Partnership HMO SNP 2016 Formulary (List of … HMO SNP 2016 Formulary (List of Covered Drugs)...

Partnership HMO SNP

2016 Formulary

(List of Covered Drugs)

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

Formulary ID: 16373, Version Number: 39

This formulary was updated on 10/17/2016. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a week

(office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit 3 www.carewisc.org. 3 T U U 3 3 T

H5209-002_CWHPFC 9-2-16_FINAL Populated Template 10/17/2016 DHS Approved 8/14/2015

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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 Care Wisconsin Health Plan, Inc. When it refers to “plan” or “our plan,” it means Partnership.

This document includes a list of the drugs (formulary) for our plan which is current as of 9/27/2016. 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, premium and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.

Partnership is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid Program. Enrollment in Partnership depends on contract renewal.

The formulary, pharmacy and/or provider network may change at any time. You will receive notice when necessary.

To receive this formulary in an alternate format or language, contact your Team or call Care Wisconsin Customer Service at 1-800-963-0035 (TTY/TDD Wisconsin Relay System 711).

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What is the Partnership Formulary?

A formulary is a list of covered drugs selected by Partnership 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. Partnership will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Partnership 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 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 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, 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 9/27/2016. To get updated information about the drugs covered by Partnership, please contact us. Our contact information appears on the front and back cover pages.

In the event of mid-year non-maintenance formulary changes, we will mail you updates to the formulary as needed on a quarterly basis. You can also get these formulary updates by contacting your Care Team or printing them from our Web site.

How do I use the Formulary?

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

Medical Condition

The formulary begins on page 9. 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

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category name in the list that begins on page number 9. 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 page 93. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

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

Quantity Limits: For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply.

Step Therapy: In some cases, Partnership 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, Partnership may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Partnership 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 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line 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.

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You can ask Partnership 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 Partnership formulary?” on page 6 for information about how to request an exception.

What are over-the-counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Partnership pays for certain OTC drugs. Care Wisconsin covers the OTC formulations of the following drugs as part of its Part D Step Therapy program:

omeprazole lansoprazole esomeprazole loratadine fexofenadine cetirizine nasal triamcinolone nasal fluticasone.

In addition, the 2016 Formulary Medicaid Supplement included with this formulary provides the list of OTC drugs covered by Partnership when they are ordered by a physician or nurse practitioner for a medical need. The drug must also have a valid National Drug Code (NDC) that is recognized by Wisconsin Medicaid. Partnership will provide these OTC drugs at no cost to you.

The cost to Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap).

What if my drug is not on the Formulary?

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

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

You can ask Customer Service for a list of similar drugs that are covered by Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Partnership.

You can ask Partnership 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 Partnership Formulary?

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

You can ask us to cover a drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Partnership limits 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.

Generally, Partnership will only approve your request for an exception if the alternative drugs included on the plan’s formulary 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 or utilization restriction exception. When you request a formulary 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 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 93-day transition supply, consistent with the 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

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emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Current members with a change in where they receive care

Partnership has a transition process that addresses unplanned transitions as members change treatment settings due to changes in the type of care they require. Changes in where you live or receive care may warrant a temporary one-time fill exception regardless of whether or not you are in the first 90 days of program enrollment. Examples of situations include:

You were discharged from the hospital and were provided a discharge list of medications based upon the formulary of the hospital.

You are in a skilled nursing facility and Medicare coverage (where payments include all pharmacy charges) comes to an end. In this circumstance your coverage will revert to our plan formulary.

Beneficiaries who give up Hospice Status to revert back to standard Medicare or Medicaid benefits. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with combinations of

medications that are highly individualized.

Please note that our transition policy applies only to those drugs that are on our formulary and are supplied by a network pharmacy.

For more information

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

If you have questions about Partnership, 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.

Partnership’s Formulary

The formulary that begins on the next page provides coverage information about the drugs covered by Partnership. If you have trouble finding your drug in the list, turn to the Index that begins on page 93.

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

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

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Formulary: 16373, Version ID: 39

Date generated: 10/17/2016

List of Abbreviations

B/D: This prescription drug has a Part B versus 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.

CB: This prescription drug has a capped benefit limit.

ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it.

GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday- Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-963-0035, 24-hours a day/7 days a week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m., CT). TTY/TDD users should call Wisconsin Relay System 711.

MO: Mail Order Drug. This prescription drug is available through a mail-order service.

PA: Prior Authorization. Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Partnership before you fill your prescriptions. If you don’t get approval, Partnership may not cover the drug.

QL: Quantity Limit. For certain drugs, Partnership limits the amount of the drug that Partnership will cover. For example, Partnership provides 9 tablets in 30 days per prescription for sumatriptan. This may be in addition to a standard one month or three month supply.

ST: Step Therapy. In some cases, Partnership 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, Partnership may not cover drug B unless you try Drug A first. If Drug A does not work for you, Partnership will then cover Drug B.

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LEGEND

TIER NAME

1 Covered

SYMBOL NAME DESCRIPTION

There is a limit on the amount of this drug that is covered per

prescription, or within a specific time frame. QL Quantity Limit

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

before you fill your prescription for this drug. Without prior

approval, we may not cover this drug.

PA Prior Authorization

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

treat your medical condition before we will cover another drug

for that condition.

ST

LA

Step Therapy

Limited Access This prescription drug is limited to certain pharmacies.

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DRUG NAME TIER REQUIREMENTS/LIMITS

Analgesics

Nonsteroidal Anti-inflammatory Drugs

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule)

1 ST

etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h)

1

1

PA

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet)

ibuprofen/oxycodone hcl 400mg-5mg tablet

ketoprofen (50 mg capsule, 75 mg capsule)

nabumetone (500 mg tablet, 750 mg tablet)

1

1

1

1

PA

PA

naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)

sulindac (150 mg tablet, 200 mg tablet) 1 PA

Opioid Analgesics, Long-acting

fentanyl (12 mcg/hr, 25 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100 mcg/hr)

1

1

1

ST, QL (10 PER 30 DAYS)

methadone hcl (5 mg/5 ml solution, 5 mg tablet, 10 mg/5 ml solution, 10 mg tablet)

morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet er, 100 mg tablet er, 200 mg tablet er)

oxycodone hcl (10 mg tab er, 15 mg tab er, 20 mg tab er, 30 mg tab er, 40 mg tab er, 60 mg tab er, 80 mg tab er)

1

1

ST

ST tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr)

Opioid Analgesics, Short-acting

acetaminophen with codeine phosphate (120- 12mg/5 solution, 300mg/12.5 solution, 300mg- 30mg tablet, 300mg-60mg tablet, 300mg-15mg tablet)

1

1 codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet)

You can find information on what the symbols and abbreviations on this table mean by going to page 11.

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DURAMORPH (5 MG/10 ML, 10 MG/10 ML) 1

ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET)

1

1

1

fentanyl citrate (200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg)

PA, ST

hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-325mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet, hydrocodone/acetaminophen 10mg- 325mg tablet)

hydrocodone/ibuprofen (hydrocodone/ibuprofen 5mg-200mg tablet, hydrocodone/ibuprofen 7.5- 200 mg tablet, hydrocodone/ibuprofen 10mg- 200mg tablet)

1

hydromorphone hcl (1 mg/ml liquid, 2 mg/ml syringe, 2 mg tablet, 4 mg tablet, 8 mg tablet)

1

1

1

hydromorphone hcl/pf (hcl/pf 10 mg/ml ampul, hcl/pf 10 mg/ml vial)

morphine sulfate (10 mg/5 ml solution, 15 mg tablet, 20 mg/5 ml solution, 30 mg tablet, 100 mg/5ml solution)

oxycodone hcl (5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

1

1 oxycodone hcl/acetaminophen (hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)

oxycodone hcl/acetaminophen 5-325/5 ml solution

1 QL (1860 ML PER 30 DAYS)

tramadol hcl 50 mg tablet 1

1 tramadol hcl/acetaminophen 37.5-325mg tablet

Anesthetics

Local Anesthetics

lidocaine 5 % adh. patch 1

1

PA, QL (93 PER 31 DAYS)

lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 5 mg/ml vial, 20 mg/ml vial, 40 mg/ml solution)


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lidocaine hcl/pf (hcl/pf 5 mg/ml vial, hcl/pf 20 mg/ml ampul luer, hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial, hcl/pf 100 mg/5ml syringe)

1

lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5 kit)

1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium 333 mg tablet dr 1

disulfiram (250 mg tablet, 500 mg tablet) 1

Opioid Dependence Treatments

buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe)

1

buprenorphine hcl (2 mg tab, 8 mg tab) 1

1

PA

buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab, /naloxone 8 mg-2 mg tab)

naltrexone hcl 50 mg tablet 1

1 Opioid Reversal Agents

naloxone hcl 1 mg/ml syringe

Smoking Cessation Agents

bupropion hcl 150 mg tablet er 1

1 CHANTIX (0.5 MG TABLET, 1 MG TABLET, STARTING MONTH BOX)

PA

NICOTROL CARTRIDGE INHALER

NICOTROL NS 10 MG/ML SPRAY

1

1

PA, ST, QL (336 PER 21 DAYS)

PA, QL (168 ML PER 30 DAYS)

Anti-inflammatory Agents

Glucocorticoids

dexamethasone sod phosphate (4 mg/ml vial, 4 mg/ml syringe)

1

1 methylprednisolone sod succ 40 mg vial

Nonsteroidal Anti-inflammatory Drugs

diclofenac sodium 3 % gel (gram) 1 PA


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naproxen sodium (275 mg tablet, 550 mg tablet)

oxaprozin 600 mg tablet

1

1 PA

Antibacterials

Aminoglycosides

GENTAK 0.3 % EYE OINTMENT 1

1 gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops, 40 mg/ml vial)

gentamicin sulfate in sodium chloride, iso- osmotic (gentamic60 mg/50ml, gentamic80 mg/50ml, gentamic80mg/100ml,

1

gentamic100mg/0.1l, gentamic120mg/0.1l)

gentamicin sulfate/pf (sulfate/pf 20 mg/2 ml vial, sulfate/pf 60 mg/6 ml vial port, sulfate/pf 80 mg/8 ml vial port, sulfate/pf 100mg/10ml vial port)

1

neomycin sulfate 500 mg tablet 1

1 neomycin sulfate/polymyxin b sulfate (su/polymyx 40-200k/ml ampul, su/polymyx 40- 200k/ml vial)

paromomycin sulfate 250 mg capsule

streptomycin sulfate 1 g vial

tobramycin 0.3 % drops

1

1

1

1 tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial)

ZYLET EYE DROPS 1

Antibacterials, Other

BACIIM 50,000 UNITS VIAL 1

1

1

bacitracin 500 unit/g oint. (g)

bacitracin/polymyxin b sulfate 500-10k/g oint. (g)

chloramphenicol sod succ 1 g vial 1

1 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule)

clindamycin phosphate (2 % cream/appl, 150 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port)

1


15


colistin (colistimethate na) 150 mg vial

CUBICIN 500 MG VIAL

1

1

1

1

linezolid (600mg/300 iv soln, 600 mg tablet)

linezolid-0.9% sodium chloride 600mg/300 iv soln

methenamine hippurate 1 g tablet 1

1 metronidazole (0.75 % gel w/appl, 250 mg tablet, 500 mg tablet)

metronidazole 0.75 % gel (gram) 1

1

ST

metronidazole/sodium chloride 500mg/0.1l piggyback

MONUROL 3 GM SACHET 1

1

1

1

mupirocin 2 % oint. (g)

neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g)

neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g)

neomycin/polymyxn b/gramicidin 1.75mg-10k drops

1

nitrofurantoin macrocrystal 50 mg capsule

nitrofurantoin monohyd/m-cryst 100 mg capsule

polymyxin b sulf/trimethoprim 10000-1/ml drops

polymyxin b sulfate 500k unit vial

silver sulfadiazine 1 % cream (g)

SSD 1% CREAM

1

1

1

1

1

1

1

1

1

1

PA

PA

SYNERCID 500 MG VIAL

trimethoprim 100 mg tablet

TYGACIL 50 MG VIAL

vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 125 mg capsule, 250 mg capsule, 500 mg vial, 500 mg vial port, 750 mg vial port, 750 mg vial)

VANDAZOLE VAGINAL 0.75% GEL 1

1

1

XIFAXAN (200 MG TABLET, 550 MG TABLET)

ZYVOX 100 MG/5 ML SUSPENSION

ST


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Beta-lactam, Cephalosporins

cefaclor (250 mg capsule, 500 mg capsule) 1

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon)

1

cefazolin sodium (1 g vial, 1 g vial port, 10 g vial, 20 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial)

1

cefazolin sodium/dextrose, iso-osmotic (sodium/dextrose,iso 1 g/50 ml froz.piggy, sodium/dextrose,iso 1 g/50 ml piggyback)

1

1 cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)

cefepime hcl (1 vial, 2 vial) 1

1

1

1

cefixime (100 mg/5ml, 200 mg/5ml)

cefoxitin sodium (1 vial, 2 vial, 10 vial)

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)

1

1 ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 10 g vial, 100 g bulkbaginj, 250 mg vial, 500 mg vial)

cefuroxime axetil (250 mg tablet, 500 mg tablet) 1

1 cefuroxime sodium (1.5 g vial, 7.5g vial, 7.5 g vial, 75 g bulkbaginj, 750 mg vial)

cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)

1

SUPRAX 400 MG CAPSULE 1

1 TEFLARO (400 MG VIAL, 600 MG VIAL)

Beta-lactam, Other

aztreonam (1 vial, 2 vial) 1

1

1

cefotetan disodium (1 vial, 2 vial, 10 vial)

imipenem/cilastatin sodium (imipenem/cilastatin 250 mg vial, imipenem/cilastatin 500 mg vial)


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INVANZ 1 GM VIAL 1

meropenem (1 g vial, 500 mg vial) 1

1 Beta-lactam, Penicillins

amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)

amoxicillin/potassium clavulanate 1 (amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h) ampicillin sodium (1 g vial, 1 g vial port, 2 g vial, 10 g vial, 250 mg vial, 500 mg vial)

1

1 ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 vial, sodium/sulbactam 3 vial, sodium/sulbactam 15 vial)

ampicillin trihydrate (250 mg capsule, 500 mg capsule)

1

1

1

1

BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS, 2,400,000 UNITS)

dicloxacillin sodium (250 mg capsule, 500 mg capsule)

nafcillin in dextrose, iso-osmotic (1 g/50 ml, 2 g/100 ml)

nafcillin sodium (1 vial, 2 vial, 10 vial) 1

1

1

1

oxacillin sodium (1 vial, 2 vial port, 2 vial, 10 vial)

penicillin g potassium (5mm vial, 20mm vial)

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)


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piperacillin sodium/tazobactam sodium (sodium/tazobactam 2.25 vial port, sodium/tazobactam 2.25 vial,

1

sodium/tazobactam 3.375 vial, sodium/tazobactam 3.375 vial port, sodium/tazobactam 4.5 vial, sodium/tazobactam 4.5 vial port, sodium/tazobactam 40.5 vial)

ZOSYN (2.25 GM/50 ML BAG, 3.375 GM/50 ML, 4.5 GM/100 ML BAG)

1

Macrolides

azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg vial port, 500 mg tablet, 500 mg vial, 600 mg tablet)

1

1 clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)

DIFICID 200 MG TABLET

E.E.S. 200 MG/5 ML GRANULES

E.E.S. 400 FILMTAB

1

1

1

1

PA, ST

ERY-TAB (EC 250 MG TABLET, 333 MG TABLET EC, EC 333 MG TABLET, EC 500 MG TABLET)

ERYPED 200 MG/5 ML SUSPENSION

ERYPED 400 MG/5 ML SUSPENSION

ERYTHROCIN 250 MG FILMTAB

1

1

1

1 ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL)

erythromycin base (5 mg/g oint. (g), 250 mg tablet, 500 mg tablet)

1

1 erythromycin base/ethyl alcohol (base/ethanol 2 % solution, base/ethanol 2 % gel (gram))

erythromycin ethylsuccinate 400 mg tablet 1

1 KETEK (300 MG TABLET, 400 MG TABLET) PA

Quinolones

AVELOX IV 400 MG/250 ML 1

1

1

CIPRO HC OTIC SUSPENSION

CIPRODEX OTIC SUSPENSION


19


ciprofloxacin (250 mg/5ml, 500 mg/5ml) 1

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)

1

1

1

ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial)

ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa 500 mg, ciprofloxacin/ciprofloxa 1000 mg)

gatifloxacin 0.5 % drops 1

1 levofloxacin (0.5 % drops, 25 mg/ml vial, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet)

levofloxacin/dextrose 5 % in water (levofloxacin/d5w 750mg/.15l, levofloxacin/d5w 250mg/50ml, levofloxacin/d5w 500mg/0.1l)

1

MOXEZA 0.5% EYE DROPS

ofloxacin 0.3 % drops

1

1

1 VIGAMOX 0.5% EYE DROPS

Sulfonamides

sulfacetamide sodium 10 % drops 1

1 sulfacetamide/prednisolone sp 10 %-0.23% drops

sulfadiazine 500 mg tablet 1

1 sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 80-16mg/ml vial, sulfamethoxazole/trimethoprim 200- 40mg/5 oral susp, sulfamethoxazole/trimethoprim 400mg-80mg tablet, sulfamethoxazole/trimethoprim 800- 160/20 oral susp, sulfamethoxazole/trimethoprim 800-160 mg tablet)

Tetracyclines

demeclocycline hcl (150 mg tablet, 300 mg tablet)

1

DOXY 100 VIAL 1

1 doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet)


20


doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet)

1

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mg capsule)

1

Anticonvulsants

Anticonvulsants, Other

APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET)

1

1 BRIVIACT (10 MG/ML ORAL SOLN, 10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET, 100 MG TABLET)

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)

1

1 levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg/5ml solution, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml vial, 750 mg tablet, 750 mg tab er 24h, 1000 mg tablet)

phenobarbital (15 mg tablet, 30 mg tablet, 60 mg tablet, 64.8 mg tablet)

1

1

1

PA, PA - FOR NEW STARTS ONLY

PA - FOR NEW STARTS ONLY phenobarbital (16.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet, 97.2mg tablet, 100 mg tablet)

POTIGA (50 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET)

ROWEEPRA 500 MG TABLET 1

1 SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET)

PA - FOR NEW STARTS ONLY

Calcium Channel Modifying Agents

CELONTIN 300 MG KAPSEAL 1

1 ethosuximide (250 mg/5ml solution, 250 mg capsule)

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)

1 QL (93 PER 31 DAYS)

zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule)

1


21


Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab rapdis, 2 mg tab rapdis)

1

1


clonazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)


PA - FOR NEW STARTS ONLY diazepam (2.5 mg, 5-7.5-10mg, 12.5-15-20) 1

1 divalproex sodium (125 mg tablet dr, 125 mg cap sprink, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tablet dr)

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg/6ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet)

1

GABITRIL (12 MG TABLET, 16 MG TABLET) 1

1 ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET)


primidone (50 mg tablet, 250 mg tablet) 1

1 SABRIL (500 MG TABLET, 500 MG POWDER PACKET)

tiagabine hcl (2 mg tablet, 4 mg tablet) 1

1 valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500 mg/5ml vial, salt) 500mg/10ml solution)

valproic acid 250 mg capsule 1

Glutamate Reducing Agents

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)

1

1 lamotrigine (25 mg tablet, 25 mg tab er 24, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24)

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE)

1 ST

topiramate (15 mg cap, 25 mg cap) 1

1


ST topiramate (25 mg cap 24, 50 mg cap 24, 100 mg cap 24, 150 mg cap 24, 200 mg cap 24)

topiramate (25 mg tablet, 100 mg tablet, 200 mg tablet)

1


22


TROKENDI XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE)

1 ST

Sodium Channel Agents

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)

1

1 carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr, 100 mg/5ml oral susp, 100 mg tab chew, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)

DILANTIN (30 MG KAPSEAL, 30 MG CAPSULE)

EPITOL 200 MG TABLET

1

1

1 fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial)

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)

1

1 OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET)

ST

PEGANONE 250 MG TABLET 1

1 phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)

phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul)

1

1

1

phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule)

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET)

Antidementia Agents

Cholinesterase Inhibitors

donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)

1

1 galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule)

1


23


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

memantine hcl (2 mg/ml solution, 5 mg-10 mg tab ds pk, 5 mg tablet, 10 mg tablet)

1

1 NAMENDA (2 MG/ML SOLUTION, 5-10 MG TITRATION PK, 5 MG TABLET, 10 MG TABLET)

Antidepressants

Antidepressants, Other

bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h)

1

maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet)

1

1 mirtazapine (15 mg tablet, 15 mg tab rapdis, 30 mg tablet, 45 mg tablet, 45 mg tab rapdis)


PA - FOR NEW STARTS ONLY mirtazapine (7.5 mg tablet, 30 mg tab rapdis) 1

1 nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet)

trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet)

1

TRINTELLIX (10 MG TABLET, 20 MG TABLET)

TRINTELLIX 5 MG TABLET

1

1

PA - FOR NEW STARTS ONLY, ST


Monoamine Oxidase Inhibitors

EMSAM (6 MG/24, 9 MG/24, 12 MG/24) 1

1

1

1


MARPLAN 10 MG TABLET

phenelzine sulfate 15 mg tablet

tranylcypromine sulfate 10 mg tablet

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

citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet)

1

1

1

desvenlafaxine (50 mg tab er 24h, 50 mg tab er 24, 100 mg tab er 24h, 100 mg tab er 24)

ST

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 40 mg capsule dr, 60 mg capsule dr)

QL (62 PER 31 DAYS)


24


escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mg tablet)

1 ST

FETZIMA (20-40 MG TITRATION PAK, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 120 MG CAPSULE)

1

1

ST

fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr)

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)

1

1 paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 37.5 mg tab er 24h, 40 mg tablet)


PA - FOR NEW STARTS ONLY paroxetine hcl (12.5 mg tab er, 25 mg tab er) 1

1 sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet)

venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg tab er 24, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24)

1

VIIBRYD (10-20 MG STARTER PACK, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET)

1

1 Tricyclics

amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)


amoxapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 150 mg tablet)

1

1

1




clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule)

desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)

doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

1 PA - FOR NEW STARTS ONLY

imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet)

1

1

PA, PA - FOR NEW STARTS ONLY, ST

PA, PA - FOR NEW STARTS ONLY nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule)


25


nortriptyline hcl 10 mg/5 ml solution 1 PA - FOR NEW STARTS ONLY



protriptyline hcl (5 mg tablet, 10 mg tablet) 1

1 SURMONTIL (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE)

trimipramine maleate (25 mg capsule, 50 mg capsule, 100 mg capsule)

1 PA - FOR NEW STARTS ONLY, ST

Antiemetics

Antiemetics, Other

meclizine hcl (12.5 mg tablet, 25 mg tablet) 1

1

PA

PA promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg/ml vial, 25 mg tablet, 25 mg/ml ampul, 25 mg supp.rect, 25 mg/ml syringe, 50 mg/ml ampul, 50 mg/ml vial)

PROMETHEGAN 25 MG SUPPOSITORY

TRANSDERM-SCOP 1.5 MG/3 DAY

1

1

PA

PA

Emetogenic Therapy Adjuncts

ANZEMET (50 MG TABLET, 100 MG TABLET) 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (9 PER 30 DAYS)

ANZEMET 20 MG/ML VIAL

dronabinol 10 mg capsule

dronabinol 2.5 mg capsule

dronabinol 5 mg capsule

1

1

1

1

1

ST




EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE)

PA - TO CONFIRM PART D COVERAGE, ST, QL (9 PER 30 DAYS)

EMEND TRIPACK 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (6 PER 30 DAYS)

granisetron hcl (1 mg/ml(1) vial, 1 mg/ml vial)

granisetron hcl 1 mg tablet

1

1

ST

PA - TO CONFIRM PART D COVERAGE, ST

granisetron hcl/pf (hcl/pf 1 mg/ml(1) vial, hcl/pf 100 mcg/ml vial)

1

1

1

ST

ondansetron (4 mg tab rapdis, 8 mg tab rapdis) PA - TO CONFIRM PART D COVERAGE, QL (62 PER 31 DAYS)

ondansetron hcl (4 mg tablet, 8 mg tablet) PA - TO CONFIRM PART D COVERAGE, QL (62 PER 31 DAYS)


26


ondansetron hcl 24 mg tablet 1 PA - TO CONFIRM PART D COVERAGE, ST, QL (31 PER 31 DAYS)

ondansetron hcl 4 mg/5 ml solution 1

1

PA - TO CONFIRM PART D COVERAGE, ST, QL (950 ML PER 31 DAYS)

ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 ml vial)

ST

Antifungals

ABELCET 100 MG/20 ML VIAL

AMBISOME 50 MG VIAL

1

1

1

1

1

1

amphotericin b 50 mg vial

CANCIDAS (50 MG VIAL, 70 MG VIAL)

ciclopirox (1 % shampoo, 8 % solution)

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)

clotrimazole (1 % cream (g), 1 % solution, 10 mg troche)

1

econazole nitrate 1 % cream (g) 1

1 fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

fluconazole in dextrose, iso-osmotic (200mg/0.1l, 400mg/0.2l)

1

flucytosine (250 mg capsule, 500 mg capsule) 1

1 griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet)

itraconazole 100 mg capsule 1

1 ketoconazole (2 % cream (g), 2 % shampoo, 200 mg tablet)

miconazole nitrate 200 mg supp.vag

MYCAMINE (50 MG VIAL, 100 MG VIAL)

NOXAFIL 40 MG/ML SUSPENSION

1

1

1

1

1

NYAMYC 100,000 UNITS/GM POWDER

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))


27


nystatin/triamcinolone acetonide (nystatin/triamcin 100000-0.1 cream (g), nystatin/triamcin 100000-0.1 oint. (g))

1

NYSTOP 100,000 UNITS/GM POWDER

SPORANOX 10 MG/ML SOLUTION

terbinafine hcl 250 mg tablet

1

1

1

1 terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)

voriconazole (50 mg tablet, 200 mg tablet, 200 mg vial, 200 mg/5ml susp recon)

1

Antigout Agents

allopurinol (100 mg tablet, 300 mg tablet)

colchicine (0.6 mg capsule, 0.6 mg tablet)

colchicine/probenecid 0.5-500mg tablet

COLCRYS 0.6 MG TABLET

1

1

1

1

1

1

MITIGARE 0.6 MG CAPSULE

probenecid 500 mg tablet

Antimigraine Agents

Ergot Alkaloids

CAFERGOT TABLET 1

1 dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial)

ST

ERGOMAR 2 MG TABLET SL 1

Prophylactic

divalproex sodium 500 mg tab er 24h 1

1 topiramate 50 mg tablet

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

naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1

1

QL (9 PER 30 DAYS)

QL (18 PER 30 DAYS) rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 10 mg tablet, 10 mg tab rapdis)

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)

1 QL (9 PER 30 DAYS)


28


sumatriptan succinate (4 mg/0.5ml pen injctr, 4 mg/0.5ml cartridge, 6 mg/0.5ml cartridge, 6 mg/0.5ml vial)

1 ST, QL (6 ML PER 30 DAYS)

zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis)

zolmitriptan (2.5 mg tablet, 5 mg tablet)

ZOMIG (2.5 MG, 5 MG)

1

1

1




Antimyasthenic Agents

Parasympathomimetics

guanidine hcl 125 mg tablet 1

1 pyridostigmine bromide 60 mg tablet

Antimycobacterials

Antimycobacterials, Other

dapsone (25 mg tablet, 100 mg tablet) 1

1 rifabutin 150 mg capsule

Antituberculars

CAPASTAT SULFATE 1 GM VIAL 1

1

1

ethambutol hcl (100 mg tablet, 400 mg tablet)

isoniazid (100 mg/ml vial, 100 mg tablet, 300 mg tablet)

PASER GRANULES 4 GM PACKET 1

1

1

pyrazinamide 500 mg tablet

rifampin (150 mg capsule, 300 mg capsule, 600 mg vial)

SIRTURO 100 MG TABLET

TRECATOR 250 MG TABLET

1

1

PA

Antineoplastics

Alkylating Agents

cyclophosphamide (25 mg capsule, 50 mg capsule)

1

1

PA - TO CONFIRM PART D COVERAGE

GLEOSTINE 5 MG CAPSULE


29


HEXALEN 50 MG CAPSULE

LEUKERAN 2 MG TABLET

MATULANE 50 MG CAPSULE

thiotepa 15 mg vial

1

1

1

1

1 VALCHLOR 0.016% GEL

Antiandrogens

bicalutamide 50 mg tablet 1

1

1

1

1

1

flutamide 125 mg capsule

NILANDRON 150 MG TABLET

nilutamide 150 mg tablet

XTANDI 40 MG CAPSULE

ZYTIGA 250 MG TABLET

Antiangiogenic Agents

CAPRELSA (100 MG TABLET, 300 MG TABLET) 1

1 REVLIMID (2.5 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE)

LA

THALOMID (50 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE)

1

Antiestrogens/Modifiers

EMCYT 140 MG CAPSULE 1

1

1

1

FARESTON 60 MG TABLET

SOLTAMOX 10 MG/5 ML SOLN

tamoxifen citrate (10 mg tablet, 20 mg tablet)

Antimetabolites

ADRUCIL (5 GRAM/100 ML VIAL, 500 MG/10 ML VIAL, 2,500 MG/50 ML VIAL)

1

ALIMTA (100 MG VIAL, 500 MG VIAL) 1

1 DROXIA (200 MG CAPSULE, 300 MG CAPSULE, 400 MG CAPSULE)

hydroxyurea 500 mg capsule 1

1 LONSURF (15 MG-6.14 MG TABLET, 20 MG-8.19 MG TABLET)


30


mercaptopurine 50 mg tablet

PURIXAN 20 MG/ML ORAL SUSP

TABLOID 40 MG TABLET

1

1

1

1 FARYDAK (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE)

VENCLEXTA (10 MG TABLET, 50 MG TABLET, 100 MG TABLET)


PA - FOR NEW STARTS ONLY VENCLEXTA STARTING PACK 1

1 ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL)

ZYKADIA 150 MG CAPSULE 1

Antineoplastics, Other

ALECENSA 150 MG CAPSULE 1

1

1

1

1

1

amifostine crystalline 500 mg vial

azacitidine 100 mg vial

BELEODAQ 500 MG VIAL

bleomycin sulfate (15 vial, 30 vial)

CABOMETYX (20 MG TABLET, 40 MG TABLET, 60 MG TABLET)

cisplatin 1 mg/ml vial 1

1


PA - FOR NEW STARTS ONLY COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK)

COTELLIC 20 MG TABLET 1

1

LA

CYRAMZA (100 MG/10 ML VIAL, 500 MG/50 ML VIAL)

daunorubicin hcl (5 mg/ml vial, 20 mg vial)

decitabine 50 mg vial

1

1

1

1

DOCEFREZ 20 MG VIAL

docetaxel (20 mg/2 ml vial, 20mg/ml(1) vial, 80 mg/8 ml vial, 80 mg/4 ml vial, 140 mg/7ml vial, 160 mg/8ml vial, 160mg/16ml vial, 200mg/20ml vial)

doxorubicin hcl (2 mg/ml vial, 10 mg vial, 10 mg/5 ml vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial)

1

1 doxorubicin hcl peg-liposomal 2 mg/ml vial


31


ERIVEDGE 150 MG CAPSULE

ERWINAZE 10,000 UNITS VIAL

1

1

1 GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET)


HALAVEN 1 MG/2 ML VIAL 1

1 IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MG CAPSULE)

IRESSA 250 MG TABLET 1

1 JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 25 MG TABLET)

JEVTANA 60 MG/1.5 ML KIT 1

1 leucovorin calcium (5 mg tablet, 10 mg/ml vial, 10 mg tablet, 15 mg tablet, 25 mg tablet, 50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg vial)

levoleucovorin calcium 10 mg/ml vial

LYNPARZA 50 MG CAPSULE

1

1

1

1

MEKINIST (0.5 MG TABLET, 2 MG TABLET)

MENEST (0.3 MG TABLET, 0.625 MG TABLET, 1.25 MG TABLET, 2.5 MG TABLET)

mesna 100 mg/ml vial 1

1

1

1

MESNEX 400 MG TABLET

mitoxantrone hcl 2 mg/ml vial

NINLARO (2.3 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE)

ODOMZO 200 MG CAPSULE 1

1

LA

ONCASPAR (750 UNIT/ML VIAL, 3,750 UNIT/5 ML VIAL)

oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, 100mg/20ml vial)

1

paclitaxel 6 mg/ml vial 1

1 POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE)

PROLEUKIN 22 MILLION UNIT VIAL 1

1

1

SYLATRON (200 MCG, 300 MCG, 600 MCG)

SYLATRON 4-PACK (200 MCG, 300 MCG)


32


SYNRIBO 3.5 MG/ML VIAL 1 PA - FOR NEW STARTS ONLY

LA TAGRISSO (40 MG TABLET, 80 MG TABLET)

TAXOTERE (20 MG/ML VIAL, 80 MG/4 ML VIAL)

TRISENOX 10 MG/10 ML AMPULE

VELCADE 3.5 MG VIAL

1

1

1

1

1 ZOLINZA 100 MG CAPSULE

Aromatase Inhibitors, 3rd Generation

anastrozole 1 mg tablet 1

1

1

exemestane 25 mg tablet

letrozole 2.5 mg tablet

Enzyme Inhibitors

etoposide 20 mg/ml vial 1

1

1

topotecan hcl (4 mg/4 ml vial, 4 mg vial)

ZYDELIG (100 MG TABLET, 150 MG TABLET)

Molecular Target Inhibitors

AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET)

1

1 AFINITOR DISPERZ (2 MG TABLET, 3 MG TABLET, 5 MG TABLET)

BOSULIF (100 MG TABLET, 500 MG TABLET)

GLEEVEC (100 MG TABLET, 400 MG TABLET)

ICLUSIG (15 MG TABLET, 45 MG TABLET)

1

1

1

1 imatinib mesylate (100 mg tablet, 400 mg tablet)

IMBRUVICA 140 MG CAPSULE 1

1

1

INLYTA (1 MG TABLET, 5 MG TABLET)

LENVIMA (8 MG, 10 MG, 14 MG, 18 MG, 20 MG, 24 MG)

NEXAVAR 200 MG TABLET 1

1 SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MG TABLET, 100 MG TABLET, 140 MG TABLET)

STIVARGA 40 MG TABLET 1


33


SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MG CAPSULE)

1

TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 1

1 TARCEVA (25 MG TABLET, 100 MG TABLET, 150 MG TABLET)

TASIGNA (150 MG CAPSULE, 200 MG CAPSULE)

TYKERB 250 MG TABLET

1

1

1

1

1

VOTRIENT 200 MG TABLET

XALKORI (200 MG CAPSULE, 250 MG CAPSULE)

ZELBORAF 240 MG TABLET



Monoclonal Antibodies

ARZERRA 1,000 MG/50 ML VIAL 1

1 AVASTIN (100 MG/4 ML VIAL, 400 MG/16 ML VIAL)

DARZALEX (100 MG/5 ML VIAL, 400 MG/20 ML VIAL)

1 LA

EMPLICITI (300 MG VIAL, 400 MG VIAL)

HERCEPTIN 440 MG VIAL

1

1

1

1

1

KADCYLA (100 MG VIAL, 160 MG VIAL)

KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL)

OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL)

PERJETA 420 MG/14 ML VIAL

RITUXAN 10 MG/ML VIAL

1

1

1

1

TECENTRIQ 1,200 MG/20 ML VIAL

YERVOY (50 MG/10 ML VIAL, 200 MG/40 ML VIAL)

Retinoids

bexarotene 75 mg capsule 1

1

1

PANRETIN 0.1% GEL

TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG CAPSULE)

tretinoin 10 mg capsule 1


34

DRUG NAME

Antiparasitics

TIER REQUIREMENTS/LIMITS

Anthelmintics

ALBENZA 200 MG TABLET 1

BILTRICIDE 600 MG TABLET 1

1 ivermectin 3 mg tablet

Antiprotozoals

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET)

1

atovaquone 750 mg/5ml oral susp 1

1 atovaquone/proguanil hcl (atovaquone/proguanil 62.5-25 mg tablet, atovaquone/proguanil 250-100 mg tablet)

chloroquine phosphate (250 mg tablet, 500 mg tablet)

1

COARTEM TABLETS 1

1

1

1

1

1

1

1

1

DARAPRIM 25 MG TABLET

hydroxychloroquine sulfate 200 mg tablet

mefloquine hcl 250 mg tablet

NEBUPENT 300 MG INHAL POWDER

PENTAM 300 VIAL

PA

PA

primaquine phosphate 26.3 mg tablet

quinine sulfate 324 mg capsule

tinidazole (250 mg tablet, 500 mg tablet)

Pediculicides/Scabicides

EURAX 10% LOTION 1

1

1

lindane 1 % shampoo

permethrin 5 % cream (g)

Antiparkinson Agents

Anticholinergics

benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

1 PA


35


trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)

1 PA

Antiparkinson Agents, Other

entacapone 200 mg tablet 1

1 tolcapone 100 mg tablet

Dopamine Agonists

APOKYN 30 MG/3 ML CARTRIDGE 1

1

ST

ST

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)

NEUPRO (1 MG/24 HR, 2 MG/24 HR, 3 MG/24 HR, 4 MG/24 HR, 6 MG/24 HR, 8 MG/24 HR)

1

1 pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)

1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa (carbidopa/levodopa 10mg- 100mg tablet, carbidopa/levodopa 25mg-250mg tablet, carbidopa/levodopa 25mg-100mg tablet er, carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa 50mg-200mg tablet er)

1

carbidopa/levodopa/entacapone 1 (carbidopa/levodopa/entacapone 12.5-50 mg tablet, carbidopa/levodopa/entacapone 18.75- 75mg tablet, carbidopa/levodopa/entacapone 25-100-200 tablet, carbidopa/levodopa/entacapone 31.25-125 tablet, carbidopa/levodopa/entacapone 37.5- 150mg tablet, carbidopa/levodopa/entacapone 50-200-200 tablet)

Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT (0.5 MG TABLET, 1 MG TABLET) 1

1

ST

selegiline hcl (5 mg tablet, 5 mg capsule)


36


Antipsychotics

1st Generation/Typical

chlorpromazine hcl (10 mg tablet, 25 mg/ml ampul)


chlorpromazine hcl (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

1 PA, PA - FOR NEW STARTS ONLY

COMPRO 25 MG SUPPOSITORY 1

1

1




fluphenazine decanoate 25 mg/ml vial

fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 2.5 mg/ml vial, 5 mg tablet, 5 mg/ml oral conc)

fluphenazine hcl 10 mg tablet 1

1


haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)

haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul, 100 mg/ml ampul, 100 mg/ml vial)

1

1

1

1

haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial, 5 mg/ml ampul)

loxapine succinate (5 mg capsule, 10 mg capsule, 25 mg capsule, 50 mg capsule)


PA - FOR NEW STARTS ONLY molindone hcl (5 mg tablet, 10 mg tablet, 25 mg tablet)

ORAP 1 MG TABLET

ORAP 2 MG TABLET

1

1

1



PA - FOR NEW STARTS ONLY perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet)

perphenazine 16 mg tablet 1

1

1

1



PA

pimozide (1 mg tablet, 2 mg tablet)

prochlorperazine 25 mg supp.rect

prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial)


prochlorperazine maleate (5 mg tablet, 10 mg tablet)

1

1

1




thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

thiothixene (1 mg capsule, 2 mg capsule, 5 mg capsule, 10 mg capsule)


37


trifluoperazine hcl (1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet)


2nd Generation/Atypical

ABILIFY MAINTENA (ER 300 MG, ER 400 MG) 1

1


PA - FOR NEW STARTS ONLY aripiprazole (10 mg tab rapdis, 15 mg tab rapdis)

aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

1

1

1

ARISTADA (ER 441 MG/1.6 ML, ER 662 MG/2.4 ML, ER 882 MG/3.2 ML)

ST

ST FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET, TITRATION PACK)

GEODON 20 MG/ML VIAL 1

1

ST

ST INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET, ER 6 MG TABLET, ER 9 MG TABLET)

INVEGA SUSTENNA (39 MG/0.25 ML, 78 MG/0.5 ML, 117 MG/0.75 ML, 156 MG/ML SYRG, 234 MG/1.5 ML)

1

1

ST

ST

ST

INVEGA TRINZA (273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML)

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET, 120 MG TABLET)

1

1

1

1

NUPLAZID 17 MG TABLET PA - FOR NEW STARTS ONLY, QL (62 PER 31 DAYS)

olanzapine (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 10 mg vial, 15 mg tablet, 20 mg tablet)


olanzapine (5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 15 mg tab rapdis, 20 mg tab rapdis)


paliperidone (1.5 mg tab er 24, 3 mg tab er 24, 6 mg tab er 24, 9 mg tab er 24)

1

1

ST

ST

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)

REXULTI (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)

1

1 RISPERDAL CONSTA (12.5 MG, 37.5 MG, 50 MG)


38


risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)

1

SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL BLK CHERRY, 5 MG TABLET SUBLINGUAL, 10 MG TAB SUBLINGUAL, 10 MG TAB SL BLK CHERY)

1

1 SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MG TABLET, 400 MG TABLET)

VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE)

1

1

1

PA - FOR NEW STARTS ONLY, QL (31 PER 31 DAYS)

ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule)

ST

ZYPREXA RELPREVV (210 MG VIAL, 210 MG VL KIT, 300 MG VL KIT, 300 MG VIAL, 405 MG VL KIT, 405 MG VIAL)


Treatment-Resistant

clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 100 mg tab rapdis, 150 mg tab rapdis, 200 mg tab rapdis)


clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

1

1


PA - FOR NEW STARTS ONLY FAZACLO (12.5 MG TABLET, 12.5 MG ODT, 25 MG TABLET, 25 MG ODT, 100 MG ODT, 100 MG TABLET)

VERSACLOZ 50 MG/ML SUSPENSION 1 PA - FOR NEW STARTS ONLY

Antispasticity Agents

baclofen (10 mg tablet, 20 mg tablet) 1

1 dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule)

tizanidine hcl (2 mg tablet, 4 mg tablet) 1 PA

Antivirals

Anti-HIV Agents, Integrase Inhibitors (INSTI)

ATRIPLA TABLET 1


39


TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET)

1

VITEKTA (85 MG TABLET, 150 MG TABLET) 1

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

COMPLERA TABLET 1

1

1

EDURANT 25 MG TABLET

INTELENCE (25 MG TABLET, 100 MG TABLET, 200 MG TABLET)

nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h)

1

ODEFSEY TABLET 1

1

1

1

RESCRIPTOR (100 MG TABLET, 200 MG TABLET)

STRIBILD TABLET

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET)

VIRAMUNE XR 100 MG TABLET 1

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

abacavir sulfate 300 mg tablet 1

abacavir/lamivudine/zidovudine 150-300mg tablet

1

DESCOVY 200-25 MG TABLET 1

1 didanosine (125 mg capsule dr, 200 mg capsule dr, 250 mg capsule dr, 400 mg capsule dr)

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)

1

EPIVIR HBV 25 MG/5 ML SOLN

EPZICOM TABLET

1

1

1

1

GENVOYA TABLET

lamivudine (10 mg/ml solution, 100 mg tablet, 150 mg tablet, 300 mg tablet)

lamivudine/zidovudine 150-300mg tablet 1

1

1

RETROVIR 200 MG/20 ML VIAL

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)

TRIUMEQ TABLET 1


40


TRUVADA (100 MG-150 MG TABLET, 133 MG- 200 MG TABLET, 167 MG-250 MG TABLET, 200 MG-300 MG TABLET)

1

VIDEX (2 GM SOLN, 4 GM SOLN) 1

1 VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)

ZIAGEN 20 MG/ML SOLUTION 1

1 zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)

Anti-HIV Agents, Other

FUZEON (90 MG VIAL, CONVENIENCE KIT) 1

1

1

SELZENTRY (150 MG TABLET, 300 MG TABLET)

TYBOST 150 MG TABLET

Anti-HIV Agents, Protease Inhibitors

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)

1

CRIXIVAN (200 MG CAPSULE, 400 MG CAPSULE)

EVOTAZ 300 MG-150 MG TABLET

1

1

1

1

INVIRASE (200 MG CAPSULE, 500 MG TABLET)

KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU)

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)

1

1 NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)

PREZCOBIX 800 MG-150 MG TABLET 1

1 PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 600 MG TABLET, 800 MG TABLET)

REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)

1

VIRACEPT (250 MG TABLET, 625 MG TABLET)

ZEPATIER 50-100 MG TABLET

1

1 PA, QL (28 PER 28 DAYS)

Anti-cytomegalovirus (CMV) Agents

cidofovir 75 mg/ml vial 1


41


ganciclovir sodium 500 mg vial

valganciclovir hcl 450 mg tablet

ZIRGAN 0.15% OPHTHALMIC GEL

1

1

1

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 10 mg tablet 1

1

1

1

BARACLUDE 0.05 MG/ML SOLUTION

entecavir (0.5 mg tablet, 1 mg tablet)

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)

TYZEKA 600 MG TABLET 1

1 Anti-hepatitis C (HCV) Agents

DAKLINZA (30 MG TABLET, 60 MG TABLET, 90

MG TABLET) PA

HARVONI 90-400 MG TABLET

MODERIBA 200 MG TABLET

OLYSIO 150 MG CAPSULE

1

1

1

1


PA

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)

PEGASYS PROCLICK (135 MCG/0.5, 180 MCG/0.5)

1

1

1

PEGINTRON (50 MCG, 80 MCG, 120 MCG, 150 MCG)

PEGINTRON REDIPEN (50 MCG, 50 MCG 4PK, 80 MCG, 80 MCG 4PK, 120 MCG 4PK, 120 MCG, 150 MCG, 150 MCG 4PK)

RIBASPHERE 200 MG TABLET

SOVALDI 400 MG TABLET

VIEKIRA PAK

1

1

1


PA

Anti-influenza Agents

amantadine hcl (100 mg tablet, 100 mg capsule) 1

1

1

1

RELENZA 5 MG DISKHALER

rimantadine hcl 100 mg tablet

TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE)


42


Antiherpetic Agents

acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)

1

acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg vial)

1

1 famciclovir (125 mg tablet, 250 mg tablet, 500 mg tablet)

trifluridine 1 % drops 1

1 valacyclovir hcl (500 mg tablet, 1000 mg tablet)

Anxiolytics

Anxiolytics, Other

buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet)

1

1 doxepin hcl 10 mg/ml oral conc PA - FOR NEW STARTS ONLY

Benzodiazepines

alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

1

1

1

1

1

PA

clorazepate dipotassium (3.75 mg tablet, 7.5 mg tablet, 15 mg tablet)





diazepam (2 mg tablet, 5 mg tablet, 10 mg tablet)

diazepam (5 mg/5 ml solution, 5 mg/ml oral conc)

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

LORAZEPAM INTENSOL 2 MG/ML 1

1

PA

PA oxazepam (10 mg capsule, 15 mg capsule, 30 mg capsule)

temazepam (7.5 mg capsule, 15 mg capsule, 22.5 mg capsule, 30 mg capsule)

1

1

PA

PA triazolam (0.125 mg tablet, 0.25 mg tablet)

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

PAXIL 10 MG/5 ML SUSPENSION 1 PA - FOR NEW STARTS ONLY


43


venlafaxine hcl 225 mg tab er 24 1

Bipolar Agents

Bipolar Agents, Other

ABILIFY MAINTENA (ER 300 MG, ER 400 MG) 1

1


RISPERDAL CONSTA 25 MG SYR

Mood Stabilizers

lamotrigine 5 mg tb chw dsp 1

1 lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule)

lithium citrate 8 meq/5 ml solution

Blood Glucose Regulators

Antidiabetic Agents

1

acarbose (25 mg tablet, 50 mg tablet, 100 mg tablet)

1

AVANDIA (2 MG TABLET, 4 MG TABLET)

BYETTA (5 MCG, 10 MCG)

1

1

1

1

1

ST

ST

CYCLOSET 0.8 MG TABLET

FARXIGA (5 MG TABLET, 10 MG TABLET) ST

glimepiride (1 mg tablet, 2 mg tablet, 4 mg tablet)

glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet)

1

1 glipizide/metformin hcl (glipizide/metformin 2.5- 250 mg tablet, glipizide/metformin 2.5-500 mg tablet, glipizide/metformin 5 mg-500mg tablet)

GLYSET (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

1

1 INVOKAMET (50-1,000 MG TABLET, 50-500 MG TABLET, 150-500 MG TABLET, 150-1,000 MG TABLET)

ST

INVOKANA (100 MG TABLET, 300 MG TABLET) 1

1

ST

ST JANUMET (50-1,000 MG TABLET, 50-500 MG TABLET)


44


JANUVIA (25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

1 ST

metformin hcl (500 mg tabergr24h, 500 mg tab er 24, 500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)

1

1 miglitol (25 mg tablet, 50 mg tablet, 100 mg tablet)

nateglinide (60 mg tablet, 120 mg tablet) 1

1 pioglitazone hcl (15 mg tablet, 30 mg tablet, 45 mg tablet)

ST

ST pioglitazone hcl/metformin hcl (/metformin 15mg-500mg tablet, /metformin 15mg-850mg tablet)

1

repaglinide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

1

1

ST

ST repaglinide/metformin hcl (repaglinide/metformin 1mg-500mg tablet, repaglinide/metformin 2 mg-500mg tablet)

SYMLINPEN 120 PEN INJECTOR

SYMLINPEN 60 PEN INJECTOR

VICTOZA 2-PAK 18 MG/3 ML PEN

VICTOZA 3-PAK 18 MG/3 ML PEN

1

1

1

1

ST

ST

ST

ST

Glycemic Agents

CLINIMIX (4.25%-20%, 5%-20%, 5%-15%) 1

1


CLINIMIX E (2.75%-5%, 2.75%-10%, 4.25%-25%, 4.25%-5%, 5%-15%, 5%-25%)

dextrose 10 % and 0.2 % nacl 10 %-0.2 % dehp fr bg

1

dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln 1

1 dextrose 10 % in water (10 % 10 % iv soln, 10 % 10 % dehp fr bg)

dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln

1

dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln

dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln

1

1

1 dextrose 5 % in water (5 % 5 % iv soln, 5 % pgy vl prt, 5 % 5 % vial, 5 % pggybk prt)


45


dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln

dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln

1

1

1 GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL, 1 MG HYPOKIT 2-PACK)

GLUCAGON 1 MG EMERGENCY KIT

IONOSOL B-D5W IV SOLUTION

1

1

1

1

1

IONOSOL MB-D5W IV SOLUTION

NORMOSOL-R-DEXTROSE 5% IV SOLN

potassium chloride in dextrose 5 % and 0.9 % sodium chloride (chloride/d5-0.9%nacl 40 meq/l soln, chloride/d5-0.9%nacl 20 meq/l soln)

potassium chloride in dextrose 5 %-0.45 % sodium chloride (chloride/d5-0.45nacl 10 meq/l soln, chloride/d5-0.45nacl 20 meq/l soln, chloride/d5-0.45nacl 40 meq/l soln, chloride/d5- 0.45nacl 30 meq/l soln)

1

potassium chloride in lr-d5 20 meq/l iv soln

potassium chloride/d5-0.2%nacl 20 meq/l iv soln

potassium chloride/d5-0.3%nacl 20 meq/l iv soln

PROGLYCEM 50 MG/ML ORAL SUSP

1

1

1

1

Insulins

APIDRA 100 UNITS/ML VIAL 1

1

1

APIDRA SOLOSTAR 100 UNITS/ML

HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL)

HUMALOG 100 UNITS/ML KWIKPEN

HUMALOG 200 UNITS/ML KWIKPEN

HUMALOG MIX 50-50 KWIKPEN

HUMALOG MIX 50-50 VIAL

1

1

1

1

1

1

1

1

1


HUMALOG MIX 75-25 VIAL

HUMULIN R 500 UNITS/ML VIAL

LANTUS 100 UNITS/ML VIAL

LANTUS SOLOSTAR 100 UNITS/ML


46


LEVEMIR 100 UNITS/ML VIAL 1

LEVEMIR FLEXPEN 100 UNITS/ML

LEVEMIR FLEXTOUCH 100 UNITS/ML

1

1

1 NOVOLOG (100 UNIT/ML CARTRIDGE, 100 UNIT/ML VIAL)

NOVOLOG 100 UNITS/ML FLEXPEN

NOVOLOG MIX 70-30 FLEXPEN SYRN

NOVOLOG MIX 70-30 VIAL

1

1

1

1 TOUJEO SOLOSTAR 300 UNITS/ML

Blood Products/Modifiers/Volume Expanders

Anticoagulants

enoxaparin sodium (100 mg/ml, 150 mg/ml) 1

1

1

1

1

1

1


PA, QL (27.2 ML PER 17 DAYS)





ST

enoxaparin sodium (80mg/0.8ml, 120mg/.8ml)

enoxaparin sodium 300mg/3ml vial

enoxaparin sodium 30mg/0.3ml syringe



fondaparinux sodium (2.5 mg/0.5, 5mg/0.4ml, 7.5mg/0.6, 10mg/0.8ml)

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL)

1 PA, ST

heparin sodium,porcine (1000/ml vial, 5000/ml vial, 5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial)

1

1 heparin sodium,porcine/dextrose 5 % in water (sodium,porcine/d5w 25000/250 soln, sodium,porcine/d5w 20k/500ml soln, sodium,porcine/d5w 12500/250 soln, sodium,porcine/d5w 25000/500 soln)

PRADAXA (75 MG CAPSULE, 110 MG CAPSULE, 150 MG CAPSULE)

1

1

PA, ST

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet)


47


XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, STARTER PACK)

1 ST

Blood Formation Modifiers

anagrelide hcl (0.5 mg capsule, 1 mg capsule) 1

1 ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/ML VIAL, 25 MCG/0.42 ML SYRING, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)

PA

EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL)

1 PA

LEUKINE 250 MCG VIAL 1

1

PA

PA NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480 MCG/0.8 ML SYR)

PROCRIT (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL)

1

1

PA

PA PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET)

Coagulants

BRILINTA (60 MG TABLET, 90 MG TABLET) 1

1 tranexamic acid (650 mg tablet, 1000 mg/10 vial, 1000 mg/10 ampul)

Platelet Modifying Agents

AGGRENOX 25 MG-200 MG CAPSULE 1

1

1

1

aspirin/dipyridamole 25mg-200mg cpmp 12hr

cilostazol (50 mg tablet, 100 mg tablet)

clopidogrel bisulfate (75 mg tablet, 300 mg tablet)


48


Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine (0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr)

1 PA

PA clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)

1

methyldopa (250 mg tablet, 500 mg tablet)

methyldopate hcl 250 mg/5ml vial

1

1

1

PA

PA

midodrine hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Alpha-adrenergic Blocking Agents

CARDURA XL (4 MG TABLET, 8 MG TABLET) 1

1

PA

PA prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule)

Angiotensin II Receptor Antagonists

candesartan cilexetil (4 mg tablet, 8 mg tablet, 16 mg tablet, 32 mg tablet)

1

1

1

1

ENTRESTO (24 MG-26 MG TABLET, 49 MG-51 MG TABLET, 97 MG-103 MG TABLET)

ST

irbesartan (75 mg tablet, 150 mg tablet, 300 mg tablet)

irbesartan/hydrochlorothiazide (irbesartan/hydrochlorothiazide 150-12.5mg tablet, irbesartan/hydrochlorothiazide 300- 12.5mg tablet)

losartan potassium (25 mg tablet, 50 mg tablet, 100 mg tablet)

1

1 losartan potassium/hydrochlorothiazide (losartan/hydrochlorothiazide 50-12.5 mg tablet, losartan/hydrochlorothiazide 100-12.5mg tablet, losartan/hydrochlorothiazide 100mg-25mg tablet)

telmisartan (20 mg tablet, 40 mg tablet, 80 mg tablet)

1 ST


49


telmisartan/hydrochlorothiazide 1 ST (telmisartan/hydrochlorothiazid 40-12.5 mg tablet, telmisartan/hydrochlorothiazid 80- 12.5mg tablet, telmisartan/hydrochlorothiazid 80 mg-25mg tablet)

valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet, 320 mg tablet)

1

1

ST

ST valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide 80-12.5mg tablet, valsartan/hydrochlorothiazide 160- 12.5mg tablet, valsartan/hydrochlorothiazide 160-25mg tablet, valsartan/hydrochlorothiazide 320mg-25mg tablet, valsartan/hydrochlorothiazide 320-12.5mg tablet)

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)

1

1 benazepril hcl/hydrochlorothiazide (benazepril/hydrochlorothiazide 5-6.25mg tablet, benazepril/hydrochlorothiazide 10- 12.5mg tablet, benazepril/hydrochlorothiazide 20-12.5 mg tablet, benazepril/hydrochlorothiazide 20 mg-25mg tablet)

captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

1

1 captopril/hydrochlorothiazide (captopril/hydrochlorothiazide 25 mg-25mg tablet, captopril/hydrochlorothiazide 25 mg- 15mg tablet, captopril/hydrochlorothiazide 50 mg-15mg tablet, captopril/hydrochlorothiazide 50 mg-25mg tablet)

enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)

1

1 enalapril maleate/hydrochlorothiazide (enalapril/hydrochlorothiazide 5mg-12.5mg tablet, enalapril/hydrochlorothiazide 10 mg- 25mg tablet)

lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)

1


50


lisinopril/hydrochlorothiazide 1 (lisinopril/hydrochlorothiazide 10-12.5mg tablet, lisinopril/hydrochlorothiazide 20-12.5 mg tablet, lisinopril/hydrochlorothiazide 20 mg-25mg tablet)

quinapril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)

1

1 quinapril hcl/hydrochlorothiazide (quinapril/hydrochlorothiazide 10-12.5mg tablet, quinapril/hydrochlorothiazide 20 mg- 25mg tablet, quinapril/hydrochlorothiazide 20- 12.5 mg tablet)

ramipril (1.25 mg capsule, 2.5 mg capsule, 5 mg capsule, 10 mg capsule)

1

Antiarrhythmics

amiodarone hcl (50 mg/ml vial, 50 mg/ml ampul, 200 mg tablet, 400 mg tablet)

1

1

1

1

1

PA

PA disopyramide phosphate (100 mg capsule, 150 mg capsule)

dofetilide (125 mcg capsule, 250 mcg capsule, 500 mcg capsule)

flecainide acetate (50 mg tablet, 100 mg tablet, 150 mg tablet)

mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule)

MULTAQ 400 MG TABLET 1

1

ST

propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mg tablet, 325 mg cap er 12h, 425 mg cap er 12h)

quinidine gluconate 324 mg tablet er 1

1

1

quinidine sulfate (200 mg tablet, 300 mg tablet)

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet)

PA

TIKOSYN (125 MCG CAPSULE, 250 MCG CAPSULE, 500 MCG CAPSULE)

1

Beta-adrenergic Blocking Agents

acebutolol hcl (200 mg capsule, 400 mg capsule) 1

1 atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)


51


bisoprolol fumarate (5 mg tablet, 10 mg tablet) 1

bisoprolol fumarate/hydrochlorothiazide (fumarate/hctz 2.5-6.25mg tablet, fumarate/hctz 5-6.25mg tablet, fumarate/hctz 10-6.25mg tablet)

1

carvedilol (3.125 mg tablet, 6.25 mg tablet, 12.5 mg tablet, 25 mg tablet)

1

1

1

1

1

COREG CR (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE)

ST

labetalol hcl (5 mg/ml vial, 100 mg tablet, 200 mg tablet, 300 mg tablet)

metoprolol succinate (25 mg tab er, 50 mg tab er, 100 mg tab er, 200 mg tab er)

metoprolol tartrate (5 mg/5 ml syringe, 5 mg/5 ml ampul, 5 mg/5 ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet)

metoprolol tartrate/hydrochlorothiazide (metoprolol/hydrochlorothiazide 50 mg-25mg tablet, metoprolol/hydrochlorothiazide 100mg- 50mg tablet, metoprolol/hydrochlorothiazide 100mg-25mg tablet)

1

1 nadolol/bendroflumethiazide (nadolol/bendroflumethiazide 40 mg tablet, nadolol/bendroflumethiazide 80 mg tablet)

pindolol (5 mg tablet, 10 mg tablet) 1

1 propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg tablet, 40 mg tablet, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)

propranolol hcl/hydrochlorothiazide (propranolol/hydrochlorothiazid 40 tablet, propranolol/hydrochlorothiazid 80 tablet)

1

Calcium Channel Blocking Agents

AFEDITAB CR (30 MG TABLET, 60 MG TABLET) 1

1 amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

CARTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE)

1

1 DILT-CD (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE)


52


DILT-XR (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE)

1

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 420 mg capsule er)

1

MATZIM LA (180 MG TABLET, 240 MG TABLET, 300 MG TABLET, 360 MG TABLET, 420 MG TABLET)

1

NIFEDICAL XL (30 MG TABLET, 60 MG TABLET) 1

1 nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er)

nimodipine 30 mg capsule 1

1 TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE)

verapamil hcl (2.5 mg/ml ampul, 2.5 mg/ml vial, 40 mg tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel)

1

Cardiovascular Agents, Other

DEMSER 250 MG CAPSULE 1

1

1

DIGOX 125 MCG TABLET

digoxin (250 mcg/ml ampul, 250 mcg/ml syringe)

PA

digoxin 125 mcg tablet 1

1

QL (62 PER 31 DAYS)

NORTHERA (100 MG CAPSULE, 200 MG CAPSULE)


NORTHERA 300 MG CAPSULE 1

1

1


PA

pentoxifylline 400 mg tablet er

RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET)


53


TEKTURNA (150 MG TABLET, 300 MG TABLET) 1 ST

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide (125 mg tablet, 250 mg tablet) 1

1

1

acetazolamide sodium 500 mg vial

methazolamide 50 mg tablet

Diuretics, Loop

bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

1

1

1

furosemide (10 mg/ml solution, 10 mg/ml vial, 20 mg tablet, 40 mg tablet, 80 mg tablet)

torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet)

Diuretics, Potassium-sparing

amiloride hcl 5 mg tablet 1

1 amiloride/hydrochlorothiazide 5 mg-50 mg tablet

spironolact/hydrochlorothiazid 25 mg-25mg tablet

1

spironolactone (50 mg tablet, 100 mg tablet)

spironolactone 25 mg tablet

1

1

1

PA

triamterene/hydrochlorothiazide (triamterene/hydrochlorothiazid 37.5-25 mg capsule, triamterene/hydrochlorothiazid 37.5-25 mg tablet, triamterene/hydrochlorothiazid 50 mg-25mg capsule, triamterene/hydrochlorothiazid 75 mg-50mg tablet)

Diuretics, Thiazide

candesartan cilexetil/hydrochlorothiazide (candesartan/hydrochlorothiazid 16-12.5mg tablet, candesartan/hydrochlorothiazid 32- 12.5mg tablet, candesartan/hydrochlorothiazid 32mg-25mg tablet)

1

chlorthalidone (25 mg tablet, 50 mg tablet) 1

1 hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet)

indapamide (1.25 mg tablet, 2.5 mg tablet) 1


54


metolazone (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

1

Dyslipidemics, Fibric Acid Derivatives

fenofibrate (40 mg tablet, 50 mg capsule, 54 mg tablet, 120 mg tablet, 150 mg capsule, 160 mg tablet)

1 ST

fenofibrate nanocrystallized (48 mg tablet, 145mg tablet)

1

1

ST

ST fenofibrate,micronized (43 mg capsule, 67 mg capsule, 130 mg capsule, 134mg capsule, 200 mg capsule)

fenofibric acid (35 mg tablet, 105 mg tablet) 1

1

ST

fenofibric acid (choline) ((choline) 45 mg capsule dr, (choline) 135 mg capsule dr)

fenoprofen calcium 400 mg capsule

FIBRICOR (35 MG TABLET, 105 MG TABLET)

gemfibrozil 600 mg tablet

1

1

1

ST

ST

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)

1

1

1

1

lovastatin (10 mg tablet, 20 mg tablet, 40 mg tablet)

pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet)

Dyslipidemics, Other

cholestyramine (with sugar) (suar) 4 powder, suar) 4 powd pack)

1

1 cholestyramine/aspartame (cholestyramine/aspartame 4 powd pack, cholestyramine/aspartame 4 powder)

colestipol hcl (1 tablet, 5 packet, 5 ranules) 1

1 JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE)

PA

PA KYNAMRO 200 MG/ML SYRINGE 1


55


niacin (500 mg tab er, 750 mg tab er, 1000 mg tab er)

1

omega-3 acid ethyl esters 1 g capsule

PREVALITE (PACKET, POWDER)

1

1

1

1

1

1

REPATHA 140 MG/ML SURECLICK

REPATHA 140 MG/ML SYRINGE

REPATHA 420 MG/3.5ML PUSHTRONX

PA, ST

PA, ST

PA, ST

VYTORIN (10-80 MG TABLET, 10-10 MG TABLET, 10-40 MG TABLET, 10-20 MG TABLET)

WELCHOL 625 MG TABLET

ZETIA 10 MG TABLET

1

1

ST

Vasodilators, Direct-acting Arterial

hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50 mg tablet, 100 mg tablet)

1

1 minoxidil (2.5 mg tablet, 10 mg tablet)

Vasodilators, Direct-acting Arterial/Venous

isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er)

1

1 isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er 24h)

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 50 mg/10ml vial)

1

1 NITROSTAT (0.3 MG TABLET, 0.4 MG TABLET, 0.6 MG TABLET)


56


Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

dextroamphetamine sulf- 1 ST, QL (62 PER 31 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 10 mg cap er, dextroamphetamine/amphetamine 15 mg cap er, dextroamphetamine/amphetamine 20 mg cap er, dextroamphetamine/amphetamine 25 mg cap er, dextroamphetamine/amphetamine 30 mg cap er)

dextroamphetamine sulf- 1 QL (93 PER 31 DAYS) saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet, dextroamphetamine/amphetamine 15 mg tablet, dextroamphetamine/amphetamine 20 mg tablet)

dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)

1

1 dextroamphetamine/amphetamine 30 mg tablet QL (62 PER 31 DAYS)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

1

1

1

guanfacine hcl (1 mg tab er, 2 mg tab er, 3 mg tab er, 4 mg tab er)


METADATE ER 20 MG TABLET


57


methylphenidate hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 ml solution, 10 mg cpbp 30-70, 18 mg tab er 24, 20 mg cpbp 30- 70, 20 mg tablet, 20 mg cpbp 50-50, 20 mg tablet er, 27 mg tab er 24, 30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24, 40 mg cpbp 50- 50, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70)

1

STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE)

1 ST

Central Nervous System, Other

HETLIOZ 20 MG CAPSULE 1

1

PA

PA HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET)

NUEDEXTA 20-10 MG CAPSULE 1

1

1

1

PA

PA

PA

PA

riluzole 50 mg tablet

tetrabenazine (12.5 mg tablet, 25 mg tablet)

XENAZINE (12.5 MG TABLET, 25 MG TABLET)

Fibromyalgia Agents

LYRICA 20 MG/ML ORAL SOLUTION 1

1

QL (1400 ML PER 31 DAYS)

QL (62 PER 31 DAYS) SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

Multiple Sclerosis Agents

AMPYRA ER 10 MG TABLET 1

1

1

PA

PA AUBAGIO (7 MG TABLET, 14 MG TABLET)

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT, PREFILLED SYR 30 MCG)

AVONEX PEN (30 MCG/0.5 ML, 30 MCG/0.5 ML KIT)

1

BETASERON (0.3 MG VIAL, 0.3 MG KIT)

COPAXONE 40 MG/ML SYRINGE

GILENYA 0.5 MG CAPSULE

1

1

1

1

1

GLATOPA 20 MG/ML SYRINGE

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE, TITRATION PACK)


58


TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE)

1

TYSABRI 300 MG/15 ML VIAL 1 PA

Dental and Oral Agents

chlorhexidine gluconate 0.12 % mouthwash

PERIOGARD 0.12% ORAL RINSE

1

1

1

1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet)

triamcinolone acetonide 0.1 % paste (g)

Dermatological Agents

8-MOP 10 MG CAPSULE 1

1 acitretin (10 mg capsule, 17.5 mg capsule, 25 mg capsule)

PA, ST

ST adapalene 0.1 % gel (gram) 1

1

1

1

ammonium lactate (12 % lotion, 12 % cream (g))

calcipotriene (0.005 % oint. (g), 0.005 % solution)

CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE)

PA

clindamycin phosphate (1 % lotion, 1 % solution)

COSENTYX 150 MG/ML PEN INJECT

COSENTYX 150 MG/ML SYRINGE

1

1

1

1

1

1

1

ST

ST

ST

ST

ST

ST

COSENTYX 300 MG DOSE-2 PENS

COSENTYX 300 MG DOSE-2 SYRINGE

diclofenac sodium 1 % gel (gram)

erythromycin/benzoyl peroxide 3 %-5 % gel (gram)

fluocinolone acetonide 0.01 % oil 1

1 fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g))

imiquimod 5 % cream pack 1

1


PA MYORISAN (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE)

podofilox 0.5 % solution 1


59


REGRANEX 0.01% GEL 1 PA, QL (15 GM PER 30 DAYS)

PA, QL (30 GM PER 30 DAYS) SANTYL OINTMENT 1

1

1

1

1

1

1

1

selenium sulfide 2.5 % lotion

sulfacetamide sodium 10 % suspension

tacrolimus (0.03 % (g), 0.1 % (g))

TAZORAC (0.05% GEL, 0.1% GEL)

TAZORAC (0.05%, 0.1%)

ST, QL (100 GM PER 30 DAYS)

ST, QL (60 GM PER 30 DAYS)

TOLAK 4% CREAM

tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.1 % cream (g))

ST

UVADEX 20 MCG/ML VIAL 1

1 ZENATANE (10 MG CAPSULE, 20 MG CAPSULE, 40 MG CAPSULE)

PA

Enzyme Replacement/Modifiers

ADAGEN 250 UNITS/ML VIAL

ALDURAZYME 2.9 MG/5 ML VIAL

CEREZYME 400 UNITS VIAL

1

1

1

1 CREON (DR 3,000 CAPSULE, DR 6,000 CAPSULE, DR 12,000 CAPSULE, DR 24,000 CAPSULE, DR 36,000 CAPSULE)

CYSTADANE POWDER 1

1

1

1

1

1

CYSTAGON (50 MG CAPSULE, 150 MG CAPSULE)

ELAPRASE 6 MG/3 ML VIAL

ELELYSO 200 UNITS VIAL

FABRAZYME (5 MG VIAL, 35 MG VIAL)

KUVAN (100 MG TABLET, 100 MG POWDER PACKET, 500 MG POWDER PACKET)

PA

LUMIZYME 50 MG VIAL 1

1

1

NAGLAZYME 5 MG/5 ML VIAL

PANCREAZE (DR 4,200 CAP, DR 10,500 CAP, DR 16,800 CAP, DR 21,000 CAP)

sodium phenylbutyrate 0.94 g/g powder 1


60


STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80 MG/0.8 ML VIAL)

1 PA

SUCRAID 8,500 UNITS/ML SOLN

VPRIV 400 UNITS VIAL

1

1

1

1

ZAVESCA 100 MG CAPSULE

ZENPEP (DR 3,000 CAPSULE, DR 5,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE)

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

dicyclomine hcl (10 mg capsule, 20 mg tablet) 1

1

PA

PA

glycopyrrolate (0.2 mg/ml vial, 1 mg/5 ml syringe, 1 mg tablet, 2 mg tablet)

Gastrointestinal Agents, Other

cromolyn sodium 20 mg/ml oral conc 1

1 diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025mg tablet, hcl/atropine 2.5-.025/5 liquid)

GATTEX (5 MG ONE-VIAL, 5 MG 30-VIAL) 1

1

1

loperamide hcl 2 mg capsule

metoclopramide hcl (5 mg tablet, 5 mg/ml vial, 10 mg tablet)

PA

ST MOVANTIK (12.5 MG TABLET, 25 MG TABLET) 1

1 RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL)

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)

1

Histamine2 (H2) Receptor Antagonists

famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg tablet)

1

1

1

famotidine in nacl,iso-osm/pf 20 mg/50ml piggyback

famotidine/pf 20 mg/2 ml vial


61


ranitidine hcl (15 mg/ml syrup, 25 mg/ml vial, 50 mg/2 ml vial, 150 mg capsule, 150 mg tablet, 300 mg tablet, 300 mg capsule)

1

Irritable Bowel Syndrome Agents

alosetron hcl (0.5 mg tablet, 1 mg tablet) 1

1

PA

AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES)

Laxatives

CONSTULOSE 10 GM/15 ML SOLN 1

1

1

1

1

1

1

1

ENULOSE 10 GM/15 ML SOLUTION

GAVILYTE-C SOLUTION

GAVILYTE-G SOLUTION

GAVILYTE-N SOLUTION

GENERLAC 10 GM/15 ML SOLUTION

lactulose (10 g/15 ml, 20 g/30 ml)

peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl (3350/na sulf,bicarb,cl/kcl 236-22.74g soln, 3350/na sulf,bicarb,cl/kcl 240-22.72g soln)

polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder)

1

1 TRILYTE WITH FLAVOR PACKETS

Protectants

CARAFATE 1 GM/10 ML SUSP 1

1

1

misoprostol (100 mcg tablet, 200 mcg tablet)

sucralfate 1 g tablet

Proton Pump Inhibitors

esomeprazole sodium (20 mg vial, 40 mg vial) 1

1

ST

ST lansoprazole (15 mg capsule dr, 30 mg capsule dr)

omeprazole (10 mg capsule dr, 20 mg capsule dr)

1

omeprazole 40 mg capsule dr 1

1

ST

ST pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)


62


PROTONIX IV 40 MG VIAL 1

Genitourinary Agents

Antispasmodics, Urinary

darifenacin hydrobromide (7.5 mg tab er, 15 mg tab er)

1

1

1

PA, ST

PA

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET)

oxybutynin chloride (5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24)

OXYTROL 3.9 MG/24HR PATCH 1

1

PA, ST

PA, ST tolterodine tartrate (1 mg tablet, 2 mg tablet, 2 mg cap er 24h, 4 mg cap er 24h)

TOVIAZ (ER 4 MG TABLET, ER 8 MG TABLET) 1

1

ST

trospium chloride (20 mg tablet, 60 mg cap er 24h)

PA, ST

VESICARE (5 MG TABLET, 10 MG TABLET) 1 PA, ST

PA

Benign Prostatic Hypertrophy Agents

AVODART 0.5 MG SOFTGEL 1

1 doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet)

dutasteride 0.5 mg capsule

finasteride 5 mg tablet

1

1

1

1

tamsulosin hcl 0.4 mg cap er 24h

terazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule, 10 mg capsule)

PA

Genitourinary Agents, Other

bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet)

1

ELMIRON 100 MG CAPSULE

THIOLA 100 MG TABLET

1

1

Phosphate Binders

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 750 MG POWDER PACKET, 1,000 MG POWDER PACK, 1,000 MG TABLET CHEW)

1


63


RENAGEL (400 MG TABLET, 800 MG TABLET) 1

RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDER PACKET, 800 MG TABLET)

1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

A-HYDROCORT 100 MG VIAL 1

1

1

betamethasone dipropionate 0.05 % lotion

betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 % cream (g), betamethasone/propylene 0.05 % oint. (g))

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))

1

1 clobetasol propionate (0.05 % shampoo, 0.05 % cream (g), 0.05 % oint. (g), 0.05 % gel (gram))

clobetasol propionate/emoll 0.05 % cream (g) 1

1

1

CLODAN 0.05% SHAMPOO

clotrimazole/betamethasone dip 1 %-0.05 % cream (g)

DEPO-MEDROL 20 MG/ML VIAL 1

1

1

desonide 0.05 % lotion

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

fludrocortisone acetate 0.1 mg tablet 1

1 fluocinolone acetonide (0.01 % cream (g), 0.025 % oint. (g), 0.025 % cream (g))

fluocinolone acetonide oil 0.01 % drops 1

1 fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g))

fluocinonide/emollient base 0.05 % cream (g) 1

1 fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g))

hydrocortisone (1 % oint. (g), 1 % cream (g), 2.5 % cream (g), 2.5 % oint. (g), 2.5 % cream/appl, 5 mg tablet, 10 mg tablet, 20 mg tablet)

1

1 hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)


64


hydrocortisone valerate 0.2 % cream (g) 1

methylprednisolone (4 mg tablet, 4 mg tab ds pk, 8 mg tablet, 16 mg tablet, 32 mg tablet)

1

1

1

1

methylprednisolone acetate (40 mg/ml vial, 80 mg/ml vial)

methylprednisolone sodium succinate (125 mg vial, 1000 mg vial)

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution)

prednisolone 15 mg/5 ml solution 1

1 prednisolone sod phosphate (5 mg/5 ml, 15 mg/5 ml, 25 mg/5 ml)

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet)

1

PROCTOSOL-HC 2.5% CREAM

PROCTOZONE-HC 2.5% CREAM

1

1

1 SOLU-CORTEF (250 MG VIAL, 500 MG VIAL, 1,000 MG VIAL)

triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.5 % oint. (g), 0.5 % cream (g))

1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 4 mcg/ml vial, 4 mcg/ml ampul, 10/spray spray/pump)

1

GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG CARTRIDGE)

1 PA

PA HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, 24 MG CARTRIDGE)

1

INCRELEX 40 MG/4 ML VIAL 1

1 NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5, 30 MG/3 ML)

PA

PA NORDITROPIN NORDIFLEX 30 MG/3 1


65


NUTROPIN AQ (20 MG/2ML CART, CARTRIDGE)

NUTROPIN AQ NUSPIN (5, 10, 20)

1 PA

PA

PA

1

1 OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG)

PREGNYL 10,000 UNITS VIAL 1

1

PA

PA SAIZEN (5 MG VIAL, 8.8 MG VIAL, 8.8 MG CLICK.EASY CARTG)

SEROSTIM (4 MG VIAL, 5 MG VIAL, 6 MG VIAL)

ZORBTIVE 8.8 MG VIAL

1

1

PA

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 300 MG TABLET 1 PA

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

Anabolic Steroids

ANADROL-50 TABLET 1

oxandrolone (2.5 mg tablet, 10 mg tablet) 1

Androgens

ANDRODERM (2 MG/24HR, 4 MG/24HR) 1

1

1

PA

PA ANDROGEL 1%(5G) GEL PACKET

danazol (50 mg capsule, 100 mg capsule, 200 mg capsule)

TESTIM 1% (50MG) GEL 1

1

PA

PA testosterone (1.25 g(1%) gel md pmp, 50 mg (1%) gel (gram), 50 mg (1%) gel packet)

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial)

1 PA

testosterone enanthate 200 mg/ml vial 1

1

PA

PA VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5 GEL PACKT)

Estrogens

AMETHIA 0.15-0.03-0.01 MG TAB

AMETHYST 90-20 MCG TABLET

APRI 28 DAY TABLET

1

1

1


66


ARANELLE 28 TABLET 1

AUBRA-28 TABLET 1

1

1

1

1

1

1

1

1

1

1

1

AVIANE-28 TABLET

BALZIVA 28 TABLET

BRIELLYN TABLET

CRYSELLE-28 TABLET

CYCLAFEM (1-35-28 TABLET, 7-7-7-28 TABLET)

DELYLA-28 TABLET

desog-e.estradiol/e.estradiol 21-5 tablet

EMOQUETTE 28 DAY TABLET

ENPRESSE-28 TABLET

ESTRACE 0.01% CREAM

estradiol (.025mg/24h, .0375mg/24, 0.05mg/24h, 0.06mg/24h, .075mg/24h, 0.1mg/24hr)

PA

estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

1

estradiol/norethindrone acet 0.5-0.1mg tablet 1

1 ethinyl estradiol/drospirenone 0.03mg-3mg tablet

FALMINA-28 TABLET 1

1

1

1

1

1

1

GIANVI 3 MG-0.02 MG TABLET

GILDAGIA 0.4 MG-0.035 MG TAB

GILDESS 1.5 MG-30 MCG TABLET

INTROVALE 0.15-0.03 MG TABLET

JINTELI 1 MG-5 MCG TABLET

JUNEL (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET)

JUNEL FE (1 MG-20 MCG TABLET, 1.5 MG-30 MCG TABLET)

1

KARIVA 28 DAY TABLET 1

1

1

1

KELNOR 1-35 28 TABLET

LARIN (1.5 MG-30 MCG TABLET, 21 1-20 TABLET)

LARIN FE (1-20 TABLET, 1.5-30 TABLET)


67


LEENA 28 TABLET 1

LESSINA-28 TABLET

LEVONEST-28 TABLET

1

1

1 levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 0.15-0.03 tbdspk 3mo, 0.15-0.03 tablet, 90- 20mcg tablet)

LEVORA-28 TABLET 1

1

1

1

1

1

1

1

LORYNA 3 MG-0.02 MG TABLET

LUTERA-28 TABLET

MARLISSA-28 TABLET

MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)

MICROGESTIN FE (1-20 TABLET, 1.5-30 TAB)

MONONESSA 28 TABLET

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 7-7- 7-28 TABLET)

NIKKI 3 MG-0.02 MG TABLET 1

1

1

norethindrone ac-eth estradiol 1mg-5mcg tablet

NORTREL (0.5-35 TABLET, 1-35 TABLET, 7-7-7-28 TABLET)

OCELLA 3 MG-0.03 MG TABLET

ORSYTHIA-28 TABLET

1

1

1

1

1

1

PIMTREA 28 DAY TABLET

PIRMELLA 1-35-28 TABLET

PORTIA-28 TABLET

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)

PA

PREMARIN VAGINAL CREAM-APPL

PREMPHASE 0.625-5 MG TABLET

1

1

1

PA

PA PREMPRO (0.3 MG-1.5 MG TABLET, 0.45-1.5 MG TABLET, 0.625-5 MG TABLET, 0.625-2.5 MG TABLET)

PREVIFEM TABLET 1

1

1

QUASENSE 0.15-0.03 MG TABLET

RECLIPSEN 28 DAY TABLET


68


SPRINTEC 28 DAY TABLET

SRONYX 0.10-0.02 MG TABLET

TARINA FE 1-20 TABLET

TRI-LEGEST FE-28 DAY TABLET

TRI-PREVIFEM TABLET

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

TRI-SPRINTEC TABLET

TRINESSA TABLET

TRIVORA-28 TABLET

VELIVET 28 DAY TABLET

VESTURA 3 MG-0.02 MG TABLET

VYFEMLA 28 TABLET

WYMZYA FE CHEWABLE TABLET

ZENCHENT 0.4 MG-35 MCG TABLET

ZOVIA 1-35E TABLET

ZOVIA 1-50E TABLET

Progestins

CAMILA 0.35 MG TABLET 1

1

1

1

1

1

1

1

DEPO-PROVERA 400 MG/ML VIAL

DEPO-SUBQ PROVERA 104 SYRINGE

ERRIN 0.35 MG TABLET

hydroxyprogesterone caproate 250 mg/ml vial

JOLIVETTE TABLET

PA

LYZA 0.35 MG TABLET

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 150 mg/ml vial, 150 mg/ml syringe)

MEGACE ES 625 MG/5 ML SUSP 1

1

PA

megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp)


megestrol acetate 625mg/5ml oral susp

NORA-BE TABLET

1

1

1

PA

norethindrone 0.35 mg tablet


69


norethindrone acetate 5 mg tablet 1

progesterone,micronized (100 mg capsule, 200 mg capsule)

1

Selective Estrogen Receptor Modifying Agents

raloxifene hcl 60 mg tablet 1

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)

1

liothyronine sodium (5 mcg tablet, 10 mcg/ml vial, 25 mcg tablet, 50 mcg tablet)

1

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 500 MG TABLET 1

1

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR (30 MG TABLET, 60 MG TABLET, 90 MG TABLET)

Hormonal Agents, Suppressant (Pituitary)

cabergoline 0.5 mg tablet 1

1 ELIGARD (7.5 MG B, 7.5 MG KIT, 22.5 MG B, 22.5 MG KIT, 30 MG B, 30 MG KIT, 45 MG B, 45 MG KIT)

FIRMAGON (2 X 120 MG VIALS, 2 X 120 MG KIT, 80 MG VIAL, 80 MG KIT)

1

1

1

leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial)

LUPRON DEPOT (DEPOT 3.75 MG, DEPOT-4 MONTH, DEPOT 7.5 MG, DEPOT 11.25 MG 3MO, DEPOT 22.5 MG 3MO, DEPOT 45 MG 6MO)

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG KIT, 15 MG KIT, 30 MG 3MO KIT)

1


70


octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul, 100 mcg/ml ampul, 100 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml vial, 1000mcg/ml vial)

1

SANDOSTATIN LAR (10 MG, 20 MG, 30 MG) 1

1 SANDOSTATIN LAR DEPOT (10 MG VL, 10 MG KT, 20 MG VL, 20 MG KT, 30 MG KT, 30 MG VL)

SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) 1

1 SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT, 40 MG VIAL, 60 MG VIAL, 60 MG KIT)

SOMATULINE DEPOT (90 MG/0.3 ML, 120 MG/0.5 ML)

1

1 SOMAVERT (10 MG VIAL, 15 MG VIAL, 20 MG VIAL, 25 MG VIAL, 30 MG VIAL)

SYNAREL 2 MG/ML NASAL SPRAY 1

1

PA

TRELSTAR (3.75 MG SYRINGE, 3.75 MG VIAL, 11.25 MG SYRINGE, 11.25 MG VIAL, 22.5 MG VIAL, 22.5 MG SYRINGE)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole (5 mg tablet, 10 mg tablet) 1

1 propylthiouracil 50 mg tablet

Immunological Agents

Angioedema (HAE) Agents

CINRYZE 500 UNIT VIAL 1

1

PA

PA FIRAZYR 30 MG/3 ML SYRINGE

Immune Suppressants

ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE)

1 PA - TO CONFIRM PART D COVERAGE

AZASAN (75 MG TABLET, 100 MG TABLET)

azathioprine 50 mg tablet

1

1

1

1



azathioprine sodium 100 mg vial

BENLYSTA (120 MG VIAL, 400 MG VIAL) PA


71


CELLCEPT 500 MG VIAL 1 PA - TO CONFIRM PART D COVERAGE

PA - TO CONFIRM PART D COVERAGE cyclosporine (25 mg capsule, 100 mg capsule, 250 mg/5ml vial, 250 mg/5ml ampul)

1

1

1

1

1

cyclosporine, modified (25 mg capsule, 100 mg/ml solution, 100 mg capsule)


ENBREL (25 MG KIT, 50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)

ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET)


PA - TO CONFIRM PART D COVERAGE GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG/ML SOLUTION, 100 MG CAPSULE)

HUMIRA (20 MG/0.4 ML, 40 MG/0.8 ML)

HUMIRA 40 MG/0.8 ML PEN

1

1

1

1

1

HUMIRA PEN CROHN-UC-HS STARTER

KINERET 100 MG/0.67 ML SYRINGE

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial)

methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial)

1

1

1

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet)




mycophenolate sodium (180 mg tablet dr, 360 mg tablet dr)

NULOJIX 250 MG VIAL 1

1

1

1

1

1

1

ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL)

ORENCIA CLICKJECT 125 MG/ML

PROGRAF 5 MG/ML AMPULE

RAPAMUNE 1 MG/ML ORAL SOLN

REMICADE 100 MG VIAL



sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)


PA - TO CONFIRM PART D COVERAGE tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)

1

TORISEL 25 MG KIT 1

1 TREXALL (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET)


72


ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MG TABLET)


Immunizing Agents, Passive

ATGAM 50 MG/ML AMPUL 1

1 CARIMUNE NF NANOFILTERED (3 GM VIAL, 6 GM VIAL, 12 GM VIAL)


GAMMAGARD LIQUID 10% VIAL 1

1


PA - TO CONFIRM PART D COVERAGE GAMMAGARD S-D (2.5 GM VL W/ST, 5 G (IGA<1) SOLN, 5 GM VL W/SET, 10 G (IGA<1) SOL, 10 GM VL W/ST)

GAMUNEX-C (1 GRAM/10 ML VIAL, 2.5 GRAM/25 ML VIAL, 5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL, 20 GRAM/200 ML VIAL, 40 GRAM/400 ML VIAL)


HYPERRAB S-D 150 UNITS/ML VIAL

THYMOGLOBULIN 25 MG VIAL

1

1

Immunomodulators

ACTIMMUNE 100 MCG/0.5 ML VIAL 1

1

1

1

1

1

ARCALYST 220 MG INJECTION

ILARIS 180 MG VIAL PA

leflunomide (10 mg tablet, 20 mg tablet)

SIMULECT (10 MG VIAL, 20 MG VIAL)

SYNAGIS (50 MG/0.5 ML VIAL, 100 MG/1 ML VIAL)

XELJANZ 5 MG TABLET 1

1

PA

PA XELJANZ XR 11 MG TABLET

Vaccines

ACTHIB (VIAL, WITH DILUENT) 1

1

1

1

1

1

1

ADACEL TDAP VIAL

bcg vaccine, live/pf 50 mg vial

BEXSERO PREFILLED SYRINGE

BOOSTRIX TDAP (SYRINGE, VIAL)

CERVARIX VACCINE SYRINGE

DAPTACEL DTAP VACCINE


73


ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL)


ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN)


GARDASIL (SYRINGE, VIAL) 1

1

1

GARDASIL 9 (9 VIAL, 9 SYRINGE)

HAVRIX (720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML SYRINGE, 1,440 UNITS/ML VIAL)

HIBERIX (VIAL, WITH DILUENT) 1

1 IMOVAX RABIES VACCINE (VACCINE VIAL, VACCINE+DILUENT)

INFANRIX DTAP VIAL 1

1

1

1

1

1

1

1

1

1

1

1

1

1

IPOL VIAL

IXIARO 6 MCG/0.5 ML SYRINGE

M-M-R II VACCINE (VIAL, WITH DILUENT)

MENACTRA VIAL

MENHIBRIX VACCINE VIAL

MENOMUNE-A-C-Y-W-135 (VIAL, W-DILUENT)

MENVEO A-C-Y-W-135-DIP VIAL KT

PEDVAXHIB VACCINE VIAL

PENTACEL ACTHIB COMPONENT VIAL

PROQUAD VIAL

QUADRACEL DTAP-IPV VIAL

RABAVERT RABIES VACCINE VIAL

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML VIAL, 10 MCG/ML SYR, 40 MCG/ML VIAL)


ROTARIX VACCINE SUSPENSION

ROTATEQ VACCINE

1

1

1

1

1

1

1

TENIVAC SYRINGE

tetanus, diphtheria tox,adult 2-2 lf/0.5 vial

tetanus,diphtheria toxd ped/pf 5-25/0.5ml vial

TRUMENBA 120 MCG/0.5 ML VACCIN

TWINRIX VACCINE VIAL


74


TYPHIM VI 25 MCG/0.5 ML VIAL

VAQTA (25 UNITS/0.5 ML, 50 UNITS/ML)

VARIVAX VACCINE (VIAL, WITH DILUENT)

VARIZIG 125 UNIT/1.2 ML VIAL

YF-VAX (1 VIAL, 5 VIAL)

1

1

1

1

1

1 ZOSTAVAX VIAL

Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO ER 0.375 GRAM CAPSULE 1

1

1

1

1

1

1

1

ASACOL HD DR 800 MG TABLET

balsalazide disodium 750 mg capsule

CANASA 1,000 MG SUPPOSITORY

DELZICOL DR 400 MG CAPSULE

DIPENTUM 250 MG CAPSULE

ST

ST LIALDA DR 1.2 GM TABLET

PENTASA (250 MG CAPSULE, 500 MG CAPSULE)

Glucocorticoids

budesonide 3 mg capdr - er 1

1 cortisone acetate 25 mg tablet

Sulfonamides

sulfasalazine (500 mg tablet, 500 mg tablet dr) 1

Metabolic Bone Disease Agents

alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg tablet)

1

1

1

1

calcitonin,salmon,synthetic 200/spray spray/pump

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution, 1 mcg/ml ampul)

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule, 4mcg/2ml ampul, 4mcg/2ml vial)


75


etidronate disodium (200 mg tablet, 400 mg tablet)

1

FORTEO 600 MCG/2.4 ML PEN INJ

FORTICAL 200 UNITS NASAL SPRAY

1

1

1

ST

ST ibandronate sodium (3 mg/3 ml vial, 150 mg tablet)

ibandronate sodium 3 mg/3 ml syringe 1

1 MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL)

PROLIA 60 MG/ML SYRINGE 1

1

1

1

ST

XGEVA 120 MG/1.7 ML VIAL

zoledronic acid (4 mg/5 ml vial, 4 mg vial) PA

ST zoledronic acid in mannitol and water for injection (acid/mannitol-water 5 mg/100ml infus. btl, acid/mannitol-water 5 mg/100ml piggyback)

Miscellaneous Therapeutic Agents

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET)

1 ST

fomepizole 1 g/ml vial 1

1

1

1

1

INTRALIPID 20% IV FAT EMUL PA - TO CONFIRM PART D COVERAGE

PA NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG)

NUTRILIPID 20% IV FAT EMULSION PA - TO CONFIRM PART D COVERAGE

pen needle, diabetic (, 30gx 5/16", , 31 gx3/16", , 31 gx5/16")

PHYSIOLYTE IRRIGATION SOLN

PHYSIOSOL IRRIGATION SOLN

1

1

1

1

1

1

ringers solution irrig soln

ringers solution,lactated irrig soln

sodium chloride irrig solution 0.9 % irrig soln

syring-needl,disp,insul,0.3 ml 30gx 5/16" disp syrin

syringe with needle, insulin, safety, 0.3 ml (ge,needle,insuln,sf,0.3ml 30gx 5/16" disp, ge,needle,insuln,sf,0.3ml 29 g x1/2" disp)

1


76


syringe with needle, insulin, safety, 0.5 ml (29 g x1/2" disp, 30gx 5/16" disp)

1

syringe with needle, insulin, safety, 1 ml (29 g x1/2" disp, 30gx 5/16" disp)

1

1 syringe with needle,disposable,insulin 1 ml (ge disp, ge 28gx1/2" disp, ge 29 g x1/2" disp, ge 30gx 5/16" disp, ge 30gx1/2" disp)

syringe with needle,insulin,0.5 ml (ml 28 gauge disp, ml 29 g x1/2" disp, ml 30gx 5/16" disp, ml 30gx1/2" disp)

1

1 water for irrigation,sterile irrig soln

Ophthalmic Agents

Ophthalmic Agents, Other

atropine sulfate 1 % drops 1

1

1

LACRISERT 5 MG EYE INSERT

RESTASIS 0.05% EYE EMULSION QL (60 PER 30 DAYS)

Ophthalmic Anti-allergy Agents

azelastine hcl 0.05 % drops 1

1

1

1

1

1

cromolyn sodium 4 % drops

epinastine hcl 0.05 % drops

olopatadine hcl 0.1 % drops

PATADAY 0.2% EYE DROPS

PATANOL 0.1% EYE DROPS



Ophthalmic Anti-inflammatories

ALREX 0.2% EYE DROPS 1

1

1

1

1

1

1

dexamethasone sod phosphate 0.1 % drops

diclofenac sodium 0.1 % drops

DUREZOL 0.05% EYE DROPS

fluorometholone 0.1 % drops susp

flurbiprofen sodium 0.03 % drops

ketorolac tromethamine (0.4 % drops, 0.5 % drops)


LOTEMAX (EYE DROPS, OPHTHALMIC GEL) 1


77


neomycin/polymyxin b sulfate/dexamethasone (neo/polymyx sulf/dexameth 0.1 % drops susp, neo/polymyx sulf/dexameth 3.5-10k-.1 oint. (g))

1

prednisolone acetate 1 % drops susp

prednisolone sod phosphate 1 % drops

TOBRADEX EYE OINTMENT

1

1

1

1 tobramycin/dexamethasone 0.3 %-0.1% drops susp

VEXOL 1% EYE DROPS 1

Ophthalmic Antiglaucoma Agents

acetazolamide 500 mg capsule er 1

1

1

1

1

1

1

1

1

1

1

1

ALPHAGAN P 0.1% DROPS

apraclonidine hcl 0.5 % drops

AZOPT 1% EYE DROPS QL (10 ML PER 30 DAYS)


brimonidine tartrate (0.15 % drops, 0.2 % drops)

dorzolamide hcl 2 % drops

dorzolamide hcl/timolol maleat 22.3-6.8/1 drops

levobunolol hcl 0.5 % drops

methazolamide 25 mg tablet

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)

SIMBRINZA 1%-0.2% EYE DROPS

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel, 0.5 % drops)

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost 0.005 % drops 1

1

1




LUMIGAN 0.01% EYE DROPS

travoprost (benzalkonium) 0.004 % drops

Otic Agents

acetic acid 2 % solution 1

1 neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin sulf/hc 3.5-10k-1 solution, neomycin/polymyxin sulf/hc 3.5-10k-1 drops susp)


78


Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS (100-50, 250-50, 500-50) 1 QL (60 PER 30 DAYS)

ADVAIR HFA (45-21 MCG, 115-21 MCG, 230-21 MCG)

1 QL (12 GM PER 30 DAYS)

ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #30, TWISTHALR 220 MCG #120)

1

ASMANEX HFA (100 MCG, 200 MCG)

BREO ELLIPTA 100-25 MCG INH

1

1

1 budesonide (0.25mg/2ml, 0.5 mg/2ml, 1 mg/2 ml)


budesonide 32mcg spray/pump 1

1

1

1

1

1

1

1

1

1

1

FLOVENT HFA (110 MCG, 220 MCG)

FLOVENT HFA 44 MCG INHALER

flunisolide 25 mcg spray

QL (24 GM PER 30 DAYS)

QL (21.2 GM PER 30 DAYS)

fluticasone propionate 50 mcg spray susp

mometasone furoate 50 mcg spray/pump

PULMICORT 1 MG/2 ML RESPULE

PULMICORT FLEXHALER (90 MCG, 180 MCG)

QVAR 40 MCG ORAL INHALER

ST


QL (8.7 GM PER 30 DAYS)

QL (17.4 GM PER 30 DAYS) QVAR 80 MCG ORAL INHALER

SYMBICORT (80-4.5 MCG, 160-4.5 MCG)

Antihistamines

azelastine hcl (137 mcg spray/pump, 205.5mcg spray/pump)

1 ST

diphenhydramine hcl 50 mg/ml vial

levocetirizine dihydrochloride 5 mg tablet

olopatadine hcl 0.6 % spray/pump

1

1

1

PA

ST

Antileukotrienes

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet)

1


79


zafirlukast (10 mg tablet, 20 mg tablet)

ZYFLO 600 MG FILMTAB

1

1

1

ST

ST ZYFLO CR 600 MG TABLET

Bronchodilators, Anticholinergic

ATROVENT HFA INHALER 1

1

1

1

1

COMBIVENT RESPIMAT INHAL SPRAY

ipratropium bromide (21 mcg, 42 mcg)

ipratropium bromide 0.2 mg/ml solution PA - TO CONFIRM PART D COVERAGE

PA - TO CONFIRM PART D COVERAGE ipratropium/albuterol sulfate 0.5-3mg/3 ampul- neb

SPIRIVA 18 MCG CP-HANDIHALER

SPIRIVA RESPIMAT 1.25 MCG INH

SPIRIVA RESPIMAT 2.5 MCG INH

TUDORZA PRESSAIR 400 MCG INH

1

1

1

1

ST

ST

ST

Bronchodilators, Sympathomimetic

ADRENACLICK (0.15 MG AUTO-INJCT, 0.3 MG AUTO-INJECT)

1

1

QL (2 PER 60 DAYS)

albuterol sulfate (0.63mg/3ml vial-neb, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 5 mg/ml solution)


epinephrine 0.3mg/0.3 auto injct

EPIPEN 0.3 MG AUTO-INJECTOR

EPIPEN 2-PAK 0.3 MG AUTO-INJCT

EPIPEN JR 0.15 MG AUTO-INJCT

EPIPEN JR 2-PAK 0.15 MG INJCTR

1

1

1

1

1

1

QL (2 PER 60 DAYS)

QL (2 PER 60 DAYS)

QL (2 PER 60 DAYS)

QL (2 PER 60 DAYS)

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet)

PROAIR HFA 90 MCG INHALER

SEREVENT DISKUS 50 MCG

1

1

1

ST

QL (60 PER 30 DAYS)

terbutaline sulfate (1 mg/ml vial, 2.5 mg tablet, 5 mg tablet)

VENTOLIN HFA (90 MCG INHALER, RELION 90 MCG INH)

1


80


Cystic Fibrosis Agents

CAYSTON 75 MG INHAL SOLUTION 1

KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET)

1 PA, QL (62 PER 31 DAYS)

ORKAMBI 200 MG-125 MG TABLET

PULMOZYME 1 MG/ML AMPUL

1

1

1

PA

PA, ST

PA tobramycin in 0.225% nacl 300 mg/5ml ampul- neb

Mast Cell Stabilizers

cromolyn sodium 20 mg/2 ml ampul-neb 1

1


Phosphodiesterase Inhibitors, Airways Disease

aminophylline (250mg/10ml vial, 250mg/10ml ampul, 500mg/20ml vial, 500mg/20ml ampul)

DALIRESP 500 MCG TABLET 1

1

PA

THEO-24 (ER 100 MG CAPSULE, ER 200 MG CAPSULE, ER 300 MG CAPSULE, ER 400 MG CAPSULE)

theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)

1

Pulmonary Antihypertensives

ADCIRCA 20 MG TABLET 1

1

PA

ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET, 2.5 MG TABLET)


LETAIRIS (5 MG TABLET, 10 MG TABLET)

OPSUMIT 10 MG TABLET

1

1

1

ST


REMODULIN (1 MG/ML VIAL, 2.5 MG/ML VIAL, 5 MG/ML VIAL, 10 MG/ML VIAL)

PA - TO CONFIRM PART D COVERAGE, ST

sildenafil citrate 20 mg tablet 1

1

PA

TRACLEER (62.5 MG TABLET, 125 MG TABLET) ST, LA

Respiratory Tract Agents, Other

acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1

1

1


PA

ARALAST NP (500 MG VIAL, 1,000 MG VIAL)

ESBRIET 267 MG CAPSULE


81


GLASSIA 1 GM/50 ML VIAL 1

OFEV (100 MG CAPSULE, 150 MG CAPSULE)

PROLASTIN C 1,000 MG VIAL

TYZINE PEDIATRIC 0.05% DROP

XOLAIR 150 MG VIAL

1

1

1

1

1

PA

ZEMAIRA 1,000 MG VIAL

Skeletal Muscle Relaxants

cyclobenzaprine hcl 10 mg tablet 1

1

PA

PA methocarbamol (500 mg tablet, 750 mg tablet)

Sleep Disorder Agents

GABA Receptor Modulators

zaleplon (5 mg capsule, 10 mg capsule) 1

1

PA

PA zolpidem tartrate (5 mg tablet, 10 mg tablet)

Sleep Disorders, Other

modafinil (100 mg tablet, 200 mg tablet) 1

1

1

PA

LA

ROZEREM 8 MG TABLET

XYREM 500 MG/ML ORAL SOLUTION

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral Modifiers

ammonium chloride 5 meq/ml vial 1

1

1

1

1

CARBAGLU 200 MG DISPER TABLET

CUPRIMINE 250 MG CAPSULE

DEPEN 250 MG TITRATAB

PA

EXJADE (125 MG TABLET, 250 MG TABLET, 500 MG TABLET)

JADENU (90 MG TABLET, 180 MG TABLET, 360 MG TABLET)

1

sodium lactate 5 meq/ml vial 1

1 sodium polystyrene sulfonate (15 g/60 ml oral susp, 30 g/120ml enema, 50 g/200ml enema, powder)


82


SYPRINE 250 MG CAPSULE 1

Electrolyte/Mineral Replacement

0.9 % sodium chloride (0.9 % 0.9 % iv soln, 0.9 % 0.9 % syringe, 0.9 % pggybk prt, 0.9 % 0.9 % vial, 0.9 % pgy vl prt)

1

AMINOSYN II (7%, 8.5%, 10%)

AMINOSYN II 8.5%-ELECTROLYTES

AMINOSYN M 3.5% IV SOLUTION

1

1

1

1




PA - TO CONFIRM PART D COVERAGE AMINOSYN WITH ELECTROLYTES (7%- ELECTROLYTE, 8.5%-ELECTROLYTES)

AMINOSYN-HBC 7% IV SOLUTION

AMINOSYN-PF (7%, 10%)

1

1

1

1



calcium acetate 667 mg capsule

CLINIMIX (2.75%-5%, 4.25%-5%, 4.25%-25%, 4.25%-10%, 5%-25%)


PA - TO CONFIRM PART D COVERAGE CLINIMIX E 4.25%-10% SOLUTION

CLINIMIX E 5%-20% SOLUTION

CLINISOL 15% SOLUTION

1

1

1

1

1


dextrose 5%-lactated ringers 5 % iv soln

FLUOR-A-DAY (0.25 MG TAB, 0.5 MG TAB, 1 MG TABLET)

FLUORITAB (0.5 MG TABLET, 1 MG TABLET)

FREAMINE HBC 6.9% IV SOLN

HEPATAMINE 8% IV SOLUTION

ISOLYTE P-DEXTROSE 5% SOLN

ISOLYTE S IV SOLUTION-EXCEL

KLOR-CON 10 MEQ TABLET

KLOR-CON 8 MEQ TABLET

1

1

1

1

1

1

1

1

1

1

1



KLOR-CON M10 TABLET

KLOR-CON M15 TABLET

KLOR-CON M20 TABLET

LUDENT FLUORIDE (0.25 MG TB CHW, 0.5 MG TB CHEW, 1 MG TAB CHEW)

magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial)

1


83


NEPHRAMINE 5.4% IV SOLUTION

NORMOSOL-M AND DEXTROSE 5%

NORMOSOL-R PH 7.4 IV SOLUTION

PLASMA-LYTE 148 IV SOLUTION

PLASMA-LYTE 56-DEXTROSE 5%

PLASMA-LYTE A PH 7.4 SOLN.


1

1

1

1

1

1 potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 8 meq capsule er, 8 meq tablet er, 10 meq tablet er, 10 meq tab er prt, 10 meq capsule er, 20 meq tablet er, 20 meq tab er prt)

potassium chloride (20meq/15ml, 40meq/15ml)

potassium chloride in 0.9%nacl 20 meq/l iv soln

1

1

1

PA

potassium chloride in 5 % dextrose in water (20 meq/l soln, 40 meq/l soln)

potassium chloride-0.45% nacl 20 meq/l iv soln 1

1 potassium citrate (5 tablet er, 10 tablet er, 15 tablet er)

PREMASOL (6%, 10%) 1

1

1

1

1

1




PROCALAMINE IV SOLUTION

PROSOL 20% INJECTION

ringers solution iv soln

ringers solution,lactated iv soln

sodium chloride 0.45 % (0.45 % pggybk prt, 0.45 % 0.45 % iv soln)

sodium chloride 2.5 meq/ml vial

sodium chloride 3 % 3 % iv soln

sodium chloride 5 % 5 % iv soln

1

1

1

1 sodium fluoride (0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew, 1mg(2.2mg) tablet)

TPN ELECTROLYTES VIAL 1

1

1

TRAVASOL 10% SOLN VIAFLEX

TROPHAMINE 10% IV SOLUTION




84


Vitamins

ACTIVE OB SOFTGEL 1

ATABEX EC CAPLET 1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

BAL-CARE DHA COMBO PACK

BAL-CARE DHA ESSENTIAL PACK

BP FOLINATAL PLUS B TABLET

C-NATE DHA SOFTGEL

CADEAU DHA SOFTGEL

CALCIUM-PNV 28-1-250 MG SFTGL

CITRANATAL 90 DHA COMBO PACK

CITRANATAL ASSURE COMBO PACK

CITRANATAL B-CALM COMBO PACK

CITRANATAL DHA PACK

CITRANATAL HARMONY CAPSULE

CITRANATAL RX TABLET

COMPLETE NATAL DHA

COMPLETENATE TABLET CHEW

CONCEPT DHA CAPSULE

CONCEPT OB CAPSULE

DOTHELLE DHA SOFTGEL

DUET DHA 400 COMBO PACK

DUET DHA 430 MG COMBO PACK

DUET DHA BALANCED (25 MG IRON)

DUET DHA EC (400 EC, 430 EC)

ELITE OB DHA SOFTGEL

ELITE-OB 400 CAPSULE

ENBRACE HR SOFTGEL

EXTRA-VIRT PLUS DHA SOFTGEL

FOCALGIN 90 DHA COMBO PACK

FOCALGIN CA COMBO PACK

FOCALGIN-B TABLET


85


FOLBECAL TABLET 1

FOLET DHA COMBO PACK

FOLET ONE SOFTGEL

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

FOLIVANE-OB CAPSULE

FOLIVANE-PRX DHA NF CAPSULE

GESTICARE DHA COMBO PACK

HEMENATAL OB + DHA COMBO PACK

HEMENATAL OB TABLET

INATAL ADVANCE TABLET

INATAL ULTRA TABLET

INFANATE BALANCE SOFTGEL

INFANATE PLUS SOFTGEL

KOSHER PRENATAL PLUS IRON TAB

M-VIT CAPLET

MACNATAL CN DHA SOFTGEL

MARNATAL-F CAPSULE

MAXINATE TABLET

MYNATAL (CAPSULE, ULTRACAPLET)

MYNATAL ADVANCE TABLET

MYNATAL PLUS CAPTAB

MYNATAL-Z CAPTAB

MYNATE 90 PLUS CAPLET SA

NATACHEW TABLET

NATALVIRT 90 DHA COMBO PACK

NATALVIRT CA COMBO PACK

NATALVIT TABLET

NATELLE ONE CAPSULE

NEEVODHA CAPSULE

NESTABS ABC PRENATAL COMBO PK

NESTABS DHA COMBO PACK

NESTABS TABLET


86


NEWGEN TABLET 1

NEXA PLUS SOFTGEL 1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

NIACOR 500 MG TABLET

NIVA-PLUS TABLET

O-CAL FA TABLET

O-CAL PRENATAL TABLET

OB COMPLETE CAPLET

OB COMPLETE GOLD SOFTGEL

OB COMPLETE ONE SOFTGEL

OB COMPLETE PETITE SOFTGEL

OB COMPLETE PREMIER TABLET

OB COMPLETE WITH DHA SOFTGEL

OBSTETRIX DHA COMBO PAK

OBSTETRIX EC CAPLET

OBSTETRIX ONE SOFTGEL

OBTREX DHA PRENATAL VITAMIN

OBTREX PRENATAL CAPLET

PAIRE OB PLUS DHA COMBO PACK

PNV 29-1 TABLET

pnv no.115/iron fumarate/fa 29 mg-1 mg tab chew

PNV OB+DHA COMBO PACK 1

1

1

pnv w-o ca no5/iron fum/fa 106.5-1mg capsule

pnv with ca#74/iron/folic acid 27 mg-1 mg tablet

pnv with ca,no.72/iron,carb/fa 29 mg-1 mg tablet

1

pnv with ca,no.72/iron/fa 27 mg-1 mg tablet 1

1 pnv#79/iron/fa/lmfolate ca/dha 27-1.13 mg capsule

PNV-DHA + DOCUSATE SOFTGEL

PNV-DHA SOFTGEL

1

1

1 PNV-OMEGA SOFTGEL


87


PNV-SELECT TABLET 1

PNV-TOTAL SOFTGEL 1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

PNV-VP-U CAPSULE

pnv115/iron fumarate/fa/dss 29-1-25 mg tablet

PR NATAL 400 COMBO PACK

PR NATAL 400 EC COMBO PACK

PR NATAL 430 COMBO PACK

PR NATAL 430 EC COMBO PACK

PREFERA OB TABLET

PREFERA-OB ONE SOFTGEL

PREFERA-OB PLUS DHA COMBO PACK

PREFOL-DHA CAPSULE

PRENA1 CHEW TABLET

PRENA1 PEARL SOFTGEL

PRENA1 TRUE COMBO PACK

PRENAISSANCE 90 DHA COMBO PACK

PRENAISSANCE BALANCE SOFTGEL

PRENAISSANCE CAPSULE

PRENAISSANCE DHA COMBO PACK

PRENAISSANCE NEXT TABLET

PRENAISSANCE NEXT-B TABLET

PRENAISSANCE PLUS SOFTGEL

PRENAISSANCE PROMISE COMBO PCK

PRENAPLUS TABLET

PRENATA CHEWABLE TABLET

PRENATABS FA TABLET

PRENATABS RX TABLET

prenatal vit #60/iron fum/fa 27 mg-1 mg tablet

prenatal vit 15/iron cb/fa/dss 90-1-50 mg tablet

PRENATE AM TABLET

PRENATE CHEWABLE TABLET


88


PRENATE DHA SOFTGEL

PRENATE ELITE TABLET

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

PRENATE ENHANCE SOFTGEL

PRENATE ESSENTIAL SOFTGEL

PRENATE MINI SOFTGEL

PRENATE PIXIE SOFTGEL

PRENATE RESTORE SOFTGEL

PRENATE STAR TABLET

PREPLUS CA-FE 27 MG-FA 1 MG TB

PREQUE 10 TABLET

PRETAB 29 MG-1 MG TABLET

PROVIDA DHA CAPSULE

PROVIDA OB CAPSULE

PUREFE OB PLUS CAPSULE

PUREFE PLUS CAPSULE

R-NATAL OB SOFTGEL

RELNATE DHA PRENATAL SOFTGEL

RULAVITE DHA SOFTGEL

SE-NATAL 19 (19 CHEWABLE TABLET, 19 TABLET)

SE-TAN DHA CAPSULE

SELECT-OB + DHA PACK

SELECT-OB CHEWABLE CAPLET

TARON-BC TABLET

TARON-C DHA CAPSULE

TARON-PREX PRENATAL DHA CAP

THRIVITE 19 TABLET

THRIVITE RX TABLET

TL FOLATE TABLET

TL-CARE DHA SOFTGEL

TL-SELECT CAPSULE

TRI-TABS DHA COMBO PACK


89


TRIADVANCE TABLET 1

TRICARE PRENATAL DHA ONE SFTGL

TRICARE PRENATAL TABLET

TRICARE PRENATAL WITH DHA PACK

TRINATAL GT TABLET

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

TRINATAL RX 1 TABLET

TRINATE TABLET

TRISTART DHA SOFTGEL

TRIVEEN-DUO DHA COMBO PACK

TRIVEEN-ONE CAPSULE

TRIVEEN-PRX RNF CAPSULE

TRUST NATAL DHA

ULTIMATECARE ONE CAPSULE

ULTIMATECARE ONE NF CAPSULE

VEMAVITE-PRX 2 CAPSULE

VENA-BAL DHA COMBO PACK

VENATAL-FA TABLET

VINACAL PRENATAL TABLET

VINATE CARE CHEWABLE TABLET

VINATE DHA GELCAP

VINATE DHA RF GELCAP

VINATE GT TABLET

VINATE II TABLET

VINATE ONE TABLET

VINATE PN CARE TABLET

VINATE ULTRA TABLET

VINATE-M TABLET

VIRT NATE TABLET

VIRT-ADVANCE TABLET

VIRT-BAL DHA COMBO PACK

VIRT-BAL DHA PLUS COMBO PACK


90


VIRT-C DHA SOFTGEL 1

VIRT-CARE ONE CAPSULE

VIRT-NATE DHA SOFTGEL

VIRT-NATE TABLET

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

VIRT-PN DHA SOFTGEL

VIRT-PN PLUS SOFTGEL

VIRT-PN TABLET

VIRT-SELECT CAPSULE

VIRT-VITE GT TABLET

VIRTPREX CAPSULE

VITAFOL FE+ DOCUSATE COMBO PCK

VITAFOL GUMMIES

VITAFOL NANO TABLET

VITAFOL ULTRA SOFTGEL

VITAFOL-OB CAPLET

VITAFOL-OB+DHA COMBO PACK

VITAFOL-ONE CAPSULE

VITAMEDMD ONE RX SOFTGEL

VITAMEDMD PLUS RX COMBO PACK

VITAMEDMD REDICHEW RX TAB CHEW

VITAPEARL SOFTGEL

VITATRUE COMBO PACK

VIVA DHA PRENATAL SOFTGEL

VOL-NATE TABLET

VOL-PLUS TABLET

VOL-TAB RX TABLET

VP CH ULTRA SOFTGEL

VP-CH PLUS SOFTGEL

VP-CH-PNV PRENATAL SOFTGEL

VP-ERA OB PLUS TABLET

VP-GGR-B6 TABLET


91


VP-HEME OB + DHA COMBO PACK

VP-HEME OB TABLET

1

1

1

1

1

1

1

1

1

VP-HEME ONE SOFTGEL

VP-PNV-DHA (CAPSULE, SOFTGEL)

ZATEAN-CH CAPSULE

ZATEAN-PN DHA CAPSULE

ZATEAN-PN PLUS SOFTGEL

ZATEAN-PN TABLET

ZINGIBER TABLET

Uncategorized

Unclassified

EZ FLU 16-17 (FLUZON QUAD PED) 1

1

1

1

1

EZ FLU 2016-17 (AFLURIA) KIT

EZ FLU 2016-17 (FLUVIRIN) KIT

FLUARIX QUAD 2016-2017 SYRINGE

FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL)

FLUMIST QUAD NASAL 2016-17 VAC

FLUZONE INTRADERM QUAD 2016-17

1

1

1 FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL)

FLUZONE QUAD PEDI 2016-17 SYR 1


92

Index of Drugs

0 ALBENZA

albuterol sulfate

ALDURAZYME

ALECENSA

alendronate sodium

ALIMTA

ALINIA

allopurinol

alosetron hcl

ALPHAGAN P

alprazolam

ALREX

amantadine hcl

AMBISOME

AMETHIA

AMETHYST

amifostine crystalline

amiloride hcl

amiloride hcl/hydrochlorothiazide

aminophylline

AMINOSYN II

35

80

60

31

75

30

35

28

62

78

43

77

42

27

66

66

31

54

54

81

83

83

83

83

83

83

51

62

25

52

82

59

25

18

18

27

18

18

18

58

66

0.9 % sodium chloride 83

59 8 8-MOP

A A-HYDROCORT

abacavir sulfate

abacavir sulfate/lamivudine/zidovudine

ABELCET

ABILIFY MAINTENA

acamprosate calcium

acarbose

acebutolol hcl

acetaminophen with codeine phosphate

acetazolamide

acetazolamide sodium

acetic acid

acetylcysteine

acitretin

ACTHIB

ACTIMMUNE

ACTIVE OB

acyclovir

acyclovir sodium

ADACEL TDAP

ADAGEN

adapalene

ADCIRCA

adefovir dipivoxil

ADEMPAS

ADRENACLICK

ADRUCIL

ADVAIR DISKUS

ADVAIR HFA

AFEDITAB CR

AFINITOR

64

40

40

27

38,44

14

44

51

12

54,78

54

78

81

59

73

73

85

43

43

73

60

59

81

42

81

80

30

79

79

52

33

33

48

AMINOSYN II WITH ELECTROLYTES

AMINOSYN M

AMINOSYN WITH ELECTROLYTES

AMINOSYN-HBC

AMINOSYN-PF

amiodarone hcl

AMITIZA

amitriptyline hcl

amlodipine besylate

ammonium chloride

ammonium lactate

amoxapine

amoxicillin

amoxicillin/potassium clavulanate

amphotericin b

ampicillin sodium

ampicillin sodium/sulbactam sodium

ampicillin trihydrate

AMPYRA AFINITOR DISPERZ

AGGRENOX ANADROL-50

93

anagrelide hcl

anastrozole

ANDRODERM

ANDROGEL

ANZEMET

APIDRA

APIDRA SOLOSTAR

APOKYN

apraclonidine hcl

APRI

APRISO

APTIOM

APTIVUS

ARALAST NP

ARANELLE

ARANESP

ARCALYST

aripiprazole

ARISTADA

ARZERRA

ASACOL HD

ASMANEX

ASMANEX HFA

aspirin/dipyridamole

ASTAGRAF XL

ATABEX EC

atenolol

48

33

66

66

26

46

46

36

78

66

75

21

41

81

67

48

73

38

38

34

75

79

79

48

71

85

51

73

55

35

35

39

77

80

58

67

44

34

19

67

63

AVONEX 58

58

31

71

71

71

77,79

36

19

78

AVONEX PEN

azacitidine

AZASAN

azathioprine

azathioprine sodium

azelastine hcl

AZILECT

azithromycin

AZOPT

aztreonam 17

B BACIIM

bacitracin

bacitracin/polymyxin b sulfate

baclofen

BAL-CARE DHA

BAL-CARE DHA ESSENTIAL

balsalazide disodium

BALZIVA

BANZEL

BARACLUDE

bcg vaccine, live/pf

BELEODAQ

benazepril hcl

benazepril hcl/hydrochlorothiazide

BENLYSTA

benztropine mesylate

betamethasone dipropionate

betamethasone dipropionate/propylene glycol 64

betamethasone valerate

BETASERON

bethanechol chloride

bexarotene

BEXSERO

15

15

15

39

85

85

75

67

23

42

73

31

50

50

71

35

64

ATGAM

atorvastatin calcium

atovaquone

atovaquone/proguanil hcl

ATRIPLA

atropine sulfate

ATROVENT HFA

AUBAGIO

AUBRA

AVANDIA

AVASTIN

AVELOX IV

AVIANE

64

58

63

34

73

30

18

35

52

52

bicalutamide

BICILLIN L-A

BILTRICIDE

bisoprolol fumarate

bisoprolol fumarate/hydrochlorothiazide AVODART

94

bleomycin sulfate

BOOSTRIX TDAP

BOSULIF

BREO ELLIPTA

BRIELLYN

BRILINTA

brimonidine tartrate

BRIVIACT

bromocriptine mesylate

budesonide

bumetanide

buprenorphine hcl

buprenorphine hcl/naloxone hcl

bupropion hcl

buspirone hcl

BYETTA

31

73

33

79

67

48

78

21

36

75,79

54

14

14

14,24

43

carbidopa/levodopa/entacapone

CARDURA XL

CARIMUNE NF NANOFILTERED

CARTIA XT

carvedilol

CAYSTON

cefaclor

cefadroxil

cefazolin sodium

cefazolin sodium/dextrose, iso-osmotic

cefdinir

36

49

73

52

52

81

17

17

17

17

17

17

17

17

17

17

17

17

17

17

12

72

21

17

60

73

14

15

59

35

37

54

55

55

27

27

41

48

71

19

19

cefepime hcl

cefixime

cefotetan disodium

cefoxitin sodium

cefpodoxime proxetil

cefprozil

ceftriaxone sodium

cefuroxime axetil

cefuroxime sodium

celecoxib

CELLCEPT

CELONTIN

cephalexin

CEREZYME

44

C C-NATE DHA

cabergoline

CABOMETYX

CADEAU DHA

CAFERGOT

calcipotriene

calcitonin,salmon,synthetic

calcitriol

calcium acetate

CALCIUM PNV

CAMILA

CANASA

CANCIDAS

candesartan cilexetil

candesartan cilexetil/hydrochlorothiazide

CAPASTAT SULFATE

CAPRELSA

captopril

captopril/hydrochlorothiazide

CARAFATE

85

70

31

85

28

59

75

75

83

85

69

75

27

49

54

29

30

50

50

62

82

23

36

CERVARIX

CHANTIX

chloramphenicol sod succ

chlorhexidine gluconate

chloroquine phosphate

chlorpromazine hcl

chlorthalidone

cholestyramine (with sugar)

cholestyramine/aspartame

ciclopirox

ciclopirox olamine

cidofovir

cilostazol

CINRYZE

CIPRO HC

CARBAGLU

carbamazepine

carbidopa/levodopa CIPRODEX

95

ciprofloxacin 20

20

20

20

31

24

85

85

85

85

85

85

59

COMPLETE NATAL DHA

COMPLETENATE

COMPRO

CONCEPT DHA

CONCEPT OB

CONSTULOSE

COPAXONE

85

85

37

85

85

62

58

52

75

59

59

59

59

ciprofloxacin hcl

ciprofloxacin lactate

ciprofloxacin/ciprofloxacin hcl

cisplatin

citalopram hydrobromide

CITRANATAL 90 DHA

CITRANATAL ASSURE

CITRANATAL B-CALM

CITRANATAL DHA

CITRANATAL HARMONY

CITRANATAL RX

COREG CR

cortisone acetate

COSENTYX (2 SYRINGES)

COSENTYX PEN

COSENTYX PEN (2 PENS)

COSENTYX SYRINGE

COTELLIC

CLARAVIS

clarithromycin 19 31

clindamycin hcl 15 CREON 60

clindamycin phosphate

CLINIMIX

CLINIMIX E

15,59

45,83

45,83

83

CRIXIVAN

cromolyn sodium

CRYSELLE

41

61,77,81

67

CLINISOL CUBICIN 16

clobetasol propionate

clobetasol propionate/emollient base

CLODAN

clomipramine hcl

clonazepam

64

64

64

25

CUPRIMINE

CYCLAFEM

cyclobenzaprine hcl

cyclophosphamide

CYCLOSET

82

67

82

29

22 44

clonidine 49 cyclosporine 72

clonidine hcl 49

48

43

27

cyclosporine, modified

CYRAMZA

CYSTADANE

72

31

60

60

clopidogrel bisulfate

clorazepate dipotassium

clotrimazole CYSTAGON

clotrimazole/betamethasone dipropionate

clozapine

COARTEM

64

39

35

D DAKLINZA 42

81

66

39

29

73

35

63

34

31

codeine sulfate

colchicine

colchicine/probenecid

COLCRYS

colestipol hcl

colistin (as colistimethate sodium)

COMBIVENT RESPIMAT

COMETRIQ

12

28

28

28

55

16

80

31

DALIRESP

danazol

dantrolene sodium

dapsone

DAPTACEL DTAP

DARAPRIM

darifenacin hydrobromide

DARZALEX

daunorubicin hcl COMPLERA 40

96

decitabine

DELYLA

DELZICOL

demeclocycline hcl

DEMSER

31

67

75

20

53

82

64

69

69

40

25

65

DILT-CD

DILT-XR

diltiazem hcl

DIPENTUM

diphenhydramine hcl

diphenoxylate hcl/atropine sulfate

disopyramide phosphate

disulfiram

divalproex sodium

DOCEFREZ

52

53

53

75

79

61

51

14

22,28

31

DEPEN

DEPO-MEDROL

DEPO-PROVERA

DEPO-SUBQ PROVERA 104

DESCOVY

desipramine hcl

desmopressin acetate

docetaxel

dofetilide

31

51

desogestrel-ethinyl estradiol/ethinyl estradiol 67 donepezil hcl 23

desonide

desvenlafaxine

dexamethasone

dexamethasone sod phosphate

dexmethylphenidate hcl

64

24

64

14,77

57

dorzolamide hcl

dorzolamide hcl/timolol maleate

DOTHELLE DHA

doxazosin mesylate

doxepin hcl

doxercalciferol

doxorubicin hcl

doxorubicin hcl pegylated liposomal

DOXY 100

doxycycline hyclate

doxycycline monohydrate

dronabinol

DROXIA

DUET DHA

78

78

85

63

25,43

75

31

31

20

20

21

26

30

85

85

85

85

dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate

dextroamphetamine sulfate

dextrose 10 % and 0.2 % sodium chloride


dextrose 10 % in water

dextrose 2.5 % and 0.45 % sodium chloride





dextrose 5 % in lactated ringers

dextrose 5 % in water

57

57

45

45

45

45

46

45

46 DUET DHA 400

DUET DHA BALANCED

DUET DHA EC

45

83

45 duloxetine hcl 24

diazepam 22,43 DURAMORPH 13

diclofenac sodium

dicloxacillin sodium

dicyclomine hcl

didanosine

DIFICID

DIGOX

digoxin

dihydroergotamine mesylate

DILANTIN

14,59,77

18

61

40

19

53

53

28

23

DUREZOL

dutasteride

77

63

E E.E.S. 200

E.E.S. 400

econazole nitrate

EDURANT

ELAPRASE

19

19

27

40

60

97

ELELYSO

ELIGARD

ELITE OB DHA

ELITE-OB 400

ELMIRON

EMCYT

EMEND

EMOQUETTE

EMPLICITI

EMSAM

60

70

85

85

63

30

26

67

34

24

40

50

50

85

72

13

74

74

47

67

36

42

49

62

72

77

80

80

80

80

80

23

40

48

40

28

32

69

32

19

19

ERYPED 400 19

19

19

19

59

19

19

81

25

62

67

67

67

29

67

21

76

12

33

35

41

33

82

85

92

92

92

ERYTHROCIN LACTOBIONATE

ERYTHROCIN STEARATE

erythromycin base

erythromycin base/benzoyl peroxide

erythromycin base/ethyl alcohol

erythromycin ethylsuccinate

ESBRIET

escitalopram oxalate

esomeprazole sodium

ESTRACE

estradiol

estradiol/norethindrone acetate

ethambutol hcl

ethinyl estradiol/drospirenone

ethosuximide

etidronate disodium

etodolac

EMTRIVA

enalapril maleate

enalapril maleate/hydrochlorothiazide

ENBRACE HR

ENBREL

ENDOCET

ENGERIX-B ADULT

ENGERIX-B PEDIATRIC-ADOLESCENT

enoxaparin sodium

ENPRESSE

entacapone

entecavir

etoposide

EURAX

EVOTAZ

exemestane

ENTRESTO

ENULOSE

EXJADE

EXTRA-VIRT PLUS DHA

EZ FLU 16-17 (FLUZON QUAD PED)

EZ FLU 2016-2017 (AFLURIA)

EZ FLU 2016-2017 (FLUVIRIN)

ENVARSUS XR

epinastine hcl

epinephrine

EPIPEN

EPIPEN 2-PAK

EPIPEN JR

EPIPEN JR 2-PAK

EPITOL

EPIVIR HBV

EPOGEN

EPZICOM

ERGOMAR

ERIVEDGE

ERRIN

ERWINAZE

ERY-TAB

ERYPED 200

F FABRAZYME

FALMINA

famciclovir

famotidine

famotidine in sodium chloride, iso-osmotic/pf 61

famotidine/pf

FANAPT

FARESTON

FARXIGA

FARYDAK

FAZACLO

felbamate

60

67

43

61

61

38

30

44

31

39

22

98

fenofibrate 55

55

55

55

55

55

12

13

76

25

55

63

71

70

51

79

92

27

27

27

64

92

92

79

59,64

64

64

64

83

83

77

59

25

37

37

77

30

64,79

25

92

92

FLUZONE QUAD PEDI 2016-2017

FOCALGIN 90 DHA

FOCALGIN CA

FOCALGIN-B

FOLBECAL

FOLET DHA

92

85

85

85

86

86

86

85

86

86

76

47

76

76

23

63

47

83

54

41

21

fenofibrate nanocrystallized

fenofibrate,micronized

fenofibric acid

fenofibric acid (choline)

fenoprofen calcium

fentanyl

fentanyl citrate

FERRIPROX

FETZIMA

FIBRICOR

finasteride

FIRAZYR

FIRMAGON

flecainide acetate

FLOVENT HFA

FLUARIX QUAD 2016-2017

fluconazole

fluconazole in dextrose, iso-osmotic

flucytosine

fludrocortisone acetate

FLULAVAL QUAD 2016-2017

FLUMIST QUAD 2016-2017

flunisolide

fluocinolone acetonide

fluocinolone acetonide oil

fluocinonide

fluocinonide/emollient base

FLUOR-A-DAY

FLUORITAB

fluorometholone

fluorouracil

fluoxetine hcl

fluphenazine decanoate

fluphenazine hcl

flurbiprofen sodium

flutamide

fluticasone propionate

fluvoxamine maleate

FLUZONE INTRADERM QUAD 2016-17

FLUZONE QUAD 2016-2017

FOLET ONE

FOLINATAL PLUS B

FOLIVANE-OB

FOLIVANE-PRX DHA NF

fomepizole

fondaparinux sodium

FORTEO

FORTICAL

fosphenytoin sodium

FOSRENOL

FRAGMIN

FREAMINE HBC

furosemide

FUZEON

FYCOMPA

G gabapentin 22

22

23

73

73

73

42

74

74

20

61

62

62

62

55

62

72

65

GABITRIL

galantamine hbr

GAMMAGARD LIQUID

GAMMAGARD S-D

GAMUNEX-C

ganciclovir sodium

GARDASIL

GARDASIL 9

gatifloxacin

GATTEX

GAVILYTE-C

GAVILYTE-G

GAVILYTE-N

gemfibrozil

GENERLAC

GENGRAF

GENOTROPIN

99

GENTAK 15

15

HEPATAMINE

HERCEPTIN

HETLIOZ

HEXALEN

HIBERIX

HORIZANT

HUMALOG

HUMALOG KWIKPEN U-100

HUMALOG KWIKPEN U-200

HUMALOG MIX 50-50


HUMALOG MIX 75-25


HUMATROPE

83

34

58

30

74

58

46

46

46

46

46

46

46

65

72

72

72

46

56

54

13

13

64

64

65

13

13

35

69

30

73

gentamicin sulfate

gentamicin sulfate in sodium chloride, iso-

osmotic

gentamicin sulfate/pf

GENVOYA

GEODON

GESTICARE DHA

GIANVI

GILDAGIA

GILDESS

GILENYA

GILOTRIF

GLASSIA

GLATOPA

GLEEVEC

GLEOSTINE

glimepiride

glipizide

glipizide/metformin hcl

GLUCAGEN

GLUCAGON EMERGENCY KIT

glycopyrrolate

GLYSET

granisetron hcl

granisetron hcl/pf

griseofulvin, microsize

guanfacine hcl

guanidine hcl

15

15

40

38

86

67

67

67

58

32

82

58

33

29

44

44

44

46

46

61

44

26

26

27

57

29

HUMIRA

HUMIRA PEN

HUMIRA PEN CROHN-UC-HS STARTER

HUMULIN R U-500

hydralazine hcl

hydrochlorothiazide

hydrocodone bitartrate/acetaminophen

hydrocodone/ibuprofen

hydrocortisone

hydrocortisone butyrate

hydrocortisone valerate

hydromorphone hcl

hydromorphone hcl/pf

hydroxychloroquine sulfate

hydroxyprogesterone caproate

hydroxyurea

H HALAVEN

HYPERRAB S-D

32

37

37

37

42

74

86

86

47

haloperidol I ibandronate sodium

IBRANCE

ibuprofen

ibuprofen/oxycodone hcl

ICLUSIG

ILARIS

imatinib mesylate

IMBRUVICA

haloperidol decanoate

haloperidol lactate

HARVONI

76

32

12

12

33

73

33

33

HAVRIX

HEMENATAL OB

HEMENATAL OB + DHA

heparin sodium,porcine

heparin sodium,porcine/dextrose 5 % in water 47

100

imipenem/cilastatin sodium

imipramine hcl

imiquimod

IMOVAX RABIES VACCINE

INATAL ADVANCE

INATAL ULTRA

INCRELEX

17

25

59

74

86

86

65

54

86

86

74

33

40

76

42

67

18

38

38

38

41

44

44

46

46

74

80

80

49

49

32

39

83

83

29

56

56

27

35

74

J JADENU 82

32

44

45

32

67

69

67

67

55

JAKAFI

JANUMET

JANUVIA

JEVTANA

JINTELI

JOLIVETTE

JUNEL

indapamide

INFANATE BALANCE

INFANATE PLUS

INFANRIX DTAP

INLYTA

INTELENCE

INTRALIPID

INTRON A

INTROVALE

INVANZ

INVEGA

INVEGA SUSTENNA

INVEGA TRINZA

INVIRASE

INVOKAMET

INVOKANA

IONOSOL B WITH DEXTROSE 5%

IONOSOL MB-DEXTROSE 5%

IPOL

ipratropium bromide

ipratropium bromide/albuterol sulfate

irbesartan

irbesartan/hydrochlorothiazide

IRESSA

ISENTRESS

JUNEL FE

JUXTAPID

K KADCYLA

KALETRA

KALYDECO

KARIVA

KELNOR 1-35

KETEK

ketoconazole

ketoprofen

ketorolac tromethamine

KEYTRUDA

34

41

81

67

67

19

27

12

77

34

72

83

83

83

83

83

66

86

60

55

KINERET

KLOR-CON 10

KLOR-CON 8

KLOR-CON M10

KLOR-CON M15

KLOR-CON M20

KORLYM

KOSHER PRENATAL PLUS IRON

KUVAN

KYNAMRO

ISOLYTE P WITH DEXTROSE

ISOLYTE S

isoniazid

isosorbide dinitrate

isosorbide mononitrate

itraconazole

L labetalol hcl

LACRISERT

lactulose

lamivudine

lamivudine/zidovudine

52

77

62

40

40

ivermectin

IXIARO

101

lamotrigine

lansoprazole

LANTUS

LANTUS SOLOSTAR

LARIN

LARIN FE

latanoprost

LATUDA

LEENA

leflunomide

LENVIMA

LESSINA

LETAIRIS

letrozole

leucovorin calcium

LEUKERAN

LEUKINE

leuprolide acetate

LEVEMIR

LEVEMIR FLEXPEN

LEVEMIR FLEXTOUCH

levetiracetam

levobunolol hcl

levocetirizine dihydrochloride

levofloxacin

levofloxacin/dextrose 5 % in water

levoleucovorin calcium

LEVONEST

levonorgestrel-ethinyl estradiol

LEVORA-28

levothyroxine sodium

LEXIVA

LIALDA

lidocaine

lidocaine hcl

lidocaine hcl/pf

lidocaine/prilocaine

lindane

linezolid

linezolid in 0.9 % sodium chloride

liothyronine sodium

22,44

62

46

46

67

67

78

38

68

73

33

68

81

33

32

30

48

70

47

47

47

21

78

79

20

20

32

68

68

68

70

41

75

13

13

14

14

35

16

16

70

lisinopril 50

51

44

44

30

61

43

43

68

49

49

77

55

37

83

78

60

70

70

68

32

21,58

70

69

lisinopril/hydrochlorothiazide

lithium carbonate

lithium citrate

LONSURF

loperamide hcl

lorazepam

LORAZEPAM INTENSOL

LORYNA

losartan potassium

losartan potassium/hydrochlorothiazide

LOTEMAX

lovastatin

loxapine succinate

LUDENT FLUORIDE

LUMIGAN

LUMIZYME

LUPRON DEPOT

LUPRON DEPOT-PED

LUTERA

LYNPARZA

LYRICA

LYSODREN

LYZA

M M-M-R II VACCINE 74

86

86

83

24

68

86

24

30

53

86

26

69

35

69

M-VIT

MACNATAL CN DHA

magnesium sulfate

maprotiline hcl

MARLISSA

MARNATAL-F

MARPLAN

MATULANE

MATZIM LA

MAXINATE

meclizine hcl

medroxyprogesterone acetate

mefloquine hcl

MEGACE ES

102

megestrol acetate

MEKINIST

memantine hcl

MENACTRA

MENEST

69

32

24

74

32

74

74

74

31

18

32

32

57

80

45

12

54,78

16

71

82

72

72

49

49

58

65

65

14,65

61

55

52

52

52

16

16

51

76

27

68

68

49

miglitol

minocycline hcl

minoxidil

mirtazapine

misoprostol

MITIGARE

mitoxantrone hcl

modafinil

45

21

56

24

62

28

32

82

42

37

65,79

68

79

16

12,13

61

20

51

16

27

72

72

86

86

86

86

86

MENHIBRIX

MENOMUNE-A-C-Y-W-135

MENVEO A-C-Y-W-135-DIP

mercaptopurine

meropenem

mesna

MESNEX

METADATE ER

metaproterenol sulfate

metformin hcl

methadone hcl

MODERIBA

molindone hcl

mometasone furoate

MONONESSA

montelukast sodium

MONUROL

morphine sulfate

MOVANTIK

MOXEZA methazolamide

methenamine hippurate

methimazole

MULTAQ

mupirocin

MYCAMINE methocarbamol

methotrexate sodium

methotrexate sodium/pf

methyldopa

methyldopate hcl

methylphenidate hcl

methylprednisolone

methylprednisolone acetate

methylprednisolone sodium succinate

metoclopramide hcl

metolazone

metoprolol succinate

metoprolol tartrate

metoprolol tartrate/hydrochlorothiazide

metronidazole

metronidazole in sodium chloride

mexiletine hcl

mycophenolate mofetil

mycophenolate sodium

MYNATAL

MYNATAL ADVANCE

MYNATAL PLUS

MYNATAL-Z

MYNATE 90 PLUS

MYORISAN

MYRBETRIQ

59

63

N nabumetone

nadolol/bendroflumethiazide

nafcillin in dextrose, iso-osmotic

nafcillin sodium

NAGLAZYME

naloxone hcl

naltrexone hcl

NAMENDA

naproxen

naproxen sodium

12

52

18

18

60

14

14

24

12

15

MIACALCIN

miconazole nitrate

MICROGESTIN

MICROGESTIN FE

midodrine hcl

103

naratriptan hcl

NATACHEW

NATALVIRT 90 DHA

NATALVIRT CA

NATALVIT

nateglinide

NATELLE ONE

NATPARA

NEBUPENT

NECON

NEEVODHA

nefazodone hcl

neomycin sulfate

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone

neomycin sulfate/bacitracin/polymyxin b

neomycin sulfate/polymyxin b sulfate

neomycin sulfate/polymyxin b sulfate/gramicidin

d

neomycin sulfate/polymyxin b

sulfate/hydrocortisone

neomycin/polymyxin b sulfate/dexamethasone 78

NEPHRAMINE

NESTABS

NESTABS ABC

NESTABS DHA

NEUPOGEN

NEUPRO

nevirapine

NEWGEN

NEXA PLUS

NEXAVAR

niacin

28

86

86

86

86

45

86

76

35

68

86

24

15

nimodipine

NINLARO

nitrofurantoin macrocrystal

nitrofurantoin monohydrate/macrocrystals

nitroglycerin

NITROSTAT

NIVA-PLUS

NORA-BE

NORDITROPIN FLEXPRO

NORDITROPIN NORDIFLEX

norethindrone

norethindrone acetate

norethindrone acetate-ethinyl estradiol

NORMOSOL-M AND DEXTROSE

NORMOSOL-R AND DEXTROSE

NORMOSOL-R PH 7.4

NORTHERA

NORTREL

nortriptyline hcl

NORVIR

NOVOLOG

NOVOLOG FLEXPEN

NOVOLOG MIX 70-30

NOVOLOG MIX 70-30 FLEXPEN

NOXAFIL

NUEDEXTA

NULOJIX

NUPLAZID

NUTRILIPID

NUTROPIN AQ

NUTROPIN AQ NUSPIN

NYAMYC

53

32

16

16

56

56

87

69

65

65

69

70

68

84

46

84

53

68

25,26

41

47

47

47

47

27

58

72

38

76

66

66

27

27

28

28

16

16

15

16

78

84

86

86

86

48

36

40

87

87

33

56

87

14

14

53

53

68

30

30

nystatin

nystatin/triamcinolone acetonide

NYSTOP

NIACOR

NICOTROL

NICOTROL NS

NIFEDICAL XL

nifedipine

NIKKI

O O-CAL FA

O-CAL PRENATAL

OB COMPLETE

OB COMPLETE GOLD

87

87

87

87

NILANDRON

nilutamide

104

OB COMPLETE ONE

OB COMPLETE PETITE

OB COMPLETE PREMIER

OB COMPLETE WITH DHA

OBSTETRIX DHA

OBSTETRIX EC

OBSTETRIX ONE

OBTREX

OBTREX DHA

OCELLA

octreotide acetate

ODEFSEY

87

87

87

87

87

87

87

87

87

68

71

40

32

82

20

38

77,79

42

56

62

66

32

26

26,27

27

22

34

81

37

72

72

81

68

18

32

66

15

43

23

23

63

oxycodone hcl

oxycodone hcl/acetaminophen

OXYTROL

12,13

13

63

P paclitaxel

PAIRE OB PLUS DHA

paliperidone

PANCREAZE

32

87

38

60

34

62

15

25

29

77

77

43

74

PANRETIN

pantoprazole sodium

paromomycin sulfate

paroxetine hcl

PASER

PATADAY

PATANOL

PAXIL

PEDVAXHIB

peg 3350/sod sulf/sod bicarbonate/sod

chloride/potassium chl

PEGANONE

PEGASYS

PEGASYS PROCLICK

PEGINTRON

PEGINTRON REDIPEN

pen needle, diabetic

penicillin g potassium

penicillin v potassium

PENTACEL ACTHIB COMPONENT

PENTAM 300

PENTASA

pentoxifylline

PERIOGARD

PERJETA

ODOMZO

OFEV

ofloxacin

olanzapine

olopatadine hcl

OLYSIO

omega-3 acid ethyl esters

omeprazole

OMNITROPE

ONCASPAR

ondansetron

ondansetron hcl

ondansetron hcl/pf

ONFI

OPDIVO

OPSUMIT

ORAP

ORENCIA

ORENCIA CLICKJECT

ORKAMBI

ORSYTHIA

oxacillin sodium

oxaliplatin

oxandrolone

oxaprozin

62

23

42

42

42

42

76

18

18

74

35

75

53

59

34

35

37

24

21

23

23

23

permethrin

perphenazine

phenelzine sulfate

phenobarbital

phenytoin

phenytoin sodium

phenytoin sodium extended

oxazepam

oxcarbazepine

OXTELLAR XR

oxybutynin chloride

105

PHYSIOLYTE

PHYSIOSOL

pilocarpine hcl

pimozide

PIMTREA

pindolol

pioglitazone hcl

pioglitazone hcl/metformin hcl

piperacillin sodium/tazobactam sodium

PIRMELLA

PLASMA-LYTE 148

PLASMA-LYTE 56 IN DEXTROSE

PLASMA-LYTE A PH 7.4

PNV 29-1

PNV OB+DHA

PNV-DHA

PNV-DHA + DOCUSATE

PNV-OMEGA

PNV-SELECT

PNV-TOTAL

PNV-VP-U

podofilox

polyethylene glycol 3350

polymyxin b sulfate

polymyxin b sulfate/trimethoprim

POMALYST

PORTIA

potassium chloride

potassium chloride in 0.45 % sodium chloride

potassium chloride in 0.9 % sodium chloride

potassium chloride in 5 % dextrose in water

potassium chloride in dextrose 5 % and 0.9 %

sodium chloride

potassium chloride in dextrose 5 %-0.2 % sodium

chloride

potassium chloride in dextrose 5 %-0.45 % sodium

chloride

76

76

59,78

37

68

52

45

45

19

68

84

84

84

87

87

87

87

87

88

88

88

59

62

16

16

32

68

84

potassium citrate

POTIGA

PR NATAL 400

PR NATAL 400 EC

PR NATAL 430

PR NATAL 430 EC

PRADAXA

pramipexole di-hcl

pravastatin sodium

prazosin hcl

84

21

88

88

88

88

47

36

55

49

65

78

65,78

65

88

88

88

88

66

68

84

68

68

88

88

88

88

88

88

88

88

88

88

88

88

88

88

88

prednisolone

prednisolone acetate

prednisolone sod phosphate

prednisone

PREFERA OB

PREFERA-OB ONE

PREFERA-OB PLUS DHA

PREFOL-DHA

PREGNYL

PREMARIN

PREMASOL

PREMPHASE

PREMPRO

PRENA1 CHEW

PRENA1 PEARL

PRENA1 TRUE

PRENAISSANCE

PRENAISSANCE 90 DHA

PRENAISSANCE BALANCE

PRENAISSANCE DHA

PRENAISSANCE NEXT

PRENAISSANCE NEXT-B

PRENAISSANCE PLUS

PRENAISSANCE PROMISE

PRENAPLUS

PRENATA

PRENATABS FA

PRENATABS RX

prenatal vitamin comb no.79/iron

fumarat/fa/lmefolate ca/dha

84

84

84

46

46

46

46

46

potassium chloride in dextrose 5% and 0.3 %

sodium chloride

potassium chloride in lactated ringers and 5 %

dextrose

87

106

prenatal vitamin no.15/iron,carbonyl/folic

acid/docusate sod

prenatal vitamins comb no.115/iron

fumarate/folic acid

prenatal vitamins comb no.115/iron

fumarate/folic acid/dss

prenatal vitamins combo no.60/ferrous

fumarate/folic acid

PROCRIT 48

65

65

70

46

72

82

32

76

48

26

26

51

52

52

71

74

84

63

26

89

89

79

79

81

89

89

31

29

29

88

87

88

88

87

PROCTOSOL-HC

PROCTOZONE-HC

progesterone,micronized

PROGLYCEM

PROGRAF

PROLASTIN C

PROLEUKIN

PROLIA

PROMACTA

promethazine hcl

PROMETHEGAN

propafenone hcl

propranolol hcl

propranolol hcl/hydrochlorothiazide

propylthiouracil

PROQUAD

PROSOL

PROTONIX IV

protriptyline hcl

PROVIDA DHA

PROVIDA OB

prenatal vits with calcium #72/ferrous

fumarate/folic acid

prenatal vits with calcium #72/iron,carbonyl/folic

acid 87

prenatal vits with calcium #74/ferrous

fumarate/folic acid

prenatal vits without calc no5/ferrous

fumarate/folic acid

PRENATE AM

PRENATE CHEWABLE

PRENATE DHA

PRENATE ELITE

PRENATE ENHANCE

PRENATE ESSENTIAL

PRENATE MINI

PRENATE PIXIE

PRENATE RESTORE

PRENATE STAR

PREPLUS

PREQUE 10

PRETAB

PREVALITE

PREVIFEM

PREZCOBIX

PREZISTA

primaquine phosphate

primidone

PROAIR HFA

probenecid

87

87

88

88

89

89

89

89

89

89

89

89

89

89

89

56

68

41

41

35

22

80

28

84

37

37

37

PULMICORT

PULMICORT FLEXHALER

PULMOZYME

PUREFE OB PLUS

PUREFE PLUS

PURIXAN

pyrazinamide

pyridostigmine bromide

Q QUADRACEL DTAP-IPV

QUASENSE

QUDEXY XR

quetiapine fumarate

quinapril hcl

quinapril hcl/hydrochlorothiazide

quinidine gluconate

quinidine sulfate

quinine sulfate

74

68

22

38

51

51

51

51

35

PROCALAMINE

prochlorperazine

prochlorperazine edisylate

prochlorperazine maleate

107

QVAR 79 RITUXAN 34

23

28

36

74

74

21

82

89

rivastigmine tartrate

rizatriptan benzoate

ropinirole hcl

ROTARIX

ROTATEQ

ROWEEPRA

R R-NATAL OB

RABAVERT

raloxifene hcl

ramipril

89

74

70

51

53

62

72

58

68

RANEXA ROZEREM

RULAVITE DHA ranitidine hcl

RAPAMUNE

REBIF S SABRIL RECLIPSEN 22

66

71

71

60

39

58

89

89

89

89

36

60

41

70

80

39

66

25

71

71

81

16

78

73

55

72

29

84

84

RECOMBIVAX HB

REGRANEX

RELENZA

RELISTOR

RELNATE DHA

REMICADE

REMODULIN

RENAGEL

RENVELA

74

60

42

61

89

72

81

64

64

45

45

56

56

56

40

77

40

30

38

41

42

29

29

58

SAIZEN

SANDOSTATIN LAR

SANDOSTATIN LAR DEPOT

SANTYL

SAPHRIS

SAVELLA

SE-NATAL 19

SE-TAN DHA

SELECT-OB

SELECT-OB + DHA

selegiline hcl

selenium sulfide

SELZENTRY

repaglinide

repaglinide/metformin hcl

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

RESCRIPTOR

RESTASIS

RETROVIR

REVLIMID

REXULTI

REYATAZ

SENSIPAR

SEREVENT DISKUS

SEROQUEL XR

SEROSTIM

sertraline hcl

SIGNIFOR

SIGNIFOR LAR

sildenafil citrate

silver sulfadiazine

SIMBRINZA

SIMULECT

simvastatin

sirolimus

SIRTURO

RIBASPHERE

rifabutin

rifampin

riluzole

rimantadine hcl

ringers solution

ringers solution,lactated

RISPERDAL CONSTA

risperidone

42

76,84

76,84

38,44

39

sodium chloride

sodium chloride 0.45 %

108

sodium chloride 3 %

sodium chloride 5 %

sodium chloride irrigating solution

sodium fluoride

sodium lactate

sodium phenylbutyrate

sodium polystyrene sulfonate

SOLTAMOX

SOLU-CORTEF

SOMATULINE DEPOT

SOMAVERT

sotalol hcl

SOVALDI

84

84

76

84

82

60

82

30

65

71

71

51

42

80

80

54

54

28

69

21

33

69

16

40

33

58

61

15

40

61

62

20,60

SUSTIVA

SUTENT

SYLATRON

SYLATRON 4-PACK

SYMBICORT

SYMLINPEN 120

SYMLINPEN 60

SYNAGIS

SYNAREL

SYNERCID

SYNRIBO

SYPRINE

syringe with needle, insulin, safety, 0.3 ml

syringe with needle, insulin, safety, 0.5 ml

syringe with needle, insulin, safety, 1 ml

syringe with needle,disposable,insulin 1 ml

syringe with needle,insulin,0.3 ml

syringe with needle,insulin,0.5 ml

40

34

32

32

79

45

45

73

71

16

33

83

76

77

77

77

76

77

SPIRIVA

SPIRIVA RESPIMAT

spironolactone

spironolactone/hydrochlorothiazide

SPORANOX

SPRINTEC

SPRITAM

SPRYCEL

SRONYX

SSD

stavudine

STIVARGA

STRATTERA

STRENSIQ

streptomycin sulfate

STRIBILD

SUCRAID

sucralfate

sulfacetamide sodium

sulfacetamide sodium/prednisolone sodium

phosphate

T TABLOID

tacrolimus

TAFINLAR

TAGRISSO

31

60,72

34

33

42

30

63

34

34

69

89

89

89

34

33

60

53

TAMIFLU

tamoxifen citrate

tamsulosin hcl

TARCEVA

TARGRETIN

TARINA FE

TARON-BC

TARON-C DHA

TARON-PREX PRENATAL

TASIGNA

TAXOTERE

TAZORAC

TAZTIA XT

TECENTRIQ

TECFIDERA

TEFLARO

20

20

20

75

12

sulfadiazine

sulfamethoxazole/trimethoprim

sulfasalazine

sulindac

sumatriptan succinate

SUPRAX

34

59

17

28,29

17

SURMONTIL 26 TEKTURNA 54

109

telmisartan

telmisartan/hydrochlorothiazide

temazepam

TENIVAC

terazosin hcl

terbinafine hcl

terbutaline sulfate

terconazole

TESTIM

testosterone

testosterone cypionate

testosterone enanthate

tetanus and diphtheria toxoids, adult

tetanus,diphtheria toxoid ped/pf

tetrabenazine

THALOMID

THEO-24

theophylline anhydrous

THIOLA

thioridazine hcl

thiotepa

thiothixene

THRIVITE 19

THRIVITE RX

THYMOGLOBULIN

tiagabine hcl

TIKOSYN

timolol maleate

tinidazole

TIVICAY

tizanidine hcl

TL FOLATE

TL-CARE DHA

TL-SELECT

TOBRADEX

tobramycin

tobramycin in 0.225 % sodium chloride

tobramycin sulfate

tobramycin/dexamethasone

TOLAK

49

50

43

74

63

28

80

28

66

66

66

66

74

74

58

30

81

81

63

37

30

37

89

89

73

22

51

78

35

40

39

89

89

89

78

15

81

15

78

60

36

tolterodine tartrate

topiramate

topotecan hcl

TORISEL

torsemide

TOUJEO SOLOSTAR

TOVIAZ

TPN ELECTROLYTES

TRACLEER

63

22,28

33

72

54

47

63

84

81

12,13

13

48

26

24

84

78

24

29

71

34,60

72

69

69

69

89

90

59,65

54

43

90

90

90

38

43

36

62

tramadol hcl

tramadol hcl/acetaminophen

tranexamic acid

TRANSDERM-SCOP

tranylcypromine sulfate

TRAVASOL

travoprost (benzalkonium)

trazodone hcl

TRECATOR

TRELSTAR

tretinoin

TREXALL

TRI-LEGEST FE

TRI-PREVIFEM

TRI-SPRINTEC

TRI-TABS DHA

TRIADVANCE

triamcinolone acetonide

triamterene/hydrochlorothiazide

triazolam

TRICARE

TRICARE PRENATAL DHA ONE

TRICARE PRENATAL WITH DHA

trifluoperazine hcl

trifluridine

trihexyphenidyl hcl

TRILYTE WITH FLAVOR PACKETS

trimethoprim

trimipramine maleate

TRINATAL GT

TRINATAL RX 1

TRINATE

16

26

90

90

tolcapone 90

110

TRINESSA

TRINTELLIX

TRISENOX

TRISTART DHA

TRIUMEQ

TRIVEEN-DUO DHA

TRIVEEN-ONE

TRIVEEN-PRX RNF

TRIVORA-28

TROKENDI XR

TROPHAMINE

trospium chloride

TRUMENBA

TRUST NATAL DHA

TRUVADA

TUDORZA PRESSAIR

TWINRIX

TYBOST

TYGACIL

TYKERB

TYPHIM VI

TYSABRI

TYZEKA

TYZINE

69

24

33

90

40

90

90

90

69

23

84

63

74

90

41

80

74

41

16

34

75

59

42

82

VANDAZOLE

VAQTA

VARIVAX VACCINE

VARIZIG

VELCADE

VELIVET

VEMAVITE-PRX 2

VENA-BAL DHA

VENATAL-FA

VENCLEXTA

VENCLEXTA STARTING PACK

venlafaxine hcl

VENTOLIN HFA

verapamil hcl

VERSACLOZ

VESICARE

16

75

75

75

33

69

90

90

90

31

31

25,44

80

53

39

63

69

78

45

45

41

42

20

25

23

90

90

90

90

90

90

90

90

90

90

41

40

41

90

90

90

VESTURA

VEXOL

VICTOZA 2-PAK

VICTOZA 3-PAK

VIDEX

VIEKIRA PAK

VIGAMOX

VIIBRYD

VIMPAT

VINACAL

VINATE CARE

VINATE DHA

VINATE DHA RF

VINATE GT

U ULTIMATECARE ONE

ULTIMATECARE ONE NF

ursodiol

90

90

61

60 UVADEX

VINATE II

V valacyclovir hcl

VALCHLOR

valganciclovir hcl

valproic acid

valproic acid (as sodium salt) (valproate

sodium)

valsartan

valsartan/hydrochlorothiazide

vancomycin hcl

VINATE ONE

VINATE PN CARE

VINATE ULTRA

VINATE-M

VIRACEPT

VIRAMUNE XR

VIREAD

VIRT NATE

VIRT-ADVANCE

VIRT-BAL DHA

43

30

42

22

22

50

50

16

111

VIRT-BAL DHA PLUS

VIRT-C DHA

VIRT-CARE ONE

VIRT-NATE

VIRT-NATE DHA

VIRT-PN

90

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

91

40

91

66

91

91

91

28

34

91

91

91

91

91

92

92

92

92

61

VRAYLAR

VYFEMLA

VYTORIN

39

69

56

W warfarin sodium

water for irrigation,sterile

WELCHOL

47

77

56

69

VIRT-PN DHA

VIRT-PN PLUS

VIRT-SELECT

VIRT-VITE GT

VIRTPREX

VITAFOL FE+

VITAFOL GUMMIES

VITAFOL NANO

VITAFOL ULTRA

VITAFOL-OB

VITAFOL-OB+DHA

VITAFOL-ONE

VITAMEDMD ONE RX

VITAMEDMD PLUS RX

VITAMEDMD REDICHEW RX

VITAPEARL

VITATRUE

VITEKTA

VIVA DHA

VOGELXO

VOL-NATE

VOL-PLUS

VOL-TAB RX

voriconazole

VOTRIENT

WYMZYA FE

X XALKORI

XARELTO

XELJANZ

XELJANZ XR

XENAZINE

XGEVA

XIFAXAN

XOLAIR

XTANDI

XYREM

34

48

73

73

58

76

16

82

30

82

Y YERVOY 34

75 YF-VAX

Z zafirlukast

zaleplon

ZALTRAP

ZATEAN-CH

ZATEAN-PN

ZATEAN-PN DHA

ZATEAN-PN PLUS

ZAVESCA

ZELBORAF

ZEMAIRA

ZENATANE

ZENCHENT

ZENPEP

80

82

31

92

92

92

92

61

34

82

60

69

61

41

VP CH ULTRA

VP-CH PLUS

VP-CH-PNV

VP-ERA OB PLUS

VP-GGR-B6

VP-HEME OB

VP-HEME OB + DHA

VP-HEME ONE

VP-PNV-DHA

VPRIV ZEPATIER

112

ZETIA

ZIAGEN

zidovudine

ZINGIBER

ziprasidone hcl

ZIRGAN

zoledronic acid

zoledronic acid in mannitol and water for

injection

56

41

41

92

39

42

76

76

33

29

82

29

21

66

73

75

19

69

69

33

80

80

31

15

39

30

16

ZOLINZA

zolmitriptan

zolpidem tartrate

ZOMIG

zonisamide

ZORBTIVE

ZORTRESS

ZOSTAVAX

ZOSYN

ZOVIA 1-35E

ZOVIA 1-50E

ZYDELIG

ZYFLO

ZYFLO CR

ZYKADIA

ZYLET

ZYPREXA RELPREVV

ZYTIGA

ZYVOX

113

List of drugs by medical condition Analgesics 12

13

14

14

15

21

23

24

26

27

28

28

29

29

29

35

35

37

39

39

43

44

44

47

49

57

59

59

60

61

63

64

65

66

66

70

70

Anesthetics

Anti-Addiction/Substance Abuse Treatment Agents

Anti-inflammatory Agents

Antibacterials

Anticonvulsants

Antidementia Agents

Antidepressants

Antiemetics

Antifungals

Antigout Agents

Antimigraine Agents

Antimyasthenic Agents

Antimycobacterials

Antineoplastics

Antiparasitics

Antiparkinson Agents

Antipsychotics

Antispasticity Agents

Antivirals

Anxiolytics

Bipolar Agents

Blood Glucose Regulators

Blood Products/Modifiers/Volume Expanders

Cardiovascular Agents

Central Nervous System Agents

Dental and Oral Agents

Dermatological Agents

Enzyme Replacement/Modifiers

Gastrointestinal Agents

Genitourinary Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

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

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Suppressant (Adrenal)

114

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Thyroid)

Immunological Agents

70

70

71

71

75

75

76

77

78

79

82

82

82

92

Inflammatory Bowel Disease Agents

Metabolic Bone Disease Agents

Miscellaneous Therapeutic Agents

Ophthalmic Agents

Otic Agents

Respiratory Tract/Pulmonary Agents

Skeletal Muscle Relaxants

Sleep Disorder Agents

Therapeutic Nutrients/Minerals/Electrolytes

Uncategorized

115

We have made no changes to this formulary since 09/27/2016. For more recent information or

other questions, please contact CARE WISCONSIN at 1-800-963-0035, or, for TTY users, 711,

8 a.m. - 8 p.m. The call is free. Or visit http://www.carewisc.org/.

This formulary was updated on 9/27/2016. For more recent information or other questions, please contact us at 1-800-963-0035 or, for TTY users, Wisconsin Relay System 711, 24-hours a day/7 days a

week (office hours: Monday-Friday, 8:00 a.m. to 4:30 p.m. CT), or visit www.carewisc.org.

Care Wisconsin Health Plan P.O. Box 14017

Madison, Wisconsin 53708-0017 1-800-963-0035

TTY/TDD Wisconsin Relay System 711 www.carewisc.org

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