Formulary Drug List - AmeriHealth Caritas Louisiana Drug List AmeriHealth Caritas Louisiana...

Formulary Drug List

AmeriHealth Caritas Louisiana PerformRxSM Pharmacy Services:

Phone 1-800-684-5502

Fax 1-855-452-9131

Pharmacy Member Services:

Phone 1-866-452-1040

Providers may request the addition or deletion of a medication to this list.

Requests for additions must include the drug name, rationale for inclusion

on the list, role in therapy and medications that may be replaced by the addition.

Please direct such requests to:

AmeriHealth Caritas

P&T Committee

P.O. Box 40849

Charleston, SC 29423

Members may request changes to the list by calling Pharmacy Member Services.

For the most current formulary, please use the searchable formulary on our

website, www.amerihealthcaritasla.com/pharmacy/formulary.aspx.

Sept. 2018

ACLA-1322-07

www.amerihealthcaritasla.com

http://www.amerihealthcaritasla.com/pharmacy/formulary.aspx

http://www.amerihealthcaritasla.com/

AL = Age Limit

GL = Gender Limit

PA = Prior Authorization

QL = Quantity Limit

ST = Step Therapy

1

Drug Name Notes Requirements/Limits

Antihistamine Drugs

Ethanolamine Derivatives

diphenhydramine HCl injection solution 50

mg/mL

diphenhydramine HCl injection syringe

diphenhydramine HCl oral capsule

diphenhydramine HCl oral syrup

diphenhydramine HCl oral tablet 25 mg

First Gen. Antihist. Derivatives, Misc.

cyproheptadine

First Generation Antihistamines

chlorpheniramine maleate oral tablet

cyproheptadine


mg/mL





ED Chlorped Jr

Phenothiazine Derivatives

promethazine oral

promethazine rectal

promethazine-phenylephrine

Piperazine Derivatives

hydroxyzine pamoate

meclizine oral tablet 12.5 mg, 25 mg

Propylamine Derivatives


ED Chlorped Jr

Second Generation Antihistamines

cetirizine oral solution 1 mg/mL

cetirizine oral tablet

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

2


cetirizine-pseudoephedrine

fexofenadine oral suspension ST

fexofenadine oral tablet 180 mg ST

levocetirizine oral tablet

loratadine oral solution

loratadine oral tablet

loratadine oral tablet,disintegrating

Loratadine-D

Anti-Infective Agents

1St Generation Cephalosporin

Antibiotics

cefadroxil oral capsule

cefadroxil oral suspension for reconstitution 250

mg/5 mL, 500 mg/5 mL

cefadroxil oral tablet

cefazolin injection recon soln 1 gram, 10 gram,

500 mg Specialty PA

cephalexin oral capsule 250 mg, 500 mg

cephalexin oral suspension for reconstitution

2Nd Generation Cephalosporin

Antibiotics

cefaclor oral capsule

cefotetan Specialty PA

cefotetan in dextrose, iso-osm Specialty PA

cefprozil

cefuroxime axetil oral suspension for

reconstitution 125 mg/5 mL

cefuroxime axetil oral tablet

cefuroxime sodium intravenous recon soln 7.5

gram Specialty PA

3Rd Generation Cephalosporin

Antibiotics

cefdinir QL

cefotaxime Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

3


cefpodoxime oral suspension for reconstitution

ceftazidime Specialty PA

ceftriaxone in dextrose,iso-os Specialty PA

ceftriaxone injection recon soln 1 gram, 10 gram,

2 gram, 250 mg, 500 mg Specialty PA

ceftriaxone intravenous Specialty PA

Claforan intravenous recon soln Specialty PA

Suprax oral capsule QL

Suprax oral suspension for reconstitution 100

mg/5 mL, 200 mg/5 mL

TAZICEF intravenous Specialty PA

4Th Generation Cephalosporin

Antibiotics

cefepime Specialty PA

cefepime in dextrose 5 % Specialty PA

cefepime in dextrose,iso-osm Specialty PA

Adamantane Antivirals

amantadine HCl oral capsule

amantadine HCl oral solution

Allylamine Antifungals

terbinafine HCl oral QL

Amebicides

metronidazole in NaCl (iso-os) Specialty PA

metronidazole oral tablet

paromomycin PA; QL

Aminoglycoside Antibiotics

amikacin injection solution 1,000 mg/4 mL, 500

mg/2 mL Specialty PA

gentamicin in NaCl (iso-osm) intravenous

piggyback 100 mg/100 mL, 100 mg/50 mL, 80

mg/100 mL, 80 mg/50 mL

Specialty PA

gentamicin injection Specialty PA

gentamicin sulfate (PF) intravenous solution 100

mg/10 mL, 60 mg/6 mL Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

4


Tobi Podhaler Specialty PA

tobramycin in 0.225 % NaCl Specialty PA

tobramycin sulfate Specialty PA

Aminopenicillin Antibiotics

amoxicillin oral capsule

amoxicillin oral suspension for reconstitution

amoxicillin oral tablet

amoxicillin oral tablet,chewable 125 mg, 250 mg

amoxicillin-pot clavulanate oral suspension for

reconstitution

amoxicillin-pot clavulanate oral tablet

amoxicillin-pot clavulanate oral tablet,chewable

ampicillin oral capsule

ampicillin sodium Specialty PA

ampicillin-sulbactam Specialty PA

Anthelmintics

Biltricide

Antifungals, Miscellaneous

griseofulvin microsize

griseofulvin ultramicrosize

SSKI

Antimalarials

atovaquone-proguanil

chloroquine phosphate

Daraprim Specialty PA

hydroxychloroquine

mefloquine

primaquine

quinidine gluconate oral

quinidine sulfate oral tablet

Antimycobacterials, Miscellaneous

dapsone oral

Antiprotozoals, Miscellaneous

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

5


atovaquone PA

dapsone oral

metronidazole in NaCl (iso-os) Specialty PA

metronidazole oral tablet

Nebupent Specialty PA

Pentam Specialty PA

Antituberculosis Agents

amikacin injection solution 1,000 mg/4 mL, 500


ciprofloxacin

ciprofloxacin (mixture)

ciprofloxacin HCl oral tablet 100 mg

ciprofloxacin HCl oral tablet 250 mg, 500 mg,

750 mg QL

ciprofloxacin in 5 % dextrose intravenous

piggyback 400 mg/200 mL Specialty PA

clarithromycin QL

ethambutol

isoniazid oral

levofloxacin in D5W Specialty PA

levofloxacin oral QL

moxifloxacin oral QL

Mycobutin

pyrazinamide

rifampin intravenous Specialty PA

rifampin oral

Antivirals, Miscellaneous

foscarnet Specialty PA

Azole Antifungals

fluconazole in dextrose(iso-o) intravenous


fluconazole in NaCl (iso-osm) intravenous

piggyback 200 mg/100 mL, 400 mg/200 mL Specialty PA

fluconazole oral suspension for reconstitution

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

6


fluconazole oral tablet 100 mg, 200 mg, 50 mg

fluconazole oral tablet 150 mg QL

itraconazole PA

ketoconazole oral

Sporanox oral solution PA

voriconazole intravenous Specialty PA

Carbapenem Antibiotics

doripenem Specialty PA

imipenem-cilastatin intravenous recon soln 250

mg Specialty PA

Invanz Specialty PA

meropenem Specialty PA

Cephamycin Antibiotics

cefotetan Specialty PA

cefotetan in dextrose, iso-osm Specialty PA

Cyclic Lipopeptide Antibiotics

daptomycin Specialty PA

Echinocandin Antifungals

caspofungin Specialty PA

Eraxis(Water Diluent) Specialty PA

Mycamine Specialty PA

Erythromycin Antibiotics

E.E.S. Granules

Ery-Tab

Erythrocin (as stearate) oral tablet 250 mg

erythromycin ethylsuccinate oral tablet

erythromycin oral capsule,delayed

release(DR/EC)

erythromycin oral tablet

Extended-Spectrum Penicillins

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram Specialty PA

Zosyn in dextrose (iso-osm) Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

7


Glycopeptide Antibiotics

vancomycin in dextrose 5 % intravenous

piggyback 1 gram/200 mL, 750 mg/150 mL Specialty PA

vancomycin intravenous Specialty PA

vancomycin oral capsule ST

Vibativ intravenous recon soln 750 mg Specialty PA

Glycylcycline Antibiotics

tigecycline Specialty PA

Hcv Polymerase Inhibitor Antivirals

Epclusa Specialty PA

Harvoni Specialty PA

Sovaldi Specialty PA

Viekira Pak Specialty PA

Viekira XR Specialty PA

Vosevi Specialty PA

Hcv Protease Inhibitor Antivirals

Mavyret Specialty PA

Olysio Specialty PA

Technivie Specialty PA



Zepatier Specialty PA

Hcv Replication Complex Inhibitors

Daklinza Specialty PA

Epclusa Specialty PA

Harvoni Specialty PA

Mavyret Specialty PA




Vosevi Specialty PA

Zepatier Specialty PA

Hiv Entry And Fusion Inhibitors

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

8


Fuzeon subcutaneous recon soln

Selzentry

Trogarzo

Hiv Integrase Inhibitor Antiretrovirals

Biktarvy

Genvoya

Isentress

Isentress HD

Juluca

Stribild

Tivicay

Triumeq

Hiv Nonnucleoside Rev.Transcrip.

Inhib.

Atripla

Complera

Edurant

efavirenz

Intelence

Juluca

nevirapine oral suspension

nevirapine oral tablet

nevirapine oral tablet extended release 24 hr 400

mg

Odefsey

Rescriptor

Symfi

Symfi Lo

Viramune XR oral tablet extended release 24 hr

100 mg

Hiv Nucleoside, Nucleotide Rt

Inhibitors

abacavir

abacavir-lamivudine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

9


Atripla

Biktarvy

Cimduo

Complera

Descovy

didanosine

Emtriva

Epivir HBV

Epivir oral solution

Genvoya

lamivudine oral tablet 150 mg, 300 mg

lamivudine-zidovudine

Odefsey

Retrovir intravenous

stavudine oral capsule

Stribild

Symfi

Symfi Lo

tenofovir disoproxil fumarate

Triumeq

Trizivir

Truvada

Videx 2 gram Pediatric

Viread oral powder

Viread oral tablet 150 mg, 200 mg, 250 mg

Zerit oral recon soln

zidovudine

Hiv Protease Inhibitor Antiretrovirals

Aptivus

atazanavir

Crixivan oral capsule 200 mg, 400 mg

Evotaz

fosamprenavir

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

10


Invirase

Kaletra oral tablet

Lexiva oral suspension

lopinavir-ritonavir

Norvir oral capsule

Norvir oral solution

Prezcobix

Prezista oral suspension

Prezista oral tablet 150 mg, 600 mg, 75 mg, 800

mg

Reyataz oral powder in packet

ritonavir




Viracept oral tablet

Interferon Antivirals

Alferon N Specialty PA

Intron A injection Specialty PA

Pegasys Specialty PA

Pegasys ProClick Specialty PA

PegIntron subcutaneous kit 50 mcg/0.5 mL Specialty PA

Sylatron Specialty PA

Lincomycin Antibiotics

clindamycin HCl oral capsule 150 mg, 300 mg

clindamycin in 5 % dextrose Specialty PA

clindamycin palmitate HCl

clindamycin phosphate injection Specialty PA

clindamycin phosphate intravenous solution 900


Lincocin Specialty PA

Macrolide Antibiotics

E.E.S. Granules

Ery-Tab

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

11


Erythrocin (as stearate) oral tablet 250 mg

erythromycin ethylsuccinate oral tablet

erythromycin oral capsule,delayed

release(DR/EC)

erythromycin oral tablet

Monobactam Antibiotics

Azactam in dextrose (iso-osm) Specialty PA

aztreonam Specialty PA

Cayston Specialty PA

Monoclonal Antibody Antivirals

Synagis Specialty PA

Natural Penicillin Antibiotics

Bicillin L-A

penicillin G potassium Specialty PA

penicillin V potassium

Neuraminidase Inhibitor Antivirals

oseltamivir QL

Relenza Diskhaler QL

Nucleoside And Nucleotide Antivirals

acyclovir oral capsule

acyclovir oral suspension 200 mg/5 mL

acyclovir oral tablet

adefovir Specialty PA

cidofovir Specialty PA

Cytovene Specialty PA

entecavir

Rebetol oral solution Specialty PA

Ribasphere oral tablet 400 mg, 600 mg Specialty PA

Ribasphere RibaPak oral tablets,dose pack 400-

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

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

Specialty PA

ribavirin oral capsule Specialty PA

ribavirin oral tablet 200 mg Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

12


valacyclovir

Other Macrolide Antibiotics

azithromycin oral QL

clarithromycin QL

Zmax QL

Oxazolidinone Antibiotics

Zyvox intravenous Specialty PA

Penicillinase-Resistant Penicillins

dicloxacillin

nafcillin in dextrose iso-osm intravenous

piggyback 2 gram/100 mL Specialty PA

nafcillin injection Specialty PA

oxacillin injection Specialty PA

Polyene Antifungals

Abelcet Specialty PA

AmBisome Specialty PA

nystatin oral powder 150 million unit, 500 million

unit

nystatin oral suspension

nystatin oral tablet

Polymyxin Antibiotics

colistin (colistimethate Na) Specialty PA

Quinolone Antibiotics

ciprofloxacin

ciprofloxacin (mixture)

ciprofloxacin HCl oral tablet 100 mg

ciprofloxacin HCl oral tablet 250 mg, 500 mg,

750 mg QL

ciprofloxacin in 5 % dextrose intravenous


levofloxacin in D5W Specialty PA

levofloxacin oral QL

moxifloxacin oral QL

ofloxacin oral tablet 400 mg QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

13


Rifamycin Antibiotics

Mycobutin

rifampin intravenous Specialty PA

rifampin oral

Xifaxan oral tablet 550 mg PA

Streptogramin Antibiotics

Synercid Specialty PA

Sulfonamide Antibiotics (Systemic)

sulfadiazine

sulfamethoxazole-trimethoprim intravenous Specialty PA

sulfamethoxazole-trimethoprim oral

sulfasalazine

Tetracycline Antibiotics

Doxy-100 Specialty PA

doxycycline hyclate oral capsule

doxycycline hyclate oral tablet 100 mg

doxycycline monohydrate oral capsule 100 mg,

50 mg

doxycycline monohydrate oral tablet 100 mg, 50

mg, 75 mg

minocycline oral capsule

minocycline oral tablet

tetracycline

Urinary Anti-Infectives

nitrofurantoin

nitrofurantoin macrocrystal

nitrofurantoin monohyd/m-cryst

trimethoprim

Antineoplastic Agents

Antineoplastic Agents

Abraxane Specialty PA

Adcetris Specialty PA

Afinitor Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

14


Afinitor Disperz Specialty PA

Alecensa Specialty PA

Alferon N Specialty PA

Alimta Specialty PA

anastrozole

Arranon Specialty PA

Arzerra intravenous solution 100 mg/5 mL Specialty PA

Avastin Specialty PA

bexarotene Specialty PA

bicalutamide

BiCNU Specialty PA

bleomycin Specialty PA

Bosulif Specialty PA

busulfan Specialty PA

Camptosar intravenous solution 300 mg/15 mL Specialty PA

capecitabine Specialty PA

Caprelsa Specialty PA

carboplatin Specialty PA

cisplatin Specialty PA

cladribine Specialty PA

clofarabine Specialty PA

Cometriq Specialty PA

cyclophosphamide intravenous Specialty PA

cytarabine Specialty PA

cytarabine (PF) injection solution Specialty PA

dacarbazine Specialty PA

Dacogen Specialty PA

dactinomycin Specialty PA

daunorubicin intravenous solution Specialty PA

Docefrez Specialty PA

docetaxel intravenous solution 160 mg/16 mL (10

mg/mL), 160 mg/8 mL (20 mg/mL), 20 mg/2 mL

(10 mg/mL), 20 mg/mL (1 mL), 80 mg/4 mL (20

mg/mL), 80 mg/8 mL (10 mg/mL)

Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

15


Doxil Specialty PA

doxorubicin intravenous solution Specialty PA

Droxia

Eligard Specialty PA

Eligard (3 month) Specialty PA



Emcyt

epirubicin intravenous recon soln 50 mg Specialty PA

epirubicin intravenous solution Specialty PA

Erbitux Specialty PA

Erivedge Specialty PA

Erwinaze Specialty PA

Etopophos Specialty PA

etoposide Specialty PA

exemestane Specialty PA

Fareston PA

Faslodex Specialty PA

Firmagon kit w diluent syringe subcutaneous

recon soln 80 mg Specialty PA

Firmagon subcutaneous recon soln 120 mg Specialty PA

floxuridine Specialty PA

fludarabine Specialty PA

fluorouracil intravenous Specialty PA

flutamide

Folotyn Specialty PA

gemcitabine intravenous recon soln Specialty PA

gemcitabine intravenous solution 1 gram/26.3 mL

(38 mg/mL), 2 gram/52.6 mL (38 mg/mL), 200

mg/5.26 mL (38 mg/mL)

Specialty PA

Gliadel Wafer Specialty PA

Halaven Specialty PA

Herceptin intravenous recon soln 440 mg Specialty PA

Hexalen

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

16


Hycamtin oral Specialty PA

hydroxyurea

Ibrance Specialty PA

Iclusig Specialty PA

idarubicin Specialty PA

ifosfamide Specialty PA

ifosfamide-mesna intravenous kit 1-1 gram Specialty PA

imatinib Specialty PA

Inlyta Specialty PA


irinotecan Specialty PA

Ixempra Specialty PA

Jakafi Specialty PA

Jevtana Specialty PA

Kadcyla Specialty PA

Kyprolis intravenous recon soln 60 mg Specialty PA

letrozole QL

Leukeran

leuprolide subcutaneous kit Specialty PA

Lupron Depot Specialty PA

Lupron Depot (3 month) Specialty PA


Lupron Depot (6 Month) Specialty PA

Lupron Depot-Ped Specialty PA

Lupron Depot-Ped (3 month) Specialty PA

Lysodren

Matulane

megestrol oral suspension 400 mg/10 mL (40

mg/mL)

megestrol oral suspension 625 mg/5 mL QL

megestrol oral tablet

melphalan

melphalan HCl Specialty PA

mercaptopurine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

17


methotrexate sodium

methotrexate sodium (PF)

mitomycin intravenous Specialty PA

mitoxantrone Specialty PA

Mustargen Specialty PA

Myleran

Nexavar Specialty PA

nilutamide Specialty PA

Oncaspar Specialty PA

oxaliplatin Specialty PA

paclitaxel Specialty PA

Perjeta Specialty PA

Photofrin Specialty PA

Pomalyst Specialty PA

Proleukin Specialty PA

Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25

mg, 5 mg Specialty PA

Rituxan Specialty PA

Rituxan Hycela Specialty PA

romidepsin Specialty PA

Sprycel Specialty PA

Stivarga Specialty PA

Supprelin LA Specialty PA

Sutent oral capsule 12.5 mg, 25 mg, 50 mg Specialty PA

Sylatron Specialty PA

Synribo Specialty PA

Tabloid

tamoxifen

Tarceva Specialty PA

Targretin topical Specialty PA

Tasigna Specialty PA

Temodar intravenous Specialty PA

temozolomide Specialty PA

teniposide Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

18


thiotepa Specialty PA

Tice BCG Specialty PA

topotecan Specialty PA

Torisel Specialty PA

Treanda intravenous recon soln Specialty PA

Trelstar Specialty PA

tretinoin (chemotherapy) Specialty PA

Trexall oral tablet 7.5 mg

Tykerb Specialty PA

Valstar Specialty PA

Vantas Specialty PA

Vectibix Specialty PA

Velcade Specialty PA

Vidaza Specialty PA

vinblastine intravenous solution Specialty PA

vincristine Specialty PA

vinorelbine Specialty PA

Votrient Specialty PA

Xalkori Specialty PA

Xtandi Specialty PA

Yervoy Specialty PA

Zaltrap Specialty PA

Zanosar Specialty PA

Zelboraf Specialty PA

Zevalin (Y-90) Specialty PA

Zoladex Specialty PA

Zolinza Specialty PA

Zykadia Specialty PA

Zytiga Specialty PA

Antitoxins,Immune

Glob,Toxoids,Vaccines

Antitoxins And Immune Globulins

Carimune NF Nanofiltered intravenous recon soln

12 gram, 6 gram Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

19


CytoGam intravenous solution 50 mg/mL Specialty PA

Flebogamma DIF intravenous solution 5 % Specialty PA

GamaSTAN S/D Specialty PA

Gamunex-C injection solution 1 gram/10 mL (10

%), 10 gram/100 mL (10 %), 2.5 gram/25 mL (10

%), 20 gram/200 mL (10 %), 5 gram/50 mL (10

%)

Specialty PA

Hizentra subcutaneous solution 1 gram/5 mL (20

%), 2 gram/10 mL (20 %), 4 gram/20 mL (20 %) Specialty PA

HyperRHO S/D Specialty

MICRhoGAM Ultra-Filtered PLUS Specialty

Privigen Specialty PA

RhoGAM Ultra-Filtered PLUS Specialty

Rhophylac Specialty

WinRho SDF Specialty

Vaccines

Afluria 2017-2018 QL; AL

Afluria 2017-2018 (PF) QL; AL

Afluria Quad 2017-2018 QL; AL

Afluria Quad 2017-2018 (PF) QL; AL

Fluarix Quad 2017-2018 (PF) QL; AL

Flucelvax Quad 2017-2018 QL; AL

Flucelvax Quad 2017-2018 (PF) QL; AL

Flulaval Quad 2017-2018 QL; AL

Flulaval Quad 2017-2018 (PF) QL; AL

Fluvirin 2017-2018 QL; AL

Fluvirin 2017-2018 (PF) QL; AL

Fluzone High-Dose 2017-18 (PF) QL; AL

Fluzone Intraderm Quad 2017-18 QL; AL

Fluzone Quad 2017-2018 QL; AL

Fluzone Quad 2017-2018 (PF) QL; AL

Fluzone Quad Pedi 2017-18 (PF) QL; AL

Tice BCG Specialty PA

Autonomic Drugs

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

20


Alpha- And Beta-Adrenergic Agonists


epinephrine injection auto-injector 0.15 mg/0.3

mL, 0.3 mg/0.3 mL QL

epinephrine injection solution

epinephrine injection syringe 0.1 mg/mL

Loratadine-D

Alpha-Adrenergic Agonists

clonidine

clonidine HCl oral tablet

Clorpres

methyldopa

methyldopa-hydrochlorothiazide

midodrine


Antimuscarinics/Antispasmodics

Anoro Ellipta

Atrovent HFA

Combivent Respimat

dicyclomine oral capsule

dicyclomine oral solution

dicyclomine oral tablet

diphenoxylate-atropine

glycopyrrolate oral tablet 1 mg, 2 mg

hyoscyamine sulfate oral

ipratropium bromide inhalation

ipratropium-albuterol

propantheline

Spiriva Respimat AL

Stiolto Respimat

Antiparkinsonian Agents

benztropine oral

trihexyphenidyl

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

21


Autonomic Drugs, Miscellaneous

Chantix QL

Chantix Starting Month Box QL

Nicotrol PA

Nicotrol NS PA; QL

Centrally Acting Skeletal Muscle

Relaxnt

carisoprodol oral tablet 350 mg ST; QL

chlorzoxazone oral tablet 500 mg

cyclobenzaprine oral tablet 10 mg, 5 mg

methocarbamol oral

tizanidine oral tablet

Gaba-Derivative Skeletal Muscle

Relaxant

baclofen

Lioresal Specialty PA

Non-Sel. Beta-Adrenergic Blocking

Agents

carvedilol

labetalol oral

nadolol

nadolol-bendroflumethiazide

pindolol

propranolol oral

propranolol-hydrochlorothiazid

Sotalol AF oral tablet 160 mg, 80 mg

sotalol oral tablet 120 mg, 240 mg

timolol maleate oral

Non-Sel.Alpha-1-Adrenergic Blocking

Agts

doxazosin

prazosin

terazosin

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

22


Non-Sel.Alpha-Adrenergic Blocking

Agents

dihydroergotamine injection

Ergomar

ergotamine-caffeine

Migranal QL

phenoxybenzamine

Parasympathomimetic (Cholinergic

Agents)

bethanechol chloride

donepezil oral tablet 10 mg, 5 mg QL; AL

donepezil oral tablet 23 mg ST; QL; AL

donepezil oral tablet,disintegrating QL; AL

Mestinon oral syrup

pyridostigmine bromide

rivastigmine tartrate AL

Selective Alpha-1-Adrenergic

Block.Agent

alfuzosin

carvedilol

labetalol oral

tamsulosin

Selective Beta-2-Adrenergic Agonists

albuterol sulfate inhalation solution for

nebulization

albuterol sulfate oral syrup

albuterol sulfate oral tablet

Anoro Ellipta

Breo Ellipta

Combivent Respimat


levalbuterol tartrate ST

metaproterenol oral syrup

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

23


Serevent Diskus

Stiolto Respimat

terbutaline oral

Ventolin HFA QL

Xopenex HFA ST

Selective Beta-Adrenergic Blocking

Agent

acebutolol

atenolol

atenolol-chlorthalidone

bisoprolol fumarate

bisoprolol-hydrochlorothiazide

metoprolol succinate

metoprolol ta-hydrochlorothiaz

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

Skeletal Muscle Relaxants,

Miscellaneous

Botox Specialty PA

Dysport Specialty PA

Myobloc Specialty PA

Xeomin Specialty PA

Blood Formation, Coagulation,

Thrombosis

Coumarin Derivatives

warfarin

Direct Factor Xa Inhibitors

Eliquis

Xarelto

Direct Thrombin Inhibitors

Pradaxa

Hematopoietic Agents

Aranesp (in polysorbate) Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

24


Epogen injection solution 10,000 unit/mL, 2,000

unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000

unit/mL, 4,000 unit/mL

Specialty PA

Granix Specialty PA

Leukine injection recon soln Specialty PA

Mozobil Specialty PA

Neulasta Specialty PA

Neupogen Specialty PA

Nplate Specialty PA

Procrit Specialty PA

Promacta Specialty PA

Zarxio Specialty PA

Hemorrheologic Agents

pentoxifylline

Hemostatics

Advate Specialty PA

Alphanate intravenous recon soln 1,000 (400

vWF) unit/10 mL, 1,500 (600 vWF) unit/10 mL,

250 (100 vWF) unit/5 mL, 500 (200 vWF) unit/5

mL

Specialty PA

AlphaNine SD Specialty PA

Amicar

aminocaproic acid intravenous Specialty PA

BeneFIX Specialty PA

Corifact Specialty PA

DDAVP nasal solution PA

desmopressin nasal spray,non-aerosol PA

desmopressin oral PA

Feiba NF Specialty PA

Hemofil M High Specialty PA

Hemofil M Low Specialty PA

Hemofil M Mid Specialty PA

Hemofil M Super High Specialty PA

Humate-P intravenous recon soln 1,000-2,400

unit Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

25


Kogenate FS intravenous recon soln 2,000 (+/-)

unit, 3,000 (+/-) unit Specialty PA

Monoclate-P intravenous recon soln 1,000 (+/-)

unit Specialty PA

Novoseven RT Specialty PA

Profilnine Specialty PA

Recombinate intravenous recon soln 1,000 (+/-)

unit, 1,500 (+/-) unit, 250 (+/-) unit, 500 (+/-) unit Specialty PA

Xyntha Specialty PA

Xyntha Solofuse Specialty PA

Heparins

enoxaparin subcutaneous solution

enoxaparin subcutaneous syringe QL

heparin (porcine) in 5 % dex Specialty PA

heparin (porcine) in NaCl (PF) Specialty PA

heparin (porcine) injection solution

heparin, porcine (PF) injection solution 5,000

unit/0.5 mL

Iron Preparations

Atabex EC

Cadeau DHA

Daily Multivitamin with Iron

Daily Prenatal

FE C Plus

Feraheme Specialty PA

Ferrlecit Specialty PA

Infed

Injectafer

Multigen

Multigen Folic

Multigen Plus

Multi-Vit with Fluoride-Iron

Mynatal oral capsule

Mynatal Plus

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

26


Mynatal-Z

Obstetrix DHA

Obstetrix EC

O-Cal FA

O-Cal Prenatal

One-A-Day Women's Prenatal 1

Prenatabs FA

Prenatal + DHA oral combo pack 28 mg iron-800

mcg-200 mg

Prenatal 19

Prenatal 19 (with docusate)

Prenatal Low Iron

Prenatal Multi-DHA (algal oil)

Prenatal Multi-DHA oral capsule 27 mg iron-800

mcg-228 mg

Prenatal Plus

Prenatal Plus DHA oral combo pack

prenatal vit-iron fum-folic ac

Se-Natal 19

Se-Natal 19 (with docusate)

TriAdvance

Trinatal Rx 1

Trinate

Triveen-Duo DHA

Tri-Vit with Fluoride and Iron

Venofer

Vinate GT

Vinate One

Vinate Ultra

Vol-Nate

Women's Prenatal + DHA

Platelet-Aggregation Inhibitors

aspirin oral tablet

aspirin oral tablet,chewable

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

27


aspirin oral tablet,delayed release (DR/EC) 325

mg, 500 mg, 81 mg

aspirin rectal

aspirin-dipyridamole

butalbital-aspirin-caffeine oral capsule

cilostazol

clopidogrel

dipyridamole oral

prasugrel

Thrombolytic Agents

Activase intravenous recon soln 50 mg Specialty PA

aspirin oral tablet



mg, 500 mg, 81 mg

aspirin rectal


Cathflo Activase Specialty PA

Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

carvedilol

doxazosin

labetalol oral

prazosin

terazosin

Alpha-Adrenergic Blocking

Agt.(Hypoten)

doxazosin

labetalol oral

prazosin

terazosin

Angiotensin Ii Receptor

Antagon.(Hypotn)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

28


amlodipine-valsartan ST

Avalide oral tablet 150-12.5 mg ST

irbesartan ST

irbesartan-hydrochlorothiazide ST

losartan

losartan-hydrochlorothiazide

olmesartan ST

olmesartan-hydrochlorothiazide ST

telmisartan ST

valsartan ST

valsartan-hydrochlorothiazide ST

Angiotensin Ii Receptor Antagonists



Entresto

irbesartan ST


losartan


olmesartan ST


telmisartan ST

valsartan ST


Angiotensin-Convert.Enzyme

Inhib(Hypotn)

amlodipine-benazepril

benazepril

benazepril-hydrochlorothiazide

captopril

captopril-hydrochlorothiazide

enalapril maleate

enalapril-hydrochlorothiazide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

29


fosinopril

fosinopril-hydrochlorothiazide

lisinopril

lisinopril-hydrochlorothiazide

moexipril

moexipril-hydrochlorothiazide

perindopril erbumine

quinapril

quinapril-hydrochlorothiazide

ramipril

trandolapril

Angiotensin-Converting Enzyme

Inhibitors


benazepril


captopril


enalapril maleate


fosinopril


lisinopril


moexipril


perindopril erbumine

quinapril


ramipril

trandolapril

Antiarrhythmics, Miscellaneous

Digox

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

30


digoxin oral solution

magnesium sulfate injection Specialty PA

Antilipemic Agents, Miscellaneous

Juxtapid Specialty PA

Kynamro Specialty PA

niacin oral capsule, extended release 250 mg

niacin oral tablet 500 mg

niacin oral tablet extended release 24 hr ST

niacin oral tablet extended release 250 mg, 500

mg, 750 mg

Beta-Adrenergic Blocking Agents

acebutolol

atenolol


bisoprolol fumarate


carvedilol

labetalol oral




mg

nadolol


pindolol

propranolol oral





Beta-Adrenergic Blocking

Agt.(Hypoten)

acebutolol

atenolol

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

31



bisoprolol fumarate


labetalol oral




mg

nadolol


pindolol

propranolol oral





Bile Acid Sequestrants

cholestyramine (with sugar)

Cholestyramine Light oral powder in packet

colestipol

Prevalite oral powder

WelChol

Calcium-Channel

Block.Agt,Misc(Hypoten)

diltiazem HCl oral capsule,ext.rel 24h degradable

diltiazem HCl oral capsule,extended release 12 hr


diltiazem HCl oral capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg

diltiazem HCl oral tablet

verapamil oral capsule,ext rel. pellets 24 hr

verapamil oral tablet

verapamil oral tablet extended release

Calcium-Channel Blocking Agents

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

32


amlodipine







120 mg, 180 mg, 240 mg, 300 mg


felodipine

nicardipine oral

nifedipine




Calcium-Channel Blocking

Agents(Hypoten)





120 mg, 180 mg, 240 mg, 300 mg





Calcium-Channel Blocking Agents,

Misc.





120 mg, 180 mg, 240 mg, 300 mg


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

33





Carbonic Anhydrase

Inhibitors(Hypoten)

acetazolamide

Cardiotonic Agents

Digox

digoxin oral solution

Central Alpha-Agonists

clonidine

clonidine HCl oral tablet

Clorpres

guanfacine oral tablet

guanfacine oral tablet extended release 24 hr AL

methyldopa


Class Ia Antiarrhythmics

disopyramide phosphate oral capsule

quinidine gluconate oral

quinidine sulfate oral tablet

Class Ib Antiarrhythmics

Dilantin

mexiletine

phenytoin oral suspension

phenytoin oral tablet,chewable

phenytoin sodium extended oral capsule 100 mg

Class Ic Antiarrhythmics

flecainide

propafenone oral tablet

Class Ii Antiarrhythmics

acebutolol

atenolol

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

34



bisoprolol fumarate


carvedilol

labetalol oral




mg

nadolol


pindolol

propranolol oral





Class Iii Antiarrhythmics

amiodarone oral tablet 200 mg, 400 mg

Pacerone oral tablet 100 mg



Class Iv Antiarrhythmics





120 mg, 180 mg, 240 mg, 300 mg





Dihydropyridines

amlodipine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

35




felodipine

nicardipine oral

nifedipine

Dihydropyridines (Antihypertensive)

amlodipine



felodipine

nicardipine oral

nifedipine

Direct Vasodilators

BiDil

hydralazine oral

minoxidil oral

Diuretics, Miscellaneous (Hypotensive)

Theo-24

theophylline oral tablet extended release 12 hr

Fibric Acid Derivatives

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg

fenofibrate nanocrystallized

fenofibrate oral tablet 160 mg, 54 mg

gemfibrozil

Hmg-Coa Reductase Inhibitors

atorvastatin

lovastatin

pravastatin

rosuvastatin

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5

mg

Hypotensive Agents, Miscellaneous

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

36


acebutolol

amlodipine



carvedilol

doxazosin

felodipine

nicardipine oral

nifedipine

phenoxybenzamine

pindolol

propranolol oral



terazosin


Loop Diuretics (Hypotensive Agents)

bumetanide oral

furosemide oral

torsemide oral

Mineralocorticoid (Aldosterone)

Antagnts

Aldactazide oral tablet 50-50 mg

spironolactone

spironolacton-hydrochlorothiaz

Mineralocorticoid(Aldoster.)Antag(Hyp

ot)


spironolactone


Nitrates And Nitrites

BiDil

Isordil

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

37


isosorbide dinitrate oral

isosorbide mononitrate

Nitro-Bid

Nitro-Dur transdermal patch 24 hour 0.3 mg/hr,

0.8 mg/hr

nitroglycerin oral capsule, extended release 2.5

mg, 6.5 mg

nitroglycerin sublingual tablet 0.4 mg

nitroglycerin transdermal patch 24 hour

Nitrostat sublingual tablet 0.3 mg, 0.6 mg

Nitro-Time oral capsule, extended release 9 mg

Pcsk9 Inhibitors

Praluent Pen Specialty PA

Repatha Pushtronex Specialty PA

Repatha SureClick Specialty PA

Repatha Syringe Specialty PA

Peripheral Adrenergic Inhibitors

reserpine oral tablet 0.25 mg

Phosphodiesterase Type 5 Inhibitors

Adcirca Specialty PA

cilostazol

Revatio intravenous Specialty PA

Revatio oral suspension for reconstitution Specialty PA

sildenafil (antihypertensive) oral Specialty PA

Potassium-Sparing Diuretics (Hypoten)


amiloride

amiloride-hydrochlorothiazide

spironolactone


triamterene-hydrochlorothiazid

Renin-Angioten.-Aldost. Sys. Inhib,

Misc

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

38


Entresto

Thiazide Diuretics(Hypotensive Agents)







chlorothiazide

Diuril



hydrochlorothiazide




methyclothiazide











Thiazide-Like Diuretics(Hypotensive

Agt)


chlorthalidone oral tablet 25 mg, 50 mg

Clorpres

indapamide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

39


metolazone

Vasodilating Agents, Miscellaneous

Adempas Specialty PA

amlodipine








120 mg, 180 mg, 240 mg, 300 mg


dipyridamole oral

epoprostenol (glycine) Specialty PA

felodipine

Letairis Specialty PA

nicardipine oral

nifedipine

Opsumit Specialty PA

Orenitram Specialty PA

Remodulin Specialty PA

Tracleer Specialty PA

Tyvaso Specialty PA

Tyvaso Refill Kit Specialty PA

Tyvaso Starter Kit Specialty PA

Uptravi Specialty PA

Veletri Specialty PA

Ventavis Specialty PA




Cellular And Gene Therapy

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

40


Cellular And Gene Therapy

Provenge Specialty PA

Cellular Therapy

Provenge Specialty PA

Central Nervous System Agents

Adamantanes (Cns)

amantadine HCl oral capsule

amantadine HCl oral solution

Amphetamines

dextroamphetamine oral capsule, extended release AL

dextroamphetamine oral tablet AL

dextroamphetamine-amphetamine AL

Vyvanse AL

Analgesics And Antipyretics, Misc.

acetaminophen oral elixir

acetaminophen oral liquid 160 mg/5 mL

acetaminophen oral suspension 160 mg/5 mL

acetaminophen oral tablet 500 mg

acetaminophen rectal

acetaminophen-codeine oral solution 120-12 mg/5

mL AL

acetaminophen-codeine oral tablet 300-15 mg,

300-60 mg QL; AL

acetaminophen-codeine oral tablet 300-30 mg AL

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

butalbital-acetaminophen oral tablet 50-325 mg

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

gabapentin oral capsule

gabapentin oral solution 250 mg/5 mL

gabapentin oral tablet 600 mg, 800 mg

hydrocodone-acetaminophen oral solution 7.5-

325 mg/15 mL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

41


hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg QL

Infant's Non-Aspirin oral drops

Non-Aspirin Jr Strength

oxycodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg QL

Prialt Specialty PA

tramadol-acetaminophen QL; AL

Anticholinergic Agents (Cns)

benztropine oral

trihexyphenidyl

Anticonvulsants, Miscellaneous

Banzel ST; AL

carbamazepine oral suspension 100 mg/5 mL

carbamazepine oral tablet

carbamazepine oral tablet extended release 12 hr

carbamazepine oral tablet,chewable

divalproex

gabapentin oral capsule

gabapentin oral solution 250 mg/5 mL

gabapentin oral tablet 600 mg, 800 mg

lamotrigine oral tablet

lamotrigine oral tablet, chewable dispersible

lamotrigine oral tablets,dose pack

levetiracetam intravenous Specialty PA

levetiracetam oral solution 100 mg/mL

levetiracetam oral tablet


oxcarbazepine oral tablet

Sabril oral tablet Specialty PA

topiramate oral capsule, sprinkle

topiramate oral tablet

valproic acid

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

42


valproic acid (as sodium salt) oral solution 250

mg/5 mL

vigabatrin Specialty PA

zonisamide

Antidepressants, Miscellaneous

bupropion HCl

bupropion HCl (smoking deter) QL

mirtazapine

Antimanic Agents

divalproex

lithium carbonate

lithium citrate oral solution 8 mEq/5 mL

valproic acid


mg/5 mL

Antimigraine Agents, Miscellaneous

aspirin oral tablet



mg, 500 mg, 81 mg

aspirin rectal


325-40-30 mg


40 mg


codeine-butalbital-ASA-caff

dihydroergotamine injection

divalproex

Ergomar

ergotamine-caffeine

Migranal QL

propranolol oral


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

43



valproic acid


mg/5 mL

Antipsychotics, Miscellaneous

loxapine succinate AL

pimozide AL

Anxiolytics,Sedatives,And

Hypnotics,Misc

buspirone

droperidol injection solution AL

eszopiclone ST

hydroxyzine pamoate

meprobamate

promethazine oral

promethazine rectal

zaleplon

zolpidem oral tablet

Atypical Antipsychotics

Abilify Maintena Specialty PA

aripiprazole oral solution AL

aripiprazole oral tablet QL; AL

Aristada Specialty PA

clozapine QL; AL

Geodon intramuscular AL

Invega Sustenna Specialty PA

Invega Trinza Specialty PA

Latuda QL; AL

olanzapine intramuscular AL

olanzapine oral QL; AL

olanzapine-fluoxetine oral capsule 12-25 mg, 12-

50 mg, 3-25 mg, 6-25 mg QL; AL

olanzapine-fluoxetine oral capsule 6-50 mg AL

paliperidone QL; AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

44


quetiapine QL; AL

Risperdal Consta Specialty PA

risperidone oral solution QL; AL

risperidone oral tablet QL; AL

risperidone oral tablet,disintegrating QL; AL

ziprasidone HCl QL; AL

Zyprexa Relprevv Specialty PA

Barbiturates (Anticonvulsants)

phenobarbital

primidone

Barbiturates (Anxiolytic, Sedative/Hyp)


325-40-30 mg

butalbital-acetaminophen oral tablet 50-325 mg


40 mg



phenobarbital

Benzodiazepines (Anticonvulsants)

clonazepam oral tablet

clorazepate dipotassium

Diazepam Intensol

diazepam oral solution

diazepam oral tablet

diazepam rectal QL

lorazepam oral

Benzodiazepines

(Anxiolytic,Sedativ/Hyp)

alprazolam oral tablet

amitriptyline-chlordiazepoxide

chlordiazepoxide HCl

clonazepam oral tablet

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

45


clorazepate dipotassium

Diazepam Intensol

diazepam oral solution

diazepam oral tablet

diazepam rectal QL

estazolam

lorazepam oral

oxazepam

temazepam oral capsule 15 mg, 30 mg

triazolam

Butyrophenones

haloperidol AL

haloperidol decanoate AL

haloperidol lactate injection AL

haloperidol lactate oral AL

Central Nervous System Agents, Misc.

atomoxetine AL

Austedo Specialty PA

guanfacine oral tablet

guanfacine oral tablet extended release 24 hr AL

Ingrezza Specialty PA

memantine oral tablet AL

memantine oral tablets,dose pack

Radicava Specialty PA

riluzole

Xenazine Specialty PA

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib QL

Dopamine Precursors

carbidopa-levodopa oral tablet

carbidopa-levodopa oral tablet extended release

Ergot-Deriv. Dopamine Receptor

Agonists

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

46


bromocriptine

cabergoline ST

Fibromyalgia Agents

duloxetine oral capsule,delayed release(DR/EC)

20 mg, 30 mg


60 mg QL

Savella

Hydantoins

Dilantin

phenytoin oral suspension

phenytoin oral tablet,chewable

phenytoin sodium extended oral capsule 100 mg

Monoamine Oxidase B Inhibitors

selegiline HCl

Monoamine Oxidase Inhibitors

phenelzine

selegiline HCl

tranylcypromine

Nonergot-Deriv.Dopamine Receptor

Agonist

APOKYN Specialty PA

pramipexole oral tablet

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg

Opiate Agonists

acetaminophen-codeine oral solution 120-12 mg/5

mL AL

acetaminophen-codeine oral tablet 300-15 mg,

300-60 mg QL; AL

acetaminophen-codeine oral tablet 300-30 mg AL


325-40-30 mg

codeine sulfate oral tablet AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

47



fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL

hydrocodone-acetaminophen oral solution 7.5-

325 mg/15 mL

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg QL

hydromorphone oral liquid

hydromorphone oral tablet QL

hydromorphone rectal

meperidine oral solution

meperidine oral tablet QL

morphine concentrate oral solution

morphine oral solution

morphine oral tablet QL

morphine oral tablet extended release QL

oxycodone oral concentrate

oxycodone oral solution

oxycodone oral tablet QL

oxycodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg QL

tramadol oral tablet QL; AL


Opiate Antagonists

naltrexone

Narcan nasal spray,non-aerosol 4 mg/actuation QL

Vivitrol QL

Opiate Partial Agonists

buprenorphine HCl sublingual QL; AL

buprenorphine-naloxone QL; AL

butorphanol tartrate nasal PA; QL

nalbuphine

Other Nonsteroidal Anti-Inflam. Agents

diclofenac potassium

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

48


diclofenac sodium oral

diclofenac sodium topical gel 1 % ST

diflunisal

etodolac oral capsule

etodolac oral tablet

fenoprofen oral tablet

Ibuprofen IB oral tablet

ibuprofen oral suspension

ibuprofen oral tablet 100 mg, 400 mg, 600 mg,

800 mg

indomethacin oral capsule

ketoprofen oral capsule

ketorolac oral QL

meclofenamate

meloxicam oral tablet

nabumetone

naproxen

naproxen sodium oral capsule

naproxen sodium oral tablet

oxaprozin

piroxicam

sulindac

Phenothiazines

chlorpromazine AL

fluphenazine decanoate AL

fluphenazine HCl injection AL

fluphenazine HCl oral tablet AL

perphenazine AL

perphenazine-amitriptyline AL

prochlorperazine AL

prochlorperazine Edisylate AL

prochlorperazine maleate AL

thioridazine

trifluoperazine AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

49


Respiratory And Cns Stimulants


325-40-30 mg


40 mg


caffeine citrate oral


dexmethylphenidate AL

methylphenidate HCl oral capsule, ER biphasic

30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60

mg

AL

methylphenidate HCl oral solution 10 mg/5 mL AL

methylphenidate HCl oral tablet AL

methylphenidate HCl oral tablet extended release

20 mg AL

methylphenidate HCl oral tablet extended release

24hr 18 mg, 27 mg, 36 mg, 54 mg AL

Salicylates

aspirin oral tablet



mg, 500 mg, 81 mg

aspirin rectal



choline,magnesium salicylate


salsalate

Sel.Serotonin,Norepi Reuptake

Inhibitor


20 mg, 30 mg, 60 mg QL

Savella

venlafaxine oral capsule,extended release 24hr

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

50


venlafaxine oral tablet

Selective Serotonin Agonists

Imitrex nasal spray,non-aerosol 5 mg/actuation QL

naratriptan

rizatriptan QL

sumatriptan nasal spray,non-aerosol 20

mg/actuation QL

sumatriptan succinate oral QL

sumatriptan succinate subcutaneous cartridge QL

sumatriptan succinate subcutaneous pen injector QL

sumatriptan succinate subcutaneous solution QL

Selective-Serotonin Reuptake Inhibitors

citalopram

escitalopram oxalate oral tablet

fluoxetine oral capsule

fluoxetine oral solution

fluvoxamine oral tablet

olanzapine-fluoxetine oral capsule 12-25 mg, 12-

50 mg, 3-25 mg, 6-25 mg QL; AL

olanzapine-fluoxetine oral capsule 6-50 mg AL

paroxetine HCl oral tablet

sertraline oral concentrate

sertraline oral tablet QL

Serotonin Modulators

nefazodone

trazodone

Succinimides

ethosuximide

Thioxanthenes

thiothixene AL

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

51


amoxapine

clomipramine

desipramine

doxepin oral

imipramine HCl

maprotiline

nortriptyline

perphenazine-amitriptyline AL

Vesicular Monoamine Transport2

Inhibitor

Austedo Specialty PA

Ingrezza Specialty PA

Xenazine Specialty PA

Contraceptives (E.G. Foams, Devices)

Contraceptives (E.G. Foams, Devices)

Vaginal Contraceptive Foam

Devices

Devices

Accu-Chek Aviva Control Soln

Accu-Chek FastClix QL

Accu-Chek FastClix kit

Accu-Chek Guide Glucose Meter QL

Accu-Chek Guide L1-L2 Ctrl Sol

Accu-Chek Multiclix Lancet QL

Accu-Chek Multiclix Lancet kit

Accu-Chek SmartView Contrl Sol

Accu-Chek Soft Dev Lancets

Accu-Chek Softclix Lancet Dev

Accu-Chek Softclix Lancets

Aerochamber Plus Flow-Vu

Euflexxa Specialty PA

Gel-One Specialty PA

Gelsyn-3 Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

52


GenVisc 850 Specialty PA

heparin (porcine) in NaCl (PF) Specialty PA

Hyalgan Specialty PA

Insulin Syringe syringe 0.5 mL 29 gauge x 1/2"

lancets

Monovisc Specialty PA

ORTHOVISC Specialty PA

pen needle, diabetic needle 29 gauge x 1/2"

sodium chloride inhalation solution for

nebulization 0.9 % QL

Soft Touch Lancets

Solesta Specialty PA

Supartz FX Specialty PA

Synvisc Specialty PA

Synvisc-One Specialty PA

Diagnostic Agents

Adrenocortical Insufficiency

Acthar H.P. Specialty PA

cosyntropin injection Specialty PA

Diabetes Mellitus

Accu-Chek Aviva Plus test strp QL

Accu-Chek Guide QL

Accu-Chek SmartView Test Strip QL

Thyroid Function

Thyrogen Specialty PA

Electrolytic, Caloric, And Water

Balance

Alkalinizing Agents

Oracit

potassium citrate oral tablet extended release 10

mEq (1,080 mg), 5 mEq (540 mg)

sodium citrate-citric acid

Ammonia Detoxicants

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

53


Carbaglu Specialty PA

lactulose oral solution 10 gram/15 mL

Caloric Agents

Clinisol SF 15 % Specialty PA

D5 %-0.45 % sodium chloride Specialty PA

dextrose 70 % in water (D70W) Specialty PA

Intralipid intravenous emulsion 20 % Specialty PA

Liposyn III intravenous emulsion 10 %, 30 % Specialty PA

Prosol 20 % Specialty PA

Travasol 10 % Specialty PA

TrophAmine 10 % Specialty PA

Carbonic Anhydrase Inhibitors

acetazolamide

Diuretics, Miscellaneous

Theo-24


Loop Diuretics

bumetanide oral

furosemide oral

torsemide oral

Phosphate-Removing Agents

calcium acetate oral capsule

sevelamer carbonate oral tablet

Potassium-Removing Agents

sodium polystyrene (sorb free)

SPS (with sorbitol) rectal

Potassium-Sparing Diuretics


amiloride


spironolactone



AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

54


Replacement Preparations

Atabex EC

Daily Prenatal

Klor-Con


Mynatal Plus

Mynatal-Z

O-Cal FA

O-Cal Prenatal


potassium bicarb-citric acid

potassium chloride oral capsule, extended release

10 mEq

potassium chloride oral liquid

potassium chloride oral tablet extended release 10

mEq, 8 mEq

potassium chloride oral tablet,ER

particles/crystals

Prenatabs FA

Prenatal Low Iron

Prenatal Plus


sodium chloride inhalation solution for

nebulization 0.9 % QL

TPN Electrolytes Specialty PA

TPN Electrolytes II Specialty PA

TriAdvance

Trinatal Rx 1

Trinate

Triveen-Duo DHA

Vinate One

Vinate Ultra

Vol-Nate

Thiazide Diuretics

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

55








chlorothiazide

Diuril



hydrochlorothiazide




methyclothiazide











Thiazide-Like Diuretics


chlorthalidone oral tablet 25 mg, 50 mg

Clorpres

indapamide

metolazone

Uricosuric Agents

probenecid

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

56


probenecid-colchicine

Vasopressin Antagonists

Samsca Specialty PA

Enzymes

Enzymes

Activase intravenous recon soln 50 mg Specialty PA

Adagen Specialty PA

Aldurazyme Specialty PA

Cathflo Activase Specialty PA

Cerezyme intravenous recon soln 400 unit Specialty PA

Elaprase Specialty PA

Elelyso Specialty PA

Elitek Specialty PA

Fabrazyme Specialty PA

Lumizyme Specialty PA

Naglazyme Specialty PA

Pulmozyme Specialty PA

Sucraid Specialty PA

Voraxaze Specialty PA

VPRIV Specialty PA

Xiaflex Specialty PA

Eye, Ear, Nose And Throat (Eent)

Preps.

Alpha-Adrenergic Agonists (Eent)

brimonidine

Antiallergic Agents

azelastine nasal

azelastine ophthalmic (eye) ST; QL

cromolyn ophthalmic (eye)

ketotifen fumarate

olopatadine ophthalmic (eye) drops 0.1 % ST; QL

Antibacterials (Eent)

bacitracin-polymyxin B ophthalmic (eye)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

57


Ciprodex

ciprofloxacin HCl ophthalmic (eye)

doxycycline hyclate oral tablet 20 mg

erythromycin ophthalmic (eye)

Gentak ophthalmic (eye) ointment

gentamicin ophthalmic (eye) drops

Moxeza

moxifloxacin ophthalmic (eye)

neomycin-bacitracin-poly-HC

neomycin-bacitracin-polymyxin

neomycin-polymyxin B-dexameth

neomycin-polymyxin-gramicidin

neomycin-polymyxin-HC

ofloxacin ophthalmic (eye)

ofloxacin otic (ear)

polymyxin B sulf-trimethoprim

sulfacetamide sodium ophthalmic (eye) drops

sulfacetamide-prednisolone

tobramycin

tobramycin-dexamethasone

Tobrex ophthalmic (eye) ointment

Antivirals (Eent)

trifluridine

Beta-Adrenergic Blocking Agents (Eent)

carteolol

dorzolamide-timolol QL

levobunolol ophthalmic (eye) drops 0.5 %

metipranolol

timolol maleate ophthalmic (eye) drops

timolol maleate ophthalmic (eye) gel forming

solution

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

58


Azopt

dorzolamide

dorzolamide-timolol QL

Corticosteroids (Eent)

Ciprodex

dexamethasone sodium phosphate ophthalmic

(eye)

Flarex

fluorometholone

fluticasone nasal

FML Forte

FML S.O.P.

hydrocortisone-acetic acid

Maxidex


neomycin-polymyxin B-dexameth

neomycin-polymyxin-HC ophthalmic (eye)

Ozurdex Specialty PA

Pred Mild

prednisolone acetate

prednisolone sodium phosphate ophthalmic (eye)

Retisert Specialty PA

tobramycin-dexamethasone

Eent Anti-Infectives, Miscellaneous

acetic acid otic (ear)

chlorhexidine gluconate mucous membrane

hydrocortisone-acetic acid

Eent Anti-Inflammatory Agents, Misc.

Restasis ST

Restasis MultiDose ST

Xiidra ST

Eent Drugs, Miscellaneous

apraclonidine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

59


Eylea Specialty PA

Iopidine ophthalmic (eye) dropperette

ipratropium bromide nasal

Lucentis intravitreal solution 0.3 mg/0.05 mL Specialty PA

Lucentis intravitreal syringe Specialty PA

Macugen Specialty PA

Visudyne Specialty PA

Eent Nonsteroidal Anti-Inflam. Agents

diclofenac sodium ophthalmic (eye)

flurbiprofen sodium

ketorolac ophthalmic (eye)

Local Anesthetics (Eent)

lidocaine HCl mucous membrane jelly in

applicator

lidocaine HCl mucous membrane solution 4 %

(40 mg/mL)

Lidocaine Viscous

proparacaine

tetracaine HCl

tetracaine HCl (PF) ophthalmic (eye)

Miotics

Phospholine Iodide

pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %,

4 %

Mydriatics

atropine ophthalmic (eye)

cyclopentolate ophthalmic (eye) drops 1 %, 2 %

tropicamide

Prostaglandin Analogs

latanoprost

Vasoconstrictors

phenylephrine HCl ophthalmic (eye)

Gastrointestinal Drugs

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

60


5-Ht3 Receptor Antagonists

granisetron (PF) Specialty PA

granisetron HCl intravenous Specialty PA

granisetron HCl oral ST

ondansetron QL

ondansetron HCl (PF) injection solution Specialty PA

ondansetron HCl intravenous Specialty PA

ondansetron HCl oral solution QL

ondansetron HCl oral tablet 4 mg, 8 mg QL

palonosetron Specialty PA

Antidiarrhea Agents


loperamide oral capsule

Antiemetics, Miscellaneous

Diclegis PA

Antihistamines (Gi Drugs)

Diclegis PA

meclizine oral tablet 12.5 mg, 25 mg

prochlorperazine AL

prochlorperazine Edisylate AL

prochlorperazine maleate AL

trimethobenzamide oral

Anti-Inflammatory Agents (Gi Drugs)

balsalazide

Canasa

Delzicol oral capsule (with del rel tablets)

Dipentum

mesalamine oral tablet,delayed release (DR/EC)

1.2 gram

mesalamine rectal

Pentasa

sulfasalazine

Cathartics And Laxatives

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

61


Amitiza

Atabex EC

Obstetrix EC

peg 3350-electrolytes

peg-electrolyte soln

polyethylene glycol 3350 oral powder


Vinate Ultra

Cholelitholytic Agents

ursodiol

Digestants

Creon

Zenpep oral capsule,delayed release(DR/EC)

10,000-32,000 -42,000 unit, 20,000-63,000-

84,000 unit, 25,000-79,000- 105,000 unit, 25,000-

85,000- 136,000 unit, 3,000-10,000- 16,000 unit,

40,000-126,000- 168,000 unit, 5,000-17,000 -

27,000 unit, 5,000-17,000- 24,000 unit

Gi Drugs, Miscellaneous

Cimzia Specialty PA

Cimzia Powder for Reconst Specialty PA

Endari Specialty PA

Entyvio Specialty PA

Gattex 30-Vial Specialty PA

Humira Specialty PA

Humira Pediatric Crohn's Start subcutaneous

syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40

mg/0.4 mL

Specialty PA

Humira Pen Crohn's-UC-HS Start Specialty PA

Humira Pen subcutaneous pen injector kit 40

mg/0.4 mL Specialty PA

Inflectra Specialty PA

Linzess oral capsule 145 mcg, 290 mcg AL

Ocaliva Specialty PA

Remicade Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

62


Renflexis Specialty PA

Histamine H2-Antagonists

cimetidine

cimetidine HCl oral

famotidine oral

nizatidine

ranitidine HCl injection solution 50 mg/2 mL (25

mg/mL) Specialty PA

ranitidine HCl oral syrup

ranitidine HCl oral tablet

Neurokinin-1 Receptor Antagonists

aprepitant oral capsule 80 mg

aprepitant oral capsule,dose pack

Emend oral capsule 125 mg

Emend oral capsule 40 mg QL

Prokinetic Agents

metoclopramide HCl oral solution

metoclopramide HCl oral tablet

Prostaglandins

misoprostol

Protectants

sucralfate oral tablet

Proton-Pump Inhibitors

esomeprazole magnesium ST; QL

lansoprazole oral capsule,delayed release(DR/EC) ST; QL

Nexium 24HR oral tablet,delayed release

(DR/EC) ST; QL

omeprazole oral capsule,delayed release(DR/EC) QL

omeprazole-sodium bicarbonate oral capsule 20-

1.1 mg-gram ST; QL

pantoprazole oral QL

Prilosec oral susp,delayed release for recon QL; AL

Gold Compounds

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

63


Gold Compounds

Ridaura

Heavy Metal Antagonists

Heavy Metal Antagonists

Chemet

deferoxamine Specialty PA

Exjade Specialty PA

Ferriprox oral tablet Specialty PA

Galzin Specialty PA

Jadenu Specialty PA

Jadenu Sprinkle Specialty PA

trientine Specialty PA

Hormones And Synthetic Substitutes

Adrenals

ArmonAir RespiClick

Arnuity Ellipta

Asmanex HFA

Asmanex Twisthaler QL

Breo Ellipta

budesonide inhalation QL; AL

cortisone

dexamethasone

Dexamethasone Intensol

dexamethasone sodium phos (PF)

dexamethasone sodium phosphate injection

solution

Emflaza Specialty PA

Flovent Diskus QL

Flovent HFA QL

fludrocortisone

hydrocortisone oral

Intrarosa

Medrol oral tablet 2 mg

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

64


methylprednisolone

methylprednisolone sodium succ intravenous Specialty PA

prednisolone oral solution 15 mg/5 mL

prednisolone sodium phosphate oral solution 15

mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5

mL)

prednisone

Prednisone Intensol

Pulmicort Flexhaler

Qvar QL

Qvar RediHaler QL

Solu-Cortef (PF) injection recon soln 100 mg/2

mL

Androgens

danazol PA

testosterone PA

testosterone cypionate QL

testosterone enanthate QL

Antidiabetic Agents, Miscellaneous

WelChol

Antiestrogens

anastrozole

exemestane Specialty PA

letrozole QL

Antigonadtropins




Antiparathyroid Agents

calcitonin (salmon)

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg

propylthiouracil

SSKI

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

65


Biguanides

alogliptin-metformin ST

glipizide-metformin

glyburide-metformin

Janumet ST

Janumet XR ST

metformin oral tablet

metformin oral tablet extended release 24 hr

pioglitazone-metformin ST

Segluromet ST

Contraceptives

Aftera

Aranelle (28)

Balziva (28)

desog-e.estradiol/e.estradiol

desogestrel-ethinyl estradiol

EContra EZ

Ella

ethynodiol diac-eth estradiol oral tablet 1-50 mg-

mcg

Kyleena

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-0.03 mg

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

levonorg-eth estrad triphasic

Liletta

Low-Ogestrel (28)

Microgestin 1.5/30 (21)

Microgestin Fe 1.5/30 (28)

Mirena

My Way

Nexplanon

norethindrone (contraceptive)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

66


norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg

norethindrone-e.estradiol-iron oral tablet 1 mg-20

mcg (21)/75 mg (7)

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-

mcg

norgestrel-ethinyl estradiol

Nortrel 0.5/35 (28)

Nortrel 1/35 (21)

Nortrel 7/7/7 (28)

NuvaRing

ParaGard T 380A

Skyla

Velivet Triphasic Regimen (28)

Xulane

Zovia 1/35E (28)

Dipeptidyl Peptidase-4(Dpp-4)

Inhibitors

alogliptin ST

alogliptin-metformin ST

alogliptin-pioglitazone ST

Janumet ST

Janumet XR ST

Januvia ST

Estrogen Agonist-Antagonists

Fareston PA

raloxifene

tamoxifen

Estrogens

estradiol oral

estradiol transdermal patch semiweekly

estradiol transdermal patch weekly 0.025 mg/24

hr, 0.075 mg/24 hr QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

67


estradiol transdermal patch weekly 0.0375 mg/24

hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.1 mg/24 hr

estropipate oral tablet 0.75 mg, 1.5 mg

Femhrt Low Dose

Jinteli

Menest oral tablet 0.3 mg, 0.625 mg, 1.25 mg

Premarin oral

Premarin vaginal

Premphase

Prempro

Glycogenolytic Agents

Glucagon Emergency Kit (human) QL

Gonadotropins













Synarel Specialty PA

Trelstar Specialty PA

Vantas Specialty PA


Gonadotropins And Antigonadotropins




AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

68











Synarel Specialty PA

Vantas Specialty PA


Incretin Mimetics

Ozempic

Trulicity

Victoza 2-Pak

Victoza 3-Pak

Insulins

Admelog SoloStar U-100 Insulin QL

Admelog U-100 Insulin lispro QL

Basaglar KwikPen U-100 Insulin QL

Humalog Junior KwikPen U-100 QL

Humalog Mix 50-50 Insuln U-100 QL

Humalog Mix 50-50 KwikPen QL

Humalog Mix 75-25 KwikPen QL

Humalog Mix 75-25(U-100)Insuln QL

Humulin 70/30 U-100 Insulin QL

Humulin 70/30 U-100 KwikPen QL

Humulin N NPH Insulin KwikPen QL

Humulin N NPH U-100 Insulin QL

Humulin R Regular U-100 Insuln QL

Humulin R U-500 (Conc) Insulin QL

Novolin 70/30 U-100 Insulin QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

69


Novolin N NPH U-100 Insulin QL

Novolin R Regular U-100 Insuln QL

Novolog Mix 70-30 U-100 Insuln QL

Novolog Mix 70-30FlexPen U-100 QL

Parathyroid Agents

Forteo Specialty PA

Tymlos Specialty PA

Parathyroid And Antiparathyroid

Agents

calcitonin (salmon)

Forteo Specialty PA

Tymlos Specialty PA

Pituitary

Acthar H.P. Specialty PA

DDAVP nasal solution PA

desmopressin nasal spray,non-aerosol PA

desmopressin oral PA

Genotropin Specialty PA

Genotropin MiniQuick Specialty PA

Humatrope Specialty PA

Norditropin FlexPro Specialty PA

Nutropin AQ Nuspin Specialty PA

Omnitrope Specialty PA

Saizen click.easy Specialty PA

Saizen subcutaneous recon soln 8.8 mg Specialty PA

Serostim subcutaneous recon soln 4 mg, 5 mg, 6

mg Specialty PA

Progestins

Crinone

Depo-Provera intramuscular suspension 400

mg/mL

Femhrt Low Dose

hydroxyprogesterone capr(bulk)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

70


hydroxyprogesterone caproate

Jinteli

Makena

Makena (PF)

medroxyprogesterone

megestrol oral suspension 400 mg/10 mL (40

mg/mL)

megestrol oral suspension 625 mg/5 mL QL

megestrol oral tablet

norethindrone acetate

progesterone micronized

Sodium-Gluc Cotransport 2 (Sglt2)

Inhib

Segluromet ST

Steglatro ST

Somatostatin Agonists

octreotide acetate Specialty PA

Signifor Specialty PA

Somatuline Depot Specialty PA

Somatotropin Agonists

Increlex Specialty PA

Somatotropin Antagonists

Somavert subcutaneous recon soln 15 mg, 20 mg Specialty PA

Sulfonylureas

chlorpropamide

glimepiride

glipizide

glipizide-metformin

glyburide

glyburide micronized

glyburide-metformin

tolazamide

tolbutamide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

71


Thiazolidinediones

alogliptin-pioglitazone ST

pioglitazone ST

pioglitazone-metformin ST

Thyroid Agents

Armour Thyroid oral tablet 180 mg, 240 mg, 30

mg, 300 mg, 60 mg, 90 mg

levothyroxine oral

liothyronine oral

Nature-Throid oral tablet 130 mg, 16.25 mg, 195

mg, 32.5 mg, 65 mg

NP Thyroid oral tablet 15 mg

thyroid (pork) oral tablet 120 mg

Thyrolar-1

Thyrolar-1/2

Thyrolar-1/4

Thyrolar-2

Thyrolar-3

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

dutasteride

finasteride oral tablet 5 mg

Alcohol Deterrents

disulfiram

naltrexone

Vivitrol QL

Antidotes

Chemet

deferoxamine Specialty PA

Glucagon Emergency Kit (human) QL

leucovorin calcium injection recon soln Specialty PA

leucovorin calcium oral

levoleucovorin Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

72



Mephyton

Narcan nasal spray,non-aerosol 4 mg/actuation QL

sevelamer carbonate oral tablet


SPS (with sorbitol) rectal

SSKI

Voraxaze Specialty PA

Antigout Agents

allopurinol

colchicine oral tablet ST; QL

indomethacin oral capsule

Krystexxa Specialty PA

naproxen

naproxen sodium oral capsule

naproxen sodium oral tablet

probenecid

probenecid-colchicine

Antisense Oligonucleotides

Kynamro Specialty PA

Spinraza (PF) Specialty PA

Bone Resorption Inhibitors

alendronate oral tablet

calcitonin (salmon)

etidronate disodium

ibandronate intravenous syringe Specialty PA

pamidronate Specialty PA

Prolia Specialty PA

raloxifene

Xgeva Specialty PA

zoledronic acid Specialty PA

zoledronic acid-mannitol-water Specialty PA

Zometa intravenous piggyback Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

73


Cariostatic Agents

fluoride (sodium) oral drops AL

fluoride (sodium) oral tablet,chewable AL

Fluoridex Daily Defense dental paste AL


Multivitamin With Fluoride

Multi-Vitamin With Fluoride oral drops

Multi-Vitamin With Fluoride oral tablet,chewable

0.25 mg, 1 mg

Multivitamins With Fluoride oral tablet,chewable

1 mg

PreviDent dental solution

SF AL

SF 5000 Plus AL


Tri-Vitamin With Fluoride

Complement Inhibitors

Berinert intravenous kit Specialty PA

Cinryze Specialty PA

Firazyr Specialty PA

Haegarda Specialty PA

Kalbitor Specialty PA

Soliris Specialty PA

Disease-Modifying Antirheumatic

Agents

Actemra Specialty PA

azathioprine

Cimzia Specialty PA


cyclosporine intravenous Specialty PA

cyclosporine modified oral capsule

cyclosporine oral capsule

Enbrel Specialty PA

Enbrel Mini Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

74


Enbrel SureClick Specialty PA

Humira Specialty PA


syringe kit 80 mg/0.8 mL Specialty PA




hydroxychloroquine


Kevzara Specialty PA

Kineret Specialty PA

leflunomide

methotrexate sodium


Orencia Specialty PA

Orencia (with maltose) Specialty PA

Orencia ClickJect Specialty PA

Otezla Specialty PA

Otezla Starter Specialty PA



Ridaura

Sandimmune intravenous Specialty PA

Sandimmune oral solution

Simponi Specialty PA

Simponi ARIA Specialty PA

Stelara intravenous Specialty PA

Stelara subcutaneous syringe Specialty PA

sulfasalazine


Xeljanz Specialty PA

Xeljanz XR Specialty PA

Gonadotropin-Releasing Hormone

Antagnts

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

75





Immunomodulatory Agents

Actemra Specialty PA

Actimmune Specialty PA

Aubagio Specialty PA

Avonex (with albumin) Specialty PA

Avonex intramuscular pen injector kit Specialty PA

Avonex intramuscular syringe kit Specialty PA

azathioprine

Betaseron Specialty PA

Cimzia Specialty PA


Copaxone subcutaneous syringe Specialty PA




Enbrel Specialty PA

Enbrel Mini Specialty PA

Enbrel SureClick Specialty PA

Entyvio Specialty PA

Extavia Specialty PA

Gilenya Specialty PA

glatiramer Specialty PA

Glatopa subcutaneous syringe 20 mg/mL Specialty PA

Humira Specialty PA


syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40

mg/0.4 mL

Specialty PA




hydroxychloroquine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

76




Kevzara Specialty PA

Kineret Specialty PA

leflunomide

Lemtrada Specialty PA

methotrexate sodium


Ocrevus Specialty PA

Orencia Specialty PA

Orencia (with maltose) Specialty PA

Orencia ClickJect Specialty PA

Plegridy Specialty PA

Pomalyst Specialty PA

Proleukin Specialty PA

Rebif (with albumin) Specialty PA

Rebif Titration Pack Specialty PA



Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25

mg, 5 mg Specialty PA

Ridaura



Simponi Specialty PA

Simponi ARIA Specialty PA



sulfasalazine

Tecfidera Specialty PA

Thalomid Specialty PA


Tysabri Specialty PA

Xeljanz Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

77


Xeljanz XR Specialty PA

Immunosuppressive Agents

Atgam Specialty PA

azathioprine

Benlysta intravenous Specialty PA

CellCept oral suspension for reconstitution

cyclophosphamide intravenous Specialty PA




Elidel PA

mercaptopurine

methotrexate sodium


mycophenolate mofetil

mycophenolate mofetil HCl Specialty PA

mycophenolate sodium PA

Prograf intravenous Specialty PA

Rapamune oral solution PA



Simulect Specialty PA

sirolimus PA

tacrolimus oral

Thymoglobulin Specialty PA


Zortress Specialty PA

Other Miscellaneous Therapeutic

Agents

acetylcysteine

Ampyra Specialty PA

Arcalyst Specialty PA

Botox Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

78


Cerdelga Specialty PA

Demser Specialty PA

Dysport Specialty PA

Endari Specialty PA

Evotaz

Ilaris (PF) subcutaneous solution Specialty PA

Kuvan Specialty PA

levocarnitine (with sugar) Specialty PA

levocarnitine oral tablet

miglustat Specialty PA

Myobloc Specialty PA

octreotide acetate Specialty PA

Orfadin oral capsule 10 mg, 2 mg, 5 mg Specialty PA

Panhematin intravenous recon soln 350 mg Specialty PA

Prezcobix


Spinraza (PF) Specialty PA

Tybost

Xeomin Specialty PA

Protective Agents

amifostine crystalline Specialty PA

dexrazoxane HCl Specialty PA

Elmiron QL

mesna Specialty PA

Oxytocics

Oxytocics

Methergine QL

Respiratory Tract Agents

Alpha And Beta Adrenergic

Agonist(Respr)


epinephrine injection auto-injector 0.15 mg/0.3

mL, 0.3 mg/0.3 mL QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

79


epinephrine injection solution

epinephrine injection syringe 0.1 mg/mL

Loratadine-D

Anticholinergic Agents (Respir.Tract)

Anoro Ellipta

Atrovent HFA

Combivent Respimat


ipratropium bromide inhalation


Spiriva Respimat AL

Antifibrotic Agents

Esbriet Specialty PA

Anti-Inflammatory Agents

(Respiratory)

Nucala Specialty PA

Antitussives

codeine sulfate oral tablet AL

Cystic Fibrosis (Cftr) Correctors

Orkambi Specialty PA

Symdeko Specialty PA

Cystic Fibrosis (Cftr) Potentiators

Kalydeco Specialty PA

Orkambi Specialty PA

Symdeko Specialty PA

Expectorants

SSKI

First Generation Antihist.(Respir Tract)


cyproheptadine

Diclegis PA


mg/mL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

80






ED Chlorped Jr

promethazine oral


Interleukin Antagonists

Cinqair Specialty PA

Fasenra Specialty PA

Leukotriene Modifiers

montelukast oral granules in packet QL; AL

montelukast oral tablet QL

montelukast oral tablet,chewable QL

Mast-Cell Stabilizers

cromolyn inhalation

cromolyn ophthalmic (eye)

Mucolytic Agents

acetylcysteine

Pulmozyme Specialty PA

Nasal Preparations (Steroids)

fluticasone nasal

Orally Inhaled Preparations (Steroids)

ArmonAir RespiClick

Arnuity Ellipta

Asmanex HFA

Asmanex Twisthaler QL

Breo Ellipta

budesonide inhalation QL; AL

Flovent Diskus QL

Flovent HFA QL

Pulmicort Flexhaler

Qvar QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

81


Qvar RediHaler QL

Phosphodiesterase Type 4 Inhibitors

Daliresp ST

Respiratory Tract Agents,

Miscellaneous

Aralast NP Specialty PA

Glassia Specialty PA

Prolastin-C intravenous recon soln Specialty PA

Xolair Specialty PA

Zemaira Specialty PA

Second Generation Antihist(Respir

Tract)

cetirizine oral solution 1 mg/mL

cetirizine oral tablet


fexofenadine oral suspension ST

fexofenadine oral tablet 180 mg ST

levocetirizine oral tablet

loratadine oral solution

loratadine oral tablet

loratadine oral tablet,disintegrating

Loratadine-D

Select.Beta-2-Adrenergic

Agonist(Respir)

albuterol sulfate inhalation solution for

nebulization

albuterol sulfate oral syrup

albuterol sulfate oral tablet

Anoro Ellipta

Breo Ellipta

Combivent Respimat


levalbuterol tartrate ST

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

82


metaproterenol oral syrup

Serevent Diskus

terbutaline oral

Ventolin HFA QL

Xopenex HFA ST

Vasodilating Agents (Respiratory Tract)

Adcirca Specialty PA

Adempas Specialty PA

epoprostenol (glycine) Specialty PA

Letairis Specialty PA

Opsumit Specialty PA

Orenitram Specialty PA

Remodulin Specialty PA

Revatio intravenous Specialty PA

Revatio oral suspension for reconstitution Specialty PA

sildenafil (antihypertensive) oral Specialty PA

Tracleer Specialty PA

Tyvaso Specialty PA

Tyvaso Refill Kit Specialty PA

Tyvaso Starter Kit Specialty PA

Uptravi Specialty PA

Veletri Specialty PA

Ventavis Specialty PA

Xanthine Derivatives

Theo-24


Skin And Mucous Membrane Agents

Antibacterials (Skin, Mucous

Membrane)

Cleocin vaginal suppository

clindamycin phosphate topical gel

clindamycin phosphate topical lotion

clindamycin phosphate topical solution

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

83


clindamycin phosphate topical swab

clindamycin phosphate vaginal

Ery Pads

erythromycin with ethanol topical gel

erythromycin with ethanol topical solution

erythromycin-benzoyl peroxide

gentamicin topical

Metrogel topical gel 1 %

metronidazole topical cream

metronidazole topical gel 0.75 %

metronidazole vaginal

mupirocin

Anti-Inflammatory Agents (Skin,

Mucous)

amcinonide topical cream

Anucort-HC

betamethasone dipropionate

betamethasone valerate topical cream

betamethasone valerate topical lotion

betamethasone valerate topical ointment

betamethasone, augmented

clobetasol scalp

clobetasol topical cream

clobetasol topical gel

clobetasol topical ointment

clobetasol-emollient topical cream

clotrimazole-betamethasone

desonide

desoximetasone topical cream

desoximetasone topical gel

desoximetasone topical ointment 0.25 %

diflorasone

fluocinolone topical cream

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

84


fluocinolone topical ointment

fluocinolone topical solution

fluocinonide topical cream 0.05 %

fluocinonide topical gel

fluocinonide topical ointment

fluocinonide topical solution

Fluocinonide-E

fluticasone topical cream

fluticasone topical ointment

hydrocortisone acetate rectal suppository 25 mg

hydrocortisone butyrate topical cream

hydrocortisone butyrate topical ointment

hydrocortisone butyrate topical solution

hydrocortisone rectal

hydrocortisone topical cream 1 %, 2.5 %

hydrocortisone topical lotion 2.5 %

hydrocortisone topical ointment 1 %, 2.5 %

hydrocortisone valerate

hydrocortisone-min oil-wht pet

hydrocortisone-pramoxine rectal cream 1-1 %

mometasone topical cream QL

mometasone topical ointment QL

mometasone topical solution

Oralone

PramCort

Proctofoam HC

triamcinolone acetonide dental

triamcinolone acetonide topical cream

triamcinolone acetonide topical lotion

triamcinolone acetonide topical ointment 0.025

%, 0.1 %, 0.5 %

Antipruritics And Local Anesthetics


lidocaine HCl topical cream 3 %

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

85


lidocaine-prilocaine topical cream QL

phenazopyridine oral tablet 100 mg, 200 mg

PramCort

Proctofoam HC

Antivirals (Skin And Mucous

Membrane)

Abreva

acyclovir topical PA

Zovirax topical cream PA

Astringents

Drysol

Azoles (Skin And Mucous Membrane)

clotrimazole mucous membrane

clotrimazole topical


econazole

ketoconazole topical cream

ketoconazole topical shampoo

Miconazole-3 vaginal suppository

terconazole

Basic Lotions And Liniments

ammonium lactate topical lotion

Basic Ointments And Protectants

ammonium lactate topical cream

Cell Stimulants And Proliferants

Kepivance Specialty PA

tretinoin topical cream AL

tretinoin topical gel 0.01 %, 0.025 % AL

Corticosteroids (Skin, Mucous

Membrane)

amcinonide topical cream

Anucort-HC

betamethasone dipropionate

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

86


betamethasone valerate topical cream

betamethasone valerate topical lotion

betamethasone valerate topical ointment

betamethasone, augmented

clobetasol scalp

clobetasol topical cream

clobetasol topical gel

clobetasol topical ointment

clobetasol-emollient topical cream


desonide

desoximetasone topical cream

desoximetasone topical gel

desoximetasone topical ointment 0.25 %

diflorasone

fluocinolone topical cream

fluocinolone topical ointment

fluocinolone topical solution

fluocinonide topical cream 0.05 %

fluocinonide topical gel

fluocinonide topical ointment

fluocinonide topical solution

Fluocinonide-E

fluticasone topical cream

fluticasone topical ointment

hydrocortisone acetate rectal suppository 25 mg

hydrocortisone butyrate topical cream

hydrocortisone butyrate topical ointment

hydrocortisone butyrate topical solution

hydrocortisone rectal

hydrocortisone topical cream 1 %, 2.5 %

hydrocortisone topical lotion 2.5 %

hydrocortisone topical ointment 1 %, 2.5 %

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

87


hydrocortisone valerate



mometasone topical cream QL

mometasone topical ointment QL

mometasone topical solution

Oralone

PramCort

Proctofoam HC

triamcinolone acetonide dental

triamcinolone acetonide topical cream

triamcinolone acetonide topical lotion

triamcinolone acetonide topical ointment 0.025

%, 0.1 %, 0.5 %

U-Cort

Hydroxypyridones (Skin, Mucous

Membrane)

ciclopirox topical suspension

Keratolytic Agents

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v)

urea topical cream 40 %, 50 %

urea topical lotion 40 %

Keratoplastic Agents

Drithocreme HP

Local Anti-Infectives, Miscellaneous

silver sulfadiazine

sulfacetamide sodium (acne)

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

88


Nonsteroidal Anti-

Inflammat.Agents(Skin)


Pigmenting Agents

Oxsoralen Ultra Specialty PA

Polyenes (Skin And Mucous Membrane)

nystatin topical

nystatin-triamcinolone

Scabicides And Pediculicides

Cutter Backwoods topical aerosol,spray QL; AL

Cutter Skinsations QL; AL

Lice Killing

Lice Killing (permethrin)

Off Active QL; AL

Off Deep Woods Dry QL; AL

Off Deep Woods topical aerosol,spray QL; AL

Off FamilyCare (with DEET) topical aerosol

powder QL; AL

permethrin topical cream QL

Repel Sportsmen QL; AL

Repel Sportsmen Max topical aerosol,spray QL; AL

Sklice ST

Skin And Mucous Membrane Agents,

Misc.

Cosentyx Specialty PA

Cosentyx (2 Syringes) Specialty PA

Cosentyx Pen Specialty PA

Cosentyx Pen (2 Pens) Specialty PA

Cutter Backwoods topical aerosol,spray QL; AL

Cutter Skinsations QL; AL


Dupixent Specialty PA

Elidel PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

89


imiquimod QL

Insect Repellent (picaridin) QL; AL

Natrapel QL; AL

Off Active QL; AL

Off Deep Woods Dry QL; AL

Off Deep Woods topical aerosol,spray QL; AL

Off FamilyCare (with DEET) topical aerosol

powder QL; AL

podofilox

Repel Sportsmen QL; AL

Repel Sportsmen Max topical aerosol,spray QL; AL

Santyl

Siliq Specialty PA



tacrolimus topical PA

Taltz Autoinjector Specialty PA

Taltz Syringe Specialty PA

Targretin topical Specialty PA

Tremfya Specialty PA

Smooth Muscle Relaxants

Antimuscarinics

flavoxate

oxybutynin chloride

Oxytrol For Women

tolterodine

trospium oral tablet

Respiratory Smooth Muscle Relaxants

Theo-24


Vitamins

Multivitamin Preparations

Atabex EC

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

90


Cadeau DHA

Children's Chewable Multivitmn

Complete Natal DHA


Daily Prenatal


Multivitamin With Fluoride

Multi-Vitamin With Fluoride oral drops

Multi-Vitamin With Fluoride oral tablet,chewable

0.25 mg, 1 mg

Multivitamins With Fluoride oral tablet,chewable

1 mg

Mynatal

Mynatal Plus

Mynatal-Z

Mynate 90 Plus

Obstetrix DHA

Obstetrix EC

O-Cal FA

O-Cal Prenatal

One Daily Essential oral tablet 0.4 mg


Prenatabs FA


mcg-200 mg

Prenatal 19


Prenatal Gummy

Prenatal Low Iron



mcg-228 mg

Prenatal Plus


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

91



Prenatal-U

Se-Natal 19


TriAdvance

Trinatal Rx 1

Trinate

Triveen-Duo DHA



Vinate GT

Vinate II

Vinate M

Vinate One

Vinate Ultra

Vol-Nate


Vitamin A


Vitamin B Complex

Atabex EC

Cadeau DHA


cyanocobalamin (vitamin B-12) injection


Daily Prenatal

Diclegis PA

FE C Plus

folic acid oral capsule 0.8 mg AL

folic acid oral tablet 1 mg

folic acid oral tablet 400 mcg, 800 mcg AL

Multigen Folic

Multigen Plus

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

92



Mynatal Plus

Mynatal-Z

Nicomide

Obstetrix DHA

Obstetrix EC

O-Cal FA

O-Cal Prenatal

One Daily Essential oral tablet 0.4 mg

Prenatabs FA


mcg-200 mg

Prenatal 19


Prenatal Gummy

Prenatal Low Iron



mcg-228 mg

Prenatal Plus



pyridoxine (vitamin B6) oral tablet 100 mg

Se-Natal 19


TriAdvance

Trinatal Rx 1

Trinate

Triveen-Duo DHA

Vinate GT

Vinate One

Vinate Ultra

Vol-Nate


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step Therapy

93


Vitamin C

FE C Plus

Multigen Folic

Multigen Plus


Vitamin D

calcitriol intravenous solution 1 mcg/mL

calcitriol oral capsule

cholecalciferol (vitamin D3) oral capsule 400 unit AL

cholecalciferol (vitamin D3) oral tablet 400 unit AL

cholecalciferol (vitamin D3) oral tablet,chewable

400 unit AL

ergocalciferol (vitamin D2) oral capsule



Vitamin K Activity

Mephyton

94

Index

A abacavir .................................... 8

abacavir-lamivudine ................. 8

Abelcet ................................... 12

Abilify Maintena .................... 43

Abraxane ................................ 13

Abreva .................................... 85

Accu-Chek Aviva Control Soln

............................................ 51

Accu-Chek Aviva Plus test strp

............................................ 52

Accu-Chek FastClix ............... 51

Accu-Chek Guide ................... 52

Accu-Chek Guide Glucose

Meter .................................. 51

Accu-Chek Guide L1-L2 Ctrl

Sol....................................... 51

Accu-Chek Multiclix Lancet .. 51

Accu-Chek SmartView Contrl

Sol....................................... 51

Accu-Chek SmartView Test

Strip .................................... 52

Accu-Chek Soft Dev Lancets . 51

Accu-Chek Softclix Lancet Dev

............................................ 51

Accu-Chek Softclix Lancets... 51

acebutolol ............. 23, 30, 33, 36

acetaminophen ........................ 40

acetaminophen-codeine .... 40, 46

acetazolamide ............. 33, 53, 57

acetic acid ............................... 58

acetylcysteine ................... 77, 80

Actemra ............................ 73, 75

Acthar H.P. ....................... 52, 69

Actimmune ............................. 75

Activase ............................ 27, 56

acyclovir ........................... 11, 85

Adagen ................................... 56

Adcetris .................................. 13

Adcirca ............................. 37, 82

adefovir................................... 11

Adempas ........................... 39, 82

Admelog SoloStar U-100

Insulin ................................. 68

Admelog U-100 Insulin lispro 68

Advate .................................... 24

Aerochamber Plus Flow-Vu ... 51

Afinitor ................................... 13

Afinitor Disperz...................... 14

Afluria 2017-2018 .................. 19

Afluria 2017-2018 (PF) .......... 19

Afluria Quad 2017-2018 ........ 19

Afluria Quad 2017-2018 (PF) 19

Aftera ...................................... 65

albuterol sulfate ................ 22, 81

Aldactazide ..... 36, 37, 38, 53, 55

Aldurazyme ............................ 56

Alecensa ................................. 14

alendronate ............................. 72

Alferon N .......................... 10, 14

alfuzosin ................................. 22

Alimta ..................................... 14

allopurinol .............................. 72

alogliptin ................................. 66

alogliptin-metformin ........ 65, 66

alogliptin-pioglitazone...... 66, 71

Alphanate................................ 24

AlphaNine SD ........................ 24

alprazolam .............................. 44

amantadine HCl .................. 3, 40

AmBisome .............................. 12

amcinonide ....................... 83, 85

Amicar .................................... 24

amifostine crystalline ............. 78

amikacin ............................... 3, 5

amiloride ........................... 37, 53


.......................... 37, 38, 53, 55

aminocaproic acid................... 24

amiodarone ............................. 34

Amitiza ................................... 61

amitriptyline ........................... 50


...................................... 44, 50

amlodipine ...... 32, 34, 35, 36, 39

amlodipine-benazepril ..... 28, 29,

32, 35, 36, 39

amlodipine-valsartan . 28, 32, 35,

36, 39

ammonium lactate .................. 85

amoxapine .............................. 51

amoxicillin ................................ 4

amoxicillin-pot clavulanate ...... 4

ampicillin .................................. 4

ampicillin sodium ..................... 4

ampicillin-sulbactam ................ 4

Ampyra ................................... 77

anastrozole ........................ 14, 64

Anoro Ellipta ........ 20, 22, 79, 81

Anucort-HC ...................... 83, 85

APOKYN ............................... 46

apraclonidine .......................... 58

aprepitant ................................ 62

Aptivus ..................................... 9

Aralast NP .............................. 81

Aranelle (28) ........................... 65

Aranesp (in polysorbate) ........ 23

Arcalyst................................... 77

aripiprazole ............................. 43

Aristada................................... 43

ArmonAir RespiClick ....... 63, 80

Armour Thyroid...................... 71

Arnuity Ellipta .................. 63, 80

Arranon ................................... 14

Arzerra .................................... 14

Asmanex HFA .................. 63, 80

Asmanex Twisthaler ......... 63, 80

aspirin ................... 26, 27, 42, 49

aspirin-dipyridamole... 27, 39, 49

Atabex EC ...... 25, 54, 61, 89, 91

atazanavir .................................. 9

atenolol ....................... 23, 30, 33

atenolol-chlorthalidone .... 23, 30,

31, 34, 38, 55

Atgam ..................................... 77

atomoxetine ............................ 45

atorvastatin ............................. 35

atovaquone ................................ 5

atovaquone-proguanil ............... 4

Atripla ................................... 8, 9

atropine ................................... 59

Atrovent HFA ................... 20, 79

Aubagio .................................. 75

Austedo ............................. 45, 51

Avalide ....................... 28, 38, 55

Avastin .................................... 14

Avonex ................................... 75

Avonex (with albumin)........... 75

Azactam in dextrose (iso-osm)

............................................ 11

azathioprine ................ 73, 75, 77

azelastine ................................ 56

azithromycin ........................... 12

Azopt ...................................... 58

aztreonam ............................... 11

B bacitracin-polymyxin B .......... 56

95

baclofen .................................. 21

balsalazide .............................. 60

Balziva (28) ............................ 65

Banzel ..................................... 41

Basaglar KwikPen U-100

Insulin ................................. 68

benazepril ......................... 28, 29


.......................... 28, 29, 38, 55

BeneFIX ................................. 24

Benlysta .................................. 77

benztropine ....................... 20, 41

Berinert ................................... 73

betamethasone dipropionate .. 83,

85

betamethasone valerate .... 83, 86

betamethasone, augmented.... 83,

86

Betaseron ................................ 75

bethanechol chloride .............. 22

bexarotene .............................. 14

bicalutamide ........................... 14

Bicillin L-A ............................ 11

BiCNU .................................... 14

BiDil ................................. 35, 36

Biktarvy ................................ 8, 9

Biltricide ................................... 4

bisoprolol fumarate ... 23, 30, 31,

34


.............. 23, 30, 31, 34, 38, 55

bleomycin ............................... 14

Bosulif .................................... 14

Botox ................................ 23, 77

Breo Ellipta .......... 22, 63, 80, 81

brimonidine ............................ 56

bromocriptine ......................... 46

budesonide ........................ 63, 80

bumetanide ....................... 36, 53

buprenorphine HCl ................. 47

buprenorphine-naloxone......... 47

bupropion HCl ........................ 42

bupropion HCl (smoking deter)

............................................ 42

buspirone ................................ 43

busulfan .................................. 14

butalbital-acetaminop-caf-cod

.................... 40, 42, 44, 46, 49

butalbital-acetaminophen . 40, 44

butalbital-acetaminophen-caff

.......................... 40, 42, 44, 49

butalbital-aspirin-caffeine 27, 42,

44, 49

butorphanol tartrate ................ 47

C cabergoline ............................. 46

Cadeau DHA .............. 25, 90, 91

caffeine citrate ........................ 49

calcitonin (salmon) ..... 64, 69, 72

calcitriol .................................. 93

calcium acetate ....................... 53

Camptosar ............................... 14

Canasa .................................... 60

capecitabine ............................ 14

Caprelsa .................................. 14

captopril ............................ 28, 29

captopril-hydrochlorothiazide28,

29, 38, 55

Carbaglu ................................. 53

carbamazepine ........................ 41

carbidopa-levodopa ................ 45

carboplatin .............................. 14

Carimune NF Nanofiltered ..... 18

carisoprodol ............................ 21

carteolol .................................. 57

carvedilol .. 21, 22, 27, 30, 34, 36

caspofungin .............................. 6

Cathflo Activase ............... 27, 56

Cayston ................................... 11

cefaclor ..................................... 2

cefadroxil .................................. 2

cefazolin ................................... 2

cefdinir...................................... 2

cefepime ................................... 3

cefepime in dextrose 5 % ......... 3

cefepime in dextrose,iso-osm ... 3

cefotaxime ................................ 2

cefotetan ............................... 2, 6

cefotetan in dextrose, iso-osm . 2,

6

cefpodoxime ............................. 3

cefprozil .................................... 2

ceftazidime ............................... 3

ceftriaxone ................................ 3

ceftriaxone in dextrose,iso-os ... 3

cefuroxime axetil ...................... 2

cefuroxime sodium ................... 2

celecoxib ................................. 45

CellCept .................................. 77

cephalexin ................................. 2

Cerdelga .................................. 78

Cerezyme ................................ 56

cetirizine ............................. 1, 81

cetirizine-pseudoephedrine 2, 20,

78, 81

Chantix ................................... 21

Chantix Starting Month Box .. 21

Chemet .............................. 63, 71


...................................... 90, 91

chlordiazepoxide HCl ............. 44

chlorhexidine gluconate.......... 58

chloroquine phosphate .............. 4

chlorothiazide ................... 38, 55

chlorpheniramine maleate .. 1, 79

chlorpromazine ....................... 48

chlorpropamide ....................... 70

chlorthalidone ................... 38, 55

chlorzoxazone ......................... 21

cholecalciferol (vitamin D3)... 93

cholestyramine (with sugar) ... 31

Cholestyramine Light ............. 31

choline,magnesium salicylate . 49

ciclopirox ................................ 87

cidofovir ................................. 11

cilostazol ........................... 27, 37

Cimduo ..................................... 9

cimetidine ............................... 62

cimetidine HCl........................ 62

Cimzia......................... 61, 73, 75

Cimzia Powder for Reconst ... 61,

73, 75

Cinqair .................................... 80

Cinryze ................................... 73

Ciprodex ........................... 57, 58

ciprofloxacin ....................... 5, 12

ciprofloxacin (mixture) ....... 5, 12

ciprofloxacin HCl ......... 5, 12, 57

ciprofloxacin in 5 % dextrose .. 5,

12

cisplatin................................... 14

citalopram ............................... 50

cladribine ................................ 14

Claforan .................................... 3

clarithromycin..................... 5, 12

Cleocin .................................... 82

clindamycin HCl ..................... 10

clindamycin in 5 % dextrose .. 10

clindamycin palmitate HCl ..... 10

96

clindamycin phosphate .... 10, 82,

83

Clinisol SF 15 % .................... 53

clobetasol .......................... 83, 86

clobetasol-emollient ......... 83, 86

clofarabine .............................. 14

clomipramine .......................... 51

clonazepam ............................. 44

clonidine ........................... 20, 33

clonidine HCl ................... 20, 33

clopidogrel .............................. 27

clorazepate dipotassium ... 44, 45

Clorpres ................ 20, 33, 38, 55

clotrimazole ............................ 85

clotrimazole-betamethasone .. 83,

85, 86

clozapine................................. 43

codeine sulfate .................. 46, 79

codeine-butalbital-ASA-caff . 42,

44, 47, 49

colchicine ............................... 72

colestipol ................................ 31

colistin (colistimethate Na) .... 12

Combivent Respimat . 20, 22, 79,

81

Cometriq ................................. 14

Complera .............................. 8, 9

Complete Natal DHA ............. 90

Copaxone ................................ 75

Corifact ................................... 24

cortisone ................................. 63

Cosentyx ................................. 88

Cosentyx (2 Syringes) ............ 88

Cosentyx Pen .......................... 88

Cosentyx Pen (2 Pens)............ 88

cosyntropin ............................. 52

Creon ...................................... 61

Crinone ................................... 69

Crixivan .................................... 9

cromolyn........................... 56, 80

Cutter Backwoods .................. 88

Cutter Skinsations .................. 88

cyanocobalamin (vitamin B-12)

............................................ 91

cyclobenzaprine ...................... 21

cyclopentolate......................... 59

cyclophosphamide ............ 14, 77

cyclosporine ............... 73, 75, 77

cyclosporine modified 73, 75, 77

cyproheptadine ................... 1, 79

cytarabine ............................... 14

cytarabine (PF) ....................... 14

CytoGam ................................ 19

Cytovene ................................. 11

D D5 %-0.45 % sodium chloride53

dacarbazine ............................. 14

Dacogen .................................. 14

dactinomycin .......................... 14

Daily Multivitamin with Iron 25,

90, 91

Daily Prenatal ....... 25, 54, 90, 91

Daklinza.................................... 7

Daliresp .................................. 81

danazol.................................... 64

dapsone ................................. 4, 5

daptomycin ............................... 6

Daraprim ................................... 4

daunorubicin ........................... 14

DDAVP ............................ 24, 69

deferoxamine .................... 63, 71

Delzicol .................................. 60

Demser.................................... 78

Depo-Provera.......................... 69

Descovy .................................... 9

desipramine ............................ 51

desmopressin .................... 24, 69

desog-e.estradiol/e.estradiol ... 65

desogestrel-ethinyl estradiol ... 65

desonide ............................ 83, 86

desoximetasone ................ 83, 86

dexamethasone ....................... 63

Dexamethasone Intensol......... 63

dexamethasone sodium phos

(PF) ..................................... 63

dexamethasone sodium

phosphate ...................... 58, 63

dexmethylphenidate................ 49

dexrazoxane HCl .................... 78

dextroamphetamine ................ 40

dextroamphetamine-

amphetamine ...................... 40

dextrose 70 % in water (D70W)

............................................ 53

diazepam ........................... 44, 45

Diazepam Intensol ............ 44, 45

Diclegis ....................... 60, 79, 91

diclofenac potassium .............. 47

diclofenac sodium....... 48, 59, 88

dicloxacillin ............................ 12

dicyclomine ............................ 20

didanosine ................................. 9

diflorasone ........................ 83, 86

diflunisal ................................. 48

Digox ................................ 29, 33

digoxin .............................. 30, 33

dihydroergotamine ............ 22, 42

Dilantin ............................. 33, 46

diltiazem HCl........ 31, 32, 34, 39

Dipentum ................................ 60

diphenhydramine HCl .. 1, 79, 80

diphenoxylate-atropine .... 20, 60,

79

dipyridamole ..................... 27, 39

disopyramide phosphate ......... 33

disulfiram ................................ 71

Diuril................................. 38, 55

divalproex ......................... 41, 42

Docefrez ................................. 14

docetaxel ................................. 14

donepezil................................. 22

doripenem ................................. 6

dorzolamide ............................ 58

dorzolamide-timolol ......... 57, 58

doxazosin .................... 21, 27, 36

doxepin ................................... 51

Doxil ....................................... 15

doxorubicin ............................. 15

Doxy-100 ................................ 13

doxycycline hyclate .......... 13, 57

doxycycline monohydrate ...... 13

Drithocreme HP ...................... 87

droperidol ............................... 43

Droxia ..................................... 15

Drysol ..................................... 85

duloxetine ......................... 46, 49

Dupixent ................................. 88

dutasteride............................... 71

Dysport ............................. 23, 78

E E.E.S. Granules................... 6, 10

econazole ................................ 85

EContra EZ ............................. 65

ED Chlorped Jr ................... 1, 80

Edurant ..................................... 8

efavirenz ................................... 8

Elaprase .................................. 56

Elelyso .................................... 56

Elidel................................. 77, 88

Eligard .............................. 15, 67

97

Eligard (3 month) ............. 15, 67

Eligard (4 month) ............. 15, 67

Eligard (6 month) ....... 15, 67, 68

Eliquis..................................... 23

Elitek ...................................... 56

Ella ......................................... 65

Elmiron ................................... 78

Emcyt ..................................... 15

Emend..................................... 62

Emflaza................................... 63

Emtriva ..................................... 9

enalapril maleate .............. 28, 29

enalapril-hydrochlorothiazide 28,

29, 38, 55

Enbrel ............................... 73, 75

Enbrel Mini ...................... 73, 75

Enbrel SureClick .............. 74, 75

Endari ............................... 61, 78

enoxaparin .............................. 25

entecavir ................................. 11

Entresto............................. 28, 38

Entyvio ............................. 61, 75

Epclusa ..................................... 7

epinephrine ................. 20, 78, 79

epirubicin ................................ 15

Epivir ........................................ 9

Epivir HBV .............................. 9

Epogen .................................... 24

epoprostenol (glycine) ...... 39, 82

Eraxis(Water Diluent) .............. 6

Erbitux .................................... 15

ergocalciferol (vitamin D2) .... 93

Ergomar ............................ 22, 42

ergotamine-caffeine .......... 22, 42

Erivedge ................................. 15

Erwinaze ................................. 15

Ery Pads.................................. 83

Ery-Tab............................... 6, 10

Erythrocin (as stearate)....... 6, 11

erythromycin ................ 6, 11, 57

erythromycin ethylsuccinate ... 6,

11

erythromycin with ethanol ..... 83

erythromycin-benzoyl peroxide

............................................ 83

Esbriet..................................... 79

escitalopram oxalate ............... 50

esomeprazole magnesium ...... 62

estazolam ................................ 45

estradiol ............................ 66, 67

estropipate .............................. 67

eszopiclone ............................. 43

ethambutol ................................ 5

ethosuximide .......................... 50

ethynodiol diac-eth estradiol .. 65

etidronate disodium ................ 72

etodolac .................................. 48

Etopophos ............................... 15

etoposide ................................. 15

Euflexxa.................................. 51

Evotaz ................................. 9, 78

exemestane ....................... 15, 64

Exjade ..................................... 63

Extavia .................................... 75

Eylea ....................................... 59

F Fabrazyme .............................. 56

famotidine ............................... 62

Fareston ............................ 15, 66

Fasenra.................................... 80

Faslodex.................................. 15

FE C Plus .................... 25, 91, 93

Feiba NF ................................. 24

felodipine .............. 32, 35, 36, 39

Femhrt Low Dose ............. 67, 69

fenofibrate .............................. 35

fenofibrate micronized ........... 35

fenofibrate nanocrystallized ... 35

fenoprofen .............................. 48

fentanyl ................................... 47

Feraheme ................................ 25

Ferriprox ................................. 63

Ferrlecit .................................. 25

fexofenadine ....................... 2, 81

finasteride ............................... 71

Firazyr .................................... 73

Firmagon .................... 15, 64, 75

Firmagon kit w diluent syringe

................................ 15, 64, 75

Flarex ...................................... 58

flavoxate ................................. 89

Flebogamma DIF .................... 19

flecainide ................................ 33

Flovent Diskus .................. 63, 80

Flovent HFA ..................... 63, 80

floxuridine .............................. 15

Fluarix Quad 2017-2018 (PF) 19

Flucelvax Quad 2017-2018 .... 19

Flucelvax Quad 2017-2018 (PF)

............................................ 19

fluconazole ........................... 5, 6

fluconazole in dextrose(iso-o) .. 5

fluconazole in NaCl (iso-osm).. 5

fludarabine .............................. 15

fludrocortisone ........................ 63

Flulaval Quad 2017-2018 ....... 19

Flulaval Quad 2017-2018 (PF)

............................................ 19

fluocinolone ................ 83, 84, 86

fluocinonide ...................... 84, 86

Fluocinonide-E ................. 84, 86

fluoride (sodium) .................... 73

Fluoridex Daily Defense......... 73

fluorometholone ..................... 58

fluorouracil ............................. 15

fluoxetine ................................ 50

fluphenazine decanoate .......... 48

fluphenazine HCl .................... 48

flurbiprofen sodium ................ 59

flutamide ................................. 15

fluticasone............. 58, 80, 84, 86

Fluvirin 2017-2018 ................. 19

Fluvirin 2017-2018 (PF) ......... 19

fluvoxamine ............................ 50

Fluzone High-Dose 2017-18

(PF) ..................................... 19

Fluzone Intraderm Quad 2017-

18 ........................................ 19

Fluzone Quad 2017-2018 ....... 19

Fluzone Quad 2017-2018 (PF)

............................................ 19

Fluzone Quad Pedi 2017-18

(PF) ..................................... 19

FML Forte .............................. 58

FML S.O.P.............................. 58

folic acid ................................. 91

Folotyn .................................... 15

Forteo ...................................... 69

fosamprenavir ........................... 9

foscarnet ................................... 5

fosinopril................................. 29


................................ 29, 38, 55

furosemide ........................ 36, 53

Fuzeon ...................................... 8

G gabapentin......................... 40, 41

Galzin ..................................... 63

GamaSTAN S/D ..................... 19

Gamunex-C............................. 19

98

Gattex 30-Vial ........................ 61

Gel-One .................................. 51

Gelsyn-3 ................................. 51

gemcitabine ............................ 15

gemfibrozil ............................. 35

Genotropin .............................. 69

Genotropin MiniQuick ........... 69

Gentak .................................... 57

gentamicin .................... 3, 57, 83

gentamicin in NaCl (iso-osm) .. 3

gentamicin sulfate (PF) ............ 3

GenVisc 850 ........................... 52

Genvoya ............................... 8, 9

Geodon ................................... 43

Gilenya ................................... 75

Glassia .................................... 81

glatiramer ............................... 75

Glatopa ................................... 75

Gliadel Wafer ......................... 15

glimepiride ............................. 70

glipizide .................................. 70

glipizide-metformin .......... 65, 70

Glucagon Emergency Kit

(human) ........................ 67, 71

glyburide................................. 70

glyburide micronized.............. 70

glyburide-metformin ........ 65, 70

glycopyrrolate......................... 20

granisetron (PF) ...................... 60

granisetron HCl ...................... 60

Granix ..................................... 24

griseofulvin microsize .............. 4

griseofulvin ultramicrosize ....... 4

guanfacine ........................ 33, 45

H Haegarda................................. 73

Halaven................................... 15

haloperidol .............................. 45

haloperidol decanoate ............. 45

haloperidol lactate .................. 45

Harvoni ..................................... 7

Hemofil M High ..................... 24

Hemofil M Low ...................... 24

Hemofil M Mid ...................... 24

Hemofil M Super High ........... 24

heparin (porcine) .................... 25

heparin (porcine) in 5 % dex .. 25

heparin (porcine) in NaCl (PF)

...................................... 25, 52

heparin, porcine (PF) .............. 25

Herceptin ................................ 15

Hexalen ................................... 15

Hizentra .................................. 19

Humalog Junior KwikPen U-

100 ...................................... 68

Humalog Mix 50-50 Insuln U-

100 ...................................... 68

Humalog Mix 50-50 KwikPen68

Humalog Mix 75-25 KwikPen68

Humalog Mix 75-25(U-

100)Insuln ........................... 68

Humate-P ................................ 24

Humatrope .............................. 69

Humira ........................ 61, 74, 75

Humira Pediatric Crohn's Start

................................ 61, 74, 75

Humira Pen ................. 61, 74, 75

Humira Pen Crohn's-UC-HS

Start ........................ 61, 74, 75

Humulin 70/30 U-100 Insulin 68

Humulin 70/30 U-100 KwikPen

............................................ 68

Humulin N NPH Insulin

KwikPen ............................. 68

Humulin N NPH U-100 Insulin

............................................ 68

Humulin R Regular U-100

Insuln .................................. 68

Humulin R U-500 (Conc)

Insulin ................................. 68

Hyalgan .................................. 52

Hycamtin ................................ 16

hydralazine ............................. 35

hydrochlorothiazide .......... 38, 55

hydrocodone-acetaminophen . 40,

41, 47

hydrocortisone ............ 63, 84, 86

hydrocortisone acetate ...... 84, 86

hydrocortisone butyrate .... 84, 86

hydrocortisone valerate .... 84, 87

hydrocortisone-acetic acid ...... 58


...................................... 84, 87

hydrocortisone-pramoxine 84, 87

hydromorphone ...................... 47

hydroxychloroquine...... 4, 74, 75

hydroxyprogesterone capr(bulk)

............................................ 69

hydroxyprogesterone caproate 70

hydroxyurea ............................ 16

hydroxyzine pamoate.......... 1, 43

hyoscyamine sulfate ............... 20

HyperRHO S/D ...................... 19

I ibandronate ............................. 72

Ibrance .................................... 16

ibuprofen................................. 48

Ibuprofen IB ........................... 48

Iclusig ..................................... 16

idarubicin ................................ 16

ifosfamide ............................... 16

ifosfamide-mesna ................... 16

Ilaris (PF) ................................ 78

imatinib ................................... 16

imipenem-cilastatin .................. 6

imipramine HCl ...................... 51

imiquimod............................... 89

Imitrex .................................... 50

Increlex ................................... 70

indapamide ....................... 38, 55

indomethacin .................... 48, 72

Infant's Non-Aspirin ............... 41

Infed ........................................ 25

Inflectra....................... 61, 74, 76

Ingrezza ............................ 45, 51

Injectafer ................................. 25

Inlyta ....................................... 16

Insect Repellent (picaridin) .... 89

Insulin Syringe........................ 52

Intelence ................................... 8

Intralipid ................................. 53

Intrarosa .................................. 63

Intron A ...................... 10, 16, 76

Invanz ....................................... 6

Invega Sustenna ...................... 43

Invega Trinza .......................... 43

Invirase ................................... 10

Iopidine ................................... 59

ipratropium bromide ... 20, 59, 79

ipratropium-albuterol . 20, 22, 79,

81

irbesartan ................................ 28

irbesartan-hydrochlorothiazide

................................ 28, 38, 55

irinotecan ................................ 16

Isentress .................................... 8

Isentress HD ............................. 8

isoniazid .................................... 5

Isordil ...................................... 36

isosorbide dinitrate ................. 37

99

isosorbide mononitrate ........... 37

itraconazole .............................. 6

Ixempra................................... 16

J Jadenu ..................................... 63

Jadenu Sprinkle ...................... 63

Jakafi ...................................... 16

Janumet............................. 65, 66

Janumet XR ...................... 65, 66

Januvia .................................... 66

Jevtana .................................... 16

Jinteli ................................ 67, 70

Juluca ........................................ 8

Juxtapid .................................. 30

K Kadcyla................................... 16

Kalbitor................................... 73

Kaletra .................................... 10

Kalydeco................................. 79

Kepivance ............................... 85

ketoconazole ....................... 6, 85

ketoprofen............................... 48

ketorolac ........................... 48, 59

ketotifen fumarate .................. 56

Kevzara............................. 74, 76

Kineret .............................. 74, 76

Klor-Con................................. 54

Kogenate FS ........................... 25

Krystexxa ............................... 72

Kuvan ..................................... 78

Kyleena................................... 65

Kynamro ........................... 30, 72

Kyprolis .................................. 16

L labetalol .... 21, 22, 27, 30, 31, 34

lactulose .................................. 53

lamivudine ................................ 9

lamivudine-zidovudine ............. 9

lamotrigine ............................. 41

lancets ..................................... 52

lansoprazole ............................ 62

latanoprost .............................. 59

Latuda ..................................... 43

leflunomide....................... 74, 76

Lemtrada................................. 76

Letairis .............................. 39, 82

letrozole ............................ 16, 64

leucovorin calcium ................. 71

Leukeran ................................. 16

Leukine ................................... 24

leuprolide .................... 16, 67, 68

levalbuterol tartrate........... 22, 81

levetiracetam .......................... 41

levobunolol ............................. 57

levocarnitine ........................... 78

levocarnitine (with sugar) ....... 78

levocetirizine ...................... 2, 81

levofloxacin ........................ 5, 12

levofloxacin in D5W .......... 5, 12

levoleucovorin ........................ 71

levonorgestrel-ethinyl estrad .. 65

levonorg-eth estrad triphasic .. 65

levothyroxine .......................... 71

Lexiva ..................................... 10

Lice Killing............................. 88

Lice Killing (permethrin) ....... 88

lidocaine HCl .................... 59, 84

Lidocaine Viscous .................. 59

lidocaine-prilocaine ................ 85

Liletta...................................... 65

Lincocin .................................. 10

Linzess .................................... 61

Lioresal ................................... 21

liothyronine ............................ 71

Liposyn III .............................. 53

lisinopril.................................. 29


................................ 29, 38, 55

lithium carbonate .................... 42

lithium citrate ......................... 42

loperamide .............................. 60

lopinavir-ritonavir .................. 10

loratadine ............................ 2, 81

Loratadine-D .......... 2, 20, 79, 81

lorazepam ......................... 44, 45

losartan ................................... 28

losartan-hydrochlorothiazide . 28,

38, 55

lovastatin ................................ 35

Low-Ogestrel (28) .................. 65

loxapine succinate .................. 43

Lucentis .................................. 59

Lumizyme ............................... 56

Lupron Depot ............. 16, 67, 68

Lupron Depot (3 month).. 16, 67,

68

Lupron Depot (4 month).. 16, 67,

68

Lupron Depot (6 Month) . 16, 67,

68

Lupron Depot-Ped ...... 16, 67, 68

Lupron Depot-Ped (3 month) 16,

67, 68

Lysodren ................................. 16

M Macugen ................................. 59

magnesium sulfate ...... 30, 41, 72

Makena ................................... 70

Makena (PF) ........................... 70

maprotiline .............................. 51

Matulane ................................. 16

Mavyret..................................... 7

Maxidex .................................. 58

meclizine............................. 1, 60

meclofenamate ........................ 48

Medrol .................................... 63

medroxyprogesterone ............. 70

mefloquine ................................ 4

megestrol .......................... 16, 70

meloxicam .............................. 48

melphalan ............................... 16

melphalan HCl ........................ 16

memantine .............................. 45

Menest .................................... 67

meperidine .............................. 47

Mephyton .......................... 72, 93

meprobamate .......................... 43

mercaptopurine ................. 16, 77

meropenem ............................... 6

mesalamine ............................. 60

mesna ...................................... 78

Mestinon ................................. 22

metaproterenol .................. 22, 82

metformin ............................... 65

Methergine .............................. 78

methimazole ........................... 64

methocarbamol ....................... 21

methotrexate sodium . 17, 74, 76,

77

methotrexate sodium (PF)17, 74,

76, 77

methyclothiazide............... 38, 55

methyldopa ....................... 20, 33


.......................... 20, 33, 38, 55

methylphenidate HCl .............. 49

methylprednisolone ................ 64

methylprednisolone sodium succ

............................................ 64

metipranolol ............................ 57

100

metoclopramide HCl .............. 62

metolazone ....................... 39, 55

metoprolol succinate . 23, 30, 31,

34


.............. 23, 30, 31, 34, 38, 55

metoprolol tartrate 23, 30, 31, 34

Metrogel ................................. 83

metronidazole ................. 3, 5, 83

metronidazole in NaCl (iso-os) 3,

5

mexiletine ............................... 33

Miconazole-3 .......................... 85

MICRhoGAM Ultra-Filtered

PLUS .................................. 19

Microgestin 1.5/30 (21) .......... 65

Microgestin Fe 1.5/30 (28) ..... 65

midodrine ............................... 20

miglustat ................................. 78

Migranal ........................... 22, 42

minocycline ............................ 13

minoxidil ................................ 35

Mirena .................................... 65

mirtazapine ............................. 42

misoprostol ............................. 62

mitomycin............................... 17

mitoxantrone........................... 17

moexipril ................................ 29


................................ 29, 38, 55

mometasone ...................... 84, 87

Monoclate-P ........................... 25

Monovisc ................................ 52

montelukast ............................ 80

morphine................................. 47

morphine concentrate ............. 47

Moxeza ................................... 57

moxifloxacin................. 5, 12, 57

Mozobil .................................. 24

Multigen ................................. 25

Multigen Folic ............ 25, 91, 93

Multigen Plus ............. 25, 91, 93

Multi-Vit with Fluoride-Iron . 25,

73, 90

Multivitamin With Fluoride .. 73,

90

Multi-Vitamin With Fluoride 73,

90

Multivitamins With Fluoride . 73,

90

mupirocin................................ 83

Mustargen ............................... 17

My Way .................................. 65

Mycamine ................................. 6

Mycobutin .......................... 5, 13

mycophenolate mofetil ........... 77

mycophenolate mofetil HCl ... 77

mycophenolate sodium ........... 77

Myleran .................................. 17

Mynatal ................. 25, 54, 90, 92

Mynatal Plus ......... 25, 54, 90, 92

Mynatal-Z ............. 26, 54, 90, 92

Mynate 90 Plus ....................... 90

Myobloc............................ 23, 78

N nabumetone ............................ 48

nadolol .................. 21, 30, 31, 34

nadolol-bendroflumethiazide. 21,

30, 31, 34, 38, 55

nafcillin ................................... 12

nafcillin in dextrose iso-osm .. 12

Naglazyme .............................. 56

nalbuphine .............................. 47

naltrexone ......................... 47, 71

naproxen ........................... 48, 72

naproxen sodium .............. 48, 72

naratriptan ............................... 50

Narcan .............................. 47, 72

Natrapel .................................. 89

Nature-Throid ......................... 71

Nebupent .................................. 5

nefazodone.............................. 50


...................................... 57, 58

neomycin-bacitracin-polymyxin

............................................ 57

neomycin-polymyxin B-

dexameth ...................... 57, 58

neomycin-polymyxin-

gramicidin ........................... 57

neomycin-polymyxin-HC . 57, 58

Neulasta .................................. 24

Neupogen................................ 24

nevirapine ................................. 8

Nexavar .................................. 17

Nexium 24HR......................... 62

Nexplanon .............................. 65

niacin ...................................... 30

nicardipine ............ 32, 35, 36, 39

Nicomide ................................ 92

Nicotrol ................................... 21

Nicotrol NS ............................. 21

nifedipine .............. 32, 35, 36, 39

nilutamide ............................... 17

Nitro-Bid................................. 37

Nitro-Dur ................................ 37

nitrofurantoin .......................... 13

nitrofurantoin macrocrystal .... 13

nitrofurantoin monohyd/m-cryst

............................................ 13

nitroglycerin ........................... 37

Nitrostat .................................. 37

Nitro-Time .............................. 37

nizatidine ................................ 62

Non-Aspirin Jr Strength ......... 41

Norditropin FlexPro................ 69

norethindrone (contraceptive) 65

norethindrone acetate .............. 70

norethindrone ac-eth estradiol 66

norethindrone-e.estradiol-iron 66

norgestimate-ethinyl estradiol 66

norgestrel-ethinyl estradiol ..... 66

Nortrel 0.5/35 (28) .................. 66

Nortrel 1/35 (21) ..................... 66

Nortrel 7/7/7 (28) .................... 66

nortriptyline ............................ 51

Norvir ..................................... 10

Novolin 70/30 U-100 Insulin.. 68

Novolin N NPH U-100 Insulin

............................................ 69

Novolin R Regular U-100 Insuln

............................................ 69

Novolog Mix 70-30 U-100

Insuln .................................. 69

Novolog Mix 70-30FlexPen U-

100 ...................................... 69

Novoseven RT ........................ 25

NP Thyroid ............................. 71

Nplate ..................................... 24

Nucala ..................................... 79

Nutropin AQ Nuspin .............. 69

NuvaRing ................................ 66

nystatin ............................. 12, 88

nystatin-triamcinolone ............ 88

O Obstetrix DHA............ 26, 90, 92

Obstetrix EC ......... 26, 61, 90, 92

O-Cal FA .............. 26, 54, 90, 92

O-Cal Prenatal ...... 26, 54, 90, 92

Ocaliva .................................... 61

101

Ocrevus................................... 76

octreotide acetate .............. 70, 78

Odefsey................................. 8, 9

Off Active ......................... 88, 89

Off Deep Woods............... 88, 89

Off Deep Woods Dry ....... 88, 89

Off FamilyCare (with DEET) 88,

89

ofloxacin ........................... 12, 57

olanzapine............................... 43

olanzapine-fluoxetine ....... 43, 50

olmesartan .............................. 28

olmesartan-hydrochlorothiazide

................................ 28, 38, 55

olopatadine ............................. 56

Olysio ....................................... 7

omeprazole ............................. 62

omeprazole-sodium bicarbonate

............................................ 62

Omnitrope............................... 69

Oncaspar ................................. 17

ondansetron ............................ 60

ondansetron HCl ..................... 60

ondansetron HCl (PF)............. 60

One Daily Essential .......... 90, 92


.......................... 26, 54, 90, 93

Opsumit ............................ 39, 82

Oracit ...................................... 52

Oralone ............................. 84, 87

Orencia ............................. 74, 76

Orencia (with maltose) ..... 74, 76

Orencia ClickJect ............. 74, 76

Orenitram ......................... 39, 82

Orfadin ................................... 78

Orkambi .................................. 79

ORTHOVISC ......................... 52

oseltamivir .............................. 11

Otezla ..................................... 74

Otezla Starter .......................... 74

oxacillin .................................. 12

oxaliplatin ............................... 17

oxaprozin ................................ 48

oxazepam ................................ 45

oxcarbazepine ......................... 41

Oxsoralen Ultra ...................... 88

oxybutynin chloride................ 89

oxycodone .............................. 47

oxycodone-acetaminophen .... 41,

47

Oxytrol For Women ............... 89

Ozempic.................................. 68

Ozurdex .................................. 58

P Pacerone ................................. 34

paclitaxel ................................ 17

paliperidone ............................ 43

palonosetron ........................... 60

pamidronate ............................ 72

Panhematin ............................. 78

pantoprazole ........................... 62

ParaGard T 380A.................... 66

paromomycin ............................ 3

paroxetine HCl ....................... 50

peg 3350-electrolytes ............. 61

Pegasys ................................... 10

Pegasys ProClick .................... 10

peg-electrolyte soln ................ 61

PegIntron ................................ 10

pen needle, diabetic ................ 52

penicillin G potassium ............ 11

penicillin V potassium ............ 11

Pentam ...................................... 5

Pentasa .................................... 60

pentoxifylline.......................... 24

perindopril erbumine .............. 29

Perjeta ..................................... 17

permethrin .............................. 88

perphenazine ........................... 48

perphenazine-amitriptyline .... 48,

51

phenazopyridine ..................... 85

phenelzine ............................... 46

phenobarbital .......................... 44

phenoxybenzamine ........... 22, 36

phenylephrine HCl ................. 59

phenytoin .......................... 33, 46

phenytoin sodium extended ... 33,

46

Phospholine Iodide ................. 59

Photofrin ................................. 17

pilocarpine HCl ...................... 59

pimozide ................................. 43

pindolol ........... 21, 30, 31, 34, 36

pioglitazone ............................ 71

pioglitazone-metformin .... 65, 71

piperacillin-tazobactam ............ 6

piroxicam ................................ 48

Plegridy .................................. 76

podofilox ................................ 89

polyethylene glycol 3350 ....... 61

polymyxin B sulf-trimethoprim

............................................ 57

Pomalyst ........................... 17, 76

potassium bicarb-citric acid .... 54

potassium chloride .................. 54

potassium citrate ..................... 52

Pradaxa ................................... 23

Praluent Pen ............................ 37

PramCort..................... 84, 85, 87

pramipexole ............................ 46

prasugrel ................................. 27

pravastatin............................... 35

prazosin............................. 21, 27

Pred Mild ................................ 58

prednisolone ........................... 64

prednisolone acetate ............... 58

prednisolone sodium phosphate

...................................... 58, 64

prednisone............................... 64

Prednisone Intensol ................ 64

Premarin ................................. 67

Premphase............................... 67

Prempro .................................. 67

Prenatabs FA ........ 26, 54, 90, 92

Prenatal + DHA .......... 26, 90, 92

Prenatal 19 .................. 26, 90, 92

Prenatal 19 (with docusate) ... 26,

90, 92

Prenatal Gummy ............... 90, 92

Prenatal Low Iron . 26, 54, 90, 92

Prenatal Multi-DHA ... 26, 90, 92


................................ 26, 90, 92

Prenatal Plus ......... 26, 54, 90, 92

Prenatal Plus DHA ..... 26, 90, 92

prenatal vit-iron fum-folic ac . 26,

54, 91, 92

Prenatal-U ............................... 91

Prevalite .................................. 31

PreviDent ................................ 73

Prezcobix .......................... 10, 78

Prezista ................................... 10

Prialt ....................................... 41

Prilosec ................................... 62

primaquine ................................ 4

primidone ................................ 44

Privigen................................... 19

probenecid ........................ 55, 72

probenecid-colchicine ....... 56, 72

102

prochlorperazine ............... 48, 60

prochlorperazine Edisylate .... 48,

60

prochlorperazine maleate . 48, 60

Procrit ..................................... 24

Proctofoam HC ........... 84, 85, 87

Profilnine ................................ 25

progesterone micronized ........ 70

Prograf .................................... 77

Prolastin-C .............................. 81

Proleukin .......................... 17, 76

Prolia ...................................... 72

Promacta ................................. 24

promethazine ................ 1, 43, 80

promethazine-phenylephrine ... 1,

20, 80

propafenone ............................ 33

propantheline .......................... 20

proparacaine ........................... 59

propranolol 21, 30, 31, 34, 36, 42


.............. 21, 30, 31, 34, 38, 55

propylthiouracil ...................... 64

Prosol 20 % ............................ 53

Provenge ................................. 40

Pulmicort Flexhaler .......... 64, 80

Pulmozyme ....................... 56, 80

pyrazinamide ............................ 5

pyridostigmine bromide ......... 22

pyridoxine (vitamin B6) ......... 92

Q quetiapine ............................... 44

quinapril ................................. 29


................................ 29, 38, 55

quinidine gluconate ............ 4, 33

quinidine sulfate ................. 4, 33

Qvar .................................. 64, 80

Qvar RediHaler ................ 64, 81

R Radicava ................................. 45

raloxifene .......................... 66, 72

ramipril ................................... 29

ranitidine HCl ......................... 62

Rapamune ............................... 77

Rebetol ................................... 11

Rebif (with albumin) .............. 76

Rebif Titration Pack ............... 76

Recombinate ........................... 25

Relenza Diskhaler .................. 11

Remicade .............. 61, 74, 76, 78

Remodulin ........................ 39, 82

Renflexis ..................... 62, 74, 76

Repatha Pushtronex ................ 37

Repatha SureClick .................. 37

Repatha Syringe ..................... 37

Repel Sportsmen............... 88, 89

Repel Sportsmen Max ...... 88, 89

Rescriptor ................................. 8

reserpine ................................. 37

Restasis ................................... 58

Restasis MultiDose ................. 58

Retisert.................................... 58

Retrovir ..................................... 9

Revatio.............................. 37, 82

Revlimid ........................... 17, 76

Reyataz ................................... 10

RhoGAM Ultra-Filtered PLUS

............................................ 19

Rhophylac ............................... 19

Ribasphere .............................. 11

Ribasphere RibaPak ............... 11

ribavirin .................................. 11

Ridaura ....................... 63, 74, 76

rifampin .............................. 5, 13

riluzole .................................... 45

Risperdal Consta..................... 44

risperidone .............................. 44

ritonavir .................................. 10

Rituxan ................................... 17

Rituxan Hycela ....................... 17

rivastigmine tartrate ................ 22

rizatriptan................................ 50

romidepsin .............................. 17

ropinirole ................................ 46

rosuvastatin ............................. 35

S Sabril ...................................... 41

Saizen ..................................... 69

Saizen click.easy .................... 69

salsalate .................................. 49

Samsca .................................... 56

Sandimmune ............... 74, 76, 77

Santyl ...................................... 89

Savella .............................. 46, 49

Segluromet........................ 65, 70

selegiline HCl ......................... 46

Selzentry ................................... 8

Se-Natal 19 ................. 26, 91, 92

Se-Natal 19 (with docusate) .. 26,

61, 91, 92

Serevent Diskus ................ 23, 82

Serostim .................................. 69

sertraline ................................. 50

sevelamer carbonate ......... 53, 72

SF ............................................ 73

SF 5000 Plus ........................... 73

Signifor ................................... 70

sildenafil (antihypertensive) .. 37,

82

Siliq......................................... 89

silver sulfadiazine ................... 87

Simponi............................. 74, 76

Simponi ARIA .................. 74, 76

Simulect .................................. 77

simvastatin .............................. 35

sirolimus ................................. 77

Sklice ...................................... 88

Skyla ....................................... 66

sodium chloride ................ 52, 54

sodium citrate-citric acid ........ 52


...................................... 53, 72

Soft Touch Lancets ................. 52

Solesta..................................... 52

Soliris ...................................... 73

Solu-Cortef (PF) ..................... 64

Somatuline Depot ................... 70

Somavert ................................. 70

sotalol ............. 21, 30, 31, 34, 36

Sotalol AF ....... 21, 30, 31, 34, 36

Sovaldi ...................................... 7

Spinraza (PF) .................... 72, 78

Spiriva Respimat .............. 20, 79

spironolactone............. 36, 37, 53


.................... 36, 37, 38, 53, 55

Sporanox ................................... 6

Sprycel .................................... 17

SPS (with sorbitol) ........... 53, 72

SSKI ....................... 4, 64, 72, 79

stavudine ................................... 9

Steglatro .................................. 70

Stelara ......................... 74, 76, 89

Stiolto Respimat ............... 20, 23

Stivarga ................................... 17

Stribild .................................. 8, 9

Sucraid .................................... 56

sucralfate................................. 62

103

sulfacetamide sodium ............. 57

sulfacetamide sodium (acne) .. 87

sulfacetamide sodium-sulfur .. 87

sulfacetamide-prednisolone .... 57

sulfadiazine............................. 13

sulfamethoxazole-trimethoprim

............................................ 13

sulfasalazine ......... 13, 60, 74, 76

sulindac................................... 48

sumatriptan ............................. 50

sumatriptan succinate ............. 50

Supartz FX.............................. 52

Supprelin LA .............. 17, 67, 68

Suprax....................................... 3

Sutent ...................................... 17

Sylatron ............................ 10, 17

Symdeko ................................. 79

Symfi .................................... 8, 9

Symfi Lo ............................... 8, 9

Synagis ................................... 11

Synarel .............................. 67, 68

Synercid .................................. 13

Synribo ................................... 17

Synvisc ................................... 52

Synvisc-One ........................... 52

T Tabloid ................................... 17

tacrolimus ......................... 77, 89

Taltz Autoinjector .................. 89

Taltz Syringe .......................... 89

tamoxifen .......................... 17, 66

tamsulosin............................... 22

Tarceva ................................... 17

Targretin ........................... 17, 89

Tasigna ................................... 17

TAZICEF ................................. 3

Tecfidera................................. 76

Technivie ............................ 7, 10

telmisartan .............................. 28

temazepam .............................. 45

Temodar ................................. 17

temozolomide ......................... 17

teniposide ............................... 17

tenofovir disoproxil fumarate ... 9

terazosin ..................... 21, 27, 36

terbinafine HCl ......................... 3

terbutaline ......................... 23, 82

terconazole ............................. 85

testosterone ............................. 64

testosterone cypionate ............ 64

testosterone enanthate............. 64

tetracaine HCl ......................... 59

tetracaine HCl (PF) ................. 59

tetracycline ............................. 13

Thalomid ................................ 76

Theo-24 ................ 35, 53, 82, 89

theophylline .......... 35, 53, 82, 89

thioridazine ............................. 48

thiotepa ................................... 18

thiothixene .............................. 50

Thymoglobulin ....................... 77

Thyrogen ................................ 52

thyroid (pork) ......................... 71

Thyrolar-1 ............................... 71

Thyrolar-1/2............................ 71

Thyrolar-1/4............................ 71

Thyrolar-2 ............................... 71

Thyrolar-3 ............................... 71

Tice BCG .......................... 18, 19

tigecycline ................................ 7

timolol maleate .... 21, 30, 31, 34,

36, 42, 57

Tivicay ...................................... 8

tizanidine ................................ 21

Tobi Podhaler ........................... 4

tobramycin .............................. 57

tobramycin in 0.225 % NaCl .... 4

tobramycin sulfate .................... 4

tobramycin-dexamethasone ... 57,

58

Tobrex .................................... 57

tolazamide .............................. 70

tolbutamide ............................. 70

tolterodine ............................... 89

topiramate ............................... 41

topotecan ................................ 18

Torisel ..................................... 18

torsemide .......................... 36, 53

TPN Electrolytes .................... 54

TPN Electrolytes II ................. 54

Tracleer ............................. 39, 82

tramadol .................................. 47

tramadol-acetaminophen . 41, 43,

47

trandolapril ............................. 29

tranylcypromine...................... 46

Travasol 10 % ......................... 53

trazodone ................................ 50

Treanda ................................... 18

Trelstar.............................. 18, 67

Tremfya .................................. 89

tretinoin................................... 85

tretinoin (chemotherapy) ........ 18

Trexall................... 18, 74, 76, 77

TriAdvance ........... 26, 54, 91, 92

triamcinolone acetonide.... 84, 87


.......................... 37, 38, 53, 55

triazolam ................................. 45

trientine ................................... 63

trifluoperazine......................... 48

trifluridine ............................... 57

trihexyphenidyl ................. 20, 41

trimethobenzamide ................. 60

trimethoprim ........................... 13

Trinatal Rx 1 ......... 26, 54, 91, 92

Trinate................... 26, 54, 91, 92

Triumeq ................................ 8, 9

Triveen-Duo DHA 26, 54, 91, 92


................................ 26, 73, 91

Tri-Vitamin With Fluoride .... 73,

91, 93

Trizivir ...................................... 9

Trogarzo ................................... 8

TrophAmine 10 % .................. 53

tropicamide ............................. 59

trospium .................................. 89

Trulicity .................................. 68

Truvada ..................................... 9

Tybost ..................................... 78

Tykerb..................................... 18

Tymlos .................................... 69

Tysabri .................................... 76

Tyvaso .............................. 39, 82

Tyvaso Refill Kit .............. 39, 82

Tyvaso Starter Kit............. 39, 82

U U-Cort ..................................... 87

Uptravi .............................. 39, 82

urea ......................................... 87

ursodiol ................................... 61

V Vaginal Contraceptive Foam .. 51

valacyclovir ............................ 12

valproic acid ............... 41, 42, 43

valproic acid (as sodium salt) 42,

43

valsartan .................................. 28

104

valsartan-hydrochlorothiazide

................................ 28, 38, 55

Valstar .................................... 18

vancomycin .............................. 7

vancomycin in dextrose 5 % .... 7

Vantas ......................... 18, 67, 68

Vectibix .................................. 18

Velcade ................................... 18

Veletri ............................... 39, 82

Velivet Triphasic Regimen (28)

............................................ 66

venlafaxine ....................... 49, 50

Venofer ................................... 26

Ventavis ............................ 39, 82

Ventolin HFA ................... 23, 82

verapamil ........ 31, 32, 33, 34, 39

Vibativ ...................................... 7

Victoza 2-Pak ......................... 68

Victoza 3-Pak ......................... 68

Vidaza..................................... 18

Videx 2 gram Pediatric ............. 9

Viekira Pak ......................... 7, 10

Viekira XR ......................... 7, 10

vigabatrin ................................ 42

Vinate GT ................... 26, 91, 92

Vinate II.................................. 91

Vinate M ................................. 91

Vinate One............ 26, 54, 91, 92

Vinate Ultra .... 26, 54, 61, 91, 92

vinblastine .............................. 18

vincristine ............................... 18

vinorelbine .............................. 18

Viracept .................................. 10

Viramune XR ........................... 8

Viread ....................................... 9

Visudyne ................................. 59

Vivitrol ............................. 47, 71

Vol-Nate ............... 26, 54, 91, 92

Voraxaze ........................... 56, 72

voriconazole ............................. 6

Vosevi ....................................... 7

Votrient ................................... 18

VPRIV .................................... 56

Vyvanse .................................. 40

W warfarin .................................. 23

WelChol............................ 31, 64

WinRho SDF .......................... 19

Women's Prenatal + DHA ..... 26,

91, 92

X Xalkori .................................... 18

Xarelto .................................... 23

Xeljanz.............................. 74, 76

Xeljanz XR ....................... 74, 77

Xenazine ........................... 45, 51

Xeomin ............................. 23, 78

Xgeva...................................... 72

Xiaflex .................................... 56

Xifaxan ................................... 13

Xiidra ...................................... 58

Xolair ...................................... 81

Xopenex HFA................... 23, 82

Xtandi ..................................... 18

Xulane .................................... 66

Xyntha .................................... 25

Xyntha Solofuse ..................... 25

Y Yervoy .................................... 18

Z zaleplon................................... 43

Zaltrap..................................... 18

Zanosar ................................... 18

Zarxio ..................................... 24

Zelboraf .................................. 18

Zemaira ................................... 81

Zenpep .................................... 61

Zepatier ..................................... 7

Zerit .......................................... 9

Zevalin (Y-90) ........................ 18

zidovudine ................................ 9

ziprasidone HCl ...................... 44

Zmax ....................................... 12

Zoladex ....................... 18, 67, 68

zoledronic acid........................ 72

zoledronic acid-mannitol-water

............................................ 72

Zolinza .................................... 18

zolpidem ................................. 43

Zometa .................................... 72

zonisamide .............................. 42

Zortress ................................... 77

Zosyn in dextrose (iso-osm) ..... 6

Zovia 1/35E (28)..................... 66

Zovirax ................................... 85

Zykadia ................................... 18

Zyprexa Relprevv ................... 44

Zytiga ...................................... 18

Zyvox ...................................... 12

Formulary Drug List - AmeriHealth Caritas Louisiana Drug List AmeriHealth Caritas Louisiana...

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Transcript of Formulary Drug List - AmeriHealth Caritas Louisiana Drug List AmeriHealth Caritas Louisiana...