35 % KITsalicylic acid & urea in lactic acid vehicle 1

KERATOLYTIC/ANTIMITOTIC AGENTS

CONDYLOX 0.5 % GELpodofilox 3 PA

keralyt 6 % shampoo 1

KERALYT SCALP 6 % KITsalicylic acid 3

PODOCON 25 % SOLUTIONpodophyllum resin 3

podofilox 0.5 % solution 1

salicylic acid 6 % cream 1

salicylic acid 6 % foam 1

salicylic acid 6 % gel 1

SALICYLIC ACID 6 % LOTIONsalicylic acid 1

salicylic acid 6 % lotion 1

salicylic acid 6 % shampoo 1

salicylic acid-cleanser 6 % (cream) kit 1

salitech forte 6 % lotion 1

SALVAX 6 % FOAMsalicylic acid 1

LINIMENTS

TURPENTINE SPIRITturpentine (topical) 3

LOCAL ANESTHETICS - TOPICAL

ANACAINE 10 % OINTMENTbenzocaine (topical) 3



lidocaine 5 % ointment 1

lidocaine 5 % patch 1 QL 90 / 30 DAYS

lidocaine hcl 3 % cream 1

lidocaine hcl urethral/mucosal 2 % gel 1

LIDOCAINE HCL URETHRAL/MUCOSAL 2 % GELlidocaine hcl 1

lidocaine hcl urethral/mucosal 2 % prsyr 1

lidocaine pak 5 % ointment 1

lidopin 3 % cream 1

premium lidocaine 5 % ointment 1

MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL

pimecrolimus 1 % cream 2 QL 60 / 30 day(s)

tacrolimus 0.03 % ointment 2

tacrolimus 0.1 % ointment 2

MISC. TOPICAL

DRYSOL 20 % SOLUTIONaluminum chloride 3

OXABOROLE-RELATED ANTIFUNGALS - TOPICAL

tavaborole 5 % solution 2QL 10 / 30 day(s)

ST

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL

EUCRISA 2 % OINTMENTcrisaborole 3 PA

ROSACEA AGENTS

azelaic acid 15 % gel 1 QL 50 / 30 DAYS

ivermectin 1 % cream 1 QL 1 / 1 day(s)

metronidazole 0.75 % cream 1

metronidazole 0.75 % gel 1

metronidazole 0.75 % lotion 1

metronidazole 1 % gel 1



MIRVASO 0.33 % GELbrimonidine tartrate (topical) 3 PA

RHOFADE 1 % CREAMoxymetazoline hcl (topical) 3 PA

rosadan 0.75 % cream 1

rosadan 0.75 % gel 1

SCABICIDES & PEDICULICIDES

EURAX 10 % CREAMcrotamiton 2

LINDANE 1 % SHAMPOOlindane 1

malathion 0.5 % lotion 1

OVIDE 0.5 % LOTIONmalathion 3

permethrin 5 % cream 1

SPINOSAD 0.9 % SUSPENSIONspinosad 1

ULESFIA 5 % LOTIONbenzyl alcohol (pediculicide) 3

SKIN PROTECTANTS

BENZOIN TINCTUREbenzoin 3

benzoin compound tincture 3

STEROID-LOCAL ANESTHETIC COMBINATIONS

CORTANE-B 10-10-1 MG/ML LOTIONhydrocortisone-pramoxine-chloroxylenol 3

EPIFOAM 1-1 % FOAMpramoxine-hc 3

hydrocortisone ace-pramoxine 2.5-1 % cream 1

NOVACORT 1-2 % GELpramoxine-hc 3 PA

PRAMOSONE 1-1 % CREAMpramoxine-hc 3

PRAMOSONE 1-1 % LOTIONpramoxine-hc 3



PRAMOSONE 1-1 % OINTMENTpramoxine-hc 3

PRAMOSONE 1-2.5 % LOTIONpramoxine-hc 3

PRAMOSONE 1-2.5 % OINTMENTpramoxine-hc 3

PRAMOSONE E 1-2.5 % CREAMpramoxine-hc emollient base 3

TOPICAL ANESTHETIC COMBINATIONS

CETACAINE 2-2-14 % AEROSOLbutamben-tetracaine-benzocaine 3

lidocaine-prilocaine 2.5-2.5 % cream 1

SYNERA 70-70 MG PATCHlidocaine-tetracaine 3

TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS

TARGRETIN 1 % GELbexarotene (topical) 4

PA

S Specialty Drug

TOPICAL STEROID COMBINATIONS

calcipotriene-betameth diprop 0.005-0.064 % suspension 3

SCALACORT DK 2 & 2-2 % KIThydrocortisone & salicylic acid-sulfur & shampoo 3

WOUND CARE - GROWTH FACTOR AGENTS

REGRANEX 0.01 % GELbecaplermin 3 PA

WOUND CLEANSERS/DECUBITUS ULCER THERAPY

LAVARE WOUND WASH GELwound cleansers 3

MICROCYN SKIN AND WOUND GELwound cleansers 3

DIAGNOSTIC PRODUCTS

DIAGNOSTIC DRUGS

GLUCAGEN DIAGNOSTIC 1 MG RECON SOLNglucagon hcl rdna (diagnostic) 2

GLUCAGON HCL (DIAGNOSTIC) 1 MG RECON SOLNglucagon hcl (diagnostic) 1 QL 1 / 30 DAYS



PROVOCHOLINE 100 MG RECON SOLNmethacholine chloride 2

DIAGNOSTIC TESTS

FREESTYLE INSULINX TEST STRIPglucose blood 2 QL 150 / 30 DAYS

FREESTYLE LITE TEST STRIPglucose blood 2 QL 150 / 30 DAYS

FREESTYLE TEST STRIPglucose blood 2 QL 150 / 30 DAYS

ONETOUCH ULTRA STRIPglucose blood 2 QL 150 / 30 DAYS

ONETOUCH VERIO STRIPglucose blood 2 QL 150 / 30 DAYS

INFECTION TESTS

ACCULA SARS-COV-2 KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative

BD VERITOR HOME COVID-19 TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

BD VERITOR SYSTEM SARS-COV-2 KITcovid-19 antigen test 2

QL 8 / 30 day(s)

PREV Preventative

BINAXNOW COVID-19 AG CARD KITcovid-19 antigen test 2

QL 8 / 30 day(s)

PREV Preventative

BINAXNOW COVID-19 AG HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

CARESTART COVID-19 HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

CLEARDETECT COVID-19 AG HOME KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

CLINITEST RAPID COVID-19 TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

COBAS LIAT SARS-COV-2 ASSAY KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative



COVID-19 AT-HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

COVID-19 OTC ANTIGEN 1-PACK KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

COVID-19 OTC ANTIGEN 2-PACK KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

DIATRUST COVID-19 HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

DXTERITY COVID-19 HOME TEST KITcovid-19 home collection test 2

QL 8 / 30 day(s)

PREV Preventative

ELLUME COVID-19 HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

EVERLYWELL COVID-19 HOME TEST KITcovid-19 home collection test 2

QL 8 / 30 day(s)

PREV Preventative

FLOWFLEX COVID-19 AG HOME TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

ID NOW COVID-19 KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative

IHEALTH COVID-19 RAPID TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

INTELISWAB COVID-19 RAPID TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

LUCIRA COVID-19 ALL-IN-ONE KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

LYRA DIRECT SARS-COV-2 ASSAY KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative

LYRA SARS-COV-2 ASSAY KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative

MYLAB BOX COVID-19 TESTING KITcovid-19 home test 2

QL 8 / 30 day(s)

PREV Preventative



ON/GO COVID-19 ANTIGEN TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

PIXEL COVID-19 PCR HOME TEST KITcovid-19 home test 2

QL 8 / 30 day(s)

PREV Preventative

QUICKVUE AT-HOME COVID-19 TEST KITcovid-19 at home test 2

QL 8 / 30 day(s)

PREV Preventative

QUICKVUE SARS ANTIGEN TEST KITcovid-19 antigen test 2

QL 8 / 30 day(s)

PREV Preventative

SIMPLICITY COVID-19 AT-HOME KITcovid-19 home collection test 2

QL 8 / 30 day(s)

PREV Preventative

SOFIA SARS ANTIGEN FIA KITcovid-19 antigen test 2

QL 8 / 30 day(s)

PREV Preventative

SOFIA2 SARS ANTIGEN FIA KITcovid-19 antigen test 2

QL 8 / 30 day(s)

PREV Preventative

XPERT XPRESS SARS-COV-2 KITcovid-19 test 2

QL 8 / 30 day(s)

PREV Preventative

DIGESTIVE AIDS

DIGESTIVE ENZYMES

CREON 12000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 2 PA

CREON 24000-76000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 2 PA

CREON 3000-9500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 2 PA



PANCREAZE 10500 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 3 PA






PANCREAZE 2600-8800 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 3 PA

PANCREAZE 37000-97300 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 3 PA


ZENPEP 10000-32000 UNIT CP DR PARTpancrelipase (lipase-protease-amylase) 2 PA








DIURETICS

CARBONIC ANHYDRASE INHIBITORS

acetazolamide 125 mg tab 1

acetazolamide 250 mg tab 1

acetazolamide er 500 mg cap er 12h 1

methazolamide 25 mg tab 1 QL 3 / 1 day(s)

methazolamide 50 mg tab 1

DIURETIC COMBINATIONS

amiloride-hydrochlorothiazide 5-50 mg tab 1



spironolactone-hctz 25-25 mg tab 1

triamterene-hctz 37.5-25 mg cap 1

triamterene-hctz 37.5-25 mg tab 1

triamterene-hctz 75-50 mg tab 1

LOOP DIURETICS

bumetanide 0.5 mg tab 1

bumetanide 1 mg tab 1

bumetanide 2 mg tab 1

ethacrynic acid 25 mg tab 1

furosemide 10 mg/ml solution 1

furosemide 20 mg tab 1


FUROSEMIDE 8 MG/ML SOLUTIONfurosemide 1 AL1 Up to 8 yrs old


torsemide 10 mg tab 1




POTASSIUM SPARING DIURETICS

amiloride hcl 5 mg tab 1

spironolactone 100 mg tab 1



triamterene 100 mg cap 1

triamterene 50 mg cap 1

THIAZIDES AND THIAZIDE-LIKE DIURETICS

CHLOROTHIAZIDE 250 MG TABchlorothiazide 1

CHLOROTHIAZIDE 500 MG TABchlorothiazide 1



chlorothiazide 500 mg tab 1

chlorthalidone 25 mg tab 1

chlorthalidone 50 mg tab 1

DIURIL 250 MG/5ML SUSPENSIONchlorothiazide 2 AL1 Up to 8 yrs old

hydrochlorothiazide 12.5 mg cap 1

hydrochlorothiazide 12.5 mg tab 1

hydrochlorothiazide 25 mg tab 1

hydrochlorothiazide 50 mg tab 1

indapamide 1.25 mg tab 1

indapamide 2.5 mg tab 1

METHYCLOTHIAZIDE 5 MG TABmethyclothiazide 1

metolazone 10 mg tab 1

metolazone 2.5 mg tab 1

metolazone 5 mg tab 1

ENDOCRINE AND METABOLIC AGENTS - MISC.

BISPHOSPHONATES

alendronate sodium 10 mg tab 1 QL 30 / 28 DAYS


ALENDRONATE SODIUM 40 MG TABalendronate sodium 1 QL 30 / 28 DAYS



alendronate sodium 70 mg/75ml solution 1QL 300 / 28 DAYS

AL1 Up to 8 yrs old

ETIDRONATE DISODIUM 200 MG TABetidronate disodium 1 MFL 3 / 365 DAYS

ETIDRONATE DISODIUM 400 MG TABetidronate disodium 1 MFL 3 / 365 DAYS

FOSAMAX PLUS D 70-2800 MG-UNIT TABalendronate sodium-cholecalciferol 3 QL 4 / 28 DAYS



FOSAMAX PLUS D 70-5600 MG-UNIT TABalendronate sodium-cholecalciferol 3 QL 4 / 28 DAYS

ibandronate sodium 150 mg tab 1 QL 1 / 28 DAYS

risedronate sodium 150 mg tab 1 QL 1 / 30 DAYS



risedronate sodium 35 mg tab dr 1 QL 4 / 28 DAYS


CALCIMIMETIC AGENTS

cinacalcet hcl 30 mg tab 1 QL 120 / 30 day(s)



CALCITONINS

calcitonin (salmon) 200 unit/act solution 1

calcitonin (salmon) 200 unit/ml solution 4PA

S Specialty Drug

CARNITINE REPLENISHER - AGENTS

CARNITOR SF 1 GM/10ML SOLUTIONlevocarnitine (metabolic modifiers) 3

levocarnitine 1 gm/10ml solution 1

levocarnitine 330 mg tab 1

levocarnitine sf 1 gm/10ml solution 1

CORTISOL SYNTHESIS INHIBITORS

ISTURISA 1 MG TABosilodrostat phosphate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



DOPAMINE RECEPTOR AGONISTS

cabergoline 0.5 mg tab 1

GNRH/LHRH ANTAGONISTS

fyremadel 250 mcg/0.5ml soln prsyr 4

PA

S Specialty Drug

FB Fertility Benefit

ganirelix acetate 250 mcg/0.5ml soln prsyr 4

PA

S Specialty Drug


ORILISSA 150 MG TABelagolix sodium 4

PA

S Specialty Drug

ORILISSA 200 MG TABelagolix sodium 4

PA

S Specialty Drug

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT 10 MG RECON SOLNpegvisomant 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

GROWTH HORMONE RELEASING HORMONES (GHRH)

EGRIFTA 1 MG RECON SOLNtesamorelin acetate 4

PA

S Specialty Drug

GROWTH HORMONES

GENOTROPIN 12 MG CARTRIDGEsomatropin 4

PA

S Specialty Drug



GENOTROPIN 5 MG CARTRIDGEsomatropin 4

PA

S Specialty Drug

GENOTROPIN MINIQUICK 0.2 MG PRSYRsomatropin 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

GENOTROPIN MINIQUICK 1 MG PRSYRsomatropin 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

GENOTROPIN MINIQUICK 2 MG PRSYRsomatropin 4

PA

S Specialty Drug

NORDITROPIN FLEXPRO 10 MG/1.5ML SOLN PENsomatropin 4

PA

S Specialty Drug


PA

S Specialty Drug

NORDITROPIN FLEXPRO 30 MG/3ML SOLN PENsomatropin 4

PA

S Specialty Drug


PA

S Specialty Drug



NUTROPIN AQ NUSPIN 10 10 MG/2ML SOLN PENsomatropin 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

OMNITROPE 10 MG/1.5ML SOLN CARTsomatropin 4

PA

S Specialty Drug

OMNITROPE 5 MG/1.5ML SOLN CARTsomatropin 4

PA

S Specialty Drug

OMNITROPE 5.8 MG RECON SOLNsomatropin 4

PA

S Specialty Drug

HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS

ORFADIN 4 MG/ML SUSPENSIONnitisinone 4

PA

S Specialty Drug

HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS

calcitriol 0.25 mcg cap 1

calcitriol 0.5 mcg cap 1

calcitriol 1 mcg/ml solution 1 AL1 Up to 8 yrs old

doxercalciferol 0.5 mcg cap 1

doxercalciferol 1 mcg cap 1

doxercalciferol 2.5 mcg cap 1

doxercalciferol 4 mcg/2ml solution 1

paricalcitol 1 mcg cap 1


paricalcitol 2 mcg/ml solution 1


paricalcitol 5 mcg/ml solution 1



HYPOPHOSPHATASIA (HPP) AGENTS

STRENSIQ 18 MG/0.45ML SOLUTIONasfotase alfa 4

PA

S Specialty Drug


PA

S Specialty Drug

STRENSIQ 40 MG/ML SOLUTIONasfotase alfa 4

PA

S Specialty Drug


PA

S Specialty Drug

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

INCRELEX 40 MG/4ML SOLUTIONmecasermin 4

PA

S Specialty Drug

LHRH/GNRH AGONIST ANALOG COMBINATIONS

LUPANETA PACK 11.25 & 5 MG KITleuprolide acetate & norethindrone acetate 4

PA

S Specialty Drug

LUPANETA PACK 3.75 & 5 MG KITleuprolide acetate & norethindrone acetate 4

PA

S Specialty Drug

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

LUPRON DEPOT-PED (1-MONTH) 11.25 MG KITleuprolide acetate (cpp) 4

PA

S Specialty Drug

LUPRON DEPOT-PED (1-MONTH) 15 MG KITleuprolide acetate (cpp) 4

PA

S Specialty Drug

LUPRON DEPOT-PED (1-MONTH) 7.5 MG KITleuprolide acetate (cpp) 4

PA

S Specialty Drug

LUPRON DEPOT-PED (3-MONTH) 11.25 MG (PED) KITleuprolide acetate (cpp) (3 month) 4

PA

S Specialty Drug

LUPRON DEPOT-PED (3-MONTH) 30 MG (PED) KITleuprolide acetate (cpp) (3 month) 4

PA

S Specialty Drug



OVULATION STIMULANTS-GONADOTROPINS

FOLLISTIM AQ 300 UNT/0.36ML SOLUTIONfollitropin beta 4

PA

S Specialty Drug



PA

S Specialty Drug



PA

S Specialty Drug


MENOPUR 75 UNIT RECON SOLNmenotropins 4

PA

S Specialty Drug


OVIDREL 250 MCG/0.5ML INJECTABLEchoriogonadotropin alfa 2 FB Fertility Benefit

PREGNYL 10000 UNIT RECON SOLNchorionic gonadotropin 2 FB Fertility Benefit

OVULATION STIMULANTS-SYNTHETIC

CLOMIPHENE CITRATE 50 MG TABclomiphene citrate 1 FB Fertility Benefit

PARATHYROID HORMONE AND DERIVATIVES

FORTEO 600 MCG/2.4ML SOLN PENteriparatide (recombinant) 4

PA

S Specialty Drug

TERIPARATIDE (RECOMBINANT) 620 MCG/2.48ML SOLNPENteriparatide (recombinant)

4PA

S Specialty Drug

TYMLOS 3120 MCG/1.56ML SOLN PENabaloparatide 4

PA

S Specialty Drug

PHENYLKETONURIA TREATMENT - AGENTS

PALYNZIQ 10 MG/0.5ML SOLN PRSYRpegvaliase-pqpz 4

PA

S Specialty Drug

PALYNZIQ 2.5 MG/0.5ML SOLN PRSYRpegvaliase-pqpz 4

PA

S Specialty Drug



PALYNZIQ 20 MG/ML SOLN PRSYRpegvaliase-pqpz 4

PA

S Specialty Drug

sapropterin dihydrochloride 100 mg packet 4PA

S Specialty Drug

sapropterin dihydrochloride 100 mg tab 4PA

S Specialty Drug

sapropterin dihydrochloride 500 mg packet 4PA

S Specialty Drug

SCLEROSTIN INHIBITORS

EVENITY 105 MG/1.17ML SOLN PRSYRromosozumab-aqqg 4

PA

MFL 12 / 999999 DAYS

S Specialty Drug

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)

OSPHENA 60 MG TABospemifene 3

raloxifene hcl 60 mg tab 1QL 30 / 30 DAYS

PREV Preventative

SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS

JYNARQUE 15 MG TABtolvaptan 4

PA

S Specialty Drug

JYNARQUE 15 MG TAB THPKtolvaptan 4

PA

S Specialty Drug

JYNARQUE 30 & 15 MG TAB THPKtolvaptan 4

PA

S Specialty Drug

JYNARQUE 30 MG TABtolvaptan 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug

TOLVAPTAN 15 MG TABtolvaptan 4

PA

S Specialty Drug

tolvaptan 15 mg tab 4PA

S Specialty Drug

tolvaptan 30 mg tab 4PA

S Specialty Drug

SOMATOSTATIC AGENTS

OCTREOTIDE ACETATE 100 MCG/ML SOLN PRSYRoctreotide acetate 2

octreotide acetate 100 mcg/ml solution 2







SIGNIFOR 0.3 MG/ML SOLUTIONpasireotide diaspartate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

SIGNIFOR LAR 10 MG SRERpasireotide pamoate 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug

UREA CYCLE DISORDER - AGENTS

BUPHENYL 3 GM/TSP POWDERsodium phenylbutyrate 4

PA

AL1 Up to 8 yrs old

S Specialty Drug

BUPHENYL 500 MG TABsodium phenylbutyrate 4

PA

S Specialty Drug

sodium phenylbutyrate 3 gm/tsp powder 1 AL1 Up to 8 yrs old

sodium phenylbutyrate 500 mg tab 1 PA

VASOPRESSIN

desmopressin ace spray refrig 0.01 % solution 1

desmopressin acetate 0.1 mg tab 1

desmopressin acetate 0.2 mg tab 1

DESMOPRESSIN ACETATE 1.5 MG/ML SOLUTIONdesmopressin acetate 2 QL 1 / 90 day(s)

desmopressin acetate 4 mcg/ml solution 1 PA

desmopressin acetate pf 4 mcg/ml solution 1 PA

desmopressin acetate spray 0.01 % solution 1

STIMATE 1.5 MG/ML SOLUTIONdesmopressin acetate 2 QL 1 / 180 day(s)

ESTROGENS

ESTROGEN & ANDROGEN

covaryx 1.25-2.5 mg tab 3

covaryx hs 0.625-1.25 mg tab 1

eemt 1.25-2.5 mg tab 3

eemt hs 0.625-1.25 mg tab 1

est estrogens-methyltest 0.625-1.25 mg tab 1



est estrogens-methyltest 1.25-2.5 mg tab 1

est estrogens-methyltest ds 1.25-2.5 mg tab 1

est estrogens-methyltest hs 0.625-1.25 mg tab 1

ESTROGEN & PROGESTIN

ACTIVELLA 0.5-0.1 MG TABestradiol & norethindrone acetate 3

ACTIVELLA 1-0.5 MG TABestradiol & norethindrone acetate 3

amabelz 0.5-0.1 mg tab 3

amabelz 1-0.5 mg tab 1

ANGELIQ 0.25-0.5 MG TABdrospirenone-estradiol 3 QL 28 / 28 DAYS

ANGELIQ 0.5-1 MG TABdrospirenone-estradiol 3 QL 28 / 28 DAYS

CLIMARA PRO 0.045-0.015 MG/DAY PATCH WKestradiol-levonorgestrel 3 QL 4 / 28 DAYS

COMBIPATCH 0.05-0.14 MG/DAY PATCH TWestradiol & norethindrone acetate 3 QL 8 / 28 DAYS

COMBIPATCH 0.05-0.25 MG/DAY PATCH TWestradiol & norethindrone acetate 3 QL 8 / 28 DAYS

estradiol-norethindrone acet 0.5-0.1 mg tab 1

estradiol-norethindrone acet 1-0.5 mg tab 1

FEMHRT 0.5-2.5 MG-MCG TABnorethindrone acetate-ethinyl estradiol 3

fyavolv 0.5-2.5 mg-mcg tab 1

fyavolv 1-5 mg-mcg tab 1

jevantique lo 0.5-2.5 mg-mcg tab 1

jinteli 1-5 mg-mcg tab 1

lopreeza 0.5-0.1 mg tab 1

lopreeza 1-0.5 mg tab 1

mimvey 1-0.5 mg tab 1

mimvey lo 0.5-0.1 mg tab 1

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1

norethindrone-eth estradiol 1-5 mg-mcg tab 1



PREFEST 1/1-0.09 MG (15/15) TABestradiol-norgestimate 3

PREMPHASE 0.625-5 MG TABconjugated estrogens-medroxyprogesterone acetate 2

PREMPRO 0.3-1.5 MG TABconjugated estrogens-medroxyprogesterone acetate 3



PREMPRO 0.625-5 MG TABconjugated estrogens-medroxyprogesterone acetate 2

ESTROGEN-PROGESTIN-GNRH ANTAGONIST

ORIAHNN 300-1-0.5 & 300 MG CAP THPKelagolix sodium-estradiol-norethindrone acetate 4

PA

S Specialty Drug

ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB

DUAVEE 0.45-20 MG TABconjugated estrogens-bazedoxifene 3 QL 30 / 30 DAYS

ALORA 0.025 MG/24HR PATCH TWestradiol 3 QL 8 / 28 DAYS




CLIMARA 0.025 MG/24HR PATCH WKestradiol 3 QL 4 / 28 DAYS








DELESTROGEN 20 MG/ML OILestradiol valerate 3

DELESTROGEN 40 MG/ML OILestradiol valerate 3

DIVIGEL 0.25 MG/0.25GM GELestradiol 3 QL 30 / 30 DAYS

DIVIGEL 0.5 MG/0.5GM GELestradiol 3 QL 30 / 30 DAYS

DIVIGEL 1 MG/GM GELestradiol 3 QL 30 / 30 DAYS

dotti 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





ELESTRIN 0.52 MG/0.87 GM (0.06%) GELestradiol 3 QL 26 / 30 DAYS

estradiol 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS

estradiol 0.025 mg/24hr patch wk 1 QL 4 / 28 DAYS










estradiol 0.5 mg tab 1

estradiol 1 mg tab 1



estradiol 2 mg tab 1

estradiol valerate 20 mg/ml oil 1

estradiol valerate 40 mg/ml oil 1

ESTROGEL 0.75 MG/1.25 GM (0.06%) GELestradiol 3 QL 50 / 30 DAYS

ESTROPIPATE 0.75 MG TABestropipate 1

ESTROPIPATE 1.5 MG TABestropipate 1

EVAMIST 1.53 MG/SPRAY SOLUTIONestradiol 3 QL 16.2 / 30 DAYS

lyllana 0.025 mg/24hr patch tw 1 QL 8 / 28 DAYS





MENEST 0.3 MG TABesterified estrogens 3




MENOSTAR 14 MCG/24HR PATCH WKestradiol 3 QL 4 / 28 DAYS

MINIVELLE 0.025 MG/24HR PATCH TWestradiol 3 QL 8 / 28 DAYS







PREMARIN 0.3 MG TABestrogens, conjugated 2





VIVELLE-DOT 0.025 MG/24HR PATCH TWestradiol 3 QL 8 / 28 DAYS





FLUOROQUINOLONES

ciprofloxacin 500 mg/5ml (10%) recon susp 1 AL1 Up to 8 yrs old

CIPROFLOXACIN HCL 100 MG TABciprofloxacin hcl 1

ciprofloxacin hcl 250 mg tab 1



CIPROFLOXACIN-CIPROFLOX HCL ER 1000 MG TAB ER24Hciprofloxacin-ciprofloxacin hcl

1

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 25 mg/ml solution 1 AL1 At least 8 yrs old

levofloxacin 250 mg tab 1 QL 14 / 14 DAYS





moxifloxacin hcl 400 mg tab 1QL 14 / 0 DAYS

MFL 1 / DAYS

ofloxacin 400 mg tab 1

GASTROINTESTINAL AGENTS - MISC.

5-HT4 RECEPTOR AGONISTS

MOTEGRITY 1 MG TABprucalopride succinate 3

QL 30 / 30 DAYS

PA

MOTEGRITY 2 MG TABprucalopride succinate 3

QL 30 / 30 DAYS

PA

CIC AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS

TRULANCE 3 MG TABplecanatide 3

QL 30 / 30 DAYS

PA

FARNESOID X RECEPTOR (FXR) AGONISTS

OCALIVA 10 MG TABobeticholic acid 4

PA

S Specialty Drug

OCALIVA 5 MG TABobeticholic acid 4

PA

S Specialty Drug

GALLSTONE SOLUBILIZING AGENTS

ursodiol 250 mg tab 1

ursodiol 300 mg cap 1

ursodiol 500 mg tab 1

GASTROINTESTINAL ANTIALLERGY AGENTS

cromolyn sodium 100 mg/5ml conc 1

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS

AMITIZA 24 MCG CAPlubiprostone 3

QL 60 / 30 day(s)

PA

AMITIZA 8 MCG CAPlubiprostone 3

QL 60 / 30 day(s)

PA

LUBIPROSTONE 24 MCG CAPlubiprostone 3

QL 60 / 30 day(s)

PA



LUBIPROSTONE 8 MCG CAPlubiprostone 3

QL 60 / 30 day(s)

PA

GASTROINTESTINAL STIMULANTS

metoclopramide hcl 10 mg tab 1

METOCLOPRAMIDE HCL 10 MG TAB DISPmetoclopramide hcl 1 QL 120 / 30 DAYS

metoclopramide hcl 10 mg/10ml solution 1

metoclopramide hcl 5 mg tab 1

METOCLOPRAMIDE HCL 5 MG TAB DISPmetoclopramide hcl 1 QL 120 / 30 DAYS

metoclopramide hcl 5 mg/5ml solution 1

IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS

LINZESS 145 MCG CAPlinaclotide 2

QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

IBS AGENT - MU-OPIOID RECEPTOR AGONISTS

VIBERZI 100 MG TABeluxadoline 3 PA

VIBERZI 75 MG TABeluxadoline 3 PA

IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS

alosetron hcl 0.5 mg tab 2QL 60 / 30 DAYS

PA

alosetron hcl 1 mg tab 2QL 60 / 30 DAYS

PA

ILEAL BILE ACID TRANSPORTER (IBAT) INHIBITORS

BYLVAY (PELLETS) 200 MCG CAP SPRINKodevixibat 4

PA

S Specialty Drug



BYLVAY (PELLETS) 600 MCG CAP SPRINKodevixibat 4

PA

S Specialty Drug

BYLVAY 1200 MCG CAPodevixibat 4

PA

S Specialty Drug

BYLVAY 400 MCG CAPodevixibat 4

PA

S Specialty Drug

INFLAMMATORY BOWEL AGENTS

balsalazide disodium 750 mg cap 1

DIPENTUM 250 MG CAPolsalazine sodium 3 PA

GIAZO 1.1 GM TABbalsalazide disodium 3

QL 180 / 30 DAYS

PA

mesalamine 1.2 gm tab dr 2 QL 120 / 30 DAYS

mesalamine 1000 mg suppos 2 QL 30 / 30 DAYS

mesalamine 4 gm enema 1 QL 1680 / 28 DAYS

mesalamine 400 mg cap dr 1 QL 6 / 1 day(s)

mesalamine 800 mg tab dr 2 QL 180 / 30 DAYS

mesalamine er 0.375 gm cap er 24h 2 QL 4 / 1 day(s)

mesalamine-cleanser 4 gm kit 1 QL 1680 / 28 DAYS

PENTASA 250 MG CAP ERmesalamine 2 QL 90 / 30 DAYS

PENTASA 500 MG CAP ERmesalamine 2 QL 240 / 30 DAYS

sulfasalazine 500 mg tab 1

sulfasalazine 500 mg tab dr 1

INTESTINAL ACIDIFIERS

enulose 10 gm/15ml solution 1

generlac 10 gm/15ml solution 1

lactulose encephalopathy 10 gm/15ml solution 1



PERIPHERAL OPIOID RECEPTOR ANTAGONISTS

MOVANTIK 12.5 MG TABnaloxegol oxalate 2

QL 30 / 30 DAYS

PA

MOVANTIK 25 MG TABnaloxegol oxalate 2

QL 30 / 30 DAYS

PA

SYMPROIC 0.2 MG TABnaldemedine tosylate 3

QL 30 / 30 DAYS

PA

PHOSPHATE BINDER AGENTS

AURYXIA 1 GM 210 MG(FE) TABferric citrate 3

QL 360 / 30 DAYS

PA

calcium acetate (phos binder) 667 mg cap 1

calcium acetate (phos binder) 667 mg tab 1

calcium acetate 667 mg tab 1

FOSRENOL 1000 MG CHEW TABlanthanum carbonate 3 PA

FOSRENOL 1000 MG PACKETlanthanum carbonate 3 PA



FOSRENOL 750 MG PACKETlanthanum carbonate 3 PA

lanthanum carbonate 1000 mg chew tab 2



PHOSLYRA 667 MG/5ML SOLUTIONcalcium acetate (phosphate binder) 3 AL1 Up to 8 yrs old

sevelamer carbonate 0.8 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 2.4 gm packet 1 AL1 Up to 8 yrs old

sevelamer carbonate 800 mg tab 1

SEVELAMER HCL 400 MG TABsevelamer hcl 2 PA



sevelamer hcl 800 mg tab 2 PA

VELPHORO 500 MG CHEW TABsucroferric oxyhydroxide 3 PA

TUMOR NECROSIS FACTOR ALPHA BLOCKERS

CIMZIA 2 X 200 MG KITcertolizumab pegol 4

PA

S Specialty Drug

CIMZIA PREFILLED 2 X 200 MG/ML PREF SY KTcertolizumab pegol 4

PA

S Specialty Drug

CIMZIA STARTER KIT 6 X 200 MG/ML PREF SY KTcertolizumab pegol 4

PA

S Specialty Drug

GENITOURINARY AGENTS - MISCELLANEOUS

5-ALPHA REDUCTASE INHIBITORS

dutasteride 0.5 mg cap 1 QL 30 / 30 DAYS

finasteride 5 mg tab 1QL 30 / 30 DAYS

GL Male

ALPHA 1-ADRENOCEPTOR ANTAGONISTS

alfuzosin hcl er 10 mg tab er 24h 1 QL 60 / 30 DAYS

CARDURA XL 4 MG TAB ER 24Hdoxazosin mesylate (bph) 3 QL 30 / 30 DAYS

CARDURA XL 8 MG TAB ER 24Hdoxazosin mesylate (bph) 3 QL 30 / 30 DAYS

silodosin 4 mg cap 1 QL 60 / 30 DAYS

silodosin 8 mg cap 1 QL 30 / 30 DAYS

tamsulosin hcl 0.4 mg cap 1 QL 60 / 30 DAYS

ANTI-INFECTIVE GENITOURINARY IRRIGANTS

NEOMYCIN-POLYMYXIN B GU 40-200000 SOLUTIONneomycin/polymyxin b gu 1

neomycin-polymyxin b gu 40-200000 solution 1



CITRATES

CYTRA K CRYSTALS 3300-1002 MG PACKETpotassium citrate-citric acid 1

ORACIT 490-640 MG/5ML SOLUTIONsodium citrate & citric acid 3 AL1 Up to 8 yrs old

pot & sod cit-cit ac 550-500-334 mg/5ml solution 1 AL1 Up to 8 yrs old

potassium citrate er 10 meq (1080 mg) tab er 1



potassium citrate-citric acid 1100-334 mg/5ml solution 1

sod citrate-citric acid 500-334 mg/5ml solution 1

taron-crystals 3300-1002 mg packet 1

tricitrates 550-500-334 mg/5ml solution 1 AL1 Up to 8 yrs old

CYSTINOSIS AGENTS

CYSTAGON 150 MG CAPcysteamine bitartrate 4

PA

S Specialty Drug

CYSTAGON 50 MG CAPcysteamine bitartrate 4

PA

S Specialty Drug

GENITOURINARY IRRIGANTS

aminoacetic acid 1.5 % solution 1

curity sterile saline 0.9 % solution 1

glycine 1.5 % solution 1

glycine urologic 1.5 % solution 1

RENACIDIN SOLUTIONcitric acid-gluconolactone-magnesium carbonate 2

RESECTISOL 5 % SOLUTIONmannitol (gu irrigant) 3

sodium chloride 0.9 % solution 1

SORBITOL 3 % SOLUTIONsorbitol irrigation 1

SORBITOL 3.3 % SOLUTIONsorbitol irrigation 1



SORBITOL-MANNITOL 2.7-0.54 GM/100ML SOLUTIONsorbitol-mannitol 3

INTERSTITIAL CYSTITIS AGENTS

ELMIRON 100 MG CAPpentosan polysulfate sodium 3 PA

PHOSPHATES

K-PHOS NO 2 305-700 MG TABpotassium & sodium acid phosphates 2

PROSTATIC HYPERTROPHY AGENT COMBINATIONS

dutasteride-tamsulosin hcl 0.5-0.4 mg cap 1 QL 30 / 30 DAYS

URINARY ANALGESICS

phenazo 200 mg tab 1

phenazopyridine hcl 100 mg tab 1

phenazopyridine hcl 200 mg tab 1

URINARY STONE AGENTS

LITHOSTAT 250 MG TABacetohydroxamic acid 3 PA

GOUT AGENTS

GOUT AGENT COMBINATIONS

colchicine-probenecid 0.5-500 mg tab 1

allopurinol 100 mg tab 1

allopurinol 300 mg tab 1

COLCHICINE 0.6 MG CAPcolchicine 2 QL 60 / 30 DAYS

colchicine 0.6 mg tab 2 QL 60 / 30 DAYS

febuxostat 40 mg tab 1 QL 3 / 1 day(s)

febuxostat 80 mg tab 1 QL 1.5 / 1 day(s)

URICOSURICS

probenecid 500 mg tab 1



HEMATOLOGICAL AGENTS - MISC.

ANTI-VON WILLEBRAND FACTOR AGENTS

CABLIVI 11 MG KITcaplacizumab-yhdp 4

PA

S Specialty Drug

ANTIHEMOPHILIC PRODUCTS

ADVATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ADYNOVATE 1000 UNIT RECON SOLNantihemophilic factor (recombinant) pegylated 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug

AFSTYLA 1000 UNIT KITantihemophilic factor (recombinant) single chain 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ALPHANATE 1000 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex (human) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ALPHANATE/VWF COMPLEX/HUMAN 1000 UNIT RECONSOLNantihemophilic factor/von willebrand factor complex (human)

4PA

S Specialty Drug




4PA

S Specialty Drug


4PA

S Specialty Drug


4PA

S Specialty Drug


4PA

S Specialty Drug

ALPHANINE SD 1000 UNIT RECON SOLNcoagulation factor ix 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ALPROLIX 1000 UNIT RECON SOLNcoagulation factor ix (recomb) fc fusion protein (rfixfc) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

BENEFIX 1000 UNIT KITcoagulation factor ix (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ELOCTATE 1000 UNIT RECON SOLNantihemophilic factor (rcmb) fc fusion protein(bdd-rfviiifc) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ESPEROCT 1000 UNIT RECON SOLNantihemophilic factor (recombinant) glycopegylated-exei 4

PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

HELIXATE FS 1000 UNIT KITantihemophilic factor (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

HEMOFIL M 1000 UNIT RECON SOLNantihemophilic factor (human) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

HUMATE-P 1000-2400 UNIT RECON SOLNantihemophilic factor/von willebrand factor complex (human) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



IDELVION 1000 UNIT RECON SOLNcoagulation factor ix recomb albumin fusion protein (rix-fp) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

IXINITY 1000 UNIT RECON SOLNcoagulation factor ix (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

JIVI 1000 UNIT RECON SOLNantihemophil fact(rcmb) pegylated-aucl (bdd-rfviii peg-aucl) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



KOATE 1000 UNIT RECON SOLNantihemophilic factor (human) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

KOATE-DVI 1000 UNIT RECON SOLNantihemophilic factor (human) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

KOGENATE FS 1000 UNIT KITantihemophilic factor (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

KOGENATE FS BIO-SET 1000 UNIT KITantihemophilic factor (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

KOVALTRY 1000 UNIT RECON SOLNantihemophilic factor (rcmb) plasma/albumin free (rahf-pfm) 4

PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

MONOCLATE-P 1000 UNIT KITantihemophilic factor (human) 4

PA

S Specialty Drug

MONOCLATE-P 1500 UNIT KITantihemophilic factor (human) 4

PA

S Specialty Drug

MONONINE 1000 UNIT RECON SOLNcoagulation factor ix 4

PA

S Specialty Drug

NOVOEIGHT 1000 UNIT RECON SOLNantihemophilic factor (rcmb) bd truncated (bd trunc-rfviii) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

NUWIQ 1000 UNIT KITantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim) 4

PA

S Specialty Drug

NUWIQ 1000 UNIT RECON SOLNantihemophilic factor (rcmb) simoctocog alfa(bdd-rfviii,sim) 4

PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

OBIZUR 500 UNIT RECON SOLNantihemophilic factor (recombinant porcine) (rpfviii) 4

PA

S Specialty Drug



REBINYN 1000 UNIT RECON SOLNcoagulation factor ix (recombinant) glycopegylated 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

RECOMBINATE 1241-1800 UNIT RECON SOLNantihemophilic factor (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

RIXUBIS 1000 UNIT RECON SOLNcoagulation factor ix (recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

WILATE 1000-1000 UNIT KITantihemophilic factor/von willebrand factor complex (human) 4

PA

S Specialty Drug

WILATE 500-500 UNIT KITantihemophilic factor/von willebrand factor complex (human) 4

PA

S Specialty Drug



XYNTHA 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

XYNTHA SOLOFUSE 1000 UNIT KITantihemophilic factor (rcmb) moroctocog alfa(bdd-rfviii,mor) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES

HEMLIBRA 105 MG/0.7ML SOLUTIONemicizumab-kxwh 4

PA

S Specialty Drug

HEMLIBRA 150 MG/ML SOLUTIONemicizumab-kxwh 4

PA

S Specialty Drug

HEMLIBRA 30 MG/ML SOLUTIONemicizumab-kxwh 4

PA

S Specialty Drug

HEMLIBRA 60 MG/0.4ML SOLUTIONemicizumab-kxwh 4

PA

S Specialty Drug

BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant acetate 30 mg/3ml solution 4PA

S Specialty Drug



sajazir 30 mg/3ml solution 4PA

S Specialty Drug

C1 INHIBITORS

BERINERT 500 UNIT KITc1 esterase inhibitor (human) 4

PA

S Specialty Drug

HAEGARDA 2000 UNIT RECON SOLNc1 esterase inhibitor (human) 4

PA

S Specialty Drug

HAEGARDA 3000 UNIT RECON SOLNc1 esterase inhibitor (human) 4

PA

S Specialty Drug

DIRECT-ACTING P2Y12 INHIBITORS

BRILINTA 60 MG TABticagrelor 2 QL 60 / 30 DAYS

BRILINTA 90 MG TABticagrelor 2 QL 60 / 30 DAYS

HEMATORHEOLOGIC AGENTS

pentoxifylline er 400 mg tab er 1

PHOSPHODIESTERASE III INHIBITORS

cilostazol 100 mg tab 1

cilostazol 50 mg tab 1

PLATELET AGGREGATION INHIBITOR COMBINATIONS

aspirin-dipyridamole er 25-200 mg cap er 12h 2

PLATELET AGGREGATION INHIBITORS

dipyridamole 25 mg tab 1



PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS

ZONTIVITY 2.08 MG TABvorapaxar sulfate 3

QL 30 / 30 DAYS

PA

QUINAZOLINE AGENTS

AGRYLIN 0.5 MG CAPanagrelide hcl 4

PA

S Specialty Drug



anagrelide hcl 0.5 mg cap 1

anagrelide hcl 1 mg cap 1

THIENOPYRIDINE DERIVATIVES

clopidogrel bisulfate 300 mg tab 1

clopidogrel bisulfate 75 mg tab 1

prasugrel hcl 10 mg tab 1

prasugrel hcl 5 mg tab 1

HEMATOPOIETIC AGENTS

AGENTS FOR GAUCHER DISEASE

CERDELGA 84 MG CAPeliglustat tartrate 4

PA

S Specialty Drug

COBALAMINS

cyanocobalamin 1000 mcg/ml solution 1

dodex 1000 mcg/ml solution 1

HYDROXOCOBALAMIN ACETATE 1000 MCG/ML SOLUTIONhydroxocobalamin acetate 1

CXCR4 RECEPTOR ANTAGONIST

MOZOBIL 24 MG/1.2ML SOLUTIONplerixafor 4

PA

S Specialty Drug

CYTOTOXIC AGENTS

DROXIA 200 MG CAPhydroxyurea (sickle cell anemia) 2



ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)

ARANESP (ALBUMIN FREE) 10 MCG/0.4ML SOLN PRSYRdarbepoetin alfa 4

PA

S Specialty Drug


PA

S Specialty Drug



ARANESP (ALBUMIN FREE) 100 MCG/ML SOLUTIONdarbepoetin alfa 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

ARANESP (ALBUMIN FREE) 500 MCG/ML SOLN PRSYRdarbepoetin alfa 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

MIRCERA 100 MCG/0.3ML SOLN PRSYRmethoxy polyethylene glycol-epoetin beta 4

PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug

PROCRIT 10000 UNIT/ML SOLUTIONepoetin alfa 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

RETACRIT 10000 UNIT/ML SOLUTIONepoetin alfa-epbx 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

FOLIC ACID/FOLATES

folic acid 1 mg tab 1

GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)

FULPHILA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-jmdb 3

QL 1.2 / 28 day(s)

PA

S Specialty Drug



GRANIX 300 MCG/0.5ML SOLN PRSYRtbo-filgrastim 3

QL 10 / 28 day(s)

PA

S Specialty Drug

GRANIX 300 MCG/ML SOLUTIONtbo-filgrastim 3

QL 20 / 28 day(s)

PA

S Specialty Drug

GRANIX 480 MCG/0.8ML SOLN PRSYRtbo-filgrastim 3

QL 16 / 28 day(s)

PA

S Specialty Drug

GRANIX 480 MCG/1.6ML SOLUTIONtbo-filgrastim 3

QL 32 / 28 day(s)

PA

S Specialty Drug

NIVESTYM 300 MCG/0.5ML SOLN PRSYRfilgrastim-aafi 2

QL 10 / 28 day(s)

S Specialty Drug

NIVESTYM 300 MCG/ML SOLUTIONfilgrastim-aafi 2

QL 20 / 28 day(s)

S Specialty Drug

NIVESTYM 480 MCG/0.8ML SOLN PRSYRfilgrastim-aafi 2

QL 16 / 28 day(s)

S Specialty Drug

NIVESTYM 480 MCG/1.6ML SOLUTIONfilgrastim-aafi 2

QL 32 / 28 day(s)

S Specialty Drug

NYVEPRIA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-apgf 2

QL 1.2 / 28 day(s)

S Specialty Drug

RELEUKO 300 MCG/0.5ML SOLN PRSYRfilgrastim-ayow 3

QL 10 / 28 day(s)

PA

S Specialty Drug

RELEUKO 300 MCG/ML SOLUTIONfilgrastim-ayow 3

QL 20 / 28 day(s)

PA

S Specialty Drug

RELEUKO 480 MCG/0.8ML SOLN PRSYRfilgrastim-ayow 3

QL 16 / 28 day(s)

PA

S Specialty Drug



RELEUKO 480 MCG/1.6ML SOLUTIONfilgrastim-ayow 3

QL 32 / 28 day(s)

PA

S Specialty Drug

UDENYCA 6 MG/0.6ML SOLN PRSYRpegfilgrastim-cbqv 3

QL 1.2 / 28 day(s)

PA

S Specialty Drug

ZARXIO 300 MCG/0.5ML SOLN PRSYRfilgrastim-sndz 2

QL 10 / 28 day(s)

S Specialty Drug

ZARXIO 480 MCG/0.8ML SOLN PRSYRfilgrastim-sndz 2

QL 16 / 28 day(s)

S Specialty Drug

ZIEXTENZO 6 MG/0.6ML SOLN PRSYRpegfilgrastim-bmez 2

QL 1.2 / 28 day(s)

S Specialty Drug

THROMBOPOIETIN (TPO) RECEPTOR AGONISTS

NPLATE 250 MCG RECON SOLNromiplostim 4

PA

S Specialty Drug

NPLATE 500 MCG RECON SOLNromiplostim 4

PA

S Specialty Drug

PROMACTA 12.5 MG PACKETeltrombopag olamine 4

PA

S Specialty Drug

PROMACTA 12.5 MG TABeltrombopag olamine 4

PA

S Specialty Drug

PROMACTA 25 MG PACKETeltrombopag olamine 4

PA

S Specialty Drug

PROMACTA 25 MG TABeltrombopag olamine 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



HEMOSTATICS

HEMOSTATICS - SYSTEMIC

aminocaproic acid 0.25 gm/ml solution 2

aminocaproic acid 1000 mg tab 2

aminocaproic acid 500 mg tab 2

tranexamic acid 650 mg tab 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

BARBITURATE HYPNOTICS

BUTISOL SODIUM 30 MG TABbutabarbital sodium 3

phenobarbital 100 mg tab 1


phenobarbital 16.2 mg tab 1

phenobarbital 20 mg/5ml elixir 1

phenobarbital 20 mg/5ml solution 1






BENZODIAZEPINE HYPNOTICS

estazolam 1 mg tab 1 QL 30 / 30 DAYS

estazolam 2 mg tab 1 QL 30 / 30 DAYS

FLURAZEPAM HCL 15 MG CAPflurazepam hcl 1 QL 30 / 30 DAYS

FLURAZEPAM HCL 30 MG CAPflurazepam hcl 1 QL 30 / 30 DAYS

midazolam hcl (pf) 10 mg/2ml solution 1

midazolam hcl (pf) 5 mg/ml solution 1

midazolam hcl 10 mg/2ml solution 1

midazolam hcl 2 mg/ml syrup 1 AL1 Up to 8 yrs old




midazolam hcl 5 mg/ml solution 1


QUAZEPAM 15 MG TABquazepam 1 QL 30 / 30 DAYS

temazepam 15 mg cap 1 QL 30 / 30 DAYS

temazepam 22.5 mg cap 1 QL 30 / 30 DAYS

temazepam 30 mg cap 1 QL 30 / 30 DAYS

temazepam 7.5 mg cap 1 QL 30 / 30 DAYS

triazolam 0.125 mg tab 1 QL 30 / 30 DAYS

triazolam 0.25 mg tab 1 QL 30 / 30 DAYS

NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS

EDLUAR 10 MG SL TABzolpidem tartrate 3

QL 30 / 30 DAYS

ST

EDLUAR 5 MG SL TABzolpidem tartrate 3

QL 30 / 30 DAYS

ST

eszopiclone 1 mg tab 1 QL 30 / 30 DAYS



zaleplon 10 mg cap 1 QL 60 / 30 DAYS

zaleplon 5 mg cap 1 QL 30 / 30 DAYS

ZOLPIDEM TARTRATE 1.75 MG SL TABzolpidem tartrate 1 QL 30 / 30 day(s)

zolpidem tartrate 1.75 mg sl tab 1 QL 30 / 30 DAYS

zolpidem tartrate 10 mg tab 1 QL 30 / 30 DAYS

ZOLPIDEM TARTRATE 3.5 MG SL TABzolpidem tartrate 1 QL 30 / 30 day(s)

zolpidem tartrate 3.5 mg sl tab 1 QL 30 / 30 DAYS

zolpidem tartrate 5 mg tab 1 QL 30 / 30 DAYS



zolpidem tartrate er 12.5 mg tab er 1 QL 30 / 30 DAYS

zolpidem tartrate er 6.25 mg tab er 1 QL 30 / 30 DAYS

ZOLPIMIST 5 MG/ACT SOLUTIONzolpidem tartrate 3 PA

OREXIN RECEPTOR ANTAGONISTS

BELSOMRA 10 MG TABsuvorexant 3

QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

DAYVIGO 10 MG TABlemborexant 3 PA

DAYVIGO 5 MG TABlemborexant 3 PA

SELECTIVE MELATONIN RECEPTOR AGONISTS

ramelteon 8 mg tab 1 QL 30 / 30 DAYS

LAXATIVES

BOWEL EVACUANT COMBINATIONS

GAVILYTE-C 240 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2

gavilyte-g 236 gm recon soln 1 PREV Preventative

gavilyte-h 5-210 mg-gm kit 1

gavilyte-n with flavor pack 420 gm recon soln 1 PREV Preventative

GOLYTELY 227.1 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2 PREV Preventative

GOLYTELY 236 GM RECON SOLNpeg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2

peg 3350-kcl-na bicarb-nacl 420 gm recon soln 1 PREV Preventative



peg 3350/electrolytes 240 gm recon soln 1 PREV Preventative

peg-3350/electrolytes 236 gm recon soln 1 PREV Preventative

PEG-PREP 5-210 MG-GM KITbisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 1

SUPREP BOWEL PREP KIT 17.5-3.13-1.6 GM/177MLSOLUTIONsodium sulfate-potassium sulfate-magnesium sulfate

2 QL 354 / 30 DAYS

trilyte 420 gm recon soln 1 PREV Preventative

LAXATIVES - MISCELLANEOUS

constulose 10 gm/15ml solution 1

LACTULOSE 10 GM PACKETlactulose 3 AL1 Up to 8 yrs old

lactulose 10 gm/15ml solution 1

lactulose 20 gm/30ml solution 1

pegylax 17 gm/scoop powder 1

polyethylene glycol 3350 17 gm packet 1

polyethylene glycol 3350 17 gm/scoop powder 1

STIMULANT LAXATIVES

CASCARA SAGRADA 1 GM/ML FL EXTRACTcascara sagrada 3 AL1 Up to 8 yrs old

MACROLIDES

AZITHROMYCIN

AZITHROMYCIN 1 GM PACKETazithromycin 1 AL1 Up to 8 yrs old

azithromycin 100 mg/5ml recon susp 1 QL 30 / 5 DAYS

azithromycin 200 mg/5ml recon susp 1 QL 90 / 5 DAYS

azithromycin 250 mg tab 1 QL 30 / 30 day(s)

azithromycin 500 mg tab 1 QL 30 / 30 DAYS

azithromycin 600 mg tab 1 QL 30 / 30 DAYS



CLARITHROMYCIN

CLARITHROMYCIN 125 MG/5ML RECON SUSPclarithromycin 1

clarithromycin 250 mg tab 1

CLARITHROMYCIN 250 MG/5ML RECON SUSPclarithromycin 1

clarithromycin 500 mg tab 1 QL 28 / 14 DAYS

clarithromycin er 500 mg tab er 24h 1 QL 28 / 14 DAYS

ERYTHROMYCINS

ery-tab 250 mg tab dr 1

ery-tab 500 mg tab dr 1

erythromycin 250 mg tab dr 1

erythromycin 500 mg tab dr 1

erythromycin base 250 mg tab dr 1

erythromycin base 500 mg tab dr 1

erythromycin ethylsuccinate 200 mg/5ml recon susp 2

PCE 333 MG TAB DRerythromycin base (coated) 3

PCE 500 MG TAB DRerythromycin base (coated) 3

FIDAXOMICIN

DIFICID 200 MG TABfidaxomicin 4

PA

S Specialty Drug

DIFICID 40 MG/ML RECON SUSPfidaxomicin 4

PA

S Specialty Drug

MEDICAL DEVICES AND SUPPLIES

CERVICAL CAPS

FEMCAP 22 MM DEVICEcervical caps 2 PREV Preventative





DIAPHRAGMS

CAYA DIAPHRAGMdiaphragm arc-spring 2 PREV Preventative

WIDE-SEAL DIAPHRAGM 60 2 % DIAPHRAGMdiaphragm wide seal 2 PREV Preventative








GLUCOSE MONITORING TEST SUPPLIES

DEXCOM G6 RECEIVER DEVICEcontinuous blood glucose system receiver 2

QL 1 / 365 day(s)

PA

DEXCOM G6 SENSOR MISCcontinuous blood glucose system sensor 2

QL 3 / 30 day(s)

PA

DEXCOM G6 TRANSMITTER MISCcontinuous blood glucose system transmitter 2

QL 1 / 90 day(s)

PA

EASY TOUCH LANCETS 30G/TWIST MISClancets 1

EASY TOUCH LANCETS 33G/TWIST MISClancets 1

FREESTYLE FLASH SYSTEM KITblood glucose monitoring supplies 2

FREESTYLE FREEDOM KITblood glucose monitoring supplies 2

FREESTYLE FREEDOM LITE W/DEVICE KITblood glucose monitoring supplies 2



FREESTYLE INSULINX SYSTEM W/DEVICE KITblood glucose monitoring supplies 2

FREESTYLE LANCETS MISClancets 1

FREESTYLE LIBRE 14 DAY READER DEVICEcontinuous blood glucose system receiver 2

QL 1 / 365 day(s)

PA

FREESTYLE LIBRE 14 DAY SENSOR MISCcontinuous blood glucose system sensor 2

QL 2 / 28 day(s)

PA

FREESTYLE LIBRE 2 READER DEVICEcontinuous blood glucose system receiver 2

QL 1 / 365 day(s)

PA

FREESTYLE LIBRE 2 SENSOR MISCcontinuous blood glucose system sensor 2

QL 2 / 28 day(s)

PA

FREESTYLE LIBRE READER DEVICEcontinuous blood glucose system receiver 2

QL 1 / 365 day(s)

PA

FREESTYLE LIBRE SENSOR SYSTEM MISCcontinuous blood glucose system sensor 2

QL 2 / 28 day(s)

PA

FREESTYLE LITE DEVICEblood glucose monitoring supplies 2

FREESTYLE LITE W/DEVICE KITblood glucose monitoring supplies 2

FREESTYLE SIDEKICK II KITblood glucose monitoring supplies 2

FREESTYLE SYSTEM KITblood glucose monitoring supplies 2

FREESTYLE UNISTICK II LANCETS MISClancets 1

KROGER HEALTHPRO LANCET 26G MISClancets 1

KROGER LANCETS MISClancets 1

KROGER LANCETS 21G MISClancets 1

KROGER LANCETS MICRO THIN 33G MISClancets 1



KROGER LANCETS SUPER THIN MISClancets 1

KROGER LANCETS THIN MISClancets 1

KROGER LANCETS THIN 26G MISClancets 1

KROGER LANCETS ULTRATHIN 30G MISClancets 1

MICROLET LANCETS MISClancets 1

ONETOUCH CLUB LANCETS FINE PT MISClancets 1

ONETOUCH DELICA LANCETS 30G MISClancets 1

ONETOUCH DELICA LANCETS 33G MISClancets 1

ONETOUCH DELICA LANCING DEV MISClancet devices 2

ONETOUCH DELICA PLUS LANCET30G MISClancets 1

ONETOUCH DELICA PLUS LANCET33G MISClancets 1

ONETOUCH DELICA PLUS LANCING MISClancet devices 2

ONETOUCH FINEPOINT LANCETS MISClancets 1

ONETOUCH PING METER REMOTE SUPPLIES MISCblood glucose monitoring supplies 2

ONETOUCH SURESOFT LANCING DEV MISClancets misc. 2

ONETOUCH ULTRA 2 W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH ULTRA MINI W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH ULTRALINK W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH ULTRASOFT LANCETS MISClancets 1



ONETOUCH VERIO FLEX SYSTEM W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH VERIO IQ SYSTEM W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH VERIO REFLECT W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH VERIO SYNC SYSTEM W/DEVICE KITblood glucose monitoring supplies 2

ONETOUCH VERIO W/DEVICE KITblood glucose monitoring supplies 2

PHARMACIST CHOICE LANCETS MISClancets 1

TRUEPLUS LANCETS 26G MISClancets 1




TRUEPLUS SAFETY LANCETS 28G MISClancets 1

INSULIN ADMINISTRATION SUPPLIES

OMNIPOD 5 G6 INTRO KIT KITinsulin infusion disposable pump 3 PA

OMNIPOD 5 G6 PODS (GEN 5) MISCinsulin infusion disposable pump 3 PA

OMNIPOD 5 PACK MISCinsulin infusion disposable pump 3 PA

OMNIPOD DASH 5 PACK PODS MISCinsulin infusion disposable pump 3 PA

OMNIPOD DASH INTRO KIT KITinsulin infusion disposable pump 3 PA

OMNIPOD DASH SYSTEM KITinsulin infusion disposable pump 3 PA

OMNIPOD STARTER KITinsulin infusion disposable pump 3 PA



NEEDLES & SYRINGES

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100 1

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100 1

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML MISCinsulin syringe/needle u-500 1

BD KLATSKIN BIOPSY NEEDLE 16G X 4" MISCneedle (disp) 16 g 2

BD OSGOOD BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g 2

BD OSGOOD BIOPSY NEEDLE 18G X 1" MISCneedle (reusable) 18 g 2

BD PEN NEEDLE NANO U/F 32G X 4 MM MISCinsulin pen needle 1

BD ROSENTHAL BIOPSY NEEDLE 16G X 1-5/16" MISCneedle (disp) 16 g 2

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 MLMISCinsulin syringe/needle u-100

1

CEQUR SIMPLICITY INSERTER MISCinjection device for insulin 2

CEQUR SIMPLICITY STARTER KITinjection device for insulin 2

J-TIP KIT W/VIAL ADAPTERS KITinjection device 2

MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML MISCinsulin syringe/needle u-100 1


MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100 1



MAGELLAN INSULIN SAFETY SYR 30G X 5/16" 1 ML MISCinsulin syringe/needle u-100 1



MARATHON MEDICAL PENTIPS 29G X 12MM MISCinsulin pen needle 1

MARATHON MEDICAL PENTIPS 31G X 5 MM MISCinsulin pen needle 1



MONOJECT INSULIN SYRINGE 27G X 1/2" 1 ML MISCinsulin syringe/needle u-100 1

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100 1








MONOJECT INSULIN SYRINGE U-100 1 ML MISCinsulin syringes (disposable) 1

MONOJECT INTRODUCER NEEDLE 18G X 1-1/4" MISCneedle (reusable) 18 g 2

MONOJECT MAGELLAN SAFETY NDL 21G X 5/8" MISCneedle (disp) 21 g 2

MONOJECT MAGELLAN SAFETY NDL 23G X 5/8" MISCneedle (disp) 23 g 2

MONOJECT MAGELLAN SYRINGE 18G X 1" 6 ML MISCsyringe/needle (disp) 6 ml 2

MONOJECT MAGELLAN SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml 2



MONOJECT MAGELLAN SYRINGE 22G X 1-1/2" 12 ML MISCsyringe/needle (disp) 12 ml 2

MONOJECT SYRINGE 21G X 1" 12 ML MISCsyringe/needle (disp) 12 ml 2

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 MLMISCinsulin syringe/needle u-100

1

MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 1 MLMISCinsulin syringe/needle u-100

1


1


1

NORDIPEN 5 INJECTION DEVICE MISCinjection device 2

OMNITROPE PEN 5 INJ DEVICE MISCinjection device 2

PENTIPS 29G X 12MM MISCinsulin pen needle 1

PENTIPS 31G X 5 MM MISCinsulin pen needle 1



PRO COMFORT PEN NEEDLES 31G X 8 MM MISCinsulin pen needle 1



ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML MISCinsulin syringe/needle u-100 1

ULTICARE INSULIN SAFETY SYR 29G X 1/2" 1 ML MISCinsulin syringe/needle u-100 1

ULTILET INSULIN SYRINGE 31G X 15/64" 0.3 ML MISCinsulin syringe/needle u-100 1



SPACER/AEROSOL-HOLDING CHAMBERS & SUPPLIES

AEROCHAMBER MINI CHAMBER DEVICEspacer/aerosol-holding chambers 2

AEROCHAMBER MV MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLO-VU MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLO-VU LARGE MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLO-VU MEDIUM MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLO-VU SMALL MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLO-VU W/MASK MISCspacer/aerosol-holding chambers 2

AEROCHAMBER PLUS FLOW VU MISCspacer/aerosol-holding chambers 2

AEROCHAMBER W/FLOWSIGNAL MISCspacer/aerosol-holding chambers 2

AEROCHAMBER Z-STAT PLUS MISCspacer/aerosol-holding chambers 2

AEROCHAMBER Z-STAT PLUS CHAMBR MISCspacer/aerosol-holding chambers 2

AEROCHAMBER Z-STAT PLUS/LARGE MISCspacer/aerosol-holding chambers 2

AEROCHAMBER Z-STAT PLUS/MEDIUM MISCspacer/aerosol-holding chambers 2

AEROCHAMBER Z-STAT PLUS/SMALL MISCspacer/aerosol-holding chambers 2

COMPACT SPACE CHAMBER DEVICEspacer/aerosol-holding chambers 2

COMPACT SPACE CHAMBER/LG MASK DEVICEspacer/aerosol-holding chambers 2

COMPACT SPACE CHAMBER/MED MASK DEVICEspacer/aerosol-holding chambers 2

COMPACT SPACE CHAMBER/SM MASK DEVICEspacer/aerosol-holding chambers 2

EASIVENT MISCspacer/aerosol-holding chambers 2



EASIVENT MASK LARGE MISCspacer/aerosol-holding chambers 2

EASIVENT MASK MEDIUM MISCspacer/aerosol-holding chambers 2

EASIVENT MASK SMALL MISCspacer/aerosol-holding chambers 2

MICROCHAMBER MISCspacer/aerosol-holding chambers 2

MICROSPACER MISCspacer/aerosol-holding chambers 2

OPTICHAMBER ADVANTAGE-LG MASK MISCspacer/aerosol-holding chambers 2

OPTICHAMBER ADVANTAGE-MED MASK MISCspacer/aerosol-holding chambers 2

OPTICHAMBER ADVANTAGE-SM MASK MISCspacer/aerosol-holding chambers 2

OPTICHAMBER DIAMOND MISCspacer/aerosol-holding chambers 2

OPTICHAMBER DIAMOND-LG MASK DEVICEspacer/aerosol-holding chambers 2

OPTICHAMBER DIAMOND-MD MASK MISCspacer/aerosol-holding chambers 2

OPTICHAMBER DIAMOND-SM MASK MISCspacer/aerosol-holding chambers 2

VALVED HOLDING CHAMBER DEVICEspacer/aerosol-holding chambers 2

MIGRAINE PRODUCTS

CALCITONIN GENE-RELATED PEPTIDE RECEPTOR ANTAG (CGRP)

NURTEC 75 MG TAB DISPrimegepant sulfate 3

QL 8 / 30 day(s)

PA

QULIPTA 10 MG TABatogepant 3 PA



UBRELVY 100 MG TABubrogepant 2

QL 12 / 30 day(s)

PA



UBRELVY 50 MG TABubrogepant 2

QL 12 / 30 day(s)

PA

CGRP RECEPTOR ANTAGONISTS - MONOCOLONAL ANTIBODIES

AIMOVIG (140 MG DOSE) 70 MG/ML SOLN A-INJerenumab-aooe 3

QL 1 / 30 DAYS

PA

AIMOVIG 140 MG/ML SOLN A-INJerenumab-aooe 3

QL 1 / 30 DAYS

PA

AIMOVIG 70 MG/ML SOLN A-INJerenumab-aooe 3

QL 1 / 30 DAYS

PA

AJOVY 225 MG/1.5ML SOLN A-INJfremanezumab-vfrm 2

QL 1.5 / 30 day(s)

PA

AJOVY 225 MG/1.5ML SOLN PRSYRfremanezumab-vfrm 2

QL 1.5 / 30 DAYS

PA

EMGALITY (300 MG DOSE) 100 MG/ML SOLN PRSYRgalcanezumab-gnlm 2

QL 1 / 30 day(s)

PA

EMGALITY 120 MG/ML SOLN A-INJgalcanezumab-gnlm 2

QL 1 / 30 DAYS

PA

EMGALITY 120 MG/ML SOLN PRSYRgalcanezumab-gnlm 2

QL 1 / 30 DAYS

PA

ERGOT COMBINATIONS

ergotamine-caffeine 1-100 mg tab 1

dihydroergotamine mesylate 1 mg/ml solution 2 QL 24 / 30 DAYS

dihydroergotamine mesylate 4 mg/ml solution 2QL 16 / 30 DAYS

PA

ERGOMAR 2 MG SL TABergotamine tartrate 3 QL 10 / 30 DAYS

MIGRAINE PRODUCTS - NSAIDS

CAMBIA 50 MG PACKETdiclofenac potassium (migraine) 3

QL 9 / 30 DAYS

AL1 Up to 8 yrs old



SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS

TREXIMET 10-60 MG TABsumatriptan-naproxen sodium 3

QL 9 / 30 DAYS

PA

SELECTIVE SEROTONIN AGONISTS 5-HT(1)

almotriptan malate 12.5 mg tab 1 QL 9 / 28 DAYS

almotriptan malate 6.25 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 20 mg tab 1 QL 9 / 28 DAYS

eletriptan hydrobromide 40 mg tab 1 QL 9 / 28 DAYS

frovatriptan succinate 2.5 mg tab 1 QL 9 / 28 DAYS

naratriptan hcl 1 mg tab 1 QL 9 / 28 DAYS

naratriptan hcl 2.5 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 10 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 10 mg tab disp 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab 1 QL 9 / 28 DAYS

rizatriptan benzoate 5 mg tab disp 1 QL 9 / 28 DAYS

sumatriptan 20 mg/act solution 2 QL 6 / 28 day(s)

sumatriptan 5 mg/act solution 1 QL 1 / 28 DAYS

sumatriptan succinate 100 mg tab 1 QL 9 / 28 DAYS


sumatriptan succinate 4 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)


sumatriptan succinate 6 mg/0.5ml soln a-inj 2 QL 2 / 28 day(s)

SUMATRIPTAN SUCCINATE 6 MG/0.5ML SOLN PRSYRsumatriptan succinate 2

sumatriptan succinate 6 mg/0.5ml solution 1 QL 5 / 28 day(s)

ZOLMITRIPTAN 2.5 MG SOLUTIONzolmitriptan 3 ST



zolmitriptan 2.5 mg tab 1 QL 12 / 30 DAYS

zolmitriptan 2.5 mg tab disp 1 QL 9 / 30 DAYS

zolmitriptan 5 mg solution 3QL 6 / 30 day(s)

ST

zolmitriptan 5 mg tab 1 QL 9 / 30 DAYS

zolmitriptan 5 mg tab disp 1 QL 9 / 30 DAYS

ZOMIG 2.5 MG SOLUTIONzolmitriptan 3

QL 6 / 30 DAYS

ST

ZOMIG 5 MG SOLUTIONzolmitriptan 3

QL 6 / 30 day(s)

ST

SELECTIVE SEROTONIN AGONISTS 5-HT(1F)

REYVOW 100 MG TABlasmiditan succinate 3

QL 4 / 30 day(s)

PA

REYVOW 50 MG TABlasmiditan succinate 3

QL 4 / 30 day(s)

PA

MINERALS & ELECTROLYTES

BICARBONATES

SODIUM BICARBONATE 8.4 % SOLUTIONsodium bicarbonate 3

sodium bicarbonate 8.4 % solution 3

FLUORIDE

fluoritab 0.55 (0.25 f) mg chew tab 1 PREV Preventative

fluoritab 1.1 (0.5 f) mg chew tab 1 PREV Preventative

fluoritab 2.2 (1 f) mg chew tab 1 PREV Preventative

FLURA-DROPS 0.55 (0.25 F) MG/DROP SOLUTIONsodium fluoride 2

AL1 Up to 8 yrs old

PREV Preventative

ludent 0.55 (0.25 f) mg chew tab 1 PREV Preventative

ludent 1.1 (0.5 f) mg chew tab 1 PREV Preventative



ludent 2.2 (1 f) mg chew tab 1 PREV Preventative

nafrinse 2.2 (1 f) mg chew tab 1 PREV Preventative

sodium fluoride 0.55 (0.25 f) mg chew tab 1 PREV Preventative

sodium fluoride 1.1 (0.5 f) mg chew tab 1 PREV Preventative

sodium fluoride 1.1 (0.5 f) mg/ml solution 1 PREV Preventative

sodium fluoride 2.2 (1 f) mg chew tab 1 PREV Preventative

PHOSPHATE

K-PHOS 500 MG TABpotassium phosphate monobasic 2

phospha 250 neutral 155-852-130 mg tab 1

phospho-trin 250 neutral 155-852-130 mg tab 1

phospho-trin k500 500 mg tab 1

phosphorous 155-852-130 mg tab 1

virt-phos 250 neutral 155-852-130 mg tab 1

POTASSIUM

effer-k 25 meq effer tab 1

k-effervescent 25 meq effer tab 1

k-prime 25 meq effer tab 1

K-TAB 10 MEQ TAB ERpotassium chloride 1

k-vescent 25 meq effer tab 1

klor-con 10 10 meq tab er 1

klor-con 8 meq tab er 2

klor-con m10 10 meq tab er 1



klor-con sprinkle 10 meq cap er 1

klor-con sprinkle 8 meq cap er 1

klor-con/ef 25 meq effer tab 1

potassium bicarbonate 25 meq effer tab 1



potassium chloride 10 % solution 1

potassium chloride 20 meq packet 2

potassium chloride 20 meq/15ml (10%) solution 1

potassium chloride crys er 10 meq tab er 1



potassium chloride er 10 meq cap er 1

potassium chloride er 10 meq tab er 1


potassium chloride er 8 meq cap er 1


POTASSIUM CHLORIDE ER 8 MEQ TAB ERpotassium chloride 1

SODIUM

sodium chloride (pf) 0.9 % solution 1

MISCELLANEOUS THERAPEUTIC CLASSES

ANTILEPROTICS

THALOMID 100 MG CAPthalidomide 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS

BENLYSTA 200 MG/ML SOLN A-INJbelimumab 4

PA

S Specialty Drug

BENLYSTA 200 MG/ML SOLN PRSYRbelimumab 4

PA

S Specialty Drug



CHELATING AGENTS

penicillamine 250 mg cap 4PA

S Specialty Drug

penicillamine 250 mg tab 4PA

S Specialty Drug

trientine hcl 250 mg cap 4PA

S Specialty Drug

CYCLOSPORINE ANALOGS

cyclosporine 100 mg cap 2

cyclosporine 25 mg cap 2

cyclosporine modified 100 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 100 mg/ml solution 1 QL 90 / 30 DAYS

cyclosporine modified 25 mg cap 1 QL 4 / 1 day(s)

cyclosporine modified 50 mg cap 2 QL 120 / 30 DAYS

gengraf 100 mg cap 1 QL 4 / 1 day(s)

gengraf 100 mg/ml solution 1 QL 90 / 30 DAYS

gengraf 25 mg cap 1 QL 4 / 1 day(s)

LUPKYNIS 7.9 MG CAPvoclosporin 4

PA

S Specialty Drug

ENZYMES

XIAFLEX 0.9 MG RECON SOLNcollagenase clostridium histolyticum 4

PA

S Specialty Drug

IMMUNOMODULATORS FOR MYELODYSPLASTIC SYNDROMES

lenalidomide 10 mg cap 4

QL 1 / 1 day(s)

PA

S Specialty Drug


QL 1 / 1 day(s)

PA

S Specialty Drug




QL 1 / 1 day(s)

PA

S Specialty Drug


QL 1 / 1 day(s)

PA

S Specialty Drug

REVLIMID 10 MG CAPlenalidomide 4

QL 1 / 1 day(s)

PA

S Specialty Drug


QL 1 / 1 day(s)

PA

S Specialty Drug

REVLIMID 2.5 MG CAPlenalidomide 4

PA

S Specialty Drug


PA

S Specialty Drug


QL 1 / 1 day(s)

PA

S Specialty Drug


QL 1 / 1 day(s)

PA

S Specialty Drug

INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS

mycophenolate mofetil 200 mg/ml recon susp 2 AL1 Up to 8 yrs old

mycophenolate mofetil 250 mg cap 1

mycophenolate mofetil 500 mg tab 1

mycophenolate sodium 180 mg tab dr 2

mycophenolate sodium 360 mg tab dr 2



IRRIGATION SOLUTIONS

lactated ringers solution 1

ringers irrigation solution 1

sterile water for irrigation solution 3

tis-u-sol solution 1

water for irrigation, sterile solution 3

MACROLIDE IMMUNOSUPPRESSANTS

ASTAGRAF XL 0.5 MG CAP ER 24Htacrolimus 3 PA

ASTAGRAF XL 1 MG CAP ER 24Htacrolimus 3 PA

ASTAGRAF XL 5 MG CAP ER 24Htacrolimus 3 PA

ENVARSUS XR 0.75 MG TAB ER 24Htacrolimus 3 PA

ENVARSUS XR 1 MG TAB ER 24Htacrolimus 3 PA

ENVARSUS XR 4 MG TAB ER 24Htacrolimus 3 PA

everolimus 0.25 mg tab 2 QL 120 / 30 day(s)



everolimus 1 mg tab 2 QL 60 / 30 day(s)

PROGRAF 0.5 MG CAPtacrolimus 3

PROGRAF 1 MG CAPtacrolimus 3

PROGRAF 5 MG CAPtacrolimus 3

sirolimus 0.5 mg tab 2 QL 1 / 1 day(s)

sirolimus 1 mg tab 2 QL 1 / 1 day(s)

sirolimus 1 mg/ml solution 4

PA

AL1 Up to 8 yrs old

S Specialty Drug



sirolimus 2 mg tab 2

tacrolimus 0.5 mg cap 1

tacrolimus 1 mg cap 1

tacrolimus 5 mg cap 1

MONOCLONAL ANTIBODIES

ENSPRYNG 120 MG/ML SOLN PRSYRsatralizumab-mwge 4

PA

S Specialty Drug

POTASSIUM REMOVING AGENTS

kionex powder 1

kionex 15 gm/60ml suspension 1

LOKELMA 10 GM PACKETsodium zirconium cyclosilicate 3 PA

LOKELMA 5 GM PACKETsodium zirconium cyclosilicate 3 PA

sodium polystyrene sulfonate powder 1

sodium polystyrene sulfonate 15 gm/60ml suspension 1

SPS 15 GM/60ML SUSPENSIONsodium polystyrene sulfonate 1

VELTASSA 16.8 GM PACKETpatiromer sorbitex calcium 3

QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 60 / 28 DAYS

PA

PURINE ANALOGS

azathioprine 50 mg tab 1

MOUTH/THROAT/DENTAL AGENTS

ANESTHETICS TOPICAL ORAL

LIDOCAINE HCL 4 % SOLUTIONlidocaine hcl (mouth-throat) 1

lidocaine viscous hcl 2 % solution 1



ANTI-INFECTIVES - THROAT

clotrimazole 10 mg troche 1

nystatin 100000 unit/ml suspension 1

ORAVIG 50 MG TABmiconazole (mouth-throat) 3

QL 14 / 14 DAYS

PA

ANTISEPTIC COMBINATIONS - MOUTH/THROAT

DEBACTEROL 30-50 % SOLUTIONsulfuric acid-sulfonated phenolics 3

DEBACTEROL 30-50 % SOLUTIONsulfuric acid-sulfonated phenolics 3

ANTISEPTICS - MOUTH/THROAT

chlorhexidine gluconate 0.12 % solution 1

paroex 0.12 % solution 1

periogard 0.12 % solution 1

PROTECTANTS - MOUTH/THROAT

EPISIL LIQUIDoral wound care products 3

SALIVA STIMULANTS

cevimeline hcl 30 mg cap 1

pilocarpine hcl 5 mg tab 1

pilocarpine hcl 7.5 mg tab 1

STEROIDS - MOUTH/THROAT/DENTAL

oralone 0.1 % paste 1

triamcinolone acetonide 0.1 % paste 1

MULTIVITAMINS

PRENATAL MV & MIN W/FE-FA

CO-NATAL FA TABprenatal vit w/ ferrous fumarate-folic acid 1 PREV Preventative

COMPLETENATE 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid 2

ENBRACE HR CAPprenatal vit w/ fe glycine cysteinate-fa-omega 3 fatty acids 3



M-NATAL PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

M-VIT TABprenatal vit w/ ferrous fumarate-folic acid 1

NEONATAL COMPLETE 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

NEONATAL COMPLETE 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1 PREV Preventative

NEONATAL PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

NIVA-PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

O-CAL FA 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

O-CAL PRENATAL TABprenatal vit w/ ferrous fumarate-folic acid 1

OB COMPLETE/DHA 30-10-1-200 MG CAPprenat vit w/ iron carbonyl-fe asp glyc-fa-omega fatty acid 2

ONE VITE WOMENS PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PNV FOLIC ACID + IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PNV PRENATAL PLUS MULTIVITAMIN 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PNV TABS 29-1 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid 2

PRENATA 29-1 MG CHEW TABprenatal without a vit w/ fe fumarate-folic acid 2

PRENATABS RX 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid 2

PRENATAL 19 CHEW TABprenatal vit w/ ferrous fumarate-folic acid 1

PRENATAL 19 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid 1

PRENATAL 19 29-1 MG TABprenatal vit w/ docusate-fe fumarate-folic acid 1

PRENATAL 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1



PRENATAL PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PRENATAL PLUS IRON 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid 1

PRENATAL PLUS VITAMIN/MINERAL 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PRENATAL VITAMIN PLUS LOW IRON 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PREPLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PRETAB 29-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1 PREV Preventative

PROVIDA OB 20-20-1.25 MG CAPprenatal without a vit w/ fe fum-iron polysacch complex -fa 1

SE-NATAL 19 29-1 MG CHEW TABprenatal vit w/ ferrous fumarate-folic acid 2

SE-NATAL 19 29-1 MG TABprenatal vit w/ docusate-fe fumarate-folic acid 2

TRICARE TABprenatal vit w/ ferrous fumarate-folic acid 1

TRINATAL RX 1 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 2

VINATE ONE 60-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 2

VITATHELY WITH GINGER 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

VOL-PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

VOL-TAB RX 29-1 MG TABprenatal vit w/ iron carbonyl-folic acid 2

WESTAB PLUS 27-1 MG TABprenatal vit w/ ferrous fumarate-folic acid 1

PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL

COMPLETE NATAL DHA 29-1-200 & 200 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 2

TRIVEEN-DUO DHA 29-1-200 & 300 MG MISCprenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 2



PRENATAL MV & MIN W/FE-FA-DHA

PNV-DHA+DOCUSATE 27-1.25-300 MG CAPprenatal w/o vit a w/ fe fumarate-dss-fa-dha 2

VITAFOL-OB+DHA 65-1 & 250 MG MISCprenatal mv & min w/fe fumarate-fa-dha 2

VITAMEDMD ONE RX/QUATREFOLIC 30-0.6-0.4-200 MGCAPprenatal without a w/ fe fumarate-l methylfolate-fa-dha

2

PRENATAL VITAMINS

VITAMEDMD REDICHEW RX 1.4 MG CHEW TABprenatal w/ vit b2-b6-b12-cholecalciferol-folic acid 2

VITAMINS A & D

COD LIVER OIL OILcod liver oil 3

MUSCULOSKELETAL THERAPY AGENTS

CENTRAL MUSCLE RELAXANTS

baclofen 10 mg tab 1 QL 90 / 30 DAYS

baclofen 20 mg tab 1 QL 6 / 1 day(s)

baclofen 5 mg tab 1 QL 90 / 30 DAYS

chlorzoxazone 500 mg tab 1

cyclobenzaprine hcl 10 mg tab 1

cyclobenzaprine hcl 5 mg tab 1

cyclobenzaprine hcl 7.5 mg tab 1

metaxall 800 mg tab 1 QL 90 / 30 DAYS

METAXALONE 400 MG TABmetaxalone 2

metaxalone 400 mg tab 2

metaxalone 800 mg tab 1 QL 90 / 30 DAYS

methocarbamol 500 mg tab 1

methocarbamol 750 mg tab 1

orphenadrine citrate 30 mg/ml solution 1

orphenadrine citrate er 100 mg tab er 12h 1



tizanidine hcl 2 mg cap 1

tizanidine hcl 2 mg tab 1


tizanidine hcl 4 mg tab 1


DIRECT MUSCLE RELAXANTS

dantrolene sodium 100 mg cap 1



NASAL AGENTS - SYSTEMIC AND TOPICAL

ANTIHISTAMINE-STEROID

azelastine-fluticasone 137-50 mcg/act suspension 2

NASAL ANTIBIOTICS

BACTROBAN NASAL 2 % OINTMENTmupirocin calcium 2

NASAL ANTICHOLINERGICS

ipratropium bromide 0.03 % solution 1 QL 30 / 28 DAYS

ipratropium bromide 0.06 % solution 1 QL 15 / 14 DAYS

NASAL ANTIHISTAMINES

azelastine hcl 0.1 % solution 1 QL 30 / 25 DAYS

azelastine hcl 0.15 % solution 1 QL 30 / 25 DAYS

azelastine hcl 137 mcg/spray solution 1 QL 30 / 25 DAYS

olopatadine hcl 0.6 % solution 1 QL 30.5 / 30 DAYS

NASAL STEROIDS

BECONASE AQ 42 MCG/SPRAY SUSPENSIONbeclomethasone diprop monohyd 3

QL 25 / 23 DAYS

ST

FLUNISOLIDE 25 MCG/ACT (0.025%) SOLUTIONflunisolide (nasal) 1 QL 25 / 25 DAYS

fluticasone propionate 50 mcg/act suspension 1 QL 16 / 30 DAYS



mometasone furoate 50 mcg/act suspension 1 QL 34 / 30 DAYS

OMNARIS 50 MCG/ACT SUSPENSIONciclesonide (nasal) 3

QL 12.5 / 30 DAYS

ST

QNASL 80 MCG/ACT AERO SOLNbeclomethasone dipropionate (nasal) 3 QL 10.6 / 30 DAYS

QNASL CHILDRENS 40 MCG/ACT AERO SOLNbeclomethasone dipropionate (nasal) 3 QL 4.9 / 30 DAYS

XHANCE 93 MCG/ACT EXHUfluticasone propionate (nasal) 2 PA

NEUROMUSCULAR AGENTS

BENZATHIAZOLES

riluzole 50 mg tab 1

SPINAL MUSCULAR ATROPHY-SMN2 SPLICING MODIFIERS

EVRYSDI 0.75 MG/ML RECON SOLNrisdiplam 4

PA

S Specialty Drug

NUTRIENTS

LIPIDS

DOJOLVI 100 % LIQUIDtriheptanoin 4

PA

S Specialty Drug

LIPOTROPIC COMBINATIONS

LECITHIN GRANULESlecithin 3 AL1 Up to 8 yrs old

OPHTHALMIC AGENTS

ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE INHIB COMB

SIMBRINZA 1-0.2 % SUSPENSIONbrinzolamide-brimonidine tartrate 3

ARTIFICIAL TEAR INSERTS

LACRISERT 5 MG INSERTartificial tear insert 3 PA

BETA-BLOCKERS - OPHTHALMIC

betaxolol hcl 0.5 % solution 1



BETIMOL 0.25 % SOLUTIONtimolol 3

BETIMOL 0.5 % SOLUTIONtimolol 3

BETOPTIC-S 0.25 % SUSPENSIONbetaxolol hcl (ophth) 3

CARTEOLOL HCL 1 % SOLUTIONcarteolol hcl (ophth) 1

LEVOBUNOLOL HCL 0.5 % SOLUTIONlevobunolol hcl 1

levobunolol hcl 0.5 % solution 1

METIPRANOLOL 0.3 % SOLUTIONmetipranolol 1

TIMOLOL MALEATE 0.25 % GEL F SOLNtimolol maleate (ophth) 1

timolol maleate 0.25 % gel f soln 1

timolol maleate 0.25 % solution 1

TIMOLOL MALEATE 0.5 % GEL F SOLNtimolol maleate (ophth) 1

timolol maleate 0.5 % gel f soln 1

timolol maleate 0.5 % solution 1

TIMOPTIC OCUDOSE 0.25 % SOLUTIONtimolol maleate (ophth) 3

TIMOPTIC OCUDOSE 0.5 % SOLUTIONtimolol maleate (ophth) 3

BETA-BLOCKERS - OPHTHALMIC COMBINATIONS

BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % SOLUTIONbrimonidine tartrate-timolol maleate 3

COMBIGAN 0.2-0.5 % SOLUTIONbrimonidine tartrate-timolol maleate 3

dorzolamide hcl-timolol mal 22.3-6.8 mg/ml solution 1

dorzolamide hcl-timolol mal pf 2-0.5 % solution 1

CYCLOPLEGIC MYDRIATIC COMBINATIONS

CYCLOMYDRIL 0.2-1 % SOLUTIONcyclopentolate w/ phenylephrine 3



CYCLOPLEGIC MYDRIATICS

altafrin 10 % solution 1

altafrin 2.5 % solution 1

atropine sulfate 1 % solution 1

cyclopentolate hcl 0.5 % solution 1

cyclopentolate hcl 1 % solution 1

cyclopentolate hcl 2 % solution 1

HOMATROPAIRE 5 % SOLUTIONhomatropine hbr 1

homatropine hbr 5 % solution 1

phenylephrine hcl 10 % solution 1

phenylephrine hcl 2.5 % solution 1

phenylephrine hcl 2.5 % solution 1

tropicamide 0.5 % solution 1

tropicamide 1 % solution 1

LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG

XIIDRA 5 % SOLUTIONlifitegrast 2

MIOTICS - CHOLINESTERASE INHIBITORS

PHOSPHOLINE IODIDE 0.125 % RECON SOLNechothiophate iodide 2

MIOTICS - DIRECT ACTING

pilocarpine hcl 1 % solution 1



OPHTHALMIC ANTI-INFECTIVE COMBINATIONS

ak-poly-bac 500-10000 unit/gm ointment 1

bacitracin-polymyxin b 500-10000 unit/gm ointment 1

neo-polycin 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 3.5-400-10000 ointment 1

neomycin-bacitracin zn-polymyx 5-400-10000 ointment 1



NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025SOLUTIONneomycin-polymyxin-gramicidin

1

polycin 500-10000 unit/gm ointment 1

polymyxin b-trimethoprim 10000-0.1 unit/ml-% solution 1

OPHTHALMIC ANTIALLERGIC

ALOCRIL 2 % SOLUTIONnedocromil sodium (ophth) 2

ALOMIDE 0.1 % SOLUTIONlodoxamide tromethamine 2

azelastine hcl 0.05 % solution 1

bepotastine besilate 1.5 % solution 2 QL 10 / 30 day(s)

BEPREVE 1.5 % SOLUTIONbepotastine besilate 3 QL 10 / 30 day(s)

cromolyn sodium 4 % solution 1

EMADINE 0.05 % SOLUTIONemedastine difumarate 3

epinastine hcl 0.05 % solution 1

LASTACAFT 0.25 % SOLUTIONalcaftadine 3

olopatadine hcl 0.1 % solution 1

olopatadine hcl 0.2 % solution 1

PAZEO 0.7 % SOLUTIONolopatadine hcl 3

QL 2.5 / 18 DAYS

PA

OPHTHALMIC ANTIBIOTICS

AZASITE 1 % SOLUTIONazithromycin (ophth) 3

BACITRACIN 500 UNIT/GM OINTMENTbacitracin (ophthalmic) 1

BESIVANCE 0.6 % SUSPENSIONbesifloxacin hcl 3

CILOXAN 0.3 % OINTMENTciprofloxacin hcl (ophth) 2

ciprofloxacin hcl 0.3 % solution 1



erythromycin 5 mg/gm ointment 1

gatifloxacin 0.5 % solution 1 QL 2.5 / 30 DAYS

GENTAK 0.3 % OINTMENTgentamicin sulfate (ophth) 1

gentamicin sulfate 0.3 % solution 1

levofloxacin 0.5 % solution 1

MOXIFLOXACIN HCL (2X DAY) 0.5 % SOLUTIONmoxifloxacin hcl (ophth) 1

moxifloxacin hcl 0.5 % solution 1

ofloxacin 0.3 % solution 1

tobramycin 0.3 % solution 1

TOBREX 0.3 % OINTMENTtobramycin (ophth) 3

OPHTHALMIC ANTIFUNGAL

NATACYN 5 % SUSPENSIONnatamycin 3

OPHTHALMIC ANTISEPTICS

BETADINE OPHTHALMIC PREP 5 % SOLUTIONpovidone-iodine (ophth) 3

POVIDONE-IODINE 5 % SOLUTIONpovidone-iodine (ophth) 3

OPHTHALMIC ANTIVIRALS

TRIFLURIDINE 1 % SOLUTIONtrifluridine 1

ZIRGAN 0.15 % GELganciclovir ophthalmic 3

OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS

brinzolamide 1 % suspension 2

dorzolamide hcl 2 % solution 1

OPHTHALMIC DIAGNOSTIC PRODUCTS

flucaine 0.25-0.5 % solution 1

PAREMYD 1-0.25 % SOLUTIONhydroxyamphetamine-tropicamide 3



proparacaine-fluorescein 0.5-0.25 % solution 1

OPHTHALMIC IMMUNOMODULATORS

RESTASIS 0.05 % EMULSIONcyclosporine (ophth) 2

RESTASIS MULTIDOSE 0.05 % EMULSIONcyclosporine (ophth) 2

OPHTHALMIC KINASE INHIBITORS - COMBINATIONS

ROCKLATAN 0.02-0.005 % SOLUTIONnetarsudil dimesylate-latanoprost 3 PA

OPHTHALMIC LOCAL ANESTHETICS

AKTEN 3.5 % GELlidocaine hcl (ophth) 3

altacaine 0.5 % solution 1

altacaine 0.5 % solution 1

proparacaine hcl 0.5 % solution 1

tetracaine hcl 0.5 % solution 1

OPHTHALMIC NERVE GROWTH FACTORS

OXERVATE 0.002 % SOLUTIONcenegermin-bkbj 4

PA

S Specialty Drug

OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

ACUVAIL 0.45 % SOLUTIONketorolac tromethamine (ophth) 3 QL 30 / 30 DAYS

bromfenac sodium (once-daily) 0.09 % solution 1 QL 3.4 / 30 DAYS

diclofenac sodium 0.1 % solution 1

FLURBIPROFEN SODIUM 0.03 % SOLUTIONflurbiprofen sodium 1

flurbiprofen sodium 0.03 % solution 1

ILEVRO 0.3 % SUSPENSIONnepafenac 3

ketorolac tromethamine 0.4 % solution 1

ketorolac tromethamine 0.5 % solution 1

NEVANAC 0.1 % SUSPENSIONnepafenac 3



PROLENSA 0.07 % SOLUTIONbromfenac sodium (ophth) 3 QL 3 / 30 DAYS

OPHTHALMIC RHO KINASE INHIBITORS

RHOPRESSA 0.02 % SOLUTIONnetarsudil dimesylate 3 PA

OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS

ALPHAGAN P 0.1 % SOLUTIONbrimonidine tartrate 3

apraclonidine hcl 0.5 % solution 1

brimonidine tartrate 0.15 % solution 1

brimonidine tartrate 0.2 % solution 1

IOPIDINE 1 % SOLUTIONapraclonidine hcl 3

OPHTHALMIC STEROID COMBINATIONS

bacitra-neomycin-polymyxin-hc 1 % ointment 1

BLEPHAMIDE 10-0.2 % SUSPENSIONsulfacetamide sod-prednisolone 3

BLEPHAMIDE S.O.P. 10-0.2 % OINTMENTsulfacetamide sod-prednisolone 3

neo-polycin hc 1 % ointment 1

neomycin-polymyxin-dexameth 3.5-10000-0.1 ointment 1

neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension 1

NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 SUSPENSIONneomycin-polymyxin-hc (ophth) 1

PRED-G 0.3-1 % SUSPENSIONgentamicin-prednisolone acetate 3

PRED-G S.O.P. 0.3-0.6 % OINTMENTgentamicin-prednisolone acetate 3

SULFACETAMIDE-PREDNISOLONE 10-0.23 % SOLUTIONsulfacetamide sod-prednisolone 1

TOBRADEX 0.3-0.1 % OINTMENTtobramycin-dexamethasone 2

TOBRADEX ST 0.3-0.05 % SUSPENSIONtobramycin-dexamethasone 3 QL 5 / 30 DAYS

tobramycin-dexamethasone 0.3-0.1 % suspension 1



ZYLET 0.5-0.3 % SUSPENSIONloteprednol etabonate-tobramycin 3

OPHTHALMIC STEROIDS

ALREX 0.2 % SUSPENSIONloteprednol etabonate 3 ST

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % SOLUTIONdexamethasone sodium phosphate (ophth) 1

difluprednate 0.05 % emulsion 1 QL 5 / 30 day(s)

FLAREX 0.1 % SUSPENSIONfluorometholone acetate 3

fluorometholone 0.1 % suspension 1

FML 0.1 % OINTMENTfluorometholone (ophth) 2

FML FORTE 0.25 % SUSPENSIONfluorometholone (ophth) 2

LOTEMAX 0.5 % OINTMENTloteprednol etabonate 3 ST

loteprednol etabonate 0.5 % gel 1

loteprednol etabonate 0.5 % suspension 1 QL 15 / 30 DAYS

MAXIDEX 0.1 % SUSPENSIONdexamethasone (ophth) 3

OMNIPRED 1 % SUSPENSIONprednisolone acetate (ophth) 2 QL 10 / 30 DAYS

PRED FORTE 1 % SUSPENSIONprednisolone acetate (ophth) 2 QL 10 / 30 DAYS

PRED MILD 0.12 % SUSPENSIONprednisolone acetate (ophth) 2

PREDNISOLONE ACETATE 1 % SUSPENSIONprednisolone acetate (ophth) 1 QL 10 / 30 DAYS

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTIONprednisolone sodium phosphate (ophth) 1

OPHTHALMIC SULFONAMIDES

SULFACETAMIDE SODIUM 10 % OINTMENTsulfacetamide sodium (ophth) 1

sulfacetamide sodium 10 % solution 1



OPHTHALMICS - CYSTINOSIS AGENTS

CYSTADROPS 0.37 % SOLUTIONcysteamine hcl 4

PA

S Specialty Drug

CYSTARAN 0.44 % SOLUTIONcysteamine hcl 4

PA

S Specialty Drug

PROSTAGLANDINS - OPHTHALMIC

bimatoprost 0.03 % solution 1

latanoprost 0.005 % solution 1 QL 5 / 30 DAYS

LUMIGAN 0.01 % SOLUTIONbimatoprost 2 QL 7 / 30 DAYS

travoprost (bak free) 0.004 % solution 2 QL 5 / 30 day(s)

ZIOPTAN 0.0015 % SOLUTIONtafluprost 3

OTIC AGENTS

OTIC AGENTS - MISCELLANEOUS

acetic acid 2 % solution 1

OTIC ANTI-INFECTIVES

CIPROFLOXACIN HCL 0.2 % SOLUTIONciprofloxacin hcl (otic) 1

ofloxacin 0.3 % solution 1

OTIC STEROID-ANTI-INFECTIVE COMBINATIONS

CIPRO HC 0.2-1 % SUSPENSIONciprofloxacin-hydrocortisone 2

ciprofloxacin-dexamethasone 0.3-0.1 % suspension 1

COLY-MYCIN S 3.3-3-10-0.5 MG/ML SUSPENSIONneomycin-colistin-hc-thonzonium 3

CORTISPORIN-TC 3.3-3-10-0.5 MG/ML SUSPENSIONneomycin-colistin-hc-thonzonium 3

neomycin-polymyxin-hc 1 % solution 1

neomycin-polymyxin-hc 3.5-10000-1 solution 1

neomycin-polymyxin-hc 3.5-10000-1 suspension 1



OTIC STEROIDS

acetasol hc 2-1 % solution 1

flac 0.01 % oil 1

fluocinolone acetonide 0.01 % oil 1

hydrocortisone-acetic acid 1-2 % solution 1

OXYTOCICS

ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS

CERVIDIL 10 MG INSERTdinoprostone 4

PA

S Specialty Drug

PROSTIN E2 20 MG SUPPOSdinoprostone 4

PA

S Specialty Drug

methergine 0.2 mg tab 2 QL 28 / 30 DAYS

methylergonovine maleate 0.2 mg tab 2 QL 28 / 30 DAYS

PASSIVE IMMUNIZING AND TREATMENT AGENTS

ANTIVIRAL MONOCLONAL ANTIBODIES

SYNAGIS 100 MG/ML SOLUTIONpalivizumab 4

PA

S Specialty Drug

SYNAGIS 50 MG/0.5ML SOLUTIONpalivizumab 4

PA

S Specialty Drug

IMMUNE SERUMS

CUVITRU 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug



HIZENTRA 1 GM/5ML SOLN PRSYRimmune globulin (human) subcutaneous 4

PA

S Specialty Drug

HIZENTRA 1 GM/5ML SOLUTIONimmune globulin (human) subcutaneous 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

PASSIVE IMMUNIZING AGENTS - COMBINATIONS

HYQVIA 10 GM/100ML KITimmune globulin (human)-hyaluronidase (human recombinant) 4

PA

S Specialty Drug

HYQVIA 2.5 GM/25ML KITimmune globulin (human)-hyaluronidase (human recombinant) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

PENICILLINS

AMINOPENICILLINS

AMOXICILLIN 125 MG CHEW TABamoxicillin 1



amoxicillin 125 mg/5ml recon susp 1


amoxicillin 250 mg cap 1

AMOXICILLIN 250 MG CHEW TABamoxicillin 1



amoxicillin 500 mg cap 1

amoxicillin 500 mg tab 1

amoxicillin 875 mg tab 1

AMPICILLIN 500 MG CAPampicillin 1

NATURAL PENICILLINS

PENICILLIN V POTASSIUM 125 MG/5ML RECON SOLNpenicillin v potassium 1

penicillin v potassium 250 mg tab 1

PENICILLIN V POTASSIUM 250 MG/5ML RECON SOLNpenicillin v potassium 1

penicillin v potassium 500 mg tab 1

PENICILLIN COMBINATIONS

AMOXICILLIN-POT CLAVULANATE 200-28.5 MG CHEW TABamoxicillin & pot clavulanate 1

amoxicillin-pot clavulanate 200-28.5 mg/5ml recon susp 1

amoxicillin-pot clavulanate 250-125 mg tab 1


AMOXICILLIN-POT CLAVULANATE 400-57 MG CHEW TABamoxicillin & pot clavulanate 1

amoxicillin-pot clavulanate 400-57 mg/5ml recon susp 1




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

AMOXICILLIN-POT CLAVULANATE ER 1000-62.5 MG TABER 12Hamoxicillin & pot clavulanate

2



AUGMENTIN 125-31.25 MG/5ML RECON SUSPamoxicillin & pot clavulanate 3 AL1 Up to 8 yrs old

PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin sodium 250 mg cap 1

dicloxacillin sodium 500 mg cap 1

PHARMACEUTICAL ADJUVANTS

COLORING AGENTS

FOOD COLOR BLUE LIQUIDdye fdc blue 1 (brilliant blue fcf) 3 AL1 Up to 8 yrs old

EXTERNAL VEHICLES

COLLODION FLEXIBLE LIQUIDcollodion flexible 3

DERMACINRX TOPICAL BASE SOLUTIONexternal vehicles 3

FOAMIL LIQUIDexternal vehicles 3

RHEOSPRAY LIQUIDexternal vehicles 3

TDM SOLUTION SOLUTIONexternal vehicles 3

MISC. VEHICLES

SERAQUA LIQUIDserum base 3

SOLYDRA LIQUIDoil base 3

ORAL VEHICLES

CHERRY SYRUPcherry syrup 3 AL1 Up to 8 yrs old

FLAVOR SWEET SYRUPoral vehicles 3 AL1 Up to 8 yrs old

ORA-BLEND SUSPENSIONoral vehicles 3 AL1 Up to 8 yrs old

ORA-BLEND SF SUSPENSIONoral vehicles 3 AL1 Up to 8 yrs old

ORA-PLUS LIQUIDoral vehicles 3 AL1 Up to 8 yrs old



ORA-SWEET SYRUPoral vehicles 3 AL1 Up to 8 yrs old

ORA-SWEET SF SYRUPoral vehicles 3 AL1 Up to 8 yrs old

PCCA ACACIA SYRUP BASE SYRUPacacia syrup 3 AL1 Up to 8 yrs old

PCCA SWEET-SF SYRUPoral vehicles 3 AL1 Up to 8 yrs old

PCCA-PLUS SUSPENSIONoral vehicles 3 AL1 Up to 8 yrs old

PURIFIED WATER LIQUIDdistilled water 3

SIMPLE SYRUP SYRUPsimple syrup 3 AL1 Up to 8 yrs old

SOLVATECH PLUS SUSPENSIONoral vehicles 3 AL1 Up to 8 yrs old

SOLVATECH SWEET SF SYRUPoral vehicles 3 AL1 Up to 8 yrs old

SUSPENSION VEHICLE SUSPENSIONoral vehicles 3 AL1 Up to 8 yrs old

SYRPALTA SYRUPoral vehicles 3 AL1 Up to 8 yrs old

SYRPALTA 85 % SYRUPsimple syrup 3 AL1 Up to 8 yrs old

SYRUP VEHICLE SYRUPoral vehicles 3 AL1 Up to 8 yrs old

VERSAPLUS SYRUPoral vehicles 3 AL1 Up to 8 yrs old

PARENTERAL VEHICLES

STERILE WATER FOR INJECTION SOLUTIONwater for injection, sterile 1

sterile water for injection solution 1

sterile water for injection solution 1

PLACEBOS

PLACEBO #00 CAPplacebo 3



SEMI SOLID VEHICLES

1ST BASE CREAMcream base 3

ADVANCED BASE PLUS CREAMcream base 3

ALBA-DERM CREAMcream base 3

ALPAWASH OINTMENTpolyethylene glycol 3

ALTADERM CREAMcream base 3

APOTHEDERM CREAMtransdermal base 3

APOTHESAR CREAMtransdermal base 3

APOTHESAR 2 CREAMcream base 3

APOTHESAR PLUS CREAMcream base 3

ATREVIS HYDROGEL CREAMcream base 3

AUXIPRO VANISHING CREAMcream base 3

BASE W301 CREAMcream base 3

CELA BASE CREAMcream base 3

CHRYSADERM DAY CREAMcream base 3

CHRYSADERM NIGHT CREAMcream base 3

CREAM BASE CREAMcream base 3

CREAM BASE WITH LIPOSOME CREAMcream base liposomic 3

CREAM CONCENTRATE CREAMcream base 3

CUTIS PLUS CREAMcream base 3



DELIVRA CREAMtransdermal base 3

DURABASE CREAMcream base 3

DURABASE ADVANCED CREAMcream base 3

EMOLIVAN CREAMcream base 3

EMOLLIENT BASE CREAMcream base 3

FAGRON LS PLUS CREAMcream base 3

FAGRON SUPREME CREAMcream base 3

FITALITE CREAMcream base 3

KRISGEL 100 GELkrisgel 100 3

LANOLIN ANHYDROUS OINTMENTlanolin anhydrous 3

LIOPEN ABSORPTION ENHANCING CREAMcream base 3

LIPO CREAM BASE CREAMcream base 3

LIPOCREAM BASE CREAMcream base 3

LIPOLAYER CREAMcream base liposomic 3

LIPOPEN ULTRA BASE CREAMcream base 3

LIPOSOMAL HEAVY CREAMcream base 3

LIPOSOMAL REGULAR CREAMcream base 3

LIPOZYME CREAMcream base liposomic 3

MEDIDERM CREAMcream base 3



MULTIBASE CREAMcream base 3

NOURILITE CREAMcream base 3

NOURIVAN ANTIOX BASE CREAMcream base 3

NOXI-K CREAMcream base 3

OCCLUVAN OINTMENThydrophilic ointment 3

OMNIBASE CREAMcream base 3

P-SILOXAN DS CREAMcream base 3

PCCA ALADERM BASE CREAMcream base 3

PCCA ANHYDROUS LIPODERM BASE CREAMcream base 3

PCCA BIOPEPTIDE BASE CREAMcream base 3

PCCA COBASE #1 OINTMENTcobase #1 3

PCCA COSMETIC HRT BASE CREAMcream base 3

PCCA CUSTOM LIPO-MAX CREAMcream base liposomic 3

PCCA LIPODERM BASE CREAMcream base 3

PCCA LIPOSOMIC BASE DRY CREAMcream base liposomic 3

PCCA LIPOSOMIC BASE NORMAL CREAMcream base liposomic 3

PCCA LIPOSOMIC BASE OILY CREAMcream base liposomic 3

PCCA LIPOSOMIC BASE SENSITIVE CREAMcream base liposomic 3

PCCA MVC BASE CREAMcream base 3



PCCA NATACREAM CREAMcream base 3

PCCA POLYPEG BASE OINTMENTpolyethylene glycol 3

PCCA PRACASIL TM-PLUS BASE CREAMcream base 3

PCCA VANISHING CREAM BASE CREAMcream base 3

PCCA VANISHING CREAM LIGHT CREAMcream base 3

PCCA VANPEN BASE CREAMcream base 3

PEG OINTMENT BASE OINTMENTpolyethylene glycol 3

PENCREAM CREAMcream base 3

PENDERM CREAMcream base 3

PENSOMAL CREAMcream base 3

PETROLATUM WHITE OINTMENTwhite petrolatum 3

PHARMABASE HEAVY CREAMcream base 3

PLO GEL - MEDIFLO KITpremium lecithin organogel base 3

PLO TRANSDERMAL CREAMtransdermal base 3

POLYETHYLENE GLYCOL 8000 OINTMENTpolyethylene glycol 8000 3

REJUVACARE PLUS CREAMcream base 3

SA3 DERM CREAMcream base 3

SALT DURABLE CREAM CREAMcream base 3

SALT STABLE LS ADVANCED CREAMcream base 3



SALTSTABLE LO CREAMcream base 3

SANARE ADVANCED SCAR THERAPY CREAMcream base 3

SANARE SCAR THERAPY CREAMcream base 3

SEDANARE CREAMcream base 3

SILOSOME TRANSDERMAL CREAMtransdermal base 3

SILPROTEX PLUS CREAMcream base 3

SKYY DERM CREAMcream base 3

STERA BASE CREAMcream base 3

TDC MAX CREAMtransdermal base 3

TERODERM CREAMcream base 3

TERODERM-PLUS CREAMcream base 3

ULTRADERM CREAMcream base 3

VANISH-PEN CREAMcream base 3

VANISHING CREAMcream base 3

VANISHING CREAM BOTANICAL BASE CREAMcream base 3

VERSAPRO CREAMcream base 3

VERSATILE CREAM BASE CREAMcream base 3

VERSATILE RICH BASE CREAMcream base 3

WHITE PETROLATUM OINTMENTwhite petrolatum 3



XEMATOP BASE CREAMcream base 3

PROGESTINS

hydroxyprogesterone caproate 250 mg/ml oil 2PA

S Specialty Drug

medroxyprogesterone acetate 10 mg tab 1

medroxyprogesterone acetate 2.5 mg tab 1

medroxyprogesterone acetate 5 mg tab 1

megestrol acetate 625 mg/5ml suspension 1

norethindrone acetate 5 mg tab 1

progesterone 100 mg cap 1

progesterone 200 mg cap 1

progesterone 50 mg/ml oil 1 FB Fertility Benefit

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

ALCOHOL DETERRENTS

acamprosate calcium 333 mg tab dr 1

disulfiram 250 mg tab 1

disulfiram 500 mg tab 1

ANTIDEMENTIA AGENT COMBINATIONS

NAMZARIC 14-10 MG CAP ER 24Hmemantine hcl-donepezil hcl 3

QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA


QL 30 / 30 DAYS

PA

BENZODIAZEPINES & TRICYCLIC AGENTS

CHLORDIAZEPOXIDE-AMITRIPTYLINE 10-25 MG TABchlordiazepoxide-amitriptyline 1



CHLORDIAZEPOXIDE-AMITRIPTYLINE 5-12.5 MG TABchlordiazepoxide-amitriptyline 1

CHOLINOMIMETICS - ACHE INHIBITORS

donepezil hcl 10 mg tab 1 QL 30 / 30 DAYS

donepezil hcl 10 mg tab disp 1 QL 30 / 30 DAYS



donepezil hcl 5 mg tab disp 1 QL 30 / 30 DAYS

galantamine hydrobromide 12 mg tab 1 QL 60 / 30 DAYS


GALANTAMINE HYDROBROMIDE 4 MG/ML SOLUTIONgalantamine hydrobromide 1 QL 180 / 30 DAYS


galantamine hydrobromide er 16 mg cap er 24h 1 QL 30 / 30 DAYS



rivastigmine 13.3 mg/24hr patch 24hr 1 QL 30 / 30 DAYS



rivastigmine tartrate 1.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 3 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 4.5 mg cap 1 QL 60 / 30 DAYS

rivastigmine tartrate 6 mg cap 1 QL 60 / 30 DAYS

FIBROMYALGIA AGENT - SNRIS

SAVELLA 100 MG TABmilnacipran hcl 3

QL 60 / 30 DAYS

PA

SAVELLA 12.5 MG TABmilnacipran hcl 3

QL 60 / 30 DAYS

PA




QL 60 / 30 DAYS

PA


QL 60 / 30 DAYS

PA

SAVELLA TITRATION PACK 12.5 & 25 & 50 MG MISCmilnacipran hcl 3

QL 60 / 30 DAYS

PA

MOVEMENT DISORDER DRUG THERAPY

tetrabenazine 12.5 mg tab 2 PA

tetrabenazine 25 mg tab 2 PA

MS AGENTS - PYRIMIDINE SYNTHESIS INHIBITORS

AUBAGIO 14 MG TABteriflunomide 4

PA

S Specialty Drug

AUBAGIO 7 MG TABteriflunomide 4

PA

S Specialty Drug

MULTIPLE SCLEROSIS AGENTS

glatiramer acetate 20 mg/ml soln prsyr 4 S Specialty Drug

glatiramer acetate 40 mg/ml soln prsyr 4 S Specialty Drug

MULTIPLE SCLEROSIS AGENTS - ANTIMETABOLITES

MAVENCLAD (10 TABS) 10 MG TAB THPKcladribine (multiple sclerosis) 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug




PA

S Specialty Drug


PA

S Specialty Drug

MULTIPLE SCLEROSIS AGENTS - INTERFERONS

AVONEX 30 MCG KITinterferon beta-1a 4

PA

S Specialty Drug

AVONEX PEN 30 MCG/0.5ML AUT-IJ KITinterferon beta-1a 4

PA

S Specialty Drug

AVONEX PREFILLED 30 MCG/0.5ML PREF SY KTinterferon beta-1a 4

PA

S Specialty Drug

BETASERON 0.3 MG KITinterferon beta-1b 4

PA

S Specialty Drug

EXTAVIA 0.3 MG KITinterferon beta-1b 4

PA

S Specialty Drug

PLEGRIDY 125 MCG/0.5ML SOLN PENpeginterferon beta-1a 4

PA

S Specialty Drug

PLEGRIDY 125 MCG/0.5ML SOLN PRSYRpeginterferon beta-1a 4

PA

S Specialty Drug

PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PENpeginterferon beta-1a 4

PA

S Specialty Drug

PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLNPRSYRpeginterferon beta-1a

4PA

S Specialty Drug

REBIF 22 MCG/0.5ML SOLN PRSYRinterferon beta-1a 4

PA

S Specialty Drug

REBIF 44 MCG/0.5ML SOLN PRSYRinterferon beta-1a 4

PA

S Specialty Drug

REBIF REBIDOSE 22 MCG/0.5ML SOLN A-INJinterferon beta-1a 4

PA

S Specialty Drug



REBIF REBIDOSE 44 MCG/0.5ML SOLN A-INJinterferon beta-1a 4

PA

S Specialty Drug

REBIF REBIDOSE TITRATION PACK 6X8.8 & 6X22 MCGSOLN A-INJinterferon beta-1a

4PA

S Specialty Drug

REBIF TITRATION PACK 6X8.8 & 6X22 MCG SOLN PRSYRinterferon beta-1a 4

PA

S Specialty Drug

MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES

KESIMPTA 20 MG/0.4ML SOLN A-INJofatumumab (ms) 4

PA

S Specialty Drug

MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS

BAFIERTAM 95 MG CAP DRmonomethyl fumarate 4

PA

S Specialty Drug

dimethyl fumarate 120 mg cap dr 4

dimethyl fumarate 240 mg cap dr 4

dimethyl fumarate starter pack 120 & 240 mg misc 4

MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS

dalfampridine er 10 mg tab er 12h 2

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

memantine hcl 10 mg tab 1 QL 60 / 30 DAYS

memantine hcl 10 mg/5ml solution 1

memantine hcl 2 mg/ml solution 1

memantine hcl 28 x 5 mg & 21 x 10 mg tab 1 QL 49 / 30 day(s)

memantine hcl 5 mg tab 1 QL 120 / 30 DAYS

memantine hcl er 14 mg cap er 24h 1 QL 30 / 30 DAYS




NAMENDA XR TITRATION PACK 7 & 14 & 21 &28 MG CAPER 24Hmemantine hcl

3 QL 28 / 365 DAYS



PHENOTHIAZINES & TRICYCLIC AGENTS

PERPHENAZINE-AMITRIPTYLINE 2-10 MG TABperphenazine-amitriptyline 1





POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS

pregabalin er 165 mg tab er 24h 2 PA

pregabalin er 330 mg tab er 24h 2 PA

pregabalin er 82.5 mg tab er 24h 2 PA

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS - SSRIS

FLUOXETINE HCL (PMDD) 10 MG CAPfluoxetine hcl (pmdd) 1 QL 90 / 30 DAYS

FLUOXETINE HCL (PMDD) 10 MG TABfluoxetine hcl (pmdd) 1 QL 90 / 30 DAYS

FLUOXETINE HCL (PMDD) 20 MG CAPfluoxetine hcl (pmdd) 1 QL 90 / 30 DAYS

FLUOXETINE HCL (PMDD) 20 MG TABfluoxetine hcl (pmdd) 1 QL 90 / 30 DAYS

PSEUDOBULBAR AFFECT AGENT COMBINATIONS

NUEDEXTA 20-10 MG CAPdextromethorphan hbr-quinidine sulfate 2 PA

ERGOLOID MESYLATES 1 MG TABergoloid mesylates 1

PIMOZIDE 1 MG TABpimozide 1 QL 30 / 30 DAYS

PIMOZIDE 2 MG TABpimozide 1 QL 60 / 30 DAYS



SMOKING DETERRENTS

APO-VARENICLINE 0.5 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

APO-VARENICLINE 1 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

bupropion hcl er (smoking det) 150 mg tab er 12h 1 PREV Preventative

CHANTIX 0.5 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

CHANTIX 1 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

CHANTIX CONTINUING MONTH PAK 1 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X 42TABvarenicline tartrate

2 PREV Preventative

NICOTROL 10 MG INHALERnicotine 2 PREV Preventative

NICOTROL NS 10 MG/ML SOLUTIONnicotine 2 PREV Preventative

VARENICLINE TARTRATE 0.5 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

VARENICLINE TARTRATE 1 MG TABvarenicline tartrate 2

QL 60 / 30 day(s)

PREV Preventative

ZYBAN 150 MG TAB ER 12Hbupropion hcl (smoking deterrent) 2 PREV Preventative

SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS

GILENYA 0.25 MG CAPfingolimod hcl 4

PA

S Specialty Drug

GILENYA 0.5 MG CAPfingolimod hcl 4

PA

S Specialty Drug

MAYZENT 0.25 MG TABsiponimod fumarate 4

PA

S Specialty Drug



MAYZENT 1 MG TABsiponimod fumarate 4

PA

S Specialty Drug

MAYZENT 2 MG TABsiponimod fumarate 4

PA

S Specialty Drug

MAYZENT STARTER PACK 0.25 MG TAB THPKsiponimod fumarate 4

PA

S Specialty Drug

MAYZENT STARTER PACK 12 X 0.25 MG TAB THPKsiponimod fumarate 4

PA

S Specialty Drug

PONVORY 20 MG TABponesimod 4

PA

S Specialty Drug

PONVORY STARTER PACK 2,3,4,5,6,7,8,9 & 10 MG TABTHPKponesimod

4PA

S Specialty Drug

ZEPOSIA 0.92 MG CAPozanimod hcl 4

PA

S Specialty Drug

ZEPOSIA 7-DAY STARTER PACK 4 X 0.23MG & 3 X 0.46MGCAP THPKozanimod hcl

4PA

S Specialty Drug

ZEPOSIA STARTER KIT 0.23MG & 0.46MG & 0.92MG CAPTHPKozanimod hcl

4PA

S Specialty Drug

VASOMOTOR SYMPTOM AGENTS - SSRIS

paroxetine mesylate 7.5 mg cap 1 QL 30 / 30 DAYS

RESPIRATORY AGENTS - MISC.

ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST NP 1000 MG RECON SOLNalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug

ARALAST NP 500 MG RECON SOLNalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug

GLASSIA 1000 MG/50ML SOLUTIONalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug



PROLASTIN-C 1000 MG RECON SOLNalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug

PROLASTIN-C 1000 MG/20ML SOLUTIONalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug

ZEMAIRA 1000 MG RECON SOLNalpha1-proteinase inhibitor (human) 4

PA

S Specialty Drug

CFTR POTENTIATORS

KALYDECO 150 MG TABivacaftor 4

PA

S Specialty Drug

KALYDECO 25 MG PACKETivacaftor 4

PA

S Specialty Drug


PA

S Specialty Drug


PA

S Specialty Drug

CYSTIC FIBROSIS AGENT - COMBINATIONS

ORKAMBI 100-125 MG PACKETlumacaftor-ivacaftor 4

PA

S Specialty Drug

ORKAMBI 100-125 MG TABlumacaftor-ivacaftor 4

PA

S Specialty Drug

ORKAMBI 150-188 MG PACKETlumacaftor-ivacaftor 4

PA

S Specialty Drug

ORKAMBI 200-125 MG TABlumacaftor-ivacaftor 4

PA

S Specialty Drug

SYMDEKO 100-150 & 150 MG TAB THPKtezacaftor-ivacaftor 4

PA

S Specialty Drug

SYMDEKO 50-75 & 75 MG TAB THPKtezacaftor-ivacaftor 4

PA

S Specialty Drug

TRIKAFTA 100-50-75 & 150 MG TAB THPKelexacaftor-tezacaftor-ivacaftor 4

PA

S Specialty Drug



TRIKAFTA 50-25-37.5 & 75 MG TAB THPKelexacaftor-tezacaftor-ivacaftor 4

PA

S Specialty Drug

HYDROLYTIC ENZYMES

PULMOZYME 2.5 MG/2.5ML SOLUTIONdornase alfa 4

PA

S Specialty Drug

PULMONARY FIBROSIS AGENTS

ESBRIET 267 MG CAPpirfenidone 4

PA

S Specialty Drug

ESBRIET 267 MG TABpirfenidone 4

PA

S Specialty Drug

ESBRIET 801 MG TABpirfenidone 4

PA

S Specialty Drug

PULMONARY FIBROSIS AGENTS - KINASE INHIBITORS

OFEV 100 MG CAPnintedanib esylate 4

PA

S Specialty Drug

OFEV 150 MG CAPnintedanib esylate 4

PA

S Specialty Drug

SULFONAMIDES

SULFADIAZINE 500 MG TABsulfadiazine 1

sulfadiazine 500 mg tab 1

TETRACYCLINES

avidoxy 100 mg tab 1

coremino 135 mg tab er 24h 2 QL 30 / 30 DAYS



demeclocycline hcl 150 mg tab 1

demeclocycline hcl 300 mg tab 1

doxycycline hyclate 100 mg cap 1



doxycycline hyclate 100 mg tab 1

doxycycline hyclate 100 mg tab dr 2


doxycycline hyclate 20 mg tab 1

doxycycline hyclate 50 mg cap 1



doxycycline monohydrate 100 mg cap 1

doxycycline monohydrate 100 mg tab 1


doxycycline monohydrate 25 mg/5ml recon susp 1 AL1 Up to 8 yrs old

doxycycline monohydrate 50 mg cap 1



lymepak 100 mg tab 1

minocycline hcl 100 mg cap 1

minocycline hcl 100 mg tab 1





minocycline hcl er 105 mg tab er 24h 2

minocycline hcl er 115 mg tab er 24h 2 QL 30 / 30 DAYS





minocycline hcl er 80 mg tab er 24h 2




mondoxyne nl 100 mg cap 1

mondoxyne nl 50 mg cap 1

morgidox 100 mg cap 1

morgidox 50 mg cap 1

tetracycline hcl 250 mg cap 1

tetracycline hcl 500 mg cap 1

VIBRAMYCIN 50 MG/5ML SYRUPdoxycycline calcium 3 AL1 Up to 8 yrs old

THYROID AGENTS

ANTITHYROID AGENTS

methimazole 10 mg tab 1

methimazole 5 mg tab 1

propylthiouracil 50 mg tab 1

THYROID HORMONES

ARMOUR THYROID 120 MG TABthyroid 2








euthyrox 100 mcg tab 1













levo-t 100 mcg tab 1







levo-t 25 mcg tab 1


levo-t 50 mcg tab 1

levo-t 75 mcg tab 1

levo-t 88 mcg tab 1

LEVOTHYROXINE SODIUM 100 MCG CAPlevothyroxine sodium 2

levothyroxine sodium 100 mcg tab 1

























levoxyl 100 mcg tab 1













liothyronine sodium 25 mcg tab 1



NATURE-THROID 113.75 MG TABthyroid 2

NATURE-THROID 130 MG TABthyroid 2












np thyroid 120 mg tab 1





SYNTHROID 100 MCG TABlevothyroxine sodium 2














thyroid 120 mg tab 1

thyroid 15 mg tab 1

thyroid 30 mg tab 1

thyroid 60 mg tab 1

thyroid 90 mg tab 1

THYROLAR-1 60 (12.5-50) MG (MCG) TABliotrix (t3-t4) 2

THYROLAR-1/2 30 (6.25-25) MG (MCG) TABliotrix (t3-t4) 2

THYROLAR-1/4 15 (3.1-12.5) MG (MCG) TABliotrix (t3-t4) 2

THYROLAR-2 120 (25-100) MG (MCG) TABliotrix (t3-t4) 2

THYROLAR-3 180 (37.5-150) MG (MCG) TABliotrix (t3-t4) 2



unithroid 100 mcg tab 1












WESTHROID 130 MG TABthyroid 3


WESTHROID 32.5 MG TABthyroid 3


WESTHROID 97.5 MG TABthyroid 3

WP THYROID 113.75 MG TABthyroid 3

WP THYROID 130 MG TABthyroid 3




WP THYROID 65 MG TABthyroid 3





TOXOIDS

TOXOID COMBINATIONS

ADACEL 5-2-15.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) 2 PREV Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSP PRSYRtetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) 2 PREV Preventative

BOOSTRIX 5-2.5-18.5 LF-MCG/0.5 SUSPENSIONtetanus toxoid-diphtheria-acellular pertussis adsorb (tdap) 2 PREV Preventative

DAPTACEL 23-15-5 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids 2 PREV Preventative

DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU/0.5MLSUSPENSIONdiphtheria-tetanus toxoids (dt)

2 PREV Preventative

INFANRIX 25-58-10 SUSPENSIONdiphtheria, acellular pertussis & tetanus toxoids 2 PREV Preventative

KINRIX SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac 2 PREV Preventative

KINRIX 0.5 ML SUSP PRSYRdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac 2 PREV Preventative

PEDIARIX SUSP PRSYRdiph-tetanus tox-acell pert-hepatitis b recomb-polio ipv vac 2 PREV Preventative

PENTACEL RECON SUSPdiph-ac pert-tet tox ad-polio ipv-haemophil b poly vac 2 PREV Preventative

QUADRACEL SUSPENSIONdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac 2 PREV Preventative

QUADRACEL 0.5 ML SUSP PRSYRdiph-tetanus tox ad-acell pertussis & polio virus, ipv vac 2 PREV Preventative

TDVAX 2-2 LF/0.5ML SUSPENSIONtetanus-diphtheria toxoids (td) 2 PREV Preventative

TENIVAC 5-2 LFU INJECTABLEtetanus-diphtheria toxoids (td) 2 PREV Preventative

TETANUS-DIPHTHERIA TOXOIDS TD 2-2 LF/0.5MLSUSPENSIONtetanus-diphtheria toxoids (td)

2 PREV Preventative

VAXELIS SUSP PRSYRdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb 2 PREV Preventative



VAXELIS SUSPENSIONdiph-tet tox-acell pert ad-polio ipv-hib-hepatitis b recomb 2 PREV Preventative

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

ANTICHOLINERGIC COMBINATIONS

BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG SUPPOSbelladonna alkaloids & opium 1

BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG SUPPOSbelladonna alkaloids & opium 1

chlordiazepoxide-clidinium 5-2.5 mg cap 1

ANTISPASMODICS

dicyclomine hcl 10 mg cap 1

dicyclomine hcl 10 mg/5ml solution 1 AL1 Up to 8 yrs old

dicyclomine hcl 10 mg/ml solution 1

dicyclomine hcl 20 mg tab 1

BELLADONNA ALKALOIDS

hyoscyamine sulfate 0.125 mg sl tab 1

hyoscyamine sulfate 0.125 mg tab 1

hyoscyamine sulfate 0.125 mg tab disp 1

hyoscyamine sulfate 0.125 mg/5ml elixir 1 AL1 Up to 8 yrs old

hyoscyamine sulfate 0.125 mg/ml solution 1

hyoscyamine sulfate er 0.375 mg tab er 12h 1

hyoscyamine sulfate sl 0.125 mg sl tab 1

oscimin 0.125 mg sl tab 1

oscimin 0.125 mg tab 1

symax-sl 0.125 mg sl tab 1

H-2 ANTAGONISTS

CIMETIDINE HCL 300 MG/5ML SOLUTIONcimetidine hcl 1 AL1 Up to 8 yrs old

cimetidine hcl 300 mg/5ml solution 1 AL1 Up to 8 yrs old

cimetidine hcl 400 mg/6.67ml solution 1 AL1 Up to 8 yrs old

famotidine 40 mg/5ml recon susp 1



ranitidine hcl 15 mg/ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 150 mg/10ml syrup 1 AL1 Up to 8 yrs old

ranitidine hcl 75 mg/5ml syrup 1 AL1 Up to 8 yrs old

MISC. ANTI-ULCER

sucralfate 1 gm tab 1

sucralfate 1 gm/10ml suspension 1

PROTON PUMP INHIBITORS

DEXLANSOPRAZOLE 30 MG CAP DRdexlansoprazole 2

QL 30 / 30 day(s)

PA

DEXLANSOPRAZOLE 60 MG CAP DRdexlansoprazole 2

QL 30 / 30 day(s)

PA

FIRST-LANSOPRAZOLE 3 MG/ML SUSPENSIONlansoprazole 1

QL 10 / 1 day(s)

AL1 Up to 8 yrs old

FIRST-OMEPRAZOLE 2 MG/ML SUSPENSIONomeprazole 1

QL 10 / 1 day(s)

AL1 Up to 8 yrs old

OMEPRAZOLE+SYRSPEND SF ALKA 2 MG/MLSUSPENSIONomeprazole

1QL 10 / 1 day(s)

AL1 Up to 8 yrs old

QUATERNARY ANTICHOLINERGICS

CUVPOSA 1 MG/5ML SOLUTIONglycopyrrolate 3

PA

AL1 Up to 8 yrs old

glycopyrrolate 0.2 mg/ml solution 1

GLYCOPYRROLATE 0.4 MG/2ML SOLN PRSYRglycopyrrolate 1

glycopyrrolate 0.4 mg/2ml solution 1

GLYCOPYRROLATE 0.6 MG/3ML SOLN PRSYRglycopyrrolate 1

glycopyrrolate 1 mg tab 1

GLYCOPYRROLATE 1 MG/5ML SOLN PRSYRglycopyrrolate 1

glycopyrrolate 1 mg/5ml solution 1



glycopyrrolate 2 mg tab 1

glycopyrrolate 4 mg/20ml solution 1

methscopolamine bromide 2.5 mg tab 1

methscopolamine bromide 5 mg tab 1

PROPANTHELINE BROMIDE 15 MG TABpropantheline bromide 1

ULCER DRUGS - PROSTAGLANDINS

misoprostol 100 mcg tab 1

misoprostol 200 mcg tab 1

URINARY ANTISPASMODICS

URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)

darifenacin hydrobromide er 15 mg tab er 24h 1 QL 30 / 30 DAYS

darifenacin hydrobromide er 7.5 mg tab er 24h 1

GELNIQUE 10 % GELoxybutynin chloride 3 QL 30 / 30 DAYS

GELNIQUE PUMP 10 % GELoxybutynin chloride 3 QL 30 / 30 DAYS

oxybutynin chloride 5 mg tab 1 QL 120 / 30 DAYS

oxybutynin chloride er 10 mg tab er 24h 1



OXYTROL 3.9 MG/24HR PATCH TWoxybutynin 3 QL 8 / 28 DAYS

solifenacin succinate 10 mg tab 2 QL 30 / 30 DAYS

solifenacin succinate 5 mg tab 2 QL 30 / 30 DAYS

tolterodine tartrate 1 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate 2 mg tab 1 QL 60 / 30 DAYS

tolterodine tartrate er 2 mg cap er 24h 1 QL 30 / 30 DAYS

tolterodine tartrate er 4 mg cap er 24h 1 QL 30 / 30 DAYS

TOVIAZ 4 MG TAB ER 24Hfesoterodine fumarate 3

QL 30 / 30 DAYS

ST



TOVIAZ 8 MG TAB ER 24Hfesoterodine fumarate 3

QL 30 / 30 DAYS

ST

trospium chloride 20 mg tab 1 QL 60 / 30 DAYS

trospium chloride er 60 mg cap er 24h 1

VESICARE LS 5 MG/5ML SUSPENSIONsolifenacin succinate 3 AL1 Up to 8 yrs old

URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS

MYRBETRIQ 25 MG TAB ER 24Hmirabegron 3

QL 30 / 30 DAYS

ST

MYRBETRIQ 50 MG TAB ER 24Hmirabegron 3

QL 30 / 30 DAYS

ST

MYRBETRIQ 8 MG/ML SRERmirabegron 3

QL 10 / 1 day(s)

ST

AL1 Up to 8 yrs old

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS

bethanechol chloride 10 mg tab 1




URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS

flavoxate hcl 100 mg tab 1

VACCINES

BACTERIAL VACCINES

ACTHIB RECON SOLNhaemophilus b polysac conj vac 2 PREV Preventative

BEXSERO SUSP PRSYRmeningococcal vac group b (recombant omv adjuvanted) 2 PREV Preventative

HIBERIX 10 MCG RECON SOLNhaemophilus b polysac conj vac 2 PREV Preventative

MENACTRA SOLUTIONmeningococcal (a,c,y&w-135) polysacch diphth conj vaccine 2 PREV Preventative



MENQUADFI SOLUTIONmeningococcal (a,c,y&w-135) polysacch tetanus conj vaccine 2 PREV Preventative

MENVEO RECON SOLNmeningococcal (a,c,y&w-135) oligosaccharide conjugate vac 2 PREV Preventative

PEDVAX HIB 7.5 MCG/0.5ML SUSPENSIONhaemophilus b polysac conj vac 2 PREV Preventative

PNEUMOVAX 23 25 MCG/0.5ML INJECTABLEpneumococcal vac polyvalent 2 PREV Preventative

PREVNAR 13 SUSPENSIONpneumococcal 13-valent conjugate vaccine 2 PREV Preventative

PREVNAR 20 0.5 ML SUSP PRSYRpneumococcal 20-valent conjugate vaccine 2 PREV Preventative

TRUMENBA SUSP PRSYRmeningococcal group b vaccine (recombinant) 2

QL 0.5 / 0 DAYS

PREV Preventative

TYPHIM VI 25 MCG/0.5ML SOLN PRSYRtyphoid vi polysaccharide vaccine 2

TYPHIM VI 25 MCG/0.5ML SOLUTIONtyphoid vi polysaccharide vaccine 2

VAXCHORA RECON SUSPcholera vaccine live attenuated 2

VAXNEUVANCE 0.5 ML SUSP PRSYRpneumococcal 15-valent conjugate vaccine 2 PREV Preventative

VIVOTIF CAP DRtyphoid vaccine 2

VIRAL VACCINE COMBINATIONS

M-M-R II RECON SOLNmeasles, mumps & rubella virus vaccines 2 PREV Preventative

PROQUAD RECON SUSPmeasles-mumps-rubella-varicella virus vaccines 2 PREV Preventative

TWINRIX 720-20 ELU-MCG/ML SUSP PRSYRhepatitis a (inactivated)-hepatitis b (recombinant) vaccines 2 PREV Preventative

VIRAL VACCINES

AFLURIA SUSPENSIONinfluenza virus vaccine split 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

AFLURIA PRESERVATIVE FREE 0.5 ML SUSP PRSYRinfluenza virus vaccine split preservative free 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative



AFLURIA QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

AFLURIA QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

AFLURIA QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

ASTRAZENECA COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine 2

MFL 3 / 1 year(s)

PREV Preventative

COMIRNATY 30 MCG/0.3ML SUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine 2

MFL 3 / 1 year(s)

PREV Preventative

ENGERIX-B 10 MCG/0.5ML INJECTABLEhepatitis b vaccine (recomb) 2 PREV Preventative

ENGERIX-B 10 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb) 2 PREV Preventative

ENGERIX-B 20 MCG/ML INJECTABLEhepatitis b vaccine (recomb) 2 PREV Preventative

ENGERIX-B 20 MCG/ML SUSPENSIONhepatitis b vaccine (recomb) 2 PREV Preventative

FLUAD 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigen adjuvant 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUAD QUADRIVALENT 0.5 ML PRSYRinfluenza virus vacc types a & b surf antigen adjuvant quad 2

MFL 1 / 365 day(s)

PREV Preventative

FLUARIX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUBLOK SOLUTIONinfluenza virus vaccine recombinant hemagglutinin (ha) 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative



FLUBLOK QUADRIVALENT 0.5 ML SOLN PRSYRinfluenza virus vac recomb hemagglutinin (ha) quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUCELVAX QUADRIVALENT SUSPENSIONinfluenza virus vaccine tissue-cultured subunit quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUCELVAX QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine tissue-cultured subunit quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLULAVAL QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLULAVAL QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUMIST QUADRIVALENT SUSPENSIONinfluenza virus vaccine live quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUVIRIN SUSPENSIONinfluenza virus vaccine types a & b surface antigen 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUVIRIN 0.5 ML SUSP PRSYRinfluenza virus vaccine types a & b surface antigen 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUZONE HIGH-DOSE 0.5 ML SUSP PRSYRinfluenza virus vaccine split high-dose preservative free 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUZONE HIGH-DOSE QUADRIVALENT 0.7 ML SUSPPRSYRinfluenza virus vac split high-dose quad preservative free

2 PREV Preventative

FLUZONE QUADRIVALENT SUSPENSIONinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative



FLUZONE QUADRIVALENT 0.25 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUZONE QUADRIVALENT 0.5 ML SUSP PRSYRinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUZONE QUADRIVALENT 0.5 ML SUSPENSIONinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

FLUZONE QUADRIVALENT 9 MCG/STRAIN SUSP PENinfluenza virus vaccine split quadrivalent 2

QL 0.5 / 0 DAYS

MFL 1 / 365 DAYS

PREV Preventative

GARDASIL 9 SUSP PRSYRhuman papillomavirus (hpv) 9-valent recombinant vaccine 2

AL1 9 to 45 yrs old

PREV Preventative

GARDASIL 9 SUSPENSIONhuman papillomavirus (hpv) 9-valent recombinant vaccine 2

AL1 9 to 45 yrs old

PREV Preventative

HAVRIX 1440 EL U/ML SUSPENSIONhepatitis a vaccine 2 PREV Preventative

HAVRIX 720 EL U/0.5ML SUSPENSIONhepatitis a vaccine 2 PREV Preventative

HEPLISAV-B 20 MCG/0.5ML SOLN PRSYRhepatitis b vaccine recombinant adjuvanted 2 PREV Preventative

HEPLISAV-B 20 MCG/0.5ML SOLUTIONhepatitis b vaccine recombinant adjuvanted 2 PREV Preventative

IMOVAX RABIES 2.5 UNIT/ML INJECTABLErabies virus vaccine, hdc 2

IPOL INJECTABLEpoliovirus vaccine, ipv 2 PREV Preventative

IXIARO SUSPENSIONjapanese encephalitis vaccine inactivated adsorbed 2

JANSSEN COVID-19 VACCINE 0.5 ML SUSPENSIONcovid-19 (sars-cov-2) adenovirus vaccine 2

MFL 2 / 1 year(s)

PREV Preventative

MODERNA COVID-19 VAC (BOOSTER) 50 MCG/0.5MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 365 day(s)

PREV Preventative



MODERNA COVID-19 VACCINE 100 MCG/0.5MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 1 year(s)

PREV Preventative

NOVAVAX COVID-19 VACCINE 5 MCG/0.5ML SUSPENSIONcovid-19 (sars-cov-2) subunit (spike) protein virus vaccine 2

MFL 3 / 1 year(s)

PREV Preventative

PFIZER COVID-19 VAC-TRIS 5-11Y 10 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 1 year(s)

PREV Preventative

PFIZER COVID-19 VAC-TRIS 6M-4Y 3 MCG/0.2MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 365 day(s)

PREV Preventative

PFIZER-BIONT COVID-19 VAC-TRIS 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 1 year(s)

PREV Preventative

PFIZER-BIONTECH COVID-19 VACC 30 MCG/0.3MLSUSPENSIONcovid-19 (sars-cov-2) mrna virus vaccine

2MFL 3 / 1 year(s)

PREV Preventative

PREHEVBRIO 10 MCG/ML SUSPENSIONhepatitis b vaccine 3-antigen recombinant 2 PREV Preventative

RABAVERT RECON SUSPrabies vaccine, pcec 2

RECOMBIVAX HB 10 MCG/ML SUSPENSIONhepatitis b vaccine (recomb) 2 PREV Preventative

RECOMBIVAX HB 40 MCG/ML SUSPENSIONhepatitis b vaccine (recomb) 2 PREV Preventative

RECOMBIVAX HB 5 MCG/0.5ML SUSPENSIONhepatitis b vaccine (recomb) 2 PREV Preventative

ROTARIX RECON SUSProtavirus vaccine, live oral 2

AL1 Up to 8 yrs old

PREV Preventative

ROTATEQ SOLUTIONrotavirus vaccine, live oral pentavalent 2

AL1 Up to 8 yrs old

PREV Preventative

SANOFI COVID-19 VAC (BOOSTER) 5 MCG/0.5MLEMULSIONcovid-19 (sars-cov-2) pres dtm subunit protein virus vaccine

2MFL 3 / 1 year(s)

PREV Preventative

SHINGRIX 50 MCG/0.5ML RECON SUSPzoster vaccine recombinant adjuvanted 2 PREV Preventative

STAMARIL RECON SUSPyellow fever vaccine 2



VAQTA 25 UNIT/0.5ML SUSPENSIONhepatitis a vaccine 2 PREV Preventative

VAQTA 50 UNIT/ML SUSPENSIONhepatitis a vaccine 2 PREV Preventative

VARIVAX 1350 PFU/0.5ML INJECTABLEvaricella virus vaccine live 2 PREV Preventative

YF-VAX INJECTABLEyellow fever vaccine 2

ZOSTAVAX 19400 UNT/0.65ML RECON SUSPzoster vaccine live 2


PREV Preventative

VAGINAL AND RELATED PRODUCTS

IMIDAZOLE-RELATED ANTIFUNGALS

GYNAZOLE-1 2 % CREAMbutoconazole nitrate (one dose) 3

terconazole 0.4 % cream 1 QL 450 / 30 DAYS

terconazole 0.8 % cream 1 QL 450 / 30 DAYS

terconazole 80 mg suppos 1 QL 3 / 3 DAYS

VAGINAL ANTI-INFECTIVES

AVC VAGINAL 15 % CREAMsulfanilamide vaginal 3

CLEOCIN 100 MG SUPPOSclindamycin phosphate vaginal 3

clindamycin phosphate 2 % cream 2

CLINDESSE 2 % CREAMclindamycin phosphate (one dose) 3

metronidazole 0.75 % gel 1

NUVESSA 1.3 % GELmetronidazole vaginal 3

QL 5 / 0 DAYS

MFL 1 / DAYS

VANDAZOLE 0.75 % GELmetronidazole vaginal 1

VAGINAL ESTROGENS

estradiol 0.1 mg/gm cream 2

estradiol 10 mcg tab 1



ESTRING 2 MG RINGestradiol vaginal 2 QL 1 / 90 DAYS

FEMRING 0.05 MG/24HR RINGestradiol acetate vaginal 3 QL 1 / 84 DAYS

FEMRING 0.1 MG/24HR RINGestradiol acetate vaginal 3 QL 1 / 84 DAYS

PREMARIN 0.625 MG/GM CREAMestrogens, conjugated vaginal 2

yuvafem 10 mcg tab 1

VAGINAL PROGESTINS

CRINONE 4 % GELprogesterone (vaginal) 4

PA

S Specialty Drug

CRINONE 8 % GELprogesterone (vaginal) 4

PA

S Specialty Drug

ENDOMETRIN 100 MG INSERTprogesterone (vaginal) 2

VASOPRESSORS

ANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE 0.15 MG/0.15ML SOLN A-INJepinephrine (anaphylaxis) 1 QL 4 / 365 day(s)

epinephrine 0.15 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

EPINEPHRINE 0.3 MG/0.3ML SOLN A-INJepinephrine (anaphylaxis) 1 QL 4 / 365 day(s)

epinephrine 0.3 mg/0.3ml soln a-inj 1 QL 4 / 365 day(s)

SYMJEPI 0.15 MG/0.3ML SOLN PRSYRepinephrine (anaphylaxis) 2 QL 4 / 365 day(s)

EPINEPHRINE 30 MG/30ML SOLUTIONepinephrine 1 QL 120 / 365 day(s)

midodrine hcl 10 mg tab 1

midodrine hcl 2.5 mg tab 1

midodrine hcl 5 mg tab 1



VITAMINS

VITAMIN D

ergocalciferol 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

vitamin d (ergocalciferol) 1.25 mg (50000 ut) cap 1 QL 4 / 28 DAYS

vitamin d (ergocalciferol) 50000 unit cap 1 QL 4 / 28 DAYS

VITAMIN K

phytonadione 5 mg tab 2 QL 5 / 30 DAYS


Index of covered drugs11st Base 278

AABACAVIR SULFATE 140,141

ABACAVIR SULFATE-LAMIVUDINE 134

ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE134

ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE 136

ABALOPARATIDE 203

ABATACEPT 15

ABEMACICLIB 116

Abilify Maintena 132

ABIRATERONE ACETATE 103

Abstral 18,19

ACACIA SYRUP 277

ACALABRUTINIB 107

ACAMPROSATE CALCIUM 283

ACARBOSE 73

Accula SARS-CoV-2 192

ACEBUTOLOL HCL 146

ACETAMINOPHEN W/ CODEINE 16,17

ACETAMINOPHEN-CAFF-DIHYDROCOD 17

ACETAZOLAMIDE 195

ACETIC ACID (OTIC) 272

ACETOHYDROXAMIC ACID 218

ACETYLCYSTEINE 173

ACETYLCYSTEINE (ANTIDOTE) 84

ACITRETIN 180

Actemra 12

Actemra ACTPen 12

ActHIB 304

Activella 207

Acuvail 269

ACYCLOVIR 144

ACYCLOVIR SODIUM 144

ACYCLOVIR TOPICAL 182

ACYCLOVIR-HYDROCORTISONE 182

Adacel 300

ADALIMUMAB 8,9

ADAPALENE 175

ADAPALENE-BENZOYL PEROXIDE 175

ADEFOVIR DIPIVOXIL 142

Adempas 153

Advanced Base Plus 278

Advate 219

Adynovate 219,220

Adzenys ER 3

Adzenys XR-ODT 3

AeroChamber Mini Chamber 248

AeroChamber MV 248

AeroChamber Plus Flo-Vu 248

AeroChamber Plus Flo-Vu Large 248

AeroChamber Plus Flo-Vu Medium 248

AeroChamber Plus Flo-Vu Small 248

AeroChamber Plus Flo-Vu w/Mask 248

AeroChamber Plus Flow VU 248

AeroChamber w/FLOWSIGnal 248

AeroChamber Z-Stat Plus 248

AeroChamber Z-Stat Plus Chambr 248

AeroChamber Z-Stat Plus/Large 248

AeroChamber Z-Stat Plus/Medium 248

AeroChamber Z-Stat Plus/Small 248

AFATINIB DIMALEATE 108

Afluria 305

Afluria Preservative Free 305

Afluria Quadrivalent 306

Afstyla 220

Agrylin 230

Aimovig 250

Aimovig (140 MG Dose) 250

Ajovy 250

Akten 269

Akynzeo 86

Ala-Quin 178

Alba-Derm 278

ALBENDAZOLE 37

ALBUTEROL SULFATE 46

Albuterol Sulfate ER 46

Albuterol Sulfate HFA 46

ALCAFTADINE 267

ALCLOMETASONE DIPROPIONATE 183


Alecensa 104

ALECTINIB HCL 104

ALENDRONATE SODIUM 197

Alendronate Sodium 197

ALENDRONATE SODIUM-

CHOLECALCIFEROL 197,198

ALFUZOSIN HCL 216

Alinia 38

ALISKIREN FUMARATE 100

ALISKIREN-HYDROCHLOROTHIAZIDE 100

ALITRETINOIN 179

Alkeran 118

Alkindi Sprinkle 170

ALLOPURINOL 218

ALMOTRIPTAN MALATE 251

Alocril 267

ALOGLIPTIN BENZOATE 75

Alogliptin Benzoate 75

Alomide 267

Alora 208

ALOSETRON HCL 213

AlpaWash 278

ALPELISIB 119

ALPHA1-PROTEINASE INHIBITOR (HUMAN) 290,291

Alphagan P 270

Alphanate 220

Alphanate/VWF Complex/Human 220,221

AlphaNine SD 221

ALPRAZOLAM 41,42

ALPRAZolam Intensol 42

Alprolix 221

Alrex 271

Altabax 177

Altaderm 278

ALTRETAMINE 103

ALUMINUM CHLORIDE 189

AMANTADINE HCL 121

AMBRISENTAN 153

AMCINONIDE 183

Amcinonide 183

AMIFAMPRIDINE 102

AMILORIDE & HYDROCHLOROTHIAZIDE 195

AMILORIDE HCL 196

AMINOCAPROIC ACID 236

AMINOSALICYLIC ACID 102

AMIODARONE HCL 44

Amitiza 212

AMITRIPTYLINE HCL 71

AMLODIPINE BENZOATE 150

AMLODIPINE BESYLATE 148

AMLODIPINE BESYLATE-ATORVASTATIN

CALCIUM 152

AMLODIPINE BESYLATE-BENAZEPRIL HCL 93

AMLODIPINE BESYLATE-OLMESARTAN

MEDOXOMIL 97

AMLODIPINE BESYLATE-VALSARTAN 96,97

Amlodipine-Atorvastatin 152

AMLODIPINE-VALSARTAN-

HYDROCHLOROTHIAZIDE 96

AMOXAPINE 72

Amoxapine 72

AMOXICILLIN 274,275

Amoxicillin 274,275

AMOXICILLIN & POT CLAVULANATE 275,276

Amoxicillin-Pot Clavulanate 275

Amoxicillin-Pot Clavulanate ER 275

AMPHETAMINE 3,4

Amphetamine ER 3

AMPHETAMINE SULFATE 3

AMPHETAMINE-DEXTROAMPHETAMINE 2,3

AMPICILLIN 275

Ampicillin 275

Anacaine 188

ANAGRELIDE HCL 230,231

ANAKINRA 12

Analpram-HC 36

ANASTROZOLE 115

Angeliq 207

Annovera 164

Anoro Ellipta 44

ANTHRALIN 180


ANTIFUNGAL COMBINATION PRODUCTS,

MISC. 179

ANTIHEMOPHIL FACT(RCMB) PEGYLATED-AUCL

(BDD-RFVIII PEG-AUCL) 224

ANTIHEMOPHILIC FACTOR (HUMAN) 223,225,226

ANTIHEMOPHILIC FACTOR (RCMB) BD

TRUNCATED (BD TRUNC-RFVIII) 226

ANTIHEMOPHILIC FACTOR (RCMB) FC FUSION

PROTEIN(BDD-RFVIIIFC) 222

ANTIHEMOPHILIC FACTOR (RCMB)

MOROCTOCOG ALFA(BDD-RFVIII,MOR) 229

ANTIHEMOPHILIC FACTOR (RCMB)

PLASMA/ALBUMIN FREE (RAHF-PFM) 219,225,226

ANTIHEMOPHILIC FACTOR (RCMB) SIMOCTOCOG

ALFA(BDD-RFVIII,SIM) 226,227

ANTIHEMOPHILIC FACTOR (RECOMBINANT

PORCINE) (RPFVIII) 227

ANTIHEMOPHILIC FACTOR

(RECOMBINANT) 223,225,228

ANTIHEMOPHILIC FACTOR (RECOMBINANT)

GLYCOPEGYLATED-EXEI 222,223


PEGYLATED 219,220


SINGLE CHAIN 220

ANTIHEMOPHILIC FACTOR/VON WILLEBRAND

FACTOR COMPLEX (HUMAN) 220,221,223,228

Anusol-HC 36

APALUTAMIDE 103

APAP-Caff-Dihydrocodeine 17

APIXABAN 51,52

APO-Varenicline 289

APOMORPHINE HYDROCHLORIDE 123,124

Apothederm 278

Apothesar 278

Apothesar 2 278

Apothesar Plus 278

APRACLONIDINE HCL 270

APREMILAST 15

APREPITANT 86

Aptiom 56

Aptivus 137,138

Aralast NP 290

Aranesp (Albumin Free) 231,232

Arcapta Neohaler 46

ARFORMOTEROL TARTRATE 46

ARIPIPRAZOLE 132,133

ARMODAFINIL 5

Armour Thyroid 294

Arnuity Ellipta 48,49

ARTEMETHER-LUMEFANTRINE 101

ARTIFICIAL TEAR INSERT 264

Arymo ER 19

Arzol Silver Nit Applicators 183

ASCIMINIB HCL 106

ASENAPINE MALEATE 129,130

ASFOTASE ALFA 202

Asmanex (120 Metered Doses) 49





Asmanex HFA 49

ASPIRIN-DIPYRIDAMOLE 230

Assure ID Insulin Safety Syr 245

Astagraf XL 257

AstraZeneca COVID-19 Vaccine 306

ATAZANAVIR SULFATE 138,139

ATAZANAVIR SULFATE-COBICISTAT 135

ATENOLOL 146

ATENOLOL & CHLORTHALIDONE 100

ATOGEPANT 249

ATOMOXETINE HCL 2

ATORVASTATIN CALCIUM 90

ATOVAQUONE 38

ATOVAQUONE-PROGUANIL HCL 101

ATREVIS HYDROGEL 278

ATROPINE SULFATE (OPHTHALMIC) 266

Atrovent HFA 47

Aubagio 285

Augmentin 276

AURANOFIN 12


Auryxia 215

Auxipro Vanishing 278

AVANAFIL 155

AVAPRITINIB 113

AVC Vaginal 310

Avonex 286

Avonex Pen 286

Avonex Prefilled 286

AXITINIB 120

Ayvakit 113

AzaSite 267

AZATHIOPRINE 258

AZELAIC ACID 189

AZELAIC ACID (ACNE) 176

AZELASTINE HCL 263

AZELASTINE HCL (OPHTH) 267

AZELASTINE HCL-FLUTICASONE PROPIONATE 263

Azelex 176

AZITHROMYCIN 239

Azithromycin 239

AZITHROMYCIN (OPHTH) 267

AZTREONAM LYSINE 39

BBacitracin 267

BACITRACIN (OPHTHALMIC) 267

BACITRACIN-POLY-NEOMYCIN-HC 270

BACITRACIN-POLYMYXIN B (OPHTH) 266,267

BACITRACIN-POLYMYXIN-NEOMYCIN HC 177

BACLOFEN 262

Bactroban Nasal 263

Bafiertam 287

Balcoltra 159

BALOXAVIR MARBOXIL 145

BALSALAZIDE DISODIUM 214

Balversa 108

Baqsimi One Pack 74

Baqsimi Two Pack 74

Baraclude 142

BARICITINIB 10

Basaglar KwikPen 76

Base W301 278

BD Insulin Syringe U-500 245

BD Klatskin Biopsy Needle 245

BD Osgood Biopsy Needle 245

BD Pen Needle Nano U/F 245

BD Rosenthal Biopsy Needle 245

BD SafetyGlide Insulin Syringe 245

BD Veritor Home Covid-19 Test 192

BD Veritor System SARS-CoV-2 192

BECAPLERMIN 191

BECLOMETHASONE DIPROP MONOHYD 263

BECLOMETHASONE DIPROPIONATE 50

BECLOMETHASONE DIPROPIONATE (NASAL) 264

BECLOMETHASONE DIPROPIONATE HFA 50

Beconase AQ 263

BEDAQUILINE FUMARATE 103

Belbuca 33

BELIMUMAB 254

BELLADONNA ALKALOIDS & OPIUM 301

Belladonna Alkaloids-Opium 301

Belsomra 238

BELZUTIFAN 109

BEMPEDOIC ACID 89

BEMPEDOIC ACID-EZETIMIBE 89

BENAZEPRIL & HYDROCHLOROTHIAZIDE 95

BENAZEPRIL HCL 94

Benazepril-Hydrochlorothiazide 95

BeneFIX 221,222

Benlysta 254

BENRALIZUMAB 48

BENZALKONIUM CHLORIDE 134

Benzalkonium Chloride 134

BENZOCAINE (TOPICAL) 188

BENZOIN 190

Benzoin 190

BENZOIN COMPOUND 190

BENZONATATE 172

BENZOYL PEROXIDE-ERYTHROMYCIN 175

BENZTROPINE MESYLATE 121

BENZYL ALCOHOL (PEDICULICIDE) 190

BEPOTASTINE BESILATE 267


Bepreve 267

Berinert 230

BESIFLOXACIN HCL 267

Besivance 267

Betadine Ophthalmic Prep 268

BETAMETHASONE DIPROPIONATE (TOPICAL) 183

BETAMETHASONE DIPROPIONATE

AUGMENTED 183,184

BETAMETHASONE VALERATE 184

Betaseron 286

BETAXOLOL HCL 146

BETAXOLOL HCL (OPHTH) 264,265

BETHANECHOL CHLORIDE 304

Betimol 265

Betoptic-S 265

BEXAROTENE 120

BEXAROTENE (TOPICAL) 191

Bexsero 304

Beyaz 159

BICALUTAMIDE 103

BICTEGRAVIR-EMTRICITABINE-TENOFOVIR

ALAFENAMIDE FUMARATE 134

BiDil 152

Biktarvy 134

BIMATOPROST 272

BinaxNOW COVID-19 Ag Card 192

BinaxNOW COVID-19 Ag Home Test 192

BINIMETINIB 110

BISACODYL-PEG 3350-POT CHLORIDE-SOD

BICARB-SOD CHLORIDE 238,239

BISOPROLOL & HYDROCHLOROTHIAZIDE 100

BISOPROLOL FUMARATE 146

Blephamide 270

Blephamide S.O.P. 270

BLOOD GLUCOSE MONITORING

SUPPLIES 241,242,243,244

Boostrix 300

BOSENTAN 153,154

Bosulif 105

BOSUTINIB 105

Braftovi 107

Breo Ellipta 44

Brexafemme 86

BREXPIPRAZOLE 133

Breztri Aerosphere 44

Brilinta 230

BRIMONIDINE TARTRATE 270

BRIMONIDINE TARTRATE (TOPICAL) 190

Brimonidine Tartrate-Timolol 265

BRIMONIDINE TARTRATE-TIMOLOL MALEATE 265

BRINZOLAMIDE 268

BRINZOLAMIDE-BRIMONIDINE TARTRATE 264

BRIVARACETAM 56

Briviact 56

BROMFENAC SODIUM (OPHTH) 269,270

BROMOCRIPTINE MESYLATE 121

BROMOCRIPTINE MESYLATE (DIABETES) 76

Brukinsa 107

BUDESONIDE 170

BUDESONIDE (INHALATION) 49,50

BUDESONIDE (INTRARECTAL) 36

BUDESONIDE-FORMOTEROL FUMARATE

DIHYDRATE 45

BUDESONIDE-GLYCOPYRROLATE-FORMOTEROL

FUMARATE 44

BUMETANIDE 196

Bunavail 33,34

Buphenyl 206

BUPRENORPHINE 34

BUPRENORPHINE HCL 33,34

BUPRENORPHINE HCL-NALOXONE HCL

DIHYDRATE 33,34

BUPROPION HCL 67

BUPROPION HCL (SMOKING DETERRENT) 289

BUSPIRONE HCL 41

BUSULFAN 103

BUTABARBITAL SODIUM 236

BUTALBITAL-ACETAMINOPHEN 16

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 16

BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/

CODEINE 17

BUTALBITAL-ASPIRIN-CAFFEINE 16


BUTALBITAL-ASPIRIN-CAFFEINE W/COD 17

BUTAMBEN-TETRACAINE-BENZOCAINE 191

Butisol Sodium 236

BUTOCONAZOLE NITRATE (ONE DOSE) 310

BUTORPHANOL TARTRATE 34

Bydureon 78

Bydureon BCise 78

Bylvay 214

Bylvay (Pellets) 213,214

CC1 ESTERASE INHIBITOR (HUMAN) 230

CABERGOLINE 199

Cablivi 219

Cabometyx 111

CABOZANTINIB S-MALATE 111,112

CADEXOMER IODINE 134

CAFFEINE CITRATE 5

CALCIPOTRIENE 179,180

Calcipotriene 179

CALCIPOTRIENE-BETAMETHASONE

DIPROPIONATE 191

CALCITONIN (SALMON) 198

Calcitriol 180

CALCITRIOL 201

CALCITRIOL (TOPICAL) 180

CALCIUM ACETATE (PHOSPHATE BINDER) 215

Calquence 107

Cambia 250

CANAKINUMAB 12

CANDESARTAN CILEXETIL 98

CANDESARTAN CILEXETIL-


CANNABIDIOL 57

CAPECITABINE 104

Capex 184

CAPLACIZUMAB-YHDP 219

Caplyta 126

CAPMATINIB HCL 110

Caprelsa 111,112

CAPTOPRIL 94

CAPTOPRIL & HYDROCHLOROTHIAZIDE 95

Captopril-Hydrochlorothiazide 95

CARBAMAZEPINE 56,57,62

CARBAMAZEPINE (ANTIPSYCHOTIC) 126

Carbatrol 57

CARBIDOPA 122

CARBIDOPA-LEVODOPA 122,123

Carbidopa-Levodopa 122

CARBIDOPA-LEVODOPA-ENTACAPONE 122,123

Carbidopa-Levodopa-Entacapone 122,123

CARBINOXAMINE MALEATE 87

Carbinoxamine Maleate 87

Cardura XL 216

Carestart COVID-19 Home Test 192

CARIPRAZINE HCL 126,127

Carnitor SF 198

Carteolol HCl 265

CARTEOLOL HCL (OPHTH) 265

CARVEDILOL 145

CARVEDILOL PHOSPHATE 145,146

CASCARA SAGRADA 239

Cascara Sagrada 239

Caya 241

Cayston 39

CEFACLOR 156

Cefaclor 156

Cefaclor ER 156

CEFACLOR MONOHYDRATE 156

CEFADROXIL 155,156

Cefadroxil 155

CEFDINIR 157

CEFDITOREN PIVOXIL 157

Cefditoren Pivoxil 157

CEFIXIME 157

CEFPODOXIME PROXETIL 157

CEFPROZIL 156

CEFUROXIME AXETIL 157

Cela Base 278

CELECOXIB 11,12

Celontin 65

CEM-Urea 187


CENEGERMIN-BKBJ 269

CENOBAMATE 64

CEPHALEXIN 156

Cephalexin 156

CeQur Simplicity Inserter 245

CeQur Simplicity Starter 245

Cerdelga 231

CERITINIB 105

CERTOLIZUMAB PEGOL 216

CERVICAL CAPS 240

Cervidil 273

Cetacaine 191

CETIRIZINE HCL 88

Cetylev 84

CEVIMELINE HCL 259

Chantix 289

Chantix Continuing Month Pak 289

Chantix Starting Month Pak 289

Chemet 83

Cherry 276

CHERRY SYRUP 276

CHLORAMBUCIL 118

CHLORDIAZEPOXIDE HCL 42

CHLORDIAZEPOXIDE HCL-CLIDINIUM

BROMIDE 301

CHLORDIAZEPOXIDE-AMITRIPTYLINE 283,284

Chlordiazepoxide-Amitriptyline 283,284

CHLORHEXIDINE GLUCONATE (MOUTH-

THROAT) 259

CHLOROQUINE PHOSPHATE 101

Chloroquine Phosphate 101

CHLOROTHIAZIDE 196,197

Chlorothiazide 196

CHLORPROMAZINE HCL 131

CHLORTHALIDONE 197

CHLORZOXAZONE 262

CHOLERA VACCINE LIVE ATTENUATED 305

CHOLESTYRAMINE 89

CHOLESTYRAMINE LIGHT 89

CHOLINE & MAG SALICYLATE 16

CHOLINE FENOFIBRATE 90

Choline-Mag Trisalicylate 16

CHORIOGONADOTROPIN ALFA 203

CHORIONIC GONADOTROPIN 203

Chrysaderm Day 278

Chrysaderm Night 278

Cialis 155

CICLESONIDE (NASAL) 264

CICLOPIROX 178

CICLOPIROX OLAMINE 178

CILOSTAZOL 230

Ciloxan 267

Cimduo 135

CIMETIDINE HCL 301

Cimetidine HCl 301

Cimzia 216

Cimzia Prefilled 216

Cimzia Starter Kit 216

CINACALCET HCL 198

Cipro HC 272

CIPROFLOXACIN 211

CIPROFLOXACIN HCL 211

Ciprofloxacin HCl 211,272

CIPROFLOXACIN HCL (OPHTH) 267

CIPROFLOXACIN HCL (OTIC) 272

Ciprofloxacin-Ciproflox HCl ER 211

CIPROFLOXACIN-CIPROFLOXACIN HCL 211

CIPROFLOXACIN-DEXAMETHASONE 272

CIPROFLOXACIN-HYDROCORTISONE 272

CITALOPRAM HYDROBROMIDE 68

CITRIC ACID-GLUCONOLACTONE-MAGNESIUM

CARBONATE 217

CITRUS BERGAMOT 8

Citrus Bergamot 8

CLADRIBINE (MULTIPLE SCLEROSIS) 285,286

CLARITHROMYCIN 240

Clarithromycin 240

ClearDetect COVID-19 AG Home 192

CLEMASTINE FUMARATE 87

Clemastine Fumarate 87

Cleocin 310

Climara 208


Climara Pro 207

CLINDAMYCIN HCL 38,39

CLINDAMYCIN PALMITATE HYDROCHLORIDE 39

CLINDAMYCIN PHOSPHATE (ONE DOSE) 310

CLINDAMYCIN PHOSPHATE (TOPICAL) 174

CLINDAMYCIN PHOSPHATE VAGINAL 310

CLINDAMYCIN PHOSPHATE-BENZOYL

PEROXIDE 175

CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE

(REFRIGERATE) 175

Clindesse 310

Clinitest Rapid COVID-19 Test 192

CLIOQUINOL-HC 178

CLOBAZAM 55

CLOBETASOL PROPIONATE 184

CLOBETASOL PROPIONATE EMOLLIENT BASE 184

CLOBETASOL PROPIONATE EMULSION 184,186

CLOCORTOLONE PIVALATE 184

Clocortolone Pivalate 184

Clocortolone Pivalate Pump 184

CLOMIPHENE CITRATE 203

ClomiPHENE Citrate 203

CLOMIPRAMINE HCL 72

CLONAZEPAM 55

CLONIDINE 99

CLONIDINE HCL 99

CLONIDINE HCL (ADHD) 2

CLOPIDOGREL BISULFATE 231

CLORAZEPATE DIPOTASSIUM 42

CLOTRIMAZOLE 259

CLOTRIMAZOLE (TOPICAL) 187

CLOTRIMAZOLE W/ BETAMETHASONE 178

CLOZAPINE 130

CloZAPine 130

Co-Natal FA 259

COAGULATION FACTOR IX 221,226

COAGULATION FACTOR IX (RECOMB) FC FUSION

PROTEIN (RFIXFC) 221

COAGULATION FACTOR IX

(RECOMBINANT) 221,222,224,228

COAGULATION FACTOR IX (RECOMBINANT)

GLYCOPEGYLATED 228

COAGULATION FACTOR IX RECOMB ALBUMIN

FUSION PROTEIN (RIX-FP) 224

Coartem 101

Cobas Liat SARS-CoV-2 Assay 192

COBASE #1 280

COBICISTAT 142

COBIMETINIB FUMARATE 110

COD LIVER OIL 262

Cod Liver Oil 262

CODEINE POLISTIREX-CHLORPHENIRAMINE

POLISTIREX 174

CODEINE SULFATE 19,20

Codeine Sulfate 19,20

COLCHICINE 218

Colchicine 218

COLCHICINE W/ PROBENECID 218

COLESEVELAM HCL 89

COLESTIPOL HCL 89

COLLAGENASE 187

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 255

COLLODION FLEXIBLE 276

Collodion Flexible 276

Coly-Mycin S 272

Combigan 265

CombiPatch 207

Combivent Respimat 45

Cometriq (100 mg Daily Dose) 112



Comirnaty 306

Compact Space Chamber 248

Compact Space Chamber/Lg Mask 248

Compact Space Chamber/Med Mask 248

Compact Space Chamber/Sm Mask 248

Complera 135

Complete Natal DHA 261

CompleteNate 259

Condylox 188

CONJUGATED ESTROGENS-BAZEDOXIFENE 208


CONJUGATED ESTROGENS-

MEDROXYPROGESTERONE ACETATE 208

CONTINUOUS BLOOD GLUCOSE SYSTEM

RECEIVER 241,242


SENSOR 241,242


TRANSMITTER 241

Copiktra 119

COPPER (IUD) 165

Cordran 184

Corlanor 155

Cortane-B 190

Cortifoam 36

CORTISONE ACETATE 170

Cortisone Acetate 170

Cortisporin 177

Cortisporin-TC 272

Cosentyx 180

Cosentyx (300 MG Dose) 180

Cosentyx Sensoready (300 MG) 180

Cosentyx Sensoready Pen 180

Cotellic 110

COVID-19 (SARS-COV-2) ADENOVIRUS

VACCINE 306,308

COVID-19 (SARS-COV-2) MRNA VIRUS

VACCINE 306,308,309

COVID-19 (SARS-COV-2) PRES DTM SUBUNIT

PROTEIN VIRUS VACCINE 309

COVID-19 (SARS-COV-2) SUBUNIT (SPIKE)

PROTEIN VIRUS VACCINE 309

COVID-19 ANTIGEN TEST 192,194

COVID-19 AT HOME TEST 192,193,194

COVID-19 At-Home Test 193

COVID-19 HOME COLLECTION TEST 193,194

COVID-19 HOME TEST 193,194

COVID-19 OTC Antigen 1-Pack 193

COVID-19 OTC Antigen 2-Pack 193

COVID-19 TEST 192,193,194

CREAM BASE 278,279,280,281,282,283

Cream Base 278

CREAM BASE LIPOSOMIC 278,279,280

Cream Base with Liposome 278

Cream Concentrate 278

Creon 194

Cresemba 87

Crinone 311

CRISABOROLE 189

Crixivan 138

CRIZOTINIB 105

CROFELEMER 83

CROMOLYN SODIUM 46

CROMOLYN SODIUM (MASTOCYTOSIS) 212

CROMOLYN SODIUM (OPHTH) 267

CROTAMITON 190

Cutis Plus 278

Cuvitru 273

Cuvposa 302

CYANOCOBALAMIN 231

CYCLOBENZAPRINE HCL 262

Cyclomydril 265

CYCLOPENTOLATE HCL 266

CYCLOPENTOLATE W/ PHENYLEPHRINE 265

CYCLOPHOSPHAMIDE 118

Cyclophosphamide 118

CYCLOSERINE 102

CycloSERINE 102

Cycloset 76

CYCLOSPORINE 255

CYCLOSPORINE (OPHTH) 269

CYCLOSPORINE MODIFIED (FOR

MICROEMULSION) 255

CYPROHEPTADINE HCL 88

Cystadrops 272

Cystagon 217

Cystaran 272

CYSTEAMINE BITARTRATE 217

CYSTEAMINE HCL 272

Cytra K Crystals 217

DDABIGATRAN ETEXILATE MESYLATE 54


DABRAFENIB MESYLATE 107

DACOMITINIB 108

DALFAMPRIDINE 287

Daliresp 48

DALTEPARIN SODIUM 54

DANAZOL 35

DANTROLENE SODIUM 263

DAPAGLIFLOZIN PROPANEDIOL 80

DAPAGLIFLOZIN-METFORMIN HCL 81

DAPSONE 38

DAPSONE (TOPICAL) 174

Daptacel 300

DARBEPOETIN ALFA 231,232

DARIFENACIN HYDROBROMIDE 303

DARUNAVIR 138,139

DARUNAVIR ETHANOLATE 138,139

DARUNAVIR-COBICISTAT 136

DARUNAVIR-COBICISTAT-EMTRICITABINE-

TENOFOVIR ALAFENAMIDE 136

DASATINIB 106

Daytrana 5

DayVigo 238

Debacterol 259

DECITABINE-CEDAZURIDINE 114

DEFERASIROX 83,84

DEFERIPRONE 84

DELAVIRDINE MESYLATE 140

Delestrogen 209

Delivra 279

DEMECLOCYCLINE HCL 292

Denavir 182

Depakene 66

Depakote 66

Depakote ER 66

Depakote Sprinkles 66

Depo-Provera 167

Depo-SubQ Provera 104 167

Depo-Testosterone 35

DermacinRx Topical Base 276

Descovy 135

DESIPRAMINE HCL 72,73

DESLORATADINE 88

Desloratadine 88

DESMOPRESSIN ACETATE 206

Desmopressin Acetate 206

DESMOPRESSIN ACETATE SPRAY 206

DESMOPRESSIN ACETATE SPRAY

REFRIGERATED 206

DESOGESTREL & ETHINYL

ESTRADIOL 158,159,160,163

DESOGESTREL-ETHINYL ESTRADIOL

(BIPHASIC) 158

DESOGESTREL-ETHINYL ESTRADIOL

(TRIPHASIC) 168,169

DESONIDE 184

DESOXIMETASONE 184,185

DESVENLAFAXINE 70,71

Desvenlafaxine ER 70

DESVENLAFAXINE SUCCINATE 70

DEXAMETHASONE 170,171

Dexamethasone 170

DEXAMETHASONE (OPHTH) 271

Dexamethasone Sodium Phosphate 271

DEXAMETHASONE SODIUM PHOSPHATE

(OPHTH) 271

Dexcom G6 Receiver 241

Dexcom G6 Sensor 241

Dexcom G6 Transmitter 241

DEXLANSOPRAZOLE 302

Dexlansoprazole 302

DEXMETHYLPHENIDATE HCL 5,6

DEXTROAMPHETAMINE SULFATE 4

DEXTROMETHORPHAN HBR-QUINIDINE

SULFATE 288

DIAPHRAGM ARC-SPRING 241

DIAPHRAGM WIDE SEAL 241

DiaTrust COVID-19 Home Test 193

DIAZEPAM 42

DiazePAM 42,55

DIAZEPAM (ANTICONVULSANT) 55,56

DIAZOXIDE 74

DICLOFENAC EPOLAMINE 177


Diclofenac Epolamine 177

DICLOFENAC POTASSIUM 12

DICLOFENAC POTASSIUM (MIGRAINE) 250

DICLOFENAC SODIUM 12

DICLOFENAC SODIUM (ACTINIC KERATOSES) 179

DICLOFENAC SODIUM (OPHTH) 269

DICLOFENAC SODIUM (TOPICAL) 177

DICLOFENAC W/ MISOPROSTOL 12

DICLOXACILLIN SODIUM 276

DICYCLOMINE HCL 301

DIDANOSINE 140,141

Didanosine 140

DIFENOXIN W/ ATROPINE 83

Dificid 240

DIFLORASONE DIACETATE 185

Diflorasone Diacetate 185

DIFLUNISAL 16

DIFLUPREDNATE 271

DIGOXIN 151

Digoxin 151

DIHYDROERGOTAMINE MESYLATE 250

Dilantin 65

Dilantin Infatabs 65

DILTIAZEM HCL 148,149

DILTIAZEM HCL COATED BEADS 148,149,150

DILTIAZEM HCL EXTENDED RELEASE

BEADS 149,150,151

DIMETHYL FUMARATE 287

DINOPROSTONE 273

Dipentum 214

DIPH-AC PERT-TET TOX AD-POLIO IPV-

HAEMOPHIL B POLY VAC 300

DIPH-TET TOX-ACELL PERT AD-POLIO IPV-HIB-

HEPATITIS B RECOMB 300,301

DIPH-TETANUS TOX AD-ACELL PERTUSSIS &

POLIO VIRUS, IPV VAC 300

DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B

RECOMB-POLIO IPV VAC 300

DIPHENHYDRAMINE HCL 88

DIPHENOXYLATE W/ ATROPINE 83

Diphenoxylate-Atropine 83

DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS

TOXOIDS 300

DIPHTHERIA-TETANUS TOXOIDS (DT) 300

Diphtheria-Tetanus Toxoids DT 300

DIPYRIDAMOLE 230

DISOPYRAMIDE PHOSPHATE 43

DISTILLED WATER 277

DISULFIRAM 283

Diuril 197

DIVALPROEX SODIUM 66

Divigel 209

DOFETILIDE 44

Dojolvi 264

DOLUTEGRAVIR SODIUM 137

DOLUTEGRAVIR SODIUM-LAMIVUDINE 135

DOLUTEGRAVIR SODIUM-RILPIVIRINE HCL 135

DONEPEZIL HYDROCHLORIDE 284

DORAVIRINE 140

DORNASE ALFA 292

DORZOLAMIDE HCL 268

DORZOLAMIDE HCL-TIMOLOL MALEATE 265

Dovato 135

DOXAZOSIN MESYLATE 99

DOXAZOSIN MESYLATE (BPH) 216

DOXEPIN HCL 72

Doxepin HCl 72,179

DOXEPIN HCL (ANTIPRURITIC) 179

DOXERCALCIFEROL 201

DOXYCYCLINE (MONOHYDRATE) 292,293,294

DOXYCYCLINE CALCIUM 294

DOXYCYCLINE HYCLATE 292,293,294

Dritho-Creme HP 180

DRONABINOL 86

DRONEDARONE HCL 44

DROSPIRENONE 168

DROSPIRENONE-ESTETROL 162

DROSPIRENONE-ESTRADIOL 207

DROSPIRENONE-ETHINYL

ESTRADIOL 159,160,161,162,163,164

DROSPIRENONE-ETHINYL ESTRADIOL-

LEVOMEFOLATE CALCIUM 159,163,164


Droxia 231

Drysol 189

Duavee 208

DULAGLUTIDE 79

Dulera 45

DULOXETINE HCL 70

Duopa 123

DUPILUMAB 182

Dupixent 182

Durabase 279

Durabase Advanced 279

DUTASTERIDE 216

DUTASTERIDE-TAMSULOSIN HCL 218

Dutoprol 100

DUVELISIB 119

DxTerity COVID-19 Home Test 193

Dyanavel XR 4

DYE FDC BLUE 1 (BRILLIANT BLUE FCF) 276

EEasiVent 248

EasiVent Mask Large 249

EasiVent Mask Medium 249

EasiVent Mask Small 249

Easy Touch Lancets 30G/Twist 241

Easy Touch Lancets 33G/Twist 241

ECHOTHIOPHATE IODIDE 266

ECONAZOLE NITRATE 187

Ecoza 187

Edluar 237

EDOXABAN TOSYLATE 52

Edurant 139

EFAVIRENZ 139,140

EFAVIRENZ-EMTRICITABINE-TENOFOVIR

DISOPROXIL FUMARATE 135

EFAVIRENZ-LAMIVUDINE-TENOFOVIR


Effexor XR 70

Egrifta 199

ELAGOLIX SODIUM 199

ELAGOLIX SODIUM-ESTRADIOL-NORETHINDRONE

ACETATE 208

Eldepryl 122

Elestrin 209

ELETRIPTAN HYDROBROMIDE 251

ELEXACAFTOR-TEZACAFTOR-IVACAFTOR 291,292

Eligard 117

ELIGLUSTAT TARTRATE 231

Eliquis 51

Eliquis DVT/PE Starter Pack 52

Elixophyllin 50

Ella 165

Ellume Covid-19 Home Test 193

Elmiron 218

Eloctate 222

ELTROMBOPAG OLAMINE 235

ELUXADOLINE 213

ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-

TENOFOVIR ALAFENAMIDE 135

ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-

TENOFOVIR DF 136

Emadine 267

Emcyt 116

EMEDASTINE DIFUMARATE 267

Emgality 250

Emgality (300 MG Dose) 250

EMICIZUMAB-KXWH 229

Emolivan 279

Emollient Base 279

EMPAGLIFLOZIN 80

EMPAGLIFLOZIN-LINAGLIPTIN 80

EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN 79,80

EMPAGLIFLOZIN-METFORMIN HCL 80,81

Emsam 67

EMTRICITABINE 141

EMTRICITABINE-RILPIVIRINE-TENOFOVIR

ALAFENAMIDE FUMARATE 136

EMTRICITABINE-RILPIVIRINE-TENOFOVIR


EMTRICITABINE-TENOFOVIR ALAFENAMIDE

FUMARATE 135


EMTRICITABINE-TENOFOVIR DISOPROXIL

FUMARATE 135

Emtriva 141

Emverm 37

ENALAPRIL MALEATE 94

ENALAPRIL MALEATE &


EnBrace HR 259

Enbrel 15

Enbrel Mini 15

Enbrel SureClick 15

ENCORAFENIB 107

Endometrin 311

ENFUVIRTIDE 137

Engerix-B 306

ENOXAPARIN SODIUM 53

Enspryng 258

ENTACAPONE 125

ENTECAVIR 142

ENTRECTINIB 113

Entresto 152

Envarsus XR 257

ENZALUTAMIDE 103,104

Epidiolex 57

Epifoam 190

EPINASTINE HCL (OPHTH) 267

EPINEPHrine 311

EPINEPHRINE 311

EPINEPHRINE (ANAPHYLAXIS) 311

Episil 259

EPLERENONE 101

EPOETIN ALFA 233

EPOETIN ALFA-EPBX 233

Eprontia 57

EPROSARTAN MESYLATE 98

Eprosartan Mesylate 98

Equetro 126

ERDAFITINIB 108

ERENUMAB-AOOE 250

ERGOCALCIFEROL 312

ERGOLOID MESYLATES 288

Ergoloid Mesylates 288

Ergomar 250

ERGOTAMINE TARTRATE 250

ERGOTAMINE W/ CAFFEINE 250

Erivedge 109

Erleada 103

ERLOTINIB HCL 107

Ertaczo 187

ERYTHROMYCIN (ACNE AID) 175

ERYTHROMYCIN (OPHTH) 268

ERYTHROMYCIN BASE 240

ERYTHROMYCIN BASE (COATED) 240

ERYTHROMYCIN ETHYLSUCCINATE 240

Esbriet 292

ESCITALOPRAM OXALATE 68

ESKETAMINE HCL 68

ESLICARBAZEPINE ACETATE 56

Esperoct 222,223

ESTAZOLAM 236

ESTERIFIED ESTROGENS 210

ESTERIFIED ESTROGENS &

METHYLTESTOSTERONE 206,207

ESTRADIOL 208,209,210,211

ESTRADIOL & NORETHINDRONE ACETATE 207

ESTRADIOL ACETATE VAGINAL 311

ESTRADIOL VAGINAL 310,311

ESTRADIOL VALERATE 209,210

ESTRADIOL VALERATE-DIENOGEST 166

ESTRADIOL-LEVONORGESTREL 207

ESTRADIOL-NORGESTIMATE 208

ESTRAMUSTINE PHOSPHATE SODIUM 116

Estring 311

Estrogel 210

ESTROGENS, CONJUGATED 211

ESTROGENS, CONJUGATED VAGINAL 311

ESTROPIPATE 210

Estropipate 210

Estrostep Fe 168

ESZOPICLONE 237

ETANERCEPT 15

ETHACRYNIC ACID 196


ETHAMBUTOL HCL 102

ETHIONAMIDE 103

ETHOSUXIMIDE 65

ETHOTOIN 65

ETHYNODIOL DIACET & ETH ESTRAD 160,161,164

ETIDRONATE DISODIUM 197

Etidronate Disodium 197

ETODOLAC 12,13

ETONOGESTREL 167

ETONOGESTREL-ETHINYL ESTRADIOL 164,165

ETOPOSIDE 118

Etoposide 118

ETRAVIRINE 139

Eucrisa 189

Eurax 190

Evamist 210

Evenity 204

EverlyWell Covid-19 Home Test 193

EVEROLIMUS 111

EVEROLIMUS (IMMUNOSUPPRESSANT) 257

EVOLOCUMAB 93

Evotaz 135

Evrysdi 264

Exelderm 187

EXEMESTANE 115

EXENATIDE 78

Exkivity 108

Exoderm 178

Extavia 286

EXTERNAL VEHICLES 276

EZETIMIBE 92

Ezetimibe-Rosuvastatin 92

EZETIMIBE-ROSUVASTATIN CALCIUM 92

EZETIMIBE-SIMVASTATIN 92

FFagron LS Plus 279

Fagron Supreme 279

FAMCICLOVIR 144

FAMOTIDINE 301

Fanapt 127

Fanapt Titration Pack 127

Farxiga 80

Farydak 109

Fasenra 48

Fasenra Pen 48

FEBUXOSTAT 218

FELBAMATE 63,64

Felbatol 64

FELODIPINE 149

FemCap 240

Femhrt 207

Femring 311

FENOFIBRATE 89,90

FENOFIBRATE MICRONIZED 89,90

FENOFIBRIC ACID 90

Fenofibric Acid 90

FENOPROFEN CALCIUM 13

Fenoprofen Calcium 13

FENTANYL 20,30,31

FENTANYL CITRATE 18,19,20,21,22,23

fentaNYL Citrate 20,21,22

FERRIC CITRATE 215

Ferriprox 84

Ferriprox Twice-A-Day 84

FESOTERODINE FUMARATE 303,304

Fetzima 71

Fetzima Titration 71

FIDAXOMICIN 240

FILGRASTIM-AAFI 234

FILGRASTIM-AYOW 234,235

FILGRASTIM-SNDZ 235

FINASTERIDE 216

FINGOLIMOD HCL 289

First-Lansoprazole 302

First-Omeprazole 302

Fitalite 279

Flarex 271

Flavor Sweet 276

FLAVOXATE HCL 304

FLECAINIDE ACETATE 44

Flovent Diskus 49


Flovent HFA 50

Flowflex COVID-19 Ag Home Test 193

Fluad 306

Fluad Quadrivalent 306

Fluarix Quadrivalent 306

Flublok 306

Flublok Quadrivalent 307

Flucelvax Quadrivalent 307

FLUCONAZOLE 87

FLUCYTOSINE 86

FLUDROCORTISONE ACETATE 172

Flulaval Quadrivalent 307

FluMist Quadrivalent 307

Flunisolide 263

FLUNISOLIDE (NASAL) 263

FLUOCINOLONE ACETONIDE 184,185

FLUOCINOLONE ACETONIDE (OTIC) 273

FLUOCINONIDE 185

FLUOCINONIDE EMULSIFIED BASE 185

FLUORESCEIN W/ PROPARACAINE 268,269

FLUOROMETHOLONE (OPHTH) 271

FLUOROMETHOLONE ACETATE 271

Fluoroplex 179

Fluorouracil 179

FLUOROURACIL (TOPICAL) 179

FLUOXETINE HCL 68

FLUoxetine HCl 68

FLUOXETINE HCL (PMDD) 288

FLUoxetine HCl (PMDD) 288

FLUPHENAZINE DECANOATE 131

FLUPHENAZINE HCL 131

FluPHENAZine HCl 131

Flura-Drops 252

FLURANDRENOLIDE 184,185,186

FLURAZEPAM HCL 236

Flurazepam HCl 236

FLURBIPROFEN 13

Flurbiprofen 13

FLURBIPROFEN SODIUM 269

Flurbiprofen Sodium 269

FLUTAMIDE 103

Flutamide 103

FLUTICASONE FUROATE (INHALATION) 48,49

FLUTICASONE FUROATE-VILANTEROL 44

FLUTICASONE PROPIONATE 183,185

FLUTICASONE PROPIONATE (INHALATION) 49

FLUTICASONE PROPIONATE (NASAL) 263,264

FLUTICASONE PROPIONATE HFA 50

FLUTICASONE-SALMETEROL 45

Fluticasone-Salmeterol 45

FLUTICASONE-UMECLIDINIUM-VILANTEROL 45

FLUVASTATIN SODIUM 90,91

Fluvirin 307

FLUVOXAMINE MALEATE 68,69

Fluzone High-Dose 307

Fluzone High-Dose Quadrivalent 307

Fluzone Quadrivalent 307,308

FML 271

FML Forte 271

Foamil 276

FOLIC ACID 233

Follistim AQ 203

FOLLITROPIN BETA 203

FONDAPARINUX SODIUM 54

Food Color Blue 276

Forfivo XL 67

FORMALDEHYDE 134

Formaldehyde 134

FORMOTEROL FUMARATE 46

Forteo 203

Fosamax Plus D 197,198

FOSAMPRENAVIR CALCIUM 138

FOSFOMYCIN TROMETHAMINE 39

FOSINOPRIL SODIUM 94

FOSINOPRIL SODIUM &


Fosrenol 215

FOSTEMSAVIR TROMETHAMINE 137

Fotivda 112

Fragmin 54

FreeStyle Flash System 241

FreeStyle Freedom 241


FreeStyle Freedom Lite 241

FreeStyle InsuLinx System 242

FreeStyle InsuLinx Test 192

FreeStyle Lancets 242

FreeStyle Libre 14 Day Reader 242

FreeStyle Libre 14 Day Sensor 242

FreeStyle Libre 2 Reader 242

FreeStyle Libre 2 Sensor 242

FreeStyle Libre Reader 242

FreeStyle Libre Sensor System 242

FreeStyle Lite 242

FreeStyle Lite Test 192

FreeStyle Sidekick II 242

FreeStyle System 242

FreeStyle Test 192

FreeStyle Unistick II Lancets 242

FREMANEZUMAB-VFRM 250

FROVATRIPTAN SUCCINATE 251

Fulphila 233

FUROSEMIDE 196

Furosemide 196

Fuzeon 137

Fycompa 54,55

GGABAPENTIN 57,60

Gabitril 64,65

GALANTAMINE HYDROBROMIDE 284

Galantamine Hydrobromide 284

GALCANEZUMAB-GNLM 250

GANCICLOVIR OPHTHALMIC 268

GANIRELIX ACETATE 199

Gardasil 9 308

GATIFLOXACIN (OPHTH) 268

GaviLyte-C 238

Gavreto 113

Gelnique 303

Gelnique Pump 303

GEMFIBROZIL 90

Generess FE 160

Genotropin 199,200

Genotropin MiniQuick 200

Gentak 268

GENTAMICIN SULFATE 8

GENTAMICIN SULFATE (OPHTH) 268

GENTAMICIN SULFATE (TOPICAL) 177

GENTAMICIN-PREDNISOLONE ACETATE 270

Genvoya 135

Giazo 214

Gilenya 289

Gilotrif 108

Glassia 290

GLATIRAMER ACETATE 285

GLECAPREVIR-PIBRENTASVIR 143

Gleostine 118,119

GLIMEPIRIDE 81

GLIPIZIDE 82

GLIPIZIDE-METFORMIN HCL 81

GlucaGen Diagnostic 191

GlucaGen HypoKit 74

GLUCAGON 74

GLUCAGON (RDNA) 74

Glucagon Emergency 74

GLUCAGON HCL (DIAGNOSTIC) 191

Glucagon HCl (Diagnostic) 191

GLUCAGON HCL (RDNA) 74

GLUCAGON HCL RDNA (DIAGNOSTIC) 191

GLUCOSE BLOOD 192

GLYBURIDE 82

GLYBURIDE MICRONIZED 82

GLYBURIDE-METFORMIN 81

GLYCINE (GU IRRIGANT) 217

GLYCOPYRROLATE 302,303

Glycopyrrolate 302

Glyxambi 80

GOLIMUMAB 9

Golytely 238

GOSERELIN ACETATE 118

GRANISETRON 85

GRANISETRON HCL 85

Granix 234

GRISEOFULVIN MICROSIZE 86


GRISEOFULVIN ULTRAMICROSIZE 87

GUAIFENESIN-CODEINE 172,173

GUANFACINE HCL 99

GUANFACINE HCL (ADHD) 2

GUANIDINE HCL 102

Guanidine HCl 102

GUSELKUMAB 181

Gvoke HypoPen 1-Pack 74

Gvoke HypoPen 2-Pack 74

Gvoke Kit 74

Gvoke PFS 74

Gynazole-1 310

HHaegarda 230

HAEMOPHILUS B POLYSAC CONJ VAC 304,305

Haldol 129

HALOBETASOL PROPIONATE 185

HALOPERIDOL 129

HALOPERIDOL DECANOATE 129

HALOPERIDOL LACTATE 129

Havrix 308

Helixate FS 223

Hemlibra 229

Hemofil M 223

Heparin (Porcine) in NaCl 52,53

HEPARIN (PORCINE) IN SODIUM CHLORIDE 52,53

Heparin Lock Flush 53

HEPARIN SOD (PORCINE) IN D5W 53

Heparin Sod (Porcine) in D5W 53

HEPARIN SODIUM (PORCINE) 53

HEPARIN SODIUM (PORCINE) LOCK FLUSH 53

HEPARIN SODIUM (PORCINE) LOCK FLUSH &

NACL LOCK FLUSH 53

HEPATITIS A (INACTIVATED)-HEPATITIS B

(RECOMBINANT) VACCINES 305

HEPATITIS A VACCINE 308,310

HEPATITIS B VACCINE (RECOMB) 306,309

HEPATITIS B VACCINE 3-ANTIGEN

RECOMBINANT 309

HEPATITIS B VACCINE RECOMBINANT

ADJUVANTED 308

Heplisav-B 308

Hexalen 103

Hiberix 304

HISTRELIN ACETATE 118

Hizentra 274

Homatropaire 266

HOMATROPINE HBR 266

HumaLOG 76

HumaLOG Junior KwikPen 76

HumaLOG KwikPen 76

HumaLOG Mix 50/50 77

HumaLOG Mix 50/50 KwikPen 77

HumaLOG Mix 75/25 77

HumaLOG Mix 75/25 KwikPen 77

HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT

RECOMBINANT VACCINE 308

Humate-P 223

Humira 8

Humira Pediatric Crohns Start 9

Humira Pen 9

Humira Pen-CD/UC/HS Starter 9

Humira Pen-Pediatric UC Start 9

Humira Pen-Ps/UV/Adol HS Start 9

Humira Pen-Psor/Uveit Starter 9

HumuLIN 70/30 77

HumuLIN 70/30 KwikPen 77

HumuLIN N 77

HumuLIN N KwikPen 77

HumuLIN R 77

HumuLIN R U-500 (CONCENTRATED) 77

HumuLIN R U-500 KwikPen 77

Hycamtin 120

Hycodan 172

HYDRALAZINE HCL 101


HYDROCODONE BITARTRATE 22,32

HYDROcodone Bitartrate ER 22

HYDROCODONE BITARTRATE-HOMATROPINE

METHYLBROMIDE 172


HYDROCODONE POLISTIREX-

CHLORPHENIRAMINE POLISTIREX 174

HYDROCODONE W/ HOMATROPINE 172

HYDROCODONE-ACETAMINOPHEN 17,18

HYDROCODONE-IBUPROFEN 18

Hydrocodone-Ibuprofen 18

HYDROCORTISONE 170,171

HYDROCORTISONE & SALICYLIC ACID-SULFUR &

SHAMPOO 191

HYDROCORTISONE (INTRARECTAL) 36

HYDROCORTISONE (RECTAL) 36,37

HYDROCORTISONE (TOPICAL) 183,185,186

HYDROCORTISONE ACETATE (INTRARECTAL) 36

HYDROCORTISONE ACETATE (RECTAL) 36,37

HYDROCORTISONE ACETATE W/ PRAMOXINE 36

HYDROCORTISONE BUTYRATE 185,186

Hydrocortisone Butyrate 185,186

HYDROCORTISONE BUTYRATE HYDROPHILIC

LIPO BASE 185

HYDROCORTISONE VALERATE 186

HYDROCORTISONE W/ACETIC ACID 273

HYDROCORTISONE-PRAMOXINE-

CHLOROXYLENOL 190

HYDROMORPHONE HCL 22,23

HYDROPHILIC OINTMENT 280

HYDROXOCOBALAMIN ACETATE 231

Hydroxocobalamin Acetate 231

HYDROXYAMPHETAMINE-TROPICAMIDE 268

HYDROXYCHLOROQUINE SULFATE 101

Hydroxychloroquine Sulfate 101

HYDROXYprogesterone Caproate 120

HYDROXYPROGESTERONE CAPROATE 283

HYDROXYPROGESTERONE CAPROATE

(ANTINEOPLASTIC) 120

HYDROXYUREA 115

HYDROXYUREA (SICKLE CELL ANEMIA) 231

HYDROXYZINE HCL 41

HYDROXYZINE PAMOATE 41

HydrOXYzine Pamoate 41

HYOSCYAMINE SULFATE 301

HyperSal 173

Hyqvia 274

IIBANDRONATE SODIUM 198

Ibrance 115,116

IBREXAFUNGERP CITRATE 86

IBRUTINIB 107

IBUPROFEN 13

ICATIBANT ACETATE 229,230

Iclusig 105,106

ICOSAPENT ETHYL 89

ID NOW COVID-19 193

IDELALISIB 119

Idelvion 224

IHealth COVID-19 Rapid Test 193

Ilaris 12

Ilevro 269

ILOPERIDONE 127

IMATINIB MESYLATE 106

Imbruvica 107

IMIPRAMINE HCL 72

IMIPRAMINE PAMOATE 72

IMIQUIMOD 188

IMMUNE GLOBULIN (HUMAN)

SUBCUTANEOUS 273,274

IMMUNE GLOBULIN (HUMAN)-HYALURONIDASE

(HUMAN RECOMBINANT) 274

Imovax Rabies 308

Impavido 37

INCLISIRAN SODIUM 93

Increlex 202

Incruse Ellipta 47

INDACATEROL MALEATE 46

INDAPAMIDE 197

Inderal XL 147

INDINAVIR SULFATE 138

INDOMETHACIN 13

Infanrix 300

INFIGRATINIB PHOSPHATE 109

INFLUENZA VIRUS VAC RECOMB

HEMAGGLUTININ (HA) QUADRIVALENT 307


INFLUENZA VIRUS VAC SPLIT HIGH-DOSE QUAD

PRESERVATIVE FREE 307

INFLUENZA VIRUS VACC TYPES A & B SURF

ANTIGEN ADJUVANT QUAD 306

INFLUENZA VIRUS VACCINE LIVE

QUADRIVALENT 307

INFLUENZA VIRUS VACCINE RECOMBINANT

HEMAGGLUTININ (HA) 306

INFLUENZA VIRUS VACCINE SPLIT 305

INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE


INFLUENZA VIRUS VACCINE SPLIT


INFLUENZA VIRUS VACCINE SPLIT

QUADRIVALENT 306,307,308

INFLUENZA VIRUS VACCINE TISSUE-CULTURED

SUBUNIT QUADRIVALENT 307

INFLUENZA VIRUS VACCINE TYPES A & B

SURFACE ANTIGEN 307

INFLUENZA VIRUS VACCINE TYPES A & B

SURFACE ANTIGEN ADJUVANT 306

INJECTION DEVICE 245,247

INJECTION DEVICE FOR INSULIN 245

Inlyta 120

InnoPran XL 147

Inqovi 114

INSULIN DEGLUDEC 78

INSULIN DEGLUDEC-LIRAGLUTIDE 79

INSULIN DETEMIR 78

INSULIN GLARGINE 76,77

INSULIN GLARGINE-LIXISENATIDE 79

INSULIN INFUSION DISPOSABLE PUMP 244

INSULIN LISPRO 76,77

Insulin Lispro 77

Insulin Lispro (1 Unit Dial) 77

Insulin Lispro Junior KwikPen 77

Insulin Lispro Prot & Lispro 77

INSULIN LISPRO PROTAMINE & LISPRO 77

INSULIN NPH (HUMAN) (ISOPHANE) 77

INSULIN NPH ISOPHANE & REG (HUMAN) 77

INSULIN PEN NEEDLE 245,246,247

INSULIN REGULAR (HUMAN) 77

INSULIN SYRINGE/NEEDLE U-100 245,246,247

INSULIN SYRINGE/NEEDLE U-500 245

INSULIN SYRINGES (DISPOSABLE) 246

Intelence 139

InteliSwab COVID-19 Rapid Test 193

INTERFERON ALFA-2B 115

INTERFERON BETA-1A 286,287

INTERFERON BETA-1B 286

Intron A 115

Invega Hafyera 127

Invega Sustenna 127,128

Invega Trinza 128

Invirase 138

Iodoflex 134

IODOQUINOL-HC 178

Iodosorb 134

Iopidine 270

Ipol 308

IPRATROPIUM BROMIDE 47

IPRATROPIUM BROMIDE (NASAL) 263

IPRATROPIUM BROMIDE HFA 47

IPRATROPIUM-ALBUTEROL 45

IRBESARTAN 98

IRBESARTAN-HYDROCHLOROTHIAZIDE 97

ISAVUCONAZONIUM SULFATE 87

Isentress 137

Isentress HD 137

ISOCARBOXAZID 67

ISONIAZID 102

Isoniazid 102

ISONIAZID & RIFAMPIN 102

ISONIAZID-RIFAMPIN W/ PYRAZINAMIDE 102

ISOSORBIDE DINITRATE 39,40

Isosorbide Dinitrate ER 40

ISOSORBIDE DINITRATE-HYDRALAZINE HCL 152

ISOSORBIDE MONONITRATE 40

ISOTRETINOIN 175,176,177

ISOXSUPRINE HCL 152,153

Isoxsuprine HCl 152

ISRADIPINE 149,150


Isturisa 198

ITRACONAZOLE 87

IVABRADINE HCL 155

IVACAFTOR 291

IVERMECTIN 37

IVERMECTIN (ROSACEA) 189

IXEKIZUMAB 181

Ixiaro 308

Ixinity 224

JJ-Tip Kit w/Vial Adapters 245

Jakafi 117

Janssen COVID-19 Vaccine 308

Janumet 75

Janumet XR 75

Januvia 75

JAPANESE ENCEPHALITIS VACCINE INACTIVATED

ADSORBED 308

Jardiance 80

Jentadueto 76

Jentadueto XR 76

Jivi 224

Juluca 135

Juxtapid 92

Jynarque 204,205

KK-Phos 253

K-Phos No 2 218

K-Tab 253

Kaletra 135

Kalydeco 291

Katerzia 150

Keppra 57

Keppra XR 57,58

Keralyt Scalp 188

Kesimpta 287

KETOCONAZOLE 87

KETOCONAZOLE (TOPICAL) 187

KETOPROFEN 13

Ketoprofen 13

Ketoprofen ER 13

KETOROLAC TROMETHAMINE 13,14

KETOROLAC TROMETHAMINE (OPHTH) 269

Khedezla 71

Kineret 12

Kinrix 300

Kloxxado 84

Koate 225

Koate-DVI 225

Kogenate FS 225

Kogenate FS Bio-Set 225

Kombiglyze XR 76

Korlym 79

Koselugo 110

Kovaltry 225,226

KRISGEL 100 279

Krisgel 100 279

Kroger HealthPro Lancet 26G 242

Kroger Lancets 242

Kroger Lancets 21G 242

Kroger Lancets Micro Thin 33G 242

Kroger Lancets Super Thin 243

Kroger Lancets Thin 243

Kroger Lancets Thin 26G 243

Kroger Lancets UltraThin 30G 243

Kyleena 167

Kynmobi 123,124

Kynmobi Titration Kit 124

LLABETALOL HCL 146

LACOSAMIDE 58,63

Lacrisert 264

LACTATED RINGER'S (IRRIGATION) 257

LACTIC ACID (AMMONIUM LACTATE) 187

LACTULOSE 239

Lactulose 239

LACTULOSE (ENCEPHALOPATHY) 214

LaMICtal 58

LaMICtal Starter 58


LaMICtal XR 58,59

LAMIVUDINE 141

LAMIVUDINE (HBV) 142

LAMIVUDINE-TENOFOVIR DISOPROXIL

FUMARATE 135,136

LAMIVUDINE-ZIDOVUDINE 136

LAMOTRIGINE 58,59,61,62

Lampit 38

LANCET DEVICES 243

LANCETS 241,242,243,244

LANCETS MISC. 243

LANOLIN ANHYDROUS 279

Lanolin Anhydrous 279

LANSOPRAZOLE 302

LANTHANUM CARBONATE 215

Lantus 77

Lantus SoloStar 77

LAPATINIB DITOSYLATE 112

LASMIDITAN SUCCINATE 252

Lastacaft 267

LATANOPROST 272

Latuda 126

Lavare Wound Wash 191

Lazanda 23

LECITHIN 264

Lecithin 264

LEDIPASVIR-SOFOSBUVIR 143

Ledipasvir-Sofosbuvir 143

LEFLUNOMIDE 15

LEMBOREXANT 238

LENALIDOMIDE 255,256

LENVATINIB MESYLATE 120,121

Lenvima (10 MG Daily Dose) 120






Leqvio 93

LETROZOLE 115

LEUCOVORIN CALCIUM 116

Leukeran 118

LEUPROLIDE ACETATE 117

LEUPROLIDE ACETATE & NORETHINDRONE

ACETATE 202

LEUPROLIDE ACETATE (3 MONTH) 117

LEUPROLIDE ACETATE (4 MONTH) 117,118

LEUPROLIDE ACETATE (6 MONTH) 117,118

LEUPROLIDE ACETATE (CPP) 202

LEUPROLIDE ACETATE (CPP) (3 MONTH) 202

LEVALBUTEROL HCL 47

LEVALBUTEROL TARTRATE 47

Levalbuterol Tartrate 47

Levemir 78

Levemir FlexTouch 78

LEVETIRACETAM 57,58,59,60,61

LEVOBUNOLOL HCL 265

Levobunolol HCl 265

LEVOCARNITINE (METABOLIC MODIFIERS) 198

LEVOCETIRIZINE DIHYDROCHLORIDE 88

LEVOFLOXACIN 211

LEVOFLOXACIN (OPHTH) 268

LEVOMILNACIPRAN HCL 71

LEVONORGESTREL & ETH

ESTRADIOL 158,159,160,161,163,164

LEVONORGESTREL (IUD) 167

LEVONORGESTREL-ETH ESTRADIOL

(TRIPHASIC) 168,169

LEVONORGESTREL-ETHINYL ESTRADIOL 164

LEVONORGESTREL-ETHINYL ESTRADIOL (91-

DAY) 165,166

LEVONORGESTREL-ETHINYL ESTRADIOL

(CONTINUOUS) 165

LEVONORGESTREL-ETHINYL ESTRADIOL-

FERROUS BISGLYCINATE 159

LEVOTHYROXINE SODIUM 294,295,296,297,298,299

Levothyroxine Sodium 295,296

Lexiva 138

LIDOCAINE 189

LIDOCAINE HCL 189

Lidocaine HCl 258

LIDOCAINE HCL (MOUTH-THROAT) 258


LIDOCAINE HCL (OPHTH) 269

Lidocaine HCl Urethral/Mucosal 189

LIDOCAINE-HYDROCORTISONE ACETATE

(RECTAL) 36

LIDOCAINE-PRILOCAINE 191

LIDOCAINE-TETRACAINE 191

LIFITEGRAST 266

Liletta (52 MG) 167

LINACLOTIDE 213

LINAGLIPTIN 75

LINAGLIPTIN-METFORMIN HCL 76

LINDANE 190

Lindane 190

LINEZOLID 39

Linzess 213

Liopen Absorption Enhancing 279

LIOTHYRONINE SODIUM 297

LIOTRIX (T3-T4) 298

Lipo Cream Base 279

Lipocream Base 279

Lipolayer 279

Lipopen Ultra Base 279

LipoSomal Heavy 279

LipoSomal Regular 279

Lipozyme 279

LIRAGLUTIDE 79

LISDEXAMFETAMINE DIMESYLATE 4,5

LISINOPRIL 94,95

LISINOPRIL & HYDROCHLOROTHIAZIDE 96

LITHIUM 125

Lithium 125

LITHIUM CARBONATE 125,126

Lithium Carbonate 125

Lithobid 126

Lithostat 218

Livtencity 142

Lo Loestrin Fe 158

Lodosyn 122

LODOXAMIDE TROMETHAMINE 267

Lokelma 258

LOMITAPIDE MESYLATE 92

LOMUSTINE 118,119

Lonsurf 114,115

LOPERAMIDE HCL 83

LOPINAVIR-RITONAVIR 135,136

LORAZEPAM 43

Lortab 18

LOSARTAN POTASSIUM 98

LOSARTAN POTASSIUM &


LoSeasonique 166

Lotemax 271

LOTEPREDNOL ETABONATE 271

LOTEPREDNOL ETABONATE-TOBRAMYCIN 271

LOVASTATIN 91

LOXAPINE SUCCINATE 131

LUBIPROSTONE 212,213

Lubiprostone 212,213

Lucira COVID-19 All-In-One 193

LUMACAFTOR-IVACAFTOR 291

Lumakras 110

LUMATEPERONE TOSYLATE 126

Lumigan 272

Lupaneta Pack 202

Lupkynis 255

Lupron Depot (1-Month) 117




Lupron Depot-Ped (1-Month) 202

Lupron Depot-Ped (3-Month) 202

LURASIDONE HCL 126

Lynparza 119

Lyra Direct SARS-CoV-2 Assay 193

Lyra SARS-CoV-2 Assay 193

Lyrica 60

Lysodren 103

MM-M-R II 305

M-Natal Plus 260

M-Vit 260


MACITENTAN 154

MAFENIDE ACETATE 183

Magellan Insulin Safety Syr 245

MALATHION 190

MANNITOL (GU IRRIGANT) 217

MAPROTILINE HCL 67

Maprotiline HCl 67

Marathon Medical Pentips 246

MARAVIROC 136

MARIBAVIR 142

Marplan 67

Matulane 115

Mavenclad (10 Tabs) 285







Mavyret 143

Maxidex 271

Mayzent 289,290

Mayzent Starter Pack 290

MEASLES, MUMPS & RUBELLA VIRUS

VACCINES 305

MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS

VACCINES 305

MEBENDAZOLE 37

MECAMYLAMINE HCL 99

MECASERMIN 202

MECHLORETHAMINE HCL (TOPICAL) 179

MECLIZINE HCL 86

MECLOFENAMATE SODIUM 14

Meclofenamate Sodium 14

Mediderm 279

Medrol 171

MEDROXYPROGESTERONE ACETATE 283

MEDROXYPROGESTERONE ACETATE

(CONTRACEPTIVE) 167

MEFENAMIC ACID 14

MEFLOQUINE HCL 101

MEGESTROL ACETATE 120

MEGESTROL ACETATE (APPETITE) 283

Mekinist 110

Mektovi 110

MELOXICAM 14

MELPHALAN 118

MEMANTINE HCL 287

MEMANTINE HCL-DONEPEZIL HCL 283

Menactra 304

Menest 210

MENINGOCOCCAL (A,C,Y&W-135)

OLIGOSACCHARIDE CONJUGATE VAC 305

MENINGOCOCCAL (A,C,Y&W-135) POLYSACCH

DIPHTH CONJ VACCINE 304

MENINGOCOCCAL (A,C,Y&W-135) POLYSACCH

TETANUS CONJ VACCINE 305

MENINGOCOCCAL GROUP B VACCINE

(RECOMBINANT) 305

MENINGOCOCCAL VAC GROUP B (RECOMBANT

OMV ADJUVANTED) 304

Menopur 203

Menostar 210

MENOTROPINS 203

MenQuadfi 305

Menveo 305

MEPOLIZUMAB 48

MEPROBAMATE 41

MERCAPTOPURINE 104

MESALAMINE 214

MESALAMINE W/ CLEANSER 214

MESNA 120

Mesnex 120

METAPROTERENOL SULFATE 47

Metaproterenol Sulfate 47

METAXALONE 262

Metaxalone 262

METFORMIN HCL 74

METHACHOLINE CHLORIDE 192

METHADONE HCL 24

Methadone HCl 24

Methadose 24


Methadose Sugar-Free 24

METHAZOLAMIDE 195

METHENAMINE HIPPURATE 39

METHENAMINE-HYOSC-METHYLENE BLUE-SOD

PHOS-PHENYL SAL 39

METHIMAZOLE 294

METHOCARBAMOL 262

METHOTREXATE (ANTIRHEUMATIC) 10,11

METHOTREXATE SODIUM 104

Methotrexate Sodium 104

METHOXSALEN RAPID 180,181

Methoxsalen Rapid 180

METHOXY POLYETHYLENE GLYCOL-EPOETIN

BETA 232,233

METHSCOPOLAMINE BROMIDE 303

METHSUXIMIDE 65

METHYCLOTHIAZIDE 197

Methyclothiazide 197

METHYLDOPA 99

Methyldopa 99

METHYLDOPA & HYDROCHLOROTHIAZIDE 96

Methyldopa-Hydrochlorothiazide 96

METHYLERGONOVINE MALEATE 273

Methylin 6

METHYLPHENIDATE 5

METHYLPHENIDATE HCL 6,7,8

Methylphenidate HCl ER 7

METHYLPREDNISOLONE 171

METHYLPREDNISOLONE SOD SUCC 171

METHYLTESTOSTERONE 35

METIPRANOLOL 265

Metipranolol 265

METOCLOPRAMIDE HCL 213

Metoclopramide HCl 213

METOLAZONE 197

METOPROLOL & HYDROCHLOROTHIAZIDE 100

METOPROLOL SUCCINATE 146

METOPROLOL TARTRATE 146

Metoprolol-Hydrochlorothiazide 100

METRONIDAZOLE 37

METRONIDAZOLE (TOPICAL) 189,190

METRONIDAZOLE VAGINAL 310

MEXILETINE HCL 43

MICONAZOLE (MOUTH-THROAT) 259

Miconazole-Zinc Oxide-Petrolat 178

MICONAZOLE-ZINC OXIDE-WHITE

PETROLATUM 178,179

Microchamber 249

Microcyn Skin and Wound 191

Microlet Lancets 243

Microspacer 249

MIDAZOLAM (ANTICONVULSANT) 55

MIDAZOLAM HCL 236,237

MIDODRINE HCL 311

MIFEPRISTONE (HYPERGLYCEMIA) 79

MIGLITOL 73

MILNACIPRAN HCL 284,285

MILTEFOSINE 37

Minastrin 24 Fe 162

Minivelle 210

MINOCYCLINE HCL 292,293

MINOXIDIL 101

MIRABEGRON 304

Mircera 232,233

Mircette 158

Mirena (52 MG) 167

MIRTAZAPINE 66,67

Mirvaso 190

MISOPROSTOL 303

MITOTANE 103

MOBOCERTINIB SUCCINATE 108

MODAFINIL 7

Moderiba (1200 MG Pack) 143



Moderna COVID-19 Vac (Booster) 308

Moderna COVID-19 Vaccine 309

MOEXIPRIL HCL 94

MOEXIPRIL-HYDROCHLOROTHIAZIDE 96

MOLINDONE HCL 131

Molindone HCl 131

MOLNUPIRAVIR 144


Molnupiravir 144

MOMETASONE FUROATE 186

MOMETASONE FUROATE (INHALATION) 49

MOMETASONE FUROATE (NASAL) 264

MOMETASONE FUROATE-FORMOTEROL

FUMARATE DIHYDRATE 45

Monoclate-P 226

Monoject Insulin Syringe 246

Monoject Introducer Needle 246

Monoject Magellan Safety Ndl 246

Monoject Magellan Syringe 246,247

Monoject Syringe 247

Monoject Ultra Comfort Syringe 247

MONOMETHYL FUMARATE 287

Mononine 226

MONTELUKAST SODIUM 48

MORPHINE SULFATE 19,24,25,26,27

Morphine Sulfate 25

MORPHINE SULFATE BEADS 27

Morphine Sulfate ER 25,26,27

Morphine Sulfate ER Beads 27

Motegrity 212

Motofen 83

Movantik 215

MOXIFLOXACIN HCL 212

Moxifloxacin HCl (2X Day) 268

MOXIFLOXACIN HCL (OPHTH) 268

Mozobil 231

Multaq 44

MultiBase 280

MUPIROCIN 177

MUPIROCIN CALCIUM 263

MYCOPHENOLATE MOFETIL 256

MYCOPHENOLATE SODIUM 256

MyLab Box Covid-19 Testing 193

Myleran 103

Myrbetriq 304

Mytesi 83

NNABUMETONE 14

NADOLOL 147

NADOLOL & BENDROFLUMETHIAZIDE 100

Nadolol-Bendroflumethiazide 100

NAFTIFINE HCL 178

Naftifine HCl 178

Naftin 178

NALDEMEDINE TOSYLATE 215

NALOXEGOL OXALATE 215

NALOXONE HCL 84,85

Naloxone HCl 84

NALTREXONE 85

NALTREXONE HCL 85

Namenda XR Titration Pack 287

Namzaric 283

NAPROXEN 12,14

NAPROXEN SODIUM 14

NARATRIPTAN HCL 251

Narcan 85

Natacyn 268

NATAMYCIN 268

Natazia 166

NATEGLINIDE 79

Natesto 35

Nature-Throid 297

Nayzilam 55

NEBIVOLOL HCL 146

Nebusal 173

NEDOCROMIL SODIUM (OPHTH) 267

NEEDLE (DISP) 16 G 245



NEEDLE (REUSABLE) 18 G 245,246

NEFAZODONE HCL 69

Nefazodone HCl 69

NELFINAVIR MESYLATE 139

Neo-Synalar 177

NEOMYCIN SULFATE 8

NEOMYCIN SULFATE-FLUOCINOLONE

ACETONIDE 177

NEOMYCIN-BACITRACIN ZN-POLYMYXIN 266

NEOMYCIN-COLISTIN-HC-THONZONIUM 272


NEOMYCIN-FLUOCINOLONE & EMOLLIENT 177

NEOMYCIN-POLYMY-DEXAMETH 270

Neomycin-Polymyxin B GU 216

NEOMYCIN-POLYMYXIN-GRAMICIDIN 267

Neomycin-Polymyxin-Gramicidin 267

NEOMYCIN-POLYMYXIN-HC 177

Neomycin-Polymyxin-HC 270

NEOMYCIN-POLYMYXIN-HC (OPHTH) 270

NEOMYCIN-POLYMYXIN-HC (OTIC) 272

NEOMYCIN/POLYMYXIN B GU 216

Neonatal Complete 260

NeoNatal Plus 260

NEPAFENAC 269

NERATINIB MALEATE 112

Nerlynx 112

NETARSUDIL DIMESYLATE 270

NETARSUDIL DIMESYLATE-LATANOPROST 269

NETUPITANT-PALONOSETRON 86

Neupro 124

Neurontin 60

Nevanac 269

NEVIRAPINE 139

Nevirapine 139

Nevirapine ER 139

NexAVAR 112

Nexletol 89

Nexlizet 89

Nexplanon 167

Nextstellis 162

NIACIN (ANTIHYPERLIPIDEMIC) 93

Niacor 93

NICARDIPINE HCL 150

NICOTINE 289

Nicotrol 289

Nicotrol NS 289

NIFEDIPINE 148,150

NIFURTIMOX 38

NILOTINIB HCL 106

NILUTAMIDE 103

NIMODIPINE 150

NINTEDANIB ESYLATE 292

NIRMATRELVIR-RITONAVIR 142

NISOLDIPINE 150

Nisoldipine ER 150

NITAZOXANIDE 38

NITISINONE 201

Nitro-Bid 40

Nitro-Dur 40

Nitro-Time 40

NITROFURANTOIN 39

NITROFURANTOIN MACROCRYSTAL 39

NITROFURANTOIN MONOHYD MACRO 39

NITROGLYCERIN 40,41

NitroMist 41

Niva-Plus 260

Nivestym 234

Nordipen 5 Injection Device 247

Norditropin FlexPro 200

NORELGESTROMIN-ETHINYL ESTRADIOL 164

NORETHIN ACET & ESTRAD-

FE 158,159,160,161,162,163

NORETHINDRONE & ETH

ESTRADIOL 158,159,162,163,164

NORETHINDRONE & ETHINYL ESTRADIOL-

FE 160,161,162,164

NORETHINDRONE (CONTRACEPTIVE) 167,168

NORETHINDRONE ACET & ETH

ESTRA 158,160,161,162

NORETHINDRONE ACETATE 283

NORETHINDRONE ACETATE-ETHINYL

ESTRADIOL 207


ESTRADIOL-FE 168,169


ESTRADIOL-FE FUM (BIPHASIC) 158

NORETHINDRONE-ETH ESTRADIOL

(TRIPHASIC) 168,169

NORGESTIMATE-ETHINYL

ESTRADIOL 160,162,163,164

NORGESTIMATE-ETHINYL ESTRADIOL

(TRIPHASIC) 168,169

NORGESTREL & ETHINYL ESTRADIOL 159,161,163


Norpace 43

Norpace CR 43

Norpramin 73

NORTRIPTYLINE HCL 73

Nortriptyline HCl 73

Norvir 138

Nourilite 280

Nourivan Antiox Base 280

Novacort 190

Novavax COVID-19 Vaccine 309

Novoeight 226

Noxafil 87

Noxi-K 280

Nplate 235

Nucala 48

Nucynta 27

Nucynta ER 27,28

Nuedexta 288

Nurtec 249

Nutropin AQ NuSpin 10 201



Nuvessa 310

Nuwiq 226,227

NYSTATIN 87

NYSTATIN (MOUTH-THROAT) 259

NYSTATIN (TOPICAL) 178

NYSTATIN-TRIAMCINOLONE 179

Nyvepria 234

OO-Cal FA 260

O-Cal Prenatal 260

OB Complete/DHA 260

OBETICHOLIC ACID 212

Obizur 227

Ocaliva 212

Occluvan 280

OCTREOTIDE ACETATE 205

Octreotide Acetate 205

Odefsey 136

ODEVIXIBAT 213,214

Odomzo 109

OFATUMUMAB (MS) 287

Ofev 292

OFLOXACIN 212

OFLOXACIN (OPHTH) 268

OFLOXACIN (OTIC) 272

Ogestrel 163

OIL BASE 276

OLANZAPINE 133

OLANZAPINE PAMOATE 133,134

OLAPARIB 119

OLMESARTAN MEDOXOMIL 98

OLMESARTAN MEDOXOMIL-AMLODIPINE-


OLMESARTAN MEDOXOMIL-


OLODATEROL HCL 47

OLOPATADINE HCL 267

OLOPATADINE HCL (NASAL) 263

OLSALAZINE SODIUM 214

Olumiant 10

OMALIZUMAB 46

OMEGA-3-ACID ETHYL ESTERS 89

OMEPRAZOLE 302

Omeprazole+Syrspend SF Alka 302

Omnaris 264

Omnibase 280

OmniPod 5 G6 Intro Kit 244

OmniPod 5 G6 Pods (Gen 5) 244

OmniPod 5 Pack 244

OmniPod Dash 5 Pack Pods 244

OmniPod Dash Intro Kit 244

OmniPod Dash System 244

OmniPod Starter 244

Omnipred 271

Omnitrope 201

Omnitrope Pen 5 Inj Device 247

On/Go Covid-19 Antigen Test 194

ONDANSETRON 85

ONDANSETRON HCL 85


One Vite Womens Plus 260

OneTouch Club Lancets Fine Pt 243

OneTouch Delica Lancets 30G 243

OneTouch Delica Lancets 33G 243

OneTouch Delica Lancing Dev 243

OneTouch Delica Plus Lancet30G 243

OneTouch Delica Plus Lancet33G 243

OneTouch Delica Plus Lancing 243

OneTouch FinePoint Lancets 243

OneTouch Ping Meter Remote 243

OneTouch SureSoft Lancing Dev 243

OneTouch Ultra 192

OneTouch Ultra 2 243

OneTouch Ultra Mini 243

OneTouch UltraLink 243

OneTouch UltraSoft Lancets 243

OneTouch Verio 192,244

OneTouch Verio Flex System 244

OneTouch Verio IQ System 244

OneTouch Verio Reflect 244

OneTouch Verio Sync System 244

Ongentys 125

Onglyza 75

OPICAPONE 125

OPIUM TINCTURE 83

Opsumit 154

OptiChamber Advantage-Lg Mask 249

OptiChamber Advantage-Med Mask 249

OptiChamber Advantage-Sm Mask 249

OptiChamber Diamond 249

OptiChamber Diamond-Lg Mask 249

OptiChamber Diamond-Md Mask 249

OptiChamber Diamond-Sm Mask 249

Ora-Blend 276

Ora-Blend SF 276

Ora-Plus 276

Ora-Sweet 277

Ora-Sweet SF 277

Oracit 217

ORAL VEHICLES 276,277

ORAL WOUND CARE PRODUCTS 259

Oravig 259

Orencia 15

Orencia ClickJect 15

Orenitram 153

Orfadin 201

Oriahnn 208

Orilissa 199

Orkambi 291

ORPHENADRINE CITRATE 262

Ortho Micronor 168

Ortho Tri-Cyclen (28) 169

Ortho Tri-Cyclen Lo 169

Ortho-Cyclen (28) 163

Ortho-Novum 1/35 (28) 163

Ortho-Novum 7/7/7 (28) 169

OSELTAMIVIR PHOSPHATE 145

OSILODROSTAT PHOSPHATE 198

OSIMERTINIB MESYLATE 108

OSPEMIFENE 204

Osphena 204

Otezla 15

Otrexup 10

Ovace Plus 181

Ovide 190

Ovidrel 203

OXANDROLONE 35

OXAPROZIN 14

OXAZEPAM 43

OXCARBAZEPINE 60,63

Oxervate 269

OXICONAZOLE NITRATE 187

Oxistat 187

Oxtellar XR 60

OXYBUTYNIN 303

OXYBUTYNIN CHLORIDE 303

OXYCODONE HCL 28,29

OxyCODONE HCl ER 29

OXYCODONE W/ ACETAMINOPHEN 32,33

OXYCODONE-ASPIRIN 33

Oxycodone-Aspirin 33

OXYCODONE-IBUPROFEN 33


Oxycodone-Ibuprofen 33

OxyCONTIN 29

OXYMETAZOLINE HCL (TOPICAL) 190

OXYMORPHONE HCL 29,30

OxyMORphone HCl ER 30

Oxytrol 303

OZANIMOD HCL 290

Ozempic (0.25 or 0.5 MG/DOSE) 78

Ozempic (1 MG/DOSE) 78

Ozempic (2 MG/DOSE) 78

PP-Siloxan DS 280

PALBOCICLIB 115,116

PALIPERIDONE 128

PALIPERIDONE PALMITATE 127,128

PALIVIZUMAB 273

Palynziq 203,204

Pancreaze 194,195

PANCRELIPASE (LIPASE-PROTEASE-

AMYLASE) 194,195

PANOBINOSTAT LACTATE 109

Panretin 179

Paragard Intrauterine Copper 165

PAREGORIC 83

Paregoric 83

Paremyd 268

PARICALCITOL 201

PAROMOMYCIN SULFATE 8

PAROXETINE HCL 69

PAROXETINE MESYLATE (VASOMOTOR) 290

Paser 102

PASIREOTIDE DIASPARTATE 205

PASIREOTIDE PAMOATE 205,206

PATIROMER SORBITEX CALCIUM 258

Paxlovid 142

Pazeo 267

PAZOPANIB HCL 113

PCCA Acacia Syrup Base 277

PCCA Aladerm Base 280

PCCA Anhydrous Lipoderm Base 280

PCCA Biopeptide Base 280

PCCA CoBase #1 280

PCCA Cosmetic HRT Base 280

PCCA Custom Lipo-Max 280

PCCA Lipoderm Base 280

PCCA Liposomic Base Dry 280

PCCA Liposomic Base Normal 280

PCCA Liposomic Base Oily 280

PCCA Liposomic Base Sensitive 280

PCCA MVC Base 280

PCCA NataCream 281

PCCA Polypeg Base 281

PCCA Pracasil TM-Plus Base 281

PCCA Sweet-SF 277

PCCA Vanishing Cream Base 281

PCCA Vanishing Cream Light 281

PCCA Vanpen Base 281

PCCA-Plus 277

PCE 240

Pediarix 300

Pedvax HIB 305

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD

SULFATE 238,239

PEG 3350-POTASSIUM CHLORIDE-SOD

BICARBONATE-SOD CHLORIDE 238,239

PEG Ointment Base 281

PEG-Prep 239

Peganone 65

Pegasys 143

Pegasys ProClick 143

PEGFILGRASTIM-APGF 234

PEGFILGRASTIM-BMEZ 235

PEGFILGRASTIM-CBQV 235

PEGFILGRASTIM-JMDB 233

PEGINTERFERON ALFA-2A 143

PEGINTERFERON ALFA-2B 143

PEGINTERFERON BETA-1A 286

PegIntron 143

PEGVALIASE-PQPZ 203,204

PEGVISOMANT 199

Pemazyre 108,109


PEMIGATINIB 108,109

PENCICLOVIR 182

PENcream 281

PenDerm 281

PENICILLAMINE 255

PENICILLIN V POTASSIUM 275

Penicillin V Potassium 275

PenSomal 281

Pentacel 300

PENTAMIDINE ISETHIONATE 37

Pentasa 214

PENTAZOCINE W/ NALOXONE 34

PenTips 247

PENTOSAN POLYSULFATE SODIUM 218

PENTOXIFYLLINE 230

PERAMPANEL 54,55

PERINDOPRIL ERBUMINE 94,95

PERMETHRIN 190

PERPHENAZINE 131,132

PERPHENAZINE-AMITRIPTYLINE 288

Perphenazine-Amitriptyline 288

Petrolatum White 281

PEXIDARTINIB HCL 113

Pfizer COVID-19 Vac-TriS 5-11y 309

Pfizer COVID-19 Vac-TriS 6m-4y 309

Pfizer-BioNT COVID-19 Vac-TriS 309

Pfizer-BioNTech COVID-19 Vacc 309

Pharmabase Heavy 281

Pharmacist Choice Lancets 244

PHENAZOPYRIDINE HCL 218

PHENELZINE SULFATE 67

PHENOBARBITAL 236

PHENYLEPHRINE HCL (MYDRIATIC) 266

Phenytek 65

PHENYTOIN 65

PHENYTOIN SODIUM EXTENDED 65

Phoslyra 215

Phospholine Iodide 266

PHYTONADIONE 312

Pifeltro 140

PILOCARPINE HCL 266

PILOCARPINE HCL (ORAL) 259

PIMECROLIMUS 189

PIMOZIDE 288

Pimozide 288

PINDOLOL 147

PIOGLITAZONE HCL 82

PIOGLITAZONE HCL-METFORMIN HCL 82

Piqray (200 MG Daily Dose) 119



PIRFENIDONE 292

PIROXICAM 14

PITOLISANT HCL 5

Pixel COVID-19 PCR Home Test 194

PLACEBO 277

Placebo #00 277

PLECANATIDE 212

Plegridy 286

Plegridy Starter Pack 286

PLERIXAFOR 231

PLO Gel - Mediflo 281

PLO Transdermal 281

PNEUMOCOCCAL 13-VALENT CONJUGATE

VACCINE 305


VACCINE 305


VACCINE 305

PNEUMOCOCCAL VAC POLYVALENT 305

Pneumovax 23 305

PNV Folic Acid + Iron 260

PNV Prenatal Plus Multivitamin 260

PNV Tabs 29-1 260

PNV-DHA+Docusate 262

Podocon 188

PODOFILOX 188

PODOPHYLLUM RESIN 188

POLIOVIRUS VACCINE, IPV 308

POLYETHYLENE GLYCOL 278,281

POLYETHYLENE GLYCOL 3350 239

POLYETHYLENE GLYCOL 8000 281


Polyethylene Glycol 8000 281

POLYMYXIN B-TRIMETHOPRIM 267

POMALIDOMIDE 110

Pomalyst 110

PONATINIB HCL 105,106

PONESIMOD 290

Ponvory 290

Ponvory Starter Pack 290

POSACONAZOLE 87

POT & SOD CITRATES W/CITRIC AC 217

POT PHOSPHATE MONOBASIC W/ SOD

PHOSPHATE DIBASIC & MONOBASIC 253

POTASSIUM & SODIUM ACID PHOSPHATES 218

POTASSIUM BICARBONATE 253

POTASSIUM CHLORIDE 253,254

Potassium Chloride ER 254

POTASSIUM CHLORIDE MICROENCAPSULATED

CRYSTALS ER 253,254

POTASSIUM CITRATE (ALKALINIZER) 217

POTASSIUM CITRATE-CITRIC ACID 217

POTASSIUM IODIDE (EXPECTORANT) 173

POTASSIUM PHOSPHATE MONOBASIC 253

Povidone-Iodine 268

POVIDONE-IODINE (OPHTH) 268

Pradaxa 54

PRALSETINIB 113

PRAMIPEXOLE DIHYDROCHLORIDE 124

PRAMLINTIDE ACETATE 73

Pramosone 190,191

Pramosone E 191

PRAMOXINE-HC 190,191

PRAMOXINE-HC EMOLLIENT BASE 191

PRASUGREL HCL 231

PRAVASTATIN SODIUM 91

PRAZIQUANTEL 37

PRAZOSIN HCL 99

Pred Forte 271

Pred Mild 271

Pred-G 270

Pred-G S.O.P. 270

PREDNICARBATE 186

Prednicarbate 186

PREDNISOLONE 171

PrednisoLONE 171

PrednisoLONE Acetate 271

PREDNISOLONE ACETATE (OPHTH) 271

PREDNISOLONE SODIUM PHOSPHATE 171

PrednisoLONE Sodium Phosphate 171,271

PREDNISOLONE SODIUM PHOSPHATE

(OPHTH) 271

PREDNISONE 171,172

PredniSONE 172

PredniSONE Intensol 172

Prefest 208

PREGABALIN 60,61

PREGABALIN (ONCE-DAILY) 288

Pregnyl 203

PreHevbrio 309

Premarin 211,311

PREMIUM LECITHIN ORGANOGEL BASE 281

Premphase 208

Prempro 208

PRENAT VIT W/ IRON CARBONYL-FE ASP GLYC-

FA-OMEGA FATTY ACID 260

PreNata 260

Prenatabs Rx 260

Prenatal 260

Prenatal 19 260

PRENATAL MV & MIN W/FE BISGLYC-FE PROT

SUCC-FA-CA-OMEGA 3 261

PRENATAL MV & MIN W/FE FUMARATE-FA-DHA262

Prenatal Plus 261

Prenatal Plus Iron 261

Prenatal Plus Vitamin/Mineral 261

PRENATAL VIT W/ DOCUSATE-FE FUMARATE-

FOLIC ACID 260,261

PRENATAL VIT W/ FE GLYCINE CYSTEINATE-FA-

OMEGA 3 FATTY ACIDS 259

PRENATAL VIT W/ FERROUS FUMARATE-FOLIC

ACID 259,260,261

PRENATAL VIT W/ IRON CARBONYL-FOLIC

ACID 260,261


Prenatal Vitamin Plus Low Iron 261

PRENATAL W/ VIT B2-B6-B12-CHOLECALCIFEROL-

FOLIC ACID 262

PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-

DHA 262

PRENATAL WITHOUT A VIT W/ FE FUM-IRON

POLYSACCH COMPLEX -FA 261

PRENATAL WITHOUT A VIT W/ FE FUMARATE-

FOLIC ACID 260

PRENATAL WITHOUT A W/ FE FUMARATE-L

METHYLFOLATE-FA-DHA 262

PrePLUS 261

PreTAB 261

PRETOMANID 102

Pretomanid 102

Prevnar 13 305

Prevnar 20 305

Prezcobix 136

Prezista 138,139

Priftin 102

PRIMAQUINE PHOSPHATE 101

Primaquine Phosphate 101

PRIMIDONE 61

Pro Comfort Pen Needles 247

PROBENECID 218

PROCARBAZINE HCL 115

PROCHLORPERAZINE 132

PROCHLORPERAZINE MALEATE 132

Procrit 233

Proctofoam HC 36

PROGESTERONE 283

PROGESTERONE (VAGINAL) 311

Prograf 257

Prolastin-C 291

Prolensa 270

Promacta 235

PROMETHAZINE & PHENYLEPHRINE 173

PROMETHAZINE HCL 88

PROMETHAZINE W/CODEINE 174

PROMETHAZINE-DM 173

Promethazine-DM 173

PROMETHAZINE-PHENYLEPHRINE-CODEINE 174

PROPAFENONE HCL 44

PROPANTHELINE BROMIDE 303

Propantheline Bromide 303

PROPARACAINE HCL 269

PROPRANOLOL & HYDROCHLOROTHIAZIDE 100

PROPRANOLOL HCL 147

Propranolol HCl 147

PROPRANOLOL HCL SUSTAINED-RELEASE

BEADS 147

Propranolol-HCTZ 100

PROPYLTHIOURACIL 294

ProQuad 305

Prostin E2 273

PROTRIPTYLINE HCL 73

Provida OB 261

Provocholine 192

PRUCALOPRIDE SUCCINATE 212

PRUSSIAN BLUE INSOLUBLE (FERRIC

HEXACYANOFERRATE II) 84

Pseudoeph-Chlorphen-Hydrocod 174

PSEUDOEPHED-BROMPHEN-DM 173

PSEUDOEPHED-CPM W/ HYDROCOD 174

Pulmicort Flexhaler 50

Pulmozyme 292

Purified Water 277

Purixan 104

PYRAZINAMIDE 102

PYRIDOSTIGMINE BROMIDE 102

QQbrelis 95

Qinlock 112

Qnasl 264

Qnasl Childrens 264

Quadracel 300

Quartette 166

QUAZEPAM 237

Quazepam 237

QUETIAPINE FUMARATE 130,131

QuickVue At-Home Covid-19 Test 194


QuickVue SARS Antigen Test 194

QuilliChew ER 7

Quillivant XR 8

QUINAPRIL HCL 95

QUINAPRIL-HYDROCHLOROTHIAZIDE 96

QUINIDINE GLUCONATE 43

QUINIDINE SULFATE 43

quiNIDine Sulfate 43

QUININE SULFATE 101

Qulipta 249

Qvar 50

Qvar RediHaler 50

RRabAvert 309

RABIES VACCINE, PCEC 309

RABIES VIRUS VACCINE, HDC 308

Radiogardase 84

RALOXIFENE HCL 204

RALTEGRAVIR POTASSIUM 137

RAMELTEON 238

RAMIPRIL 95

RANITIDINE HCL 302

RANOLAZINE 39

RASAGILINE MESYLATE 122

Rasuvo 11

Rebetol 143

Rebif 286

Rebif Rebidose 286,287

Rebif Rebidose Titration Pack 287

Rebif Titration Pack 287

Rebinyn 228

Recombinate 228

Recombivax HB 309

Recura 179

Red Yeast Rice 8

RED YEAST RICE EXTRACT 8

RediTrex 11

REGORAFENIB 112

Regranex 191

Rejuvacare Plus 281

Relenza Diskhaler 145

Releuko 234,235

Renacidin 217

REPAGLINIDE 79

Repatha 93

Repatha Pushtronex System 93

Repatha SureClick 93

Rescriptor 140

Resectisol 217

Restasis 269

Restasis Multidose 269

Retacrit 233

RETAPAMULIN 177

Retevmo 113

Retrovir 141

REVEFENACIN 48

Revlimid 256

Rexulti 133

Reyataz 139

Reyvow 252

Rheospray 276

Rhofade 190

Rhopressa 270

Ribasphere 143,144

Ribasphere RibaPak (1000 Pack) 144

Ribasphere Ribapak (1200 Pack) 144



RIBAVIRIN (HEPATITIS C) 143,144

Ridaura 12

RIFABUTIN 102

Rifamate 102

RIFAMPIN 103

RIFAPENTINE 102

Rifater 102

RIFAXIMIN 38

RILPIVIRINE HCL 139

RILUZOLE 264

RiMANTAdine HCl 144

RIMANTADINE HYDROCHLORIDE 144

RIMEGEPANT SULFATE 249


RINGER'S IRRIGATION 257

Rinvoq 10

RIOCIGUAT 153

RIPRETINIB 112

RISANKIZUMAB-RZAA 181

RISDIPLAM 264

RISEDRONATE SODIUM 198

RisperDAL Consta 128

RISPERIDONE 128,129

RisperiDONE 128

RISPERIDONE MICROSPHERES 128

RITONAVIR 138,139

RIVAROXABAN 52

RIVASTIGMINE 284

RIVASTIGMINE TARTRATE 284

Rixubis 228

RIZATRIPTAN BENZOATE 251

rocklatan 269

ROFLUMILAST 48

ROLAPITANT HCL 86

ROMIPLOSTIM 235

ROMOSOZUMAB-AQQG 204

ROPINIROLE HYDROCHLORIDE 124,125

ROSUVASTATIN CALCIUM 91

Rotarix 309

RotaTeq 309

ROTAVIRUS VACCINE, LIVE ORAL 309

ROTAVIRUS VACCINE, LIVE ORAL

PENTAVALENT 309

ROTIGOTINE 124

Rozlytrek 113

RUFINAMIDE 61

Rukobia 137

RUXOLITINIB PHOSPHATE 117

Ruzurgi 102

Rybelsus 78,79

Rytary 123

SSA3 Derm 281

SACUBITRIL-VALSARTAN 152

Safyral 163

SALICYLIC ACID 188

Salicylic Acid 188

SALICYLIC ACID & UREA IN LACTIC ACID

VEHICLE 188

SALICYLIC ACID W/ CLEANSER 188

SALMETEROL XINAFOATE 47

SALSALATE 16

Salt Durable Cream 281

Salt Stable LS Advanced 281

Saltstable LO 282

Salvax 188

Salvax Duo Plus 188

Sanare Advanced Scar Therapy 282

Sanare Scar Therapy 282

Sancuso 85

Sanofi COVID-19 Vac (Booster) 309

Santyl 187

SAPROPTERIN DIHYDROCHLORIDE 204

SAQUINAVIR MESYLATE 138

SATRALIZUMAB-MWGE 258

Savaysa 52

Savella 284,285

Savella Titration Pack 285

SAXAGLIPTIN HCL 75

SAXAGLIPTIN-METFORMIN HCL 76

Scalacort DK 191

Scemblix 106

SCOPOLAMINE 86

Se-Natal 19 261

Seasonique 166

SECUKINUMAB 180

Sedanare 282

SEGESTERONE ACETATE-ETHINYL

ESTRADIOL 164

SELEGILINE 67

SELEGILINE HCL 122

SELENIUM SULFIDE 182

SELEXIPAG 154

SELINEXOR 114

SELPERCATINIB 113


SELUMETINIB SULFATE 110

Selzentry 136

SEMAGLUTIDE 78,79

Seraqua 276

Serevent Diskus 47

SERTACONAZOLE NITRATE 187

SERTRALINE HCL 69

SERUM BASE 276

SEVELAMER CARBONATE 215

SEVELAMER HCL 215,216

Sevelamer HCl 215

Shingrix 309

Signifor 205

Signifor LAR 205,206

SILDENAFIL CITRATE 155

SILDENAFIL CITRATE (PULMONARY

HYPERTENSION) 154

SILODOSIN 216

Silosome Transdermal 282

Silprotex Plus 282

SILVER NITRATE 183

Silver Nitrate 183

SILVER NITRATE-POTASSIUM NITRATE 183

SILVER SULFADIAZINE 182

Simbrinza 264

SIMPLE SYRUP 277

Simple Syrup 277

Simplicity COVID-19 At-Home 194

Simponi 9

SIMVASTATIN 91,92

SINECATECHINS 177

SIPONIMOD FUMARATE 289,290

SIROLIMUS 257,258

Sirturo 103

SITAGLIPTIN PHOSPHATE 75

SITAGLIPTIN-METFORMIN HCL 75

Sitavig 144

Skyla 167

Skyrizi 181

Skyrizi (150 MG Dose) 181

Skyrizi Pen 181

Skyy Derm 282

Slynd 168

SODIUM BICARBONATE 252

Sodium Bicarbonate 252

SODIUM CHLORIDE 254

SODIUM CHLORIDE (GU IRRIGANT) 217

SODIUM CHLORIDE (INHALANT) 173

SODIUM CITRATE & CITRIC ACID 217

SODIUM FLUORIDE 252,253

SODIUM HYDROXIDE 157

Sodium Hydroxide 157

SODIUM PHENYLBUTYRATE 206

SODIUM POLYSTYRENE SULFONATE 258

Sodium Sulfacetamide-Bakuchiol 181

SODIUM SULFATE-POTASSIUM SULFATE-

MAGNESIUM SULFATE 239

SODIUM THIOSULFATE-SALICYLIC ACID 178

SODIUM ZIRCONIUM CYCLOSILICATE 258

Sofia SARS Antigen FIA 194

Sofia2 SARS Antigen FIA 194

SOFOSBUVIR-VELPATASVIR 143

Sofosbuvir-Velpatasvir 143

SOLIFENACIN SUCCINATE 303,304

Soliqua 79

SOLRIAMFETOL HCL 5

Soltamox 104

Solvatech Plus 277

Solvatech Sweet SF 277

Solydra 276

SOMATROPIN 199,200,201

Somavert 199

SONIDEGIB PHOSPHATE 109

SORAFENIB TOSYLATE 112

Sorbitol 217

SORBITOL IRRIGATION 217

SORBITOL-MANNITOL 218

Sorbitol-Mannitol 218

Sorilux 180

SOTALOL HCL 147,148

SOTALOL HCL (AFIB/AFL) 147,148

SOTORASIB 110


Sotylize 148

SPACER/AEROSOL-HOLDING CHAMBERS 248,249

SPINOSAD 190

Spinosad 190

Spiriva HandiHaler 47

Spiriva Respimat 47

SPIRONOLACTONE 196

SPIRONOLACTONE &


Spravato (56 MG Dose) 68

Spravato (84 MG Dose) 68

Spritam 61

Sprycel 106

SPS 258

SSKI 173

Stamaril 309

STAVUDINE 141

Stavudine 141

Stelara 181

Stendra 155

Stera Base 282

Sterile Water for Injection 277

Stimate 206

Stiolto Respimat 45

Stivarga 112

Strensiq 202

Stribild 136

Striverdi Respimat 47

Sublocade 34

Subsys 30,31

SUCCIMER 83

SUCRALFATE 302

SUCROFERRIC OXYHYDROXIDE 216

SULCONAZOLE NITRATE 187

SULFACETAMIDE SOD-PREDNISOLONE 270

SULFACETAMIDE SODIUM 181,182

Sulfacetamide Sodium 271

SULFACETAMIDE SODIUM (ACNE) 175

SULFACETAMIDE SODIUM (OPHTH) 271

SULFACETAMIDE SODIUM IN BAKUCHIOL

VEHICLE 181

SULFACETAMIDE SODIUM W/ SULFUR 175

Sulfacetamide-Prednisolone 270

SULFADIAZINE 292

sulfADIAZINE 292

SULFAMETHOXAZOLE-TRIMETHOPRIM 38

Sulfamylon 183

SULFANILAMIDE VAGINAL 310

SULFASALAZINE 214

SULFURIC ACID-SULFONATED PHENOLICS 259

SULINDAC 14

SUMATRIPTAN 251

SUMATRIPTAN SUCCINATE 251

SUMAtriptan Succinate 251

SUMATRIPTAN-NAPROXEN SODIUM 251

SUNITINIB MALATE 112

Sunosi 5

Suprax 157

Suprep Bowel Prep Kit 239

Suspension Vehicle 277

Sustiva 140

Sustol 85

SUVOREXANT 238

Symbicort 45

Symdeko 291

Symjepi 311

SymlinPen 120 73

SymlinPen 60 73

Symproic 215

Symtuza 136

Synagis 273

Synera 191

Synjardy 80

Synjardy XR 81

Synthroid 297,298

SYRINGE/NEEDLE (DISP) 12 ML 246,247

SYRINGE/NEEDLE (DISP) 6 ML 246

Syrpalta 277

Syrup Vehicle 277

TTabloid 104


Tabrecta 110

TACROLIMUS 257,258

TACROLIMUS (TOPICAL) 189

TADALAFIL 155

TADALAFIL (PULMONARY HYPERTENSION) 154

Tafinlar 107

TAFLUPROST 272

Tagrisso 108

TALAZOPARIB TOSYLATE 119

Taltz 181

Talzenna 119

TAMOXIFEN CITRATE 104

TAMSULOSIN HCL 216

TAPENTADOL HCL 27,28

Targretin 120,191

Tasigna 106

TAVABOROLE 189

Taytulla 163

TAZAROTENE 180

TAZEMETOSTAT HBR 111

Tazorac 180

Tazverik 111

TBO-FILGRASTIM 234

TDC Max 282

TDM Solution 276

TDVAX 300

TEGretol 62

TEGretol-XR 62

Tekturna HCT 100

TELMISARTAN 98

TELMISARTAN-AMLODIPINE 97

TELMISARTAN-HYDROCHLOROTHIAZIDE 97

TEMAZEPAM 237

Temixys 136

TEMOZOLOMIDE 116

Tencon 16

Tenivac 300

TENOFOVIR DISOPROXIL FUMARATE 142

Tepmetko 111

TEPOTINIB HCL 111

TERAZOSIN HCL 99

TERBINAFINE HCL 87

TERBUTALINE SULFATE 47

TERCONAZOLE VAGINAL 310

TERIFLUNOMIDE 285

TERIPARATIDE (RECOMBINANT) 203

Teriparatide (Recombinant) 203

TeroDerm 282

TeroDerm-Plus 282

TESAMORELIN ACETATE 199

TESTOSTERONE 35,36

Testosterone 35,36

TESTOSTERONE CYPIONATE 35,36

Testosterone Cypionate 36

TESTOSTERONE ENANTHATE 36

Testosterone Enanthate 36

TETANUS TOXOID-DIPHTHERIA-ACELLULAR

PERTUSSIS ADSORB (TDAP) 300

TETANUS-DIPHTHERIA TOXOIDS (TD) 300

Tetanus-Diphtheria Toxoids Td 300

TETRABENAZINE 285

TETRACAINE HCL (OPHTH) 269

TETRACYCLINE HCL 294

Texacort 186

TEZACAFTOR-IVACAFTOR 291

TEZEPELUMAB-EKKO 50

Tezspire 50

THALIDOMIDE 254

Thalomid 254

Theo-24 50

THEOPHYLLINE 50,51

Theophylline ER 51

THIOGUANINE 104

THIORIDAZINE HCL 132

THIOTHIXENE 134

THYROID 294,297,298,299,300

Thyrolar-1 298

Thyrolar-1/2 298

Thyrolar-1/4 298

Thyrolar-2 298

Thyrolar-3 298

TIAGABINE HCL 64,65


TICAGRELOR 230

TIMOLOL 265

TIMOLOL MALEATE 148

Timolol Maleate 148,265

TIMOLOL MALEATE (OPHTH) 265

Timoptic Ocudose 265

TINIDAZOLE 37

TIOTROPIUM BROMIDE MONOHYDRATE 47

TIOTROPIUM BROMIDE-OLODATEROL HCL 45

TIPRANAVIR 137,138

Tivicay 137

Tivicay PD 137

TIVOZANIB HCL 112

TIZANIDINE HCL 263

Tobi Podhaler 8

TobraDex 270

TobraDex ST 270

TOBRAMYCIN 8

TOBRAMYCIN (OPHTH) 268

TOBRAMYCIN-DEXAMETHASONE 270

Tobrex 268

TOCILIZUMAB 12

TOFACITINIB CITRATE 10

Tolak 179

TOLAZAMIDE 82

TOLAZamide 82

TOLBUTAMIDE 82

TOLBUTamide 82

TOLCAPONE 122

TOLMETIN SODIUM 14

Tolmetin Sodium 14

TOLTERODINE TARTRATE 303

TOLVAPTAN 204,205

Tolvaptan 205

Topamax 62

Topamax Sprinkle 62

TOPIRAMATE 57,62,63

TOPOTECAN HCL 120

TOREMIFENE CITRATE 104

TORSEMIDE 196

Toviaz 303,304

Tracleer 154

Tradjenta 75

TRAMADOL HCL 31,32

TraMADol HCl ER 31,32

TraMADol HCl ER (Biphasic) 31

TRAMADOL-ACETAMINOPHEN 35

TRAMETINIB DIMETHYL SULFOXIDE 110

TRANDOLAPRIL 95

TRANDOLAPRIL-VERAPAMIL HCL 93,94

Trandolapril-Verapamil HCl ER 93,94

TRANEXAMIC ACID 236

TRANSDERMAL BASE 278,279,281,282

TRANYLCYPROMINE SULFATE 67

TRAVOPROST 272

TRAZODONE HCL 69

Trecator 103

Trelegy Ellipta 45

Tremfya 181

TREPROSTINIL DIOLAMINE 153

Tresiba 78

Tresiba FlexTouch 78

TRETINOIN 176

TRETINOIN (CHEMOTHERAPY) 120

TRETINOIN MICROSPHERE 176,177

Treximet 251

Tri-Norinyl (28) 169

TRIAMCINOLONE ACETONIDE (MOUTH) 259

TRIAMCINOLONE ACETONIDE (TOPICAL) 186

TRIAMTERENE 196

TRIAMTERENE & HYDROCHLOROTHIAZIDE 196

TRIAZOLAM 237

TriCare 261

TRIENTINE HCL 255

TRIFLUOPERAZINE HCL 132

TRIFLURIDINE 268

Trifluridine 268

TRIFLURIDINE-TIPIRACIL 114,115

TRIHEPTANOIN 264

TRIHEXYPHENIDYL HCL 121

Trihexyphenidyl HCl 121

Trijardy XR 79,80


Trikafta 291,292

Trileptal 63

TRIMETHOBENZAMIDE HCL 86

TRIMETHOPRIM 37,38

Trimethoprim 37

TRIMIPRAMINE MALEATE 73

Trinatal Rx 1 261

Trintellix 70

Triumeq 136

Triumeq PD 136

Triveen-Duo DHA 261

TROPICAMIDE 266

TROSPIUM CHLORIDE 304

TRUEplus Lancets 26G 244




TRUEplus Safety Lancets 28G 244

Trulance 212

Trulicity 79

Trumenba 305

Truseltiq (100MG Daily Dose) 109




TUCATINIB 105

Tukysa 105

Turalio 113

Turpentine 188

TURPENTINE (TOPICAL) 188

Tuzistra XR 174

Twinrix 305

Twirla 164

Tyblume 163

Tybost 142

Tymlos 203

Typhim VI 305

TYPHOID VACCINE 305

TYPHOID VI POLYSACCHARIDE VACCINE 305

UUbrelvy 249,250

UBROGEPANT 249,250

Uceris 36

Udenyca 235

Ukoniq 113

Ulesfia 190

ULIPRISTAL ACETATE 165

UltiCare Insulin Safety Syr 247

Ultilet Insulin Syringe 247

Ultraderm 282

UMBRALISIB TOSYLATE 113

UMECLIDINIUM BROMIDE 47

UMECLIDINIUM-VILANTEROL 44

UPADACITINIB 10

Uptravi 154

UREA 187

URSODIOL 212

USTEKINUMAB 181

VVALACYCLOVIR HCL 144

Valchlor 179

VALGANCICLOVIR HCL 142

VALPROATE SODIUM 66

VALPROIC ACID 66

VALSARTAN 98

VALSARTAN-HYDROCHLOROTHIAZIDE 97,98

Valtoco 10 MG Dose 56




Valved Holding Chamber 249

VANCOMYCIN HCL 38

Vandazole 310

VANDETANIB 111,112

Vanish-Pen 282

Vanishing 282

Vanishing Cream Botanical Base 282

Vantas 118


Vaqta 310

VARDENAFIL HCL 155

VARENICLINE TARTRATE 289

Varenicline Tartrate 289

VARICELLA VIRUS VACCINE LIVE 310

Varivax 310

Varubi (180 MG Dose) 86

Vascepa 89

Vaxchora 305

Vaxelis 300,301

Vaxneuvance 305

Vecamyl 99

Velphoro 216

Veltassa 258

VEMURAFENIB 107

Venclexta 105

Venclexta Starting Pack 105

VENETOCLAX 105

VENLAFAXINE HCL 70,71

VERAPAMIL HCL 151

Veregen 177

Versacloz 130

VersaPlus 277

VersaPro 282

Versatile Cream Base 282

Versatile Rich Base 282

Verzenio 116

VESIcare LS 304

Viberzi 213

Vibramycin 294

Victoza 79

Videx 140,141

VIGABATRIN 65

Viibryd 70

Viibryd Starter Pack 70

VILAZODONE HCL 70

Vimpat 63

Vinate One 261

Viracept 139

Viread 142

VISMODEGIB 109

Vitafol-OB+DHA 262

VitaMedMD One Rx/Quatrefolic 262

VitaMedMD RediChew Rx 262

Vitathely with Ginger 261

Vivelle-Dot 211

Vivitrol 85

Vivotif 305

Vizimpro 108

VOCLOSPORIN 255

Vol-Plus 261

Vol-Tab Rx 261

VORAPAXAR SULFATE 230

VORICONAZOLE 87

VORINOSTAT 109

VORTIOXETINE HBR 70

Votrient 113

Vraylar 126,127

Vusion 179

Vyvanse 4,5

WWakix 5

WARFARIN SODIUM 51

WATER FOR INJECTION, STERILE 277

WATER FOR IRRIGATION, STERILE 257

Welireg 109

WesTab Plus 261

Westhroid 299

WHITE PETROLATUM 281,282

White Petrolatum 282

Wide-Seal Diaphragm 60 241








Wilate 228

WOUND CLEANSERS 191

WP Thyroid 299,300


XXalkori 105

Xarelto 52

Xarelto Starter Pack 52

Xcopri 64

Xcopri (250 MG Daily Dose) 64

Xcopri (350 MG Daily Dose) 64

Xeljanz 10

Xeljanz XR 10

Xematop Base 283

Xerese 182

Xhance 264

Xiaflex 255

Xifaxan 38

Xigduo XR 81

Xiidra 266

Xofluza (40 MG Dose) 145

Xofluza (80 MG Dose) 145

Xolair 46

Xolegel 187

Xopenex 47

Xpert Xpress SARS-CoV-2 194

Xpovio (100 MG Once Weekly) 114


Xpovio (40 MG Twice Weekly) 114





Xtandi 103,104

Xultophy 79

Xyntha 229

Xyntha Solofuse 229

YYasmin 28 164

YAZ 164

YELLOW FEVER VACCINE 309,310

YF-VAX 310

Yupelri 48

ZZAFIRLUKAST 48

ZALEPLON 237

ZANAMIVIR 145

ZANUBRUTINIB 107

Zarxio 235

Zelapar 122

Zelboraf 107

Zemaira 291

Zenpep 195

Zeposia 290

Zeposia 7-Day Starter Pack 290

Zeposia Starter Kit 290

Zerit 141

Ziagen 141

ZIDOVUDINE 141

Ziextenzo 235

Zimhi 85

Zioptan 272

ZIPRASIDONE HCL 127

Zirgan 268

Zithranol 180

Zohydro ER 32

Zoladex 118

Zolinza 109

ZOLMITRIPTAN 251,252

ZOLMitriptan 251

ZOLPIDEM TARTRATE 237,238

Zolpidem Tartrate 237

Zolpimist 238

Zomig 252

Zonegran 63

ZONISAMIDE 63

Zontivity 230

Zostavax 310

ZOSTER VACCINE LIVE 310

ZOSTER VACCINE RECOMBINANT

ADJUVANTED 309

Zubsolv 34

Zuplenz 85


Zyban 289

Zyclara Pump 188

Zydelig 119

Zykadia 105

Zylet 271

ZyPREXA Relprevv 133,134


University of Utah Health Employee Plan Preferred Drug List

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Transcript of University of Utah Health Employee Plan Preferred Drug List