FORMULARY (LIST OF COVERED DRUGS) - Advantage · 2020-06-27 · tablets per prescription for...

2017

FORMULARY (LIST OF COVERED DRUGS)Trillium Medicare Advantage

Oregon

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

3, Version Number

This formulary was updated on . For more recent information or other questions, please contact Trillium Medicare Advantage Member Services, at 1-844-867-1156 or, for TTY users, 711. October 1 - February 14, seven days a week, 8 a.m. to 8 p.m.; February 15 - September 30, Monday - Friday, 8 a.m. to 8 p.m., or visit http://trilliumadvantage.com.Y0020_CompForm17_FINAL_7

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

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Trillium Medicare Advantage. When it refers to “plan” or “our plan,” it means Trillium Advantage Dual (HMO SNP), Trillium Advantage TLC ISNP (HMO SNP), and Trillium Advantage TLC Community ISNP (HMO SNP).

This document includes a list of the drugs (formulary) for our plan which is current as of August 23, 2016 For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.

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

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug.It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 23, 2016. To get updated information about the drugs covered by Trillium Medicare Advantage please contact us. Our contact information appears on the front and back cover pages. If we make any other negative formulary changes to a drug we will notify effected members by mail. The formulary is updated monthly and posted on our website.

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

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

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

What are generic drugs?Trillium Medicare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

Prior Authorization: Trillium MedicareAdvantage requires you or your physicianto get prior authorization for certain drugs.This means that you will need to getapproval from Trillium MedicareAdvantage before you fill yourprescriptions. If you don’t get approval,Trillium Medicare Advantage may notcover the drug.Quantity Limits: For certain drugs,Trillium Medicare Advantage limits theamount of the drug that Trillium MedicareAdvantage will cover. For example,Trillium Medicare Advantage provides 30tablets per prescription for Januvia. Thismay be in addition to a standard one-month or three-month supply.Step Therapy: In some cases, TrilliumMedicare Advantage requires you to firsttry certain drugs to treat your medicalcondition before we will cover anotherdrug for that condition. For example, ifDrug A and Drug B both treat yourmedical condition, Trillium MedicareAdvantage may not cover Drug B unlessyou try Drug A first. If Drug A does notwork for you, Trillium MedicareAdvantage will then cover Drug B.

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

You can ask Trillium Medicare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I

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request an exception to the Trillium Medicare Advantage formulary?” on page iii for information about how to request an exception.

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

If you learn that Trillium Medicare Advantagedoes not cover your drug, you have two options:

You can ask Member Services for a list ofsimilar drugs that are covered by TrilliumMedicare Advantage. When you receivethe list, show it to your doctor and ask himor her to prescribe a similar drug that iscovered by Trillium Medicare Advantage.You can ask Trillium Medicare Advantageto make an exception and cover your drug.See below for information about how torequest an exception.

How do I request an exception to the Trillium Medicare AdvantageFormulary?You can ask Trillium Medicare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it isnot on our formulary. If approved, thisdrug will be covered at a pre-determinedcost-sharing level, and you would not beable to ask us to provide the drug at alower cost-sharing level.You can ask us to cover a formulary drugat a lower cost-sharing level if this drug isnot on the specialty tier. If approved thiswould lower the amount you must pay foryour drug.

You can ask us to waive coveragerestrictions or limits on your drug. Forexample, for certain drugs, TrilliumMedicare Advantage limits the amount ofthe drug that we will cover. If your drughas a quantity limit, you can ask us towaive the limit and cover a greater amount.

Generally, Trillium Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or

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request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91 to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Level of care changesThroughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to:

Members who are discharged from ahospital or skilled-nursing facility to ahome settingMembers who are admitted to a hospital orskilled-nursing facility from a home settingMembers who transfer from one skillednursing facility to another and are servedby a different pharmacyMembers who end their skilled-nursingfacility Medicare Part A stay (where

payments include all pharmacy charges) and who now need to use their Part D plan benefitMembers who give up Hospice Status andgo back to standard Medicare Part A and BcoverageMembers discharged from psychiatrichospitals with highly individualized drugregimens

For these changes in treatment settings, Trillium Medicare Advantage will cover as much as a 31-day temporary supply of a Part D covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. If you do not request an exception or prior authorization with us, you do not qualify for extra time for a level ofcare transition fill unless it is a life threateningemergency.

For more informationFor more detailed information about your Trillium Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Trillium Medicare Advantage please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Trillium Medicare Advantage FormularyThe formulary that begins on the next pageprovides coverage information about the drugs covered by Trillium Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page .

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

The information in the Requirements/Limitscolumn tells you if Trillium Medicare Advantagehas any special requirements for coverage of your drug.

List of abbreviationsB/D: This prescription drug has a Part Bversus D prior authorization requirement.This drug may be covered under MedicarePart B or D depending upon thecircumstances. Information may need to besubmitted describing the use and setting ofthe drug to make the determination.LA: Limited Access. This drug may onlybe available at one or a certain number ofpharmacies. For more information callMember Services at 1-844-867-1156,From October 1 to February 14, you cancall us 7 days a week from 8 a.m. to 8 p.m.From February 15 to September 30, youcan call us Monday through Friday from 8a.m. to 8 p.m. On weekends and holidays,an automated system will handle your call..TTY users should call 711.PA: Prior Authorization (Prior Approval).The plan requires you or your physician toget prior authorization for certain drugs.This means that you will need to getapproval from Trillium MedicareAdvantage before you fill yourprescriptions. If you don't get approval,Trillium Medicare Advantage may notcover the drug.

ST: Step Therapy. In some cases, TrilliumMedicare Advantage requires you to firsttry certain drugs to treat your medicalcondition before we will cover anotherdrug for that condition. For example, ifDrug A and Drug B both treat yourmedical condition, Trillium MedicareAdvantage may not cover Drug B unlessyou try Drug A first. If Drug A does notwork for you, Trillium MedicareAdvantage will then cover Drug B.QL: Quantity Limit. For certain drugs,Trillium Medicare Advantage limits theamount of the drug that Trillium MedicareAdvantage will cover. For example,Trillium Medicare Advantage provides 30tablets per prescription for Januvia. Thismay be in addition to a standard one monthor three month supply.MO: Mail Order. This prescription drug iseligible for up to a 90-day supply throughour mail order pharmacy as well asthrough certain retail network pharmacies.Consider using mail order for your long-term (maintenance) medications (such ashigh blood pressure medications). Retailnetwork pharmacies may be moreappropriate for short-term prescriptions(such as antibiotics).NDS: Non-Extended Day Supply. Thisprescription drug is not available for anextended days' supply.

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Cost Sharing

Drug Tier

Tier Description

Copayment and/or Co-Insurance±

1 Generic and Brand

25%- OR –

$0, $1.20, $3.30 copay or 15% of the total cost

for generic drugs$0, $3.70, $8.25 copay or 15% of the total cost for brand name drugs (depending upon your level of Extra Help)]

±For more detailed information about your out of pocket costs for prescriptions, please refer to your Evidence of Coverage and other plan materials.

Trillium Medicare Advantage is contracted with Medicare for HMO SNP and PPO plans, and with the Oregon Medicaid program. Enrollment in Trillium Medicare Advantage depends on contract renewal.

This information is available for free in other languages. Please call our Member Services number at 1-844-867-1156 or, for TTY users,711, from October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m.

Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicios para Afiliados al 1-844-867-1156 o, para usuarios de TTY, al 711 , Del 1 de octubre al 14 de febrero, puede llamarnos 7 días a la semana de 8 AM a 8 PM. Del 15 de febrero al 30 de septiembre, puede llamarnos de lunes a viernes entre 8 AM y 8 PM.

of 143 You can find information on what the symbols and abbreviations in this table mean by going to page .

Drug NameDrug Tier Requirements/Limits

AnalgesicsNonsteroidal Anti-inflammatory Drugs

celecoxib caps 100mg 1 QL (60 EA per 30 days) MOcelecoxib caps 200mg 1 QL (60 EA per 30 days) MOcelecoxib caps 400mg 1 QL (60 EA per 30 days) MOcelecoxib caps 50mg 1 QL (60 EA per 30 days) MOdiclofenac potassium tabs 50mg 1 MOdiclofenac sodium dr tbec 25mg 1 MOdiclofenac sodium dr tbec 50mg 1 MOdiclofenac sodium dr tbec 75mg 1 MOdiclofenac sodium er tb24 100mg 1 MOdiclofenac sodium xr tb24 100mg 1 MOdiclofenac sodium/misoprostol tbec 50mg; 200mcg 1 MOdiclofenac sodium/misoprostol tbec 75mg; 200mcg 1 MOdiflunisal tabs 500mg 1 MOetodolac er tb24 400mg 1 MOetodolac er tb24 500mg 1 MOetodolac er tb24 600mg 1 MOetodolac caps 200mg 1 MOetodolac caps 300mg 1 MOetodolac tabs 400mg 1 MOetodolac tabs 500mg 1 MOFENOPROFEN CALCIUM CAPS 400MG 1 MOfenoprofen calcium tabs 600mg 1 MOflurbiprofen tabs 100mg 1 MOflurbiprofen tabs 50mg 1 MOibuprofen susp 100mg/5ml 1ibuprofen tabs 400mg 1 MOibuprofen tabs 600mg 1 MOibuprofen tabs 800mg 1 MOindomethacin er cpcr 75mg 1 PA MOindomethacin sr cpcr 75mg 1 PA MOindomethacin caps 25mg 1 PA MOindomethacin caps 50mg 1 PA MOINDOMETHACIN INJ 1MG 1 PAketoprofen er cp24 200mg 1 MOketoprofen caps 50mg 1 MOketoprofen caps 75mg 1 MOketorolac tromethamine inj 15mg/ml 1 PAketorolac tromethamine inj 300mg/10ml 1 PAketorolac tromethamine inj 30mg/ml 1 PAketorolac tromethamine inj 30mg/ml 1 PAketorolac tromethamine inj 30mg/ml 1 PAketorolac tromethamine tabs 10mg 1 QL (20 EA per 30 days) PAmeclofenamate sodium caps 100mg 1 MOmeclofenamate sodium caps 50mg 1 MOmefenamic acid caps 250mg 1 MO



meloxicam susp 7.5mg/5ml 1 MOmeloxicam tabs 15mg 1 MO

meloxicam tabs 7.5mg 1 MOnabumetone tabs 500mg 1 MOnabumetone tabs 750mg 1 MOnaproxen dr tbec 375mg 1 MOnaproxen dr tbec 500mg 1 MOnaproxen sodium cr tb24 375mg 1 MOnaproxen sodium er tb24 375mg 1 MOnaproxen sodium tabs 275mg 1 MOnaproxen sodium tabs 550mg 1 MOnaproxen susp 125mg/5ml 1 MOnaproxen tabs 250mg 1 MOnaproxen tabs 375mg 1 MOnaproxen tabs 500mg 1 MOoxaprozin tabs 600mg 1 MOpiroxicam caps 10mg 1 MOpiroxicam caps 20mg 1 MOtolmetin sodium caps 400mg 1 MOtolmetin sodium tabs 200mg 1 MOtolmetin sodium tabs 600mg 1 MOZIPSOR CAPS 25MG 1

Opioid Analgesics, Long-acting buprenorphine hcl inj 0.3mg/ml 1 B/Dbuprenorphine hcl inj 0.3mg/ml 1 B/DEMBEDA CPCR 100MG; 4MG 1 NDSEMBEDA CPCR 20MG; 0.8MG 1EMBEDA CPCR 30MG; 1.2MG 1EMBEDA CPCR 50MG; 2MG 1EMBEDA CPCR 60MG; 2.4MG 1EMBEDA CPCR 80MG; 3.2MG 1 NDSfentanyl pt72 100mcg/hr 1fentanyl pt72 12mcg/hr 1fentanyl pt72 25mcg/hr 1fentanyl pt72 37.5mcg/hr 1fentanyl pt72 50mcg/hr 1fentanyl pt72 62.5mcg/hr 1fentanyl pt72 75mcg/hr 1fentanyl pt72 87.5mcg/hr 1 NDShydromorphone hcl er t24a 12mg 1hydromorphone hcl er t24a 16mg 1 NDShydromorphone hcl er t24a 32mg 1 NDShydromorphone hcl er t24a 8mg 1INFUMORPH 200 INJ 10MG/ML 1INFUMORPH 500 INJ 25MG/ML 1levorphanol tartrate tabs 2mg 1methadone hcl intensol conc 10mg/ml 1



methadone hcl conc 10mg/ml 1methadone hcl inj 10mg/ml 1methadone hcl soln 10mg/5ml 1methadone hcl soln 5mg/5ml 1methadone hcl tabs 10mg 1methadone hcl tabs 5mg 1methadose sugar-free conc 10mg/ml 1methadose conc 10mg/ml 1morphine sulfate cr tbcr 60mg 1morphine sulfate er cp24 100mg 1 NDSmorphine sulfate er cp24 10mg 1morphine sulfate er cp24 120mg 1morphine sulfate er cp24 20mg 1morphine sulfate er cp24 30mg 1morphine sulfate er cp24 30mg 1morphine sulfate er cp24 45mg 1morphine sulfate er cp24 50mg 1morphine sulfate er cp24 60mg 1morphine sulfate er cp24 60mg 1morphine sulfate er cp24 75mg 1morphine sulfate er cp24 80mg 1morphine sulfate er cp24 90mg 1morphine sulfate er tbcr 100mg 1morphine sulfate er tbcr 15mg 1morphine sulfate er tbcr 200mg 1morphine sulfate er tbcr 30mg 1morphine sulfate er tbcr 60mg 1OPANA ER (CRUSH RESISTANT) T12A 10MG 1OPANA ER (CRUSH RESISTANT) T12A 15MG 1OPANA ER (CRUSH RESISTANT) T12A 20MG 1OPANA ER (CRUSH RESISTANT) T12A 30MG 1 NDSOPANA ER (CRUSH RESISTANT) T12A 40MG 1 NDSOPANA ER (CRUSH RESISTANT) T12A 5MG 1OPANA ER (CRUSH RESISTANT) T12A 7.5MG 1oxycodone hcl er t12a 10mg 1oxycodone hcl er t12a 15mg 1oxycodone hcl er t12a 20mg 1oxycodone hcl er t12a 30mg 1oxycodone hcl er t12a 40mg 1oxycodone hcl er t12a 60mg 1oxycodone hcl er t12a 80mg 1 NDSoxymorphone hydrochloride er tb12 10mg 1oxymorphone hydrochloride er tb12 15mg 1oxymorphone hydrochloride er tb12 20mg 1oxymorphone hydrochloride er tb12 30mg 1oxymorphone hydrochloride er tb12 40mg 1oxymorphone hydrochloride er tb12 5mg 1



oxymorphone hydrochloride er tb12 7.5mg 1tramadol hcl er tb24 100mg 1tramadol hcl er tb24 100mg 1tramadol hcl er tb24 200mg 1tramadol hcl er tb24 200mg 1tramadol hcl er tb24 300mg 1tramadol hcl er tb24 300mg 1

Opioid Analgesics, Short-acting ABSTRAL SUBL 100MCG 1 PA NDSABSTRAL SUBL 200MCG 1 PA NDSABSTRAL SUBL 300MCG 1 PA NDSABSTRAL SUBL 400MCG 1 PA NDSABSTRAL SUBL 600MCG 1 PA NDSABSTRAL SUBL 800MCG 1 PA NDSacetaminophen/codeine #3 tabs 300mg; 30mg 1acetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1acetaminophen/codeine tabs 300mg; 15mg 1acetaminophen/codeine tabs 300mg; 60mg 1ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 1 PAaspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg 1butalbital compound/codeine caps 325mg; 50mg; 40mg; 30mg 1 PAbutalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg1 PAbutorphanol tartrate inj 1mg/ml 1 B/Dbutorphanol tartrate inj 2mg/ml 1 B/Dbutorphanol tartrate soln 10mg/ml 1codeine sulfate tabs 15mg 1codeine sulfate tabs 30mg 1codeine sulfate tabs 60mg 1codeine/acetaminophen tabs 300mg; 15mg 1codeine/acetaminophen tabs 300mg; 30mg 1codeine/acetaminophen tabs 300mg; 60mg 1duramorph inj 0.5mg/ml 1duramorph inj 1mg/ml 1endocet tabs 325mg; 10mg 1endocet tabs 325mg; 2.5mg 1endocet tabs 325mg; 5mg 1endocet tabs 325mg; 7.5mg 1endodan tabs 325mg; 4.835mg 1fentanyl citrate oral transmucosal lpop 1200mcg 1 PA NDSfentanyl citrate oral transmucosal lpop 1600mcg 1 PA NDSfentanyl citrate oral transmucosal lpop 200mcg 1 PAfentanyl citrate oral transmucosal lpop 400mcg 1 PAfentanyl citrate oral transmucosal lpop 600mcg 1 PA NDSfentanyl citrate oral transmucosal lpop 800mcg 1 PA NDSFENTANYL CITRATE INJ 1000MCG/20ML 1 B/Dfentanyl citrate inj 1000mcg/20ml 1 B/Dfentanyl citrate inj 100mcg/2ml 1 B/D



fentanyl citrate inj 2500mcg/50ml 1 B/Dfentanyl citrate inj 250mcg/5ml 1 B/DFENTORA TABS 100MCG 1 PA NDSFENTORA TABS 200MCG 1 PA NDSFENTORA TABS 400MCG 1 PA NDSFENTORA TABS 600MCG 1 PA NDSFENTORA TABS 800MCG 1 PA NDShydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml

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hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg 1hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg 1hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg 1hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg 1hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1hydrocodone/acetaminophen tabs 325mg; 10mg 1hydrocodone/acetaminophen tabs 325mg; 5mg 1hydrocodone/acetaminophen tabs 325mg; 7.5mg 1hydrocodone/ibuprofen tabs 10mg; 200mg 1hydrocodone/ibuprofen tabs 2.5mg; 200mg 1hydrocodone/ibuprofen tabs 5mg; 200mg 1hydrocodone/ibuprofen tabs 7.5mg; 200mg 1hydromorphone hcl inj 10mg/ml 1hydromorphone hcl inj 1mg/ml 1hydromorphone hcl inj 2mg/ml 1hydromorphone hcl inj 4mg/ml 1hydromorphone hcl inj 50mg/5ml 1hydromorphone hcl liqd 1mg/ml 1hydromorphone hcl tabs 2mg 1hydromorphone hcl tabs 4mg 1hydromorphone hcl tabs 8mg 1ibudone tabs 5mg; 200mg 1LAZANDA SOLN 100MCG/ACT 1 PA NDSLAZANDA SOLN 300MCG/ACT 1 PA NDSLAZANDA SOLN 400MCG/ACT 1 PA NDSlorcet hd tabs 325mg; 10mg 1lorcet plus tabs 325mg; 7.5mg 1lorcet tabs 325mg; 5mg 1lortab tabs 325mg; 10mg 1lortab tabs 325mg; 5mg 1lortab tabs 325mg; 7.5mg 1morphine sulfate inj 0.5mg/ml 1morphine sulfate inj 10mg/ml 1morphine sulfate inj 150mg/30ml 1 B/Dmorphine sulfate inj 15mg/ml 1morphine sulfate inj 1mg/ml 1morphine sulfate inj 1mg/ml 1 B/Dmorphine sulfate inj 2mg/ml 1morphine sulfate inj 4mg/ml 1



morphine sulfate inj 8mg/ml 1morphine sulfate soln 100mg/5ml 1morphine sulfate soln 10mg/5ml 1morphine sulfate soln 20mg/5ml 1morphine sulfate tabs 15mg 1morphine sulfate tabs 30mg 1nalbuphine hcl inj 10mg/ml 1 B/Dnalbuphine hcl inj 20mg/ml 1 B/Dopium tincture tinc 1% 1opium tinc 1% 1oxycodone hcl caps 5mg 1oxycodone hcl conc 100mg/5ml 1oxycodone hcl soln 5mg/5ml 1oxycodone hcl tabs 10mg 1oxycodone hcl tabs 15mg 1oxycodone hcl tabs 20mg 1oxycodone hcl tabs 30mg 1oxycodone hcl tabs 5mg 1oxycodone/acetaminophen soln 325mg/5ml; 5mg/5ml 1oxycodone/acetaminophen tabs 325mg; 10mg 1oxycodone/acetaminophen tabs 325mg; 2.5mg 1oxycodone/acetaminophen tabs 325mg; 5mg 1oxycodone/acetaminophen tabs 325mg; 7.5mg 1oxycodone/aspirin tabs 325mg; 4.835mg 1oxycodone/ibuprofen tabs 400mg; 5mg 1oxymorphone hydrochloride tabs 10mg 1oxymorphone hydrochloride tabs 5mg 1pentazocine/naloxone hcl tabs 0.5mg; 50mg 1 PAPRIMLEV TABS 300MG; 10MG 1PRIMLEV TABS 300MG; 5MG 1PRIMLEV TABS 300MG; 7.5MG 1reprexain tabs 10mg; 200mg 1roxicet soln 325mg/5ml; 5mg/5ml 1roxicet tabs 325mg; 5mg 1SUBSYS LIQD 100MCG 1 PA NDSSUBSYS LIQD 1200MCG 1 PA NDSSUBSYS LIQD 1600MCG 1 PA NDSSUBSYS LIQD 200MCG 1 PA NDSSUBSYS LIQD 400MCG 1 PA NDSSUBSYS LIQD 600MCG 1 PA NDSSUBSYS LIQD 800MCG 1 PA NDStramadol hcl tabs 50mg 1tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg 1vicodin es tabs 300mg; 7.5mg 1vicodin hp tabs 300mg; 10mg 1vicodin tabs 300mg; 5mg 1xylon tabs 10mg; 200mg 1



AnestheticsLocal Anesthetics

glydo gel 2% 1lidocaine and tetracaine cream crea 7%; 7% 1lidocaine hcl jelly gel 2% 1lidocaine hcl jelly gel 2% 1lidocaine hcl jelly gel 2% 1lidocaine hcl/dextrose inj 7.5%; 5% 1lidocaine hcl gel 2% 1lidocaine hcl gel 2% 1lidocaine hcl inj 0.5% 1lidocaine hcl inj 0.5% 1lidocaine hcl inj 1% 1lidocaine hcl inj 1% 1lidocaine hcl inj 1.5% 1lidocaine hcl inj 2% 1lidocaine hcl inj 2% 1lidocaine hcl inj 2% 1lidocaine hcl inj 4% 1lidocaine hcl soln 4% 1lidocaine hcl soln 4% 1lidocaine viscous soln 2% 1lidocaine/epinephrine inj 1:100000; 1% 1lidocaine/epinephrine inj 1:100000; 2% 1lidocaine/epinephrine inj 1:100000; 2% 1lidocaine/epinephrine inj 1:100000; 2% 1lidocaine/epinephrine inj 1:100000; 2% 1lidocaine/epinephrine inj 1:200000; 0.5% 1lidocaine/epinephrine inj 1:200000; 1.5% 1lidocaine/epinephrine inj 1:200000; 2% 1lidocaine/epinephrine inj 1:50000; 2% 1lidocaine/prilocaine crea 2.5%; 2.5% 1 QL (30 GM per 30 days)lidocaine/prilocaine kit 2.5%; 2.5% 1 QL (30 EA per 30 days)lidocaine oint 5% 1lidocaine ptch 5% 1 PAlidopril kit 2.5%; 2.5% 1 QL (30 EA per 30 days)PLIAGLIS CREA 7%; 7% 1relador pak plus kit 2.5%; 2.5% 1 QL (30 EA per 30 days)relador pak kit 2.5%; 2.5% 1 QL (30 EA per 30 days)xylocaine dental inj 1:100000; 2% 1xylocaine dental inj 1:50000; 2% 1

Anti-Addiction/Substance Abuse Treatment AgentsAlcohol Deterrents/Anti-craving

acamprosate calcium dr tbec 333mg 1 MOdisulfiram tabs 250mg 1 MOdisulfiram tabs 500mg 1 MOVIVITROL INJ 380MG 1 PA NDS



Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 QL (360 EA per 30 days) PAbuprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 QL (90 EA per 30 days) PAbuprenorphine hcl subl 2mg 1 PAbuprenorphine hcl subl 8mg 1 PAnaltrexone hcl tabs 50mg 1SUBOXONE FILM 12MG; 3MG 1 QL (60 EA per 30 days) PASUBOXONE FILM 2MG; 0.5MG 1 QL (360 EA per 30 days) PASUBOXONE FILM 4MG; 1MG 1 QL (180 EA per 30 days) PASUBOXONE FILM 8MG; 2MG 1 QL (90 EA per 30 days) PAZUBSOLV SUBL 1.4MG; 0.36MG 1 QL (360 EA per 30 days) PAZUBSOLV SUBL 11.4MG; 2.9MG 1 QL (30 EA per 30 days) PAZUBSOLV SUBL 2.9MG; 0.71MG 1 QL (180 EA per 30 days) PAZUBSOLV SUBL 5.7MG; 1.4MG 1 QL (90 EA per 30 days) PAZUBSOLV SUBL 8.6MG; 2.1MG 1 QL (60 EA per 30 days) PA

Opioid Reversal Agents naloxone hcl inj 0.4mg/ml 1naloxone hcl inj 1mg/ml 1NARCAN LIQD 4MG/0.1ML 1

Smoking Cessation Agents buproban tb12 150mg 1 QL (60 EA per 30 days)bupropion hcl sr tb12 150mg 1 QL (60 EA per 30 days)CHANTIX CONTINUING MONTH PAK TABS 1MG 1 QL (504 EA per 365 days)CHANTIX STARTING MONTH PAK TABS 0 1 QL (504 EA per 365 days)CHANTIX TABS 0.5MG 1 QL (504 EA per 365 days)CHANTIX TABS 1MG 1 QL (504 EA per 365 days)NICOTROL INHALER INHA 10MG 1 QL (2688 EA per 365 days)NICOTROL NS SOLN 10MG/ML 1 QL (360 ML per 365 days)

Anti-inflammatory AgentsNonsteroidal Anti-inflammatory Drugs

diclofenac sodium gel 3% 1 NDSsulindac tabs 150mg 1 MOsulindac tabs 200mg 1 MO

AntibacterialsAminoglycosides

amikacin sulfate inj 1gm/4ml 1amikacin sulfate inj 500mg/2ml 1gentak oint 0.3% 1gentamicin sulfate pediatric inj 10mg/ml 1gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 1.4mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 1mg/ml; 0.9% 1gentamicin sulfate/0.9% sodium chloride inj 2mg/ml; 0.9% 1gentamicin sulfate crea 0.1% 1



gentamicin sulfate inj 10mg/ml 1gentamicin sulfate inj 40mg/ml 1gentamicin sulfate oint 0.1% 1gentamicin sulfate oint 0.3% 1gentamicin sulfate soln 0.3% 1isotonic gentamicin inj 0.8mg/ml; 0.9% 1neomycin sulfate tabs 500mg 1neomycin/polymyxin b sulfates soln 40mg/ml; 200000unit/ml 1paromomycin sulfate caps 250mg 1streptomycin sulfate inj 1gm 1tobramycin sulfate inj 1.2gm/30ml 1tobramycin sulfate inj 1.2gm 1tobramycin sulfate inj 1.2gm 1tobramycin sulfate inj 10mg/ml 1tobramycin sulfate inj 40mg/ml 1tobramycin sulfate inj 80mg/2ml 1tobramycin sulfate soln 0.3% 1TOBREX OINT 0.3% 1

Antibacterials, Other ALCOHOL PREP PADS PADS 70% 1ALTABAX OINT 1% 1baciim inj 50000unit 1bacitracin inj 50000unit 1bacitracin oint 500unit/gm 1BACTROBAN NASAL OINT 2% 1CENTANY AT KIT 2% 1chloramphenicol sodium succinate inj 1gm 1CLEOCIN SUPP 100MG 1clindacin etz pledgets swab 1% 1clindacin-p swab 1% 1clindamycin hcl caps 150mg 1clindamycin hcl caps 300mg 1clindamycin hcl caps 75mg 1clindamycin palmitate hcl solr 75mg/5ml 1clindamycin phosphate add-vantage inj 150mg/ml 1clindamycin phosphate add-vantage inj 900mg/6ml 1clindamycin phosphate in d5w inj 300mg/50ml; 5% 1clindamycin phosphate in d5w inj 600mg/50ml; 5% 1clindamycin phosphate in d5w inj 900mg/50ml; 5% 1clindamycin phosphate pharmacy bulk package inj 150mg/ml 1clindamycin phosphate crea 2% 1clindamycin phosphate foam 1% 1clindamycin phosphate gel 1% 1clindamycin phosphate inj 150mg/ml 1clindamycin phosphate inj 300mg/2ml 1clindamycin phosphate inj 600mg/4ml 1clindamycin phosphate inj 9000mg/60ml 1



clindamycin phosphate inj 900mg/6ml 1clindamycin phosphate lotn 1% 1clindamycin phosphate soln 1% 1clindamycin phosphate swab 1% 1clindamycin inj 900mg/6ml 1CLINDESSE CREA 2% 1colistimethate sodium inj 150mg 1CUBICIN INJ 500MG 1 NDSDALVANCE INJ 500MG 1 NDSFLAGYL ER TB24 750MG 1lincomycin hcl inj 300mg/ml 1linezolid inj 600mg/300ml 1linezolid susr 100mg/5ml 1 QL (1800 ML per 30 days)linezolid tabs 600mg 1 QL (28 EA per 30 days)mafenide acetate pack 5% 1methenamine hippurate tabs 1gm 1METRO IV INJ 500MG/100ML; 0.74% 1metronidazole in nacl 0.79% inj 500mg/100ml; 0.79% 1metronidazole vaginal gel 0.75% 1metronidazole caps 375mg 1metronidazole crea 0.75% 1metronidazole gel 0.75% 1metronidazole gel 1% 1metronidazole lotn 0.75% 1metronidazole tabs 250mg 1metronidazole tabs 500mg 1MONUROL PACK 5.631GM 1mupirocin calcium crea 2% 1mupirocin crea 2% 1mupirocin oint 2% 1neo-polycin hc oint 400unit/gm; 1%; 3.5mg/gm; 10000unit/gm 1neomycin/polymyxin/bacitracin/hydrocortisone oint 400unit/gm; 1%; 0.5%; 10000unit/gm

1

neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 10000unit/ml

1

nitrofurantoin macrocrystals caps 100mg 1 QL (360 EA per 365 days)nitrofurantoin macrocrystals caps 25mg 1 QL (1440 EA per 365 days)nitrofurantoin macrocrystals caps 50mg 1 QL (720 EA per 365 days)nitrofurantoin monohydrate/macrocrystals caps 100mg 1 QL (180 EA per 365 days)nitrofurantoin monohydrate caps 100mg 1 QL (180 EA per 365 days)nitrofurantoin caps 100mg 1 QL (360 EA per 365 days)nitrofurantoin susp 25mg/5ml 1 QL (7200 ML per 365 days)NORITATE CREA 1% 1 NDSORBACTIV INJ 400MG 1 NDSpolymyxin b sulfate inj 500000unit 1PRIMSOL SOLN 50MG/5ML 1ROSADAN KIT KIT 0.75% 1ROSADAN KIT KIT 0.75% 1



rosadan crea 0.75% 1rosadan gel 0.75% 1silver sulfadiazine crea 1% 1SIVEXTRO INJ 200MG 1 QL (6 EA per 30 days) NDSSIVEXTRO TABS 200MG 1 QL (6 EA per 30 days) NDSssd crea 1% 1SULFAMYLON CREA 85MG/GM 1SYNERCID INJ 350MG; 150MG 1 NDStrimethoprim tabs 100mg 1TYGACIL INJ 50MG 1 NDSvancomycin hcl in dextrose inj 0; 1gm/200ml 1vancomycin hcl in dextrose inj 0; 500mg/100ml 1vancomycin hcl in dextrose inj 0; 750mg/150ml 1vancomycin hcl caps 125mg 1vancomycin hcl caps 250mg 1vancomycin hcl inj 1000mg 1vancomycin hcl inj 10gm 1vancomycin hcl inj 5000mg 1vancomycin hcl inj 500mg 1vancomycin hcl inj 750mg 1vandazole gel 0.75% 1VIBATIV INJ 250MG 1XIFAXAN TABS 200MG 1 PA NDSXIFAXAN TABS 550MG 1 PA MO NDS

Beta-lactam, Cephalosporins AVYCAZ INJ 0.5GM; 2GM 1 NDScefaclor er tb12 500mg 1cefaclor caps 250mg 1cefaclor caps 500mg 1cefaclor susr 125mg/5ml 1cefaclor susr 250mg/5ml 1cefaclor susr 375mg/5ml 1cefadroxil caps 500mg 1cefadroxil susr 250mg/5ml 1cefadroxil susr 500mg/5ml 1cefadroxil tabs 1gm 1cefazolin sodium/dextrose inj 1gm; 4% 1cefazolin sodium/dextrose inj 2gm; 3% 1cefazolin sodium inj 100gm 1cefazolin sodium inj 10gm 1cefazolin sodium inj 1gm 1cefazolin sodium inj 1gm 1cefazolin sodium inj 1gm; 5% 1cefazolin sodium inj 20gm 1cefazolin sodium inj 300gm 1cefazolin sodium inj 500mg 1cefazolin inj 2gm/100ml; 4% 1



cefdinir caps 300mg 1cefdinir susr 125mg/5ml 1cefdinir susr 250mg/5ml 1cefepime/dextrose inj 1gm/50ml; 5% 1cefepime inj 1gm/50ml 1cefepime inj 1gm 1cefepime inj 2gm/100ml 1cefepime inj 2gm/50ml; 5% 1cefepime inj 2gm 1cefixime susr 100mg/5ml 1cefixime susr 200mg/5ml 1cefotaxime sodium inj 10gm 1cefotaxime sodium inj 1gm 1cefotaxime sodium inj 2gm 1cefotaxime sodium inj 500mg 1cefotetan/dextrose inj 1gm; 3.58% 1cefotetan/dextrose inj 2gm; 2.08% 1cefoxitin sodium inj 10gm 1cefoxitin sodium inj 1gm 1cefoxitin sodium inj 1gm; 4% 1cefoxitin sodium inj 2gm 1cefoxitin sodium inj 2gm; 2.2% 1cefpodoxime proxetil susr 100mg/5ml 1cefpodoxime proxetil susr 50mg/5ml 1cefpodoxime proxetil tabs 100mg 1cefpodoxime proxetil tabs 200mg 1cefprozil susr 125mg/5ml 1cefprozil susr 250mg/5ml 1cefprozil tabs 250mg 1cefprozil tabs 500mg 1ceftazidime/dextrose inj 1gm/50ml; 5% 1ceftazidime/dextrose inj 2gm/50ml; 5% 1ceftazidime inj 1gm 1ceftazidime inj 2gm 1ceftazidime inj 6gm 1ceftibuten caps 400mg 1ceftriaxone in iso-osmotic dextrose inj 20mg/ml; 0 1ceftriaxone in iso-osmotic dextrose inj 40mg/ml; 0 1ceftriaxone sodium inj 100gm 1ceftriaxone sodium inj 10gm 1ceftriaxone sodium inj 1gm 1ceftriaxone sodium inj 1gm 1ceftriaxone sodium inj 250mg 1ceftriaxone sodium inj 2gm 1ceftriaxone sodium inj 2gm 1ceftriaxone sodium inj 500mg 1ceftriaxone/dextrose inj 1gm; 3.74% 1



ceftriaxone/dextrose inj 2gm; 2.22% 1cefuroxime axetil tabs 250mg 1cefuroxime axetil tabs 500mg 1cefuroxime sodium inj 1.5gm 1cefuroxime sodium inj 1.5gm 1cefuroxime sodium inj 225gm 1cefuroxime sodium inj 7.5gm 1cefuroxime sodium inj 7.5gm 1cefuroxime sodium inj 750mg 1cefuroxime sodium inj 75gm 1cephalexin caps 250mg 1cephalexin caps 500mg 1cephalexin caps 750mg 1cephalexin susr 125mg/5ml 1cephalexin susr 250mg/5ml 1cephalexin tabs 250mg 1cephalexin tabs 500mg 1SUPRAX CAPS 400MG 1SUPRAX CHEW 100MG 1SUPRAX CHEW 200MG 1SUPRAX SUSR 500MG/5ML 1tazicef inj 1gm 1tazicef inj 1gm 1tazicef inj 2gm 1tazicef inj 2gm 1tazicef inj 6gm 1TEFLARO INJ 400MG 1 NDSTEFLARO INJ 600MG 1 NDSzinacef inj 1.5gm; 0 1zinacef inj 750mg 1

Beta-lactam, Other azactam in iso-osmotic dextrose inj 1gm; 0 1AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM; 0 1aztreonam inj 1gm 1aztreonam inj 2gm 1cefotetan inj 10gm 1cefotetan inj 1gm 1cefotetan inj 2gm 1DORIBAX INJ 250MG 1DORIBAX INJ 500MG 1imipenem/cilastatin inj 250mg; 250mg 1imipenem/cilastatin inj 500mg; 500mg 1INVANZ INJ 1GM 1INVANZ INJ 1GM 1meropenem/sodium chloride inj 1gm/50ml; 0.9% 1meropenem/sodium chloride inj 500mg/50ml; 0.9% 1meropenem inj 1gm 1



meropenem inj 500mg 1Beta-lactam, Penicillins

amoxicillin/clavulanate potassium er tb12 1000mg; 62.5mg 1amoxicillin/clavulanate potassium chew 200mg; 28.5mg 1amoxicillin/clavulanate potassium chew 400mg; 57mg 1amoxicillin/clavulanate potassium susr 200mg/5ml; 28.5mg/5ml 1amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml 1amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml 1amoxicillin/clavulanate potassium susr 600mg/5ml; 42.9mg/5ml 1amoxicillin/clavulanate potassium tabs 250mg; 125mg 1amoxicillin/clavulanate potassium tabs 500mg; 125mg 1amoxicillin/clavulanate potassium tabs 875mg; 125mg 1amoxicillin caps 250mg 1amoxicillin caps 500mg 1amoxicillin chew 125mg 1amoxicillin chew 250mg 1amoxicillin susr 125mg/5ml 1amoxicillin susr 200mg/5ml 1amoxicillin susr 250mg/5ml 1amoxicillin susr 400mg/5ml 1amoxicillin tabs 500mg 1amoxicillin tabs 875mg 1ampicillin sodium inj 10gm 1ampicillin sodium inj 10gm 1ampicillin sodium inj 125mg 1ampicillin sodium inj 1gm 1ampicillin sodium inj 1gm 1ampicillin sodium inj 250mg 1ampicillin sodium inj 2gm 1ampicillin sodium inj 2gm 1ampicillin sodium inj 500mg 1ampicillin-sulbactam inj 10gm; 5gm 1ampicillin-sulbactam inj 10gm; 5gm 1ampicillin-sulbactam inj 10gm; 5gm 1ampicillin-sulbactam inj 1gm; 0.5gm 1ampicillin-sulbactam inj 1gm; 0.5gm 1ampicillin-sulbactam inj 2gm; 1gm 1ampicillin caps 250mg 1ampicillin caps 500mg 1ampicillin susr 125mg/5ml 1ampicillin susr 250mg/5ml 1AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML 1BACTOCILL IN DEXTROSE INJ 0; 1GM/50ML 1BACTOCILL IN DEXTROSE INJ 0; 2GM/50ML 1BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML 1BICILLIN C-R INJ 900000UNIT/2ML; 300000UNIT/2ML 1BICILLIN L-A INJ 1200000UNIT/2ML 1



BICILLIN L-A INJ 2400000UNIT/4ML 1BICILLIN L-A INJ 600000UNIT/ML 1dicloxacillin sodium caps 250mg 1dicloxacillin sodium caps 500mg 1nafcillin sodium inj 10gm 1nafcillin sodium inj 1gm 1nafcillin sodium inj 1gm 1nafcillin sodium inj 2gm 1nafcillin sodium inj 2gm 1NAFCILLIN INJ 0; 1GM/50ML 1NAFCILLIN INJ 0; 2GM/100ML 1oxacillin sodium inj 10gm 1 NDSoxacillin sodium inj 1gm 1oxacillin sodium inj 2gm 1penicillin g potassium in iso-osmotic dextrose inj 0; 20000unit/ml 1penicillin g potassium in iso-osmotic dextrose inj 0; 40000unit/ml 1penicillin g potassium in iso-osmotic dextrose inj 0; 60000unit/ml 1penicillin g potassium inj 20000000unit 1penicillin g potassium inj 5000000unit 1penicillin g sodium inj 5000000unit 1penicillin v potassium solr 125mg/5ml 1penicillin v potassium solr 250mg/5ml 1penicillin v potassium tabs 250mg 1penicillin v potassium tabs 500mg 1pfizerpen-g inj 5000000unit 1piperacillin sodium/ tazobactam sodium inj 36gm; 4.5gm 1piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm 1piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm 1piperacillin/tazobactam inj 2gm; 0.25gm 1piperacillin/tazobactam inj 36gm; 4.5gm 1piperacillin/tazobactam inj 4gm; 0.5gm 1ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML 1ZOSYN INJ 5%; 3GM/50ML; 0.375GM/50ML 1ZOSYN INJ 5%; 4GM/100ML; 0.5GM/100ML 1

Macrolides AZASITE SOLN 1% 1azithromycin inj 500mg 1azithromycin pack 1gm 1azithromycin susr 100mg/5ml 1azithromycin susr 200mg/5ml 1azithromycin tabs 250mg 1azithromycin tabs 250mg 1azithromycin tabs 500mg 1azithromycin tabs 600mg 1clarithromycin er tb24 500mg 1clarithromycin susr 125mg/5ml 1clarithromycin susr 250mg/5ml 1



clarithromycin tabs 250mg 1clarithromycin tabs 500mg 1DIFICID TABS 200MG 1 NDSE.E.S. GRANULES SUSR 200MG/5ML 1ERY-TAB TBEC 250MG 1ERY-TAB TBEC 333MG 1ERY-TAB TBEC 500MG 1ery pads 2% 1ERYPED 200 SUSR 200MG/5ML 1ERYPED 400 SUSR 400MG/5ML 1erythrocin lactobionate inj 500mg 1ERYTHROCIN STEARATE TABS 250MG 1erythromycin base tabs 250mg 1erythromycin base tabs 500mg 1erythromycin ethylsuccinate tabs 400mg 1erythromycin stearate tabs 250mg 1erythromycin cpep 250mg 1erythromycin gel 2% 1erythromycin oint 5mg/gm 1erythromycin pads 2% 1erythromycin soln 2% 1ilotycin oint 5mg/gm 1KETEK TABS 300MG 1KETEK TABS 400MG 1PCE TBEC 333MG 1PCE TBEC 500MG 1ZMAX SUSR 2GM 1

Quinolones BESIVANCE SUSP 0.6% 1CILOXAN OINT 0.3% 1ciprofloxacin er tb24 1000mg; 0 1ciprofloxacin er tb24 500mg; 0 1ciprofloxacin hcl soln 0.3% 1ciprofloxacin hcl tabs 100mg 1ciprofloxacin hcl tabs 250mg 1ciprofloxacin hcl tabs 500mg 1ciprofloxacin hcl tabs 750mg 1ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5% 1ciprofloxacin inj 200mg/20ml 1ciprofloxacin inj 400mg/40ml 1ciprofloxacin soln 0.2% 1ciprofloxacin susr 250mg/5ml 1ciprofloxacin susr 500mg/5ml 1gatifloxacin soln 0.5% 1levofloxacin in d5w inj 5%; 250mg/50ml 1levofloxacin in d5w inj 5%; 500mg/100ml 1



levofloxacin in d5w inj 5%; 750mg/150ml 1levofloxacin inj 25mg/ml 1levofloxacin soln 0.5% 1levofloxacin soln 25mg/ml 1levofloxacin tabs 250mg 1levofloxacin tabs 500mg 1levofloxacin tabs 750mg 1MOXEZA SOLN 0.5% 1MOXIFLOXACIN HCL INJ 400MG/250ML 1moxifloxacin hcl tabs 400mg 1ofloxacin soln 0.3% 1ofloxacin soln 0.3% 1ofloxacin tabs 400mg 1VIGAMOX SOLN 0.5% 1

Sulfonamides sodium sulfacetamide lotn 10% 1sodium sulfacetamide soln 10% 1sulfacetamide sodium oint 10% 1sulfacetamide sodium soln 10% 1sulfacetamide sodium susp 10% 1sulfadiazine tabs 500mg 1sulfamethoxazole/trimethoprim ds tabs 800mg; 160mg 1sulfamethoxazole/trimethoprim inj 400mg/5ml; 80mg/5ml 1sulfamethoxazole/trimethoprim susp 200mg/5ml; 40mg/5ml 1sulfamethoxazole/trimethoprim tabs 400mg; 80mg 1sulfatrim pediatric susp 200mg/5ml; 40mg/5ml 1

Tetracyclines demeclocycline hcl tabs 150mg 1demeclocycline hcl tabs 300mg 1DORYX TBEC 200MG 1DORYX TBEC 50MG 1doxy 100 inj 100mg 1doxycycline hyclate dr tbec 100mg 1doxycycline hyclate dr tbec 150mg 1doxycycline hyclate dr tbec 200mg 1doxycycline hyclate dr tbec 50mg 1doxycycline hyclate dr tbec 75mg 1doxycycline hyclate caps 100mg 1doxycycline hyclate caps 50mg 1doxycycline hyclate inj 100mg 1doxycycline hyclate tabs 100mg 1doxycycline hyclate tabs 20mg 1doxycycline monohydrate caps 100mg 1doxycycline monohydrate caps 50mg 1doxycycline monohydrate tabs 100mg 1doxycycline monohydrate tabs 150mg 1doxycycline monohydrate tabs 50mg 1



doxycycline monohydrate tabs 75mg 1doxycycline caps 150mg 1doxycycline caps 75mg 1doxycycline susr 25mg/5ml 1minocycline hcl er tb24 135mg 1minocycline hcl er tb24 45mg 1minocycline hcl er tb24 90mg 1minocycline hcl caps 100mg 1minocycline hcl caps 50mg 1minocycline hcl caps 75mg 1minocycline hcl tabs 100mg 1minocycline hcl tabs 50mg 1minocycline hcl tabs 75mg 1mondoxyne nl caps 100mg 1mondoxyne nl caps 50mg 1mondoxyne nl caps 75mg 1morgidox 1x100mg caps 100mg 1MORGIDOX 1X100MG KIT 0; 100MG; 0 1morgidox 2x100mg caps 100mg 1MORGIDOX 2X100MG KIT 0; 100MG; 0 1OCUDOX KIT 50MG 1TETRACYCLINE HCL CAPS 250MG 1TETRACYCLINE HCL CAPS 500MG 1VIBRAMYCIN SYRP 50MG/5ML 1

AnticonvulsantsAnticonvulsants, Other

APTIOM TABS 200MG 1 MOAPTIOM TABS 400MG 1 MO NDSAPTIOM TABS 600MG 1 MO NDSAPTIOM TABS 800MG 1 MO NDSBRIVIACT INJ 50MG/5ML 1BRIVIACT SOLN 10MG/ML 1 MO NDSBRIVIACT TABS 100MG 1 MO NDSBRIVIACT TABS 10MG 1 MO NDSBRIVIACT TABS 25MG 1 MO NDSBRIVIACT TABS 50MG 1 MO NDSBRIVIACT TABS 75MG 1 MO NDSFYCOMPA SUSP 0.5MG/ML 1 MOFYCOMPA TABS 10MG 1 MOFYCOMPA TABS 12MG 1 MOFYCOMPA TABS 2MG 1 MOFYCOMPA TABS 4MG 1 MOFYCOMPA TABS 6MG 1 MOFYCOMPA TABS 8MG 1 MOlevetiracetam er tb24 500mg 1 MOlevetiracetam er tb24 750mg 1 MOLEVETIRACETAM INJ 1000MG/100ML; 750MG/100ML 1



LEVETIRACETAM INJ 1500MG/100ML; 540MG/100ML 1LEVETIRACETAM INJ 500MG/100ML; 820MG/100ML 1levetiracetam inj 500mg/5ml 1levetiracetam soln 100mg/ml 1 MOlevetiracetam tabs 1000mg 1 MOlevetiracetam tabs 250mg 1 MOlevetiracetam tabs 500mg 1 MOlevetiracetam tabs 750mg 1 MOmagnesium sulfate in d5w inj 5%; 10mg/ml 1magnesium sulfate in d5w inj 5%; 20mg/ml 1POTIGA TABS 200MG 1 MO NDSPOTIGA TABS 300MG 1 MO NDSPOTIGA TABS 400MG 1 MO NDSPOTIGA TABS 50MG 1 MO NDSroweepra tabs 500mg 1 MOSPRITAM TB3D 1000MG 1 MOSPRITAM TB3D 250MG 1 MOSPRITAM TB3D 500MG 1 MOSPRITAM TB3D 750MG 1 MO

Calcium Channel Modifying Agents CELONTIN CAPS 300MG 1 MOethosuximide caps 250mg 1 MOethosuximide soln 250mg/5ml 1 MOLYRICA CAPS 100MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 150MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 200MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 225MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 25MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 300MG 1 QL (60 EA per 30 days) MOLYRICA CAPS 50MG 1 QL (90 EA per 30 days) MOLYRICA CAPS 75MG 1 QL (90 EA per 30 days) MOLYRICA SOLN 20MG/ML 1 QL (900 ML per 30 days) MOzonisamide caps 100mg 1 MOzonisamide caps 25mg 1 MOzonisamide caps 50mg 1 MO

Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 0.125mg 1 QL (90 EA per 30 days) MOclonazepam odt tbdp 0.25mg 1 QL (90 EA per 30 days) MOclonazepam odt tbdp 0.5mg 1 QL (90 EA per 30 days) MOclonazepam odt tbdp 1mg 1 QL (90 EA per 30 days) MOclonazepam odt tbdp 2mg 1 QL (30 EA per 30 days) MOclonazepam tabs 0.5mg 1 MOclonazepam tabs 1mg 1 MOclonazepam tabs 2mg 1 MOdiazepam gel 10mg 1diazepam gel 2.5mg 1diazepam gel 20mg 1



divalproex sodium dr tbec 125mg 1 MOdivalproex sodium dr tbec 250mg 1 MOdivalproex sodium dr tbec 500mg 1 MOdivalproex sodium er tb24 250mg 1 MOdivalproex sodium er tb24 500mg 1 MOdivalproex sodium csdr 125mg 1 MOgabapentin caps 100mg 1 MOgabapentin caps 300mg 1 MOgabapentin caps 400mg 1 MOgabapentin soln 250mg/5ml 1 MOgabapentin tabs 600mg 1 MOgabapentin tabs 800mg 1 MOGABITRIL TABS 12MG 1 MOGABITRIL TABS 16MG 1 MOONFI SUSP 2.5MG/ML 1 MO NDSONFI TABS 10MG 1 MOONFI TABS 20MG 1 MO NDSphenobarbital elix 20mg/5ml 1 PA MOphenobarbital tabs 100mg 1 PA MOphenobarbital tabs 15mg 1 PA MOphenobarbital tabs 16.2mg 1 PA MOphenobarbital tabs 30mg 1 PA MOphenobarbital tabs 32.4mg 1 PA MOphenobarbital tabs 60mg 1 PA MOphenobarbital tabs 64.8mg 1 PA MOphenobarbital tabs 97.2mg 1 PA MOprimidone tabs 250mg 1 MOprimidone tabs 50mg 1 MOSABRIL PACK 500MG 1 PA MO NDSSABRIL TABS 500MG 1 PA MO NDStiagabine hydrochloride tabs 2mg 1 MOtiagabine hydrochloride tabs 4mg 1 MOvalproate sodium inj 500mg/5ml 1valproic acid caps 250mg 1 MOvalproic acid syrp 250mg/5ml 1 MO

Glutamate Reducing Agents felbamate susp 600mg/5ml 1 MO NDSfelbamate tabs 400mg 1 MOfelbamate tabs 600mg 1 MOLAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT 01LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOTTAKING VALPROATE KIT 0

1 NDS

LAMICTAL STARTER/TAKING VALPROATE KIT 25MG 1lamotrigine er tb24 100mg 1 MOlamotrigine er tb24 200mg 1 MOlamotrigine er tb24 250mg 1 MOlamotrigine er tb24 25mg 1 MOlamotrigine er tb24 300mg 1 MO



lamotrigine er tb24 50mg 1 MOlamotrigine odt tbdp 100mg 1 MOlamotrigine odt tbdp 200mg 1 MOlamotrigine odt tbdp 25mg 1 MOlamotrigine odt tbdp 50mg 1 MOlamotrigine titration kit 0 1lamotrigine titration kit 0 1lamotrigine titration kit 0 1lamotrigine chew 25mg 1 MOlamotrigine chew 5mg 1 MOlamotrigine tabs 100mg 1 MOlamotrigine tabs 150mg 1 MOlamotrigine tabs 200mg 1 MOlamotrigine tabs 25mg 1 MOtopiramate er cs24 100mg 1 MOtopiramate er cs24 150mg 1 MOtopiramate er cs24 200mg 1 MOtopiramate er cs24 25mg 1 MOtopiramate er cs24 50mg 1 MOtopiramate cpsp 15mg 1 MOtopiramate cpsp 25mg 1 MOtopiramate tabs 100mg 1 MOtopiramate tabs 200mg 1 MOtopiramate tabs 25mg 1 MOtopiramate tabs 50mg 1 MO

Sodium Channel Agents BANZEL SUSP 40MG/ML 1 MO NDSBANZEL TABS 200MG 1 MO NDSBANZEL TABS 400MG 1 MO NDScarbamazepine er cp12 100mg 1 MOcarbamazepine er cp12 200mg 1 MOcarbamazepine er cp12 300mg 1 MOcarbamazepine er tb12 100mg 1 MOcarbamazepine er tb12 200mg 1 MOcarbamazepine er tb12 400mg 1 MOcarbamazepine chew 100mg 1 MOcarbamazepine susp 100mg/5ml 1 MOcarbamazepine tabs 200mg 1 MOCARBATROL CP12 100MG 1 MOCARBATROL CP12 200MG 1 MOCARBATROL CP12 300MG 1 MODILANTIN INFATABS CHEW 50MG 1 MODILANTIN-125 SUSP 125MG/5ML 1 MODILANTIN CAPS 100MG 1 MODILANTIN CAPS 30MG 1 MOepitol tabs 200mg 1 MOfosphenytoin sodium inj 100mg pe/2ml 1



fosphenytoin sodium inj 500mg pe/10ml 1oxcarbazepine susp 300mg/5ml 1 MOoxcarbazepine tabs 150mg 1 MOoxcarbazepine tabs 300mg 1 MOoxcarbazepine tabs 600mg 1 MOPEGANONE TABS 250MG 1 MOPHENYTEK CAPS 200MG 1 MOPHENYTEK CAPS 300MG 1 MOphenytoin sodium extended caps 100mg 1 MOphenytoin sodium extended caps 200mg 1 MOphenytoin sodium extended caps 300mg 1 MOphenytoin sodium inj 50mg/ml 1phenytoin chew 50mg 1 MOphenytoin susp 125mg/5ml 1 MOTEGRETOL-XR TB12 100MG 1 MOTEGRETOL-XR TB12 200MG 1 MOTEGRETOL-XR TB12 400MG 1 MOTEGRETOL SUSP 100MG/5ML 1 MOTEGRETOL TABS 200MG 1 MOVIMPAT INJ 200MG/20ML 1VIMPAT SOLN 10MG/ML 1 MOVIMPAT TABS 100MG 1 MOVIMPAT TABS 150MG 1 MOVIMPAT TABS 200MG 1 MOVIMPAT TABS 50MG 1 MO

Antidementia AgentsAntidementia Agents, Other

ERGOLOID MESYLATES TABS 1MG 1 PA MONAMZARIC CP24 10MG; 14MG 1 QL (30 EA per 30 days) MONAMZARIC CP24 10MG; 28MG 1 QL (30 EA per 30 days) MO

Cholinesterase Inhibitors donepezil hcl tabs 10mg 1 MOdonepezil hcl tabs 23mg 1 MOdonepezil hcl tabs 5mg 1 MOdonepezil hcl tbdp 10mg 1 MOdonepezil hcl tbdp 5mg 1 MOgalantamine hydrobromide cp24 16mg 1 MOgalantamine hydrobromide cp24 24mg 1 MOgalantamine hydrobromide cp24 8mg 1 MOgalantamine hydrobromide soln 4mg/ml 1 MOgalantamine hydrobromide tabs 12mg 1 MOgalantamine hydrobromide tabs 4mg 1 MOgalantamine hydrobromide tabs 8mg 1 MOrivastigmine tartrate caps 1.5mg 1 MOrivastigmine tartrate caps 3mg 1 MOrivastigmine tartrate caps 4.5mg 1 MOrivastigmine tartrate caps 6mg 1 MO



rivastigmine transdermal system pt24 13.3mg/24hr 1 MOrivastigmine transdermal system pt24 4.6mg/24hr 1 MOrivastigmine transdermal system pt24 9.5mg/24hr 1 MO

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl titration pak tabs 0 1memantine hcl tabs 10mg 1 MOmemantine hcl tabs 5mg 1 MOmemantine hydrochloride soln 2mg/ml 1 MONAMENDA TITRATION PAK TABS 0 1NAMENDA XR TITRATION PACK CP24 0 1 QL (56 EA per 365 days)NAMENDA XR CP24 14MG 1 QL (30 EA per 30 days) MONAMENDA XR CP24 21MG 1 QL (30 EA per 30 days) MONAMENDA XR CP24 28MG 1 QL (30 EA per 30 days) MONAMENDA XR CP24 7MG 1 QL (30 EA per 30 days) MONAMENDA SOLN 10MG/5ML 1 MONAMENDA TABS 10MG 1 MONAMENDA TABS 5MG 1 MO

AntidepressantsAntidepressants, Other

APLENZIN TB24 174MG 1 QL (30 EA per 30 days) ST MO NDSAPLENZIN TB24 348MG 1 QL (30 EA per 30 days) ST MO NDSAPLENZIN TB24 522MG 1 QL (30 EA per 30 days) ST MO NDSbupropion hcl er tb12 100mg 1 QL (90 EA per 30 days) MObupropion hcl er tb12 150mg 1 QL (90 EA per 30 days) MObupropion hcl er tb12 200mg 1 QL (90 EA per 30 days) MObupropion hcl sr tb12 100mg 1 QL (90 EA per 30 days) MObupropion hcl sr tb12 150mg 1 QL (90 EA per 30 days) MObupropion hcl sr tb12 200mg 1 QL (90 EA per 30 days) MObupropion hcl xl tb24 150mg 1 QL (90 EA per 30 days) MObupropion hcl xl tb24 300mg 1 QL (30 EA per 30 days) MObupropion hcl tabs 100mg 1 MObupropion hcl tabs 75mg 1 MOFORFIVO XL TB24 450MG 1 QL (30 EA per 30 days) MOmaprotiline hcl tabs 25mg 1 MOmaprotiline hcl tabs 50mg 1 MOmaprotiline hcl tabs 75mg 1 MOmirtazapine odt tbdp 15mg 1 MOmirtazapine odt tbdp 30mg 1 MOmirtazapine odt tbdp 45mg 1 MOmirtazapine tabs 15mg 1 MOmirtazapine tabs 30mg 1 MOmirtazapine tabs 45mg 1 MOmirtazapine tabs 7.5mg 1 MOnefazodone hcl tabs 100mg 1 MOnefazodone hcl tabs 150mg 1 MOnefazodone hcl tabs 200mg 1 MOnefazodone hcl tabs 250mg 1 MO



nefazodone hcl tabs 50mg 1 MOtrazodone hcl tabs 100mg 1 MOtrazodone hcl tabs 150mg 1 MOtrazodone hcl tabs 300mg 1 MOtrazodone hcl tabs 50mg 1 MO

Monoamine Oxidase Inhibitors EMSAM PT24 12MG/24HR 1 QL (30 EA per 30 days) ST MO NDSEMSAM PT24 6MG/24HR 1 QL (30 EA per 30 days) ST MO NDSEMSAM PT24 9MG/24HR 1 QL (30 EA per 30 days) ST MO NDSMARPLAN TABS 10MG 1 MOphenelzine sulfate tabs 15mg 1 MOtranylcypromine sulfate tabs 10mg 1 MO

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor)

TRINTELLIX TABS 10MG 1 QL (30 EA per 30 days) MOTRINTELLIX TABS 20MG 1 QL (30 EA per 30 days) MOTRINTELLIX TABS 5MG 1 QL (30 EA per 30 days) MO

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

BRINTELLIX TABS 10MG 1 QL (30 EA per 30 days) MOBRINTELLIX TABS 20MG 1 QL (30 EA per 30 days) MOBRINTELLIX TABS 5MG 1 QL (30 EA per 30 days) MOcitalopram hydrobromide soln 10mg/5ml 1 MOcitalopram hydrobromide tabs 10mg 1 MOcitalopram hydrobromide tabs 20mg 1 MOcitalopram hydrobromide tabs 40mg 1 MODESVENLAFAXINE ER TB24 100MG 1 QL (120 EA per 30 days) ST MODESVENLAFAXINE ER TB24 100MG 1 QL (120 EA per 30 days) ST MODESVENLAFAXINE ER TB24 50MG 1 QL (30 EA per 30 days) ST MODESVENLAFAXINE ER TB24 50MG 1 QL (30 EA per 30 days) ST MOduloxetine hcl cpep 20mg 1 QL (60 EA per 30 days) MOduloxetine hcl cpep 30mg 1 QL (90 EA per 30 days) MODULOXETINE HCL CPEP 40MG 1 QL (60 EA per 30 days) MOduloxetine hcl cpep 60mg 1 QL (60 EA per 30 days) MOescitalopram oxalate soln 5mg/5ml 1 MOescitalopram oxalate tabs 10mg 1 MOescitalopram oxalate tabs 20mg 1 MOescitalopram oxalate tabs 5mg 1 MOFETZIMA TITRATION PACK C4PK 0 1 QL (56 EA per 365 days) STFETZIMA CP24 120MG 1 QL (30 EA per 30 days) ST MOFETZIMA CP24 20MG 1 QL (30 EA per 30 days) ST MOFETZIMA CP24 40MG 1 QL (30 EA per 30 days) ST MOFETZIMA CP24 80MG 1 QL (30 EA per 30 days) ST MOfluoxetine dr cpdr 90mg 1 QL (4 EA per 28 days) MOfluoxetine hcl caps 10mg 1 MOfluoxetine hcl caps 20mg 1 MOfluoxetine hcl caps 40mg 1 MOfluoxetine hcl soln 20mg/5ml 1 MO



fluoxetine hcl tabs 10mg 1 MOfluoxetine hcl tabs 20mg 1 MOfluoxetine hcl tabs 60mg 1 MOfluoxetine caps 10mg 1 MOfluoxetine caps 20mg 1 MOfluvoxamine maleate er cp24 100mg 1 QL (60 EA per 30 days) MOfluvoxamine maleate er cp24 150mg 1 QL (60 EA per 30 days) MOfluvoxamine maleate tabs 100mg 1 MOfluvoxamine maleate tabs 25mg 1 MOfluvoxamine maleate tabs 50mg 1 MOKHEDEZLA TB24 100MG 1 QL (120 EA per 30 days) ST MOKHEDEZLA TB24 50MG 1 QL (30 EA per 30 days) ST MOolanzapine/fluoxetine caps 25mg; 12mg 1 QL (30 EA per 30 days) MOolanzapine/fluoxetine caps 25mg; 3mg 1 QL (90 EA per 30 days) MOolanzapine/fluoxetine caps 25mg; 6mg 1 QL (90 EA per 30 days) MOolanzapine/fluoxetine caps 50mg; 12mg 1 QL (30 EA per 30 days) MOolanzapine/fluoxetine caps 50mg; 6mg 1 QL (30 EA per 30 days) MOparoxetine hcl er tb24 12.5mg 1 MOparoxetine hcl er tb24 25mg 1 MOparoxetine hcl er tb24 37.5mg 1 MOparoxetine hcl tabs 10mg 1 MOparoxetine hcl tabs 20mg 1 MOparoxetine hcl tabs 30mg 1 MOparoxetine hcl tabs 40mg 1 MOPAXIL SUSP 10MG/5ML 1 MOPEXEVA TABS 10MG 1 QL (30 EA per 30 days) ST MOPEXEVA TABS 20MG 1 QL (30 EA per 30 days) ST MOPEXEVA TABS 30MG 1 QL (60 EA per 30 days) ST MOPEXEVA TABS 40MG 1 QL (30 EA per 30 days) ST MOPRISTIQ TB24 100MG 1 QL (120 EA per 30 days) MOPRISTIQ TB24 25MG 1 QL (30 EA per 30 days) MOPRISTIQ TB24 50MG 1 QL (30 EA per 30 days) MOsertraline hcl conc 20mg/ml 1 MOsertraline hcl tabs 100mg 1 MOsertraline hcl tabs 25mg 1 MOsertraline hcl tabs 50mg 1 MOvenlafaxine hcl er cp24 150mg 1 MOvenlafaxine hcl er cp24 37.5mg 1 MOvenlafaxine hcl er cp24 75mg 1 MOvenlafaxine hcl er tb24 150mg 1 MOvenlafaxine hcl er tb24 225mg 1 MOvenlafaxine hcl er tb24 37.5mg 1 MOvenlafaxine hcl er tb24 75mg 1 MOvenlafaxine hcl tabs 100mg 1 MOvenlafaxine hcl tabs 25mg 1 MOvenlafaxine hcl tabs 37.5mg 1 MOvenlafaxine hcl tabs 50mg 1 MO



venlafaxine hcl tabs 75mg 1 MOVIIBRYD STARTER PACK KIT 0 1 QL (60 EA per 365 days)VIIBRYD KIT 0 1 QL (60 EA per 365 days)VIIBRYD TABS 10MG 1 QL (30 EA per 30 days) MOVIIBRYD TABS 20MG 1 QL (30 EA per 30 days) MOVIIBRYD TABS 40MG 1 QL (30 EA per 30 days) MO

Tricyclics amitriptyline hcl tabs 100mg 1 PA MOamitriptyline hcl tabs 10mg 1 PA MOamitriptyline hcl tabs 150mg 1 PA MOamitriptyline hcl tabs 25mg 1 PA MOamitriptyline hcl tabs 50mg 1 PA MOamitriptyline hcl tabs 75mg 1 PA MOamoxapine tabs 100mg 1 MOamoxapine tabs 150mg 1 MOamoxapine tabs 25mg 1 MOamoxapine tabs 50mg 1 MOchlordiazepoxide/amitriptyline tabs 12.5mg; 5mg 1 PA MOchlordiazepoxide/amitriptyline tabs 25mg; 10mg 1 PA MOclomipramine hcl caps 25mg 1 PA MOclomipramine hcl caps 50mg 1 PA MOclomipramine hcl caps 75mg 1 PA MOdesipramine hcl tabs 100mg 1 MOdesipramine hcl tabs 10mg 1 MOdesipramine hcl tabs 150mg 1 MOdesipramine hcl tabs 25mg 1 MOdesipramine hcl tabs 50mg 1 MOdesipramine hcl tabs 75mg 1 MOdoxepin hcl caps 100mg 1 PA MOdoxepin hcl caps 10mg 1 PA MOdoxepin hcl caps 150mg 1 PA MOdoxepin hcl caps 25mg 1 PA MOdoxepin hcl caps 50mg 1 PA MOdoxepin hcl caps 75mg 1 PA MOdoxepin hcl conc 10mg/ml 1 PA MOimipramine hcl tabs 10mg 1 PA MOimipramine hcl tabs 25mg 1 PA MOimipramine hcl tabs 50mg 1 PA MOimipramine pamoate caps 100mg 1 PA MOimipramine pamoate caps 125mg 1 PA MOimipramine pamoate caps 150mg 1 PA MOimipramine pamoate caps 75mg 1 PA MOnortriptyline hcl caps 10mg 1 MOnortriptyline hcl caps 25mg 1 MOnortriptyline hcl caps 50mg 1 MOnortriptyline hcl caps 75mg 1 MOnortriptyline hcl soln 10mg/5ml 1 MO



perphenazine/amitriptyline tabs 10mg; 2mg 1 PA MOperphenazine/amitriptyline tabs 10mg; 4mg 1 PA MOperphenazine/amitriptyline tabs 25mg; 2mg 1 PA MOperphenazine/amitriptyline tabs 25mg; 4mg 1 PA MOperphenazine/amitriptyline tabs 50mg; 4mg 1 PA MOprotriptyline hcl tabs 10mg 1 MOprotriptyline hcl tabs 5mg 1 MOtrimipramine maleate caps 100mg 1 PA MOtrimipramine maleate caps 25mg 1 PA MOtrimipramine maleate caps 50mg 1 PA MO

AntiemeticsAntiemetics, Other

droperidol inj 2.5mg/ml 1meclizine hcl tabs 12.5mg 1meclizine hcl tabs 25mg 1phenadoz supp 12.5mg 1 PAphenadoz supp 25mg 1 PAphenergan supp 12.5mg 1 PAphenergan supp 25mg 1 PAphenergan supp 50mg 1 PApromethazine hcl inj 25mg/ml 1 PApromethazine hcl inj 50mg/ml 1 PApromethazine hcl supp 12.5mg 1 PApromethazine hcl supp 25mg 1 PApromethazine hcl supp 50mg 1 PApromethazine hcl syrp 6.25mg/5ml 1 PApromethazine hcl tabs 12.5mg 1 PApromethazine hcl tabs 25mg 1 PApromethazine hcl tabs 50mg 1 PApromethegan supp 12.5mg 1 PApromethegan supp 25mg 1 PApromethegan supp 50mg 1 PATRANSDERM-SCOP PT72 1MG/3DAYS 1trimethobenzamide hcl caps 300mg 1 PA

Emetogenic Therapy Adjuncts ALOXI INJ 0.25MG/5ML 1ANZEMET INJ 20MG/ML 1ANZEMET TABS 100MG 1 QL (5 EA per 30 days) B/D NDSANZEMET TABS 50MG 1 QL (5 EA per 30 days) B/Ddronabinol caps 10mg 1 QL (60 EA per 30 days) PAdronabinol caps 2.5mg 1 QL (60 EA per 30 days) PAdronabinol caps 5mg 1 QL (60 EA per 30 days) PAEMEND CAPS 0 1 QL (6 EA per 30 days) B/DEMEND CAPS 125MG 1 QL (2 EA per 30 days) B/DEMEND CAPS 40MG 1 QL (1 EA per 30 days) B/DEMEND CAPS 80MG 1 QL (8 EA per 30 days) B/Dgranisetron hcl inj 0.1mg/ml 1



granisetron hcl inj 1mg/ml 1granisetron hcl inj 4mg/4ml 1granisetron hcl tabs 1mg 1 QL (30 EA per 30 days) B/Dondansetron hcl inj 40mg/20ml 1 QL (120 ML per 30 days)ondansetron hcl inj 4mg/2ml 1 QL (120 ML per 30 days)ondansetron hcl inj 4mg/2ml 1 QL (120 ML per 30 days)ondansetron hcl soln 4mg/5ml 1 QL (450 ML per 30 days) B/Dondansetron hcl tabs 24mg 1 QL (14 EA per 28 days) B/Dondansetron hcl tabs 4mg 1 B/Dondansetron hcl tabs 8mg 1 B/Dondansetron odt tbdp 4mg 1 B/Dondansetron odt tbdp 8mg 1 B/DSANCUSO PTCH 3.1MG/24HR 1 QL (2 EA per 30 days) NDS

AntifungalsAntifungals

ABELCET INJ 5MG/ML 1 B/D NDSAMBISOME INJ 50MG 1 B/D NDSamphotericin b inj 50mg 1 B/DCANCIDAS INJ 50MG 1 NDSCANCIDAS INJ 70MG 1 NDSciclodan crea 0.77% 1ciclodan soln 8% 1 PAciclopirox nail lacquer soln 8% 1 PAciclopirox olamine crea 0.77% 1ciclopirox gel 0.77% 1ciclopirox sham 1% 1ciclopirox susp 0.77% 1clotrimazole crea 1% 1clotrimazole soln 1% 1clotrimazole troc 10mg 1CRESEMBA CAPS 186MG 1 NDSCRESEMBA INJ 372MG 1 NDSeconazole nitrate crea 1% 1ERAXIS INJ 100MG 1 NDSERAXIS INJ 50MG 1 NDSEXELDERM CREA 1% 1EXELDERM SOLN 1% 1fluconazole in dextrose inj 56mg/ml; 200mg/100ml 1fluconazole in nacl inj 100mg/50ml; 0.9% 1fluconazole in nacl inj 200mg/100ml; 0.9% 1fluconazole in nacl inj 400mg/200ml; 0.9% 1fluconazole susr 10mg/ml 1fluconazole susr 40mg/ml 1fluconazole tabs 100mg 1fluconazole tabs 150mg 1fluconazole tabs 200mg 1fluconazole tabs 50mg 1



flucytosine caps 250mg 1 NDSflucytosine caps 500mg 1 NDSgriseofulvin microsize susp 125mg/5ml 1griseofulvin microsize tabs 500mg 1griseofulvin ultramicrosize tabs 125mg 1griseofulvin ultramicrosize tabs 250mg 1GYNAZOLE-1 CREA 2% 1itraconazole caps 100mg 1 PAJUBLIA SOLN 10% 1ketoconazole crea 2% 1ketoconazole foam 2% 1ketoconazole sham 2% 1ketoconazole tabs 200mg 1ketodan foam 2% 1LAMISIL PACK 125MG 1LAMISIL PACK 187.5MG 1MENTAX CREA 1% 1miconazole 3 supp 200mg 1MYCAMINE INJ 100MG 1 NDSMYCAMINE INJ 50MG 1NAFTIFINE HCL CREA 1% 1naftifine hydrochloride crea 2% 1NAFTIN GEL 1% 1NAFTIN GEL 2% 1NATACYN SUSP 5% 1NOXAFIL INJ 300MG/16.7ML 1 MONOXAFIL SUSP 40MG/ML 1 MO NDSNOXAFIL TBEC 100MG 1 MO NDSnyamyc powd 100000unit/gm 1nystatin/triamcinolone crea 100000unit/gm; 0.1% 1nystatin/triamcinolone oint 100000unit/gm; 0.1% 1nystatin crea 100000unit/gm 1nystatin oint 100000unit/gm 1nystatin powd 100000unit/gm 1nystatin susp 100000unit/ml 1nystatin tabs 500000unit 1nystop powd 100000unit/gm 1ONMEL TABS 200MG 1 PA NDSoxiconazole nitrate crea 1% 1OXISTAT LOTN 1% 1SPORANOX SOLN 10MG/ML 1 PA NDSterbinafine hcl tabs 250mg 1 QL (84 EA per 180 days)terconazole crea 0.4% 1terconazole crea 0.8% 1terconazole supp 80mg 1voriconazole inj 200mg 1voriconazole susr 40mg/ml 1 NDS



voriconazole tabs 200mg 1voriconazole tabs 50mg 1zazole crea 0.4% 1zazole crea 0.8% 1zazole supp 80mg 1

Antigout AgentsAntigout Agents

allopurinol tabs 100mg 1 MOallopurinol tabs 300mg 1 MOcolchicine tabs 0.6mg 1COLCRYS TABS 0.6MG 1KRYSTEXXA INJ 8MG/ML 1 PA NDSprobenecid/colchicine tabs 0.5mg; 500mg 1 MOprobenecid tabs 500mg 1 MOULORIC TABS 40MG 1 ST MOULORIC TABS 80MG 1 ST MO

Antimigraine AgentsErgot Alkaloids

CAFERGOT TABS 100MG; 1MG 1dihydroergotamine mesylate inj 1mg/ml 1 NDSdihydroergotamine mesylate soln 4mg/ml 1 QL (8 ML per 30 days) NDSERGOMAR SUBL 2MG 1MIGERGOT SUPP 100MG; 2MG 1

Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate tabs 12.5mg 1 QL (12 EA per 30 days)almotriptan malate tabs 6.25mg 1 QL (12 EA per 30 days)frovatriptan succinate tabs 2.5mg 1 QL (9 EA per 30 days)naratriptan hcl tabs 1mg 1 QL (9 EA per 30 days)naratriptan hcl tabs 2.5mg 1 QL (9 EA per 30 days)rizatriptan benzoate odt tbdp 10mg 1 QL (18 EA per 30 days)rizatriptan benzoate odt tbdp 5mg 1 QL (18 EA per 30 days)rizatriptan benzoate tabs 10mg 1 QL (18 EA per 30 days)rizatriptan benzoate tabs 5mg 1 QL (18 EA per 30 days)SUMATRIPTAN SUCCINATE REFILL INJ 4MG/0.5ML 1 QL (5 ML per 30 days)SUMATRIPTAN SUCCINATE REFILL INJ 6MG/0.5ML 1 QL (5 ML per 30 days)SUMATRIPTAN SUCCINATE INJ 4MG/0.5ML 1 QL (5 ML per 30 days)sumatriptan succinate inj 6mg/0.5ml 1 QL (5 ML per 30 days)sumatriptan succinate inj 6mg/0.5ml 1 QL (5 ML per 30 days)sumatriptan succinate inj 6mg/0.5ml 1 QL (5 ML per 30 days)sumatriptan succinate tabs 100mg 1 QL (9 EA per 30 days)sumatriptan succinate tabs 25mg 1 QL (9 EA per 30 days)sumatriptan succinate tabs 50mg 1 QL (9 EA per 30 days)SUMATRIPTAN SOLN 20MG/ACT 1 QL (12 EA per 30 days)SUMATRIPTAN SOLN 5MG/ACT 1 QL (12 EA per 30 days)zolmitriptan odt tbdp 2.5mg 1 QL (12 EA per 30 days)zolmitriptan odt tbdp 5mg 1 QL (9 EA per 30 days)zolmitriptan tabs 2.5mg 1 QL (12 EA per 30 days)



zolmitriptan tabs 5mg 1 QL (12 EA per 30 days)Antimyasthenic Agents

Parasympathomimetics GUANIDINE HCL TABS 125MG 1MESTINON SYRP 60MG/5ML 1 NDSpyridostigmine bromide tabs 60mg 1pyridostigmine bromide tbcr 180mg 1REGONOL INJ 10MG/2ML 1

AntimycobacterialsAntimycobacterials, Other

dapsone tabs 100mg 1 MOdapsone tabs 25mg 1 MOrifabutin caps 150mg 1

Antituberculars CAPASTAT SULFATE INJ 1GM 1cycloserine caps 250mg 1ethambutol hcl tabs 100mg 1ethambutol hcl tabs 400mg 1isoniazid inj 100mg/ml 1isoniazid syrp 50mg/5ml 1 MOisoniazid tabs 100mg 1 MOisoniazid tabs 300mg 1 MOPASER PACK 4GM 1PRIFTIN TABS 150MG 1pyrazinamide tabs 500mg 1rifampin caps 150mg 1rifampin caps 300mg 1rifampin inj 600mg 1RIFATER TABS 50MG; 300MG; 120MG 1SIRTURO TABS 100MG 1 NDSTRECATOR TABS 250MG 1

AntineoplasticAntineoplastics other

hydroxyprogesterone caproate inj 1.25gm/5ml 1 PA NDSAntineoplastics

Alkylating Agents BENDEKA INJ 100MG/4ML 1 NDSBICNU INJ 100MG 1 NDSBUSULFEX INJ 6MG/ML 1 NDSCYCLOPHOSPHAMIDE CAPS 25MG 1 B/DCYCLOPHOSPHAMIDE CAPS 50MG 1 B/Dcyclophosphamide inj 1gm 1 NDScyclophosphamide inj 2gm 1 NDScyclophosphamide inj 500mg 1 NDSdacarbazine inj 100mg 1dacarbazine inj 200mg 1EVOMELA INJ 50MG 1 NDS



GLEOSTINE CAPS 100MG 1GLEOSTINE CAPS 10MG 1GLEOSTINE CAPS 40MG 1GLEOSTINE CAPS 5MG 1HEXALEN CAPS 50MG 1 NDSifosfamide inj 1gm/20ml 1ifosfamide inj 1gm 1ifosfamide inj 3gm/60ml 1IFOSFAMIDE INJ 3GM 1LEUKERAN TABS 2MG 1lomustine caps 100mg 1lomustine caps 10mg 1lomustine caps 40mg 1MATULANE CAPS 50MG 1 NDSmelphalan hydrochloride inj 50mg 1 NDSMUSTARGEN INJ 10MG 1 NDSTEMODAR INJ 100MG 1 PAthiotepa inj 15mg 1 NDSTREANDA INJ 100MG 1 NDSTREANDA INJ 180MG/2ML 1 NDSTREANDA INJ 25MG 1 NDSTREANDA INJ 45MG/0.5ML 1 NDSVALCHLOR GEL 0.016% 1 PA NDSYONDELIS INJ 1MG 1 NDSZANOSAR INJ 1GM 1 NDS

Antiandrogens bicalutamide tabs 50mg 1flutamide caps 125mg 1NILANDRON TABS 150MG 1 NDSnilutamide tabs 150mg 1 NDSXTANDI CAPS 40MG 1 PA NDSZYTIGA TABS 250MG 1 PA NDS

Antiangiogenic Agents POMALYST CAPS 1MG 1 PA NDSPOMALYST CAPS 2MG 1 PA NDSPOMALYST CAPS 3MG 1 PA NDSPOMALYST CAPS 4MG 1 PA NDSREVLIMID CAPS 10MG 1 PA NDSREVLIMID CAPS 15MG 1 PA NDSREVLIMID CAPS 2.5MG 1 PA NDSREVLIMID CAPS 20MG 1 PA NDSREVLIMID CAPS 25MG 1 PA NDSREVLIMID CAPS 5MG 1 PA NDSTHALOMID CAPS 100MG 1 PA MO NDSTHALOMID CAPS 150MG 1 PA MO NDSTHALOMID CAPS 200MG 1 PA MO NDSTHALOMID CAPS 50MG 1 PA MO NDS



Antiestrogens/Modifiers EMCYT CAPS 140MG 1 NDSFARESTON TABS 60MG 1 MO NDSFASLODEX INJ 250MG/5ML 1 NDSSOLTAMOX SOLN 10MG/5ML 1 MOtamoxifen citrate tabs 10mg 1 MOtamoxifen citrate tabs 20mg 1 MO

Antimetabolites adrucil inj 2.5gm/50ml 1 B/Dadrucil inj 500mg/10ml 1 B/Dadrucil inj 5gm/100ml 1 B/DALIMTA INJ 100MG 1 NDSALIMTA INJ 500MG 1 NDSARRANON INJ 5MG/ML 1cladribine inj 10mg/10ml 1 B/D NDSCLOLAR INJ 1MG/ML 1 NDScytarabine aqueous inj 100mg/ml 1 B/Dcytarabine aqueous inj 20mg/ml 1 B/Dcytarabine aqueous inj 20mg/ml 1 B/DDEPOCYT INJ 50MG/5ML 1 B/D NDSDROXIA CAPS 200MG 1 MODROXIA CAPS 300MG 1 MODROXIA CAPS 400MG 1 MOELITEK INJ 1.5MG 1 NDSELITEK INJ 7.5MG 1 NDSfloxuridine inj 0.5gm 1 B/Dfluorouracil inj 1gm/20ml 1 B/Dfluorouracil inj 2.5gm/50ml 1 B/Dfluorouracil inj 500mg/10ml 1 B/Dfluorouracil inj 5gm/100ml 1 B/DFOLOTYN INJ 20MG/ML 1 PA NDSFOLOTYN INJ 40MG/2ML 1 PA NDSgemcitabine hcl inj 1gm 1gemcitabine hcl inj 200mg 1gemcitabine hcl inj 2gm 1gemcitabine inj 1gm/26.3ml 1gemcitabine inj 200mg/5.26ml 1gemcitabine inj 200mg/5.26ml 1gemcitabine inj 2gm/52.6ml 1hydroxyurea caps 500mg 1LONSURF TABS 6.14MG; 15MG 1 QL (100 EA per 28 days) PA NDSLONSURF TABS 8.19MG; 20MG 1 QL (80 EA per 28 days) PA NDSmercaptopurine tabs 50mg 1NIPENT INJ 10MG 1 NDSPURIXAN SUSP 2000MG/100ML 1 NDSTABLOID TABS 40MG 1

Antineoplastics, Other



ABRAXANE INJ 900MG; 100MG 1 NDSamifostine inj 500mg 1 NDSazacitidine inj 100mg 1 NDSBELEODAQ INJ 500MG 1 PA NDSbleomycin sulfate inj 15unit 1 B/Dbleomycin sulfate inj 30unit 1 B/Dcarboplatin inj 150mg/15ml 1carboplatin inj 450mg/45ml 1carboplatin inj 50mg/5ml 1carboplatin inj 600mg/60ml 1cisplatin inj 100mg/100ml 1cisplatin inj 200mg/200ml 1cisplatin inj 50mg/50ml 1COSMEGEN INJ 0.5MG 1 NDSCOTELLIC TABS 20MG 1 QL (90 EA per 30 days) PA NDSdaunorubicin hcl inj 5mg/ml 1DAUNOXOME INJ 2MG/ML 1 NDSdecitabine inj 50mg 1 PA NDSdexrazoxane inj 250mg 1 NDSdexrazoxane inj 500mg 1 NDSDOCEFREZ INJ 20MG 1 NDSdocetaxel inj 140mg/7ml 1 NDSdocetaxel inj 160mg/16ml 1 NDSdocetaxel inj 160mg/8ml 1 NDSdocetaxel inj 200mg/20ml 1 NDSdocetaxel inj 20mg/2ml 1 NDSdocetaxel inj 20mg/ml 1 NDSdocetaxel inj 80mg/4ml 1 NDSdocetaxel inj 80mg/8ml 1 NDSdoxorubicin hcl liposome inj 2mg/ml 1 B/D NDSdoxorubicin hcl inj 10mg 1 B/Ddoxorubicin hcl inj 2mg/ml 1 B/Ddoxorubicin hcl inj 50mg 1 B/Depirubicin hcl inj 200mg/100ml 1epirubicin hcl inj 200mg/100ml 1epirubicin hcl inj 50mg/25ml 1ERWINAZE INJ 10000UNIT 1 NDSFARYDAK CAPS 10MG 1 QL (6 EA per 21 days) PA NDSFARYDAK CAPS 15MG 1 QL (6 EA per 21 days) PA NDSFARYDAK CAPS 20MG 1 QL (6 EA per 21 days) PA NDSFLUDARABINE PHOSPHATE INJ 50MG/2ML 1fludarabine phosphate inj 50mg 1FUSILEV INJ 50MG 1 NDSGILOTRIF TABS 20MG 1 QL (30 EA per 30 days) PA NDSGILOTRIF TABS 30MG 1 QL (30 EA per 30 days) PA NDSGILOTRIF TABS 40MG 1 QL (30 EA per 30 days) PA NDSHALAVEN INJ 1MG/2ML 1 PA NDS



IBRANCE CAPS 100MG 1 PA NDSIBRANCE CAPS 125MG 1 PA NDSIBRANCE CAPS 75MG 1 PA NDSidarubicin hcl inj 10mg/10ml 1 NDSidarubicin hcl inj 20mg/20ml 1 NDSidarubicin hcl inj 5mg/5ml 1 NDSirinotecan inj 100mg/5ml 1 B/Dirinotecan inj 40mg/2ml 1 B/Dirinotecan inj 500mg/25ml 1 B/DISTODAX INJ 10MG 1 PA NDSIXEMPRA KIT INJ 15MG 1 NDSIXEMPRA KIT INJ 45MG 1 NDSJEVTANA INJ 60MG/1.5ML 1 PA NDSleucovorin calcium inj 100mg 1leucovorin calcium inj 200mg 1leucovorin calcium inj 350mg 1leucovorin calcium inj 500mg 1leucovorin calcium inj 50mg 1leucovorin calcium tabs 10mg 1leucovorin calcium tabs 15mg 1leucovorin calcium tabs 25mg 1leucovorin calcium tabs 5mg 1levoleucovorin calcium inj 175mg/17.5ml 1 NDSlevoleucovorin inj 175mg/17.5ml 1 NDSlevoleucovorin inj 250mg/25ml 1 NDSlevoleucovorin inj 50mg 1 NDSlipodox 50 inj 2mg/ml 1 B/D NDSlipodox inj 2mg/ml 1 B/D NDSLYNPARZA CAPS 50MG 1 PA NDSmesna inj 100mg/ml 1MESNEX TABS 400MG 1 NDSmitomycin inj 20mg 1 NDSmitomycin inj 40mg 1 NDSmitomycin inj 5mg 1 NDSmitoxantrone hcl inj 2mg/ml 1 PAmitoxantrone hcl inj 2mg/ml 1 PAmitoxantrone hcl inj 2mg/ml 1 PANINLARO CAPS 2.3MG 1 PA NDSNINLARO CAPS 3MG 1 PA NDSNINLARO CAPS 4MG 1 PA NDSODOMZO CAPS 200MG 1 PA NDSONCASPAR INJ 750UNIT/ML 1 NDSoxaliplatin inj 100mg/20ml 1 B/Doxaliplatin inj 100mg 1 B/D NDSoxaliplatin inj 50mg/10ml 1 B/Doxaliplatin inj 50mg/10ml 1 B/Doxaliplatin inj 50mg 1 B/D NDS



paclitaxel inj 100mg/16.7ml 1paclitaxel inj 150mg/25ml 1paclitaxel inj 300mg/50ml 1paclitaxel inj 30mg/5ml 1PORTRAZZA INJ 800MG/50ML 1 QL (2 ML per 21 days) PA NDSPROLEUKIN INJ 22000000UNIT 1 NDSSYLATRON INJ 200MCG 1 PA MO NDSSYLATRON INJ 200MCG 1 PA MO NDSSYLATRON INJ 300MCG 1 PA MO NDSSYLATRON INJ 300MCG 1 PA MO NDSSYLATRON INJ 600MCG 1 PA MO NDSSYNRIBO INJ 3.5MG 1 PA NDSTAGRISSO TABS 40MG 1 QL (30 EA per 30 days) PA NDSTAGRISSO TABS 80MG 1 QL (30 EA per 30 days) PA NDSTHERACYS INJ 81MG/VIAL 1 NDSTICE BCG INJ 50MG 1TRISENOX INJ 10MG/10ML 1VALSTAR INJ 40MG/ML 1 NDSVELCADE INJ 3.5MG 1 PA NDSVENCLEXTA STARTING PACK TBPK 0 1 PA NDSVENCLEXTA TABS 100MG 1 PA NDSVENCLEXTA TABS 10MG 1 PAVENCLEXTA TABS 50MG 1 PAvinblastine sulfate inj 1mg/ml 1 B/Dvincasar pfs inj 1mg/ml 1 B/Dvincristine sulfate inj 1mg/ml 1 B/Dvinorelbine tartrate inj 10mg/ml 1vinorelbine tartrate inj 50mg/5ml 1XOFIGO INJ 30MCCI/ML 1 NDSZALTRAP INJ 100MG/4ML 1 PA NDSZALTRAP INJ 200MG/8ML 1 PA NDSZOLINZA CAPS 100MG 1 PA NDSZYKADIA CAPS 150MG 1 PA NDS

Aromatase Inhibitors, 3rd Generation anastrozole tabs 1mg 1 MOexemestane tabs 25mg 1 MOletrozole tabs 2.5mg 1 MO

Enzyme Inhibitors ETOPOPHOS INJ 100MG 1 NDSetoposide inj 100mg/5ml 1etoposide inj 100mg/5ml 1etoposide inj 1gm/50ml 1etoposide inj 1gm/50ml 1etoposide inj 500mg/25ml 1toposar inj 100mg/5ml 1toposar inj 1gm/50ml 1toposar inj 500mg/25ml 1



toposar inj 500mg/25ml 1topotecan hcl inj 4mg/4ml 1 NDStopotecan hcl inj 4mg 1 NDSZYDELIG TABS 100MG 1 PA NDSZYDELIG TABS 150MG 1 PA NDS

Molecular Target Inhibitors AFINITOR DISPERZ TBSO 2MG 1 PA NDSAFINITOR DISPERZ TBSO 3MG 1 PA NDSAFINITOR DISPERZ TBSO 5MG 1 PA NDSAFINITOR TABS 10MG 1 QL (30 EA per 30 days) PA NDSAFINITOR TABS 2.5MG 1 QL (30 EA per 30 days) PA NDSAFINITOR TABS 5MG 1 QL (30 EA per 30 days) PA NDSAFINITOR TABS 7.5MG 1 QL (30 EA per 30 days) PA NDSALECENSA CAPS 150MG 1 QL (240 EA per 30 days) PA NDSBOSULIF TABS 100MG 1 PA NDSBOSULIF TABS 500MG 1 PA NDSCABOMETYX TABS 20MG 1 PA NDSCABOMETYX TABS 40MG 1 PA NDSCABOMETYX TABS 60MG 1 PA NDSCAPRELSA TABS 100MG 1 QL (60 EA per 30 days) PA NDSCAPRELSA TABS 300MG 1 PA NDSCOMETRIQ KIT 0 1 PA NDSCOMETRIQ KIT 0 1 PA NDSCOMETRIQ KIT 20MG 1 PA NDSERIVEDGE CAPS 150MG 1 PA NDSICLUSIG TABS 15MG 1 QL (60 EA per 30 days) PA NDSICLUSIG TABS 45MG 1 PA NDSimatinib mesylate tabs 100mg 1 PA NDSimatinib mesylate tabs 400mg 1 PA NDSIMBRUVICA CAPS 140MG 1 PA NDSINLYTA TABS 1MG 1 PA NDSINLYTA TABS 5MG 1 PA NDSIRESSA TABS 250MG 1 PA NDSJAKAFI TABS 10MG 1 QL (60 EA per 30 days) PA NDSJAKAFI TABS 15MG 1 QL (60 EA per 30 days) PA NDSJAKAFI TABS 20MG 1 QL (60 EA per 30 days) PA NDSJAKAFI TABS 25MG 1 QL (60 EA per 30 days) PA NDSJAKAFI TABS 5MG 1 QL (60 EA per 30 days) PA NDSLENVIMA 10 MG DAILY DOSE CPPK 10MG 1 PA NDSLENVIMA 14 MG DAILY DOSE CPPK 0 1 PA NDSLENVIMA 18 MG DAILY DOSE CPPK 0 1 PA NDSLENVIMA 20 MG DAILY DOSE CPPK 10MG 1 PA NDSLENVIMA 24 MG DAILY DOSE CPPK 0 1 PA NDSLENVIMA 8 MG DAILY DOSE CPPK 4MG 1 PA NDSMEKINIST TABS 0.5MG 1 PA NDSMEKINIST TABS 2MG 1 PA NDSNEXAVAR TABS 200MG 1 PA NDS



SPRYCEL TABS 100MG 1 PA NDSSPRYCEL TABS 140MG 1 PA NDSSPRYCEL TABS 20MG 1 PA NDSSPRYCEL TABS 50MG 1 PA NDSSPRYCEL TABS 70MG 1 PA NDSSPRYCEL TABS 80MG 1 PA NDSSTIVARGA TABS 40MG 1 PA NDSSUTENT CAPS 12.5MG 1 PA NDSSUTENT CAPS 25MG 1 PA NDSSUTENT CAPS 37.5MG 1 PA NDSSUTENT CAPS 50MG 1 PA NDSTAFINLAR CAPS 50MG 1 PA NDSTAFINLAR CAPS 75MG 1 PA NDSTARCEVA TABS 100MG 1 QL (30 EA per 30 days) PA NDSTARCEVA TABS 150MG 1 QL (30 EA per 30 days) PA NDSTARCEVA TABS 25MG 1 QL (90 EA per 30 days) PA NDSTASIGNA CAPS 150MG 1 PA NDSTASIGNA CAPS 200MG 1 PA NDSTYKERB TABS 250MG 1 PA NDSVOTRIENT TABS 200MG 1 PA NDSXALKORI CAPS 200MG 1 PA NDSXALKORI CAPS 250MG 1 PA NDSZELBORAF TABS 240MG 1 PA NDS

Monoclonal Antibodies ARZERRA INJ 1000MG/50ML 1 PA NDSARZERRA INJ 100MG/5ML 1 PA NDSAVASTIN INJ 100MG/4ML 1 B/D NDSAVASTIN INJ 400MG/16ML 1 B/D NDSBLINCYTO INJ 35MCG 1 PA NDSCYRAMZA INJ 100MG/10ML 1 PA NDSCYRAMZA INJ 500MG/50ML 1 PA NDSDARZALEX INJ 100MG/5ML 1 PA NDSDARZALEX INJ 400MG/20ML 1 PA NDSEMPLICITI INJ 300MG 1 PA NDSEMPLICITI INJ 400MG 1 PA NDSERBITUX INJ 100MG/50ML 1 PA NDSERBITUX INJ 200MG/100ML 1 PA NDSGAZYVA INJ 1000MG/40ML 1 PA NDSHERCEPTIN INJ 440MG 1 PA NDSKADCYLA INJ 100MG 1 PA NDSKADCYLA INJ 160MG 1 PA NDSKEYTRUDA INJ 100MG/4ML 1 PA NDSKEYTRUDA INJ 50MG 1 PA NDSOPDIVO INJ 100MG/10ML 1 PA NDSOPDIVO INJ 40MG/4ML 1 PA NDSPERJETA INJ 420MG/14ML 1 PA NDSRITUXAN INJ 100MG/10ML 1 PA NDS



RITUXAN INJ 500MG/50ML 1 PA NDSSYLVANT INJ 100MG 1 PA NDSSYLVANT INJ 400MG 1 PA NDSTECENTRIQ INJ 1200MG/20ML 1 PA NDSUNITUXIN INJ 17.5MG/5ML 1 NDSVECTIBIX INJ 100MG/5ML 1 B/D NDSVECTIBIX INJ 400MG/20ML 1 B/D NDSYERVOY INJ 200MG/40ML 1 PA NDSYERVOY INJ 50MG/10ML 1 PA NDSZEVALIN Y-90 INJ 3.2MG/2ML 1 NDS

Retinoids bexarotene caps 75mg 1 PA NDSPANRETIN GEL 0.1% 1 NDSTARGRETIN GEL 1% 1 PA NDStretinoin caps 10mg 1 NDS

AntiparasiticsAnthelmintics

ALBENZA TABS 200MG 1 NDSBILTRICIDE TABS 600MG 1ivermectin tabs 3mg 1

Antiprotozoals ALINIA SUSR 100MG/5ML 1ALINIA TABS 500MG 1atovaquone/proguanil hcl tabs 250mg; 100mg 1atovaquone/proguanil hcl tabs 62.5mg; 25mg 1atovaquone susp 750mg/5ml 1 NDSchloroquine phosphate tabs 250mg 1 MOchloroquine phosphate tabs 500mg 1 MOCOARTEM TABS 20MG; 120MG 1DARAPRIM TABS 25MG 1 PA NDShydroxychloroquine sulfate tabs 200mg 1 MOmefloquine hcl tabs 250mg 1 MONEBUPENT SOLR 300MG 1 B/DPENTAM 300 INJ 300MG 1primaquine phosphate tabs 26.3mg 1quinine sulfate caps 324mg 1 PAtinidazole tabs 250mg 1tinidazole tabs 500mg 1

Pediculicides/Scabicides EURAX CREA 10% 1EURAX LOTN 10% 1lindane lotn 1% 1lindane sham 1% 1malathion lotn 0.5% 1permethrin crea 5% 1SKLICE LOTN 0.5% 1ULESFIA LOTN 5% 1



Antiparkinson AgentsAnticholinergics

benztropine mesylate inj 1mg/ml 1benztropine mesylate tabs 0.5mg 1 PA MObenztropine mesylate tabs 1mg 1 PA MObenztropine mesylate tabs 2mg 1 PA MOtrihexyphenidyl hcl elix 0.4mg/ml 1 PA MOtrihexyphenidyl hcl tabs 2mg 1 PA MOtrihexyphenidyl hcl tabs 5mg 1 PA MO

Antiparkinson Agents, Other entacapone tabs 200mg 1 MOtolcapone tabs 100mg 1 MO NDS

Dopamine Agonists APOKYN INJ 10MG/ML 1 QL (60 ML per 30 days) PA NDSbromocriptine mesylate caps 5mg 1 MObromocriptine mesylate tabs 2.5mg 1 MONEUPRO PT24 1MG/24HR 1 ST MONEUPRO PT24 2MG/24HR 1 ST MONEUPRO PT24 3MG/24HR 1 ST MONEUPRO PT24 4MG/24HR 1 ST MONEUPRO PT24 6MG/24HR 1 ST MONEUPRO PT24 8MG/24HR 1 ST MOpramipexole dihydrochloride er tb24 0.375mg 1 MOpramipexole dihydrochloride er tb24 0.75mg 1 MOpramipexole dihydrochloride er tb24 1.5mg 1 MOpramipexole dihydrochloride er tb24 2.25mg 1 MOpramipexole dihydrochloride er tb24 3mg 1 MOpramipexole dihydrochloride er tb24 4.5mg 1 MOpramipexole dihydrochloride tabs 0.125mg 1 MOpramipexole dihydrochloride tabs 0.25mg 1 MOpramipexole dihydrochloride tabs 0.5mg 1 MOpramipexole dihydrochloride tabs 0.75mg 1 MOpramipexole dihydrochloride tabs 1.5mg 1 MOpramipexole dihydrochloride tabs 1mg 1 MOropinirole er tb24 12mg 1 MOropinirole er tb24 2mg 1 MOropinirole er tb24 4mg 1 MOropinirole er tb24 6mg 1 MOropinirole er tb24 8mg 1 MOropinirole hcl tabs 0.25mg 1 MOropinirole hcl tabs 0.5mg 1 MOropinirole hcl tabs 1mg 1 MOropinirole hcl tabs 2mg 1 MOropinirole hcl tabs 3mg 1 MOropinirole hcl tabs 4mg 1 MOropinirole hcl tabs 5mg 1 MO

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors



carbidopa/levodopa er tbcr 25mg; 100mg 1 MOcarbidopa/levodopa er tbcr 50mg; 200mg 1 MOcarbidopa/levodopa odt tbdp 10mg; 100mg 1 MOcarbidopa/levodopa odt tbdp 25mg; 100mg 1 MOcarbidopa/levodopa odt tbdp 25mg; 250mg 1 MOcarbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg 1 MOcarbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg 1 MOcarbidopa/levodopa/entacapone tabs 25mg; 200mg; 100mg 1 MOcarbidopa/levodopa/entacapone tabs 31.25mg; 200mg; 125mg 1 MOcarbidopa/levodopa/entacapone tabs 37.5mg; 200mg; 150mg 1 MOcarbidopa/levodopa/entacapone tabs 50mg; 200mg; 200mg 1 MOcarbidopa/levodopa tabs 10mg; 100mg 1 MOcarbidopa/levodopa tabs 25mg; 100mg 1 MOcarbidopa/levodopa tabs 25mg; 250mg 1 MOcarbidopa tabs 25mg 1 MO NDSSTALEVO 100 TABS 25MG; 200MG; 100MG 1 MOSTALEVO 125 TABS 31.25MG; 200MG; 125MG 1 MOSTALEVO 150 TABS 37.5MG; 200MG; 150MG 1 MOSTALEVO 200 TABS 50MG; 200MG; 200MG 1 MOSTALEVO 50 TABS 12.5MG; 200MG; 50MG 1 MOSTALEVO 75 TABS 18.75MG; 200MG; 75MG 1 MO

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT TABS 0.5MG 1 MOAZILECT TABS 1MG 1 MOselegiline hcl caps 5mg 1 MOselegiline hcl tabs 5mg 1 MOZELAPAR TBDP 1.25MG 1 MO NDS

Antipsychotics1st Generation/Typical

chlorpromazine hcl inj 25mg/ml 1chlorpromazine hcl inj 50mg/2ml 1chlorpromazine hcl tabs 100mg 1 MOchlorpromazine hcl tabs 10mg 1 MOchlorpromazine hcl tabs 200mg 1 MOchlorpromazine hcl tabs 25mg 1 MOchlorpromazine hcl tabs 50mg 1 MOcompro supp 25mg 1fluphenazine decanoate inj 25mg/ml 1fluphenazine hcl conc 5mg/ml 1 MOfluphenazine hcl elix 2.5mg/5ml 1 MOfluphenazine hcl inj 2.5mg/ml 1fluphenazine hcl tabs 10mg 1 MOfluphenazine hcl tabs 1mg 1 MOfluphenazine hcl tabs 2.5mg 1 MOfluphenazine hcl tabs 5mg 1 MOhaloperidol decanoate inj 100mg/ml 1haloperidol decanoate inj 50mg/ml 1



haloperidol lactate inj 5mg/ml 1haloperidol conc 2mg/ml 1 MOhaloperidol tabs 0.5mg 1 MOhaloperidol tabs 10mg 1 MOhaloperidol tabs 1mg 1 MOhaloperidol tabs 20mg 1 MOhaloperidol tabs 2mg 1 MOhaloperidol tabs 5mg 1 MOloxapine succinate caps 10mg 1 MOloxapine succinate caps 25mg 1 MOloxapine succinate caps 50mg 1 MOloxapine succinate caps 5mg 1 MOmolindone hydrochloride tabs 10mg 1 MOmolindone hydrochloride tabs 25mg 1 MOmolindone hydrochloride tabs 5mg 1 MOperphenazine tabs 16mg 1 MOperphenazine tabs 2mg 1 MOperphenazine tabs 4mg 1 MOperphenazine tabs 8mg 1 MOpimozide tabs 1mg 1 MOpimozide tabs 2mg 1 MOprochlorperazine edisylate inj 5mg/ml 1prochlorperazine maleate tabs 10mg 1 MOprochlorperazine maleate tabs 5mg 1 MOprochlorperazine supp 25mg 1thioridazine hcl tabs 100mg 1 PA MOthioridazine hcl tabs 10mg 1 PA MOthioridazine hcl tabs 25mg 1 PA MOthioridazine hcl tabs 50mg 1 PA MOthiothixene caps 10mg 1 MOthiothixene caps 1mg 1 MOthiothixene caps 2mg 1 MOthiothixene caps 5mg 1 MOtrifluoperazine hcl tabs 10mg 1 MOtrifluoperazine hcl tabs 1mg 1 MOtrifluoperazine hcl tabs 2mg 1 MOtrifluoperazine hcl tabs 5mg 1 MO

2nd Generation/Atypical ABILIFY MAINTENA INJ 300MG 1 MO NDSABILIFY MAINTENA INJ 300MG 1 MO NDSABILIFY MAINTENA INJ 400MG 1 MO NDSABILIFY INJ 9.75MG/1.3ML 1aripiprazole odt tbdp 10mg 1 QL (60 EA per 30 days) MO NDSaripiprazole odt tbdp 15mg 1 QL (60 EA per 30 days) MO NDSaripiprazole soln 1mg/ml 1 QL (750 ML per 30 days) MOaripiprazole tabs 10mg 1 QL (30 EA per 30 days) MOaripiprazole tabs 15mg 1 QL (30 EA per 30 days) MO



aripiprazole tabs 20mg 1 QL (30 EA per 30 days) MOaripiprazole tabs 2mg 1 QL (60 EA per 30 days) MOaripiprazole tabs 30mg 1 QL (30 EA per 30 days) MOaripiprazole tabs 5mg 1 QL (60 EA per 30 days) MOARISTADA INJ 441MG/1.6ML 1 MO NDSARISTADA INJ 662MG/2.4ML 1 MO NDSARISTADA INJ 882MG/3.2ML 1 MO NDSFANAPT TITRATION PACK TABS 0 1 QL (8 EA per 180 days) STFANAPT TABS 10MG 1 QL (60 EA per 30 days) ST NDSFANAPT TABS 12MG 1 QL (60 EA per 30 days) ST NDSFANAPT TABS 1MG 1 QL (60 EA per 30 days) STFANAPT TABS 2MG 1 QL (60 EA per 30 days) STFANAPT TABS 4MG 1 QL (60 EA per 30 days) STFANAPT TABS 6MG 1 QL (60 EA per 30 days) ST NDSFANAPT TABS 8MG 1 QL (60 EA per 30 days) ST NDSGEODON INJ 20MG 1 QL (60 EA per 30 days)INVEGA SUSTENNA INJ 117MG/0.75ML 1 NDSINVEGA SUSTENNA INJ 156MG/ML 1 NDSINVEGA SUSTENNA INJ 234MG/1.5ML 1 NDSINVEGA SUSTENNA INJ 39MG/0.25ML 1INVEGA SUSTENNA INJ 78MG/0.5ML 1INVEGA TRINZA INJ 273MG/0.875ML 1 MO NDSINVEGA TRINZA INJ 410MG/1.315ML 1 MO NDSINVEGA TRINZA INJ 546MG/1.75ML 1 MO NDSINVEGA TRINZA INJ 819MG/2.625ML 1 MO NDSLATUDA TABS 120MG 1 QL (30 EA per 30 days) MO NDSLATUDA TABS 20MG 1 QL (30 EA per 30 days) MO NDSLATUDA TABS 40MG 1 QL (30 EA per 30 days) MO NDSLATUDA TABS 60MG 1 QL (30 EA per 30 days) MO NDSLATUDA TABS 80MG 1 QL (60 EA per 30 days) MO NDSNUPLAZID TABS 17MG 1 QL (60 EA per 30 days) PA MO NDSolanzapine odt tbdp 10mg 1 QL (30 EA per 30 days) MOolanzapine odt tbdp 15mg 1 QL (30 EA per 30 days) MOolanzapine odt tbdp 20mg 1 QL (30 EA per 30 days) MOolanzapine odt tbdp 5mg 1 QL (30 EA per 30 days) MOolanzapine inj 10mg 1olanzapine tabs 10mg 1 QL (30 EA per 30 days) MOolanzapine tabs 15mg 1 QL (30 EA per 30 days) MOolanzapine tabs 2.5mg 1 QL (30 EA per 30 days) MOolanzapine tabs 20mg 1 QL (30 EA per 30 days) MOolanzapine tabs 5mg 1 QL (30 EA per 30 days) MOolanzapine tabs 7.5mg 1 QL (30 EA per 30 days) MOpaliperidone er tb24 1.5mg 1 QL (30 EA per 30 days) MOpaliperidone er tb24 3mg 1 QL (30 EA per 30 days) MOpaliperidone er tb24 6mg 1 QL (60 EA per 30 days) MO NDSpaliperidone er tb24 9mg 1 QL (30 EA per 30 days) MO NDSquetiapine fumarate tabs 100mg 1 QL (90 EA per 30 days) MO



quetiapine fumarate tabs 200mg 1 QL (90 EA per 30 days) MOquetiapine fumarate tabs 25mg 1 QL (90 EA per 30 days) MOquetiapine fumarate tabs 300mg 1 QL (60 EA per 30 days) MOquetiapine fumarate tabs 400mg 1 QL (60 EA per 30 days) MOquetiapine fumarate tabs 50mg 1 QL (90 EA per 30 days) MOREXULTI TABS 0.25MG 1 QL (30 EA per 30 days) MO NDSREXULTI TABS 0.5MG 1 QL (30 EA per 30 days) MO NDSREXULTI TABS 1MG 1 QL (30 EA per 30 days) MO NDSREXULTI TABS 2MG 1 QL (30 EA per 30 days) MO NDSREXULTI TABS 3MG 1 QL (30 EA per 30 days) MO NDSREXULTI TABS 4MG 1 QL (30 EA per 30 days) MO NDSRISPERDAL CONSTA INJ 12.5MG 1RISPERDAL CONSTA INJ 25MG 1RISPERDAL CONSTA INJ 37.5MG 1 NDSRISPERDAL CONSTA INJ 50MG 1 NDSrisperidone odt tbdp 0.25mg 1 QL (60 EA per 30 days) MOrisperidone odt tbdp 0.5mg 1 QL (60 EA per 30 days) MOrisperidone odt tbdp 1mg 1 QL (60 EA per 30 days) MOrisperidone odt tbdp 2mg 1 QL (60 EA per 30 days) MOrisperidone odt tbdp 3mg 1 QL (60 EA per 30 days) MOrisperidone odt tbdp 4mg 1 QL (60 EA per 30 days) MOrisperidone soln 1mg/ml 1 QL (240 ML per 30 days) MOrisperidone tabs 0.25mg 1 QL (60 EA per 30 days) MOrisperidone tabs 0.5mg 1 QL (60 EA per 30 days) MOrisperidone tabs 1mg 1 QL (60 EA per 30 days) MOrisperidone tabs 2mg 1 QL (60 EA per 30 days) MOrisperidone tabs 3mg 1 QL (60 EA per 30 days) MOrisperidone tabs 4mg 1 QL (60 EA per 30 days) MOSAPHRIS SUBL 10MG 1 QL (60 EA per 30 days) ST MOSAPHRIS SUBL 2.5MG 1 QL (60 EA per 30 days) ST MOSAPHRIS SUBL 5MG 1 QL (60 EA per 30 days) ST MOVRAYLAR CAPS 1.5MG 1 QL (30 EA per 30 days) ST MO NDSVRAYLAR CAPS 3MG 1 QL (30 EA per 30 days) ST MO NDSVRAYLAR CAPS 4.5MG 1 QL (30 EA per 30 days) ST MO NDSVRAYLAR CAPS 6MG 1 QL (30 EA per 30 days) ST MO NDSVRAYLAR CPPK 0 1 QL (14 EA per 365 days) STziprasidone hcl caps 20mg 1 QL (60 EA per 30 days) MOziprasidone hcl caps 40mg 1 QL (60 EA per 30 days) MOziprasidone hcl caps 60mg 1 QL (60 EA per 30 days) MOziprasidone hcl caps 80mg 1 QL (60 EA per 30 days) MOZYPREXA RELPREVV INJ 210MG 1ZYPREXA RELPREVV INJ 300MG 1 NDSZYPREXA RELPREVV INJ 405MG 1 NDS

Treatment-Resistant clozapine odt tbdp 100mg 1 QL (270 EA per 30 days)clozapine odt tbdp 12.5mg 1 QL (90 EA per 30 days)clozapine odt tbdp 150mg 1 QL (180 EA per 30 days)



clozapine odt tbdp 200mg 1 QL (120 EA per 30 days) NDSclozapine odt tbdp 25mg 1 QL (270 EA per 30 days)clozapine tabs 100mg 1 QL (270 EA per 30 days)clozapine tabs 200mg 1 QL (120 EA per 30 days)clozapine tabs 25mg 1 QL (270 EA per 30 days)clozapine tabs 50mg 1 QL (180 EA per 30 days)VERSACLOZ SUSP 50MG/ML 1 QL (540 ML per 30 days) NDS

Antispasticity AgentsAntispasticity Agents

baclofen tabs 10mg 1 MObaclofen tabs 20mg 1 MOdantrolene sodium caps 100mg 1dantrolene sodium caps 25mg 1dantrolene sodium caps 50mg 1GABLOFEN INJ 10000MCG/20ML 1 B/DGABLOFEN INJ 20000MCG/20ML 1 B/DGABLOFEN INJ 20000MCG/20ML 1 B/DGABLOFEN INJ 40000MCG/20ML 1 B/D NDSGABLOFEN INJ 50MCG/ML 1 B/DLIORESAL INTRATHECAL INJ 0.05MG/ML 1 B/DLIORESAL INTRATHECAL INJ 10MG/20ML 1 B/DLIORESAL INTRATHECAL INJ 10MG/5ML 1 B/D NDSLIORESAL INTRATHECAL INJ 40MG/20ML 1 B/D NDStizanidine hcl caps 2mg 1 MOtizanidine hcl caps 4mg 1 MOtizanidine hcl caps 6mg 1 MOtizanidine hcl tabs 2mg 1 MOtizanidine hcl tabs 4mg 1 MO

AntiviralsAnti-cytomegalovirus (CMV) Agents

cidofovir inj 75mg/ml 1 NDSganciclovir inj 500mg 1 B/DVALCYTE SOLR 50MG/ML 1 MO NDSvalganciclovir tabs 450mg 1 MO NDSZIRGAN GEL 0.15% 1

Anti-hepatitis B (HBV) Agents adefovir dipivoxil tabs 10mg 1 MO NDSBARACLUDE SOLN 0.05MG/ML 1 QL (600 ML per 30 days) MOentecavir tabs 0.5mg 1 QL (30 EA per 30 days) MO NDSentecavir tabs 1mg 1 QL (30 EA per 30 days) MO NDSEPIVIR HBV SOLN 5MG/ML 1 MOINTRON A W/DILUENT INJ 10MU 1 PA MO NDSINTRON A INJ 10MU/ML 1 PA MO NDSINTRON A INJ 18MU 1 PA MO NDSINTRON A INJ 50MU 1 PA MO NDSINTRON A INJ 6000000UNIT/ML 1 PA MO NDSlamivudine tabs 100mg 1 MO



TYZEKA TABS 600MG 1 MO NDSAnti-hepatitis C (HCV) Agents

DAKLINZA TABS 30MG 1 QL (504 EA per 365 days) PA NDSDAKLINZA TABS 60MG 1 QL (168 EA per 365 days) PA NDSDAKLINZA TABS 90MG 1 QL (168 EA per 365 days) PA NDSHARVONI TABS 90MG; 400MG 1 QL (168 EA per 365 days) PA NDSMODERIBA 1200 DOSE PACK TABS 600MG 1MODERIBA 800 DOSE PACK TABS 400MG 1MODERIBA MISC 0 1 NDSMODERIBA MISC 0 1moderiba tabs 200mg 1OLYSIO CAPS 150MG 1 QL (168 EA per 365 days) PA NDSPEG-INTRON REDIPEN INJ 120MCG/0.5ML 1 PA NDSPEG-INTRON REDIPEN INJ 150MCG/0.5ML 1 PA NDSPEG-INTRON REDIPEN INJ 50MCG/0.5ML 1 PA NDSPEG-INTRON REDIPEN INJ 80MCG/0.5ML 1 PA NDSPEG-INTRON INJ 120MCG/0.5ML 1 PA NDSPEG-INTRON INJ 150MCG/0.5ML 1 PA NDSPEG-INTRON INJ 80MCG/0.5ML 1 PA NDSPEGASYS PROCLICK INJ 135MCG/0.5ML 1 PA NDSPEGASYS PROCLICK INJ 180MCG/0.5ML 1 PA NDSPEGASYS INJ 180MCG/0.5ML 1 PA NDSPEGASYS INJ 180MCG/ML 1 PA NDSPEGINTRON INJ 120MCG/0.5ML 1 PA NDSPEGINTRON INJ 150MCG/0.5ML 1 PA NDSPEGINTRON INJ 50MCG/0.5ML 1 PA NDSPEGINTRON INJ 80MCG/0.5ML 1 PA NDSREBETOL SOLN 40MG/ML 1ribasphere ribapak tabs 0 1 NDSRIBASPHERE RIBAPAK TABS 0 1RIBASPHERE RIBAPAK TABS 400MG 1ribasphere ribapak tabs 600mg 1ribasphere caps 200mg 1ribasphere tabs 200mg 1RIBASPHERE TABS 400MG 1ribasphere tabs 600mg 1RIBATAB MISC 0 1ribatab tabs 400mg 1ribavirin caps 200mg 1ribavirin tabs 200mg 1SOVALDI TABS 400MG 1 QL (336 EA per 365 days) PA NDSTECHNIVIE TABS 12.5MG; 75MG; 50MG 1 QL (168 EA per 365 days) PA NDSVIEKIRA PAK TBPK 250MG; 12.5MG; 75MG; 50MG 1 QL (672 EA per 365 days) PA NDSZEPATIER TABS 50MG; 100MG 1 QL (112 EA per 365 days) PA NDS

Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA TABS 600MG; 200MG; 300MG 1 QL (30 EA per 30 days) MO NDSGENVOYA TABS 150MG; 150MG; 200MG; 10MG 1 QL (30 EA per 30 days) MO NDS



ISENTRESS CHEW 100MG 1 MO NDSISENTRESS CHEW 25MG 1 MOISENTRESS PACK 100MG 1 MO NDSISENTRESS TABS 400MG 1 MO NDSTIVICAY TABS 10MG 1 MOTIVICAY TABS 25MG 1 MO NDSTIVICAY TABS 50MG 1 MO NDSVITEKTA TABS 150MG 1 MO NDSVITEKTA TABS 85MG 1 MO NDS

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA TABS 200MG; 25MG; 300MG 1 QL (30 EA per 30 days) MO NDSEDURANT TABS 25MG 1 MO NDSINTELENCE TABS 100MG 1 MO NDSINTELENCE TABS 200MG 1 MO NDSINTELENCE TABS 25MG 1 MOnevirapine er tb24 100mg 1 MOnevirapine er tb24 400mg 1 MOnevirapine susp 50mg/5ml 1 MOnevirapine tabs 200mg 1 MOODEFSEY TABS 200MG; 25MG; 25MG 1 QL (30 EA per 30 days) MO NDSRESCRIPTOR TABS 100MG 1 MORESCRIPTOR TABS 200MG 1 MOSTRIBILD TABS 150MG; 150MG; 200MG; 300MG 1 QL (30 EA per 30 days) MO NDSSUSTIVA CAPS 200MG 1 MO NDSSUSTIVA CAPS 50MG 1 MOSUSTIVA TABS 600MG 1 MO NDS

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir sulfate/lamivudine/zidovudine tabs 300mg; 150mg; 300mg1 QL (60 EA per 30 days) MO NDSabacavir tabs 300mg 1 MODESCOVY TABS 200MG; 25MG 1 QL (30 EA per 30 days) MO NDSdidanosine cpdr 125mg 1 MOdidanosine cpdr 200mg 1 MOdidanosine cpdr 250mg 1 MOdidanosine cpdr 400mg 1 MOEMTRIVA CAPS 200MG 1 MOEMTRIVA SOLN 10MG/ML 1 MOEPZICOM TABS 600MG; 300MG 1 QL (30 EA per 30 days) MO NDSlamivudine/zidovudine tabs 150mg; 300mg 1 QL (60 EA per 30 days) MOlamivudine soln 10mg/ml 1 MOlamivudine tabs 150mg 1 MOlamivudine tabs 300mg 1 MORETROVIR IV INFUSION INJ 10MG/ML 1stavudine caps 15mg 1 MOstavudine caps 20mg 1 MOstavudine caps 30mg 1 MOstavudine caps 40mg 1 MO



stavudine solr 1mg/ml 1 MOTRIUMEQ TABS 600MG; 50MG; 300MG 1 QL (30 EA per 30 days) MO NDSTRUVADA TABS 100MG; 150MG 1 QL (30 EA per 30 days) MO NDSTRUVADA TABS 133MG; 200MG 1 QL (30 EA per 30 days) MO NDSTRUVADA TABS 167MG; 250MG 1 QL (30 EA per 30 days) MO NDSTRUVADA TABS 200MG; 300MG 1 QL (30 EA per 30 days) MO NDSVIDEX PEDIATRIC SOLR 2GM 1 MOVIDEX PEDIATRIC SOLR 4GM 1 MOVIREAD POWD 40MG/GM 1 MO NDSVIREAD TABS 150MG 1 MOVIREAD TABS 200MG 1 MO NDSVIREAD TABS 250MG 1 MO NDSVIREAD TABS 300MG 1 MO NDSZIAGEN SOLN 20MG/ML 1 MOzidovudine caps 100mg 1 MOzidovudine syrp 50mg/5ml 1 MOzidovudine tabs 300mg 1 MO

Anti-HIV Agents, Other FUZEON INJ 90MG 1 QL (60 EA per 30 days) MO NDSSELZENTRY TABS 150MG 1 MO NDSSELZENTRY TABS 300MG 1 MO NDSTYBOST TABS 150MG 1 MO

Anti-HIV Agents, Protease Inhibitors APTIVUS CAPS 250MG 1 MO NDSAPTIVUS SOLN 100MG/ML 1 MO NDSCRIXIVAN CAPS 200MG 1 MOCRIXIVAN CAPS 400MG 1 MOEVOTAZ TABS 300MG; 150MG 1 QL (30 EA per 30 days) MO NDSINVIRASE CAPS 200MG 1 MO NDSINVIRASE TABS 500MG 1 MO NDSKALETRA SOLN 400MG/5ML; 100MG/5ML 1 MOKALETRA TABS 100MG; 25MG 1 MOKALETRA TABS 200MG; 50MG 1 MO NDSLEXIVA SUSP 50MG/ML 1 MOLEXIVA TABS 700MG 1 MO NDSNORVIR CAPS 100MG 1 MONORVIR SOLN 80MG/ML 1 MONORVIR TABS 100MG 1 MOPREZCOBIX TABS 150MG; 800MG 1 QL (30 EA per 30 days) MO NDSPREZISTA SUSP 100MG/ML 1 MO NDSPREZISTA TABS 150MG 1 MOPREZISTA TABS 600MG 1 MO NDSPREZISTA TABS 75MG 1 MOPREZISTA TABS 800MG 1 MO NDSREYATAZ CAPS 150MG 1 MO NDSREYATAZ CAPS 200MG 1 MO NDSREYATAZ CAPS 300MG 1 MO NDS



REYATAZ PACK 50MG 1 MOVIRACEPT TABS 250MG 1 MO NDSVIRACEPT TABS 625MG 1 MO NDS

Anti-influenza Agents amantadine hcl caps 100mg 1 MOamantadine hcl syrp 50mg/5ml 1 MOamantadine hcl tabs 100mg 1 MORELENZA DISKHALER AEPB 5MG/BLISTER 1 QL (240 EA per 365 days)rimantadine hcl tabs 100mg 1TAMIFLU CAPS 30MG 1 QL (112 EA per 365 days)TAMIFLU CAPS 45MG 1 QL (60 EA per 365 days)TAMIFLU CAPS 75MG 1 QL (110 EA per 365 days)TAMIFLU SUSR 6MG/ML 1 QL (720 ML per 365 days)

Antiherpetic Agents acyclovir sodium inj 1000mg 1 B/Dacyclovir sodium inj 500mg 1 B/Dacyclovir sodium inj 50mg/ml 1 B/Dacyclovir caps 200mg 1acyclovir oint 5% 1acyclovir susp 200mg/5ml 1acyclovir tabs 400mg 1acyclovir tabs 800mg 1DENAVIR CREA 1% 1 NDSfamciclovir tabs 125mg 1famciclovir tabs 250mg 1famciclovir tabs 500mg 1trifluridine soln 1% 1valacyclovir hcl tabs 1000mg 1 QL (120 EA per 30 days)valacyclovir hcl tabs 500mg 1 QL (120 EA per 30 days)ZOVIRAX CREA 5% 1

AnxiolyticsAnxiolytics, Other

buspirone hcl tabs 10mg 1buspirone hcl tabs 15mg 1buspirone hcl tabs 30mg 1buspirone hcl tabs 5mg 1buspirone hcl tabs 7.5mg 1

Benzodiazepines alprazolam er tb24 1mg 1 QL (30 EA per 30 days) PAalprazolam er tb24 2mg 1 QL (150 EA per 30 days) PAalprazolam er tb24 3mg 1 QL (90 EA per 30 days) PAalprazolam intensol conc 1mg/ml 1 PAalprazolam odt tbdp 0.25mg 1 QL (120 EA per 30 days) PAalprazolam odt tbdp 0.5mg 1 QL (120 EA per 30 days) PAalprazolam odt tbdp 1mg 1 QL (120 EA per 30 days) PAalprazolam odt tbdp 2mg 1 QL (150 EA per 30 days) PAalprazolam xr tb24 0.5mg 1 QL (30 EA per 30 days) PA



alprazolam xr tb24 1mg 1 QL (30 EA per 30 days) PAalprazolam xr tb24 2mg 1 QL (150 EA per 30 days) PAalprazolam xr tb24 3mg 1 QL (90 EA per 30 days) PAalprazolam tabs 0.25mg 1 QL (120 EA per 30 days) PAalprazolam tabs 0.5mg 1 QL (120 EA per 30 days) PAalprazolam tabs 1mg 1 QL (120 EA per 30 days) PAalprazolam tabs 2mg 1 QL (150 EA per 30 days) PAchlordiazepoxide hcl caps 10mg 1 QL (900 EA per 30 days) PAchlordiazepoxide hcl caps 25mg 1 QL (360 EA per 30 days) PAchlordiazepoxide hcl caps 5mg 1 QL (120 EA per 30 days) PAclorazepate dipotassium tabs 15mg 1 QL (180 EA per 30 days)clorazepate dipotassium tabs 3.75mg 1 QL (720 EA per 30 days)clorazepate dipotassium tabs 7.5mg 1 QL (360 EA per 30 days)diazepam intensol conc 5mg/ml 1diazepam inj 5mg/ml 1diazepam soln 1mg/ml 1diazepam tabs 10mg 1diazepam tabs 2mg 1diazepam tabs 5mg 1estazolam tabs 1mg 1 QL (30 EA per 30 days) PAestazolam tabs 2mg 1 QL (30 EA per 30 days) PAlorazepam intensol conc 2mg/ml 1 PAlorazepam inj 2mg/ml 1 PAlorazepam inj 4mg/ml 1 PAlorazepam tabs 0.5mg 1 QL (90 EA per 30 days) PAlorazepam tabs 1mg 1 QL (90 EA per 30 days) PAlorazepam tabs 2mg 1 QL (150 EA per 30 days) PAmidazolam hcl inj 10mg/10ml 1midazolam hcl inj 10mg/2ml 1midazolam hcl inj 25mg/5ml 1midazolam hcl inj 25mg/5ml 1midazolam hcl inj 2mg/2ml 1midazolam hcl inj 50mg/10ml 1midazolam hcl inj 5mg/5ml 1midazolam hcl inj 5mg/ml 1midazolam hcl inj 5mg/ml 1midazolam hcl syrp 2mg/ml 1oxazepam caps 10mg 1 QL (120 EA per 30 days) PAoxazepam caps 15mg 1 QL (120 EA per 30 days) PAoxazepam caps 30mg 1 QL (120 EA per 30 days) PA

Bipolar AgentsMood Stabilizers

EQUETRO CP12 100MG 1 MOEQUETRO CP12 200MG 1 MOEQUETRO CP12 300MG 1 MOlithium carbonate er tbcr 300mg 1 MOlithium carbonate er tbcr 450mg 1 MO



lithium carbonate caps 150mg 1 MOlithium carbonate caps 300mg 1 MOlithium carbonate caps 600mg 1 MOlithium carbonate tabs 300mg 1 MOlithium soln 8meq/5ml 1 MO

Blood Glucose RegulatorsAntidiabetic Agents

acarbose tabs 100mg 1 MOacarbose tabs 25mg 1 MOacarbose tabs 50mg 1 MOBYDUREON INJ 2MG 1 QL (4 EA per 28 days) ST MOBYDUREON INJ 2MG 1 QL (4 EA per 28 days) ST MOBYETTA INJ 10MCG/0.04ML 1 QL (2.4 ML per 28 days) ST MOBYETTA INJ 5MCG/0.02ML 1 QL (4.8 ML per 28 days) ST MOCYCLOSET TABS 0.8MG 1 MOglimepiride tabs 1mg 1 QL (240 EA per 30 days) MOglimepiride tabs 2mg 1 QL (120 EA per 30 days) MOglimepiride tabs 4mg 1 QL (60 EA per 30 days) MOglipizide er tb24 10mg 1 QL (60 EA per 30 days) MOglipizide er tb24 2.5mg 1 QL (240 EA per 30 days) MOglipizide er tb24 5mg 1 QL (120 EA per 30 days) MOglipizide xl tb24 10mg 1 QL (60 EA per 30 days) MOglipizide xl tb24 2.5mg 1 QL (240 EA per 30 days) MOglipizide xl tb24 5mg 1 QL (120 EA per 30 days) MOglipizide/metformin hcl tabs 2.5mg; 250mg 1 QL (240 EA per 30 days) MOglipizide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) MOglipizide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) MOglipizide tabs 10mg 1 QL (120 EA per 30 days) MOglipizide tabs 5mg 1 QL (240 EA per 30 days) MOglyburide micronized tabs 1.5mg 1 QL (240 EA per 30 days) PA MOglyburide micronized tabs 3mg 1 QL (120 EA per 30 days) PA MOglyburide micronized tabs 6mg 1 QL (60 EA per 30 days) PA MOglyburide/metformin hcl tabs 1.25mg; 250mg 1 QL (240 EA per 30 days) PA MOglyburide/metformin hcl tabs 2.5mg; 500mg 1 QL (120 EA per 30 days) PA MOglyburide/metformin hcl tabs 5mg; 500mg 1 QL (120 EA per 30 days) PA MOglyburide tabs 1.25mg 1 QL (480 EA per 30 days) PA MOglyburide tabs 2.5mg 1 QL (240 EA per 30 days) PA MOglyburide tabs 5mg 1 QL (120 EA per 30 days) PA MOGLYSET TABS 100MG 1 ST MOGLYSET TABS 25MG 1 ST MOGLYSET TABS 50MG 1 ST MOINVOKAMET TABS 150MG; 1000MG 1 QL (60 EA per 30 days) ST MOINVOKAMET TABS 150MG; 500MG 1 QL (60 EA per 30 days) ST MOINVOKAMET TABS 50MG; 1000MG 1 QL (60 EA per 30 days) ST MOINVOKAMET TABS 50MG; 500MG 1 QL (120 EA per 30 days) ST MOINVOKANA TABS 100MG 1 QL (90 EA per 30 days) ST MOINVOKANA TABS 300MG 1 QL (30 EA per 30 days) ST MO



JANUMET XR TB24 1000MG; 100MG 1 QL (30 EA per 30 days) ST MOJANUMET XR TB24 1000MG; 50MG 1 QL (60 EA per 30 days) ST MOJANUMET XR TB24 500MG; 50MG 1 QL (60 EA per 30 days) ST MOJANUMET TABS 1000MG; 50MG 1 QL (60 EA per 30 days) ST MOJANUMET TABS 500MG; 50MG 1 QL (60 EA per 30 days) ST MOJANUVIA TABS 100MG 1 ST MOJANUVIA TABS 25MG 1 ST MOJANUVIA TABS 50MG 1 ST MOJARDIANCE TABS 10MG 1 QL (60 EA per 30 days) ST MOJARDIANCE TABS 25MG 1 QL (30 EA per 30 days) ST MOJENTADUETO XR TB24 2.5MG; 1000MG 1 QL (60 EA per 30 days) ST MOJENTADUETO XR TB24 5MG; 1000MG 1 QL (30 EA per 30 days) ST MOJENTADUETO TABS 2.5MG; 1000MG 1 QL (60 EA per 30 days) ST MOJENTADUETO TABS 2.5MG; 500MG 1 QL (60 EA per 30 days) ST MOJENTADUETO TABS 2.5MG; 850MG 1 QL (60 EA per 30 days) ST MOKOMBIGLYZE XR TB24 1000MG; 2.5MG 1 QL (60 EA per 30 days) ST MOKOMBIGLYZE XR TB24 1000MG; 5MG 1 QL (30 EA per 30 days) ST MOKOMBIGLYZE XR TB24 500MG; 5MG 1 QL (30 EA per 30 days) ST MOmetformin hcl er tb24 500mg 1 QL (120 EA per 30 days) MOmetformin hcl er tb24 750mg 1 QL (60 EA per 30 days) MOmetformin hcl tabs 1000mg 1 QL (60 EA per 30 days) MOmetformin hcl tabs 500mg 1 QL (150 EA per 30 days) MOmetformin hcl tabs 850mg 1 QL (90 EA per 30 days) MOmiglitol tabs 100mg 1 MOmiglitol tabs 25mg 1 MOmiglitol tabs 50mg 1 MOnateglinide tabs 120mg 1 MOnateglinide tabs 60mg 1 MOONGLYZA TABS 2.5MG 1 ST MOONGLYZA TABS 5MG 1 ST MOpioglitazone hcl-glimepiride tabs 2mg; 30mg 1 QL (45 EA per 30 days) MOpioglitazone hcl-glimepiride tabs 4mg; 30mg 1 QL (45 EA per 30 days) MOpioglitazone hcl/metformin hcl tabs 500mg; 15mg 1 QL (90 EA per 30 days) MOpioglitazone hcl/metformin hcl tabs 850mg; 15mg 1 QL (90 EA per 30 days) MOpioglitazone hcl tabs 15mg 1 QL (60 EA per 30 days) MOpioglitazone hcl tabs 30mg 1 QL (45 EA per 30 days) MOpioglitazone hcl tabs 45mg 1 QL (30 EA per 30 days) MOrepaglinide/metformin hydrochloride tabs 500mg; 1mg 1 QL (150 EA per 30 days) MOrepaglinide/metformin hydrochloride tabs 500mg; 2mg 1 QL (150 EA per 30 days) MOrepaglinide tabs 0.5mg 1 MOrepaglinide tabs 1mg 1 MOrepaglinide tabs 2mg 1 MORIOMET SOLN 500MG/5ML 1 QL (765 ML per 30 days) MOSYMLINPEN 120 INJ 2700MCG/2.7ML 1 PA MO NDSSYMLINPEN 60 INJ 1500MCG/1.5ML 1 PA MO NDSSYNJARDY TABS 12.5MG; 1000MG 1 QL (60 EA per 30 days) ST MOSYNJARDY TABS 12.5MG; 500MG 1 QL (120 EA per 30 days) ST MO



SYNJARDY TABS 5MG; 1000MG 1 QL (60 EA per 30 days) ST MOSYNJARDY TABS 5MG; 500MG 1 QL (120 EA per 30 days) ST MOtolazamide tabs 250mg 1 QL (240 EA per 30 days) MOtolazamide tabs 500mg 1 QL (120 EA per 30 days) MOtolbutamide tabs 500mg 1 QL (180 EA per 30 days) MOTRADJENTA TABS 5MG 1 ST MOTRULICITY INJ 0.75MG/0.5ML 1 QL (2 ML per 28 days) ST MOTRULICITY INJ 1.5MG/0.5ML 1 QL (2 ML per 28 days) ST MOVICTOZA INJ 18MG/3ML 1 QL (9 ML per 30 days) ST MO

Glycemic Agents GLUCAGEN HYPOKIT INJ 1MG 1GLUCAGON EMERGENCY KIT INJ 1MG 1PROGLYCEM SUSP 50MG/ML 1 MO NDS

Insulins HUMALOG KWIKPEN INJ 100UNIT/ML 1 MOHUMALOG KWIKPEN INJ 200UNIT/ML 1 MOHUMALOG MIX 50/50 KWIKPEN INJ 50UNIT/ML; 50UNIT/ML1 MOHUMALOG MIX 50/50 INJ 50UNIT/ML; 50UNIT/ML 1 MOHUMALOG MIX 75/25 KWIKPEN INJ 25UNIT/ML; 75UNIT/ML1 MOHUMALOG MIX 75/25 INJ 25UNIT/ML; 75UNIT/ML 1 MOHUMALOG INJ 100UNIT/ML 1 MOHUMALOG INJ 100UNIT/ML 1 MOHUMULIN 70/30 KWIKPEN INJ 30UNIT/ML; 70UNIT/ML 1 MOHUMULIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MOHUMULIN N KWIKPEN INJ 100UNIT/ML 1 MOHUMULIN N INJ 100UNIT/ML 1 MOHUMULIN R U-500 (CONCENTRATED) INJ 500UNIT/ML 1 MOHUMULIN R U-500 KWIKPEN INJ 500UNIT/ML 1 MOHUMULIN R INJ 100UNIT/ML 1 MOLANTUS SOLOSTAR INJ 100UNIT/ML 1 MOLANTUS INJ 100UNIT/ML 1 MOLEVEMIR FLEXTOUCH INJ 100UNIT/ML 1 MOLEVEMIR INJ 100UNIT/ML 1 MONOVOLIN 70/30 RELION INJ 30UNIT/ML; 70UNIT/ML 1 MONOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MONOVOLIN N RELION INJ 100UNIT/ML 1 MONOVOLIN N INJ 100UNIT/ML 1 MONOVOLIN R RELION INJ 100UNIT/ML 1 MONOVOLIN R INJ 100UNIT/ML 1 MONOVOLOG FLEXPEN INJ 100UNIT/ML 1 MONOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ 30UNIT/ML; 70UNIT/ML

1 MO

NOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML 1 MONOVOLOG PENFILL INJ 100UNIT/ML 1 MONOVOLOG INJ 100UNIT/ML 1 MOTOUJEO SOLOSTAR INJ 300UNIT/ML 1 MO

Blood Products/Modifiers/Volume ExpandersAnticoagulants



argatroban inj 125mg/125ml; 0.9% 1ARGATROBAN INJ 250MG/2.5ML 1argatroban inj 250mg/250ml; 0.9% 1argatroban inj 50mg/50ml 1COUMADIN TABS 10MG 1 MOCOUMADIN TABS 1MG 1 MOCOUMADIN TABS 2.5MG 1 MOCOUMADIN TABS 2MG 1 MOCOUMADIN TABS 3MG 1 MOCOUMADIN TABS 4MG 1 MOCOUMADIN TABS 5MG 1 MOCOUMADIN TABS 6MG 1 MOCOUMADIN TABS 7.5MG 1 MOELIQUIS TABS 2.5MG 1 QL (60 EA per 30 days) MOELIQUIS TABS 5MG 1 QL (90 EA per 30 days) MOenoxaparin sodium inj 100mg/ml 1 QL (35 ML per 90 days)enoxaparin sodium inj 120mg/0.8ml 1 QL (28 ML per 90 days)enoxaparin sodium inj 150mg/ml 1 QL (35 ML per 90 days) NDSenoxaparin sodium inj 300mg/3ml 1 QL (105 ML per 90 days)enoxaparin sodium inj 30mg/0.3ml 1 QL (10.5 ML per 90 days)enoxaparin sodium inj 40mg/0.4ml 1 QL (14 ML per 90 days)enoxaparin sodium inj 60mg/0.6ml 1 QL (21 ML per 90 days)enoxaparin sodium inj 80mg/0.8ml 1 QL (28 ML per 90 days)fondaparinux sodium inj 10mg/0.8ml 1 QL (28 ML per 90 days) NDSfondaparinux sodium inj 2.5mg/0.5ml 1 QL (17.5 ML per 90 days)fondaparinux sodium inj 5mg/0.4ml 1 QL (14 ML per 90 days) NDSfondaparinux sodium inj 7.5mg/0.6ml 1 QL (21 ML per 90 days) NDSFRAGMIN INJ 10000UNIT/ML 1 QL (35 ML per 90 days) NDSFRAGMIN INJ 12500UNIT/0.5ML 1 QL (17.5 ML per 90 days) NDSFRAGMIN INJ 15000UNIT/0.6ML 1 QL (21 ML per 90 days) NDSFRAGMIN INJ 18000UNT/0.72ML 1 QL (25.3 ML per 90 days) NDSFRAGMIN INJ 2500UNIT/0.2ML 1 QL (7 ML per 90 days)FRAGMIN INJ 5000UNIT/0.2ML 1 QL (7 ML per 90 days)FRAGMIN INJ 7500UNIT/0.3ML 1 QL (10.5 ML per 90 days) NDSFRAGMIN INJ 95000UNIT/3.8ML 1 QL (22.8 ML per 90 days) NDSheparin sodium/d5w inj 5%; 100unit/ml 1heparin sodium/d5w inj 5%; 40unit/ml 1heparin sodium/d5w inj 5%; 50unit/ml 1heparin sodium/nacl 0.45% inj 100unit/ml; 0.45% 1heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% 1heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% 1heparin sodium/nacl 0.9% inj 2unit/ml; 0.9% 1heparin sodium/sodium chloride 0.9% premix inj 2unit/ml; 0.9% 1heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9% 1heparin sodium inj 10000unit/ml 1heparin sodium inj 1000unit/ml 1



heparin sodium inj 20000unit/ml 1heparin sodium inj 2000unit/ml 1heparin sodium inj 2500unit/ml 1heparin sodium inj 5000unit/0.5ml 1heparin sodium inj 5000unit/0.5ml 1heparin sodium inj 5000unit/ml 1jantoven tabs 10mg 1 MOjantoven tabs 1mg 1 MOjantoven tabs 2.5mg 1 MOjantoven tabs 2mg 1 MOjantoven tabs 3mg 1 MOjantoven tabs 4mg 1 MOjantoven tabs 5mg 1 MOjantoven tabs 6mg 1 MOjantoven tabs 7.5mg 1 MOPRADAXA CAPS 110MG 1 QL (60 EA per 30 days) MOPRADAXA CAPS 150MG 1 QL (60 EA per 30 days) MOPRADAXA CAPS 75MG 1 QL (60 EA per 30 days) MOSAVAYSA TABS 15MG 1 QL (30 EA per 30 days) MOSAVAYSA TABS 30MG 1 QL (30 EA per 30 days) MOSAVAYSA TABS 60MG 1 QL (30 EA per 30 days) MOwarfarin sodium tabs 10mg 1 MOwarfarin sodium tabs 1mg 1 MOwarfarin sodium tabs 2.5mg 1 MOwarfarin sodium tabs 2mg 1 MOwarfarin sodium tabs 3mg 1 MOwarfarin sodium tabs 4mg 1 MOwarfarin sodium tabs 5mg 1 MOwarfarin sodium tabs 6mg 1 MOwarfarin sodium tabs 7.5mg 1 MOXARELTO STARTER PACK TBPK 0 1 QL (102 EA per 365 days)XARELTO TABS 10MG 1 QL (30 EA per 30 days) MOXARELTO TABS 15MG 1 QL (60 EA per 30 days) MOXARELTO TABS 20MG 1 QL (30 EA per 30 days) MO

Blood Formation Modifiers anagrelide hydrochloride caps 0.5mg 1 MOanagrelide hydrochloride caps 1mg 1 MOARANESP ALBUMIN FREE INJ 100MCG/0.5ML 1 PA NDSARANESP ALBUMIN FREE INJ 100MCG/ML 1 PA NDSARANESP ALBUMIN FREE INJ 10MCG/0.4ML 1 PAARANESP ALBUMIN FREE INJ 150MCG/0.3ML 1 PA NDSARANESP ALBUMIN FREE INJ 200MCG/0.4ML 1 PA NDSARANESP ALBUMIN FREE INJ 200MCG/ML 1 PA NDSARANESP ALBUMIN FREE INJ 25MCG/0.42ML 1 PAARANESP ALBUMIN FREE INJ 25MCG/ML 1 PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML 1 PA NDSARANESP ALBUMIN FREE INJ 300MCG/ML 1 PA NDS



ARANESP ALBUMIN FREE INJ 40MCG/0.4ML 1 PAARANESP ALBUMIN FREE INJ 40MCG/ML 1 PAARANESP ALBUMIN FREE INJ 500MCG/ML 1 PA NDSARANESP ALBUMIN FREE INJ 60MCG/0.3ML 1 PAARANESP ALBUMIN FREE INJ 60MCG/ML 1 PA NDSGRANIX INJ 300MCG/0.5ML 1 PA NDSGRANIX INJ 480MCG/0.8ML 1 PA NDSLEUKINE INJ 250MCG 1 PA NDSMOZOBIL INJ 24MG/1.2ML 1 QL (38.4 ML per 365 days) PA NDSNEULASTA ONPRO KIT INJ 6MG/0.6ML 1 PA NDSNEULASTA INJ 6MG/0.6ML 1 PA NDSNEUPOGEN INJ 300MCG/0.5ML 1 PA NDSNEUPOGEN INJ 300MCG/ML 1 PA NDSNEUPOGEN INJ 480MCG/0.8ML 1 PA NDSNEUPOGEN INJ 480MCG/1.6ML 1 PA NDSNPLATE INJ 250MCG 1 PA NDSNPLATE INJ 500MCG 1 PA NDSPROCRIT INJ 10000UNIT/ML 1 PAPROCRIT INJ 20000UNIT/ML 1 PA NDSPROCRIT INJ 2000UNIT/ML 1 PAPROCRIT INJ 3000UNIT/ML 1 PAPROCRIT INJ 40000UNIT/ML 1 PA NDSPROCRIT INJ 4000UNIT/ML 1 PAPROMACTA TABS 12.5MG 1 PA MO NDSPROMACTA TABS 25MG 1 PA MO NDSPROMACTA TABS 50MG 1 PA MO NDSPROMACTA TABS 75MG 1 PA MO NDSZARXIO INJ 300MCG/0.5ML 1 PA NDSZARXIO INJ 480MCG/0.8ML 1 PA NDS

Coagulants aminocaproic acid inj 250mg/ml 1aminocaproic acid syrp 25% 1aminocaproic acid tabs 1000mg 1aminocaproic acid tabs 500mg 1tranexamic acid inj 1000mg/10ml 1tranexamic acid tabs 650mg 1

Platelet Modifying Agents AGGRENOX CP12 25MG; 200MG 1 MOaspirin/dipyridamole cp12 25mg; 200mg 1 MOBRILINTA TABS 60MG 1 MOBRILINTA TABS 90MG 1 MOcilostazol tabs 100mg 1 MOcilostazol tabs 50mg 1 MOclopidogrel tabs 300mg 1clopidogrel tabs 75mg 1 MOdipyridamole tabs 25mg 1 PA MOdipyridamole tabs 50mg 1 PA MO



dipyridamole tabs 75mg 1 PA MOEFFIENT TABS 10MG 1 MOEFFIENT TABS 5MG 1 MOticlopidine hcl tabs 250mg 1 PA MO

Cardiovascular AgentsAlpha-adrenergic Agonists

clonidine hcl inj 100mcg/ml 1clonidine hcl inj 100mcg/ml 1clonidine hcl inj 500mcg/ml 1clonidine hcl inj 500mcg/ml 1clonidine hcl ptwk 0.1mg/24hr 1 MOclonidine hcl ptwk 0.2mg/24hr 1 MOclonidine hcl ptwk 0.3mg/24hr 1 MOclonidine hcl tabs 0.1mg 1 MOclonidine hcl tabs 0.2mg 1 MOclonidine hcl tabs 0.3mg 1 MOCLORPRES TABS 15MG; 0.1MG 1 MOCLORPRES TABS 15MG; 0.2MG 1 MOCLORPRES TABS 15MG; 0.3MG 1 MOguanfacine hcl tabs 1mg 1 PA MOguanfacine hcl tabs 2mg 1 PA MOmethyldopa/hydrochlorothiazide tabs 15mg; 250mg 1 PA MOmethyldopa/hydrochlorothiazide tabs 25mg; 250mg 1 PA MOmethyldopa tabs 250mg 1 PA MOmethyldopa tabs 500mg 1 PA MOmethyldopate hcl inj 250mg/5ml 1 PAmidodrine hcl tabs 10mg 1midodrine hcl tabs 2.5mg 1midodrine hcl tabs 5mg 1phenylephrine hcl inj 10mg/ml 1

Alpha-adrenergic Blocking Agents phenoxybenzamine hydrochloride caps 10mg 1 NDSprazosin hcl caps 1mg 1 MOprazosin hcl caps 2mg 1 MOprazosin hcl caps 5mg 1 MO

Angiotensin II Receptor Antagonists BENICAR HCT TABS 12.5MG; 20MG 1 MOBENICAR HCT TABS 12.5MG; 40MG 1 MOBENICAR HCT TABS 25MG; 40MG 1 MOBENICAR TABS 20MG 1 MOBENICAR TABS 40MG 1 MOBENICAR TABS 5MG 1 MOcandesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg 1 MOcandesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg 1 MOcandesartan cilexetil/hydrochlorothiazide tabs 32mg; 25mg 1 MOcandesartan cilexetil tabs 16mg 1 MOcandesartan cilexetil tabs 32mg 1 MO



candesartan cilexetil tabs 4mg 1 MOcandesartan cilexetil tabs 8mg 1 MOEDARBI TABS 40MG 1 MOEDARBI TABS 80MG 1 MOEDARBYCLOR TABS 40MG; 12.5MG 1 MOEDARBYCLOR TABS 40MG; 25MG 1 MOENTRESTO TABS 24MG; 26MG 1 QL (60 EA per 30 days) PA MOENTRESTO TABS 49MG; 51MG 1 QL (60 EA per 30 days) PA MOENTRESTO TABS 97MG; 103MG 1 QL (60 EA per 30 days) PA MOeprosartan mesylate tabs 600mg 1 MOirbesartan/hydrochlorothiazide tabs 12.5mg; 150mg 1 MOirbesartan/hydrochlorothiazide tabs 12.5mg; 300mg 1 MOirbesartan tabs 150mg 1 MOirbesartan tabs 300mg 1 MOirbesartan tabs 75mg 1 MOlosartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg 1 MOlosartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg 1 MOlosartan potassium/hydrochlorothiazide tabs 25mg; 100mg 1 MOlosartan potassium tabs 100mg 1 MOlosartan potassium tabs 25mg 1 MOlosartan potassium tabs 50mg 1 MOtelmisartan/amlodipine tabs 10mg; 40mg 1 MOtelmisartan/amlodipine tabs 10mg; 80mg 1 MOtelmisartan/amlodipine tabs 5mg; 40mg 1 MOtelmisartan/amlodipine tabs 5mg; 80mg 1 MOtelmisartan/hydrochlorothiazide tabs 12.5mg; 40mg 1 MOtelmisartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 MOtelmisartan/hydrochlorothiazide tabs 25mg; 80mg 1 MOtelmisartan tabs 20mg 1 MOtelmisartan tabs 40mg 1 MOtelmisartan tabs 80mg 1 MOvalsartan/hydrochlorothiazide tabs 12.5mg; 160mg 1 MOvalsartan/hydrochlorothiazide tabs 12.5mg; 320mg 1 MOvalsartan/hydrochlorothiazide tabs 12.5mg; 80mg 1 MOvalsartan/hydrochlorothiazide tabs 25mg; 160mg 1 MOvalsartan/hydrochlorothiazide tabs 25mg; 320mg 1 MOvalsartan tabs 160mg 1 MOvalsartan tabs 320mg 1 MOvalsartan tabs 40mg 1 MOvalsartan tabs 80mg 1 MO

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg 1 MObenazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg 1 MObenazepril hcl/hydrochlorothiazide tabs 20mg; 25mg 1 MObenazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 1 MObenazepril hcl tabs 10mg 1 MObenazepril hcl tabs 20mg 1 MO



benazepril hcl tabs 40mg 1 MObenazepril hcl tabs 5mg 1 MOcaptopril/hydrochlorothiazide tabs 25mg; 15mg 1 MOcaptopril/hydrochlorothiazide tabs 25mg; 25mg 1 MOcaptopril/hydrochlorothiazide tabs 50mg; 15mg 1 MOcaptopril/hydrochlorothiazide tabs 50mg; 25mg 1 MOcaptopril tabs 100mg 1 MOcaptopril tabs 12.5mg 1 MOcaptopril tabs 25mg 1 MOcaptopril tabs 50mg 1 MOenalapril maleate/hydrochlorothiazide tabs 10mg; 25mg 1 MOenalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg 1 MOenalapril maleate tabs 10mg 1 MOenalapril maleate tabs 2.5mg 1 MOenalapril maleate tabs 20mg 1 MOenalapril maleate tabs 5mg 1 MOenalaprilat inj 1.25mg/ml 1EPANED SOLR 1MG/ML 1 MOfosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg 1 MOfosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg 1 MOfosinopril sodium tabs 10mg 1 MOfosinopril sodium tabs 20mg 1 MOfosinopril sodium tabs 40mg 1 MOlisinopril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MOlisinopril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MOlisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 MOlisinopril tabs 10mg 1 MOlisinopril tabs 2.5mg 1 MOlisinopril tabs 20mg 1 MOlisinopril tabs 30mg 1 MOlisinopril tabs 40mg 1 MOlisinopril tabs 5mg 1 MOmoexipril hcl tabs 15mg 1 MOmoexipril hcl tabs 7.5mg 1 MOmoexipril/hydrochlorothiazide tabs 12.5mg; 15mg 1 MOmoexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg 1 MOmoexipril/hydrochlorothiazide tabs 25mg; 15mg 1 MOperindopril erbumine tabs 2mg 1 MOperindopril erbumine tabs 4mg 1 MOperindopril erbumine tabs 8mg 1 MOquinapril hcl tabs 10mg 1 MOquinapril hcl tabs 20mg 1 MOquinapril hcl tabs 40mg 1 MOquinapril hcl tabs 5mg 1 MOquinapril/hydrochlorothiazide tabs 12.5mg; 10mg 1 MOquinapril/hydrochlorothiazide tabs 12.5mg; 20mg 1 MOquinapril/hydrochlorothiazide tabs 25mg; 20mg 1 MO



ramipril caps 1.25mg 1 MOramipril caps 10mg 1 MOramipril caps 2.5mg 1 MOramipril caps 5mg 1 MOtrandolapril/verapamil hcl er tbcr 1mg; 240mg 1 MOtrandolapril/verapamil hcl er tbcr 2mg; 180mg 1 MOtrandolapril/verapamil hcl er tbcr 2mg; 240mg 1 MOtrandolapril/verapamil hcl er tbcr 4mg; 240mg 1 MOtrandolapril/verapamil hcl tbcr 1mg; 240mg 1 MOtrandolapril/verapamil hcl tbcr 2mg; 180mg 1 MOtrandolapril/verapamil hcl tbcr 2mg; 240mg 1 MOtrandolapril/verapamil hcl tbcr 4mg; 240mg 1 MOtrandolapril tabs 1mg 1 MOtrandolapril tabs 2mg 1 MOtrandolapril tabs 4mg 1 MO

Antiarrhythmics amiodarone hcl inj 50mg/ml 1amiodarone hcl inj 50mg/ml 1amiodarone hcl inj 900mg/18ml 1amiodarone hcl tabs 100mg 1 MOamiodarone hcl tabs 200mg 1 MOamiodarone hcl tabs 400mg 1 MOdisopyramide phosphate caps 100mg 1 PA MOdisopyramide phosphate caps 150mg 1 PA MOdofetilide caps 125mcg 1 MOdofetilide caps 250mcg 1 MOdofetilide caps 500mcg 1 MOflecainide acetate tabs 100mg 1 MOflecainide acetate tabs 150mg 1 MOflecainide acetate tabs 50mg 1 MOibutilide fumarate inj 1mg/10ml 1lidocaine hcl in d5w inj 5%; 4mg/ml 1lidocaine hcl in d5w inj 5%; 8mg/ml 1lidocaine hcl/dextrose inj 5%; 4mg/ml 1lidocaine hcl/dextrose inj 5%; 8mg/ml 1lidocaine hcl inj 10mg/ml 1lidocaine hcl inj 20mg/ml 1lidocaine hcl inj 20mg/ml 1mexiletine hcl caps 150mg 1 MOmexiletine hcl caps 200mg 1 MOmexiletine hcl caps 250mg 1 MOMULTAQ TABS 400MG 1 MONORPACE CR CP12 100MG 1 PA MONORPACE CR CP12 150MG 1 PA MOpacerone tabs 200mg 1 MOprocainamide hcl inj 100mg/ml 1procainamide hcl inj 500mg/ml 1



propafenone hcl er cp12 225mg 1 MOpropafenone hcl er cp12 325mg 1 MOpropafenone hcl er cp12 425mg 1 MOpropafenone hcl tabs 150mg 1 MOpropafenone hcl tabs 225mg 1 MOpropafenone hcl tabs 300mg 1 MOquinidine gluconate cr tbcr 324mg 1 MOquinidine gluconate er tbcr 324mg 1 MOquinidine gluconate inj 80mg/ml 1quinidine sulfate er tbcr 300mg 1 MOquinidine sulfate tabs 200mg 1 MOquinidine sulfate tabs 300mg 1 MOsorine tabs 120mg 1 MOsorine tabs 160mg 1 MOsorine tabs 240mg 1 MOsorine tabs 80mg 1 MOsotalol hcl (af) tabs 120mg 1 MOsotalol hcl (af) tabs 160mg 1 MOsotalol hcl (af) tabs 80mg 1 MOsotalol hcl tabs 120mg 1 MOsotalol hcl tabs 160mg 1 MOsotalol hcl tabs 240mg 1 MOsotalol hcl tabs 80mg 1 MOsotalol hydrochloride inj 150mg/10ml 1 NDSTIKOSYN CAPS 125MCG 1 MOTIKOSYN CAPS 250MCG 1 MOTIKOSYN CAPS 500MCG 1 MO

Beta-adrenergic Blocking Agents acebutolol hcl caps 200mg 1 MOacebutolol hcl caps 400mg 1 MOatenolol/chlorthalidone tabs 100mg; 25mg 1 MOatenolol/chlorthalidone tabs 50mg; 25mg 1 MOatenolol tabs 100mg 1 MOatenolol tabs 25mg 1 MOatenolol tabs 50mg 1 MObetaxolol hcl tabs 10mg 1 MObetaxolol hcl tabs 20mg 1 MObisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg 1 MObisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg 1 MObisoprolol fumarate/hydrochlorothiazide tabs 5mg; 6.25mg 1 MObisoprolol fumarate tabs 10mg 1 MObisoprolol fumarate tabs 5mg 1 MOBREVIBLOC INJ 10MG/ML; 5.9MG/ML 1BREVIBLOC INJ 20MG/ML; 4.1MG/ML 1BYSTOLIC TABS 10MG 1 MOBYSTOLIC TABS 2.5MG 1 MOBYSTOLIC TABS 20MG 1 MO



BYSTOLIC TABS 5MG 1 MOcarvedilol tabs 12.5mg 1 MOcarvedilol tabs 25mg 1 MOcarvedilol tabs 3.125mg 1 MOcarvedilol tabs 6.25mg 1 MODUTOPROL TB24 12.5MG; 100MG 1 MODUTOPROL TB24 12.5MG; 25MG 1 MODUTOPROL TB24 12.5MG; 50MG 1 MOesmolol hcl inj 100mg/10ml 1esmolol hcl inj 10mg/ml 1INNOPRAN XL CP24 120MG 1 MOINNOPRAN XL CP24 80MG 1 MOlabetalol hcl inj 5mg/ml 1labetalol hcl tabs 100mg 1 MOlabetalol hcl tabs 200mg 1 MOlabetalol hcl tabs 300mg 1 MOmetoprolol succinate er tb24 100mg 1 MOmetoprolol succinate er tb24 200mg 1 MOmetoprolol succinate er tb24 25mg 1 MOmetoprolol succinate er tb24 50mg 1 MOmetoprolol tartrate inj 1mg/ml 1metoprolol tartrate inj 1mg/ml 1metoprolol tartrate tabs 100mg 1 MOmetoprolol tartrate tabs 25mg 1 MOmetoprolol tartrate tabs 50mg 1 MOmetoprolol/hydrochlorothiazide tabs 25mg; 100mg 1 MOmetoprolol/hydrochlorothiazide tabs 25mg; 50mg 1 MOmetoprolol/hydrochlorothiazide tabs 50mg; 100mg 1 MOnadolol/bendroflumethiazide tabs 5mg; 40mg 1 MOnadolol/bendroflumethiazide tabs 5mg; 80mg 1 MOnadolol tabs 20mg 1 MOnadolol tabs 40mg 1 MOnadolol tabs 80mg 1 MOpindolol tabs 10mg 1 MOpindolol tabs 5mg 1 MOpropranolol hcl er cp24 120mg 1 MOpropranolol hcl er cp24 160mg 1 MOpropranolol hcl er cp24 60mg 1 MOpropranolol hcl er cp24 80mg 1 MOpropranolol hcl inj 1mg/ml 1propranolol hcl soln 20mg/5ml 1 MOpropranolol hcl soln 40mg/5ml 1 MOpropranolol hcl tabs 10mg 1 MOpropranolol hcl tabs 20mg 1 MOpropranolol hcl tabs 40mg 1 MOpropranolol hcl tabs 60mg 1 MOpropranolol hcl tabs 80mg 1 MO



propranolol/hydrochlorothiazide tabs 25mg; 40mg 1 MOpropranolol/hydrochlorothiazide tabs 25mg; 80mg 1 MOtimolol maleate tabs 10mg 1 MOtimolol maleate tabs 20mg 1 MOtimolol maleate tabs 5mg 1 MO

Calcium Channel Blocking Agents afeditab cr tb24 30mg 1 MOafeditab cr tb24 60mg 1 MOamlodipine besylate/atorvastatin calcium tabs 10mg; 10mg 1 MOamlodipine besylate/atorvastatin calcium tabs 10mg; 20mg 1 MOamlodipine besylate/atorvastatin calcium tabs 10mg; 40mg 1 MOamlodipine besylate/atorvastatin calcium tabs 10mg; 80mg 1 MOamlodipine besylate/atorvastatin calcium tabs 2.5mg; 10mg 1 MOamlodipine besylate/atorvastatin calcium tabs 2.5mg; 20mg 1 MOamlodipine besylate/atorvastatin calcium tabs 2.5mg; 40mg 1 MOamlodipine besylate/atorvastatin calcium tabs 5mg; 10mg 1 MOamlodipine besylate/atorvastatin calcium tabs 5mg; 20mg 1 MOamlodipine besylate/atorvastatin calcium tabs 5mg; 40mg 1 MOamlodipine besylate/atorvastatin calcium tabs 5mg; 80mg 1 MOamlodipine besylate/benazepril hydrochloride caps 10mg; 20mg 1 MOamlodipine besylate/benazepril hydrochloride caps 10mg; 40mg 1 MOamlodipine besylate/benazepril hydrochloride caps 2.5mg; 10mg 1 MOamlodipine besylate/benazepril hydrochloride caps 5mg; 10mg 1 MOamlodipine besylate/benazepril hydrochloride caps 5mg; 20mg 1 MOamlodipine besylate/benazepril hydrochloride caps 5mg; 40mg 1 MOamlodipine besylate/valsartan tabs 10mg; 160mg 1 MOamlodipine besylate/valsartan tabs 10mg; 320mg 1 MOamlodipine besylate/valsartan tabs 5mg; 160mg 1 MOamlodipine besylate/valsartan tabs 5mg; 320mg 1 MOamlodipine besylate tabs 10mg 1 MOamlodipine besylate tabs 2.5mg 1 MOamlodipine besylate tabs 5mg 1 MOamlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg 1 MOamlodipine/valsartan/hctz tabs 10mg; 25mg; 160mg 1 MOamlodipine/valsartan/hctz tabs 10mg; 25mg; 320mg 1 MOamlodipine/valsartan/hctz tabs 5mg; 12.5mg; 160mg 1 MOamlodipine/valsartan/hctz tabs 5mg; 25mg; 160mg 1 MOCARDIZEM LA TB24 120MG 1 MOcartia xt cp24 120mg 1 MOcartia xt cp24 180mg 1 MOcartia xt cp24 240mg 1 MOcartia xt cp24 300mg 1 MOdilt-xr cp24 120mg 1 MOdilt-xr cp24 180mg 1 MOdilt-xr cp24 240mg 1 MOdiltiazem cd cp24 120mg 1 MOdiltiazem cd cp24 180mg 1 MO



diltiazem cd cp24 240mg 1 MOdiltiazem cd cp24 300mg 1 MOdiltiazem hcl cd cp24 360mg 1 MOdiltiazem hcl er cp12 120mg 1 MOdiltiazem hcl er cp12 60mg 1 MOdiltiazem hcl er cp12 90mg 1 MOdiltiazem hcl er cp24 120mg 1 MOdiltiazem hcl er cp24 120mg 1 MOdiltiazem hcl er cp24 120mg 1 MOdiltiazem hcl er cp24 180mg 1 MOdiltiazem hcl er cp24 180mg 1 MOdiltiazem hcl er cp24 180mg 1 MOdiltiazem hcl er cp24 240mg 1 MOdiltiazem hcl er cp24 240mg 1 MOdiltiazem hcl er cp24 240mg 1 MOdiltiazem hcl er cp24 300mg 1 MOdiltiazem hcl er cp24 300mg 1 MOdiltiazem hcl er cp24 360mg 1 MOdiltiazem hcl er cp24 360mg 1 MOdiltiazem hcl er cp24 420mg 1 MOdiltiazem hcl er tb24 180mg 1 MOdiltiazem hcl er tb24 240mg 1 MOdiltiazem hcl er tb24 300mg 1 MOdiltiazem hcl er tb24 360mg 1 MOdiltiazem hcl er tb24 420mg 1 MOdiltiazem hcl inj 100mg 1diltiazem hcl inj 125mg/25ml 1diltiazem hcl inj 25mg/5ml 1diltiazem hcl inj 50mg/10ml 1diltiazem hcl tabs 120mg 1 MOdiltiazem hcl tabs 30mg 1 MOdiltiazem hcl tabs 60mg 1 MOdiltiazem hcl tabs 90mg 1 MOfelodipine er tb24 10mg 1 MOfelodipine er tb24 2.5mg 1 MOfelodipine er tb24 5mg 1 MOisradipine caps 2.5mg 1 MOisradipine caps 5mg 1 MOmatzim la tb24 180mg 1 MOmatzim la tb24 240mg 1 MOmatzim la tb24 300mg 1 MOmatzim la tb24 360mg 1 MOmatzim la tb24 420mg 1 MOnicardipine hcl caps 20mg 1 MOnicardipine hcl caps 30mg 1 MOnicardipine hcl inj 2.5mg/ml 1nifedical xl tb24 30mg 1 MO



nifedical xl tb24 60mg 1 MOnifedipine er tb24 30mg 1 MOnifedipine er tb24 30mg 1 MOnifedipine er tb24 60mg 1 MOnifedipine er tb24 60mg 1 MOnifedipine er tb24 90mg 1 MOnifedipine er tb24 90mg 1 MOnifedipine caps 10mg 1 PA MOnifedipine caps 20mg 1 PA MOnimodipine caps 30mg 1 MO NDSnisoldipine er tb24 25.5mg 1 MOnisoldipine tb24 17mg 1 MOnisoldipine tb24 20mg 1 MOnisoldipine tb24 30mg 1 MOnisoldipine tb24 34mg 1 MOnisoldipine tb24 40mg 1 MOnisoldipine tb24 8.5mg 1 MONYMALIZE SOLN 60MG/20ML 1 MO NDStaztia xt cp24 120mg 1 MOtaztia xt cp24 180mg 1 MOtaztia xt cp24 240mg 1 MOtaztia xt cp24 300mg 1 MOtaztia xt cp24 360mg 1 MOverapamil hcl cr tbcr 240mg 1 MOverapamil hcl er cp24 100mg 1 MOverapamil hcl er cp24 120mg 1 MOverapamil hcl er cp24 180mg 1 MOverapamil hcl er cp24 200mg 1 MOverapamil hcl er cp24 240mg 1 MOverapamil hcl er cp24 300mg 1 MOverapamil hcl er tbcr 120mg 1 MOverapamil hcl er tbcr 180mg 1 MOverapamil hcl er tbcr 240mg 1 MOverapamil hcl sr cp24 120mg 1 MOverapamil hcl sr cp24 180mg 1 MOverapamil hcl sr cp24 240mg 1 MOverapamil hcl sr cp24 360mg 1 MOverapamil hcl sr tbcr 240mg 1 MOverapamil hcl inj 2.5mg/ml 1verapamil hcl tabs 120mg 1 MOverapamil hcl tabs 40mg 1 MOverapamil hcl tabs 80mg 1 MO

Cardiovascular Agents, Other DEMSER CAPS 250MG 1 NDSdigitek tabs 0.125mg 1 QL (30 EA per 30 days) MOdigitek tabs 0.25mg 1 PA MOdigoxin inj 0.25mg/ml 1 PA



digoxin soln 0.05mg/ml 1 PA MOdigoxin tabs 125mcg 1 QL (30 EA per 30 days) MOdigoxin tabs 250mcg 1 PA MOdigox tabs 125mcg 1 QL (30 EA per 30 days) MOdigox tabs 250mcg 1 PA MOdobutamine hcl/d5w inj 5%; 1mg/ml 1 B/Ddobutamine hcl/d5w inj 5%; 2mg/ml 1 B/Ddobutamine hcl/d5w inj 5%; 4mg/ml 1 B/Ddobutamine hcl inj 250mg/20ml 1 B/Ddobutamine hcl inj 500mg/40ml 1 B/Ddobutamine/dextrose 5% inj 5%; 2mg/ml 1 B/Ddobutamine/dextrose 5% inj 5%; 4mg/ml 1 B/Ddopamine hcl-dextrose 5% inj 5%; 0.8mg/ml 1 B/Ddopamine hcl/dextrose 5% inj 5%; 1.6mg/ml 1 B/Ddopamine hcl inj 160mg/ml 1 B/Ddopamine hcl inj 40mg/ml 1 B/Ddopamine hcl inj 80mg/ml 1 B/Ddopamine/d5w inj 5%; 0.8mg/ml 1 B/Ddopamine/d5w inj 5%; 1.6mg/ml 1 B/Ddopamine/d5w inj 5%; 3.2mg/ml 1 B/DLANOXIN TABS 125MCG 1 QL (30 EA per 30 days) MOLANOXIN TABS 187.5MCG 1 QL (30 EA per 30 days) PA MOLANOXIN TABS 250MCG 1 PA MOLANOXIN TABS 62.5MCG 1 QL (60 EA per 30 days) MOmannitol inj 10% 1mannitol inj 15% 1mannitol inj 20% 1mannitol inj 25% 1mannitol inj 5% 1milrinone in dextrose inj 5%; 20mg/100ml 1 B/Dmilrinone in dextrose inj 5%; 40mg/200ml 1 B/Dmilrinone lactate inj 10mg/10ml 1 B/Dmilrinone lactate inj 10mg/10ml 1 B/Dmilrinone lactate inj 20mg/20ml 1 B/Dmilrinone lactate inj 20mg/20ml 1 B/Dmilrinone lactate inj 50mg/50ml 1 B/Dmilrinone lactate inj 50mg/50ml 1 B/Dnorepinephrine bitartrate inj 1mg/ml 1NORTHERA CAPS 100MG 1 PA NDSNORTHERA CAPS 200MG 1 PA NDSNORTHERA CAPS 300MG 1 PA NDSosmitrol viaflex inj 10% 1osmitrol viaflex inj 15% 1osmitrol viaflex inj 20% 1osmitrol viaflex inj 5% 1pentoxifylline cr tbcr 400mg 1 MOpentoxifylline er tbcr 400mg 1 MO



PRALUENT INJ 150MG/ML 1 QL (2 ML per 28 days) PA MO NDSPRALUENT INJ 150MG/ML 1 QL (2 ML per 28 days) PA MO NDSPRALUENT INJ 75MG/ML 1 QL (2 ML per 28 days) PA MO NDSPRALUENT INJ 75MG/ML 1 QL (2 ML per 28 days) PA MO NDSRANEXA TB12 1000MG 1 MORANEXA TB12 500MG 1 MOREPATHA SURECLICK INJ 140MG/ML 1 QL (3 ML per 28 days) PA MO NDSREPATHA INJ 140MG/ML 1 QL (3 ML per 28 days) PA MO NDS

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium inj 500mg 1acetazolamide tabs 125mg 1 MOacetazolamide tabs 250mg 1 MO

Diuretics, Loop bumetanide inj 0.25mg/ml 1bumetanide tabs 0.5mg 1 MObumetanide tabs 1mg 1 MObumetanide tabs 2mg 1 MOEDECRIN TABS 25MG 1 MO NDSethacrynic acid tabs 25mg 1 MO NDSfurosemide inj 10mg/ml 1furosemide inj 10mg/ml 1furosemide soln 10mg/ml 1 MOfurosemide soln 8mg/ml 1 MOfurosemide tabs 20mg 1 MOfurosemide tabs 40mg 1 MOfurosemide tabs 80mg 1 MOtorsemide inj 20mg/2ml 1torsemide inj 50mg/5ml 1torsemide tabs 100mg 1 MOtorsemide tabs 10mg 1 MOtorsemide tabs 20mg 1 MOtorsemide tabs 5mg 1 MO

Diuretics, Potassium-sparing ALDACTAZIDE TABS 50MG; 50MG 1 MOamiloride hcl tabs 5mg 1 MOamiloride/hydrochlorothiazide tabs 5mg; 50mg 1 MODYRENIUM CAPS 0; 100MG 1 MODYRENIUM CAPS 50MG 1 MOeplerenone tabs 25mg 1 MOeplerenone tabs 50mg 1 MOspironolactone/hydrochlorothiazide tabs 25mg; 25mg 1 MOspironolactone tabs 100mg 1 MOspironolactone tabs 25mg 1 MOspironolactone tabs 50mg 1 MOtriamterene/hydrochlorothiazide caps 25mg; 37.5mg 1 MOtriamterene/hydrochlorothiazide caps 25mg; 50mg 1 MOtriamterene/hydrochlorothiazide tabs 25mg; 37.5mg 1 MO



triamterene/hydrochlorothiazide tabs 50mg; 75mg 1 MODiuretics, Thiazide

chlorothiazide sodium inj 500mg 1chlorothiazide tabs 250mg 1 MOchlorothiazide tabs 500mg 1 MOchlorthalidone tabs 25mg 1 MOchlorthalidone tabs 50mg 1 MODIURIL SUSP 250MG/5ML 1 MOhydrochlorothiazide caps 12.5mg 1 MOhydrochlorothiazide tabs 12.5mg 1 MOhydrochlorothiazide tabs 25mg 1 MOhydrochlorothiazide tabs 50mg 1 MOindapamide tabs 1.25mg 1 MOindapamide tabs 2.5mg 1 MOmethyclothiazide tabs 5mg 1 MOmetolazone tabs 10mg 1 MOmetolazone tabs 2.5mg 1 MOmetolazone tabs 5mg 1 MO

Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized caps 134mg 1 MOfenofibrate micronized caps 200mg 1 MOfenofibrate micronized caps 67mg 1 MOfenofibrate caps 130mg 1 MOfenofibrate caps 150mg 1 MOfenofibrate caps 43mg 1 MOfenofibrate caps 50mg 1 MOfenofibrate tabs 145mg 1 MOfenofibrate tabs 160mg 1 MOfenofibrate tabs 40mg 1 MOfenofibrate tabs 48mg 1 MOfenofibrate tabs 54mg 1 MOfenofibric acid dr cpdr 135mg 1 MOfenofibric acid dr cpdr 45mg 1 MOfenofibric acid tabs 105mg 1 MOfenofibric acid tabs 35mg 1 MOgemfibrozil tabs 600mg 1 MO

Dyslipidemics, HMG CoA Reductase Inhibitors ALTOPREV TB24 20MG 1 ST MOALTOPREV TB24 40MG 1 ST MOALTOPREV TB24 60MG 1 ST MOatorvastatin calcium tabs 10mg 1 MOatorvastatin calcium tabs 20mg 1 MOatorvastatin calcium tabs 40mg 1 MOatorvastatin calcium tabs 80mg 1 MOfluvastatin sodium er tb24 80mg 1 MOfluvastatin caps 20mg 1 MOfluvastatin caps 40mg 1 MO



LIVALO TABS 1MG 1 ST MOLIVALO TABS 2MG 1 ST MOLIVALO TABS 4MG 1 ST MOlovastatin tabs 10mg 1 MOlovastatin tabs 20mg 1 MOlovastatin tabs 40mg 1 MOpravastatin sodium tabs 10mg 1 MOpravastatin sodium tabs 20mg 1 MOpravastatin sodium tabs 40mg 1 MOpravastatin sodium tabs 80mg 1 MOrosuvastatin calcium tabs 10mg 1 MOrosuvastatin calcium tabs 20mg 1 MOrosuvastatin calcium tabs 40mg 1 MOrosuvastatin calcium tabs 5mg 1 MOsimvastatin tabs 10mg 1 MOsimvastatin tabs 20mg 1 MOsimvastatin tabs 40mg 1 MOsimvastatin tabs 5mg 1 MOsimvastatin tabs 80mg 1 PA MO

Dyslipidemics, Other cholestyramine light pack 4gm 1 MOcholestyramine light powd 4gm/dose 1 MOcholestyramine pack 4gm 1 MOcholestyramine powd 4gm/dose 1 MOcolestipol hcl gran 5gm 1 MOcolestipol hcl pack 5gm 1 MOcolestipol hcl tabs 1gm 1 MOJUXTAPID CAPS 10MG 1 QL (30 EA per 30 days) PA MO NDSJUXTAPID CAPS 20MG 1 QL (30 EA per 30 days) PA MO NDSJUXTAPID CAPS 30MG 1 QL (30 EA per 30 days) PA MO NDSJUXTAPID CAPS 40MG 1 QL (30 EA per 30 days) PA MO NDSJUXTAPID CAPS 5MG 1 QL (30 EA per 30 days) PA MO NDSJUXTAPID CAPS 60MG 1 QL (30 EA per 30 days) PA MO NDSKYNAMRO INJ 200MG/ML 1 QL (4 ML per 28 days) PA MO NDSniacin er tbcr 1000mg 1 MOniacin er tbcr 500mg 1 MOniacin er tbcr 750mg 1 MOniacor tabs 500mg 1omega-3-acid ethyl esters caps 375mg; 465mg; 1gm 1 MOprevalite pack 4gm 1 MOprevalite powd 4gm/dose 1 MOVASCEPA CAPS 1GM 1 MOWELCHOL PACK 3.75GM 1 MOWELCHOL TABS 625MG 1 MOZETIA TABS 10MG 1 MO

Vasodilators, Direct-acting Arterial/Venous BIDIL TABS 37.5MG; 20MG 1 MO



DILATRATE SR CPCR 40MG 1 MOISORDIL TITRADOSE TABS 40MG 1 MO NDSisosorbide dinitrate er tbcr 40mg 1 MOisosorbide dinitrate tabs 10mg 1 MOisosorbide dinitrate tabs 20mg 1 MOisosorbide dinitrate tabs 30mg 1 MOisosorbide dinitrate tabs 5mg 1 MOisosorbide mononitrate er tb24 120mg 1 MOisosorbide mononitrate er tb24 30mg 1 MOisosorbide mononitrate er tb24 60mg 1 MOisosorbide mononitrate tabs 10mg 1 MOisosorbide mononitrate tabs 20mg 1 MOminitran pt24 0.1mg/hr 1 MOminitran pt24 0.2mg/hr 1 MOminitran pt24 0.4mg/hr 1 MOminitran pt24 0.6mg/hr 1 MONITRO-BID OINT 2% 1 MONITRO-DUR PT24 0.3MG/HR 1 MONITRO-DUR PT24 0.8MG/HR 1 MOnitroglycerin in 5% dextrose inj 5%; 200mcg/ml 1nitroglycerin in 5% dextrose inj 5%; 400mcg/ml 1nitroglycerin in 5% dextrose inj 5%; 400mcg/ml 1nitroglycerin in dextrose 5% inj 5%; 100mcg/ml 1nitroglycerin in dextrose 5% inj 5%; 100mcg/ml 1nitroglycerin in dextrose 5% inj 5%; 200mcg/ml 1nitroglycerin in dextrose 5% inj 5%; 400mcg/ml 1nitroglycerin lingual aers 400mcg/spray 1 MOnitroglycerin lingual soln 0.4mg/spray 1 MOnitroglycerin transdermal pt24 0.1mg/hr 1 MOnitroglycerin transdermal pt24 0.2mg/hr 1 MOnitroglycerin transdermal pt24 0.4mg/hr 1 MOnitroglycerin transdermal pt24 0.6mg/hr 1 MOnitroglycerin inj 5mg/ml 1NITROMIST AERS 400MCG/SPRAY 1 MONITROSTAT SUBL 0.3MG 1 MONITROSTAT SUBL 0.4MG 1 MONITROSTAT SUBL 0.6MG 1 MORECTIV OINT 0.4% 1

Vasodilators, Direct-acting Arterial hydralazine hcl inj 20mg/ml 1hydralazine hcl tabs 100mg 1 MOhydralazine hcl tabs 10mg 1 MOhydralazine hcl tabs 25mg 1 MOhydralazine hcl tabs 50mg 1 MOminoxidil tabs 10mg 1 MOminoxidil tabs 2.5mg 1 MO

Central Nervous System Agents



Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine cp24 1.25mg; 1.25mg; 1.25mg; 1.25mg

1 QL (30 EA per 30 days) PA MO

amphetamine/dextroamphetamine cp24 2.5mg; 2.5mg; 2.5mg; 2.5mg1 QL (30 EA per 30 days) PA MOamphetamine/dextroamphetamine cp24 3.75mg; 3.75mg; 3.75mg; 3.75mg


amphetamine/dextroamphetamine cp24 5mg; 5mg; 5mg; 5mg 1 QL (30 EA per 30 days) PA MOamphetamine/dextroamphetamine cp24 6.25mg; 6.25mg; 6.25mg; 6.25mg


amphetamine/dextroamphetamine cp24 7.5mg; 7.5mg; 7.5mg; 7.5mg1 QL (30 EA per 30 days) PA MOamphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg

1 QL (90 EA per 30 days) MO

amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg; 1.875mg; 1.875mg


amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg; 2.5mg; 2.5mg1 QL (90 EA per 30 days) MOamphetamine/dextroamphetamine tabs 3.125mg; 3.125mg; 3.125mg; 3.125mg


amphetamine/dextroamphetamine tabs 3.75mg; 3.75mg; 3.75mg; 3.75mg


amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg 1 QL (90 EA per 30 days) MOamphetamine/dextroamphetamine tabs 7.5mg; 7.5mg; 7.5mg; 7.5mg1 QL (90 EA per 30 days) MOdexedrine tabs 10mg 1 QL (180 EA per 30 days) PA MODEXEDRINE TABS 5MG 1 QL (90 EA per 30 days) PA MOdextroamphetamine sulfate er cp24 10mg 1 QL (180 EA per 30 days) PA MOdextroamphetamine sulfate er cp24 15mg 1 QL (120 EA per 30 days) PA MOdextroamphetamine sulfate er cp24 5mg 1 QL (60 EA per 30 days) PA MOdextroamphetamine sulfate soln 5mg/5ml 1 QL (1800 ML per 30 days) PA MOdextroamphetamine sulfate tabs 10mg 1 QL (180 EA per 30 days) PA MOdextroamphetamine sulfate tabs 5mg 1 QL (90 EA per 30 days) PA MOZENZEDI TABS 10MG 1 QL (180 EA per 30 days) PA MOZENZEDI TABS 15MG 1 QL (90 EA per 30 days) PA MOZENZEDI TABS 2.5MG 1 QL (90 EA per 30 days) PA MOZENZEDI TABS 20MG 1 QL (90 EA per 30 days) PA MOZENZEDI TABS 30MG 1 QL (60 EA per 30 days) PA MOZENZEDI TABS 5MG 1 QL (90 EA per 30 days) PA MOZENZEDI TABS 7.5MG 1 QL (90 EA per 30 days) PA MO

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl er tb12 0.1mg 1 MOdexmethylphenidate hcl er cp24 10mg 1 QL (30 EA per 30 days) PA MOdexmethylphenidate hcl er cp24 15mg 1 QL (30 EA per 30 days) PA MOdexmethylphenidate hcl er cp24 20mg 1 QL (60 EA per 30 days) PA MOdexmethylphenidate hcl er cp24 30mg 1 QL (30 EA per 30 days) PA MOdexmethylphenidate hcl er cp24 40mg 1 QL (30 EA per 30 days) PA MOdexmethylphenidate hcl er cp24 5mg 1 QL (30 EA per 30 days) PA MOdexmethylphenidate hcl tabs 10mg 1 QL (60 EA per 30 days) PA MOdexmethylphenidate hcl tabs 2.5mg 1 QL (60 EA per 30 days) PA MOdexmethylphenidate hcl tabs 5mg 1 QL (60 EA per 30 days) PA MOFOCALIN XR CP24 25MG 1 QL (30 EA per 30 days) PA MOFOCALIN XR CP24 35MG 1 QL (30 EA per 30 days) PA MO



guanfacine er tb24 1mg 1 PA MOguanfacine er tb24 2mg 1 PA MOguanfacine er tb24 3mg 1 PA MOguanfacine er tb24 4mg 1 PA MOmetadate er tbcr 20mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 10mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 20mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 30mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 40mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 50mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl cd cpcr 60mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er cp24 20mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er cp24 30mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er cp24 30mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er cp24 40mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tb24 18mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tb24 27mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tb24 36mg 1 QL (60 EA per 30 days) PA MOmethylphenidate hcl er tb24 54mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tbcr 10mg 1 QL (180 EA per 30 days) PA MOmethylphenidate hcl er tbcr 18mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tbcr 20mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl er tbcr 27mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tbcr 27mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tbcr 36mg 1 QL (60 EA per 30 days) PA MOmethylphenidate hcl er tbcr 36mg 1 QL (60 EA per 30 days) PA MOmethylphenidate hcl er tbcr 54mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl er tbcr 54mg 1 QL (30 EA per 30 days) PA MOmethylphenidate hcl sr tbcr 20mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl chew 10mg 1 QL (180 EA per 30 days) PA MOmethylphenidate hcl chew 2.5mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl chew 5mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl tabs 10mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl tabs 20mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hcl tabs 5mg 1 QL (90 EA per 30 days) PA MOmethylphenidate hydrochloride soln 10mg/5ml 1 PA MOmethylphenidate hydrochloride soln 5mg/5ml 1 PA MORITALIN LA CP24 10MG 1 QL (30 EA per 30 days) PA MORITALIN LA CP24 60MG 1 QL (30 EA per 30 days) PA MOSTRATTERA CAPS 100MG 1 QL (30 EA per 30 days) ST MOSTRATTERA CAPS 10MG 1 QL (60 EA per 30 days) ST MOSTRATTERA CAPS 18MG 1 QL (30 EA per 30 days) ST MOSTRATTERA CAPS 25MG 1 QL (30 EA per 30 days) ST MOSTRATTERA CAPS 40MG 1 QL (30 EA per 30 days) ST MOSTRATTERA CAPS 60MG 1 QL (30 EA per 30 days) ST MOSTRATTERA CAPS 80MG 1 QL (30 EA per 30 days) ST MO

Central Nervous System, Other



butalbital/acetaminophen/caffeine/codeine caps 300mg; 50mg; 40mg; 30mg

1 PA

butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg

1 PA

butalbital/acetaminophen/caffeine caps 300mg; 50mg; 40mg 1 PAbutalbital/acetaminophen/caffeine caps 325mg; 50mg; 40mg 1 PAbutalbital/acetaminophen tabs 325mg; 50mg 1 PAbutalbital/aspirin/caffeine caps 325mg; 50mg; 40mg 1 PAcaffeine citrate inj 60mg/3ml 1caffeine citrate soln 20mg/ml 1caffeine citrate soln 60mg/3ml 1capacet caps 325mg; 50mg; 40mg 1 PAcephadyn tabs 650mg; 50mg 1 PAHETLIOZ CAPS 20MG 1 QL (30 EA per 30 days) PA MO NDSmargesic caps 325mg; 50mg; 40mg 1 PAmarten-tab tabs 325mg; 50mg 1 PANUEDEXTA CAPS 20MG; 10MG 1 MOriluzole tabs 50mg 1 PA MOtencon tabs 325mg; 50mg 1 PAtetrabenazine tabs 12.5mg 1 PA MO NDStetrabenazine tabs 25mg 1 PA MO NDSvanatol lq soln 325mg/15ml; 50mg/15ml; 40mg/15ml 1 PAzebutal caps 325mg; 50mg; 40mg 1 PA

Fibromyalgia Agents SAVELLA TITRATION PACK MISC 0 1 QL (110 EA per 365 days)SAVELLA TABS 100MG 1 QL (60 EA per 30 days) MOSAVELLA TABS 12.5MG 1 QL (60 EA per 30 days) MOSAVELLA TABS 25MG 1 QL (60 EA per 30 days) MOSAVELLA TABS 50MG 1 QL (60 EA per 30 days) MO

Multiple Sclerosis Agents AMPYRA TB12 10MG 1 QL (60 EA per 30 days) PA MO NDSAUBAGIO TABS 14MG 1 QL (30 EA per 30 days) PA MO NDSAUBAGIO TABS 7MG 1 QL (30 EA per 30 days) PA MO NDSAVONEX PEN INJ 30MCG/0.5ML 1 QL (4 EA per 28 days) PA MO NDSAVONEX INJ 30MCG/0.5ML 1 QL (4 EA per 28 days) PA MO NDSAVONEX INJ 30MCG/VIAL 1 QL (4 EA per 28 days) PA MO NDSBETASERON INJ 0.3MG 1 QL (15 EA per 30 days) PA MO NDSCOPAXONE INJ 20MG/ML 1 QL (30 ML per 30 days) PA MO

NDSCOPAXONE INJ 40MG/ML 1 QL (12 ML per 28 days) PA MO

NDSEXTAVIA INJ 0.3MG 1 QL (15 EA per 30 days) PA MO NDSGILENYA CAPS 0.5MG 1 QL (30 EA per 30 days) PA MO NDSglatopa inj 20mg/ml 1 QL (30 ML per 30 days) PA MO

NDSPLEGRIDY STARTER PACK INJ 0 1 QL (2 ML per 365 days) PA NDSPLEGRIDY STARTER PACK INJ 0 1 QL (2 ML per 365 days) PA NDSPLEGRIDY INJ 125MCG/0.5ML 1 QL (1 ML per 28 days) PA MO NDS



PLEGRIDY INJ 125MCG/0.5ML 1 QL (1 ML per 28 days) PA MO NDSREBIF REBIDOSE TITRATION PACK INJ 0 1 QL (8.4 ML per 365 days) PA MO

NDSREBIF REBIDOSE INJ 22MCG/0.5ML 1 QL (6 ML per 28 days) PA MO NDSREBIF REBIDOSE INJ 44MCG/0.5ML 1 QL (6 ML per 28 days) PA MO NDSREBIF TITRATION PACK INJ 0 1 QL (8.4 ML per 365 days) PA MO

NDSREBIF INJ 22MCG/0.5ML 1 QL (6 ML per 28 days) PA MO NDSREBIF INJ 44MCG/0.5ML 1 QL (6 ML per 28 days) PA MO NDSTECFIDERA STARTER PACK MISC 0 1 QL (120 EA per 365 days) PA NDSTECFIDERA CPDR 120MG 1 QL (60 EA per 30 days) PA MO NDSTECFIDERA CPDR 240MG 1 QL (60 EA per 30 days) PA MO NDSTYSABRI INJ 300MG/15ML 1 PA NDS

Dental and Oral AgentsDental and Oral Agents

ARESTIN MISC 1MG 1 NDScevimeline hcl caps 30mg 1 MOchlorhexidine gluconate oral rinse soln 0.12% 1KEPIVANCE INJ 6.25MG 1 NDSoralone pste 0.1% 1paroex soln 0.12% 1periogard soln 0.12% 1pilocarpine hcl tabs 7.5mg 1 MOpilocarpine hydrochloride tabs 5mg 1 MOtriamcinolone acetonide pste 0.1% 1triamcinolone in orabase pste 0.1% 1

Dermatological AgentsDermatological Agents

acitretin caps 10mg 1acitretin caps 17.5mg 1 NDSacitretin caps 25mg 1adapalene pump gel 0.3% 1 PAadapalene crea 0.1% 1 PAadapalene gel 0.1% 1 PAadapalene gel 0.3% 1 PAadapalene lotn 0.1% 1 PAammonium lactate crea 12% 1ammonium lactate lotn 12% 1amnesteem caps 10mg 1 PAamnesteem caps 20mg 1 PAamnesteem caps 40mg 1 PAavita crea 0.025% 1 PAavita gel 0.025% 1 PAcalcipotriene/betamethasone dipropionate oint 0.064%; 0.005% 1 QL (400 GM per 28 days)calcipotriene crea 0.005% 1calcipotriene oint 0.005% 1calcipotriene soln 0.005% 1



CALCITRIOL OINT 3MCG/GM 1CARAC CREA 0.5% 1claravis caps 10mg 1 PAclaravis caps 20mg 1 PAclaravis caps 30mg 1 PAclaravis caps 40mg 1 PAclindamycin phosphate/tretinoin gel 1.2%; 0.025% 1 PAclindamycin/benzoyl peroxide gel 5%; 1% 1clindamycin/benzoyl peroxide gel 5%; 1.2% 1CLODAN KIT KIT 0.05% 1clotrimazole/betamethasone dipropionate crea 0.05%; 1% 1clotrimazole/betamethasone dipropionate lotn 0.05%; 1% 1CONDYLOX GEL 0.5% 1CORTISPORIN CREA 0.5%; 3.5MG/GM; 10000UNIT/GM 1CORTISPORIN OINT 400UNIT/GM; 1%; 0.5%; 5000UNIT/GM 1COSENTYX SENSOREADY PEN INJ 150MG/ML 1 PA MO NDSCOSENTYX INJ 150MG/ML 1 PA MO NDSCURITY GAUZE PADS 2"X2" PADS 1desonate gel 0.05% 1diclofenac sodium gel 1% 1 QL (1000 GM per 30 days)diclofenac sodium soln 1.5% 1 PAdoxepin hydrochloride crea 5% 1doxycycline cpdr 40mg 1ELIDEL CREA 1% 1EPIDUO FORTE GEL 0.3%; 2.5% 1 PAEPIDUO GEL 0.1%; 2.5% 1 PAerythromycin/benzoyl peroxide gel 5%; 3% 1FINACEA FOAM 15% 1FINACEA GEL 15% 1fluocinolone acetonide body oil 0.01% 1fluocinolone acetonide scalp oil 0.01% 1fluocinolone acetonide soln 0.01% 1fluorouracil crea 0.5% 1 NDSfluorouracil crea 5% 1fluorouracil soln 2% 1fluorouracil soln 5% 1imiquimod crea 5% 1methoxsalen caps 10mg 1 NDSmyorisan caps 10mg 1 PAmyorisan caps 20mg 1 PAmyorisan caps 30mg 1 PAmyorisan caps 40mg 1 PANEUAC KIT KIT 5%; 1.2% 1neuac gel 5%; 1.2% 1ORACEA CPDR 40MG 1OXSORALEN LOTN 1% 1 NDSPENNSAID SOLN 2% 1 PA



PICATO GEL 0.015% 1 NDSPICATO GEL 0.05% 1 NDSpodofilox soln 0.5% 1REGRANEX GEL 0.01% 1 PA NDSSANTYL OINT 250UNIT/GM 1selenium sulfide lotn 2.5% 1STELARA INJ 45MG/0.5ML 1 PA MO NDSSTELARA INJ 90MG/ML 1 PA MO NDSSYNALAR CREAM KIT KIT 0.025% 1SYNALAR OINTMENT KIT KIT 0.025% 1TACLONEX SUSP 0.064%; 0.005% 1 QL (400 GM per 30 days) NDStacrolimus oint 0.03% 1tacrolimus oint 0.1% 1TALTZ INJ 80MG/ML 1 PA MO NDSTALTZ INJ 80MG/ML 1 PA MO NDSTAZORAC CREA 0.05% 1 QL (100 GM per 30 days) PATAZORAC CREA 0.1% 1 QL (100 GM per 30 days) PATAZORAC GEL 0.05% 1 QL (100 GM per 30 days) PATAZORAC GEL 0.1% 1 QL (100 GM per 30 days) PAtretinoin microsphere pump gel 0.04% 1 PAtretinoin microsphere pump gel 0.1% 1 PAtretinoin microsphere gel 0.04% 1 PAtretinoin microsphere gel 0.1% 1 PAtretinoin crea 0.025% 1 PAtretinoin crea 0.05% 1 PAtretinoin crea 0.1% 1 PAtretinoin gel 0.01% 1 PAtretinoin gel 0.025% 1 PAtretinoin gel 0.05% 1 PAUVADEX INJ 20MCG/ML 1VELTIN GEL 1.2%; 0.025% 1 PAVEREGEN OINT 15% 1 NDSVOLTAREN GEL 1% 1 QL (1000 GM per 30 days)zenatane caps 10mg 1 PAzenatane caps 20mg 1 PAzenatane caps 30mg 1 PAzenatane caps 40mg 1 PAZYCLARA PUMP CREA 2.5% 1 NDSZYCLARA PUMP CREA 3.75% 1 NDSZYCLARA CREA 3.75% 1 NDS

Enzyme Replacement/ModifiersEnzyme Replacement/Modifiers

ADAGEN INJ 250UNIT/ML 1 PA NDSALDURAZYME INJ 2.9MG/5ML 1 PA NDSBUPHENYL TABS 500MG 1 MO NDSCERDELGA CAPS 84MG 1 PA MO NDSCEREZYME INJ 400UNIT 1 PA NDS



CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT 1 MOCREON CPEP 15000UNIT; 3000UNIT; 9500UNIT 1 MOCREON CPEP 180000UNIT; 36000UNIT; 114000UNIT 1 MOCREON CPEP 30000UNIT; 6000UNIT; 19000UNIT 1 MOCREON CPEP 60000UNIT; 12000UNIT; 38000UNIT 1 MOCYSTADANE POWD 0 1 MO NDSCYSTAGON CAPS 150MG 1 MOCYSTAGON CAPS 50MG 1 MOELAPRASE INJ 6MG/3ML 1 PA NDSFABRAZYME INJ 35MG 1 PA NDSFABRAZYME INJ 5MG 1 PA NDSKANUMA INJ 20MG/10ML 1 PA NDSKUVAN PACK 100MG 1 PA MO NDSKUVAN PACK 500MG 1 PA MO NDSKUVAN TBSO 100MG 1 PA MO NDSLUMIZYME INJ 50MG 1 PA NDSMYOZYME INJ 50MG 1 PA NDSNAGLAZYME INJ 1MG/ML 1 PA NDSORFADIN SUSP 4MG/ML 1 MO NDSRAVICTI LIQD 1.1GM/ML 1 PA MO NDSsodium phenylbutyrate powd 3gm/tsp 1 MO NDSSTRENSIQ INJ 18MG/0.45ML 1 PA MO NDSSTRENSIQ INJ 28MG/0.7ML 1 PA MO NDSSTRENSIQ INJ 40MG/ML 1 PA MO NDSSTRENSIQ INJ 80MG/0.8ML 1 PA MO NDSSUCRAID SOLN 8500UNIT/ML 1 MO NDSVIMIZIM INJ 5MG/5ML 1 PA NDSVPRIV INJ 400UNIT 1 PA NDSXIAFLEX INJ 0.9MG 1 PA NDSZAVESCA CAPS 100MG 1 PA MO NDSZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT 1 MOZENPEP CPEP 136000UNIT; 25000UNIT; 85000UNIT 1 MOZENPEP CPEP 16000UNIT; 3000UNIT; 10000UNIT 1 MOZENPEP CPEP 218000UNIT; 40000UNIT; 136000UNIT 1 MOZENPEP CPEP 27000UNIT; 5000UNIT; 17000UNIT 1 MOZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT 1 MOZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT 1 MO

Gastrointestinal AgentsAntispasmodics, Gastrointestinal

CUVPOSA SOLN 1MG/5ML 1 MOdicyclomine hcl caps 10mg 1dicyclomine hcl inj 10mg/ml 1dicyclomine hcl soln 10mg/5ml 1dicyclomine hcl tabs 20mg 1ENTYVIO INJ 300MG 1 PA NDSglycopyrrolate inj 0.2mg/ml 1glycopyrrolate inj 0.4mg/2ml 1



glycopyrrolate inj 0.4mg/2ml 1glycopyrrolate inj 1mg/5ml 1glycopyrrolate inj 1mg/5ml 1glycopyrrolate inj 4mg/20ml 1glycopyrrolate tabs 1mg 1glycopyrrolate tabs 2mg 1methscopolamine bromide tabs 2.5mg 1methscopolamine bromide tabs 5mg 1propantheline bromide tabs 15mg 1

Gastrointestinal Agents, Other CHENODAL TABS 250MG 1 NDSCHOLBAM CAPS 250MG 1 PA MO NDSCHOLBAM CAPS 50MG 1 PA MO NDScromolyn sodium conc 100mg/5ml 1 MOdiphenatol tabs 0.025mg; 2.5mg 1diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml 1diphenoxylate/atropine tabs 0.025mg; 2.5mg 1GATTEX INJ 5MG 1 PA MO NDSgavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm 1lansoprazole/amoxicillin/clarithromycin misc 0; 0; 0 1loperamide hcl caps 2mg 1metoclopramide hcl inj 5mg/ml 1metoclopramide hcl soln 5mg/5ml 1metoclopramide hcl tabs 10mg 1metoclopramide hcl tabs 5mg 1metoclopramide odt tbdp 10mg 1metoclopramide odt tbdp 5mg 1OCALIVA TABS 10MG 1 PA MO NDSOCALIVA TABS 5MG 1 PA MO NDSPYLERA CAPS 140MG; 125MG; 125MG 1RELISTOR INJ 12MG/0.6ML 1 QL (18 ML per 30 days) PA NDSRELISTOR INJ 12MG/0.6ML 1 QL (18 ML per 30 days) PA NDSRELISTOR INJ 8MG/0.4ML 1 QL (12 ML per 30 days) PA NDSursodiol tabs 250mg 1 MOursodiol tabs 500mg 1 MO

Histamine2 (H2) Receptor Antagonists cimetidine hcl soln 300mg/5ml 1 MOcimetidine tabs 200mg 1cimetidine tabs 300mg 1 MOcimetidine tabs 400mg 1 MOcimetidine tabs 800mg 1 MOfamotidine premixed inj 0.4mg/ml; 0.9% 1famotidine inj 200mg/20ml 1famotidine inj 20mg/2ml 1famotidine inj 40mg/4ml 1famotidine inj 500mg/50ml 1famotidine susr 40mg/5ml 1 MO



famotidine tabs 20mg 1 MOfamotidine tabs 40mg 1 MOnizatidine caps 150mg 1 MOnizatidine caps 300mg 1 MOnizatidine soln 15mg/ml 1 MOranitidine hcl caps 150mg 1 MOranitidine hcl caps 300mg 1 MOranitidine hcl inj 150mg/6ml 1ranitidine hcl inj 50mg/2ml 1ranitidine hcl syrp 15mg/ml 1 MOranitidine hcl tabs 150mg 1 MOranitidine hcl tabs 300mg 1 MO

Irritable Bowel Syndrome Agents alosetron hydrochloride tabs 0.5mg 1 PA MO NDSalosetron hydrochloride tabs 1mg 1 PA MO NDSAMITIZA CAPS 24MCG 1 QL (60 EA per 30 days) MOAMITIZA CAPS 8MCG 1 QL (60 EA per 30 days) MOLINZESS CAPS 145MCG 1 QL (30 EA per 30 days) MOLINZESS CAPS 290MCG 1 QL (30 EA per 30 days) MO

Laxatives constulose soln 10gm/15ml 1 MOenulose soln 10gm/15ml 1 MOgavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm 1gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm 1gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm; 11.2gm 1generlac soln 10gm/15ml 1 MOGOLYTELY SOLR 227.1GM; 2.82GM; 6.36GM; 5.53GM; 21.5GM

1

KRISTALOSE PACK 10GM 1 MOKRISTALOSE PACK 20GM 1 MOlactulose soln 10gm/15ml 1 MOlactulose soln 10gm/15ml 1 MOMOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM; 2.691GM; 7.5GM

1

peg 3350/electrolytes solr 240gm; 2.98gm; 6.72gm; 5.84gm; 22.72gm

1

peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm

1

peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm; 5.72gm; 11.2gm

1

polyethylene glycol 3350 pack 0 1polyethylene glycol 3350 powd 0 1PREPOPIK PACK 12GM; 3.5GM; 10MG 1SUPREP BOWEL PREP SOLN 1.6GM/180ML; 3.13GM/180ML; 17.5GM/180ML

1

trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm 1Protectants

CARAFATE SUSP 1GM/10ML 1 MO



misoprostol tabs 100mcg 1 MOmisoprostol tabs 200mcg 1 MOSUCRALFATE SUSP 1GM/10ML 1 MOsucralfate tabs 1gm 1 MO

Proton Pump Inhibitors DEXILANT CPDR 30MG 1 QL (30 EA per 30 days) MODEXILANT CPDR 60MG 1 QL (30 EA per 30 days) MOesomeprazole magnesium cpdr 20mg 1 QL (30 EA per 30 days) MOesomeprazole magnesium cpdr 40mg 1 QL (30 EA per 30 days) MOesomeprazole sodium inj 20mg 1esomeprazole sodium inj 40mg 1lansoprazole cpdr 15mg 1 QL (30 EA per 30 days) MOlansoprazole cpdr 30mg 1 QL (30 EA per 30 days) MONEXIUM PACK 10MG 1 QL (30 EA per 30 days) MONEXIUM PACK 2.5MG 1 QL (30 EA per 30 days) MONEXIUM PACK 20MG 1 QL (30 EA per 30 days) MONEXIUM PACK 40MG 1 QL (30 EA per 30 days) MONEXIUM PACK 5MG 1 QL (30 EA per 30 days) MOomeprazole/sodium bicarbonate caps 20mg; 1100mg 1 QL (30 EA per 30 days) MOomeprazole/sodium bicarbonate caps 40mg; 1100mg 1 QL (30 EA per 30 days) MOomeprazole cpdr 10mg 1 QL (30 EA per 30 days) MOomeprazole cpdr 20mg 1 QL (30 EA per 30 days) MOomeprazole cpdr 40mg 1 QL (30 EA per 30 days) MOpantoprazole sodium inj 40mg 1pantoprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MOpantoprazole sodium tbec 40mg 1 QL (30 EA per 30 days) MOPRILOSEC PACK 10MG 1 MOPRILOSEC PACK 2.5MG 1 MOrabeprazole sodium tbec 20mg 1 QL (30 EA per 30 days) MO

Genitourinary AgentsAntispasmodics, Urinary

darifenacin er tb24 15mg 1 MOdarifenacin er tb24 7.5mg 1 MOdarifenacin hydrobromide er tb24 15mg 1 MOdarifenacin hydrobromide er tb24 7.5mg 1 MOflavoxate hcl tabs 100mg 1 MOGELNIQUE GEL 10% 1 MOMYRBETRIQ TB24 25MG 1 MOMYRBETRIQ TB24 50MG 1 MOoxybutynin chloride er tb24 10mg 1 MOoxybutynin chloride er tb24 15mg 1 MOoxybutynin chloride er tb24 5mg 1 MOoxybutynin chloride syrp 5mg/5ml 1 MOoxybutynin chloride tabs 5mg 1 MOtolterodine tartrate er cp24 2mg 1 MOtolterodine tartrate er cp24 4mg 1 MOtolterodine tartrate tabs 1mg 1 MO



tolterodine tartrate tabs 2mg 1 MOTOVIAZ TB24 4MG 1 MOTOVIAZ TB24 8MG 1 MOtrospium chloride er cp24 60mg 1 MOtrospium chloride tabs 20mg 1 MOVESICARE TABS 10MG 1 MOVESICARE TABS 5MG 1 MO

Benign Prostatic Hypertrophy Agents alfuzosin hcl er tb24 10mg 1 MOCARDURA XL TB24 4MG 1 MOCARDURA XL TB24 8MG 1 MOdoxazosin mesylate tabs 1mg 1 MOdoxazosin mesylate tabs 2mg 1 MOdoxazosin mesylate tabs 8mg 1 MOdoxazosin tabs 4mg 1 MOdutasteride/tamsulosin hydrochloride caps 0.5mg; 0.4mg 1 MOdutasteride caps 0.5mg 1 MOfinasteride tabs 5mg 1 MORAPAFLO CAPS 4MG 1 MORAPAFLO CAPS 8MG 1 MOtamsulosin hcl caps 0.4mg 1 MOterazosin hcl caps 10mg 1 MOterazosin hcl caps 1mg 1 MOterazosin hcl caps 2mg 1 MOterazosin hcl caps 5mg 1 MO

Genitourinary Agents, Other acetic acid 0.25% soln 0.25% 1bethanechol chloride tabs 10mg 1bethanechol chloride tabs 25mg 1bethanechol chloride tabs 50mg 1bethanechol chloride tabs 5mg 1CIALIS TABS 2.5MG 1 QL (30 EA per 30 days) PA MOCIALIS TABS 5MG 1 QL (30 EA per 30 days) PA MOELMIRON CAPS 100MG 1

Phosphate Binders calcium acetate caps 667mg 1 MOcalcium acetate tabs 667mg 1 MOeliphos tabs 667mg 1 MOFOSRENOL CHEW 1000MG 1 MO NDSFOSRENOL CHEW 500MG 1 MO NDSFOSRENOL CHEW 750MG 1 MO NDSFOSRENOL PACK 1000MG 1 MO NDSFOSRENOL PACK 750MG 1 MO NDSRENAGEL TABS 400MG 1 MORENAGEL TABS 800MG 1 MO NDSRENVELA PACK 0.8GM 1 MO NDSRENVELA PACK 2.4GM 1 MO NDS



RENVELA TABS 800MG 1 MO NDSVELPHORO CHEW 500MG 1 MO NDS

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

A-HYDROCORT INJ 100MG 1alclometasone dipropionate crea 0.05% 1alclometasone dipropionate oint 0.05% 1amcinonide crea 0.1% 1amcinonide lotn 0.1% 1amcinonide oint 0.1% 1apexicon e crea 0.05% 1ARISTOSPAN INTRA-ARTICULAR INJ 20MG/ML 1augmented betamethasone dipropionate crea 0.05% 1augmented betamethasone dipropionate gel 0.05% 1augmented betamethasone dipropionate lotn 0.05% 1augmented betamethasone dipropionate oint 0.05% 1baycadron elix 0.5mg/5ml 1betamethasone dipropionate crea 0.05% 1betamethasone dipropionate lotn 0.05% 1betamethasone dipropionate oint 0.05% 1betamethasone sodium phosphate/betamethasone acetate inj 3mg/ml; 3mg/ml

1

betamethasone valerate crea 0.1% 1betamethasone valerate foam 0.12% 1betamethasone valerate lotn 0.1% 1betamethasone valerate oint 0.1% 1budesonide cpep 3mg 1CAPEX SHAM 0.01% 1clobetasol propionate e crea 0.05% 1clobetasol propionate emollient foam 0.05% 1clobetasol propionate crea 0.05% 1clobetasol propionate foam 0.05% 1clobetasol propionate foam 0.05% 1clobetasol propionate gel 0.05% 1clobetasol propionate liqd 0.05% 1clobetasol propionate lotn 0.05% 1clobetasol propionate oint 0.05% 1clobetasol propionate sham 0.05% 1clobetasol propionate soln 0.05% 1clocortolone pivalate pump crea 0.1% 1clocortolone pivalate crea 0.1% 1clodan sham 0.05% 1colocort enem 100mg/60ml 1CORDRAN TAPE TAPE 4MCG/SQCM 1cormax scalp application soln 0.05% 1CORTIFOAM FOAM 10% 1cortisone acetate tabs 25mg 1deltasone tabs 20mg 1



DEPO-MEDROL INJ 20MG/ML 1desonide crea 0.05% 1desonide lotn 0.05% 1desonide oint 0.05% 1desoximetasone crea 0.05% 1desoximetasone crea 0.25% 1desoximetasone gel 0.05% 1DESOXIMETASONE OINT 0.05% 1desoximetasone oint 0.25% 1dexamethasone intensol conc 1mg/ml 1dexamethasone sodium phosphate inj 100mg/10ml 1dexamethasone sodium phosphate inj 10mg/ml 1dexamethasone sodium phosphate inj 10mg/ml 1dexamethasone sodium phosphate inj 120mg/30ml 1dexamethasone sodium phosphate inj 20mg/5ml 1dexamethasone sodium phosphate inj 20mg/5ml 1dexamethasone sodium phosphate inj 4mg/ml 1dexamethasone elix 0.5mg/5ml 1dexamethasone soln 0.5mg/5ml 1dexamethasone tabs 0.5mg 1dexamethasone tabs 0.75mg 1dexamethasone tabs 1.5mg 1dexamethasone tabs 1mg 1dexamethasone tabs 2mg 1dexamethasone tabs 4mg 1dexamethasone tabs 6mg 1diflorasone diacetate crea 0.05% 1diflorasone diacetate oint 0.05% 1fludrocortisone acetate tabs 0.1mg 1 MOfluocinolone acetonide ear drops oil 0.01% 1fluocinolone acetonide crea 0.01% 1fluocinolone acetonide crea 0.025% 1fluocinolone acetonide oil 0.01% 1fluocinolone acetonide oint 0.025% 1fluocinonide-e crea 0.05% 1fluocinonide crea 0.05% 1fluocinonide crea 0.1% 1fluocinonide gel 0.05% 1fluocinonide oint 0.05% 1fluocinonide soln 0.05% 1flurandrenolide crea 0.05% 1fluticasone propionate crea 0.05% 1fluticasone propionate lotn 0.05% 1fluticasone propionate oint 0.005% 1halobetasol propionate crea 0.05% 1halobetasol propionate oint 0.05% 1hydrocortisone butyrate (lipophilic) crea 0.1% 1



hydrocortisone butyrate crea 0.1% 1hydrocortisone butyrate oint 0.1% 1hydrocortisone butyrate soln 0.1% 1hydrocortisone valerate crea 0.2% 1hydrocortisone valerate oint 0.2% 1hydrocortisone crea 2.5% 1hydrocortisone enem 100mg/60ml 1hydrocortisone lotn 2.5% 1hydrocortisone oint 2.5% 1hydrocortisone tabs 10mg 1hydrocortisone tabs 20mg 1hydrocortisone tabs 5mg 1KENALOG-10 INJ 10MG/ML 1KENALOG-40 INJ 40MG/ML 1lokara lotn 0.05% 1MEDROL TABS 2MG 1methylprednisolone acetate inj 40mg/ml 1methylprednisolone acetate inj 80mg/ml 1methylprednisolone dose pack tbpk 4mg 1methylprednisolone sodiumsuccinate inj 1000mg 1methylprednisolone sodiumsuccinate inj 125mg 1methylprednisolone sodiumsuccinate inj 40mg 1methylprednisolone tabs 16mg 1methylprednisolone tabs 32mg 1methylprednisolone tabs 4mg 1methylprednisolone tabs 8mg 1MILLIPRED DP TBPK 5MG 1MILLIPRED SOLN 10MG/5ML 1MILLIPRED TABS 5MG 1mometasone furoate crea 0.1% 1mometasone furoate oint 0.1% 1mometasone furoate soln 0.1% 1PANDEL CREA 0.1% 1prednicarbate crea 0.1% 1prednicarbate oint 0.1% 1prednisolone sodium phosphate soln 15mg/5ml 1prednisolone sodium phosphate soln 25mg/5ml 1prednisolone sodium phosphate soln 5mg/5ml 1prednisolone soln 15mg/5ml 1prednisolone syrp 15mg/5ml 1prednisone intensol conc 5mg/ml 1prednisone soln 5mg/5ml 1prednisone tabs 10mg 1prednisone tabs 1mg 1prednisone tabs 2.5mg 1prednisone tabs 20mg 1prednisone tabs 50mg 1



prednisone tabs 5mg 1prednisone tbpk 10mg 1prednisone tbpk 10mg 1prednisone tbpk 5mg 1procto-med hc crea 2.5% 1procto-pak crea 1% 1proctosol hc crea 2.5% 1proctozone-hc crea 2.5% 1PSORCON CREA 0.05% 1RAYOS TBEC 1MG 1 NDSRAYOS TBEC 2MG 1 NDSRAYOS TBEC 5MG 1 NDSSOLU-CORTEF INJ 1000MG 1SOLU-CORTEF INJ 100MG 1SOLU-CORTEF INJ 250MG 1SOLU-CORTEF INJ 500MG 1SOLU-MEDROL INJ 2GM 1triamcinolone acetonide aers 0.147mg/gm 1triamcinolone acetonide crea 0.025% 1triamcinolone acetonide crea 0.1% 1triamcinolone acetonide crea 0.5% 1triamcinolone acetonide lotn 0.025% 1triamcinolone acetonide lotn 0.1% 1triamcinolone acetonide oint 0.025% 1triamcinolone acetonide oint 0.1% 1triamcinolone acetonide oint 0.5% 1triderm crea 0.1% 1UCERIS FOAM 2MG/ACT 1UCERIS TB24 9MG 1 NDSVERIPRED 20 SOLN 20MG/5ML 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

CHORIONIC GONADOTROPIN INJ 10000UNIT 1 PAdesmopressin acetate inj 4mcg/ml 1desmopressin acetate soln 0.01% 1 MOdesmopressin acetate soln 0.01% 1 MOdesmopressin acetate soln 0.01% 1 MOdesmopressin acetate tabs 0.1mg 1 MOdesmopressin acetate tabs 0.2mg 1 MOEGRIFTA INJ 1MG 1 QL (60 EA per 30 days) PA MO NDSEGRIFTA INJ 2MG 1 QL (30 EA per 30 days) PA MO NDSGENOTROPIN MINIQUICK INJ 0.2MG 1 PA MOGENOTROPIN MINIQUICK INJ 0.4MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 0.6MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 0.8MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 1.2MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 1.4MG 1 PA MO NDS



GENOTROPIN MINIQUICK INJ 1.6MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 1.8MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 1MG 1 PA MO NDSGENOTROPIN MINIQUICK INJ 2MG 1 PA MO NDSGENOTROPIN INJ 12MG 1 PA MO NDSGENOTROPIN INJ 5MG 1 PA MO NDSH.P. ACTHAR INJ 80UNIT/ML 1 PA NDSHUMATROPE COMBO PACK INJ 5MG 1 PA MO NDSHUMATROPE INJ 12MG 1 PA MO NDSHUMATROPE INJ 24MG 1 PA MO NDSHUMATROPE INJ 6MG 1 PA MO NDSINCRELEX INJ 40MG/4ML 1 PA MO NDSNORDITROPIN FLEXPRO INJ 10MG/1.5ML 1 PA MO NDSNORDITROPIN FLEXPRO INJ 15MG/1.5ML 1 PA MO NDSNORDITROPIN FLEXPRO INJ 30MG/3ML 1 PA MO NDSNORDITROPIN FLEXPRO INJ 5MG/1.5ML 1 PA MO NDSNORDITROPIN NORDIFLEX PEN INJ 30MG/3ML 1 PA MO NDSNOVAREL INJ 10000UNIT 1 PANUTROPIN AQ NUSPIN 10 INJ 10MG/2ML 1 PA MO NDSNUTROPIN AQ NUSPIN 20 INJ 20MG/2ML 1 PA MO NDSNUTROPIN AQ NUSPIN 5 INJ 5MG/2ML 1 PA MO NDSNUTROPIN AQ PEN INJ 10MG/2ML 1 PA MO NDSNUTROPIN AQ PEN INJ 20MG/2ML 1 PA MO NDSOMNITROPE INJ 10MG/1.5ML 1 PA MO NDSOMNITROPE INJ 5MG/1.5ML 1 PA MO NDSPREGNYL W/DILUENT BENZYL ALCOHOL/NACL INJ10000UNIT

1 PA

SAIZEN CLICK.EASY INJ 8.8MG 1 PA MO NDSSAIZEN INJ 5MG 1 PA MO NDSSAIZEN INJ 8.8MG 1 PA MO NDSSEROSTIM INJ 4MG 1 PA MO NDSSEROSTIM INJ 5MG 1 PA MO NDSSEROSTIM INJ 6MG 1 PA MO NDSSTIMATE SOLN 1.5MG/ML 1 MOZORBTIVE INJ 8.8MG 1 PA MO NDS

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM TABS 300MG 1 QL (120 EA per 30 days) PA MO NDS

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic Steroids ANADROL-50 TABS 50MG 1 PAoxandrolone tabs 10mg 1 QL (60 EA per 30 days) PAoxandrolone tabs 2.5mg 1 QL (240 EA per 30 days) PA

Androgens ANDRODERM PT24 2MG/24HR 1 PA MOANDRODERM PT24 4MG/24HR 1 PA MO



ANDROGEL PUMP GEL 1.62% 1 PA MOANDROGEL GEL 20.25MG/1.25GM 1 PA MOANDROGEL GEL 40.5MG/2.5GM 1 PA MOANDROXY TABS 10MG 1 PA MOdanazol caps 100mg 1danazol caps 200mg 1danazol caps 50mg 1methitest tabs 10mg 1 PA MOmethyltestosterone caps 10mg 1 PA MO NDSSTRIANT MISC 30MG 1 PA MOtestosterone cypionate inj 100mg/ml 1 PAtestosterone cypionate inj 200mg/ml 1 PAtestosterone enanthate inj 200mg/ml 1 PA

Estrogens altavera tabs 0.03mg; 0.15mg 1 MOalyacen 1/35 tabs 35mcg; 1mg 1 MOalyacen 7/7/7 tabs 0; 0 1 MOamethia lo tabs 0; 0 1 QL (91 EA per 91 days) MOamethia tabs 0; 0 1 QL (91 EA per 91 days) MOamethyst tabs 20mcg; 90mcg 1 MOapri tabs 0.15mg; 30mcg 1 MOaranelle tabs 0; 0 1 MOashlyna tabs 0; 0 1 QL (91 EA per 91 days) MOaubra tabs 20mcg; 0.1mg 1 MOaviane tabs 20mcg; 0.1mg 1 MOazurette tabs 0; 0 1 MObalziva tabs 35mcg; 0.4mg 1 MObekyree tabs 0; 0 1 MOblisovi 24 fe tabs 20mcg; 75mg; 1mg 1 MOblisovi fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MOblisovi fe 1/20 tabs 20mcg; 75mg; 1mg 1 MObriellyn tabs 35mcg; 0.4mg 1 MOcamrese lo tabs 0; 0 1 QL (91 EA per 91 days) MOcamrese tabs 0; 0 1 QL (91 EA per 91 days) MOcaziant tabs 0; 0 1 MOchateal tabs 0.03mg; 0.15mg 1 MOCLIMARA PRO PTWK 0.045MG/DAY; 0.015MG/DAY 1 PA MOCOMBIPATCH PTTW 0.05MG/DAY; 0.14MG/DAY 1 PA MOCOMBIPATCH PTTW 0.05MG/DAY; 0.25MG/DAY 1 PA MOcryselle-28 tabs 30mcg; 0.3mg 1 MOcyclafem 1/35 tabs 35mcg; 1mg 1 MOcyclafem 7/7/7 tabs 0; 0 1 MOcyred tabs 0.15mg; 30mcg 1 MOdasetta 1/35 tabs 35mcg; 1mg 1 MOdasetta 7/7/7 tabs 0; 0 1 MOdaysee tabs 0; 0 1 QL (91 EA per 91 days) MOdelyla tabs 20mcg; 0.1mg 1 MO



DEPO-ESTRADIOL INJ 5MG/ML 1desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg 1 MOdesogestrel/ethinyl estradiol tabs 0; 0 1 MOdrospirenone/ethinyl estradiol tabs 3mg; 0.02mg 1 MOdrospirenone/ethinyl estradiol tabs 3mg; 0.03mg 1 MOelinest tabs 30mcg; 0.3mg 1 MOemoquette tabs 0.15mg; 30mcg 1 MOenpresse-28 tabs 0; 0 1 MOenskyce tabs 0.15mg; 30mcg 1 MOestarylla tabs 35mcg; 0.25mg 1 MOESTRACE CREA 0.1MG/GM 1 MOestradiol valerate inj 10mg/ml 1estradiol valerate inj 20mg/ml 1estradiol valerate inj 40mg/ml 1estradiol/norethindrone acetate tabs 0.5mg; 0.1mg 1 PA MOestradiol/norethindrone acetate tabs 1mg; 0.5mg 1 PA MOestradiol pttw 0.025mg/24hr 1 PA MOestradiol pttw 0.0375mg/24hr 1 PA MOestradiol pttw 0.05mg/24hr 1 PA MOestradiol pttw 0.075mg/24hr 1 PA MOestradiol pttw 0.1mg/24hr 1 PA MOestradiol ptwk 0.025mg/24hr 1 PA MOestradiol ptwk 0.05mg/24hr 1 PA MOestradiol ptwk 0.06mg/24hr 1 PA MOestradiol ptwk 0.075mg/24hr 1 PA MOestradiol ptwk 0.1mg/24hr 1 PA MOestradiol ptwk 37.5mcg/24hr 1 PA MOestradiol tabs 0.5mg 1 PA MOestradiol tabs 1mg 1 PA MOestradiol tabs 2mg 1 PA MOESTRING RING 2MG 1 QL (1 EA per 90 days) MOestropipate tabs 0.75mg 1 PA MOestropipate tabs 1.5mg 1 PA MOestropipate tabs 3mg 1 PA MOfalmina tabs 20mcg; 0.1mg 1 MOFEMRING RING 0.05MG/24HR 1 QL (1 EA per 90 days) MOFEMRING RING 0.1MG/24HR 1 QL (1 EA per 90 days) MOFYAVOLV TABS 2.5MCG; 0.5MG 1 PA MOFYAVOLV TABS 5MCG; 1MG 1 PA MOgianvi tabs 3mg; 0.02mg 1 MOgildagia tabs 35mcg; 0.4mg 1 MOgildess 1.5/30 tabs 30mcg; 1.5mg 1 MOgildess 1/20 tabs 20mcg; 1mg 1 MOgildess 24 fe tabs 20mcg; 75mg; 1mg 1 MOgildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MOgildess fe 1/20 tabs 20mcg; 75mg; 1mg 1 MOintrovale tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MO



JEVANTIQUE LO TABS 2.5MCG; 0.5MG 1 PA MOjinteli tabs 5mcg; 1mg 1 PA MOjolessa tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MOjuleber tabs 0.15mg; 30mcg 1 MOjunel 1.5/30 tabs 30mcg; 1.5mg 1 MOjunel 1/20 tabs 20mcg; 1mg 1 MOjunel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MOjunel fe 1/20 tabs 20mcg; 75mg; 1mg 1 MOjunel fe 24 tabs 20mcg; 75mg; 1mg 1 MOkaitlib fe chew 25mcg; 75mg; 0.8mg 1 MOkariva tabs 0; 0 1 MOkelnor 1/35 tabs 35mcg; 1mg 1 MOkimidess tabs 0; 0 1 MOkurvelo tabs 0.03mg; 0.15mg 1 MOlarin 1.5/30 tabs 30mcg; 1.5mg 1 MOlarin 1/20 tabs 20mcg; 1mg 1 MOlarin 24 fe tabs 20mcg; 75mg; 1mg 1 MOlarin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MOlarin fe 1/20 tabs 20mcg; 75mg; 1mg 1 MOlayolis fe chew 25mcg; 75mg; 0.8mg 1 MOleena tabs 0; 0 1 MOlessina tabs 20mcg; 0.1mg 1 MOlevonest tabs 0; 0 1 MOlevonorgestrel and ethinyl estradiol tabs 0; 0 1 QL (91 EA per 91 days) MOlevonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 1 MOlevonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 MOlevonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MOlevonorgestrel/ethinyl estradiol tabs 0; 0 1 QL (91 EA per 91 days) MOlevonorgestrel/ethinyl estradiol tabs 0; 0 1 MOlevonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg 1 MOlevora 0.15/30-28 tabs 30mcg; 0.15mg 1 MOLO LOESTRIN FE TABS 10MCG; 75MG; 1MG 1 MOlomedia 24 fe tabs 20mcg; 75mg; 1mg 1 MOlopreeza tabs 0.5mg; 0.1mg 1 PA MOlopreeza tabs 1mg; 0.5mg 1 PA MOloryna tabs 3mg; 0.02mg 1 MOlow-ogestrel tabs 30mcg; 0.3mg 1 MOlutera tabs 20mcg; 0.1mg 1 MOmarlissa tabs 0.03mg; 0.15mg 1 MOMENEST TABS 0.3MG 1 PA MOMENEST TABS 0.625MG 1 PA MOMENEST TABS 1.25MG 1 PA MOMENEST TABS 2.5MG 1 PA MOmicrogestin 1.5/30 tabs 30mcg; 1.5mg 1 MOmicrogestin 1/20 tabs 20mcg; 1mg 1 MOmicrogestin 24 fe tabs 20mcg; 75mg; 1mg 1 MOmicrogestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg 1 MO



microgestin fe tabs 20mcg; 75mg; 1mg 1 MOmimvey lo tabs 0.5mg; 0.1mg 1 PA MOmimvey tabs 1mg; 0.5mg 1 PA MOMINASTRIN 24 FE CHEW 20MCG; 75MG; 1MG 1 MOmono-linyah tabs 35mcg; 0.25mg 1 MOmononessa tabs 35mcg; 0.25mg 1 MOmyzilra tabs 0; 0 1 MOnecon 0.5/35-28 tabs 35mcg; 0.5mg 1 MOnecon 1/35 tabs 35mcg; 1mg 1 MOnecon 1/50-28 tabs 50mcg; 1mg 1 MOnecon 10/11-28 tabs 35mcg; 0 1 MOnecon 7/7/7 tabs 0; 0 1 MOnikki tabs 3mg; 0.02mg 1 MOnorethindrone & ethinyl estradiol ferrous fumarate chew 25mcg; 75mg; 0.8mg

1 MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 20mcg; 75mg; 1mg

1 MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs 20mcg; 75mg; 1mg

1 MO

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg 1 PA MOnorethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg 1 MOnorethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg 1 PA MOnorgestimate/ethinyl estradiol tabs 0; 0 1 MOnorgestimate/ethinyl estradiol tabs 0; 0 1 MOnorgestimate/ethinyl estradiol tabs 35mcg; 0.25mg 1 MOnortrel 0.5/35 (28) tabs 35mcg; 0.5mg 1 MOnortrel 1/35 tabs 35mcg; 1mg 1 MOnortrel 1/35 tabs 35mcg; 1mg 1 MOnortrel 7/7/7 tabs 0; 0 1 MONUVARING RING 0.015MG/24HR; 0.12MG/24HR 1 MOocella tabs 3mg; 0.03mg 1 MOogestrel tabs 50mcg; 0.5mg 1 MOorsythia tabs 20mcg; 0.1mg 1 MOphilith tabs 35mcg; 0.4mg 1 MOpimtrea tabs 0; 0 1 MOpirmella 1/35 tabs 35mcg; 1mg 1 MOpirmella 7/7/7 tabs 0; 0 1 MOportia-28 tabs 0.03mg; 0.15mg 1 MOPREMARIN CREA 0.625MG/GM 1 MOPREMARIN TABS 0.3MG 1 PA MOPREMARIN TABS 0.45MG 1 PA MOPREMARIN TABS 0.625MG 1 PA MOPREMARIN TABS 0.9MG 1 PA MOPREMARIN TABS 1.25MG 1 PA MOPREMPHASE TABS 0.625MG; 5MG 1 PA MOPREMPRO TABS 0.3MG; 1.5MG 1 PA MOPREMPRO TABS 0.45MG; 1.5MG 1 PA MOPREMPRO TABS 0.625MG; 2.5MG 1 PA MO



PREMPRO TABS 0.625MG; 5MG 1 PA MOprevifem tabs 35mcg; 0.25mg 1 MOquasense tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MOreclipsen tabs 0.15mg; 30mcg 1 MOsetlakin tabs 0.03mg; 0.15mg 1 QL (91 EA per 91 days) MOsprintec 28 tabs 35mcg; 0.25mg 1 MOsronyx tabs 20mcg; 0.1mg 1 MOsyeda tabs 3mg; 0.03mg 1 MOtarina fe 1/20 tabs 20mcg; 75mg; 1mg 1 MOtilia fe tabs 0; 75mg; 1mg 1 MOtri-estarylla tabs 0; 0 1 MOtri-legest fe tabs 0; 75mg; 1mg 1 MOtri-linyah tabs 0; 0 1 MOtri-lo-estarylla tabs 0; 0 1 MOtri-lo-marzia tabs 0; 0 1 MOtri-lo-sprintec tabs 0; 0 1 MOtri-previfem tabs 0; 0 1 MOtri-sprintec tabs 0; 0 1 MOtrinessa lo tabs 0; 0 1 MOtrinessa tabs 0; 0 1 MOtrivora-28 tabs 0; 0 1 MOVAGIFEM TABS 10MCG 1 MOvelivet tabs 0; 0 1 MOvestura tabs 3mg; 0.02mg 1 MOvienva tabs 20mcg; 0.1mg 1 MOviorele tabs 0; 0 1 MOvyfemla tabs 35mcg; 0.4mg 1 MOwera tabs 35mcg; 0.5mg 1 MOwymzya fe chew 35mcg; 0; 0.4mg 1 MOxulane ptwk 35mcg/24hr; 150mcg/24hr 1 MOzarah tabs 3mg; 0.03mg 1 MOzenchent fe chew 35mcg; 0; 0.4mg 1 MOzenchent tabs 35mcg; 0.4mg 1 MOzovia 1/35e tabs 35mcg; 1mg 1 MOzovia 1/50e tabs 50mcg; 1mg 1 MO

Progesterone Agonists/Antagonists ELLA TABS 30MG 1

Progestins camila tabs 0.35mg 1 MOCRINONE GEL 4% 1 PACRINONE GEL 8% 1 PAdeblitane tabs 0.35mg 1 MODEPO-PROVERA INJ 400MG/ML 1 QL (10 ML per 28 days)DEPO-SUBQ PROVERA 104 INJ 104MG/0.65ML 1 QL (0.65 ML per 90 days)errin tabs 0.35mg 1 MOheather tabs 0.35mg 1 MOjencycla tabs 0.35mg 1 MO



jolivette tabs 0.35mg 1 MOlevonorgestrel tabs 0.75mg 1levonorgestrel tabs 1.5mg 1lyza tabs 0.35mg 1 MOMAKENA INJ 250MG/ML 1 PA NDSmedroxyprogesterone acetate inj 150mg/ml 1 QL (1 ML per 90 days)medroxyprogesterone acetate tabs 10mg 1 MOmedroxyprogesterone acetate tabs 2.5mg 1 MOmedroxyprogesterone acetate tabs 5mg 1 MOmegestrol acetate susp 40mg/ml 1 PAmegestrol acetate susp 625mg/5ml 1 PA MOmegestrol acetate tabs 20mg 1 PAmegestrol acetate tabs 40mg 1 PAmy way tabs 1.5mg 1nora-be tabs 0.35mg 1 MOnorethindrone acetate tabs 5mg 1 MOnorethindrone tabs 0.35mg 1 MOnorlyroc tabs 0.35mg 1 MOprogesterone caps 100mg 1 MOprogesterone caps 200mg 1 MOprogesterone inj 50mg/ml 1sharobel tabs 0.35mg 1 MO

Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride tabs 60mg 1 MO

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tabs 100mcg 1 MOlevothyroxine sodium tabs 112mcg 1 MOlevothyroxine sodium tabs 125mcg 1 MOlevothyroxine sodium tabs 137mcg 1 MOlevothyroxine sodium tabs 150mcg 1 MOlevothyroxine sodium tabs 175mcg 1 MOlevothyroxine sodium tabs 200mcg 1 MOlevothyroxine sodium tabs 25mcg 1 MOlevothyroxine sodium tabs 300mcg 1 MOlevothyroxine sodium tabs 50mcg 1 MOlevothyroxine sodium tabs 75mcg 1 MOlevothyroxine sodium tabs 88mcg 1 MOlevoxyl tabs 100mcg 1 MOlevoxyl tabs 112mcg 1 MOlevoxyl tabs 125mcg 1 MOlevoxyl tabs 137mcg 1 MOlevoxyl tabs 150mcg 1 MOlevoxyl tabs 175mcg 1 MOlevoxyl tabs 200mcg 1 MOlevoxyl tabs 25mcg 1 MOlevoxyl tabs 50mcg 1 MO



levoxyl tabs 75mcg 1 MOlevoxyl tabs 88mcg 1 MOliothyronine sodium inj 10mcg/ml 1liothyronine sodium tabs 25mcg 1 MOliothyronine sodium tabs 50mcg 1 MOliothyronine sodium tabs 5mcg 1 MOSYNTHROID TABS 100MCG 1 MOSYNTHROID TABS 112MCG 1 MOSYNTHROID TABS 125MCG 1 MOSYNTHROID TABS 137MCG 1 MOSYNTHROID TABS 150MCG 1 MOSYNTHROID TABS 175MCG 1 MOSYNTHROID TABS 200MCG 1 MOSYNTHROID TABS 25MCG 1 MOSYNTHROID TABS 300MCG 1 MOSYNTHROID TABS 50MCG 1 MOSYNTHROID TABS 75MCG 1 MOSYNTHROID TABS 88MCG 1 MOTHYROLAR-1/2 TABS 30MG 1 MOTHYROLAR-1/4 TABS 15MG 1 MOTHYROLAR-1 TABS 60MG 1 MOTHYROLAR-2 TABS 120MG 1 MOTHYROLAR-3 TABS 180MG 1 MOTIROSINT CAPS 100MCG 1 MOTIROSINT CAPS 112MCG 1 MOTIROSINT CAPS 125MCG 1 MOTIROSINT CAPS 137MCG 1 MOTIROSINT CAPS 13MCG 1 MOTIROSINT CAPS 150MCG 1 MOTIROSINT CAPS 25MCG 1 MOTIROSINT CAPS 50MCG 1 MOTIROSINT CAPS 75MCG 1 MOTIROSINT CAPS 88MCG 1 MOunithroid tabs 100mcg 1 MOunithroid tabs 112mcg 1 MOunithroid tabs 125mcg 1 MOunithroid tabs 137mcg 1 MOunithroid tabs 150mcg 1 MOunithroid tabs 175mcg 1 MOunithroid tabs 200mcg 1 MOunithroid tabs 25mcg 1 MOunithroid tabs 300mcg 1 MOunithroid tabs 50mcg 1 MOunithroid tabs 75mcg 1 MOunithroid tabs 88mcg 1 MO

Hormonal Agents, Suppressant (Adrenal)Hormonal Agents, Suppressant (Adrenal)



LYSODREN TABS 500MG 1Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABS 30MG 1 MOSENSIPAR TABS 60MG 1 MO NDSSENSIPAR TABS 90MG 1 MO NDS

Hormonal Agents, Suppressant (Pituitary)Hormonal Agents, Suppressant (Pituitary)

cabergoline tabs 0.5mg 1ELIGARD INJ 22.5MG 1 QL (1 EA per 84 days) PAELIGARD INJ 30MG 1 QL (1 EA per 112 days) PAELIGARD INJ 45MG 1 QL (1 EA per 168 days) PA NDSELIGARD INJ 7.5MG 1 QL (1 EA per 28 days) PAFIRMAGON INJ 120MG 1 QL (4 EA per 365 days) PA NDSFIRMAGON INJ 80MG 1 QL (1 EA per 28 days) PAleuprolide acetate inj 1mg/0.2ml 1 PALUPANETA PACK KIT 11.25MG; 5MG 1 QL (1 EA per 84 days) PA NDSLUPANETA PACK KIT 3.75MG; 5MG 1 QL (1 EA per 28 days) PA NDSLUPRON DEPOT-PED INJ 11.25MG 1 QL (1 EA per 84 days) PA NDSLUPRON DEPOT-PED INJ 11.25MG 1 QL (1 EA per 28 days) PA NDSLUPRON DEPOT-PED INJ 15MG 1 QL (1 EA per 28 days) PA NDSLUPRON DEPOT-PED INJ 30MG 1 QL (1 EA per 84 days) PA NDSLUPRON DEPOT-PED INJ 7.5MG 1 QL (1 EA per 28 days) PA NDSLUPRON DEPOT INJ 11.25MG 1 QL (1 EA per 84 days) PA NDSLUPRON DEPOT INJ 22.5MG 1 QL (1 EA per 84 days) PA NDSLUPRON DEPOT INJ 3.75MG 1 QL (1 EA per 28 days) PA NDSLUPRON DEPOT INJ 30MG 1 QL (1 EA per 112 days) PA NDSLUPRON DEPOT INJ 45MG 1 QL (1 EA per 168 days) PA NDSLUPRON DEPOT INJ 7.5MG 1 QL (1 EA per 28 days) PA NDSoctreotide acetate inj 1000mcg/ml 1 PA MOoctreotide acetate inj 100mcg/ml 1 PA MOoctreotide acetate inj 200mcg/ml 1 PA MOoctreotide acetate inj 500mcg/ml 1 PA MOoctreotide acetate inj 50mcg/ml 1 PA MOSANDOSTATIN LAR DEPOT INJ 10MG 1 PA NDSSANDOSTATIN LAR DEPOT INJ 20MG 1 PA NDSSANDOSTATIN LAR DEPOT INJ 30MG 1 PA NDSSIGNIFOR LAR INJ 20MG 1 QL (1 EA per 28 days) PA MO NDSSIGNIFOR LAR INJ 40MG 1 QL (1 EA per 28 days) PA MO NDSSIGNIFOR LAR INJ 60MG 1 QL (1 EA per 28 days) PA MO NDSSIGNIFOR INJ 0.3MG/ML 1 QL (60 ML per 30 days) PA MO

NDSSIGNIFOR INJ 0.6MG/ML 1 QL (60 ML per 30 days) PA MO

NDSSIGNIFOR INJ 0.9MG/ML 1 QL (60 ML per 30 days) PA MO

NDSSOMATULINE DEPOT INJ 120MG/0.5ML 1 PA NDS



SOMATULINE DEPOT INJ 60MG/0.2ML 1 PA NDSSOMATULINE DEPOT INJ 90MG/0.3ML 1 PA NDSSOMAVERT INJ 10MG 1 PA MO NDSSOMAVERT INJ 15MG 1 PA MO NDSSOMAVERT INJ 20MG 1 PA MO NDSSOMAVERT INJ 25MG 1 PA MO NDSSOMAVERT INJ 30MG 1 PA MO NDSSYNAREL SOLN 2MG/ML 1 NDSTRELSTAR MIXJECT INJ 11.25MG 1 QL (1 EA per 84 days) PA NDSTRELSTAR MIXJECT INJ 22.5MG 1 QL (1 EA per 168 days) PA NDSTRELSTAR MIXJECT INJ 3.75MG 1 QL (1 EA per 28 days) PA NDSTRELSTAR INJ 11.25MG 1 QL (1 EA per 84 days) PA NDSTRELSTAR INJ 3.75MG 1 QL (1 EA per 28 days) PA NDSZOLADEX INJ 10.8MG 1 QL (1 EA per 84 days)ZOLADEX INJ 3.6MG 1 QL (1 EA per 28 days)

Hormonal Agents, Suppressant (Thyroid)Antithyroid Agents

methimazole tabs 10mg 1 MOmethimazole tabs 5mg 1 MOpropylthiouracil tabs 50mg 1 MO

Immunological AgentsAngioedema (HAE) Agents

BERINERT INJ 500UNIT 1 PA NDSCINRYZE INJ 500UNIT 1 PA NDSFIRAZYR INJ 30MG/3ML 1 PA NDSRUCONEST INJ 2100UNIT 1 PA NDS

Immune Suppressants ASTAGRAF XL CP24 0.5MG 1 B/D MOASTAGRAF XL CP24 1MG 1 B/D MOASTAGRAF XL CP24 5MG 1 B/D MO NDSAZASAN TABS 100MG 1 B/D MOAZASAN TABS 75MG 1 B/D MOazathioprine inj 100mg 1 B/Dazathioprine tabs 50mg 1 B/D MOBENLYSTA INJ 120MG 1 PA NDSBENLYSTA INJ 400MG 1 PA NDSCELLCEPT INTRAVENOUS INJ 500MG 1 B/DCIMZIA STARTER KIT INJ 200MG/ML 1 PA MO NDSCIMZIA INJ 200MG/ML 1 PA MO NDSCIMZIA INJ 200MG 1 PA NDScyclosporine modified caps 100mg 1 B/D MOcyclosporine modified caps 25mg 1 B/D MOcyclosporine modified caps 50mg 1 B/D MOcyclosporine modified soln 100mg/ml 1 B/D MOcyclosporine caps 100mg 1 B/D MOcyclosporine caps 25mg 1 B/D MOcyclosporine inj 50mg/ml 1 B/D



ENBREL SURECLICK INJ 50MG/ML 1 PA MO NDSENBREL INJ 25MG/0.5ML 1 PA MO NDSENBREL INJ 25MG 1 PA MO NDSENBREL INJ 50MG/ML 1 PA MO NDSENVARSUS XR TB24 0.75MG 1 B/D MOENVARSUS XR TB24 1MG 1 B/D MOENVARSUS XR TB24 4MG 1 B/D MOgengraf caps 100mg 1 B/D MOgengraf caps 25mg 1 B/D MOgengraf caps 50mg 1 B/D MOgengraf soln 100mg/ml 1 B/D MOhecoria caps 0.5mg 1 B/D MOhecoria caps 1mg 1 B/D MOhecoria caps 5mg 1 B/D MOHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ40MG/0.8ML

1 PA MO NDS

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ40MG/0.8ML

1 PA MO NDS

HUMIRA PEN-CROHNS DISEASESTARTER INJ 40MG/0.8ML 1 PA MO NDSHUMIRA PEN-PSORIASIS STARTER INJ 40MG/0.8ML 1 PA MO NDSHUMIRA PEN INJ 40MG/0.8ML 1 PA MO NDSHUMIRA INJ 10MG/0.2ML 1 PA MO NDSHUMIRA INJ 20MG/0.4ML 1 PA MO NDSHUMIRA INJ 40MG/0.8ML 1 PA MO NDSKINERET INJ 100MG/0.67ML 1 PA MO NDSmethotrexate sodium inj 100mg/4ml 1methotrexate sodium inj 1gm/40ml 1methotrexate sodium inj 1gm 1methotrexate sodium inj 200mg/8ml 1methotrexate sodium inj 250mg/10ml 1methotrexate sodium inj 250mg/10ml 1methotrexate sodium inj 50mg/2ml 1methotrexate sodium inj 50mg/2ml 1methotrexate tabs 2.5mg 1mycophenolate mofetil caps 250mg 1 B/D MOmycophenolate mofetil susr 200mg/ml 1 B/D MO NDSmycophenolate mofetil tabs 500mg 1 B/D MOmycophenolic acid dr tbec 180mg 1 B/D MOmycophenolic acid dr tbec 360mg 1 B/D MONULOJIX INJ 250MG 1 PA NDSORENCIA INJ 125MG/ML 1 PA MO NDSORENCIA INJ 250MG 1 PA MO NDSPROGRAF INJ 5MG/ML 1 B/DRAPAMUNE SOLN 1MG/ML 1 B/D MO NDSREMICADE INJ 100MG 1 PA NDSRHEUMATREX TABS 2.5MG 1 B/D MORHEUMATREX TABS 2.5MG 1 B/D MORHEUMATREX TABS 2.5MG 1 B/D MO



RHEUMATREX TABS 2.5MG 1 B/D MORHEUMATREX TABS 2.5MG 1 B/D MOSANDIMMUNE SOLN 100MG/ML 1 B/D MOSIMPONI ARIA INJ 50MG/4ML 1 PA MO NDSSIMPONI INJ 100MG/ML 1 PA MO NDSSIMPONI INJ 100MG/ML 1 PA MO NDSSIMPONI INJ 50MG/0.5ML 1 PA MO NDSSIMPONI INJ 50MG/0.5ML 1 PA MO NDSsirolimus tabs 0.5mg 1 B/D MOsirolimus tabs 1mg 1 B/D MOSIROLIMUS TABS 2MG 1 B/D MO NDStacrolimus caps 0.5mg 1 B/D MOtacrolimus caps 1mg 1 B/D MOtacrolimus caps 5mg 1 B/D MOTORISEL INJ 25MG/ML 1 NDSTREXALL TABS 10MG 1TREXALL TABS 15MG 1TREXALL TABS 5MG 1TREXALL TABS 7.5MG 1ZORTRESS TABS 0.25MG 1 PA MOZORTRESS TABS 0.5MG 1 PA MO NDSZORTRESS TABS 0.75MG 1 PA MO NDS

Immunizing Agents, Passive ATGAM INJ 50MG/ML 1 B/D NDSBIVIGAM INJ 10GM/100ML 1 PA NDSBIVIGAM INJ 5GM/50ML 1 PA NDSCARIMUNE NANOFILTERED INJ 12GM 1 PA NDSCARIMUNE NANOFILTERED INJ 6GM 1 PA NDSFLEBOGAMMA DIF INJ 0.5GM/10ML 1 PA NDSFLEBOGAMMA DIF INJ 10% 1 PA NDSFLEBOGAMMA DIF INJ 10% 1 PA NDSFLEBOGAMMA DIF INJ 10% 1 PA NDSFLEBOGAMMA DIF INJ 10GM/200ML 1 PA NDSFLEBOGAMMA DIF INJ 2.5GM/50ML 1 PA NDSFLEBOGAMMA DIF INJ 20GM/400ML 1 PA NDSFLEBOGAMMA DIF INJ 5GM/100ML 1 PA NDSGAMASTAN S/D INJ 0 1 PAGAMMAGARD LIQUID INJ 10GM/100ML 1 PA NDSGAMMAGARD LIQUID INJ 1GM/10ML 1 PA NDSGAMMAGARD LIQUID INJ 2.5GM/25ML 1 PA NDSGAMMAGARD LIQUID INJ 20GM/200ML 1 PA NDSGAMMAGARD LIQUID INJ 30GM/300ML 1 PA NDSGAMMAGARD LIQUID INJ 5GM/50ML 1 PA NDSGAMMAGARD S/D IGA LESS THAN 1MCG/ML INJ 10GM 1 PA NDSGAMMAGARD S/D IGA LESS THAN 1MCG/ML INJ 5GM 1 PA NDSGAMMAKED INJ 10GM/100ML 1 PA NDSGAMMAKED INJ 1GM/10ML 1 PA NDS



GAMMAKED INJ 2.5GM/25ML 1 PA NDSGAMMAKED INJ 20GM/200ML 1 PA NDSGAMMAKED INJ 5GM/50ML 1 PA NDSGAMMAPLEX INJ 10GM/200ML 1 PA NDSGAMMAPLEX INJ 2.5GM/50ML 1 PA NDSGAMMAPLEX INJ 20GM/400ML 1 PA NDSGAMMAPLEX INJ 5GM/100ML 1 PA NDSGAMUNEX-C INJ 10GM/100ML 1 PA NDSGAMUNEX-C INJ 1GM/10ML 1 PA NDSGAMUNEX-C INJ 2.5GM/25ML 1 PA NDSGAMUNEX-C INJ 20GM/200ML 1 PA NDSGAMUNEX-C INJ 40GM/400ML 1 PA NDSGAMUNEX-C INJ 5GM/50ML 1 PA NDSHEPAGAM B INJ 0 1 B/D NDSHIZENTRA INJ 10GM/50ML 1 PA NDSHIZENTRA INJ 1GM/5ML 1 PA NDSHIZENTRA INJ 2GM/10ML 1 PA NDSHIZENTRA INJ 4GM/20ML 1 PA NDSHYPERHEP B S/D INJ 0 1 B/D NDSHYPERRAB S/D INJ 150UNIT/ML 1 B/DHYPERRAB S/D INJ 150UNIT/ML 1 B/DHYPERRHO S/D MINI-DOSE INJ 250UNIT 1HYPERRHO S/D INJ 1500UNIT 1IMOGAM RABIES-HT INJ 150UNIT/ML 1 B/DMICRHOGAM ULTRA-FILTERED PLUS INJ 250UNIT 1NABI-HB INJ 0 1 B/D NDSOCTAGAM INJ 10GM/100ML 1 PA NDSOCTAGAM INJ 10GM/200ML 1 PA NDSOCTAGAM INJ 1GM/20ML 1 PA NDSOCTAGAM INJ 2.5GM/50ML 1 PA NDSOCTAGAM INJ 20GM/200ML 1 PA NDSOCTAGAM INJ 25GM/500ML 1 PA NDSOCTAGAM INJ 2GM/20ML 1 PA NDSOCTAGAM INJ 5GM/100ML 1 PA NDSOCTAGAM INJ 5GM/50ML 1 PA NDSPRIVIGEN INJ 10GM/100ML 1 PA NDSPRIVIGEN INJ 20GM/200ML 1 PA NDSPRIVIGEN INJ 40GM/400ML 1 PA NDSPRIVIGEN INJ 5GM/50ML 1 PA NDSRHOGAM ULTRA-FILTERED PLUS INJ 1500UNIT 1RHOPHYLAC INJ 1500UNIT/2ML 1THYMOGLOBULIN INJ 25MG 1 B/D NDS

Immunomodulators ACTEMRA INJ 162MG/0.9ML 1 QL (3.6 ML per 28 days) PA MO

NDSACTEMRA INJ 200MG/10ML 1 PA NDSACTEMRA INJ 400MG/20ML 1 PA NDS

KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0; 10LFU/0.5ML 1Page 99 of 143 You can find information on what the symbols and abbreviations in this table mean by going to page .


ACTEMRA INJ 80MG/4ML 1 PA NDSACTIMMUNE INJ 2000000UNIT/0.5ML 1 MO NDSARCALYST INJ 220MG 1 PA MO NDSILARIS INJ 180MG 1 PA NDSleflunomide tabs 10mg 1 MOleflunomide tabs 20mg 1 MOLEMTRADA INJ 12MG/1.2ML 1 PA NDSOTEZLA TABS 30MG 1 PA MO NDSOTEZLA TBPK 0 1 PA NDSRIDAURA CAPS 3MG 1 MO NDSSIMULECT INJ 10MG 1 B/D NDSSIMULECT INJ 20MG 1 B/D NDSSYNAGIS INJ 100MG/ML 1 PA NDSSYNAGIS INJ 50MG/0.5ML 1 PA NDSXELJANZ XR TB24 11MG 1 PA MO NDSXELJANZ TABS 5MG 1 PA MO NDS

Vaccines ACTHIB INJ 0 1ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML 1BCG VACCINE INJ 0 1BEXSERO INJ 0 1BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML 1BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML; 5LF/0.5ML 1CERVARIX INJ 0 1COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML 1DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 1diphtheria/tetanus toxoids adsorbed pediatric inj 25lfu/0.5ml; 5lfu/0.5ml

1

ENGERIX-B INJ 10MCG/0.5ML 1 B/DENGERIX-B INJ 10MCG/0.5ML 1 B/DENGERIX-B INJ 20MCG/ML 1 B/DGARDASIL 9 INJ 0 1GARDASIL 9 INJ 0 1GARDASIL INJ 0 1GARDASIL INJ 0 1HAVRIX INJ 1440ELU/ML 1HAVRIX INJ 720ELU/0.5ML 1HIBERIX INJ 10MCG 1HYQVIA INJ 10GM/100ML; 800UNIT/5ML 1 PA NDSHYQVIA INJ 2.5GM/25ML; 200UNT/1.25ML 1 PA NDSHYQVIA INJ 20GM/200ML; 1600UNIT/10ML 1 PA NDSHYQVIA INJ 30GM/300ML; 2400UNIT/15ML 1 PA NDSHYQVIA INJ 5GM/50ML; 400UNIT/2.5ML 1 PA NDSIMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML 1 B/DINFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10LFU/0.5ML 1IPOL INACTIVATED IPV INJ 0 1IXIARO INJ 0 1



KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0; 10LFU/0.5ML 1M-M-R II INJ 0; 0; 0 1MENACTRA INJ 0 1MENHIBRIX INJ 2.5MCG; 5MCG; 5MCG 1MENOMUNE-A/C/Y/W-135 INJ 0 1MENVEO INJ 0 1PEDIARIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10MCG/0.5ML; 0;10LFU/0.5ML

1

PEDVAX HIB INJ 7.5MCG/0.5ML 1PENTACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0; 0; 5LFU/0.5ML

1

PROQUAD INJ 0; 0; 0; 0 1QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0; 5LFU/0.5ML

1

RABAVERT INJ 0 1 B/DRECOMBIVAX HB INJ 10MCG/ML 1 B/DRECOMBIVAX HB INJ 10MCG/ML 1 B/DRECOMBIVAX HB INJ 40MCG/ML 1 B/DRECOMBIVAX HB INJ 5MCG/0.5ML 1 B/DROTARIX SUSR 0 1ROTATEQ SOLN 0 1TENIVAC INJ 2LFU; 5LFU 1TETANUS/DIPHTHERIA TOXOIDS-ADSORBED INJ 2LF/0.5ML; 2LF/0.5ML

1

TRUMENBA INJ 0 1TWINRIX INJ 720ELU/ML; 20MCG/ML 1 B/DTYPHIM VI INJ 25MCG/0.5ML 1TYPHIM VI INJ 25MCG/0.5ML 1VAQTA INJ 25UNIT/0.5ML 1VAQTA INJ 50UNIT/ML 1VARIVAX INJ 1350PFU/0.5ML 1VARIZIG INJ 125UNIT/1.2ML 1 PA NDSYF-VAX INJ 0 1ZOSTAVAX INJ 19400UNT/0.65ML 1

Inflammatory Bowel Disease AgentsAminosalicylates

APRISO CP24 0.375GM 1 MObalsalazide disodium caps 750mg 1CANASA SUPP 1000MG 1 NDSDIPENTUM CAPS 250MG 1 MO NDSLIALDA TBEC 1.2GM 1mesalamine enem 4gm 1mesalamine kit 4gm 1PENTASA CPCR 250MG 1 MOPENTASA CPCR 500MG 1 MO

Sulfonamides sulfasalazine tabs 500mg 1 MOsulfasalazine tbec 500mg 1 MO



sulfazine tabs 500mg 1 MOMetabolic Bone Disease Agents

Metabolic Bone Disease Agents alendronate sodium soln 70mg/75ml 1 MOalendronate sodium tabs 10mg 1 MOalendronate sodium tabs 35mg 1 MOalendronate sodium tabs 40mg 1alendronate sodium tabs 5mg 1 MOalendronate sodium tabs 70mg 1 QL (4 EA per 28 days) MOBINOSTO TBEF 70MG 1 QL (4 EA per 28 days) MOcalcitonin-salmon soln 200unit/act 1 QL (3.7 ML per 30 days) MOcalcitriol caps 0.25mcg 1 MOcalcitriol caps 0.5mcg 1 MOcalcitriol inj 1mcg/ml 1calcitriol soln 1mcg/ml 1 MOdoxercalciferol caps 0.5mcg 1 MOdoxercalciferol caps 1mcg 1 MOdoxercalciferol caps 2.5mcg 1 MOdoxercalciferol inj 4mcg/2ml 1etidronate disodium tabs 200mg 1etidronate disodium tabs 400mg 1FORTEO INJ 600MCG/2.4ML 1 PA MO NDSFORTICAL SOLN 200UNIT/ACT 1 QL (3.7 ML per 30 days) MOFOSAMAX PLUS D TABS 70MG; 2800UNIT 1 QL (4 EA per 28 days) ST MOFOSAMAX PLUS D TABS 70MG; 5600UNIT 1 QL (4 EA per 28 days) ST MOibandronate sodium inj 3mg/3ml 1ibandronate sodium tabs 150mg 1 QL (1 EA per 28 days) MOMIACALCIN INJ 200UNIT/ML 1 NDSpamidronate disodium inj 30mg/10ml 1pamidronate disodium inj 30mg 1pamidronate disodium inj 6mg/ml 1pamidronate disodium inj 90mg/10ml 1pamidronate disodium inj 90mg 1paricalcitol caps 1mcg 1 MOparicalcitol caps 2mcg 1 MOparicalcitol caps 4mcg 1 MOPARICALCITOL INJ 2MCG/ML 1PARICALCITOL INJ 5MCG/ML 1PROLIA INJ 60MG/ML 1 QL (2 ML per 365 days) PArisedronate sodium dr tbec 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 150mg 1 QL (1 EA per 28 days) MOrisedronate sodium tabs 30mg 1risedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 35mg 1 QL (4 EA per 28 days) MOrisedronate sodium tabs 5mg 1 MOXGEVA INJ 120MG/1.7ML 1 PA NDS



zoledronic acid inj 4mg/5ml 1zoledronic acid inj 4mg 1 NDSzoledronic acid inj 5mg/100ml 1

Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic Agents

AMMONUL INJ 10%; 10% 1 NDSBD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" MISC 1 QL (200 EA per 30 days)BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" MISC 1 QL (200 EA per 30 days)BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" MISC 1 QL (200 EA per 30 days)BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" MISC 1 QL (200 EA per 30 days)BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM MISC 1 QL (200 EA per 30 days)BOTOX INJ 100UNIT 1 PABOTOX INJ 200UNIT 1 PAdeferoxamine mesylate inj 2gm 1 B/Ddeferoxamine mesylate inj 500mg 1 B/DINTRALIPID INJ 20GM/100ML 1 B/DKALBITOR INJ 10MG/ML 1 PA NDSKEVEYIS TABS 50MG 1 QL (120 EA per 30 days) PA NDSlactated ringers irrigation soln 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l

1

levocarnitine inj 200mg/ml 1levocarnitine soln 1gm/10ml 1 MOlevocarnitine tabs 330mg 1 MOmethergine tabs 0.2mg 1 NDSmethylergonovine maleate tabs 0.2mg 1 NDSMYALEPT INJ 11.3MG 1 PA MO NDSNATPARA INJ 100MCG 1 QL (2 EA per 28 days) PA MO NDSNATPARA INJ 25MCG 1 QL (2 EA per 28 days) PA MO NDSNATPARA INJ 50MCG 1 QL (2 EA per 28 days) PA MO NDSNATPARA INJ 75MCG 1 QL (2 EA per 28 days) PA MO NDSNUTRILIPID INJ 20GM/100ML 1 B/DORFADIN CAPS 10MG 1 MO NDSORFADIN CAPS 2MG 1 MO NDSORFADIN CAPS 5MG 1 MO NDSPHYSIOLYTE SOLN 27MEQ/1000ML; 98MEQ/1000ML; 23MEQ/1000ML; 3MEQ/1000ML; 5MEQ/1000ML; 140MEQ/1000ML

1

PHYSIOSOL IRRIGATION SOLN 30MG/100ML; 37MG/100ML; 222MG/100ML; 526MG/100ML; 502MG/100ML

1

ringers irrigation soln 4.5meq/l; 156meq/l; 4meq/l; 147meq/l 1sodium phenylacetate/sodium benzoate inj 10%; 10% 1 NDSSOLIRIS INJ 10MG/ML 1 PA NDSsterile water irrigation soln 0 1tis-u-sol soln 4.5meq/l; 156meq/l; 4meq/l; 147meq/l 1V-GO 20 KIT 1V-GO 30 KIT 1V-GO 40 KIT 1VISTOGARD PACK 10GM 1 NDS



VISTOGARD PACK 10GM 1 NDSXEOMIN INJ 100UNIT 1 PAXEOMIN INJ 200UNIT 1 PAXEOMIN INJ 50UNIT 1 PAXURIDEN PACK 2GM 1 QL (120 EA per 30 days) PA MO

NDSXURIDEN PACK 2GM 1 QL (120 EA per 30 days) PA MO

NDSOphthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost soln 0.03% 1 QL (5 ML per 30 days) MOCOMBIGAN SOLN 0.2%; 0.5% 1 MOlatanoprost soln 0.005% 1 QL (2.5 ML per 25 days) MOLUMIGAN SOLN 0.01% 1 QL (2.5 ML per 25 days) MOTRAVATAN Z SOLN 0.004% 1 QL (2.5 ML per 25 days) MOtravoprost soln 0.004% 1 QL (2.5 ML per 25 days) MO

Ophthalmic Agents, Other ak-poly-bac oint 500unit/gm; 10000unit/gm 1atropine sulfate soln 1% 1 MObacitracin/neomycin/polymyxin oint 400unit/gm; 5mg/gm; 10000unit/gm

1

bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm 1cyclopentolate hcl soln 1% 1 MOcyclopentolate hcl soln 2% 1 MOcyclopentolate hcl soln 2% 1 MOcyclopentolate hydrochloride soln 0.5% 1 MOCYSTARAN SOLN 0.44% 1 QL (60 ML per 28 days) PA MO

NDSEYLEA INJ 2MG/0.05ML 1 PA NDSLACRISERT INST 5MG 1naphazoline hcl soln 0.1% 1neo-polycin oint 400unit/gm; 3.5mg/gm; 10000unit/gm 1neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/gm; 10000unit/gm

1

neomycin/polymyxin/gramicidin soln 0.025mg/ml; 1.75mg/ml; 10000unit/ml

1

polycin oint 500unit/gm; 10000unit/gm 1polymyxin b sulfate/trimethoprim sulfate soln 10000unit/ml; 0.1% 1PROCYSBI CPDR 25MG 1 PA MO NDSPROCYSBI CPDR 75MG 1 PA MO NDSproparacaine hcl soln 0.5% 1RESTASIS EMUL 0.05% 1 MOtrimethoprim/polymyxin b soln 10000unit/ml; 0.1% 1triple antibiotic oint 400unit/gm; 5mg/gm; 10000unit/gm 1

Ophthalmic Anti-allergy Agents ALOCRIL SOLN 2% 1azelastine hcl soln 0.05% 1BEPREVE SOLN 1.5% 1



cromolyn sodium soln 4% 1EMADINE SOLN 0.05% 1epinastine hcl soln 0.05% 1LASTACAFT SOLN 0.25% 1olopatadine hcl soln 0.1% 1PATADAY SOLN 0.2% 1PATANOL SOLN 0.1% 1PAZEO SOLN 0.7% 1

Ophthalmic Anti-inflammatories ALOMIDE SOLN 0.1% 1ALREX SUSP 0.2% 1BLEPHAMIDE S.O.P. OINT 0.2%; 10% 1BLEPHAMIDE SUSP 0.2%; 10% 1bromfenac soln 0.09% 1bromfenac soln 0.09% 1dexamethasone sodium phosphate soln 0.1% 1diclofenac sodium soln 0.1% 1DUREZOL EMUL 0.05% 1FLAREX SUSP 0.1% 1fluorometholone susp 0.1% 1flurbiprofen sodium soln 0.03% 1FML FORTE SUSP 0.25% 1FML OINT 0.1% 1ILEVRO SUSP 0.3% 1 QL (6 ML per 30 days)ketorolac tromethamine soln 0.4% 1ketorolac tromethamine soln 0.5% 1LOTEMAX GEL 0.5% 1 QL (20 GM per 365 days)LOTEMAX OINT 0.5% 1 QL (14 GM per 365 days)LOTEMAX SUSP 0.5% 1MAXIDEX SUSP 0.1% 1neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/gm; 10000unit/gm

1

neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/ml; 10000unit/ml

1

NEVANAC SUSP 0.1% 1 QL (6 ML per 30 days)PRED MILD SUSP 0.12% 1PRED-G S.O.P. OINT 0.3%; 0.6% 1PRED-G SUSP 0.3%; 1% 1prednisolone acetate susp 1% 1prednisolone sodium phosphate soln 1% 1PROLENSA SOLN 0.07% 1 QL (12 ML per 365 days)sulfacetamide sodium/prednisolone sodium phosphate soln 0.23%; 10%

1

TOBRADEX ST SUSP 0.05%; 0.3% 1TOBRADEX OINT 0.1%; 0.3% 1tobramycin/dexamethasone susp 0.1%; 0.3% 1VEXOL SUSP 1% 1ZYLET SUSP 0.5%; 0.3% 1



Ophthalmic Antiglaucoma Agents acetazolamide er cp12 500mg 1 MOALPHAGAN P SOLN 0.1% 1 MOapraclonidine soln 0.5% 1AZOPT SUSP 1% 1 MObetaxolol hcl soln 0.5% 1 MOBETIMOL SOLN 0.25% 1 MOBETIMOL SOLN 0.5% 1 MOBETOPTIC-S SUSP 0.25% 1 MObrimonidine tartrate soln 0.15% 1 MObrimonidine tartrate soln 0.2% 1 MOcarteolol hcl soln 1% 1 MOCOSOPT PF SOLN 22.3MG/ML; 6.8MG/ML 1 MOdorzolamide hcl/timolol maleate soln 22.3mg/ml; 6.8mg/ml 1 MOdorzolamide hcl soln 2% 1 MOIOPIDINE SOLN 1% 1levobunolol hcl soln 0.5% 1 MOmethazolamide tabs 25mg 1 MOmethazolamide tabs 50mg 1 MOmetipranolol soln 0.3% 1 MOMIRVASO GEL 0.33% 1 PAPHOSPHOLINE IODIDE SOLR 0.125% 1 MOpilocarpine hcl soln 1% 1 MOpilocarpine hcl soln 2% 1 MOpilocarpine hcl soln 4% 1 MOSIMBRINZA SUSP 0.2%; 1% 1 MOtimolol maleate ophthalmic gel forming solg 0.25% 1 MOtimolol maleate ophthalmic gel forming solg 0.5% 1 MOtimolol maleate soln 0.25% 1 MOtimolol maleate soln 0.5% 1 MO

Otic AgentsOtic Agents

acetic acid/aluminum acetate soln 2%; 0 1acetic acid soln 2% 1antibiotic ear soln 1%; 3.5mg/ml; 10000unit/ml 1CIPRO HC SUSP 0.2%; 1% 1CIPRODEX SUSP 0.3%; 0.1% 1COLY-MYCIN S SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML

1

CORTISPORIN-TC SUSP 3MG/ML; 10MG/ML; 3.3MG/ML; 0.5MG/ML

1

hydrocortisone/acetic acid soln 2%; 1% 1neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/ml 1neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/ml; 10000unit/ml

1

Respiratory Tract/Pulmonary AgentsAnti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) MO



ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) MOADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/DOSE 1 QL (60 EA per 30 days) MOADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT 1 QL (24 GM per 30 days) MOADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT 1 QL (24 GM per 30 days) MOADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT 1 QL (24 GM per 30 days) MOAEROSPAN AERS 80MCG/ACT 1 QL (17.8 GM per 30 days) MOASMANEX HFA AERO 100MCG/ACT 1 QL (26 GM per 30 days) MOASMANEX HFA AERO 200MCG/ACT 1 QL (26 GM per 30 days) MOASMANEX TWISTHALER 120 METERED DOSES AEPB 220MCG/INH


ASMANEX TWISTHALER 14 METERED DOSES AEPB220MCG/INH




ASMANEX TWISTHALER 30 METERED DOSES AEPB 220MCG/INH




ASMANEX TWISTHALER 7 METERED DOSES AEPB 110MCG/INH


BECONASE AQ SUSP 42MCG/SPRAY 1 QL (50 GM per 25 days)BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) MOBREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) MObudesonide susp 0.25mg/2ml 1 QL (120 ML per 30 days) B/D MObudesonide susp 0.5mg/2ml 1 QL (120 ML per 30 days) B/D MObudesonide susp 1mg/2ml 1 QL (120 ML per 30 days) B/D MObudesonide susp 32mcg/act 1 QL (17.2 GM per 30 days)DULERA AERO 5MCG/ACT; 100MCG/ACT 1 QL (17.6 GM per 30 days) MODULERA AERO 5MCG/ACT; 200MCG/ACT 1 QL (17.6 GM per 30 days) MOFLOVENT DISKUS AEPB 100MCG/BLIST 1 QL (60 EA per 30 days) MOFLOVENT DISKUS AEPB 250MCG/BLIST 1 QL (240 EA per 30 days) MOFLOVENT DISKUS AEPB 50MCG/BLIST 1 QL (60 EA per 30 days) MOFLOVENT HFA AERO 110MCG/ACT 1 QL (24 GM per 30 days) MOFLOVENT HFA AERO 220MCG/ACT 1 QL (24 GM per 30 days) MOFLOVENT HFA AERO 44MCG/ACT 1 QL (21.2 GM per 30 days) MOflunisolide soln 0.025% 1 QL (50 ML per 30 days)fluticasone propionate susp 50mcg/act 1mometasone furoate susp 50mcg/act 1 QL (34 GM per 30 days)NASONEX SUSP 50MCG/ACT 1 QL (34 GM per 30 days) STQVAR AERS 40MCG/ACT 1 QL (17.4 GM per 30 days) MOQVAR AERS 80MCG/ACT 1 QL (26.1 GM per 30 days) MOSYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 1 QL (12 GM per 30 days) MOSYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 1 QL (13.8 GM per 30 days) MOtriamcinolone acetonide aero 55mcg/act 1

Antihistamines azelastine hcl soln 0.1% 1 QL (60 ML per 30 days)azelastine hcl soln 0.15% 1 QL (60 ML per 30 days)cetirizine hcl syrp 1mg/ml 1



cyproheptadine hcl syrp 2mg/5ml 1 PAcyproheptadine hcl tabs 4mg 1 PAdesloratadine tabs 5mg 1dexchlorpheniramine maleate syrp 2mg/5ml 1 PAdiphenhydramine hcl inj 50mg/ml 1DYMISTA SUSP 137MCG/ACT; 50MCG/ACT 1 QL (23 GM per 30 days)hydroxyzine hcl inj 25mg/ml 1 PAhydroxyzine hcl inj 50mg/ml 1 PAhydroxyzine hcl syrp 10mg/5ml 1 PAhydroxyzine hcl tabs 10mg 1 PAhydroxyzine hcl tabs 25mg 1 PAhydroxyzine hcl tabs 50mg 1 PAhydroxyzine pamoate caps 100mg 1 PAhydroxyzine pamoate caps 25mg 1 PAhydroxyzine pamoate caps 50mg 1 PAlevocetirizine dihydrochloride soln 2.5mg/5ml 1levocetirizine dihydrochloride tabs 5mg 1olopatadine hcl soln 0.6% 1 QL (30.5 GM per 30 days)SEMPREX-D CAPS 8MG; 60MG 1

Antileukotrienes montelukast sodium chew 4mg 1 MOmontelukast sodium chew 5mg 1 MOmontelukast sodium pack 4mg 1 MOmontelukast sodium tabs 10mg 1 MOzafirlukast tabs 10mg 1 MOzafirlukast tabs 20mg 1 MOZYFLO CR TB12 600MG 1 ST MO NDSZYFLO TABS 600MG 1 ST MO NDS

Bronchodilators, Anticholinergic ATROVENT HFA AERS 17MCG/ACT 1 QL (25.8 GM per 30 days) MOCOMBIVENT RESPIMAT AERS 100MCG/ACT; 20MCG/ACT 1 QL (8 GM per 30 days) MOipratropium bromide/albuterol sulfate soln 2.5mg/3ml; 0.5mg/3ml 1 QL (540 ML per 30 days) B/D MOipratropium bromide soln 0.02% 1 QL (312.5 ML per 30 days) B/D MOipratropium bromide soln 0.03% 1 MOipratropium bromide soln 0.06% 1 MOSPIRIVA HANDIHALER CAPS 18MCG 1 QL (30 EA per 30 days) MOSPIRIVA RESPIMAT AERS 1.25MCG/ACT 1 QL (4 GM per 30 days) MOSPIRIVA RESPIMAT AERS 2.5MCG/ACT 1 QL (4 GM per 30 days) MOTUDORZA PRESSAIR AEPB 400MCG/ACT 1 QL (60 EA per 30 days) ST MOTUDORZA PRESSAIR AEPB 400MCG/ACT 1 QL (60 EA per 30 days) ST MO

Bronchodilators, Sympathomimetic ADRENACLICK INJ 0.15MG/0.15ML 1 STADRENACLICK INJ 0.3MG/0.3ML 1 STADRENALIN INJ 1MG/ML 1ADRENALIN INJ 30MG/30ML 1albuterol sulfate er tb12 4mg 1 MOalbuterol sulfate er tb12 8mg 1 MO



albuterol sulfate nebu 0.083% 1 QL (525 ML per 30 days) B/D MOalbuterol sulfate nebu 0.5% 1 QL (100 ML per 30 days) B/D MOalbuterol sulfate nebu 0.63mg/3ml 1 QL (375 ML per 30 days) B/D MOalbuterol sulfate nebu 1.25mg/3ml 1 QL (375 ML per 30 days) B/D MOalbuterol sulfate syrp 2mg/5ml 1 MOalbuterol sulfate tabs 2mg 1 MOalbuterol sulfate tabs 4mg 1 MOANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH 1 QL (60 EA per 30 days) MOARCAPTA NEOHALER CAPS 75MCG 1 QL (30 EA per 30 days) MOBROVANA NEBU 15MCG/2ML 1 QL (120 ML per 30 days) B/D MOepinephrine inj 0.15mg/0.15ml 1epinephrine inj 0.3mg/0.3ml 1EPIPEN 2-PAK INJ 0.3MG/0.3ML 1EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML 1FORADIL AEROLIZER CAPS 12MCG 1 QL (60 EA per 30 days) MOlevalbuterol hcl nebu 0.31mg/3ml 1 QL (540 ML per 30 days) B/D MOlevalbuterol hcl nebu 0.63mg/3ml 1 QL (540 ML per 30 days) B/D MOlevalbuterol hcl nebu 1.25mg/3ml 1 QL (270 ML per 30 days) B/D MOlevalbuterol nebu 1.25mg/0.5ml 1 QL (90 EA per 30 days) B/D MOmetaproterenol sulfate syrp 10mg/5ml 1 MOmetaproterenol sulfate tabs 10mg 1 MOmetaproterenol sulfate tabs 20mg 1 MOPERFOROMIST NEBU 20MCG/2ML 1 QL (120 ML per 30 days) B/D MOPROAIR HFA AERS 108MCG/ACT 1 QL (17 GM per 30 days) MOPROAIR RESPICLICK AEPB 108MCG/ACT 1 QL (2 EA per 30 days) MOSEREVENT DISKUS AEPB 50MCG/DOSE 1 QL (60 EA per 30 days) MOSTRIVERDI RESPIMAT AERS 2.5MCG/ACT 1 QL (4 GM per 30 days) MOterbutaline sulfate inj 1mg/ml 1 NDSterbutaline sulfate tabs 2.5mg 1 MOterbutaline sulfate tabs 5mg 1 MOXOPENEX HFA AERO 45MCG/ACT 1 QL (30 GM per 30 days) MO

Cystic Fibrosis Agents BETHKIS NEBU 300MG/4ML 1 B/D NDSCAYSTON SOLR 75MG 1 PA NDSKALYDECO PACK 50MG 1 PA MO NDSKALYDECO PACK 75MG 1 PA MO NDSKALYDECO TABS 150MG 1 PA MO NDSORKAMBI TABS 125MG; 200MG 1 QL (112 EA per 28 days) PA MO

NDSPULMOZYME SOLN 1MG/ML 1 PA MO NDSTOBI PODHALER CAPS 28MG 1 QL (224 EA per 56 days) NDStobramycin nebu 300mg/5ml 1 B/D NDS

Mast Cell Stabilizers cromolyn sodium nebu 20mg/2ml 1 B/D MO

Phosphodiesterase Inhibitors, Airways Disease aminophylline inj 25mg/ml 1DALIRESP TABS 500MCG 1 PA MO



LUFYLLIN TABS 200MG 1 MOtheophylline anhydrous cr tb12 300mg 1 MOtheophylline cr tb12 100mg 1 MOtheophylline cr tb12 200mg 1 MOtheophylline er tb12 100mg 1 MOtheophylline er tb12 200mg 1 MOtheophylline er tb12 300mg 1 MOtheophylline er tb12 450mg 1 MOtheophylline er tb24 400mg 1 MOtheophylline er tb24 600mg 1 MOtheophylline/d5w inj 5%; 0.8mg/ml 1theophylline elix 80mg/15ml 1 MOtheophylline soln 80mg/15ml 1 MO

Pulmonary Antihypertensives ADCIRCA TABS 20MG 1 QL (60 EA per 30 days) PA MO NDSADEMPAS TABS 0.5MG 1 QL (90 EA per 30 days) PA MO NDSADEMPAS TABS 1.5MG 1 QL (90 EA per 30 days) PA MO NDSADEMPAS TABS 1MG 1 QL (90 EA per 30 days) PA MO NDSADEMPAS TABS 2.5MG 1 QL (90 EA per 30 days) PA MO NDSADEMPAS TABS 2MG 1 QL (90 EA per 30 days) PA MO NDSepoprostenol sodium inj 0.5mg 1 PA NDSepoprostenol sodium inj 1.5mg 1 PA NDSLETAIRIS TABS 10MG 1 QL (30 EA per 30 days) PA MO NDSLETAIRIS TABS 5MG 1 QL (30 EA per 30 days) PA MO NDSOPSUMIT TABS 10MG 1 QL (30 EA per 30 days) PA MO NDSORENITRAM TBCR 0.125MG 1 PA MOORENITRAM TBCR 0.25MG 1 PA MO NDSORENITRAM TBCR 1MG 1 PA MO NDSORENITRAM TBCR 2.5MG 1 PA MO NDSREMODULIN INJ 10MG/ML 1 PA NDSREMODULIN INJ 1MG/ML 1 PA NDSREMODULIN INJ 2.5MG/ML 1 PA NDSREMODULIN INJ 5MG/ML 1 PA NDSREVATIO SUSR 10MG/ML 1 PA MO NDSsildenafil inj 10mg/12.5ml 1 PA NDSsildenafil tabs 20mg 1 QL (90 EA per 30 days) PA MOTYVASO REFILL SOLN 0.6MG/ML 1 QL (87 ML per 30 days) PA MO

NDSTYVASO STARTER SOLN 0.6MG/ML 1 QL (87 ML per 30 days) PA MO

NDSTYVASO SOLN 0.6MG/ML 1 QL (87 ML per 30 days) PA MO

NDSUPTRAVI TABS 1000MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 1200MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 1400MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 1600MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 200MCG 1 QL (60 EA per 30 days) PA MO NDS



UPTRAVI TABS 400MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 600MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TABS 800MCG 1 QL (60 EA per 30 days) PA MO NDSUPTRAVI TBPK 0 1 QL (400 EA per 365 days) PA NDSVELETRI INJ 0.5MG 1 PA NDSVELETRI INJ 1.5MG 1 PA NDSVENTAVIS SOLN 10MCG/ML 1 QL (270 ML per 30 days) PA MO

NDSVENTAVIS SOLN 20MCG/ML 1 QL (270 ML per 30 days) PA MO

NDSRespiratory Tract Agents, Other

acetylcysteine soln 10% 1 B/Dacetylcysteine soln 20% 1 B/DARALAST NP INJ 1000MG 1 PA NDSARALAST NP INJ 400MG 1 PA NDSARALAST NP INJ 500MG 1 PA NDSARALAST NP INJ 800MG 1 PA NDSESBRIET CAPS 267MG 1 PA MO NDSGLASSIA INJ 1000MG/50ML 1 PA NDSOFEV CAPS 100MG 1 PA MO NDSOFEV CAPS 150MG 1 PA MO NDSPROLASTIN-C INJ 1000MG 1 PA NDSpromethazine vc plain syrp 5mg/5ml; 6.25mg/5ml 1 PApromethazine vc syrp 5mg/5ml; 6.25mg/5ml 1 PApromethazine/phenylephrine syrp 5mg/5ml; 6.25mg/5ml 1 PApromethazine/phenylephrine syrp 5mg/5ml; 6.25mg/5ml 1 PASTIOLTO RESPIMAT AERS 2.5MCG/ACT; 2.5MCG/ACT 1 QL (4 GM per 30 days) MOTYZINE PEDIATRIC NASAL DROPS SOLN 0.05% 1VIRAZOLE SOLR 6GM 1 NDSXOLAIR INJ 150MG 1 PA NDSZEMAIRA INJ 1000MG 1 PA NDS

Skeletal Muscle RelaxantsSkeletal Muscle Relaxants

carisoprodol tabs 250mg 1 PAcarisoprodol tabs 350mg 1 PAchlorzoxazone tabs 500mg 1 PAcyclobenzaprine hcl tabs 10mg 1 PAcyclobenzaprine hcl tabs 5mg 1 PAcyclobenzaprine hcl tabs 7.5mg 1 PAmethocarbamol tabs 500mg 1 PAmethocarbamol tabs 750mg 1 PAorphenadrine citrate er tb12 100mg 1 PA

Sleep Disorder AgentsGABA Receptor Modulators

eszopiclone tabs 1mg 1 QL (30 EA per 30 days) PAeszopiclone tabs 2mg 1 QL (30 EA per 30 days) PAeszopiclone tabs 3mg 1 QL (30 EA per 30 days) PA



temazepam caps 15mg 1 QL (30 EA per 30 days) PAtemazepam caps 22.5mg 1 QL (30 EA per 30 days) PAtemazepam caps 30mg 1 QL (30 EA per 30 days) PAtemazepam caps 7.5mg 1 QL (30 EA per 30 days) PAzaleplon caps 10mg 1 QL (60 EA per 30 days) PAzaleplon caps 5mg 1 QL (30 EA per 30 days) PAzolpidem tartrate er tbcr 12.5mg 1 QL (30 EA per 30 days) PAzolpidem tartrate er tbcr 6.25mg 1 QL (30 EA per 30 days) PAzolpidem tartrate subl 1.75mg 1 QL (30 EA per 30 days) PAzolpidem tartrate subl 3.5mg 1 QL (30 EA per 30 days) PAzolpidem tartrate tabs 10mg 1 QL (30 EA per 30 days) PAzolpidem tartrate tabs 5mg 1 QL (30 EA per 30 days) PA

Sleep Disorders, Other armodafinil tabs 150mg 1 QL (30 EA per 30 days) PA MOarmodafinil tabs 200mg 1 QL (30 EA per 30 days) PA MOarmodafinil tabs 250mg 1 QL (30 EA per 30 days) PA MOarmodafinil tabs 50mg 1 QL (60 EA per 30 days) PA MOmodafinil tabs 100mg 1 QL (30 EA per 30 days) PA MOmodafinil tabs 200mg 1 QL (30 EA per 30 days) PA MOphenobarbital sodium inj 130mg/ml 1 PAphenobarbital sodium inj 65mg/ml 1 PAROZEREM TABS 8MG 1 QL (30 EA per 30 days) MOSILENOR TABS 3MG 1 QL (30 EA per 30 days) MOSILENOR TABS 6MG 1 QL (30 EA per 30 days) MOXYREM SOLN 500MG/ML 1 QL (540 ML per 30 days) PA NDS

Therapeutic Nutrients/Minerals/ElectrolytesElectrolyte/Mineral Modifiers

CARBAGLU TABS 200MG 1 MO NDSCUPRIMINE CAPS 250MG 1 NDSDEPEN TITRATABS TABS 250MG 1 NDSEXJADE TBSO 125MG 1 PA MO NDSEXJADE TBSO 250MG 1 PA MO NDSEXJADE TBSO 500MG 1 PA MO NDSFERRIPROX SOLN 100MG/ML 1 PA MO NDSFERRIPROX TABS 500MG 1 PA MO NDSJADENU TABS 180MG 1 PA MO NDSJADENU TABS 360MG 1 PA MO NDSJADENU TABS 90MG 1 PA MO NDSkionex powd 0 1kionex susp 15gm/60ml 1SAMSCA TABS 15MG 1 QL (30 EA per 60 days) NDSSAMSCA TABS 30MG 1 QL (60 EA per 30 days) NDSsodium acetate inj 2meq/ml 1sodium lactate inj 5meq/ml 1sodium polystyrene sulfonate powd 0 1sodium polystyrene sulfonate susp 15gm/60ml 1sodium polystyrene sulfonate susp 30gm/120ml 1



sodium polystyrene sulfonate susp 50gm/200ml 1sps susp 15gm/60ml 1SYPRINE CAPS 250MG 1 NDS

Electrolyte/Mineral Replacement AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L; 900MG/100ML; 690MG/100ML; 96MEQ/L; 900MG/100ML; 210MG/100ML; 510MG/100ML; 660MG/100ML; 510MG/100ML; 10MEQ/L; 280MG/100ML; 310MG/100ML; 30MMOLE/L; 65MEQ/L; 610MG/100ML; 300MG/100ML; 65MEQ/L; 370MG/100ML; 120MG/100ML; 44MG/100ML; 560MG/100ML

1 B/D

aminosyn 8.5%/electrolytes inj 142meq/l; 1100mg/100ml; 850mg/100ml; 98meq/l; 1100mg/100ml; 260mg/100ml; 620mg/100ml; 810mg/100ml; 624mg/100ml; 10meq/l; 340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l; 750mg/100ml; 370mg/100ml; 65meq/l; 460mg/100ml; 150mg/100ml; 44mg/100ml; 680mg/100ml

1 B/D

aminosyn ii 8.5%/electrolytes inj 61meq/l; 844mg/100ml; 865mg/100ml; 595mg/100ml; 86meq/l; 627mg/100ml; 425mg/100ml; 255mg/100ml; 561mg/100ml; 850mg/100ml; 893mg/100ml; 10meq/l; 146mg/100ml; 253mg/100ml; 30mmole/l; 66meq/l; 614mg/100ml; 450mg/100ml; 80meq/l; 340mg/100ml; 170mg/100ml; 230mg/100ml; 425mg/100ml

1 B/D

AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML

1 B/D

AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 44.4MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

1 B/D

AMINOSYN M INJ 65MEQ/L; 448MG/100ML; 343MG/100ML; 40MEQ/L; 448MG/100ML; 105MG/100ML; 252MG/100ML; 329MG/100ML; 252MG/100ML; 3MEQ/L; 140MG/100ML; 154MG/100ML; 3.5MMOLE/L; 13MEQ/L; 300MG/100ML; 147MG/100ML; 40MEQ/L; 182MG/100ML; 56MG/100ML; 31MG/100ML; 280MG/100ML

1 B/D

AMINOSYN-HBC INJ 7.1MEQ/100ML; 660MG/100ML; 507MG/100ML; 4MEQ/100ML; 660MG/100ML; 154MG/100ML; 789MG/100ML; 1576MG/100ML; 265MG/100ML; 206MG/100ML; 1.12GM/100ML; 228MG/100ML; 448MG/100ML; 221MG/100ML; 272MG/100ML; 88MG/100ML; 33MG/100ML; 789MG/100ML

1 B/D

AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML; 861MG/100ML; 370MG/100ML; 576MG/100ML; 270MG/100ML; 220MG/100ML; 534MG/100ML; 831MG/100ML; 475MG/100ML; 125MG/100ML; 10.69GM/L; 300MG/100ML; 570MG/100ML; 70GM/L; 347MG/100ML; 50MG/100ML; 360MG/100ML; 125MG/100ML; 44MG/100ML; 452MG/100ML

1 B/D



AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML; 1227MG/100ML;527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML

1 B/D

AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML; 429MG/100ML;462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML

1 B/D

AMINOSYN INJ 148MEQ/L; 1280MG/100ML; 980MG/100ML; 1280MG/100ML; 300MG/100ML; 720MG/100ML; 940MG/100ML; 720MG/100ML; 400MG/100ML; 440MG/100ML; 5.4MEQ/L; 860MG/100ML; 420MG/100ML; 520MG/100ML; 160MG/100ML; 44MG/100ML; 800MG/100ML

1 B/D

CLINIMIX 2.75%/DEXTROSE 5% INJ 24MEQ/1000ML; 570MG/100ML; 316MG/100ML; 11MEQ/1000ML; 5GM/100ML; 283MG/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 110MG/100ML; 154MG/100ML; 187MG/100ML; 138MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 10% INJ 37MEQ/L;880MG/100ML; 489MG/100ML; 17MEQ/L; 10GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML;247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 20% INJ 37MEQ/L;880MG/100ML; 489MG/100ML; 17MEQ/L; 20GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 25% INJ 37MEQ/L;880MG/100ML; 489MG/100ML; 17MEQ/L; 25GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX 4.25%/DEXTROSE 5% INJ 37MEQ/L; 880MG/100ML; 489MG/100ML; 17MEQ/L; 5GM/100ML; 438MG/100ML; 204MG/100ML; 255MG/100ML; 311MG/100ML; 247MG/100ML; 170MG/100ML; 238MG/100ML; 289MG/100ML; 213MG/100ML; 179MG/100ML; 77MG/100ML; 17MG/100ML; 247MG/100ML

1 B/D

CLINIMIX 5%/DEXTROSE 15% INJ 42MEQ/1000ML;1035MG/100ML; 575MG/100ML; 20MEQ/1000ML; 15GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML

1 B/D



CLINIMIX 5%/DEXTROSE 20% INJ 42MEQ/L; 1035MG/100ML;575MG/100ML; 20MEQ/L; 20GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML

1 B/D

CLINIMIX 5%/DEXTROSE 25% INJ 42MEQ/L; 1035MG/100ML;575MG/100ML; 20MEQ/L; 25GM/100ML; 515MG/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 200MG/100ML; 280MG/100ML; 340MG/100ML; 250MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML

1 B/D

CLINIMIX E 2.75%/DEXTROSE 10% INJ 570MG/100ML; 316MG/100ML; 33MG/100ML; 10GM/100ML; 132MG/100ML; 165MG/100ML; 201MG/100ML; 159MG/100ML; 51MG/100ML; 110MG/100ML; 454MG/100ML; 154MG/100ML; 261MG/100ML; 187MG/100ML; 138MG/100ML; 217MG/100ML; 112MG/100ML; 116MG/100ML; 50MG/100ML; 11MG/100ML; 160MG/100ML

1 B/D


1 B/D


1 B/D


1 B/D


1 B/D

CLINIMIX E 5%/DEXTROSE 15% INJ 1035MG/100ML; 575MG/100ML; 33MG/100ML; 15GM/100ML; 240MG/100ML; 300MG/100ML; 365MG/100ML; 290MG/100ML; 51MG/100ML; 200MG/100ML; 826MG/100ML; 280MG/100ML; 261MG/100ML; 340MG/100ML; 250MG/100ML; 340MG/100ML; 59MG/100ML; 210MG/100ML; 90MG/100ML; 20MG/100ML; 290MG/100ML

1 B/D


1 B/D




1 B/D

dextrose 10%/nacl 0.45% inj 10%; 0.45% 1DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX INJ 24MEQ/L;5%; 23MEQ/L; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L

1

dextrose 10%/nacl 0.2% inj 10%; 0.2% 1dextrose 10% inj 10% 1dextrose 2.5%/sodium chloride 0.45% inj 2.5%; 0.45% 1dextrose 20% inj 20% 1dextrose 25% inj 250mg/ml 1dextrose 30% inj 30% 1dextrose 40% inj 40% 1dextrose 5%/nacl 0.2% inj 5%; 0.2% 1dextrose 5%/nacl 0.225% inj 5%; 0.225% 1dextrose 5%/nacl 0.3% inj 5%; 0.3% 1dextrose 5%/nacl 0.33% inj 5%; 0.33% 1dextrose 5%/nacl 0.45% inj 5%; 0.45% 1dextrose 5%/nacl 0.9% inj 5%; 0.9% 1dextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l 1dextrose 5% inj 5% 1dextrose 50% inj 50% 1dextrose 70% inj 70% 1FREAMINE HBC 6.9% INJ 59.3MEQ/L; 400MG/100ML; 580MG/100ML; 3MEQ/L; 14MG/100ML; 330MG/100ML; 160MG/100ML; 760MG/100ML; 1370MG/100ML; 410MG/100ML; 250MG/100ML; 320MG/100ML; 630MG/100ML; 330MG/100ML; 10MEQ/L; 200MG/100ML; 90MG/100ML; 880MG/100ML

1 B/D

FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

1 B/D

HEPATAMINE INJ 62MEQ/L; 770MG/100ML; 600MG/100ML; 3MEQ/L; 20MG/100ML; 900MG/100ML; 240MG/100ML; 900MG/100ML; 1100MG/100ML; 610MG/100ML; 100MG/100ML; 100MG/100ML; 115MG/100ML; 800MG/100ML; 500MG/100ML; 100MG/100ML; 450MG/100ML; 66MG/100ML; 840MG/100ML

1 B/D

IONOSOL-B/DEXTROSE 5% INJ 49MEQ/L; 5%; 25MEQ/L; 5MEQ/L; 13MEQ/L; 25MEQ/L; 57MEQ/L

1

IONOSOL-MB/DEXTROSE 5% INJ 22MEQ/L; 5%; 23MEQ/L;3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L

1

ISOLYTE-P/DEXTROSE 5% INJ 23MEQ/L; 23MEQ/L; 5%; 3MEQ/L; 3MEQ/L; 20MEQ/L; 25MEQ/L

1



ISOLYTE-S PH 7.4 INJ 27MEQ/1000ML; 98MEQ/1000ML;23MEQ/1000ML; 3MEQ/1000ML; 1MEQ/1000ML; 5MEQ/1000ML; 141MEQ/1000ML

1

ISOLYTE-S INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L

1

k-sol soln 10% 1 MOk-sol soln 20% 1 MOkcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45% 1kcl 0.15%/d5w/ nacl 0.3% inj 5%; 20meq/l; 0.33% 1kcl 0.15%/d5w/lr inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

1

kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2% 1kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225% 1kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% 1kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9% 1kcl 0.3%/d5w/lr iv lac ring inj 3meq/l; 149meq/l; 5%; 28meq/l; 44meq/l; 130meq/l

1

kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45% 1kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9% 1klor-con 10 tbcr 10meq 1 MOklor-con 8 tbcr 8meq 1 MOklor-con m10 tbcr 10meq 1 MOklor-con m15 tbcr 15meq 1 MOklor-con m20 tbcr 20meq 1 MOklor-con sprinkle cpcr 10meq 1 MOklor-con sprinkle cpcr 8meq 1 MOlactated ringers dextrose 5% viaflex inj 2.7meq/l; 109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l

1

lactated ringers viaflex inj 3meq/l; 109meq/l; 28meq/l; 4meq/l; 130meq/l

1

magnesium sulfate inj 20gm/500ml 1magnesium sulfate inj 2gm/50ml 1magnesium sulfate inj 40gm/1000ml 1magnesium sulfate inj 4gm/100ml 1magnesium sulfate inj 4gm/50ml 1magnesium sulfate inj 50% 1magnesium sulfate inj 50% 1NEPHRAMINE INJ 44MEQ/L; 20MG/100ML; 250MG/100ML; 560MG/100ML; 880MG/100ML; 640MG/100ML; 880MG/100ML; 880MG/100ML; 6MEQ/L; 400MG/100ML; 200MG/100ML; 640MG/100ML

1 B/D

NORMOSOL -R INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L;5MEQ/L; 140MEQ/L

1

NORMOSOL-M IN D5W INJ 16MEQ/L; 40MEQ/L; 5%; 3MEQ/L;13MEQ/L; 40MEQ/L

1

normosol-r in d5w inj 27meq/l; 98meq/l; 5%; 23meq/l; 3meq/l; 5meq/l; 140meq/l

1

NORMOSOL-R INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L;5MEQ/L; 140MEQ/L

1



PLASMA-LYTE A INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L;5MEQ/L; 140MEQ/L

1

PLASMA-LYTE-148 INJ 27MEQ/L; 98MEQ/L; 23MEQ/L; 3MEQ/L; 5MEQ/L; 140MEQ/L

1

PLASMA-LYTE-56/D5W INJ 16MEQ/L; 40MEQ/L; 5%; 3MEQ/L;13MEQ/L; 40MEQ/L

1

plenamine inj 151meq/l; 2170mg/100ml; 1470mg/100ml; 434mg/100ml; 749mg/100ml; 1040mg/100ml; 894mg/100ml; 749mg/100ml; 1040mg/100ml; 1180mg/100ml; 749mg/100ml; 1040mg/100ml; 894mg/100ml; 592mg/100ml; 749mg/100ml; 250mg/100ml; 39mg/100ml; 960mg/100ml

1 B/D

potassium acetate inj 2meq/ml 1potassium chloride 0.15% /nacl 0.45% viaflex inj 20meq/l; 0.45% 1potassium chloride 0.15% d5w/nacl 0.33% inj 5%; 20meq/l; 0.33% 1potassium chloride 0.15% d5w/nacl 0.45% inj 5%; 20meq/l; 0.45% 1potassium chloride 0.15%/nacl 0.9% inj 20meq/l; 0.9% 1potassium chloride 0.22% d5w/nacl 0.45% inj 5%; 30meq/l; 0.45% 1potassium chloride 0.224%/d5w/nacl 0.45% inj 5%; 30meq/l; 0.45%1potassium chloride 0.3%/ nacl 0.9% inj 40meq/l; 0.9% 1potassium chloride 0.3%/d5w inj 5%; 40meq/l 1potassium chloride cr tbcr 10meq 1 MOpotassium chloride cr tbcr 10meq 1 MOpotassium chloride cr tbcr 20meq 1 MOpotassium chloride er cpcr 10meq 1 MOpotassium chloride er cpcr 8meq 1 MOpotassium chloride er tbcr 10meq 1 MOpotassium chloride er tbcr 10meq 1 MOpotassium chloride er tbcr 20meq 1 MOpotassium chloride er tbcr 20meq 1 MOpotassium chloride er tbcr 8meq 1 MOpotassium chloride sr tbcr 8meq 1 MOpotassium chloride inj 10meq/100ml 1potassium chloride inj 10meq/50ml 1potassium chloride inj 20meq/100ml 1potassium chloride inj 20meq/50ml 1potassium chloride inj 2meq/ml 1potassium chloride inj 40meq/100ml 1potassium chloride pack 20meq 1 MOpotassium chloride soln 10% 1 MOpotassium chloride soln 20% 1 MOpotassium citrate er tbcr 1080mg 1potassium citrate er tbcr 15meq 1potassium citrate er tbcr 540mg 1PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

1 B/D



premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml

1 B/D

PROCALAMINE INJ 47MEQ/L; 210MG/100ML; 290MG/100ML; 3MEQ/L; 41MEQ/L; 20MG/100ML; 420MG/100ML;85MG/100ML; 210MG/100ML; 270MG/100ML; 220MG/100ML; 5MEQ/L; 160MG/100ML; 170MG/100ML; 7MMOLE/L; 24MEQ/L; 340MG/100ML; 180MG/100ML; 35MEQ/L; 120MG/100ML; 46MG/100ML; 200MG/100ML

1 B/D

PROSOL INJ 2.76GM/100ML; 1.96GM/100ML; 600MG/100ML; 1.02GM/100ML; 2.06GM/100ML; 1.18GM/100ML;1.08GM/100ML; 1.08GM/100ML; 1.35GM/100ML;760MG/100ML; 1GM/100ML; 1.34GM/100ML; 1.02GM/100ML; 980MG/100ML; 320MG/100ML; 50MG/100ML; 1.44GM/100ML

1 B/D

ringers injection inj 4.5meq/l; 156meq/l; 4meq/l; 147meq/l 1sodium chloride 0.45% viaflex inj 0.45% 1sodium chloride 0.9% soln 0.9% 1sodium chloride inj 0.9% 1sodium chloride inj 0.9% 1sodium chloride inj 2.5meq/ml 1sodium chloride inj 3% 1sodium chloride inj 5% 1sodium fluoride tabs 1mg 1 MOsodium phosphate inj 3mmole/ml 1tpn electrolytes inj 29.5meq/20ml; 4.5meq/20ml; 35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml

1

TRAVASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

1 B/D

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML;0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

1 B/D

Vitamins vp-pnv-dha caps 80mg; 50mg; 400unit; 1mg; 12mcg; 200mg; 15.8mg; 28mg; 1mg; 30mg; 20mg; 16mg; 2.2mg; 6mg; 30unit; 2500unit; 20mg

1

of 143

Index Drug Name Page #

abacavir 47abacavir sulfate/lamivudine/zidovudine 47

ABELCET 28ABILIFY 42

ABILIFY MAINTENA 42ABRAXANE 34

ABSTRAL 4acamprosate calcium dr 7

acarbose 51acebutolol hcl 61

acetaminophen/codeine 4acetaminophen/codeine #3 4

acetazolamide 67acetazolamide er 105

acetazolamide sodium 67acetic acid 105

acetic acid 0.25% 81acetic acid/aluminum acetate 105

acetylcysteine 110acitretin 74

ACTEMRA 98ACTHIB 99

ACTIMMUNE 99acyclovir 49

acyclovir sodium 49ADACEL 99ADAGEN 76adapalene 74

adapalene pump 74ADCIRCA 109

adefovir dipivoxil 45ADEMPAS 109

ADRENACLICK 107ADRENALIN 107

adrucil 33ADVAIR DISKUS 105

ADVAIR HFA 106AEROSPAN 106

afeditab cr 63AFINITOR 37

AFINITOR DISPERZ 37AGGRENOX 56

A-HYDROCORT 82ak-poly-bac 103ALBENZA 39

albuterol sulfate 108

Drug Name Page #albuterol sulfate er 107

alclometasone dipropionate 82ALCOHOL PREP PADS 9

ALDACTAZIDE 67ALDURAZYME 76

ALECENSA 37alendronate sodium 101

alfuzosin hcl er 81ALIMTA 33ALINIA 39

allopurinol 30almotriptan malate 30

ALOCRIL 103ALOMIDE 104

alosetron hydrochloride 79ALOXI 27

ALPHAGAN P 105alprazolam 50

alprazolam er 49alprazolam intensol 49

alprazolam odt 49alprazolam xr 49

ALREX 104ALTABAX 9

altavera 87ALTOPREV 68alyacen 1/35 87

alyacen 7/7/7 87amantadine hcl 49

AMBISOME 28amcinonide 82

amethia 87amethia lo 87

amethyst 87amifostine 34

amikacin sulfate 8amiloride hcl 67

amiloride/hydrochlorothiazide 67aminocaproic acid 56

aminophylline 108AMINOSYN 113

AMINOSYN 7%/ELECTROLYTES 112aminosyn 8.5%/electrolytes 112

AMINOSYN II 112aminosyn ii 8.5%/electrolytes 112

AMINOSYN M 112AMINOSYN-HBC 112

AMINOSYN-PF 113AMINOSYN-PF 7% 112

of 143

Drug Name Page #AMINOSYN-RF 113

amiodarone hcl 60AMITIZA 79

amitriptyline hcl 26amlodipine besylate 63

amlodipine besylate/atorvastatin calcium 63amlodipine besylate/benazepril

hydrochloride63

amlodipine besylate/valsartan 63amlodipine/valsartan/hctz 63

ammonium lactate 74AMMONUL 102

amnesteem 74amoxapine 26amoxicillin 14

amoxicillin/clavulanate potassium 14amoxicillin/clavulanate potassium er 14

amphetamine/dextroamphetamine 71amphotericin b 28

ampicillin 14ampicillin sodium 14

ampicillin-sulbactam 14AMPYRA 73

ANADROL-50 86anagrelide hydrochloride 55

anastrozole 36ANDRODERM 86

ANDROGEL 87ANDROGEL PUMP 87

ANDROXY 87ANORO ELLIPTA 108

antibiotic ear 105ANZEMET 27apexicon e 82

APLENZIN 23APOKYN 40

apraclonidine 105apri 87

APRISO 100APTIOM 18

APTIVUS 48ARALAST NP 110

aranelle 87ARANESP ALBUMIN FREE 55

ARCALYST 99ARCAPTA NEOHALER 108

ARESTIN 74argatroban 54

aripiprazole 42

Drug Name Page #aripiprazole odt 42

ARISTADA 43ARISTOSPAN INTRA-ARTICULAR 82

armodafinil 111ARRANON 33ARZERRA 38

ascomp/codeine 4ashlyna 87

ASMANEX HFA 106ASMANEX TWISTHALER 120

METERED DOSES106

ASMANEX TWISTHALER 14 METERED DOSES

106


106


106


106

aspirin/dipyridamole 56aspirin-caffeine-dihydrocodeine 4

ASTAGRAF XL 95atenolol 61

atenolol/chlorthalidone 61ATGAM 97

atorvastatin calcium 68atovaquone 39

atovaquone/proguanil hcl 39ATRIPLA 46

atropine sulfate 103ATROVENT HFA 107

AUBAGIO 73aubra 87

augmented betamethasone dipropionate 82AUGMENTIN 14

AVASTIN 38aviane 87

avita 74AVONEX 73

AVONEX PEN 73AVYCAZ 11azacitidine 34

azactam in iso-osmotic dextrose 13AZASAN 95AZASITE 15

azathioprine 95azelastine hcl 103azelastine hcl 106

AZILECT 41

of 143

Drug Name Page #azithromycin 15

AZOPT 105aztreonam 13

azurette 87baciim 9

bacitracin 9bacitracin/neomycin/polymyxin 103

bacitracin/polymyxin b 103baclofen 45

BACTOCILL IN DEXTROSE 14BACTROBAN NASAL 9

balsalazide disodium 100balziva 87

BANZEL 21BARACLUDE 45

baycadron 82BCG VACCINE 99

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"

102

BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16"

102

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"

102

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"

102

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM

102

BECONASE AQ 106bekyree 87

BELEODAQ 34benazepril hcl 58

benazepril hcl/hydrochlorothiazide 58BENDEKA 31BENICAR 57

BENICAR HCT 57BENLYSTA 95

benztropine mesylate 40BEPREVE 103

BERINERT 95BESIVANCE 16

betamethasone dipropionate 82betamethasone sodium

phosphate/betamethasone acetate82

betamethasone valerate 82BETASERON 73

betaxolol hcl 61betaxolol hcl 105

bethanechol chloride 81BETHKIS 108

Drug Name Page #BETIMOL 105

BETOPTIC-S 105bexarotene 39BEXSERO 99

bicalutamide 32BICILLIN C-R 14BICILLIN L-A 14

BICNU 31BIDIL 69

BILTRICIDE 39bimatoprost 103BINOSTO 101

bisoprolol fumarate 61bisoprolol fumarate/hydrochlorothiazide 61

BIVIGAM 97bleomycin sulfate 34

BLEPHAMIDE 104BLEPHAMIDE S.O.P. 104

BLINCYTO 38blisovi 24 fe 87

blisovi fe 1.5/30 87blisovi fe 1/20 87

BOOSTRIX 99BOSULIF 37

BOTOX 102BREO ELLIPTA 106

BREVIBLOC 61briellyn 87

BRILINTA 56brimonidine tartrate 105

BRINTELLIX 24BRIVIACT 18bromfenac 104

bromocriptine mesylate 40BROVANA 108budesonide 82budesonide 106bumetanide 67

BUPHENYL 76buprenorphine hcl 2buprenorphine hcl 8

buprenorphine hcl/naloxone hcl 8buproban 8

bupropion hcl 23bupropion hcl er 23bupropion hcl sr 8bupropion hcl sr 23bupropion hcl xl 23

buspirone hcl 49

of 143

Drug Name Page #BUSULFEX 31

butalbital compound/codeine 4butalbital/acetaminophen 73

butalbital/acetaminophen/caffeine 73butalbital/acetaminophen/caffeine/codeine 73

butalbital/aspirin/caffeine 73butalbital/aspirin/caffeine/codeine 4

butorphanol tartrate 4BYDUREON 51

BYETTA 51BYSTOLIC 61cabergoline 94

CABOMETYX 37CAFERGOT 30

caffeine citrate 73calcipotriene 74

calcipotriene/betamethasone dipropionate 74calcitonin-salmon 101

CALCITRIOL 75calcitriol 101

calcium acetate 81camila 91

camrese 87camrese lo 87CANASA 100

CANCIDAS 28candesartan cilexetil 57

candesartan cilexetil/hydrochlorothiazide 57capacet 73

CAPASTAT SULFATE 31CAPEX 82

CAPRELSA 37captopril 59

captopril/hydrochlorothiazide 59CARAC 75

CARAFATE 79CARBAGLU 111

carbamazepine 21carbamazepine er 21

CARBATROL 21carbidopa 41

carbidopa/levodopa 41carbidopa/levodopa er 41

carbidopa/levodopa odt 41carbidopa/levodopa/entacapone 41

carboplatin 34CARDIZEM LA 63CARDURA XL 81

CARIMUNE NANOFILTERED 97

Drug Name Page #carisoprodol 110carteolol hcl 105

cartia xt 63carvedilol 62

CAYSTON 108caziant 87

cefaclor 11cefaclor er 11cefadroxil 11cefazolin 11

cefazolin sodium 11cefazolin sodium/dextrose 11

cefdinir 12cefepime 12

cefepime/dextrose 12cefixime 12

cefotaxime sodium 12cefotetan 13

cefotetan/dextrose 12cefoxitin sodium 12

cefpodoxime proxetil 12cefprozil 12

ceftazidime 12ceftazidime/dextrose 12

ceftibuten 12ceftriaxone in iso-osmotic dextrose 12

ceftriaxone sodium 12ceftriaxone/dextrose 12

cefuroxime axetil 13cefuroxime sodium 13

celecoxib 1CELLCEPT INTRAVENOUS 95

CELONTIN 19CENTANY AT 9

cephadyn 73cephalexin 13

CERDELGA 76CEREZYME 76CERVARIX 99cetirizine hcl 106

cevimeline hcl 74CHANTIX 8

CHANTIX CONTINUING MONTH PAK 8CHANTIX STARTING MONTH PAK 8

chateal 87CHENODAL 78

chloramphenicol sodium succinate 9chlordiazepoxide hcl 50

chlordiazepoxide/amitriptyline 26

of 143

Drug Name Page #chlorhexidine gluconate oral rinse 74

chloroquine phosphate 39chlorothiazide 68

chlorothiazide sodium 68chlorpromazine hcl 41

chlorthalidone 68chlorzoxazone 110

CHOLBAM 78cholestyramine 69

cholestyramine light 69CHORIONIC GONADOTROPIN 85

CIALIS 81ciclodan 28

ciclopirox 28ciclopirox nail lacquer 28

ciclopirox olamine 28cidofovir 45cilostazol 56

CILOXAN 16cimetidine 78

cimetidine hcl 78CIMZIA 95

CIMZIA STARTER KIT 95CINRYZE 95CIPRO HC 105

CIPRODEX 105ciprofloxacin 16

ciprofloxacin er 16ciprofloxacin hcl 16

ciprofloxacin i.v.-in d5w 16cisplatin 34

citalopram hydrobromide 24cladribine 33

claravis 75clarithromycin 15

clarithromycin er 15CLEOCIN 9

CLIMARA PRO 87clindacin etz pledgets 9

clindacin-p 9clindamycin 10

clindamycin hcl 9clindamycin palmitate hcl 9

clindamycin phosphate 9clindamycin phosphate add-vantage 9

clindamycin phosphate in d5w 9clindamycin phosphate pharmacy bulk

package9

clindamycin phosphate/tretinoin 75

Drug Name Page #clindamycin/benzoyl peroxide 75

CLINDESSE 10CLINIMIX 2.75%/DEXTROSE 5% 113

CLINIMIX 4.25%/DEXTROSE 10% 113CLINIMIX 4.25%/DEXTROSE 20% 113CLINIMIX 4.25%/DEXTROSE 25% 113CLINIMIX 4.25%/DEXTROSE 5% 113

CLINIMIX 5%/DEXTROSE 15% 113CLINIMIX 5%/DEXTROSE 20% 114CLINIMIX 5%/DEXTROSE 25% 114

CLINIMIX E 2.75%/DEXTROSE 10% 114CLINIMIX E 2.75%/DEXTROSE 5% 114

CLINIMIX E 4.25%/DEXTROSE 10% 114CLINIMIX E 4.25%/DEXTROSE 25% 114CLINIMIX E 4.25%/DEXTROSE 5% 114

CLINIMIX E 5%/DEXTROSE 15% 114CLINIMIX E 5%/DEXTROSE 20% 114CLINIMIX E 5%/DEXTROSE 25% 115

clobetasol propionate 82clobetasol propionate e 82

clobetasol propionate emollient 82clocortolone pivalate 82

clocortolone pivalate pump 82clodan 82

CLODAN KIT 75CLOLAR 33

clomipramine hcl 26clonazepam 19

clonazepam odt 19clonidine hcl 57

clonidine hcl er 71clopidogrel 56

clorazepate dipotassium 50CLORPRES 57clotrimazole 28

clotrimazole/betamethasone dipropionate 75clozapine 45

clozapine odt 44COARTEM 39

codeine sulfate 4codeine/acetaminophen 4

colchicine 30COLCRYS 30

colestipol hcl 69colistimethate sodium 10

colocort 82COLY-MYCIN S 105

COMBIGAN 103COMBIPATCH 87

of 143

Drug Name Page #COMBIVENT RESPIMAT 107

COMETRIQ 37COMPLERA 47

compro 41COMVAX 99

CONDYLOX 75constulose 79

COPAXONE 73CORDRAN TAPE 82

cormax scalp application 82CORTIFOAM 82

cortisone acetate 82CORTISPORIN 75

CORTISPORIN-TC 105COSENTYX 75

COSENTYX SENSOREADY PEN 75COSMEGEN 34COSOPT PF 105COTELLIC 34

COUMADIN 54CREON 77

CRESEMBA 28CRINONE 91

CRIXIVAN 48cromolyn sodium 78cromolyn sodium 104cromolyn sodium 108

cryselle-28 87CUBICIN 10

CUPRIMINE 111CURITY GAUZE PADS 2"X2" 75

CUVPOSA 77cyclafem 1/35 87

cyclafem 7/7/7 87cyclobenzaprine hcl 110

cyclopentolate hcl 103cyclopentolate hydrochloride 103

CYCLOPHOSPHAMIDE 31cycloserine 31

CYCLOSET 51cyclosporine 95

cyclosporine modified 95cyproheptadine hcl 107

CYRAMZA 38cyred 87

CYSTADANE 77CYSTAGON 77CYSTARAN 103

cytarabine aqueous 33

Drug Name Page #dacarbazine 31DAKLINZA 46DALIRESP 108

DALVANCE 10danazol 87

dantrolene sodium 45dapsone 31

DAPTACEL 99DARAPRIM 39

darifenacin er 80darifenacin hydrobromide er 80

DARZALEX 38dasetta 1/35 87

dasetta 7/7/7 87daunorubicin hcl 34DAUNOXOME 34

daysee 87deblitane 91

decitabine 34deferoxamine mesylate 102

deltasone 82delyla 87

demeclocycline hcl 17DEMSER 65

DENAVIR 49DEPEN TITRATABS 111

DEPOCYT 33DEPO-ESTRADIOL 88

DEPO-MEDROL 83DEPO-PROVERA 91

DEPO-SUBQ PROVERA 104 91DESCOVY 47

desipramine hcl 26desloratadine 107

desmopressin acetate 85desogestrel/ethinyl estradiol 88

desonate 75desonide 83

desoximetasone 83DESVENLAFAXINE ER 24

dexamethasone 83dexamethasone intensol 83

dexamethasone sodium phosphate 83dexamethasone sodium phosphate 104

dexchlorpheniramine maleate 107dexedrine 71

DEXILANT 80dexmethylphenidate hcl 71

dexmethylphenidate hcl er 71

of 143

Drug Name Page #dexrazoxane 34

dextroamphetamine sulfate 71dextroamphetamine sulfate er 71

dextrose 10%/nacl 0.45% 115DEXTROSE 5% /ELECTROLYTE #48

VIAFLEX115

dextrose 10% 115dextrose 10%/nacl 0.2% 115

dextrose 2.5%/sodium chloride 0.45% 115dextrose 20% 115dextrose 25% 115dextrose 30% 115dextrose 40% 115dextrose 5% 115

dextrose 5%/nacl 0.2% 115dextrose 5%/nacl 0.225% 115

dextrose 5%/nacl 0.3% 115dextrose 5%/nacl 0.33% 115dextrose 5%/nacl 0.45% 115dextrose 5%/nacl 0.9% 115

dextrose 5%/potassium chloride 0.15% 115dextrose 50% 115dextrose 70% 115

diazepam 19diazepam 50

diazepam intensol 50diclofenac potassium 1

diclofenac sodium 8diclofenac sodium 75diclofenac sodium 104

diclofenac sodium dr 1diclofenac sodium er 1diclofenac sodium xr 1

diclofenac sodium/misoprostol 1dicloxacillin sodium 15

dicyclomine hcl 77didanosine 47

DIFICID 16diflorasone diacetate 83

diflunisal 1digitek 65digox 66

digoxin 65dihydroergotamine mesylate 30

DILANTIN 21DILANTIN INFATABS 21

DILANTIN-125 21DILATRATE SR 70

diltiazem cd 63

Drug Name Page #diltiazem hcl 64

diltiazem hcl cd 64diltiazem hcl er 64

dilt-xr 63DIPENTUM 100

diphenatol 78diphenhydramine hcl 107

diphenoxylate/atropine 78diphtheria/tetanus toxoids adsorbed

pediatric99

dipyridamole 56disopyramide phosphate 60

disulfiram 7DIURIL 68

divalproex sodium 20divalproex sodium dr 20divalproex sodium er 20

dobutamine hcl 66dobutamine hcl/d5w 66

dobutamine/dextrose 5% 66DOCEFREZ 34

docetaxel 34dofetilide 60

donepezil hcl 22dopamine hcl 66

dopamine hcl/dextrose 5% 66dopamine hcl-dextrose 5% 66

dopamine/d5w 66DORIBAX 13

DORYX 17dorzolamide hcl 105

dorzolamide hcl/timolol maleate 105doxazosin 81

doxazosin mesylate 81doxepin hcl 26

doxepin hydrochloride 75doxercalciferol 101doxorubicin hcl 34

doxorubicin hcl liposome 34doxy 100 17

doxycycline 18doxycycline 75

doxycycline hyclate 17doxycycline hyclate dr 17

doxycycline monohydrate 17dronabinol 27droperidol 27

drospirenone/ethinyl estradiol 88DROXIA 33

of 143

Drug Name Page #DULERA 106

duloxetine hcl 24duramorph 4DUREZOL 104dutasteride 81

dutasteride/tamsulosin hydrochloride 81DUTOPROL 62

DYMISTA 107DYRENIUM 67

E.E.S. GRANULES 16econazole nitrate 28

EDARBI 58EDARBYCLOR 58

EDECRIN 67EDURANT 47

EFFIENT 57EGRIFTA 85

ELAPRASE 77ELIDEL 75

ELIGARD 94elinest 88

eliphos 81ELIQUIS 54ELITEK 33

ELLA 91ELMIRON 81EMADINE 104EMBEDA 2

EMCYT 33EMEND 27

emoquette 88EMPLICITI 38

EMSAM 24EMTRIVA 47

enalapril maleate 59enalapril maleate/hydrochlorothiazide 59

enalaprilat 59ENBREL 96

ENBREL SURECLICK 96endocet 4

endodan 4ENGERIX-B 99

enoxaparin sodium 54enpresse-28 88

enskyce 88entacapone 40

entecavir 45ENTRESTO 58

ENTYVIO 77

Drug Name Page #enulose 79

ENVARSUS XR 96EPANED 59EPIDUO 75

EPIDUO FORTE 75epinastine hcl 104

epinephrine 108EPIPEN 2-PAK 108

EPIPEN-JR 2-PAK 108epirubicin hcl 34

epitol 21EPIVIR HBV 45

eplerenone 67epoprostenol sodium 109eprosartan mesylate 58

EPZICOM 47EQUETRO 50

ERAXIS 28ERBITUX 38

ERGOLOID MESYLATES 22ERGOMAR 30ERIVEDGE 37

errin 91ERWINAZE 34

ery 16ERYPED 200 16ERYPED 400 16

ERY-TAB 16erythrocin lactobionate 16

ERYTHROCIN STEARATE 16erythromycin 16

erythromycin base 16erythromycin ethylsuccinate 16

erythromycin stearate 16erythromycin/benzoyl peroxide 75

ESBRIET 110escitalopram oxalate 24

esmolol hcl 62esomeprazole magnesium 80

esomeprazole sodium 80estarylla 88

estazolam 50ESTRACE 88

estradiol 88estradiol valerate 88

estradiol/norethindrone acetate 88ESTRING 88

estropipate 88eszopiclone 110

of 143

Drug Name Page #ethacrynic acid 67ethambutol hcl 31

ethosuximide 19etidronate disodium 101

etodolac 1etodolac er 1

ETOPOPHOS 36etoposide 36EURAX 39

EVOMELA 31EVOTAZ 48

EXELDERM 28exemestane 36

EXJADE 111EXTAVIA 73

EYLEA 103FABRAZYME 77

falmina 88famciclovir 49famotidine 78

famotidine premixed 78FANAPT 43

FANAPT TITRATION PACK 43FARESTON 33FARYDAK 34

FASLODEX 33felbamate 20

felodipine er 64FEMRING 88fenofibrate 68

fenofibrate micronized 68fenofibric acid 68

fenofibric acid dr 68FENOPROFEN CALCIUM 1

fentanyl 2FENTANYL CITRATE 4

fentanyl citrate oral transmucosal 4FENTORA 5

FERRIPROX 111FETZIMA 24

FETZIMA TITRATION PACK 24FINACEA 75finasteride 81FIRAZYR 95

FIRMAGON 94FLAGYL ER 10

FLAREX 104flavoxate hcl 80

FLEBOGAMMA DIF 97

Drug Name Page #flecainide acetate 60

FLOVENT DISKUS 106FLOVENT HFA 106

floxuridine 33fluconazole 28

fluconazole in dextrose 28fluconazole in nacl 28

flucytosine 29FLUDARABINE PHOSPHATE 34

fludrocortisone acetate 83flunisolide 106

fluocinolone acetonide 75fluocinolone acetonide 83

fluocinolone acetonide body 75fluocinolone acetonide ear drops 83

fluocinolone acetonide scalp 75fluocinonide 83

fluocinonide-e 83fluorometholone 104

fluorouracil 33fluorouracil 75

fluoxetine 25fluoxetine dr 24

fluoxetine hcl 24fluphenazine decanoate 41

fluphenazine hcl 41flurandrenolide 83

flurbiprofen 1flurbiprofen sodium 104

flutamide 32fluticasone propionate 83fluticasone propionate 106

fluvastatin 68fluvastatin sodium er 68fluvoxamine maleate 25

fluvoxamine maleate er 25FML 104

FML FORTE 104FOCALIN XR 71

FOLOTYN 33fondaparinux sodium 54

FORADIL AEROLIZER 108FORFIVO XL 23

FORTEO 101FORTICAL 101

FOSAMAX PLUS D 101fosinopril sodium 59

fosinopril sodium/hydrochlorothiazide 59fosphenytoin sodium 21

of 143

Drug Name Page #FOSRENOL 81

FRAGMIN 54FREAMINE HBC 6.9% 115

FREAMINE III 115frovatriptan succinate 30

furosemide 67FUSILEV 34FUZEON 48

FYAVOLV 88FYCOMPA 18gabapentin 20GABITRIL 20

GABLOFEN 45galantamine hydrobromide 22

GAMASTAN S/D 97GAMMAGARD LIQUID 97

GAMMAGARD S/D IGA LESS THAN 1MCG/ML

97

GAMMAKED 97GAMMAPLEX 98GAMUNEX-C 98

ganciclovir 45GARDASIL 99

GARDASIL 9 99gatifloxacin 16

GATTEX 78gavilyte-c 79gavilyte-g 79gavilyte-h 78

gavilyte-n/flavor pack 79GAZYVA 38

GELNIQUE 80gemcitabine 33

gemcitabine hcl 33gemfibrozil 68

generlac 79gengraf 96

GENOTROPIN 86GENOTROPIN MINIQUICK 85

gentak 8gentamicin sulfate 8

gentamicin sulfate pediatric 8gentamicin sulfate/0.9% sodium chloride 8

GENVOYA 46GEODON 43

gianvi 88gildagia 88

gildess 1.5/30 88gildess 1/20 88

Drug Name Page #gildess 24 fe 88

gildess fe 1.5/30 88gildess fe 1/20 88

GILENYA 73GILOTRIF 34GLASSIA 110

glatopa 73GLEOSTINE 32

glimepiride 51glipizide 51

glipizide er 51glipizide xl 51

glipizide/metformin hcl 51GLUCAGEN HYPOKIT 53

GLUCAGON EMERGENCY KIT 53glyburide 51

glyburide micronized 51glyburide/metformin hcl 51

glycopyrrolate 77glydo 7

GLYSET 51GOLYTELY 79

granisetron hcl 27GRANIX 56

griseofulvin microsize 29griseofulvin ultramicrosize 29

guanfacine er 72guanfacine hcl 57

GUANIDINE HCL 31GYNAZOLE-1 29H.P. ACTHAR 86

HALAVEN 34halobetasol propionate 83

haloperidol 42haloperidol decanoate 41

haloperidol lactate 42HARVONI 46

HAVRIX 99heather 91hecoria 96

HEPAGAM B 98heparin sodium 54

heparin sodium/d5w 54heparin sodium/nacl 0.45% 54heparin sodium/nacl 0.9% 54

heparin sodium/sodium chloride 0.9% 54heparin sodium/sodium chloride 0.9%

premix54

HEPATAMINE 115

of 143

Drug Name Page #HERCEPTIN 38

HETLIOZ 73HEXALEN 32

HIBERIX 99HIZENTRA 98HUMALOG 53

HUMALOG KWIKPEN 53HUMALOG MIX 50/50 53

HUMALOG MIX 50/50 KWIKPEN 53HUMALOG MIX 75/25 53

HUMALOG MIX 75/25 KWIKPEN 53HUMATROPE 86

HUMATROPE COMBO PACK 86HUMIRA 96

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

96

HUMIRA PEN 96HUMIRA PEN-CROHNS

DISEASESTARTER96

HUMIRA PEN-PSORIASIS STARTER 96HUMULIN 70/30 53

HUMULIN 70/30 KWIKPEN 53HUMULIN N 53

HUMULIN N KWIKPEN 53HUMULIN R 53

HUMULIN R U-500 (CONCENTRATED) 53HUMULIN R U-500 KWIKPEN 53

hydralazine hcl 70hydrochlorothiazide 68

hydrocodone bitartrate/acetaminophen 5hydrocodone/acetaminophen 5

hydrocodone/ibuprofen 5hydrocortisone 84

hydrocortisone butyrate 84hydrocortisone butyrate (lipophilic) 83

hydrocortisone valerate 84hydrocortisone/acetic acid 105

hydromorphone hcl 5hydromorphone hcl er 2

hydroxychloroquine sulfate 39hydroxyprogesterone caproate 31

hydroxyurea 33hydroxyzine hcl 107

hydroxyzine pamoate 107HYPERHEP B S/D 98

HYPERRAB S/D 98HYPERRHO S/D 98

HYPERRHO S/D MINI-DOSE 98HYQVIA 99

Drug Name Page #ibandronate sodium 101

IBRANCE 35ibudone 5

ibuprofen 1ibutilide fumarate 60

ICLUSIG 37idarubicin hcl 35

ifosfamide 32ILARIS 99

ILEVRO 104ilotycin 16

imatinib mesylate 37IMBRUVICA 37

imipenem/cilastatin 13imipramine hcl 26

imipramine pamoate 26imiquimod 75

IMOGAM RABIES-HT 98IMOVAX RABIES (H.D.C.V.) 99

INCRELEX 86indapamide 68

indomethacin 1indomethacin er 1indomethacin sr 1

INFANRIX 99INFUMORPH 200 2INFUMORPH 500 2

INLYTA 37INNOPRAN XL 62

INTELENCE 47INTRALIPID 102

INTRON A 45INTRON A W/DILUENT 45

introvale 88INVANZ 13

INVEGA SUSTENNA 43INVEGA TRINZA 43

INVIRASE 48INVOKAMET 51

INVOKANA 51IONOSOL-B/DEXTROSE 5% 115

IONOSOL-MB/DEXTROSE 5% 115IOPIDINE 105

IPOL INACTIVATED IPV 99ipratropium bromide 107

ipratropium bromide/albuterol sulfate 107irbesartan 58

irbesartan/hydrochlorothiazide 58IRESSA 37

of 143

Drug Name Page #irinotecan 35

ISENTRESS 47ISOLYTE-P/DEXTROSE 5% 115

ISOLYTE-S 116ISOLYTE-S PH 7.4 116

isoniazid 31ISORDIL TITRADOSE 70

isosorbide dinitrate 70isosorbide dinitrate er 70

isosorbide mononitrate 70isosorbide mononitrate er 70

isotonic gentamicin 9isradipine 64

ISTODAX 35itraconazole 29

ivermectin 39IXEMPRA KIT 35

IXIARO 99JADENU 111JAKAFI 37jantoven 55

JANUMET 52JANUMET XR 52

JANUVIA 52JARDIANCE 52

jencycla 91JENTADUETO 52

JENTADUETO XR 52JEVANTIQUE LO 89

JEVTANA 35jinteli 89

jolessa 89jolivette 92JUBLIA 29

juleber 89junel 1.5/30 89

junel 1/20 89junel fe 1.5/30 89

junel fe 1/20 89junel fe 24 89

JUXTAPID 69KADCYLA 38

kaitlib fe 89KALBITOR 102KALETRA 48

KALYDECO 108KANUMA 77

kariva 89kcl 0.075%/d5w/nacl 0.45% 116

Drug Name Page #kcl 0.15%/d5w/ nacl 0.3% 116

kcl 0.15%/d5w/lr 116kcl 0.15%/d5w/nacl 0.2% 116

kcl 0.15%/d5w/nacl 0.225% 116kcl 0.15%/d5w/nacl 0.45% 116kcl 0.15%/d5w/nacl 0.9% 116

kcl 0.3%/d5w/lr iv lac ring 116kcl 0.3%/d5w/nacl 0.45% 116kcl 0.3%/d5w/nacl 0.9% 116

kelnor 1/35 89KENALOG-10 84KENALOG-40 84KEPIVANCE 74

KETEK 16ketoconazole 29

ketodan 29ketoprofen 1

ketoprofen er 1ketorolac tromethamine 1ketorolac tromethamine 104

KEVEYIS 102KEYTRUDA 38KHEDEZLA 25

kimidess 89KINERET 96

KINRIX 99kionex 111

klor-con 10 116klor-con 8 116

klor-con m10 116klor-con m15 116klor-con m20 116

klor-con sprinkle 116KOMBIGLYZE XR 52

KORLYM 86KRISTALOSE 79KRYSTEXXA 30

k-sol 116kurvelo 89

KUVAN 77KYNAMRO 69labetalol hcl 62

LACRISERT 103lactated ringers dextrose 5% viaflex 116

lactated ringers irrigation 102lactated ringers viaflex 116

lactulose 79LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE20

of 143

Drug Name Page #LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE

20

LAMICTAL STARTER/TAKING VALPROATE

20

LAMISIL 29lamivudine 45lamivudine 47

lamivudine/zidovudine 47lamotrigine 21

lamotrigine er 20lamotrigine odt 21

lamotrigine titration 21LANOXIN 66

lansoprazole 80lansoprazole/amoxicillin/clarithromycin 78

LANTUS 53LANTUS SOLOSTAR 53

larin 1.5/30 89larin 1/20 89larin 24 fe 89

larin fe 1.5/30 89larin fe 1/20 89

LASTACAFT 104latanoprost 103

LATUDA 43layolis fe 89

LAZANDA 5leena 89

leflunomide 99LEMTRADA 99

LENVIMA 10 MG DAILY DOSE 37LENVIMA 14 MG DAILY DOSE 37LENVIMA 18 MG DAILY DOSE 37LENVIMA 20 MG DAILY DOSE 37LENVIMA 24 MG DAILY DOSE 37LENVIMA 8 MG DAILY DOSE 37

lessina 89LETAIRIS 109

letrozole 36leucovorin calcium 35

LEUKERAN 32LEUKINE 56

leuprolide acetate 94levalbuterol 108

levalbuterol hcl 108LEVEMIR 53

LEVEMIR FLEXTOUCH 53LEVETIRACETAM 18

Drug Name Page #levetiracetam er 18levobunolol hcl 105

levocarnitine 102levocetirizine dihydrochloride 107

levofloxacin 17levofloxacin in d5w 16

levoleucovorin 35levoleucovorin calcium 35

levonest 89levonorgestrel 92

levonorgestrel and ethinyl estradiol 89levonorgestrel/ethinyl estradiol 89

levora 0.15/30-28 89levorphanol tartrate 2

levothyroxine sodium 92levoxyl 92

LEXIVA 48LIALDA 100lidocaine 7

lidocaine and tetracaine cream 7lidocaine hcl 7lidocaine hcl 60

lidocaine hcl in d5w 60lidocaine hcl jelly 7

lidocaine hcl/dextrose 7lidocaine hcl/dextrose 60

lidocaine viscous 7lidocaine/epinephrine 7

lidocaine/prilocaine 7lidopril 7

lincomycin hcl 10lindane 39

linezolid 10LINZESS 79

LIORESAL INTRATHECAL 45liothyronine sodium 93

lipodox 35lipodox 50 35

lisinopril 59lisinopril/hydrochlorothiazide 59

lithium 51lithium carbonate 51

lithium carbonate er 50LIVALO 69

LO LOESTRIN FE 89lokara 84

lomedia 24 fe 89lomustine 32

LONSURF 33

of 143

Drug Name Page #loperamide hcl 78

lopreeza 89lorazepam 50

lorazepam intensol 50lorcet 5

lorcet hd 5lorcet plus 5

lortab 5loryna 89

losartan potassium 58losartan potassium/hydrochlorothiazide 58

LOTEMAX 104lovastatin 69

low-ogestrel 89loxapine succinate 42

LUFYLLIN 109LUMIGAN 103

LUMIZYME 77LUPANETA PACK 94

LUPRON DEPOT 94LUPRON DEPOT-PED 94

lutera 89LYNPARZA 35

LYRICA 19LYSODREN 94

lyza 92mafenide acetate 10

magnesium sulfate 116magnesium sulfate in d5w 19

MAKENA 92malathion 39mannitol 66

maprotiline hcl 23margesic 73marlissa 89

MARPLAN 24marten-tab 73

MATULANE 32matzim la 64

MAXIDEX 104meclizine hcl 27

meclofenamate sodium 1MEDROL 84

medroxyprogesterone acetate 92mefenamic acid 1mefloquine hcl 39

megestrol acetate 92MEKINIST 37meloxicam 2

Drug Name Page #melphalan hydrochloride 32

memantine hcl 23memantine hcl titration pak 23

memantine hydrochloride 23MENACTRA 100

MENEST 89MENHIBRIX 100

MENOMUNE-A/C/Y/W-135 100MENTAX 29MENVEO 100

mercaptopurine 33meropenem 13

meropenem/sodium chloride 13mesalamine 100

mesna 35MESNEX 35

MESTINON 31metadate er 72

metaproterenol sulfate 108metformin hcl 52

metformin hcl er 52methadone hcl 3

methadone hcl intensol 2methadose 3

methadose sugar-free 3methazolamide 105

methenamine hippurate 10methergine 102

methimazole 95methitest 87

methocarbamol 110methotrexate 96

methotrexate sodium 96methoxsalen 75

methscopolamine bromide 78methyclothiazide 68

methyldopa 57methyldopa/hydrochlorothiazide 57

methyldopate hcl 57methylergonovine maleate 102

methylphenidate hcl 72methylphenidate hcl cd 72methylphenidate hcl er 72methylphenidate hcl sr 72

methylphenidate hydrochloride 72methylprednisolone 84

methylprednisolone acetate 84methylprednisolone dose pack 84

methylprednisolone sodiumsuccinate 84

of 143

Drug Name Page #methyltestosterone 87

metipranolol 105metoclopramide hcl 78metoclopramide odt 78

metolazone 68metoprolol succinate er 62

metoprolol tartrate 62metoprolol/hydrochlorothiazide 62

METRO IV 10metronidazole 10

metronidazole in nacl 0.79% 10metronidazole vaginal 10

mexiletine hcl 60MIACALCIN 101miconazole 3 29

MICRHOGAM ULTRA-FILTERED PLUS 98microgestin 1.5/30 89

microgestin 1/20 89microgestin 24 fe 89

microgestin fe 90microgestin fe 1.5/30 89

midazolam hcl 50midodrine hcl 57MIGERGOT 30

miglitol 52MILLIPRED 84

MILLIPRED DP 84milrinone in dextrose 66

milrinone lactate 66mimvey 90

mimvey lo 90MINASTRIN 24 FE 90

minitran 70minocycline hcl 18

minocycline hcl er 18minoxidil 70

mirtazapine 23mirtazapine odt 23

MIRVASO 105misoprostol 80

mitomycin 35mitoxantrone hcl 35

M-M-R II 100modafinil 111

MODERIBA 46MODERIBA 1200 DOSE PACK 46MODERIBA 800 DOSE PACK 46

moexipril hcl 59moexipril/hydrochlorothiazide 59

Drug Name Page #molindone hydrochloride 42

mometasone furoate 84mometasone furoate 106

mondoxyne nl 18mono-linyah 90

mononessa 90montelukast sodium 107

MONUROL 10morgidox 1x100mg 18morgidox 2x100mg 18

morphine sulfate 5morphine sulfate cr 3morphine sulfate er 3

MOVIPREP 79MOXEZA 17

MOXIFLOXACIN HCL 17MOZOBIL 56MULTAQ 60mupirocin 10

mupirocin calcium 10MUSTARGEN 32

my way 92MYALEPT 102

MYCAMINE 29mycophenolate mofetil 96mycophenolic acid dr 96

myorisan 75MYOZYME 77

MYRBETRIQ 80myzilra 90

NABI-HB 98nabumetone 2

nadolol 62nadolol/bendroflumethiazide 62

NAFCILLIN 15nafcillin sodium 15

NAFTIFINE HCL 29naftifine hydrochloride 29

NAFTIN 29NAGLAZYME 77nalbuphine hcl 6

naloxone hcl 8naltrexone hcl 8

NAMENDA 23NAMENDA TITRATION PAK 23

NAMENDA XR 23NAMENDA XR TITRATION PACK 23

NAMZARIC 22naphazoline hcl 103

of 143

Drug Name Page #naproxen 2

naproxen dr 2naproxen sodium 2

naproxen sodium cr 2naproxen sodium er 2

naratriptan hcl 30NARCAN 8

NASONEX 106NATACYN 29nateglinide 52NATPARA 102

NEBUPENT 39necon 0.5/35-28 90

necon 1/35 90necon 1/50-28 90

necon 10/11-28 90necon 7/7/7 90

nefazodone hcl 23neomycin sulfate 9

neomycin/bacitracin/polymyxin 103neomycin/polymyxin b sulfates 9

neomycin/polymyxin/bacitracin/hydrocortisone

10

neomycin/polymyxin/dexamethasone 104neomycin/polymyxin/gramicidin 103

neomycin/polymyxin/hc 105neomycin/polymyxin/hydrocortisone 10neomycin/polymyxin/hydrocortisone 105

neo-polycin 103neo-polycin hc 10

NEPHRAMINE 116neuac 75

NEUAC KIT 75NEULASTA 56

NEULASTA ONPRO KIT 56NEUPOGEN 56

NEUPRO 40NEVANAC 104

nevirapine 47nevirapine er 47NEXAVAR 37

NEXIUM 80niacin er 69

niacor 69nicardipine hcl 64

NICOTROL INHALER 8NICOTROL NS 8

nifedical xl 64nifedipine 65

Drug Name Page #nifedipine er 65

nikki 90NILANDRON 32

nilutamide 32nimodipine 65NINLARO 35

NIPENT 33nisoldipine 65

nisoldipine er 65NITRO-BID 70

NITRO-DUR 70nitrofurantoin 10

nitrofurantoin macrocrystals 10nitrofurantoin monohydrate 10

nitrofurantoin monohydrate/macrocrystals 10nitroglycerin 70

nitroglycerin in 5% dextrose 70nitroglycerin in dextrose 5% 70

nitroglycerin lingual 70nitroglycerin transdermal 70

NITROMIST 70NITROSTAT 70

nizatidine 79nora-be 92

NORDITROPIN FLEXPRO 86NORDITROPIN NORDIFLEX PEN 86

norepinephrine bitartrate 66norethindrone 92

norethindrone & ethinyl estradiol ferrous fumarate

90

norethindrone acetate 92norethindrone acetate/ethinyl estradiol 90

norethindrone acetate/ethinyl estradiol/ferrous fumarate

90

norgestimate/ethinyl estradiol 90NORITATE 10

norlyroc 92NORMOSOL -R 116

NORMOSOL-M IN D5W 116NORMOSOL-R 116

normosol-r in d5w 116NORPACE CR 60

NORTHERA 66nortrel 0.5/35 (28) 90

nortrel 1/35 90nortrel 7/7/7 90

nortriptyline hcl 26NORVIR 48

NOVAREL 86

of 143

Drug Name Page #NOVOLIN 70/30 53

NOVOLIN 70/30 RELION 53NOVOLIN N 53

NOVOLIN N RELION 53NOVOLIN R 53

NOVOLIN R RELION 53NOVOLOG 53

NOVOLOG FLEXPEN 53NOVOLOG MIX 70/30 53

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

53

NOVOLOG PENFILL 53NOXAFIL 29

NPLATE 56NUEDEXTA 73

NULOJIX 96NUPLAZID 43

NUTRILIPID 102NUTROPIN AQ NUSPIN 10 86NUTROPIN AQ NUSPIN 20 86NUTROPIN AQ NUSPIN 5 86

NUTROPIN AQ PEN 86NUVARING 90

nyamyc 29NYMALIZE 65

nystatin 29nystatin/triamcinolone 29

nystop 29OCALIVA 78

ocella 90OCTAGAM 98

octreotide acetate 94OCUDOX 18ODEFSEY 47ODOMZO 35

OFEV 110ofloxacin 17ogestrel 90

olanzapine 43olanzapine odt 43

olanzapine/fluoxetine 25olopatadine hcl 104olopatadine hcl 107

OLYSIO 46omega-3-acid ethyl esters 69

omeprazole 80omeprazole/sodium bicarbonate 80

OMNITROPE 86ONCASPAR 35

Drug Name Page #ondansetron hcl 28ondansetron odt 28

ONFI 20ONGLYZA 52

ONMEL 29OPANA ER (CRUSH RESISTANT) 3

OPDIVO 38opium 6

opium tincture 6OPSUMIT 109ORACEA 75

oralone 74ORBACTIV 10

ORENCIA 96ORENITRAM 109

ORFADIN 77ORFADIN 102

ORKAMBI 108orphenadrine citrate er 110

orsythia 90osmitrol viaflex 66

OTEZLA 99oxacillin sodium 15

oxaliplatin 35oxandrolone 86

oxaprozin 2oxazepam 50

oxcarbazepine 22oxiconazole nitrate 29

OXISTAT 29OXSORALEN 75

oxybutynin chloride 80oxybutynin chloride er 80

oxycodone hcl 6oxycodone hcl er 3

oxycodone/acetaminophen 6oxycodone/aspirin 6

oxycodone/ibuprofen 6oxymorphone hydrochloride 6

oxymorphone hydrochloride er 3pacerone 60paclitaxel 36

paliperidone er 43pamidronate disodium 101

PANDEL 84PANRETIN 39

pantoprazole sodium 80paricalcitol 101

paroex 74

of 143

Drug Name Page #paromomycin sulfate 9

paroxetine hcl 25paroxetine hcl er 25

PASER 31PATADAY 104PATANOL 104

PAXIL 25PAZEO 104

PCE 16PEDIARIX 100

PEDVAX HIB 100peg 3350/electrolytes 79peg-3350/electrolytes 79

peg-3350/nacl/na bicarbonate/kcl 79PEGANONE 22

PEGASYS 46PEGASYS PROCLICK 46

PEGINTRON 46PEG-INTRON 46

PEG-INTRON REDIPEN 46penicillin g potassium 15

penicillin g potassium in iso-osmotic dextrose

15

penicillin g sodium 15penicillin v potassium 15

PENNSAID 75PENTACEL 100

PENTAM 300 39PENTASA 100

pentazocine/naloxone hcl 6pentoxifylline cr 66pentoxifylline er 66

PERFOROMIST 108perindopril erbumine 59

periogard 74PERJETA 38

permethrin 39perphenazine 42

perphenazine/amitriptyline 27PEXEVA 25

pfizerpen-g 15phenadoz 27

phenelzine sulfate 24phenergan 27

phenobarbital 20phenobarbital sodium 111

phenoxybenzamine hydrochloride 57phenylephrine hcl 57

PHENYTEK 22

Drug Name Page #phenytoin 22

phenytoin sodium 22phenytoin sodium extended 22

philith 90PHOSPHOLINE IODIDE 105

PHYSIOLYTE 102PHYSIOSOL IRRIGATION 102

PICATO 76pilocarpine hcl 74pilocarpine hcl 105

pilocarpine hydrochloride 74pimozide 42pimtrea 90pindolol 62

pioglitazone hcl 52pioglitazone hcl/metformin hcl 52

pioglitazone hcl-glimepiride 52piperacillin sodium/ tazobactam sodium 15piperacillin sodium/tazobactam sodium 15

piperacillin/tazobactam 15pirmella 1/35 90

pirmella 7/7/7 90piroxicam 2

PLASMA-LYTE A 117PLASMA-LYTE-148 117

PLASMA-LYTE-56/D5W 117PLEGRIDY 73

PLEGRIDY STARTER PACK 73plenamine 117

PLIAGLIS 7podofilox 76

polycin 103polyethylene glycol 3350 79

polymyxin b sulfate 10polymyxin b sulfate/trimethoprim sulfate 103

POMALYST 32portia-28 90

PORTRAZZA 36potassium acetate 117

potassium chloride 117potassium chloride 0.15% /nacl 0.45%

viaflex117

potassium chloride 0.15% d5w/nacl 0.33% 117potassium chloride 0.15% d5w/nacl 0.45% 117

potassium chloride 0.15%/nacl 0.9% 117potassium chloride 0.22% d5w/nacl 0.45% 117

potassium chloride 0.224%/d5w/nacl 0.45% 117potassium chloride 0.3%/ nacl 0.9% 117

potassium chloride 0.3%/d5w 117

of 143

Drug Name Page #potassium chloride cr 117potassium chloride er 117potassium chloride sr 117

potassium citrate er 117POTIGA 19

PRADAXA 55PRALUENT 67

pramipexole dihydrochloride 40pramipexole dihydrochloride er 40

pravastatin sodium 69prazosin hcl 57

PRED MILD 104PRED-G 104

PRED-G S.O.P. 104prednicarbate 84prednisolone 84

prednisolone acetate 104prednisolone sodium phosphate 84prednisolone sodium phosphate 104

prednisone 84prednisone intensol 84

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL

86

PREMARIN 90PREMASOL 117

PREMPHASE 90PREMPRO 90PREPOPIK 79

prevalite 69previfem 91

PREZCOBIX 48PREZISTA 48

PRIFTIN 31PRILOSEC 80

primaquine phosphate 39primidone 20

PRIMLEV 6PRIMSOL 10

PRISTIQ 25PRIVIGEN 98

PROAIR HFA 108PROAIR RESPICLICK 108

probenecid 30probenecid/colchicine 30

procainamide hcl 60PROCALAMINE 118prochlorperazine 42

prochlorperazine edisylate 42prochlorperazine maleate 42

Drug Name Page #PROCRIT 56

procto-med hc 85procto-pak 85

proctosol hc 85proctozone-hc 85

PROCYSBI 103progesterone 92

PROGLYCEM 53PROGRAF 96

PROLASTIN-C 110PROLENSA 104

PROLEUKIN 36PROLIA 101

PROMACTA 56promethazine hcl 27promethazine vc 110

promethazine vc plain 110promethazine/phenylephrine 110

promethegan 27propafenone hcl 61

propafenone hcl er 61propantheline bromide 78

proparacaine hcl 103propranolol hcl 62

propranolol hcl er 62propranolol/hydrochlorothiazide 63

propylthiouracil 95PROQUAD 100

PROSOL 118protriptyline hcl 27

PSORCON 85PULMOZYME 108

PURIXAN 33PYLERA 78

pyrazinamide 31pyridostigmine bromide 31

QUADRACEL 100quasense 91

quetiapine fumarate 43quinapril hcl 59

quinapril/hydrochlorothiazide 59quinidine gluconate 61

quinidine gluconate cr 61quinidine gluconate er 61

quinidine sulfate 61quinidine sulfate er 61

quinine sulfate 39QVAR 106

RABAVERT 100

of 143

Drug Name Page #rabeprazole sodium 80

raloxifene hydrochloride 92ramipril 60

RANEXA 67ranitidine hcl 79

RAPAFLO 81RAPAMUNE 96

RAVICTI 77RAYOS 85

REBETOL 46REBIF 74

REBIF REBIDOSE 74REBIF REBIDOSE TITRATION PACK 74

REBIF TITRATION PACK 74reclipsen 91

RECOMBIVAX HB 100RECTIV 70

REGONOL 31REGRANEX 76

relador pak 7relador pak plus 7

RELENZA DISKHALER 49RELISTOR 78

REMICADE 96REMODULIN 109

RENAGEL 81RENVELA 81repaglinide 52

repaglinide/metformin hydrochloride 52REPATHA 67

REPATHA SURECLICK 67reprexain 6

RESCRIPTOR 47RESTASIS 103

RETROVIR IV INFUSION 47REVATIO 109

REVLIMID 32REXULTI 44

REYATAZ 48RHEUMATREX 96

RHOGAM ULTRA-FILTERED PLUS 98RHOPHYLAC 98

ribasphere 46ribasphere ribapak 46

RIBATAB 46ribavirin 46

RIDAURA 99rifabutin 31rifampin 31

Drug Name Page #RIFATER 31

riluzole 73rimantadine hcl 49

ringers injection 118ringers irrigation 102

RIOMET 52risedronate sodium 101

risedronate sodium dr 101RISPERDAL CONSTA 44

risperidone 44risperidone odt 44

RITALIN LA 72RITUXAN 38

rivastigmine tartrate 22rivastigmine transdermal system 23

rizatriptan benzoate 30rizatriptan benzoate odt 30

ropinirole er 40ropinirole hcl 40

rosadan 11ROSADAN KIT 10

rosuvastatin calcium 69ROTARIX 100ROTATEQ 100

roweepra 19roxicet 6

ROZEREM 111RUCONEST 95

SABRIL 20SAIZEN 86

SAIZEN CLICK.EASY 86SAMSCA 111

SANCUSO 28SANDIMMUNE 97

SANDOSTATIN LAR DEPOT 94SANTYL 76SAPHRIS 44

SAVAYSA 55SAVELLA 73

SAVELLA TITRATION PACK 73selegiline hcl 41

selenium sulfide 76SELZENTRY 48SEMPREX-D 107

SENSIPAR 94SEREVENT DISKUS 108

SEROSTIM 86sertraline hcl 25

setlakin 91

of 143

Drug Name Page #sharobel 92

SIGNIFOR 94SIGNIFOR LAR 94

sildenafil 109SILENOR 111

silver sulfadiazine 11SIMBRINZA 105

SIMPONI 97SIMPONI ARIA 97

SIMULECT 99simvastatin 69

sirolimus 97SIRTURO 31

SIVEXTRO 11SKLICE 39

sodium acetate 111sodium chloride 118

sodium chloride 0.45% viaflex 118sodium chloride 0.9% 118

sodium fluoride 118sodium lactate 111

sodium phenylacetate/sodium benzoate 102sodium phenylbutyrate 77

sodium phosphate 118sodium polystyrene sulfonate 111

sodium sulfacetamide 17SOLIRIS 102

SOLTAMOX 33SOLU-CORTEF 85

SOLU-MEDROL 85SOMATULINE DEPOT 94

SOMAVERT 95sorine 61

sotalol hcl 61sotalol hcl (af) 61

sotalol hydrochloride 61SOVALDI 46

SPIRIVA HANDIHALER 107SPIRIVA RESPIMAT 107

spironolactone 67spironolactone/hydrochlorothiazide 67

SPORANOX 29sprintec 28 91SPRITAM 19SPRYCEL 38

sps 112sronyx 91

ssd 11STALEVO 100 41

Drug Name Page #STALEVO 125 41STALEVO 150 41STALEVO 200 41STALEVO 50 41STALEVO 75 41

stavudine 47STELARA 76

sterile water irrigation 102STIMATE 86

STIOLTO RESPIMAT 110STIVARGA 38

STRATTERA 72STRENSIQ 77

streptomycin sulfate 9STRIANT 87

STRIBILD 47STRIVERDI RESPIMAT 108

SUBOXONE 8SUBSYS 6

SUCRAID 77SUCRALFATE 80

sulfacetamide sodium 17sulfacetamide sodium/prednisolone sodium

phosphate104

sulfadiazine 17sulfamethoxazole/trimethoprim 17

sulfamethoxazole/trimethoprim ds 17SULFAMYLON 11

sulfasalazine 100sulfatrim pediatric 17

sulfazine 101sulindac 8

SUMATRIPTAN 30SUMATRIPTAN SUCCINATE 30

SUMATRIPTAN SUCCINATE REFILL 30SUPRAX 13

SUPREP BOWEL PREP 79SUSTIVA 47SUTENT 38

syeda 91SYLATRON 36

SYLVANT 39SYMBICORT 106

SYMLINPEN 120 52SYMLINPEN 60 52

SYNAGIS 99SYNALAR CREAM KIT 76

SYNALAR OINTMENT KIT 76SYNAREL 95

of 143

Drug Name Page #SYNERCID 11SYNJARDY 52

SYNRIBO 36SYNTHROID 93

SYPRINE 112TABLOID 33

TACLONEX 76tacrolimus 76tacrolimus 97

TAFINLAR 38TAGRISSO 36

TALTZ 76TAMIFLU 49

tamoxifen citrate 33tamsulosin hcl 81

TARCEVA 38TARGRETIN 39tarina fe 1/20 91

TASIGNA 38tazicef 13

TAZORAC 76taztia xt 65

TECENTRIQ 39TECFIDERA 74

TECFIDERA STARTER PACK 74TECHNIVIE 46

TEFLARO 13TEGRETOL 22

TEGRETOL-XR 22telmisartan 58

telmisartan/amlodipine 58telmisartan/hydrochlorothiazide 58

temazepam 111TEMODAR 32

tencon 73TENIVAC 100

terazosin hcl 81terbinafine hcl 29

terbutaline sulfate 108terconazole 29

testosterone cypionate 87testosterone enanthate 87

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

100

tetrabenazine 73TETRACYCLINE HCL 18

THALOMID 32theophylline 109

theophylline anhydrous cr 109

Drug Name Page #theophylline cr 109theophylline er 109

theophylline/d5w 109THERACYS 36

thioridazine hcl 42thiotepa 32

thiothixene 42THYMOGLOBULIN 98

THYROLAR-1 93THYROLAR-1/2 93THYROLAR-1/4 93

THYROLAR-2 93THYROLAR-3 93

tiagabine hydrochloride 20TICE BCG 36

ticlopidine hcl 57TIKOSYN 61

tilia fe 91timolol maleate 63timolol maleate 105

timolol maleate ophthalmic gel forming 105tinidazole 39

TIROSINT 93tis-u-sol 102

TIVICAY 47tizanidine hcl 45

TOBI PODHALER 108TOBRADEX 104

TOBRADEX ST 104tobramycin 108

tobramycin sulfate 9tobramycin/dexamethasone 104

TOBREX 9tolazamide 53

tolbutamide 53tolcapone 40

tolmetin sodium 2tolterodine tartrate 80

tolterodine tartrate er 80topiramate 21

topiramate er 21toposar 36

topotecan hcl 37TORISEL 97torsemide 67

TOUJEO SOLOSTAR 53TOVIAZ 81

tpn electrolytes 118TRADJENTA 53

of 143

Drug Name Page #tramadol hcl 6

tramadol hcl er 4tramadol hydrochloride/acetaminophen 6

trandolapril 60trandolapril/verapamil hcl 60

trandolapril/verapamil hcl er 60tranexamic acid 56

TRANSDERM-SCOP 27tranylcypromine sulfate 24

TRAVASOL 118TRAVATAN Z 103

travoprost 103trazodone hcl 24

TREANDA 32TRECATOR 31TRELSTAR 95

TRELSTAR MIXJECT 95tretinoin 39tretinoin 76

tretinoin microsphere 76tretinoin microsphere pump 76

TREXALL 97triamcinolone acetonide 74triamcinolone acetonide 85triamcinolone acetonide 106

triamcinolone in orabase 74triamterene/hydrochlorothiazide 67

triderm 85tri-estarylla 91

trifluoperazine hcl 42trifluridine 49

trihexyphenidyl hcl 40tri-legest fe 91

tri-linyah 91tri-lo-estarylla 91

tri-lo-marzia 91tri-lo-sprintec 91

trilyte 79trimethobenzamide hcl 27

trimethoprim 11trimethoprim/polymyxin b 103

trimipramine maleate 27trinessa 91

trinessa lo 91TRINTELLIX 24

triple antibiotic 103tri-previfem 91TRISENOX 36tri-sprintec 91

Drug Name Page #TRIUMEQ 48trivora-28 91

TROPHAMINE 118trospium chloride 81

trospium chloride er 81TRULICITY 53

TRUMENBA 100TRUVADA 48

TUDORZA PRESSAIR 107TWINRIX 100TYBOST 48

TYGACIL 11TYKERB 38

TYPHIM VI 100TYSABRI 74TYVASO 109

TYVASO REFILL 109TYVASO STARTER 109

TYZEKA 46TYZINE PEDIATRIC NASAL DROPS 110

UCERIS 85ULESFIA 39ULORIC 30unithroid 93

UNITUXIN 39UPTRAVI 109

ursodiol 78UVADEX 76

VAGIFEM 91valacyclovir hcl 49

VALCHLOR 32VALCYTE 45

valganciclovir 45valproate sodium 20

valproic acid 20valsartan 58

valsartan/hydrochlorothiazide 58VALSTAR 36

vanatol lq 73vancomycin hcl 11

vancomycin hcl in dextrose 11vandazole 11

VAQTA 100VARIVAX 100VARIZIG 100

VASCEPA 69VECTIBIX 39VELCADE 36VELETRI 110

of 143

Drug Name Page #velivet 91

VELPHORO 82VELTIN 76

VENCLEXTA 36VENCLEXTA STARTING PACK 36

venlafaxine hcl 25venlafaxine hcl er 25

VENTAVIS 110verapamil hcl 65

verapamil hcl cr 65verapamil hcl er 65verapamil hcl sr 65

VEREGEN 76VERIPRED 20 85VERSACLOZ 45

VESICARE 81vestura 91

VEXOL 104V-GO 20 102V-GO 30 102V-GO 40 102

VIBATIV 11VIBRAMYCIN 18

vicodin 6vicodin es 6vicodin hp 6VICTOZA 53

VIDEX PEDIATRIC 48VIEKIRA PAK 46

vienva 91VIGAMOX 17

VIIBRYD 26VIIBRYD STARTER PACK 26

VIMIZIM 77VIMPAT 22

vinblastine sulfate 36vincasar pfs 36

vincristine sulfate 36vinorelbine tartrate 36

viorele 91VIRACEPT 49VIRAZOLE 110

VIREAD 48VISTOGARD 102

VITEKTA 47VIVITROL 7

VOLTAREN 76voriconazole 29VOTRIENT 38

Drug Name Page #vp-pnv-dha 118

VPRIV 77VRAYLAR 44

vyfemla 91warfarin sodium 55

WELCHOL 69wera 91

wymzya fe 91XALKORI 38XARELTO 55

XARELTO STARTER PACK 55XELJANZ 99

XELJANZ XR 99XEOMIN 103XGEVA 101

XIAFLEX 77XIFAXAN 11

XOFIGO 36XOLAIR 110

XOPENEX HFA 108XTANDI 32

xulane 91XURIDEN 103

xylocaine dental 7xylon 6

XYREM 111YERVOY 39YF-VAX 100

YONDELIS 32zafirlukast 107

zaleplon 111ZALTRAP 36ZANOSAR 32

zarah 91ZARXIO 56

ZAVESCA 77zazole 30

zebutal 73ZELAPAR 41

ZELBORAF 38ZEMAIRA 110

zenatane 76zenchent 91

zenchent fe 91ZENPEP 77

ZENZEDI 71ZEPATIER 46

ZETIA 69ZEVALIN Y-90 39

of 143

Drug Name Page #ZIAGEN 48

zidovudine 48zinacef 13

ziprasidone hcl 44ZIPSOR 2

ZIRGAN 45ZMAX 16

ZOLADEX 95zoledronic acid 102

ZOLINZA 36zolmitriptan 30

zolmitriptan odt 30zolpidem tartrate 111

zolpidem tartrate er 111zonisamide 19

ZORBTIVE 86ZORTRESS 97

ZOSTAVAX 100ZOSYN 15

zovia 1/35e 91zovia 1/50e 91ZOVIRAX 49ZUBSOLV 8ZYCLARA 76

ZYCLARA PUMP 76ZYDELIG 37

ZYFLO 107ZYFLO CR 107ZYKADIA 36

ZYLET 104ZYPREXA RELPREVV 44

ZYTIGA 32

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This formulary was updated on . For more recent information or other questions, please contact Trillium Medicare Advantage Member Services, at 1-844-867-1156 or, for TTY users, 711. October 1 - February 14, seven days a week, 8 a.m. to 8 p.m.; February 15 - September 30, Monday - Friday, 8 a.m. to 8 p.m., or visit http://trilliumadvantage.com.

Trillium Medicare Advantage UO Riverfront Research Park 1800 Millrace Drive Eugene, OR 97403

http://trilliumadvantage.com

The Formulary may change at any time. You will receive notice when necessary.

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FORMULARY (LIST OF COVERED DRUGS) - Advantage · 2020-06-27 · tablets per prescription for...

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