Iron Road Healthcare Medicare Part D Prescription Drug Plan (PDP)€¦ · Prescription Drug Plan...

Optum Insurance of Ohio, Inc. is a Medicare-approved Part D sponsor and administers this plan through its pharmacy benefit manager, OptumRx, on behalf of your trustees of a fund. If you need this information in another language or alternate format (Braille, large print, audio), please contact OptumRx at the number listed on your member ID card. Formulary ID 20067 Version 12 S8841_20_MC-DS11_UNP_C

Iron Road Healthcare Medicare Part D Prescription Drug Plan (PDP) Your 2020 Comprehensive Formulary (list of covered drugs)

Sponsored by UPREHS, administered by OptumRx® Effective January 1, 2020 – December 1, 2020

Please read: this document contains information about the drugs we cover in this plan.

This comprehensive formulary was updated on 1/1/2020, and is not a complete list of drugs covered by our plan. For more recent information or if you have questions, please contact:

OptumRx Member Services

Phone (toll-free): 1-866-443-1095 TTY users: 711 Hours of operation: 24 hours a day, 7 days a week Website: optumrx.com

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means OptumRx. When it refers to “plan” or “our plan,” it means Iron Road Healthcare Medicare Part D Prescription Drug Plan. In most instances, you must use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, 2021.

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What is the Comprehensive Formulary?

A formulary is a list of covered drugs selected by UPREHS in consultation with OptumRx and a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. This plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, and other plan rules are followed. Can the formulary (drug list) change?

Yes. If you are taking a drug on our 2020 formulary that is covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 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. If we make a negative change to our formulary (i.e. add prior authorization, quantity limit, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, if applicable), we must notify affected members. Members will receive a notice regarding the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug. The member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) 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 02/01/2020. To get updated information about covered drugs, please contact OptumRx. You may also visit our website at optum.com where you will find the most up-to-date information about our list of covered drugs (formulary) by using the “Drug Information” tool (found under the “Member Tools” tab). Our contact information is shown on the front and back cover pages. How do I use the formulary?

There are two ways to find your drug within the formulary:

• Medical Condition

The formulary begins on 8. The drugs in this formulary are grouped into categories depending on the type of medical condition(s) 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 8. Then, look under the category name for your drug.

• Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on 104. The Index provides an alphabetical list of all drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index.

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Formulary design

The formulary structure features preferred and non-preferred generic drugs, preferred brand-name drugs, non-preferred brand-name drugs, and high-cost drugs.

Drug Tier Helpful Tips

Tier 1 Preferred generic drugs are listed under Tier 1 and have the lowest copayments.

Tier 2 Drugs listed under Tier 2 include non-preferred generic drugs that have higher copayments than preferred generic drugs.

Tier 3 Drugs listed under Tier 3 include preferred brand-name drugs that have lower copayments than non-preferred brand-name drugs.

Tier 4 Drugs listed under Tier 4 include non-preferred brand-name drugs that higher copayments than preferred brand-name drugs.

Tier 5 Specialty or high-cost drugs listed under Tier 5 cost $670 or more for up to a 30-day maximum supply.

Covered Prescription

Drugs

Retail Pharmacy

(up to a

30-day supply)

Retail Pharmacy

(up to a

90-day supply)

Depot Drug Preferred

Mail-Order Pharmacy

(up to a 90-day supply)

Non-Preferred Home Delivery

Pharmacy (up to a

90-day supply)

Tier 1 (Preferred Generic)

$15 $45 $9 $45

Tier 2 (Non-Preferred Generic)

$20 $60 $30 $60

Tier 3 (Preferred Brand)

$30 $90 $45 $90

Tier 4 (Non-Preferred Brand)

Greater of: $90 or 33%




Tier 5 (High-Cost)*

33% n/a n/a n/a

* High-Cost drugs are those that cost $670 or more for up to a 30-day maximum supply. You must obtain a 90-day supply of Tier 1 Generics when using Depot Drug mail. If you need less than a 90-day supply of Tier 1 Generics, you must use a retail network pharmacy. You may obtain a 30, 60, or 90-day supply of Tier 2, 3, or 4 prescription drugs from Depot Drug mail. If you use a mail-order pharmacy outside of the plan’s network, your prescription will not be covered.

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Please refer to your Evidence of Coverage for more information. What are generic drugs?

Our plan 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 (PA) You or your physician may need to get prior authorization for certain drugs. This means you will need to get approval from OptumRx before you fill your prescriptions. If you do not get approval, the drug may not be covered.

Quantity Limits (QL) For certain drugs, there is a limit on the amount of the drug we will cover.

Step Therapy (ST) In some cases, it is required that you first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

To find out if your drug has any additional requirements or limits, look in the formulary that begins on 8. You can also get more information about restrictions applied to specific covered drugs by visiting our website or by calling OptumRx. Our contact information, along with the date we last updated the formulary, is shown on the front and back cover pages. You can ask OptumRx to make an exception to these restrictions or limits, or for a list of other similar drugs that may treat your health condition. See the section “How do I request an exception to the formulary?” on page 5 for additional information. 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 OptumRx and ask if your drug is covered. This document includes only a partial list of covered drugs, so we may cover your drug. Our contact information, along with the date we last updated the formulary, is shown on the front and back cover pages. If your drug is not covered, you have two options:

• You can ask OptumRx for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. • You can ask OptumRx to make an exception and cover your drug. See below for information about how to request an exception.

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How do I request an exception to the formulary?

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

• You can ask us to cover a drug even if it is not on our formulary. If approved, the drug will be covered at a predetermined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not in the high-cost drug tier. If approved, this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Please Note: If we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Generally, we will only approve your request for an exception if the drug is included on the plan’s formulary, or if 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 OptumRx for an initial coverage decision for a formulary, tier, or utilization restriction exception. When you request a formulary, tier, or utilization restriction exception, you must submit a statement from your doctor (or other prescriber) supporting your request. Generally, we must make our decision within 72 hours of getting your doctor’s (or other 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 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 (or other prescriber) to decide if you should switch to an appropriate drug that we cover or request a formulary exception. While you talk to your doctor (or other prescriber) 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 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.

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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 31-day transition supply, written for as many pills as necessary, 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 get a formulary exception. If you are a current enrollee with a level-of-care change and you need a drug that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days) while you seek a formulary exception. If you are in the process of seeking an exception, we will consider allowing continued coverage until a decision is made.

For more information For more detailed information about your prescription drug coverage, please review your other plan materials. If you have questions about the plan, please call OptumRx. Our contact information, along with the date we last updated the formulary, is shown 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), TTY 1-877-486-2048, 24 hours a day, 7 days a week. You may also visit medicare.gov.

Formulary The formulary below provides coverage information about some of your covered drugs. If you have trouble finding your drug in the list, turn to the Index that begins on 103. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., COZAAR), and generic drugs are listed in lower-case italics (e.g., atenolol). The abbreviations in the “Requirements/Limits” column tell you if there are any special requirements for coverage of your drug

Requirements/Limits Helpful Tips

B/D

This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

NDS Non-Extended Days' Supply. This prescription drug is not available for an extended days' supply.

PA

Prior Authorization. Our plan requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from OptumRx before you fill your prescriptions. If you do not get approval, your drug may not be covered.

QL Quantity Limit. For certain drugs, our plan limits the amount of the drug we will cover.

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ST

Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Formulary ID 20067 Effective Date: 2/1/2020 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

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Drug Name Drug Tier Requirements/Limits

Analgesics

Analgesics

butalbital-acetaminophen oral capsule

4 PA

butalbital-acetaminophen oral tablet

4 PA

butalbital-apap-caffeine oral capsule 4 PA

capacet oral capsule 50-325-40 mg 4 PA

esgic oral capsule 4 PA marten-tab oral tablet 50-325 mg 4 PA

phrenilin forte oral capsule 4 PA

tencon oral tablet 4 PA zebutal oral capsule 4 PA Nonsteroidal Anti-inflammatory Drugs

celecoxib oral capsule 2 QL (60 EA per 30 days) diclofenac potassium oral tablet 4

diclofenac sodium er oral tablet extended release 24 hour

4

diclofenac sodium oral tablet delayed release 4

diclofenac sodium transdermal gel 1 % 2

QL (1000 GM per 30 days)

diclofenac sodium transdermal gel 3 % 4

diclofenac-misoprostol oral tablet delayed release

4

diflunisal oral tablet 2 etodolac er oral tablet extended release 24 hour

2


etodolac oral capsule 2 etodolac oral tablet 2 fenoprofen calcium oral capsule 400 mg 4

fenoprofen calcium oral tablet 4

flurbiprofen oral tablet 2 ibu oral tablet 600 mg, 800 mg 1

ibuprofen oral suspension 2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

indomethacin er oral capsule extended release

4

indomethacin oral capsule 4

INDOMETHACIN SODIUM INTRAVENOUS SOLUTION RECONSTITUTED

4

ketoprofen er oral capsule extended release 24 hour

4

ketoprofen oral capsule 2 ketorolac tromethamine injection solution 4

ketorolac tromethamine intramuscular solution 4

ketorolac tromethamine oral tablet 4

QL (20 EA per 30 days)

meclofenamate sodium oral capsule 4

mefenamic acid oral capsule 4

meloxicam oral tablet 1 nabumetone oral tablet 2 naproxen dr oral tablet delayed release 2


9


naproxen oral suspension 2

naproxen oral tablet 1 naproxen sodium er oral tablet extended release 24 hour 375 mg

2

naproxen sodium oral tablet 275 mg, 550 mg 2

oxaprozin oral tablet 2 piroxicam oral capsule 2 profeno oral tablet 600 mg 4

SPRIX NASAL SOLUTION 5


sulindac oral tablet 1 tolmetin sodium oral capsule 4

tolmetin sodium oral tablet 4

Opioid Analgesics, Long-acting

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG

4 ST; NDS

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 30 MG, 60 MG

5 ST; NDS

buprenorphine hcl injection solution 5

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

3 QL (4 EA per 28 days); NDS

buprenorphine transdermal patch weekly 7.5 mcg/hr



BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR


EMBEDA ORAL CAPSULE EXTENDED RELEASE

3 NDS

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 75 mcg/hr

4 NDS

fentanyl transdermal patch 72 hour 62.5 mcg/hr, 87.5 mcg/hr

5 NDS

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 8 mg

4 NDS

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 16 mg

4

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 32 mg

5 NDS

INFUMORPH 200 INJECTION SOLUTION 4 NDS

INFUMORPH 500 INJECTION SOLUTION 4 NDS

levorphanol tartrate oral tablet 5 NDS

methadone hcl injection solution 4 NDS

methadone hcl intensol oral concentrate 2 NDS

methadone hcl oral concentrate 2 NDS

methadone hcl oral solution 2 NDS

methadone hcl oral tablet 2 NDS

methadose oral concentrate 10 mg/ml 2 NDS


10


methadose sugar-free oral concentrate 2 NDS

mitigo injection solution 2 NDS morphine sulfate er beads oral capsule extended release 24 hour

4 NDS

morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

4 NDS

morphine sulfate er oral capsule extended release 24 hour 100 mg

5 NDS

morphine sulfate er oral capsule extended release 24 hour 40 mg

4

morphine sulfate er oral tablet extended release 2 NDS

oxymorphone hcl er oral tablet extended release 12 hour

4 NDS

tramadol hcl er (biphasic) oral tablet extended release 24 hour

4 NDS

tramadol hcl er oral tablet extended release 24 hour

4 NDS

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT

3 NDS

Opioid Analgesics, Short-acting

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL

5 PA; NDS

acetaminophen-codeine #2 oral tablet 2 NDS




acetaminophen-codeine oral solution 1 NDS

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

2 NDS

ascomp-codeine oral capsule 4 PA; NDS

butalbital-apap-caff-cod oral capsule 4 PA; NDS

butalbital-asa-caff-codeine oral capsule 4 PA; NDS

butorphanol tartrate injection solution 4 NDS

butorphanol tartrate nasal solution 2 NDS

codeine sulfate oral tablet 2 NDS

DURAMORPH INJECTION SOLUTION 2 NDS

endocet oral tablet 2 NDS fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

4 B/D; NDS

fentanyl citrate (pf) injection solution 50 mcg/ml

4 B/D

fentanyl citrate (pf) injection solution cartridge

4 B/D; NDS

fentanyl citrate buccal lozenge on a handle 5 PA; NDS

fentanyl citrate buccal tablet 5 PA

hydrocodone-acetaminophen oral solution 10-325 mg/15ml

5


11


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

2 NDS

hydrocodone-acetaminophen oral tablet 10-300 mg

4 NDS

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

2 NDS

hydrocodone-ibuprofen oral tablet 2 NDS

hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

2 NDS

hydromorphone hcl oral liquid 2 NDS

hydromorphone hcl oral tablet 2 NDS

hydromorphone hcl pf injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

2

hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml

2 NDS

ibudone oral tablet 5-200 mg 2 NDS

LAZANDA NASAL SOLUTION 5 PA; NDS

lorcet hd oral tablet 2 NDS lorcet oral tablet 2 NDS lorcet plus oral tablet 2 NDS morphine sulfate (concentrate) oral solution 100 mg/5ml

2 NDS


morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 2 mg/ml

2 NDS

morphine sulfate (pf) injection solution 10 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

2 B/D; NDS

morphine sulfate (pf) intravenous solution 2 NDS

morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml

2 NDS

morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml

2 B/D; NDS

morphine sulfate oral solution 2 NDS

MORPHINE SULFATE ORAL TABLET 2 NDS

nalbuphine hcl injection solution 4 NDS

OXAYDO ORAL TABLET ABUSE-DETERRENT

5 NDS

oxycodone hcl oral capsule 2 NDS

oxycodone hcl oral concentrate 100 mg/5ml 4 NDS

oxycodone hcl oral solution 2 NDS

oxycodone hcl oral tablet 2 NDS

oxycodone-acetaminophen oral solution 5-325 mg/5ml

2 NDS

oxycodone-acetaminophen oral tablet

2 NDS

oxycodone-aspirin oral tablet 2 NDS


12


oxycodone-ibuprofen oral tablet 2 NDS

oxymorphone hcl oral tablet 2 NDS

pentazocine-naloxone hcl oral tablet 4 NDS

primlev oral tablet 10-300 mg 5 NDS

primlev oral tablet 5-300 mg, 7.5-300 mg 4 NDS

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG

5 NDS

tramadol hcl oral tablet 1 NDS tramadol-acetaminophen oral tablet

2 NDS

verdrocet oral tablet 2.5-325 mg 2 NDS

vicodin es oral tablet 2 NDS vicodin hp oral tablet 4 NDS vicodin oral tablet 5-300 mg 2 NDS

xylon oral tablet 10-200 mg 2 NDS

Anesthetics

Local Anesthetics

7t lido external gel 2 PA; QL (30 GM per 30 days) chloroprocaine hcl (pf) injection solution 4

glydo external gel 2 % 2 PA; QL (30 ML per 30 days)

lidocaine external ointment 4

PA; QL (150 GM per 30 days)

lidocaine external patch 4 PA lidocaine hcl (pf) injection solution 2


lidocaine hcl external gel 2 % 2

PA; QL (30 EA per 30 days)

lidocaine hcl external solution 2

PA; QL (250 ML per 30 days)

lidocaine hcl injection solution 2

lidocaine hcl urethral/mucosal external gel

2 PA; QL (30 ML per 30 days)

lidocaine in dextrose solution 4

lidocaine-prilocaine external cream 2


lidocaine-tetracaine external cream 4


PLIAGLIS EXTERNAL CREAM 4


polocaine injection solution 4

polocaine-mpf injection solution 4

premium lidocaine external ointment 4


Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium oral tablet delayed release

2

disulfiram oral tablet 2 VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED

5

Opioid Dependence Treatments


13


buprenorphine hcl sublingual tablet sublingual

2

buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4-1 mg

4 QL (60 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual film 8-2 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


LUCEMYRA ORAL TABLET 5


naltrexone hcl oral tablet 2

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG


SUBOXONE SUBLINGUAL FILM 2-0.5 MG


Opioid Reversal Agents

naloxone hcl injection solution 2

naloxone hcl injection solution cartridge 2

naloxone hcl injection solution prefilled syringe 2

NARCAN NASAL LIQUID 3

Smoking Cessation Agents


bupropion hcl er (smoking det) oral tablet extended release 12 hour


CHANTIX CONTINUING MONTH PAK ORAL TABLET


CHANTIX ORAL TABLET 3


CHANTIX STARTING MONTH PAK ORAL TABLET


NICOTROL INHALATION INHALER 4


NICOTROL NS NASAL SOLUTION 3

QL (360 ML per 365 days)

Antibacterials

Aminoglycosides

amikacin sulfate injection solution 2

gentak ophthalmic ointment 2

gentamicin in saline intravenous solution 2

gentamicin sulfate external cream 2

gentamicin sulfate external ointment 2

gentamicin sulfate injection solution 2

gentamicin sulfate intravenous solution 10 mg/ml

2

gentamicin sulfate ophthalmic solution 1

neomycin sulfate oral tablet 2

neomycin-polymyxin b gu irrigation solution 2

paromomycin sulfate oral capsule 4


14


streptomycin sulfate intramuscular solution reconstituted

4

tobramycin ophthalmic solution 1

tobramycin sulfate injection solution 2

tobramycin sulfate injection solution reconstituted

2

TOBREX OPHTHALMIC OINTMENT

4

Antibacterials, Other

ALTABAX EXTERNAL OINTMENT 4

baciim intramuscular solution reconstituted 2

bacitracin intramuscular solution reconstituted 2

bacitracin ophthalmic ointment 2

BACTROBAN NASAL NASAL OINTMENT 2 % 4

chloramphenicol sod succinate intravenous solution reconstituted

4

CLEOCIN VAGINAL SUPPOSITORY 4

clindacin etz external swab 2

clindacin-p external swab 2

clindamycin hcl oral capsule 2

clindamycin palmitate hcl oral solution reconstituted

2

clindamycin phosphate external foam 4

clindamycin phosphate external gel 2


clindamycin phosphate external lotion 2

clindamycin phosphate external solution 2

clindamycin phosphate external swab 2

clindamycin phosphate in d5w intravenous solution

2

clindamycin phosphate in nacl intravenous solution

2

clindamycin phosphate injection solution 2

clindamycin phosphate intravenous solution 2

clindamycin phosphate vaginal cream 2

CLINDESSE VAGINAL CREAM 4

colistimethate sodium (cba) injection solution reconstituted

4

CORTISPORIN EXTERNAL CREAM 4

CORTISPORIN EXTERNAL OINTMENT 4

DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED

5

DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

5

daptomycin intravenous solution reconstituted 500 mg

5

IMPAVIDO ORAL CAPSULE 5

lincomycin hcl injection solution 2


15


LINEZOLID IN SODIUM CHLORIDE INTRAVENOUS SOLUTION

5

linezolid intravenous solution 5

linezolid oral suspension reconstituted

5 QL (1800 ML per 28 days)

linezolid oral tablet 4 QL (56 EA per 28 days) mafenide acetate external packet 4

methenamine hippurate oral tablet 2

METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/100ML-%

4

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

2

metronidazole intravenous solution 2

metronidazole oral capsule 2

metronidazole oral tablet 2

metronidazole vaginal gel 2

MONUROL ORAL PACKET 4

mupirocin calcium external cream 4

mupirocin external ointment 2

nitrofurantoin macrocrystal oral capsule

4

nitrofurantoin monohydrate macrocrystals oral capsule

2


nitrofurantoin oral suspension 4

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED

5

polymyxin b sulfate injection solution reconstituted

2

PRIMSOL ORAL SOLUTION 4

silver sulfadiazine external cream 2

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED


SIVEXTRO ORAL TABLET 5


SSD EXTERNAL CREAM 2

SULFAMYLON EXTERNAL CREAM 4

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED

5

tigecycline intravenous solution reconstituted 5

trimethoprim oral tablet 1 TRIMPEX ORAL SOLUTION 50 MG/5ML 4

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%

2

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 100 gm, 5 gm, 500 mg, 5000 mg, 750 mg

2


16


VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

2

vancomycin hcl oral capsule 125 mg 4


vancomycin hcl oral capsule 250 mg 5


VANDAZOLE VAGINAL GEL 2

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED

4

XIFAXAN ORAL TABLET 5 PA

Beta-lactam, Cephalosporins

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED

5

cefaclor er oral tablet extended release 12 hour

4

cefaclor oral capsule 4 cefaclor oral suspension reconstituted 4

cefadroxil oral capsule 2 cefadroxil oral suspension reconstituted

2

cefadroxil oral tablet 2 cefazolin sodium injection solution reconstituted

2

cefazolin sodium intravenous solution reconstituted

2

cefazolin sodium-dextrose intravenous solution

2


cefazolin sodium-dextrose intravenous solution reconstituted

2

cefdinir oral capsule 2 cefdinir oral suspension reconstituted 2

cefditoren pivoxil oral tablet 4

cefepime hcl injection solution reconstituted 2

cefepime hcl intravenous solution 2

cefepime-dextrose intravenous solution reconstituted

2

cefixime oral capsule 3 cefixime oral suspension reconstituted

4

cefotaxime sodium injection solution reconstituted

2

cefotetan disodium injection solution reconstituted

2

cefotetan disodium-dextrose intravenous solution reconstituted

2

cefoxitin sodium injection solution reconstituted

2

cefoxitin sodium intravenous solution reconstituted

2

cefoxitin sodium-dextrose intravenous solution reconstituted

2

cefpodoxime proxetil oral suspension reconstituted

2

cefpodoxime proxetil oral tablet 2


17


cefprozil oral suspension reconstituted

2

cefprozil oral tablet 2 ceftazidime and dextrose intravenous solution reconstituted

2

ceftazidime injection solution reconstituted 2

ceftibuten oral capsule 400 mg 2

ceftibuten oral suspension reconstituted 180 mg/5ml

2

ceftriaxone sodium in dextrose intravenous solution

2

ceftriaxone sodium injection solution reconstituted

2

ceftriaxone sodium intravenous solution reconstituted

2

ceftriaxone sodium-dextrose intravenous solution reconstituted

2

cefuroxime axetil oral tablet 2

cefuroxime sodium injection solution reconstituted

2

cefuroxime sodium intravenous solution reconstituted

2

cephalexin oral capsule 1 cephalexin oral suspension reconstituted

2

cephalexin oral tablet 2 SUPRAX ORAL CAPSULE 3


SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

5

suprax oral tablet chewable 3

tazicef injection solution reconstituted 2

tazicef intravenous solution reconstituted 2

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED

5

zinacef in sterile water intravenous solution 1.5 gm

2

zinacef intravenous solution reconstituted 750 mg

2

Beta-lactam, Other

azactam in dextrose intravenous solution 1 gm/50ml

4

AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 2 GM/50ML

4

AZACTAM INJECTION SOLUTION RECONSTITUTED

4

aztreonam injection solution reconstituted 1 gm

4

aztreonam injection solution reconstituted 2 gm

5

DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

4


18


ertapenem sodium injection solution reconstituted

4

imipenem-cilastatin intravenous solution reconstituted

2

INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

4

meropenem intravenous solution reconstituted 2

meropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml

5

meropenem-sodium chloride intravenous solution reconstituted 500-0.9 mg-%

2

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED

4

Beta-lactam, Penicillins

amoxicillin oral capsule 1 amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1 amoxicillin oral tablet chewable 1

amoxicillin-potassium clavulanate er oral tablet extended release 12 hour

4


amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

2

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

2

ampicillin oral capsule 1 ampicillin sodium injection solution reconstituted

2

ampicillin sodium intravenous solution reconstituted

2

ampicillin-sulbactam sodium injection solution reconstituted

2

ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm

2

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

5

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

4

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION

4

BICILLIN C-R INTRAMUSCULAR SUSPENSION

4


19


BICILLIN L-A INTRAMUSCULAR SUSPENSION

4

dicloxacillin sodium oral capsule 2

nafcillin sodium in dextrose intravenous solution

5

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

4

nafcillin sodium intravenous solution reconstituted 1 gm

4

nafcillin sodium intravenous solution reconstituted 10 gm, 2 gm

5

oxacillin sodium injection solution reconstituted

4

PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION

4

penicillin g potassium injection solution reconstituted

2

penicillin g sodium injection solution reconstituted

5

penicillin v potassium oral solution reconstituted

1

penicillin v potassium oral tablet 1

pfizerpen injection solution reconstituted 5000000 unit

2

piperacillin sod-tazobactam so intravenous solution reconstituted

2


ZOSYN INTRAVENOUS SOLUTION

4

Macrolides

azithromycin intravenous solution reconstituted

2

AZITHROMYCIN ORAL PACKET 2

azithromycin oral suspension reconstituted

2

azithromycin oral tablet 1 clarithromycin er oral tablet extended release 24 hour

2

clarithromycin oral suspension reconstituted

2

clarithromycin oral tablet 2

DIFICID ORAL TABLET 5 ery external pad 2 ERYPED 400 ORAL SUSPENSION RECONSTITUTED

5

ery-tab oral tablet delayed release 3

erythrocin lactobionate intravenous solution reconstituted

4

erythrocin stearate oral tablet 4

erythromycin base oral capsule delayed release particles

4

erythromycin base oral tablet 4

erythromycin base oral tablet delayed release 2


20


erythromycin ethylsuccinate oral suspension reconstituted

4

erythromycin ethylsuccinate oral tablet

4

erythromycin external gel 2

erythromycin external pad 2

erythromycin external solution 2

erythromycin ophthalmic ointment 1

erythromycin stearate oral tablet 4

PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG

4

ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM

4

Quinolones

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED

5

BAXDELA ORAL TABLET 5

BESIVANCE OPHTHALMIC SUSPENSION

4

CILOXAN OPHTHALMIC OINTMENT

4

ciprofloxacin hcl ophthalmic solution 1

ciprofloxacin hcl oral tablet 1

CIPROFLOXACIN HCL OTIC SOLUTION 2


ciprofloxacin in d5w intravenous solution 2

ciprofloxacin intravenous solution 200 mg/20ml, 400 mg/40ml

2

ciprofloxacin oral suspension reconstituted

2

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

2

gatifloxacin ophthalmic solution 2

levofloxacin in d5w intravenous solution 2

levofloxacin intravenous solution 4

levofloxacin ophthalmic solution 2

levofloxacin oral solution 4

levofloxacin oral tablet 2 moxifloxacin hcl in nacl intravenous solution 4

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION

4

moxifloxacin hcl ophthalmic solution 2

moxifloxacin hcl oral tablet 4

ofloxacin ophthalmic solution 2

ofloxacin oral tablet 2 ofloxacin otic solution 2 Sulfonamides

sulfacetamide sodium (acne) external lotion 4

sulfacetamide sodium ophthalmic ointment 2


21


sulfacetamide sodium ophthalmic solution 2

sulfadiazine oral tablet 4 sulfamethoxazole-trimethoprim intravenous solution

2

sulfamethoxazole-trimethoprim oral suspension

2

sulfamethoxazole-trimethoprim oral tablet 1

sulfatrim pediatric oral suspension 2

Tetracyclines

coremino oral tablet extended release 24 hour

2

demeclocycline hcl oral tablet 2

DORYX MPC ORAL TABLET DELAYED RELEASE

4

doxy 100 intravenous solution reconstituted 4

doxycycline hyclate intravenous solution reconstituted

4

doxycycline hyclate oral capsule 2

doxycycline hyclate oral tablet 100 mg, 20 mg, 75 mg

2

doxycycline hyclate oral tablet 150 mg, 50 mg 4

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

4

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

5


doxycycline monohydrate oral capsule

2

doxycycline monohydrate oral suspension reconstituted

2

doxycycline monohydrate oral tablet 2

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED

5

minocycline hcl er oral tablet extended release 24 hour 105 mg, 115 mg, 55 mg, 65 mg, 80 mg

5

minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg

2

minocycline hcl oral capsule 2

minocycline hcl oral tablet 2

mondoxyne nl oral capsule 2

morgidox oral capsule 2 NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED

5

NUZYRA ORAL TABLET 5

okebo oral capsule 2 SEYSARA ORAL TABLET 5

soloxide oral tablet delayed release 150 mg 4

tetracycline hcl oral capsule 4


22


VIBRAMYCIN ORAL SYRUP 4

Anticonvulsants

Anticonvulsants, Other

APTIOM ORAL TABLET 5

BRIVIACT INTRAVENOUS SOLUTION

5 PA

BRIVIACT ORAL SOLUTION 5 PA

BRIVIACT ORAL TABLET 5 PA

EPIDIOLEX ORAL SOLUTION 5 PA

FYCOMPA ORAL SUSPENSION 4

FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG

5

FYCOMPA ORAL TABLET 2 MG, 8 MG 4

levetiracetam er oral tablet extended release 24 hour

2

levetiracetam in nacl solution 1000 mg/100ml intravenous

4

LEVETIRACETAM IN NACL SOLUTION 1000 MG/100ML INTRAVENOUS

4


4


4


4



4

levetiracetam intravenous solution 4

levetiracetam oral solution 2

levetiracetam oral tablet 1 roweepra oral tablet 1 roweepra xr oral tablet extended release 24 hour

2

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE

4

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE 4

ethosuximide oral capsule 2

ethosuximide oral solution 2

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 300 MG 3


LYRICA ORAL SOLUTION 3


pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule 300 mg 2


pregabalin oral solution 2 QL (900 ML per 30 days) zonisamide oral capsule 2


23


Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam oral suspension 5

clobazam oral tablet 10 mg 4

clobazam oral tablet 20 mg 5

clonazepam oral tablet 0.5 mg, 1 mg 1


clonazepam oral tablet 2 mg 1


clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet dispersible 2 mg 2


DIACOMIT ORAL CAPSULE 5 PA

DIACOMIT ORAL PACKET 5 PA

DIASTAT ACUDIAL RECTAL GEL 4

DIASTAT PEDIATRIC RECTAL GEL 4

diazepam rectal gel 4 divalproex sodium er oral tablet extended release 24 hour

2

divalproex sodium oral capsule delayed release sprinkle

2

divalproex sodium oral tablet delayed release 2

gabapentin oral capsule 100 mg, 300 mg 1


gabapentin oral capsule 400 mg 1


gabapentin oral solution 250 mg/5ml 4



gabapentin oral tablet 600 mg 2


gabapentin oral tablet 800 mg 2


phenobarbital oral elixir 4 PA phenobarbital oral tablet 4 PA phenobarbital sodium injection solution 2 PA

primidone oral tablet 2 SABRIL ORAL TABLET 5 PA SYMPAZAN ORAL FILM 5

tiagabine hcl oral tablet 4 valproate sodium intravenous solution 100 mg/ml

2

valproic acid oral capsule 2

valproic acid oral solution 2

vigabatrin oral packet 5 PA vigabatrin oral tablet 5 PA vigadrone oral packet 5 PA Glutamate Reducing Agents

felbamate oral suspension 5

felbamate oral tablet 4 lamotrigine er oral tablet extended release 24 hour

4

lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg

4

lamotrigine oral kit 42 x 50 mg & 14x100 mg 5

lamotrigine oral tablet 1 lamotrigine oral tablet chewable 2


24


lamotrigine oral tablet dispersible 4

lamotrigine starter kit-blue oral kit 2

lamotrigine starter kit-green oral kit 4

lamotrigine starter kit-orange oral kit 2

subvenite oral tablet 1 subvenite starter kit-blue oral kit 2

subvenite starter kit-green oral kit 4

subvenite starter kit-orange oral kit 2

topiramate er oral capsule er 24 hour sprinkle

4

topiramate oral capsule sprinkle 2

topiramate oral tablet 1 Sodium Channel Agents

BANZEL ORAL SUSPENSION 5

BANZEL ORAL TABLET 5

carbamazepine er oral capsule extended release 12 hour

2

carbamazepine er oral tablet extended release 12 hour

2

carbamazepine oral suspension 2

carbamazepine oral tablet 2

carbamazepine oral tablet chewable 1

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR

4


dilantin infatabs oral tablet chewable 4

dilantin oral capsule 4 DILANTIN ORAL SUSPENSION 4

epitol oral tablet 2 fosphenytoin sodium injection solution 2

oxcarbazepine oral suspension 4

oxcarbazepine oral tablet 2

PEGANONE ORAL TABLET 4

phenytek oral capsule 4 phenytoin infatabs oral tablet chewable 2

phenytoin oral suspension 2

phenytoin oral tablet chewable 2

phenytoin sodium extended oral capsule 2

phenytoin sodium injection solution 2

TEGRETOL ORAL SUSPENSION 4

TEGRETOL ORAL TABLET 4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR

4

VIMPAT INTRAVENOUS SOLUTION

4

VIMPAT ORAL SOLUTION 4

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

5


25


VIMPAT ORAL TABLET 50 MG 4

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates oral tablet 2

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg 1

donepezil hcl oral tablet 23 mg 4

donepezil hcl oral tablet dispersible 1

galantamine hydrobromide er oral capsule extended release 24 hour

2

galantamine hydrobromide oral solution

4

galantamine hydrobromide oral tablet 2

rivastigmine tartrate oral capsule 2

rivastigmine transdermal patch 24 hour

4

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl er oral capsule extended release 24 hour


memantine hcl oral solution 2 mg/ml 4

memantine hcl oral tablet 10 mg, 5 mg 2

MEMANTINE HCL ORAL TABLET 28 X 5 MG & 21 X 10 MG

4


Antidepressants

Antidepressants, Other

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR

5 ST; QL (30 EA per 30 days)

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg


bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg


bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg


bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg


bupropion hcl oral tablet 2 mirtazapine oral tablet 2 mirtazapine oral tablet dispersible 2

Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HOUR


MARPLAN ORAL TABLET 4

phenelzine sulfate oral tablet 2

tranylcypromine sulfate oral tablet 4

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

citalopram hydrobromide oral solution

2


26


citalopram hydrobromide oral tablet 1

desvenlafaxine er oral tablet extended release 24 hour 100 mg


desvenlafaxine er oral tablet extended release 24 hour 50 mg


DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG


DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG


desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg


desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg


duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg


duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg


escitalopram oxalate oral solution 1

escitalopram oxalate oral tablet 1

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK



fluoxetine hcl (pmdd) oral capsule 2

fluoxetine hcl oral capsule 1

fluoxetine hcl oral capsule delayed release 2


fluoxetine hcl oral solution 2

fluoxetine hcl oral tablet 2 fluvoxamine maleate er oral capsule extended release 24 hour


fluvoxamine maleate oral tablet 2

maprotiline hcl oral tablet 2

nefazodone hcl oral tablet 4

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg


olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg


paroxetine hcl er oral tablet extended release 24 hour

4

paroxetine hcl oral tablet 4

paroxetine mesylate oral capsule 4


PAXIL ORAL SUSPENSION 4

PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG


PEXEVA ORAL TABLET 30 MG 4


sertraline hcl oral concentrate 2

sertraline hcl oral tablet 1 trazodone hcl oral tablet 2


27


TRINTELLIX ORAL TABLET 4


venlafaxine hcl er oral capsule extended release 24 hour

2

venlafaxine hcl er oral tablet extended release 24 hour

4

venlafaxine hcl oral tablet 2

VIIBRYD ORAL TABLET 4


VIIBRYD STARTER PACK ORAL KIT 4


Tricyclics

amitriptyline hcl oral tablet 4 PA

amoxapine oral tablet 4 chlordiazepoxide-amitriptyline oral tablet 4 PA

clomipramine hcl oral capsule 4

desipramine hcl oral tablet 4

doxepin hcl oral capsule 4 PA doxepin hcl oral concentrate 4 PA

imipramine hcl oral tablet 4

imipramine pamoate oral capsule 4

nortriptyline hcl oral capsule 2

nortriptyline hcl oral solution 2

perphenazine-amitriptyline oral tablet 4 PA

protriptyline hcl oral tablet 2

trimipramine maleate oral capsule 4


Antiemetics

Antiemetics, Other

AKYNZEO ORAL CAPSULE 4

B/D; QL (2 EA per 30 days)

compro rectal suppository 2

doxylamine-pyridoxine oral tablet delayed release


droperidol injection solution 2

meclizine hcl oral tablet 4 phenadoz rectal suppository 4 PA

phenergan rectal suppository 12.5 mg, 25 mg, 50 mg

4 PA

prochlorperazine edisylate injection solution 10 mg/2ml

4

prochlorperazine maleate oral tablet 1

prochlorperazine rectal suppository 2

promethazine hcl injection solution 4 PA

promethazine hcl oral syrup 3 PA

promethazine hcl oral tablet 4 PA

promethazine hcl rectal suppository 4 PA

promethegan rectal suppository 4 PA

scopolamine transdermal patch 72 hour

4

trimethobenzamide hcl oral capsule 4 B/D

Emetogenic Therapy Adjuncts


28


ANZEMET ORAL TABLET 100 MG 5


ANZEMET ORAL TABLET 50 MG 4


aprepitant oral capsule 125 mg 4




aprepitant oral capsule 80 & 125 mg 4




CINVANTI INTRAVENOUS EMULSION

4

dronabinol oral capsule 4 PA; QL (60 EA per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED

4 B/D; QL (6 EA per 30 days)

granisetron hcl intravenous solution 2

granisetron hcl oral tablet 2


ondansetron hcl injection solution 2

ondansetron hcl oral solution 4

B/D; QL (450 ML per 30 days)

ondansetron hcl oral tablet 24 mg 2


ondansetron hcl oral tablet 4 mg, 8 mg 1 B/D

ondansetron odt oral tablet dispersible 1 B/D

palonosetron hcl intravenous solution 2

palonosetron hcl intravenous solution prefilled syringe

2


SANCUSO TRANSDERMAL PATCH


SYNDROS ORAL SOLUTION 5

PA; QL (120 ML per 30 days)

Antifungals

Antifungals

ABELCET INTRAVENOUS SUSPENSION

5 B/D

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED

5 B/D

AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG, 50 MG

5 B/D

amphotericin b intravenous solution reconstituted

4 B/D

caspofungin acetate intravenous solution reconstituted

5

ciclodan external cream 0.77 % 2

ciclodan external solution 2 PA

ciclopirox external gel 2 ciclopirox external shampoo 2

ciclopirox external solution 2 PA

ciclopirox olamine external cream 2

ciclopirox olamine external suspension 2

clotrimazole external cream 1


29


clotrimazole external solution 2

clotrimazole mouth/throat lozenge 2

clotrimazole-betamethasone external cream

1

clotrimazole-betamethasone external lotion

2

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED

5

CRESEMBA ORAL CAPSULE 5

econazole nitrate external cream 2

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

4

EXELDERM EXTERNAL CREAM 4

EXELDERM EXTERNAL SOLUTION 4

fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml

2

fluconazole in sodium chloride intravenous solution

2

fluconazole oral suspension reconstituted

2

fluconazole oral tablet 2


flucytosine oral capsule 5 griseofulvin microsize oral suspension 2

griseofulvin microsize oral tablet 4

griseofulvin ultramicrosize oral tablet

4

gynazole-1 vaginal cream 4

itraconazole oral capsule 4 PA

itraconazole oral solution 5 PA

JUBLIA EXTERNAL SOLUTION 4

ketoconazole external cream 2

ketoconazole external foam 4

ketoconazole external shampoo 1

ketoconazole oral tablet 2 MENTAX EXTERNAL CREAM 4

miconazole 3 vaginal suppository 2

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED

5

naftifine hcl external cream 4

naftifine hcl external gel 1 % 2

NAFTIN EXTERNAL GEL 4

NATACYN OPHTHALMIC SUSPENSION

4


30


NOXAFIL INTRAVENOUS SOLUTION

5

NOXAFIL ORAL SUSPENSION 5

NOXAFIL ORAL TABLET DELAYED RELEASE

5

nyamyc external powder 2

nyata external powder 100000 unit/gm 2

nystatin external cream 1 nystatin external ointment 2

nystatin external powder 2

nystatin mouth/throat suspension 1

nystatin oral tablet 2 nystatin-triamcinolone external cream 2

nystatin-triamcinolone external ointment 2

nystop external powder 2 ONMEL ORAL TABLET 200 MG 5 PA

oxiconazole nitrate external cream 4

OXISTAT EXTERNAL LOTION 4

posaconazole oral tablet delayed release 5

terbinafine hcl oral tablet 1


terconazole vaginal cream 2

terconazole vaginal suppository 2

TOLSURA ORAL CAPSULE 5 PA


voriconazole intravenous solution reconstituted

5

voriconazole oral suspension reconstituted

5

voriconazole oral tablet 5 Antigout Agents

Antigout Agents

allopurinol oral tablet 1 allopurinol sodium intravenous solution reconstituted

4

COLCHICINE ORAL CAPSULE 3

colchicine oral tablet 3 colchicine-probenecid oral tablet 2

febuxostat oral tablet 2 KRYSTEXXA INTRAVENOUS SOLUTION

5 PA

probenecid oral tablet 2 ULORIC ORAL TABLET 3 ST

Anti-inflammatory Agents

Glucocorticoids

hydrocortisone rectal cream 2

procto-med hc rectal cream 2

procto-pak rectal cream 2 proctosol hc rectal cream 2

proctozone-hc rectal cream 2

triamcinolone acetonide external aerosol solution

4


31


Antimigraine Agents

Ergot Alkaloids

dihydroergotamine mesylate injection solution

5

dihydroergotamine mesylate nasal solution 5


ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

3

ergotamine-caffeine oral tablet 2

migergot rectal suppository 5

Prophylactic

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML


AIMOVIG 4 PA; QL (2 ML per 30 days) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR


EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


timolol maleate oral tablet 2

Serotonin (5-HT) 1b/1d Receptor Agonists

almotriptan malate oral tablet 4


eletriptan hydrobromide oral tablet 4



frovatriptan succinate oral tablet 4


naratriptan hcl oral tablet 2


rizatriptan benzoate oral tablet 2


rizatriptan benzoate oral tablet dispersible 2


sumatriptan nasal solution 4


sumatriptan succinate oral tablet 1


SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE


sumatriptan succinate subcutaneous solution 4


sumatriptan succinate subcutaneous solution auto-injector


sumatriptan succinate subcutaneous solution prefilled syringe


sumatriptan-naproxen sodium oral tablet 4


zolmitriptan oral tablet 2 QL (12 EA per 30 days) zolmitriptan oral tablet dispersible 2.5 mg 2


zolmitriptan oral tablet dispersible 5 mg 2


Antimyasthenic Agents

Parasympathomimetics

GUANIDINE HCL ORAL TABLET 4

MESTINON ORAL SYRUP 60 MG/5ML 5


32


pyridostigmine bromide er oral tablet extended release

4

pyridostigmine bromide oral solution 5

pyridostigmine bromide oral tablet 60 mg 2

REGONOL INTRAVENOUS SOLUTION

4

Antimycobacterials

Antimycobacterials, Other

dapsone oral tablet 2 rifabutin oral capsule 4 Antituberculars

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED

4

cycloserine oral capsule 4 ethambutol hcl oral tablet 2

isoniazid injection solution 4

isoniazid oral syrup 2 isoniazid oral tablet 1 paser oral packet 4 PRIFTIN ORAL TABLET 4

pyrazinamide oral tablet 2 rifampin intravenous solution reconstituted 4

rifampin oral capsule 2 RIFATER ORAL TABLET 4

SIRTURO ORAL TABLET 5

TRECATOR ORAL TABLET 4

Antineoplastics


Alkylating Agents

BELRAPZO INTRAVENOUS SOLUTION

5

bendamustine hcl intravenous solution 5

BENDEKA INTRAVENOUS SOLUTION

5

BICNU INTRAVENOUS SOLUTION RECONSTITUTED

5

busulfan intravenous solution 5

carboplatin intravenous solution 2

carmustine intravenous solution reconstituted 5

cisplatin intravenous solution 2

cyclophosphamide injection solution reconstituted

5

cyclophosphamide oral capsule 2 B/D

dacarbazine intravenous solution reconstituted

2

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED

5

GLEOSTINE ORAL CAPSULE 4

HEXALEN ORAL CAPSULE 50 MG 5

ifosfamide intravenous solution 4

ifosfamide intravenous solution reconstituted 1 gm

4


33


IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM

4

KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK

5 PA

KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK

5 PA

KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK

5 PA

LEUKERAN ORAL TABLET 5

MATULANE ORAL CAPSULE 5

melphalan hcl intravenous solution reconstituted

5

MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG

5

oxaliplatin intravenous solution 4

oxaliplatin intravenous solution reconstituted 5

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED

5

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG

5

thiotepa injection solution reconstituted 5


TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

5

VALCHLOR EXTERNAL GEL 5 PA

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED

5

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED

5

Antiandrogens

abiraterone acetate oral tablet 5 PA

bicalutamide oral tablet 2 ERLEADA ORAL TABLET 5 PA

flutamide oral capsule 2 nilutamide oral tablet 5 NUBEQA ORAL TABLET 5 PA

XTANDI ORAL CAPSULE 5 PA

YONSA ORAL TABLET 5 PA ZYTIGA ORAL TABLET 500 MG 5 PA

Antiangiogenic Agents

POMALYST ORAL CAPSULE 5 PA

REVLIMID ORAL CAPSULE 5 PA

THALOMID ORAL CAPSULE 5 PA

Antiestrogens/Modifiers

EMCYT ORAL CAPSULE 5


34


FASLODEX INTRAMUSCULAR SOLUTION

5

fulvestrant intramuscular solution 5

SOLTAMOX ORAL SOLUTION 5

tamoxifen citrate oral tablet 2

toremifene citrate oral tablet 5

Antimetabolites

adrucil intravenous solution 2 B/D

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED

5

ARRANON INTRAVENOUS SOLUTION

5

cladribine intravenous solution 5 B/D

clofarabine intravenous solution 5

cytarabine (pf) injection solution 2 B/D

cytarabine injection solution 2 B/D

DROXIA ORAL CAPSULE 4

floxuridine injection solution reconstituted 5 B/D

fluorouracil external cream 0.5 % 5

fluorouracil external cream 5 % 2

fluorouracil external solution 2

fluorouracil intravenous solution 2 B/D


FOLOTYN INTRAVENOUS SOLUTION

5 PA

gemcitabine hcl intravenous solution 5

gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg

4

gemcitabine hcl intravenous solution reconstituted 2 gm

5

hydroxyurea oral capsule 2

INFUGEM INTRAVENOUS SOLUTION

5

LONSURF ORAL TABLET 5 PA

mercaptopurine oral tablet 2

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED

5

PURIXAN ORAL SUSPENSION 5

SIKLOS ORAL TABLET 100 MG 4 PA

SIKLOS ORAL TABLET 1000 MG 5 PA

TABLOID ORAL TABLET 4

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED

5 PA

Antineoplastics, Other

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED

5


35


adriamycin intravenous solution 2 B/D

adriamycin intravenous solution reconstituted 2 B/D

amifostine intravenous solution reconstituted 500 mg

5

arsenic trioxide intravenous solution 10 mg/10ml

4

arsenic trioxide intravenous solution 12 mg/6ml

5

azacitidine injection suspension reconstituted

5

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

bleomycin sulfate injection solution reconstituted

2 B/D

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

BRAFTOVI ORAL CAPSULE 5 PA

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

5

COPIKTRA ORAL CAPSULE 5 PA

COTELLIC ORAL TABLET 5 PA

dactinomycin intravenous solution reconstituted

5

daunorubicin hcl intravenous solution 20 mg/4ml

4


daunorubicin hcl intravenous solution 50 mg/10ml

2

DAURISMO ORAL TABLET 5 PA

decitabine intravenous solution reconstituted 5 PA

DOCEFREZ INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

5

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, 80 mg/4ml

5

DOCETAXEL INTRAVENOUS CONCENTRATE 200 MG/10ML

5

docetaxel intravenous solution 5

doxorubicin hcl intravenous solution 2 B/D

doxorubicin hcl intravenous solution reconstituted 10 mg, 50 mg

2 B/D

doxorubicin hcl liposomal intravenous injectable

5

ELZONRIS INTRAVENOUS SOLUTION

5 PA

epirubicin hcl intravenous solution 2

ERWINAZE INJECTION SOLUTION RECONSTITUTED

5

FARYDAK ORAL CAPSULE 5 PA

fludarabine phosphate intravenous solution reconstituted

4


36


HALAVEN INTRAVENOUS SOLUTION

5 PA

IBRANCE ORAL CAPSULE 5 PA

idarubicin hcl intravenous solution 5

INREBIC ORAL CAPSULE 5 PA

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED

5

JEVTANA INTRAVENOUS SOLUTION

5 PA

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK

5 PA


5 PA


5 PA

leucovorin calcium injection solution 100 mg/10ml

2 B/D

leucovorin calcium injection solution 500 mg/50ml

2

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg

2

leucovorin calcium injection solution reconstituted 500 mg

4

leucovorin calcium oral tablet 2


levoleucovorin calcium intravenous solution 5

LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION RECONSTITUTED 175 MG

5

levoleucovorin calcium intravenous solution reconstituted 50 mg

5

levoleucovorin calcium pf intravenous solution 5

lipodox 50 intravenous injectable 2 mg/ml 5

LORBRENA ORAL TABLET 5 PA

LYNPARZA ORAL CAPSULE 50 MG 5 PA

LYNPARZA ORAL TABLET 5 PA

MARQIBO INTRAVENOUS SUSPENSION

5

MEKTOVI ORAL TABLET 5 PA

mitomycin intravenous solution reconstituted 5

mitoxantrone hcl intravenous concentrate 2 PA

mutamycin intravenous solution reconstituted 5

NERLYNX ORAL TABLET 5


NINLARO ORAL CAPSULE 5 PA

ONCASPAR INJECTION SOLUTION 5

paclitaxel intravenous concentrate 2


37


PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK

5 PA


5 PA


5 PA

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED

5

romidepsin intravenous solution reconstituted 5 PA

RYDAPT ORAL CAPSULE 5 PA

SYLATRON SUBCUTANEOUS KIT 5 PA

SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED

5 PA

TALZENNA ORAL CAPSULE 5 PA

TENIPOSIDE INTRAVENOUS SOLUTION

5

THERACYS INTRAVESICAL SUSPENSION RECONSTITUTED 81 MG/VIAL

5

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED

4

TRISENOX INTRAVENOUS SOLUTION

5


valrubicin intravesical solution 5

VALSTAR INTRAVESICAL SOLUTION

5

VELCADE INJECTION SOLUTION RECONSTITUTED

5 PA

VERZENIO ORAL TABLET 5 PA

vinblastine sulfate intravenous solution 2 B/D

vincasar pfs intravenous solution 1 mg/ml 2 B/D

vincristine sulfate intravenous solution 2 B/D

vinorelbine tartrate intravenous solution 2

VITRAKVI ORAL CAPSULE 5 PA

VITRAKVI ORAL SOLUTION 5 PA

XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY PACK

5 PA


5 PA


5 PA

XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PACK

5 PA

ZALTRAP INTRAVENOUS SOLUTION

5 PA

ZOLINZA ORAL CAPSULE 5 PA


38


ZYKADIA ORAL TABLET 5 PA

Aromatase Inhibitors, 3rd Generation

anastrozole oral tablet 1 exemestane oral tablet 4 letrozole oral tablet 1 Enzyme Inhibitors

BALVERSA ORAL TABLET 5 PA

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED

5

etoposide intravenous solution 2

irinotecan hcl intravenous solution 2

KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

ONIVYDE INTRAVENOUS INJECTABLE

5

toposar intravenous solution 2

topotecan hcl intravenous solution 5

topotecan hcl intravenous solution reconstituted

5

ZYDELIG ORAL TABLET 5 PA

Molecular Target Inhibitors

AFINITOR DISPERZ ORAL TABLET SOLUBLE

5 PA

AFINITOR ORAL TABLET 5



ALECENSA ORAL CAPSULE 5 PA

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

ALUNBRIG ORAL TABLET 180 MG, 90 MG

5 PA; QL (30 EA per 30 days)

ALUNBRIG ORAL TABLET 30 MG 5


ALUNBRIG ORAL TABLET THERAPY PACK

5 PA; QL (60 EA per 365 days)

BOSULIF ORAL TABLET 5 PA

CABOMETYX ORAL TABLET 5 PA

CALQUENCE ORAL CAPSULE 5 PA

CAPRELSA ORAL TABLET 100 MG 5


CAPRELSA ORAL TABLET 300 MG 5 PA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT

5 PA


5 PA


5 PA

ERIVEDGE ORAL CAPSULE 5 PA

erlotinib hcl oral tablet 5 PA GILOTRIF ORAL TABLET 5


ICLUSIG ORAL TABLET 15 MG 5


ICLUSIG ORAL TABLET 45 MG 5 PA


39


IDHIFA ORAL TABLET 5 PA; QL (30 EA per 30 days) imatinib mesylate oral tablet 5 PA

IMBRUVICA ORAL CAPSULE 5 PA

IMBRUVICA ORAL TABLET 5 PA

INLYTA ORAL TABLET 5 PA IRESSA ORAL TABLET 5 PA JAKAFI ORAL TABLET 10 MG 5


JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG

5 PA

LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

5 PA


5 PA


5 PA


5 PA


5 PA


5 PA


5 PA



5 PA

MEKINIST ORAL TABLET 5 PA

NEXAVAR ORAL TABLET 5 PA

ODOMZO ORAL CAPSULE 5 PA

RUBRACA ORAL TABLET 5 PA

SPRYCEL ORAL TABLET 5 PA

STIVARGA ORAL TABLET 5 PA

SUTENT ORAL CAPSULE 5 PA

TAFINLAR ORAL CAPSULE 5 PA

TAGRISSO ORAL TABLET 40 MG 5


TAGRISSO ORAL TABLET 80 MG 5 PA

TASIGNA ORAL CAPSULE 5 PA

temsirolimus intravenous solution 5

TIBSOVO ORAL TABLET 5 PA

TORISEL INTRAVENOUS SOLUTION

5

TURALIO ORAL CAPSULE 5 PA

TYKERB ORAL TABLET 5 PA

VENCLEXTA ORAL TABLET 10 MG, 50 MG 3 PA

VENCLEXTA ORAL TABLET 100 MG 5 PA


40


VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK

5 PA

VIZIMPRO ORAL TABLET 5 PA

VOTRIENT ORAL TABLET 5 PA

XALKORI ORAL CAPSULE 5 PA

XOSPATA ORAL TABLET 5 PA

ZEJULA ORAL CAPSULE 5 PA

ZELBORAF ORAL TABLET 5 PA

ZYKADIA ORAL CAPSULE 5 PA

Monoclonal Antibody/Antibody-Drug Conjugate

ARZERRA INTRAVENOUS CONCENTRATE

5 PA

AVASTIN INTRAVENOUS SOLUTION

5

BAVENCIO INTRAVENOUS SOLUTION

5 PA

BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

CYRAMZA INTRAVENOUS SOLUTION

5 PA


DARZALEX INTRAVENOUS SOLUTION

5 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

ERBITUX INTRAVENOUS SOLUTION

5 PA

GAZYVA INTRAVENOUS SOLUTION

5 PA

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION

5 PA

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

IMFINZI INTRAVENOUS SOLUTION

5 PA

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

KEYTRUDA INTRAVENOUS SOLUTION

5 PA

KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5 PA

LARTRUVO INTRAVENOUS SOLUTION

5 PA

LIBTAYO INTRAVENOUS SOLUTION

5 PA

LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED

5 PA


41


MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

OPDIVO INTRAVENOUS SOLUTION

5 PA

PERJETA INTRAVENOUS SOLUTION

5 PA

POLIVY INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

PORTRAZZA INTRAVENOUS SOLUTION

5 PA

POTELIGEO INTRAVENOUS SOLUTION

5 PA

RITUXAN HYCELA SUBCUTANEOUS SOLUTION

5 PA

RITUXAN INTRAVENOUS SOLUTION

5 PA

TECENTRIQ INTRAVENOUS SOLUTION

5 PA

UNITUXIN INTRAVENOUS SOLUTION

5

VECTIBIX INTRAVENOUS SOLUTION

5

YERVOY INTRAVENOUS SOLUTION

5 PA

ZEVALIN Y-90 INTRAVENOUS KIT 5

Retinoids

bexarotene oral capsule 5 PA


PANRETIN EXTERNAL GEL 5

TARGRETIN EXTERNAL GEL 5 PA

tretinoin oral capsule 5 Treatment Adjuncts

dexrazoxane hcl intravenous solution reconstituted

5

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED

5

KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED

5

mesna intravenous solution 2

MESNEX ORAL TABLET 5

Antiparasitics

Anthelmintics

albendazole oral tablet 5 BENZNIDAZOLE ORAL TABLET 3

ivermectin oral tablet 2 praziquantel oral tablet 4 Antiprotozoals

ALINIA ORAL SUSPENSION RECONSTITUTED

5

ALINIA ORAL TABLET 5 atovaquone oral suspension 5

atovaquone-proguanil hcl oral tablet 2

chloroquine phosphate oral tablet 2

COARTEM ORAL TABLET 4


42


DARAPRIM ORAL TABLET 5 PA

hydroxychloroquine sulfate oral tablet 2

mefloquine hcl oral tablet 2

NEBUPENT INHALATION SOLUTION RECONSTITUTED

4 B/D

PENTAM INJECTION SOLUTION RECONSTITUTED

4

pentamidine isethionate injection solution reconstituted

2

primaquine phosphate oral tablet 2

quinine sulfate oral capsule 2 PA

tinidazole oral tablet 2 Pediculicides/Scabicides

crotan external lotion 2 EURAX EXTERNAL CREAM 4

lindane external shampoo 4

malathion external lotion 4

permethrin external cream 2

SKLICE EXTERNAL LOTION 4

ULESFIA EXTERNAL LOTION 4

Antiparkinson Agents

Anticholinergics

benztropine mesylate injection solution 2


benztropine mesylate oral tablet 2

trihexyphenidyl hcl oral solution 2

trihexyphenidyl hcl oral tablet 4

Antiparkinson Agents, Other

entacapone oral tablet 2 GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR

5 PA

tolcapone oral tablet 5 Dopamine Agonists

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE


bromocriptine mesylate oral capsule 4

bromocriptine mesylate oral tablet 4

INBRIJA INHALATION CAPSULE 5 PA

NEUPRO TRANSDERMAL PATCH 24 HOUR

4 ST

pramipexole dihydrochloride er oral tablet extended release 24 hour

4

pramipexole dihydrochloride oral tablet

2

ropinirole hcl er oral tablet extended release 24 hour

2

ropinirole hcl oral tablet 2 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors


43


carbidopa oral tablet 5 carbidopa-levodopa er oral tablet extended release

2

carbidopa-levodopa oral tablet 2

carbidopa-levodopa oral tablet dispersible 4

carbidopa-levodopa-entacapone oral tablet 4

RYTARY ORAL CAPSULE EXTENDED RELEASE

4 ST

Monoamine Oxidase B (MAO-B) Inhibitors

rasagiline m

Iron Road Healthcare Medicare Part D Prescription Drug Plan (PDP)€¦ · Prescription Drug Plan...

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Transcript of Iron Road Healthcare Medicare Part D Prescription Drug Plan (PDP)€¦ · Prescription Drug Plan...