2016 Comprehensive Formulary

Transcription

2016 Comprehensive Formulary
Coventry Health Care (list of covered drugs) B3
PLEASE READ: This document contains information about the drugs we cover in this plan.
This formulary was updated on 10/1/2016.
For more recent information or other questions, please contact Coventry Health Care at
1-844-741-8423 or for TTY: 711. October 1 to February 14, you can call us 8 a.m. to 8 p.m., 7 days
a week. From February 15 to September 30, we’re here 8 a.m. to 8 p.m., Monday through Friday, or
visit http://www.formulary.coventry-medicare.com.
Formulary ID Number: 16246 Version 18
Y0001_1085_5407_Final_22 Accepted 7/2015
16246CVH
Table of contents
2
Mail-order Pharmacy
3
What is the Coventry Health Care
Comprehensive Formulary?
4
Can the Formulary (drug list) change?
4
How do I use the Formulary?
4
What are generic drugs?
5
Are there any restrictions on my coverage?
5
What if my drug is not on the Formulary?
5
How do I request an exception to the Coventry
Health Care Formulary?
6
What do I do before I can talk to my doctor about
changing my drugs or requesting an exception?
6
For more information
7
Coventry Health Care Formulary
8
Drug tier copay levels
9
Formulary key
10
Drug list
10
Index
83
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with
State Medicaid programs. Enrollment in our plans depends on contract renewal.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by service area.
Mail-order Pharmacy
For mail order, you can get prescription drugs
shipped to your home through the network
mail-order delivery program, which is called
Aetna Rx Home Delivery. Typically, mail-order
drugs arrive within 7 to 14 days. You can call
1-844-741-8423 (TTY: 711) if you do not receive
your mail-order drugs within this timeframe.
This information is available for free in other
languages. Please call our member services
number at 1-844-741-8423 (TTY: 711).
October 1 to February 14, you can call us
8 a.m. to 8 p.m., 7 days a week. From
February 15 to September 30, we’re here
8 a.m. to 8 p.m., Monday through Friday.
Esta información está disponible en forma gratuita
en otros idiomas. Llame a nuestro número de
servicio al cliente al 1-844-741-8423 (TTY: 711).
Del 1 de octubre al 14 de febrero puede llamarnos
de 8 a. m. a 8 p. m., los siete días de la semana.
Del 15 de febrero al 30 de septiembre estamos
disponibles de lunes a viernes de 8 a. m. a 8 p. m.
When this drug list (formulary) refers to “we,” “us”,
or “our,” it means Coventry Health Care. When it
refers to “plan” or “our plan,” it means Coventry.
This document includes a list of the drugs
(formulary) for our plan which is current as of
10/1/2016. For an updated formulary, please
contact us. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
This information is not a complete description
of benefits. Contact the plan for more
information. Limitations, copayments, and
restrictions may apply.
You must generally use network pharmacies to
use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/
coinsurance may change on January 1, 2017, and
from time to time during the year.
Note to existing members: This formulary has
changed since last year. Please review this
document to make sure that it still contains
the drugs you take.
3
What is the Coventry Health Care
Comprehensive Formulary?
A formulary is a list of covered drugs selected by
our plan in consultation with a team of health care
providers, which represents the prescription
therapies believed to be a necessary part of a
quality treatment program. We will generally cover
the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is
filled at our network pharmacy, and other plan
rules are followed. For more information on how
to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary
(drug list) change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning
of the year, we will not discontinue or reduce
coverage of the drug during the 2016 coverage
year except when a new, less expensive generic
drug becomes available or when new adverse
information about the safety or effectiveness
of a drug is released. Other types of formulary
changes, such as removing a drug from our
formulary, will not affect members who are
currently taking the drug. It will remain available
at the same cost-sharing for those members
taking it for the remainder of the coverage year.
We feel it is important that you have continued
access for the remainder of the coverage year
to the formulary drugs that were available when
you chose our plan, except for cases in which
you can save additional money or we can ensure
your safety.
4
If we remove drugs from our formulary, or add
prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to
a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who
take the drug. The enclosed formulary is current
as of 10/1/2016. To get updated information about
the drugs covered by our plan, please contact us.
Our contact information appears on the front and
back cover pages.
In the event of any CMS-approved, mid-year
non-maintenance formulary changes, the
formularies will be updated monthly and posted
on our website.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
Medical Condition
The formulary begins on page 10. The drugs
in this formulary are grouped into categories
depending on the type of medical conditions that
they are used to treat. For example, drugs used
to treat a heart condition are listed under the
category, “Cardiovascular Agents”. If you know
what your drug is used for, look for the category
name in the list that begins on page 10. Then
look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 83. The Index provides an
alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic
drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the
page number where you can find coverage
information. Turn to the page listed in the Index
and find the name of your drug in the first column
of the list.
What are generic drugs?
Our plan covers both brand-name drugs and
generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the
brand-name drug. Generally, generic drugs cost
less than brand-name drugs.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 10. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted online documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our
contact information, along with the date we last
updated the formulary, appears on the front and
back cover pages.
You can ask us to make an exception to these
restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See
the section, “How do I request an exception to the
Coventry Health Care formulary?” on page 6
for information about how to request an exception.
What if my drug is not
on the Formulary?
Are there any restrictions on
my coverage?
If your drug is not included in this formulary
(list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
If you learn that our plan does not cover your
drug, you have two options:
• Prior Authorization: Our plan requires you
or your physician to get prior authorization for
certain drugs. This means that you will need
to get approval from us before you fill your
prescriptions. If you don’t get approval, we
may not cover the drug.
• Quantity Limits: For certain drugs, our plan
limits the amount of the drug that we will cover.
For example, our plan provides 30 tablets per
30 days per prescription for candesartan. This
may be in addition to a standard one-month or
three-month supply.
• You can ask Member Services for a list of
similar drugs that are covered by our plan.
When you receive the list, show it to your
doctor and ask him or her to prescribe a
similar drug that is covered by our plan.
• You can ask us to make an exception and
cover your drug. See below for information
about how to request an exception.
• Step Therapy: In some cases, our 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.
5
How do I request an
exception to the Coventry
Health Care Formulary?
What do I do before I can talk to
my doctor about changing my
drugs or requesting an exception?
You can ask us to make an exception to our
coverage rules. There are several types of
exceptions that you can ask us to make.
As a new or continuing member in our plan, you
may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For
example, you may need a prior authorization from
us before you can fill your prescription. You should
talk to your doctor to decide if you should switch to
an appropriate drug that we cover or request a
formulary exception so that we will cover the drug
you take. While you talk to your doctor to determine
the right course of action for you, we may cover
your drug in certain cases during the first 90 days
you are a member of our plan.
• You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level,
and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a
lower cost-sharing level if this drug is not on
the specialty tier. If approved this would lower
the amount you must pay for your drug.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, our plan limits the amount of the drug
that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover
a greater amount.
Generally, we will only approve your request for an
exception if the alternative drugs included on the
plan’s formulary, the lower cost-sharing drug or
additional utilization restrictions would not be as
effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you request
a formulary, tiering or utilization restriction
exception you should submit a statement from
your prescriber or physician supporting your
request. Generally, we must make our decision
within 72 hours of getting your prescriber’s
supporting statement. You can request an
expedited (fast) exception if you or your doctor
believe that your health could be seriously
harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must
give you a decision no later than 24 hours after
we get a supporting statement from your doctor
or other prescriber.
6
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have
a prescription written for fewer days) when you go
to a network pharmacy. After your first 30-day
supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we
will allow you to refill your prescription until we have
provided you with at least 91 and up to a 98-day
transition supply, consistent with dispensing
increment, (unless you have a prescription written
for fewer days). We will cover more than one refill
of these drugs for the first 90 days you are a
member of our plan. If you need a drug that is not
on our formulary or if your ability to get your drugs
is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a
formulary exception.
If you experience a change in your setting of
care (such as being discharged or admitted to
a long term care facility), your physician or
pharmacy can request a one-time prescription
override. This one-time override will provide you
with temporary coverage (up to a 30-day supply)
for the applicable drug(s).
For more information
For more detailed information about our plan’s
prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about our plan, please
contact us. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227)
24 hours a day/7 days a week. TTY users
should call 1-877-486-2048. Or, visit
http://www.medicare.gov.
7
Coventry Health Care Formulary
The comprehensive formulary that begins on
page 10 provides coverage information about
the drugs covered by our plan. If you have trouble
finding your drug in the list, turn to the Index that
begins on page 83.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., LEVEMIR)
and generic drugs are listed in lowercase italics
(e.g., candesartan).
The information in the Requirements/Limits
column tells you if our plan has any special
requirements for coverage of your drug. The
following abbreviations are used:
QL
Quantity Limits
PA
Prior Authorization
ST
Step Therapy
LA
Limited Access
MO
Mail-order Delivery
B/D
Part B vs. D Prior Authorization
QL: Quantity Limits. For certain drugs, our plan
limits the amount of the drug that we will cover.
For example, our plan provides 30 tablets per
30 days per prescription for candesartan.
PA: Prior Authorization. Our plan requires you or
your provider to get prior authorization for certain
drugs. This means that you will need to get approval
from us before you fill your prescriptions. If you don’t
get approval, we may not cover the drug.
ST: Step Therapy. In some cases, our 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.
8
LA: Limited Access. These prescriptions may be
available only at certain pharmacies. For more
Information, consult your Pharmacy Directory
or call Coventry Health Care at 1-844-741-8423
(TTY: 711). October 1 to February 14, you can call
us 8 a.m. to 8 p.m., 7 days a week. From February
15 to September 30, we’re here 8 a.m. to 8 p.m.,
Monday through Friday.
MO: Mail Order. For certain kinds of drugs, you
can use Aetna Rx Home Delivery. Generally, the
drugs available through mail order are drugs that
you take on a regular basis, for a chronic or
long-term medical condition. The drugs available
through our plan’s mail-order service are marked
as “mail-order” drugs or “MO” in our drug list. For
more information, consult your Pharmacy Directory
or call Coventry Health Care at 1-844-741-8423
(TTY: 711). October 1 to February 14, you can call
us 8 a.m. to 8 p.m., 7 days a week. From February
15 to September 30, we’re here 8 a.m. to 8 p.m.,
Monday through Friday.
B/D: Part B versus Part D. This prescription drug
has a Part B versus Part D administrative prior
authorization requirement. This drug may be
covered under Medicare Part B or D depending
upon the circumstances. Information may need to
be submitted describing the use and setting of the
drug to make the determination.
Drug tier copay levels This 2016 comprehensive formulary is a listing of
brand-name and generic drugs. The Coventry
Health Care 2016 formulary covers many of the
drugs identified by Medicare as Part D drugs, and
your copay may differ depending upon the tier at
which the drug resides.
The copay tiers for covered prescription
medications are listed below. Copay amounts and
coinsurance percentages for each tier vary by
plan. Consult your plan’s Summary of Benefits or
Evidence of Coverage for your applicable copays
and coinsurance amounts.
Copay tier
Type of drug
Tier 1
Generic drugs
Tier 2
Preferred Brand drugs
Tier 3
Non-Preferred Brand drugs
Tier 4
Specialty drugs
Our plan, in some instances, combines higher
cost generic drugs on brand tiers. Refer to the drug
list to determine the tier of coverage for each drug
you take.
9
Key*
Drug name
Drug tier
Requirements/Limits
UPPERCASE = Brand-name
prescription drugs
1, 2, 3, 4 = Copay tier level
QL = Quantity Limit
PA = Prior Authorization
ST = Step Therapy
LA = Limited Access
MO = Mail-order Delivery
B/D = Part B vs. Part D Lowercase italics = Generic
medications
Drug name
Drug tier Requirements/Limits
Analgesics
acetaminophen/codeine #3
1
QL (390 EA per 30 days) MO
acetaminophen/codeine soln
1
QL (4500 ML per 30 days) MO
acetaminophen/codeine tabs 300mg; 15mg, 300mg;
60mg
1
ascomp/codeine
2
QL (180 EA per 30 days) PA MO
butalbital compound/codeine
2
QL (180 EA per 30 days) PA
butalbital/acetaminophen/caffeine/codeine
2
butalbital/acetaminophen/caffeine caps
2
butalbital/acetaminophen/caffeine tabs 325mg;
50mg; 40mg
2
butalbital/aspirin/caffeine
2
butalbital/aspirin/caffeine/codeine
2
capacet
2
CELEBREX CAPS 400MG
3
QL (30 EA per 30 days) ST MO
CELEBREX CAPS 100MG, 200MG, 50MG
3
celecoxib caps 400mg
3
celecoxib caps 100mg, 200mg, 50mg
3
codeine sulfate tabs
3
diclofenac potassium
2
MO
diclofenac sodium dr
2
MO
diclofenac sodium er
2
MO
diflunisal tabs
2
MO
duramorph
1
B/D
ENDOCET TABS 325MG; 2.5MG
2
QL (360 EA per 30 days)
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg
3
endodan
3
esgic caps
2
etodolac
1
MO
10 *You can find information on what the symbols and abbreviations on this table mean by going to page 8.
Drug name
etodolac er
2
fenoprofen calcium caps 200mg
2
fenoprofen calcium caps 400mg
2
MO
fenoprofen calcium tabs
2
MO
fentanyl pt72
3
fentanyl citrate oral transmucosal
4
FLECTOR
3
flurbiprofen tabs
1
MO
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml
3
hydrocodone bitartrate/acetaminophen tabs 325mg;
2.5mg
3
hydrocodone bitartrate/acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg; 7.5mg
3
hydrocodone/acetaminophen soln 325mg/15ml;
10mg/15ml
3
QL (5550 ML per 30 days)
hydrocodone/acetaminophen tabs 325mg; 10mg,
325mg; 5mg, 325mg; 7.5mg
3
hydrocodone/ibuprofen
3
hydromorphone hcl liqd
3
hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml,
500mg/50ml
3
B/D MO
hydromorphone hcl immediate release tabs 4mg,
8mg
3
hydromorphone hcl tabs 2mg
3
ibudone tabs 5mg; 200mg
3
ibuprofen susp
1
MO
ibuprofen tabs 400mg, 600mg, 800mg
1
MO
ketoprofen er
3
MO
ketoprofen caps
1
MO
lorcet
3
lorcet hd
3
lorcet plus tabs 325mg; 7.5mg
3
LORTAB ELIX
3
lortab tabs
3
margesic
2
meclofenamate sodium caps
3
MO
meloxicam susp, tabs
1
MO
methadone hcl inj
1
MO
*You can find information on what the symbols and abbreviations on this table mean by going to page 8.
11
Drug name
methadone hcl tabs
1
methadone hcl oral soln
1
methadone hcl conc
1
methadone hcl tbso
1
methadose sugar-free
1
methadose conc
1
methadose tbso
1
morphine sulfate er cp24 120mg
3
morphine sulfate er cp24 45mg, 75mg, 90mg
3
morphine sulfate er cp24 100mg, 10mg, 20mg,
30mg, 50mg, 60mg, 80mg
3
morphine sulfate er tbcr
3
morphine sulfate tabs
1
morphine sulfate inj 0.5mg/ml, 10mg/ml IV,
3
150mg/30ml, 15mg/ml, 1mg/ml IV, 25mg/ml, 2mg/ml,
4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml
B/D
morphine sulfate inj 10mg/ml, 15mg/ml, 1mg/ml PF
3
B/D MO
morphine sulfate oral soln 20mg/5ml
1
morphine sulfate oral soln 100mg/5ml, 20mg/ml
1
morphine sulfate oral soln 10mg/5ml
1
nabumetone
1
MO
nalbuphine hcl inj
3
MO
NAPRELAN TB24 500MG, 750MG
3
ST MO
naproxen dr
1
MO
naproxen sodium tabs 275mg, 550mg
1
MO
naproxen susp, tabs
1
MO
oxaprozin
3
MO
oxycodone hcl conc
3
oxycodone hcl caps
3
oxycodone hcl soln
3
oxycodone hcl immediate release tabs 10mg, 15mg,
20mg, 30mg
3
oxycodone hcl tabs 5mg
3
oxycodone/acetaminophen tabs 325mg; 10mg,
325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg
2
oxycodone/aspirin
3
oxycodone/ibuprofen
3
piroxicam caps
2
MO
Drug name
ROXICET SOLN
2
roxicet tabs
3
sulindac tabs
1
MO
tolmetin sodium
1
MO
tramadol hcl immediate release tabs
1
tramadol hydrochloride/acetaminophen
3
vicodin es tabs 300mg; 7.5mg
3
vicodin hp tabs 300mg; 10mg
3
vicodin tabs 300mg; 5mg
3
VOLTAREN GEL
2
QL (1020 GM per 30 days) MO
zamicet
3
zebutal caps 325mg; 50mg; 40mg
2
glydo
1
MO
lidocaine hcl jelly
2
MO
lidocaine hcl gel 2%
2
MO
lidocaine hcl inj 0.5%, 1.5%
3
lidocaine hcl inj 1%, 2%, 4%
3
MO
lidocaine hcl external soln 4%
2
MO
lidocaine hcl mouth/throat soln 4%
2
lidocaine viscous
2
lidocaine/prilocaine kit
2
lidocaine/prilocaine crea
2
MO
lidocaine oint
2
MO
lidocaine ptch
2
LIDODERM
3
relador pak plus
2
Anesthetics
MO
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium dr
3
MO
buprenorphine hcl/naloxone hcl
2
buprenorphine hcl subl
2
buproban
2
bupropion hcl sr tb12 150mg
2
CHANTIX CONTINUING MONTH PAK
3
CHANTIX STARTING MONTH PAK
3
CHANTIX TABS 0.5MG, 1MG
3
disulfiram tabs
2
MO
13
Drug name
EVZIO
3
MO
naloxone hcl inj
1
MO
naltrexone hcl tabs
2
MO
NARCAN
3
MO
NICOTROL NS
3
SUBOXONE FILM 12MG; 3MG
3
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG;
2MG
3
amikacin sulfate inj
2
MO
amoxicillin
1
MO
amoxicillin/clavulanate potassium
1
MO
amoxicillin/clavulanate potassium er
3
MO
ampicillin sodium inj 10gm, 125mg, 1gm for IV,
250mg, 2gm for IV
1
ampicillin sodium inj 1gm, 2gm, 500mg
1
ampicillin-sulbactam
3
ampicillin caps
1
ampicillin susr 125mg/5ml
1
ampicillin susr 250mg/5ml
1
MO
azithromycin pack, susr, tabs
1
MO
azithromycin inj
3
MO
aztreonam
3
MO
baciim
3
bacitracin inj 50000unit
3
BACTOCILL IN DEXTROSE
3
BICILLIN L-A
3
MO
cefaclor
2
MO
cefaclor er
2
MO
cefadroxil
1
MO
cefazolin
3
cefazolin sodium/dextrose
3
cefazolin sodium inj 100gm, 1gm for IV, 1gm; 5%,
20gm, 300gm
3
cefazolin sodium inj 10gm, 1gm, 500mg
3
MO
cefdinir
3
MO
cefditoren pivoxil tabs 400mg
3
cefditoren pivoxil tabs 200mg
3
Antibacterials
MO
MO
MO
MO
Drug name
cefepime/dextrose
3
cefepime inj 1gm/50ml, 2gm/100ml, 2gm/50ml; 5%
3
cefepime inj 1gm, 2gm
3
MO
cefixime
3
MO
cefotaxime sodium inj 10gm, 2gm, 500mg
3
cefotaxime sodium inj 1gm
3
cefotetan
3
cefotetan/dextrose
3
MO
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm, 2gm; 2.2% 3
cefoxitin sodium inj 1gm
3
MO
cefpodoxime proxetil
3
MO
cefprozil
3
MO
ceftazidime/dextrose
3
ceftazidime inj 6gm
3
ceftazidime inj 1gm, 2gm
3
ceftriaxone in iso-osmotic dextrose
3
ceftriaxone sodium 100gm, 1gm i.v.
3
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm,
500mg
3
ceftriaxone/dextrose
3
cefuroxime axetil
1
cefuroxime sodium inj 1.5gm, 7.5gm, 75gm
3
cefuroxime sodium inj 750mg
3
cefuroxime/dextrose inj 750mg; 4.1%
3
cephalexin
1
chloramphenicol sodium succinate
3
ciprofloxacin er
1
MO
ciprofloxacin hcl tabs 100mg, 250mg, 500mg, 750mg 1
MO
MO
MO
MO
MO
MO
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
3
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%
3
MO
ciprofloxacin otic soln, susr
2
MO
ciprofloxacin inj
3
MO
clarithromycin er
1
MO
clarithromycin susr, immediate release tabs
2
MO
clindamax
2
clindamycin hcl caps
2
MO
clindamycin palmitate hcl
2
MO
clindamycin phosphate add-vantage inj 900mg/6ml
3
15
Drug name
clindamycin phosphate in d5w
3
clindamycin phosphate crea 2%
2
clindamycin phosphate inj 150mg/ml, 300mg/2ml,
9000mg/60ml
3
clindamycin phosphate inj 600mg/4ml, 900mg/6ml
3
MO
colistimethate sodium
3
PA MO
CUBICIN
4
DALVANCE
4
dicloxacillin sodium
1
MO
DIFICID
4
MO
doxy 100
3
MO
doxycycline hyclate dr
3
MO
doxycycline hyclate caps, inj, tabs
3
MO
doxycycline monohydrate caps, tabs
3
MO
doxycycline caps 150mg, 75mg
3
MO
doxycycline susr
3
MO
E.E.S. GRANULES
3
MO
ERY-TAB
2
MO
ERYPED 200
3
MO
ERYPED 400
3
MO
ERYTHROCIN LACTOBIONATE
3
ERYTHROCIN STEARATE
3
MO
erythromycin base
1
MO
erythromycin ethylsuccinate tabs
1
MO
erythromycin stearate tabs
1
MO
erythromycin cpep 250mg
2
MO
gentamicin sulfate pediatric
1
MO
MO
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/
1
ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml;
0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/
ml; 0.9%
1
MO
gentamicin sulfate inj 10mg/ml
1
gentamicin sulfate inj 40mg/ml
1
MO
imipenem/cilastatin
2
MO
INVANZ IV 1GM
3
INVANZ INJ 1GM
3
MO
isotonic gentamicin inj 0.8mg/ml; 0.9%
1
MO
Drug name
KETEK TABS 300MG
3
KETEK TABS 400MG
3
levofloxacin in d5w
3
levofloxacin inj 25mg/ml
3
levofloxacin oral soln 25mg/ml
2
MO
levofloxacin tabs 250mg, 500mg, 750mg
2
MO
linezolid susr
4
QL (1800 ML per 28 days) PA
MO
linezolid tabs
4
linezolid inj 600mg/300ml
4
PA
meropenem
3
MO
meropenem/sodium chloride
3
methenamine hippurate
3
METRO IV
1
metronidazole in nacl 0.79%
3
metronidazole vaginal
2
MO
metronidazole caps 375mg
2
MO
metronidazole tabs 250mg, 500mg
2
MO
minocycline hcl caps
1
MO
morgidox 1x100mg caps
3
morgidox 1x50mg
3
morgidox 2x100mg caps
3
MOXATAG
3
NAFCILLIN
3
nafcillin sodium inj 10gm, 1gm, 2gm for i.v.
3
nafcillin sodium inj 2gm
3
NALLPEN ISO-OSMOTIC IN DEXTROSE
3
neomycin sulfate tabs
1
MO
nitrofurantoin macrocrystals
3
MO
nitrofurantoin monohydrate
3
MO
nitrofurantoin susp
3
MO
ofloxacin tabs 400mg
1
MO
oxacillin sodium inj 10gm, 1gm
3
oxacillin sodium inj 2gm
3
MO
paromomycin sulfate
3
MO
PCE
3
MO
penicillin g potassium inj 20000000unit, 5000000unit 3
MO
3
MO
penicillin g procaine
MO
MO
MO
MO
17
Drug name
penicillin g sodium
3
penicillin v potassium
1
piperacillin sodium/tazobactam sodium
3
piperacillin/tazobactam inj 4gm; 0.5gm
3
SIVEXTRO INJ
4
SIVEXTRO TABS
4
MO
streptomycin sulfate inj
3
MO
sulfadiazine tabs
1
MO
sulfamethoxazole/trimethoprim
1
MO
sulfamethoxazole/trimethoprim ds
1
MO
sulfatrim pediatric
1
SUPRAX CAPS
3
SUPRAX CHEW 100MG
3
SUPRAX CHEW 200MG
3
SUPRAX SUSR 500MG/5ML
3
SUPRAX SUSR 100MG/5ML, 200MG/5ML
3
SYNERCID
4
tazicef inj 1gm, 2gm, 6gm
3
TEFLARO
3
tetracycline hcl caps
1
MO
tinidazole
3
MO
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/
ml
1
tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml
3
tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml
3
MO
trimethoprim tabs
1
MO
TYGACIL
4
VANCOCIN HCL
4
vancomycin
3
vancomycin hcl in dextrose
3
vancomycin hcl caps
4
VANCOMYCIN HCL INJ 0.9%; 1GM/200ML
3
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg
3
vancomycin hcl inj 500mg
3
MO
vandazole
1
MO
XIFAXAN TABS 200MG
3
XIFAXAN TABS 550MG
4
MO
MO
MO
MO
PA MO
PA MO
Drug name
ZYVOX SUSR
4
MO
ZYVOX INJ 600MG/300ML
4
PA
APTIOM TABS 200MG, 400MG, 800MG
3
APTIOM TABS 600MG
3
BANZEL TABS
3
PA MO
BANZEL SUSP
4
PA MO
BRIVIACT INJ
3
PA
BRIVIACT ORAL SOLN
4
BRIVIACT TABS 10MG, 75MG
4
BRIVIACT TABS 100MG, 25MG, 50MG
4
carbamazepine er
3
MO
carbamazepine chew, susp, tabs
1
MO
CELONTIN
3
MO
clonazepam odt tbdp 1mg
3
clonazepam odt tbdp 2mg
3
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg
3
clonazepam tabs 1mg
2
clonazepam tabs 2mg
2
clonazepam tabs 0.5mg
2
DEPAKOTE ER
3
MO
diazepam gel 10mg, 2.5mg, 20mg
3
MO
DILANTIN CAPS 30MG
3
MO
divalproex sodium
2
MO
divalproex sodium dr
2
MO
divalproex sodium er
2
MO
epitol
1
ethosuximide
3
MO
felbamate
3
MO
fosphenytoin sodium inj 100mg pe/2ml
3
fosphenytoin sodium inj 500mg pe/10ml
3
MO
FYCOMPA SUSP
4
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG
3
FYCOMPA TABS 2MG
3
gabapentin caps, soln, tabs
1
MO
GABITRIL TABS 12MG, 16MG
3
MO
Anticonvulsants
19
Drug name
lamotrigine odt
3
MO
lamotrigine titration
3
MO
lamotrigine immediate release tabs, chew
1
MO
levetiracetam oral soln, immediate release tabs
1
MO
levetiracetam inj 1000mg/100ml; 750mg/100ml,
1500mg/100ml; 540mg/100ml, 500mg/100ml;
820mg/100ml
3
levetiracetam inj 500mg/5ml
3
MO
LYRICA SOLN
3
QL (900 ML per 30 days) PA MO
LYRICA CAPS 225MG, 300MG
3
LYRICA CAPS 100MG, 150MG, 200MG, 25MG,
50MG, 75MG
3
ONFI SUSP
3
MO
ONFI TABS 10MG, 20MG
3
MO
oxcarbazepine
3
MO
PEGANONE
3
MO
phenobarbital tabs
3
phenobarbital elix
3
MO
phenytoin sodium extended
1
MO
phenytoin sodium inj
3
phenytoin chew, susp
1
MO
POTIGA TABS 50MG
3
POTIGA TABS 200MG, 300MG, 400MG
3
primidone tabs
1
MO
roweepra
1
SABRIL
4
SPRITAM TB3D 250MG, 500MG, 750MG
3
SPRITAM TB3D 1000MG
3
MO
TEGRETOL-XR TB12 100MG
3
MO
tiagabine hydrochloride
3
MO
topiramate IR tabs, IR capsule sprinkles
1
MO
valproate sodium inj
3
valproic acid caps, syrp
1
VIMPAT INJ
3
VIMPAT ORAL SOLN
3
MO
VIMPAT TABS 50MG
3
VIMPAT TABS 100MG, 150MG, 200MG
3
PA LA
MO
Drug name
zonisamide
1
MO
donepezil hcl tbdp
2
donepezil hcl tabs 23mg, 5mg
1
donepezil hcl tabs 10mg
1
ergoloid mesylates tabs
2
PA MO
EXELON PT24
2
galantamine hydrobromide soln
3
galantamine hydrobromide cp24
3
galantamine hydrobromide tabs
3
memantine hcl
1
memantine hcl titration pak
1
memantine hydrochloride soln
1
NAMENDA TITRATION PAK
2
NAMENDA XR
2
NAMENDA XR TITRATION PACK
2
NAMENDA SOLN
2
NAMENDA TABS
2
rivastigmine tartrate
3
rivastigmine transdermal system
2
amitriptyline hcl tabs
1
PA MO
amoxapine
1
MO
BRINTELLIX
3
bupropion hcl er
2
bupropion hcl sr tb12 100mg, 150mg, 200mg
2
bupropion hcl xl
2
bupropion hcl tabs
2
citalopram hydrobromide soln
1
citalopram hydrobromide tabs 10mg
1
1
1
clomipramine hcl caps
2
PA MO
CYMBALTA CPEP 20MG, 60MG
3
CYMBALTA CPEP 30MG
3
desipramine hcl tabs
2
MO
desvenlafaxine er tb24 100mg, 50mg
3
QL (30 EA per 30 days) ST
Antidementia Agents
Antidepressants
21
Drug name
doxepin hcl caps, conc
1
PA MO
duloxetine hcl cpep 20mg, 60mg
2
duloxetine hcl cpep 30mg
2
EMSAM
4
escitalopram oxalate soln
3
escitalopram oxalate tabs 20mg
3
escitalopram oxalate tabs 10mg, 5mg
3
FETZIMA
3
FETZIMA TITRATION PACK
3
fluoxetine dr
3
fluoxetine hcl caps, soln, tabs
1
MO
fluvoxamine maleate tabs
3
MO
imipramine hcl tabs
1
PA MO
KHEDEZLA
3
maprotiline hcl
3
MO
MARPLAN
3
MO
mirtazapine
1
MO
mirtazapine odt
3
nefazodone hcl
3
MO
nortriptyline hcl caps, soln
1
MO
olanzapine/fluoxetine
3
OLEPTRO TB24 300MG
3
OLEPTRO TB24 150MG
3
paroxetine hcl immediate release tabs
1
MO
paroxetine hcl er tb24 37.5mg
3
paroxetine hcl er tb24 12.5mg, 25mg
3
PAXIL SUSP
3
MO
perphenazine/amitriptyline
3
MO
phenelzine sulfate
2
MO
PRISTIQ TB24 25MG
3
PRISTIQ TB24 100MG, 50MG
3
protriptyline hcl
3
MO
sertraline hcl conc, tabs
1
MO
SURMONTIL
3
PA MO
tranylcypromine sulfate
3
MO
trazodone hcl tabs
1
MO
trimipramine maleate caps
3
PA MO
Drug name
TRINTELLIX
3
venlafaxine hcl
1
MO
venlafaxine hcl er cp24 37.5mg, 75mg
2
venlafaxine hcl er cp24 150mg
2
venlafaxine hcl er tb24 225mg, 37.5mg, 75mg
3
venlafaxine hcl er tb24 150mg
3
VIIBRYD STARTER PACK
3
VIIBRYD TABS
3
VIIBRYD KIT
3
dronabinol caps 2.5mg, 5mg
3
dronabinol caps 10mg
4
EMEND CAPS 40MG
3
QL (1 EA per 30 days) B/D MO
EMEND PAK 125MG, 80MG
3
granisetron hcl tabs
3
meclizine hcl tabs
1
MO
ondansetron hcl tabs
1
MO
ondansetron hcl oral soln
1
ondansetron hcl inj 40mg/20ml, 4mg/2ml
1
MO
ondansetron odt
1
MO
phenadoz supp 25mg
3
PA
phenadoz supp 12.5mg
3
PA MO
phenergan supp
3
PA
promethazine hcl supp 12.5mg, 25mg, 50mg
3
PA MO
promethegan supp 12.5mg, 25mg
3
PA
promethegan supp 50mg
3
PA MO
TRANSDERM-SCOP
3
MO
ABELCET
4
B/D
AMBISOME
4
B/D
amphotericin b
1
B/D MO
CANCIDAS INJ 50MG
4
CANCIDAS INJ 70MG
4
ciclodan crea, soln
3
ciclopirox
3
MO
ciclopirox nail lacquer
3
MO
ciclopirox olamine crea
3
MO
Antiemetics
Antifungals
MO
23
Drug name
clotrimazole/betamethasone dipropionate
1
MO
clotrimazole crea, soln, troc
1
MO
econazole nitrate crea
2
MO
ERAXIS
4
PA
EXELDERM
3
MO
fluconazole in dextrose
3
fluconazole in nacl
3
fluconazole susr, tabs
2
MO
flucytosine
4
MO
griseofulvin microsize
3
MO
griseofulvin ultramicrosize
3
MO
itraconazole caps
3
PA MO
ketoconazole crea, sham, tabs
1
MO
MENTAX
3
MO
NOXAFIL INJ
4
PA
NOXAFIL SUSP, TBEC
4
PA MO
nyamyc
1
nystatin/triamcinolone
1
MO
nystatin crea, oint, powd, susp, tabs
1
MO
nystop
1
MO
oxiconazole nitrate
3
MO
OXISTAT
3
MO
SPORANOX SOLN
4
PA MO
terbinafine hcl tabs
2
MO
terconazole
1
MO
voriconazole inj
3
voriconazole susr, tabs
4
zazole supp
1
MO
Antigout Agents
allopurinol tabs
1
MO
colchicine caps, tabs
2
MO
COLCRYS
2
MO
probenecid/colchicine
2
MO
probenecid tabs
2
MO
ULORIC
2
ST MO
3
Antimigraine Agents
CAFERGOT
Drug name
dihydroergotamine mesylate inj
2
MO
dihydroergotamine mesylate nasal soln
3
ERGOMAR
2
MIGERGOT
3
MIGRANAL
3
naratriptan hcl
3
rizatriptan benzoate
3
rizatriptan benzoate odt
3
sumatriptan succinate refill inj 6mg/0.5ml
3
sumatriptan succinate refill inj 4mg/0.5ml
3
sumatriptan succinate tabs
2
sumatriptan succinate inj 6mg/0.5ml
3
sumatriptan succinate inj 4mg/0.5ml
3
sumatriptan spray
2
SUMAVEL DOSEPRO
4
QL (4 ML per 30 days) ST MO
zolmitriptan odt
3
zolmitriptan tabs
3
ZOMIG NASAL SPRAY
3
ZOMIG SOLN 2.5MG
3
Antimyasthenic Agents
guanidine hcl
3
MESTINON TIMESPAN
3
MO
MESTINON SYRP
3
MO
pyridostigmine bromide tabs, tbcr
2
MO
Antimycobacterials
CAPASTAT SULFATE
3
cycloserine
3
MO
dapsone tabs
2
MO
ethambutol hcl
3
MO
isoniazid inj
1
isoniazid syrp, tabs
1
MO
PASER
3
MO
PRIFTIN
3
MO
pyrazinamide tabs
3
MO
rifabutin
3
MO
rifampin caps, inj
3
MO
RIFATER
3
MO
25
Drug name
SIRTURO
4
TRECATOR
3
MO
Antineoplastics
ABRAXANE
4
adrucil
3
B/D
AFINITOR
4
AFINITOR DISPERZ
4
ALECENSA
4
ALIMTA
4
PA
ALKERAN TABS
3
B/D MO
amifostine
4
anastrozole tabs
1
ARRANON
4
ARZERRA
4
PA LA
AVASTIN
4
PA
azacitidine
4
PA
BELEODAQ
4
PA LA
BENDEKA
4
bexarotene
4
PA
bicalutamide
2
MO
BICNU
3
BLEO 15K
4
B/D
bleomycin sulfate
3
B/D
BLINCYTO
4
PA LA
BOSULIF
4
PA
BUSULFEX
4
CABOMETYX
4
CAPRELSA TABS 300MG
4
CAPRELSA TABS 100MG
4
carboplatin
3
cisplatin
3
cladribine
1
CLOLAR
4
COMETRIQ KIT 0, 20MG
4
COSMEGEN
4
COTELLIC
4
QL (63 EA per 28 days) PA LA
cyclophosphamide caps
2
B/D MO
MO
B/D
PA
Drug name
cyclophosphamide inj
3
CYRAMZA
4
PA
cytarabine aqueous
3
B/D
dacarbazine
1
DARZALEX
4
daunorubicin hcl
1
DAUNOXOME
4
decitabine
3
DEPOCYT
3
dexrazoxane
3
DOCEFREZ
4
docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml,
200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml,
80mg/8ml
4
doxorubicin hcl
3
doxorubicin hcl liposome
3
DROXIA
3
MO
ELITEK
4
PA
EMCYT
3
MO
EMPLICITI
4
PA
epirubicin hcl inj 200mg/100ml, 50mg/25ml
3
ERBITUX
4
PA
ERIVEDGE
4
ERWINAZE
4
PA
etoposide inj
2
EVOMELA
4
PA
exemestane
3
MO
FARESTON
4
MO
FARYDAK
4
FASLODEX
4
PA
floxuridine
1
B/D
fludarabine phosphate
3
fluorouracil inj 1gm/20ml, 2.5gm/50ml, 5gm/100ml
3
B/D
flutamide
3
MO
FOLOTYN
4
FUSILEV
4
GAZYVA
4
gemcitabine
4
PA LA
B/D
PA LA
27
Drug name
gemcitabine hcl
4
GILOTRIF
4
GLEEVEC TABS 400MG
4
GLEEVEC TABS 100MG
4
GLEOSTINE CAPS 5MG
3
HALAVEN
4
PA
HERCEPTIN
4
PA
HEXALEN
4
MO
hydroxyurea caps
1
MO
IBRANCE
4
ICLUSIG TABS 45MG
4
ICLUSIG TABS 15MG
4
idarubicin hcl
1
ifosfamide
3
ifosfamide/mesna
1
imatinib mesylate tabs 400mg
4
imatinib mesylate tabs 100mg
4
IMBRUVICA
4
INLYTA TABS 5MG
4
INLYTA TABS 1MG
4
INTRON A W/DILUENT
4
PA
INTRON A INJ 10MU/ML, 6000000UNIT/ML
4
PA
IRESSA
4
irinotecan
3
ISTODAX
4
PA
IXEMPRA KIT
4
PA
JAKAFI
4
JEVTANA
4
PA
KADCYLA
4
PA
KEYTRUDA
4
PA LA
LENVIMA 10 MG DAILY DOSE
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
letrozole
3
MO
Drug name
leucovorin calcium inj
3
leucovorin calcium tabs
3
MO
LEUKERAN
3
MO
levoleucovorin calcium
4
levoleucovorin inj 50mg
3
levoleucovorin inj 250mg/25ml
4
lomustine
2
LONSURF TABS 6.14MG; 15MG
4
LONSURF TABS 8.19MG; 20MG
4
LYNPARZA
4
MARQIBO
4
PA
MATULANE
4
MEKINIST TABS 0.5MG
4
MEKINIST TABS 2MG
4
melphalan hydrochloride
4
mercaptopurine tabs
3
mesna
3
MESNEX TABS
3
mitomycin
3
mitoxantrone hcl
2
MUSTARGEN
3
NEXAVAR
4
NILANDRON
4
MO
nilutamide
4
NINLARO
4
NIPENT
4
ODOMZO
4
ONCASPAR
4
OPDIVO
4
oxaliplatin
4
paclitaxel
3
PANRETIN
4
MO
PERJETA
4
PA LA
POMALYST
4
PORTRAZZA
4
PA
PROLEUKIN
4
PURIXAN
4
MO
MO
PA LA
PA
29
Drug name
REVLIMID
4
RITUXAN
4
PA
SOLTAMOX
3
PA MO
SPRYCEL TABS 100MG, 140MG
4
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG
4
STIVARGA
4
SUTENT CAPS 25MG, 37.5MG, 50MG
4
SUTENT CAPS 12.5MG
4
SYLATRON INJ 200MCG, 300MCG, 600MCG
4
PA
SYLATRON 4-PACK INJ 200MCG, 300MCG
4
PA LA
SYLVANT
4
PA
SYNRIBO
4
PA
TABLOID
3
MO
TAFINLAR CAPS 75MG
4
TAFINLAR CAPS 50MG
4
TAGRISSO
4
tamoxifen citrate tabs
1
MO
TARCEVA TABS 25MG
4
TARCEVA TABS 100MG, 150MG
4
TARGRETIN
4
PA
TASIGNA
4
TECENTRIQ
4
PA
TEMODAR INJ
4
B/D
THALOMID CAPS 100MG, 150MG, 50MG
4
THALOMID CAPS 200MG
4
THERACYS
3
thiotepa
4
TICE BCG
3
toposar
2
topotecan hcl
4
TORISEL
4
TREANDA
4
tretinoin caps 10mg
4
MO
TRISENOX
3
PA
TYKERB
4
UVADEX
3
VALCHLOR
4
PA
Drug name
VALSTAR
4
VECTIBIX
4
PA
VELCADE
4
PA
VENCLEXTA STARTING PACK
4
VENCLEXTA TABS 10MG, 50MG
3
VENCLEXTA TABS 100MG
4
vinblastine sulfate
1
B/D
vincasar pfs
3
B/D
vincristine sulfate
3
B/D
vinorelbine tartrate
3
VOTRIENT
4
XALKORI
4
XTANDI
4
YERVOY
4
PA
YONDELIS
4
PA
ZALTRAP INJ 100MG/4ML
4
PA
ZALTRAP INJ 200MG/8ML
4
PA LA
ZANOSAR
3
ZELBORAF
4
ZOLINZA
4
ZYDELIG
4
ZYKADIA
4
ZYTIGA
4
ALBENZA
3
MO
ALINIA
3
MO
atovaquone
4
PA MO
atovaquone/proguanil hcl
3
MO
BILTRICIDE
3
MO
chloroquine phosphate tabs
1
MO
COARTEM
3
MO
DARAPRIM
3
MO
hydroxychloroquine sulfate tabs
1
MO
ivermectin tabs
1
MO
lindane lotn, sham
3
MO
malathion lotn
3
MO
mefloquine hcl
1
MO
Antiparasitics
31
Drug name
MEPRON
4
PA MO
NEBUPENT
3
B/D MO
PENTAM 300
3
MO
permethrin crea
1
MO
primaquine phosphate tabs
2
MO
QUALAQUIN
3
PA MO
quinine sulfate
3
PA MO
STROMECTOL
2
MO
amantadine hcl caps, syrp, tabs
2
MO
APOKYN
4
PA LA
AZILECT
3
benztropine mesylate tabs
2
PA MO
benztropine mesylate inj
3
PA MO
bromocriptine mesylate caps, tabs
2
MO
carbidopa/levodopa
1
MO
carbidopa/levodopa er
2
MO
carbidopa/levodopa odt
1
MO
carbidopa/levodopa/entacapone
3
MO
carbidopa tabs
2
MO
entacapone
3
MO
MIRAPEX ER
2
NEUPRO
3
pramipexole dihydrochloride IR tabs
2
MO
pramipexole dihydrochloride er
2
MO
ropinirole hcl immediate release tabs
1
MO
RYTARY
3
MO
selegiline hcl caps, tabs
2
MO
trihexyphenidyl hcl
1
PA MO
ABILIFY DISCMELT TBDP 15MG
3
ABILIFY DISCMELT TBDP 10MG
3
ABILIFY MAINTENA
3
MO
ABILIFY INJ
3
MO
ABILIFY ORAL SOLN
3
ADASUVE
3
aripiprazole odt tbdp 15mg
3
Antiparkinson Agents
Antipsychotics
Drug name
aripiprazole odt tbdp 10mg
3
aripiprazole tabs
3
aripiprazole soln
3
ARISTADA
3
chlorpromazine hcl inj, tabs
3
clozapine
2
clozapine odt
2
compazine supp
3
compro
3
MO
FANAPT
3
FANAPT TITRATION PACK
3
QL (16 EA per 365 days) ST
FAZACLO
3
ST
fluphenazine decanoate inj
2
MO
fluphenazine hcl conc, elix, inj, tabs
1
MO
GEODON INJ
3
MO
haloperidol decanoate
3
MO
haloperidol lactate
3
MO
haloperidol conc, tabs
1
MO
INVEGA SUSTENNA
3
MO
INVEGA TRINZA
3
INVEGA TB24 1.5MG, 3MG, 9MG
3
INVEGA TB24 6MG
3
LATUDA
3
loxapine succinate
3
MO
MOLINDONE HYDROCHLORIDE TABS 25MG
2
2
2
NUPLAZID
4
olanzapine odt
3
olanzapine inj
3
MO
olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg
3
olanzapine tabs 2.5mg
3
ORAP
3
MO
paliperidone er tb24 1.5mg, 3mg, 9mg
2
paliperidone er tb24 6mg
2
perphenazine tabs
3
MO
pimozide
3
MO
MO
33
Drug name
prochlorperazine sup
3
MO
prochlorperazine edisylate inj
3
MO
prochlorperazine maleate tabs
1
MO
quetiapine fumarate tabs 200mg
3
quetiapine fumarate tabs 25mg
3
quetiapine fumarate tabs 300mg, 400mg
3
quetiapine fumarate tabs 100mg, 50mg
3
REXULTI
3
RISPERDAL CONSTA
3
MO
risperidone odt tbdp 4mg
3
risperidone odt tbdp 1mg, 2mg
3
risperidone odt tbdp 0.25mg, 0.5mg, 3mg
3
risperidone soln
1
MO
risperidone tabs 4mg
1
risperidone tabs 1mg, 2mg
1
risperidone tabs 0.25mg, 0.5mg, 3mg
1
SAPHRIS
3
SEROQUEL XR TB24 50MG
2
SEROQUEL XR TB24 150MG, 200MG
2
SEROQUEL XR TB24 300MG, 400MG
2
thioridazine hcl tabs
3
PA MO
thiothixene
1
MO
trifluoperazine hcl tabs
3
MO
VERSACLOZ
4
ST
VRAYLAR CPPK
3
VRAYLAR CAPS
4
ziprasidone hcl
3
ZYPREXA RELPREVV INJ 405MG
3
ZYPREXA RELPREVV INJ 210MG, 300MG
3
baclofen tabs
2
MO
dantrolene sodium caps
3
MO
tizanidine hcl tabs
1
MO
abacavir
3
MO
abacavir sulfate/lamivudine/zidovudine
4
MO
acyclovir sodium inj 1000mg, 50mg/ml
3
B/D
Antispasticity Agents
Antivirals
Drug name
acyclovir sodium inj 500mg
3
B/D MO
acyclovir caps, susp, tabs
1
MO
acyclovir oint
3
MO
adefovir dipivoxil
2
APTIVUS SOLN
4
APTIVUS CAPS
4
MO
ATRIPLA
4
BARACLUDE SOLN
3
BARACLUDE TABS
4
COMPLERA
4
CRIXIVAN
2
MO
DENAVIR
3
MO
DESCOVY
4
didanosine
3
MO
EDURANT
4
EMTRIVA
3
MO
entecavir
4
EPCLUSA
4
EPIVIR HBV SOLN
3
MO
EPIVIR SOLN
3
MO
EPZICOM
4
MO
EVOTAZ
4
famciclovir tabs 125mg, 250mg
3
famciclovir tabs 500mg
3
foscarnet sodium
3
B/D
FUZEON
4
ganciclovir inj
1
B/D
GENVOYA
4
HARVONI
4
INTELENCE TABS 25MG
3
INTELENCE TABS 100MG, 200MG
4
INTRON A INJ 18MU, 50MU
4
PA LA
INVIRASE CAPS
3
MO
INVIRASE TABS
4
MO
ISENTRESS PACK
2
ISENTRESS TABS
4
ISENTRESS CHEW 25MG
2
35
Drug name
ISENTRESS CHEW 100MG
4
KALETRA SOLN
3
KALETRA TABS 200MG; 50MG
3
KALETRA TABS 100MG; 25MG
3
lamivudine
2
MO
lamivudine/zidovudine
4
MO
LEXIVA SUSP
3
MO
LEXIVA TABS
4
MO
moderiba tabs
2
nevirapine
3
MO
nevirapine er
3
MO
NORVIR
3
MO
ODEFSEY
4
PEG-INTRON REDIPEN
4
PA
PEGINTRON
4
PA
PREZCOBIX
4
PREZISTA SUSP
4
MO
PREZISTA TABS 75MG
3
MO
PREZISTA TABS 150MG, 600MG, 800MG
4
MO
RELENZA DISKHALER
3
RESCRIPTOR
2
MO
RETROVIR IV INFUSION
3
REYATAZ
4
ribasphere caps
3
ribasphere tabs 200mg
3
ribavirin
2
rimantadine hcl
1
MO
SELZENTRY TABS 300MG
4
SELZENTRY TABS 150MG
4
SOVALDI
4
stavudine
3
MO
STRIBILD
4
SUSTIVA
3
MO
TAMIFLU SUSR
3
TAMIFLU CAPS 30MG
3
TAMIFLU CAPS 45MG, 75MG
3
TIVICAY TABS 10MG
3
MO
Drug name
TIVICAY TABS 25MG
4
TIVICAY TABS 50MG
4
TRIUMEQ
4
TRUVADA TABS 133MG; 200MG
4
TRUVADA TABS 100MG; 150MG, 167MG; 250MG,
200MG; 300MG
4
TYBOST
2
TYZEKA
3
valacyclovir hcl
2
MO
VALCYTE
4
MO
valganciclovir
4
MO
VIDEX PEDIATRIC
3
MO
VIRACEPT
4
MO
VIRAMUNE XR TB24 100MG
3
MO
VIRAMUNE SUSP
3
MO
VIRAZOLE
4
VIREAD
3
MO
VITEKTA
4
ZIAGEN SOLN
3
MO
zidovudine
2
MO
alprazolam IR tabs 0.25mg, 0.5mg
1
alprazolam IR tabs 1mg, 2mg
1
buspirone hcl tabs
1
MO
clorazepate dipotassium tabs 15mg
3
clorazepate dipotassium tabs 3.75mg, 7.5mg
3
diazepam intensol
3
MO
diazepam inj 5mg/ml
3
diazepam oral soln 1mg/ml
3
diazepam tabs 10mg, 2mg, 5mg
3
duloxetine hcl cpep 40mg
2
lorazepam intensol
2
lorazepam tabs
2
lorazepam inj 4mg/ml
2
lorazepam inj 2mg/ml
2
temazepam caps 15mg, 30mg
1
triazolam
1
Anxiolytics
37
Drug name
Bipolar Agents
EQUETRO
3
MO
lithium
1
MO
lithium carbonate er
1
MO
lithium carbonate caps, tabs
1
MO
acarbose
1
MO
ACTOPLUS MET
3
ACTOPLUS MET XR
3
MO
ACTOS
3
AVANDAMET TABS 1000MG; 2MG, 500MG; 4MG
3
AVANDARYL TABS 4MG; 8MG
3
AVANDARYL TABS 1MG; 4MG, 2MG; 4MG
3
AVANDIA TABS 8MG
3
AVANDIA TABS 2MG, 4MG
3
BYDUREON
3
glimepiride
1
MO
glipizide er
1
MO
glipizide xl
1
MO
glipizide/metformin hcl
1
MO
glipizide tabs
1
MO
GLUCAGEN DIAGNOSTIC
1
GLUCAGEN HYPOKIT
1
GLUCAGON EMERGENCY KIT
1
glyburide micronized
3
PA MO
glyburide/metformin hcl
3
PA MO
glyburide tabs
3
PA MO
HUMALOG
1
MO
HUMALOG KWIKPEN INJ 100UNIT/ML
1
MO
humalog kwikpen inj 200unit/ml
1
MO
HUMALOG MIX 50/50
1
MO
HUMALOG MIX 50/50 KWIKPEN
1
MO
HUMALOG MIX 75/25
1
MO
HUMALOG MIX 75/25 KWIKPEN
1
MO
HUMULIN 70/30
1
MO
HUMULIN 70/30 KWIKPEN
1
MO
HUMULIN N
1
MO
Blood Glucose Regulators
Drug name
HUMULIN N KWIKPEN
1
MO
HUMULIN R
1
MO
HUMULIN R U-500 (CONCENTRATED)
1
MO
HUMULIN R U-500 KWIKPEN
1
MO
INVOKAMET
2
INVOKANA TABS 300MG
2
INVOKANA TABS 100MG
2
JANUMET
2
MO
JANUMET XR
2
MO
JANUVIA
2
MO
JARDIANCE
3
JENTADUETO
2
MO
JENTADUETO XR
2
MO
KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG;
5MG
3
KOMBIGLYZE XR TB24 1000MG; 2.5MG
3
KORLYM
4
LANTUS
1
MO
LANTUS SOLOSTAR
1
MO
LEVEMIR
1
MO
LEVEMIR FLEXTOUCH
1
MO
metformin hcl er
1
MO
metformin hcl tabs
1
MO
nateglinide
1
MO
NOVOLIN 70/30
1
MO
novolin 70/30 relion
1
MO
NOVOLIN N
1
MO
novolin n relion
1
MO
NOVOLIN R
1
MO
novolin r relion
1
MO
NOVOLOG
1
MO
NOVOLOG FLEXPEN
1
MO
NOVOLOG MIX 70/30
1
MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
1
MO
NOVOLOG PENFILL
1
MO
ONGLYZA
3
pioglitazone hcl
1
pioglitazone hcl-glimepiride
1
39
Drug name
pioglitazone hcl/metformin hcl
1
PRANDIN TABS 0.5MG, 1MG
3
PRANDIN TABS 2MG
3
PROGLYCEM
3
MO
repaglinide/metformin hydrochloride
1
repaglinide tabs 0.5mg, 1mg
1
repaglinide tabs 2mg
1
SYMLINPEN 120
3
QL (10.8 ML per 30 days) MO
SYMLINPEN 60
3
SYNJARDY
3
tolazamide
1
MO
tolbutamide
1
MO
TRADJENTA
2
MO
TRESIBA FLEXTOUCH
1
MO
TRULICITY
2
VICTOZA
2
AGGRENOX
2
anagrelide hydrochloride
1
MO
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML
2
QL (1.2 ML per 28 days) PA
2
2
2
2
ARANESP ALBUMIN FREE INJ 100MCG/ML,
25MCG/ML, 40MCG/ML, 60MCG/ML
2
ARANESP ALBUMIN FREE INJ 500MCG/ML
4
4
4
4
4
ARANESP ALBUMIN FREE INJ 200MCG/ML,
300MCG/ML
4
aspirin/dipyridamole
1
BRILINTA
2
cilostazol
1
MO
clopidogrel tabs 300mg
1
Blood Products/Modifiers/Volume Expanders
Drug name
clopidogrel tabs 75mg
1
CYKLOKAPRON
2
EFFIENT
2
ELIQUIS TABS 2.5MG
3
ELIQUIS TABS 5MG
3
enoxaparin sodium
3
MO
fondaparinux sodium
3
MO
FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,
15000UNIT/0.6ML, 18000UNT/0.72ML,
2500UNIT/0.2ML, 5000UNIT/0.2ML,
7500UNIT/0.3ML, 95000UNIT/3.8ML
3
MO
heparin sodium/d5w
3
heparin sodium/nacl 0.45%
3
heparin sodium/nacl 0.9%
3
heparin sodium/sodium chloride 0.9%
3
heparin sodium/sodium chloride 0.9% premix
3
heparin sodium inj 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/0.5ml, 5000unit/ml
3
MO
jantoven
1
MO
LEUKINE INJ 250MCG
4
PA
NEUMEGA
4
PA
NEUPOGEN
4
PA
PRADAXA CAPS 150MG, 75MG
2
pradaxa caps 110mg
2
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
2
PROCRIT INJ 40000UNIT/ML
4
PROMACTA
4
SAVAYSA
3
ticlopidine hcl
3
PA
tranexamic acid tabs
2
tranexamic acid inj
3
warfarin sodium tabs
1
MO
XARELTO STARTER PACK
2
XARELTO TABS 10MG, 20MG
2
XARELTO TABS 15MG
2
2
MO
Cardiovascular Agents
acebutolol hcl caps
41
Drug name
acetazolamide er
3
MO
acetazolamide tabs
2
MO
ADVICOR TB24 20MG; 500MG, 40MG; 1000MG
3
ADVICOR TB24 20MG; 1000MG, 20MG; 750MG
3
afeditab cr
1
ALTOPREV
3
amiloride hcl tabs
1
MO
amiloride/hydrochlorothiazide
1
MO
amiodarone hcl tabs
1
MO
amlodipine besylate/atorvastatin calcium
1
MO
amlodipine besylate/benazepril hydrochloride
1
amlodipine besylate/valsartan
1
amlodipine besylate tabs
1
MO
amlodipine/valsartan/hctz
1
AMTURNIDE TABS 150MG; 5MG; 12.5MG
2
AMTURNIDE TABS 300MG; 10MG; 12.5MG, 300MG; 2
10MG; 25MG, 300MG; 5MG; 12.5MG, 300MG; 5MG;
25MG
ANTARA
2
MO
ATACAND
3
ATACAND HCT TABS 32MG; 12.5MG, 32MG; 25MG
3
ATACAND HCT TABS 16MG; 12.5MG
3
atenolol/chlorthalidone
1
MO
atenolol tabs
1
MO
atorvastatin calcium
1
MO
benazepril hcl/hydrochlorothiazide
1
MO
benazepril hcl tabs
1
MO
BENICAR
3
BENICAR HCT
3
betaxolol hcl tabs 10mg, 20mg
2
MO
bisoprolol fumarate
1
MO
bisoprolol fumarate/hydrochlorothiazide
1
MO
bumetanide
2
MO
BYSTOLIC TABS 10MG, 2.5MG, 5MG
2
BYSTOLIC TABS 20MG
2
CADUET
3
ST MO
candesartan cilexetil
1
Drug name
candesartan cilexetil/hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg
1
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg
1
captopril/hydrochlorothiazide
1
MO
captopril tabs
1
MO
cartia xt
1
carvedilol
1
MO
CATAPRES-TTS-1
3
CATAPRES-TTS-2
3
CATAPRES-TTS-3
3
chlorothiazide tabs
1
MO
chlorthalidone tabs 25mg, 50mg
1
MO
cholestyramine light
1
MO
cholestyramine pack, powd
1
MO
clonidine hcl tabs
1
MO
clonidine hcl ptwk
3
CLORPRES
3
MO
colestipol hcl
1
MO
COREG CR
3
CORLANOR
3
PA MO
CRESTOR
2
DEMSER
4
MO
DIBENZYLINE
2
MO
digitek
1
digox
1
digoxin oral soln, tabs
1
MO
digoxin inj
3
MO
dilt-xr
1
diltiazem cd cp24 180mg
1
diltiazem cd cp24 120mg, 240mg, 300mg
1
MO
diltiazem hcl cd
1
MO
diltiazem hcl er
1
MO
diltiazem hcl tabs
1
MO
diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml,
50mg/10ml
3
DIOVAN HCT
3
DIOVAN TABS 320MG
3
43
Drug name
DIOVAN TABS 160MG, 40MG, 80MG
3
disopyramide phosphate
1
PA MO
dofetilide
3
doxazosin mesylate tabs
2
MO
DYRENIUM
3
MO
EDARBI
2
EDARBYCLOR
2
enalapril maleate/hydrochlorothiazide
1
MO
enalapril maleate tabs
1
MO
ENTRESTO
2
eplerenone
3
MO
eprosartan mesylate
1
EXFORGE
3
EXFORGE HCT
3
felodipine er
1
MO
fenofibrate micronized
1
MO
fenofibrate caps
1
MO
FENOFIBRATE TABS 40MG
2
MO
fenofibrate tabs 145mg, 160mg, 48mg, 54mg
1
MO
fenofibrate tabs 120mg
2
MO
fenofibric acid
1
MO
fenofibric acid dr
1
MO
FENOGLIDE
3
ST MO
flecainide acetate
2
MO
fluvastatin
1
MO
fluvastatin sodium er
1
fosinopril sodium
1
MO
fosinopril sodium/hydrochlorothiazide
1
MO
furosemide oral soln, tabs
1
MO
furosemide inj
3
MO
gemfibrozil tabs
1
MO
hydralazine hcl tabs
1
MO
hydralazine hcl inj
3
MO
hydrochlorothiazide caps, tabs
1
MO
indapamide
1
MO
INNOPRAN XL
3
MO
irbesartan
1
Drug name
irbesartan/hydrochlorothiazide
1
isosorbide dinitrate er
1
MO
isosorbide dinitrate tabs
1
MO
isosorbide mononitrate
1
MO
isosorbide mononitrate er
1
MO
isradipine
3
MO
KYNAMRO
4
PA LA
labetalol hcl tabs
1
MO
labetalol hcl inj
3
MO
lidocaine hcl inj 10mg/ml, 20mg/ml
3
MO
LIPOFEN
2
MO
lisinopril
1
MO
lisinopril/hydrochlorothiazide
1
MO
losartan potassium/hydrochlorothiazide
1
losartan potassium tabs 100mg
1
losartan potassium tabs 25mg, 50mg
1
lovastatin
1
MO
LOVAZA
3
matzim la
1
MO
methazolamide
3
MO
methyclothiazide tabs
1
MO
metolazone
2
MO
metoprolol succinate er
1
MO
metoprolol tartrate inj, tabs
1
MO
metoprolol/hydrochlorothiazide
1
MO
mexiletine hcl
3
MO
MICARDIS
3
MICARDIS HCT
3
midodrine hcl
3
MO
minitran
2
minoxidil tabs
2
MO
moexipril hcl
1
MO
moexipril/hydrochlorothiazide
1
MO
MULTAQ
2
MO
nadolol/bendroflumethiazide
2
MO
nadolol tabs
2
MO
niacin er
1
MO
45
Drug name
NIASPAN
3
ST MO
nicardipine hcl caps
2
MO
nifedical xl
1
nifedipine er
1
MO
nimodipine caps
3
MO
nisoldipine
3
MO
nisoldipine er
3
MO
nitroglycerin lingual spray
3
MO
nitroglycerin transdermal
1
MO
nitroglycerin inj
3
NITROMIST
3
MO
NITROSTAT
3
MO
NORTHERA
4
PA LA
NYMALIZE
4
PA
omega-3-acid ethyl esters
2
pacerone
2
pentoxifylline cr
2
MO
pentoxifylline er
2
MO
perindopril erbumine
1
MO
phenoxybenzamine hydrochloride
2
MO
pindolol
2
MO
PRALUENT
4
pravastatin sodium
1
MO
prazosin hcl
1
MO
prevalite
2
MO
propafenone hcl
3
MO
propafenone hcl er
3
MO
propranolol hcl er
1
MO
propranolol hcl inj
1
propranolol hcl oral soln, tabs
1
MO
propranolol/hydrochlorothiazide
1
MO
quinapril hcl
1
MO
quinapril/hydrochlorothiazide
1
MO
quinidine gluconate cr
3
MO
quinidine gluconate er
3
MO
quinidine sulfate
1
MO
quinidine sulfate er
1
MO
Drug name
ramipril
1
MO
RANEXA
3
REPATHA
4
REPATHA PUSHTRONEX SYSTEM
4
REPATHA SURECLICK
4
rosuvastatin calcium
2
simvastatin tabs 10mg, 20mg, 40mg, 5mg
1
MO
simvastatin tabs 80mg
1
sorine
1
sotalol hcl
1
MO
sotalol hcl (af)
2
MO
spironolactone/hydrochlorothiazide
2
MO
spironolactone tabs
1
MO
taztia xt
1
TEKAMLO TABS 300MG; 10MG, 300MG; 5MG
2
TEKAMLO TABS 150MG; 10MG, 150MG; 5MG
2
TEKTURNA
2
TEKTURNA HCT
2
telmisartan
1
telmisartan/amlodipine
1
telmisartan/hydrochlorothiazide
1
terazosin hcl
1
MO
TIKOSYN
3
timolol maleate tabs 10mg, 20mg, 5mg
1
MO
TOPROL XL
3
MO
torsemide tabs
2
MO
trandolapril
1
MO
trandolapril/verapamil hcl
1
MO
trandolapril/verapamil hcl er
1
MO
triamterene/hydrochlorothiazide
1
MO
TRIGLIDE
3
ST MO
valsartan
1
MO
valsartan/hydrochlorothiazide
1
VASCEPA
2
MO
verapamil hcl er
1
MO
verapamil hcl sr cp24
1
MO
verapamil hcl sr tbcr 240mg
1
MO
47
Drug name
verapamil hcl inj, tabs
1
MO
WELCHOL
3
MO
ZETIA
3
amphetamine/dextroamphetamine tablet 5mg,
7.5mg, 10mg, 12.5mg, 15mg, 30mg
2
amphetamine/dextroamphetamine tablet 20mg
2
AMPYRA
4
COPAXONE INJ 40MG/ML
4
COPAXONE INJ 20MG/ML
4
dexmethylphenidate hcl
1
dextroamphetamine sulfate tabs
3
dextroamphetamine sulfate soln
3
MO
EXTAVIA
4
GILENYA
4
glatopa
4
guanfacine er
3
INTUNIV
3
metadate er
3
METHYLIN CHEW
3
METHYLIN SOLN 5MG/5ML
3
MO
METHYLIN SOLN 10MG/5ML
3
methylphenidate hcl er tbcr 10mg, 20mg
3
methylphenidate hcl SR 20mg tab
3
methylphenidate hcl IR tab 5mg, 10mg, 20mg
1
PA MO
NAMZARIC
2
NUEDEXTA
2
riluzole
3
MO
tetrabenazine tabs 25mg
4
tetrabenazine tabs 12.5mg
4
XENAZINE TABS 25MG
4
XENAZINE TABS 12.5MG
4
cevimeline hcl
1
MO
chlorhexidine gluconate soln
1
MO
Central Nervous System Agents
Dental and Oral Agents
Drug name
clinpro 5000
1
MO
dentagel
1
MO
oralone
1
paroex
1
periogard
1
phos-flur
1
pilocarpine hcl tabs 7.5mg
1
MO
pilocarpine hydrochloride
1
MO
sf 1.1% gel
1
MO
triamcinolone acetonide pste 0.1%
1
MO
triamcinolone in orabase
2
MO
Dermatological Agents
8-MOP
3
acitretin
4
PA MO
ALTABAX
3
MO
ammonium lactate crea, lotn
1
MO
amnesteem
3
avita crea
3
PA
avita gel
3
PA MO
AZELEX
3
MO
calcipotriene
3
MO
calcitrene
3
MO
CLARAVIS CAPS 30MG
3
claravis caps 10mg, 20mg, 40mg
3
clindamycin phosphate foam 1%
2
MO
clindamycin phosphate gel 1%
2
MO
clindamycin phosphate lotn 1%
2
MO
clindamycin phosphate external soln 1%
2
MO
clindamycin phosphate swab 1%
2
MO
clindamycin/benzoyl peroxide
3
MO
doxepin hydrochloride
3
MO
ELIDEL
3
QL (60 GM per 30 days) ST MO
ery acne pad
1
MO
erythromycin/benzoyl peroxide
2
MO
erythromycin gel 2%
2
MO
erythromycin pads 2%
2
MO
erythromycin soln 2%
2
MO
49
Drug name
fluorouracil crea 0.5%, 5%
3
MO
fluorouracil external soln 2%, 5%
3
MO
gentamicin sulfate crea 0.1%
1
MO
gentamicin sulfate external oint 0.1%
1
MO
imiquimod crea
3
MO
methoxsalen caps
4
MO
METROGEL
3
MO
metronidazole crea 0.75%
3
MO
metronidazole gel 0.75%, 1%
3
MO
metronidazole lotn 0.75%
3
MO
mupirocin calcium cream
3
MO
mupirocin oint
1
MO
mupirocin crea
3
MO
myorisan
3
NORITATE
3
MO
OXSORALEN
3
MO
PICATO GEL 0.05%
4
PICATO GEL 0.015%
4
podofilox soln
3
MO
REGRANEX
4
QL (15 GM per 30 days) PA MO
rosadan crea, gel
3
SANTYL
2
MO
selenium sulfide lotn
1
MO
silver sulfadiazine
1
MO
sodium sulfacetamide lotn 10%
3
MO
ssd
1
sulfacetamide sodium susp 10%
3
MO
SULFAMYLON CREA
3
MO
TAZORAC
3
MO
tretinoin crea 0.025%, 0.05%, 0.1%
3
PA MO
tretinoin gel 0.01%, 0.025%, 0.05%
3
PA MO
VEREGEN
3
MO
ZENATANE CAPS 30MG
3
zenatane caps 10mg, 20mg, 40mg
3
ZONALON
3
MO
4
PA
Enzyme Replacement/Modifiers
ADAGEN
Drug name
ALDURAZYME
4
PA LA
BUPHENYL TABS
4
PA
CARBAGLU
3
CEREZYME
4
PA LA
CREON
2
MO
CYSTADANE
4
CYSTAGON
3
PA LA
FABRAZYME
4
PA LA
KUVAN TBSO
4
PA LA
KUVAN PACK 500MG
4
PA
KUVAN PACK 100MG
4
PA LA
LUMIZYME
4
LA
NAGLAZYME
4
PA LA
ORFADIN CAPS 10MG, 2MG, 5MG
4
PA
pancrelipase
1
MO
RAVICTI
4
PA LA
sodium phenylbutyrate powd
4
PA
VPRIV
4
PA
ZAVESCA
4
PA
ZENPEP
2
MO
ACIPHEX
3
ST MO
ACIPHEX SPRINKLE
3
ST MO
alosetron hydrochloride
4
AMITIZA
2
CANTIL
3
MO
cimetidine hcl
2
MO
cimetidine tabs
2
MO
constulose
1
cromolyn sodium conc 100mg/5ml
2
MO
DEXILANT
3
dicyclomine hcl caps, soln, tabs
1
PA MO
diphenatol
1
diphenoxylate/atropine
1
enulose
1
esomeprazole magnesium
2
esomeprazole sodium inj
2
Gastrointestinal Agents
MO
51
Drug name
famotidine premixed
3
famotidine susr
1
famotidine inj 200mg/20ml
1
famotidine inj 20mg/2ml, 40mg/4ml
1
MO
famotidine tabs 20mg, 40mg
1
MO
GATTEX
4
PA LA
gavilyte-c
2
MO
gavilyte-g
2
MO
gavilyte-h
2
MO
gavilyte-n/flavor pack
2
MO
generlac
1
MO
glycopyrrolate tabs
3
MO
glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml,
4mg/20ml
3
MO
GOLYTELY
3
ST MO
KRISTALOSE
3
MO
lactulose soln
1
MO
lansoprazole cpdr
2
LINZESS
2
loperamide hcl caps
1
MO
methscopolamine bromide
3
MO
metoclopramide hcl oral soln, tabs
1
MO
metoclopramide hcl inj
3
MO
misoprostol
2
MO
MOTOFEN
3
MO
MOVIPREP
3
MO
NEXIUM CAPS, GRANULES
3
nizatidine
1
MO
omeprazole cpdr 20mg
1
MO
1
1
OSMOPREP
3
ST MO
pantoprazole sodium inj
1
pantoprazole sodium tbec 20mg
1
pantoprazole sodium tbec 40mg
1
peg 3350/electrolytes
1
MO
peg-3350/nacl/na bicarbonate/kcl
1
MO
polyethylene glycol 3350 pack, powd
1
MO
MO
Drug name
PREPOPIK
3
MO
propantheline bromide
1
PA MO
ranitidine hcl caps, syrp
1
MO
ranitidine hcl inj 150mg/6ml
3
ranitidine hcl inj 50mg/2ml
3
MO
ranitidine hcl tabs 150mg, 300mg
1
MO
RELISTOR KIT 12MG/0.6ML
3
PA
RELISTOR INJ 12MG/0.6ML, 8MG/0.4ML
3
PA MO
SUCLEAR
3
MO
sucralfate susp, tabs
1
MO
SUPREP BOWEL PREP
3
MO
trilyte
2
MO
ursodiol caps, tabs
2
MO
alfuzosin hcl er
1
AURYXIA
3
MO
AVODART
2
bethanechol chloride tabs
2
MO
calcium acetate caps
2
MO
calcium acetate tabs 667mg
2
MO
CIALIS TABS 2.5MG, 5MG
1
ED CB
darifenacin hydrobromide er
3
DETROL LA
3
dutasteride
2
dutasteride/tamsulosin hydrochloride
2
ENABLEX
3
finasteride tabs 5mg
1
MO
flavoxate hcl
1
MO
FOSRENOL CHEW
3
MO
FOSRENOL PACK 750MG
3
FOSRENOL PACK 1000MG
3
MO
GELNIQUE GEL 10%
3
GELNIQUE GEL 3%
3
JALYN
2
methylergonovine maleate tab
3
MO
MYRBETRIQ
2
Genitourinary Agents
53
Drug name
oxybutynin chloride er tb24 5mg
2
oxybutynin chloride er tb24 10mg, 15mg
2
oxybutynin chloride tabs
1
oxybutynin chloride syrp
1
RAPAFLO
3
RENVELA
2
MO
sodium chloride 0.9% GU irrigant
1
MO
tamsulosin hcl
1
MO
THIOLA
2
tolterodine tartrate tab
2
tolterodine tartrate er
3
trospium chloride immediate release tabs
1
trospium chloride er
1
VELPHORO
3
MO
VESICARE
2
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort
1
MO
ALCLOMETASONE DIPROPIONATE
2
MO
amcinonide
2
MO
APEXICON E
3
MO
augmented betamethasone dipropionate
1
MO
baycadron
2
betamethasone dipropionate crea, lotn, oint
2
MO
betamethasone valerate crea, foam, lotn, oint
2
MO
budesonide cpep 3mg
4
MO
CAPEX
2
MO
clobetasol propionate e
2
MO
clobetasol propionate emollient foam
2
MO
clobetasol propionate crea, foam, gel, liqd, lotn, oint,
sham, soln
2
MO
colocort
3
CORDRAN TAPE
3
cormax scalp application
1
CORTIFOAM
2
MO
cortisone acetate tabs
1
MO
deltasone
1
desonide crea, lotn, oint
3
MO
MO
Drug name
desoximetasone crea, gel, oint
3
MO
DEXAMETHASONE INTENSOL
2
MO
dexamethasone sodium phosphate inj 10mg/ml
2
dexamethasone sodium phosphate inj 100mg/10ml,
10mg/ml PF, 120mg/30ml, 20mg/5ml, 4mg/ml
2
MO
dexamethasone elix, soln, tabs
2
MO
diflorasone diacetate
3
MO
fludrocortisone acetate tabs
2
MO
fluocinolone acetonide body
3
MO
fluocinolone acetonide scalp
3
MO
fluocinolone acetonide crea 0.01%, 0.025%
3
MO
fluocinolone acetonide oint 0.025%
3
MO
fluocinolone acetonide soln 0.01%
3
MO
fluocinonide-e
3
fluocinonide crea, gel, oint, soln
3
MO
fluticasone propionate crea 0.05%
2
MO
fluticasone propionate lotn 0.05%
2
MO
fluticasone propionate oint 0.005%
2
MO
halobetasol propionate
2
MO
HALOG
3
MO
hydrocortisone butyrate (lipophilic)
2
MO
hydrocortisone butyrate crea, oint, soln
2
MO
hydrocortisone in absorbase
1
MO
hydrocortisone valerate crea, oint
2
MO
hydrocortisone crea 1%, 2.5%
1
MO
hydrocortisone enem, tabs
1
MO
hydrocortisone lotn 2.5%
1
MO
hydrocortisone oint 1%, 2.5%
1
MO
methylprednisolone acetate inj
3
MO
methylprednisolone dose pack
1
MO
methylprednisolone sodiumsuccinate
3
MO
methylprednisolone tabs
1
MO
MILLIPRED
3
MO
MILLIPRED DP
3
MO
mometasone furoate crea, oint, soln
1
MO
prednicarbate
1
MO
prednisolone sodium phosphate oral soln 25mg/5ml,
5mg/5ml
1
MO
55
Drug name
prednisolone sodium phosphate oral soln 15mg/5ml
2
MO
prednisolone soln, syrp
2
MO
PREDNISONE INTENSOL
3
MO
prednisone soln, tabs, tbpk
1
MO
procto-med hc
2
procto-pak
2
MO
proctosol hc
2
MO
proctozone-hc
2
MO
triamcinolone acetonide aers spray 0.147mg/gm
3
MO
triamcinolone acetonide crea 0.025%, 0.1%, 0.5%
1
MO
triamcinolone acetonide lotn 0.025%, 0.1%
1
MO
triamcinolone acetonide oint 0.025%, 0.1%, 0.5%
1
MO
trianex
1
MO
triderm
1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate inj, nasal soln, tabs
2
MO
EGRIFTA INJ 2MG
4
EGRIFTA INJ 1MG
4
INCRELEX
4
PA LA
NORDITROPIN FLEXPRO
4
PA
VASOSTRICT
3
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
altavera
3
alyacen 1/35
3
alyacen 7/7/7
3
amethia
3
amethia lo
3
amethyst
3
ANADROL-50
4
MO
ANDROGEL PUMP GEL 1.62%
2
PA MO
ANDROGEL PUMP GEL 1%
2
ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM
2
PA MO
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM
2
apri
3
aranelle
3
ashlyna
3
aubra
3
Drug name
aviane
3
azurette
3
balziva
3
bekyree
3
blisovi 24 fe
3
blisovi fe 1.5/30
3
blisovi fe 1/20
3
briellyn
3
camila
3
camrese
3
camrese lo
3
caziant
3
chateal
3
cryselle-28
3
MO
cyclafem 1/35
3
MO
cyclafem 7/7/7
3
MO
cyred
3
danazol caps
3
dasetta 1/35
3
dasetta 7/7/7
3
daysee
3
deblitane
3
delyla
3
DEPO-ESTRADIOL
3
MO
DEPO-PROVERA 400MG/ML
3
MO
desogestrel/ethinyl estradiol
3
MO
DIVIGEL
3
MO
drospirenone/ethinyl estradiol
3
MO
ELESTRIN
3
MO
elinest
3
ELLA
2
emoquette
3
enpresse-28
3
enskyce
3
errin
3
estarylla
3
ESTRACE CREA
3
MO
MO
MO
MO
MO
57
Drug name
estradiol/norethindrone acetate
3
PA MO
estradiol tabs
1
PA MO
estradiol ptwk
1
estradiol pttw
1
ESTRING
3
EVAMIST
3
QL (16.2 ML per 30 days) MO
EVISTA
3
MO
falmina
3
FEMRING
3
fyavolv
3
PA
gianvi
3
gildagia
3
gildess 1.5/30
3
MO
gildess 1/20
3
MO
gildess 24 fe
3
gildess fe 1.5/30
3
gildess fe 1/20
3
heather
3
MO
hydroxyprogesterone caproate inj
4
PA
introvale
3
jencycla
3
jevantique lo
3
PA
JINTELI
3
PA MO
jolessa
3
jolivette
3
juleber
3
junel 1.5/30
3
junel 1/20
3
junel fe 1.5/30
3
MO
junel fe 1/20
3
MO
junel fe 24
3
kaitlib fe
3
kariva
3
kelnor 1/35
3
kimidess
3
kurvelo
3
larin 1.5/30
3
MO
Drug name
larin 1/20
3
larin 24 fe
3
larin fe 1.5/30
3
larin fe 1/20
3
layolis fe
3
leena
3
lessina
3
levonest
3
levonorgestrel
2
levonorgestrel/ethinyl estradiol
3
levora 0.15/30-28
3
LO LOESTRIN FE
3
MO
lomedia 24 fe
3
MO
lopreeza
3
PA
loryna
3
MO
low-ogestrel
3
lutera
3
lyza
3
marlissa
3
MO
medroxyprogesterone acetate tabs
1
MO
medroxyprogesterone acetate inj
3
MO
megestrol acetate tabs
2
PA MO
megestrol acetate susp 40mg/ml
2
PA MO
MENEST
3
PA MO
microgestin 1.5/30
3
microgestin 1/20
3
microgestin 24 fe
3
microgestin fe
3
microgestin fe 1.5/30
3
mimvey
3
PA MO
mimvey lo
3
PA MO
mono-linyah
3
mononessa
3
myzilra
3
necon 0.5/35-28
3
necon 1/35
3
NECON 1/50-28
3
MO
MO
MO
MO
59
Drug name
NECON 10/11-28
3
necon 7/7/7
3
nikki
3
nora-be
3
norethindrone & ethinyl estradiol ferrous fumarate
3
MO
norethindrone acetate/ethinyl estradiol/ferrous
fumarate
3
MO
norethindrone acetate/ethinyl estradiol tabs 20mcg;
1mg
3
MO
norethindrone acetate/ethinyl estradiol tabs 2.5mcg;
0.5mg, 5mcg; 1mg
3
PA MO
norethindrone acetate tabs
2
MO
norethindrone tabs
3
MO
norgestimate/ethinyl estradiol
3
MO
NORINYL 1+50
3
MO
norlyroc
3
nortrel 0.5/35 (28)
3
nortrel 1/35
3
nortrel 7/7/7
3
ocella
3
OGESTREL
3
orsythia
3
oxandrolone tabs 2.5mg
2
oxandrolone tabs 10mg
2
philith
3
pimtrea
3
pirmella 1/35
3
pirmella 7/7/7
3
portia-28
3
MO
PREMARIN CREA
2
MO
previfem
3
MO
progesterone caps, inj
3
MO
quasense
3
raloxifene hydrochloride
1
reclipsen
3
setlakin
3
sharobel
3
sprintec 28
3
MO
MO
MO
MO
Drug name
sronyx
3
syeda
3
tarina fe 1/20
3
TESTIM
2
testosterone cypionate inj
3
MO
testosterone enanthate inj
3
MO
TESTOSTERONE GEL 50MG/5GM
2
QL (300 GM per 30 days) PA
testosterone gel 1%, 25mg/2.5gm
2
tilia fe
3
tri-estarylla
3
tri-legest fe
3
tri-linyah
3
tri-lo-estarylla
3
tri-lo-marzia
3
tri-lo-sprintec
3
tri-previfem
3
tri-sprintec
3
trinessa
3
trinessa lo
3
trivora-28
3
VAGIFEM
2
MO
velivet
3
MO
vestura
3
vienva
3
viorele
3
MO
vyfemla
3
MO
wera
3
wymzya fe
3
MO
xulane
3
MO
zarah
3
zenchent
3
zenchent fe
3
zovia 1/35e
3
ZOVIA 1/50E
3
MO
MO
MO
MO
MO
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium inj, tabs
1
MO
levoxyl
2
MO
61
Drug name
liothyronine sodium tabs
2
MO
SYNTHROID
2
MO
THYROLAR-1
3
MO
THYROLAR-1/2
3
MO
THYROLAR-1/4
3
MO
THYROLAR-2
3
MO
THYROLAR-3
3
MO
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg,
175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg,
88mcg
1
unithroid tabs 137mcg
2
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
2
MO
SENSIPAR TABS 30MG
2
SENSIPAR TABS 90MG
4
SENSIPAR TABS 60MG
4
cabergoline
3
MO
FIRMAGON INJ 80MG
3
PA
FIRMAGON INJ 120MG
4
PA
leuprolide acetate inj
2
PA
LUPRON DEPOT
4
PA
LUPRON DEPOT-PED
4
PA
octreotide acetate
3
PA
SIGNIFOR
4
SOMATULINE DEPOT INJ 60MG/0.2ML
4
4
4
SOMAVERT
4
PA LA
SYNAREL
4
MO
TRELSTAR MIXJECT
4
PA
VANTAS
3
ZOLADEX
3
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Thyroid)
methimazole tabs
1
MO
Drug name
propylthiouracil tabs
2
MO
Immunological Agents
ACTHIB
3
ACTIMMUNE
4
ADACEL
3
ARCALYST
4
PA LA
ATGAM
4
PA
azathioprine tabs
1
B/D MO
azathioprine inj
3
B/D
bcg vaccine
1
BENLYSTA
4
BEXSERO
3
BOOSTRIX
3
CELLCEPT INTRAVENOUS
3
PA
CELLCEPT SUSR
4
PA MO
CERVARIX
3
CIMZIA
4
CIMZIA STARTER KIT
4
CINRYZE
4
PA LA
COMVAX
3
cyclosporine modified
2
PA MO
cyclosporine caps
2
PA MO
cyclosporine inj
3
PA
DAPTACEL
3
diphtheria/tetanus toxoids adsorbed pediatric
2
ENGERIX-B
2
B/D
ENVARSUS XR
3
PA MO
FIRAZYR
4
QL (270 ML per 30 days) PA LA
GAMASTAN S/D
2
PA
GAMMAPLEX INJ 10GM/200ML
4
PA
GAMMAPLEX INJ 2.5GM/50ML, 20GM/400ML,
5GM/100ML
4
PA LA
GAMUNEX-C
4
PA
GARDASIL
3
GARDASIL 9
3
gengraf caps
3
PA
gengraf soln
3
PA MO
PA LA
PA
63
Drug name
HAVRIX
3
hecoria
3
HIBERIX
3
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK
4
HUMIRA PEN
4
HUMIRA PEN-CROHNS DISEASE STARTER
4
HUMIRA PEN-PSORIASIS STARTER
4
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML
4
HUMIRA INJ 40MG/0.8ML
4
ILARIS
4
IMOVAX RABIES (H.D.C.V.)
3
B/D
INFANRIX
3
IPOL INACTIVATED IPV
2
IXIARO
3
KINRIX
3
leflunomide
1
M-M-R II
2
MENACTRA
3
MENHIBRIX
3
MENOMUNE-A/C/Y/W-135
2
MENVEO
3
methotrexate sodium inj 1gm/40ml, 1gm,
250mg/10ml
1
methotrexate tabs
1
MO
mycophenolate mofetil caps, tabs
3
PA MO
mycophenolate mofetil susr
4
PA MO
NULOJIX
4
PA
OTREXUP
3
ST
PEDIARIX
3
PEDVAX HIB
3
PENTACEL
3
PROGRAF INJ
3
PA
PROGRAF CAPS 0.5MG, 1MG
3
PA MO
PROGRAF CAPS 5MG
4
PA MO
PROQUAD
3
QUADRACEL
3
RABAVERT
3
PA
MO
B/D
Drug name
RAPAMUNE
3
PA MO
RASUVO
3
ST
RECOMBIVAX HB
3
B/D
REMICADE
4
PA
RIDAURA
3
MO
ROTARIX
3
ROTATEQ
2
SANDIMMUNE SOLN
3
PA MO
SIMULECT
4
B/D
sirolimus tabs
3
PA MO
SYNAGIS
4
PA
tacrolimus caps
3
PA MO
TENIVAC
3
tetanus/diphtheria toxoids-adsorbed
2
THYMOGLOBULIN
4
TRUMENBA
3
TWINRIX
3
TYPHIM VI
3
VAQTA
3
VARIVAX
2
YF-VAX
2
ZORTRESS TABS 0.25MG
3
PA MO
ZORTRESS TABS 0.5MG, 0.75MG
4
PA MO
ZOSTAVAX
3
APRISO
2
MO
ASACOL HD
3
MO
balsalazide disodium
1
MO
CANASA
3
MO
DELZICOL
3
MO
DIPENTUM
3
MO
LIALDA
3
MO
mesalamine dr
3
mesalamine enem, kit
3
MO
PENTASA
3
MO
sulfasalazine tabs, tbec
1
MO
sulfazine
1
B/D
Inflammatory Bowel Disease Agents
65
Drug name
sulfazine ec
1
Metabolic Bone Disease Agents
ACTONEL TABS 150MG
3
alendronate sodium soln
1
MO
alendronate sodium tabs 10mg, 40mg, 5mg
1
alendronate sodium tabs 35mg, 70mg
1
BONIVA TABS
3
BONIVA INJ
3
calcitonin-salmon
1
MO
calcitriol inj
1
calcitriol caps, oral soln
1
MO
DOXERCALCIFEROL CAPS 1MCG, 2.5MCG
3
MO
doxercalciferol caps 0.5mcg
3
MO
etidronate disodium
2
MO
FORTEO
4
FORTICAL
3
MO
FOSAMAX PLUS D
3
HECTOROL CAPS
3
MO
HECTOROL INJ 2MCG/ML
3
HECTOROL INJ 4MCG/2ML
3
MO
ibandronate sodium tabs
1
ibandronate sodium inj
1
MIACALCIN INJ
3
MO
pamidronate disodium
3
paricalcitol caps
2
paricalcitol inj 2mcg/ml
1
paricalcitol inj 5mcg/ml
2
PROLIA
3
risedronate sodium dr
1
risedronate sodium tabs 150mg
1
risedronate sodium tabs 35mg
1
risedronate sodium tabs 30mg, 5mg
1
XGEVA
4
PA
ZEMPLAR
3
MO
zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml
3
MO
Miscellaneous Therapeutic Agents
ALCOHOL PREP PADS
1
MO
Drug name
BD INSULIN SYRINGE SAFETYGLIDE/1ML/
29G X 1/2”
1
MO
BD INSULIN SYRINGE ULTRAFINE/0.3ML/
31G X 5/16”
1
MO
BD INSULIN SYRINGE ULTRAFINE/0.5ML/
30G X 1/2”
1
MO
BD INSULIN SYRINGE ULTRAFINE/1ML/
31G X 5/16”
1
MO
BD PEN NEEDLE/ULTRAFINE/
29G X 12.7M
2
MO
BOTOX INJ 200UNIT
3
BOTOX INJ 100UNIT
3
CURITY GAUZE PADS 2”X2”
1
MO
FERRIPROX SOLN 100MG/ML
4
PA
NATPARA
4
ORFADIN SUSP 4MG/ML
4
PA
V-GO 20
2
MO
V-GO 30
2
MO
V-GO 40
2
MO
ACUVAIL
3
MO
ak-poly-bac
1
ALPHAGAN P SOLN 0.1%
2
MO
ALREX
2
MO
apraclonidine
1
MO
atropine sulfate soln
1
MO
AZASITE
2
MO
azelastine hcl ophthalmic soln 0.05%
1
MO
AZOPT
2
MO
bacitracin/neomycin/polymyxin
2
MO
bacitracin/polymyxin b
1
MO
bacitracin oint 500unit/gm
1
MO
BESIVANCE
3
MO
betaxolol hcl soln 0.5%
1
MO
BETIMOL
3
MO
BETOPTIC-S
3
MO
BLEPHAMIDE
3
MO
BLEPHAMIDE S.O.P.
3
MO
Ophthalmic Agents
67
Drug name
brimonidine tartrate
1
MO
bromfenac
3
MO
carteolol hcl
1
MO
CILOXAN OINT
3
MO
ciprofloxacin hcl soln 0.3%
2
MO
COMBIGAN
2
MO
cromolyn sodium soln 4%
2
MO
CYSTARAN
4
dexamethasone sodium phosphate ophthalmic soln
0.1%
1
MO
diclofenac sodium
1
MO
dorzolamide hcl
1
MO
dorzolamide hcl/timolol maleate
1
MO
DUREZOL
3
MO
epinastine hcl
1
MO
erythromycin oint 5mg/gm
2
MO
FLAREX
3
MO
fluorometholone
1
MO
flurbiprofen sodium
1
MO
FML OINT
3
MO
FML FORTE
3
MO
gatifloxacin
3
MO
gentak
1
MO
gentamicin sulfate ophthalmic oint 0.3%
1
MO
gentamicin sulfate ophthalmic soln 0.3%
1
MO
ILEVRO
3
MO
ISOPTO CARPINE
3
MO
ISTALOL
2
MO
ketorolac tromethamine
1
MO
LACRISERT
3
MO
latanoprost
1
MO
levobunolol hcl
1
MO
levofloxacin ophthalmic soln 0.5%
2
MO
LOTEMAX
2
MO
LUMIGAN
2
MO
MAXIDEX
2
MO
metipranolol
1
MO
MOXEZA
3
MO
Drug name
naphazoline hcl
1
MO
NATACYN
2
MO
neo-polycin
1
neomycin/bacitracin/polymyxin
2
MO
neomycin/polymyxin/bacitracin/hydrocortisone
2
MO
neomycin/polymyxin/dexamethasone susp
1
MO
neomycin/polymyxin/dexamethasone oint
2
MO
neomycin/polymyxin/gramicidin
2
MO
neomycin/polymyxin/hydrocortisone ophthalmic susp 1
1%; 3.5mg/ml; 10000unit/ml
MO
NEVANAC
3
MO
ofloxacin ophthalmic soln 0.3%
1
MO
olopatadine hcl ophthalmic soln 0.1%
3
MO
PATADAY
3
MO
PATANOL
3
MO
PAZEO
3
MO
PHOSPHOLINE IODIDE
3
pilocarpine hcl soln 1%, 2%, 4%
1
polycin
1
polymyxin b sulfate/trimethoprim sulfate
1
MO
PRED MILD
3
MO
PRED-G
3
MO
PRED-G S.O.P.
3
MO
prednisolone acetate
1
MO
prednisolone sodium phosphate ophthalmic soln 1%
1
MO
PROLENSA
3
MO
proparacaine hcl
1
MO
RESTASIS
2
MO
SIMBRINZA
3
MO
sodium sulfacetamide soln 10%
1
MO
sulfacetamide sodium/prednisolone sodium
phosphate
1
MO
sulfacetamide sodium oint 10%
3
MO
sulfacetamide sodium soln 10%
3
MO
timolol maleate ophthalmic gel forming
1
MO
timolol maleate soln 0.25%, 0.5%
1
MO
TOBRADEX
3
MO
TOBRADEX ST
3
MO
MO
69
Drug name
tobramycin sulfate ophthalmic soln 0.3%
1
MO
tobramycin/dexamethasone
1
MO
TOBREX OINT
3
MO
TRAVATAN Z
3
MO
travoprost
2
MO
trifluridine
3
MO
trimethoprim sulfate/polymyxin b sulfate
1
MO
triple antibiotic
1
VEXOL
3
MO
VIGAMOX
3
MO
ZIRGAN
3
MO
ZYLET
2
MO
Otic Agents
acetasol hc
3
acetic acid
1
MO
acetic acid/aluminum acetate
1
MO
antibiotic ear
1
CIPRO HC
3
MO
CIPRODEX
3
MO
COLY-MYCIN S
3
MO
fluocinolone acetonide oil 0.01%
3
MO
hydrocortisone/acetic acid
3
MO
neomycin/polymyxin/hc
1
MO
neomycin/polymyxin/hydrocortisone otic susp 1%;
3.5mg/ml; 10000unit/ml
1
MO
ofloxacin otic soln 0.3%
1
MO
Respiratory Tract/Pulmonary Agents
acetylcysteine inj
1
acetylcysteine inhalation soln
1
B/D MO
ADEMPAS
4
ADVAIR DISKUS
2
ADVAIR HFA
2
albuterol sulfate er
2
MO
albuterol sulfate nebu
2
B/D MO
albuterol sulfate syrp, tabs
2
MO
ALVESCO
3
QL (12.2 GM per 30 days) MO
aminophylline
1
MO
Drug name
ANORO ELLIPTA
2
ARCAPTA NEOHALER
3
ASMANEX HFA
2
ASMANEX TWISTHALER 120 METERED DOSES
2
2
2
2
2
ATROVENT HFA
3
azelastine hcl nasal soln 0.15%
1
MO
azelastine hcl nasal soln 0.1%
1
BECONASE AQ
3
BREO ELLIPTA
3
BROVANA
3
QL (120 ML per 30 days) B/D MO
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml
3
B/D MO
budesonide nasal susp 32mcg/act
3
MO
CAYSTON
4
clemastine fumarate syrp
3
PA
clemastine fumarate tabs 2.68mg
3
PA MO
COMBIVENT RESPIMAT
2
cromolyn sodium nebu 20mg/2ml
2
B/D MO
DALIRESP
3
diphenhydramine hcl inj
3
PA MO
EPIPEN 2-PAK
2
EPIPEN-JR 2-PAK
2
epoprostenol sodium
2
PA LA
ESBRIET
4
FLOVENT DISKUS AEPB 250MCG/BLIST
2
FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/
BLIST
2
FLOVENT HFA AERO 44MCG/ACT
2
FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT
2
flunisolide
1
MO
fluticasone propionate susp 50mcg/act
1
MO
FORADIL AEROLIZER
2
hydroxyzine hcl inj
3
PA MO
INCRUSE ELLIPTA
2
71
Drug name
ipratropium bromide/albuterol sulfate
2
B/D MO
ipratropium bromide inhalation soln
1
B/D MO
ipratropium bromide nasal soln
1
MO
KALYDECO PACK
4
KALYDECO TABS
4
LETAIRIS
4
levalbuterol nebu
3
B/D MO
levocetirizine dihydrochloride tabs
3
levocetirizine dihydrochloride soln
3
metaproterenol sulfate syrp, tabs
1
MO
montelukast sodium
2
NASONEX
2
OFEV
4
olopatadine hcl nasal soln 0.6%
3
OMNARIS
3
OPSUMIT
4
ORKAMBI
4
PATANASE
3
PERFOROMIST
3
QL (120 ML per 30 days) B/D MO
PROAIR HFA
2
PROAIR RESPICLICK
2
PROLASTIN-C
4
PA MO
promethazine hcl tabs 12.5mg, 25mg, 50mg
3
PA MO
PROVENTIL HFA
3
QL (13.4 GM per 30 days) ST MO
PULMICORT FLEXHALER
3
PULMOZYME
4
B/D
QNASL
3
QNASL CHILDRENS
3
QVAR
2
RHINOCORT AQUA
3
SEREVENT DISKUS
3
sildenafil tabs 20mg
2
SINGULAIR
3
SPIRIVA HANDIHALER
2
SPIRIVA RESPIMAT
2
STIOLTO RESPIMAT
2
STRIVERDI RESPIMAT
2
Drug name
SYMBICORT
2
terbutaline sulfate tabs
1
MO
THEO-24
3
MO
theophylline elix
3
MO
theophylline cr tb12 100mg, 200mg
1
MO
theophylline er
1
MO
TOBI PODHALER
4
tobramycin nebu
4
QL (280 ML per 56 days) B/D
TRACLEER
4
triamcinolone acetonide aero 55mcg/act
2
MO
TYZINE PEDIATRIC NASAL DROPS
3
VENTAVIS
4
PA LA
VENTOLIN HFA
2
XOLAIR
4
XOPENEX HFA
3
zafirlukast
3
ZETONNA
3
ZYFLO IMMEDIATE RELEASE TABS
4
chlorzoxazone
3
cyclobenzaprine hcl tabs
2
armodafinil
2
eszopiclone
3
HETLIOZ
4
modafinil tabs 100mg
2
modafinil tabs 200mg
2
PROVIGIL TABS 100MG
3
PROVIGIL TABS 200MG
3
ROZEREM
3
SILENOR
2
XYREM
4
zaleplon caps 5mg
2
zaleplon caps 10mg
2
zolpidem tartrate immediate release tabs
3
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/Minerals/Electrolytes
73
Drug name
AMINOSYN
3
B/D
AMINOSYN 7%/ELECTROLYTES
3
B/D
aminosyn 8.5%/electrolytes
3
B/D
AMINOSYN II
3
B/D
aminosyn ii 8.5%/electrolytes
3
B/D
AMINOSYN M
3
B/D
AMINOSYN-HBC
3
B/D
AMINOSYN-PF
3
B/D
AMINOSYN-PF 7%
3
B/D
AMINOSYN-RF
3
B/D
BAL-CARE DHA
3
MO
CALCIUM PNV
3
MO
CITRANATAL 90 DHA
3
MO
CITRANATAL ASSURE
3
MO
CITRANATAL B-CALM
3
MO
CITRANATAL DHA
3
MO
CITRANATAL RX TABS 120MG; 125MG; 400UNIT;
3
2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 25MG
MO
CLINIMIX 2.75%/DEXTROSE 5%
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
CLINIMIX 5%/DEXTROSE 15%
3
B/D
3
B/D
3
B/D
CLINIMIX E 2.75%/DEXTROSE 10%
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
CLINIMIX E 5%/DEXTROSE 15%
3
B/D
3
B/D
3
B/D
clinisol sf 15%
3
B/D
COMPLETE NATAL DHA
3
MO
COMPLETENATE
3
MO
Drug name
CONCEPT DHA
3
MO
CONCEPT OB
3
MO
CUPRIMINE
4
MO
DEPEN TITRATABS
3
MO
dextrose 10%/nacl 0.45%
3
dextrose 5% /electrolyte #48 viaflex
3
dextrose 10%
1
3
dextrose 2.5%/nacl 0.45%
3
dextrose 20%
1
B/D
dextrose 25%
1
B/D
dextrose 30%
1
B/D
dextrose 40%
1
B/D
dextrose 5%
1
MO
dextrose 5%/lactated ringers
3
3
3
3
3
3
3
dextrose 5%/potassium chloride 0.15%
3
dextrose 50%
1
B/D
dextrose 70%
1
B/D
ESCAVITE
3
ESCAVITE D
3
ESCAVITE LQ
3
EXJADE
4
PA LA
EXTRA-VIRT PLUS DHA
3
MO
FERRIPROX TABS 500MG
4
PA
FLORIVA LIQD
3
MO
floriva chew
3
fluor-a-day soln
3
fluoride chew 1.1mg, 2.2mg
3
MO
fluoridex daily defense
1
MO
fluoritab chew 0.5mg, 1mg, 2.2mg
3
fluoritab soln
3
B/D
MO
75
Drug name
FLURA-DROPS SOLN 0.25MG/DROP
3
MO
FOCALGIN 90 DHA
3
MO
FOCALGIN CA
3
MO
FOCALGIN-B
3
FOLCAL DHA
3
MO
FOLCAPS OMEGA 3
3
MO
FOLET DHA
3
FOLET ONE
3
MO
FOLIVANE-OB
3
MO
FOLIVANE-PRX DHA NF
3
MO
fomepizole
4
HEMENATAL OB
3
MO
HEMENATAL OB + DHA
3
MO
hepatamine
3
B/D
INATAL ADVANCE
3
INATAL ULTRA
3
INTRALIPID INJ 30GM/100ML
3
B/D
intralipid inj 20gm/100ml
3
B/D
k-sol
1
MO
KABIVEN
3
B/D
kcl 0.075%/d5w/nacl 0.45%
3
kcl 0.15%/d5w/lr
3
kcl 0.15%/d5w/nacl 0.2%
3
kcl 0.15%/d5w/nacl 0.225%
3
kcl 0.15%/d5w/nacl 0.45%
3
kcl 0.15%/d5w/nacl 0.9%
3
kcl 0.3%/d5w/lr iv lac ring
3
kcl 0.3%/d5w/nacl 0.45%
3
kcl 0.3%/d5w/nacl 0.9%
3
kionex powd
3
kionex susp
3
MO
klor-con
1
MO
klor-con 10
1
MO
KLOR-CON 25
1
MO
klor-con 8
1
MO
klor-con m10
1
KLOR-CON M15
1
MO
Drug name
klor-con m20
1
MO
klor-con sprinkle
1
MO
klor-con/ef
1
MO
lactated ringers dextrose 5% viaflex
3
lactated ringers viaflex
3
levocarnitine tabs
2
MO
LIPOSYN III
3
B/D
ludent chew 0.5mg, 1mg
3
MO
magnesium sulfate inj 50%
3
MO
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg;
2500unit; 15unit
3
MO
multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
3
0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit;
2500unit
MO
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
5unit/ml; 1500unit/ml
3
MO
multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml;
10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml
3
MO
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/
ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 1500unit/ml
3
MO
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml;
2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 0.5mg/ml; 1500unit/ml
3
MO
multivitamin with fluoride chew 60mg; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg;
2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit;
400unit; 15unit
3
MO
mvc-fluoride
3
MO
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT;
12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0;
2MG; 20UNIT
3
NATALVIRT 90 DHA
3
MO
NATALVIRT CA
3
MO
NATELLE ONE
3
MO
NEPHRAMINE
3
B/D
NESTABS
3
MO
77
Drug name
NESTABS DHA
3
MO
NEXA PLUS
3
MO
NIVA-PLUS
3
MO
O-CAL PRENATAL
3
MO
OB COMPLETE GOLD
3
MO
OB COMPLETE ONE
3
MO
OB COMPLETE PETITE
3
MO
OB COMPLETE PREMIER
3
MO
OB COMPLETE/DHA
3
MO
PAIRE OB
3
MO
PERIKABIVEN
3
B/D
physiolyte
1
physiosol irrigation
1
plenamine
3
B/D
PNV FERROUS FUMARATE/DOCUSATE/FOLIC
ACID
3
MO
PNV FOLIC ACID + IRON MULTIVITAMIN
3
MO
PNV OB+DHA
3
PNV PRENATAL PLUS MULTIVITAMIN
3
MO
PNV TABS 29-1
3
MO
PNV-DHA
3
MO
PNV-SELECT
3
MO
PNV-VP-U
3
MO
poly-vitamin/fluoride chew
3
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ 3
ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/
ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml
potassium chloride 0.15% /nacl 0.45% viaflex
1
potassium chloride 0.15% d5w/nacl 0.33%
3
3
potassium chloride 0.15% d5w/nacl 0.45% viaflex
3
potassium chloride 0.15% nacl 0.9%
3
3
potassium chloride 0.224%d5w/nacl 0.45% viaflex
3
potassium chloride 0.3%/ nacl 0.9%
3
potassium chloride 0.3%/d5w
3
potassium chloride cr tbcr 10meq, 20meq
1
MO
potassium chloride er
1
MO
MO
Drug name
potassium chloride sr
1
MO
potassium chloride oral soln
1
MO
potassium chloride inj 10meq/50ml, 20meq/100ml,
40meq/100ml
3
potassium chloride inj 0.4meq/ml, 10meq/100ml,
2meq/ml
3
MO
potassium citrate er
3
MO
PR NATAL 400
3
MO
PR NATAL 400 EC
3
MO
PR NATAL 430
3
MO
PR NATAL 430 EC
3
MO
PREFERA OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG;
6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG;
50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG
3
MO
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG
3
MO
prefera ob tabs 30mcg; 10mg; 400unit; 0.8mg;
12mcg; 10unit; 1mg; 34mg; 0; 17mg; 0; 250mcg;
50mg; 1.6mg; 65mcg; 1.5mg; 4.5mg
3
PREFERAOB +DHA
3
MO
PREFERAOB ONE
3
MO
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
3
B/D
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml;
840mg/100ml; 490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml; 230mg/100ml;
5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml
3
B/D
PRENAISSANCE
3
MO
PRENAISSANCE PLUS
3
MO
PRENATA
3
MO
PRENATABS FA
3
MO
PRENATABS OBN
3
79
Drug name
PRENATAL 19 CHEW 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 29MG; 1MG; 15MG; 20MG;
3MG; 3MG; 30UNIT; 20MG
3
MO
PRENATAL 19 TABS 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 25MG; 29MG; 1MG; 15MG;
20MG; 3MG; 3MG; 30UNIT; 20MG
3
MO
PRENATAL PLUS IRON TABS 120MG; 0; 200MG;
3
400UNIT; 2MG; 12MCG; 1MG; 29MG; 20MG; 10MG;
3MG; 1.84MG; 22UNIT; 4000UNIT; 25MG
MO
PRENATAL PLUS TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG;
3MG; 1.84MG; 22MG; 4000UNIT; 25MG
3
PRENATE AM
3
MO
PRENATE DHA CAPS 90MG; 145MG; 220UNIT;
3
13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG;
26MG; 10UNIT
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG;
100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG;
400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG;
3.5MG; 3MG; 10UNIT; 15MG
3
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG;
0; 400MCG; 600MCG; 50MG; 150MCG; 26MG;
10UNIT
3
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG; 300MG;
40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG;
10UNIT
3
PRENATE MINI CAPS 60MG; 280MCG; 100MG;
220UNIT; 13MCG; 350MG; 400MCG; 29MG;
600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG
3
PRENATE MINI CAPS 600MCG; 60MG; 280MCG;
80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG;
18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG
3
MO
PRENATE PIXIE
3
MO
PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG;
12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG
3
MO
PREQUE 10
3
MO
PRETAB
3
PUREFE OB PLUS
3
QUFLORA PEDIATRIC SOLN 0.5MG/ML
3
QUFLORA PEDIATRIC SOLN 0.25MG/ML
3
MO
MO
Drug name
RELNATE DHA
3
ringers injection
1
SAMSCA TABS 15MG
4
SAMSCA TABS 30MG
4
SE-NATAL 19
3
MO
SE-TAN DHA
3
MO
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
3
0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG;
0; 1.6MG; 30UNIT; 1700UNIT; 15MG
MO
MO
SETON ET-EC
3
SETONET
3
sodium bicarbonate inj 4.2%
3
MO
sodium bicarbonate inj 8.4%
3
MO
sodium chloride 0.45% viaflex
3
sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%
3
MO
sodium fluoride chew 0.5mg, 1.1mg, 1mg
3
MO
sodium polystyrene sulfonate oral susp
2
MO
sodium polystyrene sulfonate rectal susp
3
sodium polystyrene sulfonate powd
3
MO
sterile water irrigation
1
MO
SYPRINE
4
MO
TARON-PREX
3
MO
thrivite rx
3
MO
TL FOLATE
3
TL-CARE DHA
3
MO
TL-SELECT
3
MO
tpn electrolytes
3
tri-vit/fluoride
3
MO
TRI-VIT/FLUORIDE/IRON
3
MO
tri-vitamin/fluoride
3
MO
TRIADVANCE
3
TRICARE
3
MO
TRICARE PRENATAL COMPLEAT
3
MO
TRICARE PRENATAL DHA ONE
3
MO
TRINATAL GT
3
MO
TRINATAL RX 1
3
MO
triple-vitamin/fluoride
3
MO
TRISTART DHA
3
MO
81
Drug name
TRIVEEN-DUO DHA
3
MO
TRIVEEN-PRX RNF
3
MO
ULTIMATECARE ONE NF
3
MO
VEMAVITE-PRX 2
3
MO
VENA-BAL DHA
3
MO
VIRT-ADVANCE
3
MO
VIRT-C DHA
3
MO
VIRT-CARE ONE
3
MO
VIRT-PN
3
MO
VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT;
3
12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG;
25MG; 10UNIT
MO
VIRT-PN PLUS
3
MO
VIRT-SELECT
3
MO
VITAFOL FE+
3
MO
VITAFOL GUMMIES
3
MO
VITAFOL-ONE
3
MO
VITAMEDMD ONE RX/QUATREFOLIC
3
MO
VITAMEDMD PLUS RX/QUATRE FOLIC
3
MO
vitamins a/d/c/fluoride
3
VOL-NATE
3
MO
VOL-PLUS
3
MO
VP CH ULTRA
3
MO
VP-CH-PNV
3
MO
VP-HEME OB
3
MO
VP-HEME ONE
3
MO
VP-PNV-DHA
3
MO
ZATEAN-CH
3
MO
ZATEAN-PN
3
MO
ZATEAN-PN DHA
3
MO
ZATEAN-PN PLUS
3
MO
ENBRACE HR
3
MO
PROVIDA DHA
3
Unclassified
Index
Drug name Page
Drug name Page
Drug name Page
8-MOP 49
ADASUVE 32
alyacen 1/35 56
abacavir 34
adefovir dipivoxil 35
alyacen 7/7/7 56
abacavir sulfate/ 34
lamivudine/zidovudine
ADEMPAS 70
amantadine hcl 32
adrucil 26
AMBISOME 23
ABELCET 23
ADVAIR DISKUS 70
amcinonide 54
ABILIFY 32
ADVAIR HFA 70
amethia 56
ABILIFY DISCMELT 32
ADVICOR 42
amethia lo 56
ABILIFY MAINTENA 32
afeditab cr 42
amethyst 56
ABRAXANE 26
AFINITOR 26
amifostine 26
acamprosate calcium dr 13
AFINITOR DISPERZ 26
amikacin sulfate 14
acarbose 38
AGGRENOX 40
amiloride hcl 42
acebutolol hcl 41
a-hydrocort 54
acetaminophen/codeine 10
ak-poly-bac 67
amiloride/ 42
hydrochlorothiazide
acetaminophen/codeine 10
#3
ALBENZA 31
aminophylline 70
albuterol sulfate 70
AMINOSYN 74
albuterol sulfate er 70
AMINOSYN 7%/ 74
ELECTROLYTES
acetasol hc 70
acetazolamide 42
acetazolamide er 42
ALCLOMETASONE 54
DIPROPIONATE
acetic acid 70
ALCOHOL PREP PADS 66
acetic acid/aluminum 70
acetate
ALDURAZYME 51
acetylcysteine 70
ACIPHEX 51
ACIPHEX SPRINKLE 51
acitretin 49
ACTHIB 63
ACTIMMUNE 63
ACTONEL 66
ACTOPLUS MET 38
ACTOPLUS MET XR 38
ACTOS 38
ACUVAIL 67
acyclovir 35
acyclovir sodium 34
ADACEL 63
ADAGEN 50
ALECENSA 26
alendronate sodium 66
alfuzosin hcl er 53
ALIMTA 26
ALINIA 31
ALKERAN 26
allopurinol 24
alosetron hydrochloride 51
ALPHAGAN P 67
alprazolam
ALREX 67
ALTABAX 49
altavera 56
ALTOPREV 42
ALVESCO 70
aminosyn 8.5%/ 74
electrolytes
AMINOSYN II 74
aminosyn ii 8.5%/ 74
electrolytes
AMINOSYN M 74
AMINOSYN-HBC 74
AMINOSYN-PF 74
AMINOSYN-PF 7% 74
AMINOSYN-RF 74
amiodarone hcl 42
AMITIZA 51
amitriptyline hcl 21
amlodipine besylate 42
amlodipine besylate/ 42
atorvastatin calcium
benazepril hydrochloride
valsartan
83
Drug name Page
Drug name Page
amlodipine/valsartan/ 42
hctz
ARISTADA 33
AVANDAMET 38
armodafinil 73
AVANDARYL 38
ammonium lactate 49
ARRANON 26
AVANDIA 38
amnesteem 49
ARZERRA 26
AVASTIN 26
amoxapine 21
ASACOL HD 65
aviane 57
amoxicillin 14
ascomp/codeine 10
avita 49
amoxicillin/clavulanate 14
potassium
ashlyna 56
AVODART 53
ASMANEX HFA 71
azacitidine 26
ASMANEX 71
TWISTHALER 120
METERED DOSES
AZASITE 67
amoxicillin/clavulanate 14
potassium er
amphetamine/
dextroamphetamine
amphotericin b 23
ampicillin 14
ampicillin sodium
ampicillin-sulbactam 14
AMPYRA 48
AMTURNIDE 42
ANADROL-50 56
anagrelide hydrochloride 40
anastrozole 26
ANDROGEL 56
ANDROGEL PUMP 56
ANORO ELLIPTA 71
ANTARA 42
antibiotic ear 70
APEXICON E 54
APOKYN 32
apraclonidine 67
apri 56
APRISO 65
APTIOM 19
APTIVUS 35
aranelle 56
ARANESP ALBUMIN 40
FREE
ASMANEX 71
TWISTHALER 14
METERED DOSES
ASMANEX 71
TWISTHALER 30
METERED DOSES
ASMANEX 71
TWISTHALER 60
METERED DOSES
ASMANEX 71
TWISTHALER 7
METERED DOSES
aspirin/dipyridamole 40
azelastine hcl 67
azelastine hcl 71
AZELEX 49
AZILECT 32
azithromycin 14
AZOPT 67
aztreonam 14
azurette 57
baciim 14
bacitracin 14
bacitracin 67
bacitracin/neomycin/ 67
polymyxin
ATACAND HCT 42
bacitracin/polymyxin b 67
atenolol 42
baclofen 34
atenolol/chlorthalidone 42
ATGAM 63
BACTOCILL IN 14
DEXTROSE
atorvastatin calcium 42
BAL-CARE DHA 74
atovaquone 31
balsalazide disodium 65
atovaquone/proguanil 31
hcl
balziva 57
BANZEL 19
ATRIPLA 35
BARACLUDE 35
atropine sulfate 67
baycadron 54
ATROVENT HFA 71
bcg vaccine 63
aubra 56
BD INSULIN SYRINGE 67
SAFETYGLIDE/1ML/
29G X 1/2”
ARCAPTA NEOHALER 71
aripiprazole 33
AURYXIA 53
aripiprazole odt 32
azathioprine 63
ATACAND 42
augmented 54
betamethasone
dipropionate
ARCALYST 63
84
Drug name Page
ULTRAFINE/0.3ML/
31G X 5/16”
Drug name Page
ULTRAFINE/0.5ML/
30G X 1/2”
ULTRAFINE/1ML/
31G X 5/16”
BD PEN NEEDLE/ 67
ULTRAFINE/
29G X 12.7M
BECONASE AQ 71
bekyree 57
BELEODAQ 26
benazepril hcl 42
benazepril hcl/ 42
hydrochlorothiazide
BENDEKA 26
BENICAR 42
BENICAR HCT 42
BENLYSTA 63
benztropine mesylate 32
BESIVANCE 67
Drug name Page
Drug name Page
BLEPHAMIDE S.O.P. 67
butalbital/aspirin/caffeine 10
BLINCYTO 26
blisovi 24 fe 57
butalbital/aspirin/ 10
caffeine/codeine
blisovi fe 1.5/30 57
BYDUREON 38
blisovi fe 1/20 57
BYSTOLIC 42
BONIVA 66
cabergoline 62
BOOSTRIX 63
CABOMETYX 26
BOSULIF 26
CADUET 42
BOTOX 67
CAFERGOT 24
BREO ELLIPTA 71
calcipotriene 49
briellyn 57
calcitonin-salmon 66
BRILINTA 40
calcitrene 49
brimonidine tartrate 68
calcitriol 66
BRINTELLIX 21
calcium acetate 53
BRIVIACT 19
CALCIUM PNV 74
bromfenac 68
camila 57
bromocriptine mesylate 32
camrese 57
BROVANA 71
camrese lo 57
budesonide 54
CANASA 65
betamethasone 54
dipropionate
budesonide 71
CANCIDAS 23
bumetanide 42
candesartan cilexetil 42
betamethasone valerate 54
BUPHENYL 51
betaxolol hcl 42
buprenorphine hcl 13
candesartan cilexetil/ 43
hydrochlorothiazide
betaxolol hcl 67
buprenorphine hcl/ 13
naloxone hcl
capacet 10
buproban 13
CAPASTAT SULFATE 25
bupropion hcl 21
CAPEX 54
bupropion hcl er 21
CAPRELSA 26
bupropion hcl sr 13
captopril 43
bupropion hcl sr 21
captopril/ 43
hydrochlorothiazide
bethanechol chloride 53
BETIMOL 67
BETOPTIC-S 67
bexarotene 26
BEXSERO 63
bicalutamide 26
BICILLIN L-A 14
BICNU 26
BILTRICIDE 31
bisoprolol fumarate 42
bisoprolol fumarate/ 42
hydrochlorothiazide
BLEO 15K 26
bleomycin sulfate 26
BLEPHAMIDE 67
bupropion hcl xl 21
buspirone hcl 37
BUSULFEX 26
butalbital compound/ 10
codeine
butalbital/ 10
acetaminophen/caffeine
butalbital/ 10
acetaminophen/caffeine/
codeine
CANTIL 51
CARBAGLU 51
carbamazepine 19
carbamazepine er 19
carbidopa 32
carbidopa/levodopa 32
carbidopa/levodopa er 32
carbidopa/levodopa odt 32
85
Drug name Page
carbidopa/levodopa/ 32
entacapone
Drug name Page
celecoxib 10
ciprofloxacin 15
CELLCEPT 63
ciprofloxacin er 15
ciprofloxacin hcl 15
carteolol hcl 68
CELLCEPT 63
INTRAVENOUS
ciprofloxacin hcl 68
cartia xt 43
CELONTIN 19
ciprofloxacin i.v.-in d5w 15
carvedilol 43
cephalexin 15
cisplatin 26
CATAPRES-TTS-1 43
CEREZYME 51
citalopram hydrobromide 21
CATAPRES-TTS-2 43
CERVARIX 63
CITRANATAL 90 DHA 74
CATAPRES-TTS-3 43
cevimeline hcl 48
CITRANATAL ASSURE 74
CAYSTON 71
CHANTIX 13
CITRANATAL B-CALM 74
caziant 57
CHANTIX CONTINUING 13
MONTH PAK
CITRANATAL DHA 74
CHANTIX STARTING 13
MONTH PAK
cladribine 26
carboplatin 26
cefaclor 14
cefaclor er 14
cefadroxil 14
cefazolin 14
cefazolin sodium
cefazolin sodium/ 14
dextrose
cefdinir 14
cefditoren pivoxil 14
cefepime 15
cefepime/dextrose 15
cefixime 15
cefotaxime sodium 15
cefotetan 15
cefotetan/dextrose 15
cefoxitin sodium 15
cefpodoxime proxetil 15
cefprozil 15
ceftazidime 15
ceftazidime/dextrose 15
ceftriaxone in iso 15
osmotic dextrose
ceftriaxone sodium
86
Drug name Page
chateal 57
CITRANATAL RX 74
CLARAVIS 49
clarithromycin
chloramphenicol sodium 15
succinate
clarithromycin er 15
chlorhexidine gluconate 48
clemastine fumarate 71
chloroquine phosphate 31
clindamax 15
chlorothiazide
chlorpromazine hcl 33
chlorthalidone 43
chlorzoxazone 73
cholestyramine 43
cholestyramine light 43
CIALIS 53
ciclodan
ciclopirox 23
ciclopirox nail lacquer 23
ciclopirox olamine 23
cilostazol 40
CILOXAN
cimetidine 51
cimetidine hcl 51
ceftriaxone/dextrose 15
CIMZIA 63
cefuroxime axetil 15
CIMZIA STARTER KIT 63
cefuroxime sodium 15
CINRYZE 63
cefuroxime/dextrose 15
CIPRO HC 70
CELEBREX 10
CIPRODEX 70
clindamycin hcl 15
clindamycin palmitate 15
hcl
clindamycin phosphate 16
add-vantage
in d5w
clindamycin/benzoyl 49
peroxide
CLINIMIX 2.75%/ 74
DEXTROSE 5%
CLINIMIX 4.25%/ 74
DEXTROSE 10%
CLINIMIX 4.25%/ 74
DEXTROSE 20%
CLINIMIX 4.25%/ 74
DEXTROSE 25%
CLINIMIX 4.25%/ 74
DEXTROSE 5%
CLINIMIX 5%/ 74
DEXTROSE 15%
Drug name Page
Drug name Page
Drug name Page
CLINIMIX 5%/ 74
DEXTROSE 20%
codeine sulfate 10
cyclafem 7/7/7 57
colchicine 24
cyclobenzaprine hcl 73
CLINIMIX 5%/ 74
DEXTROSE 25%
COLCRYS 24
cyclophosphamide 26
CLINIMIX E 2.75%/ 74
DEXTROSE 10%
colestipol hcl 43
cycloserine 25
colistimethate sodium 16
cyclosporine 63
DEXTROSE 5%
colocort 54
cyclosporine modified 63
COLY-MYCIN S 70
CYKLOKAPRON 41
COMBIGAN 68
CYMBALTA 21
COMBIVENT RESPIMAT 71
CYRAMZA 27
COMETRIQ 26
cyred 57
DEXTROSE 10%
DEXTROSE 25%
DEXTROSE 5%
COMPLERA 35
CYSTADANE 51
COMPLETE NATAL DHA 74
CYSTAGON 51
CLINIMIX E 5%/ 74
DEXTROSE 15%
COMPLETENATE 74
CYSTARAN 68
compro 33
cytarabine aqueous 27
COMVAX 63
dacarbazine 27
CONCEPT DHA 75
DALIRESP 71
CLINIMIX E 5%/ 74
DEXTROSE 25%
CONCEPT OB 75
DALVANCE 16
clinisol sf 15% 74
constulose 51
danazol 57
COPAXONE 48
dantrolene sodium 34
CORDRAN TAPE 54
dapsone 25
COREG CR 43
DAPTACEL 63
CORLANOR 43
DARAPRIM 31
cormax scalp application 54
CORTIFOAM 54
darifenacin 53
hydrobromide er
cortisone acetate 54
DARZALEX 27
COSMEGEN 26
dasetta 1/35 57
COTELLIC 26
dasetta 7/7/7 57
CREON 51
daunorubicin hcl 27
CRESTOR 43
DAUNOXOME 27
CRIXIVAN 35
daysee 57
cromolyn sodium 51
deblitane 57
cromolyn sodium 68
decitabine 27
cromolyn sodium 71
deltasone 54
cryselle-28 57
delyla 57
CUBICIN 16
DELZICOL 65
clozapine 33
CUPRIMINE 75
DEMSER 43
clozapine odt 33
CURITY GAUZE PADS 67
2”X2”
DENAVIR 35
cyclafem 1/35 57
DEPAKOTE ER 19
CLINIMIX E 5%/ 74
DEXTROSE 20%
clinpro 5000 49
clobetasol propionate 54
clobetasol propionate e 54
clobetasol propionate 54
emollient
CLOLAR 26
clomipramine hcl 21
clonazepam 19
clonazepam odt 19
clonidine hcl 43
clopidogrel 40
clorazepate dipotassium 37
CLORPRES 43
clotrimazole 24
clotrimazole/ 24
betamethasone
dipropionate
COARTEM 31
dentagel 49
87
Drug name Page
DEPEN TITRATABS 75
DEPOCYT 27
dextrose 5%/nacl 75
0.225%
DEPO-ESTRADIOL 57
dextrose 5%/nacl 0.3% 75
Drug name Page
diphenhydramine hcl 71
diphenoxylate/atropine 51
DESCOVY 35
diphtheria/tetanus 63
toxoids adsorbed
pediatric
desipramine hcl 21
disopyramide phosphate 44
desmopressin acetate 56
dextrose 5%/potassium 75
chloride 0.15%
disulfiram 13
divalproex sodium 19
dextrose 50% 75
divalproex sodium dr 19
desonide 54
dextrose 70% 75
divalproex sodium er 19
desoximetasone 55
diazepam 19
DIVIGEL 57
desvenlafaxine er 21
diazepam 37
DOCEFREZ 27
DETROL LA 53
diazepam intensol 37
docetaxel 27
dexamethasone 55
DIBENZYLINE 43
dofetilide 44
DEXAMETHASONE 55
INTENSOL
diclofenac potassium 10
donepezil hcl 21
diclofenac sodium 68
dorzolamide hcl 68
diclofenac sodium dr 10
diclofenac sodium er 10
dorzolamide hcl/timolol 68
maleate
dicloxacillin sodium 16
doxazosin mesylate 44
dicyclomine hcl 51
doxepin hcl 22
didanosine 35
doxepin hydrochloride 49
DIFICID 16
DOXERCALCIFEROL 66
diflorasone diacetate 55
doxorubicin hcl 27
diflunisal 10
doxorubicin hcl liposome 27
dextrose 10%/nacl 75
0.45%
digitek 43
doxy 100 16
digox 43
doxycycline 16
dextrose 5% /electrolyte 75
#48 viaflex
digoxin 43
doxycycline hyclate 16
doxycycline hyclate dr 16
dextrose 10% 75
dihydroergotamine 25
mesylate
DILANTIN 19
DEPO-PROVERA
desogestrel/ethinyl 57
estradiol
dexamethasone sodium
phosphate
dexamethasone sodium 68
phosphate
DEXILANT 51
dexmethylphenidate hcl 48
dexrazoxane 27
dextroamphetamine 48
sulfate
88
Drug name Page
diltiazem cd
dextrose 2.5%/nacl 75
0.45%
diltiazem hcl 43
dextrose 20% 75
diltiazem hcl cd 43
dextrose 25% 75
diltiazem hcl er 43
dextrose 30% 75
dilt-xr 43
dextrose 40% 75
DIOVAN 43
dextrose 5% 75
DIOVAN HCT 43
dextrose 5%/lactated 75
ringers
DIPENTUM 65
diphenatol 51
doxycycline 16
monohydrate
dronabinol 23
drospirenone/ethinyl 57
estradiol
DROXIA 27
duloxetine hcl 22
duloxetine hcl 37
duramorph 10
DUREZOL 68
dutasteride 53
Drug name Page
Drug name Page
Drug name Page
dutasteride/tamsulosin 53
hydrochloride
epinastine hcl 68
ESCAVITE LQ 75
EPIPEN 2-PAK 71
escitalopram oxalate 22
DYRENIUM 44
EPIPEN-JR 2-PAK 71
esgic 10
E.E.S. GRANULES 16
epirubicin hcl 27
econazole nitrate 24
epitol 19
esomeprazole 51
magnesium
EDARBI 44
EPIVIR 35
EDARBYCLOR 44
EPIVIR HBV 35
estarylla 57
EDURANT 35
eplerenone 44
ESTRACE 57
EFFIENT 41
epoprostenol sodium 71
estradiol 58
EGRIFTA 56
eprosartan mesylate 44
ELESTRIN 57
EPZICOM 35
estradiol/norethindrone 58
acetate
ELIDEL 49
EQUETRO 38
elinest 57
ERAXIS 24
ELIQUIS 41
ERBITUX 27
ELITEK 27
ergoloid mesylates 21
ELLA 57
ERGOMAR 25
EMCYT 27
ERIVEDGE 27
EMEND
emoquette 57
EMPLICITI 27
errin 57
ERWINAZE 27
ery
EMSAM 22
ERYPED 200 16
EMTRIVA 35
ERYPED 400 16
ENABLEX 53
ERY-TAB 16
enalapril maleate 44
ERYTHROCIN 16
LACTOBIONATE
enalapril maleate/ 44
hydrochlorothiazide
esomeprazole sodium
ESTRING 58
eszopiclone 73
ethambutol hcl 25
ethosuximide 19
etidronate disodium 66
etodolac 10
etodolac er 11
etoposide 27
EVAMIST 58
EVISTA 58
EVOMELA 27
EVOTAZ 35
EVZIO 14
EXELDERM 24
EXELON 21
ENBRACE HR 82
ERYTHROCIN 16
STEARATE
exemestane 27
ENDOCET 10
erythromycin 16
EXFORGE 44
endodan 10
erythromycin 49
EXFORGE HCT 44
ENGERIX-B 63
erythromycin 68
EXJADE 75
enoxaparin sodium 41
erythromycin base 16
EXTAVIA 48
enpresse-28 57
EXTRA-VIRT PLUS DHA 75
enskyce 57
erythromycin 16
ethylsuccinate
entacapone 32
erythromycin stearate 16
falmina 58
entecavir 35
erythromycin/benzoyl 49
peroxide
famciclovir 35
ENTRESTO 44
enulose 51
ENVARSUS XR 63
EPCLUSA 35
ESBRIET 71
ESCAVITE 75
ESCAVITE D 75
FABRAZYME 51
famotidine 52
famotidine premixed 52
FANAPT 33
89
Drug name Page
Drug name Page
FANAPT TITRATION 33
PACK
fludrocortisone acetate 55
FOLIVANE-OB 76
flunisolide 71
FOLIVANE-PRX DHA NF 76
FARESTON 27
fluocinolone acetonide 55
FOLOTYN 27
FARYDAK 27
fomepizole 76
FASLODEX 27
body
fondaparinux sodium 41
FAZACLO 33
FORADIL AEROLIZER 71
felodipine er 44
scalp
FEMRING 58
fluocinonide 55
fenofibrate 44
fluocinonide-e 55
fenofibrate micronized 44
fluor-a-day 75
fenofibric acid 44
fluoride 75
fosinopril sodium/ 44
hydrochlorothiazide
fenofibric acid dr 44
fluoridex daily defense 75
fosphenytoin sodium 19
felbamate 19
FENOGLIDE 44
fluoritab
FORTEO 66
FORTICAL 66
FOSAMAX PLUS D 66
fosinopril sodium 44
FOSRENOL 53
fluorometholone 68
FRAGMIN 41
fluorouracil 27
furosemide 44
fentanyl citrate oral 11
transmucosal
fluorouracil 50
FUSILEV 27
fluoxetine dr 22
FUZEON 35
FERRIPROX 67
fluoxetine hcl 22
fyavolv 58
FERRIPROX 75
fluphenazine decanoate 33
FYCOMPA 19
FETZIMA 22
fluphenazine hcl 33
gabapentin 19
FETZIMA TITRATION 22
PACK
FLURA-DROPS 76
GABITRIL 19
flurbiprofen 11
finasteride 53
flurbiprofen sodium 68
galantamine 21
hydrobromide
FIRAZYR 63
flutamide 27
GAMASTAN S/D 63
FIRMAGON 62
fluticasone propionate 55
GAMMAPLEX 63
FLAREX 68
fluticasone propionate 71
GAMUNEX-C 63
flavoxate hcl 53
fluvastatin 44
ganciclovir 35
flecainide acetate 44
fluvastatin sodium er 44
GARDASIL 63
fenoprofen calcium 11
fentanyl
90
Drug name Page
FLECTOR 11
fluvoxamine maleate
GARDASIL 9 63
FLORIVA 75
FML
gatifloxacin 68
FLOVENT DISKUS 71
FML FORTE 68
GATTEX 52
FLOVENT HFA 71
FOCALGIN 90 DHA 76
gavilyte-c 52
floxuridine 27
FOCALGIN CA 76
gavilyte-g 52
fluconazole 24
FOCALGIN-B 76
gavilyte-h 52
fluconazole in dextrose 24
FOLCAL DHA 76
gavilyte-n/flavor pack 52
fluconazole in nacl 24
FOLCAPS OMEGA 3 76
GAZYVA 27
flucytosine 24
FOLET DHA 76
GELNIQUE 53
fludarabine phosphate 27
FOLET ONE 76
gemcitabine 27
Drug name Page
Drug name Page
Drug name Page
gemcitabine hcl 28
glycopyrrolate 52
gemfibrozil 44
glydo 13
HUMALOG MIX 50/50 38
KWIKPEN
generlac 52
GOLYTELY 52
gengraf 63
granisetron hcl 23
gentak 68
griseofulvin microsize 24
KWIKPEN
gentamicin sulfate 16
griseofulvin 24
ultramicrosize
guanfacine er 48
pediatric
guanidine hcl 25
gentamicin sulfate/0.9% 16
sodium chloride
halobetasol propionate 55
GENVOYA 35
haloperidol 33
HUMIRA PEN 64
PSORIASIS STARTER
GEODON 33
haloperidol decanoate 33
HUMULIN 70/30 38
gianvi 58
haloperidol lactate 33
gildagia 58
HARVONI 35
HUMULIN 70/30 38
KWIKPEN
gildess 1.5/30 58
HAVRIX 64
gildess 1/20 58
heather 58
gildess 24 fe 58
hecoria 64
gildess fe 1.5/30 58
HECTOROL 66
gildess fe 1/20 58
HEMENATAL OB 76
GILENYA 48
HEMENATAL OB + DHA 76
GILOTRIF 28
HUMULIN R U-500 39
KWIKPEN
heparin sodium 41
glatopa 48
hydralazine hcl 44
heparin sodium/d5w 41
GLEEVEC 28
hydrochlorothiazide 44
heparin sodium/nacl 41
0.45%
hydrocodone bitartrate/ 11
acetaminophen
heparin sodium/nacl 41
0.9%
hydrocodone/ 11
acetaminophen
heparin sodium/sodium 41
chloride 0.9%
hydrocodone/ibuprofen 11
heparin sodium/sodium 41
chloride 0.9% premix
hydrocortisone butyrate 55
GLEOSTINE 28
glimepiride 38
glipizide 38
glipizide er 38
glipizide xl 38
glipizide/metformin hcl 38
GLUCAGEN 38
DIAGNOSTIC
GLUCAGEN HYPOKIT 38
HALAVEN 28
HALOG 55
hepatamine 76
HERCEPTIN 28
HETLIOZ 73
GLUCAGON 38
EMERGENCY KIT
HEXALEN 28
glyburide 38
HIBERIX 64
glyburide micronized 38
HUMALOG 38
glyburide/metformin hcl 38
HUMALOG KWIKPEN 38
HUMIRA 64
HUMIRA PEDIATRIC 64
CROHNS DISEASE
STARTER PACK
HUMIRA PEN 64
HUMIRA PEN-CROHNS
DISEASE STARTER
HUMULIN N 38
HUMULIN N KWIKPEN 39
HUMULIN R 39
HUMULIN R U-500 39
(CONCENTRATED)
hydrocortisone 55
hydrocortisone butyrate 55
(lipophilic)
hydrocortisone in 55
absorbase
hydrocortisone valerate
hydrocortisone/acetic 70
acid
hydromorphone hcl
91
Drug name Page
Drug name Page
hydroxychloroquine 31
sulfate
INVEGA SUSTENNA 33
JENTADUETO XR 39
INVEGA TRINZA 33
jevantique lo 58
hydroxyprogesterone 58
caproate
INVIRASE 35
JEVTANA 28
INVOKAMET 39
JINTELI 58
INVOKANA 39
jolessa 58
IPOL INACTIVATED IPV 64
jolivette 58
ipratropium bromide 72
juleber 58
ibudone 11
ipratropium bromide/ 72
albuterol sulfate
junel 1.5/30 58
ibuprofen 11
irbesartan 44
ICLUSIG 28
junel fe 1.5/30 58
idarubicin hcl 28
irbesartan/ 45
hydrochlorothiazide
junel fe 1/20 58
ifosfamide 28
IRESSA 28
ILARIS 64
irinotecan 28
ILEVRO 68
ISENTRESS 35
imatinib mesylate 28
isoniazid 25
IMBRUVICA 28
ISOPTO CARPINE 68
imipenem/cilastatin 16
isosorbide dinitrate 45
imipramine hcl 22
isosorbide dinitrate er 45
imiquimod 50
isosorbide mononitrate 45
kcl 0.075%/d5w/nacl 76
0.45%
IMOVAX RABIES 64
(H.D.C.V.)
isosorbide mononitrate 45
er
kcl 0.15%/d5w/lr 76
INATAL ADVANCE 76
isotonic gentamicin 16
INATAL ULTRA 76
isradipine 45
INCRELEX 56
ISTALOL 68
INCRUSE ELLIPTA 71
ISTODAX 28
0.45%
indapamide 44
itraconazole 24
kcl 0.15%/d5w/nacl 0.9% 76
INFANRIX 64
ivermectin 31
INLYTA 28
IXEMPRA KIT 28
kcl 0.3%/d5w/lr iv lac 76
ring
INNOPRAN XL 44
IXIARO 64
kcl 0.3%/d5w/nacl 0.45% 76
INTELENCE 35
JAKAFI 28
kcl 0.3%/d5w/nacl 0.9% 76
INTRALIPID 76
JALYN 53
kelnor 1/35 58
INTRON A 28
jantoven 41
KETEK 17
INTRON A 35
JANUMET 39
ketoconazole 24
INTRON A W/DILUENT 28
JANUMET XR 39
ketoprofen 11
introvale 58
JANUVIA 39
ketoprofen er 11
INTUNIV 48
JARDIANCE 39
ketorolac tromethamine 68
INVANZ 16
jencycla 58
KEYTRUDA 28
INVEGA 33
JENTADUETO 39
KHEDEZLA 22
hydroxyurea 28
hydroxyzine hcl 71
ibandronate sodium 66
IBRANCE 28
92
Drug name Page
junel 1/20 58
junel fe 24 58
KABIVEN 76
KADCYLA 28
kaitlib fe 58
KALETRA 36
KALYDECO 72
kariva 58
kcl 0.15%/d5w/nacl 0.2% 76
0.225%
Drug name Page
Drug name Page
kimidess 58
LATUDA 33
levora 0.15/30-28 59
KINRIX 64
layolis fe 59
levothyroxine sodium 61
kionex 76
leena 59
levoxyl 61
klor-con 76
leflunomide 64
LEXIVA 36
klor-con 10 76
LENVIMA 10 MG DAILY 28
DOSE
LIALDA 65
KLOR-CON 25 76
klor-con 8 76
klor-con m10 76
KLOR-CON M15 76
klor-con m20 77
klor-con sprinkle 77
klor-con/ef 77
KOMBIGLYZE XR 39
KORLYM 39
KRISTALOSE 52
k-sol 76
kurvelo 58
KUVAN 51
KYNAMRO 45
DOSE
DOSE
DOSE
Drug name Page
lidocaine 13
lidocaine hcl 13
lidocaine hcl 45
lidocaine hcl jelly 13
lidocaine viscous 13
lidocaine/prilocaine 13
DOSE
LIDODERM 13
DOSE
linezolid 17
lessina 59
LETAIRIS 72
letrozole 28
leucovorin calcium 29
LEUKERAN 29
lindane 31
LINZESS 52
liothyronine sodium 62
LIPOFEN 45
LIPOSYN III 77
lisinopril 45
LEUKINE 41
lisinopril/ 45
hydrochlorothiazide
leuprolide acetate 62
lithium 38
levalbuterol 72
lithium carbonate 38
lactated ringers viaflex 77
LEVEMIR 39
lithium carbonate er 38
lactulose 52
LEVEMIR FLEXTOUCH 39
LO LOESTRIN FE 59
labetalol hcl 45
LACRISERT 68
lactated ringers dextrose 77
5% viaflex
lamivudine 36
lamivudine/zidovudine 36
lamotrigine
lamotrigine odt 20
lamotrigine titration 20
lansoprazole 52
LANTUS 39
LANTUS SOLOSTAR 39
larin 1.5/30 58
larin 1/20 59
larin 24 fe 59
larin fe 1.5/30 59
larin fe 1/20 59
latanoprost 68
levetiracetam
lomedia 24 fe 59
levobunolol hcl 68
lomustine 29
levocarnitine 77
LONSURF 29
levocetirizine 72
dihydrochloride
loperamide hcl 52
levofloxacin 17
levofloxacin 68
levofloxacin in d5w 17
levoleucovorin 29
levoleucovorin calcium 29
levonest 59
levonorgestrel 59
levonorgestrel/ethinyl 59
estradiol
lopreeza 59
lorazepam 37
lorazepam intensol 37
lorcet 11
lorcet hd 11
lorcet plus 11
LORTAB 11
loryna 59
losartan potassium 45
93
Drug name Page
Drug name Page
losartan potassium/ 45
hydrochlorothiazide
memantine 21
hydrochloride
methylphenidate hcl er 48
LOTEMAX 68
MENACTRA 64
methylprednisolone 55
lovastatin 45
MENEST 59
LOVAZA 45
MENHIBRIX 64
acetate
low-ogestrel 59
loxapine succinate 33
MENOMUNE-A/C/ 64
Y/W-135
dose pack
ludent 77
MENTAX 24
LUMIGAN 68
MENVEO 64
sodiumsuccinate
LUMIZYME 51
MEPRON 32
metipranolol 68
LUPRON DEPOT 62
mercaptopurine 29
metoclopramide hcl 52
LUPRON DEPOT-PED 62
meropenem 17
metolazone 45
lutera 59
meropenem/sodium 17
chloride
metoprolol succinate er 45
mesalamine 65
mesalamine dr 65
metoprolol/ 45
hydrochlorothiazide
mesna 29
METRO IV 17
MESNEX 29
METROGEL 50
MESTINON 25
metronidazole 17
MESTINON TIMESPAN 25
metronidazole 50
metadate er 48
metronidazole in nacl 17
0.79%
LYNPARZA 29
LYRICA 20
LYSODREN 62
lyza 59
magnesium sulfate 77
malathion
maprotiline hcl 22
margesic 11
marlissa 59
MARPLAN 22
MARQIBO 29
MATULANE 29
matzim la 45
MAXIDEX 68
meclizine hcl 23
meclofenamate sodium 11
metaproterenol sulfate 72
metformin hcl 39
metformin hcl er 39
methadone hcl 11
methadose 12
methadose sugar-free 12
methazolamide 45
methenamine hippurate 17
methimazole 62
medroxyprogesterone 59
acetate
methotrexate 64
mefloquine hcl 31
methotrexate sodium 64
megestrol acetate 59
methoxsalen 50
MEKINIST 29
methscopolamine 52
bromide
meloxicam 11
melphalan hydrochloride 29
memantine hcl 21
memantine hcl titration 21
pak
94
Drug name Page
methylphenidate hcl sr
metoprolol tartrate 45
metronidazole vaginal 17
mexiletine hcl 45
MIACALCIN 66
MICARDIS 45
MICARDIS HCT 45
microgestin 1.5/30 59
microgestin 1/20 59
microgestin 24 fe 59
microgestin fe 59
microgestin fe 1.5/30 59
midodrine hcl 45
MIGERGOT 25
MIGRANAL 25
methyclothiazide 45
MILLIPRED 55
methylergonovine 53
maleate
MILLIPRED DP 55
METHYLIN 48
mimvey lo 59
methylphenidate hcl
mimvey 59
minitran 45
Drug name Page
minocycline hcl 17
Drug name Page
mupirocin calcium
Drug name Page
NEBUPENT 32
minoxidil 45
MUSTARGEN 29
necon 0.5/35-28 59
MIRAPEX ER 32
mvc-fluoride 77
necon 1/35 59
mirtazapine 22
mycophenolate mofetil 64
NECON 1/50-28 59
mirtazapine odt 22
myorisan 50
NECON 10/11-28 60
misoprostol 52
MYRBETRIQ
necon 7/7/7 60
mitomycin 29
myzilra 59
nefazodone hcl 22
mitoxantrone hcl 29
nabumetone 12
neomycin sulfate 17
M-M-R II 64
nadolol 45
modafinil 73
moderiba 36
nadolol/ 45
bendroflumethiazide
neomycin/bacitracin/ 69
polymyxin
moexipril hcl 45
NAFCILLIN 17
moexipril/ 45
hydrochlorothiazide
nafcillin sodium
NAGLAZYME 51
neomycin/polymyxin/ 69
bacitracin/
hydrocortisone
dexamethasone
MOLINDONE 33
HYDROCHLORIDE
nalbuphine hcl 12
naloxone hcl 14
mometasone furoate 55
gramicidin
naltrexone hcl 14
mono-linyah 59
neomycin/polymyxin/hc 70
NAMENDA 21
mononessa 59
montelukast sodium 72
NAMENDA TITRATION 21
PAK
hydrocortisone
morgidox 1x100mg 17
NAMENDA XR 21
morgidox 1x50mg 17
NAMENDA XR 21
TITRATION PACK
NEPHRAMINE 77
NAMZARIC 48
NESTABS 77
morphine sulfate er 12
naphazoline hcl 69
NESTABS DHA 78
MOTOFEN 52
NAPRELAN 12
NEUMEGA 41
MOVIPREP 52
naproxen 12
NEUPOGEN 41
MOXATAG 17
naproxen dr 12
NEUPRO 32
MOXEZA 68
naproxen sodium 12
NEVANAC 69
MULTAQ 45
naratriptan hcl 25
nevirapine 36
multi vitamin/fluoride 77
NARCAN 14
nevirapine er 36
multi-vit/fluoride 77
NASONEX 72
NEXA PLUS 78
multi-vit/iron/fluoride 77
NATACHEW 77
NEXAVAR 29
multivitamin with fluoride 77
NATACYN 69
multi-vitamin/fluoride 77
NATALVIRT 90 DHA 77
niacin er 45
multi-vitamin/fluoride/ 77
iron
NATALVIRT CA 77
NIASPAN 46
nateglinide 39
nicardipine hcl 46
mult-vitamin/fluoride 77
NATELLE ONE 77
NICOTROL NS 14
mupirocin 50
NATPARA 67
nifedical xl 46
morgidox 2x100mg 17
morphine sulfate
hydrocortisone
neo-polycin 69
NEXIUM
95
Drug name Page
Drug name Page
nifedipine er 46
nortrel 1/35 60
ofloxacin 70
nikki 60
nortrel 7/7/7 60
OGESTREL 60
NILANDRON 29
nortriptyline hcl 22
olanzapine 33
nilutamide 29
NORVIR 36
olanzapine odt 33
nimodipine 46
NOVOLIN 70/30 39
olanzapine/fluoxetine 22
NINLARO 29
novolin 70/30 relion 39
OLEPTRO 22
NIPENT 29
NOVOLIN N 39
olopatadine hcl 69
nisoldipine 46
novolin n relion 39
olopatadine hcl 72
nisoldipine er 46
NOVOLIN R 39
nitrofurantoin 17
novolin r relion 39
omega-3-acid ethyl 46
esters
nitrofurantoin 17
macrocrystals
NOVOLOG 39
omeprazole 52
NOVOLOG FLEXPEN 39
OMNARIS 72
NOVOLOG MIX 70/30 39
ONCASPAR 29
NOVOLOG MIX 70/30 39
PREFILLED FLEXPEN
ondansetron hcl 23
ondansetron odt 23
nitrofurantoin 17
monohydrate
nitroglycerin 46
nitroglycerin lingual
NOVOLOG PENFILL 39
ONFI 20
nitroglycerin transdermal 46
NOXAFIL 24
ONGLYZA 39
NITROMIST 46
NUEDEXTA 48
OPDIVO 29
NITROSTAT 46
NULOJIX 64
OPSUMIT 72
NIVA-PLUS 78
NUPLAZID 33
oralone 49
nizatidine 52
nyamyc 24
ORAP 33
nora-be 60
NYMALIZE 46
ORFADIN 51
NORDITROPIN 56
FLEXPRO
nystatin 24
ORFADIN 67
nystatin/triamcinolone 24
ORKAMBI 72
norethindrone 60
norethindrone & ethinyl 60
estradiol ferrous
fumarate
nystop 24
orsythia 60
OB COMPLETE GOLD 78
OSMOPREP 52
OB COMPLETE ONE 78
OTREXUP 64
norethindrone acetate 60
OB COMPLETE PETITE 78
oxacillin sodium 17
norethindrone acetate/ 60
ethinyl estradiol
OB COMPLETE 78
PREMIER
oxaliplatin 29
oxandrolone 60
norethindrone acetate/ 60
ethinyl estradiol/ferrous
fumarate
OB COMPLETE/DHA 78
oxaprozin 12
O-CAL PRENATAL 78
oxcarbazepine 20
ocella 60
oxiconazole nitrate 24
octreotide acetate 62
OXISTAT 24
ODEFSEY 36
OXSORALEN 50
ODOMZO 29
oxybutynin chloride 54
OFEV 72
oxybutynin chloride er 54
norgestimate/ethinyl 60
estradiol
NORINYL 1+50 60
NORITATE 50
norlyroc 60
NORTHERA 46
96
Drug name Page
nortrel 0.5/35 (28) 60
ofloxacin 17
ofloxacin 69
oxycodone hcl
Drug name Page
Drug name Page
Drug name Page
oxycodone/ 12
acetaminophen
pentoxifylline er 46
piperacillin sodium/ 18
tazobactam sodium
oxycodone/aspirin 12
PERFOROMIST 72
piperacillin/tazobactam 18
oxycodone/ibuprofen 12
PERIKABIVEN 78
pirmella 1/35 60
pacerone 46
perindopril erbumine 46
pirmella 7/7/7 60
paclitaxel 29
periogard 49
piroxicam 12
PAIRE OB 78
PERJETA 29
plenamine 78
paliperidone er 33
permethrin 32
pamidronate disodium 66
perphenazine 33
pancrelipase 51
PANRETIN 29
perphenazine/ 22
amitriptyline
PNV FERROUS 78
FUMARATE/
DOCUSATE/FOLIC ACID
pantoprazole sodium 52
phenadoz 23
paricalcitol 66
phenelzine sulfate 22
paroex 49
phenergan 23
PNV PRENATAL PLUS 78
MULTIVITAMIN
paromomycin sulfate 17
phenobarbital 20
PNV TABS 29-1 78
PNV-DHA 78
paroxetine hcl er 22
phenoxybenzamine 46
hydrochloride
PASER 25
phenytoin 20
PATADAY 69
phenytoin sodium 20
PATANASE 72
phenytoin sodium 20
extended
paroxetine hcl
PATANOL 69
PAXIL 22
PAZEO 69
PCE 17
PEDIARIX 64
PEDVAX HIB 64
peg 3350/electrolytes 52
peg-3350/nacl/na 52
bicarbonate/kcl
PEGANONE 20
PEGINTRON 36
PEG-INTRON REDIPEN 36
penicillin g potassium 17
penicillin g procaine 17
penicillin g sodium 18
penicillin v potassium 18
PENTACEL 64
PENTAM 300 32
pentoxifylline cr 46
philith 60
phos-flur 49
PHOSPHOLINE IODIDE 69
physiolyte 78
physiosol irrigation 78
PICATO 50
pilocarpine hcl 49
pilocarpine hcl 69
pilocarpine 49
hydrochloride
pimozide 33
pimtrea 60
pindolol 46
pioglitazone hcl 39
pioglitazone hcl/ 40
metformin hcl
pioglitazone hcl 39
glimepiride
PNV FOLIC ACID + 78
IRON MULTIVITAMIN
PNV OB+DHA 78
PNV-SELECT 78
PNV-VP-U 78
podofilox 50
polycin 69
polyethylene glycol 3350 52
polymyxin b sulfate/ 69
trimethoprim sulfate
poly-vitamin/fluoride 78
POMALYST 29
portia-28 60
PORTRAZZA 29
potassium chloride 79
0.15% /nacl 0.45% viaflex
0.15% d5w/nacl 0.33%
0.15% d5w/nacl 0.45%
0.15% d5w/nacl 0.45%
viaflex
0.15% nacl 0.9%
PENTASA 65
97
Drug name Page
Drug name Page
0.22% d5w/nacl 0.45%
PREFERA OB + DHA 79
PROCRIT 41
PREFERAOB +DHA 79
procto-med hc 56
0.224%d5w/nacl 0.45%
viaflex
PREFERAOB ONE 79
procto-pak 56
PREMARIN 60
proctosol hc 56
PREMASOL 79
proctozone-hc 56
PRENAISSANCE 79
progesterone 60
0.3%/d5w
PRENAISSANCE PLUS 79
PROGLYCEM 40
PRENATA 79
PROGRAF 64
potassium chloride cr 78
PRENATABS FA 79
PROLASTIN-C 72
potassium chloride er 78
PRENATAL 19 80
PROLENSA 69
potassium chloride sr 79
PRENATAL PLUS 80
PROLEUKIN 29
potassium citrate er 79
PRENATAL PLUS IRON 80
PROLIA 66
POTIGA 20
PRENATE AM 80
PROMACTA 41
PR NATAL 400 79
PRENATE DHA 80
promethazine hcl 23
PR NATAL 400 EC 79
PRENATE ELITE 80
promethazine hcl 72
PR NATAL 430 79
PRENATE ESSENTIAL 80
promethegan 23
PR NATAL 430 EC 79
PRENATE MINI 80
propafenone hcl 46
PRADAXA 41
PRENATE PIXIE 80
propafenone hcl er 46
PRALUENT 46
PREPLUS 80
propantheline bromide 53
PREPOPIK 53
proparacaine hcl 69
PREQUE 10 80
propranolol hcl 46
PRETAB 80
propranolol hcl er 46
prevalite 46
previfem 60
propranolol/ 46
hydrochlorothiazide
PREZCOBIX 36
propylthiouracil 63
PREZISTA 36
PROQUAD 64
PRIFTIN 25
protriptyline hcl 22
primaquine phosphate 32
PROVENTIL HFA 72
primidone 20
PROVIDA DHA 82
PRISTIQ 22
PROVIGIL 73
PROAIR HFA 72
PULMICORT 72
FLEXHALER
0.3%/ nacl 0.9%
pramipexole
dihydrochloride
pramipexole 32
dihydrochloride er
PRANDIN 40
pravastatin sodium 46
prazosin hcl 46
PRED MILD 69
PRED-G 69
PRED-G S.O.P. 69
prednicarbate 55
prednisolone 56
prednisolone acetate 69
prednisolone sodium 55
phosphate
PROAIR RESPICLICK 72
probenecid 24
prednisolone sodium 69
phosphate
probenecid/colchicine 24
prednisone 56
prochlorperazine 34
edisylate
PREDNISONE 56
INTENSOL
PREFERA OB 79
98
Drug name Page
prochlorperazine
prochlorperazine 34
maleate
PULMOZYME 72
PUREFE OB PLUS 80
PURIXAN 29
pyrazinamide 25
pyridostigmine bromide 25
QNASL 72
QNASL CHILDRENS 72
Drug name Page
Drug name Page
Drug name Page
QUADRACEL 64
RESCRIPTOR 36
SANTYL 50
QUALAQUIN 32
RESTASIS 69
SAPHRIS 34
quasense 60
RETROVIR IV INFUSION 36
SAVAYSA 41
quetiapine fumarate 34
REVLIMID 30
SELECT-OB 81
QUFLORA PEDIATRIC 81
REXULTI 34
selegiline hcl 32
quinapril hcl 46
REYATAZ 36
selenium sulfide 50
quinapril/ 46
hydrochlorothiazide
RHINOCORT AQUA 72
SELZENTRY 36
ribasphere 36
SE-NATAL 19 81
quinidine gluconate cr 46
ribavirin 36
SENSIPAR 62
quinidine gluconate er 46
RIDAURA 65
SEREVENT DISKUS 72
quinidine sulfate 46
rifabutin 25
SEROQUEL XR 34
quinidine sulfate er 46
rifampin 25
sertraline hcl 22
quinine sulfate 32
RIFATER 25
SE-TAN DHA 81
QVAR 72
riluzole 48
setlakin 60
RABAVERT 64
rimantadine hcl 36
raloxifene hydrochloride 60
ringers injection 81
sharobel 60
ramipril 47
risedronate sodium 66
SIGNIFOR 62
RANEXA 47
risedronate sodium dr 66
ranitidine hcl 53
RISPERDAL CONSTA 34
SILENOR 73
RAPAFLO 54
risperidone 34
silver sulfadiazine 50
RAPAMUNE 65
risperidone odt 34
SIMBRINZA 69
RASUVO 65
RITUXAN 30
SIMULECT 65
RAVICTI 51
rivastigmine tartrate 21
simvastatin 47
reclipsen 60
SINGULAIR 72
RECOMBIVAX HB 65
rivastigmine transdermal 21
system
REGRANEX 50
rizatriptan benzoate 25
SIRTURO 26
relador pak plus 13
rizatriptan benzoate odt 25
SIVEXTRO 18
RELENZA DISKHALER 36
RELISTOR
RELNATE DHA
ropinirole hcl
rosadan
rosuvastatin calcium 47
sf
sildenafil
sirolimus 65
sodium bicarbonate 81
sodium bicarbonate
partial fill
REMICADE 65
ROTARIX 65
sodium chloride 81
RENVELA 54
ROTATEQ 65
repaglinide 40
roweepra 20
sodium chloride 0.45% 81
viaflex
repaglinide/metformin 40
hydrochloride
ROXICET 13
ROZEREM 73
sodium fluoride 81
REPATHA 47
RYTARY 32
sodium phenylbutyrate 51
REPATHA 47
PUSHTRONEX SYSTEM
SABRIL 20
sodium polystyrene 81
sulfonate
REPATHA SURECLICK 47
SAMSCA 81
SANDIMMUNE 65
sodium chloride 0.9%
sodium sulfacetamide 50
99
Drug name Page
sodium sulfacetamide 69
SULFAMYLON
Drug name Page
tazicef 18
SOLTAMOX 30
sulfasalazine 65
TAZORAC 50
SOMATULINE DEPOT 62
sulfatrim pediatric 18
taztia xt 47
SOMAVERT 62
sulindac 13
TECENTRIQ 30
sorine 47
sumatriptan
TEFLARO 18
sotalol hcl 47
sumatriptan succinate
TEGRETOL-XR 20
sotalol hcl (af) 47
SOVALDI 36
sumatriptan succinate 25
refill
TEKTURNA 47
SPIRIVA HANDIHALER 72
SUMAVEL DOSEPRO 25
TEKTURNA HCT 47
SPIRIVA RESPIMAT 72
SUPRAX 18
telmisartan 47
spironolactone 47
SUPREP BOWEL PREP 53
telmisartan/amlodipine 47
spironolactone/ 47
hydrochlorothiazide
SURMONTIL 22
SUSTIVA 36
telmisartan/ 47
hydrochlorothiazide
SPORANOX 24
SUTENT 30
temazepam 37
sprintec 28 60
syeda 61
TEMODAR 30
SPRITAM 20
SYLATRON
TEKAMLO 47
TENIVAC 65
SPRYCEL 30
SYLVANT 30
terazosin hcl 47
sronyx 61
SYMBICORT 73
terbinafine hcl 24
ssd 50
SYMLINPEN 120 40
terbutaline sulfate 73
stavudine 36
SYMLINPEN 60 40
terconazole 24
sterile water irrigation 81
SYNAGIS 65
TESTIM 61
STIOLTO RESPIMAT 72
SYNAREL 62
testosterone 61
STIVARGA 30
SYNERCID 18
testosterone cypionate 61
streptomycin sulfate 18
SYNJARDY 40
testosterone enanthate 61
STRIBILD 36
SYNRIBO 30
STRIVERDI RESPIMAT 72
SYNTHROID 62
tetanus/diphtheria 65
toxoids-adsorbed
STROMECTOL 32
SYPRINE 81
tetrabenazine 48
SUBOXONE 14
TABLOID 30
tetracycline hcl 18
SUCLEAR 53
tacrolimus 65
THALOMID 30
sucralfate 53
TAFINLAR 30
THEO-24 73
sulfacetamide sodium 50
TAGRISSO 30
sulfacetamide sodium 69
TAMIFLU 36
theophylline cr 73
sulfacetamide sodium/ 69
prednisolone sodium
phosphate
tamoxifen citrate 30
theophylline er 73
tamsulosin hcl 54
THERACYS 30
TARCEVA 30
THIOLA 54
TARGRETIN 30
thioridazine hcl 34
tarina fe 1/20 61
thiotepa 30
TARON-PREX 81
thiothixene 34
TASIGNA 30
thrivite rx 81
sulfadiazine 18
sulfamethoxazole/ 18
trimethoprim
100
Drug name Page
sulfamethoxazole/ 18
trimethoprim ds
theophylline
Drug name Page
Drug name Page
Drug name Page
THYMOGLOBULIN 65
topotecan hcl 30
triderm 56
THYROLAR-1 62
TOPROL XL 47
tri-estarylla 61
THYROLAR-1/2 62
TORISEL 30
trifluoperazine hcl 34
THYROLAR-1/4 62
torsemide 47
trifluridine 70
THYROLAR-2 62
tpn electrolytes 81
TRIGLIDE 47
THYROLAR-3 62
TRACLEER 73
trihexyphenidyl hcl 32
tiagabine hydrochloride 20
TRADJENTA 40
tri-legest fe 61
TICE BCG 30
ticlopidine hcl 41
tramadol hcl
tri-linyah 61
tri-lo-estarylla 61
TIKOSYN 47
tramadol hydrochloride/ 13
acetaminophen
tilia fe 61
trandolapril 47
tri lo-sprintec 61
timolol maleate 47
trandolapril/verapamil 47
hcl
trilyte 53
timolol maleate 69
timolol maleate 69
ophthalmic gel forming
tinidazole 18
TIVICAY 36
tizanidine hcl 34
TL FOLATE 81
TL-CARE DHA 81
TL-SELECT 81
TOBI PODHALER 73
TOBRADEX 69
TOBRADEX ST 69
tobramycin
tobramycin sulfate 18
tobramycin sulfate 70
tobramycin sulfate/ 18
sodium chloride
tobramycin/ 70
dexamethasone
TOBREX
trandolapril/verapamil 47
hcl er
tranexamic acid 41
TRANSDERM-SCOP 23
tranylcypromine sulfate 22
TRAVATAN Z 70
travoprost 70
trazodone hcl 22
TREANDA 30
TRECATOR 26
TRELSTAR MIXJECT 62
TRESIBA FLEXTOUCH 40
tretinoin 30
tretinoin 50
TRIADVANCE 81
triamcinolone acetonide
triamcinolone acetonide 73
triamcinolone in orabase 49
tolazamide 40
triamterene/ 47
hydrochlorothiazide
tolbutamide 40
trianex 56
tolmetin sodium 13
triazolam 37
tolterodine tartrate
tolterodine tartrate er 54
topiramate
toposar 30
TRICARE 81
tri-lo-marzia 61
trimethoprim 18
trimethoprim sulfate/ 70
polymyxin b sulfate
trimipramine maleate 22
TRINATAL GT 81
TRINATAL RX 1 81
trinessa 61
trinessa lo 61
TRINTELLIX 23
triple antibiotic 70
triple-vitamin/fluoride 81
tri-previfem 61
TRISENOX 30
tri-sprintec 61
TRISTART DHA 81
TRIUMEQ 37
TRIVEEN-DUO DHA 82
TRIVEEN-PRX RNF 82
tri-vit/fluoride 81
TRI-VIT/FLUORIDE/IRON 81
tri-vitamin/fluoride 81
trivora-28 61
trospium chloride
TRICARE PRENATAL 81
COMPLEAT
trospium chloride er 54
TRICARE PRENATAL 81
DHA ONE
TRUMENBA 65
TRULICITY 40
TRUVADA 37
101
Drug name Page
Drug name Page
TWINRIX 65
VELPHORO 54
VIRAMUNE XR 37
TYBOST 37
VEMAVITE-PRX 2 82
VIRAZOLE 37
TYGACIL 18
VENA-BAL DHA 82
VIREAD 37
TYKERB 30
VENCLEXTA 31
VIRT-ADVANCE 82
TYPHIM VI 65
VENCLEXTA STARTING 31
PACK
VIRT-C DHA 82
VIRT-CARE ONE 82
TYZEKA 37
TYZINE PEDIATRIC 73
NASAL DROPS
venlafaxine hcl 23
VIRT-PN 82
venlafaxine hcl er 23
VIRT-PN DHA 82
ULORIC 24
VENTAVIS 73
VIRT-PN PLUS 82
ULTIMATECARE ONE 82
NF
VENTOLIN HFA 73
VIRT-SELECT 82
verapamil hcl 48
unithroid 62
VITAFOL FE+ 82
verapamil hcl er 47
ursodiol 53
VITAFOL GUMMIES 82
verapamil hcl sr 47
UVADEX 30
VITAFOL-ONE 82
VEREGEN 50
VAGIFEM 61
VERSACLOZ 34
VITAMEDMD ONE RX/ 82
QUATREFOLIC
valacyclovir hcl 37
VESICARE 54
VALCHLOR 30
vestura 61
VITAMEDMD PLUS RX/ 82
QUATRE FOLIC
VALCYTE 37
VEXOL 70
vitamins a/d/c/fluoride 82
valganciclovir 37
V-GO 20 67
VITEKTA 37
valproate sodium 20
V-GO 30 67
VOL-NATE 82
valproic acid 20
V-GO 40 67
VOL-PLUS 82
valsartan 47
vicodin 13
valsartan/ 47
hydrochlorothiazide
vicodin es 13
voriconazole 24
vicodin hp 13
VOTRIENT 31
VICTOZA 40
VP CH ULTRA 82
VIDEX PEDIATRIC 37
VP-CH-PNV 82
vienva 61
VP-HEME OB 82
VIGAMOX 70
VP-HEME ONE 82
VIIBRYD 23
VP-PNV-DHA 82
VIIBRYD STARTER 23
PACK
VPRIV 51
VRAYLAR 34
VIMPAT 20
vyfemla 61
vinblastine sulfate 31
warfarin sodium 41
vincasar pfs 31
WELCHOL 48
vincristine sulfate 31
wera 61
vinorelbine tartrate 31
wymzya fe 61
viorele 61
XALKORI 31
VIRACEPT 37
XARELTO 41
VALSTAR 31
VANCOCIN HCL 18
vancomycin 18
vancomycin hcl 18
vancomycin hcl in 18
dextrose
vandazole 18
VANTAS 62
VAQTA 65
VARIVAX 65
VASCEPA 47
VASOSTRICT 56
VECTIBIX 31
VELCADE 31
velivet 61
102
Drug name Page
VIRAMUNE 37
VOLTAREN
Drug name Page
Drug name Page
XARELTO STARTER 41
PACK
zoledronic acid 66
XENAZINE 48
zolmitriptan 25
XGEVA 66
zolmitriptan odt 25
XIFAXAN 18
ZOLINZA 31
zolpidem tartrate
XOLAIR 73
ZOMIG 25
XOPENEX HFA 73
ZOMIG NASAL SPRAY 25
XTANDI 31
ZONALON 50
xulane 61
zonisamide 21
XYREM 73
ZORTRESS 65
YERVOY 31
ZOSTAVAX 65
YF-VAX 65
zovia 1/35e 61
YONDELIS 31
ZOVIA 1/50E 61
zafirlukast 73
ZYDELIG 31
zaleplon 73
ZYFLO
ZALTRAP 31
ZYKADIA 31
zamicet 13
ZYLET 70
ZANOSAR 31
ZYPREXA RELPREVV 34
zarah 61
ZYTIGA 31
ZATEAN-CH 82
ZYVOX 19
ZATEAN-PN 82
ZATEAN-PN DHA 82
ZATEAN-PN PLUS 82
ZAVESCA 51
zazole 24
zebutal 13
ZELBORAF 31
ZEMPLAR 66
ZENATANE 50
zenchent 61
zenchent fe 61
ZENPEP 51
ZETIA 48
ZETONNA 73
ZIAGEN 37
zidovudine 37
ziprasidone hcl 34
ZIRGAN 70
ZOLADEX 62
103
This formulary was updated on 10/1/2016. For more recent information or other questions, please contact
Coventry Health Care at 1-844-741-8423 or for TTY: 711. October 1 to February 14, you can call us 8 a.m.
to 8 p.m., 7 days a week. From February 15 to September 30, we’re here 8 a.m. to 8 p.m., Monday through
Friday, or visit http://www.formulary.coventry-medicare.com.
Contract/PBP: H1608, 025, 026, 027, H1692, 002
81.05.361.1 K (10/16)
16246C

2016 Comprehensive Formulary

Transcription

Similar documents

2016 Comprehensive Formulary

Fidelis Care 2016 Formulary (List of Covered Drugs)

Medicare Plans | AARP

MPI 3275 1 2/1 4 - Arkansas Blue Cross and Blue Shield

WellCare 2013 Comprehensive Formulary, Medicare

Comprehensive Formulary

Medicare Part D Excluded Drug List

fixed dose combinations approved by dcg (i) since 1961 till

SilverScript 2016 Choice Formulary

MaineCare MAC List Effective 5.13.16