Table of Contents Analgesics - Drugs for Pain3 4 5...Notes Analgesics - Drugs for Pain...

Navicent Health

Table of Contents

Analgesics - Drugs for Pain............................................................................................................................................ 3Analgesics - Drugs for Pain and Inflammation................................................................................................................5Anesthetics..................................................................................................................................................................... 5Anti-Addiction / Substance Abuse Treatment Agents..................................................................................................... 6Antibacterials.................................................................................................................................................................. 7Anticoagulants.............................................................................................................................................................. 11Anticonvulsants - Drugs for Seizures............................................................................................................................11Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.......................................................................... 12Antidepressants............................................................................................................................................................ 13Antiemetics - Drugs for Nausea and Vomiting.............................................................................................................. 14Antifungals.................................................................................................................................................................... 14Antigout Agents.............................................................................................................................................................15Anti-inflammatory Agents..............................................................................................................................................15Antimigraine Agents......................................................................................................................................................15Antimyasthenic Agents................................................................................................................................................. 16Antimycobacterials........................................................................................................................................................16Antineoplastics - Drugs for Cancer............................................................................................................................... 16Antiparasitics.................................................................................................................................................................20Antiparkinson Agents.................................................................................................................................................... 21Antiplatelets.................................................................................................................................................................. 21Antipsychotics - Drugs for Mood Disorders...................................................................................................................22Antivirals....................................................................................................................................................................... 22Anxiolytics - Drugs for Anxiety...................................................................................................................................... 24Bipolar Agents - Drugs for Mood Disorders.................................................................................................................. 24Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......................................................... 25Cardiovascular Agents - Drugs for Heart and Circulation Conditions........................................................................... 26Central Nervous System Agents - Drugs for Attention Deficit Disorder....................................................................... 31Central Nervous System Agents - Drugs for Multiple Sclerosis....................................................................................31Central Nervous System Agents - Miscellaneous.........................................................................................................32Dental and Oral Agents - Drugs for Mouth and Throat Conditions............................................................................... 32Dermatological Agents - Drugs for Skin Conditions......................................................................................................33Diabetes - Antidiabetic Agents......................................................................................................................................36Diabetes - Glucose Monitoring......................................................................................................................................37Diabetes - Glycemic Agents..........................................................................................................................................38Diabetes - Insulins........................................................................................................................................................ 38Electrolytes / Minerals / Metals / Vitamins.................................................................................................................... 39Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer........................................................................................... 43Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions............................................................ 44Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment......................................................... 45Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.................................................................. 45Genitourinary Agents - Drugs for Prostate Conditions..................................................................................................46Hormonal Agents - Adrenal...........................................................................................................................................46Hormonal Agents - Men's Health.................................................................................................................................. 47Hormonal Agents - Osteoporosis..................................................................................................................................48Hormonal Agents - Pituitary.......................................................................................................................................... 48Hormonal Agents - Prostaglandins............................................................................................................................... 48Hormonal Agents - Sex Hormones and Birth Control ................................................................................................... 49Hormonal Agents - Thyroid........................................................................................................................................... 52Immunological Agents - Drugs for Immune System Stimulation or Suppression..........................................................52Immunological Agents - Drugs for Vaccination............................................................................................................. 54Inflammatory Bowel Disease Agents............................................................................................................................ 55Metabolic Bone Disease Agents - Drugs for Osteoporosis...........................................................................................55Metabolic Bone Disease Agents - Other.......................................................................................................................55Miscellaneous Therapeutic Agents............................................................................................................................... 56

1

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...................................................................... 59Ophthalmic Agents - Drugs for Glaucoma.................................................................................................................... 60Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions.....................................................................................61Otic Agents - Drugs for Ear Conditions.........................................................................................................................61Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold................................................................... 62Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...............................................63Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis................................................................................64Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension................................................................64Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................................. 65Sleep Disorder Agents.................................................................................................................................................. 65

2

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

acetaminophen-codeine TIER 01 QL

acetaminophen-codeine #2

TIER 01 QL


TIER 01 QL


TIER 01 QL

ACTIQ TIER 03 PA; QL

alfentanil hcl TIER 01

apap-caff-dihydrocodeine oral capsule

TIER 01 QL

ascomp-codeine TIER 01

BELBUCA TIER 02 PA; QL

BUPRENEX TIER 03

buprenorphine hcl injection

TIER 01

buprenorphine transdermal

TIER 01 PA; QL

butalbital-acetaminophen oral capsule

TIER 01

butalbital-acetaminophen oral tablet 50-325 mg

TIER 01

butalbital-apap-caff-cod TIER 01

butalbital-apap-caffeine TIER 01

butalbital-asa-caff-codeine

TIER 01

butalbital-aspirin-caffeine TIER 01

butorphanol tartrate injection

TIER 01

butorphanol tartrate nasal

TIER 01 QL

BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR

TIER 03 PA; QL

carisoprodol-aspirin-codeine

TIER 01

codeine sulfate TIER 01 QL

DEMEROL TIER 03

DILAUDID INJECTION TIER 03

DOLOPHINE TIER 03 PA

duramorph TIER 01


duraxin TIER 01

endocet TIER 01 QL

ESGIC TIER 03

fentanyl TIER 01 PA; QL

fentanyl citrate buccal lozenge on a handle

TIER 01 PA; QL

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION

TIER 03

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 5-0.9 MCG/ML-%, 500-0.9 MCG/50ML-%, 550-0.9 MCG/55ML-%

TIER 03

FIORINAL TIER 03

FIORINAL/CODEINE #3 TIER 03

hydrocodone bitartrate er oral capsule er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg

TIER 01 PA

hydrocodone-acetaminophen

TIER 01 QL

hydrocodone-ibuprofen TIER 01 QL

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 16 mg, 32 mg, 8 mg

TIER 01 PA; QL

HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML

TIER 03

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

TIER 01

HYDROMORPHONE HCL INTRAVENOUS

TIER 03

hydromorphone hcl oral TIER 01 QL

hydromorphone hcl pf TIER 01

HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION

TIER 03

hydromorphone hcl solution 1 mg/ml injection

TIER 01

TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, SPECIALTY: SPECIALTY

3


HYDROMORPHONE HCL-NACL

TIER 03

HYSINGLA ER TIER 02 PA; QL

INFUMORPH 200 TIER 03

INFUMORPH 500 TIER 03

LORTAB TIER 03 QL

MEDROX-RX TIER 03

meperidine hcl injection TIER 01

meperidine hcl oral TIER 01 QL

methadone hcl injection TIER 01

methadone hcl intensol TIER 01

methadone hcl oral concentrate

TIER 01

methadone hcl oral solution

TIER 01

methadone hcl oral tablet TIER 01 PA

methadone hcl oral tablet soluble

TIER 01

METHADONE HCL-NACL

TIER 03

METHADOSE ORAL CONCENTRATE 10 MG/ML

TIER 03

methadose oral tablet soluble

TIER 01

METHADOSE SUGAR-FREE

TIER 03

mitigo TIER 01

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

TIER 01 QL

morphine sulfate (pf) TIER 01

morphine sulfate er TIER 01 PA; QL

morphine sulfate er beads

TIER 01 PA; QL

MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML

TIER 03

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

TIER 01

MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML

TIER 03


MORPHINE SULFATE INTRAVENOUS SOLUTION 1 MG/ML

TIER 03

morphine sulfate oral TIER 01 QL

MORPHINE SULFATE-NACL

TIER 03

nalbuphine hcl injection TIER 01

oxycodone hcl oral capsule

TIER 01 QL

oxycodone hcl oral concentrate 100 mg/5ml

TIER 01 QL

oxycodone hcl oral solution

TIER 01 QL

oxycodone hcl oral tablet TIER 01 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

TIER 01 QL

oxycodone-aspirin TIER 01 QL

OXYCONTIN TIER 02 PA; QL

oxymorphone hcl TIER 01 QL

oxymorphone hcl er TIER 01

pentazocine-naloxone hcl

TIER 01 QL

PROBUPHINE IMPLANT KIT

TIER 03

remifentanil hcl TIER 01

tencon TIER 01

tramadol hcl er (biphasic) TIER 01 QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

TIER 01 PA; QL

tramadol hcl er oral tablet extended release 24 hour

TIER 01 QL

tramadol hcl ir TIER 01 QL

tramadol-acetaminophen TIER 01 QL

TREZIX TIER 03 QL

ULTIVA TIER 03

XTAMPZA ER TIER 02 PA; QL

ZEBUTAL TIER 03


4


Analgesics - Drugs for Pain and Inflammation

CALDOLOR TIER 03

celecoxib oral TIER 01 QL

DAYPRO TIER 03

DICLOFENAC EPOLAMINE

TIER 03 QL

diclofenac potassium TIER 01

diclofenac sodium er TIER 01

diclofenac sodium oral TIER 01

diclofenac sodium transdermal gel 1 %

TIER 01 QL

diclofenac sodium transdermal solution

TIER 01 PA

diclofenac-misoprostol TIER 01

DICLOFONO TIER 03

diflunisal oral TIER 01

EC-NAPROSYN TIER 03

ec-naproxen TIER 01

etodolac TIER 01

etodolac er TIER 01

FELDENE TIER 03

flurbiprofen oral TIER 01

ibu TIER 01

ibuprofen lysine TIER 01

ibuprofen oral suspension

TIER 01

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

TIER 01

INDOCIN ORAL TIER 03 ST

indomethacin er TIER 01

indomethacin oral capsule 25 mg, 50 mg

TIER 01

indomethacin sodium TIER 01

ketoprofen er TIER 01

ketoprofen oral capsule 50 mg, 75 mg

TIER 01

ketorolac tromethamine injection solution 15 mg/ml

TIER 01

ketorolac tromethamine intramuscular

TIER 01


ketorolac tromethamine oral

TIER 01 QL

KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION

TIER 03

ketorolac tromethamine solution 30 mg/ml injection

TIER 01

LODINE TIER 03

meclofenamate sodium oral

TIER 01

meloxicam oral TIER 01

nabumetone oral TIER 01

naproxen dr TIER 01

naproxen oral tablet TIER 01

naproxen sodium oral tablet 275 mg, 550 mg

TIER 01

NEOPROFEN TIER 03

oxaprozin TIER 01

piroxicam oral TIER 01

sulindac oral TIER 01

tolmetin sodium TIER 01

Anesthetics

ARTICADENT DENTAL TIER 03

bupivacaine fisiopharma TIER 01

bupivacaine hcl (pf) TIER 01

bupivacaine hcl injection solution 0.25 %, 0.5 %

TIER 01

bupivacaine-epinephrine TIER 01

bupivacaine-epinephrine (pf)

TIER 01

CARBOCAINE TIER 03

CARBOCAINE PRESERVATIVE-FREE

TIER 03

chloroprocaine hcl (pf) TIER 01

CITANEST FORTE DENTAL

TIER 03

CITANEST PLAIN DENTAL

TIER 03

D-CARE 100X TIER 03

ethyl chloride TIER 01

EXPAREL TIER 03


5


GEBAUERS PAIN EASE TIER 03

GEBAUERS SPRAY AND STRETCH

TIER 03

glydo TIER 01

L.E.T. TIER 03

lidocaine external ointment

TIER 01

lidocaine external patch 5 %

TIER 01

lidocaine hcl (cardiac) TIER 01

lidocaine hcl (cardiac) pf TIER 01

lidocaine hcl (pf) TIER 01

lidocaine hcl external solution

TIER 01

lidocaine hcl injection solution 0.5 %

TIER 01

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

LIDOCAINE HCL SOLUTION 1 % INJECTION

TIER 03

lidocaine hcl solution 1 % injection

TIER 01

LIDOCAINE HCL SOLUTION 2 % INJECTION

TIER 03

lidocaine hcl solution 2 % injection

TIER 01

lidocaine hcl urethral/mucosal

TIER 01

LIDOCAINE IN D5W INTRAVENOUS SOLUTION 2-5 MG/ML-%

TIER 03

lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%

TIER 01

LIDOCAINE IN DEXTROSE

TIER 03

lidocaine-epinephrine injection

TIER 01

lidocaine-prilocaine external cream

TIER 01

LIDOCAINE-SODIUM BICARBONATE

TIER 03


LIDO-EPINEPHRINE-TETRACAINE

TIER 03

MARCAINE TIER 03

MARCAINE PRESERVATIVE FREE

TIER 03

MARCAINE/EPINEPHRINE

TIER 03

MARCAINE/EPINEPHRINE PF

TIER 03

NAROPIN TIER 03

NESACAINE TIER 03

NESACAINE-MPF TIER 03

ORABLOC TIER 03

polocaine TIER 01

polocaine-mpf TIER 01

PREPIV SUPPLY TIER 03

ropivacaine hcl injection solution 10 mg/ml, 2 mg/ml, 5 mg/ml, 7.5 mg/ml

TIER 01

sensorcaine TIER 01

sensorcaine/epinephrine TIER 01

sensorcaine-mpf TIER 01

sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000

TIER 01

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %

TIER 03

VENIPUNCTURE PX1 PHLEBOTOMY

TIER 03

XYLOCAINE TIER 03

xylocaine dental TIER 01

XYLOCAINE/EPINEPHRINE

TIER 03

XYLOCAINE-MPF TIER 03

XYLOCAINE-MPF/EPINEPHRINE

TIER 03

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium TIER 01


6


ANTABUSE TIER 03

BUNAVAIL TIER 03 QL

buprenorphine hcl sublingual

TIER 01 QL

buprenorphine hcl-naloxone hcl

TIER 01 QL

bupropion hcl er (smoking det)

TIER 01 QL

CHANTIX TIER 03 QL

CHANTIX CONTINUING MONTH PAK

TIER 03 QL

CHANTIX STARTING MONTH PAK

TIER 03 QL

disulfiram oral TIER 01

LUCEMYRA TIER 03

naloxone hcl injection solution

TIER 01

naloxone hcl injection solution cartridge

TIER 01

naloxone hcl injection solution prefilled syringe

TIER 01

naltrexone hcl oral TIER 01

NARCAN TIER 02

NICOTROL TIER 03 QL

NICOTROL NS TIER 03 QL

SUBLOCADE SPECIALTY

VIVITROL SPECIALTY

ZUBSOLV TIER 02 QL

Antibacterials

AEMCOLO TIER 03 PA

ALTABAX TIER 03

amikacin sulfate injection TIER 01

amoxicillin TIER 01

amoxicillin-potassium clavulanate er

TIER 01

amoxicillin-potassium clavulanate oral

TIER 01

ampicillin TIER 01

ampicillin sodium TIER 01

ampicillin-sulbactam sodium

TIER 01

ARIKAYCE SPECIALTY

AUGMENTIN TIER 03


AUGMENTIN ES-600 TIER 03

avidoxy TIER 01

AVYCAZ TIER 03

AZACTAM TIER 03

azithromycin intravenous TIER 01

azithromycin oral TIER 01

aztreonam TIER 01

baciim TIER 01

bacitracin intramuscular TIER 01

BACTRIM TIER 03

BACTRIM DS TIER 03

BAXDELA TIER 03

benzalkonium chloride external solution

TIER 01

BICILLIN C-R TIER 03

BICILLIN C-R 900/300 TIER 03

BICILLIN L-A TIER 03

cefaclor TIER 01

cefaclor er TIER 01

cefadroxil TIER 01

CEFAZOLIN IN SODIUM CHLORIDE

TIER 03

cefazolin sodium injection

TIER 01

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

cefazolin sodium intravenous solution reconstituted

TIER 01

cefazolin sodium-dextrose

TIER 01

cefdinir TIER 01

cefditoren pivoxil TIER 01

cefepime hcl injection TIER 01

cefepime hcl intravenous solution

TIER 01

cefepime-dextrose TIER 01

cefixime TIER 01

CEFOTAN TIER 03

cefotaxime sodium TIER 01

cefotetan disodium TIER 01


7


cefotetan disodium-dextrose

TIER 01

cefoxitin sodium TIER 01

CEFOXITIN SODIUM-DEXTROSE

TIER 03

cefpodoxime proxetil TIER 01

cefprozil TIER 01

ceftazidime and dextrose TIER 01

ceftazidime injection TIER 01

ceftriaxone sodium in dextrose

TIER 01

ceftriaxone sodium injection

TIER 01

ceftriaxone sodium intravenous

TIER 01

ceftriaxone sodium-dextrose

TIER 01

cefuroxime axetil TIER 01

cefuroxime sodium TIER 01

CENTANY TIER 03

cephalexin TIER 01

chloramphenicol sod succinate

TIER 01

CIPRO TIER 03

ciprofloxacin hcl oral TIER 01

ciprofloxacin in d5w TIER 01

clarithromycin er TIER 01

clarithromycin oral TIER 01

CLEOCIN ORAL TIER 03

CLEOCIN PHOSPHATE TIER 03

CLEOCIN VAGINAL CREAM

TIER 03

CLEOCIN VAGINAL SUPPOSITORY

TIER 02

clindamycin hcl oral TIER 01

clindamycin palmitate hcl TIER 01

clindamycin phosphate in d5w

TIER 01

CLINDAMYCIN PHOSPHATE IN NACL

TIER 03

clindamycin phosphate injection

TIER 01


clindamycin phosphate vaginal

TIER 01

CLINDESSE TIER 03

colistimethate sodium (cba)

TIER 01

COLY-MYCIN M TIER 03

DALVANCE TIER 03

daptomycin TIER 01

demeclocycline hcl TIER 01

dicloxacillin sodium TIER 01

DIFICID TIER 03

doxy 100 TIER 01

doxycycline hyclate intravenous

TIER 01

doxycycline hyclate oral capsule

TIER 01

doxycycline hyclate oral tablet 100 mg, 20 mg

TIER 01

doxycycline monohydrate oral capsule 100 mg, 50 mg

TIER 01

doxycycline monohydrate oral suspension reconstituted

TIER 01

doxycycline monohydrate oral tablet

TIER 01

E.E.S. GRANULES TIER 03

ertapenem sodium TIER 01

ERYPED 200 TIER 03

ERYPED 400 TIER 03

ERY-TAB TIER 03

ERYTHROCIN LACTOBIONATE

TIER 03

ERYTHROCIN STEARATE

TIER 03

erythromycin base TIER 01

erythromycin ethylsuccinate oral

TIER 01

erythromycin oral TIER 01

FETROJA TIER 03

FIRVANQ TIER 03

FLAGYL TIER 03

FORTAZ TIER 03


8


gentamicin in saline TIER 01

gentamicin sulfate external

TIER 01

gentamicin sulfate injection

TIER 01

HIPREX TIER 03

hydrogen peroxide TIER 01

imipenem-cilastatin TIER 01

INVANZ TIER 03

KEFLEX TIER 03

levofloxacin in d5w TIER 01

levofloxacin intravenous TIER 01

levofloxacin oral TIER 01

LINCOCIN TIER 03

lincomycin hcl injection TIER 01

linezolid in sodium chloride

TIER 01

linezolid intravenous TIER 01

linezolid oral TIER 01 QL

MACROBID TIER 03

MACRODANTIN TIER 03

mafenide acetate external

TIER 01

meropenem TIER 01

MEROPENEM-SODIUM CHLORIDE

TIER 03

MERREM TIER 03

methenamine hippurate TIER 01

metronidazole in nacl TIER 01

metronidazole oral TIER 01

metronidazole vaginal TIER 01

MINOCIN INTRAVENOUS

TIER 03

minocycline hcl oral TIER 01

mondoxyne nl oral capsule 100 mg

TIER 01

MONUROL TIER 03

morgidox oral TIER 01

moxifloxacin hcl in nacl TIER 01

MOXIFLOXACIN HCL INTRAVENOUS

TIER 03

moxifloxacin hcl oral TIER 01


mupirocin external TIER 01

NAFCILLIN SODIUM IN DEXTROSE

TIER 03

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

TIER 01

nafcillin sodium intravenous

TIER 01

neomycin sulfate oral TIER 01

neomycin-polymyxin b gu

TIER 01

nitrofurantoin TIER 01

nitrofurantoin macrocrystal oral

TIER 01

nitrofurantoin monohydrate macrocrystals

TIER 01

NUZYRA TIER 03

ofloxacin oral TIER 01

ORBACTIV TIER 03

oxacillin sodium TIER 01

OXACILLIN SODIUM IN DEXTROSE

TIER 03

paromomycin sulfate oral TIER 01

PENICILLIN G POT IN DEXTROSE

TIER 03

penicillin g potassium TIER 01

penicillin g procaine TIER 01

penicillin g sodium TIER 01

penicillin v potassium TIER 01

PFIZERPEN TIER 03

piperacillin sod-tazobactam so

TIER 01

polymyxin b sulfate injection

TIER 01

PRIMAXIN IV TIER 03

PRIMSOL TIER 03

RECARBRIO TIER 03

SEYSARA TIER 03 ST

silver sulfadiazine external

TIER 01

SIVEXTRO INTRAVENOUS

TIER 03 QL

SOLOSEC TIER 03


9


ssd TIER 01

streptomycin sulfate intramuscular

TIER 01

sulfadiazine oral TIER 01

sulfamethoxazole-trimethoprim

TIER 01

SULFAMYLON EXTERNAL PACKET

TIER 03

sulfatrim pediatric TIER 01

SUPRAX TIER 03

SYNERCID TIER 03

tazicef injection TIER 01

TAZICEF INTRAVENOUS SOLUTION

TIER 03

tazicef intravenous solution reconstituted

TIER 01

TEFLARO TIER 03

tetracycline hcl oral TIER 01

tigecycline TIER 01

tinidazole oral TIER 01

tobramycin sulfate injection

TIER 01

trimethoprim oral TIER 01

TYGACIL TIER 03

UNASYN TIER 03

VABOMERE TIER 03

VANCOCIN TIER 03

VANCOCIN HCL TIER 03

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1.25-5 GM/250ML-%, 1.5-5 GM/250ML-%

TIER 03

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

TIER 01

vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%

TIER 01


VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/250ML-%, 1.25-0.9 GM/250ML-%, 1.5-0.9 GM/250ML-%, 1.75-0.9 GM/250ML-%, 2-0.9 GM/500ML-%

TIER 03

VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS

TIER 03

vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous

TIER 01

VANCOMYCIN HCL INTRAVENOUS SOLUTION 1000 MG/10ML, 1250 MG/12.5ML, 1500 MG/15ML, 1750 MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML

TIER 03

vancomycin hcl intravenous solution 1000 mg/200ml, 1250 mg/250ml, 1500 mg/300ml, 1750 mg/350ml, 2000 mg/400ml, 500 mg/100ml, 750 mg/150ml

TIER 01

vancomycin hcl intravenous solution reconstituted

TIER 01

vancomycin hcl oral TIER 01

vandazole TIER 01

VIBATIV TIER 03

VIBRAMYCIN TIER 03 ST

XENLETA TIER 03

XEPI TIER 03

XERAVA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

TIER 03

XIFAXAN TIER 03 PA

XIMINO TIER 03


10


ZEMDRI TIER 03

ZERBAXA TIER 03

ZITHROMAX TIER 03

ZITHROMAX TRI-PAK TIER 03

ZITHROMAX Z-PAK TIER 03

ZOSYN TIER 03

ZYVOX INTRAVENOUS TIER 03

ZYVOX ORAL SUSPENSION RECONSTITUTED

TIER 03 QL

Anticoagulants

ACD FORMULA A TIER 03

ACD-A NOCLOT-50 TIER 03

ANGIOMAX TIER 03

anticoagulant cit dext soln a

TIER 01

anticoagulant sodium citrate

TIER 01

argatroban TIER 01

ARIXTRA SPECIALTY QL

bivalirudin trifluoroacetate

TIER 01

ELIQUIS TIER 02 QL

ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG

TIER 02 QL

enoxaparin sodium SPECIALTY QL

fondaparinux sodium SPECIALTY QL

FRAGMIN SPECIALTY QL

heparin (porcine) in nacl intravenous solution

TIER 01

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-%

TIER 03

heparin sod (porcine) in d5w

TIER 01

heparin sodium (porcine) TIER 01

heparin sodium (porcine) pf

TIER 01


jantoven TIER 01

LOVENOX SPECIALTY QL

PRADAXA TIER 02 QL

RETAVASE TIER 03

RETAVASE HALF-KIT TIER 03

SAVAYSA TIER 03 QL

SODIUM CITRATE IN VITRO

TIER 03

SODIUM CITRATE LOCK FLUSH

TIER 03

THROMBATE III SPECIALTY

TNKASE TIER 03

TRICITRASOL TIER 03

warfarin sodium oral TIER 01

XARELTO TIER 02 QL

XARELTO STARTER PACK

TIER 02 QL

Anticonvulsants - Drugs for Seizures

BANZEL TIER 03 PA

BRIVIACT TIER 03

carbamazepine er TIER 01

carbamazepine oral TIER 01

CELONTIN TIER 03

CEREBYX TIER 03

clobazam TIER 01 PA

DIACOMIT SPECIALTY PA

DIASTAT ACUDIAL TIER 03 QL

DIASTAT PEDIATRIC TIER 03 QL

diazepam rectal TIER 01 QL

DILANTIN ORAL CAPSULE 30 MG

TIER 03

divalproex sodium er TIER 01

divalproex sodium oral TIER 01

EPIDIOLEX SPECIALTY PA

epitol TIER 01

ethosuximide oral TIER 01

felbamate TIER 01

fosphenytoin sodium TIER 01

FYCOMPA TIER 03

gabapentin oral TIER 01


11


GABITRIL TIER 03

KEPPRA INTRAVENOUS

TIER 03

LAMICTAL XR ORAL KIT

TIER 03

lamotrigine er TIER 01

lamotrigine oral TIER 01

lamotrigine starter kit-blue

TIER 01

lamotrigine starter kit-green

TIER 01

lamotrigine starter kit-orange

TIER 01

levetiracetam er TIER 01

levetiracetam in nacl TIER 01

levetiracetam intravenous

TIER 01

levetiracetam oral TIER 01

NAYZILAM TIER 03 QL

NEMBUTAL TIER 03

oxcarbazepine TIER 01

PEGANONE TIER 03

pentobarbital sodium injection

TIER 01

phenobarbital oral TIER 01

phenobarbital sodium injection

TIER 01

PHENYTEK TIER 03

phenytoin infatabs TIER 01

phenytoin oral TIER 01

phenytoin sodium extended

TIER 01

phenytoin sodium injection

TIER 01

primidone oral TIER 01

roweepra TIER 01

roweepra xr TIER 01

subvenite TIER 01

subvenite starter kit-blue TIER 01

subvenite starter kit-green

TIER 01

subvenite starter kit-orange

TIER 01


SYMPAZAN TIER 03 PA

tiagabine hcl TIER 01

topiramate er TIER 01

topiramate oral TIER 01

TROKENDI XR TIER 03

valproate sodium intravenous

TIER 01

valproic acid oral TIER 01

VALTOCO 10 MG DOSE TIER 03 QL




vigabatrin SPECIALTY PA

vigadrone SPECIALTY PA

VIMPAT TIER 03

XCOPRI TIER 03

XCOPRI (250 MG DAILY DOSE)

TIER 03

XCOPRI (350 MG DAILY DOSE)

TIER 03

ZARONTIN TIER 03

zonisamide oral TIER 01

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT TIER 03

donepezil hcl TIER 01

EXELON TIER 03

galantamine hydrobromide

TIER 01

galantamine hydrobromide er

TIER 01

memantine hcl er TIER 01 QL

memantine hcl oral TIER 01

NAMENDA TIER 03

NAMENDA TITRATION PAK

TIER 03

NAMENDA XR TIER 03 QL

NAMENDA XR TITRATION PACK

TIER 03 QL

NAMZARIC TIER 02 QL

RAZADYNE ER TIER 03


12


rivastigmine TIER 01

rivastigmine tartrate TIER 01

Antidepressants

amitriptyline hcl oral TIER 01

amoxapine TIER 01

APLENZIN TIER 03 ST; QL

bupropion hcl er (sr) TIER 01 QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

TIER 01 QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

TIER 02 QL

bupropion hcl oral TIER 01

chlordiazepoxide-amitriptyline

TIER 01

citalopram hydrobromide TIER 01

clomipramine hcl oral TIER 01

desipramine hcl oral TIER 01

DESVENLAFAXINE ER TIER 03 ST; QL

desvenlafaxine succinate er

TIER 01 QL

doxepin hcl oral capsule TIER 01

doxepin hcl oral concentrate

TIER 01

DRIZALMA SPRINKLE TIER 03 QL

duloxetine hcl oral TIER 01 QL

EMSAM TIER 03 QL

escitalopram oxalate TIER 01

FETZIMA TIER 03 ST; QL

FETZIMA TITRATION TIER 03 ST; QL

fluoxetine hcl (pmdd) TIER 01

fluoxetine hcl oral capsule

TIER 01

fluoxetine hcl oral capsule delayed release

TIER 01 QL

fluoxetine hcl oral solution

TIER 01

fluoxetine hcl oral tablet TIER 01

fluvoxamine maleate TIER 01

fluvoxamine maleate er TIER 01 QL

FORFIVO XL TIER 03 QL


imipramine hcl oral TIER 01

imipramine pamoate TIER 01

maprotiline hcl TIER 01

MARPLAN TIER 03

mirtazapine oral TIER 01

NARDIL TIER 03

nefazodone hcl TIER 01

NORPRAMIN TIER 03

nortriptyline hcl oral TIER 01

olanzapine-fluoxetine hcl TIER 01 QL

PARNATE TIER 03

paroxetine hcl TIER 01

paroxetine hcl er TIER 01

paroxetine mesylate TIER 01 QL

PAXIL ORAL SUSPENSION

TIER 02 ST

perphenazine-amitriptyline

TIER 01

PEXEVA TIER 03 QL

phenelzine sulfate oral TIER 01

protriptyline hcl TIER 01

REMERON TIER 03

REMERON SOLTAB TIER 03

SARAFEM TIER 03

sertraline hcl oral TIER 01

SPRAVATO (56 MG DOSE)

SPECIALTY

SPRAVATO (84 MG DOSE)

SPECIALTY

SYMBYAX TIER 03 QL

tranylcypromine sulfate TIER 01

trazodone hcl oral TIER 01

trimipramine maleate oral

TIER 01

TRINTELLIX TIER 03 ST; QL

venlafaxine hcl TIER 01

venlafaxine hcl er oral capsule extended release 24 hour

TIER 01

venlafaxine hcl er oral tablet extended release 24 hour 225 mg

TIER 01


13


VIIBRYD TIER 03 QL

VIIBRYD STARTER PACK

TIER 03 QL

ZULRESSO SPECIALTY

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS

TIER 03

AKYNZEO ORAL TIER 03 QL

ALOXI TIER 03

ANZEMET TIER 03 QL

aprepitant TIER 01 QL

BONJESTA TIER 03 PA; QL

CINVANTI TIER 03

compro TIER 01

DICLEGIS TIER 03 PA; QL

dimenhydrinate injection TIER 01

doxylamine-pyridoxine TIER 01 PA; QL

dronabinol TIER 01 PA; QL

droperidol injection TIER 01

EMEND INTRAVENOUS TIER 03

EMEND ORAL TIER 03 QL

EMEND TRI-PACK TIER 03 QL

fosaprepitant dimeglumine

TIER 01

granisetron hcl intravenous

TIER 01

granisetron hcl oral TIER 01 QL

MARINOL TIER 03 PA; QL

meclizine hcl oral tablet TIER 01

metoclopramide hcl injection

TIER 01

metoclopramide hcl oral TIER 01

ondansetron hcl injection TIER 01

ondansetron hcl oral solution

TIER 01 QL

ondansetron hcl oral tablet 24 mg

TIER 01 QL

ondansetron hcl oral tablet 4 mg, 8 mg

TIER 01

ondansetron odt TIER 01

palonosetron hcl TIER 01


perphenazine oral TIER 01

prochlorperazine TIER 01

prochlorperazine edisylate injection

TIER 01

prochlorperazine maleate oral

TIER 01

REGLAN TIER 03

scopolamine TIER 01

SUSTOL TIER 03 QL

SYNDROS TIER 03 PA; QL

TIGAN TIER 03

TRANSDERM SCOP (1.5 MG)

TIER 03

TRANSDERM-SCOP (1.5 MG)

TIER 03

trimethobenzamide hcl oral

TIER 01

VARUBI (180 MG DOSE)

TIER 03 QL

Antifungals

ABELCET TIER 03

AMBISOME TIER 03

amphotericin b intravenous

TIER 01

ANCOBON TIER 03

BIO-STATIN ORAL CAPSULE

TIER 03

CANCIDAS TIER 03

caspofungin acetate TIER 01

ciclodan TIER 01

ciclopirox external TIER 01

ciclopirox olamine external

TIER 01

clotrimazole external TIER 01

clotrimazole mouth/throat TIER 01

clotrimazole-betamethasone

TIER 01

CRESEMBA SPECIALTY

DIFLUCAN TIER 03

econazole nitrate external

TIER 01

ERAXIS TIER 03


14


EXODERM EXTERNAL LOTION

TIER 02

fluconazole in sodium chloride

TIER 01

fluconazole oral TIER 01

flucytosine oral TIER 01

griseofulvin microsize oral

TIER 01

griseofulvin ultramicrosize

TIER 01

GYNAZOLE-1 TIER 03

itraconazole oral TIER 01 PA

KERYDIN TIER 03 PA

ketoconazole external cream

TIER 01

ketoconazole external shampoo

TIER 01

ketoconazole oral TIER 01

LOPROX EXTERNAL CREAM

TIER 03

LOPROX EXTERNAL SHAMPOO

TIER 03

LOPROX EXTERNAL SUSPENSION

TIER 03

micafungin sodium TIER 01

miconazole 3 vaginal suppository

TIER 01

MYCAMINE TIER 03

naftifine hcl TIER 01

NAFTIN TIER 03

NOXAFIL SPECIALTY

nyamyc TIER 01

nystatin external TIER 01

nystatin mouth/throat TIER 01

nystatin oral TIER 01

nystatin-triamcinolone TIER 01

nystop TIER 01

posaconazole SPECIALTY

SPORANOX TIER 03 PA

SPORANOX PULSEPAK TIER 03 PA

terbinafine hcl oral TIER 01 QL

terconazole TIER 01

VFEND IV SPECIALTY


VFEND ORAL SUSPENSION RECONSTITUTED

SPECIALTY

voriconazole intravenous SPECIALTY

voriconazole oral SPECIALTY

Antigout Agents

allopurinol oral TIER 01

allopurinol sodium TIER 01

ALOPRIM TIER 03

colchicine oral tablet TIER 01

colchicine-probenecid TIER 01

COLCRYS TIER 02

febuxostat TIER 01 ST

KRYSTEXXA SPECIALTY PA

probenecid TIER 01

ULORIC TIER 03 ST

ZYLOPRIM TIER 03

Anti-inflammatory Agents

EMFLAZA SPECIALTY PA

Antimigraine Agents

AIMOVIG SPECIALTY

almotriptan malate TIER 01 QL

AMERGE TIER 03 QL

CAFERGOT TIER 03

D.H.E. 45 TIER 03

dihydroergotamine mesylate injection

TIER 01

dihydroergotamine mesylate nasal

TIER 01 QL

eletriptan hydrobromide TIER 01 QL

EMGALITY SPECIALTY

EMGALITY (300 MG DOSE)

SPECIALTY

ERGOMAR TIER 03

ergotamine-caffeine TIER 01

MIGERGOT TIER 03

MIGRANAL TIER 03 QL

naratriptan hcl TIER 01 QL

NURTEC TIER 02

rizatriptan benzoate TIER 01 QL


15


sumatriptan nasal TIER 01 QL

sumatriptan succinate oral

TIER 01 QL

sumatriptan succinate refill

TIER 01 QL

sumatriptan succinate subcutaneous

TIER 01 QL

UBRELVY TIER 02

VYEPTI TIER 03

zolmitriptan oral TIER 01 QL

ZOMIG NASAL TIER 03 ST; QL

Antimyasthenic Agents

BLOXIVERZ TIER 03

GUANIDINE HCL TIER 03

MESTINON ORAL SOLUTION

TIER 03

MESTINON ORAL TABLET EXTENDED RELEASE

TIER 03

neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml

TIER 01

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 MG/5ML

TIER 03

NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

pyridostigmine bromide er

TIER 01

pyridostigmine bromide oral

TIER 01

REGONOL TIER 03

Antimycobacterials

CAPASTAT SULFATE TIER 03

cycloserine oral TIER 01

dapsone oral TIER 01

ethambutol hcl oral TIER 01

isoniazid injection TIER 01


isoniazid oral TIER 01

MYAMBUTOL TIER 03

MYCOBUTIN TIER 03

PASER TIER 03

PRETOMANID TIER 03

PRIFTIN TIER 03

pyrazinamide oral TIER 01

rifabutin TIER 01

RIFADIN TIER 03

rifampin intravenous TIER 01

rifampin oral TIER 01

SIRTURO TIER 03

TRECATOR TIER 03

Antineoplastics - Drugs for Cancer

abiraterone acetate SPECIALTY PA

ABRAXANE SPECIALTY

ADCETRIS SPECIALTY PA

adriamycin SPECIALTY

AFINITOR DISPERZ SPECIALTY PA

AFINITOR ORAL TABLET 10 MG

SPECIALTY PA; QL

ALECENSA SPECIALTY PA

ALIMTA SPECIALTY

ALIQOPA SPECIALTY PA

ALKERAN SPECIALTY

ALUNBRIG SPECIALTY PA; QL

anastrozole oral TIER 01

AROMASIN SPECIALTY

ARRANON SPECIALTY

arsenic trioxide intravenous

SPECIALTY

ARZERRA SPECIALTY PA

ASPARLAS SPECIALTY

AVASTIN SPECIALTY PA

AYVAKIT SPECIALTY PA; QL

azacitidine SPECIALTY

BALVERSA SPECIALTY PA

BAVENCIO SPECIALTY PA

BELEODAQ SPECIALTY PA

BENDEKA SPECIALTY PA


16


BESPONSA SPECIALTY PA

bexarotene SPECIALTY PA

bicalutamide TIER 01

BICNU SPECIALTY

bleomycin sulfate SPECIALTY

BLINCYTO SPECIALTY PA

BORTEZOMIB SPECIALTY PA

BOSULIF SPECIALTY PA

BRAFTOVI SPECIALTY PA

BRUKINSA SPECIALTY PA

busulfan SPECIALTY

BUSULFEX SPECIALTY

CABOMETYX SPECIALTY PA

CALQUENCE SPECIALTY PA

CAMPATH SPECIALTY

CAMPTOSAR SPECIALTY

capecitabine SPECIALTY PA

CAPRELSA ORAL TABLET 100 MG

SPECIALTY PA; QL

CAPRELSA ORAL TABLET 300 MG

SPECIALTY PA

carboplatin SPECIALTY

carmustine SPECIALTY

CASODEX TIER 03

cisplatin intravenous solution

SPECIALTY

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

SPECIALTY

cladribine SPECIALTY

clofarabine SPECIALTY

CLOLAR SPECIALTY

COMETRIQ (100 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

COPIKTRA SPECIALTY PA

COSMEGEN SPECIALTY

COTELLIC SPECIALTY PA


cyclophosphamide injection

SPECIALTY

cyclophosphamide oral SPECIALTY

CYRAMZA SPECIALTY PA

cytarabine SPECIALTY

cytarabine (pf) SPECIALTY

dacarbazine SPECIALTY

DACOGEN SPECIALTY PA

dactinomycin SPECIALTY

DARZALEX SPECIALTY PA

daunorubicin hcl SPECIALTY

DAURISMO SPECIALTY PA

decitabine SPECIALTY PA

dexrazoxane hcl SPECIALTY

docetaxel SPECIALTY

DOXIL SPECIALTY

doxorubicin hcl SPECIALTY

doxorubicin hcl liposomal SPECIALTY

DROXIA TIER 03

ELITEK SPECIALTY

ELLENCE SPECIALTY

EMCYT SPECIALTY

EMPLICITI SPECIALTY PA

ENHERTU SPECIALTY PA

epirubicin hcl SPECIALTY

ERBITUX SPECIALTY PA

ERIVEDGE SPECIALTY PA

erlotinib hcl oral tablet 100 mg, 150 mg

SPECIALTY PA

erlotinib hcl oral tablet 25 mg

SPECIALTY PA; QL

ERWINAZE SPECIALTY

ETHYOL TIER 03

ETOPOPHOS SPECIALTY

etoposide intravenous SPECIALTY

etoposide oral SPECIALTY

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

SPECIALTY PA; QL

EVOMELA SPECIALTY

exemestane SPECIALTY

FARESTON SPECIALTY


17


FARYDAK SPECIALTY PA

FASLODEX SPECIALTY

FEMARA TIER 03

floxuridine injection SPECIALTY

fludarabine phosphate SPECIALTY

fluorouracil intravenous SPECIALTY

flutamide TIER 01

FOLOTYN SPECIALTY PA

fulvestrant SPECIALTY

GAZYVA SPECIALTY PA

gemcitabine hcl SPECIALTY

GILOTRIF SPECIALTY PA; QL

GLEOSTINE SPECIALTY

HALAVEN SPECIALTY PA

HERCEPTIN SPECIALTY PA

HERCEPTIN HYLECTA SPECIALTY PA

HYCAMTIN SPECIALTY

HYDREA TIER 03

hydroxyurea oral TIER 01

IBRANCE SPECIALTY PA

ICLUSIG ORAL TABLET 15 MG

SPECIALTY PA; QL

ICLUSIG ORAL TABLET 45 MG

SPECIALTY PA

IDAMYCIN PFS SPECIALTY

idarubicin hcl SPECIALTY

IDHIFA SPECIALTY PA; QL

IFEX SPECIALTY

ifosfamide SPECIALTY

imatinib mesylate SPECIALTY PA

IMBRUVICA SPECIALTY PA

IMFINZI SPECIALTY PA

INFUGEM SPECIALTY

INLYTA SPECIALTY PA

INREBIC SPECIALTY PA

IRESSA SPECIALTY PA

irinotecan hcl SPECIALTY

ISTODAX (OVERFILL) SPECIALTY PA

IXEMPRA KIT SPECIALTY

JAKAFI ORAL TABLET 10 MG

SPECIALTY PA; QL


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

SPECIALTY PA

JEVTANA SPECIALTY PA

KADCYLA SPECIALTY PA

KANJINTI SPECIALTY PA

KEYTRUDA SPECIALTY PA

KHAPZORY SPECIALTY

KISQALI (200 MG DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

KISQALI FEMARA (400 MG DOSE)

SPECIALTY PA

KISQALI FEMARA (600 MG DOSE)

SPECIALTY PA

KISQALI FEMARA(200 MG DOSE)

SPECIALTY PA

KOSELUGO SPECIALTY PA

KYPROLIS SPECIALTY PA

LARTRUVO SPECIALTY PA

LENVIMA (10 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

letrozole oral TIER 01

leucovorin calcium injection

TIER 01

leucovorin calcium oral TIER 01

LEUKERAN SPECIALTY

levoleucovorin calcium SPECIALTY


18


levoleucovorin calcium pf SPECIALTY

LIBTAYO SPECIALTY PA

LONSURF SPECIALTY PA

LORBRENA SPECIALTY PA

LUMOXITI SPECIALTY PA

LYNPARZA SPECIALTY PA

LYSODREN SPECIALTY

MARQIBO SPECIALTY

MATULANE SPECIALTY

MEKINIST SPECIALTY PA

MEKTOVI SPECIALTY PA

melphalan SPECIALTY

melphalan hcl SPECIALTY

mercaptopurine oral TIER 01

mesna SPECIALTY

MESNEX SPECIALTY

mitomycin intravenous SPECIALTY

mitoxantrone hcl SPECIALTY PA

mutamycin SPECIALTY

MVASI SPECIALTY PA

MYLERAN SPECIALTY

MYLOTARG SPECIALTY PA

NAVELBINE SPECIALTY

NERLYNX SPECIALTY PA; QL

NEXAVAR SPECIALTY PA

NILANDRON SPECIALTY

nilutamide SPECIALTY

NINLARO SPECIALTY PA

NIPENT SPECIALTY

NUBEQA SPECIALTY PA

ODOMZO SPECIALTY PA

ONCASPAR SPECIALTY

ONIVYDE SPECIALTY

OPDIVO SPECIALTY PA

oxaliplatin SPECIALTY

paclitaxel SPECIALTY

PADCEV SPECIALTY PA

PANRETIN SPECIALTY

paraplatin SPECIALTY

PERJETA SPECIALTY PA


PHOTOFRIN SPECIALTY

PIQRAY (200 MG DAILY DOSE)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

POLIVY SPECIALTY PA

POMALYST SPECIALTY PA

PORTRAZZA SPECIALTY PA

POTELIGEO SPECIALTY PA

PROLEUKIN SPECIALTY

PURIXAN SPECIALTY

QINLOCK SPECIALTY PA

QUADRAMET TIER 03

REVLIMID SPECIALTY PA

RITUXAN SPECIALTY PA

RITUXAN HYCELA SPECIALTY PA

ROZLYTREK SPECIALTY PA

RUBRACA SPECIALTY PA

RUXIENCE SPECIALTY PA

RYDAPT SPECIALTY PA

SIKLOS TIER 03

SOLTAMOX TIER 03

SPRYCEL SPECIALTY PA

STIVARGA SPECIALTY PA

SUTENT SPECIALTY PA

SYLVANT SPECIALTY PA

SYNRIBO SPECIALTY PA

TABLOID SPECIALTY

TAFINLAR SPECIALTY PA

TAGRISSO ORAL TABLET 40 MG

SPECIALTY PA; QL

TAGRISSO ORAL TABLET 80 MG

SPECIALTY PA

TALZENNA SPECIALTY PA

tamoxifen citrate oral TIER 01

TARCEVA ORAL TABLET 100 MG, 150 MG

SPECIALTY PA

TARCEVA ORAL TABLET 25 MG

SPECIALTY PA; QL


19


TARGRETIN EXTERNAL

SPECIALTY PA

TASIGNA SPECIALTY PA

TAXOTERE SPECIALTY

TECENTRIQ SPECIALTY PA

TEMODAR INTRAVENOUS

SPECIALTY

TEMODAR ORAL SPECIALTY PA

temozolomide SPECIALTY PA

teniposide SPECIALTY

TEPADINA SPECIALTY

THALOMID SPECIALTY PA

thiotepa injection SPECIALTY

TIBSOVO SPECIALTY PA

toposar SPECIALTY

topotecan hcl SPECIALTY

toremifene citrate SPECIALTY

TOTECT SPECIALTY

TRAZIMERA SPECIALTY PA

tretinoin oral SPECIALTY

TRISENOX SPECIALTY

TUKYSA SPECIALTY PA

TURALIO SPECIALTY PA

TYKERB SPECIALTY PA

UNITUXIN SPECIALTY PA

VALCHLOR SPECIALTY PA

valrubicin SPECIALTY

VALSTAR SPECIALTY

VECTIBIX SPECIALTY

VELCADE SPECIALTY PA

VENCLEXTA SPECIALTY PA

VENCLEXTA STARTING PACK

SPECIALTY PA

VERZENIO SPECIALTY PA

VIDAZA SPECIALTY

vinblastine sulfate SPECIALTY

vincristine sulfate SPECIALTY

vinorelbine tartrate SPECIALTY

VITRAKVI SPECIALTY PA

VIZIMPRO SPECIALTY PA

VORAXAZE TIER 03


VOTRIENT SPECIALTY PA

VYXEOS SPECIALTY PA

XALKORI SPECIALTY PA

XELODA SPECIALTY PA

XOFIGO TIER 02

XOSPATA SPECIALTY PA

XPOVIO (100 MG ONCE WEEKLY)

SPECIALTY PA


SPECIALTY PA

XPOVIO (40 MG TWICE WEEKLY)

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

XTANDI SPECIALTY PA

YERVOY SPECIALTY PA

YONDELIS SPECIALTY

ZALTRAP SPECIALTY PA

ZANOSAR SPECIALTY

ZEJULA SPECIALTY PA

ZELBORAF SPECIALTY PA

ZEVALIN Y-90 SPECIALTY

ZIRABEV SPECIALTY PA

ZOLINZA SPECIALTY PA

ZYDELIG SPECIALTY PA

ZYKADIA SPECIALTY PA

Antiparasitics

albendazole oral TIER 01

ALINIA TIER 02

ARAKODA TIER 03

atovaquone oral TIER 01

atovaquone-proguanil hcl TIER 01

BENZNIDAZOLE TIER 03

BILTRICIDE TIER 03

chloroquine phosphate oral

TIER 01


20


COARTEM TIER 03

crotan TIER 01

DARAPRIM SPECIALTY

EGATEN TIER 03

ELIMITE TIER 03

EMVERM TIER 02

hydroxychloroquine sulfate oral

TIER 01

IMPAVIDO TIER 03

ivermectin oral TIER 01

KRINTAFEL TIER 03

lindane TIER 01

MALARONE TIER 03

malathion TIER 01

mefloquine hcl TIER 01

MEPRON TIER 03

NEBUPENT TIER 03

OVIDE TIER 03

PENTAM TIER 03

pentamidine isethionate TIER 01

permethrin external TIER 01

PLAQUENIL TIER 02

praziquantel oral TIER 01

primaquine phosphate TIER 01

pyrimethamine oral SPECIALTY

PYRIMETHAMINE-LEUCOVORIN

TIER 03

QUALAQUIN TIER 03 PA

quinine sulfate oral TIER 01 PA

SKLICE TIER 03

spinosad TIER 01

STROMECTOL TIER 03

sulfurated lime TIER 01

Antiparkinson Agents

amantadine hcl oral TIER 01

APOKYN SPECIALTY PA; QL

AZILECT TIER 03

benztropine mesylate TIER 01

bromocriptine mesylate oral

TIER 01

carbidopa oral TIER 01


carbidopa-levodopa TIER 01

carbidopa-levodopa er TIER 01

carbidopa-levodopa-entacapone

TIER 01

COGENTIN TIER 03

COMTAN TIER 03

DUOPA TIER 03 PA

entacapone TIER 01

INBRIJA SPECIALTY

MIRAPEX TIER 03

MIRAPEX ER TIER 03

NEUPRO TIER 03 ST

NOURIANZ TIER 03 PA

PARLODEL TIER 03

pramipexole dihydrochloride

TIER 01

pramipexole dihydrochloride er

TIER 01

rasagiline mesylate oral TIER 01

REQUIP XL TIER 03

ropinirole hcl TIER 01

ropinirole hcl er TIER 01

RYTARY TIER 03 ST

selegiline hcl oral TIER 01

SINEMET TIER 03

STALEVO 100 TIER 03

STALEVO 125 TIER 03

STALEVO 150 TIER 03

STALEVO 200 TIER 03

STALEVO 50 TIER 03

STALEVO 75 TIER 03

TASMAR TIER 03

tolcapone TIER 01

trihexyphenidyl hcl TIER 01

XADAGO SPECIALTY ST

ZELAPAR TIER 03

Antiplatelets

AGGRASTAT TIER 03

AGGRENOX TIER 03

aspirin-dipyridamole er TIER 01

BRILINTA TIER 02


21


CABLIVI SPECIALTY

cilostazol TIER 01

clopidogrel bisulfate oral TIER 01

dipyridamole oral TIER 01

EFFIENT TIER 03

eptifibatide TIER 01

INTEGRILIN TIER 03

KENGREAL TIER 03

prasugrel hcl TIER 01

ZONTIVITY TIER 03

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA TIER 03

ADASUVE TIER 03 PA

aripiprazole TIER 01 QL

ARISTADA TIER 03

ARISTADA INITIO TIER 03

CAPLYTA TIER 03 ST; QL

chlorpromazine hcl injection

TIER 01

chlorpromazine hcl oral TIER 01

clozapine TIER 01 QL

CLOZARIL TIER 03 QL

FANAPT TIER 03 ST; QL

FANAPT TITRATION PACK

TIER 03 ST; QL

fluphenazine decanoate injection

TIER 01

fluphenazine hcl TIER 01

GEODON INTRAMUSCULAR

TIER 03

HALDOL TIER 03

HALDOL DECANOATE TIER 03

haloperidol decanoate intramuscular

TIER 01

haloperidol lactate TIER 01

haloperidol oral TIER 01

INVEGA TIER 03 QL

INVEGA SUSTENNA TIER 03

INVEGA TRINZA TIER 03

LATUDA TIER 03 QL


loxapine succinate TIER 01

molindone hcl TIER 01

NUPLAZID TIER 03 PA

olanzapine intramuscular TIER 01

olanzapine oral TIER 01 QL

paliperidone er TIER 01 QL

PERSERIS TIER 03

pimozide TIER 01

quetiapine fumarate TIER 01 QL

quetiapine fumarate er TIER 01 QL

REXULTI TIER 03 QL

RISPERDAL CONSTA TIER 03

risperidone TIER 01 QL

SAPHRIS TIER 02 QL

thioridazine hcl oral TIER 01

thiothixene TIER 01

trifluoperazine hcl TIER 01

VERSACLOZ TIER 03 QL

VRAYLAR TIER 03 ST; QL

ziprasidone hcl TIER 01 QL

ziprasidone mesylate TIER 01

ZYPREXA RELPREVV TIER 03

ZYPREXA ZYDIS TIER 03 QL

Antivirals

abacavir sulfate TIER 01

abacavir sulfate-lamivudine

TIER 01

abacavir-lamivudine-zidovudine

TIER 01

acyclovir external TIER 01

acyclovir oral TIER 01

acyclovir sodium TIER 01

adefovir dipivoxil SPECIALTY

APTIVUS TIER 02

atazanavir sulfate TIER 01

BARACLUDE ORAL SOLUTION

SPECIALTY QL

BIKTARVY TIER 03

cidofovir intravenous TIER 01

CIMDUO TIER 02

COMBIVIR TIER 03


22


COMPLERA TIER 02

CRIXIVAN TIER 02

CYTOVENE TIER 03

DELSTRIGO TIER 03

DESCOVY TIER 03 PA

didanosine TIER 01

DOVATO TIER 02

EDURANT TIER 02

efavirenz TIER 01

efavirenz-lamivudine-tenofovir

TIER 01

emtricitabine TIER 01

EMTRIVA ORAL CAPSULE

TIER 03

EMTRIVA ORAL SOLUTION

TIER 02

entecavir SPECIALTY QL

EPCLUSA SPECIALTY PA; QL

EPIVIR TIER 03

EPIVIR HBV SPECIALTY

EPZICOM TIER 03

EVOTAZ TIER 02

famciclovir oral TIER 01

FAVIPIRAVIR TIER 03

fosamprenavir calcium TIER 01

FOSCAVIR TIER 03

FUZEON SPECIALTY

GANCICLOVIR TIER 03

ganciclovir sodium TIER 01

GENVOYA TIER 03

HARVONI SPECIALTY PA; QL

HEPSERA SPECIALTY

INTELENCE TIER 02

INTRON A SPECIALTY PA

INVIRASE TIER 02

ISENTRESS TIER 02

ISENTRESS HD TIER 02

JULUCA TIER 02

KALETRA ORAL SOLUTION

TIER 03


KALETRA ORAL TABLET

TIER 02

lamivudine oral solution TIER 01

lamivudine oral tablet 100 mg

SPECIALTY

lamivudine oral tablet 150 mg, 300 mg

TIER 01

lamivudine-zidovudine TIER 01

LEXIVA ORAL SUSPENSION

TIER 02

LEXIVA ORAL TABLET TIER 03

lopinavir-ritonavir TIER 01

MAVYRET SPECIALTY PA; QL

nevirapine TIER 01

nevirapine er TIER 01

NORVIR ORAL PACKET TIER 02

NORVIR ORAL SOLUTION

TIER 02

NORVIR ORAL TABLET TIER 03

ODEFSEY TIER 03

oseltamivir phosphate oral

TIER 01 QL

PEGASYS SPECIALTY PA

PEGASYS PROCLICK SPECIALTY PA

PEGINTRON SPECIALTY PA

PIFELTRO TIER 03

PREVYMIS SPECIALTY

PREZCOBIX TIER 02

PREZISTA TIER 02

RAPIVAB TIER 03

RELENZA DISKHALER TIER 03 QL

RETROVIR INTRAVENOUS

TIER 02

RETROVIR ORAL TIER 03

REYATAZ ORAL CAPSULE

TIER 03

REYATAZ ORAL PACKET

TIER 02

ribavirin inhalation TIER 01

ribavirin oral SPECIALTY

rimantadine hcl TIER 01

ritonavir TIER 01


23


SELZENTRY TIER 02 PA

SITAVIG TIER 03 QL

SOVALDI SPECIALTY PA; QL

stavudine TIER 01

STRIBILD TIER 03

SUSTIVA TIER 03

SYMFI TIER 02

SYMFI LO TIER 02

SYMTUZA TIER 03

tenofovir disoproxil fumarate

TIER 01

TIVICAY TIER 02

TIVICAY PD TIER 02

TRIUMEQ TIER 02

TRIZIVIR TIER 03

TROGARZO TIER 03 PA

TRUVADA TIER 02

TYBOST TIER 02

valacyclovir hcl oral TIER 01 QL

valganciclovir hcl TIER 01

VEMLIDY SPECIALTY

VIEKIRA PAK SPECIALTY PA; QL

VIRACEPT TIER 02

VIRAMUNE TIER 03

VIRAMUNE XR TIER 03

VIRAZOLE TIER 03

VIREAD ORAL POWDER

TIER 02

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

TIER 02

VIREAD ORAL TABLET 300 MG

TIER 03

VOSEVI SPECIALTY PA; QL

XOFLUZA (40 MG DOSE)

TIER 03 QL

XOFLUZA (80 MG DOSE)

TIER 03 QL

ZEPATIER SPECIALTY PA; QL

ZIAGEN TIER 03

zidovudine TIER 01


Anxiolytics - Drugs for Anxiety

alprazolam er TIER 01 QL

alprazolam intensol TIER 01 QL

alprazolam oral tablet TIER 01 QL

alprazolam xr TIER 01 QL

ATIVAN INJECTION TIER 03

buspirone hcl oral TIER 01

chlordiazepoxide hcl TIER 01 QL

clonazepam oral TIER 01 QL

clorazepate dipotassium TIER 01 QL

diazepam intensol TIER 01

diazepam intramuscular TIER 01

diazepam oral TIER 01

diazepam solution 5 mg/ml injection

TIER 01

DIAZEPAM SOLUTION 5 MG/ML INJECTION

TIER 03

DORAL TIER 03 QL

estazolam TIER 01 QL

HALCION TIER 03 QL

hydroxyzine hcl intramuscular

TIER 01

hydroxyzine hcl oral TIER 01

hydroxyzine pamoate oral

TIER 01

lorazepam injection TIER 01

lorazepam intensol TIER 01 QL

lorazepam oral concentrate 2 mg/ml

TIER 01 QL

lorazepam oral tablet TIER 01 QL

meprobamate TIER 01

oxazepam TIER 01 QL

quazepam TIER 01 QL

TRANXENE-T TIER 03 QL

triazolam TIER 01 QL

VISTARIL TIER 03

Bipolar Agents - Drugs for Mood Disorders

EQUETRO TIER 03

lithium TIER 01


24


lithium carbonate er TIER 01

lithium carbonate oral TIER 01

LITHOBID TIER 03

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

ADVATE SPECIALTY

ADYNOVATE SPECIALTY

AFSTYLA SPECIALTY

AGRYLIN TIER 03

ALPHANATE/VWF COMPLEX/HUMAN

SPECIALTY

ALPHANINE SD SPECIALTY

ALPROLIX SPECIALTY

AMICAR SPECIALTY

aminocaproic acid intravenous

SPECIALTY

aminocaproic acid oral SPECIALTY

anagrelide hcl TIER 01

ARANESP (ALBUMIN FREE)

SPECIALTY PA

ASTRINGYN TIER 03

BENEFIX SPECIALTY

CEPROTIN SPECIALTY

COAGADEX SPECIALTY

CORIFACT SPECIALTY

CYKLOKAPRON TIER 03

DOPTELET SPECIALTY PA

ELOCTATE SPECIALTY

FEIBA SPECIALTY

FIBRYGA SPECIALTY

HEMLIBRA SPECIALTY

HEMOFIL M SPECIALTY

HESPAN TIER 03

hetastarch-nacl TIER 01

HEXTEND TIER 03

HUMATE-P SPECIALTY

IDELVION SPECIALTY

IXINITY SPECIALTY

JIVI SPECIALTY


KCENTRA TIER 03

KOATE SPECIALTY

KOATE-DVI SPECIALTY

KOGENATE FS SPECIALTY

KOVALTRY SPECIALTY

LEUKINE SPECIALTY PA

LMD IN D5W TIER 03

LMD IN NACL TIER 03

LYSTEDA TIER 03

MIRCERA SPECIALTY PA

MONONINE SPECIALTY

MOZOBIL SPECIALTY PA; QL

MULPLETA SPECIALTY PA

NEULASTA SPECIALTY PA

NEULASTA ONPRO SPECIALTY PA

NIVESTYM SPECIALTY PA

NOVOEIGHT SPECIALTY

NOVOSEVEN RT SPECIALTY

NPLATE SPECIALTY PA

NUWIQ SPECIALTY

OBIZUR SPECIALTY

PANHEMATIN SPECIALTY

PROFILNINE SPECIALTY

PROMACTA SPECIALTY PA

protamine sulfate intravenous

TIER 01

REBINYN SPECIALTY

REBLOZYL SPECIALTY

RECOMBINATE SPECIALTY

RECOTHROM TIER 03

RECOTHROM SPRAY KIT

TIER 03

RETACRIT SPECIALTY PA

RIASTAP SPECIALTY

RIXUBIS SPECIALTY

SOLIRIS SPECIALTY PA

TAVALISSE SPECIALTY

THROMBIN-JMI TIER 03

THROMBIN-JMI EPISTAXIS

TIER 03

THROMBOGEN TIER 03


25


tranexamic acid intravenous

TIER 01

tranexamic acid oral TIER 01

TRANEXAMIC ACID-NACL

TIER 03

TRETTEN SPECIALTY

UDENYCA SPECIALTY PA

ULTOMIRIS SPECIALTY PA

VONVENDI SPECIALTY

WILATE SPECIALTY

XYNTHA SPECIALTY

XYNTHA SOLOFUSE SPECIALTY

ZARXIO SPECIALTY PA

ZIEXTENZO SPECIALTY PA

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL TIER 03

ACCURETIC TIER 03

acebutolol hcl oral TIER 01

acetazolamide sodium TIER 01

ADENOCARD TIER 03

adenosine intravenous solution 12 mg/4ml, 6 mg/2ml

TIER 01

AKOVAZ TIER 03

ALDACTAZIDE TIER 03

ALDACTONE TIER 03

aliskiren fumarate TIER 01

alprostadil injection TIER 01

amiloride hcl oral TIER 01

amiloride-hydrochlorothiazide

TIER 01

amiodarone hcl TIER 01

amlodipine besylate oral TIER 01

amlodipine besylate-benazepril hcl

TIER 01

amlodipine besylate-valsartan

TIER 01

amlodipine-atorvastatin TIER 01

amlodipine-olmesartan TIER 01


amlodipine-valsartan-hctz

TIER 01

ASCLERA TIER 03

ATACAND HCT TIER 03

atenolol oral TIER 01

atenolol-chlorthalidone TIER 01

atorvastatin calcium oral TIER 01

AVALIDE TIER 03

benazepril hcl oral TIER 01

benazepril-hydrochlorothiazide

TIER 01

BETAPACE AF TIER 03

betaxolol hcl oral TIER 01

BIDIL TIER 03

BIORPHEN TIER 03

bisoprolol fumarate TIER 01

bisoprolol-hydrochlorothiazide

TIER 01

BREVIBLOC TIER 03

BREVIBLOC IN NACL TIER 03

BREVIBLOC PREMIXED TIER 03

BREVIBLOC PREMIXED DS

TIER 03

bumetanide TIER 01

BUMEX TIER 03

BYSTOLIC TIER 02

CADUET TIER 03

CALAN SR TIER 03

candesartan cilexetil TIER 01

candesartan cilexetil-hctz TIER 01

captopril oral TIER 01

captopril-hydrochlorothiazide

TIER 01

CARDENE IV TIER 03

CARDIZEM TIER 03

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

TIER 03

CARDURA TIER 03

CAROSPIR TIER 03

cartia xt TIER 01


26


carvedilol TIER 01

carvedilol phosphate er TIER 01

CATAPRES TIER 03

chlorothiazide sodium TIER 01

chlorthalidone TIER 01

cholestyramine light TIER 01

cholestyramine oral TIER 01

CLEVIPREX TIER 03

clonidine TIER 01

clonidine hcl oral TIER 01

colesevelam hcl TIER 01

colestipol hcl TIER 01

CONJUPRI TIER 03

CORLANOR TIER 03 PA; QL

CORLOPAM TIER 03

CORVERT TIER 03

DEMSER TIER 03

DIBENZYLINE TIER 03

digitek TIER 01

digox TIER 01

digoxin injection TIER 01

digoxin oral TIER 01

DILATRATE-SR TIER 03

diltiazem hcl er TIER 01

diltiazem hcl er beads TIER 01

diltiazem hcl er coated beads

TIER 01

diltiazem hcl intravenous TIER 01

diltiazem hcl oral TIER 01

DILTIAZEM HCL-DEXTROSE

TIER 03

DILTIAZEM HCL-SODIUM CHLORIDE

TIER 03

dilt-xr TIER 01

disopyramide phosphate TIER 01

DIURIL TIER 03

dobutamine hcl TIER 01

dobutamine in d5w TIER 01

dofetilide TIER 01

dopamine hcl intravenous

TIER 01


dopamine in d5w TIER 01

doxazosin mesylate oral TIER 01

DYRENIUM TIER 03

EDARBI TIER 03 ST

EDARBYCLOR TIER 03 ST

EDECRIN TIER 03

enalapril maleate oral TIER 01

enalaprilat TIER 01

enalapril-hydrochlorothiazide

TIER 01

ENTRESTO TIER 02 QL

EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 25 MG/5ML, 50 MG/5ML

TIER 03

ephedrine sulfate intravenous solution

TIER 01

EPHEDRINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

EPHEDRINE SULFATE-NACL

TIER 03

EPINEPHRINE HCL-DEXTROSE

TIER 03

EPINEPHRINE HCL-NACL

TIER 03

EPINEPHRINE INTRAVENOUS

TIER 03

epinephrine pf TIER 01

epinephrine solution prefilled syringe 1 mg/10ml injection

TIER 01

EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION

TIER 03

EPINEPHRINE-DEXTROSE

TIER 03

EPINEPHRINE-NACL INTRAVENOUS SOLUTION 2-0.9 MG/250ML-%

TIER 03


27


EPINEPHRINE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

eplerenone TIER 01

esmolol hcl intravenous solution 100 mg/10ml

TIER 01

ESMOLOL HCL INTRAVENOUS SOLUTION 2000 MG/100ML, 2500 MG/250ML

TIER 03

esmolol hcl-sodium chloride

TIER 01

ethacrynate sodium TIER 01

ethacrynic acid TIER 01

ETHAMOLIN TIER 03

EZALLOR SPRINKLE TIER 03 ST

ezetimibe TIER 01

ezetimibe-simvastatin TIER 01

felodipine er TIER 01

fenofibrate micronized TIER 01

fenofibrate oral capsule TIER 01

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

TIER 01

fenofibric acid oral capsule delayed release

TIER 01

FIBRICOR ORAL TABLET 105 MG

TIER 03 ST

FIBRICOR ORAL TABLET 35 MG

TIER 03

flecainide acetate TIER 01

FLOLIPID TIER 03 ST

fosinopril sodium TIER 01

fosinopril sodium-hctz TIER 01

FUROSEMIDE IN SODIUM CHLORIDE

TIER 03

furosemide injection TIER 01

furosemide oral TIER 01

gemfibrozil oral TIER 01

GONITRO TIER 03

guanfacine hcl TIER 01

HEMANGEOL TIER 03


hydralazine hcl injection TIER 01

hydralazine hcl oral TIER 01

hydrochlorothiazide oral TIER 01

ibutilide fumarate TIER 01

indapamide TIER 01

INSPRA TIER 03

irbesartan TIER 01

irbesartan-hydrochlorothiazide

TIER 01

isoproterenol hcl injection

TIER 01

ISORDIL TITRADOSE TIER 03

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

TIER 01

isosorbide mononitrate TIER 01

isosorbide mononitrate er

TIER 01

isradipine TIER 01

ISUPREL TIER 03

JUXTAPID SPECIALTY PA; QL

LABETALOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

labetalol hcl oral TIER 01

labetalol hcl solution 5 mg/ml intravenous

TIER 01

LABETALOL HCL SOLUTION 5 MG/ML INTRAVENOUS

TIER 03

LANOXIN INJECTION TIER 03

LANOXIN ORAL TIER 02

LANOXIN PEDIATRIC TIER 03

LEVOPHED TIER 03

LIPOFEN TIER 03

lisinopril oral TIER 01

lisinopril-hydrochlorothiazide

TIER 01

LIVALO TIER 03 ST

LOPID TIER 03

LOPRESSOR TIER 03

LOPRESSOR HCT TIER 03


28


losartan potassium oral TIER 01

losartan potassium-hctz TIER 01

LOTENSIN TIER 03

LOTENSIN HCT TIER 03

lovastatin TIER 01

mannitol intravenous TIER 01

matzim la TIER 01

MAXZIDE TIER 03

MAXZIDE-25 TIER 03

methyldopa TIER 01

methyldopa-hydrochlorothiazide

TIER 01

metolazone TIER 01

metoprolol succinate er TIER 01

metoprolol tartrate intravenous

TIER 01

metoprolol tartrate oral TIER 01

metoprolol-hydrochlorothiazide

TIER 01

metyrosine TIER 01

mexiletine hcl oral TIER 01

midodrine hcl TIER 01

milrinone lactate TIER 01

milrinone lactate in dextrose

TIER 01

MINIPRESS TIER 03

minoxidil oral TIER 01

moexipril hcl TIER 01

MULTAQ TIER 03

NEXLETOL TIER 02

NEXLIZET TIER 02

NEXTERONE TIER 03

niacin er (antihyperlipidemic)

TIER 01

nicardipine hcl TIER 01

NICARDIPINE HCL IN NACL

TIER 03

nifedipine er TIER 01

nifedipine er osmotic release

TIER 01

nifedipine oral TIER 01

nimodipine oral TIER 01


nisoldipine er TIER 01

NITRO-BID TIER 03

NITRO-DUR TIER 03

nitroglycerin TIER 01

nitroglycerin in d5w TIER 01

NITROLINGUAL TIER 03

NITROMIST TIER 03

NITROPRESS TIER 03

nitroprusside sodium TIER 01

nitro-time oral capsule extended release 2.5 mg

TIER 01

norepinephrine bitartrate intravenous

TIER 01

NOREPINEPHRINE-DEXTROSE

TIER 03

NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 8-0.9 MG/250ML-%

TIER 03

NORPACE TIER 03

NORPACE CR TIER 02

NORTHERA SPECIALTY PA

NYMALIZE TIER 03

olmesartan medoxomil oral

TIER 01

olmesartan medoxomil-hctz

TIER 01

olmesartan-amlodipine-hctz

TIER 01

omega-3-acid ethyl esters

TIER 01

OSMITROL INTRAVENOUS SOLUTION 10 %

TIER 03

osmitrol intravenous solution 15 %, 20 %

TIER 01

PACERONE ORAL TABLET 100 MG, 400 MG

TIER 03

pacerone oral tablet 200 mg

TIER 01

pentoxifylline er TIER 01

perindopril erbumine TIER 01


29


phenoxybenzamine hcl oral

TIER 01

phentolamine mesylate injection

TIER 01

PHENYLEPHRINE HCL (PRESSORS)

TIER 03

phenylephrine hcl intravenous solution

TIER 01

PHENYLEPHRINE HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/250ML-%, 40-0.9 MG/250ML-%, 50-0.9 MG/250ML-%, 80-0.9 MG/250ML-%

TIER 03

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

pindolol TIER 01

PRALUENT TIER 02

pravastatin sodium TIER 01

prazosin hcl oral TIER 01

PRESTALIA TIER 03

prevalite TIER 01

procainamide hcl injection

TIER 01

PROCARDIA TIER 03

PROCARDIA XL TIER 03

propafenone hcl TIER 01

propafenone hcl er TIER 01

propranolol hcl er TIER 01

propranolol hcl intravenous

TIER 01

propranolol hcl oral TIER 01

propranolol-hctz TIER 01

PROSTIN VR TIER 03

quinapril hcl TIER 01

quinapril-hydrochlorothiazide

TIER 01

quinidine gluconate er TIER 01


quinidine sulfate TIER 01

ramipril TIER 01

ranolazine er TIER 01

RECTIV TIER 03

REPATHA TIER 02

REPATHA PUSHTRONEX SYSTEM

TIER 02

REPATHA SURECLICK TIER 02

rosuvastatin calcium TIER 01

RYTHMOL SR TIER 03

simvastatin oral TIER 01

SODIUM DIURIL TIER 03

SODIUM EDECRIN TIER 03

sorine TIER 01

sotalol hcl (af) TIER 01

SOTALOL HCL INTRAVENOUS

TIER 03

sotalol hcl oral TIER 01

SOTYLIZE TIER 03

spironolactone oral TIER 01

spironolactone-hctz TIER 01

SULAR TIER 03

TARKA TIER 03

taztia xt TIER 01

TEKTURNA TIER 02

TEKTURNA HCT TIER 02 ST

telmisartan TIER 01

telmisartan-amlodipine TIER 01

telmisartan-hctz TIER 01

TENORETIC 100 TIER 03

TENORETIC 50 TIER 03

tiadylt er TIER 01

TIAZAC TIER 03

timolol maleate oral TIER 01

torsemide TIER 01

trandolapril TIER 01

trandolapril-verapamil hcl er

TIER 01

triamterene oral TIER 01

triamterene-hctz TIER 01


30


TRILIPIX TIER 03

TWYNSTA TIER 03

valsartan TIER 01

valsartan-hydrochlorothiazide

TIER 01

VARITHENA TIER 03

VASCEPA TIER 02

VASERETIC TIER 03

VAZCULEP TIER 03

VECAMYL TIER 03

verapamil hcl er TIER 01

verapamil hcl intravenous

TIER 01

verapamil hcl oral TIER 01

VERELAN TIER 03

VERELAN PM TIER 03

VYNDAMAX SPECIALTY

VYNDAQEL SPECIALTY

ZIAC TIER 03

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADZENYS ER TIER 03 PA; QL

ADZENYS XR-ODT TIER 03 ST; QL

AMPHETAMINE ER TIER 03 PA; QL

amphetamine sulfate TIER 01 PA; QL

amphetamine-dextroamphetamine

TIER 01 PA; QL

amphetamine-dextroamphetamine er

TIER 01 PA; QL

APTENSIO XR TIER 03 ST; QL

atomoxetine hcl TIER 01 QL

clonidine hcl er TIER 01

COTEMPLA XR-ODT TIER 03 ST; QL

DAYTRANA TIER 03 ST; QL

dexmethylphenidate hcl TIER 01 PA; QL

dexmethylphenidate hcl er

TIER 01 PA; QL

dextroamphetamine sulfate

TIER 01 PA; QL

dextroamphetamine sulfate er

TIER 01 PA; QL


DYANAVEL XR TIER 03 ST; QL

EVEKEO ODT TIER 03 PA; QL

guanfacine hcl er TIER 01

JORNAY PM TIER 03 ST; QL

KAPVAY TIER 03 ST

metadate er TIER 01 PA; QL

METHYLIN TIER 03 ST; QL

methylphenidate hcl er TIER 01 PA; QL

methylphenidate hcl er (cd)

TIER 01 PA; QL

methylphenidate hcl er (la)

TIER 01 PA; QL

methylphenidate hcl oral TIER 01 PA; QL

MYDAYIS TIER 03 ST; QL

PROCENTRA TIER 03 ST; QL

QUILLICHEW ER TIER 03 ST; QL

QUILLIVANT XR TIER 03 ST; QL

relexxii TIER 01 PA; QL

VYVANSE TIER 02 PA; QL

ZENZEDI ORAL TABLET 10 MG, 5 MG

TIER 03 PA; QL

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

TIER 03 ST; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA SPECIALTY PA; QL

AUBAGIO SPECIALTY PA; QL

AVONEX PEN SPECIALTY PA; QL

AVONEX PREFILLED SPECIALTY PA; QL

BAFIERTAM SPECIALTY PA; QL

BETASERON SPECIALTY PA; QL

COPAXONE SPECIALTY PA; QL

dalfampridine er SPECIALTY PA; QL

dimethyl fumarate oral SPECIALTY PA; QL

GILENYA SPECIALTY PA; QL

glatiramer acetate SPECIALTY PA; QL

glatopa SPECIALTY PA; QL

LEMTRADA SPECIALTY PA

MAVENCLAD (10 TABS) SPECIALTY PA


31








MAYZENT SPECIALTY PA; QL

MAYZENT STARTER PACK

SPECIALTY PA; QL

OCREVUS SPECIALTY PA; QL

REBIF SPECIALTY PA; QL

REBIF REBIDOSE SPECIALTY PA; QL

REBIF REBIDOSE TITRATION PACK

SPECIALTY PA; QL

REBIF TITRATION PACK

SPECIALTY PA; QL

TECFIDERA SPECIALTY PA; QL

TYSABRI SPECIALTY PA; QL

VUMERITY SPECIALTY PA; QL

VUMERITY (STARTER) SPECIALTY PA; QL

Central Nervous System Agents - Miscellaneous

ADDYI TIER 03 PA; QL

ANECTINE TIER 03

atracurium besylate TIER 01

AUSTEDO SPECIALTY PA

CAFCIT TIER 03

caffeine citrate TIER 01

CAFFEINE-SODIUM BENZOATE

TIER 03

cisatracurium besylate TIER 01

cisatracurium besylate (pf)

TIER 01

DOPRAM TIER 03

GRALISE TIER 03 ST; QL

HORIZANT TIER 03 PA; QL

INGREZZA SPECIALTY PA

LYRICA CR TIER 03 ST; QL

NIMBEX TIER 03

NUEDEXTA TIER 03 PA

ONPATTRO SPECIALTY


pancuronium bromide TIER 01

pregabalin oral TIER 01 QL

QUELICIN TIER 03

RADICAVA SPECIALTY PA

RILUTEK SPECIALTY PA; QL

riluzole SPECIALTY PA; QL

rocuronium bromide intravenous solution

TIER 01

ROCURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

SAVELLA TIER 03 ST; QL

SAVELLA TITRATION PACK

TIER 03 ST; QL

SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

SUCCINYLCHOLINE CHLORIDE INTRAVENOUS

TIER 03

succinylcholine chloride solution 20 mg/ml injection

TIER 01

SUCCINYLCHOLINE CHLORIDE SOLUTION 20 MG/ML INJECTION

TIER 03

TEGSEDI SPECIALTY

tetrabenazine SPECIALTY PA

TIGLUTIK SPECIALTY PA; QL

VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE

TIER 03

vecuronium bromide intravenous solution reconstituted

TIER 01

VYLEESI TIER 03 PA; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

cevimeline hcl TIER 01


32


chlorhexidine gluconate mouth/throat

TIER 01

DEBACTEROL TIER 03

EVOXAC TIER 03

fluoridex sensitivity relief TIER 01

KEPIVANCE SPECIALTY

lidocaine hcl mouth/throat

TIER 01

lidocaine viscous hcl TIER 01

MI PASTE TIER 03

MI PASTE PLUS TIER 03

NAFRINSE DAILY ACIDULATED

TIER 03

oralone TIER 01

paroex TIER 01

PERIDEX TIER 03

periogard TIER 01

pilocarpine hcl oral TIER 01

PREVIDENT 5000 ENAMEL PROTECT

TIER 03

PREVIDENT 5000 SENSITIVE

TIER 03

REMESENSE TIER 03

SALAGEN TIER 03

sodium fluoride 5000 sensitive

TIER 01

TOPEX TOPICAL ANESTHETIC

TIER 03

triamcinolone acetonide mouth/throat

TIER 01

Dermatological Agents - Drugs for Skin Conditions

ABSORICA LD TIER 03

acitretin TIER 01

ACZONE EXTERNAL GEL 7.5 %

TIER 02

adapalene external cream

TIER 01 PA

adapalene external gel TIER 01 PA

ADAPALENE EXTERNAL SOLUTION

TIER 03 PA

adapalene-benzoyl peroxide

TIER 01


ala-cort TIER 01

alclometasone dipropionate

TIER 01

ALCOHOL PREP PADS EXTERNAL 70 %

TIER 03

ALTRENO TIER 03 PA

amcinonide external lotion

TIER 01

ammonium lactate external

TIER 01

amnesteem TIER 01

AMZEEQ TIER 03

ATRALIN TIER 03 PA

avita TIER 01 PA

azelaic acid external TIER 01

AZELEX TIER 03

balsam peru-castor oil TIER 01

benzoyl peroxide-erythromycin

TIER 01

beser external lotion TIER 01

betamethasone dipropionate aug

TIER 01

betamethasone dipropionate external

TIER 01

betamethasone valerate external

TIER 01

BPCO TIER 03

calcipotriene external cream

TIER 01

calcipotriene external ointment

TIER 01

calcipotriene external solution

TIER 01

calcipotriene-betameth diprop external suspension

TIER 01 QL

CALCITRENE TIER 03

calcitriol external TIER 01

CARAC TIER 03

claravis TIER 01

CLEOCIN-T EXTERNAL LOTION

TIER 03

clindacin etz external swab

TIER 01


33


clindacin-p TIER 01

clindamycin phosphate-benzoyl peroxide

TIER 01

clindamycin phosphate external

TIER 01

clindamycin-tretinoin TIER 01

clobetasol prop emollient base

TIER 01

clobetasol propionate e TIER 01

clobetasol propionate emulsion

TIER 01

clobetasol propionate external

TIER 01

clocortolone pivalate TIER 01

clodan external shampoo TIER 01

coal tar external TIER 01

CONDYLOX TIER 03

CORTISPORIN TIER 03

CUTIVATE TIER 03

dapsone external gel 5 %

TIER 01

DERMA-SMOOTHE/FS BODY

TIER 03

DERMA-SMOOTHE/FS SCALP

TIER 03

DERMULCERA TIER 03

desonide external TIER 01

DESOWEN TIER 03

desoximetasone external cream 0.25 %

TIER 01

desoximetasone external gel

TIER 01

desoximetasone external liquid

TIER 01

desoximetasone external ointment 0.25 %

TIER 01

diclofenac sodium transdermal gel 3 %

TIER 01 ST; QL

DIPROLENE TIER 03

DIPROLENE AF TIER 03

DOVONEX TIER 03

DRYSOL TIER 03

DUPIXENT SPECIALTY PA; QL


EFUDEX TIER 03

EPIDUO FORTE TIER 03

EPIFOAM TIER 03

ery TIER 01

ERYGEL TIER 03

erythromycin external TIER 01

EUCRISA TIER 02 ST

EVOCLIN TIER 03

FINACEA EXTERNAL FOAM

TIER 03 ST

fluocinolone acetonide body

TIER 01

fluocinolone acetonide external

TIER 01

fluocinolone acetonide scalp

TIER 01

fluocinonide emulsified base

TIER 01

fluocinonide external cream 0.05 %

TIER 01

fluocinonide external gel TIER 01

fluocinonide external ointment

TIER 01

fluocinonide external solution

TIER 01

FLUOROPLEX TIER 03

FLUOROURACIL EXTERNAL CREAM 0.5 %

TIER 02

fluorouracil external cream 5 %

TIER 01

fluorouracil external solution

TIER 01

fluticasone propionate external

TIER 01

GORDOFILM TIER 03

halobetasol propionate external cream

TIER 01

halobetasol propionate external ointment

TIER 01

HALOG EXTERNAL SOLUTION

TIER 03

hydrocortisone butyrate external cream

TIER 01


34


hydrocortisone butyrate external ointment

TIER 01

hydrocortisone butyrate external solution

TIER 01

hydrocortisone external cream 1 %, 2.5 %

TIER 01

hydrocortisone external lotion 2.5 %

TIER 01

hydrocortisone external ointment 1 %, 2.5 %

TIER 01

hydrocortisone valerate TIER 01

imiquimod external TIER 01

isotretinoin oral TIER 01

KERAMATRIX REPLICINE 5CMX5CM

TIER 03

KLARON TIER 03

lactic acid e TIER 01

lactic acid external TIER 01

LEVULAN KERASTICK TIER 03

LUXIQ TIER 03

methoxsalen rapid TIER 01

METROCREAM TIER 03

METROLOTION TIER 03

metronidazole external TIER 01

MICROCYN EXTERNAL LIQUID 0.023 %

TIER 03

MIRVASO TIER 02

mometasone furoate external

TIER 01

myorisan TIER 01

NEO-SYNALAR EXTERNAL CREAM

TIER 03

neuac external gel TIER 01

OLUX TIER 03

OLUX-E TIER 03

ONEXTON TIER 03

OXSORALEN ULTRA TIER 03

PICATO TIER 03 ST

pimecrolimus TIER 01

podofilox external TIER 01

prednicarbate TIER 01

PROTOPIC TIER 03


PYROGALLIC ACID TIER 03

QBREXZA TIER 03 QL

RADIAPLEXRX TIER 03

REGENECARE TIER 03

REGRANEX TIER 03 PA

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

TIER 02 PA

RHOFADE TIER 03

rosadan external cream TIER 01

rosadan external gel TIER 01

SANTYL TIER 03

SCENESSE SPECIALTY

selenium sulfide external lotion

TIER 01

SERNIVO TIER 03

SOOLANTRA TIER 02

SORIATANE TIER 03

sulfacetamide sodium (acne)

TIER 01

SYNALAR TIER 03

TACLONEX EXTERNAL SUSPENSION

TIER 03 QL

tacrolimus external ointment

TIER 01

tazarotene external TIER 01

TAZORAC EXTERNAL CREAM 0.05 %

TIER 03

TAZORAC EXTERNAL GEL

TIER 03

TEMOVATE TIER 03

TEXACORT TIER 03

THERAHONEY EXTERNAL SHEET

TIER 03

TOLAK TIER 03

TOPICORT EXTERNAL CREAM 0.25 %

TIER 03

TOPICORT EXTERNAL GEL

TIER 03

TOPICORT EXTERNAL OINTMENT

TIER 03

tovet external foam TIER 01

tretinoin external TIER 01 PA


35


tretinoin microsphere TIER 01 PA

tretinoin microsphere pump

TIER 01 PA

triamcinolone acetonide external cream

TIER 01

triamcinolone acetonide external lotion

TIER 01

triamcinolone acetonide external ointment

TIER 01

trianex TIER 01

TRI-CHLOR TIER 03

triderm TIER 01

TRIDESILON TIER 03

vashe cleansing TIER 01

VENELEX TIER 03

XERAC AC TIER 03

XEROFORM OIL EMULSION 2"X2"

TIER 03

XEROFORM OIL EMULSION GAUZE

TIER 03

XEROFORM OIL EMULSION STRIP

TIER 03

XEROFORM OIL ROLL 4"X9'

TIER 03

XEROFORM PETROLAT GAUZE 1"X8"

TIER 03

XEROFORM PETROLAT GAUZE 5"X9"

TIER 03

XEROFORM PETROLAT PATCH 2"X2"

TIER 03

XEROFORM PETROLAT PATCH 4"X4"

TIER 03

XEROFORM PETROLATUM ROLL 4"X9'

TIER 03

zenatane TIER 01

Diabetes - Antidiabetic Agents

acarbose oral TIER 01

ACTOPLUS MET TIER 03

ACTOS TIER 03


AMARYL TIER 03

AVANDIA TIER 03 ST

BYDUREON TIER 02 ST; QL

BYDUREON BCISE AUTOINJECTOR

TIER 02 ST; QL

BYETTA 10 MCG PEN TIER 02 ST; QL

BYETTA 5 MCG PEN TIER 02 ST; QL

CYCLOSET TIER 03 ST

DUETACT TIER 03

FARXIGA TIER 02 ST

glimepiride TIER 01

glipizide er TIER 01

glipizide ir TIER 01

glipizide xl TIER 01

glipizide-metformin hcl TIER 01

GLUCOTROL TIER 03

GLUCOTROL XL TIER 03

glyburide micronized TIER 01

glyburide oral TIER 01

glyburide-metformin TIER 01

GLYNASE TIER 03

GLYSET TIER 03

GLYXAMBI TIER 02 ST

JANUMET TIER 02 ST

JANUMET XR TIER 02 ST

JANUVIA TIER 02 ST

JARDIANCE TIER 02 ST

JENTADUETO TIER 02 ST

JENTADUETO XR TIER 02 ST

metformin hcl er TIER 01

metformin hcl ir TIER 01

miglitol TIER 01

nateglinide TIER 01

OZEMPIC TIER 02 ST; QL

pioglitazone hcl TIER 01

pioglitazone hcl-glimepiride

TIER 01

pioglitazone hcl-metformin hcl

TIER 01

PRECOSE TIER 03

repaglinide TIER 01


36


RIOMET TIER 03 ST

RIOMET ER TIER 03 ST

RYBELSUS TIER 02 ST; QL

SOLIQUA TIER 02 ST; QL

STARLIX TIER 03

SYMLINPEN 120 TIER 03 PA

SYMLINPEN 60 TIER 03 PA

SYNJARDY TIER 02 ST

SYNJARDY XR TIER 02 ST

tolbutamide TIER 01

TRADJENTA TIER 02 ST

TRIJARDY XR TIER 02 ST

TRULICITY TIER 02 ST; QL

VICTOZA TIER 02 ST; QL

XIGDUO XR TIER 02 ST

XULTOPHY TIER 03 ST; QL

Diabetes - Glucose Monitoring

ACCU-CHEK FASTCLIX LANCET KIT

TIER 02

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

TIER 02

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

TIER 02

AUTOLET II CLINISAFE TIER 03

AUTOLET LANCING DEVICE

TIER 03

CARETOUCH LANCING/EJECTOR

TIER 03

CEQUR SIMPLICITY 2U TIER 03

CEQUR SIMPLICITY STARTER

TIER 03

CHEMSTRIP UGK TIER 03

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

TIER 02


DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

TIER 02

DIATHRIVE LANCING DEVICE

TIER 03

ENLITE GLUCOSE SENSOR

TIER 03

EVERSENSE SENSOR/HOLDER

TIER 03

EVERSENSE SMART TRANSMITTER

TIER 03

FREESTYLE LIBRE 14 DAY READER

TIER 02

FREESTYLE LIBRE 14 DAY SENSOR

TIER 02

GENTEEL LANCING KIT (BLUE)

TIER 03

GOJJI LANCING DEVICE/CLEAR CAP

TIER 03

GUARDIAN CONNECT TRANSMITTER

TIER 03

GUARDIAN LINK 3 TRANSMITTER

TIER 03

GUARDIAN SENSOR (3) TIER 03

INPEN 100-BLUE-LILLY TIER 03

INPEN 100-BLUE-NOVO TIER 03

INPEN 100-GRAY-LILLY TIER 03

INPEN 100-GREY-NOVO

TIER 03

INPEN 100-PINK-LILLY TIER 03

INPEN 100-PINK-NOVO TIER 03

KETONE TEST TIER 03

KETOSTIX TIER 03

LANCETS TIER 02

LANCETS TIER 03

LANCETS KIT TIER 03

MICROLET NEXT LANCING DEVICE

TIER 03

MINIMED GUARDIAN SENSOR 3

TIER 03

NOVOPEN ECHO TIER 03


37


OMNIPOD DASH SYSTEM

TIER 03

OMNIPOD STARTER TIER 03

ONETOUCH DELICA LANCING DEV

TIER 03

ONETOUCH DELICA PLUS LANCING

TIER 03

ONETOUCH ULTRA TIER 02 QL

ONETOUCH ULTRA 2 KIT W/DEVICE

TIER 02

ONETOUCH ULTRA MINI KIT W/DEVICE

TIER 02

ONETOUCH VERIO KIT W/DEVICE

TIER 02

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

TIER 02

ONETOUCH VERIO IN VITRO SOLUTION HIGH

TIER 03

ONETOUCH VERIO TEST STRIPS

TIER 02 QL

ONETOUCH VERIO IQ SYSTEM

TIER 02

ONETOUCH VERIO REFLECT KIT W/DEVICE

TIER 02

ONETOUCH VERIO REFLECT KIT W/DEVICE

TIER 03

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

TIER 02

SURESTEP PRO HIGH GLUCOSE

TIER 03

SURESTEP PRO LOW GLUCOSE

TIER 03

SURESTEP PRO NORMAL GLUCOSE

TIER 03

V-GO 20 TIER 02

V-GO 30 TIER 02

V-GO 40 TIER 02

VIVAGUARD LANCING DEVICE

TIER 03

Diabetes - Glycemic Agents

BAQSIMI ONE PACK TIER 02


BAQSIMI TWO PACK TIER 02

diazoxide oral TIER 01

GLUCAGEN HYPOKIT TIER 03

GLUCAGON EMERGENCY KIT

TIER 02

GVOKE HYPOPEN 1-PACK

TIER 02

GVOKE HYPOPEN 2-PACK

TIER 02

GVOKE PFS TIER 02

PROGLYCEM TIER 03

Diabetes - Insulins

AFREZZA TIER 03 PA

BD AUTOSHIELD DUO PEN NEEDLES

TIER 02

BD ULTRA-FINE INSULIN SYRINGES

TIER 02

BD ULTRA-FINE PEN NEEDLES

TIER 02

BD VEO INSULIN SYR U/F 1/2UNIT

TIER 02

DIATHRIVE PEN NEEDLE

TIER 02

DROPLET MICRON TIER 02

HUMALOG KWIKPEN TIER 02

HUMALOG MIX 50/50 KWIKPEN

TIER 02

HUMALOG MIX 50/50 VIAL

TIER 02

HUMALOG MIX 75/25 KWIKPEN

TIER 02

HUMALOG MIX 75/25 VIAL

TIER 02

HUMALOG U-100 JUNIOR KWIKPEN

TIER 02

HUMALOG VIAL TIER 02

HUMULIN 70/30 KWIKPEN

TIER 02

HUMULIN 70/30 VIAL TIER 02

HUMULIN N KWIKPEN TIER 02

HUMULIN N VIAL TIER 02

HUMULIN R U-500 KWIKPEN

TIER 02

HUMULIN R U-500 VIAL TIER 02


38


HUMULIN R VIAL TIER 02

INSULIN PEN NEEDLES TIER 02

INSULIN SYRINGES TIER 02

LANTUS SOLOSTAR TIER 02

LANTUS U-100 VIAL TIER 02

MAXICOMFORT SYR 27G X 1/2"

TIER 02

MYXREDLIN TIER 03

NOVOFINE AUTOCOVER PEN NEEDLE

TIER 02

NOVOFINE PEN NEEDLE

TIER 02

NOVOFINE PLUS PEN NEEDLE

TIER 02

NOVOTWIST PEN NEEDLE

TIER 02

TOUJEO MAX SOLOSTAR

TIER 02

TOUJEO SOLOSTAR TIER 02

Electrolytes / Minerals / Metals / Vitamins

ACTIVE FE TIER 03

AMINO ACID TIER 03

AMINOPROTECT TIER 03

AMINOSYN II TIER 03

AMINOSYN-PF TIER 03

AQUASOL A TIER 03

ARGININE HCL INJECTION

TIER 03

argyle sterile saline TIER 01

argyle sterile water TIER 01

ATABEX OB TIER 02

CALCIFOL TIER 03

CALCIUM CHLORIDE SOLUTION 10 % INTRAVENOUS

TIER 03

calcium chloride solution 10 % intravenous

TIER 01

calcium gluconate intravenous

TIER 01


CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.675 GM/50ML-%

TIER 03

CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.9 GM/100ML-%, 2-0.9 GM/100ML-%

TIER 03

CARBAGLU SPECIALTY

CARNITOR INTRAVENOUS

TIER 03

CENTRATEX TIER 03

CHEMET TIER 03

chromagen TIER 01

chromic chloride intravenous

TIER 01

CLINIMIX E/DEXTROSE (2.75/5)

TIER 03


TIER 03


TIER 03

CLINIMIX E/DEXTROSE (5/15)

TIER 03

CLINIMIX E/DEXTROSE (5/20)

TIER 03

CLINIMIX/DEXTROSE (4.25/10)

TIER 03

CLINIMIX/DEXTROSE (4.25/5)

TIER 03

CLINIMIX/DEXTROSE (5/15)

TIER 03

CLINIMIX/DEXTROSE (5/20)

TIER 03

CLINISOL SF TIER 03

CLINOLIPID TIER 03

clovique SPECIALTY PA

corvita 150 TIER 01

CORVITE 150 ORAL TABLET

TIER 03

CORVITE 150 ORAL TABLET 150-1.25 MG

TIER 02

CORVITE FE TIER 03


39


CUPRIC CHLORIDE TIER 03

curity sterile saline TIER 01

cyanocobalamin injection solution 1000 mcg/ml

TIER 01

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML

TIER 03

deferasirox SPECIALTY PA

deferasirox granules SPECIALTY PA

deferiprone SPECIALTY PA

dehydrated alcohol TIER 01

DEXPANTHENOL INJECTION

TIER 03

dextrose intravenous solution 10 %, 20 %, 30 %, 40 %, 5 %, 70 %

TIER 01

DEXTROSE SOLUTION 250 MG/ML INTRAVENOUS

TIER 03

dextrose solution 250 mg/ml intravenous

TIER 01

DEXTROSE SOLUTION 50 % INTRAVENOUS

TIER 03

dextrose solution 50 % intravenous

TIER 01

DILUENT FOR LEFAMULIN

TIER 03

DRISDOL TIER 03

EDETATE DISODIUM INTRAVENOUS

TIER 03

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

TIER 03

effer-k oral tablet effervescent 25 meq

TIER 01

ELITE-OB TIER 02

ergocalciferol oral capsule

TIER 01

EXJADE SPECIALTY PA

FERAHEME TIER 03

ferocon TIER 01

ferotrinsic TIER 01

FERRALET 90 TIER 03

FERRAPLUS 90 TIER 02


FERRIPROX SPECIALTY PA

FERRIPROX TWICE-A-DAY

SPECIALTY PA

FERRLECIT TIER 03

ferrocite plus TIER 01

FERRO-PLEX HEMATINIC

TIER 03

FERROTRIN TIER 03

folic acid injection TIER 01

folic acid oral tablet 1 mg TIER 01

FOLIVANE-F TIER 03

FOLIVANE-PLUS TIER 03

foltrin TIER 01

FREAMINE HBC TIER 03

FREAMINE III TIER 03

FUSION PLUS TIER 03

GALZIN TIER 03

GLUTATHIONE INJECTION SOLUTION 200 MG/ML

TIER 03

GLUTATHIONE INTRAVENOUS

TIER 03

GLYCINE INJECTION TIER 03

GLYCOPHOS TIER 03

hematinic plus vit/minerals

TIER 01

hematinic/folic acid TIER 01

hematogen TIER 01

hematogen forte TIER 01

HEMATRON-AF TIER 03

HEMOCYTE PLUS TIER 03

hemocyte-f TIER 01

hemocyte-plus TIER 01

HEPATAMINE TIER 03

hydroxocobalamin acetate

TIER 01

ICAR-C PLUS TIER 02

iferex 150 forte TIER 01

INFED TIER 03

INJECTAFER TIER 03

INTEGRA F TIER 03

INTEGRA PLUS TIER 03


40


intralipid intravenous emulsion 20 %

TIER 01

INTRALIPID INTRAVENOUS EMULSION 30 %

TIER 03

iodine strong oral TIER 01

IS 24/6 TIER 03

JADENU SPECIALTY PA

JADENU SPRINKLE SPECIALTY PA

JYNARQUE SPECIALTY QL

KABIVEN TIER 03

kionex TIER 01

klor-con TIER 01

klor-con 10 TIER 01

klor-con m10 TIER 01

KLOR-CON M15 TIER 03

klor-con m20 TIER 01

klor-con sprinkle TIER 01

klor-con/ef TIER 01

K-PHOS TIER 03

K-PHOS-NEUTRAL TIER 03

k-prime TIER 01

k-tan plus TIER 01

lactated ringers irrigation TIER 01

LEVOCARNITINE INJECTION

TIER 03

levocarnitine oral solution

TIER 01

levocarnitine oral tablet TIER 01

levocarnitine sf TIER 01

LIPO TIER 03

LIPO-C TIER 03

LOKELMA TIER 03

LYSINE HCL INJECTION

TIER 03

MAGNEBIND 400 TIER 03

magnesium chloride injection

TIER 01

magnesium sulfate in d5w

TIER 01


MAGNESIUM SULFATE INTRAVENOUS SOLUTION 1000 MG/1.6ML, 2000 MG/3.2ML, 3000 MG/4.8ML, 4000 MG/6.4ML

TIER 03

magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml

TIER 01

MAGNESIUM SULFATE SOLUTION 50 % INJECTION

TIER 03

magnesium sulfate solution 50 % injection

TIER 01

MAGNESIUM SULFATE-NACL

TIER 03

MANGANESE CHLORIDE

TIER 03

MEPHYTON TIER 03

METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED

TIER 03

M-NATAL PLUS TIER 02

monoject flush syringe TIER 01

monoject sodium chloride flush

TIER 01

MULTIGEN TIER 03

MULTIGEN FOLIC TIER 03

MULTIGEN PLUS TIER 03

myferon 150 forte TIER 01

na ferric gluc cplx in sucrose

TIER 01

n-acetyl-l-cysteine oral TIER 01

NASCOBAL TIER 03

NEOKE ALCAR TIER 03

NEONATAL PLUS TIER 02

NEPHRAMINE TIER 03

NEPHRON FA TIER 03

NESTABS TIER 02

NIFEREX TIER 03

normal saline flush TIER 01

NUFERA TIER 03


41


nutrilipid TIER 01

NUTRIVIT TIER 03

ONE VITE WOMENS PLUS

TIER 02

ORACIT TIER 03

PERIKABIVEN TIER 03

phospha 250 neutral TIER 01

phosphorous TIER 01

phospho-trin 250 neutral TIER 01

PHYSIOLYTE TIER 03

PHYSIOSOL IRRIGATION

TIER 03

phytonadione injection TIER 01

phytonadione oral TIER 01

PLENAMINE TIER 03

poly-iron 150 forte TIER 01

polysaccharide iron forte TIER 01

pot bicarb-pot chloride TIER 01

potassium acetate intravenous

TIER 01

potassium bicarbonate oral

TIER 01

potassium chloride crys er

TIER 01

potassium chloride er TIER 01

potassium chloride intravenous

TIER 01

potassium chloride oral TIER 01

potassium citrate er TIER 01

potassium phosphates(71 meq k)

TIER 01

PREMASOL TIER 03

prenatal oral tablet 27-1 mg

TIER 01

prenatal plus iron TIER 01

PRENATVITE PLUS TIER 02

PRENATVITE RX TIER 02

PRISMASOL B22GK 4/0 TIER 03

PRISMASOL BGK 0/2.5 TIER 03

PRISMASOL BGK 2/0 TIER 03




PRISMASOL BK 0/0/1.2 TIER 03

PROCALAMINE TIER 03

PROSOL TIER 03

purevit dualfe plus TIER 01

PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION

TIER 03

pyridoxine hcl solution 100 mg/ml injection

TIER 01

RELNATE DHA TIER 02

RENATABS WITH IRON TIER 03

ringers irrigation TIER 01

saline bacteriostatic TIER 01

saline flush TIER 01

saline flush zr TIER 01

SALINE-PHENOL TIER 03

SAMSCA SPECIALTY QL

se-tan plus TIER 01

SMOFLIPID TIER 03

sod citrate-citric acid TIER 01

sodium acetate intravenous

TIER 01

sodium bicarbonate intravenous solution 4.2 %, 7.5 %

TIER 01

SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS

TIER 03

sodium bicarbonate solution 8.4 % intravenous

TIER 01

sodium chloride (pf) TIER 01

sodium chloride bacteriostatic

TIER 01

sodium chloride flush TIER 01

sodium chloride injection TIER 01

sodium chloride intravenous

TIER 01

sodium chloride irrigation TIER 01

sodium phosphates TIER 01

sodium polystyrene sulfonate

TIER 01

sps TIER 01


42


sterile water for irrigation TIER 01

swabflush saline flush TIER 01

TARON FORTE TIER 03

TAURINE INJECTION TIER 03

THAM TIER 03

THE LIQUILIFT TRACE TIER 03

thiamine hcl injection TIER 01

tis-u-sol TIER 01

tl-hem 150 TIER 01

tolvaptan SPECIALTY QL

TRALEMENT TIER 03

TRAVASOL TIER 03

TRI-AMINO TIER 03

TRICARE PRENATAL DHA ONE

TIER 02

tricon TIER 01

trientine hcl SPECIALTY PA

TRIFERIC HEMODIALYSIS PACKET

TIER 03

trigels-f forte TIER 01

trinate TIER 01

TRISODIUM CITRATE/CRRT

TIER 03

TROPHAMINE TIER 03

UROCIT-K 10 TIER 03

UROCIT-K 15 TIER 03

UROCIT-K 5 TIER 03

VELTASSA TIER 03

VENOFER TIER 03

VIRT-FEFA PLUS TIER 03

virt-phos 250 neutral TIER 01

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

TIER 01

vitamin k1 injection TIER 01

vp-pnv-dha TIER 01

water for irrigation, sterile TIER 01

ZINC CHLORIDE INTRAVENOUS

TIER 03


ZINC SULFATE INTRAVENOUS SOLUTION 5 MG/ML

TIER 03

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

CARAFATE ORAL SUSPENSION

TIER 03

cimetidine hcl TIER 01

cimetidine oral TIER 01

CYTOTEC TIER 03

DEXILANT TIER 02 QL

esomeprazole magnesium

TIER 01 QL

esomeprazole sodium TIER 01

famotidine intravenous TIER 01

famotidine oral suspension reconstituted

TIER 01

famotidine oral tablet 20 mg, 40 mg

TIER 01

famotidine premixed TIER 01

FIRST-LANSOPRAZOLE

TIER 03 ST

FIRST-OMEPRAZOLE TIER 03 ST

lansoprazole oral capsule delayed release

TIER 01 QL

lansoprazole oral tablet delayed release dispersible 15 mg

TIER 01 QL

misoprostol oral TIER 01

NEXIUM I.V. TIER 03

NEXIUM ORAL PACKET TIER 03 QL

nizatidine TIER 01

omeprazole oral capsule delayed release

TIER 01 QL

OMEPRAZOLE+SYRSPEND SF ALKA

TIER 03 ST

pantoprazole sodium intravenous

TIER 01 QL

pantoprazole sodium oral TIER 01 QL

PRILOSEC TIER 03 ST; QL

PROTONIX INTRAVENOUS

TIER 03 QL


43


PROTONIX ORAL PACKET

TIER 03 ST; QL

rabeprazole sodium oral tablet delayed release

TIER 01 QL

sucralfate oral TIER 01

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL TIER 03

alosetron hcl TIER 01 PA

amoxicill-clarithro-lansopraz

TIER 01

ANASPAZ TIER 03

ATROPEN TIER 03

atropine sulfate injection solution 8 mg/20ml

TIER 01

atropine sulfate injection solution prefilled syringe

TIER 01

ATROPINE SULFATE INTRAVENOUS

TIER 03

BENTYL TIER 03

cascara sagrada oral fluid extract

TIER 01

CHENODAL SPECIALTY

chlordiazepoxide-clidinium

TIER 01

CLENPIQ TIER 03

constulose TIER 01

cromolyn sodium oral TIER 01

CUVPOSA TIER 03

dicyclomine hcl intramuscular

TIER 01

dicyclomine hcl oral TIER 01

diphenoxylate-atropine TIER 01

ed-spaz TIER 01

ENTEREG TIER 03

enulose TIER 01

GASTROCROM TIER 03

GATTEX SPECIALTY PA

gavilyte-c TIER 01

gavilyte-g TIER 01

gavilyte-h TIER 01


gavilyte-n with flavor pack

TIER 01

generlac TIER 01

glycopyrrolate injection solution

TIER 01

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE

TIER 03

GLYCOPYRROLATE INTRAVENOUS

TIER 03

glycopyrrolate oral tablet 1 mg, 2 mg

TIER 01

glycopyrrolate pf TIER 01

GLYRX-PF TIER 03

HELIDAC THERAPY TIER 03

hyoscyamine sulfate oral TIER 01

hyoscyamine sulfate sl TIER 01

hyoscyamine sulfate sublingual

TIER 01

lactulose encephalopathy

TIER 01

lactulose oral solution TIER 01

LINZESS TIER 02 ST; QL

LOMOTIL TIER 03

loperamide hcl oral capsule

TIER 01

methscopolamine bromide oral

TIER 01

mineral oil heavy oral TIER 01

MOTEGRITY TIER 03 ST; QL

MYTESI TIER 03 QL

nulev TIER 01

OMECLAMOX-PAK TIER 02

oscimin TIER 01

OSMOPREP TIER 03

peg 3350-kcl-na bicarb-nacl

TIER 01

peg-3350/electrolytes TIER 01

peg-3350/electrolytes/ascorbat

TIER 01

peg-kcl-nacl-nasulf-na asc-c

TIER 01

peg-prep TIER 01


44


PLENVU TIER 03

propantheline bromide oral

TIER 01

PYLERA TIER 02

RESTORA RX TIER 03

SEROSTIM SPECIALTY PA

sodium bicarbonate oral powder

TIER 01

SUPREP BOWEL PREP KIT

TIER 03

SYMPROIC SPECIALTY QL

TALICIA TIER 03

trilyte TIER 01

URSO 250 TIER 03

URSO FORTE TIER 03

ursodiol oral TIER 01

VIBERZI TIER 03 PA

XERMELO SPECIALTY

ZELNORM TIER 03 QL

ZORBTIVE SPECIALTY PA

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

ALDURAZYME SPECIALTY PA

AMMONUL TIER 03

BUPHENYL SPECIALTY

CERDELGA SPECIALTY PA

CEREZYME SPECIALTY PA

CHOLBAM SPECIALTY PA

CREON TIER 02

CRYSVITA SPECIALTY

CYSTADANE SPECIALTY

CYSTAGON SPECIALTY

ELAPRASE SPECIALTY PA

ELELYSO SPECIALTY PA

FABRAZYME SPECIALTY PA

GALAFOLD SPECIALTY PA; QL

KANUMA SPECIALTY PA

KUVAN SPECIALTY PA

LUMIZYME SPECIALTY PA


MEPSEVII SPECIALTY PA

miglustat SPECIALTY PA

MYALEPT SPECIALTY PA

NAGLAZYME SPECIALTY PA

nitisinone SPECIALTY

NITYR SPECIALTY

OCALIVA SPECIALTY PA; QL

ORFADIN SPECIALTY

PALYNZIQ SPECIALTY PA

PROCYSBI SPECIALTY PA

RAVICTI SPECIALTY PA

REVCOVI SPECIALTY PA

sapropterin dihydrochloride

SPECIALTY PA

sod benz-sod phenylacet TIER 01

sodium phenylbutyrate oral

SPECIALTY

STRENSIQ SPECIALTY PA

SUCRAID SPECIALTY

VIMIZIM SPECIALTY PA

VPRIV SPECIALTY PA

XURIDEN SPECIALTY PA; QL

ZAVESCA SPECIALTY PA

ZENPEP TIER 02

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation TIER 01

aminoacetic acid TIER 01

AURYXIA TIER 03

bethanechol chloride oral TIER 01

calcium acetate (phos binder)

TIER 01

calcium acetate oral tablet 667 mg

TIER 01

CUPRIMINE SPECIALTY PA

darifenacin hydrobromide er

TIER 01

DEPEN TITRATABS SPECIALTY

DETROL TIER 03

DETROL LA TIER 03


45


DITROPAN XL TIER 03

ELMIRON TIER 02

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG

TIER 03

flavoxate hcl TIER 01

FOSRENOL TIER 03

GELNIQUE TIER 03

glycine irrigation TIER 01

glycine urologic TIER 01

INTRAROSA TIER 03

lanthanum carbonate TIER 01

LITHOSTAT TIER 03

MUSE TIER 03 QL

MYRBETRIQ TIER 02

oxybutynin chloride er TIER 01

oxybutynin chloride oral TIER 01

OXYTROL TIER 03 QL

penicillamine oral capsule

SPECIALTY PA

penicillamine oral tablet SPECIALTY

phenazo oral tablet 200 mg

TIER 01

phenazopyridine hcl oral tablet 100 mg, 200 mg

TIER 01

PHOSLYRA TIER 03

RENACIDIN TIER 03

RIMSO-50 TIER 03

sevelamer carbonate TIER 01

sevelamer hcl TIER 01

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

TIER 01 QL

solifenacin succinate TIER 01

tadalafil oral TIER 01 QL

THIOLA SPECIALTY

THIOLA EC SPECIALTY

tolterodine tartrate TIER 01

tolterodine tartrate er TIER 01

TOVIAZ TIER 03

trospium chloride TIER 01


trospium chloride er TIER 01

uretron d/s oral tablet TIER 01

urin ds oral tablet TIER 01

utrona-c TIER 01

vardenafil hcl oral TIER 01 QL

VELPHORO TIER 03

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er TIER 01

CARDURA XL TIER 03 ST

dutasteride oral TIER 01

dutasteride-tamsulosin hcl

TIER 01

finasteride oral tablet 5 mg

TIER 01

JALYN TIER 03

PROSCAR TIER 03

RAPAFLO TIER 03

silodosin TIER 01

tamsulosin hcl TIER 01

terazosin hcl TIER 01

Hormonal Agents - Adrenal

betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml

TIER 01

CELESTONE SOLUSPAN

TIER 03

cortisone acetate oral TIER 01

DEPO-MEDROL TIER 03

DEXAMETHASONE (LA) TIER 03

dexamethasone intensol TIER 01

dexamethasone oral TIER 01

dexamethasone sod phosphate pf

TIER 01

dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml

TIER 01


46


DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MG/ML INJECTION

TIER 03

dexamethasone sodium phosphate solution 10 mg/ml injection

TIER 01

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MG/ML INJECTION

TIER 03

dexamethasone sodium phosphate solution 4 mg/ml injection

TIER 01

DEXONTO 0.4% TIER 03

fludrocortisone acetate oral

TIER 01

hydrocortisone oral TIER 01

KENALOG INJECTION SUSPENSION 10 MG/ML

TIER 03

KENALOG-80 TIER 03

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

TIER 03

MEDROL ORAL TABLET 2 MG

TIER 02

MEDROL ORAL TABLET THERAPY PACK

TIER 03

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML

TIER 03

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION

TIER 03

methylprednisolone acetate suspension 40 mg/ml injection

TIER 01

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION

TIER 03


methylprednisolone acetate suspension 80 mg/ml injection

TIER 01

methylprednisolone oral TIER 01

methylprednisolone sodium succ

TIER 01

METHYLPREDNISOLONE-BUPIVACAINE

TIER 03

MILLIPRED TIER 02

MILLIPRED DP 12-DAY TIER 03

ORAPRED ODT TIER 03

PEDIAPRED TIER 03

prednisolone oral solution

TIER 01

prednisolone sodium phosphate oral

TIER 01

prednisone intensol TIER 01

prednisone oral TIER 01

SOLU-CORTEF TIER 03

SOLU-MEDROL TIER 03

triamcinolone acetonide suspension 40 mg/ml injection

TIER 01

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION

TIER 03

TRIAMCINOLONE DIACETATE INJECTION SUSPENSION 80 MG/ML

TIER 03

TRIAMCINOLONE-BUPIVACAINE

TIER 03

ZILRETTA TIER 03

Hormonal Agents - Men's Health

ANDRODERM TIER 02 PA

NATESTO TIER 03 PA

testosterone cypionate intramuscular

TIER 01 PA

testosterone enanthate intramuscular

TIER 01 PA

testosterone transdermal TIER 01 PA

XYOSTED TIER 03 PA


47


Hormonal Agents - Osteoporosis

EVISTA TIER 03

OSPHENA TIER 03

raloxifene hcl TIER 01

Hormonal Agents - Pituitary

ACTHAR SPECIALTY PA

cabergoline TIER 01

DDAVP TIER 03

DDAVP RHINAL TUBE TIER 02

desmopressin ace spray refrig

TIER 01

desmopressin acetate injection

TIER 01

desmopressin acetate oral

TIER 01

desmopressin acetate spray

TIER 01

EGRIFTA SV SPECIALTY PA; QL

ELIGARD SPECIALTY PA; QL

FIRMAGON SPECIALTY PA; QL

FIRMAGON (240 MG DOSE)

SPECIALTY PA; QL

INCRELEX SPECIALTY PA

leuprolide acetate injection

SPECIALTY PA

LEUPROLIDE ACETATE-BUPIVACAINE

TIER 03

LUPANETA PACK SPECIALTY PA; QL

LUPRON DEPOT (1-MONTH)

SPECIALTY PA

LUPRON DEPOT (3-MONTH)

SPECIALTY PA

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

SPECIALTY PA

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

SPECIALTY PA

LUPRON DEPOT-PED (1-MONTH)

SPECIALTY PA


LUPRON DEPOT-PED (3-MONTH)

SPECIALTY PA

NOCDURNA TIER 03

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

SPECIALTY PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML

SPECIALTY PA


SPECIALTY PA


SPECIALTY PA

octreotide acetate SPECIALTY PA

ORILISSA TIER 02

oxytocin injection TIER 01

OXYTOCIN-LACTATED RINGERS

TIER 03

OXYTOCIN-SODIUM CHLORIDE

TIER 03

PITOCIN TIER 03

SIGNIFOR SPECIALTY PA

SIGNIFOR LAR SPECIALTY PA

SOMATULINE DEPOT SPECIALTY PA

SOMAVERT SPECIALTY PA

STIMATE SPECIALTY

SUPPRELIN LA SPECIALTY PA; QL

SYNAREL SPECIALTY

TEPEZZA SPECIALTY

TRELSTAR MIXJECT SPECIALTY PA; QL

TRIPTODUR SPECIALTY PA; QL

VANTAS SPECIALTY PA; QL

VAPRISOL TIER 03

VASOSTRICT TIER 03

ZOLADEX SPECIALTY QL

Hormonal Agents - Prostaglandins

KORLYM SPECIALTY PA; QL


48


Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA TIER 03

afirmelle TIER 01

ALORA TIER 03

altavera TIER 01

alyacen 1/35 TIER 01

alyacen 7/7/7 TIER 01

amabelz TIER 01

amethia TIER 01 QL

amethia lo TIER 01 QL

amethyst TIER 01

ANGELIQ TIER 03

apri TIER 01

aranelle TIER 01

ashlyna TIER 01 QL

aubra TIER 01

aubra eq TIER 01

aurovela 1.5/30 TIER 01

aurovela 1/20 TIER 01

aurovela 24 fe TIER 01

aurovela fe 1.5/30 TIER 01

aurovela fe 1/20 TIER 01

aviane TIER 01

AYGESTIN TIER 03

ayuna TIER 01

azurette TIER 01

balziva TIER 01

bekyree TIER 01

BIJUVA TIER 03

blisovi 24 fe TIER 01

blisovi fe 1.5/30 TIER 01

blisovi fe 1/20 TIER 01

briellyn TIER 01

camila TIER 01

camrese TIER 01 QL

camrese lo TIER 01 QL

caziant TIER 01

charlotte 24 fe TIER 01


chateal TIER 01

chateal eq TIER 01

CLIMARA PRO TIER 02

COMBIPATCH TIER 03

CRINONE TIER 03 QL

cryselle-28 TIER 01

cyclafem 1/35 TIER 01

cyclafem 7/7/7 TIER 01

cyred TIER 01

cyred eq TIER 01

dasetta 1/35 TIER 01

dasetta 7/7/7 TIER 01

daysee TIER 01 QL

deblitane TIER 01

DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

TIER 03

delyla TIER 01

DEPO-ESTRADIOL TIER 03

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

TIER 03

desogestrel-ethinyl estradiol

TIER 01

DIVIGEL TIER 03

dotti TIER 01

drospiren-eth estrad-levomefol

TIER 01

drospirenone-ethinyl estradiol

TIER 01

DUAVEE TIER 02

ELESTRIN TIER 03

elinest TIER 01

ELLA TIER 03

emoquette TIER 01

ENDOMETRIN TIER 02

enpresse-28 TIER 01

enskyce TIER 01

errin TIER 01

estarylla TIER 01

estradiol oral TIER 01


49


estradiol transdermal TIER 01

estradiol vaginal TIER 01

estradiol valerate intramuscular

TIER 01

estradiol-norethindrone acet

TIER 01

ESTRING TIER 03 QL

ESTROGEL TIER 03

ESTROSTEP FE TIER 03

ethynodiol diac-eth estradiol

TIER 01

EVAMIST TIER 03

falmina TIER 01

fayosim TIER 01 QL

FEMHRT LOW DOSE TIER 03

FEMRING TIER 03 QL

femynor TIER 01

fyavolv TIER 01

gianvi TIER 01

hailey 1.5/30 TIER 01

hailey 24 fe TIER 01

hailey fe 1.5/30 TIER 01

hailey fe 1/20 TIER 01

heather TIER 01

hydroxyprogesterone caproate intramuscular oil

SPECIALTY

hydroxyprogesterone caproate intramuscular solution

SPECIALTY PA

IMVEXXY MAINTENANCE PACK

TIER 03

IMVEXXY STARTER PACK

TIER 03

incassia TIER 01

introvale TIER 01 QL

isibloom TIER 01

jaimiess TIER 01 QL

jasmiel TIER 01

jencycla TIER 01

jinteli TIER 01

jolessa TIER 01 QL


juleber TIER 01

junel 1.5/30 TIER 01

junel 1/20 TIER 01

junel fe 1.5/30 TIER 01

junel fe 1/20 TIER 01

junel fe 24 TIER 01

kaitlib fe TIER 01

kalliga TIER 01

kariva TIER 01

kelnor 1/35 TIER 01

kelnor 1/50 TIER 01

kurvelo TIER 01

larin 1.5/30 TIER 01

larin 1/20 TIER 01

larin 24 fe TIER 01

larin fe 1.5/30 TIER 01

larin fe 1/20 TIER 01

larissia TIER 01

layolis fe TIER 01

leena TIER 01

lessina TIER 01

levonest TIER 01

levonorgest-eth est & eth est

TIER 01 QL

levonorgest-eth estrad 91-day

TIER 01 QL

levonorgestrel-ethinyl estrad

TIER 01

levonorg-eth estrad triphasic

TIER 01

levora 0.15/30 (28) TIER 01

lillow TIER 01

lojaimiess TIER 01 QL

lopreeza TIER 01

loryna TIER 01

LOSEASONIQUE TIER 03 QL

low-ogestrel TIER 01

lo-zumandimine TIER 01

lutera TIER 01

lyza TIER 01

MAKENA SPECIALTY


50


marlissa TIER 01

medroxyprogesterone acetate oral

TIER 01

megestrol acetate oral TIER 01

melodetta 24 fe TIER 01

MENEST TIER 02

MENOSTAR TIER 03

mibelas 24 fe TIER 01

microgestin 1.5/30 TIER 01

microgestin 1/20 TIER 01

microgestin fe 1.5/30 TIER 01

microgestin fe 1/20 TIER 01

mili TIER 01

mimvey TIER 01

MINIVELLE TIER 03

MIRCETTE TIER 03

mono-linyah TIER 01

NATAZIA TIER 02

necon 0.5/35 (28) TIER 01

nikki TIER 01

nora-be TIER 01

norethin ace-eth estrad-fe

TIER 01

norethindrone acetate oral

TIER 01

norethindrone acet-ethinyl est

TIER 01

norethindrone oral TIER 01

norethindrone-eth estradiol

TIER 01

norethin-eth estradiol-fe TIER 01

norgestimate-eth estradiol

TIER 01

norgestimate-ethinyl estradiol triphasic

TIER 01

norlyda TIER 01

norlyroc TIER 01

nortrel 0.5/35 (28) TIER 01

nortrel 1/35 (21) TIER 01

nortrel 1/35 (28) TIER 01

nortrel 7/7/7 TIER 01

NUVARING TIER 03


ocella TIER 01

orsythia TIER 01

philith TIER 01

pimtrea TIER 01

pirmella 1/35 TIER 01

pirmella 7/7/7 TIER 01

portia-28 TIER 01

PREFEST TIER 03

PREMARIN INJECTION TIER 03

PREMARIN ORAL TIER 02

PREMARIN VAGINAL TIER 02

PREMPHASE TIER 02

PREMPRO TIER 02

previfem TIER 01

progesterone intramuscular

TIER 01

progesterone micronized oral

TIER 01

PROVERA TIER 03

QUARTETTE TIER 03 QL

reclipsen TIER 01

rivelsa TIER 01 QL

setlakin TIER 01 QL

sharobel TIER 01

simliya TIER 01

simpesse TIER 01 QL

sprintec 28 TIER 01

sronyx TIER 01

syeda TIER 01

tarina 24 fe TIER 01

tarina fe 1/20 TIER 01

tarina fe 1/20 eq TIER 01

tilia fe TIER 01

tri femynor TIER 01

tri-estarylla TIER 01

tri-legest fe TIER 01

tri-linyah TIER 01

tri-lo-estarylla TIER 01

tri-lo-marzia TIER 01

tri-lo-mili TIER 01

tri-lo-sprintec TIER 01


51


tri-mili TIER 01

tri-previfem TIER 01

tri-sprintec TIER 01

trivora (28) TIER 01

tri-vylibra TIER 01

tri-vylibra lo TIER 01

tulana TIER 01

tydemy TIER 01

velivet TIER 01

vienva TIER 01

viorele TIER 01

volnea TIER 01

vyfemla TIER 01

vylibra TIER 01

wera TIER 01

wymzya fe TIER 01

yuvafem TIER 01

zarah TIER 01

zovia 1/35e (28) TIER 01

zumandimine TIER 01

Hormonal Agents - Thyroid

ARMOUR THYROID TIER 03

euthyrox TIER 01

levo-t TIER 01

levothyroxine sodium intravenous

TIER 01

levothyroxine sodium oral

TIER 01

levoxyl TIER 01

liothyronine sodium intravenous

TIER 01

liothyronine sodium oral TIER 01

methimazole oral TIER 01

NATURE-THROID TIER 03

np thyroid TIER 01

propylthiouracil oral TIER 01

TAPAZOLE TIER 03

TRIOSTAT TIER 03

unithroid TIER 01

WESTHROID TIER 03


WP THYROID TIER 03

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA SPECIALTY PA

ACTEMRA ACTPEN SPECIALTY PA

ACTIMMUNE SPECIALTY

ALFERON N SPECIALTY

ARCALYST SPECIALTY PA

ASTAGRAF XL SPECIALTY

ATGAM TIER 02

AZASAN TIER 03

azathioprine oral TIER 01

azathioprine sodium TIER 01

BENLYSTA SPECIALTY PA

BERINERT SPECIALTY PA

BIVIGAM SPECIALTY PA

CARIMUNE NF SPECIALTY PA

CELLCEPT SPECIALTY

CELLCEPT INTRAVENOUS

SPECIALTY

CIMZIA SPECIALTY PA

CIMZIA PREFILLED KIT SPECIALTY PA

CIMZIA STARTER KIT SPECIALTY PA

CINRYZE SPECIALTY PA

CUVITRU SPECIALTY PA

cyclosporine intravenous TIER 01

cyclosporine modified TIER 01

cyclosporine oral TIER 01

CYTOGAM SPECIALTY PA

ENBREL SPECIALTY PA

ENBREL MINI SPECIALTY PA

ENBREL SURECLICK SPECIALTY PA

ENTYVIO SPECIALTY PA

ENVARSUS XR SPECIALTY

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

SPECIALTY PA

FIRAZYR SPECIALTY PA

FLEBOGAMMA DIF SPECIALTY PA


52


GAMASTAN SPECIALTY PA

GAMIFANT SPECIALTY

GAMMAGARD SPECIALTY PA

GAMMAGARD S/D LESS IGA

SPECIALTY PA

GAMMAKED SPECIALTY PA

GAMMAPLEX SPECIALTY PA

GAMUNEX-C SPECIALTY PA

gengraf TIER 01

HAEGARDA SPECIALTY PA

HEPAGAM B TIER 03

HIZENTRA SPECIALTY PA

HUMIRA SPECIALTY PA

HUMIRA PEDIATRIC CROHNS START

SPECIALTY PA

HUMIRA PEN SPECIALTY PA

HUMIRA PEN-CD/UC/HS STARTER

SPECIALTY PA

HUMIRA PEN-PS/UV/ADOL HS START

SPECIALTY PA

HYPERHEP B S/D TIER 03

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

TIER 02

HYPERRAB INJECTION SOLUTION 900 UNIT/3ML

TIER 03

HYPERRAB S/D TIER 02

HYPERRHO S/D SPECIALTY

HYPERTET S/D TIER 03

HYQVIA SPECIALTY PA

icatibant acetate SPECIALTY PA

ILARIS SPECIALTY PA; QL

ILUMYA SPECIALTY PA

IMOGAM RABIES-HT TIER 02

IMURAN TIER 03

INFLECTRA SPECIALTY PA

KALBITOR SPECIALTY PA

KEDRAB TIER 02

KEVZARA SPECIALTY PA

KINERET SPECIALTY PA

leflunomide oral TIER 01


methotrexate (anti-rheumatic)

TIER 01

methotrexate oral TIER 01

methotrexate sodium TIER 01

methotrexate sodium (pf) TIER 01

MICRHOGAM ULTRA-FILTERED PLUS

SPECIALTY

mycophenolate mofetil SPECIALTY

mycophenolate mofetil hcl

SPECIALTY

mycophenolate sodium SPECIALTY

MYFORTIC SPECIALTY

NABI-HB TIER 03

NEORAL TIER 03

NULOJIX TIER 03 PA

OCTAGAM SPECIALTY PA

ORENCIA SPECIALTY PA

ORENCIA CLICKJECT SPECIALTY PA

OTEZLA SPECIALTY PA

OTREXUP SPECIALTY PA; QL

PRIVIGEN SPECIALTY PA

PROGRAF SPECIALTY

RAPAMUNE SPECIALTY

RASUVO SPECIALTY PA; QL

RENFLEXIS SPECIALTY PA

RHOGAM ULTRA-FILTERED PLUS

SPECIALTY

RHOPHYLAC TIER 02

RIDAURA SPECIALTY

RINVOQ SPECIALTY PA

RUCONEST SPECIALTY PA

SANDIMMUNE INTRAVENOUS

TIER 02

SANDIMMUNE ORAL CAPSULE

TIER 03

SANDIMMUNE ORAL SOLUTION

TIER 02

SILIQ SPECIALTY PA

SIMPONI SPECIALTY PA

SIMPONI ARIA SPECIALTY PA

SIMULECT TIER 03

sirolimus oral SPECIALTY


53


SKYRIZI (150 MG DOSE)

SPECIALTY PA

STELARA SPECIALTY PA

SYNAGIS SPECIALTY PA

tacrolimus oral SPECIALTY

TAKHZYRO SPECIALTY PA

TALTZ SPECIALTY PA

temsirolimus SPECIALTY

THYMOGLOBULIN TIER 03

TICE BCG SPECIALTY

TORISEL SPECIALTY

TREMFYA SPECIALTY PA

TREXALL TIER 03

VARIZIG TIER 03 PA

WINRHO SDF SPECIALTY

XATMEP SPECIALTY

XELJANZ SPECIALTY PA

XELJANZ XR SPECIALTY PA

XEMBIFY SPECIALTY PA

ZINPLAVA TIER 03

ZORTRESS SPECIALTY PA

Immunological Agents - Drugs for Vaccination

ACTHIB TIER 03

ADACEL TIER 03

AFLURIA QUADRIVALENT

TIER 03

BCG VACCINE TIER 03

BEXSERO TIER 03

BIOTHRAX TIER 03

BOOSTRIX TIER 03

DAPTACEL TIER 03

DIPHTHERIA-TETANUS TOXOIDS DT

TIER 03

ENGERIX-B INJECTION TIER 03

FLUAD TIER 03

FLUAD QUADRIVALENT

TIER 03

FLUARIX QUADRIVALENT

TIER 03


FLUBLOK QUADRIVALENT

TIER 03

FLUCELVAX QUADRIVALENT

TIER 03

FLULAVAL QUADRIVALENT

TIER 03

FLUMIST QUADRIVALENT

TIER 03

FLUZONE HIGH-DOSE QUADRIVALENT

TIER 03

FLUZONE QUADRIVALENT

TIER 03

GARDASIL 9 TIER 03

HAVRIX TIER 03

HEPLISAV-B TIER 03

HIBERIX TIER 03

IMOVAX RABIES TIER 03

INFANRIX TIER 03

IPOL TIER 03

IXIARO TIER 03

KINRIX TIER 03

MENACTRA TIER 03

MENQUADFI TIER 03

MENVEO TIER 03

M-M-R II TIER 03

PEDIARIX TIER 03

PEDVAX HIB TIER 03

PENTACEL TIER 03

PNEUMOVAX 23 TIER 03

PREVNAR 13 TIER 03

PROQUAD TIER 03

QUADRACEL TIER 03

RABAVERT TIER 03

RECOMBIVAX HB TIER 03

ROTARIX TIER 03

ROTATEQ TIER 03

SHINGRIX TIER 03

STAMARIL TIER 03

TDVAX TIER 03

TENIVAC TIER 03

TETANUS-DIPHTHERIA TOXOIDS TD

TIER 03


54


TRUMENBA TIER 03

TWINRIX TIER 03

TYPHIM VI TIER 03

VAQTA TIER 03

VARIVAX TIER 03

VAXCHORA TIER 03

VIVOTIF TIER 03

YF-VAX TIER 03

Inflammatory Bowel Disease Agents

ANUSOL-HC EXTERNAL

TIER 03

APRISO TIER 02

AZULFIDINE TIER 03

AZULFIDINE EN-TABS TIER 03

balsalazide disodium TIER 01

budesonide er TIER 01

budesonide oral TIER 01

CORTENEMA TIER 03

CORTIFOAM TIER 03

ENTOCORT EC TIER 03

hydrocortisone (perianal) TIER 01

hydrocortisone ace-pramoxine external cream 1-1 %

TIER 01

hydrocortisone rectal TIER 01

mesalamine er TIER 01

mesalamine oral TIER 01

mesalamine rectal TIER 01

mesalamine-cleanser TIER 01

PENTASA TIER 03

PROCTOFOAM HC TIER 02

procto-med hc TIER 01

procto-pak TIER 01

proctosol hc TIER 01

proctozone-hc TIER 01

ROWASA TIER 03

SFROWASA TIER 02

sulfasalazine oral TIER 01

UCERIS RECTAL TIER 03


Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG, 35 MG

TIER 03 QL

ACTONEL ORAL TABLET 30 MG, 5 MG

TIER 03

alendronate sodium oral solution

TIER 01

alendronate sodium oral tablet 10 mg, 5 mg

TIER 01

alendronate sodium oral tablet 35 mg, 70 mg

TIER 01 QL

ATELVIA TIER 03 QL

BINOSTO TIER 03 QL

BONIVA TIER 03 QL

calcitonin (salmon) TIER 01 QL

EVENITY SPECIALTY PA; QL

FORTEO SPECIALTY PA

FOSAMAX TIER 03 QL

FOSAMAX PLUS D TIER 03 QL

ibandronate sodium TIER 01 QL

MIACALCIN INJECTION TIER 03

pamidronate disodium SPECIALTY

PROLIA SPECIALTY PA; QL

RAYALDEE TIER 03

RECLAST SPECIALTY

risedronate sodium oral tablet 150 mg, 35 mg

TIER 01 QL

risedronate sodium oral tablet 30 mg, 5 mg

TIER 01

risedronate sodium oral tablet delayed release

TIER 01 QL

TERIPARATIDE (RECOMBINANT)

SPECIALTY PA

TYMLOS SPECIALTY PA

XGEVA SPECIALTY PA

zoledronic acid SPECIALTY

Metabolic Bone Disease Agents - Other

calcitriol intravenous TIER 01


55


calcitriol oral TIER 01

cinacalcet hcl SPECIALTY PA

doxercalciferol intravenous

TIER 01

HECTOROL TIER 03

NATPARA SPECIALTY PA; QL

paricalcitol SPECIALTY

PARSABIV SPECIALTY

ROCALTROL TIER 03

ZEMPLAR SPECIALTY

Miscellaneous Therapeutic Agents

ACCU-CHEK FLEXLINK PLUS 6MM

TIER 03

ACCU-CHEK ULTRAFLEX INF SET

TIER 03

ACETADOTE TIER 03

acetylcysteine intravenous

TIER 01

ADAKVEO SPECIALTY

ALBUKED 25 TIER 03

ALBUKED 5 TIER 03

albumin human TIER 01

ALBUMINEX TIER 03

albumin-zlb TIER 01

alburx TIER 01

ALBUTEIN TIER 03

ALCOHOL PREP PADS PAD

TIER 03

ALCOHOL PREP PADS PAD 70 %

TIER 03

ALPHA-LIPOIC ACID INJECTION

TIER 03

AMD FOAM DRESSING TIER 03

AMD FOAM DRESSING TOPSHEET

TIER 03

AMPHADASE TIER 03

ANASCORP TIER 03

ANAVIP TIER 03

ANTIVENIN LATRODECTUS MACTANS

TIER 03


ANTIVENIN MICRURUS FULVIUS

TIER 03

ARTISS TIER 03

AUTOSOFT 30 INFUSION SET

TIER 03

AUTOSOFT 90 INFUSION SET

TIER 03

AUTOSOFT XC INFUSION SET

TIER 03

BACTERIOSTATIC WATER(BENZ ALC)

TIER 03

bal in oil TIER 01

BIOGUARD GAUZE SPONGES PAD 4"X4"

TIER 03

BIOGUARD ISLAND DRESSINGS

TIER 03

BIOGUARD NON-ADHERENT DRESSING

TIER 03

BOTOX SPECIALTY PA

BREATHE EASE LARGE

TIER 02

BREATHE EASE MEDIUM

TIER 02

BREATHE EASE SMALL TIER 02

BREATHERITE TIER 02

BRIDION TIER 03

CALCIUM DISODIUM VERSENATE

TIER 03

CARTICEL TIER 03

CAYA TIER 03

CHLORHEXIDINE GLUCONATE SOLUTION 20 %

TIER 03

CLEVER CHOICE HOLDING CHAMBER

TIER 02

COMPACT SPACE CHAMBER/LG MASK

TIER 02

COMPACT SPACE CHAMBER/MED MASK

TIER 02

COMPACT SPACE CHAMBER/SM MASK

TIER 02

CROFAB TIER 03

CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"

TIER 03


56


CURITY AMD ANTIMICROBIAL STRIP

TIER 03

CURITY IODOFORM PACKING STRIP

TIER 03

CYANOKIT TIER 03

CYTOTINE ORAL POWDER

TIER 03

deferoxamine mesylate TIER 01

DELTEC COZMO CLEO SET 24" 6MM

TIER 03

DESFERAL TIER 03

dexmedetomidine hcl in nacl intravenous solution 200 mcg/50ml, 400 mcg/100ml, 80 mcg/20ml

TIER 01

DEXMEDETOMIDINE HCL INTRAVENOUS SOLUTION 1000 MCG/10ML, 400 MCG/4ML

TIER 03

dexmedetomidine hcl intravenous solution 200 mcg/2ml

TIER 01

DEXMEDETOMIDINE HCL-DEXTROSE

TIER 03

DIGIFAB TIER 03

diluent for treprostinil TIER 01

DUODOTE TIER 03

DUROLANE SPECIALTY PA

DYSPORT SPECIALTY PA

EASIVENT TIER 02

ENDARI SPECIALTY PA

ergoloid mesylates oral TIER 01

EROS-CTD TIER 03

EUFLEXXA SPECIALTY PA

EXCILON AMD DRAIN SPONGES

TIER 03

FEMCAP TIER 03

FLEXBUMIN TIER 03

FLEXICHAMBER ADULT MASK/SMALL

TIER 02

FLEXICHAMBER CHILD MASK/LARGE

TIER 02

FLEXICHAMBER CHILD MASK/SMALL

TIER 02


flumazenil intravenous TIER 01

fomepizole TIER 01

FORA D40G GLUCOSE/PRESSURE

TIER 03

formaldehyde external solution 37 %

TIER 01

GELSYN-3 SPECIALTY PA

glutaraldehyde external TIER 01

GRASTEK SPECIALTY PA; QL

heparin lock flush TIER 01

heparin sodium lock flush

TIER 01

HUMAN ALBUMIN GRIFOLS

TIER 03

HYLENEX TIER 03

INSPIREASE RESERVOIR BAGS

TIER 02

IV STABILIZER FOR LUMOXITI

TIER 03

J-TIP KIT W/VIAL ADAPTERS

TIER 03

kedbumin TIER 01

KERLIX AMD ANTIMICROBIAL

TIER 03

KERLIX AMD SUPER SPONGES

TIER 03

MASK VORTEX TIER 02

methergine TIER 01

methylergonovine maleate

TIER 01

MICROCHAMBER DEVICE

TIER 02

MINIMED MIO ADVANCE INFUSE SET

TIER 03

MINIMED MIO INFUSION SET

TIER 03

MINIMED PUMP RESERVOIR 3ML

TIER 03

MINIMED QUICK SET INF SET 18"

TIER 03


TIER 03


TIER 03


57



TIER 03

MINIMED SILHOUETTE INF SET 32"

TIER 03

MINIMED SILHOUETTE INF SET 43"

TIER 03

MYOBLOC SPECIALTY PA

NEOKE RA LIPOIC TIER 03

NEXAVIR TIER 03

NITHIODOTE TIER 03

NOZIN NASAL SANITIZER POPSWAB

TIER 03

OCTAPLAS BLOOD GROUP A

TIER 03

OCTAPLAS BLOOD GROUP AB

TIER 03

OCTAPLAS BLOOD GROUP B

TIER 03

OCTAPLAS BLOOD GROUP O

TIER 03

ODACTRA TIER 03 PA; QL

OMNIPOD 5 PACK TIER 03

OMNIPOD DASH 5 PACK PODS

TIER 03

ORALAIR SPECIALTY PA; QL

ORALAIR ADULT SAMPLE KIT

SPECIALTY PA; QL

ORALAIR ADULT STARTER PACK

SPECIALTY PA; QL

ORALAIR CHILDRENS STARTER PACK

SPECIALTY PA; QL

PANDA MASK LARGE TIER 02

PANDA MASK MEDIUM TIER 02

PANDA MASK SMALL TIER 02

PARADIGM QUICK-SET 23" 9MM

TIER 03

PEDIATRIC PANDA MASK

TIER 02

PENTETATE CALCIUM TRISODIUM

TIER 03

PENTETATE ZINC TRISODIUM

TIER 03

PHOTREXA VISCOUS TIER 03


PHOTREXA-PHOTREXA VISCOUS KIT

TIER 03

PLASBUMIN-25 TIER 03

PLASBUMIN-5 TIER 03

PLASMANATE TIER 03

POCKET SPACER TIER 02

PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML

TIER 03

PRO COMFORT SPACER ADULT

TIER 02

PRO COMFORT SPACER CHILD

TIER 02

PRO COMFORT SPACER INFANT

TIER 02

PROCARE SPACER/ADULT MASK

TIER 02

PROCARE SPACER/CHILD MASK

TIER 02

PROTOPAM CHLORIDE TIER 03

PROVAYBLUE TIER 03

RADIOGARDASE SPECIALTY

RAGWITEK SPECIALTY PA; QL

RAPPORT RLS TIER 03

RAPPORT VTD TIER 03

RUZURGI SPECIALTY

SILHOUETTE 23" INFUSION SET

TIER 03

SILHOUETTE 43" INFUSION SET

TIER 03

SILHOUETTE INFUSION SET 18"

TIER 03

sodium nitrite intravenous

TIER 01

sodium saccharin powder

TIER 01

sodium thiosulfate intravenous

TIER 01

SORBITOL IRRIGATION SOLUTION 3 %

TIER 03

sorbitol irrigation solution 3.3 %

TIER 01

sorbitol-mannitol TIER 01


58


STERILE DILUENT FLOLAN PH 12

TIER 03

sterile diluent/epoprostenol

TIER 01

sterile water for injection TIER 01

SURE T INFUSION SET 18"/6MM

TIER 03


TIER 03


TIER 03


TIER 03


TIER 03


TIER 03


TIER 03

T: SLIM X2 INS PMP/CONTROL 7.4

TIER 03

T:SLIM X2 3ML CARTRIDGE

TIER 03

T:SLIM X2 INS PUMP/CONTROL-IQ

TIER 03

T:SLIM X2 INSULIN PMP BASAL IQ

TIER 03

T:SLIM X2 INSULIN PMP BASAL6.4

TIER 03

T:SLIM X2 INSULIN PMP/RFURB IQ

TIER 03

T:SLIM X2/CONTROL-IQ/REFURB

TIER 03

TACHOSIL TIER 03

TELFA AMD ISLAND DRESSING

TIER 03

TELFA AMD NON-ADHERENT

TIER 03

TISSEEL TIER 03

TRUSTEEL INFUSION SET

TIER 03

VARISOFT INFUSION SET

TIER 03

VISTOGARD TIER 03

VITRASE TIER 03


WIDE-SEAL DIAPHRAGM 60

TIER 03


TIER 03


TIER 03


TIER 03


TIER 03


TIER 03


TIER 03


TIER 03

XEOMIN SPECIALTY PA

XIAFLEX SPECIALTY PA

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR TIER 03

ACULAR LS TIER 03

ALOMIDE TIER 03

AZASITE TIER 03

azelastine hcl ophthalmic TIER 01

bacitracin ophthalmic TIER 01

BEPREVE TIER 03 ST

BESIVANCE TIER 03

BETADINE OPHTHALMIC PREP

TIER 03

BLEPH-10 TIER 03

bromfenac sodium (once-daily)

TIER 01 QL

CILOXAN TIER 03

ciprofloxacin hcl ophthalmic

TIER 01

cromolyn sodium ophthalmic

TIER 01

dexamethasone sodium phosphate ophthalmic

TIER 01

diclofenac sodium ophthalmic

TIER 01


59


epinastine hcl TIER 01

erythromycin ophthalmic TIER 01

FLAREX TIER 03

fluorometholone TIER 01

flurbiprofen sodium TIER 01

FML TIER 02

FML FORTE TIER 03

FML LIQUIFILM TIER 03

gatifloxacin ophthalmic TIER 01

gentak TIER 01

gentamicin sulfate ophthalmic

TIER 01

INVELTYS TIER 03

ketorolac tromethamine ophthalmic

TIER 01

levofloxacin ophthalmic TIER 01

LOTEMAX SM TIER 03

loteprednol etabonate TIER 01

MAXIDEX TIER 03

MITOSOL TIER 03

MOXEZA TIER 02

moxifloxacin hcl (2x day) TIER 01

moxifloxacin hcl ophthalmic

TIER 01

NATACYN TIER 02

OCUFLOX TIER 03

ofloxacin ophthalmic TIER 01

olopatadine hcl ophthalmic

TIER 01

OZURDEX SPECIALTY

POVIDONE-IODINE OPHTHALMIC

TIER 03

PRED MILD TIER 03

prednisolone acetate ophthalmic

TIER 01

prednisolone sodium phosphate ophthalmic

TIER 01

PROLENSA TIER 02 QL

sulfacetamide sodium ophthalmic

TIER 01

tobramycin ophthalmic TIER 01

TOBREX TIER 03


trifluridine TIER 01

ZIRGAN TIER 03

ZYMAXID TIER 03

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er TIER 01

acetazolamide oral TIER 01

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

TIER 02

apraclonidine hcl TIER 01

AZOPT TIER 02

betaxolol hcl ophthalmic TIER 01

BETIMOL TIER 03

BETOPTIC-S TIER 03

bimatoprost ophthalmic TIER 01 QL

brimonidine tartrate ophthalmic

TIER 01

carteolol hcl TIER 01

COMBIGAN TIER 02

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC

TIER 03

dorzolamide hcl solution 2 % ophthalmic

TIER 01

dorzolamide hcl-timolol mal

TIER 01

dorzolamide hcl-timolol mal pf

TIER 01

IOPIDINE TIER 03

ISOPTO CARPINE TIER 03

ISTALOL TIER 03

KEVEYIS SPECIALTY PA; QL

latanoprost ophthalmic TIER 01

levobunolol hcl TIER 01

LUMIGAN TIER 02 QL

methazolamide oral TIER 01

PHOSPHOLINE IODIDE TIER 02

pilocarpine hcl ophthalmic

TIER 01

RHOPRESSA TIER 02

ROCKLATAN TIER 02 QL

SIMBRINZA TIER 02


60


timolol maleate ophthalmic

TIER 01

TRAVATAN Z TIER 03 QL

travoprost (bak free) TIER 01 QL

TRUSOPT TIER 03

XELPROS TIER 03 QL

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac TIER 01

AKTEN TIER 03

ALCAINE TIER 03

altacaine TIER 01

altafrin TIER 01

atropine sulfate ophthalmic ointment

TIER 01

atropine sulfate ophthalmic solution 1 %

TIER 01

bacitracin-polymyxin b ophthalmic

TIER 01

bacitra-neomycin-polymyxin-hc

TIER 01

BLEPHAMIDE TIER 03

BLEPHAMIDE S.O.P. TIER 03

CYCLOGYL TIER 03

CYCLOMYDRIL TIER 03

cyclopentolate hcl ophthalmic

TIER 01

CYSTARAN SPECIALTY PA; QL

EYLEA SPECIALTY

homatropaire TIER 01

ISOPTO ATROPINE TIER 03

LACRISERT TIER 03

LASTACAFT TIER 03 ST

LUCENTIS SPECIALTY

MAXITROL TIER 03

MEMBRANEBLUE TIER 03

neomycin-bacitracin zn-polymyx

TIER 01

neomycin-polymyxin-dexameth ophthalmic ointment

TIER 01


neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

TIER 01

neomycin-polymyxin-gramicidin

TIER 01

neomycin-polymyxin-hc ophthalmic

TIER 01

neo-polycin TIER 01

neo-polycin hc TIER 01

OXERVATE SPECIALTY PA; QL

phenylephrine hcl ophthalmic

TIER 01

polycin TIER 01

polymyxin b-trimethoprim TIER 01

POLYTRIM TIER 03

PRED-G TIER 03

PRED-G S.O.P. TIER 03

proparacaine hcl ophthalmic

TIER 01

RESTASIS TIER 02 PA

RESTASIS MULTIDOSE TIER 02 PA

sulfacetamide-prednisolone ophthalmic solution

TIER 01

tetracaine hcl ophthalmic TIER 01

TOBRADEX OPHTHALMIC OINTMENT

TIER 03

TOBRADEX ST TIER 03

tobramycin-dexamethasone

TIER 01

TROPICAMIDE-CYCLOPENTOLATE-PE

TIER 03

TROPIC-CYCLOP-PE-KETO-PROPAR

TIER 03

VISIONBLUE TIER 03

VISUDYNE SPECIALTY

XIIDRA TIER 02 PA

ZYLET TIER 03

Otic Agents - Drugs for Ear Conditions

acetic acid otic TIER 01

CETRAXAL TIER 03


61


CIPRO HC TIER 03

CIPRODEX TIER 02

ciprofloxacin hcl otic TIER 01

ciprofloxacin-dexamethasone

TIER 01

DERMOTIC TIER 03

flac TIER 01

fluocinolone acetonide otic

TIER 01

hydrocortisone-acetic acid

TIER 01

neomycin-polymyxin-hc otic

TIER 01

ofloxacin otic TIER 01

PRAMOTIC TIER 03

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal TIER 01 QL

azelastine-fluticasone TIER 01

BECONASE AQ TIER 03 QL

benzonatate TIER 01

bromfed dm TIER 01

brompheniramine tannate

TIER 01

carbinoxamine maleate oral solution

TIER 01

carbinoxamine maleate oral tablet 4 mg

TIER 01

cetirizine hcl oral solution TIER 01

CINQAIR SPECIALTY PA

clemastine fumarate oral tablet 2.68 mg

TIER 01

CUROSURF TIER 03

cyproheptadine hcl oral TIER 01

desloratadine TIER 01

diphenhydramine hcl injection

TIER 01

diphenhydramine hcl oral elixir

TIER 01

DYMISTA TIER 02

FASENRA SPECIALTY


FASENRA PEN SPECIALTY

flunisolide nasal TIER 01 QL

fluticasone propionate nasal

TIER 01

guaiatussin ac TIER 01 PA; QL

guaifenesin ac TIER 01 PA; QL

hydrocodone polst-chlorphen polst er susp

TIER 01 PA; QL

hydrocodone-homatropine

TIER 01 PA; QL

hydromet TIER 01 PA; QL

HYPERSAL TIER 03

INFASURF TIER 03

ipratropium bromide nasal

TIER 01

levocetirizine dihydrochloride oral

TIER 01

maxi-tuss ac TIER 01 PA; QL

mometasone furoate nasal

TIER 01 QL

nebusal inhalation nebulization solution 3 %

TIER 01

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

TIER 03

NUCALA SPECIALTY QL

olopatadine hcl nasal TIER 01 QL

OMNARIS TIER 03 QL

PATANASE TIER 03 QL

PHENERGAN TIER 03

promethazine hcl injection

TIER 01

promethazine hcl oral TIER 01

promethazine hcl rectal TIER 01

promethazine-codeine TIER 01 PA; QL

promethazine-dm TIER 01

promethazine-phenyleph-codeine

TIER 01 PA; QL

promethazine-phenylephrine

TIER 01

promethegan TIER 01

pseudoephedrine-bromphen-dm

TIER 01


62


pulmosal TIER 01

QNASL TIER 03 QL

QNASL CHILDRENS TIER 03 QL

RYCLORA TIER 03

ryvent TIER 01

SINUVA TIER 03

sodium chloride inhalation

TIER 01

SURVANTA TIER 03

TESSALON PERLES TIER 03

virtussin ac w/alc TIER 01 PA; QL

XOLAIR SPECIALTY

ZETONNA TIER 03 QL

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE TIER 03

acetylcysteine inhalation TIER 01

ADRENALIN INJECTION TIER 03

ADVAIR DISKUS TIER 02 QL

ADVAIR HFA TIER 02 QL

albuterol sulfate er TIER 01

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

TIER 01 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

TIER 03 QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml

TIER 01 QL

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml

TIER 01

albuterol sulfate oral TIER 01

aminophylline intravenous

TIER 01

ANORO ELLIPTA TIER 02 QL


ARALAST NP SPECIALTY PA

ARCAPTA NEOHALER TIER 03 ST

ARNUITY ELLIPTA TIER 02 QL

ATROVENT HFA TIER 03 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML

TIER 03

BREO ELLIPTA TIER 02 QL

BROVANA TIER 03 QL

budesonide inhalation TIER 01 QL

COMBIVENT RESPIMAT

TIER 02 QL

cromolyn sodium inhalation

TIER 01

DALIRESP TIER 03 PA

difil-g forte TIER 01

ELIXOPHYLLIN TIER 02

epinephrine injection solution

TIER 01

epinephrine injection solution auto-injector

TIER 01

EPIPEN 2-PAK TIER 03

ESBRIET SPECIALTY PA

FLOVENT DISKUS TIER 02 QL

FLOVENT HFA TIER 02 QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

TIER 01 QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

TIER 01 QL

GLASSIA SPECIALTY PA

INCRUSE ELLIPTA TIER 02 QL

ipratropium bromide inhalation

TIER 01 QL

ipratropium-albuterol TIER 01 QL


63


levalbuterol hcl inhalation TIER 01 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

TIER 03 QL

LONHALA MAGNAIR REFILL KIT

TIER 03 QL

LONHALA MAGNAIR STARTER KIT

TIER 03 QL

metaproterenol sulfate oral

TIER 01

montelukast sodium oral TIER 01

OFEV SPECIALTY PA

PERFOROMIST TIER 03 QL

PROAIR DIGIHALER TIER 03 QL

PROAIR HFA TIER 02 QL

PROAIR RESPICLICK TIER 02 QL

PROLASTIN-C SPECIALTY PA

PROVENTIL HFA TIER 03 QL

PULMICORT FLEXHALER

TIER 02 QL

SCLEROSOL INTRAPLEURAL

TIER 03

SEREVENT DISKUS TIER 02 QL

SPIRIVA HANDIHALER TIER 02 QL

SPIRIVA RESPIMAT TIER 02 QL

STERILE TALC POWDER

TIER 03

STERITALC TIER 03

STIOLTO RESPIMAT TIER 02 QL

STRIVERDI RESPIMAT TIER 02 QL

SYMBICORT TIER 02 QL

SYMJEPI TIER 03

terbutaline sulfate injection

TIER 01

terbutaline sulfate oral TIER 01

THEO-24 TIER 03

theophylline TIER 01

theophylline er TIER 01

theophylline in d5w TIER 01

TRELEGY ELLIPTA TIER 02 QL

VENTOLIN HFA TIER 02 QL

wixela inhub TIER 01 QL


XOPENEX TIER 03 QL

XOPENEX CONCENTRATE

TIER 03 QL

XOPENEX HFA TIER 03 QL

YUPELRI TIER 03 QL

zafirlukast TIER 01

ZEMAIRA SPECIALTY PA

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS SPECIALTY

CAYSTON SPECIALTY PA

KALYDECO SPECIALTY PA

ORKAMBI SPECIALTY PA; QL

PULMOZYME SPECIALTY PA

SYMDEKO SPECIALTY PA; QL

TOBI PODHALER SPECIALTY QL

tobramycin inhalation SPECIALTY

TRIKAFTA SPECIALTY PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADEMPAS SPECIALTY PA; QL

alyq SPECIALTY PA; QL

ambrisentan SPECIALTY PA; QL

bosentan SPECIALTY PA; QL

epoprostenol sodium SPECIALTY PA

FLOLAN SPECIALTY PA

OPSUMIT SPECIALTY PA; QL

ORENITRAM SPECIALTY PA

REVATIO INTRAVENOUS

SPECIALTY PA

REVATIO ORAL SUSPENSION RECONSTITUTED

SPECIALTY PA; QL

sildenafil citrate intravenous

SPECIALTY PA

sildenafil citrate oral suspension reconstituted

SPECIALTY PA; QL

sildenafil citrate oral tablet 20 mg

SPECIALTY PA; QL


64


tadalafil (pah) SPECIALTY PA; QL

TRACLEER 32 MG SPECIALTY PA; QL

treprostinil SPECIALTY PA

TYVASO SPECIALTY PA; QL

TYVASO REFILL SPECIALTY PA; QL

TYVASO STARTER SPECIALTY PA; QL

UPTRAVI SPECIALTY PA; QL

VELETRI SPECIALTY PA

VENTAVIS SPECIALTY PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral TIER 01

carisoprodol oral TIER 01

chlorzoxazone oral tablet 500 mg

TIER 01

cyclobenzaprine hcl oral TIER 01

DANTRIUM TIER 03

dantrolene sodium intravenous

TIER 01

dantrolene sodium oral TIER 01

FEXMID TIER 03

LORZONE TIER 03

metaxalone TIER 01

methocarbamol injection TIER 01

methocarbamol oral TIER 01

orphenadrine citrate er TIER 01

orphenadrine citrate injection

TIER 01

orphenadrine-asa-caffeine

TIER 01

revonto TIER 01

ROBAXIN TIER 03

ROBAXIN-750 TIER 03

RYANODEX TIER 03

tizanidine hcl oral TIER 01

Sleep Disorder Agents

armodafinil TIER 01 PA; QL

BELSOMRA TIER 03 ST; QL

doxepin hcl oral tablet TIER 01 QL


eszopiclone TIER 01 QL

flurazepam hcl TIER 01 PA; QL

HETLIOZ SPECIALTY PA; QL

modafinil TIER 01 PA; QL

ramelteon TIER 01 QL

ROZEREM TIER 03 QL

SECONAL TIER 03

SILENOR TIER 03 QL

SUNOSI TIER 02 PA; QL

temazepam TIER 01 QL

WAKIX SPECIALTY

XYREM SPECIALTY PA; QL

XYWAV SPECIALTY

zaleplon TIER 01 QL

zolpidem tartrate er TIER 01 QL

zolpidem tartrate oral TIER 01 QL

ZOLPIMIST TIER 03 ST; QL


65


66

Index of Drugs

abacavir sulfate.............................22abacavir sulfate-lamivudine.......... 22abacavir-lamivudine-zidovudine... 22ABELCET..................................... 14ABILIFY MAINTENA.....................22abiraterone acetate.......................16ABRAXANE.................................. 16ABSORICA LD..............................33acamprosate calcium......................6acarbose.......................................36ACCOLATE.................................. 63ACCU-CHEK FASTCLIX LANCET KIT.................................37ACCU-CHEK FLEXLINK PLUS 6MM..............................................56ACCU-CHEK MULTICLIX LANCET DEVICE KIT...................37ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...................37ACCU-CHEK ULTRAFLEX INF SET...............................................56ACCUPRIL....................................26ACCURETIC.................................26ACD FORMULA A........................ 11ACD-A NOCLOT-50..................... 11acebutolol hcl ................................26ACETADOTE................................56acetaminophen-codeine................. 3acetaminophen-codeine #2............ 3acetaminophen-codeine #3............ 3acetaminophen-codeine #4............ 3acetazolamide...............................60acetazolamide er.......................... 60acetazolamide sodium..................26acetic acid...............................45, 61acetylcysteine......................... 56, 63acitretin......................................... 33ACTEMRA.................................... 52ACTEMRA ACTPEN.....................52ACTHAR.......................................48ACTHIB.........................................54ACTIGALL.................................... 44ACTIMMUNE................................52ACTIQ.............................................3ACTIVE FE................................... 39ACTIVELLA.................................. 49ACTONEL.....................................55ACTOPLUS MET..........................36ACTOS......................................... 36ACULAR....................................... 59ACULAR LS..................................59acyclovir ........................................22acyclovir sodium........................... 22ACZONE.......................................33ADACEL....................................... 54ADAKVEO.................................... 56

adapalene.....................................33ADAPALENE................................ 33adapalene-benzoyl peroxide.........33ADASUVE.....................................22ADCETRIS....................................16ADDYI...........................................32adefovir dipivoxil ........................... 22ADEMPAS.................................... 64ADENOCARD...............................26adenosine..................................... 26ADRENALIN................................. 63adriamycin.................................... 16ADVAIR DISKUS..........................63ADVAIR HFA................................ 63ADVATE....................................... 25ADYNOVATE................................25ADZENYS ER...............................31ADZENYS XR-ODT......................31AEMCOLO......................................7AFINITOR.....................................16AFINITOR DISPERZ.................... 16afirmelle........................................ 49AFLURIA QUADRIVALENT..........54AFREZZA..................................... 38AFSTYLA......................................25AGGRASTAT................................21AGGRENOX.................................21AGRYLIN......................................25AIMOVIG...................................... 15AKOVAZ....................................... 26ak-poly-bac................................... 61AKTEN..........................................61AKYNZEO.....................................14ala-cort ..........................................33albendazole.................................. 20ALBUKED 25................................56ALBUKED 5..................................56albumin human............................. 56ALBUMINEX.................................56albumin-zlb................................... 56alburx............................................56ALBUTEIN.................................... 56albuterol sulfate............................ 63albuterol sulfate er........................ 63albuterol sulfate hfa...................... 63ALBUTEROL SULFATE HFA.......63ALCAINE...................................... 61alclometasone dipropionate..........33ALCOHOL PREP PADS.........33, 56ALDACTAZIDE.............................26ALDACTONE................................26ALDURAZYME............................. 45ALECENSA...................................16alendronate sodium...................... 55alfentanil hcl ....................................3ALFERON N................................. 52

alfuzosin hcl er..............................46ALIMTA.........................................16ALINIA.......................................... 20ALIQOPA......................................16aliskiren fumarate......................... 26ALKERAN.....................................16allopurinol..................................... 15allopurinol sodium.........................15almotriptan malate........................ 15ALOMIDE......................................59ALOPRIM......................................15ALORA..........................................49alosetron hcl ................................. 44ALOXI........................................... 14ALPHAGAN P...............................60ALPHA-LIPOIC ACID................... 56ALPHANATE/VWF COMPLEX/HUMAN......................25ALPHANINE SD........................... 25alprazolam.................................... 24alprazolam er................................24alprazolam intensol.......................24alprazolam xr................................ 24ALPROLIX.................................... 25alprostadil ..................................... 26ALTABAX........................................7altacaine....................................... 61altafrin...........................................61altavera.........................................49ALTRENO.....................................33ALUNBRIG................................... 16alyacen 1/35................................. 49alyacen 7/7/7................................ 49alyq............................................... 64amabelz........................................ 49amantadine hcl............................. 21AMARYL.......................................36AMBISOME.................................. 14ambrisentan..................................64amcinonide................................... 33AMD FOAM DRESSING...............56AMD FOAM DRESSING TOPSHEET.................................. 56AMERGE...................................... 15amethia.........................................49amethia lo..................................... 49amethyst....................................... 49AMICAR........................................25amikacin sulfate..............................7amiloride hcl ..................................26amiloride-hydrochlorothiazide.......26AMINO ACID................................ 39aminoacetic acid...........................45aminocaproic acid.........................25aminophylline................................63AMINOPROTECT.........................39

67

AMINOSYN II ................................39AMINOSYN-PF.............................39amiodarone hcl............................. 26amitriptyline hcl .............................13amlodipine besylate......................26amlodipine besylate-benazepril hcl ................................................. 26amlodipine besylate-valsartan...... 26amlodipine-atorvastatin.................26amlodipine-olmesartan................. 26amlodipine-valsartan-hctz.............26ammonium lactate........................ 33AMMONUL................................... 45amnesteem...................................33amoxapine.................................... 13amoxicill-clarithro-lansopraz......... 44amoxicillin....................................... 7amoxicillin-potassium clavulanate.. 7amoxicillin-potassium clavulanate er.....................................................7AMPHADASE............................... 56AMPHETAMINE ER..................... 31amphetamine sulfate.................... 31amphetamine-dextroamphetamine......................31amphetamine-dextroamphetamine er..................31amphotericin b.............................. 14ampicillin.........................................7ampicillin sodium............................ 7ampicillin-sulbactam sodium...........7AMPYRA.......................................31AMZEEQ.......................................33anagrelide hcl............................... 25ANASCORP..................................56ANASPAZ.....................................44anastrozole................................... 16ANAVIP.........................................56ANCOBON....................................14ANDRODERM.............................. 47ANECTINE....................................32ANGELIQ......................................49ANGIOMAX.................................. 11ANORO ELLIPTA......................... 63ANTABUSE.................................... 7anticoagulant cit dext soln a......... 11anticoagulant sodium citrate.........11ANTIVENIN LATRODECTUS MACTANS.................................... 56ANTIVENIN MICRURUS FULVIUS.......................................56ANUSOL-HC.................................55ANZEMET.....................................14apap-caff-dihydrocodeine............... 3APLENZIN.................................... 13APOKYN.......................................21apraclonidine hcl...........................60

aprepitant......................................14apri ................................................49APRISO........................................ 55APTENSIO XR..............................31APTIVUS...................................... 22AQUASOL A.................................39ARAKODA.................................... 20ARALAST NP............................... 63aranelle.........................................49ARANESP (ALBUMIN FREE).......25ARCALYST...................................52ARCAPTA NEOHALER................63argatroban.................................... 11ARGININE HCL............................ 39argyle sterile saline.......................39argyle sterile water........................39ARICEPT...................................... 12ARIKAYCE......................................7aripiprazole................................... 22ARISTADA....................................22ARISTADA INITIO........................ 22ARIXTRA...................................... 11armodafinil .................................... 65ARMOUR THYROID.....................52ARNUITY ELLIPTA.......................63AROMASIN...................................16ARRANON....................................16arsenic trioxide..............................16ARTICADENT DENTAL..................5ARTISS.........................................56ARZERRA.....................................16ASCLERA.....................................26ascomp-codeine............................. 3ashlyna......................................... 49ASPARLAS...................................16aspirin-dipyridamole er................. 21ASTAGRAF XL.............................52ASTRINGYN.................................25ATABEX OB................................. 39ATACAND HCT............................ 26atazanavir sulfate..........................22ATELVIA.......................................55atenolol ......................................... 26atenolol-chlorthalidone..................26ATGAM.........................................52ATIVAN.........................................24atomoxetine hcl.............................31atorvastatin calcium......................26atovaquone...................................20atovaquone-proguanil hcl ............. 20atracurium besylate...................... 32ATRALIN.......................................33ATROPEN.................................... 44atropine sulfate....................... 44, 61ATROPINE SULFATE.................. 44ATROVENT HFA..........................63AUBAGIO..................................... 31

aubra.............................................49aubra eq........................................49AUGMENTIN.................................. 7AUGMENTIN ES-600..................... 7aurovela 1.5/30.............................49aurovela 1/20................................49aurovela 24 fe...............................49aurovela fe 1.5/30.........................49aurovela fe 1/20............................49AURYXIA......................................45AUSTEDO.................................... 32AUTOLET II CLINISAFE...............37AUTOLET LANCING DEVICE......37AUTOSOFT 30 INFUSION SET...56AUTOSOFT 90 INFUSION SET...56AUTOSOFT XC INFUSION SET..56AUVI-Q......................................... 63AVALIDE.......................................26AVANDIA......................................36AVASTIN...................................... 16aviane........................................... 49avidoxy............................................7avita.............................................. 33AVONEX PEN.............................. 31AVONEX PREFILLED.................. 31AVYCAZ......................................... 7AYGESTIN....................................49ayuna............................................49AYVAKIT.......................................16azacitidine.....................................16AZACTAM.......................................7AZASAN....................................... 52AZASITE.......................................59azathioprine.................................. 52azathioprine sodium......................52azelaic acid...................................33azelastine hcl..........................59, 62azelastine-fluticasone................... 62AZELEX........................................33AZILECT.......................................21azithromycin....................................7AZOPT..........................................60aztreonam.......................................7AZULFIDINE.................................55AZULFIDINE EN-TABS................ 55azurette.........................................49baciim............................................. 7bacitracin.................................. 7, 59bacitracin-polymyxin b.................. 61bacitra-neomycin-polymyxin-hc.... 61baclofen........................................ 65BACTERIOSTATIC WATER(BENZ ALC).....................56BACTRIM........................................7BACTRIM DS..................................7BAFIERTAM................................. 31bal in oil .........................................56

68

balsalazide disodium.................... 55balsam peru-castor oil .................. 33BALVERSA...................................16balziva...........................................49BANZEL........................................11BAQSIMI ONE PACK................... 38BAQSIMI TWO PACK...................38BARACLUDE................................22BAVENCIO................................... 16BAXDELA....................................... 7BCG VACCINE.............................54BD AUTOSHIELD DUO PEN NEEDLES.....................................38BD ULTRA-FINE INSULIN SYRINGES................................... 38BD ULTRA-FINE PEN NEEDLES 38BD VEO INSULIN SYR U/F 1/2UNIT........................................ 38BECONASE AQ............................62bekyree.........................................49BELBUCA.......................................3BELEODAQ..................................16BELSOMRA..................................65benazepril hcl ................................26benazepril-hydrochlorothiazide.....26BENDEKA.....................................16BENEFIX...................................... 25BENLYSTA...................................52BENTYL........................................44benzalkonium chloride....................7BENZNIDAZOLE.......................... 20benzonatate..................................62benzoyl peroxide-erythromycin.....33benztropine mesylate....................21BEPREVE.....................................59BERINERT....................................52beser.............................................33BESIVANCE................................. 59BESPONSA..................................17BETADINE OPHTHALMIC PREP 59betamethasone dipropionate........ 33betamethasone dipropionate aug. 33betamethasone sod phos & acet.. 46betamethasone valerate............... 33BETAPACE AF.............................26BETASERON................................31betaxolol hcl ............................26, 60bethanechol chloride.....................45BETHKIS...................................... 64BETIMOL......................................60BETOPTIC-S................................ 60bexarotene....................................17BEXSERO.................................... 54bicalutamide..................................17BICILLIN C-R..................................7BICILLIN C-R 900/300....................7BICILLIN L-A...................................7

BICNU...........................................17BIDIL.............................................26BIJUVA......................................... 49BIKTARVY....................................22BILTRICIDE..................................20bimatoprost...................................60BINOSTO......................................55BIOGUARD GAUZE SPONGES.. 56BIOGUARD ISLAND DRESSINGS.................................56BIOGUARD NON-ADHERENT DRESSING...................................56BIORPHEN...................................26BIO-STATIN..................................14BIOTHRAX................................... 54bisoprolol fumarate....................... 26bisoprolol-hydrochlorothiazide......26bivalirudin trifluoroacetate.............11BIVIGAM.......................................52bleomycin sulfate..........................17BLEPH-10.....................................59BLEPHAMIDE...............................61BLEPHAMIDE S.O.P....................61BLINCYTO....................................17blisovi 24 fe...................................49blisovi fe 1.5/30.............................49blisovi fe 1/20................................49BLOXIVERZ..................................16BONIVA........................................ 55BONJESTA...................................14BOOSTRIX................................... 54BORTEZOMIB..............................17bosentan.......................................64BOSULIF...................................... 17BOTOX......................................... 56BPCO............................................33BRAFTOVI....................................17BREATHE EASE LARGE.............56BREATHE EASE MEDIUM...........56BREATHE EASE SMALL............. 56BREATHERITE.............................56BREO ELLIPTA............................ 63BREVIBLOC................................. 26BREVIBLOC IN NACL..................26BREVIBLOC PREMIXED............. 26BREVIBLOC PREMIXED DS....... 26BRIDION.......................................56briellyn.......................................... 49BRILINTA......................................21brimonidine tartrate.......................60BRIVIACT..................................... 11bromfed dm...................................62bromfenac sodium (once-daily).... 59bromocriptine mesylate.................21brompheniramine tannate.............62BROVANA.................................... 63BRUKINSA................................... 17

budesonide............................. 55, 63budesonide er...............................55bumetanide...................................26BUMEX.........................................26BUNAVAIL......................................7BUPHENYL.................................. 45bupivacaine fisiopharma.................5bupivacaine hcl...............................5bupivacaine hcl (pf) .........................5bupivacaine-epinephrine.................5bupivacaine-epinephrine (pf) .......... 5BUPRENEX....................................3buprenorphine.................................3buprenorphine hcl.......................3, 7buprenorphine hcl-naloxone hcl......7bupropion hcl................................ 13bupropion hcl er (smoking det)....... 7bupropion hcl er (sr)......................13bupropion hcl er (xl) ......................13BUPROPION HCL ER (XL).......... 13buspirone hcl................................ 24busulfan........................................ 17BUSULFEX...................................17butalbital-acetaminophen................3butalbital-apap-caff-cod.................. 3butalbital-apap-caffeine.................. 3butalbital-asa-caff-codeine..............3butalbital-aspirin-caffeine................3butorphanol tartrate........................ 3BUTRANS.......................................3BYDUREON................................. 36BYDUREON BCISE AUTOINJECTOR..........................36BYETTA 10 MCG PEN.................36BYETTA 5 MCG PEN...................36BYSTOLIC....................................26cabergoline................................... 48CABLIVI........................................22CABOMETYX............................... 17CADUET.......................................26CAFCIT.........................................32CAFERGOT..................................15caffeine citrate.............................. 32CAFFEINE-SODIUM BENZOATE.................................. 32CALAN SR....................................26CALCIFOL.................................... 39calcipotriene..................................33calcipotriene-betameth diprop...... 33calcitonin (salmon)........................55CALCITRENE...............................33calcitriol .............................33, 55, 56calcium acetate.............................45calcium acetate (phos binder).......45CALCIUM CHLORIDE..................39calcium chloride............................39

69

CALCIUM DISODIUM VERSENATE................................56calcium gluconate.........................39CALCIUM GLUCONATE-NACL... 39CALDOLOR....................................5CALQUENCE............................... 17camila........................................... 49CAMPATH.................................... 17CAMPTOSAR...............................17camrese........................................49camrese lo.................................... 49CANCIDAS................................... 14candesartan cilexetil ..................... 26candesartan cilexetil-hctz............. 26CAPASTAT SULFATE..................16capecitabine..................................17CAPLYTA..................................... 22CAPRELSA...................................17captopril ........................................ 26captopril-hydrochlorothiazide........26CARAC......................................... 33CARAFATE...................................43CARBAGLU..................................39carbamazepine............................. 11carbamazepine er.........................11carbidopa......................................21carbidopa-levodopa...................... 21carbidopa-levodopa er..................21carbidopa-levodopa-entacapone.. 21carbinoxamine maleate.................62CARBOCAINE................................5CARBOCAINE PRESERVATIVE-FREE................. 5carboplatin.................................... 17CARDENE IV................................26CARDIZEM...................................26CARDIZEM LA..............................26CARDURA....................................26CARDURA XL...............................46CARETOUCH LANCING/EJECTOR....................37CARIMUNE NF.............................52carisoprodol.................................. 65carisoprodol-aspirin-codeine...........3carmustine.................................... 17CARNITOR...................................39CAROSPIR...................................26carteolol hcl ...................................60cartia xt......................................... 26CARTICEL....................................56carvedilol .......................................27carvedilol phosphate er.................27cascara sagrada........................... 44CASODEX.................................... 17caspofungin acetate......................14CATAPRES.................................. 27CAYA............................................56

CAYSTON.................................... 64caziant.......................................... 49cefaclor........................................... 7cefaclor er.......................................7cefadroxil ........................................ 7CEFAZOLIN IN SODIUM CHLORIDE..................................... 7cefazolin sodium.............................7CEFAZOLIN SODIUM.................... 7cefazolin sodium-dextrose..............7cefdinir ............................................ 7cefditoren pivoxil .............................7cefepime hcl....................................7cefepime-dextrose.......................... 7cefixime...........................................7CEFOTAN.......................................7cefotaxime sodium..........................7cefotetan disodium..........................7cefotetan disodium-dextrose...........8cefoxitin sodium..............................8CEFOXITIN SODIUM-DEXTROSE....................................8cefpodoxime proxetil .......................8cefprozil .......................................... 8ceftazidime......................................8ceftazidime and dextrose................8ceftriaxone sodium..........................8ceftriaxone sodium in dextrose.......8ceftriaxone sodium-dextrose...........8cefuroxime axetil .............................8cefuroxime sodium..........................8celecoxib.........................................5CELESTONE SOLUSPAN........... 46CELLCEPT................................... 52CELLCEPT INTRAVENOUS........ 52CELONTIN....................................11CENTANY.......................................8CENTRATEX................................39cephalexin.......................................8CEPROTIN................................... 25CEQUR SIMPLICITY 2U.............. 37CEQUR SIMPLICITY STARTER..37CERDELGA..................................45CEREBYX.....................................11CEREZYME..................................45cetirizine hcl ..................................62CETRAXAL...................................61cevimeline hcl ............................... 32CHANTIX........................................7CHANTIX CONTINUING MONTH PAK.................................. 7CHANTIX STARTING MONTH PAK.................................................7charlotte 24 fe...............................49chateal.......................................... 49chateal eq..................................... 49CHEMET.......................................39

CHEMSTRIP UGK........................37CHENODAL..................................44chloramphenicol sod succinate.......8chlordiazepoxide hcl..................... 24chlordiazepoxide-amitriptyline...... 13chlordiazepoxide-clidinium............44chlorhexidine gluconate................33CHLORHEXIDINE GLUCONATE.56chloroprocaine hcl (pf) .................... 5chloroquine phosphate................. 20chlorothiazide sodium...................27chlorpromazine hcl........................22chlorthalidone............................... 27chlorzoxazone...............................65CHOLBAM....................................45cholestyramine..............................27cholestyramine light......................27chromagen....................................39chromic chloride............................39ciclodan.........................................14ciclopirox.......................................14ciclopirox olamine......................... 14cidofovir ........................................ 22cilostazol.......................................22CILOXAN......................................59CIMDUO....................................... 22cimetidine......................................43cimetidine hcl................................43CIMZIA..........................................52CIMZIA PREFILLED KIT.............. 52CIMZIA STARTER KIT................. 52cinacalcet hcl ................................ 56CINQAIR.......................................62CINRYZE......................................52CINVANTI.....................................14CIPRO............................................ 8CIPRO HC.................................... 62CIPRODEX...................................62ciprofloxacin hcl .................. 8, 59, 62ciprofloxacin in d5w........................ 8ciprofloxacin-dexamethasone.......62cisatracurium besylate..................32cisatracurium besylate (pf) ............32cisplatin.........................................17CISPLATIN................................... 17citalopram hydrobromide.............. 13CITANEST FORTE DENTAL..........5CITANEST PLAIN DENTAL........... 5cladribine...................................... 17claravis..........................................33clarithromycin..................................8clarithromycin er............................. 8clemastine fumarate..................... 62CLENPIQ......................................44CLEOCIN........................................8CLEOCIN PHOSPHATE.................8CLEOCIN-T.................................. 33

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CLEVER CHOICE HOLDING CHAMBER....................................56CLEVIPREX..................................27CLIMARA PRO.............................49clindacin etz..................................33clindacin-p.....................................34clindamycin hcl............................... 8clindamycin palmitate hcl ................8clindamycin phosphate............. 8, 34clindamycin phosphate in d5w........8CLINDAMYCIN PHOSPHATE IN NACL.............................................. 8clindamycin phosphate-benzoyl peroxide........................................34clindamycin-tretinoin.....................34CLINDESSE................................... 8CLINIMIX E/DEXTROSE (2.75/5).39CLINIMIX E/DEXTROSE (4.25/10)....................................... 39CLINIMIX E/DEXTROSE (4.25/5).39CLINIMIX E/DEXTROSE (5/15)....39CLINIMIX E/DEXTROSE (5/20)....39CLINIMIX/DEXTROSE (4.25/10)..39CLINIMIX/DEXTROSE (4.25/5)....39CLINIMIX/DEXTROSE (5/15).......39CLINIMIX/DEXTROSE (5/20).......39CLINISOL SF................................39CLINOLIPID..................................39clobazam...................................... 11clobetasol prop emollient base..... 34clobetasol propionate....................34clobetasol propionate e.................34clobetasol propionate emulsion.... 34clocortolone pivalate.....................34clodan........................................... 34clofarabine.................................... 17CLOLAR....................................... 17clomipramine hcl...........................13clonazepam.................................. 24clonidine........................................27clonidine hcl..................................27clonidine hcl er..............................31clopidogrel bisulfate......................22clorazepate dipotassium...............24clotrimazole...................................14clotrimazole-betamethasone.........14clovique.........................................39clozapine.......................................22CLOZARIL.................................... 22COAGADEX................................. 25coal tar..........................................34COARTEM....................................21codeine sulfate................................3COGENTIN...................................21colchicine......................................15colchicine-probenecid...................15COLCRYS.................................... 15

colesevelam hcl............................ 27colestipol hcl ................................. 27colistimethate sodium (cba)............8COLY-MYCIN M............................. 8COMBIGAN.................................. 60COMBIPATCH..............................49COMBIVENT RESPIMAT.............63COMBIVIR....................................22COMETRIQ (100 MG DAILY DOSE).......................................... 17COMETRIQ (140 MG DAILY DOSE).......................................... 17COMETRIQ (60 MG DAILY DOSE).......................................... 17COMPACT SPACE CHAMBER/LG MASK...................56COMPACT SPACE CHAMBER/MED MASK................56COMPACT SPACE CHAMBER/SM MASK.................. 56COMPLERA..................................23compro..........................................14COMTAN...................................... 21CONDYLOX..................................34CONJUPRI................................... 27constulose.....................................44COPAXONE................................. 31COPIKTRA................................... 17CORIFACT................................... 25CORLANOR................................. 27CORLOPAM................................. 27CORTENEMA...............................55CORTIFOAM................................ 55cortisone acetate.......................... 46CORTISPORIN.............................34CORVERT.................................... 27corvita 150.................................... 39CORVITE 150...............................39CORVITE FE................................ 39COSMEGEN.................................17COTELLIC.................................... 17COTEMPLA XR-ODT................... 31CREON.........................................45CRESEMBA..................................14CRINONE..................................... 49CRIXIVAN.....................................23CROFAB.......................................56cromolyn sodium...............44, 59, 63crotan............................................21cryselle-28.................................... 49CRYSVITA....................................45CUPRIC CHLORIDE.................... 40CUPRIMINE..................................45CURITY AMD ANTIMICROBIAL SPNGE......................................... 56CURITY AMD ANTIMICROBIAL STRIP........................................... 57

CURITY IODOFORM PACKING STRIP........................................... 57curity sterile saline........................ 40CUROSURF................................. 62CUTIVATE....................................34CUVITRU......................................52CUVPOSA.................................... 44cyanocobalamin............................40CYANOCOBALAMIN....................40CYANOKIT................................... 57cyclafem 1/35................................49cyclafem 7/7/7...............................49cyclobenzaprine hcl ...................... 65CYCLOGYL.................................. 61CYCLOMYDRIL............................61cyclopentolate hcl ......................... 61cyclophosphamide........................17cycloserine....................................16CYCLOSET.................................. 36cyclosporine..................................52cyclosporine modified................... 52CYKLOKAPRON.......................... 25cyproheptadine hcl ........................62CYRAMZA.................................... 17cyred.............................................49cyred eq........................................49CYSTADANE................................45CYSTAGON..................................45CYSTARAN.................................. 61cytarabine..................................... 17cytarabine (pf)...............................17CYTOGAM....................................52CYTOTEC.....................................43CYTOTINE....................................57CYTOVENE..................................23D.H.E. 45...................................... 15dacarbazine.................................. 17DACOGEN....................................17dactinomycin.................................17dalfampridine er............................31DALIRESP....................................63DALVANCE.................................... 8DANTRIUM...................................65dantrolene sodium........................ 65dapsone..................................16, 34DAPTACEL...................................54daptomycin..................................... 8DARAPRIM...................................21darifenacin hydrobromide er.........45DARZALEX...................................17dasetta 1/35..................................49dasetta 7/7/7.................................49daunorubicin hcl ............................17DAURISMO.................................. 17DAYPRO.........................................5daysee.......................................... 49DAYTRANA.................................. 31

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D-CARE 100X.................................5DDAVP......................................... 48DDAVP RHINAL TUBE.................48DEBACTEROL............................. 33deblitane....................................... 49decitabine..................................... 17deferasirox....................................40deferasirox granules..................... 40deferiprone....................................40deferoxamine mesylate.................57dehydrated alcohol....................... 40DELESTROGEN...........................49DELSTRIGO.................................23DELTEC COZMO CLEO SET 24" 6MM....................................... 57delyla............................................ 49demeclocycline hcl..........................8DEMEROL......................................3DEMSER...................................... 27DEPEN TITRATABS.....................45DEPO-ESTRADIOL......................49DEPO-MEDROL...........................46DEPO-PROVERA.........................49DERMA-SMOOTHE/FS BODY.....34DERMA-SMOOTHE/FS SCALP...34DERMOTIC...................................62DERMULCERA.............................34DESCOVY.................................... 23DESFERAL...................................57desipramine hcl.............................13desloratadine................................ 62desmopressin ace spray refrig......48desmopressin acetate...................48desmopressin acetate spray.........48desogestrel-ethinyl estradiol .........49desonide....................................... 34DESOWEN................................... 34desoximetasone............................34DESVENLAFAXINE ER................13desvenlafaxine succinate er......... 13DETROL....................................... 45DETROL LA..................................45dexamethasone............................ 46DEXAMETHASONE (LA)............. 46dexamethasone intensol...............46dexamethasone sod phosphate pf...................................................46dexamethasone sodium phosphate.........................46, 47, 59DEXAMETHASONE SODIUM PHOSPHATE................................47DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)................................. 37DEXILANT.................................... 43

DEXMEDETOMIDINE HCL.......... 57dexmedetomidine hcl ....................57dexmedetomidine hcl in nacl........ 57DEXMEDETOMIDINE HCL-DEXTROSE..................................57dexmethylphenidate hcl ................31dexmethylphenidate hcl er............31DEXONTO 0.4%...........................47DEXPANTHENOL........................ 40dexrazoxane hcl ............................17dextroamphetamine sulfate.......... 31dextroamphetamine sulfate er...... 31dextrose........................................40DEXTROSE..................................40DIACOMIT.................................... 11DIASTAT ACUDIAL......................11DIASTAT PEDIATRIC.................. 11DIATHRIVE LANCING DEVICE... 37DIATHRIVE PEN NEEDLE...........38diazepam................................ 11, 24DIAZEPAM................................... 24diazepam intensol.........................24diazoxide.......................................38DIBENZYLINE.............................. 27DICLEGIS.....................................14DICLOFENAC EPOLAMINE...........5diclofenac potassium...................... 5diclofenac sodium...............5, 34, 59diclofenac sodium er.......................5diclofenac-misoprostol ....................5DICLOFONO.................................. 5dicloxacillin sodium.........................8dicyclomine hcl............................. 44didanosine.................................... 23DIFICID...........................................8difil-g forte.....................................63DIFLUCAN....................................14diflunisal..........................................5DIGIFAB....................................... 57digitek........................................... 27digox............................................. 27digoxin.......................................... 27dihydroergotamine mesylate.........15DILANTIN..................................... 11DILATRATE-SR............................27DILAUDID.......................................3diltiazem hcl..................................27diltiazem hcl er..............................27diltiazem hcl er beads...................27diltiazem hcl er coated beads....... 27DILTIAZEM HCL-DEXTROSE......27DILTIAZEM HCL-SODIUM CHLORIDE................................... 27dilt-xr.............................................27DILUENT FOR LEFAMULIN.........40diluent for treprostinil .................... 57dimenhydrinate............................. 14

dimethyl fumarate......................... 31diphenhydramine hcl.....................62diphenoxylate-atropine................. 44DIPHTHERIA-TETANUS TOXOIDS DT................................54DIPROLENE.................................34DIPROLENE AF........................... 34dipyridamole................................. 22disopyramide phosphate...............27disulfiram........................................ 7DITROPAN XL..............................46DIURIL..........................................27divalproex sodium.........................11divalproex sodium er.....................11DIVIGEL........................................49dobutamine hcl............................. 27dobutamine in d5w........................27docetaxel...................................... 17dofetilide....................................... 27DOLOPHINE...................................3donepezil hcl .................................12dopamine hcl................................ 27dopamine in d5w...........................27DOPRAM......................................32DOPTELET...................................25DORAL......................................... 24DORZOLAMIDE HCL................... 60dorzolamide hcl.............................60dorzolamide hcl-timolol mal.......... 60dorzolamide hcl-timolol mal pf...... 60dotti ...............................................49DOVATO.......................................23DOVONEX....................................34doxazosin mesylate...................... 27doxepin hcl ..............................13, 65doxercalciferol ...............................56DOXIL...........................................17doxorubicin hcl ..............................17doxorubicin hcl liposomal..............17doxy 100......................................... 8doxycycline hyclate.........................8doxycycline monohydrate............... 8doxylamine-pyridoxine..................14DRISDOL......................................40DRIZALMA SPRINKLE.................13dronabinol.....................................14droperidol......................................14DROPLET MICRON..................... 38drospiren-eth estrad-levomefol.....49drospirenone-ethinyl estradiol .......49DROXIA........................................17DRYSOL.......................................34DUAVEE.......................................49DUETACT.....................................36duloxetine hcl................................13DUODOTE....................................57DUOPA.........................................21

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DUPIXENT....................................34duramorph...................................... 3duraxin............................................3DUROLANE..................................57dutasteride....................................46dutasteride-tamsulosin hcl............46DYANAVEL XR.............................31DYMISTA......................................62DYRENIUM...................................27DYSPORT.................................... 57E.E.S. GRANULES.........................8EASIVENT....................................57EC-NAPROSYN............................. 5ec-naproxen....................................5econazole nitrate.......................... 14EDARBI........................................ 27EDARBYCLOR.............................27EDECRIN......................................27EDETATE DISODIUM.................. 40ed-spaz.........................................44EDURANT.................................... 23efavirenz....................................... 23efavirenz-lamivudine-tenofovir ......23EFFER-K...................................... 40effer-k............................................40EFFIENT.......................................22EFUDEX....................................... 34EGATEN.......................................21EGRIFTA SV................................ 48ELAPRASE...................................45ELELYSO..................................... 45ELESTRIN.................................... 49eletriptan hydrobromide................15ELIGARD......................................48ELIMITE........................................21elinest........................................... 49ELIQUIS........................................11ELIQUIS DVT/PE STARTER PACK............................................11ELITEK......................................... 17ELITE-OB..................................... 40ELIXOPHYLLIN............................ 63ELLA.............................................49ELLENCE..................................... 17ELMIRON..................................... 46ELOCTATE...................................25EMCYT......................................... 17EMEND.........................................14EMEND TRI-PACK.......................14EMFLAZA..................................... 15EMGALITY....................................15EMGALITY (300 MG DOSE)........ 15emoquette.....................................49EMPLICITI.................................... 17EMSAM.........................................13emtricitabine................................. 23EMTRIVA......................................23

EMVERM......................................21ENABLEX..................................... 46enalapril maleate.......................... 27enalaprilat ..................................... 27enalapril-hydrochlorothiazide........27ENBREL....................................... 52ENBREL MINI...............................52ENBREL SURECLICK..................52ENDARI........................................ 57endocet...........................................3ENDOMETRIN..............................49ENGERIX-B..................................54ENHERTU.................................... 17ENLITE GLUCOSE SENSOR...... 37enoxaparin sodium....................... 11enpresse-28..................................49enskyce.........................................49entacapone...................................21entecavir ....................................... 23ENTEREG.................................... 44ENTOCORT EC............................55ENTRESTO.................................. 27ENTYVIO......................................52enulose......................................... 44ENVARSUS XR............................52EPCLUSA.....................................23ephedrine sulfate.......................... 27EPHEDRINE SULFATE................27EPHEDRINE SULFATE (PRESSORS)............................... 27EPHEDRINE SULFATE-NACL.....27EPIDIOLEX...................................11EPIDUO FORTE...........................34EPIFOAM......................................34epinastine hcl ................................60EPINEPHRINE............................. 27epinephrine.............................27, 63EPINEPHRINE HCL-DEXTROSE..................................27EPINEPHRINE HCL-NACL.......... 27epinephrine pf...............................27EPINEPHRINE-DEXTROSE........ 27EPINEPHRINE-NACL.............27, 28EPIPEN 2-PAK............................. 63epirubicin hcl .................................17epitol ............................................. 11EPIVIR..........................................23EPIVIR HBV..................................23eplerenone....................................28epoprostenol sodium.................... 64eptifibatide.................................... 22EPZICOM..................................... 23EQUETRO....................................24ERAXIS.........................................14ERBITUX...................................... 17ergocalciferol ................................ 40ergoloid mesylates........................57

ERGOMAR................................... 15ergotamine-caffeine......................15ERIVEDGE................................... 17erlotinib hcl ....................................17EROS-CTD...................................57errin...............................................49ertapenem sodium..........................8ERWINAZE...................................17ery.................................................34ERYGEL....................................... 34ERYPED 200..................................8ERYPED 400..................................8ERY-TAB........................................ 8ERYTHROCIN LACTOBIONATE... 8ERYTHROCIN STEARATE............8erythromycin....................... 8, 34, 60erythromycin base.......................... 8erythromycin ethylsuccinate........... 8ESBRIET...................................... 63escitalopram oxalate.....................13ESGIC.............................................3esmolol hcl ....................................28ESMOLOL HCL............................ 28esmolol hcl-sodium chloride......... 28esomeprazole magnesium............43esomeprazole sodium...................43estarylla........................................ 49estazolam..................................... 24estradiol .................................. 49, 50estradiol valerate.......................... 50estradiol-norethindrone acet.........50ESTRING......................................50ESTROGEL.................................. 50ESTROSTEP FE.......................... 50eszopiclone...................................65ethacrynate sodium...................... 28ethacrynic acid..............................28ethambutol hcl .............................. 16ETHAMOLIN.................................28ethosuximide.................................11ethyl chloride...................................5ethynodiol diac-eth estradiol .........50ETHYOL....................................... 17etodolac.......................................... 5etodolac er......................................5ETOPOPHOS...............................17etoposide...................................... 17EUCRISA......................................34EUFLEXXA...................................57euthyrox........................................52EVAMIST......................................50EVEKEO ODT.............................. 31EVENITY...................................... 55everolimus.............................. 17, 52EVERSENSE SENSOR/HOLDER.......................37

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EVERSENSE SMART TRANSMITTER............................ 37EVISTA.........................................48EVOCLIN......................................34EVOMELA.................................... 17EVOTAZ....................................... 23EVOXAC.......................................33EXCILON AMD DRAIN SPONGES....................................57EXELON....................................... 12exemestane.................................. 17EXJADE........................................40EXODERM....................................15EXPAREL....................................... 5EYLEA.......................................... 61EZALLOR SPRINKLE...................28ezetimibe...................................... 28ezetimibe-simvastatin................... 28FABRAZYME................................45falmina.......................................... 50famciclovir .....................................23famotidine..................................... 43famotidine premixed..................... 43FANAPT........................................22FANAPT TITRATION PACK.........22FARESTON.................................. 17FARXIGA......................................36FARYDAK.....................................18FASENRA.....................................62FASENRA PEN............................ 62FASLODEX...................................18FAVIPIRAVIR............................... 23fayosim......................................... 50febuxostat..................................... 15FEIBA........................................... 25felbamate......................................11FELDENE....................................... 5felodipine er.................................. 28FEMARA.......................................18FEMCAP.......................................57FEMHRT LOW DOSE.................. 50FEMRING..................................... 50femynor.........................................50fenofibrate.....................................28fenofibrate micronized.................. 28fenofibric acid................................28fentanyl........................................... 3fentanyl citrate................................ 3FENTANYL CITRATE-NACL..........3FERAHEME..................................40ferocon..........................................40ferotrinsic...................................... 40FERRALET 90..............................40FERRAPLUS 90........................... 40FERRIPROX.................................40FERRIPROX TWICE-A-DAY........40FERRLECIT..................................40

ferrocite plus................................. 40FERRO-PLEX HEMATINIC..........40FERROTRIN.................................40FETROJA....................................... 8FETZIMA...................................... 13FETZIMA TITRATION.................. 13FEXMID........................................ 65FIBRICOR.....................................28FIBRYGA......................................25FINACEA...................................... 34finasteride..................................... 46FIORINAL....................................... 3FIORINAL/CODEINE #3.................3FIRAZYR...................................... 52FIRMAGON.................................. 48FIRMAGON (240 MG DOSE).......48FIRST-LANSOPRAZOLE............. 43FIRST-OMEPRAZOLE................. 43FIRVANQ........................................8flac................................................ 62FLAGYL..........................................8FLAREX........................................60flavoxate hcl ..................................46FLEBOGAMMA DIF......................52flecainide acetate..........................28FLEXBUMIN................................. 57FLEXICHAMBER ADULT MASK/SMALL...............................57FLEXICHAMBER CHILD MASK/LARGE.............................. 57FLEXICHAMBER CHILD MASK/SMALL...............................57FLOLAN........................................64FLOLIPID......................................28FLOVENT DISKUS.......................63FLOVENT HFA.............................63floxuridine..................................... 18FLUAD..........................................54FLUAD QUADRIVALENT.............54FLUARIX QUADRIVALENT..........54FLUBLOK QUADRIVALENT........ 54FLUCELVAX QUADRIVALENT....54fluconazole....................................15fluconazole in sodium chloride......15flucytosine.....................................15fludarabine phosphate.................. 18fludrocortisone acetate................. 47FLULAVAL QUADRIVALENT.......54flumazenil ......................................57FLUMIST QUADRIVALENT......... 54flunisolide......................................62fluocinolone acetonide............34, 62fluocinolone acetonide body......... 34fluocinolone acetonide scalp.........34fluocinonide...................................34fluocinonide emulsified base.........34fluoridex sensitivity relief ...............33

fluorometholone............................60FLUOROPLEX..............................34fluorouracil .............................. 18, 34FLUOROURACIL..........................34fluoxetine hcl .................................13fluoxetine hcl (pmdd).................... 13fluphenazine decanoate................22fluphenazine hcl............................22flurazepam hcl.............................. 65flurbiprofen......................................5flurbiprofen sodium....................... 60flutamide....................................... 18fluticasone propionate.............34, 62fluticasone-salmeterol ...................63FLUTICASONE-SALMETEROL... 63fluvoxamine maleate.....................13fluvoxamine maleate er.................13FLUZONE HIGH-DOSE QUADRIVALENT..........................54FLUZONE QUADRIVALENT........54FML...............................................60FML FORTE................................. 60FML LIQUIFILM............................60folic acid........................................40FOLIVANE-F.................................40FOLIVANE-PLUS......................... 40FOLOTYN.....................................18foltrin.............................................40fomepizole.................................... 57fondaparinux sodium.................... 11FORA D40G GLUCOSE/PRESSURE............... 57FORFIVO XL................................ 13formaldehyde................................57FORTAZ......................................... 8FORTEO.......................................55FOSAMAX.................................... 55FOSAMAX PLUS D...................... 55fosamprenavir calcium..................23fosaprepitant dimeglumine............14FOSCAVIR................................... 23fosinopril sodium...........................28fosinopril sodium-hctz...................28fosphenytoin sodium.....................11FOSRENOL..................................46FRAGMIN..................................... 11FREAMINE HBC...........................40FREAMINE III ............................... 40FREESTYLE LIBRE 14 DAY READER.......................................37FREESTYLE LIBRE 14 DAY SENSOR.......................................37fulvestrant..................................... 18furosemide....................................28FUROSEMIDE IN SODIUM CHLORIDE................................... 28FUSION PLUS..............................40

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FUZEON.......................................23fyavolv...........................................50FYCOMPA....................................11gabapentin....................................11GABITRIL..................................... 12GALAFOLD...................................45galantamine hydrobromide........... 12galantamine hydrobromide er.......12GALZIN.........................................40GAMASTAN..................................53GAMIFANT................................... 53GAMMAGARD..............................53GAMMAGARD S/D LESS IGA..... 53GAMMAKED.................................53GAMMAPLEX...............................53GAMUNEX-C................................53GANCICLOVIR.............................23ganciclovir sodium........................ 23GARDASIL 9.................................54GASTROCROM............................44gatifloxacin....................................60GATTEX....................................... 44gavilyte-c.......................................44gavilyte-g...................................... 44gavilyte-h...................................... 44gavilyte-n with flavor pack.............44GAZYVA....................................... 18GEBAUERS PAIN EASE................6GEBAUERS SPRAY AND STRETCH.......................................6GELNIQUE................................... 46GELSYN-3....................................57gemcitabine hcl.............................18gemfibrozil .................................... 28generlac........................................44gengraf..........................................53gentak...........................................60gentamicin in saline........................ 9gentamicin sulfate.....................9, 60GENTEEL LANCING KIT (BLUE).37GENVOYA....................................23GEODON......................................22gianvi............................................ 50GILENYA...................................... 31GILOTRIF..................................... 18GLASSIA...................................... 63glatiramer acetate.........................31glatopa..........................................31GLEOSTINE................................. 18glimepiride.................................... 36glipizide er.....................................36glipizide ir ......................................36glipizide xl ..................................... 36glipizide-metformin hcl ..................36GLUCAGEN HYPOKIT.................38GLUCAGON EMERGENCY KIT.. 38GLUCOTROL............................... 36

GLUCOTROL XL..........................36glutaraldehyde.............................. 57GLUTATHIONE............................ 40glyburide....................................... 36glyburide micronized.....................36glyburide-metformin......................36GLYCINE......................................40glycine...........................................46glycine urologic.............................46GLYCOPHOS...............................40glycopyrrolate............................... 44GLYCOPYRROLATE................... 44glycopyrrolate pf........................... 44glydo............................................... 6GLYNASE.....................................36GLYRX-PF....................................44GLYSET........................................36GLYXAMBI................................... 36GOJJI LANCING DEVICE/CLEAR CAP...................37GONITRO.....................................28GORDOFILM................................34GRALISE...................................... 32granisetron hcl .............................. 14GRASTEK.....................................57griseofulvin microsize................... 15griseofulvin ultramicrosize............ 15guaiatussin ac...............................62guaifenesin ac...............................62guanfacine hcl ...............................28guanfacine hcl er.......................... 31GUANIDINE HCL..........................16GUARDIAN CONNECT TRANSMITTER............................ 37GUARDIAN LINK 3 TRANSMITTER............................ 37GUARDIAN SENSOR (3)............. 37GVOKE HYPOPEN 1-PACK........ 38GVOKE HYPOPEN 2-PACK........ 38GVOKE PFS.................................38GYNAZOLE-1...............................15HAEGARDA..................................53hailey 1.5/30................................. 50hailey 24 fe................................... 50hailey fe 1.5/30............................. 50hailey fe 1/20................................ 50HALAVEN.....................................18HALCION......................................24HALDOL....................................... 22HALDOL DECANOATE................22halobetasol propionate................. 34HALOG......................................... 34haloperidol.................................... 22haloperidol decanoate.................. 22haloperidol lactate.........................22HARVONI..................................... 23HAVRIX........................................ 54

heather..........................................50HECTOROL..................................56HELIDAC THERAPY.................... 44HEMANGEOL...............................28hematinic plus vit/minerals............40hematinic/folic acid....................... 40hematogen....................................40hematogen forte............................40HEMATRON-AF........................... 40HEMLIBRA................................... 25HEMOCYTE PLUS.......................40hemocyte-f ....................................40hemocyte-plus.............................. 40HEMOFIL M..................................25HEPAGAM B................................ 53heparin (porcine) in nacl............... 11HEPARIN (PORCINE) IN NACL...11heparin lock flush..........................57heparin sod (porcine) in d5w........ 11heparin sodium (porcine)..............11heparin sodium (porcine) pf..........11heparin sodium lock flush............. 57HEPATAMINE.............................. 40HEPLISAV-B.................................54HEPSERA.....................................23HERCEPTIN.................................18HERCEPTIN HYLECTA............... 18HESPAN.......................................25hetastarch-nacl............................. 25HETLIOZ.......................................65HEXTEND.....................................25HIBERIX....................................... 54HIPREX.......................................... 9HIZENTRA....................................53homatropaire.................................61HORIZANT................................... 32HUMALOG KWIKPEN..................38HUMALOG MIX 50/50 KWIKPEN.38HUMALOG MIX 50/50 VIAL......... 38HUMALOG MIX 75/25 KWIKPEN.38HUMALOG MIX 75/25 VIAL......... 38HUMALOG U-100 JUNIOR KWIKPEN..................................... 38HUMALOG VIAL...........................38HUMAN ALBUMIN GRIFOLS.......57HUMATE-P...................................25HUMIRA........................................53HUMIRA PEDIATRIC CROHNS START..........................................53HUMIRA PEN............................... 53HUMIRA PEN-CD/UC/HS STARTER.....................................53HUMIRA PEN-PS/UV/ADOL HS START..........................................53HUMULIN 70/30 KWIKPEN..........38HUMULIN 70/30 VIAL...................38HUMULIN N KWIKPEN................ 38

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HUMULIN N VIAL.........................38HUMULIN R U-500 KWIKPEN..... 38HUMULIN R U-500 VIAL.............. 38HUMULIN R VIAL.........................39HYCAMTIN...................................18hydralazine hcl..............................28HYDREA.......................................18hydrochlorothiazide.......................28hydrocodone bitartrate er................3hydrocodone polst-chlorphen polst er susp................................. 62hydrocodone-acetaminophen......... 3hydrocodone-homatropine............62hydrocodone-ibuprofen...................3hydrocortisone.................. 35, 47, 55hydrocortisone (perianal)..............55hydrocortisone ace-pramoxine..... 55hydrocortisone butyrate.......... 34, 35hydrocortisone valerate................ 35hydrocortisone-acetic acid............62hydrogen peroxide..........................9hydromet.......................................62HYDROMORPHONE HCL............. 3hydromorphone hcl.........................3hydromorphone hcl er.....................3hydromorphone hcl pf.....................3HYDROMORPHONE HCL-NACL...4hydroxocobalamin acetate............40hydroxychloroquine sulfate...........21hydroxyprogesterone caproate.....50hydroxyurea..................................18hydroxyzine hcl.............................24hydroxyzine pamoate....................24HYLENEX.....................................57hyoscyamine sulfate..................... 44hyoscyamine sulfate sl ..................44HYPERHEP B S/D........................53HYPERRAB..................................53HYPERRAB S/D...........................53HYPERRHO S/D.......................... 53HYPERSAL...................................62HYPERTET S/D............................53HYQVIA........................................ 53HYSINGLA ER................................4ibandronate sodium...................... 55IBRANCE......................................18ibu...................................................5ibuprofen.........................................5ibuprofen lysine...............................5ibutilide fumarate.......................... 28ICAR-C PLUS...............................40icatibant acetate............................53ICLUSIG....................................... 18IDAMYCIN PFS............................ 18idarubicin hcl .................................18IDELVION.....................................25IDHIFA..........................................18

iferex 150 forte..............................40IFEX..............................................18ifosfamide..................................... 18ILARIS.......................................... 53ILUMYA........................................ 53imatinib mesylate..........................18IMBRUVICA..................................18IMFINZI.........................................18imipenem-cilastatin.........................9imipramine hcl ...............................13imipramine pamoate..................... 13imiquimod..................................... 35IMOGAM RABIES-HT...................53IMOVAX RABIES..........................54IMPAVIDO.................................... 21IMURAN........................................53IMVEXXY MAINTENANCE PACK............................................50IMVEXXY STARTER PACK......... 50INBRIJA........................................21incassia.........................................50INCRELEX....................................48INCRUSE ELLIPTA...................... 63indapamide................................... 28INDOCIN.........................................5indomethacin.................................. 5indomethacin er.............................. 5indomethacin sodium......................5INFANRIX.....................................54INFASURF....................................62INFED...........................................40INFLECTRA..................................53INFUGEM..................................... 18INFUMORPH 200...........................4INFUMORPH 500...........................4INGREZZA....................................32INJECTAFER................................40INLYTA......................................... 18INPEN 100-BLUE-LILLY...............37INPEN 100-BLUE-NOVO............. 37INPEN 100-GRAY-LILLY..............37INPEN 100-GREY-NOVO.............37INPEN 100-PINK-LILLY................37INPEN 100-PINK-NOVO.............. 37INREBIC....................................... 18INSPIREASE RESERVOIR BAGS............................................57INSPRA........................................ 28INSULIN PEN NEEDLES............. 39INSULIN SYRINGES....................39INTEGRA F...................................40INTEGRA PLUS........................... 40INTEGRILIN..................................22INTELENCE..................................23intralipid........................................ 41INTRALIPID..................................41INTRAROSA.................................46

INTRON A.....................................23introvale........................................ 50INVANZ...........................................9INVEGA........................................ 22INVEGA SUSTENNA....................22INVEGA TRINZA.......................... 22INVELTYS.................................... 60INVIRASE.....................................23iodine strong................................. 41IOPIDINE......................................60IPOL..............................................54ipratropium bromide................62, 63ipratropium-albuterol .....................63irbesartan......................................28irbesartan-hydrochlorothiazide..... 28IRESSA.........................................18irinotecan hcl.................................18IS 24/6.......................................... 41ISENTRESS................................. 23ISENTRESS HD........................... 23isibloom.........................................50isoniazid........................................16isoproterenol hcl ........................... 28ISOPTO ATROPINE.....................61ISOPTO CARPINE....................... 60ISORDIL TITRADOSE..................28isosorbide dinitrate........................28isosorbide mononitrate................. 28isosorbide mononitrate er............. 28isotretinoin.................................... 35isradipine...................................... 28ISTALOL.......................................60ISTODAX (OVERFILL)................. 18ISUPREL...................................... 28itraconazole.................................. 15IV STABILIZER FOR LUMOXITI.. 57ivermectin..................................... 21IXEMPRA KIT...............................18IXIARO..........................................54IXINITY......................................... 25JADENU....................................... 41JADENU SPRINKLE.....................41jaimiess.........................................50JAKAFI..........................................18JALYN...........................................46jantoven........................................ 11JANUMET.....................................36JANUMET XR...............................36JANUVIA.......................................36JARDIANCE................................. 36jasmiel...........................................50jencycla.........................................50JENTADUETO..............................36JENTADUETO XR........................36JEVTANA......................................18jinteli ..............................................50JIVI................................................25

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jolessa...........................................50JORNAY PM.................................31J-TIP KIT W/VIAL ADAPTERS.....57juleber...........................................50JULUCA........................................23junel 1.5/30................................... 50junel 1/20...................................... 50junel fe 1.5/30............................... 50junel fe 1/20.................................. 50junel fe 24..................................... 50JUXTAPID.................................... 28JYNARQUE.................................. 41KABIVEN...................................... 41KADCYLA.....................................18kaitlib fe.........................................50KALBITOR....................................53KALETRA..................................... 23kalliga............................................50KALYDECO.................................. 64KANJINTI......................................18KANUMA...................................... 45KAPVAY....................................... 31kariva............................................ 50KCENTRA.....................................25kedbumin...................................... 57KEDRAB.......................................53KEFLEX..........................................9kelnor 1/35....................................50kelnor 1/50....................................50KENALOG.................................... 47KENALOG-80............................... 47KENGREAL.................................. 22KEPIVANCE................................. 33KEPPRA....................................... 12KERAMATRIX REPLICINE 5CMX5CM.................................... 35KERLIX AMD ANTIMICROBIAL...57KERLIX AMD SUPER SPONGES....................................57KERYDIN......................................15ketoconazole.................................15KETONE TEST.............................37ketoprofen.......................................5ketoprofen er...................................5ketorolac tromethamine............ 5, 60KETOROLAC TROMETHAMINE... 5KETOSTIX....................................37KEVEYIS...................................... 60KEVZARA.....................................53KEYTRUDA.................................. 18KHAPZORY..................................18KINERET...................................... 53KINRIX..........................................54kionex........................................... 41KISQALI (200 MG DOSE)............ 18KISQALI (400 MG DOSE)............ 18KISQALI (600 MG DOSE)............ 18

KISQALI FEMARA (400 MG DOSE).......................................... 18KISQALI FEMARA (600 MG DOSE).......................................... 18KISQALI FEMARA(200 MG DOSE).......................................... 18KLARON.......................................35klor-con.........................................41klor-con 10....................................41klor-con m10.................................41KLOR-CON M15...........................41klor-con m20.................................41klor-con sprinkle............................41klor-con/ef.....................................41KOATE..........................................25KOATE-DVI.................................. 25KOGENATE FS............................ 25KORLYM.......................................48KOSELUGO..................................18KOVALTRY...................................25K-PHOS........................................41K-PHOS-NEUTRAL......................41k-prime..........................................41KRINTAFEL..................................21KRYSTEXXA................................ 15k-tan plus...................................... 41kurvelo.......................................... 50KUVAN......................................... 45KYPROLIS....................................18L.E.T............................................... 6LABETALOL HCL.........................28labetalol hcl ...................................28LACRISERT..................................61lactated ringers............................. 41lactic acid......................................35lactic acid e...................................35lactulose........................................44lactulose encephalopathy............. 44LAMICTAL XR.............................. 12lamivudine.....................................23lamivudine-zidovudine.................. 23lamotrigine.................................... 12lamotrigine er................................12lamotrigine starter kit-blue............ 12lamotrigine starter kit-green..........12lamotrigine starter kit-orange........12LANCETS..................................... 37LANOXIN......................................28LANOXIN PEDIATRIC..................28lansoprazole................................. 43lanthanum carbonate....................46LANTUS SOLOSTAR...................39LANTUS U-100 VIAL....................39larin 1.5/30....................................50larin 1/20.......................................50larin 24 fe......................................50larin fe 1.5/30................................50

larin fe 1/20...................................50larissia...........................................50LARTRUVO.................................. 18LASTACAFT.................................61latanoprost....................................60LATUDA........................................22layolis fe........................................50leena.............................................50leflunomide................................... 53LEMTRADA.................................. 31LENVIMA (10 MG DAILY DOSE). 18LENVIMA (12 MG DAILY DOSE). 18LENVIMA (14 MG DAILY DOSE). 18LENVIMA (18 MG DAILY DOSE). 18LENVIMA (20 MG DAILY DOSE). 18LENVIMA (24 MG DAILY DOSE). 18LENVIMA (4 MG DAILY DOSE)... 18LENVIMA (8 MG DAILY DOSE)... 18lessina...........................................50letrozole........................................ 18leucovorin calcium........................ 18LEUKERAN.................................. 18LEUKINE...................................... 25leuprolide acetate......................... 48LEUPROLIDE ACETATE-BUPIVACAINE..............................48levalbuterol hcl ..............................64LEVALBUTEROL HFA................. 64levetiracetam................................ 12levetiracetam er............................ 12levetiracetam in nacl.....................12levobunolol hcl ..............................60LEVOCARNITINE.........................41levocarnitine..................................41levocarnitine sf..............................41levocetirizine dihydrochloride........62levofloxacin...............................9, 60levofloxacin in d5w..........................9levoleucovorin calcium..................18levoleucovorin calcium pf..............19levonest........................................ 50levonorgest-eth est & eth est........50levonorgest-eth estrad 91-day......50levonorgestrel-ethinyl estrad.........50levonorg-eth estrad triphasic........ 50LEVOPHED.................................. 28levora 0.15/30 (28)........................50levo-t.............................................52levothyroxine sodium....................52levoxyl...........................................52LEVULAN KERASTICK................35LEXIVA......................................... 23LIBTAYO.......................................19lidocaine..........................................6lidocaine hcl ..............................6, 33LIDOCAINE HCL............................ 6lidocaine hcl (cardiac).....................6

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lidocaine hcl (cardiac) pf.................6lidocaine hcl (pf) ..............................6lidocaine hcl urethral/mucosal........ 6LIDOCAINE IN D5W.......................6lidocaine in d5w.............................. 6LIDOCAINE IN DEXTROSE...........6lidocaine viscous hcl.....................33lidocaine-epinephrine......................6lidocaine-prilocaine.........................6LIDOCAINE-SODIUM BICARBONATE..............................6LIDO-EPINEPHRINE-TETRACAINE.................................6lillow..............................................50LINCOCIN.......................................9lincomycin hcl ................................. 9lindane.......................................... 21linezolid...........................................9linezolid in sodium chloride.............9LINZESS.......................................44liothyronine sodium.......................52LIPO..............................................41LIPO-C..........................................41LIPOFEN...................................... 28lisinopril .........................................28lisinopril-hydrochlorothiazide........ 28lithium........................................... 24lithium carbonate.......................... 25lithium carbonate er...................... 25LITHOBID..................................... 25LITHOSTAT..................................46LIVALO......................................... 28LMD IN D5W.................................25LMD IN NACL...............................25LODINE.......................................... 5lojaimiess......................................50LOKELMA.....................................41LOMOTIL......................................44LONHALA MAGNAIR REFILL KIT................................................ 64LONHALA MAGNAIR STARTER KIT................................................ 64LONSURF.....................................19loperamide hcl.............................. 44LOPID...........................................28lopinavir-ritonavir .......................... 23lopreeza........................................50LOPRESSOR............................... 28LOPRESSOR HCT.......................28LOPROX.......................................15lorazepam.....................................24lorazepam intensol........................24LORBRENA..................................19LORTAB......................................... 4loryna............................................50LORZONE.................................... 65losartan potassium........................29

losartan potassium-hctz................29LOSEASONIQUE......................... 50LOTEMAX SM.............................. 60LOTENSIN....................................29LOTENSIN HCT........................... 29loteprednol etabonate...................60lovastatin.......................................29LOVENOX.................................... 11low-ogestrel .................................. 50loxapine succinate........................ 22lo-zumandimine............................ 50LUCEMYRA....................................7LUCENTIS....................................61LUMIGAN..................................... 60LUMIZYME................................... 45LUMOXITI.....................................19LUPANETA PACK........................48LUPRON DEPOT (1-MONTH)......48LUPRON DEPOT (3-MONTH)......48LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..... 48LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..... 48LUPRON DEPOT-PED (1-MONTH)....................................... 48LUPRON DEPOT-PED (3-MONTH)....................................... 48lutera.............................................50LUXIQ...........................................35LYNPARZA...................................19LYRICA CR...................................32LYSINE HCL.................................41LYSODREN..................................19LYSTEDA..................................... 25lyza............................................... 50MACROBID.................................... 9MACRODANTIN.............................9mafenide acetate............................ 9MAGNEBIND 400.........................41magnesium chloride......................41MAGNESIUM SULFATE.............. 41magnesium sulfate........................41magnesium sulfate in d5w............ 41MAGNESIUM SULFATE-NACL....41MAKENA.......................................50MALARONE..................................21malathion...................................... 21MANGANESE CHLORIDE........... 41mannitol ........................................ 29maprotiline hcl ...............................13MARCAINE.....................................6MARCAINE PRESERVATIVE FREE.............................................. 6MARCAINE/EPINEPHRINE........... 6MARCAINE/EPINEPHRINE PF......6MARINOL..................................... 14marlissa........................................ 51

MARPLAN.................................... 13MARQIBO.....................................19MASK VORTEX............................57MATULANE.................................. 19matzim la...................................... 29MAVENCLAD (10 TABS)..............31MAVENCLAD (4 TABS)................32MAVENCLAD (5 TABS)................32MAVENCLAD (6 TABS)................32MAVENCLAD (7 TABS)................32MAVENCLAD (8 TABS)................32MAVENCLAD (9 TABS)................32MAVYRET.................................... 23MAXICOMFORT SYR 27G X 1/2"............................................... 39MAXIDEX......................................60MAXITROL................................... 61maxi-tuss ac..................................62MAXZIDE......................................29MAXZIDE-25.................................29MAYZENT.....................................32MAYZENT STARTER PACK........32meclizine hcl ................................. 14meclofenamate sodium...................5MEDROL...................................... 47MEDROX-RX..................................4medroxyprogesterone acetate......51mefloquine hcl ...............................21megestrol acetate......................... 51MEKINIST.....................................19MEKTOVI......................................19melodetta 24 fe.............................51meloxicam.......................................5melphalan..................................... 19melphalan hcl................................19memantine hcl .............................. 12memantine hcl er.......................... 12MEMBRANEBLUE........................61MENACTRA..................................54MENEST.......................................51MENOSTAR................................. 51MENQUADFI................................ 54MENVEO...................................... 54meperidine hcl ................................ 4MEPHYTON................................. 41meprobamate................................24MEPRON......................................21MEPSEVII.....................................45mercaptopurine.............................19meropenem.....................................9MEROPENEM-SODIUM CHLORIDE..................................... 9MERREM........................................9mesalamine.................................. 55mesalamine er.............................. 55mesalamine-cleanser....................55mesna...........................................19

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MESNEX.......................................19MESTINON...................................16metadate er...................................31metaproterenol sulfate..................64metaxalone................................... 65metformin hcl er............................36metformin hcl ir ............................. 36methadone hcl................................ 4methadone hcl intensol...................4METHADONE HCL-NACL..............4METHADOSE.................................4methadose......................................4METHADOSE SUGAR-FREE........ 4methazolamide............................. 60methenamine hippurate..................9methergine....................................57methimazole................................. 52methocarbamol.............................65methotrexate.................................53methotrexate (anti-rheumatic).......53methotrexate sodium.................... 53methotrexate sodium (pf)..............53methoxsalen rapid........................ 35methscopolamine bromide............44METHYLCOBALAMIN..................41methyldopa................................... 29methyldopa-hydrochlorothiazide...29methylergonovine maleate............57METHYLIN....................................31methylphenidate hcl ......................31methylphenidate hcl er..................31methylphenidate hcl er (cd).......... 31methylphenidate hcl er (la)........... 31methylprednisolone.......................47METHYLPREDNISOLONE ACETATE..................................... 47methylprednisolone acetate..........47methylprednisolone sodium succ..47METHYLPREDNISOLONE-BUPIVACAINE..............................47metoclopramide hcl.......................14metolazone................................... 29metoprolol succinate er.................29metoprolol tartrate.........................29metoprolol-hydrochlorothiazide.....29METROCREAM............................35METROLOTION........................... 35metronidazole........................... 9, 35metronidazole in nacl......................9metyrosine.................................... 29mexiletine hcl................................29MI PASTE.....................................33MI PASTE PLUS...........................33MIACALCIN.................................. 55mibelas 24 fe................................ 51micafungin sodium........................15miconazole 3.................................15

MICRHOGAM ULTRA-FILTERED PLUS..........................53MICROCHAMBER........................57MICROCYN.................................. 35microgestin 1.5/30........................ 51microgestin 1/20........................... 51microgestin fe 1.5/30.................... 51microgestin fe 1/20....................... 51MICROLET NEXT LANCING DEVICE........................................ 37midodrine hcl................................ 29MIGERGOT.................................. 15miglitol ...........................................36miglustat....................................... 45MIGRANAL...................................15mili ................................................ 51MILLIPRED...................................47MILLIPRED DP 12-DAY............... 47milrinone lactate............................29milrinone lactate in dextrose.........29mimvey......................................... 51mineral oil heavy...........................44MINIMED GUARDIAN SENSOR 3....................................................37MINIMED MIO ADVANCE INFUSE SET.................................57MINIMED MIO INFUSION SET.... 57MINIMED PUMP RESERVOIR 3ML...............................................57MINIMED QUICK SET INF SET 18"................................................ 57MINIMED QUICK SET INF SET 23"................................................ 57MINIMED QUICK SET INF SET 32"................................................ 57MINIMED QUICK SET INF SET 43"................................................ 58MINIMED SILHOUETTE INF SET 32"........................................ 58MINIMED SILHOUETTE INF SET 43"........................................ 58MINIPRESS..................................29MINIVELLE...................................51MINOCIN........................................ 9minocycline hcl ............................... 9minoxidil ........................................29MIRAPEX......................................21MIRAPEX ER................................21MIRCERA..................................... 25MIRCETTE................................... 51mirtazapine................................... 13MIRVASO..................................... 35misoprostol ................................... 43mitigo.............................................. 4mitomycin......................................19MITOSOL......................................60mitoxantrone hcl ........................... 19

M-M-R II ........................................54M-NATAL PLUS............................41modafinil ....................................... 65moexipril hcl ..................................29molindone hcl................................22mometasone furoate...............35, 62mondoxyne nl................................. 9monoject flush syringe..................41monoject sodium chloride flush.... 41mono-linyah.................................. 51MONONINE..................................25montelukast sodium......................64MONUROL..................................... 9morgidox.........................................9MORPHINE SULFATE................... 4morphine sulfate............................. 4morphine sulfate (concentrate).......4morphine sulfate (pf) .......................4morphine sulfate er.........................4morphine sulfate er beads.............. 4MORPHINE SULFATE-NACL........ 4MOTEGRITY................................ 44MOXEZA.......................................60MOXIFLOXACIN HCL.................... 9moxifloxacin hcl ........................ 9, 60moxifloxacin hcl (2x day).............. 60moxifloxacin hcl in nacl...................9MOZOBIL......................................25MULPLETA...................................25MULTAQ.......................................29MULTIGEN................................... 41MULTIGEN FOLIC........................41MULTIGEN PLUS.........................41mupirocin........................................ 9MUSE........................................... 46mutamycin.................................... 19MVASI...........................................19MYALEPT.....................................45MYAMBUTOL...............................16MYCAMINE.................................. 15MYCOBUTIN................................ 16mycophenolate mofetil ..................53mycophenolate mofetil hcl ............ 53mycophenolate sodium.................53MYDAYIS......................................31myferon 150 forte..........................41MYFORTIC...................................53MYLERAN.................................... 19MYLOTARG..................................19MYOBLOC....................................58myorisan....................................... 35MYRBETRIQ................................ 46MYTESI........................................ 44MYXREDLIN.................................39na ferric gluc cplx in sucrose........ 41NABI-HB....................................... 53nabumetone....................................5

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n-acetyl-l-cysteine.........................41nafcillin sodium............................... 9NAFCILLIN SODIUM IN DEXTROSE....................................9NAFRINSE DAILY ACIDULATED 33naftifine hcl....................................15NAFTIN.........................................15NAGLAZYME................................45nalbuphine hcl.................................4naloxone hcl....................................7naltrexone hcl................................. 7NAMENDA....................................12NAMENDA TITRATION PAK........12NAMENDA XR..............................12NAMENDA XR TITRATION PACK............................................12NAMZARIC...................................12naproxen.........................................5naproxen dr.....................................5naproxen sodium............................ 5naratriptan hcl...............................15NARCAN.........................................7NARDIL.........................................13NAROPIN....................................... 6NASCOBAL.................................. 41NATACYN.....................................60NATAZIA.......................................51nateglinide.................................... 36NATESTO.....................................47NATPARA.....................................56NATURE-THROID........................52NAVELBINE..................................19NAYZILAM....................................12NEBUPENT.................................. 21nebusal......................................... 62NEBUSAL.....................................62necon 0.5/35 (28)..........................51nefazodone hcl............................. 13NEMBUTAL.................................. 12NEOKE ALCAR............................ 41NEOKE RA LIPOIC...................... 58neomycin sulfate.............................9neomycin-bacitracin zn-polymyx...61neomycin-polymyxin b gu............... 9neomycin-polymyxin-dexameth.... 61neomycin-polymyxin-gramicidin....61neomycin-polymyxin-hc.......... 61, 62NEONATAL PLUS........................41neo-polycin................................... 61neo-polycin hc...............................61NEOPROFEN.................................5NEORAL.......................................53neostigmine methylsulfate............ 16NEOSTIGMINE METHYLSULFATE.......................16NEO-SYNALAR............................35NEPHRAMINE..............................41

NEPHRON FA.............................. 41NERLYNX.....................................19NESACAINE...................................6NESACAINE-MPF.......................... 6NESTABS.....................................41neuac............................................35NEULASTA...................................25NEULASTA ONPRO.....................25NEUPRO...................................... 21nevirapine..................................... 23nevirapine er.................................23NEXAVAR.....................................19NEXAVIR......................................58NEXIUM........................................43NEXIUM I.V.................................. 43NEXLETOL...................................29NEXLIZET.....................................29NEXTERONE............................... 29niacin er (antihyperlipidemic)........29nicardipine hcl ...............................29NICARDIPINE HCL IN NACL....... 29NICOTROL..................................... 7NICOTROL NS............................... 7nifedipine...................................... 29nifedipine er.................................. 29nifedipine er osmotic release........29NIFEREX...................................... 41nikki ...............................................51NILANDRON.................................19nilutamide..................................... 19NIMBEX........................................32nimodipine.................................... 29NINLARO......................................19NIPENT.........................................19nisoldipine er.................................29NITHIODOTE................................58nitisinone.......................................45NITRO-BID................................... 29NITRO-DUR..................................29nitrofurantoin...................................9nitrofurantoin macrocrystal ............. 9nitrofurantoin monohydrate macrocrystals..................................9nitroglycerin.................................. 29nitroglycerin in d5w.......................29NITROLINGUAL........................... 29NITROMIST..................................29NITROPRESS.............................. 29nitroprusside sodium.....................29nitro-time.......................................29NITYR...........................................45NIVESTYM................................... 25nizatidine.......................................43NOCDURNA.................................48nora-be......................................... 51NORDITROPIN FLEXPRO...........48norepinephrine bitartrate...............29

NOREPINEPHRINE-DEXTROSE 29NOREPINEPHRINE-SODIUM CHLORIDE................................... 29norethin ace-eth estrad-fe.............51norethindrone................................51norethindrone acetate...................51norethindrone acet-ethinyl est...... 51norethindrone-eth estradiol ...........51norethin-eth estradiol-fe................51norgestimate-eth estradiol ............ 51norgestimate-ethinyl estradiol triphasic........................................ 51norlyda..........................................51norlyroc.........................................51normal saline flush........................41NORPACE....................................29NORPACE CR..............................29NORPRAMIN................................13NORTHERA..................................29nortrel 0.5/35 (28)......................... 51nortrel 1/35 (21)............................ 51nortrel 1/35 (28)............................ 51nortrel 7/7/7...................................51nortriptyline hcl ..............................13NORVIR........................................23NOURIANZ...................................21NOVOEIGHT................................ 25NOVOFINE AUTOCOVER PEN NEEDLE....................................... 39NOVOFINE PEN NEEDLE........... 39NOVOFINE PLUS PEN NEEDLE.39NOVOPEN ECHO........................ 37NOVOSEVEN RT......................... 25NOVOTWIST PEN NEEDLE........ 39NOXAFIL...................................... 15NOZIN NASAL SANITIZER POPSWAB....................................58np thyroid......................................52NPLATE........................................25NUBEQA.......................................19NUCALA....................................... 62NUEDEXTA.................................. 32NUFERA.......................................41nulev............................................. 44NULOJIX.......................................53NUPLAZID....................................22NURTEC.......................................15nutrilipid........................................ 42NUTRIVIT..................................... 42NUTROPIN AQ NUSPIN 10......... 48NUTROPIN AQ NUSPIN 20......... 48NUTROPIN AQ NUSPIN 5........... 48NUVARING...................................51NUWIQ......................................... 25NUZYRA.........................................9nyamyc......................................... 15NYMALIZE....................................29

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nystatin......................................... 15nystatin-triamcinolone...................15nystop........................................... 15OBIZUR........................................ 25OCALIVA...................................... 45ocella............................................ 51OCREVUS....................................32OCTAGAM....................................53OCTAPLAS BLOOD GROUP A... 58OCTAPLAS BLOOD GROUP AB.58OCTAPLAS BLOOD GROUP B... 58OCTAPLAS BLOOD GROUP O...58octreotide acetate......................... 48OCUFLOX.................................... 60ODACTRA.................................... 58ODEFSEY.....................................23ODOMZO......................................19OFEV............................................64ofloxacin..............................9, 60, 62olanzapine.................................... 22olanzapine-fluoxetine hcl.............. 13olmesartan medoxomil ..................29olmesartan medoxomil-hctz..........29olmesartan-amlodipine-hctz..........29olopatadine hcl........................60, 62OLUX............................................35OLUX-E........................................ 35OMECLAMOX-PAK......................44omega-3-acid ethyl esters............ 29omeprazole...................................43OMEPRAZOLE+SYRSPEND SF ALKA.............................................43OMNARIS.....................................62OMNIPOD 5 PACK.......................58OMNIPOD DASH 5 PACK PODS.58OMNIPOD DASH SYSTEM..........38OMNIPOD STARTER...................38ONCASPAR..................................19ondansetron hcl............................ 14ondansetron odt............................14ONE VITE WOMENS PLUS.........42ONETOUCH DELICA LANCING DEV.............................................. 38ONETOUCH DELICA PLUS LANCING......................................38ONETOUCH ULTRA.................... 38ONETOUCH ULTRA 2 KIT W/DEVICE....................................38ONETOUCH ULTRA MINI KIT W/DEVICE....................................38ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..............38ONETOUCH VERIO IQ SYSTEM 38ONETOUCH VERIO KIT W/DEVICE....................................38ONETOUCH VERIO REFLECT....38

ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..............38ONEXTON....................................35ONIVYDE......................................19ONPATTRO..................................32OPDIVO........................................19OPSUMIT..................................... 64ORABLOC...................................... 6ORACIT........................................ 42ORALAIR......................................58ORALAIR ADULT SAMPLE KIT...58ORALAIR ADULT STARTER PACK............................................58ORALAIR CHILDRENS STARTER PACK.......................... 58oralone..........................................33ORAPRED ODT........................... 47ORBACTIV..................................... 9ORENCIA..................................... 53ORENCIA CLICKJECT.................53ORENITRAM................................ 64ORFADIN......................................45ORILISSA..................................... 48ORKAMBI..................................... 64orphenadrine citrate......................65orphenadrine citrate er..................65orphenadrine-asa-caffeine............65orsythia......................................... 51oscimin..........................................44oseltamivir phosphate...................23OSMITROL...................................29osmitrol ......................................... 29OSMOPREP.................................44OSPHENA.................................... 48OTEZLA........................................53OTREXUP.................................... 53OVIDE...........................................21oxacillin sodium.............................. 9OXACILLIN SODIUM IN DEXTROSE....................................9oxaliplatin......................................19oxaprozin........................................ 5oxazepam..................................... 24oxcarbazepine.............................. 12OXERVATE.................................. 61OXSORALEN ULTRA...................35oxybutynin chloride.......................46oxybutynin chloride er...................46oxycodone hcl.................................4oxycodone-acetaminophen.............4oxycodone-aspirin...........................4OXYCONTIN.................................. 4oxymorphone hcl............................ 4oxymorphone hcl er........................ 4oxytocin.........................................48OXYTOCIN-LACTATED RINGERS..................................... 48

OXYTOCIN-SODIUM CHLORIDE................................... 48OXYTROL.....................................46OZEMPIC..................................... 36OZURDEX.................................... 60PACERONE..................................29pacerone.......................................29paclitaxel.......................................19PADCEV.......................................19paliperidone er..............................22palonosetron hcl........................... 14PALYNZIQ....................................45pamidronate disodium.................. 55pancuronium bromide...................32PANDA MASK LARGE.................58PANDA MASK MEDIUM...............58PANDA MASK SMALL................. 58PANHEMATIN.............................. 25PANRETIN....................................19pantoprazole sodium.................... 43PARADIGM QUICK-SET 23" 9MM..............................................58paraplatin......................................19paricalcitol .....................................56PARLODEL...................................21PARNATE.....................................13paroex...........................................33paromomycin sulfate.......................9paroxetine hcl............................... 13paroxetine hcl er........................... 13paroxetine mesylate......................13PARSABIV....................................56PASER..........................................16PATANASE...................................62PAXIL............................................13PEDIAPRED.................................47PEDIARIX.....................................54PEDIATRIC PANDA MASK..........58PEDVAX HIB................................ 54peg 3350-kcl-na bicarb-nacl......... 44peg-3350/electrolytes................... 44peg-3350/electrolytes/ascorbat.....44PEGANONE................................. 12PEGASYS.....................................23PEGASYS PROCLICK................. 23PEGINTRON................................ 23peg-kcl-nacl-nasulf-na asc-c.........44peg-prep....................................... 44penicillamine.................................46PENICILLIN G POT IN DEXTROSE....................................9penicillin g potassium......................9penicillin g procaine........................ 9penicillin g sodium.......................... 9penicillin v potassium......................9PENTACEL...................................54PENTAM.......................................21

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pentamidine isethionate................21PENTASA.....................................55pentazocine-naloxone hcl...............4PENTETATE CALCIUM TRISODIUM..................................58PENTETATE ZINC TRISODIUM..58pentobarbital sodium.................... 12pentoxifylline er.............................29PERFOROMIST........................... 64PERIDEX......................................33PERIKABIVEN..............................42perindopril erbumine.....................29periogard.......................................33PERJETA......................................19permethrin.....................................21perphenazine................................14perphenazine-amitriptyline............13PERSERIS....................................22PEXEVA....................................... 13PFIZERPEN....................................9phenazo........................................46phenazopyridine hcl......................46phenelzine sulfate.........................13PHENERGAN...............................62phenobarbital ................................12phenobarbital sodium................... 12phenoxybenzamine hcl.................30phentolamine mesylate.................30phenylephrine hcl....................30, 61PHENYLEPHRINE HCL............... 30PHENYLEPHRINE HCL (PRESSORS)............................... 30PHENYLEPHRINE HCL-NACL.... 30PHENYTEK.................................. 12phenytoin...................................... 12phenytoin infatabs.........................12phenytoin sodium..........................12phenytoin sodium extended..........12philith............................................ 51PHOSLYRA.................................. 46phospha 250 neutral .....................42PHOSPHOLINE IODIDE.............. 60phosphorous.................................42phospho-trin 250 neutral ...............42PHOTOFRIN.................................19PHOTREXA VISCOUS.................58PHOTREXA-PHOTREXA VISCOUS KIT...............................58PHYSIOLYTE............................... 42PHYSIOSOL IRRIGATION...........42phytonadione................................ 42PICATO........................................ 35PIFELTRO.................................... 23pilocarpine hcl.........................33, 60pimecrolimus.................................35pimozide....................................... 22pimtrea..........................................51

pindolol ......................................... 30pioglitazone hcl.............................36pioglitazone hcl-glimepiride.......... 36pioglitazone hcl-metformin hcl ...... 36piperacillin sod-tazobactam so....... 9PIQRAY (200 MG DAILY DOSE). 19PIQRAY (250 MG DAILY DOSE). 19PIQRAY (300 MG DAILY DOSE). 19pirmella 1/35................................. 51pirmella 7/7/7................................ 51piroxicam........................................ 5PITOCIN....................................... 48PLAQUENIL..................................21PLASBUMIN-25............................58PLASBUMIN-5..............................58PLASMANATE..............................58PLENAMINE.................................42PLENVU....................................... 45PNEUMOVAX 23..........................54POCKET SPACER....................... 58podofilox....................................... 35POLIVY.........................................19polocaine........................................ 6polocaine-mpf................................. 6polycin...........................................61poly-iron 150 forte.........................42polymyxin b sulfate......................... 9polymyxin b-trimethoprim..............61polysaccharide iron forte...............42POLYTRIM................................... 61POMALYST.................................. 19portia-28........................................51PORTRAZZA................................19posaconazole................................15pot bicarb-pot chloride.................. 42potassium acetate.........................42potassium bicarbonate..................42potassium chloride........................42potassium chloride crys er............42potassium chloride er....................42potassium citrate er...................... 42potassium phosphates(71 meq k).42POTELIGEO.................................19POVIDONE-IODINE..................... 60PRADAXA.....................................11PRALUENT...................................30pramipexole dihydrochloride.........21pramipexole dihydrochloride er.....21PRAMOTIC...................................62prasugrel hcl ................................. 22pravastatin sodium........................30praziquantel .................................. 21prazosin hcl ...................................30PRECEDEX..................................58PRECOSE.................................... 36PRED MILD.................................. 60PRED-G........................................61

PRED-G S.O.P............................. 61prednicarbate................................35prednisolone................................. 47prednisolone acetate.................... 60prednisolone sodium phosphate................................................ 47, 60prednisone....................................47prednisone intensol.......................47PREFEST..................................... 51pregabalin.....................................32PREMARIN...................................51PREMASOL..................................42PREMPHASE............................... 51PREMPRO....................................51prenatal .........................................42prenatal plus iron.......................... 42PRENATVITE PLUS.....................42PRENATVITE RX......................... 42PREPIV SUPPLY........................... 6PRESTALIA..................................30PRETOMANID..............................16prevalite........................................ 30PREVIDENT 5000 ENAMEL PROTECT.....................................33PREVIDENT 5000 SENSITIVE.... 33previfem........................................51PREVNAR 13............................... 54PREVYMIS................................... 23PREZCOBIX.................................23PREZISTA.................................... 23PRIFTIN........................................16PRILOSEC....................................43primaquine phosphate.................. 21PRIMAXIN IV..................................9primidone......................................12PRIMSOL........................................9PRISMASOL B22GK 4/0.............. 42PRISMASOL BGK 0/2.5............... 42PRISMASOL BGK 2/0.................. 42PRISMASOL BGK 2/3.5............... 42PRISMASOL BGK 4/2.5............... 42PRISMASOL BK 0/0/1.2...............42PRIVIGEN.....................................53PRO COMFORT SPACER ADULT..........................................58PRO COMFORT SPACER CHILD...........................................58PRO COMFORT SPACER INFANT.........................................58PROAIR DIGIHALER....................64PROAIR HFA................................64PROAIR RESPICLICK..................64probenecid....................................15PROBUPHINE IMPLANT KIT.........4procainamide hcl...........................30PROCALAMINE............................42PROCARDIA................................ 30

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PROCARDIA XL...........................30PROCARE SPACER/ADULT MASK............................................58PROCARE SPACER/CHILD MASK............................................58PROCENTRA............................... 31prochlorperazine...........................14prochlorperazine edisylate............14prochlorperazine maleate............. 14PROCTOFOAM HC......................55procto-med hc...............................55procto-pak.....................................55proctosol hc.................................. 55proctozone-hc...............................55PROCYSBI................................... 45PROFILNINE................................ 25progesterone.................................51progesterone micronized.............. 51PROGLYCEM...............................38PROGRAF....................................53PROLASTIN-C..............................64PROLENSA.................................. 60PROLEUKIN.................................19PROLIA.........................................55PROMACTA................................. 25promethazine hcl.......................... 62promethazine-codeine.................. 62promethazine-dm..........................62promethazine-phenyleph-codeine 62promethazine-phenylephrine........ 62promethegan.................................62propafenone hcl............................30propafenone hcl er........................30propantheline bromide..................45proparacaine hcl........................... 61propranolol hcl .............................. 30propranolol hcl er..........................30propranolol-hctz............................30propylthiouracil ..............................52PROQUAD....................................54PROSCAR....................................46PROSOL.......................................42PROSTIN VR................................30protamine sulfate.......................... 25PROTONIX.............................43, 44PROTOPAM CHLORIDE..............58PROTOPIC...................................35protriptyline hcl..............................13PROVAYBLUE............................. 58PROVENTIL HFA......................... 64PROVERA.................................... 51pseudoephedrine-bromphen-dm.. 62PULMICORT FLEXHALER...........64pulmosal....................................... 63PULMOZYME...............................64purevit dualfe plus.........................42PURIXAN......................................19

PYLERA........................................45pyrazinamide................................ 16pyridostigmine bromide.................16pyridostigmine bromide er............ 16PYRIDOXINE HCL....................... 42pyridoxine hcl................................42pyrimethamine.............................. 21PYRIMETHAMINE-LEUCOVORIN..............................21PYROGALLIC ACID..................... 35QBREXZA.....................................35QINLOCK......................................19QNASL..........................................63QNASL CHILDRENS....................63QUADRACEL............................... 54QUADRAMET...............................19QUALAQUIN.................................21QUARTETTE................................51quazepam.....................................24QUELICIN.....................................32quetiapine fumarate......................22quetiapine fumarate er..................22QUILLICHEW ER......................... 31QUILLIVANT XR...........................31quinapril hcl ...................................30quinapril-hydrochlorothiazide........30quinidine gluconate er...................30quinidine sulfate............................30quinine sulfate...............................21RABAVERT.................................. 54rabeprazole sodium...................... 44RADIAPLEXRX.............................35RADICAVA................................... 32RADIOGARDASE.........................58RAGWITEK...................................58raloxifene hcl.................................48ramelteon......................................65ramipril ..........................................30ranolazine er.................................30RAPAFLO.....................................46RAPAMUNE................................. 53RAPIVAB...................................... 23RAPPORT RLS............................ 58RAPPORT VTD............................ 58rasagiline mesylate.......................21RASUVO.......................................53RAVICTI........................................45RAYALDEE...................................55RAZADYNE ER............................ 12REBIF........................................... 32REBIF REBIDOSE........................32REBIF REBIDOSE TITRATION PACK............................................32REBIF TITRATION PACK............ 32REBINYN......................................25REBLOZYL...................................25RECARBRIO.................................. 9

RECLAST..................................... 55reclipsen....................................... 51RECOMBINATE........................... 25RECOMBIVAX HB........................54RECOTHROM.............................. 25RECOTHROM SPRAY KIT.......... 25RECTIV.........................................30REGENECARE.............................35REGLAN.......................................14REGONOL....................................16REGRANEX..................................35RELENZA DISKHALER................23relexxii ...........................................31RELNATE DHA.............................42REMERON................................... 13REMERON SOLTAB.................... 13REMESENSE............................... 33remifentanil hcl ................................4RENACIDIN..................................46RENATABS WITH IRON.............. 42RENFLEXIS..................................53repaglinide.................................... 36REPATHA.....................................30REPATHA PUSHTRONEX SYSTEM.......................................30REPATHA SURECLICK............... 30REQUIP XL...................................21RESTASIS....................................61RESTASIS MULTIDOSE..............61RESTORA RX.............................. 45RETACRIT....................................25RETAVASE...................................11RETAVASE HALF-KIT..................11RETIN-A MICRO PUMP...............35RETROVIR................................... 23REVATIO......................................64REVCOVI......................................45REVLIMID.....................................19revonto..........................................65REXULTI.......................................22REYATAZ..................................... 23RHOFADE.................................... 35RHOGAM ULTRA-FILTERED PLUS............................................ 53RHOPHYLAC............................... 53RHOPRESSA............................... 60RIASTAP...................................... 25ribavirin......................................... 23RIDAURA......................................53rifabutin.........................................16RIFADIN....................................... 16rifampin.........................................16RILUTEK.......................................32riluzole.......................................... 32rimantadine hcl............................. 23RIMSO-50.....................................46ringers irrigation............................42

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RINVOQ........................................53RIOMET........................................37RIOMET ER..................................37risedronate sodium....................... 55RISPERDAL CONSTA................. 22risperidone....................................22ritonavir .........................................23RITUXAN......................................19RITUXAN HYCELA.......................19rivastigmine...................................13rivastigmine tartrate...................... 13rivelsa........................................... 51RIXUBIS....................................... 25rizatriptan benzoate...................... 15ROBAXIN......................................65ROBAXIN-750.............................. 65ROCALTROL................................56ROCKLATAN................................60rocuronium bromide......................32ROCURONIUM BROMIDE...........32ropinirole hcl................................. 21ropinirole hcl er............................. 21ropivacaine hcl................................6rosadan.........................................35rosuvastatin calcium..................... 30ROTARIX......................................54ROTATEQ.................................... 54ROWASA......................................55roweepra.......................................12roweepra xr...................................12ROZEREM....................................65ROZLYTREK................................ 19RUBRACA.................................... 19RUCONEST..................................53RUXIENCE................................... 19RUZURGI..................................... 58RYANODEX..................................65RYBELSUS...................................37RYCLORA.................................... 63RYDAPT....................................... 19RYTARY....................................... 21RYTHMOL SR.............................. 30ryvent............................................63SALAGEN.....................................33saline bacteriostatic...................... 42saline flush....................................42saline flush zr................................42SALINE-PHENOL.........................42SAMSCA.......................................42SANDIMMUNE............................. 53SANTYL........................................35SAPHRIS......................................22sapropterin dihydrochloride.......... 45SARAFEM.................................... 13SAVAYSA.....................................11SAVELLA......................................32SAVELLA TITRATION PACK.......32

SCENESSE.................................. 35SCLEROSOL INTRAPLEURAL....64scopolamine..................................14SECONAL.....................................65selegiline hcl ................................. 21selenium sulfide............................35SELZENTRY.................................24sensorcaine.................................... 6sensorcaine/epinephrine.................6sensorcaine-mpf............................. 6sensorcaine-mpf/epinephrine......... 6SENSORCAINE-MPF/EPINEPHRINE.......................6SEREVENT DISKUS....................64SERNIVO......................................35SEROSTIM...................................45sertraline hcl ................................. 13se-tan plus.................................... 42setlakin..........................................51sevelamer carbonate.................... 46sevelamer hcl ................................46SEYSARA.......................................9SFROWASA................................. 55sharobel........................................51SHINGRIX.................................... 54SIGNIFOR.................................... 48SIGNIFOR LAR............................ 48SIKLOS.........................................19sildenafil citrate.......................46, 64SILENOR......................................65SILHOUETTE 23" INFUSION SET...............................................58SILHOUETTE 43" INFUSION SET...............................................58SILHOUETTE INFUSION SET 18"................................................ 58SILIQ.............................................53silodosin........................................46silver sulfadiazine........................... 9SIMBRINZA.................................. 60simliya...........................................51simpesse.......................................51SIMPONI.......................................53SIMPONI ARIA............................. 53SIMULECT....................................53simvastatin....................................30SINEMET......................................21SINUVA........................................ 63sirolimus........................................53SIRTURO......................................16SITAVIG........................................24SIVEXTRO......................................9SKLICE.........................................21SKYRIZI (150 MG DOSE)............ 54SMOFLIPID.................................. 42sod benz-sod phenylacet..............45sod citrate-citric acid.....................42

sodium acetate............................. 42sodium bicarbonate................ 42, 45SODIUM BICARBONATE.............42sodium chloride.......................42, 63sodium chloride (pf) ...................... 42sodium chloride bacteriostatic...... 42sodium chloride flush....................42SODIUM CITRATE.......................11SODIUM CITRATE LOCK FLUSH..........................................11SODIUM DIURIL...........................30SODIUM EDECRIN...................... 30sodium fluoride 5000 sensitive..... 33sodium nitrite................................ 58sodium phenylbutyrate..................45sodium phosphates.......................42sodium polystyrene sulfonate....... 42sodium saccharin..........................58sodium thiosulfate.........................58solifenacin succinate.....................46SOLIQUA......................................37SOLIRIS........................................25SOLOSEC...................................... 9SOLTAMOX..................................19SOLU-CORTEF............................47SOLU-MEDROL........................... 47SOMATULINE DEPOT.................48SOMAVERT..................................48SOOLANTRA................................35SORBITOL....................................58sorbitol .......................................... 58sorbitol-mannitol ........................... 58SORIATANE.................................35sorine............................................30SOTALOL HCL.............................30sotalol hcl ......................................30sotalol hcl (af) ............................... 30SOTYLIZE.................................... 30SOVALDI...................................... 24spinosad....................................... 21SPIRIVA HANDIHALER............... 64SPIRIVA RESPIMAT.................... 64spironolactone.............................. 30spironolactone-hctz.......................30SPORANOX................................. 15SPORANOX PULSEPAK............. 15SPRAVATO (56 MG DOSE).........13SPRAVATO (84 MG DOSE).........13sprintec 28.................................... 51SPRYCEL.....................................19sps................................................ 42sronyx........................................... 51ssd................................................ 10STALEVO 100.............................. 21STALEVO 125.............................. 21STALEVO 150.............................. 21STALEVO 200.............................. 21

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STALEVO 50................................ 21STALEVO 75................................ 21STAMARIL....................................54STARLIX.......................................37stavudine...................................... 24STELARA..................................... 54STERILE DILUENT FLOLAN PH 12..................................................59sterile diluent/epoprostenol...........59STERILE TALC POWDER........... 64sterile water for injection...............59sterile water for irrigation.............. 43STERITALC..................................64STIMATE...................................... 48STIOLTO RESPIMAT...................64STIVARGA....................................19STRENSIQ................................... 45streptomycin sulfate......................10STRIBILD......................................24STRIVERDI RESPIMAT............... 64STROMECTOL.............................21SUBLOCADE..................................7subvenite...................................... 12subvenite starter kit-blue...............12subvenite starter kit-green............ 12subvenite starter kit-orange.......... 12SUCCINYLCHOLINE CHLORIDE................................... 32succinylcholine chloride................32SUCRAID......................................45sucralfate...................................... 44SULAR..........................................30sulfacetamide sodium...................60sulfacetamide sodium (acne)........35sulfacetamide-prednisolone..........61sulfadiazine...................................10sulfamethoxazole-trimethoprim.....10SULFAMYLON............................. 10sulfasalazine.................................55sulfatrim pediatric..........................10sulfurated lime.............................. 21sulindac...........................................5sumatriptan...................................16sumatriptan succinate...................16sumatriptan succinate refill ........... 16SUNOSI........................................65SUPPRELIN LA............................48SUPRAX.......................................10SUPREP BOWEL PREP KIT........45SURE T INFUSION SET 18"/6MM....................................... 59SURE T INFUSION SET 23"/10MM..................................... 59SURE T INFUSION SET 23"/6MM....................................... 59SURE T INFUSION SET 23"/8MM....................................... 59

SURE T INFUSION SET 32"/10MM..................................... 59SURE T INFUSION SET 32"/6MM....................................... 59SURE T INFUSION SET 32"/8MM....................................... 59SURESTEP PRO HIGH GLUCOSE.................................... 38SURESTEP PRO LOW GLUCOSE.................................... 38SURESTEP PRO NORMAL GLUCOSE.................................... 38SURVANTA.................................. 63SUSTIVA...................................... 24SUSTOL....................................... 14SUTENT....................................... 19swabflush saline flush...................43syeda............................................ 51SYLVANT..................................... 19SYMBICORT................................ 64SYMBYAX.................................... 13SYMDEKO....................................64SYMFI...........................................24SYMFI LO.....................................24SYMJEPI...................................... 64SYMLINPEN 120..........................37SYMLINPEN 60............................37SYMPAZAN..................................12SYMPROIC...................................45SYMTUZA.....................................24SYNAGIS......................................54SYNALAR.....................................35SYNAREL.....................................48SYNDROS....................................14SYNERCID................................... 10SYNJARDY...................................37SYNJARDY XR.............................37SYNRIBO......................................19T: SLIM X2 INS PMP/CONTROL 7.4.................................................59T:SLIM X2 3ML CARTRIDGE.......59T:SLIM X2 INS PUMP/CONTROL-IQ....................59T:SLIM X2 INSULIN PMP BASAL IQ..................................... 59T:SLIM X2 INSULIN PMP BASAL6.4..................................... 59T:SLIM X2 INSULIN PMP/RFURB IQ............................59T:SLIM X2/CONTROL-IQ/REFURB.................................. 59TABLOID...................................... 19TACHOSIL....................................59TACLONEX.................................. 35tacrolimus............................... 35, 54tadalafil ......................................... 46tadalafil (pah)................................65

TAFINLAR.................................... 19TAGRISSO................................... 19TAKHZYRO.................................. 54TALICIA........................................ 45TALTZ...........................................54TALZENNA...................................19tamoxifen citrate........................... 19tamsulosin hcl...............................46TAPAZOLE...................................52TARCEVA.....................................19TARGRETIN.................................20tarina 24 fe....................................51tarina fe 1/20.................................51tarina fe 1/20 eq............................51TARKA..........................................30TARON FORTE............................43TASIGNA......................................20TASMAR.......................................21TAURINE......................................43TAVALISSE.................................. 25TAXOTERE.................................. 20tazarotene.....................................35tazicef........................................... 10TAZICEF.......................................10TAZORAC.....................................35taztia xt......................................... 30TDVAX..........................................54TECENTRIQ.................................20TECFIDERA................................. 32TEFLARO..................................... 10TEGSEDI......................................32TEKTURNA.................................. 30TEKTURNA HCT..........................30TELFA AMD ISLAND DRESSING...................................59TELFA AMD NON-ADHERENT....59telmisartan.................................... 30telmisartan-amlodipine..................30telmisartan-hctz............................ 30temazepam...................................65TEMODAR....................................20TEMOVATE..................................35temozolomide............................... 20temsirolimus..................................54tencon.............................................4teniposide..................................... 20TENIVAC...................................... 54tenofovir disoproxil fumarate.........24TENORETIC 100..........................30TENORETIC 50............................30TEPADINA....................................20TEPEZZA......................................48terazosin hcl ..................................46terbinafine hcl............................... 15terbutaline sulfate......................... 64terconazole................................... 15

85

TERIPARATIDE (RECOMBINANT).........................55TESSALON PERLES................... 63testosterone..................................47testosterone cypionate..................47testosterone enanthate.................47TETANUS-DIPHTHERIA TOXOIDS TD................................54tetrabenazine................................32tetracaine hcl................................ 61tetracycline hcl..............................10TEXACORT.................................. 35THALOMID................................... 20THAM............................................43THE LIQUILIFT TRACE................43THEO-24.......................................64theophylline...................................64theophylline er.............................. 64theophylline in d5w....................... 64THERAHONEY.............................35thiamine hcl...................................43THIOLA.........................................46THIOLA EC...................................46thioridazine hcl..............................22thiotepa.........................................20thiothixene.................................... 22THROMBATE III ........................... 11THROMBIN-JMI............................25THROMBIN-JMI EPISTAXIS........25THROMBOGEN............................25THYMOGLOBULIN.......................54tiadylt er........................................ 30tiagabine hcl..................................12TIAZAC.........................................30TIBSOVO......................................20TICE BCG.....................................54TIGAN...........................................14tigecycline.....................................10TIGLUTIK......................................32tilia fe............................................ 51timolol maleate........................30, 61tinidazole.......................................10TISSEEL.......................................59tis-u-sol......................................... 43TIVICAY........................................24TIVICAY PD..................................24tizanidine hcl .................................65tl-hem 150.....................................43TNKASE....................................... 11TOBI PODHALER.........................64TOBRADEX..................................61TOBRADEX ST............................ 61tobramycin.............................. 60, 64tobramycin sulfate.........................10tobramycin-dexamethasone......... 61TOBREX.......................................60TOLAK..........................................35

tolbutamide................................... 37tolcapone...................................... 21tolmetin sodium...............................5tolterodine tartrate.........................46tolterodine tartrate er.................... 46tolvaptan....................................... 43TOPEX TOPICAL ANESTHETIC. 33TOPICORT................................... 35topiramate.....................................12topiramate er.................................12toposar..........................................20topotecan hcl................................ 20toremifene citrate..........................20TORISEL...................................... 54torsemide......................................30TOTECT....................................... 20TOUJEO MAX SOLOSTAR..........39TOUJEO SOLOSTAR...................39tovet..............................................35TOVIAZ.........................................46TRACLEER...................................65TRADJENTA.................................37TRALEMENT................................43tramadol hcl er................................4tramadol hcl er (biphasic)............... 4tramadol hcl ir ................................. 4tramadol-acetaminophen................4trandolapril ....................................30trandolapril-verapamil hcl er......... 30tranexamic acid.............................26TRANEXAMIC ACID-NACL..........26TRANSDERM SCOP (1.5 MG).....14TRANSDERM-SCOP (1.5 MG).... 14TRANXENE-T...............................24tranylcypromine sulfate.................13TRAVASOL...................................43TRAVATAN Z............................... 61travoprost (bak free)..................... 61TRAZIMERA.................................20trazodone hcl................................ 13TRECATOR..................................16TRELEGY ELLIPTA......................64TRELSTAR MIXJECT...................48TREMFYA.....................................54treprostinil ..................................... 65tretinoin...................................20, 35tretinoin microsphere.................... 36tretinoin microsphere pump.......... 36TRETTEN..................................... 26TREXALL......................................54TREZIX...........................................4tri femynor.....................................51triamcinolone acetonide....33, 36, 47TRIAMCINOLONE ACETONIDE..47TRIAMCINOLONE DIACETATE...47TRIAMCINOLONE-BUPIVACAINE..............................47

TRI-AMINO...................................43triamterene....................................30triamterene-hctz............................30trianex...........................................36triazolam....................................... 24TRICARE PRENATAL DHA ONE.43TRI-CHLOR.................................. 36TRICITRASOL..............................11tricon.............................................43triderm...........................................36TRIDESILON................................ 36trientine hcl................................... 43tri-estarylla.................................... 51TRIFERIC..................................... 43trifluoperazine hcl..........................22trifluridine...................................... 60trigels-f forte..................................43trihexyphenidyl hcl ........................ 21TRIJARDY XR.............................. 37TRIKAFTA.................................... 64tri-legest fe....................................51tri-linyah........................................ 51TRILIPIX....................................... 31tri-lo-estarylla................................ 51tri-lo-marzia...................................51tri-lo-mili ........................................ 51tri-lo-sprintec.................................51trilyte............................................. 45trimethobenzamide hcl..................14trimethoprim..................................10tri-mili ............................................ 52trimipramine maleate.................... 13trinate............................................43TRINTELLIX................................. 13TRIOSTAT....................................52tri-previfem....................................52TRIPTODUR.................................48TRISENOX................................... 20TRISODIUM CITRATE/CRRT...... 43tri-sprintec.....................................52TRIUMEQ..................................... 24trivora (28).................................... 52tri-vylibra....................................... 52tri-vylibra lo................................... 52TRIZIVIR.......................................24TROGARZO................................. 24TROKENDI XR............................. 12TROPHAMINE..............................43TROPICAMIDE-CYCLOPENTOLATE-PE..............61TROPIC-CYCLOP-PE-KETO-PROPAR.......................................61trospium chloride.......................... 46trospium chloride er...................... 46TRULICITY................................... 37TRUMENBA..................................55TRUSOPT.....................................61

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TRUSTEEL INFUSION SET.........59TRUVADA.....................................24TUKYSA....................................... 20tulana............................................52TURALIO...................................... 20TWINRIX.......................................55TWYNSTA.................................... 31TYBOST....................................... 24tydemy.......................................... 52TYGACIL...................................... 10TYKERB....................................... 20TYMLOS.......................................55TYPHIM VI....................................55TYSABRI...................................... 32TYVASO....................................... 65TYVASO REFILL..........................65TYVASO STARTER..................... 65UBRELVY.....................................16UCERIS........................................ 55UDENYCA.................................... 26ULORIC........................................ 15ULTIVA........................................... 4ULTOMIRIS.................................. 26UNASYN.......................................10unithroid........................................52UNITUXIN.....................................20UPTRAVI...................................... 65uretron d/s.....................................46urin ds...........................................46UROCIT-K 10............................... 43UROCIT-K 15............................... 43UROCIT-K 5................................. 43URSO 250.................................... 45URSO FORTE.............................. 45ursodiol ......................................... 45utrona-c.........................................46VABOMERE................................. 10valacyclovir hcl ..............................24VALCHLOR.................................. 20valganciclovir hcl ...........................24valproate sodium.......................... 12valproic acid..................................12valrubicin.......................................20valsartan....................................... 31valsartan-hydrochlorothiazide.......31VALSTAR..................................... 20VALTOCO 10 MG DOSE..............12VALTOCO 15 MG DOSE..............12VALTOCO 20 MG DOSE..............12VALTOCO 5 MG DOSE................12VANCOCIN...................................10VANCOCIN HCL...........................10VANCOMYCIN HCL..................... 10vancomycin hcl ............................. 10VANCOMYCIN HCL IN DEXTROSE..................................10vancomycin hcl in dextrose...........10

vancomycin hcl in nacl..................10VANCOMYCIN HCL IN NACL......10vandazole..................................... 10VANTAS....................................... 48VAPRISOL....................................48VAQTA..........................................55vardenafil hcl .................................46VARISOFT INFUSION SET..........59VARITHENA................................. 31VARIVAX...................................... 55VARIZIG....................................... 54VARUBI (180 MG DOSE).............14VASCEPA.....................................31VASERETIC................................. 31vashe cleansing............................36VASOSTRICT...............................48VAXCHORA..................................55VAZCULEP...................................31VECAMYL.....................................31VECTIBIX..................................... 20VECURONIUM BROMIDE........... 32vecuronium bromide..................... 32VELCADE.....................................20VELETRI.......................................65velivet............................................52VELPHORO..................................46VELTASSA................................... 43VEMLIDY......................................24VENCLEXTA................................ 20VENCLEXTA STARTING PACK.. 20VENELEX..................................... 36VENIPUNCTURE PX1 PHLEBOTOMY...............................6venlafaxine hcl ..............................13venlafaxine hcl er..........................13VENOFER.................................... 43VENTAVIS....................................65VENTOLIN HFA............................64verapamil hcl .................................31verapamil hcl er............................ 31VERELAN.....................................31VERELAN PM...............................31VERSACLOZ................................22VERZENIO................................... 20VFEND..........................................15VFEND IV..................................... 15V-GO 20........................................38V-GO 30........................................38V-GO 40........................................38VIBATIV........................................10VIBERZI........................................45VIBRAMYCIN............................... 10VICTOZA...................................... 37VIDAZA.........................................20VIEKIRA PAK............................... 24vienva........................................... 52vigabatrin...................................... 12

vigadrone......................................12VIIBRYD....................................... 14VIIBRYD STARTER PACK...........14VIMIZIM........................................ 45VIMPAT........................................ 12vinblastine sulfate......................... 20vincristine sulfate.......................... 20vinorelbine tartrate........................20viorele........................................... 52VIRACEPT....................................24VIRAMUNE...................................24VIRAMUNE XR.............................24VIRAZOLE....................................24VIREAD........................................ 24VIRT-FEFA PLUS.........................43virt-phos 250 neutral .....................43virtussin ac w/alc...........................63VISIONBLUE................................ 61VISTARIL......................................24VISTOGARD.................................59VISUDYNE................................... 61vitamin d (ergocalciferol) ...............43vitamin k1......................................43VITRAKVI..................................... 20VITRASE...................................... 59VIVAGUARD LANCING DEVICE. 38VIVITROL....................................... 7VIVOTIF........................................55VIZIMPRO.................................... 20volnea........................................... 52VONVENDI...................................26VORAXAZE.................................. 20voriconazole..................................15VOSEVI........................................ 24VOTRIENT....................................20vp-pnv-dha....................................43VPRIV...........................................45VRAYLAR.....................................22VUMERITY................................... 32VUMERITY (STARTER)...............32VYEPTI.........................................16vyfemla......................................... 52VYLEESI.......................................32vylibra........................................... 52VYNDAMAX..................................31VYNDAQEL.................................. 31VYVANSE.....................................31VYXEOS.......................................20WAKIX.......................................... 65warfarin sodium............................ 11water for irrigation, sterile............. 43wera..............................................52WESTHROID................................52WIDE-SEAL DIAPHRAGM 60...... 59WIDE-SEAL DIAPHRAGM 65...... 59WIDE-SEAL DIAPHRAGM 70...... 59WIDE-SEAL DIAPHRAGM 75...... 59

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WIDE-SEAL DIAPHRAGM 80...... 59WIDE-SEAL DIAPHRAGM 85...... 59WIDE-SEAL DIAPHRAGM 90...... 59WIDE-SEAL DIAPHRAGM 95...... 59WILATE........................................ 26WINRHO SDF...............................54wixela inhub..................................64WP THYROID...............................52wymzya fe.....................................52XADAGO...................................... 21XALKORI...................................... 20XARELTO.....................................11XARELTO STARTER PACK........ 11XATMEP.......................................54XCOPRI........................................12XCOPRI (250 MG DAILY DOSE). 12XCOPRI (350 MG DAILY DOSE). 12XELJANZ......................................54XELJANZ XR................................54XELODA....................................... 20XELPROS.....................................61XEMBIFY......................................54XENLETA..................................... 10XEOMIN........................................59XEPI..............................................10XERAC AC................................... 36XERAVA....................................... 10XERMELO.................................... 45XEROFORM OIL EMULSION 2"X2".............................................36XEROFORM OIL EMULSION GAUZE......................................... 36XEROFORM OIL EMULSION STRIP........................................... 36XEROFORM OIL ROLL 4"X9'...... 36XEROFORM PETROLAT GAUZE 1"X8"............................... 36XEROFORM PETROLAT GAUZE 5"X9"............................... 36XEROFORM PETROLAT PATCH 2"X2"................................36XEROFORM PETROLAT PATCH 4"X4"................................36XEROFORM PETROLATUM ROLL 4"X9'................................... 36XGEVA......................................... 55XIAFLEX.......................................59XIFAXAN...................................... 10XIGDUO XR..................................37XIIDRA..........................................61XIMINO.........................................10XOFIGO........................................20XOFLUZA (40 MG DOSE)............24XOFLUZA (80 MG DOSE)............24XOLAIR.........................................63XOPENEX.................................... 64XOPENEX CONCENTRATE........64

XOPENEX HFA............................ 64XOSPATA.....................................20XPOVIO (100 MG ONCE WEEKLY)......................................20XPOVIO (40 MG ONCE WEEKLY)......................................20XPOVIO (40 MG TWICE WEEKLY)......................................20XPOVIO (60 MG ONCE WEEKLY)......................................20XPOVIO (60 MG TWICE WEEKLY)......................................20XPOVIO (80 MG ONCE WEEKLY)......................................20XPOVIO (80 MG TWICE WEEKLY)......................................20XTAMPZA ER.................................4XTANDI.........................................20XULTOPHY.................................. 37XURIDEN......................................45XYLOCAINE................................... 6xylocaine dental ..............................6XYLOCAINE/EPINEPHRINE..........6XYLOCAINE-MPF.......................... 6XYLOCAINE-MPF/EPINEPHRINE.......................6XYNTHA....................................... 26XYNTHA SOLOFUSE...................26XYOSTED.....................................47XYREM.........................................65XYWAV.........................................65YERVOY.......................................20YF-VAX.........................................55YONDELIS....................................20YUPELRI...................................... 64yuvafem........................................ 52zafirlukast......................................64zaleplon........................................ 65ZALTRAP......................................20ZANOSAR.................................... 20zarah.............................................52ZARONTIN................................... 12ZARXIO........................................ 26ZAVESCA.....................................45ZEBUTAL........................................4ZEJULA........................................ 20ZELAPAR..................................... 21ZELBORAF...................................20ZELNORM.................................... 45ZEMAIRA......................................64ZEMDRI........................................11ZEMPLAR.....................................56zenatane.......................................36ZENPEP....................................... 45ZENZEDI...................................... 31ZEPATIER.................................... 24ZERBAXA.....................................11

ZETONNA.....................................63ZEVALIN Y-90.............................. 20ZIAC..............................................31ZIAGEN........................................ 24zidovudine.....................................24ZIEXTENZO..................................26ZILRETTA.....................................47ZINC CHLORIDE..........................43ZINC SULFATE............................ 43ZINPLAVA.................................... 54ziprasidone hcl..............................22ziprasidone mesylate....................22ZIRABEV...................................... 20ZIRGAN........................................ 60ZITHROMAX.................................11ZITHROMAX TRI-PAK................. 11ZITHROMAX Z-PAK.....................11ZOLADEX.....................................48zoledronic acid..............................55ZOLINZA.......................................20zolmitriptan................................... 16zolpidem tartrate...........................65zolpidem tartrate er.......................65ZOLPIMIST...................................65ZOMIG..........................................16zonisamide....................................12ZONTIVITY...................................22ZORBTIVE....................................45ZORTRESS.................................. 54ZOSYN......................................... 11zovia 1/35e (28)............................52ZUBSOLV.......................................7ZULRESSO.................................. 14zumandimine................................ 52ZYDELIG...................................... 20ZYKADIA...................................... 20ZYLET...........................................61ZYLOPRIM................................... 15ZYMAXID......................................60ZYPREXA RELPREVV.................22ZYPREXA ZYDIS......................... 22ZYVOX..........................................11

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Table of Contents Analgesics - Drugs for Pain3 4 5...Notes Analgesics - Drugs for Pain...

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