Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

Prime Detailed Formulary

Guide

v. 2020-01

Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in

writing by an authorized representative of Universal Rx. v. 2020-01

2

Prime Detailed Formulary Guide The Prime Formulary Guide outlines the tier coverage and suggested limitations of the most commonly prescribed medications. A formulary is the list of drugs available for certain conditions and organized by tiers (cost levels).

Drug Tier Types of Drugs Included Cost

1 Generic Drugs Lowest Copay

2 Preferred Brand Name Drugs Medium Copay

3 Non-Preferred Brand Name Drugs Higher Copay

Limits Description

INJ – Injectable Drug Product is administered via an injectable route of

administration and may be subject to a separate benefit.

QL – Quantity Limit Drug is subject to a specific quantity per days supply due to

patient safety or cost containment measures.

SP – Specialty Program Drug is designated as a specialty drug and may be subject to a

separate specialty benefit.

ST – Step Therapy A more cost-effective option must be tried before a Step

Therapy drug may be covered.

Preferred and non-preferred brand name medications are listed to help identify clinically appropriate and cost-effective options within drug categories. Unless specifically indicated, drug list products will include all dosage forms. This is not an all-inclusive list and does not guarantee coverage. Medications listed may change to a lower tier at any time. Medications may also be moved to non-preferred status twice a year on January 1 and July 1.

A brand-name drug for which a generic product becomes available may be designated as a non-preferred option upon release of the generic product to the market. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. When a medication changes tiers, the member may have to pay a different amount for that medication. The member's specific prescription benefit plan design may not cover certain products or categories regardless of their appearance in this document. For the most up-to-date list call customer service at the toll-free member phone number on the ID card.

Need assistance finding a drug on this formulary guide? An alphabetical index is included at the end of the

formulary listing. You may also press Control + F to search for the product name.

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

3

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

ADDERALL 3

ADDERALL XR 3

ADHANSIA XR 3

ADIPEX-P 3

ADZENYS ER 3

ADZENYS XR-ODT 3

amphetamine sulfate 1

amphetamine/dextroampheta 1

APTENSIO XR 3

armodafinil 1

atomoxetine 1

atomoxetine hydrochloride 1

BELVIQ 3

BELVIQ XR 3

benzphetamine hcl 1

CAFCIT 3 INJ

caffeine cit inj 60mg/3ml 1 INJ

caffeine citrate 1

clonidine hcl er 1

CONCERTA 3

CONTRAVE 3

COTEMPLA XR-ODT 3

DAYTRANA 2

dexmethylphenidate hcl 1

dexmethylphenidate hcl er 1

dexmethylphenidate hydroc 1

dextroamphetamine sulfate 1

diethylpropion hcl 1

diethylpropion hcl er 1

DOPRAM 3 INJ

DYANAVEL XR 2

EVEKEO 3

EVEKEO ODT 3

FOCALIN 3

FOCALIN XR 3

guanfacine er 1

INTUNIV 3

JORNAY PM 3

LOMAIRA 3

methamphetamine hcl 1

METHYLIN 3

METHYLPHENIDATE CAP ER 1

METHYLPHENIDATE TAB ER 3

modafinil 1

MYDAYIS 2

NUVIGIL 3

phendimetraz tab 35mg 1

PHENDIMETRAZ CAP 105MG ER 3

phentermine hcl 1

phentermine hydrochloride 1

PROCENTRA 2

QSYMIA 3

QUILLICHEW ER 2

QUILLIVANT XR 2

RITALIN 3

RITALIN LA 3

SAXENDA 3 INJ

STRATTERA 3

SUNOSI 3

VYVANSE 2

XENICAL 3

zenzedi tab 5mg 1

ZENZEDI TAB 7.5MG 3

Amebicides

SOLOSEC 3

Aminoglycosides

amikacin sulfate 1 INJ

BETHKIS 2 SP

gentamicin sulfate 1 INJ

KITABIS PAK 2 SP

neomycin sulfate 1

paromomycin sulfate 1

TOBI 3 SP

TOBI PODHALER 2 SP

tobramycin 1 SP

tobramycin sulfate 1 INJ

ANALGESICS - ANTI-INFLAMMATORY

ACTEMRA 2 INJ SP

ACTEMRA ACTPEN 2 INJ SP

ARAVA 3

ARTHROTEC 50 3

ARTHROTEC 75 3

CELEBREX 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

4

celecoxib 1

DAYPRO 3

diclofenac potassium 1

diclofenac sodium dr 1

diclofenac sodium er 1

diclofenac sodium/misopro 1

DUEXIS 3

EC-NAPROXEN 3

ENBREL 2 INJ SP

ENBREL MINI 2 INJ SP

ENBREL SURECLICK 2 INJ SP

etodolac 1

etodolac er 1

FELDENE 3

fenoprofen tab 600mg 1

FENOPROFEN CAP 400MG 3

flurbiprofen 1

HUMIRA 2 INJ SP

HUMIRA PEDIATRIC CROHNS D 2 INJ SP

HUMIRA PEN 2 INJ SP

HUMIRA PEN-CD/UC/HS START 2 INJ SP

HUMIRA PEN-PS/UV STARTER 2 INJ SP

ibu 1

ibuprofen 1

ILARIS 2 INJ SP

INDOCIN 3

indomethacin inj 1mg 1 INJ

indomethacin cap 1

indomethacin er 1

indomethacin sr 1

ketoprofen er 1

ketorolac tab 10mg 1 QL

ketorolac tromethamine 1 INJ

KEVZARA 3 INJ SP

KINERET 3 INJ SP

leflunomide 1

meclofenamate sodium 1

mefenamic acid 1

meloxicam 1

MOBIC 3

nabumetone 1

naproxen 1

naproxen dr 1

naproxen sodium 1

naproxen sodium er 1

OLUMIANT 2 SP

ORENCIA 3 INJ SP

ORENCIA CLICKJECT 3 INJ SP

OTEZLA 2 SP

OTREXUP 2 INJ

oxaprozin 1

piroxicam 1

QMIIZ ODT 3

RASUVO 2 INJ

RELAFEN DS 3

RIDAURA 2

RINVOQ 3 SP

SIMPONI INJ 50/0.5ML 3 INJ SP

SIMPONI INJ 100MG/ML 2 INJ SP

SIMPONI ARIA 3 INJ SP

SPRIX 3

sulindac 1

tolmetin sodium 1

VIMOVO 3

XELJANZ 2 SP

XELJANZ XR 2 SP

ZIPSOR 3

ZORVOLEX 3

ANALGESICS - NonNarcotic

bupap 1

butal/apap tab 50-325mg 1

BUTAL/APAP CAP 50-300MG 3

butalbital/acetaminophen/ 1

BUTALBITAL/ASPIRIN/CAFFEI 2

clonidine inj 1 INJ

diflunisal 1

FIORICET 3

FIORINAL 3

PRIALT 2 INJ SP

salsalate 1

TENCON 2

ANALGESICS - OPIOID

acetaminophen/caffeine/di 1

acetaminophen/codeine 1

alfentanil 1 INJ

ALFENTANIL HCL 3 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

5

APADAZ 3

ascomp/codeine 1

BELBUCA 2

BENZHYDROCODONE/ACETAMINO 3

BUNAVAIL 3

BUPRENEX 3 INJ

buprenorphine 1

BUPRENORPHIN DIS 7.5/HR 3

buprenorphin sub 2mg 1

buprenorphin inj 0.3mg/ml 1 INJ

buprenorphine hcl/naloxon 1

buprenorphine hydrochlori 1

but/asa/caf/ cap cod 30mg 1

butorphanol sol 10mg/ml 1 QL

BUTORPHANOL TARTRATE 3 INJ QL

BUTRANS 3

codeine sulfate 1

CONZIP 3

DEMEROL 3 INJ

DOLOPHINE 3

duramorph 1 INJ

endocet 1

fentanyl 1

FENTANYL CITRATE 3 INJ

fentanyl citrate oral tra 1

FIORICET/CODEINE 3

FIORINAL/CODEINE #3 3

hydrocodone bitartrate/ac 1

hydrocodone/acetaminophen 1

hydrocodone/ibuprofen 1

hydromorphone hcl tab 1

hydromorphon inj 4mg/ml 1 INJ

hydromorphon sup 3mg 1

hydromorphone hcl er 1

hydromorphon inj 2mg/ml 1 INJ

hydromorphone hydrochlori 1

HYSINGLA ER 2

INFUMORPH 200 2 INJ

INFUMORPH 500 2 INJ

KADIAN 3

LAZANDA 3

lorcet 1

lorcet hd 1

LORTAB 3

meperidine sol 50mg/5ml 1

meperidine inj 25mg/ml 1 INJ

methadone con 10mg/ml 1

METHADONE SOL 10MG/5ML 2

methadone inj 10mg/ml 1 INJ

METHADOSE 2

MORPHABOND ER 3

morphine sul tab 1

morphine sulfate inj 1 INJ

morphine sul sup 5mg 1

morphine sulfate er 1

MS CONTIN 3

nalbuphine hcl 1 INJ

NORCO 3

NUCYNTA 2

NUCYNTA ER 2

OXAYDO 3

oxycodone hcl 1

OXYCODONE HCL ER 3

oxycodone hydrochloride 1

OXYCODONE HYDROCHLORIDE E 3

oxycodone/acetaminophen 1

oxycodone/ibuprofen 1

OXYCONTIN 2

oxymorphone hydrochloride 1

OXYMORPHONE TAB 5MG ER 3

pentazocine/naloxone hcl 1

PERCOCET 3

PRIMLEV 3

ROXICODONE 3

SUBLOCADE 2 INJ SP

SUBOXONE 2

SUBSYS 3

tramadol hcl 1

tramadol hcl tab 100mg er 1

TRAMADOL HCL CAP ER 100MG 3

tramadol hydrochloride/ac 1

TREZIX 3

TYLENOL/CODEINE #3 3

ULTRAM 3

vicodin es 1

vicodin hp 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

6

XTAMPZA ER 3

ZOHYDRO ER 3

ZUBSOLV 2

ANDROGENS-ANABOLIC

ANDRODERM 2

ANDROGEL 3

ANDROGEL PUMP 3

AVEED 3 INJ SP

danazol 1

DEPO-TESTOSTERONE 3 INJ

METHITEST 2

methyltestosterone 1

oxandrolone 1

TESTIM 3

TESTOPEL 3 INJ SP

testosterone 1

TESTOSTERONE 3

testosterone cypionate 1 INJ

testosterone enanthate 1 INJ

TESTOSTERONE PUMP 3

testosterone topical solu 1

VOGELXO 3

VOGELXO PUMP 3

XYOSTED 3 INJ

ANORECTAL AGENTS

ANALPRAM HC 3

ANALPRAM-HC 3

anucort-hc 1

anusol-hc 1

colocort 1

CORTIFOAM 3

hemmorex-hc 1

hydrocort ene 100mg 1

hydrocort ac sup 25mg 1

hc pramoxine cre 1-1% 1

lidocaine/hc cre 3%-0.5% 1

LIDO-HYDRO GEL 2.8-0.55 2

PROCORT 3

PROCTOFOAM HC 3

procto-med hc 1

proctosol hc 1

proctozone-hc 1

RECTIV 2

UCERIS AER 2MG/ACT 2

Anthelmintics

albendazole 1

BENZNIDAZOLE 2

EMVERM 2

ivermectin tab 3mg 1

praziquantel 1

STROMECTOL 3

ANTIANGINAL AGENTS

ISORDIL TITRADOSE 3

isosorbide dinitrate 1

isosorbide dinitrate sa 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

NITRO-BID 2

NITRO-DUR 3

nitroglycer inj 5mg/ml 1 INJ

nitroglycern sub 1

nitroglycerin er 1

NITROGLYCERIN IN DEXTROSE 2 INJ

nitroglycerin lingual 1

nitroglycerin transdermal 1

NITROMIST 3

NITROSTAT 3

RANEXA 3

ranolazine er 1

ANTIANXIETY AGENTS

alprazolam 1

alprazolam er 1

ALPRAZOLAM INTENSOL 2

alprazolam odt 1

alprazolam xr 1

ATIVAN 3

ATIVAN INJ 2MG/ML 3 INJ

buspirone hcl 1

buspirone hydrochloride 1

chlordiazepoxide hcl 1

chlordiazepoxide hydrochl 1

clorazepate dipotassium 1

diazepam sol 5mg/5ml 1

diazepam 1 INJ

diazepam intensol 1

droperidol 1 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

7

hydroxyzine hcl inj 1 INJ

hydroxyzine hcl tab 1

hydroxyzine pamoate 1

lorazepam 1

lorazepam inj 1 INJ

lorazepam intensol 1

meprobamate 1

oxazepam 1

VALIUM 3

VISTARIL 3

XANAX 3

XANAX XR 3

ANTIARRHYTHMICS

ADENOCARD 3 INJ

adenosine 1 INJ

amiodarone inj 1 INJ

amiodarone hcl 1

amiodarone hydrochloride 1

CORVERT 3 INJ

disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

lidocaine hcl in d5w 1 INJ

mexiletine hcl 1

MULTAQ 3

NORPACE 3

NORPACE CR 3

pacerone 1

procainamide hcl 1 INJ

procainamide hydrochlorid 1 INJ

propafenone hcl 1

propafenone hydrochloride 1

quinidine gluconate cr 1

quinidine sulfate 1

RYTHMOL SR 3

TIKOSYN 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ADVAIR DISKUS 3

ADVAIR HFA 2

AIRDUO RESPICLICK 113/14 3

albuterol tab 1

albuterol neb 1

albuterol sulfate er 1

ALBUTEROL SULFATE HFA 3

ALVESCO 3

aminophylline 1 INJ

ANORO ELLIPTA 2

ARNUITY ELLIPTA 2

ASMANEX HFA 2

ASMANEX TWISTHALER 120 ME 2

ASMANEX TWISTHALER 7 METE 2

ATROVENT HFA 3

BEVESPI AEROSPHERE 2

BREO ELLIPTA 2

BROVANA 3

budesonide sus 1

COMBIVENT RESPIMAT 2

cromolyn sod neb 1

DALIRESP 2

difil-g forte 1

DULERA 2

ELIXOPHYLLIN 2

FASENRA 2 INJ SP

FASENRA PEN 3 INJ SP

FLOVENT DISKUS 2

FLOVENT HFA 2

FLUTICASONE/SALMETEROL INH 2

fluticasone/salmeterol aero 1

INCRUSE ELLIPTA 2

ipratropium bromide 1

ipratropium bromide/albut 1

isoproterenol hydrochlori 1 INJ

ISUPREL 3 INJ

levalbuterol 1

levalbuterol hcl 1

LEVALBUTEROL TARTRATE HFA 3

montelukast sodium 1

NUCALA 2 INJ SP

PERFOROMIST 2

PROAIR HFA 2

PROAIR RESPICLICK 2

PROVENTIL HFA 3

PULMICORT 3

PULMICORT FLEXHALER 2

QVAR REDIHALER 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

8

SEEBRI NEOHALER 3

SEREVENT DISKUS 2

SINGULAIR 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2

SYMBICORT 2

terbutaline sulfate 1

THEO-24 3

THEOCHRON TAB 100MG CR 3

theochron 1

theophylline 1

theophylline cr 1

theophylline er 1

theophylline/d5w 1 INJ

TRELEGY ELLIPTA 2

TUDORZA PRESSAIR 3

VENTOLIN HFA 2

wixela inhub 1

XOLAIR 2 INJ SP

XOPENEX 3

XOPENEX CONCENTRATE 3

XOPENEX HFA 3

YUPELRI 2

zafirlukast 1

ZYFLO 3 ST

ANTICOAGULANTS

bivalirudin 1 INJ SP

BIVALIRUDIN/SODIUM CHLORI 3 INJ SP

COUMADIN 3

ELIQUIS 2

enoxaparin sodium 1 INJ

fondaparinux sodium 1 INJ SP

FRAGMIN 2 INJ SP

heparin lock flush 1 INJ

heparin sodium 1 INJ

heparin sodium/d5w 1 INJ

heparin sodium/nacl 0.9% 1 INJ

jantoven 1

LOVENOX 3 INJ

PRADAXA 3

sash kit for flushing vas 1 INJ

SAVAYSA 3

TRICITRASOL 2

warfarin sodium 1

XARELTO 2

XARELTO STARTER PACK 2

ANTICONVULSANTS

APTIOM 3

BANZEL 2

BRIVIACT 3

carbamazepine 1

carbamazepine er 1

CARBATROL 3

CELONTIN 2

CEREBYX 3 INJ

clobazam 1

clonazepam 1

clonazepam odt 1

DEPACON 3 INJ

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIACOMIT 2 SP

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

DIAZEPAM RECTAL GEL 2

DILANTIN CAP 100MG 3

DILANTIN CAP 30MG 2

DILANTIN INFATABS 3

DILANTIN-125 3

divalproex sodium 1

divalproex sodium dr 1

divalproex sodium er 1

EPIDIOLEX 2 SP

epitol 1

ethosuximide 1

felbamate 1

FELBATOL 3

fosphenytoin sodium 1 INJ

FYCOMPA 2

gabapentin 1

GABITRIL 3

KEPPRA 3

KEPPRA XR 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

9

KLONOPIN 3

LAMICTAL 3

LAMICTAL CHEWABLE DISPERS 3

LAMICTAL ODT 3

LAMICTAL STARTER/NOT TAKI 3

LAMICTAL STARTER/TAKING C 3

LAMICTAL STARTER/TAKING V 3

LAMICTAL XR 3

lamotrigine 1

lamotrigine er 1

lamotrigine odt 1

lamotrigine starter kit/g 1

lamotrigine starter kit/o 1

levetiracetam 1

levetiracetam inj 1 INJ

levetiracetam er 1

LYRICA 3

MYSOLINE 3

NEURONTIN 3

ONFI 3

oxcarbazepine 1

OXTELLAR XR 3

PHENYTEK 3

phenytoin 1

phenytoin sodium 1 INJ

phenytoin sodium extended 1

pregabalin 1

primidone 1

QUDEXY XR 2

roweepra 1

roweepra xr 1

SABRIL 2 SP

subvenite 1

subvenite starter kit/ora 1

SYMPAZAN 3 SP

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hydrochloride 1

TOPAMAX 3

topiramate 1

TOPIRAMATE ER 3

TRILEPTAL 3

TROKENDI XR 3

valproate sodium 1 INJ

valproic acid 1

vigabatrin 1 SP

vigadrone 1 SP

VIMPAT 2 INJ

ZARONTIN 3

ZONEGRAN 3

zonisamide 1

ANTIDEPRESSANTS

amitriptyline hcl 1

amitriptyline hydrochlori 1

amoxapine 1

ANAFRANIL 3

APLENZIN 3 ST

bupropion hcl 1

bupropion tab sr 1

BUPROPION TAB 450MG XL 3

CELEXA 3

citalopram hydrobromide 1

clomipramine hcl 1

CYMBALTA 3

desipramine hcl 1

desipramine hydrochloride 1

desvenlafaxine er 1

DESVENLAFAX TAB 100MG ER 3

doxepin hcl 1

doxepin hydrochloride 1

duloxetine hcl 1

duloxetine hydrochloride 1

EFFEXOR XR 3

EMSAM 3

escitalopram oxalate 1

FETZIMA 2 ST

FETZIMA TITRATION PACK 2 ST

fluoxetine dr 1

fluoxetine hcl 1

FLUOXETINE TAB 60MG 3

fluvoxamine maleate 1

fluvoxamine maleate er 1

FORFIVO XL 3

imipramine hcl 1

imipramine pamoate 1

LEXAPRO 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

10

maprotiline hcl 1

MARPLAN 3

mirtazapine 1

mirtazapine odt 1

NARDIL 3

nefazodone hcl 1

nefazodone hydrochloride 1

NORPRAMIN 3

nortriptyline hcl 1

nortriptyline hydrochlori 1

PAMELOR 3

paroxetine hcl 1

paroxetine hcl er 1

paroxetine hydrochloride 1

PAXIL 3

PAXIL CR 3

phenelzine sulfate 1

PRISTIQ 3

protriptyline hcl 1

PROZAC 3

REMERON 3

REMERON SOLTAB 3

sertraline hcl 1

sertraline hydrochloride 1

SPRAVATO 56MG DOSE 3 SP

SPRAVATO 84MG DOSE 3 SP

TOFRANIL 3

tranylcypromine sulfate 1

trazodone hydrochloride 1

TRINTELLIX 3 ST

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD 2 ST

VIIBRYD STARTER PACK 2 ST

WELLBUTRIN SR 3

WELLBUTRIN XL 3

ZOLOFT 3

ANTIDIABETICS

acarbose 1

ADLYXIN 3 INJ

ADLYXIN STARTER PACK 3 INJ

ADMELOG 3 INJ

ADMELOG SOLOSTAR 3 INJ

AFREZZA 3

ALOGLIPTIN 3 ST

ALOGLIPTIN/METFORMIN HCL 3 ST

ALOGLIPTIN/PIOGLITAZONE 3 ST

AMARYL 3

APIDRA 3 INJ

APIDRA SOLOSTAR 3 INJ

AVANDIA 3

BAQSIMI ONE PACK 3

BASAGLAR KWIKPEN 3 INJ

BYDUREON BCISE 2 INJ

BYDUREON PEN 2 INJ

BYETTA 2 INJ

CYCLOSET 3

FARXIGA 2 ST

FIASP 2 INJ

FIASP FLEXTOUCH 2 INJ

FIASP PENFILL 2 INJ

glimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glipizide/metformin hydro 1

GLUCAGEN HYPOKIT 2 INJ

GLUCAGON EMERGENCY KIT 2 INJ

GLUCOPHAGE 3

GLUCOPHAGE XR 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUMETZA 3

glyburide 1

glyburide micronized 1

glyburide/metformin hydro 1

GLYNASE 3

GLYSET 3

GLYXAMBI 2 ST

HUMALOG 2 INJ

HUMALOG JUNIOR KWIKPEN 2 INJ

HUMALOG KWIKPEN 2 INJ

HUMALOG MIX 50/50 2 INJ

HUMALOG MIX 50/50 KWIKPEN 2 INJ

HUMALOG MIX 75/25 2 INJ

HUMALOG MIX 75/25 KWIKPEN 2 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

11

HUMULIN R U-500 (CONCENTR 2 INJ

HUMULIN R U-500 KWIKPEN 2 INJ

INSULIN LISPRO 3 INJ

INSULIN LISPRO KWIKPEN 3 INJ

INVOKAMET 2 ST

INVOKAMET XR 2 ST

INVOKANA 2 ST

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2

JENTADUETO 2 ST

JENTADUETO XR 2 ST

KOMBIGLYZE XR 3 ST

KORLYM 3 SP

LANTUS 2 INJ

LANTUS SOLOSTAR 2 INJ

LEVEMIR 2 INJ

LEVEMIR FLEXTOUCH 2 INJ

metformin hydrochloride 1

metformin hydrochloride e 1

miglitol 1

MYXREDLIN 3 INJ

nateglinide 1

NESINA 3 ST

NOVOLOG 2 INJ

NOVOLOG FLEXPEN 2 INJ

NOVOLOG MIX 70/30 2 INJ

NOVOLOG MIX 70/30 PREFILL 2 INJ

NOVOLOG PENFILL 2 INJ

ONGLYZA 3 ST

OSENI 3 ST

OZEMPIC 2 INJ

pioglitazone hcl 1

pioglitazone hcl/metformi 1

pioglitazone hcl-glimepir 1

pioglitazone hydrochlorid 1

PROGLYCEM 2

QTERN 3 ST

repaglinide 1

RIOMET 3

RYBELSUS 2

SEGLUROMET 2 ST

SOLIQUA 100/33 2 INJ

STARLIX 3

STEGLATRO 2 ST

STEGLUJAN 3 ST

SYMLINPEN 120 2 INJ

SYMLINPEN 60 2 INJ

SYNJARDY 2 ST

SYNJARDY XR 2 ST

tolbutamide 1

TOUJEO MAX SOLOSTAR 2 INJ

TOUJEO SOLOSTAR 2 INJ

TRADJENTA 2 ST

TRESIBA 2 INJ

TRESIBA FLEXTOUCH 2 INJ

TRULICITY 2 INJ

VICTOZA 2 INJ

XIGDUO XR 2 ST

XULTOPHY 100/3.6 2 INJ

ANTIDIARRHEAL/PROBIOTIC AGENTS

diphenoxylate hydrochlori 1

diphenoxylate/atropine 1

LOMOTIL 3

loperamide hcl 1

MYTESI 3

opium 1

paregoric 1

PRODIGEN 3

RESTORA RX 3

VSL#3 DS 3

ZELAC 3

Antidotes and Specific Antagonists

acetylcysteine 1 INJ

BAL IN OIL 2 INJ

BRIDION 3 INJ

CHEMET 2

CYANOKIT 3 INJ

deferoxamine mesylate 1 INJ SP

DESFERAL 3 INJ SP

DUODOTE 3 INJ

EXJADE 3 SP

flumazenil 1 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

12

fomepizole 1 INJ

JADENU 3 SP

JADENU SPRINKLE 3 SP

methylene blue 1 INJ

naloxone hcl 1 INJ

naltrexone hcl 1

NARCAN 2

PHYSOSTIGMINE SALICYLATE 2 INJ

PRALIDOXIME CHLORIDE 3 INJ

PRAXBIND 3 INJ

PROVAYBLUE 3 INJ

VIVITROL 2 INJ SP

ANTIEMETICS

AKYNZEO 3

ANZEMET 3 QL

aprepitant 1 QL

BONJESTA 3

DICLEGIS 3

doxylamine succinate/pyri 1

dronabinol 1

EMEND 3 QL

EMEND TRIPACK 3 QL

FOSAPREPITANT DIMEGLUMINE 3 INJ

granisetron hcl 1

granisetron inj 1mg/ml 1 INJ

MARINOL 3

meclizine hcl 1

ondansetron hcl 1

ondansetron inj 1 INJ

ondansetron hydrochloride 1

ondansetron odt 1

palonosetron hydrochlorid 1 INJ

SANCUSO 3

scopolamine 1

SYNDROS 3

TRANSDERM SCOP 3

TRANSDERM-SCOP 3

trimethobenzamide hydroch 1

ZOFRAN 3

ZUPLENZ 3

Antifungals

AMBISOME 2 INJ

amphotericin b 1 INJ

ANCOBON 3

CANCIDAS 3 INJ

caspofungin acetate 1 INJ

CRESEMBA INJ 2 INJ SP

CRESEMBA 2 SP

DIFLUCAN 3

ERAXIS 2 INJ

fluconazole 1

fluconazole in nacl 1 INJ

flucytosine 1

griseofulvin microsize 1

griseofulvin ultramicrosi 1

itraconazole 1

ketoconazole tab 1

MYCAMINE 2 INJ

NOXAFIL 2

nystatin tab 1

posaconazole dr 1

terbinafine hcl 1

VFEND 3

VFEND IV 3 INJ

voriconazole 1

voriconazole inj 200mg 1 INJ

ANTIHISTAMINES

carbinoxamine maleate 1

cetirizine hydrochloride 1

CLARINEX 3

clemastine fumarate 1

cyproheptadine hcl 1

cyproheptadine hydrochlor 1

desloratadine 1

desloratadine odt 1

diphenhydramine hcl 1

diphenhydramine inj 1 INJ

KARBINAL ER 3

levocetirizine dihydrochl 1

phenadoz 1

PHENERGAN 3 INJ

promethazine tab 1

promethazine inj 1 INJ

promethazine sup 1

promethazine hcl plain 1

promethazine hydrochlorid 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

13

promethegan 1

RYCLORA 3

RYVENT 3

ANTIHYPERLIPIDEMICS

ANTARA 3

atorvastatin calcium 1

cholestyramine 1

cholestyramine light 1

colesevelam hydrochloride 1

COLESTID 3

colestipol hcl 1

CRESTOR 3

ezetimibe 1

ezetimibe/simvastatin 1

fenofibrate tab 1

FENOFIBRATE CAP 3

fenofibrate micronized 1

fenofibric acid dr 1

FLOLIPID 3 ST

fluvastatin 1

fluvastatin sodium er 1

gemfibrozil 1

LESCOL XL 3

LIPITOR 3

LIPOFEN 2

LIVALO 2 ST

LOPID 3

lovastatin 1

LOVAZA 3

niacin er 1

NIACOR 3

NIASPAN 3

omega-3-acid ethyl esters 1

PRALUENT 2 INJ SP

PRAVACHOL 3

pravastatin sodium 1

QUESTRAN LIGHT 3

REPATHA 2 INJ SP

REPATHA PUSHTRONEX SYSTEM 2 INJ SP

REPATHA SURECLICK 2 INJ SP

rosuvastatin calcium 1

simvastatin 1

TRICOR 3

TRILIPIX 3

VASCEPA 2

VYTORIN 3

WELCHOL 3

ZETIA 3

ZOCOR 3

ZYPITAMAG 3 ST

ANTIHYPERTENSIVES

ACCUPRIL 3

ACCURETIC 3

aliskiren 1

amlodipine besylate/benaz 1

amlodipine besylate/valsa 1

amlodipine/olmesartan med 1

amlodipine/valsartan/hctz 1

amlodipine/valsartan/hydr 1

ATACAND 3

atenolol/chlorthalidone 1

AVALIDE 3

AVAPRO 3

AZOR 3

benazepril hcl 1

benazepril hcl/hydrochlor 1

benazepril hydrochloride 1

benazepril hydrochloride/ 1

BENICAR 3

BENICAR HCT 3

bisoprolol fumarate/hydro 1

candesartan cilexetil 1

candesartan cilexetil/hyd 1

captopril 1

captopril/hydrochlorothia 1

CARDURA 3

CATAPRES 3

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

clonidine tab 0.1mg 1

clonidine dis 0.1/24hr 1

clonidine hydrochloride 1

CORLOPAM 3 INJ

COZAAR 3

DEMSER 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

14

DIOVAN 3

DIOVAN HCT 3

doxazosin mesylate 1

EDARBI 2 ST

EDARBYCLOR 2 ST

enalapril maleate 1

enalapril maleate/hydroch 1

enalaprilat 1 INJ

EPANED 3

eplerenone 1

eprosartan mesylate 1

EXFORGE 3

EXFORGE HCT 3

fosinopril sodium 1

fosinopril sodium/hydroch 1

guanfacine hcl 1

hydralazine hcl 1

hydralazine inj 1 INJ

hydralazine hydrochloride 1

HYZAAR 3

INSPRA 3

irbesartan 1

irbesartan/hydrochlorothi 1

lisinopril 1

lisinopril/hydrochlorothi 1

LOPRESSOR HCT 3

losartan potassium 1

losartan potassium/hydroc 1

LOTENSIN 3

LOTENSIN HCT 3

LOTREL 3

methyldopa 1

methyldopa/hydrochlorothi 1

metoprolol/hydrochlorothi 1

MICARDIS 3

MICARDIS HCT 3

MINIPRESS 3

minoxidil 1

moexipril hcl 1

NITROPRESS 3 INJ

olmesartan medoxomil 1

olmesartan medoxomil/amlo 1

olmesartan medoxomil/hydr 1

perindopril erbumine 1

phenoxybenzamine hydrochl 1

phentolamine mesylate 1 INJ

prazosin hcl 1

prazosin hydrochloride 1

PRINIVIL 3

propranolol/hydrochloroth 1

QBRELIS 3

quinapril hcl 1

quinapril hydrochloride 1

quinapril/hydrochlorothia 1

ramipril 1

sodium nitroprusside 1 INJ

TARKA 3

TEKTURNA 2

TEKTURNA HCT 2

telmisartan 1

telmisartan/amlodipine 1

telmisartan/hydrochloroth 1

terazosin hcl 1

terazosin hydrochloride 1

trandolapril 1

trandolapril/verapamil hc 1

TRIBENZOR 3

TWYNSTA 3

valsartan 1

valsartan/hydrochlorothia 1

VASERETIC 3

VASOTEC 3

ZESTRIL 3

Anti-infective Agents - Misc.

ALINIA 2

atovaquone 1

AZACTAM 3 INJ

bacitracin 1 INJ

CAYSTON 2 SP

CLEOCIN 3

CLEOCIN PEDIATRIC GRANULE 3

CLEOCIN PHOSPHATE 3 INJ

clindamycin hcl 1

clindamycin palmitate hcl 1

clindamycin inj 1 INJ

clindamycin phosphate in 1 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

15

CLINDAMYCIN/SODIUM CHLORI 3 INJ

colistimethate sodium 1 INJ SP

dapsone 1

daptomycin 1 INJ

ertapenem sodium 1 INJ

FIRST-METRONIDAZOLE 100 3

FIRST-METRONIDAZOLE 50 3

FIRVANQ 3

FLAGYL 3

imipenem/cilastatin 1 INJ

INVANZ 3 INJ

LINCOCIN 3 INJ

linezolid 1

linezolid inj 2mg/ml 1 INJ

MEPRON 3

meropenem 1 INJ

MEROPENEM/SODIUM CHLORIDE 2 INJ

MERREM 3 INJ

metronidazole tab 1

metronidazole 1 INJ

metronidazole in nacl 0.7 1 INJ

NEBUPENT 2

pentamidine isethionate 1 INJ

PRIMAXIN IV 3 INJ

SIVEXTRO 3 SP

sulfamethoxazole/trimetho 1

sulfamethoxazole/trimetho 1 INJ

sulfatrim pediatric 1

tinidazole 1

trimethoprim 1

VANCOMYCIN 2 INJ

vancomycin hcl 1 INJ

VANCOMYCIN HCL IN DEXTROS 2 INJ

vancomycin hydrochloride 1

XIFAXAN 2

ZYVOX 3 INJ

Antimalarials

atovaquone/proguanil hcl 1

chloroquine phosphate 1

COARTEM 2

hydroxychloroquine sulfat 1

KRINTAFEL 3

MALARONE 3

mefloquine hcl 1

PLAQUENIL 3

primaquine phosphate 1

QUALAQUIN 3

quinine sulfate 1

Antimyasthenic/Cholinergic Agents

GUANIDINE HCL 2

MESTINON 3

MESTINON TIMESPAN 3

neostigmine methylsulfate 1 INJ

pyridostigmine bromide 1

pyridostigmine bromide er 1

REGONOL 2 INJ

Antimycobacterial Agents

CAPASTAT SULFATE 2 INJ

cycloserine 1

ethambutol hcl 1

ethambutol hydrochloride 1

isoniazid 1

isoniazid inj 1 INJ

MYCOBUTIN 3

PRIFTIN 2

pyrazinamide 1

rifabutin 1

RIFADIN 3

RIFAMATE 3

rifampin 1

rifampin inj 1 INJ

RIFATER 3

TRECATOR 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

abiraterone acetate 1 SP

ADRIAMYCIN 3 INJ SP

adrucil 1 INJ

AFINITOR 2 SP

AFINITOR DISPERZ 2 SP

ALECENSA 2 SP

ALIMTA 2 INJ

anastrozole 1

ARIMIDEX 3

AROMASIN 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

16

ARRANON 2 INJ SP

arsenic trioxide 1 INJ SP

ARZERRA 3 INJ SP

AVASTIN 2 INJ SP

azacitidine 1 INJ SP

BESPONSA 2 INJ SP

bexarotene 1 SP

bicalutamide 1

BICNU 3 INJ SP

bleomycin 1 INJ SP

bleomycin sulfate 1 INJ SP

BOSULIF 2 SP

BRAFTOVI 3 SP

busulfan 1 INJ SP

CABOMETYX 2 SP

CALQUENCE 3 SP

CAMPTOSAR 3 INJ SP

capecitabine 1 SP

CAPRELSA 2 SP

carboplatin 1 INJ

cisplatin 1 INJ

clofarabine 1 INJ SP

CLOLAR 3 INJ SP

CYCLOPHOSPHAMIDE CAP 25MG 2

cyclophosphamide inj 1 INJ

cyclophosphamide 1

CYRAMZA 2 INJ SP

cytarabine 1 INJ

dacarbazine 1 INJ

daunorubicin hcl 1 INJ SP

DAUNORUBICIN HYDROCHLORID 2 INJ SP

DAURISMO 3 SP

decitabine 1 INJ SP

DEPO-PROVERA 2 INJ

dexrazoxane 1 INJ SP

DOXIL 3 INJ SP

doxorubicin hcl 1 INJ SP

doxorubicin hydrochloride 1 INJ SP

ELIGARD 2 INJ SP

ELITEK 2 INJ SP

ELLENCE 3 INJ SP

EMCYT 2 SP

EMPLICITI 3 INJ SP

epirubicin hcl 1 INJ SP

ERIVEDGE 2 SP

erlotinib hydrochloride 1 SP

ETOPOPHOS 2 INJ SP

etoposide 1 INJ SP

exemestane 1

FARYDAK 3 SP

FASLODEX 2 INJ SP

FEMARA 3

floxuridine 1 INJ SP

fludarabine phosphate 1 INJ SP

fluorouracil 1 INJ

flutamide 1

GEMCITABINE 3 INJ SP

gemcitabine hcl 1 INJ SP

GILOTRIF 2 SP

GLEEVEC 3 SP

GLEOSTINE 2 SP

GLIADEL WAFER 3 INJ SP

HERCEPTIN 2 INJ SP

HYCAMTIN CAP 0.25MG 2 SP

HYCAMTIN INJ 4MG 3 INJ SP

HYDREA 3

hydroxyurea 1

IBRANCE 2 SP

IDAMYCIN PFS 3 INJ SP

idarubicin hcl 1 INJ SP

IFEX 3 INJ SP

imatinib mesylate 1 SP

IMBRUVICA 2 SP

IMFINZI 2 INJ SP

INLYTA 2 SP

INTRON A 2 INJ SP

IRESSA 2 SP

irinotecan hcl 1 INJ SP

irinotecan hydrochloride 1 INJ SP

JAKAFI 2 SP

JEVTANA 2 INJ SP

KEYTRUDA 2 INJ SP

KISQALI 3 SP

KISQALI FEMARA 200 DOSE 3 SP

KISQALI FEMARA 400 DOSE 3 SP

KISQALI FEMARA 600 DOSE 3 SP

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

17

KYMRIAH 2 INJ SP

LARTRUVO 3 INJ SP

LENVIMA 12MG DAILY DOSE 2 SP

letrozole 1

leucovorin calcium 1

LEUCOVORIN CALCIUM TAB 10MG 2

leucovorin calcium inj 1 INJ

LEUKERAN 2

leuprolide acetate 1 INJ SP

levoleucovorin 1 INJ SP

levoleucovorin calcium 1 INJ SP

LONSURF 2 SP

LORBRENA 2 SP

LUMOXITI 3 INJ SP

LUPRON DEPOT INJ 3.75MG 2 INJ SP

LUPRON DEPOT INJ 7.5MG 3 INJ SP

LUPRON DEPOT INJ 22.5MG 3 INJ SP

LUPRON DEPOT INJ 11.25MG 2 INJ SP

LUPRON DEPOT INJ 30MG 3 INJ SP

LUPRON DEPOT INJ 45MG 3 INJ SP

LYNPARZA 2 SP

LYSODREN 2 SP

MARQIBO 2 INJ SP

MATULANE 2 SP

megestrol acetate 1

MEKINIST 2 SP

MEKTOVI 3 SP

melphalan hydrochloride 1 INJ SP

mercaptopurine 1 SP

mesna 1 INJ SP

MESNEX INJ 1GM 3 INJ SP

MESNEX TAB 400MG 2 SP

methotrexate 1

methotrexate sodium 1 INJ

mitomycin 1 INJ SP

mitoxantrone hcl 1 INJ SP

MYLOTARG 2 INJ SP

NERLYNX 2 SP

NEXAVAR 2 SP

NINLARO 2 SP

NIPENT 3 INJ SP

ONCASPAR 2 INJ

ONIVYDE 2 INJ

OPDIVO 2 INJ SP

oxaliplatin 1 INJ SP

paclitaxel 1 INJ SP

PERJETA 2 INJ SP

PIQRAY 200MG DAILY DOSE 3 SP

PIQRAY 250MG DAILY DOSE 3 SP

PIQRAY 300MG DAILY DOSE 3 SP

POMALYST 2 SP

PORTRAZZA 3 INJ SP

PROVENGE 2 INJ

PURIXAN 2 SP

QUADRAMET 3 INJ

RITUXAN 2 INJ SP

ROMIDEPSIN 3 INJ SP

RUBRACA 2 SP

RYDAPT 2 SP

SPRYCEL 2 SP

STIVARGA 2 SP

SUTENT 2 SP

SYLATRON 2 INJ SP

TABLOID 3 SP

TAFINLAR 2 SP

TAGRISSO 2 SP

TALZENNA 2 SP

tamoxifen citrate 1

TARCEVA 3 SP

TARGRETIN CAP 3 SP

TASIGNA 2 SP

TAXOTERE 3 INJ SP

TEMODAR CAP 100MG 3 SP

TEMODAR INJ 100MG 2 INJ SP

temozolomide 1 SP

temsirolimus 1 INJ SP

thiotepa 1 INJ SP

TICE BCG 2 INJ

toposar 1 INJ SP

TORISEL 3 INJ SP

TRELSTAR MIXJECT 3 INJ SP

tretinoin cap 10mg 1 SP

TREXALL 3

TYKERB 2 SP

valrubicin 1 INJ SP

VELCADE 2 INJ SP

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

18

VENCLEXTA 2 SP

VENCLEXTA STARTING PACK 2 SP

VERZENIO 2 SP

vinorelbine tartrate 1 INJ SP

VIZIMPRO 2 SP

VOTRIENT 2 SP

XALKORI 2 SP

XELODA 3 SP

XOSPATA 2 SP

XTANDI 2 SP

YERVOY 2 INJ SP

ZALTRAP 2 INJ SP

ZANOSAR 2 INJ SP

ZELBORAF 2 SP

ZINECARD 3 INJ SP

ZOLADEX 2 INJ SP

ZOLINZA 2 SP

ZYKADIA 2 SP

ZYTIGA 2 SP

ANTIPARKINSON AND RELATED THERAPY AGENTS

amantadine hcl 1

APOKYN 2 INJ SP

AZILECT 3

benztropine inj 1mg/ml 1 INJ

benztropine mesylate 1

bromocriptine mesylate 1

carbidopa 1

carbidopa/levodopa 1

carbidopa/levodopa er 1

carbidopa/levodopa odt 1

CARB/LEVO 50 TAB /ENTACAP 2

carb/levo100 tab /entacap 1

COMTAN 3

DUOPA 3 SP

entacapone 1

INBRIJA 2 SP

LODOSYN 3

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

PARLODEL 3

pramipexole dihydrochlori 1

rasagiline mesylate 1

REQUIP XL 3

ropinirole er 1

ropinirole hcl 1

ropinirole hydrochloride 1

RYTARY 3

selegiline hcl 1

selegiline hydrochloride 1

SINEMET 3

SINEMET CR 3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR 3

trihexyphenidyl hcl 1

trihexyphenidyl hydrochlo 1

XADAGO 3

ZELAPAR 3

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ABILIFY 3

ABILIFY MAINTENA 2 INJ

ADASUVE 3

aripiprazole 1

aripiprazole odt 1

ARISTADA 2 INJ SP

ARISTADA INITIO 2 INJ SP

chlorpromazine hcl 1

CHLORPROMAZINE INJ 2 INJ

clozapine 1

CLOZAPINE TAB 150/ODT 3

clozapine odt 1

compro 1

EQUETRO 3

FANAPT 3 ST

FAZACLO 3

fluphenazine decanoate 1 INJ

fluphenazine hcl 1

FLUPHENAZINE HYDROCHLORID 2

GEODON 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

19

haloperidol 1

haloperidol decanoate 1 INJ

haloperidol lactate 1 INJ

INVEGA 3

INVEGA SUSTENNA 3 INJ

INVEGA TRINZA 3 INJ

LATUDA 2 ST

lithium 1

lithium carbonate 1

lithium carbonate er 1

loxapine 1

loxapine succinate 1

olanzapine 1

olanzapine inj 1 INJ

olanzapine odt 1

paliperidone er 1

perphenazine 1

PERSERIS 3 INJ SP

prochlorperazine 1

prochlorperazine edisylat 1 INJ

prochlorperazine maleate 1

quetiapine fumarate 1

quetiapine fumarate er 1

REXULTI 3 ST

RISPERDAL CONSTA 2 INJ

risperidone 1

risperidone odt 1

SAPHRIS 3 ST

SEROQUEL 3

SEROQUEL XR 3

thioridazine hcl 1

thiothixene 1

trifluoperazine hcl 1

trifluoperazine hydrochlo 1

VRAYLAR 3 SP ST

ziprasidone hcl 1

ZYPREXA 3

ZYPREXA RELPREVV 3 INJ

ZYPREXA ZYDIS 3

Antiseptics & Disinfectants

CETYLCIDE-G 2

formaldehyde 1

LUGOLS STRONG IODINE 2

ANTIVIRALS

abacavir 1 SP

abacavir sulfate/lamivudi 1 SP

acyclovir 1

APTIVUS 2 SP

atazanavir sulfate 1 SP

ATRIPLA 3 SP

BARACLUDE 3 SP

BARACLUDE SOL 2 SP

BIKTARVY 2 SP

cidofovir 1 INJ SP

COMPLERA 3 SP

CRIXIVAN 2 SP

DELSTRIGO 3 SP

DESCOVY 2 SP

DOVATO 2 SP

EDURANT 2 SP

efavirenz 1 SP

entecavir 1 SP

EPCLUSA 2 SP

EPIVIR 3

EPIVIR HBV TAB 100MG 3 SP

EPIVIR HBV SOL 5MG/ML 2 SP

EVOTAZ 3 SP

famciclovir 1

fosamprenavir calcium 1 SP

FUZEON 2 INJ SP

GANCICLOVIR 3 INJ SP

GENVOYA 2 SP

HARVONI 2 SP

INTELENCE 2 SP

INVIRASE 2 SP

ISENTRESS 2 SP

ISENTRESS HD 2 SP

JULUCA 2 SP

KALETRA TAB 100-25MG 2 SP

KALETRA SOL 3 SP

lamivudine 1 SP

lamivudine/zidovudine 1 SP

LEDIPASVIR/SOFOSBUVIR 2 SP

lopinavir/ritonavir 1 SP

MAVYRET 2 SP

nevirapine 1 SP

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

20

nevirapine er 1 SP

NORVIR SOL 80MG/ML 2 SP

NORVIR TAB 100MG 3 SP

ODEFSEY 2 SP

oseltamivir phosphate 1 QL

PEGASYS 2 INJ SP

PEGASYS PROCLICK 2 INJ SP

PEGINTRON 3 INJ SP

PIFELTRO 3 SP

PREVYMIS 2 SP

PREZCOBIX 3 SP

PREZISTA 2 SP

RELENZA DISKHALER 3 QL

REYATAZ 3 SP

ribavirin 1 SP

rimantadine hcl 1

ritonavir 1 SP

SELZENTRY 2 SP

SITAVIG 3

SOFOSBUVIR/VELPATASVIR 2 SP

stavudine 1 SP

STRIBILD 3 SP

SUSTIVA 3 SP

SYMTUZA 3 SP

TAMIFLU 3 QL

tenofovir disoproxil fuma 1 SP

TIVICAY 2 SP

TRIUMEQ 2 SP

TRUVADA 2 SP

valacyclovir hcl 1

valacyclovir hydrochlorid 1

VALCYTE 3 SP

valganciclovir 1 SP

valganciclovir hydrochlor 1 SP

VALTREX 3

VEMLIDY 2 SP

VIDEX 2 SP

VIDEX EC 3 SP

VIEKIRA PAK 2 SP

VIRAMUNE 3 SP

VIRAMUNE XR 3 SP

VIRAZOLE 3 SP

VIREAD 3 SP

VOSEVI 2 SP

XOFLUZA 3

ZEPATIER 2 SP

zidovudine 1 SP

BETA BLOCKERS

acebutolol hcl 1

acebutolol hydrochloride 1

atenolol 1

BETAPACE 3

betaxolol tab 1

bisoprolol fumarate 1

BREVIBLOC 3 INJ

BREVIBLOC PREMIXED 3 INJ

BREVIBLOC PREMIXED DOUBLE 3 INJ

BYSTOLIC 2 ST

carvedilol 1

carvedilol phosphate 1

COREG 3

COREG CR 3

CORGARD 3

esmolol hcl 1 INJ

HEMANGEOL 3

INDERAL LA 3

KAPSPARGO SPRINKLE 3 ST

labetalol inj 1 INJ

labetalol hydrochloride 1

LOPRESSOR 3

metoprolol succinate er 1

metoprolol tartrate 1 INJ

metoprolol tartrate tab 1

nadolol 1

pindolol 1

propranolol hcl 1

propranolol hcl er 1

propranolol hydrochloride 1

sotalol hcl 1

sotalol hcl (af) 1

sotalol hcl af 1

sotalol hydrochloride 1

SOTYLIZE 2

TENORMIN 3

timolol maleate 1

TOPROL XL 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

21

Calcium Channel Blockers

amlodipine besylate 1

CALAN 3

CALAN SR 3

CARDENE IV 3 INJ

CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

cartia xt 1

CLEVIPREX 3 INJ

diltiazem tab 1

diltiazem hcl cd 1

diltiazem hcl er 1

diltiazem hydrochloride e 1

DILT-XR CAP 120MG 3

dilt-xr 1

felodipine er 1

ISOPTIN SR 3

isradipine 1

matzim la 1

nicardipine inj 1 INJ

nicardipine cap 1

nifedipine 1

nifedipine er 1

nimodipine 1

nisoldipine er 1

NORVASC 3

NYMALIZE 3

PROCARDIA 3

PROCARDIA XL 3

taztia xt 1

TIAZAC 3

verapamil hcl 1

verapamil hcl er 1

verapamil hcl sa 1

verapamil hcl sr 1

verapamil tab 1

verapamil inj 1 INJ

CARDIOTONICS

digox 1

digoxin 1

digoxin inj 1 INJ

DIGOXIN SOL 50MCG/ML 2

milrinone in dextrose 1 INJ

milrinone lactate 1 INJ

CARDIOVASCULAR AGENTS - MISC.

ADEMPAS 2 SP

alyq 1 SP

ambrisentan 1 SP

amlodipine besylate/atorv 1

BIDIL 3

bosentan 1 SP

CADUET 3

cardioplegic 1 INJ

CAVERJECT 2 INJ QL

CAVERJECT IMPULSE 2 INJ QL

CIALIS 3 QL

CORLANOR 2

EDEX 3 INJ QL

ENTRESTO 2

epoprostenol sodium 1 INJ SP

FLOLAN 2 INJ SP

LETAIRIS 2 SP

LEVITRA 3 QL

MUSE 2 QL

OPSUMIT 2 SP

papaverine hcl 1 INJ

PLEGISOL 3 INJ

REMODULIN 2 INJ SP

REVATIO 3 INJ SP

sildenafil citrate 1 QL

STAXYN 3 QL

STENDRA 3 QL ST

tadalafil 1 QL

treprostinil 1 INJ SP

TYVASO REFILL 2 SP

UPTRAVI 2 SP

vardenafil hydrochloride 1 QL

VELETRI 2 INJ SP

VIAGRA 3 QL

VYNDAMAX 3 SP

VYNDAQEL 2 SP

CEPHALOSPORINS

AVYCAZ 2 INJ

cefaclor 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

22

CEFACLOR SUS 125/5ML 2

cefaclor er 1

cefadroxil 1

cefdinir 1

cefepime 1 INJ

CEFEPIME/DEXTROSE 3 INJ

cefixime 1

cefotaxime sodium 1 INJ

cefotetan 1 INJ

CEFOTETAN/DEXTROSE 3 INJ

cefoxitin sodium 1 INJ

cefpodoxime proxetil 1

cefprozil 1

ceftazidime 1 INJ

CEFTAZIDIME/DEXTROSE 2 INJ

ceftriaxone in iso-osmoti 1 INJ

ceftriaxone sodium 1 INJ

CEFTRIAXONE/DEXTROSE 2 INJ

cefuroxime axetil 1

cefuroxime sodium 1 INJ

CEPHALEXIN TAB 250MG 2

cephalexin 1

KEFLEX 3

MAXIPIME 3 INJ

SUPRAX 3

TAZICEF 3 INJ

TEFLARO 2 INJ

CONTRACEPTIVES

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

amethia 1

amethia lo 1

amethyst 1

apri 1

aranelle 1

ashlyna 1

aubra 1

aubra eq 1

aurovela 1/20 1

aurovela 24 fe 1

aviane 1

azurette 1

BALCOLTRA 3

balziva 1

BEYAZ 3

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camila 1

camrese 1

camrese lo 1

caziant 1

chateal eq 1

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1

daysee 1

deblitane 1

DEPO-PROVERA CONTRACEPTIV 3 INJ

DEPO-SUBQ PROVERA 104 3 INJ

desogestrel/ethinyl estra 1

drospirenone/ethinyl estr 1

elinest 1

ELLA 3

enpresse-28 1

enskyce 1

errin 1

estarylla 1

ESTROSTEP FE 3

ethynodiol diacetate/ethi 1

falmina 1

fayosim 1

femynor 1

GENERESS FE 3

gianvi 1

hailey 24 fe 1

heather 1

introvale 1

isibloom 1

jasmiel 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

23

jencycla 1

jolessa 1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kaitlib fe 1

kariva 1

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

KYLEENA 2

larin 1.5/30 1

larin 1/20 1

larin 24 fe 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 1

lessina 1

levonest 1

levonorgestrel and ethiny 1

levonorgestrel/ethinyl es 1

levora 0.15/30-28 1

LILETTA 3

lillow 1

LO LOESTRIN FE 2

LOESTRIN 1.5/30-21 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

loryna 1

low-ogestrel 1

lo-zumandimine 1

lutera 1

marlissa 1

medroxyprogesterone inj 1 INJ

melodetta 24 fe 1

mibelas 24 fe 1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1

microgestin fe 1.5/30 1

mili 1

MINASTRIN 24 FE 3

MIRCETTE 3

MIRENA 2

mono-linyah 1

NATAZIA 3

necon 0.5/35-28 1

NEXPLANON 2 INJ

nikki 1

nora-be 1

norethindrone 1

norethindrone & ethinyl e 1

norethindrone acetate/eth 1

norethindrone/ethinyl est 1

norgestimate/ethinyl estr 1

norlyda 1

nortrel 0.5/35 (28) 1

nortrel 1/35 1

nortrel 7/7/7 1

NUVARING 2

ocella 1

ogestrel 1

orsythia 1

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN LO 3

ORTHO-NOVUM 1/35-28 3

PARAGARD INTRAUTERINE COP 3

philith 1

pimtrea 1

pirmella 1/35 1

pirmella 7/7/7 1

portia-28 1

previfem 1

QUARTETTE 3

reclipsen 1

rivelsa 1

SAFYRAL 3

SEASONIQUE 3

setlakin 1

sharobel 1

simpesse 1

SKYLA 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

24

SLYND 3

solia 1

sprintec 28 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1/20 1

tarina fe 1/20 eq 1

TAYTULLA 2

tilia fe 1

tri femynor 1

tri-estarylla 1

tri-legest fe 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-sprintec 1

tri-previfem 1

tri-sprintec 1

trivora-28 1

tri-vylibra 1

tri-vylibra lo 1

tulana 1

tydemy 1

velivet 1

vienva 1

viorele 1

vyfemla 1

vylibra 1

wera 1

wymzya fe 1

XULANE 2

YASMIN 28 3

YAZ 3

zarah 1

zovia 1/35e 1

CORTICOSTEROIDS

betamethasone sodium phos 1 INJ

budesonide 1

budesonide er 1

CELESTONE-SOLUSPAN 3 INJ

CONTRAST ALLERGY PREMED P 3

CORTEF 3

CORTISONE ACETATE 2

DEPO-MEDROL 3 INJ

DEXAMETHASONE SOL 0.5/5ML 2

dexamethasone 1

dexamethasone 10-day dose 1

dexamethasone 6-day dose 1

DEXAMETHASONE INTENSOL 2

dexamethasone pho inj 1 INJ

dexpak 10 day 1

dexpak 13 day 1

dexpak 6 day 1

EMFLAZA 3 SP

ENTOCORT EC 3

fludrocortisone acetate 1

hidex 6-day 1

hydrocort tab 5mg 1

KENALOG-10 3 INJ

KENALOG-40 3 INJ

KENALOG-80 3 INJ

MEDROL 3

MEDROL DOSEPAK 3

methylprednisolone 1

methylprednisolone acetat 1 INJ

methylprednisolone dose p 1

methylprednisolone sodium 1 INJ

MILLIPRED 2

MILLIPRED DP 2

prednisolone 1

prednisolone sodium phosp 1

prednisone 1

PREDNISONE SOL 5MG/5ML 2

PREDNISONE INTENSOL 2

RAYOS 3

SOLU-CORTEF 2 INJ

SOLU-MEDROL 3 INJ

taperdex 6-day 1

TAPERDEX 7-DAY 3

triamcinolone acetonide 1 INJ

UCERIS TAB 9MG 3

COUGH/COLD/ALLERGY

acetylcystine sol 1

benzonatate 1

bromfed dm 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

25

bromphen/pseudoephedrine 1

CLARINEX-D 12 HOUR 3

GILTUSS TR 3

hydrocodone bitartrate/ho 1

hydrocodone polistirex/ch 1

hydromet 1

NEBUSAL 3

NEOTUSS PLUS 2

promethazine/codeine 1

promethazine/dextromethor 1

promethazine/phenylephrin 1

SEMPREX-D 3

sodium chlor neb 10% 1

SSKI 3

TESSALON PERLES 3

TUSSICAPS 3

DERMATOLOGICALS

ABSORICA 3

ACANYA 3

acitretin 1 SP

ACUICYN DAILY EYELID & EY 2

acyclovir cream 1

ACZONE 3

adapalene gel 0.1% 1

ADAPALENE SOL 0.1% 3

adapalene pump 1

adapalene/benzoyl peroxid 1

agoneaze 1

AKLIEF 3

AKTIPAK 3

ALA SCALP 3

ALA-QUIN 3

alclometasone dipropionat 1

ALCORTIN A 3

ALLEVYN GENTLE 3

ALTABAX 3

ALTRENO 3

amcinonide 1

ammonium lactate 1

amnesteem 1

ANACAINE 3

APEXICON E 2

arzol silver nitrate app 1

ATOPADERM 3

ATRALIN 3

ATRAPRO ANTIPRURITIC HYDR 3

ATRAPRO CP 3

ATRAPRO DERMAL SPRAY 3

augmented betamethasone d 1

AVAGE 3

AVAR 3

avar cleanser 1

AVAR LS 3

AVAR LS CLEANSER 3

avar-e green 1

AVAR-E LS 3

AVENOVA 3

avita 1

azelaic acid 1

AZELEX 3

BEAU RX 3

BENSAL HP 3

BENZAC AC WASH 3

BENZACLIN WITH PUMP 3

BENZAMYCIN 3

benzepro foaming cloths 1

BENZIQ 3

BENZIQ LS 3

BENZIQ WASH 3

benzoin compound tincture 1

betamethasone dipropionat 1

betamethasone valerate 1

bimatoprost 1

BOTOX COSMETIC 3 INJ SP

bp foam 1

bp wash 1

BPCO 3

BRYHALI 3

calcipotriene 1

calcipotriene/betamethaso 1

calcitriol oin 3mcg/gm 1

CAPEX 3

CARAC 2

CARRASYN HYDROGEL WOUND D 3

celacyn 1

CERACADE 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

26

CERAMAX 3

CETACAINE 3

ciclopirox 1

ciclopirox nail lacquer 1

ciclopirox olamine 1

ciclopirox treatment 1

claravis 1

CLEOCIN-T 3

clindacin etz pledgets 1

CLINDACIN PAC 3

CLINDAGEL 3

clindamycin sol 1% 1

CLINDAMYCIN GEL 1% 3

clindamycin phosphate/ben 1

clindamycin phosphate/tre 1

clindamycin/benzoyl perox 1

clobetasol propionate 1

clobetasol propionate emo 1

CLOBEX 3

CLOCORTOLONE PIVALATE 3

CLODERM 3

clotrimazole sol 1% 1

clotrimazole anti-fungal 1

clotrimazole/betamethason 1

CONDYLOX 3

CORDRAN 3

COSENTYX 2 INJ SP

COSENTYX SENSOREADY PEN 2 INJ SP

crotan 1

c-topical 1

CURITY HYPERTONIC SODIUM 3

CURITY SODIUM CHLORIDE DR 3

CUTIVATE 3

dapsone gel 5% 1

DENAVIR 3

DERMACINRX LEXITRAL PHARM 3

DERMACINRX PHN PAK 3

DERMACINRX ZRM PAK 3

DERMA-SMOOTHE/FS BODY 3

DERMA-SMOOTHE/FS SCALP 3

dermazene 1

desonide 1

DESOWEN 3

desoximetasone 1

DICLOFENAC EPOLAMINE 2

diclofenac gel 1

diclofex dc 1

DIFFERIN 3

diflorasone diacetate 1

DIPROLENE 3

DIPROLENE AF 3

DOXYCYCLINE CAP 40MG 3

DRITHO-CREME HP 2

DRYSOL 3

DUAC 3

DUOBRII 3

DUPIXENT 2 INJ SP

econazole nitrate 1

ECOZA 3 ST

EFUDEX 3

ELETONE TWINPACK 2

ELIDEL 2

ELOCON 3

ENSTILAR 2

ENTTY SPRAY EMULSION 3

EPICERAM 3

EPICYN 3

EPIDUO 3

EPIDUO FORTE 2

EPIFOAM 3

ERTACZO 3 ST

ERY 3

ERYGEL 2

erythromycin gel 2% 1

erythromycin/benzoyl pero 1

ETHYL CHLORIDE/FINE STREA 2

ethyl chloride/mist 1

EUCRISA 3

EURAX 3

EVOCLIN 3

EXELDERM 3 ST

EXODERM 3

EXTINA 3

FABIOR 3

FINACEA GEL 15% 3

FINACEA AER 15% 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

27

FLECTOR 2

fluocinonide 1

FLUOROPLEX 3

fluorouracil cre 5% 1

FLUOROURACIL CRE 0.5% 3

flurandrenolide 1

fluticasone oin 0.005% 1

GEBAUERS SPRAY AND STRETC 3

GENADUR 3

gentamicin oin 0.1% 1

glydo 1

GORDOFILM 3

grafco silver nitrate app 1

halcinonide 1

halobetasol cre 0.05% 1

HALOBETASOL AER 0.05% 3

HALOG 3

HPR PLUS 2

HYCLODEX 3

HYDRO 35 3

HYDRO 40 FOAM 3

hydrocort cre 1% 1

hc pramoxine cre 2.5-1% 1

hc butyrate sol 0.1% 1

hc butyrate cre 0.1% 1

hydrocortisone valerate 1

hydrocortisone/iodoquinol 1

HYDROFERA BLUE FOAM DRESS 3

HYDROFERA BLUE READY FOAM 3

hydroquinone 1

hydroquinone time release 1

HYLATOPIC PLUS 3

HYPOCYN 3

ILUMYA 3 INJ SP

imiquimod 1

IMIQUIMOD PUMP 3

IMPOYZ 3

iodoquinol/hydrocortisone 1

isotretinoin 1

ivermectin cre 1% 1

JUBLIA 3 ST

KAMDOY 3

KENALOG 3

KERALAC 3

KERALYT 3

KERALYT SCALP 3

KERYDIN 3 ST

ketoconazole cream 1

KLARON 3

LAC-HYDRIN 3

LATISSE 3

LAVARE WOUND WASH 3

LEVICYN 3

levicyn dermal spray 1

LEVULAN KERASTICK 3

LEXETTE 3

lidocaine 1

LIDOCAINE AND TETRACAINE 3

lidocaine sol 1

lidocaine hcl jelly 1

lidocaine/prilocaine 1

LIDODERM 3

lidozion 1

lindane 1

livixil pak 1

LOCOID 3

LOCOID LIPOCREAM 3

LOTRISONE 3

LOYON 3

LULICONAZOLE 3 ST

LUXIQ 3

LUZU 3 ST

malathion 1

MENTAX 3

methoxsalen 1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazol gel 1

MICONAZOLE NITRATE/ZINC O 3

MIMYX 3

MIRVASO 2

mometasone oin 0.1% 1

mupirocin 1

myorisan 1

naftifine hcl 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

28

naftifine hydrochloride 1

NAFTIN 3 ST

NATROBA 3

NEOCERA 3

NEOSALUS 3

NEOSALUS CP 3

NEUAC KIT 3

NIVATOPIC PLUS 2

NIZORAL 3

nolix 1

NORITATE 3

NUCORT 3

nudiclo solupak 1

NUTRASEB 3

NUVAIL 3

nyamyc 1

nystatin cre 1

nystatin/triamcinolone 1

nystop 1

OLUX 3

OLUX-E 3

ONEXTON 2

ORACEA 2

OVACE PLUS 3

OVACE PLUS WASH 3

OVACE WASH 3

oxiconazole nitrate 1

OXISTAT 3 ST

OXSORALEN ULTRA 3

PANDEL 3

PENLAC NAIL LACQUER 3

PENNSAID 3

permethrin 1

PICATO 2

PICO SINGLE USE NEGATIVE 3

pimecrolimus 1

PLEXION 3

PLEXION CLEANSER 3

PODOCON 25 IN BENZOIN TIN 3

podofilox 1

PRAMOSONE 3

prednicarbate 1

PRESERA 3

PROMISEB 3

PROPECIA 3

PROTOPIC 3

PSORCON 3

PYROGALLIC ACID 3

QBREXZA 2

RECEDO 2

RECURA 3

REGENECARE 3

REGRANEX 2

RENOVA 3

RETIN-A 3

RETIN-A MICRO 3

RETIN-A MICRO PUMP 3

RHOFADE 3

RIAX 3

ROSADAN KIT 3

SALEX 3

salicylic acid 1

salicylic acid cream 1

salicylic acid er 1

salicylic acid lotion 1

salicylic acid wart remov 1

SALVAX 2

SALVAX DUO PLUS 3

SANTYL 2

selenium sulfide 1

selenium sulfide shampoo 1

SELRX 3

SERNIVO 3

SILIQ 3 INJ SP

SILVADENE 3

SILVER NITRATE 2

silver sulfadiazine 1

SKLICE 3

SKYRIZI 2 INJ SP

sodium sulfacetamide sham 10% 1

sodium sulfacetamide wash 1

SOD SUL/SULF EMU 10-5% 2

sod sul/sulf liq wash 1

SOOLANTRA 2

SORIATANE 3 SP

SORILUX 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

29

SPINOSAD 2

ssd 1

sss 10%-5% 1

STELARA 2 INJ SP

sulfacetamide sodium 1

sulfacetamide sodium/sulf 1

sulfacleanse 8/4 1

SUMADAN WASH 3

SUVICORT 3

SYNERA 3

TACLONEX 2

tacrolimus oin 0.1% 1

TALTZ 2 INJ SP

TARGRETIN GEL 1% 2 SP

tazarotene 1

TAZORAC GEL 0.1% 2

TAZORAC CRE 0.1% 3

TEMOVATE 3

TETRIX 3

TEXACORT 3

THERAHONEY 3

tl hydroquinone 1

TOLAK 3

TOPICORT 3

TREMFYA 2 INJ SP

tretinoin gel 0.01% 1

tretinoin microsphere 1

tretinoin microsphere pum 1

triamcinolon cre 0.5% 1

TRIANEX 2

TRI-CHLOR 2

TRIDESILON 3

TRI-LUMA 3

ULESFIA 3

ULTRAVATE 3

urea 1

urea nail 1

UTOPIC 3

VALCHLOR 2 SP

VANIQA 3

vanoxide-hc 1

VECTICAL 3

VELTIN 3

VENELEX 3

VERDESO 3

VEREGEN 3

VEXASYN 3

VOLTAREN 3

VUSION 3

VYTONE 3

XALIX 3

XEPI 3

XERAC AC 3

XERALUX 3

XERESE 3

XEROFORM NON-OCCLUSIVE OI 2

XEROFORM OCCLUSIVE PETROL 2

XOLEGEL 3 ST

XOLEGEL COREPAK 3

XOLEGEL DUO/HEAD & SHOULD 3

XOLEGEL DUO/XOLEX 3

XRYLIX 3

zenatane 1

ZIANA 3

ZITHRANOL 3

ZONALON 3

ZOVIRAX OIN 5% 3

ZOVIRAX CRE 5% 2

ZTLIDO 2

ZYCLARA 3

ZYCLARA PUMP 3

DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS

CAMINO PRO 15PE 3

CAMINO PRO PKU 2

CEREFOLIN 3

CEREFOLIN NAC 3

DEPLIN 15 3

DEPLIN 7.5 3

ELFOLATE 3

ENLYTE 3

ENTERAGAM 3

folbic 1

FOLBIC RF 3

FOLTANX RF 3

FOLTX 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

30

GLYTACTIN BETTERMILK 15 2

GLYTACTIN BETTERMILK DE-L 2

GLYTACTIN BUILD 10PE 3

GLYTACTIN BUILD 20/20 PKU 3

GLYTACTIN COMPLETE 10PE 3

GLYTACTIN RESTORE 10 3

GLYTACTIN RESTORE 5 3

GLYTACTIN RESTORE LITE 10 3

GLYTACTIN RTD 10 3

GLYTACTIN RTD 15 3

GLYTACTIN RTD LITE 15 3

GLYTACTIN SWIRL 15PE 3

HOMACTIN AA PLUS 3

ISOVACTIN AA PLUS 3

KETOVIE 3

KETOVIE PEPTIDE 3

LEVOMEFOLATE CALCIUM ALGA 3

LEVOMEFOLATE CALCIUM/N-AC 3

LEVOMEFOLATE CALCIUM/PYRI 3

L-METHYL-B6-B12 2

L-METHYLFOLATE 2

L-METHYLFOLATE CA/S-ALGAL 3

L-METHYLFOLATE FORTE 3

L-METHYL-MC NAC 2

METANX 3

NICAPRIN 3

niva-fol 1

PHENACTIN AA PLUS 3

PODIAPN 3

PROMACTIN AA PLUS 20PE 3

RHEUMATE 3

TL-ICARE 3

TYLACTIN BUILD 20PE TYR 3

TYLACTIN COMPLETE 15 PE 3

TYLACTIN RESTORE 10 3

TYLACTIN RESTORE 5PE 3

TYLACTIN RTD 15 3

VASCAZEN 3

VASCULERA 3

VILACTIN AA PLUS 3

VISBIOME 3

XYZBAC 3

ZYVEXOL 3

ZYVIT 3

DIGESTIVE AIDS

CREON 2

PANCREAZE 3

PERTZYE 3

SUCRAID 2 SP

VIOKACE 2

ZENPEP 2

DIURETICS

acetazolamide 1

acetazolamide er 1

acetazolamide sodium 1 INJ

ALDACTAZIDE 3

ALDACTONE 3

amiloride hcl 1

amiloride/hydrochlorothia 1

bumetanide tab 1

bumetanide inj 1 INJ

BUMEX 3

CAROSPIR 3

chlorothiazide 1

chlorothiazide sodium 1 INJ

chlorthalidone 1

DIURIL 3

DYAZIDE 3

DYRENIUM 3

EDECRIN 3

ethacrynic acid 1

furosemide 1

furosemide inj 1 INJ

hydrochlorothiazide 1

indapamide 1

LASIX 3

mannitol 1 INJ

MAXZIDE 3

MAXZIDE-25 3

methazolamide 1

metolazone 1

SODIUM EDECRIN 3 INJ

spironolactone 1

spironolactone/hydrochlor 1

torsemide 1

triamterene 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

31

triamterene/hydrochloroth 1

ENDOCRINE AND METABOLIC AGENTS - MISC.

ACTHAR 3 INJ SP

ACTONEL 3

alendronate sodium 1

ALENDRONATE TAB 40MG 2

AMMONUL 3 INJ SP

ATELVIA 3

BINOSTO 3 ST

BONIVA 3

cabergoline 1

calcitonin-salmon 1

calcitriol 1

calcitriol inj 1 INJ

CARNITOR 3

CARNITOR SF 3

CETROTIDE 2 INJ

chorionic gonadotropin 1 INJ SP

cinacalcet hydrochloride 1 SP

clomiphene citrate 1

CYSTADANE 2 SP

desmopressin inj 1 INJ

desmopressin acetate 1

desmopressin spr 0.01% 1

doxercalciferol 1 SP

etidronate disodium 1

EVISTA 3

FABRAZYME 2 INJ SP

FOLLISTIM AQ 3 INJ SP

FORTEO 2 INJ SP

FOSAMAX 3

FOSAMAX PLUS D 3 ST

GALAFOLD 3 SP

GENOTROPIN 2 INJ SP

GENOTROPIN MINIQUICK 2 INJ SP

GONAL-F 2 INJ SP

GONAL-F RFF REDIJECT 2 INJ SP

HUMATROPE 2 INJ SP

HUMATROPE COMBO PACK 2 INJ SP

ibandronate inj 1 INJ SP

ibandronate sodium 1

INCRELEX 2 INJ SP

KANUMA 2 INJ SP

KUVAN 2 SP

levocarnitine 1

LUMIZYME 2 INJ SP

LUPANETA PACK 2 SP

LUPRON DEPOT-PED (1-MONTH 2 INJ SP

LUPRON DEPOT-PED (3-MONTH 2 INJ SP

MENOPUR 2 INJ SP

nitisinone 1 SP

NORDITROPIN FLEXPRO 2 INJ SP

NOVAREL 2 INJ

NUTROPIN AQ NUSPIN 10 3 INJ SP

NUTROPIN AQ NUSPIN 20 3 INJ SP

NUTROPIN AQ NUSPIN 5 3 INJ SP

octreotide acetate 1 INJ SP

OMNITROPE 3 INJ SP

ORILISSA 2

OSPHENA 3

OVIDREL 2 INJ SP

PALYNZIQ 2 INJ SP

paricalcitol inj 1 INJ SP

paricalcitol 1 SP

PREGNYL W/DILUENT BENZYL 3 INJ SP

PROLIA 3 INJ SP

raloxifene hydrochloride 1

RAYALDEE 3

RECLAST 3 INJ SP

risedronate sodium 1

risedronate sodium dr 1

ROCALTROL 3

SANDOSTATIN 3 INJ SP

SANDOSTATIN LAR DEPOT 3 INJ SP

SENSIPAR 3 SP

SIGNIFOR 2 INJ SP

SIGNIFOR LAR 3 INJ SP

sodium phenylacetate/sodi 1 INJ SP

SOMATULINE DEPOT 2 INJ SP

SOMAVERT 2 INJ SP

STIMATE 2 SP

STRENSIQ 2 INJ SP

SUPPRELIN LA 3 INJ SP

SYNAREL 2 SP

TRIPTODUR 2 INJ SP

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

32

TYMLOS 2 INJ SP

XGEVA 2 INJ SP

ZEMPLAR 3 INJ SP

zoledronic acid 1 INJ SP

ZOMACTON 3 INJ SP

Estrogens

ALORA 3

amabelz 1

ANGELIQ 3

BI-EST 50:50 COMPOUNDING 3

BI-EST 50:50 PROGESTERONE 3

BI-EST 80:20 PROGESTERONE 3

BIJUVA 3

CLIMARA 3

CLIMARA PRO 3

COMBIPATCH 2

covaryx 1

covaryx hs 1

DELESTROGEN 3 INJ

DEPO-ESTRADIOL 2 INJ

DIVIGEL 2

dotti 1

DUAVEE 2

eemt 1

eemt hs 1

ELESTRIN 3

esterified estrogens/meth 1

ESTRACE TAB 3

estradiol 1

estradiol valerate 1 INJ

estradiol/norethindrone a 1

ESTRIOL-PROGESTERONE COMP 3

ESTROGEL 3

EVAMIST 3

FEMHRT LOW DOSE 3

fyavolv 1

jinteli 1

lopreeza 1

MENEST 3

MENOSTAR 3

mimvey 1

mimvey lo 1

MINIVELLE 3

PREMARIN 2 INJ

PREMPHASE 2

PREMPRO 2

VIVELLE-DOT 3

Fluoroquinolones

BAXDELA 3

CIPRO 3

ciprofloxacin hcl 1

ciprofloxacin i.v.-in d5w 1 INJ

levofloxacin 1

levofloxacin inj 1 INJ

levofloxacin in d5w 1 INJ

moxifloxacin tab 1

ofloxacin 1

GASTROINTESTINAL AGENTS - MISC.

ACTIGALL 3

alosetron hydrochloride 1

AMITIZA 3

APRISO 3

ASACOL HD 3

AURYXIA 3

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

calcium acetate 1

CANASA 3

CIMZIA 3 INJ SP

CIMZIA STARTER KIT 3 INJ SP

cromolyn sodium 1

DELZICOL 3

DIPENTUM 3

ENTYVIO 2 INJ SP

enulose 1

FOSRENOL 3

GASTROCROM 3

generlac 1

INFLECTRA 3 INJ SP

lanthanum carbonate 1

LIALDA 3

LINZESS 2

mesalamine 1

mesalamine dr 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

33

metoclopramide hcl 1

metoclopramide inj 1 INJ

metoclopramide hydrochlor 1

METOCLOPRAMIDE ODT 2

MOTEGRITY 3

MOVANTIK 2

OCALIVA 2 SP

PENTASA 2

RELISTOR TAB 2 SP QL

RELISTOR INJ 2 INJ SP QL

REMICADE 2 INJ SP

RENAGEL 3

RENFLEXIS 3 INJ SP

RENVELA 3

ROWASA 3

sevelamer carbonate 1

sevelamer hydrochloride 1

SFROWASA 3

SIMETHICONE 3

STELARA INJ 5MG/ML 3 INJ SP

sulfasalazine 1

sulfazine 1

SYMPROIC 2

TRULANCE 2

ursodiol 1

VELPHORO 2 SP

VIBERZI 2

ZELNORM 3

GENERAL ANESTHETICS

AMIDATE 3 INJ

desflurane 1

etomidate 1 INJ

FORANE 2

ketamine hcl 1 INJ

propofol 1 INJ

sevoflurane 1

SUPRANE 3

ULTANE 3

GENITOURINARY AGENTS - MISCELLANEOUS

acetic acid 0.25% 1

alfuzosin hcl er 1

aminoacetic acid 1

argyle sterile saline 100 1

AVODART 3 QL

CARDURA XL 3

curity sterile saline 1

CYSTAGON 2 SP

dutasteride 1 QL

dutasteride/tamsulosin hc 1

ELMIRON 2

finasteride 1

FLOMAX 3

glycine 1

JALYN 3

K-PHOS NO 2 3

LITHOSTAT 3

ORACIT 3

phenazo 1

phenazopyridine hcl 1

phenazopyridine hydrochlo 1

potassium citrate er 1

potassium citrate/citric 1

PROSCAR 3

PYRIDIUM 3

RAPAFLO 3

RENACIDIN 2

RIMSO-50 3 INJ

silodosin 1

sodium chloride 0.9% 1

sodium citrate/citric aci 1

SORBITOL 3

SORBITOL-MANNITOL 3

tamsulosin hydrochloride 1

taron-crystals 1

THIOLA 3 SP

THIOLA EC 3 SP

tricitrates 1

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

Gout Agents

allopurinol 1

allopurinol sodium 1 INJ

COLCHICINE 3

COLCRYS 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

34

febuxostat 1

MITIGARE 2

probenecid 1

probenecid/colchicine 1

ULORIC 3 ST

ZYLOPRIM 3

HEMATOLOGICAL AGENTS - MISC.

ADVATE 2 INJ SP

ADYNOVATE 2 INJ SP

AGGRASTAT 3 INJ

AGGRENOX 3

anagrelide hydrochloride 1

aspirin/dipyridamole er 1

BRILINTA 2

CEPROTIN 2 INJ SP

cilostazol 1

clopidogrel 1

dipyridamole 1

EFFIENT 3

ELOCTATE 2 INJ SP

eptifibatide 1 INJ

FIRAZYR 2 INJ SP

flexbumin 1 INJ

HEMLIBRA 2 INJ SP

HEMOFIL M 2 INJ SP

HESPAN 3 INJ

hetastarch 6%/nacl 1 INJ

HEXTEND 2 INJ

icatibant acetate 1 INJ SP

INTEGRILIN 3 INJ

JIVI 2 INJ SP

KENGREAL 3 INJ

KOGENATE FS 2 INJ SP

KOVALTRY 2 INJ SP

LMD 10% DEXTROSE 5% 2 INJ

LMD 10% SODIUM CHLORIDE 0 2 INJ

MONONINE 2 INJ SP

NOVOEIGHT 2 INJ SP

NOVOSEVEN RT 2 INJ SP

OBIZUR 2 INJ SP

pentoxifylline er 1

plasbumin-25 1 INJ

plasbumin-5 1 INJ

PLASMANATE 2 INJ

PLAVIX 3

prasugrel 1

REBINYN 3 INJ SP

RECOMBINATE 3 INJ SP

RETAVASE 3 INJ SP

RETAVASE HALF-KIT 3 INJ SP

RIXUBIS 3 INJ SP

SOLIRIS 2 INJ SP

TAKHZYRO 3 INJ SP

THROMBATE III 2 INJ SP

THROMBATE III W/20 ML STE 2 INJ SP

TRETTEN 2 INJ SP

ULTOMIRIS 3 INJ SP

VOLUVEN 2 INJ

VONVENDI 2 INJ

ZONTIVITY 3

HEMATOPOIETIC AGENTS

ACTIVE FE 3

airavite 1

ANIMI-3 3

ARANESP ALBUMIN FREE 2 INJ SP

CENFOL 3

CENTRATEX 2

chromagen 1

corvita 150 1

CORVITE FE 3

cyanocobalamin 1 INJ

DOPTELET 2 SP

DROXIA 2

ELELYSO 3 INJ SP

EPOGEN 3 INJ SP

fabb 1

FERAHEME 2 INJ

FERIVA 21/7 3

FERIVAFA 3

ferocon 1

ferotrinsic 1

FERRALET 90 3

FERRAPLUS 90 2

FERRLECIT 3 INJ SP

folbee 1

FOLGARD RX 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

35

folic acid 1

folic acid/vitamin b-6/vi 1

FOLIVANE-F 2

FOLIVANE-PLUS 2

foltrin 1

FULPHILA 3 INJ SP

FUSION PLUS 3

GENICIN VITA-D 3

hematinic/folic acid 1

HEMATOGEN FA 2

hematogen forte 1

HEMATRON-AF 3

hemocyte-f 1

hydroxocobalamin 1 INJ

INFED 2 INJ

INJECTAFER 3 INJ

INTEGRA F 3

INTEGRA PLUS 3

IROSPAN 24/6 3

LEUKINE 2 INJ SP

miglustat 1 SP

MOZOBIL 2 INJ SP

MULPLETA 3 SP

MULTIGEN 2

MULTIGEN PLUS 2

NASCOBAL 2

NEPHRON FA 3

NEULASTA 2 INJ SP

NEULASTA ONPRO KIT 2 INJ SP

NEUPOGEN 2 INJ SP

NIVESTYM 2 INJ SP

NPLATE 2 INJ SP

NUFERA 3

ORTHO DF 3

poly-iron 150 forte 1

polysaccharide iron forte 1

PROCRIT 2 INJ SP

PROMACTA 2 SP

RETACRIT 3 INJ SP

se-tan plus 1

sodium ferric gluconate c 1 INJ SP

TALIVA 3

TARON FORTE 2

tl gard rx 1

tl icon 1

tl-hem 150 1

trigels-f forte 1

UDENYCA 2 INJ SP

VENOFER 2 INJ SP

virt-gard 1

VPRIV 3 INJ SP

ZARXIO 2 INJ SP

HEMOSTATICS

AMICAR 2

aminocaproic acid 1 INJ

aminocaproic acid 1

CYKLOKAPRON 3 INJ

GEL-FLOW 3

MONSELS FERRIC SUBSULFATE 2

TISSEEL 3

tranexamic acid inj 1 INJ

tranexamic acid 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

AMBIEN 3 QL

AMBIEN CR 3 QL

AMYTAL SODIUM 2 INJ

BELSOMRA 3 QL ST

BUTISOL SODIUM 3

dexmedetomidine hcl 1 INJ

dexmedetomidine hydrochlo 1 INJ

DORAL 3

EDLUAR 3 QL ST

estazolam 1

eszopiclone 1 QL

flurazepam hcl 1

HALCION 3 QL

LUNESTA 3 QL

midazolam hcl 1

midazolam inj 1 INJ

midazolam hydrochloride 1 INJ

pentobarbital sodium 1 INJ

phenobarbital 1

PHENOBARB INJ 65MG/ML 2 INJ

phenobarb inj 130mg/ml 1 INJ

PRECEDEX 3 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

36

QUAZEPAM 3

ramelteon 1 QL ST

RESTORIL 3

ROZEREM 3 QL ST

SECONAL SODIUM 2

SILENOR 3 ST

temazepam 1

triazolam 1 QL

zaleplon 1 QL

zolpidem tartrate 1 QL

zolpidem tartrate er 1 QL

LAXATIVES

CLENPIQ 2

COLYTE-FLAVOR PACKS 3

constulose 1

gavilyte-c 1

gavilyte-n/flavor pack 1

GOLYTELY 3

KRISTALOSE 3

lactulose 1

MOVIPREP 3

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

peg 3350/electrolytes 1

peg-3350/electrolytes 1

peg-3350/nacl/na bicarbon 1

PLENVU 3

PREPOPIK 2

SUPREP BOWEL PREP KIT 2

trilyte 1

LOCAL ANESTHETICS-Parenteral

bupivacaine hcl 1 INJ

bupivacaine spinal 1 INJ

bupivacaine/epinephrine 1 INJ

chloroprocaine hydrochlor 1 INJ

CLOROTEKAL 3 INJ

DURASAFE SPINAL/EPIDURAL 3 INJ

lidocaine inj 1 INJ

LIDOCAINE HCL/DEXTROSE 2

lidocaine/epinephrine 1 INJ

MARCAINE 3 INJ

MARCAINE SPINAL 3 INJ

MARCAINE/EPINEPHRINE 3 INJ

MONOJECT BONE MARROW BIOP 3 INJ

ropivacaine 1 INJ

ropivacaine hcl 1 INJ

sensorcaine-mpf 1 INJ

tetracaine hcl 1 INJ

XYLOCAINE 3 INJ

XYLOCAINE-MPF 3 INJ

MACROLIDES

azithromycin 1

AZITHROMYCIN POW 1GM PAK 2

clarithromycin 1

clarithromycin er 1

DIFICID 3

e.e.s. 400 1

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3

ery-tab 1

ERYTHROCIN LACTOBIONATE 2 INJ

ERYTHROCIN STEARATE 2

erythromycin cap 1

erythromycin base 1

erythromycin dr 1

erythromycin ethylsuccina 1

ZITHROMAX 3 INJ

MEDICAL DEVICES AND SUPPLIES

CAYA 3

FEMCAP 2

RAPPORT RING LOADING SYST 2

RAPPORT VACUUM THERAPY DE 2

REMESENSE 3

WIDE-SEAL SILICONE DIAPHR 3

Migraine Products

AIMOVIG 2 INJ QL

ST

AJOVY 2 INJ QL

ST

almotriptan 1 QL

almotriptan malate 1 QL

AMERGE 3 QL

CAFERGOT 3

CAMBIA 3 QL

dihydroergotamine mesylat 1 INJ QL

DIHYDROERGOTAMINE SPR 2 QL ST

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

37

eletriptan hydrobromide 1 QL

EMGALITY 2 INJ ST

ERGOMAR 3

ergotamine tartrate/caffe 1

frovatriptan succinate 1 QL

IMITREX 3 QL

IMITREX STATDOSE REFILL 3 INJ QL

IMITREX STATDOSE SYSTEM 3 INJ QL

MAXALT 3 QL

MAXALT-MLT 3 QL

MIGRANAL 3 QL ST

naratriptan hcl 1 QL

ONZETRA XSAIL 3 QL ST

RELPAX 3 QL

rizatriptan benzoate 1 QL

rizatriptan benzoate odt 1 QL

sumatriptan 1 QL

sumatriptan inj 1 INJ QL

sumatriptan succinate 1 QL

SUMATRIPTAN INJ 6MG/0.5 3 INJ QL

sumatriptan succinate ref 1 INJ QL

sumatriptan/naproxen sodi 1 QL

TREXIMET 3 QL

ZEMBRACE SYMTOUCH 3 INJ QL

ST

zolmitriptan 1 QL

zolmitriptan odt 1 QL

ZOMIG 3 QL

ZOMIG SPR 5MG 2 QL ST

MINERALS AND ELECTROLYTES

bd posiflush 1 INJ

CALCIFOL 3

calcium chloride 1 INJ

calcium gluconate 1 INJ

COPPER TRACE METAL 2 INJ

DEXTROSE 10%/NACL 0.45% 2 INJ

DEXTROSE 5% 2 INJ

dextrose 10%/nacl 0.2% 1 INJ

dextrose 2.5%/nacl 0.45% 1 INJ

dextrose 5%/lactated ring 1 INJ

dextrose 5%/nacl 0.2% 1 INJ

dextrose 5%/nacl 0.225% 1 INJ

dextrose 5%/nacl 0.3% 1 INJ

dextrose 5%/nacl 0.33% 1 INJ

dextrose 5%/nacl 0.45% 1 INJ

dextrose 5%/nacl 0.9% 1 INJ

DEXTROSE/SODIUM CHLORIDE 2 INJ

effer-k 1

EFFER-K TAB 20MEQ 3

FLUORABON 3

fluoride 1

fluoritab 1

GALZIN 3

HYPERLYTE-CR 3 INJ

iodine strong 1

IONOSOL-MB/DEXTROSE 5% 2 INJ

ISOLYTE-P/DEXTROSE 5% 2 INJ

ISOLYTE-S 2 INJ

ISOLYTE-S PH 7.4 2 INJ

kcl 0.075%/d5w/nacl 0.45% 1 INJ

kcl 0.15%/d5w/nacl 0.2% 1 INJ

kcl 0.15%/d5w/nacl 0.225% 1 INJ

kcl 0.15%/d5w/nacl 0.45% 1 INJ

kcl 0.15%/d5w/nacl 0.9% 1 INJ

kcl 0.3%/d5w/nacl 0.45% 1 INJ

KCL 0.3%/D5W/NACL 0.9% 2 INJ

klor-con 1

klor-con 10 1

klor-con 8 1

klor-con m10 1

KLOR-CON M15 2

klor-con m20 1

klor-con sprinkle 1

klor-con/ef 1

K-PHOS 2

K-PHOS NEUTRAL 2

k-prime 1

K-TAB TAB 20MEQ 3

K-TAB 2

lactated ringers 1 INJ

LACTATED RINGERS VIAFLEX 3 INJ

ludent 1

nafrinse 1

nafrinse drops 1

NEUT 2 INJ

normal saline flush 1 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

38

NORMOSOL -R 3 INJ

NORMOSOL-M IN D5W 2 INJ

NORMOSOL-R 2 INJ

NORMOSOL-R IN D5W 2 INJ

phospha 250 neutral 1

phospho-trin 250 neutral 1

PLASMA-LYTE A 2 INJ

PLASMA-LYTE-148 2 INJ

potassium acetate 1 INJ

potassium chloride 1

potassium chloride cr 1

potassium chloride er 1

potassium chloride sr 1

potassium chloride/sodium 1 INJ

potassium phosphate 1 INJ

ringers injection 1 INJ

selenium 1 INJ

sodium bicarbonate 1 INJ

sod chloride inj 0.9% 1 INJ

sodium chloride 0.45% 1 INJ

sodium chloride flush 1 INJ

sodium fluoride 1

sodium phosphate 1 INJ

TPN ELECTROLYTES 3 INJ

TRACE ELEMENTS 4/PEDIATRI 2 INJ

virt-phos 250 neutral 1

ZINC SULFATE 2 INJ

Miscellaneous Therapeutic Classes

alprostadil 1 INJ

AMPHADASE 3 INJ

argyle sterile water 100m 1

ASTAGRAF XL 3 SP

ATGAM 2 INJ SP

AZASAN 3 SP

AZATHIOPRINE INJ 2 INJ SP

azathioprine 1

BENLYSTA 2 INJ SP

CELLCEPT 3 SP

CELLCEPT INTRAVENOUS 3 INJ SP

CUPRIMINE 3 SP

cyclosporine inj 1 INJ

cyclosporine 1

CYCLOSPORINE CAP 50MG MOD 2

cyclosporine cap 25mg mod 1

DEPEN TITRATABS 2 SP

DIANEAL LOW CALCIUM/1.5% 3 INJ

DIANEAL LOW CALCIUM/2.5% 3 INJ

DIANEAL LOW CALCIUM/4.25% 3 INJ

DIANEAL PD-2/1.5% DEXTROS 3 INJ

DIANEAL PD-2/2.5% DEXTROS 3 INJ

DIANEAL PD-2/4.25% DEXTRO 3 INJ

D-PENAMINE 2 SP

ENVARSUS XR 3 SP

EXTRANEAL 2 INJ

gengraf 1

HYLENEX 3 INJ

IMURAN 3

kionex 1

lactated ringers irrigati 1

LOKELMA 2

mycophenolate mofetil 1 SP

mycophenolate inj 1 INJ SP

mycophenolic acid dr 1 SP

MYFORTIC 3 SP

NEORAL 3

NEXAVIR 3 INJ

NULOJIX 2 INJ SP

penicillamine 1 SP

physiolyte 1

physiosol irrigation 1

PRISMASOL B22GK 4/0 3 INJ

PRISMASOL BGK 0/2.5 3 INJ

PRISMASOL BGK 2/0 3 INJ

PRISMASOL BGK 2/3.5 3 INJ

PRISMASOL BGK 4/2.5 3 INJ

PRISMASOL BK 0/0/1.2 3 INJ

PROGRAF CAP 3 SP

PROGRAF GRA 0.2MG 2 SP

PROGRAF INJ 2 INJ SP

PROSTIN VR PEDIATRIC 3 INJ

RAPAMUNE 3 SP

REVLIMID 2 SP

ringers irrigation 1

SANDIMMUNE INJ 3 INJ

SANDIMMUNE 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

39

SIMULECT 2 INJ SP

sirolimus 1 SP

sodium polystyrene sulfon 1

sps 1

sterile water irrigation 1

SYPRINE 3 SP

tacrolimus cap 1 SP

TRAUMANIL 3

trientine hydrochloride 1 SP

ULTRABAG/DIANEAL LOW CALC 3 INJ

ULTRABAG/DIANEAL PD-2/1.5 3 INJ

ULTRABAG/DIANEAL PD-2/2.5 3 INJ

ULTRABAG/DIANEAL PD-2/4.2 3 INJ

VELTASSA 3

VITRASE 3 INJ

XIAFLEX 2 INJ SP

ZORTRESS 2 SP

MOUTH/THROAT/DENTAL AGENTS

AQUORAL 3

ARESTIN 3

CAPHOSOL 3

cevimeline hcl 1

chlorhexidine gluconate 1

clinpro 5000 1

clotrimazole troche 10mg 1

DEBACTEROL 3

denta 5000 plus 1

dentagel 1

FIRST-MOUTHWASH BLM 2

lidocaine viscous 1

NAFRINSE DAILY/ACIDULATED 3

NAFRINSE DAILY/NEUTRAL 3

NAFRINSE WEEKLY 3

NEUTRASAL 3

NUMOISYN 3

nystatin susp 1

paroex 1

pilocarpine tab 1

pilocarpine hydrochloride 1

PREVIDENT 5000 BOOSTER PL 3

PREVIDENT 5000 DRY MOUTH 3

PREVIDENT 5000 ENAMEL PRO 3

PREVIDENT 5000 PLUS 3

PREVIDENT FLUORIDE 3

PREVIDENT RINSE 3

SALIVAMAX 3

sf 1

sf 5000 plus 1

topex topical anesthetic 1

triamcinolone acetonide d 1

XEROSTOMIA RELIEF SPRAY 3

MULTIVITAMINS

ADVANCED AM/PM 2

BACMIN 3

b-plex 1

b-plex plus 1

CITRANATAL ASSURE 3

CITRANATAL B-CALM 3

CITRANATAL BLOOM 3

CITRANATAL BLOOM DHA 3

CITRANATAL DHA 3

CITRANATAL HARMONY 3

CITRANATAL MEDLEY 3

CITRANATAL RX 3

C-NATE DHA 2

complete natal dha 1

completenate 1

co-natal fa 1

CONCEPT DHA 3

CORVITA 3

dialyvite 1

DIALYVITE 3000 3

DIALYVITE 5000 3

DIALYVITE SUPREME D 3

DIALYVITE/ZINC 2

DUET DHA BALANCED 3

elite-ob 1

ENBRACE HR 3

FLORIVA PLUS 3

folbee plus 1

FOLGARD OS 3

FOLIVANE-OB 2

hylavite 1

MARNATAL-F 3

M-NATAL PLUS 3

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

40

multivitamin with fluorid 1

MULTIVIT/FL CHW 0.5MG 3

MULTIVIT/FL CHW 0.25MG 2

multi-vitamin/fluoride dr 1

multi-vitamin/fluoride/ir 1

m-vit 1

NATELLE ONE 3

NEEVO DHA 3

NEPHRO-VITE RX 2

NESTABS ONE 3

NICOMIDE 3

OB COMPLETE 3

OB COMPLETE ONE 3

OB COMPLETE PETITE 3

OB COMPLETE/DHA 3

OBSTETRIX DHA 2

obstetrix ec 1

OBSTETRIX ONE 3

O-CAL FA 3

O-CAL PRENATAL 3

PNV PRENATAL TAB PLUS 2

PRENATAL PLS MIS MV + DHA 3

PNV TABS 29-1 2

pnv-dha 1

PNV-DHA+DOCUSATE 2

PNV-OMEGA 2

POLY-VI-FLOR 3

POLY-VI-FLOR FS 3

POLY-VI-FLOR/IRON 3

PRENA1 CHEW 2

PRENA1 PEARL 2

PRENATA 3

prenatabs rx 1

PRENATAL 2

prenatal 19 1

PRENATAL LOW IRON 3

PRENATAL PLUS IRON 2

PRENATAL PLUS/IRON 3

PRENATAL VITAMINS PLUS LO 2

PRENATAL-U 2

PRENATE 3

PRENATE DHA 3

PRENATE ELITE 3

PRENATE ENHANCE 3

PRENATE MINI 3

PRENATE PIXIE 3

PREPLUS 2

PROVIDA OB 3

QUFLORA FE 3

QUFLORA FE PEDIATRIC 3

QUFLORA GUMMIES 3

QUFLORA PEDIATRIC 3

RELNATE DHA 2

renal caps 1

reno caps 1

SELECT-OB 3

SELECT-OB+DHA 3

se-natal 19 1

SIDEROL 3

STROVITE FORTE 3

STROVITE ONE 3

SUPERVITE 3

SUPPORT 2

SUPPORT-500 3

TARON-BC 2

TARON-C DHA 2

TARON-PREX 2

THRIVITE RX 3

TL FOLATE 3

TL G-FOL OS 2

TL-CARE DHA 2

TL-FLUORIVITE 2

TL-SELECT 2

trinatal rx 1 1

triphrocaps 1

TRISTART DHA 3

TRISTART ONE 3

TRI-TABS DHA 2

TRIVEEN-DUO DHA 2

TRI-VI-FLOR 3

TRI-VI-FLORO 3

tri-vitamin/fluoride 1

ultimatecare one 1

v-c forte 1

VENA-BAL DHA 2

VINATE M 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

41

vinate one 1

virt-caps 1

VIRT-PN DHA 2

VITAFOL 3

VITAFOL FE+ 3

VITAFOL GUMMIES 3

VITAFOL STRIPS 3

VITAFOL ULTRA 3

VITAFOL-NANO 3

VITAFOL-OB 3

VITAFOL-OB+DHA 3

VITAFOL-ONE 3

VITAMEDMD ONE RX/QUATREFO 3

VITAMEDMD REDICHEW RX 3

vitamins a/c/d/fluoride 1

VITAPEARL 3

VITATRUE 3

vol-care rx 1

VOL-NATE 2

VOL-PLUS 2

VOL-TAB RX 2

VP-PNV-DHA 3

ZATEAN-PN DHA 2

ZATEAN-PN PLUS 2

MUSCULOSKELETAL THERAPY AGENTS

AMRIX 3 QL

baclofen 1

carisoprodol 1

carisoprodol/aspirin 1

chlorzoxazone 1

cyclobenzaprine hydrochlo 1 QL

dantrolene sodium 1

DUROLANE 3 INJ SP

EUFLEXXA 2 INJ SP

FIRST-BACLOFEN 5 2

GEL-ONE 3 INJ SP

HYALGAN 3 INJ SP

LORZONE 3

metaxalone 1

methocarbamol 1

methocarbamol inj 1 INJ

MONOVISC 2 INJ SP

orphenadrine citrate 1 INJ

orphenadrine citrate er 1

ORTHOVISC 2 INJ SP

revonto 1 INJ

ROBAXIN 3 INJ

SKELAXIN 3

SOMA 3

SUPARTZ FX 3 INJ SP

SYNVISC 3 INJ SP

SYNVISC ONE 3 INJ SP

tizanidine hcl 1

tizanidine hydrochloride 1

VISCO-3 3 INJ SP

ZANAFLEX 3

NASAL AGENTS - SYSTEMIC AND TOPICAL

ASTEPRO 3

azelastine spray 1

BECONASE AQ 3 ST

DYMISTA 2 ST

flunisolide 1

fluticasone spr 50mcg 1

ipratropium spray 1

mometasone spr 50mcg 1

NASONEX 3

olopatadine spr 0.6% 1

OMNARIS 3 ST

PATANASE 3

QNASL 2 ST

QNASL CHILDRENS 2 ST

SINUVA 3 SP

XHANCE 3

ZETONNA 3 ST

NEUROMUSCULAR AGENTS

ANECTINE 3 INJ

atracurium besylate 1 INJ

BOTOX 2 INJ SP

cisatracurium besylate 1 INJ

DYSPORT 3 INJ SP

MYOBLOC 2 INJ SP

NIMBEX 3 INJ

pancuronium bromide 1 INJ

QUELICIN 3 INJ

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

42

riluzole 1 SP

rocuronium bromide 1 INJ

SPINRAZA 2 INJ SP

vecuronium bromide 1 INJ

XEOMIN 3 INJ SP

OPHTHALMIC AGENTS

ACULAR 3

ACULAR LS 3

ACUVAIL 3

ak-poly-bac 1

AKTEN 3

ALCAINE 3

ALOCRIL 3

ALOMIDE 3 ST

ALPHAGAN P SOL 0.15% 3

ALPHAGAN P SOL 0.1% 2

ALREX 2

apraclonidine 1

atropine sul sol 1% op 1

AZASITE 2

azelastine dro 0.05% 1

AZOPT 3

BACITRACIN OIN OP 2

bacitracin/polymyxin b 1

balanced salt solution 1 INJ

BEOVU 3 SP

BEPREVE 2 ST

BESIVANCE 3

BETADINE OPHTHALMIC PREP 3

betaxolol sol 0.5% op 1

BETIMOL 3

BETOPTIC-S 3

bimatoprost 1

BLEPH-10 3

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 3

brimonidine tartrate 1

bromfenac 1

BROMSITE 3

BSS 3 INJ

carteolol hcl 1

CEQUA 3

CILOXAN 3

ciprofloxacn sol 0.3% op 1

COMBIGAN 2

COSOPT 3

COSOPT PF 3

cromolyn sodium 1

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl 1

cyclopentolate hydrochlor 1

dexamethasone pho sol 0.1% op 1

diclofenac sol 0.1% op 1

dorzolamide hcl 1

dorzolamide hcl/timolol m 1

dorzolamide hydrochloride 1

DUREZOL 3

epinastine hcl 1

erythromycin oin 5mg/gm 1

EYLEA 2 SP

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 3

FML FORTE 3

FML LIQUIFILM 3

gatifloxacin 1

GELFILM OP 3

GENTAK 2

gentamicin sol 0.3% op 1

HEALON 3 INJ

HEALON GV 3 INJ

HEALON5 3 INJ

homatropine hbr 1

ILEVRO 2

INVELTYS 2

IOPIDINE 3

ISOPTO ATROPINE 3

ISOPTO CARPINE 3

ISTALOL 3

JETREA 2 SP

ketorolac sol 0.5% 1

LACRISERT 3

LASTACAFT 3 ST

latanoprost 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

43

levobunolol hcl 1

levofloxacin sol 0.5% 1

LOTEMAX 2

LOTEMAX SM 2

loteprednol etabonate 1

LUMIGAN 2 ST

MAXIDEX 3

MAXITROL 3

MIOCHOL-E 3 INJ

MIOSTAT 2 INJ

MOXEZA 3

moxifloxacin sol 1

NATACYN 2

neomycin/bacitracin/polym 1

neomycin/polymyxin/bacitr 1

neomycin/polymyxin/dexame 1

neomycin/polymyxin/gramic 1

neo/poly/hc sus op 1

neo-polycin 1

neo-polycin hc 1

NEVANAC 3

OCUFLOX 3

ofloxacin dro 0.3% op 1

olopatadine dro 0.1% 1

olopatadine hydrochloride 1

OZURDEX 2 SP

PATADAY 3

PATANOL 3

PAZEO 2 ST

phenylephrin sol 2.5% op 1

PHOSPHOLINE IODIDE 2

PHOTREXA VISCOUS 3

PHOTREXA/PHOTREXA VISCOUS 3 SP

pilocarpine sol 1% op 1

polycin 1

polymyxin b sulfate/trime 1

POLYTRIM 3

PRED FORTE 3

PRED MILD 3

PRED-G 3

PRED-G S.O.P. 3

prednisolone acetate 1

pred sod pho sol 1% op 1

PROLENSA 2

proparacaine hcl 1

PROVISC 3 INJ

RESTASIS MULTIDOSE 2

RETISERT 3 SP

RHOPRESSA 2

ROCKLATAN 3

SIMBRINZA 3

sodium sulfacetamide 1

SULFACET SOD OIN 10% OP 2

sulfacet sod sol 10% op 1

sulfacetamide sodium/pred 1

tetracaine hydrochloride 1

timolol sol 0.5% op 1

TIMOLOL MALEATE OPHTHALMI 3

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TOBRADEX SUS 0.3-0.1% 3

TOBRADEX OIN 0.3-0.1% 2

TOBRADEX ST 2

tobramycin sol 0.3% op 1

tobramycin/dexamethasone 1

TOBREX 3

TRAVATAN Z 2 ST

TRIESENCE 3 INJ

trifluridine 1

trimethoprim sulfate/poly 1

TRUSOPT 3

VIGAMOX 3

VISUDYNE 2 INJ SP

VYZULTA 3

XALATAN 3

XIIDRA 2

ZIOPTAN 3 ST

ZIRGAN 3

ZYLET 2

ZYMAXID 3

OTIC AGENTS

acetic acid 1

CIPRO HC 3

CIPRODEX 2

CIPROFLOXACIN 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

44

COLY-MYCIN S 3

cortic-nd 1

CORTISPORIN-TC 3

DERMOTIC 3

exotic-hc 1

fluocinolone acetonide 1

hydrocortisone/acetic aci 1

neomycin/polymyxin/hc 1

neo/poly/hc sus 1% otic 1

ofloxacin dro 0.3%otic 1

OTOVEL 2

Oxytocics

HEMABATE 2 INJ

methergine 1

methylergonovine maleate 1

methylergon inj 0.2mg/ml 1 INJ

PREPIDIL 3

PROSTIN E2 3

PASSIVE IMMUNIZING AND TREATMENT AGENTS

ANTIVENIN LATRODECTUS MAC 3 INJ

ANTIVENIN NORTH AMERICAN 3 INJ

CUTAQUIG 3 INJ SP

CUVITRU 3 INJ SP

FLEBOGAMMA DIF 3 INJ SP

GAMASTAN 2 INJ SP

GAMASTAN S/D 2 INJ SP

GAMMAGARD LIQUID 2 INJ SP

GAMMAGARD S/D IGA LESS TH 2 INJ SP

GAMMAKED 3 INJ SP

GAMUNEX-C 2 INJ SP

HIZENTRA 2 INJ SP

HYPERHEP B S/D 2 INJ SP

HYPERRAB 2 INJ SP

HYPERRAB S/D 2 INJ SP

HYPERRHO S/D 2 INJ SP

HYPERRHO S/D MINI-DOSE 2 INJ SP

HYPERTET S/D 2 INJ SP

HYQVIA 3 INJ SP

IMOGAM RABIES-HT 2 INJ SP

MICRHOGAM ULTRA-FILTERED 3 INJ SP

PANZYGA 3 INJ SP

PRIVIGEN 2 INJ SP

RHOGAM ULTRA-FILTERED PLU 3 INJ SP

SYNAGIS 2 INJ SP

XEMBIFY 3 INJ SP

ZINPLAVA 3 INJ

PENICILLINS

amoxicillin 1

amoxicillin/clavulanate p 1

ampicillin 1

ampicillin sodium 1 INJ

ampicillin-sulbactam 1 INJ

BICILLIN L-A 2 INJ

dicloxacillin sodium 1

NAFCILLIN 2 INJ

nafcillin sodium 1 INJ

OXACILLIN 2 INJ

oxacillin sodium 1 INJ

penicillin g potassium 1 INJ

PENICILLIN G POTASSIUM IN 2 INJ

penicillin g sodium 1 INJ

penicillin v potassium 1

PFIZERPEN 2 INJ

piperacillin sodium/tazob 1 INJ

piperacillin/tazobactam 1 INJ

UNASYN 3 INJ

UNASYN BULK PACK 3 INJ

Progestins

hydroxyprogesterone capro 1 INJ SP

MAKENA 3 INJ SP

medroxyprogesterone tab 1

norethindrone acetate 1

progesterone 1 INJ

progesterone cap 100mg 1

PROGESTERONE COMPOUNDING 3

PROMETRIUM 3

PROVERA 3

Psychotherapeutic and Neurological Agents - Misc.

acamprosate calcium dr 1

ADDYI 3 SP

AMPYRA 3 SP

ANTABUSE 3

AUBAGIO 3 SP

AUSTEDO 2 SP

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

45

AVONEX 2 INJ SP

AVONEX PEN 2 INJ SP

BETASERON 2 INJ SP

BRISDELLE 3

CHANTIX 2 QL

CHANTIX CONTINUING MONTH 2 QL

CHANTIX STARTING MONTH PA 2 QL

chlordiazepoxide/amitript 1

COPAXONE 2 INJ SP

dalfampridine er 1 SP

disulfiram 1

donepezil hcl 1

donepezil hydrochloride 1

donepezil hydrochloride o 1

EXELON 3

EXTAVIA 3 INJ SP

galantamine hydrobromide 1

GILENYA 2 SP

glatiramer acetate 1 INJ SP

glatopa 1 INJ SP

GRALISE 3 ST

GRALISE STARTER 3 ST

HORIZANT 3 ST

INGREZZA 3 SP

LUCEMYRA 2 SP

LYRICA CR 3 ST

MAYZENT 2 SP

memantine hcl titration p 1

memantine hydrochloride 1

memantine hydrochloride e 1

NAMENDA 3

NAMENDA TITRATION PAK 3

NAMENDA XR 3

NAMENDA XR TITRATION PACK 3

NAMZARIC 2

NICOTROL INHALER 3

NICOTROL NS 3

NUEDEXTA 2

OCREVUS 2 INJ SP

olanzapine/fluoxetine 1

paroxetine 1

perphenazine/amitriptylin 1

pimozide 1

PLEGRIDY 2 INJ SP

PLEGRIDY STARTER PACK 2 INJ SP

REBIF 2 INJ SP

REBIF REBIDOSE 2 INJ SP

rivastigmine tartrate 1

rivastigmine transdermal 1

SARAFEM 3

SAVELLA 2

SAVELLA TITRATION PACK 2

SYMBYAX 3

TECFIDERA 2 SP

TECFIDERA STARTER PACK 2 SP

tetrabenazine 1 SP

TYSABRI 2 INJ SP

XENAZINE 3 SP

XYREM 2 SP

Respiratory Agents - Misc.

ARALAST NP 2 INJ SP

CUROSURF 3

ESBRIET 2 SP

GLASSIA 2 INJ SP

KALYDECO 2 SP

OFEV 2 SP

ORKAMBI 2 SP

PROLASTIN-C 2 INJ SP

PULMOZYME 2 SP

SURVANTA INTRATRACHEAL 3

SYMDEKO 2 SP

ZEMAIRA 2 INJ SP

Sulfonamides

sulfadiazine 1

Tetracyclines

ACTICLATE 3

demeclocycline hcl 1

DORYX MPC 3

doxycycline sus 25mg/5ml 1

doxycycline hyclate 1

DOXYCYCLINE HYC TAB 50MG 3

doxycycline hyclate dr 1

doxycycline monohydrate 1

MINOCIN 3

minocycline hcl 1

minocycline hcl er 1

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

46

minocycline hydrochloride 1

MINOLIRA 3

okebo 1

SEYSARA 3

SOLODYN 3

TARGADOX 3

tetracycline hydrochlorid 1

TYGACIL 3 INJ

VIBRAMYCIN 3

XIMINO 3

THYROID AGENTS

ARMOUR THYROID 2

CYTOMEL 3

euthyrox 1

levothyroxine sodium 1

levothyroxine/liothyronin 1

levoxyl 1

liothyronine sodium 1

methimazole 1

NATURE-THROID 2

np thyroid 120 1

np thyroid 15 1

np thyroid 30 1

np thyroid 60 1

np thyroid 90 1

propylthiouracil 1

SYNTHROID 3

TIROSINT 3

TIROSINT-SOL 3

unithroid 1

WP THYROID 3

Toxoids

ADACEL 2 INJ

BOOSTRIX 2 INJ

PENTACEL 2 INJ

TDVAX 2 INJ

TENIVAC 3 INJ

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

ACIPHEX 3 QL

ACIPHEX SPRINKLE 3 QL ST

ANASPAZ 2

ATROPEN 3 INJ

BELLA/OPIUM SUP 16.2-60 3

belladonna/opium 1

CARAFATE SUS 1GM/10ML 2

CARAFATE TAB 1GM 3

chlordiazepoxide hcl/clid 1

cimetidine 1

cimetidine hcl 1

CUVPOSA 3

CYTOTEC 3

DEXILANT 3 QL ST

dicyclomine hcl 1 INJ

dicyclomine sol 10mg/5ml 1

dicyclomine hydrochloride 1

DONNATAL 3

ed-spaz 1

esomeprazole magnesium 1 QL

esomeprazole sodium 1 INJ

famotidine 1

famotidine inj 1 INJ

famotidine premixed 1 INJ

FIRST-LANSOPRAZOLE 2 QL

FIRST-OMEPRAZOLE 2 QL

GLYCATE 3

glycopyrrolate inj 0.2mg/ml 1 INJ

glycopyrrolate tab 1mg 1

hyoscyamine tab 0.125mg 1

hyoscyamine sub 0.125mg 1

hyoscyamine sulfate er 1

hyosyne 1

lansoprazole 1 QL

lansoprazole odt 1 QL

lansoprazole/amoxicillin/ 1

LEVSIN 2 INJ

LIBRAX 3

methscopolamine bromide 1

misoprostol 1

NEXIUM GRA DR 2 QL ST

NEXIUM CAP 20MG 3 QL

NEXIUM I.V. 3 INJ

nizatidine 1

NIZATIDINE SOL 15MG/ML 2

omeprazole 1 QL

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

47

omeprazole dr 1 QL

omeprazole/sodium bicarbo 1

oscimin sub 0.125mg 1

oscimin tab 0.125mg 1

oscimin sr 1

pantoprazole inj sod 40mg 1 INJ QL

pantoprazole tab 40mg 1 QL

pantoprazole sodium dr 1 QL

PEPCID 3

phenobarbital/belladonna 1

phenohytro 1

PREVACID 3 QL

PREVACID SOLUTAB 3 QL

PRILOSEC 3

propantheline bromide 1

PROTONIX 3 QL

PYLERA 2

rabeprazole sodium 1 QL

ranitidine hcl 1

ranitidine hydrochloride 1

sucralfate tab 1gm 1

SUCRALFATE SUS 1GM/10ML 2

SYMAX DUOTAB 3

ZEGERID 3

Urinary Anti-infectives

HIPREX 3

HYOPHEN 2

MACROBID 3

me/naphos/mb/hyo 1 1

methenamine hippurate 1

methenamine mandelate 1

MONUROL 3

nitrofurantoin 1

nitrofurantoin macrocryst 1

nitrofurantoin monohydrat 1

phosphasal 1

urelle 1

uretron d/s 1

uribel 1

URIMAR-T 2

uro-458 1

UROGESIC-BLUE 2

uro-mp 1

ustell 1

vilamit mb 1

Urinary Antispasmodics

bethanechol chloride 1

darifenacin hydrobromide 1 QL

DETROL 3 QL

DETROL LA 3 QL

ENABLEX 3 QL

flavoxate hcl 1

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride 1

oxybutynin chloride er 1 QL

OXYTROL 3

solifenacin succinate 1 QL

tolterodine tartrate 1 QL

tolterodine tartrate er 1 QL

TOVIAZ 2 QL

trospium chloride 1 QL

trospium chloride er 1 QL

VESICARE 2 QL

VACCINES

AFLURIA QUADRIVALENT 2019 2 INJ

BEXSERO 2 INJ

ENGERIX-B 2 INJ

FLUAD 2019-2020 2 INJ

FLUARIX QUADRIVALENT 2019 2 INJ

FLUBLOK QUADRIVALENT 2019 2 INJ

FLUCELVAX QUADRIVALENT 20 2 INJ

FLULAVAL QUADRIVALENT 201 2 INJ

FLUZONE HIGH-DOSE PF 2019 2 INJ

FLUZONE QUADRIVALENT 2019 2 INJ

GARDASIL 9 2 INJ

HAVRIX 2

HEPLISAV-B 3

IMOVAX RABIES (H.D.C.V.) 2

IPOL INACTIVATED IPV 2

IXIARO 2

MENACTRA 2

MENVEO 3

M-M-R II 2

PEDVAX HIB 2

PNEUMOVAX 23 2

Drug Name Drug Tier Limits Drug Name Drug Tier Limits

Bold Upper Case = Brand-name drug QL Quantity Limits SP Specialty Program

Lower Case = generic drug INJ Injectable ST Step Therapy

48

PREVNAR 13 2

PROQUAD 2

RECOMBIVAX HB 2

ROTATEQ 2

SHINGRIX 2

STAMARIL 2

TRUMENBA 2

TWINRIX 2

TYPHIM VI 2

VAQTA 3

VARIVAX 2

VAXCHORA 2

VIVOTIF 2

ZOSTAVAX 3

VAGINAL AND RELATED PRODUCTS

AVC 3

clindamycin cre 2% vag 1

CLINDESSE 3

clotrimazole vag cre 2% 1

CRINONE 2

ENDOMETRIN 3

ESTRACE VAG CRE 0.01% 3

estradiol vag tab 1

ESTRING 2

FEM PH 2

FEMRING 3

FIRST-PROGESTERONE VGS 20 3

GYNAZOLE-1 3

IMVEXXY MAINTENANCE PACK 3

IMVEXXY STARTER PACK 3

INTRAROSA 3

metronidazole vaginal 1

MICONAZOLE 3 2

NUVESSA 3

terconazole 1

TRIMO-SAN 2

VAGIFEM 3

vandazole 1

yuvafem 1

Vasopressors

AUVI-Q 3 SP

dobutamine hcl 1

dobutamine hcl/d5w 1

dobutamine hydrochloride/ 1

dobutamine/dextrose 5% 1

dopamine hcl 1

dopamine hydrochloride/de 1

dopamine/d5w 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

EPISNAP 3

LEVOPHED 3

midodrine hcl 1

midodrine hydrochloride 1

norepinephrine bitartrate 1

NORTHERA 3 SP

SYMJEPI 2

VITAMINS

DRISDOL 3

ergocalciferol 1

MEPHYTON 3

phytonadione 1

POTABA 3

vitamin d 1

vitamin k1 1

49

A

abacavir ____________ 19

abacavir sulfate/lamivudi

_________________ 19

ABILIFY _____________ 18

ABILIFY MAINTENA ___ 18

abiraterone acetate ___ 15

ABSORICA __________ 25

acamprosate calcium dr 44

ACANYA ____________ 25

acarbose ____________ 10

ACCUPRIL ___________ 13

ACCURETIC __________ 13

acebutolol hcl ________ 20

acebutolol hydrochloride

_________________ 20

acetaminophen/caffeine/di

__________________ 4

acetaminophen/codeine 4

acetazolamide _______ 30

acetazolamide er _____ 30

acetazolamide sodium _ 30

acetic acid________ 33, 43

acetic acid 0.25% _____ 33

acetylcysteine _______ 11

acetylcystine sol _____ 24

ACIPHEX ____________ 46

ACIPHEX SPRINKLE ___ 46

acitretin ____________ 25

ACTEMRA ____________ 3

ACTEMRA ACTPEN _____ 3

ACTHAR ____________ 31

ACTICLATE __________ 45

ACTIGALL ___________ 32

ACTIVE FE ___________ 34

ACTONEL ___________ 31

ACUICYN DAILY EYELID &

EY _______________ 25

ACULAR ____________ 42

ACULAR LS __________ 42

ACUVAIL ____________ 42

acyclovir _________ 19, 25

acyclovir cream _____ 25

ACZONE ____________ 25

ADACEL_____________ 46

adapalene gel 0.1% __ 25

ADAPALENE SOL 0.1% 25

adapalene pump _____ 25

adapalene/benzoyl peroxid

_________________ 25

ADASUVE ___________ 18

ADDERALL ___________ 3

ADDERALL XR _________ 3

ADDYI ______________ 44

ADEMPAS ___________ 21

ADENOCARD _________ 7

adenosine ____________ 7

ADHANSIA XR _________ 3

ADHD/ANTI-

NARCOLEPSY/ANTI-

OBESITY/ANOREXIANTS

__________________ 3

ADIPEX-P ____________ 3

ADLYXIN ____________ 10

ADLYXIN STARTER PACK 10

ADMELOG ___________ 10

ADMELOG SOLOSTAR _ 10

ADRIAMYCIN ________ 15

adrucil ______________ 15

ADVAIR DISKUS _______ 7

ADVAIR HFA __________ 7

ADVANCED AM/PM ___ 39

ADVATE ____________ 34

ADYNOVATE _________ 34

ADZENYS ER __________ 3

ADZENYS XR-ODT ______ 3

AFINITOR ___________ 15

AFINITOR DISPERZ ____ 15

AFLURIA QUADRIVALENT

2019 _____________ 47

AFREZZA ____________ 10

AGGRASTAT _________ 34

AGGRENOX __________ 34

agoneaze____________ 25

AIMOVIG ___________ 36

airavite _____________ 34

AIRDUO RESPICLICK

113/14 ____________ 7

AJOVY ______________ 36

AKLIEF ______________ 25

ak-poly-bac __________ 42

AKTEN ______________ 42

AKTIPAK ____________ 25

AKYNZEO ___________ 12

ALA SCALP __________ 25

ALA-QUIN ___________ 25

albendazole __________ 6

albuterol neb ________ 7

albuterol tab ________ 7

albuterol sulfate er _____ 7

ALBUTEROL SULFATE HFA 7

ALCAINE ____________ 42

alclometasone dipropionat

_________________ 25

ALCORTIN A _________ 25

ALDACTAZIDE ________ 30

ALDACTONE _________ 30

ALECENSA ___________ 15

ALENDRONATE TAB 40MG

_________________ 31

alendronate sodium ___ 31

alfentanil _____________ 4

ALFENTANIL HCL ______ 4

alfuzosin hcl er _______ 33

ALIMTA _____________ 15

ALINIA ______________ 14

aliskiren _____________ 13

ALLEVYN GENTLE _____ 25

allopurinol ___________ 33

allopurinol sodium ____ 33

almotriptan __________ 36

almotriptan malate ____ 36

ALOCRIL ____________ 42

ALOGLIPTIN _________ 10

ALOGLIPTIN/METFORMIN

HCL ______________ 10

ALOGLIPTIN/PIOGLITAZON

E ________________ 10

ALOMIDE____________ 42

ALORA ______________ 32

alosetron hydrochloride 32

ALPHAGAN P SOL 0.1% 42

ALPHAGAN P SOL 0.15%

_________________ 42

alprazolam ___________ 6

alprazolam er _________ 6

ALPRAZOLAM INTENSOL 6

alprazolam odt ________ 6

alprazolam xr _________ 6

alprostadil ___________ 38

ALREX ______________ 42

ALTABAX ____________ 25

altavera _____________ 22

ALTRENO ____________ 25

ALVESCO _____________ 7

alyacen 1/35 _________ 22

alyacen 7/7/7 ________ 22

alyq ________________ 21

amabelz _____________ 32

amantadine hcl _______ 18

AMARYL ____________ 10

AMBIEN _____________ 35

AMBIEN CR __________ 35

AMBISOME __________ 12

ambrisentan _________ 21

amcinonide __________ 25

Amebicides ___________ 3

AMERGE ____________ 36

amethia _____________ 22

amethia lo ___________ 22

amethyst ____________ 22

AMICAR _____________ 35

AMIDATE____________ 33

amikacin sulfate _______ 3

amiloride hcl _________ 30

amiloride/hydrochlorothia

_________________ 30

aminoacetic acid ______ 33

aminocaproic acid _____ 35

Aminoglycosides ______ 3

aminophylline _________ 7

amiodarone inj _______ 7

amiodarone hcl ________ 7

amiodarone hydrochloride

__________________ 7

AMITIZA ____________ 32

amitriptyline hcl _______ 9

amitriptyline hydrochlori 9

amlodipine besylate 13, 21

amlodipine besylate/atorv

_________________ 21

amlodipine besylate/benaz

_________________ 13

amlodipine besylate/valsa

_________________ 13

amlodipine/olmesartan

med ______________ 13

amlodipine/valsartan/hctz

_________________ 13

amlodipine/valsartan/hydr

_________________ 13

ammonium lactate ____ 25

AMMONUL __________ 31

amnesteem __________ 25

amoxapine ____________ 9

amoxicillin ___________ 44

amoxicillin/clavulanate p 44

AMPHADASE _________ 38

amphetamine sulfate ___ 3

amphetamine/dextroamph

eta ________________ 3

amphotericin b _______ 12

ampicillin ____________ 44

ampicillin sodium _____ 44

ampicillin-sulbactam ___ 44

AMPYRA ____________ 44

AMRIX ______________ 41

AMYTAL SODIUM _____ 35

ANACAINE ___________ 25

ANAFRANIL ___________ 9

anagrelide hydrochloride

_________________ 34

ANALGESICS - ANTI-

INFLAMMATORY ____ 3

ANALGESICS - NonNarcotic

__________________ 4

ANALGESICS - OPIOID ___ 4

ANALPRAM HC ________ 6

ANALPRAM-HC ________ 6

ANASPAZ ____________ 46

anastrozole __________ 15

ANCOBON ___________ 12

ANDRODERM _________ 6

ANDROGEL ___________ 6

ANDROGEL PUMP______ 6

ANDROGENS-ANABOLIC 6

ANECTINE ___________ 41

ANGELIQ ____________ 32

ANIMI-3 _____________ 34

ANORECTAL AGENTS ___ 6

ANORO ELLIPTA _______ 7

50

ANTABUSE __________ 44

ANTARA ____________ 13

Anthelmintics ________ 6

ANTIANGINAL AGENTS _ 6

ANTIANXIETY AGENTS__ 6

ANTIARRHYTHMICS ____ 7

ANTIASTHMATIC AND

BRONCHODILATOR

AGENTS ___________ 7

ANTICOAGULANTS ____ 8

ANTICONVULSANTS ___ 8

ANTIDEPRESSANTS ____ 9

ANTIDIABETICS ______ 10

ANTIDIARRHEAL/PROBIOT

IC AGENTS ________ 11

Antidotes and Specific

Antagonists _______ 11

ANTIEMETICS ________ 12

Antifungals __________ 12

ANTIHISTAMINES ____ 12

ANTIHYPERLIPIDEMICS 13

ANTIHYPERTENSIVES __ 13

Anti-infective Agents -

Misc. ____________ 14

Antimalarials ________ 15

Antimyasthenic/Cholinergi

c Agents __________ 15

Antimycobacterial Agents

_________________ 15

ANTINEOPLASTICS AND

ADJUNCTIVE

THERAPIES _______ 15

ANTIPARKINSON AND

RELATED THERAPY

AGENTS __________ 18

ANTIPSYCHOTICS/ANTIMA

NIC AGENTS ______ 18

Antiseptics & Disinfectants

_________________ 19

ANTIVENIN LATRODECTUS

MAC _____________ 44

ANTIVENIN NORTH

AMERICAN _______ 44

ANTIVIRALS _________ 19

anucort-hc ___________ 6

anusol-hc ____________ 6

ANZEMET ___________ 12

APADAZ _____________ 5

APEXICON E _________ 25

APIDRA _____________ 10

APIDRA SOLOSTAR ___ 10

APLENZIN ____________ 9

APOKYN ____________ 18

apraclonidine ________ 42

aprepitant __________ 12

apri ________________ 22

APRISO _____________ 32

APTENSIO XR _________ 3

APTIOM _____________ 8

APTIVUS ____________ 19

AQUORAL ___________ 39

ARALAST NP _________ 45

aranelle _____________ 22

ARANESP ALBUMIN FREE

_________________ 34

ARAVA ______________ 3

ARESTIN ____________ 39

argyle sterile saline 100 33

argyle sterile water 100m

_________________ 38

ARIMIDEX ___________ 15

aripiprazole __________ 18

aripiprazole odt ______ 18

ARISTADA ___________ 18

ARISTADA INITIO _____ 18

armodafinil ___________ 3

ARMOUR THYROID ___ 46

ARNUITY ELLIPTA ______ 7

AROMASIN __________ 15

ARRANON ___________ 16

arsenic trioxide _______ 16

ARTHROTEC 50 ________ 3

ARTHROTEC 75 ________ 3

ARZERRA____________ 16

arzol silver nitrate app _ 25

ASACOL HD __________ 32

ascomp/codeine _______ 5

ashlyna _____________ 22

ASMANEX HFA ________ 7

ASMANEX TWISTHALER

120 ME ____________ 7

ASMANEX TWISTHALER 7

METE _____________ 7

aspirin/dipyridamole er 34

ASTAGRAF XL ________ 38

ASTEPRO ____________ 41

ATACAND ___________ 13

atazanavir sulfate _____ 19

ATELVIA ____________ 31

atenolol __________ 13, 20

atenolol/chlorthalidone 13

ATGAM _____________ 38

ATIVAN ______________ 6

ATIVAN INJ 2MG/ML 6

atomoxetine __________ 3

atomoxetine hydrochloride

__________________ 3

ATOPADERM ________ 25

atorvastatin calcium ___ 13

atovaquone ______ 14, 15

atovaquone/proguanil hcl

_________________ 15

atracurium besylate ___ 41

ATRALIN ____________ 25

ATRAPRO ANTIPRURITIC

HYDR ____________ 25

ATRAPRO CP _________ 25

ATRAPRO DERMAL SPRAY

_________________ 25

ATRIPLA ____________ 19

ATROPEN ___________ 46

atropine sul sol 1% op _ 42

ATROVENT HFA _______ 7

AUBAGIO ___________ 44

aubra _______________ 22

aubra eq ____________ 22

augmented

betamethasone d ___ 25

aurovela 1/20 ________ 22

aurovela 24 fe ________ 22

AURYXIA ____________ 32

AUSTEDO ___________ 44

AUVI-Q _____________ 48

AVAGE ______________ 25

AVALIDE ____________ 13

AVANDIA____________ 10

AVAPRO ____________ 13

AVAR _______________ 25

avar cleanser _________ 25

AVAR LS ____________ 25

AVAR LS CLEANSER ___ 25

avar-e green _________ 25

AVAR-E LS ___________ 25

AVASTIN ____________ 16

AVC ________________ 48

AVEED _______________ 6

AVENOVA ___________ 25

aviane ______________ 22

avita ________________ 25

AVODART ___________ 33

AVONEX ____________ 45

AVONEX PEN ________ 45

AVYCAZ _____________ 21

azacitidine ___________ 16

AZACTAM ___________ 14

AZASAN _____________ 38

AZASITE _____________ 42

azathioprine _________ 38

AZATHIOPRINE INJ ____ 38

azelaic acid __________ 25

azelastine dro 0.05% __ 42

azelastine spray _____ 41

AZELEX _____________ 25

AZILECT _____________ 18

azithromycin _________ 36

AZITHROMYCIN POW 1GM

PAK ______________ 36

AZOPT ______________ 42

AZOR _______________ 13

AZULFIDINE __________ 32

AZULFIDINE EN-TABS __ 32

azurette _____________ 22

B

bacitracin ________ 14, 42

BACITRACIN OIN OP __ 42

bacitracin/polymyxin b _ 42

baclofen ____________ 41

BACMIN ____________ 39

BAL IN OIL ___________ 11

balanced salt solution __ 42

BALCOLTRA __________ 22

balsalazide disodium ___ 32

balziva ______________ 22

BANZEL ______________ 8

BAQSIMI ONE PACK ___ 10

BARACLUDE _________ 19

BARACLUDE SOL ____ 19

BASAGLAR KWIKPEN __ 10

BAXDELA ____________ 32

bd posiflush __________ 37

BEAU RX ____________ 25

BECONASE AQ ________ 41

BELBUCA _____________ 5

BELLA/OPIUM SUP 16.2-

60 _______________ 46

belladonna/opium ____ 46

BELSOMRA __________ 35

BELVIQ _______________ 3

BELVIQ XR ____________ 3

benazepril hcl ________ 13

benazepril hcl/hydrochlor

_________________ 13

benazepril hydrochloride13

benazepril hydrochloride/

_________________ 13

BENICAR ____________ 13

BENICAR HCT ________ 13

BENLYSTA ___________ 38

BENSAL HP __________ 25

BENZAC AC WASH ____ 25

BENZACLIN WITH PUMP 25

BENZAMYCIN ________ 25

benzepro foaming cloths 25

BENZHYDROCODONE/ACE

TAMINO ___________ 5

BENZIQ _____________ 25

BENZIQ LS ___________ 25

BENZIQ WASH ________ 25

BENZNIDAZOLE ________ 6

benzoin compound

tincture ___________ 25

benzonatate _________ 24

benzphetamine hcl _____ 3

benztropine inj 1mg/ml 18

benztropine mesylate __ 18

BEOVU ______________ 42

BEPREVE ____________ 42

BESIVANCE __________ 42

BESPONSA ___________ 16

BETA BLOCKERS ______ 20

BETADINE OPHTHALMIC

PREP _____________ 42

betamethasone

dipropionat ________ 25

betamethasone sodium

phos _____________ 24

betamethasone valerate 25

BETAPACE ___________ 20

51

BETASERON _________ 45

betaxolol sol 0.5% op 42

betaxolol tab _______ 20

bethanechol chloride __ 47

BETHKIS _____________ 3

BETIMOL ___________ 42

BETOPTIC-S _________ 42

BEVESPI AEROSPHERE __ 7

bexarotene __________ 16

BEXSERO ___________ 47

BEYAZ ______________ 22

bicalutamide ________ 16

BICILLIN L-A _________ 44

BICNU ______________ 16

BIDIL _______________ 21

BI-EST 50

50 COMPOUNDING 32

50 PROGESTERONE_ 32

BI-EST 80

20 PROGESTERONE_ 32

BIJUVA _____________ 32

BIKTARVY ___________ 19

bimatoprost ______ 25, 42

BINOSTO ___________ 31

bisoprolol fumarate 13, 20

bisoprolol fumarate/hydro

_________________ 13

bivalirudin ___________ 8

BIVALIRUDIN/SODIUM

CHLORI ___________ 8

bleomycin ___________ 16

bleomycin sulfate _____ 16

BLEPH-10 ___________ 42

BLEPHAMIDE ________ 42

BLEPHAMIDE S.O.P.___ 42

blisovi 24 fe _________ 22

blisovi fe 1.5/30 ______ 22

blisovi fe 1/20________ 22

BONIVA ____________ 31

BONJESTA __________ 12

BOOSTRIX___________ 46

bosentan ___________ 21

BOSULIF ____________ 16

BOTOX __________ 25, 41

BOTOX COSMETIC ____ 25

bp foam ____________ 25

bp wash ____________ 25

BPCO_______________ 25

b-plex ______________ 39

b-plex plus __________ 39

BRAFTOVI ___________ 16

BREO ELLIPTA_________ 7

BREVIBLOC __________ 20

BREVIBLOC PREMIXED 20

BREVIBLOC PREMIXED

DOUBLE __________ 20

BRIDION ____________ 11

briellyn _____________ 22

BRILINTA ___________ 34

brimonidine tartrate __ 42

BRISDELLE ___________ 45

BRIVIACT ____________ 8

bromfed dm _________ 24

bromfenac __________ 42

bromocriptine mesylate 18

bromphen/pseudoephedri

ne _______________ 25

BROMSITE __________ 42

BROVANA ____________ 7

BRYHALI ____________ 25

BSS ________________ 42

budesonide ________ 7, 24

budesonide sus _______ 7

budesonide er________ 24

bumetanide inj ______ 30

bumetanide tab _____ 30

BUMEX _____________ 30

BUNAVAIL____________ 5

bupap _______________ 4

bupivacaine hcl _______ 36

bupivacaine spinal ____ 36

bupivacaine/epinephrine

_________________ 36

BUPRENEX ___________ 5

BUPRENORPHIN DIS

7.5/HR ____________ 5

buprenorphin inj 0.3mg/ml

__________________ 5

buprenorphin sub 2mg _ 5

buprenorphine ________ 5

buprenorphine hcl/naloxon

__________________ 5

buprenorphine hydrochlori

__________________ 5

bupropion tab sr _____ 9

BUPROPION TAB 450MG

XL ________________ 9

bupropion hcl _________ 9

buspirone hcl _________ 6

buspirone hydrochloride 6

busulfan ____________ 16

but/asa/caf/ cap cod 30mg

__________________ 5

BUTAL/APAP CAP 50-

300MG ____________ 4

butal/apap tab 50-325mg

__________________ 4

butalbital/acetaminophen/

__________________ 4

BUTALBITAL/ASPIRIN/CAF

FEI _______________ 4

BUTISOL SODIUM ____ 35

butorphanol sol 10mg/ml 5

BUTORPHANOL TARTRATE

__________________ 5

BUTRANS ____________ 5

BYDUREON BCISE _____ 10

BYDUREON PEN ______ 10

BYETTA _____________ 10

BYSTOLIC ___________ 20

C

cabergoline __________ 31

CABOMETYX _________ 16

CADUET _____________ 21

CAFCIT _______________ 3

CAFERGOT___________ 36

caffeine cit inj 60mg/3ml 3

caffeine citrate ________ 3

CALAN ______________ 21

CALAN SR ___________ 21

CALCIFOL ____________ 37

calcipotriene _________ 25

calcipotriene/betamethaso

_________________ 25

calcitonin-salmon _____ 31

calcitriol __________ 25, 31

calcitriol inj _________ 31

calcitriol oin 3mcg/gm 25

calcium acetate _______ 32

Calcium Channel Blockers

_________________ 21

calcium chloride ______ 37

calcium gluconate _____ 37

CALQUENCE _________ 16

CAMBIA _____________ 36

camila ______________ 22

CAMINO PRO 15PE ____ 29

CAMINO PRO PKU ____ 29

CAMPTOSAR _________ 16

camrese _____________ 22

camrese lo ___________ 22

CANASA ____________ 32

CANCIDAS ___________ 12

candesartan cilexetil ___ 13

candesartan cilexetil/hyd

_________________ 13

CAPASTAT SULFATE ___ 15

capecitabine _________ 16

CAPEX ______________ 25

CAPHOSOL __________ 39

CAPRELSA ___________ 16

captopril ____________ 13

captopril/hydrochlorothia

_________________ 13

CARAC ______________ 25

CARAFATE SUS

1GM/10ML _______ 46

CARAFATE TAB 1GM_ 46

CARB/LEVO 50 TAB

/ENTACAP ________ 18

carb/levo100 tab /entacap

_________________ 18

carbamazepine ________ 8

carbamazepine er ______ 8

CARBATROL __________ 8

carbidopa ___________ 18

carbidopa/levodopa ___ 18

carbidopa/levodopa er _ 18

carbidopa/levodopa odt 18

carbinoxamine maleate 12

carboplatin __________ 16

CARDENE IV _________ 21

cardioplegic __________ 21

CARDIOTONICS _______ 21

CARDIOVASCULAR

AGENTS - MISC. ____ 21

CARDIZEM ___________ 21

CARDIZEM CD ________ 21

CARDIZEM LA ________ 21

CARDURA ________ 13, 33

CARDURA XL _________ 33

carisoprodol _________ 41

carisoprodol/aspirin ___ 41

CARNITOR ___________ 31

CARNITOR SF _________ 31

CAROSPIR ___________ 30

CARRASYN HYDROGEL

WOUND D ________ 25

carteolol hcl __________ 42

cartia xt _____________ 21

carvedilol ____________ 20

carvedilol phosphate___ 20

caspofungin acetate ___ 12

CATAPRES ___________ 13

CATAPRES-TTS-1 ______ 13

CATAPRES-TTS-2 ______ 13

CATAPRES-TTS-3 ______ 13

CAVERJECT __________ 21

CAVERJECT IMPULSE __ 21

CAYA _______________ 36

CAYSTON ____________ 14

caziant ______________ 22

cefaclor __________ 21, 22

CEFACLOR SUS 125/5ML

_________________ 22

cefaclor er ___________ 22

cefadroxil ____________ 22

cefdinir _____________ 22

cefepime ____________ 22

CEFEPIME/DEXTROSE __ 22

cefixime _____________ 22

cefotaxime sodium ____ 22

cefotetan ____________ 22

CEFOTETAN/DEXTROSE 22

cefoxitin sodium ______ 22

cefpodoxime proxetil __ 22

cefprozil _____________ 22

ceftazidime __________ 22

CEFTAZIDIME/DEXTROSE

_________________ 22

ceftriaxone in iso-osmoti 22

ceftriaxone sodium ____ 22

CEFTRIAXONE/DEXTROSE

_________________ 22

cefuroxime axetil______ 22

cefuroxime sodium ____ 22

celacyn ______________ 25

CELEBREX ____________ 3

celecoxib _____________ 4

52

CELESTONE-SOLUSPAN 24

CELEXA ______________ 9

CELLCEPT ___________ 38

CELLCEPT INTRAVENOUS

_________________ 38

CELONTIN ____________ 8

CENFOL _____________ 34

CENTRATEX _________ 34

cephalexin __________ 22

CEPHALEXIN TAB 250MG

_________________ 22

CEPHALOSPORINS ____ 21

CEPROTIN ___________ 34

CEQUA _____________ 42

CERACADE __________ 25

CERAMAX ___________ 26

CEREBYX _____________ 8

CEREFOLIN __________ 29

CEREFOLIN NAC ______ 29

CETACAINE __________ 26

cetirizine hydrochloride 12

CETROTIDE __________ 31

CETYLCIDE-G ________ 19

cevimeline hcl _______ 39

CHANTIX ____________ 45

CHANTIX CONTINUING

MONTH __________ 45

CHANTIX STARTING

MONTH PA _______ 45

chateal eq ___________ 22

CHEMET ____________ 11

chlordiazepoxide hcl 6, 46

chlordiazepoxide hcl/clid 46

chlordiazepoxide hydrochl

__________________ 6

chlordiazepoxide/amitript

_________________ 45

chlorhexidine gluconate 39

chloroprocaine hydrochlor

_________________ 36

chloroquine phosphate 15

chlorothiazide _______ 30

chlorothiazide sodium _ 30

CHLORPROMAZINE INJ 18

chlorpromazine hcl ___ 18

chlorthalidone _______ 30

chlorzoxazone _______ 41

cholestyramine ______ 13

cholestyramine light __ 13

chorionic gonadotropin 31

chromagen __________ 34

CIALIS ______________ 21

ciclopirox ___________ 26

ciclopirox nail lacquer _ 26

ciclopirox olamine ____ 26

ciclopirox treatment __ 26

cidofovir ____________ 19

cilostazol ____________ 34

CILOXAN ____________ 42

cimetidine __________ 46

cimetidine hcl ________ 46

CIMZIA _____________ 32

CIMZIA STARTER KIT __ 32

cinacalcet hydrochloride 31

CIPRO ___________ 32, 43

CIPRO HC ___________ 43

CIPRODEX ___________ 43

CIPROFLOXACIN ______ 43

ciprofloxacin hcl ______ 32

ciprofloxacin i.v.-in d5w 32

ciprofloxacn sol 0.3% op 42

cisatracurium besylate _ 41

cisplatin_____________ 16

citalopram hydrobromide 9

CITRANATAL ASSURE __ 39

CITRANATAL B-CALM __ 39

CITRANATAL BLOOM __ 39

CITRANATAL BLOOM DHA

_________________ 39

CITRANATAL DHA ____ 39

CITRANATAL HARMONY 39

CITRANATAL MEDLEY _ 39

CITRANATAL RX ______ 39

claravis _____________ 26

CLARINEX ________ 12, 25

CLARINEX-D 12 HOUR _ 25

clarithromycin _______ 36

clarithromycin er _____ 36

clemastine fumarate __ 12

CLENPIQ ____________ 36

CLEOCIN _________ 14, 26

CLEOCIN PEDIATRIC

GRANULE _________ 14

CLEOCIN PHOSPHATE _ 14

CLEOCIN-T __________ 26

CLEVIPREX __________ 21

CLIMARA____________ 32

CLIMARA PRO _______ 32

clindacin etz pledgets __ 26

CLINDACIN PAC ______ 26

CLINDAGEL __________ 26

clindamycin cre 2% vag 48

CLINDAMYCIN GEL 1% 26

clindamycin inj _______ 14

clindamycin sol 1% ___ 26

clindamycin hcl _______ 14

clindamycin palmitate hcl

_________________ 14

clindamycin phosphate in

_________________ 14

clindamycin

phosphate/ben ____ 26

clindamycin phosphate/tre

_________________ 26

clindamycin/benzoyl perox

_________________ 26

CLINDAMYCIN/SODIUM

CHLORI ___________ 15

CLINDESSE __________ 48

clinpro 5000 _________ 39

clobazam _____________ 8

clobetasol propionate _ 26

clobetasol propionate emo

_________________ 26

CLOBEX _____________ 26

CLOCORTOLONE PIVALATE

_________________ 26

CLODERM ___________ 26

clofarabine __________ 16

CLOLAR _____________ 16

clomiphene citrate ____ 31

clomipramine hcl ______ 9

clonazepam ___________ 8

clonazepam odt _______ 8

clonidine dis 0.1/24hr 13

clonidine inj _________ 4

clonidine tab 0.1mg __ 13

clonidine hcl er ________ 3

clonidine hydrochloride 13

clopidogrel __________ 34

clorazepate dipotassium 6

CLOROTEKAL _________ 36

clotrimazole anti-fungal 26

clotrimazole sol 1% ____ 26

clotrimazole troche 10mg

_________________ 39

clotrimazole vag cre 2% 48

clotrimazole/betamethaso

n ________________ 26

clozapine ____________ 18

CLOZAPINE TAB

150/ODT _________ 18

clozapine odt_________ 18

C-NATE DHA _________ 39

COARTEM ___________ 15

codeine sulfate ________ 5

COLCHICINE _________ 33

COLCRYS ____________ 33

colesevelam hydrochloride

_________________ 13

COLESTID ___________ 13

colestipol hcl _________ 13

colistimethate sodium _ 15

colocort ______________ 6

COLY-MYCIN S _______ 44

COLYTE-FLAVOR PACKS 36

COMBIGAN __________ 42

COMBIPATCH ________ 32

COMBIVENT RESPIMAT _ 7

COMPLERA __________ 19

complete natal dha ____ 39

completenate ________ 39

compro _____________ 18

COMTAN ____________ 18

co-natal fa ___________ 39

CONCEPT DHA _______ 39

CONCERTA ___________ 3

CONDYLOX __________ 26

constulose ___________ 36

CONTRACEPTIVES _____ 22

CONTRAST ALLERGY

PREMED P ________ 24

CONTRAVE ___________ 3

CONZIP ______________ 5

COPAXONE __________ 45

COPPER TRACE METAL _ 37

CORDRAN ___________ 26

COREG ______________ 20

COREG CR ___________ 20

CORGARD ___________ 20

CORLANOR __________ 21

CORLOPAM __________ 13

CORTEF _____________ 24

cortic-nd ____________ 44

CORTICOSTEROIDS ____ 24

CORTIFOAM __________ 6

CORTISONE ACETATE __ 24

CORTISPORIN-TC _____ 44

CORVERT _____________ 7

CORVITA ____________ 39

corvita 150___________ 34

CORVITE FE __________ 34

COSENTYX ___________ 26

COSENTYX SENSOREADY

PEN ______________ 26

COSOPT _____________ 42

COSOPT PF __________ 42

COTEMPLA XR-ODT ____ 3

COUGH/COLD/ALLERGY 24

COUMADIN ___________ 8

covaryx _____________ 32

covaryx hs ___________ 32

COZAAR _____________ 13

CREON ______________ 30

CRESEMBA __________ 12

CRESEMBA INJ ______ 12

CRESTOR ____________ 13

CRINONE ____________ 48

CRIXIVAN ____________ 19

cromolyn sod neb ______ 7

cromolyn sodium __ 32, 42

crotan ______________ 26

cryselle-28 ___________ 22

c-topical _____________ 26

CUPRIMINE __________ 38

CURITY HYPERTONIC

SODIUM __________ 26

CURITY SODIUM

CHLORIDE DR ______ 26

curity sterile saline ____ 33

CUROSURF __________ 45

CUTAQUIG ___________ 44

CUTIVATE ___________ 26

CUVITRU ____________ 44

CUVPOSA ___________ 46

cyanocobalamin ______ 34

CYANOKIT ___________ 11

cyclafem 1/35 ________ 22

cyclafem 7/7/7 _______ 22

53

cyclobenzaprine hydrochlo

_________________ 41

CYCLOGYL ___________ 42

CYCLOMYDRIL _______ 42

cyclopentolate hcl ____ 42

cyclopentolate hydrochlor

_________________ 42

cyclophosphamide ____ 16

CYCLOPHOSPHAMIDE CAP

25MG ____________ 16

cyclophosphamide inj _ 16

cycloserine __________ 15

CYCLOSET ___________ 10

cyclosporine _________ 38

cyclosporine cap 25mg

mod _____________ 38

CYCLOSPORINE CAP 50MG

MOD ____________ 38

cyclosporine inj ______ 38

CYKLOKAPRON ______ 35

CYMBALTA ___________ 9

cyproheptadine hcl ___ 12

cyproheptadine hydrochlor

_________________ 12

CYRAMZA ___________ 16

cyred _______________ 22

cyred eq ____________ 22

CYSTADANE _________ 31

CYSTAGON __________ 33

cytarabine __________ 16

CYTOMEL ___________ 46

CYTOTEC ____________ 46

D

dacarbazine _________ 16

dalfampridine er _____ 45

DALIRESP ____________ 7

danazol ______________ 6

dantrolene sodium____ 41

dapsone _________ 15, 26

dapsone gel 5% ____ 26

daptomycin _________ 15

darifenacin hydrobromide

_________________ 47

dasetta 1/35 _________ 22

dasetta 7/7/7 ________ 22

daunorubicin hcl _____ 16

DAUNORUBICIN

HYDROCHLORID ___ 16

DAURISMO __________ 16

DAYPRO _____________ 4

daysee _____________ 22

DAYTRANA ___________ 3

DEBACTEROL ________ 39

deblitane ___________ 22

decitabine___________ 16

deferoxamine mesylate 11

DELESTROGEN _______ 32

DELSTRIGO __________ 19

DELZICOL ___________ 32

demeclocycline hcl ____ 45

DEMEROL ____________ 5

DEMSER ____________ 13

DENAVIR ____________ 26

denta 5000 plus ______ 39

dentagel ____________ 39

DEPACON ____________ 8

DEPAKOTE ___________ 8

DEPAKOTE ER _________ 8

DEPAKOTE SPRINKLES __ 8

DEPEN TITRATABS ____ 38

DEPLIN 15 ___________ 29

DEPLIN 7.5 __________ 29

DEPO-ESTRADIOL _____ 32

DEPO-MEDROL _______ 24

DEPO-PROVERA ___ 16, 22

DEPO-PROVERA

CONTRACEPTIV ____ 22

DEPO-SUBQ PROVERA 104

_________________ 22

DEPO-TESTOSTERONE __ 6

DERMACINRX LEXITRAL

PHARM __________ 26

DERMACINRX PHN PAK 26

DERMACINRX ZRM PAK 26

DERMA-SMOOTHE/FS

BODY ____________ 26

DERMA-SMOOTHE/FS

SCALP ____________ 26

DERMATOLOGICALS __ 25

dermazene __________ 26

DERMOTIC __________ 44

DESCOVY ___________ 19

DESFERAL ___________ 11

desflurane ___________ 33

desipramine hcl _______ 9

desipramine hydrochloride

__________________ 9

desloratadine ________ 12

desloratadine odt _____ 12

desmopressin acetate _ 31

desmopressin inj _____ 31

desmopressin spr 0.01% 31

desogestrel/ethinyl estra22

desonide ____________ 26

DESOWEN ___________ 26

desoximetasone ______ 26

DESVENLAFAX TAB

100MG ER _________ 9

desvenlafaxine er ______ 9

DETROL _____________ 47

DETROL LA __________ 47

dexamethasone ___ 24, 42

dexamethasone 10-day

dose _____________ 24

dexamethasone 6-day dose

_________________ 24

DEXAMETHASONE

INTENSOL ________ 24

dexamethasone pho inj 24

dexamethasone pho sol

0.1% op __________ 42

DEXAMETHASONE SOL

0.5/5ML __________ 24

DEXILANT ___________ 46

dexmedetomidine hcl __ 35

dexmedetomidine

hydrochlo _________ 35

dexmethylphenidate hcl _ 3

dexmethylphenidate hcl er

__________________ 3

dexmethylphenidate

hydroc ____________ 3

dexpak 10 day ________ 24

dexpak 13 day ________ 24

dexpak 6 day _________ 24

dexrazoxane _________ 16

dextroamphetamine

sulfate ____________ 3

DEXTROSE 10%/NACL

0.45% ____________ 37

DEXTROSE 5% _______ 37

dextrose 10%/nacl 0.2% 37

dextrose 2.5%/nacl 0.45%

_________________ 37

dextrose 5%/lactated ring

_________________ 37

dextrose 5%/nacl 0.2% _ 37

dextrose 5%/nacl 0.225%

_________________ 37

dextrose 5%/nacl 0.3% _ 37

dextrose 5%/nacl 0.33% 37

dextrose 5%/nacl 0.45% 37

dextrose 5%/nacl 0.9% _ 37

DEXTROSE/SODIUM

CHLORIDE_________ 37

DIACOMIT ____________ 8

dialyvite _____________ 39

DIALYVITE 3000 ______ 39

DIALYVITE 5000 ______ 39

DIALYVITE SUPREME D 39

DIALYVITE/ZINC ______ 39

DIANEAL LOW

CALCIUM/1.5% ____ 38

DIANEAL LOW

CALCIUM/2.5% ____ 38

DIANEAL LOW

CALCIUM/4.25% ___ 38

DIANEAL PD-2/1.5%

DEXTROS _________ 38

DIANEAL PD-2/2.5%

DEXTROS _________ 38

DIANEAL PD-2/4.25%

DEXTRO __________ 38

DIASTAT ACUDIAL _____ 8

DIASTAT PEDIATRIC ____ 8

diazepam _____________ 6

diazepam sol 5mg/5ml 6

diazepam intensol______ 6

DIAZEPAM RECTAL GEL _ 8

DICLEGIS ____________ 12

diclofenac gel _______ 26

diclofenac sol 0.1% op_ 42

DICLOFENAC EPOLAMINE

_________________ 26

diclofenac potassium ___ 4

diclofenac sodium dr____ 4

diclofenac sodium er ____ 4

diclofenac sodium/misopro

__________________ 4

diclofex dc ___________ 26

dicloxacillin sodium ____ 44

dicyclomine sol 10mg/5ml

_________________ 46

dicyclomine hcl _______ 46

dicyclomine hydrochloride

_________________ 46

DIETARY

PRODUCTS/DIETARY

MANAGEMENT

PRODUCTS ________ 29

diethylpropion hcl ______ 3

diethylpropion hcl er ____ 3

DIFFERIN ____________ 26

DIFICID ______________ 36

difil-g forte ____________ 7

diflorasone diacetate __ 26

DIFLUCAN ___________ 12

diflunisal _____________ 4

DIGESTIVE AIDS ______ 30

digox _______________ 21

digoxin ______________ 21

digoxin inj _________ 21

DIGOXIN SOL

50MCG/ML ________ 21

dihydroergotamine

mesylat ___________ 36

DIHYDROERGOTAMINE

SPR ______________ 36

DILANTIN CAP 100MG 8

DILANTIN CAP 30MG _ 8

DILANTIN INFATABS ____ 8

DILANTIN-125 _________ 8

diltiazem tab ________ 21

diltiazem hcl cd _______ 21

diltiazem hcl er _______ 21

diltiazem hydrochloride e

_________________ 21

dilt-xr _______________ 21

DILT-XR CAP 120MG 21

DIOVAN _____________ 14

DIOVAN HCT _________ 14

DIPENTUM __________ 32

diphenhydramine hcl __ 12

diphenhydramine inj ___ 12

diphenoxylate hydrochlori

_________________ 11

diphenoxylate/atropine 11

DIPROLENE __________ 26

54

DIPROLENE AF _______ 26

dipyridamole ________ 34

disopyramide phosphate 7

disulfiram ___________ 45

DIURETICS __________ 30

DIURIL _____________ 30

divalproex sodium _____ 8

divalproex sodium dr ___ 8

divalproex sodium er ___ 8

DIVIGEL ____________ 32

dobutamine hcl ______ 48

dobutamine hcl/d5w __ 48

dobutamine

hydrochloride/ ____ 48

dobutamine/dextrose 5%

_________________ 48

dofetilide ____________ 7

DOLOPHINE __________ 5

donepezil hcl ________ 45

donepezil hydrochloride 45

donepezil hydrochloride o

_________________ 45

DONNATAL__________ 46

dopamine hcl ________ 48

dopamine

hydrochloride/de __ 48

dopamine/d5w_______ 48

DOPRAM ____________ 3

DOPTELET ___________ 34

DORAL _____________ 35

DORYX MPC _________ 45

dorzolamide hcl ______ 42

dorzolamide hcl/timolol m

_________________ 42

dorzolamide hydrochloride

_________________ 42

dotti _______________ 32

DOVATO ____________ 19

doxazosin mesylate ___ 14

doxepin hcl ___________ 9

doxepin hydrochloride __ 9

doxercalciferol _______ 31

DOXIL ______________ 16

doxorubicin hcl _______ 16

doxorubicin hydrochloride

_________________ 16

DOXYCYCLINE CAP 40MG

_________________ 26

doxycycline sus 25mg/5ml

_________________ 45

DOXYCYCLINE HYC TAB

50MG ____________ 45

doxycycline hyclate ___ 45

doxycycline hyclate dr _ 45

doxycycline monohydrate

_________________ 45

doxylamine succinate/pyri

_________________ 12

D-PENAMINE ________ 38

DRISDOL ____________ 48

DRITHO-CREME HP ___ 26

dronabinol __________ 12

droperidol ____________ 6

drospirenone/ethinyl estr

_________________ 22

DROXIA _____________ 34

DRYSOL _____________ 26

DUAC ______________ 26

DUAVEE ____________ 32

DUET DHA BALANCED _ 39

DUEXIS ______________ 4

DULERA ______________ 7

duloxetine hcl _________ 9

duloxetine hydrochloride 9

DUOBRII ____________ 26

DUODOTE ___________ 11

DUOPA _____________ 18

DUPIXENT ___________ 26

duramorph ___________ 5

DURASAFE

SPINAL/EPIDURAL __ 36

DUREZOL ___________ 42

DUROLANE __________ 41

dutasteride __________ 33

dutasteride/tamsulosin hc

_________________ 33

DYANAVEL XR ________ 3

DYAZIDE ____________ 30

DYMISTA____________ 41

DYRENIUM __________ 30

DYSPORT ___________ 41

E

e.e.s. 400 ___________ 36

E.E.S. GRANULES _____ 36

EC-NAPROXEN ________ 4

econazole nitrate _____ 26

ECOZA ______________ 26

EDARBI _____________ 14

EDARBYCLOR ________ 14

EDECRIN ____________ 30

EDEX _______________ 21

EDLUAR _____________ 35

ed-spaz _____________ 46

EDURANT ___________ 19

eemt _______________ 32

eemt hs _____________ 32

efavirenz ____________ 19

effer-k ______________ 37

EFFER-K TAB 20MEQ 37

EFFEXOR XR __________ 9

EFFIENT _____________ 34

EFUDEX _____________ 26

ELELYSO ____________ 34

ELESTRIN ____________ 32

ELETONE TWINPACK __ 26

eletriptan hydrobromide 37

ELFOLATE ___________ 29

ELIDEL ______________ 26

ELIGARD ____________ 16

elinest ______________ 22

ELIQUIS ______________ 8

ELITEK ______________ 16

elite-ob _____________ 39

ELIXOPHYLLIN _________ 7

ELLA ________________ 22

ELLENCE ____________ 16

ELMIRON ____________ 33

ELOCON _____________ 26

ELOCTATE ___________ 34

EMCYT ______________ 16

EMEND _____________ 12

EMEND TRIPACK ______ 12

EMFLAZA ____________ 24

EMGALITY ___________ 37

EMPLICITI ___________ 16

EMSAM ______________ 9

EMVERM _____________ 6

ENABLEX ____________ 47

enalapril maleate _____ 14

enalapril maleate/hydroch

_________________ 14

enalaprilat ___________ 14

ENBRACE HR _________ 39

ENBREL ______________ 4

ENBREL MINI _________ 4

ENBREL SURECLICK _____ 4

endocet ______________ 5

ENDOCRINE AND

METABOLIC AGENTS -

MISC. ____________ 31

ENDOMETRIN ________ 48

ENGERIX-B __________ 47

ENLYTE _____________ 29

enoxaparin sodium _____ 8

enpresse-28 _________ 22

enskyce _____________ 22

ENSTILAR ___________ 26

entacapone __________ 18

entecavir ____________ 19

ENTERAGAM _________ 29

ENTOCORT EC ________ 24

ENTRESTO ___________ 21

ENTTY SPRAY EMULSION

_________________ 26

ENTYVIO ____________ 32

enulose _____________ 32

ENVARSUS XR ________ 38

EPANED _____________ 14

EPCLUSA ____________ 19

EPICERAM ___________ 26

EPICYN _____________ 26

EPIDIOLEX ____________ 8

EPIDUO _____________ 26

EPIDUO FORTE _______ 26

EPIFOAM ____________ 26

epinastine hcl ________ 42

EPIPEN 2-PAK ________ 48

EPIPEN-JR 2-PAK ______ 48

epirubicin hcl _________ 16

EPISNAP_____________ 48

epitol ________________ 8

EPIVIR ______________ 19

EPIVIR HBV SOL 5MG/ML

_________________ 19

EPIVIR HBV TAB 100MG

_________________ 19

eplerenone __________ 14

EPOGEN _____________ 34

epoprostenol sodium __ 21

eprosartan mesylate ___ 14

eptifibatide __________ 34

EQUETRO____________ 18

ERAXIS ______________ 12

ergocalciferol_________ 48

ERGOMAR ___________ 37

ergotamine tartrate/caffe

_________________ 37

ERIVEDGE ___________ 16

erlotinib hydrochloride _ 16

errin ________________ 22

ERTACZO ____________ 26

ertapenem sodium ____ 15

ERY _________________ 26

ERYGEL _____________ 26

ERYPED 200 __________ 36

ERYPED 400 __________ 36

ery-tab ______________ 36

ERYTHROCIN

LACTOBIONATE ____ 36

ERYTHROCIN STEARATE 36

erythromycin base ____ 36

erythromycin cap _____ 36

erythromycin dr ______ 36

erythromycin ethylsuccina

_________________ 36

erythromycin gel 2% ___ 26

erythromycin oin 5mg/gm

_________________ 42

erythromycin/benzoyl pero

_________________ 26

ESBRIET _____________ 45

escitalopram oxalate ____ 9

esmolol hcl __________ 20

esomeprazole magnesium

_________________ 46

esomeprazole sodium __ 46

estarylla _____________ 22

estazolam ___________ 35

esterified estrogens/meth

_________________ 32

ESTRACE TAB ______ 32

ESTRACE VAG CRE 0.01%

_________________ 48

estradiol__________ 32, 48

estradiol vag tab _____ 48

estradiol valerate _____ 32

estradiol/norethindrone a

_________________ 32

55

ESTRING ____________ 48

ESTRIOL-PROGESTERONE

COMP ___________ 32

ESTROGEL ___________ 32

Estrogens ___________ 32

ESTROSTEP FE _______ 22

eszopiclone _________ 35

ethacrynic acid _______ 30

ethambutol hcl _______ 15

ethambutol hydrochloride

_________________ 15

ethosuximide _________ 8

ETHYL CHLORIDE/FINE

STREA ___________ 26

ethyl chloride/mist____ 26

ethynodiol diacetate/ethi

_________________ 22

etidronate disodium __ 31

etodolac _____________ 4

etodolac er ___________ 4

etomidate ___________ 33

ETOPOPHOS _________ 16

etoposide ___________ 16

EUCRISA ____________ 26

EUFLEXXA ___________ 41

EURAX _____________ 26

euthyrox ____________ 46

EVAMIST ___________ 32

EVEKEO______________ 3

EVEKEO ODT _________ 3

EVISTA _____________ 31

EVOCLIN ____________ 26

EVOTAZ ____________ 19

EXELDERM __________ 26

EXELON_____________ 45

exemestane _________ 16

EXFORGE ___________ 14

EXFORGE HCT________ 14

EXJADE _____________ 11

EXODERM___________ 26

exotic-hc ____________ 44

EXTAVIA ____________ 45

EXTINA _____________ 26

EXTRANEAL _________ 38

EYLEA ______________ 42

ezetimibe ___________ 13

ezetimibe/simvastatin _ 13

F

fabb _______________ 34

FABIOR _____________ 26

FABRAZYME _________ 31

falmina _____________ 22

famciclovir __________ 19

famotidine __________ 46

famotidine inj _______ 46

famotidine premixed __ 46

FANAPT ____________ 18

FARXIGA ____________ 10

FARYDAK ___________ 16

FASENRA _____________ 7

FASENRA PEN _________ 7

FASLODEX ___________ 16

fayosim _____________ 22

FAZACLO ____________ 18

febuxostat___________ 34

felbamate ____________ 8

FELBATOL ____________ 8

FELDENE _____________ 4

felodipine er _________ 21

FEM PH _____________ 48

FEMARA ____________ 16

FEMCAP ____________ 36

FEMHRT LOW DOSE ___ 32

FEMRING ___________ 48

femynor ____________ 22

FENOFIBRATE CAP ___ 13

fenofibrate tab ______ 13

fenofibrate micronized 13

fenofibric acid dr _____ 13

FENOPROFEN CAP

400MG ____________ 4

fenoprofen tab 600mg _ 4

fentanyl ______________ 5

FENTANYL CITRATE ____ 5

fentanyl citrate oral tra _ 5

FERAHEME __________ 34

FERIVA 21/7 _________ 34

FERIVAFA ___________ 34

ferocon _____________ 34

ferotrinsic ___________ 34

FERRALET 90 _________ 34

FERRAPLUS 90 _______ 34

FERRLECIT ___________ 34

FETZIMA _____________ 9

FETZIMA TITRATION PACK

__________________ 9

FIASP _______________ 10

FIASP FLEXTOUCH ____ 10

FIASP PENFILL ________ 10

FINACEA AER 15% __ 26

FINACEA GEL 15% __ 26

finasteride___________ 33

FIORICET ___________ 4, 5

FIORICET/CODEINE ____ 5

FIORINAL __________ 4, 5

FIORINAL/CODEINE #3 _ 5

FIRAZYR ____________ 34

FIRST-BACLOFEN 5 ____ 41

FIRST-LANSOPRAZOLE _ 46

FIRST-METRONIDAZOLE

100 ______________ 15

FIRST-METRONIDAZOLE 50

_________________ 15

FIRST-MOUTHWASH BLM

_________________ 39

FIRST-OMEPRAZOLE __ 46

FIRST-PROGESTERONE

VGS 20 ___________ 48

FIRVANQ ____________ 15

FLAGYL _____________ 15

FLAREX _____________ 42

flavoxate hcl _________ 47

FLEBOGAMMA DIF ____ 44

flecainide acetate ______ 7

FLECTOR ____________ 27

flexbumin ___________ 34

FLOLAN _____________ 21

FLOLIPID ____________ 13

FLOMAX ____________ 33

FLORIVA PLUS ________ 39

FLOVENT DISKUS ______ 7

FLOVENT HFA _________ 7

floxuridine ___________ 16

FLUAD 2019-2020 _____ 47

FLUARIX QUADRIVALENT

2019 _____________ 47

FLUBLOK QUADRIVALENT

2019 _____________ 47

FLUCELVAX

QUADRIVALENT 20 _ 47

fluconazole __________ 12

fluconazole in nacl ____ 12

flucytosine ___________ 12

fludarabine phosphate _ 16

fludrocortisone acetate 24

FLULAVAL QUADRIVALENT

201 ______________ 47

flumazenil ___________ 11

flunisolide ___________ 41

fluocinolone acetonide _ 44

fluocinonide _________ 27

FLUORABON _________ 37

fluoride _____________ 37

fluoritab ____________ 37

fluorometholone _____ 42

FLUOROPLEX_________ 27

Fluoroquinolones _____ 32

fluorouracil _______ 16, 27

FLUOROURACIL CRE 0.5%

_________________ 27

fluorouracil cre 5% ____ 27

FLUOXETINE TAB 60MG 9

fluoxetine dr __________ 9

fluoxetine hcl _________ 9

fluphenazine decanoate 18

fluphenazine hcl ______ 18

FLUPHENAZINE

HYDROCHLORID ___ 18

flurandrenolide _______ 27

flurazepam hcl _______ 35

flurbiprofen ________ 4, 42

flurbiprofen sodium ___ 42

flutamide ____________ 16

fluticasone oin 0.005% 27

fluticasone spr 50mcg _ 41

fluticasone/salmeterol

aero ______________ 7

FLUTICASONE/SALMETER

OL INH ____________ 7

fluvastatin ___________ 13

fluvastatin sodium er __ 13

fluvoxamine maleate ___ 9

fluvoxamine maleate er _ 9

FLUZONE HIGH-DOSE PF

2019 _____________ 47

FLUZONE QUADRIVALENT

2019 _____________ 47

FML ________________ 42

FML FORTE __________ 42

FML LIQUIFILM _______ 42

FOCALIN _____________ 3

FOCALIN XR ___________ 3

folbee ___________ 34, 39

folbee plus ___________ 39

folbic _______________ 29

FOLBIC RF ___________ 29

FOLGARD OS _________ 39

FOLGARD RX _________ 34

folic acid ____________ 35

folic acid/vitamin b-6/vi 35

FOLIVANE-F __________ 35

FOLIVANE-OB ________ 39

FOLIVANE-PLUS ______ 35

FOLLISTIM AQ ________ 31

FOLTANX RF _________ 29

foltrin _______________ 35

FOLTX ______________ 29

fomepizole ___________ 12

fondaparinux sodium ___ 8

FORANE _____________ 33

FORFIVO XL ___________ 9

formaldehyde ________ 19

FORTEO _____________ 31

FOSAMAX ___________ 31

FOSAMAX PLUS D _____ 31

fosamprenavir calcium _ 19

FOSAPREPITANT

DIMEGLUMINE _____ 12

fosinopril sodium _____ 14

fosinopril sodium/hydroch

_________________ 14

fosphenytoin sodium ___ 8

FOSRENOL ___________ 32

FRAGMIN ____________ 8

frovatriptan succinate __ 37

FULPHILA ____________ 35

furosemide __________ 30

furosemide inj _______ 30

FUSION PLUS _________ 35

FUZEON _____________ 19

fyavolv ______________ 32

FYCOMPA ____________ 8

G

gabapentin ___________ 8

GABITRIL _____________ 8

56

GALAFOLD __________ 31

galantamine hydrobromide

_________________ 45

GALZIN _____________ 37

GAMASTAN _________ 44

GAMASTAN S/D ______ 44

GAMMAGARD LIQUID _ 44

GAMMAGARD S/D IGA

LESS TH __________ 44

GAMMAKED ________ 44

GAMUNEX-C ________ 44

GANCICLOVIR________ 19

GARDASIL 9 _________ 47

GASTROCROM _______ 32

GASTROINTESTINAL

AGENTS - MISC. ___ 32

gatifloxacin __________ 42

gavilyte-c ___________ 36

gavilyte-n/flavor pack _ 36

GEBAUERS SPRAY AND

STRETC___________ 27

GELFILM OP _________ 42

GEL-FLOW __________ 35

GELNIQUE __________ 47

GEL-ONE ____________ 41

GEMCITABINE _______ 16

gemcitabine hcl ______ 16

gemfibrozil __________ 13

GENADUR ___________ 27

GENERAL ANESTHETICS 33

GENERESS FE ________ 22

generlac ____________ 32

gengraf _____________ 38

GENICIN VITA-D ______ 35

GENITOURINARY AGENTS -

MISCELLANEOUS __ 33

GENOTROPIN ________ 31

GENOTROPIN MINIQUICK

_________________ 31

GENTAK ____________ 42

gentamicin oin 0.1% __ 27

gentamicin sol 0.3% op 42

gentamicin sulfate _____ 3

GENVOYA ___________ 19

GEODON____________ 18

gianvi ______________ 22

GILENYA ____________ 45

GILOTRIF ___________ 16

GILTUSS TR __________ 25

GLASSIA ____________ 45

glatiramer acetate ____ 45

glatopa _____________ 45

GLEEVEC ____________ 16

GLEOSTINE __________ 16

GLIADEL WAFER ______ 16

glimepiride __________ 10

glipizide ____________ 10

glipizide er __________ 10

glipizide xl ___________ 10

glipizide/metformin hydro

_________________ 10

GLUCAGEN HYPOKIT __ 10

GLUCAGON EMERGENCY

KIT ______________ 10

GLUCOPHAGE ________ 10

GLUCOPHAGE XR _____ 10

GLUCOTROL _________ 10

GLUCOTROL XL _______ 10

GLUMETZA __________ 10

glyburide ____________ 10

glyburide micronized __ 10

glyburide/metformin hydro

_________________ 10

GLYCATE ____________ 46

glycine ______________ 33

glycopyrrolate inj

0.2mg/ml _________ 46

glycopyrrolate tab 1mg 46

glydo _______________ 27

GLYNASE ____________ 10

GLYSET _____________ 10

GLYTACTIN BETTERMILK

15 _______________ 30

GLYTACTIN BETTERMILK

DE-L _____________ 30

GLYTACTIN BUILD 10PE 30

GLYTACTIN BUILD 20/20

PKU _____________ 30

GLYTACTIN COMPLETE

10PE _____________ 30

GLYTACTIN RESTORE 10 30

GLYTACTIN RESTORE 5 30

GLYTACTIN RESTORE LITE

10 _______________ 30

GLYTACTIN RTD 10 ____ 30

GLYTACTIN RTD 15 ____ 30

GLYTACTIN RTD LITE 15 30

GLYTACTIN SWIRL 15PE 30

GLYXAMBI __________ 10

GOLYTELY ___________ 36

GONAL-F ____________ 31

GONAL-F RFF REDIJECT 31

GORDOFILM _________ 27

Gout Agents _________ 33

grafco silver nitrate app 27

GRALISE ____________ 45

GRALISE STARTER ____ 45

granisetron inj 1mg/ml 12

granisetron hcl _______ 12

griseofulvin microsize__ 12

griseofulvin ultramicrosi 12

guanfacine er _________ 3

guanfacine hcl _______ 14

GUANIDINE HCL ______ 15

GYNAZOLE-1 _________ 48

H

hailey 24 fe __________ 22

halcinonide __________ 27

HALCION ____________ 35

HALOBETASOL AER 0.05%

_________________ 27

halobetasol cre 0.05% _ 27

HALOG______________ 27

haloperidol __________ 19

haloperidol decanoate _ 19

haloperidol lactate ____ 19

HARVONI ___________ 19

HAVRIX _____________ 47

hc butyrate cre 0.1% __ 27

hc butyrate sol 0.1% __ 27

hc pramoxine cre 1-1% __ 6

hc pramoxine cre 2.5-1% 27

HEALON ____________ 42

HEALON GV __________ 42

HEALON5 ___________ 42

heather _____________ 22

HEMABATE __________ 44

HEMANGEOL ________ 20

hematinic/folic acid ___ 35

HEMATOGEN FA ______ 35

hematogen forte ______ 35

HEMATOLOGICAL AGENTS

- MISC. ___________ 34

HEMATOPOIETIC AGENTS

_________________ 34

HEMATRON-AF _______ 35

HEMLIBRA ___________ 34

hemmorex-hc _________ 6

hemocyte-f __________ 35

HEMOFIL M __________ 34

HEMOSTATICS _______ 35

heparin lock flush ______ 8

heparin sodium ________ 8

heparin sodium/d5w ___ 8

heparin sodium/nacl 0.9% 8

HEPLISAV-B __________ 47

HERCEPTIN __________ 16

HESPAN _____________ 34

hetastarch 6%/nacl ____ 34

HEXTEND ____________ 34

hidex 6-day __________ 24

HIPREX _____________ 47

HIZENTRA ___________ 44

HOMACTIN AA PLUS __ 30

homatropine hbr _____ 42

HORIZANT ___________ 45

HPR PLUS ___________ 27

HUMALOG __________ 10

HUMALOG JUNIOR

KWIKPEN _________ 10

HUMALOG KWIKPEN __ 10

HUMALOG MIX 50/50 _ 10

HUMALOG MIX 50/50

KWIKPEN _________ 10

HUMALOG MIX 75/25 _ 10

HUMALOG MIX 75/25

KWIKPEN _________ 10

HUMATROPE _________ 31

HUMATROPE COMBO

PACK _____________ 31

HUMIRA _____________ 4

HUMIRA PEDIATRIC

CROHNS D _________ 4

HUMIRA PEN __________ 4

HUMIRA PEN-CD/UC/HS

START _____________ 4

HUMIRA PEN-PS/UV

STARTER ___________ 4

HUMULIN R U-500

(CONCENTR _______ 11

HUMULIN R U-500

KWIKPEN _________ 11

HYALGAN ___________ 41

HYCAMTIN CAP 0.25MG

_________________ 16

HYCAMTIN INJ 4MG _ 16

HYCLODEX ___________ 27

hydralazine inj _______ 14

hydralazine hcl _______ 14

hydralazine hydrochloride

_________________ 14

HYDREA _____________ 16

HYDRO 35 ___________ 27

HYDRO 40 FOAM _____ 27

hydrochlorothiazide ___ 30

hydrocodone bitartrate/ac

__________________ 5

hydrocodone bitartrate/ho

_________________ 25

hydrocodone polistirex/ch

_________________ 25

hydrocodone/acetaminoph

en ________________ 5

hydrocodone/ibuprofen _ 5

hydrocort cre 1% ____ 27

hydrocort ene 100mg __ 6

hydrocort tab 5mg ___ 24

hydrocort ac sup 25mg __ 6

hydrocortisone valerate 27

hydrocortisone/acetic aci

_________________ 44

hydrocortisone/iodoquinol

_________________ 27

HYDROFERA BLUE FOAM

DRESS ____________ 27

HYDROFERA BLUE READY

FOAM ____________ 27

hydromet ____________ 25

hydromorphon inj 2mg/ml

__________________ 5

hydromorphon inj 4mg/ml

__________________ 5

hydromorphon sup 3mg _ 5

hydromorphone hcl tab _ 5

hydromorphone hcl er __ 5

hydromorphone

hydrochlori _________ 5

57

hydroquinone ________ 27

hydroquinone time release

_________________ 27

hydroxocobalamin ____ 35

hydroxychloroquine sulfat

_________________ 15

hydroxyprogesterone

capro ____________ 44

hydroxyurea _________ 16

hydroxyzine hcl inj _____ 7

hydroxyzine hcl tab ____ 7

hydroxyzine pamoate __ 7

HYLATOPIC PLUS _____ 27

hylavite _____________ 39

HYLENEX ____________ 38

HYOPHEN ___________ 47

hyoscyamine sub 0.125mg

_________________ 46

hyoscyamine tab 0.125mg

_________________ 46

hyoscyamine sulfate er 46

hyosyne ____________ 46

HYPERHEP B S/D _____ 44

HYPERLYTE-CR _______ 37

HYPERRAB __________ 44

HYPERRAB S/D _______ 44

HYPERRHO S/D ______ 44

HYPERRHO S/D MINI-

DOSE ____________ 44

HYPERTET S/D _______ 44

HYPNOTICS/SEDATIVES/SL

EEP DISORDER AGENTS

_________________ 35

HYPOCYN ___________ 27

HYQVIA ____________ 44

HYSINGLA ER _________ 5

HYZAAR ____________ 14

I

ibandronate inj ______ 31

ibandronate sodium __ 31

IBRANCE ____________ 16

ibu __________________ 4

ibuprofen ____________ 4

icatibant acetate _____ 34

IDAMYCIN PFS _______ 16

idarubicin hcl ________ 16

IFEX ________________ 16

ILARIS _______________ 4

ILEVRO _____________ 42

ILUMYA ____________ 27

imatinib mesylate ____ 16

IMBRUVICA _________ 16

IMFINZI _____________ 16

imipenem/cilastatin ___ 15

imipramine hcl ________ 9

imipramine pamoate ___ 9

imiquimod __________ 27

IMIQUIMOD PUMP ___ 27

IMITREX ____________ 37

IMITREX STATDOSE REFILL

_________________ 37

IMITREX STATDOSE

SYSTEM __________ 37

IMOGAM RABIES-HT __ 44

IMOVAX RABIES (H.D.C.V.)

_________________ 47

IMPOYZ _____________ 27

IMURAN ____________ 38

IMVEXXY MAINTENANCE

PACK ____________ 48

IMVEXXY STARTER PACK

_________________ 48

INBRIJA _____________ 18

INCRELEX ___________ 31

INCRUSE ELLIPTA ______ 7

indapamide __________ 30

INDERAL LA _________ 20

INDOCIN _____________ 4

indomethacin cap ______ 4

indomethacin er _______ 4

indomethacin inj 1mg __ 4

indomethacin sr _______ 4

INFED ______________ 35

INFLECTRA __________ 32

INFUMORPH 200 ______ 5

INFUMORPH 500 ______ 5

INGREZZA ___________ 45

INJECTAFER _________ 35

INLYTA _____________ 16

INSPRA _____________ 14

INSULIN LISPRO ______ 11

INSULIN LISPRO KWIKPEN

_________________ 11

INTEGRA F __________ 35

INTEGRA PLUS _______ 35

INTEGRILIN __________ 34

INTELENCE __________ 19

INTRAROSA _________ 48

INTRON A ___________ 16

introvale ____________ 22

INTUNIV _____________ 3

INVANZ _____________ 15

INVEGA _____________ 19

INVEGA SUSTENNA ___ 19

INVEGA TRINZA ______ 19

INVELTYS ___________ 42

INVIRASE ___________ 19

INVOKAMET _________ 11

INVOKAMET XR ______ 11

INVOKANA __________ 11

iodine strong ________ 37

iodoquinol/hydrocortisone

_________________ 27

IONOSOL-MB/DEXTROSE

5% ______________ 37

IOPIDINE ____________ 42

IPOL INACTIVATED IPV 47

ipratropium spray ____ 41

ipratropium bromide ___ 7

ipratropium bromide/albut

__________________ 7

irbesartan ___________ 14

irbesartan/hydrochlorothi

_________________ 14

IRESSA ______________ 16

irinotecan hcl ________ 16

irinotecan hydrochloride 16

IROSPAN 24/6 _______ 35

ISENTRESS ___________ 19

ISENTRESS HD ________ 19

isibloom _____________ 22

ISOLYTE-P/DEXTROSE 5%

_________________ 37

ISOLYTE-S ___________ 37

ISOLYTE-S PH 7.4 _____ 37

isoniazid ____________ 15

isoniazid inj _________ 15

isoproterenol hydrochlori 7

ISOPTIN SR __________ 21

ISOPTO ATROPINE ____ 42

ISOPTO CARPINE _____ 42

ISORDIL TITRADOSE ____ 6

isosorbide dinitrate ____ 6

isosorbide dinitrate sa __ 6

isosorbide mononitrate _ 6

isosorbide mononitrate er 6

isotretinoin __________ 27

ISOVACTIN AA PLUS ___ 30

isradipine ___________ 21

ISTALOL _____________ 42

ISUPREL ______________ 7

itraconazole _________ 12

ivermectin cre 1% ____ 27

ivermectin tab 3mg ____ 6

IXIARO ______________ 47

J

JADENU _____________ 12

JADENU SPRINKLE ____ 12

JAKAFI ______________ 16

JALYN ______________ 33

jantoven _____________ 8

JANUMET ___________ 11

JANUMET XR_________ 11

JANUVIA ____________ 11

JARDIANCE __________ 11

jasmiel ______________ 22

jencycla _____________ 23

JENTADUETO ________ 11

JENTADUETO XR ______ 11

JETREA______________ 42

JEVTANA ____________ 16

jinteli _______________ 32

JIVI _________________ 34

jolessa ______________ 23

JORNAY PM __________ 3

JUBLIA ______________ 27

juleber ______________ 23

JULUCA _____________ 19

junel 1.5/30 __________ 23

junel 1/20 ___________ 23

junel fe 1.5/30 ________ 23

junel fe 1/20 _________ 23

junel fe 24 ___________ 23

K

KADIAN ______________ 5

kaitlib fe _____________ 23

KALETRA SOL ______ 19

KALETRA TAB 100-

25MG ____________ 19

KALYDECO ___________ 45

KAMDOY ____________ 27

KANUMA ____________ 31

KAPSPARGO SPRINKLE _ 20

KARBINAL ER _________ 12

kariva _______________ 23

kcl 0.075%/d5w/nacl

0.45% ____________ 37

kcl 0.15%/d5w/nacl 0.2%

_________________ 37

kcl 0.15%/d5w/nacl

0.225% ___________ 37

kcl 0.15%/d5w/nacl 0.45%

_________________ 37

kcl 0.15%/d5w/nacl 0.9%

_________________ 37

kcl 0.3%/d5w/nacl 0.45%

_________________ 37

KCL 0.3%/D5W/NACL 0.9%

_________________ 37

KEFLEX ______________ 22

kelnor 1/35 __________ 23

kelnor 1/50 __________ 23

KENALOG _________ 24, 27

KENALOG-10 _________ 24

KENALOG-40 _________ 24

KENALOG-80 _________ 24

KENGREAL ___________ 34

KEPPRA ______________ 8

KEPPRA XR ___________ 8

KERALAC ____________ 27

KERALYT ____________ 27

KERALYT SCALP _______ 27

KERYDIN ____________ 27

ketamine hcl _________ 33

ketoconazole cream ___ 27

ketoconazole tab ______ 12

ketoprofen er _________ 4

ketorolac sol 0.5% ___ 42

ketorolac tab 10mg ___ 4

ketorolac tromethamine _ 4

KETOVIE _____________ 30

KETOVIE PEPTIDE _____ 30

KEVZARA _____________ 4

KEYTRUDA ___________ 16

58

KINERET _____________ 4

kionex ______________ 38

KISQALI _____________ 16

KISQALI FEMARA 200

DOSE ____________ 16

KISQALI FEMARA 400

DOSE ____________ 16

KISQALI FEMARA 600

DOSE ____________ 16

KITABIS PAK __________ 3

KLARON ____________ 27

KLONOPIN ___________ 9

klor-con ____________ 37

klor-con 10 __________ 37

klor-con 8 ___________ 37

klor-con m10 ________ 37

KLOR-CON M15 ______ 37

klor-con m20 ________ 37

klor-con sprinkle _____ 37

klor-con/ef __________ 37

KOGENATE FS _______ 34

KOMBIGLYZE XR _____ 11

KORLYM ____________ 11

KOVALTRY __________ 34

K-PHOS __________ 33, 37

K-PHOS NEUTRAL ____ 37

K-PHOS NO 2 ________ 33

k-prime _____________ 37

KRINTAFEL __________ 15

KRISTALOSE _________ 36

K-TAB ______________ 37

K-TAB TAB 20MEQ 37

kurvelo _____________ 23

KUVAN _____________ 31

KYLEENA ____________ 23

KYMRIAH ___________ 17

L

labetalol inj ________ 20

labetalol hydrochloride 20

LAC-HYDRIN _________ 27

LACRISERT __________ 42

lactated ringers ___ 37, 38

lactated ringers irrigati 38

LACTATED RINGERS

VIAFLEX __________ 37

lactulose ____________ 36

LAMICTAL ____________ 9

LAMICTAL CHEWABLE

DISPERS ___________ 9

LAMICTAL ODT _______ 9

LAMICTAL STARTER/NOT

TAKI ______________ 9

LAMICTAL

STARTER/TAKING C _ 9

LAMICTAL

STARTER/TAKING V _ 9

LAMICTAL XR _________ 9

lamivudine __________ 19

lamivudine/zidovudine 19

lamotrigine ___________ 9

lamotrigine er _________ 9

lamotrigine odt ________ 9

lamotrigine starter kit/g _ 9

lamotrigine starter kit/o_ 9

lansoprazole _________ 46

lansoprazole odt ______ 46

lansoprazole/amoxicillin/

_________________ 46

lanthanum carbonate __ 32

LANTUS _____________ 11

LANTUS SOLOSTAR ___ 11

larin 1.5/30 __________ 23

larin 1/20 ___________ 23

larin 24 fe ___________ 23

larin fe 1.5/30 ________ 23

larin fe 1/20 _________ 23

larissia ______________ 23

LARTRUVO __________ 17

LASIX _______________ 30

LASTACAFT __________ 42

latanoprost __________ 42

LATISSE _____________ 27

LATUDA ____________ 19

LAVARE WOUND WASH 27

LAXATIVES __________ 36

layolis fe ____________ 23

LAZANDA ____________ 5

LEDIPASVIR/SOFOSBUVIR

_________________ 19

leflunomide __________ 4

LENVIMA 12MG DAILY

DOSE ____________ 17

LESCOL XL ___________ 13

lessina ______________ 23

LETAIRIS ____________ 21

letrozole ____________ 17

leucovorin calcium ____ 17

leucovorin calcium inj _ 17

LEUCOVORIN CALCIUM

TAB 10MG ________ 17

LEUKERAN __________ 17

LEUKINE ____________ 35

leuprolide acetate ____ 17

levalbuterol __________ 7

levalbuterol hcl ________ 7

LEVALBUTEROL TARTRATE

HFA ______________ 7

LEVEMIR ____________ 11

LEVEMIR FLEXTOUCH _ 11

levetiracetam _________ 9

levetiracetam er _______ 9

levetiracetam inj_______ 9

LEVICYN ____________ 27

levicyn dermal spray __ 27

LEVITRA ____________ 21

levobunolol hcl _______ 43

levocarnitine _________ 31

levocetirizine dihydrochl 12

levofloxacin _______ 32, 43

levofloxacin in d5w ____ 32

levofloxacin inj _______ 32

levofloxacin sol 0.5% __ 43

levoleucovorin _______ 17

levoleucovorin calcium _ 17

LEVOMEFOLATE CALCIUM

ALGA ____________ 30

LEVOMEFOLATE

CALCIUM/N-AC ____ 30

LEVOMEFOLATE

CALCIUM/PYRI_____ 30

levonest _____________ 23

levonorgestrel and ethiny

_________________ 23

levonorgestrel/ethinyl es23

LEVOPHED___________ 48

levora 0.15/30-28 _____ 23

levothyroxine sodium __ 46

levothyroxine/liothyronin

_________________ 46

levoxyl ______________ 46

LEVSIN ______________ 46

LEVULAN KERASTICK __ 27

LEXAPRO _____________ 9

LEXETTE _____________ 27

LIALDA ______________ 32

LIBRAX______________ 46

lidocaine __ 6, 7, 27, 36, 39

lidocaine inj ________ 36

lidocaine sol ________ 27

LIDOCAINE AND

TETRACAINE_______ 27

lidocaine hcl in d5w ____ 7

lidocaine hcl jelly _____ 27

LIDOCAINE HCL/DEXTROSE

_________________ 36

lidocaine viscous ______ 39

lidocaine/epinephrine _ 36

lidocaine/hc cre 3%-0.5% 6

lidocaine/prilocaine ___ 27

LIDODERM __________ 27

LIDO-HYDRO GEL 2.8-0.55

__________________ 6

lidozion _____________ 27

LILETTA _____________ 23

lillow _______________ 23

LINCOCIN ___________ 15

lindane _____________ 27

linezolid _____________ 15

linezolid inj 2mg/ml __ 15

LINZESS _____________ 32

liothyronine sodium ___ 46

LIPITOR _____________ 13

LIPOFEN ____________ 13

lisinopril_____________ 14

lisinopril/hydrochlorothi 14

lithium ______________ 19

lithium carbonate _____ 19

lithium carbonate er ___ 19

LITHOSTAT __________ 33

LIVALO ______________ 13

livixil pak ____________ 27

LMD 10% DEXTROSE 5% 34

LMD 10% SODIUM

CHLORIDE 0 _______ 34

L-METHYL-B6-B12 _____ 30

L-METHYLFOLATE _____ 30

L-METHYLFOLATE CA/S-

ALGAL ____________ 30

L-METHYLFOLATE FORTE

_________________ 30

L-METHYL-MC NAC ____ 30

LO LOESTRIN FE ______ 23

LOCAL ANESTHETICS-

Parenteral ________ 36

LOCOID _____________ 27

LOCOID LIPOCREAM ___ 27

LODOSYN____________ 18

LOESTRIN 1.5/30-21 ___ 23

LOESTRIN FE 1.5/30 ___ 23

LOESTRIN FE 1/20 _____ 23

LOKELMA ____________ 38

LOMAIRA _____________ 3

LOMOTIL ____________ 11

LONSURF ____________ 17

loperamide hcl _______ 11

LOPID _______________ 13

lopinavir/ritonavir _____ 19

lopreeza _____________ 32

LOPRESSOR _______ 14, 20

LOPRESSOR HCT ______ 14

lorazepam ____________ 7

lorazepam inj ________ 7

lorazepam intensol _____ 7

LORBRENA ___________ 17

lorcet ________________ 5

lorcet hd _____________ 5

LORTAB ______________ 5

loryna _______________ 23

LORZONE ____________ 41

losartan potassium ____ 14

losartan potassium/hydroc

_________________ 14

LOTEMAX ___________ 43

LOTEMAX SM ________ 43

LOTENSIN ___________ 14

LOTENSIN HCT________ 14

loteprednol etabonate _ 43

LOTREL______________ 14

LOTRISONE __________ 27

lovastatin ____________ 13

LOVAZA _____________ 13

LOVENOX ____________ 8

low-ogestrel _________ 23

loxapine _____________ 19

loxapine succinate_____ 19

LOYON ______________ 27

lo-zumandimine ______ 23

LUCEMYRA __________ 45

59

ludent ______________ 37

LUGOLS STRONG IODINE

_________________ 19

LULICONAZOLE ______ 27

LUMIGAN ___________ 43

LUMIZYME __________ 31

LUMOXITI ___________ 17

LUNESTA ___________ 35

LUPANETA PACK _____ 31

LUPRON DEPOT INJ

11.25MG _________ 17

LUPRON DEPOT INJ

22.5MG __________ 17

LUPRON DEPOT INJ

3.75MG __________ 17

LUPRON DEPOT INJ 30MG

_________________ 17

LUPRON DEPOT INJ 45MG

_________________ 17

LUPRON DEPOT INJ 7.5MG

_________________ 17

LUPRON DEPOT-PED (1-

MONTH __________ 31

LUPRON DEPOT-PED (3-

MONTH __________ 31

lutera ______________ 23

LUXIQ ______________ 27

LUZU _______________ 27

LYNPARZA __________ 17

LYRICA ___________ 9, 45

LYRICA CR ___________ 45

LYSODREN __________ 17

M

MACROBID __________ 47

MACROLIDES ________ 36

MAKENA____________ 44

MALARONE _________ 15

malathion ___________ 27

mannitol ____________ 30

maprotiline hcl _______ 10

MARCAINE __________ 36

MARCAINE SPINAL ___ 36

MARCAINE/EPINEPHRINE

_________________ 36

MARINOL ___________ 12

marlissa ____________ 23

MARNATAL-F ________ 39

MARPLAN___________ 10

MARQIBO ___________ 17

MATULANE _________ 17

matzim la ___________ 21

MAVYRET ___________ 19

MAXALT ____________ 37

MAXALT-MLT ________ 37

MAXIDEX ___________ 43

MAXIPIME __________ 22

MAXITROL __________ 43

MAXZIDE ___________ 30

MAXZIDE-25 _________ 30

MAYZENT ___________ 45

me/naphos/mb/hyo 1 _ 47

meclizine hcl _________ 12

meclofenamate sodium _ 4

MEDICAL DEVICES AND

SUPPLIES _________ 36

MEDROL ____________ 24

MEDROL DOSEPAK ___ 24

medroxyprogesterone inj

_________________ 23

medroxyprogesterone tab

_________________ 44

mefenamic acid _______ 4

mefloquine hcl _______ 15

megestrol acetate ____ 17

MEKINIST ___________ 17

MEKTOVI ___________ 17

melodetta 24 fe ______ 23

meloxicam ___________ 4

melphalan hydrochloride

_________________ 17

memantine hcl titration p

_________________ 45

memantine hydrochloride

_________________ 45

memantine hydrochloride

e ________________ 45

MENACTRA __________ 47

MENEST ____________ 32

MENOPUR __________ 31

MENOSTAR __________ 32

MENTAX ____________ 27

MENVEO ____________ 47

meperidine inj 25mg/ml 5

meperidine sol 50mg/5ml

__________________ 5

MEPHYTON _________ 48

meprobamate _________ 7

MEPRON ____________ 15

mercaptopurine ______ 17

meropenem _________ 15

MEROPENEM/SODIUM

CHLORIDE ________ 15

MERREM ____________ 15

mesalamine _________ 32

mesalamine dr _______ 32

mesna ______________ 17

MESNEX INJ 1GM __ 17

MESNEX TAB 400MG 17

MESTINON __________ 15

MESTINON TIMESPAN _ 15

METANX ____________ 30

metaxalone __________ 41

metformin hydrochloride

_________________ 11

metformin hydrochloride e

_________________ 11

methadone con 10mg/ml

__________________ 5

methadone inj 10mg/ml 5

METHADONE SOL

10MG/5ML ________ 5

METHADOSE __________ 5

methamphetamine hcl __ 3

methazolamide _______ 30

methenamine hippurate 47

methenamine mandelate

_________________ 47

methergine __________ 44

methimazole _________ 46

METHITEST ___________ 6

methocarbamol ______ 41

methocarbamol inj ___ 41

methotrexate ________ 17

methotrexate sodium __ 17

methoxsalen _________ 27

methscopolamine bromide

_________________ 46

methyldopa __________ 14

methyldopa/hydrochloroth

i _________________ 14

methylene blue _______ 12

methylergon inj 0.2mg/ml

_________________ 44

methylergonovine maleate

_________________ 44

METHYLIN ____________ 3

METHYLPHENIDATE CAP ER

__________________ 3

METHYLPHENIDATE TAB

ER ________________ 3

methylprednisolone ___ 24

methylprednisolone acetat

_________________ 24

methylprednisolone dose p

_________________ 24

methylprednisolone

sodium ___________ 24

methyltestosterone ____ 6

metoclopramide inj ___ 33

metoclopramide hcl ___ 33

metoclopramide

hydrochlor ________ 33

METOCLOPRAMIDE ODT33

metolazone __________ 30

metoprolol succinate er 20

metoprolol tartrate ___ 20

metoprolol tartrate tab 20

metoprolol/hydrochlorothi

_________________ 14

METROCREAM _______ 27

METROGEL __________ 27

METROLOTION _______ 27

metronidazol gel ______ 27

metronidazole _____ 15, 48

metronidazole in nacl 0.7

_________________ 15

metronidazole tab ____ 15

metronidazole vaginal _ 48

mexiletine hcl _________ 7

mibelas 24 fe _________ 23

MICARDIS ___________ 14

MICARDIS HCT _______ 14

MICONAZOLE 3 _______ 48

MICONAZOLE

NITRATE/ZINC O ___ 27

MICRHOGAM ULTRA-

FILTERED__________ 44

microgestin 1.5/30 ____ 23

microgestin 1/20 ______ 23

microgestin fe ________ 23

microgestin fe 1.5/30 __ 23

midazolam inj _______ 35

midazolam hcl ________ 35

midazolam hydrochloride

_________________ 35

midodrine hcl ________ 48

midodrine hydrochloride 48

miglitol ______________ 11

miglustat ____________ 35

Migraine Products ____ 36

MIGRANAL __________ 37

mili _________________ 23

MILLIPRED ___________ 24

MILLIPRED DP ________ 24

milrinone in dextrose __ 21

milrinone lactate ______ 21

mimvey _____________ 32

mimvey lo ___________ 32

MIMYX _____________ 27

MINASTRIN 24 FE _____ 23

MINERALS AND

ELECTROLYTES _____ 37

MINIPRESS __________ 14

MINIVELLE ___________ 32

MINOCIN ____________ 45

minocycline hcl _______ 45

minocycline hcl er _____ 45

minocycline hydrochloride

_________________ 46

MINOLIRA ___________ 46

minoxidil ____________ 14

MIOCHOL-E __________ 43

MIOSTAT ____________ 43

MIRAPEX ____________ 18

MIRAPEX ER _________ 18

MIRCETTE ___________ 23

MIRENA _____________ 23

mirtazapine __________ 10

mirtazapine odt _______ 10

MIRVASO____________ 27

Miscellaneous Therapeutic

Classes ___________ 38

misoprostol __________ 46

MITIGARE ___________ 34

mitomycin ___________ 17

mitoxantrone hcl ______ 17

M-M-R II ____________ 47

M-NATAL PLUS _______ 39

60

MOBIC ______________ 4

modafinil ____________ 3

moexipril hcl _________ 14

mometasone oin 0.1% 27

mometasone spr 50mcg

_________________ 41

MONOJECT BONE

MARROW BIOP ____ 36

mono-linyah _________ 23

MONONINE _________ 34

MONOVISC __________ 41

MONSELS FERRIC

SUBSULFATE ______ 35

montelukast sodium ___ 7

MONUROL __________ 47

MORPHABOND ER _____ 5

morphine sul sup 5mg __ 5

morphine sul tab ______ 5

morphine sulfate er ____ 5

morphine sulfate inj ____ 5

MOTEGRITY _________ 33

MOUTH/THROAT/DENTAL

AGENTS __________ 39

MOVANTIK __________ 33

MOVIPREP __________ 36

MOXEZA ____________ 43

moxifloxacin sol ______ 43

moxifloxacin tab ______ 32

MOZOBIL ___________ 35

MS CONTIN __________ 5

MULPLETA __________ 35

MULTAQ _____________ 7

MULTIGEN __________ 35

MULTIGEN PLUS _____ 35

MULTIVIT/FL CHW

0.25MG __________ 40

MULTIVIT/FL CHW 0.5MG

_________________ 40

multivitamin with fluorid 40

multi-vitamin/fluoride dr40

multi-vitamin/fluoride/ir 40

MULTIVITAMINS _____ 39

mupirocin ___________ 27

MUSCULOSKELETAL

THERAPY AGENTS __ 41

MUSE ______________ 21

m-vit _______________ 40

MYCAMINE _________ 12

MYCOBUTIN _________ 15

mycophenolate inj ____ 38

mycophenolate mofetil 38

mycophenolic acid dr __ 38

MYDAYIS ____________ 3

MYFORTIC __________ 38

MYLOTARG _________ 17

MYOBLOC ___________ 41

myorisan ____________ 27

MYRBETRIQ _________ 47

MYSOLINE ___________ 9

MYTESI _____________ 11

MYXREDLIN _________ 11

N

nabumetone __________ 4

nadolol _____________ 20

NAFCILLIN ___________ 44

nafcillin sodium ______ 44

nafrinse _____________ 37

NAFRINSE

DAILY/ACIDULATED 39

NAFRINSE DAILY/NEUTRAL

_________________ 39

nafrinse drops________ 37

NAFRINSE WEEKLY ____ 39

naftifine hcl __________ 27

naftifine hydrochloride 28

NAFTIN _____________ 28

nalbuphine hcl ________ 5

naloxone hcl _________ 12

naltrexone hcl ________ 12

NAMENDA __________ 45

NAMENDA TITRATION PAK

_________________ 45

NAMENDA XR _______ 45

NAMENDA XR TITRATION

PACK ____________ 45

NAMZARIC __________ 45

naproxen_____________ 4

naproxen dr __________ 4

naproxen sodium ______ 4

naproxen sodium er ____ 4

naratriptan hcl _______ 37

NARCAN ____________ 12

NARDIL _____________ 10

NASAL AGENTS -

SYSTEMIC AND

TOPICAL __________ 41

NASCOBAL __________ 35

NASONEX ___________ 41

NATACYN ___________ 43

NATAZIA ____________ 23

nateglinide __________ 11

NATELLE ONE ________ 40

NATROBA ___________ 28

NATURE-THROID _____ 46

NEBUPENT __________ 15

NEBUSAL____________ 25

necon 0.5/35-28 ______ 23

NEEVO DHA _________ 40

nefazodone hcl _______ 10

nefazodone hydrochloride

_________________ 10

neo/poly/hc sus 1% otic 44

neo/poly/hc sus op ___ 43

NEOCERA ___________ 28

neomycin sulfate ______ 3

neomycin/bacitracin/poly

m _______________ 43

neomycin/polymyxin/bacit

r ________________ 43

neomycin/polymyxin/dexa

me ______________ 43

neomycin/polymyxin/gram

ic ________________ 43

neomycin/polymyxin/hc 44

neo-polycin __________ 43

neo-polycin hc _______ 43

NEORAL _____________ 38

NEOSALUS___________ 28

NEOSALUS CP ________ 28

neostigmine methylsulfate

_________________ 15

NEOTUSS PLUS _______ 25

NEPHRON FA ________ 35

NEPHRO-VITE RX _____ 40

NERLYNX ____________ 17

NESINA _____________ 11

NESTABS ONE ________ 40

NEUAC KIT __________ 28

NEULASTA ___________ 35

NEULASTA ONPRO KIT _ 35

NEUPOGEN __________ 35

NEUPRO ____________ 18

NEUROMUSCULAR

AGENTS __________ 41

NEURONTIN __________ 9

NEUT _______________ 37

NEUTRASAL _________ 39

NEVANAC ___________ 43

nevirapine ________ 19, 20

nevirapine er _________ 20

NEXAVAR ___________ 17

NEXAVIR ____________ 38

NEXIUM CAP 20MG 46

NEXIUM GRA DR ___ 46

NEXIUM I.V. _________ 46

NEXPLANON _________ 23

niacin er ____________ 13

NIACOR _____________ 13

NIASPAN ____________ 13

NICAPRIN ___________ 30

nicardipine cap _______ 21

nicardipine inj _______ 21

NICOMIDE ___________ 40

NICOTROL INHALER ___ 45

NICOTROL NS ________ 45

nifedipine ___________ 21

nifedipine er _________ 21

nikki ________________ 23

NIMBEX _____________ 41

nimodipine __________ 21

NINLARO ____________ 17

NIPENT _____________ 17

nisoldipine er ________ 21

nitisinone ___________ 31

NITRO-BID ____________ 6

NITRO-DUR ___________ 6

nitrofurantoin ________ 47

nitrofurantoin macrocryst

_________________ 47

nitrofurantoin monohydrat

_________________ 47

nitroglycer inj 5mg/ml __ 6

nitroglycerin er ________ 6

NITROGLYCERIN IN

DEXTROSE _________ 6

nitroglycerin lingual ____ 6

nitroglycerin transdermal 6

nitroglycern sub _______ 6

NITROMIST ___________ 6

NITROPRESS _________ 14

NITROSTAT ___________ 6

niva-fol ______________ 30

NIVATOPIC PLUS ______ 28

NIVESTYM ___________ 35

nizatidine ____________ 46

NIZATIDINE SOL

15MG/ML _________ 46

NIZORAL ____________ 28

nolix ________________ 28

nora-be _____________ 23

NORCO ______________ 5

NORDITROPIN FLEXPRO 31

norepinephrine bitartrate

_________________ 48

norethindrone _____ 23, 44

norethindrone & ethinyl e

_________________ 23

norethindrone acetate 23,

44

norethindrone acetate/eth

_________________ 23

norethindrone/ethinyl est

_________________ 23

norgestimate/ethinyl estr

_________________ 23

NORITATE ___________ 28

norlyda _____________ 23

normal saline flush ____ 37

NORMOSOL -R _______ 38

NORMOSOL-M IN D5W 38

NORMOSOL-R ________ 38

NORMOSOL-R IN D5W _ 38

NORPACE_____________ 7

NORPACE CR __________ 7

NORPRAMIN _________ 10

NORTHERA __________ 48

nortrel 0.5/35 (28) ____ 23

nortrel 1/35 __________ 23

nortrel 7/7/7 _________ 23

nortriptyline hcl_______ 10

nortriptyline hydrochlori 10

NORVASC ___________ 21

NORVIR SOL 80MG/ML

_________________ 20

NORVIR TAB 100MG 20

NOVAREL ____________ 31

NOVOEIGHT _________ 34

61

NOVOLOG __________ 11

NOVOLOG FLEXPEN ___ 11

NOVOLOG MIX 70/30 _ 11

NOVOLOG MIX 70/30

PREFILL __________ 11

NOVOLOG PENFILL ___ 11

NOVOSEVEN RT ______ 34

NOXAFIL ____________ 12

np thyroid 120 _______ 46

np thyroid 15 ________ 46

np thyroid 30 ________ 46

np thyroid 60 ________ 46

np thyroid 90 ________ 46

NPLATE _____________ 35

NUCALA _____________ 7

NUCORT ____________ 28

NUCYNTA ____________ 5

NUCYNTA ER _________ 5

nudiclo solupak ______ 28

NUEDEXTA __________ 45

NUFERA ____________ 35

NULOJIX ____________ 38

NULYTELY/FLAVOR PACKS

_________________ 36

NUMOISYN _________ 39

NUTRASEB __________ 28

NUTROPIN AQ NUSPIN 10

_________________ 31

NUTROPIN AQ NUSPIN 20

_________________ 31

NUTROPIN AQ NUSPIN 5

_________________ 31

NUVAIL _____________ 28

NUVARING __________ 23

NUVESSA ___________ 48

NUVIGIL _____________ 3

nyamyc _____________ 28

NYMALIZE __________ 21

nystatin cre ________ 28

nystatin susp_______ 39

nystatin tab________ 12

nystatin/triamcinolone 28

nystop ______________ 28

O

OB COMPLETE _______ 40

OB COMPLETE ONE ___ 40

OB COMPLETE PETITE _ 40

OB COMPLETE/DHA __ 40

OBIZUR _____________ 34

OBSTETRIX DHA ______ 40

obstetrix ec _________ 40

OBSTETRIX ONE ______ 40

O-CAL FA ___________ 40

O-CAL PRENATAL _____ 40

OCALIVA ____________ 33

ocella ______________ 23

OCREVUS ___________ 45

octreotide acetate ____ 31

OCUFLOX ___________ 43

ODEFSEY ____________ 20

OFEV _______________ 45

ofloxacin ______ 32, 43, 44

ofloxacin dro 0.3% op 43

ofloxacin dro 0.3%otic 44

ogestrel _____________ 23

okebo ______________ 46

olanzapine _______ 19, 45

olanzapine inj _______ 19

olanzapine odt _______ 19

olanzapine/fluoxetine _ 45

olmesartan medoxomil 14

olmesartan

medoxomil/amlo ___ 14

olmesartan

medoxomil/hydr ___ 14

olopatadine dro 0.1% _ 43

olopatadine spr 0.6%__ 41

olopatadine hydrochloride

_________________ 43

OLUMIANT ___________ 4

OLUX _______________ 28

OLUX-E _____________ 28

omega-3-acid ethyl esters

_________________ 13

omeprazole _______ 46, 47

omeprazole dr _______ 47

omeprazole/sodium

bicarbo ___________ 47

OMNARIS ___________ 41

OMNITROPE _________ 31

ONCASPAR __________ 17

ondansetron inj ______ 12

ondansetron hcl ______ 12

ondansetron hydrochloride

_________________ 12

ondansetron odt______ 12

ONEXTON ___________ 28

ONFI ________________ 9

ONGLYZA ___________ 11

ONIVYDE ____________ 17

ONZETRA XSAIL ______ 37

OPDIVO_____________ 17

OPHTHALMIC AGENTS _ 42

opium ______________ 11

OPSUMIT ___________ 21

ORACEA ____________ 28

ORACIT _____________ 33

ORENCIA _____________ 4

ORENCIA CLICKJECT ____ 4

ORILISSA ____________ 31

ORKAMBI ___________ 45

orphenadrine citrate __ 41

orphenadrine citrate er 41

orsythia _____________ 23

ORTHO DF___________ 35

ORTHO MICRONOR ___ 23

ORTHO TRI-CYCLEN LO 23

ORTHO-NOVUM 1/35-28

_________________ 23

ORTHOVISC __________ 41

oscimin sub 0.125mg 47

oscimin tab 0.125mg 47

oscimin sr ___________ 47

oseltamivir phosphate _ 20

OSENI ______________ 11

OSMOPREP __________ 36

OSPHENA ___________ 31

OTEZLA ______________ 4

OTIC AGENTS ________ 43

OTOVEL _____________ 44

OTREXUP_____________ 4

OVACE PLUS _________ 28

OVACE PLUS WASH ___ 28

OVACE WASH ________ 28

OVIDREL ____________ 31

OXACILLIN ___________ 44

oxacillin sodium ______ 44

oxaliplatin ___________ 17

oxandrolone __________ 6

oxaprozin ____________ 4

OXAYDO _____________ 5

oxazepam ____________ 7

oxcarbazepine _________ 9

oxiconazole nitrate ____ 28

OXISTAT ____________ 28

OXSORALEN ULTRA ___ 28

OXTELLAR XR _________ 9

oxybutynin chloride ___ 47

oxybutynin chloride er _ 47

oxycodone hcl _________ 5

OXYCODONE HCL ER ___ 5

oxycodone hydrochloride 5

OXYCODONE

HYDROCHLORIDE E __ 5

oxycodone/acetaminophen

__________________ 5

oxycodone/ibuprofen ___ 5

OXYCONTIN __________ 5

OXYMORPHONE TAB

5MG ER ___________ 5

oxymorphone

hydrochloride _______ 5

Oxytocics ___________ 44

OXYTROL ____________ 47

OZEMPIC ____________ 11

OZURDEX ___________ 43

P

pacerone _____________ 7

paclitaxel ____________ 17

paliperidone er _______ 19

palonosetron hydrochlorid

_________________ 12

PALYNZIQ ___________ 31

PAMELOR ___________ 10

PANCREAZE__________ 30

pancuronium bromide _ 41

PANDEL _____________ 28

pantoprazole inj sod 40mg

_________________ 47

pantoprazole sodium dr 47

pantoprazole tab 40mg _ 47

PANZYGA ____________ 44

papaverine hcl ________ 21

PARAGARD INTRAUTERINE

COP ______________ 23

paregoric ____________ 11

paricalcitol ___________ 31

paricalcitol inj ________ 31

PARLODEL ___________ 18

paroex ______________ 39

paromomycin sulfate ___ 3

paroxetine ________ 10, 45

paroxetine hcl ________ 10

paroxetine hcl er ______ 10

paroxetine hydrochloride

_________________ 10

PASSIVE IMMUNIZING

AND TREATMENT

AGENTS __________ 44

PATADAY ____________ 43

PATANASE ___________ 41

PATANOL ____________ 43

PAXIL _______________ 10

PAXIL CR ____________ 10

PAZEO ______________ 43

PEDVAX HIB _________ 47

peg 3350/electrolytes __ 36

peg-3350/electrolytes __ 36

peg-3350/nacl/na bicarbon

_________________ 36

PEGASYS ____________ 20

PEGASYS PROCLICK ___ 20

PEGINTRON __________ 20

penicillamine _________ 38

penicillin g potassium __ 44

PENICILLIN G POTASSIUM

IN _______________ 44

penicillin g sodium ____ 44

penicillin v potassium __ 44

PENICILLINS __________ 44

PENLAC NAIL LACQUER 28

PENNSAID ___________ 28

PENTACEL ___________ 46

pentamidine isethionate 15

PENTASA ____________ 33

pentazocine/naloxone hcl 5

pentobarbital sodium __ 35

pentoxifylline er ______ 34

PEPCID ______________ 47

PERCOCET ____________ 5

PERFOROMIST ________ 7

perindopril erbumine __ 14

PERJETA _____________ 17

permethrin __________ 28

perphenazine _____ 19, 45

62

perphenazine/amitriptylin

_________________ 45

PERSERIS ___________ 19

PERTZYE ____________ 30

PFIZERPEN __________ 44

PHENACTIN AA PLUS __ 30

phenadoz ___________ 12

phenazo ____________ 33

phenazopyridine hcl___ 33

phenazopyridine hydrochlo

_________________ 33

PHENDIMETRAZ CAP

105MG ER _________ 3

phendimetraz tab 35mg 3

phenelzine sulfate ____ 10

PHENERGAN ________ 12

phenobarb inj 130mg/ml

_________________ 35

PHENOBARB INJ

65MG/ML ________ 35

phenobarbital_____ 35, 47

phenobarbital/belladonna

_________________ 47

phenohytro _________ 47

phenoxybenzamine

hydrochl _________ 14

phentermine hcl _______ 3

phentermine

hydrochloride ______ 3

phentolamine mesylate 14

phenylephrin sol 2.5% op

_________________ 43

PHENYTEK ___________ 9

phenytoin ____________ 9

phenytoin sodium _____ 9

phenytoin sodium

extended __________ 9

philith ______________ 23

phospha 250 neutral __ 38

phosphasal __________ 47

PHOSPHOLINE IODIDE _ 43

phospho-trin 250 neutral

_________________ 38

PHOTREXA VISCOUS __ 43

PHOTREXA/PHOTREXA

VISCOUS _________ 43

physiolyte ___________ 38

physiosol irrigation ___ 38

PHYSOSTIGMINE

SALICYLATE _______ 12

phytonadione ________ 48

PICATO _____________ 28

PICO SINGLE USE

NEGATIVE ________ 28

PIFELTRO ___________ 20

pilocarpine sol 1% op _ 43

pilocarpine tab ______ 39

pilocarpine hydrochloride

_________________ 39

pimecrolimus ________ 28

pimozide ____________ 45

pimtrea _____________ 23

pindolol _____________ 20

pioglitazone hcl ______ 11

pioglitazone hcl/metformi

_________________ 11

pioglitazone hcl-glimepir 11

pioglitazone hydrochlorid

_________________ 11

piperacillin sodium/tazob

_________________ 44

piperacillin/tazobactam 44

PIQRAY 200MG DAILY

DOSE ____________ 17

PIQRAY 250MG DAILY

DOSE ____________ 17

PIQRAY 300MG DAILY

DOSE ____________ 17

pirmella 1/35 ________ 23

pirmella 7/7/7 _______ 23

piroxicam ____________ 4

PLAQUENIL __________ 15

plasbumin-25 ________ 34

plasbumin-5 _________ 34

PLASMA-LYTE A ______ 38

PLASMA-LYTE-148 ____ 38

PLASMANATE ________ 34

PLAVIX _____________ 34

PLEGISOL ___________ 21

PLEGRIDY ___________ 45

PLEGRIDY STARTER PACK

_________________ 45

PLENVU _____________ 36

PLEXION ____________ 28

PLEXION CLEANSER ___ 28

PNEUMOVAX 23 _____ 47

PNV PRENATAL TAB PLUS

_________________ 40

PNV TABS 29-1 _______ 40

pnv-dha _____________ 40

PNV-DHA+DOCUSATE _ 40

PNV-OMEGA ________ 40

PODIAPN ___________ 30

PODOCON 25 IN BENZOIN

TIN ______________ 28

podofilox ____________ 28

polycin _____________ 43

poly-iron 150 forte ____ 35

polymyxin b sulfate/trime

_________________ 43

polysaccharide iron forte35

POLYTRIM ___________ 43

POLY-VI-FLOR ________ 40

POLY-VI-FLOR FS _____ 40

POLY-VI-FLOR/IRON __ 40

POMALYST __________ 17

portia-28 ____________ 23

PORTRAZZA _________ 17

posaconazole dr ______ 12

POTABA ____________ 48

potassium acetate ____ 38

potassium chloride ____ 38

potassium chloride cr __ 38

potassium chloride er __ 38

potassium chloride sr __ 38

potassium chloride/sodium

_________________ 38

potassium citrate er ___ 33

potassium citrate/citric 33

potassium phosphate __ 38

PRADAXA ____________ 8

PRALIDOXIME CHLORIDE

_________________ 12

PRALUENT ___________ 13

pramipexole dihydrochlori

_________________ 18

PRAMOSONE ________ 28

prasugrel ____________ 34

PRAVACHOL _________ 13

pravastatin sodium ____ 13

PRAXBIND ___________ 12

praziquantel __________ 6

prazosin hcl __________ 14

prazosin hydrochloride _ 14

PRECEDEX ___________ 35

PRED FORTE _________ 43

PRED MILD __________ 43

pred sod pho sol 1% op 43

PRED-G _____________ 43

PRED-G S.O.P. ________ 43

prednicarbate ________ 28

prednisolone ______ 24, 43

prednisolone acetate __ 43

prednisolone sodium

phosp ____________ 24

prednisone __________ 24

PREDNISONE SOL

5MG/5ML ________ 24

PREDNISONE INTENSOL 24

pregabalin ____________ 9

PREGNYL W/DILUENT

BENZYL ___________ 31

PREMARIN __________ 32

PREMPHASE _________ 32

PREMPRO ___________ 32

PRENA1 CHEW _______ 40

PRENA1 PEARL _______ 40

PRENATA ____________ 40

prenatabs rx _________ 40

PRENATAL ___________ 40

prenatal 19 __________ 40

PRENATAL LOW IRON _ 40

PRENATAL PLS MIS MV +

DHA _____________ 40

PRENATAL PLUS IRON _ 40

PRENATAL PLUS/IRON _ 40

PRENATAL VITAMINS PLUS

LO _______________ 40

PRENATAL-U _________ 40

PRENATE ____________ 40

PRENATE DHA ________ 40

PRENATE ELITE _______ 40

PRENATE ENHANCE ___ 40

PRENATE MINI _______ 40

PRENATE PIXIE _______ 40

PREPIDIL ____________ 44

PREPLUS ____________ 40

PREPOPIK ___________ 36

PRESERA ____________ 28

PREVACID ___________ 47

PREVACID SOLUTAB ___ 47

PREVIDENT 5000 BOOSTER

PL _______________ 39

PREVIDENT 5000 DRY

MOUTH __________ 39

PREVIDENT 5000 ENAMEL

PRO ______________ 39

PREVIDENT 5000 PLUS _ 39

PREVIDENT FLUORIDE _ 39

PREVIDENT RINSE _____ 39

previfem ____________ 23

PREVNAR 13 _________ 48

PREVYMIS ___________ 20

PREZCOBIX __________ 20

PREZISTA ____________ 20

PRIALT _______________ 4

PRIFTIN _____________ 15

PRILOSEC ____________ 47

primaquine phosphate _ 15

PRIMAXIN IV _________ 15

primidone ____________ 9

PRIMLEV _____________ 5

PRINIVIL ____________ 14

PRISMASOL B22GK 4/0 38

PRISMASOL BGK 0/2.5 _ 38

PRISMASOL BGK 2/0 __ 38

PRISMASOL BGK 2/3.5 _ 38

PRISMASOL BGK 4/2.5 _ 38

PRISMASOL BK 0/0/1.2 38

PRISTIQ _____________ 10

PRIVIGEN ____________ 44

PROAIR HFA __________ 7

PROAIR RESPICLICK ____ 7

probenecid __________ 34

probenecid/colchicine _ 34

procainamide hcl _______ 7

procainamide hydrochlorid

__________________ 7

PROCARDIA __________ 21

PROCARDIA XL _______ 21

PROCENTRA __________ 3

prochlorperazine ______ 19

prochlorperazine edisylat

_________________ 19

prochlorperazine maleate

_________________ 19

PROCORT _____________ 6

PROCRIT ____________ 35

PROCTOFOAM HC ______ 6

procto-med hc _________ 6

63

proctosol hc __________ 6

proctozone-hc ________ 6

PRODIGEN __________ 11

progesterone ________ 44

progesterone cap 100mg44

PROGESTERONE

COMPOUNDING ___ 44

Progestins __________ 44

PROGLYCEM _________ 11

PROGRAF CAP _____ 38

PROGRAF GRA 0.2MG

_________________ 38

PROGRAF INJ ______ 38

PROLASTIN-C ________ 45

PROLENSA __________ 43

PROLIA _____________ 31

PROMACTA _________ 35

PROMACTIN AA PLUS

20PE _____________ 30

promethazine hcl plain 12

promethazine hydrochlorid

_________________ 12

promethazine inj _____ 12

promethazine sup ____ 12

promethazine tab ____ 12

promethazine/codeine 25

promethazine/dextrometh

or _______________ 25

promethazine/phenylephri

n ________________ 25

promethegan ________ 13

PROMETRIUM _______ 44

PROMISEB __________ 28

propafenone hcl _______ 7

propafenone hydrochloride

__________________ 7

propantheline bromide 47

proparacaine hcl _____ 43

PROPECIA ___________ 28

propofol ____________ 33

propranolol hcl _______ 20

propranolol hcl er ____ 20

propranolol hydrochloride

_________________ 20

propranolol/hydrochloroth

_________________ 14

propylthiouracil ______ 46

PROQUAD __________ 48

PROSCAR ___________ 33

PROSTIN E2 _________ 44

PROSTIN VR PEDIATRIC 38

PROTONIX __________ 47

PROTOPIC___________ 28

protriptyline hcl ______ 10

PROVAYBLUE ________ 12

PROVENGE __________ 17

PROVENTIL HFA _______ 7

PROVERA ___________ 44

PROVIDA OB ________ 40

PROVISC ____________ 43

PROZAC ____________ 10

PSORCON ___________ 28

Psychotherapeutic and

Neurological Agents -

Misc. ____________ 44

PULMICORT __________ 7

PULMICORT FLEXHALER 7

PULMOZYME ________ 45

PURIXAN ____________ 17

PYLERA _____________ 47

pyrazinamide ________ 15

PYRIDIUM ___________ 33

pyridostigmine bromide 15

pyridostigmine bromide er

_________________ 15

PYROGALLIC ACID ____ 28

Q

QBRELIS ____________ 14

QBREXZA ___________ 28

QMIIZ ODT ___________ 4

QNASL ______________ 41

QNASL CHILDRENS ____ 41

QSYMIA _____________ 3

QTERN _____________ 11

QUADRAMET ________ 17

QUALAQUIN _________ 15

QUARTETTE _________ 23

QUAZEPAM _________ 36

QUDEXY XR __________ 9

QUELICIN ___________ 41

QUESTRAN LIGHT _____ 13

quetiapine fumarate __ 19

quetiapine fumarate er 19

QUFLORA FE _________ 40

QUFLORA FE PEDIATRIC 40

QUFLORA GUMMIES __ 40

QUFLORA PEDIATRIC __ 40

QUILLICHEW ER _______ 3

QUILLIVANT XR _______ 3

quinapril hcl _________ 14

quinapril hydrochloride 14

quinapril/hydrochlorothia

_________________ 14

quinidine gluconate cr __ 7

quinidine sulfate _______ 7

quinine sulfate _______ 15

QVAR REDIHALER _____ 7

R

rabeprazole sodium ___ 47

raloxifene hydrochloride 31

ramelteon ___________ 36

ramipril _____________ 14

RANEXA _____________ 6

ranitidine hcl _________ 47

ranitidine hydrochloride 47

ranolazine er __________ 6

RAPAFLO ____________ 33

RAPAMUNE _________ 38

RAPPORT RING LOADING

SYST _____________ 36

RAPPORT VACUUM

THERAPY DE _______ 36

rasagiline mesylate ____ 18

RASUVO _____________ 4

RAYALDEE ___________ 31

RAYOS ______________ 24

REBIF _______________ 45

REBIF REBIDOSE ______ 45

REBINYN ____________ 34

RECEDO _____________ 28

RECLAST ____________ 31

reclipsen ____________ 23

RECOMBINATE _______ 34

RECOMBIVAX HB _____ 48

RECTIV _______________ 6

RECURA _____________ 28

REGENECARE ________ 28

REGONOL ___________ 15

REGRANEX __________ 28

RELAFEN DS __________ 4

RELENZA DISKHALER __ 20

RELISTOR INJ _______ 33

RELISTOR TAB ______ 33

RELNATE DHA ________ 40

RELPAX _____________ 37

REMERON ___________ 10

REMERON SOLTAB ____ 10

REMESENSE _________ 36

REMICADE ___________ 33

REMODULIN _________ 21

RENACIDIN __________ 33

RENAGEL ____________ 33

renal caps ___________ 40

RENFLEXIS ___________ 33

reno caps ____________ 40

RENOVA ____________ 28

RENVELA ____________ 33

repaglinide __________ 11

REPATHA ____________ 13

REPATHA PUSHTRONEX

SYSTEM __________ 13

REPATHA SURECLICK __ 13

REQUIP XL ___________ 18

Respiratory Agents - Misc.

_________________ 45

RESTASIS MULTIDOSE _ 43

RESTORA RX _________ 11

RESTORIL ____________ 36

RETACRIT ___________ 35

RETAVASE ___________ 34

RETAVASE HALF-KIT ___ 34

RETIN-A _____________ 28

RETIN-A MICRO ______ 28

RETIN-A MICRO PUMP _ 28

RETISERT ____________ 43

REVATIO ____________ 21

REVLIMID ___________ 38

revonto _____________ 41

REXULTI _____________ 19

REYATAZ ____________ 20

RHEUMATE __________ 30

RHOFADE____________ 28

RHOGAM ULTRA-FILTERED

PLU ______________ 44

RHOPRESSA __________ 43

RIAX ________________ 28

ribavirin _____________ 20

RIDAURA _____________ 4

rifabutin _____________ 15

RIFADIN _____________ 15

RIFAMATE ___________ 15

rifampin _____________ 15

rifampin inj ________ 15

RIFATER _____________ 15

riluzole ______________ 42

rimantadine hcl _______ 20

RIMSO-50 ___________ 33

ringers injection ______ 38

ringers irrigation ______ 38

RINVOQ ______________ 4

RIOMET _____________ 11

risedronate sodium ____ 31

risedronate sodium dr _ 31

RISPERDAL CONSTA ___ 19

risperidone __________ 19

risperidone odt _______ 19

RITALIN ______________ 3

RITALIN LA ____________ 3

ritonavir _____________ 20

RITUXAN ____________ 17

rivastigmine tartrate ___ 45

rivastigmine transdermal45

rivelsa ______________ 23

RIXUBIS _____________ 34

rizatriptan benzoate ___ 37

rizatriptan benzoate odt 37

ROBAXIN ____________ 41

ROCALTROL __________ 31

ROCKLATAN _________ 43

rocuronium bromide ___ 42

ROMIDEPSIN _________ 17

ropinirole er _________ 18

ropinirole hcl _________ 18

ropinirole hydrochloride 18

ropivacaine __________ 36

ropivacaine hcl _______ 36

ROSADAN KIT ________ 28

rosuvastatin calcium ___ 13

ROTATEQ ____________ 48

ROWASA ____________ 33

roweepra _____________ 9

roweepra xr ___________ 9

ROXICODONE _________ 5

ROZEREM ___________ 36

RUBRACA ___________ 17

RYBELSUS ___________ 11

64

RYCLORA ___________ 13

RYDAPT ____________ 17

RYTARY _____________ 18

RYTHMOL SR _________ 7

RYVENT ____________ 13

S

SABRIL ______________ 9

SAFYRAL ____________ 23

SALEX ______________ 28

salicylic acid _________ 28

salicylic acid cream ___ 28

salicylic acid er _______ 28

salicylic acid lotion ____ 28

salicylic acid wart remov 28

SALIVAMAX _________ 39

salsalate _____________ 4

SALVAX _____________ 28

SALVAX DUO PLUS ___ 28

SANCUSO ___________ 12

SANDIMMUNE _______ 38

SANDIMMUNE INJ ___ 38

SANDOSTATIN _______ 31

SANDOSTATIN LAR DEPOT

_________________ 31

SANTYL _____________ 28

SAPHRIS ____________ 19

SARAFEM ___________ 45

sash kit for flushing vas _ 8

SAVAYSA ____________ 8

SAVELLA ____________ 45

SAVELLA TITRATION PACK

_________________ 45

SAXENDA ____________ 3

scopolamine _________ 12

SEASONIQUE ________ 23

SECONAL SODIUM ____ 36

SEEBRI NEOHALER _____ 8

SEGLUROMET _______ 11

SELECT-OB __________ 40

SELECT-OB+DHA _____ 40

selegiline hcl _________ 18

selegiline hydrochloride 18

selenium _________ 28, 38

selenium sulfide ______ 28

selenium sulfide shampoo

_________________ 28

SELRX ______________ 28

SELZENTRY __________ 20

SEMPREX-D _________ 25

se-natal 19 __________ 40

SENSIPAR ___________ 31

sensorcaine-mpf _____ 36

SEREVENT DISKUS _____ 8

SERNIVO ____________ 28

SEROQUEL __________ 19

SEROQUEL XR _______ 19

sertraline hcl ________ 10

sertraline hydrochloride 10

se-tan plus __________ 35

setlakin _____________ 23

sevelamer carbonate __ 33

sevelamer hydrochloride 33

sevoflurane __________ 33

SEYSARA ____________ 46

sf 39

sf 5000 plus__________ 39

SFROWASA __________ 33

sharobel ____________ 23

SHINGRIX ___________ 48

SIDEROL ____________ 40

SIGNIFOR ___________ 31

SIGNIFOR LAR ________ 31

sildenafil citrate ______ 21

SILENOR ____________ 36

SILIQ _______________ 28

silodosin ____________ 33

SILVADENE __________ 28

SILVER NITRATE ______ 28

silver sulfadiazine _____ 28

SIMBRINZA __________ 43

SIMETHICONE________ 33

simpesse ____________ 23

SIMPONI INJ

100MG/ML ________ 4

SIMPONI INJ 50/0.5ML 4

SIMPONI ARIA ________ 4

SIMULECT ___________ 39

simvastatin __________ 13

SINEMET ____________ 18

SINEMET CR _________ 18

SINGULAIR ___________ 8

SINUVA _____________ 41

sirolimus ____________ 39

SITAVIG _____________ 20

SIVEXTRO ___________ 15

SKELAXIN ___________ 41

SKLICE ______________ 28

SKYLA ______________ 23

SKYRIZI _____________ 28

SLYND ______________ 24

sod chloride inj 0.9% __ 38

SOD SUL/SULF EMU 10-5%

_________________ 28

sod sul/sulf liq wash ___ 28

sodium bicarbonate ___ 38

sodium chlor neb 10% _ 25

sodium chloride 0.9% _ 33

sodium chloride 0.45% _ 38

sodium chloride flush __ 38

sodium citrate/citric aci 33

SODIUM EDECRIN ____ 30

sodium ferric gluconate c

_________________ 35

sodium fluoride ______ 38

sodium nitroprusside __ 14

sodium phenylacetate/sodi

_________________ 31

sodium phosphate ____ 38

sodium polystyrene sulfon

_________________ 39

sodium sulfacetamide _28,

43

sodium sulfacetamide

sham 10% _________ 28

sodium sulfacetamide

wash _____________ 28

SOFOSBUVIR/VELPATASVI

R ________________ 20

solia ________________ 24

solifenacin succinate __ 47

SOLIQUA 100/33 _____ 11

SOLIRIS _____________ 34

SOLODYN ___________ 46

SOLOSEC _____________ 3

SOLU-CORTEF ________ 24

SOLU-MEDROL _______ 24

SOMA ______________ 41

SOMATULINE DEPOT __ 31

SOMAVERT __________ 31

SOOLANTRA _________ 28

SORBITOL ___________ 33

SORBITOL-MANNITOL _ 33

SORIATANE __________ 28

SORILUX ____________ 28

sotalol hcl ___________ 20

sotalol hcl (af) ________ 20

sotalol hcl af _________ 20

sotalol hydrochloride __ 20

SOTYLIZE ____________ 20

SPINOSAD ___________ 29

SPINRAZA ___________ 42

SPIRIVA HANDIHALER __ 8

SPIRIVA RESPIMAT _____ 8

spironolactone _______ 30

spironolactone/hydrochlor

_________________ 30

SPRAVATO 56MG DOSE 10

SPRAVATO 84MG DOSE 10

sprintec 28 __________ 24

SPRIX ________________ 4

SPRYCEL ____________ 17

sps _________________ 39

sronyx ______________ 24

ssd _________________ 29

SSKI ________________ 25

sss 10%-5% __________ 29

STALEVO 100 ________ 18

STALEVO 125 ________ 18

STALEVO 150 ________ 18

STALEVO 200 ________ 18

STALEVO 50 _________ 18

STALEVO 75 _________ 18

STAMARIL ___________ 48

STARLIX _____________ 11

stavudine____________ 20

STAXYN _____________ 21

STEGLATRO __________ 11

STEGLUJAN __________ 11

STELARA _________ 29, 33

STELARA INJ 5MG/ML

_________________ 33

STENDRA ____________ 21

sterile water irrigation _ 39

STIMATE ____________ 31

STIOLTO RESPIMAT ____ 8

STIVARGA ___________ 17

STRATTERA ___________ 3

STRENSIQ ___________ 31

STRIBILD ____________ 20

STRIVERDI RESPIMAT ___ 8

STROMECTOL _________ 6

STROVITE FORTE ______ 40

STROVITE ONE _______ 40

SUBLOCADE___________ 5

SUBOXONE ___________ 5

SUBSYS ______________ 5

subvenite _____________ 9

subvenite starter kit/ora _ 9

SUCRAID ____________ 30

SUCRALFATE SUS

1GM/10ML ________ 47

sucralfate tab 1gm ___ 47

SULFACET SOD OIN 10%

OP _______________ 43

sulfacet sod sol 10% op _ 43

sulfacetamide sodium _ 29,

43

sulfacetamide

sodium/pred _______ 43

sulfacetamide sodium/sulf

_________________ 29

sulfacleanse 8/4 ______ 29

sulfadiazine __________ 45

sulfamethoxazole/trimetho

_________________ 15

sulfasalazine _________ 33

sulfatrim pediatric _____ 15

sulfazine ____________ 33

Sulfonamides ________ 45

sulindac ______________ 4

SUMADAN WASH _____ 29

sumatriptan __________ 37

sumatriptan inj _______ 37

SUMATRIPTAN INJ

6MG/0.5 __________ 37

sumatriptan succinate _ 37

sumatriptan succinate ref

_________________ 37

sumatriptan/naproxen sodi

_________________ 37

SUNOSI ______________ 3

SUPARTZ FX__________ 41

SUPERVITE___________ 40

SUPPORT ____________ 40

SUPPORT-500 ________ 40

SUPPRELIN LA ________ 31

SUPRANE ____________ 33

SUPRAX _____________ 22

65

SUPREP BOWEL PREP KIT

_________________ 36

SURVANTA

INTRATRACHEAL ___ 45

SUSTIVA ____________ 20

SUTENT _____________ 17

SUVICORT ___________ 29

syeda ______________ 24

SYLATRON __________ 17

SYMAX DUOTAB _____ 47

SYMBICORT __________ 8

SYMBYAX ___________ 45

SYMDEKO ___________ 45

SYMJEPI ____________ 48

SYMLINPEN 120 ______ 11

SYMLINPEN 60 _______ 11

SYMPAZAN ___________ 9

SYMPROIC __________ 33

SYMTUZA ___________ 20

SYNAGIS ____________ 44

SYNAREL ____________ 31

SYNDROS ___________ 12

SYNERA ____________ 29

SYNJARDY __________ 11

SYNJARDY XR ________ 11

SYNTHROID _________ 46

SYNVISC ____________ 41

SYNVISC ONE ________ 41

SYPRINE ____________ 39

T

TABLOID ____________ 17

TACLONEX __________ 29

tacrolimus cap ______ 39

tacrolimus oin 0.1% __ 29

tadalafil ____________ 21

TAFINLAR ___________ 17

TAGRISSO ___________ 17

TAKHZYRO __________ 34

TALIVA _____________ 35

TALTZ ______________ 29

TALZENNA __________ 17

TAMIFLU____________ 20

tamoxifen citrate _____ 17

tamsulosin hydrochloride

_________________ 33

taperdex 6-day _______ 24

TAPERDEX 7-DAY _____ 24

TARCEVA ___________ 17

TARGADOX__________ 46

TARGRETIN CAP ____ 17

TARGRETIN GEL 1% __ 29

tarina 24 fe __________ 24

tarina fe 1/20 ________ 24

tarina fe 1/20 eq _____ 24

TARKA _____________ 14

TARON FORTE _______ 35

TARON-BC __________ 40

TARON-C DHA _______ 40

taron-crystals ________ 33

TARON-PREX ________ 40

TASIGNA ____________ 17

TASMAR ____________ 18

TAXOTERE___________ 17

TAYTULLA ___________ 24

tazarotene __________ 29

TAZICEF _____________ 22

TAZORAC CRE 0.1% _ 29

TAZORAC GEL 0.1% _ 29

taztia xt _____________ 21

TDVAX______________ 46

TECFIDERA __________ 45

TECFIDERA STARTER PACK

_________________ 45

TEFLARO ____________ 22

TEGRETOL ____________ 9

TEGRETOL-XR _________ 9

TEKTURNA __________ 14

TEKTURNA HCT ______ 14

telmisartan __________ 14

telmisartan/amlodipine 14

telmisartan/hydrochloroth

_________________ 14

temazepam __________ 36

TEMODAR CAP 100MG

_________________ 17

TEMODAR INJ 100MG

_________________ 17

TEMOVATE __________ 29

temozolomide _______ 17

temsirolimus _________ 17

TENCON _____________ 4

TENIVAC ____________ 46

tenofovir disoproxil fuma

_________________ 20

TENORMIN __________ 20

terazosin hcl _________ 14

terazosin hydrochloride 14

terbinafine hcl _______ 12

terbutaline sulfate _____ 8

terconazole __________ 48

TESSALON PERLES ____ 25

TESTIM ______________ 6

TESTOPEL ____________ 6

testosterone __________ 6

TESTOSTERONE _______ 6

testosterone cypionate _ 6

testosterone enanthate _ 6

TESTOSTERONE PUMP __ 6

testosterone topical solu 6

tetrabenazine ________ 45

tetracaine hcl ________ 36

tetracaine hydrochloride 43

tetracycline hydrochlorid

_________________ 46

Tetracyclines ________ 45

TETRIX ______________ 29

TEXACORT __________ 29

THEO-24 _____________ 8

theochron ____________ 8

THEOCHRON TAB 100MG

CR ________________ 8

theophylline __________ 8

theophylline cr ________ 8

theophylline er ________ 8

theophylline/d5w ______ 8

THERAHONEY ________ 29

THIOLA _____________ 33

THIOLA EC ___________ 33

thioridazine hcl _______ 19

thiotepa _____________ 17

thiothixene __________ 19

THRIVITE RX _________ 40

THROMBATE III _______ 34

THROMBATE III W/20 ML

STE ______________ 34

THYROID AGENTS _____ 46

tiagabine hydrochloride _ 9

TIAZAC _____________ 21

TICE BCG ____________ 17

TIKOSYN _____________ 7

tilia fe ______________ 24

timolol sol 0.5% op ___ 43

timolol maleate _______ 20

TIMOLOL MALEATE

OPHTHALMI _______ 43

TIMOPTIC ___________ 43

TIMOPTIC OCUDOSE __ 43

TIMOPTIC-XE ________ 43

tinidazole ___________ 15

TIROSINT ____________ 46

TIROSINT-SOL ________ 46

TISSEEL _____________ 35

TIVICAY _____________ 20

tizanidine hcl _________ 41

tizanidine hydrochloride 41

TL FOLATE ___________ 40

tl gard rx ____________ 35

TL G-FOL OS _________ 40

tl hydroquinone ______ 29

tl icon ______________ 35

TL-CARE DHA ________ 40

TL-FLUORIVITE _______ 40

tl-hem 150 ___________ 35

TL-ICARE ____________ 30

TL-SELECT ___________ 40

TOBI ________________ 3

TOBI PODHALER _______ 3

TOBRADEX OIN 0.3-0.1%

_________________ 43

TOBRADEX SUS 0.3-0.1%

_________________ 43

TOBRADEX ST ________ 43

tobramycin ________ 3, 43

tobramycin sol 0.3% op 43

tobramycin sulfate _____ 3

tobramycin/dexamethason

e ________________ 43

TOBREX _____________ 43

TOFRANIL ___________ 10

TOLAK ______________ 29

tolbutamide __________ 11

tolmetin sodium _______ 4

tolterodine tartrate ____ 47

tolterodine tartrate er _ 47

TOPAMAX ____________ 9

topex topical anesthetic 39

TOPICORT ___________ 29

topiramate ___________ 9

TOPIRAMATE ER _______ 9

toposar _____________ 17

TOPROL XL __________ 20

TORISEL _____________ 17

torsemide ___________ 30

TOUJEO MAX SOLOSTAR

_________________ 11

TOUJEO SOLOSTAR ____ 11

TOVIAZ _____________ 47

Toxoids _____________ 46

TPN ELECTROLYTES ____ 38

TRACE ELEMENTS

4/PEDIATRI ________ 38

TRADJENTA __________ 11

tramadol hcl __________ 5

TRAMADOL HCL CAP ER

100MG ____________ 5

tramadol hcl tab 100mg er

__________________ 5

tramadol hydrochloride/ac

__________________ 5

trandolapril __________ 14

trandolapril/verapamil hc

_________________ 14

tranexamic acid _______ 35

tranexamic acid inj ____ 35

TRANSDERM SCOP ____ 12

TRANSDERM-SCOP ____ 12

tranylcypromine sulfate 10

TRAUMANIL _________ 39

TRAVATAN Z _________ 43

trazodone hydrochloride 10

TRECATOR ___________ 15

TRELEGY ELLIPTA ______ 8

TRELSTAR MIXJECT ____ 17

TREMFYA ____________ 29

treprostinil ___________ 21

TRESIBA _____________ 11

TRESIBA FLEXTOUCH __ 11

tretinoin cap 10mg ___ 17

tretinoin gel 0.01% ___ 29

tretinoin microsphere __ 29

tretinoin microsphere pum

_________________ 29

TRETTEN ____________ 34

TREXALL _____________ 17

TREXIMET ___________ 37

TREZIX _______________ 5

tri femynor __________ 24

triamcinolon cre 0.5% __ 29

66

triamcinolone acetonide

______________ 24, 39

triamcinolone acetonide d

_________________ 39

triamterene ______ 30, 31

triamterene/hydrochloroth

_________________ 31

TRIANEX ____________ 29

triazolam ___________ 36

TRIBENZOR __________ 14

TRI-CHLOR __________ 29

TRICITRASOL _________ 8

tricitrates ___________ 33

TRICOR _____________ 13

TRIDESILON _________ 29

trientine hydrochloride 39

TRIESENCE __________ 43

tri-estarylla __________ 24

trifluoperazine hcl ____ 19

trifluoperazine hydrochlo

_________________ 19

trifluridine __________ 43

trigels-f forte ________ 35

trihexyphenidyl hcl ___ 18

trihexyphenidyl hydrochlo

_________________ 18

tri-legest fe __________ 24

TRILEPTAL ___________ 9

tri-linyah ____________ 24

TRILIPIX ____________ 13

tri-lo-estarylla ________ 24

tri-lo-marzia _________ 24

tri-lo-sprintec ________ 24

TRI-LUMA ___________ 29

trilyte ______________ 36

trimethobenzamide

hydroch __________ 12

trimethoprim _____ 15, 43

trimethoprim sulfate/poly

_________________ 43

TRIMO-SAN _________ 48

trinatal rx 1 __________ 40

TRINTELLIX __________ 10

triphrocaps __________ 40

tri-previfem _________ 24

TRIPTODUR _________ 31

tri-sprintec __________ 24

TRISTART DHA _______ 40

TRISTART ONE _______ 40

TRI-TABS DHA _______ 40

TRIUMEQ ___________ 20

TRIVEEN-DUO DHA ___ 40

TRI-VI-FLOR _________ 40

TRI-VI-FLORO ________ 40

tri-vitamin/fluoride ___ 40

trivora-28 ___________ 24

tri-vylibra ___________ 24

tri-vylibra lo _________ 24

TROKENDI XR _________ 9

trospium chloride _____ 47

trospium chloride er ___ 47

TRULANCE __________ 33

TRULICITY ___________ 11

TRUMENBA _________ 48

TRUSOPT ___________ 43

TRUVADA ___________ 20

TUDORZA PRESSAIR ____ 8

tulana ______________ 24

TUSSICAPS __________ 25

TWINRIX ____________ 48

TWYNSTA ___________ 14

tydemy _____________ 24

TYGACIL ____________ 46

TYKERB _____________ 17

TYLACTIN BUILD 20PE TYR

_________________ 30

TYLACTIN COMPLETE 15

PE _______________ 30

TYLACTIN RESTORE 10 _ 30

TYLACTIN RESTORE 5PE 30

TYLACTIN RTD 15 _____ 30

TYLENOL/CODEINE #3 __ 5

TYMLOS ____________ 32

TYPHIM VI __________ 48

TYSABRI ____________ 45

TYVASO REFILL _______ 21

U

UCERIS AER 2MG/ACT 6

UCERIS TAB 9MG __ 24

UDENYCA ___________ 35

ULCER

DRUGS/ANTISPASMODI

CS/ANTICHOLINERGICS

_________________ 46

ULESFIA_____________ 29

ULORIC _____________ 34

ULTANE _____________ 33

ultimatecare one _____ 40

ULTOMIRIS __________ 34

ULTRABAG/DIANEAL LOW

CALC _____________ 39

ULTRABAG/DIANEAL PD-

2/1.5 ____________ 39

ULTRABAG/DIANEAL PD-

2/2.5 ____________ 39

ULTRABAG/DIANEAL PD-

2/4.2 ____________ 39

ULTRAM _____________ 5

ULTRAVATE _________ 29

UNASYN ____________ 44

UNASYN BULK PACK __ 44

unithroid ____________ 46

UPTRAVI ____________ 21

urea ________________ 29

urea nail ____________ 29

urelle _______________ 47

uretron d/s __________ 47

uribel _______________ 47

URIMAR-T ___________ 47

Urinary Anti-infectives _ 47

Urinary Antispasmodics 47

uro-458 _____________ 47

UROCIT-K 10 _________ 33

UROCIT-K 15 _________ 33

UROCIT-K 5 __________ 33

UROGESIC-BLUE ______ 47

uro-mp _____________ 47

ursodiol _____________ 33

ustell _______________ 47

UTOPIC _____________ 29

V

VACCINES ___________ 47

VAGIFEM ____________ 48

VAGINAL AND RELATED

PRODUCTS ________ 48

valacyclovir hcl _______ 20

valacyclovir hydrochlorid20

VALCHLOR ___________ 29

VALCYTE ____________ 20

valganciclovir ________ 20

valganciclovir hydrochlor20

VALIUM ______________ 7

valproate sodium ______ 9

valproic acid __________ 9

valrubicin ___________ 17

valsartan ____________ 14

valsartan/hydrochlorothia

_________________ 14

VALTREX ____________ 20

VANCOMYCIN ________ 15

vancomycin hcl _______ 15

VANCOMYCIN HCL IN

DEXTROS _________ 15

vancomycin hydrochloride

_________________ 15

vandazole ___________ 48

VANIQA _____________ 29

vanoxide-hc __________ 29

VAQTA _____________ 48

vardenafil hydrochloride 21

VARIVAX ____________ 48

VASCAZEN ___________ 30

VASCEPA ____________ 13

VASCULERA __________ 30

VASERETIC __________ 14

Vasopressors ________ 48

VASOTEC ____________ 14

VAXCHORA __________ 48

v-c forte _____________ 40

VECTICAL ____________ 29

vecuronium bromide __ 42

VELCADE ____________ 17

VELETRI _____________ 21

velivet ______________ 24

VELPHORO __________ 33

VELTASSA ___________ 39

VELTIN ______________ 29

VEMLIDY ____________ 20

VENA-BAL DHA _______ 40

VENCLEXTA __________ 18

VENCLEXTA STARTING

PACK _____________ 18

VENELEX ____________ 29

venlafaxine hcl _______ 10

venlafaxine hcl er _____ 10

VENOFER ____________ 35

VENTOLIN HFA ________ 8

verapamil inj ________ 21

verapamil tab _______ 21

verapamil hcl _________ 21

verapamil hcl er_______ 21

verapamil hcl sa ______ 21

verapamil hcl sr _______ 21

VERDESO ____________ 29

VEREGEN ____________ 29

VERZENIO ___________ 18

VESICARE ____________ 47

VEXASYN ____________ 29

VFEND ______________ 12

VFEND IV ____________ 12

VIAGRA _____________ 21

VIBERZI _____________ 33

VIBRAMYCIN _________ 46

vicodin es _____________ 5

vicodin hp ____________ 5

VICTOZA ____________ 11

VIDEX _______________ 20

VIDEX EC ____________ 20

VIEKIRA PAK _________ 20

vienva ______________ 24

vigabatrin ____________ 9

vigadrone_____________ 9

VIGAMOX ___________ 43

VIIBRYD _____________ 10

VIIBRYD STARTER PACK 10

VILACTIN AA PLUS ____ 30

vilamit mb ___________ 47

VIMOVO _____________ 4

VIMPAT ______________ 9

VINATE M ___________ 40

vinate one ___________ 41

vinorelbine tartrate ____ 18

VIOKACE ____________ 30

viorele ______________ 24

VIRAMUNE __________ 20

VIRAMUNE XR _______ 20

VIRAZOLE ___________ 20

VIREAD _____________ 20

virt-caps _____________ 41

virt-gard _____________ 35

virt-phos 250 neutral __ 38

VIRT-PN DHA _________ 41

VISBIOME ___________ 30

VISCO-3 _____________ 41

VISTARIL _____________ 7

VISUDYNE ___________ 43

67

VITAFOL ____________ 41

VITAFOL FE+ _________ 41

VITAFOL GUMMIES ___ 41

VITAFOL STRIPS ______ 41

VITAFOL ULTRA ______ 41

VITAFOL-NANO ______ 41

VITAFOL-OB _________ 41

VITAFOL-OB+DHA ____ 41

VITAFOL-ONE ________ 41

VITAMEDMD ONE

RX/QUATREFO ____ 41

VITAMEDMD REDICHEW

RX ______________ 41

vitamin d ___________ 48

vitamin k1 ___________ 48

VITAMINS ___________ 48

vitamins a/c/d/fluoride 41

VITAPEARL __________ 41

VITATRUE ___________ 41

VITRASE ____________ 39

VIVELLE-DOT ________ 32

VIVITROL ___________ 12

VIVOTIF ____________ 48

VIZIMPRO ___________ 18

VOGELXO ____________ 6

VOGELXO PUMP ______ 6

vol-care rx___________ 41

VOL-NATE ___________ 41

VOL-PLUS ___________ 41

VOL-TAB RX _________ 41

VOLTAREN __________ 29

VOLUVEN ___________ 34

VONVENDI __________ 34

voriconazole _________ 12

voriconazole inj 200mg 12

VOSEVI _____________ 20

VOTRIENT ___________ 18

VP-PNV-DHA ________ 41

VPRIV ______________ 35

VRAYLAR ___________ 19

VSL#3 DS ___________ 11

VUSION ____________ 29

vyfemla _____________ 24

vylibra ______________ 24

VYNDAMAX _________ 21

VYNDAQEL __________ 21

VYTONE ____________ 29

VYTORIN____________ 13

VYVANSE ____________ 3

VYZULTA ____________ 43

W

warfarin sodium _______ 8

WELCHOL ___________ 13

WELLBUTRIN SR ______ 10

WELLBUTRIN XL ______ 10

wera _______________ 24

WIDE-SEAL SILICONE

DIAPHR __________ 36

wixela inhub __________ 8

WP THYROID ________ 46

wymzya fe ___________ 24

X

XADAGO ____________ 18

XALATAN ___________ 43

XALIX ______________ 29

XALKORI ____________ 18

XANAX ______________ 7

XANAX XR ____________ 7

XARELTO _____________ 8

XARELTO STARTER PACK 8

XELJANZ _____________ 4

XELJANZ XR __________ 4

XELODA_____________ 18

XEMBIFY ____________ 44

XENAZINE ___________ 45

XENICAL _____________ 3

XEOMIN ____________ 42

XEPI ________________ 29

XERAC AC ___________ 29

XERALUX ____________ 29

XERESE _____________ 29

XEROFORM NON-

OCCLUSIVE OI _____ 29

XEROFORM OCCLUSIVE

PETROL __________ 29

XEROSTOMIA RELIEF

SPRAY ___________ 39

XGEVA ______________ 32

XHANCE ____________ 41

XIAFLEX _____________ 39

XIFAXAN ____________ 15

XIGDUO XR __________ 11

XIIDRA______________ 43

XIMINO _____________ 46

XOFLUZA ____________ 20

XOLAIR ______________ 8

XOLEGEL ____________ 29

XOLEGEL COREPAK ___ 29

XOLEGEL DUO/HEAD &

SHOULD __________ 29

XOLEGEL DUO/XOLEX _ 29

XOPENEX _____________ 8

XOPENEX CONCENTRATE 8

XOPENEX HFA _________ 8

XOSPATA ____________ 18

XRYLIX ______________ 29

XTAMPZA ER __________ 6

XTANDI _____________ 18

XULANE _____________ 24

XULTOPHY 100/3.6 ___ 11

XYLOCAINE __________ 36

XYLOCAINE-MPF ______ 36

XYOSTED _____________ 6

XYREM _____________ 45

XYZBAC _____________ 30

Y

YASMIN 28 __________ 24

YAZ ________________ 24

YERVOY _____________ 18

YUPELRI ______________ 8

yuvafem ____________ 48

Z

zafirlukast ____________ 8

zaleplon _____________ 36

ZALTRAP ____________ 18

ZANAFLEX ___________ 41

ZANOSAR ___________ 18

zarah _______________ 24

ZARONTIN ____________ 9

ZARXIO _____________ 35

ZATEAN-PN DHA______ 41

ZATEAN-PN PLUS _____ 41

ZEGERID ____________ 47

ZELAC ______________ 11

ZELAPAR ____________ 18

ZELBORAF ___________ 18

ZELNORM ___________ 33

ZEMAIRA ____________ 45

ZEMBRACE SYMTOUCH 37

ZEMPLAR____________ 32

zenatane ____________ 29

ZENPEP _____________ 30

zenzedi tab 5mg _____ 3

ZENZEDI TAB 7.5MG _ 3

ZEPATIER ____________ 20

ZESTRIL _____________ 14

ZETIA _______________ 13

ZETONNA ___________ 41

ZIANA ______________ 29

zidovudine ___________ 20

ZINC SULFATE ________ 38

ZINECARD ___________ 18

ZINPLAVA ___________ 44

ZIOPTAN ____________ 43

ziprasidone hcl _______ 19

ZIPSOR _______________ 4

ZIRGAN _____________ 43

ZITHRANOL __________ 29

ZITHROMAX _________ 36

ZOCOR ______________ 13

ZOFRAN _____________ 12

ZOHYDRO ER __________ 6

ZOLADEX ____________ 18

zoledronic acid _______ 32

ZOLINZA ____________ 18

zolmitriptan __________ 37

zolmitriptan odt ______ 37

ZOLOFT _____________ 10

zolpidem tartrate _____ 36

zolpidem tartrate er ___ 36

ZOMACTON __________ 32

ZOMIG ______________ 37

ZOMIG SPR 5MG __ 37

ZONALON ___________ 29

ZONEGRAN ___________ 9

zonisamide ___________ 9

ZONTIVITY ___________ 34

ZORTRESS ___________ 39

ZORVOLEX ____________ 4

ZOSTAVAX ___________ 48

zovia 1/35e __________ 24

ZOVIRAX CRE 5% ___ 29

ZOVIRAX OIN 5% ___ 29

ZTLIDO ______________ 29

ZUBSOLV _____________ 6

ZUPLENZ ____________ 12

ZYCLARA ____________ 29

ZYCLARA PUMP ______ 29

ZYFLO ________________ 8

ZYKADIA ____________ 18

ZYLET _______________ 43

ZYLOPRIM ___________ 34

ZYMAXID ____________ 43

ZYPITAMAG __________ 13

ZYPREXA ____________ 19

ZYPREXA RELPREVV ___ 19

ZYPREXA ZYDIS _______ 19

ZYTIGA ______________ 18

ZYVEXOL ____________ 30

ZYVIT _______________ 30

ZYVOX ______________ 15