2016 Comprehensive Formulary

Transcription

2016 Comprehensive Formulary
Coventry Health Care (list of covered drugs) B1
PLEASE READ: This document contains information about the drugs we cover in this plan.
This formulary was updated on 10/1/2016.
For more recent information or other questions, please contact Coventry Health Care at
1-844-741-8423 or for TTY: 711. October 1 to February 14, you can call us 8 a.m. to 8 p.m., 7
days a week. From February 15 to September 30, we’re here 8 a.m. to 8 p.m., Monday through
Friday, or visit http://www.formulary.coventry-medicare.com.
Formulary ID Number: 16244 Version 19
Y0001_1085_5407_Final_6 Accepted 7/2015
16244CVH
Table of contents
2
Mail-order Pharmacy
3
What is the Coventry Health Care
Comprehensive Formulary?
4
Can the Formulary (drug list) change?
4
How do I use the Formulary?
4
What are generic drugs?
5
Are there any restrictions on my coverage?
5
What if my drug is not on the Formulary?
5
How do I request an exception to the Coventry
Health Care Formulary?
6
What do I do before I can talk to my doctor about
changing my drugs or requesting an exception?
6
For more information
7
Coventry Health Care Formulary
8
Drug tier copay levels
9
Formulary key
10
Drug list
10
Index
79
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with
State Medicaid programs. Enrollment in our plans depends on contract renewal.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by service area.
Mail-order Pharmacy
For mail order, you can get prescription drugs
shipped to your home through the network
mail-order delivery program, which is called
Aetna Rx Home Delivery. Typically, mail-order
drugs arrive within 7 to 14 days. You can call
1-844-741-8423 (TTY: 711) if you do not receive
your mail-order drugs within this timeframe.
This information is available for free in other
languages. Please call our member services
number at 1-844-741-8423 (TTY: 711).
October 1 to February 14, you can call us
8 a.m. to 8 p.m., 7 days a week. From
February 15 to September 30, we’re here
8 a.m. to 8 p.m., Monday through Friday.
Esta información está disponible en forma gratuita
en otros idiomas. Llame a nuestro número de
servicio al cliente al 1-844-741-8423 (TTY: 711).
Del 1 de octubre al 14 de febrero puede llamarnos
de 8 a.m. a 8 p.m., los siete días de la semana.
Del 15 de febrero al 30 de septiembre estamos
disponibles de lunes a viernes de 8 a.m. a 8 p.m.
When this drug list (formulary) refers to “we,” “us”,
or “our,” it means Coventry Health Care. When it
refers to “plan” or “our plan,” it means Coventry.
This document includes a list of the drugs
(formulary) for our plan which is current as of
10/1/2016. For an updated formulary, please
contact us. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
This information is not a complete description
of benefits. Contact the plan for more
information. Limitations, copayments, and
restrictions may apply.
You must generally use network pharmacies
to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/
coinsurance may change on January 1, 2017, and
from time to time during the year.
Note to existing members: This formulary has
changed since last year. Please review this
document to make sure that it still contains
the drugs you take.
3
What is the Coventry Health Care
Comprehensive Formulary?
A formulary is a list of covered drugs selected
by our plan in consultation with a team of health
care providers, which represents the prescription
therapies believed to be a necessary part of a
quality treatment program. We will generally
cover the drugs listed in our formulary as long
as the drug is medically necessary, the
prescription is filled at our network pharmacy, and
other plan rules are followed. For more information
on how to fill your prescriptions, please review
your Evidence of Coverage.
Can the Formulary
(drug list) change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning
of the year, we will not discontinue or reduce
coverage of the drug during the 2016 coverage
year except when a new, less expensive generic
drug becomes available or when new adverse
information about the safety or effectiveness
of a drug is released. Other types of formulary
changes, such as removing a drug from our
formulary, will not affect members who are
currently taking the drug. It will remain available
at the same cost-sharing for those members
taking it for the remainder of the coverage year.
We feel it is important that you have continued
access for the remainder of the coverage year
to the formulary drugs that were available when
you chose our plan, except for cases in which
you can save additional money or we can ensure
your safety.
4
If we remove drugs from our formulary, or add
prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to
a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who
take the drug. The enclosed formulary is current
as of 10/1/2016. To get updated information about
the drugs covered by our plan, please contact us.
Our contact information appears on the front and
back cover pages.
In the event of any CMS-approved, mid-year
non-maintenance formulary changes, the
formularies will be updated monthly and posted
on our website.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
Medical Condition
The formulary begins on page 10. The drugs
in this formulary are grouped into categories
depending on the type of medical conditions that
they are used to treat. For example, drugs used to
treat a heart condition are listed under the
category, “Cardiovascular Agents”. If you know
what your drug is used for, look for the category
name in the list that begins on page 10. Then
look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 79. The Index provides an
alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic
drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the
page number where you can find coverage
information. Turn to the page listed in the Index
and find the name of your drug in the first column
of the list.
What are generic drugs?
Our plan covers both brand-name drugs and
generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the
brand-name drug. Generally, generic drugs cost
less than brand-name drugs.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 10. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted online documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our
contact information, along with the date we last
updated the formulary, appears on the front and
back cover pages.
You can ask us to make an exception to these
restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See
the section, “How do I request an exception to the
Coventry Health Care formulary?” on page 6
for information about how to request an exception.
What if my drug is not
on the Formulary?
Are there any restrictions
on my coverage?
If your drug is not included in this formulary (list of
covered drugs), you should first contact Member
Services and ask if your drug is covered.
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
If you learn that our plan does not cover your
drug, you have two options:
• Prior Authorization: Our plan requires you or
your physician to get prior authorization for
certain drugs. This means that you will need
to get approval from us before you fill your
prescriptions. If you don’t get approval, we
may not cover the drug.
• Quantity Limits: For certain drugs, our plan
limits the amount of the drug that we will cover.
For example, our plan provides 30 tablets per
30 days per prescription for candesartan. This
may be in addition to a standard one-month or
three-month supply.
• You can ask Member Services for a list of
similar drugs that are covered by our plan.
When you receive the list, show it to your
doctor and ask him or her to prescribe a similar
drug that is covered by our plan.
• You can ask us to make an exception and
cover your drug. See below for information
about how to request an exception.
• Step Therapy: In some cases, our plan
requires you to first try certain drugs to treat
your medical condition before we will cover
another drug for that condition. For example, if
Drug A and Drug B both treat your medical
condition, we may not cover Drug B unless you
try Drug A first. If Drug A does not work for you,
we will then cover Drug B.
5
How do I request an
exception to the Coventry
Health Care Formulary?
What do I do before I can talk to
my doctor about changing my
drugs or requesting an exception?
You can ask us to make an exception to our
coverage rules. There are several types of
exceptions that you can ask us to make.
As a new or continuing member in our plan, you
may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For
example, you may need a prior authorization from
us before you can fill your prescription. You should
talk to your doctor to decide if you should switch
to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug
you take. While you talk to your doctor to
determine the right course of action for you, we
may cover your drug in certain cases during the
first 90 days you are a member of our plan.
• You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level,
and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a
lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the
amount you must pay for your drug.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, our plan limits the amount of the drug
that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover
a greater amount.
Generally, we will only approve your request for an
exception if the alternative drugs included on the
plan’s formulary, the lower cost-sharing drug or
additional utilization restrictions would not be as
effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you request
a formulary, tiering or utilization restriction
exception you should submit a statement from
your prescriber or physician supporting your
request. Generally, we must make our decision
within 72 hours of getting your prescriber’s
supporting statement. You can request an
expedited (fast) exception if you or your doctor
believe that your health could be seriously
harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must
give you a decision no later than 24 hours after
we get a supporting statement from your doctor
or other prescriber.
6
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have
a prescription written for fewer days) when you go
to a network pharmacy. After your first 30-day
supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we
will allow you to refill your prescription until we have
provided you with at least 91 and up to a 98-day
transition supply, consistent with dispensing
increment, (unless you have a prescription written
for fewer days). We will cover more than one refill
of these drugs for the first 90 days you are a
member of our plan. If you need a drug that is not
on our formulary or if your ability to get your drugs
is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception. If you experience a change
in your setting of care (such as being discharged
or admitted to a long term care facility), your
physician or pharmacy can request a one-time
prescription override. This one-time override will
provide you with temporary coverage (up to a
30-day supply) for the applicable drug(s).
For more information
For more detailed information about our plan’s
prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about our plan, please
contact us. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227)
24 hours a day/7 days a week. TTY users
should call 1-877-486-2048. Or, visit
http://www.medicare.gov.
7
Coventry Health Care Formulary
The comprehensive formulary that begins on
page 10 provides coverage information about
the drugs covered by our plan. If you have trouble
finding your drug in the list, turn to the Index that
begins on page 79.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., LEVEMIR)
and generic drugs are listed in lowercase italics
(e.g., candesartan).
The information in the Requirements/Limits
column tells you if our plan has any special
requirements for coverage of your drug. The
following abbreviations are used:
QL
Quantity Limits
PA
Prior Authorization
ST
Step Therapy
LA
Limited Access
MO
Mail-order Delivery
B/D
Part B vs. D Prior Authorization
QL: Quantity Limits. For certain drugs, our plan
limits the amount of the drug that we will cover.
For example, our plan provides 30 tablets per
30 days per prescription for candesartan.
PA: Prior Authorization. Our plan requires you
or your provider to get prior authorization for
certain drugs. This means that you will need
to get approval from us before you fill your
prescriptions. If you don’t get approval, we may
not cover the drug.
ST: Step Therapy. In some cases, our plan
requires you to first try certain drugs to treat your
medical condition, before we will cover another
drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, we may
not cover Drug B unless you try Drug A first. If
Drug A does not work for you, we will then cover
Drug B.
8
LA: Limited Access. These prescriptions may be
available only at certain pharmacies. For more
Information, consult your Pharmacy Directory or
call Coventry Health Care at 1-844-741-8423
(TTY: 711). October 1 to February 14, you can
call us 8 a.m. to 8 p.m., 7 days a week. From
February 15 to September 30, we’re here 8 a.m.
to 8 p.m., Monday through Friday.
MO: Mail Order. For certain kinds of drugs, you
can use Aetna Rx Home Delivery. Generally, the
drugs available through mail order are drugs that
you take on a regular basis, for a chronic or
long-term medical condition. The drugs available
through our plan’s mail-order service are marked
as “mail-order” drugs or “MO” in our drug list. For
more information, consult your Pharmacy Directory
or call Coventry Health Care at 1-844-741-8423
(TTY: 711). October 1 to February 14, you can call
us 8 a.m. to 8 p.m., 7 days a week. From February
15 to September 30, we’re here 8 a.m. to 8 p.m.,
Monday through Friday.
B/D: Part B versus Part D. This prescription drug
has a Part B versus Part D administrative prior
authorization requirement. This drug may be
covered under Medicare Part B or D depending
upon the circumstances. Information may need to
be submitted describing the use and setting of the
drug to make the determination.
Drug tier copay levels This 2016 comprehensive formulary is a listing of
brand-name and generic drugs. The Coventry
Health Care 2016 formulary covers many of the
drugs identified by Medicare as Part D drugs, and
your copay may differ depending upon the tier at
which the drug resides.
The copay tiers for covered prescription
medications are listed below. Copay amounts and
coinsurance percentages for each tier vary by plan.
Consult your plan’s Summary of Benefits or
Evidence of Coverage for your applicable copays
and coinsurance amounts.
Copay tier
Type of drug
Tier 1
Preferred Generic drugs
Tier 2
Generic drugs
Tier 3
Preferred Brand drugs
Tier 4
Non-Preferred Brand drugs
Tier 5
Specialty drugs
Our plan, in some instances, combines higher
cost generic drugs on brand tiers. Refer to the drug
list to determine the tier of coverage for each drug
you take.
9
Key*
Drug name
Drug tier
Requirements/Limits
UPPERCASE = Brand-name
prescription drugs
1, 2, 3, 4, 5 = Copay tier level
QL = Quantity Limit
PA = Prior Authorization
ST = Step Therapy
LA = Limited Access
MO = Mail-order Delivery
B/D = Part B vs. Part D
Lowercase italics = Generic
medications
Drug name
Drug tier Requirements/Limits
Analgesics
acetaminophen/codeine #3
2
QL (390 EA per 30 days) MO
acetaminophen/codeine soln
2
QL (4500 ML per 30 days) MO
acetaminophen/codeine tabs 300mg; 15mg, 300mg;
60mg
2
ascomp/codeine
3
QL (180 EA per 30 days) PA MO
butalbital compound/codeine
3
QL (180 EA per 30 days) PA
butalbital/acetaminophen/caffeine/codeine
3
butalbital/acetaminophen/caffeine caps
3
butalbital/acetaminophen/caffeine tabs 325mg;
50mg; 40mg
3
butalbital/aspirin/caffeine
3
butalbital/aspirin/caffeine/codeine
3
capacet
3
CELEBREX CAPS 400MG
4
QL (30 EA per 30 days) ST MO
CELEBREX CAPS 100MG, 200MG, 50MG
4
celecoxib caps 400mg
4
celecoxib caps 100mg, 200mg, 50mg
4
codeine sulfate tabs
4
diclofenac potassium
3
MO
diclofenac sodium dr
3
MO
diclofenac sodium er
3
MO
diflunisal tabs
3
MO
duramorph
2
B/D
endocet tabs 325mg; 2.5mg
3
QL (360 EA per 30 days)
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg
4
endodan
4
esgic caps
3
10 *You can find information on what the symbols and abbreviations on this table mean by going to page 8.
Drug name
etodolac
2
MO
etodolac er
3
MO
fenoprofen calcium caps 200mg
3
fenoprofen calcium caps 400mg
3
MO
fenoprofen calcium tabs
3
MO
fentanyl pt72
4
fentanyl citrate oral transmucosal
5
flurbiprofen tabs
2
MO
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml
4
hydrocodone bitartrate/acetaminophen tabs 325mg;
2.5mg
4
hydrocodone bitartrate/acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg; 7.5mg
4
hydrocodone/acetaminophen soln 325mg/15ml;
10mg/15ml
4
QL (5550 ML per 30 days)
hydrocodone/acetaminophen tabs 325mg; 10mg,
325mg; 5mg, 325mg; 7.5mg
4
hydrocodone/ibuprofen
4
hydromorphone hcl liqd
4
hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml,
500mg/50ml
4
B/D MO
hydromorphone hcl immediate release tabs 4mg,
8mg
4
hydromorphone hcl tabs 2mg
4
ibudone tabs 5mg; 200mg
4
ibuprofen susp
1
MO
ibuprofen tabs 400mg, 600mg, 800mg
1
MO
ketoprofen er
4
MO
ketoprofen caps
2
MO
lorcet
4
lorcet hd
4
lorcet plus tabs 325mg; 7.5mg
4
margesic
3
meclofenamate sodium caps
4
MO
meloxicam susp, tabs
1
MO
methadone hcl inj
2
methadone hcl tabs
2
methadone hcl oral soln
2
*You can find information on what the symbols and abbreviations on this table mean by going to page 8.
11
Drug name
methadone hcl conc
2
methadone hcl tbso
2
methadose sugar-free
2
methadose conc
2
methadose tbso
2
morphine sulfate er cp24 120mg
4
morphine sulfate er cp24 45mg, 75mg, 90mg
4
morphine sulfate er cp24 100mg, 10mg, 20mg,
30mg, 50mg, 60mg, 80mg
4
morphine sulfate er tbcr
4
morphine sulfate tabs
2
morphine sulfate inj 0.5mg/ml, 10mg/ml IV,
4
150mg/30ml, 15mg/ml, 1mg/ml IV, 25mg/ml, 2mg/ml,
4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml
B/D
morphine sulfate inj 10mg/ml, 15mg/ml, 1mg/ml PF
4
B/D MO
morphine sulfate oral soln 20mg/5ml
2
morphine sulfate oral soln 100mg/5ml, 20mg/ml
2
morphine sulfate oral soln 10mg/5ml
2
nabumetone
2
MO
nalbuphine hcl inj
4
MO
naproxen dr
2
MO
naproxen sodium tabs 275mg, 550mg
2
MO
naproxen susp, tabs
2
MO
oxaprozin
4
MO
oxycodone hcl conc
4
oxycodone hcl caps
4
oxycodone hcl soln
4
oxycodone hcl immediate release tabs 10mg, 15mg,
20mg, 30mg
4
oxycodone hcl tabs 5mg
4
oxycodone/acetaminophen tabs 325mg; 10mg,
325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg
3
oxycodone/aspirin
4
oxycodone/ibuprofen
4
piroxicam caps
3
MO
ROXICET SOLN
3
roxicet tabs
4
sulindac tabs
2
MO
Drug name
tolmetin sodium
2
MO
tramadol hcl immediate release tabs
2
tramadol hydrochloride/acetaminophen
4
vicodin es tabs 300mg; 7.5mg
4
vicodin hp tabs 300mg; 10mg
4
vicodin tabs 300mg; 5mg
4
VOLTAREN GEL
3
QL (1020 GM per 30 days) MO
zamicet
4
zebutal caps 325mg; 50mg; 40mg
3
glydo
2
MO
lidocaine hcl jelly
3
MO
lidocaine hcl gel 2%
3
MO
lidocaine hcl inj 0.5%, 1.5%
4
lidocaine hcl inj 1%, 2%, 4%
4
MO
lidocaine hcl external soln 4%
3
MO
lidocaine hcl mouth/throat soln 4%
3
lidocaine viscous
3
lidocaine/prilocaine kit
3
lidocaine/prilocaine crea
3
MO
lidocaine oint
3
MO
lidocaine ptch
3
relador pak plus
3
Anesthetics
MO
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium dr
4
MO
buprenorphine hcl/naloxone hcl
3
buprenorphine hcl subl
3
buproban
3
bupropion hcl sr tb12 150mg
3
CHANTIX CONTINUING MONTH PAK
4
CHANTIX STARTING MONTH PAK
4
CHANTIX TABS 0.5MG, 1MG
4
disulfiram tabs
3
MO
EVZIO
4
MO
naloxone hcl inj
2
MO
naltrexone hcl tabs
3
MO
13
Drug name
NARCAN
4
MO
NICOTROL NS
4
SUBOXONE FILM 12MG; 3MG
4
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG;
2MG
4
amikacin sulfate inj
3
MO
amoxicillin
1
MO
amoxicillin/clavulanate potassium
2
MO
amoxicillin/clavulanate potassium er
4
MO
ampicillin sodium inj 10gm, 125mg, 1gm for IV,
250mg, 2gm for IV
2
ampicillin sodium inj 1gm, 2gm, 500mg
2
ampicillin-sulbactam
4
ampicillin caps
2
ampicillin susr 125mg/5ml
2
ampicillin susr 250mg/5ml
2
MO
azithromycin pack, susr, tabs
2
MO
azithromycin inj
4
MO
aztreonam
4
MO
baciim
4
bacitracin inj 50000unit
4
MO
BICILLIN L-A
4
MO
cefaclor
3
MO
cefaclor er
3
MO
cefadroxil
2
MO
cefazolin
4
cefazolin sodium/dextrose
4
cefazolin sodium inj 100gm, 1gm for IV, 1gm; 5%,
20gm, 300gm
4
cefazolin sodium inj 10gm, 1gm, 500mg
4
MO
cefdinir
4
MO
cefditoren pivoxil tabs 400mg
4
cefditoren pivoxil tabs 200mg
4
cefepime/dextrose
4
cefepime inj 1gm/50ml, 2gm/100ml, 2gm/50ml; 5%
4
cefepime inj 1gm, 2gm
4
Antibacterials
MO
MO
MO
MO
Drug name
cefixime
4
cefotaxime sodium inj 10gm, 2gm, 500mg
4
cefotaxime sodium inj 1gm
4
cefotetan
4
cefotetan/dextrose
4
MO
MO
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm, 2gm; 2.2% 4
cefoxitin sodium inj 1gm
4
MO
cefpodoxime proxetil
4
MO
cefprozil
4
MO
ceftazidime/dextrose
4
ceftazidime inj 6gm
4
ceftazidime inj 1gm, 2gm
4
ceftriaxone in iso-osmotic dextrose
4
ceftriaxone sodium 100gm, 1gm i.v.
4
ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm,
500mg
4
ceftriaxone/dextrose
4
cefuroxime axetil
2
cefuroxime sodium inj 1.5gm, 7.5gm, 75gm
4
cefuroxime sodium inj 750mg
4
cefuroxime/dextrose inj 750mg; 4.1%
4
cephalexin
2
chloramphenicol sodium succinate
4
ciprofloxacin er
1
MO
ciprofloxacin hcl tabs 100mg, 250mg, 500mg, 750mg 1
MO
MO
MO
MO
MO
MO
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
4
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%
4
MO
ciprofloxacin otic soln, susr
3
MO
ciprofloxacin inj
4
MO
clarithromycin susr, immediate release tabs
3
MO
clindamax
3
clindamycin hcl caps
3
MO
clindamycin palmitate hcl
3
MO
clindamycin phosphate add-vantage inj 900mg/6ml
4
clindamycin phosphate in d5w
4
clindamycin phosphate crea 2%
3
MO
15
Drug name
clindamycin phosphate inj 150mg/ml, 300mg/2ml,
9000mg/60ml
4
clindamycin phosphate inj 600mg/4ml, 900mg/6ml
4
MO
colistimethate sodium
4
PA MO
CUBICIN
5
DALVANCE
5
dicloxacillin sodium
2
MO
DIFICID
5
MO
doxy 100
4
MO
doxycycline hyclate dr
4
MO
doxycycline hyclate caps, inj, tabs
4
MO
doxycycline monohydrate caps, tabs
4
MO
doxycycline caps 150mg, 75mg
4
MO
doxycycline susr
4
MO
E.E.S. GRANULES
4
MO
ERYPED 200
4
MO
ERYPED 400
4
MO
ERYTHROCIN LACTOBIONATE
4
ERYTHROCIN STEARATE
4
MO
erythromycin base
2
MO
erythromycin ethylsuccinate tabs
2
MO
erythromycin stearate tabs
2
MO
erythromycin cpep 250mg
3
MO
gentamicin sulfate pediatric
2
MO
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/
2
ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml;
0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/
ml; 0.9%
2
MO
gentamicin sulfate inj 10mg/ml
2
gentamicin sulfate inj 40mg/ml
2
MO
imipenem/cilastatin
3
MO
INVANZ IV 1GM
4
INVANZ INJ 1GM
4
MO
isotonic gentamicin inj 0.8mg/ml; 0.9%
2
MO
KETEK TABS 300MG
4
KETEK TABS 400MG
4
levofloxacin in d5w
4
MO
Drug name
levofloxacin inj 25mg/ml
4
levofloxacin oral soln 25mg/ml
3
MO
levofloxacin tabs 250mg, 500mg, 750mg
3
MO
linezolid susr
5
QL (1800 ML per 28 days) PA
MO
linezolid tabs
5
linezolid inj 600mg/300ml
5
PA
MEFOXIN
4
meropenem
4
meropenem/sodium chloride
4
methenamine hippurate
4
METRO IV
4
metronidazole in nacl 0.79%
4
metronidazole vaginal
3
MO
metronidazole caps 375mg
3
MO
metronidazole tabs 250mg, 500mg
3
MO
minocycline hcl caps
2
MO
morgidox 1x100mg caps
4
morgidox 1x50mg
4
morgidox 2x100mg caps
4
MOXATAG
4
NAFCILLIN
4
nafcillin sodium inj 10gm, 1gm, 2gm for i.v.
4
nafcillin sodium inj 2gm
4
NALLPEN ISO-OSMOTIC IN DEXTROSE
4
neomycin sulfate tabs
2
MO
nitrofurantoin macrocrystals
4
MO
nitrofurantoin monohydrate
4
MO
nitrofurantoin susp
4
MO
ofloxacin tabs 400mg
2
MO
oxacillin sodium inj 10gm, 1gm
4
oxacillin sodium inj 2gm
4
MO
paromomycin sulfate
4
MO
PCE
4
MO
penicillin g potassium inj 20000000unit, 5000000unit 4
MO
penicillin g procaine
4
MO
penicillin g sodium
4
MO
MO
MO
MO
17
Drug name
penicillin v potassium
1
piperacillin sodium/tazobactam sodium
4
piperacillin/tazobactam inj 4gm; 0.5gm
4
SIVEXTRO INJ
5
SIVEXTRO TABS
5
MO
streptomycin sulfate inj
4
MO
sulfadiazine tabs
2
MO
sulfamethoxazole/trimethoprim
1
MO
sulfamethoxazole/trimethoprim ds
1
MO
sulfatrim pediatric
1
SUPRAX CAPS
4
SUPRAX CHEW 100MG
4
SUPRAX CHEW 200MG
4
SUPRAX SUSR 500MG/5ML
4
SUPRAX SUSR 100MG/5ML, 200MG/5ML
4
SYNERCID
5
tazicef inj 1gm, 2gm, 6gm
4
TEFLARO
4
tetracycline hcl caps
2
MO
tinidazole
4
MO
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/
ml
2
tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml
4
tobramycin sulfate inj 1.2gm/30ml, 80mg/2ml
4
MO
trimethoprim tabs
2
MO
TYGACIL
5
vancomycin
4
vancomycin hcl in dextrose
4
vancomycin hcl caps
5
MO
MO
MO
MO
PA MO
vancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, 4
5000mg, 750mg
vancomycin hcl inj 500mg
4
MO
vandazole
2
MO
XIFAXAN TABS 200MG
4
XIFAXAN TABS 550MG
5
ZYVOX SUSR
5
MO
ZYVOX INJ 600MG/300ML
5
PA
Drug name
Anticonvulsants
APTIOM TABS 200MG, 400MG, 800MG
4
APTIOM TABS 600MG
4
BANZEL TABS
4
PA MO
BANZEL SUSP
5
PA MO
BRIVIACT INJ
4
PA
BRIVIACT ORAL SOLN
5
BRIVIACT TABS 10MG, 75MG
5
BRIVIACT TABS 100MG, 25MG, 50MG
5
carbamazepine er
4
MO
carbamazepine chew, susp, tabs
2
MO
CELONTIN
4
MO
clonazepam odt tbdp 1mg
4
clonazepam odt tbdp 2mg
4
clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg
4
clonazepam tabs 1mg
3
clonazepam tabs 2mg
3
clonazepam tabs 0.5mg
3
diazepam gel 10mg, 2.5mg, 20mg
4
MO
DILANTIN CAPS 30MG
4
MO
divalproex sodium
3
MO
divalproex sodium dr
3
MO
divalproex sodium er
3
MO
epitol
2
ethosuximide
4
MO
felbamate
4
MO
fosphenytoin sodium inj 100mg pe/2ml
4
fosphenytoin sodium inj 500mg pe/10ml
4
MO
FYCOMPA SUSP
5
FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG
4
FYCOMPA TABS 2MG
4
gabapentin caps, soln, tabs
2
MO
GABITRIL TABS 12MG, 16MG
4
MO
lamotrigine immediate release tabs, chew
2
MO
levetiracetam oral soln, immediate release tabs
2
MO
19
Drug name
levetiracetam inj 1000mg/100ml; 750mg/100ml,
1500mg/100ml; 540mg/100ml, 500mg/100ml;
820mg/100ml
4
levetiracetam inj 500mg/5ml
4
MO
LYRICA SOLN
4
QL (900 ML per 30 days) PA MO
LYRICA CAPS 225MG, 300MG
4
LYRICA CAPS 100MG, 150MG, 200MG, 25MG,
50MG, 75MG
4
ONFI SUSP
4
MO
ONFI TABS 10MG, 20MG
4
MO
oxcarbazepine
4
MO
PEGANONE
4
MO
phenobarbital tabs
4
phenobarbital elix
4
MO
phenytoin sodium extended
2
MO
phenytoin sodium inj
4
phenytoin chew, susp
2
MO
POTIGA TABS 50MG
4
POTIGA TABS 200MG, 300MG, 400MG
4
primidone tabs
2
MO
roweepra
2
SABRIL
5
SPRITAM TB3D 250MG, 500MG, 750MG
4
SPRITAM TB3D 1000MG
4
MO
TEGRETOL-XR TB12 100MG
4
MO
tiagabine hydrochloride
4
MO
topiramate IR tabs, IR capsule sprinkles
2
MO
valproate sodium inj
4
valproic acid caps, syrp
2
VIMPAT INJ
4
VIMPAT ORAL SOLN
4
MO
VIMPAT TABS 50MG
4
VIMPAT TABS 100MG, 150MG, 200MG
4
zonisamide
2
MO
donepezil hcl tbdp
3
donepezil hcl tabs 23mg, 5mg
2
PA LA
MO
Antidementia Agents
Drug name
donepezil hcl tabs 10mg
2
ergoloid mesylates tabs
3
PA MO
EXELON PT24
3
galantamine hydrobromide soln
4
galantamine hydrobromide cp24
4
galantamine hydrobromide tabs
4
memantine hcl
2
memantine hcl titration pak
2
memantine hydrochloride soln
2
NAMENDA TITRATION PAK
3
NAMENDA XR
3
NAMENDA XR TITRATION PACK
3
NAMENDA SOLN
3
NAMENDA TABS
3
rivastigmine tartrate
4
rivastigmine transdermal system
3
amitriptyline hcl tabs
2
PA MO
amoxapine
2
MO
BRINTELLIX
4
bupropion hcl er
3
bupropion hcl sr tb12 100mg, 150mg, 200mg
3
bupropion hcl xl
3
bupropion hcl tabs
3
citalopram hydrobromide soln
1
citalopram hydrobromide tabs 10mg
1
1
1
clomipramine hcl caps
3
PA MO
desipramine hcl tabs
3
MO
desvenlafaxine er tb24 100mg, 50mg
4
QL (30 EA per 30 days) ST
doxepin hcl caps, conc
2
PA MO
duloxetine hcl cpep 20mg, 60mg
3
duloxetine hcl cpep 30mg
3
EMSAM
5
escitalopram oxalate soln
4
escitalopram oxalate tabs 20mg
4
Antidepressants
21
Drug name
escitalopram oxalate tabs 10mg, 5mg
4
FETZIMA
4
FETZIMA TITRATION PACK
4
fluoxetine dr
4
fluoxetine hcl caps, soln, tabs
2
MO
fluvoxamine maleate tabs
4
MO
imipramine hcl tabs
2
PA MO
maprotiline hcl
4
MO
MARPLAN
4
MO
mirtazapine
2
MO
mirtazapine odt
4
nefazodone hcl
4
MO
nortriptyline hcl caps, soln
2
MO
olanzapine/fluoxetine
4
paroxetine hcl immediate release tabs
2
MO
paroxetine hcl er tb24 37.5mg
4
paroxetine hcl er tb24 12.5mg, 25mg
4
PAXIL SUSP
4
MO
perphenazine/amitriptyline
4
MO
phenelzine sulfate
3
MO
PRISTIQ TB24 25MG
4
protriptyline hcl
4
MO
sertraline hcl conc, tabs
1
MO
SURMONTIL
4
PA MO
tranylcypromine sulfate
4
MO
trazodone hcl tabs
2
MO
trimipramine maleate caps
4
PA MO
TRINTELLIX
4
venlafaxine hcl
2
MO
venlafaxine hcl er cp24 37.5mg, 75mg
3
venlafaxine hcl er cp24 150mg
3
venlafaxine hcl er tb24 225mg, 37.5mg, 75mg
4
venlafaxine hcl er tb24 150mg
4
VIIBRYD STARTER PACK
4
VIIBRYD TABS
4
VIIBRYD KIT
4
Antiemetics
Drug name
dronabinol caps 2.5mg, 5mg
4
dronabinol caps 10mg
5
EMEND CAPS 40MG
4
QL (1 EA per 30 days) B/D MO
EMEND PAK 125MG, 80MG
4
granisetron hcl tabs
4
meclizine hcl tabs
2
MO
ondansetron hcl tabs
2
MO
ondansetron hcl oral soln
2
ondansetron hcl inj 40mg/20ml, 4mg/2ml
2
MO
ondansetron odt
2
MO
phenadoz supp 25mg
4
PA
phenadoz supp 12.5mg
4
PA MO
phenergan supp
4
PA
promethazine hcl supp 12.5mg, 25mg, 50mg
4
PA MO
promethegan supp 12.5mg, 25mg
4
PA
promethegan supp 50mg
4
PA MO
TRANSDERM-SCOP
4
MO
ABELCET
5
B/D
AMBISOME
5
B/D
amphotericin b
2
B/D MO
CANCIDAS INJ 50MG
5
CANCIDAS INJ 70MG
5
ciclodan crea, soln
4
ciclopirox
4
MO
ciclopirox nail lacquer
4
MO
ciclopirox olamine crea
4
MO
clotrimazole/betamethasone dipropionate
2
MO
clotrimazole crea, soln, troc
2
MO
econazole nitrate crea
3
MO
ERAXIS
5
PA
fluconazole in dextrose
4
fluconazole in nacl
4
fluconazole susr, tabs
3
MO
flucytosine
5
MO
griseofulvin microsize
4
MO
griseofulvin ultramicrosize
4
MO
Antifungals
MO
23
Drug name
itraconazole caps
4
PA MO
ketoconazole crea, sham, tabs
2
MO
MENTAX
4
MO
NOXAFIL INJ
5
PA
NOXAFIL SUSP, TBEC
5
PA MO
nyamyc
2
nystatin/triamcinolone
2
MO
nystatin crea, oint, powd, susp, tabs
2
MO
nystop
2
MO
SPORANOX SOLN
5
PA MO
terbinafine hcl tabs
3
MO
terconazole
2
MO
voriconazole inj
4
voriconazole susr, tabs
5
zazole supp
2
MO
Antigout Agents
allopurinol tabs
1
MO
colchicine caps, tabs
3
MO
COLCRYS
3
MO
probenecid/colchicine
3
MO
probenecid tabs
3
MO
ULORIC
3
ST MO
dihydroergotamine mesylate inj
3
MO
MIGERGOT
4
naratriptan hcl
4
rizatriptan benzoate
4
rizatriptan benzoate odt
4
sumatriptan succinate refill inj 6mg/0.5ml
4
sumatriptan succinate refill inj 4mg/0.5ml
4
sumatriptan succinate tabs
3
sumatriptan succinate inj 6mg/0.5ml
4
sumatriptan succinate inj 4mg/0.5ml
4
sumatriptan spray
3
Antimigraine Agents
Antimyasthenic Agents
guanidine hcl
4
Drug name
MESTINON TIMESPAN
4
MO
MESTINON SYRP
4
MO
pyridostigmine bromide tabs, tbcr
3
MO
Antimycobacterials
CAPASTAT SULFATE
4
cycloserine
4
MO
dapsone tabs
3
MO
ethambutol hcl
4
MO
isoniazid inj
2
isoniazid syrp, tabs
2
MO
PASER
4
MO
PRIFTIN
4
MO
pyrazinamide tabs
4
MO
rifabutin
4
MO
rifampin caps, inj
4
MO
RIFATER
4
MO
SIRTURO
5
TRECATOR
4
MO
Antineoplastics
ABRAXANE
5
adrucil
4
B/D
AFINITOR
5
AFINITOR DISPERZ
5
ALECENSA
5
ALIMTA
5
PA
ALKERAN TABS
4
B/D MO
amifostine
5
anastrozole tabs
2
ARRANON
5
ARZERRA
5
PA LA
AVASTIN
5
PA
azacitidine
5
PA
BELEODAQ
5
PA LA
BENDEKA
5
bexarotene
5
PA
bicalutamide
3
MO
MO
25
Drug name
BICNU
4
BLEO 15K
5
B/D
bleomycin sulfate
4
B/D
BLINCYTO
5
PA LA
BOSULIF
5
PA
BUSULFEX
5
CABOMETYX
5
CAPRELSA TABS 300MG
5
CAPRELSA TABS 100MG
5
carboplatin
4
cisplatin
4
cladribine
2
CLOLAR
5
COMETRIQ KIT 0, 20MG
5
COSMEGEN
5
COTELLIC
5
QL (63 EA per 28 days) PA LA
cyclophosphamide caps
3
B/D MO
cyclophosphamide inj
4
CYRAMZA
5
PA
cytarabine aqueous
4
B/D
dacarbazine
2
DARZALEX
5
daunorubicin hcl
2
DAUNOXOME
5
decitabine
4
DEPOCYT
4
dexrazoxane
4
DOCEFREZ
5
docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml,
200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml,
80mg/8ml
5
doxorubicin hcl
4
doxorubicin hcl liposome
4
DROXIA
4
MO
ELITEK
5
PA
EMCYT
4
MO
EMPLICITI
5
PA
B/D
PA
PA LA
B/D
Drug name
epirubicin hcl inj 200mg/100ml, 50mg/25ml
4
ERBITUX
5
PA
ERIVEDGE
5
ERWINAZE
5
PA
etoposide inj
3
EVOMELA
5
PA
exemestane
4
MO
FARESTON
5
MO
FARYDAK
5
FASLODEX
5
PA
floxuridine
2
B/D
fludarabine phosphate
4
fluorouracil inj 1gm/20ml, 2.5gm/50ml, 5gm/100ml
4
B/D
flutamide
4
MO
FOLOTYN
5
FUSILEV
5
GAZYVA
5
gemcitabine
5
gemcitabine hcl
5
GILOTRIF
5
GLEEVEC TABS 400MG
5
GLEEVEC TABS 100MG
5
GLEOSTINE CAPS 5MG
4
HALAVEN
5
PA
HERCEPTIN
5
PA
HEXALEN
5
MO
hydroxyurea caps
2
MO
IBRANCE
5
ICLUSIG TABS 45MG
5
ICLUSIG TABS 15MG
5
idarubicin hcl
2
ifosfamide
4
ifosfamide/mesna
2
imatinib mesylate tabs 400mg
5
imatinib mesylate tabs 100mg
5
IMBRUVICA
5
INLYTA TABS 5MG
5
PA LA
27
Drug name
INLYTA TABS 1MG
5
INTRON A W/DILUENT
5
PA
INTRON A INJ 10MU/ML, 6000000UNIT/ML
5
PA
IRESSA
5
irinotecan
4
ISTODAX
5
PA
IXEMPRA KIT
5
PA
JAKAFI
5
JEVTANA
5
PA
KADCYLA
5
PA
KEYTRUDA
5
PA LA
LENVIMA 10 MG DAILY DOSE
5
PA
5
PA
5
PA
5
PA
5
PA
5
PA
letrozole
4
MO
leucovorin calcium inj
4
leucovorin calcium tabs
4
MO
LEUKERAN
4
MO
levoleucovorin calcium
5
levoleucovorin inj 50mg
4
levoleucovorin inj 250mg/25ml
5
lomustine
3
LONSURF TABS 6.14MG; 15MG
5
LONSURF TABS 8.19MG; 20MG
5
LYNPARZA
5
MARQIBO
5
PA
MATULANE
5
MEKINIST TABS 0.5MG
5
MEKINIST TABS 2MG
5
melphalan hydrochloride
5
mercaptopurine tabs
4
mesna
4
MESNEX TABS
4
mitomycin
4
MO
MO
Drug name
mitoxantrone hcl
3
MUSTARGEN
4
NEXAVAR
5
NILANDRON
5
MO
nilutamide
5
NINLARO
5
NIPENT
5
ODOMZO
5
ONCASPAR
5
OPDIVO
5
oxaliplatin
5
paclitaxel
4
PANRETIN
5
MO
PERJETA
5
PA LA
POMALYST
5
PORTRAZZA
5
PA
PROLEUKIN
5
PURIXAN
5
PA
REVLIMID
5
RITUXAN
5
PA
SOLTAMOX
4
PA MO
SPRYCEL TABS 100MG, 140MG
5
SPRYCEL TABS 20MG, 50MG, 70MG, 80MG
5
STIVARGA
5
SUTENT CAPS 25MG, 37.5MG, 50MG
5
SUTENT CAPS 12.5MG
5
SYLATRON INJ 200MCG, 300MCG, 600MCG
5
PA
SYLATRON 4-PACK INJ 200MCG, 300MCG
5
PA LA
SYLVANT
5
PA
SYNRIBO
5
PA
TABLOID
4
MO
TAFINLAR CAPS 75MG
5
TAFINLAR CAPS 50MG
5
TAGRISSO
5
tamoxifen citrate tabs
2
MO
TARCEVA TABS 25MG
5
TARCEVA TABS 100MG, 150MG
5
PA LA
29
Drug name
TARGRETIN
5
PA
TASIGNA
5
TECENTRIQ
5
PA
TEMODAR INJ
5
B/D
THALOMID CAPS 100MG, 150MG, 50MG
5
THALOMID CAPS 200MG
5
THERACYS
4
thiotepa
5
TICE BCG
4
toposar
3
topotecan hcl
5
TORISEL
5
TREANDA
5
tretinoin caps 10mg
5
MO
TRISENOX
4
PA
TYKERB
5
UVADEX
4
VALCHLOR
5
VALSTAR
5
VECTIBIX
5
PA
VELCADE
5
PA
VENCLEXTA STARTING PACK
5
VENCLEXTA TABS 10MG, 50MG
4
VENCLEXTA TABS 100MG
5
vinblastine sulfate
2
B/D
vincasar pfs
4
B/D
vincristine sulfate
4
B/D
vinorelbine tartrate
4
VOTRIENT
5
XALKORI
5
XTANDI
5
YERVOY
5
PA
YONDELIS
5
PA
ZALTRAP INJ 100MG/4ML
5
PA
ZALTRAP INJ 200MG/8ML
5
PA LA
ZANOSAR
4
ZELBORAF
5
PA
Drug name
ZOLINZA
5
ZYDELIG
5
ZYKADIA
5
ZYTIGA
5
ALBENZA
4
MO
ALINIA
4
MO
atovaquone
5
PA MO
atovaquone/proguanil hcl
4
MO
chloroquine phosphate tabs
2
MO
COARTEM
4
MO
DARAPRIM
4
MO
hydroxychloroquine sulfate tabs
2
MO
ivermectin tabs
2
MO
lindane lotn, sham
4
MO
malathion lotn
4
MO
mefloquine hcl
2
MO
MEPRON
5
PA MO
NEBUPENT
4
B/D MO
PENTAM 300
4
MO
permethrin crea
2
MO
primaquine phosphate tabs
3
MO
quinine sulfate
4
PA MO
STROMECTOL
3
MO
amantadine hcl caps, syrp, tabs
3
MO
APOKYN
5
PA LA
AZILECT
4
benztropine mesylate tabs
3
PA MO
benztropine mesylate inj
4
PA MO
bromocriptine mesylate caps, tabs
3
MO
carbidopa/levodopa
2
MO
carbidopa/levodopa er
3
MO
carbidopa/levodopa odt
2
MO
carbidopa/levodopa/entacapone
4
MO
carbidopa tabs
3
MO
Antiparasitics
Antiparkinson Agents
31
Drug name
entacapone
4
MO
MIRAPEX ER
3
NEUPRO
4
pramipexole dihydrochloride IR tabs
2
MO
pramipexole dihydrochloride er
3
MO
ropinirole hcl immediate release tabs
2
MO
RYTARY
4
MO
selegiline hcl caps, tabs
3
MO
trihexyphenidyl hcl
2
PA MO
ABILIFY DISCMELT TBDP 15MG
4
ABILIFY DISCMELT TBDP 10MG
4
ABILIFY MAINTENA
4
MO
ABILIFY INJ
4
MO
ABILIFY ORAL SOLN
4
ADASUVE
4
aripiprazole odt tbdp 15mg
4
aripiprazole odt tbdp 10mg
4
aripiprazole tabs
4
aripiprazole soln
4
ARISTADA
4
chlorpromazine hcl inj, tabs
4
clozapine
3
clozapine odt
3
compazine supp
4
compro
4
MO
FANAPT
4
FANAPT TITRATION PACK
4
QL (16 EA per 365 days) ST
FAZACLO
4
ST
fluphenazine decanoate inj
3
MO
fluphenazine hcl conc, elix, inj, tabs
2
MO
GEODON INJ
4
MO
haloperidol decanoate
4
MO
haloperidol lactate
4
MO
haloperidol conc, tabs
2
MO
INVEGA SUSTENNA
4
MO
INVEGA TRINZA
4
Antipsychotics
MO
Drug name
INVEGA TB24 1.5MG, 3MG, 9MG
4
INVEGA TB24 6MG
4
LATUDA
4
loxapine succinate
4
MO
MOLINDONE HYDROCHLORIDE TABS 25MG
3
3
3
NUPLAZID
5
olanzapine odt
4
olanzapine inj
4
MO
olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg
4
olanzapine tabs 2.5mg
4
ORAP
4
MO
paliperidone er tb24 1.5mg, 3mg, 9mg
3
paliperidone er tb24 6mg
3
perphenazine tabs
4
MO
pimozide
4
MO
prochlorperazine sup
4
MO
prochlorperazine edisylate inj
4
MO
prochlorperazine maleate tabs
2
MO
quetiapine fumarate tabs 200mg
4
quetiapine fumarate tabs 25mg
4
quetiapine fumarate tabs 300mg, 400mg
4
quetiapine fumarate tabs 100mg, 50mg
4
REXULTI
4
RISPERDAL CONSTA
4
MO
risperidone odt tbdp 4mg
4
risperidone odt tbdp 1mg, 2mg
4
risperidone odt tbdp 0.25mg, 0.5mg, 3mg
4
risperidone soln
2
MO
risperidone tabs 4mg
2
risperidone tabs 1mg, 2mg
2
risperidone tabs 0.25mg, 0.5mg, 3mg
2
SAPHRIS
4
SEROQUEL XR TB24 50MG
3
SEROQUEL XR TB24 150MG, 200MG
3
SEROQUEL XR TB24 300MG, 400MG
3
33
Drug name
thioridazine hcl tabs
4
PA MO
thiothixene
2
MO
trifluoperazine hcl tabs
4
MO
VERSACLOZ
5
ST
VRAYLAR CPPK
4
VRAYLAR CAPS
5
ziprasidone hcl
4
ZYPREXA RELPREVV INJ 405MG
4
ZYPREXA RELPREVV INJ 210MG, 300MG
4
baclofen tabs
3
MO
dantrolene sodium caps
4
MO
tizanidine hcl tabs
2
MO
abacavir
4
MO
abacavir sulfate/lamivudine/zidovudine
5
MO
acyclovir sodium inj 1000mg, 50mg/ml
4
B/D
acyclovir sodium inj 500mg
4
B/D MO
acyclovir caps, susp, tabs
2
MO
acyclovir oint
4
MO
adefovir dipivoxil
3
APTIVUS SOLN
5
APTIVUS CAPS
5
MO
ATRIPLA
5
BARACLUDE SOLN
4
BARACLUDE TABS
5
COMPLERA
5
CRIXIVAN
3
MO
DENAVIR
4
MO
DESCOVY
5
didanosine
4
MO
EDURANT
5
EMTRIVA
4
MO
entecavir
5
EPCLUSA
5
EPIVIR HBV SOLN
4
MO
Antispasticity Agents
Antivirals
Drug name
EPIVIR SOLN
4
MO
EPZICOM
5
MO
EVOTAZ
5
famciclovir tabs 125mg, 250mg
4
famciclovir tabs 500mg
4
foscarnet sodium
4
B/D
FUZEON
5
ganciclovir inj
2
B/D
GENVOYA
5
HARVONI
5
INTELENCE TABS 25MG
4
INTELENCE TABS 100MG, 200MG
5
INTRON A INJ 18MU, 50MU
5
PA LA
INVIRASE CAPS
4
MO
INVIRASE TABS
5
MO
ISENTRESS PACK
3
ISENTRESS TABS
5
ISENTRESS CHEW 25MG
3
ISENTRESS CHEW 100MG
5
KALETRA SOLN
4
KALETRA TABS 200MG; 50MG
4
KALETRA TABS 100MG; 25MG
4
lamivudine
3
MO
lamivudine/zidovudine
5
MO
LEXIVA SUSP
4
MO
LEXIVA TABS
5
MO
moderiba tabs
3
nevirapine
4
MO
nevirapine er
4
MO
NORVIR
4
MO
ODEFSEY
5
PEG-INTRON REDIPEN
5
PA
PEGINTRON
5
PA
PREZCOBIX
5
PREZISTA SUSP
5
MO
PREZISTA TABS 75MG
4
MO
PREZISTA TABS 150MG, 600MG, 800MG
5
MO
35
Drug name
RELENZA DISKHALER
4
RESCRIPTOR
3
MO
RETROVIR IV INFUSION
4
REYATAZ
5
ribavirin
3
rimantadine hcl
2
MO
SELZENTRY TABS 300MG
5
SELZENTRY TABS 150MG
5
SOVALDI
5
stavudine
4
MO
STRIBILD
5
SUSTIVA
4
MO
TAMIFLU SUSR
4
TAMIFLU CAPS 30MG
4
TAMIFLU CAPS 45MG, 75MG
4
TIVICAY TABS 10MG
4
TIVICAY TABS 25MG
5
TIVICAY TABS 50MG
5
TRIUMEQ
5
TRUVADA TABS 133MG; 200MG
5
TRUVADA TABS 100MG; 150MG, 167MG; 250MG,
200MG; 300MG
5
TYBOST
3
TYZEKA
4
valacyclovir hcl
3
MO
VALCYTE
5
MO
valganciclovir
5
MO
VIDEX PEDIATRIC
4
MO
VIRACEPT
5
MO
VIRAMUNE XR TB24 100MG
4
MO
VIRAMUNE SUSP
4
MO
VIRAZOLE
5
VIREAD
4
MO
VITEKTA
5
ZIAGEN SOLN
4
MO
zidovudine
3
MO
MO
Anxiolytics
Drug name
alprazolam IR tabs 0.25mg, 0.5mg
2
alprazolam IR tabs 1mg, 2mg
2
buspirone hcl tabs
2
MO
clorazepate dipotassium tabs 15mg
4
clorazepate dipotassium tabs 3.75mg, 7.5mg
4
diazepam intensol
4
MO
diazepam inj 5mg/ml
4
diazepam oral soln 1mg/ml
4
diazepam tabs 10mg, 2mg, 5mg
4
duloxetine hcl cpep 40mg
3
lorazepam intensol
3
lorazepam tabs
3
lorazepam inj 4mg/ml
3
lorazepam inj 2mg/ml
3
EQUETRO
4
MO
lithium
2
MO
lithium carbonate er
2
MO
lithium carbonate caps, tabs
2
MO
acarbose
1
MO
AVANDAMET TABS 1000MG; 2MG, 500MG; 4MG
4
AVANDARYL TABS 4MG; 8MG
4
AVANDARYL TABS 1MG; 4MG, 2MG; 4MG
4
AVANDIA TABS 8MG
4
AVANDIA TABS 2MG, 4MG
4
glimepiride
1
MO
glipizide er
1
MO
glipizide xl
1
MO
glipizide/metformin hcl
1
MO
glipizide tabs
1
MO
GLUCAGEN DIAGNOSTIC
3
GLUCAGEN HYPOKIT
3
GLUCAGON EMERGENCY KIT
3
glyburide micronized
4
PA MO
glyburide/metformin hcl
4
PA MO
Bipolar Agents
Blood Glucose Regulators
37
Drug name
glyburide tabs
4
PA MO
INVOKAMET
3
INVOKANA TABS 300MG
3
INVOKANA TABS 100MG
3
JANUMET
3
MO
JANUMET XR
3
MO
JANUVIA
3
MO
JARDIANCE
4
JENTADUETO
3
MO
JENTADUETO XR
3
MO
KORLYM
5
LEVEMIR
3
MO
LEVEMIR FLEXTOUCH
3
MO
metformin hcl er
1
MO
metformin hcl tabs
1
MO
nateglinide
1
MO
NOVOLIN 70/30
3
MO
NOVOLIN 70/30 RELION
3
MO
NOVOLIN N
3
MO
NOVOLIN N RELION
3
MO
NOVOLIN R
3
MO
NOVOLIN R RELION
3
MO
NOVOLOG
3
MO
NOVOLOG FLEXPEN
3
MO
NOVOLOG MIX 70/30
3
MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
3
MO
NOVOLOG PENFILL
3
MO
pioglitazone hcl
1
pioglitazone hcl-glimepiride
1
pioglitazone hcl/metformin hcl
1
PROGLYCEM
4
MO
repaglinide/metformin hydrochloride
1
repaglinide tabs 0.5mg, 1mg
1
repaglinide tabs 2mg
1
SYMLINPEN 120
4
QL (10.8 ML per 30 days) MO
SYMLINPEN 60
4
SYNJARDY
4
Drug name
tolazamide
1
MO
tolbutamide
1
MO
TRADJENTA
3
MO
TRESIBA FLEXTOUCH
3
MO
TRULICITY
3
VICTOZA
3
AGGRENOX
3
anagrelide hydrochloride
2
MO
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML
3
QL (1.2 ML per 28 days) PA
3
3
3
3
ARANESP ALBUMIN FREE INJ 100MCG/ML,
25MCG/ML, 40MCG/ML, 60MCG/ML
3
ARANESP ALBUMIN FREE INJ 500MCG/ML
5
5
5
5
5
ARANESP ALBUMIN FREE INJ 200MCG/ML,
300MCG/ML
5
aspirin/dipyridamole
2
BRILINTA
3
cilostazol
2
MO
clopidogrel tabs 300mg
2
clopidogrel tabs 75mg
2
EFFIENT
3
ELIQUIS TABS 2.5MG
4
ELIQUIS TABS 5MG
4
enoxaparin sodium
4
MO
fondaparinux sodium
4
MO
heparin sodium/d5w
4
heparin sodium/nacl 0.45%
4
heparin sodium/nacl 0.9%
4
heparin sodium/sodium chloride 0.9%
4
Blood Products/Modifiers/Volume Expanders
39
Drug name
heparin sodium/sodium chloride 0.9% premix
4
heparin sodium inj 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/0.5ml, 5000unit/ml
4
MO
jantoven
2
MO
LEUKINE INJ 250MCG
5
PA
NEUMEGA
5
PA
NEUPOGEN
5
PA
PRADAXA
3
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
3
PROCRIT INJ 40000UNIT/ML
5
PROMACTA
5
SAVAYSA
4
ticlopidine hcl
4
PA
tranexamic acid tabs
3
tranexamic acid inj
4
warfarin sodium tabs
1
MO
XARELTO STARTER PACK
3
XARELTO TABS 10MG, 20MG
3
XARELTO TABS 15MG
3
acebutolol hcl caps
3
MO
acetazolamide er
4
MO
acetazolamide tabs
3
MO
afeditab cr
2
ALTOPREV
4
amiloride hcl tabs
2
MO
amiloride/hydrochlorothiazide
2
MO
amiodarone hcl tabs
2
MO
amlodipine besylate/atorvastatin calcium
1
MO
amlodipine besylate/benazepril hydrochloride
1
amlodipine besylate/valsartan
1
amlodipine besylate tabs
1
MO
amlodipine/valsartan/hctz
1
AMTURNIDE TABS 150MG; 5MG; 12.5MG
3
Cardiovascular Agents
AMTURNIDE TABS 300MG; 10MG; 12.5MG, 300MG; 3
10MG; 25MG, 300MG; 5MG; 12.5MG, 300MG; 5MG;
25MG
Drug name
ATACAND
4
ATACAND HCT TABS 32MG; 12.5MG, 32MG; 25MG
4
ATACAND HCT TABS 16MG; 12.5MG
4
atenolol/chlorthalidone
1
MO
atenolol tabs
1
MO
atorvastatin calcium
1
MO
benazepril hcl/hydrochlorothiazide
1
MO
benazepril hcl tabs
1
MO
betaxolol hcl tabs 10mg, 20mg
3
MO
bisoprolol fumarate
2
MO
bisoprolol fumarate/hydrochlorothiazide
2
MO
bumetanide
3
MO
candesartan cilexetil
1
candesartan cilexetil/hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg
1
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg
1
captopril/hydrochlorothiazide
1
MO
captopril tabs
1
MO
cartia xt
2
carvedilol
1
MO
chlorothiazide tabs
2
MO
chlorthalidone tabs 25mg, 50mg
1
MO
cholestyramine light
2
MO
cholestyramine pack, powd
2
MO
clonidine hcl tabs
2
MO
clonidine hcl ptwk
4
CLORPRES
4
MO
colestipol hcl
1
MO
COREG
4
MO
COREG CR
4
CORLANOR
4
PA MO
CRESTOR
3
digitek
2
digox
2
digoxin oral soln, tabs
2
MO
digoxin inj
4
MO
41
Drug name
dilt-xr
2
diltiazem cd cp24 180mg
2
diltiazem cd cp24 120mg, 240mg, 300mg
2
MO
diltiazem hcl cd
2
MO
diltiazem hcl er
2
MO
diltiazem hcl tabs
2
MO
diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml,
50mg/10ml
4
DIOVAN HCT
4
DIOVAN TABS 320MG
4
DIOVAN TABS 160MG, 40MG, 80MG
4
disopyramide phosphate
2
PA MO
dofetilide
4
doxazosin mesylate tabs
3
MO
EDARBI
3
EDARBYCLOR
3
enalapril maleate/hydrochlorothiazide
1
MO
enalapril maleate tabs
1
MO
ENTRESTO
3
eplerenone
4
MO
eprosartan mesylate
1
felodipine er
2
MO
fenofibrate micronized
2
MO
fenofibrate caps
2
MO
fenofibrate tabs 145mg, 160mg, 48mg, 54mg
2
MO
fenofibric acid
2
MO
fenofibric acid dr
2
MO
flecainide acetate
3
MO
fluvastatin
1
MO
fluvastatin sodium er
1
fosinopril sodium
1
MO
fosinopril sodium/hydrochlorothiazide
1
MO
furosemide oral soln, tabs
1
MO
furosemide inj
4
MO
gemfibrozil tabs
1
MO
hydralazine hcl tabs
2
MO
hydralazine hcl inj
4
MO
Drug name
hydrochlorothiazide caps, tabs
1
MO
indapamide
1
MO
irbesartan
1
irbesartan/hydrochlorothiazide
1
isosorbide dinitrate er
2
MO
isosorbide dinitrate tabs
2
MO
isosorbide mononitrate
2
MO
isosorbide mononitrate er
2
MO
isradipine
4
MO
KYNAMRO
5
PA LA
labetalol hcl tabs
2
MO
labetalol hcl inj
4
MO
lidocaine hcl inj 10mg/ml, 20mg/ml
4
MO
lisinopril
1
MO
lisinopril/hydrochlorothiazide
1
MO
losartan potassium/hydrochlorothiazide
1
losartan potassium tabs 100mg
1
losartan potassium tabs 25mg, 50mg
1
lovastatin
1
MO
LOVAZA
4
matzim la
2
MO
methazolamide
4
MO
methyclothiazide tabs
2
MO
metolazone
3
MO
metoprolol succinate er
1
MO
metoprolol tartrate inj, tabs
1
MO
metoprolol/hydrochlorothiazide
2
MO
mexiletine hcl
4
MO
midodrine hcl
4
MO
minitran
3
minoxidil tabs
3
MO
moexipril hcl
1
MO
moexipril/hydrochlorothiazide
1
MO
MULTAQ
3
MO
nadolol/bendroflumethiazide
3
MO
nadolol tabs
3
MO
niacin er
2
MO
43
Drug name
NIASPAN
4
ST MO
nicardipine hcl caps
3
MO
nifedical xl
2
nifedipine er
2
MO
nimodipine caps
4
MO
nisoldipine
4
MO
nisoldipine er
4
MO
nitroglycerin lingual spray
4
MO
nitroglycerin transdermal
2
MO
nitroglycerin inj
4
NITROSTAT
4
MO
NORTHERA
5
PA LA
omega-3-acid ethyl esters
3
pacerone
3
pentoxifylline cr
3
MO
pentoxifylline er
3
MO
perindopril erbumine
1
MO
pindolol
3
MO
PRALUENT
5
pravastatin sodium
1
MO
prazosin hcl
2
MO
prevalite
3
MO
propafenone hcl
4
MO
propafenone hcl er
4
MO
propranolol hcl er
2
MO
propranolol hcl inj
2
propranolol hcl oral soln, tabs
2
MO
propranolol/hydrochlorothiazide
2
MO
quinapril hcl
1
MO
quinapril/hydrochlorothiazide
1
MO
quinidine gluconate cr
4
MO
quinidine gluconate er
4
MO
quinidine sulfate
2
MO
quinidine sulfate er
2
MO
ramipril
1
MO
RANEXA
4
REPATHA
5
Drug name
REPATHA PUSHTRONEX SYSTEM
5
REPATHA SURECLICK
5
rosuvastatin calcium
3
simvastatin tabs 10mg, 20mg, 40mg, 5mg
1
MO
simvastatin tabs 80mg
1
sorine
2
sotalol hcl
2
MO
sotalol hcl (af)
3
MO
spironolactone/hydrochlorothiazide
3
MO
spironolactone tabs
2
MO
taztia xt
2
TEKAMLO TABS 300MG; 10MG, 300MG; 5MG
3
TEKAMLO TABS 150MG; 10MG, 150MG; 5MG
3
TEKTURNA
3
TEKTURNA HCT
3
telmisartan
1
telmisartan/amlodipine
1
telmisartan/hydrochlorothiazide
1
terazosin hcl
2
MO
TIKOSYN
4
timolol maleate tabs 10mg, 20mg, 5mg
1
MO
torsemide tabs
3
MO
trandolapril
1
MO
trandolapril/verapamil hcl
1
MO
trandolapril/verapamil hcl er
1
MO
triamterene/hydrochlorothiazide
1
MO
valsartan
1
MO
valsartan/hydrochlorothiazide
1
VASCEPA
3
MO
verapamil hcl er
2
MO
verapamil hcl sr cp24
2
MO
verapamil hcl sr tbcr 240mg
2
MO
verapamil hcl inj, tabs
2
MO
ZETIA
4
3
Central Nervous System Agents
amphetamine/dextroamphetamine tablet 5mg,
7.5mg, 10mg, 12.5mg, 15mg, 30mg
45
Drug name
amphetamine/dextroamphetamine tablet 20mg
3
AMPYRA
5
COPAXONE INJ 40MG/ML
5
COPAXONE INJ 20MG/ML
5
dextroamphetamine sulfate tabs
4
dextroamphetamine sulfate soln
4
MO
EXTAVIA
5
GILENYA
5
glatopa
5
guanfacine er
4
INTUNIV
4
metadate er
4
methylphenidate hcl er tbcr 10mg, 20mg
4
methylphenidate hcl SR 20mg tab
4
methylphenidate hcl IR tab 5mg, 10mg, 20mg
2
PA MO
NAMZARIC
3
NUEDEXTA
3
riluzole
4
MO
tetrabenazine tabs 25mg
5
tetrabenazine tabs 12.5mg
5
XENAZINE TABS 25MG
5
XENAZINE TABS 12.5MG
5
chlorhexidine gluconate soln
1
MO
clinpro 5000
2
MO
dentagel
2
MO
oralone
2
paroex
2
periogard
2
phos-flur
2
pilocarpine hcl tabs 7.5mg
2
MO
pilocarpine hydrochloride
2
MO
PREVIDENT 5000 BOOSTER
4
MO
PREVIDENT 5000 ENAMEL PROTECT
4
MO
PREVIDENT 5000 PLUS
4
MO
PREVIDENT 5000 SENSITIVE
4
MO
Dental and Oral Agents
Drug name
PREVIDENT FLUORIDE
4
MO
PREVIDENT SOLN
4
MO
sf 1.1% gel
2
MO
triamcinolone acetonide pste 0.1%
2
MO
triamcinolone in orabase
3
MO
Dermatological Agents
8-MOP
4
acitretin
5
PA MO
ALTABAX
4
MO
ammonium lactate crea, lotn
2
MO
amnesteem
4
avita crea
4
PA
avita gel
4
PA MO
AZELEX
4
MO
calcipotriene
4
MO
calcitrene
4
MO
CLARAVIS CAPS 30MG
4
claravis caps 10mg, 20mg, 40mg
4
clindamycin phosphate foam 1%
3
MO
clindamycin phosphate gel 1%
3
MO
clindamycin phosphate lotn 1%
3
MO
clindamycin phosphate external soln 1%
3
MO
clindamycin phosphate swab 1%
3
MO
clindamycin/benzoyl peroxide
4
MO
doxepin hydrochloride
4
MO
ELIDEL
4
QL (60 GM per 30 days) ST MO
ery acne pad
2
MO
erythromycin/benzoyl peroxide
3
MO
erythromycin gel 2%
3
MO
erythromycin pads 2%
3
MO
erythromycin soln 2%
3
MO
fluorouracil crea 0.5%, 5%
4
MO
fluorouracil external soln 2%, 5%
4
MO
gentamicin sulfate crea 0.1%
2
MO
gentamicin sulfate external oint 0.1%
2
MO
imiquimod crea
4
MO
methoxsalen caps
5
MO
47
Drug name
metronidazole crea 0.75%
4
MO
metronidazole gel 0.75%, 1%
4
MO
metronidazole lotn 0.75%
4
MO
mupirocin calcium cream
4
MO
mupirocin oint
2
MO
mupirocin crea
4
MO
myorisan
4
OXSORALEN
4
MO
podofilox soln
4
MO
PROCTOFOAM HC
4
MO
REGRANEX
5
QL (15 GM per 30 days) PA MO
rosadan crea, gel
4
SANTYL
3
MO
selenium sulfide lotn
2
MO
silver sulfadiazine
2
MO
sodium sulfacetamide lotn 10%
4
MO
ssd
2
sulfacetamide sodium susp 10%
4
MO
SULFAMYLON CREA
4
MO
TAZORAC
4
MO
tretinoin crea 0.025%, 0.05%, 0.1%
4
PA MO
tretinoin gel 0.01%, 0.025%, 0.05%
4
PA MO
VEREGEN
4
MO
ZENATANE CAPS 30MG
4
zenatane caps 10mg, 20mg, 40mg
4
ZONALON
4
MO
ADAGEN
5
PA
ALDURAZYME
5
PA LA
BUPHENYL TABS
5
PA
CARBAGLU
4
CEREZYME
5
PA LA
CREON
3
MO
CYSTADANE
5
CYSTAGON
4
PA LA
FABRAZYME
5
PA LA
KUVAN TBSO
5
PA LA
Enzyme Replacement/Modifiers
Drug name
KUVAN PACK 500MG
5
PA
KUVAN PACK 100MG
5
PA LA
LUMIZYME
5
LA
NAGLAZYME
5
PA LA
ORFADIN CAPS 10MG, 2MG, 5MG
5
PA
pancrelipase
2
MO
RAVICTI
5
PA LA
sodium phenylbutyrate powd
5
PA
VPRIV
5
PA
ZAVESCA
5
PA
ZENPEP
3
MO
alosetron hydrochloride
5
AMITIZA
3
cimetidine hcl
3
MO
cimetidine tabs
3
MO
constulose
2
cromolyn sodium conc 100mg/5ml
3
MO
dicyclomine hcl caps, soln, tabs
2
PA MO
diphenatol
2
diphenoxylate/atropine
2
enulose
2
esomeprazole magnesium cpdr
3
esomeprazole sodium inj
3
famotidine premixed
4
famotidine susr
2
famotidine inj 200mg/20ml
2
famotidine inj 20mg/2ml, 40mg/4ml
2
MO
famotidine tabs 20mg, 40mg
2
MO
GATTEX
5
PA LA
gavilyte-c
3
MO
gavilyte-g
3
MO
gavilyte-h
3
MO
gavilyte-n/flavor pack
3
MO
generlac
2
MO
glycopyrrolate tabs
4
MO
Gastrointestinal Agents
MO
MO
49
Drug name
glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml,
4mg/20ml
4
MO
lactulose soln
2
MO
lansoprazole cpdr
3
LINZESS
3
loperamide hcl caps
2
MO
methscopolamine bromide
4
MO
metoclopramide hcl oral soln, tabs
2
MO
metoclopramide hcl inj
4
MO
misoprostol
3
MO
MOVIPREP
4
MO
NEXIUM CAPS, GRANULES
4
nizatidine
2
MO
omeprazole cpdr 20mg
1
MO
1
1
pantoprazole sodium inj
1
pantoprazole sodium tbec 20mg
1
pantoprazole sodium tbec 40mg
1
peg 3350/electrolytes
2
MO
peg-3350/nacl/na bicarbonate/kcl
2
MO
polyethylene glycol 3350 pack, powd
2
MO
PREPOPIK
4
MO
ranitidine hcl caps, syrp
2
MO
ranitidine hcl inj 150mg/6ml
4
ranitidine hcl inj 50mg/2ml
4
MO
ranitidine hcl tabs 150mg, 300mg
2
MO
RELISTOR KIT 12MG/0.6ML
4
PA
RELISTOR INJ 12MG/0.6ML, 8MG/0.4ML
4
PA MO
sucralfate susp, tabs
2
MO
SUPREP BOWEL PREP
4
MO
trilyte
3
MO
ursodiol caps, tabs
3
MO
alfuzosin hcl er
2
AURYXIA
4
MO
AVODART
3
Genitourinary Agents
Drug name
bethanechol chloride tabs
3
MO
calcium acetate caps
3
MO
calcium acetate tabs 667mg
3
MO
DETROL LA
4
dutasteride
3
dutasteride/tamsulosin hydrochloride
3
finasteride tabs 5mg
2
MO
flavoxate hcl
2
MO
FOSRENOL CHEW
4
MO
FOSRENOL PACK 750MG
4
FOSRENOL PACK 1000MG
4
MO
JALYN
3
methylergonovine maleate tab
4
MO
MYRBETRIQ
3
neomycin/polymyxin b sulfates GU irrigant
4
MO
oxybutynin chloride er tb24 5mg
2
oxybutynin chloride er tb24 10mg, 15mg
2
oxybutynin chloride tabs
2
oxybutynin chloride syrp
2
RENVELA
3
MO
RIMSO-50
4
MO
sodium chloride 0.9% GU irrigant
2
MO
tamsulosin hcl
2
MO
THIOLA
3
tolterodine tartrate tab
3
tolterodine tartrate er
4
trospium chloride immediate release tabs
2
VELPHORO
4
MO
VESICARE
3
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort
2
MO
alclometasone dipropionate
3
MO
amcinonide
3
MO
APEXICON E
4
MO
augmented betamethasone dipropionate
2
MO
baycadron
3
betamethasone dipropionate crea, lotn, oint
3
MO
51
Drug name
betamethasone valerate crea, foam, lotn, oint
3
MO
budesonide cpep 3mg
5
MO
clobetasol propionate e
3
MO
clobetasol propionate emollient foam
3
MO
clobetasol propionate crea, foam, gel, liqd, lotn, oint,
sham, soln
3
MO
colocort
4
CORDRAN TAPE
4
cormax scalp application
2
cortisone acetate tabs
2
deltasone
1
desonide crea, lotn, oint
4
MO
desoximetasone crea, gel, oint
4
MO
DEXAMETHASONE INTENSOL
3
MO
dexamethasone sodium phosphate inj 10mg/ml
3
dexamethasone sodium phosphate inj 100mg/10ml,
10mg/ml PF, 120mg/30ml, 20mg/5ml, 4mg/ml
3
MO
dexamethasone elix, soln, tabs
3
MO
diflorasone diacetate
4
MO
fludrocortisone acetate tabs
3
MO
fluocinolone acetonide body
4
MO
fluocinolone acetonide scalp
4
MO
fluocinolone acetonide crea 0.01%, 0.025%
4
MO
fluocinolone acetonide oint 0.025%
4
MO
fluocinolone acetonide soln 0.01%
4
MO
fluocinonide-e
4
fluocinonide crea, gel, oint, soln
4
MO
fluticasone propionate crea 0.05%
3
MO
fluticasone propionate lotn 0.05%
3
MO
fluticasone propionate oint 0.005%
3
MO
halobetasol propionate
3
MO
hydrocortisone butyrate (lipophilic)
3
MO
hydrocortisone butyrate crea, oint, soln
3
MO
hydrocortisone in absorbase
2
MO
hydrocortisone valerate crea, oint
3
MO
hydrocortisone crea 1%, 2.5%
2
MO
hydrocortisone enem, tabs
2
MO
MO
MO
Drug name
hydrocortisone lotn 2.5%
2
MO
hydrocortisone oint 1%, 2.5%
2
MO
methylprednisolone acetate inj
4
MO
methylprednisolone dose pack
2
MO
methylprednisolone sodiumsuccinate
4
MO
methylprednisolone tabs
2
MO
MILLIPRED
4
MO
MILLIPRED DP
4
MO
mometasone furoate crea, oint, soln
2
MO
prednicarbate
2
MO
prednisolone sodium phosphate oral soln 15mg/5ml,
25mg/5ml, 5mg/5ml
2
MO
prednisolone soln, syrp
2
MO
PREDNISONE INTENSOL
4
MO
prednisone soln, tabs, tbpk
1
MO
procto-med hc
3
procto-pak
2
MO
proctosol hc
3
MO
proctozone-hc
3
MO
triamcinolone acetonide aers spray 0.147mg/gm
4
MO
triamcinolone acetonide crea 0.025%, 0.1%, 0.5%
2
MO
triamcinolone acetonide lotn 0.025%, 0.1%
2
MO
triamcinolone acetonide oint 0.025%, 0.1%, 0.5%
2
MO
triderm
2
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate inj, nasal soln, tabs
3
MO
EGRIFTA INJ 2MG
5
EGRIFTA INJ 1MG
5
INCRELEX
5
PA LA
NORDITROPIN FLEXPRO
5
PA
VASOSTRICT
4
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
altavera
4
alyacen 1/35
4
alyacen 7/7/7
4
amethia
4
amethia lo
4
53
Drug name
amethyst
4
ANADROL-50
5
MO
ANDROGEL PUMP GEL 1.62%
3
PA MO
ANDROGEL PUMP GEL 1%
3
ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM
3
PA MO
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM
3
apri
4
aranelle
4
ashlyna
4
aubra
4
aviane
4
azurette
4
balziva
4
bekyree
4
blisovi 24 fe
4
blisovi fe 1.5/30
4
blisovi fe 1/20
4
briellyn
4
camila
4
camrese
4
camrese lo
4
caziant
4
chateal
4
cryselle-28
4
MO
cyclafem 1/35
4
MO
cyclafem 7/7/7
4
MO
cyred
4
danazol caps
4
dasetta 1/35
4
dasetta 7/7/7
4
daysee
4
deblitane
4
delyla
4
DEPO-ESTRADIOL
4
MO
DEPO-PROVERA 400MG/ML
4
MO
desogestrel/ethinyl estradiol
4
MO
drospirenone/ethinyl estradiol
4
MO
MO
MO
MO
Drug name
elinest
4
ELLA
3
emoquette
4
enpresse-28
4
enskyce
4
errin
4
estarylla
4
ESTRACE CREA
4
MO
estradiol/norethindrone acetate
4
PA MO
estradiol tabs
2
PA MO
estradiol ptwk
2
estradiol pttw
2
EVISTA
4
MO
falmina
4
fyavolv tabs 5mcg; 1mg
4
gianvi
4
gildagia
4
gildess 1.5/30
4
MO
gildess 1/20
4
MO
gildess 24 fe
4
gildess fe 1.5/30
4
gildess fe 1/20
4
heather
4
MO
hydroxyprogesterone caproate inj
5
PA
introvale
4
jencycla
4
JINTELI
4
jolessa
4
jolivette
4
juleber
4
junel 1.5/30
4
junel 1/20
4
junel fe 1.5/30
4
MO
junel fe 1/20
4
MO
junel fe 24
4
kaitlib fe
4
kariva
4
MO
PA
PA MO
55
Drug name
kelnor 1/35
4
kimidess
4
kurvelo
4
larin 1.5/30
4
larin 1/20
4
larin 24 fe
4
larin fe 1.5/30
4
larin fe 1/20
4
layolis fe
4
leena
4
lessina
4
levonest
4
levonorgestrel
3
levonorgestrel/ethinyl estradiol
4
levora 0.15/30-28
4
lomedia 24 fe
4
MO
lopreeza
3
PA
loryna
4
MO
low-ogestrel
4
lutera
4
lyza
4
marlissa
4
MO
medroxyprogesterone acetate tabs
2
MO
medroxyprogesterone acetate inj
4
MO
megestrol acetate tabs
3
PA MO
megestrol acetate susp 40mg/ml
3
PA MO
MENEST
4
PA MO
microgestin 1.5/30
4
microgestin 1/20
4
microgestin 24 fe
4
microgestin fe
4
microgestin fe 1.5/30
4
mimvey
4
PA MO
mimvey lo
4
PA MO
mono-linyah
4
mononessa
4
myzilra
4
MO
MO
MO
MO
Drug name
necon 0.5/35-28
4
necon 1/35
4
NECON 1/50-28
4
MO
NECON 10/11-28
4
MO
necon 7/7/7
4
nikki
4
nora-be
4
norethindrone & ethinyl estradiol ferrous fumarate
4
MO
norethindrone acetate/ethinyl estradiol/ferrous
fumarate
4
MO
norethindrone acetate/ethinyl estradiol tabs 20mcg;
1mg
4
MO
norethindrone acetate/ethinyl estradiol tabs 5mcg;
1mg
4
PA MO
norethindrone acetate tabs
3
MO
norethindrone tabs
4
MO
norgestimate/ethinyl estradiol
4
MO
NORINYL 1+50
4
MO
norlyroc
4
nortrel 0.5/35 (28)
4
nortrel 1/35
4
nortrel 7/7/7
4
ocella
4
OGESTREL
4
orsythia
4
oxandrolone tabs 2.5mg
3
oxandrolone tabs 10mg
3
philith
4
pimtrea
4
pirmella 1/35
4
pirmella 7/7/7
4
portia-28
4
MO
previfem
4
MO
progesterone caps, inj
4
MO
quasense
4
raloxifene hydrochloride
1
reclipsen
4
setlakin
4
MO
MO
MO
57
Drug name
sharobel
4
sprintec 28
4
sronyx
4
syeda
4
tarina fe 1/20
4
TESTIM
3
testosterone cypionate inj
4
MO
testosterone enanthate inj
4
MO
TESTOSTERONE GEL 50MG/5GM
3
QL (300 GM per 30 days) PA
testosterone gel 1%, 25mg/2.5gm
3
tilia fe
4
tri-estarylla
4
tri-legest fe
4
tri-linyah
4
tri-lo-estarylla
4
tri-lo-marzia
4
tri-lo-sprintec
4
tri-previfem
4
tri-sprintec
4
trinessa
4
trinessa lo
4
trivora-28
4
VAGIFEM
3
MO
velivet
4
MO
vestura
4
vienva
4
viorele
4
MO
vyfemla
4
MO
wera
4
wymzya fe
4
zarah
4
zenchent
4
zenchent fe
4
zovia 1/35e
4
ZOVIA 1/50E
4
MO
MO
MO
MO
MO
MO
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium inj, tabs
1
MO
Drug name
levoxyl
2
MO
liothyronine sodium tabs
3
MO
SYNTHROID
3
MO
THYROLAR-1
4
MO
THYROLAR-1/2
4
MO
THYROLAR-1/4
4
MO
THYROLAR-2
4
MO
THYROLAR-3
4
MO
unithroid
2
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
3
MO
SENSIPAR TABS 30MG
3
SENSIPAR TABS 90MG
5
SENSIPAR TABS 60MG
5
cabergoline
4
MO
FIRMAGON INJ 80MG
4
PA
FIRMAGON INJ 120MG
5
PA
leuprolide acetate inj
3
PA
LUPRON DEPOT
5
PA
LUPRON DEPOT-PED
5
PA
octreotide acetate
4
PA
SIGNIFOR
5
SOMATULINE DEPOT INJ 60MG/0.2ML
5
5
5
SOMAVERT
5
PA LA
SYNAREL
5
MO
TRELSTAR MIXJECT
5
PA
VANTAS
4
ZOLADEX
4
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Thyroid)
methimazole tabs
2
MO
propylthiouracil tabs
3
MO
59
Drug name
Immunological Agents
ACTHIB
4
ACTIMMUNE
5
ADACEL
4
ARCALYST
5
PA LA
ATGAM
5
PA
AZASAN
4
B/D MO
azathioprine tabs
2
B/D MO
azathioprine inj
4
B/D
bcg vaccine
2
BENLYSTA
5
BEXSERO
4
BOOSTRIX
4
CELLCEPT INTRAVENOUS
4
PA
CELLCEPT SUSR
5
PA MO
CERVARIX
4
CIMZIA
5
CIMZIA STARTER KIT
5
CINRYZE
5
PA LA
COMVAX
4
cyclosporine modified
3
PA MO
cyclosporine caps
3
PA MO
cyclosporine inj
4
PA
DAPTACEL
4
diphtheria/tetanus toxoids adsorbed pediatric
2
ENGERIX-B
3
B/D
ENVARSUS XR
4
PA MO
FIRAZYR
5
QL (270 ML per 30 days) PA LA
GAMASTAN S/D
3
PA
GAMMAPLEX INJ 10GM/200ML
5
PA
GAMMAPLEX INJ 2.5GM/50ML, 20GM/400ML,
5GM/100ML
5
PA LA
GAMUNEX-C
5
PA
GARDASIL
4
GARDASIL 9
4
gengraf caps
4
PA
gengraf soln
4
PA MO
PA LA
PA
Drug name
HAVRIX
4
hecoria
4
HIBERIX
4
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK
5
HUMIRA PEN
5
HUMIRA PEN-CROHNS DISEASE STARTER
5
HUMIRA PEN-PSORIASIS STARTER
5
HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML
5
HUMIRA INJ 40MG/0.8ML
5
HYPERTET S/D
4
B/D
ILARIS
5
IMOVAX RABIES (H.D.C.V.)
4
B/D
INFANRIX
4
IPOL INACTIVATED IPV
3
IXIARO
4
KINRIX
4
leflunomide
2
M-M-R II
3
MENACTRA
4
MENHIBRIX
4
MENOMUNE-A/C/Y/W-135
3
MENVEO
4
methotrexate sodium inj 1gm/40ml, 1gm,
250mg/10ml
2
methotrexate tabs
2
MO
mycophenolate mofetil caps, tabs
4
PA MO
mycophenolate mofetil susr
5
PA MO
NULOJIX
5
PA
OTREXUP
4
ST
PEDIARIX
4
PEDVAX HIB
4
PENTACEL
4
PROGRAF INJ
4
PROQUAD
4
QUADRACEL
4
RABAVERT
4
PA
MO
PA
B/D
61
Drug name
RAPAMUNE SOLN
4
PA MO
RASUVO
4
ST
RECOMBIVAX HB
4
B/D
REMICADE
5
PA
RIDAURA
4
MO
ROTARIX
4
ROTATEQ
3
SANDIMMUNE SOLN
4
PA MO
SIMULECT
5
B/D
sirolimus tabs
4
PA MO
SYNAGIS
5
PA
tacrolimus caps
4
PA MO
TENIVAC
4
tetanus/diphtheria toxoids-adsorbed
3
THYMOGLOBULIN
5
B/D
TREXALL
4
B/D MO
TRUMENBA
4
TWINRIX
4
TYPHIM VI
4
VAQTA
4
VARIVAX
3
YF-VAX
3
ZORTRESS TABS 0.25MG
4
PA MO
ZORTRESS TABS 0.5MG, 0.75MG
5
PA MO
ZOSTAVAX
4
APRISO
3
MO
ASACOL HD
4
MO
balsalazide disodium
2
MO
DELZICOL
4
MO
LIALDA
4
MO
mesalamine dr
4
mesalamine enem, kit
4
MO
PENTASA
4
MO
sulfasalazine tabs, tbec
2
MO
sulfazine
2
sulfazine ec
2
Inflammatory Bowel Disease Agents
Drug name
Metabolic Bone Disease Agents
ACTONEL TABS 150MG
4
alendronate sodium soln
1
MO
alendronate sodium tabs 10mg, 40mg, 5mg
1
alendronate sodium tabs 35mg, 70mg
1
calcitonin-salmon
2
MO
calcitriol inj
2
calcitriol caps, oral soln
2
MO
doxercalciferol caps
4
MO
etidronate disodium
3
MO
FORTEO
5
FORTICAL
4
MO
FOSAMAX PLUS D
4
ibandronate sodium tabs
1
ibandronate sodium inj
1
MIACALCIN INJ
4
MO
pamidronate disodium
4
paricalcitol caps
3
paricalcitol inj 2mcg/ml
2
paricalcitol inj 5mcg/ml
3
PROLIA
4
risedronate sodium dr
2
risedronate sodium tabs 150mg
2
risedronate sodium tabs 35mg
2
risedronate sodium tabs 30mg, 5mg
2
XGEVA
5
PA
zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml
4
MO
Miscellaneous Therapeutic Agents
ALCOHOL PREP PADS
3
MO
BD INSULIN SYRINGE SAFETYGLIDE/1ML/
29G X 1/2”
3
MO
BD INSULIN SYRINGE ULTRAFINE/0.3ML/
31G X 5/16”
3
MO
BD INSULIN SYRINGE ULTRAFINE/0.5ML/
30G X 1/2”
3
MO
BD INSULIN SYRINGE ULTRAFINE/1ML/
31G X 5/16”
3
MO
63
Drug name
BD PEN NEEDLE/ULTRAFINE/
29G X 12.7M
3
MO
CURITY GAUZE PADS 2”X2”
3
MO
FERRIPROX SOLN 100MG/ML
5
PA
NATPARA
5
ORFADIN SUSP 4MG/ML
5
PA
V-GO 20
3
MO
V-GO 30
3
MO
V-GO 40
3
MO
ACUVAIL
4
MO
ak-poly-bac
2
ALPHAGAN P SOLN 0.1%
3
MO
ALREX
3
MO
apraclonidine
2
MO
atropine sulfate soln
2
MO
AZASITE
3
MO
azelastine hcl ophthalmic soln 0.05%
2
MO
AZOPT
3
MO
bacitracin/neomycin/polymyxin
3
MO
bacitracin/polymyxin b
2
MO
bacitracin oint 500unit/gm
2
MO
BESIVANCE
4
MO
betaxolol hcl soln 0.5%
1
MO
BETIMOL
4
MO
BETOPTIC-S
4
MO
BLEPHAMIDE
4
MO
BLEPHAMIDE S.O.P.
4
MO
brimonidine tartrate
2
MO
carteolol hcl
1
MO
CILOXAN OINT
4
MO
ciprofloxacin hcl soln 0.3%
3
MO
COMBIGAN
3
MO
cromolyn sodium soln 4%
3
MO
CYSTARAN
5
dexamethasone sodium phosphate ophthalmic soln
0.1%
2
MO
Ophthalmic Agents
Drug name
dorzolamide hcl
1
MO
dorzolamide hcl/timolol maleate
1
MO
DUREZOL
4
MO
epinastine hcl
2
MO
erythromycin oint 5mg/gm
3
MO
fluorometholone
2
MO
flurbiprofen sodium
2
MO
gentak
2
MO
gentamicin sulfate ophthalmic oint 0.3%
2
MO
gentamicin sulfate ophthalmic soln 0.3%
2
MO
ILEVRO
4
MO
ISOPTO CARPINE
4
MO
ketorolac tromethamine
2
MO
latanoprost
1
MO
levobunolol hcl
1
MO
levofloxacin ophthalmic soln 0.5%
3
MO
LOTEMAX
3
MO
LUMIGAN
3
MO
metipranolol
1
MO
MOXEZA
4
MO
naphazoline hcl
2
MO
neo-polycin
2
neomycin/bacitracin/polymyxin
3
MO
neomycin/polymyxin/bacitracin/hydrocortisone
3
MO
neomycin/polymyxin/dexamethasone susp
2
MO
neomycin/polymyxin/dexamethasone oint
3
MO
neomycin/polymyxin/gramicidin
3
MO
neomycin/polymyxin/hydrocortisone ophthalmic susp 2
1%; 3.5mg/ml; 10000unit/ml
MO
NEVANAC
4
MO
ofloxacin ophthalmic soln 0.3%
2
MO
olopatadine hcl ophthalmic soln 0.1%
4
MO
PATADAY
4
MO
PATANOL
4
MO
PAZEO
4
MO
PHOSPHOLINE IODIDE
4
pilocarpine hcl soln 1%, 2%, 4%
2
MO
65
Drug name
polycin
2
polymyxin b sulfate/trimethoprim sulfate
2
MO
PRED-G
4
MO
PRED-G S.O.P.
4
MO
prednisolone acetate
2
MO
prednisolone sodium phosphate ophthalmic soln 1%
2
MO
PROLENSA
4
MO
proparacaine hcl
2
MO
RESTASIS
3
MO
SIMBRINZA
4
MO
sodium sulfacetamide soln 10%
2
MO
sulfacetamide sodium/prednisolone sodium
phosphate
2
MO
sulfacetamide sodium oint 10%
4
MO
sulfacetamide sodium soln 10%
4
MO
timolol maleate ophthalmic gel forming
1
MO
timolol maleate soln 0.25%, 0.5%
1
MO
TOBRADEX
4
MO
TOBRADEX ST
4
MO
tobramycin sulfate ophthalmic soln 0.3%
2
MO
tobramycin/dexamethasone
2
MO
TOBREX OINT
4
MO
TRAVATAN Z
4
MO
travoprost
3
MO
trifluridine
4
MO
trimethoprim sulfate/polymyxin b sulfate
2
MO
triple antibiotic
2
VIGAMOX
4
MO
ZIRGAN
4
MO
ZYLET
3
MO
Otic Agents
acetasol hc
4
acetic acid
2
MO
acetic acid/aluminum acetate
2
MO
antibiotic ear
2
CIPRODEX
4
MO
fluocinolone acetonide oil 0.01%
4
MO
Drug name
hydrocortisone/acetic acid
4
MO
neomycin/polymyxin/hc
2
MO
neomycin/polymyxin/hydrocortisone otic susp 1%;
3.5mg/ml; 10000unit/ml
2
MO
ofloxacin otic soln 0.3%
2
MO
Respiratory Tract/Pulmonary Agents
acetylcysteine inj
2
acetylcysteine inhalation soln
2
B/D MO
ADEMPAS
5
ADVAIR DISKUS
3
ADVAIR HFA
3
albuterol sulfate er
3
MO
albuterol sulfate nebu
3
B/D MO
albuterol sulfate syrp, tabs
3
MO
aminophylline
2
MO
ANORO ELLIPTA
3
ARCAPTA NEOHALER
4
ASMANEX HFA
3
ASMANEX TWISTHALER 120 METERED DOSES
3
3
3
3
3
ATROVENT HFA
4
QL (25.8 GM per 30 days) MO
azelastine hcl nasal soln 0.15%
2
MO
azelastine hcl nasal soln 0.1%
2
BREO ELLIPTA
4
budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml,
1mg/2ml
4
B/D MO
budesonide nasal susp 32mcg/act
4
MO
CAYSTON
5
clemastine fumarate syrp
4
PA
clemastine fumarate tabs 2.68mg
4
PA MO
COMBIVENT RESPIMAT
3
cromolyn sodium nebu 20mg/2ml
3
B/D MO
DALIRESP
4
DIPHENHYDRAMINE HCL INJ
4
PA MO
67
Drug name
EPIPEN 2-PAK
3
EPIPEN-JR 2-PAK
3
epoprostenol sodium
3
PA LA
ESBRIET
5
FLOVENT DISKUS AEPB 250MCG/BLIST
3
FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/
BLIST
3
FLOVENT HFA AERO 44MCG/ACT
3
FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT
3
flunisolide
2
MO
fluticasone propionate susp 50mcg/act
2
MO
FORADIL AEROLIZER
3
hydroxyzine hcl inj
4
PA MO
INCRUSE ELLIPTA
3
ipratropium bromide/albuterol sulfate
3
B/D MO
ipratropium bromide inhalation soln
2
B/D MO
ipratropium bromide nasal soln
2
MO
KALYDECO PACK
5
KALYDECO TABS
5
LETAIRIS
5
levalbuterol nebu
4
B/D MO
levocetirizine dihydrochloride tabs
4
levocetirizine dihydrochloride soln
4
metaproterenol sulfate syrp, tabs
2
MO
montelukast sodium
3
NASONEX
3
OFEV
5
olopatadine hcl nasal soln 0.6%
4
OPSUMIT
5
ORKAMBI
5
PATANASE
4
PERFOROMIST
4
QL (120 ML per 30 days) B/D MO
PROAIR HFA
3
PROAIR RESPICLICK
3
PROLASTIN-C
5
PA MO
promethazine hcl tabs 12.5mg, 25mg, 50mg
4
PA MO
PULMOZYME
5
B/D
Drug name
QVAR
3
SEREVENT DISKUS
4
sildenafil tabs 20mg
3
SPIRIVA HANDIHALER
3
SPIRIVA RESPIMAT
3
STIOLTO RESPIMAT
3
STRIVERDI RESPIMAT
3
SYMBICORT
3
terbutaline sulfate tabs
2
MO
THEO-24
4
MO
theophylline elix
4
MO
theophylline cr tb12 100mg, 200mg
2
MO
theophylline er
2
MO
tobramycin nebu
5
QL (280 ML per 56 days) B/D
TRACLEER
5
triamcinolone acetonide aero 55mcg/act
3
MO
TYZINE PEDIATRIC NASAL DROPS
4
VENTAVIS
5
PA LA
VENTOLIN HFA
3
XOLAIR
5
zafirlukast
4
chlorzoxazone
4
cyclobenzaprine hcl tabs
3
armodafinil
3
HETLIOZ
5
modafinil tabs 100mg
3
modafinil tabs 200mg
3
ROZEREM
4
SILENOR
3
XYREM
5
zaleplon caps 5mg
3
zaleplon caps 10mg
3
zolpidem tartrate immediate release tabs
4
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/Minerals/Electrolytes
69
Drug name
AMINOSYN
4
B/D
AMINOSYN 7%/ELECTROLYTES
4
B/D
aminosyn 8.5%/electrolytes
4
B/D
AMINOSYN II
4
B/D
aminosyn ii 8.5%/electrolytes
4
B/D
AMINOSYN M
4
B/D
AMINOSYN-HBC
4
B/D
AMINOSYN-PF
4
B/D
AMINOSYN-PF 7%
4
B/D
AMINOSYN-RF
4
B/D
BAL-CARE DHA
4
MO
CALCIUM PNV
4
MO
CITRANATAL 90 DHA
4
MO
CITRANATAL ASSURE
4
MO
CITRANATAL B-CALM
4
MO
CITRANATAL DHA
4
MO
CITRANATAL RX TABS 120MG; 125MG; 400UNIT;
4
2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 25MG
MO
clinisol sf 15%
4
B/D
COMPLETE NATAL DHA
4
MO
COMPLETENATE
4
MO
CONCEPT DHA
4
MO
CONCEPT OB
4
MO
CUPRIMINE
5
MO
DEPEN TITRATABS
4
MO
dextrose 10%/nacl 0.45%
4
dextrose 5% /electrolyte #48 viaflex
4
dextrose 10%
2
4
dextrose 2.5%/nacl 0.45%
4
dextrose 20%
2
B/D
dextrose 25%
2
B/D
dextrose 30%
2
B/D
dextrose 40%
2
B/D
dextrose 5%
2
MO
dextrose 5%/lactated ringers
4
4
B/D
Drug name
4
4
4
4
4
dextrose 5%/potassium chloride 0.15%
4
dextrose 50%
2
B/D
dextrose 70%
2
B/D
ESCAVITE
4
ESCAVITE D
4
ESCAVITE LQ
4
EXJADE
5
PA LA
EXTRA-VIRT PLUS DHA
4
MO
FERRIPROX TABS 500MG
5
PA
FLORIVA LIQD
4
MO
floriva chew
4
fluor-a-day soln
4
fluoride chew 1.1mg, 2.2mg
4
MO
fluoridex daily defense
2
MO
fluoritab chew 0.5mg, 1mg, 2.2mg
4
fluoritab soln
4
FLURA-DROPS SOLN 0.25MG/DROP
4
MO
FOCALGIN 90 DHA
4
MO
FOCALGIN CA
4
MO
FOCALGIN-B
4
FOLCAL DHA
4
MO
FOLCAPS OMEGA 3
4
MO
FOLET DHA
4
FOLET ONE
4
MO
FOLIVANE-OB
4
MO
FOLIVANE-PRX DHA NF
4
MO
fomepizole
5
HEMENATAL OB
4
MO
HEMENATAL OB + DHA
4
MO
hepatamine
4
B/D
INATAL ADVANCE
4
INATAL ULTRA
4
MO
71
Drug name
INTRALIPID INJ 30GM/100ML
4
B/D
intralipid inj 20gm/100ml
4
B/D
k-sol
2
MO
KABIVEN
4
B/D
kcl 0.075%/d5w/nacl 0.45%
4
kcl 0.15%/d5w/lr
4
kcl 0.15%/d5w/nacl 0.2%
4
kcl 0.15%/d5w/nacl 0.225%
4
kcl 0.15%/d5w/nacl 0.45%
4
kcl 0.15%/d5w/nacl 0.9%
4
kcl 0.3%/d5w/lr iv lac ring
4
kcl 0.3%/d5w/nacl 0.45%
4
kcl 0.3%/d5w/nacl 0.9%
4
kionex powd
4
kionex susp
4
MO
klor-con
2
MO
klor-con 10
2
MO
KLOR-CON 25
4
MO
klor-con 8
2
MO
klor-con m10
2
KLOR-CON M15
4
MO
klor-con m20
2
MO
klor-con sprinkle
2
MO
klor-con/ef
2
MO
lactated ringers dextrose 5% viaflex
4
lactated ringers viaflex
4
levocarnitine tabs
3
MO
LIPOSYN III
4
B/D
ludent chew 0.5mg, 1mg
4
MO
magnesium sulfate inj 50%
4
MO
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg;
2500unit; 15unit
4
MO
multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
4
0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit;
2500unit
MO
Drug name
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
5unit/ml; 1500unit/ml
4
MO
multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml;
10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml;
0.5mg/ml; 5unit/ml; 1500unit/ml
4
MO
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/
ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 1500unit/ml
4
MO
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml;
2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 0.5mg/ml; 1500unit/ml
4
MO
multivitamin with fluoride chew 60mg; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg;
2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit;
400unit; 15unit
4
MO
mvc-fluoride
4
MO
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT;
12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0;
2MG; 20UNIT
4
NATALVIRT 90 DHA
4
MO
NATALVIRT CA
4
MO
NATELLE ONE
4
MO
NEPHRAMINE
4
B/D
NESTABS
4
MO
NESTABS DHA
4
MO
NEXA PLUS
4
MO
NIVA-PLUS
4
MO
NORMOSOL -R
4
NORMOSOL-R
4
NORMOSOL-R IN D5W
4
O-CAL PRENATAL
4
MO
OB COMPLETE GOLD
4
MO
OB COMPLETE ONE
4
MO
OB COMPLETE PETITE
4
MO
OB COMPLETE PREMIER
4
MO
OB COMPLETE/DHA
4
MO
PAIRE OB
4
MO
PERIKABIVEN
4
B/D
73
Drug name
physiolyte
2
physiosol irrigation
2
plenamine
4
B/D
PNV FERROUS FUMARATE/DOCUSATE/FOLIC
ACID
4
MO
PNV FOLIC ACID + IRON MULTIVITAMIN
4
MO
PNV OB+DHA
4
PNV PRENATAL PLUS MULTIVITAMIN
4
MO
PNV TABS 29-1
4
MO
PNV-DHA
4
MO
PNV-SELECT
4
MO
PNV-VP-U
4
MO
poly-vitamin/fluoride chew
4
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ 4
ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/
ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml
potassium chloride 0.15% /nacl 0.45% viaflex
2
potassium chloride 0.15% d5w/nacl 0.33%
4
4
potassium chloride 0.15% d5w/nacl 0.45% viaflex
4
potassium chloride 0.15% nacl 0.9%
4
4
potassium chloride 0.224%d5w/nacl 0.45% viaflex
4
potassium chloride 0.3%/ nacl 0.9%
4
potassium chloride 0.3%/d5w
4
potassium chloride cr tbcr 10meq, 20meq
2
MO
potassium chloride er
2
MO
potassium chloride sr
2
MO
potassium chloride oral soln
2
MO
potassium chloride inj 10meq/50ml, 20meq/100ml,
40meq/100ml
4
potassium chloride inj 0.4meq/ml, 10meq/100ml,
2meq/ml
4
MO
potassium citrate er
4
MO
PR NATAL 400
4
MO
PR NATAL 400 EC
4
MO
PR NATAL 430
4
MO
PR NATAL 430 EC
4
MO
MO
Drug name
PREFERA OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG;
6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG;
50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG
4
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 34MG; 0; 17MG; 0;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG
4
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG
4
MO
PREFERAOB +DHA
4
MO
PREFERAOB ONE
4
MO
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML
4
B/D
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml;
840mg/100ml; 490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml; 230mg/100ml;
5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml
4
B/D
PRENAISSANCE
4
MO
PRENAISSANCE PLUS
4
MO
PRENATA
4
MO
PRENATABS FA
4
MO
PRENATABS OBN
4
PRENATAL 19 CHEW 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 29MG; 1MG; 15MG; 20MG;
3MG; 3MG; 30UNIT; 20MG
4
MO
PRENATAL 19 TABS 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 25MG; 29MG; 1MG; 15MG;
20MG; 3MG; 3MG; 30UNIT; 20MG
4
MO
PRENATAL PLUS IRON TABS 120MG; 0; 200MG;
4
400UNIT; 2MG; 12MCG; 1MG; 29MG; 20MG; 10MG;
3MG; 1.84MG; 22UNIT; 4000UNIT; 25MG
MO
PRENATAL PLUS TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG;
3MG; 1.84MG; 22MG; 4000UNIT; 25MG
4
PRENATE AM
4
MO
MO
75
Drug name
PRENATE DHA CAPS 90MG; 145MG; 220UNIT;
4
13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG;
26MG; 10UNIT
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG;
100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG;
400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG;
3.5MG; 3MG; 10UNIT; 15MG
4
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG;
0; 400MCG; 600MCG; 50MG; 150MCG; 26MG;
10UNIT
4
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG; 300MG;
40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG;
10UNIT
4
PRENATE MINI CAPS 60MG; 280MCG; 100MG;
220UNIT; 13MCG; 350MG; 400MCG; 29MG;
600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG
4
PRENATE MINI CAPS 600MCG; 60MG; 280MCG;
80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG;
18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG
4
MO
PRENATE PIXIE
4
MO
PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG;
12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG
4
MO
PREQUE 10
4
MO
PRETAB
4
PUREFE OB PLUS
4
QUFLORA PEDIATRIC SOLN 0.5MG/ML
4
QUFLORA PEDIATRIC SOLN 0.25MG/ML
4
MO
RELNATE DHA
4
MO
ringers injection
2
SAMSCA TABS 15MG
5
SAMSCA TABS 30MG
5
SE-NATAL 19
4
MO
SE-TAN DHA
4
MO
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
4
0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG;
0; 1.6MG; 30UNIT; 1700UNIT; 15MG
MO
SETON ET-EC
4
SETONET
4
MO
Drug name
sodium bicarbonate inj 4.2%
4
MO
sodium bicarbonate inj 8.4%
4
MO
sodium chloride 0.45% viaflex
4
sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%
4
MO
sodium fluoride chew 0.5mg, 1.1mg, 1mg
4
MO
sodium polystyrene sulfonate oral susp
3
MO
sodium polystyrene sulfonate rectal susp
4
sodium polystyrene sulfonate powd
4
MO
sterile water irrigation
2
MO
SYPRINE
5
MO
TARON-PREX
4
MO
thrivite rx
4
MO
TL FOLATE
4
TL-CARE DHA
4
MO
TL-SELECT
4
MO
tpn electrolytes
4
tri-vit/fluoride
4
MO
TRI-VIT/FLUORIDE/IRON
4
MO
tri-vitamin/fluoride
4
MO
TRIADVANCE
4
TRICARE
4
MO
TRICARE PRENATAL COMPLEAT
4
MO
TRICARE PRENATAL DHA ONE
4
MO
TRINATAL GT
4
MO
TRINATAL RX 1
4
MO
triple-vitamin/fluoride
4
MO
TRISTART DHA
4
MO
TRIVEEN-DUO DHA
4
MO
TRIVEEN-PRX RNF
4
MO
ULTIMATECARE ONE NF
4
MO
VEMAVITE-PRX 2
4
MO
VENA-BAL DHA
4
MO
VIRT-ADVANCE
4
MO
VIRT-C DHA
4
MO
VIRT-CARE ONE
4
MO
VIRT-PN
4
MO
77
Drug name
VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT;
4
12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG;
25MG; 10UNIT
MO
VIRT-PN PLUS
4
MO
VIRT-SELECT
4
MO
VITAFOL FE+
4
MO
VITAFOL GUMMIES
4
MO
VITAFOL-ONE
4
MO
VITAMEDMD ONE RX/QUATREFOLIC
4
MO
VITAMEDMD PLUS RX/QUATRE FOLIC
4
MO
vitamins a/d/c/fluoride
4
VOL-NATE
4
MO
VOL-PLUS
4
MO
VP CH ULTRA
4
MO
VP-CH-PNV
4
MO
VP-HEME OB
4
MO
VP-HEME ONE
4
MO
VP-PNV-DHA
4
MO
ZATEAN-CH
4
MO
ZATEAN-PN
4
MO
ZATEAN-PN DHA
4
MO
ZATEAN-PN PLUS
4
MO
ENBRACE HR
4
MO
PROVIDA DHA
4
Unclassified
Index
Drug name Page
Drug name Page
Drug name Page
8-MOP 47
ADVAIR HFA 67
amethyst 54
abacavir 34
afeditab cr 40
amifostine 25
abacavir sulfate/ 34
lamivudine/zidovudine
AFINITOR 25
amikacin sulfate 14
AFINITOR DISPERZ 25
amiloride hcl 40
ABELCET 23
AGGRENOX 39
ABILIFY 32
a-hydrocort 51
amiloride/ 40
hydrochlorothiazide
ABILIFY DISCMELT 32
ak-poly-bac 64
aminophylline 67
ABILIFY MAINTENA 32
ALBENZA 31
AMINOSYN 70
ABRAXANE 25
albuterol sulfate 67
acamprosate calcium dr 13
albuterol sulfate er 67
AMINOSYN 7%/ 70
ELECTROLYTES
acarbose 37
acebutolol hcl 40
alclometasone 51
dipropionate
acetaminophen/codeine 10
ALCOHOL PREP PADS 63
acetaminophen/codeine 10
#3
ALDURAZYME 48
acetasol hc 66
alendronate sodium 63
acetazolamide 40
alfuzosin hcl er 50
acetazolamide er 40
ALIMTA 25
acetic acid 66
ALINIA 31
acetic acid/aluminum 66
acetate
ALKERAN 25
acetylcysteine 67
acitretin 47
ACTHIB 60
ACTIMMUNE 60
ACTONEL 63
ACUVAIL 64
acyclovir 34
acyclovir sodium 34
ADACEL 60
ADAGEN 48
ADASUVE 32
adefovir dipivoxil 34
ADEMPAS 67
adrucil 25
ADVAIR DISKUS 67
ALECENSA 25
allopurinol 24
alosetron hydrochloride 49
ALPHAGAN P 64
alprazolam
ALREX 64
ALTABAX 47
altavera 53
ALTOPREV 40
alyacen 1/35 53
alyacen 7/7/7 53
amantadine hcl 31
AMBISOME 23
amcinonide 51
amethia 53
amethia lo 53
aminosyn 8.5%/ 70
electrolytes
AMINOSYN II 70
aminosyn ii 8.5%/ 70
electrolytes
AMINOSYN M 70
AMINOSYN-HBC 70
AMINOSYN-PF 70
AMINOSYN-PF 7% 70
AMINOSYN-RF 70
amiodarone hcl 40
AMITIZA 49
amitriptyline hcl 21
amlodipine besylate 40
amlodipine besylate/ 40
atorvastatin calcium
benazepril hydrochloride
valsartan
amlodipine/valsartan/ 40
hctz
ammonium lactate 47
amnesteem 47
amoxapine 21
amoxicillin 14
79
Drug name Page
amoxicillin/clavulanate 14
potassium
amoxicillin/clavulanate 14
potassium er
amphetamine/
dextroamphetamine
amphotericin b 23
ampicillin 14
ampicillin sodium
ampicillin-sulbactam 14
AMPYRA 46
AMTURNIDE 40
ANADROL-50 54
anagrelide hydrochloride 39
anastrozole 25
ANDROGEL 54
ANDROGEL PUMP 54
Drug name Page
ashlyna 54
AVODART 50
ASMANEX HFA 67
azacitidine 25
ASMANEX 67
TWISTHALER 120
METERED DOSES
AZASAN 60
ASMANEX 67
TWISTHALER 14
METERED DOSES
ASMANEX 67
TWISTHALER 30
METERED DOSES
ASMANEX 67
TWISTHALER 60
METERED DOSES
ASMANEX 67
TWISTHALER 7
METERED DOSES
aspirin/dipyridamole 39
ATACAND 41
AZASITE 64
azathioprine 60
azelastine hcl 64
azelastine hcl 67
AZELEX 47
AZILECT 31
azithromycin 14
AZOPT 64
aztreonam 14
azurette 54
baciim 14
bacitracin 14
bacitracin 64
ATACAND HCT 41
bacitracin/neomycin/ 64
polymyxin
atenolol 41
bacitracin/polymyxin b 64
atenolol/chlorthalidone 41
baclofen 34
ATGAM 60
BAL-CARE DHA 70
atorvastatin calcium 41
balsalazide disodium 62
atovaquone 31
balziva 54
APTIOM 19
atovaquone/proguanil 31
hcl
BANZEL 19
APTIVUS 34
ATRIPLA 34
aranelle 54
atropine sulfate 64
ARANESP ALBUMIN 39
FREE
ATROVENT HFA 67
ANORO ELLIPTA 67
antibiotic ear 66
APEXICON E 51
APOKYN 31
apraclonidine 64
apri 54
APRISO 62
ARCALYST 60
aubra 54
aripiprazole 32
augmented 51
betamethasone
dipropionate
aripiprazole odt 32
AURYXIA 50
ARISTADA 32
AVANDAMET 37
armodafinil 69
AVANDARYL 37
ARRANON 25
AVANDIA 37
ARZERRA 25
AVASTIN 25
ASACOL HD 62
aviane 54
ascomp/codeine 10
avita 47
ARCAPTA NEOHALER 67
80
Drug name Page
BARACLUDE 34
baycadron 51
bcg vaccine 60
BD INSULIN SYRINGE 63
SAFETYGLIDE/1ML/
29G X 1/2”
ULTRAFINE/0.3ML/
31G X 5/16”
ULTRAFINE/0.5ML/
30G X 1/2”
ULTRAFINE/1ML/
31G X 5/16”
Drug name Page
BD PEN NEEDLE/ 64
ULTRAFINE/
29G X 12.7M
bekyree 54
BELEODAQ 25
benazepril hcl 41
benazepril hcl/ 41
hydrochlorothiazide
BENDEKA 25
BENLYSTA 60
benztropine mesylate 31
BESIVANCE 64
betamethasone 51
dipropionate
betamethasone valerate 52
betaxolol hcl 41
betaxolol hcl 64
bethanechol chloride 51
BETIMOL 64
BETOPTIC-S 64
bexarotene 25
BEXSERO 60
bicalutamide 25
BICILLIN L-A 14
BICNU 26
bisoprolol fumarate 41
bisoprolol fumarate/ 41
hydrochlorothiazide
BLEO 15K 26
Drug name Page
Drug name Page
BRILINTA 39
camrese lo 54
brimonidine tartrate 64
CANCIDAS 23
BRINTELLIX 21
candesartan cilexetil 41
BRIVIACT 19
bromocriptine mesylate 31
candesartan cilexetil/ 41
hydrochlorothiazide
budesonide 52
capacet 10
budesonide 67
CAPASTAT SULFATE 25
bumetanide 41
CAPRELSA 26
BUPHENYL 48
captopril 41
buprenorphine hcl 13
captopril/ 41
hydrochlorothiazide
buprenorphine hcl/ 13
naloxone hcl
CARBAGLU 48
buproban 13
carbamazepine 19
bupropion hcl 21
carbamazepine er 19
bupropion hcl er 21
carbidopa 31
bupropion hcl sr 13
carbidopa/levodopa 31
bupropion hcl sr 21
carbidopa/levodopa er 31
bupropion hcl xl 21
carbidopa/levodopa odt 31
buspirone hcl 37
carbidopa/levodopa/ 31
entacapone
BUSULFEX 26
butalbital compound/ 10
codeine
butalbital/ 10
acetaminophen/caffeine
butalbital/ 10
acetaminophen/caffeine/
codeine
butalbital/aspirin/caffeine 10
bleomycin sulfate 26
butalbital/aspirin/ 10
caffeine/codeine
BLEPHAMIDE 64
cabergoline 59
BLEPHAMIDE S.O.P. 64
CABOMETYX 26
BLINCYTO 26
calcipotriene 47
blisovi 24 fe 54
calcitonin-salmon 63
blisovi fe 1.5/30 54
calcitrene 47
blisovi fe 1/20 54
calcitriol 63
BOOSTRIX 60
calcium acetate 51
BOSULIF 26
CALCIUM PNV 70
BREO ELLIPTA 67
camila 54
briellyn 54
camrese 54
carboplatin 26
carteolol hcl 64
cartia xt 41
carvedilol 41
CAYSTON 67
caziant 54
cefaclor 14
cefaclor er 14
cefadroxil 14
cefazolin 14
cefazolin sodium
cefazolin sodium/ 14
dextrose
cefdinir 14
cefditoren pivoxil 14
cefepime 14
cefepime/dextrose 14
cefixime 15
cefotaxime sodium 15
81
Drug name Page
Drug name Page
cefotetan 15
ciclopirox 23
clinisol sf 15% 70
cefotetan/dextrose 15
ciclopirox nail lacquer 23
clinpro 5000 46
cefoxitin sodium 15
ciclopirox olamine 23
clobetasol propionate 52
cefpodoxime proxetil 15
cilostazol 39
clobetasol propionate e 52
cefprozil 15
ceftazidime 15
cimetidine 49
clobetasol propionate 52
emollient
ceftazidime/dextrose 15
cimetidine hcl 49
CLOLAR 26
ceftriaxone in iso 15
osmotic dextrose
CIMZIA 60
clomipramine hcl 21
CIMZIA STARTER KIT 60
clonazepam 19
CINRYZE 60
clonazepam odt 19
ceftriaxone/dextrose 15
CIPRODEX 66
clonidine hcl 41
cefuroxime axetil 15
ciprofloxacin 15
clopidogrel 39
cefuroxime sodium 15
ciprofloxacin er 15
clorazepate dipotassium 37
cefuroxime/dextrose 15
ciprofloxacin hcl 15
CLORPRES 41
CELEBREX 10
ciprofloxacin hcl 64
clotrimazole 23
celecoxib 10
ciprofloxacin i.v.-in d5w 15
CELLCEPT 60
cisplatin 26
CELLCEPT 60
INTRAVENOUS
citalopram hydrobromide 21
clotrimazole/ 23
betamethasone
dipropionate
ceftriaxone sodium
CELONTIN 19
cephalexin 15
CEREZYME 48
CERVARIX 60
CHANTIX 13
CHANTIX CONTINUING 13
MONTH PAK
CITRANATAL 90 DHA 70
CITRANATAL ASSURE 70
CITRANATAL B-CALM 70
CITRANATAL DHA 70
CITRANATAL RX 70
cladribine 26
CLARAVIS 47
clarithromycin
CHANTIX STARTING 13
MONTH PAK
clemastine fumarate 67
chateal 54
clindamax 15
chloramphenicol sodium 15
succinate
clindamycin hcl 15
chlorhexidine gluconate 46
clindamycin palmitate 15
hcl
chloroquine phosphate 31
clindamycin phosphate 15
chlorothiazide
chlorpromazine hcl 32
add-vantage
chlorthalidone 41
chlorzoxazone 69
cholestyramine 41
cholestyramine light 41
82
CILOXAN
Drug name Page
ciclodan
clozapine 32
clozapine odt 32
COARTEM 31
codeine sulfate 10
colchicine 24
COLCRYS 24
colestipol hcl 41
colistimethate sodium 16
colocort 52
COMBIGAN 64
COMBIVENT RESPIMAT 67
COMETRIQ 26
COMPLERA 34
COMPLETE NATAL DHA 70
COMPLETENATE 70
compro 32
COMVAX 60
in d5w
CONCEPT DHA 70
clindamycin/benzoyl 47
peroxide
constulose 49
CONCEPT OB 70
COPAXONE 46
Drug name Page
Drug name Page
Drug name Page
CORDRAN TAPE 52
DARAPRIM 31
COREG 41
DARZALEX 26
dextrose 5% /electrolyte 70
#48 viaflex
COREG CR 41
dasetta 1/35 54
dextrose 10% 70
CORLANOR 41
dasetta 7/7/7 54
dextrose 10%/nacl 0.2% 70
cormax scalp application 52
daunorubicin hcl 26
cortisone acetate 52
DAUNOXOME 26
dextrose 2.5%/nacl 70
0.45%
COSMEGEN 26
daysee 54
COTELLIC 26
deblitane 54
CREON 48
decitabine 26
CRESTOR 41
deltasone 52
CRIXIVAN 34
delyla 54
cromolyn sodium 49
DELZICOL 62
cromolyn sodium 64
DENAVIR 34
cromolyn sodium 67
dentagel 46
cryselle-28 54
DEPEN TITRATABS 70
dextrose 5%/nacl 71
0.225%
CUBICIN 16
DEPOCYT 26
CUPRIMINE 70
DEPO-ESTRADIOL 54
CURITY GAUZE PADS 64
2”X2”
DEPO-PROVERA
dextrose 20% 70
dextrose 25% 70
dextrose 30% 70
dextrose 40% 70
dextrose 5% 70
dextrose 5%/lactated 70
ringers
DESCOVY 34
cyclafem 1/35 54
desipramine hcl 21
cyclafem 7/7/7 54
desmopressin acetate 53
dextrose 5%/potassium 71
chloride 0.15%
cyclobenzaprine hcl 69
dextrose 50% 71
cyclophosphamide 26
desogestrel/ethinyl 54
estradiol
cycloserine 25
desonide 52
diazepam 19
cyclosporine 60
desoximetasone 52
diazepam 37
cyclosporine modified 60
desvenlafaxine er 21
diazepam intensol 37
CYRAMZA 26
DETROL LA 51
diclofenac potassium 10
cyred 54
dexamethasone 52
diclofenac sodium dr 10
CYSTADANE 48
DEXAMETHASONE 52
INTENSOL
diclofenac sodium er 10
CYSTAGON 48
CYSTARAN 64
cytarabine aqueous 26
dacarbazine 26
DALIRESP 67
DALVANCE 16
danazol 54
dantrolene sodium 34
dapsone 25
dexamethasone sodium
phosphate
dexamethasone sodium 64
phosphate
dextrose 70% 71
dicloxacillin sodium 16
dicyclomine hcl 49
didanosine 34
DIFICID 16
dexrazoxane 26
diflorasone diacetate 52
dextroamphetamine 46
sulfate
diflunisal 10
dextrose 10%/nacl 70
0.45%
digox 41
digitek 41
digoxin 41
DAPTACEL 60
83
Drug name Page
Drug name Page
Drug name Page
dihydroergotamine 24
mesylate
doxycycline 16
monohydrate
enpresse-28 55
DILANTIN 19
dronabinol 23
entacapone 32
entecavir 34
diltiazem hcl 42
drospirenone/ethinyl 54
estradiol
diltiazem hcl cd 42
DROXIA 26
diltiazem hcl er 42
duloxetine hcl 21
dilt-xr 42
duloxetine hcl 37
DIOVAN 42
duramorph 10
DIOVAN HCT 42
DUREZOL 65
diphenatol 49
dutasteride 51
DIPHENHYDRAMINE 67
HCL
dutasteride/tamsulosin 51
hydrochloride
diphenoxylate/atropine 49
E.E.S. GRANULES 16
diphtheria/tetanus 60
toxoids adsorbed
pediatric
econazole nitrate 23
disopyramide phosphate 42
EDURANT 34
disulfiram 13
EFFIENT 39
divalproex sodium 19
EGRIFTA 53
divalproex sodium dr 19
ELIDEL 47
divalproex sodium er 19
elinest 55
DOCEFREZ 26
ELIQUIS 39
docetaxel 26
ELITEK 26
dofetilide 42
ELLA 55
donepezil hcl 20
EMCYT 26
diltiazem cd
dorzolamide hcl 65
dorzolamide hcl/timolol 65
maleate
doxazosin mesylate 42
doxepin hcl 21
doxepin hydrochloride 47
doxercalciferol 63
84
EDARBI 42
EDARBYCLOR 42
EMEND
emoquette 55
EMPLICITI 26
EMSAM 21
EMTRIVA 34
enalapril maleate 42
doxorubicin hcl 26
enalapril maleate/ 42
hydrochlorothiazide
doxorubicin hcl liposome 26
ENBRACE HR 78
doxy 100 16
endocet 10
doxycycline 16
endodan 10
doxycycline hyclate 16
ENGERIX-B 60
doxycycline hyclate dr 16
enoxaparin sodium 39
enskyce 55
ENTRESTO 42
enulose 49
ENVARSUS XR 60
EPCLUSA 34
epinastine hcl 65
EPIPEN 2-PAK 68
EPIPEN-JR 2-PAK 68
epirubicin hcl 27
epitol 19
EPIVIR 35
EPIVIR HBV 34
eplerenone 42
epoprostenol sodium 68
eprosartan mesylate 42
EPZICOM 35
EQUETRO 37
ERAXIS 23
ERBITUX 27
ergoloid mesylates 21
ERIVEDGE 27
errin 55
ERWINAZE 27
ery
ERYPED 200 16
ERYPED 400 16
ERYTHROCIN 16
LACTOBIONATE
ERYTHROCIN 16
STEARATE
erythromycin 16
erythromycin 47
erythromycin 65
erythromycin base 16
erythromycin 16
ethylsuccinate
Drug name Page
erythromycin stearate 16
erythromycin/benzoyl 47
peroxide
Drug name Page
Drug name Page
FANAPT TITRATION 32
PACK
fluocinolone acetonide 52
body
FARESTON 27
ESBRIET 68
FARYDAK 27
scalp
ESCAVITE 71
FASLODEX 27
fluocinonide 52
ESCAVITE D 71
FAZACLO 32
fluocinonide-e 52
ESCAVITE LQ 71
felbamate 19
fluor-a-day 71
escitalopram oxalate 21
felodipine er 42
fluoride 71
esgic 10
fenofibrate 42
fluoridex daily defense 71
fluoritab
esomeprazole
magnesium
fenofibrate micronized 42
fenofibric acid 42
fluorometholone 65
esomeprazole sodium
fenofibric acid dr 42
fluorouracil 27
fenoprofen calcium 11
fluorouracil 47
estarylla 55
ESTRACE 55
estradiol 55
fentanyl
fluoxetine dr 22
fluoxetine hcl 22
fentanyl citrate oral 11
transmucosal
fluphenazine decanoate 32
FERRIPROX 64
fluphenazine hcl 32
ethambutol hcl 25
FERRIPROX 71
FLURA-DROPS 71
ethosuximide 19
FETZIMA 22
flurbiprofen 11
etidronate disodium 63
FETZIMA TITRATION 22
PACK
flurbiprofen sodium 65
etodolac 11
etodolac er 11
finasteride 51
fluticasone propionate 52
etoposide 27
FIRAZYR 60
fluticasone propionate 68
EVISTA 55
FIRMAGON 59
fluvastatin 42
EVOMELA 27
flavoxate hcl 51
fluvastatin sodium er 42
EVOTAZ 35
flecainide acetate 42
EVZIO 13
FLORIVA 71
FOCALGIN 90 DHA 71
EXELON 21
FLOVENT DISKUS 68
FOCALGIN CA 71
exemestane 27
FLOVENT HFA 68
FOCALGIN-B 71
EXJADE 71
floxuridine 27
FOLCAL DHA 71
EXTAVIA 46
fluconazole 23
FOLCAPS OMEGA 3 71
EXTRA-VIRT PLUS DHA 71
fluconazole in dextrose 23
FOLET DHA 71
FABRAZYME 48
fluconazole in nacl 23
FOLET ONE 71
falmina 55
flucytosine 23
FOLIVANE-OB 71
famciclovir 35
fludarabine phosphate 27
FOLIVANE-PRX DHA NF 71
famotidine 49
fludrocortisone acetate 52
FOLOTYN 27
famotidine premixed 49
flunisolide 68
fomepizole 71
FANAPT 32
fondaparinux sodium 39
FORADIL AEROLIZER 68
estradiol/norethindrone 55
acetate
flutamide 27
fluvoxamine maleate
85
Drug name Page
FORTEO 63
FORTICAL 63
FOSAMAX PLUS D 63
fosinopril sodium 42
fosinopril sodium/ 42
hydrochlorothiazide
Drug name Page
gentamicin sulfate 16
pediatric
halobetasol propionate 52
gentamicin sulfate/0.9% 16
sodium chloride
haloperidol decanoate 32
GENVOYA 35
GEODON 32
haloperidol 32
haloperidol lactate 32
HARVONI 35
HAVRIX 61
fosphenytoin sodium 19
gianvi 55
FOSRENOL 51
gildagia 55
furosemide 42
gildess 1.5/30 55
FUSILEV 27
gildess 1/20 55
FUZEON 35
gildess 24 fe 55
fyavolv 55
gildess fe 1.5/30 55
FYCOMPA 19
gildess fe 1/20 55
gabapentin 19
GILENYA 46
GABITRIL 19
GILOTRIF 27
galantamine 21
hydrobromide
glatopa 46
GLEEVEC 27
GAMASTAN S/D 60
GLEOSTINE 27
GAMMAPLEX 60
glimepiride 37
GAMUNEX-C 60
glipizide 37
ganciclovir 35
glipizide er 37
GARDASIL 60
glipizide xl 37
GARDASIL 9 60
glipizide/metformin hcl 37
GATTEX 49
gavilyte-c 49
GLUCAGEN 37
DIAGNOSTIC
gavilyte-g 49
GLUCAGEN HYPOKIT 37
HUMIRA 61
gavilyte-h 49
GLUCAGON 37
EMERGENCY KIT
HUMIRA PEDIATRIC 61
CROHNS DISEASE
STARTER PACK
gavilyte-n/flavor pack 49
GAZYVA 27
gemcitabine 27
gemcitabine hcl 27
gemfibrozil 42
generlac 49
gengraf 60
gentak 65
86
Drug name Page
glyburide 38
glyburide micronized 37
glyburide/metformin hcl 37
glycopyrrolate 49
heather 55
hecoria 61
HEMENATAL OB 71
HEMENATAL OB + DHA 71
heparin sodium 40
heparin sodium/d5w 39
heparin sodium/nacl 39
0.45%
heparin sodium/nacl 39
0.9%
heparin sodium/sodium 39
chloride 0.9%
heparin sodium/sodium 40
chloride 0.9% premix
hepatamine 71
HERCEPTIN 27
HETLIOZ 69
HEXALEN 27
HIBERIX 61
HUMIRA PEN 61
HUMIRA PEN-CROHNS
DISEASE STARTER
glydo 13
HUMIRA PEN 61
PSORIASIS STARTER
granisetron hcl 23
hydralazine hcl 42
griseofulvin microsize 23
hydrochlorothiazide 43
griseofulvin 23
ultramicrosize
hydrocodone bitartrate/ 11
acetaminophen
guanfacine er 46
guanidine hcl 24
hydrocodone/ 11
acetaminophen
HALAVEN 27
hydrocodone/ibuprofen 11
Drug name Page
Drug name Page
Drug name Page
hydrocortisone 52
INTELENCE 35
JALYN 51
hydrocortisone butyrate 52
INTRALIPID 72
jantoven 40
hydrocortisone butyrate 52
(lipophilic)
INTRON A 28
JANUMET 38
INTRON A 35
JANUMET XR 38
INTRON A W/DILUENT 28
JANUVIA 38
introvale 55
JARDIANCE 38
INTUNIV 46
jencycla 55
INVANZ 16
JENTADUETO 38
INVEGA 33
JENTADUETO XR 38
hydroxychloroquine 31
sulfate
INVEGA SUSTENNA 32
JEVTANA 28
INVEGA TRINZA 32
JINTELI 55
hydroxyprogesterone 55
caproate
INVIRASE 35
jolessa 55
INVOKAMET 38
jolivette 55
hydroxyurea 27
INVOKANA 38
juleber 55
hydroxyzine hcl 68
IPOL INACTIVATED IPV 61
junel 1.5/30 55
HYPERTET S/D 61
ipratropium bromide 68
junel 1/20 55
ibandronate sodium 63
junel fe 1.5/30 55
IBRANCE 27
ipratropium bromide/ 68
albuterol sulfate
ibudone 11
irbesartan 43
junel fe 24 55
ibuprofen 11
irbesartan/ 43
hydrochlorothiazide
KABIVEN 72
hydrocortisone in 52
absorbase
hydrocortisone valerate
hydrocortisone/acetic 67
acid
hydromorphone hcl
ICLUSIG 27
idarubicin hcl 27
ifosfamide 27
ILARIS 61
ILEVRO 65
imatinib mesylate 27
IMBRUVICA 27
imipenem/cilastatin 16
imipramine hcl 22
imiquimod 47
IMOVAX RABIES 61
(H.D.C.V.)
INATAL ADVANCE 71
INATAL ULTRA 71
INCRELEX 53
INCRUSE ELLIPTA 68
indapamide 43
INFANRIX 61
INLYTA 27
IRESSA 28
irinotecan 28
ISENTRESS 35
isoniazid 25
ISOPTO CARPINE 65
junel fe 1/20 55
KADCYLA 28
kaitlib fe 55
KALETRA 35
KALYDECO 68
kariva 55
isosorbide dinitrate 43
kcl 0.075%/d5w/nacl 72
0.45%
isosorbide dinitrate er 43
kcl 0.15%/d5w/lr 72
isosorbide mononitrate 43
kcl 0.15%/d5w/nacl 0.2% 72
isosorbide mononitrate 43
er
0.225%
isotonic gentamicin 16
isradipine 43
0.45%
ISTODAX 28
kcl 0.15%/d5w/nacl 0.9% 72
itraconazole 24
ivermectin 31
kcl 0.3%/d5w/lr iv lac 72
ring
IXEMPRA KIT 28
kcl 0.3%/d5w/nacl 0.45% 72
IXIARO 61
kcl 0.3%/d5w/nacl 0.9% 72
JAKAFI 28
kelnor 1/35 56
87
Drug name Page
Drug name Page
KETEK 16
layolis fe 56
levothyroxine sodium 58
ketoconazole 24
leena 56
levoxyl 59
ketoprofen 11
leflunomide 61
LEXIVA 35
ketoprofen er 11
LENVIMA 10 MG DAILY 28
DOSE
LIALDA 62
ketorolac tromethamine 65
KEYTRUDA 28
kimidess 56
KINRIX 61
kionex 72
klor-con 72
klor-con 10 72
KLOR-CON 25 72
klor-con 8 72
klor-con m10 72
KLOR-CON M15 72
klor-con m20 72
klor-con sprinkle 72
klor-con/ef 72
KORLYM 38
k-sol 72
kurvelo 56
KUVAN 48
KYNAMRO 43
labetalol hcl 43
DOSE
DOSE
DOSE
DOSE
DOSE
lessina 56
LETAIRIS 68
letrozole 28
lidocaine 13
lidocaine hcl 13
lidocaine hcl 43
lidocaine hcl jelly 13
lidocaine viscous 13
lidocaine/prilocaine 13
lindane 31
linezolid 17
LINZESS 50
liothyronine sodium 59
LIPOSYN III 72
lisinopril 43
leucovorin calcium 28
lisinopril/ 43
hydrochlorothiazide
LEUKERAN 28
lithium 37
LEUKINE 40
lithium carbonate 37
leuprolide acetate 59
lithium carbonate er 37
levalbuterol 68
lomedia 24 fe 56
LEVEMIR 38
lomustine 28
LEVEMIR FLEXTOUCH 38
LONSURF 28
levetiracetam
loperamide hcl 50
lactated ringers dextrose 72
5% viaflex
levobunolol hcl 65
lopreeza 56
lactated ringers viaflex 72
levocarnitine 72
lorazepam 37
lactulose 50
levocetirizine 68
dihydrochloride
lorazepam intensol 37
lamivudine 35
lamivudine/zidovudine 35
lamotrigine
lansoprazole 50
larin 1.5/30 56
larin 1/20 56
larin 24 fe 56
larin fe 1.5/30 56
larin fe 1/20 56
latanoprost 65
LATUDA 33
88
Drug name Page
levofloxacin 17
levofloxacin 65
levofloxacin in d5w 16
levoleucovorin 28
levoleucovorin calcium 28
lorcet 11
lorcet hd 11
lorcet plus 11
loryna 56
losartan potassium 43
levonest 56
losartan potassium/ 43
hydrochlorothiazide
levonorgestrel 56
LOTEMAX 65
levonorgestrel/ethinyl 56
estradiol
lovastatin 43
levora 0.15/30-28 56
LOVAZA 43
low-ogestrel 56
Drug name Page
Drug name Page
Drug name Page
loxapine succinate 33
MENTAX 24
ludent 72
MENVEO 61
methylprednisolone 53
sodiumsuccinate
LUMIGAN 65
MEPRON 31
metipranolol 65
LUMIZYME 49
mercaptopurine 28
metoclopramide hcl 50
LUPRON DEPOT 59
meropenem 17
metolazone 43
LUPRON DEPOT-PED 59
metoprolol succinate er 43
lutera 56
meropenem/sodium 17
chloride
LYNPARZA 28
mesalamine 62
LYRICA 20
mesalamine dr 62
metoprolol/ 43
hydrochlorothiazide
LYSODREN 59
mesna 28
METRO IV 17
lyza 56
MESNEX 28
metronidazole 17
magnesium sulfate 72
MESTINON 25
metronidazole 48
MESTINON TIMESPAN 25
metronidazole in nacl 17
0.79%
malathion
metoprolol tartrate 43
maprotiline hcl 22
metadate er 46
margesic 11
metaproterenol sulfate 68
marlissa 56
metformin hcl 38
MARPLAN 22
metformin hcl er 38
MARQIBO 28
methadone hcl 11
MATULANE 28
methadose 12
matzim la 43
methadose sugar-free 12
meclizine hcl 23
methazolamide 43
meclofenamate sodium 11
methenamine hippurate 17
medroxyprogesterone 56
acetate
methimazole 59
methotrexate 61
mefloquine hcl 31
methotrexate sodium 61
megestrol acetate 56
methoxsalen 47
MEKINIST 28
meloxicam 11
methscopolamine 50
bromide
mimvey lo 56
melphalan hydrochloride 28
methyclothiazide 43
minitran 43
memantine hcl 21
methylergonovine 51
maleate
minocycline hcl 17
memantine hcl titration 21
pak
methylphenidate hcl
metronidazole vaginal 17
mexiletine hcl 43
MIACALCIN 63
microgestin 1.5/30 56
microgestin 1/20 56
microgestin 24 fe 56
microgestin fe 56
microgestin fe 1.5/30 56
midodrine hcl 43
MIGERGOT 24
MILLIPRED 53
MILLIPRED DP 53
mimvey 56
minoxidil 43
MIRAPEX ER 32
memantine 21
hydrochloride
methylphenidate hcl er 46
MENACTRA 61
misoprostol 50
MENEST 56
mitomycin 28
MENHIBRIX 61
acetate
MENOMUNE-A/C/ 61
Y/W-135
dose pack
methylphenidate hcl sr
mirtazapine 22
mirtazapine odt 22
mitoxantrone hcl 29
M-M-R II 61
modafinil 69
89
Drug name Page
moderiba 35
moexipril hcl 43
moexipril/ 43
hydrochlorothiazide
MOLINDONE 33
HYDROCHLORIDE
NAFCILLIN 17
nafcillin sodium
NAGLAZYME 49
nalbuphine hcl 12
naloxone hcl 13
Drug name Page
neomycin/polymyxin/ 65
bacitracin/
hydrocortisone
dexamethasone
naltrexone hcl 13
gramicidin
NAMENDA 21
neomycin/polymyxin/hc 67
mononessa 56
NAMENDA TITRATION 21
PAK
montelukast sodium 68
hydrocortisone
NAMENDA XR 21
morgidox 1x100mg 17
morgidox 1x50mg 17
NAMENDA XR 21
TITRATION PACK
hydrocortisone
morgidox 2x100mg 17
NAMZARIC 46
NEPHRAMINE 73
naphazoline hcl 65
NESTABS 73
morphine sulfate er 12
naproxen 12
NESTABS DHA 73
MOVIPREP 50
naproxen dr 12
NEUMEGA 40
MOXATAG 17
naproxen sodium 12
NEUPOGEN 40
MOXEZA 65
naratriptan hcl 24
NEUPRO 32
MULTAQ 43
NARCAN 14
NEVANAC 65
multi vitamin/fluoride 72
NASONEX 68
nevirapine 35
multi-vit/fluoride 73
NATACHEW 73
nevirapine er 35
multi-vit/iron/fluoride 73
NATALVIRT 90 DHA 73
NEXA PLUS 73
multivitamin with fluoride 73
NATALVIRT CA 73
NEXAVAR 29
multi-vitamin/fluoride 73
nateglinide 38
multi-vitamin/fluoride/ 73
iron
NATELLE ONE 73
niacin er 43
NATPARA 64
mult-vitamin/fluoride 72
NIASPAN 44
NEBUPENT 31
mupirocin 48
nicardipine hcl 44
necon 0.5/35-28 57
NICOTROL NS 14
mometasone furoate 53
mono-linyah 56
morphine sulfate
mupirocin calcium
neo-polycin 65
NEXIUM
necon 1/35 57
MUSTARGEN 29
nifedical xl 44
NECON 1/50-28 57
mvc-fluoride 73
nifedipine er 44
NECON 10/11-28 57
mycophenolate mofetil 61
nikki 57
necon 7/7/7 57
myorisan 48
NILANDRON 29
nefazodone hcl 22
nilutamide 29
neomycin sulfate 17
nimodipine 44
neomycin/bacitracin/ 65
polymyxin
NINLARO 29
MYRBETRIQ
myzilra 56
nabumetone 12
nadolol 43
nadolol/ 43
bendroflumethiazide
90
Drug name Page
neomycin/polymyxin b
sulfates
NIPENT 29
nisoldipine 44
nisoldipine er 44
nitrofurantoin 17
Drug name Page
Drug name Page
Drug name Page
nitrofurantoin 17
macrocrystals
NOVOLIN R RELION 38
ONCASPAR 29
NOVOLOG 38
ondansetron hcl 23
nitrofurantoin 17
monohydrate
NOVOLOG FLEXPEN 38
ondansetron odt 23
NOVOLOG MIX 70/30 38
ONFI 20
NOVOLOG MIX 70/30 38
PREFILLED FLEXPEN
OPDIVO 29
nitroglycerin transdermal 44
OPSUMIT 68
NOVOLOG PENFILL 38
NITROSTAT 44
oralone 46
NOXAFIL 24
NIVA-PLUS 73
ORAP 33
NUEDEXTA 46
nizatidine 50
ORFADIN 49
NULOJIX 61
nora-be 57
ORFADIN 64
NUPLAZID 33
NORDITROPIN 53
FLEXPRO
ORKAMBI 68
nyamyc 24
orsythia 57
nystatin 24
OTREXUP 61
nystatin/triamcinolone 24
oxacillin sodium 17
nitroglycerin 44
nitroglycerin lingual
norethindrone 57
norethindrone & ethinyl 57
estradiol ferrous
fumarate
nystop 24
oxaliplatin 29
OB COMPLETE GOLD 73
oxandrolone 57
norethindrone acetate 57
OB COMPLETE ONE 73
oxaprozin 12
norethindrone acetate/ 57
ethinyl estradiol
OB COMPLETE PETITE 73
oxcarbazepine 20
OB COMPLETE 73
PREMIER
OXSORALEN 48
norethindrone acetate/ 57
ethinyl estradiol/ferrous
fumarate
OB COMPLETE/DHA 73
norgestimate/ethinyl 57
estradiol
ocella 57
NORINYL 1+50 57
norlyroc 57
NORMOSOL -R 73
NORMOSOL-R 73
NORMOSOL-R IN D5W 73
NORTHERA 44
nortrel 0.5/35 (28) 57
nortrel 1/35 57
nortrel 7/7/7 57
nortriptyline hcl 22
NORVIR 35
NOVOLIN 70/30 38
NOVOLIN 70/30 RELION 38
NOVOLIN N 38
NOVOLIN N RELION 38
NOVOLIN R 38
O-CAL PRENATAL 73
oxybutynin chloride 51
oxybutynin chloride er 51
oxycodone hcl
octreotide acetate 59
oxycodone/ 12
acetaminophen
ODEFSEY 35
oxycodone/aspirin 12
ODOMZO 29
oxycodone/ibuprofen 12
OFEV 68
pacerone 44
ofloxacin 17
paclitaxel 29
ofloxacin 65
PAIRE OB 73
ofloxacin 67
paliperidone er 33
OGESTREL 57
pamidronate disodium 63
olanzapine 33
pancrelipase 49
olanzapine odt 33
PANRETIN 29
olanzapine/fluoxetine 22
pantoprazole sodium 50
olopatadine hcl 65
paricalcitol 63
olopatadine hcl 68
paroex 46
omega-3-acid ethyl 44
esters
paromomycin sulfate 17
omeprazole 50
paroxetine hcl
paroxetine hcl er 22
91
Drug name Page
PASER 25
Drug name Page
PATADAY 65
phenytoin sodium 20
extended
polymyxin b sulfate/ 66
trimethoprim sulfate
PATANASE 68
philith 57
poly-vitamin/fluoride 74
PATANOL 65
phos-flur 46
POMALYST 29
PAXIL 22
PHOSPHOLINE IODIDE 65
portia-28 57
PAZEO 65
physiolyte 74
PORTRAZZA 29
PCE 17
physiosol irrigation 74
potassium chloride 74
PEDIARIX 61
pilocarpine hcl 46
PEDVAX HIB 61
pilocarpine hcl 65
0.15% /nacl 0.45% viaflex
peg 3350/electrolytes 50
pilocarpine 46
hydrochloride
0.15% d5w/nacl 0.33%
pimozide 33
0.15% d5w/nacl 0.45%
peg-3350/nacl/na 50
bicarbonate/kcl
PEGANONE 20
pimtrea 57
PEGINTRON 35
pindolol 44
PEG-INTRON REDIPEN 35
pioglitazone hcl 38
0.15% d5w/nacl 0.45%
viaflex
penicillin g potassium 17
pioglitazone hcl/ 38
metformin hcl
0.15% nacl 0.9%
pioglitazone hcl 38
glimepiride
0.22% d5w/nacl 0.45%
PENTACEL 61
piperacillin sodium/ 18
tazobactam sodium
PENTAM 300 31
piperacillin/tazobactam 18
0.224%d5w/nacl 0.45%
viaflex
PENTASA 62
pirmella 1/35 57
pentoxifylline cr 44
pirmella 7/7/7 57
pentoxifylline er 44
piroxicam 12
PERFOROMIST 68
plenamine 74
PERIKABIVEN 73
PNV FERROUS 74
FUMARATE/
DOCUSATE/FOLIC ACID
penicillin g procaine 17
penicillin g sodium 17
penicillin v potassium 18
perindopril erbumine 44
periogard 46
PERJETA 29
permethrin 31
perphenazine 33
perphenazine/ 22
amitriptyline
phenadoz 23
phenelzine sulfate 22
phenergan 23
phenobarbital 20
phenytoin 20
phenytoin sodium 20
92
Drug name Page
0.3%/ nacl 0.9%
0.3%/d5w
potassium chloride cr 74
potassium chloride er 74
potassium chloride sr 74
PNV FOLIC ACID + 74
IRON MULTIVITAMIN
potassium citrate er 74
PNV OB+DHA 74
PR NATAL 400 74
PNV PRENATAL PLUS 74
MULTIVITAMIN
PR NATAL 400 EC 74
PNV TABS 29-1 74
PR NATAL 430 EC 74
PNV-DHA 74
PNV-SELECT 74
PNV-VP-U 74
podofilox 48
polycin 66
polyethylene glycol 3350 50
POTIGA 20
PR NATAL 430 74
PRADAXA 40
PRALUENT 44
pramipexole
dihydrochloride
pramipexole 32
dihydrochloride er
Drug name Page
pravastatin sodium 44
prazosin hcl 44
PRED-G 66
PRED-G S.O.P. 66
prednicarbate 53
prednisolone 53
prednisolone acetate 66
prednisolone sodium 53
phosphate
prednisolone sodium 66
phosphate
Drug name Page
PREVIDENT 5000 46
BOOSTER
PREVIDENT 5000 46
ENAMEL PROTECT
PREVIDENT 5000 PLUS 46
PREVIDENT 5000 46
SENSITIVE
PREVIDENT FLUORIDE 47
previfem 57
PREZCOBIX 35
PREZISTA 35
prednisone 53
PRIFTIN 25
PREDNISONE 53
INTENSOL
primaquine phosphate 31
PREFERA OB 75
PRISTIQ 22
PREFERA OB + DHA 75
PROAIR HFA 68
PREFERAOB +DHA 75
PROAIR RESPICLICK 68
PREFERAOB ONE 75
probenecid 24
PREMASOL 75
probenecid/colchicine 24
PRENAISSANCE 75
PRENAISSANCE PLUS 75
PRENATA 75
PRENATABS FA 75
PRENATAL 19 75
PRENATAL PLUS 75
PRENATAL PLUS IRON 75
PRENATE AM 75
PRENATE DHA 76
PRENATE ELITE 76
PRENATE ESSENTIAL 76
PRENATE MINI 76
PRENATE PIXIE 76
PREPLUS 76
PREPOPIK 50
PREQUE 10 76
PRETAB 76
prevalite 44
PREVIDENT 47
primidone 20
prochlorperazine
prochlorperazine 33
edisylate
prochlorperazine 33
maleate
PROCRIT 40
PROCTOFOAM HC 48
procto-med hc 53
procto-pak 53
proctosol hc 53
proctozone-hc 53
progesterone 57
PROGLYCEM 38
PROGRAF 61
PROLASTIN-C 68
PROLENSA 66
PROLEUKIN 29
PROLIA 63
PROMACTA 40
promethazine hcl 23
promethazine hcl 68
Drug name Page
promethegan 23
propafenone hcl 44
propafenone hcl er 44
proparacaine hcl 66
propranolol hcl 44
propranolol hcl er 44
propranolol/ 44
hydrochlorothiazide
propylthiouracil 59
PROQUAD 61
protriptyline hcl 22
PROVIDA DHA 78
PULMOZYME 68
PUREFE OB PLUS 76
PURIXAN 29
pyrazinamide 25
pyridostigmine bromide 25
QUADRACEL 61
quasense 57
quetiapine fumarate 33
QUFLORA PEDIATRIC 76
quinapril hcl 44
quinapril/ 44
hydrochlorothiazide
quinidine gluconate cr 44
quinidine gluconate er 44
quinidine sulfate 44
quinidine sulfate er 44
quinine sulfate 31
QVAR 69
RABAVERT 61
raloxifene hydrochloride 57
ramipril 44
RANEXA 44
ranitidine hcl 50
RAPAMUNE 62
RASUVO 62
RAVICTI 49
reclipsen 57
93
Drug name Page
Drug name Page
RECOMBIVAX HB 62
rizatriptan benzoate 24
SIRTURO 25
REGRANEX 48
rizatriptan benzoate odt 24
SIVEXTRO 18
relador pak plus 13
ropinirole hcl
RELENZA DISKHALER 36
rosadan
sodium bicarbonate 77
sodium bicarbonate
partial fill
RELISTOR
rosuvastatin calcium 45
RELNATE DHA
ROTARIX 62
sodium chloride 77
REMICADE 62
ROTATEQ 62
RENVELA 51
roweepra 20
sodium chloride 0.45% 77
viaflex
repaglinide 38
ROXICET 12
repaglinide/metformin 38
hydrochloride
ROZEREM 69
REPATHA 44
SABRIL 20
REPATHA 45
PUSHTRONEX SYSTEM
SAMSCA 76
REPATHA SURECLICK 45
RESCRIPTOR 36
RESTASIS 66
RETROVIR IV INFUSION 36
REVLIMID 29
REXULTI 33
REYATAZ 36
ribavirin 36
RIDAURA 62
rifabutin 25
rifampin 25
RIFATER 25
riluzole 46
rimantadine hcl 36
RIMSO-50 51
ringers injection 76
risedronate sodium 63
risedronate sodium dr 63
RISPERDAL CONSTA 33
risperidone 33
risperidone odt 33
RITUXAN 29
rivastigmine tartrate 21
rivastigmine transdermal 21
system
94
Drug name Page
RYTARY 32
SANDIMMUNE 62
SANTYL 48
SAPHRIS 33
SAVAYSA 40
SELECT-OB 76
selegiline hcl 32
selenium sulfide 48
SELZENTRY 36
SE-NATAL 19 76
SENSIPAR 59
SEREVENT DISKUS 69
SEROQUEL XR 33
sodium chloride 0.9%
sodium fluoride 77
sodium phenylbutyrate 49
sodium polystyrene 77
sulfonate
sodium sulfacetamide 48
sodium sulfacetamide 66
SOLTAMOX 29
SOMATULINE DEPOT 59
SOMAVERT 59
sorine 45
sotalol hcl 45
sotalol hcl (af) 45
SOVALDI 36
SPIRIVA HANDIHALER 69
SPIRIVA RESPIMAT 69
spironolactone 45
sertraline hcl 22
spironolactone/ 45
hydrochlorothiazide
SE-TAN DHA 76
SPORANOX 24
setlakin 57
sprintec 28 58
sf
SPRITAM 20
sharobel 58
SPRYCEL 29
SIGNIFOR 59
sronyx 58
sildenafil
ssd 48
SILENOR 69
stavudine 36
silver sulfadiazine 48
sterile water irrigation 77
SIMBRINZA 66
STIOLTO RESPIMAT 69
SIMULECT 62
STIVARGA 29
simvastatin 45
streptomycin sulfate 18
sirolimus 62
STRIBILD 36
Drug name Page
Drug name Page
Drug name Page
STRIVERDI RESPIMAT 69
TABLOID 29
THALOMID 30
STROMECTOL 31
tacrolimus 62
THEO-24 69
SUBOXONE 14
TAFINLAR 29
sucralfate 50
TAGRISSO 29
theophylline cr 69
sulfacetamide sodium 48
TAMIFLU 36
theophylline er 69
sulfacetamide sodium 66
tamoxifen citrate 29
THERACYS 30
sulfacetamide sodium/ 66
prednisolone sodium
phosphate
tamsulosin hcl 51
THIOLA 51
TARCEVA 29
thioridazine hcl 34
TARGRETIN 30
thiotepa 30
sulfadiazine 18
theophylline
sulfamethoxazole/ 18
trimethoprim
tarina fe 1/20 58
thiothixene 34
TARON-PREX 77
thrivite rx 77
sulfamethoxazole/ 18
trimethoprim ds
TASIGNA 30
THYMOGLOBULIN 62
tazicef 18
THYROLAR-1 59
SULFAMYLON
TAZORAC 48
THYROLAR-1/2 59
sulfasalazine 62
taztia xt 45
THYROLAR-1/4 59
sulfatrim pediatric 18
TECENTRIQ 30
THYROLAR-2 59
sulindac 12
TEFLARO 18
THYROLAR-3 59
sumatriptan
TEGRETOL-XR 20
tiagabine hydrochloride 20
sumatriptan succinate
TEKAMLO 45
TICE BCG 30
sumatriptan succinate 24
refill
TEKTURNA 45
ticlopidine hcl 40
TEKTURNA HCT 45
TIKOSYN 45
SUPRAX 18
telmisartan 45
tilia fe 58
SUPREP BOWEL PREP 50
telmisartan/amlodipine 45
timolol maleate 45
SURMONTIL 22
timolol maleate 66
SUSTIVA 36
telmisartan/ 45
hydrochlorothiazide
SUTENT 29
TEMODAR 30
timolol maleate 66
ophthalmic gel forming
syeda 58
TENIVAC 62
tinidazole 18
terazosin hcl 45
TIVICAY 36
SYLVANT 29
terbinafine hcl 24
tizanidine hcl 34
SYMBICORT 69
terbutaline sulfate 69
TL FOLATE 77
SYMLINPEN 120 38
terconazole 24
TL-CARE DHA 77
SYMLINPEN 60 38
TESTIM 58
TL-SELECT 77
SYNAGIS 62
testosterone 58
TOBRADEX 66
SYNAREL 59
testosterone cypionate 58
TOBRADEX ST 66
SYNERCID 18
testosterone enanthate 58
tobramycin
SYNJARDY 38
tetanus/diphtheria 62
toxoids-adsorbed
SYLATRON
SYNRIBO 29
SYNTHROID 59
SYPRINE 77
tetrabenazine 46
tetracycline hcl 18
tobramycin sulfate 18
tobramycin sulfate 66
tobramycin sulfate/ 18
sodium chloride
95
Drug name Page
tobramycin/ 66
dexamethasone
Drug name Page
triamcinolone acetonide 69
TRI-VIT/FLUORIDE/IRON 77
triamcinolone in orabase 47
tri-vitamin/fluoride 77
trivora-28 58
tolazamide 39
triamterene/ 45
hydrochlorothiazide
tolbutamide 39
TRICARE 77
TRULICITY 39
tolmetin sodium 13
TRICARE PRENATAL 77
COMPLEAT
TRUMENBA 62
TRICARE PRENATAL 77
DHA ONE
TWINRIX 62
TOBREX
tolterodine tartrate
tolterodine tartrate er 51
topiramate
toposar 30
topotecan hcl 30
TORISEL 30
torsemide 45
tpn electrolytes 77
TRACLEER 69
TRADJENTA 39
triderm 53
tri-estarylla 58
trifluoperazine hcl 34
trifluridine 66
trihexyphenidyl hcl 32
tri-legest fe 58
tri-linyah 58
tri-lo-estarylla 58
trospium chloride
TRUVADA 36
TYBOST 36
TYGACIL 18
TYKERB 30
TYPHIM VI 62
TYZEKA 36
TYZINE PEDIATRIC 69
NASAL DROPS
ULORIC 24
tramadol hydrochloride/ 13
acetaminophen
tri-lo-marzia 58
ULTIMATECARE ONE 77
NF
tri-lo-sprintec 58
unithroid 59
trandolapril 45
trilyte 50
ursodiol 50
trandolapril/verapamil 45
hcl
trimethoprim 18
UVADEX 30
trimethoprim sulfate/ 66
polymyxin b sulfate
VAGIFEM 58
tramadol hcl
trandolapril/verapamil 45
hcl er
trimipramine maleate 22
tranexamic acid 40
TRINATAL GT 77
TRANSDERM-SCOP 23
TRINATAL RX 1 77
tranylcypromine sulfate 22
trinessa 58
TRAVATAN Z 66
trinessa lo 58
travoprost 66
TRINTELLIX 22
trazodone hcl 22
triple antibiotic 66
TREANDA 30
triple-vitamin/fluoride 77
valsartan/ 45
hydrochlorothiazide
TRECATOR 25
tri-previfem 58
VALSTAR 30
TRELSTAR MIXJECT 59
TRISENOX 30
vancomycin 18
TRESIBA FLEXTOUCH 39
tri-sprintec 58
vancomycin hcl 18
tretinoin 30
TRISTART DHA 77
tretinoin 48
TRIUMEQ 36
vancomycin hcl in 18
dextrose
TREXALL 62
TRIVEEN-DUO DHA 77
vandazole 18
TRIADVANCE 77
TRIVEEN-PRX RNF 77
VANTAS 59
tri-vit/fluoride 77
VAQTA 62
triamcinolone acetonide
96
Drug name Page
valacyclovir hcl 36
VALCHLOR 30
VALCYTE 36
valganciclovir 36
valproate sodium 20
valproic acid 20
valsartan 45
Drug name Page
Drug name Page
Drug name Page
VARIVAX 62
vincristine sulfate 30
wymzya fe 58
VASCEPA 45
vinorelbine tartrate 30
XALKORI 30
VASOSTRICT 53
viorele 58
XARELTO 40
VECTIBIX 30
VIRACEPT 36
VELCADE 30
VIRAMUNE 36
XARELTO STARTER 40
PACK
velivet 58
VIRAMUNE XR 36
XENAZINE 46
VELPHORO 51
VIRAZOLE 36
XGEVA 63
VEMAVITE-PRX 2 77
VIREAD 36
XIFAXAN 18
VENA-BAL DHA 77
VIRT-ADVANCE 77
XOLAIR 69
VENCLEXTA 30
VIRT-C DHA 77
XTANDI 30
VENCLEXTA STARTING 30
PACK
VIRT-CARE ONE 77
XYREM 69
VIRT-PN 77
YERVOY 30
venlafaxine hcl 22
VIRT-PN DHA 78
YF-VAX 62
venlafaxine hcl er 22
VIRT-PN PLUS 78
YONDELIS 30
VENTAVIS 69
VIRT-SELECT 78
zafirlukast 69
VENTOLIN HFA 69
VITAFOL FE+ 78
zaleplon 69
verapamil hcl 45
VITAFOL GUMMIES 78
ZALTRAP 30
verapamil hcl er 45
VITAFOL-ONE 78
zamicet 13
verapamil hcl sr 45
VITAMEDMD ONE RX/ 78
QUATREFOLIC
ZANOSAR 30
ZATEAN-CH 78
VESICARE 51
VITAMEDMD PLUS RX/ 78
QUATRE FOLIC
vestura 58
vitamins a/d/c/fluoride 78
ZATEAN-PN DHA 78
V-GO 20 64
VITEKTA 36
ZATEAN-PN PLUS 78
V-GO 30 64
VOL-NATE 78
ZAVESCA 49
V-GO 40 64
VOL-PLUS 78
zazole 24
VEREGEN 48
VERSACLOZ 34
vicodin 13
VOLTAREN
zarah 58
ZATEAN-PN 78
zebutal 13
vicodin es 13
voriconazole 24
ZELBORAF 30
vicodin hp 13
VOTRIENT 30
ZENATANE 48
VICTOZA 39
VP CH ULTRA 78
zenchent 58
VIDEX PEDIATRIC 36
VP-CH-PNV 78
zenchent fe 58
vienva 58
VP-HEME OB 78
ZENPEP 49
VIGAMOX 66
VP-HEME ONE 78
ZETIA 45
VIIBRYD 22
VP-PNV-DHA 78
ZIAGEN 36
VIIBRYD STARTER 22
PACK
VPRIV 49
zidovudine 36
VRAYLAR 34
ziprasidone hcl 34
VIMPAT 20
vyfemla 58
ZIRGAN 66
vinblastine sulfate 30
warfarin sodium 40
ZOLADEX 59
vincasar pfs 30
wera 58
zoledronic acid 63
97
Drug name Page
ZOLINZA 31
zolpidem tartrate
ZONALON 48
zonisamide 20
ZORTRESS 62
ZOSTAVAX 62
zovia 1/35e 58
ZOVIA 1/50E 58
ZYDELIG 31
ZYKADIA 31
ZYLET 66
ZYPREXA RELPREVV 34
ZYTIGA 31
ZYVOX 18
98
This page was intentionally left blank
This formulary was updated on 10/1/2016. For more recent information or other questions, please contact
Coventry Health Care at 1-844-741-8423 or for TTY: 711. October 1 to February 14, you can call us 8 a.m.
to 8 p.m., 7 days a week. From February 15 to September 30, we’re here 8 a.m. to 8 p.m., Monday through
Friday, or visit http://www.formulary.coventry-medicare.com.
Contract/PBP: H3928, 001, 002, H7301, 007
81.05.357.1 K (10/16)
16244C

2016 Comprehensive Formulary

Transcription

Similar documents

2016 Comprehensive Formulary

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

WellCare 2013 Comprehensive Formulary, Medicare

3-tier QHP forumulary

Medicare Plans | AARP

2016 Kaiser Permanente Hawaii Marketplace Drug Formulary

SilverScript 2016 Choice Formulary

Comprehensive Formulary - Medicare Part D Plans

English - UHCCommunityPlan.com

Comprehensive Formulary

Medicare Part D Excluded Drug List

Fidelis Care 2016 Formulary (List of Covered Drugs)

MaineCare MAC List Effective 5.13.16