Printable Formulary

Transcription

Printable Formulary

General Formulary Information
This formulary was designed to be a useful tool if you have prescription drug coverage. It lists the
drugs covered by your benefit. Medications are listed in this formulary in easy-to-understand
groupings, but we encourage you to call our Pharmacy Service Team at (800) 988-4861 if you have
any questions about this information.
You can also view the formulary online by logging onto thehealthplan.com.
Pharmacy Customer Service Team Contact Information
Telephone: (800) 988-4861 or (570)-271-5673; TDD/TTY 711
Fax: 570-271-5610
Mailing address:
Geisinger Health Plan
Pharmacy Department
Internal Mail Code 32-46
100 North Academy Avenue
Danville, PA 17822
CHIP Pharmacy Benefit
The CHIP Pharmacy benefit assigns each prescription medication to one of two different tiers,
each representing a set copayment amount. The copay amount will depend on your
prescription medication rider. Additional medications, other than those included in this
formulary, may be covered under the CHIP Pharmacy benefit. The definitions of the copay
levels are listed below:
•
•
Tier 1–Includes most generic medications and has the lowest copayment. Prior
authorization is usually not necessary for medications in this tier.
Tier 2–Includes certain formulary brand name medications with no generic equivalent.
Prior authorization may be necessary for medications in this tier.
The Plan maintains sole discretion of assigning medications to tiers and moving medications
from one tier to another. Several factors are considered when assigning medications to tiers.
These factors include but are not limited to:
•
•
•
•
•
Availability of a generic equivalent
Absolute cost of a medication
Cost of the medication relative to other medications in the same therapeutic class
Availability of over-the-counter alternatives
Clinical and economic factors
Please note: A medication may change in tier status without notice due to immediate generic
availability or changes in medication availability in the marketplace
Specialty Vendor Drug Program
Certain medications require the use of a contracted specialty pharmacy vendor for purchase.
Please contact the Pharmacy Service Team at (800) 988-4861 for additional information on the
program and a complete list of the medications included.
A few things you should remember when using this formulary and your prescription
benefit:
All prescriptions must be filled at a participating pharmacy.
• You will pay the applicable copay, coinsurance or deductible when you receive the
prescription.
• Coverage is for generic drugs when they have equivalent rating in the drug products
list (Orange Book–U.S. Department of Health and Human Services).
• Some medications on the formulary require prior authorization which your provider
may request through our Pharmacy Service Team at (800) 988-4861.
• If you require medications not listed on this formulary, your provider may request an
exception through our Pharmacy Customer Service Team, except for those items
listed as specific exclusions. Non-formulary medications not requiring prior
authorization will be available at the highest copay level.
• Some medications and diabetic supplies may be restricted to a specific manufacturer,
vendor or supplier and may be subject to quantity limits.
• Quantity limits may apply to certain medications.
• Insulin syringes, lancets, and inhaler spacers are covered at Tier 2.
• Non-prescription (over-the-counter) medications are not covered unless required by
healthcare reform legislation.
• Note that if certain conditions are met some medications may be covered with no
copay/coinsurance due to healthcare reform legislation. Please contact the pharmacy
customer service team for more information.
Using this formulary
• The medication Tier is listed in the Drug Tier Column.
• Medication names with QL in the Requirements/Limits column have quantity limits
• Medication names followed by PA in the Requirements/Limits column require prior
authorization.
• Medication names followed by ST in the Requirements/Limits column have step
therapy requirements.
• Medication names followed by SP in the Requirements/Limits column must be
obtained from a network specialty vendor.
• This formulary is accurate as of October 1, 2016, and is subject to change. Any
additions or deletions to the formulary throughout the year may be found in the
following quarterly publications: “Member Update” for members and “Briefly” for
providers. The most up-to-date source for formulary information is the online formulary
search available at www.thehealthplan.com.
• Restrictions in medication availability may result from use of a formulary.
Please be aware that if you choose to obtain a non-formulary drug, you may be required to pay
the full price of that drug. For information about your specific prescription drug
benefits, please contact the Pharmacy Service Team at (800) 988-4861 or (570) 271-5673.
Quantity Limits
• Quantity limits are listed in the Requirements/Limits Column
• Note that non-formulary medications in the same class/category as formulary drugs
with quantity limits will have the same quantity limits applied.
• If not listed above the maximum days supply for specialty vendor medications is 34
days or as otherwise defined in the prescription medication benefit documents.
Step Therapy
For details regarding step therapy requirements please contact the Pharmacy Service Team at
(800) 988-4861 or (570) 271-5673.
What is a medication formulary?
A medication formulary is a continually updated list of prescription medications. It represents
the medications currently covered based upon the clinical judgment of the Pharmacy and
Therapeutics Committee, which is made up of pharmacists and physicians. (The formulary is
continually updated due to the high number of medications currently on the market, as well as
the continuous introduction of new medications.) This committee thoroughly reviews medical
literature to first determine which medications are likely to produce the best results for patients.
Then, if two or more medications produce the same clinical results, elements like cost and
ease of use are considered.
A well-developed formulary enhances quality of patient care by encouraging physicians to
prescribe medications that are safe, effective, and likely to achieve the best possible outcome
for the patient. When you use a formulary medication, it is considered a “covered” medication
and you pay your particular co-pay or coinsurance for that medication.
The Plan recognizes that, in some situations, you may not respond well to a given formulary
medication, or may have an allergy or other condition that warrants the use of a non-formulary
medication. An exception process exists for these special instances. Your physician may
initiate a request for a formulary exception by contacting our Pharmacy Service Team. Your
request will be reviewed, including review of pertinent medical records, treatment and
laboratory data. We respond to such requests within 48 hours of receiving all necessary
information. If an exception is approved under the Triple Choice benefit, you will be charged at
the highest applicable copay level. If your request is denied, the medication will be excluded
from coverage under your prescription medication benefits.
Formulary exclusions
There are certain medications that your plan will not cover under any circumstance. These are
called exclusions. Examples of exclusions include, but are not limited to, over-the-counter
medications, medications used for experimental, investigational or unproven medication
therapies, medications used for weight loss and weight management, life-style medications,
medications used for cosmetic purposes, and medications for erectile dysfunction. Exclusions
are subject to change so you should contact the Pharmacy Service Team when you are
unsure whether a medication is covered.
Formulary development
When deciding whether or not a medication should be included in the formulary, the Pharmacy
and Therapeutics Committee carefully considers each medication for coverage or noncoverage in order to ensure safety and effectiveness in the medications being prescribed. This
information is then shared with participating providers for review and feedback. Based upon
the gathered information and provider feedback, the Pharmacy and Therapeutics Committee
will determine a medication’s inclusion or exclusion in the formulary. For the specific criteria
used to determine a medication’s inclusion or exclusion in this formulary, please contact the
Pharmacy Customer Service Team.
What are generics?
When a company develops a new medication, it receives a patent that protects the medication
company’s right to be the only manufacturer of that medication for a certain period of time,
which means that no generic can be manufactured. After that patent expires, other companies
can then make the same medication and sell it in its generic form. The generic form of a
medication has the same active ingredients, the same strength, and the same dosage as the
brand name medication. The inactive ingredients (which provide texture, shape and color) may
be different, which is why a generic typically looks different than its brand name counterpart.
Generic medications are usually less expensive than brand name medications, but are just as
safe and effective. This is because generic manufacturers have lower advertising costs and
greater competition from other generic manufacturers. Additionally, the U.S. Food and Drug
Administration regulates all pharmaceuticals, including generics, to assure quality, strength,
purity and potency.
Your prescription medication coverage is a generic-based plan and, whenever possible,
you should use a cost-effective generic medication.
Notes for Providers
Formulary review process: Medications selected for inclusion in the formulary are chosen
in consideration of effectiveness, safety and overall value. Evaluation for formulary inclusion
is based on formalized selection criteria to determine the most optimal benefit to members.
These criteria include but are not limited to:
• Medication name/dosage form
• Medication class/pharmacology
• FDA-approved indications
• Adverse reactions
• Clinical evidence of safety and efficacy
• Recommendations of national agencies and organizations
• Therapeutic equivalence
• Cost analysis
The criteria are reviewed by the Health Plan Pharmacy and Therapeutics Committee, which is
comprised of pharmacists and participating physicians in active clinical practice from various
specialties. The medication is then reviewed and evaluated by clinicians in particular
specialties for additional feedback. The feedback is discussed by the Pharmacy and
Therapeutics Committee prior to finalizing a decision on formulary status. To be included, the
medication must offer a distinct advantage over existing formulary medications in the same
therapeutic class. Specifically, the medication must demonstrate such attributes as:
• A distinct or unique therapeutic feature
• Greater efficacy, proven in clinical trials, over other medications in the same
therapeutic category
• An improved dosing schedule, safety profile or cost-effectiveness over existing
formulary medications
If there are comparable therapeutic agents, additional analysis may be considered. These
factors include:
• Member satisfaction
• Cost analysis
• Contract terms and conditions
• Market share analysis
• Patent life assessment
• Utilization management
• Consumer advertising
• Per member per month costs
Generic substitution policy: The Health Plan prescription benefits are generically based.
Generic substitution will occur for those medications included in the “Approved Medication
Products with Therapeutic Equivalence Evaluations,” also known as “The Orange Book,”
published by the U.S. Department of Health and Human Services. Generic medications, which
have an equivalent rating by these standards, are generally provided under the member’s
prescription medication benefit. The Health Plan may also elect to include only one brand- name
medication in the formulary even if the medication is marketed by more than one company, or if the
brand name medication does not significantly differ from the generic medication.
Health Care Reform: The Affordable Care Act (ACA) was signed into law on March 23, 2010. Under
the ACA, the government created “provisions,” or laws, that health insurers must adapt to, which
change health benefits for consumers. These changes include the expansion of preventive services,
including vaccinations, prescription drugs, and more. In accordance with the ACA requirements, and
subject to any applicable limitations of your pharmacy plan, the following preventive medications will
be covered with no cost-sharing under the prescription drug benefit:
•
Aspirin Products – Low dose (81 mg) aspirin products for all females and males 45 – 79 years
of age
•
Contraceptives – For females
•
Bowel Preparations for Colonoscopy – In preparation of a screening colonoscopy for members
50-75 years of age
•
Breast Cancer Prevention – Generic raloxifene and generic tamoxifen for females
•
Folic Acid Supplements – Generic folic acid 0.4 mg tablets for females
•
Fluoride Supplements – Fluoride drops and chewable tablets for males and females 6 months
– 6 years of age
•
Iron Supplements – Pediatric Iron supplements for males and females 6 – 12 months of age
•
Smoking Cessation Products – Two, 90 day treatment courses per benefit year for males and
females
•
Vaccinations – Herpes Zoster and Influenza (Flu) Vaccine for males and females (Other
preventive vaccinations may be covered under the medical benefit)
•
Vitamin D – Generic vitamin D supplements to prevent falls in community-dwelling adults age
65 years and older who are at increased risk for falls
Please note: For details about how these medications may be covered under your specific plan
please contact the Pharmacy Customer Service Team. A prescription is required to process any
claim for preventive care medications or products under the pharmacy plan, including over-thecounter medications.
Prior authorization: To promote the most appropriate utilization, select medications may require
prior authorization by the Health Plan to be eligible for coverage under the member’s prescription
benefit. The Pharmacy and Therapeutics Committee determines prior authorization criteria. In
order for a member to receive coverage for a medication requiring prior authorization, the
prescribing physician must obtain prior authorization by contacting the Health Plan Pharmacy
Department at the address, telephone, or fax number above. Submission of medical
documentation is required.
Step Therapy: Some medications may require that other medications be tried prior to or
concomitantly with the requested medication. The pharmacy claims system looks for a record of
the required medications and if they are not found, medical documentation must be submitted
showing use of these medications or rationale for skipping the step therapy medications.
Non-formulary medications: The formulary is designed to meet most therapeutic needs of the
population served by the Health Plan. Occasionally, because of allergy, therapeutic failure, or a
specific diagnostic-related need, formulary medications may not meet the special needs of an
individual member. In these special instances, the prescribing physician may make
requests to the Health Plan Pharmacy Department for non-formulary or restricted medications. The
prescribing physician will receive written documentation and/or a verbal response from the Health
Plan Pharmacy Department regarding the request.
Formulary addition requests: Requests for changes or additions, comments, and suggestions
for the formulary are welcome and can be made by written request to the Health Plan Pharmacy
Department.
Sources:
Academy of Managed Care Pharmacy (AMCP), “Formulary Management,” “Formularies,”
www.amcp.org., November 2001.
Health Insurance Association of America (HIAA), “Guide to Managed Care: Choosing and
Using a Health Plan.” www.hiaa.org., November 2001.
National Consumers League (NCL), “Consumer Guide to Generic Medications,”
www.nclnet.org., November 2001.
“From the Pharmacist,” www.cvs.com., November 2001.
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
acetaminophen/caff/dihydrocod capsule:
356-30-16; tablet
acetaminophen/phenyltolx tablet: 50055mg, 650mg-50mg
aspirin/caffein/dihydrocodeine
butalb/acetaminophen/caffeine
butalbit/acetamin/caff/codeine
butalbital/acetaminophen
butalbital/aspirin/caffeine
butorphanol tartrate spray
codeine sulfate
CODEINE SULFATE
codeine/butalbital/asa/caffein
DISKETS
fentanyl citrate
fentanyl
hydrocodone/acetaminophen various
dosage and/or strengths are available
hydrocodone/ibuprofen
hydromorphone hcl tablet
ibuprofen/oxycodone hcl
levorphanol tartrate
meperidine hcl solution, tablet
methadone hcl oral conc, solution, tablet,
tablet sol
morphine sulfate cap er pel, cpmp 24hr,
solution, supp.rect, syringe: 20mg/ml;
tablet er
MORPHINE SULFATE
opium/belladonna alkaloids
oxycodone hcl tab er 12h
oxycodone hcl capsule, oral conc, solution,
tablet
(Tylenol-Codeine
No.3)
(Acetaminophen/Caff/
Dihydrocod)
(Relagesic)
1
(Synalgos-Dc)
(Fioricet)
(Fioricet with Codeine)
(Tencon)
(Fiorinal)
(Butorphanol Tartrate)
(Codeine Sulfate)
1
1
1
1
1
1
1
1
1
(Fiorinal with Codeine
#3)
(Actiq)
(Duragesic)
(Norco)
1
1
1
1
1
1
(Ibudone)
(Dilaudid)
(Ibuprofen/Oxycodone
HCl)
(Levorphanol Tartrate)
(Demerol)
(Dolophine HCl)
1
1
1
(Morphine Sulfate ER)
1
(Opium/Belladonna
Alkaloids)
(Oxycontin)
(Roxicodone)
PA, QL: 136 in 34 days
1
1
1
1
1
1
1
PA
1
Geisinger 2016 CHIP Formulary
Formulary ID: 82117.000, Version: 4Q2016
Effective: October 01, 2016
oxycodone hcl/acetaminophen
oxycodone hcl/aspirin
oxymorphone hcl tablet
pentazocine hcl/acetaminophen
pentazocine hcl/naloxone hcl
(OxycodoneAcetaminophen)
(Percodan)
(Opana)
(Pentazocine HCl/
Acetaminophen)
(Pentazocine HCl/
Naloxone HCl)
ROXICODONE tablet: 5mg
tramadol hcl cpbp 25-75, tab er 24h, tablet (Ultram)
tramadol hcl/acetaminophen
(Ultracet)
ABSTRAL
BUTRANS
FENTORA
NUCYNTA ER
NUCYNTA
ONSOLIS
OXYCONTIN
PHRENILIN FORTE
SUBSYS
Nonsteroidal Anti-Inflammatory Agents
celecoxib
(Celebrex)
choline sal/mag salicylate
(Choline Sal/Mag
Salicylate)
COMFORT PAC-IBUPROFEN
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
(Cataflam)
diclofenac sodium tab er 24h, tablet dr
(Diclofenac Sodium)
diclofenac sodium drops, gel (gram): 1%
(Pennsaid)
diclofenac sodium/misoprostol
(Arthrotec 75)
diflunisal
(Diflunisal)
etodolac
(Etodolac)
fenoprofen calcium capsule: 200mg; tablet (Fenoprofen Calcium)
flurbiprofen
(Flurbiprofen)
ibuprofen oral susp: 100mg/5ml; tablet
(Ibuprofen)
indomethacin
(Indomethacin)
ketoprofen
(Ketoprofen)
ketorolac tromethamine tablet
(Ketorolac
Tromethamine)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
QL: 20 per fill
2
meclofenamate sodium
mefenamic acid
meloxicam
methyl salicylate
nabumetone
naproxen sodium tablet
naproxen
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
FLECTOR
INDOCIN oral susp
VIMOVO
(Meclofenamate
Sodium)
(Ponstel)
(Mobic)
(Methyl Salicylate)
(Nabumetone)
(Anaprox Ds)
(Naprosyn)
(Daypro)
(Feldene)
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
PA
PA
Anesthetics
Local Anesthetics
benzocaine drops
lidocaine hcl cream (g), jel (ml), jel/pf app,
lotion, solution
lidocaine oint. (g)
lidocaine adh. patch
lidocaine/hydrocortisone ac
lidocaine/prilocaine
RELADOR PAK
(Benzocaine)
(Pre-Attached Lta Kit)
1
1
(Lidocaine)
(Lidoderm)
(Lidocaine/
Hydrocortisone Ac)
(EMLA)
1
1
1
PA
1
1
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
buprenorphine hcl
(Buprenorphine HCl)
1
buprenorphine hcl/naloxone hcl
disulfiram
naloxone hcl syringe
naltrexone hcl
NARCAN
SUBOXONE film
(Suboxone)
(Antabuse)
(Naloxone HCl)
(Naltrexone HCl)
1
1
1
1
2
2
bupropion hcl
CHANTIX tab ds pk
CHANTIX tablet: 0.5mg
CHANTIX tablet: 1mg
CHANTIX tablet: 1mg
(Zyban)
0
0
0
0
0
PA (QL: 34 days supply
per fill)
PA
QL: 4 in 30 days
per fill)
QL: 106 in 365 days
QL: 22 in 365 days
QL: 224 in 365 days
QL: 308 in 365 days
3
NICOTINE PATCH
nicotine polacrilex lozenge
nicotine polacrilex gum: 2mg, 4mg
nicotine
NICOTROL NS
NICOTROL
(Nicorette)
(Nicorette)
(Nicoderm Cq)
0
0
0
0
0
0
QL: 180 in 365 days
QL: 2436 in 365 days
QL: 180 in 365 days
QL: 720 in 365 days
Antianxiety Agents
Benzodiazepines
alprazolam
chlordiazepoxide hcl
clonazepam
clorazepate dipotassium
diazepam kit, oral conc, solution, tablet
estazolam
flurazepam hcl
lorazepam oral conc, tablet
midazolam hcl syrup
oxazepam
quazepam
temazepam
triazolam
ALPRAZOLAM INTENSOL
DIASTAT ACUDIAL
ONFI
(Xanax)
(Chlordiazepoxide
HCl)
(Klonopin)
(Tranxene T-Tab)
(Valium)
(Estazolam)
(Flurazepam HCl)
(Ativan)
(Midazolam HCl)
(Oxazepam)
(Doral)
(Restoril)
(Halcion)
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
PA
(Neomycin Sulfate)
(Tobi)
1
1
2
2
PA
PA
(Cleocin HCl)
(Cleocin Palmitate)
(Zyvox)
(Zyvox)
1
1
1
1
(Urelle)
(Methen/M-Blue/Sal/
Na Phos/Hyos)
(Methen/Sod Phos/
Meth Blue/Hyos)
(Hiprex)
1
1
Antibacterials
Aminoglycosides
neomycin sulfate
tobramycin in 0.225% nacl
BETHKIS
TOBI PODHALER
Antibacterials, Miscellaneous
clindamycin hcl
clindamycin palmitate hcl
linezolid susp recon
linezolid tablet
meth/meblue/sod phos/psal/hyos
methen/m-blue/sal/na phos/hyos tablet:
120-0.12mg
methen/sod phos/meth blue/hyos
methenamine hippurate
PA
QL: 112 in 56 days, QL:
2 in 1 days
1
1
4
methenamine mandelate
metronidazole
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst
nitrofurantoin
trimethoprim
vancomycin hcl capsule, vial: 5g, 10g,
750mg
methen/m-blue/sal/na phos/hyos tablet:
120-0.12mg
PHOSPHASAL
SIVEXTRO tablet
URETRON D-S
URIN D.S.
XIFAXAN
Cephalosporins
cefaclor
cefadroxil
cefdinir
cefditoren pivoxil
cefixime
cefpodoxime proxetil
cefprozil
cefuroxime axetil
CEFUROXIME AXETIL
cephalexin capsule: 250mg, 500mg; susp
recon, tablet
CEFTIN susp recon
SUPRAX capsule, susp recon: 500mg/
5ml; tab chew, tablet
Macrolides
azithromycin packet, susp recon, tablet
clarithromycin
ery e-succ/sulfisoxazole
ERY-TAB
erythromycin base
erythromycin ethylsuccinate susp recon:
200mg/5ml; tablet
erythromycin stearate
(Methenamine
Mandelate)
(Flagyl)
(Macrodantin)
(Macrobid)
(Furadantin)
(Trimethoprim)
(Vancocin HCl)
1
(Methen/M-Blue/Sal/
Na Phos/Hyos)
2
1
1
1
1
1
1
2
2
2
2
2
(Cefaclor)
(Cefadroxil)
(Cefdinir)
(Spectracef)
(Suprax)
(Cefpodoxime Proxetil)
(Cefprozil)
(Ceftin)
(Keflex)
PA
1
1
1
1
1
1
1
1
1
1
2
2
(Zithromax)
(Biaxin)
(Ery E-Succ/
Sulfisoxazole)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
DIFICID
1
1
1
1
1
1
1
2
PA, QL: 20 per fill
5
ERYPED 200
ERYPED 400
erythromycin ethylsuccinate susp recon:
200mg/5ml
Penicillins
amoxicillin capsule, susp recon, tab chew,
tablet
amoxicillin/potassium clav
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
AUGMENTIN susp recon: 125-31.25/
Quinolones
ciprofloxacin hcl
ciprofloxacin
ciprofloxacin/ciprofloxa hcl
levofloxacin solution, tablet
moxifloxacin hcl
ofloxacin
Sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim oral susp,
tablet
sulfasalazine
Tetracyclines
demeclocycline hcl
doxycycline hyclate capsule, tablet, tablet
dr: 75mg, 100mg, 150mg
doxycycline monohydrate capsule, susp
recon, tablet
minocycline hcl
tetracycline hcl
(Eryped 200)
2
2
2
(Amoxicillin)
1
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Penicillin V
Potassium)
1
1
1
1
2
(Cipro)
(Cipro)
(Cipro XR)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
1
1
(Sulfadiazine)
(Bactrim DS)
1
1
(Azulfidine)
1
(Demeclocycline HCl)
(Vibramycin)
1
1
(Avidoxy)
1
(Minocin)
(Tetracycline HCl)
1
1
6
Anticancer Agents
Anticancer Agents
anastrozole
bexarotene
bicalutamide
capecitabine
CYCLOPHOSPHAMIDE
etoposide capsule
exemestane
flutamide
hydroxyurea
imatinib mesylate
letrozole
leuprolide acetate
lomustine
megestrol acetate
mercaptopurine
methotrexate sodium
nilutamide
tamoxifen citrate
TEMODAR capsule: 20mg
temozolomide
tretinoin
AFINITOR
(Arimidex)
(Targretin)
(Casodex)
(Xeloda)
(Etoposide)
(Aromasin)
(Flutamide)
(Hydrea)
(Gleevec)
(Femara)
(Leuprolide Acetate)
(Lomustine)
(Megestrol Acetate)
(Purinethol)
(Methotrexate Sodium)
(Nilandron)
(Tamoxifen Citrate)
(Temodar)
(Tretinoin)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
AFINITOR
2
AFINITOR
2
ALECENSA
ALKERAN tablet
BOSULIF tablet: 100mg
BOSULIF tablet: 500mg
CABOMETYX
CAPRELSA
2
2
2
2
2
2
COMETRIQ
COTELLIC
EMCYT
ERIVEDGE
FARYDAK
2
2
2
2
2
PA
PA (1 copay/coinsurance
per 15 days supply)
PA (QL: 1 copay/
coinsurance per 15 days
supply
PA (QL: 1 copay/
supply)
per fill)
PA
PA, QL: 90 per fill
7
GILOTRIF
GLEOSTINE capsule: 5mg
HEXALEN
HYCAMTIN capsule
IBRANCE
ICLUSIG
IMBRUVICA
INLYTA
IRESSA
JAKAFI
LENVIMA
LEUKERAN
LONSURF
LYNPARZA
LYSODREN
MATULANE
MEKINIST tablet: 2mg
MEKINIST tablet: 0.5mg
MYLERAN
NEXAVAR
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
NINLARO
ODOMZO
POMALYST
REVLIMID
REVLIMID
2
2
2
2
2
SPRYCEL
2
SPRYCEL
2
STIVARGA
SUTENT
SUTENT
2
2
2
TAFINLAR
TARCEVA
TARGRETIN gel (gram)
2
2
2
PA, QL: 21 per fill
PA
PA, QL: 120 per fill
PA
PA
PA, QL: 1 in 1 days
PA, QL: 3 in 1 days
PA (QL: 1 copay/
supply)
PA
per fill)
PA (QL: 1 copay/
supply
PA (QL: 1 copay/
supply)
PA
PA (QL: 1 copay/
supply)
PA NSO
PA
8
TASIGNA
2
TYKERB
2
VENCLEXTA STARTING PACK
VENCLEXTA tablet: 100mg
VOTRIENT
2
2
2
2
2
XALKORI
XTANDI
ZELBORAF
ZOLINZA
2
2
2
2
ZYDELIG
ZYKADIA
ZYTIGA
2
2
2
PA (QL: 1 copay/
supply)
per fill)
PA (QL: 1 copay/
supply; 4 tablets per day)
per fill)
PA, QL: 2 in 1 days
Anticholinergic Agents
Antimuscarinics/Antispasmodics
chlordiazepoxide/clidinium br
phenobarb/hyoscy/atropine/scop
propantheline bromide
(Librax)
(Donnatal)
(Propantheline
Bromide)
1
1
1
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal)
1
1
1
1
1
1
(Keppra)
(Trileptal)
(Phenobarbital)
(Dilantin)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
1
1
1
1
1
1
1
1
Anticonvulsants
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide
felbamate
gabapentin
lamotrigine tab ds pk, tab er 24, tablet, tb
chw dsp
levetiracetam solution, tab er 24h, tablet
oxcarbazepine
phenobarbital
phenytoin sodium extended
phenytoin
primidone
tiagabine hcl
topiramate cap sprink, tablet
9
valproic acid (as sodium salt) solution
valproic acid
zonisamide
APTIOM tablet: 200mg, 400mg, 800mg
APTIOM tablet: 600mg
BANZEL
DILANTIN capsule: 30mg
DILANTIN tab chew
FYCOMPA tablet
FYCOMPA oral susp
GABITRIL tablet: 12mg, 16mg
LYRICA
PHENYTEK
POTIGA
SABRIL
TROKENDI XR
VIMPAT solution, tablet
(Depakene)
(Depakene)
(Zonegran)
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA, QL: 1 in 1 days
PA, QL: 2 in 1 days
PA
PA, QL: 1 in 1 days
PA
PA
PA
PA
Antidementia Agents
Antidementia Agents
donepezil hcl
galantamine hbr
memantine hcl solution, tablet
rivastigmine tartrate
(Aricept)
(Razadyne)
(Namenda)
(Exelon)
1
1
1
1
(Amitriptyline HCl)
(Amitriptyline/
Chlordiazepoxide)
(Amoxapine)
(Wellbutrin XL)
1
1
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Cymbalta)
1
1
1
1
1
(Lexapro)
(Prozac)
1
1
1
1
1
1
Antidepressants
Antidepressants
amitriptyline hcl
amitriptyline/chlordiazepoxide
amoxapine
bupropion hcl tab er 24h, tablet, tablet er:
100mg, 150mg, 200mg
citalopram hydrobromide
clomipramine hcl
desipramine hcl
doxepin hcl
duloxetine hcl capsule dr: 20mg, 30mg,
60mg
escitalopram oxalate
fluoxetine hcl
FLUOXETINE HCL
fluvoxamine maleate tablet
imipramine hcl
imipramine pamoate
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
1
1
10
maprotiline hcl
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
perphenazine/amitriptyline hcl
phenelzine sulfate
protriptyline hcl
sertraline hcl
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
venlafaxine hcl
APLENZIN
BRINTELLIX
FETZIMA
FORFIVO XL
OLEPTRO ER
PAXIL oral susp
PRISTIQ ER
TRINTELLIX
VIIBRYD
bupropion hcl tablet er: 150mg
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Symbyax)
(Paxil)
(Perphenazine/
Amitriptyline HCl)
(Nardil)
(Protriptyline HCl)
(Zoloft)
(Parnate)
(Trazodone HCl)
(Trimipramine
Maleate)
(Effexor XR)
(Wellbutrin SR)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
0
PA
PA
PA
PA, QL: 1 in 1 days
PA
PA
PA
PA
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
metformin hcl tab er 24h, tablet
(Glucophage)
miglitol
(Glyset)
nateglinide
(Starlix)
pioglitazone hcl
(Actos)
pioglitazone hcl/glimepiride
(Duetact)
pioglitazone hcl/metformin hcl
(Actoplus Met)
repaglinide
(Prandin)
BYDUREON PEN
BYDUREON
GLYXAMBI
INVOKAMET
INVOKANA
JANUMET XR
JANUMET
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
ST
ST
PA, QL: 1 in 1 days
ST, QL: 2 in 1 days
ST, QL: 1 in 1 days
11
JANUVIA
JARDIANCE
JENTADUETO XR
JENTADUETO
KOMBIGLYZE XR
KORLYM
ONGLYZA
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
SYNJARDY
TANZEUM
TRADJENTA
TRULICITY
VICTOZA 3-PAK
Insulins
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXTOUCH
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
NOVOLOG
TOUJEO SOLOSTAR
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
tolazamide
tolbutamide
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Chlorpropamide)
(Amaryl)
(Glucotrol)
(Glipizide/Metformin
HCl)
(Glyburide)
(Glynase)
(Glucovance)
(Tolazamide)
(Tolbutamide)
1
1
1
1
(Ciclopirox Olamine)
1
ST
ST, QL: 1 in 1 days
PA
PA
PA
PA
PA
PA
PA
ST, QL: 2 in 1 days
ST
PA
PA
ST
(Vial, FlexPen)
(Vial, FlexPen)
(Vial, FlexPen)
(Vial, FlexPen)
(Vial, FlexPen)
1
1
1
1
1
Antifungals
Antifungals
ciclopirox olamine
12
ciclopirox gel (gram), shampoo
clotrimazole cream (g): 1%; solution: 1%;
troche
clotrimazole/betamethasone dip
econazole nitrate
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole cream (g), foam: 2%;
shampoo, tablet
miconazole nitrate supp.vag
naftifine hcl
nystatin
nystatin/triamcin
NYSTATIN
terbinafine hcl tablet
voriconazole susp recon, tablet
voriconazole susp recon, tablet
LAMISIL gran pack
LUZU
NAFTIN cream (g): 2%; gel (gram)
NOXAFIL oral susp, tablet dr
(Loprox)
(Clotrimazole)
1
1
(Lotrisone)
(Econazole Nitrate)
(Diflucan)
(Ancobon)
(Gris-Peg)
(Griseofulvin,
Microsize)
(Sporanox)
(Ketoconazole)
1
1
1
1
1
1
(Miconazole Nitrate)
(Naftin)
(Nystatin)
(Nystatin/Triamcin)
1
1
1
1
1
1
1
(Lamisil)
(Vfend)
(Vfend)
1
1
1
2
2
2
2
NOXAFIL oral susp, tablet dr
SPORANOX solution
2
2
PA
per fill)
PA
PA
per fill)
PA
PA
Antihistamines
Antihistamines
carbinoxamine maleate
chlorpheniramine/phenylephrine drops:
1mg-2mg/ml
clemastine fumarate syrup, tablet: 2.68mg
cyproheptadine hcl
desloratadine tablet
dexchlorpheniramine maleate
diphenhydramine hcl capsule: 50mg; elixir
levocetirizine dihydrochloride
(Carbinoxamine
Maleate)
(Chlorpheniramine/
Phenylephrine)
(Clemastine Fumarate)
(Cyproheptadine HCl)
(Clarinex)
(Dexchlorpheniramine
Maleate)
(Diphenhydramine
HCl)
(Xyzal)
1
1
1
1
1
1
1
1
13
phenylephrine hcl/prometh hcl
promethazine hcl
V-HIST
CLARINEX syrup
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
(Phenylephrine HCl/
Prometh HCl)
(Promethazine HCl)
1
1
1
2
2
2
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate
(Cleocin)
metronidazole
(Metrogel-Vaginal)
terconazole
(Terazol 7)
AVC
CLEOCIN supp.vag
CLINDESSE
1
1
1
2
2
2
Antimigraine Agents
Antimigraine Agents
almotriptan malate
dihydroergotamine mesylate
ergotamine tartrate/caffeine
frovatriptan succinate
isomethept/dichlphn/acetaminop capsule:
65-100-325
isomethepten/caf/acetaminophen
MIGERGOT
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate cartridge: 6mg/
0.5ml; pen injctr: 6mg/0.5ml; syringe,
tablet
sumatriptan succinate cartridge: 4mg/
0.5ml; pen injctr: 4mg/0.5ml; vial
sumatriptan
zolmitriptan
CAFERGOT
RELPAX
(Axert)
1
(D.H.E.45)
(Ergotamine Tartrate/
Caffeine)
(Frova)
1
1
(Isomethept/Dichlphn/
Acetaminop)
(Isomethepten/Caf/
Acetaminophen)
1
1
PA NSO, QL: 16 in 28
days
days
1
(Amerge)
(Maxalt)
(Imitrex)
1
1
1
1
QL: 16 in 28 days
QL: 16 in 28 days
QL: 16 in 28 days
(Imitrex)
1
QL: 8 in 28 days
(Imitrex)
(Zomig)
1
1
2
2
QL: 16 in 28 days
QL: 16 in 28 days
TREXIMET
2
days
14
ZOMIG spray
2
days
Antimycobacterials
Antimycobacterials
dapsone
ethambutol hcl
isoniazid solution, tablet
pyrazinamide
rifabutin
rifampin capsule
rifampin/isoniazid
RIFATER
SIRTURO
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifampin/Isoniazid)
1
1
1
1
1
1
1
2
2
PA
Antinausea Agents
Antinausea Agents
dronabinol
granisetron hcl tablet
granisetron hcl solution
meclizine hcl
ondansetron hcl
ondansetron
prochlorperazine maleate
prochlorperazine
promethazine hcl supp.rect, tablet
trimethobenzamide hcl capsule
AKYNZEO
DICLEGIS
EMEND cap ds pk, capsule, susp recon
SANCUSO
TRANSDERM-SCOP
VARUBI
(Marinol)
(Granisetron HCl)
(Granisetron HCl)
(Meclizine HCl)
(Zofran)
(Zofran Odt)
(Prochlorperazine
Maleate)
(Prochlorperazine)
(Promethazine HCl)
(Tigan)
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
(QL: 2 tablets per 1 fill)
QL: 30 per fill
QL: 2 in 28 days
PA, QL: 4 in 1 days
PA
QL: 2 in 14 days
Antiparasite Agents
Antiparasite Agents
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate
hydroxychloroquine sulfate
ivermectin
mefloquine hcl
paromomycin sulfate
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
1
1
1
1
1
1
1
15
quinine sulfate
tinidazole
ALBENZA
ALINIA
DARAPRIM
NEBUPENT
YODOXIN
(Qualaquin)
(Tindamax)
1
1
2
2
2
2
2
PA
QL: 4 per fill
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
benztropine mesylate tablet
bromocriptine mesylate
cabergoline
carbidopa/levodopa
carbidopa/levodopa/entacapone
entacapone
pramipexole di-hcl tab er 24h
pramipexole di-hcl tablet
ropinirole hcl
selegiline hcl
tolcapone
trihexyphenidyl hcl
APOKYN
AZILECT
(Amantadine HCl)
(Benztropine Mesylate)
(Bromocriptine
Mesylate)
(Cabergoline)
(Sinemet 25-100)
(Stalevo 200)
(Comtan)
(Mirapex ER)
(Mirapex)
(Requip)
(Eldepryl)
(Tasmar)
(Trihexyphenidyl HCl)
1
1
1
(Abilify Discmelt)
(Chlorpromazine HCl)
(Clozaril)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
(Haloperidol
Decanoate)
(Haloperidol Lactate)
(Haloperidol)
(Loxapine Succinate)
(Zyprexa)
(Invega)
(Perphenazine)
(Orap)
(Seroquel)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
PA
Antipsychotic Agents
Antipsychotic Agents
aripiprazole
chlorpromazine hcl tablet
clozapine
fluphenazine decanoate
fluphenazine hcl elixir, oral conc, tablet
haloperidol decanoate
haloperidol lactate
haloperidol
loxapine succinate
olanzapine
paliperidone
perphenazine
pimozide
quetiapine fumarate
1
1
1
1
1
1
1
1
1
1
PA
16
risperidone
thioridazine hcl
thiothixene
trifluoperazine hcl
ziprasidone hcl
FANAPT
LATUDA
NUPLAZID
SAPHRIS
SEROQUEL XR
VRAYLAR
(Risperdal)
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
(Geodon)
1
1
1
1
1
2
2
2
2
2
2
PA
PA
PA, QL: 2 in 1 days
PA
PA, QL: 1 in 1 days
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
didanosine
lamivudine tablet: 100mg
lamivudine solution
lamivudine/zidovudine
nevirapine tab er 24h: 400mg
nevirapine tab er 24h: 100mg
nevirapine tablet
nevirapine oral susp
stavudine soln recon
stavudine capsule
zidovudine capsule, syrup
zidovudine tablet
APTIVUS solution
APTIVUS capsule
ATRIPLA
COMPLERA
CRIXIVAN capsule: 200mg
CRIXIVAN capsule: 400mg
DESCOVY
EDURANT
(Ziagen)
(Trizivir)
(Videx EC)
(Epivir Hbv)
(Epivir Hbv)
(Epivir Hbv)
(Epivir)
(Combivir)
(Viramune XR)
(Viramune XR)
(Viramune)
(Viramune)
(Zerit)
(Zerit)
(Retrovir)
(Zidovudine)
EMTRIVA capsule
EMTRIVA solution
EPIVIR HBV solution
EPZICOM
EVOTAZ
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
QL: 2 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 30 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 3 in 1 days
QL: 2 in 1 days
QL: 40 in 1 days
QL: 2 in 1 days
QL: 6 in 1 days
QL: 2 in 1 days
QL: 10 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 3 in 1 days
QL: 6 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days, QL: 1 in
1 days
QL: 1 in 1 days
QL: 24 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
17
FUZEON
GENVOYA
INTELENCE tablet: 25mg, 100mg
INTELENCE tablet: 200mg
INVIRASE capsule
INVIRASE tablet
ISENTRESS powd pack
ISENTRESS tab chew: 25mg; tablet
ISENTRESS tab chew: 100mg
KALETRA tablet: 100mg-25mg
KALETRA solution
KALETRA tablet: 200mg-50mg
LEXIVA
NORVIR capsule, tablet
NORVIR solution
ODEFSEY
PREZCOBIX
PREZISTA tablet: 75mg, 150mg, 400mg
PREZISTA tablet: 800mg
PREZISTA oral susp
PREZISTA tablet: 600mg
RESCRIPTOR
REYATAZ capsule: 100mg
REYATAZ capsule: 300mg
REYATAZ capsule: 150mg, 200mg
REYATAZ powd pack
SELZENTRY tablet: 150mg
SELZENTRY tablet: 300mg
STRIBILD
SUSTIVA tablet
SUSTIVA capsule: 200mg
SUSTIVA capsule: 50mg
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT tablet: 625mg
VIRACEPT tablet: 250mg
VIRAMUNE XR tab er 24h: 100mg
VIREAD tablet
VIREAD powder
VITEKTA
ZIAGEN solution
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL: 2 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 10 in 1 days
QL: 4 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 6 in 1 days
QL: 1 in 1 days
QL: 14 in 1 days
QL: 4 in 1 days
QL: 12 in 1 days
QL: 16 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 13.34 in 1 days
QL: 2 in 1 days
QL: 6 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 6 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 3 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 40 in 1 days
QL: 4 in 1 days
QL: 9 in 1 days
QL: 3 in 1 days
QL: 1 in 1 days
QL: 8 in 1 days
QL: 1 in 1 days
QL: 30 in 1 days
18
Antivirals, Miscellaneous
rimantadine hcl
RELENZA
(Rimantadine HCl)
1
2
TAMIFLU capsule
2
TAMIFLU susp recon
2
Hcv Antivirals
HARVONI
SOVALDI
ZEPATIER
Interferons
INFERGEN
2
2
2
PA, QL: 28 per fill
PA, QL: 28 per fill
2
(QL: 34 days supply per
fill)
INFERGEN
INTRON A
2
2
INTRON A
PEGASYS PROCLICK
2
2
PEGASYS
2
PEGASYS
PEGINTRON REDIPEN
2
2
PEGINTRON REDIPEN
PEGINTRON
2
2
SYLATRON
Nucleosides and Nucleotides
acyclovir
adefovir dipivoxil
entecavir
famciclovir
ribavirin
valacyclovir hcl
valganciclovir hcl
BARACLUDE solution
TYZEKA
2
(Zovirax)
(Hepsera)
(Baraclude)
(Famvir)
(Ribavirin)
(Valtrex)
(Valcyte)
(QL: 1 fill of Tamiflu or
Relenza per season)
QL: 20 in 180 days (QL:
1 fill of Tamiflu or
Relenza per season)
QL: 250 in 180 days
(QL: 1 fill of Tamiflu or
Relenza per season)
fill)
fill)
fill)
fill)
fill)
1
1
1
1
1
1
1
2
2
19
VALCYTE soln recon
2
VIRAZOLE
2
fill)
Blood Products/Modifiers/Volume Expanders
Anticoagulants
enoxaparin sodium
(Lovenox)
1
enoxaparin sodium
fondaparinux sodium
(Lovenox)
(Arixtra)
1
1
heparin sodium,porcine vial: 1000/ml,
5000/ml, 10000/ml, 20000/ml
heparin sodium,porcine/pf syringe: 5000/
0.5ml; vial: 5000/0.5ml
warfarin sodium
ELIQUIS
PRADAXA
XARELTO tab ds pk, tablet: 15mg, 20mg
XARELTO tablet: 10mg
Blood Formation Modifiers
ARANESP
ARANESP
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Jantoven)
1
fill)
fill)
1
1
2
2
2
2
2
2
EPOGEN
2
LEUKINE
2
NEULASTA
NEULASTA
2
2
NEUMEGA
NEUPOGEN
NEUPOGEN
2
2
2
PROCRIT
PROCRIT
2
2
PROMACTA
2
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet
(Aminocaproic Acid)
anagrelide hcl
(Agrylin)
tranexamic acid tablet
(Lysteda)
1
1
1
PA NSO
QL: 34 per fill
PA
per fill)
per fill)
per fill)
PA
per fill)
PA
PA
per fill)
PA
per fill)
per fill)
20
ADVATE
2
ALPHANATE
2
ALPROLIX
ELOCTATE
FEIBA NF
2
2
2
HELIXATE FS
2
HEMOFIL M
2
HUMATE-P
2
IXINITY
KOATE-DVI
2
2
KOGENATE FS
2
MONOCLATE-P
NOVOEIGHT
OBIZUR
RECOMBINATE
2
2
2
2
WILATE
2
XYNTHA SOLOFUSE
XYNTHA
2
2
Platelet-Aggregation Inhibitors
aspirin/dipyridamole
cilostazol
clopidogrel bisulfate
dipyridamole
pentoxifylline
ticlopidine hcl
BRILINTA
EFFIENT
ZONTIVITY
(Aggrenox)
(Pletal)
(Plavix)
(Persantine)
(Pentoxifylline)
(Ticlopidine HCl)
1
1
1
1
1
1
2
2
2
per fill)
per fill)
PA
PA
per fill)
per fill)
per fill)
per fill)
PA
per fill)
per fill)
PA
PA
PA
per fill)
per fill)
PA
per fill)
PA
PA
PA
Caloric Agents
Caloric Agents
dextrose
(Dextrose)
2
Cardiovascular Agents
21
Alpha-Adrenergic Agents
clonidine hcl
clonidine hcl/chlorthalidone
(Catapres)
(Clonidine HCl/
Chlorthalidone)
clonidine
(Catapres-Tts 3)
doxazosin mesylate
(Cardura)
guanfacine hcl
(Tenex)
methyldopa
(Methyldopa)
methyldopa/hydrochlorothiazide
(Methyldopa/
Hydrochlorothiazide)
midodrine hcl
(Midodrine HCl)
phenoxybenzamine hcl
(Dibenzyline)
prazosin hcl
(Minipress)
Angiotensin II Receptor Antagonists
candesartan cilexetil
(Atacand)
candesartan/hydrochlorothiazid
(Atacand HCT)
eprosartan mesylate
(Teveten)
irbesartan
(Avapro)
irbesartan/hydrochlorothiazide
(Avalide)
losartan potassium
(Cozaar)
losartan/hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan/hydrochlorothiazid
(Micardis HCT)
valsartan
(Diovan)
valsartan/hydrochlorothiazide
(Diovan HCT)
BENICAR HCT
BENICAR
EDARBI
EDARBYCLOR
ENTRESTO
TEVETEN HCT
TEVETEN tablet: 400mg
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
captopril/hydrochlorothiazide
(Captopril/
enalapril maleate
(Vasotec)
enalapril/hydrochlorothiazide
(Vaseretic)
fosinopril sodium
(Fosinopril Sodium)
fosinopril/hydrochlorothiazide
(Fosinopril/
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
PA
PA
PA
PA
PA
PA
PA
PA
PA, QL: 2 in 1 days
PA
PA
1
1
1
1
1
1
1
1
22
lisinopril
lisinopril/hydrochlorothiazide
moexipril hcl
moexipril/hydrochlorothiazide
perindopril erbumine
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril
trandolapril/verapamil hcl
(Zestril)
(Zestoretic)
(Univasc)
(Uniretic)
(Perindopril Erbumine)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
(Tarka)
1
1
1
1
1
1
1
1
1
1
23
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
dofetilide
flecainide acetate
mexiletine hcl
propafenone hcl
quinidine gluconate tablet er
quinidine sulfate
MULTAQ
NORPACE CR
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet
metoprolol/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
pindolol
propranolol hcl cap sa 24h, solution, tablet
propranolol/hydrochlorothiazid
(Cordarone)
(Norpace)
(Tikosyn)
(Tambocor)
(Mexiletine HCl)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
1
1
1
1
1
1
1
1
2
2
(Sectral)
(Tenormin)
(Tenoretic 50)
(Betaxolol HCl)
(Zebeta)
(Ziac)
(Coreg)
(Trandate)
(Toprol XL)
(Lopressor)
(Lopressor HCT)
(Corgard)
(Corzide)
(Pindolol)
(Propranolol HCl)
(Propranolol/
Hydrochlorothiazid)
(Betapace AF)
(Timolol Maleate)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
sotalol hcl
timolol maleate tablet: 5mg, 10mg
BYSTOLIC
COREG CR
INNOPRAN XL
Calcium-Channel Blocking Agents
diltiazem hcl cap er 12h, cap er 24h, cap er (Cardizem CD)
deg, capsule er, tab er 24h, tablet
verapamil hcl cap24h pct, cap24h pel,
(Calan SR)
tablet, tablet er
Cardiovascular Agents, Miscellaneous
digoxin tablet
(Lanoxin)
DIGOXIN
epinephrine auto injct
(Epinephrine)
1
1
2
2
2
PA
PA
1
1
1
1
1
(QL: 2 kits per 1 fill)
24
epinephrine auto injct
hydralazine hcl tablet
isoxsuprine hcl tablet: 20mg
papaverine hcl capsule er
reserpine
CORLANOR
EPIPEN 2-PAK
EPIPEN JR 2-PAK
FIRAZYR
RANEXA
Dihydropyridines
amlodipine besylate
amlodipine besylate/benazepril
amlodipine/valsartan
amlodipine/valsartan/hcthiazid
felodipine
isradipine
nicardipine hcl capsule
nifedipine
nimodipine
nisoldipine
AZOR
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
bumetanide tablet
chlorothiazide
chlorthalidone
furosemide solution, tablet
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
torsemide tablet
triamterene/hydrochlorothiazid
DIURIL
Dyslipidemics
amlodipine/atorvastatin
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
colestipol hcl
(Epinephrine)
(Hydralazine HCl)
(Isoxsuprine HCl)
(Papaverine HCl)
(Reserpine)
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Adalat CC)
(Nimodipine)
(Sular)
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
2
(Amiloride HCl)
(Amiloride/
(Bumetanide)
(Chlorothiazide)
(Chlorthalidone)
(Lasix)
(Microzide)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Maxzide-25 Mg)
1
1
(Caduet)
(Lipitor)
(Questran)
(Questran Light)
(Colestid)
1
1
1
1
1
PA, QL: 2 in 1 days
PA
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
2
25
fenofibrate nanocrystallized
(Tricor)
fenofibrate
(Fenoglide)
fenofibrate,micronized
(Antara)
fenofibric acid (choline)
(Trilipix)
fenofibric acid
(Fibricor)
fluvastatin sodium tab er 24h
(Lescol XL)
fluvastatin sodium capsule
(Lescol)
gemfibrozil
(Lopid)
lovastatin
(Mevacor)
niacin tab er 24h
(Niaspan)
omega-3 acid ethyl esters
(Lovaza)
pravastatin sodium
(Pravachol)
rosuvastatin calcium
(Crestor)
simvastatin
(Zocor)
ANTARA capsule: 30mg, 90mg
JUXTAPID
KYNAMRO
LIPTRUZET
LIVALO
PRALUENT PEN
PRALUENT SYRINGE
REPATHA PUSHTRONEX
REPATHA SURECLICK
REPATHA SYRINGE
VASCEPA
VYTORIN
WELCHOL
ZETIA
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
spironolact/hydrochlorothiazid
(Aldactazide)
spironolactone
(Aldactone)
AMTURNIDE
TEKTURNA HCT
TEKTURNA
Vasodilators
isosorbide dinitrate
(Isordil Titradose)
isosorbide mononitrate
(Imdur)
minoxidil
(Minoxidil)
nitroglycerin capsule er, patch td24, spray, (Nitro-Dur)
tab subl
NITRO-BID
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
2
PA
PA
PA
PA
PA, QL: 3.5 in 28 days
QL: 4 in 1 days
PA
PA
PA
PA
1
1
1
1
2
26
NITRO-DUR patch td24: 0.3mg/hr,
0.8mg/hr
NITROSTAT
2
2
Central Nervous System Agents
Central Nervous System Agents
caffeine citrated solution
dexmethylphenidate hcl cpbp 50-50
dexmethylphenidate hcl tablet
dextroamphetamine sulfate capsule er,
tablet: 5mg, 10mg
dextroamphetamine/amphetamine
guanfacine hcl
lithium carbonate
lithium citrate
methamphetamine hcl
methylphenidate hcl cpbp 30-70, solution,
tab er 24, tablet, tablet er: 10mg, 20mg
riluzole
tetrabenazine
AMPYRA
(Cafcit)
(Focalin XR)
(Focalin)
(Dextroamphetamine
Sulfate)
(Adderall)
(Intuniv)
(Lithium Carbonate)
(Lithium Citrate)
(Desoxyn)
(Concerta)
1
1
1
1
(Rilutek)
(Xenazine)
1
1
2
DAYTRANA
FOCALIN XR cpbp 50-50: 35mg
RITALIN LA cpbp 50-50: 10mg, 60mg
SAVELLA
STRATTERA
VYVANSE
PA
1
1
1
1
1
1
2
2
2
2
2
2
PA
PA
per fill)
PA
PA
PA
PA
Contraceptives
Contraceptives
levonorgestrel-ethin estradiol tablet: 0.10.02
AMETHYST
BEYAZ
CAYA CONTOURED
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
(Amethyst)
1
(Mircette)
(Desogen)
0
0
0
0
0
0
0
0
(Yaz)
(Ethynodiol D-Ethinyl
Estradiol)
FC CONDOM, FEMALE
FC2 FEMALE CONDOM
FEMCAP
0
0
0
27
GYNOL II
IMPLANON
levonorgestrel
levonorgestrel-ethin estradiol tablet: 0.10.02, 0.15-0.03, 6-5-10, 90-20mcg; tbdspk
3mo
l-norgest/e.estradiol-e.estrad
LO LOESTRIN FE
LO MINASTRIN FE
MINASTRIN 24 FE
NATAZIA
nonoxynol 9
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
(Plan B One-Step)
(Amethyst)
(Seasonique)
(Nonoxynol 9)
(Ortho Evra)
(Generess Fe)
(Loestrin)
(Ortho Micronor)
(Loestrin 24 Fe)
(Ortho-Novum)
(Norinyl 1+50)
(Ortho Tri-Cyclen Lo)
(Norgestrel-Ethinyl
Estradiol)
NUVARING
ORTHO ALL-FLEX each
ORTHO ALL-FLEX kit
QUARTETTE
SAFYRAL
TODAY CONTRACEPTIVE SPONGE
VCF
WIDE SEAL DIAPHRAGM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Cough And Cold Products
Cough And Cold Products
benzonatate
bromphenira/pseudoephed/codein liquid:
1.3-10-6.3
brompheniram/phenylephrine/dm liquid
brompheniramine/pseudoephed/dm syrup:
2-30-10/5
bromphenrm/pseudoeph/dihydrocd
chlorpheniramine/codeine phos liquid:
2mg-10mg/5
(Zonatuss)
(Bromphenira/
Pseudoephed/Codein)
(Ala-Hist Dm)
(Brompheniramine/
Pseudoephed/Dm)
(Bromphenrm/
Pseudoeph/Dihydrocd)
(Chlorpheniramine/
Codeine Phos)
1
1
1
1
1
1
28
dihydrocodeine/guaifenesin
guaifenesin/codeine phosphate
guaifenesin/phenylephrine hcl liquid: 2007.5/5
hydrocodone bit/homatrop me-br
hydrocodone/chlorphen p-stirex
hydrocodone/cpm/pseudoephed
promethazine hcl/codeine
promethazine/dextromethorphan
promethazine/phenyleph/codeine
(Dihydrocodeine/
Guaifenesin)
(M-Clear Wc)
(Rescon-Gg)
1
(Hydrocodone Bit/
Homatrop Me-Br)
(Hydrocodone/
Chlorphen P-Stirex)
(Zutripro)
(Promethazine HCl/
Codeine)
(Promethazine/
Dextromethorphan)
(Promethazine/
Phenyleph/Codeine)
1
REZIRA
VITUZ
1
1
1
1
1
1
1
1
1
Dental And Oral Agents
Dental And Oral Agents
chlorhexidine gluconate
pilocarpine hcl
sodium fluoride
stannous fluoride
triamcinolone acetonide
(Peridex)
(Salagen)
(Prevident 5000 Plus)
(Stannous Fluoride)
(Triamcinolone
Acetonide)
1
1
1
1
1
(Soriatane)
(Zovirax)
(Aluminum Chloride)
(Ammonium Lactate)
1
1
1
1
(Benzoyl Peroxide
Microspheres)
(Benzoyl Peroxide)
1
Dermatological Agents
Dermatological Agents, Other
acitretin
acyclovir
aluminum chloride
ammonium lactate cream (g): 12%; lotion:
12%
benzoyl peroxide microspheres kit cl-crm
benzoyl peroxide cleanser: 3%, 4%, 6%,
7%, 9%; foam, gel (gram): 4%, 5%, 8%,
10%; kit: 4%-5%; towelette: 3%, 6%, 9%
BP WASH cleanser: 2.5%, 7%, 10%
calcipotriene
calcitriol
fluorouracil
(Dovonex)
(Vectical)
(Carac)
PA
PA
1
1
1
1
1
29
hydrocortisone/lidocaine/aloe
imiquimod
isotretinoin capsule: 10mg, 20mg, 30mg,
40mg
isotretinoin capsule: 10mg, 20mg, 30mg,
40mg
lactic acid
LUGOL'S
podofilox
potassium hydroxide
salicylic acid cream (g), foam, gel (gram):
6%; liq-film, liquid: 26%; lotion: 6%;
shampoo: 6%
salicylic acid/ceramide cmb #1
sodium thiosulfate/sal acid
sulfacetamide sod/sulfur/urea cleanser
sulfacetamide sodium cleanser
sulfacetamide sodium/sulfur
sulfacetamide sodium/urea
sulfacetm na/avobenzone/sulfur
trypsin/balsam peru/castor oil oint. (g)
urea cream (g): 40%, 45%, 50%; foam:
35%; gel (ml), lotion
urea/hyaluronate sodium
urea/lactic ac/zn undecylenate
ABSORICA
alcohol antiseptic pads
(Hydrocortisone/
Lidocaine/Aloe)
(Aldara)
(Isotretinoin)
1
(Isotretinoin)
1
(Lactic Acid)
1
1
1
1
1
(Condylox)
(Potassium Hydroxide)
(Virasal)
1
1
(Salex)
(Sodium Thiosulfate/
Sal Acid)
(Claris)
(Sulfacetamide
Sodium)
(Sumadan)
(Sulfacetamide
Sodium/Urea)
(Sulfacetm Na/
Avobenzone/Sulfur)
(Xenaderm)
(Aluvea)
1
1
(Urea/Hyaluronate
Sodium)
(Urea/Lactic Ac/Zn
Undecylenate)
1
(Alcohol Antiseptic
Pads)
ALCOH-WIPE
CONDYLOX gel (gram)
DENAVIR
DRITHOCREME HP
FINACEA PLUS
FINACEA
MIRVASO
fill)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
PA, QL: 30 per fill
30
OXSORALEN
2
PICATO gel (ea): 0.05%
PICATO gel (ea): 0.015%
SANTYL
VALCHLOR
VEREGEN
XERESE
ZOVIRAX cream (g)
Dermatological Antibacterials
clindamycin phos/benzoyl perox gel (gram): (Duac)
1%-5%, 1.2(1)%-5%
clindamycin phosphate
(Cleocin T)
erythromycin base/ethanol
(Erythromycin Base/
Ethanol)
erythromycin/benzoyl peroxide
(Benzamycin)
gentamicin sulfate
(Gentamicin Sulfate)
metronidazole
(Metrogel)
mupirocin calcium
(Bactroban)
mupirocin
(Bactroban)
selenium sulfide
(Selenium Sulfide)
silver nitrate
(Silver Nitrate)
silver sulfadiazine
(Silvadene)
sulfacetamide sodium
(Klaron)
THERMAZENE
ALTABAX
BACTROBAN NASAL
Dermatological Anti-Inflammatory Agents
alclometasone dipropionate
(Aclovate)
amcinonide
(Amcinonide)
betamethasone dipropionate
(Betamethasone
Dipropionate)
betamethasone valerate
(Betamethasone
Valerate)
betamethasone/propylene glyc
(Diprolene AF)
clobetasol propionate cream (g), foam, gel (Temovate)
(gram), lotion, oint. (g), shampoo, solution
desonide
(Desowen)
desoximetasone
(Topicort)
diflorasone diacetate
(Diflorasone Diacetate)
fluocinolone acetonide
(Derma-Smoothe-Fs)
fluocinonide
(Vanos)
flurandrenolide
(Flurandrenolide)
2
2
2
2
2
2
2
per fill)
PA, QL: 2 per fill
PA, QL: 3 per fill
PA
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
PA
1
1
1
1
1
1
1
1
1
1
1
1
31
fluticasone propionate
halobetasol propionate
hydrocort/pramoxin/emol/pram#1
hydrocort/pramoxn/skn clnsr#16
hydrocortisone acetate
hydrocortisone acetate/aloe v
hydrocortisone acetate/urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone cream (g): 1%, 2.5%;
cream/appl, enema, kit, lotion: 1%, 2%,
2.5%; oint. (g): 1%, 2.5%
hydrocortisone/iodoquinol
hydrocortisone/pramoxine
lidocaine/hydrocortisone ac
mometasone furoate
prednicarbate
tacrolimus
CORDRAN lotion, med. tape, oint. (g)
ELIDEL
ONFI
PROCTOFOAM-HC
VERDESO
Dermatological Retinoids
adapalene
tretinoin microspheres
tretinoin
tretinoin/emollient base cream (g): 0.05%
FABIOR
TAZORAC
Scabicides and Pediculicides
lindane
(Cutivate)
(Ultravate)
(Analpram E)
(Hydrocort/Pramoxn/
Skn Clnsr#16)
(Anusol-HC)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate/Urea)
(Locoid)
(Hydrocortisone
Valerate)
(Anusol-HC)
1
1
1
1
(Hydrocortisone/
Iodoquinol)
(Hydrocortisone/
Lidocaine/Aloe)
(Analpram HC)
(Lidocaine/
Hydrocortisone Ac)
(Elocon)
(Dermatop)
(Protopic)
(Triamcinolone
Acetonide)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
(Differin)
(Retin-A Micro)
(Retin-A)
(Tretinoin/Emollient
Base)
PA
PA
PA
1
1
1
1
2
2
(Lindane)
PA
PA
1
32
malathion
permethrin
spinosad
SKLICE
(Ovide)
(Elimite)
(Natroba)
1
1
1
2
PA
Detergents
Detergents
TRITON X-100
0
Devices
Devices
1ST CHOICE LANCETS
1ST TIER UNILET COMFORTOUCH
ACCU-CHEK FASTCLIX
ACCU-CHEK SAFE-T-PRO PLUS
ACCU-CHEK SAFE-T-PRO
ACCU-CHEK SOFTCLIX
ACCU-CHEK
ACTI-LANCE
ADVANCED TRAVEL LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ALTERNATE SITE LANCETS
ASSURE HAEMOLANCE PLUS each:
18gauge, 21gauge, 25gauge, 28gauge
ASSURE LANCE PLUS
ASSURE LANCE
AURORA SUPER THIN LANCETS
BD MICROTAINER LANCETS
BD ULTRA-FINE II
BD ULTRA-FINE
BLOOD LANCETS
BULLSEYE MINI SAFETY LANCETS
CAREONE
CARESENS
CLEVER CHEK LANCETS
COAGUCHEK
COLOR LANCETS
COMFORT EZ
COMFORT LANCETS
DROPLET LANCETS
EASY COMFORT
EASY TOUCH LANCETS
EASY TOUCH
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
33
EASY TWIST AND CAP LANCETS
EMBRACE
E-Z JECT LANCETS
EZ SMART LANCETS
E-ZJECT LANCETS
FIFTY50 SAFETY SEAL LANCETS
FINE 30 UNIVERSAL LANCETS
FINGERSTIX
FORA LANCETS
FORACARE LANCETS
FREESTYLE LANCETS
FREESTYLE UNISTIK 2
GLUCOCOM LANCETS
GLUCOCOM
GLUCOSOURCE
GMATE
HEALTHY ACCENTS UNILET LANCET
INCONTROL SUPER THIN LANCETS
INCONTROL ULTRA THIN LANCETS
INJECT EASE LANCETS
INVACARE LANCETS
KINNEY BRAND LANCETS
LANCETS THIN
LANCETS ULTRA THIN
LANCETS
LANCING DEVICE
LITE TOUCH
LUER-LOK SYRINGE-NEEDLE
MAJOR COMFORT
MEDI-LANCE
MEDISENSE THIN LANCETS
MEDLANCE PLUS
MICRO THIN LANCETS
MICROLET
MICROTAINER LANCETS
MONOLET LANCETS
MONOLET THIN LANCETS
MYGLUCOHEALTH LANCETS
NOVA SAFETY LANCETS
NOVA SUREFLEX
ON CALL LANCET
ON CALL PLUS LANCET
ONE TOUCH DELICA
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
34
ONETOUCH DELICA each
ONETOUCH DELICA kit
ONETOUCH FINEPOINT LANCETS
ONETOUCH LANCETS
ONETOUCH SURESOFT
ONETOUCH ULTRA CONTROL SOLN
ONETOUCH ULTRA SMART
ONETOUCH ULTRA SYSTEM
ONETOUCH ULTRA TEST STRIPS
2
2
2
2
2
2
2
2
2
ONETOUCH ULTRA2
ONETOUCH ULTRALINK
ONETOUCH ULTRAMINI
ONETOUCH VERIO FLEX
ONETOUCH VERIO IQ
ONETOUCH VERIO SYNC
ONETOUCH VERIO each: n/a
ONETOUCH VERIO strip
ON-THE-GO
OPTICHAMBER DIAMOND
OPTICHAMBER each
OPTICHAMBER spacer
PEDIATRIC MASK
pen needle, diabetic
PENLET PLUS BLOOD SAMPLER
PRESSURE ACTIVATED LANCETS
PRODIGY LANCETS
PRODIGY TWIST TOP LANCET
PUSH BUTTON SAFETY LANCETS
RELIAMED SAFETY SEAL LANCETS
RELIAMED
RELION THIN
RENEW ADVANCED MICROLANCETS
RIGHTEST GL300 LANCETS
SAFETY LANCETS
SAFETY SEAL LANCETS
SAFETY-LET
SINGLE-LET
SMART SENSE LANCETS
SMART SENSE
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Pen Needle, Diabetic)
(QL: 1 copay per 100
strips)
2
2
2
2
2
2
2
35
SMARTDIABETES VANTAGE
SMARTEST LANCET
SOFT TOUCH
SOLUS V2 LANCETS
SOLUS V2
STERILANCE TL
sub-q insulin device, 40 unit
(Sub-Q Insulin Device,
40 Unit)
2
2
2
2
2
2
2
SUPER THIN LANCETS
SURE COMFORT LANCETS
SURE-LANCE
SURESTEP CONTROL SOLUTION
SURESTEP PRO strip
2
2
2
2
2
SURESTEP PRO each: n/a
SURESTEP PRO kit
SURE-TOUCH
syringe and needle,insulin,1ml
2
2
2
2
2
2
syringe-needle,insulin,0.5 ml
syring-needl,disp,insul,0.3 ml
(Syringe and
Needle,Insulin,1ml)
(SyringeNeedle,Insulin,0.5 Ml)
(SyringNeedl,Disp,Insul,0.3
Ml)
TECHLITE LANCETS
TELCARE
THIN LANCETS
TOPCARE UNIVERSAL1 LANCET
TOPCARE UNIVERSAL1 THIN
LANCET
TRUEPLUS LANCETS
ULTICARE
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET SAFETY
ULTRA THIN LANCETS
ULTRA THIN PLUS LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II LANCETS
(QL: 1 copay per 100
strips)
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
36
ULTRA-THIN II
ULTRATLC LANCETS
UNILET COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNILET LANCETS
UNISTIK 3 EXTRA
UNISTIK 3
UNISTIK CZT
UNISTIK SAFETY
UNISTIK TOUCH
UNIVERSAL 1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
lipase/protease/amylase
CREON
CYSTAGON
KUVAN
KUVAN
(Zenpep)
1
2
2
2
2
PERTZYE
PULMOZYME
2
2
STRENSIQ
SUCRAID
ULTRESA
VIOKACE
ZAVESCA
2
2
2
2
2
ZENPEP capsule dr: 3k-10k-16k, 10-3455k, 15-51-82k, 20-68-109k, 25-85-136k,
40k-136k
2
PA
per fill)
PA
per fill)
PA
PA
PA
PA
per fill)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
apraclonidine hcl
(Iopidine)
atropine sulfate
(Isopto Atropine)
azelastine hcl
(Astepro)
balanced salt irrig soln no.2
(Bss)
carteolol hcl
(Carteolol HCl)
cromolyn sodium
(Cromolyn Sodium)
cyclopentolate hcl
(Cyclogyl)
1
1
1
1
1
1
1
37
epinastine hcl
(Elestat)
homatropine hbr
(Isopto Homatropine)
ipratropium bromide
(Atrovent)
naphazoline hcl
(Naphazoline HCl)
olopatadine hcl spray/pump
(Patanase)
olopatadine hcl drops
(Patanol)
phenylephrine hcl
(Mydfrin)
tropicamide
(Mydriacyl)
ALOMIDE
DYMISTA
EMADINE
ISOPTO HOMATROPINE drops: 2%
ISOPTO HYOSCINE
LASTACAFT
PATADAY
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid/aluminum acetate
(Acetic Acid/
Aluminum Acetate)
acetic acid/hydrocortisone
(Vosol HC)
antipyrine/benzocaine drops: 5.4%-1.4%
(Antipyrine/
Benzocaine)
bacitracin
(Bacitracin)
bacitracin/polymyxin b sulfate
(Bacitracin/Polymyxin
B Sulfate)
ciprofloxacin hcl
(Ciloxan)
cresyl acetate
(Cresyl Acetate)
erythromycin base
(Erythromycin Base)
gentamicin sulfate
(Garamycin)
levofloxacin
(Levofloxacin)
neo/polymyx b sulf/dexameth
(Maxitrol)
neomycin su/baci zn/poly/hc
(Neomycin Su/Baci Zn/
Poly/HC)
neomycin su/bacitra/polymyxin oint. (g):
(Neomycin Su/Bacitra/
3.5mg-400
Polymyxin)
neomycin/polymyxin b sulf/hc
(Cortisporin)
neomycin/polymyxn b/gramicidin
(Neosporin)
ofloxacin
(Ocuflox)
polymyxin b sulf/trimethoprim
(Polytrim)
sulfacetamide sodium
(Sulfacetamide
Sodium)
sulfacetamide/prednisolone sp
(Sulfacetamide/
Prednisolone Sp)
tobramycin
(Tobrex)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
PA
PA
PA
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
38
tobramycin/dexamethasone
(Tobradex)
trifluridine
(Viroptic)
AZASITE
BESIVANCE
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN oint. (g)
CIPRO HC
CIPRODEX
NATACYN
PRED-G drops susp
TOBRADEX oint. (g)
VIGAMOX
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
bromfenac sodium
(Bromfenac Sodium)
budesonide
(Rhinocort Aqua)
dexamethasone sod phosphate
(Dexasol)
diclofenac sodium
(Diclofenac Sodium)
flunisolide
(Flunisolide)
fluocinolone acetonide oil
(Dermotic)
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
fluticasone propionate
(Flonase)
hc/pramoxine hcl/chloroxylenol drops: 10- (Oticin HC)
10-1/ml
ketorolac tromethamine
(Acular LS)
mometasone furoate
(Nasonex)
prednisolone acetate
(Pred Forte)
prednisolone sod phosphate
(Prednisolone Sod
Phosphate)
(Nasacort Aq)
BECONASE AQ
BROMDAY
FML S.O.P.
MAXIDEX
OMNARIS
QNASL CHILDREN
QNASL
RESTASIS
VERAMYST
ZETONNA
1
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
PA
PA
PA
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
39
cimetidine hcl
cimetidine
esomeprazole magnesium
famotidine
lansoprazole
misoprostol
nizatidine
omeprazole
omeprazole/sodium bicarbonate capsule:
20mg-1.1g, 40mg-1.1g; packet
pantoprazole sodium tablet dr
rabeprazole sodium
ranitidine hcl capsule, syrup, tablet
sucralfate
ACIPHEX SPRINKLE
CARAFATE oral susp
DEXILANT
NEXIUM suspdr pkt
Gastrointestinal Agents, Other
cromolyn sodium
dicyclomine hcl capsule, solution, tablet
diphenoxylate hcl/atropine
glycopyrrolate tablet
hyoscyamine sulfate drops, elixir, tab er
12h: 0.375mg; tab rapdis: 0.125mg; tab
subl: 0.125mg; tablet: 0.125mg
lactulose
loperamide hcl
methscopolamine bromide
metoclopramide hcl solution, tablet
opium tincture
paregoric
sodium polystyrene sulfon/sorb
sodium polystyrene sulfonate
ursodiol
AMITIZA
CHOLBAM
FULYZAQ
GATTEX
KRISTALOSE
(Cimetidine HCl)
(Cimetidine)
(Nexium)
(Pepcid)
(Prevacid)
(Cytotec)
(Axid)
(Prilosec)
(Zegerid)
1
1
1
1
1
1
1
1
1
(Protonix)
(Aciphex)
(Zantac)
(Carafate)
1
1
1
1
2
2
2
2
(Gastrocrom)
(Bentyl)
(Lomotil)
(Robinul)
(Levsin-Sl)
1
1
1
1
1
(Lactulose)
(Loperamide HCl)
(Methscopolamine
Bromide)
(Reglan)
(Opium Tincture)
(Paregoric)
(Sodium Polystyrene
Sulfon/Sorb)
(Sodium Polystyrene
Sulfonate)
(Urso)
1
1
1
PA
PA
PA
PA
1
1
1
1
1
1
2
2
2
2
2
QL: 68 in 34 days
PA
PA
40
LINZESS
MOVANTIK
RELISTOR syringe, vial
VELPHORO
VELTASSA
Laxatives
bisac/nacl/nahco3/kcl/peg 3350
peg 3350/na sulf,bicarb,cl/kcl
PEG 3350-GRX
polyethylene glycol 3350
sodium chloride/nahco3/kcl/peg
GOLYTELY powd pack
MOVIPREP
PREPOPIK
SUCLEAR
SUPREP
Phosphate Binders
calcium acetate
sevelamer carbonate
FOSRENOL
RENAGEL
RENVELA powd pack
2
2
2
2
2
(Halflytely-Bisacodyl)
(Golytely)
(Polyethylene Glycol
3350)
(Nulytely with Flavor
Packs)
QL: 1 in 1 days
QL: 1 in 1 days
PA
PA
PA, QL: 1 in 1 days
1
1
1
1
1
2
2
2
2
2
(Phoslo)
(Sevelamer Carbonate)
1
1
2
2
2
PA
PA
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide
(Enablex)
flavoxate hcl
(Flavoxate HCl)
oxybutynin chloride
(Oxybutynin Chloride)
tolterodine tartrate cap er 24h
(Detrol LA)
tolterodine tartrate tablet
(Detrol)
trospium chloride cap er 24h
(Sanctura XR)
trospium chloride tablet
(Sanctura)
GELNIQUE gel md pmp
GELNIQUE gel packet
MYRBETRIQ
OXYTROL
TOVIAZ
VESICARE
Genitourinary Agents, Miscellaneous
alfuzosin hcl
(Uroxatral)
(Uribel)
methen/m-blue/sal/na phos/hyos
(Uta)
1
1
1
1
1
1
1
2
2
2
2
2
2
PA
PA
PA
PA
PA
PA
PA
PA
1
1
1
41
methenam/me blue/ba/salicy/hyo
phenazopyridine hcl
tamsulosin hcl
terazosin hcl
RAPAFLO
(Methen/Sod Phos/
Meth Blue/Hyos)
(Methenam/Me Blue/
Ba/Salicy/Hyo)
(Phenazopyridine HCl)
(Flomax)
(Terazosin HCl)
1
1
1
1
1
2
PA
Heavy Metal Antagonists
Heavy Metal Antagonists
DEPEN
EXJADE
2
2
FERRIPROX
2
PA NSO (QL: 1 copay/
supply; 34 days per fill)
PA
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
danazol
estrogen,ester/me-testosterone
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone gel (gram), gel md pmp:
1.25g(1%); gel packet
ANDRODERM patch td24: 2mg/24hr,
4mg/24hr
ANDROGEL gel md pmp: 20.25/1.25; gel
packet: 1.25g-1.62, 2.5g-1.62%
Estrogens and Antiestrogens
clomiphene citrate
estradiol
estradiol/norethindrone acet tablet: 0.50.1mg, 1mg-0.5mg
estropipate
raloxifene hcl
COMBIPATCH
DIVIGEL
DUAVEE
ELESTRIN
(Danazol)
(Estrogen,Ester/MeTestosterone)
(Fluoxymesterone)
(Oxandrin)
(Depo-Testosterone)
(Testosterone
Enanthate)
(Testim)
1
1
1
1
1
1
1
2
2
(Clomiphene Citrate)
(Estrace)
(Activella)
1
1
1
(Estropipate)
(Femhrt)
(Evista)
1
1
1
2
2
2
2
PA
42
ESTRACE cream/appl
ESTRING
OSPHENA
PREMARIN cream/appl, tablet
PREMPHASE
PREMPRO
VAGIFEM
estradiol/norethindrone acet tablet: 0.5(Activella)
0.1mg, 1mg-0.5mg
Glucocorticoids/Mineralocorticoids
cortisone acetate
(Cortisone Acetate)
dexamethasone
(Dexamethasone)
fludrocortisone acetate
(Fludrocortisone
Acetate)
hydrocortisone
(Cortef)
methylprednisolone
(Medrol)
prednisolone sod phosphate solution
(Orapred)
prednisolone
(Prednisolone)
prednisone
(Prednisone)
VERIPRED 20
Pituitary
desmopressin acetate solution, spray/pump, (DDAVP)
tablet
octreotide acetate
(Octreotide Acetate)
CETROTIDE
CHORIONIC GONADOTROPIN
FOLLISTIM AQ
2
2
2
2
2
2
2
0
GONAL-F RFF REDI-JECT
GONAL-F RFF
2
2
GONAL-F
2
MENOPUR
2
NORDITROPIN FLEXPRO
NORDITROPIN FLEXPRO
2
2
NOVAREL
2
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
2
2
2
PA, QL: 1 in 1 days
1
1
1
1
1
1
1
1
1
1
1
2
2
2
PA
fill)
PA
per fill)
per fill)
fill)
PA
per fill)
fill)
PA
PA
PA
43
OVIDREL
2
PREGNYL
2
REPRONEX
2
SOMATULINE DEPOT
SOMAVERT
STIMATE
Progestins
HYDROXYPROGESTERONE
CAPROATE
medroxyprogesterone acetate tablet
megestrol acetate oral susp: 400mg/10ml
norethindrone acetate
progesterone
progesterone,micronized
CRINONE
DEPO-PROVERA vial: 400mg/ml
DEPO-SUBQ PROVERA 104
medroxyprogesterone acetate syringe, vial
Thyroid and Antithyroid Agents
levothyroxine sodium tablet
liothyronine sodium tablet
methimazole
potassium iodide
potassium iodide/iodine
2
2
2
propylthiouracil
thyroid
thyroid,pork various dosage and/or
strengths are available
ARMOUR THYROID tablet: 15mg,
120mg, 180mg, 240mg, 300mg
per fill)
fill)
fill)
PA
PA
1
(Provera)
(Megace Es)
(Aygestin)
(Progesterone)
(Prometrium)
(Depo-Provera)
(Synthroid)
(Cytomel)
(Tapazole)
(Potassium Iodide)
(Potassium Iodide/
Iodine)
(Propylthiouracil)
(Thyroid)
(Thyroid,Pork)
1
1
1
1
1
2
2
0
0
1
1
1
1
1
1
1
1
2
Immunological Agents
Immunological Agents
azathioprine
cyclosporine capsule
cyclosporine, modified capsule: 25mg,
50mg, 100mg; solution
leflunomide
mycophenolate mofetil
mycophenolate sodium
(Imuran)
(Sandimmune)
(Neoral)
1
1
1
(Arava)
(Cellcept)
(Myfortic)
1
1
1
44
sirolimus
tacrolimus
ARCALYST
(Rapamune)
(Prograf)
1
1
2
ASTAGRAF XL
AUBAGIO
CIMZIA syringekit
2
2
2
ENBREL
ENBREL
2
2
HUMIRA PEDIATRIC CROHN'S
HUMIRA PEN CROHN-UC-HS
STARTER
HUMIRA PEN PSORIASIS-UVEITIS
HUMIRA PEN
2
2
HUMIRA syringekit: 20mg/0.4ml, 40mg/
0.8ml
HUMIRA syringekit: 10mg/0.2ml
HUMIRA syringekit: 20mg/0.4ml, 40mg/
0.8ml
KINERET
ORENCIA syringe
RAPAMUNE solution
RIDAURA
SANDIMMUNE solution
ZORTRESS
Vaccines
VIVOTIF
2
2
2
2
2
PA
per fill)
PA, QL: 28 per fill
per fill)
PA
per fill)
PA
per fill)
PA
per fill)
per fill)
PA, QL: 2 per fill
PA
2
2
2
2
2
2
PA
PA
2
QL: 4 per fill
PA
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
alosetron hcl
(Alosetron HCl)
balsalazide disodium
(Colazal)
budesonide
(Entocort EC)
mesalamine
(Sfrowasa)
APRISO
CANASA
DELZICOL
DIPENTUM
LIALDA
PENTASA
1
1
1
1
2
2
2
2
2
2
PA
Metabolic Bone Disease Agents
45
Metabolic Bone Disease Agents
alendronate sodium
calcitonin,salmon,synthetic
calcitriol capsule, solution
doxercalciferol capsule
etidronate disodium
ibandronate sodium tablet
paricalcitol
risedronate sodium tablet
BINOSTO
FORTEO
(Fosamax)
(Miacalcin)
(Rocaltrol)
(Hectorol)
(Etidronate Disodium)
(Boniva)
(Zemplar)
(Actonel)
FORTICAL
FOSAMAX PLUS D
MIACALCIN vial
1
1
1
1
1
1
1
1
2
2
PA
per fill)
2
2
2
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
allopurinol
bethanechol chloride
buspirone hcl
chloral hydrate
colchicine tablet
colchicine/probenecid
dutasteride
dutasteride/tamsulosin hcl
emollient combination no.10
ergoloid mesylates
finasteride tablet: 5mg
guanidine hcl
hydroxyzine hcl solution, tablet
hydroxyzine pamoate
leucovorin calcium tablet
levocarnitine (with sugar)
levocarnitine tablet
meprobamate
methylergonovine maleate tablet
probenecid
pyridostigmine bromide
ACTEMRA syringe
(Zyloprim)
(Urecholine)
(Buspirone HCl)
(Chloral Hydrate)
(Colcrys)
(Colchicine/
Probenecid)
(Avodart)
(Jalyn)
(Emollient
Combination No.10)
(Ergoloid Mesylates)
(Propecia)
(Guanidine HCl)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin Calcium)
(Carnitor)
(Carnitor)
(Meprobamate)
(Methylergonovine
Maleate)
(Probenecid)
(Mestinon)
1
1
1
1
1
1
1
1
1
PA
1
1
1
1
1
1
1
1
1
1
1
1
2
PA, QL: 3.6 per fill
46
ACTIMMUNE
2
AVONEX PEN
AVONEX kit
2
2
AVONEX syringekit
2
BETASERON
COPAXONE syringe: 20mg/ml
2
2
COPAXONE syringe: 40mg/ml
ELMIRON
EXTAVIA
GANIRELIX ACETATE
GILENYA
2
2
2
2
2
GLUCAGEN
GLUCAGON EMERGENCY KIT
LITHOSTAT
MESNEX tablet
MESTINON syrup
ORENCIA CLICKJECT
OTEZLA tab ds pk
OTEZLA tablet
PLEGRIDY PEN
PLEGRIDY
PROCYSBI
PROSTIGMIN
REBIF REBIDOSE
REBIF
2
2
2
2
2
2
2
2
2
2
2
2
2
2
SENSIPAR
SIGNIFOR
SIMPONI
SIMPONI
2
2
2
2
SYNAREL
TECFIDERA
THALOMID
ULORIC
XELJANZ XR
XELJANZ
2
2
2
2
2
2
per fill))
PA
per fill)
per fill)
fill)
QL: 12 per fill
PA
PA
fill)
PA, QL: 27 per fill
PA, QL: 60 per fill
PA, QL: 2 per fill
PA, QL: 2 per fill
PA
PA
per fill)
PA
per fill)
PA
PA, QL: 68 per fill
Ophthalmic Agents
47
Antiglaucoma Agents
acetazolamide
betaxolol hcl
bimatoprost
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl
methazolamide
metipranolol
pilocarpine hcl
timolol maleate
travoprost (benzalkonium)
(Acetazolamide)
(Betaxolol HCl)
(Lumigan)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Metipranolol)
(Isopto Carpine)
(Timolol Maleate)
(Travoprost
(Benzalkonium))
ALPHAGAN P drops: 0.1%
AZOPT
BETOPTIC S
LUMIGAN drops: 0.01%
PHOSPHOLINE IODIDE
PILOPINE HS
RESCULA
SIMBRINZA
TRAVATAN Z
ZIOPTAN
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
Replacement Preparations
Replacement Preparations
citric acid/sodium citrate
KLOR-CON 10
KLOR-CON 8
KLOR-CON
KLOR-CON-EF
phosphorus #1 tablet: 250mg
pot chloride/pot bicarb/cit ac
potassium bicarbonate/cit ac
potassium chloride capsule er, liquid,
packet, tab er prt, tablet er
potassium citrate
potassium citrate/citric acid
(Citric Acid/Sodium
Citrate)
(K-Phos Neutral)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Potassium Chloride)
(Urocit-K)
(Potassium Citrate/
Citric Acid)
SHOHL'S MODIFIED
1
1
1
1
1
1
1
1
1
1
1
1
48
sod/pot/k cit/sod cit/cit acid
zinc sulfate capsule: 220(50)mg
K-PHOS ORIGINAL
ORACIT
(Sod/Pot/K Cit/Sod Cit/
Cit Acid)
(Zinc Sulfate)
1
1
2
2
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
budesonide
(Pulmicort)
ADVAIR DISKUS
ADVAIR HFA
ARNUITY ELLIPTA
ASMANEX HFA
ASMANEX
BREO ELLIPTA
DULERA
FLOVENT DISKUS
FLOVENT HFA
PULMICORT FLEXHALER
Antileukotrienes
montelukast sodium
(Singulair)
zafirlukast
(Accolate)
Bronchodilators
albuterol sulfate
(Accuneb)
ipratropium bromide
(Ipratropium Bromide)
ipratropium/albuterol sulfate
(Duoneb)
levalbuterol hcl
(Xopenex)
metaproterenol sulfate
(Metaproterenol
Sulfate)
terbutaline sulfate tablet
(Terbutaline Sulfate)
theophylline anhydrous
(Theophylline
Anhydrous)
VENTOLIN HFA
ANORO ELLIPTA
ATROVENT HFA
BROVANA
COMBIVENT RESPIMAT
COMBIVENT
FORADIL
MAXAIR AUTOHALER
PERFOROMIST
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA
1
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
PA
PA
49
THEO-24
TUDORZA PRESSAIR
XOPENEX HFA
Respiratory Tract Agents, Other
acetylcysteine vial: 100mg/ml, 200mg/ml
cromolyn sodium
guaifen/theop anhyd/p-ephed
guaifenesin/dyphylline
sodium chloride for inhalation vial-neb:
3%, 7%, 10%
DALIRESP
HYPER-SAL vial-neb: 3.5%
KALYDECO gran pack
KALYDECO tablet
NEBUSAL
ORKAMBI
2
2
2
(Acetadote)
(Cromolyn Sodium)
(Guaifen/Theop Anhyd/
P-Ephed)
(Guaifenesin/
Dyphylline)
(Sodium Chloride For
Inhalation)
ST
PA
1
1
1
1
1
2
2
2
2
2
2
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
carisoprodol/aspirin
chlorzoxazone
codeine/carisoprodol/aspirin
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine hcl tablet
dantrolene sodium capsule
metaxalone
methocarbamol tablet
orphenadrine citrate tablet er
orphenadrine/aspirin/caffeine
tizanidine hcl
(Baclofen)
(Soma)
(Carisoprodol/Aspirin)
(Parafon Forte DSC)
(Codeine/Carisoprodol/
Aspirin)
(Fexmid)
(Dantrium)
(Skelaxin)
(Robaxin)
(Orphenadrine Citrate)
(Orphenadrine/Aspirin/
Caffeine)
(Zanaflex)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil
eszopiclone
modafinil
(Nuvigil)
(Lunesta)
(Provigil)
1
1
1
PA
PA
50
zaleplon
(Sonata)
1
zaleplon
zolpidem tartrate tab mphase, tablet
(Sonata)
(Ambien)
1
1
zolpidem tartrate tab subl
ROZEREM
(Intermezzo)
1
2
XYREM
2
(QL: 1 copay/
coinsurance per 15
capsules)
(QL: 1 copay/
coinsurance per 15
tablets)
PA
PA (QL: 1 copay/
coinsurance per 15
tablets)
per fill)
Urine And Feces Contents
Ketones
KETOSTIX REAGENT
2
QL: 100 per fill
1
2
PA
PA (QL: 1 copay/
supply)
PA (QL: 1 copay/
PA, QL: 30 per fill
PA
PA
(QL: 1 copay/
PA
PA (QL: 1 copay/
PA
PA
PA (QL: 1 copay/
Vasodilating Agents
Vasodilating Agents
sildenafil citrate tablet
ADCIRCA
(Revatio)
ADEMPAS
LETAIRIS
2
2
OPSUMIT
ORENITRAM ER
REVATIO susp recon
TRACLEER
2
2
2
2
TYVASO REFILL KIT
TYVASO STARTER KIT
2
2
TYVASO
UPTRAVI
VENTAVIS
2
2
2
Vitamins and Minerals
Vitamins and Minerals
51
calcium/mag/d3/b12/fa/b6/boron wafer
ergocalciferol (vitamin d2) capsule
folic acid tablet: 1mg
multivitamin no.44/vit d3/k
pedi m.vit no.17 with fluoride
pnv with ca,no.72/iron/fa
pnv#71/iron/folic acid/dha
pnv#79/iron/fa/lmfolate ca/dha
MEPHYTON
FALESSA
(Calcium/Mag/D3/B12/
Fa/B6/Boron)
(Drisdol)
(Folic Acid)
(Multivitamin No.44/
Vit D3/K)
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with Ca,No.72/
Iron/Fa)
(Pnv#71/Iron/Folic
Acid/Dha)
(Neevo Dha)
1
1
1
1
1
1
1
1
2
0
52
INDEX
1ST CHOICE LANCETS ..... 33
1ST TIER UNILET
COMFORTOUCH ............ 33
abacavir sulfate ..................... 17
abacavir/lamivudine/zidovudine
........................................... 17
ABSORICA .......................... 31
ABSTRAL .............................. 2
acarbose ................................ 11
ACCU-CHEK ....................... 33
ACCU-CHEK FASTCLIX ... 33
ACCU-CHEK SAFE-T-PRO 33
ACCU-CHEK SAFE-T-PRO
PLUS ................................. 33
ACCU-CHEK SOFTCLIX ... 33
acebutolol hcl ........................ 24
acetaminophen with codeine ... 1
acetaminophen/caff/dihydrocod
............................................. 1
acetaminophen/phenyltolx ...... 1
acetazolamide ....................... 49
acetic acid/aluminum acetate 39
acetic acid/hydrocortisone .... 39
acetylcysteine ........................ 51
ACIPHEX SPRINKLE ......... 41
acitretin ................................. 29
ACTEMRA ........................... 48
ACTI-LANCE....................... 33
ACTIMMUNE ...................... 48
acyclovir .......................... 20, 29
adapalene .............................. 33
ADCIRCA............................. 52
adefovir dipivoxil .................. 20
ADEMPAS ........................... 52
ADVAIR DISKUS................ 50
ADVAIR HFA ...................... 50
ADVANCED TRAVEL
LANCETS......................... 33
ADVATE .............................. 21
ADVOCATE LANCET ........ 33
ADVOCATE LANCETS...... 33
AFINITOR .............................. 7
AKYNZEO ........................... 16
ALBENZA ............................ 16
albuterol sulfate .................... 50
alclometasone dipropionate .. 31
alcohol antiseptic pads ......... 31
ALCOH-WIPE ...................... 31
ALECENSA ............................ 7
alendronate sodium............... 47
alfuzosin hcl .......................... 42
ALINIA ................................. 16
ALKERAN ............................. 7
allopurinol............................. 47
almotriptan malate ................ 14
ALOMIDE ............................ 38
alosetron hcl.......................... 46
ALPHAGAN P ..................... 49
ALPHANATE....................... 21
alprazolam .............................. 4
ALPRAZOLAM INTENSOL. 4
ALPROLIX ........................... 21
ALTABAX ........................... 31
ALTERNATE SITE LANCETS
........................................... 33
aluminum chloride ................ 29
amantadine hcl ...................... 16
amcinonide ............................ 32
AMETHYST ......................... 27
amiloride hcl ......................... 25
amiloride/hydrochlorothiazide
........................................... 25
aminocaproic acid ................ 21
amiodarone hcl ..................... 24
AMITIZA .............................. 41
amitriptyline hcl .................... 10
amitriptyline/chlordiazepoxide
........................................... 10
amlodipine besylate .............. 25
amlodipine besylate/benazepril
........................................... 25
amlodipine/atorvastatin ........ 25
amlodipine/valsartan ............ 25
amlodipine/valsartan/hcthiazid
........................................... 25
ammonium lactate ................. 30
amoxapine ............................. 10
amoxicillin............................... 6
amoxicillin/potassium clav...... 6
ampicillin trihydrate ............... 6
AMPYRA ............................. 27
AMTURNIDE....................... 26
anagrelide hcl ....................... 21
anastrozole .............................. 7
ANDRODERM ..................... 43
ANDROGEL......................... 43
ANORO ELLIPTA ............... 50
ANTARA .............................. 26
antipyrine/benzocaine ........... 39
APLENZIN ........................... 11
APOKYN .............................. 16
apraclonidine hcl .................. 38
APRISO ................................ 46
APTIOM ............................... 10
APTIVUS .............................. 18
ARANESP ............................ 21
ARCALYST ......................... 46
aripiprazole ........................... 17
armodafinil............................ 52
ARMOUR THYROID .......... 45
ARNUITY ELLIPTA ........... 50
ASMANEX ........................... 50
ASMANEX HFA .................. 50
aspirin/caffein/dihydrocodeine 1
aspirin/dipyridamole ............. 22
ASSURE HAEMOLANCE
PLUS ................................. 33
ASSURE LANCE ................. 34
ASSURE LANCE PLUS ...... 33
I-1
ASTAGRAF XL ................... 46
atenolol ................................. 24
atenolol/chlorthalidone ......... 24
atorvastatin calcium.............. 26
atovaquone ............................ 16
atovaquone/proguanil hcl ..... 16
ATRIPLA .............................. 18
atropine sulfate ..................... 38
ATROVENT HFA ................ 50
AUBAGIO ............................ 46
AUGMENTIN ........................ 6
AURORA SUPER THIN
LANCETS......................... 34
AVC ...................................... 14
AVONEX .............................. 48
AVONEX PEN ..................... 48
AZASITE .............................. 39
azathioprine .......................... 45
azelastine hcl ......................... 38
AZILECT .............................. 17
azithromycin ............................ 5
AZOPT .................................. 49
AZOR .................................... 25
bacitracin .............................. 39
bacitracin/polymyxin b sulfate
........................................... 39
baclofen ................................. 51
BACTROBAN NASAL........ 31
balanced salt irrig soln no.2 . 38
balsalazide disodium............. 46
BANZEL ............................... 10
BARACLUDE ...................... 20
BD MICROTAINER
LANCETS......................... 34
BD ULTRA-FINE ................ 34
BD ULTRA-FINE II ............. 34
BECONASE AQ ................... 40
benazepril hcl ........................ 23
benazepril/hydrochlorothiazide
........................................... 23
BENICAR ............................. 23
BENICAR HCT .................... 23
benzocaine............................... 3
benzonatate ........................... 28
benzoyl peroxide ................... 30
benzoyl peroxide microspheres
........................................... 30
benztropine mesylate ............. 16
BESIVANCE ........................ 39
betamethasone dipropionate . 32
betamethasone valerate ........ 32
betamethasone/propylene glyc
........................................... 32
BETASERON ....................... 48
betaxolol hcl .................... 24, 49
bethanechol chloride ............. 47
BETHKIS ................................ 4
BETOPTIC S ........................ 49
bexarotene ............................... 7
BEYAZ ................................. 27
bicalutamide............................ 7
bimatoprost ........................... 49
BINOSTO ............................. 47
bisac/nacl/nahco3/kcl/peg 3350
........................................... 41
bisoprolol fumarate............... 24
bisoprolol fumarate/hctz ....... 24
BLEPHAMIDE ..................... 39
BLEPHAMIDE S.O.P. ......... 39
BLOOD LANCETS .............. 34
BOSULIF ................................ 7
BP WASH ............................. 30
BREO ELLIPTA ................... 50
BRILINTA ............................ 22
brimonidine tartrate .............. 49
BRINTELLIX ....................... 11
BROMDAY .......................... 40
bromfenac sodium ................. 40
bromocriptine mesylate ......... 16
bromphenira/pseudoephed/
codein ................................ 29
brompheniram/phenylephrine/
dm...................................... 29
brompheniramine/pseudoephed/
dm...................................... 29
bromphenrm/pseudoeph/
dihydrocd .......................... 29
BROVANA ........................... 51
budesonide ................ 40, 46, 50
BULLSEYE MINI SAFETY
LANCETS......................... 34
bumetanide ............................ 25
buprenorphine hcl ................... 3
buprenorphine hcl/naloxone hcl
............................................. 3
bupropion hcl .............. 3, 10, 11
buspirone hcl ......................... 47
butalb/acetaminophen/caffeine 1
butalbit/acetamin/caff/codeine 1
butalbital/acetaminophen ....... 1
butalbital/aspirin/caffeine ....... 1
butorphanol tartrate................ 1
BUTRANS .............................. 2
BYDUREON ........................ 12
BYDUREON PEN ................ 12
BYSTOLIC ........................... 24
cabergoline ........................... 16
CABOMETYX ....................... 7
CAFERGOT ......................... 15
caffeine citrated .................... 27
calcipotriene ......................... 30
calcitonin,salmon,synthetic ... 47
calcitriol .......................... 30, 47
calcium acetate ..................... 42
calcium/mag/d3/b12/fa/b6/
boron ................................. 53
CANASA .............................. 46
candesartan cilexetil ............. 23
candesartan/hydrochlorothiazid
........................................... 23
capecitabine ............................ 7
CAPRELSA ............................ 7
captopril ................................ 23
captopril/hydrochlorothiazide
........................................... 23
CARAFATE ......................... 41
carbamazepine ........................ 9
carbidopa/levodopa .............. 16
I-2
carbidopa/levodopa/entacapone
........................................... 16
carbinoxamine maleate ......... 14
CAREONE ............................ 34
CARESENS .......................... 34
carisoprodol .......................... 51
carisoprodol/aspirin ............. 51
carteolol hcl .......................... 38
carvedilol .............................. 24
CAYA CONTOURED.......... 27
cefaclor ................................... 5
cefadroxil ................................ 5
cefdinir .................................... 5
cefditoren pivoxil .................... 5
cefixime ................................... 5
cefpodoxime proxetil ............... 5
cefprozil................................... 5
CEFTIN................................... 5
cefuroxime axetil ..................... 5
CEFUROXIME AXETIL ....... 5
celecoxib ................................. 2
cephalexin ............................... 5
CETROTIDE ........................ 44
CHANTIX........................... 3, 4
chloral hydrate ...................... 47
chlordiazepoxide hcl ............... 4
chlordiazepoxide/clidinium br 9
chlorhexidine gluconate ........ 29
chloroquine phosphate .......... 16
chlorothiazide ....................... 25
chlorpheniramine/codeine phos
........................................... 29
chlorpheniramine/
phenylephrine .................... 14
chlorpromazine hcl ............... 17
chlorpropamide ..................... 12
chlorthalidone ....................... 25
chlorzoxazone ....................... 51
CHOLBAM........................... 41
cholestyramine (with sugar) . 26
cholestyramine/aspartame .... 26
choline sal/mag salicylate ....... 2
CHORIONIC
GONADOTROPIN ........... 44
ciclopirox .............................. 13
ciclopirox olamine ................ 13
cilostazol ............................... 22
CILOXAN............................. 39
cimetidine .............................. 40
cimetidine hcl ........................ 40
CIMZIA ................................ 46
CIPRO HC ............................ 39
CIPRODEX........................... 39
ciprofloxacin ........................... 6
ciprofloxacin hcl ............... 6, 39
ciprofloxacin/ciprofloxa hcl .... 6
citalopram hydrobromide ..... 10
citric acid/sodium citrate ...... 49
CLARINEX .......................... 14
CLARINEX-D 12 HOUR ..... 14
CLARINEX-D 24 HOUR ..... 14
clarithromycin ......................... 5
clemastine fumarate .............. 14
CLEOCIN ............................. 14
CLEVER CHEK LANCETS 34
clindamycin hcl ....................... 4
clindamycin palmitate hcl ....... 4
clindamycin phos/benzoyl perox
........................................... 31
clindamycin phosphate.... 14, 31
CLINDESSE ......................... 14
clobetasol propionate............ 32
clomiphene citrate ................. 43
clomipramine hcl .................. 10
clonazepam ............................. 4
clonidine................................ 22
clonidine hcl .......................... 22
clonidine hcl/chlorthalidone . 22
clopidogrel bisulfate ............. 22
clorazepate dipotassium.......... 4
clotrimazole........................... 13
clotrimazole/betamethasone dip
........................................... 13
clozapine ............................... 17
COAGUCHEK ..................... 34
codeine sulfate ........................ 1
CODEINE SULFATE ............ 1
codeine/butalbital/asa/caffein . 1
codeine/carisoprodol/aspirin 51
colchicine .............................. 47
colchicine/probenecid ........... 47
colestipol hcl ......................... 26
COLOR LANCETS .............. 34
COMBIPATCH .................... 43
COMBIVENT ....................... 51
COMBIVENT RESPIMAT .. 51
COMETRIQ ............................ 7
COMFORT EZ ..................... 34
COMFORT LANCETS ........ 34
COMFORT PACCYCLOBENZAPRINE .... 51
COMFORT PAC-IBUPROFEN
............................................. 2
COMFORT PACMELOXICAM .................... 2
COMFORT PAC-NAPROXEN
............................................. 2
COMFORT PACTIZANIDINE .................... 51
COMPLERA ......................... 18
CONDYLOX ........................ 31
COPAXONE ......................... 48
CORDRAN ........................... 33
COREG CR........................... 24
CORLANOR......................... 25
cortisone acetate ................... 44
COTELLIC ............................. 7
CREON ................................. 38
cresyl acetate ........................ 39
CRINONE ............................. 45
CRIXIVAN ........................... 18
cromolyn sodium ....... 38, 41, 51
cyclobenzaprine hcl .............. 51
cyclopentolate hcl ................. 38
CYCLOPHOSPHAMIDE....... 7
cyclosporine .......................... 45
cyclosporine, modified .......... 45
cyproheptadine hcl ................ 14
I-3
CYSTAGON ......................... 38
DALIRESP ........................... 51
danazol .................................. 43
dantrolene sodium ................. 51
dapsone ................................. 15
DARAPRIM ......................... 16
darifenacin hydrobromide .... 42
DAYTRANA ........................ 27
DELZICOL ........................... 46
demeclocycline hcl .................. 6
DENAVIR............................. 31
DEPEN.................................. 43
DEPO-PROVERA ................ 45
DEPO-SUBQ PROVERA 104
........................................... 45
DESCOVY ............................ 18
desipramine hcl ..................... 10
desloratadine......................... 14
desmopressin acetate ............ 44
desog-e.estradiol/e.estradiol . 27
desogestrel-ethinyl estradiol . 27
desonide ................................ 32
desoximetasone ..................... 32
dexamethasone ...................... 44
dexamethasone sod phosphate
........................................... 40
dexchlorpheniramine maleate14
DEXILANT .......................... 41
dexmethylphenidate hcl ......... 27
dextroamphetamine sulfate ... 27
dextroamphetamine/
amphetamine ..................... 27
dextrose ................................. 22
DIASTAT ACUDIAL ............ 4
diazepam ................................. 4
DICLEGIS ............................ 16
diclofenac potassium ............... 2
diclofenac sodium ............. 2, 40
diclofenac sodium/misoprostol 2
dicloxacillin sodium ................ 6
dicyclomine hcl ..................... 41
didanosine ............................. 17
DIFICID .................................. 6
diflorasone diacetate............. 32
diflunisal ................................. 2
digoxin................................... 24
DIGOXIN ............................. 25
dihydrocodeine/guaifenesin .. 29
dihydroergotamine mesylate . 14
DILANTIN ........................... 10
diltiazem hcl .......................... 24
DIPENTUM .......................... 46
diphenhydramine hcl ............. 14
diphenoxylate hcl/atropine.... 41
dipyridamole ......................... 22
DISKETS ................................ 1
disopyramide phosphate ....... 24
disulfiram ................................ 3
DIURIL ................................. 25
divalproex sodium ................... 9
DIVIGEL .............................. 43
dofetilide ............................... 24
donepezil hcl ......................... 10
dorzolamide hcl ..................... 49
dorzolamide hcl/timolol maleat
........................................... 49
doxazosin mesylate................ 22
doxepin hcl ............................ 10
doxercalciferol ...................... 47
doxycycline hyclate ................. 6
doxycycline monohydrate........ 6
DRITHOCREME HP............ 31
dronabinol ............................. 15
DROPLET LANCETS.......... 34
DUAVEE .............................. 43
DULERA .............................. 50
duloxetine hcl ........................ 11
dutasteride............................. 47
dutasteride/tamsulosin hcl .... 47
DYMISTA ............................ 38
EASY COMFORT ................ 34
EASY TOUCH ..................... 34
EASY TOUCH LANCETS .. 34
EASY TWIST AND CAP
LANCETS......................... 34
econazole nitrate ................... 13
EDARBI ................................ 23
EDARBYCLOR ................... 23
EDURANT ........................... 18
EFFIENT............................... 22
ELESTRIN ............................ 43
ELIDEL................................. 33
ELIQUIS ............................... 20
ELLA .................................... 28
ELMIRON ............................ 48
ELOCTATE .......................... 21
EMADINE ............................ 38
EMBRACE ........................... 34
EMCYT................................... 7
EMEND ................................ 16
emollient combination no.10 . 47
EMTRIVA ............................ 18
enalapril maleate .................. 23
enalapril/hydrochlorothiazide
........................................... 23
ENBREL ............................... 46
enoxaparin sodium ................ 20
entacapone ............................ 16
entecavir ................................ 20
ENTRESTO .......................... 23
epinastine hcl ........................ 38
epinephrine ........................... 25
EPIPEN 2-PAK ..................... 25
EPIPEN JR 2-PAK ............... 25
EPIVIR HBV ........................ 18
eplerenone ............................. 26
EPOGEN ............................... 21
eprosartan mesylate .............. 23
EPZICOM ............................. 18
ergocalciferol (vitamin d2) ... 53
ergoloid mesylates ................ 47
ergotamine tartrate/caffeine . 14
ERIVEDGE............................. 8
ery e-succ/sulfisoxazole .......... 5
ERYPED 200 .......................... 6
ERYPED 400 .......................... 6
ERY-TAB ............................... 6
erythromycin base ............. 6, 39
erythromycin base/ethanol .... 31
I-4
erythromycin ethylsuccinate ... 6
erythromycin stearate ............. 6
erythromycin/benzoyl peroxide
........................................... 31
escitalopram oxalate ............. 11
esomeprazole magnesium ..... 40
estazolam................................. 4
ESTRACE ............................. 43
estradiol ................................ 43
estradiol/norethindrone acet 43,
44
ESTRING .............................. 43
estrogen,ester/me-testosterone
........................................... 43
estropipate............................. 43
eszopiclone ............................ 52
ethambutol hcl ....................... 15
ethinyl estradiol/drospirenone
........................................... 28
ethosuximide ........................... 9
ethynodiol d-ethinyl estradiol 28
etidronate disodium .............. 47
etodolac ................................... 2
etoposide ................................. 7
EVOTAZ............................... 18
exemestane .............................. 7
EXJADE ............................... 43
EXTAVIA ............................. 48
E-Z JECT LANCETS ........... 34
EZ SMART LANCETS ........ 34
E-ZJECT LANCETS ............ 34
FABIOR ................................ 33
FALESSA ............................. 53
famciclovir ............................ 20
famotidine ............................. 40
FANAPT ............................... 17
FARYDAK ............................. 8
FC CONDOM, FEMALE ..... 28
FC2 FEMALE CONDOM .... 28
FEIBA NF ............................. 21
felbamate ................................. 9
felodipine............................... 25
FEMCAP............................... 28
fenofibrate ............................. 26
fenofibrate nanocrystallized.. 26
fenofibrate,micronized .......... 26
fenofibric acid ....................... 26
fenofibric acid (choline) ........ 26
fenoprofen calcium.................. 2
fentanyl .................................... 1
fentanyl citrate ........................ 1
FENTORA .............................. 2
FERRIPROX......................... 43
FETZIMA ............................. 11
FIFTY50 SAFETY SEAL
LANCETS......................... 34
FINACEA ............................. 31
FINACEA PLUS .................. 31
finasteride ............................. 47
FINE 30 UNIVERSAL
LANCETS......................... 34
FINGERSTIX ....................... 34
FIRAZYR ............................. 25
flavoxate hcl .......................... 42
flecainide acetate .................. 24
FLECTOR ............................... 3
FLOVENT DISKUS ............. 50
FLOVENT HFA ................... 50
fluconazole ............................ 13
flucytosine ............................. 13
fludrocortisone acetate ......... 44
flunisolide.............................. 40
fluocinolone acetonide .......... 32
fluocinolone acetonide oil ..... 40
fluocinonide........................... 32
fluorometholone .................... 40
fluorouracil ........................... 30
fluoxetine hcl ......................... 11
FLUOXETINE HCL ............. 11
fluoxymesterone .................... 43
fluphenazine decanoate ......... 17
fluphenazine hcl .................... 17
flurandrenolide ..................... 32
flurazepam hcl ......................... 4
flurbiprofen ............................. 2
flurbiprofen sodium............... 40
flutamide ................................. 7
fluticasone propionate .... 32, 40
fluvastatin sodium ................. 26
fluvoxamine maleate ............. 11
FML S.O.P. ........................... 40
FOCALIN XR ....................... 27
folic acid................................ 53
FOLLISTIM AQ ................... 44
fondaparinux sodium ............ 20
FORA LANCETS ................. 34
FORACARE LANCETS ...... 34
FORADIL ............................. 51
FORFIVO XL ....................... 11
FORTEO ............................... 47
FORTICAL ........................... 47
FOSAMAX PLUS D ............ 47
fosinopril sodium .................. 23
fosinopril/hydrochlorothiazide
........................................... 23
FOSRENOL .......................... 42
FREESTYLE LANCETS ..... 34
FREESTYLE UNISTIK 2 .... 34
frovatriptan succinate ........... 14
FULYZAQ ............................ 41
furosemide ............................. 25
FUZEON ............................... 18
FYCOMPA ........................... 10
gabapentin............................... 9
GABITRIL ............................ 10
galantamine hbr .................... 10
GANIRELIX ACETATE...... 48
GATTEX............................... 41
GELNIQUE .......................... 42
gemfibrozil ............................ 26
gentamicin sulfate ........... 31, 39
GENVOYA ........................... 18
GILENYA ............................. 48
GILOTRIF .............................. 8
GLEOSTINE........................... 8
glimepiride ............................ 13
glipizide ................................. 13
glipizide/metformin hcl ......... 13
GLUCAGEN......................... 48
I-5
GLUCAGON EMERGENCY
KIT .................................... 48
GLUCOCOM ........................ 34
GLUCOCOM LANCETS..... 34
GLUCOSOURCE ................. 34
glyburide ............................... 13
glyburide,micronized ............ 13
glyburide/metformin hcl ........ 13
glycopyrrolate ....................... 41
GLYXAMBI ......................... 12
GMATE ................................ 34
GOLYTELY ......................... 42
GONAL-F ............................. 44
GONAL-F RFF ..................... 44
GONAL-F RFF REDI-JECT 44
granisetron hcl ...................... 15
griseofulvin ultramicrosize ... 13
griseofulvin, microsize .......... 13
guaifen/theop anhyd/p-ephed 51
guaifenesin/codeine phosphate
........................................... 29
guaifenesin/dyphylline .......... 51
guaifenesin/phenylephrine hcl
........................................... 29
guanfacine hcl ................. 22, 27
guanidine hcl ......................... 47
GYNOL II ............................. 28
halobetasol propionate ......... 32
haloperidol ............................ 17
haloperidol decanoate .......... 17
haloperidol lactate ................ 17
HARVONI ............................ 19
hc/pramoxine hcl/chloroxylenol
........................................... 40
HEALTHY ACCENTS
UNILET LANCET ........... 34
HELIXATE FS ..................... 21
HEMOFIL M ........................ 21
heparin sodium,porcine ........ 20
heparin sodium,porcine/pf .... 20
HEXALEN .............................. 8
homatropine hbr.................... 38
HUMATE-P .......................... 21
HUMIRA .............................. 46
HUMIRA PEDIATRIC
CROHN'S.......................... 46
HUMIRA PEN ...................... 46
HUMIRA PEN CROHN-UCHS STARTER................... 46
HUMIRA PEN PSORIASISUVEITIS ........................... 46
HYCAMTIN ........................... 8
hydralazine hcl ...................... 25
hydrochlorothiazide .............. 25
hydrocodone bit/homatrop mebr ....................................... 29
hydrocodone/acetaminophen .. 1
hydrocodone/chlorphen p-stirex
........................................... 29
hydrocodone/cpm/pseudoephed
........................................... 29
hydrocodone/ibuprofen ........... 1
hydrocort/pramoxin/emol/
pram#1 .............................. 32
hydrocort/pramoxn/skn
clnsr#16............................. 32
hydrocortisone ................ 32, 44
hydrocortisone acetate .......... 32
hydrocortisone acetate/aloe v 32
hydrocortisone acetate/urea . 32
hydrocortisone butyrate ........ 32
hydrocortisone valerate ........ 32
hydrocortisone/iodoquinol .... 32
..................................... 30, 32
hydrocortisone/pramoxine .... 32
hydromorphone hcl ................. 1
hydroxychloroquine sulfate ... 16
HYDROXYPROGESTERONE
CAPROATE ..................... 45
hydroxyurea ............................ 7
hydroxyzine hcl ..................... 47
hydroxyzine pamoate ............ 47
hyoscyamine sulfate .............. 41
HYPER-SAL......................... 51
ibandronate sodium .............. 47
IBRANCE ............................... 8
ibuprofen ................................. 2
ibuprofen/oxycodone hcl ......... 1
ICLUSIG ................................. 8
imatinib mesylate .................... 7
IMBRUVICA .......................... 8
imipramine hcl ...................... 11
imipramine pamoate ............. 11
imiquimod ............................. 30
IMPLANON ......................... 28
INCONTROL SUPER THIN
LANCETS......................... 34
INCONTROL ULTRA THIN
LANCETS......................... 34
indapamide ............................ 25
INDOCIN ................................ 3
indomethacin ........................... 2
INFERGEN ........................... 19
INJECT EASE LANCETS ... 34
INLYTA .................................. 8
INNOPRAN XL.................... 24
INTELENCE......................... 18
INTRON A............................ 20
INVACARE LANCETS ....... 34
INVIRASE ............................ 18
INVOKAMET ...................... 12
INVOKANA ......................... 12
ipratropium bromide ....... 38, 50
ipratropium/albuterol sulfate 50
irbesartan .............................. 23
irbesartan/hydrochlorothiazide
........................................... 23
IRESSA ................................... 8
ISENTRESS .......................... 18
isomethept/dichlphn/
acetaminop ........................ 14
isomethepten/caf/
acetaminophen .................. 15
isoniazid ................................ 15
ISOPTO HOMATROPINE .. 38
ISOPTO HYOSCINE ........... 38
isosorbide dinitrate ............... 26
isosorbide mononitrate ......... 27
I-6
isotretinoin ............................ 30
isoxsuprine hcl ...................... 25
isradipine .............................. 25
itraconazole........................... 13
ivermectin .............................. 16
IXINITY ............................... 21
JAKAFI ................................... 8
JANUMET ............................ 12
JANUMET XR ..................... 12
JANUVIA ............................. 12
JARDIANCE ........................ 12
JENTADUETO ..................... 12
JENTADUETO XR .............. 12
JUXTAPID ........................... 26
KALETRA ............................ 18
KALYDECO......................... 51
ketoconazole .......................... 13
ketoprofen ............................... 2
ketorolac tromethamine .... 2, 40
KETOSTIX REAGENT ....... 52
KINERET ............................. 46
KINNEY BRAND LANCETS
........................................... 34
KLOR-CON .......................... 49
KLOR-CON 10 ..................... 49
KLOR-CON 8 ....................... 49
KLOR-CON-EF .................... 49
KOATE-DVI......................... 22
KOGENATE FS ................... 22
KOMBIGLYZE XR.............. 12
KORLYM ............................. 12
K-PHOS ORIGINAL ............ 50
KRISTALOSE ...................... 41
KUVAN ................................ 38
KYNAMRO .......................... 26
labetalol hcl .......................... 24
lactic acid .............................. 30
lactulose ................................ 41
LAMISIL .............................. 13
lamivudine ............................. 17
lamivudine/zidovudine .......... 17
lamotrigine .............................. 9
LANCETS............................. 35
LANCETS THIN .................. 34
LANCETS ULTRA THIN .... 35
LANCING DEVICE ............. 35
lansoprazole .......................... 40
LANTUS ............................... 12
LANTUS SOLOSTAR ......... 12
LASTACAFT ....................... 38
latanoprost ............................ 49
LATUDA .............................. 17
leflunomide............................ 45
LENVIMA .............................. 8
LETAIRIS ............................. 52
letrozole................................... 7
leucovorin calcium ................ 47
LEUKERAN ........................... 8
LEUKINE ............................. 21
leuprolide acetate.................... 7
levalbuterol hcl ..................... 50
LEVEMIR ............................. 12
LEVEMIR FLEXTOUCH .... 12
levetiracetam ........................... 9
levobunolol hcl ...................... 49
levocarnitine ......................... 47
levocarnitine (with sugar) ..... 47
levocetirizine dihydrochloride
........................................... 14
levofloxacin ....................... 6, 39
levonorgestrel ....................... 28
levonorgestrel-ethin estradiol
..................................... 27, 28
levorphanol tartrate ................ 1
levothyroxine sodium ............ 45
LEXIVA ................................ 18
LIALDA ................................ 46
lidocaine.................................. 3
lidocaine hcl ............................ 3
lidocaine/hydrocortisone ac... 3,
32
lidocaine/prilocaine ................ 3
lindane................................... 33
linezolid ................................... 4
LINZESS............................... 41
liothyronine sodium .............. 45
lipase/protease/amylase ........ 37
LIPTRUZET ......................... 26
lisinopril ................................ 23
lisinopril/hydrochlorothiazide
........................................... 23
LITE TOUCH ....................... 35
lithium carbonate .................. 27
lithium citrate ........................ 27
LITHOSTAT......................... 48
LIVALO ................................ 26
l-norgest/e.estradiol-e.estrad 28
LO LOESTRIN FE ............... 28
LO MINASTRIN FE ............ 28
lomustine ................................. 7
LONSURF .............................. 8
loperamide hcl ...................... 41
lorazepam ................................ 4
losartan potassium ................ 23
losartan/hydrochlorothiazide 23
lovastatin ............................... 26
loxapine succinate ................. 17
LUER-LOK SYRINGENEEDLE ........................... 35
LUGOL'S .............................. 30
LUMIGAN ............................ 49
LUZU .................................... 13
LYNPARZA ........................... 8
LYRICA ................................ 10
LYSODREN ........................... 8
MAJOR COMFORT............. 35
malathion .............................. 33
maprotiline hcl ...................... 11
MATULANE .......................... 8
MAXAIR AUTOHALER ..... 51
MAXIDEX ............................ 40
meclizine hcl.......................... 15
meclofenamate sodium ............ 3
MEDI-LANCE ...................... 35
MEDISENSE THIN LANCETS
........................................... 35
MEDLANCE PLUS.............. 35
medroxyprogesterone acetate 45
mefenamic acid ....................... 3
I-7
mefloquine hcl ....................... 16
megestrol acetate .............. 7, 45
MEKINIST ............................. 8
meloxicam ............................... 3
memantine hcl ....................... 10
MENOPUR ........................... 44
meperidine hcl ......................... 1
MEPHYTON ........................ 53
meprobamate......................... 47
mercaptopurine ....................... 7
mesalamine ........................... 46
MESNEX .............................. 48
MESTINON .......................... 48
metaproterenol sulfate .......... 50
metaxalone ............................ 51
metformin hcl ........................ 11
....................................... 4, 42
methadone hcl ......................... 1
methamphetamine hcl ........... 27
methazolamide ...................... 49
methen/m-blue/sal/na phos/hyos
....................................... 5, 42
....................................... 5, 42
methenam/me blue/ba/salicy/
hyo ..................................... 42
methenamine hippurate ........... 5
methenamine mandelate.......... 5
methimazole .......................... 45
methocarbamol ..................... 51
methotrexate sodium ............... 7
methscopolamine bromide .... 41
methyclothiazide ................... 25
methyl salicylate...................... 3
methyldopa ............................ 22
methyldopa/
hydrochlorothiazide .......... 22
methylergonovine maleate .... 47
methylphenidate hcl .............. 27
methylprednisolone ............... 44
metipranolol .......................... 49
metoclopramide hcl ............... 41
metolazone ............................ 25
metoprolol succinate ............. 24
metoprolol tartrate ................ 24
metoprolol/hydrochlorothiazide
........................................... 24
metronidazole.............. 5, 14, 31
mexiletine hcl ........................ 24
MIACALCIN ........................ 47
miconazole nitrate ................. 13
MICRO THIN LANCETS .... 35
MICROLET .......................... 35
MICROTAINER LANCETS 35
midazolam hcl ......................... 4
midodrine hcl ........................ 22
MIGERGOT ......................... 15
miglitol .................................. 11
MINASTRIN 24 FE .............. 28
minocycline hcl ....................... 6
minoxidil ............................... 27
mirtazapine ........................... 11
MIRVASO ............................ 31
misoprostol............................ 40
modafinil ............................... 52
moexipril hcl ......................... 23
moexipril/hydrochlorothiazide
........................................... 23
mometasone furoate ........ 32, 40
MONOCLATE-P .................. 22
MONOLET LANCETS ........ 35
MONOLET THIN LANCETS
........................................... 35
montelukast sodium............... 50
morphine sulfate...................... 1
MORPHINE SULFATE ......... 1
MOVANTIK ......................... 41
MOVIPREP .......................... 42
moxifloxacin hcl ...................... 6
MULTAQ ............................. 24
multivitamin no.44/vit d3/k ... 53
mupirocin .............................. 31
mupirocin calcium ................ 31
mycophenolate mofetil .......... 45
mycophenolate sodium .......... 45
MYGLUCOHEALTH
LANCETS......................... 35
MYLERAN ............................. 8
MYRBETRIQ ....................... 42
nabumetone ............................. 3
nadolol .................................. 24
nadolol/bendroflumethiazide 24
naftifine hcl ........................... 13
NAFTIN ................................ 13
naloxone hcl ............................ 3
naltrexone hcl.......................... 3
naphazoline hcl ..................... 38
naproxen ................................. 3
naproxen sodium ..................... 3
naratriptan hcl ...................... 15
NARCAN ................................ 3
NATACYN ........................... 39
NATAZIA ............................. 28
nateglinide............................. 11
NEBUPENT .......................... 16
NEBUSAL ............................ 51
nefazodone hcl ...................... 11
neo/polymyx b sulf/dexameth 39
neomycin su/baci zn/poly/hc . 39
neomycin su/bacitra/polymyxin
........................................... 39
neomycin sulfate...................... 4
neomycin/polymyxin b sulf/hc 39
neomycin/polymyxn b/
gramicidin ......................... 39
NEULASTA ......................... 21
NEUMEGA........................... 21
NEUPOGEN ......................... 21
nevirapine ....................... 17, 18
NEXAVAR ............................. 8
NEXIUM............................... 41
niacin..................................... 26
nicardipine hcl ...................... 25
nicotine.................................... 4
NICOTINE PATCH................ 4
nicotine polacrilex .................. 4
NICOTROL ............................ 4
NICOTROL NS ...................... 4
I-8
nifedipine............................... 25
nilutamide ............................... 7
nimodipine............................. 25
NINLARO............................... 8
nisoldipine ............................. 25
NITRO-BID .......................... 27
NITRO-DUR......................... 27
nitrofurantoin .......................... 5
nitrofurantoin macrocrystal .... 5
nitrofurantoin monohyd/m-cryst
............................................. 5
nitroglycerin .......................... 27
NITROSTAT ........................ 27
nizatidine ............................... 40
nonoxynol 9 ........................... 28
NORDITROPIN FLEXPRO . 44
norelgestromin/ethin.estradiol
........................................... 28
noreth-ethinyl estradiol/iron . 28
norethindrone........................ 28
norethindrone acetate ........... 45
..................................... 28, 43
norethindrone-e.estradiol-iron
........................................... 28
norethindrone-ethinyl estrad 28
norethindrone-mestranol ...... 28
norgestimate-ethinyl estradiol
........................................... 28
norgestrel-ethinyl estradiol ... 28
NORPACE CR...................... 24
nortriptyline hcl .................... 11
NORVIR ............................... 18
NOVA SAFETY LANCETS 35
NOVA SUREFLEX .............. 35
NOVAREL ........................... 44
NOVOEIGHT ....................... 22
NOVOLIN 70-30 .................. 12
NOVOLIN N ........................ 12
NOVOLIN R ......................... 12
NOVOLOG ........................... 12
NOVOLOG FLEXPEN ........ 12
NOVOLOG MIX 70-30 ........ 12
NOVOLOG MIX 70-30
FLEXPEN ......................... 12
NOXAFIL ............................. 13
NUCYNTA ............................. 2
NUCYNTA ER ....................... 2
NUPLAZID........................... 17
NUTROPIN .......................... 44
NUTROPIN AQ.................... 44
NUTROPIN AQ NUSPIN .... 44
NUVARING ......................... 28
nystatin .................................. 13
NYSTATIN........................... 13
nystatin/triamcin ................... 13
OBIZUR ................................ 22
octreotide acetate .................. 44
ODEFSEY............................. 18
ODOMZO ............................... 8
ofloxacin ............................ 6, 39
olanzapine ............................. 17
olanzapine/fluoxetine hcl ...... 11
OLEPTRO ER ...................... 11
olopatadine hcl...................... 38
omega-3 acid ethyl esters...... 26
omeprazole ............................ 40
omeprazole/sodium bicarbonate
........................................... 40
OMNARIS ............................ 40
ON CALL LANCET............. 35
ON CALL PLUS LANCET .. 35
ondansetron........................... 15
ondansetron hcl ..................... 15
ONE TOUCH DELICA ........ 35
ONETOUCH DELICA ......... 35
ONETOUCH FINEPOINT
LANCETS......................... 35
ONETOUCH LANCETS...... 35
ONETOUCH SURESOFT.... 35
ONETOUCH ULTRA
CONTROL SOLN ............ 35
ONETOUCH ULTRA SMART
........................................... 35
ONETOUCH ULTRA
SYSTEM ........................... 35
ONETOUCH ULTRA TEST
STRIPS ............................. 35
ONETOUCH ULTRA2 ........ 35
ONETOUCH ULTRALINK . 35
ONETOUCH ULTRAMINI . 35
ONETOUCH VERIO ........... 35
ONETOUCH VERIO FLEX 35
ONETOUCH VERIO IQ ...... 35
ONETOUCH VERIO SYNC 35
ONFI ................................. 4, 33
ONGLYZA ........................... 12
ONSOLIS ................................ 2
ON-THE-GO......................... 35
opium tincture ....................... 41
opium/belladonna alkaloids .... 1
OPSUMIT ............................. 52
OPTICHAMBER .................. 36
OPTICHAMBER DIAMOND
........................................... 36
ORACIT ................................ 50
ORENCIA ............................. 46
ORENCIA CLICKJECT ....... 48
ORENITRAM ER ................. 52
ORKAMBI ............................ 51
orphenadrine citrate ............. 52
orphenadrine/aspirin/caffeine52
ORTHO ALL-FLEX ............. 28
OSPHENA ............................ 43
OTEZLA ............................... 48
OVIDREL ............................. 44
oxandrolone .......................... 43
oxaprozin................................. 3
oxazepam................................. 4
oxcarbazepine ......................... 9
OXSORALEN ...................... 31
oxybutynin chloride ............... 42
oxycodone hcl.......................... 1
oxycodone hcl/acetaminophen 2
oxycodone hcl/aspirin ............. 2
OXYCONTIN ......................... 2
oxymorphone hcl ..................... 2
OXYTROL ........................... 42
paliperidone .......................... 17
I-9
pantoprazole sodium ............. 40
papaverine hcl ....................... 25
paregoric ............................... 41
paricalcitol ............................ 47
paromomycin sulfate ............. 16
paroxetine hcl........................ 11
PATADAY ........................... 38
PAXIL ................................... 11
pedi m.vit no.17 with fluoride 53
PEDIATRIC MASK ............. 36
peg 3350/na sulf,bicarb,cl/kcl41
PEG 3350-GRX .................... 41
PEGASYS ............................. 20
PEGASYS PROCLICK ........ 20
PEGINTRON ........................ 20
PEGINTRON REDIPEN ...... 20
pen needle, diabetic .............. 36
penicillin v potassium ............. 6
PENLET PLUS BLOOD
SAMPLER ........................ 36
PENTASA............................. 47
pentazocine hcl/acetaminophen
............................................. 2
pentazocine hcl/naloxone hcl .. 2
pentoxifylline ......................... 22
PERFOROMIST ................... 51
perindopril erbumine ............ 23
permethrin ............................. 33
perphenazine ......................... 17
perphenazine/amitriptyline hcl
........................................... 11
PERTZYE ............................. 38
phenazopyridine hcl .............. 42
phenelzine sulfate .................. 11
phenobarb/hyoscy/atropine/
scop ..................................... 9
phenobarbital .......................... 9
phenoxybenzamine hcl .......... 22
phenylephrine hcl .................. 38
phenylephrine hcl/prometh hcl
........................................... 14
PHENYTEK ......................... 10
phenytoin ............................... 10
phenytoin sodium extended ... 10
PHOSPHASAL ....................... 5
PHOSPHOLINE IODIDE .... 49
phosphorus #1 ....................... 49
PHRENILIN FORTE .............. 2
PICATO ................................ 31
pilocarpine hcl ................ 29, 49
PILOPINE HS ....................... 49
pimozide ................................ 17
pindolol ................................. 24
pioglitazone hcl ..................... 11
pioglitazone hcl/glimepiride . 12
pioglitazone hcl/metformin hcl
........................................... 12
piroxicam ................................ 3
PLEGRIDY ........................... 48
PLEGRIDY PEN .................. 48
pnv with ca,no.72/iron/fa ...... 53
pnv#71/iron/folic acid/dha .... 53
pnv#79/iron/fa/lmfolate ca/dha
........................................... 53
podofilox ............................... 30
polyethylene glycol 3350....... 42
polymyxin b sulf/trimethoprim
........................................... 39
POMALYST ........................... 8
pot chloride/pot bicarb/cit ac 49
potassium bicarbonate/cit ac 50
potassium chloride ................ 50
potassium citrate ................... 50
potassium citrate/citric acid . 50
potassium hydroxide ............. 30
potassium iodide ................... 45
potassium iodide/iodine ........ 45
POTIGA ................................ 10
PRADAXA ........................... 20
PRALUENT PEN ................. 26
PRALUENT SYRINGE ....... 26
pramipexole di-hcl ................ 16
pravastatin sodium ................ 26
prazosin hcl ........................... 22
PRED-G ................................ 39
prednicarbate ........................ 32
prednisolone .......................... 44
prednisolone acetate ............. 40
prednisolone sod phosphate . 40,
44
prednisone ............................. 44
PREGNYL ............................ 45
PREMARIN .......................... 43
PREMPHASE ....................... 43
PREMPRO ............................ 44
PREPOPIK ............................ 42
PRESSURE ACTIVATED
LANCETS......................... 36
PREZCOBIX ........................ 18
PREZISTA ...................... 18, 19
primidone .............................. 10
PRISTIQ ER ......................... 11
probenecid............................. 48
prochlorperazine ................... 15
prochlorperazine maleate ..... 15
PROCRIT .............................. 21
PROCTOFOAM-HC ............ 33
PROCYSBI ........................... 48
PRODIGY LANCETS .......... 36
PRODIGY TWIST TOP
LANCET ........................... 36
progesterone ......................... 45
progesterone,micronized ....... 45
PROMACTA ........................ 21
promethazine hcl ............. 14, 15
promethazine hcl/codeine ..... 29
promethazine/
dextromethorphan ............. 29
promethazine/phenyleph/
codeine .............................. 29
propafenone hcl .................... 24
propantheline bromide ............ 9
propranolol hcl ..................... 24
propranolol/hydrochlorothiazid
........................................... 24
propylthiouracil .................... 45
PROSTIGMIN ...................... 48
protriptyline hcl .................... 11
PULMICORT FLEXHALER 50
I-10
PULMOZYME ..................... 38
PUSH BUTTON SAFETY
LANCETS......................... 36
pyrazinamide ......................... 15
pyridostigmine bromide ........ 48
QNASL ................................. 40
QNASL CHILDREN ............ 40
QUARTETTE ....................... 28
quazepam ................................ 4
quetiapine fumarate .............. 17
quinapril hcl .......................... 23
quinapril/hydrochlorothiazide
........................................... 23
quinidine gluconate............... 24
quinidine sulfate .................... 24
quinine sulfate ....................... 16
rabeprazole sodium ............... 41
raloxifene hcl ........................ 43
ramipril ................................. 23
RANEXA .............................. 25
ranitidine hcl ......................... 41
RAPAFLO ............................ 43
RAPAMUNE ........................ 46
REBIF ................................... 48
REBIF REBIDOSE ............... 48
RECOMBINATE .................. 22
RELADOR PAK ..................... 3
RELENZA ............................ 19
RELIAMED .......................... 36
RELIAMED SAFETY SEAL
LANCETS......................... 36
RELION THIN ..................... 36
RELISTOR ........................... 41
RELPAX ............................... 15
RENAGEL ............................ 42
RENEW ADVANCED
MICRO-LANCETS .......... 36
RENVELA ............................ 42
repaglinide ............................ 12
REPATHA PUSHTRONEX . 26
REPATHA SURECLICK ..... 26
REPATHA SYRINGE .......... 26
REPRONEX ......................... 45
RESCRIPTOR ...................... 19
RESCULA ............................ 49
reserpine ............................... 25
RESTASIS ............................ 40
REVATIO ............................. 52
REVLIMID ............................. 8
REYATAZ ............................ 19
REZIRA ................................ 29
ribavirin ................................ 20
RIDAURA ............................ 46
rifabutin................................. 15
rifampin ................................. 15
rifampin/isoniazid ................. 15
RIFATER .............................. 15
RIGHTEST GL300 LANCETS
........................................... 36
riluzole .................................. 27
rimantadine hcl ..................... 19
risedronate sodium................ 47
risperidone ............................ 17
RITALIN LA ........................ 27
rivastigmine tartrate ............. 10
rizatriptan benzoate .............. 15
ropinirole hcl ........................ 16
rosuvastatin calcium ............. 26
ROXICODONE ...................... 2
ROZEREM ........................... 52
SABRIL ................................ 10
SAFETY LANCETS ............ 36
SAFETY SEAL LANCETS . 36
SAFETY-LET ....................... 36
SAFYRAL ............................ 28
salicylic acid ......................... 30
salicylic acid/ceramide cmb #1
........................................... 30
salsalate .................................. 3
SANCUSO ............................ 16
SANDIMMUNE ................... 46
SANTYL ............................... 31
SAPHRIS .............................. 17
SAVELLA ............................ 27
selegiline hcl ......................... 16
selenium sulfide..................... 31
SELZENTRY ........................ 19
SENSIPAR ............................ 48
SEREVENT DISKUS ........... 51
SEROQUEL XR ................... 17
sertraline hcl ......................... 11
sevelamer carbonate ............. 42
SHOHL'S MODIFIED .......... 50
SIGNIFOR ............................ 48
sildenafil citrate .................... 52
silver nitrate .......................... 31
silver sulfadiazine ................. 31
SIMBRINZA......................... 49
SIMPONI .............................. 48
simvastatin ............................ 26
SINGLE-LET ........................ 36
sirolimus................................ 46
SIRTURO ............................. 15
SIVEXTRO ............................. 5
SKLICE................................. 33
SMART SENSE.................... 36
SMART SENSE LANCETS. 36
SMARTDIABETES
VANTAGE ....................... 36
SMARTEST LANCET ......... 36
sod/pot/k cit/sod cit/cit acid .. 50
sodium chloride for inhalation
........................................... 51
sodium chloride/nahco3/kcl/peg
........................................... 42
sodium fluoride ..................... 29
sodium polystyrene sulfon/sorb
........................................... 41
sodium polystyrene sulfonate 41
sodium thiosulfate/sal acid ... 30
SOFT TOUCH ...................... 36
SOLUS V2 ............................ 36
SOLUS V2 LANCETS ......... 36
SOMATULINE DEPOT ....... 45
SOMAVERT......................... 45
sotalol hcl .............................. 24
SOVALDI ............................. 19
spinosad ................................ 33
SPIRIVA ............................... 51
I-11
SPIRIVA RESPIMAT .......... 51
spironolact/hydrochlorothiazid
........................................... 26
spironolactone....................... 26
SPORANOX ......................... 13
SPRYCEL ............................... 8
stannous fluoride................... 29
stavudine ............................... 18
STERILANCE TL ................ 36
STIMATE ............................. 45
STIVARGA ............................ 8
STRATTERA ....................... 27
STRENSIQ ........................... 38
STRIBILD............................. 19
SUBOXONE ........................... 3
sub-q insulin device, 40 unit . 36
SUBSYS ................................. 2
SUCLEAR ............................ 42
SUCRAID ............................. 38
sucralfate............................... 41
sulfacetamide sod/sulfur/urea 30
sulfacetamide sodium 30, 31, 39
sulfacetamide sodium/sulfur . 30
sulfacetamide sodium/urea ... 30
sulfacetamide/prednisolone sp
........................................... 39
sulfacetm na/avobenzone/sulfur
........................................... 30
sulfadiazine ............................. 6
sulfamethoxazole/trimethoprim6
sulfasalazine............................ 6
sulindac ................................... 3
sumatriptan ........................... 15
sumatriptan succinate ........... 15
SUPER THIN LANCETS .... 36
SUPRAX ................................. 5
SUPREP ................................ 42
SURE COMFORT LANCETS
........................................... 36
SURE-LANCE ...................... 36
SURESTEP CONTROL
SOLUTION....................... 36
SURESTEP PRO .................. 36
SURE-TOUCH ..................... 36
SUSTIVA .............................. 19
SUTENT ................................. 8
SYLATRON ......................... 20
SYMLIN ............................... 12
SYMLINPEN 120 ................. 12
SYMLINPEN 60 ................... 12
SYNAREL ............................ 48
SYNJARDY.......................... 12
syringe and needle,insulin,1ml
........................................... 37
syringe-needle,insulin,0.5 ml 37
syring-needl,disp,insul,0.3 ml 37
tacrolimus ....................... 32, 46
TAFINLAR ............................. 9
TAMIFLU ............................. 19
tamoxifen citrate ..................... 7
tamsulosin hcl ....................... 42
TANZEUM ........................... 12
TARCEVA .............................. 9
TARGRETIN .......................... 9
TASIGNA ............................... 9
TAZORAC ............................ 33
TECFIDERA......................... 48
TECHLITE LANCETS ........ 37
TEKTURNA ......................... 26
TEKTURNA HCT ................ 26
TELCARE............................. 37
telmisartan ............................ 23
telmisartan/hydrochlorothiazid
........................................... 23
temazepam............................... 4
TEMODAR ............................. 7
temozolomide .......................... 7
terazosin hcl .......................... 42
terbinafine hcl ....................... 13
terbutaline sulfate ................. 50
terconazole ............................ 14
testosterone ........................... 43
testosterone cypionate ........... 43
testosterone enanthate .......... 43
tetrabenazine ......................... 27
tetracycline hcl ........................ 6
TEVETEN............................. 23
TEVETEN HCT.................... 23
THALOMID ......................... 49
THEO-24............................... 51
theophylline anhydrous ......... 50
THERMAZENE ................... 31
THIN LANCETS .................. 37
thioridazine hcl ..................... 17
thiothixene ............................. 17
thyroid ................................... 45
thyroid,pork ........................... 45
tiagabine hcl.......................... 10
ticlopidine hcl........................ 22
timolol maleate................ 24, 49
tinidazole ............................... 16
TIVICAY .............................. 19
tizanidine hcl ......................... 52
TOBI PODHALER ................. 4
TOBRADEX ......................... 39
tobramycin ............................ 39
tobramycin in 0.225% nacl ..... 4
tobramycin/dexamethasone... 39
TODAY CONTRACEPTIVE
SPONGE ........................... 28
tolazamide ............................. 13
tolbutamide ........................... 13
tolcapone ............................... 16
tolmetin sodium ....................... 3
tolterodine tartrate ................ 42
TOPCARE UNIVERSAL1
LANCET ........................... 37
TOPCARE UNIVERSAL1
THIN LANCET ................ 37
topiramate ............................. 10
torsemide ............................... 25
TOUJEO SOLOSTAR .......... 12
TOVIAZ ................................ 42
TRACLEER .......................... 52
TRADJENTA ....................... 12
tramadol hcl ............................ 2
tramadol hcl/acetaminophen .. 2
trandolapril ........................... 23
trandolapril/verapamil hcl .... 23
I-12
tranexamic acid ..................... 21
TRANSDERM-SCOP........... 16
tranylcypromine sulfate ........ 11
TRAVATAN Z ..................... 49
travoprost (benzalkonium) .... 49
trazodone hcl ......................... 11
tretinoin ............................. 7, 33
tretinoin microspheres .......... 33
tretinoin/emollient base ........ 33
TREXIMET .......................... 15
triamcinolone acetonide. 29, 33,
40
triamterene/hydrochlorothiazid
........................................... 25
triazolam ................................. 4
trifluoperazine hcl ................. 17
trifluridine ............................. 39
trihexyphenidyl hcl ................ 16
trimethobenzamide hcl .......... 16
trimethoprim ........................... 5
trimipramine maleate ............ 11
TRINTELLIX ....................... 11
TRITON X-100 ..................... 33
TRIUMEQ ............................ 19
TROKENDI XR.................... 10
tropicamide ........................... 38
trospium chloride .................. 42
TRUEPLUS LANCETS ....... 37
TRULICITY ......................... 12
TRUVADA ........................... 19
trypsin/balsam peru/castor oil
........................................... 30
TUDORZA PRESSAIR ........ 51
TYKERB................................. 9
TYVASO .............................. 53
TYVASO REFILL KIT ........ 53
TYVASO STARTER KIT .... 53
TYZEKA............................... 20
ULORIC ................................ 49
ULTICARE ........................... 37
ULTILET BASIC ................. 37
ULTILET CLASSIC ............. 37
ULTILET LANCETS ........... 37
ULTILET SAFETY .............. 37
ULTRA THIN LANCETS .... 37
ULTRA THIN PLUS ............ 37
ULTRA THIN PLUS
LANCETS......................... 37
ULTRALANCE .................... 37
ULTRA-THIN II................... 37
ULTRA-THIN II LANCETS 37
ULTRATLC LANCETS ....... 37
ULTRESA............................. 38
UNILET COMFORTOUCH 37
UNILET EXCELITE ............ 37
UNILET EXCELITE II ........ 37
UNILET GP LANCET ......... 37
UNILET LANCET ............... 37
UNILET LANCETS ............. 37
UNISTIK 3............................ 37
UNISTIK 3 EXTRA ............. 37
UNISTIK CZT ...................... 37
UNISTIK SAFETY .............. 37
UNISTIK TOUCH ................ 37
UNIVERSAL 1 ..................... 37
UPTRAVI ............................. 53
urea ....................................... 30
urea/hyaluronate sodium ...... 30
urea/lactic ac/zn undecylenate
........................................... 31
URETRON D-S ...................... 5
URIN D.S. ............................... 5
ursodiol ................................. 41
VAGIFEM ............................ 44
valacyclovir hcl ..................... 20
VALCHLOR ......................... 31
VALCYTE ............................ 20
valganciclovir hcl.................. 20
valproic acid ......................... 10
valproic acid (as sodium salt)10
valsartan ............................... 23
valsartan/hydrochlorothiazide
........................................... 23
vancomycin hcl........................ 5
VARUBI ............................... 16
VASCEPA ............................ 26
VCF ....................................... 28
VELPHORO ......................... 41
VELTASSA .......................... 41
VENCLEXTA......................... 9
VENCLEXTA STARTING
PACK .................................. 9
venlafaxine hcl ...................... 11
VENTAVIS........................... 53
VENTOLIN HFA ................. 50
VERAMYST......................... 40
verapamil hcl ........................ 24
VERDESO ............................ 33
VEREGEN ............................ 31
VERIPRED 20 ...................... 44
VESICARE ........................... 42
V-HIST ................................. 14
VICTOZA 3-PAK ................. 12
VIDEX .................................. 19
VIGAMOX ........................... 39
VIIBRYD .............................. 11
VIMOVO ................................ 3
VIMPAT ............................... 10
VIOKACE............................. 38
VIRACEPT ........................... 19
VIRAMUNE XR .................. 19
VIRAZOLE........................... 20
VIREAD ............................... 19
VITEKTA ............................. 19
VITUZ................................... 29
VIVOTIF............................... 46
voriconazole .......................... 13
VOTRIENT............................. 9
VRAYLAR ........................... 17
VYTORIN............................. 26
VYVANSE ........................... 27
warfarin sodium .................... 20
WELCHOL ........................... 26
WIDE SEAL DIAPHRAGM 28
WILATE ............................... 22
XALKORI............................... 9
XARELTO ............................ 21
XELJANZ ............................. 49
XELJANZ XR ...................... 49
I-13
XERESE ............................... 31
XIFAXAN............................... 5
XOPENEX HFA ................... 51
XTANDI ................................. 9
XYNTHA .............................. 22
XYNTHA SOLOFUSE ........ 22
XYREM ................................ 52
YODOXIN ............................ 16
zafirlukast.............................. 50
zaleplon ................................. 52
ZAVESCA ............................ 38
ZELBORAF ............................ 9
ZENPEP ................................ 38
ZEPATIER ............................ 19
ZETIA ................................... 26
ZETONNA ............................ 40
ZIAGEN ................................ 19
zidovudine ............................. 18
zinc sulfate ............................ 50
ZIOPTAN ............................. 49
ziprasidone hcl ...................... 17
ZOLINZA ............................... 9
zolmitriptan ........................... 15
zolpidem tartrate ................... 52
ZOMIG ................................. 15
zonisamide............................. 10
ZONTIVITY ......................... 22
ZORTRESS........................... 46
ZOVIRAX............................. 31
ZYDELIG ............................... 9
ZYKADIA .............................. 9
ZYTIGA .................................. 9
I-14

Printable Formulary

Transcription

Similar documents

GHP Family Formulary - Geisinger Health Plan

CHIP Cover.indd - Geisinger Health Plan

4D Pharmacy Managed Formulary Updates

2016 Formulary (List of Covered Drugs)

OHP Formulary