Stanford Health Care Advantage 2020 Formulary List of ...

Stanford Health Care Advantage2020 FormularyList of Covered Drugs

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN00020019 21This formulary was updated on 12012020 For more recent information or other questions please contact Stanford Health Care Advantage Member Care Services at 1-855-996-8422 or for TTY users 711 8 am to 8 pm seven days a week (except Thanksgiving and Christmas) from October 1 through March 31 and Monday through Friday (except holidays) from April 1 through September 30 or visit StanfordHealthCareAdvantageorg

III

III

IV

IV

V

V

VI

VI

VII

VII

bull

o

bull

bull

o

bull

bull

bull

bull

bull

bull

bull

bull

Table of Contents

Analgesics3Anesthetics 7Anti-AddictionSubstance Abuse Treatment Agents 8Antianxiety Agents9Antibacterials 10Anticancer Agents 17Anticholinergic Agents 32Anticonvulsants32Antidementia Agents 36Antidepressants 37Antidiabetic Agents 40Antifungals45Antigout Agents 46Antihistamines47Anti-Infectives (Skin And Mucous Membrane)47Antimigraine Agents48Antimycobacterials49Antinausea Agents50Antiparasite Agents 52Antiparkinsonian Agents52Antipsychotic Agents54Antivirals (Systemic)59Blood ProductsModifiersVolume Expanders 66Caloric Agents70Cardiovascular Agents 75Central Nervous System Agents 85Contraceptives89Dental And Oral Agents97Dermatological Agents97Devices 101Enzyme ReplacementModifiers 102Eye Ear Nose Throat Agents 104Gastrointestinal Agents 108Genitourinary Agents 112Heavy Metal Antagonists 113Hormonal Agents StimulantReplacementModifying113

1

Immunological Agents121Inflammatory Bowel Disease Agents 132Irrigating Solutions132Metabolic Bone Disease Agents133Miscellaneous Therapeutic Agents134Ophthalmic Agents 137Replacement Preparations 138Respiratory Tract Agents 140Skeletal Muscle Relaxants 145Sleep Disorder Agents 146Vasodilating Agents146Vitamins And Minerals147

2

Drug Name Drug Tier RequirementsLimits

AnalgesicsAnalgesics Miscellaneousacetaminophen-codeine oral solution120-12 mg5 ml

1 GC NDS NM QL (4500 per 30 days)

acetaminophen-codeine oral tablet300-15 mg 300-30 mg

2 NDS NM QL (360 per 30 days)

acetaminophen-codeine oral tablet300-60 mg


buprenorphine hcl injection solution03 mgml

(Buprenex) 2

buprenorphine hcl injection syringe03 mgml

2

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

(Esgic) 2 QL (180 per 30 days)

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

(Fiorinal) 2 QL (180 per 30 days)

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

2 QL (180 per 30 days)

codeine sulfate oral tablet 15 mg 30 mg 60 mg


endocet oral tablet 10-325 mg 2 NDS NM QL (180 per 30 days)

endocet oral tablet 25-325 mg 5-325 mg



fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 200 mcg 400 mcg 600 mcg 800 mcg

(Actiq) 5 PA NM NDS QL (120 per 30 days)

fentanyl transdermal patch 72 hour100 mcghr 12 mcghr 25 mcghr 50 mcghr 75 mcghr

(Duragesic) 2 NDS NM QL (10 per 30 days)

hydrocodone-acetaminophen oral solution 75-325 mg15 ml


hydrocodone-acetaminophen oral tablet 10-325 mg

(Lorcet HD) 2 NDS NM QL (180 per 30 days)




(Norco) 2 NDS NM QL (240 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

3




hydrocodone-ibuprofen oral tablet75-200 mg


hydromorphone (pf) injection solution 10 (mgml) (5 ml) 10 mgml

2

hydromorphone oral liquid 1 mgml (Dilaudid) 2 NDS NM QL (1200 per 30 days)

hydromorphone oral tablet 2 mg 4 mg 8 mg

(Dilaudid) 2 NDS NM QL (180 per 30 days)

LAZANDA NASAL SPRAYNON-AEROSOL 100 MCGSPRAY 300 MCGSPRAY 400 MCGSPRAY

5 PA NM NDS QL (30 per 30 days)

lorcet (hydrocodone) oral tablet 5-325 mg


lorcet hd oral tablet 10-325 mg 2 NDS NM QL (180 per 30 days)

lorcet plus oral tablet 75-325 mg 2 NDS NM QL (180 per 30 days)

methadone injection solution 10 mgml

2

methadone oral solution 10 mg5 ml 2 NDS NM QL (600 per 30 days)


methadone oral tablet 10 mg (Dolophine) 2 NDS NM QL (120 per 30 days)


methadose oral tabletsoluble 40 mg 2 NDS NM QL (30 per 30 days)

morphine concentrate oral solution100 mg5 ml (20 mgml)


MORPHINE INJECTION SYRINGE 10 MGML

4

morphine intravenous solution 10 mgml 4 mgml 8 mgml

2

morphine oral solution 10 mg5 ml 2 NDS NM QL (700 per 30 days)


4


morphine oral solution 20 mg5 ml (4 mgml)


MORPHINE ORAL TABLET 15 MG




morphine oral tablet extended release 100 mg 200 mg 60 mg

(MS Contin) 2 NDS NM QL (60 per 30 days)

morphine oral tablet extended release 15 mg 30 mg


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG 150 MG 200 MG 250 MG 50 MG


NUCYNTA ORAL TABLET 100 MG 50 MG 75 MG


oxycodone oral solution 5 mg5 ml 2 NDS QL (1300 per 30 days)

oxycodone oral tablet 10 mg 2 NDS NM QL (180 per 30 days)

oxycodone oral tablet 15 mg 30 mg (Roxicodone) 2 NDS NM QL (120 per 30 days)


oxycodone oral tablet 5 mg (Roxicodone) 2 NDS NM QL (180 per 30 days)

oxycodone oral tabletoral onlyextrel12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 60 mg 80 mg

(OxyContin) 3 NDS NM QL (60 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg

(Endocet) 2 NDS NM QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 25-325 mg 5-325 mg




oxycodone-aspirin oral tablet48355-325 mg



5


OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG 60 MG 80 MG


tramadol oral tablet 50 mg (Ultram) 1 GC NDS NM QL (240 per 30 days)

tramadol-acetaminophen oral tablet375-325 mg

(Ultracet) 2 NDS NM QL (300 per 30 days)

XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 135 MG 18 MG 9 MG


XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 27 MG




Nonsteroidal Anti-Inflammatory AgentsCALDOLOR INTRAVENOUS RECON SOLN 800 MG8 ML (100 MGML)

4

celecoxib oral capsule 100 mg 200 mg 50 mg

(Celebrex) 2 QL (60 per 30 days)

diclofenac epolamine transdermal patch 12 hour 13

(Flector) 2 PA

diclofenac potassium oral tablet 50 mg

2

diclofenac sodium oral tablet extended release 24 hr 100 mg

(Voltaren-XR) 2

diclofenac sodium oral tabletdelayed release (drec) 25 mg 50 mg 75 mg

2

diclofenac sodium topical drops 15


diclofenac sodium topical gel 1 (Voltaren) 2

diclofenac sodium topical gel 3 (Solaraze) 2 PA QL (100 per 28 days)

etodolac oral capsule 200 mg 300 mg

2


6


etodolac oral tablet 400 mg (Lodine) 2

etodolac oral tablet 500 mg 2

flurbiprofen oral tablet 100 mg 50 mg

2

ibu oral tablet 400 mg 600 mg 800 mg

1 GC

ibuprofen oral suspension 100 mg5 ml

(Childrens Advil) 2

ibuprofen oral tablet 400 mg 600 mg 800 mg

(IBU) 1 GC

indomethacin oral capsule 25 mg 1 GC QL (240 per 30 days)


ketorolac oral tablet 10 mg 2 QL (20 per 30 days)

mefenamic acid oral capsule 250 mg 2

meloxicam oral tablet 15 mg 75 mg (Mobic) 1 GC

nabumetone oral tablet 500 mg 750 mg

(Relafen) 2

naproxen oral tablet 250 mg 375 mg

1 GC

naproxen oral tablet 500 mg (Naprosyn) 1 GC

naproxen oral tabletdelayed release (drec) 375 mg 500 mg

(EC-Naprosyn) 2

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MGGRAM ACTUATION(2 )


sulindac oral tablet 150 mg 200 mg 2

VOLTAREN TOPICAL GEL 1 2

AnestheticsLocal Anestheticsglydo mucous membrane jelly in applicator 2


lidocaine (pf) injection solution 10 mgml (1 ) 15 mgml (15 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine-MPF) 1 GC

lidocaine (pf) injection solution 40 mgml (4 )

1 GC

lidocaine (pf) intravenous solution20 mgml (2 )

(Xylocaine (Cardiac) (PF))

1 GC


7


lidocaine hcl injection solution 10 mgml (1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1 GC

lidocaine hcl mucous membrane jelly2


lidocaine hcl mucous membrane solution 4 (40 mgml)

2

lidocaine topical adhesive patchmedicated 5

(Lidoderm) 2 PA QL (90 per 30 days)

lidocaine topical ointment 5 2 PA QL (90 per 30 days)

lidocaine viscous mucous membrane solution 2

2

lidocaine-prilocaine topical cream25-25

2 PA QL (30 per 30 days)

ZTLIDO TOPICAL ADHESIVE PATCHMEDICATED 18


Anti-AddictionSubstance Abuse Treatment AgentsAnti-AddictionSubstance Abuse Treatment Agentsacamprosate oral tabletdelayed release (drec) 333 mg

2

buprenorphine hcl sublingual tablet2 mg 8 mg


buprenorphine-naloxone sublingual film 12-3 mg 8-2 mg

(Suboxone) 2 QL (60 per 30 days)



buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

2

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

3 QL (336 per 365 days)

CHANTIX ORAL TABLET 05 MG 1 MG

3 QL (336 per 365 days)

CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)

3


8


disulfiram oral tablet 250 mg 500 mg

(Antabuse) 2

LUCEMYRA ORAL TABLET 018 MG

5 NM NDS QL (228 per 14 days)

naloxone injection solution 04 mgml

2

naloxone injection syringe 04 mgml 1 mgml

2

naltrexone oral tablet 50 mg 2

NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION


NICOTROL INHALATION CARTRIDGE 10 MG

4 QL (1008 per 90 days)

SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML 300 MG15 ML

5 NM NDS

ZUBSOLV SUBLINGUAL TABLET 07-018 MG 14-036 MG 114-29 MG 29-071 MG 57-14 MG


ZUBSOLV SUBLINGUAL TABLET 86-21 MG


Antianxiety AgentsBenzodiazepinesalprazolam oral tablet 025 mg 05 mg 1 mg

(Xanax) 1 GC NDS NM QL (120 per 30 days)

alprazolam oral tablet 2 mg (Xanax) 1 GC NDS NM QL (150 per 30 days)

buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg

2

chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg


clonazepam oral tablet 05 mg 1 mg (Klonopin) 1 GC NDS NM QL (90 per 30 days)

clonazepam oral tablet 2 mg (Klonopin) 1 GC NDS NM QL (300 per 30 days)

clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg



9


clonazepam oral tabletdisintegrating 2 mg


clorazepate dipotassium oral tablet15 mg 375 mg


clorazepate dipotassium oral tablet75 mg

(Tranxene T-Tab) 2 NDS NM QL (180 per 30 days)

diazepam 5 mgml oral conc 5 mgml 2 NDS NM QL (1200 per 30 days)

diazepam injection solution 5 mgml 2 QL (10 per 28 days)

diazepam injection syringe 5 mgml 2 QL (10 per 28 days)

diazepam oral concentrate 5 mgml (Diazepam Intensol) 2 NDS NM QL (1200 per 30 days)

diazepam oral solution 5 mg5 ml (1 mgml)


diazepam oral tablet 10 mg 2 mg 5 mg

(Valium) 1 GC NDS NM QL (120 per 30 days)

lorazepam injection solution 2 mgml 4 mgml

(Ativan) 1 GC QL (2 per 30 days)

lorazepam injection syringe 2 mgml 4 mgml


lorazepam oral tablet 05 mg 1 mg (Ativan) 1 GC NDS NM QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) 1 GC NDS NM QL (150 per 30 days)

temazepam oral capsule 15 mg 30 mg

(Restoril) 1 GC NDS NM QL (30 per 30 days)

AntibacterialsAminoglycosidesBETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG4 ML

5 PA BvD NM NDS

gentamicin injection solution 20 mg2 ml 40 mgml

2

gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml

2

gentamicin sulfate (pf) intravenous solution 100 mg10 ml 60 mg6 ml 80 mg8 ml

2

neomycin oral tablet 500 mg 1 GC

streptomycin intramuscular recon soln 1 gram

2


10


TOBI PODHALER INHALATION CAPSULE WINHALATION DEVICE 28 MG


tobramycin in 0225 nacl inhalation solution for nebulization300 mg5 ml

(Tobi) 5 PA BvD NM NDS

tobramycin inhalation solution for nebulization 300 mg4 ml

(Bethkis) 5 PA BvD NM NDS

tobramycin sulfate injection solution40 mgml

2

Antibacterials Miscellaneousbaciim intramuscular recon soln50000 unit

2

chloramphenicol sod succinate intravenous recon soln 1 gram

2

clindamycin hcl oral capsule 150 mg 300 mg 75 mg

(Cleocin HCl) 1 GC

clindamycin in 5 dextrose intravenous piggyback 300 mg50 ml 600 mg50 ml 900 mg50 ml

2

clindamycin phosphate injection solution 150 (mgml) (6 ml)

2

clindamycin phosphate injection solution 150 mgml

(Cleocin) 2

clindamycin phosphate intravenous solution 600 mg4 ml

2

colistin (colistimethate na) injection recon soln 150 mg

(Coly-Mycin M Parenteral)

5 PA BvD NM NDS

daptomycin intravenous recon soln500 mg

(Cubicin) 5 NM NDS

FIRVANQ ORAL RECON SOLN 25 MGML 50 MGML

4

linezolid 600 mg300 ml-09 nacl600 mg300 ml

5 NM NDS

linezolid in dextrose 5 intravenous piggyback 600 mg300 ml

(Zyvox) 5 NM NDS

linezolid oral suspension for reconstitution 100 mg5 ml

(Zyvox) 5 NM NDS

linezolid oral tablet 600 mg (Zyvox) 2


11


methenamine hippurate oral tablet 1 gram

(Hiprex) 2

metronidazole in nacl (iso-os) intravenous piggyback 500 mg100 ml

(Metro IV) 2

metronidazole oral tablet 250 mg 1 GC

metronidazole oral tablet 500 mg (Flagyl) 1 GC

nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg

(Macrodantin) 2 QL (120 per 30 days)

nitrofurantoin monohydm-cryst oral capsule 100 mg

(Macrobid) 2 QL (60 per 30 days)

polymyxin b sulfate injection recon soln 500000 unit

2

SYNERCID INTRAVENOUS RECON SOLN 500 MG

5 NM NDS

trimethoprim oral tablet 100 mg 1 GC

vancomycin intravenous recon soln1000 mg 125 gram 10 gram 5 gram 500 mg 750 mg

2

vancomycin oral capsule 125 mg 250 mg

(Vancocin) 2

XIFAXAN ORAL TABLET 200 MG



5 PA NM NDS

Cephalosporinscefaclor oral capsule 250 mg 500 mg

2

cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml

2

cefadroxil oral capsule 500 mg 2

cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml

2

cefazolin injection recon soln 1 gram 10 gram 500 mg

2

cefdinir oral capsule 300 mg 2

cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2


12


cefditoren pivoxil oral tablet 200 mg 4

cefditoren pivoxil oral tablet 400 mg (Spectracef) 4

cefepime injection recon soln 1 gram 2 gram

2

cefixime oral capsule 400 mg (Suprax) 2

cefotaxime injection recon soln 1 gram

2

cefoxitin intravenous recon soln 1 gram 10 gram 2 gram

2

cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml

2

cefpodoxime oral tablet 100 mg 200 mg

2

cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cefprozil oral tablet 250 mg 500 mg 2

ceftazidime injection recon soln 1 gram 2 gram

(Fortaz) 2

ceftazidime injection recon soln 6 gram

(Tazicef) 2

ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg

2

cefuroxime axetil oral tablet 250 mg 500 mg

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous recon soln 15 gram 75 gram

2

cephalexin oral capsule 250 mg 500 mg

(Keflex) 1 GC

cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG

5 NM NDS

Macrolidesazithromycin intravenous recon soln500 mg

(Zithromax) 2


13


azithromycin oral packet 1 gram (Zithromax) 4

azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

(Zithromax) 2

azithromycin oral tablet 250 mg (6 pack) 500 mg (3 pack) 600 mg

1 GC

azithromycin oral tablet 250 mg 500 mg

(Zithromax) 1 GC

clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

clarithromycin oral tablet 250 mg 500 mg

2

DIFICID ORAL TABLET 200 MG

5 ST NM NDS QL (20 per 10 days)

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml

(EES Granules) 2


(EryPed 400) 2

erythromycin oral tablet 250 mg 500 mg

2

Miscellaneous B-Lactam Antibioticsaztreonam injection recon soln 1 gram 2 gram

(Azactam) 2

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML

5 PA NM LA NDS

ertapenem injection recon soln 1 gram

(Invanz) 2

imipenem-cilastatin intravenous recon soln 250 mg

2


(Primaxin IV) 2

meropenem intravenous recon soln 1 gram

(Merrem) 2

meropenem intravenous recon soln500 mg

(Merrem) 2

meropenem-09 nacl 500 mg50500 mg50 ml

2


14


Penicillinsamoxicillin oral capsule 250 mg 500 mg

1 GC

amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml

1 GC

amoxicillin oral tablet 500 mg 875 mg

1 GC

amoxicillin oral tabletchewable 125 mg 250 mg

1 GC

amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 400-57 mg5 ml

2

amoxicillin-pot clavulanate oral suspension for reconstitution 600-429 mg5 ml

(Augmentin ES-600) 2

amoxicillin-pot clavulanate oral tablet 500-125 mg 875-125 mg

(Augmentin) 1 GC

amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg

2

ampicillin oral capsule 250 mg 500 mg

2

ampicillin sodium injection recon soln 1 gram 10 gram 125 mg 2 gram 250 mg 500 mg

2

ampicillin-sulbactam injection recon soln 15 gram 15 gram 3 gram

(Unasyn) 2

BICILLIN L-A INTRAMUSCULAR SYRINGE 1200000 UNIT2 ML 2400000 UNIT4 ML 600000 UNITML

4

dicloxacillin oral capsule 250 mg 500 mg

2

nafcillin 1 gm 50 ml inj 1 gram50 ml

2

nafcillin injection recon soln 1 gram 2

nafcillin injection recon soln 10 gram

5 NM NDS



15


penicillin g potassium injection recon soln 20 million unit

(Pfizerpen-G) 2

penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml

2

penicillin v potassium oral recon soln125 mg5 ml 250 mg5 ml

2

penicillin v potassium oral tablet 250 mg 500 mg

1 GC

pfizerpen-g injection recon soln 20 million unit

2

piperacillin-tazobactam intravenous recon soln 225 gram 3375 gram 45 gram 405 gram

2 PA BvD

QuinolonesBAXDELA ORAL TABLET 450 MG


ciprofloxacin hcl oral tablet 250 mg 500 mg

(Cipro) 1 GC

ciprofloxacin hcl oral tablet 750 mg 1 GC

ciprofloxacin in 5 dextrose intravenous piggyback 200 mg100 ml 400 mg200 ml

2

ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml

(Cipro) 2

levofloxacin in d5w intravenous piggyback 250 mg50 ml 500 mg100 ml 750 mg150 ml

2

levofloxacin intravenous solution 25 mgml

2

levofloxacin oral solution 250 mg10 ml

2

levofloxacin oral tablet 250 mg 500 mg 750 mg

1 GC

moxifloxacin oral tablet 400 mg 2Sulfonamidessulfadiazine oral tablet 500 mg 2

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg5 ml

2


16


sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml

(Sulfatrim) 2

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) 1 GC


(Bactrim DS) 1 GC

sulfatrim oral suspension 200-40 mg5 ml

4

Tetracyclinesdoxy-100 intravenous recon soln 100 mg

2

doxycycline hyclate intravenous recon soln 100 mg

(Doxy-100) 2

doxycycline hyclate oral capsule 100 mg 50 mg

(Morgidox) 2

doxycycline hyclate oral tablet 100 mg 20 mg

2

doxycycline monohydrate oral capsule 100 mg

(Mondoxyne NL) 2


(Monodox) 2

doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml

(Vibramycin) 2

doxycycline monohydrate oral tablet100 mg

(Avidoxy) 2


2

minocycline oral capsule 100 mg 50 mg 75 mg

2

mondoxyne nl oral capsule 100 mg 50 mg

2

tetracycline oral capsule 250 mg 500 mg

2

tigecycline intravenous recon soln 50 mg

(Tygacil) 5 NM NDS

Anticancer AgentsAnticancer AgentsABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG

5 NM NDS


17


ADCETRIS INTRAVENOUS RECON SOLN 50 MG

5 PA NSO NM NDS

adriamycin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

2 PA BvD

adrucil intravenous solution 25 gram50 ml 500 mg10 ml

2 PA BvD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG 3 MG 5 MG

5 PA NSO NM NDS QL (112 per 28 days)

AFINITOR ORAL TABLET 10 MG


AFINITOR ORAL TABLET 25 MG 5 MG 75 MG


ALECENSA ORAL CAPSULE 150 MG


ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG

5 NM NDS

ALIQOPA INTRAVENOUS RECON SOLN 60 MG


ALUNBRIG ORAL TABLET 180 MG 90 MG


ALUNBRIG ORAL TABLET 30 MG


ALUNBRIG ORAL TABLETSDOSE PACK 90 MG (7)- 180 MG (23)

5 PA NSO NM NDS

anastrozole oral tablet 1 mg (Arimidex) 1 GC

arsenic trioxide intravenous solution1 mgml

5 NM NDS


(Trisenox) 5 NM NDS

AVASTIN INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

AYVAKIT ORAL TABLET 100 MG 200 MG 300 MG


azacitidine injection recon soln 100 mg

(Vidaza) 5 NM NDS

BALVERSA ORAL TABLET 3 MG



18






BAVENCIO INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM NDS

BELEODAQ INTRAVENOUS RECON SOLN 500 MG

5 PA NSO NM NDS

BENDEKA INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)

5 PA NSO NM NDS

bexarotene oral capsule 75 mg (Targretin) 5 PA NSO NM NDS QL (420 per 30 days)

bicalutamide oral tablet 50 mg (Casodex) 2

BLENREP INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

bleomycin injection recon soln 15 unit 30 unit

2

BLINCYTO INTRAVENOUS KIT 35 MCG

5 PA NSO NM NDS

BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG

5 PA NSO NM NDS

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG 500 MG


BRAFTOVI ORAL CAPSULE 50 MG




BRUKINSA ORAL CAPSULE 80 MG

5 PA NSO NM NDS

CABOMETYX ORAL TABLET 20 MG 60 MG


CABOMETYX ORAL TABLET 40 MG


CALQUENCE ORAL CAPSULE 100 MG



19


CAPRELSA ORAL TABLET 100 MG




clofarabine intravenous solution 20 mg20 ml

(Clolar) 5 NM NDS

COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)


COPIKTRA ORAL CAPSULE 15 MG 25 MG


COTELLIC ORAL TABLET 20 MG

5 PA NSO NM LA NDS QL (63 per 28 days)

cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg

5 PA BvD NM NDS

cyclophosphamide intravenous solution 200 mgml

5 PA BvD NM NDS

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NM NDS

DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800 MG-30000 UNIT15 ML

5 PA NSO NM LA NDS

DARZALEX INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM LA NDS

DAURISMO ORAL TABLET 100 MG




decitabine intravenous recon soln 50 mg

(Dacogen) 5 NM NDS

doxorubicin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

(Adriamycin) 2 PA BvD

doxorubicin peg-liposomal intravenous suspension 2 mgml

(Doxil) 5 PA BvD NM NDS


20


DROXIA ORAL CAPSULE 200 MG 300 MG 400 MG

4

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG

4


4


4

ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)

4

EMCYT ORAL CAPSULE 140 MG

5 NM NDS

EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG

5 PA NSO NM NDS

ENHERTU INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

ERIVEDGE ORAL CAPSULE 150 MG


ERLEADA ORAL TABLET 60 MG


erlotinib oral tablet 100 mg 25 mg (Tarceva) 5 PA NSO NM NDS QL (60 per 30 days)

erlotinib oral tablet 150 mg (Tarceva) 5 PA NSO NM NDS QL (90 per 30 days)

ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG

4

etoposide intravenous solution 20 mgml

(Toposar) 2

exemestane oral tablet 25 mg (Aromasin) 2

FARYDAK ORAL CAPSULE 10 MG 15 MG 20 MG

5 PA NSO NM NDS

floxuridine injection recon soln 05 gram

2 PA BvD

fluorouracil intravenous solution 1 gram20 ml 5 gram100 ml 500 mg10 ml

2 PA BvD

flutamide oral capsule 125 mg 2


21


fulvestrant intramuscular syringe250 mg5 ml

(Faslodex) 5 NM NDS

GAVRETO ORAL CAPSULE 100 MG


GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML

5 PA NSO NM NDS

GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG


GLEOSTINE ORAL CAPSULE 10 MG 40 MG 5 MG

4

GLEOSTINE ORAL CAPSULE 100 MG

5 NM NDS

HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML


HERCEPTIN INTRAVENOUS RECON SOLN 150 MG 440 MG

5 PA NSO NM NDS

HERZUMA INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

hydroxyurea oral capsule 500 mg (Hydrea) 2

IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG


IBRANCE ORAL TABLET 100 MG 125 MG 75 MG


ICLUSIG ORAL TABLET 15 MG




IDHIFA ORAL TABLET 100 MG 50 MG


ifosfamide intravenous recon soln 1 gram

(Ifex) 2

ifosfamide intravenous solution 1 gram20 ml 3 gram60 ml

2

ifosfamide-mesna intravenous kit 1-1 gram 3000-1000 mg

2

imatinib oral tablet 100 mg (Gleevec) 2 PA NSO QL (90 per 30 days)



22


IMBRUVICA ORAL CAPSULE 140 MG




IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG


IMFINZI INTRAVENOUS SOLUTION 50 MGML

5 PA NSO NM NDS

IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML




INLYTA ORAL TABLET 1 MG 5 PA NSO NM NDS QL (180 per 30 days)


INQOVI ORAL TABLET 35-100 MG


INREBIC ORAL CAPSULE 100 MG


IRESSA ORAL TABLET 250 MG 5 PA NSO NM NDS QL (60 per 30 days)

IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG

5 NM NDS

JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG


KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

KEYTRUDA INTRAVENOUS SOLUTION 25 MGML


KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG





23




KISQALI ORAL TABLET 200 MGDAY (200 MG X 1)






KOSELUGO ORAL CAPSULE 10 MG




KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG

5 PA NSO NM NDS

lapatinib oral tablet 250 mg (Tykerb) 5 PA NSO NM NDS

LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)

5 PA NSO NM NDS

letrozole oral tablet 25 mg (Femara) 2

LEUKERAN ORAL TABLET 2 MG

4

leuprolide subcutaneous kit 1 mg02 ml

2

LIBTAYO INTRAVENOUS SOLUTION 50 MGML


LONSURF ORAL TABLET 15-614 MG




LORBRENA ORAL TABLET 100 MG





24


LUMOXITI INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NM NDS

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 225 MG

5 NM NDS


5 NM NDS


5 NM NDS

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG

5 NM NDS

LYNPARZA ORAL TABLET 100 MG 150 MG


LYSODREN ORAL TABLET 500 MG

5 NM NDS

MATULANE ORAL CAPSULE 50 MG

5 NM NDS

megestrol oral tablet 20 mg 40 mg 2

MEKINIST ORAL TABLET 05 MG




MEKTOVI ORAL TABLET 15 MG


mercaptopurine oral tablet 50 mg 2

methotrexate sodium (pf) injection recon soln 1 gram

2 PA BvD

methotrexate sodium (pf) injection solution 25 mgml

2 PA BvD

methotrexate sodium injection solution 25 mgml

2 PA BvD

methotrexate sodium oral tablet 25 mg

2 PA BvD ST

mitoxantrone intravenous concentrate 2 mgml

2

MONJUVI INTRAVENOUS RECON SOLN 200 MG

5 PA NSO NM NDS


25


MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)

5 PA NSO NM NDS

NERLYNX ORAL TABLET 40 MG


NEXAVAR ORAL TABLET 200 MG


nilutamide oral tablet 150 mg (Nilandron) 5 NM NDS

NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG


NUBEQA ORAL TABLET 300 MG


ODOMZO ORAL CAPSULE 200 MG

5 PA NSO NM LA NDS

OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

ONCASPAR INJECTION SOLUTION 750 UNITML

5 PA NSO NM NDS

ONIVYDE INTRAVENOUS DISPERSION 43 MGML

5 NM NDS

ONTRUZANT INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

ONUREG ORAL TABLET 200 MG 300 MG


OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML

5 PA NSO NM NDS

PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG

5 PA NSO NM NDS

PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG


PHESGO SUBCUTANEOUS SOLUTION 1200 MG-600MG- 30000 UNIT15ML


PHESGO SUBCUTANEOUS SOLUTION 600 MG-600 MG- 20000 UNIT10ML


PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1)



26


PIQRAY ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)


POLIVY INTRAVENOUS RECON SOLN 140 MG 30 MG

5 PA NSO NM NDS

POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG


PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)


PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

5 NM NDS

PURIXAN ORAL SUSPENSION 20 MGML

5 NM NDS

QINLOCK ORAL TABLET 50 MG


RETEVMO ORAL CAPSULE 40 MG




REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG


RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)

5 PA NSO NM NDS

RITUXAN INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NM NDS

ROZLYTREK ORAL CAPSULE 100 MG




RUBRACA ORAL TABLET 200 MG 250 MG 300 MG


RUXIENCE INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NM NDS

RYDAPT ORAL CAPSULE 25 MG



27


SARCLISA INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM NDS

SOLTAMOX ORAL SOLUTION 20 MG10 ML

5 NM NDS

SPRYCEL ORAL TABLET 100 MG 140 MG 50 MG 70 MG 80 MG


SPRYCEL ORAL TABLET 20 MG


STIVARGA ORAL TABLET 40 MG


SUTENT ORAL CAPSULE 125 MG 25 MG 375 MG 50 MG


SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG

5 PA NSO NM NDS

SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG

5 PA NSO NM NDS

TABLOID ORAL TABLET 40 MG

4

TABRECTA ORAL TABLET 150 MG 200 MG


TAFINLAR ORAL CAPSULE 50 MG 75 MG


TAGRISSO ORAL TABLET 40 MG 80 MG


TALZENNA ORAL CAPSULE 025 MG




tamoxifen oral tablet 10 mg 20 mg 2

TARGRETIN TOPICAL GEL 1


TASIGNA ORAL CAPSULE 150 MG 200 MG


TASIGNA ORAL CAPSULE 50 MG


TAZVERIK ORAL TABLET 200 MG



28


TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)

5 PA NSO NM NDS

TEMODAR INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

thiotepa injection recon soln 100 mg 15 mg

(Tepadina) 5 NM NDS

TIBSOVO ORAL TABLET 250 MG


toposar intravenous solution 20 mgml

2

toremifene oral tablet 60 mg (Fareston) 5 NM NDS

TRAZIMERA INTRAVENOUS RECON SOLN 420 MG

5 PA NSO NM NDS

TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG

5 PA NSO NM NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG






tretinoin (antineoplastic) oral capsule 10 mg

5 NM NDS

TRODELVY INTRAVENOUS RECON SOLN 180 MG

5 PA NSO NM NDS

TRUXIMA INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NM NDS

TUKYSA ORAL TABLET 150 MG




TURALIO ORAL CAPSULE 200 MG



29


TYKERB ORAL TABLET 250 MG

5 PA NSO NM NDS

UNITUXIN INTRAVENOUS SOLUTION 35 MGML

5 PA NSO NM NDS

valrubicin intravesical solution 40 mgml

(Valstar) 5 NM NDS

VELCADE INJECTION RECON SOLN 35 MG

5 PA NSO NM NDS

VENCLEXTA ORAL TABLET 10 MG

3 PA NSO LA QL (60 per 30 days)





VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG

5 PA NSO NM LA NDS

VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG


vinorelbine intravenous solution 10 mgml 50 mg5 ml

(Navelbine) 2

VITRAKVI ORAL CAPSULE 100 MG




VITRAKVI ORAL SOLUTION 20 MGML


VIZIMPRO ORAL TABLET 15 MG 30 MG 45 MG


VOTRIENT ORAL TABLET 200 MG


VYXEOS INTRAVENOUS RECON SOLN 44-100 MG

5 PA BvD NM NDS

XALKORI ORAL CAPSULE 200 MG 250 MG


XATMEP ORAL SOLUTION 25 MGML

4 PA BvD ST

XOSPATA ORAL TABLET 40 MG



30


XPOVIO ORAL TABLET 100 MGWEEK (20 MG X 5)




XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MGWEEK) 80 MGWEEK (20 MG X 4)




XPOVIO ORAL TABLET 60MG TWICE WEEK (120 MGWEEK)




XTANDI ORAL CAPSULE 40 MG


YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)

5 PA NSO NM NDS

YONDELIS INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NM NDS

YONSA ORAL TABLET 125 MG 5 PA NSO NM NDS QL (120 per 30 days)

ZEJULA ORAL CAPSULE 100 MG


ZELBORAF ORAL TABLET 240 MG


ZEPZELCA INTRAVENOUS RECON SOLN 4 MG

5 PA NSO NM NDS

ZIRABEV INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG




ZOLINZA ORAL CAPSULE 100 MG

5 NM NDS

ZYDELIG ORAL TABLET 100 MG 150 MG


ZYKADIA ORAL CAPSULE 150 MG



31


ZYKADIA ORAL TABLET 150 MG


ZYTIGA ORAL TABLET 250 MG 500 MG


Anticholinergic AgentsAntimuscarinicsAntispasmodicsatropine injection syringe 005 mgml 01 mgml

4

AnticonvulsantsAnticonvulsantsAPTIOM ORAL TABLET 200 MG 400 MG


APTIOM ORAL TABLET 600 MG 800 MG


BANZEL ORAL SUSPENSION 40 MGML

5 ST NM NDS

BANZEL ORAL TABLET 200 MG 400 MG

5 ST NM NDS

BRIVIACT INTRAVENOUS SOLUTION 50 MG5 ML


BRIVIACT ORAL SOLUTION 10 MGML


BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG


carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg

(Carbatrol) 2

carbamazepine oral suspension 100 mg5 ml

(Tegretol) 2

carbamazepine oral tablet 200 mg (Epitol) 2

carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg

(Tegretol XR) 2

carbamazepine oral tabletchewable100 mg

2

CELONTIN ORAL CAPSULE 300 MG

4

clobazam oral suspension 25 mgml (Onfi) 2 PA NSO QL (480 per 30 days)


32


clobazam oral tablet 10 mg 20 mg (Onfi) 2 PA NSO QL (60 per 30 days)

DIASTAT ACUDIAL RECTAL KIT 125-15-175-20 MG 5-75-10 MG

4

DIASTAT RECTAL KIT 25 MG 4

diazepam rectal kit 125-15-175-20 mg 5-75-10 mg

(Diastat AcuDial) 4

diazepam rectal kit 25 mg (Diastat) 4

divalproex oral capsule delayed rel sprinkle 125 mg

(Depakote Sprinkles) 2

divalproex oral tablet extended release 24 hr 250 mg 500 mg

(Depakote ER) 2

divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg

(Depakote) 2

EPIDIOLEX ORAL SOLUTION 100 MGML

5 PA NSO NM NDS

epitol oral tablet 200 mg 2

ethosuximide oral capsule 250 mg (Zarontin) 2

ethosuximide oral solution 250 mg5 ml

(Zarontin) 2

felbamate oral suspension 600 mg5 ml

(Felbatol) 2

felbamate oral tablet 400 mg 600 mg

(Felbatol) 2

FINTEPLA ORAL SOLUTION 22 MGML

5 PA NSO NM NDS

fosphenytoin injection solution 100 mg pe2 ml 500 mg pe10 ml

(Cerebyx) 2

FYCOMPA ORAL SUSPENSION 05 MGML

4 ST QL (720 per 30 days)

FYCOMPA ORAL TABLET 10 MG 12 MG 8 MG


FYCOMPA ORAL TABLET 2 MG


FYCOMPA ORAL TABLET 4 MG 6 MG


gabapentin oral capsule 100 mg 300 mg

(Neurontin) 1 GC QL (360 per 30 days)


33


gabapentin oral capsule 400 mg (Neurontin) 1 GC QL (270 per 30 days)

gabapentin oral solution 250 mg5 ml

(Neurontin) 2 QL (2160 per 30 days)

gabapentin oral tablet 600 mg (Neurontin) 2 QL (180 per 30 days)


lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg

(Subvenite) 1 GC

lamotrigine oral tablet chewable dispersible 25 mg 5 mg

(Lamictal) 2

levetiracetam intravenous solution500 mg5 ml

(Keppra) 2

levetiracetam oral solution 100 mgml

(Keppra) 2

levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg

(Keppra) 2

levetiracetam oral tablet extended release 24 hr 500 mg 750 mg

(Keppra XR) 2

NAYZILAM NASAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)


oxcarbazepine oral suspension 300 mg5 ml (60 mgml)

(Trileptal) 2

oxcarbazepine oral tablet 150 mg 300 mg 600 mg

(Trileptal) 2

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG 300 MG 600 MG

4 ST

PEGANONE ORAL TABLET 250 MG

4

phenobarbital oral elixir 20 mg5 ml (4 mgml)

2

phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg

2

phenytoin oral suspension 125 mg5 ml

(Dilantin-125) 2

phenytoin oral tabletchewable 50 mg

(Dilantin Infatabs) 2

phenytoin sodium extended oral capsule 100 mg

(Dilantin Extended) 2


34


phenytoin sodium extended oral capsule 200 mg 300 mg

(Phenytek) 2

phenytoin sodium intravenous solution 50 mgml

2

phenytoin sodium intravenous syringe 50 mgml

2

pregabalin oral capsule 100 mg 150 mg 200 mg 225 mg 25 mg 300 mg 50 mg 75 mg

(Lyrica) 2 QL (90 per 30 days)

pregabalin oral solution 20 mgml (Lyrica) 2 QL (900 per 30 days)

primidone oral tablet 250 mg 50 mg (Mysoline) 2

SABRIL ORAL TABLET 500 MG


SPRITAM ORAL TABLET FOR SUSPENSION 1000 MG


SPRITAM ORAL TABLET FOR SUSPENSION 250 MG 500 MG 750 MG


subvenite oral tablet 100 mg 150 mg 200 mg 25 mg

1 GC

SYMPAZAN ORAL FILM 10 MG 20 MG


SYMPAZAN ORAL FILM 5 MG 4 PA NSO QL (60 per 30 days)

tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg

(Gabitril) 2

topiramate oral capsule sprinkle 15 mg 25 mg

(Topamax) 2

topiramate oral capsulesprinkleer 24hr 100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

topiramate oral tablet 100 mg 200 mg 25 mg 50 mg

(Topamax) 1 GC

valproate sodium intravenous solution 500 mg5 ml (100 mgml)

2

valproic acid (as sodium salt) oral solution 250 mg5 ml

2

valproic acid oral capsule 250 mg 2


35


VALTOCO NASAL SPRAYNON-AEROSOL 10 MGSPRAY (01 ML) 15 MG2 SPRAY (7501ML X 2) 20 MG2 SPRAY (10MG01ML X2) 5 MGSPRAY (01 ML)

4

vigabatrin oral powder in packet 500 mg

(Vigadrone) 5 PA NSO NM NDS QL (180 per 30 days)

vigabatrin oral tablet 500 mg (Sabril) 5 PA NSO NM NDS QL (180 per 30 days)

vigadrone oral powder in packet 500 mg


VIMPAT INTRAVENOUS SOLUTION 200 MG20 ML


VIMPAT ORAL SOLUTION 10 MGML

3 QL (1200 per 30 days)

VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG


XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 350 MGDAY (200 MG X1-150MG X1)


XCOPRI ORAL TABLET 100 MG 50 MG




XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14)

4 PA NSO

XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)

5 PA NSO NM NDS

zonisamide oral capsule 100 mg 25 mg

(Zonegran) 2

zonisamide oral capsule 50 mg 2

Antidementia AgentsAntidementia Agentsdonepezil oral tablet 10 mg 5 mg (Aricept) 1 GC QL (30 per 30

days)


36


donepezil oral tabletdisintegrating10 mg 5 mg


galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg

(Razadyne ER) 2 QL (30 per 30 days)

galantamine oral solution 4 mgml 2 QL (200 per 30 days)

galantamine oral tablet 12 mg 4 mg 8 mg


memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg

(Namenda XR) 2 QL (30 per 30 days)

memantine oral solution 2 mgml 2 QL (360 per 30 days)

memantine oral tablet 10 mg 5 mg (Namenda) 2 QL (60 per 30 days)

NAMZARIC ORAL CAPSPRINKLEER 24HR DOSE PACK 7142128 MG-10 MG

3

NAMZARIC ORAL CAPSULESPRINKLEER 24HR 14-10 MG 21-10 MG 28-10 MG 7-10 MG


rivastigmine tartrate oral capsule15 mg 3 mg 45 mg 6 mg


rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hr 95 mg24 hr

(Exelon) 2 QL (30 per 30 days)

AntidepressantsAntidepressantsamitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg

2

bupropion hcl oral tablet 100 mg 75 mg

2

bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg

(Wellbutrin XL) 2

bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg

(Wellbutrin SR) 2

citalopram oral solution 10 mg5 ml 2 QL (600 per 30 days)

citalopram oral tablet 10 mg 20 mg 40 mg

(Celexa) 1 GC QL (30 per 30 days)


37


clomipramine oral capsule 25 mg 50 mg 75 mg

(Anafranil) 2

desipramine oral tablet 10 mg 25 mg

(Norpramin) 2

desipramine oral tablet 100 mg 150 mg 50 mg 75 mg

2

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg

(Pristiq) 2 QL (30 per 30 days)

doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

doxepin oral concentrate 10 mgml 1 GC

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 20 MG 30 MG 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 40 MG


duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 60 mg

(Cymbalta) 2 QL (60 per 30 days)

EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR


escitalopram oxalate oral solution 5 mg5 ml

2

escitalopram oxalate oral tablet 10 mg 20 mg 5 mg

(Lexapro) 1 GC

FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

4 ST

FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG


fluoxetine oral capsule 10 mg 20 mg 40 mg

(Prozac) 1 GC

fluoxetine oral solution 20 mg5 ml (4 mgml)

2


38


fluvoxamine oral tablet 100 mg 25 mg 50 mg

2

imipramine hcl oral tablet 10 mg 25 mg 50 mg

2

maprotiline oral tablet 25 mg 50 mg 75 mg

2

MARPLAN ORAL TABLET 10 MG

4

mirtazapine oral tablet 15 mg 30 mg

(Remeron) 2


2

mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg

(Remeron SolTab) 2

nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg

2

nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg

(Pamelor) 1 GC

nortriptyline oral solution 10 mg5 ml

2

paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg

(Paxil) 1 GC

PAXIL ORAL SUSPENSION 10 MG5 ML

4

perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg

2

phenelzine oral tablet 15 mg (Nardil) 2

protriptyline oral tablet 10 mg 5 mg 2

sertraline oral concentrate 20 mgml (Zoloft) 2

sertraline oral tablet 100 mg 25 mg 50 mg

(Zoloft) 1 GC

SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)

5 PA NSO NM NDS

tranylcypromine oral tablet 10 mg (Parnate) 2

trazodone oral tablet 100 mg 150 mg 50 mg

1 GC

trazodone oral tablet 300 mg 2


39


trimipramine oral capsule 100 mg 25 mg 50 mg

2

TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG


venlafaxine oral capsuleextended release 24hr 150 mg

(Effexor XR) 2 QL (30 per 30 days)

venlafaxine oral capsuleextended release 24hr 375 mg 75 mg


venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg

2

VIIBRYD ORAL TABLET 10 MG 20 MG 40 MG


VIIBRYD ORAL TABLETSDOSE PACK 10 MG (7)- 20 MG (23)

3

ZULRESSO INTRAVENOUS SOLUTION 5 MGML

5 NM NDS

Antidiabetic AgentsAntidiabetic Agents Miscellaneousacarbose oral tablet 100 mg 25 mg 50 mg

(Precose) 2 QL (90 per 30 days)

GLYXAMBI ORAL TABLET 10-5 MG 25-5 MG


INVOKAMET ORAL TABLET 150-1000 MG 150-500 MG 50-1000 MG


INVOKAMET ORAL TABLET 50-500 MG


INVOKAMET XR ORAL TABLET IR - ER BIPHASIC 24HR 150-1000 MG 150-500 MG 50-1000 MG 50-500 MG


INVOKANA ORAL TABLET 100 MG




JANUMET ORAL TABLET 50-1000 MG 50-500 MG


JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG



40


JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 50-1000 MG 50-500 MG


JANUVIA ORAL TABLET 100 MG 25 MG 50 MG


JARDIANCE ORAL TABLET 10 MG 25 MG


JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG


JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG




KORLYM ORAL TABLET 300 MG


metformin oral tablet 1000 mg (Glucophage) 6 GC QL (75 per 30 days)



metformin oral tablet extended release 24 hr 500 mg

(Glucophage XR) 6 GC QL (120 per 30 days)



OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 1 MGDOSE (2 MG15 ML)


pioglitazone oral tablet 15 mg 30 mg 45 mg

(Actos) 6 GC QL (30 per 30 days)

repaglinide oral tablet 05 mg 2 QL (120 per 30 days)

repaglinide oral tablet 1 mg (Prandin) 2 QL (120 per 30 days)


RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG



41


SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML




SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG


SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 25-1000 MG




TRADJENTA ORAL TABLET 5 MG


TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML


VICTOZA SUBCUTANEOUS PEN INJECTOR 06 MG01 ML (18 MG3 ML)


InsulinsFIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)


FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML



42


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)


LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


NOVOLIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)


NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)


NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML


NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML


NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)


NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)



43


NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML


NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML


SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML


TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)


TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)


TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)




TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)


Sulfonylureasglimepiride oral tablet 1 mg 2 mg (Amaryl) 6 GC QL (30 per 30

days)

glimepiride oral tablet 4 mg (Amaryl) 6 GC QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 6 GC QL (120 per 30 days)


glipizide oral tablet extended release 24hr 10 mg

(Glucotrol XL) 2 QL (60 per 30 days)


44


glipizide oral tablet extended release 24hr 25 mg 5 mg


glipizide-metformin oral tablet 25-250 mg


glipizide-metformin oral tablet 25-500 mg 5-500 mg


glyburide micronized oral tablet 15 mg 3 mg 6 mg

(Glynase) 2

glyburide oral tablet 125 mg 25 mg 5 mg

2

glyburide-metformin oral tablet125-250 mg 25-500 mg 5-500 mg

6 GC

tolazamide oral tablet 250 mg 2 QL (120 per 30 days)


AntifungalsAntifungalsABELCET INTRAVENOUS SUSPENSION 5 MGML

5 PA BvD NM NDS

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

5 PA BvD NM NDS

amphotericin b injection recon soln50 mg

2 PA BvD

caspofungin intravenous recon soln50 mg 70 mg

(Cancidas) 5 NM NDS

ciclopirox topical cream 077 (Ciclodan) 2

ciclopirox topical solution 8 (Ciclodan) 2

clotrimazole mucous membrane troche 10 mg

2

clotrimazole topical cream 1 (Antifungal (clotrimazole))

1 GC

clotrimazole-betamethasone topical cream 1-005

2

econazole topical cream 1 2

fluconazole in nacl (iso-osm) intravenous piggyback 100 mg50 ml 200 mg100 ml 400 mg200 ml

2 PA BvD

fluconazole oral suspension for reconstitution 10 mgml 40 mgml

(Diflucan) 2

fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg

(Diflucan) 2


45


flucytosine oral capsule 250 mg 500 mg

(Ancobon) 5 NM NDS

griseofulvin microsize oral suspension 125 mg5 ml

2

griseofulvin microsize oral tablet500 mg

2

itraconazole oral capsule 100 mg (Sporanox) 2

ketoconazole oral tablet 200 mg 2

ketoconazole topical cream 2 2

ketoconazole topical shampoo 2 2

miconazole-3 vaginal suppository200 mg

2

NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)

5 NM NDS

nyamyc topical powder 100000 unitgram

2

nystatin oral suspension 100000 unitml

2

nystatin oral tablet 500000 unit 2

nystatin topical cream 100000 unitgram

2

nystatin topical ointment 100000 unitgram

2

nystatin topical powder 100000 unitgram

(Nyamyc) 2

nystop topical powder 100000 unitgram

2

posaconazole oral tabletdelayed release (drec) 100 mg

(Noxafil) 5 NM NDS

terbinafine hcl oral tablet 250 mg 1 GC

voriconazole intravenous recon soln200 mg

(Vfend IV) 5 PA BvD NM NDS

voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)

(Vfend) 5 NM NDS

voriconazole oral tablet 200 mg 50 mg

(Vfend) 5 NM NDS

Antigout AgentsAntigout Agents Otherallopurinol oral tablet 100 mg 300 mg

(Zyloprim) 1 GC


46


colchicine oral tablet 06 mg (Colcrys) 4 PA QL (120 per 30 days)

febuxostat oral tablet 40 mg 80 mg (Uloric) 2 QL (30 per 30 days)

MITIGARE ORAL CAPSULE 06 MG


probenecid oral tablet 500 mg 2

probenecid-colchicine oral tablet500-05 mg

2

AntihistaminesAntihistaminescyproheptadine oral syrup 2 mg5 ml 2

diphenhydramine hcl injection solution 50 mgml

2

diphenhydramine hcl injection syringe 50 mgml

2

diphenhydramine hcl oral elixir 125 mg5 ml

(Diphen) 1 GC

hydroxyzine hcl intramuscular solution 25 mgml 50 mgml

2

hydroxyzine hcl oral solution 10 mg5 ml

2

hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg

1 GC

levocetirizine oral solution 25 mg5 ml

(Xyzal) 2

levocetirizine oral tablet 5 mg (24HR Allergy Relief) 1 GC

promethazine oral syrup 625 mg5 ml

1 GC

Anti-Infectives (Skin And Mucous Membrane)Anti-Infectives (Skin And Mucous Membrane)clindamycin phosphate vaginal cream 2

(Cleocin) 2

metronidazole vaginal gel 075 (Metrogel Vaginal) 2

terconazole vaginal cream 04 08

2

terconazole vaginal suppository 80 mg

2


47


Antimigraine AgentsAntimigraine AgentsAIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MGML


AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML


AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG15 ML


AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG15 ML


dihydroergotamine injection solution1 mgml

(DHE45) 5 NM NDS QL (24 per 28 days)

dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)

(Migranal) 5 NM NDS QL (8 per 28 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG3 ML (100 MGML X 3)


ERGOMAR SUBLINGUAL TABLET 2 MG


NURTEC ODT ORAL TABLETDISINTEGRATING 75 MG


REYVOW ORAL TABLET 100 MG




rizatriptan oral tablet 10 mg (Maxalt) 2 QL (12 per 30 days)

rizatriptan oral tablet 5 mg 2 QL (12 per 30 days)

rizatriptan oral tabletdisintegrating10 mg

(Maxalt-MLT) 2 QL (12 per 30 days)


48




sumatriptan nasal spraynon-aerosol20 mgactuation

(Imitrex) 2 QL (12 per 30 days)



sumatriptan succinate oral tablet100 mg

(Imitrex) 1 GC QL (9 per 30 days)

sumatriptan succinate oral tablet 25 mg 50 mg


sumatriptan succinate subcutaneous cartridge 6 mg05 ml

(Imitrex STATdose Refill)


sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml

(Imitrex STATdose Pen)


sumatriptan succinate subcutaneous solution 6 mg05 ml


sumatriptan succinate subcutaneous syringe 6 mg05 ml


UBRELVY ORAL TABLET 100 MG 50 MG


VYEPTI INTRAVENOUS SOLUTION 100 MGML


AntimycobacterialsAntimycobacterialsCAPASTAT INJECTION RECON SOLN 1 GRAM

4

dapsone oral tablet 100 mg 25 mg 2

ethambutol oral tablet 100 mg 2

ethambutol oral tablet 400 mg (Myambutol) 2

isoniazid oral solution 50 mg5 ml 2

isoniazid oral tablet 100 mg 300 mg 1 GC

PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM

4

PRETOMANID ORAL TABLET 200 MG


PRIFTIN ORAL TABLET 150 MG

4

pyrazinamide oral tablet 500 mg 2

rifabutin oral capsule 150 mg (Mycobutin) 2


49


rifampin intravenous recon soln 600 mg

(Rifadin) 2

rifampin oral capsule 150 mg 300 mg

(Rifadin) 2

SIRTURO ORAL TABLET 100 MG 20 MG

5 PA NM NDS

TRECATOR ORAL TABLET 250 MG

4

Antinausea AgentsAntinausea AgentsAKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN 235-025 MG

4

AKYNZEO (FOSNETUPITANT) INTRAVENOUS SOLUTION 235 MG-025 MG 20 ML

4

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG

4 PA BvD

aprepitant oral capsule 125 mg 2 PA BvD QL (2 per 28 days)

aprepitant oral capsule 40 mg (Emend) 2 PA BvD QL (1 per 28 days)


aprepitant oral capsuledose pack125 mg (1)- 80 mg (2)

(Emend) 2 PA BvD QL (6 per 28 days)

CINVANTI INTRAVENOUS EMULSION 72 MGML


compro rectal suppository 25 mg 2

dimenhydrinate injection solution 50 mgml

2

dronabinol oral capsule 10 mg 25 mg 5 mg

(Marinol) 2 PA QL (60 per 30 days)

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)

4 PA BvD QL (6 per 28 days)

fosaprepitant intravenous recon soln150 mg

(Emend (fosaprepitant))


granisetron (pf) intravenous solution 100 mcgml

2


50


granisetron hcl intravenous solution1 mgml 1 mgml (1 ml)

2

granisetron hcl oral tablet 1 mg 2 PA BvD

meclizine oral tablet 125 mg 2

meclizine oral tablet 25 mg (Dramamine Less Drowsy)

2

ondansetron hcl (pf) injection solution 4 mg2 ml

1 GC

ondansetron hcl (pf) injection syringe 4 mg2 ml

1 GC

ondansetron hcl intravenous solution2 mgml

2

ondansetron hcl oral tablet 24 mg 8 mg

2 PA BvD

ondansetron hcl oral tablet 4 mg (Zofran) 2 PA BvD

ondansetron oral tabletdisintegrating 4 mg 8 mg

2 PA BvD

phenadoz rectal suppository 125 mg 25 mg

2

prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml

2

prochlorperazine maleate oral tablet10 mg 5 mg

(Compazine) 1 GC

prochlorperazine rectal suppository25 mg

(Compro) 2

promethazine injection solution 25 mgml 50 mgml

(Phenergan) 2

promethazine oral tablet 125 mg 25 mg 50 mg

1 GC

promethazine rectal suppository125 mg 50 mg

(Promethegan) 2

promethazine rectal suppository 25 mg

(Phenadoz) 2

promethegan rectal suppository 125 mg 25 mg 50 mg

2

scopolamine base transdermal patch 3 day 1 mg over 3 days

(Transderm-Scop) 2 QL (10 per 30 days)

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS



51


Antiparasite AgentsAntiparasite Agentsalbendazole oral tablet 200 mg (Albenza) 5 NM NDS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG5 ML

5 NM NDS

ALINIA ORAL TABLET 500 MG

5 NM NDS

atovaquone oral suspension 750 mg5 ml

(Mepron) 5 NM NDS

atovaquone-proguanil oral tablet250-100 mg

(Malarone) 2


(Malarone Pediatric) 2

chloroquine phosphate oral tablet250 mg 500 mg

2

COARTEM ORAL TABLET 20-120 MG

4

hydroxychloroquine oral tablet 200 mg

(Plaquenil) 2

IMPAVIDO ORAL CAPSULE 50 MG


ivermectin oral tablet 3 mg (Stromectol) 2

KRINTAFEL ORAL TABLET 150 MG

4

mefloquine oral tablet 250 mg 2

paromomycin oral capsule 250 mg 2

pentamidine inhalation recon soln300 mg

(Nebupent) 2 PA BvD

pentamidine injection recon soln 300 mg

(Pentam) 2

PRIMAQUINE ORAL TABLET 263 MG

2

pyrimethamine oral tablet 25 mg (Daraprim) 5 PA NM NDS

Antiparkinsonian AgentsAntiparkinsonian Agentsamantadine hcl oral capsule 100 mg 2

amantadine hcl oral solution 50 mg5 ml

2


52


APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML


benztropine injection solution 1 mgml

(Cogentin) 2

benztropine oral tablet 05 mg 1 mg 2 mg

2

bromocriptine oral capsule 5 mg (Parlodel) 2

bromocriptine oral tablet 25 mg (Parlodel) 2

cabergoline oral tablet 05 mg 2

carbidopa-levodopa oral tablet 10-100 mg 25-100 mg 25-250 mg

(Sinemet) 2

carbidopa-levodopa oral tablet extended release 25-100 mg 50-200 mg

2

carbidopa-levodopa-entacapone oral tablet 125-50-200 mg

(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4

entacapone oral tablet 200 mg (Comtan) 2

GOCOVRI ORAL CAPSULEEXTENDED RELEASE 24HR 137 MG




INBRIJA 42 MG INHALATION CAP 42 MG


INBRIJA INHALATION CAPSULE WINHALATION DEVICE 42 MG


KYNMOBI SUBLINGUAL FILM 10 MG 15 MG 20 MG 25 MG 30 MG



53


KYNMOBI SUBLINGUAL FILM 10-15-20-25-30 MG

5 PA NM NDS

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG24 HOUR 2 MG24 HOUR 3 MG24 HOUR 4 MG24 HOUR 6 MG24 HOUR 8 MG24 HOUR


OSMOLEX ER ORAL TABLET IR - ER BIPHASIC 24HR 129 MG 193 MG 258 MG


OSMOLEX ER ORAL TABLET IR - ER BIPHASIC 24HR 322 MGDAY(129 MG X1-193MG X1)


pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1 GC

rasagiline oral tablet 05 mg 1 mg (Azilect) 2

ropinirole oral tablet 025 mg 3 mg 5 mg

(Requip) 2

ropinirole oral tablet 05 mg 1 mg 2 mg 4 mg

2

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

trihexyphenidyl oral elixir 04 mgml

2

trihexyphenidyl oral tablet 2 mg 5 mg

1 GC

XADAGO ORAL TABLET 100 MG 50 MG


Antipsychotic AgentsAntipsychotic AgentsABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 300 MG 400 MG


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 300 MG 400 MG



54


aripiprazole oral solution 1 mgml 5 NM NDS QL (900 per 30 days)

aripiprazole oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg

(Abilify) 2 QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 2 QL (60 per 30 days)

aripiprazole oral tabletdisintegrating 10 mg




ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML


ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML








CAPLYTA ORAL CAPSULE 42 MG


chlorpromazine injection solution 25 mgml

2

chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg

2

clozapine oral tablet 100 mg (Clozaril) 2 QL (270 per 30 days)


clozapine oral tablet 25 mg 50 mg (Clozaril) 2 QL (90 per 30 days)

clozapine oral tabletdisintegrating100 mg 125 mg 25 mg



55


clozapine oral tabletdisintegrating150 mg




FANAPT ORAL TABLET 1 MG 2 MG 4 MG


FANAPT ORAL TABLET 10 MG 12 MG 6 MG 8 MG


FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

4 ST

fluphenazine decanoate injection solution 25 mgml

2

fluphenazine hcl injection solution25 mgml

2

fluphenazine hcl oral concentrate 5 mgml

2

fluphenazine hcl oral elixir 25 mg5 ml

2

fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg

2

haloperidol decanoate intramuscular solution 100 mgml

(Haldol Decanoate) 2

haloperidol decanoate intramuscular solution 100 mgml (1 ml) 50 mgml(1ml)

2



haloperidol lactate injection solution5 mgml

(Haldol) 2

haloperidol lactate intramuscular syringe 5 mgml

2

haloperidol lactate oral concentrate2 mgml

2

haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg

2

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML



56


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MGML








INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG0875 ML








LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG


LATUDA ORAL TABLET 80 MG


loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg

2

molindone oral tablet 10 mg 2 QL (240 per 30 days)



NUPLAZID ORAL CAPSULE 34 MG


NUPLAZID ORAL TABLET 10 MG


olanzapine intramuscular recon soln10 mg

(Zyprexa) 2 QL (30 per 30 days)

olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg



57


olanzapine oral tabletdisintegrating10 mg 15 mg 20 mg 5 mg

(Zyprexa Zydis) 2 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 15 mg 3 mg

(Invega) 2 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg



(Invega) 5 NM NDS QL (30 per 30 days)

perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg

2

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSIONEXTEND REL SYR KIT 120 MG 90 MG


pimozide oral tablet 1 mg 2 mg 2

quetiapine oral tablet 100 mg 200 mg 25 mg 300 mg 400 mg 50 mg

(Seroquel) 2 QL (90 per 30 days)

REXULTI ORAL TABLET 025 MG




REXULTI ORAL TABLET 1 MG 2 MG 3 MG 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML




risperidone oral solution 1 mgml (Risperdal) 2 QL (480 per 30 days)

risperidone oral tablet 025 mg 1 GC QL (60 per 30 days)

risperidone oral tablet 05 mg 1 mg 2 mg 3 mg 4 mg

(Risperdal) 1 GC QL (60 per 30 days)

risperidone oral tabletdisintegrating025 mg 05 mg 1 mg 2 mg



58


risperidone oral tabletdisintegrating3 mg 4 mg


SAPHRIS SUBLINGUAL TABLET 10 MG 25 MG 5 MG


SECUADO TRANSDERMAL PATCH 24 HOUR 38 MG24 HOUR 57 MG24 HOUR 76 MG24 HOUR


thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg

2

trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg

2

VERSACLOZ ORAL SUSPENSION 50 MGML


VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG


VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)

4 ST

ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg

(Geodon) 2 QL (60 per 30 days)

ziprasidone mesylate intramuscular recon soln 20 mgml (final conc)


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG






Antivirals (Systemic)Antiretroviralsabacavir oral solution 20 mgml (Ziagen) 2

abacavir oral tablet 300 mg (Ziagen) 2


59


abacavir-lamivudine oral tablet 600-300 mg

(Epzicom) 2

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) 5 NM NDS

APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MGML

5 NM NDS

APTIVUS ORAL CAPSULE 250 MG

5 NM NDS

atazanavir oral capsule 150 mg 200 mg 300 mg

(Reyataz) 5 NM NDS

ATRIPLA ORAL TABLET 600-200-300 MG

5 NM NDS

BIKTARVY ORAL TABLET 50-200-25 MG

5 NM NDS

CIMDUO ORAL TABLET 300-300 MG

5 NM NDS

COMPLERA ORAL TABLET 200-25-300 MG

5 NM NDS

CRIXIVAN ORAL CAPSULE 200 MG 400 MG

4

DELSTRIGO ORAL TABLET 100-300-300 MG

5 NM NDS

DESCOVY ORAL TABLET 200-25 MG

5 NM NDS

didanosine oral capsuledelayed release(drec) 125 mg 200 mg 250 mg 400 mg

2

DOVATO ORAL TABLET 50-300 MG

5 NM NDS

EDURANT ORAL TABLET 25 MG

5 NM NDS

efavirenz oral capsule 200 mg (Sustiva) 5 NM NDS

efavirenz oral capsule 50 mg (Sustiva) 2

efavirenz oral tablet 600 mg (Sustiva) 5 NM NDS

efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg

(Atripla) 5 NM NDS

efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg

(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS

emtricitabine oral capsule 200 mg (Emtriva) 2


60


emtricitabine-tenofovir (tdf) oral tablet 200-300 mg

(Truvada) 5 NM NDS

EMTRIVA ORAL CAPSULE 200 MG

4

EMTRIVA ORAL SOLUTION 10 MGML

4

EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)

4

EVOTAZ ORAL TABLET 300-150 MG

5 NM NDS

fosamprenavir oral tablet 700 mg (Lexiva) 5 NM NDS

FUZEON SUBCUTANEOUS RECON SOLN 90 MG

5 NM NDS

GENVOYA ORAL TABLET 150-150-200-10 MG

5 NM NDS

INTELENCE ORAL TABLET 100 MG 200 MG

5 NM NDS

INTELENCE ORAL TABLET 25 MG

4

INVIRASE ORAL TABLET 500 MG

5 NM NDS

ISENTRESS HD ORAL TABLET 600 MG

5 NM NDS

ISENTRESS ORAL POWDER IN PACKET 100 MG

4

ISENTRESS ORAL TABLET 400 MG

5 NM NDS

ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG

4

JULUCA ORAL TABLET 50-25 MG

5 NM NDS

KALETRA ORAL TABLET 100-25 MG

4


5 NM NDS

lamivudine oral solution 10 mgml (Epivir) 2

lamivudine oral tablet 100 mg (Epivir HBV) 2

lamivudine oral tablet 150 mg 300 mg

(Epivir) 2


61


lamivudine-zidovudine oral tablet150-300 mg

(Combivir) 2

LEXIVA ORAL SUSPENSION 50 MGML

4

lopinavir-ritonavir oral solution 400-100 mg5 ml

(Kaletra) 2

nevirapine oral suspension 50 mg5 ml

(Viramune) 2

nevirapine oral tablet 200 mg (Viramune) 2

nevirapine oral tablet extended release 24 hr 100 mg

2


(Viramune XR) 2

NORVIR ORAL POWDER IN PACKET 100 MG

4

NORVIR ORAL SOLUTION 80 MGML

4

ODEFSEY ORAL TABLET 200-25-25 MG

5 NM NDS

PIFELTRO ORAL TABLET 100 MG

5 NM NDS

PREZCOBIX ORAL TABLET 800-150 MG-MG

5 NM NDS

PREZISTA ORAL SUSPENSION 100 MGML

5 NM NDS

PREZISTA ORAL TABLET 150 MG 600 MG 800 MG

5 NM NDS

PREZISTA ORAL TABLET 75 MG

4

RESCRIPTOR ORAL TABLET 200 MG

4

RESCRIPTOR ORAL TABLET DISPERSIBLE 100 MG

4

RETROVIR INTRAVENOUS SOLUTION 10 MGML

4

REYATAZ ORAL POWDER IN PACKET 50 MG

5 NM NDS

ritonavir oral tablet 100 mg (Norvir) 2

RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG

5 NM NDS


62


SELZENTRY ORAL SOLUTION 20 MGML

4

SELZENTRY ORAL TABLET 150 MG 300 MG 75 MG

5 NM NDS

SELZENTRY ORAL TABLET 25 MG

4

stavudine oral capsule 15 mg 20 mg 30 mg 40 mg

2

STRIBILD ORAL TABLET 150-150-200-300 MG

5 NM NDS

SYMFI LO ORAL TABLET 400-300-300 MG

5 NM NDS

SYMFI ORAL TABLET 600-300-300 MG

5 NM NDS

SYMTUZA ORAL TABLET 800-150-200-10 MG

5 NM NDS

TEMIXYS ORAL TABLET 300-300 MG

5 NM NDS

tenofovir disoproxil fumarate oral tablet 300 mg

(Viread) 2

TIVICAY ORAL TABLET 10 MG

4

TIVICAY ORAL TABLET 25 MG 50 MG

5 NM NDS

TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG

4

TRIUMEQ ORAL TABLET 600-50-300 MG

5 NM NDS

TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)

5 NM NDS

TRUVADA ORAL TABLET 100-150 MG 133-200 MG 167-250 MG 200-300 MG

5 NM NDS

VEMLIDY ORAL TABLET 25 MG


VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MGML (FINAL)

4


63


VIDEX EC ORAL CAPSULEDELAYED RELEASE(DREC) 125 MG

4

VIRACEPT ORAL TABLET 250 MG 625 MG

5 NM NDS

VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)

5 NM NDS

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

5 NM NDS

zidovudine oral capsule 100 mg (Retrovir) 2

zidovudine oral syrup 10 mgml (Retrovir) 2

zidovudine oral tablet 300 mg 2Antivirals Miscellaneousfoscarnet intravenous solution 24 mgml

(Foscavir) 2 PA BvD

oseltamivir oral capsule 30 mg (Tamiflu) 2 QL (84 per 180 days)



oseltamivir oral suspension for reconstitution 6 mgml

(Tamiflu) 2 QL (540 per 180 days)

PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML




PREVYMIS ORAL TABLET 240 MG 480 MG


RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION


rimantadine oral tablet 100 mg (Flumadine) 2

SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML

5 PA NM NDS

XOFLUZA ORAL TABLET 20 MG 40 MG


Hcv AntiviralsEPCLUSA ORAL TABLET 200-50 MG 400-100 MG


HARVONI ORAL PELLETS IN PACKET 3375-150 MG



64




HARVONI ORAL TABLET 45-200 MG 90-400 MG


ledipasvir-sofosbuvir oral tablet 90-400 mg

(Harvoni) 5 PA NM NDS QL (28 per 28 days)

MAVYRET ORAL TABLET 100-40 MG


sofosbuvir-velpatasvir oral tablet400-100 mg

(Epclusa) 5 PA NM NDS QL (28 per 28 days)

SOVALDI ORAL PELLETS IN PACKET 150 MG




SOVALDI ORAL TABLET 200 MG 400 MG


TECHNIVIE ORAL TABLET 125-75-50 MG


VIEKIRA PAK ORAL TABLETSDOSE PACK 125 MG-75 MG -50 MG250 MG

5 PA NM NDS

VOSEVI ORAL TABLET 400-100-100 MG


ZEPATIER ORAL TABLET 50-100 MG


InterferonsINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)

5 PA NSO NM NDS

INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML

5 PA NSO NM NDS

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG05 ML

5 NM NDS

PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML

5 NM NDS


65


PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML

5 NM NDS

PEGINTRON SUBCUTANEOUS KIT 50 MCG05 ML

5 NM NDS

SYLATRON SUBCUTANEOUS KIT 200 MCG 300 MCG 600 MCG

5 PA NSO NM NDS

Nucleosides And Nucleotidesacyclovir oral capsule 200 mg 2

acyclovir oral suspension 200 mg5 ml

(Zovirax) 2

acyclovir oral tablet 400 mg 800 mg 2

acyclovir sodium intravenous recon soln 1000 mg 500 mg

2 PA BvD

acyclovir sodium intravenous solution 50 mgml

2 PA BvD

adefovir oral tablet 10 mg (Hepsera) 5 NM NDS

entecavir oral tablet 05 mg 1 mg (Baraclude) 2

famciclovir oral tablet 125 mg 250 mg 500 mg

2

ganciclovir sodium intravenous recon soln 500 mg

(Cytovene) 2 PA BvD

ganciclovir sodium intravenous solution 50 mgml

2 PA BvD

ribasphere oral capsule 200 mg 2

ribasphere oral tablet 600 mg 5 NM NDS

ribavirin inhalation recon soln 6 gram

(Virazole) 5 PA BvD NM NDS

ribavirin oral capsule 200 mg 2

ribavirin oral tablet 200 mg 2

valacyclovir oral tablet 1 gram 500 mg

(Valtrex) 2

valganciclovir oral tablet 450 mg (Valcyte) 5 NM NDS

Blood ProductsModifiersVolume ExpandersAnticoagulantsBEVYXXA ORAL CAPSULE 40 MG 80 MG



66


ELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)

3

ELIQUIS ORAL TABLET 25 MG 5 MG


enoxaparin subcutaneous solution300 mg3 ml

(Lovenox) 2

enoxaparin subcutaneous syringe100 mgml 120 mg08 ml 150 mgml 30 mg03 ml 40 mg04 ml 60 mg06 ml 80 mg08 ml

(Lovenox) 2

fondaparinux subcutaneous syringe10 mg08 ml 5 mg04 ml 75 mg06 ml

(Arixtra) 5 NM NDS

fondaparinux subcutaneous syringe25 mg05 ml

(Arixtra) 2

heparin (porcine) injection cartridge5000 unitml (1 ml)

2

heparin (porcine) injection solution1000 unitml 10000 unitml 20000 unitml 5000 unitml

2

heparin (porcine) injection syringe5000 unitml

2

heparin porcine (pf) injection solution 1000 unitml

2

heparin porcine (pf) injection syringe 5000 unit05 ml

2

jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

1 GC

PRADAXA ORAL CAPSULE 110 MG 150 MG 75 MG


warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Jantoven) 1 GC

XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)

3

XARELTO ORAL TABLET 10 MG 20 MG



67




Blood Formation ModifiersCINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)


DOPTELET (10 TAB PACK) ORAL TABLET 20 MG






EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 3000 UNITML 4000 UNITML


EPOGEN INJECTION SOLUTION 20000 UNITML


FULPHILA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML

5 PA NM NDS

GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT




LEUKINE INJECTION RECON SOLN 250 MCG

5 NM NDS

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)

5 NM NDS

MULPLETA ORAL TABLET 3 MG


NEULASTA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS


68


NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16 ML

5 PA NM NDS

NEUPOGEN INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML

5 NM NDS

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

PROCRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 3000 UNITML 4000 UNITML


PROCRIT INJECTION SOLUTION 20000 UNITML




PROMACTA ORAL POWDER IN PACKET 125 MG




PROMACTA ORAL TABLET 125 MG 50 MG


PROMACTA ORAL TABLET 25 MG




RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 3000 UNITML 4000 UNITML


RETACRIT INJECTION SOLUTION 40000 UNITML


UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS


69


ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

5 NM NDS

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

Hematologic Agents MiscellaneousADAKVEO INTRAVENOUS SOLUTION 10 MGML

5 PA NM NDS

anagrelide oral capsule 05 mg (Agrylin) 2

anagrelide oral capsule 1 mg 2

GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML

5 PA NM NDS

protamine intravenous solution 10 mgml

2

SIKLOS ORAL TABLET 1000 MG 100 MG

4 PA

TAVALISSE ORAL TABLET 100 MG 150 MG


tranexamic acid intravenous solution1000 mg10 ml (100 mgml)

(Cyklokapron) 2

tranexamic acid oral tablet 650 mg (Lysteda) 2 QL (30 per 30 days)Platelet-Aggregation Inhibitorsaspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg

(Aggrenox) 2 QL (60 per 30 days)

BRILINTA ORAL TABLET 60 MG 90 MG

3

cilostazol oral tablet 100 mg 50 mg 2

clopidogrel oral tablet 75 mg (Plavix) 1 GC

dipyridamole oral tablet 25 mg 50 mg 75 mg

2

pentoxifylline oral tablet extended release 400 mg

2

prasugrel oral tablet 10 mg 5 mg (Effient) 2 QL (30 per 30 days)

Caloric AgentsCaloric AgentsAMINOSYN 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD


70


AMINOSYN 7 WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

AMINOSYN 85 INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN 85 -ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN II 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD

AMINOSYN II 85 -ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 85

4 PA BvD

AMINOSYN M 35 INTRAVENOUS PARENTERAL SOLUTION 35

4 PA BvD

AMINOSYN-HBC 7 INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD


71


AMINOSYN-PF 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

AMINOSYN-PF 7 (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

AMINOSYN-RF 52 INTRAVENOUS PARENTERAL SOLUTION 52

4 PA BvD

CLINIMIX 5D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 5D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 425D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 425D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 425-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 5-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX E 275D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 275

4 PA BvD

CLINIMIX E 275D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 275

4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD

CLINIMIX E 5D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD


4 PA BvD


4 PA BvD

CLINOLIPID INTRAVENOUS EMULSION 20

4 PA BvD

dextrose 10 in water (d10w) intravenous parenteral solution 10

4 PA BvD

dextrose 25 in water (d25w) intravenous syringe

4 PA BvD

dextrose 30 in water (d30w) intravenous parenteral solution

4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73


FREAMINE HBC 69 INTRAVENOUS PARENTERAL SOLUTION 69

4 PA BvD

FREAMINE III 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

HEPATAMINE 8 INTRAVENOUS PARENTERAL SOLUTION 8

4 PA BvD

INTRALIPID INTRAVENOUS EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS EMULSION 331-98-39

4 PA BvD

NEPHRAMINE 54 INTRAVENOUS PARENTERAL SOLUTION 54

4 PA BvD

NUTRILIPID INTRAVENOUS EMULSION 20

4 PA BvD

PERIKABIVEN INTRAVENOUS EMULSION 236-68-35

4 PA BvD

PROCALAMINE 3 INTRAVENOUS PARENTERAL SOLUTION 3

4 PA BvD

PROSOL 20 INTRAVENOUS PARENTERAL SOLUTION

4 PA BvD

smoflipid intravenous emulsion 20 4 PA BvD

TRAVASOL 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

TROPHAMINE 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD


4 PA BvD


74


Cardiovascular AgentsAlpha-Adrenergic Agentsclonidine hcl oral tablet 01 mg 02 mg 03 mg

(Catapres) 1 GC

clonidine transdermal patch weekly01 mg24 hr

(Catapres-TTS-1) 2 QL (4 per 28 days)





doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg

(Cardura) 2

guanfacine oral tablet 1 mg 2 mg 1 GC

midodrine oral tablet 10 mg 25 mg 5 mg

2

NORTHERA ORAL CAPSULE 100 MG 200 MG 300 MG


phenylephrine hcl injection solution10 mgml

(Vazculep) 2

prazosin oral capsule 1 mg 2 mg 5 mg

(Minipress) 2

Angiotensin Ii Receptor AntagonistsEDARBI ORAL TABLET 40 MG 80 MG

3

EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG

3

ENTRESTO ORAL TABLET 24-26 MG 49-51 MG 97-103 MG


irbesartan oral tablet 150 mg 300 mg 75 mg

(Avapro) 6 GC

irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg

(Avalide) 2

losartan oral tablet 100 mg 25 mg 50 mg

(Cozaar) 6 GC

losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 6 GC

olmesartan oral tablet 20 mg 40 mg 5 mg

(Benicar) 2


75


olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

telmisartan oral tablet 20 mg 40 mg 80 mg

(Micardis) 2

valsartan oral tablet 160 mg 320 mg 40 mg 80 mg

(Diovan) 2

valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg

(Diovan HCT) 2

Angiotensin-Converting Enzyme Inhibitorsbenazepril oral tablet 10 mg 20 mg 40 mg

(Lotensin) 6 GC

benazepril oral tablet 5 mg 6 GC

captopril oral tablet 100 mg 125 mg 25 mg 50 mg

2

enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg

(Vasotec) 2

enalaprilat intravenous solution 125 mgml

2

enalapril-hydrochlorothiazide oral tablet 10-25 mg

(Vaseretic) 6 GC


6 GC

fosinopril oral tablet 10 mg 20 mg 40 mg

6 GC

lisinopril oral tablet 10 mg 20 mg (Prinivil) 6 GC

lisinopril oral tablet 25 mg 30 mg 40 mg 5 mg

(Zestril) 6 GC

lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 6 GC

perindopril erbumine oral tablet 2 mg 4 mg 8 mg

2

quinapril oral tablet 10 mg 20 mg 40 mg 5 mg

(Accupril) 6 GC

ramipril oral capsule 125 mg 10 mg 25 mg 5 mg

(Altace) 6 GC

trandolapril oral tablet 1 mg 2 mg 4 mg

2


76


Antiarrhythmic Agentsamiodarone oral tablet 200 mg (Pacerone) 1 GC

amiodarone oral tablet 400 mg (Pacerone) 2

disopyramide phosphate oral capsule100 mg 150 mg

(Norpace) 2

dofetilide oral capsule 125 mcg 250 mcg 500 mcg

(Tikosyn) 2

flecainide oral tablet 100 mg 150 mg 50 mg

2

lidocaine (pf) intravenous syringe100 mg5 ml (2 ) 50 mg5 ml (1 )

1 GC

mexiletine oral capsule 150 mg 200 mg 250 mg

2

MULTAQ ORAL TABLET 400 MG

3

pacerone oral tablet 200 mg 1 GC

pacerone oral tablet 400 mg 2

procainamide injection solution 100 mgml 500 mgml

2

procainamide intravenous syringe100 mgml

2

propafenone oral tablet 150 mg 225 mg 300 mg

2

quinidine sulfate oral tablet 200 mg 300 mg

2

Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg 400 mg

2

atenolol oral tablet 100 mg 25 mg 50 mg

(Tenormin) 1 GC

atenolol-chlorthalidone oral tablet100-25 mg

(Tenoretic 100) 2


(Tenoretic 50) 2

betaxolol oral tablet 10 mg 20 mg 2

bisoprolol fumarate oral tablet 10 mg 5 mg

2

bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg

(Ziac) 1 GC


77


BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG

3

BYVALSON ORAL TABLET 5-80 MG

3

carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg

(Coreg) 1 GC

labetalol intravenous solution 5 mgml

2

labetalol intravenous syringe 20 mg4 ml (5 mgml)

2

labetalol oral tablet 100 mg 200 mg 300 mg

2

metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg

(Toprol XL) 2

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg

2

metoprolol ta-hydrochlorothiaz oral tablet 50-25 mg

(Lopressor HCT) 2

metoprolol tartrate intravenous solution 5 mg5 ml

(Lopressor) 2

metoprolol tartrate intravenous syringe 5 mg5 ml

2

metoprolol tartrate oral tablet 100 mg 50 mg

(Lopressor) 1 GC

metoprolol tartrate oral tablet 25 mg

1 GC

propranolol intravenous solution 1 mgml

2

propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)

2

propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg

2

propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg

2

sorine oral tablet 120 mg 160 mg 240 mg 80 mg

2


78


sotalol af oral tablet 120 mg 160 mg 80 mg

2

sotalol oral tablet 120 mg 160 mg 240 mg 80 mg

(Sorine) 2

timolol maleate oral tablet 10 mg 20 mg 5 mg

2

Calcium-Channel Blocking Agentscartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

2

diltiazem hcl intravenous solution 5 mgml

2

diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg

2

diltiazem hcl oral capsuleextended release 24 hr 420 mg

(Tiadylt ER) 2

diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

(Cartia XT) 2

diltiazem hcl oral tablet 120 mg 30 mg 60 mg

(Cardizem) 2

diltiazem hcl oral tablet 90 mg 2

dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg

2

taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg

2

tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg

2

verapamil intravenous syringe 25 mgml

2

verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg

(Verelan PM) 2

verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg

(Verelan) 2

verapamil oral capsuleext rel pellets 24 hr 360 mg

(Verelan) 4

verapamil oral tablet 120 mg 40 mg 80 mg

1 GC


79


verapamil oral tablet extended release 120 mg 180 mg 240 mg

(Calan SR) 1 GC

Cardiovascular Agents MiscellaneousCORLANOR ORAL SOLUTION 5 MG5 ML


CORLANOR ORAL TABLET 5 MG 75 MG


DEMSER ORAL CAPSULE 250 MG

5 NM NDS

digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

2

digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

2

digoxin injection syringe 250 mcgml (025 mgml)

2

DIGOXIN ORAL SOLUTION 50 MCGML (005 MGML)

4

digoxin oral tablet 125 mcg (0125 mg)

(Digitek) 2


(Digitek) 2

epinephrine injection auto-injector015 mg03 ml

(EpiPen Jr) 2 QL (4 per 30 days)


(Auvi-Q) 2 QL (4 per 30 days)

epinephrine injection solution 1 mgml

(Adrenalin) 1 GC

hydralazine injection solution 20 mgml

2

hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

icatibant subcutaneous syringe 30 mg3 ml

(Firazyr) 5 PA NM NDS QL (18 per 30 days)

metyrosine oral capsule 250 mg (Demser) 5 NM NDS

ranolazine oral tablet extended release 12 hr 1000 mg 500 mg

(Ranexa) 2

SYMJEPI INJECTION SYRINGE 015 MG03 ML 03 MG03 ML



80


VYNDAMAX ORAL CAPSULE 61 MG


VYNDAQEL ORAL CAPSULE 20 MG


Dihydropyridinesafeditab cr oral tablet extended release 30 mg

2

amlodipine oral tablet 10 mg 25 mg 5 mg

(Norvasc) 1 GC

amlodipine-benazepril oral capsule10-20 mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

amlodipine-benazepril oral capsule25-10 mg

2

amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

nicardipine oral capsule 20 mg 30 mg

2

nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

nifedipine oral tablet extended release 30 mg 60 mg 90 mg

(Adalat CC) 2

Diureticsamiloride oral tablet 5 mg 2

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2

bumetanide injection solution 025 mgml

2

bumetanide oral tablet 05 mg 1 mg 2 mg

2

chlorothiazide oral tablet 250 mg 500 mg

2

chlorothiazide sodium intravenous recon soln 500 mg

(Diuril IV) 2

chlorthalidone oral tablet 25 mg 50 mg

2

furosemide injection solution 10 mgml

2

furosemide injection syringe 10 mgml

2


81


furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)

1 GC

furosemide oral tablet 20 mg 40 mg 80 mg

(Lasix) 1 GC

hydrochlorothiazide oral capsule125 mg

1 GC

hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg

1 GC

indapamide oral tablet 125 mg 25 mg

1 GC

JYNARQUE ORAL TABLET 15 MG 30 MG


JYNARQUE ORAL TABLETS SEQUENTIAL 15 MG (AM) 15 MG (PM) 30 MG (AM) 15 MG (PM) 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)


methyclothiazide oral tablet 5 mg 2

spironolactone oral tablet 100 mg 25 mg 50 mg

(Aldactone) 1 GC

torsemide oral tablet 10 mg 100 mg 20 mg 5 mg

1 GC

triamterene-hydrochlorothiazid oral capsule 375-25 mg

(Dyazide) 1 GC


1 GC

triamterene-hydrochlorothiazid oral tablet 375-25 mg

(Maxzide-25mg) 1 GC


(Maxzide) 1 GC

Dyslipidemicsatorvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Lipitor) 6 GC

cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) 2

cholestyramine light oral powder 4 gram

2

cholestyramine light packet 4 gram 2

colesevelam oral tablet 625 mg (WelChol) 2

colestipol oral packet 5 gram (Colestid) 2


82


colestipol oral tablet 1 gram (Colestid) 2

ezetimibe oral tablet 10 mg (Zetia) 2 QL (30 per 30 days)

fenofibrate micronized oral capsule134 mg 200 mg 67 mg

2

fenofibrate nanocrystallized oral tablet 145 mg 48 mg

(Tricor) 2

fenofibrate oral tablet 160 mg 54 mg

2

gemfibrozil oral tablet 600 mg (Lopid) 1 GC

JUXTAPID ORAL CAPSULE 10 MG 30 MG 40 MG 60 MG


JUXTAPID ORAL CAPSULE 20 MG




LIVALO ORAL TABLET 1 MG 2 MG 4 MG


lovastatin oral tablet 10 mg 20 mg 40 mg

6 GC

NEXLETOL ORAL TABLET 180 MG


NEXLIZET ORAL TABLET 180-10 MG


niacin oral tablet 500 mg (Niacor) 2

niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg

(Niaspan Extended-Release)

2

niacor oral tablet 500 mg 2

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza) 2 QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MGML 75 MGML


pravastatin oral tablet 10 mg 80 mg 6 GC

pravastatin oral tablet 20 mg 40 mg (Pravachol) 6 GC

prevalite oral powder in packet 4 gram

2

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML



83


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML


rosuvastatin oral tablet 10 mg 20 mg 40 mg 5 mg

(Crestor) 2 QL (30 per 30 days)

simvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Zocor) 6 GC QL (30 per 30 days)

simvastatin oral tablet 5 mg 6 GC QL (30 per 30 days)

VASCEPA ORAL CAPSULE 05 GRAM




WELCHOL ORAL POWDER IN PACKET 375 GRAM

2

WELCHOL ORAL TABLET 625 MG

2

Renin-Angiotensin-Aldosterone System Inhibitorsaliskiren oral tablet 150 mg 300 mg (Tekturna) 2

eplerenone oral tablet 25 mg 50 mg (Inspra) 2

TEKTURNA HCT ORAL TABLET 150-125 MG 150-25 MG 300-125 MG 300-25 MG

3 ST

VasodilatorsBIDIL ORAL TABLET 20-375 MG

3

isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg

2

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 2

isosorbide dinitrate oral tablet extended release 40 mg

(ISOCHRON) 2

isosorbide mononitrate oral tablet10 mg 20 mg

2

isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg

1 GC


84


minitran transdermal patch 24 hour01 mghr 02 mghr 04 mghr 06 mghr

2

minoxidil oral tablet 10 mg 25 mg 2

nitroglycerin intravenous solution 50 mg10 ml (5 mgml)

2

nitroglycerin sublingual tablet 03 mg 04 mg 06 mg

(Nitrostat) 2

nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr

(Minitran) 2

Central Nervous System AgentsCentral Nervous System Agentsatomoxetine oral capsule 10 mg 18 mg 25 mg 40 mg

(Strattera) 2 QL (60 per 30 days)

atomoxetine oral capsule 100 mg 60 mg 80 mg


AUBAGIO ORAL TABLET 14 MG 7 MG


AUSTEDO ORAL TABLET 12 MG 9 MG


AUSTEDO ORAL TABLET 6 MG


AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG


AVONEX INTRAMUSCULAR PEN INJECTOR 30 MCG05 ML


AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML


BETASERON SUBCUTANEOUS KIT 03 MG


caffeine citrate intravenous solution60 mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

caffeine citrate oral solution 60 mg3 ml (20 mgml)

2

COPAXONE SUBCUTANEOUS SYRINGE 20 MGML



85




dalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra) 5 PA NM NDS QL (60 per 30 days)

dexmethylphenidate oral tablet 10 mg 25 mg 5 mg

(Focalin) 2 QL (60 per 30 days)

dextroamphetamine oral tablet 10 mg 5 mg

(Zenzedi) 2 QL (180 per 30 days)

dextroamphetamine-amphetamine oral capsuleextended release 24hr10 mg 15 mg 5 mg

(Adderall XR) 2 QL (30 per 30 days)



dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg

(Adderall) 2 QL (60 per 30 days)

dimethyl fumarate oral capsuledelayed release(drec) 120 mg

(Tecfidera) 5 PA NM NDS QL (14 per 7 days)

dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)

(Tecfidera) 5 PA NM NDS



EXTAVIA SUBCUTANEOUS KIT 03 MG


flumazenil intravenous solution 01 mgml

2

GILENYA ORAL CAPSULE 025 MG 05 MG


glatiramer subcutaneous syringe 20 mgml

(Copaxone) 5 PA NM NDS QL (30 per 30 days)



glatopa subcutaneous syringe 20 mgml





86


guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg

(Intuniv ER) 2

INGREZZA INITIATION PACK ORAL CAPSULEDOSE PACK 40 MG (7)- 80 MG (21)

5 PA NM NDS

INGREZZA ORAL CAPSULE 40 MG 80 MG


KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 MG04 ML


LEMTRADA INTRAVENOUS SOLUTION 12 MG12 ML


lithium carbonate oral capsule 150 mg 300 mg 600 mg

1 GC

lithium carbonate oral tablet 300 mg 1 GC

lithium carbonate oral tablet extended release 300 mg

(Lithobid) 2


2

lithium citrate oral solution 8 meq5 ml

4

MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG

5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS

MAYZENT ORAL TABLET 025 MG





87


methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 40 mg 50 mg 60 mg


methylphenidate hcl oral capsule er biphasic 30-70 30 mg


methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 40 mg

(Ritalin LA) 2 QL (30 per 30 days)

methylphenidate hcl oral capsuleer biphasic 50-50 30 mg




methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml

(Methylin) 2 QL (900 per 30 days)

methylphenidate hcl oral tablet 10 mg 20 mg 5 mg

(Ritalin) 2 QL (90 per 30 days)

methylphenidate la 30 mg cap 30 mg (Ritalin LA) 2 QL (60 per 30 days)

NUEDEXTA ORAL CAPSULE 20-10 MG


OCREVUS INTRAVENOUS SOLUTION 30 MGML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML

5 PA NM NDS

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML

5 PA NM NDS

RADICAVA INTRAVENOUS PIGGYBACK 30 MG100 ML


REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG05 ML 44 MCG05 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML



88


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)

5 PA NM NDS

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 88MCG02ML-22 MCG05ML (6)

5 PA NM NDS

riluzole oral tablet 50 mg (Rilutek) 2

SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG


SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)

3

TECFIDERA ORAL CAPSULEDELAYED RELEASE(DREC) 120 MG


TECFIDERA ORAL CAPSULEDELAYED RELEASE(DREC) 120 MG (14)- 240 MG (46)

5 PA NM NDS



tetrabenazine oral tablet 125 mg 25 mg

(Xenazine) 5 PA NM NDS QL (112 per 28 days)

VUMERITY ORAL CAPSULEDELAYED RELEASE(DREC) 231 MG


ZEPOSIA ORAL CAPSULE 092 MG


ZEPOSIA STARTER KIT ORAL CAPSULEDOSE PACK 023-046-092 MG

5 PA NM NDS

ZEPOSIA STARTER PACK ORAL CAPSULEDOSE PACK 023 MG (4)- 046 MG (3)

5 PA NM NDS

ContraceptivesContraceptivesafirmelle oral tablet 01-20 mg-mcg 2


89


altavera (28) oral tablet 015-003 mg

2

alyacen 135 (28) oral tablet 1-35 mg-mcg

2

alyacen 777 (28) oral tablet050751 mg- 35 mcg

2

amethia lo oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)


amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


apri oral tablet 015-003 mg 2

aranelle (28) oral tablet 05105-35 mg-mcg

2

ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


aubra oral tablet 01-20 mg-mcg 2

aurovela 1530 (21) oral tablet 15-30 mg-mcg

2


2

aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

aurovela fe 1530 (28) oral tablet15 mg-30 mcg (21)75 mg (7)

2

aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

2

aviane oral tablet 01-20 mg-mcg 2

ayuna oral tablet 015-003 mg 2

azurette (28) oral tablet 015-002 mgx21 001 mg x 5

2

balziva (28) oral tablet 04-35 mg-mcg

2

bekyree (28) oral tablet 015-002 mgx21 001 mg x 5

2

blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


90



2

briellyn oral tablet 04-35 mg-mcg 2

camila oral tablet 035 mg 2

caziant (28) oral tablet0112515-25 mg-mcg

2

cryselle (28) oral tablet 03-30 mg-mcg

2

cyclafem 135 (28) oral tablet 1-35 mg-mcg

2

cyclafem 777 (28) oral tablet050751 mg- 35 mcg

2

cyred oral tablet 015-003 mg 2

dasetta 135 (28) oral tablet 1-35 mg-mcg

2

dasetta 777 (28) oral tablet050751 mg- 35 mcg

2

daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


deblitane oral tablet 035 mg 2

delyla (28) oral tablet 01-20 mg-mcg

2

desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5

(Azurette (28)) 2

desogestrel-ethinyl estradiol oral tablet 015-003 mg

(Apri) 2

drospirenone-ethinyl estradiol oral tablet 3-002 mg

(Jasmiel (28)) 2


(Syeda) 2

elinest oral tablet 03-30 mg-mcg 2

ELLA ORAL TABLET 30 MG 4 QL (6 per 365 days)

eluryng vaginal ring 012-0015 mg24 hr


emoquette oral tablet 015-003 mg 2

enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)

2

enskyce oral tablet 015-003 mg 2

errin oral tablet 035 mg 2

estarylla oral tablet 025-35 mg-mcg 2


91


ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg

(Kelnor 135 (28)) 2


(Kelnor 1-50) 2

etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr

(EluRyng) 2 QL (1 per 28 days)

falmina (28) oral tablet 01-20 mg-mcg

2

femynor oral tablet 025-35 mg-mcg 2

hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


2

hailey oral tablet 15-30 mg-mcg 2

heather oral tablet 035 mg 2

incassia oral tablet 035 mg 2

introvale oral tabletsdose pack3 month 015 mg-30 mcg (91)


isibloom oral tablet 015-003 mg 2

jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


jasmiel (28) oral tablet 3-002 mg 2

jencycla oral tablet 035 mg 1 GC

jolivette oral tablet 035 mg 4

juleber oral tablet 015-003 mg 2

junel 1530 (21) oral tablet 15-30 mg-mcg

2


2

junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


2

junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4)

2

kalliga oral tablet 015-003 mg 2

kariva (28) oral tablet 015-002 mgx21 001 mg x 5

2


92


kelnor 135 (28) oral tablet 1-35 mg-mcg

2

kelnor 1-50 oral tablet 1-50 mg-mcg 2

kurvelo (28) oral tablet 015-003 mg

2

l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)

(Amethia Lo) 2 QL (91 per 84 days)

l norgesteestradiol-eestrad oral tabletsdose pack3 month 015 mg-20 mcg 015 mg-25 mcg

(Fayosim) 2 QL (91 per 84 days)


(Amethia) 2 QL (91 per 84 days)

larin 1530 (21) oral tablet 15-30 mg-mcg

2


2

larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)

2


2

larissia oral tablet 01-20 mg-mcg 2

leena 28 oral tablet 05105-35 mg-mcg

4

lessina oral tablet 01-20 mg-mcg 2

levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

2

levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg

(Afirmelle) 2

levonorgestrel-ethinyl estrad oral tablet 015-003 mg

(Altavera (28)) 2

levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)

(Introvale) 2 QL (91 per 84 days)

levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

levora-28 oral tablet 015-003 mg 2


93


lillow (28) oral tablet 015-003 mg 2

lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)


loryna (28) oral tablet 3-002 mg 2

low-ogestrel (28) oral tablet 03-30 mg-mcg

2

lo-zumandimine (28) oral tablet 3-002 mg

2

lutera (28) oral tablet 01-20 mg-mcg

2

lyza oral tablet 035 mg 2

marlissa (28) oral tablet 015-003 mg

2

microgestin fe 120 (28) oral tablet1 mg-20 mcg (21)75 mg (7)

2

mili oral tablet 025-35 mg-mcg 2

mono-linyah oral tablet 025-35 mg-mcg

2

mononessa (28) oral tablet 025-35 mg-mcg

4

myzilra oral tablet 50-30 (6)75-40 (5)125-30(10)

2

necon 0535 (28) oral tablet 05-35 mg-mcg

2

nikki (28) oral tablet 3-002 mg 2

nora-be oral tablet 035 mg 4

norethindrone (contraceptive) oral tablet 035 mg

(Jencycla) 2

norethindrone ac-eth estradiol oral tablet 15-30 mg-mcg

(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2

norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7)

(Aurovela Fe 1-20 (28)) 2


(Aurovela 24 Fe) 2


(Aurovela Fe 1530 (28))

2


94


norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg

(Tri-Lo-Estarylla) 2

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-35 mcg (28)

(Tri Femynor) 2

norgestimate-ethinyl estradiol oral tablet 025-35 mg-mcg

(Estarylla) 2

norlyda oral tablet 035 mg 2

norlyroc oral tablet 035 mg 2

nortrel 0535 (28) oral tablet 05-35 mg-mcg

2

nortrel 135 (21) oral tablet 1-35 mg-mcg (21)

2


2

nortrel 777 (28) oral tablet050751 mg- 35 mcg

2

ogestrel (28) oral tablet 05-50 mg-mcg

2

orsythia oral tablet 01-20 mg-mcg 2

philith oral tablet 04-35 mg-mcg 2

pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5

2

pirmella oral tablet 050751 mg- 35 mcg 1-35 mg-mcg

2

portia 28 oral tablet 015-003 mg 2

previfem oral tablet 025-35 mg-mcg 2

reclipsen (28) oral tablet 015-003 mg

2

setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)


sharobel oral tablet 035 mg 2

simliya (28) oral tablet 015-002 mgx21 001 mg x 5

2

simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)


sprintec (28) oral tablet 025-35 mg-mcg

2

sronyx oral tablet 01-20 mg-mcg 2

syeda oral tablet 3-003 mg 2


95


tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

2

tarina fe 120 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)

2

tilia fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

2

tri femynor oral tablet0180215025 mg-35 mcg (28)

2

tri-estarylla oral tablet0180215025 mg-35 mcg (28)

2

tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

2

tri-linyah oral tablet 0180215025 mg-35 mcg (28)

2

tri-lo-estarylla oral tablet0180215025 mg-25 mcg

2

tri-lo-marzia oral tablet0180215025 mg-25 mcg

2

tri-lo-mili oral tablet 0180215025 mg-25 mcg

2

tri-lo-sprintec oral tablet0180215025 mg-25 mcg

2

tri-mili oral tablet 0180215025 mg-35 mcg (28)

2

tri-previfem (28) oral tablet0180215025 mg-35 mcg (28)

2

tri-sprintec (28) oral tablet0180215025 mg-35 mcg (28)

2

trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)

2

tri-vylibra lo oral tablet0180215025 mg-25 mcg

2

tri-vylibra oral tablet0180215025 mg-35 mcg (28)

2

tulana oral tablet 035 mg 2

velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg

2

vienva oral tablet 01-20 mg-mcg 2

viorele (28) oral tablet 015-002 mgx21 001 mg x 5

2


96


volnea (28) oral tablet 015-002 mgx21 001 mg x 5

2

vyfemla (28) oral tablet 04-35 mg-mcg

2

vylibra oral tablet 025-35 mg-mcg 2

wera (28) oral tablet 05-35 mg-mcg

2

xulane transdermal patch weekly150-35 mcg24 hr


zarah oral tablet 3-003 mg 2

zenchent (28) oral tablet 04-35 mg-mcg

2

zovia 135e (28) oral tablet 1-35 mg-mcg

2

zumandimine (28) oral tablet 3-003 mg

2

Dental And Oral AgentsDental And Oral Agentschlorhexidine gluconate mucous membrane mouthwash 012

(Paroex Oral Rinse) 1 GC

oralone dental paste 01 2

paroex oral rinse mucous membrane mouthwash 012

1 GC

periogard mucous membrane mouthwash 012

1 GC

pilocarpine hcl oral tablet 5 mg 75 mg

(Salagen (pilocarpine)) 2

triamcinolone acetonide dental paste01

(Oralone) 2

Dermatological AgentsDermatological Agents Otheracitretin oral capsule 10 mg 25 mg (Soriatane) 2

acitretin oral capsule 175 mg 2

acyclovir topical ointment 5 (Zovirax) 2 QL (30 per 30 days)

ALCOHOL PADS TOPICAL PADS MEDICATED

1 GC

ammonium lactate topical cream 12

(Geri-Hydrolac) 2

ammonium lactate topical lotion 12

(Geri-Hydrolac) 2


97


calcipotriene scalp solution 0005 2

calcipotriene topical cream 0005 (Dovonex) 2

fluorouracil topical cream 05 (Carac) 5 NM NDS

fluorouracil topical cream 5 (Efudex) 2

fluorouracil topical solution 2 5

2

imiquimod topical cream in packet 5

(Aldara) 2 QL (24 per 30 days)

methoxsalen oral capsuleliqd-filledrapid rel 10 mg

(Oxsoralen Ultra) 5 NM NDS

PANRETIN TOPICAL GEL 01

5 NM NDS

PICATO TOPICAL GEL 0015 3 QL (3 per 56 days)


podofilox topical solution 05 2

SANTYL TOPICAL OINTMENT 250 UNITGRAM

4

TOLAK TOPICAL CREAM 4 4

VALCHLOR TOPICAL GEL 0016

5 NM NDS

zenatane oral capsule 10 mg 20 mg 30 mg 40 mg

2

Dermatological Antibacterialsclindamycin phosphate topical solution 1

(Cleocin T) 2

clindamycin phosphate topical swab1

(Clindacin ETZ) 2

ery pads topical swab 2 2

erythromycin with ethanol topical gel 2

(Erygel) 2

erythromycin with ethanol topical solution 2

2

erythromycin with ethanol topical swab 2

(Ery Pads) 2

gentamicin topical cream 01 2

gentamicin topical ointment 01 2

metronidazole topical cream 075 (Rosadan) 2

metronidazole topical gel 075 (Rosadan) 2

metronidazole topical gel 1 (Metrogel) 2

metronidazole topical lotion 075 (MetroLotion) 2


98


mupirocin topical ointment 2 (Centany) 1 GC

neomycin-polymyxin b gu irrigation solution 40 mg-200000 unitml

2

rosadan topical cream 075 2

selenium sulfide topical lotion 25 2

silver sulfadiazine topical cream 1 (SSD) 2

ssd topical cream 1 4

sulfacetamide sodium (acne) topical suspension 10

(Klaron) 2

Dermatological Anti-Inflammatory Agentsala-cort topical cream 1 1 GC

alclometasone topical cream 005 2

alclometasone topical ointment 005

2

betamethasone dipropionate topical cream 005

2

betamethasone dipropionate topical lotion 005

2

betamethasone dipropionate topical ointment 005

2

betamethasone valerate topical cream 01

2

betamethasone valerate topical lotion 01

2

betamethasone valerate topical ointment 01

2

betamethasone augmented topical cream 005

2

betamethasone augmented topical gel 005

2

betamethasone augmented topical lotion 005

2

betamethasone augmented topical ointment 005

(Diprolene (augmented))

2

clobetasol scalp solution 005 2

clobetasol topical cream 005 (Temovate) 2

clobetasol-emollient topical cream005

2

clocortolone pivalate topical cream01

(Cloderm) 4


99


cormax scalp solution 005 2

desoximetasone topical cream 025

(Topicort) 2

EUCRISA TOPICAL OINTMENT 2

3

fluocinolone topical cream 001 2

fluocinolone topical cream 0025 (Synalar) 2

fluocinolone topical ointment 0025

(Synalar) 2

fluocinonide topical cream 005 2

fluocinonide topical solution 005 2

fluocinonide-e topical cream 005 2

fluticasone propionate topical cream005

(Cutivate) 2

fluticasone propionate topical ointment 0005

2

halobetasol propionate topical cream 005

2

halobetasol propionate topical ointment 005

2

hydrocortisone topical cream 1 (Ala-Cort) 1 GC

hydrocortisone topical cream 25 1 GC

hydrocortisone topical lotion 25 2

hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1 GC

hydrocortisone topical ointment 25

1 GC

mometasone topical cream 01 2

mometasone topical ointment 01 2

mometasone topical solution 01 2

pimecrolimus topical cream 1 (Elidel) 2

prednicarbate topical cream 01 4

prednicarbate topical ointment 01

2

procto-med hc topical cream with perineal applicator 25

2

proctosol hc topical cream with perineal applicator 25

2

proctozone-hc topical cream with perineal applicator 25

2


100


tacrolimus topical ointment 003 01

(Protopic) 2 QL (100 per 30 days)

triamcinolone acetonide topical cream 0025

1 GC

triamcinolone acetonide topical cream 01 05

(Triderm) 1 GC

triamcinolone acetonide topical lotion 0025 01

2

triamcinolone acetonide topical ointment 0025 01 05

2

triamcinolone acetonide topical ointment 005

(Trianex) 2

Dermatological Retinoidsadapalene topical cream 01 (Differin) 2

adapalene topical gel 01 (Differin) 2

ALTRENO TOPICAL LOTION 005

4 PA

tazarotene topical cream 01 (Tazorac) 2

TAZORAC TOPICAL CREAM 005

4

tretinoin topical cream 0025 (Avita) 2 PA

tretinoin topical cream 005 01

(Retin-A) 2 PA

tretinoin topical gel 001 (Retin-A) 2 PA

tretinoin topical gel 0025 (Avita) 2 PA

tretinoin topical gel 005 (Atralin) 2 PAScabicides And Pediculicidesmalathion topical lotion 05 (Ovide) 2

permethrin topical cream 5 (Elimite) 2

DevicesDevicesASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 12

2

BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 532

2

BD VEO INS 03 ML 6MMX31G (12) 03 ML 31 GAUGE X 1564

2


101


BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 1564

2

BD VEO INS SYRN 05 ML 6MMX31G 12 ML 31 GAUGE X 1564

2

GAUZE PAD TOPICAL BANDAGE 2 X 2

1 GC

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 03 ML 29 GAUGE

(Ultilet Insulin Syringe) 2

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 GAUGE X 12

(Advocate Syringes) 2


(Lite Touch Insulin Syringe)

2

PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12

(1st Tier Unifine Pentips)

2

V-GO 40 DISPOSABLE DEVICE 2

Enzyme ReplacementModifiersEnzyme ReplacementModifiersADAGEN INTRAMUSCULAR SOLUTION 250 UNITML

5 NM NDS

ALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML

5 NM NDS

CERDELGA ORAL CAPSULE 84 MG

5 PA NM NDS

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 NM NDS

CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT

3

ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML

5 NM NDS


102


ELITEK INTRAVENOUS RECON SOLN 15 MG 75 MG

5 NM NDS

FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG

5 PA NM NDS

GALAFOLD ORAL CAPSULE 123 MG


KANUMA INTRAVENOUS SOLUTION 2 MGML

5 PA NM NDS

KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML

5 PA BvD NM NDS

KUVAN ORAL TABLETSOLUBLE 100 MG

5 NM NDS

MEPSEVII INTRAVENOUS SOLUTION 2 MGML

5 PA NM NDS

miglustat oral capsule 100 mg (Zavesca) 5 PA NM NDS QL (90 per 30 days)

NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML

5 NM NDS

nitisinone oral capsule 10 mg 2 mg 5 mg

(Orfadin) 5 PA NM NDS

NITYR ORAL TABLET 10 MG 2 MG 5 MG

5 PA NM NDS

ORFADIN ORAL CAPSULE 20 MG

5 PA NM NDS

ORFADIN ORAL SUSPENSION 4 MGML

5 PA NM NDS

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML

5 PA NM NDS

PULMOZYME INHALATION SOLUTION 1 MGML

5 PA BvD NM NDS

REVCOVI INTRAMUSCULAR SOLUTION 24 MG15 ML (16 MGML)

5 PA NM NDS

sapropterin oral tabletsoluble 100 mg

(Kuvan) 5 NM NDS

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML

5 PA NM LA NDS


103


VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)

5 PA NM NDS

VPRIV INTRAVENOUS RECON SOLN 400 UNIT

5 NM NDS

ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 25000-79000- 105000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT

3

Eye Ear Nose Throat AgentsEye Ear Nose Throat Agents Miscellaneousapraclonidine ophthalmic (eye) drops 05

2

atropine ophthalmic (eye) drops 1

(Isopto Atropine) 4

azelastine nasal aerosolspray 137 mcg (01 )


azelastine ophthalmic (eye) drops005

2

cromolyn ophthalmic (eye) drops 4

2

cyclopentolate ophthalmic (eye) drops 05 1 2

(Cyclogyl) 2

CYSTARAN OPHTHALMIC (EYE) DROPS 044

5 NM NDS

epinastine ophthalmic (eye) drops005

2

ipratropium bromide nasal spraynon-aerosol 003


ipratropium bromide nasal spraynon-aerosol 42 mcg (006 )


olopatadine ophthalmic (eye) drops01 02

(Pataday) 2


104


phenylephrine hcl ophthalmic (eye) drops 10 25

4

proparacaine ophthalmic (eye) drops 05

(Alcaine) 2

TEPEZZA INTRAVENOUS RECON SOLN 500 MG

5 PA NM NDS

Eye Ear Nose Throat Anti-Infectives Agentsacetic acid otic (ear) solution 2 2

acetic acid-aluminum acetate otic (ear) drops 2

2

bacitracin ophthalmic (eye) ointment 500 unitgram

(Baciguent) 2

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram

(Polycin) 2

bleph-10 ophthalmic (eye) drops 10

2

CIPRODEX OTIC (EAR) DROPSSUSPENSION 03-01

3

ciprofloxacin hcl ophthalmic (eye) drops 03

(Ciloxan) 1 GC

ciprofloxacin hcl otic (ear) dropperette 02

(Cetraxal) 4

ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01

(Ciprodex) 2

erythromycin ophthalmic (eye) ointment 5 mggram (05 )

2

gentak ophthalmic (eye) ointment03 (3 mggram)

2

gentamicin ophthalmic (eye) drops03

1 GC

levofloxacin ophthalmic (eye) drops05

2

MOXEZA OPHTHALMIC (EYE) DROPS VISCOUS 05

3

moxifloxacin ophthalmic (eye) drops 05

(Vigamox) 2

NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5

4


105


neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

(Neo-Polycin HC) 2

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

(Neo-Polycin) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension35mgml-10000 unitml-01

(Maxitrol) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01

(Maxitrol) 2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml

2

neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml

2

neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-

2

neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-

2

neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

2

neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

2

ofloxacin ophthalmic (eye) drops03

(Ocuflox) 2

ofloxacin otic (ear) drops 03 2

polycin ophthalmic (eye) ointment500-10000 unitgram

2

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml

(Polytrim) 1 GC

sulfacetamide sodium ophthalmic (eye) drops 10

(Bleph-10) 2


106


sulfacetamide sodium ophthalmic (eye) ointment 10

2

sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )

2

tobramycin ophthalmic (eye) drops03

(Tobrex) 1 GC

tobramycin-dexamethasone ophthalmic (eye) dropssuspension03-01

(TobraDex) 2

trifluridine ophthalmic (eye) drops1

2

ZIRGAN OPHTHALMIC (EYE) GEL 015

4

ZYLET OPHTHALMIC (EYE) DROPSSUSPENSION 03-05

3

Eye Ear Nose Throat Anti-Inflammatory AgentsALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02

3 ST

BROMSITE OPHTHALMIC (EYE) DROPS 0075

3

dexamethasone sodium phosphate ophthalmic (eye) drops 01

2

diclofenac sodium ophthalmic (eye) drops 01

2

DUREZOL OPHTHALMIC (EYE) DROPS 005

3

flunisolide nasal spraynon-aerosol25 mcg (0025 )


fluorometholone ophthalmic (eye) dropssuspension 01

(FML Liquifilm) 4

flurbiprofen sodium ophthalmic (eye) drops 003

1 GC

fluticasone propionate nasal spraysuspension 50 mcgactuation

(24 Hour Allergy Relief)

1 GC QL (16 per 30 days)

ILEVRO OPHTHALMIC (EYE) DROPSSUSPENSION 03

3

INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1

3


107


ketorolac ophthalmic (eye) drops05

(Acular) 2

LOTEMAX OPHTHALMIC (EYE) DROPSGEL 05

3

LOTEMAX OPHTHALMIC (EYE) OINTMENT 05

3

LOTEMAX SM OPHTHALMIC (EYE) DROPSGEL 038

3

mometasone nasal spraynon-aerosol50 mcgactuation

(Nasonex) 2 QL (34 per 28 days)

prednisolone acetate ophthalmic (eye) dropssuspension 1

(Pred Forte) 4

prednisolone sodium phosphate ophthalmic (eye) drops 1

2

PROLENSA OPHTHALMIC (EYE) DROPS 007

3

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005


XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCGACTUATION


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5


Gastrointestinal AgentsAntiulcer Agents And Acid Suppressantscimetidine hcl oral solution 300 mg5 ml

2

esomeprazole sodium intravenous recon soln 20 mg

2


(Nexium IV) 2

famotidine (pf) intravenous solution20 mg2 ml

1 GC

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg50 ml

2

famotidine intravenous solution 10 mgml

2

famotidine oral tablet 20 mg (Acid Controller) 1 GC

famotidine oral tablet 40 mg (Pepcid) 1 GC


108


lansoprazole oral capsuledelayed release(drec) 15 mg

(Prevacid) 2 QL (30 per 30 days)



misoprostol oral tablet 100 mcg 200 mcg

(Cytotec) 2

nizatidine oral capsule 150 mg 300 mg

2

omeprazole oral capsuledelayed release(drec) 10 mg 20 mg 40 mg

1 GC

omeprazole-sodium bicarbonate oral capsule 20-11 mg-gram 40-11 mg-gram

(Zegerid) 2 ST QL (30 per 30 days)

pantoprazole intravenous recon soln40 mg

(Protonix) 2

pantoprazole oral tabletdelayed release (drec) 20 mg

(Protonix) 1 GC QL (30 per 30 days)



sucralfate oral tablet 1 gram (Carafate) 2Gastrointestinal Agents OtherAMITIZA ORAL CAPSULE 24 MCG 8 MCG


CARBAGLU ORAL TABLET DISPERSIBLE 200 MG

5 NM NDS

constulose oral solution 10 gram15 ml

2

cromolyn oral concentrate 100 mg5 ml

(Gastrocrom) 2

dicyclomine oral capsule 10 mg 2

dicyclomine oral solution 10 mg5 ml 2

dicyclomine oral tablet 20 mg 2

diphenoxylate-atropine oral liquid25-0025 mg5 ml

2

diphenoxylate-atropine oral tablet25-0025 mg

(Lomotil) 2

enulose oral solution 10 gram15 ml 2

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG

5 PA NM NDS

generlac oral solution 10 gram15 ml 2


109


glycopyrrolate injection solution 02 mgml

2

glycopyrrolate oral tablet 1 mg 2 mg

2

kionex (with sorbitol) oral suspension 15-193 gram60 ml

2

lactulose oral solution 10 gram15 ml

(Constulose) 2

LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG


LOKELMA ORAL POWDER IN PACKET 10 GRAM 5 GRAM


loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))

2

methscopolamine oral tablet 25 mg 5 mg

2

metoclopramide hcl injection solution 5 mgml

2

metoclopramide hcl injection syringe5 mgml

2

metoclopramide hcl oral solution 5 mg5 ml

2

metoclopramide hcl oral tablet 10 mg 5 mg

(Reglan) 1 GC

MOVANTIK ORAL TABLET 125 MG 25 MG


OCALIVA ORAL TABLET 10 MG 5 MG


RAVICTI ORAL LIQUID 11 GRAMML

5 PA NM NDS

RELISTOR ORAL TABLET 150 MG


RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML


RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML




sodium phenylbutyrate oral tablet500 mg

(Buphenyl) 5 NM NDS


110


sodium polystyrene (sorb free) oral suspension 15 gram60 ml

2

sodium polystyrene sulfonate oral powder

2

sps (with sorbitol) oral suspension15-20 gram60 ml

2

ursodiol oral capsule 300 mg (Actigall) 2

ursodiol oral tablet 250 mg (URSO 250) 2

ursodiol oral tablet 500 mg (URSO Forte) 2

VELTASSA ORAL POWDER IN PACKET 168 GRAM 252 GRAM 84 GRAM


VIBERZI ORAL TABLET 100 MG 75 MG


XERMELO ORAL TABLET 250 MG


LaxativesCLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML

3

gavilyte-c oral recon soln 240-2272-672 -584 gram

2

gavilyte-g oral recon soln 236-2274-674 -586 gram

2

gavilyte-n oral recon soln 420 gram 2

peg 3350-electrolytes oral recon soln240-2272-672 -584 gram

(Gavilyte-C) 4

SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM

3

trilyte with flavor packets oral recon soln 420 gram

2

Phosphate Binderscalcium acetate(phosphat bind) oral capsule 667 mg

2

calcium acetate(phosphat bind) oral tablet 667 mg

2

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)5 ML

4


111


sevelamer carbonate oral powder in packet 08 gram 24 gram

(Renvela) 5 NM NDS

sevelamer carbonate oral tablet 800 mg

(Renvela) 2

sevelamer hcl oral tablet 400 mg 2

sevelamer hcl oral tablet 800 mg (Renagel) 2

VELPHORO ORAL TABLETCHEWABLE 500 MG

3

Genitourinary AgentsAntispasmodics Urinarybethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg

2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG

3

oxybutynin chloride oral syrup 5 mg5 ml

2

oxybutynin chloride oral tablet 5 mg 2

oxybutynin chloride oral tablet extended release 24hr 10 mg 5 mg

(Ditropan XL) 2

oxybutynin chloride oral tablet extended release 24hr 15 mg

2

tolterodine oral capsuleextended release 24hr 2 mg 4 mg

(Detrol LA) 2

tolterodine oral tablet 1 mg 2 mg (Detrol) 2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG 8 MG

3

Genitourinary Agents Miscellaneousalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) 1 GC

dutasteride oral capsule 05 mg (Avodart) 2

finasteride oral tablet 5 mg (Proscar) 1 GC

PROCYSBI ORAL CAPSULE DELAYED REL SPRINKLE 25 MG 75 MG

5 NM NDS

tamsulosin oral capsule 04 mg (Flomax) 1 GC

terazosin oral capsule 1 mg 10 mg 2 mg 5 mg

1 GC


112


THIOLA EC ORAL TABLETDELAYED RELEASE (DREC) 100 MG 300 MG

5 PA NM NDS

THIOLA ORAL TABLET 100 MG

5 NM NDS

Heavy Metal AntagonistsHeavy Metal Antagonistsclovique oral capsule 250 mg 5 PA NM NDS QL

(240 per 30 days)

deferasirox oral granules in packet180 mg 360 mg 90 mg

(Jadenu Sprinkle) 5 PA NM NDS

deferasirox oral tablet 180 mg 360 mg 90 mg

(Jadenu) 5 PA NM NDS

deferasirox oral tablet dispersible125 mg 250 mg 500 mg

(Exjade) 5 PA NM NDS

deferiprone oral tablet 500 mg (Ferriprox) 5 PA NM NDS

deferoxamine injection recon soln 2 gram 500 mg

(Desferal) 2 PA

FERRIPROX ORAL SOLUTION 100 MGML

5 PA NM NDS

FERRIPROX ORAL TABLET 1000 MG 500 MG

5 PA NM NDS

JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG 360 MG 90 MG

5 PA NM NDS

penicillamine oral capsule 250 mg (Cuprimine) 5 PA NM NDS

penicillamine oral tablet 250 mg (Depen Titratabs) 5 PA NM NDS

trientine oral capsule 250 mg (Clovique) 5 PA NM NDS QL (240 per 30 days)

Hormonal Agents StimulantReplacementModifyingAndrogensANADROL-50 ORAL TABLET 50 MG

5 PA NM NDS

danazol oral capsule 100 mg 200 mg 50 mg

2

testosterone cypionate intramuscular oil 100 mgml 200 mgml

(Depo-Testosterone) 2 PA


113


testosterone cypionate intramuscular oil 200 mgml (1 ml)

2 PA

testosterone enanthate intramuscular oil 200 mgml


testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )

(Vogelxo) 2 PA QL (300 per 30 days)

testosterone transdermal gel in metered-dose pump 2025 mg125 gram (162 )

(AndroGel) 2 PA QL (150 per 30 days)

testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram)


testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)


XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG05 ML 50 MG05 ML 75 MG05 ML


Estrogens And Antiestrogensamabelz oral tablet 05-01 mg 1-05 mg

2

dotti transdermal patch semiweekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


DUAVEE ORAL TABLET 045-20 MG

3

estradiol oral tablet 05 mg 1 mg 2 mg

(Estrace) 1 GC

estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr

(Dotti) 2 QL (8 per 28 days)

estradiol transdermal patch weekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr

(Climara) 2 QL (4 per 28 days)

estradiol vaginal cream 001 (01 mggram)

(Estrace) 2

estradiol vaginal tablet 10 mcg (Yuvafem) 2 QL (18 per 28 days)


114


estradiol valerate intramuscular oil20 mgml 40 mgml

(Delestrogen) 2

estradiol-norethindrone acet oral tablet 05-01 mg

(Amabelz) 2

FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR


fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg

2

jinteli oral tablet 1-5 mg-mcg 2

mimvey lo oral tablet 05-01 mg 2

mimvey oral tablet 1-05 mg 2

norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg

(Fyavolv) 2

PREMARIN INJECTION RECON SOLN 25 MG

3

PREMARIN ORAL TABLET 03 MG 045 MG 0625 MG 09 MG 125 MG

3

PREMARIN VAGINAL CREAM 0625 MGGRAM

3

PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)

3

PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG

3

raloxifene oral tablet 60 mg (Evista) 2

yuvafem vaginal tablet 10 mcg 2 QL (18 per 28 days)GlucocorticoidsMineralocorticoidsa-hydrocort injection recon soln 100 mg

2

betamethasone acetsod phos injection suspension 6 mgml

(Celestone Soluspan) 2

cortisone oral tablet 25 mg 2

decadron oral elixir 05 mg5 ml 2 PA BvD

dexamethasone oral elixir 05 mg5 ml

2 PA BvD

dexamethasone oral tablet 05 mg 075 mg 4 mg 6 mg

(Decadron) 1 PA BvD GC

dexamethasone oral tablet 1 mg 15 mg 2 mg

1 PA BvD GC


115


dexamethasone sodium phos (pf) injection solution 10 mgml

1 GC

dexamethasone sodium phos (pf) injection syringe 10 mgml

1 GC

dexamethasone sodium phosphate injection solution 10 mgml 4 mgml

1 GC

dexamethasone sodium phosphate injection syringe 4 mgml

1 GC

EMFLAZA ORAL SUSPENSION 2275 MGML


EMFLAZA ORAL TABLET 18 MG


EMFLAZA ORAL TABLET 30 MG 36 MG 6 MG


fludrocortisone oral tablet 01 mg 2

hydrocortisone oral tablet 10 mg 20 mg 5 mg

(Cortef) 2

methylprednisolone acetate injection suspension 40 mgml 80 mgml

(Depo-Medrol) 2

methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg

(Medrol) 2

methylprednisolone oral tabletsdose pack 4 mg

(Medrol (Pak)) 2

methylprednisolone sodium succ injection recon soln 125 mg 40 mg

2

methylprednisolone sodium succ intravenous recon soln 1000 mg 500 mg

(Solu-Medrol) 2

prednisolone 15 mg5 ml soln af df15 mg5 ml (3 mgml)

2 PA BvD

prednisolone oral solution 15 mg5 ml

2 PA BvD

prednisolone sodium phosphate oral solution 25 mg5 ml (5 mgml)

2 PA BvD

prednisolone sodium phosphate oral solution 5 mg base5 ml (67 mg5 ml)

(Pediapred) 2 PA BvD

prednisone oral solution 5 mg5 ml 2 PA BvD

prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg

1 PA BvD GC


116


prednisone oral tabletsdose pack 10 mg 10 mg (48 pack) 5 mg 5 mg (48 pack)

2

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 100 MG2 ML

4

triamcinolone acetonide injection suspension 40 mgml

(Kenalog) 2

PituitaryBYNFEZIA SUBCUTANEOUS PEN INJECTOR 2500 MCGML

5 NM NDS

desmopressin 10 mcg01 ml spr 10 mcgspray (01 ml)

2

desmopressin injection solution 4 mcgml

(DDAVP) 2

desmopressin nasal spraynon-aerosol 10 mcgspray (01 ml)

2

desmopressin oral tablet 01 mg 02 mg

(DDAVP) 2

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG


EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG


GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 02 MG025 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 04 MG025 ML 06 MG025 ML 08 MG025 ML 1 MG025 ML 12 MG025 ML 14 MG025 ML 16 MG025 ML 18 MG025 ML 2 MG025 ML

5 PA NM NDS

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MGML (36 UNITML) 5 MGML (15 UNITML)

5 PA NM NDS


117


HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT) 24 MG (72 UNIT) 6 MG (18 UNIT)

5 PA NM NDS

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG

5 PA NM NDS

INCRELEX SUBCUTANEOUS SOLUTION 10 MGML

5 NM NDS


5 NM NDS


5 NM NDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 NM NDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG

5 NM NDS

NOCDURNA (MEN) SUBLINGUAL TABLETDISINTEGRATING 553 MCG


NOCDURNA (WOMEN) SUBLINGUAL TABLETDISINTEGRATING 277 MCG


NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG15 ML (67 MGML) 15 MG15 ML (10 MGML) 30 MG3 ML (10 MGML)

5 PA NM NDS

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG15 ML (33 MGML)

4 PA


118


NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG2 ML (5 MGML) 20 MG2 ML (10 MGML) 5 MG2 ML (25 MGML)

5 PA NM NDS

octreotide acetate injection solution1000 mcgml 200 mcgml

2

octreotide acetate injection solution100 mcgml 50 mcgml 500 mcgml

(Sandostatin) 2

octreotide acetate injection syringe100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)

2

OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG15 ML (67 MGML) 5 MG15 ML (33 MGML)

5 PA NM NDS

OMNITROPE SUBCUTANEOUS RECON SOLN 58 MG

5 PA NM NDS

ORILISSA ORAL TABLET 150 MG




SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE 88 MG151 ML (FINAL CONC)

5 PA NM NDS

SAIZEN SUBCUTANEOUS RECON SOLN 5 MG 88 MG

5 PA NM NDS

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 10 MG 20 MG 30 MG

5 NM NDS

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG

5 PA NM NDS

SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)



119


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG02 ML 90 MG03 ML


SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG

5 PA NM NDS

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)


SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML

5 NM NDS

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 225 MG


ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG

5 PA NM NDS


4 PA

ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG

5 PA NM NDS

ProgestinsDEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MGML


hydroxyprogesterone cap(ppres) intramuscular oil 250 mgml

(Makena) 5 NM NDS

medroxyprogesterone intramuscular suspension 150 mgml

(Depo-Provera) 2 QL (1 per 84 days)

medroxyprogesterone intramuscular syringe 150 mgml


medroxyprogesterone oral tablet 10 mg 25 mg 5 mg

(Provera) 1 GC

megestrol oral suspension 400 mg10 ml (40 mgml)

2

norethindrone acetate oral tablet 5 mg

(Aygestin) 2


120


progesterone intramuscular oil 50 mgml

2

progesterone micronized oral capsule 100 mg 200 mg

(Prometrium) 2

Thyroid And Antithyroid Agentslevothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg

(Euthyrox) 1 GC

levothyroxine oral tablet 300 mcg (Levo-T) 1 GC

liothyronine oral tablet 25 mcg 5 mcg 50 mcg

(Cytomel) 2

methimazole oral tablet 10 mg 5 mg (Tapazole) 1 GC

propylthiouracil oral tablet 50 mg 2

Immunological AgentsImmunological AgentsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML

5 PA NM NDS

ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)

5 PA NM NDS

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML

5 PA NM NDS

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

5 NM NDS

AVSOLA INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

azathioprine oral tablet 50 mg (Imuran) 2 PA BvD

azathioprine sodium injection recon soln 100 mg

2 PA BvD

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

5 PA NM NDS

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)

5 PA NM NDS


121


COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML

5 PA NM NDS

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML

5 PA NM NDS

cyclosporine intravenous solution250 mg5 ml

(Sandimmune) 2 PA BvD

cyclosporine modified oral capsule100 mg 25 mg

(Gengraf) 2 PA BvD

cyclosporine modified oral capsule50 mg

2 PA BvD

cyclosporine modified oral solution100 mgml

(Gengraf) 2 PA BvD

cyclosporine oral capsule 100 mg 25 mg


DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML

5 PA NM NDS

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML 300 MG2 ML

5 PA NM NDS

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)

5 PA NM NDS

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

5 PA NM NDS

ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML

5 PA NM NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)

5 PA NM NDS

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)

5 PA NM NDS

everolimus (immunosuppressive) oral tablet 025 mg

(Zortress) 2 PA BvD

everolimus (immunosuppressive) oral tablet 05 mg 075 mg

(Zortress) 5 PA BvD NM NDS


122


FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5

5 PA BvD NM NDS

GAMASTAN INTRAMUSCULAR SOLUTION 15-18 RANGE

4 PA BvD

GAMMAGARD LIQUID INJECTION SOLUTION 10

5 PA BvD NM NDS

GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM

5 PA BvD NM NDS

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5

5 PA BvD NM NDS

GAMMAPLEX INTRAVENOUS SOLUTION 10 10 (100 ML) 10 (200 ML)

5 PA BvD NM NDS

gengraf oral capsule 100 mg 25 mg 2 PA BvD

gengraf oral solution 100 mgml 2 PA BvD

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG08 ML

5 PA NM NDS

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG02 ML 20 MG04 ML 40 MG08 ML

5 PA NM NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML

5 PA NM NDS


123


HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

5 PA NM NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML

5 PA NM NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML

5 PA NM NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML

5 PA NM NDS

HYPERRAB (PF) INTRAMUSCULAR SOLUTION 300 UNITML

4

HYPERRAB SD (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )

5 PA BvD NM NDS

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML

5 PA NM NDS

ILUMYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NM NDS

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

INFLECTRA INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNITML

4

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML

5 PA NM NDS


124


KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML

5 PA NM NDS

KINERET SUBCUTANEOUS SYRINGE 100 MG067 ML

5 PA NM NDS

leflunomide oral tablet 10 mg 20 mg (Arava) 2

mycophenolate mofetil (hcl) intravenous recon soln 500 mg

(CellCept Intravenous) 2 PA BvD

mycophenolate mofetil oral capsule250 mg

(CellCept) 2 PA BvD

mycophenolate mofetil oral suspension for reconstitution 200 mgml

(CellCept) 5 PA BvD NM NDS

mycophenolate mofetil oral tablet500 mg

(CellCept) 2 PA BvD

NULOJIX INTRAVENOUS RECON SOLN 250 MG

5 PA BvD NM NDS

OCTAGAM INTRAVENOUS SOLUTION 10 5

5 PA BvD NM NDS

OLUMIANT ORAL TABLET 1 MG 2 MG

5 PA NM NDS

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG

5 PA NM NDS

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML

5 PA NM NDS

ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML

5 PA NM NDS

OTEZLA ORAL TABLET 30 MG 5 PA NM NDS

OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 10 MG (4)-20 MG (4)-30 MG(19)

5 PA NM NDS

PRIVIGEN INTRAVENOUS SOLUTION 10

5 PA BvD NM NDS

PROGRAF INTRAVENOUS SOLUTION 5 MGML

4 PA BvD

PROGRAF ORAL GRANULES IN PACKET 02 MG 1 MG

4 PA BvD ST


125


RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG02 ML 125 MG025 ML 15 MG03 ML 175 MG035 ML 20 MG04 ML 225 MG045 ML 25 MG05 ML 30 MG06 ML 75 MG015 ML

3

REMICADE INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

RENFLEXIS INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

RIDAURA ORAL CAPSULE 3 MG

5 NM NDS

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG

5 PA NM NDS

SILIQ SUBCUTANEOUS SYRINGE 210 MG15 ML

5 PA NM NDS

SIMPONI ARIA INTRAVENOUS SOLUTION 125 MGML

5 PA NM NDS

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MGML 50 MG05 ML

5 PA NM NDS

SIMPONI SUBCUTANEOUS SYRINGE 100 MGML 50 MG05 ML

5 PA NM NDS

sirolimus oral solution 1 mgml (Rapamune) 5 PA BvD NM NDS

sirolimus oral tablet 05 mg 1 mg (Rapamune) 2 PA BvD

sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD NM NDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)

5 PA NM NDS

STELARA INTRAVENOUS SOLUTION 130 MG26 ML

5 PA NM NDS

STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML

5 PA NM NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML

5 PA NM NDS


126


tacrolimus oral capsule 05 mg 1 mg 5 mg

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML

5 PA NM NDS

TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML

5 PA NM NDS

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG

4

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA NM NDS

TREMFYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NM NDS

TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML

5 PA NM LA NDS

XELJANZ ORAL TABLET 10 MG 5 MG

5 PA NM NDS

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG

5 PA NM NDS

ZORTRESS ORAL TABLET 1 MG

5 PA BvD NM NDS

VaccinesACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

3

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML

3

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML

3

BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

3


127


BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML

3

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML

3

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML

3

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML

3

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML

3 PA BvD

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML

3 PA BvD

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML

3 PA BvD

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML


GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML


HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1440 ELISA UNITML 720 ELISA UNIT05 ML

3

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML

3

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

3


128


IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT

3 PA BvD

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF05ML

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML

3

IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML

3

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML

3

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF05 ML

3

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML

3

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML

3

MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML

3

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML

3

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML

3

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML

3

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML

3


129


PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML

3

PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 62 DU05 ML

3

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005

3

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML

3

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT

3 PA BvD

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML

3 PA BvD

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML

3 PA BvD

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50ML

3

ROTATEQ VACCINE ORAL SOLUTION 2 ML

3

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML


TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML

3


130


TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML

3

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML

3

TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML

3

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML

3

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML

3

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML

3

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML

3

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML

3

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML

3

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML


YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML

3


131


ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML


Inflammatory Bowel Disease AgentsInflammatory Bowel Disease Agentsalosetron oral tablet 05 mg 1 mg (Lotronex) 5 NM NDS

balsalazide oral capsule 750 mg (Colazal) 2

budesonide oral capsuledelayedextendrelease 3 mg

(Entocort EC) 2

colocort rectal enema 100 mg60 ml 2

DIPENTUM ORAL CAPSULE 250 MG

5 ST NM NDS

hydrocortisone rectal enema 100 mg60 ml

(Cortenema) 4

LIALDA ORAL TABLETDELAYED RELEASE (DREC) 12 GRAM

2

mesalamine oral capsule (with del rel tablets) 400 mg

(Delzicol) 2

mesalamine oral capsuleextended release 24hr 0375 gram

(Apriso) 2

mesalamine oral tabletdelayed release (drec) 12 gram

(Lialda) 2

mesalamine oral tabletdelayed release (drec) 800 mg

(Asacol HD) 2

mesalamine rectal suppository 1000 mg

(Canasa) 5 NM NDS

sulfasalazine oral tablet 500 mg (Azulfidine) 2

sulfasalazine oral tabletdelayed release (drec) 500 mg

(Azulfidine EN-tabs) 2

UCERIS RECTAL FOAM 2 MGACTUATION

3

Irrigating SolutionsIrrigating Solutionsacetic acid irrigation solution 025 4

LACTATED RINGERS IRRIGATION SOLUTION

4


132


sodium chloride irrigation solution09

(Aqua Care Sodium Chloride)

4

water for irrigation sterile irrigation solution

(Aqua Care Sterile Water)

4

Metabolic Bone Disease AgentsMetabolic Bone Disease Agentsalendronate oral tablet 10 mg 5 mg 1 GC

alendronate oral tablet 35 mg 1 GC QL (4 per 28 days)

alendronate oral tablet 70 mg (Fosamax) 1 GC QL (4 per 28 days)

calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation


calcitriol intravenous solution 1 mcgml

2

calcitriol oral capsule 025 mcg 05 mcg

(Rocaltrol) 2

calcitriol oral solution 1 mcgml (Rocaltrol) 2

cinacalcet oral tablet 30 mg 60 mg (Sensipar) 5 NM NDS QL (60 per 30 days)

cinacalcet oral tablet 90 mg (Sensipar) 5 NM NDS QL (120 per 30 days)

doxercalciferol intravenous solution4 mcg2 ml

(Hectorol) 2

EVENITY 105 MG117 ML SYRINGE 105 MG117 ML


EVENITY SUBCUTANEOUS SYRINGE 210MG234ML ( 105MG117MLX2)


FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCGDOSE (600MCG24ML)


ibandronate intravenous solution 3 mg3 ml


ibandronate intravenous syringe 3 mg3 ml

(Boniva) 2 QL (3 per 84 days)

ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days)

MIACALCIN INJECTION SOLUTION 200 UNITML

5 NM NDS

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE



133


paricalcitol hemodialysis port injection solution 2 mcgml

2

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCGML

2

paricalcitol oral capsule 1 mcg 2 mcg

(Zemplar) 2

paricalcitol oral capsule 4 mcg 2

PROLIA SUBCUTANEOUS SYRINGE 60 MGML


RAYALDEE ORAL CAPSULEEXTENDED RELEASE 24 HR 30 MCG


teriparatide subcutaneous pen injector 20 mcgdose - 620 mcg248 ml


TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)


zoledronic acid intravenous recon soln 4 mg

2

zoledronic acid intravenous solution4 mg5 ml

2

zoledronic acid-mannitol-water intravenous piggyback 5 mg100 ml

(Reclast) 2 QL (100 per 300 days)

Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML

5 NM NDS

amifostine crystalline intravenous recon soln 500 mg

(Ethyol) 2

BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG

5 PA NM NDS

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML


BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML



134


CABLIVI INJECTION KIT 11 MG


CETYLEV ORAL TABLET EFFERVESCENT 25 GRAM 500 MG

4

CYSTADANE ORAL POWDER 1 GRAM17 ML

5 NM NDS

diazoxide oral suspension 50 mgml (Proglycem) 2

droperidol injection solution 25 mgml

2

ELMIRON ORAL CAPSULE 100 MG


ENDARI ORAL POWDER IN PACKET 5 GRAM


ergoloid oral tablet 1 mg 2

EVRYSDI ORAL RECON SOLN 075 MGML

5 PA NM NDS

EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML

5 PA NM LA NDS

fomepizole intravenous solution 1 gramml

5 NM NDS

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

3

guanidine oral tablet 125 mg 4

GVOKE HYPOPEN 1PK 05 MG01 ML 05 MG01 ML

3

GVOKE HYPOPEN 1-PK 1 MG02 ML 1 MG02 ML

3

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS AUTO-INJECTOR 05 MG01 ML 1 MG02 ML

3

GVOKE PFS 1PK 05 MG01 ML SYR 05 MG01 ML

3

GVOKE PFS 1-PK 1 MG02 ML SYR 1 MG02 ML

3

GVOKE PFS 2-PACK SYRINGE SUBCUTANEOUS SYRINGE 05 MG01 ML 1 MG02 ML

3


135


hydroxyzine pamoate oral capsule100 mg

1 GC

hydroxyzine pamoate oral capsule25 mg 50 mg

(Vistaril) 1 GC

KEVEYIS ORAL TABLET 50 MG


leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg

2

leucovorin calcium injection solution10 mgml

2

leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg

2

levocarnitine (with sugar) oral solution 100 mgml

(Carnitor) 2

levocarnitine oral tablet 330 mg (Carnitor) 2

LEVOLEUCOVORIN CALCIUM INTRAVENOUS RECON SOLN 175 MG

4

levoleucovorin calcium intravenous recon soln 50 mg

(Fusilev) 5 NM NDS

mesna intravenous solution 100 mgml

(Mesnex) 2

MESNEX ORAL TABLET 400 MG

5 NM NDS

MESTINON ORAL SYRUP 60 MG5 ML

5 NM NDS

PROCYSBI ORAL GRANULES DEL RELEASE IN PACKET 300 MG 75 MG

5 NM NDS

PROGLYCEM ORAL SUSPENSION 50 MGML

4

pyridostigmine bromide oral syrup60 mg5 ml

(Mestinon) 2

pyridostigmine bromide oral tablet30 mg

2


(Mestinon) 2

RECTIV RECTAL OINTMENT 04 (WW)



136


TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)


THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG


TOTECT INTRAVENOUS RECON SOLN 500 MG

5 NM NDS

TYBOST ORAL TABLET 150 MG


VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


XURIDEN ORAL GRANULES IN PACKET 2 GRAM


Ophthalmic AgentsAntiglaucoma Agentsacetazolamide oral capsule extended release 500 mg

2

acetazolamide oral tablet 125 mg 250 mg

2

acetazolamide sodium injection recon soln 500 mg

2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 01

3

AZOPT OPHTHALMIC (EYE) DROPSSUSPENSION 1

3

brimonidine ophthalmic (eye) drops02

1 GC

carteolol ophthalmic (eye) drops 1

1 GC

COMBIGAN OPHTHALMIC (EYE) DROPS 02-05

3

dorzolamide ophthalmic (eye) drops2

(Trusopt) 2

dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml

(Cosopt) 2

latanoprost ophthalmic (eye) drops0005

(Xalatan) 1 GC QL (25 per 25 days)

levobunolol ophthalmic (eye) drops05

1 GC


137


LUMIGAN OPHTHALMIC (EYE) DROPS 001


metipranolol ophthalmic (eye) drops 03

2

pilocarpine hcl ophthalmic (eye) drops 1 2 4

(Isopto Carpine) 2

RHOPRESSA OPHTHALMIC (EYE) DROPS 002


ROCKLATAN OPHTHALMIC (EYE) DROPS 002-0005


SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02

3

timolol maleate ophthalmic (eye) drops 025 05

(Timoptic) 1 GC

timolol maleate ophthalmic (eye) gel forming solution 025 05

(Timoptic-XE) 4

travoprost ophthalmic (eye) drops0004

(Travatan Z) 2 QL (25 per 25 days)

Replacement PreparationsReplacement Preparationscalcium chloride intravenous syringe100 mgml (10 )

2

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5

4

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5

4

ISOLYTE-P IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5

4

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

4

klor-con m10 oral tableter particlescrystals 10 meq

2


2


2


138


klor-con sprinkle oral capsule extended release 8 meq

2

K-SOL ORAL LIQUID 20 MEQ15 ML

2

magnesium sulfate in d5w intravenous piggyback 1 gram100 ml

2

magnesium sulfate in water intravenous parenteral solution 20 gram500 ml (4 ) 40 gram1000 ml (4 )

2 PA BvD

magnesium sulfate in water intravenous piggyback 2 gram50 ml (4 ) 4 gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

magnesium sulfate injection solution4 meqml (50 )

2 PA BvD

magnesium sulfate injection syringe4 meqml

2 PA BvD

NORMOSOL-M IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

NORMOSOL-R PH 74 INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

4

potassium chloride intravenous solution 2 meqml 2 meqml (20 ml)

2 PA BvD

potassium chloride oral capsule extended release 10 meq 8 meq

2

potassium chloride oral liquid 20 meq15 ml 40 meq15 ml

2

potassium chloride oral tablet extended release 10 meq 8 meq

(K-Tab) 2

potassium chloride oral tablet extended release 20 meq

(K-Tab) 4


139


potassium chloride oral tableter particlescrystals 10 meq

(Klor-Con M10) 2


(Klor-Con M20) 2

potassium chloride-045 nacl intravenous parenteral solution 20 meql

2

potassium citrate oral tablet extended release 10 meq (1080 mg)

(Urocit-K 10) 2

potassium citrate oral tablet extended release 15 meq

(Urocit-K 15) 2


(Urocit-K 5) 2

sodium chloride 09 intravenous parenteral solution

2

Respiratory Tract AgentsAnti-Inflammatories Inhaled CorticosteroidsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCGDOSE 250-50 MCGDOSE 500-50 MCGDOSE


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION 50 MCGACTUATION


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE 200-25 MCGDOSE


budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml 1 mg2 ml

(Pulmicort) 2 PA BvD


140


FLOVENT 100 MCG DISKUS 100 MCGACTUATION




FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION






SYMBICORT 160-45 MCG INHALER 160-45 MCGACTUATION




SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION


Antileukotrienesmontelukast oral tablet 10 mg (Singulair) 1 GC

montelukast oral tabletchewable 4 mg 5 mg

(Singulair) 1 GC

zafirlukast oral tablet 10 mg 20 mg (Accolate) 2Bronchodilatorsalbuterol 5 mgml solution 5 mgml 2 PA BvD

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation

(ProAir HFA) 2 QL (17 per 30 days)


141


albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (nda020503)




albuterol sulfate inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

albuterol sulfate oral syrup 2 mg5 ml

2

albuterol sulfate oral tablet extended release 12 hr 4 mg 8 mg

2

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION

3

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION


BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-48 MCGACTUATION

3

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION


INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 625 MCGACTUATION

3

ipratropium bromide inhalation solution 002

2 PA BvD

LONHALA MAGNAIR 25 MCG STARTER 25 MCGML


LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION 25 MCGML


metaproterenol oral syrup 10 mg5 ml

1 GC


142


metaproterenol oral tablet 10 mg 20 mg

2

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCGACTUATION


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE


SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION




SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG


STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION

3

STRIVERDI RESPIMAT INHALATION MIST 25 MCGACTUATION


terbutaline oral tablet 25 mg 5 mg 2

terbutaline subcutaneous solution 1 mgml

5 NM NDS

theophylline oral solution 80 mg15 ml

2

theophylline oral tablet extended release 12 hr 100 mg 200 mg 300 mg 450 mg

2

theophylline oral tablet extended release 24 hr 400 mg 600 mg

2

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG

3


143


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCGACTUATION


TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCGACTUATION (30 ACTUAT)


Respiratory Tract Agents Otheracetylcysteine intravenous solution200 mgml (20 )

(Acetadote) 2

acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )

2 PA BvD

CINQAIR INTRAVENOUS SOLUTION 10 MGML

5 PA NM NDS

cromolyn inhalation solution for nebulization 20 mg2 ml

2 PA BvD

DALIRESP ORAL TABLET 250 MCG




ESBRIET ORAL CAPSULE 267 MG


ESBRIET ORAL TABLET 267 MG




FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML


FASENRA SUBCUTANEOUS SYRINGE 30 MGML


KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG


KALYDECO ORAL TABLET 150 MG


NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA NM LA NDS QL (3 per 28 days)


144


NUCALA SUBCUTANEOUS RECON SOLN 100 MG


NUCALA SUBCUTANEOUS SYRINGE 100 MGML


OFEV ORAL CAPSULE 100 MG 150 MG


ORKAMBI ORAL GRANULES IN PACKET 100-125 MG 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG 200-125 MG


PROLASTIN C 1000 MG20 ML VL PRICEONE MGLFSUV 1000 MG (+-)20 ML

5 PA BvD NM NDS

PROLASTIN-C INTRAVENOUS RECON SOLN 1000 MG

5 PA BvD NM NDS

SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)


TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N)


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

5 PA NM NDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML

5 PA NM NDS

Skeletal Muscle RelaxantsSkeletal Muscle Relaxantsbaclofen oral tablet 10 mg 20 mg 2

chlorzoxazone oral tablet 500 mg 2

cyclobenzaprine oral tablet 10 mg 5 mg

1 GC

dantrolene oral capsule 100 mg 2

dantrolene oral capsule 25 mg 50 mg

(Dantrium) 2

methocarbamol oral tablet 500 mg 2

methocarbamol oral tablet 750 mg (Robaxin-750) 2

revonto intravenous recon soln 20 mg

2


145


tizanidine oral tablet 2 mg 2

tizanidine oral tablet 4 mg (Zanaflex) 2

Sleep Disorder AgentsSleep Disorder Agentsarmodafinil oral tablet 150 mg 200 mg 250 mg 50 mg

(Nuvigil) 2 PA QL (30 per 30 days)

BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG


eszopiclone oral tablet 1 mg 2 mg 3 mg

(Lunesta) 2 QL (30 per 30 days)

HETLIOZ ORAL CAPSULE 20 MG


SILENOR ORAL TABLET 3 MG 6 MG


SUNOSI ORAL TABLET 150 MG 75 MG


XYREM ORAL SOLUTION 500 MGML


XYWAV ORAL SOLUTION 05 GRAMML


zaleplon oral capsule 10 mg 5 mg 2 QL (30 per 30 days)

zolpidem oral tablet 10 mg 5 mg (Ambien) 1 GC QL (30 per 30 days)

Vasodilating AgentsVasodilating AgentsADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG


alyq oral tablet 20 mg 5 PA NM NDS QL (60 per 30 days)

ambrisentan oral tablet 10 mg 5 mg (Letairis) 5 PA NM NDS QL (30 per 30 days)

epoprostenol (glycine) intravenous recon soln 05 mg

(Flolan) 2 PA


(Flolan) 5 PA NM NDS

OPSUMIT ORAL TABLET 10 MG


ORENITRAM ORAL TABLET EXTENDED RELEASE 0125 MG

3 PA


146


ORENITRAM ORAL TABLET EXTENDED RELEASE 025 MG 1 MG 25 MG 5 MG

5 PA NM NDS

sildenafil (pulmhypertension) intravenous solution 10 mg125 ml

(Revatio) 5 PA NM NDS QL (375 per 1 day)

sildenafil (pulmhypertension) oral tablet 20 mg

(Revatio) 2 PA QL (90 per 30 days)

tadalafil (pulm hypertension) oral tablet 20 mg

(Alyq) 5 PA NM NDS QL (60 per 30 days)

TRACLEER ORAL TABLET 125 MG 625 MG


TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


treprostinil sodium injection solution1 mgml 10 mgml 25 mgml 5 mgml

(Remodulin) 5 PA NM NDS

TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)

5 PA NM NDS

UPTRAVI ORAL TABLET 1000 MCG 1200 MCG 1400 MCG 1600 MCG 400 MCG 600 MCG 800 MCG


UPTRAVI ORAL TABLET 200 MCG


UPTRAVI ORAL TABLETSDOSE PACK 200 MCG (140)- 800 MCG (60)

5 PA NM NDS

Vitamins And MineralsVitamins And Mineralspnv prenatal plus multivit tab sf gluten-free (rx) 27 mg iron- 1 mg

3

prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg

3


147


148

INDEX

abacavir 59abacavir-lamivudine 60abacavir-lamivudine-zidovudine 60ABELCET 45ABILIFY MAINTENA 54ABRAXANE17acamprosate 8acarbose 40acebutolol 77acetaminophen-codeine 3acetazolamide 137acetazolamide sodium 137acetic acid 105 132acetic acid-aluminum acetate 105acetylcysteine 144acitretin 97ACTEMRA 121ACTEMRA ACTPEN121ACTHIB (PF) 127ACTIMMUNE 134acyclovir 66 97acyclovir sodium 66ADACEL(TDAP ADOLESNADULT)(PF) 127ADAGEN102ADAKVEO 70adapalene 101ADCETRIS 18adefovir 66ADEMPAS 146adriamycin 18adrucil 18ADVAIR DISKUS 140ADVAIR HFA 140afeditab cr 81AFINITOR18AFINITOR DISPERZ 18

afirmelle 89a-hydrocort 115AIMOVIG AUTOINJECTOR 48AIMOVIG AUTOINJECTOR (2 PACK)48AJOVY AUTOINJECTOR48AJOVY SYRINGE48AKYNZEO (FOSNETUPITANT)50AKYNZEO (NETUPITANT) 50ala-cort 99albendazole 52albuterol sulfate 141 142alclometasone 99ALCOHOL PADS97ALDURAZYME102ALECENSA 18alendronate 133alfuzosin 112ALIMTA 18ALINIA 52ALIQOPA18aliskiren 84allopurinol 46alosetron 132ALPHAGAN P137alprazolam 9ALREX107altavera (28) 90ALTRENO 101ALUNBRIG18alyacen 135 (28) 90alyacen 777 (28) 90alyq 146amabelz 114amantadine hcl 52

AMBISOME45ambrisentan 146amethia 90amethia lo 90amifostine crystalline 134amiloride 81amiloride-hydrochlorothiazide 81AMINOSYN 10 70AMINOSYN 7 WITH ELECTROLYTES71AMINOSYN 85 71AMINOSYN 85 -ELECTROLYTES71AMINOSYN II 10 71AMINOSYN II 15 71AMINOSYN II 7 71AMINOSYN II 85 71AMINOSYN II 85 -ELECTROLYTES71AMINOSYN M 35 71AMINOSYN-HBC 7 71AMINOSYN-PF 10 72AMINOSYN-PF 7 (SULFITE-FREE)72AMINOSYN-RF 52 72amiodarone 77AMITIZA 109amitriptyline 37amlodipine 81amlodipine-benazepril 81amlodipine-valsartan 81ammonium lactate 97amoxapine 37amoxicillin 15amoxicillin-pot clavulanate 15amphotericin b 45ampicillin 15ampicillin sodium 15

I-1

ampicillin-sulbactam 15ANADROL-50 113anagrelide 70anastrozole 18ANORO ELLIPTA 142APOKYN 53apraclonidine 104aprepitant 50apri 90APTIOM32APTIVUS 60APTIVUS (WITH VITAMIN E) 60aranelle (28) 90ARCALYST 121aripiprazole 55ARISTADA55ARISTADA INITIO 55armodafinil 146ARNUITY ELLIPTA 140arsenic trioxide 18ashlyna 90aspirin-dipyridamole 70ASSURE ID INSULIN SAFETY 101atazanavir 60atenolol 77atenolol-chlorthalidone 77atomoxetine 85atorvastatin 82atovaquone 52atovaquone-proguanil 52ATRIPLA60atropine 32 104ATROVENT HFA 142AUBAGIO85aubra 90aurovela 1530 (21) 90aurovela 120 (21) 90aurovela 24 fe 90

aurovela fe 1530 (28) 90aurovela fe 1-20 (28) 90AUSTEDO 85AVASTIN18aviane 90AVONEX 85AVONEX (WITH ALBUMIN)85AVSOLA 121ayuna 90AYVAKIT18azacitidine 18azathioprine 121azathioprine sodium 121azelastine 104azithromycin 13 14AZOPT 137aztreonam 14azurette (28) 90baciim 11bacitracin 105bacitracin-polymyxin b 105baclofen 145balsalazide 132BALVERSA18 19balziva (28) 90BANZEL 32BAVENCIO19BAXDELA 16BCG VACCINE LIVE (PF) 127BD ULTRA-FINE NANO PEN NEEDLE101BD VEO INSULIN SYR HALF UNIT 101BD VEO INSULIN SYRINGE UF 102bekyree (28) 90BELEODAQ19BELSOMRA146benazepril 76

BENDEKA19BENLYSTA134benztropine 53BESPONSA 19betamethasone acetsod phos 115betamethasone dipropionate 99betamethasone valerate 99betamethasone augmented 99BETASERON85betaxolol 77bethanechol chloride 112BETHKIS 10BEVYXXA 66bexarotene 19BEXSERO 128bicalutamide 19BICILLIN L-A 15BIDIL 84BIKTARVY 60bisoprolol fumarate 77bisoprolol-hydrochlorothiazide 77BLENREP 19bleomycin 19bleph-10 105BLINCYTO19blisovi 24 fe 90blisovi fe 1530 (28) 90blisovi fe 120 (28) 91BOOSTRIX TDAP128BORTEZOMIB 19BOSULIF 19BRAFTOVI 19BREO ELLIPTA 140BREZTRI AEROSPHERE 142briellyn 91BRILINTA 70brimonidine 137BRIVIACT 32bromocriptine 53BROMSITE 107

I-2

BRUKINSA 19budesonide 132 140bumetanide 81buprenorphine hcl 3 8buprenorphine-naloxone 8bupropion hcl 37bupropion hcl (smoking deter) 8buspirone 9butalbital-acetaminophen-caff 3butalbital-aspirin-caffeine 3BYNFEZIA 117BYSTOLIC78BYVALSON78cabergoline 53CABLIVI 135CABOMETYX 19caffeine citrate 85calcipotriene 98calcitonin (salmon) 133calcitriol 133calcium acetate(phosphat bind) 111calcium chloride 138CALDOLOR6CALQUENCE19camila 91CAPASTAT49CAPLYTA55CAPRELSA20captopril 76CARBAGLU 109carbamazepine 32carbidopa-levodopa 53carbidopa-levodopa-entacapone 53carteolol 137cartia xt 79carvedilol 78caspofungin 45CAYSTON 14

caziant (28) 91cefaclor 12cefadroxil 12cefazolin 12cefdinir 12cefditoren pivoxil 13cefepime 13cefixime 13cefotaxime 13cefoxitin 13cefpodoxime 13cefprozil 13ceftazidime 13ceftriaxone 13cefuroxime axetil 13cefuroxime sodium 13celecoxib 6CELONTIN32cephalexin 13CERDELGA 102CEREZYME 102CETYLEV 135CHANTIX8CHANTIX CONTINUING MONTH BOX8CHANTIX STARTING MONTH BOX8chloramphenicol sod succinate 11chlordiazepoxide hcl 9chlorhexidine gluconate 97chloroquine phosphate 52chlorothiazide 81chlorothiazide sodium 81chlorpromazine 55chlorthalidone 81chlorzoxazone 145cholestyramine (with sugar) 82cholestyramine light 82ciclopirox 45cilostazol 70

CIMDUO 60cimetidine hcl 108CIMZIA121CIMZIA POWDER FOR RECONST121cinacalcet 133CINQAIR 144CINRYZE 68CINVANTI 50CIPRODEX105ciprofloxacin 16ciprofloxacin hcl 16 105ciprofloxacin in 5 dextrose 16ciprofloxacin-dexamethasone 105citalopram 37clarithromycin 14CLENPIQ 111clindamycin hcl 11clindamycin in 5 dextrose 11clindamycin phosphate 11 47 98CLINIMIX 5D15W SULFITE FREE72CLINIMIX 5D25W SULFITE-FREE 72CLINIMIX 425D10W SULF FREE72CLINIMIX 425D5W SULFIT FREE 72CLINIMIX 425-D25W SULF-FREE72CLINIMIX 5-D20W(SULFITE-FREE) 72CLINIMIX E 275D10W SUL FREE 72CLINIMIX E 275D5W SULF FREE72CLINIMIX E 425D10W SUL FREE 73CLINIMIX E 425D25W SUL FREE 73

I-3

CLINIMIX E 425D5W SULF FREE73CLINIMIX E 5D15W SULFIT FREE 73CLINIMIX E 5D20W SULFIT FREE 73CLINIMIX E 5D25W SULFIT FREE 73CLINOLIPID 73clobazam 32 33clobetasol 99clobetasol-emollient 99clocortolone pivalate 99clofarabine 20clomipramine 38clonazepam 9 10clonidine 75clonidine hcl 75clopidogrel 70clorazepate dipotassium 10clotrimazole 45clotrimazole-betamethasone 45clovique 113clozapine 55 56COARTEM 52codeine sulfate 3colchicine 47colesevelam 82colestipol 82 83colistin (colistimethate na) 11colocort 132COMBIGAN 137COMBIVENT RESPIMAT142COMETRIQ20COMPLERA 60compro 50constulose 109COPAXONE85 86COPIKTRA20CORLANOR80

cormax 100cortisone 115COSENTYX (2 SYRINGES) 122COSENTYX PEN (2 PENS) 122COTELLIC20CREON 102CRIXIVAN 60cromolyn 104 109 144cryselle (28) 91cyclafem 135 (28) 91cyclafem 777 (28) 91cyclobenzaprine 145cyclopentolate 104cyclophosphamide 20CYCLOPHOSPHAMIDE20cyclosporine 122cyclosporine modified 122cyproheptadine 47CYRAMZA20cyred 91CYSTADANE 135CYSTARAN104dalfampridine 86DALIRESP144danazol 113dantrolene 145dapsone 49DAPTACEL (DTAP PEDIATRIC) (PF) 128daptomycin 11DARZALEX 20DARZALEX FASPRO 20dasetta 135 (28) 91dasetta 777 (28) 91DAURISMO 20daysee 91deblitane 91decadron 115decitabine 20

deferasirox 113deferiprone 113deferoxamine 113DELSTRIGO 60delyla (28) 91DEMSER80DEPO-PROVERA120DESCOVY 60desipramine 38desmopressin 117desog-eestradioleestradiol 91desogestrel-ethinyl estradiol 91desoximetasone 100desvenlafaxine succinate 38dexamethasone 115dexamethasone sodium phos (pf) 116dexamethasone sodium phosphate 107 116dexmethylphenidate 86dextroamphetamine 86dextroamphetamine-amphetamine 86dextrose 10 in water (d10w) 73dextrose 25 in water (d25w) 73dextrose 30 in water (d30w) 73dextrose 40 in water (d40w) 73dextrose 5 in water (d5w) 73dextrose 50 in water (d50w) 73dextrose 70 in water (d70w) 73DIASTAT33DIASTAT ACUDIAL33diazepam 10 33diazepam intensol 10diazoxide 135diclofenac epolamine 6diclofenac potassium 6diclofenac sodium 6 107dicloxacillin 15dicyclomine 109

I-4

didanosine 60DIFICID14digitek 80digox 80digoxin 80DIGOXIN 80dihydroergotamine 48diltiazem hcl 79dilt-xr 79dimenhydrinate 50dimethyl fumarate 86DIPENTUM132diphenhydramine hcl 47diphenoxylate-atropine 109dipyridamole 70disopyramide phosphate 77disulfiram 9divalproex 33dofetilide 77donepezil 36 37DOPTELET (10 TAB PACK) 68DOPTELET (15 TAB PACK) 68DOPTELET (30 TAB PACK) 68dorzolamide 137dorzolamide-timolol 137dotti 114DOVATO 60doxazosin 75doxepin 38doxercalciferol 133doxorubicin 20doxorubicin peg-liposomal 20doxy-100 17doxycycline hyclate 17doxycycline monohydrate 17DRIZALMA SPRINKLE 38dronabinol 50droperidol 135drospirenone-ethinyl estradiol 91DROXIA 21

DUAVEE114duloxetine 38DUPIXENT PEN 122DUPIXENT SYRINGE 122DUREZOL 107dutasteride 112econazole 45EDARBI 75EDARBYCLOR75EDURANT 60efavirenz 60efavirenz-emtricitabin-tenofov 60efavirenz-lamivu-tenofov disop 60EGRIFTA117EGRIFTA SV 117ELAPRASE 102ELIGARD21ELIGARD (3 MONTH)21ELIGARD (4 MONTH)21ELIGARD (6 MONTH)21elinest 91ELIQUIS 67ELIQUIS DVT-PE TREAT 30D START67ELITEK103ELLA91ELMIRON 135eluryng 91EMCYT 21EMEND 50EMFLAZA 116EMGALITY PEN 48EMGALITY SYRINGE 48emoquette 91EMPLICITI21EMSAM 38emtricitabine 60emtricitabine-tenofovir (tdf) 61EMTRIVA61enalapril maleate 76

enalaprilat 76enalapril-hydrochlorothiazide 76ENBREL 122ENBREL MINI 122ENBREL SURECLICK122ENDARI135endocet 3ENGERIX-B (PF) 128ENGERIX-B PEDIATRIC (PF) 128ENHERTU21enoxaparin 67enpresse 91enskyce 91entacapone 53entecavir 66ENTRESTO 75enulose 109EPCLUSA 64EPIDIOLEX33epinastine 104epinephrine 80epitol 33EPIVIR HBV61eplerenone 84EPOGEN 68epoprostenol (glycine) 146ergoloid 135ERGOMAR 48ERIVEDGE21ERLEADA 21erlotinib 21errin 91ertapenem 14ery pads 98erythromycin 14 105erythromycin ethylsuccinate 14erythromycin with ethanol 98ESBRIET 144escitalopram oxalate 38

I-5

esomeprazole sodium 108estarylla 91estradiol 114estradiol valerate 115estradiol-norethindrone acet 115eszopiclone 146ethambutol 49ethosuximide 33ethynodiol diac-eth estradiol 92etodolac 6 7etonogestrel-ethinyl estradiol 92ETOPOPHOS 21etoposide 21EUCRISA100EVENITY133everolimus (immunosuppressive) 122EVOTAZ 61EVRYSDI135exemestane 21EXONDYS-51 135EXTAVIA 86ezetimibe 83FABRAZYME 103falmina (28) 92famciclovir 66famotidine 108famotidine (pf) 108famotidine (pf)-nacl (iso-os) 108FANAPT 56FARYDAK 21FASENRA144FASENRA PEN 144febuxostat 47felbamate 33FEMRING 115femynor 92fenofibrate 83fenofibrate micronized 83fenofibrate nanocrystallized 83

fentanyl 3fentanyl citrate 3FERRIPROX 113FETZIMA 38FIASP FLEXTOUCH U-100 INSULIN42FIASP PENFILL U-100 INSULIN42FIASP U-100 INSULIN42finasteride 112FINTEPLA33FIRVANQ11FLEBOGAMMA DIF123flecainide 77FLOVENT DISKUS 141FLOVENT HFA141floxuridine 21fluconazole 45fluconazole in nacl (iso-osm) 45flucytosine 46fludrocortisone 116flumazenil 86flunisolide 107fluocinolone 100fluocinonide 100fluocinonide-e 100fluorometholone 107fluorouracil 21 98fluoxetine 38fluphenazine decanoate 56fluphenazine hcl 56flurbiprofen 7flurbiprofen sodium 107flutamide 21fluticasone propionate 100 107fluvoxamine 39fomepizole 135fondaparinux 67FORTEO 133fosamprenavir 61

fosaprepitant 50foscarnet 64fosinopril 76fosphenytoin 33FREAMINE HBC 69 74FREAMINE III 10 74FULPHILA 68fulvestrant 22furosemide 81 82FUZEON61fyavolv 115FYCOMPA 33gabapentin 33 34GALAFOLD 103galantamine 37GAMASTAN 123GAMMAGARD LIQUID 123GAMMAGARD S-D (IGA lt 1 MCGML)123GAMMAPLEX 123GAMMAPLEX (WITH SORBITOL)123ganciclovir sodium 66GARDASIL 9 (PF)128GATTEX 30-VIAL109GAUZE PAD 102gavilyte-c 111gavilyte-g 111gavilyte-n 111GAVRETO22GAZYVA 22gemfibrozil 83generlac 109gengraf 123GENOTROPIN 117GENOTROPIN MINIQUICK117gentak 105gentamicin 10 98 105gentamicin sulfate (ped) (pf) 10

I-6

gentamicin sulfate (pf) 10GENVOYA 61GILENYA86GILOTRIF 22GIVLAARI 70glatiramer 86glatopa 86GLEOSTINE22glimepiride 44glipizide 44 45glipizide-metformin 45GLUCAGEN HYPOKIT135glyburide 45glyburide micronized 45glyburide-metformin 45glycopyrrolate 110glydo 7GLYXAMBI 40GOCOVRI53granisetron (pf) 50granisetron hcl 51GRANIX 68griseofulvin microsize 46guanfacine 75 87guanidine 135GVOKE HYPOPEN 1-PACK 135GVOKE HYPOPEN 2-PACK 135GVOKE PFS 1-PACK SYRINGE 135GVOKE PFS 2-PACK SYRINGE 135HAEGARDA 68hailey 92hailey 24 fe 92hailey fe 1530 (28) 92hailey fe 120 (28) 92halobetasol propionate 100haloperidol 56

haloperidol decanoate 56haloperidol lactate 56HARVONI64 65HAVRIX (PF) 128heather 92heparin (porcine) 67heparin porcine (pf) 67HEPATAMINE 874HERCEPTIN 22HERCEPTIN HYLECTA22HERZUMA22HETLIOZ 146HIBERIX (PF)128HUMATROPE118HUMIRA 123HUMIRA PEDIATRIC CROHNS START 123HUMIRA PEN123HUMIRA PEN CROHNS-UC-HS START123HUMIRA PEN PSOR-UVEITS-ADOL HS123HUMIRA(CF)124HUMIRA(CF) PEDI CROHNS STARTER123HUMIRA(CF) PEN 124HUMIRA(CF) PEN CROHNS-UC-HS 124HUMIRA(CF) PEN PSOR-UV-ADOL HS 124HUMULIN R U-500 (CONC) INSULIN 42HUMULIN R U-500 (CONC) KWIKPEN43hydralazine 80hydrochlorothiazide 82hydrocodone-acetaminophen 3 4hydrocodone-ibuprofen 4hydrocortisone 100 116 132hydromorphone 4

hydromorphone (pf) 4hydroxychloroquine 52hydroxyprogesterone cap(ppres) 120hydroxyurea 22hydroxyzine hcl 47hydroxyzine pamoate 136HYPERRAB (PF)124HYPERRAB SD (PF) 124HYQVIA124ibandronate 133IBRANCE 22ibu 7ibuprofen 7icatibant 80ICLUSIG 22IDHIFA22ifosfamide 22ifosfamide-mesna 22ILARIS (PF) 124ILEVRO 107ILUMYA124imatinib 22IMBRUVICA 23IMFINZI 23imipenem-cilastatin 14imipramine hcl 39imiquimod 98IMLYGIC23IMOGAM RABIES-HT (PF) 124IMOVAX RABIES VACCINE (PF) 129IMPAVIDO52INBRIJA 53incassia 92INCRELEX 118INCRUSE ELLIPTA 142indapamide 82indomethacin 7

I-7

INFANRIX (DTAP) (PF) 129INFLECTRA124INGREZZA 87INGREZZA INITIATION PACK 87INLYTA 23INQOVI23INREBIC23INSULIN SYRINGE-NEEDLE U-100102INTELENCE61INTRALIPID74INTRON A65introvale 92INVEGA SUSTENNA 56 57INVEGA TRINZA57INVELTYS107INVIRASE 61INVOKAMET40INVOKAMET XR 40INVOKANA 40IONOSOL-B IN D5W 138IONOSOL-MB IN D5W 138IPOL 129ipratropium bromide 104 142irbesartan 75irbesartan-hydrochlorothiazide 75IRESSA 23ISENTRESS 61ISENTRESS HD 61isibloom 92ISOLYTE-P IN 5 DEXTROSE 138ISOLYTE-S 138isoniazid 49isosorbide dinitrate 84isosorbide mononitrate 84itraconazole 46ivermectin 52IXEMPRA23

IXIARO (PF)129JADENU SPRINKLE113jaimiess 92JAKAFI23jantoven 67JANUMET40JANUMET XR40 41JANUVIA41JARDIANCE 41jasmiel (28) 92jencycla 92JENTADUETO41JENTADUETO XR 41jinteli 115jolivette 92juleber 92JULUCA 61junel 1530 (21) 92junel 120 (21) 92junel fe 1530 (28) 92junel fe 120 (28) 92junel fe 24 92JUXTAPID83JYNARQUE 82KABIVEN 74KALETRA 61kalliga 92KALYDECO 144KANJINTI 23KANUMA103kariva (28) 92KEDRAB (PF) 124kelnor 135 (28) 93kelnor 1-50 93KESIMPTA PEN 87ketoconazole 46ketorolac 7 108KEVEYIS 136KEVZARA124 125KEYTRUDA 23

KINERET 125KINRIX (PF) 129kionex (with sorbitol) 110KISQALI 24KISQALI FEMARA CO-PACK23 24klor-con m10 138klor-con m15 138klor-con m20 138klor-con sprinkle 139KORLYM 41KOSELUGO 24KRINTAFEL 52KRYSTEXXA 103K-SOL139kurvelo (28) 93KUVAN103KYNMOBI 53 54KYPROLIS 24l norgesteestradiol-eestrad 93labetalol 78LACTATED RINGERS 132lactulose 110lamivudine 61lamivudine-zidovudine 62lamotrigine 34lansoprazole 109LANTUS SOLOSTAR U-100 INSULIN43LANTUS U-100 INSULIN 43lapatinib 24larin 1530 (21) 93larin 120 (21) 93larin 24 fe 93larin fe 1530 (28) 93larin fe 120 (28) 93larissia 93latanoprost 137LATUDA 57LAZANDA 4

I-8

ledipasvir-sofosbuvir 65leena 28 93leflunomide 125LEMTRADA 87LENVIMA 24lessina 93letrozole 24leucovorin calcium 136LEUKERAN24LEUKINE 68leuprolide 24levetiracetam 34levobunolol 137levocarnitine 136levocarnitine (with sugar) 136levocetirizine 47levofloxacin 16 105levofloxacin in d5w 16LEVOLEUCOVORIN CALCIUM 136levoleucovorin calcium 136levonest (28) 93levonorgestrel-ethinyl estrad 93levonorg-eth estrad triphasic 93levora-28 93levothyroxine 121LEXIVA 62LIALDA 132LIBTAYO24lidocaine 8lidocaine (pf) 7 77lidocaine hcl 8lidocaine viscous 8lidocaine-prilocaine 8lillow (28) 94linezolid 11linezolid in dextrose 5 11linezolid-09 sodium chloride 11LINZESS 110liothyronine 121

lisinopril 76lisinopril-hydrochlorothiazide 76lithium carbonate 87lithium citrate 87LIVALO 83lojaimiess 94LOKELMA 110LONHALA MAGNAIR REFILL 142LONHALA MAGNAIR STARTER 142LONSURF 24loperamide 110lopinavir-ritonavir 62lorazepam 10LORBRENA 24lorcet (hydrocodone) 4lorcet hd 4lorcet plus 4loryna (28) 94losartan 75losartan-hydrochlorothiazide 75LOTEMAX108LOTEMAX SM 108lovastatin 83low-ogestrel (28) 94loxapine succinate 57lo-zumandimine (28) 94LUCEMYRA 9LUMIGAN138LUMOXITI25LUPRON DEPOT 25 118LUPRON DEPOT (3 MONTH) 25 118LUPRON DEPOT (4 MONTH)25LUPRON DEPOT (6 MONTH)25LUPRON DEPOT-PED118

LUPRON DEPOT-PED (3 MONTH)118lutera (28) 94LYNPARZA 25LYSODREN 25lyza 94magnesium sulfate 139magnesium sulfate in d5w 139magnesium sulfate in water 139malathion 101maprotiline 39marlissa (28) 94MARPLAN 39MATULANE 25MAVENCLAD (10 TABLET PACK) 87MAVENCLAD (4 TABLET PACK) 87MAVENCLAD (5 TABLET PACK) 87MAVENCLAD (6 TABLET PACK) 87MAVENCLAD (7 TABLET PACK) 87MAVENCLAD (8 TABLET PACK) 87MAVENCLAD (9 TABLET PACK) 87MAVYRET 65MAYZENT 87meclizine 51medroxyprogesterone 120mefenamic acid 7mefloquine 52megestrol 25 120MEKINIST 25MEKTOVI 25meloxicam 7memantine 37MENACTRA (PF) 129

I-9

MENQUADFI (PF) 129MENVEO A-C-Y-W-135-DIP (PF) 129MEPSEVII103mercaptopurine 25meropenem 14meropenem-09 sodium chloride 14mesalamine 132mesna 136MESNEX136MESTINON 136metaproterenol 142 143metformin 41methadone 4methadose 4methenamine hippurate 12methimazole 121methocarbamol 145methotrexate sodium 25methotrexate sodium (pf) 25methoxsalen 98methscopolamine 110methyclothiazide 82methylphenidate hcl 88methylprednisolone 116methylprednisolone acetate 116methylprednisolone sodium succ 116metipranolol 138metoclopramide hcl 110metoprolol succinate 78metoprolol ta-hydrochlorothiaz 78metoprolol tartrate 78metronidazole 12 47 98metronidazole in nacl (iso-os) 12metyrosine 80mexiletine 77MIACALCIN 133miconazole-3 46

microgestin fe 120 (28) 94midodrine 75miglustat 103mili 94mimvey 115mimvey lo 115minitran 85minocycline 17minoxidil 85mirtazapine 39misoprostol 109MITIGARE47mitoxantrone 25M-M-R II (PF)129molindone 57mometasone 100 108mondoxyne nl 17MONJUVI25mono-linyah 94mononessa (28) 94montelukast 141MORPHINE4 5morphine 4 5morphine concentrate 4MOVANTIK 110MOXEZA 105moxifloxacin 16 105MOZOBIL68MULPLETA 68MULTAQ77mupirocin 99mycophenolate mofetil 125mycophenolate mofetil (hcl) 125MYLOTARG 26MYRBETRIQ 112myzilra 94nabumetone 7nafcillin 15nafcillin in dextrose iso-osm 15NAGLAZYME103

naloxone 9naltrexone 9NAMZARIC 37naproxen 7NARCAN9NATACYN 105NATPARA 133NAYZILAM 34necon 0535 (28) 94nefazodone 39neomycin 10neomycin-bacitracin-poly-hc 106neomycin-bacitracin-polymyxin 106neomycin-polymyxin b gu 99neomycin-polymyxin b-dexameth 106neomycin-polymyxin-gramicidin 106neomycin-polymyxin-hc 106neo-polycin 106neo-polycin hc 106NEPHRAMINE 54 74NERLYNX 26NEULASTA68NEUPOGEN69NEUPRO54nevirapine 62NEXAVAR 26NEXLETOL 83NEXLIZET 83niacin 83niacor 83nicardipine 81NICOTROL 9nifedipine 81nikki (28) 94nilutamide 26NINLARO26nitisinone 103

I-10

nitrofurantoin macrocrystal 12nitrofurantoin monohydm-cryst 12nitroglycerin 85NITYR103NIVESTYM 69nizatidine 109NOCDURNA (MEN) 118NOCDURNA (WOMEN)118nora-be 94NORDITROPIN FLEXPRO 118norethindrone (contraceptive) 94norethindrone acetate 120norethindrone ac-eth estradiol94 115norethindrone-eestradiol-iron 94norgestimate-ethinyl estradiol 95norlyda 95norlyroc 95NORMOSOL-M IN 5 DEXTROSE 139NORMOSOL-R PH 74139NORTHERA75nortrel 0535 (28) 95nortrel 135 (21) 95nortrel 135 (28) 95nortrel 777 (28) 95nortriptyline 39NORVIR 62NOVOLIN 7030 U-100 INSULIN43NOVOLIN 70-30 FLEXPEN U-100 43NOVOLIN N FLEXPEN43NOVOLIN N NPH U-100 INSULIN43NOVOLIN R FLEXPEN 43NOVOLIN R REGULAR U-100 INSULN43

NOVOLOG FLEXPEN U-100 INSULIN 43NOVOLOG MIX 70-30 U-100 INSULN43NOVOLOG MIX 70-30FLEXPEN U-10043NOVOLOG PENFILL U-100 INSULIN44NOVOLOG U-100 INSULIN ASPART44NOXAFIL 46NUBEQA 26NUCALA144 145NUCYNTA 5NUCYNTA ER5NUEDEXTA88NULOJIX125NUPLAZID 57NURTEC ODT 48NUTRILIPID74NUTROPIN AQ NUSPIN119nyamyc 46nystatin 46nystop 46OCALIVA 110OCREVUS 88OCTAGAM125octreotide acetate 119ODEFSEY62ODOMZO 26OFEV145ofloxacin 106ogestrel (28) 95OGIVRI26olanzapine 57 58olmesartan 75olmesartan-hydrochlorothiazide 76olopatadine 104OLUMIANT 125

omega-3 acid ethyl esters 83omeprazole 109omeprazole-sodium bicarbonate 109OMNITROPE 119ONCASPAR26ondansetron 51ondansetron hcl 51ondansetron hcl (pf) 51ONIVYDE26ONTRUZANT 26ONUREG26OPDIVO 26OPSUMIT 146oralone 97ORENCIA 125ORENCIA (WITH MALTOSE) 125ORENCIA CLICKJECT125ORENITRAM 146 147ORFADIN103ORILISSA 119ORKAMBI 145orsythia 95oseltamivir 64OSMOLEX ER54OTEZLA125OTEZLA STARTER125oxcarbazepine 34OXTELLAR XR 34oxybutynin chloride 112oxycodone 5oxycodone-acetaminophen 5oxycodone-aspirin 5OXYCONTIN6OZEMPIC 41pacerone 77PADCEV 26paliperidone 58PALYNZIQ 103

I-11

PANRETIN98pantoprazole 109paricalcitol 134PARICALCITOL 134paroex oral rinse 97paromomycin 52paroxetine hcl 39PASER49PAXIL 39PEDIARIX (PF) 129PEDVAX HIB (PF) 129peg 3350-electrolytes 111PEGANONE 34PEGASYS65 66PEGASYS PROCLICK 65PEGINTRON66PEMAZYRE 26PEN NEEDLE DIABETIC102penicillamine 113penicillin g potassium 16penicillin g procaine 16penicillin v potassium 16PENNSAID7PENTACEL (PF) 130PENTACEL DTAP-IPV COMPNT (PF) 130pentamidine 52pentoxifylline 70PERIKABIVEN 74perindopril erbumine 76periogard 97permethrin 101perphenazine 58perphenazine-amitriptyline 39PERSERIS58pfizerpen-g 16phenadoz 51phenelzine 39phenobarbital 34phenylephrine hcl 75 105

phenytoin 34phenytoin sodium 35phenytoin sodium extended 34 35PHESGO 26philith 95PHOSLYRA 111PICATO98PIFELTRO62pilocarpine hcl 97 138pimecrolimus 100pimozide 58pimtrea (28) 95pioglitazone 41piperacillin-tazobactam 16PIQRAY 26 27pirmella 95PLASMA-LYTE 148 139PLASMA-LYTE A139PLEGRIDY88podofilox 98POLIVY27polycin 106polymyxin b sulfate 12polymyxin b sulf-trimethoprim106POMALYST27portia 28 95PORTRAZZA 27posaconazole 46potassium chloride 139 140potassium chloride-045 nacl 140potassium citrate 140PRADAXA67PRALUENT PEN 83pramipexole 54prasugrel 70pravastatin 83prazosin 75prednicarbate 100prednisolone 116

prednisolone acetate 108prednisolone sodium phosphate 108 116prednisone 116 117pregabalin 35PREMARIN115PREMPHASE 115PREMPRO 115prenatal plus (calcium carb) 147prenatal vitamin plus low iron 147PRETOMANID 49prevalite 83previfem 95PREVYMIS64PREZCOBIX62PREZISTA 62PRIFTIN 49PRIMAQUINE 52primidone 35PRIVIGEN 125PROAIR RESPICLICK 143probenecid 47probenecid-colchicine 47procainamide 77PROCALAMINE 374prochlorperazine 51prochlorperazine edisylate 51prochlorperazine maleate 51PROCRIT69procto-med hc 100proctosol hc 100proctozone-hc 100PROCYSBI 112 136progesterone 121progesterone micronized 121PROGLYCEM 136PROGRAF 125PROLASTIN-C 145PROLENSA 108PROLEUKIN27

I-12

PROLIA134PROMACTA69promethazine 47 51promethegan 51propafenone 77proparacaine 105propranolol 78propranolol-hydrochlorothiazid 78propylthiouracil 121PROQUAD (PF) 130PROSOL 20 74protamine 70protriptyline 39PULMOZYME103PURIXAN27pyrazinamide 49pyridostigmine bromide 136pyrimethamine 52QINLOCK27QUADRACEL (PF) 130quetiapine 58quinapril 76quinidine sulfate 77RABAVERT (PF)130RADICAVA88raloxifene 115ramipril 76ranolazine 80rasagiline 54RASUVO (PF)126RAVICTI110RAYALDEE 134REBIF (WITH ALBUMIN)88REBIF REBIDOSE 88 89REBIF TITRATION PACK89reclipsen (28) 95RECOMBIVAX HB (PF) 130RECTIV136RELENZA DISKHALER 64RELISTOR110

REMICADE126RENFLEXIS 126repaglinide 41REPATHA PUSHTRONEX83REPATHA SURECLICK84REPATHA SYRINGE84RESCRIPTOR 62RESTASIS 108RETACRIT 69RETEVMO27RETROVIR62REVCOVI103REVLIMID 27revonto 145REXULTI 58REYATAZ 62REYVOW48RHOPRESSA 138ribasphere 66ribavirin 66RIDAURA 126rifabutin 49rifampin 50riluzole 89rimantadine 64RINVOQ126RISPERDAL CONSTA 58risperidone 58 59ritonavir 62RITUXAN27RITUXAN HYCELA 27rivastigmine 37rivastigmine tartrate 37rizatriptan 48 49ROCKLATAN 138ropinirole 54rosadan 99rosuvastatin 84ROTARIX 130ROTATEQ VACCINE130

ROZLYTREK27RUBRACA 27RUKOBIA62RUXIENCE 27RYBELSUS41RYDAPT27SABRIL 35SAIZEN119SAIZEN SAIZENPREP 119SANDOSTATIN LAR DEPOT 119SANTYL 98SAPHRIS59sapropterin 103SARCLISA28SAVELLA 89scopolamine base 51SECUADO 59selegiline hcl 54selenium sulfide 99SELZENTRY 63SEREVENT DISKUS 143SEROSTIM 119sertraline 39setlakin 95sevelamer carbonate 112sevelamer hcl 112sharobel 95SHINGRIX (PF) 130SIGNIFOR 119SIKLOS 70sildenafil (pulmhypertension) 147SILENOR 146SILIQ 126silver sulfadiazine 99SIMBRINZA 138simliya (28) 95simpesse 95SIMPONI126SIMPONI ARIA126

I-13

simvastatin 84sirolimus 126SIRTURO50SKYRIZI 126smoflipid 74sodium chloride 133sodium chloride 09 140sodium phenylbutyrate 110sodium polystyrene (sorb free) 111sodium polystyrene sulfonate 111sofosbuvir-velpatasvir 65SOLIQUA 10033 44SOLTAMOX 28SOLU-CORTEF ACT-O-VIAL (PF)117SOMATULINE DEPOT 120SOMAVERT 120sorine 78sotalol 79sotalol af 79SOVALDI65SPIRIVA RESPIMAT143SPIRIVA WITH HANDIHALER 143spironolactone 82SPRAVATO 39sprintec (28) 95SPRITAM35SPRYCEL 28sps (with sorbitol) 111sronyx 95ssd 99stavudine 63STELARA 126STIOLTO RESPIMAT143STIVARGA28STRENSIQ 103streptomycin 10STRIBILD63

STRIVERDI RESPIMAT 143SUBLOCADE 9subvenite 35sucralfate 109sulfacetamide sodium 106 107sulfacetamide sodium (acne) 99sulfacetamide-prednisolone 107sulfadiazine 16sulfamethoxazole-trimethoprim 16 17sulfasalazine 132sulfatrim 17sulindac 7sumatriptan 49sumatriptan succinate 49SUNOSI146SUPPRELIN LA 120SUPREP BOWEL PREP KIT 111SUTENT28syeda 95SYLATRON66SYLVANT28SYMBICORT 141SYMDEKO 145SYMFI63SYMFI LO 63SYMJEPI80SYMLINPEN 120 42SYMLINPEN 60 42SYMPAZAN 35SYMTUZA63SYNAGIS64SYNAREL120SYNERCID12SYNJARDY42SYNJARDY XR 42SYNRIBO28TABLOID 28TABRECTA 28

tacrolimus 101 127tadalafil (pulm hypertension) 147TAFINLAR28TAGRISSO 28TAKHZYRO137TALTZ AUTOINJECTOR 127TALTZ SYRINGE127TALZENNA 28tamoxifen 28tamsulosin 112TARGRETIN28tarina 24 fe 96tarina fe 120 (28) 96TASIGNA 28TAVALISSE70tazarotene 101TAZORAC 101taztia xt 79TAZVERIK28TDVAX 130TECENTRIQ 29TECFIDERA 89TECHNIVIE 65TEFLARO13TEKTURNA HCT84telmisartan 76temazepam 10TEMIXYS 63TEMODAR29TENIVAC (PF)131tenofovir disoproxil fumarate 63TEPEZZA105terazosin 112terbinafine hcl 46terbutaline 143terconazole 47teriparatide 134testosterone 114testosterone cypionate 113 114testosterone enanthate 114

I-14

TETANUSDIPHTHERIA TOX PED(PF) 131tetrabenazine 89tetracycline 17THALOMID 137theophylline 143THIOLA 113THIOLA EC 113thioridazine 59thiotepa 29thiothixene 59tiadylt er 79tiagabine 35TIBSOVO 29TICE BCG 127tigecycline 17tilia fe 96timolol maleate 79 138TIVICAY63TIVICAY PD63tizanidine 146TOBI PODHALER 11tobramycin 11 107tobramycin in 0225 nacl 11tobramycin sulfate 11tobramycin-dexamethasone 107TOLAK 98tolazamide 45tolterodine 112topiramate 35toposar 29toremifene 29torsemide 82TOTECT137TOUJEO MAX U-300 SOLOSTAR44TOUJEO SOLOSTAR U-300 INSULIN44TOVIAZ 112TRACLEER 147

TRADJENTA 42tramadol 6tramadol-acetaminophen 6trandolapril 76tranexamic acid 70TRANSDERM-SCOP51tranylcypromine 39TRAVASOL 10 74travoprost 138TRAZIMERA 29trazodone 39TREANDA 29TRECATOR50TRELEGY ELLIPTA 143TRELSTAR29TREMFYA127treprostinil sodium 147TRESIBA FLEXTOUCH U-100 44TRESIBA FLEXTOUCH U-200 44TRESIBA U-100 INSULIN 44tretinoin 101tretinoin (antineoplastic) 29tri femynor 96triamcinolone acetonide 97 101 117triamterene-hydrochlorothiazid 82trientine 113tri-estarylla 96trifluoperazine 59trifluridine 107trihexyphenidyl 54TRIKAFTA145tri-legest fe 96tri-linyah 96tri-lo-estarylla 96tri-lo-marzia 96tri-lo-mili 96tri-lo-sprintec 96

trilyte with flavor packets 111trimethoprim 12tri-mili 96trimipramine 40TRINTELLIX 40tri-previfem (28) 96TRIPTODUR 120tri-sprintec (28) 96TRIUMEQ 63trivora (28) 96tri-vylibra 96tri-vylibra lo 96TRODELVY 29TROGARZO63TROPHAMINE 10 74TROPHAMINE 6 74TRULICITY 42TRUMENBA 131TRUVADA 63TRUXIMA29TUDORZA PRESSAIR 144TUKYSA29tulana 96TURALIO 29TWINRIX (PF) 131TYBOST 137TYKERB30TYMLOS134TYPHIM VI131TYSABRI 127TYVASO 147UBRELVY 49UCERIS132UDENYCA 69UNITUXIN30UPTRAVI147ursodiol 111valacyclovir 66VALCHLOR 98valganciclovir 66

I-15

valproate sodium 35valproic acid 35valproic acid (as sodium salt) 35valrubicin 30valsartan 76valsartan-hydrochlorothiazide 76VALTOCO 36vancomycin 12VAQTA (PF) 131VARIVAX (PF) 131VASCEPA 84VELCADE 30velivet triphasic regimen (28) 96VELPHORO112VELTASSA 111VEMLIDY 63VENCLEXTA 30VENCLEXTA STARTING PACK 30venlafaxine 40verapamil 79 80VERSACLOZ59VERZENIO30V-GO 40102VIBERZI 111VICTOZA42VIDEX 2 GRAM PEDIATRIC63VIDEX EC64VIEKIRA PAK 65vienva 96vigabatrin 36vigadrone 36VIIBRYD 40VIMIZIM 104VIMPAT36vinorelbine 30viorele (28) 96VIRACEPT 64VIREAD64

VISTOGARD 137VITRAKVI30VIZIMPRO 30volnea (28) 97VOLTAREN 7voriconazole 46VOSEVI 65VOTRIENT30VPRIV 104VRAYLAR59VUMERITY89VYEPTI 49vyfemla (28) 97vylibra 97VYNDAMAX 81VYNDAQEL81VYXEOS 30warfarin 67water for irrigation sterile 133WELCHOL 84wera (28) 97XADAGO54XALKORI30XARELTO67 68XARELTO DVT-PE TREAT 30D START67XATMEP30XCOPRI 36XCOPRI MAINTENANCE PACK 36XCOPRI TITRATION PACK 36XELJANZ 127XELJANZ XR127XERMELO111XHANCE 108XIFAXAN12XIIDRA108XOFLUZA 64XOLAIR145

XOSPATA30XPOVIO 31XTAMPZA ER 6XTANDI 31xulane 97XULTOPHY 10036 44XURIDEN 137XYOSTED114XYREM146XYWAV 146YERVOY31YF-VAX (PF) 131YONDELIS31YONSA 31yuvafem 115zafirlukast 141zaleplon 146zarah 97ZARXIO70ZEJULA 31ZELBORAF 31zenatane 98zenchent (28) 97ZENPEP 104ZEPATIER65ZEPOSIA89ZEPOSIA STARTER KIT 89ZEPOSIA STARTER PACK 89ZEPZELCA 31zidovudine 64ZIEXTENZO70ziprasidone hcl 59ziprasidone mesylate 59ZIRABEV31ZIRGAN107ZOLADEX 31zoledronic acid 134zoledronic acid-mannitol-water 134ZOLINZA 31

I-16

zolpidem 146ZOMACTON 120zonisamide 36ZORBTIVE120ZORTRESS 127ZOSTAVAX (PF) 132zovia 135e (28) 97ZTLIDO 8ZUBSOLV9ZULRESSO40zumandimine (28) 97ZYDELIG 31ZYKADIA31 32ZYLET 107ZYPREXA RELPREVV 59ZYTIGA 32

I-17

注意如果您使用繁體中文您可以免費獲得語言援助服務請致電

주의 한국어를사용하시는경우 언어지원서비스를무료로이용하실수있습니다

번으로전화해주십시오

ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթեխոսում եք հայերեն ապա ձեզանվճար կարող են

տրամադրվել լեզվականաջակցության ծառայություններ Զանգահարեք

հեռատիպ

با باشد ی م فراهم شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی م گفتگوفارسی زبان به اگر توجه

د یریبگ تماس

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода

Звоните телетайп

注意事項日本語を話される場合無料の言語支援をご利用いただけます

（）までお電話にてご連絡ください

)رقم هاتف الصم والبكم 8422-996-855 المساعدة اللغویة تتوافر لك بالمجان اتصل برقمملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات

711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿਚ ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹਤ ਕਾਲ ਕਰ

បរយតន បរើសនជាអនកនយាយភាសាខមែរ បសវាជនយខននកភាសា

បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ

धयान द यददआप द िदी बोलत तोआपक ललए मफत म भाषा स ायता सवाएि उपलबध पर कॉलकर

เรยน ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร

PO Box 2336Dublin CA 94568-9802StanfordHealthCareAdvantageorg

Stanford Health Care Advantage is an HMO with a Medicare Contract Enrollment in Stanford Health Care Advantage depends on contract renewal

ATTENTION If you speak English language assistance services free of charge are available to you Call 1-855-996-8422 (TTY 711) ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-855-996-8422 (TTY 711) 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-855-996-8422（TTY711）

00020019 21This formulary was updated on 12012020 For more recent information or other questions please contact Stanford Health Care Advantage Member Care Services at 1-855-996-8422 or for TTY users 711 8 am to 8 pm seven days a week (except Thanksgiving and Christmas) from October 1 through March 31 and Monday through Friday (except holidays) from April 1 through September 30 or visit StanfordHealthCareAdvantageorg

H2986_PD20102_C

Analgesics

Anesthetics

Anti-AddictionSubstance Abuse Treatment Agents

Antianxiety Agents

Antibacterials

Anticancer Agents

Anticholinergic Agents

Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines

Anti-Infectives (Skin And Mucous Membrane)

Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents

Antiparkinsonian Agents

Antipsychotic Agents

Antivirals (Systemic)

Blood ProductsModifiersVolume Expanders

Caloric Agents

Cardiovascular Agents

Central Nervous System Agents

Contraceptives

Dental And Oral Agents

Dermatological Agents

Devices

Enzyme ReplacementModifiers

Eye Ear Nose Throat Agents

Gastrointestinal Agents

Genitourinary Agents

Heavy Metal Antagonists

Hormonal Agents StimulantReplacementModifying

Immunological Agents

Inflammatory Bowel Disease Agents

Irrigating Solutions

Metabolic Bone Disease Agents

Miscellaneous Therapeutic Agents

Ophthalmic Agents

Replacement Preparations

Respiratory Tract Agents

Skeletal Muscle Relaxants

Sleep Disorder Agents

Vasodilating Agents

Vitamins And Minerals

III

III

IV

IV

V

V

VI

VI

VII

VII

bull

o

bull

bull

o

bull

bull

bull

bull

bull

bull

bull

bull

Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


bull

o

bull

bull

o

bull

bull

bull

bull

bull

bull

bull

bull

Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


o

bull

bull

bull

bull

bull

bull

bull

bull

Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


bull

bull

bull

bull

bull

bull

bull

bull

Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


bull

bull

bull

bull

Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


Table of Contents


1


2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents



2









(Buprenex) 2


2


























3







2











2









4


2



4
































5














4




(Flector) 2 PA


2


(Voltaren-XR) 2


2






2


6





2


1 GC


(Childrens Advil) 2


(IBU) 1 GC







(Relafen) 2


1 GC



(EC-Naprosyn) 2










1 GC



1 GC


7



(Xylocaine) 1 GC




2





2






2










2


3 QL (336 per 365 days)


3 QL (336 per 365 days)


3


8



(Antabuse) 2




2


2





4 QL (1008 per 90 days)


5 NM NDS









2








9

























5 PA BvD NM NDS


2


2


2



2


10









2


2


2


(Cleocin HCl) 1 GC


2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


5 NM NDS


(Zyvox) 5 NM NDS


(Zyvox) 5 NM NDS



11



(Hiprex) 2


(Metro IV) 2








2


5 NM NDS



2


(Vancocin) 2




5 PA NM NDS


2


2



2


2



2


12





2



2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


(Keflex) 1 GC


2


5 NM NDS


(Zithromax) 2


13




(Zithromax) 2


1 GC


(Zithromax) 1 GC


2


2




(EES Granules) 2


(EryPed 400) 2


2


(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


(Merrem) 2


(Merrem) 2


2


14



1 GC


1 GC


1 GC


1 GC


2




(Augmentin) 1 GC


2


2


2


(Unasyn) 2


4


2


2



5 NM NDS



15



(Pfizerpen-G) 2


2


2


1 GC


2


2 PA BvD




(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


16



(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


4


2


(Doxy-100) 2


(Morgidox) 2


2


(Mondoxyne NL) 2


(Monodox) 2


(Vibramycin) 2


(Avidoxy) 2


2


2


2


2


(Tygacil) 5 NM NDS


5 NM NDS


17



5 PA NSO NM NDS


2 PA BvD


2 PA BvD










5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS




(Vidaza) 5 NM NDS




18







5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS










5 PA NSO NM NDS








19







(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD ST


5 PA NSO NM NDS


5 PA NSO NM LA NDS


5 PA NSO NM LA NDS






(Dacogen) 5 NM NDS






20



4


4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








4


(Toposar) 2



5 PA NSO NM NDS


2 PA BvD


2 PA BvD



21



(Faslodex) 5 NM NDS




5 PA NSO NM NDS




4


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS













(Ifex) 2


2


2




22









5 PA NSO NM NDS













5 NM NDS




5 PA NSO NM NDS








23















5 PA NSO NM NDS



5 PA NSO NM NDS



4


2












24



5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS










2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


2


5 PA NSO NM NDS


25



5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS










26





5 PA NSO NM NDS






5 NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS




27



5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


4





















28



5 PA NSO NM NDS


5 PA NSO NM NDS


(Tepadina) 5 NM NDS




2



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








29



5 PA NSO NM NDS


5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




(Navelbine) 2












5 PA BvD NM NDS




4 PA BvD ST




30

















5 PA NSO NM NDS


5 PA NSO NM NDS







5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






31







4






5 ST NM NDS


5 ST NM NDS








(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4



32




4



(Diastat AcuDial) 4





(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2












33








(Subvenite) 1 GC


(Lamictal) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4 ST


4


2


2


(Dilantin-125) 2






34



(Phenytek) 2


2


2












1 GC





(Gabitril) 2


(Topamax) 2


(Qudexy XR) 4


(Topamax) 1 GC


2


2



35



4









3 QL (1200 per 30 days)










4 PA NSO


5 PA NSO NM NDS


(Zonegran) 2



days)


36














3








2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





37



(Anafranil) 2


(Norpramin) 2


2




2











2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


38



2


2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 1 GC


4


2





(Zoloft) 1 GC


5 PA NSO NM NDS



1 GC



39



2








2




3


5 NM NDS




















40

































41



























42



























43





















days)







44









(Glynase) 2


2


6 GC




5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS




2


1 GC


2



2 PA BvD


(Diflucan) 2


(Diflucan) 2


45



(Ancobon) 5 NM NDS


2


2






2


5 NM NDS


2


2



2


2


(Nyamyc) 2


2


(Noxafil) 5 NM NDS





(Vfend) 5 NM NDS


(Vfend) 5 NM NDS


(Zyloprim) 1 GC


46








2



2


2


(Diphen) 1 GC


2


2


1 GC


(Xyzal) 2



1 GC


(Cleocin) 2



2


2


47

































48



























4







4




4




49



(Rifadin) 2


(Rifadin) 2


5 PA NM NDS


4


4


4


4 PA BvD










2









2


50



2




2


1 GC


1 GC


2


2 PA BvD



2 PA BvD


2


2


(Compazine) 1 GC


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(Phenadoz) 2


2






51




5 NM NDS


5 NM NDS


(Mepron) 5 NM NDS


(Malarone) 2




2


4


(Plaquenil) 2





4




(Nebupent) 2 PA BvD


(Pentam) 2


2




2


52





(Cogentin) 2


2





(Sinemet) 2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4













53



5 PA NM NDS








(Mirapex) 1 GC



(Requip) 2


2




2


1 GC








54























2


2







55











4 ST


2


2


2


2


2




2




(Haldol) 2


2


2


2




56























2













57











2























58









2


2


2






4 ST














59



(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


5 NM NDS





(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



60



(Truvada) 5 NM NDS


4


4


4


5 NM NDS



5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


5 NM NDS


4


5 NM NDS




(Epivir) 2


61



(Combivir) 2


4


(Kaletra) 2


(Viramune) 2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


4


4


5 NM NDS



5 NM NDS


62



4


5 NM NDS


4


2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS


5 NM NDS




4


63



4


5 NM NDS


5 NM NDS


5 NM NDS




(Foscavir) 2 PA BvD
















5 PA NM NDS








64





















5 PA NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


65



5 NM NDS


5 NM NDS


5 PA NSO NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD




2


(Cytovene) 2 PA BvD


2 PA BvD








(Valtrex) 2





66



3




(Lovenox) 2


(Lovenox) 2


(Arixtra) 5 NM NDS


(Arixtra) 2


2


2


2


2


2


1 GC




(Jantoven) 1 GC


3




67

















5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


68



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS






















5 PA NM NDS


69



5 NM NDS


5 PA NM NDS


5 PA NM NDS




5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3




2


2



4 PA BvD


70



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


71



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


72



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2


4 PA BvD


4 PA BvD


4 PA BvD


73



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD



4 PA BvD


4 PA BvD


4 PA BvD


74



(Catapres) 1 GC








(Cardura) 2



2




(Vazculep) 2


(Minipress) 2


3


3




(Avapro) 6 GC


(Avalide) 2


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 2


75



(Benicar HCT) 2


(Micardis) 2


(Diovan) 2


(Diovan HCT) 2


(Lotensin) 6 GC



2


(Vasotec) 2


2


(Vaseretic) 6 GC


6 GC


6 GC



(Zestril) 6 GC


(Zestoretic) 6 GC


2


(Accupril) 6 GC


(Altace) 6 GC


2


76





(Norpace) 2


(Tikosyn) 2


2


1 GC


2


3




2


2


2


2


2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 1 GC


77



3


3


(Coreg) 1 GC


2


2


2


(Toprol XL) 2


2


(Lopressor HCT) 2


(Lopressor) 2


2


(Lopressor) 1 GC


1 GC


2


(Inderal LA) 2


2


2


2


2


78



2


(Sorine) 2


2


2


2


2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



2


2


2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


79



(Calan SR) 1 GC






5 NM NDS


2


2


2


4


(Digitek) 2


(Digitek) 2






(Adrenalin) 1 GC


2


2





(Ranexa) 2




80







2


(Norvasc) 1 GC


(Lotrel) 2


2


(Exforge) 2


2


(Procardia XL) 2


(Adalat CC) 2



2


2


2


2


(Diuril IV) 2


2


2


2


81



1 GC


(Lasix) 1 GC


1 GC


1 GC


1 GC







(Aldactone) 1 GC


1 GC


(Dyazide) 1 GC


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


(Lipitor) 6 GC


(Questran) 2


2





82





2


(Tricor) 2


2











6 GC








2









2




83
















2


2




3 ST


3


2



(ISOCHRON) 2


2


1 GC


84



2



2


(Nitrostat) 2


(Minitran) 2






















(Cafcit) 2 PA BvD


2




85

























2












86



(Intuniv ER) 2


5 PA NM NDS








1 GC



(Lithobid) 2


2


4


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






87
























5 PA NM NDS




5 PA NM NDS








88



5 PA NM NDS


5 PA NM NDS





3




5 PA NM NDS










5 PA NM NDS


5 PA NM NDS



89



2


2


2







2





2


2


2


2


2




2


2


2


2


2


90



2




2


2


2


2



2


2





2


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


(Syeda) 2







2





91



(Kelnor 135 (28)) 2


(Kelnor 1-50) 2




2



2


2


2














2


2


2


2


2



2


92



2



2








2


2


2


2


2



4



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2



93







2


2


2



2


2



2


4


2


2




(Jencycla) 2


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2




(Aurovela 24 Fe) 2



2


94





(Tri Femynor) 2


(Estarylla) 2




2


2


2


2


2




2


2




2





2




2




95



2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2


2



2



2


96



2


2



2





2


2


2





1 GC


1 GC




(Oralone) 2





1 GC


(Geri-Hydrolac) 2


(Geri-Hydrolac) 2


97







2






5 NM NDS





4



5 NM NDS


2


(Cleocin T) 2


(Clindacin ETZ) 2



(Erygel) 2


2


(Ery Pads) 2








98




2






(Klaron) 2




2


2


2


2


2


2


2


2


2


2



2




2


(Cloderm) 4


99




(Topicort) 2


3




(Synalar) 2





(Cutivate) 2


2


2


2






1 GC







2


2


2


2


100





1 GC


(Triderm) 1 GC


2


2


(Trianex) 2




4 PA



4



(Retin-A) 2 PA






2


2


2


101



2


2


1 GC







2



2



5 NM NDS


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


102



5 NM NDS


5 PA NM NDS




5 PA NM NDS


5 PA BvD NM NDS


5 NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


103



5 PA NM NDS


5 NM NDS


3


2


(Isopto Atropine) 4




2


2


(Cyclogyl) 2


5 NM NDS


2






(Pataday) 2


104



4


(Alcaine) 2


5 PA NM NDS



2


(Baciguent) 2


(Polycin) 2


2


3


(Ciloxan) 1 GC


(Cetraxal) 4


(Ciprodex) 2


2


2


1 GC


2


3


(Vigamox) 2


4


105



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2


2


2


(Ocuflox) 2



2


(Polytrim) 1 GC


(Bleph-10) 2


106



2


2


(Tobrex) 1 GC


(TobraDex) 2


2


4


3


3 ST


3


2


2


3




(FML Liquifilm) 4


1 GC





3


3


107



(Acular) 2


3


3


3




(Pred Forte) 4


2


3








2


2


(Nexium IV) 2


1 GC


2


2




108







(Cytotec) 2


2


1 GC




(Protonix) 2








5 NM NDS


2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



109



2


2


2


(Constulose) 2






2


2


2


2


2


(Reglan) 1 GC






5 PA NM NDS










(Buphenyl) 5 NM NDS


110



2


2


2











3


2


2



(Gavilyte-C) 4


3


2


2


2


4


111



(Renvela) 5 NM NDS


(Renvela) 2




3


2


3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


(Uroxatral) 1 GC




5 NM NDS



1 GC


112



5 PA NM NDS


5 NM NDS


(240 per 30 days)









(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2




113



2 PA














2




3


(Estrace) 1 GC






(Estrace) 2



114



(Delestrogen) 2


(Amabelz) 2




2





(Fyavolv) 2


3


3


3


3


3



2






2 PA BvD




1 PA BvD GC


115



1 GC


1 GC


1 GC


1 GC









(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





1 PA BvD GC


116



2


4


(Kenalog) 2


5 NM NDS


2


(DDAVP) 2


2


(DDAVP) 2






4 PA


5 PA NM NDS


5 PA NM NDS


117



5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS






5 PA NM NDS


4 PA


118



5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS




119







5 PA NM NDS




5 NM NDS




5 PA NM NDS


4 PA


5 PA NM NDS




(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


120



2


(Prometrium) 2


(Euthyrox) 1 GC



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS


5 PA NM NDS


121



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




122



5 PA BvD NM NDS


4 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


123



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


4


4


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


4


5 PA NM NDS


124



5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD




(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


125



3


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


126



(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


4


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


3


3


3


3


127



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD






3


3


3


128



3 PA BvD


3


3


3


3


3


3


3


3


3


3


3


3


129



3


3


3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3




3


130



3


3


3


3


3


3


3


3


3




3


131







(Entocort EC) 2



5 ST NM NDS


(Cortenema) 4


2


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 5 NM NDS





3



4


132




4



4







2


(Rocaltrol) 2





(Hectorol) 2













5 NM NDS




133



2


2


(Zemplar) 2











2


2




5 NM NDS


(Ethyol) 2


5 PA NM NDS






134





4


5 NM NDS



2







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3



3


3


3


3


3


3


135



1 GC


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



4


(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 NM NDS


5 NM NDS


4


(Mestinon) 2


2


(Mestinon) 2




136







5 NM NDS








2


2


2


3


3


1 GC


1 GC


3


(Trusopt) 2


(Cosopt) 2




1 GC


137





2


(Isopto Carpine) 2






3


(Timoptic) 1 GC


(Timoptic-XE) 4




2


4


4


4


4


2


2


2


138



2


2


2


2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


4


2 PA BvD


2


2


(K-Tab) 2


(K-Tab) 4


139



(Klor-Con M10) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2












140
























(Singulair) 1 GC





141







2 PA BvD


2


2


3




3




3


2 PA BvD






1 GC


142



2












3





5 NM NDS


2


2


2


3


143







(Acetadote) 2


2 PA BvD


5 PA NM NDS


2 PA BvD






















144













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS




1 GC



(Dantrium) 2




2


145



























(Flolan) 2 PA






3 PA


146



5 PA NM NDS














5 PA NM NDS






5 PA NM NDS


3


3


147


148

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16


I-17






հեռատիպ








711)










H2986_PD20102_C

Analgesics

Anesthetics


Antianxiety Agents

Antibacterials

Anticancer Agents


Anticonvulsants

Antidementia Agents

Antidepressants

Antidiabetic Agents

Antifungals

Antigout Agents

Antihistamines


Antimigraine Agents

Antimycobacterials

Antinausea Agents

Antiparasite Agents





Caloric Agents



Contraceptives



Devices












Ophthalmic Agents





Vasodilating Agents


Stanford Health Care Advantage 2020 Formulary List of ...

Documents

Transcript of Stanford Health Care Advantage 2020 Formulary List of ...