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Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
Prime Detailed Formulary
Guide
v. 2020-01
Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in
writing by an authorized representative of Universal Rx. v. 2020-01
2
Prime Detailed Formulary Guide The Prime Formulary Guide outlines the tier coverage and suggested limitations of the most commonly prescribed medications. A formulary is the list of drugs available for certain conditions and organized by tiers (cost levels).
Drug Tier Types of Drugs Included Cost
1 Generic Drugs Lowest Copay
2 Preferred Brand Name Drugs Medium Copay
3 Non-Preferred Brand Name Drugs Higher Copay
Limits Description
INJ – Injectable Drug Product is administered via an injectable route of
administration and may be subject to a separate benefit.
QL – Quantity Limit Drug is subject to a specific quantity per days supply due to
patient safety or cost containment measures.
SP – Specialty Program Drug is designated as a specialty drug and may be subject to a
separate specialty benefit.
ST – Step Therapy A more cost-effective option must be tried before a Step
Therapy drug may be covered.
Preferred and non-preferred brand name medications are listed to help identify clinically appropriate and cost-effective options within drug categories. Unless specifically indicated, drug list products will include all dosage forms. This is not an all-inclusive list and does not guarantee coverage. Medications listed may change to a lower tier at any time. Medications may also be moved to non-preferred status twice a year on January 1 and July 1.
A brand-name drug for which a generic product becomes available may be designated as a non-preferred option upon release of the generic product to the market. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. When a medication changes tiers, the member may have to pay a different amount for that medication. The member's specific prescription benefit plan design may not cover certain products or categories regardless of their appearance in this document. For the most up-to-date list call customer service at the toll-free member phone number on the ID card.
Need assistance finding a drug on this formulary guide? An alphabetical index is included at the end of the
formulary listing. You may also press Control + F to search for the product name.
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
3
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
ADDERALL 3
ADDERALL XR 3
ADHANSIA XR 3
ADIPEX-P 3
ADZENYS ER 3
ADZENYS XR-ODT 3
amphetamine sulfate 1
amphetamine/dextroampheta 1
APTENSIO XR 3
armodafinil 1
atomoxetine 1
atomoxetine hydrochloride 1
BELVIQ 3
BELVIQ XR 3
benzphetamine hcl 1
CAFCIT 3 INJ
caffeine cit inj 60mg/3ml 1 INJ
caffeine citrate 1
clonidine hcl er 1
CONCERTA 3
CONTRAVE 3
COTEMPLA XR-ODT 3
DAYTRANA 2
dexmethylphenidate hcl 1
dexmethylphenidate hcl er 1
dexmethylphenidate hydroc 1
dextroamphetamine sulfate 1
diethylpropion hcl 1
diethylpropion hcl er 1
DOPRAM 3 INJ
DYANAVEL XR 2
EVEKEO 3
EVEKEO ODT 3
FOCALIN 3
FOCALIN XR 3
guanfacine er 1
INTUNIV 3
JORNAY PM 3
LOMAIRA 3
methamphetamine hcl 1
METHYLIN 3
METHYLPHENIDATE CAP ER 1
METHYLPHENIDATE TAB ER 3
modafinil 1
MYDAYIS 2
NUVIGIL 3
phendimetraz tab 35mg 1
PHENDIMETRAZ CAP 105MG ER 3
phentermine hcl 1
phentermine hydrochloride 1
PROCENTRA 2
QSYMIA 3
QUILLICHEW ER 2
QUILLIVANT XR 2
RITALIN 3
RITALIN LA 3
SAXENDA 3 INJ
STRATTERA 3
SUNOSI 3
VYVANSE 2
XENICAL 3
zenzedi tab 5mg 1
ZENZEDI TAB 7.5MG 3
Amebicides
SOLOSEC 3
Aminoglycosides
amikacin sulfate 1 INJ
BETHKIS 2 SP
gentamicin sulfate 1 INJ
KITABIS PAK 2 SP
neomycin sulfate 1
paromomycin sulfate 1
TOBI 3 SP
TOBI PODHALER 2 SP
tobramycin 1 SP
tobramycin sulfate 1 INJ
ANALGESICS - ANTI-INFLAMMATORY
ACTEMRA 2 INJ SP
ACTEMRA ACTPEN 2 INJ SP
ARAVA 3
ARTHROTEC 50 3
ARTHROTEC 75 3
CELEBREX 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
4
celecoxib 1
DAYPRO 3
diclofenac potassium 1
diclofenac sodium dr 1
diclofenac sodium er 1
diclofenac sodium/misopro 1
DUEXIS 3
EC-NAPROXEN 3
ENBREL 2 INJ SP
ENBREL MINI 2 INJ SP
ENBREL SURECLICK 2 INJ SP
etodolac 1
etodolac er 1
FELDENE 3
fenoprofen tab 600mg 1
FENOPROFEN CAP 400MG 3
flurbiprofen 1
HUMIRA 2 INJ SP
HUMIRA PEDIATRIC CROHNS D 2 INJ SP
HUMIRA PEN 2 INJ SP
HUMIRA PEN-CD/UC/HS START 2 INJ SP
HUMIRA PEN-PS/UV STARTER 2 INJ SP
ibu 1
ibuprofen 1
ILARIS 2 INJ SP
INDOCIN 3
indomethacin inj 1mg 1 INJ
indomethacin cap 1
indomethacin er 1
indomethacin sr 1
ketoprofen er 1
ketorolac tab 10mg 1 QL
ketorolac tromethamine 1 INJ
KEVZARA 3 INJ SP
KINERET 3 INJ SP
leflunomide 1
meclofenamate sodium 1
mefenamic acid 1
meloxicam 1
MOBIC 3
nabumetone 1
naproxen 1
naproxen dr 1
naproxen sodium 1
naproxen sodium er 1
OLUMIANT 2 SP
ORENCIA 3 INJ SP
ORENCIA CLICKJECT 3 INJ SP
OTEZLA 2 SP
OTREXUP 2 INJ
oxaprozin 1
piroxicam 1
QMIIZ ODT 3
RASUVO 2 INJ
RELAFEN DS 3
RIDAURA 2
RINVOQ 3 SP
SIMPONI INJ 50/0.5ML 3 INJ SP
SIMPONI INJ 100MG/ML 2 INJ SP
SIMPONI ARIA 3 INJ SP
SPRIX 3
sulindac 1
tolmetin sodium 1
VIMOVO 3
XELJANZ 2 SP
XELJANZ XR 2 SP
ZIPSOR 3
ZORVOLEX 3
ANALGESICS - NonNarcotic
bupap 1
butal/apap tab 50-325mg 1
BUTAL/APAP CAP 50-300MG 3
butalbital/acetaminophen/ 1
BUTALBITAL/ASPIRIN/CAFFEI 2
clonidine inj 1 INJ
diflunisal 1
FIORICET 3
FIORINAL 3
PRIALT 2 INJ SP
salsalate 1
TENCON 2
ANALGESICS - OPIOID
acetaminophen/caffeine/di 1
acetaminophen/codeine 1
alfentanil 1 INJ
ALFENTANIL HCL 3 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
5
APADAZ 3
ascomp/codeine 1
BELBUCA 2
BENZHYDROCODONE/ACETAMINO 3
BUNAVAIL 3
BUPRENEX 3 INJ
buprenorphine 1
BUPRENORPHIN DIS 7.5/HR 3
buprenorphin sub 2mg 1
buprenorphin inj 0.3mg/ml 1 INJ
buprenorphine hcl/naloxon 1
buprenorphine hydrochlori 1
but/asa/caf/ cap cod 30mg 1
butorphanol sol 10mg/ml 1 QL
BUTORPHANOL TARTRATE 3 INJ QL
BUTRANS 3
codeine sulfate 1
CONZIP 3
DEMEROL 3 INJ
DOLOPHINE 3
duramorph 1 INJ
endocet 1
fentanyl 1
FENTANYL CITRATE 3 INJ
fentanyl citrate oral tra 1
FIORICET/CODEINE 3
FIORINAL/CODEINE #3 3
hydrocodone bitartrate/ac 1
hydrocodone/acetaminophen 1
hydrocodone/ibuprofen 1
hydromorphone hcl tab 1
hydromorphon inj 4mg/ml 1 INJ
hydromorphon sup 3mg 1
hydromorphone hcl er 1
hydromorphon inj 2mg/ml 1 INJ
hydromorphone hydrochlori 1
HYSINGLA ER 2
INFUMORPH 200 2 INJ
INFUMORPH 500 2 INJ
KADIAN 3
LAZANDA 3
lorcet 1
lorcet hd 1
LORTAB 3
meperidine sol 50mg/5ml 1
meperidine inj 25mg/ml 1 INJ
methadone con 10mg/ml 1
METHADONE SOL 10MG/5ML 2
methadone inj 10mg/ml 1 INJ
METHADOSE 2
MORPHABOND ER 3
morphine sul tab 1
morphine sulfate inj 1 INJ
morphine sul sup 5mg 1
morphine sulfate er 1
MS CONTIN 3
nalbuphine hcl 1 INJ
NORCO 3
NUCYNTA 2
NUCYNTA ER 2
OXAYDO 3
oxycodone hcl 1
OXYCODONE HCL ER 3
oxycodone hydrochloride 1
OXYCODONE HYDROCHLORIDE E 3
oxycodone/acetaminophen 1
oxycodone/ibuprofen 1
OXYCONTIN 2
oxymorphone hydrochloride 1
OXYMORPHONE TAB 5MG ER 3
pentazocine/naloxone hcl 1
PERCOCET 3
PRIMLEV 3
ROXICODONE 3
SUBLOCADE 2 INJ SP
SUBOXONE 2
SUBSYS 3
tramadol hcl 1
tramadol hcl tab 100mg er 1
TRAMADOL HCL CAP ER 100MG 3
tramadol hydrochloride/ac 1
TREZIX 3
TYLENOL/CODEINE #3 3
ULTRAM 3
vicodin es 1
vicodin hp 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
6
XTAMPZA ER 3
ZOHYDRO ER 3
ZUBSOLV 2
ANDROGENS-ANABOLIC
ANDRODERM 2
ANDROGEL 3
ANDROGEL PUMP 3
AVEED 3 INJ SP
danazol 1
DEPO-TESTOSTERONE 3 INJ
METHITEST 2
methyltestosterone 1
oxandrolone 1
TESTIM 3
TESTOPEL 3 INJ SP
testosterone 1
TESTOSTERONE 3
testosterone cypionate 1 INJ
testosterone enanthate 1 INJ
TESTOSTERONE PUMP 3
testosterone topical solu 1
VOGELXO 3
VOGELXO PUMP 3
XYOSTED 3 INJ
ANORECTAL AGENTS
ANALPRAM HC 3
ANALPRAM-HC 3
anucort-hc 1
anusol-hc 1
colocort 1
CORTIFOAM 3
hemmorex-hc 1
hydrocort ene 100mg 1
hydrocort ac sup 25mg 1
hc pramoxine cre 1-1% 1
lidocaine/hc cre 3%-0.5% 1
LIDO-HYDRO GEL 2.8-0.55 2
PROCORT 3
PROCTOFOAM HC 3
procto-med hc 1
proctosol hc 1
proctozone-hc 1
RECTIV 2
UCERIS AER 2MG/ACT 2
Anthelmintics
albendazole 1
BENZNIDAZOLE 2
EMVERM 2
ivermectin tab 3mg 1
praziquantel 1
STROMECTOL 3
ANTIANGINAL AGENTS
ISORDIL TITRADOSE 3
isosorbide dinitrate 1
isosorbide dinitrate sa 1
isosorbide mononitrate 1
isosorbide mononitrate er 1
NITRO-BID 2
NITRO-DUR 3
nitroglycer inj 5mg/ml 1 INJ
nitroglycern sub 1
nitroglycerin er 1
NITROGLYCERIN IN DEXTROSE 2 INJ
nitroglycerin lingual 1
nitroglycerin transdermal 1
NITROMIST 3
NITROSTAT 3
RANEXA 3
ranolazine er 1
ANTIANXIETY AGENTS
alprazolam 1
alprazolam er 1
ALPRAZOLAM INTENSOL 2
alprazolam odt 1
alprazolam xr 1
ATIVAN 3
ATIVAN INJ 2MG/ML 3 INJ
buspirone hcl 1
buspirone hydrochloride 1
chlordiazepoxide hcl 1
chlordiazepoxide hydrochl 1
clorazepate dipotassium 1
diazepam sol 5mg/5ml 1
diazepam 1 INJ
diazepam intensol 1
droperidol 1 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
7
hydroxyzine hcl inj 1 INJ
hydroxyzine hcl tab 1
hydroxyzine pamoate 1
lorazepam 1
lorazepam inj 1 INJ
lorazepam intensol 1
meprobamate 1
oxazepam 1
VALIUM 3
VISTARIL 3
XANAX 3
XANAX XR 3
ANTIARRHYTHMICS
ADENOCARD 3 INJ
adenosine 1 INJ
amiodarone inj 1 INJ
amiodarone hcl 1
amiodarone hydrochloride 1
CORVERT 3 INJ
disopyramide phosphate 1
dofetilide 1
flecainide acetate 1
lidocaine hcl in d5w 1 INJ
mexiletine hcl 1
MULTAQ 3
NORPACE 3
NORPACE CR 3
pacerone 1
procainamide hcl 1 INJ
procainamide hydrochlorid 1 INJ
propafenone hcl 1
propafenone hydrochloride 1
quinidine gluconate cr 1
quinidine sulfate 1
RYTHMOL SR 3
TIKOSYN 3
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ADVAIR DISKUS 3
ADVAIR HFA 2
AIRDUO RESPICLICK 113/14 3
albuterol tab 1
albuterol neb 1
albuterol sulfate er 1
ALBUTEROL SULFATE HFA 3
ALVESCO 3
aminophylline 1 INJ
ANORO ELLIPTA 2
ARNUITY ELLIPTA 2
ASMANEX HFA 2
ASMANEX TWISTHALER 120 ME 2
ASMANEX TWISTHALER 7 METE 2
ATROVENT HFA 3
BEVESPI AEROSPHERE 2
BREO ELLIPTA 2
BROVANA 3
budesonide sus 1
COMBIVENT RESPIMAT 2
cromolyn sod neb 1
DALIRESP 2
difil-g forte 1
DULERA 2
ELIXOPHYLLIN 2
FASENRA 2 INJ SP
FASENRA PEN 3 INJ SP
FLOVENT DISKUS 2
FLOVENT HFA 2
FLUTICASONE/SALMETEROL INH 2
fluticasone/salmeterol aero 1
INCRUSE ELLIPTA 2
ipratropium bromide 1
ipratropium bromide/albut 1
isoproterenol hydrochlori 1 INJ
ISUPREL 3 INJ
levalbuterol 1
levalbuterol hcl 1
LEVALBUTEROL TARTRATE HFA 3
montelukast sodium 1
NUCALA 2 INJ SP
PERFOROMIST 2
PROAIR HFA 2
PROAIR RESPICLICK 2
PROVENTIL HFA 3
PULMICORT 3
PULMICORT FLEXHALER 2
QVAR REDIHALER 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
8
SEEBRI NEOHALER 3
SEREVENT DISKUS 2
SINGULAIR 3
SPIRIVA HANDIHALER 2
SPIRIVA RESPIMAT 2
STIOLTO RESPIMAT 2
STRIVERDI RESPIMAT 2
SYMBICORT 2
terbutaline sulfate 1
THEO-24 3
THEOCHRON TAB 100MG CR 3
theochron 1
theophylline 1
theophylline cr 1
theophylline er 1
theophylline/d5w 1 INJ
TRELEGY ELLIPTA 2
TUDORZA PRESSAIR 3
VENTOLIN HFA 2
wixela inhub 1
XOLAIR 2 INJ SP
XOPENEX 3
XOPENEX CONCENTRATE 3
XOPENEX HFA 3
YUPELRI 2
zafirlukast 1
ZYFLO 3 ST
ANTICOAGULANTS
bivalirudin 1 INJ SP
BIVALIRUDIN/SODIUM CHLORI 3 INJ SP
COUMADIN 3
ELIQUIS 2
enoxaparin sodium 1 INJ
fondaparinux sodium 1 INJ SP
FRAGMIN 2 INJ SP
heparin lock flush 1 INJ
heparin sodium 1 INJ
heparin sodium/d5w 1 INJ
heparin sodium/nacl 0.9% 1 INJ
jantoven 1
LOVENOX 3 INJ
PRADAXA 3
sash kit for flushing vas 1 INJ
SAVAYSA 3
TRICITRASOL 2
warfarin sodium 1
XARELTO 2
XARELTO STARTER PACK 2
ANTICONVULSANTS
APTIOM 3
BANZEL 2
BRIVIACT 3
carbamazepine 1
carbamazepine er 1
CARBATROL 3
CELONTIN 2
CEREBYX 3 INJ
clobazam 1
clonazepam 1
clonazepam odt 1
DEPACON 3 INJ
DEPAKOTE 3
DEPAKOTE ER 3
DEPAKOTE SPRINKLES 3
DIACOMIT 2 SP
DIASTAT ACUDIAL 3
DIASTAT PEDIATRIC 3
DIAZEPAM RECTAL GEL 2
DILANTIN CAP 100MG 3
DILANTIN CAP 30MG 2
DILANTIN INFATABS 3
DILANTIN-125 3
divalproex sodium 1
divalproex sodium dr 1
divalproex sodium er 1
EPIDIOLEX 2 SP
epitol 1
ethosuximide 1
felbamate 1
FELBATOL 3
fosphenytoin sodium 1 INJ
FYCOMPA 2
gabapentin 1
GABITRIL 3
KEPPRA 3
KEPPRA XR 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
9
KLONOPIN 3
LAMICTAL 3
LAMICTAL CHEWABLE DISPERS 3
LAMICTAL ODT 3
LAMICTAL STARTER/NOT TAKI 3
LAMICTAL STARTER/TAKING C 3
LAMICTAL STARTER/TAKING V 3
LAMICTAL XR 3
lamotrigine 1
lamotrigine er 1
lamotrigine odt 1
lamotrigine starter kit/g 1
lamotrigine starter kit/o 1
levetiracetam 1
levetiracetam inj 1 INJ
levetiracetam er 1
LYRICA 3
MYSOLINE 3
NEURONTIN 3
ONFI 3
oxcarbazepine 1
OXTELLAR XR 3
PHENYTEK 3
phenytoin 1
phenytoin sodium 1 INJ
phenytoin sodium extended 1
pregabalin 1
primidone 1
QUDEXY XR 2
roweepra 1
roweepra xr 1
SABRIL 2 SP
subvenite 1
subvenite starter kit/ora 1
SYMPAZAN 3 SP
TEGRETOL 3
TEGRETOL-XR 3
tiagabine hydrochloride 1
TOPAMAX 3
topiramate 1
TOPIRAMATE ER 3
TRILEPTAL 3
TROKENDI XR 3
valproate sodium 1 INJ
valproic acid 1
vigabatrin 1 SP
vigadrone 1 SP
VIMPAT 2 INJ
ZARONTIN 3
ZONEGRAN 3
zonisamide 1
ANTIDEPRESSANTS
amitriptyline hcl 1
amitriptyline hydrochlori 1
amoxapine 1
ANAFRANIL 3
APLENZIN 3 ST
bupropion hcl 1
bupropion tab sr 1
BUPROPION TAB 450MG XL 3
CELEXA 3
citalopram hydrobromide 1
clomipramine hcl 1
CYMBALTA 3
desipramine hcl 1
desipramine hydrochloride 1
desvenlafaxine er 1
DESVENLAFAX TAB 100MG ER 3
doxepin hcl 1
doxepin hydrochloride 1
duloxetine hcl 1
duloxetine hydrochloride 1
EFFEXOR XR 3
EMSAM 3
escitalopram oxalate 1
FETZIMA 2 ST
FETZIMA TITRATION PACK 2 ST
fluoxetine dr 1
fluoxetine hcl 1
FLUOXETINE TAB 60MG 3
fluvoxamine maleate 1
fluvoxamine maleate er 1
FORFIVO XL 3
imipramine hcl 1
imipramine pamoate 1
LEXAPRO 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
10
maprotiline hcl 1
MARPLAN 3
mirtazapine 1
mirtazapine odt 1
NARDIL 3
nefazodone hcl 1
nefazodone hydrochloride 1
NORPRAMIN 3
nortriptyline hcl 1
nortriptyline hydrochlori 1
PAMELOR 3
paroxetine hcl 1
paroxetine hcl er 1
paroxetine hydrochloride 1
PAXIL 3
PAXIL CR 3
phenelzine sulfate 1
PRISTIQ 3
protriptyline hcl 1
PROZAC 3
REMERON 3
REMERON SOLTAB 3
sertraline hcl 1
sertraline hydrochloride 1
SPRAVATO 56MG DOSE 3 SP
SPRAVATO 84MG DOSE 3 SP
TOFRANIL 3
tranylcypromine sulfate 1
trazodone hydrochloride 1
TRINTELLIX 3 ST
venlafaxine hcl 1
venlafaxine hcl er 1
VIIBRYD 2 ST
VIIBRYD STARTER PACK 2 ST
WELLBUTRIN SR 3
WELLBUTRIN XL 3
ZOLOFT 3
ANTIDIABETICS
acarbose 1
ADLYXIN 3 INJ
ADLYXIN STARTER PACK 3 INJ
ADMELOG 3 INJ
ADMELOG SOLOSTAR 3 INJ
AFREZZA 3
ALOGLIPTIN 3 ST
ALOGLIPTIN/METFORMIN HCL 3 ST
ALOGLIPTIN/PIOGLITAZONE 3 ST
AMARYL 3
APIDRA 3 INJ
APIDRA SOLOSTAR 3 INJ
AVANDIA 3
BAQSIMI ONE PACK 3
BASAGLAR KWIKPEN 3 INJ
BYDUREON BCISE 2 INJ
BYDUREON PEN 2 INJ
BYETTA 2 INJ
CYCLOSET 3
FARXIGA 2 ST
FIASP 2 INJ
FIASP FLEXTOUCH 2 INJ
FIASP PENFILL 2 INJ
glimepiride 1
glipizide 1
glipizide er 1
glipizide xl 1
glipizide/metformin hydro 1
GLUCAGEN HYPOKIT 2 INJ
GLUCAGON EMERGENCY KIT 2 INJ
GLUCOPHAGE 3
GLUCOPHAGE XR 3
GLUCOTROL 3
GLUCOTROL XL 3
GLUMETZA 3
glyburide 1
glyburide micronized 1
glyburide/metformin hydro 1
GLYNASE 3
GLYSET 3
GLYXAMBI 2 ST
HUMALOG 2 INJ
HUMALOG JUNIOR KWIKPEN 2 INJ
HUMALOG KWIKPEN 2 INJ
HUMALOG MIX 50/50 2 INJ
HUMALOG MIX 50/50 KWIKPEN 2 INJ
HUMALOG MIX 75/25 2 INJ
HUMALOG MIX 75/25 KWIKPEN 2 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
11
HUMULIN R U-500 (CONCENTR 2 INJ
HUMULIN R U-500 KWIKPEN 2 INJ
INSULIN LISPRO 3 INJ
INSULIN LISPRO KWIKPEN 3 INJ
INVOKAMET 2 ST
INVOKAMET XR 2 ST
INVOKANA 2 ST
JANUMET 2 ST
JANUMET XR 2 ST
JANUVIA 2 ST
JARDIANCE 2
JENTADUETO 2 ST
JENTADUETO XR 2 ST
KOMBIGLYZE XR 3 ST
KORLYM 3 SP
LANTUS 2 INJ
LANTUS SOLOSTAR 2 INJ
LEVEMIR 2 INJ
LEVEMIR FLEXTOUCH 2 INJ
metformin hydrochloride 1
metformin hydrochloride e 1
miglitol 1
MYXREDLIN 3 INJ
nateglinide 1
NESINA 3 ST
NOVOLOG 2 INJ
NOVOLOG FLEXPEN 2 INJ
NOVOLOG MIX 70/30 2 INJ
NOVOLOG MIX 70/30 PREFILL 2 INJ
NOVOLOG PENFILL 2 INJ
ONGLYZA 3 ST
OSENI 3 ST
OZEMPIC 2 INJ
pioglitazone hcl 1
pioglitazone hcl/metformi 1
pioglitazone hcl-glimepir 1
pioglitazone hydrochlorid 1
PROGLYCEM 2
QTERN 3 ST
repaglinide 1
RIOMET 3
RYBELSUS 2
SEGLUROMET 2 ST
SOLIQUA 100/33 2 INJ
STARLIX 3
STEGLATRO 2 ST
STEGLUJAN 3 ST
SYMLINPEN 120 2 INJ
SYMLINPEN 60 2 INJ
SYNJARDY 2 ST
SYNJARDY XR 2 ST
tolbutamide 1
TOUJEO MAX SOLOSTAR 2 INJ
TOUJEO SOLOSTAR 2 INJ
TRADJENTA 2 ST
TRESIBA 2 INJ
TRESIBA FLEXTOUCH 2 INJ
TRULICITY 2 INJ
VICTOZA 2 INJ
XIGDUO XR 2 ST
XULTOPHY 100/3.6 2 INJ
ANTIDIARRHEAL/PROBIOTIC AGENTS
diphenoxylate hydrochlori 1
diphenoxylate/atropine 1
LOMOTIL 3
loperamide hcl 1
MYTESI 3
opium 1
paregoric 1
PRODIGEN 3
RESTORA RX 3
VSL#3 DS 3
ZELAC 3
Antidotes and Specific Antagonists
acetylcysteine 1 INJ
BAL IN OIL 2 INJ
BRIDION 3 INJ
CHEMET 2
CYANOKIT 3 INJ
deferoxamine mesylate 1 INJ SP
DESFERAL 3 INJ SP
DUODOTE 3 INJ
EXJADE 3 SP
flumazenil 1 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
12
fomepizole 1 INJ
JADENU 3 SP
JADENU SPRINKLE 3 SP
methylene blue 1 INJ
naloxone hcl 1 INJ
naltrexone hcl 1
NARCAN 2
PHYSOSTIGMINE SALICYLATE 2 INJ
PRALIDOXIME CHLORIDE 3 INJ
PRAXBIND 3 INJ
PROVAYBLUE 3 INJ
VIVITROL 2 INJ SP
ANTIEMETICS
AKYNZEO 3
ANZEMET 3 QL
aprepitant 1 QL
BONJESTA 3
DICLEGIS 3
doxylamine succinate/pyri 1
dronabinol 1
EMEND 3 QL
EMEND TRIPACK 3 QL
FOSAPREPITANT DIMEGLUMINE 3 INJ
granisetron hcl 1
granisetron inj 1mg/ml 1 INJ
MARINOL 3
meclizine hcl 1
ondansetron hcl 1
ondansetron inj 1 INJ
ondansetron hydrochloride 1
ondansetron odt 1
palonosetron hydrochlorid 1 INJ
SANCUSO 3
scopolamine 1
SYNDROS 3
TRANSDERM SCOP 3
TRANSDERM-SCOP 3
trimethobenzamide hydroch 1
ZOFRAN 3
ZUPLENZ 3
Antifungals
AMBISOME 2 INJ
amphotericin b 1 INJ
ANCOBON 3
CANCIDAS 3 INJ
caspofungin acetate 1 INJ
CRESEMBA INJ 2 INJ SP
CRESEMBA 2 SP
DIFLUCAN 3
ERAXIS 2 INJ
fluconazole 1
fluconazole in nacl 1 INJ
flucytosine 1
griseofulvin microsize 1
griseofulvin ultramicrosi 1
itraconazole 1
ketoconazole tab 1
MYCAMINE 2 INJ
NOXAFIL 2
nystatin tab 1
posaconazole dr 1
terbinafine hcl 1
VFEND 3
VFEND IV 3 INJ
voriconazole 1
voriconazole inj 200mg 1 INJ
ANTIHISTAMINES
carbinoxamine maleate 1
cetirizine hydrochloride 1
CLARINEX 3
clemastine fumarate 1
cyproheptadine hcl 1
cyproheptadine hydrochlor 1
desloratadine 1
desloratadine odt 1
diphenhydramine hcl 1
diphenhydramine inj 1 INJ
KARBINAL ER 3
levocetirizine dihydrochl 1
phenadoz 1
PHENERGAN 3 INJ
promethazine tab 1
promethazine inj 1 INJ
promethazine sup 1
promethazine hcl plain 1
promethazine hydrochlorid 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
13
promethegan 1
RYCLORA 3
RYVENT 3
ANTIHYPERLIPIDEMICS
ANTARA 3
atorvastatin calcium 1
cholestyramine 1
cholestyramine light 1
colesevelam hydrochloride 1
COLESTID 3
colestipol hcl 1
CRESTOR 3
ezetimibe 1
ezetimibe/simvastatin 1
fenofibrate tab 1
FENOFIBRATE CAP 3
fenofibrate micronized 1
fenofibric acid dr 1
FLOLIPID 3 ST
fluvastatin 1
fluvastatin sodium er 1
gemfibrozil 1
LESCOL XL 3
LIPITOR 3
LIPOFEN 2
LIVALO 2 ST
LOPID 3
lovastatin 1
LOVAZA 3
niacin er 1
NIACOR 3
NIASPAN 3
omega-3-acid ethyl esters 1
PRALUENT 2 INJ SP
PRAVACHOL 3
pravastatin sodium 1
QUESTRAN LIGHT 3
REPATHA 2 INJ SP
REPATHA PUSHTRONEX SYSTEM 2 INJ SP
REPATHA SURECLICK 2 INJ SP
rosuvastatin calcium 1
simvastatin 1
TRICOR 3
TRILIPIX 3
VASCEPA 2
VYTORIN 3
WELCHOL 3
ZETIA 3
ZOCOR 3
ZYPITAMAG 3 ST
ANTIHYPERTENSIVES
ACCUPRIL 3
ACCURETIC 3
aliskiren 1
amlodipine besylate/benaz 1
amlodipine besylate/valsa 1
amlodipine/olmesartan med 1
amlodipine/valsartan/hctz 1
amlodipine/valsartan/hydr 1
ATACAND 3
atenolol/chlorthalidone 1
AVALIDE 3
AVAPRO 3
AZOR 3
benazepril hcl 1
benazepril hcl/hydrochlor 1
benazepril hydrochloride 1
benazepril hydrochloride/ 1
BENICAR 3
BENICAR HCT 3
bisoprolol fumarate/hydro 1
candesartan cilexetil 1
candesartan cilexetil/hyd 1
captopril 1
captopril/hydrochlorothia 1
CARDURA 3
CATAPRES 3
CATAPRES-TTS-1 3
CATAPRES-TTS-2 3
CATAPRES-TTS-3 3
clonidine tab 0.1mg 1
clonidine dis 0.1/24hr 1
clonidine hydrochloride 1
CORLOPAM 3 INJ
COZAAR 3
DEMSER 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
14
DIOVAN 3
DIOVAN HCT 3
doxazosin mesylate 1
EDARBI 2 ST
EDARBYCLOR 2 ST
enalapril maleate 1
enalapril maleate/hydroch 1
enalaprilat 1 INJ
EPANED 3
eplerenone 1
eprosartan mesylate 1
EXFORGE 3
EXFORGE HCT 3
fosinopril sodium 1
fosinopril sodium/hydroch 1
guanfacine hcl 1
hydralazine hcl 1
hydralazine inj 1 INJ
hydralazine hydrochloride 1
HYZAAR 3
INSPRA 3
irbesartan 1
irbesartan/hydrochlorothi 1
lisinopril 1
lisinopril/hydrochlorothi 1
LOPRESSOR HCT 3
losartan potassium 1
losartan potassium/hydroc 1
LOTENSIN 3
LOTENSIN HCT 3
LOTREL 3
methyldopa 1
methyldopa/hydrochlorothi 1
metoprolol/hydrochlorothi 1
MICARDIS 3
MICARDIS HCT 3
MINIPRESS 3
minoxidil 1
moexipril hcl 1
NITROPRESS 3 INJ
olmesartan medoxomil 1
olmesartan medoxomil/amlo 1
olmesartan medoxomil/hydr 1
perindopril erbumine 1
phenoxybenzamine hydrochl 1
phentolamine mesylate 1 INJ
prazosin hcl 1
prazosin hydrochloride 1
PRINIVIL 3
propranolol/hydrochloroth 1
QBRELIS 3
quinapril hcl 1
quinapril hydrochloride 1
quinapril/hydrochlorothia 1
ramipril 1
sodium nitroprusside 1 INJ
TARKA 3
TEKTURNA 2
TEKTURNA HCT 2
telmisartan 1
telmisartan/amlodipine 1
telmisartan/hydrochloroth 1
terazosin hcl 1
terazosin hydrochloride 1
trandolapril 1
trandolapril/verapamil hc 1
TRIBENZOR 3
TWYNSTA 3
valsartan 1
valsartan/hydrochlorothia 1
VASERETIC 3
VASOTEC 3
ZESTRIL 3
Anti-infective Agents - Misc.
ALINIA 2
atovaquone 1
AZACTAM 3 INJ
bacitracin 1 INJ
CAYSTON 2 SP
CLEOCIN 3
CLEOCIN PEDIATRIC GRANULE 3
CLEOCIN PHOSPHATE 3 INJ
clindamycin hcl 1
clindamycin palmitate hcl 1
clindamycin inj 1 INJ
clindamycin phosphate in 1 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
15
CLINDAMYCIN/SODIUM CHLORI 3 INJ
colistimethate sodium 1 INJ SP
dapsone 1
daptomycin 1 INJ
ertapenem sodium 1 INJ
FIRST-METRONIDAZOLE 100 3
FIRST-METRONIDAZOLE 50 3
FIRVANQ 3
FLAGYL 3
imipenem/cilastatin 1 INJ
INVANZ 3 INJ
LINCOCIN 3 INJ
linezolid 1
linezolid inj 2mg/ml 1 INJ
MEPRON 3
meropenem 1 INJ
MEROPENEM/SODIUM CHLORIDE 2 INJ
MERREM 3 INJ
metronidazole tab 1
metronidazole 1 INJ
metronidazole in nacl 0.7 1 INJ
NEBUPENT 2
pentamidine isethionate 1 INJ
PRIMAXIN IV 3 INJ
SIVEXTRO 3 SP
sulfamethoxazole/trimetho 1
sulfamethoxazole/trimetho 1 INJ
sulfatrim pediatric 1
tinidazole 1
trimethoprim 1
VANCOMYCIN 2 INJ
vancomycin hcl 1 INJ
VANCOMYCIN HCL IN DEXTROS 2 INJ
vancomycin hydrochloride 1
XIFAXAN 2
ZYVOX 3 INJ
Antimalarials
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 2
hydroxychloroquine sulfat 1
KRINTAFEL 3
MALARONE 3
mefloquine hcl 1
PLAQUENIL 3
primaquine phosphate 1
QUALAQUIN 3
quinine sulfate 1
Antimyasthenic/Cholinergic Agents
GUANIDINE HCL 2
MESTINON 3
MESTINON TIMESPAN 3
neostigmine methylsulfate 1 INJ
pyridostigmine bromide 1
pyridostigmine bromide er 1
REGONOL 2 INJ
Antimycobacterial Agents
CAPASTAT SULFATE 2 INJ
cycloserine 1
ethambutol hcl 1
ethambutol hydrochloride 1
isoniazid 1
isoniazid inj 1 INJ
MYCOBUTIN 3
PRIFTIN 2
pyrazinamide 1
rifabutin 1
RIFADIN 3
RIFAMATE 3
rifampin 1
rifampin inj 1 INJ
RIFATER 3
TRECATOR 3
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
abiraterone acetate 1 SP
ADRIAMYCIN 3 INJ SP
adrucil 1 INJ
AFINITOR 2 SP
AFINITOR DISPERZ 2 SP
ALECENSA 2 SP
ALIMTA 2 INJ
anastrozole 1
ARIMIDEX 3
AROMASIN 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
16
ARRANON 2 INJ SP
arsenic trioxide 1 INJ SP
ARZERRA 3 INJ SP
AVASTIN 2 INJ SP
azacitidine 1 INJ SP
BESPONSA 2 INJ SP
bexarotene 1 SP
bicalutamide 1
BICNU 3 INJ SP
bleomycin 1 INJ SP
bleomycin sulfate 1 INJ SP
BOSULIF 2 SP
BRAFTOVI 3 SP
busulfan 1 INJ SP
CABOMETYX 2 SP
CALQUENCE 3 SP
CAMPTOSAR 3 INJ SP
capecitabine 1 SP
CAPRELSA 2 SP
carboplatin 1 INJ
cisplatin 1 INJ
clofarabine 1 INJ SP
CLOLAR 3 INJ SP
CYCLOPHOSPHAMIDE CAP 25MG 2
cyclophosphamide inj 1 INJ
cyclophosphamide 1
CYRAMZA 2 INJ SP
cytarabine 1 INJ
dacarbazine 1 INJ
daunorubicin hcl 1 INJ SP
DAUNORUBICIN HYDROCHLORID 2 INJ SP
DAURISMO 3 SP
decitabine 1 INJ SP
DEPO-PROVERA 2 INJ
dexrazoxane 1 INJ SP
DOXIL 3 INJ SP
doxorubicin hcl 1 INJ SP
doxorubicin hydrochloride 1 INJ SP
ELIGARD 2 INJ SP
ELITEK 2 INJ SP
ELLENCE 3 INJ SP
EMCYT 2 SP
EMPLICITI 3 INJ SP
epirubicin hcl 1 INJ SP
ERIVEDGE 2 SP
erlotinib hydrochloride 1 SP
ETOPOPHOS 2 INJ SP
etoposide 1 INJ SP
exemestane 1
FARYDAK 3 SP
FASLODEX 2 INJ SP
FEMARA 3
floxuridine 1 INJ SP
fludarabine phosphate 1 INJ SP
fluorouracil 1 INJ
flutamide 1
GEMCITABINE 3 INJ SP
gemcitabine hcl 1 INJ SP
GILOTRIF 2 SP
GLEEVEC 3 SP
GLEOSTINE 2 SP
GLIADEL WAFER 3 INJ SP
HERCEPTIN 2 INJ SP
HYCAMTIN CAP 0.25MG 2 SP
HYCAMTIN INJ 4MG 3 INJ SP
HYDREA 3
hydroxyurea 1
IBRANCE 2 SP
IDAMYCIN PFS 3 INJ SP
idarubicin hcl 1 INJ SP
IFEX 3 INJ SP
imatinib mesylate 1 SP
IMBRUVICA 2 SP
IMFINZI 2 INJ SP
INLYTA 2 SP
INTRON A 2 INJ SP
IRESSA 2 SP
irinotecan hcl 1 INJ SP
irinotecan hydrochloride 1 INJ SP
JAKAFI 2 SP
JEVTANA 2 INJ SP
KEYTRUDA 2 INJ SP
KISQALI 3 SP
KISQALI FEMARA 200 DOSE 3 SP
KISQALI FEMARA 400 DOSE 3 SP
KISQALI FEMARA 600 DOSE 3 SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
17
KYMRIAH 2 INJ SP
LARTRUVO 3 INJ SP
LENVIMA 12MG DAILY DOSE 2 SP
letrozole 1
leucovorin calcium 1
LEUCOVORIN CALCIUM TAB 10MG 2
leucovorin calcium inj 1 INJ
LEUKERAN 2
leuprolide acetate 1 INJ SP
levoleucovorin 1 INJ SP
levoleucovorin calcium 1 INJ SP
LONSURF 2 SP
LORBRENA 2 SP
LUMOXITI 3 INJ SP
LUPRON DEPOT INJ 3.75MG 2 INJ SP
LUPRON DEPOT INJ 7.5MG 3 INJ SP
LUPRON DEPOT INJ 22.5MG 3 INJ SP
LUPRON DEPOT INJ 11.25MG 2 INJ SP
LUPRON DEPOT INJ 30MG 3 INJ SP
LUPRON DEPOT INJ 45MG 3 INJ SP
LYNPARZA 2 SP
LYSODREN 2 SP
MARQIBO 2 INJ SP
MATULANE 2 SP
megestrol acetate 1
MEKINIST 2 SP
MEKTOVI 3 SP
melphalan hydrochloride 1 INJ SP
mercaptopurine 1 SP
mesna 1 INJ SP
MESNEX INJ 1GM 3 INJ SP
MESNEX TAB 400MG 2 SP
methotrexate 1
methotrexate sodium 1 INJ
mitomycin 1 INJ SP
mitoxantrone hcl 1 INJ SP
MYLOTARG 2 INJ SP
NERLYNX 2 SP
NEXAVAR 2 SP
NINLARO 2 SP
NIPENT 3 INJ SP
ONCASPAR 2 INJ
ONIVYDE 2 INJ
OPDIVO 2 INJ SP
oxaliplatin 1 INJ SP
paclitaxel 1 INJ SP
PERJETA 2 INJ SP
PIQRAY 200MG DAILY DOSE 3 SP
PIQRAY 250MG DAILY DOSE 3 SP
PIQRAY 300MG DAILY DOSE 3 SP
POMALYST 2 SP
PORTRAZZA 3 INJ SP
PROVENGE 2 INJ
PURIXAN 2 SP
QUADRAMET 3 INJ
RITUXAN 2 INJ SP
ROMIDEPSIN 3 INJ SP
RUBRACA 2 SP
RYDAPT 2 SP
SPRYCEL 2 SP
STIVARGA 2 SP
SUTENT 2 SP
SYLATRON 2 INJ SP
TABLOID 3 SP
TAFINLAR 2 SP
TAGRISSO 2 SP
TALZENNA 2 SP
tamoxifen citrate 1
TARCEVA 3 SP
TARGRETIN CAP 3 SP
TASIGNA 2 SP
TAXOTERE 3 INJ SP
TEMODAR CAP 100MG 3 SP
TEMODAR INJ 100MG 2 INJ SP
temozolomide 1 SP
temsirolimus 1 INJ SP
thiotepa 1 INJ SP
TICE BCG 2 INJ
toposar 1 INJ SP
TORISEL 3 INJ SP
TRELSTAR MIXJECT 3 INJ SP
tretinoin cap 10mg 1 SP
TREXALL 3
TYKERB 2 SP
valrubicin 1 INJ SP
VELCADE 2 INJ SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
18
VENCLEXTA 2 SP
VENCLEXTA STARTING PACK 2 SP
VERZENIO 2 SP
vinorelbine tartrate 1 INJ SP
VIZIMPRO 2 SP
VOTRIENT 2 SP
XALKORI 2 SP
XELODA 3 SP
XOSPATA 2 SP
XTANDI 2 SP
YERVOY 2 INJ SP
ZALTRAP 2 INJ SP
ZANOSAR 2 INJ SP
ZELBORAF 2 SP
ZINECARD 3 INJ SP
ZOLADEX 2 INJ SP
ZOLINZA 2 SP
ZYKADIA 2 SP
ZYTIGA 2 SP
ANTIPARKINSON AND RELATED THERAPY AGENTS
amantadine hcl 1
APOKYN 2 INJ SP
AZILECT 3
benztropine inj 1mg/ml 1 INJ
benztropine mesylate 1
bromocriptine mesylate 1
carbidopa 1
carbidopa/levodopa 1
carbidopa/levodopa er 1
carbidopa/levodopa odt 1
CARB/LEVO 50 TAB /ENTACAP 2
carb/levo100 tab /entacap 1
COMTAN 3
DUOPA 3 SP
entacapone 1
INBRIJA 2 SP
LODOSYN 3
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3
PARLODEL 3
pramipexole dihydrochlori 1
rasagiline mesylate 1
REQUIP XL 3
ropinirole er 1
ropinirole hcl 1
ropinirole hydrochloride 1
RYTARY 3
selegiline hcl 1
selegiline hydrochloride 1
SINEMET 3
SINEMET CR 3
STALEVO 100 3
STALEVO 125 3
STALEVO 150 3
STALEVO 200 3
STALEVO 50 3
STALEVO 75 3
TASMAR 3
trihexyphenidyl hcl 1
trihexyphenidyl hydrochlo 1
XADAGO 3
ZELAPAR 3
ANTIPSYCHOTICS/ANTIMANIC AGENTS
ABILIFY 3
ABILIFY MAINTENA 2 INJ
ADASUVE 3
aripiprazole 1
aripiprazole odt 1
ARISTADA 2 INJ SP
ARISTADA INITIO 2 INJ SP
chlorpromazine hcl 1
CHLORPROMAZINE INJ 2 INJ
clozapine 1
CLOZAPINE TAB 150/ODT 3
clozapine odt 1
compro 1
EQUETRO 3
FANAPT 3 ST
FAZACLO 3
fluphenazine decanoate 1 INJ
fluphenazine hcl 1
FLUPHENAZINE HYDROCHLORID 2
GEODON 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
19
haloperidol 1
haloperidol decanoate 1 INJ
haloperidol lactate 1 INJ
INVEGA 3
INVEGA SUSTENNA 3 INJ
INVEGA TRINZA 3 INJ
LATUDA 2 ST
lithium 1
lithium carbonate 1
lithium carbonate er 1
loxapine 1
loxapine succinate 1
olanzapine 1
olanzapine inj 1 INJ
olanzapine odt 1
paliperidone er 1
perphenazine 1
PERSERIS 3 INJ SP
prochlorperazine 1
prochlorperazine edisylat 1 INJ
prochlorperazine maleate 1
quetiapine fumarate 1
quetiapine fumarate er 1
REXULTI 3 ST
RISPERDAL CONSTA 2 INJ
risperidone 1
risperidone odt 1
SAPHRIS 3 ST
SEROQUEL 3
SEROQUEL XR 3
thioridazine hcl 1
thiothixene 1
trifluoperazine hcl 1
trifluoperazine hydrochlo 1
VRAYLAR 3 SP ST
ziprasidone hcl 1
ZYPREXA 3
ZYPREXA RELPREVV 3 INJ
ZYPREXA ZYDIS 3
Antiseptics & Disinfectants
CETYLCIDE-G 2
formaldehyde 1
LUGOLS STRONG IODINE 2
ANTIVIRALS
abacavir 1 SP
abacavir sulfate/lamivudi 1 SP
acyclovir 1
APTIVUS 2 SP
atazanavir sulfate 1 SP
ATRIPLA 3 SP
BARACLUDE 3 SP
BARACLUDE SOL 2 SP
BIKTARVY 2 SP
cidofovir 1 INJ SP
COMPLERA 3 SP
CRIXIVAN 2 SP
DELSTRIGO 3 SP
DESCOVY 2 SP
DOVATO 2 SP
EDURANT 2 SP
efavirenz 1 SP
entecavir 1 SP
EPCLUSA 2 SP
EPIVIR 3
EPIVIR HBV TAB 100MG 3 SP
EPIVIR HBV SOL 5MG/ML 2 SP
EVOTAZ 3 SP
famciclovir 1
fosamprenavir calcium 1 SP
FUZEON 2 INJ SP
GANCICLOVIR 3 INJ SP
GENVOYA 2 SP
HARVONI 2 SP
INTELENCE 2 SP
INVIRASE 2 SP
ISENTRESS 2 SP
ISENTRESS HD 2 SP
JULUCA 2 SP
KALETRA TAB 100-25MG 2 SP
KALETRA SOL 3 SP
lamivudine 1 SP
lamivudine/zidovudine 1 SP
LEDIPASVIR/SOFOSBUVIR 2 SP
lopinavir/ritonavir 1 SP
MAVYRET 2 SP
nevirapine 1 SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
20
nevirapine er 1 SP
NORVIR SOL 80MG/ML 2 SP
NORVIR TAB 100MG 3 SP
ODEFSEY 2 SP
oseltamivir phosphate 1 QL
PEGASYS 2 INJ SP
PEGASYS PROCLICK 2 INJ SP
PEGINTRON 3 INJ SP
PIFELTRO 3 SP
PREVYMIS 2 SP
PREZCOBIX 3 SP
PREZISTA 2 SP
RELENZA DISKHALER 3 QL
REYATAZ 3 SP
ribavirin 1 SP
rimantadine hcl 1
ritonavir 1 SP
SELZENTRY 2 SP
SITAVIG 3
SOFOSBUVIR/VELPATASVIR 2 SP
stavudine 1 SP
STRIBILD 3 SP
SUSTIVA 3 SP
SYMTUZA 3 SP
TAMIFLU 3 QL
tenofovir disoproxil fuma 1 SP
TIVICAY 2 SP
TRIUMEQ 2 SP
TRUVADA 2 SP
valacyclovir hcl 1
valacyclovir hydrochlorid 1
VALCYTE 3 SP
valganciclovir 1 SP
valganciclovir hydrochlor 1 SP
VALTREX 3
VEMLIDY 2 SP
VIDEX 2 SP
VIDEX EC 3 SP
VIEKIRA PAK 2 SP
VIRAMUNE 3 SP
VIRAMUNE XR 3 SP
VIRAZOLE 3 SP
VIREAD 3 SP
VOSEVI 2 SP
XOFLUZA 3
ZEPATIER 2 SP
zidovudine 1 SP
BETA BLOCKERS
acebutolol hcl 1
acebutolol hydrochloride 1
atenolol 1
BETAPACE 3
betaxolol tab 1
bisoprolol fumarate 1
BREVIBLOC 3 INJ
BREVIBLOC PREMIXED 3 INJ
BREVIBLOC PREMIXED DOUBLE 3 INJ
BYSTOLIC 2 ST
carvedilol 1
carvedilol phosphate 1
COREG 3
COREG CR 3
CORGARD 3
esmolol hcl 1 INJ
HEMANGEOL 3
INDERAL LA 3
KAPSPARGO SPRINKLE 3 ST
labetalol inj 1 INJ
labetalol hydrochloride 1
LOPRESSOR 3
metoprolol succinate er 1
metoprolol tartrate 1 INJ
metoprolol tartrate tab 1
nadolol 1
pindolol 1
propranolol hcl 1
propranolol hcl er 1
propranolol hydrochloride 1
sotalol hcl 1
sotalol hcl (af) 1
sotalol hcl af 1
sotalol hydrochloride 1
SOTYLIZE 2
TENORMIN 3
timolol maleate 1
TOPROL XL 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
21
Calcium Channel Blockers
amlodipine besylate 1
CALAN 3
CALAN SR 3
CARDENE IV 3 INJ
CARDIZEM 3
CARDIZEM CD 3
CARDIZEM LA 3
cartia xt 1
CLEVIPREX 3 INJ
diltiazem tab 1
diltiazem hcl cd 1
diltiazem hcl er 1
diltiazem hydrochloride e 1
DILT-XR CAP 120MG 3
dilt-xr 1
felodipine er 1
ISOPTIN SR 3
isradipine 1
matzim la 1
nicardipine inj 1 INJ
nicardipine cap 1
nifedipine 1
nifedipine er 1
nimodipine 1
nisoldipine er 1
NORVASC 3
NYMALIZE 3
PROCARDIA 3
PROCARDIA XL 3
taztia xt 1
TIAZAC 3
verapamil hcl 1
verapamil hcl er 1
verapamil hcl sa 1
verapamil hcl sr 1
verapamil tab 1
verapamil inj 1 INJ
CARDIOTONICS
digox 1
digoxin 1
digoxin inj 1 INJ
DIGOXIN SOL 50MCG/ML 2
milrinone in dextrose 1 INJ
milrinone lactate 1 INJ
CARDIOVASCULAR AGENTS - MISC.
ADEMPAS 2 SP
alyq 1 SP
ambrisentan 1 SP
amlodipine besylate/atorv 1
BIDIL 3
bosentan 1 SP
CADUET 3
cardioplegic 1 INJ
CAVERJECT 2 INJ QL
CAVERJECT IMPULSE 2 INJ QL
CIALIS 3 QL
CORLANOR 2
EDEX 3 INJ QL
ENTRESTO 2
epoprostenol sodium 1 INJ SP
FLOLAN 2 INJ SP
LETAIRIS 2 SP
LEVITRA 3 QL
MUSE 2 QL
OPSUMIT 2 SP
papaverine hcl 1 INJ
PLEGISOL 3 INJ
REMODULIN 2 INJ SP
REVATIO 3 INJ SP
sildenafil citrate 1 QL
STAXYN 3 QL
STENDRA 3 QL ST
tadalafil 1 QL
treprostinil 1 INJ SP
TYVASO REFILL 2 SP
UPTRAVI 2 SP
vardenafil hydrochloride 1 QL
VELETRI 2 INJ SP
VIAGRA 3 QL
VYNDAMAX 3 SP
VYNDAQEL 2 SP
CEPHALOSPORINS
AVYCAZ 2 INJ
cefaclor 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
22
CEFACLOR SUS 125/5ML 2
cefaclor er 1
cefadroxil 1
cefdinir 1
cefepime 1 INJ
CEFEPIME/DEXTROSE 3 INJ
cefixime 1
cefotaxime sodium 1 INJ
cefotetan 1 INJ
CEFOTETAN/DEXTROSE 3 INJ
cefoxitin sodium 1 INJ
cefpodoxime proxetil 1
cefprozil 1
ceftazidime 1 INJ
CEFTAZIDIME/DEXTROSE 2 INJ
ceftriaxone in iso-osmoti 1 INJ
ceftriaxone sodium 1 INJ
CEFTRIAXONE/DEXTROSE 2 INJ
cefuroxime axetil 1
cefuroxime sodium 1 INJ
CEPHALEXIN TAB 250MG 2
cephalexin 1
KEFLEX 3
MAXIPIME 3 INJ
SUPRAX 3
TAZICEF 3 INJ
TEFLARO 2 INJ
CONTRACEPTIVES
altavera 1
alyacen 1/35 1
alyacen 7/7/7 1
amethia 1
amethia lo 1
amethyst 1
apri 1
aranelle 1
ashlyna 1
aubra 1
aubra eq 1
aurovela 1/20 1
aurovela 24 fe 1
aviane 1
azurette 1
BALCOLTRA 3
balziva 1
BEYAZ 3
blisovi 24 fe 1
blisovi fe 1.5/30 1
blisovi fe 1/20 1
briellyn 1
camila 1
camrese 1
camrese lo 1
caziant 1
chateal eq 1
cryselle-28 1
cyclafem 1/35 1
cyclafem 7/7/7 1
cyred 1
cyred eq 1
dasetta 1/35 1
dasetta 7/7/7 1
daysee 1
deblitane 1
DEPO-PROVERA CONTRACEPTIV 3 INJ
DEPO-SUBQ PROVERA 104 3 INJ
desogestrel/ethinyl estra 1
drospirenone/ethinyl estr 1
elinest 1
ELLA 3
enpresse-28 1
enskyce 1
errin 1
estarylla 1
ESTROSTEP FE 3
ethynodiol diacetate/ethi 1
falmina 1
fayosim 1
femynor 1
GENERESS FE 3
gianvi 1
hailey 24 fe 1
heather 1
introvale 1
isibloom 1
jasmiel 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
23
jencycla 1
jolessa 1
juleber 1
junel 1.5/30 1
junel 1/20 1
junel fe 1.5/30 1
junel fe 1/20 1
junel fe 24 1
kaitlib fe 1
kariva 1
kelnor 1/35 1
kelnor 1/50 1
kurvelo 1
KYLEENA 2
larin 1.5/30 1
larin 1/20 1
larin 24 fe 1
larin fe 1.5/30 1
larin fe 1/20 1
larissia 1
layolis fe 1
lessina 1
levonest 1
levonorgestrel and ethiny 1
levonorgestrel/ethinyl es 1
levora 0.15/30-28 1
LILETTA 3
lillow 1
LO LOESTRIN FE 2
LOESTRIN 1.5/30-21 3
LOESTRIN FE 1.5/30 3
LOESTRIN FE 1/20 3
loryna 1
low-ogestrel 1
lo-zumandimine 1
lutera 1
marlissa 1
medroxyprogesterone inj 1 INJ
melodetta 24 fe 1
mibelas 24 fe 1
microgestin 1.5/30 1
microgestin 1/20 1
microgestin fe 1
microgestin fe 1.5/30 1
mili 1
MINASTRIN 24 FE 3
MIRCETTE 3
MIRENA 2
mono-linyah 1
NATAZIA 3
necon 0.5/35-28 1
NEXPLANON 2 INJ
nikki 1
nora-be 1
norethindrone 1
norethindrone & ethinyl e 1
norethindrone acetate/eth 1
norethindrone/ethinyl est 1
norgestimate/ethinyl estr 1
norlyda 1
nortrel 0.5/35 (28) 1
nortrel 1/35 1
nortrel 7/7/7 1
NUVARING 2
ocella 1
ogestrel 1
orsythia 1
ORTHO MICRONOR 3
ORTHO TRI-CYCLEN LO 3
ORTHO-NOVUM 1/35-28 3
PARAGARD INTRAUTERINE COP 3
philith 1
pimtrea 1
pirmella 1/35 1
pirmella 7/7/7 1
portia-28 1
previfem 1
QUARTETTE 3
reclipsen 1
rivelsa 1
SAFYRAL 3
SEASONIQUE 3
setlakin 1
sharobel 1
simpesse 1
SKYLA 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
24
SLYND 3
solia 1
sprintec 28 1
sronyx 1
syeda 1
tarina 24 fe 1
tarina fe 1/20 1
tarina fe 1/20 eq 1
TAYTULLA 2
tilia fe 1
tri femynor 1
tri-estarylla 1
tri-legest fe 1
tri-linyah 1
tri-lo-estarylla 1
tri-lo-marzia 1
tri-lo-sprintec 1
tri-previfem 1
tri-sprintec 1
trivora-28 1
tri-vylibra 1
tri-vylibra lo 1
tulana 1
tydemy 1
velivet 1
vienva 1
viorele 1
vyfemla 1
vylibra 1
wera 1
wymzya fe 1
XULANE 2
YASMIN 28 3
YAZ 3
zarah 1
zovia 1/35e 1
CORTICOSTEROIDS
betamethasone sodium phos 1 INJ
budesonide 1
budesonide er 1
CELESTONE-SOLUSPAN 3 INJ
CONTRAST ALLERGY PREMED P 3
CORTEF 3
CORTISONE ACETATE 2
DEPO-MEDROL 3 INJ
DEXAMETHASONE SOL 0.5/5ML 2
dexamethasone 1
dexamethasone 10-day dose 1
dexamethasone 6-day dose 1
DEXAMETHASONE INTENSOL 2
dexamethasone pho inj 1 INJ
dexpak 10 day 1
dexpak 13 day 1
dexpak 6 day 1
EMFLAZA 3 SP
ENTOCORT EC 3
fludrocortisone acetate 1
hidex 6-day 1
hydrocort tab 5mg 1
KENALOG-10 3 INJ
KENALOG-40 3 INJ
KENALOG-80 3 INJ
MEDROL 3
MEDROL DOSEPAK 3
methylprednisolone 1
methylprednisolone acetat 1 INJ
methylprednisolone dose p 1
methylprednisolone sodium 1 INJ
MILLIPRED 2
MILLIPRED DP 2
prednisolone 1
prednisolone sodium phosp 1
prednisone 1
PREDNISONE SOL 5MG/5ML 2
PREDNISONE INTENSOL 2
RAYOS 3
SOLU-CORTEF 2 INJ
SOLU-MEDROL 3 INJ
taperdex 6-day 1
TAPERDEX 7-DAY 3
triamcinolone acetonide 1 INJ
UCERIS TAB 9MG 3
COUGH/COLD/ALLERGY
acetylcystine sol 1
benzonatate 1
bromfed dm 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
25
bromphen/pseudoephedrine 1
CLARINEX-D 12 HOUR 3
GILTUSS TR 3
hydrocodone bitartrate/ho 1
hydrocodone polistirex/ch 1
hydromet 1
NEBUSAL 3
NEOTUSS PLUS 2
promethazine/codeine 1
promethazine/dextromethor 1
promethazine/phenylephrin 1
SEMPREX-D 3
sodium chlor neb 10% 1
SSKI 3
TESSALON PERLES 3
TUSSICAPS 3
DERMATOLOGICALS
ABSORICA 3
ACANYA 3
acitretin 1 SP
ACUICYN DAILY EYELID & EY 2
acyclovir cream 1
ACZONE 3
adapalene gel 0.1% 1
ADAPALENE SOL 0.1% 3
adapalene pump 1
adapalene/benzoyl peroxid 1
agoneaze 1
AKLIEF 3
AKTIPAK 3
ALA SCALP 3
ALA-QUIN 3
alclometasone dipropionat 1
ALCORTIN A 3
ALLEVYN GENTLE 3
ALTABAX 3
ALTRENO 3
amcinonide 1
ammonium lactate 1
amnesteem 1
ANACAINE 3
APEXICON E 2
arzol silver nitrate app 1
ATOPADERM 3
ATRALIN 3
ATRAPRO ANTIPRURITIC HYDR 3
ATRAPRO CP 3
ATRAPRO DERMAL SPRAY 3
augmented betamethasone d 1
AVAGE 3
AVAR 3
avar cleanser 1
AVAR LS 3
AVAR LS CLEANSER 3
avar-e green 1
AVAR-E LS 3
AVENOVA 3
avita 1
azelaic acid 1
AZELEX 3
BEAU RX 3
BENSAL HP 3
BENZAC AC WASH 3
BENZACLIN WITH PUMP 3
BENZAMYCIN 3
benzepro foaming cloths 1
BENZIQ 3
BENZIQ LS 3
BENZIQ WASH 3
benzoin compound tincture 1
betamethasone dipropionat 1
betamethasone valerate 1
bimatoprost 1
BOTOX COSMETIC 3 INJ SP
bp foam 1
bp wash 1
BPCO 3
BRYHALI 3
calcipotriene 1
calcipotriene/betamethaso 1
calcitriol oin 3mcg/gm 1
CAPEX 3
CARAC 2
CARRASYN HYDROGEL WOUND D 3
celacyn 1
CERACADE 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
26
CERAMAX 3
CETACAINE 3
ciclopirox 1
ciclopirox nail lacquer 1
ciclopirox olamine 1
ciclopirox treatment 1
claravis 1
CLEOCIN-T 3
clindacin etz pledgets 1
CLINDACIN PAC 3
CLINDAGEL 3
clindamycin sol 1% 1
CLINDAMYCIN GEL 1% 3
clindamycin phosphate/ben 1
clindamycin phosphate/tre 1
clindamycin/benzoyl perox 1
clobetasol propionate 1
clobetasol propionate emo 1
CLOBEX 3
CLOCORTOLONE PIVALATE 3
CLODERM 3
clotrimazole sol 1% 1
clotrimazole anti-fungal 1
clotrimazole/betamethason 1
CONDYLOX 3
CORDRAN 3
COSENTYX 2 INJ SP
COSENTYX SENSOREADY PEN 2 INJ SP
crotan 1
c-topical 1
CURITY HYPERTONIC SODIUM 3
CURITY SODIUM CHLORIDE DR 3
CUTIVATE 3
dapsone gel 5% 1
DENAVIR 3
DERMACINRX LEXITRAL PHARM 3
DERMACINRX PHN PAK 3
DERMACINRX ZRM PAK 3
DERMA-SMOOTHE/FS BODY 3
DERMA-SMOOTHE/FS SCALP 3
dermazene 1
desonide 1
DESOWEN 3
desoximetasone 1
DICLOFENAC EPOLAMINE 2
diclofenac gel 1
diclofex dc 1
DIFFERIN 3
diflorasone diacetate 1
DIPROLENE 3
DIPROLENE AF 3
DOXYCYCLINE CAP 40MG 3
DRITHO-CREME HP 2
DRYSOL 3
DUAC 3
DUOBRII 3
DUPIXENT 2 INJ SP
econazole nitrate 1
ECOZA 3 ST
EFUDEX 3
ELETONE TWINPACK 2
ELIDEL 2
ELOCON 3
ENSTILAR 2
ENTTY SPRAY EMULSION 3
EPICERAM 3
EPICYN 3
EPIDUO 3
EPIDUO FORTE 2
EPIFOAM 3
ERTACZO 3 ST
ERY 3
ERYGEL 2
erythromycin gel 2% 1
erythromycin/benzoyl pero 1
ETHYL CHLORIDE/FINE STREA 2
ethyl chloride/mist 1
EUCRISA 3
EURAX 3
EVOCLIN 3
EXELDERM 3 ST
EXODERM 3
EXTINA 3
FABIOR 3
FINACEA GEL 15% 3
FINACEA AER 15% 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
27
FLECTOR 2
fluocinonide 1
FLUOROPLEX 3
fluorouracil cre 5% 1
FLUOROURACIL CRE 0.5% 3
flurandrenolide 1
fluticasone oin 0.005% 1
GEBAUERS SPRAY AND STRETC 3
GENADUR 3
gentamicin oin 0.1% 1
glydo 1
GORDOFILM 3
grafco silver nitrate app 1
halcinonide 1
halobetasol cre 0.05% 1
HALOBETASOL AER 0.05% 3
HALOG 3
HPR PLUS 2
HYCLODEX 3
HYDRO 35 3
HYDRO 40 FOAM 3
hydrocort cre 1% 1
hc pramoxine cre 2.5-1% 1
hc butyrate sol 0.1% 1
hc butyrate cre 0.1% 1
hydrocortisone valerate 1
hydrocortisone/iodoquinol 1
HYDROFERA BLUE FOAM DRESS 3
HYDROFERA BLUE READY FOAM 3
hydroquinone 1
hydroquinone time release 1
HYLATOPIC PLUS 3
HYPOCYN 3
ILUMYA 3 INJ SP
imiquimod 1
IMIQUIMOD PUMP 3
IMPOYZ 3
iodoquinol/hydrocortisone 1
isotretinoin 1
ivermectin cre 1% 1
JUBLIA 3 ST
KAMDOY 3
KENALOG 3
KERALAC 3
KERALYT 3
KERALYT SCALP 3
KERYDIN 3 ST
ketoconazole cream 1
KLARON 3
LAC-HYDRIN 3
LATISSE 3
LAVARE WOUND WASH 3
LEVICYN 3
levicyn dermal spray 1
LEVULAN KERASTICK 3
LEXETTE 3
lidocaine 1
LIDOCAINE AND TETRACAINE 3
lidocaine sol 1
lidocaine hcl jelly 1
lidocaine/prilocaine 1
LIDODERM 3
lidozion 1
lindane 1
livixil pak 1
LOCOID 3
LOCOID LIPOCREAM 3
LOTRISONE 3
LOYON 3
LULICONAZOLE 3 ST
LUXIQ 3
LUZU 3 ST
malathion 1
MENTAX 3
methoxsalen 1
METROCREAM 3
METROGEL 3
METROLOTION 3
metronidazol gel 1
MICONAZOLE NITRATE/ZINC O 3
MIMYX 3
MIRVASO 2
mometasone oin 0.1% 1
mupirocin 1
myorisan 1
naftifine hcl 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
28
naftifine hydrochloride 1
NAFTIN 3 ST
NATROBA 3
NEOCERA 3
NEOSALUS 3
NEOSALUS CP 3
NEUAC KIT 3
NIVATOPIC PLUS 2
NIZORAL 3
nolix 1
NORITATE 3
NUCORT 3
nudiclo solupak 1
NUTRASEB 3
NUVAIL 3
nyamyc 1
nystatin cre 1
nystatin/triamcinolone 1
nystop 1
OLUX 3
OLUX-E 3
ONEXTON 2
ORACEA 2
OVACE PLUS 3
OVACE PLUS WASH 3
OVACE WASH 3
oxiconazole nitrate 1
OXISTAT 3 ST
OXSORALEN ULTRA 3
PANDEL 3
PENLAC NAIL LACQUER 3
PENNSAID 3
permethrin 1
PICATO 2
PICO SINGLE USE NEGATIVE 3
pimecrolimus 1
PLEXION 3
PLEXION CLEANSER 3
PODOCON 25 IN BENZOIN TIN 3
podofilox 1
PRAMOSONE 3
prednicarbate 1
PRESERA 3
PROMISEB 3
PROPECIA 3
PROTOPIC 3
PSORCON 3
PYROGALLIC ACID 3
QBREXZA 2
RECEDO 2
RECURA 3
REGENECARE 3
REGRANEX 2
RENOVA 3
RETIN-A 3
RETIN-A MICRO 3
RETIN-A MICRO PUMP 3
RHOFADE 3
RIAX 3
ROSADAN KIT 3
SALEX 3
salicylic acid 1
salicylic acid cream 1
salicylic acid er 1
salicylic acid lotion 1
salicylic acid wart remov 1
SALVAX 2
SALVAX DUO PLUS 3
SANTYL 2
selenium sulfide 1
selenium sulfide shampoo 1
SELRX 3
SERNIVO 3
SILIQ 3 INJ SP
SILVADENE 3
SILVER NITRATE 2
silver sulfadiazine 1
SKLICE 3
SKYRIZI 2 INJ SP
sodium sulfacetamide sham 10% 1
sodium sulfacetamide wash 1
SOD SUL/SULF EMU 10-5% 2
sod sul/sulf liq wash 1
SOOLANTRA 2
SORIATANE 3 SP
SORILUX 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
29
SPINOSAD 2
ssd 1
sss 10%-5% 1
STELARA 2 INJ SP
sulfacetamide sodium 1
sulfacetamide sodium/sulf 1
sulfacleanse 8/4 1
SUMADAN WASH 3
SUVICORT 3
SYNERA 3
TACLONEX 2
tacrolimus oin 0.1% 1
TALTZ 2 INJ SP
TARGRETIN GEL 1% 2 SP
tazarotene 1
TAZORAC GEL 0.1% 2
TAZORAC CRE 0.1% 3
TEMOVATE 3
TETRIX 3
TEXACORT 3
THERAHONEY 3
tl hydroquinone 1
TOLAK 3
TOPICORT 3
TREMFYA 2 INJ SP
tretinoin gel 0.01% 1
tretinoin microsphere 1
tretinoin microsphere pum 1
triamcinolon cre 0.5% 1
TRIANEX 2
TRI-CHLOR 2
TRIDESILON 3
TRI-LUMA 3
ULESFIA 3
ULTRAVATE 3
urea 1
urea nail 1
UTOPIC 3
VALCHLOR 2 SP
VANIQA 3
vanoxide-hc 1
VECTICAL 3
VELTIN 3
VENELEX 3
VERDESO 3
VEREGEN 3
VEXASYN 3
VOLTAREN 3
VUSION 3
VYTONE 3
XALIX 3
XEPI 3
XERAC AC 3
XERALUX 3
XERESE 3
XEROFORM NON-OCCLUSIVE OI 2
XEROFORM OCCLUSIVE PETROL 2
XOLEGEL 3 ST
XOLEGEL COREPAK 3
XOLEGEL DUO/HEAD & SHOULD 3
XOLEGEL DUO/XOLEX 3
XRYLIX 3
zenatane 1
ZIANA 3
ZITHRANOL 3
ZONALON 3
ZOVIRAX OIN 5% 3
ZOVIRAX CRE 5% 2
ZTLIDO 2
ZYCLARA 3
ZYCLARA PUMP 3
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
CAMINO PRO 15PE 3
CAMINO PRO PKU 2
CEREFOLIN 3
CEREFOLIN NAC 3
DEPLIN 15 3
DEPLIN 7.5 3
ELFOLATE 3
ENLYTE 3
ENTERAGAM 3
folbic 1
FOLBIC RF 3
FOLTANX RF 3
FOLTX 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
30
GLYTACTIN BETTERMILK 15 2
GLYTACTIN BETTERMILK DE-L 2
GLYTACTIN BUILD 10PE 3
GLYTACTIN BUILD 20/20 PKU 3
GLYTACTIN COMPLETE 10PE 3
GLYTACTIN RESTORE 10 3
GLYTACTIN RESTORE 5 3
GLYTACTIN RESTORE LITE 10 3
GLYTACTIN RTD 10 3
GLYTACTIN RTD 15 3
GLYTACTIN RTD LITE 15 3
GLYTACTIN SWIRL 15PE 3
HOMACTIN AA PLUS 3
ISOVACTIN AA PLUS 3
KETOVIE 3
KETOVIE PEPTIDE 3
LEVOMEFOLATE CALCIUM ALGA 3
LEVOMEFOLATE CALCIUM/N-AC 3
LEVOMEFOLATE CALCIUM/PYRI 3
L-METHYL-B6-B12 2
L-METHYLFOLATE 2
L-METHYLFOLATE CA/S-ALGAL 3
L-METHYLFOLATE FORTE 3
L-METHYL-MC NAC 2
METANX 3
NICAPRIN 3
niva-fol 1
PHENACTIN AA PLUS 3
PODIAPN 3
PROMACTIN AA PLUS 20PE 3
RHEUMATE 3
TL-ICARE 3
TYLACTIN BUILD 20PE TYR 3
TYLACTIN COMPLETE 15 PE 3
TYLACTIN RESTORE 10 3
TYLACTIN RESTORE 5PE 3
TYLACTIN RTD 15 3
VASCAZEN 3
VASCULERA 3
VILACTIN AA PLUS 3
VISBIOME 3
XYZBAC 3
ZYVEXOL 3
ZYVIT 3
DIGESTIVE AIDS
CREON 2
PANCREAZE 3
PERTZYE 3
SUCRAID 2 SP
VIOKACE 2
ZENPEP 2
DIURETICS
acetazolamide 1
acetazolamide er 1
acetazolamide sodium 1 INJ
ALDACTAZIDE 3
ALDACTONE 3
amiloride hcl 1
amiloride/hydrochlorothia 1
bumetanide tab 1
bumetanide inj 1 INJ
BUMEX 3
CAROSPIR 3
chlorothiazide 1
chlorothiazide sodium 1 INJ
chlorthalidone 1
DIURIL 3
DYAZIDE 3
DYRENIUM 3
EDECRIN 3
ethacrynic acid 1
furosemide 1
furosemide inj 1 INJ
hydrochlorothiazide 1
indapamide 1
LASIX 3
mannitol 1 INJ
MAXZIDE 3
MAXZIDE-25 3
methazolamide 1
metolazone 1
SODIUM EDECRIN 3 INJ
spironolactone 1
spironolactone/hydrochlor 1
torsemide 1
triamterene 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
31
triamterene/hydrochloroth 1
ENDOCRINE AND METABOLIC AGENTS - MISC.
ACTHAR 3 INJ SP
ACTONEL 3
alendronate sodium 1
ALENDRONATE TAB 40MG 2
AMMONUL 3 INJ SP
ATELVIA 3
BINOSTO 3 ST
BONIVA 3
cabergoline 1
calcitonin-salmon 1
calcitriol 1
calcitriol inj 1 INJ
CARNITOR 3
CARNITOR SF 3
CETROTIDE 2 INJ
chorionic gonadotropin 1 INJ SP
cinacalcet hydrochloride 1 SP
clomiphene citrate 1
CYSTADANE 2 SP
desmopressin inj 1 INJ
desmopressin acetate 1
desmopressin spr 0.01% 1
doxercalciferol 1 SP
etidronate disodium 1
EVISTA 3
FABRAZYME 2 INJ SP
FOLLISTIM AQ 3 INJ SP
FORTEO 2 INJ SP
FOSAMAX 3
FOSAMAX PLUS D 3 ST
GALAFOLD 3 SP
GENOTROPIN 2 INJ SP
GENOTROPIN MINIQUICK 2 INJ SP
GONAL-F 2 INJ SP
GONAL-F RFF REDIJECT 2 INJ SP
HUMATROPE 2 INJ SP
HUMATROPE COMBO PACK 2 INJ SP
ibandronate inj 1 INJ SP
ibandronate sodium 1
INCRELEX 2 INJ SP
KANUMA 2 INJ SP
KUVAN 2 SP
levocarnitine 1
LUMIZYME 2 INJ SP
LUPANETA PACK 2 SP
LUPRON DEPOT-PED (1-MONTH 2 INJ SP
LUPRON DEPOT-PED (3-MONTH 2 INJ SP
MENOPUR 2 INJ SP
nitisinone 1 SP
NORDITROPIN FLEXPRO 2 INJ SP
NOVAREL 2 INJ
NUTROPIN AQ NUSPIN 10 3 INJ SP
NUTROPIN AQ NUSPIN 20 3 INJ SP
NUTROPIN AQ NUSPIN 5 3 INJ SP
octreotide acetate 1 INJ SP
OMNITROPE 3 INJ SP
ORILISSA 2
OSPHENA 3
OVIDREL 2 INJ SP
PALYNZIQ 2 INJ SP
paricalcitol inj 1 INJ SP
paricalcitol 1 SP
PREGNYL W/DILUENT BENZYL 3 INJ SP
PROLIA 3 INJ SP
raloxifene hydrochloride 1
RAYALDEE 3
RECLAST 3 INJ SP
risedronate sodium 1
risedronate sodium dr 1
ROCALTROL 3
SANDOSTATIN 3 INJ SP
SANDOSTATIN LAR DEPOT 3 INJ SP
SENSIPAR 3 SP
SIGNIFOR 2 INJ SP
SIGNIFOR LAR 3 INJ SP
sodium phenylacetate/sodi 1 INJ SP
SOMATULINE DEPOT 2 INJ SP
SOMAVERT 2 INJ SP
STIMATE 2 SP
STRENSIQ 2 INJ SP
SUPPRELIN LA 3 INJ SP
SYNAREL 2 SP
TRIPTODUR 2 INJ SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
32
TYMLOS 2 INJ SP
XGEVA 2 INJ SP
ZEMPLAR 3 INJ SP
zoledronic acid 1 INJ SP
ZOMACTON 3 INJ SP
Estrogens
ALORA 3
amabelz 1
ANGELIQ 3
BI-EST 50:50 COMPOUNDING 3
BI-EST 50:50 PROGESTERONE 3
BI-EST 80:20 PROGESTERONE 3
BIJUVA 3
CLIMARA 3
CLIMARA PRO 3
COMBIPATCH 2
covaryx 1
covaryx hs 1
DELESTROGEN 3 INJ
DEPO-ESTRADIOL 2 INJ
DIVIGEL 2
dotti 1
DUAVEE 2
eemt 1
eemt hs 1
ELESTRIN 3
esterified estrogens/meth 1
ESTRACE TAB 3
estradiol 1
estradiol valerate 1 INJ
estradiol/norethindrone a 1
ESTRIOL-PROGESTERONE COMP 3
ESTROGEL 3
EVAMIST 3
FEMHRT LOW DOSE 3
fyavolv 1
jinteli 1
lopreeza 1
MENEST 3
MENOSTAR 3
mimvey 1
mimvey lo 1
MINIVELLE 3
PREMARIN 2 INJ
PREMPHASE 2
PREMPRO 2
VIVELLE-DOT 3
Fluoroquinolones
BAXDELA 3
CIPRO 3
ciprofloxacin hcl 1
ciprofloxacin i.v.-in d5w 1 INJ
levofloxacin 1
levofloxacin inj 1 INJ
levofloxacin in d5w 1 INJ
moxifloxacin tab 1
ofloxacin 1
GASTROINTESTINAL AGENTS - MISC.
ACTIGALL 3
alosetron hydrochloride 1
AMITIZA 3
APRISO 3
ASACOL HD 3
AURYXIA 3
AZULFIDINE 3
AZULFIDINE EN-TABS 3
balsalazide disodium 1
calcium acetate 1
CANASA 3
CIMZIA 3 INJ SP
CIMZIA STARTER KIT 3 INJ SP
cromolyn sodium 1
DELZICOL 3
DIPENTUM 3
ENTYVIO 2 INJ SP
enulose 1
FOSRENOL 3
GASTROCROM 3
generlac 1
INFLECTRA 3 INJ SP
lanthanum carbonate 1
LIALDA 3
LINZESS 2
mesalamine 1
mesalamine dr 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
33
metoclopramide hcl 1
metoclopramide inj 1 INJ
metoclopramide hydrochlor 1
METOCLOPRAMIDE ODT 2
MOTEGRITY 3
MOVANTIK 2
OCALIVA 2 SP
PENTASA 2
RELISTOR TAB 2 SP QL
RELISTOR INJ 2 INJ SP QL
REMICADE 2 INJ SP
RENAGEL 3
RENFLEXIS 3 INJ SP
RENVELA 3
ROWASA 3
sevelamer carbonate 1
sevelamer hydrochloride 1
SFROWASA 3
SIMETHICONE 3
STELARA INJ 5MG/ML 3 INJ SP
sulfasalazine 1
sulfazine 1
SYMPROIC 2
TRULANCE 2
ursodiol 1
VELPHORO 2 SP
VIBERZI 2
ZELNORM 3
GENERAL ANESTHETICS
AMIDATE 3 INJ
desflurane 1
etomidate 1 INJ
FORANE 2
ketamine hcl 1 INJ
propofol 1 INJ
sevoflurane 1
SUPRANE 3
ULTANE 3
GENITOURINARY AGENTS - MISCELLANEOUS
acetic acid 0.25% 1
alfuzosin hcl er 1
aminoacetic acid 1
argyle sterile saline 100 1
AVODART 3 QL
CARDURA XL 3
curity sterile saline 1
CYSTAGON 2 SP
dutasteride 1 QL
dutasteride/tamsulosin hc 1
ELMIRON 2
finasteride 1
FLOMAX 3
glycine 1
JALYN 3
K-PHOS NO 2 3
LITHOSTAT 3
ORACIT 3
phenazo 1
phenazopyridine hcl 1
phenazopyridine hydrochlo 1
potassium citrate er 1
potassium citrate/citric 1
PROSCAR 3
PYRIDIUM 3
RAPAFLO 3
RENACIDIN 2
RIMSO-50 3 INJ
silodosin 1
sodium chloride 0.9% 1
sodium citrate/citric aci 1
SORBITOL 3
SORBITOL-MANNITOL 3
tamsulosin hydrochloride 1
taron-crystals 1
THIOLA 3 SP
THIOLA EC 3 SP
tricitrates 1
UROCIT-K 10 3
UROCIT-K 15 3
UROCIT-K 5 3
Gout Agents
allopurinol 1
allopurinol sodium 1 INJ
COLCHICINE 3
COLCRYS 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
34
febuxostat 1
MITIGARE 2
probenecid 1
probenecid/colchicine 1
ULORIC 3 ST
ZYLOPRIM 3
HEMATOLOGICAL AGENTS - MISC.
ADVATE 2 INJ SP
ADYNOVATE 2 INJ SP
AGGRASTAT 3 INJ
AGGRENOX 3
anagrelide hydrochloride 1
aspirin/dipyridamole er 1
BRILINTA 2
CEPROTIN 2 INJ SP
cilostazol 1
clopidogrel 1
dipyridamole 1
EFFIENT 3
ELOCTATE 2 INJ SP
eptifibatide 1 INJ
FIRAZYR 2 INJ SP
flexbumin 1 INJ
HEMLIBRA 2 INJ SP
HEMOFIL M 2 INJ SP
HESPAN 3 INJ
hetastarch 6%/nacl 1 INJ
HEXTEND 2 INJ
icatibant acetate 1 INJ SP
INTEGRILIN 3 INJ
JIVI 2 INJ SP
KENGREAL 3 INJ
KOGENATE FS 2 INJ SP
KOVALTRY 2 INJ SP
LMD 10% DEXTROSE 5% 2 INJ
LMD 10% SODIUM CHLORIDE 0 2 INJ
MONONINE 2 INJ SP
NOVOEIGHT 2 INJ SP
NOVOSEVEN RT 2 INJ SP
OBIZUR 2 INJ SP
pentoxifylline er 1
plasbumin-25 1 INJ
plasbumin-5 1 INJ
PLASMANATE 2 INJ
PLAVIX 3
prasugrel 1
REBINYN 3 INJ SP
RECOMBINATE 3 INJ SP
RETAVASE 3 INJ SP
RETAVASE HALF-KIT 3 INJ SP
RIXUBIS 3 INJ SP
SOLIRIS 2 INJ SP
TAKHZYRO 3 INJ SP
THROMBATE III 2 INJ SP
THROMBATE III W/20 ML STE 2 INJ SP
TRETTEN 2 INJ SP
ULTOMIRIS 3 INJ SP
VOLUVEN 2 INJ
VONVENDI 2 INJ
ZONTIVITY 3
HEMATOPOIETIC AGENTS
ACTIVE FE 3
airavite 1
ANIMI-3 3
ARANESP ALBUMIN FREE 2 INJ SP
CENFOL 3
CENTRATEX 2
chromagen 1
corvita 150 1
CORVITE FE 3
cyanocobalamin 1 INJ
DOPTELET 2 SP
DROXIA 2
ELELYSO 3 INJ SP
EPOGEN 3 INJ SP
fabb 1
FERAHEME 2 INJ
FERIVA 21/7 3
FERIVAFA 3
ferocon 1
ferotrinsic 1
FERRALET 90 3
FERRAPLUS 90 2
FERRLECIT 3 INJ SP
folbee 1
FOLGARD RX 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
35
folic acid 1
folic acid/vitamin b-6/vi 1
FOLIVANE-F 2
FOLIVANE-PLUS 2
foltrin 1
FULPHILA 3 INJ SP
FUSION PLUS 3
GENICIN VITA-D 3
hematinic/folic acid 1
HEMATOGEN FA 2
hematogen forte 1
HEMATRON-AF 3
hemocyte-f 1
hydroxocobalamin 1 INJ
INFED 2 INJ
INJECTAFER 3 INJ
INTEGRA F 3
INTEGRA PLUS 3
IROSPAN 24/6 3
LEUKINE 2 INJ SP
miglustat 1 SP
MOZOBIL 2 INJ SP
MULPLETA 3 SP
MULTIGEN 2
MULTIGEN PLUS 2
NASCOBAL 2
NEPHRON FA 3
NEULASTA 2 INJ SP
NEULASTA ONPRO KIT 2 INJ SP
NEUPOGEN 2 INJ SP
NIVESTYM 2 INJ SP
NPLATE 2 INJ SP
NUFERA 3
ORTHO DF 3
poly-iron 150 forte 1
polysaccharide iron forte 1
PROCRIT 2 INJ SP
PROMACTA 2 SP
RETACRIT 3 INJ SP
se-tan plus 1
sodium ferric gluconate c 1 INJ SP
TALIVA 3
TARON FORTE 2
tl gard rx 1
tl icon 1
tl-hem 150 1
trigels-f forte 1
UDENYCA 2 INJ SP
VENOFER 2 INJ SP
virt-gard 1
VPRIV 3 INJ SP
ZARXIO 2 INJ SP
HEMOSTATICS
AMICAR 2
aminocaproic acid 1 INJ
aminocaproic acid 1
CYKLOKAPRON 3 INJ
GEL-FLOW 3
MONSELS FERRIC SUBSULFATE 2
TISSEEL 3
tranexamic acid inj 1 INJ
tranexamic acid 1
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
AMBIEN 3 QL
AMBIEN CR 3 QL
AMYTAL SODIUM 2 INJ
BELSOMRA 3 QL ST
BUTISOL SODIUM 3
dexmedetomidine hcl 1 INJ
dexmedetomidine hydrochlo 1 INJ
DORAL 3
EDLUAR 3 QL ST
estazolam 1
eszopiclone 1 QL
flurazepam hcl 1
HALCION 3 QL
LUNESTA 3 QL
midazolam hcl 1
midazolam inj 1 INJ
midazolam hydrochloride 1 INJ
pentobarbital sodium 1 INJ
phenobarbital 1
PHENOBARB INJ 65MG/ML 2 INJ
phenobarb inj 130mg/ml 1 INJ
PRECEDEX 3 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
36
QUAZEPAM 3
ramelteon 1 QL ST
RESTORIL 3
ROZEREM 3 QL ST
SECONAL SODIUM 2
SILENOR 3 ST
temazepam 1
triazolam 1 QL
zaleplon 1 QL
zolpidem tartrate 1 QL
zolpidem tartrate er 1 QL
LAXATIVES
CLENPIQ 2
COLYTE-FLAVOR PACKS 3
constulose 1
gavilyte-c 1
gavilyte-n/flavor pack 1
GOLYTELY 3
KRISTALOSE 3
lactulose 1
MOVIPREP 3
NULYTELY/FLAVOR PACKS 3
OSMOPREP 3
peg 3350/electrolytes 1
peg-3350/electrolytes 1
peg-3350/nacl/na bicarbon 1
PLENVU 3
PREPOPIK 2
SUPREP BOWEL PREP KIT 2
trilyte 1
LOCAL ANESTHETICS-Parenteral
bupivacaine hcl 1 INJ
bupivacaine spinal 1 INJ
bupivacaine/epinephrine 1 INJ
chloroprocaine hydrochlor 1 INJ
CLOROTEKAL 3 INJ
DURASAFE SPINAL/EPIDURAL 3 INJ
lidocaine inj 1 INJ
LIDOCAINE HCL/DEXTROSE 2
lidocaine/epinephrine 1 INJ
MARCAINE 3 INJ
MARCAINE SPINAL 3 INJ
MARCAINE/EPINEPHRINE 3 INJ
MONOJECT BONE MARROW BIOP 3 INJ
ropivacaine 1 INJ
ropivacaine hcl 1 INJ
sensorcaine-mpf 1 INJ
tetracaine hcl 1 INJ
XYLOCAINE 3 INJ
XYLOCAINE-MPF 3 INJ
MACROLIDES
azithromycin 1
AZITHROMYCIN POW 1GM PAK 2
clarithromycin 1
clarithromycin er 1
DIFICID 3
e.e.s. 400 1
E.E.S. GRANULES 3
ERYPED 200 3
ERYPED 400 3
ery-tab 1
ERYTHROCIN LACTOBIONATE 2 INJ
ERYTHROCIN STEARATE 2
erythromycin cap 1
erythromycin base 1
erythromycin dr 1
erythromycin ethylsuccina 1
ZITHROMAX 3 INJ
MEDICAL DEVICES AND SUPPLIES
CAYA 3
FEMCAP 2
RAPPORT RING LOADING SYST 2
RAPPORT VACUUM THERAPY DE 2
REMESENSE 3
WIDE-SEAL SILICONE DIAPHR 3
Migraine Products
AIMOVIG 2 INJ QL
ST
AJOVY 2 INJ QL
ST
almotriptan 1 QL
almotriptan malate 1 QL
AMERGE 3 QL
CAFERGOT 3
CAMBIA 3 QL
dihydroergotamine mesylat 1 INJ QL
DIHYDROERGOTAMINE SPR 2 QL ST
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
37
eletriptan hydrobromide 1 QL
EMGALITY 2 INJ ST
ERGOMAR 3
ergotamine tartrate/caffe 1
frovatriptan succinate 1 QL
IMITREX 3 QL
IMITREX STATDOSE REFILL 3 INJ QL
IMITREX STATDOSE SYSTEM 3 INJ QL
MAXALT 3 QL
MAXALT-MLT 3 QL
MIGRANAL 3 QL ST
naratriptan hcl 1 QL
ONZETRA XSAIL 3 QL ST
RELPAX 3 QL
rizatriptan benzoate 1 QL
rizatriptan benzoate odt 1 QL
sumatriptan 1 QL
sumatriptan inj 1 INJ QL
sumatriptan succinate 1 QL
SUMATRIPTAN INJ 6MG/0.5 3 INJ QL
sumatriptan succinate ref 1 INJ QL
sumatriptan/naproxen sodi 1 QL
TREXIMET 3 QL
ZEMBRACE SYMTOUCH 3 INJ QL
ST
zolmitriptan 1 QL
zolmitriptan odt 1 QL
ZOMIG 3 QL
ZOMIG SPR 5MG 2 QL ST
MINERALS AND ELECTROLYTES
bd posiflush 1 INJ
CALCIFOL 3
calcium chloride 1 INJ
calcium gluconate 1 INJ
COPPER TRACE METAL 2 INJ
DEXTROSE 10%/NACL 0.45% 2 INJ
DEXTROSE 5% 2 INJ
dextrose 10%/nacl 0.2% 1 INJ
dextrose 2.5%/nacl 0.45% 1 INJ
dextrose 5%/lactated ring 1 INJ
dextrose 5%/nacl 0.2% 1 INJ
dextrose 5%/nacl 0.225% 1 INJ
dextrose 5%/nacl 0.3% 1 INJ
dextrose 5%/nacl 0.33% 1 INJ
dextrose 5%/nacl 0.45% 1 INJ
dextrose 5%/nacl 0.9% 1 INJ
DEXTROSE/SODIUM CHLORIDE 2 INJ
effer-k 1
EFFER-K TAB 20MEQ 3
FLUORABON 3
fluoride 1
fluoritab 1
GALZIN 3
HYPERLYTE-CR 3 INJ
iodine strong 1
IONOSOL-MB/DEXTROSE 5% 2 INJ
ISOLYTE-P/DEXTROSE 5% 2 INJ
ISOLYTE-S 2 INJ
ISOLYTE-S PH 7.4 2 INJ
kcl 0.075%/d5w/nacl 0.45% 1 INJ
kcl 0.15%/d5w/nacl 0.2% 1 INJ
kcl 0.15%/d5w/nacl 0.225% 1 INJ
kcl 0.15%/d5w/nacl 0.45% 1 INJ
kcl 0.15%/d5w/nacl 0.9% 1 INJ
kcl 0.3%/d5w/nacl 0.45% 1 INJ
KCL 0.3%/D5W/NACL 0.9% 2 INJ
klor-con 1
klor-con 10 1
klor-con 8 1
klor-con m10 1
KLOR-CON M15 2
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 1
K-PHOS 2
K-PHOS NEUTRAL 2
k-prime 1
K-TAB TAB 20MEQ 3
K-TAB 2
lactated ringers 1 INJ
LACTATED RINGERS VIAFLEX 3 INJ
ludent 1
nafrinse 1
nafrinse drops 1
NEUT 2 INJ
normal saline flush 1 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
38
NORMOSOL -R 3 INJ
NORMOSOL-M IN D5W 2 INJ
NORMOSOL-R 2 INJ
NORMOSOL-R IN D5W 2 INJ
phospha 250 neutral 1
phospho-trin 250 neutral 1
PLASMA-LYTE A 2 INJ
PLASMA-LYTE-148 2 INJ
potassium acetate 1 INJ
potassium chloride 1
potassium chloride cr 1
potassium chloride er 1
potassium chloride sr 1
potassium chloride/sodium 1 INJ
potassium phosphate 1 INJ
ringers injection 1 INJ
selenium 1 INJ
sodium bicarbonate 1 INJ
sod chloride inj 0.9% 1 INJ
sodium chloride 0.45% 1 INJ
sodium chloride flush 1 INJ
sodium fluoride 1
sodium phosphate 1 INJ
TPN ELECTROLYTES 3 INJ
TRACE ELEMENTS 4/PEDIATRI 2 INJ
virt-phos 250 neutral 1
ZINC SULFATE 2 INJ
Miscellaneous Therapeutic Classes
alprostadil 1 INJ
AMPHADASE 3 INJ
argyle sterile water 100m 1
ASTAGRAF XL 3 SP
ATGAM 2 INJ SP
AZASAN 3 SP
AZATHIOPRINE INJ 2 INJ SP
azathioprine 1
BENLYSTA 2 INJ SP
CELLCEPT 3 SP
CELLCEPT INTRAVENOUS 3 INJ SP
CUPRIMINE 3 SP
cyclosporine inj 1 INJ
cyclosporine 1
CYCLOSPORINE CAP 50MG MOD 2
cyclosporine cap 25mg mod 1
DEPEN TITRATABS 2 SP
DIANEAL LOW CALCIUM/1.5% 3 INJ
DIANEAL LOW CALCIUM/2.5% 3 INJ
DIANEAL LOW CALCIUM/4.25% 3 INJ
DIANEAL PD-2/1.5% DEXTROS 3 INJ
DIANEAL PD-2/2.5% DEXTROS 3 INJ
DIANEAL PD-2/4.25% DEXTRO 3 INJ
D-PENAMINE 2 SP
ENVARSUS XR 3 SP
EXTRANEAL 2 INJ
gengraf 1
HYLENEX 3 INJ
IMURAN 3
kionex 1
lactated ringers irrigati 1
LOKELMA 2
mycophenolate mofetil 1 SP
mycophenolate inj 1 INJ SP
mycophenolic acid dr 1 SP
MYFORTIC 3 SP
NEORAL 3
NEXAVIR 3 INJ
NULOJIX 2 INJ SP
penicillamine 1 SP
physiolyte 1
physiosol irrigation 1
PRISMASOL B22GK 4/0 3 INJ
PRISMASOL BGK 0/2.5 3 INJ
PRISMASOL BGK 2/0 3 INJ
PRISMASOL BGK 2/3.5 3 INJ
PRISMASOL BGK 4/2.5 3 INJ
PRISMASOL BK 0/0/1.2 3 INJ
PROGRAF CAP 3 SP
PROGRAF GRA 0.2MG 2 SP
PROGRAF INJ 2 INJ SP
PROSTIN VR PEDIATRIC 3 INJ
RAPAMUNE 3 SP
REVLIMID 2 SP
ringers irrigation 1
SANDIMMUNE INJ 3 INJ
SANDIMMUNE 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
39
SIMULECT 2 INJ SP
sirolimus 1 SP
sodium polystyrene sulfon 1
sps 1
sterile water irrigation 1
SYPRINE 3 SP
tacrolimus cap 1 SP
TRAUMANIL 3
trientine hydrochloride 1 SP
ULTRABAG/DIANEAL LOW CALC 3 INJ
ULTRABAG/DIANEAL PD-2/1.5 3 INJ
ULTRABAG/DIANEAL PD-2/2.5 3 INJ
ULTRABAG/DIANEAL PD-2/4.2 3 INJ
VELTASSA 3
VITRASE 3 INJ
XIAFLEX 2 INJ SP
ZORTRESS 2 SP
MOUTH/THROAT/DENTAL AGENTS
AQUORAL 3
ARESTIN 3
CAPHOSOL 3
cevimeline hcl 1
chlorhexidine gluconate 1
clinpro 5000 1
clotrimazole troche 10mg 1
DEBACTEROL 3
denta 5000 plus 1
dentagel 1
FIRST-MOUTHWASH BLM 2
lidocaine viscous 1
NAFRINSE DAILY/ACIDULATED 3
NAFRINSE DAILY/NEUTRAL 3
NAFRINSE WEEKLY 3
NEUTRASAL 3
NUMOISYN 3
nystatin susp 1
paroex 1
pilocarpine tab 1
pilocarpine hydrochloride 1
PREVIDENT 5000 BOOSTER PL 3
PREVIDENT 5000 DRY MOUTH 3
PREVIDENT 5000 ENAMEL PRO 3
PREVIDENT 5000 PLUS 3
PREVIDENT FLUORIDE 3
PREVIDENT RINSE 3
SALIVAMAX 3
sf 1
sf 5000 plus 1
topex topical anesthetic 1
triamcinolone acetonide d 1
XEROSTOMIA RELIEF SPRAY 3
MULTIVITAMINS
ADVANCED AM/PM 2
BACMIN 3
b-plex 1
b-plex plus 1
CITRANATAL ASSURE 3
CITRANATAL B-CALM 3
CITRANATAL BLOOM 3
CITRANATAL BLOOM DHA 3
CITRANATAL DHA 3
CITRANATAL HARMONY 3
CITRANATAL MEDLEY 3
CITRANATAL RX 3
C-NATE DHA 2
complete natal dha 1
completenate 1
co-natal fa 1
CONCEPT DHA 3
CORVITA 3
dialyvite 1
DIALYVITE 3000 3
DIALYVITE 5000 3
DIALYVITE SUPREME D 3
DIALYVITE/ZINC 2
DUET DHA BALANCED 3
elite-ob 1
ENBRACE HR 3
FLORIVA PLUS 3
folbee plus 1
FOLGARD OS 3
FOLIVANE-OB 2
hylavite 1
MARNATAL-F 3
M-NATAL PLUS 3
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
40
multivitamin with fluorid 1
MULTIVIT/FL CHW 0.5MG 3
MULTIVIT/FL CHW 0.25MG 2
multi-vitamin/fluoride dr 1
multi-vitamin/fluoride/ir 1
m-vit 1
NATELLE ONE 3
NEEVO DHA 3
NEPHRO-VITE RX 2
NESTABS ONE 3
NICOMIDE 3
OB COMPLETE 3
OB COMPLETE ONE 3
OB COMPLETE PETITE 3
OB COMPLETE/DHA 3
OBSTETRIX DHA 2
obstetrix ec 1
OBSTETRIX ONE 3
O-CAL FA 3
O-CAL PRENATAL 3
PNV PRENATAL TAB PLUS 2
PRENATAL PLS MIS MV + DHA 3
PNV TABS 29-1 2
pnv-dha 1
PNV-DHA+DOCUSATE 2
PNV-OMEGA 2
POLY-VI-FLOR 3
POLY-VI-FLOR FS 3
POLY-VI-FLOR/IRON 3
PRENA1 CHEW 2
PRENA1 PEARL 2
PRENATA 3
prenatabs rx 1
PRENATAL 2
prenatal 19 1
PRENATAL LOW IRON 3
PRENATAL PLUS IRON 2
PRENATAL PLUS/IRON 3
PRENATAL VITAMINS PLUS LO 2
PRENATAL-U 2
PRENATE 3
PRENATE DHA 3
PRENATE ELITE 3
PRENATE ENHANCE 3
PRENATE MINI 3
PRENATE PIXIE 3
PREPLUS 2
PROVIDA OB 3
QUFLORA FE 3
QUFLORA FE PEDIATRIC 3
QUFLORA GUMMIES 3
QUFLORA PEDIATRIC 3
RELNATE DHA 2
renal caps 1
reno caps 1
SELECT-OB 3
SELECT-OB+DHA 3
se-natal 19 1
SIDEROL 3
STROVITE FORTE 3
STROVITE ONE 3
SUPERVITE 3
SUPPORT 2
SUPPORT-500 3
TARON-BC 2
TARON-C DHA 2
TARON-PREX 2
THRIVITE RX 3
TL FOLATE 3
TL G-FOL OS 2
TL-CARE DHA 2
TL-FLUORIVITE 2
TL-SELECT 2
trinatal rx 1 1
triphrocaps 1
TRISTART DHA 3
TRISTART ONE 3
TRI-TABS DHA 2
TRIVEEN-DUO DHA 2
TRI-VI-FLOR 3
TRI-VI-FLORO 3
tri-vitamin/fluoride 1
ultimatecare one 1
v-c forte 1
VENA-BAL DHA 2
VINATE M 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
41
vinate one 1
virt-caps 1
VIRT-PN DHA 2
VITAFOL 3
VITAFOL FE+ 3
VITAFOL GUMMIES 3
VITAFOL STRIPS 3
VITAFOL ULTRA 3
VITAFOL-NANO 3
VITAFOL-OB 3
VITAFOL-OB+DHA 3
VITAFOL-ONE 3
VITAMEDMD ONE RX/QUATREFO 3
VITAMEDMD REDICHEW RX 3
vitamins a/c/d/fluoride 1
VITAPEARL 3
VITATRUE 3
vol-care rx 1
VOL-NATE 2
VOL-PLUS 2
VOL-TAB RX 2
VP-PNV-DHA 3
ZATEAN-PN DHA 2
ZATEAN-PN PLUS 2
MUSCULOSKELETAL THERAPY AGENTS
AMRIX 3 QL
baclofen 1
carisoprodol 1
carisoprodol/aspirin 1
chlorzoxazone 1
cyclobenzaprine hydrochlo 1 QL
dantrolene sodium 1
DUROLANE 3 INJ SP
EUFLEXXA 2 INJ SP
FIRST-BACLOFEN 5 2
GEL-ONE 3 INJ SP
HYALGAN 3 INJ SP
LORZONE 3
metaxalone 1
methocarbamol 1
methocarbamol inj 1 INJ
MONOVISC 2 INJ SP
orphenadrine citrate 1 INJ
orphenadrine citrate er 1
ORTHOVISC 2 INJ SP
revonto 1 INJ
ROBAXIN 3 INJ
SKELAXIN 3
SOMA 3
SUPARTZ FX 3 INJ SP
SYNVISC 3 INJ SP
SYNVISC ONE 3 INJ SP
tizanidine hcl 1
tizanidine hydrochloride 1
VISCO-3 3 INJ SP
ZANAFLEX 3
NASAL AGENTS - SYSTEMIC AND TOPICAL
ASTEPRO 3
azelastine spray 1
BECONASE AQ 3 ST
DYMISTA 2 ST
flunisolide 1
fluticasone spr 50mcg 1
ipratropium spray 1
mometasone spr 50mcg 1
NASONEX 3
olopatadine spr 0.6% 1
OMNARIS 3 ST
PATANASE 3
QNASL 2 ST
QNASL CHILDRENS 2 ST
SINUVA 3 SP
XHANCE 3
ZETONNA 3 ST
NEUROMUSCULAR AGENTS
ANECTINE 3 INJ
atracurium besylate 1 INJ
BOTOX 2 INJ SP
cisatracurium besylate 1 INJ
DYSPORT 3 INJ SP
MYOBLOC 2 INJ SP
NIMBEX 3 INJ
pancuronium bromide 1 INJ
QUELICIN 3 INJ
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
42
riluzole 1 SP
rocuronium bromide 1 INJ
SPINRAZA 2 INJ SP
vecuronium bromide 1 INJ
XEOMIN 3 INJ SP
OPHTHALMIC AGENTS
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ak-poly-bac 1
AKTEN 3
ALCAINE 3
ALOCRIL 3
ALOMIDE 3 ST
ALPHAGAN P SOL 0.15% 3
ALPHAGAN P SOL 0.1% 2
ALREX 2
apraclonidine 1
atropine sul sol 1% op 1
AZASITE 2
azelastine dro 0.05% 1
AZOPT 3
BACITRACIN OIN OP 2
bacitracin/polymyxin b 1
balanced salt solution 1 INJ
BEOVU 3 SP
BEPREVE 2 ST
BESIVANCE 3
BETADINE OPHTHALMIC PREP 3
betaxolol sol 0.5% op 1
BETIMOL 3
BETOPTIC-S 3
bimatoprost 1
BLEPH-10 3
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
brimonidine tartrate 1
bromfenac 1
BROMSITE 3
BSS 3 INJ
carteolol hcl 1
CEQUA 3
CILOXAN 3
ciprofloxacn sol 0.3% op 1
COMBIGAN 2
COSOPT 3
COSOPT PF 3
cromolyn sodium 1
CYCLOGYL 3
CYCLOMYDRIL 3
cyclopentolate hcl 1
cyclopentolate hydrochlor 1
dexamethasone pho sol 0.1% op 1
diclofenac sol 0.1% op 1
dorzolamide hcl 1
dorzolamide hcl/timolol m 1
dorzolamide hydrochloride 1
DUREZOL 3
epinastine hcl 1
erythromycin oin 5mg/gm 1
EYLEA 2 SP
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 3
FML FORTE 3
FML LIQUIFILM 3
gatifloxacin 1
GELFILM OP 3
GENTAK 2
gentamicin sol 0.3% op 1
HEALON 3 INJ
HEALON GV 3 INJ
HEALON5 3 INJ
homatropine hbr 1
ILEVRO 2
INVELTYS 2
IOPIDINE 3
ISOPTO ATROPINE 3
ISOPTO CARPINE 3
ISTALOL 3
JETREA 2 SP
ketorolac sol 0.5% 1
LACRISERT 3
LASTACAFT 3 ST
latanoprost 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
43
levobunolol hcl 1
levofloxacin sol 0.5% 1
LOTEMAX 2
LOTEMAX SM 2
loteprednol etabonate 1
LUMIGAN 2 ST
MAXIDEX 3
MAXITROL 3
MIOCHOL-E 3 INJ
MIOSTAT 2 INJ
MOXEZA 3
moxifloxacin sol 1
NATACYN 2
neomycin/bacitracin/polym 1
neomycin/polymyxin/bacitr 1
neomycin/polymyxin/dexame 1
neomycin/polymyxin/gramic 1
neo/poly/hc sus op 1
neo-polycin 1
neo-polycin hc 1
NEVANAC 3
OCUFLOX 3
ofloxacin dro 0.3% op 1
olopatadine dro 0.1% 1
olopatadine hydrochloride 1
OZURDEX 2 SP
PATADAY 3
PATANOL 3
PAZEO 2 ST
phenylephrin sol 2.5% op 1
PHOSPHOLINE IODIDE 2
PHOTREXA VISCOUS 3
PHOTREXA/PHOTREXA VISCOUS 3 SP
pilocarpine sol 1% op 1
polycin 1
polymyxin b sulfate/trime 1
POLYTRIM 3
PRED FORTE 3
PRED MILD 3
PRED-G 3
PRED-G S.O.P. 3
prednisolone acetate 1
pred sod pho sol 1% op 1
PROLENSA 2
proparacaine hcl 1
PROVISC 3 INJ
RESTASIS MULTIDOSE 2
RETISERT 3 SP
RHOPRESSA 2
ROCKLATAN 3
SIMBRINZA 3
sodium sulfacetamide 1
SULFACET SOD OIN 10% OP 2
sulfacet sod sol 10% op 1
sulfacetamide sodium/pred 1
tetracaine hydrochloride 1
timolol sol 0.5% op 1
TIMOLOL MALEATE OPHTHALMI 3
TIMOPTIC 3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE 3
TOBRADEX SUS 0.3-0.1% 3
TOBRADEX OIN 0.3-0.1% 2
TOBRADEX ST 2
tobramycin sol 0.3% op 1
tobramycin/dexamethasone 1
TOBREX 3
TRAVATAN Z 2 ST
TRIESENCE 3 INJ
trifluridine 1
trimethoprim sulfate/poly 1
TRUSOPT 3
VIGAMOX 3
VISUDYNE 2 INJ SP
VYZULTA 3
XALATAN 3
XIIDRA 2
ZIOPTAN 3 ST
ZIRGAN 3
ZYLET 2
ZYMAXID 3
OTIC AGENTS
acetic acid 1
CIPRO HC 3
CIPRODEX 2
CIPROFLOXACIN 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
44
COLY-MYCIN S 3
cortic-nd 1
CORTISPORIN-TC 3
DERMOTIC 3
exotic-hc 1
fluocinolone acetonide 1
hydrocortisone/acetic aci 1
neomycin/polymyxin/hc 1
neo/poly/hc sus 1% otic 1
ofloxacin dro 0.3%otic 1
OTOVEL 2
Oxytocics
HEMABATE 2 INJ
methergine 1
methylergonovine maleate 1
methylergon inj 0.2mg/ml 1 INJ
PREPIDIL 3
PROSTIN E2 3
PASSIVE IMMUNIZING AND TREATMENT AGENTS
ANTIVENIN LATRODECTUS MAC 3 INJ
ANTIVENIN NORTH AMERICAN 3 INJ
CUTAQUIG 3 INJ SP
CUVITRU 3 INJ SP
FLEBOGAMMA DIF 3 INJ SP
GAMASTAN 2 INJ SP
GAMASTAN S/D 2 INJ SP
GAMMAGARD LIQUID 2 INJ SP
GAMMAGARD S/D IGA LESS TH 2 INJ SP
GAMMAKED 3 INJ SP
GAMUNEX-C 2 INJ SP
HIZENTRA 2 INJ SP
HYPERHEP B S/D 2 INJ SP
HYPERRAB 2 INJ SP
HYPERRAB S/D 2 INJ SP
HYPERRHO S/D 2 INJ SP
HYPERRHO S/D MINI-DOSE 2 INJ SP
HYPERTET S/D 2 INJ SP
HYQVIA 3 INJ SP
IMOGAM RABIES-HT 2 INJ SP
MICRHOGAM ULTRA-FILTERED 3 INJ SP
PANZYGA 3 INJ SP
PRIVIGEN 2 INJ SP
RHOGAM ULTRA-FILTERED PLU 3 INJ SP
SYNAGIS 2 INJ SP
XEMBIFY 3 INJ SP
ZINPLAVA 3 INJ
PENICILLINS
amoxicillin 1
amoxicillin/clavulanate p 1
ampicillin 1
ampicillin sodium 1 INJ
ampicillin-sulbactam 1 INJ
BICILLIN L-A 2 INJ
dicloxacillin sodium 1
NAFCILLIN 2 INJ
nafcillin sodium 1 INJ
OXACILLIN 2 INJ
oxacillin sodium 1 INJ
penicillin g potassium 1 INJ
PENICILLIN G POTASSIUM IN 2 INJ
penicillin g sodium 1 INJ
penicillin v potassium 1
PFIZERPEN 2 INJ
piperacillin sodium/tazob 1 INJ
piperacillin/tazobactam 1 INJ
UNASYN 3 INJ
UNASYN BULK PACK 3 INJ
Progestins
hydroxyprogesterone capro 1 INJ SP
MAKENA 3 INJ SP
medroxyprogesterone tab 1
norethindrone acetate 1
progesterone 1 INJ
progesterone cap 100mg 1
PROGESTERONE COMPOUNDING 3
PROMETRIUM 3
PROVERA 3
Psychotherapeutic and Neurological Agents - Misc.
acamprosate calcium dr 1
ADDYI 3 SP
AMPYRA 3 SP
ANTABUSE 3
AUBAGIO 3 SP
AUSTEDO 2 SP
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
45
AVONEX 2 INJ SP
AVONEX PEN 2 INJ SP
BETASERON 2 INJ SP
BRISDELLE 3
CHANTIX 2 QL
CHANTIX CONTINUING MONTH 2 QL
CHANTIX STARTING MONTH PA 2 QL
chlordiazepoxide/amitript 1
COPAXONE 2 INJ SP
dalfampridine er 1 SP
disulfiram 1
donepezil hcl 1
donepezil hydrochloride 1
donepezil hydrochloride o 1
EXELON 3
EXTAVIA 3 INJ SP
galantamine hydrobromide 1
GILENYA 2 SP
glatiramer acetate 1 INJ SP
glatopa 1 INJ SP
GRALISE 3 ST
GRALISE STARTER 3 ST
HORIZANT 3 ST
INGREZZA 3 SP
LUCEMYRA 2 SP
LYRICA CR 3 ST
MAYZENT 2 SP
memantine hcl titration p 1
memantine hydrochloride 1
memantine hydrochloride e 1
NAMENDA 3
NAMENDA TITRATION PAK 3
NAMENDA XR 3
NAMENDA XR TITRATION PACK 3
NAMZARIC 2
NICOTROL INHALER 3
NICOTROL NS 3
NUEDEXTA 2
OCREVUS 2 INJ SP
olanzapine/fluoxetine 1
paroxetine 1
perphenazine/amitriptylin 1
pimozide 1
PLEGRIDY 2 INJ SP
PLEGRIDY STARTER PACK 2 INJ SP
REBIF 2 INJ SP
REBIF REBIDOSE 2 INJ SP
rivastigmine tartrate 1
rivastigmine transdermal 1
SARAFEM 3
SAVELLA 2
SAVELLA TITRATION PACK 2
SYMBYAX 3
TECFIDERA 2 SP
TECFIDERA STARTER PACK 2 SP
tetrabenazine 1 SP
TYSABRI 2 INJ SP
XENAZINE 3 SP
XYREM 2 SP
Respiratory Agents - Misc.
ARALAST NP 2 INJ SP
CUROSURF 3
ESBRIET 2 SP
GLASSIA 2 INJ SP
KALYDECO 2 SP
OFEV 2 SP
ORKAMBI 2 SP
PROLASTIN-C 2 INJ SP
PULMOZYME 2 SP
SURVANTA INTRATRACHEAL 3
SYMDEKO 2 SP
ZEMAIRA 2 INJ SP
Sulfonamides
sulfadiazine 1
Tetracyclines
ACTICLATE 3
demeclocycline hcl 1
DORYX MPC 3
doxycycline sus 25mg/5ml 1
doxycycline hyclate 1
DOXYCYCLINE HYC TAB 50MG 3
doxycycline hyclate dr 1
doxycycline monohydrate 1
MINOCIN 3
minocycline hcl 1
minocycline hcl er 1
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
46
minocycline hydrochloride 1
MINOLIRA 3
okebo 1
SEYSARA 3
SOLODYN 3
TARGADOX 3
tetracycline hydrochlorid 1
TYGACIL 3 INJ
VIBRAMYCIN 3
XIMINO 3
THYROID AGENTS
ARMOUR THYROID 2
CYTOMEL 3
euthyrox 1
levothyroxine sodium 1
levothyroxine/liothyronin 1
levoxyl 1
liothyronine sodium 1
methimazole 1
NATURE-THROID 2
np thyroid 120 1
np thyroid 15 1
np thyroid 30 1
np thyroid 60 1
np thyroid 90 1
propylthiouracil 1
SYNTHROID 3
TIROSINT 3
TIROSINT-SOL 3
unithroid 1
WP THYROID 3
Toxoids
ADACEL 2 INJ
BOOSTRIX 2 INJ
PENTACEL 2 INJ
TDVAX 2 INJ
TENIVAC 3 INJ
ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS
ACIPHEX 3 QL
ACIPHEX SPRINKLE 3 QL ST
ANASPAZ 2
ATROPEN 3 INJ
BELLA/OPIUM SUP 16.2-60 3
belladonna/opium 1
CARAFATE SUS 1GM/10ML 2
CARAFATE TAB 1GM 3
chlordiazepoxide hcl/clid 1
cimetidine 1
cimetidine hcl 1
CUVPOSA 3
CYTOTEC 3
DEXILANT 3 QL ST
dicyclomine hcl 1 INJ
dicyclomine sol 10mg/5ml 1
dicyclomine hydrochloride 1
DONNATAL 3
ed-spaz 1
esomeprazole magnesium 1 QL
esomeprazole sodium 1 INJ
famotidine 1
famotidine inj 1 INJ
famotidine premixed 1 INJ
FIRST-LANSOPRAZOLE 2 QL
FIRST-OMEPRAZOLE 2 QL
GLYCATE 3
glycopyrrolate inj 0.2mg/ml 1 INJ
glycopyrrolate tab 1mg 1
hyoscyamine tab 0.125mg 1
hyoscyamine sub 0.125mg 1
hyoscyamine sulfate er 1
hyosyne 1
lansoprazole 1 QL
lansoprazole odt 1 QL
lansoprazole/amoxicillin/ 1
LEVSIN 2 INJ
LIBRAX 3
methscopolamine bromide 1
misoprostol 1
NEXIUM GRA DR 2 QL ST
NEXIUM CAP 20MG 3 QL
NEXIUM I.V. 3 INJ
nizatidine 1
NIZATIDINE SOL 15MG/ML 2
omeprazole 1 QL
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
47
omeprazole dr 1 QL
omeprazole/sodium bicarbo 1
oscimin sub 0.125mg 1
oscimin tab 0.125mg 1
oscimin sr 1
pantoprazole inj sod 40mg 1 INJ QL
pantoprazole tab 40mg 1 QL
pantoprazole sodium dr 1 QL
PEPCID 3
phenobarbital/belladonna 1
phenohytro 1
PREVACID 3 QL
PREVACID SOLUTAB 3 QL
PRILOSEC 3
propantheline bromide 1
PROTONIX 3 QL
PYLERA 2
rabeprazole sodium 1 QL
ranitidine hcl 1
ranitidine hydrochloride 1
sucralfate tab 1gm 1
SUCRALFATE SUS 1GM/10ML 2
SYMAX DUOTAB 3
ZEGERID 3
Urinary Anti-infectives
HIPREX 3
HYOPHEN 2
MACROBID 3
me/naphos/mb/hyo 1 1
methenamine hippurate 1
methenamine mandelate 1
MONUROL 3
nitrofurantoin 1
nitrofurantoin macrocryst 1
nitrofurantoin monohydrat 1
phosphasal 1
urelle 1
uretron d/s 1
uribel 1
URIMAR-T 2
uro-458 1
UROGESIC-BLUE 2
uro-mp 1
ustell 1
vilamit mb 1
Urinary Antispasmodics
bethanechol chloride 1
darifenacin hydrobromide 1 QL
DETROL 3 QL
DETROL LA 3 QL
ENABLEX 3 QL
flavoxate hcl 1
GELNIQUE 2
MYRBETRIQ 2
oxybutynin chloride 1
oxybutynin chloride er 1 QL
OXYTROL 3
solifenacin succinate 1 QL
tolterodine tartrate 1 QL
tolterodine tartrate er 1 QL
TOVIAZ 2 QL
trospium chloride 1 QL
trospium chloride er 1 QL
VESICARE 2 QL
VACCINES
AFLURIA QUADRIVALENT 2019 2 INJ
BEXSERO 2 INJ
ENGERIX-B 2 INJ
FLUAD 2019-2020 2 INJ
FLUARIX QUADRIVALENT 2019 2 INJ
FLUBLOK QUADRIVALENT 2019 2 INJ
FLUCELVAX QUADRIVALENT 20 2 INJ
FLULAVAL QUADRIVALENT 201 2 INJ
FLUZONE HIGH-DOSE PF 2019 2 INJ
FLUZONE QUADRIVALENT 2019 2 INJ
GARDASIL 9 2 INJ
HAVRIX 2
HEPLISAV-B 3
IMOVAX RABIES (H.D.C.V.) 2
IPOL INACTIVATED IPV 2
IXIARO 2
MENACTRA 2
MENVEO 3
M-M-R II 2
PEDVAX HIB 2
PNEUMOVAX 23 2
Drug Name Drug Tier Limits Drug Name Drug Tier Limits
Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program
Lower Case = generic drug INJ Injectable ST Step Therapy
48
PREVNAR 13 2
PROQUAD 2
RECOMBIVAX HB 2
ROTATEQ 2
SHINGRIX 2
STAMARIL 2
TRUMENBA 2
TWINRIX 2
TYPHIM VI 2
VAQTA 3
VARIVAX 2
VAXCHORA 2
VIVOTIF 2
ZOSTAVAX 3
VAGINAL AND RELATED PRODUCTS
AVC 3
clindamycin cre 2% vag 1
CLINDESSE 3
clotrimazole vag cre 2% 1
CRINONE 2
ENDOMETRIN 3
ESTRACE VAG CRE 0.01% 3
estradiol vag tab 1
ESTRING 2
FEM PH 2
FEMRING 3
FIRST-PROGESTERONE VGS 20 3
GYNAZOLE-1 3
IMVEXXY MAINTENANCE PACK 3
IMVEXXY STARTER PACK 3
INTRAROSA 3
metronidazole vaginal 1
MICONAZOLE 3 2
NUVESSA 3
terconazole 1
TRIMO-SAN 2
VAGIFEM 3
vandazole 1
yuvafem 1
Vasopressors
AUVI-Q 3 SP
dobutamine hcl 1
dobutamine hcl/d5w 1
dobutamine hydrochloride/ 1
dobutamine/dextrose 5% 1
dopamine hcl 1
dopamine hydrochloride/de 1
dopamine/d5w 1
EPIPEN 2-PAK 2
EPIPEN-JR 2-PAK 2
EPISNAP 3
LEVOPHED 3
midodrine hcl 1
midodrine hydrochloride 1
norepinephrine bitartrate 1
NORTHERA 3 SP
SYMJEPI 2
VITAMINS
DRISDOL 3
ergocalciferol 1
MEPHYTON 3
phytonadione 1
POTABA 3
vitamin d 1
vitamin k1 1
49
A
abacavir ____________ 19
abacavir sulfate/lamivudi
_________________ 19
ABILIFY _____________ 18
ABILIFY MAINTENA ___ 18
abiraterone acetate ___ 15
ABSORICA __________ 25
acamprosate calcium dr 44
ACANYA ____________ 25
acarbose ____________ 10
ACCUPRIL ___________ 13
ACCURETIC __________ 13
acebutolol hcl ________ 20
acebutolol hydrochloride
_________________ 20
acetaminophen/caffeine/di
__________________ 4
acetaminophen/codeine 4
acetazolamide _______ 30
acetazolamide er _____ 30
acetazolamide sodium _ 30
acetic acid________ 33, 43
acetic acid 0.25% _____ 33
acetylcysteine _______ 11
acetylcystine sol _____ 24
ACIPHEX ____________ 46
ACIPHEX SPRINKLE ___ 46
acitretin ____________ 25
ACTEMRA ____________ 3
ACTEMRA ACTPEN _____ 3
ACTHAR ____________ 31
ACTICLATE __________ 45
ACTIGALL ___________ 32
ACTIVE FE ___________ 34
ACTONEL ___________ 31
ACUICYN DAILY EYELID &
EY _______________ 25
ACULAR ____________ 42
ACULAR LS __________ 42
ACUVAIL ____________ 42
acyclovir _________ 19, 25
acyclovir cream _____ 25
ACZONE ____________ 25
ADACEL_____________ 46
adapalene gel 0.1% __ 25
ADAPALENE SOL 0.1% 25
adapalene pump _____ 25
adapalene/benzoyl peroxid
_________________ 25
ADASUVE ___________ 18
ADDERALL ___________ 3
ADDERALL XR _________ 3
ADDYI ______________ 44
ADEMPAS ___________ 21
ADENOCARD _________ 7
adenosine ____________ 7
ADHANSIA XR _________ 3
ADHD/ANTI-
NARCOLEPSY/ANTI-
OBESITY/ANOREXIANTS
__________________ 3
ADIPEX-P ____________ 3
ADLYXIN ____________ 10
ADLYXIN STARTER PACK 10
ADMELOG ___________ 10
ADMELOG SOLOSTAR _ 10
ADRIAMYCIN ________ 15
adrucil ______________ 15
ADVAIR DISKUS _______ 7
ADVAIR HFA __________ 7
ADVANCED AM/PM ___ 39
ADVATE ____________ 34
ADYNOVATE _________ 34
ADZENYS ER __________ 3
ADZENYS XR-ODT ______ 3
AFINITOR ___________ 15
AFINITOR DISPERZ ____ 15
AFLURIA QUADRIVALENT
2019 _____________ 47
AFREZZA ____________ 10
AGGRASTAT _________ 34
AGGRENOX __________ 34
agoneaze____________ 25
AIMOVIG ___________ 36
airavite _____________ 34
AIRDUO RESPICLICK
113/14 ____________ 7
AJOVY ______________ 36
AKLIEF ______________ 25
ak-poly-bac __________ 42
AKTEN ______________ 42
AKTIPAK ____________ 25
AKYNZEO ___________ 12
ALA SCALP __________ 25
ALA-QUIN ___________ 25
albendazole __________ 6
albuterol neb ________ 7
albuterol tab ________ 7
albuterol sulfate er _____ 7
ALBUTEROL SULFATE HFA 7
ALCAINE ____________ 42
alclometasone dipropionat
_________________ 25
ALCORTIN A _________ 25
ALDACTAZIDE ________ 30
ALDACTONE _________ 30
ALECENSA ___________ 15
ALENDRONATE TAB 40MG
_________________ 31
alendronate sodium ___ 31
alfentanil _____________ 4
ALFENTANIL HCL ______ 4
alfuzosin hcl er _______ 33
ALIMTA _____________ 15
ALINIA ______________ 14
aliskiren _____________ 13
ALLEVYN GENTLE _____ 25
allopurinol ___________ 33
allopurinol sodium ____ 33
almotriptan __________ 36
almotriptan malate ____ 36
ALOCRIL ____________ 42
ALOGLIPTIN _________ 10
ALOGLIPTIN/METFORMIN
HCL ______________ 10
ALOGLIPTIN/PIOGLITAZON
E ________________ 10
ALOMIDE____________ 42
ALORA ______________ 32
alosetron hydrochloride 32
ALPHAGAN P SOL 0.1% 42
ALPHAGAN P SOL 0.15%
_________________ 42
alprazolam ___________ 6
alprazolam er _________ 6
ALPRAZOLAM INTENSOL 6
alprazolam odt ________ 6
alprazolam xr _________ 6
alprostadil ___________ 38
ALREX ______________ 42
ALTABAX ____________ 25
altavera _____________ 22
ALTRENO ____________ 25
ALVESCO _____________ 7
alyacen 1/35 _________ 22
alyacen 7/7/7 ________ 22
alyq ________________ 21
amabelz _____________ 32
amantadine hcl _______ 18
AMARYL ____________ 10
AMBIEN _____________ 35
AMBIEN CR __________ 35
AMBISOME __________ 12
ambrisentan _________ 21
amcinonide __________ 25
Amebicides ___________ 3
AMERGE ____________ 36
amethia _____________ 22
amethia lo ___________ 22
amethyst ____________ 22
AMICAR _____________ 35
AMIDATE____________ 33
amikacin sulfate _______ 3
amiloride hcl _________ 30
amiloride/hydrochlorothia
_________________ 30
aminoacetic acid ______ 33
aminocaproic acid _____ 35
Aminoglycosides ______ 3
aminophylline _________ 7
amiodarone inj _______ 7
amiodarone hcl ________ 7
amiodarone hydrochloride
__________________ 7
AMITIZA ____________ 32
amitriptyline hcl _______ 9
amitriptyline hydrochlori 9
amlodipine besylate 13, 21
amlodipine besylate/atorv
_________________ 21
amlodipine besylate/benaz
_________________ 13
amlodipine besylate/valsa
_________________ 13
amlodipine/olmesartan
med ______________ 13
amlodipine/valsartan/hctz
_________________ 13
amlodipine/valsartan/hydr
_________________ 13
ammonium lactate ____ 25
AMMONUL __________ 31
amnesteem __________ 25
amoxapine ____________ 9
amoxicillin ___________ 44
amoxicillin/clavulanate p 44
AMPHADASE _________ 38
amphetamine sulfate ___ 3
amphetamine/dextroamph
eta ________________ 3
amphotericin b _______ 12
ampicillin ____________ 44
ampicillin sodium _____ 44
ampicillin-sulbactam ___ 44
AMPYRA ____________ 44
AMRIX ______________ 41
AMYTAL SODIUM _____ 35
ANACAINE ___________ 25
ANAFRANIL ___________ 9
anagrelide hydrochloride
_________________ 34
ANALGESICS - ANTI-
INFLAMMATORY ____ 3
ANALGESICS - NonNarcotic
__________________ 4
ANALGESICS - OPIOID ___ 4
ANALPRAM HC ________ 6
ANALPRAM-HC ________ 6
ANASPAZ ____________ 46
anastrozole __________ 15
ANCOBON ___________ 12
ANDRODERM _________ 6
ANDROGEL ___________ 6
ANDROGEL PUMP______ 6
ANDROGENS-ANABOLIC 6
ANECTINE ___________ 41
ANGELIQ ____________ 32
ANIMI-3 _____________ 34
ANORECTAL AGENTS ___ 6
ANORO ELLIPTA _______ 7
50
ANTABUSE __________ 44
ANTARA ____________ 13
Anthelmintics ________ 6
ANTIANGINAL AGENTS _ 6
ANTIANXIETY AGENTS__ 6
ANTIARRHYTHMICS ____ 7
ANTIASTHMATIC AND
BRONCHODILATOR
AGENTS ___________ 7
ANTICOAGULANTS ____ 8
ANTICONVULSANTS ___ 8
ANTIDEPRESSANTS ____ 9
ANTIDIABETICS ______ 10
ANTIDIARRHEAL/PROBIOT
IC AGENTS ________ 11
Antidotes and Specific
Antagonists _______ 11
ANTIEMETICS ________ 12
Antifungals __________ 12
ANTIHISTAMINES ____ 12
ANTIHYPERLIPIDEMICS 13
ANTIHYPERTENSIVES __ 13
Anti-infective Agents -
Misc. ____________ 14
Antimalarials ________ 15
Antimyasthenic/Cholinergi
c Agents __________ 15
Antimycobacterial Agents
_________________ 15
ANTINEOPLASTICS AND
ADJUNCTIVE
THERAPIES _______ 15
ANTIPARKINSON AND
RELATED THERAPY
AGENTS __________ 18
ANTIPSYCHOTICS/ANTIMA
NIC AGENTS ______ 18
Antiseptics & Disinfectants
_________________ 19
ANTIVENIN LATRODECTUS
MAC _____________ 44
ANTIVENIN NORTH
AMERICAN _______ 44
ANTIVIRALS _________ 19
anucort-hc ___________ 6
anusol-hc ____________ 6
ANZEMET ___________ 12
APADAZ _____________ 5
APEXICON E _________ 25
APIDRA _____________ 10
APIDRA SOLOSTAR ___ 10
APLENZIN ____________ 9
APOKYN ____________ 18
apraclonidine ________ 42
aprepitant __________ 12
apri ________________ 22
APRISO _____________ 32
APTENSIO XR _________ 3
APTIOM _____________ 8
APTIVUS ____________ 19
AQUORAL ___________ 39
ARALAST NP _________ 45
aranelle _____________ 22
ARANESP ALBUMIN FREE
_________________ 34
ARAVA ______________ 3
ARESTIN ____________ 39
argyle sterile saline 100 33
argyle sterile water 100m
_________________ 38
ARIMIDEX ___________ 15
aripiprazole __________ 18
aripiprazole odt ______ 18
ARISTADA ___________ 18
ARISTADA INITIO _____ 18
armodafinil ___________ 3
ARMOUR THYROID ___ 46
ARNUITY ELLIPTA ______ 7
AROMASIN __________ 15
ARRANON ___________ 16
arsenic trioxide _______ 16
ARTHROTEC 50 ________ 3
ARTHROTEC 75 ________ 3
ARZERRA____________ 16
arzol silver nitrate app _ 25
ASACOL HD __________ 32
ascomp/codeine _______ 5
ashlyna _____________ 22
ASMANEX HFA ________ 7
ASMANEX TWISTHALER
120 ME ____________ 7
ASMANEX TWISTHALER 7
METE _____________ 7
aspirin/dipyridamole er 34
ASTAGRAF XL ________ 38
ASTEPRO ____________ 41
ATACAND ___________ 13
atazanavir sulfate _____ 19
ATELVIA ____________ 31
atenolol __________ 13, 20
atenolol/chlorthalidone 13
ATGAM _____________ 38
ATIVAN ______________ 6
ATIVAN INJ 2MG/ML 6
atomoxetine __________ 3
atomoxetine hydrochloride
__________________ 3
ATOPADERM ________ 25
atorvastatin calcium ___ 13
atovaquone ______ 14, 15
atovaquone/proguanil hcl
_________________ 15
atracurium besylate ___ 41
ATRALIN ____________ 25
ATRAPRO ANTIPRURITIC
HYDR ____________ 25
ATRAPRO CP _________ 25
ATRAPRO DERMAL SPRAY
_________________ 25
ATRIPLA ____________ 19
ATROPEN ___________ 46
atropine sul sol 1% op _ 42
ATROVENT HFA _______ 7
AUBAGIO ___________ 44
aubra _______________ 22
aubra eq ____________ 22
augmented
betamethasone d ___ 25
aurovela 1/20 ________ 22
aurovela 24 fe ________ 22
AURYXIA ____________ 32
AUSTEDO ___________ 44
AUVI-Q _____________ 48
AVAGE ______________ 25
AVALIDE ____________ 13
AVANDIA____________ 10
AVAPRO ____________ 13
AVAR _______________ 25
avar cleanser _________ 25
AVAR LS ____________ 25
AVAR LS CLEANSER ___ 25
avar-e green _________ 25
AVAR-E LS ___________ 25
AVASTIN ____________ 16
AVC ________________ 48
AVEED _______________ 6
AVENOVA ___________ 25
aviane ______________ 22
avita ________________ 25
AVODART ___________ 33
AVONEX ____________ 45
AVONEX PEN ________ 45
AVYCAZ _____________ 21
azacitidine ___________ 16
AZACTAM ___________ 14
AZASAN _____________ 38
AZASITE _____________ 42
azathioprine _________ 38
AZATHIOPRINE INJ ____ 38
azelaic acid __________ 25
azelastine dro 0.05% __ 42
azelastine spray _____ 41
AZELEX _____________ 25
AZILECT _____________ 18
azithromycin _________ 36
AZITHROMYCIN POW 1GM
PAK ______________ 36
AZOPT ______________ 42
AZOR _______________ 13
AZULFIDINE __________ 32
AZULFIDINE EN-TABS __ 32
azurette _____________ 22
B
bacitracin ________ 14, 42
BACITRACIN OIN OP __ 42
bacitracin/polymyxin b _ 42
baclofen ____________ 41
BACMIN ____________ 39
BAL IN OIL ___________ 11
balanced salt solution __ 42
BALCOLTRA __________ 22
balsalazide disodium ___ 32
balziva ______________ 22
BANZEL ______________ 8
BAQSIMI ONE PACK ___ 10
BARACLUDE _________ 19
BARACLUDE SOL ____ 19
BASAGLAR KWIKPEN __ 10
BAXDELA ____________ 32
bd posiflush __________ 37
BEAU RX ____________ 25
BECONASE AQ ________ 41
BELBUCA _____________ 5
BELLA/OPIUM SUP 16.2-
60 _______________ 46
belladonna/opium ____ 46
BELSOMRA __________ 35
BELVIQ _______________ 3
BELVIQ XR ____________ 3
benazepril hcl ________ 13
benazepril hcl/hydrochlor
_________________ 13
benazepril hydrochloride13
benazepril hydrochloride/
_________________ 13
BENICAR ____________ 13
BENICAR HCT ________ 13
BENLYSTA ___________ 38
BENSAL HP __________ 25
BENZAC AC WASH ____ 25
BENZACLIN WITH PUMP 25
BENZAMYCIN ________ 25
benzepro foaming cloths 25
BENZHYDROCODONE/ACE
TAMINO ___________ 5
BENZIQ _____________ 25
BENZIQ LS ___________ 25
BENZIQ WASH ________ 25
BENZNIDAZOLE ________ 6
benzoin compound
tincture ___________ 25
benzonatate _________ 24
benzphetamine hcl _____ 3
benztropine inj 1mg/ml 18
benztropine mesylate __ 18
BEOVU ______________ 42
BEPREVE ____________ 42
BESIVANCE __________ 42
BESPONSA ___________ 16
BETA BLOCKERS ______ 20
BETADINE OPHTHALMIC
PREP _____________ 42
betamethasone
dipropionat ________ 25
betamethasone sodium
phos _____________ 24
betamethasone valerate 25
BETAPACE ___________ 20
51
BETASERON _________ 45
betaxolol sol 0.5% op 42
betaxolol tab _______ 20
bethanechol chloride __ 47
BETHKIS _____________ 3
BETIMOL ___________ 42
BETOPTIC-S _________ 42
BEVESPI AEROSPHERE __ 7
bexarotene __________ 16
BEXSERO ___________ 47
BEYAZ ______________ 22
bicalutamide ________ 16
BICILLIN L-A _________ 44
BICNU ______________ 16
BIDIL _______________ 21
BI-EST 50
50 COMPOUNDING 32
50 PROGESTERONE_ 32
BI-EST 80
20 PROGESTERONE_ 32
BIJUVA _____________ 32
BIKTARVY ___________ 19
bimatoprost ______ 25, 42
BINOSTO ___________ 31
bisoprolol fumarate 13, 20
bisoprolol fumarate/hydro
_________________ 13
bivalirudin ___________ 8
BIVALIRUDIN/SODIUM
CHLORI ___________ 8
bleomycin ___________ 16
bleomycin sulfate _____ 16
BLEPH-10 ___________ 42
BLEPHAMIDE ________ 42
BLEPHAMIDE S.O.P.___ 42
blisovi 24 fe _________ 22
blisovi fe 1.5/30 ______ 22
blisovi fe 1/20________ 22
BONIVA ____________ 31
BONJESTA __________ 12
BOOSTRIX___________ 46
bosentan ___________ 21
BOSULIF ____________ 16
BOTOX __________ 25, 41
BOTOX COSMETIC ____ 25
bp foam ____________ 25
bp wash ____________ 25
BPCO_______________ 25
b-plex ______________ 39
b-plex plus __________ 39
BRAFTOVI ___________ 16
BREO ELLIPTA_________ 7
BREVIBLOC __________ 20
BREVIBLOC PREMIXED 20
BREVIBLOC PREMIXED
DOUBLE __________ 20
BRIDION ____________ 11
briellyn _____________ 22
BRILINTA ___________ 34
brimonidine tartrate __ 42
BRISDELLE ___________ 45
BRIVIACT ____________ 8
bromfed dm _________ 24
bromfenac __________ 42
bromocriptine mesylate 18
bromphen/pseudoephedri
ne _______________ 25
BROMSITE __________ 42
BROVANA ____________ 7
BRYHALI ____________ 25
BSS ________________ 42
budesonide ________ 7, 24
budesonide sus _______ 7
budesonide er________ 24
bumetanide inj ______ 30
bumetanide tab _____ 30
BUMEX _____________ 30
BUNAVAIL____________ 5
bupap _______________ 4
bupivacaine hcl _______ 36
bupivacaine spinal ____ 36
bupivacaine/epinephrine
_________________ 36
BUPRENEX ___________ 5
BUPRENORPHIN DIS
7.5/HR ____________ 5
buprenorphin inj 0.3mg/ml
__________________ 5
buprenorphin sub 2mg _ 5
buprenorphine ________ 5
buprenorphine hcl/naloxon
__________________ 5
buprenorphine hydrochlori
__________________ 5
bupropion tab sr _____ 9
BUPROPION TAB 450MG
XL ________________ 9
bupropion hcl _________ 9
buspirone hcl _________ 6
buspirone hydrochloride 6
busulfan ____________ 16
but/asa/caf/ cap cod 30mg
__________________ 5
BUTAL/APAP CAP 50-
300MG ____________ 4
butal/apap tab 50-325mg
__________________ 4
butalbital/acetaminophen/
__________________ 4
BUTALBITAL/ASPIRIN/CAF
FEI _______________ 4
BUTISOL SODIUM ____ 35
butorphanol sol 10mg/ml 5
BUTORPHANOL TARTRATE
__________________ 5
BUTRANS ____________ 5
BYDUREON BCISE _____ 10
BYDUREON PEN ______ 10
BYETTA _____________ 10
BYSTOLIC ___________ 20
C
cabergoline __________ 31
CABOMETYX _________ 16
CADUET _____________ 21
CAFCIT _______________ 3
CAFERGOT___________ 36
caffeine cit inj 60mg/3ml 3
caffeine citrate ________ 3
CALAN ______________ 21
CALAN SR ___________ 21
CALCIFOL ____________ 37
calcipotriene _________ 25
calcipotriene/betamethaso
_________________ 25
calcitonin-salmon _____ 31
calcitriol __________ 25, 31
calcitriol inj _________ 31
calcitriol oin 3mcg/gm 25
calcium acetate _______ 32
Calcium Channel Blockers
_________________ 21
calcium chloride ______ 37
calcium gluconate _____ 37
CALQUENCE _________ 16
CAMBIA _____________ 36
camila ______________ 22
CAMINO PRO 15PE ____ 29
CAMINO PRO PKU ____ 29
CAMPTOSAR _________ 16
camrese _____________ 22
camrese lo ___________ 22
CANASA ____________ 32
CANCIDAS ___________ 12
candesartan cilexetil ___ 13
candesartan cilexetil/hyd
_________________ 13
CAPASTAT SULFATE ___ 15
capecitabine _________ 16
CAPEX ______________ 25
CAPHOSOL __________ 39
CAPRELSA ___________ 16
captopril ____________ 13
captopril/hydrochlorothia
_________________ 13
CARAC ______________ 25
CARAFATE SUS
1GM/10ML _______ 46
CARAFATE TAB 1GM_ 46
CARB/LEVO 50 TAB
/ENTACAP ________ 18
carb/levo100 tab /entacap
_________________ 18
carbamazepine ________ 8
carbamazepine er ______ 8
CARBATROL __________ 8
carbidopa ___________ 18
carbidopa/levodopa ___ 18
carbidopa/levodopa er _ 18
carbidopa/levodopa odt 18
carbinoxamine maleate 12
carboplatin __________ 16
CARDENE IV _________ 21
cardioplegic __________ 21
CARDIOTONICS _______ 21
CARDIOVASCULAR
AGENTS - MISC. ____ 21
CARDIZEM ___________ 21
CARDIZEM CD ________ 21
CARDIZEM LA ________ 21
CARDURA ________ 13, 33
CARDURA XL _________ 33
carisoprodol _________ 41
carisoprodol/aspirin ___ 41
CARNITOR ___________ 31
CARNITOR SF _________ 31
CAROSPIR ___________ 30
CARRASYN HYDROGEL
WOUND D ________ 25
carteolol hcl __________ 42
cartia xt _____________ 21
carvedilol ____________ 20
carvedilol phosphate___ 20
caspofungin acetate ___ 12
CATAPRES ___________ 13
CATAPRES-TTS-1 ______ 13
CATAPRES-TTS-2 ______ 13
CATAPRES-TTS-3 ______ 13
CAVERJECT __________ 21
CAVERJECT IMPULSE __ 21
CAYA _______________ 36
CAYSTON ____________ 14
caziant ______________ 22
cefaclor __________ 21, 22
CEFACLOR SUS 125/5ML
_________________ 22
cefaclor er ___________ 22
cefadroxil ____________ 22
cefdinir _____________ 22
cefepime ____________ 22
CEFEPIME/DEXTROSE __ 22
cefixime _____________ 22
cefotaxime sodium ____ 22
cefotetan ____________ 22
CEFOTETAN/DEXTROSE 22
cefoxitin sodium ______ 22
cefpodoxime proxetil __ 22
cefprozil _____________ 22
ceftazidime __________ 22
CEFTAZIDIME/DEXTROSE
_________________ 22
ceftriaxone in iso-osmoti 22
ceftriaxone sodium ____ 22
CEFTRIAXONE/DEXTROSE
_________________ 22
cefuroxime axetil______ 22
cefuroxime sodium ____ 22
celacyn ______________ 25
CELEBREX ____________ 3
celecoxib _____________ 4
52
CELESTONE-SOLUSPAN 24
CELEXA ______________ 9
CELLCEPT ___________ 38
CELLCEPT INTRAVENOUS
_________________ 38
CELONTIN ____________ 8
CENFOL _____________ 34
CENTRATEX _________ 34
cephalexin __________ 22
CEPHALEXIN TAB 250MG
_________________ 22
CEPHALOSPORINS ____ 21
CEPROTIN ___________ 34
CEQUA _____________ 42
CERACADE __________ 25
CERAMAX ___________ 26
CEREBYX _____________ 8
CEREFOLIN __________ 29
CEREFOLIN NAC ______ 29
CETACAINE __________ 26
cetirizine hydrochloride 12
CETROTIDE __________ 31
CETYLCIDE-G ________ 19
cevimeline hcl _______ 39
CHANTIX ____________ 45
CHANTIX CONTINUING
MONTH __________ 45
CHANTIX STARTING
MONTH PA _______ 45
chateal eq ___________ 22
CHEMET ____________ 11
chlordiazepoxide hcl 6, 46
chlordiazepoxide hcl/clid 46
chlordiazepoxide hydrochl
__________________ 6
chlordiazepoxide/amitript
_________________ 45
chlorhexidine gluconate 39
chloroprocaine hydrochlor
_________________ 36
chloroquine phosphate 15
chlorothiazide _______ 30
chlorothiazide sodium _ 30
CHLORPROMAZINE INJ 18
chlorpromazine hcl ___ 18
chlorthalidone _______ 30
chlorzoxazone _______ 41
cholestyramine ______ 13
cholestyramine light __ 13
chorionic gonadotropin 31
chromagen __________ 34
CIALIS ______________ 21
ciclopirox ___________ 26
ciclopirox nail lacquer _ 26
ciclopirox olamine ____ 26
ciclopirox treatment __ 26
cidofovir ____________ 19
cilostazol ____________ 34
CILOXAN ____________ 42
cimetidine __________ 46
cimetidine hcl ________ 46
CIMZIA _____________ 32
CIMZIA STARTER KIT __ 32
cinacalcet hydrochloride 31
CIPRO ___________ 32, 43
CIPRO HC ___________ 43
CIPRODEX ___________ 43
CIPROFLOXACIN ______ 43
ciprofloxacin hcl ______ 32
ciprofloxacin i.v.-in d5w 32
ciprofloxacn sol 0.3% op 42
cisatracurium besylate _ 41
cisplatin_____________ 16
citalopram hydrobromide 9
CITRANATAL ASSURE __ 39
CITRANATAL B-CALM __ 39
CITRANATAL BLOOM __ 39
CITRANATAL BLOOM DHA
_________________ 39
CITRANATAL DHA ____ 39
CITRANATAL HARMONY 39
CITRANATAL MEDLEY _ 39
CITRANATAL RX ______ 39
claravis _____________ 26
CLARINEX ________ 12, 25
CLARINEX-D 12 HOUR _ 25
clarithromycin _______ 36
clarithromycin er _____ 36
clemastine fumarate __ 12
CLENPIQ ____________ 36
CLEOCIN _________ 14, 26
CLEOCIN PEDIATRIC
GRANULE _________ 14
CLEOCIN PHOSPHATE _ 14
CLEOCIN-T __________ 26
CLEVIPREX __________ 21
CLIMARA____________ 32
CLIMARA PRO _______ 32
clindacin etz pledgets __ 26
CLINDACIN PAC ______ 26
CLINDAGEL __________ 26
clindamycin cre 2% vag 48
CLINDAMYCIN GEL 1% 26
clindamycin inj _______ 14
clindamycin sol 1% ___ 26
clindamycin hcl _______ 14
clindamycin palmitate hcl
_________________ 14
clindamycin phosphate in
_________________ 14
clindamycin
phosphate/ben ____ 26
clindamycin phosphate/tre
_________________ 26
clindamycin/benzoyl perox
_________________ 26
CLINDAMYCIN/SODIUM
CHLORI ___________ 15
CLINDESSE __________ 48
clinpro 5000 _________ 39
clobazam _____________ 8
clobetasol propionate _ 26
clobetasol propionate emo
_________________ 26
CLOBEX _____________ 26
CLOCORTOLONE PIVALATE
_________________ 26
CLODERM ___________ 26
clofarabine __________ 16
CLOLAR _____________ 16
clomiphene citrate ____ 31
clomipramine hcl ______ 9
clonazepam ___________ 8
clonazepam odt _______ 8
clonidine dis 0.1/24hr 13
clonidine inj _________ 4
clonidine tab 0.1mg __ 13
clonidine hcl er ________ 3
clonidine hydrochloride 13
clopidogrel __________ 34
clorazepate dipotassium 6
CLOROTEKAL _________ 36
clotrimazole anti-fungal 26
clotrimazole sol 1% ____ 26
clotrimazole troche 10mg
_________________ 39
clotrimazole vag cre 2% 48
clotrimazole/betamethaso
n ________________ 26
clozapine ____________ 18
CLOZAPINE TAB
150/ODT _________ 18
clozapine odt_________ 18
C-NATE DHA _________ 39
COARTEM ___________ 15
codeine sulfate ________ 5
COLCHICINE _________ 33
COLCRYS ____________ 33
colesevelam hydrochloride
_________________ 13
COLESTID ___________ 13
colestipol hcl _________ 13
colistimethate sodium _ 15
colocort ______________ 6
COLY-MYCIN S _______ 44
COLYTE-FLAVOR PACKS 36
COMBIGAN __________ 42
COMBIPATCH ________ 32
COMBIVENT RESPIMAT _ 7
COMPLERA __________ 19
complete natal dha ____ 39
completenate ________ 39
compro _____________ 18
COMTAN ____________ 18
co-natal fa ___________ 39
CONCEPT DHA _______ 39
CONCERTA ___________ 3
CONDYLOX __________ 26
constulose ___________ 36
CONTRACEPTIVES _____ 22
CONTRAST ALLERGY
PREMED P ________ 24
CONTRAVE ___________ 3
CONZIP ______________ 5
COPAXONE __________ 45
COPPER TRACE METAL _ 37
CORDRAN ___________ 26
COREG ______________ 20
COREG CR ___________ 20
CORGARD ___________ 20
CORLANOR __________ 21
CORLOPAM __________ 13
CORTEF _____________ 24
cortic-nd ____________ 44
CORTICOSTEROIDS ____ 24
CORTIFOAM __________ 6
CORTISONE ACETATE __ 24
CORTISPORIN-TC _____ 44
CORVERT _____________ 7
CORVITA ____________ 39
corvita 150___________ 34
CORVITE FE __________ 34
COSENTYX ___________ 26
COSENTYX SENSOREADY
PEN ______________ 26
COSOPT _____________ 42
COSOPT PF __________ 42
COTEMPLA XR-ODT ____ 3
COUGH/COLD/ALLERGY 24
COUMADIN ___________ 8
covaryx _____________ 32
covaryx hs ___________ 32
COZAAR _____________ 13
CREON ______________ 30
CRESEMBA __________ 12
CRESEMBA INJ ______ 12
CRESTOR ____________ 13
CRINONE ____________ 48
CRIXIVAN ____________ 19
cromolyn sod neb ______ 7
cromolyn sodium __ 32, 42
crotan ______________ 26
cryselle-28 ___________ 22
c-topical _____________ 26
CUPRIMINE __________ 38
CURITY HYPERTONIC
SODIUM __________ 26
CURITY SODIUM
CHLORIDE DR ______ 26
curity sterile saline ____ 33
CUROSURF __________ 45
CUTAQUIG ___________ 44
CUTIVATE ___________ 26
CUVITRU ____________ 44
CUVPOSA ___________ 46
cyanocobalamin ______ 34
CYANOKIT ___________ 11
cyclafem 1/35 ________ 22
cyclafem 7/7/7 _______ 22
53
cyclobenzaprine hydrochlo
_________________ 41
CYCLOGYL ___________ 42
CYCLOMYDRIL _______ 42
cyclopentolate hcl ____ 42
cyclopentolate hydrochlor
_________________ 42
cyclophosphamide ____ 16
CYCLOPHOSPHAMIDE CAP
25MG ____________ 16
cyclophosphamide inj _ 16
cycloserine __________ 15
CYCLOSET ___________ 10
cyclosporine _________ 38
cyclosporine cap 25mg
mod _____________ 38
CYCLOSPORINE CAP 50MG
MOD ____________ 38
cyclosporine inj ______ 38
CYKLOKAPRON ______ 35
CYMBALTA ___________ 9
cyproheptadine hcl ___ 12
cyproheptadine hydrochlor
_________________ 12
CYRAMZA ___________ 16
cyred _______________ 22
cyred eq ____________ 22
CYSTADANE _________ 31
CYSTAGON __________ 33
cytarabine __________ 16
CYTOMEL ___________ 46
CYTOTEC ____________ 46
D
dacarbazine _________ 16
dalfampridine er _____ 45
DALIRESP ____________ 7
danazol ______________ 6
dantrolene sodium____ 41
dapsone _________ 15, 26
dapsone gel 5% ____ 26
daptomycin _________ 15
darifenacin hydrobromide
_________________ 47
dasetta 1/35 _________ 22
dasetta 7/7/7 ________ 22
daunorubicin hcl _____ 16
DAUNORUBICIN
HYDROCHLORID ___ 16
DAURISMO __________ 16
DAYPRO _____________ 4
daysee _____________ 22
DAYTRANA ___________ 3
DEBACTEROL ________ 39
deblitane ___________ 22
decitabine___________ 16
deferoxamine mesylate 11
DELESTROGEN _______ 32
DELSTRIGO __________ 19
DELZICOL ___________ 32
demeclocycline hcl ____ 45
DEMEROL ____________ 5
DEMSER ____________ 13
DENAVIR ____________ 26
denta 5000 plus ______ 39
dentagel ____________ 39
DEPACON ____________ 8
DEPAKOTE ___________ 8
DEPAKOTE ER _________ 8
DEPAKOTE SPRINKLES __ 8
DEPEN TITRATABS ____ 38
DEPLIN 15 ___________ 29
DEPLIN 7.5 __________ 29
DEPO-ESTRADIOL _____ 32
DEPO-MEDROL _______ 24
DEPO-PROVERA ___ 16, 22
DEPO-PROVERA
CONTRACEPTIV ____ 22
DEPO-SUBQ PROVERA 104
_________________ 22
DEPO-TESTOSTERONE __ 6
DERMACINRX LEXITRAL
PHARM __________ 26
DERMACINRX PHN PAK 26
DERMACINRX ZRM PAK 26
DERMA-SMOOTHE/FS
BODY ____________ 26
DERMA-SMOOTHE/FS
SCALP ____________ 26
DERMATOLOGICALS __ 25
dermazene __________ 26
DERMOTIC __________ 44
DESCOVY ___________ 19
DESFERAL ___________ 11
desflurane ___________ 33
desipramine hcl _______ 9
desipramine hydrochloride
__________________ 9
desloratadine ________ 12
desloratadine odt _____ 12
desmopressin acetate _ 31
desmopressin inj _____ 31
desmopressin spr 0.01% 31
desogestrel/ethinyl estra22
desonide ____________ 26
DESOWEN ___________ 26
desoximetasone ______ 26
DESVENLAFAX TAB
100MG ER _________ 9
desvenlafaxine er ______ 9
DETROL _____________ 47
DETROL LA __________ 47
dexamethasone ___ 24, 42
dexamethasone 10-day
dose _____________ 24
dexamethasone 6-day dose
_________________ 24
DEXAMETHASONE
INTENSOL ________ 24
dexamethasone pho inj 24
dexamethasone pho sol
0.1% op __________ 42
DEXAMETHASONE SOL
0.5/5ML __________ 24
DEXILANT ___________ 46
dexmedetomidine hcl __ 35
dexmedetomidine
hydrochlo _________ 35
dexmethylphenidate hcl _ 3
dexmethylphenidate hcl er
__________________ 3
dexmethylphenidate
hydroc ____________ 3
dexpak 10 day ________ 24
dexpak 13 day ________ 24
dexpak 6 day _________ 24
dexrazoxane _________ 16
dextroamphetamine
sulfate ____________ 3
DEXTROSE 10%/NACL
0.45% ____________ 37
DEXTROSE 5% _______ 37
dextrose 10%/nacl 0.2% 37
dextrose 2.5%/nacl 0.45%
_________________ 37
dextrose 5%/lactated ring
_________________ 37
dextrose 5%/nacl 0.2% _ 37
dextrose 5%/nacl 0.225%
_________________ 37
dextrose 5%/nacl 0.3% _ 37
dextrose 5%/nacl 0.33% 37
dextrose 5%/nacl 0.45% 37
dextrose 5%/nacl 0.9% _ 37
DEXTROSE/SODIUM
CHLORIDE_________ 37
DIACOMIT ____________ 8
dialyvite _____________ 39
DIALYVITE 3000 ______ 39
DIALYVITE 5000 ______ 39
DIALYVITE SUPREME D 39
DIALYVITE/ZINC ______ 39
DIANEAL LOW
CALCIUM/1.5% ____ 38
DIANEAL LOW
CALCIUM/2.5% ____ 38
DIANEAL LOW
CALCIUM/4.25% ___ 38
DIANEAL PD-2/1.5%
DEXTROS _________ 38
DIANEAL PD-2/2.5%
DEXTROS _________ 38
DIANEAL PD-2/4.25%
DEXTRO __________ 38
DIASTAT ACUDIAL _____ 8
DIASTAT PEDIATRIC ____ 8
diazepam _____________ 6
diazepam sol 5mg/5ml 6
diazepam intensol______ 6
DIAZEPAM RECTAL GEL _ 8
DICLEGIS ____________ 12
diclofenac gel _______ 26
diclofenac sol 0.1% op_ 42
DICLOFENAC EPOLAMINE
_________________ 26
diclofenac potassium ___ 4
diclofenac sodium dr____ 4
diclofenac sodium er ____ 4
diclofenac sodium/misopro
__________________ 4
diclofex dc ___________ 26
dicloxacillin sodium ____ 44
dicyclomine sol 10mg/5ml
_________________ 46
dicyclomine hcl _______ 46
dicyclomine hydrochloride
_________________ 46
DIETARY
PRODUCTS/DIETARY
MANAGEMENT
PRODUCTS ________ 29
diethylpropion hcl ______ 3
diethylpropion hcl er ____ 3
DIFFERIN ____________ 26
DIFICID ______________ 36
difil-g forte ____________ 7
diflorasone diacetate __ 26
DIFLUCAN ___________ 12
diflunisal _____________ 4
DIGESTIVE AIDS ______ 30
digox _______________ 21
digoxin ______________ 21
digoxin inj _________ 21
DIGOXIN SOL
50MCG/ML ________ 21
dihydroergotamine
mesylat ___________ 36
DIHYDROERGOTAMINE
SPR ______________ 36
DILANTIN CAP 100MG 8
DILANTIN CAP 30MG _ 8
DILANTIN INFATABS ____ 8
DILANTIN-125 _________ 8
diltiazem tab ________ 21
diltiazem hcl cd _______ 21
diltiazem hcl er _______ 21
diltiazem hydrochloride e
_________________ 21
dilt-xr _______________ 21
DILT-XR CAP 120MG 21
DIOVAN _____________ 14
DIOVAN HCT _________ 14
DIPENTUM __________ 32
diphenhydramine hcl __ 12
diphenhydramine inj ___ 12
diphenoxylate hydrochlori
_________________ 11
diphenoxylate/atropine 11
DIPROLENE __________ 26
54
DIPROLENE AF _______ 26
dipyridamole ________ 34
disopyramide phosphate 7
disulfiram ___________ 45
DIURETICS __________ 30
DIURIL _____________ 30
divalproex sodium _____ 8
divalproex sodium dr ___ 8
divalproex sodium er ___ 8
DIVIGEL ____________ 32
dobutamine hcl ______ 48
dobutamine hcl/d5w __ 48
dobutamine
hydrochloride/ ____ 48
dobutamine/dextrose 5%
_________________ 48
dofetilide ____________ 7
DOLOPHINE __________ 5
donepezil hcl ________ 45
donepezil hydrochloride 45
donepezil hydrochloride o
_________________ 45
DONNATAL__________ 46
dopamine hcl ________ 48
dopamine
hydrochloride/de __ 48
dopamine/d5w_______ 48
DOPRAM ____________ 3
DOPTELET ___________ 34
DORAL _____________ 35
DORYX MPC _________ 45
dorzolamide hcl ______ 42
dorzolamide hcl/timolol m
_________________ 42
dorzolamide hydrochloride
_________________ 42
dotti _______________ 32
DOVATO ____________ 19
doxazosin mesylate ___ 14
doxepin hcl ___________ 9
doxepin hydrochloride __ 9
doxercalciferol _______ 31
DOXIL ______________ 16
doxorubicin hcl _______ 16
doxorubicin hydrochloride
_________________ 16
DOXYCYCLINE CAP 40MG
_________________ 26
doxycycline sus 25mg/5ml
_________________ 45
DOXYCYCLINE HYC TAB
50MG ____________ 45
doxycycline hyclate ___ 45
doxycycline hyclate dr _ 45
doxycycline monohydrate
_________________ 45
doxylamine succinate/pyri
_________________ 12
D-PENAMINE ________ 38
DRISDOL ____________ 48
DRITHO-CREME HP ___ 26
dronabinol __________ 12
droperidol ____________ 6
drospirenone/ethinyl estr
_________________ 22
DROXIA _____________ 34
DRYSOL _____________ 26
DUAC ______________ 26
DUAVEE ____________ 32
DUET DHA BALANCED _ 39
DUEXIS ______________ 4
DULERA ______________ 7
duloxetine hcl _________ 9
duloxetine hydrochloride 9
DUOBRII ____________ 26
DUODOTE ___________ 11
DUOPA _____________ 18
DUPIXENT ___________ 26
duramorph ___________ 5
DURASAFE
SPINAL/EPIDURAL __ 36
DUREZOL ___________ 42
DUROLANE __________ 41
dutasteride __________ 33
dutasteride/tamsulosin hc
_________________ 33
DYANAVEL XR ________ 3
DYAZIDE ____________ 30
DYMISTA____________ 41
DYRENIUM __________ 30
DYSPORT ___________ 41
E
e.e.s. 400 ___________ 36
E.E.S. GRANULES _____ 36
EC-NAPROXEN ________ 4
econazole nitrate _____ 26
ECOZA ______________ 26
EDARBI _____________ 14
EDARBYCLOR ________ 14
EDECRIN ____________ 30
EDEX _______________ 21
EDLUAR _____________ 35
ed-spaz _____________ 46
EDURANT ___________ 19
eemt _______________ 32
eemt hs _____________ 32
efavirenz ____________ 19
effer-k ______________ 37
EFFER-K TAB 20MEQ 37
EFFEXOR XR __________ 9
EFFIENT _____________ 34
EFUDEX _____________ 26
ELELYSO ____________ 34
ELESTRIN ____________ 32
ELETONE TWINPACK __ 26
eletriptan hydrobromide 37
ELFOLATE ___________ 29
ELIDEL ______________ 26
ELIGARD ____________ 16
elinest ______________ 22
ELIQUIS ______________ 8
ELITEK ______________ 16
elite-ob _____________ 39
ELIXOPHYLLIN _________ 7
ELLA ________________ 22
ELLENCE ____________ 16
ELMIRON ____________ 33
ELOCON _____________ 26
ELOCTATE ___________ 34
EMCYT ______________ 16
EMEND _____________ 12
EMEND TRIPACK ______ 12
EMFLAZA ____________ 24
EMGALITY ___________ 37
EMPLICITI ___________ 16
EMSAM ______________ 9
EMVERM _____________ 6
ENABLEX ____________ 47
enalapril maleate _____ 14
enalapril maleate/hydroch
_________________ 14
enalaprilat ___________ 14
ENBRACE HR _________ 39
ENBREL ______________ 4
ENBREL MINI _________ 4
ENBREL SURECLICK _____ 4
endocet ______________ 5
ENDOCRINE AND
METABOLIC AGENTS -
MISC. ____________ 31
ENDOMETRIN ________ 48
ENGERIX-B __________ 47
ENLYTE _____________ 29
enoxaparin sodium _____ 8
enpresse-28 _________ 22
enskyce _____________ 22
ENSTILAR ___________ 26
entacapone __________ 18
entecavir ____________ 19
ENTERAGAM _________ 29
ENTOCORT EC ________ 24
ENTRESTO ___________ 21
ENTTY SPRAY EMULSION
_________________ 26
ENTYVIO ____________ 32
enulose _____________ 32
ENVARSUS XR ________ 38
EPANED _____________ 14
EPCLUSA ____________ 19
EPICERAM ___________ 26
EPICYN _____________ 26
EPIDIOLEX ____________ 8
EPIDUO _____________ 26
EPIDUO FORTE _______ 26
EPIFOAM ____________ 26
epinastine hcl ________ 42
EPIPEN 2-PAK ________ 48
EPIPEN-JR 2-PAK ______ 48
epirubicin hcl _________ 16
EPISNAP_____________ 48
epitol ________________ 8
EPIVIR ______________ 19
EPIVIR HBV SOL 5MG/ML
_________________ 19
EPIVIR HBV TAB 100MG
_________________ 19
eplerenone __________ 14
EPOGEN _____________ 34
epoprostenol sodium __ 21
eprosartan mesylate ___ 14
eptifibatide __________ 34
EQUETRO____________ 18
ERAXIS ______________ 12
ergocalciferol_________ 48
ERGOMAR ___________ 37
ergotamine tartrate/caffe
_________________ 37
ERIVEDGE ___________ 16
erlotinib hydrochloride _ 16
errin ________________ 22
ERTACZO ____________ 26
ertapenem sodium ____ 15
ERY _________________ 26
ERYGEL _____________ 26
ERYPED 200 __________ 36
ERYPED 400 __________ 36
ery-tab ______________ 36
ERYTHROCIN
LACTOBIONATE ____ 36
ERYTHROCIN STEARATE 36
erythromycin base ____ 36
erythromycin cap _____ 36
erythromycin dr ______ 36
erythromycin ethylsuccina
_________________ 36
erythromycin gel 2% ___ 26
erythromycin oin 5mg/gm
_________________ 42
erythromycin/benzoyl pero
_________________ 26
ESBRIET _____________ 45
escitalopram oxalate ____ 9
esmolol hcl __________ 20
esomeprazole magnesium
_________________ 46
esomeprazole sodium __ 46
estarylla _____________ 22
estazolam ___________ 35
esterified estrogens/meth
_________________ 32
ESTRACE TAB ______ 32
ESTRACE VAG CRE 0.01%
_________________ 48
estradiol__________ 32, 48
estradiol vag tab _____ 48
estradiol valerate _____ 32
estradiol/norethindrone a
_________________ 32
55
ESTRING ____________ 48
ESTRIOL-PROGESTERONE
COMP ___________ 32
ESTROGEL ___________ 32
Estrogens ___________ 32
ESTROSTEP FE _______ 22
eszopiclone _________ 35
ethacrynic acid _______ 30
ethambutol hcl _______ 15
ethambutol hydrochloride
_________________ 15
ethosuximide _________ 8
ETHYL CHLORIDE/FINE
STREA ___________ 26
ethyl chloride/mist____ 26
ethynodiol diacetate/ethi
_________________ 22
etidronate disodium __ 31
etodolac _____________ 4
etodolac er ___________ 4
etomidate ___________ 33
ETOPOPHOS _________ 16
etoposide ___________ 16
EUCRISA ____________ 26
EUFLEXXA ___________ 41
EURAX _____________ 26
euthyrox ____________ 46
EVAMIST ___________ 32
EVEKEO______________ 3
EVEKEO ODT _________ 3
EVISTA _____________ 31
EVOCLIN ____________ 26
EVOTAZ ____________ 19
EXELDERM __________ 26
EXELON_____________ 45
exemestane _________ 16
EXFORGE ___________ 14
EXFORGE HCT________ 14
EXJADE _____________ 11
EXODERM___________ 26
exotic-hc ____________ 44
EXTAVIA ____________ 45
EXTINA _____________ 26
EXTRANEAL _________ 38
EYLEA ______________ 42
ezetimibe ___________ 13
ezetimibe/simvastatin _ 13
F
fabb _______________ 34
FABIOR _____________ 26
FABRAZYME _________ 31
falmina _____________ 22
famciclovir __________ 19
famotidine __________ 46
famotidine inj _______ 46
famotidine premixed __ 46
FANAPT ____________ 18
FARXIGA ____________ 10
FARYDAK ___________ 16
FASENRA _____________ 7
FASENRA PEN _________ 7
FASLODEX ___________ 16
fayosim _____________ 22
FAZACLO ____________ 18
febuxostat___________ 34
felbamate ____________ 8
FELBATOL ____________ 8
FELDENE _____________ 4
felodipine er _________ 21
FEM PH _____________ 48
FEMARA ____________ 16
FEMCAP ____________ 36
FEMHRT LOW DOSE ___ 32
FEMRING ___________ 48
femynor ____________ 22
FENOFIBRATE CAP ___ 13
fenofibrate tab ______ 13
fenofibrate micronized 13
fenofibric acid dr _____ 13
FENOPROFEN CAP
400MG ____________ 4
fenoprofen tab 600mg _ 4
fentanyl ______________ 5
FENTANYL CITRATE ____ 5
fentanyl citrate oral tra _ 5
FERAHEME __________ 34
FERIVA 21/7 _________ 34
FERIVAFA ___________ 34
ferocon _____________ 34
ferotrinsic ___________ 34
FERRALET 90 _________ 34
FERRAPLUS 90 _______ 34
FERRLECIT ___________ 34
FETZIMA _____________ 9
FETZIMA TITRATION PACK
__________________ 9
FIASP _______________ 10
FIASP FLEXTOUCH ____ 10
FIASP PENFILL ________ 10
FINACEA AER 15% __ 26
FINACEA GEL 15% __ 26
finasteride___________ 33
FIORICET ___________ 4, 5
FIORICET/CODEINE ____ 5
FIORINAL __________ 4, 5
FIORINAL/CODEINE #3 _ 5
FIRAZYR ____________ 34
FIRST-BACLOFEN 5 ____ 41
FIRST-LANSOPRAZOLE _ 46
FIRST-METRONIDAZOLE
100 ______________ 15
FIRST-METRONIDAZOLE 50
_________________ 15
FIRST-MOUTHWASH BLM
_________________ 39
FIRST-OMEPRAZOLE __ 46
FIRST-PROGESTERONE
VGS 20 ___________ 48
FIRVANQ ____________ 15
FLAGYL _____________ 15
FLAREX _____________ 42
flavoxate hcl _________ 47
FLEBOGAMMA DIF ____ 44
flecainide acetate ______ 7
FLECTOR ____________ 27
flexbumin ___________ 34
FLOLAN _____________ 21
FLOLIPID ____________ 13
FLOMAX ____________ 33
FLORIVA PLUS ________ 39
FLOVENT DISKUS ______ 7
FLOVENT HFA _________ 7
floxuridine ___________ 16
FLUAD 2019-2020 _____ 47
FLUARIX QUADRIVALENT
2019 _____________ 47
FLUBLOK QUADRIVALENT
2019 _____________ 47
FLUCELVAX
QUADRIVALENT 20 _ 47
fluconazole __________ 12
fluconazole in nacl ____ 12
flucytosine ___________ 12
fludarabine phosphate _ 16
fludrocortisone acetate 24
FLULAVAL QUADRIVALENT
201 ______________ 47
flumazenil ___________ 11
flunisolide ___________ 41
fluocinolone acetonide _ 44
fluocinonide _________ 27
FLUORABON _________ 37
fluoride _____________ 37
fluoritab ____________ 37
fluorometholone _____ 42
FLUOROPLEX_________ 27
Fluoroquinolones _____ 32
fluorouracil _______ 16, 27
FLUOROURACIL CRE 0.5%
_________________ 27
fluorouracil cre 5% ____ 27
FLUOXETINE TAB 60MG 9
fluoxetine dr __________ 9
fluoxetine hcl _________ 9
fluphenazine decanoate 18
fluphenazine hcl ______ 18
FLUPHENAZINE
HYDROCHLORID ___ 18
flurandrenolide _______ 27
flurazepam hcl _______ 35
flurbiprofen ________ 4, 42
flurbiprofen sodium ___ 42
flutamide ____________ 16
fluticasone oin 0.005% 27
fluticasone spr 50mcg _ 41
fluticasone/salmeterol
aero ______________ 7
FLUTICASONE/SALMETER
OL INH ____________ 7
fluvastatin ___________ 13
fluvastatin sodium er __ 13
fluvoxamine maleate ___ 9
fluvoxamine maleate er _ 9
FLUZONE HIGH-DOSE PF
2019 _____________ 47
FLUZONE QUADRIVALENT
2019 _____________ 47
FML ________________ 42
FML FORTE __________ 42
FML LIQUIFILM _______ 42
FOCALIN _____________ 3
FOCALIN XR ___________ 3
folbee ___________ 34, 39
folbee plus ___________ 39
folbic _______________ 29
FOLBIC RF ___________ 29
FOLGARD OS _________ 39
FOLGARD RX _________ 34
folic acid ____________ 35
folic acid/vitamin b-6/vi 35
FOLIVANE-F __________ 35
FOLIVANE-OB ________ 39
FOLIVANE-PLUS ______ 35
FOLLISTIM AQ ________ 31
FOLTANX RF _________ 29
foltrin _______________ 35
FOLTX ______________ 29
fomepizole ___________ 12
fondaparinux sodium ___ 8
FORANE _____________ 33
FORFIVO XL ___________ 9
formaldehyde ________ 19
FORTEO _____________ 31
FOSAMAX ___________ 31
FOSAMAX PLUS D _____ 31
fosamprenavir calcium _ 19
FOSAPREPITANT
DIMEGLUMINE _____ 12
fosinopril sodium _____ 14
fosinopril sodium/hydroch
_________________ 14
fosphenytoin sodium ___ 8
FOSRENOL ___________ 32
FRAGMIN ____________ 8
frovatriptan succinate __ 37
FULPHILA ____________ 35
furosemide __________ 30
furosemide inj _______ 30
FUSION PLUS _________ 35
FUZEON _____________ 19
fyavolv ______________ 32
FYCOMPA ____________ 8
G
gabapentin ___________ 8
GABITRIL _____________ 8
56
GALAFOLD __________ 31
galantamine hydrobromide
_________________ 45
GALZIN _____________ 37
GAMASTAN _________ 44
GAMASTAN S/D ______ 44
GAMMAGARD LIQUID _ 44
GAMMAGARD S/D IGA
LESS TH __________ 44
GAMMAKED ________ 44
GAMUNEX-C ________ 44
GANCICLOVIR________ 19
GARDASIL 9 _________ 47
GASTROCROM _______ 32
GASTROINTESTINAL
AGENTS - MISC. ___ 32
gatifloxacin __________ 42
gavilyte-c ___________ 36
gavilyte-n/flavor pack _ 36
GEBAUERS SPRAY AND
STRETC___________ 27
GELFILM OP _________ 42
GEL-FLOW __________ 35
GELNIQUE __________ 47
GEL-ONE ____________ 41
GEMCITABINE _______ 16
gemcitabine hcl ______ 16
gemfibrozil __________ 13
GENADUR ___________ 27
GENERAL ANESTHETICS 33
GENERESS FE ________ 22
generlac ____________ 32
gengraf _____________ 38
GENICIN VITA-D ______ 35
GENITOURINARY AGENTS -
MISCELLANEOUS __ 33
GENOTROPIN ________ 31
GENOTROPIN MINIQUICK
_________________ 31
GENTAK ____________ 42
gentamicin oin 0.1% __ 27
gentamicin sol 0.3% op 42
gentamicin sulfate _____ 3
GENVOYA ___________ 19
GEODON____________ 18
gianvi ______________ 22
GILENYA ____________ 45
GILOTRIF ___________ 16
GILTUSS TR __________ 25
GLASSIA ____________ 45
glatiramer acetate ____ 45
glatopa _____________ 45
GLEEVEC ____________ 16
GLEOSTINE __________ 16
GLIADEL WAFER ______ 16
glimepiride __________ 10
glipizide ____________ 10
glipizide er __________ 10
glipizide xl ___________ 10
glipizide/metformin hydro
_________________ 10
GLUCAGEN HYPOKIT __ 10
GLUCAGON EMERGENCY
KIT ______________ 10
GLUCOPHAGE ________ 10
GLUCOPHAGE XR _____ 10
GLUCOTROL _________ 10
GLUCOTROL XL _______ 10
GLUMETZA __________ 10
glyburide ____________ 10
glyburide micronized __ 10
glyburide/metformin hydro
_________________ 10
GLYCATE ____________ 46
glycine ______________ 33
glycopyrrolate inj
0.2mg/ml _________ 46
glycopyrrolate tab 1mg 46
glydo _______________ 27
GLYNASE ____________ 10
GLYSET _____________ 10
GLYTACTIN BETTERMILK
15 _______________ 30
GLYTACTIN BETTERMILK
DE-L _____________ 30
GLYTACTIN BUILD 10PE 30
GLYTACTIN BUILD 20/20
PKU _____________ 30
GLYTACTIN COMPLETE
10PE _____________ 30
GLYTACTIN RESTORE 10 30
GLYTACTIN RESTORE 5 30
GLYTACTIN RESTORE LITE
10 _______________ 30
GLYTACTIN RTD 10 ____ 30
GLYTACTIN RTD 15 ____ 30
GLYTACTIN RTD LITE 15 30
GLYTACTIN SWIRL 15PE 30
GLYXAMBI __________ 10
GOLYTELY ___________ 36
GONAL-F ____________ 31
GONAL-F RFF REDIJECT 31
GORDOFILM _________ 27
Gout Agents _________ 33
grafco silver nitrate app 27
GRALISE ____________ 45
GRALISE STARTER ____ 45
granisetron inj 1mg/ml 12
granisetron hcl _______ 12
griseofulvin microsize__ 12
griseofulvin ultramicrosi 12
guanfacine er _________ 3
guanfacine hcl _______ 14
GUANIDINE HCL ______ 15
GYNAZOLE-1 _________ 48
H
hailey 24 fe __________ 22
halcinonide __________ 27
HALCION ____________ 35
HALOBETASOL AER 0.05%
_________________ 27
halobetasol cre 0.05% _ 27
HALOG______________ 27
haloperidol __________ 19
haloperidol decanoate _ 19
haloperidol lactate ____ 19
HARVONI ___________ 19
HAVRIX _____________ 47
hc butyrate cre 0.1% __ 27
hc butyrate sol 0.1% __ 27
hc pramoxine cre 1-1% __ 6
hc pramoxine cre 2.5-1% 27
HEALON ____________ 42
HEALON GV __________ 42
HEALON5 ___________ 42
heather _____________ 22
HEMABATE __________ 44
HEMANGEOL ________ 20
hematinic/folic acid ___ 35
HEMATOGEN FA ______ 35
hematogen forte ______ 35
HEMATOLOGICAL AGENTS
- MISC. ___________ 34
HEMATOPOIETIC AGENTS
_________________ 34
HEMATRON-AF _______ 35
HEMLIBRA ___________ 34
hemmorex-hc _________ 6
hemocyte-f __________ 35
HEMOFIL M __________ 34
HEMOSTATICS _______ 35
heparin lock flush ______ 8
heparin sodium ________ 8
heparin sodium/d5w ___ 8
heparin sodium/nacl 0.9% 8
HEPLISAV-B __________ 47
HERCEPTIN __________ 16
HESPAN _____________ 34
hetastarch 6%/nacl ____ 34
HEXTEND ____________ 34
hidex 6-day __________ 24
HIPREX _____________ 47
HIZENTRA ___________ 44
HOMACTIN AA PLUS __ 30
homatropine hbr _____ 42
HORIZANT ___________ 45
HPR PLUS ___________ 27
HUMALOG __________ 10
HUMALOG JUNIOR
KWIKPEN _________ 10
HUMALOG KWIKPEN __ 10
HUMALOG MIX 50/50 _ 10
HUMALOG MIX 50/50
KWIKPEN _________ 10
HUMALOG MIX 75/25 _ 10
HUMALOG MIX 75/25
KWIKPEN _________ 10
HUMATROPE _________ 31
HUMATROPE COMBO
PACK _____________ 31
HUMIRA _____________ 4
HUMIRA PEDIATRIC
CROHNS D _________ 4
HUMIRA PEN __________ 4
HUMIRA PEN-CD/UC/HS
START _____________ 4
HUMIRA PEN-PS/UV
STARTER ___________ 4
HUMULIN R U-500
(CONCENTR _______ 11
HUMULIN R U-500
KWIKPEN _________ 11
HYALGAN ___________ 41
HYCAMTIN CAP 0.25MG
_________________ 16
HYCAMTIN INJ 4MG _ 16
HYCLODEX ___________ 27
hydralazine inj _______ 14
hydralazine hcl _______ 14
hydralazine hydrochloride
_________________ 14
HYDREA _____________ 16
HYDRO 35 ___________ 27
HYDRO 40 FOAM _____ 27
hydrochlorothiazide ___ 30
hydrocodone bitartrate/ac
__________________ 5
hydrocodone bitartrate/ho
_________________ 25
hydrocodone polistirex/ch
_________________ 25
hydrocodone/acetaminoph
en ________________ 5
hydrocodone/ibuprofen _ 5
hydrocort cre 1% ____ 27
hydrocort ene 100mg __ 6
hydrocort tab 5mg ___ 24
hydrocort ac sup 25mg __ 6
hydrocortisone valerate 27
hydrocortisone/acetic aci
_________________ 44
hydrocortisone/iodoquinol
_________________ 27
HYDROFERA BLUE FOAM
DRESS ____________ 27
HYDROFERA BLUE READY
FOAM ____________ 27
hydromet ____________ 25
hydromorphon inj 2mg/ml
__________________ 5
hydromorphon inj 4mg/ml
__________________ 5
hydromorphon sup 3mg _ 5
hydromorphone hcl tab _ 5
hydromorphone hcl er __ 5
hydromorphone
hydrochlori _________ 5
57
hydroquinone ________ 27
hydroquinone time release
_________________ 27
hydroxocobalamin ____ 35
hydroxychloroquine sulfat
_________________ 15
hydroxyprogesterone
capro ____________ 44
hydroxyurea _________ 16
hydroxyzine hcl inj _____ 7
hydroxyzine hcl tab ____ 7
hydroxyzine pamoate __ 7
HYLATOPIC PLUS _____ 27
hylavite _____________ 39
HYLENEX ____________ 38
HYOPHEN ___________ 47
hyoscyamine sub 0.125mg
_________________ 46
hyoscyamine tab 0.125mg
_________________ 46
hyoscyamine sulfate er 46
hyosyne ____________ 46
HYPERHEP B S/D _____ 44
HYPERLYTE-CR _______ 37
HYPERRAB __________ 44
HYPERRAB S/D _______ 44
HYPERRHO S/D ______ 44
HYPERRHO S/D MINI-
DOSE ____________ 44
HYPERTET S/D _______ 44
HYPNOTICS/SEDATIVES/SL
EEP DISORDER AGENTS
_________________ 35
HYPOCYN ___________ 27
HYQVIA ____________ 44
HYSINGLA ER _________ 5
HYZAAR ____________ 14
I
ibandronate inj ______ 31
ibandronate sodium __ 31
IBRANCE ____________ 16
ibu __________________ 4
ibuprofen ____________ 4
icatibant acetate _____ 34
IDAMYCIN PFS _______ 16
idarubicin hcl ________ 16
IFEX ________________ 16
ILARIS _______________ 4
ILEVRO _____________ 42
ILUMYA ____________ 27
imatinib mesylate ____ 16
IMBRUVICA _________ 16
IMFINZI _____________ 16
imipenem/cilastatin ___ 15
imipramine hcl ________ 9
imipramine pamoate ___ 9
imiquimod __________ 27
IMIQUIMOD PUMP ___ 27
IMITREX ____________ 37
IMITREX STATDOSE REFILL
_________________ 37
IMITREX STATDOSE
SYSTEM __________ 37
IMOGAM RABIES-HT __ 44
IMOVAX RABIES (H.D.C.V.)
_________________ 47
IMPOYZ _____________ 27
IMURAN ____________ 38
IMVEXXY MAINTENANCE
PACK ____________ 48
IMVEXXY STARTER PACK
_________________ 48
INBRIJA _____________ 18
INCRELEX ___________ 31
INCRUSE ELLIPTA ______ 7
indapamide __________ 30
INDERAL LA _________ 20
INDOCIN _____________ 4
indomethacin cap ______ 4
indomethacin er _______ 4
indomethacin inj 1mg __ 4
indomethacin sr _______ 4
INFED ______________ 35
INFLECTRA __________ 32
INFUMORPH 200 ______ 5
INFUMORPH 500 ______ 5
INGREZZA ___________ 45
INJECTAFER _________ 35
INLYTA _____________ 16
INSPRA _____________ 14
INSULIN LISPRO ______ 11
INSULIN LISPRO KWIKPEN
_________________ 11
INTEGRA F __________ 35
INTEGRA PLUS _______ 35
INTEGRILIN __________ 34
INTELENCE __________ 19
INTRAROSA _________ 48
INTRON A ___________ 16
introvale ____________ 22
INTUNIV _____________ 3
INVANZ _____________ 15
INVEGA _____________ 19
INVEGA SUSTENNA ___ 19
INVEGA TRINZA ______ 19
INVELTYS ___________ 42
INVIRASE ___________ 19
INVOKAMET _________ 11
INVOKAMET XR ______ 11
INVOKANA __________ 11
iodine strong ________ 37
iodoquinol/hydrocortisone
_________________ 27
IONOSOL-MB/DEXTROSE
5% ______________ 37
IOPIDINE ____________ 42
IPOL INACTIVATED IPV 47
ipratropium spray ____ 41
ipratropium bromide ___ 7
ipratropium bromide/albut
__________________ 7
irbesartan ___________ 14
irbesartan/hydrochlorothi
_________________ 14
IRESSA ______________ 16
irinotecan hcl ________ 16
irinotecan hydrochloride 16
IROSPAN 24/6 _______ 35
ISENTRESS ___________ 19
ISENTRESS HD ________ 19
isibloom _____________ 22
ISOLYTE-P/DEXTROSE 5%
_________________ 37
ISOLYTE-S ___________ 37
ISOLYTE-S PH 7.4 _____ 37
isoniazid ____________ 15
isoniazid inj _________ 15
isoproterenol hydrochlori 7
ISOPTIN SR __________ 21
ISOPTO ATROPINE ____ 42
ISOPTO CARPINE _____ 42
ISORDIL TITRADOSE ____ 6
isosorbide dinitrate ____ 6
isosorbide dinitrate sa __ 6
isosorbide mononitrate _ 6
isosorbide mononitrate er 6
isotretinoin __________ 27
ISOVACTIN AA PLUS ___ 30
isradipine ___________ 21
ISTALOL _____________ 42
ISUPREL ______________ 7
itraconazole _________ 12
ivermectin cre 1% ____ 27
ivermectin tab 3mg ____ 6
IXIARO ______________ 47
J
JADENU _____________ 12
JADENU SPRINKLE ____ 12
JAKAFI ______________ 16
JALYN ______________ 33
jantoven _____________ 8
JANUMET ___________ 11
JANUMET XR_________ 11
JANUVIA ____________ 11
JARDIANCE __________ 11
jasmiel ______________ 22
jencycla _____________ 23
JENTADUETO ________ 11
JENTADUETO XR ______ 11
JETREA______________ 42
JEVTANA ____________ 16
jinteli _______________ 32
JIVI _________________ 34
jolessa ______________ 23
JORNAY PM __________ 3
JUBLIA ______________ 27
juleber ______________ 23
JULUCA _____________ 19
junel 1.5/30 __________ 23
junel 1/20 ___________ 23
junel fe 1.5/30 ________ 23
junel fe 1/20 _________ 23
junel fe 24 ___________ 23
K
KADIAN ______________ 5
kaitlib fe _____________ 23
KALETRA SOL ______ 19
KALETRA TAB 100-
25MG ____________ 19
KALYDECO ___________ 45
KAMDOY ____________ 27
KANUMA ____________ 31
KAPSPARGO SPRINKLE _ 20
KARBINAL ER _________ 12
kariva _______________ 23
kcl 0.075%/d5w/nacl
0.45% ____________ 37
kcl 0.15%/d5w/nacl 0.2%
_________________ 37
kcl 0.15%/d5w/nacl
0.225% ___________ 37
kcl 0.15%/d5w/nacl 0.45%
_________________ 37
kcl 0.15%/d5w/nacl 0.9%
_________________ 37
kcl 0.3%/d5w/nacl 0.45%
_________________ 37
KCL 0.3%/D5W/NACL 0.9%
_________________ 37
KEFLEX ______________ 22
kelnor 1/35 __________ 23
kelnor 1/50 __________ 23
KENALOG _________ 24, 27
KENALOG-10 _________ 24
KENALOG-40 _________ 24
KENALOG-80 _________ 24
KENGREAL ___________ 34
KEPPRA ______________ 8
KEPPRA XR ___________ 8
KERALAC ____________ 27
KERALYT ____________ 27
KERALYT SCALP _______ 27
KERYDIN ____________ 27
ketamine hcl _________ 33
ketoconazole cream ___ 27
ketoconazole tab ______ 12
ketoprofen er _________ 4
ketorolac sol 0.5% ___ 42
ketorolac tab 10mg ___ 4
ketorolac tromethamine _ 4
KETOVIE _____________ 30
KETOVIE PEPTIDE _____ 30
KEVZARA _____________ 4
KEYTRUDA ___________ 16
58
KINERET _____________ 4
kionex ______________ 38
KISQALI _____________ 16
KISQALI FEMARA 200
DOSE ____________ 16
KISQALI FEMARA 400
DOSE ____________ 16
KISQALI FEMARA 600
DOSE ____________ 16
KITABIS PAK __________ 3
KLARON ____________ 27
KLONOPIN ___________ 9
klor-con ____________ 37
klor-con 10 __________ 37
klor-con 8 ___________ 37
klor-con m10 ________ 37
KLOR-CON M15 ______ 37
klor-con m20 ________ 37
klor-con sprinkle _____ 37
klor-con/ef __________ 37
KOGENATE FS _______ 34
KOMBIGLYZE XR _____ 11
KORLYM ____________ 11
KOVALTRY __________ 34
K-PHOS __________ 33, 37
K-PHOS NEUTRAL ____ 37
K-PHOS NO 2 ________ 33
k-prime _____________ 37
KRINTAFEL __________ 15
KRISTALOSE _________ 36
K-TAB ______________ 37
K-TAB TAB 20MEQ 37
kurvelo _____________ 23
KUVAN _____________ 31
KYLEENA ____________ 23
KYMRIAH ___________ 17
L
labetalol inj ________ 20
labetalol hydrochloride 20
LAC-HYDRIN _________ 27
LACRISERT __________ 42
lactated ringers ___ 37, 38
lactated ringers irrigati 38
LACTATED RINGERS
VIAFLEX __________ 37
lactulose ____________ 36
LAMICTAL ____________ 9
LAMICTAL CHEWABLE
DISPERS ___________ 9
LAMICTAL ODT _______ 9
LAMICTAL STARTER/NOT
TAKI ______________ 9
LAMICTAL
STARTER/TAKING C _ 9
LAMICTAL
STARTER/TAKING V _ 9
LAMICTAL XR _________ 9
lamivudine __________ 19
lamivudine/zidovudine 19
lamotrigine ___________ 9
lamotrigine er _________ 9
lamotrigine odt ________ 9
lamotrigine starter kit/g _ 9
lamotrigine starter kit/o_ 9
lansoprazole _________ 46
lansoprazole odt ______ 46
lansoprazole/amoxicillin/
_________________ 46
lanthanum carbonate __ 32
LANTUS _____________ 11
LANTUS SOLOSTAR ___ 11
larin 1.5/30 __________ 23
larin 1/20 ___________ 23
larin 24 fe ___________ 23
larin fe 1.5/30 ________ 23
larin fe 1/20 _________ 23
larissia ______________ 23
LARTRUVO __________ 17
LASIX _______________ 30
LASTACAFT __________ 42
latanoprost __________ 42
LATISSE _____________ 27
LATUDA ____________ 19
LAVARE WOUND WASH 27
LAXATIVES __________ 36
layolis fe ____________ 23
LAZANDA ____________ 5
LEDIPASVIR/SOFOSBUVIR
_________________ 19
leflunomide __________ 4
LENVIMA 12MG DAILY
DOSE ____________ 17
LESCOL XL ___________ 13
lessina ______________ 23
LETAIRIS ____________ 21
letrozole ____________ 17
leucovorin calcium ____ 17
leucovorin calcium inj _ 17
LEUCOVORIN CALCIUM
TAB 10MG ________ 17
LEUKERAN __________ 17
LEUKINE ____________ 35
leuprolide acetate ____ 17
levalbuterol __________ 7
levalbuterol hcl ________ 7
LEVALBUTEROL TARTRATE
HFA ______________ 7
LEVEMIR ____________ 11
LEVEMIR FLEXTOUCH _ 11
levetiracetam _________ 9
levetiracetam er _______ 9
levetiracetam inj_______ 9
LEVICYN ____________ 27
levicyn dermal spray __ 27
LEVITRA ____________ 21
levobunolol hcl _______ 43
levocarnitine _________ 31
levocetirizine dihydrochl 12
levofloxacin _______ 32, 43
levofloxacin in d5w ____ 32
levofloxacin inj _______ 32
levofloxacin sol 0.5% __ 43
levoleucovorin _______ 17
levoleucovorin calcium _ 17
LEVOMEFOLATE CALCIUM
ALGA ____________ 30
LEVOMEFOLATE
CALCIUM/N-AC ____ 30
LEVOMEFOLATE
CALCIUM/PYRI_____ 30
levonest _____________ 23
levonorgestrel and ethiny
_________________ 23
levonorgestrel/ethinyl es23
LEVOPHED___________ 48
levora 0.15/30-28 _____ 23
levothyroxine sodium __ 46
levothyroxine/liothyronin
_________________ 46
levoxyl ______________ 46
LEVSIN ______________ 46
LEVULAN KERASTICK __ 27
LEXAPRO _____________ 9
LEXETTE _____________ 27
LIALDA ______________ 32
LIBRAX______________ 46
lidocaine __ 6, 7, 27, 36, 39
lidocaine inj ________ 36
lidocaine sol ________ 27
LIDOCAINE AND
TETRACAINE_______ 27
lidocaine hcl in d5w ____ 7
lidocaine hcl jelly _____ 27
LIDOCAINE HCL/DEXTROSE
_________________ 36
lidocaine viscous ______ 39
lidocaine/epinephrine _ 36
lidocaine/hc cre 3%-0.5% 6
lidocaine/prilocaine ___ 27
LIDODERM __________ 27
LIDO-HYDRO GEL 2.8-0.55
__________________ 6
lidozion _____________ 27
LILETTA _____________ 23
lillow _______________ 23
LINCOCIN ___________ 15
lindane _____________ 27
linezolid _____________ 15
linezolid inj 2mg/ml __ 15
LINZESS _____________ 32
liothyronine sodium ___ 46
LIPITOR _____________ 13
LIPOFEN ____________ 13
lisinopril_____________ 14
lisinopril/hydrochlorothi 14
lithium ______________ 19
lithium carbonate _____ 19
lithium carbonate er ___ 19
LITHOSTAT __________ 33
LIVALO ______________ 13
livixil pak ____________ 27
LMD 10% DEXTROSE 5% 34
LMD 10% SODIUM
CHLORIDE 0 _______ 34
L-METHYL-B6-B12 _____ 30
L-METHYLFOLATE _____ 30
L-METHYLFOLATE CA/S-
ALGAL ____________ 30
L-METHYLFOLATE FORTE
_________________ 30
L-METHYL-MC NAC ____ 30
LO LOESTRIN FE ______ 23
LOCAL ANESTHETICS-
Parenteral ________ 36
LOCOID _____________ 27
LOCOID LIPOCREAM ___ 27
LODOSYN____________ 18
LOESTRIN 1.5/30-21 ___ 23
LOESTRIN FE 1.5/30 ___ 23
LOESTRIN FE 1/20 _____ 23
LOKELMA ____________ 38
LOMAIRA _____________ 3
LOMOTIL ____________ 11
LONSURF ____________ 17
loperamide hcl _______ 11
LOPID _______________ 13
lopinavir/ritonavir _____ 19
lopreeza _____________ 32
LOPRESSOR _______ 14, 20
LOPRESSOR HCT ______ 14
lorazepam ____________ 7
lorazepam inj ________ 7
lorazepam intensol _____ 7
LORBRENA ___________ 17
lorcet ________________ 5
lorcet hd _____________ 5
LORTAB ______________ 5
loryna _______________ 23
LORZONE ____________ 41
losartan potassium ____ 14
losartan potassium/hydroc
_________________ 14
LOTEMAX ___________ 43
LOTEMAX SM ________ 43
LOTENSIN ___________ 14
LOTENSIN HCT________ 14
loteprednol etabonate _ 43
LOTREL______________ 14
LOTRISONE __________ 27
lovastatin ____________ 13
LOVAZA _____________ 13
LOVENOX ____________ 8
low-ogestrel _________ 23
loxapine _____________ 19
loxapine succinate_____ 19
LOYON ______________ 27
lo-zumandimine ______ 23
LUCEMYRA __________ 45
59
ludent ______________ 37
LUGOLS STRONG IODINE
_________________ 19
LULICONAZOLE ______ 27
LUMIGAN ___________ 43
LUMIZYME __________ 31
LUMOXITI ___________ 17
LUNESTA ___________ 35
LUPANETA PACK _____ 31
LUPRON DEPOT INJ
11.25MG _________ 17
LUPRON DEPOT INJ
22.5MG __________ 17
LUPRON DEPOT INJ
3.75MG __________ 17
LUPRON DEPOT INJ 30MG
_________________ 17
LUPRON DEPOT INJ 45MG
_________________ 17
LUPRON DEPOT INJ 7.5MG
_________________ 17
LUPRON DEPOT-PED (1-
MONTH __________ 31
LUPRON DEPOT-PED (3-
MONTH __________ 31
lutera ______________ 23
LUXIQ ______________ 27
LUZU _______________ 27
LYNPARZA __________ 17
LYRICA ___________ 9, 45
LYRICA CR ___________ 45
LYSODREN __________ 17
M
MACROBID __________ 47
MACROLIDES ________ 36
MAKENA____________ 44
MALARONE _________ 15
malathion ___________ 27
mannitol ____________ 30
maprotiline hcl _______ 10
MARCAINE __________ 36
MARCAINE SPINAL ___ 36
MARCAINE/EPINEPHRINE
_________________ 36
MARINOL ___________ 12
marlissa ____________ 23
MARNATAL-F ________ 39
MARPLAN___________ 10
MARQIBO ___________ 17
MATULANE _________ 17
matzim la ___________ 21
MAVYRET ___________ 19
MAXALT ____________ 37
MAXALT-MLT ________ 37
MAXIDEX ___________ 43
MAXIPIME __________ 22
MAXITROL __________ 43
MAXZIDE ___________ 30
MAXZIDE-25 _________ 30
MAYZENT ___________ 45
me/naphos/mb/hyo 1 _ 47
meclizine hcl _________ 12
meclofenamate sodium _ 4
MEDICAL DEVICES AND
SUPPLIES _________ 36
MEDROL ____________ 24
MEDROL DOSEPAK ___ 24
medroxyprogesterone inj
_________________ 23
medroxyprogesterone tab
_________________ 44
mefenamic acid _______ 4
mefloquine hcl _______ 15
megestrol acetate ____ 17
MEKINIST ___________ 17
MEKTOVI ___________ 17
melodetta 24 fe ______ 23
meloxicam ___________ 4
melphalan hydrochloride
_________________ 17
memantine hcl titration p
_________________ 45
memantine hydrochloride
_________________ 45
memantine hydrochloride
e ________________ 45
MENACTRA __________ 47
MENEST ____________ 32
MENOPUR __________ 31
MENOSTAR __________ 32
MENTAX ____________ 27
MENVEO ____________ 47
meperidine inj 25mg/ml 5
meperidine sol 50mg/5ml
__________________ 5
MEPHYTON _________ 48
meprobamate _________ 7
MEPRON ____________ 15
mercaptopurine ______ 17
meropenem _________ 15
MEROPENEM/SODIUM
CHLORIDE ________ 15
MERREM ____________ 15
mesalamine _________ 32
mesalamine dr _______ 32
mesna ______________ 17
MESNEX INJ 1GM __ 17
MESNEX TAB 400MG 17
MESTINON __________ 15
MESTINON TIMESPAN _ 15
METANX ____________ 30
metaxalone __________ 41
metformin hydrochloride
_________________ 11
metformin hydrochloride e
_________________ 11
methadone con 10mg/ml
__________________ 5
methadone inj 10mg/ml 5
METHADONE SOL
10MG/5ML ________ 5
METHADOSE __________ 5
methamphetamine hcl __ 3
methazolamide _______ 30
methenamine hippurate 47
methenamine mandelate
_________________ 47
methergine __________ 44
methimazole _________ 46
METHITEST ___________ 6
methocarbamol ______ 41
methocarbamol inj ___ 41
methotrexate ________ 17
methotrexate sodium __ 17
methoxsalen _________ 27
methscopolamine bromide
_________________ 46
methyldopa __________ 14
methyldopa/hydrochloroth
i _________________ 14
methylene blue _______ 12
methylergon inj 0.2mg/ml
_________________ 44
methylergonovine maleate
_________________ 44
METHYLIN ____________ 3
METHYLPHENIDATE CAP ER
__________________ 3
METHYLPHENIDATE TAB
ER ________________ 3
methylprednisolone ___ 24
methylprednisolone acetat
_________________ 24
methylprednisolone dose p
_________________ 24
methylprednisolone
sodium ___________ 24
methyltestosterone ____ 6
metoclopramide inj ___ 33
metoclopramide hcl ___ 33
metoclopramide
hydrochlor ________ 33
METOCLOPRAMIDE ODT33
metolazone __________ 30
metoprolol succinate er 20
metoprolol tartrate ___ 20
metoprolol tartrate tab 20
metoprolol/hydrochlorothi
_________________ 14
METROCREAM _______ 27
METROGEL __________ 27
METROLOTION _______ 27
metronidazol gel ______ 27
metronidazole _____ 15, 48
metronidazole in nacl 0.7
_________________ 15
metronidazole tab ____ 15
metronidazole vaginal _ 48
mexiletine hcl _________ 7
mibelas 24 fe _________ 23
MICARDIS ___________ 14
MICARDIS HCT _______ 14
MICONAZOLE 3 _______ 48
MICONAZOLE
NITRATE/ZINC O ___ 27
MICRHOGAM ULTRA-
FILTERED__________ 44
microgestin 1.5/30 ____ 23
microgestin 1/20 ______ 23
microgestin fe ________ 23
microgestin fe 1.5/30 __ 23
midazolam inj _______ 35
midazolam hcl ________ 35
midazolam hydrochloride
_________________ 35
midodrine hcl ________ 48
midodrine hydrochloride 48
miglitol ______________ 11
miglustat ____________ 35
Migraine Products ____ 36
MIGRANAL __________ 37
mili _________________ 23
MILLIPRED ___________ 24
MILLIPRED DP ________ 24
milrinone in dextrose __ 21
milrinone lactate ______ 21
mimvey _____________ 32
mimvey lo ___________ 32
MIMYX _____________ 27
MINASTRIN 24 FE _____ 23
MINERALS AND
ELECTROLYTES _____ 37
MINIPRESS __________ 14
MINIVELLE ___________ 32
MINOCIN ____________ 45
minocycline hcl _______ 45
minocycline hcl er _____ 45
minocycline hydrochloride
_________________ 46
MINOLIRA ___________ 46
minoxidil ____________ 14
MIOCHOL-E __________ 43
MIOSTAT ____________ 43
MIRAPEX ____________ 18
MIRAPEX ER _________ 18
MIRCETTE ___________ 23
MIRENA _____________ 23
mirtazapine __________ 10
mirtazapine odt _______ 10
MIRVASO____________ 27
Miscellaneous Therapeutic
Classes ___________ 38
misoprostol __________ 46
MITIGARE ___________ 34
mitomycin ___________ 17
mitoxantrone hcl ______ 17
M-M-R II ____________ 47
M-NATAL PLUS _______ 39
60
MOBIC ______________ 4
modafinil ____________ 3
moexipril hcl _________ 14
mometasone oin 0.1% 27
mometasone spr 50mcg
_________________ 41
MONOJECT BONE
MARROW BIOP ____ 36
mono-linyah _________ 23
MONONINE _________ 34
MONOVISC __________ 41
MONSELS FERRIC
SUBSULFATE ______ 35
montelukast sodium ___ 7
MONUROL __________ 47
MORPHABOND ER _____ 5
morphine sul sup 5mg __ 5
morphine sul tab ______ 5
morphine sulfate er ____ 5
morphine sulfate inj ____ 5
MOTEGRITY _________ 33
MOUTH/THROAT/DENTAL
AGENTS __________ 39
MOVANTIK __________ 33
MOVIPREP __________ 36
MOXEZA ____________ 43
moxifloxacin sol ______ 43
moxifloxacin tab ______ 32
MOZOBIL ___________ 35
MS CONTIN __________ 5
MULPLETA __________ 35
MULTAQ _____________ 7
MULTIGEN __________ 35
MULTIGEN PLUS _____ 35
MULTIVIT/FL CHW
0.25MG __________ 40
MULTIVIT/FL CHW 0.5MG
_________________ 40
multivitamin with fluorid 40
multi-vitamin/fluoride dr40
multi-vitamin/fluoride/ir 40
MULTIVITAMINS _____ 39
mupirocin ___________ 27
MUSCULOSKELETAL
THERAPY AGENTS __ 41
MUSE ______________ 21
m-vit _______________ 40
MYCAMINE _________ 12
MYCOBUTIN _________ 15
mycophenolate inj ____ 38
mycophenolate mofetil 38
mycophenolic acid dr __ 38
MYDAYIS ____________ 3
MYFORTIC __________ 38
MYLOTARG _________ 17
MYOBLOC ___________ 41
myorisan ____________ 27
MYRBETRIQ _________ 47
MYSOLINE ___________ 9
MYTESI _____________ 11
MYXREDLIN _________ 11
N
nabumetone __________ 4
nadolol _____________ 20
NAFCILLIN ___________ 44
nafcillin sodium ______ 44
nafrinse _____________ 37
NAFRINSE
DAILY/ACIDULATED 39
NAFRINSE DAILY/NEUTRAL
_________________ 39
nafrinse drops________ 37
NAFRINSE WEEKLY ____ 39
naftifine hcl __________ 27
naftifine hydrochloride 28
NAFTIN _____________ 28
nalbuphine hcl ________ 5
naloxone hcl _________ 12
naltrexone hcl ________ 12
NAMENDA __________ 45
NAMENDA TITRATION PAK
_________________ 45
NAMENDA XR _______ 45
NAMENDA XR TITRATION
PACK ____________ 45
NAMZARIC __________ 45
naproxen_____________ 4
naproxen dr __________ 4
naproxen sodium ______ 4
naproxen sodium er ____ 4
naratriptan hcl _______ 37
NARCAN ____________ 12
NARDIL _____________ 10
NASAL AGENTS -
SYSTEMIC AND
TOPICAL __________ 41
NASCOBAL __________ 35
NASONEX ___________ 41
NATACYN ___________ 43
NATAZIA ____________ 23
nateglinide __________ 11
NATELLE ONE ________ 40
NATROBA ___________ 28
NATURE-THROID _____ 46
NEBUPENT __________ 15
NEBUSAL____________ 25
necon 0.5/35-28 ______ 23
NEEVO DHA _________ 40
nefazodone hcl _______ 10
nefazodone hydrochloride
_________________ 10
neo/poly/hc sus 1% otic 44
neo/poly/hc sus op ___ 43
NEOCERA ___________ 28
neomycin sulfate ______ 3
neomycin/bacitracin/poly
m _______________ 43
neomycin/polymyxin/bacit
r ________________ 43
neomycin/polymyxin/dexa
me ______________ 43
neomycin/polymyxin/gram
ic ________________ 43
neomycin/polymyxin/hc 44
neo-polycin __________ 43
neo-polycin hc _______ 43
NEORAL _____________ 38
NEOSALUS___________ 28
NEOSALUS CP ________ 28
neostigmine methylsulfate
_________________ 15
NEOTUSS PLUS _______ 25
NEPHRON FA ________ 35
NEPHRO-VITE RX _____ 40
NERLYNX ____________ 17
NESINA _____________ 11
NESTABS ONE ________ 40
NEUAC KIT __________ 28
NEULASTA ___________ 35
NEULASTA ONPRO KIT _ 35
NEUPOGEN __________ 35
NEUPRO ____________ 18
NEUROMUSCULAR
AGENTS __________ 41
NEURONTIN __________ 9
NEUT _______________ 37
NEUTRASAL _________ 39
NEVANAC ___________ 43
nevirapine ________ 19, 20
nevirapine er _________ 20
NEXAVAR ___________ 17
NEXAVIR ____________ 38
NEXIUM CAP 20MG 46
NEXIUM GRA DR ___ 46
NEXIUM I.V. _________ 46
NEXPLANON _________ 23
niacin er ____________ 13
NIACOR _____________ 13
NIASPAN ____________ 13
NICAPRIN ___________ 30
nicardipine cap _______ 21
nicardipine inj _______ 21
NICOMIDE ___________ 40
NICOTROL INHALER ___ 45
NICOTROL NS ________ 45
nifedipine ___________ 21
nifedipine er _________ 21
nikki ________________ 23
NIMBEX _____________ 41
nimodipine __________ 21
NINLARO ____________ 17
NIPENT _____________ 17
nisoldipine er ________ 21
nitisinone ___________ 31
NITRO-BID ____________ 6
NITRO-DUR ___________ 6
nitrofurantoin ________ 47
nitrofurantoin macrocryst
_________________ 47
nitrofurantoin monohydrat
_________________ 47
nitroglycer inj 5mg/ml __ 6
nitroglycerin er ________ 6
NITROGLYCERIN IN
DEXTROSE _________ 6
nitroglycerin lingual ____ 6
nitroglycerin transdermal 6
nitroglycern sub _______ 6
NITROMIST ___________ 6
NITROPRESS _________ 14
NITROSTAT ___________ 6
niva-fol ______________ 30
NIVATOPIC PLUS ______ 28
NIVESTYM ___________ 35
nizatidine ____________ 46
NIZATIDINE SOL
15MG/ML _________ 46
NIZORAL ____________ 28
nolix ________________ 28
nora-be _____________ 23
NORCO ______________ 5
NORDITROPIN FLEXPRO 31
norepinephrine bitartrate
_________________ 48
norethindrone _____ 23, 44
norethindrone & ethinyl e
_________________ 23
norethindrone acetate 23,
44
norethindrone acetate/eth
_________________ 23
norethindrone/ethinyl est
_________________ 23
norgestimate/ethinyl estr
_________________ 23
NORITATE ___________ 28
norlyda _____________ 23
normal saline flush ____ 37
NORMOSOL -R _______ 38
NORMOSOL-M IN D5W 38
NORMOSOL-R ________ 38
NORMOSOL-R IN D5W _ 38
NORPACE_____________ 7
NORPACE CR __________ 7
NORPRAMIN _________ 10
NORTHERA __________ 48
nortrel 0.5/35 (28) ____ 23
nortrel 1/35 __________ 23
nortrel 7/7/7 _________ 23
nortriptyline hcl_______ 10
nortriptyline hydrochlori 10
NORVASC ___________ 21
NORVIR SOL 80MG/ML
_________________ 20
NORVIR TAB 100MG 20
NOVAREL ____________ 31
NOVOEIGHT _________ 34
61
NOVOLOG __________ 11
NOVOLOG FLEXPEN ___ 11
NOVOLOG MIX 70/30 _ 11
NOVOLOG MIX 70/30
PREFILL __________ 11
NOVOLOG PENFILL ___ 11
NOVOSEVEN RT ______ 34
NOXAFIL ____________ 12
np thyroid 120 _______ 46
np thyroid 15 ________ 46
np thyroid 30 ________ 46
np thyroid 60 ________ 46
np thyroid 90 ________ 46
NPLATE _____________ 35
NUCALA _____________ 7
NUCORT ____________ 28
NUCYNTA ____________ 5
NUCYNTA ER _________ 5
nudiclo solupak ______ 28
NUEDEXTA __________ 45
NUFERA ____________ 35
NULOJIX ____________ 38
NULYTELY/FLAVOR PACKS
_________________ 36
NUMOISYN _________ 39
NUTRASEB __________ 28
NUTROPIN AQ NUSPIN 10
_________________ 31
NUTROPIN AQ NUSPIN 20
_________________ 31
NUTROPIN AQ NUSPIN 5
_________________ 31
NUVAIL _____________ 28
NUVARING __________ 23
NUVESSA ___________ 48
NUVIGIL _____________ 3
nyamyc _____________ 28
NYMALIZE __________ 21
nystatin cre ________ 28
nystatin susp_______ 39
nystatin tab________ 12
nystatin/triamcinolone 28
nystop ______________ 28
O
OB COMPLETE _______ 40
OB COMPLETE ONE ___ 40
OB COMPLETE PETITE _ 40
OB COMPLETE/DHA __ 40
OBIZUR _____________ 34
OBSTETRIX DHA ______ 40
obstetrix ec _________ 40
OBSTETRIX ONE ______ 40
O-CAL FA ___________ 40
O-CAL PRENATAL _____ 40
OCALIVA ____________ 33
ocella ______________ 23
OCREVUS ___________ 45
octreotide acetate ____ 31
OCUFLOX ___________ 43
ODEFSEY ____________ 20
OFEV _______________ 45
ofloxacin ______ 32, 43, 44
ofloxacin dro 0.3% op 43
ofloxacin dro 0.3%otic 44
ogestrel _____________ 23
okebo ______________ 46
olanzapine _______ 19, 45
olanzapine inj _______ 19
olanzapine odt _______ 19
olanzapine/fluoxetine _ 45
olmesartan medoxomil 14
olmesartan
medoxomil/amlo ___ 14
olmesartan
medoxomil/hydr ___ 14
olopatadine dro 0.1% _ 43
olopatadine spr 0.6%__ 41
olopatadine hydrochloride
_________________ 43
OLUMIANT ___________ 4
OLUX _______________ 28
OLUX-E _____________ 28
omega-3-acid ethyl esters
_________________ 13
omeprazole _______ 46, 47
omeprazole dr _______ 47
omeprazole/sodium
bicarbo ___________ 47
OMNARIS ___________ 41
OMNITROPE _________ 31
ONCASPAR __________ 17
ondansetron inj ______ 12
ondansetron hcl ______ 12
ondansetron hydrochloride
_________________ 12
ondansetron odt______ 12
ONEXTON ___________ 28
ONFI ________________ 9
ONGLYZA ___________ 11
ONIVYDE ____________ 17
ONZETRA XSAIL ______ 37
OPDIVO_____________ 17
OPHTHALMIC AGENTS _ 42
opium ______________ 11
OPSUMIT ___________ 21
ORACEA ____________ 28
ORACIT _____________ 33
ORENCIA _____________ 4
ORENCIA CLICKJECT ____ 4
ORILISSA ____________ 31
ORKAMBI ___________ 45
orphenadrine citrate __ 41
orphenadrine citrate er 41
orsythia _____________ 23
ORTHO DF___________ 35
ORTHO MICRONOR ___ 23
ORTHO TRI-CYCLEN LO 23
ORTHO-NOVUM 1/35-28
_________________ 23
ORTHOVISC __________ 41
oscimin sub 0.125mg 47
oscimin tab 0.125mg 47
oscimin sr ___________ 47
oseltamivir phosphate _ 20
OSENI ______________ 11
OSMOPREP __________ 36
OSPHENA ___________ 31
OTEZLA ______________ 4
OTIC AGENTS ________ 43
OTOVEL _____________ 44
OTREXUP_____________ 4
OVACE PLUS _________ 28
OVACE PLUS WASH ___ 28
OVACE WASH ________ 28
OVIDREL ____________ 31
OXACILLIN ___________ 44
oxacillin sodium ______ 44
oxaliplatin ___________ 17
oxandrolone __________ 6
oxaprozin ____________ 4
OXAYDO _____________ 5
oxazepam ____________ 7
oxcarbazepine _________ 9
oxiconazole nitrate ____ 28
OXISTAT ____________ 28
OXSORALEN ULTRA ___ 28
OXTELLAR XR _________ 9
oxybutynin chloride ___ 47
oxybutynin chloride er _ 47
oxycodone hcl _________ 5
OXYCODONE HCL ER ___ 5
oxycodone hydrochloride 5
OXYCODONE
HYDROCHLORIDE E __ 5
oxycodone/acetaminophen
__________________ 5
oxycodone/ibuprofen ___ 5
OXYCONTIN __________ 5
OXYMORPHONE TAB
5MG ER ___________ 5
oxymorphone
hydrochloride _______ 5
Oxytocics ___________ 44
OXYTROL ____________ 47
OZEMPIC ____________ 11
OZURDEX ___________ 43
P
pacerone _____________ 7
paclitaxel ____________ 17
paliperidone er _______ 19
palonosetron hydrochlorid
_________________ 12
PALYNZIQ ___________ 31
PAMELOR ___________ 10
PANCREAZE__________ 30
pancuronium bromide _ 41
PANDEL _____________ 28
pantoprazole inj sod 40mg
_________________ 47
pantoprazole sodium dr 47
pantoprazole tab 40mg _ 47
PANZYGA ____________ 44
papaverine hcl ________ 21
PARAGARD INTRAUTERINE
COP ______________ 23
paregoric ____________ 11
paricalcitol ___________ 31
paricalcitol inj ________ 31
PARLODEL ___________ 18
paroex ______________ 39
paromomycin sulfate ___ 3
paroxetine ________ 10, 45
paroxetine hcl ________ 10
paroxetine hcl er ______ 10
paroxetine hydrochloride
_________________ 10
PASSIVE IMMUNIZING
AND TREATMENT
AGENTS __________ 44
PATADAY ____________ 43
PATANASE ___________ 41
PATANOL ____________ 43
PAXIL _______________ 10
PAXIL CR ____________ 10
PAZEO ______________ 43
PEDVAX HIB _________ 47
peg 3350/electrolytes __ 36
peg-3350/electrolytes __ 36
peg-3350/nacl/na bicarbon
_________________ 36
PEGASYS ____________ 20
PEGASYS PROCLICK ___ 20
PEGINTRON __________ 20
penicillamine _________ 38
penicillin g potassium __ 44
PENICILLIN G POTASSIUM
IN _______________ 44
penicillin g sodium ____ 44
penicillin v potassium __ 44
PENICILLINS __________ 44
PENLAC NAIL LACQUER 28
PENNSAID ___________ 28
PENTACEL ___________ 46
pentamidine isethionate 15
PENTASA ____________ 33
pentazocine/naloxone hcl 5
pentobarbital sodium __ 35
pentoxifylline er ______ 34
PEPCID ______________ 47
PERCOCET ____________ 5
PERFOROMIST ________ 7
perindopril erbumine __ 14
PERJETA _____________ 17
permethrin __________ 28
perphenazine _____ 19, 45
62
perphenazine/amitriptylin
_________________ 45
PERSERIS ___________ 19
PERTZYE ____________ 30
PFIZERPEN __________ 44
PHENACTIN AA PLUS __ 30
phenadoz ___________ 12
phenazo ____________ 33
phenazopyridine hcl___ 33
phenazopyridine hydrochlo
_________________ 33
PHENDIMETRAZ CAP
105MG ER _________ 3
phendimetraz tab 35mg 3
phenelzine sulfate ____ 10
PHENERGAN ________ 12
phenobarb inj 130mg/ml
_________________ 35
PHENOBARB INJ
65MG/ML ________ 35
phenobarbital_____ 35, 47
phenobarbital/belladonna
_________________ 47
phenohytro _________ 47
phenoxybenzamine
hydrochl _________ 14
phentermine hcl _______ 3
phentermine
hydrochloride ______ 3
phentolamine mesylate 14
phenylephrin sol 2.5% op
_________________ 43
PHENYTEK ___________ 9
phenytoin ____________ 9
phenytoin sodium _____ 9
phenytoin sodium
extended __________ 9
philith ______________ 23
phospha 250 neutral __ 38
phosphasal __________ 47
PHOSPHOLINE IODIDE _ 43
phospho-trin 250 neutral
_________________ 38
PHOTREXA VISCOUS __ 43
PHOTREXA/PHOTREXA
VISCOUS _________ 43
physiolyte ___________ 38
physiosol irrigation ___ 38
PHYSOSTIGMINE
SALICYLATE _______ 12
phytonadione ________ 48
PICATO _____________ 28
PICO SINGLE USE
NEGATIVE ________ 28
PIFELTRO ___________ 20
pilocarpine sol 1% op _ 43
pilocarpine tab ______ 39
pilocarpine hydrochloride
_________________ 39
pimecrolimus ________ 28
pimozide ____________ 45
pimtrea _____________ 23
pindolol _____________ 20
pioglitazone hcl ______ 11
pioglitazone hcl/metformi
_________________ 11
pioglitazone hcl-glimepir 11
pioglitazone hydrochlorid
_________________ 11
piperacillin sodium/tazob
_________________ 44
piperacillin/tazobactam 44
PIQRAY 200MG DAILY
DOSE ____________ 17
PIQRAY 250MG DAILY
DOSE ____________ 17
PIQRAY 300MG DAILY
DOSE ____________ 17
pirmella 1/35 ________ 23
pirmella 7/7/7 _______ 23
piroxicam ____________ 4
PLAQUENIL __________ 15
plasbumin-25 ________ 34
plasbumin-5 _________ 34
PLASMA-LYTE A ______ 38
PLASMA-LYTE-148 ____ 38
PLASMANATE ________ 34
PLAVIX _____________ 34
PLEGISOL ___________ 21
PLEGRIDY ___________ 45
PLEGRIDY STARTER PACK
_________________ 45
PLENVU _____________ 36
PLEXION ____________ 28
PLEXION CLEANSER ___ 28
PNEUMOVAX 23 _____ 47
PNV PRENATAL TAB PLUS
_________________ 40
PNV TABS 29-1 _______ 40
pnv-dha _____________ 40
PNV-DHA+DOCUSATE _ 40
PNV-OMEGA ________ 40
PODIAPN ___________ 30
PODOCON 25 IN BENZOIN
TIN ______________ 28
podofilox ____________ 28
polycin _____________ 43
poly-iron 150 forte ____ 35
polymyxin b sulfate/trime
_________________ 43
polysaccharide iron forte35
POLYTRIM ___________ 43
POLY-VI-FLOR ________ 40
POLY-VI-FLOR FS _____ 40
POLY-VI-FLOR/IRON __ 40
POMALYST __________ 17
portia-28 ____________ 23
PORTRAZZA _________ 17
posaconazole dr ______ 12
POTABA ____________ 48
potassium acetate ____ 38
potassium chloride ____ 38
potassium chloride cr __ 38
potassium chloride er __ 38
potassium chloride sr __ 38
potassium chloride/sodium
_________________ 38
potassium citrate er ___ 33
potassium citrate/citric 33
potassium phosphate __ 38
PRADAXA ____________ 8
PRALIDOXIME CHLORIDE
_________________ 12
PRALUENT ___________ 13
pramipexole dihydrochlori
_________________ 18
PRAMOSONE ________ 28
prasugrel ____________ 34
PRAVACHOL _________ 13
pravastatin sodium ____ 13
PRAXBIND ___________ 12
praziquantel __________ 6
prazosin hcl __________ 14
prazosin hydrochloride _ 14
PRECEDEX ___________ 35
PRED FORTE _________ 43
PRED MILD __________ 43
pred sod pho sol 1% op 43
PRED-G _____________ 43
PRED-G S.O.P. ________ 43
prednicarbate ________ 28
prednisolone ______ 24, 43
prednisolone acetate __ 43
prednisolone sodium
phosp ____________ 24
prednisone __________ 24
PREDNISONE SOL
5MG/5ML ________ 24
PREDNISONE INTENSOL 24
pregabalin ____________ 9
PREGNYL W/DILUENT
BENZYL ___________ 31
PREMARIN __________ 32
PREMPHASE _________ 32
PREMPRO ___________ 32
PRENA1 CHEW _______ 40
PRENA1 PEARL _______ 40
PRENATA ____________ 40
prenatabs rx _________ 40
PRENATAL ___________ 40
prenatal 19 __________ 40
PRENATAL LOW IRON _ 40
PRENATAL PLS MIS MV +
DHA _____________ 40
PRENATAL PLUS IRON _ 40
PRENATAL PLUS/IRON _ 40
PRENATAL VITAMINS PLUS
LO _______________ 40
PRENATAL-U _________ 40
PRENATE ____________ 40
PRENATE DHA ________ 40
PRENATE ELITE _______ 40
PRENATE ENHANCE ___ 40
PRENATE MINI _______ 40
PRENATE PIXIE _______ 40
PREPIDIL ____________ 44
PREPLUS ____________ 40
PREPOPIK ___________ 36
PRESERA ____________ 28
PREVACID ___________ 47
PREVACID SOLUTAB ___ 47
PREVIDENT 5000 BOOSTER
PL _______________ 39
PREVIDENT 5000 DRY
MOUTH __________ 39
PREVIDENT 5000 ENAMEL
PRO ______________ 39
PREVIDENT 5000 PLUS _ 39
PREVIDENT FLUORIDE _ 39
PREVIDENT RINSE _____ 39
previfem ____________ 23
PREVNAR 13 _________ 48
PREVYMIS ___________ 20
PREZCOBIX __________ 20
PREZISTA ____________ 20
PRIALT _______________ 4
PRIFTIN _____________ 15
PRILOSEC ____________ 47
primaquine phosphate _ 15
PRIMAXIN IV _________ 15
primidone ____________ 9
PRIMLEV _____________ 5
PRINIVIL ____________ 14
PRISMASOL B22GK 4/0 38
PRISMASOL BGK 0/2.5 _ 38
PRISMASOL BGK 2/0 __ 38
PRISMASOL BGK 2/3.5 _ 38
PRISMASOL BGK 4/2.5 _ 38
PRISMASOL BK 0/0/1.2 38
PRISTIQ _____________ 10
PRIVIGEN ____________ 44
PROAIR HFA __________ 7
PROAIR RESPICLICK ____ 7
probenecid __________ 34
probenecid/colchicine _ 34
procainamide hcl _______ 7
procainamide hydrochlorid
__________________ 7
PROCARDIA __________ 21
PROCARDIA XL _______ 21
PROCENTRA __________ 3
prochlorperazine ______ 19
prochlorperazine edisylat
_________________ 19
prochlorperazine maleate
_________________ 19
PROCORT _____________ 6
PROCRIT ____________ 35
PROCTOFOAM HC ______ 6
procto-med hc _________ 6
63
proctosol hc __________ 6
proctozone-hc ________ 6
PRODIGEN __________ 11
progesterone ________ 44
progesterone cap 100mg44
PROGESTERONE
COMPOUNDING ___ 44
Progestins __________ 44
PROGLYCEM _________ 11
PROGRAF CAP _____ 38
PROGRAF GRA 0.2MG
_________________ 38
PROGRAF INJ ______ 38
PROLASTIN-C ________ 45
PROLENSA __________ 43
PROLIA _____________ 31
PROMACTA _________ 35
PROMACTIN AA PLUS
20PE _____________ 30
promethazine hcl plain 12
promethazine hydrochlorid
_________________ 12
promethazine inj _____ 12
promethazine sup ____ 12
promethazine tab ____ 12
promethazine/codeine 25
promethazine/dextrometh
or _______________ 25
promethazine/phenylephri
n ________________ 25
promethegan ________ 13
PROMETRIUM _______ 44
PROMISEB __________ 28
propafenone hcl _______ 7
propafenone hydrochloride
__________________ 7
propantheline bromide 47
proparacaine hcl _____ 43
PROPECIA ___________ 28
propofol ____________ 33
propranolol hcl _______ 20
propranolol hcl er ____ 20
propranolol hydrochloride
_________________ 20
propranolol/hydrochloroth
_________________ 14
propylthiouracil ______ 46
PROQUAD __________ 48
PROSCAR ___________ 33
PROSTIN E2 _________ 44
PROSTIN VR PEDIATRIC 38
PROTONIX __________ 47
PROTOPIC___________ 28
protriptyline hcl ______ 10
PROVAYBLUE ________ 12
PROVENGE __________ 17
PROVENTIL HFA _______ 7
PROVERA ___________ 44
PROVIDA OB ________ 40
PROVISC ____________ 43
PROZAC ____________ 10
PSORCON ___________ 28
Psychotherapeutic and
Neurological Agents -
Misc. ____________ 44
PULMICORT __________ 7
PULMICORT FLEXHALER 7
PULMOZYME ________ 45
PURIXAN ____________ 17
PYLERA _____________ 47
pyrazinamide ________ 15
PYRIDIUM ___________ 33
pyridostigmine bromide 15
pyridostigmine bromide er
_________________ 15
PYROGALLIC ACID ____ 28
Q
QBRELIS ____________ 14
QBREXZA ___________ 28
QMIIZ ODT ___________ 4
QNASL ______________ 41
QNASL CHILDRENS ____ 41
QSYMIA _____________ 3
QTERN _____________ 11
QUADRAMET ________ 17
QUALAQUIN _________ 15
QUARTETTE _________ 23
QUAZEPAM _________ 36
QUDEXY XR __________ 9
QUELICIN ___________ 41
QUESTRAN LIGHT _____ 13
quetiapine fumarate __ 19
quetiapine fumarate er 19
QUFLORA FE _________ 40
QUFLORA FE PEDIATRIC 40
QUFLORA GUMMIES __ 40
QUFLORA PEDIATRIC __ 40
QUILLICHEW ER _______ 3
QUILLIVANT XR _______ 3
quinapril hcl _________ 14
quinapril hydrochloride 14
quinapril/hydrochlorothia
_________________ 14
quinidine gluconate cr __ 7
quinidine sulfate _______ 7
quinine sulfate _______ 15
QVAR REDIHALER _____ 7
R
rabeprazole sodium ___ 47
raloxifene hydrochloride 31
ramelteon ___________ 36
ramipril _____________ 14
RANEXA _____________ 6
ranitidine hcl _________ 47
ranitidine hydrochloride 47
ranolazine er __________ 6
RAPAFLO ____________ 33
RAPAMUNE _________ 38
RAPPORT RING LOADING
SYST _____________ 36
RAPPORT VACUUM
THERAPY DE _______ 36
rasagiline mesylate ____ 18
RASUVO _____________ 4
RAYALDEE ___________ 31
RAYOS ______________ 24
REBIF _______________ 45
REBIF REBIDOSE ______ 45
REBINYN ____________ 34
RECEDO _____________ 28
RECLAST ____________ 31
reclipsen ____________ 23
RECOMBINATE _______ 34
RECOMBIVAX HB _____ 48
RECTIV _______________ 6
RECURA _____________ 28
REGENECARE ________ 28
REGONOL ___________ 15
REGRANEX __________ 28
RELAFEN DS __________ 4
RELENZA DISKHALER __ 20
RELISTOR INJ _______ 33
RELISTOR TAB ______ 33
RELNATE DHA ________ 40
RELPAX _____________ 37
REMERON ___________ 10
REMERON SOLTAB ____ 10
REMESENSE _________ 36
REMICADE ___________ 33
REMODULIN _________ 21
RENACIDIN __________ 33
RENAGEL ____________ 33
renal caps ___________ 40
RENFLEXIS ___________ 33
reno caps ____________ 40
RENOVA ____________ 28
RENVELA ____________ 33
repaglinide __________ 11
REPATHA ____________ 13
REPATHA PUSHTRONEX
SYSTEM __________ 13
REPATHA SURECLICK __ 13
REQUIP XL ___________ 18
Respiratory Agents - Misc.
_________________ 45
RESTASIS MULTIDOSE _ 43
RESTORA RX _________ 11
RESTORIL ____________ 36
RETACRIT ___________ 35
RETAVASE ___________ 34
RETAVASE HALF-KIT ___ 34
RETIN-A _____________ 28
RETIN-A MICRO ______ 28
RETIN-A MICRO PUMP _ 28
RETISERT ____________ 43
REVATIO ____________ 21
REVLIMID ___________ 38
revonto _____________ 41
REXULTI _____________ 19
REYATAZ ____________ 20
RHEUMATE __________ 30
RHOFADE____________ 28
RHOGAM ULTRA-FILTERED
PLU ______________ 44
RHOPRESSA __________ 43
RIAX ________________ 28
ribavirin _____________ 20
RIDAURA _____________ 4
rifabutin _____________ 15
RIFADIN _____________ 15
RIFAMATE ___________ 15
rifampin _____________ 15
rifampin inj ________ 15
RIFATER _____________ 15
riluzole ______________ 42
rimantadine hcl _______ 20
RIMSO-50 ___________ 33
ringers injection ______ 38
ringers irrigation ______ 38
RINVOQ ______________ 4
RIOMET _____________ 11
risedronate sodium ____ 31
risedronate sodium dr _ 31
RISPERDAL CONSTA ___ 19
risperidone __________ 19
risperidone odt _______ 19
RITALIN ______________ 3
RITALIN LA ____________ 3
ritonavir _____________ 20
RITUXAN ____________ 17
rivastigmine tartrate ___ 45
rivastigmine transdermal45
rivelsa ______________ 23
RIXUBIS _____________ 34
rizatriptan benzoate ___ 37
rizatriptan benzoate odt 37
ROBAXIN ____________ 41
ROCALTROL __________ 31
ROCKLATAN _________ 43
rocuronium bromide ___ 42
ROMIDEPSIN _________ 17
ropinirole er _________ 18
ropinirole hcl _________ 18
ropinirole hydrochloride 18
ropivacaine __________ 36
ropivacaine hcl _______ 36
ROSADAN KIT ________ 28
rosuvastatin calcium ___ 13
ROTATEQ ____________ 48
ROWASA ____________ 33
roweepra _____________ 9
roweepra xr ___________ 9
ROXICODONE _________ 5
ROZEREM ___________ 36
RUBRACA ___________ 17
RYBELSUS ___________ 11
64
RYCLORA ___________ 13
RYDAPT ____________ 17
RYTARY _____________ 18
RYTHMOL SR _________ 7
RYVENT ____________ 13
S
SABRIL ______________ 9
SAFYRAL ____________ 23
SALEX ______________ 28
salicylic acid _________ 28
salicylic acid cream ___ 28
salicylic acid er _______ 28
salicylic acid lotion ____ 28
salicylic acid wart remov 28
SALIVAMAX _________ 39
salsalate _____________ 4
SALVAX _____________ 28
SALVAX DUO PLUS ___ 28
SANCUSO ___________ 12
SANDIMMUNE _______ 38
SANDIMMUNE INJ ___ 38
SANDOSTATIN _______ 31
SANDOSTATIN LAR DEPOT
_________________ 31
SANTYL _____________ 28
SAPHRIS ____________ 19
SARAFEM ___________ 45
sash kit for flushing vas _ 8
SAVAYSA ____________ 8
SAVELLA ____________ 45
SAVELLA TITRATION PACK
_________________ 45
SAXENDA ____________ 3
scopolamine _________ 12
SEASONIQUE ________ 23
SECONAL SODIUM ____ 36
SEEBRI NEOHALER _____ 8
SEGLUROMET _______ 11
SELECT-OB __________ 40
SELECT-OB+DHA _____ 40
selegiline hcl _________ 18
selegiline hydrochloride 18
selenium _________ 28, 38
selenium sulfide ______ 28
selenium sulfide shampoo
_________________ 28
SELRX ______________ 28
SELZENTRY __________ 20
SEMPREX-D _________ 25
se-natal 19 __________ 40
SENSIPAR ___________ 31
sensorcaine-mpf _____ 36
SEREVENT DISKUS _____ 8
SERNIVO ____________ 28
SEROQUEL __________ 19
SEROQUEL XR _______ 19
sertraline hcl ________ 10
sertraline hydrochloride 10
se-tan plus __________ 35
setlakin _____________ 23
sevelamer carbonate __ 33
sevelamer hydrochloride 33
sevoflurane __________ 33
SEYSARA ____________ 46
sf 39
sf 5000 plus__________ 39
SFROWASA __________ 33
sharobel ____________ 23
SHINGRIX ___________ 48
SIDEROL ____________ 40
SIGNIFOR ___________ 31
SIGNIFOR LAR ________ 31
sildenafil citrate ______ 21
SILENOR ____________ 36
SILIQ _______________ 28
silodosin ____________ 33
SILVADENE __________ 28
SILVER NITRATE ______ 28
silver sulfadiazine _____ 28
SIMBRINZA __________ 43
SIMETHICONE________ 33
simpesse ____________ 23
SIMPONI INJ
100MG/ML ________ 4
SIMPONI INJ 50/0.5ML 4
SIMPONI ARIA ________ 4
SIMULECT ___________ 39
simvastatin __________ 13
SINEMET ____________ 18
SINEMET CR _________ 18
SINGULAIR ___________ 8
SINUVA _____________ 41
sirolimus ____________ 39
SITAVIG _____________ 20
SIVEXTRO ___________ 15
SKELAXIN ___________ 41
SKLICE ______________ 28
SKYLA ______________ 23
SKYRIZI _____________ 28
SLYND ______________ 24
sod chloride inj 0.9% __ 38
SOD SUL/SULF EMU 10-5%
_________________ 28
sod sul/sulf liq wash ___ 28
sodium bicarbonate ___ 38
sodium chlor neb 10% _ 25
sodium chloride 0.9% _ 33
sodium chloride 0.45% _ 38
sodium chloride flush __ 38
sodium citrate/citric aci 33
SODIUM EDECRIN ____ 30
sodium ferric gluconate c
_________________ 35
sodium fluoride ______ 38
sodium nitroprusside __ 14
sodium phenylacetate/sodi
_________________ 31
sodium phosphate ____ 38
sodium polystyrene sulfon
_________________ 39
sodium sulfacetamide _28,
43
sodium sulfacetamide
sham 10% _________ 28
sodium sulfacetamide
wash _____________ 28
SOFOSBUVIR/VELPATASVI
R ________________ 20
solia ________________ 24
solifenacin succinate __ 47
SOLIQUA 100/33 _____ 11
SOLIRIS _____________ 34
SOLODYN ___________ 46
SOLOSEC _____________ 3
SOLU-CORTEF ________ 24
SOLU-MEDROL _______ 24
SOMA ______________ 41
SOMATULINE DEPOT __ 31
SOMAVERT __________ 31
SOOLANTRA _________ 28
SORBITOL ___________ 33
SORBITOL-MANNITOL _ 33
SORIATANE __________ 28
SORILUX ____________ 28
sotalol hcl ___________ 20
sotalol hcl (af) ________ 20
sotalol hcl af _________ 20
sotalol hydrochloride __ 20
SOTYLIZE ____________ 20
SPINOSAD ___________ 29
SPINRAZA ___________ 42
SPIRIVA HANDIHALER __ 8
SPIRIVA RESPIMAT _____ 8
spironolactone _______ 30
spironolactone/hydrochlor
_________________ 30
SPRAVATO 56MG DOSE 10
SPRAVATO 84MG DOSE 10
sprintec 28 __________ 24
SPRIX ________________ 4
SPRYCEL ____________ 17
sps _________________ 39
sronyx ______________ 24
ssd _________________ 29
SSKI ________________ 25
sss 10%-5% __________ 29
STALEVO 100 ________ 18
STALEVO 125 ________ 18
STALEVO 150 ________ 18
STALEVO 200 ________ 18
STALEVO 50 _________ 18
STALEVO 75 _________ 18
STAMARIL ___________ 48
STARLIX _____________ 11
stavudine____________ 20
STAXYN _____________ 21
STEGLATRO __________ 11
STEGLUJAN __________ 11
STELARA _________ 29, 33
STELARA INJ 5MG/ML
_________________ 33
STENDRA ____________ 21
sterile water irrigation _ 39
STIMATE ____________ 31
STIOLTO RESPIMAT ____ 8
STIVARGA ___________ 17
STRATTERA ___________ 3
STRENSIQ ___________ 31
STRIBILD ____________ 20
STRIVERDI RESPIMAT ___ 8
STROMECTOL _________ 6
STROVITE FORTE ______ 40
STROVITE ONE _______ 40
SUBLOCADE___________ 5
SUBOXONE ___________ 5
SUBSYS ______________ 5
subvenite _____________ 9
subvenite starter kit/ora _ 9
SUCRAID ____________ 30
SUCRALFATE SUS
1GM/10ML ________ 47
sucralfate tab 1gm ___ 47
SULFACET SOD OIN 10%
OP _______________ 43
sulfacet sod sol 10% op _ 43
sulfacetamide sodium _ 29,
43
sulfacetamide
sodium/pred _______ 43
sulfacetamide sodium/sulf
_________________ 29
sulfacleanse 8/4 ______ 29
sulfadiazine __________ 45
sulfamethoxazole/trimetho
_________________ 15
sulfasalazine _________ 33
sulfatrim pediatric _____ 15
sulfazine ____________ 33
Sulfonamides ________ 45
sulindac ______________ 4
SUMADAN WASH _____ 29
sumatriptan __________ 37
sumatriptan inj _______ 37
SUMATRIPTAN INJ
6MG/0.5 __________ 37
sumatriptan succinate _ 37
sumatriptan succinate ref
_________________ 37
sumatriptan/naproxen sodi
_________________ 37
SUNOSI ______________ 3
SUPARTZ FX__________ 41
SUPERVITE___________ 40
SUPPORT ____________ 40
SUPPORT-500 ________ 40
SUPPRELIN LA ________ 31
SUPRANE ____________ 33
SUPRAX _____________ 22
65
SUPREP BOWEL PREP KIT
_________________ 36
SURVANTA
INTRATRACHEAL ___ 45
SUSTIVA ____________ 20
SUTENT _____________ 17
SUVICORT ___________ 29
syeda ______________ 24
SYLATRON __________ 17
SYMAX DUOTAB _____ 47
SYMBICORT __________ 8
SYMBYAX ___________ 45
SYMDEKO ___________ 45
SYMJEPI ____________ 48
SYMLINPEN 120 ______ 11
SYMLINPEN 60 _______ 11
SYMPAZAN ___________ 9
SYMPROIC __________ 33
SYMTUZA ___________ 20
SYNAGIS ____________ 44
SYNAREL ____________ 31
SYNDROS ___________ 12
SYNERA ____________ 29
SYNJARDY __________ 11
SYNJARDY XR ________ 11
SYNTHROID _________ 46
SYNVISC ____________ 41
SYNVISC ONE ________ 41
SYPRINE ____________ 39
T
TABLOID ____________ 17
TACLONEX __________ 29
tacrolimus cap ______ 39
tacrolimus oin 0.1% __ 29
tadalafil ____________ 21
TAFINLAR ___________ 17
TAGRISSO ___________ 17
TAKHZYRO __________ 34
TALIVA _____________ 35
TALTZ ______________ 29
TALZENNA __________ 17
TAMIFLU____________ 20
tamoxifen citrate _____ 17
tamsulosin hydrochloride
_________________ 33
taperdex 6-day _______ 24
TAPERDEX 7-DAY _____ 24
TARCEVA ___________ 17
TARGADOX__________ 46
TARGRETIN CAP ____ 17
TARGRETIN GEL 1% __ 29
tarina 24 fe __________ 24
tarina fe 1/20 ________ 24
tarina fe 1/20 eq _____ 24
TARKA _____________ 14
TARON FORTE _______ 35
TARON-BC __________ 40
TARON-C DHA _______ 40
taron-crystals ________ 33
TARON-PREX ________ 40
TASIGNA ____________ 17
TASMAR ____________ 18
TAXOTERE___________ 17
TAYTULLA ___________ 24
tazarotene __________ 29
TAZICEF _____________ 22
TAZORAC CRE 0.1% _ 29
TAZORAC GEL 0.1% _ 29
taztia xt _____________ 21
TDVAX______________ 46
TECFIDERA __________ 45
TECFIDERA STARTER PACK
_________________ 45
TEFLARO ____________ 22
TEGRETOL ____________ 9
TEGRETOL-XR _________ 9
TEKTURNA __________ 14
TEKTURNA HCT ______ 14
telmisartan __________ 14
telmisartan/amlodipine 14
telmisartan/hydrochloroth
_________________ 14
temazepam __________ 36
TEMODAR CAP 100MG
_________________ 17
TEMODAR INJ 100MG
_________________ 17
TEMOVATE __________ 29
temozolomide _______ 17
temsirolimus _________ 17
TENCON _____________ 4
TENIVAC ____________ 46
tenofovir disoproxil fuma
_________________ 20
TENORMIN __________ 20
terazosin hcl _________ 14
terazosin hydrochloride 14
terbinafine hcl _______ 12
terbutaline sulfate _____ 8
terconazole __________ 48
TESSALON PERLES ____ 25
TESTIM ______________ 6
TESTOPEL ____________ 6
testosterone __________ 6
TESTOSTERONE _______ 6
testosterone cypionate _ 6
testosterone enanthate _ 6
TESTOSTERONE PUMP __ 6
testosterone topical solu 6
tetrabenazine ________ 45
tetracaine hcl ________ 36
tetracaine hydrochloride 43
tetracycline hydrochlorid
_________________ 46
Tetracyclines ________ 45
TETRIX ______________ 29
TEXACORT __________ 29
THEO-24 _____________ 8
theochron ____________ 8
THEOCHRON TAB 100MG
CR ________________ 8
theophylline __________ 8
theophylline cr ________ 8
theophylline er ________ 8
theophylline/d5w ______ 8
THERAHONEY ________ 29
THIOLA _____________ 33
THIOLA EC ___________ 33
thioridazine hcl _______ 19
thiotepa _____________ 17
thiothixene __________ 19
THRIVITE RX _________ 40
THROMBATE III _______ 34
THROMBATE III W/20 ML
STE ______________ 34
THYROID AGENTS _____ 46
tiagabine hydrochloride _ 9
TIAZAC _____________ 21
TICE BCG ____________ 17
TIKOSYN _____________ 7
tilia fe ______________ 24
timolol sol 0.5% op ___ 43
timolol maleate _______ 20
TIMOLOL MALEATE
OPHTHALMI _______ 43
TIMOPTIC ___________ 43
TIMOPTIC OCUDOSE __ 43
TIMOPTIC-XE ________ 43
tinidazole ___________ 15
TIROSINT ____________ 46
TIROSINT-SOL ________ 46
TISSEEL _____________ 35
TIVICAY _____________ 20
tizanidine hcl _________ 41
tizanidine hydrochloride 41
TL FOLATE ___________ 40
tl gard rx ____________ 35
TL G-FOL OS _________ 40
tl hydroquinone ______ 29
tl icon ______________ 35
TL-CARE DHA ________ 40
TL-FLUORIVITE _______ 40
tl-hem 150 ___________ 35
TL-ICARE ____________ 30
TL-SELECT ___________ 40
TOBI ________________ 3
TOBI PODHALER _______ 3
TOBRADEX OIN 0.3-0.1%
_________________ 43
TOBRADEX SUS 0.3-0.1%
_________________ 43
TOBRADEX ST ________ 43
tobramycin ________ 3, 43
tobramycin sol 0.3% op 43
tobramycin sulfate _____ 3
tobramycin/dexamethason
e ________________ 43
TOBREX _____________ 43
TOFRANIL ___________ 10
TOLAK ______________ 29
tolbutamide __________ 11
tolmetin sodium _______ 4
tolterodine tartrate ____ 47
tolterodine tartrate er _ 47
TOPAMAX ____________ 9
topex topical anesthetic 39
TOPICORT ___________ 29
topiramate ___________ 9
TOPIRAMATE ER _______ 9
toposar _____________ 17
TOPROL XL __________ 20
TORISEL _____________ 17
torsemide ___________ 30
TOUJEO MAX SOLOSTAR
_________________ 11
TOUJEO SOLOSTAR ____ 11
TOVIAZ _____________ 47
Toxoids _____________ 46
TPN ELECTROLYTES ____ 38
TRACE ELEMENTS
4/PEDIATRI ________ 38
TRADJENTA __________ 11
tramadol hcl __________ 5
TRAMADOL HCL CAP ER
100MG ____________ 5
tramadol hcl tab 100mg er
__________________ 5
tramadol hydrochloride/ac
__________________ 5
trandolapril __________ 14
trandolapril/verapamil hc
_________________ 14
tranexamic acid _______ 35
tranexamic acid inj ____ 35
TRANSDERM SCOP ____ 12
TRANSDERM-SCOP ____ 12
tranylcypromine sulfate 10
TRAUMANIL _________ 39
TRAVATAN Z _________ 43
trazodone hydrochloride 10
TRECATOR ___________ 15
TRELEGY ELLIPTA ______ 8
TRELSTAR MIXJECT ____ 17
TREMFYA ____________ 29
treprostinil ___________ 21
TRESIBA _____________ 11
TRESIBA FLEXTOUCH __ 11
tretinoin cap 10mg ___ 17
tretinoin gel 0.01% ___ 29
tretinoin microsphere __ 29
tretinoin microsphere pum
_________________ 29
TRETTEN ____________ 34
TREXALL _____________ 17
TREXIMET ___________ 37
TREZIX _______________ 5
tri femynor __________ 24
triamcinolon cre 0.5% __ 29
66
triamcinolone acetonide
______________ 24, 39
triamcinolone acetonide d
_________________ 39
triamterene ______ 30, 31
triamterene/hydrochloroth
_________________ 31
TRIANEX ____________ 29
triazolam ___________ 36
TRIBENZOR __________ 14
TRI-CHLOR __________ 29
TRICITRASOL _________ 8
tricitrates ___________ 33
TRICOR _____________ 13
TRIDESILON _________ 29
trientine hydrochloride 39
TRIESENCE __________ 43
tri-estarylla __________ 24
trifluoperazine hcl ____ 19
trifluoperazine hydrochlo
_________________ 19
trifluridine __________ 43
trigels-f forte ________ 35
trihexyphenidyl hcl ___ 18
trihexyphenidyl hydrochlo
_________________ 18
tri-legest fe __________ 24
TRILEPTAL ___________ 9
tri-linyah ____________ 24
TRILIPIX ____________ 13
tri-lo-estarylla ________ 24
tri-lo-marzia _________ 24
tri-lo-sprintec ________ 24
TRI-LUMA ___________ 29
trilyte ______________ 36
trimethobenzamide
hydroch __________ 12
trimethoprim _____ 15, 43
trimethoprim sulfate/poly
_________________ 43
TRIMO-SAN _________ 48
trinatal rx 1 __________ 40
TRINTELLIX __________ 10
triphrocaps __________ 40
tri-previfem _________ 24
TRIPTODUR _________ 31
tri-sprintec __________ 24
TRISTART DHA _______ 40
TRISTART ONE _______ 40
TRI-TABS DHA _______ 40
TRIUMEQ ___________ 20
TRIVEEN-DUO DHA ___ 40
TRI-VI-FLOR _________ 40
TRI-VI-FLORO ________ 40
tri-vitamin/fluoride ___ 40
trivora-28 ___________ 24
tri-vylibra ___________ 24
tri-vylibra lo _________ 24
TROKENDI XR _________ 9
trospium chloride _____ 47
trospium chloride er ___ 47
TRULANCE __________ 33
TRULICITY ___________ 11
TRUMENBA _________ 48
TRUSOPT ___________ 43
TRUVADA ___________ 20
TUDORZA PRESSAIR ____ 8
tulana ______________ 24
TUSSICAPS __________ 25
TWINRIX ____________ 48
TWYNSTA ___________ 14
tydemy _____________ 24
TYGACIL ____________ 46
TYKERB _____________ 17
TYLACTIN BUILD 20PE TYR
_________________ 30
TYLACTIN COMPLETE 15
PE _______________ 30
TYLACTIN RESTORE 10 _ 30
TYLACTIN RESTORE 5PE 30
TYLACTIN RTD 15 _____ 30
TYLENOL/CODEINE #3 __ 5
TYMLOS ____________ 32
TYPHIM VI __________ 48
TYSABRI ____________ 45
TYVASO REFILL _______ 21
U
UCERIS AER 2MG/ACT 6
UCERIS TAB 9MG __ 24
UDENYCA ___________ 35
ULCER
DRUGS/ANTISPASMODI
CS/ANTICHOLINERGICS
_________________ 46
ULESFIA_____________ 29
ULORIC _____________ 34
ULTANE _____________ 33
ultimatecare one _____ 40
ULTOMIRIS __________ 34
ULTRABAG/DIANEAL LOW
CALC _____________ 39
ULTRABAG/DIANEAL PD-
2/1.5 ____________ 39
ULTRABAG/DIANEAL PD-
2/2.5 ____________ 39
ULTRABAG/DIANEAL PD-
2/4.2 ____________ 39
ULTRAM _____________ 5
ULTRAVATE _________ 29
UNASYN ____________ 44
UNASYN BULK PACK __ 44
unithroid ____________ 46
UPTRAVI ____________ 21
urea ________________ 29
urea nail ____________ 29
urelle _______________ 47
uretron d/s __________ 47
uribel _______________ 47
URIMAR-T ___________ 47
Urinary Anti-infectives _ 47
Urinary Antispasmodics 47
uro-458 _____________ 47
UROCIT-K 10 _________ 33
UROCIT-K 15 _________ 33
UROCIT-K 5 __________ 33
UROGESIC-BLUE ______ 47
uro-mp _____________ 47
ursodiol _____________ 33
ustell _______________ 47
UTOPIC _____________ 29
V
VACCINES ___________ 47
VAGIFEM ____________ 48
VAGINAL AND RELATED
PRODUCTS ________ 48
valacyclovir hcl _______ 20
valacyclovir hydrochlorid20
VALCHLOR ___________ 29
VALCYTE ____________ 20
valganciclovir ________ 20
valganciclovir hydrochlor20
VALIUM ______________ 7
valproate sodium ______ 9
valproic acid __________ 9
valrubicin ___________ 17
valsartan ____________ 14
valsartan/hydrochlorothia
_________________ 14
VALTREX ____________ 20
VANCOMYCIN ________ 15
vancomycin hcl _______ 15
VANCOMYCIN HCL IN
DEXTROS _________ 15
vancomycin hydrochloride
_________________ 15
vandazole ___________ 48
VANIQA _____________ 29
vanoxide-hc __________ 29
VAQTA _____________ 48
vardenafil hydrochloride 21
VARIVAX ____________ 48
VASCAZEN ___________ 30
VASCEPA ____________ 13
VASCULERA __________ 30
VASERETIC __________ 14
Vasopressors ________ 48
VASOTEC ____________ 14
VAXCHORA __________ 48
v-c forte _____________ 40
VECTICAL ____________ 29
vecuronium bromide __ 42
VELCADE ____________ 17
VELETRI _____________ 21
velivet ______________ 24
VELPHORO __________ 33
VELTASSA ___________ 39
VELTIN ______________ 29
VEMLIDY ____________ 20
VENA-BAL DHA _______ 40
VENCLEXTA __________ 18
VENCLEXTA STARTING
PACK _____________ 18
VENELEX ____________ 29
venlafaxine hcl _______ 10
venlafaxine hcl er _____ 10
VENOFER ____________ 35
VENTOLIN HFA ________ 8
verapamil inj ________ 21
verapamil tab _______ 21
verapamil hcl _________ 21
verapamil hcl er_______ 21
verapamil hcl sa ______ 21
verapamil hcl sr _______ 21
VERDESO ____________ 29
VEREGEN ____________ 29
VERZENIO ___________ 18
VESICARE ____________ 47
VEXASYN ____________ 29
VFEND ______________ 12
VFEND IV ____________ 12
VIAGRA _____________ 21
VIBERZI _____________ 33
VIBRAMYCIN _________ 46
vicodin es _____________ 5
vicodin hp ____________ 5
VICTOZA ____________ 11
VIDEX _______________ 20
VIDEX EC ____________ 20
VIEKIRA PAK _________ 20
vienva ______________ 24
vigabatrin ____________ 9
vigadrone_____________ 9
VIGAMOX ___________ 43
VIIBRYD _____________ 10
VIIBRYD STARTER PACK 10
VILACTIN AA PLUS ____ 30
vilamit mb ___________ 47
VIMOVO _____________ 4
VIMPAT ______________ 9
VINATE M ___________ 40
vinate one ___________ 41
vinorelbine tartrate ____ 18
VIOKACE ____________ 30
viorele ______________ 24
VIRAMUNE __________ 20
VIRAMUNE XR _______ 20
VIRAZOLE ___________ 20
VIREAD _____________ 20
virt-caps _____________ 41
virt-gard _____________ 35
virt-phos 250 neutral __ 38
VIRT-PN DHA _________ 41
VISBIOME ___________ 30
VISCO-3 _____________ 41
VISTARIL _____________ 7
VISUDYNE ___________ 43
67
VITAFOL ____________ 41
VITAFOL FE+ _________ 41
VITAFOL GUMMIES ___ 41
VITAFOL STRIPS ______ 41
VITAFOL ULTRA ______ 41
VITAFOL-NANO ______ 41
VITAFOL-OB _________ 41
VITAFOL-OB+DHA ____ 41
VITAFOL-ONE ________ 41
VITAMEDMD ONE
RX/QUATREFO ____ 41
VITAMEDMD REDICHEW
RX ______________ 41
vitamin d ___________ 48
vitamin k1 ___________ 48
VITAMINS ___________ 48
vitamins a/c/d/fluoride 41
VITAPEARL __________ 41
VITATRUE ___________ 41
VITRASE ____________ 39
VIVELLE-DOT ________ 32
VIVITROL ___________ 12
VIVOTIF ____________ 48
VIZIMPRO ___________ 18
VOGELXO ____________ 6
VOGELXO PUMP ______ 6
vol-care rx___________ 41
VOL-NATE ___________ 41
VOL-PLUS ___________ 41
VOL-TAB RX _________ 41
VOLTAREN __________ 29
VOLUVEN ___________ 34
VONVENDI __________ 34
voriconazole _________ 12
voriconazole inj 200mg 12
VOSEVI _____________ 20
VOTRIENT ___________ 18
VP-PNV-DHA ________ 41
VPRIV ______________ 35
VRAYLAR ___________ 19
VSL#3 DS ___________ 11
VUSION ____________ 29
vyfemla _____________ 24
vylibra ______________ 24
VYNDAMAX _________ 21
VYNDAQEL __________ 21
VYTONE ____________ 29
VYTORIN____________ 13
VYVANSE ____________ 3
VYZULTA ____________ 43
W
warfarin sodium _______ 8
WELCHOL ___________ 13
WELLBUTRIN SR ______ 10
WELLBUTRIN XL ______ 10
wera _______________ 24
WIDE-SEAL SILICONE
DIAPHR __________ 36
wixela inhub __________ 8
WP THYROID ________ 46
wymzya fe ___________ 24
X
XADAGO ____________ 18
XALATAN ___________ 43
XALIX ______________ 29
XALKORI ____________ 18
XANAX ______________ 7
XANAX XR ____________ 7
XARELTO _____________ 8
XARELTO STARTER PACK 8
XELJANZ _____________ 4
XELJANZ XR __________ 4
XELODA_____________ 18
XEMBIFY ____________ 44
XENAZINE ___________ 45
XENICAL _____________ 3
XEOMIN ____________ 42
XEPI ________________ 29
XERAC AC ___________ 29
XERALUX ____________ 29
XERESE _____________ 29
XEROFORM NON-
OCCLUSIVE OI _____ 29
XEROFORM OCCLUSIVE
PETROL __________ 29
XEROSTOMIA RELIEF
SPRAY ___________ 39
XGEVA ______________ 32
XHANCE ____________ 41
XIAFLEX _____________ 39
XIFAXAN ____________ 15
XIGDUO XR __________ 11
XIIDRA______________ 43
XIMINO _____________ 46
XOFLUZA ____________ 20
XOLAIR ______________ 8
XOLEGEL ____________ 29
XOLEGEL COREPAK ___ 29
XOLEGEL DUO/HEAD &
SHOULD __________ 29
XOLEGEL DUO/XOLEX _ 29
XOPENEX _____________ 8
XOPENEX CONCENTRATE 8
XOPENEX HFA _________ 8
XOSPATA ____________ 18
XRYLIX ______________ 29
XTAMPZA ER __________ 6
XTANDI _____________ 18
XULANE _____________ 24
XULTOPHY 100/3.6 ___ 11
XYLOCAINE __________ 36
XYLOCAINE-MPF ______ 36
XYOSTED _____________ 6
XYREM _____________ 45
XYZBAC _____________ 30
Y
YASMIN 28 __________ 24
YAZ ________________ 24
YERVOY _____________ 18
YUPELRI ______________ 8
yuvafem ____________ 48
Z
zafirlukast ____________ 8
zaleplon _____________ 36
ZALTRAP ____________ 18
ZANAFLEX ___________ 41
ZANOSAR ___________ 18
zarah _______________ 24
ZARONTIN ____________ 9
ZARXIO _____________ 35
ZATEAN-PN DHA______ 41
ZATEAN-PN PLUS _____ 41
ZEGERID ____________ 47
ZELAC ______________ 11
ZELAPAR ____________ 18
ZELBORAF ___________ 18
ZELNORM ___________ 33
ZEMAIRA ____________ 45
ZEMBRACE SYMTOUCH 37
ZEMPLAR____________ 32
zenatane ____________ 29
ZENPEP _____________ 30
zenzedi tab 5mg _____ 3
ZENZEDI TAB 7.5MG _ 3
ZEPATIER ____________ 20
ZESTRIL _____________ 14
ZETIA _______________ 13
ZETONNA ___________ 41
ZIANA ______________ 29
zidovudine ___________ 20
ZINC SULFATE ________ 38
ZINECARD ___________ 18
ZINPLAVA ___________ 44
ZIOPTAN ____________ 43
ziprasidone hcl _______ 19
ZIPSOR _______________ 4
ZIRGAN _____________ 43
ZITHRANOL __________ 29
ZITHROMAX _________ 36
ZOCOR ______________ 13
ZOFRAN _____________ 12
ZOHYDRO ER __________ 6
ZOLADEX ____________ 18
zoledronic acid _______ 32
ZOLINZA ____________ 18
zolmitriptan __________ 37
zolmitriptan odt ______ 37
ZOLOFT _____________ 10
zolpidem tartrate _____ 36
zolpidem tartrate er ___ 36
ZOMACTON __________ 32
ZOMIG ______________ 37
ZOMIG SPR 5MG __ 37
ZONALON ___________ 29
ZONEGRAN ___________ 9
zonisamide ___________ 9
ZONTIVITY ___________ 34
ZORTRESS ___________ 39
ZORVOLEX ____________ 4
ZOSTAVAX ___________ 48
zovia 1/35e __________ 24
ZOVIRAX CRE 5% ___ 29
ZOVIRAX OIN 5% ___ 29
ZTLIDO ______________ 29
ZUBSOLV _____________ 6
ZUPLENZ ____________ 12
ZYCLARA ____________ 29
ZYCLARA PUMP ______ 29
ZYFLO ________________ 8
ZYKADIA ____________ 18
ZYLET _______________ 43
ZYLOPRIM ___________ 34
ZYMAXID ____________ 43
ZYPITAMAG __________ 13
ZYPREXA ____________ 19
ZYPREXA RELPREVV ___ 19
ZYPREXA ZYDIS _______ 19
ZYTIGA ______________ 18
ZYVEXOL ____________ 30
ZYVIT _______________ 30
ZYVOX ______________ 15
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