Fidelis Care 2016 Formulary (List of Covered Drugs)

Transcription

Fidelis Care
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
H3328_FC 15054 CMS Accepted
00016379. Version 10
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.
This document includes the list of the drugs (formulary) for our plan which is current as of
10/01/2016. 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.
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, 2016,
and from time to time during the year.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on
contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New
York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on
contract renewal.
This information is available for free in other languages. Please contact our Member Services
number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544).
Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday
through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services
also has free language interpreter services available for non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con
nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los
usuarios con deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención
es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero,
y de lunes a viernes, de 8:a.m. hasta las 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre.
1
Servicios al Socio también tiene servicios gratuitos de intérprete disponibles para personas que no
hablan inglés.
What is the Fidelis Care Formulary?
A formulary is a list of covered drugs selected by Fidelis Care 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. Fidelis Care will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Fidelis Care 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.
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 10/01/2016. To get updated information about the drugs covered by Fidelis Care,
please contact us. Our contact information appears on the front and back cover pages. To get
updated information about the drugs covered by Fidelis Care, please visit our Web site at
www.fideliscare.org or call Member Services at 1-800-247-1447. Hours are 8:00 a.m. to 8:00 p.m.
seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00
p.m. from February 15 through September 30. TTY/TDD users should call 1-800-695-8544.
We will mail you updated information about our formulary in the event that there are mid-year
non-maintenance formulary changes.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
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Medical Condition
The formulary begins on page 7. 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”. If you know
what your drug is used for, look for the category name in the list that begins on page number 7.
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 74. 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?
Fidelis Care 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.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:

Prior Authorization: Fidelis Care requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from Fidelis Care before
you fill your prescriptions. If you don’t get approval, Fidelis Care may not cover the drug.

Quantity Limits: For certain drugs, Fidelis Care limits the amount of the drug that Fidelis
Care will cover. For example, Fidelis Care provides 30 pills per prescription for
ROZEREM. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Fidelis Care 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, Fidelis Care may not cover Drug
B unless you try Drug A first. If Drug A does not work for you, Fidelis Care will then
cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 7. You can also get more information about the restrictions applied
to specific covered drugs by visiting our Web site. We have posted on line a document that
explains 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.
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You can ask Fidelis Care 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 Fidelis Care’s formulary?” on page 4 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that Fidelis Care does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Fidelis Care.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by Fidelis Care.

You can ask Fidelis Care to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Fidelis Care’s Formulary?
You can ask Fidelis Care to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.


You can ask us to cover a drug even if it is not on our formulary.
You can ask us to provide a higher level of coverage for your drug. If your drug is
contained in our non-preferred brand or specialty tier you can ask us to cover it at the costsharing amount that applies to drugs in our preferred brand tier. If your drug is in our nonpreferred generic tier, you can ask us to cover it at the cost-sharing amount that applies to
drugs in our preferred generic tier instead. This would lower the amount you must pay for
your drug. Please note, if we grant your request to cover a drug that is not on our
formulary, you may not ask us to provide a higher level of coverage for the drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, Fidelis Care 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, Fidelis Care 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 exception. When
you request a formulary exception you should submit a statement from your prescriber or
physician supporting your request. Generally, we must make our decision within 72 hours of
getting your prescriber’s supporting statement. You can request an expedited (fast) exception if
you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours
for a decision. If your request to expedite is granted, we must give you a decision no later than 24
hours after we get a supporting statement from your doctor or other prescriber.
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What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (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 a 93-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 34-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
For more information
For more detailed information about your Fidelis Care prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Fidelis Care, 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 1877-486-2048. Or, visit http://www.medicare.gov.
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Fidelis Care’s Formulary
The formulary below provides coverage information about the drugs covered by Fidelis Care. If
you have trouble finding your drug in the list, turn to the Index that begins on page 74.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
BICILLIN) and generic drugs are listed in lower-case italics (e.g., ampicillin).
The information in the Requirements/Limits column tells you if Fidelis Care has any special
requirements for coverage of your drug. For example, “PA” means prior authorization is required.
(This means that you will need to get approval from Fidelis Care before you fill your
prescriptions); "ST" means that step therapy is required. (This means you may be required to try
certain drugs for your medical condition before we will cover another drug for that condition);
“QL” means that quantity limits apply (Fidelis Care limits the amount of the drug that Fidelis Care
will cover); “B/D” means that the drug is covered under Part B and Part D of Medicare (Fidelis
Care will determine whether a particular prescription is covered under Part B or Part D).
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BG_CY16_5T_PERFORMANCE eff 10/01/2016
Drug Name
Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol tab
ALOPRIM
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
1
4
2
3
2
3
QL (120 tabs / 30 days)
ST
MISCELLANEOUS
diclofenac w/ misoprostol
DUEXIS
VIMOVO
2
5
5
NSAIDS
celecoxib CAPS
diclofenac potassium
diclofenac sodium TB24
diclofenac sodium TBEC
diflunisal
etodolac
etodolac er
FENOPROFEN CALCIUM CAPS 400mg
fenoprofen calcium TABS
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg, 600mg, 800mg
ketoprofen CAPS; CP24
mefenamic acid CAPS
MELOXICAM SUSP
meloxicam tabs
nabumetone TABS
NAPRELAN 375mg, 750mg
naproxen SUSP
naproxen TABS; TBEC
naproxen sodium TABS 275mg, 550mg
naproxen sodium TB24 375mg
NAPROXEN SODIUM TB24 500mg
oxaprozin
piroxicam CAPS
sulindac TABS
tolmetin sodium
VIVLODEX
ZIPSOR
ZORVOLEX
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
1
2
5
2
1
1
5
5
2
2
1
2
4
4
4
OPIOID ANALGESICS
7
Drug Name
acetaminophen w/ codeine SOLN
2
QL (5000 mL / 30 days)
acetaminophen w/ codeine TABS
2
acetaminophen-caff-dihydrocod
2
QL (360 caps / 30 days)
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP2
356.4-30-16 MG
BELBUCA 75mcg, 150mcg, 300mcg,
4
QL (120 buccal films /
450mcg
30 days), PA
BELBUCA 600mcg, 750mcg, 900mcg
4
QL (60 buccal films / 30
days), PA
butorphanol nasal spray
2
QL (10 mL / 30 days)
butorphanol tartrate SOLN
2
BUTRANS 5mcg/hr
3
QL (16 patches / 28
days)
BUTRANS 7.5mcg/hr, 10mcg/hr
3
QL (8 patches / 28
days)
BUTRANS 15mcg/hr, 20mcg/hr
3
QL (4 patches / 28
days)
capital and codeine
4
QL (5000 mL / 30 days)
CONZIP 100mg
4
CONZIP 200mg
4
CONZIP 300mg
4
nalbuphine hcl SOLN
2
TRAMADOL HCL CP24 100mg
2
2
2
tramadol hcl er TB24 100mg
2
tramadol hcl er TB24 200mg
2
TRAMADOL HCL ER TB24 300mg
2
tramadol hcl er (biphasic) 100mg
2
2
2
tramadol hcl tab 50 mg
2
tramadol-acetaminophen
2
trezix
4
OPIOID ANALGESICS, CII
ABSTRAL
5
CODEINE SULFATE 15mg
DILAUDID-HP INJ 250MG
DURAMORPH
EMBEDA
endocet
fentanyl citrate LPOP
2
2
2
4
2
4
2
5
QL (120 tabs / 30 days),
PA
B/D
B/D
QL (120 lozenges / 30
days), PA
8
Drug Name
fentanyl patch 12 mcg/hr
FENTORA
hydrocodone-acetaminophen 2.5-325mg
hydrocodone-acetaminophen 5-300mg
hydrocodone-acetaminophen 7.5-325
mg/15ml
hydrocodone-acetaminophen tab 10325mg
hydrocodone-ibuprofen tab 2.5-200mg
hydrocodone-ibuprofen tab 5-200mg
hydrocodone-ibuprofen tab 7.5-200 mg
hydrocodone-ibuprofen tab 10-200mg
hydromorphone hcl LIQD
HYDROMORPHONE HCL SOLN 1mg/ml,
2mg/ml, 4mg/ml
hydromorphone hcl SOLN 500mg/50ml
hydromorphone hcl TABS
hydromorphone tab 8mg er
HYDROMORPHONE TABS 32MG
HYSINGLA ER 20mg, 30mg, 40mg, 60mg
HYSINGLA ER 80mg, 100mg, 120mg
ibudone tab 5-200mg
ibudone tab 10-200mg
INFUMORPH 200
INFUMORPH 500
KADIAN 40mg, 200mg
LAZANDA
levorphanol tartrate TABS
lorcet hd tab 10-325mg
lorcet plus tab 7.5-325
lorcet tab 5-325mg
2
QL (10 patches / 30
days)
2
QL (10 patches / 30
days)
2
QL (10 patches / 30
days), PA
2
QL (10 patches / 30
days), PA
2
QL (10 patches / 30
days), PA
5
PA
2
2
2
2
2
QL (5400 mL / 30 days)
2
2
2
2
2
2
2
2
2
QL
QL
QL
QL
2
2
2
2
5
5
4
5
2
2
4
4
5
5
B/D
B/D
B/D
QL (30 bottles / 30
days), PA
2
2
2
2
(150
(150
(150
(150
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
B/D
9
Drug Name
lortab tab 5-325mg
lortab tab 7.5-325
lortab tab 10-325mg
methadone hcl CONC
methadone hcl SOLN
methadone hcl TABS
METHADONE INJ 10MG/ML
MORPHINE SUL 20MG/ML ORAL SOL
MORPHINE SUL INJ 1MG/ML
morphine sulfate CP24 10mg, 20mg,
30mg, 50mg, 60mg
morphine sulfate CP24 80mg, 100mg
MORPHINE SULFATE SOLN 2mg/ml,
8mg/ml
MORPHINE SULFATE SOLN 10mg/5ml,
20mg/5ml
morphine sulfate SOLN .5mg/ml, 1mg/ml,
4mg/ml, 8mg/ml
MORPHINE SULFATE TABS
morphine sulfate beads
morphine sulfate ext-rel tab 15mg, 30mg,
60mg, 100mg
morphine sulfate ext-rel tab 200mg
NUCYNTA 50mg
NUCYNTA 75mg
NUCYNTA 100mg
NUCYNTA ER 50mg, 100mg
NUCYNTA ER 150mg, 200mg, 250mg
OPANA ER (CRUSH RESISTANT 5mg,
7.5mg, 10mg, 15mg, 20mg
OPANA ER (CRUSH RESISTANT 30mg,
40mg
oxycodone hcl CAPS
oxycodone hcl CONC
OXYCODONE HCL SOLN
oxycodone hcl TABS
oxycodone w/ acetaminophen 2.5-325mg
oxycodone w/ acetaminophen 5-325mg
oxycodone w/ acetaminophen soln 5-325
mg/5ml
oxycodone-aspirin
oxycodone-ibuprofen
2
2
2
2
QL (120 mL / 30 days)
2
QL (600 mL / 30 days)
2
4
2
2
B/D
2
B/D
2
B/D
2
B/D
2
5
2
B/D
2
2
B/D
2
2
2
2
4
4
4
4
4
4
QL
QL
QL
QL
QL
QL
QL
5
2
2
2
2
2
2
2
2
2
2
2
QL
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(360 tabs / 30 days)
(60 tabs / 30 days)
(180 tabs
(360 tabs
(360 tabs
(360 tabs
(360 tabs
(1800 mL
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
10
Drug Name
OXYCONTIN 10mg, 15mg, 20mg, 30mg,
40mg
OXYCONTIN 60mg, 80mg
oxymorphone hcl TABS
reprexain tab 10-200mg
roxicet tab 5-325mg
SUBSYS
4
5
2
2
2
5
vicodin
2
vicodin es
2
vicodin hp
2
XARTEMIS XR
4
XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg 4
XTAMPZA ER 36mg
4
xylon tab 10-200mg
2
zamicet
2
ZOHYDRO ER (ABUSE DETERRENT) 10mg, 4
15mg, 20mg
ZOHYDRO ER (ABUSE DETERRENT) 30mg, 4
40mg, 50mg
QL (120 sprays / 30
days), PA
QL (5400 mL / 30 days)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
hcl (local anesth.) 4%
hcl (local anesth.) .5%, 1%
inj 0.5%
inj 1%
inj 1.5%
inj 2%
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
BETHKIS
gentamicin in saline
gentamicin sulfate SOLN
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
TOBI PODHALER
tobramycin NEBU
tobramycin sulfate SOLN; SOLR
2
5
2
2
2
2
2
4
5
5
2
B/D, NM
NM, LA, PA
B/D, NM
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone SUSP
AZACTAM/DEX INJ 1GM
4
4
5
4
11
Drug Name
AZACTAM/DEX INJ 2GM
aztreonam
BILTRICIDE
CAYSTON
clindamycin hcl CAPS
clindamycin palmitate hydrochloride
clindamycin phosphate SOLN
clindamycin phosphate in d5w
colistimethate sodium SOLR
CUBICIN
DALVANCE
dapsone TABS
DARAPRIM
DORIBAX
emverm
imipenem-cilastatin
INVANZ
ivermectin TABS
linezolid SOLN
LINEZOLID SUSR; TABS
LINEZOLID IN SODIUM CHLORIDE
MACRODANTIN 25mg
meropenem
MEROPENEM/SODIUM CHLORIDE
methenamine hippurate
METRO IV
metronidazole CAPS
metronidazole TABS
metronidazole inj
NEBUPENT
nitrofurantoin SUSP
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
PENTAM 300
polymyxin b sulfate SOLR
PRIMSOL
5
2
3
5
NM, LA, PA
1
2
2
2
2
5
5
2
4
4
4
2
4
2
5
5
5
4
PA; PA applies if 65
years and older after a
90 day supply in a
calendar year
2
2
2
3
2
1
2
4
B/D
2
90 day supply in a
calendar year
4
90 day supply in a
calendar year
4
90 day supply in a
calendar year
4
2
4
12
Drug Name
SIVEXTRO
sulfamethoxazole-trimethop SUSP
sulfamethoxazole-trimethop TABS
sulfamethoxazole-trimethoprim inj
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl CAPS
vancomycin hcl SOLR
VANCOMYCIN IN NACL
XIFAXAN TAB 200MG
ZYVOX TABS
5
2
1
2
5
1
5
5
2
4
5
5
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
CRESEMBA
ERAXIS
fluconazole SUSR; TABS
fluconazole in dextrose
fluconazole in nacl
flucytosine CAPS
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole CAPS
ketoconazole TABS
LAMISIL PACK
MYCAMINE
NOXAFIL
nystatin TABS
ONMEL
SPORANOX SOL 10MG/ML
terbinafine hcl TABS
voriconazole SUSR; TABS
voriconazole inj 200mg
5
5
2
5
5
5
2
2
2
5
2
2
2
2
4
5
5
2
5
5
1
5
2
B/D
B/D
B/D
PA
PA
PA
ANTIMALARIALS
atovaquone-proguanil hcl tab 62.5-25 mg 2
atovaquone-proguanil hcl tab 250-100 mg 2
chloroquine phosphate TABS
2
COARTEM
4
mefloquine hcl
2
PRIMAQUINE PHOSPHATE
3
quinine sulfate CAPS
2
PA
ANTIRETROVIRAL AGENTS
abacavir sulfate
2
13
Drug Name
APTIVUS
CRIXIVAN
didanosine
EDURANT
EMTRIVA
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP
nevirapine TABS; TB24
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg, 150mg
PREZISTA TABS 600mg, 800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine
SUSTIVA CAPS
SUSTIVA TABS
TIVICAY 10mg
TIVICAY 25mg, 50mg
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE XR 100mg
VIREAD
VITEKTA
ZIAGEN SOLN
zidovudine
5
4
2
5
3
5
NM
4
5
5
3
5
3
5
2
4
5
2
2
3
5
3
5
4
3
5
5
2
3
5
3
5
3
4
5
4
5
5
3
2
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine-zidovudine
ATRIPLA
COMPLERA
DESCOVY
EPZICOM
EVOTAZ
5
5
5
5
5
5
14
Drug Name
GENVOYA
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
ODEFSEY
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
5
5
3
5
5
5
5
5
5
5
5
5
5
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
ethambutol hcl TABS
isoniazid SOLN; SYRP
isoniazid tabs
paser d/r
PRIFTIN
pyrazinamide TABS
rifabutin
rifamate
rifampin CAPS; SOLR
RIFATER
SIRTURO
TRECATOR
4
5
2
2
1
3
4
2
2
4
2
4
5
4
LA, PA
ANTIVIRALS
acyclovir CAPS; TABS
acyclovir SUSP
acyclovir sodium SOLN
acyclovir sodium SOLR 500mg
adefovir dipivoxil
BARACLUDE SOLN
cidofovir
DAKLINZA
entecavir
EPIVIR HBV SOLN
famciclovir TABS
ganciclovir inj 500mg
HARVONI
lamivudine (hbv)
moderiba pak MISC
moderiba pak TABS 400mg
MODERIBA PAK TABS 600mg
1
2
2
2
5
3
5
5
5
4
2
2
5
2
5
5
5
B/D
B/D
NM, PA
B/D
NM, PA
NM
NM
NM
15
Drug Name
moderiba tab 200mg
PEG-INTRON REDIPEN
PEGASYS
PEGASYS PROCLICK
PEGINTRON
REBETOL SOLN
RELENZA DISKHALER
ribapak mis 600/day
ribasphere CAPS
ribasphere TABS 200mg, 400mg
ribasphere TABS 600mg
ribasphere ribapak 800
ribavirin 200mg
rimantadine hydrochloride
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl TABS
VALCYTE SOLR
valganciclovir hcl
2
NM
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM
3
5
NM
2
NM
2
NM
5
NM
5
NM
5
NM
5
NM
2
NM
2
5
NM, PA
3
5
2
5
5
CEPHALOSPORINS
AVYCAZ
5
cefaclor
2
cefaclor er tab 500mg
3
cefadroxil CAPS
1
cefadroxil SUSR; TABS
2
cefazolin in dextrose 1gm/50ml-5%
3
CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 3
cefazolin inj
2
cefazolin sodium 1gm, 20gm
2
cefdinir
2
CEFEPIME 1GM SOLN
4
CEFEPIME 2GM SOLN
4
CEFEPIME HCL AND DEXTROSE
4
cefepime inj 1gm
2
cefepime inj 2gm
2
cefixime
2
cefotaxime sodium 1gm, 2gm, 500mg
2
cefotetan disodium
2
cefoxitin sodium
2
CEFOXITIN SODIUM IN DEXTROSE
4
cefpodoxime proxetil
2
cefprozil
2
ceftazidime
2
16
Drug Name
CEFTAZIDIME/DEXTROSE
CEFTIBUTEN
CEFTIN SUSR
ceftriaxone sodium SOLR 1gm, 2gm,
10gm, 250mg, 500mg
cefuroxime axetil
cefuroxime sodium 1.5gm, 7.5gm, 750mg
cephalexin CAPS 250mg, 500mg
cephalexin CAPS 750mg
cephalexin SUSR
cephalexin TABS
claforan 1gm, 2gm
CLAFORAN/D5W
FORTAZ SOLN
FORTAZ SOLR 500mg
MAXIPIME
SUPRAX CAPS
suprax CHEW
SUPRAX SUSR 500mg/5ml
tazicef SOLR
tazicef vial
TEFLARO
ZERBAXA
ZINACEF SOLR 750mg
4
2
4
2
2
2
1
2
2
2
4
4
4
4
4
3
4
3
2
2
4
5
4
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin SOLR; SUSR
azithromycin TABS
clarithromycin SUSR; TABS; TB24
DIFICID
e.e.s. 400 tab 400mg
E.E.S. GRANULES
ery-tab
ERYPED 200
ERYPED 400
erythrocin lactobionate
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
PCE
ZMAX
2
2
1
2
5
2
4
2
4
4
4
2
2
2
2
4
4
FLUOROQUINOLONES
AVELOX SOLN
ciprofloxacin SUSR
ciprofloxacin er
4
2
2
17
Drug Name
ciprofloxacin hcl TABS
ciprofloxacin in d5w
ciprofloxacin inj 200mg/20ml
ciprofloxacin inj 400mg/40ml
levofloxacin SOLN
levofloxacin TABS
levofloxacin in d5w
MOXIFLOXACIN HCL SOLN
moxifloxacin hcl TABS
1
2
2
2
2
1
2
4
2
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
ampicillin & sulbactam sodium
ampicillin cap 250mg
ampicillin cap 500 mg
ampicillin inj
ampicillin sodium
ampicillin susp
AUGMENTIN SUSR
BACTOCILL INJ DEX 1GM
BACTOCILL INJ DEX 2GM
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
MOXATAG
NAFCILLIN
nafcillin sodium 1gm
nafcillin sodium 2gm, 10gm
NAFCILLIN SODIUM IN DEXTROSE
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN DEXTROSE
PENICILLIN G POTASSIUM IN
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
penicilln gk inj 20mu
pfizerpen-g inj 5mu
pfizerpen-g inj 20mu
piperacillin sodium-tazobactam sodium
ZOSYN SOLN
1
2
2
1
1
2
2
2
4
4
5
4
4
2
4
4
2
5
4
2
5
4
4
3
2
1
2
2
2
2
2
4
TETRACYCLINES
demeclocycline hcl
doxy
doxycycline (monohydrate)
2
2
2
18
Drug Name
doxycycline hyclate CAPS; SOLR; TABS;
TBEC
doxycycline hyclate tab 75 mg dr
minocycline hcl CAPS; TABS; TB24
morgidox
SOLODYN
TETRACYCLINE HCL CAPS
VIBRAMYCIN SYRP
2
2
2
2
2
2
5
2
4
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE CAPS
cyclophosphamide SOLR 1gm, 500mg
cyclophosphamide SOLR 2gm
dacarbazine
EMCYT
GLEOSTINE
HEXALEN
IFEX INJ 3GM
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
LEUKERAN
melphalan hcl
MUSTARGEN
thiotepa SOLR
TREANDA
ZANOSAR
5
4
5
4
5
2
2
4
4
5
4
2
2
4
2
4
5
4
5
5
4
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
2
2
5
B/D
B/D
B/D
2
2
2
5
B/D
B/D
B/D
B/D
2
5
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D
ANTHRACYCLINES
daunorubicin hcl
doxorubicin hcl 50mg
doxorubicin hcl liposomal inj (for iv
infusion) 2 mg/ml
doxorubicin inj 50mg
epirubicin inj 50mg/25ml
epirubicin inj 200mg
idarubicin hcl
ANTIBIOTICS
bleomycin sulfate
COSMEGEN
mitomycin SOLR
19
Drug Name
ANTIMETABOLITES
adrucil
ALIMTA
ARRANON
azacitidine
cladribine
CLOLAR
cytarabine inj
decitabine
fludarabine phosphate
fluorouracil SOLN
GEMCITABINE HCL SOLN
gemcitabine hcl SOLR
mercaptopurine TABS
METHOTREXATE SODIUM 50mg/2ml
methotrexate sodium 50mg/2ml,
100mg/4ml, 200mg/8ml, 250mg/10ml
methotrexate sodium inj
NIPENT
PURIXAN
TABLOID
2
5
5
5
5
5
2
5
2
2
5
5
2
2
2
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
2
5
5
4
B/D
B/D
NM
5
5
5
2
5
B/D
B/D
B/D
B/D
B/D
5
2
B/D
B/D
3
2
2
2
B/D
B/D
B/D
B/D
5
5
5
5
5
5
5
5
5
5
B/D, NM
B/D, NM, LA
NM, PA
B/D, NM
NM, LA, PA
NM, LA, PA
B/D, NM
NM, LA, PA
B/D, NM
B/D, NM
B/D
B/D
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCETAXEL CONC 20mg/ml, 80mg/4ml
docetaxel CONC 140mg/7ml
DOCETAXEL SOLN 20mg/2ml
DOCETAXEL SOLN 160mg/16ml,
200mg/20ml
DOCETAXEL SOLN 80MG/8ML
paclitaxel
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincasar
vincristine sulfate
vinorelbine tartrate
BIOLOGIC RESPONSE MODIFIERS
ARZERRA
AVASTIN
BELEODAQ
ERBITUX
ERIVEDGE
FARYDAK
HERCEPTIN
IBRANCE
ISTODAX
KADCYLA
20
Drug Name
KEYTRUDA
LYNPARZA
NINLARO
PERJETA
PROLEUKIN
RITUXAN
TECENTRIQ
TORISEL
VECTIBIX
VELCADE
VENCLEXTA 10mg, 50mg
VENCLEXTA 100mg
VENCLEXTA STARTING PACK
YERVOY
ZOLINZA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
B/D, NM
5
NM, LA, PA
5
NM, LA, PA
5
B/D, NM
5
B/D, NM
5
B/D, NM
4
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole TABS
bicalutamide
DEPO-PROVERA INJ 400/ML
ELIGARD INJ 7.5MG
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
ELIGARD INJ 45MG
exemestane
FARESTON
FASLODEX
FIRMAGON 80mg
FIRMAGON 120mg
flutamide
hydroxyprogesterone caproate
(antineoplastic)
letrozole TABS
leuprolide acetate KIT
LUPRON DEP INJ 11.25MG
LUPRON DEP-PED INJ 7.5MG
LUPRON DEP-PED INJ 11.25MG
LUPRON DEP-PED INJ 15MG
LUPRON DEP-PED INJ 30MG (3-MONTH)
LUPRON DEPOT 3.75mg, 7.5mg
LUPRON DEPOT INJ 22.5MG (3-MONTH)
LUPRON DEPOT INJ 30MG (3-MONTH)
LYSODREN
megestrol ac sus 40mg/ml
2
2
4
4
4
4
4
2
5
5
4
5
2
4
megestrol ac tab 20mg
4
2
2
5
5
5
5
5
5
5
5
3
4
B/D
B/D,
B/D,
B/D,
B/D,
NM
NM
NM
NM
B/D
B/D, NM
B/D, NM
B/D
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA; PA if 65 years and
older
older
21
Drug Name
megestrol ac tab 40mg
MEGESTROL SUS 625MG/5ML
NILANDRON
nilutamide
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR MIXJECT
XTANDI
ZYTIGA
4
older
5
PA
5
5
4
1
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
ALECENSA
BOSULIF
CABOMETYX
CAPRELSA
COMETRIQ
COTELLIC
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG
imatinib mesylate
IMBRUVICA CAP 140MG
INLYTA
IRESSA
JAKAFI
LENVIMA 8 MG DAILY DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
LA,
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
LA,
PA
LA,
LA,
LA,
PA
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
22
Drug Name
ZYDELIG
ZYKADIA
5
NM, LA, PA
5
NM, LA, PA
MISCELLANEOUS
bexarotene
DROXIA
HALAVEN
hydroxyurea CAPS
IXEMPRA KIT
LONSURF
MATULANE
mitoxantrone hcl
ODOMZO
POMALYST
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO
tretinoin CAPS
TRISENOX
UVADEX
5
3
5
2
5
5
5
2
5
5
5
5
5
5
5
5
4
NM, PA
2
2
5
5
B/D
B/D
B/D
B/D
5
5
5
5
5
2
2
2
2
5
2
5
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
4
4
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D, NM
NM, PA
LA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
B/D
B/D
PLATINUM-BASED AGENTS
carboplatin
cisplatin
ELOXATIN
oxaliplatin
PROTECTIVE AGENTS
amifostine crystalline
dexrazoxane 250mg
ELITEK
FUSILEV
KEPIVANCE
leucovor ca inj
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium 500 mg
levoleucovorin calcium
mesna
MESNEX TABS
B/D
B/D, NM
B/D
TOPOISOMERASE INHIBITORS
CAMPTOSAR 300mg/15ml
ETOPOPHOS
etoposide SOLN 500mg/25ml
irinotecan inj 40mg/2ml
irinotecan inj 100/5ml
irinotecan inj 500mg/25ml
toposar 1gm/50ml
23
Drug Name
topotecan hcl SOLR
5
B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
trandolapril-verapamil hcl
1
1
1
1
1
1
1
1
1
ACE INHIBITORS
benazepril hcl TABS
captopril TABS
enalapril maleate TABS
fosinopril sodium
lisinopril TABS
moexipril hcl
perindopril erbumine
quinapril hcl
ramipril
trandolapril
1
1
1
1
1
1
1
1
1
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
spironolactone TABS
2
1
ALPHA BLOCKERS
doxazosin mesylate
prazosin hcl
terazosin hcl
2
2
1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-valsartan tab 5-160
mg
mg
mg
mg
amlodipine-valsartan-hydrochlorothiazide
5-160-12.5mg
5-160-25mg
10-160-12.5mg
10-160-25mg
1
1
1
1
1
1
1
1
24
Drug Name
10-320-25mg
AZOR
BENICAR HCT
candesartan cilexetil-hydrochlorothiazide
EDARBYCLOR
ENTRESTO
irbesartan-hydrochlorothiazide
losartan-hydrochlorothiazide
telmisartan-amlodipine
telmisartan-hydrochlorothiazide
TRIBENZOR
valsartan-hydrochlorothiazide
1
3
3
1
4
4
1
1
1
1
3
1
PA
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR
candesartan cilexetil
EDARBI
eprosartan mesylate
irbesartan
losartan potassium
telmisartan
valsartan
3
1
4
1
1
1
1
1
ANTIARRHYTHMICS
amiodarone hcl SOLN
amiodarone hcl TABS 100mg, 400mg
amiodarone hcl TABS 200mg
amiodarone inj 50mg/ml
disopyramide phosphate
2
2
1
2
4
dofetilide
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
2
2
2
4
4
pacerone 100mg, 400mg
pacerone 200mg
propafenone hcl
propafenone hcl 12hr
quinidine gluconate TBCR
quinidine sulfate TABS
sorine
sotalol hcl
sotalol hcl (afib/afl)
TIKOSYN
2
1
2
2
2
2
2
1
2
4
older
NM
older
NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
25
Drug Name
ALTOPREV
atorvastatin calcium TABS
CRESTOR
fluvastatin sodium cap 20 mg
fluvastatin sodium cap 40 mg
fluvastatin sodium tab sr 24 hr 80 mg
LESCOL XL
LIVALO
lovastatin
pravastatin sodium
rosuvastatin calcium
simvastatin TABS 5mg, 10mg, 20mg,
40mg
simvastatin TABS 80mg
4
1
1
1
1
1
4
4
1
1
1
1
1
ANTILIPEMICS, MISCELLANEOUS
ANTARA
cholestyramine
cholestyramine light
choline fenofibrate
colestipol hcl
FENOFIBRATE CAPS
FENOFIBRATE TABS 40mg, 120mg
fenofibrate TABS 48mg, 54mg, 145mg,
160mg
fenofibrate micronized
FENOFIBRIC ACID
FENOGLIDE
gemfibrozil TABS
JUXTAPID
KYNAMRO
niacin er (antihyperlipidemic)
niacor
omega-3-acid ethyl esters
PRALUENT
prevalite
TRIGLIDE
VASCEPA
VYTORIN
WELCHOL
ZETIA TAB 10MG
4
2
2
2
2
2
2
2
2
2
4
1
5
5
2
2
2
5
2
4
4
4
3
3
NM, LA, PA
NM, PA
NM, PA
ST
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone
bisoprolol & hydrochlorothiazide
DUTOPROL
metoprolol & hctz tab 50-25mg
2
1
4
2
2
26
Drug Name
nadolol & bendroflumethiazide
propranolol & hydrochlorothiazide
2
2
2
BETA-BLOCKERS
acebutolol hcl CAPS
atenolol TABS
betaxolol hcl
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
labetalol hcl SOLN; TABS
metoprolol succinate
metoprolol tartrate SOLN
metoprolol tartrate TABS 25mg, 50mg,
100mg
nadolol TABS
pindolol
propranolol hcl er
propranolol inj 1mg/ml
propranolol sol
propranolol tab
SOTYLIZE
timolol maleate TABS
1
1
2
2
4
1
4
2
2
2
1
2
2
2
2
2
1
5
2
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine besylate/atorv
1
CALCIUM CHANNEL BLOCKERS
afeditab cr
amlodipine besylate TABS
CARDIZEM LA 120mg
cartia xt
dilt-xr cap
diltiazem cap 120mg/24hr
diltiazem cap 240mg/24hr
diltiazem cap er/12hr
diltiazem hcl TABS
diltiazem hcl coated beads
diltiazem hcl er
diltiazem hcl extended release beads
diltiazem inj 25mg/5ml
diltiazem inj 50/10ml
diltiazem inj 100mg
diltiazem inj 125/25ml
felodipine
isradipine
matzim la
2
1
4
2
2
2
2
2
1
2
2
2
2
2
4
2
2
2
2
27
Drug Name
nicardipine hcl CAPS
nifedical
nifedipine TB24
nifedipine er
nimodipine CAPS
nisoldipine
NYMALIZE
taztia xt
verapamil hcl CP24 100mg, 120mg,
180mg, 200mg, 240mg, 300mg
VERAPAMIL HCL CP24 360mg
verapamil hcl SOLN
verapamil hcl TABS
verapamil hcl TBCR
2
2
2
2
5
2
5
2
2
2
2
1
1
DIGITALIS GLYCOSIDES
digitek .25mg
2
digitek .125mg
digox 125mcg
digox 250mcg
2
2
2
digoxin TABS 125mcg
digoxin TABS 250mcg
2
2
digoxin inj
DIGOXIN SOL 50MCG/ML
2
2
LANOXIN TABS 62.5mcg
LANOXIN TABS 187.5mcg
4
4
LANOXIN PEDIATRIC
4
PA; PA
older
QL (30
QL (30
PA; PA
older
QL (30
PA; PA
older
if 65 years and
tabs / 30 days)
tabs / 30 days)
if 65 years and
tabs / 30 days)
if 65 years and
older
older
DIRECT RENIN INHIBITORS/COMBINATIONS
TEKTURNA
TEKTURNA HCT
3
3
DIURETICS
acetazolamide CP12; TABS
acetazolamide sodium
ALDACTAZIDE TAB 50/50
amiloride & hydrochlorothiazide
amiloride hcl TABS
bumetanide
chlorothiazide tabs
chlorthalidone 25mg, 50mg
DIURIL SUS 250/5ML
DYRENIUM
EDECRIN
ethacrynic acid
2
2
4
1
2
2
2
2
4
4
4
2
28
Drug Name
furosemide SOLN; TABS
furosemide inj 10mg/ml
FUROSEMIDE INJ 10mg/ml
furosemide oral soln 8 mg/ml
hydrochlorothiazide CAPS; TABS
indapamide
methazolamide TABS
methyclothiazide
metolazone
spironolactone & hydrochlorothiazide
torsemide inj 50mg/5ml
torsemide tabs
triamt/hctz cap 37.5-25
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25
triamt/hctz tab 75-50mg
1
2
2
1
1
1
2
2
2
2
2
1
1
1
1
1
MISCELLANEOUS
BIDIL
clonidine hcl PTWK
clonidine hcl TABS
clorpres
CORLANOR
DEMSER
DIBENZYLINE
hydralazine hcl SOLN; TABS
KEVEYIS
midodrine hcl
minoxidil TABS
phenoxybenzamine hcl CAPS
RANEXA
3
2
1
2
4
5
5
2
5
2
2
5
3
NM, PA
NITRATES
DILATRATE SR
ISORDIL TITRADOSE 40mg
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
minitran
nitro-bid
NITRO-DUR .3mg/hr, .8mg/hr
nitroglycerin SOLN .4mg/spray
NITROGLYCERIN LINGUAL
nitroglycerin patches
NITROSTAT
4
4
2
2
1
1
2
3
4
2
2
2
3
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
5
NM, PA
29
Drug Name
ADEMPAS
5
NM, LA, PA
LETAIRIS
5
NM, LA, PA
OPSUMIT
5
NM, LA, PA
ORENITRAM TAB 0.25MG
5
NM, LA, PA
ORENITRAM TAB 0.125MG
4
NM, LA, PA
ORENITRAM TAB 1MG
5
NM, LA, PA
ORENITRAM TAB 2.5MG
5
NM, LA, PA
REMODULIN
5
B/D, NM, LA
REVATIO SUSR
5
NM, PA
sildenafil citrate (pulmonary hypertension) 2
NM, PA
TABS
TRACLEER
5
NM, LA, PA
TYVASO
5
B/D, NM
UPTRAVI
5
NM, LA, PA
VENTAVIS
5
B/D, NM
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam CONC
alprazolam TABS 1mg
alprazolam TABS 2mg
alprazolam TABS .5mg
alprazolam TABS .25mg
buspirone hcl TABS
fluvoxamine maleate 25mg, 50mg
fluvoxamine maleate 100mg
fluvoxamine maleate er 100mg
fluvoxamine maleate er 150mg
lorazepam CONC
lorazepam SOLN
lorazepam TABS
2
1
1
1
1
2
2
2
2
2
2
2
1
QL
QL
QL
QL
QL
(300
(120
(150
(240
(480
mL / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
QL (150 mL / 30 days)
ANTICONVULSANTS
APTIOM 200mg
APTIOM 400mg, 600mg, 800mg
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT INJ
BRIVIACT SOLN 10MG/ML
BRIVIACT TABS
carbamazepine CHEW; CP12; SUSP;
TABS; TB12
CELONTIN
clonazepam TABS 1mg
clonazepam TABS 2mg
clonazepam TABS .5mg
clonazepam TBDP 1mg
4
5
5
4
5
4
5
5
2
4
1
1
1
2
PA
PA
PA
PA
PA
PA
QL
QL
QL
QL
(120
(300
(240
(120
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
30
Drug Name
clonazepam TBDP 2mg
clonazepam TBDP .5mg
clorazepate dipotassium 3.75mg, 7.5mg
clorazepate dipotassium 15mg
diazepam CONC
diazepam SOLN 1mg/ml
diazepam SOLN 5mg/ml
diazepam TABS
DIAZEPAM GEL (ANTICONVULSANT)
dilantin
DILANTIN-125
divalproex sodium
epitol
ethosuximide CAPS; SOLN
felbamate SUSP
felbamate TABS
FYCOMPA
gabapentin CAPS 100mg
gabapentin SOLN
gabapentin TABS 600mg
gabapentin TABS 800mg
GABITRIL 12mg, 16mg
LAMICTAL ODT KIT
LAMICTAL STARTER
LAMICTAL XR KIT
lamotrigine CHEW; KIT; TB24; TBDP
lamotrigine TABS
levetiracetam SOLN; TABS; TB24
LEVETIRACETAM IV
levetiracetam oral soln 100 mg/ml
LYRICA CAPS 25mg, 50mg, 75mg,
100mg, 150mg
LYRICA CAPS 200mg
LYRICA CAPS 225mg, 300mg
LYRICA SOLN
ONFI SUSP
ONFI TABS 10mg
2
2
2
2
2
PA
2
PA
2
QL (240 mL / 30 days),
PA
2
QL (1200 mL / 30 days),
PA
2
1
PA
2
3
3
2
2
2
5
2
4
PA
1
QL (1080 caps / 30
days)
1
1
2
QL (2160 mL / 30 days)
2
2
4
4
4
4
2
1
2
4
2
3
3
3
3
5
4
QL (946 mL / 30 days)
PA
PA
31
Drug Name
ONFI TABS 20mg
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital ELIX; TABS
5
PA
2
4
4
4
older
PHENOBARBITAL SODIUM SOLN 65mg/ml 4
older
phenobarbital sodium SOLN 130mg/ml
4
older
phenytek
3
phenytoin CHEW; SUSP
2
phenytoin inj 50mg/ml
2
phenytoin sodium extended
2
POTIGA 50mg
4
POTIGA 200mg
5
POTIGA 300mg, 400mg
5
primidone TABS
2
roweepra
2
SABRIL PACK
5
QL (180 packets / 30
days), NM, LA, PA
SABRIL TABS
5
NM, LA, PA
SPRITAM
4
TEGRETOL
4
TEGRETOL-XR
4
tiagabine hcl
2
topiramate CPSP
2
TOPIRAMATE CS24
2
topiramate TABS
1
TROKENDI XR 25mg, 50mg, 100mg
4
TROKENDI XR 200mg
5
valproate sodium SOLN; SYRP
2
valproic acid
2
VIMPAT SOLN
4
VIMPAT TABS 50mg
4
VIMPAT TABS 100mg, 150mg, 200mg
5
zonisamide CAPS
2
ANTIDEMENTIA
donepezil odt 5mg
donepezil odt 10mg
donepezil tab hcl 23mg
donepezil tabs 5mg
donepezil tabs 10mg
EXELON PATCHES
galantamine hydrobromide
galantamine hydrobromide er
2
2
2
2
2
2
2
2
32
Drug Name
memantine hcl
NAMENDA XR
NAMENDA XR TITRATION PACK
NAMZARIC
rivastigmine tartrate
2
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
2
ANTIDEPRESSANTS
amitriptyline hcl TABS
4
amoxapine
APLENZIN
BRINTELLIX
bupropion hcl TABS; TB12; TB24
citalopram hydrobromide SOLN
citalopram hydrobromide TABS
clomipramine hcl CAPS
2
5
4
2
2
1
4
desipramine hcl TABS
doxepin hcl CAPS; CONC
2
4
duloxetine hcl CPEP 20mg, 30mg, 60mg
EMSAM
escitalopram oxalate
FETZIMA
FETZIMA TITRATION PACK
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine hcl CPDR
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg, 20mg
FLUOXETINE HCL TABS 60mg
FORFIVO XL
imipramine hcl TABS
2
5
2
4
4
1
1
1
2
2
2
4
4
4
imipramine pamoate
4
maprotiline hcl
MARPLAN
mirtazapine TABS
mirtazapine TBDP
nefazodone hcl
nortriptyline hcl CAPS
nortriptyline hcl SOLN
paroxetine er tab
paroxetine hcl tabs
PAXIL SUSP
PEXEVA
2
4
1
2
2
1
2
2
1
4
4
older
older
older
PA
older
older
33
Drug Name
phenelzine sulfate TABS
PRISTIQ
protriptyline hcl
sertraline hcl CONC
sertraline hcl TABS
SURMONTIL
2
3
2
2
1
4
older
tranylcypromine sulfate
2
trazodone hcl TABS 50mg, 100mg, 150mg 1
trazodone hcl TABS 300mg
2
trimipramine maleate CAPS
4
older
TRINTELLIX
4
venlafaxine cap er
2
venlafaxine hcl
2
venlafaxine tab
2
VENLAFAXINE TAB 225MG ER
2
venlafaxine tab er
2
VIIBRYD
4
VIIBRYD STARTER PACK
4
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS; SYRP; TABS
APOKYN
AZILECT
BENZTROPINE MESYLATE SOLN
benztropine mesylate TABS
2
5
3
2
4
bromocriptine mesylate CAPS; TABS
carbidopa TABS
carbidopa-levodopa
CARBIDOPA/LEVODOPA/ENTACAPONE
DUOPA
ENTACAPONE
MIRAPEX .75mg
MIRAPEX ER .375mg, 2.25mg, 3mg,
3.75mg, 4.5mg
NEUPRO
pramipexole dihydrochloride
ropinirole hydrochloride
RYTARY
selegiline hcl CAPS; TABS
ZELAPAR
2
5
2
2
4
2
4
4
NM, LA, PA
older
B/D, NM
4
2
2
4
2
5
ANTIPSYCHOTICS
ABILIFY DISCMELT TAB 10MG
ABILIFY MAINTENA
5
5
aripiprazole
5
QL (1 injection / 28
days)
34
Drug Name
aripiprazole oral solution 1 mg/ml
aripiprazole tabs
ARISTADA
chlorpromazine hcl TABS
chlorpromazine inj
clozapine TABS 25mg, 50mg
clozapine TABS 100mg
clozapine TABS 200mg
CLOZAPINE TBDP 150mg
CLOZAPINE TBDP 200mg
CLOZAPINE ODT 12.5mg, 25mg
CLOZAPINE ODT 100mg
FANAPT
FANAPT TITRATION PACK
FAZACLO 150mg
FAZACLO 200mg
fluphenazine decanoate SOLN
fluphenazine hcl
GEODON INJ
haloperidol TABS
haloperidol decanoate SOLN
haloperidol lactate
haloperidol lactate inj 5 mg/ml
INVEGA 1.5mg, 3mg, 9mg
INVEGA 6mg
INVEGA SUST INJ 39 MG/0.25 ML
INVEGA SUST INJ 156MG/ML
INVEGA TRINZA
LATUDA 20mg
LATUDA 40mg, 120mg
LATUDA 60mg, 80mg
loxapine succinate
molindone hcl
5
QL (900ml / 30 days)
5
5
QL (1 syringe / 28 days)
2
4
2
2
2
5
PA
5
PA
2
PA
2
PA
4
ST
4
ST
5
PA
5
PA
2
2
4
QL (6 mL / 3 days)
2
2
2
2
4
4
4
days)
5
days)
5
days)
5
days)
5
days)
5
QL (1 syringe / 90 days)
4
4
4
2
2
35
Drug Name
NUPLAZID
olanzapine SOLR
olanzapine TABS 2.5mg, 5mg, 7.5mg
olanzapine TABS 10mg, 15mg, 20mg
olanzapine odt 5mg
olanzapine odt 10mg, 15mg, 20mg
paliperidone 1.5mg, 3mg, 9mg
paliperidone 6mg
perphenazine TABS
pimozide
quetiapine fumarate
REXULTI 1mg
REXULTI 2mg
REXULTI 3mg, 4mg
REXULTI .5mg
REXULTI .25mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone SOLN
risperidone TABS 1mg, 2mg, 3mg
risperidone TABS 4mg
risperidone TABS .25mg, .5mg
risperidone odt 1mg, 2mg, 3mg
risperidone odt 4mg
risperidone odt .25mg, .5mg
SAPHRIS 2.5mg
SAPHRIS 5mg
SAPHRIS 10mg
SEROQUEL XR 50mg
SEROQUEL XR 150mg, 200mg
SEROQUEL XR 300mg, 400mg
thioridazine hcl TABS
thiothixene
trifluoperazine hcl
5
NM, LA, PA
2
QL (3 vials / 1 day)
2
2
2
2
2
2
2
2
2
5
ST
5
ST
5
ST
5
ST
5
ST
4
QL (2 injections / 28
days)
4
days)
5
days)
5
days)
2
QL (240 mL / 30 days)
2
2
2
2
2
2
4
4
4
4
4
4
4
older
2
2
36
Drug Name
VERSACLOZ
VRAYLAR CAPS 1.5mg
VRAYLAR CAPS 3mg
VRAYLAR CAPS 4.5mg, 6mg
VRAYLAR CPPK
ziprasidone hcl 20mg, 40mg
ziprasidone hcl 60mg, 80mg
ZYPREXA RELPREVV 300mg
ZYPREXA RELPREVV 405mg
ZYPREXA RELPREVV INJ 210MG
5
QL (600 mL / 30 days),
PA
5
QL (120 caps / 30
days), ST
5
QL (60 caps / 30 days),
ST
5
ST
4
ST
2
2
5
QL (2 vials / 28 days),
PA
5
QL (1 vial / 28 days), PA
5
QL (2 vials / 28 days),
PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine cap 10mg er
amphetamine-dextroamphetamine cap sr
24hr 5 mg
amphetamine-dextroamphetamine tab 5
mg
amphetamine-dextroamphetamine tab 7.5
mg
mg
amphetamine-dextroamphetamine tab
12.5 mg
mg
mg
mg
APTENSIO XR 10mg, 15mg, 20mg, 30mg
APTENSIO XR 40mg, 50mg, 60mg
DAYTRANA
2
2
2
2
2
2
QL
QL
QL
QL
QL
QL
(90
(30
(30
(30
(30
(90
caps
caps
caps
caps
caps
caps
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
2
2
2
2
2
2
2
4
4
4
guanfacine er (adhd)
4
metadate er tab 20mg
methylphenidate hcl CHEW
methylphenidate hcl CP24 20mg
METHYLPHENIDATE HCL CP24 30mg
2
2
2
2
QL (30 patches / 30
days)
older
37
Drug Name
methylphenidate hcl CP24 40mg
methylphenidate hcl CPCR 10mg, 20mg,
30mg
methylphenidate hcl CPCR 40mg, 50mg,
60mg
methylphenidate hcl SOLN 5mg/5ml
methylphenidate hcl SOLN 10mg/5ml
methylphenidate hcl TABS 5mg, 10mg
methylphenidate hcl TABS 20mg
methylphenidate hcl TB24
methylphenidate hcl TBCR
methylphenidate hcl er TB24 27mg, 36mg
methylphenidate hcl er TB24 54mg
QUILLICHEW ER 20mg
QUILLICHEW ER 30mg
QUILLICHEW ER 40mg
QUILLIVANT XR
RITALIN LA 10mg
RITALIN LA 60mg
STRATTERA 10mg, 18mg, 25mg
STRATTERA 40mg
STRATTERA 60mg, 80mg, 100mg
VYVANSE 10mg, 20mg, 30mg
VYVANSE 40mg, 50mg, 60mg, 70mg
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
HETLIOZ
ROZEREM
SILENOR 3mg
SILENOR 6mg
temazepam 7.5mg
5
4
3
3
2
temazepam 15mg
2
zolpidem tartrate TABS
4
NM, LA, PA
90 day supply in a
calendar year
90 day supply in a
calendar year
90 day supply in a
calendar year
(1800 mL / 30 days)
(900 mL / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(360 mL / 30 days)
(30 caps / 30 days)
(120 caps / 30 days)
(60 caps / 30 days)
(30 caps / 30 days)
(60 caps / 30 days)
(30 caps / 30 days)
HYPNOTICS
MIGRAINE
almotriptan malate
AXERT
2
4
ST
38
Drug Name
cafergot tab 1-100mg
4
dihydroergotamine mesylate 1mg/ml
2
DIHYDROERGOTAMINE MESYLATE 4mg/ml 5
QL (8 mL / 30 days)
ergomar
4
FROVA TAB 2.5MG
4
ST
frovatriptan succinate
2
migergot
5
naratriptan hcl
2
ONZETRA XSAIL
4
QL (8 pouches / 30
days), ST
RELPAX
3
rizatriptan benzoate
2
sumatriptan inj 4mg/0.5ml SOAJ
2
days)
SUMATRIPTAN INJ 4MG/0.5ML SOCT
2
days)
sumatriptan inj 6mg/0.5ml SOAJ; SOLN; 2
SOSY
days)
SUMATRIPTAN INJ 6MG/0.5ML SOCT
2
days)
SUMATRIPTAN SUCCINATE SOLN 5mg/act 2
QL (24 inhalers / 30
days)
SUMATRIPTAN SUCCINATE SOLN
2
20mg/act
days)
sumatriptan succinate TABS
2
SUMAVEL DOSEPRO
5
days)
TREXIMET
5
ST
ZEMBRACE SYMTOUCH
4
days), ST
zolmitriptan TABS
2
zolmitriptan odt
2
ZOMIG NASAL SPRAY
4
days)
MISCELLANEOUS
BRISDELLE
EQUETRO
GRALISE 300mg
GRALISE 600mg
GRALISE STARTER
HORIZANT
lithium carbonate CAPS; TABS
lithium carbonate TBCR
LITHIUM SOLN 8MEQ/5ML
MESTINON SYRUP
MESTINON TIMESPAN
4
4
3
3
3
4
1
2
3
4
4
39
Drug Name
NUEDEXTA
pyridostigmine bromide TABS; TBCR
riluzole
SAVELLA 12.5mg
SAVELLA 25mg
SAVELLA 50mg
SAVELLA 100mg
SAVELLA TITRATION PACK
tetrabenazine 12.5mg
tetrabenazine 25mg
3
PA
2
2
4
4
4
4
4
5
NM, PA
5
NM, PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
AUBAGIO
5
5
AVONEX
5
AVONEX PEN
5
BETASERON
5
COPAXONE INJ 20MG/ML
5
COPAXONE INJ 40MG/ML
5
EXTAVIA
5
GILENYA CAP 0.5MG
5
LEMTRADA
PLEGRIDY SOPN
5
5
PLEGRIDY SOSY
5
PLEGRIDY STARTER PACK SOPN
5
PLEGRIDY STARTER PACK SOSY
5
REBIF
5
REBIF REBIDOSE
5
REBIF REBIDOSE TITRATION
5
REBIF TITRATION PACK
5
TECFIDERA CAP 120MG
5
NM, LA, PA
NM, LA, PA
days), NM, PA
days), NM, PA
QL (14 syringes / 28
days), NM, PA
days), NM, PA
days), NM, PA
days), NM, PA
NM, PA
NM, LA, PA
QL (2 pens / 28 days),
NM, PA
QL (2 syringes / 28
days), NM, PA
QL (2 pens / 28 days),
NM, PA
QL (2 syringes / 28
days), NM, PA
QL (6 mL / 28 days),
NM, PA
NM, PA
NM, PA
NM, PA
NM, LA, PA
40
Drug Name
TECFIDERA CAP 240MG
TECFIDERA MIS STARTER
TYSABRI
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
BOTOX INJ 100UNIT
BOTOX INJ 200UNIT
dantrolene sodium CAPS
tizanidine
XEOMIN 50UNIT
XEOMIN 100UNIT
XEOMIN 200UNIT
2
5
5
2
2
4
5
5
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NARCOLEPSY/CATAPLEXY
modafinil 100mg
2
modafinil 200mg
5
NUVIGIL 50mg
3
NUVIGIL 150mg
3
NUVIGIL 200mg, 250mg
3
XYREM
5
PA
PA
PA
PA
PA
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
BUNAVAIL MIS 2.1-0.3MG
2
4
BUNAVAIL MIS 4.2-0.7MG
4
BUNAVAIL MIS 6.3-1MG
4
buprenorphine hcl SUBL
buprenorphine hcl-naloxone hcl sl
2
2
buproban tab (smoking deterrent)
bupropion hcl (smoking deterrent)
CHANTIX
CHANTIX CONTINUING MONTH
CHANTIX STARTER PACK
disulfiram TABS
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl TABS
NICOTROL INHALER
2
2
4
4
4
2
2
2
2
4
30 days), PA
30 days), PA
QL (60 buccal films / 30
days), PA
PA
PA
PA
PA
PA
41
Drug Name
NICOTROL NS
SARAFEM
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE MIS 12-3MG
VIVITROL
ZUBSOLV SUB 1.4-0.36MG
4
4
4
QL (120 SL films / 30
days), PA
4
days), PA
4
days), PA
4
days), PA
5
NM
4
PA
4
PA
4
PA
4
PA
4
PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM
4
ANDROGEL 20.25mg/1.25gm,
40.5mg/2.5gm
ANDROGEL 25mg/2.5gm
4
ANDROGEL 1%
4
ANDROGEL 1.62%
4
AXIRON
3
depo-testosterone 100mg/ml
FORTESTA
4
4
oxandrolone TABS 2.5mg
oxandrolone TABS 10mg
STRIANT
2
5
4
TESTIM
4
TESTOSTERONE GEL 1%, 25mg/2.5gm
2
TESTOSTERONE GEL 10mg/act
2
testosterone cypionate SOLN
2
4
QL (30 patches / 30
days), PA
QL (150 grams / 30
days), PA
QL (300 grams / 30
days), PA
QL (300 grams / 30
days), PA
QL (150 grams / 30
days), PA
QL (440 mL / 30 days),
PA
PA
QL (120 grams / 30
days), PA
PA
PA
QL (60 buccal systems /
30 days), PA
QL (300 grams / 30
days), PA
QL (300 grams / 30
days), PA
QL (120 grams / 30
days), PA
PA
42
Drug Name
testosterone enanthate SOLN
VOGELXO
VOGELXO PUMP
2
PA
4
QL (300 grams / 30
days), PA
4
QL (300 grams / 30
days), PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
APIDRA
APIDRA SOLOSTAR
BYDUREON
BYDUREON PEN
BYETTA
GAUZE PADS 2X2
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50 KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25 KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500 KWIKPEN
HUMULIN R U-500 VIAL (CONCENTRATE)
INSULIN PEN NEEDLES
INSULIN SAFETY NEEDLES
INSULIN SYRINGES
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
NOVOLIN R RELION
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
SYMLINPEN 120
TANZEUM
3
4
4
3
3
4
3
4
4
4
4
4
4
4
4
4
4
4
5
5
3
3
3
3
3
3
3
3
4
3
4
3
4
3
3
3
3
3
4
5
4
QL (4 vials / 28 days)
QL (4 pens / 28 days)
QL (1 pen / 30 days)
B/D
PA
PA
43
Drug Name
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
TRULICITY
VICTOZA
3
3
4
3
ANTIDIABETICS, ORAL
acarbose
ACTOPLUS MET XR 15-1000MG
ACTOPLUS MET XR 30-1000MG
FARXIGA 5mg
FARXIGA 10mg
glimepiride 1mg
glimepiride 2mg
glimepiride 4mg
glipizide TABS 5mg
glipizide TABS 10mg
glipizide er 2.5mg
glipizide er 5mg
glipizide er 10mg
GLIPIZIDE XL TB24 2.5MG
GLIPIZIDE XL TB24 5MG
glipizide-metformin 2.5-250 mg
glipizide-metformin 2.5-500 mg
glipizide-metformin 5-500mg
GLUMETZA 500mg
GLUMETZA 1000mg
GLYSET
GLYXAMBI
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA
JARDIANCE 10mg
JARDIANCE 25mg
JENTADUETO
JENTADUETO XR 2.5-1000MG
JENTADUETO XR 5-1000MG
KAZANO
KOMBIGLYZE XR 2.5-1000MG
KOMBIGLYZE XR 5-500MG
2
4
4
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
4
4
4
4
3
3
3
3
3
3
3
3
3
3
3
4
4
3
3
3
4
4
4
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(90 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
44
Drug Name
KOMBIGLYZE XR 5-1000MG
metformin er 500mg
metformin er 750mg
metformin hcl TABS 500mg
metformin hcl TB24 500mg
metformin hcl TB24 1000mg
metformin hcl osmotic 500mg
metformin hcl osmotic 1000mg
miglitol
nateglinide
NESINA 6.25mg
NESINA 12.5mg
NESINA 25mg
ONGLYZA
OSENI TAB 12.5-15MG
OSENI TAB 12.5-30MG
OSENI TAB 12.5-45MG
OSENI TAB 25-15MG
OSENI TAB 25-30MG
OSENI TAB 25-45MG
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl-metformin hcl
PRANDIMET
repaglinide 2mg
repaglinide .5mg, 1mg
repaglinide-metformin hcl
RIOMET
SYNJARDY TAB 5-500MG
SYNJARDY TAB 5-1000MG
SYNJARDY TAB 12.5-500
SYNJARDY TAB 12.5-1000
TRADJENTA
XIGDUO XR TAB 5-500MG
4
1
1
1
1
1
1
1
1
1
2
1
4
4
4
4
4
4
4
4
4
4
1
1
1
4
1
1
1
4
QL (946 mL / 30 days)
4
4
4
4
3
3
3
3
3
BISPHOSPHONATES
alendronate sodium SOLN
alendronate sodium TABS
BINOSTO
FOSAMAX PLUS D
ibandronate sodium
2
1
4
4
2
ibandronate tab 150mg
2
QL (300 mL / 28 days)
ST
B/D, QL (1 injection / 90
days)
B/D
45
Drug Name
pamidronate disodium SOLN
RISEDRONATE SODIUM TABS 5mg, 30mg
risedronate sodium TABS 35mg, 150mg
risedronate sodium TBEC
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
ZOMETA SOLN
2
B/D
2
2
2
2
B/D, NM
2
B/D, NM
5
B/D, NM
CALCIUM RECEPTOR AGONISTS
SENSIPAR 30mg
SENSIPAR 60mg, 90mg
3
5
NM
NM
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
FERRIPROX
JADENU
kionex
sodium polystyrene sulfonate
sps
SYPRINE
VELTASSA
4
5
5
5
5
2
2
2
5
4
NM, LA, PA
NM, LA, PA
NM, PA
NM, LA
ENDOMETRIOSIS
danazol CAPS
LUPANETA PACK
SYNAREL
2
5
5
NM, PA
5
5
5
5
5
5
5
4
5
5
5
5
2
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
B/D
NM,
NM,
NM,
NM,
NM,
NM,
NM
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CERDELGA
CEREZYME
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PROCYSBI
RAVICTI
sodium phenylbutyrate
LA,
LA,
LA,
LA,
PA
LA,
LA
LA,
LA,
PA
LA,
LA,
PA
PA
PA
PA
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
46
Drug Name
VIMIZIM
VPRIV
ZAVESCA
5
NM, PA
5
NM, PA
5
NM, LA, PA
ESTROGENS
ALORA
4
DELESTROGEN 10mg/ml
depo-estradiol
estrace CREA
estradiol PTTW; PTWK; TABS
4
4
4
4
estradiol valerate OIL
ESTRING
FEMRING
fyavolv tab 1 mg-5 mcg
2
4
4
4
jinteli
4
MENOSTAR
4
MINIVELLE
4
norethindrone acetate-ethinyl estradiol
4
PREMARIN CREAM
PREMARIN INJ
VAGIFEM
4
4
4
older
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
GLUCOCORTICOIDS
a-hydrocort
cortisone acetate TABS
DEPO-MEDROL INJ 20MG/ML
dexamethasone CONC; ELIX; SOLN
dexamethasone TABS
dexamethasone sodium phosphate
dexpak 6 day
dexpak 10 day
dexpak taperpak 13 day
fludrocortisone acetate TABS
hydrocortisone TABS
MEDROL TAB 2MG
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 1gm
methylpr ss inj 40mg
methylpr ss inj 125mg
methylpred pak 4mg
methylpred tab 4mg
2
2
4
2
1
2
4
4
4
2
2
4
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
47
Drug Name
methylpred tab 8mg
methylpred tab 16mg
methylpred tab 32mg
millipred
millipred dp
pred sod pho sol 5mg/5ml
prednisolone sodium phosphate
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syrup 15 mg/5ml
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
RAYOS TAB 1MG
RAYOS TAB 2MG
RAYOS TAB 5MG
SOLU-CORTEF 100MG
SOLU-CORTEF 250MG
SOLU-CORTEF 500MG
SOLU-CORTEF 1000MG
SOLU-MEDROL INJ 2GM
veripred
2
B/D
2
B/D
2
B/D
4
B/D
4
2
B/D
2
B/D
2
B/D
2
B/D
1
B/D
3
B/D
2
2
2
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
1
B/D
5
B/D
5
B/D
5
B/D
4
4
4
4
4
B/D
4
B/D
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
KORLYM
PROGLYCEM SUS 50MG/ML
3
3
5
4
NM, LA, PA
HUMAN GROWTH HORMONES
GENOTROPIN
GENOTROPIN MINIQUICK .2mg
GENOTROPIN MINIQUICK .4mg, .6mg,
.8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg,
2mg
HUMATROPE
HUMATROPE COMBO PACK
NORDITROPIN FLEXPRO
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ NUSPIN 5
5
4
5
NM, PA
NM, PA
NM, PA
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
LA, PA
LA, PA
LA, PA
48
Drug Name
NUTROPIN AQ PEN
OMNITROPE 5.8MG
OMNITROPE 5MG
OMNITROPE 10MG
SAIZEN
SAIZEN CLICK.EASY
SEROSTIM
ZOMACTON
ZORBTIVE
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
MISCELLANEOUS
AFREZZA
cabergoline
calcitonin (salmon) nasal spray
CHORIONIC GONADOTROPIN SOLR
EGRIFTA 1mg
FORTICAL SPR 200/ACT
H.P. ACTHAR
4
2
2
2
5
3
5
INCRELEX
methylergonovine maleate TABS
MIACALCIN INJ 200U/ML
NOVAREL INJ 10000UNT
octreotide acetate 50mcg/ml, 100mcg/ml
octreotide acetate 200mcg/ml,
500mcg/ml, 1000mcg/ml
PREGNYL W/DILUENT BENZYL
PROLIA
5
2
5
2
2
5
raloxifene hcl
SAMSCA
SANDOSTATIN LAR DEPOT
SIGNIFOR
SIGNIFOR LAR
SOMATULINE DEPOT
SOMAVERT
XGEVA
2
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
5
5
NM, PA
NM, PA
2
4
NM, PA
NM, LA, PA
QL (1.5 ml / 1 day), NM,
LA, PA
NM, LA, PA
B/D
NM, PA
NM, PA
NM, PA
NM, PA
QL (1 syringe / 180
days), NM
PA
PA
LA, PA
LA, PA
PA
LA, PA
PA
PARATHYROID HORMONES
FORTEO
NATPARA
PHOSPHATE BINDER AGENTS
AURYXIA
calcium acetate (phosphate binder)
FOSRENOL
PHOSLYRA
RENAGEL 400mg
5
2
5
4
4
49
Drug Name
RENAGEL 800mg
RENVELA PAK
RENVELA TAB 800MG
VELPHORO
5
5
5
5
PROGESTINS
CRINONE
medroxyprogesterone acetate
norethindrone acetate TABS
progesterone micronized CAPS
4
1
2
2
THYROID AGENTS
levothyroxine sodium TABS
LEVOXYL
liothyronine sodium SOLN; TABS
methimazole TABS
propylthiouracil TABS
SYNTHROID
TIROSINT
UNITHROID
1
1
2
1
2
4
4
1
VASOPRESSINS
DESMOPRESSIN ACETATE SOLN
desmopressin acetate TABS
desmopressin acetate inj
desmopressin acetate spray
desmopressin acetate spray refrigerated
STIMATE
2
2
2
2
2
5
NM
GASTROINTESTINAL
ANTIEMETICS
AKYNZEO
ALOXI
CESAMET
4
5
5
compro supp
dronabinol 2.5mg, 5mg
2
2
dronabinol 10mg
5
EMEND SUSR
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN; TABS
metoclopramide hcl TBDP
4
4
4
4
4
2
2
2
1
2
B/D
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D
B/D
B/D
B/D
B/D
B/D
50
Drug Name
metoclopramide hcl inj 5 mg/ml
metoclopramide odt
ondansetron hcl TABS
ondansetron hcl inj
ondansetron hcl oral soln
ondansetron odt
phenadoz
phenergan SUPP
prochlorperazine inj 5 mg/ml
prochlorperazine maleate TABS
prochlorperazine supp
promethazine hcl SOLN; SUPP; SYRP;
TABS
promethegan
SANCUSO
TRANSDERM-SCOP
VARUBI
ZUPLENZ
2
2
2
B/D
2
2
B/D
2
B/D
4
older
4
older
2
1
2
4
older
4
older
5
QL (4 patches / 30
days)
4
QL (10 patches / 30
days), PA; PA if 65 years
and older
4
B/D
5
B/D
ANTISPASMODICS
ATROPINE SULFATE SOLN .05mg/ml,
.1mg/ml
BENTYL SOLN
CANTIL
CUVPOSA
dicyclomine hcl CAPS; TABS
dicyclomine hcl SOLN
glycopyrrolate SOLN; TABS
methscopolamine bromide TABS
2
4
4
4
1
2
2
2
H2-RECEPTOR ANTAGONISTS
cimetidine TABS
cimetidine sol 300/5ml
famotidine SUSR
famotidine TABS 20mg, 40mg
famotidine inj
nizatidine
ranitidine hcl CAPS
ranitidine hcl SOLN
ranitidine hcl SYRP
ranitidine hcl TABS 150mg, 300mg
2
2
2
1
2
2
2
2
2
1
INFLAMMATORY BOWEL DISEASE
APRISO
3
51
Drug Name
ASACOL HD
balsalazide disodium
budesonide CPEP
CANASA
colocort
DELZICOL
DIPENTUM
ENTYVIO
GIAZO
HYDROCORTISONE (INTRARECTAL)
LIALDA
mesalamine enema
PENTASA
SF-ROWASA
sulfasalazine dr
sulfasalazine ir
UCERIS FOAM
UCERIS TB24
4
2
5
5
2
4
5
5
NM, PA
5
2
4
2
4
5
2
2
4
5
LAXATIVES
COLYTE-FLAVOR PACKS 227.1 GM
constulose
enulose
gaviltye-g
gavilyte-c
gavilyte-h
gavilyte-n
generlac
GOLYTELY
kristalose
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
OSMOPREP
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
polyethylene glycol 3350 PACK; POWD
PREPOPIK
RELISTOR SOLN
SUCLEAR
SUPREP BOWEL PREP
trilyte
4
2
2
1
1
2
2
2
3
3
2
2
4
3
4
1
2
2
4
5
4
4
2
PA
MISCELLANEOUS
alosetron hcl
5
PA
52
Drug Name
AMITIZA
amoxicillin-clarithromycin w/ lansoprazole
CARAFATE SUSP
cromolyn sodium (mastocytosis)
diphenoxylate w/ atropine
GATTEX
LINZESS
loperamide hcl CAPS
misoprostol TABS
MOVANTIK
OMECLAMOX-PAK
PYLERA
SUCRAID
sucralfate TABS
ursodiol CAPS; TABS
VIBERZI
XIFAXAN TAB 550MG
3
2
4
5
2
5
NM, LA, PA
3
1
2
3
4
5
5
LA
2
2
5
PA
5
PA
PANCREATIC ENZYMES
CREON
PANCREAZE
PERTZYE
ULTRESA
VIOKACE 10
VIOKACE 20
ZENPEP
3
4
4
4
4
5
4
PROTON PUMP INHIBITORS
ACIPHEX SPR CAP 5MG
ACIPHEX SPR CAP 10MG
DEXILANT
esomeprazole sodium inj
lansoprazole CPDR
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
4
4
3
2
2
2
2
3
3
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole CPDR 10mg, 40mg
omeprazole CPDR 20mg
OMEPRAZOLE-SODIUM BICARBONATE
CAPS
OMEPRAZOLE-SODIUM BICARBONATE
PACK
1
1
2
4
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
QL (60
QL (30
packets / 30
packets / 30
packets / 30
caps / 30 days)
caps / 30 days)
caps / 30 days)
QL (30 packets / 30
days)
53
Drug Name
pantoprazole sodium SOLR
pantoprazole sodium TBEC
PREVACID SOLUTAB
PRILOSEC PACK
PROTONIX PACK
rabeprazole sodium
ZEGERID PACK
2
1
4
3
4
QL (30 packets / 30
days)
2
4
QL (30 packets / 30
days)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
CARDURA XL
dutasteride
dutasteride-tamsulosin hcl
finasteride TABS 5mg
RAPAFLO
tamsulosin hcl
2
4
2
2
1
4
2
ST
MISCELLANEOUS
bethanechol chloride TABS
ELMIRON
potassium citrate (alkalinizer) 15meq
POTASSIUM CITRATE (ALKALINIZER)
540mg, 1080mg
2
4
2
2
URINARY ANTISPASMODICS
DARIFENACIN HYDROBROMIDE
ENABLEX
GELNIQUE
MYRBETRIQ
oxybutynin chloride SYRP
oxybutynin chloride TABS; TB24
OXYTROL
tolterodine tartrate er
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
TOVIAZ
trospium chloride
trospium chloride er
VESICARE
2
4
4
4
1
2
4
2
2
2
3
2
2
4
ST
ST
VAGINAL ANTI-INFECTIVES
AVC
CLEOCIN VAG SUPP 100MG
clindamycin cre 2% vag
CLINDESSE
metronidazole vaginal
miconazole 3 sup 200mg
4
4
2
4
2
2
54
Drug Name
NUVESSA
terconazole vaginal
VANDAZOLE
ZAZOLE CRE 0.8%
4
2
2
2
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
4
ELIQUIS TAB 2.5MG
3
ELIQUIS TAB 5MG
3
enoxaparin sodium 30mg/0.3ml,
2
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
300mg/3ml
enoxaparin sodium 100mg/ml,
5
120mg/0.8ml, 150mg/ml
fondaparinux sodium 2.5mg/0.5ml
2
fondaparinux sodium 5mg/0.4ml,
5
7.5mg/0.6ml, 10mg/0.8ml
FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml 4
FRAGMIN 7500unit/0.3ml, 10000unit/ml, 5
12500unit/0.5ml, 15000unit/0.6ml,
18000unt/0.72ml, 95000unit/3.8ml
HEP SOD/NACL INJ 25000
3
HEPARIN (PORCINE) IN SODIUM
3
CHLORIDE 100U/ML
heparin sod inj 1000u/ml
2
HEPARIN SOD INJ 2000U/ML
3
HEPARIN SOD INJ 2500U/ML
3
heparin sod inj 5000u/0.5ml
2
2
2
2
HEPARIN SODIUM/D5W
3
HEPARIN SODIUM/NACL 0.45%
3
jantoven
1
PRADAXA
3
SAVAYSA
4
warfarin sodium
1
XARELTO
3
XARELTO STARTER PACK
3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE SOLN
3
10mcg/0.4ml, 25mcg/ml, 40mcg/ml,
60mcg/ml
ARANESP ALBUMIN FREE SOLN
5
100mcg/ml, 150mcg/0.75ml, 200mcg/ml,
300mcg/ml
NM, PA
NM, PA
55
Drug Name
ARANESP ALBUMIN FREE SOSY
3
NM, PA
25mcg/0.42ml, 40mcg/0.4ml,
60mcg/0.3ml
ARANESP ALBUMIN FREE SOSY
5
NM, PA
100mcg/0.5ml, 150mcg/0.3ml,
200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml
EPOGEN 2000unit/ml, 3000unit/ml,
4
NM, PA
4000unit/ml, 10000unit/ml
EPOGEN 20000unit/ml
5
NM, PA
GRANIX
5
NM, PA
LEUKINE
5
NM, PA
MIRCERA
4
NM, PA
MOZOBIL
5
NM, PA
NEULASTA
5
NM, PA
NEULASTA ONPRO KIT
5
NM, PA
NEUMEGA
5
NM
NEUPOGEN
5
NM, PA
PROCRIT 2000unit/ml, 3000unit/ml,
3
NM, PA
4000unit/ml, 10000unit/ml
PROCRIT 20000unit/ml, 40000unit/ml
5
NM, PA
MISCELLANEOUS
anagrelide hcl
cilostazol
CINRYZE
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
2
2
5
5
2
5
PROMACTA 25mg
5
PROMACTA 50mg
5
PROMACTA 75mg
5
RUCONEST
tranexamic acid SOLN; TABS
5
2
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
PLATELET AGGREGATION INHIBITORS
AGGRENOX
BRILINTA
clopidogrel bisulfate 75mg
clopidogrel bisulfate 300mg
DURLAZA
EFFIENT
ZONTIVITY
2
3
1
2
4
4
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA
5
NM, PA
56
Drug Name
CIMZIA
ENBREL
ENBREL SURECLICK
HUMIRA INJ 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEDIATRIC CROHNS
HUMIRA PEN
HUMIRA PEN-CROHNS STARTER KIT
HUMIRA PEN-PSORIASIS STARTER KIT
hydroxychloroquine sulfate
KINERET
leflunomide TABS
methotrexate sodium tabs
ORENCIA
ORENCIA CLICKJECT
OTEZLA
REMICADE
RHEUMATREX
SIMPONI
SIMPONI ARIA
trexall
XELJANZ
XELJANZ XR
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
2
5
NM, PA
2
2
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
4
5
NM, PA
5
NM, PA
4
B/D
5
NM, PA
5
NM, PA
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAGARD S/D IGA LESS TH
GAMMAKED
GAMMAPLEX 2.5gm/50ml, 5gm/100ml,
10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml, 2gm/20ml,
2.5gm/50ml, 5gm/100ml, 10gm/200ml,
25gm/500ml
PRIVIGEN
5
5
5
5
3
5
5
5
5
5
NM, PA
NM, PA
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
5
5
NM, PA
NM, PA
5
NM, PA
5
5
4
5
5
NM, LA, PA
NM, PA
PA
B/D, NM
B/D, NM
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
GRASTEK
INTRON-A INJ 10MU
INTRON-A INJ 18MU
57
Drug Name
INTRON-A INJ 25MU
INTRON-A INJ 50MU
RAGWITEK
REVLIMID
THALOMID
5
B/D, NM
5
B/D, NM
4
PA
5
NM, LA, PA
5
NM, PA
IMMUNOSUPPRESSANTS
ASTAGRAF XL 5mg
ASTAGRAF XL .5mg, 1mg
ATGAM
azasan
azathioprine SOLR; TABS
BENLYSTA
CELLCEPT INTRAVENOUS
cyclosporine CAPS; SOLN
cyclosporine modified (for microemulsion)
ENVARSUS XR
gengraf
mycophenolate mofetil CAPS; TABS
mycophenolate mofetil SUSR
mycophenolate sodium 180mg
mycophenolate sodium 360mg
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg, 1mg
PROGRAF SOLN
RAPAMUNE SOLN
SANDIMMUNE SOLN
SIMULECT 10mg
SIMULECT 20mg
SIROLIMUS TABS 2mg
sirolimus TABS .5mg, 1mg
tacrolimus CAPS 5mg
tacrolimus CAPS .5mg, 1mg
THYMOGLOBULIN
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
5
4
5
4
2
5
4
2
2
4
2
2
5
2
5
3
5
5
4
4
5
3
4
5
5
2
5
2
5
5
4
5
B/D
B/D
B/D
B/D
B/D
NM, PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
CERVARIX
COMVAX
3
3
3
3
3
3
3
58
Drug Name
DAPTACEL
DIPHTHERIA/TETANUS TOXOID
ENGERIX-B SUSP
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS/DIPHTHERIA TOXOID
TRUMENBA
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
3
3
B/D
3
B/D
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D
3
3
5
NM
3
B/D
3
B/D
3
3
3
3
3
3
3
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
ammonium chloride SOLN
KLOR-CON 8
KLOR-CON 10
klor-con m10
klor-con m15
klor-con m20
klor-con pow 20meq
klor-con spr cap 8meq
4
2
2
2
2
2
2
2
59
Drug Name
klor-con spr cap 10meq
MAGNESIUM SULFATE SOLN 2gm/50ml,
4gm/100ml, 4gm/50ml, 20gm/500ml,
40gm/1000ml
magnesium sulfate SOLN 2gm/50ml, 50%
MAGNESIUM SULFATE IN D5W
MAGNESIUM SULFATE INJ 50%
POTASSIUM CHLORIDE SOLN 10%, 20%
potassium chloride TBCR 8meq
POTASSIUM CHLORIDE TBCR 20meq
potassium chloride caps er
potassium chloride microencapsulated
crystals cr
POTASSIUM CHLORIDE TAB CR 10 MEQ
SODIUM CHLORIDE SOLN 2.5meq/ml
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
F) MG/ML SOLN
TPN ELECTROLYTES
2
3
2
3
2
2
2
2
2
2
2
2
2
4
B/D
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV NUTRITION
AMINOSYN
AMINOSYN 7%/ELECTROLYTES
AMINOSYN II
AMINOSYN II 8.5%/ELECTROL
AMINOSYN INJ 8.5/LYTE
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF 7%
AMINOSYN-PF INJ 10%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX E 2.75%/DEXTROSE 5%
CLINIMIX E 4.25%/D10
CLINIMIX E 5%/DEXTROSE 15%
clinisol 15
FREAMINE HBC 6.9%
60
Drug Name
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
LIPOSYN III
NEPHRAMINE
NUTRILIPID INJ 20%
plenamine
premasol 6%
premasol 10%
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE INJ 10%
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
2
B/D
2
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
IV REPLACEMENT SOLUTIONS
DEXTROSE SOLN
DEXTROSE 2.5%/NACL 0.45%
DEXTROSE 5%
DEXTROSE 5% /ELECTROLYTE
DEXTROSE 5%/LACTATED RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/POTASSIUM CHL
DEXTROSE 10% FLEX CONTAIN
DEXTROSE 10% W/ SODIUM CHLORIDE
0.2%
ELECTROLYTE-R IN DEXTROSE
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE P
ISOLYTE S
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225%
KCL 0.3%/D5W/LR IV LAC RI
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/LR
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL 0.45%
KCL IN NACL INJ .15-0.45
KCL/D5W/NACL INJ 0.22%/0.45%
KCL/D5W/NACL INJ .15/.33%
2
2
2
3
2
2
2
2
2
2
2
2
2
3
2
4
4
4
4
4
2
3
4
2
2
4
2
2
2
2
2
61
Drug Name
KCL/D5W/NACL INJ .15/.45%
KCL/NACL INJ 0.15%-0.9%
LACTATED RINGERS VIAFLEX
NORMOSOL-M IN D5W
NORMOSOL-R
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
pot chloride inj 2meq/ml
POTASSIUM CHLORIDE SOLN .4meq/ml,
10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
POTASSIUM CHLORIDE 0.3%/D
potassium chloride in nacl
POTASSIUM CHLORIDE IN NACL
RINGER'S
SODIUM CHLORIDE SOLN .9%, 3%, 5%
SODIUM CHLORIDE 0.45% VIA
2
2
2
2
4
4
4
4
2
2
2
2
2
2
2
2
VITAMINS
calcitriol CAPS; SOLN
2
doxercalciferol CAPS 1mcg, 2.5mcg
5
doxercalciferol CAPS .5mcg
2
doxercalciferol SOLN
2
HECTOROL SOLN 2mcg/ml
4
paricalcitol CAPS
2
PARICALCITOL SOLN
2
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG 2
(GENERIC)
ZEMPLAR SOLN 2mcg/ml
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
BLEPHAMIDE SUSP
neomycin-polymy-dexameth
neomycin-polymyxin-hc (ophth)
PRED-G
PRED-G S.O.P.
sulfacetamide sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
ZYLET
2
4
4
2
2
4
4
2
3
3
2
3
ANTI-INFECTIVES
AZASITE
bacitracin (ophthalmic)
4
2
62
Drug Name
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OIN 0.3% OP
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gatifloxacin (ophth)
gentak
gentamicin sulfate (ophth) OINT
gentamicin sulfate (ophth) SOLN
ilotycin
levofloxacin (ophth)
MOXEZA
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymyxin-gramicidin
ofloxacin (ophth)
polymyxin b-trimethoprim
sulfacet sod oin 10% op
sulfacetamide sodium (ophth)
tobramycin (ophth)
TOBREX OINT 0.3%
trifluridine SOLN
VIGAMOX
ZIRGAN
2
3
3
2
1
2
2
2
1
1
2
3
4
2
2
2
1
2
2
1
4
2
3
4
ANTI-INFLAMMATORIES
ACUVAIL
4
ALREX
3
bromfenac sodium (ophth)
2
BROMFENAC SODIUM (OPHTH)(ONCE2
DAILY)
dexamethasone sodium phosphate (ophth) 2
diclofenac sodium (ophth)
2
DUREZOL
3
FLAREX
4
FLUOROMETHOLONE (OPHTH)
2
flurbiprofen sodium
1
FML
4
FML FORTE
4
ILEVRO
3
ketorolac tromethamine (ophth)
2
LOTEMAX
3
MAXIDEX
3
PRED MILD
4
PREDNISOLONE ACETATE (OPHTH)
2
prednisolone sodium phosphate (ophth)
3
VEXOL
4
63
Drug Name
ANTIALLERGICS
ALOCRIL
ALOMIDE
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
EMADINE
epinastine hcl (ophth)
LASTACAFT
olopatadine hcl
PATADAY
PATANOL
PAZEO
4
4
2
3
1
4
2
4
2
3
4
3
ANTIGLAUCOMA
ALPHAGAN P 0.1%
AZOPT
betaxolol hcl (ophth)
BETIMOL
BETOPTIC-S
brimonidine sol 0.2%
BRIMONIDINE SOL 0.15%
carteolol hcl (ophth)
COMBIGAN
COSOPT PF
dorzolamide hcl
dorzolamide hcl-timolol maleate
ISTALOL
latanoprost SOLN
levobunolol hcl
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA SUS 1-0.2%
timolol maleate (ophth)
TIMOLOL MALEATE GEL
TIMOPTIC OCUDOSE
TRAVATAN Z
ZIOPTAN
3
3
2
4
3
1
2
1
3
4
2
2
3
1
2
3
2
4
2
3
1
2
4
3
4
ST
MISCELLANEOUS
LACRISERT
naphazoline hcl SOLN
PROLENSA
proparacaine hcl SOLN
RESTASIS
4
1
3
1
3
RESPIRATORY
64
Drug Name
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPT AER 62.5-25
3
COMBIVENT RESPIMAT
4
ipratropium-albuterol
STIOLTO RESPIMAT
UTIBRON NEOHALER
2
4
4
QL (60 inhalations / 30
days)
QL (2 inhalers / 30
days)
B/D
QL (1 inhaler / 30 days)
ANTICHOLINERGICS
ATROVENT HFA
4
INCRUSE ELLIPTA
ipratropium bromide (nasal)
ipratropium sol inhal
SEEBRI NEOHALER
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
TUDORZA PRESSAIR
TUDORZA PRESSAIR (INSTITUTIONAL
PACK)
3
2
2
4
4
4
4
4
QL (2 inhalers / 30
days)
B/D
QL (2 inhalers / 30
days)
ANTIHISTAMINE COMBINATIONS
CLARINEX-D TAB 2.5-120
DYMISTA SPR 137-50
SEMPREX-D
4
4
4
QL (1 bottle / 30 days)
ANTIHISTAMINES
ASTEPRO
azelastine spr 0.1%
azelastine spr 0.15%
cetirizine syrup
CLARINEX SYRP
desloratadine
diphenhydram inj 50mg/ml
hydroxyzine hcl SOLN
3
2
2
2
4
2
2
4
levocetirizine soln 2.5mg/5ml
levocetirizine tab 5 mg
olopatadine hcl (nasal)
2
2
2
older
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP
albuterol sulfate TABS
albuterol sulfate er
ARCAPTA NEOHALER
BROVANA
FORADIL AEROLIZER
levalbuterol conc 1.25mg/0.5ml
2
1
2
2
4
4
4
2
B/D
B/D
B/D
65
Drug Name
LEVALBUTEROL HCL NEBU 1.25mg/3ml
levalbuterol hcl NEBU .31mg/3ml,
.63mg/3ml
PERFOROMIST
PROAIR HFA
2
B/D
2
B/D
4
4
PROAIR RESPICLICK
4
PROVENTIL HFA
4
SEREVENT DISKUS
3
STRIVERDI RESPIMAT
terbutaline sulfate SOLN
terbutaline sulfate TABS
VENTOLIN HFA
4
5
2
3
XOPENEX HFA
3
B/D
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium CHEW; PACK; TABS
zafirlukast
ZYFLO CR
2
2
5
MAST CELL STABILIZERS
cromolyn sodium NEBU
2
B/D
2
5
5
4
2
3
3
5
5
5
5
5
5
5
5
4
5
5
B/D
NM, LA, PA
NM, LA, PA
4
QL (2 inhalers / 30
days)
MISCELLANEOUS
acetylcysteine SOLN 10%, 20%
ARALAST NP
CINQAIR
DALIRESP
EPINEPHRINE SOAJ
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ESBRIET
GLASSIA
KALYDECO
NUCALA
OFEV
ORKAMBI
PROLASTIN-C
PULMOZYME
tyzine .05%
XOLAIR
ZEMAIRA
NM, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, PA
NM, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NASAL STEROIDS
BECONASE AQ
66
Drug Name
budesonide (nasal)
flunisolide (nasal)
fluticasone propionate (nasal)
NASONEX
OMNARIS
QNASL
QNASL CHILDRENS
TRIAMCINOLONE ACETONIDE (NASAL)
VERAMYST
ZETONNA
2
QL (2 bottles / 30 days)
2
QL (2 bottles / 30 days)
2
4
QL (2 inhalers / 30
days)
4
4
4
2
4
4
STEROID INHALANTS
AEROSPAN
4
ALVESCO
4
ARNUITY ELLIPTA
3
ASMANEX
4
ASMANEX HFA 100mcg/act
4
ASMANEX HFA 200mcg/act
budesonide (inhalation)
FLOVENT DISKUS 50mcg/blist,
100mcg/blist
FLOVENT DISKUS 250mcg/blist
4
2
3
FLOVENT HFA
3
PULMICORT FLEXHALER
3
PULMICORT INH SUSP 1MG/2ML
QVAR 40mcg/act
QVAR 80mcg/act
5
4
4
3
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
B/D
days)
days)
QL (2 inhalers / 30
days)
QL (2 inhalers / 30
days)
B/D
QL (2 inhalers / 30
days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
3
ADVAIR HFA
BREO ELLIPTA
3
3
DULERA
SYMBICORT
4
3
days)
QL (60 blisters / 30
days)
XANTHINES
aminophylline inj
elixophyllin
theo-24
2
4
4
67
Drug Name
theophylline
2
TOPICAL
DERMATOLOGY, ACNE
ABSORICA
ACANYA
ACZONE
adapalene CREA; GEL
amnesteem
ATRALIN
AVITA
AZELEX
benzoyl peroxide-erythromycin
claravis
clindacin-p
CLINDAGEL
clindamax
clindamycin phosphate (topical)
clindamycin phosphate-benzoyl peroxide
(refrigerate)
clindamycin phosphate-tretinoin
DIFFERIN LOTN
EPIDUO
EPIDUO FORTE
ery pad 2%
erythromycin (acne aid)
FABIOR
myorisan
neuac gel 1.2-5%
ONEXTON
RETIN-A MICRO PUMP .08%
sulfacetamide sodium (acne)
tretin-x CREA
tretinoin CREA
TRETINOIN GEL .01%
tretinoin GEL .025%, .05%
TRETINOIN MICROSPHERE
VELTIN
zenatane
ZIANA
5
4
4
2
2
4
2
4
2
2
2
4
2
2
2
2
2
4
4
4
2
2
4
2
2
4
4
2
4
2
2
2
2
4
2
4
DERMATOLOGY, ANTIBIOTICS
BACTROBAN NASAL
CENTANY
CORTISPORIN
gentamicin sulfate (topical)
mupirocin OINT
4
4
4
2
1
68
Drug Name
mupirocin calcium (topical)
SILVER SULFADIAZINE CREA
SSD
SULFAMYLON CREA
SULFAMYLON PACK
2
2
2
4
5
DERMATOLOGY, ANTIFUNGALS
ciclopirox GEL
ciclopirox cre 0.77%
ciclopirox shampoo 1%
ciclopirox sus 0.77%
clotrimazole (topical)
econazole nitrate CREA
ERTACZO
EXELDERM
ketoconazole (topical)
ketodan aer 2%
LUZU
MENTAX
NAFTIFINE HCL 1%
naftifine hcl 2%
NAFTIN
nyamyc
nystatin (topical)
nystatin pow 100000
nystop
oxiconazole nitrate cream
OXISTAT
2
2
2
2
2
2
4
4
2
2
4
4
2
2
4
2
2
2
2
2
4
DERMATOLOGY, ANTIPRURITIC
CORTIFOAM
DOXEPIN HCL (ANTIPRURITIC)
procto-med
procto-pak
proctosol hc 2.5 %
proctozone hc
PRUDOXIN CRE 5%
4
2
2
2
2
2
2
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene CREA; OINT; SOLN
calcitrene oin 0.005%
CALCITRIOL OINT
COSENTYX
COSENTYX SENSOREADY PEN
methoxsalen rapid
8-MOP
SORILUX
STELARA
5
2
2
2
5
5
5
4
4
5
PA
NM, PA
NM, PA
NM, PA
69
Drug Name
TAZORAC
4
PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide LOTN
1
1
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate
amcinonide CREA; LOTN
amcinonide OINT
apexicon e cream
betamethasone dipropionate (topical)
betamethasone dipropionate augmented
betamethasone valerate CREA; FOAM;
LOTN; OINT
calcipotriene/betamethasone
CAPEX
clobetasol e cream 0.05%
clobetasol propionate CREA; FOAM; GEL;
LIQD; LOTN; OINT; SHAM; SOLN
clobetasol propionate emulsion
CLOCORTOLONE PIVALATE
clodan sha 0.05%
CORDRAN TAPE
cormax
DESONATE
DESONIDE CREA
desonide LOTN; OINT
desoximetasone CREA
desoximetasone GEL
DESOXIMETASONE OINT .05%
desoximetasone OINT .25%
diflorasone diacetate
ENSTILAR
fluocinolone acetonide CREA; OIL; OINT;
SOLN
fluocinonide CREA .1%
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide OINT
fluocinonide SOLN
fluocinonide-e 0.05% cream
flurandrenolide
fluticasone propionate CREA
fluticasone propionate LOTN
fluticasone propionate OINT
halobetasol propionate
HALOG
1
2
2
4
4
2
2
2
5
4
2
2
2
2
2
4
2
4
2
2
2
2
2
2
2
5
2
5
2
2
2
2
2
2
2
2
2
2
4
70
Drug Name
hydrocortisone (topical) CREA; OINT
hydrocortisone (topical) LOTN
hydrocortisone butyrate
hydrocortisone butyrate hydrophilic lipo
base
hydrocortisone valerate
LOCOID LOTN
lokara
mometasone furoate CREA; OINT; SOLN
PANDEL
PREDNICARBATE CREA
prednicarbate OINT
SERNIVO
TACLONEX SUSP
texacort
TOPICORT SPRAY 0.25%
triamcinolone acetonide (topical) AERS;
LOTN
triamcinolone acetonide (topical) CREA;
OINT
trianex
triderm
ULTRAVATE LOTN
1
2
2
2
2
4
2
2
4
2
2
5
5
4
4
2
1
4
1
4
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine OINT
lidocaine PTCH
lidocaine hcl GEL
lidocaine hcl SOLN 4%
lidocaine-prilocaine
SYNERA
2
2
2
1
2
4
PA
B/D
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir topical
ammonium lactate CREA; LOTN
CONDYLOX GEL
DENAVIR
diclofenac sodium (actinic keratoses)
diclofenac sodium (topical) 1.5% soln
DOXYCYCLINE (ROSACEA)
ELIDEL
FINACEA AER 15%
FINACEA GEL 15%
fluorouracil (topical) CREA 5%
FLUOROURACIL (TOPICAL) CREA .5%
fluorouracil (topical) SOLN
imiquimod CREA
metronidazole (topical)
NORITATE
2
2
4
5
5
2
2
4
4
4
2
5
2
2
2
5
PA
PA
71
Drug Name
ORACEA
PANRETIN
PENNSAID
PICATO
podofilox SOLN
RECTIV
rosadan cre 0.75%
SOOLANTRA
tacrolimus (topical)
TARGRETIN GEL
TOLAK
VALCHLOR
VOLTAREN GEL 1%
XERESE
ZOVIRAX CREA
ZYCLARA
4
5
4
5
2
4
2
4
2
PA
5
NM, PA
4
5
NM, LA, PA
3
5
5
5
DERMATOLOGY, SCABICIDES AND PEDICULIDES
EURAX
malathion
permethrin
SKLICE
4
2
2
4
DERMATOLOGY, WOUND CARE AGENTS
acetic acid .25%
neomycin/polymyxin b gu
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER IRRIGATION
1
2
5
4
1
2
PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl
chlorhexidine gluconate (mouth-throat)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
ORAVIG
paroex sol 0.12%
periogard soln 0.12%
PILOCARPINE HCL (ORAL) 5mg
pilocarpine hcl (oral) 7.5mg
triamcinolone acetonide (mouth)
2
1
2
1
2
5
1
1
2
2
2
OTIC
acetasol hc
acetic acid (otic)
acetic acid sol/hc
acetic acid-aluminum acetate
CIPRO HC
2
2
2
2
4
72
Drug Name
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
fluocinolone acetonide (otic)
neomycin-polymyxin-hc (otic)
ofloxacin (otic)
3
4
4
2
2
2
73
Index
8
8-MOP .............................................69
A
abacavir sulfate ................................13
abacavir sulfate-lamivudine-zidovudine14
ABELCET ..........................................13
ABILIFY DISCMELT TAB 10MG ............34
ABILIFY MAINTENA ...........................34
ABRAXANE .......................................20
ABSORICA .......................................68
ABSTRAL .......................................... 8
acamprosate calcium .........................41
ACANYA ...........................................68
acarbose ..........................................44
acebutolol hcl ...................................27
acetaminophen w/ codeine .................. 8
acetaminophen-caff-dihydrocod ........... 8
acetasol hc .......................................72
acetazolamide ..................................28
acetazolamide sodium .......................28
acetic acid........................................72
acetic acid (otic) ...............................72
acetic acid sol/hc ..............................72
acetic acid-aluminum acetate .............72
acetylcysteine ..................................66
ACIPHEX SPR CAP 10MG ....................53
ACIPHEX SPR CAP 5MG......................53
acitretin ...........................................69
ACTEMRA .........................................56
ACTHIB ...........................................58
ACTIMMUNE .....................................57
ACTOPLUS MET XR 15-1000MG ..........44
ACTOPLUS MET XR 30-1000MG ..........44
ACUVAIL ..........................................63
acyclovir ..........................................15
acyclovir sodium ...............................15
acyclovir topical ................................71
ACZONE ..........................................68
ADACEL ...........................................58
ADAGEN ..........................................46
adapalene ........................................68
ADCIRCA .........................................29
adefovir dipivoxil ..............................15
ADEMPAS.........................................30
adrucil .............................................20
ADVAIR DISKUS ...............................67
ADVAIR HFA .....................................67
AEROSPAN ...................................... 67
afeditab cr ....................................... 27
AFINITOR ........................................ 22
AFINITOR DISPERZ .......................... 22
AFREZZA ......................................... 49
AGGRENOX ..................................... 56
a-hydrocort ..................................... 47
AKYNZEO ........................................ 50
ala-cort ........................................... 70
ALBENZA......................................... 11
albuterol sulfate ............................... 65
albuterol sulfate er ........................... 65
alclometasone dipropionate ............... 70
ALCOHOL SWABS ............................. 43
ALDACTAZIDE TAB 50/50 .................. 28
ALDURAZYME .................................. 46
ALECENSA ....................................... 22
alendronate sodium .......................... 45
alfuzosin hcl .................................... 54
ALIMTA ........................................... 20
ALINIA ............................................ 11
allopurinol tab.................................... 7
almotriptan malate ........................... 38
ALOCRIL ......................................... 64
ALOMIDE ........................................ 64
ALOPRIM ........................................... 7
ALORA ............................................ 47
alosetron hcl .................................... 52
ALOXI ............................................. 50
ALPHAGAN P 0.1% ........................... 64
alprazolam ...................................... 30
ALREX ............................................ 63
ALTOPREV ....................................... 26
ALVESCO ........................................ 67
amantadine hcl ................................ 34
AMBISOME ...................................... 13
amcinonide ...................................... 70
amifostine crystalline ........................ 23
amikacin sulfate ............................... 11
amiloride & hydrochlorothiazide ......... 28
amiloride hcl .................................... 28
aminophylline inj .............................. 67
AMINOSYN ...................................... 60
AMINOSYN 7%/ELECTROLYTES .......... 60
AMINOSYN II ................................... 60
AMINOSYN II 8.5%/ELECTROL ........... 60
AMINOSYN INJ 8.5/LYTE ................... 60
74
AMINOSYN M....................................60
AMINOSYN-HBC ................................60
AMINOSYN-PF 7%.............................60
AMINOSYN-PF INJ 10% .....................60
AMINOSYN-RF ..................................60
amiodarone hcl .................................25
amiodarone inj 50mg/ml....................25
AMITIZA ..........................................53
amitriptyline hcl ................................33
amlodipine besylate ..........................27
amlodipine besylate/atorv ..................27
amlodipine besylate-benazepril hcl ......24
amlodipine besylate-valsartan tab 10160 mg ...........................................24
amlodipine besylate-valsartan tab 10320 mg ...........................................24
mg ..................................................24
mg ..................................................24
10-160-12.5mg ................................24
10-160-25mg ...................................24
10-320-25mg ...................................25
5-160-12.5mg ..................................24
5-160-25mg .....................................24
ammonium chloride ..........................59
ammonium lactate ............................71
amnesteem ......................................68
amoxapine .......................................33
amoxicillin .......................................18
amoxicillin & pot clavulanate ..............18
amoxicillin-clarithromycin w/
lansoprazole .....................................53
amphetamine cap 10mg er ................37
amphetamine-dextroamphetamine cap sr
24hr 5 mg........................................37
10 mg .............................................37
12.5 mg .......................................... 37
15 mg............................................. 37
20 mg............................................. 37
30 mg............................................. 37
mg ................................................. 37
7.5 mg............................................ 37
amphotericin b ................................. 13
ampicillin & sulbactam sodium ........... 18
ampicillin cap 250mg ........................ 18
ampicillin cap 500 mg ....................... 18
ampicillin inj .................................... 18
ampicillin sodium ............................. 18
ampicillin susp ................................. 18
AMPYRA .......................................... 40
anagrelide hcl .................................. 56
anastrozole ..................................... 21
ANDRODERM ................................... 42
ANDROGEL ...................................... 42
ANDROGEL 1% ................................ 42
ANDROGEL 1.62%............................ 42
ANORO ELLIPT AER 62.5-25 .............. 65
ANTARA .......................................... 26
apexicon e cream ............................. 70
APIDRA ........................................... 43
APIDRA SOLOSTAR........................... 43
APLENZIN ....................................... 33
APOKYN .......................................... 34
APRISO ........................................... 51
APTENSIO XR .................................. 37
APTIOM........................................... 30
APTIVUS ......................................... 14
ARALAST NP .................................... 66
ARANESP ALBUMIN FREE ............. 55, 56
ARCALYST ....................................... 57
ARCAPTA NEOHALER ........................ 65
aripiprazole ..................................... 34
aripiprazole oral solution 1 mg/ml ...... 35
aripiprazole tabs .............................. 35
ARISTADA ....................................... 35
ARNUITY ELLIPTA ............................. 67
ARRANON........................................ 20
ARZERRA ........................................ 20
ASACOL HD ..................................... 52
75
ASMANEX ........................................67
ASMANEX HFA ..................................67
ASPIRIN-CAFFEINE-DIHYDROCODEINE
CAP 356.4-30-16 MG.......................... 8
ASTAGRAF XL ...................................58
ASTEPRO .........................................65
atenolol ...........................................27
atenolol & chlorthalidone ...................26
ATGAM ............................................58
atorvastatin calcium ..........................26
atovaquone ......................................11
atovaquone-proguanil hcl tab 250-100
mg ..................................................13
atovaquone-proguanil hcl tab 62.5-25
mg ..................................................13
ATRALIN ..........................................68
ATRIPLA ..........................................14
ATROPINE SULFATE ..........................51
ATROVENT HFA ................................65
AUBAGIO .........................................40
AUGMENTIN .....................................18
AURYXIA ..........................................49
AVASTIN ..........................................20
AVC ................................................54
AVELOX ...........................................17
AVITA ..............................................68
AVONEX ..........................................40
AVONEX PEN ....................................40
AVYCAZ ...........................................16
AXERT .............................................38
AXIRON ...........................................42
azacitidine .......................................20
AZACTAM/DEX INJ 1GM .....................11
AZACTAM/DEX INJ 2GM .....................12
azasan.............................................58
AZASITE ..........................................62
azathioprine .....................................58
azelastine drop 0.05% .......................64
azelastine spr 0.1% ..........................65
azelastine spr 0.15% .........................65
AZELEX ...........................................68
AZILECT ..........................................34
azithromycin ....................................17
AZITHROMYCIN ................................17
AZOPT .............................................64
AZOR ..............................................25
aztreonam .......................................12
B
bacitracin (ophthalmic) ..................... 62
bacitracin-polymyxin b (ophth) .......... 63
bacitracin-poly-neomycin-hc .............. 62
baclofen .......................................... 41
BACTOCILL INJ DEX 1GM .................. 18
BACTOCILL INJ DEX 2GM .................. 18
BACTROBAN NASAL .......................... 68
balsalazide disodium ......................... 52
BANZEL SUS 40MG/ML ..................... 30
BANZEL TAB 200MG ......................... 30
BANZEL TAB 400MG ......................... 30
BARACLUDE .................................... 15
BCG VACCINE .................................. 58
BECONASE AQ ................................. 66
BELBUCA........................................... 8
BELEODAQ ...................................... 20
benazepril & hydrochlorothiazide ........ 24
benazepril hcl .................................. 24
BENDEKA ........................................ 19
BENICAR ......................................... 25
BENICAR HCT .................................. 25
BENLYSTA ....................................... 58
BENTYL ........................................... 51
benzoyl peroxide-erythromycin .......... 68
benztropine mesylate ....................... 34
BENZTROPINE MESYLATE .................. 34
BEPREVE ......................................... 64
BESIVANCE ..................................... 63
betamethasone dipropionate (topical) . 70
betamethasone dipropionate augmented
...................................................... 70
betamethasone valerate .................... 70
BETASERON .................................... 40
betaxolol hcl .................................... 27
betaxolol hcl (ophth) ........................ 64
bethanechol chloride ......................... 54
BETHKIS ......................................... 11
BETIMOL ......................................... 64
BETOPTIC-S .................................... 64
bexarotene ...................................... 23
BEXSERO ........................................ 58
bicalutamide .................................... 21
BICILLIN C-R ................................... 18
BICILLIN L-A ................................... 18
BICNU ............................................ 19
BIDIL.............................................. 29
BILTRICIDE ..................................... 12
76
BINOSTO .........................................45
bisoprolol & hydrochlorothiazide .........26
bisoprolol fumarate ...........................27
BIVIGAM ..........................................57
bleomycin sulfate ..............................19
blephamide ......................................62
BLEPHAMIDE ....................................62
BOOSTRIX .......................................58
BOSULIF ..........................................22
BOTOX INJ 100UNIT..........................41
BOTOX INJ 200UNIT..........................41
BREO ELLIPTA ..................................67
BRILINTA .........................................56
BRIMONIDINE SOL 0.15% .................64
brimonidine sol 0.2% ........................64
BRINTELLIX .....................................33
BRISDELLE.......................................39
BRIVIACT INJ ...................................30
BRIVIACT SOLN 10MG/ML ..................30
BRIVIACT TABS ................................30
bromfenac sodium (ophth) .................63
BROMFENAC SODIUM (OPHTH)(ONCEDAILY) ............................................63
bromocriptine mesylate .....................34
BROVANA ........................................65
budesonide ......................................52
budesonide (inhalation) .....................67
budesonide (nasal) ...........................67
bumetanide ......................................28
BUNAVAIL MIS 2.1-0.3MG..................41
BUNAVAIL MIS 4.2-0.7MG..................41
BUNAVAIL MIS 6.3-1MG ....................41
BUPHENYL .......................................46
buprenorphine hcl .............................41
buprenorphine hcl-naloxone hcl sl .......41
buproban tab (smoking deterrent) ......41
bupropion hcl ...................................33
bupropion hcl (smoking deterrent) ......41
buspirone hcl....................................30
BUSULFEX........................................19
butorphanol nasal spray ..................... 8
butorphanol tartrate ........................... 8
BUTRANS .......................................... 8
BYDUREON ......................................43
BYDUREON PEN ................................43
BYETTA ...........................................43
BYSTOLIC ........................................27
C
cabergoline ..................................... 49
CABOMETYX .................................... 22
cafergot tab 1-100mg ....................... 39
calcipotriene .................................... 69
calcipotriene/betamethasone ............. 70
calcitonin (salmon) nasal spray .......... 49
calcitrene oin 0.005% ....................... 69
calcitriol .......................................... 62
CALCITRIOL .................................... 69
calcium acetate (phosphate binder) .... 49
CAMPTOSAR .................................... 23
CANASA .......................................... 52
CANCIDAS....................................... 13
candesartan cilexetil ......................... 25
candesartan cilexetil-hydrochlorothiazide
...................................................... 25
CANTIL ........................................... 51
CAPASTAT SULFATE ......................... 15
CAPEX ............................................ 70
capital
and codeine .................................... 8
CAPRELSA ....................................... 22
captopril ......................................... 24
captopril & hydrochlorothiazide .......... 24
CARAFATE ....................................... 53
CARBAGLU ...................................... 46
carbamazepine ................................ 30
carbidopa ........................................ 34
CARBIDOPA/LEVODOPA/ENTACAPONE 34
carbidopa-levodopa .......................... 34
carboplatin ...................................... 23
CARDIZEM LA .................................. 27
CARDURA XL ................................... 54
CARIMUNE NANOFILTERED................ 57
carteolol hcl (ophth) ......................... 64
cartia xt .......................................... 27
carvedilol ........................................ 27
CAYSTON ........................................ 12
cefaclor ........................................... 16
cefaclor er tab 500mg ....................... 16
cefadroxil ........................................ 16
cefazolin in dextrose 1gm/50ml-5% ... 16
CEFAZOLIN IN DEXTROSE 2GM/100ML4% ................................................. 16
cefazolin inj ..................................... 16
cefazolin sodium .............................. 16
cefdinir ........................................... 16
77
CEFEPIME 1GM SOLN ........................16
CEFEPIME 2GM SOLN ........................16
CEFEPIME HCL AND DEXTROSE ..........16
cefepime inj 1gm ..............................16
cefepime inj 2gm ..............................16
cefixime ...........................................16
cefotaxime sodium ............................16
cefotetan disodium ............................16
cefoxitin sodium ...............................16
CEFOXITIN SODIUM IN DEXTROSE .....16
cefpodoxime proxetil .........................16
cefprozil...........................................16
ceftazidime ......................................16
CEFTAZIDIME/DEXTROSE ..................17
CEFTIBUTEN.....................................17
CEFTIN ............................................17
ceftriaxone sodium ............................17
cefuroxime axetil ..............................17
cefuroxime sodium ............................17
celecoxib .......................................... 7
CELLCEPT INTRAVENOUS ...................58
CELONTIN ........................................30
CENTANY .........................................68
cephalexin .......................................17
CERDELGA .......................................46
CEREZYME .......................................46
CERVARIX ........................................58
CESAMET .........................................50
cetirizine syrup .................................65
cevimeline hcl ..................................72
CHANTIX .........................................41
CHANTIX CONTINUING MONTH ..........41
CHANTIX STARTER PACK ...................41
CHEMET ...........................................46
chlorhexidine gluconate (mouth-throat)
......................................................72
chloroquine phosphate ......................13
chlorothiazide tabs ............................28
chlorpromazine hcl ............................35
chlorpromazine inj ............................35
chlorthalidone ..................................28
cholestyramine .................................26
cholestyramine light ..........................26
choline fenofibrate ............................26
CHORIONIC GONADOTROPIN .............49
ciclopirox .........................................69
ciclopirox cre 0.77%..........................69
ciclopirox shampoo 1% ......................69
ciclopirox sus 0.77% ........................ 69
cidofovir .......................................... 15
cilostazol ......................................... 56
CILOXAN OIN 0.3% OP ..................... 63
cimetidine ....................................... 51
cimetidine sol 300/5ml...................... 51
CIMZIA ........................................... 57
CINQAIR ......................................... 66
CINRYZE ......................................... 56
CIPRO HC ........................................ 72
CIPRODEX ....................................... 73
ciprofloxacin .................................... 17
ciprofloxacin er ................................ 17
ciprofloxacin hcl ............................... 18
ciprofloxacin hcl (ophth).................... 63
ciprofloxacin in d5w .......................... 18
ciprofloxacin inj 200mg/20ml ............. 18
ciprofloxacin inj 400mg/40ml ............. 18
cisplatin .......................................... 23
citalopram hydrobromide .................. 33
cladribine ........................................ 20
claforan .......................................... 17
CLAFORAN/D5W............................... 17
claravis ........................................... 68
CLARINEX ....................................... 65
CLARINEX-D TAB 2.5-120 ................. 65
clarithromycin .................................. 17
CLEOCIN VAG SUPP 100MG ............... 54
clindacin-p ...................................... 68
CLINDAGEL ..................................... 68
clindamax ....................................... 68
clindamycin cre 2% vag .................... 54
clindamycin hcl ................................ 12
clindamycin palmitate hydrochloride ... 12
clindamycin phosphate ...................... 12
clindamycin phosphate (topical) ......... 68
clindamycin phosphate in d5w ........... 12
...................................................... 68
(refrigerate) .................................... 68
clindamycin phosphate-tretinoin......... 68
CLINDESSE ..................................... 54
CLINIMIX 2.75%/DEXTROSE 5% ........ 60
CLINIMIX 4.25%/DEXTROSE 10% ...... 60
CLINIMIX 4.25%/DEXTROSE 5% ........ 60
78
CLINIMIX 5%/DEXTROSE 15% ...........60
CLINIMIX E 2.75%/DEXTROSE 10% ....60
CLINIMIX E 2.75%/DEXTROSE 5%......60
CLINIMIX E 4.25%/D10 .....................60
CLINIMIX E 4.25%/DEXTROSE 25% ....60
CLINIMIX E 4.25%/DEXTROSE 5%......60
CLINIMIX E 5%/DEXTROSE 15% ........60
clinisol 15 ........................................60
clobetasol e cream 0.05% ..................70
clobetasol propionate ........................70
clobetasol propionate emulsion ...........70
CLOCORTOLONE PIVALATE ................70
clodan sha 0.05% .............................70
CLOLAR ...........................................20
clomipramine hcl ..............................33
clonazepam ................................ 30, 31
clonidine hcl .....................................29
clopidogrel bisulfate ..........................56
clorazepate dipotassium ....................31
clorpres ...........................................29
clotrimazole .....................................72
clotrimazole (topical) .........................69
clozapine .........................................35
CLOZAPINE ......................................35
CLOZAPINE ODT ...............................35
COARTEM ........................................13
codeine
and capital ..................................... 8
CODEINE SULFATE ............................. 8
colchicine w/ probenecid ..................... 7
COLCRYS .......................................... 7
colestipol hcl ....................................26
colistimethate sodium........................12
colocort ...........................................52
COLY-MYCIN S .................................73
COLYTE-FLAVOR PACKS 227.1 GM ......52
COMBIGAN.......................................64
COMBIVENT RESPIMAT ......................65
COMETRIQ .......................................22
COMPLERA .......................................14
compro supp ....................................50
COMVAX ..........................................58
CONDYLOX ......................................71
constulose .......................................52
CONZIP............................................. 8
COPAXONE INJ 20MG/ML .................. 40
COPAXONE INJ 40MG/ML .................. 40
CORDRAN ....................................... 70
COREG CR ....................................... 27
CORLANOR ...................................... 29
cormax ........................................... 70
CORTIFOAM..................................... 69
cortisone acetate.............................. 47
CORTISPORIN .................................. 68
CORTISPORIN-TC ............................. 73
COSENTYX ...................................... 69
COSENTYX SENSOREADY PEN ............ 69
COSMEGEN ..................................... 19
COSOPT PF ...................................... 64
COTELLIC ........................................ 22
COUMADIN ...................................... 55
CREON ............................................ 53
CRESEMBA ...................................... 13
CRESTOR ........................................ 26
CRINONE ........................................ 50
CRIXIVAN........................................ 14
cromolyn sodium .............................. 66
cromolyn sodium (mastocytosis) ........ 53
cromolyn sodium (ophth) .................. 64
CUBICIN ......................................... 12
CUVPOSA ........................................ 51
cyclophosphamide ............................ 19
CYCLOPHOSPHAMIDE ....................... 19
cycloserine ...................................... 15
cyclosporine .................................... 58
cyclosporine modified (for
microemulsion) ................................ 58
CYSTADANE .................................... 46
CYSTAGON ...................................... 46
cytarabine inj .................................. 20
D
dacarbazine ..................................... 19
DAKLINZA ....................................... 15
DALIRESP ....................................... 66
DALVANCE ...................................... 12
danazol ........................................... 46
dantrolene sodium ........................... 41
dapsone .......................................... 12
DAPTACEL ....................................... 59
DARAPRIM....................................... 12
DARIFENACIN HYDROBROMIDE ......... 54
daunorubicin hcl............................... 19
79
DAYTRANA .......................................37
decitabine ........................................20
DELESTROGEN .................................47
DELZICOL ........................................52
demeclocycline hcl ............................18
DEMSER ..........................................29
DENAVIR .........................................71
DEPEN TITRATABS ............................46
depo-estradiol ..................................47
DEPO-MEDROL INJ 20MG/ML ..............47
DEPO-PROVERA INJ 400/ML ...............21
depo-testosterone .............................42
DESCOVY .........................................14
desipramine hcl ................................33
desloratadine ...................................65
desmopressin acetate ........................50
DESMOPRESSIN ACETATE ..................50
desmopressin acetate inj ...................50
desmopressin acetate spray ...............50
desmopressin acetate spray refrigerated
......................................................50
DESONATE .......................................70
desonide ..........................................70
DESONIDE .......................................70
desoximetasone ................................70
DESOXIMETASONE ...........................70
dexamethasone ................................47
dexamethasone sodium phosphate .....47
dexamethasone sodium phosphate
(ophth) ............................................63
DEXILANT ........................................53
dexpak 10 day ..................................47
dexpak 6 day ...................................47
dexpak taperpak 13 day ....................47
dexrazoxane ....................................23
DEXTROSE .......................................61
DEXTROSE 10% FLEX CONTAIN..........61
DEXTROSE 10% W/ SODIUM CHLORIDE
0.2% ...............................................61
DEXTROSE 10%/NACL 0.45% ............61
DEXTROSE 2.5%/NACL 0.45% ...........61
DEXTROSE 5% .................................61
DEXTROSE 5% /ELECTROLYTE ...........61
DEXTROSE 5%/LACTATED RING .........61
DEXTROSE 5%/NACL 0.2% ................61
DEXTROSE 5%/NACL 0.225% ............61
DEXTROSE 5%/NACL 0.3% ................61
DEXTROSE 5%/NACL 0.33% ..............61
DEXTROSE 5%/NACL 0.45% ............. 61
DEXTROSE 5%/NACL 0.9% ............... 61
DEXTROSE 5%/POTASSIUM CHL ........ 61
diazepam ........................................ 31
DIAZEPAM GEL (ANTICONVULSANT) ... 31
DIBENZYLINE .................................. 29
diclofenac potassium .......................... 7
diclofenac sodium............................... 7
diclofenac sodium (actinic keratoses) .. 71
diclofenac sodium (ophth) ................. 63
diclofenac sodium (topical) 1.5% soln . 71
diclofenac w/ misoprostol .................... 7
dicloxacillin sodium .......................... 18
dicyclomine hcl ................................ 51
didanosine....................................... 14
DIFFERIN ........................................ 68
DIFICID .......................................... 17
diflorasone diacetate ........................ 70
diflunisal ........................................... 7
digitek ............................................ 28
digox .............................................. 28
digoxin ........................................... 28
digoxin inj ....................................... 28
DIGOXIN SOL 50MCG/ML .................. 28
dihydroergotamine mesylate.............. 39
DIHYDROERGOTAMINE MESYLATE ...... 39
dilantin ........................................... 31
DILANTIN-125 ................................. 31
DILATRATE SR ................................. 29
DILAUDID-HP INJ 250MG .................... 8
diltiazem cap 120mg/24hr ................. 27
diltiazem cap 240mg/24hr ................. 27
diltiazem cap er/12hr........................ 27
diltiazem hcl .................................... 27
diltiazem hcl coated beads ................ 27
diltiazem hcl er ................................ 27
diltiazem hcl extended release beads .. 27
diltiazem inj 100mg .......................... 27
diltiazem inj 125/25ml ...................... 27
diltiazem inj 25mg/5ml ..................... 27
diltiazem inj 50/10ml ........................ 27
dilt-xr cap ....................................... 27
DIPENTUM ....................................... 52
diphenhydram inj 50mg/ml ............... 65
diphenoxylate w/ atropine ................. 53
DIPHTHERIA/TETANUS TOXOID ......... 59
disopyramide phosphate ................... 25
disulfiram ........................................ 41
80
DIURIL SUS 250/5ML ........................28
divalproex sodium .............................31
docetaxel .........................................20
DOCETAXEL .....................................20
DOCETAXEL SOLN 80MG/8ML .............20
dofetilide .........................................25
donepezil odt 10mg...........................32
donepezil odt 5mg ............................32
donepezil tab hcl 23mg ......................32
donepezil tabs 10mg .........................32
donepezil tabs 5mg ...........................32
DORIBAX .........................................12
dorzolamide hcl ................................64
dorzolamide hcl-timolol maleate .........64
doxazosin mesylate ...........................24
doxepin hcl ......................................33
DOXEPIN HCL (ANTIPRURITIC) ...........69
doxercalciferol ..................................62
doxorubicin hcl .................................19
doxorubicin hcl liposomal inj (for iv
infusion) 2 mg/ml .............................19
doxorubicin inj 50mg .........................19
doxy ...............................................18
doxycycline (monohydrate) ................18
DOXYCYCLINE (ROSACEA) .................71
doxycycline hyclate ...........................19
doxycycline hyclate tab 100 mg dr ......19
doxycycline hyclate tab 150 mg dr ......19
doxycycline hyclate tab 75 mg dr ........19
dronabinol .......................................50
DROXIA ...........................................23
DUEXIS ............................................ 7
DULERA ...........................................67
duloxetine hcl ...................................33
DUOPA ............................................34
DURAMORPH ..................................... 8
DUREZOL .........................................63
DURLAZA .........................................56
dutasteride ......................................54
dutasteride-tamsulosin hcl .................54
DUTOPROL .......................................26
DYMISTA SPR 137-50 ........................65
DYRENIUM .......................................28
E
e.e.s. 400 tab 400mg ........................17
E.E.S. GRANULES .............................17
econazole nitrate ..............................69
EDARBI ...........................................25
EDARBYCLOR................................... 25
EDECRIN ......................................... 28
EDURANT ........................................ 14
EFFIENT .......................................... 56
EGRIFTA ......................................... 49
ELAPRASE ....................................... 46
ELECTROLYTE-R IN DEXTROSE .......... 61
ELELYSO ......................................... 46
ELIDEL ............................................ 71
ELIGARD INJ 22.5MG ........................ 21
ELIGARD INJ 30MG .......................... 21
ELIGARD INJ 45MG .......................... 21
ELIGARD INJ 7.5MG ......................... 21
ELIQUIS TAB 2.5MG ......................... 55
ELIQUIS TAB 5MG ............................ 55
ELITEK ............................................ 23
elixophyllin ...................................... 67
ELMIRON......................................... 54
ELOXATIN ....................................... 23
EMADINE ........................................ 64
EMBEDA ............................................ 8
EMCYT ............................................ 19
EMEND ........................................... 50
EMEND CAP 125MG .......................... 50
EMEND CAP 40MG ............................ 50
EMEND CAP 80MG ............................ 50
EMEND PAK 80 & 125 ....................... 50
EMSAM ........................................... 33
EMTRIVA ......................................... 14
emverm .......................................... 12
ENABLEX ......................................... 54
enalapril maleate ............................. 24
enalapril maleate & hydrochlorothiazide
...................................................... 24
ENBREL........................................... 57
ENBREL SURECLICK ......................... 57
endocet ............................................ 8
ENGERIX-B...................................... 59
enoxaparin sodium ........................... 55
ENSTILAR........................................ 70
ENTACAPONE................................... 34
entecavir ......................................... 15
ENTRESTO ...................................... 25
ENTYVIO ......................................... 52
enulose ........................................... 52
ENVARSUS XR ................................. 58
EPIDUO........................................... 68
EPIDUO FORTE ................................ 68
81
epinastine hcl (ophth) .......................64
EPINEPHRINE ...................................66
EPIPEN 2-PAK...................................66
EPIPEN-JR 2-PAK ..............................66
epirubicin inj 200mg .........................19
epirubicin inj 50mg/25ml ...................19
epitol ..............................................31
EPIVIR HBV ......................................15
eplerenone .......................................24
EPOGEN...........................................56
eprosartan mesylate .........................25
EPZICOM .........................................14
EQUETRO .........................................39
ERAXIS ............................................13
ERBITUX ..........................................20
ergomar ..........................................39
ERIVEDGE ........................................20
ERTACZO .........................................69
ery pad 2% ......................................68
ERYPED 200 .....................................17
ERYPED 400 .....................................17
ery-tab ............................................17
erythrocin lactobionate ......................17
erythrocin stearate............................17
erythromycin (acne aid).....................68
erythromycin (ophth) ........................63
erythromycin base ............................17
erythromycin cap 250mg ec ...............17
erythromycin ethylsuccinate ...............17
ESBRIET ..........................................66
escitalopram oxalate .........................33
esomeprazole sodium inj ...................53
estrace ............................................47
estradiol ..........................................47
estradiol valerate ..............................47
ESTRING .........................................47
ethacrynic acid .................................28
ethambutol hcl .................................15
ethosuximide....................................31
etodolac ........................................... 7
etodolac er ........................................ 7
ETOPOPHOS .....................................23
etoposide .........................................23
EURAX .............................................72
EVOTAZ ...........................................14
EXELDERM .......................................69
EXELON PATCHES .............................32
exemestane .....................................21
EXJADE ........................................... 46
EXTAVIA ......................................... 40
F
FABIOR ........................................... 68
FABRAZYME..................................... 46
famciclovir ...................................... 15
famotidine ....................................... 51
famotidine inj .................................. 51
FANAPT ........................................... 35
FANAPT TITRATION PACK .................. 35
FARESTON ...................................... 21
FARXIGA ......................................... 44
FARYDAK ........................................ 20
FASLODEX ....................................... 21
FAZACLO......................................... 35
felbamate ........................................ 31
felodipine ........................................ 27
FEMRING ........................................ 47
fenofibrate ...................................... 26
FENOFIBRATE .................................. 26
fenofibrate micronized ...................... 26
FENOFIBRIC ACID ............................ 26
FENOGLIDE ..................................... 26
fenoprofen calcium ............................. 7
FENOPROFEN CALCIUM ....................... 7
fentanyl citrate .................................. 8
fentanyl patch 100 mcg/hr .................. 9
fentanyl patch 12 mcg/hr .................... 9
FENTORA .......................................... 9
FERRIPROX ..................................... 46
FETZIMA ......................................... 33
FETZIMA TITRATION PACK ................ 33
FINACEA AER 15% ........................... 71
FINACEA GEL 15% ........................... 71
finasteride ....................................... 54
FIRAZYR ......................................... 56
FIRMAGON ...................................... 21
FLAREX ........................................... 63
FLEBOGAMMA .................................. 57
FLEBOGAMMA DIF ............................ 57
flecainide acetate ............................. 25
FLOVENT DISKUS ............................. 67
FLOVENT HFA .................................. 67
fluconazole ...................................... 13
fluconazole in dextrose ..................... 13
82
fluconazole in nacl ............................13
flucytosine .......................................13
fludarabine phosphate .......................20
fludrocortisone acetate ......................47
flunisolide (nasal) .............................67
fluocinolone acetonide .......................70
fluocinolone acetonide (otic)...............73
fluocinonide .....................................70
fluocinonide-e 0.05% cream ...............70
FLUOROMETHOLONE (OPHTH) ............63
fluorouracil.......................................20
fluorouracil (topical) ..........................71
FLUOROURACIL (TOPICAL).................71
fluoxetine cap 10mg ..........................33
fluoxetine hcl ...................................33
FLUOXETINE HCL ..............................33
fluphenazine decanoate .....................35
fluphenazine hcl................................35
flurandrenolide .................................70
flurbiprofen ....................................... 7
flurbiprofen sodium ...........................63
flutamide .........................................21
fluticasone propionate .......................70
fluticasone propionate (nasal) ............67
fluvastatin sodium cap 20 mg .............26
fluvastatin sodium cap 40 mg .............26
fluvastatin sodium tab sr 24 hr 80 mg .26
fluvoxamine maleate .........................30
fluvoxamine maleate er .....................30
FML .................................................63
FML FORTE.......................................63
fondaparinux sodium .........................55
FORADIL AEROLIZER .........................65
FORFIVO XL .....................................33
FORTAZ ...........................................17
FORTEO ...........................................49
FORTESTA .......................................42
FORTICAL SPR 200/ACT .....................49
FOSAMAX PLUS D .............................45
fosinopril sodium ..............................24
fosinopril sodium & hydrochlorothiazide
......................................................24
FOSRENOL .......................................49
FRAGMIN .........................................55
FREAMINE HBC 6.9% ........................60
FREAMINE III ...................................61
FROVA TAB 2.5MG ........................... 39
frovatriptan succinate ....................... 39
furosemide ...................................... 29
furosemide inj.................................. 29
FUROSEMIDE INJ ............................. 29
furosemide oral soln 8 mg/ml ............ 29
FUSILEV .......................................... 23
FUZEON .......................................... 14
fyavolv tab 1 mg-5 mcg .................... 47
FYCOMPA ........................................ 31
G
gabapentin ...................................... 31
GABITRIL ........................................ 31
galantamine hydrobromide ................ 32
galantamine hydrobromide er ............ 32
GAMASTAN S/D ............................... 57
GAMMAGARD LIQUID........................ 57
GAMMAGARD S/D ............................ 57
GAMMAGARD S/D IGA LESS TH ......... 57
GAMMAKED ..................................... 57
GAMMAPLEX .................................... 57
GAMUNEX-C .................................... 57
ganciclovir inj 500mg........................ 15
GARDASIL ....................................... 59
GARDASIL 9 .................................... 59
gatifloxacin (ophth) .......................... 63
GATTEX .......................................... 53
GAUZE PADS 2X2 ............................. 43
gaviltye-g........................................ 52
gavilyte-c ........................................ 52
gavilyte-h........................................ 52
gavilyte-n........................................ 52
GELNIQUE ....................................... 54
gemcitabine hcl ................................ 20
GEMCITABINE HCL ........................... 20
gemfibrozil ...................................... 26
generlac .......................................... 52
gengraf ........................................... 58
GENOTROPIN................................... 48
GENOTROPIN MINIQUICK .................. 48
gentak ............................................ 63
gentamicin in saline .......................... 11
gentamicin sulfate ............................ 11
gentamicin sulfate (ophth) ................ 63
gentamicin sulfate (topical) ............... 68
GENVOYA ........................................ 15
GEODON INJ.................................... 35
GIAZO ............................................ 52
83
GILENYA CAP 0.5MG .........................40
GILOTRIF TAB 20MG .........................22
GILOTRIF TAB 30MG .........................22
GILOTRIF TAB 40MG .........................22
GLASSIA ..........................................66
GLEOSTINE ......................................19
glimepiride .......................................44
glipizide ...........................................44
glipizide er .......................................44
GLIPIZIDE XL TB24 2.5MG .................44
GLIPIZIDE XL TB24 5MG ....................44
glipizide-metformin 2.5-250 mg..........44
glipizide-metformin 2.5-500 mg..........44
glipizide-metformin 5-500mg .............44
GLUCAGEN HYPOKIT .........................48
GLUCAGON EMERGENCY KIT ..............48
GLUMETZA .......................................44
glycopyrrolate ..................................51
GLYSET ...........................................44
GLYXAMBI........................................44
GOLYTELY ........................................52
GRALISE ..........................................39
GRALISE STARTER ............................39
granisetron hcl .................................50
GRANIX ...........................................56
GRASTEK .........................................57
griseofulvin microsize ........................13
griseofulvin ultramicrosize..................13
guanfacine er (adhd) .........................37
H
H.P. ACTHAR ....................................49
HALAVEN .........................................23
halobetasol propionate ......................70
HALOG ............................................70
haloperidol .......................................35
haloperidol decanoate .......................35
haloperidol lactate ............................35
haloperidol lactate inj 5 mg/ml ...........35
HARVONI .........................................15
HAVRIX ...........................................59
HECTOROL .......................................62
HEP SOD/NACL INJ 25000 .................55
HEPARIN (PORCINE) IN SODIUM
CHLORIDE 100U/ML ..........................55
heparin sod inj 10000u/ml .................55
heparin sod inj 1000u/ml ...................55
heparin sod inj 20000u/ml .................55
HEPARIN SOD INJ 2000U/ML ..............55
HEPARIN SOD INJ 2500U/ML ............. 55
heparin sod inj 5000u/0.5ml .............. 55
heparin sod inj 5000u/ml .................. 55
HEPARIN SODIUM/D5W .................... 55
HEPARIN SODIUM/NACL 0.45% ......... 55
HEPATAMINE ................................... 61
HERCEPTIN ..................................... 20
HETLIOZ ......................................... 38
HEXALEN ........................................ 19
HIBERIX.......................................... 59
HORIZANT....................................... 39
HUMALOG ....................................... 43
HUMALOG KWIKPEN ......................... 43
HUMALOG MIX 50/50 ........................ 43
HUMALOG MIX 50/50 KWIKPEN ......... 43
HUMALOG MIX 75/25 ........................ 43
HUMALOG MIX 75/25 KWIKPEN ......... 43
HUMATROPE .................................... 48
HUMATROPE COMBO PACK ................ 48
HUMIRA INJ 10MG/0.2ML .................. 57
HUMIRA KIT 20MG/0.4ML .................. 57
HUMIRA KIT 40MG/0.8ML .................. 57
HUMIRA PEDIATRIC CROHNS............. 57
HUMIRA PEN .................................... 57
HUMIRA PEN-CROHNS STARTER KIT ... 57
HUMIRA PEN-PSORIASIS STARTER KIT 57
HUMULIN 70/30 ............................... 43
HUMULIN 70/30 KWIKPEN ................. 43
HUMULIN N ..................................... 43
HUMULIN N KWIKPEN ....................... 43
HUMULIN R ..................................... 43
HUMULIN R U-500 KWIKPEN ............. 43
HUMULIN R U-500 VIAL (CONCENTRATE)
...................................................... 43
hydralazine hcl................................. 29
hydrochlorothiazide .......................... 29
hydrocodone-acetaminophen 10-300mg 9
........................................................ 9
hydrocodone-acetaminophen 5-300mg . 9
hydrocodone-acetaminophen 5-325mg . 9
........................................................ 9
hydrocodone-acetaminophen 7.5-325
mg/15ml ........................................... 9
........................................................ 9
hydrocodone-acetaminophen tab 1084
325mg ............................................. 9
hydrocodone-ibuprofen tab 10-200mg .. 9
hydrocodone-ibuprofen tab 2.5-200mg . 9
hydrocodone-ibuprofen tab 5-200mg.... 9
hydrocodone-ibuprofen tab 7.5-200 mg 9
hydrocortisone .................................47
HYDROCORTISONE (INTRARECTAL) ....52
hydrocortisone (topical) .....................71
hydrocortisone butyrate .....................71
hydrocortisone butyrate hydrophilic lipo
base ................................................71
hydrocortisone valerate .....................71
hydromorphone hcl ............................ 9
HYDROMORPHONE HCL ...................... 9
hydromorphone tab 12mg er ............... 9
hydromorphone tab 16mg er ............... 9
hydromorphone tab 8mg er................. 9
HYDROMORPHONE TABS 32MG ........... 9
hydroxychloroquine sulfate ................57
hydroxyprogesterone caproate
(antineoplastic) ................................21
hydroxyurea .....................................23
hydroxyzine hcl ................................65
HYSINGLA ER .................................... 9
I
ibandronate sodium ..........................45
ibandronate tab 150mg .....................45
IBRANCE..........................................20
ibudone tab 10-200mg ....................... 9
ibudone tab 5-200mg ......................... 9
ibuprofen .......................................... 7
ICLUSIG ..........................................22
idarubicin hcl ....................................19
IFEX INJ 3GM ...................................19
ifosfamide inj 1gm ............................19
ifosfamide inj 1gm/20ml ....................19
IFOSFAMIDE INJ 3GM ........................19
ifosfamide inj 3gm/60ml ....................19
ILEVRO ............................................63
ilotycin ............................................63
imatinib mesylate .............................22
IMBRUVICA CAP 140MG .....................22
imipenem-cilastatin ...........................12
imipramine hcl..................................33
imipramine pamoate .........................33
imiquimod ........................................71
IMOVAX RABIES (H.D.C.V.) ................59
INCRELEX ........................................49
INCRUSE ELLIPTA ............................ 65
indapamide ..................................... 29
INFANRIX ........................................ 59
INFUMORPH 200 ................................ 9
INFUMORPH 500 ................................ 9
INLYTA ........................................... 22
INSULIN PEN NEEDLES ..................... 43
INSULIN SAFETY NEEDLES ................ 43
INSULIN SYRINGES .......................... 43
INTELENCE ...................................... 14
INTRALIPID INJ 20% ........................ 61
INTRALIPID INJ 30% ........................ 61
INTRON-A INJ 10MU ......................... 57
INTRON-A INJ 18MU ......................... 57
INTRON-A INJ 25MU ......................... 58
INTRON-A INJ 50MU ......................... 58
INVANZ .......................................... 12
INVEGA........................................... 35
INVEGA SUST INJ 117 MG/0.75 ML .... 35
INVEGA SUST INJ 156MG/ML ............. 35
INVEGA SUST INJ 234 MG/1.5 ML ...... 35
INVEGA SUST INJ 39 MG/0.25 ML ...... 35
INVEGA SUST INJ 78 MG/0.5 ML ........ 35
INVEGA TRINZA ............................... 35
INVIRASE ........................................ 14
INVOKAMET TAB 150-1000 ............... 44
INVOKAMET TAB 150-500 ................. 44
INVOKAMET TAB 50-1000 ................. 44
INVOKAMET TAB 50-500MG .............. 44
INVOKANA TAB 100MG ..................... 44
INVOKANA TAB 300MG ..................... 44
IONOSOL-B/DEXTROSE 5% ............... 61
IONOSOL-MB/DEXTROSE 5% ............ 61
IPOL INACTIVATED IPV ..................... 59
ipratropium bromide (nasal) .............. 65
ipratropium sol inhal ......................... 65
ipratropium-albuterol ........................ 65
irbesartan ....................................... 25
irbesartan-hydrochlorothiazide ........... 25
IRESSA ........................................... 22
irinotecan inj 100/5ml....................... 23
irinotecan inj 40mg/2ml .................... 23
irinotecan inj 500mg/25ml ................ 23
ISENTRESS ..................................... 14
ISOLYTE P ....................................... 61
ISOLYTE S ....................................... 61
isoniazid ......................................... 15
isoniazid tabs ................................... 15
85
ISORDIL TITRADOSE .........................29
isosorbide dinitrate ...........................29
isosorbide dinitrate er ........................29
isosorbide mononitrate ......................29
isosorbide mononitrate er ..................29
isradipine .........................................27
ISTALOL ..........................................64
ISTODAX .........................................20
itraconazole .....................................13
ivermectin........................................12
IXEMPRA KIT ....................................23
IXIARO ............................................59
J
JADENU ...........................................46
JAKAFI ............................................22
jantoven ..........................................55
JANUMET .........................................44
JANUMET XR TAB 100-1000 ...............44
JANUMET XR TAB 50-1000 .................44
JANUMET XR TAB 50-500MG ..............44
JANUVIA ..........................................44
JARDIANCE ......................................44
JENTADUETO ....................................44
JENTADUETO XR 2.5-1000MG ............44
JENTADUETO XR 5-1000MG ...............44
jinteli ..............................................47
JUXTAPID ........................................26
K
KADCYLA .........................................20
KADIAN ............................................ 9
KALETRA SOL ...................................15
KALETRA TAB 100-25MG ...................15
KALETRA TAB 200-50MG ...................15
KALYDECO .......................................66
KAZANO ..........................................44
KCL 0.075%/D5W/NACL 0.45% ..........61
KCL 0.15%/D5W/LR ..........................61
KCL 0.15%/D5W/NACL 0.9% .............61
KCL 0.3%/D5W/LR IV LAC RI .............61
KCL 0.3%/D5W/NACL 0.45% .............61
KCL 0.3%/D5W/NACL 0.9% ...............61
KCL IN NACL INJ .15-0.45..................61
KCL/D5W/NACL INJ .15/.33% ............61
KCL/D5W/NACL INJ .15/.45% ............62
KCL/D5W/NACL INJ 0.22%/0.45% ......61
KCL/NACL INJ 0.15%-0.9% ...............62
KCL0.15%/D5W/NACL0.2% ...............61
KCL0.15%/D5W/NACL0.225% ............61
KEPIVANCE ..................................... 23
ketoconazole ................................... 13
ketoconazole (topical) ....................... 69
ketoconazole shampoo ...................... 70
ketodan aer 2% ............................... 69
ketoprofen ........................................ 7
ketorolac tromethamine (ophth) ........ 63
KEVEYIS ......................................... 29
KEYTRUDA ...................................... 21
KINERET ......................................... 57
KINRIX ........................................... 59
kionex ............................................ 46
KLOR-CON 10 .................................. 59
KLOR-CON 8 .................................... 59
klor-con m10 ................................... 59
klor-con m15 ................................... 59
klor-con m20 ................................... 59
klor-con pow 20meq ......................... 59
klor-con spr cap 10meq .................... 60
klor-con spr cap 8meq ...................... 59
KOMBIGLYZE XR 2.5-1000MG ............ 44
KOMBIGLYZE XR 5-1000MG............... 45
KOMBIGLYZE XR 5-500MG ................ 44
KORLYM .......................................... 48
kristalose ........................................ 52
KUVAN ............................................ 46
KYNAMRO ....................................... 26
L
labetalol hcl ..................................... 27
LACRISERT ...................................... 64
LACTATED RINGERS VIAFLEX ............ 62
lactulose ......................................... 52
lactulose (encephalopathy) ................ 52
LAMICTAL ODT ................................ 31
LAMICTAL STARTER .......................... 31
LAMICTAL XR ................................... 31
LAMISIL .......................................... 13
lamivudine ...................................... 14
lamivudine (hbv) .............................. 15
lamivudine-zidovudine ...................... 15
lamotrigine ...................................... 31
LANOXIN ......................................... 28
LANOXIN PEDIATRIC ........................ 28
lansoprazole .................................... 53
LANTUS .......................................... 43
LANTUS SOLOSTAR .......................... 43
LASTACAFT ..................................... 64
latanoprost ...................................... 64
86
LATUDA ...........................................35
LAZANDA .......................................... 9
leflunomide ......................................57
LEMTRADA .......................................40
LENVIMA 10 MG DAILY DOSE .............22
LENVIMA 8 MG DAILY DOSE ...............22
LESCOL XL .......................................26
LETAIRIS .........................................30
letrozole ..........................................21
leucovor ca inj ..................................23
leucovorin calcium ............................23
leucovorin calcium 500 mg .................23
LEUKERAN .......................................19
LEUKINE ..........................................56
leuprolide acetate .............................21
levalbuterol conc 1.25mg/0.5ml..........65
levalbuterol hcl .................................66
LEVALBUTEROL HCL ..........................66
LEVEMIR ..........................................43
LEVEMIR FLEXTOUCH ........................43
levetiracetam ...................................31
LEVETIRACETAM IV ...........................31
levetiracetam oral soln 100 mg/ml ......31
levobunolol hcl .................................64
levocarnitine (metabolic modifiers) .....46
levocetirizine soln 2.5mg/5ml .............65
levocetirizine tab 5 mg ......................65
levofloxacin ......................................18
levofloxacin (ophth) ..........................63
levofloxacin in d5w ...........................18
levoleucovorin calcium .......................23
levorphanol tartrate ........................... 9
levothyroxine sodium ........................50
LEVOXYL ..........................................50
LEXIVA ............................................14
LIALDA ............................................52
lidocaine ..........................................71
lidocaine hcl .....................................71
lidocaine hcl (local anesth.) ................11
lidocaine hcl (mouth-throat) ...............72
lidocaine inj 0.5% .............................11
lidocaine inj 1% ................................11
lidocaine inj 1.5% .............................11
lidocaine inj 2% ................................11
lidocaine-prilocaine ........................... 71
linezolid .......................................... 12
LINEZOLID ...................................... 12
LINEZOLID IN SODIUM CHLORIDE ..... 12
LINZESS ......................................... 53
liothyronine sodium .......................... 50
LIPOSYN III ..................................... 61
lisinopril .......................................... 24
lisinopril & hydrochlorothiazide........... 24
lithium carbonate ............................. 39
LITHIUM SOLN 8MEQ/5ML ................. 39
LIVALO ........................................... 26
LOCOID .......................................... 71
lokara ............................................. 71
LONSURF ........................................ 23
loperamide hcl ................................. 53
lorazepam ....................................... 30
lorcet hd tab 10-325mg ...................... 9
lorcet plus tab 7.5-325 ....................... 9
lorcet tab 5-325mg ............................ 9
lortab tab 10-325mg ........................ 10
lortab tab 5-325mg .......................... 10
lortab tab 7.5-325 ............................ 10
losartan potassium ........................... 25
losartan-hydrochlorothiazide .............. 25
LOTEMAX ........................................ 63
lovastatin ........................................ 26
loxapine succinate ............................ 35
LUMIGAN ........................................ 64
LUMIZYME ....................................... 46
LUPANETA PACK .............................. 46
LUPRON DEP INJ 11.25MG ................ 21
LUPRON DEPOT ................................ 21
LUPRON DEPOT INJ 22.5MG (3-MONTH)
...................................................... 21
LUPRON DEPOT INJ 30MG (3-MONTH) 21
LUPRON DEP-PED INJ 11.25MG .......... 21
LUPRON DEP-PED INJ 15MG .............. 21
LUPRON DEP-PED INJ 30MG (3-MONTH)
...................................................... 21
LUPRON DEP-PED INJ 7.5MG ............. 21
LUZU .............................................. 69
LYNPARZA ....................................... 21
LYRICA ........................................... 31
LYSODREN ...................................... 21
M
MACRODANTIN ................................ 12
magnesium sulfate ........................... 60
87
MAGNESIUM SULFATE .......................60
MAGNESIUM SULFATE IN D5W ...........60
MAGNESIUM SULFATE INJ 50% ..........60
malathion ........................................72
maprotiline hcl .................................33
MARPLAN .........................................33
MATULANE .......................................23
matzim la ........................................27
MAXIDEX .........................................63
MAXIPIME ........................................17
meclizine hcl ....................................50
MEDROL TAB 2MG.............................47
medroxyprogesterone acetate ............50
mefenamic acid ................................. 7
mefloquine hcl ..................................13
megestrol ac sus 40mg/ml .................21
megestrol ac tab 20mg ......................21
megestrol ac tab 40mg ......................22
MEGESTROL SUS 625MG/5ML ............22
MEKINIST ........................................22
MELOXICAM ...................................... 7
meloxicam tabs ................................. 7
melphalan hcl ...................................19
memantine hcl .................................33
MENACTRA .......................................59
MENHIBRIX ......................................59
MENOMUNE-A/C/Y/W-135 ..................59
MENOSTAR ......................................47
MENTAX ..........................................69
MENVEO ..........................................59
mercaptopurine ................................20
meropenem .....................................12
MEROPENEM/SODIUM CHLORIDE ........12
mesalamine enema ...........................52
mesna .............................................23
MESNEX ..........................................23
MESTINON SYRUP .............................39
MESTINON TIMESPAN .......................39
metadate er tab 20mg .......................37
metformin er ....................................45
metformin hcl ...................................45
metformin hcl osmotic 1000mg ..........45
metformin hcl osmotic 500mg ............45
methadone hcl..................................10
METHADONE INJ 10MG/ML .................10
methazolamide .................................29
methenamine hippurate .....................12
methimazole ....................................50
methotrexate sodium........................ 20
METHOTREXATE SODIUM .................. 20
methotrexate sodium inj ................... 20
methotrexate sodium tabs ................. 57
methoxsalen rapid ............................ 69
methscopolamine bromide ................. 51
methyclothiazide .............................. 29
methylergonovine maleate ................ 49
methylphenidate hcl .................... 37, 38
METHYLPHENIDATE HCL.................... 37
methylphenidate hcl er ..................... 38
methylpr ace inj 40mg/ml ................. 47
methylpr ace inj 80mg/ml ................. 47
methylpr ss inj 125mg ...................... 47
methylpr ss inj 1gm ......................... 47
methylpr ss inj 40mg ........................ 47
methylpred pak 4mg ........................ 47
methylpred tab 16mg ....................... 48
methylpred tab 32mg ....................... 48
methylpred tab 4mg ......................... 47
methylpred tab 8mg ......................... 48
metipranolol .................................... 64
metoclopramide hcl .......................... 50
metoclopramide hcl inj 5 mg/ml ......... 51
metoclopramide odt.......................... 51
metolazone ..................................... 29
metoprolol & hctz tab 100-25mg ........ 26
metoprolol & hctz tab 100-50mg ........ 27
metoprolol & hctz tab 50-25mg .......... 26
metoprolol succinate......................... 27
metoprolol tartrate ........................... 27
METRO IV........................................ 12
metronidazole .................................. 12
metronidazole (topical) ..................... 71
metronidazole inj ............................. 12
metronidazole vaginal ....................... 54
mexiletine hcl .................................. 25
MIACALCIN INJ 200U/ML ................... 49
miconazole 3 sup 200mg................... 54
midodrine hcl ................................... 29
migergot ......................................... 39
miglitol ........................................... 45
millipred ......................................... 48
millipred dp ..................................... 48
minitran .......................................... 29
MINIVELLE ...................................... 47
minocycline hcl ................................ 19
minoxidil ......................................... 29
88
MIRAPEX..........................................34
MIRAPEX ER .....................................34
MIRCERA .........................................56
mirtazapine ......................................33
misoprostol ......................................53
mitomycin ........................................19
mitoxantrone hcl...............................23
M-M-R II ..........................................59
modafinil .........................................41
moderiba pak ...................................15
MODERIBA PAK ................................15
moderiba tab 200mg .........................16
moexipril hcl ....................................24
moexipril-hydrochlorothiazide .............24
molindone hcl ...................................35
mometasone furoate .........................71
montelukast sodium ..........................66
morgidox .........................................19
MORPHINE SUL 20MG/ML ORAL SOL ...10
MORPHINE SUL INJ 10MG/ML .............10
MORPHINE SUL INJ 15MG/ML .............10
MORPHINE SUL INJ 1MG/ML ...............10
MORPHINE SUL INJ 4MG/ML ...............10
morphine sulfate ...............................10
MORPHINE SULFATE..........................10
morphine sulfate beads .....................10
morphine sulfate ext-rel tab ...............10
MOVANTIK .......................................53
MOVIPREP........................................52
MOXATAG ........................................18
MOXEZA ..........................................63
moxifloxacin hcl ................................18
MOXIFLOXACIN HCL ..........................18
MOZOBIL .........................................56
MULTAQ ..........................................25
mupirocin ........................................68
mupirocin calcium (topical) ................69
MUSTARGEN ....................................19
MYCAMINE .......................................13
mycophenolate mofetil ......................58
mycophenolate sodium ......................58
myorisan .........................................68
MYOZYME ........................................46
MYRBETRIQ......................................54
N
nabumetone ...................................... 7
nadolol ............................................27
nadolol & bendroflumethiazide ............27
NAFCILLIN ...................................... 18
nafcillin sodium ................................ 18
NAFCILLIN SODIUM IN DEXTROSE ..... 18
naftifine hcl ..................................... 69
NAFTIFINE HCL ................................ 69
NAFTIN ........................................... 69
NAGLAZYME .................................... 46
nalbuphine hcl ................................... 8
naloxone inj 0.4mg/ml ...................... 41
naloxone inj 1mg/ml......................... 41
naltrexone hcl .................................. 41
NAMENDA XR................................... 33
NAMENDA XR TITRATION PACK.......... 33
NAMZARIC ...................................... 33
naphazoline hcl ................................ 64
NAPRELAN ......................................... 7
naproxen .......................................... 7
naproxen sodium ............................... 7
NAPROXEN SODIUM ........................... 7
naratriptan hcl ................................. 39
NASONEX ........................................ 67
NATACYN ........................................ 63
nateglinide ...................................... 45
NATPARA ........................................ 49
NEBUPENT....................................... 12
nefazodone hcl................................. 33
neomycin sulfate .............................. 11
neomycin/polymyxin b gu ................. 72
neomycin-bacitracin zn-polymyxin...... 63
neomycin-polymy-dexameth.............. 62
neomycin-polymyxin-gramicidin ......... 63
neomycin-polymyxin-hc (ophth)......... 62
neomycin-polymyxin-hc (otic)............ 73
NEORAL .......................................... 58
NEPHRAMINE ................................... 61
NESINA ........................................... 45
neuac gel 1.2-5%............................. 68
NEULASTA ....................................... 56
NEULASTA ONPRO KIT ...................... 56
NEUMEGA ....................................... 56
NEUPOGEN ...................................... 56
NEUPRO .......................................... 34
nevirapine ....................................... 14
NEVIRAPINE .................................... 14
NEXAVAR ........................................ 22
NEXIUM CAP 20MG ........................... 53
NEXIUM CAP 40MG ........................... 53
NEXIUM GRA 10MG DR ..................... 53
89
NEXIUM GRA 2.5MG DR .....................53
NEXIUM GRA 20MG DR ......................53
NEXIUM GRA 40MG DR ......................53
NEXIUM GRA 5MG DR ........................53
niacin er (antihyperlipidemic) .............26
niacor ..............................................26
nicardipine hcl ..................................28
NICOTROL INHALER ..........................41
NICOTROL NS ..................................42
nifedical ...........................................28
nifedipine .........................................28
nifedipine er .....................................28
NILANDRON .....................................22
nilutamide........................................22
nimodipine .......................................28
NINLARO .........................................21
NIPENT ............................................20
nisoldipine .......................................28
nitro-bid ..........................................29
NITRO-DUR ......................................29
nitrofurantoin ...................................12
nitrofurantoin macrocrystal ................12
nitrofurantoin monohyd macro ...........12
nitroglycerin .....................................29
NITROGLYCERIN LINGUAL .................29
nitroglycerin patches .........................29
NITROSTAT ......................................29
nizatidine .........................................51
NORDITROPIN FLEXPRO ....................48
norethindrone acetate .......................50
norethindrone acetate-ethinyl estradiol 47
NORITATE ........................................71
NORMOSOL-M IN D5W ......................62
NORMOSOL-R ...................................62
NORPACE CR ....................................25
nortriptyline hcl ................................33
NORVIR ...........................................14
NOVAREL INJ 10000UNT ....................49
NOVOLIN 70/30 ................................43
NOVOLIN 70/30 RELION ....................43
NOVOLIN N ......................................43
NOVOLIN N RELION ..........................43
NOVOLIN R ......................................43
NOVOLIN R RELION ..........................43
NOVOLOG ........................................43
NOVOLOG FLEXPEN ...........................43
NOVOLOG MIX 70/30 ........................43
NOVOLOG MIX 70/30 PREFILL ............43
NOVOLOG PENFILL ........................... 43
NOXAFIL ......................................... 13
NUCALA .......................................... 66
NUCYNTA ........................................ 10
NUCYNTA ER ................................... 10
NUEDEXTA ...................................... 40
NULOJIX ......................................... 58
NULYTELY/FLAVOR PACKS ................. 52
NUPLAZID ....................................... 36
NUTRILIPID INJ 20% ........................ 61
NUTROPIN AQ INJ 20MG/2ML ............ 48
NUTROPIN AQ NUSPIN 10 ................. 48
NUTROPIN AQ NUSPIN 20 ................. 49
NUTROPIN AQ NUSPIN 5 ................... 48
NUTROPIN AQ PEN ........................... 49
NUVESSA ........................................ 55
NUVIGIL ......................................... 41
nyamyc ........................................... 69
NYMALIZE ....................................... 28
nystatin .......................................... 13
nystatin (mouth-throat) .................... 72
nystatin (topical) .............................. 69
nystatin pow 100000 ........................ 69
nystop ............................................ 69
O
OCTAGAM ....................................... 57
octreotide acetate ............................ 49
ODEFSEY ........................................ 15
ODOMZO......................................... 23
OFEV .............................................. 66
ofloxacin (ophth) .............................. 63
ofloxacin (otic) ................................. 73
olanzapine ....................................... 36
olanzapine odt ................................. 36
olopatadine hcl ................................ 64
olopatadine hcl (nasal) ...................... 65
OMECLAMOX-PAK ............................. 53
omega-3-acid ethyl esters ................. 26
omeprazole ..................................... 53
OMEPRAZOLE-SODIUM BICARBONATE 53
OMNARIS ........................................ 67
OMNITROPE 10MG ........................... 49
OMNITROPE 5.8MG .......................... 49
OMNITROPE 5MG ............................. 49
ondansetron hcl ............................... 51
ondansetron hcl inj ........................... 51
ondansetron hcl oral soln .................. 51
ondansetron odt ............................... 51
90
ONEXTON ........................................68
ONFI ......................................... 31, 32
ONGLYZA .........................................45
ONMEL ............................................13
ONZETRA XSAIL ...............................39
OPANA ER (CRUSH RESISTANT ...........10
OPSUMIT .........................................30
ORACEA...........................................72
ORAVIG ...........................................72
ORENCIA .........................................57
ORENCIA CLICKJECT .........................57
ORENITRAM TAB 0.125MG .................30
ORENITRAM TAB 0.25MG ...................30
ORENITRAM TAB 1MG .......................30
ORENITRAM TAB 2.5MG .....................30
ORFADIN .........................................46
ORKAMBI .........................................66
OSENI TAB 12.5-15MG ......................45
OSENI TAB 12.5-30MG ......................45
OSENI TAB 12.5-45MG ......................45
OSENI TAB 25-15MG .........................45
OSENI TAB 25-30MG .........................45
OSENI TAB 25-45MG .........................45
OSMOPREP.......................................52
OTEZLA ...........................................57
oxacillin sodium ................................18
oxaliplatin ........................................23
oxandrolone .....................................42
oxaprozin .......................................... 7
oxcarbazepine ..................................32
oxiconazole nitrate cream ..................69
OXISTAT ..........................................69
OXTELLAR XR ...................................32
oxybutynin chloride ...........................54
oxycodone hcl ..................................10
OXYCODONE HCL..............................10
......................................................10
......................................................10
......................................................10
......................................................10
oxycodone w/ acetaminophen soln 5-325
mg/5ml ...........................................10
oxycodone-aspirin .............................10
oxycodone-ibuprofen .........................10
OXYCONTIN..................................... 11
oxymorphone hcl ............................. 11
OXYTROL ........................................ 54
P
pacerone ......................................... 25
paclitaxel ........................................ 20
paliperidone .................................... 36
pamidronate disodium ...................... 46
PANCREAZE ..................................... 53
PANDEL .......................................... 71
PANRETIN ....................................... 72
pantoprazole sodium ........................ 54
paricalcitol....................................... 62
PARICALCITOL ................................. 62
paroex sol 0.12% ............................. 72
paromomycin sulfate ........................ 11
paroxetine er tab ............................. 33
paroxetine hcl tabs ........................... 33
paser d/r ......................................... 15
PATADAY ......................................... 64
PATANOL......................................... 64
PAXIL ............................................. 33
PAZEO ............................................ 64
PCE ................................................ 17
PEDIARIX ........................................ 59
PEDVAX HIB .................................... 59
PEG 3350-KCL-SOD BICARB-SOD
CHLORIDE-SOD SULFATE .................. 52
peg 3350-potassium chloride-sod
bicarbonate-sod chloride ................... 52
PEGANONE ...................................... 32
PEGASYS......................................... 16
PEGASYS PROCLICK ......................... 16
PEGINTRON ..................................... 16
PEG-INTRON REDIPEN ...................... 16
PENICILLIN G POT IN DEXTROSE ....... 18
PENICILLIN G POTASSIUM IN ............ 18
penicillin g procaine .......................... 18
penicillin g sodium ............................ 18
penicillin v potassium ....................... 18
penicilln gk inj 20mu ........................ 18
penicilln gk inj 5mu .......................... 18
PENNSAID ....................................... 72
PENTACEL ....................................... 59
PENTAM 300 .................................... 12
PENTASA ......................................... 52
pentoxifylline ................................... 56
PERFOROMIST ................................. 66
91
perindopril erbumine .........................24
periogard soln 0.12% ........................72
PERJETA ..........................................21
permethrin .......................................72
perphenazine ...................................36
PERTZYE ..........................................53
PEXEVA ...........................................33
pfizerpen-g inj 20mu .........................18
pfizerpen-g inj 5mu ...........................18
phenadoz .........................................51
phenelzine sulfate .............................34
phenergan .......................................51
phenobarbital ...................................32
phenobarbital sodium ........................32
PHENOBARBITAL SODIUM ..................32
phenoxybenzamine hcl ......................29
phenytek .........................................32
phenytoin ........................................32
phenytoin inj 50mg/ml ......................32
phenytoin sodium extended ...............32
PHOSLYRA .......................................49
PHOSPHOLINE IODIDE ......................64
PICATO ............................................72
PILOCARPINE HCL .............................64
pilocarpine hcl (oral) .........................72
PILOCARPINE HCL (ORAL)..................72
pimozide ..........................................36
pindolol ...........................................27
pioglitazone hcl ................................45
pioglitazone hcl-glimepiride ................45
pioglitazone hcl-metformin hcl ............45
piperacillin sodium-tazobactam sodium 18
piroxicam .......................................... 7
PLASMA-LYTE A ................................62
PLASMA-LYTE-148 ............................62
PLASMA-LYTE-56/D5W ......................62
PLEGRIDY ........................................40
PLEGRIDY STARTER PACK ..................40
plenamine ........................................61
podofilox..........................................72
polyethylene glycol 3350 ...................52
polymyxin b sulfate ...........................12
polymyxin b-trimethoprim..................63
POMALYST .......................................23
pot chloride inj 2meq/ml ....................62
potassium chloride ............................60
POTASSIUM CHLORIDE ................ 60, 62
POTASSIUM CHLORIDE 0.3%/D ..........62
potassium chloride caps er ................ 60
potassium chloride in nacl ................. 62
POTASSIUM CHLORIDE IN NACL ........ 62
potassium chloride microencapsulated
crystals cr ....................................... 60
POTASSIUM CHLORIDE TAB CR 10 MEQ
...................................................... 60
potassium citrate (alkalinizer) ............ 54
POTASSIUM CITRATE (ALKALINIZER) . 54
POTIGA ........................................... 32
PRADAXA ........................................ 55
PRALUENT ....................................... 26
pramipexole dihydrochloride .............. 34
PRANDIMET ..................................... 45
pravastatin sodium ........................... 26
prazosin hcl ..................................... 24
PRED MILD ...................................... 63
pred sod pho sol 5mg/5ml ................. 48
PRED-G ........................................... 62
PRED-G S.O.P. ................................. 62
prednicarbate .................................. 71
PREDNICARBATE .............................. 71
PREDNISOLONE ACETATE (OPHTH) .... 63
prednisolone sodium phosphate ......... 48
prednisolone sodium phosphate (ophth)
...................................................... 63
prednisolone sol 15mg/5ml ............... 48
prednisolone sol 25mg/5ml ............... 48
prednisolone syrup 15 mg/5ml........... 48
prednisone con 5mg/ml .................... 48
prednisone pak 10mg ....................... 48
prednisone pak 5mg ......................... 48
prednisone sol 5mg/5ml .................... 48
prednisone tab 10mg ........................ 48
prednisone tab 1mg.......................... 48
prednisone tab 2.5mg ....................... 48
prednisone tab 5mg.......................... 48
PREGNYL W/DILUENT BENZYL ........... 49
PREMARIN CREAM ............................ 47
PREMARIN INJ ................................. 47
premasol 10% ................................. 61
premasol 6% ................................... 61
PRENATAL VITAMIN/FOLIC ACID > 0.8
MG (GENERIC) ................................. 62
PREPOPIK........................................ 52
PREVACID SOLUTAB ......................... 54
92
prevalite ..........................................26
PREZCOBIX ......................................15
PREZISTA ........................................14
PRIFTIN ...........................................15
PRILOSEC PACK ................................54
PRIMAQUINE PHOSPHATE ..................13
primidone ........................................32
PRIMSOL .........................................12
PRISTIQ ..........................................34
PRIVIGEN ........................................57
PROAIR HFA .....................................66
PROAIR RESPICLICK .........................66
probenecid ........................................ 7
PROCALAMINE ..................................61
prochlorperazine inj 5 mg/ml..............51
prochlorperazine maleate ...................51
prochlorperazine supp .......................51
PROCRIT ..........................................56
procto-med ......................................69
procto-pak .......................................69
proctosol hc 2.5 % ............................69
proctozone hc ...................................69
PROCYSBI ........................................46
progesterone micronized ....................50
PROGLYCEM SUS 50MG/ML ................48
PROGRAF .........................................58
PROLASTIN-C ...................................66
PROLENSA .......................................64
PROLEUKIN ......................................21
PROLIA ............................................49
PROMACTA.......................................56
promethazine hcl ..............................51
promethegan....................................51
propafenone hcl ................................25
propafenone hcl 12hr ........................25
proparacaine hcl ...............................64
propranolol & hydrochlorothiazide .......27
propranolol hcl er ..............................27
propranolol inj 1mg/ml ......................27
propranolol sol .................................27
propranolol tab .................................27
propylthiouracil .................................50
PROQUAD ........................................59
PROSOL ...........................................61
PROTONIX .......................................54
protriptyline hcl ................................34
PROVENTIL HFA ................................66
PRUDOXIN CRE 5% ...........................69
PULMICORT FLEXHALER .................... 67
PULMICORT INH SUSP 1MG/2ML ........ 67
PULMOZYME .................................... 66
PURIXAN ......................................... 20
PYLERA ........................................... 53
pyrazinamide ................................... 15
pyridostigmine bromide .................... 40
Q
QNASL ............................................ 67
QNASL CHILDRENS .......................... 67
QUADRACEL .................................... 59
quetiapine fumarate ......................... 36
QUILLICHEW ER ............................... 38
QUILLIVANT XR ............................... 38
quinapril hcl .................................... 24
quinapril-hydrochlorothiazide ............. 24
quinidine gluconate .......................... 25
quinidine sulfate .............................. 25
quinine sulfate ................................. 13
QVAR .............................................. 67
R
RABAVERT....................................... 59
rabeprazole sodium .......................... 54
RAGWITEK ...................................... 58
raloxifene hcl ................................... 49
ramipril ........................................... 24
RANEXA .......................................... 29
ranitidine hcl ................................... 51
RAPAFLO ......................................... 54
RAPAMUNE ...................................... 58
RAVICTI .......................................... 46
RAYOS TAB 1MG .............................. 48
RAYOS TAB 2MG .............................. 48
RAYOS TAB 5MG .............................. 48
REBETOL ......................................... 16
REBIF ............................................. 40
REBIF REBIDOSE ............................. 40
REBIF REBIDOSE TITRATION ............. 40
REBIF TITRATION PACK .................... 40
RECOMBIVAX HB .............................. 59
RECTIV ........................................... 72
REGRANEX ...................................... 72
RELENZA DISKHALER ....................... 16
RELISTOR ....................................... 52
RELPAX ........................................... 39
REMICADE....................................... 57
REMODULIN .................................... 30
RENAGEL ................................... 49, 50
93
RENVELA PAK ...................................50
RENVELA TAB 800MG ........................50
repaglinide .......................................45
repaglinide-metformin hcl ..................45
reprexain tab 10-200mg ....................11
RESCRIPTOR ....................................14
RESTASIS ........................................64
RETIN-A MICRO PUMP .......................68
RETROVIR IV INFUSION ....................14
REVATIO ..........................................30
REVLIMID ........................................58
REXULTI ..........................................36
REYATAZ .........................................14
RHEUMATREX ...................................57
ribapak mis 600/day .........................16
ribasphere .......................................16
ribasphere ribapak 1000 ....................16
ribasphere ribapak 1200 ....................16
ribasphere ribapak 800 ......................16
ribavirin 200mg ................................16
rifabutin ..........................................15
rifamate ..........................................15
rifampin ...........................................15
RIFATER ..........................................15
riluzole ............................................40
rimantadine hydrochloride .................16
RINGER'S.........................................62
RIOMET ...........................................45
risedronate sodium ...........................46
RISEDRONATE SODIUM .....................46
RISPERDAL INJ 12.5MG .....................36
RISPERDAL INJ 25MG ........................36
RISPERDAL INJ 37.5MG .....................36
RISPERDAL INJ 50MG ........................36
risperidone .......................................36
risperidone odt .................................36
RITALIN LA ......................................38
RITUXAN .........................................21
rivastigmine tartrate .........................33
rizatriptan benzoate ..........................39
ropinirole hydrochloride .....................34
rosadan cre 0.75% ...........................72
rosuvastatin calcium .........................26
ROTARIX .........................................59
ROTATEQ .........................................59
roweepra .........................................32
roxicet tab 5-325mg..........................11
ROZEREM ........................................38
RUCONEST ...................................... 56
RYTARY ........................................... 34
S
SABRIL ........................................... 32
SAIZEN ........................................... 49
SAIZEN CLICK.EASY ......................... 49
SAMSCA .......................................... 49
SANCUSO ........................................ 51
SANDIMMUNE SOLN ......................... 58
SANDOSTATIN LAR DEPOT ................ 49
SANTYL ........................................... 72
SAPHRIS ......................................... 36
SARAFEM ........................................ 42
SAVAYSA ........................................ 55
SAVELLA ......................................... 40
SAVELLA TITRATION PACK ................ 40
SEEBRI NEOHALER ........................... 65
selegiline hcl .................................... 34
selenium sulfide ............................... 70
SELZENTRY ..................................... 14
SEMPREX-D ..................................... 65
SENSIPAR ....................................... 46
SEREVENT DISKUS ........................... 66
SERNIVO ......................................... 71
SEROQUEL XR ................................. 36
SEROSTIM ....................................... 49
sertraline hcl ................................... 34
SF-ROWASA .................................... 52
SIGNIFOR ....................................... 49
SIGNIFOR LAR ................................. 49
sildenafil citrate (pulmonary
hypertension) .................................. 30
SILENOR ......................................... 38
SILVER SULFADIAZINE ..................... 69
SIMBRINZA SUS 1-0.2% ................... 64
SIMPONI ......................................... 57
SIMPONI ARIA ................................. 57
SIMULECT ....................................... 58
simvastatin ..................................... 26
sirolimus ......................................... 58
SIROLIMUS ..................................... 58
SIRTURO ......................................... 15
SIVEXTRO ....................................... 13
SKLICE ........................................... 72
SODIUM CHLORIDE ..................... 60, 62
SODIUM CHLORIDE 0.45% VIA .......... 62
SODIUM CHLORIDE 0.9%.................. 72
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
94
F) MG/ML SOLN ................................60
sodium phenylbutyrate ......................46
sodium polystyrene sulfonate .............46
SOLODYN ........................................19
SOLTAMOX.......................................22
SOLU-CORTEF 1000MG ......................48
SOLU-CORTEF 100MG .......................48
SOLU-CORTEF 250MG .......................48
SOLU-CORTEF 500MG .......................48
SOLU-MEDROL INJ 2GM.....................48
SOMATULINE DEPOT .........................49
SOMAVERT.......................................49
SOOLANTRA .....................................72
SORILUX..........................................69
sorine ..............................................25
sotalol hcl ........................................25
sotalol hcl (afib/afl) ...........................25
SOTYLIZE ........................................27
SOVALDI .........................................16
SPIRIVA HANDIHALER .......................65
SPIRIVA RESPIMAT ...........................65
spironolactone ..................................24
spironolactone & hydrochlorothiazide ..29
SPORANOX SOL 10MG/ML ..................13
SPRITAM..........................................32
SPRYCEL ..........................................22
sps..................................................46
SSD ................................................69
stavudine .........................................14
STELARA..........................................69
STERILE WATER IRRIGATION .............72
STIMATE ..........................................50
STIOLTO RESPIMAT ..........................65
STIVARGA ........................................22
STRATTERA ......................................38
streptomycin sulfate ..........................11
STRIANT ..........................................42
STRIBILD .........................................15
STRIVERDI RESPIMAT .......................66
SUBOXONE MIS 12-3MG ....................42
SUBOXONE MIS 2-0.5MG ...................42
SUBOXONE MIS 4-1MG......................42
SUBOXONE MIS 8-2MG......................42
SUBSYS ...........................................11
SUCLEAR .........................................52
SUCRAID .........................................53
sucralfate.........................................53
sulfacet sod oin 10% op ....................63
sulfacetamide sodium (acne) ............. 68
sulfacetamide sodium (ophth) ............ 63
sulfacetamide sod-prednisolone ......... 62
sulfadiazine ..................................... 11
sulfamethoxazole-trimethop .............. 13
sulfamethoxazole-trimethoprim inj ..... 13
SULFAMYLON ................................... 69
sulfasalazine dr ................................ 52
sulfasalazine ir ................................. 52
sulindac ............................................ 7
sumatriptan inj 4mg/0.5ml ................ 39
SUMATRIPTAN INJ 4MG/0.5ML ........... 39
sumatriptan inj 6mg/0.5ml ................ 39
SUMATRIPTAN INJ 6MG/0.5ML ........... 39
sumatriptan succinate ....................... 39
SUMATRIPTAN SUCCINATE ................ 39
SUMAVEL DOSEPRO ......................... 39
suprax ............................................ 17
SUPRAX .......................................... 17
SUPREP BOWEL PREP ....................... 52
SURMONTIL ..................................... 34
SUSTIVA ......................................... 14
SUTENT .......................................... 22
SYLATRON KIT 200MCG .................... 23
SYLATRON KIT 300MCG .................... 23
SYLATRON KIT 600MCG .................... 23
SYMBICORT ..................................... 67
SYMLINPEN 120 ............................... 43
SYMLINPEN 60 ................................. 43
SYNAGIS ......................................... 59
SYNAREL ......................................... 46
SYNERA .......................................... 71
SYNERCID ....................................... 13
SYNJARDY TAB 12.5-1000 ................. 45
SYNJARDY TAB 12.5-500................... 45
SYNJARDY TAB 5-1000MG ................. 45
SYNJARDY TAB 5-500MG................... 45
SYNRIBO ......................................... 23
SYNTHROID..................................... 50
SYPRINE ......................................... 46
T
TABLOID ......................................... 20
TACLONEX ...................................... 71
tacrolimus ....................................... 58
tacrolimus (topical) .......................... 72
TAFINLAR ........................................ 22
TAGRISSO ....................................... 22
TAMIFLU ......................................... 16
95
tamoxifen citrate ..............................22
tamsulosin hcl ..................................54
TANZEUM ........................................43
TARCEVA .........................................22
TARGRETIN ......................................72
TASIGNA .........................................22
tazicef .............................................17
tazicef vial .......................................17
TAZORAC .........................................70
taztia xt ...........................................28
TECENTRIQ ......................................21
TECFIDERA CAP 120MG .....................40
TECFIDERA CAP 240MG .....................41
TECFIDERA MIS STARTER ..................41
TEFLARO..........................................17
TEGRETOL .......................................32
TEGRETOL-XR ..................................32
TEKTURNA .......................................28
TEKTURNA HCT ................................28
telmisartan ......................................25
telmisartan-amlodipine ......................25
telmisartan-hydrochlorothiazide ..........25
temazepam ......................................38
TENIVAC ..........................................59
terazosin hcl.....................................24
terbinafine hcl ..................................13
terbutaline sulfate .............................66
terconazole vaginal ...........................55
TESTIM ............................................42
TESTOSTERONE................................42
testosterone cypionate ......................42
testosterone enanthate ......................43
TETANUS/DIPHTHERIA TOXOID ..........59
tetrabenazine ...................................40
TETRACYCLINE HCL ..........................19
texacort ...........................................71
THALOMID .......................................58
theo-24 ...........................................67
theophylline .....................................68
thioridazine hcl .................................36
thiotepa ...........................................19
thiothixene.......................................36
THYMOGLOBULIN..............................58
tiagabine hcl ....................................32
TIKOSYN..........................................25
timolol maleate.................................27
timolol maleate (ophth) .....................64
TIMOLOL MALEATE GEL .....................64
TIMOPTIC OCUDOSE ........................ 64
TIROSINT ........................................ 50
TIVICAY .......................................... 14
tizanidine ........................................ 41
TOBI PODHALER .............................. 11
TOBRADEX ...................................... 62
TOBRADEX ST ................................. 62
tobramycin ...................................... 11
tobramycin (ophth) .......................... 63
tobramycin sulfate ........................... 11
tobramycin-dexamethasone .............. 62
TOBREX OINT 0.3% ......................... 63
TOLAK ............................................ 72
tolmetin sodium ................................. 7
tolterodine tartrate er ....................... 54
tolterodine tartrate tab 1 mg ............. 54
tolterodine tartrate tab 2 mg ............. 54
TOPICORT SPRAY 0.25% ................... 71
topiramate ...................................... 32
TOPIRAMATE ................................... 32
toposar ........................................... 23
topotecan hcl ................................... 24
TORISEL ......................................... 21
torsemide inj 50mg/5ml .................... 29
torsemide tabs ................................. 29
TOUJEO SOLOSTAR .......................... 44
TOVIAZ ........................................... 54
TPN ELECTROLYTES .......................... 60
TRACLEER ....................................... 30
TRADJENTA ..................................... 45
TRAMADOL HCL ................................. 8
tramadol hcl er .................................. 8
TRAMADOL HCL ER ............................. 8
tramadol hcl er (biphasic) 100mg ......... 8
tramadol hcl tab 50 mg ....................... 8
tramadol-acetaminophen .................... 8
trandolapril...................................... 24
trandolapril-verapamil hcl.................. 24
tranexamic acid ............................... 56
TRANSDERM-SCOP ........................... 51
tranylcypromine sulfate..................... 34
TRAVASOL....................................... 61
TRAVATAN Z .................................... 64
trazodone hcl ................................... 34
TREANDA ........................................ 19
TRECATOR ...................................... 15
96
TRELSTAR MIXJECT ...........................22
TRESIBA FLEXTOUCH ........................44
tretinoin .................................... 23, 68
TRETINOIN ......................................68
TRETINOIN MICROSPHERE .................68
tretin-x ............................................68
trexall .............................................57
TREXIMET ........................................39
trezix ............................................... 8
triamcinolone acetonide (mouth) ........72
TRIAMCINOLONE ACETONIDE (NASAL) 67
triamcinolone acetonide (topical) ........71
triamt/hctz cap 37.5-25 .....................29
triamt/hctz cap 50-25mg ...................29
triamt/hctz tab 37.5-25 .....................29
triamt/hctz tab 75-50mg ...................29
trianex ............................................71
TRIBENZOR ......................................25
triderm ............................................71
trifluoperazine hcl .............................36
trifluridine ........................................63
TRIGLIDE .........................................26
trilyte ..............................................52
trimethoprim ....................................13
trimipramine maleate ........................34
TRINTELLIX ......................................34
TRISENOX........................................23
TRIUMEQ .........................................15
TROKENDI XR ..................................32
TROPHAMINE INJ 10% ......................61
trospium chloride ..............................54
trospium chloride er ..........................54
TRULICITY .......................................44
TRUMENBA.......................................59
TRUVADA TAB 100-150 .....................15
TRUVADA TAB 133-200 .....................15
TRUVADA TAB 167-250 .....................15
TRUVADA TAB 200-300 .....................15
TUDORZA PRESSAIR .........................65
TUDORZA PRESSAIR (INSTITUTIONAL
PACK) .............................................65
TWINRIX INJ ....................................59
TYBOST ...........................................14
TYGACIL ..........................................13
TYKERB ...........................................22
TYPHIM VI .......................................59
TYSABRI ..........................................41
TYVASO ...........................................30
TYZEKA........................................... 16
tyzine ............................................. 66
U
UCERIS ........................................... 52
ULORIC ............................................. 7
ULTRAVATE ..................................... 71
ULTRESA ......................................... 53
UNITHROID ..................................... 50
UPTRAVI ......................................... 30
ursodiol .......................................... 53
UTIBRON NEOHALER ........................ 65
UVADEX .......................................... 23
V
VAGIFEM ......................................... 47
valacyclovir hcl ................................ 16
VALCHLOR ...................................... 72
VALCYTE ......................................... 16
valganciclovir hcl .............................. 16
valproate sodium ............................. 32
valproic acid .................................... 32
valsartan ......................................... 25
valsartan-hydrochlorothiazide ............ 25
vancomycin hcl ................................ 13
VANCOMYCIN IN NACL ...................... 13
VANDAZOLE .................................... 55
VAQTA ............................................ 59
VARIVAX ......................................... 59
VARUBI ........................................... 51
VASCEPA......................................... 26
VECTIBIX ........................................ 21
VELCADE......................................... 21
VELPHORO ...................................... 50
VELTASSA ....................................... 46
VELTIN ........................................... 68
VENCLEXTA ..................................... 21
VENCLEXTA STARTING PACK ............. 21
venlafaxine cap er ............................ 34
venlafaxine hcl ................................. 34
venlafaxine tab ................................ 34
VENLAFAXINE TAB 225MG ER ............ 34
venlafaxine tab er ............................ 34
VENTAVIS ....................................... 30
VENTOLIN HFA................................. 66
VERAMYST ...................................... 67
verapamil hcl ................................... 28
VERAPAMIL HCL ............................... 28
veripred .......................................... 48
VERSACLOZ..................................... 37
97
VESICARE ........................................54
VEXOL .............................................63
VIBERZI ..........................................53
VIBRAMYCIN ....................................19
vicodin ............................................11
vicodin es ........................................11
vicodin hp ........................................11
VICTOZA .........................................44
VIDEX PEDIATRIC .............................14
VIGAMOX .........................................63
VIIBRYD ..........................................34
VIIBRYD STARTER PACK ....................34
VIMIZIM ..........................................47
VIMOVO ........................................... 7
VIMPAT ...........................................32
vinblastine sulfate .............................20
vincasar ...........................................20
vincristine sulfate ..............................20
vinorelbine tartrate ...........................20
VIOKACE 10 .....................................53
VIOKACE 20 .....................................53
VIRACEPT ........................................14
VIRAMUNE XR ..................................14
VIREAD ...........................................14
VITEKTA ..........................................14
VIVITROL .........................................42
VIVLODEX ......................................... 7
VOGELXO.........................................43
VOGELXO PUMP ................................43
VOLTAREN GEL 1% ...........................72
voriconazole .....................................13
voriconazole inj 200mg ......................13
VOTRIENT ........................................22
VPRIV ..............................................47
VRAYLAR .........................................37
VYTORIN .........................................26
VYVANSE .........................................38
W
warfarin sodium ................................55
WELCHOL ........................................26
X
XALKORI ..........................................22
XARELTO .........................................55
XARELTO STARTER PACK ...................55
XARTEMIS XR ...................................11
XELJANZ ..........................................57
XELJANZ XR .....................................57
XEOMIN 100UNIT .............................41
XEOMIN 200UNIT ............................. 41
XEOMIN 50UNIT............................... 41
XERESE........................................... 72
XGEVA ............................................ 49
XIFAXAN TAB 200MG ........................ 13
XIFAXAN TAB 550MG ........................ 53
XIGDUO XR TAB 10-1000MG ............. 45
XIGDUO XR TAB 10-500MG ............... 45
XIGDUO XR TAB 5-1000MG ............... 45
XIGDUO XR TAB 5-500MG ................. 45
XOLAIR ........................................... 66
XOPENEX HFA .................................. 66
XTAMPZA ER.................................... 11
XTANDI ........................................... 22
xylon tab 10-200mg ......................... 11
XYREM ............................................ 41
Y
YERVOY .......................................... 21
YF-VAX ........................................... 59
Z
zafirlukast ....................................... 66
zamicet ........................................... 11
ZANOSAR ........................................ 19
ZAVESCA ........................................ 47
ZAZOLE CRE 0.8% ........................... 55
ZEGERID ......................................... 54
ZELAPAR ......................................... 34
ZELBORAF ....................................... 22
ZEMAIRA ......................................... 66
ZEMBRACE SYMTOUCH ..................... 39
ZEMPLAR ........................................ 62
zenatane ......................................... 68
ZENPEP ........................................... 53
ZERBAXA ........................................ 17
ZETIA TAB 10MG.............................. 26
ZETONNA ........................................ 67
ZIAGEN........................................... 14
ZIANA............................................. 68
zidovudine ....................................... 14
ZINACEF ......................................... 17
ZIOPTAN ......................................... 64
ziprasidone hcl ................................. 37
ZIPSOR ............................................. 7
ZIRGAN .......................................... 63
ZMAX ............................................. 17
ZOHYDRO ER (ABUSE DETERRENT) .... 11
zoledronic inj 4mg/5ml ..................... 46
zoledronic inj 5/100ml ...................... 46
98
ZOLINZA .........................................21
zolmitriptan......................................39
zolmitriptan odt ................................39
zolpidem tartrate ..............................38
ZOMACTON ......................................49
ZOMETA ..........................................46
ZOMIG NASAL SPRAY ........................39
zonisamide.......................................32
ZONTIVITY .......................................56
ZORBTIVE ........................................49
ZORTRESS TAB 0.25MG .....................58
ZORTRESS TAB 0.5MG ......................58
ZORTRESS TAB 0.75MG .....................58
ZORVOLEX ........................................ 7
ZOSTAVAX .......................................59
ZOSYN ............................................18
ZOVIRAX ......................................... 72
ZUBSOLV SUB 1.4-0.36MG ................ 42
ZUBSOLV SUB 11.4-2.9MG ................ 42
ZUBSOLV SUB 2.9-0.71MG ................ 42
ZUBSOLV SUB 5.7-1.4MG.................. 42
ZUBSOLV SUB 8.6-2.1MG.................. 42
ZUPLENZ ......................................... 51
ZYCLARA ......................................... 72
ZYDELIG ......................................... 23
ZYFLO CR ........................................ 66
ZYKADIA ......................................... 23
ZYLET ............................................. 62
ZYPREXA RELPREVV ......................... 37
ZYPREXA RELPREVV INJ 210MG ......... 37
ZYTIGA ........................................... 22
ZYVOX ............................................ 13
99
Multi-Language Insert
Multi-language Interpreter Services
H3328_FC 15056 Accepted
English: We have free interpreter services to answer any questions you may have about
our health or drug plan. To get an interpreter, just call us at 1-800-247-1447.
Someone who speaks English/Language can help you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier
pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con
un intérprete, por favor llame al 1-800-247-1447. Alguien que hable español le podrá
ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑
问。如果您需要此翻译服务，请致电 1-800-247-1447。我们的中文工作人员很乐意帮助您。
这是一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯
服務。如需翻譯服務，請致電 1-800-247-1447。我們講中文的人員將樂意為您提供幫助。這
是一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang
anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o
panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-2471447. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng
serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes
vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour
accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-247-1447.
Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương
sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-2471447 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-2471447. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고
있습니다. 통역 서비스를 이용하려면 전화 1-800-247-1447번으로 문의해 주십시오. 한국어를 하는
담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
100
Russian: Если у вас возникнут вопросы относительно страхового или
медикаментного плана, вы можете воспользоваться нашими бесплатными услугами
переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по
телефону 1-800-247-1447. Вам окажет помощь сотрудник, который говорит поpусски. Данная услуга бесплатная.
Arabic:
‫ للحصول على مترجم‬.‫إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا‬
‫ سيقوم شخص ما يتحدث العربية‬. 1447-247-800-1‫ ليس عليك سوى االتصال بنا على‬،‫ هذه خدمة فوري‬.‫بمساعدتك‬
‫مجانية‬.
Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब दे ने के लिए हमारे पास मुफ्त
दभ
ु ाषिया सेवाएँ उपिब्ध हैं. एक दभ
ु ाषिया प्राप्त करने के लिए, बस हमें 1-800-247-1447 पर फोन करें . कोई व्यक्तत जो
हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मुफ्त सेवा है.
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali
domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il
numero 1-800-247-1447. Un nostro incaricato che parla Italianovi fornirà l'assistenza
necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer
questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um
intérprete, contacte-nos através do número 1-800-247-1447. Irá encontrar alguém que
fale o idioma Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen
konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1800-247-1447. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w
uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby
skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1800-247-1447. Ta usługa jest bezpłatna.
Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするため
に、無料の通訳サービスがありますございます。通訳をご用命になるには、1-800-2471447にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。
101
This formulary was updated on 10/01/2016.
This information is available for free in other languages. Please contact our Member Services number at 1-800247-1447 for additional information. (TTY users should call 1-800-695-8544). Hours are 8:00 a.m. to 8:00 p.m.
seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from
February 15 through September 30. Member Services also has free language interpreter services available for
non-English speakers.
Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con nuestro
número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los usuarios con
deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención es de 8:00 a.m. a 8:00
p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:a.m. hasta
las 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también tiene servicios
gratuitos de intérprete disponibles para personas que no hablan inglés.
Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal.
Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State
Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal.
H3328_FC 15054 CMS Accepted
00016379. Version 10
102

Fidelis Care 2016 Formulary (List of Covered Drugs)

Transcription

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