2020 FORMULARY...Jun 01, 2020 · drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing

Medicare HMO BlueSM SaverRx (HMO) Medicare HMO BlueSM ValueRx (HMO)Medicare HMO BlueSM PlusRx (HMO)

Medicare HMO BlueSM FlexRx (HMO-POS)

2020 FORMULARY(LIST OF COVERED DRUGS)

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

20160, Version 7

This formulary was updated on 6/01/2020. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare-options.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield of Massachusetts. When it refers to “plan” or “our plan,” it means Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx.

This document includes a list of the drugs (formulary) for our plan, which is current as of 6/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/co-insurance may change on January 1, 2021, and from time to time during the year.

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What is the Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue PlusRx (HMO), and Medicare HMO Blue FlexRx (HMO-POS) Formulary?A formulary is a list of covered drugs selected by Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• Drugs removed from the market. If the Food and Drug Administration deems a drug onour formulary to be unsafe or the drug’s manufacturer removes the drug from the market,we will immediately remove the drug from our formulary and provide notice to memberswho take the drug.

• Other changes. We may make other changes that affect members currently taking a drug.For instance, we may add a new generic drug to replace a brand name drug currently onthe formulary, or add new restrictions to the brand name drug or move it to a differentcost-sharing tier. Or we may make changes based on new clinical guidelines. If we removedrugs from our formulary, or add prior authorization, quantity limits and/or step therapyrestrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affectedmembers of the change at least 30 days before the change becomes effective, or at thetime the member requests a refill of the drug, at which time the member will receivea 30-day supply of the drug.

» If we make these other changes, you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find informationin the section below entitled “How do I request an exception to the Medicare HMO BlueSaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue PlusRx (HMO),and Medicare HMO Blue FlexRx (HMO-POS) Formulary?”

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2020 Formulary

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

Our contact information appears on the front and back cover pages. The enclosed formulary is current as of 6/01/2020. To get updated information about the drugs covered by our plans, please contact us.

If we have a mid-year non-maintenance formulary change, we will provide a notice in the monthly Explanation of Benefits and on our website, www.bluecrossma.com/medicare-options. You may ask for a copy of the most recent formulary by contacting us. Our contact information appears on the front and back cover pages.

How do I use the Formulary?There are two ways to find your drug within the formulary:• Medical Condition. The formulary begins on page 9. The drugs in this formulary are

grouped into categories depending on the type of medical conditions that they are usedto treat. For example, drugs used to treat a heart condition are listed under the category,“Cardiovascular Agents.” If you know what your drug is used for, look for the categoryname in the list that begins on page 103. Then look under the category name for your drug.

• Alphabetical Listing. If you are not sure what category to look under, you should look foryour drug in the Index that begins on page 103. The Index provides an alphabetical listof all of the drugs included in this document. Both brand name drugs and generic drugsare listed in the Index. Look in the Index and find your drug. Next to your drug, you will seethe page number where you can find coverage information. Turn to the page listed in theIndex and find the name of your drug in the first column of the list.

What are generic drugs?Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue PlusRx (HMO), and Medicare HMO Blue FlexRx (HMO-POS) cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: Our plans require you or your physician to get prior authorization

for certain drugs. This means that you will need to get approval from our plan before youfill your prescriptions. If you don’t get approval, our plan may not cover the drug.

• Quantity Limits: For certain drugs, our plans limit the amount of the drug that our planswill cover. For example, our plans provide up to 30 capsules per 30 days per prescriptionfor Omeprazole 10 mg capsules. This may be in addition to a standard one-month orthree-month supply.

• Opioid Safety Edits: For certain drugs or combinations of drugs, there may be a safetylimit applied to prevent opioid overutilization. The limit on these medications may becumulative with other, similar medications that you may be taking in the same class.A dosage adjustment by your physician or an exception may be required if you exceedthe safety limit.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx formulary?” on page 4 for information about how to request an exception.

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2020 Formulary

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Member Service and ask if your drug is covered.

If you learn that Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx does not cover your drug, you have two options:• You can ask Member Services for a list of similar drugs that are covered by our plans.

When you receive the list, show it to your doctor and ask him or her to prescribea similar drug that is covered by our plans.

• You can ask our plans to make an exception and cover your drug. See below forinformation about how to request an exception.

How do I request an exception to the Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue PlusRx (HMO), and Medicare HMO Blue FlexRx (HMO-POS) Formulary?You can ask our plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug

will be covered at a pre-determined cost-sharing level, and you would not be able to askus to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is noton the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example,for certain drugs, our plans limit the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan’s exception process.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that might be covered under Medicare Part B.

For more informationFor more detailed information about your Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov.

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2020 Formulary

Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx FormularyThe formulary that begins on page 9 provides coverage information about the drugs covered by Medicare HMO Blue SaverRx, Medicare HMO Blue ValueRx, Medicare HMO Blue PlusRx, and Medicare HMO Blue FlexRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 103.

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

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

The abbreviations you may see in the formulary (list of covered drugs) include: Quantity Limits (QL): To help ensure that the quantity and dosage of your medications remains consistent with manufacturer, clinical, and Food and Drug Administration (FDA) recommendations, we maintain a list of medications subject to QL. When you fill a prescription for a medication subject to QL, your prescription is reviewed for:

• Dose Consolidation. Dose consolidation checks to see whether you’re taking twoor more daily doses of medicine that could be replaced with one daily dose providingthe same total amount of medication.

• Recommended Monthly Dosing Level. This process checks to see that your monthlydosage of medication is consistent with both the manufacturer’s and the FDA’s monthlydosing recommendations and clinical information. Your doctor can also apply for anexception to QL guidelines when medically necessary.

Mail Order (MO): These prescription drugs are available through mail-order.

Home Infusion (HI): This prescription drug may be covered under our medical benefit. For more information, call Member Services at 1-800-200-4255, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY users should call 711. Our contact information appears on the front and back cover pages.

Medical Benefit (MB): These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmacies or mail-order service.*

Prior Authorization (PA): These prescription drugs require prior authorization from the plan.

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Step Therapy (ST): These prescription drugs require you to first try another drug to treat your medical condition.

Limited Pharmacy Availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at 1-800-200-4255, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. TTY users should call 711. Our contact information appears on the front and back cover pages.

Medicare Part B or D (B/D): This prescription drug may be covered under Medicare Part B or D, depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

How much will I pay for my Medicare Advantage plan’s covered drugs?Your Medicare prescription drug costs: The amount you pay depends on which drug tier your drug is in under our plan. You can find out which drug tier your drug is in by looking in the formulary included in this booklet. See the next page for the copayment/co-insurance amount for each type of drug.

If you qualify for extra help with your drug costs, your costs for your drugs may be different than those described on the next page. Please refer to the plan Summary of Benefits or your Evidence of Coverage or call Member Service to find out what your costs are.

Your costs for drugs and supplies covered under your plan’s medical benefit: You will find some drugs and supplies listed in the formulary drug list with a “MB” note in the tier column. These drugs and supplies covered under your plan’s medical benefit are available through network retail pharmacies or mail-order service. However, they do not qualify for exception requests, extra help on drug costs, transition fills, or accumulate toward your total out-of-pocket costs to bring you through the coverage gap faster, like drugs covered under your Medicare prescription drug benefit.



2020 Formulary

Explanation of Tiers and Copayments/Co-insurance: Initial Coverage Stage

Plans Drug Tier Annual Deductible

30-day supply at a preferred network retail pharmacy

30-day supply at a standard network retail pharmacy

90-day supply at a network mail-order pharmacy

Medicare HMO Blue SaverRx (HMO)

Tier 1: Preferred Generic Drugs $0 for Tier 1 and Tier 2

$2 $8 $2

Tier 2: Generic Drugs $8 $16 $16

Tier 3: Preferred Brand Drugs

$320 for Tiers 3, 4, and 5

$42 $47 $84

Tier 4: Non-Preferred Brand Drugs

$95 $100 $190

Tier 5: Specialty Tier Drugs 26% 26% 26%

Medicare HMO Blue ValueRx (HMO)


$2 $8 $2



$320 for Tiers 3, 4, and 5

$42 $47 $84


$95 $100 $190


Medicare HMO Blue PlusRx (HMO)


$1 $6 $1



$200

for Tiers 3, 4, and 5

$42 $47 $84


$95 $100 $190


Medicare HMO Blue FlexRx (HMO-POS)


$1 $6 $1



$260

for Tiers 3, 4, and 5

$42 $47 $84


$95 $100 $190


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ANTI - INFECTIVES: ANTIFUNGALAGENTSDrug Name Tier Requirements/

LimitsAMBISOME 5 B/D PA, MO, HIamphotericin b 2 B/D PA, MO, HIcaspofungin 5 B/D PA, HIclotrimazole mucousmembrane

2 MO

CRESEMBAINTRAVENOUS

5 HI

CRESEMBA ORAL 5 MOfluconazole 2 MOfluconazole in nacl(iso-osm) intravenouspiggyback 200mg/100 ml

2 MO, HI

fluconazole in nacl(iso-osm) intravenouspiggyback 400mg/200 ml

2 HI

flucytosine 5 MOgriseofulvin microsize 2 MOgriseofulvinultramicrosize

2 MO

itraconazole oralcapsule

2 MO, QL (120 per30 days)

itraconazole oralsolution

2 MO

ketoconazole oral 2 MOmicafungin 5MYCAMINE 5 MO, HINOXAFILINTRAVENOUS

3 HI

NOXAFIL ORALSUSPENSION

5 MO

nystatin oralsuspension

2 MO

nystatin oral tablet 2 MO

ANTI - INFECTIVES: ANTIFUNGALAGENTS (continued)Drug Name Tier Requirements/

Limitsposaconazole oraltablet,delayedrelease (dr/ec)

5 MO

terbinafine hcl oral 2 MO, QL (30 per30 days)

voriconazoleintravenous

2 MO, HI

voriconazole oral 5 MO

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7. 9

ANTI - INFECTIVES: ANTIVIRALSDrug Name Tier Requirements/

Limitsabacavir 2 MOabacavir-lamivudine 2 MOabacavir-lamivudine-zidovudine

5 MO

acyclovir oral capsule 2 MOacyclovir oralsuspension 200 mg/5ml

2 MO

acyclovir oral tablet 2 MOacyclovir sodiumintravenous solution

2 B/D PA, MO, HI

adefovir 5 MOamantadine hcl 2 MOAPTIVUS 5 MOAPTIVUS (WITHVITAMIN E)

5

atazanavir oralcapsule 150 mg, 200mg

2 MO

atazanavir oralcapsule 300 mg

5 MO

ATRIPLA 5 MOBARACLUDE ORALSOLUTION

5 MO

BIKTARVY 5 MOcidofovir 5 B/D PA, MO, HICIMDUO 5 MOCOMPLERA 5 MOCRIXIVAN ORALCAPSULE 200 MG,400 MG

3 MO

DELSTRIGO 5 MODESCOVY 5 MO

ANTI - INFECTIVES: ANTIVIRALS(continued)Drug Name Tier Requirements/

Limitsdidanosine oralcapsule,delayedrelease(dr/ec) 200mg

2

didanosine oralcapsule,delayedrelease(dr/ec) 250mg, 400 mg

2 MO

DOVATO 5 MOEDURANT 5 MOefavirenz oral capsule200 mg

5 MO

efavirenz oral capsule50 mg

2 MO

efavirenz oral tablet 5 MOEMTRIVA 3 MOentecavir 2 MOEPCLUSA 5 PA, MO, QL (28

per 28 days)EPIVIR HBV ORALSOLUTION

3 MO

EVOTAZ 5 MOfamciclovir 2 MOfosamprenavir 5 MOFUZEONSUBCUTANEOUSRECON SOLN

5 MO

ganciclovir sodiumintravenous

2 B/D PA, MO, HI

ganciclovir sodiumintravenous reconsoln

2 B/D PA, MO, HI

GENVOYA 5 MOHARVONI 5 PA, MO, QL (28

per 28 days)

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7.10


LimitsINTELENCE ORALTABLET 100 MG,200 MG

5 MO

INTELENCE ORALTABLET 25 MG

3 MO

INVIRASE ORALTABLET

5 MO

ISENTRESS HD 5 MOISENTRESS ORALPOWDER INPACKET

5 MO

ISENTRESS ORALTABLET

5 MO

ISENTRESS ORALTABLET,CHEWABLE100 MG

5 MO

ISENTRESS ORALTABLET,CHEWABLE25 MG

3 MO

JULUCA 5 MOKALETRA ORALTABLET 100-25 MG

3 MO

KALETRA ORALTABLET 200-50 MG

5 MO

lamivudine 2 MOlamivudine-zidovudine 2 MOLEXIVA ORALSUSPENSION

3 MO

lopinavir-ritonavir 2 MOMAVYRET 5 PA, MO, QL (84

per 28 days)nevirapine oralsuspension

2

nevirapine oral tablet 2 MOnevirapine oral tabletextended release 24hr

2 MO


LimitsNORVIR ORALPOWDER INPACKET

3 MO

NORVIR ORALSOLUTION

3 MO

ODEFSEY 5 MOoseltamivir oralcapsule 30 mg


oseltamivir oralcapsule 45 mg, 75mg


oseltamivir oralsuspension forreconstitution


PIFELTRO 5 MOPREVYMISINTRAVENOUS

5 HI

PREVYMIS ORAL 5 MOPREZCOBIX 5 MOPREZISTA ORALSUSPENSION

5 MO

PREZISTA ORALTABLET 150 MG, 75MG

3 MO

PREZISTA ORALTABLET 600 MG,800 MG

5 MO

RELENZADISKHALER


RETROVIRINTRAVENOUS

3 MO, HI

REYATAZ ORALPOWDER INPACKET

5 MO

ribavirin oral capsule 2 MOribavirin oral tablet200 mg

2 MO



Limitsrimantadine 2 MOritonavir 2 MOSELZENTRY ORALSOLUTION

3 MO

SELZENTRY ORALTABLET 150 MG,300 MG

5 MO

SELZENTRY ORALTABLET 25 MG, 75MG

3 MO

SOVALDI ORALTABLET 200 MG

5 PA, MO, QL (28per 28 days)

SOVALDI ORALTABLET 400 MG


stavudine oral capsule 2 MOSTRIBILD 5 MOSYMFI 5 MOSYMFI LO 5 MOSYMTUZA 5 MOSYNAGIS 5 MO, LATEMIXYS 5 MOtenofovir disoproxilfumarate

2 MO

TIVICAY ORALTABLET 10 MG

3 MO

TIVICAY ORALTABLET 25 MG, 50MG

5 MO

TRIUMEQ 5 MOTROGARZO 5 MOTRUVADA 5 MOTYBOST 3 MOvalacyclovir 2 MOvalganciclovir oralrecon soln

5 MO


Limitsvalganciclovir oraltablet

5 MO

VEMLIDY 5 MOVIDEX 2 GRAMPEDIATRIC

3 MO

VIDEX EC ORALCAPSULE,DELAYEDRELEASE(DR/EC)125 MG

3 MO

VIEKIRA PAK 5 PA, MO, QL(112 per 28days)

VIRACEPT ORALTABLET

5 MO

VIREAD ORALPOWDER

5 MO

VIREAD ORALTABLET 150 MG,200 MG, 250 MG

5 MO

VOSEVI 5 PA, MO, QL (28per 28 days)

XOFLUZA ORALTABLET 20 MG


XOFLUZA ORALTABLET 40 MG


ZEPATIER 5 PA, MO, QL (28per 28 days)

zidovudine 2 MO


ANTI - INFECTIVES:CEPHALOSPORINSDrug Name Tier Requirements/

Limitscefaclor oral capsule 2 MOcefaclor oralsuspension forreconstitution 125mg/5 ml

2 MO

cefaclor oralsuspension forreconstitution 250mg/5 ml, 375 mg/5 ml

2

cefaclor oral tabletextended release 12hr

2 MO

cefadroxil oral capsule 2 MOcefadroxil oralsuspension forreconstitution 250mg/5 ml, 500 mg/5 ml

2 MO

cefadroxil oral tablet 2 MOcefazolin in dextrose(iso-os) intravenouspiggyback 1 gram/50ml, 2 gram/50 ml

2 MO, HI

cefazolin injectionrecon soln 1 gram,500 mg

2 MO, HI

cefazolin injectionrecon soln 10 gram

2 HI

cefazolin injectionrecon soln 100 gram,20 gram, 300 g

2 HI

cefazolin intravenous 2 HIcefdinir 2 MOcefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50ml

2

ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefepime in dextrose,iso-osm intravenouspiggyback 2gram/100 ml

2 MO

cefepime injection 2 MO, HIcefixime 2 MOcefotetan injection 2 HIcefotetan intravenous 2 HIcefoxitin in dextrose,iso-osm

2

cefoxitin intravenousrecon soln 1 gram, 2gram

2 MO, HI

cefoxitin intravenousrecon soln 10 gram

2 HI

cefpodoxime oralsuspension forreconstitution 100mg/5 ml

2 MO

cefpodoxime oralsuspension forreconstitution 50mg/5 ml

2

cefpodoxime oraltablet

2 MO

cefprozil 2 MOceftazidime injectionrecon soln 1 gram, 2gram

2 MO, HI

ceftazidime injectionrecon soln 6 gram

2 HI

ceftriaxone indextrose,iso-os

2 MO, HI

ceftriaxone injectionrecon soln 1 gram, 2gram, 250 mg, 500mg

2 MO, HI


ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitsceftriaxone injectionrecon soln 10 gram

2 HI

ceftriaxoneintravenous

2 MO, HI

cefuroxime axetil oraltablet

2 MO

cefuroxime sodiuminjection recon soln750 mg

2 MO, HI

cefuroxime sodiumintravenous reconsoln 1.5 gram

2 MO, HI

cefuroxime sodiumintravenous reconsoln 7.5 gram

2 HI

cephalexin 2 MOFETROJA 5SUPRAX ORALTABLET,CHEWABLE

3 MO

tazicef injection reconsoln 1 gram

2 HI

tazicef injection reconsoln 2 gram, 6 gram

2 MO, HI

tazicef intravenous 2TEFLARO 5 MO, HIZERBAXA 5 HI

ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDESDrug Name Tier Requirements/

Limitsazithromycinintravenous

2 MO, HI

azithromycin oral 2 MOclarithromycin oralsuspension forreconstitution

2 MO

clarithromycin oraltablet

2 MO

clarithromycin oraltablet extendedrelease 24 hr

2 MO

DIFICID 5 MOe.e.s. 400 oral tablet 2 MOery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

2 MO

erythrocin (asstearate) oral tablet250 mg

2 MO

ERYTHROCININTRAVENOUSRECON SOLN 500MG

3 MO, HI

erythromycinethylsuccinate oralsuspension forreconstitution

2 MO

erythromycinethylsuccinate oraltablet

2 MO

erythromycin oral 2 MO


ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVESDrug Name Tier Requirements/

Limitsalbendazole 5 MOALINIA ORALSUSPENSION FORRECONSTITUTION

3 MO

ALINIA ORAL TABLET 5 MOamikacin injectionsolution 1,000 mg/4ml

2 MO, HI

amikacin injectionsolution 500 mg/2 ml

2 MO, HI

ARIKAYCE 5 PA, MO, LAatovaquone 5 MOatovaquone-proguanil 2 MOaztreonam injectionrecon soln 1 gram

2 MO, HI

aztreonam injectionrecon soln 2 gram

2 MO, HI

bacitracinintramuscular

2 MO

BENZNIDAZOLE 3BETHKIS 5 B/D PA, MOCAPASTAT 3 HICAYSTON 5 MO, LAchloramphenicol sodsuccinate

2 HI

chloroquinephosphate

2 MO

cleocin intravenoussolution 300 mg/2 ml

2

clindamycin hcl 2 MOclindamycin in 5 %dextrose

2 MO, HI

clindamycin palmitatehcl

2 MO

clindamycin pediatric 2 MO

ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVES(continued)Drug Name Tier Requirements/

Limitsclindamycinphosphate injection

2 MO, HI

clindamycinphosphateintravenous solution600 mg/4 ml

2 MO, HI

COARTEM 3 MOcolistin (colistimethatena)

2 MO, HI

CYCLOSERINE 3 MODALVANCE 3 MO, HIdapsone oral 2 MODAPTOMYCININTRAVENOUSRECON SOLN 350MG (BRAND)

3 MO, HI

daptomycinintravenous reconsoln 500 mg

5 MO, HI

DARAPRIM 5 MOEMVERM 5 MOertapenem 2 MO, HIethambutol 2 MOgentamicin in nacl(iso-osm) intravenouspiggyback 100mg/100 ml, 60 mg/50ml, 80 mg/50 ml

2 MO, HI

gentamicin in nacl(iso-osm) intravenouspiggyback 80 mg/100ml

2 HI

gentamicin injectionsolution 40 mg/ml

2 MO, HI

gentamicin sulfate(ped) (pf)

2 MO



Limitshydroxychloroquine 2 MOimipenem-cilastatinintravenous reconsoln 250 mg

2 HI

imipenem-cilastatinintravenous reconsoln 500 mg

2 MO, HI

IMPAVIDO 3 MOisoniazid injection 2isoniazid oral 2 MOivermectin oral 2 MOlincomycin 2 HIlinezolid in dextrose5%

5 HI

linezolid oralsuspension forreconstitution

5 MO

linezolid oral tablet 2 MOlinezolid-0.9% sodiumchloride

5

mefloquine 2 MOmeropenem 2 MO, HImetro i.v. 2 MO, HImetronidazole in nacl(iso-os)

2 MO, HI

metronidazole oral 2 MONEBUPENT 3 B/D PA, MOneomycin 2 MOORBACTIV 5 MO, HIparomomycin 2 MOPASER 3 MOPENTAM 4 MOpentamidine inhalation 2 B/D PA, MO


Limitspentamidine injection 2 MOpolymyxin b sulfate 2 HIpraziquantel 2 MOPRETOMANID 3PRIFTIN 3 MOPRIMAQUINE 4 MOprimaquine (generic) 2 MOpyrazinamide 2 MOpyrimethamine 5 MOquinine sulfate 2 MORECARBRIO 5rifabutin 2 MOrifampin intravenous 2 MO, HIrifampin oral 2 MORIFATER 4 MOSIRTURO 5 MO, LASIVEXTROINTRAVENOUS

5 HI

SIVEXTRO ORAL 5 MOSTREPTOMYCIN 3 MOSYNERCID 5 HItigecycline 5 HItinidazole 2 MOTOBI PODHALERINHALATIONCAPSULE

5

TOBI PODHALERINHALATIONCAPSULE, W/INHALATIONDEVICE

5 MO

tobramycin in 0.225 %nacl

5 B/D PA, MO



Limitstobramycin sulfateinjection recon soln

2 HI

tobramycin sulfateinjection solution

2 MO, HI

TRECATOR 3 MOVANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 1GRAM/200 ML(BRAND)

3 MO

VANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 500MG/100 ML, 750MG/150 ML (BRAND)

3

VANCOMYCIN INDEXTROSE ISO-OSM (BRAND)

3

VANCOMYCININJECTION(BRAND)

3

vancomycinintravenous reconsoln 1,000 mg, 10gram, 500 mg, 750mg

2 MO, HI

VANCOMYCININTRAVENOUSRECON SOLN 1.25GRAM, 1.5 GRAM(BRAND)

3 MO, HI

VANCOMYCININTRAVENOUSRECON SOLN 1.25GRAM, 1.5 GRAM(BRAND)

3 HI


LimitsVANCOMYCININTRAVENOUSRECON SOLN 250MG (BRAND)

3 HI

vancomycinintravenous reconsoln 5 gram

2 MO, HI

vancomycin oralcapsule 125 mg

2 MO

vancomycin oralcapsule 250 mg

5 MO

vancomycin oral reconsoln

5 MO

VIBATIVINTRAVENOUSRECON SOLN 750MG

3

XENLETAINTRAVENOUS

3

XENLETA ORAL 3 QL (10 per 30days)

XIFAXAN ORALTABLET 550 MG

5 MO


ANTI - INFECTIVES: PENICILLINSDrug Name Tier Requirements/

Limitsamoxicillin oralcapsule

2 MO

amoxicillin oralsuspension forreconstitution

2 MO

amoxicillin oral tablet 2 MOamoxicillin oral tablet,chewable 125 mg,250 mg

2 MO

amoxicillin-potclavulanate oralsuspension forreconstitution

2 MO

amoxicillin-potclavulanate oraltablet

2 MO

amoxicillin-potclavulanate oraltablet extendedrelease 12 hr

2 MO

amoxicillin-potclavulanate oraltablet,chewable

2 MO

ampicillin oral capsule500 mg

2 MO

ampicillin sodiuminjection recon soln 1gram, 10 gram, 125mg

2 MO, HI

ampicillin sodiuminjection recon soln 2gram, 250 mg, 500mg

2 MO, HI

ampicillin sodiumintravenous

2 HI

ampicillin-sulbactaminjection recon soln1.5 gram, 3 gram

2 MO, HI

ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsampicillin-sulbactaminjection recon soln15 gram

2 HI

ampicillin-sulbactamintravenous reconsoln 1.5 gram

2 HI

ampicillin-sulbactamintravenous reconsoln 3 gram

2 MO, HI

BICILLIN L-A 4 MOdicloxacillin 2 MOnafcillin in dextroseiso-osm intravenouspiggyback 1 gram/50ml

2 HI

nafcillin in dextroseiso-osm intravenouspiggyback 2gram/100 ml

2 MO, HI

nafcillin injection reconsoln 1 gram, 2 gram

2 MO, HI

nafcillin injection reconsoln 10 gram

5 MO, HI

nafcillin intravenousrecon soln 1 gram

2 MO, HI

nafcillin intravenousrecon soln 2 gram

2 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50ml

2 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50ml

2 MO, HI

oxacillin injectionrecon soln 1 gram

2 HI


ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsoxacillin injectionrecon soln 10 gram

5 HI

oxacillin injectionrecon soln 2 gram

2 MO, HI

penicillin g potassiuminjection recon soln20 million unit

2 MO, HI

penicillin g potassiuminjection recon soln 5million unit

2 MO, HI

penicillin g procaine 2 MOpenicillin g sodium 2 MO, HIpenicillin v potassium 2 MOpfizerpen-g 2 HIpiperacillin-tazobactamintravenous reconsoln 13.5 gram

2 MO, HI

piperacillin-tazobactamintravenous reconsoln 2.25 gram,3.375 gram, 4.5 gram

2 MO, HI

piperacillin-tazobactamintravenous reconsoln 40.5 gram

2 HI

ANTI - INFECTIVES: QUINOLONESDrug Name Tier Requirements/

LimitsBAXDELAINTRAVENOUS

5 HI

BAXDELA ORAL 5 MOciprofloxacin 2ciprofloxacin hcl oral 2 MOciprofloxacin in 5 %dextrose intravenouspiggyback 200mg/100 ml

2 MO, HI

ciprofloxacin in 5 %dextrose intravenouspiggyback 400mg/200 ml

2 MO, HI

levofloxacin in d5wintravenouspiggyback 250 mg/50ml

2 HI

levofloxacin in d5wintravenouspiggyback 500mg/100 ml, 750mg/150 ml

2 MO, HI

levofloxacinintravenous

2 MO, HI

levofloxacin oral 2 MOmoxifloxacin oral 2 MOmoxifloxacin-sod.chloride(iso)

2 HI

ofloxacin oral tablet300 mg

2

ofloxacin oral tablet400 mg

2 MO


ANTI - INFECTIVES: SULFA'S /RELATED AGENTSDrug Name Tier Requirements/

Limitssulfadiazine 2 MOsulfamethoxazole-trimethoprimintravenous

2 MO, HI

sulfamethoxazole-trimethoprim oral

2 MO

sulfatrim 2 MO

ANTI - INFECTIVES:TETRACYCLINESDrug Name Tier Requirements/

Limitsdemeclocycline 2 MOdoxy-100 2 MO, HIdoxycycline hyclateintravenous

2

doxycycline hyclateoral capsule

2 MO

doxycycline hyclateoral tablet

2 MO

doxycycline hyclateoral tablet,delayedrelease (dr/ec) 100mg, 150 mg, 200 mg,50 mg, 75 mg

2 MO

doxycyclinemonohydrate oralcapsule

2 MO

doxycyclinemonohydrate oralsuspension forreconstitution

2 MO

doxycyclinemonohydrate oraltablet

2 MO

minocycline oralcapsule

2 MO

minocycline oral tablet 2 MOminocycline oral tabletextended release 24hr 105 mg, 55 mg, 65mg, 80 mg

5 MO

minocycline oral tabletextended release 24hr 115 mg, 135 mg,45 mg, 90 mg

2 MO

mondoxyne nl oralcapsule 100 mg, 75mg

2 MO

morgidox 2 MO


ANTI - INFECTIVES:TETRACYCLINES (continued)Drug Name Tier Requirements/

LimitsNUZYRAINTRAVENOUS

5 HI

NUZYRA ORAL 5 MOokebo oral capsule 75mg

2 MO

tetracycline 2 MO

ANTI - INFECTIVES: URINARYTRACT AGENTSDrug Name Tier Requirements/

Limitsmethenaminehippurate

2 MO

methenaminemandelate

2 MO

nitrofurantoin 2 MOnitrofurantoinmacrocrystal

2 MO

nitrofurantoinmonohyd/m-cryst

2 MO

trimethoprim 2 MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS:ADJUNCTIVE AGENTSDrug Name Tier Requirements/

Limitsdexrazoxane hclintravenous reconsoln 250 mg

5 HI

dexrazoxane hclintravenous reconsoln 500 mg

5 MO, HI

ELITEK 5 MO, HIKEPIVANCE 5 MO, HIleucovorin calciuminjection recon soln100 mg, 200 mg, 350mg, 50 mg

2 MO, HI

leucovorin calciuminjection recon soln500 mg

2 HI

leucovorin calciuminjection solution 10mg/ml

2 HI

leucovorin calciumoral

2 MO

levoleucovorin calciumintravenous reconsoln 50 mg

5 HI

levoleucovorin calciumintravenous solution

5 HI

mesna 2 MO, HIMESNEX ORAL 5 MOVISTOGARD 5 MOXGEVA 5 PA, MO


ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSDrug Name Tier Requirements/

Limitsabiraterone 5 PA, MOABRAXANE 5 MO, HIADAKVEO 5 PA, MOadriamycinintravenous reconsoln 10 mg

2 MO, HI

adriamycinintravenous solution

2 HI

adrucil intravenoussolution 2.5 gram/50ml

2 B/D PA, HI

adrucil intravenoussolution 500 mg/10ml

2 B/D PA, MO, HI

AFINITOR DISPERZ 5 PA, MOAFINITOR ORALTABLET 10 MG

5 PA, MO

ALECENSA 5 PA, MOALIMTA 5 MO, HIALIQOPA 5 MO, HI, LAALUNBRIG 5 PA, MOanastrozole 2 MOARRANON 5 HIARSENIC TRIOXIDEINTRAVENOUSSOLUTION 1 MG/ML

5

arsenic trioxideintravenous solution2 mg/ml

2

ARZERRA 5 B/D PA, MO, HIASTAGRAF XL 4 B/D PA, MOAVASTIN 5 MO, HIAYVAKIT 5 PA, MO, LAazacitidine 5 MO, HIazathioprine 2 B/D PA, MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS(continued)Drug Name Tier Requirements/

Limitsazathioprine sodium 2 B/D PA, HIBALVERSA 5 PA, MO, LABAVENCIO 5 MO, HI, LABELEODAQ 5 MO, HIBENDEKA 5 MOBESPONSA 5 MO, HIbexarotene 5 MObicalutamide 2 MObleomycin 2 B/D PA, MO, HIBLINCYTOINTRAVENOUS KIT

3 B/D PA, MO

BORTEZOMIB 5 MO, HIBOSULIF 5 PA, MOBRAFTOVI 5 MO, LABRUKINSA 5 PA, MO, LAbusulfan 5 HICABOMETYX 5 PA, MO, LACALQUENCE 5 PA, MO, LAcapecitabine MB MOCAPRELSA ORALTABLET 100 MG

5 PA, LA

CAPRELSA ORALTABLET 300 MG

5 PA, MO, LA

carboplatinintravenous solution

2 MO, HI

carmustine 5 MOcisplatin intravenoussolution

2 MO, HI

cladribine 5 B/D PA, MO, HIclofarabine 5 HICOMETRIQ 5 PA, MOCOPIKTRA 5 PA, MO, LA



LimitsCOTELLIC 5 PA, MO, LAcyclophosphamideintravenous

2 MO

cyclophosphamideoral capsule

2 B/D PA, MO

cyclosporineintravenous

2 B/D PA, HI

cyclosporine modified 2 B/D PA, MOcyclosporine oralcapsule

2 B/D PA, MO

CYRAMZA 5 B/D PA, MO, HIcytarabine 2 B/D PA, MO, HIcytarabine (pf)injection solution 100mg/5 ml (20 mg/ml),2 gram/20 ml (100mg/ml)

2 B/D PA, MO, HI

cytarabine (pf)injection solution 20mg/ml

2 B/D PA, HI

dacarbazine 2 MO, HIdactinomycin 5 HIDARZALEX 5 MO, HI, LAdaunorubicinintravenous solution

2 HI

DAURISMO 5 PA, MOdecitabine 5 MO, HIdocetaxel intravenoussolution 160 mg/16ml (10 mg/ml), 20mg/2 ml (10 mg/ml)

5 HI


Limitsdocetaxel intravenoussolution 160 mg/8 ml(20 mg/ml), 20 mg/ml(1 ml), 80 mg/4 ml(20 mg/ml), 80 mg/8ml (10 mg/ml)

5 MO, HI

DOCETAXELINTRAVENOUSSOLUTION 20 MG/ML (BRAND)

5 HI

doxorubicinintravenous reconsoln 50 mg

2 MO, HI

doxorubicinintravenous solution

2 MO, HI

doxorubicin, peg-liposomal

5 MO, HI

ELIGARD 3 MOELIGARD (3 MONTH) 3 MOELIGARD (4 MONTH) 3 MOELIGARD (6 MONTH) 3 MOEMCYT 5 MOEMPLICITI 5 B/D PA, MO, HIENHERTU 5 MOENVARSUS XR 4 B/D PA, MOepirubicin intravenoussolution

2 MO, HI

ERBITUX 5 MO, HIERIVEDGE 5 PA, MOERLEADA 5 PA, MOerlotinib 5 PA, MOERWINAZE 5 MO, HIETOPOPHOS 3 MO, HIetoposide intravenous 2 MO, HI



Limitsetoposide oral MB MOeverolimus(antineoplastic)

5 PA, MO

everolimus(immunosuppressive)

5 B/D PA, MO

exemestane 2 MOFARYDAK 5 PA, MOFASLODEX 5 MOFIRMAGON KIT WDILUENT SYRINGESUBCUTANEOUSRECON SOLN 120MG

5 MO

FIRMAGON KIT WDILUENT SYRINGESUBCUTANEOUSRECON SOLN 80MG

3 MO

floxuridine 2 B/D PAfludarabineintravenous reconsoln

2 MO, HI

fludarabineintravenous solution

2 HI

fluorouracilintravenous

2 B/D PA, MO, HI

flutamide 2 MOFOLOTYNINTRAVENOUSSOLUTION 20 MG/ML (1 ML)

3 MO, HI

FOLOTYNINTRAVENOUSSOLUTION 40 MG/2ML (20 MG/ML)

5 MO, HI

fulvestrant 5 MO


LimitsGAZYVA 3 MOgemcitabineintravenous reconsoln 1 gram, 200 mg

2 MO, HI

gemcitabineintravenous reconsoln 2 gram

2 HI

gemcitabineintravenous solution1 gram/26.3 ml (38mg/ml), 200 mg/5.26ml (38 mg/ml)

2 MO, HI

gemcitabineintravenous solution2 gram/52.6 ml (38mg/ml)

2 HI

gengraf oral capsule100 mg, 25 mg

2 B/D PA, MO

gengraf oral solution 2 B/D PA, MOGILOTRIF 5 PA, MOGLEOSTINE ORALCAPSULE 10 MG,100 MG, 40 MG

3 MO

HALAVEN 5 MO, HIHERCEPTINHYLECTA

5 MO

HERCEPTININTRAVENOUSRECON SOLN 150MG

5 MO, HI

HERZUMA 5HYCAMTIN ORAL MB MOhydroxyurea 2 MOIBRANCE 5 PA, MOICLUSIG 5 PAidarubicin 2 HI



LimitsIDHIFA 5 PA, MO, LAifosfamide intravenousrecon soln

2 MO, HI

ifosfamide intravenoussolution 1 gram/20 ml

2 MO, HI

ifosfamide intravenoussolution 3 gram/60 ml

2 HI

imatinib 5 MOIMBRUVICA 5 PA, MOIMFINZI 5 MO, HI, LAINFUGEM 5 HIINLYTA 5 PA, MOINREBIC 5 PA, MO, LAIRESSA 5 PA, MOirinotecan intravenoussolution 100 mg/5 ml,40 mg/2 ml

2 MO, HI

irinotecan intravenoussolution 300 mg/15ml, 500 mg/25 ml

2 HI

ISTODAX 5 MO, HIIXEMPRA 5 MO, HIJAKAFI 5 PA, MOJEVTANA 5 MO, HIKADCYLA 5 PA, MO, HIKANJINTI 5 MOKEYTRUDAINTRAVENOUSSOLUTION

5 PA, MO, HI

KISQALI 5 PA, MOKISQALI FEMARACO-PACK

5 PA, MO

KYPROLIS 5 MO, HI


LimitsLENVIMA 5 PA, MOletrozole 2 MOLEUKERAN 3 MOleuprolidesubcutaneous kit

5 MO

LIBTAYO 5 PA, MO, HILONSURF 5 PA, MOLORBRENA 5 PA, MOLUMOXITI 5 PA, MO, HI, LALUPRON DEPOT 5 MOLUPRON DEPOT (3MONTH)

5 MO

LUPRON DEPOT (4MONTH)

5 MO

LUPRON DEPOT (6MONTH)

5 MO

LUPRON DEPOT-PED

5 MO

LUPRON DEPOT-PED (3 MONTH)

5 MO

LYNPARZA ORALTABLET

5 PA, MO

LYSODREN 3 MOMATULANE 5 MOmegestrol oralsuspension 400mg/10 ml (10 ml)

2 PA

megestrol oralsuspension 400mg/10 ml (40 mg/ml),625 mg/5 ml

2 PA, MO

megestrol oral tablet 2 PA, MOMEKINIST 5 PA, MOMEKTOVI 5 MO, LA



Limitsmelphalan 2 B/D PA, MOmelphalan hcl 5 HImercaptopurine 2 MOmethotrexate sodium(pf) injection reconsoln

2 B/D PA, HI

methotrexate sodium(pf) injection solution

2 B/D PA, MO, HI

methotrexate sodiuminjection

2 B/D PA, MO, HI

methotrexate sodiumoral

2 B/D PA, MO

mitomycin intravenousrecon soln 20 mg, 5mg

2 MO, HI

mitomycin intravenousrecon soln 40 mg

5 MO, HI

mitoxantrone 2 MO, HIMVASI 5 MOmycophenolate mofetil(hcl)

2 B/D PA, HI

mycophenolate mofetiloral capsule

2 B/D PA, MO

mycophenolate mofetiloral suspension forreconstitution

5 B/D PA, MO

mycophenolate mofetiloral tablet

2 B/D PA, MO

mycophenolatesodium oral tablet,delayed release (dr/ec)

2 B/D PA, MO

MYLERAN MB MOMYLOTARG 5 MO, HI, LANERLYNX 5 PA, MO, LA


LimitsNEXAVAR 5 PA, MO, LAnilutamide 5 MONINLARO 5 PA, MONUBEQA 5 PA, MO, LANULOJIX 5 B/D PA, MO, HIoctreotide acetateinjection solution1,000 mcg/ml, 500mcg/ml

5 MO

octreotide acetateinjection solution 100mcg/ml, 200 mcg/ml,50 mcg/ml

2 MO

octreotide acetateinjection syringe 100mcg/ml (1 ml), 50mcg/ml (1 ml)

2 MO

octreotide acetateinjection syringe 500mcg/ml (1 ml)

5 MO

ODOMZO 5 PA, MO, LAOGIVRI 5 MOONCASPAR 5 MOONIVYDE 5 MOONTRUZANT 5OPDIVO 5 PA, MO, HIoxaliplatin intravenousrecon soln 100 mg

2 MO, HI

oxaliplatin intravenousrecon soln 50 mg

2 HI

oxaliplatin intravenoussolution

2 MO, HI

paclitaxel 2 MO, HIPADCEV 5 MOparaplatin 2 HI



LimitsPERJETA 5 MO, HIPIQRAY 5 PA, MOPOLIVY 5 PA, MOPOMALYST 5 PA, MO, LAPORTRAZZA 5 B/D PA, MOPOTELIGEO 5 MOPROGRAFINTRAVENOUS

3 B/D PA, MO, HI

PROGRAF ORALGRANULES INPACKET

3 B/D PA, MO

PURIXAN 5REVLIMID 5 PA, MO, LARITUXAN 5 PA, MO, HIRITUXAN HYCELA 5 MOROMIDEPSININTRAVENOUSRECON SOLN

5 MO

ROMIDEPSININTRAVENOUSSOLUTION

5

ROZLYTREK 5 PA, MORUBRACA 5 PA, MO, LARUXIENCE 5 MORYDAPT 5 PA, MOSANDOSTATIN LARDEPOTINTRAMUSCULARSUSPENSION,EXTENDED RELRECON

5 MO

SARCLISA 5 MOSIGNIFOR 5 MOSIGNIFOR LAR 5 MO


LimitsSIKLOS 5 MOSIMULECTINTRAVENOUSRECON SOLN 10MG

3 B/D PA, HI

SIMULECTINTRAVENOUSRECON SOLN 20MG

3 B/D PA, MO, HI

sirolimus oral solution 5 B/D PA, MOsirolimus oral tablet0.5 mg, 1 mg

2 B/D PA, MO

sirolimus oral tablet 2mg

5 B/D PA, MO

SOLTAMOX 4 MOSOMATULINEDEPOT

5 MO

SPRYCEL 5 PA, MOSTIVARGA 5 PA, MOSUTENT 5 PA, MOSYLVANT 5 MO, HISYNRIBO 5 MOTABLOID 3 MOtacrolimus oral 2 B/D PA, MOTAFINLAR 5 PA, MOTAGRISSO 5 PA, MO, LATALZENNA 5 PA, MOtamoxifen 2 MOTARGRETIN 1% GEL 5 MOTASIGNA 5 PA, MOTAZVERIK 5 PA, MO, LATECENTRIQ 5 MO, HI, LA



LimitsTEMODARINTRAVENOUS

3 MO

temozolomide MB MOtemsirolimus 5 MOTHALOMID 5 PA, MOthiotepa injectionrecon soln 100 mg

5

thiotepa injectionrecon soln 15 mg

5 MO

TIBSOVO 5 MOtoposar 2 MO, HItopotecan intravenousrecon soln

5 HI

topotecan intravenoussolution

5 MO, HI

toremifene 5 MOTRAZIMERA 5 MOTREANDAINTRAVENOUSRECON SOLN

5 MO, HI

TRELSTARINTRAMUSCULARSUSPENSION FORRECONSTITUTION

5 MO

tretinoin(antineoplastic)

5 MO

TRISENOXINTRAVENOUSSOLUTION 2 MG/ML

5 MO, HI

TRUXIMA 5 MOTURALIO 5 MO, LATYKERB 5 PA, MO, LAUNITUXIN 5 MOvalrubicin 2 MO


LimitsVALSTAR 3 MOVANTAS 3 MOVECTIBIX 5 B/D PA, MO, HIVELCADE 5 MO, HIVENCLEXTA ORALTABLET 10 MG, 50MG

3 PA, MO, LA

VENCLEXTA ORALTABLET 100 MG

5 PA, MO, LA

VENCLEXTASTARTING PACK

5 PA, MO, LA

VERZENIO 5 PA, MO, LAvinblastineintravenous solution

2 B/D PA, MO, HI

vincasar pfsintravenous solution1 mg/ml

2 B/D PA, MO, HI

vincristine 2 B/D PA, MO, HIvinorelbine 2 MO, HIVITRAKVI 5 PA, MO, LAVIZIMPRO 5 PA, MOVOTRIENT 5 PA, MOVYXEOS 5 B/D PA, MO, HIXALKORI 5 PA, MOXATMEP 3 B/D PA, MOXERMELO 5 MO, LAXOSPATA 5 PA, MO, LAXPOVIO 5 PA, MO, LAXTANDI 5 PA, MOYERVOY 5 MO, HIYONDELIS 5 MO, HIYONSA 5 PA, MOZALTRAP 5 MO, HI



LimitsZANOSAR 3 MO, HIZEJULA 5 PA, MO, LAZELBORAF 5 PA, MOZIRABEV 5 MOZOLADEX 3 MOZOLINZA 5 MOZORTRESS 5 B/D PA, MOZYDELIG 5 PA, MOZYKADIA ORALTABLET

5 PA, MO

ZYTIGA ORALTABLET 500 MG

5 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTSDrug Name Tier Requirements/

LimitsAPTIOM ORALTABLET 200 MG,400 MG, 800 MG

3 MO

APTIOM ORALTABLET 600 MG

5 MO

BANZEL 5 MOBRIVIACTINTRAVENOUS

3 HI

BRIVIACT ORAL 5 MOcarbamazepine oralcapsule, ermultiphase 12 hr

2 MO

carbamazepine oralsuspension 100 mg/5ml

2 MO

carbamazepine oraltablet

1 MO

carbamazepine oraltablet extendedrelease 12 hr

2 MO

carbamazepine oraltablet,chewable

1 MO

CELONTIN ORALCAPSULE 300 MG

3 MO

clobazam oralsuspension

2 PA, MO

clobazam oral tablet10 mg

2 PA, MO

clobazam oral tablet20 mg

5 PA, MO

clonazepam oral tablet 2 MOclonazepam oraltablet,disintegrating

2 MO

DIASTAT 4 MOdiazepam rectal 2 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTS (continued)Drug Name Tier Requirements/

LimitsDILANTIN 30 MG 3 MOdivalproex oralcapsule, delayed relsprinkle

2 MO

divalproex oral tabletextended release 24hr

2 MO

divalproex oral tablet,delayed release (dr/ec)

1 MO

EPIDIOLEX 5 MO, LAepitol 1 MOethosuximide 2 MOfelbamate oralsuspension

5 MO

felbamate oral tablet 2 MOfosphenytoin 2 MO, HIFYCOMPA ORALSUSPENSION

5 MO

FYCOMPA ORALTABLET

4 MO

gabapentin oralcapsule

1 MO

gabapentin oralsolution 250 mg/5 ml

2 MO

gabapentin oralsolution 250 mg/5 ml(5 ml), 300 mg/6 ml(6 ml)

2

gabapentin oral tablet600 mg, 800 mg

1 MO

lamotrigine oral tablet 1 MOlamotrigine oral tabletdisintegrating, dosepk

2 MO


Limitslamotrigine oral tabletextended release24hr

2 MO

lamotrigine oral tablet,chewable dispersible

2 MO

lamotrigine oral tablet,disintegrating

2 MO

lamotrigine oraltablets,dose pack

2 MO

levetiracetam in nacl(iso-os) intravenouspiggyback 1,000mg/100 ml, 1,500mg/100 ml

2 HI

levetiracetam in nacl(iso-os) intravenouspiggyback 500mg/100 ml

2 MO, HI

levetiracetamintravenous

2 MO, HI

levetiracetam oralsolution 100 mg/ml

2 MO

levetiracetam oralsolution 500 mg/5 ml(5 ml)

2

levetiracetam oraltablet

2 MO

levetiracetam oraltablet extendedrelease 24 hr

2 MO

NAYZILAM 5 MOoxcarbazepine 2 MOOXTELLAR XR 4 MOPEGANONE 3 MOphenobarbital 2 PA, MO



Limitsphenobarbital sodiuminjection solution 130mg/ml

2 MO

phenobarbital sodiuminjection solution 65mg/ml

2

phenytoin oralsuspension 100 mg/4ml

2

phenytoin oralsuspension 125 mg/5ml

2 MO

phenytoin oral tablet,chewable

2 MO

phenytoin sodiumextended

2 MO

phenytoin sodiumintravenous solution

2

pregabalin 2 MOprimidone 2 MOQUDEXY XR 4 PA, MOroweepra 2 MOroweepra xr 2SPRITAM 4 MOsubvenite 2 MOsubvenite starter(blue) kit

2 MO

subvenite starter(green) kit

2 MO

subvenite starter(orange) kit

2 MO

SYMPAZAN ORALFILM 10 MG, 20 MG

5 PA, MO

SYMPAZAN ORALFILM 5 MG

4 PA, MO


Limitstiagabine 2 MOtopiramate oralcapsule, sprinkle

2 PA, MO

topiramate oral tablet 1 PA, MOTROKENDI XR ORALCAPSULE,EXTENDEDRELEASE 24HR 100MG, 25 MG, 50 MG

4 PA, MO

TROKENDI XR ORALCAPSULE,EXTENDEDRELEASE 24HR 200MG

5 PA, MO

valproate sodium 2 MO, HIvalproic acid 2 MOvalproic acid (assodium salt) oralsolution 250 mg/5 ml

2 MO

valproic acid (assodium salt) oralsolution 250 mg/5 ml(5 ml), 500 mg/10 ml(10 ml)

2

VALTOCO 5 MOvigabatrin 5 MO, LAvigadrone 5 MO, LAVIMPATINTRAVENOUS

3 MO, HI

VIMPAT ORALSOLUTION

3 MO

VIMPAT ORALTABLET

3 MO

XCOPRIMAINTENANCEPACK

5 MO



LimitsXCOPRI ORALTABLET 100 MG,150 MG, 50 MG

4 MO

XCOPRI ORALTABLET 200 MG

5 MO

XCOPRI TITRATIONPACK

4 MO

zonisamide 2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTSDrug Name Tier Requirements/

LimitsAPOKYN 5 MO, LAbenztropine injection 2 MO, HIbenztropine oral 1 MObromocriptine 2 MOcarbidopa 2 MOcarbidopa-levodopaoral tablet

2 MO

carbidopa-levodopaoral tablet extendedrelease

2 MO

carbidopa-levodopaoral tablet,disintegrating

2 MO

carbidopa-levodopa-entacapone

2 MO

entacapone 2 MOINBRIJA INHALATIONCAPSULE, W/INHALATIONDEVICE

5 PA, MO

NEUPRO 4 MONOURIANZ 4 PA, MO, LApramipexole oraltablet

2 MO

pramipexole oraltablet extendedrelease 24 hr

2 MO

rasagiline 2 MOropinirole oral tablet 2 MOropinirole oral tabletextended release 24hr

2 MO

selegiline hcl 2 MOtolcapone 5 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTS(continued)Drug Name Tier Requirements/

Limitstrihexyphenidyl oralelixir

2 MO

trihexyphenidyl oraltablet

1 MO

ZELAPAR 4 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPYDrug Name Tier Requirements/

LimitsAIMOVIGAUTOINJECTOR


almotriptan malateoral tablet 12.5 mg


almotriptan malateoral tablet 6.25 mg


dihydroergotamineinjection

2 MO

dihydroergotaminenasal


eletriptan 2 MO, QL (24 per30 days)

EMGALITY PEN 3 PA, MO, QL (2per 30 days)

EMGALITY SYRINGESUBCUTANEOUSSYRINGE 120 MG/ML


EMGALITY SYRINGESUBCUTANEOUSSYRINGE 300 MG/3ML (100 MG/ML X 3)


ergotamine-caffeine 2 MOfrovatriptan 2 MO, QL (27 per

30 days)migergot 2 MOnaratriptan 2 MO, QL (18 per

30 days)rizatriptan oral tablet 2 MO, QL (36 per

30 days)rizatriptan oral tablet,disintegrating


sumatriptan nasalspray,non-aerosol 20mg/actuation



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPY(continued)Drug Name Tier Requirements/

Limitssumatriptan nasalspray,non-aerosol 5mg/actuation


sumatriptan succinateoral


sumatriptan succinatesubcutaneouscartridge


sumatriptan succinatesubcutaneous peninjector


sumatriptan succinatesubcutaneoussolution


sumatriptan succinatesubcutaneoussyringe 6 mg/0.5 ml


sumatriptan-naproxen 2 MO, QL (18 per30 days)

zolmitriptan 2 MO, QL (18 per30 days)

ZOMIG NASAL 3 MO, QL (18 per30 days)

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPYDrug Name Tier Requirements/

LimitsAUBAGIO 5 PA, MOAUSTEDO 5 MO, LAdalfampridine oraltablet extendedrelease 12 hr


donepezil oral tablet10 mg, 5 mg

1 MO

donepezil oral tablet23 mg

2 MO

donepezil oral tablet,disintegrating

1 MO

galantamine oralcapsule,ext rel.pellets 24 hr

2 MO

galantamine oralsolution

2 MO

galantamine oraltablet

2 MO

GILENYA ORALCAPSULE 0.5 MG

5 PA, MO

glatiramersubcutaneoussyringe 20 mg/ml


glatiramersubcutaneoussyringe 40 mg/ml


glatopa subcutaneoussyringe 20 mg/ml


glatopa subcutaneoussyringe 40 mg/ml


HORIZANT 3 MOINGREZZA 5 MO, LAINGREZZAINITIATION PACK

5 MO, LA

KEVEYIS 5 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

LimitsLEMTRADA 3 MOMAVENCLAD (10TABLET PACK)

5 PA, MO, LA

MAVENCLAD (4TABLET PACK)

5 PA, MO, LA


5 PA, MO, LA


5 PA, MO, LA


5 PA, MO, LA


5 PA, MO, LA


5 PA, MO, LA

MAYZENT 5 PA, MOmemantine oralcapsule,sprinkle,er24hr

2 MO

memantine oralsolution

2 MO

memantine oral tablet 2 MONUEDEXTA 5 PA, MOOCREVUS 5 MOONPATTRO 5 PA, MO, HI, LARADICAVA 5 MO, HIrivastigmine tartrate 2 MOrivastigminetransdermal

2 MO

RUZURGI 5 MOTECFIDERA 5 PA, MO, LATEGSEDI 5 PA, MO, LAtetrabenazine 5 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

LimitsTYSABRI 5 PA, MO, HI, LA


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPYDrug Name Tier Requirements/

Limitsbaclofen intrathecal 2 B/D PA, MObaclofen oral tablet 10mg, 20 mg

2 MO

carisoprodol 2 PA, MOcarisoprodol-aspirin 2 PA, MOcarisoprodol-aspirin-codeine

2 PA, MO

chlorzoxazone oraltablet 250 mg

2 PA

chlorzoxazone oraltablet 375 mg, 500mg, 750 mg

2 PA, MO

cyclobenzaprine 2 PA, MOdantroleneintravenous

2

dantrolene oral 2 MOmeprobamate 2 MOmetaxall 2 PA, MOmetaxalone 2 PA, MOmethocarbamolinjection

2 PA, HI

methocarbamol oral 2 PA, MOneostigminemethylsulfateintravenous solution0.5 mg/ml

2 MO

neostigminemethylsulfateintravenous solution1 mg/ml

2

orphenadrine citrateinjection

2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPY (continued)Drug Name Tier Requirements/

Limitsorphenadrine citrateoral tablet extendedrelease

2 PA, MO

orphenadrine-asa-caffeine oral tablet50-770-60 mg

2 PA

orphengesic forte 2 PApyridostigminebromide oral syrup

5 MO

pyridostigminebromide oral tablet

2 MO

pyridostigminebromide oral tabletextended release

2 MO

regonol 2revonto 2tizanidine 2 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICSDrug Name Tier Requirements/

Limitsacetaminophen-caff-dihydrocod oralcapsule

2 MO

acetaminophen-caff-dihydrocod oral tablet325-30-16 mg

2 MO

acetaminophen-codeine oral solution120 mg-12 mg /5 ml(5 ml), 300 mg-30 mg/12.5 ml

2

acetaminophen-codeine oral solution120-12 mg/5 ml

2 MO

acetaminophen-codeine oral tablet

2 MO

ascomp with codeine 2 PA, MObuprenorphine 2 PA, MObuprenorphine hclinjection solution

2 MO, HI

buprenorphine hclinjection syringe

2 HI

buprenorphine hclsublingual

2 MO

butalbital compoundw/codeine

2 PA, MO

butalbital-acetaminop-caf-cod

2 PA, MO

butalbital-acetaminophen oralcapsule

2 PA, MO

butalbital-acetaminophen oraltablet 25-325 mg

2 PA

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICS (continued)Drug Name Tier Requirements/

Limitsbutalbital-acetaminophen oraltablet 50-300 mg,50-325 mg

2 PA, MO

butalbital-acetaminophen-cafforal capsule

2 PA, MO

butalbital-acetaminophen-cafforal tablet 50-325-40mg

2 PA, MO

butalbital-aspirin-caffeine

2 PA, MO

codeine sulfate oraltablet

2 MO

codeine-butalbital-asa-caff

2 PA, MO

demerol (pf) injectionsolution 100 mg/ml

2 MO

duramorph (pf)injection solution 0.5mg/ml

2 MO, HI

duramorph (pf)injection solution 1mg/ml

2 HI

dvorah 2endocet oral tablet10-325 mg, 2.5-325mg, 5-325 mg,7.5-325 mg

2 MO

fentanyl citrate (pf)injection solution

2 MO

fentanyl citrate (pf)intravenous syringe100 mcg/2 ml (50mcg/ml)

2



Limitsfentanyl citrate buccallozenge on a handle

5 PA, MO

fentanyl transdermalpatch 72 hour 100mcg/hr, 12 mcg/hr, 25mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5mcg/hour, 75 mcg/hr

2 MO

fentanyl transdermalpatch 72 hour 87.5mcg/hour

5 MO

hydrocodone bitartrate 2 PA, MOhydrocodone-acetaminophen oralsolution 10-325mg/15 ml(15 ml)

2

hydrocodone-acetaminophen oralsolution 7.5-325mg/15 ml

2 MO

HYDROCODONE-ACETAMINOPHENORAL SOLUTION7.5-325 MG/15 ML(BRAND)

3

hydrocodone-acetaminophen oraltablet 10-300 mg,10-325 mg, 5-300mg, 5-325 mg,7.5-300 mg, 7.5-325mg

2 MO

hydrocodone-ibuprofen oral tablet10-200 mg, 5-200mg, 7.5-200 mg

2 MO


Limitshydromorphone (pf)injection solution 10(mg/ml) (5 ml), 10mg/ml

2 MO

hydromorphone (pf)injection solution 2mg/ml

2

hydromorphoneinjection solution 1mg/ml

2

hydromorphoneinjection solution 2mg/ml, 4 mg/ml

2 MO

hydromorphoneinjection syringe 1mg/ml, 4 mg/ml

2 MO

hydromorphoneinjection syringe 2mg/ml

2

hydromorphone oralliquid

2 MO

hydromorphone oraltablet

2 MO

hydromorphone oraltablet extendedrelease 24 hr 12 mg,16 mg, 8 mg

2 PA, MO

hydromorphone oraltablet extendedrelease 24 hr 32 mg

5 PA, MO

ibuprofen-oxycodone 2 MOlevorphanol tartrateoral tablet 2 mg

2 MO

LEVORPHANOLTARTRATE ORALTABLET 3 MG(BRAND)

5 MO



Limitslorcet (hydrocodone) 2 MOlorcet hd 2 MOlorcet plus oral tablet7.5-325 mg

2 MO

meperidine (pf)injection solution 100mg/ml, 50 mg/ml

2 MO

meperidine (pf)injection solution 25mg/ml

2

meperidine oral 2 MOmethadone injectionsolution

2 HI

methadone intensol 2 PA, MOmethadone oralconcentrate

2 PA, MO

methadone oralsolution

2 PA, MO

methadone oral tablet 2 PA, MOmethadose oralconcentrate

2 PA, MO

morphine (pf) injectionsolution 0.5 mg/ml

2

morphine (pf) injectionsolution 1 mg/ml

2 MO

morphine (pf)intravenous patientcontrol.analgesiasoln 150 mg/30 ml

2 B/D PA, MO

morphine concentrateoral solution

2 MO


LimitsMORPHINEINJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND)

3

MORPHINEINJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND)

3 MO

morphine injectionsolution 8 mg/ml

2

morphine injectionsyringe 10 mg/ml, 2mg/ml, 4 mg/ml

2 MO

morphine injectionsyringe 5 mg/ml, 8mg/ml

2

morphine intravenoussolution 10 mg/ml

2 MO

MORPHINEINTRAVENOUSSOLUTION 4 MG/ML, 8 MG/ML(BRAND)

3 MO

MORPHINEINTRAVENOUSSYRINGE 10 MG/ML, 8 MG/ML(BRAND)

3

morphine intravenoussyringe 2 mg/ml, 4mg/ml

2

morphine oralcapsule, ermultiphase 24 hr

2 PA, MO



Limitsmorphine oralcapsule,extend.release pellets

2 PA, MO

morphine oral solution 2 MOmorphine oral tablet 2 MOmorphine oral tabletextended release

2 PA, MO

oxycodone oralcapsule

2 MO

oxycodone oralconcentrate

2 MO

oxycodone oralsolution

2 MO

oxycodone oral tablet 2 MOOXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 20 MG, 40 MG,80 MG (BRAND)

3 PA, MO

OXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 20 MG, 40 MG,80 MG (BRAND)

3 PA

OXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 15MG, 30 MG, 60 MG(BRAND)

3 PA

oxycodone-acetaminophen oraltablet 10-325 mg,2.5-325 mg, 5-325mg, 7.5-325 mg

2 MO

oxycodone-acetaminophen oraltablet 2.5-300 mg

2


Limitsoxycodone-aspirin 2 MOOXYCONTIN ORALTABLET,ORAL ONLY,EXT.REL.12 HR

3 PA, MO

oxymorphone oraltablet

2 MO

oxymorphone oraltablet

2 PA, MO

oxymorphone oraltablet extendedrelease 12 hr

2 MO

oxymorphone oraltablet extendedrelease 12 hr

2 PA, MO

prolate 2tencon oral tablet50-325 mg

2 PA, MO

vtol lq 2 PAzebutal oral capsule50-325-40 mg

2 PA, MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICSDrug Name Tier Requirements/

Limitsbuprenorphine-naloxone

2 MO

butorphanol tartrateinjection

2 MO, HI

butorphanol tartratenasal

2 MO

celecoxib 2 MO, QL (60 per30 days)

clonidine (pf) epiduralsolution 5,000mcg/10 ml

2

diclofenac potassium 2 MOdiclofenac sodium oraltablet extendedrelease 24 hr

2 MO

diclofenac sodium oraltablet,delayedrelease (dr/ec)

2 MO

diclofenac sodiumtopical drops

2 MO

diclofenac sodiumtopical gel 1 %

2 MO

diclofenac-misoprostoloral tablet,ir,delayedrel,biphasic

2 MO

diflunisal 2 MOec-naproxen oraltablet,delayedrelease (dr/ec) 375mg

1

ec-naproxen oraltablet,delayedrelease (dr/ec) 500mg

1 MO

etodolac oral capsule 2 MOetodolac oral tablet 2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICS (continued)Drug Name Tier Requirements/

Limitsetodolac oral tabletextended release 24hr

2 MO

fenoprofen oral tablet 2 MOflurbiprofen oral tablet100 mg

2 MO

HYALGAN MB MOHYMOVIS MBibu 1 MOibuprofen lysine (pf) 2ibuprofen oralsuspension

2 MO

ibuprofen oral tablet400 mg, 600 mg, 800mg

1 MO

indomethacin oralcapsule

2 MO

indomethacin oralcapsule, extendedrelease

2 MO

indomethacin sodium 2ketoprofen oralcapsule 25 mg

2 MO

ketoprofen oralcapsule 50 mg, 75mg

2

ketoprofen oralcapsule,ext rel.pellets 24 hr 200 mg

2 MO

ketorolac injectioncartridge 30 mg/ml

2 MO

ketorolac injectionsolution 15 mg/ml, 30mg/ml (1 ml)

2 MO

ketorolac injectionsyringe 15 mg/ml

2



Limitsketorolac injectionsyringe 30 mg/ml

2 MO

ketorolacintramuscularcartridge

2 MO

ketorolacintramuscularsolution

2 MO

ketorolacintramuscular syringe

2

ketorolac oral 2 MOLUCEMYRA 5 MO, QL (224 per

180 days)meclofenamate 2 MOmefenamic acid 2 MOmeloxicam oral tablet 1 MO, QL (30 per

30 days)nabumetone 2 MOnalbuphine 2 MO, HInaloxone injectionsolution

2 MO

naloxone injectionsyringe

2 MO

naltrexone 2 MOnaproxen oralsuspension

2 MO

naproxen oral tablet 1 MOnaproxen oral tablet,delayed release (dr/ec)

1 MO

naproxen sodium oraltablet 275 mg, 550mg

1 MO


Limitsnaproxen sodium oraltablet, er multiphase24 hr

1 MO

NARCAN NASALSPRAY,NON-AEROSOL 4 MG/ACTUATION

2 MO

oxaprozin 2 MOpentazocine-naloxone 2 MOpiroxicam 2 MOsalsalate 1 MOsulindac 1 MOSYNVISC MB MOSYNVISC-ONE MB MOtolmetin 2 MOtramadol oral tablet 50mg

2 MO

tramadol oral tabletextended release 24hr

2 PA, MO

tramadol oral tablet, ermultiphase 24 hr

2 PA, MO

tramadol-acetaminophen

2 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGSDrug Name Tier Requirements/

LimitsABILIFY MAINTENA 5 MOADASUVE 4alprazolam intensol 2 PA, MOalprazolam oral tablet 2 PA, MOalprazolam oral tabletextended release 24hr

2 PA, MO

alprazolam oral tablet,disintegrating

2 PA, MO

amitriptyline 2 PA, MOamitriptyline-chlordiazepoxide

2 PA, MO

amoxapine 2 MOamphetamine sulfate 2 MOaripiprazole oralsolution

5 MO

aripiprazole oral tablet 2 MOaripiprazole oraltablet,disintegrating

5 MO

ARISTADA 5 MOARISTADA INITIO 5 MOarmodafinil 2 PA, MOatomoxetine 2 MO, QL (30 per

30 days)bupropion hcl oraltablet

1 MO

bupropion hcl oraltablet extendedrelease 24 hr 150mg, 300 mg

2 MO

bupropion hcl oraltablet sustained-release 12 hr

2 MO

buspirone 2 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGS(continued)Drug Name Tier Requirements/

LimitsCAPLYTA 5chlordiazepoxide hcl 2 PA, MOchlorpromazineinjection

2 MO, HI

chlorpromazine oral 2 MOcitalopram oralsolution

2 MO

citalopram oral tablet 1 MOclomipramine 2 PA, MOclonidine hcl oraltablet extendedrelease 12 hr

2 MO

clorazepatedipotassium

2 PA, MO

clozapine oral tablet 2 MOclozapine oral tablet,disintegrating 100mg, 12.5 mg, 25 mg

2

CLOZAPINE ORALTABLET,DISINTEGRATING150 MG, 200 MG(BRAND)

4

desipramine 2 MOdesvenlafaxinesuccinate oral tabletextended release 24hr

2 MO

dexmethylphenidateoral capsule,erbiphasic 50-50 10mg, 5 mg




Limitsdexmethylphenidateoral capsule,erbiphasic 50-50 15mg, 20 mg, 25 mg,30 mg, 35 mg, 40 mg


dexmethylphenidateoral tablet

2 MO

dextroamphetamineoral capsule,extended release

2 MO

dextroamphetamineoral solution

2 MO

dextroamphetamineoral tablet

2 MO

dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr


dextroamphetamine-amphetamine oraltablet

2 MO

diazepam injectionsolution

2 PA

diazepam injectionsyringe

2 PA, MO

diazepam intensol 2 PA, MOdiazepam oralconcentrate

2 PA, MO

diazepam oral solution5 mg/5 ml (1 mg/ml)

2 PA, MO

diazepam oral tablet 2 PA, MOdoxepin oral capsule 2 PA, MOdoxepin oralconcentrate

2 PA, MO

doxepin oral tablet 2 MO


LimitsDRIZALMASPRINKLE

4 MO

duloxetine oralcapsule,delayedrelease (dr/ec)

2 MO

EMSAM 5 MOergoloid 2 MOescitalopram oxalateoral solution

2 MO

escitalopram oxalateoral tablet

1 MO

estazolam 2 PA, MOeszopiclone 2 MO, QL (30 per

30 days)FANAPT ORALTABLET 1 MG, 2MG, 4 MG

4 MO

FANAPT ORALTABLET 10 MG, 12MG, 6 MG, 8 MG

5 MO

FANAPT ORALTABLETS,DOSEPACK

4 MO

FETZIMA 4 MOflumazenil 2 MOfluoxetine oral capsule 1 MOfluoxetine oralcapsule,delayedrelease(dr/ec)

2 MO

fluoxetine oral solution 2 MOfluoxetine oral tablet 2 MOfluphenazinedecanoate

2 MO

fluphenazine hcl 2 MO



Limitsflurazepam 2 PA, MOfluvoxamine oralcapsule,extendedrelease 24hr

2 MO

fluvoxamine oral tablet 2 MOFORFIVO XL 4 MOGEODONINTRAMUSCULAR

3 MO

guanfacine oral tabletextended release 24hr

2 MO

guanidine 2 MOhaloperidol 1 MOhaloperidol decanoate 2 MOhaloperidol lactateinjection

2 MO

haloperidol lactate oral 2 MOHETLIOZ 5 PA, MO, QL (30

per 30 days)imipramine hcl 2 PA, MOimipramine pamoate 2 PA, MOINVEGA SUSTENNAINTRAMUSCULARSYRINGE 117MG/0.75 ML, 156MG/ML, 234 MG/1.5ML, 78 MG/0.5 ML

5 MO

INVEGA SUSTENNAINTRAMUSCULARSYRINGE 39MG/0.25 ML

4 MO

INVEGA TRINZA 5 MOLATUDA 5 MO


Limitslithium carbonate oralcapsule

1 MO

lithium carbonate oraltablet

1 MO

lithium carbonate oraltablet extendedrelease

1 MO

lithium citrate oralsolution 8 meq/5 ml

2 MO

lorazepam injectionsolution

2 PA, MO

lorazepam injectionsyringe 2 mg/ml

2 PA, MO

lorazepam injectionsyringe 4 mg/ml

2 PA

lorazepam intensol 2 PA, MOlorazepam oral 2 PA, MOloxapine succinate 2 MOmaprotiline 2 MOMARPLAN 3 MOmetadate er oral tabletextended release

2 QL (90 per 30days)

methamphetamine 2 PA, MOmethylphenidate hcloral capsule, erbiphasic 30-70 10mg, 20 mg, 30 mg


methylphenidate hcloral capsule, erbiphasic 30-70 40mg, 50 mg, 60 mg


methylphenidate hcloral capsule,erbiphasic 50-50




Limitsmethylphenidate hcloral solution

2 MO

methylphenidate hcloral tablet

2 MO

methylphenidate hcloral tablet extendedrelease 10 mg


methylphenidate hcloral tablet extendedrelease 20 mg


methylphenidate hcloral tablet extendedrelease 24hr 18 mg(bx rating), 27 mg (bxrating), 54 mg (bxrating)


methylphenidate hcloral tablet extendedrelease 24hr 18 mg,27 mg, 54 mg


methylphenidate hcloral tablet extendedrelease 24hr 36 mg


methylphenidate hcloral tablet extendedrelease 24hr 36 mg(bx rating)


methylphenidate hcloral tablet,chewable

2 MO

midazolam (pf)injection

2

midazolam injection 2midazolam oral syrup2 mg/ml

2 MO

mirtazapine oral tablet 1 MO


Limitsmirtazapine oraltablet,disintegrating

2 MO

modafinil 2 PA, MOmolindone 2 MOnefazodone 2 MOnortriptyline 2 MONUPLAZID ORALCAPSULE

5 MO

NUPLAZID ORALTABLET 10 MG

5 MO

olanzapineintramuscular reconsoln

2 MO

olanzapine oral tablet 2 MOolanzapine oral tablet,disintegrating

2 MO

olanzapine-fluoxetine 2 MOoxazepam 2 PA, MOpaliperidone oraltablet extendedrelease 24hr 1.5 mg,3 mg, 6 mg

2 MO

paliperidone oraltablet extendedrelease 24hr 9 mg

5 MO

paroxetine hcl oraltablet

1 MO

paroxetine hcl oraltablet extendedrelease 24 hr

2 MO

paroxetine mesylate(menop.sym)

2 MO

PAXIL ORALSUSPENSION

4 MO



Limitspentobarbital sodiuminjection solution

2

perphenazine 2 MOperphenazine-amitriptyline

2 PA, MO

PERSERIS 5 MOphenelzine 2 MOpimozide 2 MOprocentra 2 MOprotriptyline 2 MOquetiapine oral tablet 2 MOquetiapine oral tabletextended release 24hr

2 MO

ramelteon 2 MOREXULTI 5 MORISPERDAL CONSTAINTRAMUSCULARSUSPENSION,EXTENDED RELRECON 12.5 MG/2ML, 25 MG/2 ML

3 MO

RISPERDAL CONSTAINTRAMUSCULARSUSPENSION,EXTENDED RELRECON 37.5 MG/2ML, 50 MG/2 ML

5 MO

risperidone oralsolution

2 MO

risperidone oral tablet 1 MOrisperidone oral tablet,disintegrating

2 MO

SAPHRIS 5 MO


Limitsseconal sodium 2 PASECUADO 5sertraline oralconcentrate

2 MO

sertraline oral tablet 1 MOtemazepam 2 PA, MOthioridazine 2 MOthiothixene 1 MOtranylcypromine 2 MOtrazodone 1 MOtriazolam 2 PA, MOtrifluoperazine 2 MOtrimipramine 2 PA, MOTRINTELLIX 4 MOvenlafaxine oralcapsule,extendedrelease 24hr

2 MO

venlafaxine oral tablet 2 MOvenlafaxine oral tabletextended release24hr

2 MO

VERSACLOZ 5VIIBRYD ORALTABLET

4 MO

VIIBRYD ORALTABLETS,DOSEPACK 10 MG (7)- 20MG (23)

4 MO

VRAYLAR ORALCAPSULE

5 MO

VRAYLAR ORALCAPSULE,DOSEPACK

4 MO



LimitsXYREM 5 PA, MO, LAzaleplon 2 MO, QL (30 per

30 days)zenzedi oral tablet 10mg, 5 mg

2 MO

ZENZEDI ORALTABLET 15 MG, 2.5MG, 20 MG, 30 MG,7.5 MG (BRAND)

4 MO

ziprasidone hcl 2 MOziprasidone mesylate 2zolpidem oral tablet 2 MO, QL (30 per

30 days)zolpidem oral tablet,ext releasemultiphase


zolpidem sublingual 2 MO, QL (30 per30 days)

ZYPREXARELPREVV

4 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIARRHYTHMIC AGENTSDrug Name Tier Requirements/

Limitsadenosine 2amiodaroneintravenous solution

2 B/D PA, MO, HI

amiodaroneintravenous syringe

2 B/D PA, HI

amiodarone oral 2 MObretylium tosylate 5disopyramidephosphate oralcapsule

2 MO

dofetilide 2 MOflecainide 2 MOibutilide fumarate 2 MOlidocaine (pf) in d7.5w 2 MOlidocaine (pf)intravenous solution

2 MO, HI

lidocaine (pf)intravenous syringe

2 HI

lidocaine in 5 %dextrose (pf)intravenousparenteral solution 4mg/ml (0.4 %), 8 mg/ml (0.8 %)

2

mexiletine 2 MOMULTAQ 4 MOpacerone oral tablet100 mg, 200 mg, 400mg

2 MO

procainamide injectionsolution 100 mg/ml

2 MO, HI

procainamide injectionsolution 500 mg/ml

2 HI


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIARRHYTHMIC AGENTS(continued)Drug Name Tier Requirements/

Limitspropafenone oralcapsule,extendedrelease 12 hr

2 MO

propafenone oraltablet

2 MO

quinidine gluconateoral tablet extendedrelease

2 MO

quinidine sulfate oraltablet

2 MO

sorine oral tablet 120mg, 160 mg, 80 mg

2 MO

sorine oral tablet 240mg

2

sotalol af 2 MOsotalol oral 2 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIHYPERTENSIVE THERAPYDrug Name Tier Requirements/

Limitsacebutolol 1 MOaliskiren 1 MOamiloride 1 MOamiloride-hydrochlorothiazide

1 MO

amlodipine 1 MOamlodipine-benazepril 1 MOamlodipine-olmesartan

1 MO

amlodipine-valsartan 1 MOamlodipine-valsartan-hcthiazid

1 MO

atenolol 1 MOatenolol-chlorthalidone 1 MObenazepril 1 MObenazepril-hydrochlorothiazide

1 MO

betaxolol oral 1 MObisoprolol fumarate 1 MObisoprolol-hydrochlorothiazide

1 MO

bumetanide injection 2 MO, HIbumetanide oral 1 MOcandesartan 1 MOcandesartan-hydrochlorothiazid

1 MO

captopril 1 MOcaptopril-hydrochlorothiazide

1 MO

cartia xt oral capsule,extended release24hr

1 MO

carvedilol 1 MO


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIHYPERTENSIVETHERAPY (continued)Drug Name Tier Requirements/

Limitscarvedilol phosphateoral capsule, ermultiphase 24 hr

1 MO

chlorothiazide oraltablet 500 mg

1 MO

chlorothiazide sodium 2 MO, HIchlorthalidone oraltablet 25 mg, 50 mg

1 MO

clonidine (pf) epiduralsolution 1,000mcg/10 ml (100 mcg/ml)

2

clonidine hcl oraltablet

1 MO

clonidine transdermal 2 MODEMSER 5 MOdiltiazem hclintravenous

2 HI

diltiazem hcl oralcapsule,extendedrelease 12 hr

1 MO

diltiazem hcl oralcapsule,extendedrelease 24 hr

1 MO

diltiazem hcl oralcapsule,extendedrelease 24hr

1 MO

diltiazem hcl oraltablet

1 MO

diltiazem hcl oraltablet extendedrelease 24 hr

1 MO

dilt-xr oral capsule,extrelease degradable

1 MO

doxazosin 1 MOenalapril maleate 1 MO


Limitsenalaprilat intravenoussolution

2

enalapril-hydrochlorothiazide

1 MO

eplerenone 1 MOepoprostenol (glycine) 2 B/D PA, MOeprosartan 1 MOesmolol in nacl (iso-osm)

2

esmolol intravenoussolution

2

ethacrynate sodium 5 MO, HIethacrynic acid 5 MOfelodipine oral tabletextended release 24hr

1 MO

fosinopril 1 MOfosinopril-hydrochlorothiazide

1 MO

furosemide injection 2 MO, HIfurosemide oralsolution 10 mg/ml, 40mg/5 ml (8 mg/ml)

1 MO

furosemide oral tablet 1 MOguanfacine oral tablet 1 MOhydralazine injection 2 MO, HIhydralazine oral 1 MOhydrochlorothiazide 1 MOindapamide 1 MOirbesartan 1 MOirbesartan-hydrochlorothiazide

1 MO

isradipine 1 MO



Limitslabetalol intravenoussolution

2 MO, HI

labetalol intravenoussyringe 20 mg/4 ml (5mg/ml)

2 HI

labetalol oral 1 MOlisinopril 1 MOlisinopril-hydrochlorothiazide

1 MO

losartan 1 MOlosartan-hydrochlorothiazide

1 MO

mannitol 20 % 2mannitol 25 %intravenous solution

2 MO

matzim la oral tabletextended release 24hr

1 MO

methyldopa 1 MOmethyldopa-hydrochlorothiazide

1 MO

metolazone 1 MOmetoprolol succinateoral tablet extendedrelease 24 hr

1 MO

metoprolol ta-hydrochlorothiaz

1 MO

metoprolol tartrateintravenous solution

2 MO, HI

metoprolol tartrateintravenous syringe

2

metoprolol tartrate oraltablet

1 MO

minoxidil oral 1 MOmoexipril 1 MO


Limitsnadolol 1 MOnadolol-bendroflumethiazideoral tablet 80-5 mg

1 MO

nicardipineintravenous solution

2 HI

nicardipine oral 1 MOnifedipine oral capsule 1 MOnifedipine oral tabletextended release

1 MO

nifedipine oral tabletextended release24hr

1 MO

nimodipine 1 MOnisoldipine oral tabletextended release 24hr

1 MO

olmesartan 1 MOolmesartan-amlodipin-hcthiazid

1 MO

olmesartan-hydrochlorothiazide

1 MO

ORENITRAM ORALTABLET EXTENDEDRELEASE 0.125 MG

3 PA, MO

ORENITRAM ORALTABLET EXTENDEDRELEASE 0.25 MG,1 MG, 2.5 MG, 5 MG

5 PA, MO

osmitrol 15 % 2osmitrol 20 % 2perindopril erbumine 1 MOphenoxybenzamine 5 MOphentolamine injectionrecon soln

2



Limitspindolol 1 MOprazosin 1 MOpropranololintravenous

2 HI

propranolol oralcapsule,extendedrelease 24 hr

1 MO

propranolol oralsolution

1 MO

propranolol oral tablet 1 MOpropranolol-hydrochlorothiazid

1 MO

quinapril 1 MOquinapril-hydrochlorothiazide

1 MO

ramipril 1 MOspironolactone 1 MOspironolacton-hydrochlorothiaz

1 MO

taztia xt oral capsule,extended release

1 MO

TEKTURNA HCT 3 MOtelmisartan 1 MOtelmisartan-amlodipine 1 MOtelmisartan-hydrochlorothiazid

1 MO

terazosin 1 MOtiadylt er 1timolol maleate oral 1 MOtorsemide oral 1 MOtrandolapril 1 MOtrandolapril-verapamiloral tablet, ir - er,biphasic 24hr

1 MO


Limitstreprostinil sodium 5 PA, MOtriamterene 1 MOtriamterene-hydrochlorothiazidoral capsule 37.5-25mg

1 MO

triamterene-hydrochlorothiazidoral tablet

1 MO

UPTRAVI 5 PA, MO, LAvalsartan 1 MOvalsartan-hydrochlorothiazide

1 MO

veletri 2 B/D PA, MOverapamil intravenoussolution

2 MO, HI

verapamil intravenoussyringe

2 HI

verapamil oralcapsule, 24 hr erpellet ct

1 MO

verapamil oralcapsule,ext rel.pellets 24 hr

1 MO

verapamil oral tablet 1 MOverapamil oral tabletextended release

1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:COAGULATION THERAPYDrug Name Tier Requirements/

Limitsaminocaproic acid 2 MOANDEXXA 5aspirin-dipyridamoleoral capsule, ermultiphase 12 hr

2 MO

BEVYXXA 3 MO, QL (43 per180 days)

BRILINTA 4 MOCABLIVI INJECTIONKIT

5 MO, LA

cilostazol 2 MOclopidogrel 1 MOdipyridamoleintravenous

2

dipyridamole oral 2 MODOPTELET (10 TABPACK)

5 MO, LA, QL (15per 180 days)

DOPTELET (15 TABPACK)


DOPTELET (30 TABPACK)


ELIQUIS 3 MOELIQUIS DVT-PETREAT 30D START

3 MO

enoxaparinsubcutaneoussolution


enoxaparinsubcutaneoussyringe 100 mg/ml,150 mg/ml


enoxaparinsubcutaneoussyringe 120 mg/0.8ml, 80 mg/0.8 ml


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsenoxaparinsubcutaneoussyringe 30 mg/0.3 ml


enoxaparinsubcutaneoussyringe 40 mg/0.4 ml


enoxaparinsubcutaneoussyringe 60 mg/0.6 ml


fondaparinuxsubcutaneoussyringe 10 mg/0.8 ml


fondaparinuxsubcutaneoussyringe 2.5 mg/0.5 ml


fondaparinuxsubcutaneoussyringe 5 mg/0.4 ml


fondaparinuxsubcutaneoussyringe 7.5 mg/0.6 ml


hep flush-10 (pf) MB MOheparin (porcine) in5 % dex intravenousparenteral solution20,000 unit/500 ml(40 unit/ml)

2 HI

heparin (porcine) in5 % dex intravenousparenteral solution25,000 unit/250 ml(100 unit/ml), 25,000unit/500 ml (50 unit/ml)

2 MO, HI

heparin (porcine) innacl (pf)

2

heparin (porcine)injection cartridge

2 MO, HI



Limitsheparin (porcine)injection solution

2 MO, HI

heparin (porcine)injection syringe5,000 unit/ml

2 MO, HI

heparin flush(porcine)-0.9nacl

MB MO

heparin lock flush MB MOheparin lock flush(porcine) intravenoussolution

MB MO

heparin lockflush(porcine)(pf)

MB MO

heparin(porcine) in0.45% naclintravenousparenteral solution25,000 unit/250 ml,25,000 unit/500 ml

2 MO

heparin, porcine (pf)injection solution

2 MO

heparin, porcine (pf)injection syringe5,000 unit/0.5 ml

2 MO

heparin, porcine (pf)intravenous syringe 1unit/ml

MB

heparin, porcine (pf)intravenous syringe10 unit/ml, 100 unit/ml

MB MO

jantoven 1 MOMULPLETA 5 MO, QL (7 per

180 days)NPLATE 3 MO


Limitspentoxifylline oraltablet extendedrelease

2 MO

PRADAXA 4 MOprasugrel 2 MOPRAXBIND 5PROMACTA 5 MO, LAprotamine 2TAVALISSE 5 MO, LAwarfarin 1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS: LIPID/CHOLESTEROL LOWERINGAGENTSDrug Name Tier Requirements/

Limitsamlodipine-atorvastatin

1 MO

atorvastatin 1 MOcholestyramine (withsugar)

1 MO

cholestyramine light 1 MOcolesevelam oralpowder in packet

2 MO

colesevelam oraltablet

2 MO

colestipol 1 MOezetimibe 1 MOezetimibe-simvastatin 1 MOfenofibrate micronized 1 MOfenofibratenanocrystallized oraltablet 145 mg, 48 mg

1 MO

FENOFIBRATE ORALCAPSULE (BRAND)

3 MO

fenofibrate oral tablet120 mg, 40 mg, 54mg

1 MO

fenofibrate oral tablet160 mg (generic)

1 MO

fenofibric acid 1 MOfenofibric acid(choline) oralcapsule,delayedrelease(dr/ec)

1 MO

fluvastatin 1 MOgemfibrozil 1 MOJUXTAPID 5 PA, MO, LAlovastatin 1 MO

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: LIPID/CHOLESTEROLLOWERING AGENTS (continued)Drug Name Tier Requirements/

Limitsniacin oral tablet 500mg

2

niacin oral tabletextended release 24hr

2 MO

omega-3 acid ethylesters

2 MO

PRALUENTSUBCUTANEOUSPEN INJECTOR 150MG/ML


PRALUENTSUBCUTANEOUSPEN INJECTOR 75MG/ML


pravastatin 1 MOprevalite 1 MOrosuvastatin 1 MOsimvastatin oral tablet 1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:MISCELLANEOUSCARDIOVASCULAR AGENTSDrug Name Tier Requirements/

Limitscardioplegic soln 2CORLANOR ORALSOLUTION

3 PA

CORLANOR ORALTABLET

3 PA, MO

digitek 1 MOdigox 1 MOdigoxin injectionsolution

2 MO, HI

digoxin oral solution50 mcg/ml (0.05 mg/ml)

2 MO

digoxin oral tablet 1 MOdobutamine in d5wintravenousparenteral solution1,000 mg/250 ml(4,000 mcg/ml), 250mg/250 ml (1 mg/ml)

2 B/D PA, MO

dobutamine in d5wintravenousparenteral solution500 mg/250 ml(2,000 mcg/ml)

2 B/D PA

dobutamineintravenous solution250 mg/20 ml (12.5mg/ml)

2 B/D PA

dopamine in 5 %dextrose intravenoussolution 200 mg/250ml (800 mcg/ml), 400mg/250 ml (1,600mcg/ml), 400 mg/500ml (800 mcg/ml), 800mg/500 ml (1,600mcg/ml)

2 B/D PA

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: MISCELLANEOUSCARDIOVASCULAR AGENTS(continued)Drug Name Tier Requirements/

Limitsdopamine in 5 %dextrose intravenoussolution 800 mg/250ml (3,200 mcg/ml)

2 B/D PA, MO

dopamine intravenoussolution 200 mg/5 ml(40 mg/ml)

2 B/D PA

dopamine intravenoussolution 400 mg/10ml (40 mg/ml)

2 B/D PA, MO

ENTRESTO 3 MO, QL (60 per30 days)

isoproterenol hcl 2milrinone 2 B/D PA, MOmilrinone in 5 %dextrose

2 B/D PA, MO

norepinephrinebitartrate

2

ranolazine 2 MOsodium nitroprusside 2 B/D PAVECAMYL 5VYNDAMAX 5 PA, MOVYNDAQEL 5 PA, MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS: NITRATESDrug Name Tier Requirements/

Limitsisosorbide dinitrateoral tablet

2 MO

isosorbidemononitrate oraltablet

1 MO

isosorbidemononitrate oraltablet extendedrelease 24 hr

1 MO

nitro-bid 2 MOnitroglycerin in 5 %dextrose intravenoussolution 100 mg/250ml (400 mcg/ml), 50mg/250 ml (200 mcg/ml)

2 B/D PA

nitroglycerin in 5 %dextrose intravenoussolution 25 mg/250ml (100 mcg/ml)

2 B/D PA, MO

nitroglycerinintravenous

2 B/D PA, HI

nitroglycerinsublingual

2 MO

nitroglycerintransdermal patch 24hour

2 MO

nitroglycerintranslingual spray,non-aerosol

2 MO

DERMATOLOGICALS/TOPICALTHERAPY: ANTIPSORIATIC /ANTISEBORRHEICDrug Name Tier Requirements/

Limitsacitretin oral capsule10 mg, 25 mg

2 MO

acitretin oral capsule17.5 mg

5 MO

calcipotriene scalp 2 MOcalcipotriene topicalcream

2 MO

calcipotriene topicalointment

2 MO

calcipotriene-betamethasonetopical ointment

2 MO

calcitriol topical 2 MOCOSENTYX 5 PA, MO, QL (2

per 28 days)COSENTYX (2SYRINGES)


COSENTYX PEN 5 PA, MO, QL (2per 28 days)

COSENTYX PEN (2PENS)


selenium sulfidetopical lotion

2 MO

SKYRIZISUBCUTANEOUSSYRINGE KIT


STELARAINTRAVENOUS

5 PA, MO, HI

STELARASUBCUTANEOUS

5 PA, MO


DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALSDrug Name Tier Requirements/

Limitsammonium lactate 2 MOcarbocaine (pf)injection solution 15mg/ml (1.5 %)

2

chloroprocaine (pf) 2CONDYLOXTOPICAL GEL

3 MO

diclofenac sodiumtopical gel 3 %

2 MO

doxepin topical 5 MODUPIXENT 5 PA, MOFLUOROURACILTOPICAL CREAM0.5 % (BRAND)

5 MO

fluorouracil topicalcream 5 %

2 MO

fluorouracil topicalsolution

2 MO

glydo 2 MOimiquimod topicalcream in packet

2 MO

lidocaine (pf) injectionsolution 10 mg/ml(1 %), 20 mg/ml(2 %), 40 mg/ml(4 %), 5 mg/ml(0.5 %)

2 MO, HI

lidocaine (pf) injectionsolution 15 mg/ml(1.5 %)

2 HI

lidocaine hcl injectionsolution

2 MO, HI

lidocaine hcllaryngotracheal

2 MO

lidocaine hcl mucousmembrane jelly

2 MO

DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALS (continued)Drug Name Tier Requirements/

Limitslidocaine hcl mucousmembrane jelly inapplicator

2 MO

lidocaine hcl mucousmembrane solution4 % (40 mg/ml)

2 MO

lidocaine topicaladhesive patch,medicated 5 %

2 PA, MO

lidocaine topicalointment

2 MO

lidocaine viscous 2 MOlidocaine-epinephrineinjection solution0.5 %-1:200,000,1.5 %-1:200,000,2 %-1:200,000

2

lidocaine-epinephrineinjection solution1 %-1:100,000,2 %-1:100,000

2 MO

lidocaine-prilocainetopical cream

2 MO

methoxsalen 5 MOPANRETIN 5 MOpimecrolimus 2 PA, MOpodofilox 2 MOpolocaine injectionsolution 1 % (10 mg/ml)

2

polocaine-mpf 2prudoxin 2 MOREGRANEX 5 MOSANTYL 3 MOsilver sulfadiazine 2 MO


DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALS (continued)Drug Name Tier Requirements/

Limitsssd 2 MOtacrolimus topical 2 PA, MOUVADEX 3VALCHLOR 5 MOxylocaine dental-epinephrine

2

DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNEDrug Name Tier Requirements/

Limitsadapalene topicalcream

2 PA, MO

adapalene topical gel 2 PA, MOadapalene topical gelwith pump

2 PA, MO

adapalene topicalsolution

2 PA

adapalene topicalswab

2 PA

adapalene-benzoylperoxide

2 PA, MO

amnesteem 2 MOavita topical cream 2 PA, MOazelaic acid 2 MOclaravis 2 MOclindacin etz topicalswab

2 MO

clindacin p 2 MOclindamycinphosphate topicalfoam

2 MO

clindamycinphosphate topical gel

2 MO

clindamycinphosphate topicallotion

2 MO

clindamycinphosphate topicalsolution

2 MO

clindamycinphosphate topicalswab

2 MO

clindamycin-benzoylperoxide

2 MO

clindamycin-tretinoin 2 PA, MOdapsone topical gel 2 MO


DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNE(continued)Drug Name Tier Requirements/

Limitsdapsone topical gelwith pump

2

ery pads 2 MOerygel 2 MOerythromycin withethanol topical gel

2 MO

erythromycin withethanol topicalsolution

2 MO

erythromycin-benzoylperoxide

2 MO

FABIOR 4 MOisotretinoin 2 MOivermectin topical 2 MOmetronidazole topical 2 MOmyorisan 2 MOneuac 2 MOrosadan topical cream 2 MOrosadan topical gel 2 MOtazarotene 2 PA, MOTAZORAC TOPICALCREAM 0.05 %

4 PA, MO

TAZORAC TOPICALGEL

4 PA, MO

tretinoin microspheres 2 PA, MOtretinoin topical 2 PA, MOzenatane 2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALANTIBACTERIALSDrug Name Tier Requirements/

Limitsgentamicin topical 2 MOmafenide acetate 2 MOmupirocin 2 MOmupirocin calcium 2 MOsulfacetamide sodium(acne)

2 MO

SULFAMYLONTOPICAL CREAM

3 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIFUNGALSDrug Name Tier Requirements/

Limitsciclodan topicalsolution

2 MO

ciclopirox 2 MOclotrimazole topical 2 MOclotrimazole-betamethasone

2 MO

econazole 2 MOketoconazole topical 2 MOketodan 2 MOLULICONAZOLE 4 MOLUZU 4 MOnaftifine 2 MOnyamyc 2 MOnystatin topical 2 MOnystatin-triamcinolone 2 MOnystop 2 MOoxiconazole 2 MO


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIVIRALSDrug Name Tier Requirements/

Limitsacyclovir topical 2 MODENAVIR 3 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDSDrug Name Tier Requirements/

Limitsala-cort topical cream1 %

2 MO

alclometasone 2 MOamcinonide topicalcream

2 MO

amcinonide topicallotion

2 MO

amcinonide topicalointment

2

apexicon e 2 MObeser 2 MObetamethasonedipropionate

2 MO

betamethasonevalerate

2 MO

betamethasone,augmented

2 MO

clobetasol 2 MOclobetasol-emollient 2 MOclodan 2 MOdesonide 2 MOdesoximetasone 2 MOdiflorasone 2 MOfluocinolone 2 MOfluocinolone andshower cap

2 MO

fluocinonide 2 MOfluocinonide-e 2 MOfluocinonide-emollient 2 MOflurandrenolide 2 MOfluticasone propionatetopical

2 MO

halcinonide 2 MO


DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDS (continued)Drug Name Tier Requirements/

Limitshalobetasolpropionate topicalcream

2 MO

halobetasolpropionate topicalointment

2 MO

hydrocortisonebutyrate

2 MO

hydrocortisone butyr-emollient

2 MO

hydrocortisone topicalcream 1 %, 2.5 %

2 MO

hydrocortisone topicallotion 2.5 %

2 MO

hydrocortisone topicalointment 1 %, 2.5 %

2 MO

hydrocortisonevalerate

2 MO

mometasone topical 2 MOnolix 2 MOprednicarbate 2 MOtovet emollient 2 MOtriamcinoloneacetonide topicalaerosol

2 MO

triamcinoloneacetonide topicalcream

2 MO

triamcinoloneacetonide topicallotion

2 MO

triamcinoloneacetonide topicalointment 0.025 %,0.1 %, 0.5 %

2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDS (continued)Drug Name Tier Requirements/

Limitstriamcinoloneacetonide topicalointment 0.05 %

2

trianex 2 MOtriderm topical cream 2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL SCABICIDES /PEDICULICIDESDrug Name Tier Requirements/

Limitscrotan 2lindane topicalshampoo

2 MO

malathion 2 MOpermethrin topicalcream

2 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: ANTIDOTESDrug Name Tier Requirements/

Limitsacetylcysteineintravenous

2 MO


DIAGNOSTICS / MISCELLANEOUSAGENTS: IRRIGATING SOLUTIONSDrug Name Tier Requirements/

Limitslactated ringersirrigation

2 MO

neomycin-polymyxin bgu

2 MO

ringer's irrigation 2 MOSORBITOLIRRIGATION

3

tis-u-sol pentalyte 2 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsacamprosate oraltablet,delayedrelease (dr/ec)

2 MO

acetic acid irrigation 2 MOanagrelide 2 MOARALAST NPINTRAVENOUSRECON SOLN 1,000MG

5 PA, MO, HI, LA

ARALAST NPINTRAVENOUSRECON SOLN 500MG

5 PA, MO, HI, LA

bacteriostatic water(parabens)

MB

bd pre-filled normalsaline

MB MO

caffeine citrateintravenous

2

caffeine citrate oral 2 MOCARBAGLU 5 MO, LAcevimeline 2 MOCHEMET 3 MOCLINIMIX 4.25%/D5WSULFIT FREE

4 B/D PA, HI

CLINIMIX E 2.75%/D5W SULF FREE

4 B/D PA, HI

clovique 5d10 %-0.45 % sodiumchloride

2 HI

d2.5 %-0.45 % sodiumchloride

2 HI

d5 % and 0.9 %sodium chloride

2 MO, HI


DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUS AGENTS(continued)Drug Name Tier Requirements/

Limitsd5 %-0.45 % sodiumchloride

2 MO, HI

deferasirox 5 MOdeferoxamine 2 MOdextrose 10 % and0.2 % nacl

2 HI

dextrose 10 % inwater (d10w)

2 MO, HI


2


2


2


2

dextrose 5 % in water(d5w) intravenousparenteral solution

2 MO, HI

dextrose 5 % in water(d5w) intravenouspiggyback

2 MO

dextrose 5 %-lactatedringers

2 MO, HI

dextrose 5%-0.2 %sod chloride

2 HI

dextrose 5%-0.3 %sod.chloride

2 HI


2 MO


2 MO

dextrose with sodiumchloride

2 HI

disulfiram 2 MO


LimitsFERRIPROX 5 MOGIVLAARI 5 PA, MOGLASSIA 5 PA, MO, HI, LAINCRELEX 5 PA, MO, LAJADENU ORALTABLET 180 MG

5 MO

JADENU SPRINKLE 5 MOkionex (with sorbitol)oral suspension

2 MO

lanthanum oral tablet,chewable

2 MO

levocarnitine (withsugar)

2 MO

levocarnitine oralsolution 100 mg/ml

2 MO

levocarnitine oraltablet

2 MO

midodrine 2 MOmonoject 0.9%sodium chloride

MB

monoject prefilladvanced ns

MB MO

nitisinone 5 MONITYR 3 MO, LAnormal saline flush MB MONORTHERA 5 MOORFADIN 5 MO, LAOXBRYTA 5 PA, MO, LA, QL

(90 per 30days)

pilocarpine hcl oral 2 MOPROLASTIN-CINTRAVENOUSRECON SOLN

5 PA, HI, LA



LimitsPROLASTIN-CINTRAVENOUSSOLUTION

5 PA, MO, HI, LA

RAVICTI 5 MOREVCOVI 5 MOriluzole 2 MOrisedronate oral tablet30 mg


sevelamer carbonateoral powder in packet

5 MO

sevelamer carbonateoral tablet

2 MO

sevelamer hcl 2 MOsodium benzoate-sodphenylacet

2

sodium chlor 0.9%bacteriostat

MB

sodium chloride 0.9 %(flush) injectionsyringe

MB MO

sodium chloride 0.9 %injection

MB

sodium chloride 0.9 %intravenousparenteral solution

2 MO, HI

sodium chloride 0.9 %intravenouspiggyback

2 MO, HI

sodium chlorideinjection

MB

sodium chlorideirrigation

2 MO

sodium phenylbutyrate 5 MOsodium polystyrene(sorb free)

2 MO


Limitssodium polystyrenesulfonate oral powder

2 MO

sps (with sorbitol) oral 2 MOsps (with sorbitol)rectal

2

THIOLA 5 MOTHIOLA EC 5 MOTIGLUTIK 5 MOtrientine 5 MOVELTASSA 4 MOwater for inject,bacteriostat

MB

water for irrigation,sterile

2 MO

XURIDEN 5 MOzoledronic acid-mannitol-waterintravenouspiggyback 5 mg/100ml

2 MO, HI


DIAGNOSTICS / MISCELLANEOUSAGENTS: SMOKING DETERRENTSDrug Name Tier Requirements/

Limitsbupropion hcl(smoking deter) oraltablet extendedrelease

2 MO

CHANTIX 3 MOCHANTIXCONTINUINGMONTH BOX

3 MO

CHANTIX STARTINGMONTH BOX

3 MO

NICOTROL 3 MONICOTROL NS 3 MO

EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsazelastine nasal 2 MO, QL (60 per

30 days)chlorhexidinegluconate mucousmembrane

2 MO

denta 5000 plus 2 MOdentagel 2 MOfluoride (sodium)dental cream

2

fluoride (sodium)dental gel

2

ipratropium bromidenasal spray,non-aerosol 0.03 %


ipratropium bromidenasal spray,non-aerosol 42 mcg(0.06 %)


olopatadine nasal 2 MO, QL (30.5per 30 days)

oralone 2 MOparoex oral rinse 2 MOperiogard 2 MOsf 2 MOsf 5000 plus 2 MOsodium fluoride 5000plus

2

triamcinoloneacetonide dental

2 MO


EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSOTIC PREPARATIONSDrug Name Tier Requirements/

Limitsacetic acid otic (ear) 2 MOciprofloxacin hcl otic(ear)

2 MO

flac otic oil 2fluocinolone acetonideoil

2 MO

hydrocortisone-aceticacid

2 MO

ofloxacin otic (ear) 2 MO

EAR, NOSE / THROATMEDICATIONS: OTIC STEROID /ANTIBIOTICDrug Name Tier Requirements/

LimitsCIPRODEX 3 MOneomycin-polymyxin-hc otic (ear)

2 MO

ENDOCRINE/DIABETES: ADRENALHORMONESDrug Name Tier Requirements/

Limitsbetamethasone acet,sod phos

2 MO

cortisone 2 MOdecadron oral tablet 2dexabliss 2dexamethasoneintensol

2 MO

dexamethasone oralelixir

2 MO

dexamethasone oralsolution

2 MO

dexamethasone oraltablet

1 MO

dexamethasone oraltablets,dose pack

2 MO

dexamethasonesodium phos (pf)injection solution

2 MO

dexamethasonesodium phosphateinjection

2 MO

fludrocortisone 2 MOhidex 2hydrocortisone oral 2 MOmethylprednisoloneacetate

2 MO

methylprednisoloneoral tablet

1 B/D PA, MO

methylprednisoloneoral tablets,dosepack

1 MO

methylprednisolonesodium succ injectionrecon soln 125 mg,40 mg

2 MO, HI


ENDOCRINE/DIABETES: ADRENALHORMONES (continued)Drug Name Tier Requirements/

Limitsmethylprednisolonesodium succintravenous reconsoln 1,000 mg

2 MO, HI

methylprednisolonesodium succintravenous reconsoln 500 mg

2

millipred dp 1 MOmillipred oral tablet 1 B/D PA, MOprednisolone oralsolution 15 mg/5 ml

2 MO

prednisolone sodiumphosphate oralsolution 10 mg/5 ml,15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml(5 mg/ml), 5 mgbase/5 ml (6.7 mg/5ml)

2 MO

prednisolone sodiumphosphate oralsolution 15 mg/5 ml(5 ml)

2

prednisolone sodiumphosphate oral tablet,disintegrating

2 B/D PA, MO

prednisone intensol 2 B/D PA, MOprednisone oralsolution

2 MO

prednisone oral tablet 1 B/D PA, MOprednisone oraltablets,dose pack

1 MO

triamcinoloneacetonide injection

2 MO

ENDOCRINE/DIABETES:ANTITHYROID AGENTSDrug Name Tier Requirements/

Limitsmethimazole oraltablet 10 mg, 5 mg

2 MO

propylthiouracil 1 MO


ENDOCRINE/DIABETES: DIABETESTHERAPYDrug Name Tier Requirements/

Limitsacarbose 1 MOALCOHOL PADS 3 MOAVANDIA ORALTABLET 2 MG, 4 MG

4 MO

BAQSIMI 3 MOBYDUREON BCISE 3 MO, QL (3.4 per

28 days)BYDUREONSUBCUTANEOUSPEN INJECTOR


BYETTASUBCUTANEOUSPEN INJECTOR 10MCG/DOSE(250MCG/ML) 2.4 ML

3 MO, QL (2.4 per30 days)

BYETTASUBCUTANEOUSPEN INJECTOR 5MCG/DOSE (250MCG/ML) 1.2 ML


CYCLOSET 4 MOdiazoxide 2 MOGAUZE PADS 2X2 3 MOglimepiride 1 MOglipizide oral tablet 1 MOglipizide oral tabletextended release24hr

1 MO

glipizide-metformin 1 MOGLUCAGENHYPOKIT

3 MO

GLUCAGON (HCL)EMERGENCY KIT

3

GLUCAGONEMERGENCY KIT(HUMAN)

3 MO

ENDOCRINE/DIABETES: DIABETESTHERAPY (continued)Drug Name Tier Requirements/

Limitsglyburide 1 MOglyburide micronized 1 MOglyburide-metformin 1 MOHUMALOG JUNIORKWIKPEN U-100

3 MO

HUMALOG KWIKPENINSULIN

3 MO

HUMALOG MIX 50-50INSULN U-100

3 MO

HUMALOG MIX 50-50KWIKPEN

3 MO

HUMALOG MIX 75-25KWIKPEN

3 MO

HUMALOG MIX 75-25(U-100)INSULN

3 MO

HUMALOG U-100INSULIN

3 MO

HUMULIN 70/30U-100 INSULIN

3 MO

HUMULIN 70/30U-100 KWIKPEN

3 MO

HUMULIN N NPHINSULIN KWIKPEN

3 MO

HUMULIN N NPHU-100 INSULIN

3 MO

HUMULIN RREGULAR U-100INSULN

3 MO

HUMULIN R U-500(CONC) INSULIN

3 MO

INPEN (FORHUMALOG)


INSULIN PENNEEDLE

3 MO

INSULIN SYRINGE(DISP) U-100 0.3 ML

3 MO



LimitsINSULIN SYRINGE(DISP) U-100 1 ML

3 MO

INSULIN SYRINGE(DISP) U-100 1/2 ML

3 MO

INVOKAMET 3 MOINVOKAMET XR 3 MOINVOKANA 3 MOJANUMET 3 MOJANUMET XR 3 MOJANUVIA 3 MOJARDIANCE 3 MOLANTUS SOLOSTARU-100 INSULIN

3 MO

LANTUS U-100INSULIN

3 MO

metformin oralsolution

2 MO

metformin oral tablet 1 MOmetformin oral tabletextended release 24hr (generic -GLUCOPHAGE XR)

1 MO

miglitol 1 MOnateglinide 1 MONEEDLES, INSULINDISP.,SAFETY

3 MO

ONETOUCH BLOODGLUCOSE METERS

MB QL (1 per 365days)

ONETOUCH ULTRABLUE TEST STRIP

MB MO, QL (300 per30 days)

ONETOUCH VERIOTEST STRIP

MB MO, QL (300 per30 days)


LimitsOZEMPICSUBCUTANEOUSPEN INJECTOR 0.25MG OR 0.5 MG(2MG/1.5 ML)

4 ST, MO, QL (1.5per 28 days)

OZEMPICSUBCUTANEOUSPEN INJECTOR 1MG/DOSE (2 MG/1.5ML)

4 ST, MO, QL (3per 28 days)

pioglitazone 1 MOpioglitazone-glimepiride

1 MO

pioglitazone-metformin

1 MO

PROGLYCEM 3 MOrepaglinide 1 MOrepaglinide-metformin 1 MORYBELSUS 4 ST, MO, QL (30

per 30 days)SYMLINPEN 120 5 MOSYMLINPEN 60 5 MOSYNJARDY 3 MOSYNJARDY XR 3 MOTOUJEO MAX U-300SOLOSTAR

3 MO

TOUJEO SOLOSTARU-300 INSULIN

3 MO

TRULICITY 3 MO, QL (2 per28 days)

VGO 3


ENDOCRINE/DIABETES:MISCELLANEOUS HORMONESDrug Name Tier Requirements/

LimitsALDURAZYME 5 MO, HIANADROL-50 5 PA, MOcabergoline 2 MOcalcitonin (salmon) 2 MOcalcitriol intravenoussolution 1 mcg/ml

2 MO, HI

calcitriol oral capsule 1 MOcalcitriol oral solution 2 MOCERDELGA 5 MOCEREZYMEINTRAVENOUSRECON SOLN 400UNIT

5 PA, MO, HI

CHORIONICGONADOTROPIN,HUMANINTRAMUSCULAR

3 PA, MO

cinacalcet oral tablet30 mg

2 MO

cinacalcet oral tablet60 mg, 90 mg

5 MO

clomiphene citrate 2 PA, MOCRYSVITA 5 MOdanazol 2 MOdesmopressininjection

2 MO, HI

desmopressin nasalspray with pump

2 MO

desmopressin nasalspray,non-aerosol

2 MO

desmopressin oral 2 MOdoxercalciferolintravenous

2

doxercalciferol oral 2 MOELELYSO 5 MO, HI

ENDOCRINE/DIABETES:MISCELLANEOUS HORMONES(continued)Drug Name Tier Requirements/

LimitsFABRAZYME 5 MO, HIGALAFOLD 5 PA, MO, LAJYNARQUE ORALTABLET

5 LA

JYNARQUE ORALTABLETS,SEQUENTIAL

5 MO, LA

KANUMA 5 MO, HIKORLYM 5 PA, MOKUVAN 5 MOMEPSEVII 5 MOMETHITEST 3 MOmethyltestosteroneoral capsule

5 MO

MIACALCININJECTION

4 MO

miglustat 5 MO, LAMYALEPT 5 MO, LANAGLAZYME 5 MO, HI, LANATPARA 5 PA, MO, LANOVAREL 3 PA, MOoxandrolone oraltablet 10 mg

5 PA, MO

oxandrolone oraltablet 2.5 mg

2 PA, MO

PALYNZIQ 5 MO, LApamidronate 2 MO, HIPARICALCITOLHEMODIALYSISPORT INJECTION

3

paricalcitolintravenous

2 HI



LimitsPARICALCITOLINTRAVENOUSSOLUTION 2 MCG/ML (BRAND)

3 HI

PARICALCITOLINTRAVENOUSSOLUTION 5 MCG/ML (BRAND)

3 MO, HI

paricalcitol oral 2 MOPARSABIV 5 MOSAMSCA 5 MOSOMAVERT 5 MOSTIMATE 3 MOSTRENSIQ 5 MO, LASYNAREL 5 MOTEPEZZA 5 PA, MOtestosterone cypionateintramuscular oil 100mg/ml, 200 mg/ml

2 MO

testosterone cypionateintramuscular oil 200mg/ml (1 ml)

2

testosteroneenanthate

2 MO

testosteronetransdermal gel(generic)

2 MO

testosteronetransdermal gel inmetered-dose pump10 mg/0.5 gram(Fortesta generic)

2 MO


Limitstestosteronetransdermal gel inmetered-dose pump12.5 mg/ 1.25 gram(1 %) (Androgelgeneric)

2 MO

testosteronetransdermal gel inmetered-dose pump20.25 mg/1.25 gram(1.62 %) (Androgelgeneric)

2 MO

testosteronetransdermal gel inpacket (Androgelgeneric)

2 MO

testosteronetransdermal solutionin metered pump w/app (Axiron generic)

2 MO

VIMIZIM 3 MOzoledronic acidintravenous solution

2 MO, HI

zoledronic acid-mannitol-waterintravenouspiggyback 4 mg/100ml

2 MO, HI


ENDOCRINE/DIABETES: THYROIDHORMONESDrug Name Tier Requirements/

Limitslevothyroxineintravenous reconsoln

2 MO

levothyroxine oral 1 MOlevoxyl oral tablet 100mcg, 112 mcg, 125mcg, 137 mcg, 150mcg, 175 mcg, 200mcg, 25 mcg, 50mcg, 75 mcg, 88 mcg

1 MO

liothyronineintravenous

2 MO, HI

liothyronine oral 2 MOnp thyroid 2 MOthyroid (pork) oraltablet 120 mg, 30mg, 60 mg

2

thyroid (pork) oraltablet 15 mg, 90 mg

2 MO

unithroid 1 MO

GASTROENTEROLOGY:ANTIDIARRHEALS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsatropine injectionsolution 0.4 mg/ml

2

atropine injectionsyringe 0.05 mg/ml

2

atropine injectionsyringe 0.1 mg/ml

2 MO

chlordiazepoxide-clidinium

2 MO

CUVPOSA 4 MOdicyclomineintramuscular

2 MO

dicyclomine oralcapsule

2 MO

dicyclomine oralsolution

2 MO

dicyclomine oral tablet 2 MOdiphenoxylate-atropine

2 MO

glycopyrrolate (pf) inwater intravenoussyringe 0.4 mg/2 ml(0.2 mg/ml)

2

glycopyrrolateinjection

2 MO

glycopyrrolate oraltablet 1 mg, 2 mg

2 MO

glycopyrrolate oraltablet 1.5 mg

2

loperamide oralcapsule

2 MO

methscopolamine 2 MOMYTESI 3 MOopium tincture 2 MOpropantheline 2 MO


GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTSDrug Name Tier Requirements/

Limitsalosetron 5 MO, QL (60 per

30 days)AMITIZA 3 MO, QL (60 per

30 days)aprepitant 2 B/D PA, MObalsalazide 2 MObudesonide oralcapsule,delayed,extend.release

2 MO

budesonide oraltablet,delayed andext.release

5 MO

CHOLBAM 5 MOCIMZIA 5 PA, MO, QL (3

per 28 days)CIMZIA POWDERFOR RECONST


CIMZIA STARTER KIT 5 PA, MO, QL (3per 28 days)

CINVANTI 3 MO, HIcolocort 2 MOcompro 2 MOconstulose 2 MOCREON 3 MOcromolyn oral 2 MOCYSTADANE 5 MOdimenhydrinateinjection solution

2 MO

DIPENTUM 5 MOdoxylamine-pyridoxine(vit b6)

2 MO

dronabinol 2 B/D PA, MOdroperidol injectionsolution

2 MO

GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTS(continued)Drug Name Tier Requirements/

LimitsEMEND(FOSAPREPITANT)

3 MO, HI

EMEND ORALSUSPENSION FORRECONSTITUTION

3 B/D PA, MO

ENTYVIO 3 PA, MOenulose 2 MOfosaprepitant 2 MOGATTEX 30-VIAL 5 PA, MOGATTEX ONE-VIAL 5 PA, MOgavilyte-c 2 MOgavilyte-g 2 MOgavilyte-n 2 MOgenerlac 2 MOgranisetron (pf)intravenous solution1 mg/ml (1 ml)

2 MO, HI

granisetron hclintravenous

2 MO, HI

granisetron hcl oral 2 B/D PA, MOhydrocortisone rectal 2 MOhydrocortisone topicalcream with perinealapplicator

2 MO

hydrocortisone-pramoxine rectalcream 1-1 %

2 MO

INFLECTRA 5 PA, MO, HIlactulose oral packet 2lactulose oral solution 2 MOLINZESS 3 MO, QL (30 per

30 days)



Limitsmeclizine oral tablet12.5 mg, 25 mg

2 MO

mesalamine 2 MOmesalamine oraltablet,delayedrelease (dr/ec)

2 MO

mesalamine rectal 2 MOmetoclopramide hclinjection solution

2 MO, HI

metoclopramide hclinjection syringe

2 HI

metoclopramide hcloral solution

2 MO

metoclopramide hcloral tablet

1 MO

metoclopramide hcloral tablet,disintegrating

2 MO

MOTEGRITY 4 MO, QL (30 per30 days)

OCALIVA 5 MO, LA, QL (30per 30 days)

ondansetron hcl (pf)injection solution

2 MO, HI

ondansetron hcl (pf)injection syringe

2 HI

ondansetron hclintravenous

2 MO, HI

ondansetron hcl oralsolution

2 B/D PA, MO

ondansetron hcl oraltablet 24 mg

2 B/D PA

ondansetron hcl oraltablet 4 mg, 8 mg

2 B/D PA, MO


Limitsondansetron oraltablet,disintegrating

2 B/D PA, MO

OSMOPREP 4 MOpalonosetronintravenous solution0.25 mg/5 ml

2 MO

palonosetronintravenous syringe

2

peg 3350-electrolytesoral recon soln236-22.74-6.74 -5.86gram

2 MO

peg-electrolyte 2PENTASA ORALCAPSULE,EXTENDEDRELEASE 250 MG

3 MO

PENTASA ORALCAPSULE,EXTENDEDRELEASE 500 MG

5 MO

polyethylene glycol3350

2 MO

prochlorperazine 2 MOprochlorperazineedisylate injectionsolution 10 mg/2 ml(5 mg/ml)

2 MO

prochlorperazineedisylate injectionsolution 5 mg/ml

2

prochlorperazinemaleate oral

1 MO

procto-med hc 2 MOprocto-pak 2 MOproctosol hc topical 2 MO



Limitsproctozone-hc 2 MORECTIV 4 MORELISTOR ORAL 5 MORELISTORSUBCUTANEOUSSOLUTION

5 MO

RELISTORSUBCUTANEOUSSYRINGE

5 MO

scopolamine base 2 MOSUCRAID 5 MOsulfasalazine oraltablet

2 MO

sulfasalazine oraltablet,delayedrelease (dr/ec)

2 MO

SYNDROS 5 B/D PA, MOtrilyte with flavorpackets

2 MO

trimethobenzamideoral

2 B/D PA, MO

UCERIS RECTAL 4 MOursodiol 2 MOVARUBI ORAL 3 B/D PA, MO


LimitsZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)10,000-32,000 -42,000UNIT,15,000-47,000 -63,000UNIT, 20,000-63,000-84,000 UNIT,25,000-79,000-105,000 UNIT,3,000-10,000 -14,000-UNIT,40,000-126,000-168,000 UNIT,5,000-17,000- 24,000UNIT

3 MO


GASTROENTEROLOGY: ULCERTHERAPYDrug Name Tier Requirements/

Limitsamoxicil-clarithromy-lansopraz

2 MO

cimetidine 2 MOcimetidine hcl oral 2 MOesomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 20 mg


esomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 40 mg


esomeprazolemagnesium oralgranules dr for suspin packet

2 ST, MO

esomeprazole sodiumintravenous reconsoln 20 mg

2 HI

esomeprazole sodiumintravenous reconsoln 40 mg

2 MO, HI

famotidine (pf) 2 MO, HIfamotidine (pf)-nacl(iso-os)

2 MO, HI

famotidine intravenoussolution

2 MO, HI

famotidine oralsuspension

2 MO

famotidine oral tablet20 mg, 40 mg

1 MO

lansoprazole oralcapsule,delayedrelease(dr/ec) 15 mg


lansoprazole oralcapsule,delayedrelease(dr/ec) 30 mg


GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitslansoprazole oraltablet,disintegrat,delay rel 15 mg


lansoprazole oraltablet,disintegrat,delay rel 30 mg


misoprostol 2 MOnizatidine 2 MOomeprazole oralcapsule,delayedrelease(dr/ec) 10 mg


omeprazole oralcapsule,delayedrelease(dr/ec) 20 mg,40 mg


omeprazole-sodiumbicarbonate oralcapsule 20-1.1 mg-gram


omeprazole-sodiumbicarbonate oralcapsule 40-1.1 mg-gram


omeprazole-sodiumbicarbonate oralpacket 20-1,680 mg


omeprazole-sodiumbicarbonate oralpacket 40-1,680 mg


pantoprazoleintravenous

2 MO, HI

pantoprazole oraltablet,delayedrelease (dr/ec) 20 mg


pantoprazole oraltablet,delayedrelease (dr/ec) 40 mg



GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitsrabeprazole oraltablet,delayedrelease (dr/ec)


ranitidine hcl oralsyrup

2 MO

ranitidine hcl oraltablet 150 mg, 300mg

1 MO

sucralfate 2 MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGSDrug Name Tier Requirements/

LimitsACTIMMUNE 5 PA, MOARCALYST 5 MOAVONEXINTRAMUSCULARPEN INJECTOR KIT


AVONEXINTRAMUSCULARSYRINGE KIT


EGRIFTASUBCUTANEOUSRECON SOLN 1 MG

5 PA, MO

EGRIFTA SV 5 PA, MOFULPHILA 5 MO, QL (1.2 per

30 days)GRANIX 5 MOILARIS (PF)SUBCUTANEOUSSOLUTION

5 PA, MO, LA

INTRON AINJECTION RECONSOLN

5 PA, MO

INTRON AINJECTIONSOLUTION 10MILLION UNIT/ML

3 PA, MO

INTRON AINJECTIONSOLUTION 6MILLION UNIT/ML

5 PA, MO

LEUKINE INJECTIONRECON SOLN

5 MO, HI

MOZOBIL 5 MOOMNITROPE 5 PA, MO


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsPEGASYSPROCLICKSUBCUTANEOUSPEN INJECTOR 180MCG/0.5 ML

5 QL (2 per 28days)

PEGASYSSUBCUTANEOUSSOLUTION


PEGASYSSUBCUTANEOUSSYRINGE


PEGINTRONSUBCUTANEOUSKIT 50 MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 125MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 63MCG/0.5 ML- 94MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSSYRINGE


PROLEUKIN 5 PA, MO, HIREBIF (WITHALBUMIN)


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR 22MCG/0.5 ML, 44MCG/0.5 ML


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR8.8MCG/0.2ML-22MCG/0.5ML (6)


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsREBIF TITRATIONPACK


REBLOZYL 5 PA, MORETACRITINJECTIONSOLUTION 10,000UNIT/ML, 2,000UNIT/ML, 3,000UNIT/ML, 4,000UNIT/ML

3 PA, MO

RETACRITINJECTIONSOLUTION 40,000UNIT/ML

5 PA, MO

SEROSTIMSUBCUTANEOUSRECON SOLN 4 MG,5 MG, 6 MG

5 PA, MO

SYLATRONSUBCUTANEOUSKIT 200 MCG, 300MCG

5 MO

UDENYCA 5 MO, QL (1.2 per30 days)

ZARXIO 5 MOZIEXTENZO 5 MO, QL (1.2 per

28 days)ZORBTIVE 5 PA, MO


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALSDrug Name Tier Requirements/

LimitsACTHIB (PF) 1 MOADACEL(TDAPADOLESN/ADULT)(PF)

1 MO

AFLURIA QD 2019-20(3YR UP)(PF)

MB MO

AFLURIA QD 2019-20(6-35MO)(PF)

MB

AFLURIA QUAD2019-20(6MO UP)

MB

BCG VACCINE, LIVE(PF)

1 MO

BEXSERO 1 MOBOOSTRIX TDAP 1 MOBOTOX 4 PA, MODAPTACEL (DTAPPEDIATRIC) (PF)

1 MO

DYSPORT 4 PA, MOENGERIX-B (PF)INTRAMUSCULARSUSPENSION

1 B/D PA, MO

ENGERIX-B (PF)INTRAMUSCULARSYRINGE

1 B/D PA, MO

ENGERIX-BPEDIATRIC (PF)INTRAMUSCULARSYRINGE

1 B/D PA, MO

FLUAD 2019-2020 (65YR UP)(PF)

MB MO

FLUARIX QUAD2019-2020 (PF)

MB MO

FLUBLOK QUAD2019-2020 (PF)

MB MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALS (continued)Drug Name Tier Requirements/

LimitsFLUCELVAX QUAD2019-2020

MB

FLUCELVAX QUAD2019-2020 (PF)

MB MO

FLULAVAL QUAD2019-2020

MB

FLULAVAL QUAD2019-2020 (PF)

MB MO

FLUMIST QUAD2019-2020

MB

FLUZONE HIGH-DOSE 2019-20 (PF)

MB MO

FLUZONE QUAD2019-2020

MB

FLUZONE QUAD2019-2020 (PF)INTRAMUSCULARSUSPENSION

MB

FLUZONE QUAD2019-2020 (PF)INTRAMUSCULARSYRINGE

MB MO

FLUZONE QUADPEDI 2019-20 (PF)

MB MO

fomepizole 2 HIGAMASTAN 3 MOGAMASTAN S/D 3GAMMAGARDLIQUID

5 PA, MO, HI

GAMMAGARD S-D(IGA < 1 MCG/ML)

5 PA, MO, HI

GAMUNEX-CINJECTIONSOLUTION 1GRAM/10 ML (10 %)

5 PA, MO, HI



LimitsGAMUNEX-CINJECTIONSOLUTION 10GRAM/100 ML(10 %), 2.5 GRAM/25ML (10 %), 20GRAM/200 ML(10 %), 40GRAM/400 ML(10 %), 5 GRAM/50ML (10 %)

5 PA, MO, HI

GARDASIL 9 (PF) 1 MOGRASTEK 4 MOHAVRIX (PF)INTRAMUSCULARSUSPENSION

1 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 1,440ELISA UNIT/ML

1 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 720 ELISAUNIT/0.5 ML

1

HIBERIX (PF) 1 MOIMOVAX RABIESVACCINE (PF)

1 MO

INFANRIX (DTAP)(PF)INTRAMUSCULARSUSPENSION

1 MO

INFANRIX (DTAP)(PF)INTRAMUSCULARSYRINGE

1 MO

IPOL 1 MOIXIARO (PF) 1 MO


LimitsKINRIX (PF)INTRAMUSCULARSUSPENSION

1

KINRIX (PF)INTRAMUSCULARSYRINGE

1 MO

MENACTRA (PF)INTRAMUSCULARSOLUTION

1 MO

MENVEO A-C-Y-W-135-DIP (PF)

1 MO

M-M-R II (PF) 1 MOORALAIRSUBLINGUALTABLET 300 INDXREACTIVITY

4 MO

PEDIARIX (PF) 1 MOPEDVAX HIB (PF) 1 MOPENTACEL (PF)INTRAMUSCULARKIT 15 LF UNIT-20MCG-5 LF/0.5 ML

1 MO

PENTACEL (PF)INTRAMUSCULARKIT15LF-48MCG-62DU-10 MCG/0.5ML

1

PNEUMOVAX-23 MB MOPREVNAR 13 (PF) MB MOPROQUAD (PF) 1QUADRACEL (PF) 1 MORABAVERT (PF) 1 MORAGWITEK 4 MO



LimitsRECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION 10MCG/ML, 40 MCG/ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION 5MCG/0.5 ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 10 MCG/ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 5 MCG/0.5ML

1 B/D PA

ROTARIX 1ROTATEQ VACCINE 1 MOSHINGRIX (PF) 1 MOSTAMARIL (PF) 1TDVAX 1 MOTENIVAC (PF)INTRAMUSCULARSUSPENSION

1 MO

TENIVAC (PF)INTRAMUSCULARSYRINGE

1 MO

TETANUS,DIPHTHERIA TOXPED(PF)

1 MO

TICE BCG 1 MO


LimitsTRUMENBA 1 MOTWINRIX (PF)INTRAMUSCULARSYRINGE

1 MO

TYPHIM VIINTRAMUSCULARSOLUTION

1

TYPHIM VIINTRAMUSCULARSYRINGE

1 MO

VAQTA (PF) 1 MOVARIVAX (PF) 1 MOVARIZIGINTRAMUSCULARSOLUTION

1 MO

XEOMININTRAMUSCULARRECON SOLN 100UNIT, 50 UNIT

4 PA, MO

XEOMININTRAMUSCULARRECON SOLN 200UNIT

5 PA, MO

YF-VAX (PF) 1 MOZINPLAVA 5 PA, MO, HIZOSTAVAX (PF) 1 MO


MUSCULOSKELETAL /RHEUMATOLOGY: GOUT THERAPYDrug Name Tier Requirements/

Limitsallopurinol 1 MOallopurinol sodium 2 HIaloprim 2 HIcolchicine oral tablet(Brand - Colcrys)

2 MO

COLCRYS 3 MOfebuxostat 2 MOKRYSTEXXA 4 MOprobenecid 2 MOprobenecid-colchicine 2 MO

MUSCULOSKELETAL /RHEUMATOLOGY: OSTEOPOROSISTHERAPYDrug Name Tier Requirements/

Limitsalendronate oralsolution


alendronate oral tablet10 mg, 5 mg


alendronate oral tablet35 mg, 70 mg


EVENITYSUBCUTANEOUSSYRINGE 105MG/1.17 ML

5 PA, QL (2.34 per30 days)

EVENITYSUBCUTANEOUSSYRINGE210MG/2.34ML( 105MG/1.17MLX2)

5 PA, MO, QL(2.34 per 30days)

FORTEO 5 PA, MO, QL (2.4per 28 days)

ibandronateintravenous

2 MO

ibandronate oral 2 MO, QL (1 per30 days)

PROLIA 4 PA, MOraloxifene 2 MOrisedronate oral tablet150 mg


risedronate oral tablet35 mg, 35 mg (12pack), 35 mg (4pack)


risedronate oral tablet5 mg


risedronate oral tablet,delayed release (dr/ec)


TYMLOS 5 PA, MO, QL(1.56 per 30days)


MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALSDrug Name Tier Requirements/

LimitsACTEMRA ACTPEN 5 PA, MO, QL (3.6

per 28 days)ACTEMRAINTRAVENOUS

5 PA, MO, HI, QL(40 per 28days)

ACTEMRASUBCUTANEOUS

5 PA, MO, QL (3.6per 28 days)

BENLYSTAINTRAVENOUS

5 MO, HI

BENLYSTASUBCUTANEOUS

5 MO

DEPEN TITRATABS 5 MOD-PENAMINE 5 MOENBREL MINI 5 PA, MO, QL (8

per 28 days)ENBRELSUBCUTANEOUSRECON SOLN


ENBRELSUBCUTANEOUSSYRINGE


ENBREL SURECLICK 5 PA, MO, QL (8per 28 days)

HUMIRA PEN 5 PA, MO, QL (4per 28 days)

HUMIRA PENCROHNS-UC-HSSTART


HUMIRA PEN PSOR-UVEITS-ADOL HS


HUMIRASUBCUTANEOUSSYRINGE KIT 10MG/0.2 ML, 20MG/0.4 ML


MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsHUMIRASUBCUTANEOUSSYRINGE KIT 40MG/0.8 ML


HUMIRA(CF) PEDICROHNS STARTERSUBCUTANEOUSSYRINGE KIT 80MG/0.8 ML


HUMIRA(CF) PEDICROHNS STARTERSUBCUTANEOUSSYRINGE KIT 80MG/0.8 ML-40MG/0.4 ML


HUMIRA(CF) PENCROHNS-UC-HS


HUMIRA(CF) PENPSOR-UV-ADOL HS


HUMIRA(CF) PENSUBCUTANEOUSINJECTOR KIT 40MG/0.4 ML


HUMIRA(CF)SUBCUTANEOUSSYRINGE KIT 10MG/0.1 ML, 20MG/0.2 ML


HUMIRA(CF)SUBCUTANEOUSSYRINGE KIT 40MG/0.4 ML


KEVZARA 5 PA, MO, QL(2.28 per 28days)

KINERET 5 PA, MOleflunomide 2 MO, QL (30 per

30 days)



LimitsORENCIA (WITHMALTOSE)

5 PA, MO, HI, QL(4 per 28 days)

ORENCIACLICKJECT


ORENCIASUBCUTANEOUSSYRINGE 125 MG/ML


ORENCIASUBCUTANEOUSSYRINGE 50 MG/0.4ML


ORENCIASUBCUTANEOUSSYRINGE 87.5MG/0.7 ML


OTEZLA 5 PA, MO, QL (60per 30 days)

OTEZLA STARTERORAL TABLETS,DOSE PACK 10 MG(4)-20 MG (4)-30 MG(47)


penicillamine 5 MORIDAURA 5 MORINVOQ 5 PA, MO, QL (30

per 30 days)SIMPONI ARIA 5 PA, MO, HISIMPONISUBCUTANEOUSPEN INJECTOR 100MG/ML


SIMPONISUBCUTANEOUSPEN INJECTOR 50MG/0.5 ML



LimitsSIMPONISUBCUTANEOUSSYRINGE 100 MG/ML


SIMPONISUBCUTANEOUSSYRINGE 50 MG/0.5ML


XELJANZ 5 PA, MO, QL (60per 30 days)

XELJANZ XR 5 PA, MO, QL (30per 30 days)


OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINSDrug Name Tier Requirements/

Limitsamabelz 2 MOcamila 2 MOdeblitane 2 MOdotti 2 MOerrin 2 MOestradiol 2 MOestradiol valerateintramuscular oil 20mg/ml, 40 mg/ml

2 MO

estradiol-norethindrone acet

2 MO

fyavolv 2 MOheather 2 MOhydroxyprogesteronecaproate

5 MO

incassia 2 MOjencycla 2 MOjinteli 2 MOlopreeza oral tablet1-0.5 mg

2 MO

lyza 2 MOmedroxyprogesterone 2 MOmimvey 2 MOnora-be 2 MOnorethindrone(contraceptive)

2 MO

norethindrone acetate 2 MOnorethindrone ac-ethestradiol oral tablet0.5-2.5 mg-mcg, 1-5mg-mcg

2 MO

norlyda 2 MOPREMARININJECTION

4 MO, HI

OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINS(continued)Drug Name Tier Requirements/

Limitsprogesterone 2 MOprogesteronemicronized

2 MO

sharobel 2 MOtulana 2 MOyuvafem 2 MO

OBSTETRICS / GYNECOLOGY:MISCELLANEOUS OB/GYNDrug Name Tier Requirements/

LimitsCLEOCIN VAGINALSUPPOSITORY

3 MO

clindamycinphosphate vaginal

2 MO

eluryng 2 MOetonogestrel-ethinylestradiol

2 MO

GYNAZOLE-1 4 MOLUPANETA PACK (1MONTH)

5 MO

LUPANETA PACK (3MONTH)

5 MO

metronidazole vaginal 2 MOmiconazole-3 vaginalsuppository

2 MO

terconazole 2 MOtranexamic acid oral 2 MOvandazole 2 MOxulane 2 MO


OBSTETRICS / GYNECOLOGY:ORAL CONTRACEPTIVES /RELATED AGENTSDrug Name Tier Requirements/

Limitsafirmelle 2altavera (28) 2 MOalyacen 1/35 (28) 2 MOalyacen 7/7/7 (28) 2 MOamethia 2 MOamethia lo 2 MOamethyst (28) 2 MOapri 2 MOaranelle (28) 2 MOashlyna 2 MOaubra 2 MOaubra eq 2 MOaurovela 1.5/30 (21) 2 MOaurovela 1/20 (21) 2 MOaurovela 24 fe 2 MOaurovela fe 1.5/30 (28) 2 MOaurovela fe 1-20 (28) 2 MOaviane 2 MOayuna 2azurette (28) 2 MObalziva (28) 2 MObekyree (28) 2 MOblisovi 24 fe 2 MOblisovi fe 1.5/30 (28) 2 MOblisovi fe 1/20 (28) 2 MObriellyn 2 MOcamrese 2 MOcamrese lo 2 MOcaziant (28) 2 MOchateal (28) 2

OBSTETRICS / GYNECOLOGY: ORALCONTRACEPTIVES / RELATEDAGENTS (continued)Drug Name Tier Requirements/

Limitschateal eq (28) 2 MOcryselle (28) 2 MOcyclafem 1/35 (28) 2 MOcyclafem 7/7/7 (28) 2 MOcyred 2 MOcyred eq 2 MOdasetta 1/35 (28) 2 MOdasetta 7/7/7 (28) 2 MOdaysee 2 MOdesog-e.estradiol/e.estradiol

2 MO

desogestrel-ethinylestradiol

2 MO

drospirenone-e.estradiol-lm.fa

2 MO

drospirenone-ethinylestradiol

2 MO

elinest 2 MOELLA 3emoquette 2 MOenpresse 2 MOenskyce 2 MOestarylla 2 MOethynodiol diac-ethestradiol

2

falmina (28) 2 MOfayosim 2 MOfemynor 2 MOgianvi (28) 2 MOhailey 2 MOhailey 24 fe 2 MOintrovale 2 MO



Limitsisibloom 2 MOjaimiess 2 MOjasmiel (28) 2 MOjolessa 2 MOjuleber 2 MOjunel 1.5/30 (21) 2 MOjunel 1/20 (21) 2 MOjunel fe 1.5/30 (28) 2 MOjunel fe 1/20 (28) 2 MOjunel fe 24 2 MOkaitlib fe 2 MOkalliga 2kariva (28) 2 MOkelnor 1/35 (28) 2 MOkelnor 1-50 2 MOkurvelo (28) 2 MOl norgest/e.estradiol-e.estrad

2 MO

larin 1.5/30 (21) 2 MOlarin 1/20 (21) 2 MOlarin 24 fe 2 MOlarin fe 1.5/30 (28) 2 MOlarin fe 1/20 (28) 2 MOlarissia 2 MOlayolis fe 2 MOleena 28 2 MOlessina 2 MOlevonest (28) 2 MOlevonorgestrel-ethinylestrad

2 MO


Limitslevonorg-eth estradtriphasic

2 MO

levora-28 2 MOlillow (28) 2 MOlojaimiess 2 MOloryna (28) 2 MOlow-ogestrel (28) 2 MOlo-zumandimine (28) 2 MOlutera (28) 2 MOmarlissa (28) 2 MOmelodetta 24 fe 2 MOmibelas 24 fe 2 MOmicrogestin 1.5/30(21)

2 MO

microgestin 1/20 (21) 2 MOmicrogestin fe 1.5/30(28)

2 MO

microgestin fe 1/20(28)

2 MO

mili 2 MOmono-linyah 2 MOnecon 0.5/35 (28) 2 MOnikki (28) 2 MOnoreth-ethinylestradiol-iron

2 MO

norethindrone ac-ethestradiol oral tablet1.5-30 mg-mcg

2

norethindrone ac-ethestradiol oral tablet1-20 mg-mcg

2 MO



Limitsnorethindrone-e.estradiol-iron oraltablet 1 mg-20 mcg(21)/75 mg (7)

2 MO

norethindrone-e.estradiol-iron oraltablet 1.5 mg-30 mcg(21)/75 mg (7)

2

norethindrone-e.estradiol-iron oraltablet,chewable

2 MO

norgestimate-ethinylestradiol

2 MO

nortrel 0.5/35 (28) 2 MOnortrel 1/35 (21) 2 MOnortrel 1/35 (28) 2 MOnortrel 7/7/7 (28) 2 MOocella 2 MOogestrel (28) 2 MOorsythia 2 MOphilith 2 MOpimtrea (28) 2 MOpirmella 2 MOportia 28 2 MOprevifem 2 MOreclipsen (28) 2 MOrivelsa 2 MOsetlakin 2 MOsimliya (28) 2 MOsimpesse 2sprintec (28) 2 MOsronyx 2 MOsyeda 2 MO


Limitstarina 24 fe 2 MOtarina fe 1/20 (28) 2 MOtarina fe 1-20 eq (28) 2 MOtilia fe 2 MOtri femynor 2 MOtri-estarylla 2 MOtri-legest fe 2 MOtri-linyah 2 MOtri-lo-estarylla 2 MOtri-lo-marzia 2 MOtri-lo-mili 2 MOtri-lo-sprintec 2 MOtri-mili 2 MOtri-previfem (28) 2 MOtri-sprintec (28) 2 MOtrivora (28) 2 MOtri-vylibra 2 MOtri-vylibra lo 2 MOtydemy 2 MOvelivet triphasicregimen (28)

2 MO

vienva 2 MOviorele (28) 2 MOvolnea (28) 2vyfemla (28) 2 MOvylibra 2 MOwera (28) 2 MOwymzya fe 2 MOzarah 2 MOzovia 1/35e (28) 2 MOzumandimine (28) 2


OBSTETRICS / GYNECOLOGY:OXYTOCICSDrug Name Tier Requirements/

Limitsmethergine 2methylergonovineinjection

2

methylergonovine oral 2 MOoxytocin injectionsolution

2 MO

OPHTHALMOLOGY: ANTIBIOTICSDrug Name Tier Requirements/

Limitsak-poly-bac 2 MObacitracin ophthalmic(eye)

2 MO

bacitracin-polymyxin bophthalmic (eye)

2 MO

ciprofloxacin hclophthalmic (eye)

2 MO

erythromycinophthalmic (eye)

1 MO

gatifloxacin 2 MOgentak ophthalmic(eye) ointment

1 MO

gentamicin ophthalmic(eye) drops

1 MO

levofloxacinophthalmic (eye)

2 MO

moxifloxacinophthalmic (eye)

2 MO

NATACYN 3 MOneomycin-bacitracin-polymyxin

2 MO

neomycin-polymyxin-gramicidin

2 MO

neo-polycin 2 MOofloxacin ophthalmic(eye)

2 MO

polycin 2 MOpolymyxin b sulf-trimethoprim

1 MO

tobramycin 1 MO


OPHTHALMOLOGY: ANTIVIRALSDrug Name Tier Requirements/

Limitstrifluridine 2 MOZIRGAN 4 MO

OPHTHALMOLOGY: BETA-BLOCKERSDrug Name Tier Requirements/

Limitsbetaxolol ophthalmic(eye)

2 MO

carteolol 1 MOlevobunololophthalmic (eye)drops 0.5 %

1 MO

timolol maleateophthalmic (eye)drops

1 MO

timolol maleateophthalmic (eye)drops, once daily

2 MO

timolol maleateophthalmic (eye) gelforming solution

1 MO

OPHTHALMOLOGY:MISCELLANEOUSOPHTHALMOLOGICSDrug Name Tier Requirements/

Limitsatropine ophthalmic(eye) drops

2 MO

azelastine ophthalmic(eye)

2 MO

balanced salt 2BLEPHAMIDE 4 MOBLEPHAMIDE S.O.P. 4 MObss 2 MOcromolyn ophthalmic(eye)

2 MO

CYSTARAN 5 MOepinastine 2 MOLACRISERT 3 MOolopatadineophthalmic (eye)

2 MO

OXERVATE 5 PA, MOPHOSPHOLINEIODIDE

3 MO

pilocarpine hclophthalmic (eye)drops 1 %, 2 %, 4 %

1 MO

RESTASIS 3 MO, QL (60 per30 days)

RESTASISMULTIDOSE


sulfacetamide sodiumophthalmic (eye)drops

1 MO

sulfacetamide sodiumophthalmic (eye)ointment

2 MO

sulfacetamide-prednisolone

2 MO


OPHTHALMOLOGY: NON-STEROIDAL ANTI-INFLAMMATORYAGENTSDrug Name Tier Requirements/

Limitsbromfenac 2 MOdiclofenac sodiumophthalmic (eye)

2 MO

flurbiprofen sodium 2 MOketorolac ophthalmic(eye)

2 MO

OPHTHALMOLOGY: ORAL DRUGSFOR GLAUCOMADrug Name Tier Requirements/

Limitsacetazolamide oralcapsule, extendedrelease

2 MO

acetazolamide oraltablet

2 MO

acetazolamide sodium 2 MO, HImethazolamide 2 MO

OPHTHALMOLOGY: OTHERGLAUCOMA DRUGSDrug Name Tier Requirements/

Limitsbimatoprostophthalmic (eye)

2 MO

dorzolamide 2 MOdorzolamide-timolol 2 MOdorzolamide-timolol(pf) ophthalmic (eye)dropperette

2 MO

latanoprost 2 MOmiostat 2travoprost 2 MO

OPHTHALMOLOGY: STEROID-ANTIBIOTIC COMBINATIONSDrug Name Tier Requirements/

Limitsneomycin-bacitracin-poly-hc

2 MO

neomycin-polymyxinb-dexameth

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

2 MO

neo-polycin hc 2 MOtobramycin-dexamethasone

2 MO

OPHTHALMOLOGY: STEROIDSDrug Name Tier Requirements/

Limitsdexamethasonesodium phosphateophthalmic (eye)

2 MO

fluorometholone 2 MOFML S.O.P. 3 MOloteprednol etabonate 2 MOPRED MILD 3 MOprednisolone acetate 2 MOprednisolone sodiumphosphateophthalmic (eye)

2 MO

OPHTHALMOLOGY:SYMPATHOMIMETICSDrug Name Tier Requirements/

Limitsapraclonidine 2 MObrimonidine 1 MO


RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTSDrug Name Tier Requirements/

Limitsadrenalin injection 2 MOcarbinoxaminemaleate

2 MO

cetirizine oral solution1 mg/ml

2 MO

clemastine oral tablet2.68 mg

2 MO

cyproheptadine 2 MOdesloratadine oraltablet

2 MO

desloratadine oraltablet,disintegrating

2 MO

dexchlorpheniraminemaleate oral solution

2

diphenhydramine hclinjection solution 50mg/ml

2 MO, HI

diphenhydramine hclinjection syringe

2 MO, HI

diphenhydramine hcloral elixir

2 PA

epinephrine injectionauto-injector 0.15mg/0.3 ml, 0.3mg/0.3 ml

2 MO

EPINEPHRINEINJECTION AUTO-INJECTOR 0.15MG/0.3 ML, 0.3MG/0.3 ML (BRAND -EPIPEN)

2 MO

epinephrine injectionsolution 1 mg/ml

2

EPIPEN 3 MOEPIPEN 2-PAK 3 MOEPIPEN JR 3 MO

RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTS (continued)Drug Name Tier Requirements/

LimitsEPIPEN JR 2-PAK 3 MOhydroxyzine hclintramuscular

2 MO

hydroxyzine hcl oralsolution 10 mg/5 ml

2 PA, MO

hydroxyzine hcl oraltablet

2 PA, MO

hydroxyzine pamoate 2 PA, MOlevocetirizine oralsolution

2 MO

levocetirizine oraltablet

2 MO

phenadoz 2 MOpromethazine injectionsolution

2 MO

promethazine oral 2 PA, MOpromethazine rectalsuppository 12.5 mg,25 mg

2 MO

promethegan 2 MO


RESPIRATORY AND ALLERGY:PULMONARY AGENTSDrug Name Tier Requirements/

Limitsacetylcysteine 2 B/D PA, MOADEMPAS 5 PA, MO, LAADVAIR DISKUS 2 MO, QL (60 per

30 days)ADVAIR HFA 4 PA, MO, QL (24

per 30 days)albuterol sulfateinhalation hfa aerosolinhaler 90 mcg/actuation

2 MO, QL (25.5per 30 days)

albuterol sulfateinhalation solution fornebulization

2 B/D PA, MO

albuterol sulfate oralsyrup

2 MO

albuterol sulfate oraltablet

2 MO

albuterol sulfate oraltablet extendedrelease 12 hr

2 MO

alyq 5 PA, MOambrisentan 5 PA, MO, LAaminophyllineintravenous

2 HI

ANORO ELLIPTA 3 MO, QL (60 per30 days)

ARCAPTANEOHALER


ARNUITY ELLIPTA 3 MO, QL (30 per30 days)

ATROVENT HFA 3 MO, QL (25.8per 30 days)

azelastine-fluticasone 2 MOBEVESPIAEROSPHERE


bosentan 5 PA, MO, LA

RESPIRATORY AND ALLERGY:PULMONARY AGENTS (continued)Drug Name Tier Requirements/

LimitsBROVANA 3 B/D PA, MObudesonide inhalation 2 B/D PA, MOCINRYZE 5 MO, HICOMBIVENTRESPIMAT


cromolyn inhalation 2 B/D PA, MODALIRESP 3 MODULERAINHALATION HFAAEROSOL INHALER100-5 MCG/ACTUATION, 200-5MCG/ACTUATION


DULERAINHALATION HFAAEROSOL INHALER50-5 MCG/ACTUATION


ESBRIET 5 PA, MOFASENRA 5 PA, MOFASENRA PEN 5 PA, MOFLOVENT DISKUSINHALATIONBLISTER WITHDEVICE 100 MCG/ACTUATION, 50MCG/ACTUATION


FLOVENT DISKUSINHALATIONBLISTER WITHDEVICE 250 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER110 MCG/ACTUATION




LimitsFLOVENT HFAAEROSOL INHALER220 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER44 MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg(0.025 %)


fluticasone propionatenasal


fluticasone propion-salmeterol inhalationblister with device


HYPER-SAL MB MOicatibant 5 MOINCRUSE ELLIPTA 3 MO, QL (30 per

30 days)ipratropium bromideinhalation

2 B/D PA, MO

ipratropium-albuterol 2 B/D PA, MOKALYDECO ORALGRANULES INPACKET 25 MG


KALYDECO ORALGRANULES INPACKET 50 MG, 75MG


KALYDECO ORALTABLET


levalbuterol hcl 2 B/D PA, MOmetaproterenol oralsyrup

2 MO

mometasone nasal 2 MO, QL (34 per30 days)


Limitsmontelukast 2 MOnebusal inhalationsolution fornebulization 3 %

MB MO

NEBUSALINHALATIONSOLUTION FORNEBULIZATION 6 %(BRAND)

MB MO

NUCALA 5 PA, MO, LAOFEV 5 PA, MOOPSUMIT 5 PA, MO, LAORKAMBI ORALGRANULES INPACKET


ORKAMBI ORALTABLET

5 PA, MO, QL(112 per 28days)

PROAIR HFA 3 MO, QL (25.5per 30 days)

PROAIR RESPICLICK 3 MO, QL (2 per30 days)

pulmosal MB MOPULMOZYME 5 B/D PA, MORUCONEST 5 MO, HISEREVENT DISKUS 3 MO, QL (60 per

30 days)sildenafil (pulmonaryarterial hypertension)intravenous solution10 mg/12.5 ml

5 PA, HI

sildenafil (pulmonaryarterial hypertension)oral suspension forreconstitution 10 mg/ml

5 PA, MO



Limitssildenafil (pulmonaryarterial hypertension)oral tablet 20 mg

2 PA, MO

sodium chlorideinhalation

MB MO

SPIRIVA RESPIMAT 3 MO, QL (4 per30 days)

SPIRIVA WITHHANDIHALER


STIOLTO RESPIMAT 3 MO, QL (4 per30 days)

STRIVERDIRESPIMAT


SYMBICORT 3 MO, QL (13.8per 30 days)

SYMDEKO ORALTABLETS,SEQUENTIAL100-150 MG (D)/ 150MG (N)


SYMDEKO ORALTABLETS,SEQUENTIAL 50-75MG (D)/ 75 MG (N)


tadalafil (pulmonaryarterial hypertension)oral tablet 20 mg

5 PA, MO

TAKHZYRO 5 MO, LAterbutaline 2 MOtheophylline oral elixir 2theophylline oralsolution

2 MO

theophylline oral tabletextended release 12hr

2 MO

theophylline oral tabletextended release 24hr

2 MO


LimitsTRACLEER ORALTABLET FORSUSPENSION

5 PA, MO, LA

TRELEGY ELLIPTA 3 MO, QL (60 per30 days)

TRIKAFTA 5 PA, MO, QL (84per 28 days)

TYVASO 5 B/D PA, MOTYVASOINSTITUTIONALSTART KIT

5 B/D PA

TYVASO REFILL KIT 5 B/D PA, MOTYVASO STARTERKIT

5 B/D PA, MO

VENTAVIS 5 B/D PA, MOwixela inhub 2 PA, MO, QL (60

per 30 days)XOLAIR 5 PA, MO, LAYUPELRI 5 B/D PA, MO, QL

(90 per 30days)

zafirlukast 2 MOzileuton oral tablet,extended release12hr mphase

5 MO


UROLOGICALS:ANTICHOLINERGICS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsdarifenacin oral tabletextended release 24hr

2 MO

flavoxate 2 MOMYRBETRIQ 4 MOoxybutynin chlorideoral syrup

2 MO

oxybutynin chlorideoral tablet

2 MO

oxybutynin chlorideoral tablet extendedrelease 24hr

2 MO

solifenacin 2 MOtolterodine oralcapsule,extendedrelease 24hr

2 MO

tolterodine oral tablet 2 MOtrospium oral capsule,extended release24hr

2 MO

trospium oral tablet 2 MO

UROLOGICALS: BENIGNPROSTATIC HYPERPLASIA(BPH)THERAPYDrug Name Tier Requirements/

Limitsalfuzosin oral tabletextended release 24hr

2 MO

dutasteride 2 MOdutasteride-tamsulosinoral capsule, ermultiphase 24 hr

2 MO

finasteride oral tablet5 mg

2 MO

silodosin 2 MOtamsulosin oralcapsule,extendedrelease 24hr

1 MO

UROLOGICALS: MISCELLANEOUSUROLOGICALSDrug Name Tier Requirements/

Limitsalprostadil 2 MObethanechol chloride 2 MOCYSTAGON 3 MO, LAELMIRON 3 MOglycine urologic 2glycine urologicsolution

2

potassium citrate oraltablet extendedrelease

2 MO

PROCYSBI 5 MOtadalafil oral tablet 2.5mg, 5 mg



VITAMINS, HEMATINICS /ELECTROLYTES: BLOODDERIVATIVESDrug Name Tier Requirements/

Limitsalbumin, human 25 % 2albuminar 25 % 2 MOalburx (human) 25 % 2 MOalburx (human) 5 % 2albutein 25 % 2albutein 5 % 2plasbumin 25 % 2plasbumin 5 % 2

VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTESDrug Name Tier Requirements/

Limitscalcium acetate(phosphat bind)

2 MO

calcium chloride 2calcium gluconateintravenous

2

effer-k oral tablet,effervescent 25 meq

1 MO

GLYCOPHOS 3klor-con 10 oral tabletextended release

1 MO

klor-con 20 meqpacket

1 MO

klor-con 8 oral tabletextended release

1 MO

klor-con m10 oraltablet,er particles/crystals

1 MO


1 MO


1 MO

klor-con/ef 1 MOk-tab oral tabletextended release 8meq

1 MO

lactated ringersintravenous

2 MO, HI

magnesium chlorideinjection

2 MO

magnesium sulfate inwater intravenousparenteral solution

2


VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTES(continued)Drug Name Tier Requirements/

Limitsmagnesium sulfate inwater intravenouspiggyback 2 gram/50ml (4 %), 4 gram/50ml (8 %)

2

magnesium sulfate inwater intravenouspiggyback 4gram/100 ml (4 %)

2 MO

magnesium sulfateinjection solution

2 MO, HI

magnesium sulfateinjection syringe

2 HI

NORMOSOL-R 4 MONORMOSOL-R IN5 % DEXTROSE

4 HI

potassium acetateintravenous solution2 meq/ml

2

potassium chlorid-d5-0.45%naclintravenousparenteral solution 10meq/l, 30 meq/l, 40meq/l

2 HI

potassium chlorid-d5-0.45%naclintravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride in0.9%nacl intravenousparenteral solution 20meq/l, 40 meq/l

2 HI

potassium chloride in5 % dex intravenousparenteral solution 20meq/l, 40 meq/l

2 HI


Limitspotassium chloride in5 % dex intravenousparenteral solution 30meq/l

2 HI

potassium chloride inlr-d5 intravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride inlr-d5 intravenousparenteral solution 40meq/l

2 HI

potassium chloride inwater intravenouspiggyback 10meq/100 ml

2 MO, HI

potassium chloride inwater intravenouspiggyback 10 meq/50ml

2 MO, HI

potassium chloride inwater intravenouspiggyback 20meq/100 ml, 40meq/100 ml

2 HI

potassium chloride inwater intravenouspiggyback 20 meq/50ml, 30 meq/100 ml

2 HI

potassium chlorideintravenous

2 MO, HI

potassium chlorideoral capsule,extended release

1 MO

potassium chlorideoral liquid

2 MO

potassium chlorideoral packet

2 MO



Limitspotassium chlorideoral tablet extendedrelease

1 MO

potassium chlorideoral tablet,erparticles/crystals

1 MO

potassiumchloride-0.45 % nacl

2 HI

potassium chloride-d5-0.2%naclintravenousparenteral solution 20meq/l

2 MO, HI

potassium chloride-d5-0.2%naclintravenousparenteral solution 30meq/l, 40 meq/l

2 HI


2


2 MO, HI


2 HI

potassium phosphatem-/d-basicintravenous solution3 mmol/ml

2

ringer's intravenous 2 HIsodium acetate 2


Limitssodium bicarbonateintravenous solution1 meq/ml (8.4 %)

2 MO

sodium bicarbonateintravenous syringe10 meq/10 ml(8.4 %), 7.5 % (0.9meq/ml)

2 MO

sodium bicarbonateintravenous syringe8.4 % (1 meq/ml)

2

sodium chloride0.45 % intravenousparenteral solution

2 MO, HI

sodium chloride 3 % 2 MO, HIsodium chloride 5 % 2 MO, HIsodium chlorideintravenous

2 MO, HI

sodium phosphate 2 MO


VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTSDrug Name Tier Requirements/

LimitsAMINOSYN II 10 % 4 B/D PA, HIAMINOSYN II 15 % 4 B/D PA, HIAMINOSYN-PF 10 % 4 B/D PA, HIAMINOSYN-PF 7 %(SULFITE-FREE)

4 B/D PA, HI

CLINIMIX 5%/D15WSULFITE FREE

4 B/D PA, HI

CLINIMIX 4.25%/D10W SULF FREE

4 B/D PA, HI

CLINIMIX 5%-D20W(SULFITE-FREE)

4 B/D PA, HI

CLINIMIX E 4.25%/D10W SUL FREE

4 B/D PA, HI

CLINIMIX E 4.25%/D5W SULF FREE

4 B/D PA, HI

CLINIMIX E 5%/D15WSULFIT FREE

4 B/D PA, HI

CLINIMIX E 5%/D20WSULFIT FREE

4 B/D PA, HI

CLINISOL SF 15 % 4 B/D PA, MO, HICLINOLIPID 4 B/D PAelectrolyte-48 in d5w 2FREAMINE HBC6.9 %

4 B/D PA, HI

freamine iii 10 % 2 B/D PA, HIHEPATAMINE 8% 4 B/D PA, HIintralipid intravenousemulsion 20 %

2 B/D PA, HI

INTRALIPIDINTRAVENOUSEMULSION 30 %

4 B/D PA, HI

NEPHRAMINE 5.4 % 4 B/D PA, HINORMOSOL-M IN5 % DEXTROSE

4 HI

VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

LimitsNORMOSOL-R PH7.4

4 HI

plasmanate 2plenamine 2 B/D PA, HIpremasol 10 % 2 B/D PA, MO, HIPROCALAMINE 3% 4 B/D PA, HIPROSOL 20 % 4 B/D PA, MO, HISMOFLIPID 4 B/D PA, HItravasol 10 % 2 B/D PA, MO, HITROPHAMINE 10 % 4 B/D PA, MO, HITROPHAMINE 6% 4 B/D PA, HI

VITAMINS, HEMATINICS /ELECTROLYTES: VITAMINS /HEMATINICSDrug Name Tier Requirements/

Limitsfluoride (sodium) oraltablet

2 MO

fluoride (sodium) oraltablet,chewable 1 mg(2.2 mg sod. fluoride)

2 MO

prenatal vitamin oraltablet

2 MO


Index of DrugsAabacavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10abacavir-lamivudine. . . . . . . . . . . . . . . . . . . . 10abacavir-lamivudine-zidovudine. . . . . . . . . . 10ABILIFY MAINTENA. . . . . . . . . . . . . . . . . . . 43abiraterone. . . . . . . . . . . . . . . . . . . . . . . . . . . 22ABRAXANE. . . . . . . . . . . . . . . . . . . . . . . . . . 22acamprosate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

acarbose. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69acebutolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49acetaminophen-caff-dihydrocod oral capsule 37acetaminophen-caff-dihydrocod oral tablet325-30-16 mg. . . . . . . . . . . . . . . . . . . . . . . . 37

acetaminophen-codeine oral solution 120 mg-12mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml. . . 37

acetaminophen-codeine oral solution 120-12mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

acetaminophen-codeine oral tablet. . . . . . . . 37acetazolamide oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

acetazolamide oral tablet. . . . . . . . . . . . . . . . 92acetazolamide sodium. . . . . . . . . . . . . . . . . . 92acetic acid irrigation. . . . . . . . . . . . . . . . . . . . 63acetic acid otic (ear). . . . . . . . . . . . . . . . . . . . 67acetylcysteine. . . . . . . . . . . . . . . . . . . . . . . . . 94acetylcysteine intravenous. . . . . . . . . . . . . . . 62acitretin oral capsule 10 mg, 25 mg. . . . . . . . 57acitretin oral capsule 17.5 mg. . . . . . . . . . . . 57ACTEMRA ACTPEN. . . . . . . . . . . . . . . . . . . 84ACTEMRA INTRAVENOUS. . . . . . . . . . . . . . 84ACTEMRA SUBCUTANEOUS. . . . . . . . . . . . 84ACTHIB (PF). . . . . . . . . . . . . . . . . . . . . . . . . 80ACTIMMUNE. . . . . . . . . . . . . . . . . . . . . . . . . 78acyclovir oral capsule. . . . . . . . . . . . . . . . . . 10acyclovir oral suspension 200 mg/5 ml. . . . . 10acyclovir oral tablet. . . . . . . . . . . . . . . . . . . . 10acyclovir sodium intravenous solution. . . . . . 10acyclovir topical. . . . . . . . . . . . . . . . . . . . . . . 61ADACEL(TDAP ADOLESN/ADULT)(PF). . . . 80

ADAKVEO. . . . . . . . . . . . . . . . . . . . . . . . . . . 22adapalene topical cream. . . . . . . . . . . . . . . . 59adapalene topical gel. . . . . . . . . . . . . . . . . . . 59adapalene topical gel with pump. . . . . . . . . . 59adapalene topical solution. . . . . . . . . . . . . . . 59adapalene topical swab. . . . . . . . . . . . . . . . . 59adapalene-benzoyl peroxide. . . . . . . . . . . . . 59ADASUVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 43adefovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ADEMPAS. . . . . . . . . . . . . . . . . . . . . . . . . . . 94adenosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48adrenalin injection. . . . . . . . . . . . . . . . . . . . . 93adriamycin intravenous recon soln 10 mg. . . 22adriamycin intravenous solution. . . . . . . . . . 22adrucil intravenous solution 2.5 gram/50 ml. 22adrucil intravenous solution 500 mg/10 ml. . 22ADVAIR DISKUS. . . . . . . . . . . . . . . . . . . . . . 94ADVAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 94AFINITOR DISPERZ. . . . . . . . . . . . . . . . . . . 22AFINITOR ORAL TABLET 10 MG. . . . . . . . . 22afirmelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87AFLURIA QD 2019-20(3YR UP)(PF). . . . . . . 80AFLURIA QD 2019-20(6-35MO)(PF). . . . . . . 80AFLURIA QUAD 2019-20(6MO UP). . . . . . . 80AIMOVIG AUTOINJECTOR. . . . . . . . . . . . . . 33ak-poly-bac. . . . . . . . . . . . . . . . . . . . . . . . . . 90ala-cort topical cream 1 %. . . . . . . . . . . . . . . 61albendazole. . . . . . . . . . . . . . . . . . . . . . . . . . 15albumin, human 25 %. . . . . . . . . . . . . . . . . . 98albuminar 25 %. . . . . . . . . . . . . . . . . . . . . . . 98alburx (human) 25 %. . . . . . . . . . . . . . . . . . . 98alburx (human) 5 %. . . . . . . . . . . . . . . . . . . . 98albutein 25 %. . . . . . . . . . . . . . . . . . . . . . . . . 98albutein 5 %. . . . . . . . . . . . . . . . . . . . . . . . . . 98albuterol sulfate inhalation hfa aerosol inhaler90 mcg/actuation. . . . . . . . . . . . . . . . . . . . . 94

albuterol sulfate inhalation solution fornebulization. . . . . . . . . . . . . . . . . . . . . . . . . . 94

albuterol sulfate oral syrup. . . . . . . . . . . . . . . 94albuterol sulfate oral tablet. . . . . . . . . . . . . . . 94albuterol sulfate oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

103

alclometasone. . . . . . . . . . . . . . . . . . . . . . . . 61ALCOHOL PADS. . . . . . . . . . . . . . . . . . . . . . 69ALDURAZYME. . . . . . . . . . . . . . . . . . . . . . . . 71ALECENSA. . . . . . . . . . . . . . . . . . . . . . . . . . 22alendronate oral solution. . . . . . . . . . . . . . . . 83alendronate oral tablet 10 mg, 5 mg. . . . . . . 83alendronate oral tablet 35 mg, 70 mg. . . . . . 83alfuzosin oral tablet extended release 24 hr. 97ALIMTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ALINIA ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 15

ALINIA ORAL TABLET. . . . . . . . . . . . . . . . . . 15ALIQOPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22aliskiren. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49allopurinol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83allopurinol sodium. . . . . . . . . . . . . . . . . . . . . 83almotriptan malate oral tablet 12.5 mg. . . . . 33almotriptan malate oral tablet 6.25 mg. . . . . 33aloprim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83alosetron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74alprazolam intensol. . . . . . . . . . . . . . . . . . . . 43alprazolam oral tablet. . . . . . . . . . . . . . . . . . 43alprazolam oral tablet extended release 24 hr 43alprazolam oral tablet,disintegrating. . . . . . . 43alprostadil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97altavera (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87ALUNBRIG. . . . . . . . . . . . . . . . . . . . . . . . . . . 22alyacen 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 87alyacen 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . 87alyq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94amabelz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86amantadine hcl. . . . . . . . . . . . . . . . . . . . . . . 10AMBISOME. . . . . . . . . . . . . . . . . . . . . . . . . . . 9ambrisentan. . . . . . . . . . . . . . . . . . . . . . . . . . 94amcinonide topical cream. . . . . . . . . . . . . . . 61amcinonide topical lotion. . . . . . . . . . . . . . . . 61amcinonide topical ointment. . . . . . . . . . . . . 61amethia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87amethia lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 87amethyst (28). . . . . . . . . . . . . . . . . . . . . . . . . 87amikacin injection solution 1,000 mg/4 ml. . . 15amikacin injection solution 500 mg/2 ml. . . . 15

amiloride. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49amiloride-hydrochlorothiazide. . . . . . . . . . . . 49aminocaproic acid. . . . . . . . . . . . . . . . . . . . . 53aminophylline intravenous. . . . . . . . . . . . . . . 94AMINOSYN II 10 %. . . . . . . . . . . . . . . . . . . 101AMINOSYN II 15 %. . . . . . . . . . . . . . . . . . . 101AMINOSYN-PF 10 %. . . . . . . . . . . . . . . . . . 101AMINOSYN-PF 7 % (SULFITE-FREE). . . . 101amiodarone intravenous solution. . . . . . . . . . 48amiodarone intravenous syringe. . . . . . . . . . 48amiodarone oral. . . . . . . . . . . . . . . . . . . . . . . 48AMITIZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74amitriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . 43amitriptyline-chlordiazepoxide. . . . . . . . . . . . 43amlodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 49amlodipine-atorvastatin. . . . . . . . . . . . . . . . . 55amlodipine-benazepril. . . . . . . . . . . . . . . . . . 49amlodipine-olmesartan. . . . . . . . . . . . . . . . . 49amlodipine-valsartan. . . . . . . . . . . . . . . . . . . 49amlodipine-valsartan-hcthiazid. . . . . . . . . . . 49ammonium lactate. . . . . . . . . . . . . . . . . . . . . 58amnesteem. . . . . . . . . . . . . . . . . . . . . . . . . . 59amoxapine. . . . . . . . . . . . . . . . . . . . . . . . . . . 43amoxicil-clarithromy-lansopraz. . . . . . . . . . . 77amoxicillin oral capsule. . . . . . . . . . . . . . . . . 18amoxicillin oral suspension for reconstitution 18amoxicillin oral tablet. . . . . . . . . . . . . . . . . . . 18amoxicillin oral tablet,chewable 125 mg, 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

amoxicillin-pot clavulanate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 18

amoxicillin-pot clavulanate oral tablet. . . . . . 18amoxicillin-pot clavulanate oral tablet extendedrelease 12 hr. . . . . . . . . . . . . . . . . . . . . . . . 18

amoxicillin-pot clavulanate oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 18

amphetamine sulfate. . . . . . . . . . . . . . . . . . . 43amphotericin b. . . . . . . . . . . . . . . . . . . . . . . . . 9ampicillin oral capsule 500 mg. . . . . . . . . . . . 18ampicillin sodium injection recon soln 1 gram,10 gram, 125 mg. . . . . . . . . . . . . . . . . . . . . 18

ampicillin sodium injection recon soln 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 18

104

ampicillin sodium intravenous. . . . . . . . . . . . 18ampicillin-sulbactam injection recon soln 1.5gram, 3 gram. . . . . . . . . . . . . . . . . . . . . . . . 18

ampicillin-sulbactam injection recon soln 15gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ampicillin-sulbactam intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ampicillin-sulbactam intravenous recon soln 3gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ANADROL-50. . . . . . . . . . . . . . . . . . . . . . . . 71anagrelide. . . . . . . . . . . . . . . . . . . . . . . . . . . 63anastrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . 22ANDEXXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 53ANORO ELLIPTA. . . . . . . . . . . . . . . . . . . . . 94apexicon e. . . . . . . . . . . . . . . . . . . . . . . . . . . 61APOKYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32apraclonidine. . . . . . . . . . . . . . . . . . . . . . . . . 92aprepitant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74apri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87APTIOM ORAL TABLET 200 MG, 400 MG, 800MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

APTIOM ORAL TABLET 600 MG. . . . . . . . . 29APTIVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10APTIVUS (WITH VITAMIN E). . . . . . . . . . . . 10ARALAST NP INTRAVENOUS RECON SOLN1,000 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 63

ARALAST NP INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

aranelle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87ARCALYST. . . . . . . . . . . . . . . . . . . . . . . . . . . 78ARCAPTA NEOHALER. . . . . . . . . . . . . . . . . 94ARIKAYCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 15aripiprazole oral solution. . . . . . . . . . . . . . . . 43aripiprazole oral tablet. . . . . . . . . . . . . . . . . . 43aripiprazole oral tablet,disintegrating. . . . . . . 43ARISTADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 43ARISTADA INITIO. . . . . . . . . . . . . . . . . . . . . 43armodafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . 43ARNUITY ELLIPTA. . . . . . . . . . . . . . . . . . . . 94ARRANON. . . . . . . . . . . . . . . . . . . . . . . . . . . 22ARSENIC TRIOXIDE INTRAVENOUSSOLUTION 1 MG/ML. . . . . . . . . . . . . . . . . . 22

arsenic trioxide intravenous solution 2 mg/ml 22

ARZERRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22ascomp with codeine. . . . . . . . . . . . . . . . . . . 37ashlyna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87aspirin-dipyridamole oral capsule, er multiphase12 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

ASTAGRAF XL. . . . . . . . . . . . . . . . . . . . . . . 22atazanavir oral capsule 150 mg, 200 mg. . . . 10atazanavir oral capsule 300 mg. . . . . . . . . . . 10atenolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49atenolol-chlorthalidone. . . . . . . . . . . . . . . . . . 49atomoxetine. . . . . . . . . . . . . . . . . . . . . . . . . . 43atorvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 55atovaquone. . . . . . . . . . . . . . . . . . . . . . . . . . 15atovaquone-proguanil. . . . . . . . . . . . . . . . . . 15ATRIPLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10atropine injection solution 0.4 mg/ml. . . . . . . 73atropine injection syringe 0.05 mg/ml. . . . . . 73atropine injection syringe 0.1 mg/ml. . . . . . . 73atropine ophthalmic (eye) drops. . . . . . . . . . 91ATROVENT HFA. . . . . . . . . . . . . . . . . . . . . . 94AUBAGIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34aubra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87aubra eq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87aurovela 1.5/30 (21). . . . . . . . . . . . . . . . . . . . 87aurovela 1/20 (21). . . . . . . . . . . . . . . . . . . . . 87aurovela 24 fe. . . . . . . . . . . . . . . . . . . . . . . . 87aurovela fe 1-20 (28). . . . . . . . . . . . . . . . . . . 87aurovela fe 1.5/30 (28). . . . . . . . . . . . . . . . . . 87AUSTEDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 34AVANDIA ORAL TABLET 2 MG, 4 MG. . . . . 69AVASTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22aviane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87avita topical cream. . . . . . . . . . . . . . . . . . . . . 59AVONEX INTRAMUSCULAR PEN INJECTORKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

AVONEX INTRAMUSCULAR SYRINGE KIT. 78ayuna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87AYVAKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22azacitidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 22azathioprine. . . . . . . . . . . . . . . . . . . . . . . . . . 22azathioprine sodium. . . . . . . . . . . . . . . . . . . . 22azelaic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 59

105

azelastine nasal. . . . . . . . . . . . . . . . . . . . . . . 66azelastine ophthalmic (eye). . . . . . . . . . . . . . 91azelastine-fluticasone. . . . . . . . . . . . . . . . . . 94azithromycin intravenous. . . . . . . . . . . . . . . . 14azithromycin oral. . . . . . . . . . . . . . . . . . . . . . 14aztreonam injection recon soln 1 gram. . . . . 15aztreonam injection recon soln 2 gram. . . . . 15azurette (28). . . . . . . . . . . . . . . . . . . . . . . . . 87

Bbacitracin intramuscular. . . . . . . . . . . . . . . . . 15bacitracin ophthalmic (eye). . . . . . . . . . . . . . 90bacitracin-polymyxin b ophthalmic (eye). . . . 90baclofen intrathecal. . . . . . . . . . . . . . . . . . . . 36baclofen oral tablet 10 mg, 20 mg. . . . . . . . . 36bacteriostatic water(parabens). . . . . . . . . . . 63balanced salt. . . . . . . . . . . . . . . . . . . . . . . . . 91balsalazide. . . . . . . . . . . . . . . . . . . . . . . . . . . 74BALVERSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22balziva (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87BANZEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29BAQSIMI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69BARACLUDE ORAL SOLUTION. . . . . . . . . . 10BAVENCIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BAXDELA INTRAVENOUS. . . . . . . . . . . . . . 19BAXDELA ORAL. . . . . . . . . . . . . . . . . . . . . . 19BCG VACCINE, LIVE (PF). . . . . . . . . . . . . . 80bd pre-filled normal saline. . . . . . . . . . . . . . . 63bekyree (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87BELEODAQ. . . . . . . . . . . . . . . . . . . . . . . . . . 22benazepril. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49benazepril-hydrochlorothiazide. . . . . . . . . . . 49BENDEKA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BENLYSTA INTRAVENOUS. . . . . . . . . . . . . 84BENLYSTA SUBCUTANEOUS. . . . . . . . . . . 84BENZNIDAZOLE. . . . . . . . . . . . . . . . . . . . . . 15benztropine injection. . . . . . . . . . . . . . . . . . . 32benztropine oral. . . . . . . . . . . . . . . . . . . . . . . 32beser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61BESPONSA. . . . . . . . . . . . . . . . . . . . . . . . . . 22betamethasone acet,sod phos. . . . . . . . . . . . 67betamethasone dipropionate. . . . . . . . . . . . . 61

betamethasone valerate. . . . . . . . . . . . . . . . 61betamethasone, augmented. . . . . . . . . . . . . 61betaxolol ophthalmic (eye). . . . . . . . . . . . . . . 91betaxolol oral. . . . . . . . . . . . . . . . . . . . . . . . . 49bethanechol chloride. . . . . . . . . . . . . . . . . . . 97BETHKIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15BEVESPI AEROSPHERE. . . . . . . . . . . . . . . 94BEVYXXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 53bexarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BEXSERO. . . . . . . . . . . . . . . . . . . . . . . . . . . 80bicalutamide. . . . . . . . . . . . . . . . . . . . . . . . . . 22BICILLIN L-A. . . . . . . . . . . . . . . . . . . . . . . . . 18BIKTARVY. . . . . . . . . . . . . . . . . . . . . . . . . . . 10bimatoprost ophthalmic (eye). . . . . . . . . . . . 92bisoprolol fumarate. . . . . . . . . . . . . . . . . . . . 49bisoprolol-hydrochlorothiazide. . . . . . . . . . . . 49bleomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22BLEPHAMIDE. . . . . . . . . . . . . . . . . . . . . . . . 91BLEPHAMIDE S.O.P.. . . . . . . . . . . . . . . . . . 91BLINCYTO INTRAVENOUS KIT. . . . . . . . . . 22blisovi 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 87blisovi fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . 87blisovi fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 87BOOSTRIX TDAP. . . . . . . . . . . . . . . . . . . . . 80BORTEZOMIB. . . . . . . . . . . . . . . . . . . . . . . . 22bosentan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94BOSULIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22BOTOX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80BRAFTOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . 22bretylium tosylate. . . . . . . . . . . . . . . . . . . . . . 48briellyn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87BRILINTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53brimonidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 92BRIVIACT INTRAVENOUS. . . . . . . . . . . . . . 29BRIVIACT ORAL. . . . . . . . . . . . . . . . . . . . . . 29bromfenac. . . . . . . . . . . . . . . . . . . . . . . . . . . 92bromocriptine. . . . . . . . . . . . . . . . . . . . . . . . . 32BROVANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 94BRUKINSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22bss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91budesonide inhalation. . . . . . . . . . . . . . . . . . 94

106

budesonide oralcapsule,delayed,extend.release. . . . . . . . . . 74

budesonide oral tablet,delayed andext.release. . . . . . . . . . . . . . . . . . . . . . . . . . 74

bumetanide injection. . . . . . . . . . . . . . . . . . . 49bumetanide oral. . . . . . . . . . . . . . . . . . . . . . . 49buprenorphine. . . . . . . . . . . . . . . . . . . . . . . . 37buprenorphine hcl injection solution. . . . . . . 37buprenorphine hcl injection syringe. . . . . . . . 37buprenorphine hcl sublingual. . . . . . . . . . . . . 37buprenorphine-naloxone. . . . . . . . . . . . . . . . 41bupropion hcl (smoking deter) oral tabletextended release. . . . . . . . . . . . . . . . . . . . . 66

bupropion hcl oral tablet. . . . . . . . . . . . . . . . 43bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg. . . . . . . . . . . . . . . . . . . . . . 43

bupropion hcl oral tablet sustained-release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

buspirone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43busulfan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22butalbital compound w/codeine. . . . . . . . . . . 37butalbital-acetaminop-caf-cod. . . . . . . . . . . . 37butalbital-acetaminophen oral capsule. . . . . 37butalbital-acetaminophen oral tablet 25-325mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

butalbital-acetaminophen oral tablet 50-300 mg,50-325 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 37

butalbital-acetaminophen-caff oral capsule. . 37butalbital-acetaminophen-caff oral tablet50-325-40 mg. . . . . . . . . . . . . . . . . . . . . . . . 37

butalbital-aspirin-caffeine. . . . . . . . . . . . . . . . 37butorphanol tartrate injection. . . . . . . . . . . . . 41butorphanol tartrate nasal. . . . . . . . . . . . . . . 41BYDUREON BCISE. . . . . . . . . . . . . . . . . . . . 69BYDUREON SUBCUTANEOUS PENINJECTOR. . . . . . . . . . . . . . . . . . . . . . . . . . 69

BYETTA SUBCUTANEOUS PEN INJECTOR 10MCG/DOSE(250 MCG/ML) 2.4 ML. . . . . . . 69

BYETTA SUBCUTANEOUS PEN INJECTOR 5MCG/DOSE (250 MCG/ML) 1.2 ML. . . . . . . 69

Ccabergoline. . . . . . . . . . . . . . . . . . . . . . . . . . . 71CABLIVI INJECTION KIT. . . . . . . . . . . . . . . . 53

CABOMETYX. . . . . . . . . . . . . . . . . . . . . . . . . 22caffeine citrate intravenous. . . . . . . . . . . . . . 63caffeine citrate oral. . . . . . . . . . . . . . . . . . . . 63calcipotriene scalp. . . . . . . . . . . . . . . . . . . . . 57calcipotriene topical cream. . . . . . . . . . . . . . 57calcipotriene topical ointment. . . . . . . . . . . . 57calcipotriene-betamethasone topicalointment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

calcitonin (salmon). . . . . . . . . . . . . . . . . . . . . 71calcitriol intravenous solution 1 mcg/ml. . . . . 71calcitriol oral capsule. . . . . . . . . . . . . . . . . . . 71calcitriol oral solution. . . . . . . . . . . . . . . . . . . 71calcitriol topical. . . . . . . . . . . . . . . . . . . . . . . 57calcium acetate(phosphat bind). . . . . . . . . . . 98calcium chloride. . . . . . . . . . . . . . . . . . . . . . . 98calcium gluconate intravenous. . . . . . . . . . . 98CALQUENCE. . . . . . . . . . . . . . . . . . . . . . . . . 22camila. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86camrese. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87camrese lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 87candesartan. . . . . . . . . . . . . . . . . . . . . . . . . . 49candesartan-hydrochlorothiazid. . . . . . . . . . . 49CAPASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . 15capecitabine. . . . . . . . . . . . . . . . . . . . . . . . . . 22CAPLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CAPRELSA ORAL TABLET 100 MG. . . . . . . 22CAPRELSA ORAL TABLET 300 MG. . . . . . . 22captopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49captopril-hydrochlorothiazide. . . . . . . . . . . . . 49CARBAGLU. . . . . . . . . . . . . . . . . . . . . . . . . . 63carbamazepine oral capsule, er multiphase 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

carbamazepine oral suspension 100 mg/5 ml 29carbamazepine oral tablet. . . . . . . . . . . . . . . 29carbamazepine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

carbamazepine oral tablet,chewable. . . . . . . 29carbidopa. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32carbidopa-levodopa oral tablet. . . . . . . . . . . 32carbidopa-levodopa oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

carbidopa-levodopa oral tablet,disintegrating 32carbidopa-levodopa-entacapone. . . . . . . . . . 32

107

carbinoxamine maleate. . . . . . . . . . . . . . . . . 93carbocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

carboplatin intravenous solution. . . . . . . . . . 22cardioplegic soln. . . . . . . . . . . . . . . . . . . . . . 56carisoprodol. . . . . . . . . . . . . . . . . . . . . . . . . . 36carisoprodol-aspirin. . . . . . . . . . . . . . . . . . . . 36carisoprodol-aspirin-codeine. . . . . . . . . . . . . 36carmustine. . . . . . . . . . . . . . . . . . . . . . . . . . . 22carteolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91cartia xt oral capsule,extended release 24hr. 49carvedilol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49carvedilol phosphate oral capsule, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

caspofungin. . . . . . . . . . . . . . . . . . . . . . . . . . . 9CAYSTON. . . . . . . . . . . . . . . . . . . . . . . . . . . 15caziant (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87cefaclor oral capsule. . . . . . . . . . . . . . . . . . . 13cefaclor oral suspension for reconstitution 125mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

cefaclor oral suspension for reconstitution 250mg/5 ml, 375 mg/5 ml. . . . . . . . . . . . . . . . . . 13

cefaclor oral tablet extended release 12 hr. . 13cefadroxil oral capsule. . . . . . . . . . . . . . . . . . 13cefadroxil oral suspension for reconstitution 250mg/5 ml, 500 mg/5 ml. . . . . . . . . . . . . . . . . . 13

cefadroxil oral tablet. . . . . . . . . . . . . . . . . . . . 13cefazolin in dextrose (iso-os) intravenouspiggyback 1 gram/50 ml, 2 gram/50 ml. . . . 13

cefazolin injection recon soln 1 gram, 500 mg 13cefazolin injection recon soln 10 gram. . . . . . 13cefazolin injection recon soln 100 gram, 20gram, 300 g. . . . . . . . . . . . . . . . . . . . . . . . . 13

cefazolin intravenous. . . . . . . . . . . . . . . . . . . 13cefdinir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13cefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 13

cefepime in dextrose,iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 13

cefepime injection. . . . . . . . . . . . . . . . . . . . . 13cefixime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13cefotetan injection. . . . . . . . . . . . . . . . . . . . . 13cefotetan intravenous. . . . . . . . . . . . . . . . . . 13cefoxitin in dextrose, iso-osm. . . . . . . . . . . . 13

cefoxitin intravenous recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

cefoxitin intravenous recon soln 10 gram. . . 13cefpodoxime oral suspension for reconstitution100 mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . 13

cefpodoxime oral suspension for reconstitution50 mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 13

cefpodoxime oral tablet. . . . . . . . . . . . . . . . . 13cefprozil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13ceftazidime injection recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ceftazidime injection recon soln 6 gram. . . . . 13ceftriaxone in dextrose,iso-os. . . . . . . . . . . . 13ceftriaxone injection recon soln 1 gram, 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 13

ceftriaxone injection recon soln 10 gram. . . . 14ceftriaxone intravenous. . . . . . . . . . . . . . . . . 14cefuroxime axetil oral tablet. . . . . . . . . . . . . . 14cefuroxime sodium injection recon soln 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

cefuroxime sodium intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

cefuroxime sodium intravenous recon soln 7.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

celecoxib. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41CELONTIN ORAL CAPSULE 300 MG. . . . . 29cephalexin. . . . . . . . . . . . . . . . . . . . . . . . . . . 14CERDELGA. . . . . . . . . . . . . . . . . . . . . . . . . . 71CEREZYME INTRAVENOUS RECON SOLN400 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 71

cetirizine oral solution 1 mg/ml. . . . . . . . . . . 93cevimeline. . . . . . . . . . . . . . . . . . . . . . . . . . . 63CHANTIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66CHANTIX CONTINUING MONTH BOX. . . . 66CHANTIX STARTING MONTH BOX. . . . . . . 66chateal (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87chateal eq (28). . . . . . . . . . . . . . . . . . . . . . . . 87CHEMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63chloramphenicol sod succinate. . . . . . . . . . . 15chlordiazepoxide hcl. . . . . . . . . . . . . . . . . . . 43chlordiazepoxide-clidinium. . . . . . . . . . . . . . . 73chlorhexidine gluconate mucous membrane. 66chloroprocaine (pf). . . . . . . . . . . . . . . . . . . . . 58chloroquine phosphate. . . . . . . . . . . . . . . . . 15

108

chlorothiazide oral tablet 500 mg. . . . . . . . . . 50chlorothiazide sodium. . . . . . . . . . . . . . . . . . 50chlorpromazine injection. . . . . . . . . . . . . . . . 43chlorpromazine oral. . . . . . . . . . . . . . . . . . . . 43chlorthalidone oral tablet 25 mg, 50 mg. . . . . 50chlorzoxazone oral tablet 250 mg. . . . . . . . . 36chlorzoxazone oral tablet 375 mg, 500 mg, 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

CHOLBAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 74cholestyramine (with sugar). . . . . . . . . . . . . . 55cholestyramine light. . . . . . . . . . . . . . . . . . . . 55CHORIONIC GONADOTROPIN, HUMANINTRAMUSCULAR. . . . . . . . . . . . . . . . . . . . 71

ciclodan topical solution. . . . . . . . . . . . . . . . . 60ciclopirox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60cidofovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cilostazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53CIMDUO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cimetidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77cimetidine hcl oral. . . . . . . . . . . . . . . . . . . . . 77CIMZIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74CIMZIA POWDER FOR RECONST. . . . . . . . 74CIMZIA STARTER KIT. . . . . . . . . . . . . . . . . . 74cinacalcet oral tablet 30 mg. . . . . . . . . . . . . . 71cinacalcet oral tablet 60 mg, 90 mg. . . . . . . . 71CINRYZE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94CINVANTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74CIPRODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 67ciprofloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . 19ciprofloxacin hcl ophthalmic (eye). . . . . . . . . 90ciprofloxacin hcl oral. . . . . . . . . . . . . . . . . . . 19ciprofloxacin hcl otic (ear). . . . . . . . . . . . . . . 67ciprofloxacin in 5 % dextrose intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . 19

ciprofloxacin in 5 % dextrose intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . 19

cisplatin intravenous solution. . . . . . . . . . . . . 22citalopram oral solution. . . . . . . . . . . . . . . . . 43citalopram oral tablet. . . . . . . . . . . . . . . . . . . 43cladribine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22claravis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59clarithromycin oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 14

clarithromycin oral tablet. . . . . . . . . . . . . . . . 14clarithromycin oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

clemastine oral tablet 2.68 mg. . . . . . . . . . . . 93cleocin intravenous solution 300 mg/2 ml. . . 15CLEOCIN VAGINAL SUPPOSITORY. . . . . . 86clindacin etz topical swab. . . . . . . . . . . . . . . 59clindacin p. . . . . . . . . . . . . . . . . . . . . . . . . . . 59clindamycin hcl. . . . . . . . . . . . . . . . . . . . . . . 15clindamycin in 5 % dextrose. . . . . . . . . . . . . 15clindamycin palmitate hcl. . . . . . . . . . . . . . . . 15clindamycin pediatric. . . . . . . . . . . . . . . . . . . 15clindamycin phosphate injection. . . . . . . . . . 15clindamycin phosphate intravenous solution 600mg/4 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

clindamycin phosphate topical foam. . . . . . . 59clindamycin phosphate topical gel. . . . . . . . . 59clindamycin phosphate topical lotion. . . . . . . 59clindamycin phosphate topical solution. . . . . 59clindamycin phosphate topical swab. . . . . . . 59clindamycin phosphate vaginal. . . . . . . . . . . 86clindamycin-benzoyl peroxide. . . . . . . . . . . . 59clindamycin-tretinoin. . . . . . . . . . . . . . . . . . . 59CLINIMIX 5%/D15W SULFITE FREE. . . . . 101CLINIMIX 4.25%/D10W SULF FREE. . . . . 101CLINIMIX 4.25%/D5W SULFIT FREE. . . . . . 63CLINIMIX 5%-D20W(SULFITE-FREE). . . . 101CLINIMIX E 2.75%/D5W SULF FREE. . . . . . 63CLINIMIX E 4.25%/D10W SUL FREE. . . . . 101CLINIMIX E 4.25%/D5W SULF FREE. . . . . 101CLINIMIX E 5%/D15W SULFIT FREE. . . . . 101CLINIMIX E 5%/D20W SULFIT FREE. . . . . 101CLINISOL SF 15 %. . . . . . . . . . . . . . . . . . . 101CLINOLIPID. . . . . . . . . . . . . . . . . . . . . . . . . 101clobazam oral suspension. . . . . . . . . . . . . . . 29clobazam oral tablet 10 mg. . . . . . . . . . . . . . 29clobazam oral tablet 20 mg. . . . . . . . . . . . . . 29clobetasol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61clobetasol-emollient. . . . . . . . . . . . . . . . . . . . 61clodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61clofarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . 22clomiphene citrate. . . . . . . . . . . . . . . . . . . . . 71

109

clomipramine. . . . . . . . . . . . . . . . . . . . . . . . . 43clonazepam oral tablet. . . . . . . . . . . . . . . . . . 29clonazepam oral tablet,disintegrating. . . . . . 29clonidine (pf) epidural solution 1,000 mcg/10 ml(100 mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . 50

clonidine (pf) epidural solution 5,000 mcg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

clonidine hcl oral tablet. . . . . . . . . . . . . . . . . 50clonidine hcl oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

clonidine transdermal. . . . . . . . . . . . . . . . . . . 50clopidogrel. . . . . . . . . . . . . . . . . . . . . . . . . . . 53clorazepate dipotassium. . . . . . . . . . . . . . . . 43clotrimazole mucous membrane. . . . . . . . . . . 9clotrimazole topical. . . . . . . . . . . . . . . . . . . . 60clotrimazole-betamethasone. . . . . . . . . . . . . 60clovique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63clozapine oral tablet. . . . . . . . . . . . . . . . . . . . 43clozapine oral tablet,disintegrating 100 mg, 12.5mg, 25 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 43

CLOZAPINE ORAL TABLET,DISINTEGRATING150 MG, 200 MG (BRAND). . . . . . . . . . . . . 43

COARTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . 15codeine sulfate oral tablet. . . . . . . . . . . . . . . 37codeine-butalbital-asa-caff. . . . . . . . . . . . . . . 37colchicine oral tablet (Brand - Colcrys). . . . . 83COLCRYS. . . . . . . . . . . . . . . . . . . . . . . . . . . 83colesevelam oral powder in packet. . . . . . . . 55colesevelam oral tablet. . . . . . . . . . . . . . . . . 55colestipol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55colistin (colistimethate na). . . . . . . . . . . . . . . 15colocort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74COMBIVENT RESPIMAT. . . . . . . . . . . . . . . . 94COMETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . . 22COMPLERA. . . . . . . . . . . . . . . . . . . . . . . . . . 10compro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74CONDYLOX TOPICAL GEL. . . . . . . . . . . . . 58constulose. . . . . . . . . . . . . . . . . . . . . . . . . . . 74COPIKTRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22CORLANOR ORAL SOLUTION. . . . . . . . . . 56CORLANOR ORAL TABLET. . . . . . . . . . . . . 56cortisone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67COSENTYX. . . . . . . . . . . . . . . . . . . . . . . . . . 57

COSENTYX (2 SYRINGES). . . . . . . . . . . . . 57COSENTYX PEN. . . . . . . . . . . . . . . . . . . . . . 57COSENTYX PEN (2 PENS). . . . . . . . . . . . . 57COTELLIC. . . . . . . . . . . . . . . . . . . . . . . . . . . 23CREON. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74CRESEMBA INTRAVENOUS. . . . . . . . . . . . . 9CRESEMBA ORAL. . . . . . . . . . . . . . . . . . . . . 9CRIXIVAN ORAL CAPSULE 200 MG, 400MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

cromolyn inhalation. . . . . . . . . . . . . . . . . . . . 94cromolyn ophthalmic (eye). . . . . . . . . . . . . . . 91cromolyn oral. . . . . . . . . . . . . . . . . . . . . . . . . 74crotan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62cryselle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87CRYSVITA. . . . . . . . . . . . . . . . . . . . . . . . . . . 71CUVPOSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 73cyclafem 1/35 (28). . . . . . . . . . . . . . . . . . . . . 87cyclafem 7/7/7 (28). . . . . . . . . . . . . . . . . . . . 87cyclobenzaprine. . . . . . . . . . . . . . . . . . . . . . . 36cyclophosphamide intravenous. . . . . . . . . . . 23cyclophosphamide oral capsule. . . . . . . . . . . 23CYCLOSERINE. . . . . . . . . . . . . . . . . . . . . . . 15CYCLOSET. . . . . . . . . . . . . . . . . . . . . . . . . . 69cyclosporine intravenous. . . . . . . . . . . . . . . . 23cyclosporine modified. . . . . . . . . . . . . . . . . . 23cyclosporine oral capsule. . . . . . . . . . . . . . . 23cyproheptadine. . . . . . . . . . . . . . . . . . . . . . . . 93CYRAMZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 23cyred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87cyred eq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87CYSTADANE. . . . . . . . . . . . . . . . . . . . . . . . . 74CYSTAGON. . . . . . . . . . . . . . . . . . . . . . . . . . 97CYSTARAN. . . . . . . . . . . . . . . . . . . . . . . . . . 91cytarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23cytarabine (pf) injection solution 100 mg/5 ml(20 mg/ml), 2 gram/20 ml (100 mg/ml). . . . . 23

cytarabine (pf) injection solution 20 mg/ml. . 23

DD-PENAMINE. . . . . . . . . . . . . . . . . . . . . . . . 84d10 %-0.45 % sodium chloride. . . . . . . . . . . 63d2.5 %-0.45 % sodium chloride. . . . . . . . . . . 63

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d5 % and 0.9 % sodium chloride. . . . . . . . . . 63d5 %-0.45 % sodium chloride. . . . . . . . . . . . 64dacarbazine. . . . . . . . . . . . . . . . . . . . . . . . . . 23dactinomycin. . . . . . . . . . . . . . . . . . . . . . . . . 23dalfampridine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

DALIRESP. . . . . . . . . . . . . . . . . . . . . . . . . . . 94DALVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 15danazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71dantrolene intravenous. . . . . . . . . . . . . . . . . 36dantrolene oral. . . . . . . . . . . . . . . . . . . . . . . . 36dapsone oral. . . . . . . . . . . . . . . . . . . . . . . . . 15dapsone topical gel. . . . . . . . . . . . . . . . . . . . 59dapsone topical gel with pump. . . . . . . . . . . 60DAPTACEL (DTAP PEDIATRIC) (PF). . . . . . 80DAPTOMYCIN INTRAVENOUS RECON SOLN350 MG (BRAND). . . . . . . . . . . . . . . . . . . . 15

daptomycin intravenous recon soln 500 mg. 15DARAPRIM. . . . . . . . . . . . . . . . . . . . . . . . . . 15darifenacin oral tablet extended release 24 hr 97DARZALEX. . . . . . . . . . . . . . . . . . . . . . . . . . 23dasetta 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 87dasetta 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 87daunorubicin intravenous solution. . . . . . . . . 23DAURISMO. . . . . . . . . . . . . . . . . . . . . . . . . . 23daysee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87deblitane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86decadron oral tablet. . . . . . . . . . . . . . . . . . . . 67decitabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23deferasirox. . . . . . . . . . . . . . . . . . . . . . . . . . . 64deferoxamine. . . . . . . . . . . . . . . . . . . . . . . . . 64DELSTRIGO. . . . . . . . . . . . . . . . . . . . . . . . . 10demeclocycline. . . . . . . . . . . . . . . . . . . . . . . . 20demerol (pf) injection solution 100 mg/ml. . . 37DEMSER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50DENAVIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61denta 5000 plus. . . . . . . . . . . . . . . . . . . . . . . 66dentagel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66DEPEN TITRATABS. . . . . . . . . . . . . . . . . . . 84DESCOVY. . . . . . . . . . . . . . . . . . . . . . . . . . . 10desipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 43desloratadine oral tablet. . . . . . . . . . . . . . . . 93

desloratadine oral tablet,disintegrating. . . . . 93desmopressin injection. . . . . . . . . . . . . . . . . 71desmopressin nasal spray with pump. . . . . . 71desmopressin nasal spray,non-aerosol. . . . . 71desmopressin oral. . . . . . . . . . . . . . . . . . . . . 71desog-e.estradiol/e.estradiol. . . . . . . . . . . . . 87desogestrel-ethinyl estradiol. . . . . . . . . . . . . 87desonide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61desoximetasone. . . . . . . . . . . . . . . . . . . . . . . 61desvenlafaxine succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 43

dexabliss. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67dexamethasone intensol. . . . . . . . . . . . . . . . 67dexamethasone oral elixir. . . . . . . . . . . . . . . 67dexamethasone oral solution. . . . . . . . . . . . . 67dexamethasone oral tablet. . . . . . . . . . . . . . 67dexamethasone oral tablets,dose pack. . . . . 67dexamethasone sodium phos (pf) injectionsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

dexamethasone sodium phosphate injection. 67dexamethasone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

dexchlorpheniramine maleate oral solution. . 93dexmethylphenidate oral capsule,er biphasic50-50 10 mg, 5 mg. . . . . . . . . . . . . . . . . . . . 43

dexmethylphenidate oral capsule,er biphasic50-50 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

dexmethylphenidate oral tablet. . . . . . . . . . . 44dexrazoxane hcl intravenous recon soln 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

dexrazoxane hcl intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

dextroamphetamine oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

dextroamphetamine oral solution. . . . . . . . . . 44dextroamphetamine oral tablet. . . . . . . . . . . 44dextroamphetamine-amphetamine oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . 44

dextroamphetamine-amphetamine oral tablet 44dextrose 10 % and 0.2 % nacl. . . . . . . . . . . . 64dextrose 10 % in water (d10w). . . . . . . . . . . 64dextrose 20 % in water (d20w). . . . . . . . . . . 64dextrose 25 % in water (d25w). . . . . . . . . . . 64

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dextrose 30 % in water (d30w). . . . . . . . . . . 64dextrose 40 % in water (d40w). . . . . . . . . . . 64dextrose 5 % in water (d5w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 64

dextrose 5 % in water (d5w) intravenouspiggyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 64

dextrose 5 %-lactated ringers. . . . . . . . . . . . 64dextrose 5%-0.2 % sod chloride. . . . . . . . . . 64dextrose 5%-0.3 % sod.chloride. . . . . . . . . . 64dextrose 50 % in water (d50w). . . . . . . . . . . 64dextrose 70 % in water (d70w). . . . . . . . . . . 64dextrose with sodium chloride. . . . . . . . . . . . 64DIASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29diazepam injection solution. . . . . . . . . . . . . . 44diazepam injection syringe. . . . . . . . . . . . . . 44diazepam intensol. . . . . . . . . . . . . . . . . . . . . 44diazepam oral concentrate. . . . . . . . . . . . . . 44diazepam oral solution 5 mg/5 ml (1 mg/ml). 44diazepam oral tablet. . . . . . . . . . . . . . . . . . . 44diazepam rectal. . . . . . . . . . . . . . . . . . . . . . . 29diazoxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69diclofenac potassium. . . . . . . . . . . . . . . . . . . 41diclofenac sodium ophthalmic (eye). . . . . . . 92diclofenac sodium oral tablet extended release24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

diclofenac sodium oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

diclofenac sodium topical drops. . . . . . . . . . . 41diclofenac sodium topical gel 1 %. . . . . . . . . 41diclofenac sodium topical gel 3 %. . . . . . . . . 58diclofenac-misoprostol oral tablet,ir,delayedrel,biphasic. . . . . . . . . . . . . . . . . . . . . . . . . . 41

dicloxacillin. . . . . . . . . . . . . . . . . . . . . . . . . . . 18dicyclomine intramuscular. . . . . . . . . . . . . . . 73dicyclomine oral capsule. . . . . . . . . . . . . . . . 73dicyclomine oral solution. . . . . . . . . . . . . . . . 73dicyclomine oral tablet. . . . . . . . . . . . . . . . . . 73didanosine oral capsule,delayed release(dr/ec)200 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

didanosine oral capsule,delayed release(dr/ec)250 mg, 400 mg. . . . . . . . . . . . . . . . . . . . . . 10

DIFICID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14diflorasone. . . . . . . . . . . . . . . . . . . . . . . . . . . 61

diflunisal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41digitek. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56digox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56digoxin injection solution. . . . . . . . . . . . . . . . 56digoxin oral solution 50 mcg/ml (0.05 mg/ml) 56digoxin oral tablet. . . . . . . . . . . . . . . . . . . . . . 56dihydroergotamine injection. . . . . . . . . . . . . . 33dihydroergotamine nasal. . . . . . . . . . . . . . . . 33DILANTIN 30 MG. . . . . . . . . . . . . . . . . . . . . . 30dilt-xr oral capsule,ext release degradable. . 50diltiazem hcl intravenous. . . . . . . . . . . . . . . . 50diltiazem hcl oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

diltiazem hcl oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

diltiazem hcl oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

diltiazem hcl oral tablet. . . . . . . . . . . . . . . . . 50diltiazem hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

dimenhydrinate injection solution. . . . . . . . . . 74DIPENTUM. . . . . . . . . . . . . . . . . . . . . . . . . . 74diphenhydramine hcl injection solution 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

diphenhydramine hcl injection syringe. . . . . . 93diphenhydramine hcl oral elixir. . . . . . . . . . . 93diphenoxylate-atropine. . . . . . . . . . . . . . . . . 73dipyridamole intravenous. . . . . . . . . . . . . . . . 53dipyridamole oral. . . . . . . . . . . . . . . . . . . . . . 53disopyramide phosphate oral capsule. . . . . . 48disulfiram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64divalproex oral capsule, delayed rel sprinkle. 30divalproex oral tablet extended release 24 hr 30divalproex oral tablet,delayed release (dr/ec) 30dobutamine in d5w intravenous parenteralsolution 1,000 mg/250 ml (4,000 mcg/ml), 250mg/250 ml (1 mg/ml). . . . . . . . . . . . . . . . . . 56

dobutamine in d5w intravenous parenteralsolution 500 mg/250 ml (2,000 mcg/ml). . . . 56

dobutamine intravenous solution 250 mg/20 ml(12.5 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 56

docetaxel intravenous solution 160 mg/16 ml(10 mg/ml), 20 mg/2 ml (10 mg/ml). . . . . . . 23

112

docetaxel intravenous solution 160 mg/8 ml (20mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml). . . . . . . . . . . . . 23

DOCETAXEL INTRAVENOUS SOLUTION 20MG/ML (BRAND). . . . . . . . . . . . . . . . . . . . . 23

dofetilide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48donepezil oral tablet 10 mg, 5 mg. . . . . . . . . 34donepezil oral tablet 23 mg. . . . . . . . . . . . . . 34donepezil oral tablet,disintegrating. . . . . . . . 34dopamine in 5 % dextrose intravenous solution200 mg/250 ml (800 mcg/ml), 400 mg/250 ml(1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml),800 mg/500 ml (1,600 mcg/ml). . . . . . . . . . 56

dopamine in 5 % dextrose intravenous solution800 mg/250 ml (3,200 mcg/ml). . . . . . . . . . 56

dopamine intravenous solution 200 mg/5 ml (40mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

dopamine intravenous solution 400 mg/10 ml(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 56

DOPTELET (10 TAB PACK). . . . . . . . . . . . . 53DOPTELET (15 TAB PACK). . . . . . . . . . . . . 53DOPTELET (30 TAB PACK). . . . . . . . . . . . . 53dorzolamide. . . . . . . . . . . . . . . . . . . . . . . . . . 92dorzolamide-timolol. . . . . . . . . . . . . . . . . . . . 92dorzolamide-timolol (pf) ophthalmic (eye)dropperette. . . . . . . . . . . . . . . . . . . . . . . . . . 92

dotti. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86DOVATO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10doxazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50doxepin oral capsule. . . . . . . . . . . . . . . . . . . 44doxepin oral concentrate. . . . . . . . . . . . . . . . 44doxepin oral tablet. . . . . . . . . . . . . . . . . . . . . 44doxepin topical. . . . . . . . . . . . . . . . . . . . . . . . 58doxercalciferol intravenous. . . . . . . . . . . . . . 71doxercalciferol oral. . . . . . . . . . . . . . . . . . . . . 71doxorubicin intravenous recon soln 50 mg. . 23doxorubicin intravenous solution. . . . . . . . . . 23doxorubicin, peg-liposomal. . . . . . . . . . . . . . 23doxy-100. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20doxycycline hyclate intravenous. . . . . . . . . . 20doxycycline hyclate oral capsule. . . . . . . . . . 20doxycycline hyclate oral tablet. . . . . . . . . . . . 20

doxycycline hyclate oral tablet,delayed release(dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

doxycycline monohydrate oral capsule. . . . . 20doxycycline monohydrate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 20

doxycycline monohydrate oral tablet. . . . . . . 20doxylamine-pyridoxine (vit b6). . . . . . . . . . . . 74DRIZALMA SPRINKLE. . . . . . . . . . . . . . . . . 44dronabinol. . . . . . . . . . . . . . . . . . . . . . . . . . . 74droperidol injection solution. . . . . . . . . . . . . . 74drospirenone-e.estradiol-lm.fa. . . . . . . . . . . . 87drospirenone-ethinyl estradiol. . . . . . . . . . . . 87DULERA INHALATION HFA AEROSOLINHALER 100-5 MCG/ACTUATION, 200-5MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 94

DULERA INHALATION HFA AEROSOLINHALER 50-5 MCG/ACTUATION. . . . . . . . 94

duloxetine oral capsule,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

DUPIXENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 58duramorph (pf) injection solution 0.5 mg/ml. . 37duramorph (pf) injection solution 1 mg/ml. . . 37dutasteride. . . . . . . . . . . . . . . . . . . . . . . . . . . 97dutasteride-tamsulosin oral capsule, ermultiphase 24 hr. . . . . . . . . . . . . . . . . . . . . . 97

dvorah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37DYSPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Ee.e.s. 400 oral tablet. . . . . . . . . . . . . . . . . . . 14ec-naproxen oral tablet,delayed release (dr/ec)375 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ec-naproxen oral tablet,delayed release (dr/ec)500 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

econazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60EDURANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 10efavirenz oral capsule 200 mg. . . . . . . . . . . . 10efavirenz oral capsule 50 mg. . . . . . . . . . . . . 10efavirenz oral tablet. . . . . . . . . . . . . . . . . . . . 10effer-k oral tablet, effervescent 25 meq. . . . . 98EGRIFTA SUBCUTANEOUS RECON SOLN 1MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

EGRIFTA SV. . . . . . . . . . . . . . . . . . . . . . . . . 78

113

electrolyte-48 in d5w. . . . . . . . . . . . . . . . . . 101ELELYSO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71eletriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ELIGARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ELIGARD (3 MONTH). . . . . . . . . . . . . . . . . . 23ELIGARD (4 MONTH). . . . . . . . . . . . . . . . . . 23ELIGARD (6 MONTH). . . . . . . . . . . . . . . . . . 23elinest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87ELIQUIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ELIQUIS DVT-PE TREAT 30D START. . . . . . 53ELITEK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ELLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87ELMIRON. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97eluryng. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86EMCYT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23EMEND (FOSAPREPITANT). . . . . . . . . . . . . 74EMEND ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 74

EMGALITY PEN. . . . . . . . . . . . . . . . . . . . . . 33EMGALITY SYRINGE SUBCUTANEOUSSYRINGE 120 MG/ML. . . . . . . . . . . . . . . . . 33

EMGALITY SYRINGE SUBCUTANEOUSSYRINGE 300 MG/3 ML (100 MG/ML X 3). 33

emoquette. . . . . . . . . . . . . . . . . . . . . . . . . . . 87EMPLICITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 23EMSAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44EMTRIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10EMVERM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15enalapril maleate. . . . . . . . . . . . . . . . . . . . . . 50enalapril-hydrochlorothiazide. . . . . . . . . . . . . 50enalaprilat intravenous solution. . . . . . . . . . . 50ENBREL MINI. . . . . . . . . . . . . . . . . . . . . . . . 84ENBREL SUBCUTANEOUS RECON SOLN. 84ENBREL SUBCUTANEOUS SYRINGE. . . . . 84ENBREL SURECLICK. . . . . . . . . . . . . . . . . . 84endocet oral tablet 10-325 mg, 2.5-325 mg,5-325 mg, 7.5-325 mg. . . . . . . . . . . . . . . . . 37

ENGERIX-B (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 80

ENGERIX-B (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 80

ENGERIX-B PEDIATRIC (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 80

ENHERTU. . . . . . . . . . . . . . . . . . . . . . . . . . . 23enoxaparin subcutaneous solution. . . . . . . . 53enoxaparin subcutaneous syringe 100 mg/ml,150 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 53

enoxaparin subcutaneous syringe 120 mg/0.8ml, 80 mg/0.8 ml. . . . . . . . . . . . . . . . . . . . . . 53

enoxaparin subcutaneous syringe 30 mg/0.3ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53



enpresse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87enskyce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87entacapone. . . . . . . . . . . . . . . . . . . . . . . . . . 32entecavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ENTRESTO. . . . . . . . . . . . . . . . . . . . . . . . . . 56ENTYVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74enulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74ENVARSUS XR. . . . . . . . . . . . . . . . . . . . . . . 23EPCLUSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 10EPIDIOLEX. . . . . . . . . . . . . . . . . . . . . . . . . . 30epinastine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91epinephrine injection auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3 ml. . . . . . . . . . . . . . . . . . . . . 93

EPINEPHRINE INJECTION AUTO-INJECTOR0.15 MG/0.3 ML, 0.3 MG/0.3 ML (BRAND -EPIPEN). . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

epinephrine injection solution 1 mg/ml. . . . . . 93EPIPEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93EPIPEN 2-PAK. . . . . . . . . . . . . . . . . . . . . . . 93EPIPEN JR. . . . . . . . . . . . . . . . . . . . . . . . . . 93EPIPEN JR 2-PAK. . . . . . . . . . . . . . . . . . . . . 93epirubicin intravenous solution. . . . . . . . . . . 23epitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30EPIVIR HBV ORAL SOLUTION. . . . . . . . . . . 10eplerenone. . . . . . . . . . . . . . . . . . . . . . . . . . . 50epoprostenol (glycine). . . . . . . . . . . . . . . . . . 50eprosartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 50ERBITUX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ergoloid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ergotamine-caffeine. . . . . . . . . . . . . . . . . . . . 33ERIVEDGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 23

114

ERLEADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 23erlotinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23errin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ertapenem. . . . . . . . . . . . . . . . . . . . . . . . . . . 15ERWINAZE. . . . . . . . . . . . . . . . . . . . . . . . . . 23ery pads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ery-tab oral tablet,delayed release (dr/ec) 250mg, 333 mg. . . . . . . . . . . . . . . . . . . . . . . . . 14

erygel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60erythrocin (as stearate) oral tablet 250 mg. . 14ERYTHROCIN INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

erythromycin ethylsuccinate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 14

erythromycin ethylsuccinate oral tablet. . . . . 14erythromycin ophthalmic (eye). . . . . . . . . . . . 90erythromycin oral. . . . . . . . . . . . . . . . . . . . . . 14erythromycin with ethanol topical gel. . . . . . . 60erythromycin with ethanol topical solution. . . 60erythromycin-benzoyl peroxide. . . . . . . . . . . 60ESBRIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94escitalopram oxalate oral solution. . . . . . . . . 44escitalopram oxalate oral tablet. . . . . . . . . . . 44esmolol in nacl (iso-osm). . . . . . . . . . . . . . . . 50esmolol intravenous solution. . . . . . . . . . . . . 50esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 20 mg. . . . . . . . . . . . . . . . . . 77

esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 40 mg. . . . . . . . . . . . . . . . . . 77

esomeprazole magnesium oral granules dr forsusp in packet. . . . . . . . . . . . . . . . . . . . . . . 77

esomeprazole sodium intravenous recon soln20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

esomeprazole sodium intravenous recon soln40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87estazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44estradiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86estradiol valerate intramuscular oil 20 mg/ml, 40mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

estradiol-norethindrone acet. . . . . . . . . . . . . 86eszopiclone. . . . . . . . . . . . . . . . . . . . . . . . . . 44ethacrynate sodium. . . . . . . . . . . . . . . . . . . . 50ethacrynic acid. . . . . . . . . . . . . . . . . . . . . . . . 50

ethambutol. . . . . . . . . . . . . . . . . . . . . . . . . . . 15ethosuximide. . . . . . . . . . . . . . . . . . . . . . . . . 30ethynodiol diac-eth estradiol. . . . . . . . . . . . . 87etodolac oral capsule. . . . . . . . . . . . . . . . . . . 41etodolac oral tablet. . . . . . . . . . . . . . . . . . . . 41etodolac oral tablet extended release 24 hr. . 41etonogestrel-ethinyl estradiol. . . . . . . . . . . . . 86ETOPOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 23etoposide intravenous. . . . . . . . . . . . . . . . . . 23etoposide oral. . . . . . . . . . . . . . . . . . . . . . . . 24EVENITY SUBCUTANEOUS SYRINGE 105MG/1.17 ML. . . . . . . . . . . . . . . . . . . . . . . . . 83

EVENITY SUBCUTANEOUS SYRINGE210MG/2.34ML ( 105MG/1.17MLX2). . . . . . 83

everolimus (antineoplastic). . . . . . . . . . . . . . 24everolimus (immunosuppressive). . . . . . . . . 24EVOTAZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10exemestane. . . . . . . . . . . . . . . . . . . . . . . . . . 24ezetimibe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55ezetimibe-simvastatin. . . . . . . . . . . . . . . . . . 55

FFABIOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60FABRAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 71falmina (28). . . . . . . . . . . . . . . . . . . . . . . . . . 87famciclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 10famotidine (pf). . . . . . . . . . . . . . . . . . . . . . . . 77famotidine (pf)-nacl (iso-os). . . . . . . . . . . . . 77famotidine intravenous solution. . . . . . . . . . . 77famotidine oral suspension. . . . . . . . . . . . . . 77famotidine oral tablet 20 mg, 40 mg. . . . . . . 77FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG. 44FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG,8 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

FANAPT ORAL TABLETS,DOSE PACK. . . . 44FARYDAK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24FASENRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 94FASENRA PEN. . . . . . . . . . . . . . . . . . . . . . . 94FASLODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 24fayosim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87febuxostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83felbamate oral suspension. . . . . . . . . . . . . . . 30

115

felbamate oral tablet. . . . . . . . . . . . . . . . . . . 30felodipine oral tablet extended release 24 hr. 50femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87fenofibrate micronized. . . . . . . . . . . . . . . . . . 55fenofibrate nanocrystallized oral tablet 145 mg,48 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

FENOFIBRATE ORAL CAPSULE (BRAND). 55fenofibrate oral tablet 120 mg, 40 mg, 54 mg 55fenofibrate oral tablet 160 mg (generic) . . . . 55fenofibric acid. . . . . . . . . . . . . . . . . . . . . . . . . 55fenofibric acid (choline) oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 55

fenoprofen oral tablet. . . . . . . . . . . . . . . . . . . 41fentanyl citrate (pf) injection solution. . . . . . . 37fentanyl citrate (pf) intravenous syringe 100mcg/2 ml (50 mcg/ml). . . . . . . . . . . . . . . . . . 37

fentanyl citrate buccal lozenge on a handle. . 38fentanyl transdermal patch 72 hour 100 mcg/hr,12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr. . . . . . . . . . . . 38

fentanyl transdermal patch 72 hour 87.5mcg/hour. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

FERRIPROX. . . . . . . . . . . . . . . . . . . . . . . . . 64FETROJA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14FETZIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44finasteride oral tablet 5 mg. . . . . . . . . . . . . . 97FIRMAGON KIT W DILUENT SYRINGESUBCUTANEOUS RECON SOLN 120 MG. 24

FIRMAGON KIT W DILUENT SYRINGESUBCUTANEOUS RECON SOLN 80 MG. . 24

flac otic oil. . . . . . . . . . . . . . . . . . . . . . . . . . . 67flavoxate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97flecainide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48FLOVENT DISKUS INHALATION BLISTERWITH DEVICE 100 MCG/ACTUATION, 50MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 94

FLOVENT DISKUS INHALATION BLISTERWITH DEVICE 250 MCG/ACTUATION. . . . 94

FLOVENT HFA AEROSOL INHALER 110MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 94



floxuridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

FLUAD 2019-2020 (65 YR UP)(PF). . . . . . . 80FLUARIX QUAD 2019-2020 (PF). . . . . . . . . 80FLUBLOK QUAD 2019-2020 (PF). . . . . . . . . 80FLUCELVAX QUAD 2019-2020. . . . . . . . . . . 80FLUCELVAX QUAD 2019-2020 (PF). . . . . . . 80fluconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9fluconazole in nacl (iso-osm) intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . . 9

fluconazole in nacl (iso-osm) intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . . 9

flucytosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9fludarabine intravenous recon soln. . . . . . . . 24fludarabine intravenous solution. . . . . . . . . . 24fludrocortisone. . . . . . . . . . . . . . . . . . . . . . . . 67FLULAVAL QUAD 2019-2020. . . . . . . . . . . . 80FLULAVAL QUAD 2019-2020 (PF). . . . . . . . 80flumazenil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44FLUMIST QUAD 2019-2020. . . . . . . . . . . . . 80flunisolide nasal spray,non-aerosol 25 mcg(0.025 %). . . . . . . . . . . . . . . . . . . . . . . . . . . 95

fluocinolone. . . . . . . . . . . . . . . . . . . . . . . . . . 61fluocinolone acetonide oil. . . . . . . . . . . . . . . 67fluocinolone and shower cap. . . . . . . . . . . . . 61fluocinonide. . . . . . . . . . . . . . . . . . . . . . . . . . 61fluocinonide-e. . . . . . . . . . . . . . . . . . . . . . . . 61fluocinonide-emollient. . . . . . . . . . . . . . . . . . 61fluoride (sodium) dental cream. . . . . . . . . . . 66fluoride (sodium) dental gel. . . . . . . . . . . . . . 66fluoride (sodium) oral tablet. . . . . . . . . . . . . 101fluoride (sodium) oral tablet,chewable 1 mg (2.2mg sod. fluoride). . . . . . . . . . . . . . . . . . . . 101

fluorometholone. . . . . . . . . . . . . . . . . . . . . . . 92fluorouracil intravenous. . . . . . . . . . . . . . . . . 24FLUOROURACIL TOPICAL CREAM 0.5 %(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

fluorouracil topical cream 5 %. . . . . . . . . . . . 58fluorouracil topical solution. . . . . . . . . . . . . . 58fluoxetine oral capsule. . . . . . . . . . . . . . . . . . 44fluoxetine oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 44

fluoxetine oral solution. . . . . . . . . . . . . . . . . . 44fluoxetine oral tablet. . . . . . . . . . . . . . . . . . . . 44fluphenazine decanoate. . . . . . . . . . . . . . . . . 44

116

fluphenazine hcl. . . . . . . . . . . . . . . . . . . . . . . 44flurandrenolide. . . . . . . . . . . . . . . . . . . . . . . . 61flurazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . 45flurbiprofen oral tablet 100 mg. . . . . . . . . . . . 41flurbiprofen sodium. . . . . . . . . . . . . . . . . . . . 92flutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24fluticasone propion-salmeterol inhalation blisterwith device. . . . . . . . . . . . . . . . . . . . . . . . . . 95

fluticasone propionate nasal. . . . . . . . . . . . . 95fluticasone propionate topical. . . . . . . . . . . . 61fluvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55fluvoxamine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

fluvoxamine oral tablet. . . . . . . . . . . . . . . . . . 45FLUZONE HIGH-DOSE 2019-20 (PF). . . . . 80FLUZONE QUAD 2019-2020. . . . . . . . . . . . 80FLUZONE QUAD 2019-2020 (PF)INTRAMUSCULAR SUSPENSION. . . . . . . 80

FLUZONE QUAD 2019-2020 (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 80

FLUZONE QUAD PEDI 2019-20 (PF). . . . . . 80FML S.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . 92FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML). . . . . . . . . . . . . . . . . . . . . . . . . . . 24

FOLOTYN INTRAVENOUS SOLUTION 40MG/2 ML (20 MG/ML). . . . . . . . . . . . . . . . . 24

fomepizole. . . . . . . . . . . . . . . . . . . . . . . . . . . 80fondaparinux subcutaneous syringe 10 mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 2.5 mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 5 mg/0.4ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

fondaparinux subcutaneous syringe 7.5 mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

FORFIVO XL. . . . . . . . . . . . . . . . . . . . . . . . . 45FORTEO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83fosamprenavir. . . . . . . . . . . . . . . . . . . . . . . . . 10fosaprepitant. . . . . . . . . . . . . . . . . . . . . . . . . 74fosinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50fosinopril-hydrochlorothiazide. . . . . . . . . . . . 50fosphenytoin. . . . . . . . . . . . . . . . . . . . . . . . . . 30FREAMINE HBC 6.9 %. . . . . . . . . . . . . . . . 101freamine iii 10 %. . . . . . . . . . . . . . . . . . . . . 101

frovatriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 33FULPHILA. . . . . . . . . . . . . . . . . . . . . . . . . . . 78fulvestrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24furosemide injection. . . . . . . . . . . . . . . . . . . . 50furosemide oral solution 10 mg/ml, 40 mg/5 ml(8 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . 50

furosemide oral tablet. . . . . . . . . . . . . . . . . . 50FUZEON SUBCUTANEOUS RECON SOLN 10fyavolv. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86FYCOMPA ORAL SUSPENSION. . . . . . . . . 30FYCOMPA ORAL TABLET. . . . . . . . . . . . . . . 30

Ggabapentin oral capsule. . . . . . . . . . . . . . . . . 30gabapentin oral solution 250 mg/5 ml. . . . . . 30gabapentin oral solution 250 mg/5 ml (5 ml), 300mg/6 ml (6 ml). . . . . . . . . . . . . . . . . . . . . . . 30

gabapentin oral tablet 600 mg, 800 mg. . . . . 30GALAFOLD. . . . . . . . . . . . . . . . . . . . . . . . . . 71galantamine oral capsule,ext rel. pellets 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

galantamine oral solution. . . . . . . . . . . . . . . . 34galantamine oral tablet. . . . . . . . . . . . . . . . . 34GAMASTAN. . . . . . . . . . . . . . . . . . . . . . . . . . 80GAMASTAN S/D. . . . . . . . . . . . . . . . . . . . . . 80GAMMAGARD LIQUID. . . . . . . . . . . . . . . . . 80GAMMAGARD S-D (IGA < 1 MCG/ML). . . . . 80GAMUNEX-C INJECTION SOLUTION 1GRAM/10 ML (10 %). . . . . . . . . . . . . . . . . . 80

GAMUNEX-C INJECTION SOLUTION 10GRAM/100 ML (10 %), 2.5 GRAM/25 ML(10 %), 20 GRAM/200 ML (10 %), 40GRAM/400 ML (10 %), 5 GRAM/50 ML (10%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

ganciclovir sodium intravenous. . . . . . . . . . . 10ganciclovir sodium intravenous recon soln. . 10GARDASIL 9 (PF). . . . . . . . . . . . . . . . . . . . . 81gatifloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 90GATTEX 30-VIAL. . . . . . . . . . . . . . . . . . . . . . 74GATTEX ONE-VIAL. . . . . . . . . . . . . . . . . . . . 74GAUZE PADS 2X2. . . . . . . . . . . . . . . . . . . . 69gavilyte-c. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74gavilyte-g. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

117

gavilyte-n. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74GAZYVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24gemcitabine intravenous recon soln 1 gram, 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

gemcitabine intravenous recon soln 2 gram. 24gemcitabine intravenous solution 1 gram/26.3ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml). 24

gemcitabine intravenous solution 2 gram/52.6ml (38 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . 24

gemfibrozil. . . . . . . . . . . . . . . . . . . . . . . . . . . 55generlac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74gengraf oral capsule 100 mg, 25 mg. . . . . . . 24gengraf oral solution. . . . . . . . . . . . . . . . . . . 24gentak ophthalmic (eye) ointment. . . . . . . . . 90gentamicin in nacl (iso-osm) intravenouspiggyback 100 mg/100 ml, 60 mg/50 ml, 80mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 15

gentamicin in nacl (iso-osm) intravenouspiggyback 80 mg/100 ml. . . . . . . . . . . . . . . 15

gentamicin injection solution 40 mg/ml. . . . . 15gentamicin ophthalmic (eye) drops. . . . . . . . 90gentamicin sulfate (ped) (pf). . . . . . . . . . . . . 15gentamicin topical. . . . . . . . . . . . . . . . . . . . . 60GENVOYA. . . . . . . . . . . . . . . . . . . . . . . . . . . 10GEODON INTRAMUSCULAR. . . . . . . . . . . . 45gianvi (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 87GILENYA ORAL CAPSULE 0.5 MG. . . . . . . 34GILOTRIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24GIVLAARI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64GLASSIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64glatiramer subcutaneous syringe 20 mg/ml. . 34glatiramer subcutaneous syringe 40 mg/ml. . 34glatopa subcutaneous syringe 20 mg/ml. . . . 34glatopa subcutaneous syringe 40 mg/ml. . . . 34GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,40 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

glimepiride. . . . . . . . . . . . . . . . . . . . . . . . . . . 69glipizide oral tablet. . . . . . . . . . . . . . . . . . . . . 69glipizide oral tablet extended release 24hr. . 69glipizide-metformin. . . . . . . . . . . . . . . . . . . . . 69GLUCAGEN HYPOKIT. . . . . . . . . . . . . . . . . 69GLUCAGON (HCL) EMERGENCY KIT. . . . . 69GLUCAGON EMERGENCY KIT (HUMAN). . 69

glyburide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69glyburide micronized. . . . . . . . . . . . . . . . . . . 69glyburide-metformin. . . . . . . . . . . . . . . . . . . . 69glycine urologic. . . . . . . . . . . . . . . . . . . . . . . 97glycine urologic solution. . . . . . . . . . . . . . . . . 97GLYCOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 98glycopyrrolate (pf) in water intravenous syringe0.4 mg/2 ml (0.2 mg/ml). . . . . . . . . . . . . . . . 73

glycopyrrolate injection. . . . . . . . . . . . . . . . . 73glycopyrrolate oral tablet 1 mg, 2 mg. . . . . . . 73glycopyrrolate oral tablet 1.5 mg. . . . . . . . . . 73glydo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58granisetron (pf) intravenous solution 1 mg/ml (1ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

granisetron hcl intravenous. . . . . . . . . . . . . . 74granisetron hcl oral. . . . . . . . . . . . . . . . . . . . 74GRANIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78GRASTEK. . . . . . . . . . . . . . . . . . . . . . . . . . . 81griseofulvin microsize. . . . . . . . . . . . . . . . . . . 9griseofulvin ultramicrosize. . . . . . . . . . . . . . . . 9guanfacine oral tablet. . . . . . . . . . . . . . . . . . 50guanfacine oral tablet extended release 24 hr 45guanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45GYNAZOLE-1. . . . . . . . . . . . . . . . . . . . . . . . 86

Hhailey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87hailey 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 87HALAVEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24halcinonide. . . . . . . . . . . . . . . . . . . . . . . . . . . 61halobetasol propionate topical cream. . . . . . 62halobetasol propionate topical ointment. . . . 62haloperidol. . . . . . . . . . . . . . . . . . . . . . . . . . . 45haloperidol decanoate. . . . . . . . . . . . . . . . . . 45haloperidol lactate injection. . . . . . . . . . . . . . 45haloperidol lactate oral. . . . . . . . . . . . . . . . . . 45HARVONI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10HAVRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 81

HAVRIX (PF) INTRAMUSCULAR SYRINGE1,440 ELISA UNIT/ML. . . . . . . . . . . . . . . . . 81

HAVRIX (PF) INTRAMUSCULAR SYRINGE720 ELISA UNIT/0.5 ML. . . . . . . . . . . . . . . . 81

118

heather. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86hep flush-10 (pf). . . . . . . . . . . . . . . . . . . . . . . 53heparin (porcine) in 5 % dex intravenousparenteral solution 20,000 unit/500 ml (40unit/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

heparin (porcine) in 5 % dex intravenousparenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml). . . . . . . 53

heparin (porcine) in nacl (pf). . . . . . . . . . . . . 53heparin (porcine) injection cartridge. . . . . . . 53heparin (porcine) injection solution. . . . . . . . 54heparin (porcine) injection syringe 5,000unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin flush(porcine)-0.9nacl. . . . . . . . . . . . 54heparin lock flush. . . . . . . . . . . . . . . . . . . . . . 54heparin lock flush (porcine) intravenoussolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin lockflush(porcine)(pf). . . . . . . . . . . . 54heparin(porcine) in 0.45% nacl intravenousparenteral solution 25,000 unit/250 ml, 25,000unit/500 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin, porcine (pf) injection solution. . . . . . 54heparin, porcine (pf) injection syringe 5,000unit/0.5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin, porcine (pf) intravenous syringe 1unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 54

HEPATAMINE 8%. . . . . . . . . . . . . . . . . . . . 101HERCEPTIN HYLECTA. . . . . . . . . . . . . . . . . 24HERCEPTIN INTRAVENOUS RECON SOLN150 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

HERZUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . 24HETLIOZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45HIBERIX (PF). . . . . . . . . . . . . . . . . . . . . . . . 81hidex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67HORIZANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 34HUMALOG JUNIOR KWIKPEN U-100. . . . . 69HUMALOG KWIKPEN INSULIN. . . . . . . . . . 69HUMALOG MIX 50-50 INSULN U-100. . . . . 69HUMALOG MIX 50-50 KWIKPEN. . . . . . . . . 69HUMALOG MIX 75-25 KWIKPEN. . . . . . . . . 69HUMALOG MIX 75-25(U-100)INSULN. . . . . 69HUMALOG U-100 INSULIN. . . . . . . . . . . . . . 69

HUMIRA PEN. . . . . . . . . . . . . . . . . . . . . . . . 84HUMIRA PEN CROHNS-UC-HS START. . . . 84HUMIRA PEN PSOR-UVEITS-ADOL HS. . . 84HUMIRA SUBCUTANEOUS SYRINGE KIT 10MG/0.2 ML, 20 MG/0.4 ML. . . . . . . . . . . . . . 84

HUMIRA SUBCUTANEOUS SYRINGE KIT 40MG/0.8 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 84

HUMIRA(CF) PEDI CROHNS STARTERSUBCUTANEOUS SYRINGE KIT 80 MG/0.8ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

HUMIRA(CF) PEDI CROHNS STARTERSUBCUTANEOUS SYRINGE KIT 80 MG/0.8ML-40 MG/0.4 ML. . . . . . . . . . . . . . . . . . . . 84

HUMIRA(CF) PEN CROHNS-UC-HS. . . . . . 84HUMIRA(CF) PEN PSOR-UV-ADOL HS. . . . 84HUMIRA(CF) PEN SUBCUTANEOUSINJECTOR KIT 40 MG/0.4 ML. . . . . . . . . . . 84

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT10 MG/0.1 ML, 20 MG/0.2 ML. . . . . . . . . . . 84

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT40 MG/0.4 ML. . . . . . . . . . . . . . . . . . . . . . . 84

HUMULIN 70/30 U-100 INSULIN. . . . . . . . . 69HUMULIN 70/30 U-100 KWIKPEN. . . . . . . . 69HUMULIN N NPH INSULIN KWIKPEN. . . . . 69HUMULIN N NPH U-100 INSULIN. . . . . . . . 69HUMULIN R REGULAR U-100 INSULN. . . . 69HUMULIN R U-500 (CONC) INSULIN. . . . . . 69HYALGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 41HYCAMTIN ORAL. . . . . . . . . . . . . . . . . . . . . 24hydralazine injection. . . . . . . . . . . . . . . . . . . 50hydralazine oral. . . . . . . . . . . . . . . . . . . . . . . 50hydrochlorothiazide. . . . . . . . . . . . . . . . . . . . 50hydrocodone bitartrate. . . . . . . . . . . . . . . . . . 38hydrocodone-acetaminophen oral solution10-325 mg/15 ml(15 ml). . . . . . . . . . . . . . . . 38

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml. . . . . . . . . . . . . . . . . . . . . 38

HYDROCODONE-ACETAMINOPHEN ORALSOLUTION 7.5-325 MG/15 ML (BRAND). . 38

hydrocodone-acetaminophen oral tablet 10-300mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300mg, 7.5-325 mg. . . . . . . . . . . . . . . . . . . . . . 38

hydrocodone-ibuprofen oral tablet 10-200 mg,5-200 mg, 7.5-200 mg. . . . . . . . . . . . . . . . . 38

hydrocortisone butyr-emollient. . . . . . . . . . . . 62

119

hydrocortisone butyrate. . . . . . . . . . . . . . . . . 62hydrocortisone oral. . . . . . . . . . . . . . . . . . . . 67hydrocortisone rectal. . . . . . . . . . . . . . . . . . . 74hydrocortisone topical cream 1 %, 2.5 %. . . 62hydrocortisone topical cream with perinealapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 74

hydrocortisone topical lotion 2.5 %. . . . . . . . 62hydrocortisone topical ointment 1 %, 2.5 %. . 62hydrocortisone valerate. . . . . . . . . . . . . . . . . 62hydrocortisone-acetic acid. . . . . . . . . . . . . . . 67hydrocortisone-pramoxine rectal cream 1-1%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml. . . . . . . . . . . . . . . . . . . 38

hydromorphone (pf) injection solution 2mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone injection solution 1 mg/ml. . 38hydromorphone injection solution 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone injection syringe 1 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydromorphone injection syringe 2 mg/ml. . . 38hydromorphone oral liquid. . . . . . . . . . . . . . . 38hydromorphone oral tablet. . . . . . . . . . . . . . . 38hydromorphone oral tablet extended release 24hr 12 mg, 16 mg, 8 mg. . . . . . . . . . . . . . . . . 38

hydromorphone oral tablet extended release 24hr 32 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

hydroxychloroquine. . . . . . . . . . . . . . . . . . . . 16hydroxyprogesterone caproate. . . . . . . . . . . 86hydroxyurea. . . . . . . . . . . . . . . . . . . . . . . . . . 24hydroxyzine hcl intramuscular. . . . . . . . . . . . 93hydroxyzine hcl oral solution 10 mg/5 ml. . . . 93hydroxyzine hcl oral tablet. . . . . . . . . . . . . . . 93hydroxyzine pamoate. . . . . . . . . . . . . . . . . . . 93HYMOVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41HYPER-SAL. . . . . . . . . . . . . . . . . . . . . . . . . 95

Iibandronate intravenous. . . . . . . . . . . . . . . . 83ibandronate oral. . . . . . . . . . . . . . . . . . . . . . . 83IBRANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ibu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ibuprofen lysine (pf). . . . . . . . . . . . . . . . . . . . 41ibuprofen oral suspension. . . . . . . . . . . . . . . 41ibuprofen oral tablet 400 mg, 600 mg, 800mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ibuprofen-oxycodone. . . . . . . . . . . . . . . . . . . 38ibutilide fumarate. . . . . . . . . . . . . . . . . . . . . . 48icatibant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ICLUSIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24idarubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24IDHIFA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ifosfamide intravenous recon soln. . . . . . . . . 25ifosfamide intravenous solution 1 gram/20 ml 25ifosfamide intravenous solution 3 gram/60 ml 25ILARIS (PF) SUBCUTANEOUS SOLUTION. 78imatinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25IMBRUVICA. . . . . . . . . . . . . . . . . . . . . . . . . . 25IMFINZI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25imipenem-cilastatin intravenous recon soln 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

imipenem-cilastatin intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

imipramine hcl. . . . . . . . . . . . . . . . . . . . . . . . 45imipramine pamoate. . . . . . . . . . . . . . . . . . . 45imiquimod topical cream in packet. . . . . . . . . 58IMOVAX RABIES VACCINE (PF). . . . . . . . . 81IMPAVIDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 16INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 32

incassia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86INCRELEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 64INCRUSE ELLIPTA. . . . . . . . . . . . . . . . . . . . 95indapamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 50indomethacin oral capsule. . . . . . . . . . . . . . . 41indomethacin oral capsule, extended release 41indomethacin sodium. . . . . . . . . . . . . . . . . . . 41INFANRIX (DTAP) (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 81

INFANRIX (DTAP) (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 81

INFLECTRA. . . . . . . . . . . . . . . . . . . . . . . . . . 74INFUGEM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25INGREZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 34INGREZZA INITIATION PACK. . . . . . . . . . . . 34

120

INLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25INPEN (FOR HUMALOG). . . . . . . . . . . . . . . 69INREBIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25INSULIN PEN NEEDLE. . . . . . . . . . . . . . . . . 69INSULIN SYRINGE (DISP) U-100 0.3 ML. . . 69INSULIN SYRINGE (DISP) U-100 1 ML. . . . 70INSULIN SYRINGE (DISP) U-100 1/2 ML. . . 70INTELENCE ORAL TABLET 100 MG, 200MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

INTELENCE ORAL TABLET 25 MG. . . . . . . 11intralipid intravenous emulsion 20 %. . . . . . 101INTRALIPID INTRAVENOUS EMULSION 30%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

INTRON A INJECTION RECON SOLN. . . . . 78INTRON A INJECTION SOLUTION 10 MILLIONUNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

INTRON A INJECTION SOLUTION 6 MILLIONUNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

introvale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87INVEGA SUSTENNA INTRAMUSCULARSYRINGE 117 MG/0.75 ML, 156 MG/ML, 234MG/1.5 ML, 78 MG/0.5 ML. . . . . . . . . . . . . . 45

INVEGA SUSTENNA INTRAMUSCULARSYRINGE 39 MG/0.25 ML. . . . . . . . . . . . . . 45

INVEGA TRINZA. . . . . . . . . . . . . . . . . . . . . . 45INVIRASE ORAL TABLET. . . . . . . . . . . . . . . 11INVOKAMET. . . . . . . . . . . . . . . . . . . . . . . . . 70INVOKAMET XR. . . . . . . . . . . . . . . . . . . . . . 70INVOKANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 70IPOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81ipratropium bromide inhalation. . . . . . . . . . . 95ipratropium bromide nasal spray,non-aerosol0.03 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

ipratropium bromide nasal spray,non-aerosol 42mcg (0.06 %). . . . . . . . . . . . . . . . . . . . . . . . 66

ipratropium-albuterol. . . . . . . . . . . . . . . . . . . 95irbesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50irbesartan-hydrochlorothiazide. . . . . . . . . . . 50IRESSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25irinotecan intravenous solution 100 mg/5 ml, 40mg/2 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

irinotecan intravenous solution 300 mg/15 ml,500 mg/25 ml. . . . . . . . . . . . . . . . . . . . . . . . 25

ISENTRESS HD. . . . . . . . . . . . . . . . . . . . . . 11

ISENTRESS ORAL POWDER IN PACKET. . 11ISENTRESS ORAL TABLET. . . . . . . . . . . . . 11ISENTRESS ORAL TABLET,CHEWABLE 100MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ISENTRESS ORAL TABLET,CHEWABLE 25MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

isibloom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88isoniazid injection. . . . . . . . . . . . . . . . . . . . . . 16isoniazid oral. . . . . . . . . . . . . . . . . . . . . . . . . 16isoproterenol hcl. . . . . . . . . . . . . . . . . . . . . . 56isosorbide dinitrate oral tablet. . . . . . . . . . . . 57isosorbide mononitrate oral tablet. . . . . . . . . 57isosorbide mononitrate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 57

isotretinoin. . . . . . . . . . . . . . . . . . . . . . . . . . . 60isradipine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ISTODAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25itraconazole oral capsule. . . . . . . . . . . . . . . . . 9itraconazole oral solution. . . . . . . . . . . . . . . . . 9ivermectin oral. . . . . . . . . . . . . . . . . . . . . . . . 16ivermectin topical. . . . . . . . . . . . . . . . . . . . . . 60IXEMPRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25IXIARO (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 81

JJADENU ORAL TABLET 180 MG. . . . . . . . . 64JADENU SPRINKLE. . . . . . . . . . . . . . . . . . . 64jaimiess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88JAKAFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25jantoven. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54JANUMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70JANUMET XR. . . . . . . . . . . . . . . . . . . . . . . . 70JANUVIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70JARDIANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 70jasmiel (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88jencycla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86JEVTANA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25jinteli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86jolessa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88juleber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88JULUCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11junel 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 88

121

junel 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . 88junel fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 88junel fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . 88junel fe 24. . . . . . . . . . . . . . . . . . . . . . . . . . . 88JUXTAPID. . . . . . . . . . . . . . . . . . . . . . . . . . . 55JYNARQUE ORAL TABLET. . . . . . . . . . . . . . 71JYNARQUE ORAL TABLETS, SEQUENTIAL 71

Kk-tab oral tablet extended release 8 meq. . . 98KADCYLA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25kaitlib fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88KALETRA ORAL TABLET 100-25 MG. . . . . . 11KALETRA ORAL TABLET 200-50 MG. . . . . . 11kalliga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88KALYDECO ORAL GRANULES IN PACKET 25MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

KALYDECO ORAL GRANULES IN PACKET 50MG, 75 MG. . . . . . . . . . . . . . . . . . . . . . . . . . 95

KALYDECO ORAL TABLET. . . . . . . . . . . . . . 95KANJINTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25KANUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71kariva (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88kelnor 1-50. . . . . . . . . . . . . . . . . . . . . . . . . . . 88kelnor 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 88KEPIVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 21ketoconazole oral. . . . . . . . . . . . . . . . . . . . . . . 9ketoconazole topical. . . . . . . . . . . . . . . . . . . 60ketodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ketoprofen oral capsule 25 mg. . . . . . . . . . . 41ketoprofen oral capsule 50 mg, 75 mg. . . . . 41ketoprofen oral capsule,ext rel. pellets 24 hr 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ketorolac injection cartridge 30 mg/ml. . . . . . 41ketorolac injection solution 15 mg/ml, 30 mg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

ketorolac injection syringe 15 mg/ml. . . . . . . 41ketorolac injection syringe 30 mg/ml. . . . . . . 42ketorolac intramuscular cartridge. . . . . . . . . . 42ketorolac intramuscular solution. . . . . . . . . . 42ketorolac intramuscular syringe. . . . . . . . . . . 42ketorolac ophthalmic (eye). . . . . . . . . . . . . . . 92ketorolac oral. . . . . . . . . . . . . . . . . . . . . . . . . 42

KEVEYIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34KEVZARA. . . . . . . . . . . . . . . . . . . . . . . . . . . 84KEYTRUDA INTRAVENOUS SOLUTION. . . 25KINERET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84KINRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 81

KINRIX (PF) INTRAMUSCULAR SYRINGE. 81kionex (with sorbitol) oral suspension. . . . . . 64KISQALI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25KISQALI FEMARA CO-PACK. . . . . . . . . . . . 25klor-con 10 oral tablet extended release. . . . 98klor-con 20 meq packet. . . . . . . . . . . . . . . . . 98klor-con 8 oral tablet extended release. . . . . 98klor-con m10 oral tablet,er particles/crystals. 98klor-con m15 oral tablet,er particles/crystals. 98klor-con m20 oral tablet,er particles/crystals. 98klor-con/ef. . . . . . . . . . . . . . . . . . . . . . . . . . . 98KORLYM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71KRYSTEXXA. . . . . . . . . . . . . . . . . . . . . . . . . 83kurvelo (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88KUVAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71KYPROLIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ll norgest/e.estradiol-e.estrad. . . . . . . . . . . . . 88labetalol intravenous solution. . . . . . . . . . . . 51labetalol intravenous syringe 20 mg/4 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

labetalol oral. . . . . . . . . . . . . . . . . . . . . . . . . 51LACRISERT. . . . . . . . . . . . . . . . . . . . . . . . . . 91lactated ringers intravenous. . . . . . . . . . . . . . 98lactated ringers irrigation. . . . . . . . . . . . . . . . 63lactulose oral packet. . . . . . . . . . . . . . . . . . . 74lactulose oral solution. . . . . . . . . . . . . . . . . . 74lamivudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 11lamivudine-zidovudine. . . . . . . . . . . . . . . . . . 11lamotrigine oral tablet. . . . . . . . . . . . . . . . . . 30lamotrigine oral tablet disintegrating, dose pk 30lamotrigine oral tablet extended release 24hr 30lamotrigine oral tablet, chewable dispersible. 30lamotrigine oral tablet,disintegrating. . . . . . . 30lamotrigine oral tablets,dose pack. . . . . . . . . 30

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lansoprazole oral capsule,delayed release(dr/ec) 15 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 77

lansoprazole oral capsule,delayed release(dr/ec) 30 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 77

lansoprazole oral tablet,disintegrat, delay rel 15mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

lansoprazole oral tablet,disintegrat, delay rel 30mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

lanthanum oral tablet,chewable. . . . . . . . . . . 64LANTUS SOLOSTAR U-100 INSULIN. . . . . 70LANTUS U-100 INSULIN. . . . . . . . . . . . . . . . 70larin 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 88larin 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . . 88larin 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88larin fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 88larin fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . . 88larissia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88latanoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . 92LATUDA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45layolis fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88leena 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88leflunomide. . . . . . . . . . . . . . . . . . . . . . . . . . . 84LEMTRADA. . . . . . . . . . . . . . . . . . . . . . . . . . 35LENVIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25lessina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88letrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25leucovorin calcium injection recon soln 100 mg,200 mg, 350 mg, 50 mg. . . . . . . . . . . . . . . . 21

leucovorin calcium injection recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

leucovorin calcium injection solution 10mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

leucovorin calcium oral. . . . . . . . . . . . . . . . . 21LEUKERAN. . . . . . . . . . . . . . . . . . . . . . . . . . 25LEUKINE INJECTION RECON SOLN. . . . . . 78leuprolide subcutaneous kit. . . . . . . . . . . . . . 25levalbuterol hcl. . . . . . . . . . . . . . . . . . . . . . . . 95levetiracetam in nacl (iso-os) intravenouspiggyback 1,000 mg/100 ml, 1,500 mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml. . . . . . . . . . . . . . 30

levetiracetam intravenous. . . . . . . . . . . . . . . 30levetiracetam oral solution 100 mg/ml. . . . . . 30

levetiracetam oral solution 500 mg/5 ml (5ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

levetiracetam oral tablet. . . . . . . . . . . . . . . . . 30levetiracetam oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

levobunolol ophthalmic (eye) drops 0.5 %. . . 91levocarnitine (with sugar). . . . . . . . . . . . . . . . 64levocarnitine oral solution 100 mg/ml. . . . . . 64levocarnitine oral tablet. . . . . . . . . . . . . . . . . 64levocetirizine oral solution. . . . . . . . . . . . . . . 93levocetirizine oral tablet. . . . . . . . . . . . . . . . . 93levofloxacin in d5w intravenous piggyback 250mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 19

levofloxacin in d5w intravenous piggyback 500mg/100 ml, 750 mg/150 ml. . . . . . . . . . . . . . 19

levofloxacin intravenous. . . . . . . . . . . . . . . . 19levofloxacin ophthalmic (eye). . . . . . . . . . . . 90levofloxacin oral. . . . . . . . . . . . . . . . . . . . . . . 19levoleucovorin calcium intravenous recon soln50 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

levoleucovorin calcium intravenous solution. 21levonest (28). . . . . . . . . . . . . . . . . . . . . . . . . 88levonorg-eth estrad triphasic. . . . . . . . . . . . . 88levonorgestrel-ethinyl estrad. . . . . . . . . . . . . 88levora-28. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88levorphanol tartrate oral tablet 2 mg. . . . . . . 38LEVORPHANOL TARTRATE ORAL TABLET 3MG (BRAND). . . . . . . . . . . . . . . . . . . . . . . . 38

levothyroxine intravenous recon soln. . . . . . 73levothyroxine oral. . . . . . . . . . . . . . . . . . . . . . 73levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,137 mcg, 150 mcg, 175 mcg, 200 mcg, 25mcg, 50 mcg, 75 mcg, 88 mcg. . . . . . . . . . . 73

LEXIVA ORAL SUSPENSION. . . . . . . . . . . . 11LIBTAYO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25lidocaine (pf) in d7.5w. . . . . . . . . . . . . . . . . . 48lidocaine (pf) injection solution 10 mg/ml (1 %),20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine (pf) intravenous solution. . . . . . . . . 48lidocaine (pf) intravenous syringe. . . . . . . . . 48lidocaine hcl injection solution. . . . . . . . . . . . 58

123

lidocaine hcl laryngotracheal. . . . . . . . . . . . . 58lidocaine hcl mucous membrane jelly. . . . . . 58lidocaine hcl mucous membrane jelly inapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine hcl mucous membrane solution 4 %(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine in 5 % dextrose (pf) intravenousparenteral solution 4 mg/ml (0.4 %), 8 mg/ml(0.8 %). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

lidocaine topical adhesive patch,medicated 5%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine topical ointment. . . . . . . . . . . . . . . 58lidocaine viscous. . . . . . . . . . . . . . . . . . . . . . 58lidocaine-epinephrine injection solution0.5 %-1:200,000, 1.5 %-1:200,000, 2 %-1:200,000. . . . . . . . . . . . . . . . . . . . . . . . . . . 58

lidocaine-epinephrine injection solution1 %-1:100,000, 2 %-1:100,000. . . . . . . . . . 58

lidocaine-prilocaine topical cream. . . . . . . . . 58lillow (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 88lincomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 16lindane topical shampoo. . . . . . . . . . . . . . . . 62linezolid in dextrose 5%. . . . . . . . . . . . . . . . . 16linezolid oral suspension for reconstitution. . 16linezolid oral tablet. . . . . . . . . . . . . . . . . . . . . 16linezolid-0.9% sodium chloride. . . . . . . . . . . 16LINZESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74liothyronine intravenous. . . . . . . . . . . . . . . . . 73liothyronine oral. . . . . . . . . . . . . . . . . . . . . . . 73lisinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51lisinopril-hydrochlorothiazide. . . . . . . . . . . . . 51lithium carbonate oral capsule. . . . . . . . . . . . 45lithium carbonate oral tablet. . . . . . . . . . . . . . 45lithium carbonate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

lithium citrate oral solution 8 meq/5 ml. . . . . 45lo-zumandimine (28). . . . . . . . . . . . . . . . . . . 88lojaimiess. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88LONSURF. . . . . . . . . . . . . . . . . . . . . . . . . . . 25loperamide oral capsule. . . . . . . . . . . . . . . . . 73lopinavir-ritonavir. . . . . . . . . . . . . . . . . . . . . . 11lopreeza oral tablet 1-0.5 mg. . . . . . . . . . . . . 86lorazepam injection solution. . . . . . . . . . . . . 45lorazepam injection syringe 2 mg/ml. . . . . . . 45

lorazepam injection syringe 4 mg/ml. . . . . . . 45lorazepam intensol. . . . . . . . . . . . . . . . . . . . . 45lorazepam oral. . . . . . . . . . . . . . . . . . . . . . . . 45LORBRENA. . . . . . . . . . . . . . . . . . . . . . . . . . 25lorcet (hydrocodone). . . . . . . . . . . . . . . . . . . 39lorcet hd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39lorcet plus oral tablet 7.5-325 mg. . . . . . . . . 39loryna (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88losartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51losartan-hydrochlorothiazide. . . . . . . . . . . . . 51loteprednol etabonate. . . . . . . . . . . . . . . . . . 92lovastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55low-ogestrel (28). . . . . . . . . . . . . . . . . . . . . . 88loxapine succinate. . . . . . . . . . . . . . . . . . . . . 45LUCEMYRA. . . . . . . . . . . . . . . . . . . . . . . . . . 42LULICONAZOLE. . . . . . . . . . . . . . . . . . . . . . 60LUMOXITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 25LUPANETA PACK (1 MONTH). . . . . . . . . . . 86LUPANETA PACK (3 MONTH). . . . . . . . . . . 86LUPRON DEPOT. . . . . . . . . . . . . . . . . . . . . . 25LUPRON DEPOT (3 MONTH). . . . . . . . . . . . 25LUPRON DEPOT (4 MONTH). . . . . . . . . . . . 25LUPRON DEPOT (6 MONTH). . . . . . . . . . . . 25LUPRON DEPOT-PED. . . . . . . . . . . . . . . . . 25LUPRON DEPOT-PED (3 MONTH). . . . . . . 25lutera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88LUZU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60LYNPARZA ORAL TABLET. . . . . . . . . . . . . . 25LYSODREN. . . . . . . . . . . . . . . . . . . . . . . . . . 25lyza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

MM-M-R II (PF). . . . . . . . . . . . . . . . . . . . . . . . . 81mafenide acetate. . . . . . . . . . . . . . . . . . . . . . 60magnesium chloride injection. . . . . . . . . . . . 98magnesium sulfate in water intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 98

magnesium sulfate in water intravenouspiggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

magnesium sulfate in water intravenouspiggyback 4 gram/100 ml (4 %). . . . . . . . . . 99

magnesium sulfate injection solution. . . . . . . 99

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magnesium sulfate injection syringe. . . . . . . 99malathion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62mannitol 20 %. . . . . . . . . . . . . . . . . . . . . . . . 51mannitol 25 % intravenous solution. . . . . . . . 51maprotiline. . . . . . . . . . . . . . . . . . . . . . . . . . . 45marlissa (28). . . . . . . . . . . . . . . . . . . . . . . . . 88MARPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 45MATULANE. . . . . . . . . . . . . . . . . . . . . . . . . . 25matzim la oral tablet extended release 24 hr. 51MAVENCLAD (10 TABLET PACK). . . . . . . . . 35MAVENCLAD (4 TABLET PACK). . . . . . . . . . 35MAVENCLAD (5 TABLET PACK). . . . . . . . . . 35MAVENCLAD (6 TABLET PACK). . . . . . . . . . 35MAVENCLAD (7 TABLET PACK). . . . . . . . . . 35MAVENCLAD (8 TABLET PACK). . . . . . . . . . 35MAVENCLAD (9 TABLET PACK). . . . . . . . . . 35MAVYRET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11MAYZENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35meclizine oral tablet 12.5 mg, 25 mg. . . . . . . 75meclofenamate. . . . . . . . . . . . . . . . . . . . . . . . 42medroxyprogesterone. . . . . . . . . . . . . . . . . . 86mefenamic acid. . . . . . . . . . . . . . . . . . . . . . . 42mefloquine. . . . . . . . . . . . . . . . . . . . . . . . . . . 16megestrol oral suspension 400 mg/10 ml (10ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

megestrol oral suspension 400 mg/10 ml (40mg/ml), 625 mg/5 ml. . . . . . . . . . . . . . . . . . 25

megestrol oral tablet. . . . . . . . . . . . . . . . . . . 25MEKINIST. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25MEKTOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25melodetta 24 fe. . . . . . . . . . . . . . . . . . . . . . . 88meloxicam oral tablet. . . . . . . . . . . . . . . . . . . 42melphalan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26melphalan hcl. . . . . . . . . . . . . . . . . . . . . . . . . 26memantine oral capsule,sprinkle,er 24hr. . . . 35memantine oral solution. . . . . . . . . . . . . . . . . 35memantine oral tablet. . . . . . . . . . . . . . . . . . 35MENACTRA (PF) INTRAMUSCULARSOLUTION. . . . . . . . . . . . . . . . . . . . . . . . . . 81

MENVEO A-C-Y-W-135-DIP (PF). . . . . . . . . 81meperidine (pf) injection solution 100 mg/ml, 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

meperidine (pf) injection solution 25 mg/ml. . 39

meperidine oral. . . . . . . . . . . . . . . . . . . . . . . 39meprobamate. . . . . . . . . . . . . . . . . . . . . . . . . 36MEPSEVII. . . . . . . . . . . . . . . . . . . . . . . . . . . 71mercaptopurine. . . . . . . . . . . . . . . . . . . . . . . 26meropenem. . . . . . . . . . . . . . . . . . . . . . . . . . 16mesalamine. . . . . . . . . . . . . . . . . . . . . . . . . . 75mesalamine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

mesalamine rectal. . . . . . . . . . . . . . . . . . . . . 75mesna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21MESNEX ORAL. . . . . . . . . . . . . . . . . . . . . . . 21metadate er oral tablet extended release. . . 45metaproterenol oral syrup. . . . . . . . . . . . . . . 95metaxall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36metaxalone. . . . . . . . . . . . . . . . . . . . . . . . . . . 36metformin oral solution. . . . . . . . . . . . . . . . . 70metformin oral tablet. . . . . . . . . . . . . . . . . . . 70metformin oral tablet extended release 24 hr(generic - GLUCOPHAGE XR). . . . . . . . . . 70

methadone injection solution. . . . . . . . . . . . . 39methadone intensol. . . . . . . . . . . . . . . . . . . . 39methadone oral concentrate. . . . . . . . . . . . . 39methadone oral solution. . . . . . . . . . . . . . . . 39methadone oral tablet. . . . . . . . . . . . . . . . . . 39methadose oral concentrate. . . . . . . . . . . . . 39methamphetamine. . . . . . . . . . . . . . . . . . . . . 45methazolamide. . . . . . . . . . . . . . . . . . . . . . . . 92methenamine hippurate. . . . . . . . . . . . . . . . . 21methenamine mandelate. . . . . . . . . . . . . . . . 21methergine. . . . . . . . . . . . . . . . . . . . . . . . . . . 90methimazole oral tablet 10 mg, 5 mg. . . . . . . 68METHITEST. . . . . . . . . . . . . . . . . . . . . . . . . . 71methocarbamol injection. . . . . . . . . . . . . . . . 36methocarbamol oral. . . . . . . . . . . . . . . . . . . . 36methotrexate sodium (pf) injection recon soln 26methotrexate sodium (pf) injection solution. . 26methotrexate sodium injection. . . . . . . . . . . . 26methotrexate sodium oral. . . . . . . . . . . . . . . 26methoxsalen. . . . . . . . . . . . . . . . . . . . . . . . . . 58methscopolamine. . . . . . . . . . . . . . . . . . . . . . 73methyldopa. . . . . . . . . . . . . . . . . . . . . . . . . . . 51methyldopa-hydrochlorothiazide. . . . . . . . . . 51

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methylergonovine injection. . . . . . . . . . . . . . 90methylergonovine oral. . . . . . . . . . . . . . . . . . 90methylphenidate hcl oral capsule, er biphasic30-70 10 mg, 20 mg, 30 mg. . . . . . . . . . . . . 45

methylphenidate hcl oral capsule, er biphasic30-70 40 mg, 50 mg, 60 mg. . . . . . . . . . . . . 45

methylphenidate hcl oral capsule,er biphasic 50-50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

methylphenidate hcl oral solution. . . . . . . . . 46methylphenidate hcl oral tablet. . . . . . . . . . . 46methylphenidate hcl oral tablet extendedrelease 10 mg. . . . . . . . . . . . . . . . . . . . . . . 46

methylphenidate hcl oral tablet extendedrelease 20 mg. . . . . . . . . . . . . . . . . . . . . . . 46

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg (bx rating), 27 mg (bxrating), 54 mg (bx rating). . . . . . . . . . . . . . . 46

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg, 27 mg, 54 mg. . . . . . . 46

methylphenidate hcl oral tablet extendedrelease 24hr 36 mg. . . . . . . . . . . . . . . . . . . 46

methylphenidate hcl oral tablet extendedrelease 24hr 36 mg (bx rating). . . . . . . . . . . 46

methylphenidate hcl oral tablet,chewable. . . 46methylprednisolone acetate. . . . . . . . . . . . . . 67methylprednisolone oral tablet. . . . . . . . . . . . 67methylprednisolone oral tablets,dose pack. . 67methylprednisolone sodium succ injection reconsoln 125 mg, 40 mg. . . . . . . . . . . . . . . . . . . 67

methylprednisolone sodium succ intravenousrecon soln 1,000 mg. . . . . . . . . . . . . . . . . . . 68

methylprednisolone sodium succ intravenousrecon soln 500 mg. . . . . . . . . . . . . . . . . . . . 68

methyltestosterone oral capsule. . . . . . . . . . 71metoclopramide hcl injection solution. . . . . . 75metoclopramide hcl injection syringe. . . . . . . 75metoclopramide hcl oral solution. . . . . . . . . . 75metoclopramide hcl oral tablet. . . . . . . . . . . . 75metoclopramide hcl oral tablet,disintegrating 75metolazone. . . . . . . . . . . . . . . . . . . . . . . . . . . 51metoprolol succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 51

metoprolol ta-hydrochlorothiaz. . . . . . . . . . . 51metoprolol tartrate intravenous solution. . . . . 51metoprolol tartrate intravenous syringe. . . . . 51

metoprolol tartrate oral tablet. . . . . . . . . . . . . 51metro i.v.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16metronidazole in nacl (iso-os). . . . . . . . . . . . 16metronidazole oral. . . . . . . . . . . . . . . . . . . . . 16metronidazole topical. . . . . . . . . . . . . . . . . . . 60metronidazole vaginal. . . . . . . . . . . . . . . . . . 86mexiletine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48MIACALCIN INJECTION. . . . . . . . . . . . . . . . 71mibelas 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . 88micafungin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9miconazole-3 vaginal suppository. . . . . . . . . 86microgestin 1.5/30 (21). . . . . . . . . . . . . . . . . 88microgestin 1/20 (21). . . . . . . . . . . . . . . . . . . 88microgestin fe 1.5/30 (28). . . . . . . . . . . . . . . 88microgestin fe 1/20 (28). . . . . . . . . . . . . . . . . 88midazolam (pf) injection. . . . . . . . . . . . . . . . . 46midazolam injection. . . . . . . . . . . . . . . . . . . . 46midazolam oral syrup 2 mg/ml. . . . . . . . . . . . 46midodrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64migergot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33miglitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70miglustat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88millipred dp. . . . . . . . . . . . . . . . . . . . . . . . . . 68millipred oral tablet. . . . . . . . . . . . . . . . . . . . . 68milrinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56milrinone in 5 % dextrose. . . . . . . . . . . . . . . 56mimvey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86minocycline oral capsule. . . . . . . . . . . . . . . . 20minocycline oral tablet. . . . . . . . . . . . . . . . . . 20minocycline oral tablet extended release 24 hr105 mg, 55 mg, 65 mg, 80 mg. . . . . . . . . . . 20

minocycline oral tablet extended release 24 hr115 mg, 135 mg, 45 mg, 90 mg. . . . . . . . . . 20

minoxidil oral. . . . . . . . . . . . . . . . . . . . . . . . . 51miostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92mirtazapine oral tablet. . . . . . . . . . . . . . . . . . 46mirtazapine oral tablet,disintegrating. . . . . . . 46misoprostol. . . . . . . . . . . . . . . . . . . . . . . . . . . 77mitomycin intravenous recon soln 20 mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

mitomycin intravenous recon soln 40 mg. . . 26

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mitoxantrone. . . . . . . . . . . . . . . . . . . . . . . . . 26modafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46moexipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51molindone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46mometasone nasal. . . . . . . . . . . . . . . . . . . . 95mometasone topical. . . . . . . . . . . . . . . . . . . . 62mondoxyne nl oral capsule 100 mg, 75 mg. . 20mono-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . 88monoject 0.9% sodium chloride. . . . . . . . . . . 64monoject prefill advanced ns. . . . . . . . . . . . . 64montelukast. . . . . . . . . . . . . . . . . . . . . . . . . . 95morgidox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20morphine (pf) injection solution 0.5 mg/ml. . . 39morphine (pf) injection solution 1 mg/ml. . . . 39morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml. . . . . . . . . . . . 39

morphine concentrate oral solution. . . . . . . . 39MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine injection solution 8 mg/ml. . . . . . . 39morphine injection syringe 10 mg/ml, 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine injection syringe 5 mg/ml, 8 mg/ml 39morphine intravenous solution 10 mg/ml. . . . 39MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 39

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 39

morphine intravenous syringe 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

morphine oral capsule, er multiphase 24 hr. . 39morphine oral capsule,extend.release pellets 40morphine oral solution. . . . . . . . . . . . . . . . . . 40morphine oral tablet. . . . . . . . . . . . . . . . . . . . 40morphine oral tablet extended release. . . . . 40MOTEGRITY. . . . . . . . . . . . . . . . . . . . . . . . . 75moxifloxacin ophthalmic (eye). . . . . . . . . . . . 90moxifloxacin oral. . . . . . . . . . . . . . . . . . . . . . 19moxifloxacin-sod.chloride(iso). . . . . . . . . . . . 19MOZOBIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78MULPLETA. . . . . . . . . . . . . . . . . . . . . . . . . . . 54MULTAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

mupirocin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60mupirocin calcium. . . . . . . . . . . . . . . . . . . . . 60MVASI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26MYALEPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71MYCAMINE. . . . . . . . . . . . . . . . . . . . . . . . . . . 9mycophenolate mofetil (hcl). . . . . . . . . . . . . . 26mycophenolate mofetil oral capsule. . . . . . . 26mycophenolate mofetil oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 26

mycophenolate mofetil oral tablet. . . . . . . . . 26mycophenolate sodium oral tablet,delayedrelease (dr/ec). . . . . . . . . . . . . . . . . . . . . . . 26

MYLERAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 26MYLOTARG. . . . . . . . . . . . . . . . . . . . . . . . . . 26myorisan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60MYRBETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 97MYTESI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Nnabumetone. . . . . . . . . . . . . . . . . . . . . . . . . . 42nadolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51nadolol-bendroflumethiazide oral tablet 80-5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

nafcillin in dextrose iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 18

nafcillin in dextrose iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 18

nafcillin injection recon soln 1 gram, 2 gram. 18nafcillin injection recon soln 10 gram. . . . . . . 18nafcillin intravenous recon soln 1 gram. . . . . 18nafcillin intravenous recon soln 2 gram. . . . . 18naftifine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60NAGLAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 71nalbuphine. . . . . . . . . . . . . . . . . . . . . . . . . . . 42naloxone injection solution. . . . . . . . . . . . . . . 42naloxone injection syringe. . . . . . . . . . . . . . . 42naltrexone. . . . . . . . . . . . . . . . . . . . . . . . . . . 42naproxen oral suspension. . . . . . . . . . . . . . . 42naproxen oral tablet. . . . . . . . . . . . . . . . . . . . 42naproxen oral tablet,delayed release (dr/ec). 42naproxen sodium oral tablet 275 mg, 550 mg 42naproxen sodium oral tablet, er multiphase 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

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naratriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 33NARCAN NASAL SPRAY,NON-AEROSOL 4MG/ACTUATION. . . . . . . . . . . . . . . . . . . . . 42

NATACYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90nateglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 70NATPARA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71NAYZILAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 30NEBUPENT. . . . . . . . . . . . . . . . . . . . . . . . . . 16nebusal inhalation solution for nebulization 3%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

NEBUSAL INHALATION SOLUTION FORNEBULIZATION 6 % (BRAND). . . . . . . . . . 95

necon 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . . 88NEEDLES, INSULIN DISP.,SAFETY. . . . . . . 70nefazodone. . . . . . . . . . . . . . . . . . . . . . . . . . 46neo-polycin. . . . . . . . . . . . . . . . . . . . . . . . . . 90neo-polycin hc. . . . . . . . . . . . . . . . . . . . . . . . 92neomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16neomycin-bacitracin-poly-hc. . . . . . . . . . . . . 92neomycin-bacitracin-polymyxin. . . . . . . . . . . 90neomycin-polymyxin b gu. . . . . . . . . . . . . . . 63neomycin-polymyxin b-dexameth. . . . . . . . . 92neomycin-polymyxin-gramicidin. . . . . . . . . . . 90neomycin-polymyxin-hc ophthalmic (eye). . . 92neomycin-polymyxin-hc otic (ear). . . . . . . . . 67neostigmine methylsulfate intravenous solution0.5 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 36

neostigmine methylsulfate intravenous solution1 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

NEPHRAMINE 5.4 %. . . . . . . . . . . . . . . . . . 101NERLYNX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26neuac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60NEUPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32nevirapine oral suspension. . . . . . . . . . . . . . 11nevirapine oral tablet. . . . . . . . . . . . . . . . . . . 11nevirapine oral tablet extended release 24 hr 11NEXAVAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26niacin oral tablet 500 mg. . . . . . . . . . . . . . . . 55niacin oral tablet extended release 24 hr. . . . 55nicardipine intravenous solution. . . . . . . . . . 51nicardipine oral. . . . . . . . . . . . . . . . . . . . . . . 51NICOTROL. . . . . . . . . . . . . . . . . . . . . . . . . . . 66NICOTROL NS. . . . . . . . . . . . . . . . . . . . . . . 66

nifedipine oral capsule. . . . . . . . . . . . . . . . . . 51nifedipine oral tablet extended release. . . . . 51nifedipine oral tablet extended release 24hr. 51nikki (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 88nilutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nimodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 51NINLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nisoldipine oral tablet extended release 24 hr 51nitisinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64nitro-bid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57nitrofurantoin. . . . . . . . . . . . . . . . . . . . . . . . . 21nitrofurantoin macrocrystal. . . . . . . . . . . . . . 21nitrofurantoin monohyd/m-cryst. . . . . . . . . . . 21nitroglycerin in 5 % dextrose intravenoussolution 100 mg/250 ml (400 mcg/ml), 50mg/250 ml (200 mcg/ml). . . . . . . . . . . . . . . 57

nitroglycerin in 5 % dextrose intravenoussolution 25 mg/250 ml (100 mcg/ml). . . . . . 57

nitroglycerin intravenous. . . . . . . . . . . . . . . . 57nitroglycerin sublingual. . . . . . . . . . . . . . . . . 57nitroglycerin transdermal patch 24 hour. . . . . 57nitroglycerin translingual spray,non-aerosol. 57NITYR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64nizatidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77nolix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62nora-be. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86norepinephrine bitartrate. . . . . . . . . . . . . . . . 56noreth-ethinyl estradiol-iron. . . . . . . . . . . . . . 88norethindrone (contraceptive). . . . . . . . . . . . 86norethindrone ac-eth estradiol oral tablet 0.5-2.5mg-mcg, 1-5 mg-mcg. . . . . . . . . . . . . . . . . . 86

norethindrone ac-eth estradiol oral tablet 1-20mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

norethindrone ac-eth estradiol oral tablet 1.5-30mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

norethindrone acetate. . . . . . . . . . . . . . . . . . 86norethindrone-e.estradiol-iron oral tablet 1mg-20 mcg (21)/75 mg (7). . . . . . . . . . . . . . 89

norethindrone-e.estradiol-iron oral tablet 1.5mg-30 mcg (21)/75 mg (7). . . . . . . . . . . . . . 89

norethindrone-e.estradiol-iron oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 89

norgestimate-ethinyl estradiol. . . . . . . . . . . . 89norlyda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

128

normal saline flush. . . . . . . . . . . . . . . . . . . . . 64NORMOSOL-M IN 5 % DEXTROSE. . . . . . 101NORMOSOL-R. . . . . . . . . . . . . . . . . . . . . . . 99NORMOSOL-R IN 5 % DEXTROSE. . . . . . . 99NORMOSOL-R PH 7.4. . . . . . . . . . . . . . . . 101NORTHERA. . . . . . . . . . . . . . . . . . . . . . . . . . 64nortrel 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . 89nortrel 1/35 (21). . . . . . . . . . . . . . . . . . . . . . . 89nortrel 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 89nortrel 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 89nortriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 46NORVIR ORAL POWDER IN PACKET. . . . . 11NORVIR ORAL SOLUTION. . . . . . . . . . . . . . 11NOURIANZ. . . . . . . . . . . . . . . . . . . . . . . . . . 32NOVAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 71NOXAFIL INTRAVENOUS. . . . . . . . . . . . . . . . 9NOXAFIL ORAL SUSPENSION. . . . . . . . . . . 9np thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73NPLATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54NUBEQA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26NUCALA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95NUEDEXTA. . . . . . . . . . . . . . . . . . . . . . . . . . 35NULOJIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26NUPLAZID ORAL CAPSULE. . . . . . . . . . . . . 46NUPLAZID ORAL TABLET 10 MG. . . . . . . . 46NUZYRA INTRAVENOUS. . . . . . . . . . . . . . . 21NUZYRA ORAL. . . . . . . . . . . . . . . . . . . . . . . 21nyamyc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60nystatin oral suspension. . . . . . . . . . . . . . . . . 9nystatin oral tablet. . . . . . . . . . . . . . . . . . . . . . 9nystatin topical. . . . . . . . . . . . . . . . . . . . . . . . 60nystatin-triamcinolone. . . . . . . . . . . . . . . . . . 60nystop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

OOCALIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75ocella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89OCREVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . 35octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml. . . . . . . . . . . . . . . . . . . . . . . 26

octreotide acetate injection solution 100 mcg/ml,200 mcg/ml, 50 mcg/ml. . . . . . . . . . . . . . . . 26

octreotide acetate injection syringe 100 mcg/ml(1 ml), 50 mcg/ml (1 ml). . . . . . . . . . . . . . . . 26

octreotide acetate injection syringe 500 mcg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

ODEFSEY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ODOMZO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26OFEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ofloxacin ophthalmic (eye). . . . . . . . . . . . . . . 90ofloxacin oral tablet 300 mg. . . . . . . . . . . . . . 19ofloxacin oral tablet 400 mg. . . . . . . . . . . . . . 19ofloxacin otic (ear). . . . . . . . . . . . . . . . . . . . . 67ogestrel (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89OGIVRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26okebo oral capsule 75 mg. . . . . . . . . . . . . . . 21olanzapine intramuscular recon soln. . . . . . . 46olanzapine oral tablet. . . . . . . . . . . . . . . . . . . 46olanzapine oral tablet,disintegrating. . . . . . . 46olanzapine-fluoxetine. . . . . . . . . . . . . . . . . . . 46olmesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 51olmesartan-amlodipin-hcthiazid. . . . . . . . . . . 51olmesartan-hydrochlorothiazide. . . . . . . . . . . 51olopatadine nasal. . . . . . . . . . . . . . . . . . . . . . 66olopatadine ophthalmic (eye). . . . . . . . . . . . . 91omega-3 acid ethyl esters. . . . . . . . . . . . . . . 55omeprazole oral capsule,delayed release(dr/ec)10 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

omeprazole oral capsule,delayed release(dr/ec)20 mg, 40 mg. . . . . . . . . . . . . . . . . . . . . . . . 77

omeprazole-sodium bicarbonate oral capsule20-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 77

omeprazole-sodium bicarbonate oral capsule40-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 77

omeprazole-sodium bicarbonate oral packet20-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 77

omeprazole-sodium bicarbonate oral packet40-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 77

OMNITROPE. . . . . . . . . . . . . . . . . . . . . . . . . 78ONCASPAR. . . . . . . . . . . . . . . . . . . . . . . . . . 26ondansetron hcl (pf) injection solution. . . . . . 75ondansetron hcl (pf) injection syringe. . . . . . 75ondansetron hcl intravenous. . . . . . . . . . . . . 75ondansetron hcl oral solution. . . . . . . . . . . . . 75ondansetron hcl oral tablet 24 mg. . . . . . . . . 75

129

ondansetron hcl oral tablet 4 mg, 8 mg. . . . . 75ondansetron oral tablet,disintegrating. . . . . . 75ONETOUCH BLOOD GLUCOSE METERS. 70ONETOUCH ULTRA BLUE TEST STRIP. . . 70ONETOUCH VERIO TEST STRIP. . . . . . . . . 70ONIVYDE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ONPATTRO. . . . . . . . . . . . . . . . . . . . . . . . . . 35ONTRUZANT. . . . . . . . . . . . . . . . . . . . . . . . . 26OPDIVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26opium tincture. . . . . . . . . . . . . . . . . . . . . . . . 73OPSUMIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ORALAIR SUBLINGUAL TABLET 300 INDXREACTIVITY. . . . . . . . . . . . . . . . . . . . . . . . . 81

oralone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66ORBACTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 16ORENCIA (WITH MALTOSE). . . . . . . . . . . . 85ORENCIA CLICKJECT. . . . . . . . . . . . . . . . . 85ORENCIA SUBCUTANEOUS SYRINGE 125MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

ORENCIA SUBCUTANEOUS SYRINGE 50MG/0.4 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 85

ORENCIA SUBCUTANEOUS SYRINGE 87.5MG/0.7 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 85

ORENITRAM ORAL TABLET EXTENDEDRELEASE 0.125 MG. . . . . . . . . . . . . . . . . . 51

ORENITRAM ORAL TABLET EXTENDEDRELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG. 51

ORFADIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64ORKAMBI ORAL GRANULES IN PACKET. . 95ORKAMBI ORAL TABLET. . . . . . . . . . . . . . . 95orphenadrine citrate injection. . . . . . . . . . . . . 36orphenadrine citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

orphenadrine-asa-caffeine oral tablet 50-770-60mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

orphengesic forte. . . . . . . . . . . . . . . . . . . . . . 36orsythia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89oseltamivir oral capsule 30 mg. . . . . . . . . . . 11oseltamivir oral capsule 45 mg, 75 mg. . . . . 11oseltamivir oral suspension for reconstitution 11osmitrol 15 %. . . . . . . . . . . . . . . . . . . . . . . . . 51osmitrol 20 %. . . . . . . . . . . . . . . . . . . . . . . . . 51OSMOPREP. . . . . . . . . . . . . . . . . . . . . . . . . . 75

OTEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85OTEZLA STARTER ORAL TABLETS,DOSEPACK 10 MG (4)-20 MG (4)-30 MG (47). . . 85

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 18

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50 ml. . . . . . . . . . . . . . . . 18

oxacillin injection recon soln 1 gram. . . . . . . 18oxacillin injection recon soln 10 gram. . . . . . 19oxacillin injection recon soln 2 gram. . . . . . . 19oxaliplatin intravenous recon soln 100 mg. . . 26oxaliplatin intravenous recon soln 50 mg. . . . 26oxaliplatin intravenous solution. . . . . . . . . . . 26oxandrolone oral tablet 10 mg. . . . . . . . . . . . 71oxandrolone oral tablet 2.5 mg. . . . . . . . . . . 71oxaprozin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42oxazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46OXBRYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 64oxcarbazepine. . . . . . . . . . . . . . . . . . . . . . . . 30OXERVATE. . . . . . . . . . . . . . . . . . . . . . . . . . 91oxiconazole. . . . . . . . . . . . . . . . . . . . . . . . . . 60OXTELLAR XR. . . . . . . . . . . . . . . . . . . . . . . 30oxybutynin chloride oral syrup. . . . . . . . . . . . 97oxybutynin chloride oral tablet. . . . . . . . . . . . 97oxybutynin chloride oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

oxycodone oral capsule. . . . . . . . . . . . . . . . . 40oxycodone oral concentrate. . . . . . . . . . . . . . 40oxycodone oral solution. . . . . . . . . . . . . . . . . 40oxycodone oral tablet. . . . . . . . . . . . . . . . . . . 40OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg. . . . 40

oxycodone-acetaminophen oral tablet 2.5-300mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxycodone-aspirin. . . . . . . . . . . . . . . . . . . . . 40OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR. . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxymorphone oral tablet. . . . . . . . . . . . . . . . 40

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oxymorphone oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

oxytocin injection solution. . . . . . . . . . . . . . . 90OZEMPIC SUBCUTANEOUS PEN INJECTOR0.25 MG OR 0.5 MG(2 MG/1.5 ML). . . . . . . 70

OZEMPIC SUBCUTANEOUS PEN INJECTOR1 MG/DOSE (2 MG/1.5 ML). . . . . . . . . . . . . 70

Ppacerone oral tablet 100 mg, 200 mg, 400mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

paclitaxel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26PADCEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26paliperidone oral tablet extended release 24hr1.5 mg, 3 mg, 6 mg. . . . . . . . . . . . . . . . . . . 46

paliperidone oral tablet extended release 24hr 9mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

palonosetron intravenous solution 0.25 mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

palonosetron intravenous syringe. . . . . . . . . 75PALYNZIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 71pamidronate. . . . . . . . . . . . . . . . . . . . . . . . . . 71PANRETIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 58pantoprazole intravenous. . . . . . . . . . . . . . . 77pantoprazole oral tablet,delayed release (dr/ec)20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

pantoprazole oral tablet,delayed release (dr/ec)40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

paraplatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26PARICALCITOL HEMODIALYSIS PORTINJECTION. . . . . . . . . . . . . . . . . . . . . . . . . . 71

paricalcitol intravenous. . . . . . . . . . . . . . . . . 71PARICALCITOL INTRAVENOUS SOLUTION 2MCG/ML (BRAND) . . . . . . . . . . . . . . . . . . . 72

PARICALCITOL INTRAVENOUS SOLUTION 5MCG/ML (BRAND) . . . . . . . . . . . . . . . . . . . 72

paricalcitol oral. . . . . . . . . . . . . . . . . . . . . . . . 72paroex oral rinse. . . . . . . . . . . . . . . . . . . . . . 66paromomycin. . . . . . . . . . . . . . . . . . . . . . . . . 16paroxetine hcl oral tablet. . . . . . . . . . . . . . . . 46paroxetine hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

paroxetine mesylate(menop.sym). . . . . . . . . 46PARSABIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 72

PASER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16PAXIL ORAL SUSPENSION. . . . . . . . . . . . . 46PEDIARIX (PF). . . . . . . . . . . . . . . . . . . . . . . 81PEDVAX HIB (PF). . . . . . . . . . . . . . . . . . . . . 81peg 3350-electrolytes oral recon soln236-22.74-6.74 -5.86 gram. . . . . . . . . . . . . 75

peg-electrolyte. . . . . . . . . . . . . . . . . . . . . . . . 75PEGANONE. . . . . . . . . . . . . . . . . . . . . . . . . . 30PEGASYS PROCLICK SUBCUTANEOUS PENINJECTOR 180 MCG/0.5 ML. . . . . . . . . . . . 79

PEGASYS SUBCUTANEOUS SOLUTION. . 79PEGASYS SUBCUTANEOUS SYRINGE. . . 79PEGINTRON SUBCUTANEOUS KIT 50MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 79

penicillamine. . . . . . . . . . . . . . . . . . . . . . . . . 85penicillin g potassium injection recon soln 20million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 19

penicillin g potassium injection recon soln 5million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 19

penicillin g procaine. . . . . . . . . . . . . . . . . . . . 19penicillin g sodium. . . . . . . . . . . . . . . . . . . . . 19penicillin v potassium. . . . . . . . . . . . . . . . . . . 19PENTACEL (PF) INTRAMUSCULAR KIT 15 LFUNIT-20 MCG-5 LF/0.5 ML. . . . . . . . . . . . . 81

PENTACEL (PF) INTRAMUSCULAR KIT15LF-48MCG-62DU -10 MCG/0.5ML. . . . . . 81

PENTAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16pentamidine inhalation. . . . . . . . . . . . . . . . . . 16pentamidine injection. . . . . . . . . . . . . . . . . . . 16PENTASA ORAL CAPSULE, EXTENDEDRELEASE 250 MG. . . . . . . . . . . . . . . . . . . . 75

PENTASA ORAL CAPSULE, EXTENDEDRELEASE 500 MG. . . . . . . . . . . . . . . . . . . . 75

pentazocine-naloxone. . . . . . . . . . . . . . . . . . 42pentobarbital sodium injection solution. . . . . 47pentoxifylline oral tablet extended release. . . 54perindopril erbumine. . . . . . . . . . . . . . . . . . . 51periogard. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66PERJETA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27permethrin topical cream. . . . . . . . . . . . . . . . 62perphenazine. . . . . . . . . . . . . . . . . . . . . . . . . 47perphenazine-amitriptyline. . . . . . . . . . . . . . . 47PERSERIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 47pfizerpen-g. . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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phenadoz. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93phenelzine. . . . . . . . . . . . . . . . . . . . . . . . . . . 47phenobarbital. . . . . . . . . . . . . . . . . . . . . . . . . 30phenobarbital sodium injection solution 130mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

phenobarbital sodium injection solution 65mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

phenoxybenzamine. . . . . . . . . . . . . . . . . . . . 51phentolamine injection recon soln. . . . . . . . . 51phenytoin oral suspension 100 mg/4 ml. . . . 31phenytoin oral suspension 125 mg/5 ml. . . . 31phenytoin oral tablet,chewable. . . . . . . . . . . 31phenytoin sodium extended. . . . . . . . . . . . . . 31phenytoin sodium intravenous solution. . . . . 31philith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89PHOSPHOLINE IODIDE. . . . . . . . . . . . . . . . 91PIFELTRO. . . . . . . . . . . . . . . . . . . . . . . . . . . 11pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,4 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

pilocarpine hcl oral. . . . . . . . . . . . . . . . . . . . . 64pimecrolimus. . . . . . . . . . . . . . . . . . . . . . . . . 58pimozide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47pimtrea (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89pindolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52pioglitazone. . . . . . . . . . . . . . . . . . . . . . . . . . 70pioglitazone-glimepiride. . . . . . . . . . . . . . . . . 70pioglitazone-metformin. . . . . . . . . . . . . . . . . 70piperacillin-tazobactam intravenous recon soln13.5 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . 19

piperacillin-tazobactam intravenous recon soln2.25 gram, 3.375 gram, 4.5 gram. . . . . . . . . 19

piperacillin-tazobactam intravenous recon soln40.5 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . 19

PIQRAY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27pirmella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89piroxicam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42plasbumin 25 %. . . . . . . . . . . . . . . . . . . . . . . 98plasbumin 5 %. . . . . . . . . . . . . . . . . . . . . . . . 98plasmanate. . . . . . . . . . . . . . . . . . . . . . . . . . 101PLEGRIDY SUBCUTANEOUS PEN INJECTOR125 MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . 79

PLEGRIDY SUBCUTANEOUS PEN INJECTOR63 MCG/0.5 ML- 94 MCG/0.5 ML. . . . . . . . 79

PLEGRIDY SUBCUTANEOUS SYRINGE. . . 79plenamine. . . . . . . . . . . . . . . . . . . . . . . . . . . 101PNEUMOVAX-23. . . . . . . . . . . . . . . . . . . . . . 81podofilox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58POLIVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27polocaine injection solution 1 % (10 mg/ml). 58polocaine-mpf. . . . . . . . . . . . . . . . . . . . . . . . 58polycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90polyethylene glycol 3350. . . . . . . . . . . . . . . . 75polymyxin b sulf-trimethoprim. . . . . . . . . . . . 90polymyxin b sulfate. . . . . . . . . . . . . . . . . . . . 16POMALYST. . . . . . . . . . . . . . . . . . . . . . . . . . 27portia 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89PORTRAZZA. . . . . . . . . . . . . . . . . . . . . . . . . 27posaconazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

potassium acetate intravenous solution 2meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chlorid-d5-0.45%nacl intravenousparenteral solution 10 meq/l, 30 meq/l, 40meq/l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chlorid-d5-0.45%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 99

potassium chloride in 0.9%nacl intravenousparenteral solution 20 meq/l, 40 meq/l. . . . . 99

potassium chloride in 5 % dex intravenousparenteral solution 20 meq/l, 40 meq/l. . . . . 99

potassium chloride in 5 % dex intravenousparenteral solution 30 meq/l. . . . . . . . . . . . . 99

potassium chloride in lr-d5 intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 99

potassium chloride in lr-d5 intravenousparenteral solution 40 meq/l. . . . . . . . . . . . . 99

potassium chloride in water intravenouspiggyback 10 meq/100 ml. . . . . . . . . . . . . . 99

potassium chloride in water intravenouspiggyback 10 meq/50 ml. . . . . . . . . . . . . . . 99

potassium chloride in water intravenouspiggyback 20 meq/100 ml, 40 meq/100 ml. 99

potassium chloride in water intravenouspiggyback 20 meq/50 ml, 30 meq/100 ml. . 99

potassium chloride intravenous. . . . . . . . . . . 99potassium chloride oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride oral liquid. . . . . . . . . . . . 99

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potassium chloride oral packet. . . . . . . . . . . 99potassium chloride oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

potassium chloride oral tablet,erparticles/crystals. . . . . . . . . . . . . . . . . . . . . 100

potassium chloride-0.45 % nacl. . . . . . . . . . 100potassium chloride-d5-0.2%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . 100

potassium chloride-d5-0.2%nacl intravenousparenteral solution 30 meq/l, 40 meq/l. . . . 100

potassium chloride-d5-0.3%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . 100



potassium citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

potassium phosphate m-/d-basic intravenoussolution 3 mmol/ml. . . . . . . . . . . . . . . . . . . 100

POTELIGEO. . . . . . . . . . . . . . . . . . . . . . . . . 27PRADAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 54PRALUENT SUBCUTANEOUS PEN INJECTOR150 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 55

PRALUENT SUBCUTANEOUS PEN INJECTOR75 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . 55

pramipexole oral tablet. . . . . . . . . . . . . . . . . 32pramipexole oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

prasugrel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54pravastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 55PRAXBIND. . . . . . . . . . . . . . . . . . . . . . . . . . . 54praziquantel. . . . . . . . . . . . . . . . . . . . . . . . . . 16prazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52PRED MILD. . . . . . . . . . . . . . . . . . . . . . . . . . 92prednicarbate. . . . . . . . . . . . . . . . . . . . . . . . . 62prednisolone acetate. . . . . . . . . . . . . . . . . . . 92prednisolone oral solution 15 mg/5 ml. . . . . . 68prednisolone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

prednisolone sodium phosphate oral solution 10mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml(6.7 mg/5 ml). . . . . . . . . . . . . . . . . . . . . . . . 68

prednisolone sodium phosphate oral solution 15mg/5 ml (5 ml). . . . . . . . . . . . . . . . . . . . . . . 68

prednisolone sodium phosphate oraltablet,disintegrating. . . . . . . . . . . . . . . . . . . . 68

prednisone intensol. . . . . . . . . . . . . . . . . . . . 68prednisone oral solution. . . . . . . . . . . . . . . . . 68prednisone oral tablet. . . . . . . . . . . . . . . . . . 68prednisone oral tablets,dose pack. . . . . . . . . 68pregabalin. . . . . . . . . . . . . . . . . . . . . . . . . . . 31PREMARIN INJECTION. . . . . . . . . . . . . . . . 86premasol 10 %. . . . . . . . . . . . . . . . . . . . . . . 101prenatal vitamin oral tablet. . . . . . . . . . . . . . 101PRETOMANID. . . . . . . . . . . . . . . . . . . . . . . . 16prevalite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55previfem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89PREVNAR 13 (PF). . . . . . . . . . . . . . . . . . . . 81PREVYMIS INTRAVENOUS. . . . . . . . . . . . . 11PREVYMIS ORAL. . . . . . . . . . . . . . . . . . . . . 11PREZCOBIX. . . . . . . . . . . . . . . . . . . . . . . . . . 11PREZISTA ORAL SUSPENSION. . . . . . . . . . 11PREZISTA ORAL TABLET 150 MG, 75 MG. 11PREZISTA ORAL TABLET 600 MG, 800 MG 11PRIFTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16PRIMAQUINE. . . . . . . . . . . . . . . . . . . . . . . . 16primaquine (generic). . . . . . . . . . . . . . . . . . . 16primidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31PROAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 95PROAIR RESPICLICK. . . . . . . . . . . . . . . . . . 95probenecid. . . . . . . . . . . . . . . . . . . . . . . . . . . 83probenecid-colchicine. . . . . . . . . . . . . . . . . . 83procainamide injection solution 100 mg/ml. . 48procainamide injection solution 500 mg/ml. . 48PROCALAMINE 3%. . . . . . . . . . . . . . . . . . 101procentra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47prochlorperazine. . . . . . . . . . . . . . . . . . . . . . 75prochlorperazine edisylate injection solution 10mg/2 ml (5 mg/ml). . . . . . . . . . . . . . . . . . . . 75

prochlorperazine edisylate injection solution 5mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

prochlorperazine maleate oral. . . . . . . . . . . . 75procto-med hc. . . . . . . . . . . . . . . . . . . . . . . . 75procto-pak. . . . . . . . . . . . . . . . . . . . . . . . . . . 75proctosol hc topical. . . . . . . . . . . . . . . . . . . . 75

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proctozone-hc. . . . . . . . . . . . . . . . . . . . . . . . 76PROCYSBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 97progesterone. . . . . . . . . . . . . . . . . . . . . . . . . 86progesterone micronized. . . . . . . . . . . . . . . . 86PROGLYCEM. . . . . . . . . . . . . . . . . . . . . . . . . 70PROGRAF INTRAVENOUS. . . . . . . . . . . . . 27PROGRAF ORAL GRANULES IN PACKET. 27PROLASTIN-C INTRAVENOUS RECONSOLN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

PROLASTIN-C INTRAVENOUS SOLUTION 65prolate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40PROLEUKIN. . . . . . . . . . . . . . . . . . . . . . . . . 79PROLIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83PROMACTA. . . . . . . . . . . . . . . . . . . . . . . . . . 54promethazine injection solution. . . . . . . . . . . 93promethazine oral. . . . . . . . . . . . . . . . . . . . . 93promethazine rectal suppository 12.5 mg, 25mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

promethegan. . . . . . . . . . . . . . . . . . . . . . . . . 93propafenone oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

propafenone oral tablet. . . . . . . . . . . . . . . . . 49propantheline. . . . . . . . . . . . . . . . . . . . . . . . . 73propranolol intravenous. . . . . . . . . . . . . . . . . 52propranolol oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

propranolol oral solution. . . . . . . . . . . . . . . . 52propranolol oral tablet. . . . . . . . . . . . . . . . . . 52propranolol-hydrochlorothiazid. . . . . . . . . . . 52propylthiouracil. . . . . . . . . . . . . . . . . . . . . . . . 68PROQUAD (PF). . . . . . . . . . . . . . . . . . . . . . . 81PROSOL 20 %. . . . . . . . . . . . . . . . . . . . . . . 101protamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54protriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 47prudoxin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58pulmosal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95PULMOZYME. . . . . . . . . . . . . . . . . . . . . . . . 95PURIXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27pyrazinamide. . . . . . . . . . . . . . . . . . . . . . . . . 16pyridostigmine bromide oral syrup. . . . . . . . . 36pyridostigmine bromide oral tablet. . . . . . . . . 36pyridostigmine bromide oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

pyrimethamine. . . . . . . . . . . . . . . . . . . . . . . . 16

QQUADRACEL (PF). . . . . . . . . . . . . . . . . . . . . 81QUDEXY XR. . . . . . . . . . . . . . . . . . . . . . . . . 31quetiapine oral tablet. . . . . . . . . . . . . . . . . . . 47quetiapine oral tablet extended release 24 hr 47quinapril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52quinapril-hydrochlorothiazide. . . . . . . . . . . . . 52quinidine gluconate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

quinidine sulfate oral tablet. . . . . . . . . . . . . . 49quinine sulfate. . . . . . . . . . . . . . . . . . . . . . . . 16

RRABAVERT (PF). . . . . . . . . . . . . . . . . . . . . . 81rabeprazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

RADICAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 35RAGWITEK. . . . . . . . . . . . . . . . . . . . . . . . . . 81raloxifene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83ramelteon. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ramipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ranitidine hcl oral syrup. . . . . . . . . . . . . . . . . 78ranitidine hcl oral tablet 150 mg, 300 mg. . . . 78ranolazine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56rasagiline. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32RAVICTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65REBIF (WITH ALBUMIN). . . . . . . . . . . . . . . . 79REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 22 MCG/0.5 ML, 44 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML(6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

REBIF TITRATION PACK. . . . . . . . . . . . . . . 79REBLOZYL. . . . . . . . . . . . . . . . . . . . . . . . . . 79RECARBRIO. . . . . . . . . . . . . . . . . . . . . . . . . 16reclipsen (28). . . . . . . . . . . . . . . . . . . . . . . . . 89RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION 10 MCG/ML, 40 MCG/ML. . 82

RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION 5 MCG/0.5 ML. . . . . . . . . . . 82

134

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 10 MCG/ML. . . . . . . . . . . . . . . . . 82

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 5 MCG/0.5 ML. . . . . . . . . . . . . . . 82

RECTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76regonol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36REGRANEX. . . . . . . . . . . . . . . . . . . . . . . . . . 58RELENZA DISKHALER. . . . . . . . . . . . . . . . . 11RELISTOR ORAL. . . . . . . . . . . . . . . . . . . . . 76RELISTOR SUBCUTANEOUS SOLUTION. . 76RELISTOR SUBCUTANEOUS SYRINGE. . . 76repaglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 70repaglinide-metformin. . . . . . . . . . . . . . . . . . 70RESTASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 91RESTASIS MULTIDOSE. . . . . . . . . . . . . . . . 91RETACRIT INJECTION SOLUTION 10,000UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML,4,000 UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . 79

RETACRIT INJECTION SOLUTION 40,000UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

RETROVIR INTRAVENOUS. . . . . . . . . . . . . 11REVCOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65REVLIMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 27revonto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36REXULTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47REYATAZ ORAL POWDER IN PACKET. . . . 11ribavirin oral capsule. . . . . . . . . . . . . . . . . . . 11ribavirin oral tablet 200 mg. . . . . . . . . . . . . . . 11RIDAURA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85rifabutin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16rifampin intravenous. . . . . . . . . . . . . . . . . . . 16rifampin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 16RIFATER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16riluzole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65rimantadine. . . . . . . . . . . . . . . . . . . . . . . . . . 12ringer's intravenous. . . . . . . . . . . . . . . . . . . 100ringer's irrigation. . . . . . . . . . . . . . . . . . . . . . 63RINVOQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85risedronate oral tablet 150 mg. . . . . . . . . . . . 83risedronate oral tablet 30 mg. . . . . . . . . . . . . 65risedronate oral tablet 35 mg, 35 mg (12 pack),35 mg (4 pack). . . . . . . . . . . . . . . . . . . . . . . 83

risedronate oral tablet 5 mg. . . . . . . . . . . . . . 83

risedronate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

RISPERDAL CONSTA INTRAMUSCULARSUSPENSION,EXTENDED REL RECON 12.5MG/2 ML, 25 MG/2 ML. . . . . . . . . . . . . . . . . 47

RISPERDAL CONSTA INTRAMUSCULARSUSPENSION,EXTENDED REL RECON 37.5MG/2 ML, 50 MG/2 ML. . . . . . . . . . . . . . . . . 47

risperidone oral solution. . . . . . . . . . . . . . . . . 47risperidone oral tablet. . . . . . . . . . . . . . . . . . 47risperidone oral tablet,disintegrating. . . . . . . 47ritonavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12RITUXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27RITUXAN HYCELA. . . . . . . . . . . . . . . . . . . . 27rivastigmine tartrate. . . . . . . . . . . . . . . . . . . . 35rivastigmine transdermal. . . . . . . . . . . . . . . . 35rivelsa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89rizatriptan oral tablet. . . . . . . . . . . . . . . . . . . 33rizatriptan oral tablet,disintegrating. . . . . . . . 33ROMIDEPSIN INTRAVENOUS RECONSOLN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

ROMIDEPSIN INTRAVENOUS SOLUTION. 27ropinirole oral tablet. . . . . . . . . . . . . . . . . . . . 32ropinirole oral tablet extended release 24 hr. 32rosadan topical cream. . . . . . . . . . . . . . . . . . 60rosadan topical gel. . . . . . . . . . . . . . . . . . . . . 60rosuvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . 55ROTARIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82ROTATEQ VACCINE. . . . . . . . . . . . . . . . . . . 82roweepra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31roweepra xr. . . . . . . . . . . . . . . . . . . . . . . . . . 31ROZLYTREK. . . . . . . . . . . . . . . . . . . . . . . . . 27RUBRACA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27RUCONEST. . . . . . . . . . . . . . . . . . . . . . . . . . 95RUXIENCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 27RUZURGI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35RYBELSUS. . . . . . . . . . . . . . . . . . . . . . . . . . 70RYDAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Ssalsalate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42SAMSCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

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SANDOSTATIN LAR DEPOTINTRAMUSCULAR SUSPENSION,EXTENDED REL RECON. . . . . . . . . . . . . . 27

SANTYL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58SAPHRIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47SARCLISA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27scopolamine base. . . . . . . . . . . . . . . . . . . . . 76seconal sodium. . . . . . . . . . . . . . . . . . . . . . . 47SECUADO. . . . . . . . . . . . . . . . . . . . . . . . . . . 47selegiline hcl. . . . . . . . . . . . . . . . . . . . . . . . . 32selenium sulfide topical lotion. . . . . . . . . . . . 57SELZENTRY ORAL SOLUTION. . . . . . . . . . 12SELZENTRY ORAL TABLET 150 MG, 300MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

SELZENTRY ORAL TABLET 25 MG, 75 MG 12SEREVENT DISKUS. . . . . . . . . . . . . . . . . . . 95SEROSTIM SUBCUTANEOUS RECON SOLN4 MG, 5 MG, 6 MG. . . . . . . . . . . . . . . . . . . . 79

sertraline oral concentrate. . . . . . . . . . . . . . . 47sertraline oral tablet. . . . . . . . . . . . . . . . . . . . 47setlakin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89sevelamer carbonate oral powder in packet. 65sevelamer carbonate oral tablet. . . . . . . . . . 65sevelamer hcl. . . . . . . . . . . . . . . . . . . . . . . . . 65sf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66sf 5000 plus. . . . . . . . . . . . . . . . . . . . . . . . . . 66sharobel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86SHINGRIX (PF). . . . . . . . . . . . . . . . . . . . . . . 82SIGNIFOR. . . . . . . . . . . . . . . . . . . . . . . . . . . 27SIGNIFOR LAR. . . . . . . . . . . . . . . . . . . . . . . 27SIKLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27sildenafil (pulmonary arterial hypertension)intravenous solution 10 mg/12.5 ml. . . . . . . 95

sildenafil (pulmonary arterial hypertension) oralsuspension for reconstitution 10 mg/ml. . . . 95

sildenafil (pulmonary arterial hypertension) oraltablet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 96

silodosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97silver sulfadiazine. . . . . . . . . . . . . . . . . . . . . 58simliya (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89simpesse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89SIMPONI ARIA. . . . . . . . . . . . . . . . . . . . . . . 85

SIMPONI SUBCUTANEOUS PEN INJECTOR100 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 85

SIMPONI SUBCUTANEOUS PEN INJECTOR50 MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . 85

SIMPONI SUBCUTANEOUS SYRINGE 100MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

SIMPONI SUBCUTANEOUS SYRINGE 50MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 85

SIMULECT INTRAVENOUS RECON SOLN 10MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

SIMULECT INTRAVENOUS RECON SOLN 20MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

simvastatin oral tablet. . . . . . . . . . . . . . . . . . 55sirolimus oral solution. . . . . . . . . . . . . . . . . . 27sirolimus oral tablet 0.5 mg, 1 mg. . . . . . . . . 27sirolimus oral tablet 2 mg. . . . . . . . . . . . . . . . 27SIRTURO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16SIVEXTRO INTRAVENOUS. . . . . . . . . . . . . 16SIVEXTRO ORAL. . . . . . . . . . . . . . . . . . . . . 16SKYRIZI SUBCUTANEOUS SYRINGE KIT. . 57SMOFLIPID. . . . . . . . . . . . . . . . . . . . . . . . . 101sodium acetate. . . . . . . . . . . . . . . . . . . . . . 100sodium benzoate-sod phenylacet. . . . . . . . . 65sodium bicarbonate intravenous solution 1 meq/ml (8.4 %). . . . . . . . . . . . . . . . . . . . . . . . . . 100

sodium bicarbonate intravenous syringe 10meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml). . . 100

sodium bicarbonate intravenous syringe 8.4 %(1 meq/ml). . . . . . . . . . . . . . . . . . . . . . . . . 100

sodium chlor 0.9% bacteriostat. . . . . . . . . . . 65sodium chloride 0.45 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

sodium chloride 0.9 % (flush) injectionsyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

sodium chloride 0.9 % injection. . . . . . . . . . . 65sodium chloride 0.9 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

sodium chloride 0.9 % intravenous piggyback 65sodium chloride 3 %. . . . . . . . . . . . . . . . . . 100sodium chloride 5 %. . . . . . . . . . . . . . . . . . 100sodium chloride inhalation. . . . . . . . . . . . . . . 96sodium chloride injection. . . . . . . . . . . . . . . . 65sodium chloride intravenous. . . . . . . . . . . . 100sodium chloride irrigation. . . . . . . . . . . . . . . . 65

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sodium fluoride 5000 plus. . . . . . . . . . . . . . . 66sodium nitroprusside. . . . . . . . . . . . . . . . . . . 56sodium phenylbutyrate. . . . . . . . . . . . . . . . . . 65sodium phosphate. . . . . . . . . . . . . . . . . . . . 100sodium polystyrene (sorb free). . . . . . . . . . . 65sodium polystyrene sulfonate oral powder. . . 65solifenacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 97SOLTAMOX. . . . . . . . . . . . . . . . . . . . . . . . . . 27SOMATULINE DEPOT. . . . . . . . . . . . . . . . . . 27SOMAVERT. . . . . . . . . . . . . . . . . . . . . . . . . . 72SORBITOL IRRIGATION. . . . . . . . . . . . . . . . 63sorine oral tablet 120 mg, 160 mg, 80 mg. . . 49sorine oral tablet 240 mg. . . . . . . . . . . . . . . . 49sotalol af. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49sotalol oral. . . . . . . . . . . . . . . . . . . . . . . . . . . 49SOVALDI ORAL TABLET 200 MG. . . . . . . . . 12SOVALDI ORAL TABLET 400 MG. . . . . . . . . 12SPIRIVA RESPIMAT. . . . . . . . . . . . . . . . . . . 96SPIRIVA WITH HANDIHALER. . . . . . . . . . . . 96spironolacton-hydrochlorothiaz. . . . . . . . . . . 52spironolactone. . . . . . . . . . . . . . . . . . . . . . . . 52sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89SPRITAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31SPRYCEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27sps (with sorbitol) oral. . . . . . . . . . . . . . . . . . 65sps (with sorbitol) rectal. . . . . . . . . . . . . . . . . 65sronyx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89ssd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59STAMARIL (PF). . . . . . . . . . . . . . . . . . . . . . . 82stavudine oral capsule. . . . . . . . . . . . . . . . . . 12STELARA INTRAVENOUS. . . . . . . . . . . . . . 57STELARA SUBCUTANEOUS. . . . . . . . . . . . 57STIMATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72STIOLTO RESPIMAT. . . . . . . . . . . . . . . . . . . 96STIVARGA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27STRENSIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 72STREPTOMYCIN. . . . . . . . . . . . . . . . . . . . . . 16STRIBILD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12STRIVERDI RESPIMAT. . . . . . . . . . . . . . . . . 96subvenite. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31subvenite starter (blue) kit. . . . . . . . . . . . . . . 31subvenite starter (green) kit. . . . . . . . . . . . . . 31

subvenite starter (orange) kit. . . . . . . . . . . . . 31SUCRAID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76sucralfate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78sulfacetamide sodium (acne). . . . . . . . . . . . . 60sulfacetamide sodium ophthalmic (eye)drops. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

sulfacetamide sodium ophthalmic (eye)ointment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

sulfacetamide-prednisolone. . . . . . . . . . . . . . 91sulfadiazine. . . . . . . . . . . . . . . . . . . . . . . . . . 20sulfamethoxazole-trimethoprim intravenous. 20sulfamethoxazole-trimethoprim oral. . . . . . . . 20SULFAMYLON TOPICAL CREAM. . . . . . . . 60sulfasalazine oral tablet. . . . . . . . . . . . . . . . . 76sulfasalazine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

sulfatrim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20sulindac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42sumatriptan nasal spray,non-aerosol 20mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 33

sumatriptan nasal spray,non-aerosol 5mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate oral. . . . . . . . . . . . . . . 34sumatriptan succinate subcutaneouscartridge. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate subcutaneous peninjector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan succinate subcutaneous solution 34sumatriptan succinate subcutaneous syringe 6mg/0.5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 34

sumatriptan-naproxen. . . . . . . . . . . . . . . . . . 34SUPRAX ORAL TABLET,CHEWABLE. . . . . 14SUTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27syeda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89SYLATRON SUBCUTANEOUS KIT 200 MCG,300 MCG. . . . . . . . . . . . . . . . . . . . . . . . . . . 79

SYLVANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27SYMBICORT. . . . . . . . . . . . . . . . . . . . . . . . . 96SYMDEKO ORAL TABLETS, SEQUENTIAL100-150 MG (D)/ 150 MG (N). . . . . . . . . . . 96

SYMDEKO ORAL TABLETS, SEQUENTIAL50-75 MG (D)/ 75 MG (N). . . . . . . . . . . . . . 96

SYMFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYMFI LO. . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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SYMLINPEN 120. . . . . . . . . . . . . . . . . . . . . . 70SYMLINPEN 60. . . . . . . . . . . . . . . . . . . . . . . 70SYMPAZAN ORAL FILM 10 MG, 20 MG. . . . 31SYMPAZAN ORAL FILM 5 MG. . . . . . . . . . . 31SYMTUZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYNAGIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12SYNAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 72SYNDROS. . . . . . . . . . . . . . . . . . . . . . . . . . . 76SYNERCID. . . . . . . . . . . . . . . . . . . . . . . . . . . 16SYNJARDY. . . . . . . . . . . . . . . . . . . . . . . . . . . 70SYNJARDY XR. . . . . . . . . . . . . . . . . . . . . . . 70SYNRIBO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27SYNVISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42SYNVISC-ONE. . . . . . . . . . . . . . . . . . . . . . . 42

TTABLOID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27tacrolimus oral. . . . . . . . . . . . . . . . . . . . . . . . 27tacrolimus topical. . . . . . . . . . . . . . . . . . . . . . 59tadalafil (pulmonary arterial hypertension) oraltablet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 96

tadalafil oral tablet 2.5 mg, 5 mg. . . . . . . . . . 97TAFINLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 27TAGRISSO. . . . . . . . . . . . . . . . . . . . . . . . . . . 27TAKHZYRO. . . . . . . . . . . . . . . . . . . . . . . . . . 96TALZENNA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27tamoxifen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27tamsulosin oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

TARGRETIN 1% GEL. . . . . . . . . . . . . . . . . . 27tarina 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 89tarina fe 1-20 eq (28). . . . . . . . . . . . . . . . . . . 89tarina fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 89TASIGNA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27TAVALISSE. . . . . . . . . . . . . . . . . . . . . . . . . . 54tazarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 60tazicef injection recon soln 1 gram. . . . . . . . 14tazicef injection recon soln 2 gram, 6 gram. . 14tazicef intravenous. . . . . . . . . . . . . . . . . . . . . 14TAZORAC TOPICAL CREAM 0.05 %. . . . . . 60TAZORAC TOPICAL GEL. . . . . . . . . . . . . . . 60taztia xt oral capsule, extended release. . . . 52

TAZVERIK. . . . . . . . . . . . . . . . . . . . . . . . . . . 27TDVAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82TECENTRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 27TECFIDERA. . . . . . . . . . . . . . . . . . . . . . . . . . 35TEFLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14TEGSEDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35TEKTURNA HCT. . . . . . . . . . . . . . . . . . . . . . 52telmisartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 52telmisartan-amlodipine. . . . . . . . . . . . . . . . . . 52telmisartan-hydrochlorothiazid. . . . . . . . . . . . 52temazepam. . . . . . . . . . . . . . . . . . . . . . . . . . 47TEMIXYS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12TEMODAR INTRAVENOUS. . . . . . . . . . . . . 28temozolomide. . . . . . . . . . . . . . . . . . . . . . . . . 28temsirolimus. . . . . . . . . . . . . . . . . . . . . . . . . . 28tencon oral tablet 50-325 mg. . . . . . . . . . . . . 40TENIVAC (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 82

TENIVAC (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 82

tenofovir disoproxil fumarate. . . . . . . . . . . . . 12TEPEZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72terazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52terbinafine hcl oral. . . . . . . . . . . . . . . . . . . . . . 9terbutaline. . . . . . . . . . . . . . . . . . . . . . . . . . . 96terconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 86testosterone cypionate intramuscular oil 100mg/ml, 200 mg/ml. . . . . . . . . . . . . . . . . . . . . 72

testosterone cypionate intramuscular oil 200mg/ml (1 ml). . . . . . . . . . . . . . . . . . . . . . . . . 72

testosterone enanthate. . . . . . . . . . . . . . . . . 72testosterone transdermal gel (generic). . . . . 72testosterone transdermal gel in metered-dosepump 10 mg/0.5 gram (Fortesta generic). . . 72

testosterone transdermal gel in metered-dosepump 12.5 mg/ 1.25 gram (1 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

testosterone transdermal gel in metered-dosepump 20.25 mg/1.25 gram (1.62 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

testosterone transdermal gel in packet(Androgel generic). . . . . . . . . . . . . . . . . . . . 72

testosterone transdermal solution in meteredpump w/app (Axiron generic). . . . . . . . . . . . 72

138

TETANUS,DIPHTHERIA TOX PED(PF). . . . 82tetrabenazine. . . . . . . . . . . . . . . . . . . . . . . . . 35tetracycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 21THALOMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 28theophylline oral elixir. . . . . . . . . . . . . . . . . . 96theophylline oral solution. . . . . . . . . . . . . . . . 96theophylline oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

theophylline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

THIOLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65THIOLA EC. . . . . . . . . . . . . . . . . . . . . . . . . . 65thioridazine. . . . . . . . . . . . . . . . . . . . . . . . . . . 47thiotepa injection recon soln 100 mg. . . . . . . 28thiotepa injection recon soln 15 mg. . . . . . . . 28thiothixene. . . . . . . . . . . . . . . . . . . . . . . . . . . 47thyroid (pork) oral tablet 120 mg, 30 mg, 60mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

thyroid (pork) oral tablet 15 mg, 90 mg. . . . . 73tiadylt er. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52tiagabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31TIBSOVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28TICE BCG. . . . . . . . . . . . . . . . . . . . . . . . . . . 82tigecycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 16TIGLUTIK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65tilia fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89timolol maleate ophthalmic (eye) drops. . . . . 91timolol maleate ophthalmic (eye) drops, oncedaily. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

timolol maleate ophthalmic (eye) gel formingsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

timolol maleate oral. . . . . . . . . . . . . . . . . . . . 52tinidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16tis-u-sol pentalyte. . . . . . . . . . . . . . . . . . . . . . 63TIVICAY ORAL TABLET 10 MG. . . . . . . . . . 12TIVICAY ORAL TABLET 25 MG, 50 MG. . . . 12tizanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36TOBI PODHALER INHALATION CAPSULE. 16TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 16

tobramycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 90tobramycin in 0.225 % nacl. . . . . . . . . . . . . . 16tobramycin sulfate injection recon soln. . . . . 17

tobramycin sulfate injection solution. . . . . . . 17tobramycin-dexamethasone. . . . . . . . . . . . . 92tolcapone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32tolmetin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42tolterodine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

tolterodine oral tablet. . . . . . . . . . . . . . . . . . . 97topiramate oral capsule, sprinkle. . . . . . . . . . 31topiramate oral tablet. . . . . . . . . . . . . . . . . . . 31toposar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28topotecan intravenous recon soln. . . . . . . . . 28topotecan intravenous solution. . . . . . . . . . . 28toremifene. . . . . . . . . . . . . . . . . . . . . . . . . . . 28torsemide oral. . . . . . . . . . . . . . . . . . . . . . . . 52TOUJEO MAX U-300 SOLOSTAR. . . . . . . . 70TOUJEO SOLOSTAR U-300 INSULIN. . . . . 70tovet emollient. . . . . . . . . . . . . . . . . . . . . . . . 62TRACLEER ORAL TABLET FORSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 96

tramadol oral tablet 50 mg. . . . . . . . . . . . . . . 42tramadol oral tablet extended release 24 hr. 42tramadol oral tablet, er multiphase 24 hr. . . . 42tramadol-acetaminophen. . . . . . . . . . . . . . . . 42trandolapril. . . . . . . . . . . . . . . . . . . . . . . . . . . 52trandolapril-verapamil oral tablet, ir - er, biphasic24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

tranexamic acid oral. . . . . . . . . . . . . . . . . . . . 86tranylcypromine. . . . . . . . . . . . . . . . . . . . . . . 47travasol 10 %. . . . . . . . . . . . . . . . . . . . . . . . 101travoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . . 92TRAZIMERA. . . . . . . . . . . . . . . . . . . . . . . . . 28trazodone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47TREANDA INTRAVENOUS RECON SOLN. 28TRECATOR. . . . . . . . . . . . . . . . . . . . . . . . . . 17TRELEGY ELLIPTA. . . . . . . . . . . . . . . . . . . . 96TRELSTAR INTRAMUSCULAR SUSPENSIONFOR RECONSTITUTION. . . . . . . . . . . . . . . 28

treprostinil sodium. . . . . . . . . . . . . . . . . . . . . 52tretinoin (antineoplastic). . . . . . . . . . . . . . . . . 28tretinoin microspheres. . . . . . . . . . . . . . . . . . 60tretinoin topical. . . . . . . . . . . . . . . . . . . . . . . . 60tri femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

139

tri-legest fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-lo-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . 89tri-lo-marzia. . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-lo-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-lo-sprintec. . . . . . . . . . . . . . . . . . . . . . . . . 89tri-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-previfem (28). . . . . . . . . . . . . . . . . . . . . . . 89tri-sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . 89tri-vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89tri-vylibra lo. . . . . . . . . . . . . . . . . . . . . . . . . . 89triamcinolone acetonide dental. . . . . . . . . . . 66triamcinolone acetonide injection. . . . . . . . . . 68triamcinolone acetonide topical aerosol. . . . . 62triamcinolone acetonide topical cream. . . . . 62triamcinolone acetonide topical lotion. . . . . . 62triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %. . . . . . . . . . . . . . . . . 62

triamcinolone acetonide topical ointment 0.05%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

triamterene. . . . . . . . . . . . . . . . . . . . . . . . . . . 52triamterene-hydrochlorothiazid oral capsule37.5-25 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 52

triamterene-hydrochlorothiazid oral tablet. . . 52trianex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62triazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47triderm topical cream. . . . . . . . . . . . . . . . . . . 62trientine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65trifluoperazine. . . . . . . . . . . . . . . . . . . . . . . . . 47trifluridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91trihexyphenidyl oral elixir. . . . . . . . . . . . . . . . 33trihexyphenidyl oral tablet. . . . . . . . . . . . . . . 33TRIKAFTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 96trilyte with flavor packets. . . . . . . . . . . . . . . . 76trimethobenzamide oral. . . . . . . . . . . . . . . . . 76trimethoprim. . . . . . . . . . . . . . . . . . . . . . . . . . 21trimipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 47TRINTELLIX. . . . . . . . . . . . . . . . . . . . . . . . . . 47TRISENOX INTRAVENOUS SOLUTION 2MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

TRIUMEQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12trivora (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 89TROGARZO. . . . . . . . . . . . . . . . . . . . . . . . . . 12

TROKENDI XR ORAL CAPSULE,EXTENDEDRELEASE 24HR 100 MG, 25 MG, 50 MG. . 31

TROKENDI XR ORAL CAPSULE,EXTENDEDRELEASE 24HR 200 MG. . . . . . . . . . . . . . . 31

TROPHAMINE 10 %. . . . . . . . . . . . . . . . . . 101TROPHAMINE 6%. . . . . . . . . . . . . . . . . . . . 101trospium oral capsule,extended release 24hr 97trospium oral tablet. . . . . . . . . . . . . . . . . . . . 97TRULICITY. . . . . . . . . . . . . . . . . . . . . . . . . . . 70TRUMENBA. . . . . . . . . . . . . . . . . . . . . . . . . . 82TRUVADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 12TRUXIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28tulana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86TURALIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28TWINRIX (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 82

TYBOST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12tydemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89TYKERB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28TYMLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83TYPHIM VI INTRAMUSCULAR SOLUTION. 82TYPHIM VI INTRAMUSCULAR SYRINGE. . 82TYSABRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35TYVASO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96TYVASO INSTITUTIONAL START KIT. . . . . 96TYVASO REFILL KIT. . . . . . . . . . . . . . . . . . . 96TYVASO STARTER KIT. . . . . . . . . . . . . . . . . 96

UUCERIS RECTAL. . . . . . . . . . . . . . . . . . . . . 76UDENYCA. . . . . . . . . . . . . . . . . . . . . . . . . . . 79unithroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73UNITUXIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 28UPTRAVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52ursodiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76UVADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Vvalacyclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 12VALCHLOR. . . . . . . . . . . . . . . . . . . . . . . . . . 59valganciclovir oral recon soln. . . . . . . . . . . . . 12valganciclovir oral tablet. . . . . . . . . . . . . . . . 12valproate sodium. . . . . . . . . . . . . . . . . . . . . . 31

140

valproic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 31valproic acid (as sodium salt) oral solution 250mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

valproic acid (as sodium salt) oral solution 250mg/5 ml (5 ml), 500 mg/10 ml (10 ml). . . . . 31

valrubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28valsartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52valsartan-hydrochlorothiazide. . . . . . . . . . . . 52VALSTAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28VALTOCO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 1 GRAM/200 ML (BRAND). . 17

VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 500 MG/100 ML, 750 MG/150ML (BRAND). . . . . . . . . . . . . . . . . . . . . . . . 17

VANCOMYCIN IN DEXTROSE ISO-OSM(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

VANCOMYCIN INJECTION (BRAND). . . . . . 17vancomycin intravenous recon soln 1,000 mg,10 gram, 500 mg, 750 mg. . . . . . . . . . . . . . 17

VANCOMYCIN INTRAVENOUS RECON SOLN1.25 GRAM, 1.5 GRAM (BRAND). . . . . . . . 17

VANCOMYCIN INTRAVENOUS RECON SOLN250 MG (BRAND). . . . . . . . . . . . . . . . . . . . 17

vancomycin intravenous recon soln 5 gram. 17vancomycin oral capsule 125 mg. . . . . . . . . 17vancomycin oral capsule 250 mg. . . . . . . . . 17vancomycin oral recon soln. . . . . . . . . . . . . . 17vandazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86VANTAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28VAQTA (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 82VARIVAX (PF). . . . . . . . . . . . . . . . . . . . . . . . 82VARIZIG INTRAMUSCULAR SOLUTION. . . 82VARUBI ORAL. . . . . . . . . . . . . . . . . . . . . . . . 76VECAMYL. . . . . . . . . . . . . . . . . . . . . . . . . . . 56VECTIBIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28VELCADE. . . . . . . . . . . . . . . . . . . . . . . . . . . 28veletri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52velivet triphasic regimen (28). . . . . . . . . . . . . 89VELTASSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 65VEMLIDY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12VENCLEXTA ORAL TABLET 10 MG, 50 MG 28VENCLEXTA ORAL TABLET 100 MG. . . . . . 28VENCLEXTA STARTING PACK. . . . . . . . . . 28

venlafaxine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

venlafaxine oral tablet. . . . . . . . . . . . . . . . . . 47venlafaxine oral tablet extended release 24hr 47VENTAVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 96verapamil intravenous solution. . . . . . . . . . . 52verapamil intravenous syringe. . . . . . . . . . . . 52verapamil oral capsule, 24 hr er pellet ct. . . . 52verapamil oral capsule,ext rel. pellets 24 hr. . 52verapamil oral tablet. . . . . . . . . . . . . . . . . . . 52verapamil oral tablet extended release. . . . . 52VERSACLOZ. . . . . . . . . . . . . . . . . . . . . . . . . 47VERZENIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 28VGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70VIBATIV INTRAVENOUS RECON SOLN 750MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

VIDEX 2 GRAM PEDIATRIC. . . . . . . . . . . . . 12VIDEX EC ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 125 MG. . . . . . . . . . . . . 12

VIEKIRA PAK. . . . . . . . . . . . . . . . . . . . . . . . . 12vienva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89vigabatrin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31vigadrone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31VIIBRYD ORAL TABLET. . . . . . . . . . . . . . . . 47VIIBRYD ORAL TABLETS,DOSE PACK 10 MG(7)- 20 MG (23). . . . . . . . . . . . . . . . . . . . . . 47

VIMIZIM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72VIMPAT INTRAVENOUS. . . . . . . . . . . . . . . . 31VIMPAT ORAL SOLUTION. . . . . . . . . . . . . . 31VIMPAT ORAL TABLET. . . . . . . . . . . . . . . . . 31vinblastine intravenous solution. . . . . . . . . . . 28vincasar pfs intravenous solution 1 mg/ml. . . 28vincristine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28vinorelbine. . . . . . . . . . . . . . . . . . . . . . . . . . . 28viorele (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 89VIRACEPT ORAL TABLET. . . . . . . . . . . . . . 12VIREAD ORAL POWDER. . . . . . . . . . . . . . . 12VIREAD ORAL TABLET 150 MG, 200 MG, 250MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

VISTOGARD. . . . . . . . . . . . . . . . . . . . . . . . . 21VITRAKVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28VIZIMPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . 28volnea (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 89

141

voriconazole intravenous. . . . . . . . . . . . . . . . . 9voriconazole oral. . . . . . . . . . . . . . . . . . . . . . . 9VOSEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12VOTRIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 28VRAYLAR ORAL CAPSULE. . . . . . . . . . . . . 47VRAYLAR ORAL CAPSULE,DOSE PACK. . 47vtol lq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40vyfemla (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89VYNDAMAX. . . . . . . . . . . . . . . . . . . . . . . . . . 56VYNDAQEL. . . . . . . . . . . . . . . . . . . . . . . . . . 56VYXEOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Wwarfarin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54water for inject, bacteriostat. . . . . . . . . . . . . . 65water for irrigation, sterile. . . . . . . . . . . . . . . 65wera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 89wixela inhub. . . . . . . . . . . . . . . . . . . . . . . . . . 96wymzya fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

XXALKORI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XATMEP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XCOPRI MAINTENANCE PACK. . . . . . . . . . 31XCOPRI ORAL TABLET 100 MG, 150 MG, 50MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

XCOPRI ORAL TABLET 200 MG. . . . . . . . . 32XCOPRI TITRATION PACK. . . . . . . . . . . . . . 32XELJANZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85XELJANZ XR. . . . . . . . . . . . . . . . . . . . . . . . . 85XENLETA INTRAVENOUS. . . . . . . . . . . . . . 17XENLETA ORAL. . . . . . . . . . . . . . . . . . . . . . 17XEOMIN INTRAMUSCULAR RECON SOLN100 UNIT, 50 UNIT. . . . . . . . . . . . . . . . . . . . 82

XEOMIN INTRAMUSCULAR RECON SOLN200 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 82

XERMELO. . . . . . . . . . . . . . . . . . . . . . . . . . . 28XGEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21XIFAXAN ORAL TABLET 550 MG. . . . . . . . . 17XOFLUZA ORAL TABLET 20 MG. . . . . . . . . 12XOFLUZA ORAL TABLET 40 MG. . . . . . . . . 12XOLAIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

XOSPATA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XPOVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XTANDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28xulane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86XURIDEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65xylocaine dental-epinephrine. . . . . . . . . . . . . 59XYREM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

YYERVOY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28YF-VAX (PF). . . . . . . . . . . . . . . . . . . . . . . . . 82YONDELIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 28YONSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28YUPELRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96yuvafem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Zzafirlukast. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96zaleplon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ZALTRAP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZANOSAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 29zarah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89ZARXIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79zebutal oral capsule 50-325-40 mg. . . . . . . . 40ZEJULA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZELAPAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZELBORAF. . . . . . . . . . . . . . . . . . . . . . . . . . . 29zenatane. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 10,000-32,000 -42,000UNIT, 15,000-47,000 -63,000 UNIT,20,000-63,000- 84,000 UNIT, 25,000-79,000-105,000 UNIT, 3,000-10,000 -14,000-UNIT,40,000-126,000- 168,000 UNIT, 5,000-17,000-24,000 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . 76

zenzedi oral tablet 10 mg, 5 mg. . . . . . . . . . . 48ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20MG, 30 MG, 7.5 MG (BRAND). . . . . . . . . . . 48

ZEPATIER. . . . . . . . . . . . . . . . . . . . . . . . . . . 12ZERBAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 14zidovudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 12ZIEXTENZO. . . . . . . . . . . . . . . . . . . . . . . . . . 79zileuton oral tablet,extended release 12hrmphase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

142

ZINPLAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 82ziprasidone hcl. . . . . . . . . . . . . . . . . . . . . . . . 48ziprasidone mesylate. . . . . . . . . . . . . . . . . . . 48ZIRABEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZIRGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91ZOLADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 29zoledronic acid intravenous solution. . . . . . . 72zoledronic acid-mannitol-water intravenouspiggyback 4 mg/100 ml. . . . . . . . . . . . . . . . 72

zoledronic acid-mannitol-water intravenouspiggyback 5 mg/100 ml. . . . . . . . . . . . . . . . 65

ZOLINZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29zolmitriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 34zolpidem oral tablet. . . . . . . . . . . . . . . . . . . . 48zolpidem oral tablet,ext release multiphase. . 48zolpidem sublingual. . . . . . . . . . . . . . . . . . . . 48ZOMIG NASAL. . . . . . . . . . . . . . . . . . . . . . . 34zonisamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZORBTIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 79ZORTRESS. . . . . . . . . . . . . . . . . . . . . . . . . . 29ZOSTAVAX (PF). . . . . . . . . . . . . . . . . . . . . . 82zovia 1/35e (28). . . . . . . . . . . . . . . . . . . . . . . 89zumandimine (28). . . . . . . . . . . . . . . . . . . . . 89ZYDELIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZYKADIA ORAL TABLET. . . . . . . . . . . . . . . . 29ZYPREXA RELPREVV. . . . . . . . . . . . . . . . . 48ZYTIGA ORAL TABLET 500 MG. . . . . . . . . . 29

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2020 Formulary

NONDISCRIMINATION NOTICEBlue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

Blue Cross Blue Shield of Massachusetts provides:• Fr ee aids and services to people with disabilities to communicate effectively with us,

such as qualified sign language interpreters and written information in other formats(large print or other formats).

• Fr ee language services to people whose primary language is not English, suchas qualified interpreters and information written in other languages.

If you need these services, contact the Medicare Advantage Appeals and Grievance Manager.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Mondaythrough Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; faxat 617-246-8506; or email at [email protected]. You can file agrievance in person, by mail, fax, or email, or you can call 1-800-200-4255 (TTY: 711).

If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at www.hhs.gov.

144

mailto:MedicareAdvantageRXAppeals%40bcbsma.com?subject=

https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

http://www.hhs.gov

TRANSLATION RESOURCES Proficiency of Language Assistance Services

Translation ResourcesProficiency of Language Assistance Services

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc.,and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Y0014_16110 Accepted 08302016 163136M | 55-1490B (REV 3/17)

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare Contract. Enrollment in Blue Cross andBlue Shield depends upon contract renewal.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate onthe basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.


English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

Chinese/繁體中文: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/االعربية: ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255

.(هاتف الصم والبكم: 711)

Mon-Khmer, Cambodian/ :1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수있습니다. 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

Hindi/ :1-800-200-4255 (TTY: 711)

Gujarati/ :1-800-200-4255 (TTY: 711)


www.bluecrossma.com/medicare-options | Medicare Plan Sales: 1-800-678-2265 (TTY: 711)

April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday

October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with an Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,

disability, sex, sexual orientation, or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

This formulary was updated on 6/01/2020. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31,

8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare-options.

The Formulary may change at any time. You will receive notice when necessary.

®, SM, Registered and Service Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of the medications listed are the property of their respective manufacturers.

© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000508279 55-0650-20 (6/20)



Documents

2020 FORMULARY...Jun 01, 2020 · drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing