Your Guide to Prescription Drug Benefits - Health Insurance · Drug Name Drug Tier Requirements/Limits Anti - Infectives Antifungal Agents clotrimazole mucous membrane troche Tier

Your Guide to Prescription Drug Benefits2018 ESSENTIAL FORMULARY GUIDE FOR INDIVIDUAL AND SMALL GROUP* PLANS

* Does not apply to the following Small Group plans. For these plans, please refer to the 2018 Essential Formulary with Preventive Drug Copays:

• BlueCross SG Bronze 17• BlueCross SG Silver 23• BlueCross SG Silver 25• BlueCross SG Silver 41

• BlueCross SG Gold 24• BlueCross SG Gold 25• BlueCross SG Gold 26

18PHM254828RX-17_2018 (1/18)

Essential Formulary Individual Small Group

1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.comBlueCross BlueShield of Tennessee

BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.BlueCross:• Provides free aids and services to people with

disabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats.

• Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and (2) written information in other languages.

If you need these services, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711).If you believe that BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting your Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID card or call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208 (fax); [email protected] (email).You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1–800–368–1019, 800–537–7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. BlueCross BlueShield of Tennessee is a Qualified Health Plan Issuer in the Health Insurance Marketplace.BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-565-9140 (TTY: 1-800-848-0298).

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1-9140-565-800 (رقمھاتف الصم والبكم: 800-848-0298-1).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-565-9140 (TTY:1-800-848-0298) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-565-9140 (TTY:1-800-848-0298).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-565-9140 (TTY: 1-800-848-0298) 번으로 전화해 주십시오.

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-565-9140 (ATS : 1-800-848-0298).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ,ການບໍລິການຊ່ວຍເຫຼືອດ້ ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-565-9140 (TTY: 1-800-848-0298).

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-565-9140 (መስማት ለተሳናቸው: 1-800-848-0298).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-565-9140 (TTY: 1-800-848-0298).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-565-9140 (TTY:1-800-848-0298)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-800-565-9140 (TTY:1-800-848-0298) まで、お電話にてご連絡ください。

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-565-9140 (TTY:1-800-848-0298).

ध्यान दें: यिद आप िहंदी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-565-9140 (TTY:1-800-848-0298) पर कॉल करें।

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-565-9140 (телетайп: 1-800-848-0298).

-توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با(TTY:1-800-848-0298) 9140-565-800-1 .تماس بگیرید .

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-565-9140 (TTY: 1-800-848-0298).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-565-9140 (TTY: 1-800-848-0298).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-565-9140 (TTY: 1-800-848-0298).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-565-9140 (TTY: 1-800-848-0298).

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-565-9140 (TTY: 1-800-848-0298).

1

2018 Essential Formulary for Individual and Small Groups

Table of Contents

Abbreviations and Key to Drug Tiers ……………………………………………………………………….....2 Drug Classes:

Anti - Infectives .................................................................................................................................................... 6 Antineoplastic & Immunosuppressant Drugs .................................................................................................... 14 Autonomic & Cns Drugs, Neurology & Psych .................................................................................................. 18 Cardiovascular, Hypertension & Lipids ............................................................................................................. 35 Dermatologicals/Topical Therapy ...................................................................................................................... 45 Diagnostics & Miscellaneous Agents ................................................................................................................ 53 Ear, Nose & Throat Medications........................................................................................................................ 55 Endocrine/Diabetes ............................................................................................................................................ 56 Gastroenterology ................................................................................................................................................ 72 Immunology, Vaccines & Biotechnology .......................................................................................................... 77 Musculoskeletal & Rheumatology ..................................................................................................................... 84 Obstetrics & Gynecology ................................................................................................................................... 86 Ophthalmology ................................................................................................................................................... 93 Respiratory, Allergy, Cough & Cold ................................................................................................................. 98 Urologicals ....................................................................................................................................................... 104 Vitamins, Hematinics & Electrolytes ............................................................................................................... 106 Index of Drugs .................................................................................................................................................. 113

2

Requirements/Limits AGE-A = Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review. ACA = Affordable Care Act. The products with the ACA indicator are available to you at no out-of-pocket cost based on the Affordable Care Act (ACA) $0 Copay Preventive List. LD = Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. PA = Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review for a drug that requires prior authorization. QL = Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. SPRx = Specialty Medication. Includes high-cost medications for chronic, serious diseases such as hepatitis C, multiple sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy.

ST = Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review. Please refer to the Step Therapy list included within this guidebook on page 3 for medications that require step therapy and the agents that are required to be taken first. lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs

3

Step Therapy

Medication(s) Requiring Step Therapy Step Therapy Requirements

Edarbi Edarbyclor Trial and failure of generic ARB

Non-preferred diabetic test strips (e.g., Accu-Chek, Freestyle) QL

Trial and failure of preferred products made by Lifescan (OneTouch) or Ascensia (Contour or Breeze2) QL

Zioptan Trial and failure of latanoprost, Lumigan, or Travatan Z

Apidra Apidra Solostar Humalog

Trial and failure of Novolog or Fiasp

Humulin Trial and failure of Novolin

Proventil HFA QL Ventolin HFA QL Xopenex HFA QL

Trial and failure of ProAir HFA QL or ProAir Respiclick QL

Nevanac Trial and failure of Prolensa

Alocril Alomide Bepreve Emadine Lastacaft

Trial and failure of Pazeo

Azopt Betimol Betoptic S Istalol Simbrinza

Trial and failure of Alphagan P 0.1 % or Combigan

Osphena Premarin Cream Trial and failure of Estrace 0.01% cream

4

For drugs used to treat various inflammatory immune conditions, preferred drugs are required to be used before other non-preferred drugs based on a specific medical condition. A trial of one or two preferred agents will be required before a non-preferred drug will be covered. Below is a table of preferred and non-preferred agents based on various medical conditions.

Medical Condition Preferred Agents Non-Preferred Agents (directed to ONE Preferred agent)

Non-Preferred Agents (directed to TWO Preferred agents)

Rheumatoid arthritis

Actemra SC Enbrel Humira Xeljanz/XR

Cimzia Orencia SC Simponi SC Kineret

Ankylosing spondylitis Cosentyx Enbrel Humira

Cimzia Simponi SC

Juvenile idiopathic arthritis

Enbrel Humira Orencia SC

Psoriatic arthritis

Cosentyx Enbrel Humira Stelara SC

Otezla

Cimzia Simponi SC

Psoriasis

Cosentyx Humira Otezla Stelara SC

Enbrel* See note below

Siliq Taltz

Crohn’s disease Humira Cimzia Stelara SC

Ulcerative colitis Humira Simponi SC

SC – subcutaneous *Access to Enbrel for Psoriasis will be approved if the patient has tried the Preferred agent Humira specifically. Other Preferred agents not requiring Humira first for Psoriasis are Cosentyx, Otezla, and Stelara SC.

5

Drug Tiers Tier 1= Generic Drugs Tier 2= Preferred Brand Drugs Tier 3= Non-Preferred Brand Drugs Tier 4= Specialty Drugs Tier 5= Drugs with $0 Cost Share- per Affordable Care Act (ACA) $0 Copay Preventive List Pharmacy Appeals To appeal a denial based on the prior authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555 Fax: 1-888-343-4232 Please provide the following information with your written request:

1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information

This list is subject to change. Please call Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card or visit our website at bcbst.com for the most up‐to‐date information.

6

Drug Name Drug Tier Requirements/Limits

Anti - Infectives Antifungal Agents clotrimazole mucous membrane troche Tier 1

CRESEMBA ORAL CAPSULE Tier 3

fluconazole oral suspension for reconstitution Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension Tier 1

griseofulvin microsize oral tablet Tier 1

griseofulvin ultramicrosize oral tablet Tier 1

itraconazole oral capsule Tier 1

ketoconazole oral tablet Tier 1

NOXAFIL ORAL SUSPENSION Tier 3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

nystatin oral powder Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

ONMEL ORAL TABLET Tier 3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

SPORANOX ORAL SOLUTION Tier 3

terbinafine hcl oral tablet Tier 1

voriconazole oral suspension for reconstitution Tier 1

voriconazole oral tablet Tier 1

Antivirals abacavir oral solution Tier 1

abacavir oral tablet Tier 1

abacavir-lamivudine oral tablet Tier 4 SPRx

abacavir-lamivudine-zidovudine oral tablet Tier 1

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet Tier 1

7


adefovir oral tablet Tier 1

amantadine hcl oral capsule Tier 1

amantadine hcl oral solution Tier 1

amantadine hcl oral tablet Tier 1

APTIVUS ORAL CAPSULE Tier 3

APTIVUS ORAL SOLUTION Tier 3

atazanavir oral capsule Tier 4 SPRx

ATRIPLA ORAL TABLET Tier 4 SPRx

BARACLUDE ORAL SOLUTION Tier 3

COMPLERA ORAL TABLET Tier 4 SPRx

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 3

DESCOVY ORAL TABLET Tier 4 SPRx

didanosine oral capsule,delayed release(dr/ec) Tier 1

EDURANT ORAL TABLET Tier 3

efavirenz oral capsule Tier 1

EMTRIVA ORAL CAPSULE Tier 3

EMTRIVA ORAL SOLUTION Tier 3

entecavir oral tablet Tier 1

EPCLUSA ORAL TABLET Tier 4 PA; SPRx

EPIVIR HBV ORAL SOLUTION Tier 3

EPZICOM ORAL TABLET Tier 4 SPRx

EVOTAZ ORAL TABLET Tier 4 SPRx

famciclovir oral tablet Tier 1

fosamprenavir oral tablet Tier 1

FUZEON SUBCUTANEOUS RECON SOLN Tier 4 SPRx

GENVOYA ORAL TABLET Tier 4 SPRx

HARVONI ORAL TABLET Tier 4 PA; SPRx

INTELENCE ORAL TABLET Tier 3

INVIRASE ORAL CAPSULE Tier 3

INVIRASE ORAL TABLET Tier 3

ISENTRESS HD ORAL TABLET Tier 4

ISENTRESS ORAL POWDER IN PACKET Tier 4 SPRx

8


ISENTRESS ORAL TABLET Tier 4 SPRx

ISENTRESS ORAL TABLET,CHEWABLE Tier 4 SPRx

KALETRA ORAL SOLUTION Tier 3

KALETRA ORAL TABLET Tier 3

lamivudine oral solution Tier 1

lamivudine oral tablet Tier 1

lamivudine-zidovudine oral tablet Tier 1

LEXIVA ORAL SUSPENSION Tier 3

LEXIVA ORAL TABLET Tier 3

lopinavir-ritonavir oral solution Tier 1

MAVYRET ORAL TABLET Tier 4 PA; SPRx

nevirapine oral suspension Tier 1

nevirapine oral tablet Tier 1

nevirapine oral tablet extended release 24 hr Tier 1

NORVIR ORAL CAPSULE Tier 3

NORVIR ORAL SOLUTION Tier 3

NORVIR ORAL TABLET Tier 3

ODEFSEY ORAL TABLET Tier 4 SPRx

oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 180 days)

oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 180 days)

oseltamivir oral suspension for reconstitution Tier 1 QL (180 ML per 180 days)

PREZCOBIX ORAL TABLET Tier 4 SPRx

PREZISTA ORAL SUSPENSION Tier 4 SPRx

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 4 SPRx

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 3 QL (20 EA per 180 days)

RESCRIPTOR ORAL TABLET Tier 3

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 3

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 4 SPRx

REYATAZ ORAL POWDER IN PACKET Tier 4 SPRx

rimantadine oral tablet Tier 1

9


SELZENTRY ORAL SOLUTION Tier 3

SELZENTRY ORAL TABLET Tier 3

stavudine oral capsule Tier 1

stavudine oral recon soln Tier 1

STRIBILD ORAL TABLET Tier 4 SPRx

SUSTIVA ORAL CAPSULE Tier 3

SUSTIVA ORAL TABLET Tier 3

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 QL (180 ML per 180 days)

tenofovir disoproxil fumarate oral tablet Tier 1

TIVICAY ORAL TABLET Tier 4 SPRx

TRIUMEQ ORAL TABLET Tier 4 SPRx

TRUVADA ORAL TABLET Tier 4 SPRx

TYBOST ORAL TABLET Tier 3

TYZEKA ORAL TABLET Tier 3

valacyclovir oral tablet Tier 1

valganciclovir oral recon soln Tier 1

valganciclovir oral tablet Tier 1

VEMLIDY ORAL TABLET Tier 4 LD; SPRx

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

Tier 3

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

Tier 3

VIRACEPT ORAL TABLET Tier 3

VIREAD ORAL POWDER Tier 3

VIREAD ORAL TABLET Tier 3

VITEKTA ORAL TABLET Tier 4 SPRx

VOSEVI ORAL TABLET Tier 4 PA; SPRx

ZIAGEN ORAL SOLUTION Tier 3

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

Cephalosporins cefaclor oral capsule Tier 1

10


cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Tier 1

cefaclor oral tablet extended release 12 hr Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution Tier 1

cefditoren pivoxil oral tablet Tier 1

cefixime oral suspension for reconstitution Tier 1

cefpodoxime oral suspension for reconstitution Tier 1

cefpodoxime oral tablet Tier 1

cefprozil oral suspension for reconstitution Tier 1

cefprozil oral tablet Tier 1

ceftibuten oral capsule Tier 1

ceftibuten oral suspension for reconstitution Tier 1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

cefuroxime axetil oral tablet Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution Tier 1

cephalexin oral tablet Tier 1

SUPRAX ORAL CAPSULE Tier 3

SUPRAX ORAL TABLET,CHEWABLE Tier 3

Erythromycins & Other Macrolides azithromycin oral packet Tier 1

azithromycin oral suspension for reconstitution Tier 1

azithromycin oral tablet Tier 1

clarithromycin oral suspension for reconstitution Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr Tier 1

DIFICID ORAL TABLET Tier 3

e.e.s. 400 oral tablet Tier 1

11


E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

Tier 1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

Tier 3

erythrocin (as stearate) oral tablet 250 mg Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

erythromycin oral capsule,delayed release(dr/ec) Tier 1

erythromycin oral tablet Tier 1

PCE ORAL TABLET, PARTICLES/CRYSTALS

Tier 3

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

Tier 3

Miscellaneous Antiinfectives ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension Tier 1

atovaquone-proguanil oral tablet Tier 1

BILTRICIDE ORAL TABLET Tier 3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

chloroquine phosphate oral tablet Tier 1

clindamycin hcl oral capsule Tier 1

clindamycin palmitate hcl oral recon soln Tier 1

clindamycin pediatric oral recon soln Tier 1

COARTEM ORAL TABLET Tier 3

cycloserine oral capsule Tier 3

dapsone oral tablet Tier 1

DARAPRIM ORAL TABLET Tier 4 PA; LD; SPRx

EMVERM ORAL TABLET,CHEWABLE Tier 3

12


ethambutol oral tablet Tier 1

FLAGYL ER ORAL TABLET EXTENDED RELEASE

Tier 3

hydroxychloroquine oral tablet Tier 1

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

ivermectin oral tablet Tier 1

KETEK ORAL TABLET Tier 3

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

Tier 4 SPRx; QL (56 ML per 30 days)

linezolid oral suspension for reconstitution Tier 1 QL (14 day supply per 30 days)

linezolid oral tablet Tier 1 QL (14 day supply per 30 days)

mefloquine oral tablet Tier 1

MEPRON ORAL SUSPENSION Tier 3

metronidazole oral capsule Tier 1

metronidazole oral tablet Tier 1

NEBUPENT INHALATION RECON SOLN Tier 3

neomycin oral tablet Tier 1

paromomycin oral capsule Tier 1

PRIFTIN ORAL TABLET Tier 3

primaquine oral tablet Tier 3

pyrazinamide oral tablet Tier 1

quinine sulfate oral capsule Tier 1

rifabutin oral capsule Tier 1

RIFAMATE ORAL CAPSULE Tier 3

rifampin oral capsule Tier 1

RIFATER ORAL TABLET Tier 3

SIRTURO ORAL TABLET Tier 4 PA; SPRx

tinidazole oral tablet Tier 1

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4 SPRx; QL (56 ML per 30 days)

TRECATOR ORAL TABLET Tier 3

XIFAXAN ORAL TABLET 200 MG Tier 3

XIFAXAN ORAL TABLET 550 MG Tier 2

13


Penicillins amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable Tier 1

ampicillin oral capsule Tier 1

ampicillin oral suspension for reconstitution Tier 1

dicloxacillin oral capsule Tier 1

penicillin v potassium oral recon soln Tier 1

penicillin v potassium oral tablet Tier 1

Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 1

ciprofloxacin hcl oral tablet Tier 1

ciprofloxacin oral suspension,microcapsule recon Tier 1

FACTIVE ORAL TABLET Tier 3

levofloxacin oral solution Tier 1

levofloxacin oral tablet Tier 1

moxifloxacin oral tablet Tier 1

ofloxacin oral tablet 400 mg Tier 1

Sulfa's & Related Agents sulfadiazine oral tablet Tier 1

sulfamethoxazole-trimethoprim oral suspension Tier 1

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

Tier 1

sulfatrim oral suspension Tier 1

Tetracyclines demeclocycline oral tablet Tier 1

14


doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1

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

Tier 1

doxycycline monohydrate oral capsule Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

tetracycline oral capsule Tier 1

VIBRAMYCIN ORAL SYRUP Tier 3

Urinary Tract Agents methenamine hippurate oral tablet Tier 1

methenamine mandelate oral tablet Tier 1

MONUROL ORAL PACKET Tier 3

nitrofurantoin macrocrystal oral capsule Tier 1

nitrofurantoin monohyd/m-cryst oral capsule Tier 1

nitrofurantoin oral suspension Tier 1

PRIMSOL ORAL SOLUTION Tier 3

trimethoprim oral tablet Tier 1

Vancomycin vancomycin oral capsule Tier 1

Antineoplastic & Immunosuppressant Drugs Adjunctive Agents leucovorin calcium oral tablet Tier 1

MESNEX ORAL TABLET Tier 3

Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 4 PA; SPRx

AFINITOR ORAL TABLET Tier 4 PA; SPRx

ALECENSA ORAL CAPSULE Tier 4 PA; SPRx

ALKERAN ORAL TABLET Tier 2

15


anastrozole oral tablet Tier 1

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 4 SPRx

azathioprine oral tablet Tier 1

bexarotene oral capsule Tier 4 SPRx

bicalutamide oral tablet Tier 1

BOSULIF ORAL TABLET 100 MG, 500 MG Tier 4 PA; SPRx

CABOMETYX ORAL TABLET Tier 4 PA; SPRx

capecitabine oral tablet Tier 4 SPRx

CAPRELSA ORAL TABLET Tier 4 PA; LD; SPRx

COMETRIQ ORAL CAPSULE Tier 4 LD; SPRx

COTELLIC ORAL TABLET Tier 4 PA; SPRx

CYCLOPHOSPHAMIDE ORAL CAPSULE Tier 3

cyclosporine modified oral capsule Tier 1

cyclosporine modified oral solution Tier 1

cyclosporine oral capsule Tier 1

DROXIA ORAL CAPSULE Tier 3

EMCYT ORAL CAPSULE Tier 3

ERIVEDGE ORAL CAPSULE Tier 4 PA; SPRx

etoposide oral capsule Tier 1

exemestane oral tablet Tier 1

FARESTON ORAL TABLET Tier 3

FARYDAK ORAL CAPSULE Tier 4 PA; SPRx

flutamide oral capsule Tier 1

gengraf oral capsule 100 mg, 25 mg Tier 1

gengraf oral solution Tier 1

GILOTRIF ORAL TABLET Tier 4 PA; SPRx

GLEOSTINE ORAL CAPSULE Tier 3

HEXALEN ORAL CAPSULE Tier 3

HYCAMTIN ORAL CAPSULE Tier 4 SPRx

hydroxyurea oral capsule Tier 1

IBRANCE ORAL CAPSULE Tier 4 PA; SPRx

ICLUSIG ORAL TABLET Tier 4 PA; LD; SPRx

16


IDHIFA ORAL TABLET Tier 4 PA; LD; SPRx

imatinib oral tablet Tier 4 SPRx

IMBRUVICA ORAL CAPSULE Tier 4 PA; LD; SPRx

INLYTA ORAL TABLET Tier 4 PA; SPRx

IRESSA ORAL TABLET Tier 4 PA; SPRx

JAKAFI ORAL TABLET Tier 4 PA; SPRx

KISQALI ORAL TABLET Tier 4 PA; SPRx

LENVIMA ORAL CAPSULE Tier 4 PA; SPRx

letrozole oral tablet Tier 1

LEUKERAN ORAL TABLET Tier 3

leuprolide subcutaneous kit Tier 4 PA; SPRx

LONSURF ORAL TABLET Tier 4 PA; SPRx

LYNPARZA ORAL CAPSULE Tier 4 PA; SPRx

LYNPARZA ORAL TABLET Tier 4 PA; LD; SPRx

LYSODREN ORAL TABLET Tier 3

MATULANE ORAL CAPSULE Tier 4 LD; SPRx

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

Tier 1

megestrol oral tablet Tier 1

MEKINIST ORAL TABLET Tier 4 PA; SPRx

melphalan oral tablet Tier 1

mercaptopurine oral tablet Tier 1

methotrexate sodium (pf) injection recon soln Tier 1

methotrexate sodium (pf) injection solution Tier 1

methotrexate sodium injection solution Tier 1

methotrexate sodium oral tablet Tier 1

mycophenolate mofetil oral capsule Tier 1

mycophenolate mofetil oral suspension for reconstitution

Tier 1

mycophenolate mofetil oral tablet Tier 1

mycophenolate sodium oral tablet,delayed release (dr/ec)

Tier 1

MYLERAN ORAL TABLET Tier 3

NERLYNX ORAL TABLET Tier 4 PA; LD; SPRx

17


NEXAVAR ORAL TABLET Tier 4 PA; SPRx

nilutamide oral tablet Tier 4 SPRx

NINLARO ORAL CAPSULE Tier 4 PA; SPRx

octreotide acetate injection solution Tier 4 SPRx

octreotide acetate injection syringe Tier 4 SPRx

ODOMZO ORAL CAPSULE Tier 4 PA; SPRx

PURIXAN ORAL SUSPENSION Tier 4 LD; SPRx

RAPAMUNE ORAL SOLUTION Tier 3

RUBRACA ORAL TABLET Tier 4 PA; LD; SPRx

SANDIMMUNE ORAL SOLUTION Tier 3

SIGNIFOR SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

sirolimus oral tablet Tier 1

SOLTAMOX ORAL SOLUTION Tier 5 ACA

SPRYCEL ORAL TABLET Tier 4 SPRx

STIVARGA ORAL TABLET Tier 4 PA; SPRx

SUTENT ORAL CAPSULE Tier 4 PA; SPRx

TABLOID ORAL TABLET Tier 3

tacrolimus oral capsule Tier 1

TAFINLAR ORAL CAPSULE Tier 4 PA; SPRx

TAGRISSO ORAL TABLET Tier 4 PA; SPRx

tamoxifen oral tablet Tier 5 ACA

TARCEVA ORAL TABLET Tier 4 PA; SPRx

TARGRETIN TOPICAL GEL Tier 4 SPRx

TASIGNA ORAL CAPSULE Tier 4 SPRx

temozolomide oral capsule Tier 4 PA; SPRx

THALOMID ORAL CAPSULE Tier 4 PA; SPRx

tretinoin (chemotherapy) oral capsule Tier 1

TYKERB ORAL TABLET Tier 4 PA; SPRx

VENCLEXTA ORAL TABLET Tier 4 PA; LD; SPRx

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

Tier 4 PA; LD; SPRx

VERZENIO ORAL TABLET Tier 4 PA; SPRx

VOTRIENT ORAL TABLET Tier 4 PA; SPRx

18


XALKORI ORAL CAPSULE Tier 4 PA; SPRx

XTANDI ORAL CAPSULE Tier 4 SPRx

ZEJULA ORAL CAPSULE Tier 4 PA; LD; SPRx

ZELBORAF ORAL TABLET Tier 4 PA; SPRx

ZOLINZA ORAL CAPSULE Tier 4 SPRx

ZORTRESS ORAL TABLET Tier 4 SPRx

ZYDELIG ORAL TABLET Tier 4 PA; LD; SPRx

ZYKADIA ORAL CAPSULE Tier 4 PA; SPRx

ZYTIGA ORAL TABLET Tier 4 SPRx

Autonomic & Cns Drugs, Neurology & Psych Agents For Narcotic Withdrawal BUNAVAIL BUCCAL FILM Tier 2 QL (90 EA per 30 days)

buprenorphine hcl injection syringe Tier 1

buprenorphine-naloxone sublingual tablet Tier 1 QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM Tier 2 QL (90 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET Tier 3 QL (90 EA per 30 days)

Anticonvulsants APTIOM ORAL TABLET Tier 3

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr Tier 1

carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr Tier 1

carbamazepine oral tablet,chewable Tier 1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

CELONTIN ORAL CAPSULE 300 MG Tier 3

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating Tier 1

DEPAKENE ORAL CAPSULE Tier 3

DEPAKENE ORAL SOLUTION Tier 3

19


DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3

DIASTAT ACUDIAL RECTAL KIT Tier 3

DIASTAT RECTAL KIT Tier 3

diazepam rectal kit Tier 1

DILANTIN EXTENDED ORAL CAPSULE Tier 2

DILANTIN INFATABS ORAL TABLET,CHEWABLE

Tier 2

DILANTIN KAPSEAL ORAL CAPSULE Tier 2

DILANTIN ORAL CAPSULE Tier 2

DILANTIN-125 ORAL SUSPENSION Tier 2

divalproex oral capsule, delayed rel sprinkle Tier 1

divalproex oral tablet extended release 24 hr Tier 1

divalproex oral tablet,delayed release (dr/ec) Tier 1

epitol oral tablet Tier 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

FELBATOL ORAL SUSPENSION Tier 3

FELBATOL ORAL TABLET Tier 3

FYCOMPA ORAL TABLET Tier 3

gabapentin oral capsule Tier 1

gabapentin oral solution Tier 1

gabapentin oral tablet 600 mg, 800 mg Tier 1

GABITRIL ORAL TABLET Tier 3

KEPPRA ORAL SOLUTION Tier 3

KEPPRA ORAL TABLET Tier 3

20


KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

KLONOPIN ORAL TABLET Tier 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING

Tier 3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ORAL TABLET Tier 3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

Tier 3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

lamotrigine oral tablet Tier 1

lamotrigine oral tablet disintegrating, dose pk Tier 1

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

lamotrigine oral tablet,disintegrating Tier 1

lamotrigine oral tablets,dose pack Tier 1

levetiracetam oral solution Tier 1

21


levetiracetam oral tablet Tier 1

levetiracetam oral tablet extended release 24 hr Tier 1

LYRICA ORAL CAPSULE Tier 2

LYRICA ORAL SOLUTION Tier 2

MYSOLINE ORAL TABLET Tier 3

NEURONTIN ORAL CAPSULE Tier 3

NEURONTIN ORAL SOLUTION Tier 3

NEURONTIN ORAL TABLET Tier 3

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

PEGANONE ORAL TABLET Tier 3

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

PHENYTEK ORAL CAPSULE Tier 3

phenytoin oral suspension Tier 1

phenytoin oral tablet,chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

POTIGA ORAL TABLET Tier 3

primidone oral tablet Tier 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

roweepra oral tablet Tier 1

SABRIL ORAL POWDER IN PACKET Tier 3

SABRIL ORAL TABLET Tier 3

SPRITAM ORAL TABLET FOR SUSPENSION

Tier 3

TEGRETOL ORAL SUSPENSION Tier 3

TEGRETOL ORAL TABLET Tier 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

22


tiagabine oral tablet Tier 1

TOPAMAX ORAL CAPSULE, SPRINKLE Tier 3

TOPAMAX ORAL TABLET Tier 3

topiramate oral capsule, sprinkle Tier 1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 3

topiramate oral tablet Tier 1

TRILEPTAL ORAL SUSPENSION Tier 3

TRILEPTAL ORAL TABLET Tier 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

valproic acid (as sodium salt) oral solution Tier 1

valproic acid oral capsule Tier 1

vigabatrin oral powder in packet Tier 1

VIMPAT ORAL SOLUTION Tier 2

VIMPAT ORAL TABLET Tier 2

ZARONTIN ORAL CAPSULE Tier 3

ZARONTIN ORAL SOLUTION Tier 3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

Tier 3

zonisamide oral capsule Tier 1

Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 4 SPRx

benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 1

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet extended release Tier 1

carbidopa-levodopa oral tablet,disintegrating Tier 1

carbidopa-levodopa-entacapone oral tablet Tier 1

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

Tier 4 PA; SPRx

entacapone oral tablet Tier 1

23


NEUPRO TRANSDERMAL PATCH 24 HOUR

Tier 3

pramipexole oral tablet Tier 1

pramipexole oral tablet extended release 24 hr Tier 1

rasagiline oral tablet Tier 1

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr Tier 1

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

tolcapone oral tablet Tier 1

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ZELAPAR ORAL TABLET,DISINTEGRATING

Tier 3

Migraine & Cluster Headache Therapy almotriptan malate oral tablet Tier 1 QL (18 EA per 30 days)

dihydroergotamine injection solution Tier 1

dihydroergotamine nasal spray,non-aerosol Tier 1 QL (8 ML per 30 days)

eletriptan hbr oral tablet Tier 1 QL (18 EA per 30 days)

ergotamine-caffeine oral tablet Tier 1

frovatriptan oral tablet Tier 1

isometh-dichloral-acetaminophn oral capsule Tier 1

MIGERGOT RECTAL SUPPOSITORY Tier 1

naratriptan oral tablet Tier 1 QL (18 EA per 30 days)

nodolor oral capsule Tier 1

RELPAX ORAL TABLET Tier 2 QL (18 EA per 30 days)

rizatriptan oral tablet Tier 1 QL (18 EA per 30 days)

rizatriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol Tier 1 QL (12 EA per 30 days)

sumatriptan succinate oral tablet Tier 1 QL (18 EA per 30 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml


sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml


24


sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml


sumatriptan succinate subcutaneous solution Tier 1 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML


zolmitriptan oral tablet Tier 1 QL (18 EA per 30 days)

zolmitriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

ZOMIG NASAL SPRAY,NON-AEROSOL Tier 3

Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 4 PA; SPRx

donepezil oral tablet Tier 1

donepezil oral tablet,disintegrating Tier 1

galantamine oral capsule,ext rel. pellets 24 hr Tier 1

galantamine oral solution Tier 1

galantamine oral tablet Tier 1

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 3

KEVEYIS ORAL TABLET Tier 4 PA; LD; SPRx

memantine oral solution Tier 1

memantine oral tablet Tier 1

MEMANTINE ORAL TABLETS,DOSE PACK

Tier 3

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 3

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 2

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 2

25


NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

Tier 2

NUEDEXTA ORAL CAPSULE Tier 3

rivastigmine tartrate oral capsule Tier 1

rivastigmine transdermal patch 24 hour Tier 1

tetrabenazine oral tablet Tier 4 PA; SPRx

Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet Tier 1

carisoprodol oral tablet Tier 1

carisoprodol-asa-codeine oral tablet Tier 1

carisoprodol-aspirin oral tablet Tier 1

chlorzoxazone oral tablet Tier 1

cyclobenzaprine oral tablet Tier 1

dantrolene oral capsule Tier 1

meprobamate oral tablet Tier 1

MESTINON ORAL SYRUP Tier 3

metaxalone oral tablet 800 mg Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate oral tablet extended release Tier 1

pyridostigmine bromide oral tablet Tier 1

pyridostigmine bromide oral tablet extended release

Tier 1

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

Narcotic Analgesics acetaminophen-caff-dihydrocod oral capsule Tier 1 QL (120 EA per 30 days)

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


acetaminophen-codeine oral tablet Tier 1 QL (180 EA per 30 days)

ascomp with codeine oral capsule Tier 1 QL (120 EA per 30 days)

aspirin-caffeine-dihydrocodein oral capsule Tier 1 QL (240 EA per 30 days)

butalbital compound w/codeine oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-acetaminop-caf-cod oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-acetaminophen oral tablet Tier 1 QL (120 EA per 30 days)

26


butalbital-acetaminophen-caff oral capsule Tier 1 QL (120 EA per 30 days)

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


butalbital-aspirin-caffeine oral capsule Tier 1 QL (120 EA per 30 days)

butorphanol tartrate nasal spray,non-aerosol Tier 1 QL (5 ML per 28 days)

BUTRANS TRANSDERMAL PATCH WEEKLY

Tier 2 PA; QL (4 EA per 28 days)

capacet oral capsule Tier 1 QL (120 EA per 30 days)

codeine sulfate oral tablet Tier 1 QL (180 EA per 30 days)

codeine-butalbital-asa-caff oral capsule Tier 1 QL (120 EA per 30 days)

diskets oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


fentanyl citrate buccal lozenge on a handle 1,200 mcg


fentanyl citrate buccal lozenge on a handle 1,600 mcg


fentanyl citrate buccal lozenge on a handle 200 mcg








fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml)


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


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


hydromorphone oral liquid Tier 1 QL (30 ML per 30 days)

hydromorphone oral tablet Tier 1 QL (120 EA per 30 days)

27


hydromorphone rectal suppository Tier 1 QL (60 EA per 30 days)

ibuprofen-oxycodone oral tablet Tier 1 QL (28 EA per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG


levorphanol tartrate oral tablet Tier 1 QL (120 EA per 30 days)

lorcet (hydrocodone) oral tablet Tier 1 QL (120 EA per 30 days)

lorcet hd oral tablet Tier 1 QL (120 EA per 30 days)

lorcet plus oral tablet 7.5-325 mg Tier 1 QL (120 EA per 30 days)

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML


meperidine oral solution Tier 1 QL (480 ML per 30 days)

meperidine oral tablet Tier 1 QL (120 EA per 30 days)

methadone intensol oral concentrate Tier 1 PA; QL (120 ML per 30 days)

methadone oral concentrate Tier 1 PA; QL (120 ML per 30 days)

methadone oral solution 10 mg/5 ml Tier 1 PA; QL (480 ML per 30 days)

methadone oral solution 5 mg/5 ml Tier 1 PA; QL (960 ML per 30 days)

methadone oral tablet Tier 1 PA; QL (120 EA per 30 days)

methadone oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

methadose oral concentrate Tier 1 PA; QL (120 ML per 30 days)

methadose oral tablet,soluble Tier 1 PA; QL (50 EA per 30 days)

morphine concentrate oral solution Tier 1 QL (300 ML per 30 days)

morphine oral capsule, er multiphase 24 hr 120 mg


morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


morphine oral capsule,extend.release pellets Tier 1 PA; QL (60 EA per 30 days)

morphine oral solution Tier 1 QL (900 ML per 30 days)

morphine oral tablet Tier 1 QL (120 EA per 30 days)

morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg


morphine oral tablet extended release 200 mg Tier 1 PA; QL (30 EA per 30 days)

morphine rectal suppository Tier 1 QL (120 EA per 30 days)

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR


28


NUCYNTA ORAL TABLET Tier 3 QL (120 EA per 30 days)

oxycodone oral capsule Tier 1 QL (120 EA per 30 days)

oxycodone oral concentrate Tier 1 QL (120 ML per 30 days)

oxycodone oral solution Tier 1 QL (480 ML per 30 days)

oxycodone oral tablet Tier 1 QL (120 EA per 30 days)

oxycodone-acetaminophen oral solution Tier 1 QL (480 ML per 30 days)

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


oxycodone-aspirin oral tablet Tier 1 QL (120 EA per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


oxymorphone oral tablet Tier 1 QL (120 EA per 30 days)

oxymorphone oral tablet extended release 12 hr Tier 1 PA; QL (60 EA per 30 days)

pentazocine-naloxone oral tablet Tier 1 QL (120 EA per 30 days)

reprexain oral tablet Tier 1 QL (120 EA per 30 days)

tencon oral tablet 50-325 mg Tier 1 QL (120 EA per 30 days)

tramadol oral tablet Tier 1 QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol oral tablet, er multiphase 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol-acetaminophen oral tablet Tier 1 QL (240 EA per 30 days)

verdrocet oral tablet Tier 1 QL (120 EA per 30 days)

vicodin es oral tablet Tier 1 QL (120 EA per 30 days)

vicodin hp oral tablet Tier 1 QL (120 EA per 30 days)

vicodin oral tablet Tier 1 QL (120 EA per 30 days)

xylon 10 oral tablet Tier 1 QL (150 EA per 30 days)

zamicet oral solution Tier 1 QL (480 ML per 30 days)

zebutal oral capsule 50-325-40 mg Tier 1 QL (120 EA per 30 days)

Non-Narcotic Analgesics celecoxib oral capsule Tier 1

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral tablet extended release 24 hr

Tier 1

29


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

Tier 1

diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

Tier 1

diflunisal oral tablet Tier 1

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet extended release 24 hr Tier 1

fenoprofen oral tablet Tier 1

flurbiprofen oral tablet Tier 1

ibuprofen oral suspension Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

INDOCIN ORAL SUSPENSION Tier 3

indomethacin oral capsule Tier 1

indomethacin oral capsule, extended release Tier 1

ketoprofen oral capsule Tier 1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Tier 1

ketorolac oral tablet Tier 1

meclofenamate oral capsule Tier 1

mefenamic acid oral capsule Tier 1

meloxicam oral suspension Tier 1

meloxicam oral tablet Tier 1

nabumetone oral tablet Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

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

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

salsalate oral tablet Tier 1

SPRIX NASAL SPRAY,NON-AEROSOL Tier 4 LD; SPRx

sulindac oral tablet Tier 1

30


tolmetin oral capsule Tier 1

tolmetin oral tablet Tier 1

Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution Tier 1 QL (2 units per 1 claim)

naloxone injection syringe Tier 1 QL (2 units per 1 claim)

naltrexone oral tablet Tier 1

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

Tier 3 QL (2 units per 1 claim)

Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Tier 4 SPRx; AGE-A

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 4 SPRx; AGE-A

alprazolam intensol oral concentrate Tier 1

alprazolam oral tablet Tier 1

alprazolam oral tablet extended release 24 hr Tier 1

alprazolam oral tablet,disintegrating Tier 1

amitriptyline oral tablet Tier 1

amitriptyline-chlordiazepoxide oral tablet Tier 1

amoxapine oral tablet Tier 1

aripiprazole oral solution Tier 1 AGE-A

aripiprazole oral tablet Tier 1 AGE-A

aripiprazole oral tablet,disintegrating Tier 1 AGE-A

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 4 LD; SPRx; AGE-A

armodafinil oral tablet Tier 1 PA

atomoxetine oral capsule Tier 1

bupropion hcl oral tablet Tier 1

bupropion hcl oral tablet extended release 12 hr Tier 1

bupropion hcl oral tablet extended release 24 hr Tier 1

buspirone oral tablet Tier 1

chlordiazepoxide hcl oral capsule Tier 1

chlorpromazine oral tablet Tier 1

citalopram oral solution Tier 1

31


citalopram oral tablet Tier 1

clomipramine oral capsule Tier 1

clonidine hcl oral tablet extended release 12 hr Tier 1

clorazepate dipotassium oral tablet Tier 1

clozapine oral tablet Tier 1 AGE-A

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

Tier 1 AGE-A

clozapine oral tablet,disintegrating 150 mg, 200 mg

Tier 3 AGE-A

DAYTRANA TRANSDERMAL PATCH 24 HOUR

Tier 2

desipramine oral tablet Tier 1

desvenlafaxine succinate oral tablet extended release 24 hr

Tier 1

dexedrine oral tablet Tier 1

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1

dexmethylphenidate oral tablet Tier 1

dextroamphetamine oral capsule, extended release Tier 1

dextroamphetamine oral solution Tier 1

dextroamphetamine oral tablet Tier 1

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg

Tier 1

dextroamphetamine-amphetamine oral tablet Tier 1

diazepam intensol oral concentrate Tier 1

diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1

diazepam oral tablet Tier 1

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral capsule,delayed release(dr/ec) Tier 1

EMSAM TRANSDERMAL PATCH 24 HOUR Tier 3

ergoloid oral tablet Tier 1

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

32


estazolam oral tablet Tier 1

eszopiclone oral tablet Tier 1

FANAPT ORAL TABLET Tier 3 AGE-A

FANAPT ORAL TABLETS,DOSE PACK Tier 3 AGE-A

FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

Tier 3 AGE-A

fluoxetine oral capsule Tier 1

fluoxetine oral capsule,delayed release(dr/ec) Tier 1

fluoxetine oral solution Tier 1

fluoxetine oral tablet Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

flurazepam oral capsule Tier 1

fluvoxamine oral capsule,extended release 24hr Tier 1

fluvoxamine oral tablet Tier 1

guanfacine oral tablet extended release 24 hr Tier 1

guanidine oral tablet Tier 1

haloperidol lactate oral concentrate Tier 1

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

imipramine pamoate oral capsule Tier 1

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

INVEGA TRINZA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

LATUDA ORAL TABLET Tier 2 AGE-A

lithium carbonate oral capsule Tier 1

lithium carbonate oral tablet Tier 1

lithium carbonate oral tablet extended release Tier 1

lithium citrate oral solution 8 meq/5 ml Tier 1

lorazepam intensol oral concentrate Tier 1

lorazepam oral concentrate Tier 1

33


lorazepam oral tablet Tier 1

loxapine succinate oral capsule Tier 1

maprotiline oral tablet Tier 1

MARPLAN ORAL TABLET Tier 3

metadate er oral tablet extended release Tier 1

methamphetamine oral tablet Tier 1

methylphenidate hcl oral capsule, er biphasic 30-70

Tier 1

methylphenidate hcl oral capsule,er biphasic 50-50

Tier 1

methylphenidate hcl oral solution Tier 1

methylphenidate hcl oral tablet Tier 1

methylphenidate hcl oral tablet extended release Tier 1

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Tier 1

methylphenidate hcl oral tablet,chewable Tier 1

midazolam oral syrup 2 mg/ml Tier 1

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating Tier 1

modafinil oral tablet Tier 1 PA

molindone oral tablet Tier 1

nefazodone oral tablet Tier 1

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

NUPLAZID ORAL TABLET Tier 4 PA; SPRx

olanzapine oral tablet Tier 1 AGE-A

olanzapine oral tablet,disintegrating Tier 1 AGE-A

olanzapine-fluoxetine oral capsule Tier 1 AGE-A

oxazepam oral capsule Tier 1

paliperidone oral tablet extended release 24hr Tier 1 AGE-A

paroxetine hcl oral tablet Tier 1

paroxetine hcl oral tablet extended release 24 hr Tier 1

PAXIL ORAL SUSPENSION Tier 3

perphenazine oral tablet Tier 1

34


perphenazine-amitriptyline oral tablet Tier 1

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 1

procentra oral solution Tier 1

protriptyline oral tablet Tier 1

quazepam oral tablet Tier 1

quetiapine oral tablet Tier 1 AGE-A

quetiapine oral tablet extended release 24 hr Tier 1 AGE-A

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

Tier 2

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE

Tier 4 SPRx; AGE-A

risperidone oral solution Tier 1 AGE-A

risperidone oral tablet Tier 1 AGE-A

risperidone oral tablet,disintegrating Tier 1 AGE-A

ROZEREM ORAL TABLET Tier 3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 3 AGE-A

SARAFEM ORAL TABLET 10 MG, 20 MG Tier 3

sertraline oral concentrate Tier 1

sertraline oral tablet Tier 1

STRATTERA ORAL CAPSULE Tier 3

temazepam oral capsule Tier 1

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

triazolam oral tablet Tier 1

trifluoperazine oral tablet Tier 1

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET Tier 3

venlafaxine oral capsule,extended release 24hr Tier 1

venlafaxine oral tablet Tier 1

VIIBRYD ORAL TABLET Tier 2

35


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

Tier 2

VRAYLAR ORAL CAPSULE Tier 3 AGE-A

VRAYLAR ORAL CAPSULE,DOSE PACK Tier 3 AGE-A

VYVANSE ORAL CAPSULE Tier 2

VYVANSE ORAL TABLET,CHEWABLE Tier 2

XYREM ORAL SOLUTION Tier 4 PA; SPRx

zaleplon oral capsule Tier 1

zenzedi oral tablet 10 mg, 5 mg Tier 1

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

Tier 3

ziprasidone hcl oral capsule Tier 1 AGE-A

zolpidem oral tablet Tier 1

zolpidem oral tablet,ext release multiphase Tier 1

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 4 SPRx; AGE-A

Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral tablet Tier 1

disopyramide phosphate oral capsule Tier 1

dofetilide oral capsule Tier 1

flecainide oral tablet Tier 1

mexiletine oral capsule Tier 1

MULTAQ ORAL TABLET Tier 3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

Tier 3

pacerone oral tablet 100 mg, 200 mg, 400 mg Tier 1

propafenone oral capsule,extended release 12 hr Tier 1

propafenone oral tablet Tier 1

quinidine gluconate oral tablet extended release Tier 1

quinidine sulfate oral tablet Tier 1

sorine oral tablet Tier 1

sotalol af oral tablet Tier 1

sotalol oral tablet Tier 1

36


SOTYLIZE ORAL SOLUTION Tier 3

Antihypertensive Therapy acebutolol oral capsule Tier 1

afeditab cr oral tablet extended release Tier 1

amiloride oral tablet Tier 1

amiloride-hydrochlorothiazide oral tablet Tier 1

amlodipine oral tablet Tier 1

amlodipine-benazepril oral capsule Tier 1

amlodipine-olmesartan oral tablet Tier 1

amlodipine-valsartan oral tablet Tier 1

amlodipine-valsartan-hcthiazid oral tablet Tier 1

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet Tier 1

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet Tier 1

betaxolol oral tablet Tier 1

BIDIL ORAL TABLET Tier 3

bisoprolol fumarate oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

bumetanide oral tablet Tier 1

BYSTOLIC ORAL TABLET Tier 2

candesartan oral tablet Tier 1

candesartan-hydrochlorothiazid oral tablet Tier 1

captopril oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

Tier 3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

cartia xt oral capsule,extended release 24hr Tier 1

carvedilol oral tablet Tier 1

carvedilol phosphate oral capsule, er multiphase 24 hr

Tier 1

chlorothiazide oral tablet Tier 1

37


chlorthalidone oral tablet 25 mg, 50 mg Tier 1

clonidine hcl oral tablet Tier 1

clonidine transdermal patch weekly Tier 1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg Tier 1

CLORPRES ORAL TABLET 0.3-15 MG Tier 3

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

Tier 2

diltiazem hcl oral capsule,ext.rel 24h degradable Tier 1

diltiazem hcl oral capsule,extended release 12 hr Tier 1

diltiazem hcl oral capsule,extended release 24 hr Tier 1

diltiazem hcl oral capsule,extended release 24hr Tier 1

diltiazem hcl oral tablet Tier 1

diltiazem hcl oral tablet extended release 24 hr Tier 1

dilt-xr oral capsule,ext.rel 24h degradable Tier 1

DIURIL ORAL SUSPENSION Tier 3

doxazosin oral tablet Tier 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DYRENIUM ORAL CAPSULE Tier 3

EDARBI ORAL TABLET Tier 3 ST

EDARBYCLOR ORAL TABLET Tier 3 ST

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide oral tablet Tier 1

EPANED ORAL RECON SOLN Tier 3

EPANED ORAL SOLUTION Tier 3

eplerenone oral tablet Tier 1

epoprostenol (glycine) intravenous recon soln Tier 4 PA; SPRx

eprosartan oral tablet Tier 1

ethacrynic acid oral tablet Tier 1

felodipine oral tablet extended release 24 hr Tier 1

FLOLAN INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet Tier 1

38


furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

Tier 1

furosemide oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

indapamide oral tablet Tier 1

irbesartan oral tablet Tier 1

irbesartan-hydrochlorothiazide oral tablet Tier 1

isradipine oral capsule Tier 1

labetalol oral tablet Tier 1

LEVATOL ORAL TABLET Tier 3

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet Tier 1

losartan oral tablet Tier 1

losartan-hydrochlorothiazide oral tablet Tier 1

matzim la oral tablet extended release 24 hr Tier 1

methyclothiazide oral tablet Tier 1

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet Tier 1

metoprolol tartrate oral tablet Tier 1

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

nadolol oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

nicardipine oral capsule Tier 1

nifedical xl oral tablet extended release 24hr Tier 1

nifedipine oral capsule Tier 1

39


nifedipine oral tablet extended release Tier 1

nifedipine oral tablet extended release 24hr Tier 1

nimodipine oral capsule Tier 1

nisoldipine oral tablet extended release 24 hr Tier 1

olmesartan oral tablet Tier 1

olmesartan-amlodipin-hcthiazid oral tablet Tier 1

olmesartan-hydrochlorothiazide oral tablet Tier 1

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

Tier 4 PA; SPRx

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG

Tier 4 PA; LD; SPRx

perindopril erbumine oral tablet Tier 1

phenoxybenzamine oral capsule Tier 1

pindolol oral tablet Tier 1

prazosin oral capsule Tier 1

propranolol oral capsule,extended release 24 hr Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION Tier 4 PA; SPRx

reserpine oral tablet Tier 1

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz oral tablet Tier 1

taztia xt oral capsule,extended release 24 hr Tier 1

TEKTURNA HCT ORAL TABLET Tier 3

TEKTURNA ORAL TABLET Tier 3

telmisartan oral tablet Tier 1

telmisartan-amlodipine oral tablet Tier 1

telmisartan-hydrochlorothiazid oral tablet Tier 1

terazosin oral capsule Tier 1

timolol maleate oral tablet Tier 1

40


torsemide oral tablet Tier 1

trandolapril oral tablet Tier 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet Tier 1

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide oral tablet Tier 1

VELETRI INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

verapamil oral capsule, 24 hr er pellet ct Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet Tier 1

verapamil oral tablet extended release Tier 1

Cardiac Glycosides digitek oral tablet Tier 1

digox oral tablet Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1

LANOXIN ORAL TABLET Tier 2

Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 4 SPRx

ALPHANATE INTRAVENOUS RECON SOLN

Tier 4 SPRx

ALPHANINE SD INTRAVENOUS RECON SOLN

Tier 4 SPRx

ALPROLIX INTRAVENOUS RECON SOLN Tier 4 SPRx

AMICAR ORAL SOLUTION Tier 3

AMICAR ORAL TABLET Tier 3

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 1

BEBULIN INTRAVENOUS RECON SOLN Tier 4 SPRx

BENEFIX INTRAVENOUS RECON SOLN Tier 4 SPRx

BRILINTA ORAL TABLET Tier 2

cilostazol oral tablet Tier 1

41


clopidogrel oral tablet Tier 1

COAGADEX INTRAVENOUS RECON SOLN Tier 4 LD; SPRx

CORIFACT INTRAVENOUS RECON SOLN Tier 4 SPRx

COUMADIN ORAL TABLET Tier 3

dipyridamole oral tablet Tier 1

ELIQUIS ORAL TABLET Tier 2

enoxaparin subcutaneous solution Tier 1 QL (42 ML per 365 days)

enoxaparin subcutaneous syringe Tier 1 QL (42 ML per 365 days)

FEIBA NF INTRAVENOUS RECON SOLN Tier 4 SPRx

fondaparinux subcutaneous syringe Tier 1 QL (42 ML per 365 days)

FRAGMIN SUBCUTANEOUS SOLUTION Tier 3 QL (42 ML per 365 days)

FRAGMIN SUBCUTANEOUS SYRINGE Tier 3 QL (42 ML per 365 days)

HELIXATE FS INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M LOW INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M MID INTRAVENOUS RECON SOLN

Tier 4 SPRx

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

Tier 4 SPRx

hep flush-10 (pf) intravenous solution Tier 1

heparin (porcine) injection solution Tier 1

heparin lock flush (porcine) intravenous solution 100 unit/ml

Tier 1

heparin lock flush (porcine) intravenous syringe Tier 1

heparin lock flush intravenous solution Tier 1

heparin lockflush(porcine)(pf) intravenous syringe Tier 1

heparin, porcine (pf) injection solution Tier 1

heparin, porcine (pf) injection syringe Tier 1

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

Tier 1

heparin, porcine (pf) intravenous syringe Tier 1

HUMATE-P INTRAVENOUS RECON SOLN Tier 4 SPRx

42


jantoven oral tablet Tier 1

KOATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT

Tier 4 SPRx

KOATE-DVI INTRAVENOUS RECON SOLN Tier 4 SPRx

KOGENATE FS INTRAVENOUS RECON SOLN

Tier 4 SPRx

MEPHYTON ORAL TABLET Tier 3

MONOCLATE-P INTRAVENOUS RECON SOLN

Tier 4 SPRx

NOVOSEVEN RT INTRAVENOUS RECON SOLN

Tier 4 SPRx

pentoxifylline oral tablet extended release Tier 1

PRADAXA ORAL CAPSULE Tier 3

prasugrel oral tablet Tier 1

PROFILNINE INTRAVENOUS RECON SOLN

Tier 4 SPRx

PROMACTA ORAL TABLET Tier 4 SPRx

RECOMBINATE INTRAVENOUS RECON SOLN

Tier 4 SPRx

RIXUBIS INTRAVENOUS RECON SOLN Tier 4 SPRx

ticlopidine oral tablet Tier 1

warfarin oral tablet Tier 1

XARELTO ORAL TABLET Tier 2

XARELTO ORAL TABLETS,DOSE PACK Tier 2

XYNTHA INTRAVENOUS SOLUTION Tier 4 SPRx

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

Tier 4 SPRx

ZONTIVITY ORAL TABLET Tier 3

Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet Tier 1

ANTARA ORAL CAPSULE 30 MG, 90 MG Tier 3

atorvastatin oral tablet 10 mg, 20 mg Tier 5 ACA

atorvastatin oral tablet 40 mg, 80 mg Tier 1

cholestyramine (with sugar) oral powder Tier 1

cholestyramine (with sugar) oral powder in packet Tier 1

43


cholestyramine light oral powder Tier 1

cholestyramine light oral powder in packet Tier 1

COLESTID FLAVORED ORAL PACKET Tier 3

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

ezetimibe oral tablet Tier 1

ezetimibe-simvastatin oral tablet Tier 1

fenofibrate micronized oral capsule Tier 1

fenofibrate nanocrystallized oral tablet Tier 1

fenofibrate oral tablet Tier 1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

Tier 1

fenofibric acid oral tablet Tier 1

fluvastatin oral capsule Tier 5 ACA

fluvastatin oral tablet extended release 24 hr Tier 5 ACA

gemfibrozil oral tablet Tier 1

KYNAMRO SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

LIPOFEN ORAL CAPSULE Tier 3

LIVALO ORAL TABLET Tier 3

lovastatin oral tablet Tier 5 ACA

niacin oral tablet extended release 24 hr Tier 1

NIACOR ORAL TABLET Tier 3

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

PRALUENT SYRINGE SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

pravastatin oral tablet Tier 5 ACA

prevalite oral powder Tier 1

prevalite oral powder in packet Tier 1

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

Tier 4 PA; SPRx

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

44


REPATHA SYRINGE SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

rosuvastatin oral tablet 10 mg, 5 mg Tier 5 ACA

rosuvastatin oral tablet 20 mg, 40 mg Tier 1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 5 ACA

simvastatin oral tablet 80 mg Tier 1

TRIGLIDE ORAL TABLET 160 MG Tier 3

WELCHOL ORAL POWDER IN PACKET Tier 3

WELCHOL ORAL TABLET Tier 3

Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET Tier 3

ENTRESTO ORAL TABLET Tier 3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

Tier 3

ISORDIL ORAL TABLET Tier 3

isosorbide dinitrate oral tablet Tier 1

isosorbide dinitrate oral tablet extended release Tier 1

isosorbide mononitrate oral tablet Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

MINITRAN TRANSDERMAL PATCH 24 HOUR

Tier 3

nitro-bid transdermal ointment Tier 1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR

Tier 3

nitroglycerin oral capsule, extended release Tier 1

nitroglycerin sublingual tablet Tier 1

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual aerosol,spray Tier 1

nitroglycerin translingual spray,non-aerosol Tier 1

NITROSTAT SUBLINGUAL TABLET Tier 3

nitro-time oral capsule, extended release Tier 1

45


Dermatologicals/Topical Therapy Antipsoriatic / Antiseborrheic acitretin oral capsule Tier 1

calcipotriene scalp solution Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment Tier 1

calcipotriene-betamethasone topical ointment Tier 1

calcitrene topical ointment Tier 1

calcitriol topical ointment Tier 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 4 PA; SPRx

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

COSENTYX SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

drithocreme hp topical cream Tier 1

ENSTILAR TOPICAL FOAM Tier 3

hydrocortisone-pramoxine topical cream Tier 1

seb-prev topical cleanser Tier 1

selenium sulfide topical lotion Tier 1

selenium sulfide topical shampoo 2.25 % Tier 1

STELARA SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx

sulfacetamide sodium topical cleanser Tier 1

sulfacetamide sodium topical shampoo Tier 1

TACLONEX TOPICAL SUSPENSION Tier 3

Burn Therapy silver sulfadiazine topical cream Tier 1

ssd topical cream Tier 1

thermazene topical cream Tier 1

Keratolytics PODOCON TOPICAL LIQUID Tier 3

POTASSIUM HYDROXIDE TOPICAL SOLUTION

Tier 3

46


salicylic acid er-ceramides topical combo pack Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release Tier 1

salicylic acid topical film forming liquid w/appl Tier 1

salicylic acid topical liquid 26 % Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical shampoo Tier 1

Miscellaneous Dermatologicals ammonium lactate topical cream Tier 1

diclofenac sodium topical gel 3 % Tier 1 QL (100 GM per 30 days)

doxepin topical cream Tier 1

DUPIXENT SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx; QL (2 ML per 30 days)

ELIDEL TOPICAL CREAM Tier 2

EUCRISA TOPICAL OINTMENT Tier 3

fluorouracil topical cream 5 % Tier 1

fluorouracil topical solution Tier 1

methoxsalen oral capsule,liqd-filled,rapid rel Tier 1

PICATO TOPICAL GEL Tier 3

podofilox topical solution Tier 1

pruclair topical cream Tier 1

REGRANEX TOPICAL GEL Tier 3

silver nitrate applicators topical stick Tier 1

silver nitrate topical solution 10 % Tier 1

tacrolimus topical ointment Tier 1

VALCHLOR TOPICAL GEL Tier 4 PA; SPRx

VEREGEN TOPICAL OINTMENT Tier 3

Therapy For Acne ACANYA TOPICAL GEL WITH PUMP Tier 2

adapalene topical cream Tier 1

adapalene topical gel Tier 1

adapalene topical gel with pump Tier 1

adapalene-benzoyl peroxide topical gel with pump Tier 1

47


amnesteem oral capsule Tier 1

avita topical cream Tier 1 PA

benzoyl peroxide topical cleanser 7 % Tier 1

benzoyl peroxide topical foam 9.8 % Tier 1

claravis oral capsule Tier 1

clindamycin phosphate topical foam Tier 1

clindamycin phosphate topical gel Tier 1

clindamycin phosphate topical lotion Tier 1

clindamycin phosphate topical solution Tier 1

clindamycin phosphate topical swab Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with pump

Tier 1

EPIDUO FORTE TOPICAL GEL WITH PUMP

Tier 2

EPIDUO TOPICAL GEL Tier 2

EPIDUO TOPICAL GEL WITH PUMP Tier 2

ery pads topical swab Tier 1

erygel topical gel Tier 1

erythromycin with ethanol topical gel Tier 1

erythromycin with ethanol topical solution Tier 1

erythromycin with ethanol topical swab Tier 1

erythromycin-benzoyl peroxide topical gel Tier 1

FINACEA TOPICAL FOAM Tier 2

FINACEA TOPICAL GEL Tier 2

metronidazole topical cream Tier 1

metronidazole topical gel Tier 1

metronidazole topical gel with pump Tier 1

metronidazole topical lotion Tier 1

MIRVASO TOPICAL GEL Tier 3

MIRVASO TOPICAL GEL WITH PUMP Tier 3

myorisan oral capsule Tier 1

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

48


sulfacetamide sodium-sulfur topical cleanser Tier 1

sulfacetamide sodium-sulfur topical cream Tier 1

sulfacetamide sodium-sulfur topical lotion Tier 1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension Tier 1

sulfacetamide sod-sulfur-urea topical cleanser Tier 1

tazarotene topical cream Tier 1 PA

TAZORAC TOPICAL CREAM 0.05 % Tier 3 PA

TAZORAC TOPICAL GEL Tier 3 PA

tretinoin microspheres topical gel 0.04 % Tier 1 PA

tretinoin topical cream Tier 1 PA

tretinoin topical gel Tier 1 PA

VANOXIDE-HC TOPICAL SUSPENSION Tier 3

zenatane oral capsule Tier 1

Topical Anesthetics glydo mucous membrane jelly in applicator Tier 1

lidocaine hcl mucous membrane jelly Tier 1

lidocaine hcl mucous membrane jelly in applicator Tier 1

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

Tier 1

lidocaine hcl-hydrocortison ac topical cream Tier 1

lidocaine topical adhesive patch,medicated Tier 1 QL (90 EA per 30 days)

lidocaine topical ointment Tier 1 QL (100 GM per 30 days)

lidocaine viscous mucous membrane solution Tier 1

lidocaine-prilocaine topical cream Tier 1 QL (60 GM per 30 days)

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

Topical Antibacterials ALTABAX TOPICAL OINTMENT Tier 3

CORTISPORIN TOPICAL CREAM Tier 3

CORTISPORIN TOPICAL OINTMENT Tier 3

gentamicin topical cream Tier 1

gentamicin topical ointment Tier 1

49


mupirocin calcium topical cream Tier 1

mupirocin topical ointment Tier 1

sulfacetamide sodium (acne) topical suspension Tier 1

SULFAMYLON TOPICAL CREAM Tier 3

SULFAMYLON TOPICAL PACKET Tier 3

Topical Antifungals ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension Tier 1

ciclopirox-ure-camph-menth-euc topical solution Tier 1

clotrimazole-betamethasone topical cream Tier 1

clotrimazole-betamethasone topical lotion Tier 1

econazole topical cream Tier 1

ERTACZO TOPICAL CREAM Tier 3

EXELDERM TOPICAL CREAM Tier 3

EXELDERM TOPICAL SOLUTION Tier 3

ketoconazole topical cream Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo Tier 1

naftifine topical cream Tier 1

NAFTIN TOPICAL GEL Tier 3

nyamyc topical powder Tier 1

nyata topical powder Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream Tier 1

nystatin-triamcinolone topical ointment Tier 1

nystop topical powder Tier 1

50


oxiconazole topical cream Tier 1

VUSION TOPICAL OINTMENT Tier 3

Topical Antivirals acyclovir topical ointment Tier 1

DENAVIR TOPICAL CREAM Tier 3

ZOVIRAX TOPICAL CREAM Tier 2

Topical Corticosteroids ala-cort topical cream 2.5 % Tier 1

alclometasone topical cream Tier 1

alclometasone topical ointment Tier 1

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment Tier 1

apexicon e topical cream Tier 1

AQUA GLYCOLIC HC TOPICAL COMBO PACK

Tier 3

betamethasone dipropionate topical cream Tier 1

betamethasone dipropionate topical lotion Tier 1

betamethasone dipropionate topical ointment Tier 1

betamethasone valerate topical cream Tier 1

betamethasone valerate topical foam Tier 1

betamethasone valerate topical lotion Tier 1

betamethasone valerate topical ointment Tier 1

betamethasone, augmented topical cream Tier 1

betamethasone, augmented topical gel Tier 1

betamethasone, augmented topical lotion Tier 1

betamethasone, augmented topical ointment Tier 1

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

51


clobetasol topical shampoo Tier 1

clobetasol topical spray,non-aerosol Tier 1

clobetasol-emollient topical cream Tier 1

clobetasol-emollient topical foam Tier 1

CLODERM TOPICAL CREAM Tier 3

desonide topical cream Tier 1

desonide topical lotion Tier 1

desonide topical ointment Tier 1

desoximetasone topical cream Tier 1

desoximetasone topical gel Tier 1

desoximetasone topical ointment Tier 1

diflorasone topical cream Tier 1

diflorasone topical ointment Tier 1

fluocinolone and shower cap scalp oil Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment Tier 1

fluocinolone topical solution Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1

fluocinonide topical ointment Tier 1

fluocinonide topical solution Tier 1

fluocinonide-e topical cream Tier 1

flurandrenolide topical cream Tier 1

flurandrenolide topical lotion Tier 1

flurandrenolide topical ointment Tier 1

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment Tier 1

halobetasol propionate topical cream Tier 1

halobetasol propionate topical ointment Tier 1

HALOG TOPICAL CREAM Tier 3

HALOG TOPICAL OINTMENT Tier 3

52


hydrocortisone butyrate topical cream Tier 1

hydrocortisone butyrate topical ointment Tier 1

hydrocortisone butyrate topical solution Tier 1

hydrocortisone butyr-emollient topical cream Tier 1

hydrocortisone topical cream 2.5 % Tier 1

hydrocortisone topical lotion 2.5 % Tier 1

hydrocortisone topical ointment 2.5 % Tier 1

hydrocortisone valerate topical cream Tier 1

hydrocortisone valerate topical ointment Tier 1

hydrocortisone-min oil-wht pet topical ointment Tier 1

mometasone topical cream Tier 1

mometasone topical ointment Tier 1

mometasone topical solution Tier 1

prednicarbate topical cream Tier 1

prednicarbate topical ointment Tier 1

triamcinolone acetonide topical aerosol Tier 1

triamcinolone acetonide topical cream Tier 1

triamcinolone acetonide topical lotion Tier 1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 1

ULTRAVATE X TOPICAL COMBO PACK Tier 3

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 3

Topical Enzymes SANTYL TOPICAL OINTMENT Tier 3

Topical Scabicides / Pediculicides EURAX TOPICAL CREAM Tier 3

EURAX TOPICAL LOTION Tier 3

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

permethrin topical cream Tier 1

SKLICE TOPICAL LOTION Tier 3

spinosad topical suspension Tier 1

53


ULESFIA TOPICAL LOTION Tier 3

Diagnostics & Miscellaneous Agents Irrigating Solutions neomycin-polymyxin b gu irrigation solution Tier 1

SORBITOL IRRIGATION SOLUTION Tier 3

SORBITOL-MANNITOL URETHRAL SOLUTION

Tier 3

tis-u-sol pentalyte irrigation solution Tier 1

Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 1

acetic acid irrigation solution Tier 1

alendronate oral tablet 40 mg Tier 1

anagrelide oral capsule Tier 1

bd pre-filled normal saline injection syringe Tier 1

BUPHENYL ORAL TABLET Tier 3

caffeine citrate oral solution Tier 1

CARBAGLU ORAL TABLET, DISPERSIBLE Tier 3

cevimeline oral capsule Tier 1

CHEMET ORAL CAPSULE Tier 3

disulfiram oral tablet Tier 1

etidronate disodium oral tablet Tier 1

EXJADE ORAL TABLET, DISPERSIBLE Tier 4 SPRx

FERRIPROX ORAL TABLET Tier 4 LD; SPRx

finasteride oral tablet 1 mg Tier 1

JADENU ORAL TABLET Tier 4 SPRx

levocarnitine (with sugar) oral solution Tier 1

levocarnitine oral tablet Tier 1

METOPIRONE ORAL CAPSULE Tier 3

midodrine oral tablet Tier 1

monoject 0.9% sodium chloride injection syringe Tier 1

monoject prefill advanced ns injection syringe Tier 1

monoject prefill saline flush injection syringe Tier 1

NITYR ORAL TABLET Tier 4 LD; SPRx

54


normal saline flush injection syringe Tier 1

NORTHERA ORAL CAPSULE Tier 4 PA; SPRx

ORFADIN ORAL CAPSULE Tier 4 LD; SPRx

pilocarpine hcl oral tablet 5 mg Tier 1

RADIOGARDASE ORAL CAPSULE Tier 3

RAVICTI ORAL LIQUID Tier 4 SPRx

riluzole oral tablet Tier 1

risedronate oral tablet 30 mg Tier 1

sodium chlor 0.9% bacteriostat injection solution Tier 1

sodium chloride 0.9 % injection syringe Tier 1

sodium chloride irrigation solution Tier 1

sodium phenylbutyrate oral powder Tier 1

sodium phenylbutyrate oral tablet Tier 1

syrex sodium chloride 0.9 % injection syringe Tier 1

THIOLA ORAL TABLET Tier 4 LD; SPRx

water for irrigation, sterile irrigation solution Tier 1

Smoking Deterrents bupropion hcl (smoking deter) oral tablet extended release 12 hr

Tier 5 ACA

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 5 ACA

CHANTIX ORAL TABLET Tier 5 ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 5 ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR

Tier 5 ACA

NICORETTE BUCCAL GUM Tier 5 ACA

NICORETTE BUCCAL LOZENGE Tier 5 ACA

NICORETTE BUCCAL MINI LOZENGE Tier 5 ACA

nicotine (polacrilex) buccal gum Tier 5 ACA

nicotine (polacrilex) buccal lozenge Tier 5 ACA

nicotine (polacrilex) buccal mini lozenge Tier 5 ACA

nicotine transdermal patch 24 hour Tier 5 ACA

nicotine transdermal patch, td daily, sequential Tier 5 ACA

55


NICOTROL INHALATION CARTRIDGE Tier 5 ACA

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Tier 5 ACA

nts step 1 transdermal patch 24 hour Tier 5 ACA

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Tier 5 ACA

Ear, Nose & Throat Medications Miscellaneous Agents azelastine nasal aerosol,spray Tier 1

azelastine nasal spray,non-aerosol Tier 1

BACTROBAN NASAL NASAL OINTMENT Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1

denta 5000 plus dental cream Tier 1

dentagel dental gel Tier 1

ipratropium bromide nasal spray,non-aerosol Tier 1

olopatadine nasal spray,non-aerosol Tier 1

periogard mucous membrane mouthwash Tier 1

pilocarpine hcl oral tablet 7.5 mg Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

PREVIDENT 5000 DRY MOUTH DENTAL GEL

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 3

PREVIDENT 5000 SENSITIVE DENTAL PASTE

Tier 3

sf 5000 plus dental cream Tier 1

sf dental gel Tier 1

triamcinolone acetonide dental paste Tier 1

Miscellaneous Otic Preparations acetic acid otic (ear) solution Tier 1

acetic acid-aluminum acetate otic (ear) drops Tier 1

ciprofloxacin hcl otic (ear) dropperette Tier 1

fluocinolone acetonide oil otic (ear) drops Tier 1

56


hydrocortisone-acetic acid otic (ear) drops Tier 1

ofloxacin otic (ear) drops Tier 1

Otic Steroid / Antibiotic CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Tier 2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Tier 3

neomycin-polymyxin-hc otic (ear) drops,suspension

Tier 1

neomycin-polymyxin-hc otic (ear) solution Tier 1

OTOVEL OTIC (EAR) SOLUTION Tier 2

Endocrine/Diabetes Adrenal Hormones ACTHAR H.P. INJECTION GEL Tier 4 PA; SPRx

cortisone oral tablet Tier 1

deltasone oral tablet 20 mg Tier 1

dexamethasone intensol oral drops Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

EMFLAZA ORAL SUSPENSION Tier 4 PA; LD; SPRx

EMFLAZA ORAL TABLET Tier 4 PA; LD; SPRx

fludrocortisone oral tablet Tier 1

hydrocortisone oral tablet Tier 1

methylprednisolone oral tablet Tier 1

methylprednisolone oral tablets,dose pack Tier 1

millipred dp oral tablets,dose pack Tier 1

millipred oral tablet Tier 1

prednisolone oral solution 15 mg/5 ml Tier 1

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

57


prednisolone sodium phosphate oral tablet,disintegrating

Tier 1

prednisone intensol oral concentrate Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack Tier 1

veripred 20 oral solution Tier 1

Antithyroid Agents methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet Tier 1

SSKI ORAL SOLUTION Tier 3

Blood Glucose Monitoring Devices & Supplies ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK COMPACT PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK GUIDE STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP STRIP


ACCUTREND GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVANCED GLUC METER TEST STRIP STRIP


ADVOCATE REDI-CODE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

AGAMATRIX AMP TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE 4 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PLATINUM STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PRISM MULTI STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

BIONIME RIGHTEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

BREEZE 2 TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

CARESENS N TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE MICRO TEST STRIP STRIP


CLEVER CHOICE PRO STRIP Tier 3 ST; QL (102 EA per 30 days)

58


CLEVER CHOICE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE VOICE+ TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CONTOUR NEXT STRIPS STRIP Tier 2 QL (102 EA per 30 days)

CONTOUR TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)

COOL GLUCOSE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

DIATRUE PLUS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY PLUS II TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY STEP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TALK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TOUCH TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TRAK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYMAX STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT COMPACT TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE BLOOD GLUCOSE SYSTEM STRIP


EMBRACE EVO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE PRO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G2 STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G3 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE MINI GLUCOSE TEST STR STRIP


EVOLUTION TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FIFTY50 TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D15G STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D40-G31 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G30A STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA GD50 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

59


FORA TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TN'G VOICE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V12 GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD40 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORTISCARE GLUCOSE TEST STRIPS STRIP


FREESTYLE INSULINX STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX TEST STRIPS STRIP


FREESTYLE LITE STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE PRECISION NEO STRIPS STRIP


FREESTYLE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GE100 BLOOD GLUCOSE TEST STRIP STRIP


GENSTRIP TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCO NAVII TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD 01 SENSOR PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD EXPRESSION STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD SHINE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL SENSOR STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCOM GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

GM100 STRIP Tier 3 ST; QL (102 EA per 30 days)

HEALTHPRO TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

LIBERTY TEST STRIP Tier 3 ST

MICRO BLOOD GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRODOT BLOOD GLUCOSE SYSTEM STRIP


MYGLUCOHEALTH STRIP Tier 3 ST; QL (102 EA per 30 days)

NEUTEK 2TEK TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

60


NOVA MAX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL EXPRESS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL PLUS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL VIVID TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

ONETOUCH ULTRA TEST STRIP Tier 2 QL (102 EA per 30 days)

ONETOUCH VERIO STRIP Tier 2 ST; QL (102 EA per 30 days)

OPTIUM EZ STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTIUM TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTUMRX STRIP Tier 3 ST; QL (102 EA per 30 days)

PHARMACIST CHOICE STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION POINT OF CARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION Q-I-D TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION XTRA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIUM V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

PRODIGY NO CODING STRIP Tier 3 ST; QL (102 EA per 30 days)

QUINTET AC STRIP Tier 3 ST; QL (102 EA per 30 days)

REFUAH PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION CONFIRM-MICRO STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION PRIME TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

REVEAL TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

RIGHTEST GS550 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

SMART SENSE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

SMARTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SURE-TEST EASYPLUS MINI STRIP Tier 3 ST; QL (102 EA per 30 days)

TELCARE TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

TEST N'GO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUE METRIX GLUCOSE TEST STRIP STRIP


TRUETEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETRACK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTIMA TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)

61


ULTRATRAK STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK ULTIMATE STRIP Tier 3 ST; QL (102 EA per 30 days)

UNISTRIP1 TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE JAZZ STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE PRESTO STRIP Tier 3 ST; QL (102 EA per 30 days)

Diabetes, Supplies, & Durable Medical Equipment GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

insulin syringe-needle u-100 syringe 0.5 ml 29 gauge x 1/2"


Glucose Elevating Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 2

Insulin Syringes/Miscellaneous Durable Medical Equ 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"


1ST TIER UNILET COMFORTOUCH 28 GAUGE

Tier 2

ACCU-CHEK FASTCLIX Tier 2

ACCU-CHEK SAFE-T-PRO Tier 2

ACCU-CHEK SOFTCLIX LANCETS Tier 2

ACTI-LANCE LANCETS 23 GAUGE Tier 2

ADVANCED TRAVEL LANCETS 30 GAUGE Tier 2

ADVOCATE LANCET 30 GAUGE Tier 2

ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


ALTERNATE SITE LANCET Tier 2

ASSURE HAEMOLANCE PLUS 1.2 MM Tier 3

ASSURE LANCE 25 GAUGE Tier 2

ASSURE LANCE PLUS 21 GAUGE Tier 2

BD ECLIPSE NEEDLE 25 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

BD FILTER NEEDLE-5 MICRON NEEDLE Tier 2 QL (1000 EA per 30 days)

62


BD INSULIN PEN NEEDLE UF SHORT NEEDLE


BD INTEGRA NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

BD MICROTAINER LANCET 30 GAUGE Tier 2

BD NOKOR ADMIX NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

BD PRECISIONGLIDE NEEDLE 27 GAUGE X 1 1/2"


BD PRECISIONGLIDE NON-STERILE NEEDLE 18 GAUGE X 1 1/2"


BD SAFETYGLIDE NEEDLE NEEDLE 22 GAUGE X 1 1/2"


BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X 1/2"


BD ULTRA FINE LANCETS Tier 2

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE


blunt needle, disposable needle 18 x 1 1/2 " Tier 2 QL (1000 EA per 30 days)

BULLSEYE MINI SAFETY LANCETS 21 GAUGE

Tier 2

CAREFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4"


CAREONE THIN LANCET Tier 2

CLEVER CHEK LANCETS Tier 2

CLICKFINE NEEDLE 31 GAUGE X 1/4" Tier 2 QL (1000 EA per 30 days)

COAGUCHEK LANCETS Tier 2

COLOR LANCETS Tier 2

COMFORT EZ PEN NEEDLES NEEDLE 31 GAUGE X 5/16"


COMFORT LANCETS Tier 2

DROPLET LANCETS Tier 2

DROPLET PEN NEEDLE NEEDLE 32 GAUGE X 5/32"


EASY COMFORT LANCETS Tier 2

EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 3/16"


63


EASY TOUCH FLIPLOCK NEEDLE NEEDLE 22 GAUGE X 3/4", 25 GAUGE X 1 1/2"


EASY TOUCH HYPODERMIC NEEDLE NEEDLE 32 GAUGE X 5/16"


EXEL HYPODERMIC NEEDLES NEEDLE 27 GAUGE X 1/2"


e-z ject lancets 26 gauge Tier 1

EZ SMART LANCETS Tier 2

FIFTY50 SAFETY SEAL LANCETS 30 GAUGE

Tier 2

FINE 30 UNIVERSAL LANCETS Tier 2

FINGERSTIX LANCETS Tier 2

FLOW-EZE VENTED NEEDLE NEEDLE Tier 2 QL (1000 EA per 30 days)

FORA V10-V12-D10-D20 STRP-LNCT COMBO PACK

Tier 3

FORACARE LANCETS Tier 2

FREESTYLE LANCETS Tier 2

FREESTYLE UNISTIK 2 Tier 2

GLUCOCOM LANCETS 28 GAUGE, 33 GAUGE

Tier 2

HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 GAUGE X 1/2"


HEALTHY ACCENTS UNILET LANCET Tier 2

huber safety needles (disp.) needle Tier 1 QL (1000 EA per 30 days)

INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


INCONTROL SUPER THIN LANCETS Tier 2

INCONTROL ULTRA THIN LANCETS Tier 2

INJECT EASE LANCETS 28 GAUGE Tier 2

INSUPEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

INVACARE LANCETS Tier 2

lancets , 30 gauge Tier 2

LANCETS,THIN , 28 GAUGE Tier 2

LIFESHIELD BLUNT CANNULA NEEDLE Tier 2 QL (1000 EA per 30 days)

LITE TOUCH LANCETS 33 GAUGE Tier 2

64


MEDISENSE THIN LANCETS Tier 2

MEDLANCE PLUS LANCETS 25 GAUGE Tier 2

MEDLANCE PLUS SPECIAL BLADE Tier 3

MICRO THIN LANCETS Tier 2

MICROLET LANCET Tier 2

MINI ULTRA-THIN II NEEDLE Tier 2 QL (1000 EA per 30 days)

MONOJECT BLOOD COLLECTION NEEDLE 20 GAUGE X 1"


MONOJECT HYPODERMIC NEEDLES NEEDLE 18 GAUGE X 1"


MONOJECT MEDICATION TRANSF NDL NEEDLE


MONOLET THIN LANCETS Tier 2

MULTI-DRAW NEEDLE NEEDLE 20 GAUGE X 1"


MYGLUCOHEALTH LANCETS Tier 2

needles, huber disposable needle Tier 2 QL (1000 EA per 30 days)

NOKOR NEEDLE NEEDLE 16 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

NOVA SAFETY LANCETS 28 GAUGE Tier 2

NOVA SUREFLEX LANCETS Tier 2

NOVOFINE 32 NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE AUTOCOVER NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE PLUS NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN

Tier 3

ON CALL LANCET Tier 2

ON CALL PLUS LANCET Tier 2

ONETOUCH ULTRASOFT LANCETS Tier 2

ON-THE-GO LANCETS Tier 2

PEN NEEDLE NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

pen needle, diabetic needle 29 gauge x 1/2" Tier 2 QL (1000 EA per 30 days)

PENTIPS NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"


PHASEAL PROTECTOR DEVICE 20 MM Tier 2 QL (1000 EA per 30 days)

65


POLY HUB NEEDLE NEEDLE 18 GAUGE X 1"


PRESSURE ACTIVATED LANCETS 21 GAUGE

Tier 2

PRODIGY LANCETS 28 GAUGE Tier 2

PRODIGY TWIST TOP LANCET Tier 2

RELIAMED LANCET 28 GAUGE Tier 2

RELIAMED SAFETY SEAL LANCETS 28 GAUGE

Tier 2

RELION NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days)

RELION PEN NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days)

RELION THIN LANCETS Tier 2

RELION ULTRA THIN PLUS LANCETS Tier 2

RIGHTEST GL300 LANCETS Tier 2

SAFETY LANCETS 21 GAUGE Tier 2

SAFETY SEAL LANCETS 28 GAUGE Tier 2

SAFETY-LET LANCETS Tier 2

SINGLE-LET Tier 2

SMART SENSE LANCETS 26 GAUGE, 33 GAUGE

Tier 2

SMARTEST LANCET Tier 2

SOFT TOUCH LANCETS Tier 2

SOLUS V2 LANCETS 30 GAUGE Tier 2

STERILANCE TL 30 GAUGE Tier 2

SUPER THIN LANCETS 30 GAUGE Tier 2

SURE COMFORT LANCETS 28 GAUGE Tier 2

SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2"


SURE-LANCE 28 GAUGE Tier 2

SURE-TOUCH LANCET Tier 2

SURGUARD2 SAFETY NEEDLE 18 GAUGE X 1"


TECHLITE LANCETS 25 GAUGE Tier 2

66


TECHLITE PEN NEEDLE NEEDLE 31 GAUGE X 5/16"


TOPCARE UNIVERSAL1 LANCET Tier 2

TRUEPLUS LANCETS 28 GAUGE Tier 2

ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2"


ULTILET BASIC LANCETS Tier 2

ULTILET CLASSIC LANCETS Tier 2

ULTILET LANCETS 28 GAUGE Tier 2

ULTILET PEN NEEDLE NEEDLE 29 GAUGE


ULTILET SAFETY LANCETS Tier 2

ULTRA THIN LANCETS 28 GAUGE Tier 2

ULTRA THIN PLUS LANCETS Tier 2

ULTRA TLC LANCETS Tier 2

ULTRALANCE LANCETS 26 GAUGE Tier 2

ULTRA-THIN II INS PEN NEEDLES NEEDLE


UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"


UNIFINE PENTIPS PLUS NEEDLE 31 GAUGE X 5/16"


UNILET COMFORTOUCH LANCET 26 GAUGE

Tier 2

UNILET EXCELITE II LANCET Tier 2

UNILET EXCELITE LANCET Tier 2

UNILET GP LANCET Tier 2

UNILET LANCET 28 GAUGE Tier 2

UNISTIK 3 EXTRA LANCET Tier 2

UNISTIK CZT LANCET 23 GAUGE Tier 2

UNISTIK SAFETY 30 GAUGE Tier 2

UNISTIK TOUCH LANCETS 28 GAUGE Tier 2

UNIVERSAL 1 LANCETS 26 GAUGE Tier 2

VGO 20 DEVICE Tier 2


67



Insulin Therapy AFREZZA INHALATION CARTRIDGE WITH INHALER

Tier 3

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA SUBCUTANEOUS SOLUTION Tier 3 ST

FIASP FLEXTOUCH SUBCUTANEOUS INSULIN PEN

Tier 2

FIASP SUBCUTANEOUS SOLUTION Tier 2

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS INSULIN PEN, HALF-UNIT

Tier 3 ST

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG SUBCUTANEOUS CARTRIDGE Tier 3 ST

HUMALOG SUBCUTANEOUS SOLUTION Tier 3 ST

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN R U-100 INJECTION SOLUTION Tier 3 ST

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

Tier 2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

Tier 2

68


LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS SUBCUTANEOUS SOLUTION Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR SUBCUTANEOUS SOLUTION Tier 2

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R INJECTION SOLUTION Tier 2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG SUBCUTANEOUS SOLUTION Tier 2

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN

Tier 2

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

Tier 2

XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN

Tier 2

Miscellaneous Hormones ANADROL-50 ORAL TABLET Tier 3 PA

ANDRODERM TRANSDERMAL PATCH 24 HOUR

Tier 3 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 2 PA

69


ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Tier 2 PA

androxy oral tablet Tier 1 PA

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol Tier 1

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

CERDELGA ORAL CAPSULE Tier 4 PA; SPRx

danazol oral capsule Tier 1

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML

Tier 3 PA

desmopressin nasal solution Tier 1

desmopressin nasal spray,non-aerosol Tier 1

desmopressin oral tablet Tier 1

doxercalciferol oral capsule Tier 1

KORLYM ORAL TABLET Tier 4 PA; LD; SPRx

KUVAN ORAL POWDER IN PACKET Tier 4 SPRx

KUVAN ORAL TABLET,SOLUBLE Tier 4 SPRx

methyltestosterone oral capsule Tier 1 PA

MIACALCIN INJECTION SOLUTION Tier 2

MYALEPT SUBCUTANEOUS RECON SOLN Tier 4 PA; SPRx

NATPARA SUBCUTANEOUS CARTRIDGE Tier 4 PA; SPRx

oxandrolone oral tablet Tier 1 PA

paricalcitol oral capsule Tier 1

SAMSCA ORAL TABLET Tier 4 SPRx

SENSIPAR ORAL TABLET Tier 4 SPRx

SOMAVERT SUBCUTANEOUS RECON SOLN

Tier 4 SPRx

STIMATE NASAL SPRAY,NON-AEROSOL Tier 4 SPRx

SYNAREL NASAL SPRAY,NON-AEROSOL Tier 3

testosterone cypionate intramuscular oil Tier 1 PA

testosterone enanthate intramuscular oil Tier 1 PA

testosterone transdermal gel Tier 1 PA

70


testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Tier 1 PA

testosterone transdermal gel in packet Tier 1 PA

ZAVESCA ORAL CAPSULE Tier 4 SPRx

Non-Insulin Hypoglycemic Agents acarbose oral tablet Tier 1

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 2

BYETTA SUBCUTANEOUS PEN INJECTOR Tier 2

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET Tier 3

FARXIGA ORAL TABLET Tier 2

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1

glipizide oral tablet extended release 24hr Tier 1

glipizide-metformin oral tablet Tier 1

glyburide micronized oral tablet Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet Tier 1

GLYXAMBI ORAL TABLET Tier 2

INVOKAMET ORAL TABLET Tier 2

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

INVOKANA ORAL TABLET Tier 2

JANUMET ORAL TABLET Tier 2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 2

JANUVIA ORAL TABLET Tier 2

71


JENTADUETO ORAL TABLET Tier 2

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr Tier 1

miglitol oral tablet Tier 1

nateglinide oral tablet Tier 1

pioglitazone oral tablet Tier 1

pioglitazone-glimepiride oral tablet Tier 1

pioglitazone-metformin oral tablet Tier 1

repaglinide oral tablet Tier 1

repaglinide-metformin oral tablet Tier 1

RIOMET ORAL SOLUTION Tier 3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL TABLET Tier 2

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 2

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG

Tier 2

Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 3

levothyroxine oral tablet Tier 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1

liothyronine oral tablet Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

SYNTHROID ORAL TABLET Tier 3

72


thyroid (pork) oral tablet Tier 1

THYROLAR-1 ORAL TABLET Tier 3

THYROLAR-1/2 ORAL TABLET Tier 3

THYROLAR-1/4 ORAL TABLET Tier 3



unithroid oral tablet Tier 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Tier 1

WP THYROID ORAL TABLET 130 MG, 32.5 MG, 65 MG, 81.25 MG

Tier 3

Gastroenterology Antidiarrheals & Antispasmodics chlordiazepoxide-clidinium oral capsule Tier 1

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

diphenoxylate-atropine oral liquid Tier 1

diphenoxylate-atropine oral tablet Tier 1

DONNATAL ORAL TABLET Tier 3

FULYZAQ ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

hyoscyamine sulfate oral drops Tier 1

hyoscyamine sulfate oral elixir Tier 1

hyoscyamine sulfate oral tablet Tier 1

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 1

hyoscyamine sulfate oral tablet,disintegrating Tier 1

hyoscyamine sulfate sublingual tablet Tier 1

methscopolamine oral tablet Tier 1

MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

paregoric oral liquid Tier 1

73


propantheline oral tablet Tier 1

Miscellaneous Gastrointestinal Agents alosetron oral tablet Tier 1

AMITIZA ORAL CAPSULE Tier 2

anucort-hc rectal suppository Tier 1

ANZEMET ORAL TABLET Tier 3

aprepitant oral capsule Tier 1

aprepitant oral capsule,dose pack Tier 1

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

AURYXIA ORAL TABLET Tier 3

balsalazide oral capsule Tier 1

bisacodyl oral tablet,delayed release (dr/ec) Tier 5 ACA

budesonide oral capsule,delayed,extend.release Tier 1

calcium acetate oral capsule Tier 1

calcium acetate oral tablet 667 mg Tier 1

CANASA RECTAL SUPPOSITORY Tier 2

CESAMET ORAL CAPSULE Tier 3

CHENODAL ORAL TABLET Tier 4 LD; SPRx

CIMZIA SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SPRx

CITRATE OF MAGNESIA ORAL SOLUTION

Tier 5 ACA

colocort rectal enema Tier 1

compro rectal suppository Tier 1

constulose oral solution Tier 1

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

cromolyn oral concentrate Tier 1

CYSTADANE ORAL POWDER Tier 4 LD; SPRx

DIPENTUM ORAL CAPSULE Tier 3

dronabinol oral capsule 2.5 mg, 5 mg Tier 1

eliphos oral tablet Tier 1

enulose oral solution Tier 1

FOSRENOL ORAL POWDER IN PACKET Tier 3

74


FOSRENOL ORAL TABLET,CHEWABLE Tier 3

GATTEX 30-VIAL SUBCUTANEOUS KIT Tier 4 PA; SPRx

gavilyte-c oral recon soln Tier 5 ACA

gavilyte-g oral recon soln Tier 5 ACA

gavilyte-h and bisacodyl oral kit Tier 5 ACA

gavilyte-n oral recon soln Tier 5 ACA

generlac oral solution Tier 1

GOLYTELY ORAL POWDER IN PACKET Tier 5 ACA

granisetron hcl oral tablet Tier 1

hemmorex-hc rectal suppository Tier 1

hydrocortisone acetate rectal suppository Tier 1

hydrocortisone rectal enema Tier 1

hydrocortisone topical cream with perineal applicator

Tier 1

hydrocortisone-pramoxine rectal cream Tier 1

kionex (with sorbitol) oral suspension Tier 1

kionex oral powder Tier 1

KRISTALOSE ORAL PACKET Tier 2

lactulose oral solution 10 gram/15 ml Tier 1

lanthanum oral tablet,chewable Tier 1

laxaclear oral powder Tier 5 ACA

laxative peg 3350 oral powder Tier 5 ACA

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 2

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

Tier 1

lidocaine-hydrocortisone-aloe rectal gel Tier 1

LINZESS ORAL CAPSULE Tier 2

meclizine oral tablet 25 mg Tier 1

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

Tier 1

mesalamine rectal enema Tier 1

metoclopramide hcl oral solution Tier 1

metoclopramide hcl oral tablet Tier 1

75


MILK OF MAGNESIA CONCENTRATED ORAL SUSPENSION

Tier 5 ACA

MOVIPREP ORAL POWDER IN PACKET Tier 5 ACA

OCALIVA ORAL TABLET Tier 4 PA; LD; SPRx

ondansetron hcl oral solution Tier 1

ondansetron hcl oral tablet Tier 1

ondansetron oral tablet,disintegrating Tier 1

OSMOPREP ORAL TABLET Tier 5 ACA

peg 3350-electrolytes oral recon soln Tier 5 ACA

peg-3350 with flavor packs oral recon soln Tier 5 ACA

peg-electrolyte soln oral recon soln Tier 5 ACA

peg-prep oral kit Tier 5 ACA

PENTASA ORAL CAPSULE, EXTENDED RELEASE

Tier 2

PHOSLYRA ORAL SOLUTION Tier 2

PHOSPHATE LAXATIVE ORAL LIQUID Tier 5 ACA

polyethylene glycol 3350 oral powder Tier 5 ACA

polyethylene glycol 3350 oral powder in packet Tier 5 ACA

pramcort rectal cream Tier 1

PREPOPIK ORAL POWDER IN PACKET Tier 5 ACA

prochlorperazine maleate oral tablet Tier 1

prochlorperazine rectal suppository Tier 1

procto-med hc topical cream with perineal applicator

Tier 1

procto-pak topical cream with perineal applicator Tier 1

proctosol hc topical cream with perineal applicator

Tier 1

proctozone-hc topical cream with perineal applicator

Tier 1

RELISTOR SUBCUTANEOUS SOLUTION Tier 3

RELISTOR SUBCUTANEOUS SYRINGE Tier 3

RENAGEL ORAL TABLET Tier 3

RENVELA ORAL POWDER IN PACKET Tier 2

RENVELA ORAL TABLET Tier 2

scopolamine base transdermal patch 3 day Tier 1

76


sevelamer carbonate oral powder in packet Tier 1

sevelamer carbonate oral tablet Tier 1

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension Tier 1

sodium polystyrene sulfonate rectal enema 50 gram/200 ml

Tier 1

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE

Tier 3

sps (with sorbitol) oral suspension Tier 1

SUCRAID ORAL SOLUTION Tier 3

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet,delayed release (dr/ec) Tier 1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 5 ACA

SYNDROS ORAL SOLUTION Tier 3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

Tier 3

trilyte with flavor packets oral recon soln Tier 5 ACA

trimethobenzamide oral capsule Tier 1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

Tier 3

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 1

VELPHORO ORAL TABLET,CHEWABLE Tier 2

VIBERZI ORAL TABLET Tier 3

women's gentle laxative(bisac) oral tablet,delayed release (dr/ec)

Tier 5 ACA

women's laxative (bisacodyl) oral tablet Tier 5 ACA

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-136,000- 218,000 UNIT

Tier 2

Ulcer Therapy amoxicil-clarithromy-lansopraz oral combo pack Tier 1

77


cimetidine hcl oral solution Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3

esomeprazole magnesium oral capsule,delayed release(dr/ec)

Tier 1

famotidine oral suspension Tier 1

famotidine oral tablet 40 mg Tier 1

lansoprazole oral capsule,delayed release(dr/ec) 30 mg

Tier 1

misoprostol oral tablet Tier 1

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

Tier 2

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

OMECLAMOX-PAK ORAL COMBO PACK Tier 2

omeprazole oral capsule,delayed release(dr/ec) Tier 1

pantoprazole oral tablet,delayed release (dr/ec) Tier 1

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

Tier 3

PYLERA ORAL CAPSULE Tier 2

rabeprazole oral tablet,delayed release (dr/ec) Tier 1

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 300 mg Tier 1

sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1

Immunology, Vaccines & Biotechnology Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA; SPRx

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA; SPRx

78


EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 4 PA; SPRx

MIRCERA INJECTION SYRINGE Tier 4 PA; LD; SPRx

MOZOBIL SUBCUTANEOUS SOLUTION Tier 4 SPRx

NEULASTA SUBCUTANEOUS SYRINGE Tier 4 SPRx

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 4 SPRx

NEUPOGEN INJECTION SOLUTION Tier 4 SPRx

NEUPOGEN INJECTION SYRINGE Tier 4 SPRx

PROCRIT INJECTION SOLUTION Tier 4 PA; SPRx

ZARXIO INJECTION SYRINGE Tier 4 SPRx

Growth Hormones NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

Interferons AUBAGIO ORAL TABLET Tier 4 PA; SPRx

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

Tier 4 SPRx

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

Tier 4 SPRx

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 4 SPRx

BETASERON SUBCUTANEOUS KIT Tier 4 SPRx

COPAXONE SUBCUTANEOUS SYRINGE Tier 4 SPRx

EXTAVIA SUBCUTANEOUS KIT Tier 4 SPRx

EXTAVIA SUBCUTANEOUS RECON SOLN Tier 4 SPRx

GILENYA ORAL CAPSULE Tier 4 SPRx

glatiramer subcutaneous syringe Tier 4 SPRx

glatopa subcutaneous syringe Tier 4 SPRx

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (7)- 400 MG (7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7)

Tier 4 PA; SPRx

MODERIBA ORAL TABLET Tier 4 PA; SPRx

79


PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

PEGASYS SUBCUTANEOUS SOLUTION Tier 4 SPRx

PEGASYS SUBCUTANEOUS SYRINGE Tier 4 SPRx

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SPRx

PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 80 MCG/0.5 ML

Tier 4 PA; SPRx

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 4 SPRx

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

PLEGRIDY SUBCUTANEOUS SYRINGE Tier 4 SPRx

POMALYST ORAL CAPSULE Tier 4 PA; SPRx

REBETOL ORAL SOLUTION Tier 4 PA; SPRx

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 4 SPRx

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 4 SPRx

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 4 SPRx

REVLIMID ORAL CAPSULE Tier 4 PA; SPRx

RIBASPHERE ORAL CAPSULE Tier 4 PA; SPRx

RIBASPHERE ORAL TABLET Tier 4 PA; SPRx

ribavirin oral capsule Tier 4 PA; SPRx

ribavirin oral tablet 200 mg Tier 4 PA; SPRx

SYLATRON SUBCUTANEOUS KIT Tier 4 SPRx

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 4 SPRx

ZINBRYTA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

Interleukins ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 4 SPRx

ARCALYST SUBCUTANEOUS RECON SOLN

Tier 4 SPRx

imiquimod topical cream in packet Tier 1

80


INTRON A INJECTION RECON SOLN Tier 4 SPRx

INTRON A INJECTION SOLUTION Tier 4 SPRx

KINERET SUBCUTANEOUS SYRINGE Tier 4 PA; LD; SPRx

Vaccines & Miscellaneous Immunologicals ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

bcg vaccine, live (pf) percutaneous suspension for reconstitution

Tier 5 ACA

BEXSERO INTRAMUSCULAR SYRINGE Tier 5 ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION

Tier 5 ACA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 5 ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 5 ACA

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

CUVITRU SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

81


ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUMIST QUAD 2017-2018 NASAL NASAL SPRAY SYRINGE

Tier 5 ACA

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

Tier 5 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Tier 5 ACA

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

GAMMAGARD LIQUID INJECTION SOLUTION

Tier 4 PA; SPRx

GAMUNEX-C INJECTION SOLUTION Tier 4 PA; SPRx

82


GARDASIL (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

GRASTEK SUBLINGUAL TABLET Tier 2 PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

HIZENTRA SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

HYQVIA SUBCUTANEOUS SOLUTION Tier 4 PA; SPRx

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

IPOL INJECTION SUSPENSION Tier 5 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

Tier 5 ACA

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

Tier 5 ACA

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

Tier 5 ACA

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

Tier 5 ACA

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

Tier 5 ACA

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

Tier 4 PA; LD; SPRx

83


PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 5 ACA

PENTACEL (PF) INTRAMUSCULAR KIT Tier 5 ACA

PNEUMOVAX 23 INJECTION SOLUTION Tier 5 ACA

PNEUMOVAX 23 INJECTION SYRINGE Tier 5 ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

RAGWITEK SUBLINGUAL TABLET Tier 3 PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

ROTATEQ VACCINE ORAL SOLUTION Tier 5 ACA

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

tetanus,diphtheria tox ped(pf) intramuscular suspension

Tier 5 ACA

tetanus-diphtheria toxoids-td intramuscular suspension

Tier 5 ACA

TRUMENBA INTRAMUSCULAR SYRINGE Tier 5 ACA

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

84


TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 5 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION Tier 5 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE Tier 5 ACA

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 5 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE Tier 5 ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 5 ACA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 5 ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 5 ACA

Musculoskeletal & Rheumatology Gout Therapy allopurinol oral tablet Tier 1

COLCRYS ORAL TABLET Tier 2

probenecid oral tablet Tier 1

probenecid-colchicine oral tablet Tier 1

ULORIC ORAL TABLET Tier 2

Osteoporosis Therapy alendronate oral solution Tier 1

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Tier 1

FORTEO SUBCUTANEOUS PEN INJECTOR Tier 4 SPRx

FOSAMAX PLUS D ORAL TABLET Tier 3

ibandronate oral tablet Tier 1

raloxifene oral tablet Tier 5 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg Tier 1

risedronate oral tablet,delayed release (dr/ec) Tier 1

85


TYMLOS SUBCUTANEOUS PEN INJECTOR Tier 3

Other Rheumatologicals ACTEMRA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; LD; SPRx

BENLYSTA SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

DEPEN TITRATABS ORAL TABLET Tier 3

ENBREL MINI SUBCUTANEOUS CARTRIDGE

Tier 4 PA; SPRx

ENBREL SUBCUTANEOUS RECON SOLN Tier 4 PA; SPRx

ENBREL SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SPRx; QL (2 EA per 30 days)

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA SUBCUTANEOUS SYRINGE KIT Tier 4 PA; SPRx; QL (2 EA per 30 days)

leflunomide oral tablet Tier 1

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

Tier 4 PA; SPRx; QL (4 ML per 30 days)

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML

Tier 4 PA; LD; SPRx; QL (4 ML per 28 days)

OTEZLA ORAL TABLET Tier 4 PA; SPRx

OTEZLA STARTER ORAL TABLETS,DOSE PACK

Tier 4 PA; SPRx

RIDAURA ORAL CAPSULE Tier 3

SAVELLA ORAL TABLET Tier 2

SAVELLA ORAL TABLETS,DOSE PACK Tier 2

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SPRx

SIMPONI SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

86


XELJANZ ORAL TABLET Tier 4 PA; SPRx

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 4 PA; SPRx

Obstetrics & Gynecology Estrogens & Progestins ALORA TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

amabelz oral tablet Tier 1

ANGELIQ ORAL TABLET Tier 3

camila oral tablet Tier 5 ACA

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

Tier 3

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

CRINONE VAGINAL GEL 4 % Tier 3

deblitane oral tablet Tier 5 ACA

DEPO-ESTRADIOL INTRAMUSCULAR OIL Tier 3

depo-subq provera 104 subcutaneous syringe Tier 5 ACA

DIVIGEL TRANSDERMAL GEL IN PACKET

Tier 2

DUAVEE ORAL TABLET Tier 3

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

errin oral tablet Tier 5 ACA

ESTRACE VAGINAL CREAM Tier 2

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly Tier 1

estradiol transdermal patch weekly Tier 1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

Tier 1

estradiol-norethindrone acet oral tablet Tier 1

87


ESTRING VAGINAL RING Tier 3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

estrogens-methyltestosterone oral tablet Tier 1

estropipate oral tablet Tier 1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL

Tier 3

FEMRING VAGINAL RING Tier 3

fyavolv oral tablet Tier 1

heather oral tablet Tier 5 ACA

jencycla oral tablet Tier 5 ACA

JEVANTIQUE LO ORAL TABLET Tier 5 ACA

JINTELI ORAL TABLET Tier 5 ACA

jolivette oral tablet Tier 5 ACA

lopreeza oral tablet Tier 1

lyza oral tablet Tier 5 ACA

medroxyprogesterone intramuscular suspension Tier 5 ACA

medroxyprogesterone intramuscular syringe Tier 5 ACA

medroxyprogesterone oral tablet Tier 1

MENEST ORAL TABLET Tier 3

MENOSTAR TRANSDERMAL PATCH WEEKLY

Tier 3

mimvey lo oral tablet Tier 1

mimvey oral tablet Tier 1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

Tier 2

nora-be oral tablet Tier 5 ACA

norethindrone (contraceptive) oral tablet Tier 5 ACA

norethindrone acetate oral tablet Tier 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 5 ACA

norlyda oral tablet Tier 5 ACA

norlyroc oral tablet Tier 5 ACA

PREFEST ORAL TABLET Tier 3

PREMARIN ORAL TABLET Tier 2

88


PREMARIN VAGINAL CREAM Tier 3 ST

PREMPHASE ORAL TABLET Tier 2

PREMPRO ORAL TABLET Tier 2

progesterone micronized oral capsule Tier 1

sharobel oral tablet Tier 5 ACA

yuvafem vaginal tablet Tier 1

Miscellaneous Ob/Gyn AVC VAGINAL VAGINAL CREAM Tier 3

CLEOCIN VAGINAL SUPPOSITORY Tier 3

clindamycin phosphate vaginal cream Tier 1

fem ph vaginal gel Tier 1

GYNAZOLE-1 VAGINAL CREAM Tier 3

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SPRx

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SPRx

metronidazole vaginal gel Tier 1

miconazole-3 vaginal suppository Tier 1

nuvaring vaginal ring Tier 5 ACA

OSPHENA ORAL TABLET Tier 3 ST

terconazole vaginal cream Tier 1

terconazole vaginal suppository Tier 1

tranexamic acid oral tablet Tier 1

vandazole vaginal gel Tier 1

xulane transdermal patch weekly Tier 5 ACA

Oral Contraceptives & Related Agents altavera (28) oral tablet Tier 5 ACA

alyacen 1/35 (28) oral tablet Tier 5 ACA

alyacen 7/7/7 (28) oral tablet Tier 5 ACA

amethia lo oral tablets,dose pack,3 month Tier 5 ACA

amethia oral tablets,dose pack,3 month Tier 5 ACA

amethyst oral tablet Tier 5 ACA

apri oral tablet Tier 5 ACA

89


aranelle (28) oral tablet Tier 5 ACA

ashlyna oral tablets,dose pack,3 month Tier 5 ACA

aubra oral tablet Tier 5 ACA

aviane oral tablet Tier 5 ACA

azurette (28) oral tablet Tier 5 ACA

balziva (28) oral tablet Tier 5 ACA

bekyree (28) oral tablet Tier 5 ACA

blisovi 24 fe oral tablet Tier 5 ACA

blisovi fe 1.5/30 (28) oral tablet Tier 5 ACA

blisovi fe 1/20 (28) oral tablet Tier 5 ACA

briellyn oral tablet Tier 5 ACA

camrese lo oral tablets,dose pack,3 month Tier 5 ACA

camrese oral tablets,dose pack,3 month Tier 5 ACA

caziant (28) oral tablet Tier 5 ACA

chateal oral tablet Tier 5 ACA

cryselle (28) oral tablet Tier 5 ACA

cyclafem 1/35 (28) oral tablet Tier 5 ACA

cyclafem 7/7/7 (28) oral tablet Tier 5 ACA

cyred oral tablet Tier 5 ACA

dasetta 1/35 (28) oral tablet Tier 5 ACA

dasetta 7/7/7 (28) oral tablet Tier 5 ACA

daysee oral tablets,dose pack,3 month Tier 5 ACA

delyla (28) oral tablet Tier 5 ACA

desog-e.estradiol/e.estradiol oral tablet Tier 5 ACA

desogestrel-ethinyl estradiol oral tablet Tier 5 ACA

drospirenone-e.estradiol-lm.fa oral tablet Tier 5 ACA

drospirenone-ethinyl estradiol oral tablet Tier 5 ACA

elinest oral tablet Tier 5 ACA

ella oral tablet Tier 5 ACA; QL (3 EA per 365 days)

emoquette oral tablet Tier 5 ACA

enpresse oral tablet Tier 5 ACA

enskyce oral tablet Tier 5 ACA

estarylla oral tablet Tier 5 ACA

90


ethynodiol diac-eth estradiol oral tablet Tier 5 ACA

falmina (28) oral tablet Tier 5 ACA

fayosim oral tablets,dose pack,3 month Tier 5 ACA

femynor oral tablet Tier 5 ACA

gianvi (28) oral tablet Tier 5 ACA

gildagia oral tablet Tier 5 ACA

introvale oral tablets,dose pack,3 month Tier 5 ACA

isibloom oral tablet Tier 5 ACA

jolessa oral tablets,dose pack,3 month Tier 5 ACA

juleber oral tablet Tier 5 ACA

junel 1.5/30 (21) oral tablet Tier 5 ACA

junel 1/20 (21) oral tablet Tier 5 ACA

junel fe 1.5/30 (28) oral tablet Tier 5 ACA

junel fe 1/20 (28) oral tablet Tier 5 ACA

junel fe 24 oral tablet Tier 5 ACA

kaitlib fe oral tablet,chewable Tier 5 ACA

kariva (28) oral tablet Tier 5 ACA

kelnor 1/35 (28) oral tablet Tier 5 ACA

kimidess (28) oral tablet Tier 5 ACA

kurvelo oral tablet Tier 5 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Tier 5 ACA

larin 1.5/30 (21) oral tablet Tier 5 ACA

larin 1/20 (21) oral tablet Tier 5 ACA

larin 24 fe oral tablet Tier 5 ACA

larin fe 1.5/30 (28) oral tablet Tier 5 ACA

larin fe 1/20 (28) oral tablet Tier 5 ACA

larissia oral tablet Tier 5 ACA

layolis fe oral tablet,chewable Tier 5 ACA

leena 28 oral tablet Tier 5 ACA

lessina oral tablet Tier 5 ACA

levonest (28) oral tablet Tier 5 ACA

levonorgestrel-ethinyl estrad oral tablet Tier 5 ACA

91


levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Tier 5 ACA

levonorg-eth estrad triphasic oral tablet Tier 5 ACA

levora 0.15/30 (28) oral tablet Tier 5 ACA

levora-28 oral tablet Tier 5 ACA

lillow oral tablet Tier 5 ACA

lomedia 24 fe oral tablet Tier 5 ACA

loryna (28) oral tablet Tier 5 ACA

low-ogestrel (28) oral tablet Tier 5 ACA

lutera (28) oral tablet Tier 5 ACA

marlissa oral tablet Tier 5 ACA

melodetta 24 fe oral tablet,chewable Tier 5 ACA

mibelas 24 fe oral tablet,chewable Tier 5 ACA

microgestin 1.5/30 (21) oral tablet Tier 5 ACA

microgestin 1/20 (21) oral tablet Tier 5 ACA

microgestin fe 1.5/30 (28) oral tablet Tier 5 ACA

microgestin fe 1/20 (28) oral tablet Tier 5 ACA

mono-linyah oral tablet Tier 5 ACA

mononessa (28) oral tablet Tier 5 ACA

myzilra oral tablet Tier 5 ACA

natazia oral tablet Tier 5 ACA

necon 0.5/35 (28) oral tablet Tier 5 ACA

necon 1/50 (28) oral tablet Tier 5 ACA

necon 10/11 (28) oral tablet Tier 5 ACA

necon 7/7/7 (28) oral tablet Tier 5 ACA

nikki (28) oral tablet Tier 5 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable Tier 5 ACA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Tier 5 ACA

norethindrone-e.estradiol-iron oral tablet Tier 5 ACA

norgestimate-ethinyl estradiol oral tablet Tier 5 ACA

norgestrel-ethinyl estradiol oral tablet Tier 5 ACA

nortrel 0.5/35 (28) oral tablet Tier 5 ACA

nortrel 1/35 (21) oral tablet Tier 5 ACA

92


nortrel 1/35 (28) oral tablet Tier 5 ACA

nortrel 7/7/7 (28) oral tablet Tier 5 ACA

ocella oral tablet Tier 5 ACA

ogestrel (28) oral tablet Tier 5 ACA

orsythia oral tablet Tier 5 ACA

philith oral tablet Tier 5 ACA

pimtrea (28) oral tablet Tier 5 ACA

pirmella oral tablet Tier 5 ACA

portia oral tablet Tier 5 ACA

previfem oral tablet Tier 5 ACA

quasense oral tablets,dose pack,3 month Tier 5 ACA

rajani oral tablet Tier 5 ACA

reclipsen (28) oral tablet Tier 5 ACA

rivelsa oral tablets,dose pack,3 month Tier 5 ACA

safyral oral tablet Tier 5 ACA

setlakin oral tablets,dose pack,3 month Tier 5 ACA

sprintec (28) oral tablet Tier 5 ACA

sronyx oral tablet Tier 5 ACA

syeda oral tablet Tier 5 ACA

tarina fe 1/20 (28) oral tablet Tier 5 ACA

tilia fe oral tablet Tier 5 ACA

tri femynor oral tablet Tier 5 ACA

tri-estarylla oral tablet Tier 5 ACA

tri-legest fe oral tablet Tier 5 ACA

tri-linyah oral tablet Tier 5 ACA

tri-lo-estarylla oral tablet Tier 5 ACA

tri-lo-marzia oral tablet Tier 5 ACA

tri-lo-sprintec oral tablet Tier 5 ACA

trinessa (28) oral tablet Tier 5 ACA

trinessa lo oral tablet Tier 5 ACA

tri-previfem (28) oral tablet Tier 5 ACA

tri-sprintec (28) oral tablet Tier 5 ACA

trivora (28) oral tablet Tier 5 ACA

93


velivet triphasic regimen (28) oral tablet Tier 5 ACA

vestura (28) oral tablet Tier 5 ACA

vienva oral tablet Tier 5 ACA

viorele (28) oral tablet Tier 5 ACA

vyfemla (28) oral tablet Tier 5 ACA

wera (28) oral tablet Tier 5 ACA

wymzya fe oral tablet,chewable Tier 5 ACA

zarah oral tablet Tier 5 ACA

zenchent (28) oral tablet Tier 5 ACA

zenchent fe oral tablet,chewable Tier 5 ACA

zovia 1/35e (28) oral tablet Tier 5 ACA

zovia 1/50e (28) oral tablet Tier 5 ACA

Ophthalmology Antibiotics AZASITE OPHTHALMIC (EYE) DROPS Tier 3

bacitracin ophthalmic (eye) ointment Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment Tier 1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) SOLUTION

Tier 3

CILOXAN OPHTHALMIC (EYE) OINTMENT

Tier 3

ciprofloxacin hcl ophthalmic (eye) drops Tier 1

erythromycin ophthalmic (eye) ointment Tier 1

gatifloxacin ophthalmic (eye) drops Tier 1

gentamicin ophthalmic (eye) drops Tier 1

gentamicin ophthalmic (eye) ointment Tier 1

levofloxacin ophthalmic (eye) drops Tier 1

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS

Tier 2

moxifloxacin ophthalmic (eye) drops Tier 1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

94


neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 1

neo-polycin ophthalmic (eye) ointment Tier 1

ofloxacin ophthalmic (eye) drops Tier 1

polycin ophthalmic (eye) ointment Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 1

tobramycin ophthalmic (eye) drops Tier 1

TOBREX OPHTHALMIC (EYE) OINTMENT Tier 3

VIGAMOX OPHTHALMIC (EYE) DROPS Tier 2

Antivirals trifluridine ophthalmic (eye) drops Tier 1

ZIRGAN OPHTHALMIC (EYE) GEL Tier 3

Beta-Blockers betaxolol ophthalmic (eye) drops Tier 1

BETIMOL OPHTHALMIC (EYE) DROPS Tier 3 ST

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3 ST

carteolol ophthalmic (eye) drops Tier 1

ISTALOL OPHTHALMIC (EYE) DROPS, ONCE DAILY

Tier 3 ST

levobunolol ophthalmic (eye) drops 0.5 % Tier 1

metipranolol ophthalmic (eye) drops Tier 1

timolol maleate ophthalmic (eye) drops Tier 1

timolol maleate ophthalmic (eye) gel forming solution

Tier 1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3

Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 3

Cycloplegic Mydriatics atropine ophthalmic (eye) drops Tier 1

95


atropine ophthalmic (eye) ointment Tier 1

cyclopentolate ophthalmic (eye) drops Tier 1

homatropine hbr ophthalmic (eye) drops Tier 1

tropicamide ophthalmic (eye) drops Tier 1

Direct Acting Miotics MIOCHOL-E INTRAOCULAR KIT Tier 3

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Tier 1

Miscellaneous Ophthalmologics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 3

ALOCRIL OPHTHALMIC (EYE) DROPS Tier 3 ST

ALOMIDE OPHTHALMIC (EYE) DROPS Tier 3 ST

azelastine ophthalmic (eye) drops Tier 1

BEPREVE OPHTHALMIC (EYE) DROPS Tier 3 ST

cromolyn ophthalmic (eye) drops Tier 1

CYSTARAN OPHTHALMIC (EYE) DROPS Tier 4 LD; SPRx

EMADINE OPHTHALMIC (EYE) DROPS Tier 3 ST

epinastine ophthalmic (eye) drops Tier 1

flucaine ophthalmic (eye) drops Tier 1

fluorescein-proparacaine ophthalmic (eye) drops Tier 1

LACRISERT OPHTHALMIC (EYE) INSERT Tier 3

LASTACAFT OPHTHALMIC (EYE) DROPS Tier 3 ST

olopatadine ophthalmic (eye) drops Tier 1

PATADAY OPHTHALMIC (EYE) DROPS Tier 2

PAZEO OPHTHALMIC (EYE) DROPS Tier 2

proparacaine ophthalmic (eye) drops Tier 1

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS

Tier 2

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Tier 2

tetracaine hcl (pf) ophthalmic (eye) drops Tier 3

tetracaine hcl ophthalmic (eye) drops Tier 1

Non-Steroidal Anti-Inflammatory Agents bromfenac ophthalmic (eye) drops Tier 1

96


diclofenac sodium ophthalmic (eye) drops Tier 1

flurbiprofen sodium ophthalmic (eye) drops Tier 1

ketorolac ophthalmic (eye) drops Tier 1

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3 ST

PROLENSA OPHTHALMIC (EYE) DROPS Tier 2

Oral Drugs For Glaucoma acetazolamide oral capsule, extended release Tier 1

acetazolamide oral tablet Tier 1

methazolamide oral tablet Tier 1

Other Glaucoma Drugs AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3 ST

bimatoprost ophthalmic (eye) drops Tier 1

COMBIGAN OPHTHALMIC (EYE) DROPS Tier 2

COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3 ST

dorzolamide ophthalmic (eye) drops Tier 1

dorzolamide-timolol ophthalmic (eye) drops Tier 1

latanoprost ophthalmic (eye) drops Tier 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Tier 2

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3 ST

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Tier 2

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3 ST

Steroid-Antibiotic Combinations neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 1

97


neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Tier 1

neo-polycin hc ophthalmic (eye) ointment Tier 1

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

TOBRADEX OPHTHALMIC (EYE) OINTMENT

Tier 2

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 2

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 1

Steroids dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 1

DUREZOL OPHTHALMIC (EYE) DROPS Tier 2

fluorometholone ophthalmic (eye) drops,suspension

Tier 1

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Tier 2

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 2

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Tier 2

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 1

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 1

VEXOL OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

Steroid-Sulfonamide Combinations

98


BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 1

Sulfonamides sulfacetamide sodium ophthalmic (eye) drops Tier 1

sulfacetamide sodium ophthalmic (eye) ointment Tier 1

Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

Tier 2

apraclonidine ophthalmic (eye) drops Tier 1

brimonidine ophthalmic (eye) drops Tier 1

Vasoconstrictor Decongestants CYCLOMYDRIL OPHTHALMIC (EYE) DROPS

Tier 3

naphazoline ophthalmic (eye) drops Tier 1

phenylephrine hcl ophthalmic (eye) drops Tier 1

Respiratory, Allergy, Cough & Cold Antihistamine & Antiallergenic Agents carbinoxamine maleate oral liquid Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

CLARINEX ORAL SYRUP Tier 3

clemastine oral tablet 2.68 mg Tier 1

cyproheptadine oral syrup Tier 1

cyproheptadine oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet,disintegrating Tier 1

diphenhydramine hcl injection solution 50 mg/ml Tier 1

diphenhydramine hcl injection syringe Tier 1

EPINEPHRINE INJECTION AUTO-INJECTOR


epinephrine injection solution Tier 1

99


epinephrine injection syringe 0.1 mg/ml Tier 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR


EPIPEN INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR


EPIPEN JR INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule Tier 1

levocetirizine oral solution Tier 1

levocetirizine oral tablet Tier 1

phenadoz rectal suppository Tier 1

phenergan rectal suppository Tier 1

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

promethazine rectal suppository Tier 1

promethegan rectal suppository Tier 1

Cough & Cold Therapy benzonatate oral capsule Tier 1

brompheniramine-pseudoeph-dm oral syrup Tier 1

cheratussin ac oral liquid Tier 1

codeine-guaifenesin oral liquid Tier 1

guaifenesin ac oral liquid Tier 1

guaifenesin dac oral syrup Tier 1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1

hydrocodone-cpm-pseudoephed oral solution Tier 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

Tier 1

hydrocodone-homatropine oral tablet Tier 1

hydromet oral syrup Tier 1

MAR-COF BP ORAL LIQUID Tier 3

MAR-COF CG ORAL LIQUID Tier 3

100


M-CLEAR WC ORAL LIQUID Tier 3

promethazine vc oral syrup Tier 1

promethazine vc-codeine oral syrup Tier 1

promethazine-codeine oral syrup Tier 1

promethazine-dm oral syrup Tier 1

promethazine-phenyleph-codeine oral syrup Tier 1

REZIRA ORAL SOLUTION Tier 3

SEMPREX-D ORAL CAPSULE Tier 3

tussigon oral tablet Tier 1

VIRTUSSIN AC ORAL LIQUID Tier 3

ZODRYL AC 25 ORAL SUSPENSION Tier 3







ZODRYL DAC 25 ORAL SUSPENSION Tier 3







ZODRYL DEC 25 ORAL SUSPENSION Tier 3







Z-TUSS AC ORAL LIQUID Tier 3

Pulmonary Agents

101


acetylcysteine solution Tier 1

ADCIRCA ORAL TABLET Tier 4 PA; SPRx

ADEMPAS ORAL TABLET Tier 4 PA; SPRx

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2

AEROSPAN INHALATION HFA AEROSOL INHALER

Tier 3

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

albuterol sulfate oral tablet extended release 12 hr Tier 1

ALVESCO INHALATION HFA AEROSOL INHALER

Tier 3

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

Tier 2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

Tier 3

BERINERT INTRAVENOUS KIT Tier 4 PA; SPRx

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 2

budesonide inhalation suspension for nebulization Tier 1

budesonide nasal spray,non-aerosol Tier 1

102


CINRYZE INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

COMBIVENT RESPIMAT INHALATION MIST

Tier 2

cromolyn inhalation solution for nebulization Tier 1

DALIRESP ORAL TABLET Tier 2

DULERA INHALATION HFA AEROSOL INHALER

Tier 2

ESBRIET ORAL CAPSULE Tier 4 PA; SPRx

ESBRIET ORAL TABLET Tier 4 PA; SPRx

FIRAZYR SUBCUTANEOUS SYRINGE Tier 4 PA; SPRx

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Tier 2

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

Tier 1

fluticasone nasal spray,suspension Tier 1

HAEGARDA SUBCUTANEOUS RECON SOLN

Tier 4 PA; LD; SPRx

ipratropium bromide inhalation solution Tier 1

ipratropium-albuterol inhalation solution for nebulization

Tier 1

KALYDECO ORAL GRANULES IN PACKET

Tier 4 PA; SPRx

KALYDECO ORAL TABLET Tier 4 PA; SPRx

levalbuterol hcl inhalation solution for nebulization

Tier 1

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

mometasone nasal spray,non-aerosol Tier 1

montelukast oral granules in packet Tier 1

montelukast oral tablet Tier 1

montelukast oral tablet,chewable Tier 1

OFEV ORAL CAPSULE Tier 4 PA; SPRx

OPSUMIT ORAL TABLET Tier 4 PA; SPRx

ORKAMBI ORAL TABLET Tier 4 PA; SPRx

103


PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 2

PROAIR HFA INHALATION HFA AEROSOL INHALER


PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED


PROVENTIL HFA INHALATION HFA AEROSOL INHALER


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

pulmosal inhalation solution for nebulization Tier 1

PULMOZYME INHALATION SOLUTION Tier 4 SPRx

QVAR INHALATION AEROSOL Tier 2

REVATIO INTRAVENOUS SOLUTION Tier 4 PA; SPRx

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

Tier 4 PA; SPRx

RUCONEST INTRAVENOUS RECON SOLN Tier 4 PA; SPRx

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

sildenafil (antihypertensive) intravenous solution Tier 4 PA; SPRx

sildenafil (antihypertensive) oral tablet Tier 4 PA; SPRx

sodium chloride inhalation solution for nebulization

Tier 1

SPIRIVA RESPIMAT INHALATION MIST Tier 2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

STIOLTO RESPIMAT INHALATION MIST Tier 2

STRIVERDI RESPIMAT INHALATION MIST

Tier 2

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2

terbutaline oral tablet Tier 1

terbutaline subcutaneous solution Tier 1

theochron oral tablet extended release 12 hr Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release 12 hr Tier 1

104


theophylline oral tablet extended release 24 hr Tier 1

TRACLEER ORAL TABLET Tier 4 PA; SPRx

TRACLEER ORAL TABLET FOR SUSPENSION

Tier 4 PA; SPRx

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

TYVASO INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 4 PA; SPRx

VENTOLIN HFA INHALATION HFA AEROSOL INHALER


XOPENEX HFA INHALATION HFA AEROSOL INHALER


zafirlukast oral tablet Tier 1

zileuton oral tablet, er multiphase 12 hr Tier 1 PA

Urologicals Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 1

flavoxate oral tablet Tier 1

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

Tier 2

GELNIQUE TRANSDERMAL GEL IN PACKET

Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

105


oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1

tolterodine oral capsule,extended release 24hr Tier 1

tolterodine oral tablet Tier 1

trospium oral capsule,extended release 24hr Tier 1

trospium oral tablet Tier 1

VESICARE ORAL TABLET Tier 2

Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin oral tablet extended release 24 hr Tier 1

CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 3 PA

dutasteride oral capsule Tier 1

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

Tier 1

finasteride oral tablet 5 mg Tier 1

RAPAFLO ORAL CAPSULE Tier 3

tamsulosin oral capsule,extended release 24hr Tier 1

Cholinergic Stimulants bethanechol chloride oral tablet Tier 1

Miscellaneous Urologicals alprostadil injection solution Tier 1

CYSTAGON ORAL CAPSULE Tier 4 LD; SPRx

ELMIRON ORAL CAPSULE Tier 3

K-PHOS NO 2 ORAL TABLET Tier 3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

Tier 3

potassium citrate oral tablet extended release Tier 1

potassium citrate-citric acid oral packet Tier 1

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 4 PA; SPRx

PROSTIN VR PEDIATRIC INJECTION SOLUTION

Tier 3

Urinary Anesthetics

106


phenazopyridine oral tablet 100 mg, 200 mg Tier 1

Vitamins, Hematinics & Electrolytes Electrolytes calcium 500 with d oral tablet Tier 5 ACA

calcium 600 with vitamin d3 oral capsule 600 mg(1,500mg) -500 unit

Tier 5 ACA

calcium carb and citrate-vitd3 oral tablet extended release

Tier 5 ACA

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit

Tier 5 ACA

calcium citrate + d oral tablet Tier 5 ACA

calcium citrate-vitamin d2 oral tablet Tier 5 ACA

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 315-200 mg-unit

Tier 5 ACA

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

effer-k oral tablet, effervescent 25 meq Tier 1

GALZIN ORAL CAPSULE Tier 3

k-effervescent oral tablet, effervescent Tier 1

klor-con 10 oral tablet extended release Tier 1

klor-con 8 oral tablet extended release Tier 1

klor-con m10 oral tablet,er particles/crystals Tier 1



klor-con oral packet Tier 1

klor-con sprinkle oral capsule, extended release Tier 1

KLOR-CON/25 ORAL PACKET Tier 3

klor-con/ef oral tablet, effervescent Tier 1

k-phos-neutral oral tablet Tier 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

Tier 3

k-tab oral tablet extended release 8 meq Tier 1

oyster shell calcium-vit d3 oral tablet 500 mg(1,250mg) -400 unit

Tier 5 ACA

phospha 250 neutral oral tablet Tier 1

107


potassium bicarb and chloride oral tablet, effervescent

Tier 1

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral packet Tier 1

potassium chloride oral tablet extended release Tier 1

potassium chloride oral tablet,er particles/crystals Tier 1

virt-phos 250 neutral oral tablet Tier 1

Vitamins & Hematinics ANIMI-3 WITH VITAMIN D ORAL CAPSULE

Tier 3

b complex-vitamin b12 oral tablet Tier 5 ACA

b complex-vitamin c-folic acid oral tablet Tier 5 ACA

balanced b-100 complex oral tablet extended release 100 mg

Tier 5 ACA

b-complex with vitamin c oral tablet Tier 5 ACA

calcium pnv oral capsule Tier 1

centratex oral capsule Tier 1

cholecalciferol (vitamin d3) oral capsule 50,000 unit

Tier 1

classic prenatal oral tablet Tier 5 ACA

c-nate dha oral capsule Tier 1

complete natal dha oral combo pack Tier 1

completenate oral tablet,chewable Tier 1

corvita 150 oral tablet Tier 1

cyanocobalamin (vitamin b-12) injection solution Tier 1

decara oral capsule 50,000 unit Tier 1

dialyvite 800 oral tablet Tier 5 ACA

dialyvite oral tablet 100-1 mg Tier 1

dothelle dha oral capsule Tier 1

elite-ob oral tablet Tier 1

ergocalciferol (vitamin d2) oral capsule Tier 1

fabb oral tablet Tier 1

108


FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

Tier 3

ferraplus 90 oral tablet Tier 1

ferrocite plus oral tablet Tier 1

fluorabon oral drops Tier 5 ACA

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg

Tier 5 ACA

fluoride (sodium) oral drops Tier 5 ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

flura-drops oral drops Tier 5 ACA

folbecal oral tablet, er multiphase 24 hr Tier 1

folic acid oral tablet 400 mcg, 800 mcg Tier 5 ACA

folivane-f oral capsule Tier 1

folivane-ob oral capsule Tier 1

foltabs 800 oral tablet Tier 5 ACA

full spectrum b-vitamin c oral tablet Tier 5 ACA

hematinic plus vit/minerals oral tablet Tier 1

hematinic/folic acid oral tablet Tier 1

hematogen oral capsule Tier 1

hemenatal ob + dha oral combo pack Tier 1

hemenatal ob oral tablet Tier 1

IROSPAN 24/6 ORAL TABLET Tier 3

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 5 ACA

macnatal cn dha oral capsule Tier 1

MULTI-VIT WITH FLUORIDE-IRON ORAL DROPS

Tier 5 ACA

multi-vitamin with fluoride oral drops Tier 5 ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 5 ACA

multi-vitamin with fluoride oral tablet,chewable 1 mg

Tier 1

109


multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 5 ACA

multivit-fluor (vit e acetate) oral drops Tier 5 ACA

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg Tier 5 ACA

mynatal advance oral tablet Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release Tier 1

natural b-100 complex oral tablet Tier 5 ACA

newgen oral tablet Tier 1

obstetrix dha oral combo pack,tablet and cap,dr Tier 1

one daily prenatal oral combo pack 28-800-440 mg-mcg-mg

Tier 5 ACA

perry prenatal oral capsule Tier 5 ACA

pnv 29-1 oral tablet Tier 1

pnv ob+dha oral combo pack 27-1-50-250 mg Tier 1

pnv-dha + docusate oral capsule Tier 1

pnv-dha oral capsule Tier 1

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

pnv-vp-u oral capsule Tier 1

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 3

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

Tier 3

poly-vitamin with iron oral drops Tier 5 ACA

pr natal 400 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 400 oral combo pack Tier 1

pr natal 430 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 430 oral combo pack Tier 1

prena1 chew oral tablet,chew,ir - dr,biphase Tier 1

prena1 pearl oral capsule,ir - delay rel,biphase Tier 1

110


prena1 true oral combo pack Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral capsule Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

prenatal complete oral tablet Tier 5 ACA

prenatal low iron oral tablet Tier 1

prenatal multi-dha (algal oil) oral capsule Tier 5 ACA

prenatal one daily oral tablet Tier 5 ACA

prenatal oral tablet 28 mg iron- 800 mcg Tier 5 ACA

prenatal plus (calcium carb) oral tablet Tier 1

prenatal plus oral tablet Tier 1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg Tier 5 ACA

prenatal vitamin plus low iron oral tablet Tier 1

prenatal vits96-iron fum-folic oral tablet Tier 5 ACA

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

pretab oral tablet Tier 1

relnate dha oral capsule Tier 1

rena-vite oral tablet Tier 5 ACA

rena-vite rx oral tablet Tier 1

reno caps oral capsule Tier 1

risacal-d oral tablet Tier 5 ACA

rulavite dha oral capsule Tier 1

se-natal 19 (with docusate) oral tablet Tier 1

se-natal 19 oral tablet,chewable Tier 1

se-tan plus oral capsule Tier 1

STRESS FORMULA ORAL TABLET Tier 5 ACA

STRESS FORMULA WITH IRON ORAL TABLET

Tier 5 ACA

STRESS FORMULA WITH IRON(SULF) ORAL TABLET

Tier 5 ACA

taron-c dha oral capsule Tier 1

taron-prex prenatal-dha oral capsule Tier 1

111


thrivite-19 oral tablet Tier 1

tl gard rx oral tablet Tier 1

tricon oral capsule Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

tri-tabs dha oral combo pack Tier 1

triveen-duo dha oral combo pack Tier 1

triveen-one oral capsule Tier 1

triveen-prx rnf oral capsule Tier 1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

Tier 3

tri-vit with fluoride and iron oral drops Tier 5 ACA

tri-vitamin with fluoride oral drops Tier 5 ACA

trust natal dha oral combo pack Tier 1

UDAMIN SP ORAL TABLET Tier 3

ultimatecare one nf oral capsule Tier 1

ultimatecare one oral capsule Tier 1

v-c forte oral capsule Tier 1

vemavite-prx-2 oral capsule Tier 1

vinate care oral tablet,chewable Tier 1

vinate dha oral capsule Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate ultra oral tablet Tier 1

virt-advance oral tablet Tier 1

virt-c dha oral capsule Tier 1

virt-nate dha oral capsule Tier 1

virt-nate oral tablet Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

112


virt-select oral capsule Tier 1

virt-vite gt oral tablet Tier 1

virt-vite oral tablet Tier 1

VIRT-VITE PLUS ORAL TABLET Tier 3

vit b complex-folic acid oral tablet Tier 5 ACA

vitamin d3 oral tablet 400 unit Tier 5 ACA

vitamins a,c,d and fluoride oral drops Tier 5 ACA

vol-nate oral tablet Tier 1

vol-plus oral tablet Tier 1

vol-tab rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral capsule Tier 1

zatean-pn plus oral capsule Tier 1

zingiber oral tablet Tier 1

113

Index of Drugs 1 1ST TIER UNIFINE PENTIPS

.......................................... 61 1ST TIER UNILET

COMFORTOUCH ........... 61 A abacavir .................................. 6 abacavir-lamivudine ............... 6 abacavir-lamivudine-

zidovudine .......................... 6 ABILIFY MAINTENA ........ 30 acamprosate .......................... 53 ACANYA ............................. 46 acarbose ................................ 70 ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 57 ACCU-CHEK COMPACT

PLUS TEST...................... 57 ACCU-CHEK FASTCLIX .. 61 ACCU-CHEK GUIDE ......... 57 ACCU-CHEK SAFE-T-PRO

.......................................... 61 ACCU-CHEK SMARTVIEW

TEST STRIP .................... 57 ACCU-CHEK SOFTCLIX

LANCETS ........................ 61 ACCUTREND GLUCOSE .. 57 acebutolol ............................. 36 acetaminophen-caff-

dihydrocod ........................ 25 acetaminophen-codeine ........ 25 acetazolamide ....................... 96 acetic acid ....................... 53, 55 acetic acid-aluminum acetate 55 acetylcysteine ..................... 101 acitretin ................................. 45 ACTEMRA .......................... 85 ACTHAR H.P. ..................... 56 ACTHIB (PF) ....................... 80 ACTI-LANCE LANCETS ... 61 ACTIMMUNE ..................... 79 ACTOPLUS MET XR ......... 70 acyclovir ........................... 6, 50 ADACEL(TDAP

ADOLESN/ADULT)(PF) 80 adapalene .............................. 46 adapalene-benzoyl peroxide . 46 ADCIRCA .......................... 101

adefovir ................................... 7 ADEMPAS ......................... 101 ADVAIR DISKUS ............. 101 ADVAIR HFA ................... 101 ADVANCED GLUC METER

TEST STRIP..................... 57 ADVANCED TRAVEL

LANCETS ........................ 61 ADVATE.............................. 40 ADVOCATE LANCET ....... 61 ADVOCATE PEN NEEDLE

.......................................... 61 ADVOCATE REDI-CODE . 57 ADVOCATE TEST STRIPS 57 AEROSPAN ....................... 101 afeditab cr ............................. 36 AFINITOR ........................... 14 AFINITOR DISPERZ .......... 14 AFLURIA 2017-2018 .......... 80 AFLURIA 2017-2018 (PF) .. 80 AFLURIA QUAD 2017-2018

.......................................... 80 AFLURIA QUAD 2017-2018

(PF) ................................... 80 AFREZZA ............................ 67 AGAMATRIX AMP TEST

STRIPS ............................. 57 AKTEN (PF) ........................ 95 ala-cort .................................. 50 albuterol sulfate .................. 101 alclometasone ....................... 50 ALECENSA ......................... 14 alendronate ..................... 53, 84 alfuzosin ............................. 105 ALINIA ................................ 11 ALKERAN ........................... 14 allopurinol ............................ 84 almotriptan malate ................ 23 ALOCRIL ............................. 95 ALOMIDE............................ 95 ALORA ................................ 86 alosetron ............................... 73 ALPHAGAN P ..................... 98 ALPHANATE ...................... 40 ALPHANINE SD ................. 40 alprazolam ............................ 30 alprazolam intensol............... 30 ALPROLIX .......................... 40

alprostadil ........................... 105 ALTABAX ........................... 48 altavera (28) .......................... 88 ALTERNATE SITE LANCET

.......................................... 61 ALVESCO .......................... 101 alyacen 1/35 (28) .................. 88 alyacen 7/7/7 (28) ................. 88 amabelz ................................. 86 amantadine hcl ........................ 7 amcinonide ........................... 50 amethia ................................. 88 amethia lo ............................. 88 amethyst ................................ 88 AMICAR .............................. 40 amiloride ............................... 36 amiloride-hydrochlorothiazide

.......................................... 36 amiodarone ........................... 35 AMITIZA ............................. 73 amitriptyline ......................... 30 amitriptyline-chlordiazepoxide

.......................................... 30 amlodipine ............................ 36 amlodipine-atorvastatin ........ 42 amlodipine-benazepril .......... 36 amlodipine-olmesartan ......... 36 amlodipine-valsartan ............ 36 amlodipine-valsartan-hcthiazid

.......................................... 36 ammonium lactate ................ 46 amnesteem ............................ 47 amoxapine ............................. 30 amoxicil-clarithromy-lansopraz

.......................................... 76 amoxicillin ............................ 13 amoxicillin-pot clavulanate .. 13 ampicillin .............................. 13 AMPYRA ............................. 24 ANADROL-50 ..................... 68 anagrelide ............................. 53 anastrozole ............................ 15 ANDRODERM .................... 68 ANDROGEL .................. 68, 69 androxy ................................. 69 ANGELIQ ............................ 86 ANIMI-3 WITH VITAMIN D

........................................ 107

114

ANORO ELLIPTA ............ 101 ANTARA ............................. 42 anucort-hc ............................. 73 ANZEMET ........................... 73 apexicon e ............................. 50 APIDRA ............................... 67 APIDRA SOLOSTAR ......... 67 APOKYN ............................. 22 apraclonidine ........................ 98 aprepitant .............................. 73 apri ........................................ 88 APRISO ................................ 73 APTIOM............................... 18 APTIVUS ............................... 7 AQUA GLYCOLIC HC....... 50 aranelle (28).......................... 89 ARANESP (IN

POLYSORBATE) ............ 77 ARCALYST ......................... 79 ARCAPTA NEOHALER ... 101 aripiprazole ........................... 30 ARISTADA .......................... 30 armodafinil ........................... 30 ARMOUR THYROID ......... 71 ARNUITY ELLIPTA ......... 101 ascomp with codeine ............ 25 ashlyna .................................. 89 ASMANEX HFA ............... 101 ASMANEX TWISTHALER

........................................ 101 aspirin-caffeine-dihydrocodein

.......................................... 25 aspirin-dipyridamole ............ 40 ASSURE 4 STRIPS ............. 57 ASSURE HAEMOLANCE

PLUS ................................ 61 ASSURE LANCE ................ 61 ASSURE LANCE PLUS ..... 61 ASSURE PLATINUM ......... 57 ASSURE PRISM MULTI

STRIP ............................... 57 ASTAGRAF XL .................. 15 atazanavir ............................... 7 atenolol ................................. 36 atenolol-chlorthalidone......... 36 atomoxetine .......................... 30 atorvastatin ........................... 42 atovaquone ........................... 11 atovaquone-proguanil ........... 11 ATRIPLA ............................... 7

atropine ........................... 94, 95 ATROVENT HFA ............. 101 AUBAGIO............................ 78 aubra ..................................... 89 AURYXIA............................ 73 AVANDIA ........................... 70 AVC VAGINAL .................. 88 aviane.................................... 89 avita ...................................... 47 AVONEX ............................. 78 AVONEX (WITH ALBUMIN)

.......................................... 78 AZASITE ............................. 93 azathioprine .......................... 15 azelastine ........................ 55, 95 azithromycin ......................... 10 AZOPT ................................. 96 azurette (28) .......................... 89 B b complex-vitamin b12 ....... 107 b complex-vitamin c-folic acid

........................................ 107 bacitracin .............................. 93 bacitracin-polymyxin b......... 93 baclofen ................................ 25 BACTROBAN NASAL ....... 55 balanced b-100 complex ..... 107 balsalazide ............................ 73 balziva (28) ........................... 89 BANZEL .............................. 18 BARACLUDE........................ 7 bcg vaccine, live (pf) ............ 80 b-complex with vitamin c ... 107 BD ECLIPSE ........................ 61 BD FILTER NEEDLE-5

MICRON .......................... 61 BD INSULIN PEN NEEDLE

UF SHORT ....................... 62 BD INTEGRA NEEDLE ..... 62 BD MICROTAINER

LANCET .......................... 62 BD NOKOR ADMIX

NEEDLE .......................... 62 BD PRECISIONGLIDE ....... 62 BD PRECISIONGLIDE NON-

STERILE .......................... 62 bd pre-filled normal saline ... 53 BD SAFETYGLIDE NEEDLE

.......................................... 62

BD SPECIALTY USE NEEDLES ........................ 62

BD ULTRA FINE LANCETS .......................................... 62

BD ULTRA-FINE NANO PEN NEEDLES ................ 62

BEBULIN ............................. 40 bekyree (28) .......................... 89 benazepril ............................. 36 benazepril-hydrochlorothiazide

.......................................... 36 BENEFIX ............................. 40 BENLYSTA ......................... 85 benzonatate ........................... 99 benzoyl peroxide .................. 47 benztropine ........................... 22 BEPREVE ............................ 95 BERINERT ......................... 101 BESIVANCE ........................ 93 BETADINE OPHTHALMIC

PREP ................................. 93 betamethasone dipropionate . 50 betamethasone valerate ......... 50 betamethasone, augmented ... 50 BETASERON ....................... 78 betaxolol ......................... 36, 94 bethanechol chloride ........... 105 BETIMOL ............................ 94 BETOPTIC S ........................ 94 BEVESPI AEROSPHERE . 101 bexarotene ............................. 15 BEXSERO ............................ 80 bicalutamide ......................... 15 BIDIL ................................... 36 BILTRICIDE ........................ 11 bimatoprost ........................... 96 BIONIME RIGHTEST TEST

STRIPS ............................. 57 BIOTHRAX ......................... 80 bisacodyl ............................... 73 bisoprolol fumarate ............... 36 bisoprolol-hydrochlorothiazide

.......................................... 36 BLEPHAMIDE .................... 98 BLEPHAMIDE S.O.P. ......... 98 blisovi 24 fe .......................... 89 blisovi fe 1.5/30 (28) ............ 89 blisovi fe 1/20 (28) ............... 89 BLOOD GLUCOSE TEST .. 57 blunt needle, disposable ........ 62

115

BOOSTRIX TDAP .............. 80 BOSULIF ............................. 15 BREEZE 2 TEST STRIPS ... 57 BREO ELLIPTA ................ 101 briellyn ................................. 89 BRILINTA ........................... 40 brimonidine .......................... 98 bromfenac ............................. 95 bromocriptine ....................... 22 brompheniramine-pseudoeph-

dm ..................................... 99 BROVANA ........................ 101 budesonide .................... 73, 101 BULLSEYE MINI SAFETY

LANCETS ........................ 62 bumetanide ........................... 36 BUNAVAIL ......................... 18 BUPHENYL......................... 53 buprenorphine hcl ................. 18 buprenorphine-naloxone....... 18 bupropion hcl........................ 30 bupropion hcl (smoking deter)

.......................................... 54 buspirone .............................. 30 butalbital compound w/codeine

.......................................... 25 butalbital-acetaminop-caf-cod

.......................................... 25 butalbital-acetaminophen ..... 25 butalbital-acetaminophen-caff

.......................................... 26 butalbital-aspirin-caffeine .... 26 butorphanol tartrate .............. 26 BUTRANS ........................... 26 BYDUREON ........................ 70 BYDUREON BCISE ........... 70 BYETTA .............................. 70 BYSTOLIC .......................... 36 C cabergoline ........................... 69 CABOMETYX..................... 15 caffeine citrate ...................... 53 calcipotriene ......................... 45 calcipotriene-betamethasone 45 calcitonin (salmon) ............... 69 calcitrene .............................. 45 calcitriol .......................... 45, 69 calcium 500 with d ............. 106 calcium 600 with vitamin d3

........................................ 106

calcium acetate ..................... 73 calcium carb and citrate-vitd3

........................................ 106 calcium carbonate-vitamin d3

........................................ 106 calcium citrate + d .............. 106 calcium citrate-vitamin d2 .. 106 calcium citrate-vitamin d3 .. 106 calcium pnv ........................ 107 camila ................................... 86 camrese ................................. 89 camrese lo ............................. 89 CANASA.............................. 73 candesartan ........................... 36 candesartan-hydrochlorothiazid

.......................................... 36 capacet .................................. 26 capecitabine .......................... 15 CAPRELSA.......................... 15 captopril ................................ 36 captopril-hydrochlorothiazide

.......................................... 36 CARBAGLU ........................ 53 carbamazepine ...................... 18 CARBATROL ...................... 18 carbidopa .............................. 22 carbidopa-levodopa .............. 22 carbidopa-levodopa-

entacapone ........................ 22 carbinoxamine maleate ......... 98 CARDIZEM LA ................... 36 CARDURA XL .................... 36 CAREFINE PEN NEEDLE . 62 CAREONE THIN LANCET 62 CARESENS N TEST STRIPS

.......................................... 57 carisoprodol .......................... 25 carisoprodol-asa-codeine ...... 25 carisoprodol-aspirin .............. 25 carteolol ................................ 94 cartia xt ................................. 36 carvedilol .............................. 36 carvedilol phosphate ............. 36 CAYSTON ........................... 11 caziant (28) ........................... 89 cefaclor ............................. 9, 10 cefadroxil .............................. 10 cefdinir.................................. 10 cefditoren pivoxil ................. 10 cefixime ................................ 10

cefpodoxime ......................... 10 cefprozil ................................ 10 ceftibuten .............................. 10 CEFTIN ................................ 10 cefuroxime axetil .................. 10 celecoxib ............................... 28 CELONTIN .......................... 18 centratex ............................. 107 cephalexin ............................. 10 CERDELGA ......................... 69 CERVARIX VACCINE (PF)

.......................................... 80 CESAMET ........................... 73 cevimeline ............................. 53 CHANTIX ............................ 54 CHANTIX CONTINUING

MONTH BOX .................. 54 CHANTIX STARTING

MONTH BOX .................. 54 chateal ................................... 89 CHEMET .............................. 53 CHENODAL ........................ 73 cheratussin ac ........................ 99 chlordiazepoxide hcl ............. 30 chlordiazepoxide-clidinium .. 72 chlorhexidine gluconate ........ 55 chloroquine phosphate .......... 11 chlorothiazide ....................... 36 chlorpromazine ..................... 30 chlorpropamide ..................... 70 chlorthalidone ....................... 37 chlorzoxazone ....................... 25 cholecalciferol (vitamin d3) 107 cholestyramine (with sugar) . 42 cholestyramine light ............. 43 CIALIS ............................... 105 ciclodan ................................. 49 ciclopirox .............................. 49 ciclopirox-ure-camph-menth-

euc ..................................... 49 cilostazol ............................... 40 CILOXAN ............................ 93 cimetidine ............................. 77 cimetidine hcl ....................... 77 CIMZIA ................................ 73 CINRYZE ........................... 102 CIPRO HC ............................ 56 CIPRODEX .......................... 56 ciprofloxacin ......................... 13 ciprofloxacin (mixture) ......... 13

116

ciprofloxacin hcl ....... 13, 55, 93 citalopram ....................... 30, 31 CITRATE OF MAGNESIA . 73 claravis ................................. 47 CLARINEX .......................... 98 clarithromycin ...................... 10 classic prenatal ................... 107 clemastine ............................. 98 CLEOCIN............................. 88 CLEVER CHEK LANCETS 62 CLEVER CHOICE MICRO

TEST STRIP .................... 57 CLEVER CHOICE PRO ...... 57 CLEVER CHOICE TEST

STRIPS ............................. 58 CLEVER CHOICE VOICE+

TEST ................................ 58 CLICKFINE ......................... 62 CLIMARA PRO ................... 86 clindamycin hcl .................... 11 clindamycin palmitate hcl .... 11 clindamycin pediatric ........... 11 clindamycin phosphate ... 47, 88 clindamycin-benzoyl peroxide

.......................................... 47 clobetasol ........................ 50, 51 clobetasol-emollient ............. 51 CLODERM .......................... 51 clomipramine ........................ 31 clonazepam ........................... 18 clonidine ............................... 37 clonidine hcl ................... 31, 37 clopidogrel ............................ 41 clorazepate dipotassium ....... 31 clorpres ................................. 37 CLORPRES .......................... 37 clotrimazole ............................ 6 clotrimazole-betamethasone . 49 clozapine............................... 31 c-nate dha ........................... 107 COAGADEX ....................... 41 COAGUCHEK LANCETS .. 62 COARTEM .......................... 11 codeine sulfate ...................... 26 codeine-butalbital-asa-caff ... 26 codeine-guaifenesin .............. 99 COLCRYS ........................... 84 COLESTID FLAVORED .... 43 colestipol .............................. 43 colocort ................................. 73

COLOR LANCETS ............. 62 COLY-MYCIN S ................. 56 COMBIGAN ........................ 96 COMBIPATCH .................... 86 COMBIVENT RESPIMAT 102 COMETRIQ ......................... 15 COMFORT EZ PEN

NEEDLES ........................ 62 COMFORT LANCETS ........ 62 COMPLERA .......................... 7 complete natal dha .............. 107 completenate ....................... 107 compro .................................. 73 constulose ............................. 73 CONTOUR NEXT STRIPS . 58 CONTOUR TEST STRIPS .. 58 COOL GLUCOSE TEST

STRIP ............................... 58 COPAXONE ........................ 78 COREG CR .......................... 37 CORIFACT .......................... 41 CORLANOR ........................ 44 cortisone ............................... 56 CORTISPORIN .................... 48 corvita 150 .......................... 107 COSENTYX ......................... 45 COSENTYX (2 SYRINGES)

.......................................... 45 COSENTYX PEN ................ 45 COSENTYX PEN (2 PENS) 45 COSOPT (PF)....................... 96 COTELLIC ........................... 15 COUMADIN ........................ 41 covaryx ................................. 86 covaryx h.s............................ 86 CREON ................................ 73 CRESEMBA .......................... 6 CRINONE ............................ 86 CRIXIVAN ............................ 7 cromolyn ................. 73, 95, 102 cryselle (28) .......................... 89 CUVITRU ............................ 80 cyanocobalamin (vitamin b-12)

........................................ 107 cyclafem 1/35 (28)................ 89 cyclafem 7/7/7 (28) .............. 89 cyclobenzaprine .................... 25 CYCLOMYDRIL ................. 98 cyclopentolate ....................... 95 CYCLOPHOSPHAMIDE .... 15

cycloserine ............................ 11 CYCLOSET ......................... 70 cyclosporine .......................... 15 cyclosporine modified .......... 15 cyproheptadine ..................... 98 cyred ..................................... 89 CYSTADANE ...................... 73 CYSTAGON ...................... 105 CYSTARAN ......................... 95 D DALIRESP ......................... 102 danazol .................................. 69 dantrolene ............................. 25 dapsone ................................. 11 DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 80 DARAPRIM ......................... 11 darifenacin .......................... 104 dasetta 1/35 (28) ................... 89 dasetta 7/7/7 (28) .................. 89 daysee ................................... 89 DAYTRANA ........................ 31 deblitane ............................... 86 decara .................................. 107 deltasone ............................... 56 delyla (28) ............................. 89 demeclocycline ..................... 13 DENAVIR ............................ 50 denta 5000 plus ..................... 55 dentagel ................................. 55 DEPAKENE ......................... 18 DEPAKOTE ......................... 19 DEPAKOTE ER ................... 19 DEPAKOTE SPRINKLES ... 19 DEPEN TITRATABS .......... 85 DEPO-ESTRADIOL ............ 86 depo-subq provera 104 ......... 86 DEPO-TESTOSTERONE .... 69 DESCOVY ............................. 7 desipramine ........................... 31 desloratadine ......................... 98 desmopressin ........................ 69 desog-e.estradiol/e.estradiol . 89 desogestrel-ethinyl estradiol . 89 desonide ................................ 51 desoximetasone ..................... 51 desvenlafaxine succinate ...... 31 dexamethasone ..................... 56 dexamethasone intensol ........ 56

117

dexamethasone sodium phosphate .......................... 97

dexedrine .............................. 31 DEXILANT .......................... 77 dexmethylphenidate ............. 31 dextroamphetamine .............. 31 dextroamphetamine-

amphetamine .................... 31 dialyvite .............................. 107 dialyvite 800 ....................... 107 DIASTAT ............................. 19 DIASTAT ACUDIAL .......... 19 DIATRUE PLUS TEST STRIP

.......................................... 58 diazepam......................... 19, 31 diazepam intensol ................. 31 diclofenac potassium ............ 28 diclofenac sodium ... 28, 29, 46,

96 diclofenac-misoprostol ......... 29 dicloxacillin .......................... 13 dicyclomine .......................... 72 didanosine............................... 7 DIFICID ............................... 10 diflorasone ............................ 51 diflunisal ............................... 29 digitek ................................... 40 digox ..................................... 40 digoxin .................................. 40 dihydroergotamine ............... 23 DILANTIN ........................... 19 DILANTIN EXTENDED .... 19 DILANTIN INFATABS ...... 19 DILANTIN KAPSEAL ........ 19 DILANTIN-125 ................... 19 DILATRATE-SR ................. 44 diltiazem hcl ......................... 37 dilt-xr .................................... 37 DIPENTUM ......................... 73 diphenhydramine hcl ............ 98 diphenoxylate-atropine ......... 72 dipyridamole......................... 41 diskets ................................... 26 disopyramide phosphate ....... 35 disulfiram ............................. 53 DIURIL ................................ 37 divalproex ............................. 19 DIVIGEL .............................. 86 dofetilide............................... 35 donepezil .............................. 24

DONNATAL ........................ 72 dorzolamide .......................... 96 dorzolamide-timolol ............. 96 dothelle dha ........................ 107 doxazosin .............................. 37 doxepin ........................... 31, 46 doxercalciferol ...................... 69 doxycycline hyclate .............. 14 doxycycline monohydrate .... 14 drithocreme hp ...................... 45 dronabinol ............................. 73 DROPLET LANCETS ......... 62 DROPLET PEN NEEDLE ... 62 drospirenone-e.estradiol-lm.fa

.......................................... 89 drospirenone-ethinyl estradiol

.......................................... 89 DROXIA .............................. 15 DUAVEE.............................. 86 DULERA ............................ 102 duloxetine ............................. 31 DUOPA ................................ 22 DUPIXENT .......................... 46 DUREZOL ........................... 97 dutasteride .......................... 105 dutasteride-tamsulosin ........ 105 DUTOPROL ......................... 37 DYRENIUM ........................ 37 E e.e.s. 400 ............................... 10 E.E.S. GRANULES.............. 11 EASY COMFORT LANCETS

.......................................... 62 EASY COMFORT PEN

NEEDLES ........................ 62 EASY PLUS II TEST........... 58 EASY STEP ......................... 58 EASY TALK GLUCOSE

TEST ................................ 58 EASY TOUCH FLIPLOCK

NEEDLE .......................... 63 EASY TOUCH

HYPODERMIC NEEDLE .......................................... 63

EASY TOUCH TEST STRIP .......................................... 58

EASY TRAK GLUCOSE TEST ................................ 58

EASYGLUCO PLUS ........... 58 EASYGLUCO TEST ........... 58

EASYMAX .......................... 58 econazole .............................. 49 EDARBI ............................... 37 EDARBYCLOR ................... 37 EDURANT ............................. 7 eemt ...................................... 86 eemt hs .................................. 86 efavirenz ................................. 7 effer-k ................................. 106 EFFER-K ............................ 106 ELEMENT COMPACT TEST

STRIPS ............................. 58 ELEMENT TEST STRIPS ... 58 ELESTRIN ........................... 86 eletriptan hbr ......................... 23 ELIDEL ................................ 46 elinest .................................... 89 eliphos ................................... 73 ELIQUIS ............................... 41 elite-ob ................................ 107 ella ........................................ 89 ELMIRON .......................... 105 EMADINE ............................ 95 EMBRACE BLOOD

GLUCOSE SYSTEM ....... 58 EMBRACE EVO TEST

STRIPS ............................. 58 EMBRACE PRO TEST

STRIPS ............................. 58 EMCYT ................................ 15 EMFLAZA ........................... 56 emoquette ............................. 89 EMSAM ............................... 31 EMTRIVA .............................. 7 EMVERM ............................. 11 enalapril maleate ................... 37 enalapril-hydrochlorothiazide

.......................................... 37 ENBREL ............................... 85 ENBREL MINI .................... 85 ENBREL SURECLICK ....... 85 endocet .................................. 26 ENGERIX-B (PF) ................ 80 ENGERIX-B PEDIATRIC

(PF) ............................. 80, 81 enoxaparin ............................ 41 enpresse ................................ 89 enskyce ................................. 89 ENSTILAR ........................... 45 entacapone ............................ 22

118

entecavir ................................. 7 ENTRESTO ......................... 44 enulose .................................. 73 EPANED .............................. 37 EPCLUSA .............................. 7 EPIDUO ............................... 47 EPIDUO FORTE.................. 47 epinastine .............................. 95 epinephrine ..................... 98, 99 EPINEPHRINE .................... 98 EPIPEN ................................ 99 EPIPEN 2-PAK .................... 99 EPIPEN JR ........................... 99 EPIPEN JR 2-PAK ............... 99 epitol ..................................... 19 EPIVIR HBV.......................... 7 eplerenone ............................ 37 EPOGEN .............................. 78 epoprostenol (glycine) .......... 37 eprosartan ............................. 37 EPZICOM .............................. 7 EQUETRO ........................... 19 ergocalciferol (vitamin d2) . 107 ergoloid................................. 31 ergotamine-caffeine .............. 23 ERIVEDGE .......................... 15 errin ...................................... 86 ERTACZO ........................... 49 ery pads ................................ 47 erygel .................................... 47 ERYPED 200 ....................... 11 ERYPED 400 ....................... 11 ery-tab................................... 11 ERY-TAB............................. 11 erythrocin (as stearate) ......... 11 erythromycin .................. 11, 93 erythromycin ethylsuccinate 11 erythromycin with ethanol ... 47 erythromycin-benzoyl peroxide

.......................................... 47 ESBRIET ............................ 102 escitalopram oxalate ............. 31 esomeprazole magnesium .... 77 estarylla ................................ 89 estazolam .............................. 32 ESTRACE ............................ 86 estradiol ................................ 86 estradiol valerate .................. 86 estradiol-norethindrone acet . 86 ESTRING ............................. 87

ESTROGEL.......................... 87 estrogens-methyltestosterone 87 estropipate ............................ 87 eszopiclone ........................... 32 ethacrynic acid ...................... 37 ethambutol ............................ 12 ethosuximide ........................ 19 ethynodiol diac-eth estradiol 90 etidronate disodium .............. 53 etodolac ................................ 29 etoposide ............................... 15 EUCRISA ............................. 46 EURAX ................................ 52 EVAMIST ............................ 87 EVENCARE G2 ................... 58 EVENCARE G3 TEST ........ 58 EVENCARE MINI

GLUCOSE TEST STR ..... 58 EVOLUTION TEST STRIPS

.......................................... 58 EVOTAZ ................................ 7 EXEL HYPODERMIC

NEEDLES ........................ 63 EXELDERM ........................ 49 exemestane ........................... 15 EXJADE ............................... 53 EXTAVIA ............................ 78 e-z ject lancets ...................... 63 EZ SMART LANCETS ....... 63 EZ SMART PLUS TEST ..... 58 EZ SMART TEST ................ 58 ezetimibe .............................. 43 ezetimibe-simvastatin ........... 43 F fabb ..................................... 107 FACTIVE ............................. 13 falmina (28) .......................... 90 famciclovir.............................. 7 famotidine ............................. 77 FANAPT .............................. 32 FARESTON ......................... 15 FARXIGA ............................ 70 FARYDAK ........................... 15 fayosim ................................. 90 FAZACLO............................ 32 FEIBA NF ............................ 41 felbamate .............................. 19 FELBATOL.......................... 19 felodipine .............................. 37 fem ph ................................... 88

FEMRING ............................ 87 femynor ................................. 90 fenofibrate ............................. 43 fenofibrate micronized .......... 43 fenofibrate nanocrystallized . 43 fenofibric acid ....................... 43 fenofibric acid (choline) ....... 43 fenoprofen ............................. 29 fentanyl ................................. 26 fentanyl citrate ...................... 26 FERRALET 90 DUAL-IRON

DELIVERY .................... 108 ferraplus 90 ......................... 108 FERRIPROX ........................ 53 ferrocite plus ....................... 108 FIASP ................................... 67 FIASP FLEXTOUCH .......... 67 FIFTY50 SAFETY SEAL

LANCETS ........................ 63 FIFTY50 TEST STRIP ......... 58 FINACEA ............................. 47 finasteride ..................... 53, 105 FINE 30 UNIVERSAL

LANCETS ........................ 63 FINGERSTIX LANCETS .... 63 FIRAZYR ........................... 102 FLAGYL ER ........................ 12 flavoxate ............................. 104 flecainide .............................. 35 FLOLAN .............................. 37 FLOVENT DISKUS .......... 102 FLOVENT HFA ................. 102 FLOW-EZE VENTED

NEEDLE ........................... 63 FLUAD 2017-2018 (65 YR

UP)(PF) ............................. 81 FLUARIX QUAD 2017-2018

(PF) ................................... 81 FLUBLOK 2017-2018 (PF) . 81 FLUBLOK QUAD 2017-2018

(PF) ................................... 81 flucaine ................................. 95 FLUCELVAX QUAD 2017-

2018 .................................. 81 FLUCELVAX QUAD 2017-

2018 (PF) .......................... 81 fluconazole ............................. 6 flucytosine .............................. 6 fludrocortisone ...................... 56

119

FLULAVAL QUAD 2017-2018 .................................. 81

FLULAVAL QUAD 2017-2018 (PF) .......................... 81

FLUMIST QUAD 2017-2018 .......................................... 81

flunisolide ........................... 102 fluocinolone .......................... 51 fluocinolone acetonide oil .... 55 fluocinolone and shower cap 51 fluocinonide .......................... 51 fluocinonide-e....................... 51 fluorabon ............................ 108 fluor-a-day (with xylitol) .... 108 fluorescein-proparacaine ...... 95 fluoride (sodium) ................ 108 fluoritab .............................. 108 fluorometholone ................... 97 fluorouracil ........................... 46 fluoxetine .............................. 32 fluphenazine hcl ................... 32 flura-drops .......................... 108 flurandrenolide ..................... 51 flurazepam ............................ 32 flurbiprofen........................... 29 flurbiprofen sodium .............. 96 flutamide............................... 15 fluticasone .................... 51, 102 fluvastatin ............................. 43 FLUVIRIN 2017-2018 ......... 81 FLUVIRIN 2017-2018 (PF) . 81 fluvoxamine .......................... 32 FLUZONE HIGH-DOSE

2017-18 (PF) .................... 81 FLUZONE INTRADERM

QUAD 2017-18 ................ 81 FLUZONE QUAD 2017-2018

.......................................... 81 FLUZONE QUAD 2017-2018

(PF) ................................... 81 FLUZONE QUAD PEDI

2017-18 (PF) .................... 81 FML FORTE ........................ 97 FML S.O.P. .......................... 97 folbecal ............................... 108 folic acid ............................. 108 folivane-f ............................ 108 folivane-ob ......................... 108 foltabs 800 .......................... 108 fondaparinux......................... 41

FORA D15G......................... 58 FORA D20 ........................... 58 FORA D40-G31 TEST

STRIPS ............................. 58 FORA G20 ........................... 58 FORA G30A......................... 58 FORA GD50 TEST STRIPS 58 FORA TEST STRIP ............. 59 FORA TN'G VOICE TEST

STRIPS ............................. 59 FORA V10 ........................... 59 FORA V10-V12-D10-D20

STRP-LNCT ..................... 63 FORA V12 GLUCOSE ........ 59 FORA V20 ........................... 59 FORACARE GD20 .............. 59 FORACARE GD40 .............. 59 FORACARE LANCETS ...... 63 FORTEO .............................. 84 FORTISCARE GLUCOSE

TEST STRIPS .................. 59 FOSAMAX PLUS D ............ 84 fosamprenavir ......................... 7 fosinopril .............................. 37 fosinopril-hydrochlorothiazide

.......................................... 37 FOSRENOL ................... 73, 74 FRAGMIN............................ 41 FREESTYLE INSULINX .... 59 FREESTYLE INSULINX

TEST STRIPS .................. 59 FREESTYLE LANCETS ..... 63 FREESTYLE LITE STRIPS 59 FREESTYLE PRECISION

NEO STRIPS .................... 59 FREESTYLE TEST ............. 59 FREESTYLE UNISTIK 2 .... 63 frovatriptan ........................... 23 full spectrum b-vitamin c ... 108 FULYZAQ ........................... 72 furosemide ............................ 38 FUZEON ................................ 7 fyavolv .................................. 87 FYCOMPA ........................... 19 G gabapentin ............................ 19 GABITRIL ........................... 19 galantamine .......................... 24 GALZIN ............................. 106 GAMMAGARD LIQUID .... 81

GAMUNEX-C ...................... 81 GARDASIL (PF) .................. 82 GARDASIL 9 (PF) ............... 82 gatifloxacin ........................... 93 GATTEX 30-VIAL .............. 74 gavilyte-c .............................. 74 gavilyte-g .............................. 74 gavilyte-h and bisacodyl ....... 74 gavilyte-n .............................. 74 GE100 BLOOD GLUCOSE

TEST STRIP ..................... 59 GELNIQUE ........................ 104 gemfibrozil ........................... 43 generlac ................................. 74 gengraf .................................. 15 GENSTRIP TEST STRIP ..... 59 gentamicin ...................... 48, 93 GENVOYA ............................ 7 gianvi (28) ............................ 90 gildagia ................................. 90 GILENYA ............................ 78 GILOTRIF ............................ 15 glatiramer .............................. 78 glatopa .................................. 78 GLEOSTINE ........................ 15 glimepiride ............................ 70 glipizide ................................ 70 glipizide-metformin .............. 70 GLUCAGEN DIAGNOSTIC

KIT ................................... 61 GLUCAGEN HYPOKIT ...... 61 GLUCAGON EMERGENCY

KIT (HUMAN) ................. 61 GLUCO NAVII TEST STRIP

.......................................... 59 GLUCOCARD 01 SENSOR

PLUS ................................ 59 GLUCOCARD EXPRESSION

.......................................... 59 GLUCOCARD SHINE TEST

STRIPS ............................. 59 GLUCOCARD VITAL

SENSOR ........................... 59 GLUCOCARD VITAL TEST

STRIPS ............................. 59 GLUCOCOM GLUCOSE .... 59 GLUCOCOM LANCETS .... 63 glyburide ............................... 70 glyburide micronized ............ 70 glyburide-metformin ............. 70

120

glycopyrrolate....................... 72 glydo ..................................... 48 GLYXAMBI ........................ 70 GM100 ................................. 59 GOLYTELY......................... 74 granisetron hcl ...................... 74 GRASTEK ........................... 82 griseofulvin microsize ............ 6 griseofulvin ultramicrosize ..... 6 guaifenesin ac ....................... 99 guaifenesin dac ..................... 99 guanfacine ...................... 32, 38 guanidine .............................. 32 GYNAZOLE-1 ..................... 88 H HAEGARDA ..................... 102 halobetasol propionate.......... 51 HALOG ................................ 51 haloperidol ............................ 32 haloperidol lactate ................ 32 HARVONI ............................. 7 HAVRIX (PF) ...................... 82 HEALTHPRO TEST STRIPS

.......................................... 59 HEALTHY ACCENTS

UNIFINE PENTIP ........... 63 HEALTHY ACCENTS

UNILET LANCET ........... 63 heather .................................. 87 HELIXATE FS ..................... 41 hematinic plus vit/minerals 108 hematinic/folic acid ............ 108 hematogen .......................... 108 hemenatal ob ...................... 108 hemenatal ob + dha ............ 108 hemmorex-hc ........................ 74 HEMOFIL M HIGH............. 41 HEMOFIL M LOW ............. 41 HEMOFIL M MID ............... 41 HEMOFIL M SUPER HIGH41 hep flush-10 (pf) ................... 41 heparin (porcine) .................. 41 heparin lock flush ................. 41 heparin lock flush (porcine) . 41 heparin lockflush(porcine)(pf)

.......................................... 41 heparin, porcine (pf) ............. 41 HEXALEN ........................... 15 HIZENTRA .......................... 82 homatropine hbr ................... 95

HORIZANT.......................... 24 huber safety needles (disp.) .. 63 HUMALOG.......................... 67 HUMALOG JUNIOR

KWIKPEN........................ 67 HUMALOG KWIKPEN ...... 67 HUMALOG MIX 50-50 ...... 67 HUMALOG MIX 50-50

KWIKPEN........................ 67 HUMALOG MIX 75-25 ...... 67 HUMALOG MIX 75-25

KWIKPEN........................ 67 HUMATE-P ......................... 41 HUMIRA .............................. 85 HUMIRA PEDIATRIC

CROHN'S START ........... 85 HUMIRA PEN ..................... 85 HUMIRA PEN CROHN'S-

UC-HS START ................ 85 HUMIRA PEN PSORIASIS-

UVEITIS .......................... 85 HUMULIN 70/30 ................. 67 HUMULIN 70/30 KWIKPEN

.......................................... 67 HUMULIN N ....................... 67 HUMULIN N KWIKPEN .... 67 HUMULIN R U-100 ............ 67 HUMULIN R U-500 (CONC)

KWIKPEN........................ 67 HUMULIN R U-500

(CONCENTRATED) ....... 67 HYCAMTIN ........................ 15 hydralazine ........................... 38 hydrochlorothiazide .............. 38 hydrocodone-acetaminophen 26 hydrocodone-chlorpheniramine

.......................................... 99 hydrocodone-cpm-

pseudoephed ..................... 99 hydrocodone-homatropine .... 99 hydrocodone-ibuprofen ........ 26 hydrocortisone .......... 52, 56, 74 hydrocortisone acetate .......... 74 hydrocortisone butyrate ........ 52 hydrocortisone butyr-emollient

.......................................... 52 hydrocortisone valerate ........ 52 hydrocortisone-acetic acid .... 56 hydrocortisone-min oil-wht pet

.......................................... 52

hydrocortisone-pramoxine ... 45, 74

hydromet ............................... 99 hydromorphone ............... 26, 27 hydroxychloroquine .............. 12 hydroxyurea .......................... 15 hydroxyzine hcl .................... 99 hydroxyzine pamoate ............ 99 hyoscyamine sulfate ............. 72 HYQVIA .............................. 82 I ibandronate ........................... 84 IBRANCE ............................. 15 ibuprofen ............................... 29 ibuprofen-oxycodone ............ 27 ICLUSIG .............................. 15 IDHIFA ................................. 16 imatinib ................................. 16 IMBRUVICA ....................... 16 imipramine hcl ...................... 32 imipramine pamoate ............. 32 imiquimod ............................. 79 IMOVAX RABIES VACCINE

(PF) ................................... 82 INCONTROL PEN NEEDLE

.......................................... 63 INCONTROL SUPER THIN

LANCETS ........................ 63 INCONTROL ULTRA THIN

LANCETS ........................ 63 indapamide ........................... 38 INDOCIN ............................. 29 indomethacin ........................ 29 INFANRIX (DTAP) (PF) ..... 82 INFINITY TEST STRIPS .... 59 INJECT EASE LANCETS ... 63 INLYTA ............................... 16 insulin syringe-needle u-100 61 INSUPEN ............................. 63 INTELENCE .......................... 7 INTRON A ........................... 80 introvale ................................ 90 INVACARE LANCETS ...... 63 INVEGA SUSTENNA ......... 32 INVEGA TRINZA ............... 32 INVIRASE ............................. 7 INVOKAMET ...................... 70 INVOKAMET XR ............... 70 INVOKANA ......................... 70 IPOL ..................................... 82

121

ipratropium bromide ..... 55, 102 ipratropium-albuterol ......... 102 irbesartan .............................. 38 irbesartan-hydrochlorothiazide

.......................................... 38 IRESSA ................................ 16 IROSPAN 24/6 ................... 108 ISENTRESS ....................... 7, 8 ISENTRESS HD .................... 7 isibloom ................................ 90 isometh-dichloral-

acetaminophn ................... 23 isoniazid ............................... 12 ISORDIL .............................. 44 isosorbide dinitrate ............... 44 isosorbide mononitrate ......... 44 isradipine .............................. 38 ISTALOL ............................. 94 itraconazole ............................ 6 ivermectin ............................. 12 IXIARO (PF) ........................ 82 J JADENU .............................. 53 JAKAFI ................................ 16 jantoven ................................ 42 JANUMET ........................... 70 JANUMET XR ..................... 70 JANUVIA............................. 70 jencycla................................. 87 JENTADUETO .................... 71 JENTADUETO XR.............. 71 JEVANTIQUE LO ............... 87 JINTELI ............................... 87 jolessa ................................... 90 jolivette ................................. 87 juleber ................................... 90 junel 1.5/30 (21) ................... 90 junel 1/20 (21) ...................... 90 junel fe 1.5/30 (28) ............... 90 junel fe 1/20 (28) .................. 90 junel fe 24 ............................. 90 K KADIAN .............................. 27 kaitlib fe................................ 90 KALETRA ............................. 8 KALYDECO ...................... 102 kariva (28) ............................ 90 k-effervescent ..................... 106 kelnor 1/35 (28) .................... 90 KEPPRA............................... 19

KEPPRA XR ........................ 20 KETEK ................................. 12 ketoconazole ..................... 6, 49 ketoprofen ............................. 29 ketorolac ......................... 29, 96 KEVEYIS ............................. 24 kimidess (28) ........................ 90 KINERET ............................. 80 KINRIX (PF) ........................ 82 kionex ................................... 74 kionex (with sorbitol) ........... 74 KISQALI .............................. 16 KITABIS PAK ..................... 12 KLONOPIN.......................... 20 klor-con .............................. 106 klor-con 10 ......................... 106 klor-con 8 ........................... 106 klor-con m10 ...................... 106 klor-con m15 ...................... 106 klor-con m20 ...................... 106 klor-con sprinkle................. 106 KLOR-CON/25 .................. 106 klor-con/ef .......................... 106 KOATE ................................ 42 KOATE-DVI ........................ 42 KOGENATE FS ................... 42 KORLYM ............................. 69 K-PHOS NO 2 .................... 105 K-PHOS ORIGINAL ......... 105 k-phos-neutral ..................... 106 KRISTALOSE...................... 74 k-tab .................................... 106 K-TAB ................................ 106 kurvelo .................................. 90 KUVAN................................ 69 KYNAMRO ......................... 43 L l norgest/e.estradiol-e.estrad . 90 labetalol ................................ 38 LACRISERT ........................ 95 lactulose ................................ 74 LAMICTAL ......................... 20 LAMICTAL ODT ................ 20 LAMICTAL ODT STARTER

(BLUE) ............................. 20 LAMICTAL ODT STARTER

(GREEN) .......................... 20 LAMICTAL ODT STARTER

(ORANGE) ....................... 20

LAMICTAL STARTER (BLUE) KIT ..................... 20

LAMICTAL STARTER (GREEN) KIT .................. 20

LAMICTAL STARTER (ORANGE) KIT ............... 20

LAMICTAL XR ................... 20 LAMICTAL XR STARTER

(BLUE) ............................. 20 LAMICTAL XR STARTER

(GREEN) .......................... 20 LAMICTAL XR STARTER

(ORANGE) ....................... 20 lamivudine .............................. 8 lamivudine-zidovudine ........... 8 lamotrigine ............................ 20 lancets ................................... 63 LANCETS,THIN .................. 63 LANOXIN ............................ 40 lansoprazole .......................... 77 lanthanum ............................. 74 LANTUS .............................. 68 LANTUS SOLOSTAR ......... 68 larin 1.5/30 (21) .................... 90 larin 1/20 (21) ....................... 90 larin 24 fe .............................. 90 larin fe 1.5/30 (28) ................ 90 larin fe 1/20 (28) ................... 90 larissia ................................... 90 LASTACAFT ....................... 95 latanoprost ............................ 96 LATUDA .............................. 32 laxaclear ................................ 74 laxative peg 3350 .................. 74 layolis fe ............................... 90 leena 28 ................................. 90 leflunomide ........................... 85 LENVIMA ............................ 16 lessina ................................... 90 letrozole ................................ 16 leucovorin calcium ............... 14 LEUKERAN ......................... 16 leuprolide .............................. 16 levalbuterol hcl ................... 102 LEVATOL ............................ 38 LEVEMIR ............................ 68 LEVEMIR FLEXTOUCH .... 68 levetiracetam ................... 20, 21 levobunolol ........................... 94 levocarnitine ......................... 53

122

levocarnitine (with sugar)..... 53 levocetirizine ........................ 99 levofloxacin .................... 13, 93 levonest (28) ......................... 90 levonorgestrel-ethinyl estrad

.................................... 90, 91 levonorg-eth estrad triphasic 91 levora 0.15/30 (28) ............... 91 levora-28............................... 91 levorphanol tartrate .............. 27 levothyroxine ........................ 71 levoxyl .................................. 71 LEXIVA ................................. 8 LIALDA ............................... 74 LIBERTY TEST .................. 59 lidocaine ............................... 48 lidocaine hcl ......................... 48 lidocaine hcl-hydrocortison ac

.................................... 48, 74 lidocaine viscous .................. 48 lidocaine-hydrocortisone-aloe

.......................................... 74 lidocaine-prilocaine .............. 48 LIFESHIELD BLUNT

CANNULA ...................... 63 lillow..................................... 91 lindane .................................. 52 linezolid ................................ 12 LINZESS .............................. 74 liothyronine .......................... 71 LIPOFEN ............................. 43 lisinopril ............................... 38 lisinopril-hydrochlorothiazide

.......................................... 38 LITE TOUCH LANCETS ... 63 lithium carbonate .................. 32 lithium citrate ....................... 32 LIVALO ............................... 43 lomedia 24 fe ........................ 91 LONSURF ............................ 16 lopinavir-ritonavir .................. 8 lopreeza ................................ 87 lorazepam ....................... 32, 33 lorazepam intensol................ 32 lorcet (hydrocodone) ............ 27 lorcet hd ................................ 27 lorcet plus ............................. 27 LORTAB ELIXIR ................ 27 loryna (28) ............................ 91 losartan ................................. 38

losartan-hydrochlorothiazide 38 LOTEMAX .......................... 97 lovastatin .............................. 43 low-ogestrel (28) .................. 91 loxapine succinate ................ 33 ludent fluoride .................... 108 LUMIGAN ........................... 96 LUPANETA PACK (1

MONTH) .......................... 88 LUPANETA PACK (3

MONTH) .......................... 88 lutera (28) ............................. 91 LYNPARZA ......................... 16 LYRICA ............................... 21 LYSODREN ......................... 16 lyza ....................................... 87 M macnatal cn dha .................. 108 malathion .............................. 52 maprotiline............................ 33 MAR-COF BP ...................... 99 MAR-COF CG ..................... 99 marlissa ................................. 91 MARPLAN .......................... 33 MATULANE........................ 16 matzim la .............................. 38 MAVYRET ............................ 8 M-CLEAR WC................... 100 meclizine .............................. 74 meclofenamate...................... 29 MEDISENSE THIN

LANCETS ........................ 64 MEDLANCE PLUS

LANCETS ........................ 64 MEDLANCE PLUS SPECIAL

BLADE ............................. 64 medroxyprogesterone ........... 87 mefenamic acid..................... 29 mefloquine ............................ 12 megestrol .............................. 16 MEKINIST ........................... 16 melodetta 24 fe ..................... 91 meloxicam ............................ 29 melphalan ............................. 16 memantine ............................ 24 MEMANTINE...................... 24 MENACTRA (PF) ............... 82 MENEST .............................. 87 MENHIBRIX (PF) ............... 82

MENOMUNE - A/C/Y/W-135 .......................................... 82

MENOMUNE - A/C/Y/W-135 (PF) ................................... 82

MENOSTAR ........................ 87 MENVEO A-C-Y-W-135-DIP

(PF) ................................... 82 meperidine ............................ 27 MEPHYTON ........................ 42 meprobamate ........................ 25 MEPRON ............................. 12 mercaptopurine ..................... 16 mesalamine ........................... 74 MESNEX .............................. 14 MESTINON ......................... 25 metadate er ............................ 33 metaproterenol .................... 102 metaxalone ............................ 25 metformin ............................. 71 methadone ............................. 27 methadone intensol ............... 27 methadose ............................. 27 methamphetamine ................. 33 methazolamide ...................... 96 methenamine hippurate ........ 14 methenamine mandelate ....... 14 methimazole ......................... 57 methocarbamol ..................... 25 methotrexate sodium ............ 16 methotrexate sodium (pf) ..... 16 methoxsalen .......................... 46 methscopolamine .................. 72 methyclothiazide ................... 38 methyldopa ........................... 38 methyldopa-

hydrochlorothiazide .......... 38 methylphenidate hcl .............. 33 methylprednisolone .............. 56 methyltestosterone ................ 69 metipranolol .......................... 94 metoclopramide hcl .............. 74 metolazone ............................ 38 METOPIRONE .................... 53 metoprolol succinate ............. 38 metoprolol ta-hydrochlorothiaz

.......................................... 38 metoprolol tartrate ................ 38 metronidazole ........... 12, 47, 88 mexiletine ............................. 35 MIACALCIN ....................... 69

123

mibelas 24 fe ........................ 91 miconazole-3 ........................ 88 MICRO BLOOD GLUCOSE

.......................................... 59 MICRO THIN LANCETS ... 64 MICRODOT BLOOD

GLUCOSE SYSTEM ....... 59 microgestin 1.5/30 (21) ........ 91 microgestin 1/20 (21) ........... 91 microgestin fe 1.5/30 (28) .... 91 microgestin fe 1/20 (28) ....... 91 MICROLET LANCET ......... 64 midazolam ............................ 33 midodrine ............................. 53 MIGERGOT ......................... 23 miglitol ................................. 71 MILK OF MAGNESIA

CONCENTRATED .......... 75 millipred ............................... 56 millipred dp .......................... 56 mimvey ................................. 87 mimvey lo ............................. 87 MINI ULTRA-THIN II ........ 64 MINITRAN .......................... 44 MINIVELLE ........................ 87 minocycline .......................... 14 minoxidil .............................. 38 MIOCHOL-E ....................... 95 MIRCERA ............................ 78 mirtazapine ........................... 33 MIRVASO ........................... 47 misoprostol ........................... 77 M-M-R II (PF) ...................... 82 modafinil .............................. 33 MODERIBA......................... 78 MODERIBA DOSE PACK . 78 moexipril .............................. 38 moexipril-hydrochlorothiazide

.......................................... 38 molindone ............................. 33 mometasone .................. 52, 102 MONOCLATE-P ................. 42 monoject 0.9% sodium

chloride ............................. 53 MONOJECT BLOOD

COLLECTION ................. 64 MONOJECT HYPODERMIC

NEEDLES ........................ 64 MONOJECT MEDICATION

TRANSF NDL ................. 64

monoject prefill advanced ns 53 monoject prefill saline flush . 53 MONOLET THIN LANCETS

.......................................... 64 mono-linyah.......................... 91 mononessa (28)..................... 91 montelukast ........................ 102 MONUROL .......................... 14 morphine ............................... 27 morphine concentrate ........... 27 MOVIPREP .......................... 75 MOXEZA ............................. 93 moxifloxacin ................... 13, 93 MOZOBIL ............................ 78 MULTAQ ............................. 35 MULTI-DRAW NEEDLE ... 64 MULTI-VIT WITH

FLUORIDE-IRON ......... 108 multi-vitamin with fluoride 108 multivitamins with fluoride 109 multivit-fluor (vit e acetate) 109 mupirocin.............................. 49 mupirocin calcium ................ 49 mvc-fluoride ....................... 109 MYALEPT ........................... 69 mycophenolate mofetil ......... 16 mycophenolate sodium ......... 16 MYGLUCOHEALTH .......... 59 MYGLUCOHEALTH

LANCETS ........................ 64 MYLERAN .......................... 16 mynatal ............................... 109 mynatal advance ................. 109 mynatal plus ....................... 109 mynatal-z ............................ 109 mynate 90 plus.................... 109 myorisan ............................... 47 MYRBETRIQ .................... 104 MYSOLINE ......................... 21 MYTESI ............................... 72 myzilra .................................. 91 N nabumetone .......................... 29 nadolol .................................. 38 nadolol-bendroflumethiazide 38 naftifine ................................ 49 NAFTIN ............................... 49 naloxone ............................... 30 naltrexone ............................. 30

NAMENDA TITRATION PAK .................................. 24

NAMENDA XR ................... 24 NAMZARIC ................... 24, 25 naphazoline ........................... 98 naproxen ............................... 29 naproxen sodium .................. 29 naratriptan ............................. 23 NARCAN ............................. 30 NATACYN ........................... 93 natazia ................................... 91 nateglinide ............................ 71 NATPARA ........................... 69 natural b-100 complex ........ 109 nature-throid ......................... 71 NEBUPENT ......................... 12 necon 0.5/35 (28) .................. 91 necon 1/50 (28) ..................... 91 necon 10/11 (28) ................... 91 necon 7/7/7 (28) .................... 91 needles, huber disposable ..... 64 nefazodone ............................ 33 neomycin .............................. 12 neomycin-bacitracin-poly-hc 96 neomycin-bacitracin-

polymyxin ......................... 94 neomycin-polymyxin b gu .... 53 neomycin-polymyxin b-

dexameth ........................... 96 neomycin-polymyxin-

gramicidin ......................... 94 neomycin-polymyxin-hc . 56, 97 neo-polycin ........................... 94 neo-polycin hc ...................... 97 NERLYNX ........................... 16 NEULASTA ......................... 78 NEUPOGEN ......................... 78 NEUPRO .............................. 23 NEURONTIN ....................... 21 NEUTEK 2TEK TEST

STRIPS ............................. 59 NEVANAC ........................... 96 nevirapine ............................... 8 newgen ................................ 109 NEXAVAR ........................... 17 NEXIUM PACKET .............. 77 niacin .................................... 43 NIACOR ............................... 43 nicardipine ............................ 38 NICODERM CQ .................. 54

124

NICORETTE ........................ 54 nicotine ................................. 54 nicotine (polacrilex) ............. 54 NICOTROL .......................... 55 NICOTROL NS.................... 55 nifedical xl ............................ 38 nifedipine ........................ 38, 39 nikki (28) .............................. 91 nilutamide ............................. 17 nimodipine ............................ 39 NINLARO ............................ 17 nisoldipine ............................ 39 nitro-bid ................................ 44 NITRO-DUR ........................ 44 nitrofurantoin ........................ 14 nitrofurantoin macrocrystal .. 14 nitrofurantoin monohyd/m-

cryst .................................. 14 nitroglycerin ......................... 44 NITROSTAT ........................ 44 nitro-time .............................. 44 NITYR .................................. 53 nizatidine .............................. 77 nodolor ................................. 23 NOKOR NEEDLE ............... 64 nora-be .................................. 87 NORDITROPIN FLEXPRO 78 noreth-ethinyl estradiol-iron . 91 norethindrone (contraceptive)

.......................................... 87 norethindrone acetate ........... 87 norethindrone ac-eth estradiol

.................................... 87, 91 norethindrone-e.estradiol-iron

.......................................... 91 norgestimate-ethinyl estradiol

.......................................... 91 norgestrel-ethinyl estradiol ... 91 norlyda .................................. 87 norlyroc ................................ 87 normal saline flush ............... 54 NORPACE CR ..................... 35 NORTHERA ........................ 54 nortrel 0.5/35 (28) ................ 91 nortrel 1/35 (21) ................... 91 nortrel 1/35 (28) ................... 92 nortrel 7/7/7 (28) .................. 92 nortriptyline .......................... 33 NORVIR................................. 8

NOVA MAX GLUCOSE TEST ................................ 60

NOVA SAFETY LANCETS 64 NOVA SUREFLEX

LANCETS ........................ 64 NOVOFINE 32..................... 64 NOVOFINE AUTOCOVER 64 NOVOFINE PLUS ............... 64 NOVOLIN 70/30 .................. 68 NOVOLIN N ........................ 68 NOVOLIN R ........................ 68 NOVOLOG .......................... 68 NOVOLOG FLEXPEN ........ 68 NOVOLOG MIX 70-30 ....... 68 NOVOLOG MIX 70-30

FLEXPEN ........................ 68 NOVOLOG PENFILL ......... 68 NOVOPEN ECHO ............... 64 NOVOSEVEN RT ............... 42 NOXAFIL .............................. 6 np thyroid ............................. 71 nts step 1 ............................... 55 NUCYNTA .......................... 28 NUCYNTA ER .................... 27 NUEDEXTA ........................ 25 NUPLAZID .......................... 33 nuvaring ................................ 88 nyamyc ................................. 49 nyata ..................................... 49 nystatin ............................. 6, 49 nystatin-triamcinolone .......... 49 nystop ................................... 49 O obstetrix dha ....................... 109 OCALIVA ............................ 75 ocella .................................... 92 octreotide acetate .................. 17 ODEFSEY .............................. 8 ODOMZO ............................ 17 OFEV.................................. 102 ofloxacin ................... 13, 56, 94 ogestrel (28) .......................... 92 olanzapine ............................. 33 olanzapine-fluoxetine ........... 33 olmesartan ............................ 39 olmesartan-amlodipin-

hcthiazid ........................... 39 olmesartan-

hydrochlorothiazide .......... 39 olopatadine ..................... 55, 95

OMECLAMOX-PAK ........... 77 omeprazole ........................... 77 ON CALL EXPRESS TEST

STRIP ............................... 60 ON CALL LANCET ............ 64 ON CALL PLUS LANCET . 64 ON CALL PLUS TEST STRIP

.......................................... 60 ON CALL VIVID TEST

STRIP ............................... 60 ondansetron ........................... 75 ondansetron hcl ..................... 75 one daily prenatal ............... 109 ONETOUCH ULTRA TEST

.......................................... 60 ONETOUCH ULTRASOFT

LANCETS ........................ 64 ONETOUCH VERIO ........... 60 ONFI ..................................... 21 ONMEL .................................. 6 ON-THE-GO LANCETS ..... 64 OPSUMIT ........................... 102 OPTIUM EZ ......................... 60 OPTIUM TEST .................... 60 OPTUMRX ........................... 60 ORALAIR ............................ 82 ORAVIG ................................. 6 ORENCIA ............................ 85 ORENITRAM ...................... 39 ORFADIN ............................ 54 ORKAMBI ......................... 102 orphenadrine citrate .............. 25 orsythia ................................. 92 oseltamivir .............................. 8 OSMOPREP ......................... 75 OSPHENA ............................ 88 OTEZLA ............................... 85 OTEZLA STARTER ............ 85 OTOVEL .............................. 56 oxandrolone .......................... 69 oxaprozin .............................. 29 oxazepam .............................. 33 oxcarbazepine ....................... 21 oxiconazole ........................... 50 OXTELLAR XR .................. 21 oxybutynin chloride ............ 105 oxycodone ............................. 28 oxycodone-acetaminophen ... 28 oxycodone-aspirin ................ 28 OXYCONTIN ...................... 28

125

oxymorphone ........................ 28 oyster shell calcium-vit d3 . 106 P pacerone ............................... 35 paliperidone .......................... 33 pantoprazole ......................... 77 paregoric ............................... 72 paricalcitol ............................ 69 paromomycin ........................ 12 paroxetine hcl ....................... 33 PATADAY ........................... 95 PAXIL .................................. 33 PAZEO ................................. 95 PCE....................................... 11 PEDIARIX (PF) ................... 83 PEDVAX HIB (PF) .............. 83 peg 3350-electrolytes ........... 75 peg-3350 with flavor packs .. 75 PEGANONE ........................ 21 PEGASYS ............................ 79 PEGASYS PROCLICK ....... 79 peg-electrolyte soln .............. 75 PEGINTRON ....................... 79 PEGINTRON REDIPEN ..... 79 peg-prep ................................ 75 PEN NEEDLE ...................... 64 pen needle, diabetic .............. 64 penicillin v potassium........... 13 PENTACEL (PF) ................. 83 PENTASA ............................ 75 pentazocine-naloxone ........... 28 PENTIPS .............................. 64 pentoxifylline ....................... 42 PERFOROMIST ................ 103 perindopril erbumine ............ 39 periogard............................... 55 permethrin ............................ 52 perphenazine......................... 33 perphenazine-amitriptyline... 34 perry prenatal...................... 109 PHARMACIST CHOICE .... 60 PHASEAL PROTECTOR ... 64 phenadoz............................... 99 phenazopyridine ................. 106 phenelzine............................. 34 phenergan ............................. 99 phenobarbital ........................ 21 phenoxybenzamine ............... 39 phenylephrine hcl ................. 98 PHENYTEK ......................... 21

phenytoin .............................. 21 phenytoin sodium extended .. 21 philith.................................... 92 PHOSLYRA ......................... 75 phospha 250 neutral............ 106 PHOSPHATE LAXATIVE .. 75 PHOSPHOLINE IODIDE .... 94 PICATO................................ 46 pilocarpine hcl .......... 54, 55, 95 pimozide ............................... 34 pimtrea (28) .......................... 92 pindolol ................................. 39 pioglitazone .......................... 71 pioglitazone-glimepiride ...... 71 pioglitazone-metformin ........ 71 pirmella ................................. 92 piroxicam .............................. 29 PLEGRIDY .......................... 79 PNEUMOVAX 23 ............... 83 pnv 29-1 .............................. 109 pnv ob+dha ......................... 109 pnv-dha ............................... 109 pnv-dha + docusate ............. 109 pnv-omega .......................... 109 pnv-select............................ 109 pnv-vp-u ............................. 109 PODOCON ........................... 45 podofilox .............................. 46 POLY HUB NEEDLE.......... 65 polycin .................................. 94 polyethylene glycol 3350 ..... 75 polymyxin b sulf-trimethoprim

.......................................... 94 POLY-VI-FLOR ................ 109 POLY-VI-FLOR WITH IRON

........................................ 109 poly-vitamin with iron ........ 109 POMALYST ........................ 79 portia ..................................... 92 potassium bicarb and chloride

........................................ 107 potassium bicarb-citric acid 107 potassium chloride .............. 107 potassium citrate ................. 105 potassium citrate-citric acid 105 POTASSIUM HYDROXIDE

.......................................... 45 POTIGA ............................... 21 pr natal 400 ......................... 109 pr natal 400 ec .................... 109

pr natal 430 ......................... 109 pr natal 430 ec .................... 109 PRADAXA ........................... 42 PRALUENT PEN ................. 43 PRALUENT SYRINGE ....... 43 pramcort ................................ 75 pramipexole .......................... 23 prasugrel ............................... 42 pravastatin ............................. 43 prazosin ................................. 39 PRECISION PCX PLUS TEST

.......................................... 60 PRECISION PCX TEST ...... 60 PRECISION POINT OF

CARE TEST ..................... 60 PRECISION Q-I-D TEST .... 60 PRECISION XTRA TEST ... 60 PRED MILD ......................... 97 PRED-G ................................ 97 PRED-G S.O.P. .................... 97 prednicarbate ........................ 52 prednisolone ......................... 56 prednisolone acetate ............. 97 prednisolone sodium phosphate

.............................. 56, 57, 97 prednisone ............................. 57 prednisone intensol ............... 57 PREFEST ............................. 87 PREMARIN ................... 87, 88 PREMIUM V10 .................... 60 PREMPHASE ....................... 88 PREMPRO ........................... 88 prena1 chew ........................ 109 prena1 pearl ........................ 109 prena1 true .......................... 110 prenaissance ........................ 110 prenaissance plus ................ 110 prenatabs fa ......................... 110 prenatabs rx ........................ 110 prenatal ............................... 110 prenatal complete ................ 110 prenatal low iron ................. 110 prenatal multi-dha (algal oil)

........................................ 110 prenatal one daily ............... 110 prenatal plus ........................ 110 prenatal plus (calcium carb)110 prenatal vitamin .................. 110 prenatal vitamin plus low iron

........................................ 110

126

prenatal vits96-iron fum-folic ........................................ 110

prenatal-u ............................ 110 preplus ................................ 110 PREPOPIK ........................... 75 PRESSURE ACTIVATED

LANCETS ........................ 65 pretab .................................. 110 PREVACID SOLUTAB ...... 77 prevalite ................................ 43 PREVIDENT 5000 BOOSTER

PLUS ................................ 55 PREVIDENT 5000 DRY

MOUTH ........................... 55 PREVIDENT 5000 ENAMEL

PROTECT ........................ 55 PREVIDENT 5000

SENSITIVE ...................... 55 previfem ............................... 92 PREVNAR 13 (PF) .............. 83 PREZCOBIX .......................... 8 PREZISTA ............................. 8 PRIFTIN ............................... 12 primaquine ............................ 12 primidone ............................. 21 PRIMSOL............................. 14 PROAIR HFA .................... 103 PROAIR RESPICLICK ..... 103 probenecid ............................ 84 probenecid-colchicine .......... 84 procentra ............................... 34 prochlorperazine ................... 75 prochlorperazine maleate ..... 75 PROCRIT ............................. 78 procto-med hc ....................... 75 procto-pak............................. 75 proctosol hc .......................... 75 proctozone-hc ....................... 75 PROCYSBI ........................ 105 PRODIGY LANCETS ......... 65 PRODIGY NO CODING ..... 60 PRODIGY TWIST TOP

LANCET .......................... 65 PROFILNINE....................... 42 progesterone micronized ...... 88 PROLENSA ......................... 96 PROMACTA ........................ 42 promethazine ........................ 99 promethazine vc ................. 100 promethazine vc-codeine.... 100

promethazine-codeine ........ 100 promethazine-dm ................ 100 promethazine-phenyleph-

codeine............................ 100 promethegan ......................... 99 propafenone .......................... 35 propantheline ........................ 73 proparacaine ......................... 95 propranolol ........................... 39 propranolol-hydrochlorothiazid

.......................................... 39 propylthiouracil .................... 57 PROQUAD (PF)................... 83 PROSTIN VR PEDIATRIC

........................................ 105 protriptyline .......................... 34 PROVENTIL HFA ............. 103 pruclair.................................. 46 PULMICORT FLEXHALER

........................................ 103 pulmosal ............................. 103 PULMOZYME ................... 103 PURIXAN ............................ 17 PYLERA .............................. 77 pyrazinamide ........................ 12 pyridostigmine bromide ....... 25 Q QUADRACEL (PF) ............. 83 quasense................................ 92 quazepam .............................. 34 QUDEXY XR....................... 21 quetiapine ............................. 34 QUILLIVANT XR ............... 34 quinapril................................ 39 quinapril-hydrochlorothiazide

.......................................... 39 quinidine gluconate .............. 35 quinidine sulfate ................... 35 quinine sulfate ...................... 12 QUINTET AC ...................... 60 QVAR ................................. 103 R RABAVERT (PF) ................ 83 rabeprazole ........................... 77 RADIOGARDASE .............. 54 RAGWITEK ......................... 83 rajani ..................................... 92 raloxifene .............................. 84 ramipril ................................. 39 RANEXA ............................. 44

ranitidine hcl ......................... 77 RAPAFLO .......................... 105 RAPAMUNE ........................ 17 rasagiline ............................... 23 RAVICTI .............................. 54 REBETOL ............................ 79 REBIF (WITH ALBUMIN) . 79 REBIF REBIDOSE .............. 79 REBIF TITRATION PACK . 79 reclipsen (28) ........................ 92 RECOMBINATE ................. 42 RECOMBIVAX HB (PF) ..... 83 REFUAH PLUS ................... 60 REGRANEX ........................ 46 RELENZA DISKHALER ...... 8 RELIAMED LANCET ......... 65 RELIAMED SAFETY SEAL

LANCETS ........................ 65 RELION CONFIRM-MICRO

.......................................... 60 RELION NEEDLES ............. 65 RELION PEN NEEDLES .... 65 RELION PRIME TEST

STRIPS ............................. 60 RELION THIN LANCETS .. 65 RELION ULTRA THIN PLUS

LANCETS ........................ 65 RELISTOR ........................... 75 relnate dha .......................... 110 RELPAX ............................... 23 REMODULIN ...................... 39 RENAGEL ........................... 75 rena-vite .............................. 110 rena-vite rx .......................... 110 reno caps ............................. 110 RENVELA ........................... 75 repaglinide ............................ 71 repaglinide-metformin .......... 71 REPATHA PUSHTRONEX 43 REPATHA SURECLICK .... 43 REPATHA SYRINGE ......... 44 reprexain ............................... 28 RESCRIPTOR ........................ 8 reserpine ............................... 39 RESTASIS ............................ 95 RESTASIS MULTIDOSE .... 95 REVATIO ........................... 103 REVEAL TEST STRIP ........ 60 REVLIMID ........................... 79 REYATAZ ............................. 8

127

REZIRA ............................. 100 RIBASPHERE ..................... 79 ribavirin ................................ 79 RIDAURA ............................ 85 rifabutin ................................ 12 RIFAMATE ......................... 12 rifampin ................................ 12 RIFATER ............................. 12 RIGHTEST GL300 LANCETS

.......................................... 65 RIGHTEST GS550 TEST

STRIPS ............................. 60 riluzole .................................. 54 rimantadine ............................. 8 RIOMET............................... 71 risacal-d .............................. 110 risedronate ...................... 54, 84 RISPERDAL CONSTA ....... 34 risperidone ............................ 34 rivastigmine .......................... 25 rivastigmine tartrate.............. 25 rivelsa ................................... 92 RIXUBIS .............................. 42 rizatriptan ............................. 23 ropinirole .............................. 23 rosuvastatin........................... 44 ROTARIX ............................ 83 ROTATEQ VACCINE ........ 83 roweepra ............................... 21 ROZEREM ........................... 34 RUBRACA........................... 17 RUCONEST ....................... 103 rulavite dha ......................... 110 S SABRIL ................................ 21 SAFETY LANCETS ............ 65 SAFETY SEAL LANCETS . 65 SAFETY-LET LANCETS ... 65 safyral ................................... 92 salicylic acid ......................... 46 salicylic acid er-ceramides ... 46 salsalate ................................ 29 SAMSCA ............................. 69 SANDIMMUNE .................. 17 SANTYL .............................. 52 SAPHRIS (BLACK

CHERRY) ........................ 34 SARAFEM ........................... 34 SAVELLA ............................ 85 scopolamine base.................. 75

seb-prev ................................ 45 selegiline hcl ......................... 23 selenium sulfide .................... 45 SELZENTRY ......................... 9 SEMPREX-D ..................... 100 se-natal 19........................... 110 se-natal 19 (with docusate) . 110 SENSIPAR ........................... 69 SEREVENT DISKUS ........ 103 sertraline ............................... 34 se-tan plus ........................... 110 setlakin.................................. 92 sevelamer carbonate ............. 76 sf 55 sf 5000 plus .......................... 55 sharobel ................................ 88 SHINGRIX (PF) ................... 83 SIGNIFOR............................ 17 sildenafil (antihypertensive)

........................................ 103 silver nitrate .......................... 46 silver nitrate applicators ....... 46 silver sulfadiazine ................. 45 SIMBRINZA ........................ 96 SIMPONI.............................. 85 simvastatin ............................ 44 SINGLE-LET ....................... 65 sirolimus ............................... 17 SIRTURO ............................. 12 SKLICE ................................ 52 SMART SENSE LANCETS 65 SMART SENSE TEST

STRIPS ............................. 60 SMARTEST LANCET ........ 65 SMARTEST TEST............... 60 sodium chlor 0.9% bacteriostat

.......................................... 54 sodium chloride ............ 54, 103 sodium chloride 0.9 % .......... 54 sodium phenylbutyrate ......... 54 sodium polystyrene sulfonate

.......................................... 76 SOFT TOUCH LANCETS .. 65 SOLESTA ............................ 76 SOLIQUA 100/33 ................ 68 SOLTAMOX ........................ 17 SOLUS V2 LANCETS ........ 65 SOMAVERT ........................ 69 SORBITOL .......................... 53 SORBITOL-MANNITOL .... 53

sorine .................................... 35 sotalol ................................... 35 sotalol af ............................... 35 SOTYLIZE ........................... 36 spinosad ................................ 52 SPIRIVA RESPIMAT ........ 103 SPIRIVA WITH

HANDIHALER .............. 103 spironolactone ....................... 39 spironolacton-hydrochlorothiaz

.......................................... 39 SPORANOX ........................... 6 sprintec (28) .......................... 92 SPRITAM ............................. 21 SPRIX ................................... 29 SPRYCEL ............................. 17 sps (with sorbitol) ................. 76 sronyx ................................... 92 ssd ......................................... 45 SSKI ..................................... 57 sss 10-5 ................................. 47 STAMARIL (PF) .................. 83 stavudine ................................. 9 STELARA ............................ 45 STERILANCE TL ................ 65 STIMATE ............................. 69 STIOLTO RESPIMAT ....... 103 STIVARGA .......................... 17 STRATTERA ....................... 34 STRESS FORMULA ......... 110 STRESS FORMULA WITH

IRON .............................. 110 STRESS FORMULA WITH

IRON(SULF) .................. 110 STRIBILD .............................. 9 STRIVERDI RESPIMAT .. 103 SUBOXONE ........................ 18 SUCRAID ............................. 76 sucralfate ............................... 77 sulfacetamide sodium ..... 45, 98 sulfacetamide sodium (acne) 49 sulfacetamide sodium-sulfur 48 sulfacetamide sod-sulfur-urea

.......................................... 48 sulfacetamide-prednisolone .. 98 sulfadiazine ........................... 13 sulfamethoxazole-trimethoprim

.......................................... 13 SULFAMYLON ................... 49 sulfasalazine ......................... 76

128

sulfatrim ............................... 13 sulindac................................. 29 sumatriptan ........................... 23 sumatriptan succinate ..... 23, 24 SUMAVEL DOSEPRO ....... 24 SUPER THIN LANCETS .... 65 SUPRAX .............................. 10 SUPREP BOWEL PREP KIT

.......................................... 76 SURE COMFORT LANCETS

.......................................... 65 SURE COMFORT PEN

NEEDLE .......................... 65 SURE-FINE PEN NEEDLES

.......................................... 65 SURE-LANCE ..................... 65 SURE-TEST EASYPLUS

MINI ................................. 60 SURE-TOUCH LANCET .... 65 SURGUARD2 SAFETY ...... 65 SUSTIVA ............................... 9 SUTENT............................... 17 syeda ..................................... 92 SYLATRON......................... 79 SYMBICORT..................... 103 SYMLINPEN 120 ................ 71 SYMLINPEN 60 .................. 71 SYNAREL ........................... 69 SYNDROS ........................... 76 SYNERA .............................. 48 SYNTHROID ....................... 71 syrex sodium chloride 0.9 % 54 T TABLOID ............................ 17 TACLONEX ........................ 45 tacrolimus ....................... 17, 46 TAFINLAR .......................... 17 TAGRISSO .......................... 17 TAMIFLU .............................. 9 tamoxifen .............................. 17 tamsulosin........................... 105 TARCEVA ........................... 17 TARGRETIN ....................... 17 tarina fe 1/20 (28) ................. 92 taron-c dha .......................... 110 taron-prex prenatal-dha ...... 110 TASIGNA ............................ 17 tazarotene ............................. 48 TAZORAC ........................... 48 taztia xt ................................. 39

TECFIDERA ........................ 79 TECHLITE LANCETS ........ 65 TECHLITE PEN NEEDLE .. 66 TEGRETOL ......................... 21 TEGRETOL XR ................... 21 TEKTURNA ........................ 39 TEKTURNA HCT ............... 39 TELCARE TEST STRIPS ... 60 telmisartan ............................ 39 telmisartan-amlodipine ......... 39 telmisartan-hydrochlorothiazid

.......................................... 39 temazepam ............................ 34 temozolomide ....................... 17 tencon ................................... 28 TENIVAC (PF) .................... 83 tenofovir disoproxil fumarate . 9 terazosin................................ 39 terbinafine hcl ......................... 6 terbutaline ........................... 103 terconazole............................ 88 TEST N'GO TEST ............... 60 testosterone ..................... 69, 70 testosterone cypionate .......... 69 testosterone enanthate........... 69 tetanus,diphtheria tox ped(pf)

.......................................... 83 tetanus-diphtheria toxoids-td 83 tetrabenazine ......................... 25 tetracaine hcl......................... 95 tetracaine hcl (pf).................. 95 tetracycline ........................... 14 THALOMID ......................... 17 theochron ............................ 103 theophylline ................ 103, 104 thermazene............................ 45 THIOLA ............................... 54 thioridazine ........................... 34 thiothixene ............................ 34 thrivite-19 ........................... 111 thyroid (pork) ....................... 72 THYROLAR-1 ..................... 72 THYROLAR-1/2 .................. 72 THYROLAR-1/4 .................. 72 THYROLAR-2 ..................... 72 THYROLAR-3 ..................... 72 tiagabine ............................... 22 ticlopidine ............................. 42 tilia fe .................................... 92 timolol maleate ............... 39, 94

TIMOPTIC OCUDOSE (PF) .......................................... 94

tinidazole .............................. 12 tis-u-sol pentalyte ................. 53 TIVICAY ................................ 9 tizanidine .............................. 25 tl gard rx ............................. 111 TOBRADEX ........................ 97 TOBRADEX ST ................... 97 tobramycin ............................ 94 tobramycin in 0.225 % nacl .. 12 tobramycin-dexamethasone .. 97 TOBREX .............................. 94 tolazamide ............................. 71 tolbutamide ........................... 71 tolcapone ............................... 23 tolmetin ................................. 30 tolterodine ........................... 105 TOPAMAX .......................... 22 TOPCARE UNIVERSAL1

LANCET .......................... 66 topiramate ............................. 22 TOPIRAMATE .................... 22 torsemide .............................. 40 TOUJEO SOLOSTAR ......... 68 TRACLEER ....................... 104 TRADJENTA ....................... 71 tramadol ................................ 28 tramadol-acetaminophen ...... 28 trandolapril ........................... 40 trandolapril-verapamil .......... 40 tranexamic acid ..................... 88 TRANSDERM-SCOP .......... 76 tranylcypromine .................... 34 TRAVATAN Z ..................... 96 trazodone .............................. 34 TRECATOR ......................... 12 TRELEGY ELLIPTA ......... 104 TRESIBA FLEXTOUCH U-

100 .................................... 68 TRESIBA FLEXTOUCH U-

200 .................................... 68 tretinoin ................................. 48 tretinoin (chemotherapy) ...... 17 tretinoin microspheres .......... 48 tri femynor ............................ 92 triamcinolone acetonide .. 52, 55 triamterene-hydrochlorothiazid

.......................................... 40 triazolam ............................... 34

129

tricon................................... 111 tri-estarylla ........................... 92 trifluoperazine ...................... 34 trifluridine............................. 94 TRIGLIDE ........................... 44 trihexyphenidyl..................... 23 tri-legest fe............................ 92 TRILEPTAL......................... 22 tri-linyah ............................... 92 tri-lo-estarylla ....................... 92 tri-lo-marzia .......................... 92 tri-lo-sprintec ........................ 92 trilyte with flavor packets ..... 76 trimethobenzamide ............... 76 trimethoprim ......................... 14 trimipramine ......................... 34 trinatal gt ............................ 111 trinatal rx 1 ......................... 111 trinate .................................. 111 trinessa (28) .......................... 92 trinessa lo.............................. 92 TRINTELLIX....................... 34 tri-previfem (28) ................... 92 tri-sprintec (28) ..................... 92 tri-tabs dha .......................... 111 TRIUMEQ .............................. 9 triveen-duo dha ................... 111 triveen-one .......................... 111 triveen-prx rnf .................... 111 TRI-VI-FLOR .................... 111 tri-vit with fluoride and iron

........................................ 111 tri-vitamin with fluoride ..... 111 trivora (28)............................ 92 TROKENDI XR ................... 22 tropicamide ........................... 95 trospium .............................. 105 TRUE METRIX GLUCOSE

TEST STRIP .................... 60 TRUEPLUS LANCETS ....... 66 TRUETEST TEST STRIPS . 60 TRUETRACK TEST ........... 60 TRULICITY ......................... 71 TRUMENBA ....................... 83 trust natal dha ..................... 111 TRUVADA ............................ 9 TUDORZA PRESSAIR ..... 104 tussigon............................... 100 TWINRIX (PF) .............. 83, 84 TYBOST ................................ 9

TYKERB .............................. 17 TYMLOS.............................. 85 TYPHIM VI ......................... 84 TYVASO ............................ 104 TYVASO INSTITUTIONAL

START KIT .................... 104 TYVASO REFILL KIT...... 104 TYVASO STARTER KIT . 104 TYZEKA ................................ 9 U UCERIS ................................ 76 UDAMIN SP ...................... 111 ULESFIA.............................. 53 ULORIC ............................... 84 ULTICARE PEN NEEDLE . 66 ULTILET BASIC LANCETS

.......................................... 66 ULTILET CLASSIC

LANCETS ........................ 66 ULTILET LANCETS........... 66 ULTILET PEN NEEDLE .... 66 ULTILET SAFETY

LANCETS ........................ 66 ULTIMA TEST STRIPS ...... 60 ultimatecare one ................. 111 ultimatecare one nf ............. 111 ULTRA THIN LANCETS ... 66 ULTRA THIN PLUS

LANCETS ........................ 66 ULTRA TLC LANCETS ..... 66 ULTRALANCE LANCETS 66 ULTRA-THIN II INS PEN

NEEDLES ........................ 66 ULTRATRAK ...................... 61 ULTRATRAK ULTIMATE 61 ULTRAVATE X .................. 52 UNIFINE PENTIPS ............. 66 UNIFINE PENTIPS PLUS .. 66 UNILET COMFORTOUCH

LANCET .......................... 66 UNILET EXCELITE II

LANCET .......................... 66 UNILET EXCELITE

LANCET .......................... 66 UNILET GP LANCET ......... 66 UNILET LANCET ............... 66 UNISTIK 3 EXTRA LANCET

.......................................... 66 UNISTIK CZT LANCET ..... 66 UNISTIK SAFETY .............. 66

UNISTIK TOUCH LANCETS .......................................... 66

UNISTRIP1 TEST STRIP .... 61 unithroid ............................... 72 UNIVERSAL 1 LANCETS . 66 ursodiol ................................. 76 UTIBRON NEOHALER .... 104 V valacyclovir ............................ 9 VALCHLOR ........................ 46 valganciclovir ......................... 9 valproic acid ......................... 22 valproic acid (as sodium salt)

.......................................... 22 valsartan ................................ 40 valsartan-hydrochlorothiazide

.......................................... 40 vancomycin ........................... 14 vandazole .............................. 88 VANOXIDE-HC .................. 48 VAQTA (PF) ........................ 84 VARIVAX (PF) .................... 84 VAXCHORA VACCINE ..... 84 v-c forte .............................. 111 VELETRI ............................. 40 velivet triphasic regimen (28)

.......................................... 93 VELPHORO ......................... 76 vemavite-prx-2 ................... 111 VEMLIDY .............................. 9 VENCLEXTA ...................... 17 VENCLEXTA STARTING

PACK ............................... 17 venlafaxine ........................... 34 VENTAVIS ........................ 104 VENTOLIN HFA ............... 104 verapamil .............................. 40 verdrocet ............................... 28 VEREGEN ........................... 46 veripred 20 ............................ 57 VERZENIO .......................... 17 VESICARE ......................... 105 vestura (28) ........................... 93 VEXOL ................................. 97 VGO 20 ................................ 66 VGO 30 ................................ 66 VGO 40 ................................ 67 VIBERZI .............................. 76 VIBRAMYCIN .................... 14 vicodin .................................. 28

130

vicodin es.............................. 28 vicodin hp ............................. 28 VIDEX 2 GRAM PEDIATRIC

............................................ 9 VIDEX 4 GRAM PEDIATRIC

............................................ 9 vienva ................................... 93 vigabatrin .............................. 22 VIGAMOX........................... 94 VIIBRYD ....................... 34, 35 VIMPAT............................... 22 vinate care .......................... 111 vinate dha ........................... 111 vinate ii ............................... 111 vinate m .............................. 111 vinate one ........................... 111 vinate ultra .......................... 111 viorele (28) ........................... 93 VIRACEPT ............................ 9 VIREAD ................................. 9 virt-advance ........................ 111 virt-c dha ............................ 111 virt-nate .............................. 111 virt-nate dha........................ 111 virt-phos 250 neutral .......... 107 virt-pn ................................. 111 virt-pn dha .......................... 111 virt-pn plus ......................... 111 virt-select ............................ 112 VIRTUSSIN AC ................ 100 virt-vite ............................... 112 virt-vite gt ........................... 112 VIRT-VITE PLUS ............. 112 vit b complex-folic acid...... 112 vitamin d3 ........................... 112 vitamins a,c,d and fluoride . 112 VITEKTA............................... 9 VIVOTIF .............................. 84 VIVOTIF BERNA VACCINE

.......................................... 84 vol-nate ............................... 112 vol-plus ............................... 112 vol-tab rx ............................ 112 voriconazole ........................... 6 VOSEVI ................................. 9 VOTRIENT .......................... 17 vp-ch plus ........................... 112 vp-ch-pnv ........................... 112 vp-ggr-b6 ............................ 112 vp-heme ob ......................... 112

vp-heme one ....................... 112 VRAYLAR ........................... 35 VUSION ............................... 50 vyfemla (28) ......................... 93 VYVANSE ........................... 35 W warfarin ................................ 42 water for irrigation, sterile .... 54 WAVESENSE JAZZ ........... 61 WAVESENSE PRESTO ...... 61 WELCHOL .......................... 44 wera (28)............................... 93 westhroid .............................. 72 women's gentle laxative(bisac)

.......................................... 76 women's laxative (bisacodyl)76 WP THYROID ..................... 72 wymzya fe ............................ 93 X XALKORI ............................ 18 XARELTO ........................... 42 XELJANZ ............................ 86 XELJANZ XR ...................... 86 XIFAXAN ............................ 12 XIGDUO XR ........................ 71 XOPENEX HFA ................ 104 XTANDI ............................... 18 xulane ................................... 88 XULTOPHY 100/3.6 ........... 68 xylon 10 ................................ 28 XYNTHA ............................. 42 XYNTHA SOLOFUSE ........ 42 XYREM................................ 35 Y YF-VAX (PF) ....................... 84 yuvafem ................................ 88 Z zafirlukast ........................... 104 zaleplon ................................ 35 zamicet.................................. 28 zarah ..................................... 93 ZARONTIN.......................... 22 ZARXIO ............................... 78 zatean-ch ............................. 112 zatean-pn dha ...................... 112 zatean-pn plus ..................... 112 ZAVESCA............................ 70 zebutal .................................. 28 ZEJULA ............................... 18 ZELAPAR ............................ 23

ZELBORAF ......................... 18 zenatane ................................ 48 zenchent (28) ........................ 93 zenchent fe ............................ 93 ZENPEP ............................... 76 zenzedi .................................. 35 ZENZEDI ............................. 35 ZIAGEN ................................. 9 zidovudine .............................. 9 zileuton ............................... 104 ZINBRYTA .......................... 79 zingiber ............................... 112 ZIOPTAN (PF) ..................... 96 ziprasidone hcl ...................... 35 ZIRGAN ............................... 94 ZMAX .................................. 11 ZODRYL AC 25 ................ 100 ZODRYL AC 30 ................ 100 ZODRYL AC 35 ................ 100 ZODRYL AC 40 ................ 100 ZODRYL AC 50 ................ 100 ZODRYL AC 60 ................ 100 ZODRYL AC 80 ................ 100 ZODRYL DAC 25 ............. 100 ZODRYL DAC 30 ............. 100 ZODRYL DAC 35 ............. 100 ZODRYL DAC 40 ............. 100 ZODRYL DAC 50 ............. 100 ZODRYL DAC 60 ............. 100 ZODRYL DAC 80 ............. 100 ZODRYL DEC 25 .............. 100 ZODRYL DEC 30 .............. 100 ZODRYL DEC 35 .............. 100 ZODRYL DEC 40 .............. 100 ZODRYL DEC 50 .............. 100 ZODRYL DEC 60 .............. 100 ZODRYL DEC 80 .............. 100 ZOLINZA ............................. 18 zolmitriptan ........................... 24 zolpidem ............................... 35 ZOMIG ................................. 24 ZONEGRAN ........................ 22 zonisamide ............................ 22 ZONTIVITY ......................... 42 ZORTRESS .......................... 18 ZOSTAVAX (PF) ................ 84 zovia 1/35e (28) .................... 93 zovia 1/50e (28) .................... 93 ZOVIRAX ............................ 50 Z-TUSS AC ........................ 100

131

ZUBSOLV ........................... 18 ZYBAN ................................ 55

ZYDELIG ............................. 18 ZYKADIA ............................ 18

ZYPREXA RELPREVV ...... 35 ZYTIGA ............................... 18

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