IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN … · IMPORTANTE LEER: ESTE DOCUMENTO...

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Formulario completo del 2016

Lista de medicamentos cubiertos

IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE

INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS

EN ESTE PLAN

Formulary ID: 00016484, Version: 12

Este formulario se actualizó el 03/23/2016. Para obtener información más reciente o si

tiene preguntas, llame a Servicios al miembro de Denver Health Medical Plan, Inc.

al 1-877-956-2111. Los usuarios de TTY deben llamar al 711.

Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la

semana, o puede visitar www.denverhealthmedicalplan.org.

Nota para aquellos que ya son miembros:

Este formulario presenta cambios respecto del año pasado. Sírvase revisar

este documento para asegurarse de que todavía contenga los

medicamentos que usted toma. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.

Esta información está disponible de manera gratuita en otros idiomas. Para obtener más información, llame a

nuestro departamento de Servicios al miembro al 303-602-2111 o al número gratuito 1-877-956-2111. Los

usuarios de TTY deben llamar al 711. Nuestro horario de atención es de 8 a. m. a 8 p. m. los siete días de la

semana.

This information is available for free in other languages. Please contact our Member Services department at

303-602-2111 or toll free at 1-877-956-2111 for more information. TTY users should call 711. Our hours of

operation are from 8 a.m. - 8 p.m. seven days a week.

Denver Health Medical Plan, Inc. es un plan HMO aprobado por Medicare y tiene un contrato con el

Colorado Medicaid Program. La inscripción en Denver Health Medical Plan, Inc. depende de la renovación

del contrato. H5608_1085 CF16_001_SP accepted

http://www.denverhealthmedicalplan.org/

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Cuando en esta lista de medicamentos (formulario) figuran los términos “nosotros”, “a nosotros” o

“nuestro”, se hace referencia a Denver Health Medical Plan, Inc. Donde dice “plan” o “nuestro plan”,

significa Medicare Choice HMO SNP.

Este documento incluye una lista parcial de los medicamentos (formulario) de nuestro plan que está

en vigencia desde el April 01, 2016. Para obtener el formulario actualizado, comuníquese con nosotros.

Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario,

aparece en las páginas de portada y contraportada.

En general, usted debe utilizar farmacias de la red para utilizar su beneficio de medicamentos

recetados. Los beneficios, la lista de medicamentos, la red de farmacias, y/o los copagos/coseguro

pueden cambiar el 01 de enero 2017, y de vez en cuando durante el año.

¿Qué es el Formulario completo de Denver Health Medical Plan, Inc.?

Un formulario es una lista de medicamentos cubiertos seleccionados por nosotros en colaboración con un

equipo de proveedores de atención médica, que representa los tratamientos recetados que se consideran parte

necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos incluidos en

nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en

una farmacia de la red de Denver Health Medical Plan, Inc. y se sigan otras reglas del plan. Para obtener más

información sobre cómo obtener sus medicamentos recetados, revise su Evidencia de cobertura.

¿Puede el Formulario (lista de medicamentos) modificarse?

En general, si usted está tomando un medicamento de nuestro formulario del 2016 que estaba cubierto a

principios del año, no vamos a interrumpir ni a reducir la cobertura del medicamento durante el año de

cobertura 2016, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o se

publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de

cambios en el formulario, tales como eliminar un medicamento de nuestro formulario, no afectarán a los

miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo

compartido durante el resto del año de cobertura para aquellos miembros que lo toman. Consideramos que es

importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del

formulario que estaban disponibles cuando eligió nuestro plan, excepto por los casos en los que usted pudiera

ahorrar dinero adicional o nosotros podamos garantizar su seguridad.

Si eliminamos medicamentos de nuestro formulario o añadimos requisitos de autorización previa, límites

de cantidad o restricciones de terapia escalonada para un medicamento, debemos notificar a los miembros

afectados acerca del cambio al menos 60 días antes de que el cambio entre en vigencia o en el momento en

que el miembro solicite una renovación del medicamento, momento en el cual el miembro recibirá un

suministro para 60 días del medicamento. Si la Administración de Medicamentos y Alimentos considera

que un medicamento en nuestro formulario no es seguro o si el fabricante del medicamento retira el

medicamento del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y

notificaremos a los miembros que toman el medicamento. El formulario adjunto tiene vigencia a partir del

April 01, 2016. Para obtener información actualizada sobre los medicamentos que cubrimos, comuníquese

con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada.

Los futuros cambios en el formulario se le enviarán con su Explicación mensual de Beneficios de la Parte D.

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Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no

es seguro o el fabricante del medicamento retira el medicamento del mercado, los miembros afectados

recibirán una notificación aparte. En nuestro sitio web, encontrará una lista de los futuros cambios que se

realizarán en el Formulario.

¿Cómo uso el Formulario?

Hay dos maneras de encontrar un medicamento en el formulario:

Afección médica

El formulario comienza en la página 13. Los medicamentos en este formulario están agrupados en

categorías que dependen del tipo de afección médica para la que se usan como tratamiento. Por ejemplo,

los medicamentos utilizados para tratar una afección cardíaca aparecen bajo la categoría “Agentes

cardiovasculares”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la

lista que comienza en la página 13. Luego busque su medicamento en esa categoría.

Lista en orden alfabético

Si no sabe con certeza en qué categoría buscar, deberá buscar su medicamento en el Índice que comienza

en la página I-1. El Índice ofrece una lista en orden alfabético de todos los medicamentos incluidos en

este documento. Tanto los medicamentos de marca como los genéricos aparecen en el Índice. Busque en

el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede

encontrar información sobre la cobertura. Vaya a la página indicada en el Índice y busque el nombre de

su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

Nuestro plan cubre tanto medicamentos de marca como genéricos. Un medicamento genérico está

aprobado por la FDA porque se considera que tiene los mismos ingredientes activos que el medicamento

de marca. En general, los medicamentos genéricos tienen un costo menor que los de marca.

¿Hay alguna restricción en mi cobertura?

Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos

y límites pueden ser los siguientes:

Autorización previa: nuestro plan exige que usted o su médico obtengan una autorización previa

para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener nuestra aprobación

antes de adquirir sus medicamentos recetados. Si usted no obtiene la aprobación, es posible que no

cubramos el medicamento.

Límites de cantidad: para ciertos medicamentos, limitamos la cantidad del medicamento que

cubriremos. Por ejemplo, nuestro plan ofrece 90 cápsulas por receta para LYRICA. Esto puede ser

además del suministro estándar de un mes o tres meses.

Terapia escalonada: en algunos casos, requerimos que para tratar su afección de salud, pruebe

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ciertos medicamentos primero antes de que aprobemos otro medicamento para tratar esa afección. Por

ejemplo, si el medicamento A y el medicamento B tratan su afección de salud, es posible que no

cubramos el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento

A no funciona para usted, cubriremos el Medicamento B.

Para averiguar si su medicamento tiene otros requisitos o límites adicionales, puede consultar el formulario

que comienza en la página 13. También puede visitar nuestro sitio web para obtener más información sobre

las restricciones que se aplican a un medicamento específico. Hemos publicado en línea documentos que

explican nuestras restricciones de autorización previa y de terapia escalonada. También puede solicitarnos

que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última vez que

actualizamos el formulario, aparece en las páginas de portada y contraportada.

Puede solicitarnos que hagamos una excepción a esas restricciones o límites o pedirnos una lista de otros

medicamentos similares para tratar su afección médica. Consulte la sección “¿Cómo puedo solicitar una

excepción respecto del formulario de Denver Health Medical Plan?” en la parte inferior de esta página

para obtener información sobre cómo solicitar una excepción.

¿Qué pasa si mi medicamento no figura en el Formulario?

Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), usted debe primero

comunicarse con Servicios al miembro y averiguar si su medicamento está cubierto.

Si usted se entera de que nuestro plan no cubre su medicamento, usted tiene dos opciones:

Puede solicitar a Servicios al miembro una lista de medicamentos similares que cubramos. Cuando

reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté

cubierto por nuestro plan.

Puede pedirnos que hagamos una excepción y que cubramos su medicamento. Consulte la

información que figura más abajo sobre cómo solicitar una excepción.

¿Cómo puedo solicitar una excepción respecto del formulario de Denver Health Medical

Plan, Inc.?

Puede pedirnos que hagamos una excepción respecto de nuestras reglas de cobertura. Hay varios tipos de

excepciones que usted puede solicitarnos que hagamos.

Puede pedirnos que cubramos un medicamento aunque no esté en nuestro formulario. Si

aprobamos su pedido, cubriremos este medicamento a un nivel de costo compartido

predeterminado, y usted no podrá solicitarnos que le proporcionemos el medicamento a un nivel

de costo compartido menor.

Puede pedirnos que anulemos las restricciones o los límites de cobertura de su medicamento. Por

ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos.

Si su medicamento tiene un límite de cantidad, usted puede pedirnos que anulemos el límite y

cubramos una cantidad mayor.

Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el

formulario del plan, el medicamento con el nivel más bajo de costo compartido o las restricciones

adicionales de utilización no resultaran tan eficaces para tratar su afección o le causaran efectos de salud

adversos.

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Usted debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para obtener una

excepción respecto del formulario o de la restricción de utilización. Cuando usted solicita una excepción

respecto del formulario o de la restricción de utilización, debe presentar una declaración del

proveedor o médico, que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72

horas de recibir la declaración de respaldo de su médico. Usted puede solicitar una excepción acelerada

(rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera las 72 horas que

lleva tomar la decisión. Si se le concede su petición de acelerar la decisión, debemos darle una decisión

a más tardar 24 horas después de recibir la declaración de respaldo de su médico u otro proveedor.

¿Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis

medicamentos o solicitar una excepción?

Como miembro nuevo o continuo en nuestro plan, usted puede tomar medicamentos que no están en nuestro

formulario. O bien, usted puede tomar un medicamento que está en nuestro formulario pero su capacidad

para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes

de poder obtener su medicamento con receta. Usted debe hablar con su médico para decidir si debe cambiar

por otro medicamento apropiado que cubrimos o solicitar una excepción al formulario de modo que cubramos

el medicamento que toma. Mientras hable con su médico para determinar el curso de acción correcto para

usted, es posible que cubramos su medicamento en ciertos casos durante los primeros 90 días que usted sea

miembro de nuestro plan.

Por cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus

medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que usted tenga una

receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro para

30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de

90 días.

Si usted es residente de un centro de atención a largo plazo, permitiremos la renovación de su medicamento

recetado hasta que le hayamos proporcionado un suministro de transición para 91 días, coherente con el

incremento de dispensación, (a menos que tenga una receta escrita para menos días). Cubriremos más de una

renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si

necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos

es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de

emergencia para 31 días de ese medicamento (a menos usted tiene una receta escrita menos días) mientras

solicita una excepción al formulario.

Si experimenta un cambio en el nivel de atención, por ejemplo, se le interna en un centro de atención a

largo plazo o se le da el alta de este, y se encuentra fuera de sus primeros 90 días de cobertura, Denver

Health Medical Plan, Inc. proporcionará un suministro por única vez un los medicamentos de la Parte D

que no están en el formulario, como se describió anteriormente.

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Para obtener más información

Para obtener información más detallada sobre la cobertura de medicamentos recetados que ofrece nuestro

plan, consulte su Evidencia de cobertura y otros materiales del plan.

Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto

con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y

contraportada.

Si tiene preguntas generales sobre la cobertura de Medicare para medicamentos recetados, puede llamar a

Medicare al 1-800- MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los

usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

Formulario de Denver Health Medical Plan, Inc.

El formulario completo que comienza en la página 13 proporciona información sobre la cobertura de los

medicamentos cubiertos por nuestro plan. Si tiene inconvenientes para encontrar su medicamento en la

lista, consulte el Índice que comienza en la página I-1.

La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en

mayúsculas (por ejemplo, ADVAIR DISKUS) y los medicamentos genéricos aparecen en letra cursiva en

minúsculas con un nombre de medicamento de marca de referencia que aparece junto al nombre genérico del

fármaco (por ejemplo, amoxicilina (Amoxil)). Los medicamentos genéricos en cursiva con nombres de marca

de referencia entre paréntesis indican que sólo el medicamento genérico está en el formulario.

Durante la etapa inicial de su cobertura, su costo compartido será de 25% cuando obtenga un

medicamento recetado de la Parte D en una farmacia de la red. Si usted califica para recibir un

subsidio por bajos ingresos, su costo compartido por bajos ingresos dependerá del tipo de

medicamento que reciba. Si recibe un medicamento genérico, incluso un medicamento de marca que se

considere genérico, usted tendrá que pagar $0, $1.20 o $2.95, dependiendo de su nivel de subsidio.

Para medicamentos de marca y todos los demás, usted tendrá que pagar $ 0, $3.60 o $7.40,

dependiendo de su nivel de subsidio. Para obtener más información sobre sus responsabilidades de costo

compartido, consulte el Capítulo 6 de su Evidencia de cobertura.

La información en la columna de Requisitos/Límites le indica si Denver Health Medical Plan, Inc. tiene

algún requisito especial para la cobertura de su medicamento.

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Las siguientes abreviaturas pueden encontrarse en el cuerpo de este

documento.

ABREVIATURAS SOBRE NOTAS DE COBERTURA

ABREVIATURA

DESCRIPCIÓN

EXPLICACIÓN

Restricciones sobre la Administración de la Utilización de Servicios

PA

Restricción de

autorización previa

previa

Usted (o su médico) tiene la obligación de obtener

autorización previa de Denver Health Medical Plan

(DHMP), Inc. antes de obtener el medicamento de su receta.

Sin autorización previa, Denver Health Medical Plan Inc. no

puede cubrir este medicamento.

PA BvD

Restricción de

autorización previa para

una determinación de

Parte B frente a Parte D

Este medicamento puede ser elegible para el pago bajo la

Parte B o la Parte D de Medicare. Usted (o su médico) tiene

la obligación de obtener una autorización previa de Denver

Health Medical Plan, Inc. para determinar que este

medicamento esté cubierto por la Parte D de Medicare antes

de obtener el medicamento indicado en su receta. Sin

autorización previa, Denver Health Medical Plan Inc. no

puede cubrir este medicamento.

PA-HRM

Restricción de


para medicamentos

de alto riesgo

Este medicamento ha sido considerado por CMS como

potencialmente perjudicial y, por lo tanto, como

medicamento de alto riesgo para los beneficiarios de

Medicare de 65 años o más. Los miembros de 65 años o

más tienen la obligación de obtener una autorización previa

de Denver Health Medical Plan, Inc. antes de obtener el

medicamento de su receta. Sin autorización previa, Denver

Health Medical Plan Inc. no puede cubrir este

medicamento.

PA NSO

Restricción de


para nuevos

miembros solamente

Si usted es un miembro nuevo o si usted no ha tomado este

medicamento antes, usted (o su médico) tiene la obligación

de obtener una autorización previa de Denver Health

Medical Plan, Inc. antes de obtener el medicamento que

figura en su receta. Sin aprobación previa, DHMP no

cubrirá este medicamento.

QL

Restricción de límite

de cantidad

Denver Health Medical Plan, Inc. establece un límite de

cobertura respecto de la cantidad de este medicamento por

receta o dentro de un marco de tiempo específico.

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ST

Restricción de terapia

escalonada

Antes de que Denver Health Medical Plan, Inc. proporcione

cobertura para este medicamento, usted debe primero probar

otro(s) medicamento(s) para el tratamiento de su afección

médica. Este medicamento sólo será cubierto si otro(s)

fármaco(s) no funciona(n) para usted.

LA

Medicamento de acceso

limitado

Es posible que este medicamento recetado sólo esté

disponible en algunas farmacias. Para obtener más

información, consulte su Directorio de farmacias o llame a

Servicios al miembro al 1-877-956-2111, de 8 a. m. a 8 p. m.

los siete días de la semana. Los usuarios de TTY deben

llamar al 711.

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ABREVIATURAS DE DOSIS Y PRESENTACIÓN

ABREVIATURA DESCRIPCIÓN

adh. patch parche adhesivo

aer br act aerosol, activado por aliento

aer pow aerosol, polvo

aer pow ba polvo aerosol, activado por aliento

aer refill repuesto de aerosol

aer w/adap aerosol con adaptador

ampul ampolla

blkbaginj inyección en bolsas a granel

cap dr mp cápsula, multifásica de liberación prolongada

cap ds pk cápsula, paquete de dosis

cap er 12h cápsula, 12 horas liberación prolongada

cap er 24h cápsula, 24 horas liberación prolongada

cap er deg cápsula, liberación prolongada degradable

cap er pel cápsula, pellets liberación prolongada

cap mphase cápsula, multifásica

cap.sa 24h cápsula, 24 horas liberación sostenida

cap.sr 12h cápsula, 12 horas liberación sostenida

cap.sr 24h cápsula, 24 horas liberación sostenida

cap24h pct cápsula, 24 horas pellets de inicio controlado

cap24h pel cápsula, 24 horas pellets liberación sostenida

cap sprink cápsula, esparcir

cap sr pel cápsula pellets liberación sostenida

cap w/dev cápsula con dispositivo

capsule dr cápsula, liberación retardada

capsule er cápsula, liberación prolongada

capsule sa cápsula, acción sostenida

cmb cappad combinación: cápsula, almohadilla

cmb ont fm combinación: ungüento, espuma

cmb ont lt combinación: ungüento, loción

cmb tabpad combinación: comprimido, almohadilla

combo. pkg paquete combinado

cpmp 12hr cápsula, 12 horas multifásica

cpmp 24hr cápsula, 24 horas multifásica

cpmp 30-70 cápsula, multifásica, 30%-70%

cpmp 50-50 cápsula, multifásica, 50%-50%

cream(g), cream(gm) crema (gramos)

cream(ml) crema (mililitros)

cream/appl crema con aplicador

cream, er (g) crema, liberación prolongada (gramos)

cream pack crema, paquete

dehp fr bg bolsa sin di(2-etilhexil) ftalato

dis needle aguja desechable

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disk w/dev disco con dispositivo para inhalación

disp syrin jeringa desechable

drops susp gotas, suspensión

drps hpvis gotas, hiperviscosas

emul adhes adhesivo emulsión

emul packt paquete de emulsión

emulsn(g) emulsión (gramos)

foam/appl. espuma con aplicador

froz.piggy accesorio congelado

g gramo

gel/pf app gel con aplicador precargado

gel (gm) gel (gramos)

gel (ml) gel (mililitros)

gel md pmp gel en bomba con dosis medida

gel w/appl gel con aplicador

gel w/pump gel con bomba

gran pack paquete de gránulos

hfa aer ad adaptador para aerosol hfahidrofluoroalcano

infus. btl frasco para infusión

insuln pen pluma de insulina

ip soln solución intraperitoneal

irrig soln solución de irrigación

iv soln. solución intravenosa

jel jalea

jelly/app jalea con aplicador

jel/pf app jalea con aplicador precargado

kit cl&crm kit: limpiador y crema

kt crm le kit: crema, loción emoliente

kt lotn ce kit: loción, crema emoliente

kt oint le kit: ungüento, loción emoliente

lotion, er loción, liberación prolongada

lozenge hd pastillas con soporte

m.ht patch parche de calor con medicamento

ma buc tab comprimidos bucales mucoadhesivos

mcg microgramo

med. pad almohadilla con medicamento

med. swab hisopo con medicamento

med. tape cinta adhesiva con medicamento

mg miligramo

ml mililitro

muc er 12h sistema mucoadhesivo, 12 horas liberación prolongada

ndl fr inj aguja para inyección

nl fm susp suspensión para cubierta de uñas

oint. (g), oint.(gm) ungüento (gramos)

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oral conc concentrado oral

oral susp suspensión oral

paste (g) pasta (gramos)

patch td24 parche, 24 horas transdérmico

patch td72 parche, 72 horas transdérmico

patch tdsw parche, 2 veces por semana transdérmico

patch tdwk parche, 1 vez por semana transdérmico

pca syring jeringa analgésica controlada por paciente

pca vial vial analgésico controlado por paciente

pellet(ea) pellet (cada uno)

pen ij kit kit con pluma para inyección

pen injctr pluma para inyección

pggybk btl frasco accesorio

plast. bag bolsa plástica

powd pack paquete de polvo

sol md pmp solución con bomba multidosis

sol w/appl solución con aplicador

sol/pf app solución con aplicador precargado

sol-gel solución, formadora de gel

soln recon solución, reconstituida

soln(gram) solución (gramos)

spray susp atomizador, suspensión

spray/pump atomizador con bomba

stick(ea) varilla (cada una)

supp.rect supositorio, rectal

supp.vag supositorio, vaginal

suppos. supositorio

sus er 24h suspensión, 24 horas liberación prolongada

sus er rec suspensión, reconstituida de liberación prolongada

sus mc rec suspensión, microcápsula reconstituida

suspdr pkt suspensión, paquete de liberación retardada

susp recon suspensión, reconstituida

syringekit kit de jeringa

tab chew comprimido, masticable

tab er 12h comprimido, 12 horas liberación prolongada

tab er 24h comprimido, 24 horas liberación prolongada

tab er prt comprimido, partículas de liberación prolongada

tab er seq comprimido, efectos de liberación prolongada de liberación prolongada tab disper comprimido, dispersable

tab ds pk comprimido, paquete de dosis

tab er 24 comprimido, 24 horas liberación prolongada

tab mphase comprimido, multifásico

tab part comprimido, partículas

tab rap dr comprimido, liberación retardada de desintegración rápida

12


tab rapdis comprimido, desintegración rápida

tab subl comprimido, sublingual

tab.sr 12h comprimido, 12 horas liberación sostenida

tab.sr 24h comprimido, 24 horas liberación sostenida

tabergr24hr comprimido, 24 horas liberación prolongada gradual

tablet dr comprimido, liberación retardada

tablet, er comprimido, liberación prolongada

tablet eff comprimido, efervescente

tablet sa comprimido, acción sostenida

tablet sol comprimido, soluble

tb er dspk comprimido, paquete de dosis de liberación prolongada

tb mp dspk comprimido, paquete de dosis multifásica

tb rd dspk comprimido, paquete de dosis de desintegración rápida

tbdspk 3mo comprimido, paquete de dosis de 3 meses

tbmp 12hr comprimido, 12 horas multifásico

tbmp 24hr comprimido, 24 horas multifásico

u unidad

vag ring anillo vaginal

You can find information on what the symbols and abbreviations in this table mean by going to the introduction

pages of this document

13

Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB

Formulary ID: 16484.001, Version: 12

Effective: April 01, 2016

Drug Name

Drug Tier Requirements/Limits

Analgesics

Analgesics, Miscellaneous

acetaminophen-codeine 120 mg-12 mg/5

ml solution

(Acetaminophen with

Codeine)

1 QL (2700 per 30 days)

acetaminophen-codeine oral solution 300

mg-30 mg /12.5 ml

(Acetaminophen with

Codeine)

1 QL (2700 per 30 days)

acetaminophen-codeine oral tablet 300-15

mg, 300-30 mg

(Tylenol-Codeine No.3) 1 QL (360 per 30 days)

acetaminophen-codeine oral tablet 300-60

mg

(Tylenol-Codeine No.3) 1 QL (180 per 30 days)

ALLZITAL 1

BELBUCA 1 ST; QL (60 per 30 days)

buprenorphine hcl injection syringe (Buprenorphine HCl) 1

butalb-acetaminophen-caffeine oral

capsule 50-325-40 mg

(Esgic) 1 PA-HRM; QL (180 per

30 days)

butalbital-acetaminop-caf-cod (Fioricet with Codeine) 1 PA-HRM; QL (180 per

30 days)

butalbital-acetaminophen oral tablet 50-

325 mg

(Tencon) 1 PA-HRM; QL (180 per

30 days)

butalbital-acetaminophen-caff oral

capsule 50-325-40 mg


30 days)

butalbital-acetaminophen-caff oral tablet

50-325-40 mg


30 days)

butalbital-aspirin-caffeine oral capsule (Fiorinal) 1 PA-HRM; QL (180 per

30 days)

BUTRANS 1 QL (4 per 28 days)

codeine sulfate oral tablet (Codeine Sulfate) 1 QL (180 per 30 days)

codeine-butalbital-asa-caffein oral

capsule 30-50-325-40 mg

(Fiorinal with Codeine

#3)

1 PA-HRM; QL (180 per

30 days)

fentanyl (Duragesic) 1 PA; QL (10 per 30 days)

fentanyl citrate (Actiq) 1 PA; QL (120 per 30

days)

hydrocodone-acetaminophen oral solution

10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml,

7.5-325 mg/15 ml

(Hycet) 1 QL (2700 per 30 days)

hydrocodone-acetaminophen oral tablet

10-300 mg, 5-300 mg, 7.5-300 mg

(Norco) 1 (includes Vicodin,

Vicodin ES and Vicodin

HP); QL (390 per 30

days)



14




Drug Name


hydrocodone-acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325

mg

(Norco) 1 QL (360 per 30 days)

hydrocodone-ibuprofen (Ibudone) 1 QL (150 per 30 days)

hydromorphone (pf) injection solution 10

mg/ml

(Dilaudid-HP) 1

hydromorphone (pf) injection solution 4

mg/ml

(Dilaudid) 1

hydromorphone injection solution (Hydromorphone HCl) 1

hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) 1

hydromorphone oral liquid (Dilaudid) 1 QL (1200 per 30 days)

hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) 1 QL (180 per 30 days)

hydromorphone oral tablet 8 mg (Dilaudid) 1 QL (240 per 30 days)

LAZANDA 1 PA; QL (30 per 30 days)

methadone hcl oral tablet,soluble 40 mg (Diskets) 1 QL (90 per 30 days)

methadone injection (Methadone HCl) 1

methadone oral solution (Methadone HCl) 1 QL (1800 per 30 days)

methadone oral tablet (Diskets) 1 QL (360 per 30 days)

morphine (pf) in 0.9 % nacl intravenous pt

controlled analgesia syring 50 mg/25 ml

(2 mg/ml)

(Morphine Sulfate/0.9%

Nacl/PF)

1

morphine 10 mg/ml carpuject (Morphine Sulfate) 1



morphine 8 mg/ml syringe (Morphine Sulfate) 1

morphine concentrate oral solution (Morphine Sulfate) 1 QL (200 per 30 days)

morphine concentrate oral syringe (Morphine Sulfate) 1

morphine in dextrose 5 % injection pt

controlled analgesia syring

(Morphine

Sulfate/D5W)

1

morphine injection solution 15 mg/ml, 8

mg/ml

(Morphine Sulfate) 1

morphine injection syringe 10 mg/ml (Morphine Sulfate) 1

morphine intramuscular (Morphine Sulfate) 1

morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) 1

morphine intravenous solution 25 mg/ml,

50 mg/ml

(Morphine Sulfate) 1

morphine intravenous syringe (Morphine Sulfate) 1

morphine oral solution 10 mg/5 ml (Morphine Sulfate) 1 QL (700 per 30 days)



15




Drug Name


morphine oral solution 20 mg/5 ml (Morphine Sulfate) 1 QL (300 per 30 days)

MORPHINE ORAL TABLET 1 QL (180 per 30 days)

morphine oral tablet extended release 100

mg, 30 mg, 60 mg

(MS Contin) 1 QL (120 per 30 days)

morphine oral tablet extended release 15

mg, 200 mg

(MS Contin) 1 QL (180 per 30 days)

morphine rectal (Morphine Sulfate) 1

NUCYNTA 1 QL (181 per 30 days)

NUCYNTA ER 1 QL (60 per 30 days)

oxycodone hcl-acetaminophen oral

solution 5-325 mg/5 ml

(Oxycodone

HCl/Acetaminophen)

1 QL (1800 per 30 days)

oxycodone hcl-acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325

mg

(Xolox) 1 QL (360 per 30 days)

oxycodone hcl-aspirin (Percodan) 1 QL (360 per 30 days)

oxycodone oral concentrate (Oxycodone HCl) 1 QL (180 per 30 days)

oxycodone oral solution (Oxycodone HCl) 1 QL (1300 per 30 days)

oxycodone oral tablet (Roxicodone) 1 QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 10-

325 mg, 2.5-325 mg, 5-325 mg, 7.5-325

mg


oxycodone-acetaminophen oral tablet 10-

650 mg


oxycodone-acetaminophen oral tablet 7.5-

500 mg


oxycodone-aspirin (Percodan) 1 QL (360 per 30 days)

OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 10 MG, 15 MG,

20 MG, 30 MG, 40 MG, 60 MG

1 QL (60 per 30 days)

OXYCONTIN ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR 80 MG


oxymorphone oral tablet (Opana) 1 QL (180 per 30 days)

oxymorphone oral tablet extended release

12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg

(Opana ER) 1 QL (60 per 30 days)

oxymorphone oral tablet extended release

12 hr 30 mg, 40 mg

(Opana ER) 1 QL (120 per 30 days)

tramadol oral tablet (Ultram) 1 QL (240 per 30 days)

tramadol-acetaminophen (Ultracet) 1 QL (240 per 30 days)

xylon 10 (Ibudone) 1 QL (150 per 30 days)



16




Drug Name


Nonsteroidal Anti-Inflammatory

Agents

CALDOLOR INTRAVENOUS RECON

SOLN 400 MG/4 ML (100 MG/ML)

1

celecoxib (Celebrex) 1 QL (60 per 30 days)

choline,magnesium salicylate (Choline Sal/Mag

Salicylate)

1

diclofenac potassium (Diclofenac Potassium) 1

diclofenac sodium oral tablet extended

release 24 hr

(Voltaren-XR) 1

diclofenac sodium oral tablet,delayed

release (dr/ec)

(Diclofenac Sodium) 1

diclofenac sodium topical gel (Solaraze) 1

diclofenac-misoprostol (Arthrotec 50) 1

diflunisal (Diflunisal) 1

etodolac (Etodolac) 1

fenoprofen oral tablet (Fenoprofen Calcium) 1

FLECTOR 1 PA

flurbiprofen (Flurbiprofen) 1

ibuprofen oral suspension (Ibuprofen) 1

ibuprofen oral tablet 400 mg, 600 mg, 800

mg

(Ibuprofen) 1

indomethacin oral capsule 25 mg (Indomethacin) 1 PA-HRM; QL (240 per

30 days)

indomethacin oral capsule 50 mg (Indomethacin) 1 PA-HRM; QL (120 per

30 days)

indomethacin oral capsule, extended

release

(Indomethacin) 1 PA-HRM; QL (60 per 30

days)

indomethacin sodium (Indomethacin Sodium) 1 PA-HRM

ketoprofen oral capsule (Ketoprofen) 1

ketoprofen oral capsule,ext rel. pellets 24

hr 200 mg

(Ketoprofen) 1

ketorolac oral (Ketorolac

Tromethamine)


mefenamic acid (Ponstel) 1

meloxicam (Mobic) 1

nabumetone (Nabumetone) 1

naproxen oral suspension (Naprosyn) 1



17




Drug Name


naproxen oral tablet (Naprosyn) 1

naproxen oral tablet,delayed release

(dr/ec)

(Ec-Naprosyn) 1

naproxen sodium oral tablet 275 mg, 550

mg

(Anaprox) 1

piroxicam (Feldene) 1

salsalate (Salsalate) 1

sulindac oral (Sulindac) 1

tolmetin (Tolmetin Sodium) 1

VOLTAREN TOPICAL 1

Anesthetics

Local Anesthetics

glydo (Lidocaine HCl) 1

lidocaine (pf) injection solution 15 mg/ml

(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

(Xylocaine-MPF) 1 (PA for ESRD Only)

lidocaine 2% viscous soln 2 % (Xylocaine) 1

lidocaine hcl injection solution 10 mg/ml

(1 %), 20 mg/ml (2 %)

(Xylocaine) 1 (PA for ESRD Only)

lidocaine hcl laryngotracheal (Xylocaine) 1

lidocaine hcl mucous membrane gel (Lidocaine HCl) 1

lidocaine hcl mucous membrane jelly in

applicator

(Lidocaine HCl) 1

lidocaine hcl mucous membrane solution (Xylocaine) 1

lidocaine hcl urethral (Lidocaine HCl) 1

lidocaine topical adhesive

patch,medicated

(Lidoderm) 1 PA

lidocaine topical ointment (Lidocaine) 1 (PA for ESRD Only)

lidocaine-prilocaine topical cream (EMLA) 1 (PA for ESRD Only)

lidocaine-prilocaine topical kit (Relador Pak) 1 (PA for ESRD Only)

RELADOR PAK 1 (PA for ESRD Only)

Anti-Addiction/Substance Abuse

Treatment Agents

Anti-Addiction/Substance Abuse

Treatment Agents

acamprosate (Acamprosate Calcium) 1

buprenorphine hcl sublingual (Buprenorphine HCl) 1 PA; QL (90 per 30 days)

buprenorphine-naloxone (Buprenorphine

HCl/Naloxone HCl)

1 PA; QL (90 per 30 days)



18




Drug Name


bupropion hcl sr 150 mg tablet f/c (Zyban) 1

CHANTIX 1 QL (168 per 84 days)

CHANTIX CONTINUING MONTH

BOX


CHANTIX STARTING MONTH BOX 1 QL (53 per 28 days)

disulfiram (Antabuse) 1

naloxone (Naloxone HCl) 1

naltrexone oral (Revia) 1

NICOTROL 1 QL (1008 per 90 days)

ZUBSOLV 1 PA; QL (90 per 30 days)

Antianxiety Agents

Benzodiazepines

alprazolam oral tablet (Xanax) 1 QL (120 per 30 days)

chlordiazepoxide hcl (Chlordiazepoxide HCl) 1 QL (120 per 30 days)

clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 1 QL (90 per 30 days)

clonazepam oral tablet 2 mg (Klonopin) 1 QL (300 per 30 days)

clonazepam oral tablet,disintegrating

0.125 mg, 0.25 mg, 0.5 mg, 1 mg

(Clonazepam) 1 QL (90 per 30 days)

clonazepam oral tablet,disintegrating 2

mg

(Clonazepam) 1 QL (300 per 30 days)

clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) 1 QL (120 per 30 days)

clorazepate dipotassium oral tablet 3.75

mg, 7.5 mg

(Tranxene T-Tab) 1 QL (60 per 30 days)

diazepam injection solution 1 QL (10 per 28 days)

diazepam intensol (Diazepam) 1 QL (1200 per 30 days)

diazepam oral solution 5 mg/5 ml (1

mg/ml)

(Diazepam) 1 QL (1200 per 30 days)

diazepam oral tablet (Valium) 1 QL (120 per 30 days)

diazepam rectal (Diastat) 1

lorazepam oral tablet (Ativan) 1 QL (90 per 30 days)

ONFI ORAL SUSPENSION 1 PA NSO; QL (480 per 30

days)

Antibacterials

Aminoglycosides

BETHKIS 1 PA BvD



19




Drug Name


gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 100 mg/50 ml,

60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,

80 mg/50 ml, 90 mg/100 ml

(Gentamicin In Nacl,

Iso-Osm)

1

gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) 1

gentamicin ped 20 mg/2 ml vial

25's,pedi,latex-free

(Gentamicin Sulfate/PF) 1

gentamicin sulfate (pf) intravenous

solution 80 mg/8 ml

(Gentamicin Sulfate/PF) 1

neomycin (Neomycin Sulfate) 1

streptomycin intramuscular (Streptomycin Sulfate) 1

TOBI PODHALER INHALATION

CAPSULE, W/INHALATION DEVICE


tobramycin in 0.225 % nacl (Tobi) 1 PA BvD

tobramycin in 0.9 % nacl (Tobramycin/Sodium

Chloride)

1

tobramycin sulfate injection solution (Tobramycin Sulfate) 1

Antibacterials, Miscellaneous

bacitracin intramuscular (Bacitracin) 1

chloramphenicol sod succinate (Chloramphenicol Sod

Succ)

1

clindamycin 75 mg/5 ml soln (Cleocin Palmitate) 1

clindamycin hcl (Cleocin HCl) 1

clindamycin in 5 % dextrose (Cleocin Phosphate In

D5w)

1

clindamycin ph 9 g/60 ml vial bulk vial (Cleocin Phosphate) 1

clindamycin phosphate intravenous

solution 600 mg/4 ml

(Cleocin Phosphate) 1

colistin (colistimethate na) (Coly-Mycin M

Parenteral)

1

CUBICIN 1

linezolid (Zyvox) 1

methenamine hippurate (Hiprex) 1

methenamine mandelate (Methenamine

Mandelate)

1

metronidazole in nacl (iso-os) (Metronidazole/Sodium

Chloride)

1

metronidazole oral (Flagyl) 1



20




Drug Name


nitrofurantoin macrocrystal oral capsule

100 mg, 25 mg

(Macrodantin/Macrobid) 1 PA-HRM; QL (120 per

30 days)

nitrofurantoin macrocrystal oral capsule

50 mg

(Macrodantin/Macrobid) 1 PA-HRM; (High Risk

Med. QL applies to all

members; PA required

for 65 years and older

with over 90 days

cumulative use of

nitrofurantoin drugs); QL

(120 per 30 days)

nitrofurantoin monohyd/m-cryst (Macrobid) 1 PA-HRM; (High Risk




with over 90 days

cumulative use of

nitrofurantoin drugs); QL

(120 per 30 days)

polymyxin b sulfate (Polymyxin B Sulfate) 1

SYNERCID 1

trimethoprim (Trimethoprim) 1

vancomycin hcl 1g/200 ml bag (Vancomycin

HCl/D5W)

1

vancomycin intravenous recon soln 1,000

mg, 10 gram, 750 mg

(Vancomycin HCl) 1

vancomycin intravenous recon soln 500

mg

(Vancomycin

HCl/D5W)

1

vancomycin oral (Vancocin HCl) 1

XIFAXAN ORAL TABLET 200 MG 1 PA; QL (9 per 30 days)

XIFAXAN ORAL TABLET 550 MG 1 PA

ZYVOX ORAL SUSPENSION FOR

RECONSTITUTION

1

Cephalosporins

cefaclor oral capsule (Cefaclor) 1

cefaclor oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

(Cefaclor) 1

cefadroxil oral capsule (Cefadroxil) 1

cefadroxil oral suspension for

reconstitution 250 mg/5 ml, 500 mg/5 ml

(Cefadroxil) 1



21




Drug Name


cefadroxil oral tablet (Cefadroxil) 1

CEFAZOLIN IN DEXTROSE (ISO-OS)

INTRAVENOUS PIGGYBACK 1

GRAM/50 ML

1

cefazolin in dextrose (iso-os) intravenous

piggyback 2 gram/50 ml

(Cefazolin

Sodium/Dextrose, Iso)

1

cefazolin injection recon soln 1 gram, 10

gram, 100 gram, 300 g, 500 mg

(Cefazolin Sodium) 1

cefdinir (Cefdinir) 1

cefditoren pivoxil (Spectracef) 1

cefepime (Maxipime) 1

CEFEPIME 2 GM INJECTION 1

CEFEPIME IN DEXTROSE 5 % 1

cefotaxime (Claforan) 1

cefoxitin (Cefoxitin Sodium) 1

cefoxitin in dextrose, iso-osm intravenous

piggyback 2 gram/50 ml

(Cefoxitin


1

cefpodoxime (Cefpodoxime Proxetil) 1

cefprozil (Cefprozil) 1

ceftazidime injection recon soln 2 gram, 6

gram

(Fortaz) 1

ceftibuten (Cedax) 1

ceftriaxone 1 gm piggyback 50ml

galaxycontainer

(Ceftriaxone

Na/Dextrose, Iso)

1

ceftriaxone 1 gm vial 10's, fliptop,l/f (Rocephin) 1

CEFTRIAXONE 2 GM PIGGYBACK

50ML GALAXYCONTAINER

1

ceftriaxone injection recon soln 10 gram,

250 mg, 500 mg

(Rocephin) 1

ceftriaxone intravenous recon soln 1 gram (Ceftriaxone

Na/Dextrose, Iso)

1

CEFTRIAXONE INTRAVENOUS

RECON SOLN 2 GRAM

1

cefuroxime axetil oral tablet (Ceftin) 1

cefuroxime sodium injection recon soln

1.5 gram, 750 mg

(Zinacef) 1

cefuroxime sodium intravenous (Zinacef) 1

cephalexin oral capsule (Keflex) 1



22




Drug Name


cephalexin oral suspension for

reconstitution

(Cephalexin) 1

cephalexin oral tablet (Cephalexin) 1

MEFOXIN IN DEXTROSE (ISO-OSM) 1

SUPRAX ORAL TABLET,CHEWABLE 1

TEFLARO 1

Macrolides

azithromycin (Zithromax) 1

clarithromycin oral suspension for

reconstitution

(Biaxin) 1

clarithromycin oral tablet (Biaxin) 1

clarithromycin oral tablet extended

release 24 hr

(Clarithromycin) 1

DIFICID 1 QL (20 per 10 days)

ERYTHROCIN 1

erythromycin base oral tablet,delayed

release (dr/ec) 250 mg, 500 mg

(Erythromycin Base) 1

ERYTHROMYCIN BASE ORAL

TABLET,DELAYED RELEASE

(DR/EC) 333 MG

1

erythromycin ethylsuccinate oral

suspension for reconstitution 200 mg/5 ml

(Eryped 200) 1

erythromycin ethylsuccinate oral tablet (Erythromycin

Ethylsuccinate)

1

erythromycin oral capsule,delayed

release(dr/ec)

(Erythromycin Base) 1

erythromycin oral tablet (Erythromycin Base) 1

erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) 1

Miscellaneous B-Lactam

Antibiotics

aztreonam injection recon soln 1 gram (Azactam) 1

CAYSTON 1 LA

imipenem-cilastatin (Primaxin) 1

INVANZ INJECTION 1

meropenem intravenous recon soln 500

mg

(Merrem) 1

meropenem iv 1 gm vial outer, latex-free (Merrem) 1

Penicillins



23




Drug Name


amoxicillin oral capsule (Amoxicillin) 1

amoxicillin oral suspension for

reconstitution

(Amoxicillin) 1

amoxicillin oral tablet (Amoxicillin) 1

amoxicillin oral tablet,chewable 125 mg,

250 mg

(Amoxicillin) 1

amoxicillin-pot clavulanate oral

suspension for reconstitution

(Augmentin) 1

amoxicillin-pot clavulanate oral tablet (Augmentin) 1

amoxicillin-pot clavulanate oral tablet

extended release 12 hr

(Augmentin XR) 1

amoxicillin-pot clavulanate oral

tablet,chewable

(Amoxicillin/Potassium

Clav)

1

ampicillin (Ampicillin Trihydrate) 1

ampicillin 2 gm vial 10's, latex-free (Ampicillin Sodium) 1

ampicillin sodium injection recon soln 1

gram, 10 gram, 125 mg

(Ampicillin Sodium) 1

ampicillin sodium intravenous recon soln

2 gram

(Ampicillin Sodium) 1

ampicillin-sulbactam 1.5 gm vl p/f, latex-

free

1

ampicillin-sulbactam injection recon soln

15 gram

(Unasyn) 1

ampicillin-sulbactam injection recon soln

3 gram

1

ampicillin-sulbactam intravenous recon

soln 1.5 gram

1

BICILLIN C-R 1

BICILLIN L-A 1

dicloxacillin (Dicloxacillin Sodium) 1

nafcillin 2 gm vial sterile, latex-free (Nafcillin Sodium) 1

nafcillin injection recon soln 1 gram, 10

gram

(Nafcillin Sodium) 1

nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) 1

oxacillin 1 gm add-vantage vl add-

vantage, inner

(Oxacillin Sodium) 1

oxacillin in dextrose(iso-osm) (Oxacillin


1

oxacillin injection recon soln 10 gram (Oxacillin Sodium) 1



24




Drug Name


oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) 1

penicillin g pot in dextrose (Pen G Pot/Dextrose-

Water)

1

penicillin g potassium injection recon soln

20 million unit, 5 million unit

(Penicillin G Potassium) 1

penicillin g procaine (Penicillin G Procaine) 1

penicillin gk 20 million unit (Penicillin G Potassium) 1

penicillin v potassium (Penicillin V Potassium) 1

piperacillin-tazobactam intravenous recon

soln 2.25 gram, 3.375 gram, 4.5 gram

(Zosyn) 1

piperacil-tazobact 40.5 gram p/f,

pharmacy bulk

(Zosyn) 1

Quinolones

ciprofloxacin (Cipro) 1

ciprofloxacin 200 mg/20 ml vl sdv,latex-

free

(Ciprofloxacin Lactate) 1

ciprofloxacin hcl oral (Cipro) 1

ciprofloxacin in 5 % dextrose intravenous

piggyback 200 mg/100 ml

(Cipro I.V.) 1

ciprofloxacin lactate intravenous solution

400 mg/40 ml

(Ciprofloxacin Lactate) 1

ciprofloxacn-d5w 400 mg/200 ml

p/f,latex/f, in d5w

(Cipro I.V.) 1

levofloxacin in d5w intravenous piggyback

500 mg/100 ml

(Levaquin) 1

levofloxacin intravenous (Levofloxacin) 1

levofloxacin oral (Levaquin) 1

levofloxacin-d5w 750 mg/150 ml

24's,outer, p/f

(Levaquin) 1

moxifloxacin (Avelox) 1

ofloxacin oral tablet 400 mg (Ofloxacin) 1

Sulfonamides

sulfadiazine oral (Sulfadiazine) 1

sulfamethoxazole-trimethoprim

intravenous

(Sulfamethoxazole/Trim

ethoprim)

1

sulfamethoxazole-trimethoprim oral

suspension

(Sulfamethoxazole/Trim

ethoprim)

1

sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1



25




Drug Name


sulfasalazine dr 500 mg tab (Azulfidine) 1

sulfasalazine oral tablet (Azulfidine) 1

sulfatrim (Sulfamethoxazole/Trim

ethoprim)

1

sulfazine ec (Azulfidine) 1

Tetracyclines

doxy 100 vial 10's, p/f 100 mg (Doxycycline Hyclate) 1

doxycycline hyclate 100 mg cap (Morgidox) 1

doxycycline hyclate 100 mg tab f/c (Doryx) 1

doxycycline hyclate intravenous (Doxycycline Hyclate) 1

doxycycline hyclate oral capsule 100 mg (Adoxa) 1

doxycycline hyclate oral capsule 50 mg (Morgidox) 1

doxycycline hyclate oral tablet 100 mg, 50

mg

(Avidoxy) 1

doxycycline hyclate oral tablet 20 mg (Doryx) 1

doxycycline mono 100 mg cap (Adoxa) 1

doxycycline mono 100 mg tablet f/c (Avidoxy) 1

doxycycline mono 50 mg tablet (Avidoxy) 1

doxycycline monohydrate oral capsule 150

mg, 50 mg, 75 mg

(Adoxa) 1

doxycycline monohydrate oral suspension

for reconstitution

(Vibramycin) 1

doxycycline monohydrate oral tablet 150

mg, 75 mg

(Avidoxy) 1

minocycline oral capsule (Minocin) 1

minocycline oral tablet (Minocycline HCl) 1

tetracycline (Tetracycline HCl) 1

TYGACIL 1

Anticancer Agents

Anticancer Agents

ABRAXANE 1

ADCETRIS 1 PA NSO; QL (4 per 21

days)

adrucil 2,500 mg/50 ml vial outer, latex-

free 2.5 gram/50 ml

(Fluorouracil) 1 PA BvD

AFINITOR DISPERZ 1 PA NSO; QL (112 per 28

days)



26




Drug Name


AFINITOR ORAL TABLET 10 MG 1 PA NSO; QL (56 per 28

days)

AFINITOR ORAL TABLET 2.5 MG, 5

MG, 7.5 MG

1 PA NSO; QL (28 per 28

days)

ALECENSA 1 PA NSO; QL (240 per 30

days)

ALIMTA INTRAVENOUS RECON

SOLN 500 MG

1

anastrozole (Arimidex) 1

AVASTIN 1 PA NSO

azacitidine (Vidaza) 1

BELEODAQ 1 PA NSO

BENDEKA 1 PA NSO

bexarotene (Targretin) 1 PA NSO; QL (420 per 30

days)

bicalutamide (Casodex) 1

bleomycin injection recon soln 30 unit (Bleomycin Sulfate) 1 PA BvD

bleomycin sulfate 15 unit vial latex-free (Bleomycin Sulfate) 1 PA BvD

BLINCYTO 1 PA NSO; QL (140 per

365 days)

BOSULIF ORAL TABLET 100 MG 1 PA NSO; QL (120 per 30

days)

BOSULIF ORAL TABLET 500 MG 1 PA NSO; QL (30 per 30

days)

CAPRELSA ORAL TABLET 100 MG 1 PA NSO; QL (60 per 30

days)

CAPRELSA ORAL TABLET 300 MG 1 PA NSO; QL (30 per 30

days)

COMETRIQ 1 PA NSO; QL (112 per 28

days)

COTELLIC 1 PA NSO; LA; QL (63

per 28 days)

cyclophosphamide intravenous recon soln

2 gram

(Cyclophosphamide) 1 PA BvD

CYCLOPHOSPHAMIDE ORAL

CAPSULE

1 PA BvD; ST

cyclophosphamide oral tablet (Cyclophosphamide) 1 PA BvD; ST

CYRAMZA 1 PA NSO

dactinomycin (Dactinomycin) 1



27




Drug Name


DARZALEX 1 PA NSO; LA

decitabine (Dacogen) 1

doxorubicin hcl intravenous recon soln 10

mg, 20 mg, 50 mg

(Doxorubicin HCl) 1 PA BvD

doxorubicin hcl intravenous solution 10

mg/5 ml

(Doxorubicin HCl) 1 PA BvD

doxorubicin hcl peg-liposomal intravenous

suspension 2 mg/ml

(Doxil) 1 PA BvD

doxorubicin, peg-liposomal (Doxil) 1 PA BvD

DROXIA 1

ELIGARD SUBCUTANEOUS SYRINGE

22.5 MG (3 MONTH)



30 MG (4 MONTH)



45 MG (6 MONTH)



7.5 MG (1 MONTH)

1

EMCYT 1

EMPLICITI 1 PA NSO

ERIVEDGE 1 PA NSO; QL (30 per 30

days)

ETOPOPHOS 1

etoposide intravenous (Etoposide) 1

exemestane (Aromasin) 1

FARESTON 1

FARYDAK 1 PA NSO

FASLODEX 1

floxuridine (Floxuridine) 1 PA BvD

fluorouracil 5,000 mg/100 ml latex-free (Fluorouracil) 1 PA BvD

fluorouracil intravenous solution 2.5

gram/50 ml, 500 mg/10 ml

(Fluorouracil) 1 PA BvD

flutamide (Flutamide) 1

GAZYVA 1 PA NSO

GILOTRIF 1 PA NSO; QL (30 per 30

days)

GLEEVEC ORAL TABLET 100 MG 1 PA NSO; QL (90 per 30

days)



28




Drug Name


GLEEVEC ORAL TABLET 400 MG 1 PA NSO; QL (60 per 30

days)

GLEOSTINE ORAL CAPSULE 10 MG,

100 MG, 40 MG

1

HERCEPTIN 1 PA NSO

HEXALEN 1

hydroxyurea (Hydrea) 1

IBRANCE 1 PA NSO; QL (21 per 28

days)

ICLUSIG ORAL TABLET 15 MG 1 PA NSO; QL (60 per 30

days)

ICLUSIG ORAL TABLET 45 MG 1 PA NSO; QL (30 per 30

days)

ifosfamide 1 gm/20 ml vial sd polymer vial (Ifex) 1 PA BvD

ifosfamide intravenous recon soln 1 gram (Ifex) 1 PA BvD

ifosfamide-mesna (Ifosfamide/Mesna) 1 PA BvD

IMBRUVICA 1 PA NSO

IMLYGIC INJECTION SUSPENSION

10EXP6 (1 MILLION) PFU/ML


days)

IMLYGIC INJECTION SUSPENSION

10EXP8 (100 MILLION) PFU/ML


days)

INLYTA ORAL TABLET 1 MG 1 PA NSO; QL (180 per 30

days)

INLYTA ORAL TABLET 5 MG 1 PA NSO; QL (60 per 30

days)

IRESSA 1 PA NSO; QL (60 per 30

days)

IXEMPRA 15 MG KIT WITH DILUENT 1

IXEMPRA INTRAVENOUS RECON

SOLN 45 MG

1

JAKAFI 1 PA NSO; QL (60 per 30

days)

KEYTRUDA 100 MG/4 ML VIAL

LATEX-FREE,P/F,INNER

1 PA NSO

KEYTRUDA INTRAVENOUS RECON

SOLN

1 PA NSO

KYPROLIS 1 PA NSO; QL (6 per 28

days)

LENVIMA 1 PA NSO



29




Drug Name


letrozole (Femara) 1

LEUKERAN 1

leuprolide subcutaneous kit (Leuprolide Acetate) 1

lomustine (Lomustine) 1

LONSURF ORAL TABLET 15-6.14 MG 1 PA NSO; QL (100 per 28

days)

LONSURF ORAL TABLET 20-8.19 MG 1 PA NSO; QL (80 per 28

days)

LUPRON DEPOT 1

LUPRON DEPOT (3 MONTH) 1 QL (1 per 84 days)



LYNPARZA 1 PA NSO; QL (480 per 30

days)

LYSODREN 1

MATULANE 1

megestrol oral tablet (Megestrol Acetate) 1

MEKINIST ORAL TABLET 0.5 MG 1 PA NSO; QL (90 per 30

days)

MEKINIST ORAL TABLET 2 MG 1 PA NSO; QL (30 per 30

days)

mercaptopurine (Mercaptopurine) 1

methotrexate 50 mg/2 ml vial latex-free,

5's, mdv

(Methotrexate Sodium) 1 PA BvD

methotrexate sodium (pf) injection recon

soln

(Methotrexate

Sodium/PF)

1 PA BvD

methotrexate sodium (pf) injection

solution

(Methotrexate Sodium) 1 PA BvD

methotrexate sodium oral (Methotrexate Sodium) 1 PA BvD; ST

mitoxantrone (Mitoxantrone HCl) 1

NEXAVAR 1 PA NSO; QL (120 per 30

days)

NILANDRON 1

NINLARO 1 PA NSO; QL (3 per 28

days)

ODOMZO 1 PA NSO; LA

ONCASPAR 1 PA NSO



30




Drug Name


OPDIVO INTRAVENOUS SOLUTION

40 MG/4 ML

1 PA NSO

POMALYST 1 PA NSO; QL (21 per 28

days)

PORTRAZZA 1 PA NSO; QL (100 per 21

days)

PROLEUKIN 1

PURIXAN 1

REVLIMID 1 PA NSO; LA

RITUXAN 1 PA NSO

SOLTAMOX 1

SPRYCEL ORAL TABLET 100 MG, 140

MG, 50 MG, 70 MG, 80 MG


days)

SPRYCEL ORAL TABLET 20 MG 1 PA NSO; QL (60 per 30

days)

STIVARGA 1 PA NSO; QL (84 per 28

days)

SUTENT 1 PA NSO; QL (30 per 30

days)

SYLVANT 1 PA NSO

SYNRIBO 1 PA NSO; QL (28 per 28

days)

TABLOID 1

TAFINLAR 1 PA NSO; QL (120 per 30

days)

TAGRISSO 1 PA NSO; LA; QL (30

per 30 days)

tamoxifen (Tamoxifen Citrate) 1

TARCEVA ORAL TABLET 100 MG, 25

MG


days)

TARCEVA ORAL TABLET 150 MG 1 PA NSO; QL (90 per 30

days)

TARGRETIN ORAL 1 PA NSO; QL (420 per 30

days)

TARGRETIN TOPICAL 1 PA NSO; QL (60 per 28

days)

TASIGNA 1 PA NSO; QL (112 per 28

days)

TEMODAR INTRAVENOUS 1 PA NSO; (vial only)



31




Drug Name


thiotepa (Thiotepa) 1

toposar (Etoposide) 1

TREANDA 25 MG VIAL 1

TREANDA INTRAVENOUS RECON

SOLN 100 MG

1

TREANDA INTRAVENOUS

SOLUTION

1

TRELSTAR 22.5 MG SYRINGE WITH

MIXJECT


TRELSTAR INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION



SYRINGE 11.25 MG/2 ML



SYRINGE 3.75 MG/2 ML

1

tretinoin (chemotherapy) (Tretinoin) 1 (capsule: 10mg)

TREXALL 1 PA BvD; ST

TYKERB 1

UNITUXIN 1 PA NSO

VALSTAR 1

VELCADE 1 PA NSO

vinorelbine intravenous solution 50 mg/5

ml

(Navelbine) 1

VOTRIENT 1 PA NSO; QL (120 per 30

days)

XALKORI 1 PA NSO; QL (60 per 30

days)

XTANDI 1 PA NSO; QL (120 per 30

days)

YERVOY INTRAVENOUS SOLUTION

50 MG/10 ML (5 MG/ML)

1 PA NSO

YONDELIS 1 PA NSO

ZELBORAF 1 PA NSO; QL (240 per 30

days)

ZOLADEX SUBCUTANEOUS

IMPLANT 10.8 MG


ZOLADEX SUBCUTANEOUS

IMPLANT 3.6 MG


ZOLINZA 1



32




Drug Name


ZYDELIG 1 PA NSO; QL (60 per 30

days)

ZYKADIA 1 PA NSO; QL (140 per 28

days)

ZYTIGA 1 PA NSO; QL (120 per 30

days)

Anticholinergic Agents

Antimuscarinics/Antispasmodics

atropine injection solution 0.4 mg/ml (Atropine Sulfate) 1

atropine injection syringe 0.05 mg/ml, 0.1

mg/ml

(Atropine Sulfate) 1

propantheline (Propantheline Bromide) 1

STIOLTO RESPIMAT 1 QL (4 per 28 days)

Anticonvulsants

Anticonvulsants

APTIOM 1 ST

BANZEL 1 ST

carbamazepine oral capsule, er

multiphase 12 hr

(Carbatrol) 1

carbamazepine oral suspension 100 mg/5

ml

(Tegretol) 1

carbamazepine oral tablet extended

release 12 hr

(Tegretol XR) 1

carbamazepine oral tablet,chewable (Carbamazepine) 1

CELONTIN ORAL CAPSULE 300 MG 1

DILANTIN 1

divalproex oral capsule, sprinkle (Depakote Sprinkle) 1

divalproex oral tablet extended release 24

hr

(Depakote ER) 1

divalproex oral tablet,delayed release

(dr/ec)

(Depakote) 1

ethosuximide (Zarontin) 1

felbamate (Felbatol) 1

fosphenytoin 500 mg pe/10 ml

10's,sdv,latex-free

(Cerebyx) 1

fosphenytoin injection solution 100 mg

pe/2 ml

(Cerebyx) 1

FYCOMPA ORAL TABLET 1 ST



33




Drug Name


gabapentin oral capsule (Neurontin) 1

gabapentin oral solution 250 mg/5 ml (Neurontin) 1

gabapentin oral tablet 600 mg, 800 mg (Neurontin) 1

GABITRIL ORAL TABLET 12 MG, 16

MG

1

LAMICTAL ORAL TABLET,

CHEWABLE DISPERSIBLE 2 MG

1

lamotrigine oral tablet (Lamictal) 1

lamotrigine oral tablet extended release

24hr

(Lamictal XR) 1

lamotrigine oral tablet, chewable

dispersible

(Lamictal) 1

lamotrigine oral tablets,dose pack 25 mg

(35)

(Lamictal (Blue)) 1

levetiracetam intravenous (Keppra) 1

levetiracetam oral solution 100 mg/ml (Keppra) 1

levetiracetam oral tablet (Keppra) 1

levetiracetam oral tablet extended release

24 hr

(Keppra XR) 1

LYRICA ORAL CAPSULE 1 QL (90 per 30 days)

LYRICA ORAL SOLUTION 1 QL (900 per 30 days)

oxcarbazepine (Trileptal) 1

OXTELLAR XR 1 ST

PEGANONE 1

phenobarbital oral elixir (Phenobarbital) 1 QL (1500 per 30 days)

phenobarbital oral tablet 100 mg, 15 mg,

16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2

mg

(Phenobarbital) 1 QL (90 per 30 days)

phenobarbital oral tablet 30 mg (Phenobarbital) 1 QL (200 per 30 days)

phenobarbital sodium injection solution (Phenobarbital Sodium) 1 QL (2 per 30 days)

phenytoin oral suspension 125 mg/5 ml (Dilantin-125) 1

phenytoin oral tablet,chewable (Dilantin) 1

phenytoin sodium (Phenytoin Sodium) 1

phenytoin sodium extended (Dilantin) 1

POTIGA ORAL TABLET 200 MG, 300

MG, 400 MG


POTIGA ORAL TABLET 50 MG 1 QL (270 per 30 days)

primidone (Mysoline) 1



34




Drug Name


SABRIL 1

tiagabine (Gabitril) 1

topiramate (Topamax) 1

topiramate oral capsule, sprinkle (Topamax) 1

topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 1

TROKENDI XR 1 ST

valproate sodium (Depacon) 1

valproic acid (Depakene) 1

valproic acid (as sodium salt) oral

solution 250 mg/5 ml

(Depakene) 1

VIMPAT INTRAVENOUS 1 QL (200 per 5 days)

VIMPAT ORAL SOLUTION 1 QL (1200 per 30 days)

VIMPAT ORAL TABLET 1 QL (60 per 30 days)

zonisamide (Zonegran) 1

Antidementia Agents

Antidementia Agents

donepezil oral tablet (Aricept) 1 QL (30 per 30 days)

donepezil oral tablet,disintegrating (Donepezil HCl) 1 QL (30 per 30 days)

EXELON TRANSDERMAL 1 QL (30 per 30 days)

galantamine oral capsule,ext rel. pellets

24 hr

(Razadyne ER) 1 QL (30 per 30 days)

galantamine oral solution (Galantamine Hbr) 1 QL (200 per 30 days)

galantamine oral tablet (Razadyne) 1 QL (60 per 30 days)

memantine oral solution (Namenda) 1 QL (360 per 30 days)

memantine oral tablet (Namenda) 1 QL (60 per 30 days)

memantine oral tablets,dose pack (Namenda) 1 QL (49 per 28 days)

NAMENDA XR ORAL

CAP,SPRINKLE,ER 24HR DOSE PACK


NAMENDA XR ORAL

CAPSULE,SPRINKLE,ER 24HR


NAMZARIC 1

rivastigmine (Exelon) 1 QL (30 per 30 days)

rivastigmine tartrate (Exelon) 1 QL (60 per 30 days)

Antidepressants

Antidepressants

amitriptyline (Amitriptyline HCl) 1 PA NSO-HRM

amoxapine (Amoxapine) 1



35




Drug Name


BRINTELLIX 1 ST

bupropion hcl oral tablet (Wellbutrin) 1

bupropion hcl oral tablet extended release

, 150 mg

(Wellbutrin SR) 1

bupropion hcl oral tablet extended release

24 hr

(Wellbutrin XL) 1

citalopram oral solution (Citalopram

Hydrobromide)

1

citalopram oral tablet (Celexa) 1 QL (30 per 30 days)

clomipramine (Anafranil) 1 PA NSO-HRM

desipramine oral (Norpramin) 1

doxepin oral (Doxepin HCl) 1 PA NSO-HRM

duloxetine oral capsule,delayed

release(dr/ec) 20 mg, 60 mg

(Duloxetine) 1 (Cymbalta); QL (60 per

30 days)


release(dr/ec) 30 mg

(Duloxetine) 1 (Cymbalta); QL (30 per

30 days)


release(dr/ec) 40 mg

(Duloxetine) 1 (Irenka); QL (30 per 30

days)

EMSAM 1 QL (30 per 30 days)

escitalopram oxalate (Lexapro) 1

FETZIMA 1 ST

fluoxetine oral capsule (Prozac) 1

fluoxetine oral capsule,delayed

release(dr/ec)

(Prozac Weekly) 1

fluoxetine oral solution (Fluoxetine HCl) 1

fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 1

fluvoxamine (Fluvoxamine Maleate) 1

imipramine hcl (Tofranil) 1 PA NSO-HRM

imipramine pamoate (Tofranil-Pm) 1 PA NSO-HRM

maprotiline (Maprotiline HCl) 1

MARPLAN 1

mirtazapine (Remeron) 1

nefazodone (Nefazodone HCl) 1

nortriptyline oral capsule (Pamelor) 1

nortriptyline oral solution (Nortriptyline HCl) 1

olanzapine-fluoxetine (Symbyax) 1

paroxetine hcl oral tablet (Paxil) 1



36




Drug Name


paroxetine hcl oral tablet extended release

24 hr

(Paxil CR) 1

PAXIL ORAL SUSPENSION 1

perphenazine-amitriptyline (Perphenazine/Amitripty

line HCl)

1 PA NSO-HRM

phenelzine (Nardil) 1

PRISTIQ 1 ST ; QL (30 per 30 days)

protriptyline (Protriptyline HCl) 1

sertraline (Zoloft) 1

SILENOR 1 QL (30 per 30 days)

SURMONTIL 1 PA NSO-HRM

tranylcypromine (Parnate) 1

trazodone (Trazodone HCl) 1

trimipramine (Trimipramine Maleate) 1 PA NSO-HRM

venlafaxine oral capsule,extended release

24hr

(Effexor XR) 1

venlafaxine oral tablet (Venlafaxine HCl) 1

venlafaxine oral tablet extended release

24hr 150 mg, 37.5 mg, 75 mg

(Venlafaxine HCl) 1

VIIBRYD 1

Antidiabetic Agents

Antidiabetic Agents,

Miscellaneous

acarbose (Precose) 1 QL (90 per 30 days)

CYCLOSET 1 QL (180 per 30 days)

GLYXAMBI 1 ST; QL (30 per 30 days)

INVOKAMET ORAL TABLET 150-

1,000 MG, 150-500 MG, 50-1,000 MG

1 ST; QL (60 per 30 days)

INVOKAMET ORAL TABLET 50-500

MG

1 ST; QL (120 per 30

days)

INVOKANA ORAL TABLET 100 MG 1 ST; QL (60 per 30 days)

INVOKANA ORAL TABLET 300 MG 1 ST; QL (30 per 30 days)

JANUMET 1

JANUMET XR 1

JANUVIA 1

JARDIANCE 1 ST; QL (30 per 30 days)

JENTADUETO 1



37




Drug Name


KORLYM 1 PA; QL (112 per 28

days)

metformin oral tablet 1,000 mg (Glucophage) 1 QL (60 per 30 days)

metformin oral tablet 500 mg (Glucophage) 1 QL (150 per 30 days)

metformin oral tablet 850 mg (Glucophage) 1 QL (90 per 30 days)

metformin oral tablet extended release 24

hr 500 mg

(Glucophage XR) 1 QL (120 per 30 days)

metformin oral tablet extended release 24

hr 750 mg

(Glucophage XR) 1 QL (90 per 30 days)

metformin oral tablet extended release

24hr 1,000 mg

(Fortamet) 1 QL (60 per 30 days)

nateglinide (Starlix) 1 QL (90 per 30 days)

pioglitazone (Actos) 1 QL (30 per 30 days)

pioglitazone-glimepiride (Duetact) 1 QL (30 per 30 days)

pioglitazone-metformin (Actoplus Met) 1 QL (90 per 30 days)

PRANDIMET 1 QL (150 per 30 days)

repaglinide (Prandin) 1 QL (240 per 30 days)

repaglinide-metformin (Prandimet) 1 QL (150 per 30 days)

SYMLINPEN 120 1 PA; QL (10.8 per 28

days)

SYMLINPEN 60 1 PA; QL (6 per 28 days)

SYNJARDY 1 ST; QL (60 per 30 days)

TRADJENTA 1

TRULICITY 1

VICTOZA 3-PAK 1

Insulins

HUMULIN R U-500

(CONCENTRATED)


LANTUS 1

LANTUS SOLOSTAR 1

NOVOLIN 70/30 1 QL (40 per 28 days)

NOVOLIN N 1 QL (40 per 28 days)

NOVOLIN R 1 QL (40 per 28 days)

NOVOLOG 1 QL (40 per 28 days)

NOVOLOG FLEXPEN 1 QL (30 per 28 days)

NOVOLOG MIX 70-30 1 QL (40 per 28 days)

NOVOLOG MIX 70-30 FLEXPEN 1 QL (30 per 28 days)

NOVOLOG PENFILL 1 QL (30 per 28 days)



38




Drug Name


TOUJEO SOLOSTAR 1

Sulfonylureas

glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 QL (30 per 30 days)

glimepiride oral tablet 4 mg (Amaryl) 1 QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 1 QL (120 per 30 days)

glipizide oral tablet 5 mg (Glucotrol) 1 QL (60 per 30 days)

glipizide oral tablet extended release 24hr

10 mg

(Glucotrol XL) 1 QL (60 per 30 days)

glipizide oral tablet extended release 24hr

2.5 mg, 5 mg

(Glucotrol XL) 1 QL (30 per 30 days)

glipizide-metformin oral tablet 2.5-250 mg (Glipizide/Metformin

HCl)


glipizide-metformin oral tablet 2.5-500

mg, 5-500 mg

(Glipizide/Metformin

HCl)


glyburide micronized oral tablet 1.5 mg (Glynase) 1 PA-HRM; QL (400 per

30 days)

glyburide micronized oral tablet 3 mg (Glynase) 1 PA-HRM; QL (180 per

30 days)

glyburide micronized oral tablet 6 mg (Glynase) 1 PA-HRM; QL (120 per

30 days)

glyburide oral tablet 1.25 mg (Glyburide) 1 PA-HRM; QL (280 per

30 days)

glyburide oral tablet 2.5 mg (Glyburide) 1 PA-HRM; QL (240 per

30 days)

glyburide oral tablet 5 mg (Glyburide) 1 PA-HRM; QL (120 per

30 days)

glyburide-metformin oral tablet 1.25-250

mg

(Glucovance) 1 PA-HRM; QL (240 per

30 days)

glyburide-metformin oral tablet 2.5-500

mg, 5-500 mg

(Glucovance) 1 PA-HRM; QL (120 per

30 days)

tolazamide oral tablet 250 mg (Tolazamide) 1 QL (120 per 30 days)

tolazamide oral tablet 500 mg (Tolazamide) 1 QL (60 per 30 days)

tolbutamide (Tolbutamide) 1 QL (180 per 30 days)

Antifungals

Antifungals

ABELCET 1 PA BvD

AMBISOME 1 PA BvD

amphotericin b (Amphotericin B) 1 PA BvD



39




Drug Name


CANCIDAS 1

ciclopirox topical cream (Ciclodan) 1

ciclopirox topical gel (Loprox) 1

ciclopirox topical shampoo (Loprox) 1

ciclopirox topical solution (Penlac) 1

ciclopirox topical suspension (Ciclopirox Olamine) 1

ciclopirox-ure-camph-menth-euc (Ciclodan) 1

clotrimazole mucous membrane (Clotrimazole) 1

clotrimazole topical (Clotrimazole) 1

clotrimazole-betamethasone topical cream (Lotrisone) 1

clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth

asone Dip)

1

econazole topical (Econazole Nitrate) 1

fluconazole (Diflucan) 1

fluconazole in dextrose(iso-o) intravenous

piggyback 400 mg/200 ml

(Fluconazole In

Nacl,Iso-Osm)

1

fluconazole-nacl 400 mg/200 ml latex-free,

outer

(Fluconazole In

Nacl,Iso-Osm)

1

flucytosine (Ancobon) 1

griseofulvin microsize oral tablet (Grifulvin V) 1

itraconazole (Sporanox) 1

ketoconazole oral (Ketoconazole) 1

ketoconazole topical cream (Ketoconazole) 1

ketoconazole topical shampoo (Nizoral) 1

miconazole nitrate vaginal suppository

200 mg

(Miconazole Nitrate) 1

NOXAFIL ORAL 1

NYSTATIN (BULK) POWDER 1

BILLION UNIT, 10 BILLION UNIT

1

nystatin oral suspension (Nystatin) 1

nystatin oral tablet (Nystatin) 1

nystatin topical (Nystatin) 1

nystatin topical powder 100,000 unit/gram (Nystatin) 1

nystatin-triamcinolone (Nystatin/Triamcin) 1

terbinafine hcl oral (Lamisil) 1

voriconazole intravenous (Vfend IV) 1

voriconazole oral (Vfend) 1

Antihistamines



40




Drug Name


Antihistamines

cyproheptadine (Cyproheptadine HCl) 1

diphenhydramine hcl injection solution 50

mg/ml

(Diphenhydramine HCl) 1

levocetirizine (Xyzal) 1

promethazine oral syrup (Promethazine HCl) 1 PA-HRM

Anti-Infectives (Skin And Mucous

Membrane)

Anti-Infectives (Skin And

Mucous Membrane)

AVC VAGINAL 1

clindamycin phosphate vaginal (Cleocin) 1

metronidazole vaginal (Metrogel-Vaginal) 1

terconazole vaginal cream (Terazol 7) 1

terconazole vaginal suppository (Terconazole) 1

Antimigraine Agents

Antimigraine Agents

dihydroergotamine injection (D.H.E.45) 1 QL (30 per 28 days)

dihydroergotamine nasal (Migranal) 1 QL (8 per 28 days)

ERGOMAR 1 QL (40 per 28 days)

naratriptan (Amerge) 1 QL (18 per 28 days)

rizatriptan oral tablet (Maxalt) 1 QL (18 per 28 days)

rizatriptan oral tablet,disintegrating (Maxalt Mlt) 1 QL (18 per 28 days)

sumatriptan (Imitrex) 1 QL (12 per 28 days)

sumatriptan 4 mg/0.5 ml inject latex-free (Sumatriptan Succinate) 1 QL (4 per 28 days)

sumatriptan 4 mg/0.5 ml refill (Imitrex) 1 QL (4 per 28 days)

sumatriptan 6 mg/0.5 ml refill latex-free (Imitrex) 1 QL (4 per 28 days)

sumatriptan succinate oral (Imitrex) 1 QL (18 per 28 days)

sumatriptan succinate subcutaneous

cartridge 4 mg/0.5 ml

(Sumatriptan Succinate) 1 QL (4 per 28 days)

sumatriptan succinate subcutaneous pen

injector 6 mg/0.5 ml

(Imitrex) 1 QL (4 per 28 days)

sumatriptan succinate subcutaneous pen

injector 6 mg/0.5 ml (auto-injector)

(Sumatriptan Succinate) 1 QL (4 per 28 days)

sumatriptan succinate subcutaneous

solution

(Imitrex) 1 QL (4 per 28 days)

zolmitriptan oral tablet (Zomig) 1 QL (12 per 28 days)

zolmitriptan oral tablet,disintegrating (Zomig Zmt) 1 QL (12 per 28 days)



41




Drug Name


Antimycobacterials

Antimycobacterials

CAPASTAT 1

dapsone (Dapsone) 1

ethambutol (Myambutol) 1

isoniazid oral (Isoniazid) 1

PASER 1

PRIFTIN 1

pyrazinamide (Pyrazinamide) 1

rifabutin (Mycobutin) 1

rifampin intravenous (Rifadin) 1

rifampin oral (Rifadin) 1

RIFATER 1

SIRTURO 1 PA; QL (188 per 168

days)

TRECATOR 1

Antinausea Agents

Antinausea Agents

AKYNZEO 1 PA BvD

dimenhydrinate injection solution (Dimenhydrinate) 1

dronabinol (Marinol) 1

EMEND INTRAVENOUS 1 QL (2 per 28 days)

EMEND ORAL CAPSULE 125 MG, 80

MG

1 PA BvD

EMEND ORAL CAPSULE 40 MG 1

EMEND ORAL CAPSULE,DOSE PACK 1 PA BvD

granisetron (pf) intravenous solution 100

mcg/ml

(Granisetron HCl/PF) 1

granisetron hcl intravenous solution 1

mg/ml (1 ml)

(Granisetron HCl) 1

granisetron hcl oral (Granisetron HCl) 1 PA BvD

meclizine oral tablet 12.5 mg, 25 mg (Antivert) 1

ondansetron (Zofran Odt) 1 PA BvD

ondansetron hcl (pf) (Ondansetron HCl/PF) 1

ondansetron hcl oral (Zofran) 1 PA BvD

prochlorperazine (Compazine) 1



42




Drug Name


prochlorperazine edisylate injection

solution 10 mg/2 ml (5 mg/ml)

(Prochlorperazine

Edisylate)

1

prochlorperazine maleate oral (Compazine) 1

promethazine hcl (Phenergan) 1 PA-HRM

promethazine oral tablet (Promethazine HCl) 1 PA-HRM

promethazine rectal (Phenergan) 1 PA-HRM

TRANSDERM-SCOP 1 QL (10 per 30 days)

Antiparasite Agents

Antiparasite Agents

ALBENZA 1

ALINIA 1

atovaquone (Mepron) 1

atovaquone-proguanil (Malarone) 1

chloroquine phosphate oral (Chloroquine Phosphate) 1

COARTEM 1

DARAPRIM 1

hydroxychloroquine oral (Plaquenil) 1

ivermectin oral (Stromectol) 1

mefloquine (Mefloquine HCl) 1

NEBUPENT 1 PA BvD

paromomycin (Paromomycin Sulfate) 1

PENTAM 1

PRIMAQUINE 1 QL (90 per 30 days)

quinine sulfate (Qualaquin) 1 PA; QL (42 per 7 days)

Antiparkinsonian Agents

Antiparkinsonian Agents

amantadine hcl (Amantadine HCl) 1

APOKYN 1 QL (60 per 30 days)

AZILECT 1

benztropine oral (Benztropine Mesylate) 1 PA-HRM

bromocriptine (Parlodel) 1

cabergoline (Cabergoline) 1

carbidopa (Lodosyn) 1

carbidopa-levodopa oral tablet (Sinemet CR) 1

carbidopa-levodopa oral tablet extended

release

(Sinemet CR) 1

carbidopa-levodopa-entacapone (Stalevo 50) 1



43




Drug Name


entacapone (Comtan) 1

NEUPRO 1 ST; QL (30 per 30 days)

pramipexole oral tablet (Mirapex) 1

ropinirole oral tablet (Requip) 1

ropinirole oral tablet extended release 24

hr

(Requip XL) 1

selegiline hcl oral capsule (Eldepryl) 1

selegiline hcl oral tablet (Selegiline HCl) 1

trihexyphenidyl (Trihexyphenidyl HCl) 1 PA-HRM

Antipsychotic Agents

Antipsychotic Agents

ABILIFY DISCMELT ORAL

TABLET,DISINTEGRATING 10 MG


ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSION,EXTENDED REL

RECON 300 MG

1

ABILIFY MAINTENA

INTRAMUSCULAR


RECON 400 MG


ABILIFY MAINTENA

INTRAMUSCULAR


SYRING


aripiprazole oral solution (Abilify) 1 QL (900 per 30 days)

aripiprazole oral tablet 10 mg, 15 mg, 20

mg, 30 mg, 5 mg

(Abilify) 1 QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 1 QL (60 per 30 days)

aripiprazole oral tablet,disintegrating 10

mg

(Abilify Discmelt) 1 QL (90 per 30 days)

aripiprazole oral tablet,disintegrating 15

mg

(Abilify Discmelt) 1 QL (60 per 30 days)

ARISTADA INTRAMUSCULAR


SYRING 441 MG/1.6 ML

1 QL (1.6 per 28 days)







44




Drug Name






chlorpromazine (Chlorpromazine HCl) 1

clozapine oral tablet 100 mg (Clozaril) 1 QL (270 per 30 days)

clozapine oral tablet 200 mg (Clozaril) 1 QL (135 per 30 days)

clozapine oral tablet 25 mg, 50 mg (Clozaril) 1 QL (90 per 30 days)

clozapine oral tablet,disintegrating (Fazaclo) 1 ST

FANAPT ORAL TABLET 1 ST ; QL (60 per 30 days)

FANAPT ORAL TABLETS,DOSE

PACK

1 ST ; QL (8 per 28 days)

fluphenazine decanoate (Fluphenazine

Decanoate)

1

fluphenazine hcl (Fluphenazine HCl) 1

GEODON INTRAMUSCULAR 1 QL (6 per 28 days)

haloperidol (Haloperidol) 1

haloperidol decanoate intramuscular

solution 100 mg/ml

(Haloperidol Decanoate) 1

haloperidol decanoate intramuscular

solution 50 mg/ml

(Haldol Decanoate 50) 1

haloperidol lactate (Haloperidol Lactate) 1

INVEGA ORAL TABLET EXTENDED

RELEASE 24HR 1.5 MG, 3 MG, 9 MG


INVEGA ORAL TABLET EXTENDED

RELEASE 24HR 6 MG


INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 117

MG/0.75 ML

1 QL (0.75 per 28 days)

INVEGA SUSTENNA


MG/ML


INVEGA SUSTENNA


MG/1.5 ML


INVEGA SUSTENNA


MG/0.25 ML

1 QL (0.25 per 28 days)



45




Drug Name


INVEGA SUSTENNA


MG/0.5 ML


INVEGA TRINZA INTRAMUSCULAR

SYRINGE 273 MG/0.875 ML

1 QL (0.875 per 84 days)



1 QL (1.315 per 84 days)



1 QL (1.75 per 84 days)



1 QL (2.625 per 84 days)

LATUDA 1

loxapine succinate (Loxapine Succinate) 1

molindone oral tablet 10 mg (Moban) 1 QL (240 per 30 days)



olanzapine intramuscular (Zyprexa) 1 QL (30 per 30 days)

olanzapine oral tablet (Zyprexa) 1 QL (30 per 30 days)

olanzapine oral tablet,disintegrating 10

mg, 15 mg, 5 mg

(Zyprexa Zydis) 1 QL (30 per 30 days)

olanzapine oral tablet,disintegrating 20

mg

(Zyprexa Zydis) 1 QL (31 per 30 days)

ORAP 1

paliperidone oral tablet extended release

24hr 1.5 mg, 3 mg, 9 mg

(Invega) 1 QL (30 per 30 days)

paliperidone oral tablet extended release

24hr 6 mg

(Invega) 1 QL (60 per 30 days)

perphenazine (Perphenazine) 1

pimozide (Orap) 1

quetiapine (Seroquel) 1 QL (90 per 30 days)

REXULTI ORAL TABLET 0.25 MG 1 QL (120 per 30 days)

REXULTI ORAL TABLET 0.5 MG 1 QL (60 per 30 days)

REXULTI ORAL TABLET 1 MG, 2 MG,

3 MG, 4 MG


RISPERDAL CONSTA 1 QL (4 per 28 days)

risperidone oral solution (Risperdal) 1 QL (480 per 30 days)

risperidone oral tablet (Risperdal) 1 QL (60 per 30 days)



46




Drug Name


risperidone oral tablet,disintegrating 0.25

mg, 0.5 mg, 1 mg, 2 mg

(Risperdal M-Tab) 1 QL (60 per 30 days)

risperidone oral tablet,disintegrating 3

mg, 4 mg

(Risperdal M-Tab) 1 QL (120 per 30 days)

SAPHRIS (BLACK CHERRY) 1 ST ; QL (60 per 30 days)

thioridazine (Thioridazine HCl) 1 PA NSO-HRM

thiothixene (Thiothixene) 1

trifluoperazine (Trifluoperazine HCl) 1

VERSACLOZ 1 ST ; QL (540 per 30

days)

VRAYLAR ORAL CAPSULE 1 ST ; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE,DOSE

PACK

1 ST ; QL (7 per 30 days)

ziprasidone hcl (Geodon) 1 QL (60 per 30 days)

ZYPREXA RELPREVV 405 MG VL KIT

W/ DILUENT, OUTER

1

ZYPREXA RELPREVV

INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION 210 MG

1

Antivirals (Systemic)

Antiretrovirals

abacavir (Ziagen) 1

abacavir-lamivudine-zidovudine (Trizivir) 1

APTIVUS 1

ATRIPLA 1

COMPLERA 1

CRIXIVAN ORAL CAPSULE 200 MG,

400 MG

1

didanosine (Videx EC) 1

EDURANT 1

EMTRIVA 1

EPIVIR HBV ORAL SOLUTION 1

EPZICOM 1

EVOTAZ 1

FUZEON SUBCUTANEOUS RECON

SOLN

1

GENVOYA 1

INTELENCE 1



47




Drug Name


INVIRASE 1

ISENTRESS 1

KALETRA 1

lamivudine (Epivir) 1

lamivudine-zidovudine (Combivir) 1

LEXIVA 1

nevirapine oral suspension (Viramune) 1

nevirapine oral tablet (Viramune) 1

nevirapine oral tablet extended release 24

hr

(Viramune XR) 1

NORVIR 1

PREZCOBIX 1

PREZISTA 1

RESCRIPTOR 1

RETROVIR INTRAVENOUS 1

REYATAZ ORAL CAPSULE 150 MG,

200 MG, 300 MG

1

REYATAZ ORAL POWDER IN

PACKET

1

SELZENTRY 1

stavudine (Zerit) 1

STRIBILD 1

SUSTIVA 1

TIVICAY 1

TRIUMEQ 1

TRUVADA 1

VIDEX 2 GRAM PEDIATRIC 1

VIDEX 4 GM PEDIATRIC SOLN 1

VIRACEPT ORAL TABLET 1

VIRAMUNE XR ORAL TABLET

EXTENDED RELEASE 24 HR 100 MG

1

VIREAD 1

VITEKTA 1

ZIAGEN ORAL SOLUTION 1

zidovudine oral capsule (Retrovir) 1

zidovudine oral syrup (Retrovir) 1

zidovudine oral tablet (Zidovudine) 1

Antivirals, Miscellaneous



48




Drug Name


foscarnet (Foscavir) 1 PA BvD

RELENZA DISKHALER 1

rimantadine (Flumadine) 1

SYNAGIS 100 MG/1 ML VIAL 1

SYNAGIS INTRAMUSCULAR

SOLUTION 50 MG/0.5 ML

1

TAMIFLU ORAL CAPSULE 30 MG 1 QL (84 per 180 days)



TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION

1 QL (540 per 180 days)

Hcv Antivirals

DAKLINZA 1 PA; QL (28 per 28 days)

HARVONI 1 PA; QL (30 per 30 days)

OLYSIO 1 PA; QL (28 per 28 days)

SOVALDI 1 PA; QL (28 per 28 days)

TECHNIVIE 1 PA; QL (56 per 28 days)

VIEKIRA PAK 1 PA; QL (112 per 28

days)

ZEPATIER 1 PA; QL (30 per 30 days)

Interferons

INTRON A 10 MILLION UNIT/ML 1 PA NSO

INTRON A INJECTION RECON SOLN 1 PA NSO

INTRON A INJECTION SOLUTION 6

MILLION UNIT/ML

1 PA NSO

PEGASYS 1 PA

PEGASYS PROCLICK 1 PA

PEGINTRON 1 PA

SYLATRON 1 PA NSO; QL (4 per 28

days)

Nucleosides And Nucleotides

acyclovir oral capsule (Zovirax) 1

acyclovir oral suspension 200 mg/5 ml (Zovirax) 1

acyclovir oral tablet (Zovirax) 1

acyclovir sodium intravenous solution (Acyclovir Sodium) 1 PA BvD

adefovir (Hepsera) 1

entecavir (Baraclude) 1

famciclovir (Famvir) 1



49




Drug Name


ganciclovir sodium (Cytovene) 1 PA BvD

ribavirin oral capsule 200 mg (Rebetol) 1

ribavirin oral tablet 200 mg, 400 mg, 600

mg

(Copegus) 1

TYZEKA 1

valacyclovir (Valtrex) 1

valganciclovir (Valcyte) 1

VIRAZOLE 1 PA BvD

Blood Products/Modifiers/Volume

Expanders

Anticoagulants

CEPROTIN (BLUE BAR) 1

ELIQUIS 1

enoxaparin subcutaneous solution (Lovenox) 1 QL (36 per 30 days)

enoxaparin subcutaneous syringe 100

mg/ml

(Lovenox) 1 QL (36 per 30 days)


mg/0.8 ml, 80 mg/0.8 ml

(Lovenox) 1 QL (27.2 per 30 days)


mg/ml



mg/0.3 ml



mg/0.4 ml



mg/0.6 ml


fondaparinux subcutaneous syringe 10

mg/0.8 ml

(Arixtra) 1 QL (24 per 30 days)

fondaparinux subcutaneous syringe 2.5

mg/0.5 ml


fondaparinux subcutaneous syringe 5

mg/0.4 ml


fondaparinux subcutaneous syringe 7.5

mg/0.6 ml


heparin (porcine) in 5 % dex intravenous

parenteral solution 12,500 unit/250 ml,

20,000 unit/500 ml (40 unit/ml), 25,000

unit/500 ml (50 unit/ml)

(Heparin

Sodium,Porcine/D5W)

1



50




Drug Name


heparin (porcine) in 5 % dex intravenous

parenteral solution 25,000 unit/250

ml(100 unit/ml)

(Heparin Sod,Pork In

0.45% NaCl)

1

heparin (porcine) in nacl (pf) intravenous

parenteral solution 1,000 unit/500 ml

(Heparin

Sodium,Porcine/Ns/PF)

1

heparin (porcine) injection solution 1,000

unit/ml, 20,000 unit/ml, 5,000 unit/ml

(Heparin

Sodium,Porcine)

1 (PA for ESRD Only)

heparin (porcine) injection solution

10,000 unit/ml

(Heparin

Sodium,Porcine)

1

heparin sodium,porcine-pf intravenous

syringe 10 unit/ml

(Monoject Prefill

Advanced)

1

heparin, porcine (pf) injection solution

5,000 unit/0.5 ml

(Heparin

Sodium,Porcine/PF)


heparin, porcine (pf) injection syringe (Monoject Prefill

Advanced)


heparin, porcine (pf) intravenous syringe (Monoject Prefill

Advanced)

1

heparin-0.45% nacl 25,000 units/250 ml

(100 units/ml) bag latex-free, inner

(Heparin Sod,Pork In

0.45% NaCl)

1

heparin-d5w 25,000 units/250 ml (100

units/ml) bag excel container

(Heparin

Sodium,Porcine/D5W)

1

IPRIVASK 1 PA; QL (24 per 28 days)

jantoven (Coumadin) 1

PRADAXA 1 ST; QL (60 per 30 days)

warfarin (Coumadin) 1

XARELTO 1

Blood Formation Modifiers

CINRYZE 1 PA

EPOGEN 10,000 UNITS/ML VIAL SDV,

P/F, OUTER


EPOGEN INJECTION SOLUTION 2,000

UNIT/ML, 20,000 UNIT/2 ML, 20,000

UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML


GRANIX 1

LEUKINE INJECTION RECON SOLN 1

MIRCERA 1 PA; QL (0.6 per 28 days)

MOZOBIL 1

NEULASTA 1



51




Drug Name


NEUMEGA 1

NEUPOGEN 1

PROCRIT 10,000 UNITS/ML VIAL 4'S,

MDV, OUTER


PROCRIT INJECTION SOLUTION

10,000 UNIT/ML, 2,000 UNIT/ML,

20,000 UNIT/ML, 3,000 UNIT/ML, 4,000

UNIT/ML


PROCRIT INJECTION SOLUTION

40,000 UNIT/ML


PROMACTA 1 PA; QL (30 per 30 days)

ZARXIO 1

Hematologic Agents,

Miscellaneous

aminocaproic acid oral (Aminocaproic Acid) 1

anagrelide (Agrylin) 1

protamine (Protamine Sulfate) 1 (PA for ESRD Only)

tranexamic acid intravenous (Tranexamic Acid) 1

tranexamic acid oral (Lysteda) 1 QL (30 per 30 days)

Platelet-Aggregation Inhibitors

AGGRENOX 1 QL (60 per 30 days)

aspirin-dipyridamole (Aggrenox) 1

BRILINTA 1

cilostazol (Pletal) 1

clopidogrel (Plavix) 1

EFFIENT 1 QL (30 per 30 days)

pentoxifylline (Pentoxifylline) 1

Volume Expanders

ALBUKED-25 1

ALBUKED-5 1

ALBUMIN, HUMAN 20 % 1



ALBUMINAR 25 % 1

ALBUMINAR 5 % 1

ALBURX (HUMAN) 5 % 1

ALBUTEIN 25 % 1

ALBUTEIN 5 % 1



52




Drug Name


BUMINATE 25 % 1

BUMINATE 5 % 1

FLEXBUMIN 25 % 1

FLEXBUMIN 5 % 1

KEDBUMIN 1

PLASBUMIN 25 % 1

PLASBUMIN 5 % 1

Caloric Agents

Caloric Agents

AMINO ACIDS 15 % 1 PA BvD

AMINOSYN 10 % 1 PA BvD

AMINOSYN 3.5 % 1 PA BvD

AMINOSYN 7 % 1 PA BvD

AMINOSYN 7 % WITH

ELECTROLYTES

1 PA BvD

AMINOSYN 8.5 % 1 PA BvD

AMINOSYN 8.5 %-ELECTROLYTES 1 PA BvD

AMINOSYN II 10 % 1 PA BvD



AMINOSYN II 8.5 % 1 PA BvD

AMINOSYN II 8.5 %-ELECTROLYTES 1 PA BvD

AMINOSYN M 3.5 % 1 PA BvD

AMINOSYN-HBC 7% 1 PA BvD

AMINOSYN-PF 10 % 1 PA BvD

AMINOSYN-PF 7 % (SULFITE-FREE) 1 PA BvD

AMINOSYN-RF 5.2 % 1 PA BvD

CLINIMIX 5%/D15W SULFITE FREE 1 PA BvD

CLINIMIX 5%/D25W SULFITE-FREE 1 PA BvD

CLINIMIX 2.75%/D5W SULFIT FREE 1 PA BvD

CLINIMIX 4.25%/D10W SULF FREE 1 PA BvD

CLINIMIX 4.25%/D5W SULFIT FREE 1 PA BvD

CLINIMIX 4.25%-D20W SULF-FREE 1 PA BvD

CLINIMIX 4.25%-D25W SULF-FREE 1 PA BvD

CLINIMIX 5%-D20W(SULFITE-FREE) 1 PA BvD

CLINIMIX E 2.75%/D10W SUL FREE 1 PA BvD

CLINIMIX E 2.75%/D5W SULF FREE 1 PA BvD



53




Drug Name




CLINIMIX E 4.25%/D5W SULF FREE 1 PA BvD

CLINIMIX E 5%/D15W SULFIT FREE 1 PA BvD



CLINISOL SF 15 % 1 PA BvD

cysteine (l-cysteine) intravenous solution (Cysteine HCl) 1 PA BvD

dextrose 10 % in water (d10w) (Dextrose 10 % in

Water)

1 PA BvD


Water)

1 PA BvD


Water)

1 PA BvD


Water)

1 PA BvD

dextrose 5 % in ringers (Dextrose 5% In

Ringers)

1

dextrose 5 % in water (d5w) intravenous

parenteral solution

(Dextrose 5 % in Water) 1


Water)

1 PA BvD


Water)

1 PA BvD

FREAMINE HBC 6.9 % 1 PA BvD

FREAMINE III 10 % 1 PA BvD

HEPATAMINE 8% 1 PA BvD

HEPATASOL 8 % 1 PA BvD

INTRALIPID INTRAVENOUS

EMULSION 20 %, 30 %

1 PA BvD

KABIVEN 1 PA BvD

LIPOSYN II 1 PA BvD

LIPOSYN III 1 PA BvD

NEPHRAMINE 5.4 % 1 PA BvD

NUTRILIPID 1 PA BvD

PERIKABIVEN 1 PA BvD

PREMASOL 10 % 1 PA BvD

PREMASOL 6 % 1 PA BvD



54




Drug Name


PROCALAMINE 3% 1 PA BvD

PROSOL 20 % 1 PA BvD

TRAVASOL 10 % 1 PA BvD

TROPHAMINE 10 % 1 PA BvD

TROPHAMINE 6% 1 PA BvD

Cardiovascular Agents

Alpha-Adrenergic Agents

clonidine hcl oral tablet (Catapres) 1

clonidine hcl-chlorthalidone (Clonidine

HCl/Chlorthalidone)

1

clonidine transdermal patch weekly 0.1

mg/24 hr, 0.2 mg/24 hr

(Catapres-Tts 1) 1 QL (4 per 28 days)

clonidine transdermal patch weekly 0.3

mg/24 hr

(Catapres-Tts 1) 1 QL (8 per 28 days)

doxazosin (Cardura) 1

guanfacine oral tablet (Tenex) 1 PA-HRM

midodrine (Midodrine HCl) 1

NORTHERA 1 PA; QL (180 per 30

days)

phenylephrine hcl injection (Vazculep) 1

prazosin oral (Minipress) 1

Angiotensin Ii Receptor

Antagonists

BENICAR 1

BENICAR HCT 1

candesartan (Atacand) 1

candesartan-hydrochlorothiazid (Atacand HCT) 1

ENTRESTO 1 PA; QL (60 per 30 days)

irbesartan (Avapro) 1

irbesartan-hydrochlorothiazide (Avalide) 1

losartan (Cozaar) 1

losartan-hydrochlorothiazide (Hyzaar) 1

telmisartan (Micardis) 1

telmisartan-hydrochlorothiazid (Micardis HCT) 1

TRIBENZOR 1 ST

valsartan (Diovan) 1

valsartan-hydrochlorothiazide (Diovan HCT) 1



55




Drug Name


Angiotensin-Converting Enzyme

Inhibitors

benazepril (Lotensin) 1

benazepril-hydrochlorothiazide (Lotensin HCT) 1

captopril (Captopril) 1

captopril-hydrochlorothiazide (Captopril/Hydrochlorot

hiazide)

1

enalapril maleate (Vasotec) 1

enalaprilat intravenous solution (Enalaprilat Dihydrate) 1

enalapril-hydrochlorothiazide (Vaseretic) 1

fosinopril (Fosinopril Sodium) 1

fosinopril-hydrochlorothiazide (Fosinopril/Hydrochloro

thiazide)

1

lisinopril (Zestril) 1

lisinopril-hydrochlorothiazide (Zestoretic) 1

moexipril (Moexipril HCl) 1

moexipril-hydrochlorothiazide (Moexipril/Hydrochlorot

hiazide)

1

perindopril erbumine (Aceon) 1

quinapril (Accupril) 1

quinapril-hydrochlorothiazide (Accuretic) 1

ramipril (Altace) 1

trandolapril (Mavik) 1

Antiarrhythmic Agents

amiodarone hcl oral tablet 100 mg, 200

mg, 400 mg

(Cordarone) 1

amiodarone oral (Cordarone) 1

disopyramide phosphate oral capsule (Norpace) 1

flecainide (Tambocor) 1

lidocaine (pf) intravenous syringe 50 mg/5

ml (1 %)

(Lidocaine HCl/PF) 1

lidocaine in 5 % dextrose (pf) intravenous

parenteral solution 8 mg/ml (0.8 %)

(Lidocaine

HCl/D5w/PF)

1

mexiletine (Mexiletine HCl) 1

MULTAQ 1

procainamide injection (Procainamide HCl) 1

propafenone oral capsule,extended release

12 hr

(Rythmol SR) 1



56




Drug Name


propafenone oral tablet (Rythmol) 1

quinidine gluconate oral (Quinidine Gluconate) 1

quinidine sulfate (Quinidine Sulfate) 1

TIKOSYN 1

Beta-Adrenergic Blocking Agents

acebutolol (Sectral) 1

atenolol (Tenormin) 1

atenolol-chlorthalidone (Tenoretic 50) 1

betaxolol oral (Kerlone) 1

bisoprolol fumarate (Zebeta) 1

bisoprolol-hydrochlorothiazide (Ziac) 1

BYSTOLIC 1

carvedilol (Coreg) 1

esmolol intravenous solution (Esmolol HCl) 1 PA BvD

labetalol intravenous solution (Labetalol HCl) 1

labetalol oral (Trandate) 1

metoprolol succinate (Toprol XL) 1

metoprolol ta-hydrochlorothiaz (Lopressor HCT) 1

metoprolol tartrate intravenous solution (Lopressor) 1

metoprolol tartrate oral tablet 100 mg, 25

mg, 50 mg

(Lopressor) 1

nadolol (Corgard) 1

pindolol (Pindolol) 1

propranolol intravenous (Propranolol HCl) 1

propranolol oral capsule,extended release

24 hr

(Inderal LA) 1

propranolol oral solution (Propranolol HCl) 1

propranolol oral tablet (Propranolol HCl) 1

propranolol-hydrochlorothiazid (Propranolol/Hydrochlor

othiazid)

1

sotalol 120 mg tablet (Betapace) 1

sotalol hcl oral tablet 120 mg, 160 mg,

240 mg, 80 mg

(Betapace) 1

sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) 1

timolol maleate oral (Timolol Maleate) 1

Calcium-Channel Blocking

Agents

cartia xt (Cardizem CD) 1



57




Drug Name


diltiazem 24hr er 180 mg cap (Cardizem CD) 1

diltiazem 24hr er 360 mg cap once a day

dosage

(Cardizem CD) 1

diltiazem hcl intravenous (Cardizem CD) 1

diltiazem hcl oral capsule, extended

release 180 mg, 360 mg, 420 mg

(Cardizem CD) 1

diltiazem hcl oral capsule,extended

release 12 hr

(Cardizem CD) 1

diltiazem hcl oral capsule,extended

release 24hr 120 mg, 240 mg, 300 mg

(Cardizem CD) 1

diltiazem hcl oral tablet (Cardizem CD) 1

diltiazem hcl oral tablet extended release

24 hr

(Cardizem LA) 1

dilt-xr (Cardizem CD) 1

matzim la (Cardizem CD) 1

taztia xt (Cardizem CD) 1

verapamil intravenous syringe (Verapamil HCl) 1

verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 1

verapamil oral capsule,ext rel. pellets 24

hr

(Verelan) 1

verapamil oral tablet (Calan) 1

verapamil oral tablet extended release (Calan SR) 1

Cardiovascular Agents,

Miscellaneous

CORLANOR 1 ST

DEMSER 1

digitek oral tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk

Med for Ages 65 and

Older and Dose is

Greater Than 125mcg

Per Day); QL (30 per 30

days)

digitek oral tablet 250 mcg (Lanoxin) 1 PA-HRM; QL (30 per 30

days)



58




Drug Name


digox 125 mcg tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk

Med for Ages 65 and

Older and Dose is

Greater Than 125mcg


days)

digox 250 mcg tablet 250 mcg (Lanoxin) 1 PA-HRM; (High Risk

Med for Ages 65 and

Older and Dose is

Greater Than 125mcg


days)

digoxin 0.25 mg/ml syringe (Digoxin) 1 PA-HRM

digoxin injection solution (Digoxin) 1 PA-HRM

DIGOXIN ORAL SOLUTION 50

MCG/ML

1 PA-HRM; QL (300 per

30 days)

digoxin oral tablet (Lanoxin) 1 PA-HRM; (High Risk

Med for Ages 65 and

Older and Dose is

Greater Than 125mcg


days)

dobutamine in d5w intravenous parenteral

solution 1,000 mg/250 ml (4,000 mcg/ml),

250 mg/250 ml (1 mg/ml), 500 mg/250 ml

(2,000 mcg/ml)

(Dobutamine HCl/D5W) 1 PA BvD

dobutamine intravenous solution 250

mg/20 ml (12.5 mg/ml)

(Dobutamine HCl) 1 PA BvD

dopamine in 5 % dextrose intravenous

solution 200 mg/250 ml (800 mcg/ml), 400

mg/250 ml (1,600 mcg/ml), 800 mg/250 ml

(3,200 mcg/ml)

(Dopamine HCl/D5W) 1 PA BvD

dopamine intravenous solution 200 mg/5

ml (40 mg/ml), 800 mg/10 ml (80 mg/ml),

800 mg/5 ml (160 mg/ml)

(Dopamine HCl) 1 PA BvD

ephedrine sulfate injection solution (Ephedrine Sulfate) 1

epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) 1

epinephrine injection auto-injector (Adrenaclick) 1

epinephrine injection solution 1 mg/ml (1

ml)

(Epinephrine) 1



59




Drug Name


epinephrine injection syringe 0.1 mg/ml (Epinephrine) 1

EPIPEN 2-PAK 1

EPIPEN JR 2-PAK 1

ethamolin (Ethanolamine Oleate) 1

FIRAZYR 1

hydralazine (Hydralazine HCl) 1

LANOXIN ORAL TABLET 187.5 MCG,

62.5 MCG

1 PA-HRM; (High Risk

Med for Ages 65 and

Older and Dose is

Greater Than 125mcg


days)

milrinone (Milrinone Lactate) 1 PA BvD

milrinone in 5 % dextrose intravenous

piggyback 40 mg/200 ml (200 mcg/ml)

(Milrinone

Lactate/D5W)

1 PA BvD

norepinephrine bitartrate (Levophed Bitartrate) 1 PA BvD

papaverine injection solution (Papaverine HCl) 1 PA

papaverine oral (Papaverine HCl) 1 PA

RANEXA 1

Dihydropyridines

amlodipine (Norvasc) 1

amlodipine-benazepril (Lotrel) 1

amlodipine-valsartan (Exforge) 1

amlodipine-valsartan-hcthiazid (Exforge HCT) 1

AZOR 1 ST

CLEVIPREX INTRAVENOUS

EMULSION 50 MG/100 ML

1

felodipine (Felodipine) 1

isradipine (Isradipine) 1

nicardipine oral (Nicardipine HCl) 1

nifedipine er 30 mg tablet f/c (Adalat CC) 1

nifedipine oral tablet extended release

24hr 30 mg

(Adalat CC) 1

nifedipine oral tablet extended release

24hr 60 mg, 90 mg

(Procardia XL) 1

nifedipine oral tablet extended release 30

mg, 60 mg

(Adalat CC) 1

Diuretics



60




Drug Name


amiloride oral (Midamor) 1

amiloride-hydrochlorothiazide (Amiloride/Hydrochloro

thiazide)

1

bumetanide (Bumetanide) 1

chlorothiazide (Chlorothiazide) 1

chlorothiazide sodium (Sodium Diuril) 1

chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 1

DYRENIUM 1

furosemide injection (Furosemide) 1

furosemide oral solution 10 mg/ml, 40

mg/5 ml

(Furosemide) 1

furosemide oral tablet (Lasix) 1

hydrochlorothiazide oral capsule (Microzide) 1

hydrochlorothiazide oral tablet (Hydrochlorothiazide) 1

indapamide (Indapamide) 1

methyclothiazide (Methyclothiazide) 1

metolazone (Zaroxolyn) 1

torsemide oral (Demadex) 1

triamterene-hydrochlorothiazid oral

capsule

(Dyazide) 1

triamterene-hydrochlorothiazid oral tablet (Maxzide) 1

Dyslipidemics

amlodipine-atorvastatin (Caduet) 1

atorvastatin (Lipitor) 1

cholestyramine packet (Questran) 1

cholestyramine-aspartame oral powder 4

gram

(Cholestyramine/Asparta

me)

1

cholestyramine-aspartame oral powder in

packet 4 gram

(Questran) 1

colestipol hcl granules packet (Colestid) 1

colestipol oral granules (Colestid) 1

colestipol oral tablet (Colestid) 1

CRESTOR 1

fenofibrate micronized (Lofibra) 1

fenofibrate nanocrystallized (Tricor) 1

fenofibrate oral tablet (Lofibra) 1

fenofibric acid (Fibricor) 1

fenofibric acid (choline) (Trilipix) 1



61




Drug Name


gemfibrozil oral (Lopid) 1

JUXTAPID 1 PA

KYNAMRO 1 PA; QL (4 per 28 days)

lovastatin (Mevacor) 1

niacin (Niacin) 1

niacin oral tablet extended release 24 hr (Niaspan) 1

omega-3 acid ethyl esters (Lovaza) 1

PRALUENT PEN 1 PA; QL (2 per 28 days)

PRALUENT SYRINGE 1 PA; QL (2 per 28 days)

pravastatin (Pravachol) 1

prevalite packet outer 4 gram (Cholestyramine/Asparta

me)

1

REPATHA SURECLICK 1 PA; QL (3 per 28 days)

REPATHA SYRINGE 1 PA; QL (3 per 28 days)

simvastatin oral tablet 10 mg, 20 mg, 40

mg, 5 mg

(Zocor) 1

simvastatin oral tablet 80 mg (Zocor) 1 QL (30 per 30 days)

VASCEPA 1

ZETIA 1

Renin-Angiotensin-Aldosterone

System Inhibitors

eplerenone (Inspra) 1

spironolactone (Aldactone) 1

spironolacton-hydrochlorothiaz (Aldactazide) 1

Vasodilators

isosorbide dinitrate oral (Isochron) 1

isosorbide dinitrate sublingual (Isosorbide Dinitrate) 1

isosorbide mononitrate oral tablet (Isosorbide Mononitrate) 1

isosorbide mononitrate oral tablet

extended release 24 hr

(Imdur) 1

minitran transdermal patch 24 hour 0.1

mg/hr, 0.2 mg/hr, 0.6 mg/hr

(Nitro-Dur) 1 QL (30 per 30 days)

minitran transdermal patch 24 hour 0.4

mg/hr


minoxidil oral (Minoxidil) 1

NITRO-BID 1



62




Drug Name


nitroglycerin in 5 % dextrose intravenous

solution 100 mg/250 ml (400 mcg/ml), 25

mg/250 ml (100 mcg/ml), 50 mg/250 ml

(200 mcg/ml)

(Nitroglycerin/D5W) 1

nitroglycerin intravenous (Nitroglycerin) 1

nitroglycerin transdermal patch 24 hour

0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr


nitroglycerin transdermal patch 24 hour

0.4 mg/hr


NITROSTAT 1

PROGLYCEM 1

Central Nervous System Agents

Central Nervous System Agents

amphetamine salt combo (Adderall) 1 QL (60 per 30 days)

AMPYRA 1 PA; QL (60 per 30 days)

caffeine citrated intravenous (Cafcit) 1

caffeine citrated oral (Cafcit) 1

caffeine-sodium benzoate (Caffeine/Sodium

Benzoate)

1

clonidine hcl oral tablet extended release

12 hr

(Kapvay) 1

dexmethylphenidate oral tablet (Focalin) 1 QL (60 per 30 days)

dextroamphetamine oral capsule, extended

release

(Dexedrine) 1 QL (120 per 30 days)

dextroamphetamine oral tablet (Dexedrine) 1 QL (180 per 30 days)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15

mg, 5 mg

(Adderall XR) 1 QL (30 per 30 days)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 20 mg, 25

mg, 30 mg

(Adderall XR) 1 QL (60 per 30 days)

flumazenil (Romazicon) 1

guanfacine oral tablet extended release 24

hr

(Intuniv) 1

lithium carbonate oral capsule (Lithium Carbonate) 1

lithium carbonate oral tablet (Lithobid) 1

lithium carbonate oral tablet extended

release

(Lithobid) 1



63




Drug Name


lithium citrate oral solution 8 meq/5 ml (Lithium Citrate) 1

methylphenidate cd 20 mg cap (Metadate Cd) 1 QL (30 per 30 days)

methylphenidate cd 40 mg cap (Metadate Cd) 1 QL (30 per 30 days)

methylphenidate oral capsule, er biphasic

30-70 10 mg, 50 mg, 60 mg

(Metadate Cd) 1 QL (30 per 30 days)

methylphenidate oral capsule, er biphasic

30-70 30 mg


methylphenidate oral capsule,er biphasic

50-50 20 mg, 40 mg


methylphenidate oral solution (Methylin) 1 QL (900 per 30 days)

methylphenidate oral tablet (Ritalin) 1 QL (90 per 30 days)

methylphenidate oral tablet extended

release

(Methylphenidate HCl) 1 QL (90 per 30 days)


release 24hr 18 mg, 27 mg, 54 mg

(Concerta) 1 QL (30 per 30 days)


release 24hr 36 mg

(Concerta) 1 QL (60 per 30 days)

NUEDEXTA 1 QL (60 per 30 days)

QUILLIVANT XR 1

riluzole (Rilutek) 1

SAVELLA 1 QL (60 per 30 days)

STRATTERA 1

tetrabenazine (Xenazine) 1 PA; QL (112 per 28

days)

XENAZINE 1 PA; QL (112 per 28

days)

Contraceptives

Contraceptives

ashlyna (Seasonique) 1

bekyree (28) (Mircette) 1

blisovi 24 fe (Loestrin Fe) 1

blisovi fe 1.5/30 (28) (Loestrin Fe) 1

blisovi fe 1/20 (28) (Loestrin Fe) 1

cyred (Desogen) 1

deblitane (Nor-Q-D) 1

desog-e.estradiol/e.estradiol (Mircette) 1

desogestrel-ethinyl estradiol (Desogen) 1



64




Drug Name


desogestrel-ethinyl estradiol oral tablet

0.1/.125/.15-25 mg-mcg

(Desogen) 1

drospirenone-ethinyl estradiol (Yaz) 1

ELLA 1 QL (6 per 365 days)

ethinyl estradiol/drospirenone (Yaz) 1

ethynodiol d-ethinyl estradiol (Demulen 1-50-21) 1

gildess 1/20 (21) (Loestrin) 1

gildess 24 fe (Loestrin Fe) 1

gildess fe 1/20 (28) (Loestrin Fe) 1

juleber (Desogen) 1

junel fe 24 (Loestrin Fe) 1

kimidess (28) (Mircette) 1

l norgest/e.estradiol-e.estrad (Seasonique) 1 QL (91 per 84 days)

larin 24 fe (Loestrin Fe) 1

larin fe 1/20 (28) (Loestrin Fe) 1

levonor-eth estrad 0.15-0.03 outer (Amethyst) 1 QL (91 per 84 days)

levonorgestrel oral tablet 0.75 mg (Plan B One-Step) 1 QL (12 per 365 days)

levonorgestrel oral tablet 1.5 mg (Plan B One-Step) 1 QL (6 per 365 days)

levonorgestrel-ethin estradiol oral tablet

0.1-20 mg-mcg, 0.15-0.03 mg, 50-30

(6)/75-40 (5)/125-30(10)

(Amethyst) 1

levonorgestrel-ethin estradiol oral

tablets,dose pack,3 month 0.15-30 mg-mcg

(Levonorgestrel-Ethin

Estradiol)


levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg

(Amethyst) 1

levonorgestrel-ethinyl estrad oral

tablets,dose pack,3 month

(Amethyst) 1 QL (91 per 84 days)

l-norgest-eth estr/ethin estra (Seasonique) 1 QL (91 per 84 days)

norelgestromin/ethin.estradiol (Ortho Evra) 1 QL (3 per 28 days)

norethindrone (Nor-Q-D) 1

norethindrone (contraceptive) (Nor-Q-D) 1

norethindrone ac-eth estradiol oral tablet

1-20 mg-mcg, 1.5-30 mg-mcg

(Loestrin) 1

norethindrone-e.estradiol-iron oral tablet

1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg

(24)/75 mg (4), 1-20(5)/1-30(7) /1mg-

35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7)

(Loestrin Fe) 1



65




Drug Name


norethindrone-ethinyl estrad oral tablet

0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/1-

35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35

mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg

(Modicon) 1

norethindrone-mestranol (Norinyl 1+50) 1

norg-ee 0.18-0.215-0.25/0.035 (Ortho-Cyclen) 1

norgestimate-ethinyl estradiol (Ortho-Cyclen) 1

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-25 mcg

(Ortho-Cyclen) 1

norgestrel-ethinyl estradiol (Norgestrel-Ethinyl

Estradiol)

1

NUVARING 1 ST; QL (1 per 28 days)

setlakin (Levonorgestrel-Ethin

Estradiol)


tarina fe 1/20 (28) (Loestrin Fe) 1

tri-lo-estarylla (Ortho-Cyclen) 1

tri-lo-marzia (Ortho-Cyclen) 1

tri-lo-sprintec (Ortho-Cyclen) 1

vienva (Amethyst) 1

Dental And Oral Agents

Dental And Oral Agents

cevimeline (Evoxac) 1

chlorhexidine gluconate mucous

membrane

(Peridex) 1

pilocarpine hcl oral (Salagen) 1

sodium fluoride oral tablet,chewable 0.25

mg fluorid (0.55 mg)

(Sodium Fluoride) 1

triamcinolone acetonide (Triamcinolone

Acetonide)

1

Dermatological Agents

Dermatological Agents, Other

8-MOP 1

acitretin (Soriatane) 1

acyclovir topical (Zovirax) 1 QL (30 per 30 days)

ALCOHOL PADS 1

ALCOHOL PREP PADS 1

ammonium lactate topical (Lac-Hydrin) 1

ANACAINE 1



66




Drug Name


calcipotriene (Calcipotriene) 1

calcipotriene scalp (Calcipotriene) 1

calcipotriene topical cream (Dovonex) 1

calcitriol topical (Vectical) 1

CONDYLOX TOPICAL GEL 1

COSENTYX 1 PA

COSENTYX (150 MG/ML) 300 MG

DOSE-2 PENS

1 PA

COSENTYX (150 MG/ML) 300 MG

DOSE-2 SYRINGES

1 PA

COSENTYX PEN 1 PA

FLUOROPLEX 1

fluorouracil topical cream (Carac) 1

fluorouracil topical solution (Fluorouracil) 1

imiquimod (Aldara) 1 PA NSO; QL (24 per 30

days)

isotretinoin oral capsule 10 mg, 20 mg, 30

mg, 40 mg

(Isotretinoin) 1

methoxsalen rapid (Oxsoralen-Ultra) 1

PANRETIN 1

PICATO TOPICAL GEL 0.015 % 1 QL (3 per 56 days)

PICATO TOPICAL GEL 0.05 % 1 QL (2 per 56 days)

podofilox (Condylox) 1

podophyllum resin (Podophyllum Resin) 1

potassium hydroxide (Potassium Hydroxide) 1

SANTYL 1

TOLAK 1

VALCHLOR 1

ZOVIRAX TOPICAL CREAM 1 QL (15 per 30 days)

Dermatological Antibacterials

clindamycin phosphate topical gel (Cleocin T) 1

clindamycin phosphate topical lotion (Cleocin T) 1

clindamycin phosphate topical solution (Cleocin T) 1

clindamycin phosphate topical swab (Cleocin T) 1

erythromycin base-ethanol (Erythromycin

Base/Ethanol)

1

erythromycin with ethanol topical gel (Emgel) 1



67




Drug Name


erythromycin with ethanol topical solution (Erythromycin

Base/Ethanol)

1

erythromycin with ethanol topical swab (Erythromycin

Base/Ethanol)

1

gentamicin topical (Gentamicin Sulfate) 1

metronidazole topical cream 0.75 % (Metrocream) 1

metronidazole topical gel (Rosadan) 1

metronidazole topical lotion (Metrolotion) 1

mupirocin (Centany) 1

mupirocin calcium (Bactroban) 1

neomycin-polymyxin b gu (Neosporin G.U.

Irrigant)

1

selenium sulfide topical lotion (Selenium Sulfide) 1

selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) 1

silver nitrate applicators (Silver Nitrate

Applicator)

1

silver nitrate topical (Silver Nitrate) 1

silver sulfadiazine (Silvadene) 1

sulfacetamide sodium (acne) (Klaron) 1

Dermatological Anti-

Inflammatory Agents

alclometasone (Alclometasone

Dipropionate)

1

betamethasone dipropionate (Betamethasone

Dipropionate)

1

betamethasone valerate topical cream (Betamethasone

Valerate)

1

betamethasone valerate topical foam (Luxiq) 1

betamethasone valerate topical lotion (Betamethasone

Valerate)

1

betamethasone valerate topical ointment (Betamethasone

Valerate)

1

betamethasone, augmented topical cream (Diprolene AF) 1

betamethasone, augmented topical gel (Betamethasone

Dipropionate)

1

betamethasone, augmented topical lotion (Diprolene) 1

betamethasone, augmented topical

ointment

(Diprolene) 1



68




Drug Name


clobetasol 0.05% cream (Temovate) 1

clobetasol propionate scalp solution 0.05

%

(Clobetasol Propionate) 1

clobetasol scalp (Clobetasol Propionate) 1

clobetasol topical foam (Olux) 1

clobetasol topical gel (Clobetasol Propionate) 1

clobetasol topical lotion (Clobex) 1

clobetasol topical ointment (Temovate) 1

clobetasol topical shampoo (Clobex) 1

clobetasol-emollient topical cream (Temovate) 1

clocortolone pivalate (Cloderm) 1

desonide topical cream (Desowen) 1

desonide topical ointment (Desonide) 1

desoximetasone (Topicort) 1

ELIDEL 1

fluocinonide 0.05% cream (Vanos) 1

fluocinonide topical gel (Fluocinonide) 1

fluocinonide topical ointment (Fluocinonide) 1

fluocinonide topical solution (Fluocinonide) 1

fluocinonide-emollient base (Vanos) 1

fluticasone topical cream (Cutivate) 1

fluticasone topical ointment (Fluticasone Propionate) 1

halobetasol propionate (Ultravate) 1

hydrocortisone 1% ointment carton (otc) (Hydrocortisone) 1

hydrocortisone acet-aloe vera topical gel (Hydrocortisone

Acetate/Aloe V)

1

hydrocortisone acetate-urea (Hydrocortisone

Acetate/Urea)

1

hydrocortisone buty 0.1% cream (Hydrocortisone

Butyrate)

1

hydrocortisone butyrate topical ointment (Locoid) 1

hydrocortisone butyrate topical solution (Locoid) 1

hydrocortisone butyr-emollient (Hydrocortisone

Butyrate)

1

hydrocortisone rectal cream 1 % (Anusol-HC) 1

hydrocortisone rectal cream 2.5 % (Hydrocortisone) 1

hydrocortisone rectal enema (Cortenema) 1

hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 1



69




Drug Name


hydrocortisone topical lotion 2 %, 2.5 % (Scalacort) 1

hydrocortisone topical ointment 1 %, 2.5

%

(Hydrocortisone) 1

hydrocortisone valerate topical cream (Hydrocortisone

Valerate)

1

hydrocortisone valerate topical ointment (Westcort) 1

mometasone (Elocon) 1

ONFI ORAL TABLET 10 MG, 20 MG 1 PA NSO; QL (60 per 30

days)

prednicarbate (Dermatop) 1

tacrolimus topical (Protopic) 1

triamcinolone acetonide (Triamcinolone

Acetonide)

1

triamcinolone acetonide topical cream (Triamcinolone

Acetonide)

1

triamcinolone acetonide topical lotion (Triamcinolone

Acetonide)

1

triamcinolone acetonide topical ointment

0.025 %, 0.1 %, 0.5 %

(Triamcinolone

Acetonide)

1

Dermatological Retinoids

adapalene topical cream (Differin) 1

adapalene topical gel 0.1 % (Differin) 1

TAZORAC TOPICAL CREAM 1

tretinoin gel micro 0.04% tube (Retin-A Micro) 1 PA

tretinoin gel micro 0.1% tube (Retin-A Micro) 1 PA

tretinoin microspheres topical gel with

pump

(Retin-A Micro) 1 PA

tretinoin topical (Retin-A) 1 PA

Scabicides And Pediculicides

malathion (Ovide) 1

permethrin topical cream (Elimite) 1

Devices

Devices

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X 1/2"

1

BD ECLIPSE LUER-LOK SYRINGE 1

ML 27 X 1/2"

1

BD INSULIN SYR 0.3 ML 31GX5/16 1



70




Drug Name


BD INSULIN SYR 0.5 ML 31GX5/16" 1

BD INSULIN SYR 1 ML 31GX5/16" 1

BD ULTRA-FINE PEN NDL 8MMX31G

SHORT

1

INSULIN SYRINGE-NEEDLE U-100

SYRINGE 0.3 ML 29, 1 ML 29 X 1/2",

1/2 ML 28 GAUGE

1

PEN NEEDLE, DIABETIC NEEDLE 29

GAUGE X 1/2 "

1

VGO 40 DISPOSABLE DEVICE 1

Enzyme Replacement/Modifiers

Enzyme Replacement/Modifiers

ADAGEN 1

ALDURAZYME 1

CEREZYME INTRAVENOUS RECON

SOLN 400 UNIT

1

CREON 1

ELAPRASE 1

ELITEK INTRAVENOUS RECON

SOLN 1.5 MG

1

FABRAZYME INTRAVENOUS RECON

SOLN 35 MG

1

KANUMA 1 PA

KRYSTEXXA 1

KUVAN ORAL TABLET,SOLUBLE 1

lipase-protease-amylase (Lipase/Protease/Amylas

e)

1

MYOZYME 1

NAGLAZYME 1

ORFADIN 1

PULMOZYME 1 PA BvD

STRENSIQ 1 PA; LA

VIMIZIM 1 PA

VPRIV 1

ZAVESCA 1 QL (90 per 30 days)

ZENPEP 1

Eye, Ear, Nose, Throat Agents



71




Drug Name


Eye, Ear, Nose, Throat Agents,

Miscellaneous

AKTEN (PF) 1

altacaine (Tetravisc) 1

apraclonidine (Iopidine) 1

atropine ophthalmic drops (Isopto Atropine) 1

atropine ophthalmic ointment (Atropine Sulfate) 1

atropine sulfate ophthalmic drops 1 % (Isopto Atropine) 1

azelastine nasal aerosol,spray (Astepro) 1 QL (30 per 25 days)

azelastine ophthalmic (Azelastine HCl) 1

carteolol (Carteolol HCl) 1

cromolyn ophthalmic (Cromolyn Sodium) 1

CYCLOGYL OPHTHALMIC DROPS 0.5

%

1

cyclopentolate (Cyclogyl) 1

CYSTARAN 1

epinastine (Elestat) 1

homatropine hbr (Isopto Homatropine) 1

ipratropium bromide nasal spray,non-

aerosol 0.03 %

(Atrovent) 1 QL (30 per 28 days)

ipratropium bromide nasal spray,non-

aerosol 0.06 %

(Atrovent) 1 QL (15 per 10 days)

LACRISERT 1

naphazoline (Naphazoline HCl) 1

olopatadine ophthalmic (Patanol) 1

PATADAY 1 ST

phenylephrine hcl ophthalmic (Mydfrin) 1

proparacaine (Proparacaine HCl) 1

proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) 1

proparacaine-fluorescein sod (Proparacaine/Fluorescei

n Sod)

1

tetracaine hcl (pf) ophthalmic (Tetracaine HCl/PF) 1

Eye, Ear, Nose, Throat Anti-

Infectives Agents

acetic acid otic (Acetic Acid) 1

bacitracin ophthalmic (Bacitracin) 1

bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B

Sulfate)

1



72




Drug Name


CIPRODEX 1

ciprofloxacin hcl ophthalmic (Ciloxan) 1

ciprofloxacin hcl otic (Cetraxal) 1

COLY-MYCIN S 1

erythromycin ophthalmic (Ilotycin) 1

gatifloxacin (Zymaxid) 1

gentamicin ophthalmic (Garamycin) 1

gentamicin sulfate ophthalmic ointment

0.3 % (3 mg/gram)

(Garamycin) 1

levofloxacin ophthalmic (Levofloxacin) 1

MOXEZA 1

NATACYN 1

neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci

Zn/Poly/HC)

1

neomycin-bacitracin-poly-hc (Neomycin Su/Baci

Zn/Poly/HC)

1

neomycin-bacitracin-polymyxin (Neomycin

Su/Bacitra/Polymyxin)

1

neomycin-polymyxin b-dexameth (Maxitrol) 1

neomycin-polymyxin-gramicidin (Neosporin) 1

neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B

Sulf/HC)

1

neomycin-polymyxin-hc otic

drops,suspension

(Neomycin/Polymyxin B

Sulf/HC)

1

neomycin-polymyxin-hc otic solution (Cortisporin) 1

neo-polycin (Neomycin

Su/Bacitra/Polymyxin)

1

ofloxacin ophthalmic (Ocuflox) 1

ofloxacin otic (Ocuflox) 1

polymyxin b sulf-trimethoprim (Polytrim) 1

sulfacetamide sodium ophthalmic (Sulfacetamide Sodium) 1

sulfacetamide-prednisolone (Sulfacetamide/Predniso

lone Sp)

1

TOBRADEX OPHTHALMIC

OINTMENT

1

TOBRADEX ST 1

tobramycin (Tobrex) 1

tobramycin-dexamethasone (Tobradex) 1



73




Drug Name


trifluridine (Viroptic) 1

VIGAMOX 1

ZIRGAN 1

ZYLET 1

Eye, Ear, Nose, Throat Anti-

Inflammatory Agents

ALREX 1 ST

bromfenac (Bromfenac Sodium) 1

dexamethasone sodium phosphate

ophthalmic

(Dexasol) 1

diclofenac sodium ophthalmic (Diclofenac Sodium) 1

DUREZOL 1

flunisolide nasal spray,non-aerosol 25

mcg (0.025 %)

(Flunisolide) 1 QL (50 per 25 days)

fluorometholone (FML) 1

flurbiprofen sodium (Ocufen) 1

fluticasone nasal (Fluticasone Propionate) 1

ILEVRO 1

ketorolac ophthalmic (Acular) 1

LOTEMAX 1

NEVANAC 1

prednisolone acetate (Omnipred) 1

prednisolone sodium phosphate

ophthalmic

(Prednisolone Sod

Phosphate)

1

PROLENSA 1

RESTASIS 1 QL (60 per 30 days)

Gastrointestinal Agents

Antiulcer Agents And Acid

Suppressants

amoxicil-clarithromy-lansopraz (Prevpac) 1

CARAFATE ORAL SUSPENSION 1

cimetidine (Cimetidine) 1 (Rx Product Only)

cimetidine hcl oral (Cimetidine HCl) 1

esomeprazole sodium (Nexium I.V.) 1

famotidine (pf) (Famotidine) 1

famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-

Osm/PF)

1

famotidine 40 mg/4 ml vial 25's,outer (Famotidine) 1



74




Drug Name


famotidine oral tablet 20 mg, 40 mg (Pepcid) 1 (Rx Product Only)

lansoprazole oral capsule,delayed

release(dr/ec)

(Prevacid) 1 (Rx Product Only)

misoprostol (Cytotec) 1

omeprazole oral capsule,delayed

release(dr/ec)

(Prilosec) 1

pantoprazole oral (Protonix) 1

ranitidine hcl 50 mg/2 ml vial sdv (Zantac) 1 (Rx Product Only)

ranitidine hcl injection solution 25 mg/ml (Zantac) 1 (Rx Product Only)

ranitidine hcl oral capsule (Ranitidine HCl) 1 (Rx Product Only)

ranitidine hcl oral syrup (Ranitidine HCl) 1 (Rx Product Only)

ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) 1 (Rx Product Only)

sucralfate oral suspension (Sucralfate) 1

sucralfate oral tablet (Carafate) 1

Gastrointestinal Agents, Other

AMITIZA 1 QL (60 per 30 days)

BUPHENYL ORAL TABLET 1

CARBAGLU 1

cromolyn oral (Gastrocrom) 1

dicyclomine oral capsule (Bentyl) 1

dicyclomine oral solution (Dicyclomine HCl) 1

dicyclomine oral tablet (Bentyl) 1

diphenoxylate-atropine oral liquid (Diphenoxylate

HCl/Atropine)

1

diphenoxylate-atropine oral tablet (Lomotil) 1

GATTEX 5 MG 30-VIAL KIT 1 PA

GATTEX ONE-VIAL 1 PA

glycopyrrolate injection (Robinul) 1

glycopyrrolate oral (Robinul) 1

kionex 15 gm/60 ml suspension 15

gram/60 ml

(Sodium Polystyrene

Sulfonate)

1

lactulose oral solution 10 gram/15 ml (Lactulose) 1

LINZESS 1 QL (30 per 30 days)

loperamide oral capsule (Loperamide HCl) 1

LOTRONEX 1

methscopolamine oral (Methscopolamine

Bromide)

1

metoclopramide hcl injection solution (Metoclopramide HCl) 1



75




Drug Name


metoclopramide hcl oral solution (Metoclopramide HCl) 1

metoclopramide hcl oral tablet (Reglan) 1

MOVANTIK 1 QL (30 per 30 days)

NUTRESTORE 1

RAVICTI 1 PA

RELISTOR SUBCUTANEOUS

SOLUTION


RELISTOR SUBCUTANEOUS

SYRINGE


sodium polystyrene sulfonate oral powder (Sodium Polystyrene

Sulfonate)

1

sodium polystyrene sulfonate oral

suspension 15 gram/60 ml

(Sodium Polystyrene

Sulfonate)

1

sodium polystyrene sulfonate rectal enema

30 gram/120 ml

(Sodium Polystyrene

Sulfonate)

1

sps 15 gm/60 ml suspension 15 gram/60

ml

(Sodium Polystyrene

Sulfonate)

1

ursodiol oral capsule (Actigall) 1

ursodiol oral tablet (Urso) 1

VIBERZI 1 ST; QL (60 per 30 days)

Laxatives

MOVIPREP 1

peg 3350-electrolytes (Golytely) 1

PEG 3350-GRX 1

peg 3350-na sulf,bicarb,cl-kcl (Golytely) 1

peg-electrolyte soln (Nulytely with Flavor

Packs)

1

polyethylene glycol 3350 oral powder (Gavilyte-N) 1

polyethylene glycol 3350 powd 17 gm

packets (rx)

(Gavilyte-N) 1

sodium chloride-nahco3-kcl-peg oral

recon soln 420 gram

(Nulytely with Flavor

Packs)

1

Phosphate Binders

calcium acetate oral capsule (Phoslo) 1

calcium acetate oral tablet 667 mg (Calcium Acetate) 1

calcium carbonate-mag carb-fa (Calcium

Carbonate/Mag Carb/Fa)

1

PHOSLYRA 1



76




Drug Name


RENAGEL 1

RENVELA 1

Genitourinary Agents

Antispasmodics, Urinary

MYRBETRIQ 1

oxybutynin chloride oral tablet (Oxybutynin Chloride) 1

oxybutynin chloride oral tablet extended

release 24hr

(Ditropan XL) 1

tolterodine oral capsule,extended release

24hr

(Detrol LA) 1

tolterodine oral tablet (Detrol) 1

TOVIAZ 1

trospium (Trospium Chloride) 1

Genitourinary Agents,

Miscellaneous

alfuzosin (Uroxatral) 1

tamsulosin (Flomax) 1

terazosin (Terazosin HCl) 1

Heavy Metal Antagonists

Heavy Metal Antagonists

deferoxamine (Desferal) 1 PA BvD

DEPEN TITRATABS 1

EXJADE 1

FERRIPROX 1

sodium thiosulfate intravenous solution 1

gram/10 ml (100 mg/ml), 12.5 gram/50 ml

(250 mg/ml)

(Sodium Thiosulfate) 1

SYPRINE 1

Hormonal Agents,

Stimulant/Replacement/Modifying

Androgens

ANDRODERM 1 PA; QL (30 per 30 days)

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25

GRAM (1.62 %)

1 PA; QL (150 per 30

days)

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25

GRAM), 1.62 % (40.5 MG/2.5 GRAM)

1 PA; QL (150 per 30

days)



77




Drug Name


danazol oral (Danazol) 1

fluoxymesterone (Fluoxymesterone) 1

oxandrolone (Oxandrin) 1

testosterone cypionate (Depo-Testosterone) 1 PA

testosterone enanthate (Testosterone Enanthate) 1 PA; QL (5 per 28 days)

testosterone transdermal gel (Testim) 1 PA; QL (300 per 30

days)

testosterone transdermal gel in metered-

dose pump 1.25 gram/ actuation (1 %)

(Vogelxo) 1 PA; QL (300 per 30

days)

testosterone transdermal gel in packet 1 %

(25 mg/2.5gram)

(Androgel) 1 PA; QL (300 per 30

days)

testosterone transdermal gel in packet 1 %

(50 mg/5 gram)

(Testim) 1 PA; QL (300 per 30

days)

Estrogens And Antiestrogens

COMBIPATCH 1 PA-HRM; QL (8 per 28

days)

DUAVEE 1 PA-HRM

ESTRACE VAGINAL 1

estradiol oral (Estrace) 1 PA-HRM

estradiol transdermal patch semiweekly (Vivelle-Dot) 1 PA-HRM; QL (8 per 28

days)

estradiol transdermal patch weekly (Climara) 1 PA-HRM; QL (4 per 28

days)

estradiol valerate (Delestrogen) 1

estradiol/norethindrone acet (Activella) 1 PA-HRM

estradiol-norethindrone acet (Activella) 1 PA-HRM

estropipate (Estropipate) 1 PA-HRM

FEMRING 1 QL (1 per 84 days)

MENEST 1 PA-HRM

PREMARIN INJECTION 1

PREMARIN ORAL 1 PA-HRM

PREMARIN VAGINAL 1

PREMPHASE 1 PA-HRM

PREMPRO 1 PA-HRM

raloxifene (Evista) 1

VAGIFEM 1 QL (18 per 28 days)

Glucocorticoids/Mineralocorticoids

betamethasone acet,sod phos (Celestone) 1



78




Drug Name


cortisone (Cortisone Acetate) 1 PA BvD

dexamethasone oral elixir (Dexamethasone) 1 PA BvD

dexamethasone oral tablet (Dexamethasone) 1 PA BvD

dexamethasone sodium phosphate

injection solution

(Dexamethasone Sod

Phosphate)

1

fludrocortisone (Fludrocortisone

Acetate)

1

hydrocortisone oral (Cortef) 1 PA BvD

hydrocortisone sod succinate (Hydrocortisone Sod

Succinate)

1

methylprednisolone (Medrol) 1 PA BvD

methylprednisolone acetate (Depo-Medrol) 1

methylprednisolone sodium succ injection

recon soln 125 mg, 40 mg

(A-Methapred) 1

methylprednisolone sodium succ

intravenous

(A-Methapred) 1

prednisolone sodium phosphate oral

solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml

(5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

(Pediapred) 1 PA BvD

prednisone oral (Prednisone) 1 PA BvD

SOLU-CORTEF (PF) INJECTION

RECON SOLN 100 MG/2 ML

1

triamcinolone acetonide injection (Triamcinolone

Acetonide)

1

Pituitary

desmopressin injection (Desmopressin Acetate) 1

desmopressin nasal solution (DDAVP) 1 QL (15 per 30 days)

desmopressin nasal spray,non-aerosol (Desmopressin Acetate) 1 QL (15 per 30 days)

desmopressin oral (DDAVP) 1

GENOTROPIN 1 PA

GENOTROPIN MINIQUICK 1 PA

INCRELEX 1

LUPRON DEPOT-PED 1

LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 30

MG


NORDITROPIN FLEXPRO 1 PA



79




Drug Name


octreotide acet 50 mcg/ml syr outer,single-

dose,10

(Octreotide Acetate) 1

octreotide acetate injection solution 1,000

mcg/ml, 100 mcg/ml, 200 mcg/ml, 500

mcg/ml

(Sandostatin) 1

octreotide acetate injection solution 50

mcg/ml

(Octreotide Acetate) 1

SAIZEN 1 PA

SAIZEN CLICK.EASY 1 PA

SANDOSTATIN LAR 10 MG KIT 1



SANDOSTATIN LAR DEPOT

INTRAMUSCULAR


RECON

1

SEROSTIM SUBCUTANEOUS RECON

SOLN 4 MG, 5 MG, 6 MG

1 PA

SOMATULINE DEPOT 1 QL (1 per 28 days)

SOMAVERT 1

SUPPRELIN LA 1 QL (1 per 360 days)

Progestins

DEPO-PROVERA INTRAMUSCULAR

SOLUTION


medroxyprogesterone intramuscular (Depo-Provera) 1 QL (1 per 84 days)

medroxyprogesterone oral (Provera) 1

MEGACE ES 1

megestrol oral suspension 400 mg/10 ml

(40 mg/ml), 625 mg/5 ml

(Megace Es) 1

norethindrone acetate (Aygestin) 1

progesterone (Progesterone) 1

progesterone micronized (Prometrium) 1

Thyroid And Antithyroid Agents

levothyroxine intravenous (Levothyroxine Sodium) 1

levothyroxine oral (Levoxyl) 1

liothyronine oral (Cytomel) 1

methimazole oral tablet 10 mg, 5 mg (Tapazole) 1

propylthiouracil (Propylthiouracil) 1



80




Drug Name


Immunological Agents

Immunological Agents

ARCALYST 1

ASTAGRAF XL 1 PA BvD

AUBAGIO 1 PA; QL (28 per 28 days)

azathioprine (Imuran) 1 PA BvD

azathioprine sodium (Azathioprine Sodium) 1 PA BvD

CARIMUNE NF NANOFILTERED

INTRAVENOUS RECON SOLN 6

GRAM

1 PA BvD

CELLCEPT INTRAVENOUS 1 PA BvD

CIMZIA 1 PA

CIMZIA POWDER FOR RECONST 1 PA

cyclosporine intravenous (Sandimmune) 1 PA BvD

cyclosporine modified (Neoral) 1 PA BvD

cyclosporine oral capsule (Sandimmune) 1 PA BvD

cyclosporine, modified (Neoral) 1 PA BvD

ENBREL 1 PA

ENBREL SURECLICK 1 PA

ENVARSUS XR 1 PA BvD

FLEBOGAMMA DIF 1 PA BvD

GAMASTAN S/D 1 PA BvD

GAMMAGARD LIQUID 1 PA BvD

GAMMAPLEX 1 PA BvD

HUMIRA 1 PA

HUMIRA PEN 1 PA

HUMIRA PEN CROHN'S-UC-HS

START

1 PA

HYPERRAB S/D (PF) 1

HYQVIA 1 PA BvD

ILARIS (PF) 1 PA

IMOGAM RABIES-HT (PF) 1

KINERET 1 PA; QL (18.76 per 28

days)

leflunomide (Arava) 1

mycophenolate mofetil (Cellcept) 1 PA BvD

mycophenolate sodium (Myfortic) 1 PA BvD



81




Drug Name


NULOJIX 1 PA BvD

OCTAGAM 1 PA BvD

ORENCIA 1 PA

ORENCIA (WITH MALTOSE) 1 PA

PRIVIGEN 1 PA BvD

PROGRAF INTRAVENOUS 1 PA BvD

RAPAMUNE ORAL SOLUTION 1 PA BvD

RIDAURA 1

sirolimus (Rapamune) 1 PA BvD

tacrolimus oral (Hecoria) 1 PA BvD

TYSABRI 1 PA; LA; QL (15 per 28

days)

ZORTRESS 1 PA BvD; QL (120 per 30

days)

Vaccines

ACTHIB (PF) 1 (Vaccine for

Haemophilus B

Conjugate)

ADACEL(TDAP

ADOLESN/ADULT)(PF)

1 (Vaccine for Tetanus,

Diphtheria, and Pertussis

[Tdap])

BCG (TICE STRAIN) VIAL 1 PA BvD; (Vaccine for

Tuberculosis)

BCG VACCINE, LIVE (PF) 1 PA BvD; (Vaccine for

Tuberculosis)

BEXSERO (PF) 1

BOOSTRIX TDAP 1 (Vaccine for Tetanus,


[Tdap])

CERVARIX VACCINE (PF) 1 (Vaccine for Human

Papillomavirus 16, 18)

COMVAX (PF) 1 (Vaccine for

Haemophilus B

Conjugate/Hepatitis B)

DAPTACEL (DTAP PEDIATRIC) (PF) 1 (Vaccine for Pertussis,

Diphtheria, and Tetanus

[Dtap])



82




Drug Name


ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

1 PA BvD; (Vaccine for

Hepatitis B); QL (3 per

365 days)

ENGERIX-B 20 MCG/ML VIAL

10'S,ADULT,P/F,OUTER



365 days)

ENGERIX-B PEDIATRIC (PF) 1 PA BvD; (Vaccine for


365 days)

GARDASIL (PF) 1 (Vaccine for Human

Papillomavirus 6, 11, 16,

18); QL (1.5 per 365

days)

GARDASIL 9 (PF) 1 (Vaccine for Human

Papillomavirus 6, 11, 16,

18); QL (1.5 per 365

days)

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML

1 (Vaccine for Hepatitis A)

HAVRIX (PF) INTRAMUSCULAR

SYRINGE


IMOVAX RABIES VACCINE (PF) 1 PA BvD; (Vaccine for

Rabies)

INFANRIX (DTAP) (PF)

INTRAMUSCULAR SUSPENSION

1 (Vaccine for Tetanus,


[Td/Tdap])

IPOL INJECTION SUSPENSION 1 (Vaccine for Polio)

IXIARO (PF) 1 (Vaccine for Japanese

Encephalitis)

KINRIX (PF) INTRAMUSCULAR

SUSPENSION

1

KINRIX (PF) INTRAMUSCULAR

SYRINGE

1 (Vaccine for

Diphtheria/Tetanus/Pertu

ssis/Polio)

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

1 (Vaccine for

Meningococcal

Diphtheria)

MENHIBRIX (PF) 1 (Vaccine for

Haemophilus B/Tetanus

Toxoid Conjugate)



83




Drug Name


MENOMUNE - A/C/Y/W-135 (PF) 1 (Vaccine for

Meningococcal

Polysaccharide)

MENVEO A-C-Y-W-135-DIP (PF) 1 (Vaccine for

Meningococcal

Oligosaccharide/Diphthe

ria)

MENVEO MENA COMPONENT (PF) 1 (Vaccine for

Meningoccal

Oligopsaccharide/Dipthe

ria)

MENVEO MENCYW-135 COMPNT

(PF)

1 (Vaccine for

Meningococcal

Oligosaccharide/Diphthe

ria)

M-M-R II (PF) 1 (Vaccine for

Measles/Mumps/Rubella

); QL (2 per 365 days)

PEDIARIX (PF) 1

PEDVAX HIB (PF) 1 (Vaccine for

Haemophilis B

Conjugate)

PENTACEL (PF) 1 (Vaccine for

Diphtheria/Haemophilis

B/Pertussis/Polio/Tetanu

s)

PENTACEL ACTHIB COMPONENT

(PF)

1 (Vaccine for

Diphtheria/Haemophilis

B/Pertussis/Polio/Tetanu

s)

PROQUAD (PF) 1 (Vaccine for

Measles/Mumps/Rubella

/Varicella); QL (2 per

365 days)

QUADRACEL (PF) 1

RABAVERT (PF) 1 PA BvD; (Vaccine for

Rabies)

RECOMBIVAX HB (PF)

INTRAMUSCULAR SUSPENSION 10

MCG/ML, 40 MCG/ML



365 days)



84




Drug Name


RECOMBIVAX HB (PF)

INTRAMUSCULAR SYRINGE



365 days)

ROTARIX 1

ROTATEQ VACCINE 1 (Vaccine for Rotavirus)

TENIVAC (PF) INTRAMUSCULAR

SYRINGE

1 (Vaccine for Tetanus and

Diphtheria [Td])

TETANUS TOXOID,ADSORBED (PF) 1 PA BvD; (Vaccine for

Tetanus)

TETANUS,DIPHTHERIA TOX PED(PF) 1 (Vaccine for Tetanus and

Diphtheria [DT])

TETANUS-DIPHTHERIA TOXOIDS-TD 1 (Vaccine for Tetanus and

Diphtheria [Td])

TRUMENBA 1

TWINRIX (PF) 1 (Vaccine for Hepatitis

A/Hepatitis B)

TYPHIM VI INTRAMUSCULAR

SOLUTION

1 (Vaccine for Typhoid

VI)

TYPHIM VI INTRAMUSCULAR

SYRINGE

1

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 50 UNIT/ML


VAQTA (PF) INTRAMUSCULAR

SYRINGE


VAQTA 25 UNITS/0.5 ML VIAL SDV,

OUTER


VARIVAX (PF) 1 (Vaccine for Varicella);

QL (2 per 365 days)

YF-VAX (PF) 1 (Vaccine for Yellow

Fever)

ZOSTAVAX (PF) 1 (Vaccine for Shingles);

QL (1 per 365 days)

Inflammatory Bowel Disease

Agents

Inflammatory Bowel Disease

Agents

alosetron (Alosetron HCl) 1

APRISO 1

ASACOL HD 1



85




Drug Name


balsalazide (Colazal) 1

budesonide oral (Entocort EC) 1

DELZICOL 1

DIPENTUM 1 ST

Irrigating Solutions

Irrigating Solutions

acetic acid irrigation (Acetic Acid) 1

LACTATED RINGERS IRRIGATION 1

ringers irrigation (Ringers Solution) 1

sodium chloride irrigation (Sodium Chloride Irrig

Solution)

1

sorbitol irrigation (Sorbitol Solution) 1

sorbitol-mannitol (Mannitol/Sorbitol

Solution)

1

water for irrigation, sterile (Water For

Irrigation,Sterile)

1

Metabolic Bone Disease Agents

Metabolic Bone Disease Agents

alendronate oral solution (Alendronate Sodium) 1 QL (300 per 28 days)

alendronate oral tablet 10 mg, 40 mg, 5

mg

(Fosamax) 1

alendronate oral tablet 35 mg, 70 mg (Fosamax) 1 QL (4 per 28 days)

calcitonin (salmon) (Miacalcin) 1 QL (3.7 per 28 days)

calcitriol intravenous solution 1 mcg/ml (Calcitriol) 1 (PA for ESRD Only)

calcitriol oral (Rocaltrol) 1 (PA for ESRD Only)

doxercalciferol intravenous (Doxercalciferol) 1 (PA for ESRD Only)

doxercalciferol oral (Hectorol) 1 (PA for ESRD Only)

FORTEO 1 PA; QL (2.4 per 28 days)

FORTICAL 1 QL (3.7 per 28 days)

ibandronate intravenous solution (Ibandronate Sodium) 1 (PA for ESRD Only);

QL (3 per 84 days)

ibandronate intravenous syringe (Boniva) 1 QL (3 per 84 days)

ibandronate oral (Boniva) 1 QL (1 per 28 days)

MIACALCIN INJECTION 1 (PA for ESRD Only)

NATPARA 1 PA; QL (2 per 28 days)

paricalcitol oral (Zemplar) 1 (PA for ESRD Only)

PROLIA 1 QL (1 per 180 days)



86




Drug Name


risedronate oral tablet 150 mg (Actonel) 1 QL (1 per 28 days)

risedronate oral tablet 30 mg, 5 mg (Actonel) 1 QL (30 per 28 days)

ZEMPLAR INTRAVENOUS 1 (PA for ESRD Only)

zoledronic acid intravenous solution (Zometa) 1

zoledronic acid-mannitol-water

intravenous piggyback 4 mg/100 ml

(Zoledronic

Acid/Mannitol and

Water)

1


intravenous solution

(Reclast) 1 QL (100 per 300 days)

ZOMETA INTRAVENOUS SOLUTION

4 MG/100 ML

1

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic

Agents

ACTEMRA INTRAVENOUS

SOLUTION 200 MG/10 ML (20 MG/ML)

1 PA

ACTEMRA SUBCUTANEOUS 1 PA

ACTIMMUNE 1

allopurinol (Zyloprim) 1

amifostine crystalline (Amifostine Crystalline) 1

anticoag citrate phos dextrose (Citrate Phosphate

Dextros Soln)

1

AVONEX (WITH ALBUMIN) 1 ST

AVONEX INTRAMUSCULAR PEN

INJECTOR KIT

1 ST

AVONEX INTRAMUSCULAR

SYRINGE KIT

1 ST

BENLYSTA INTRAVENOUS RECON

SOLN 120 MG

1 PA

BETASERON SUBCUTANEOUS KIT 1 ST

bethanechol chloride (Urecholine) 1

buspirone (Buspirone HCl) 1

CERDELGA 1 PA

colchicine oral tablet (Colcrys) 1

colchicine-probenecid (Colchicine/Probenecid) 1

COPAXONE SUBCUTANEOUS

SYRINGE

1

CYSTADANE 1



87




Drug Name


droperidol injection solution (Droperidol) 1

dutasteride (Avodart) 1

dutasteride-tamsulosin (Jalyn) 1 QL (30 per 30 days)

ELMIRON 1

ergoloid (Ergoloid Mesylates) 1

EXTAVIA SUBCUTANEOUS KIT 1 ST

finasteride oral tablet 5 mg (Proscar) 1

fomepizole (Fomepizole) 1

FUSILEV 1

GAUZE PAD TOPICAL BANDAGE 2 X

2 "

1

GILENYA 1 PA; QL (28 per 28 days)

GLUCAGEN HYPOKIT 1

GLUCAGON EMERGENCY KIT

(HUMAN)

1

guanidine (Guanidine HCl) 1

hydroxyzine hcl intramuscular (Hydroxyzine HCl) 1 PA-HRM

hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) 1 PA-HRM

hydroxyzine hcl oral tablet (Hydroxyzine HCl) 1 PA-HRM

hydroxyzine pamoate (Vistaril) 1 PA-HRM

JALYN 1 QL (30 per 30 days)

KEVEYIS 1 PA NSO; QL (120 per 30

days)

LEMTRADA 1 PA

leucovorin calcium 200 mg vial sdv, p/f,

latex-free

(Leucovorin Calcium) 1

leucovorin calcium injection recon soln

100 mg, 350 mg

(Leucovorin Calcium) 1

leucovorin calcium oral (Leucovorin Calcium) 1

levocarnitine (with sugar) (Levocarnitine (With

Sugar))


levocarnitine oral tablet (Carnitor) 1 (PA for ESRD Only)

mesna (Mesnex) 1

MESNEX ORAL 1

MESTINON ORAL SYRUP 1

MESTINON TIMESPAN 1

morrhuate sodium (Sodium Morrhuate) 1

OTEZLA 1 PA; QL (60 per 30 days)



88




Drug Name


OTEZLA STARTER 1 PA; QL (60 per 30 days)

OTREXUP (PF) 1

PLEGRIDY SUBCUTANEOUS PEN

INJECTOR

1 ST

PLEGRIDY SUBCUTANEOUS

SYRINGE 125 MCG/0.5 ML

1 ST

PLEGRIDY SYRINGE STARTER PACK 1 ST

probenecid (Probenecid) 1

PROCYSBI 1

pyridostigmine bromide (Mestinon) 1

RASUVO (PF) 1

REBIF (WITH ALBUMIN) 1

REBIF REBIDOSE 1

REBIF TITRATION PACK 1

REMICADE 1 PA

SENSIPAR 1

SIGNIFOR 1 QL (60 per 30 days)

SIMPONI 1 PA

SIMPONI ARIA 1 PA

STELARA SUBCUTANEOUS

SYRINGE

1 PA

STERILE PADS 2" X 2" 1

SYNAREL 1

TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG


TECFIDERA ORAL

CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG (14)- 240

MG (46), 240 MG


THALOMID 1 PA NSO; QL (60 per 30

days)

TYBOST 1 QL (30 per 30 days)

ULORIC 1 ST; QL (30 per 30 days)

XELJANZ 1 PA; QL (60 per 30 days)

Ophthalmic Agents

Antiglaucoma Agents



89




Drug Name


acetazolamide oral capsule, extended

release

(Diamox Sequels) 1

acetazolamide oral tablet (Acetazolamide) 1

acetazolamide sodium (Acetazolamide Sodium) 1

ALPHAGAN P OPHTHALMIC DROPS

0.1 %

1

AZOPT 1

betaxolol ophthalmic (Betaxolol HCl) 1

bimatoprost (Bimatoprost) 1

brimonidine (Alphagan P) 1 (drops: 0.15%, 0.20%)

COMBIGAN 1

dorzolamide (Trusopt) 1

dorzolamide-timolol (Cosopt) 1

latanoprost (Xalatan) 1

levobunolol (Betagan) 1

LUMIGAN OPHTHALMIC DROPS 0.01

%


methazolamide oral (Neptazane) 1

metipranolol (Metipranolol) 1

PHOSPHOLINE IODIDE 1

pilocarpine hcl ophthalmic drops 1 %, 2

%, 4 %

(Isopto Carpine) 1

SIMBRINZA 1

timolol maleate ophthalmic drops (Timoptic) 1

timolol maleate ophthalmic gel forming

solution

(Timoptic-Xe) 1

TRAVATAN Z 1 QL (2.5 per 25 days)

travoprost (benzalkonium) (Travoprost

(Benzalkonium))


Replacement Preparations

Replacement Preparations

calcium chloride intravenous (Calcium Chloride) 1

calcium gluconate intravenous (Calcium Gluconate) 1 (PA for ESRD Only)

citric acid-sodium citrate (Citric Acid/Sodium

Citrate)

1

d10 %-0.45 % sodium chloride (Dextrose 10 % and 0.45

% NaCl)

1



90




Drug Name


d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and

0.45 % NaCl)

1

d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 %

NaCl)

1

d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 %

NaCl)

1

dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2

% NaCl)

1

dextrose 5 %-lactated ringers (Dextrose 5%-Lactated

Ringers)

1

dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 %

NaCl)

1

dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 %

NaCl)

1

dextrose with sodium chloride (Dextrose 5 %-0.2 %

NaCl)

1

electrolyte-48 in d5w (Electrolyte-48

Solution/D5W)

1

HYPERLYTE CR 1

IONOSOL-B IN D5W 1

IONOSOL-MB IN D5W 1

ISOLYTE M IN 5 % DEXTROSE 1

ISOLYTE-H IN 5 % DEXTROSE 1

ISOLYTE-P IN 5 % DEXTROSE 1

ISOLYTE-S 1

klor-con 10 (Potassium Chloride) 1

klor-con m10 tablet (Potassium Chloride) 1

klor-con m15 (Potassium Chloride) 1

klor-con m20 (Potassium Chloride) 1

klor-con sprinkle (Potassium Chloride) 1

magnesium chloride injection (Magnesium Chloride) 1

magnesium sulf in 0.45% nacl (Magnesium Sulf In

0.45% NaCl)

1

magnesium sulfate in d5w intravenous

piggyback 1 gram/100 ml, 4 gram/100 ml

(Magnesium

Sulfate/D5W)

1

magnesium sulfate in water (Magnesium Sulfate in

Water)

1

magnesium sulfate injection (Magnesium Sulfate) 1



91




Drug Name


NORMOSOL-M IN 5 % DEXTROSE 1

NORMOSOL-R PH 7.4 1

NUTRILYTE 1

NUTRILYTE II 1

phosphorus #1 (K-Phos Neutral) 1

PLASMA-LYTE 148 1

PLASMA-LYTE A 1

PLASMA-LYTE-56 IN 5 % DEXTROSE 1

potassium acetate intravenous (Potassium Acetate) 1

potassium bicarb and chloride (Pot Chloride/Pot

Bicarb/Cit Ac)

1

potassium bicarb-citric acid (Klor-Con-Ef) 1

potassium bicarbonate-cit ac oral tablet,

effervescent 25 meq

(Klor-Con-Ef) 1

potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-

0.45nacl)

1

potassium chloride in 0.9%nacl

intravenous parenteral solution 20 meq/l,

40 meq/l

(Potassium Chloride In

0.9%NaCl)

1

potassium chloride in 5 % dex intravenous

parenteral solution 20 meq/l, 30 meq/l, 40

meq/l


D5w)

1

potassium chloride in lr-d5 intravenous

parenteral solution 20 meq/l


Lr-D5)

1

potassium chloride intravenous piggyback

10 meq/100 ml, 20 meq/100 ml, 30

meq/100 ml, 40 meq/100 ml

(Potassium Chloride) 1

potassium chloride intravenous solution (Potassium Chloride) 1

potassium chloride oral capsule, extended

release


potassium chloride oral liquid (Potassium Chloride) 1

potassium chloride oral packet (Klor-Con) 1

potassium chloride oral tablet extended

release 8 meq

(K-Tab ER) 1

potassium chloride oral tablet,er

particles/crystals 10 meq

(K-Tab ER) 1

potassium chloride oral tablet,er

particles/crystals 20 meq




92




Drug Name


potassium chloride-0.45 % nacl (Potassium Chloride-

0.45% NaCl)

1

potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-

0.2%NaCl)

1

potassium chloride-d5-0.3%nacl

intravenous parenteral solution 20 meq/l

(Potassium Chloride/D5-

0.3%NaCl)

1

potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-

0.9%NaCl)

1

potassium citrate (Urocit-K) 1

potassium citrate-citric acid oral packet (Potassium Citrate/Citric

Acid)

1

potassium cl 10 meq/50 ml sol (Potassium Chloride) 1

potassium cl 20 meq/50 ml sol (Potassium Chloride) 1

potassium cl er 10 meq tablet f/c (K-Tab ER) 1

potassium phosphate m-/d-basic (Potassium Phos,M-

Basic-D-Basic)

1

ringers intravenous (Ringers Solution) 1

sodium acetate intravenous (Sodium Acetate) 1

sodium bicarbonate intravenous solution 1

meq/ml (8.4 %)

(Sodium Bicarbonate) 1

sodium bicarbonate intravenous syringe (Sodium Bicarbonate) 1

sodium chloride 0.45 % intravenous

parenteral solution

(Sodium Chloride 0.45

%)

1

sodium chloride 0.9 % injection solution (0.9 % Sodium

Chloride)

1

sodium chloride 0.9 % intravenous

parenteral solution

(0.9 % Sodium

Chloride)

1

sodium chloride 3 % (Sodium Chloride 3 %) 1

sodium chloride 5 % (Sodium Chloride 5 %) 1

sodium chloride intravenous (Sodium Chloride) 1

sodium citrate-citric acid (Citric Acid/Sodium

Citrate)

1

sodium lactate (Sodium Lactate) 1

sodium phosphate (Sodium Phos,M-Basic-

D-Basic)

1

sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod

Cit/Cit Acid)

1

TPN ELECTROLYTES 1



93




Drug Name


TPN ELECTROLYTES II IV SOLN

25'S,20ML/50ML FTV

1

Respiratory Tract Agents

Anti-Inflammatories, Inhaled

Corticosteroids

ADVAIR DISKUS 1 QL (60 per 30 days)

ADVAIR HFA 1 QL (12 per 28 days)

BREO ELLIPTA 1 QL (60 per 30 days)

DULERA 1 QL (13 per 28 days)

FLOVENT DISKUS INHALATION

BLISTER WITH DEVICE 100

MCG/ACTUATION, 50

MCG/ACTUATION


FLOVENT DISKUS INHALATION

BLISTER WITH DEVICE 250

MCG/ACTUATION


FLOVENT HFA INHALATION HFA

AEROSOL INHALER 110

MCG/ACTUATION



AEROSOL INHALER 220

MCG/ACTUATION



AEROSOL INHALER 44

MCG/ACTUATION

1 QL (21.2 per 28 days)

QVAR 1 QL (17.4 per 25 days)

Antileukotrienes

montelukast (Singulair) 1

zafirlukast (Accolate) 1

Bronchodilators

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,

2.5 mg /3 ml (0.083 %), 5 mg/ml

(Albuterol Sulfate) 1 PA BvD

albuterol sulfate oral syrup (Albuterol Sulfate) 1

albuterol sulfate oral tablet (Albuterol Sulfate) 1

albuterol sulfate oral tablet extended

release 12 hr

(Vospire ER) 1

ATROVENT HFA 1 QL (25.8 per 28 days)

COMBIVENT RESPIMAT 1 QL (8 per 30 days)



94




Drug Name


metaproterenol oral (Metaproterenol Sulfate) 1

PROAIR HFA 1

PROAIR RESPICLICK 1

SEREVENT DISKUS 1 QL (60 per 30 days)

SPIRIVA RESPIMAT 1

SPIRIVA WITH HANDIHALER 1

STRIVERDI RESPIMAT 1

terbutaline oral (Terbutaline Sulfate) 1

terbutaline subcutaneous (Terbutaline Sulfate) 1

theophylline anhydrous oral tablet

extended release 12 hr 100 mg, 200 mg,

300 mg

(Theophylline

Anhydrous)

1

theophylline in dextrose 5 % intravenous

parenteral solution 200 mg/100 ml, 200

mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,

800 mg/250 ml

(Theophylline/D5W) 1

theophylline oral solution (Theophylline

Anhydrous)

1

theophylline oral tablet extended release (Theophylline

Anhydrous)

1

theophylline oral tablet extended release

12 hr

(Theophylline

Anhydrous)

1

TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH

ACTIVATED 400 MCG/ACTUATION


TUDORZA PRESSAIR INHALATION

AEROSOL POWDR BREATH

ACTIVATED 400 MCG/ACTUATION

(30 ACTUAT)


VENTOLIN HFA 1

Respiratory Tract Agents, Other

acetylcysteine (Acetadote) 1 PA BvD

acetylcysteine (Acetadote) 1 PA BvD

cromolyn inhalation (Cromolyn Sodium) 1 PA BvD

DALIRESP 1 QL (30 per 30 days)

ESBRIET 1 PA; QL (270 per 30

days)

KALYDECO 1 PA; QL (60 per 30 days)



95




Drug Name


NUCALA 1 PA; LA; QL (1 per 28

days)

OFEV 1 PA

ORKAMBI 1 PA; QL (120 per 30

days)

PROLASTIN-C 1

XOLAIR 1 PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxants

baclofen (Baclofen) 1

carisoprodol (Soma) 1 PA-HRM; QL (120 per

30 days)

chlorzoxazone (Parafon Forte DSC) 1 PA-HRM

cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) 1 PA-HRM

dantrolene (Dantrium) 1

dantrolene sodium (Dantrium) 1

metaxall (Skelaxin) 1 PA-HRM

metaxalone (Skelaxin) 1 PA-HRM

methocarbamol oral (Robaxin) 1 PA-HRM

tizanidine (Zanaflex) 1

Sleep Disorder Agents

Sleep Disorder Agents

BELSOMRA 1 QL (30 per 30 days)

HETLIOZ 1 PA

NUVIGIL 1 PA

ROZEREM 1

XYREM 1 LA

zaleplon (Sonata) 1 PA-HRM; (High Risk




with over 90 days

cumulative use with any

non-benzodiazepine

hypnotic drug); QL (60

per 30 days)



96




Drug Name


zolpidem oral tablet (Ambien) 1 PA-HRM; (High Risk




with over 90 days


non-benzodiazepine


per 30 days)

zolpidem oral tablet,ext release multiphase (Ambien CR) 1 PA-HRM; (High Risk




with over 90 days


non-benzodiazepine


per 30 days)

Vasodilating Agents

Vasodilating Agents

ADCIRCA 1 PA; QL (60 per 30 days)

ADEMPAS 1 PA; QL (90 per 30 days)

epoprostenol (glycine) (Flolan) 1 PA BvD

LETAIRIS 1 PA; QL (30 per 30 days)

OPSUMIT 1 PA; QL (30 per 30 days)

ORENITRAM 1 PA

REMODULIN 1 PA BvD

sildenafil intravenous (Revatio) 1 PA; QL (37.5 per 1 day)

sildenafil oral (Revatio) 1 PA; QL (90 per 30 days)

TRACLEER 1 PA; LA; QL (60 per 30

days)

TYVASO 1 PA BvD

TYVASO REFILL KIT 1 PA BvD

TYVASO STARTER KIT 1 PA BvD

UPTRAVI ORAL TABLET 1,000 MCG,

1,200 MCG, 1,400 MCG, 1,600 MCG,

400 MCG, 600 MCG, 800 MCG


UPTRAVI ORAL TABLET 200 MCG 1 PA; QL (240 per 30

days)



97




Drug Name


UPTRAVI ORAL TABLETS,DOSE

PACK

1 PA; QL (200 per 365

days)

Vitamins And Minerals

Vitamins And Minerals

multivit-fluor 0.5 mg tab chew chewable,

d/f, s/f 0.5 mg

(Pedi M.Vit No.17 with

Fluoride)

1

pnv prenatal plus multivit tab s/f, gluten-

free 27 mg iron- 1 mg

(Pnv with

Ca,No.72/Iron/Fa)

1 (All Rx Prenatal

Vitamins Covered)

prenatal vitamins oral tablet 27 mg iron- 1

mg

(Pnv with

Ca,No.72/Iron/Fa)

1 (All Rx Prenatal

Vitamins Covered)

sodium fluoride oral tablet (Pedi M.Vit No.17 with

Fluoride)

1

VITAFOL FE+ (WITH DOCUSATE) 1

I-1




8 8-MOP .................................... 65

A abacavir .................................. 46

abacavir-lamivudine-zidovudine

............................................ 46

ABELCET .............................. 38

ABILIFY DISCMELT ........... 43

ABILIFY MAINTENA .......... 43

ABRAXANE .......................... 25

acamprosate ............................ 17

acarbose .................................. 36

acebutolol ............................... 56

acetaminophen-codeine .......... 13

acetazolamide ................... 88, 89

acetazolamide sodium ............ 89

acetic acid ......................... 71, 85

acetylcysteine ......................... 94

acitretin ................................... 65

ACTEMRA ............................ 86

ACTHIB (PF) ......................... 81

ACTIMMUNE ....................... 86

acyclovir ........................... 48, 65

acyclovir sodium .................... 48

ADACEL(TDAP

ADOLESN/ADULT)(PF) .. 81

ADAGEN ............................... 70

adapalene ................................ 69

ADCETRIS ............................ 25

ADCIRCA .............................. 96

adefovir................................... 48

ADEMPAS ............................. 96

ADVAIR DISKUS ................. 93

ADVAIR HFA ....................... 93

AFINITOR ............................. 26

AFINITOR DISPERZ ............ 25

AGGRENOX ......................... 51

AKTEN (PF) .................... 70, 71

AKYNZEO ............................ 41

ALBENZA............................. 42

ALBUKED-25 ....................... 51

ALBUKED-5 ......................... 51

ALBUMIN, HUMAN 20 % .. 51

ALBUMIN, HUMAN 25 % .. 51

ALBUMIN, HUMAN 5 % .... 51

ALBUMINAR 25 % .............. 51

ALBUMINAR 5 % ................ 51

ALBURX (HUMAN) 5 % ..... 51

ALBUTEIN 25 % .................. 51

ALBUTEIN 5 % .................... 51

albuterol sulfate ..................... 93

alclometasone ........................ 67

ALCOHOL PADS ................. 65

ALCOHOL PREP PADS ...... 65

ALDURAZYME ................... 70

ALECENSA .......................... 26

alendronate ............................. 85

alfuzosin................................. 76

ALIMTA ................................ 26

ALINIA ................................. 42

allopurinol .............................. 86

ALLZITAL ............................ 13

alosetron................................. 84

ALPHAGAN P ...................... 89

alprazolam ............................. 18

ALREX .................................. 73

altacaine ................................. 71

amantadine hcl ....................... 42

AMBISOME .......................... 38

amifostine crystalline ............. 86

amiloride .......................... 59, 60

amiloride-hydrochlorothiazide

........................................... 60

AMINO ACIDS 15 % ........... 52

aminocaproic acid .................. 51

AMINOSYN 10 % ................ 52

AMINOSYN 3.5 % ................ 52

AMINOSYN 7 % ................... 52

AMINOSYN 7 % WITH

ELECTROLYTES ............. 52

AMINOSYN 8.5 % ................ 52

AMINOSYN 8.5 %-


AMINOSYN II 10 % ............. 52

AMINOSYN II 15 % ............. 52

AMINOSYN II 7 % ............... 52

AMINOSYN II 8.5 % ............ 52

AMINOSYN II 8.5 %-


AMINOSYN M 3.5 % ........... 52

AMINOSYN-HBC 7% .......... 52

AMINOSYN-PF 10 % ........... 52

AMINOSYN-PF 7 %

(SULFITE-FREE) .............. 52

AMINOSYN-RF 5.2 % ......... 52

amiodarone ............................. 55

amiodarone hcl ....................... 55

AMITIZA ............................... 74

amitriptyline ........................... 34

amlodipine.............................. 59

amlodipine-atorvastatin.......... 60

amlodipine-benazepril............ 59

amlodipine-valsartan .............. 59

amlodipine-valsartan-hcthiazid

............................................ 59

ammonium lactate .................. 65

amoxapine .............................. 34

amoxicil-clarithromy-lansopraz

............................................ 73

amoxicillin ....................... 22, 23

amoxicillin-pot clavulanate .... 23

amphetamine salt combo........ 62

amphotericin b ....................... 38

ampicillin ............................... 23

INDEX

I-2




ampicillin sodium ................... 23

ampicillin-sulbactam .............. 23

AMPYRA ............................... 62

ANACAINE ........................... 65

anagrelide ............................... 51

anastrozole .............................. 26

ANDRODERM ...................... 76

ANDROGEL .......................... 76

anticoag citrate phos dextrose 86

APOKYN ............................... 42

apraclonidine .......................... 71

APRISO .................................. 84

APTIOM................................. 32

APTIVUS ............................... 46

ARCALYST ........................... 80

aripiprazole ............................. 43

ARISTADA ...................... 43, 44

ASACOL HD ......................... 84

ashlyna .................................... 63

aspirin-dipyridamole .............. 51

ASSURE ID INSULIN

SAFETY ............................. 69

ASTAGRAF XL .................... 80

atenolol ................................... 56

atenolol-chlorthalidone........... 56

atorvastatin ............................. 60

atovaquone ............................. 42

atovaquone-proguanil ............. 42

ATRIPLA ............................... 46

atropine ............................. 32, 71

atropine sulfate ....................... 71

ATROVENT HFA ................. 93

AUBAGIO ............................. 80

AVASTIN .............................. 26

AVC VAGINAL .................... 40

AVONEX ............................... 86

AVONEX (WITH ALBUMIN)

............................................ 86

azacitidine............................... 26

azathioprine ............................ 80

azathioprine sodium ............... 80

azelastine ................................ 71

AZILECT............................... 42

azithromycin .......................... 22

AZOPT .................................. 89

AZOR .................................... 59

aztreonam ............................... 22

B bacitracin ......................... 19, 71

bacitracin-polymyxin b .......... 71

baclofen ................................. 95

balsalazide ............................. 85

BANZEL ............................... 32

BCG VACCINE, LIVE (PF) . 81

BD ECLIPSE LUER-LOK .... 69

BD INSULIN PEN NEEDLE

UF SHORT ........................ 70

BD INSULIN SYRINGE

ULTRA-FINE .............. 69, 70

bekyree (28) ........................... 63

BELBUCA............................. 13

BELEODAQ .......................... 26

BELSOMRA ......................... 95

benazepril ............................... 55

benazepril-hydrochlorothiazide

........................................... 55

BENDEKA ............................ 26

BENICAR .............................. 54

BENICAR HCT ..................... 54

BENLYSTA .......................... 86

benztropine ............................ 42

betamethasone acet,sod phos . 77

betamethasone dipropionate .. 67

betamethasone valerate .......... 67

betamethasone, augmented .... 67

BETASERON ........................ 86

betaxolol .......................... 56, 89

bethanechol chloride .............. 86

BETHKIS .............................. 18

bexarotene .............................. 26

BEXSERO (PF) ..................... 81

bicalutamide ........................... 26

BICILLIN C-R ...................... 23

BICILLIN L-A ...................... 23

bimatoprost ............................ 89

bisoprolol fumarate ................ 56

bisoprolol-hydrochlorothiazide

............................................ 56

bleomycin ............................... 26

BLINCYTO ........................... 26

blisovi 24 fe............................ 63

blisovi fe 1.5/30 (28) .............. 63

blisovi fe 1/20 (28) ................. 63

BOOSTRIX TDAP ................ 81

BOSULIF ............................... 26

BREO ELLIPTA .................... 93

BRILINTA ............................. 51

brimonidine ............................ 89

BRINTELLIX ........................ 35

bromfenac .............................. 73

bromocriptine ......................... 42

budesonide ............................. 85

bumetanide ............................. 60

BUMINATE 25 % ................. 52

BUMINATE 5 % ................... 52

BUPHENYL .......................... 74

buprenorphine hcl ............ 13, 17

buprenorphine-naloxone ........ 17

bupropion hcl ................... 18, 35

buspirone ................................ 86

butalb-acetaminophen-caffeine

............................................ 13

butalbital-acetaminop-caf-cod 13

butalbital-acetaminophen ....... 13

butalbital-acetaminophen-caff 13

butalbital-aspirin-caffeine ...... 13

BUTRANS ............................. 13

BYSTOLIC ............................ 56

C cabergoline ............................. 42

caffeine citrated ...................... 62

caffeine-sodium benzoate ...... 62

calcipotriene ........................... 66

calcitonin (salmon)................. 85

calcitriol ........................... 66, 85

calcium acetate ....................... 75

I-3




calcium carbonate-mag carb-fa

............................................ 75

calcium chloride ..................... 89

calcium gluconate ................... 89

CALDOLOR .......................... 16

CANCIDAS ........................... 39

candesartan ............................. 54

candesartan-hydrochlorothiazid

............................................ 54

CAPASTAT ........................... 41

CAPRELSA ........................... 26

captopril .................................. 55

captopril-hydrochlorothiazide 55

CARAFATE ........................... 73

CARBAGLU .......................... 74

carbamazepine ........................ 32

carbidopa ................................ 42

carbidopa-levodopa ................ 42

carbidopa-levodopa-entacapone

............................................ 42

CARIMUNE NF

NANOFILTERED ............. 80

carisoprodol ............................ 95

carteolol .................................. 71

cartia xt ................................... 56

carvedilol ................................ 56

CAYSTON ............................. 22

cefaclor ................................... 20

cefadroxil .......................... 20, 21

cefazolin ................................. 21

cefazolin in dextrose (iso-os) . 21

CEFAZOLIN IN DEXTROSE

(ISO-OS) ............................ 21

cefdinir ................................... 21

cefditoren pivoxil ................... 21

cefepime ................................. 21

CEFEPIME IN DEXTROSE 5

%......................................... 21

CEFEPIME IN

DEXTROSE,ISO-OSM...... 21

cefotaxime .............................. 21

cefoxitin .................................. 21

cefoxitin in dextrose, iso-osm 21

cefpodoxime .......................... 21

cefprozil ................................. 21

ceftazidime ............................. 21

ceftibuten ............................... 21

ceftriaxone ............................. 21

CEFTRIAXONE ................... 21

ceftriaxone in dextrose,iso-os 21

CEFTRIAXONE IN

DEXTROSE,ISO-OS ........ 21

cefuroxime axetil ................... 21

cefuroxime sodium ................ 21

celecoxib ................................ 16

CELLCEPT INTRAVENOUS

........................................... 80

CELONTIN ........................... 32

cephalexin ........................ 21, 22

CEPROTIN (BLUE BAR) .... 49

CERDELGA .......................... 86

CEREZYME .......................... 70

CERVARIX VACCINE (PF) 81

cevimeline .............................. 65

CHANTIX ............................. 18

CHANTIX CONTINUING

MONTH BOX ................... 18

CHANTIX STARTING

MONTH BOX ................... 18

chloramphenicol sod succinate

........................................... 19

chlordiazepoxide hcl .............. 18

chlorhexidine gluconate ......... 65

chloroquine phosphate ........... 42

chlorothiazide ........................ 60

chlorothiazide sodium............ 60

chlorpromazine ...................... 44

chlorthalidone ........................ 60

chlorzoxazone ........................ 95

cholestyramine (with sugar) .. 60

cholestyramine-aspartame 60, 61

choline,magnesium salicylate 16

ciclopirox ............................... 39

ciclopirox-ure-camph-menth-

euc ...................................... 39

cilostazol ................................ 51

cimetidine ............................... 73

cimetidine hcl ......................... 73

CIMZIA ................................. 80

CIMZIA POWDER FOR

RECONST ......................... 80

CINRYZE .............................. 50

CIPRODEX............................ 72

ciprofloxacin .......................... 24

ciprofloxacin hcl .............. 24, 72

ciprofloxacin in 5 % dextrose 24

ciprofloxacin lactate ............... 24

citalopram .............................. 35

citric acid-sodium citrate........ 89

clarithromycin ........................ 22

CLEVIPREX.......................... 59

clindamycin hcl ...................... 19

clindamycin in 5 % dextrose .. 19

clindamycin palmitate hcl ...... 19

clindamycin phosphate.... 19, 40,

66

CLINIMIX 5%/D15W

SULFITE FREE ................. 52

CLINIMIX 5%/D25W

SULFITE-FREE ................ 52

CLINIMIX 2.75%/D5W

SULFIT FREE ................... 52

CLINIMIX 4.25%/D10W SULF

FREE .................................. 52

CLINIMIX 4.25%/D5W

SULFIT FREE ................... 52

CLINIMIX 4.25%-D20W

SULF-FREE ....................... 52

CLINIMIX 4.25%-D25W

SULF-FREE ....................... 52

CLINIMIX 5%-

D20W(SULFITE-FREE) ... 52

CLINIMIX E 2.75%/D10W

SUL FREE ......................... 52

I-4





SULF FREE ....................... 52


SUL FREE.......................... 53


SUL FREE.......................... 53


SULF FREE ....................... 53

CLINIMIX E 5%/D15W

SULFIT FREE.................... 53

CLINIMIX E 5%/D20W

SULFIT FREE.................... 53

CLINIMIX E 5%/D25W

SULFIT FREE.................... 53

CLINISOL SF 15 % ............... 53

clobetasol ................................ 68

clobetasol propionate.............. 68

clobetasol-emollient ............... 68

clocortolone pivalate .............. 68

clomipramine .......................... 35

clonazepam ............................. 18

clonidine ................................. 54

clonidine hcl ..................... 54, 62

clonidine hcl-chlorthalidone ... 54

clopidogrel .............................. 51

clorazepate dipotassium ......... 18

clotrimazole ............................ 39

clotrimazole-betamethasone ... 39

clozapine................................. 44

COARTEM ............................ 42

codeine sulfate ........................ 13

codeine-butalbital-asa-caffein 13

colchicine ............................... 86

colchicine-probenecid ............ 86

colestipol ................................ 60

colistin (colistimethate na) ..... 19

COLY-MYCIN S ................... 72

COMBIGAN .......................... 89

COMBIPATCH ...................... 77

COMBIVENT RESPIMAT ... 93

COMETRIQ ........................... 26

COMPLERA .......................... 46

COMVAX (PF) ..................... 81

CONDYLOX ......................... 66

COPAXONE ......................... 86

CORLANOR ......................... 57

cortisone................................. 78

COSENTYX .......................... 66

COSENTYX (2 SYRINGES) 66

COSENTYX PEN ................. 66

COSENTYX PEN (2 PENS) . 66

COTELLIC ............................ 26

CREON .................................. 70

CRESTOR ............................. 60

CRIXIVAN ............................ 46

cromolyn .................... 71, 74, 94

CUBICIN ............................... 19

cyclobenzaprine ..................... 95

CYCLOGYL ......................... 71

cyclopentolate ........................ 71

cyclophosphamide ................. 26

CYCLOPHOSPHAMIDE ..... 26

CYCLOSET........................... 36

cyclosporine ........................... 80

cyclosporine modified ........... 80

cyclosporine, modified .......... 80

cyproheptadine ................. 39, 40

CYRAMZA ........................... 26

cyred ...................................... 63

CYSTADANE ....................... 86

CYSTARAN .......................... 71

cysteine (l-cysteine) ............... 53

D d10 %-0.45 % sodium chloride

........................................... 89

d2.5 %-0.45 % sodium chloride

........................................... 90

d5 % and 0.9 % sodium chloride

........................................... 90

d5 %-0.45 % sodium chloride 90

dactinomycin ......................... 26

DAKLINZA........................... 48

DALIRESP ............................ 94

danazol ................................... 77

dantrolene ............................... 95

dantrolene sodium .................. 95

dapsone .................................. 41

DAPTACEL (DTAP

PEDIATRIC) (PF) ............. 81

DARAPRIM .......................... 42

DARZALEX .......................... 27

deblitane ................................. 63

decitabine ............................... 27

deferoxamine.......................... 76

DELZICOL ............................ 85

DEMSER ............................... 57

DEPEN TITRATABS ............ 76

DEPO-PROVERA ................. 79

desipramine ............................ 35

desmopressin .......................... 78

desog-e.estradiol/e.estradiol ... 63

desogestrel-ethinyl estradiol . 63,

64

desonide ................................. 68

desoximetasone ...................... 68

dexamethasone ....................... 78

dexamethasone sodium

phosphate ..................... 73, 78

dexmethylphenidate ............... 62

dextroamphetamine ................ 62

dextroamphetamine-

amphetamine ...................... 62

dextrose 10 % and 0.2 % nacl 90

dextrose 10 % in water (d10w)

............................................ 53


............................................ 53


............................................ 53


............................................ 53

dextrose 5 % in ringers .......... 53

dextrose 5 % in water (d5w) .. 53

dextrose 5 %-lactated ringers . 90

dextrose 5%-0.2 % sod chloride

............................................ 90

I-5




dextrose 5%-0.3 % sod.chloride

............................................ 90


............................................ 53


............................................ 53

dextrose with sodium chloride90

diazepam................................. 18

diazepam intensol ................... 18

diclofenac potassium .............. 16

diclofenac sodium ............ 16, 73

diclofenac-misoprostol ........... 16

dicloxacillin ............................ 23

dicyclomine ............................ 74

didanosine............................... 46

DIFICID ................................. 22

diflunisal ................................. 16

digitek ..................................... 57

digoxin .................................... 58

DIGOXIN ............................... 58

dihydroergotamine ................. 40

DILANTIN ............................. 32

diltiazem hcl ........................... 57

dilt-xr ...................................... 57

dimenhydrinate ....................... 41

DIPENTUM ........................... 85

diphenhydramine hcl .............. 40

diphenoxylate-atropine ........... 74

disopyramide phosphate ......... 55

disulfiram ............................... 18

divalproex ............................... 32

dobutamine ............................. 58

dobutamine in d5w ................. 58

donepezil ................................ 34

dopamine ................................ 58

dopamine in 5 % dextrose ...... 58

dorzolamide ............................ 89

dorzolamide-timolol ............... 89

doxazosin ................................ 54

doxepin ................................... 35

doxercalciferol ........................ 85

doxorubicin hcl ....................... 27

doxorubicin hcl peg-liposomal

........................................... 27

doxorubicin, peg-liposomal ... 27

doxycycline hyclate ............... 25

doxycycline monohydrate ...... 25

dronabinol .............................. 41

droperidol............................... 87

drospirenone-ethinyl estradiol 64

DROXIA ................................ 27

DUAVEE ............................... 77

DULERA ............................... 93

duloxetine .............................. 35

DUREZOL............................. 73

dutasteride .............................. 87

dutasteride-tamsulosin ........... 87

DYRENIUM .......................... 60

E econazole ............................... 39

EDURANT ............................ 46

EFFIENT ............................... 51

ELAPRASE ........................... 70

electrolyte-48 in d5w ............. 90

ELIDEL ................................. 68

ELIGARD .............................. 27

ELIQUIS ................................ 49

ELITEK ................................. 70

ELLA ..................................... 64

ELMIRON ............................. 87

EMCYT ................................. 27

EMEND ................................. 41

EMPLICITI ........................... 27

EMSAM................................. 35

EMTRIVA ............................. 46

enalapril maleate .................... 55

enalaprilat .............................. 55

enalapril-hydrochlorothiazide 55

ENBREL ................................ 80

ENBREL SURECLICK ........ 80

ENGERIX-B (PF).................. 82

ENGERIX-B PEDIATRIC (PF)

........................................... 82

enoxaparin ............................. 49

entacapone.............................. 43

entecavir ................................. 48

ENTRESTO ........................... 54

ENVARSUS XR .................... 80

ephedrine sulfate .................... 58

epinastine ............................... 71

epinephrine ....................... 58, 59

epinephrine hcl (pf) ................ 58

EPIPEN 2-PAK ...................... 59

EPIPEN JR 2-PAK ................ 59

EPIVIR HBV ......................... 46

eplerenone .............................. 61

EPOGEN ................................ 50

epoprostenol (glycine) ........... 96

EPZICOM .............................. 46

ergoloid .................................. 87

ERGOMAR............................ 40

ERIVEDGE............................ 27

ERYTHROCIN ...................... 22

erythromycin .................... 22, 72

erythromycin base .................. 22

ERYTHROMYCIN BASE .... 22

erythromycin base-ethanol ..... 66

erythromycin ethylsuccinate .. 22

erythromycin stearate ............. 22

erythromycin with ethanol 66, 67

ESBRIET ............................... 94

escitalopram oxalate............... 35

esmolol ................................... 56

esomeprazole sodium ............. 73

ESTRACE .............................. 77

estradiol .................................. 77

estradiol valerate .................... 77

estradiol/norethindrone acet ... 77

estradiol-norethindrone acet... 77

estropipate .............................. 77

ethambutol.............................. 41

ethamolin................................ 59

ethinyl estradiol/drospirenone 64

ethosuximide .......................... 32

ethynodiol d-ethinyl estradiol 64

etodolac .................................. 16

I-6




ETOPOPHOS ......................... 27

etoposide................................. 27

EVOTAZ ................................ 46

EXELON ................................ 34

exemestane ............................. 27

EXJADE ................................. 76

EXTAVIA .............................. 87

F FABRAZYME ....................... 70

famciclovir ............................. 48

famotidine......................... 73, 74

famotidine (pf)........................ 73

famotidine (pf)-nacl (iso-os) . 73

FANAPT ................................ 44

FARESTON ........................... 27

FARYDAK............................. 27

FASLODEX ........................... 27

felbamate ................................ 32

felodipine ................................ 59

FEMRING .............................. 77

fenofibrate .............................. 60

fenofibrate micronized ........... 60

fenofibrate nanocrystallized ... 60

fenofibric acid ........................ 60

fenofibric acid (choline) ......... 60

fenoprofen .............................. 16

fentanyl ................................... 13

fentanyl citrate ........................ 13

FERRIPROX .......................... 76

FETZIMA............................... 35

finasteride ............................... 87

FIRAZYR ............................... 59

FLEBOGAMMA DIF ............ 80

flecainide ................................ 55

FLECTOR .............................. 16

FLEXBUMIN 25 % ............... 52

FLEXBUMIN 5 % ................. 52

FLOVENT DISKUS .............. 93

FLOVENT HFA ..................... 93

floxuridine .............................. 27

fluconazole ............................. 39

fluconazole in dextrose(iso-o) 39

fluconazole in nacl (iso-osm) 39

flucytosine ............................. 39

fludrocortisone ....................... 78

flumazenil .............................. 62

flunisolide .............................. 73

fluocinonide ........................... 68

fluocinonide-emollient base .. 68

fluorometholone..................... 73

FLUOROPLEX ..................... 66

fluorouracil ................ 25, 27, 66

fluoxetine ............................... 35

fluoxymesterone .................... 77

fluphenazine decanoate .......... 44

fluphenazine hcl ..................... 44

flurbiprofen ............................ 16

flurbiprofen sodium ............... 73

flutamide ................................ 27

fluticasone ........................ 68, 73

fluvoxamine ........................... 35

fomepizole ............................. 87

fondaparinux .......................... 49

FORTEO ................................ 85

FORTICAL ............................ 85

foscarnet ........................... 47, 48

fosinopril ................................ 55

fosinopril-hydrochlorothiazide

........................................... 55

fosphenytoin .......................... 32

FREAMINE HBC 6.9 % ....... 53

FREAMINE III 10 % ............ 53

furosemide ............................. 60

FUSILEV ............................... 87

FUZEON ............................... 46

FYCOMPA ............................ 32

G gabapentin .............................. 33

GABITRIL............................. 33

galantamine ............................ 34

GAMASTAN S/D ................. 80

GAMMAGARD LIQUID ..... 80

GAMMAPLEX ..................... 80

ganciclovir sodium ................ 49

GARDASIL (PF) ................... 82

GARDASIL 9 (PF) ................ 82

gatifloxacin ............................ 72

GATTEX 30-VIAL ................ 74

GATTEX ONE-VIAL ........... 74

GAUZE PAD ......................... 87

GAZYVA ............................... 27

gemfibrozil ............................. 61

GENOTROPIN ...................... 78

GENOTROPIN MINIQUICK 78

gentamicin .................. 19, 67, 72

gentamicin in nacl (iso-osm) .. 19

gentamicin sulfate .................. 72

gentamicin sulfate (ped) (pf) .. 19

gentamicin sulfate (pf) ........... 19

GENVOYA ............................ 46

GEODON ............................... 44

gildess 1/20 (21) ..................... 64

gildess 24 fe ........................... 64

gildess fe 1/20 (28)................. 64

GILENYA .............................. 87

GILOTRIF ............................. 27

GLEEVEC ....................... 27, 28

GLEOSTINE.......................... 28

glimepiride ............................. 38

glipizide.................................. 38

glipizide-metformin ............... 38

GLUCAGEN HYPOKIT ....... 87

GLUCAGON EMERGENCY

KIT (HUMAN) .................. 87

glyburide ................................ 38

glyburide micronized ............. 38

glyburide-metformin .............. 38

glycopyrrolate ........................ 74

glydo ...................................... 17

GLYXAMBI .......................... 36

granisetron (pf)....................... 41

granisetron hcl ........................ 41

GRANIX ................................ 50

griseofulvin microsize ............ 39

guanfacine ........................ 54, 62

guanidine ................................ 87

I-7




H halobetasol propionate............ 68

haloperidol .............................. 44

haloperidol decanoate ............. 44

haloperidol lactate .................. 44

HARVONI ............................. 48

HAVRIX (PF) ........................ 82

heparin (porcine) .................... 50

heparin (porcine) in 5 % dex . 49,

50

heparin (porcine) in nacl (pf) . 50

heparin sodium,porcine-pf ..... 50

heparin(porcine) in 0.45% nacl

............................................ 50

heparin, porcine (pf) ............... 50

HEPATAMINE 8%................ 53

HEPATASOL 8 % ................. 53

HERCEPTIN .......................... 28

HETLIOZ ............................... 95

HEXALEN ............................. 28

homatropine hbr ..................... 71

HUMIRA ................................ 80

HUMIRA PEN ....................... 80

HUMIRA PEN CROHN'S-UC-

HS START ......................... 80

HUMULIN R U-500

(CONCENTRATED) ......... 37

hydralazine ............................. 59

hydrochlorothiazide ................ 60

hydrocodone-acetaminophen 13,

14

hydrocodone-ibuprofen .......... 14

hydrocortisone ............ 68, 69, 78

hydrocortisone acet-aloe vera. 68

hydrocortisone acetate-urea.... 68

hydrocortisone butyrate .......... 68

hydrocortisone butyr-emollient

............................................ 68

hydrocortisone sod succinate . 78

hydrocortisone valerate .......... 69

hydromorphone ...................... 14

hydromorphone (pf) ............... 14

hydroxychloroquine ............... 42

hydroxyurea ........................... 28

hydroxyzine hcl ..................... 87

hydroxyzine pamoate ............. 87

HYPERLYTE CR.................. 90

HYPERRAB S/D (PF)........... 80

HYQVIA ............................... 80

I ibandronate ............................ 85

IBRANCE .............................. 28

ibuprofen ................................ 16

ICLUSIG ............................... 28

ifosfamide .............................. 28

ifosfamide-mesna ................... 28

ILARIS (PF) .......................... 80

ILEVRO................................. 73

IMBRUVICA ........................ 28

imipenem-cilastatin ............... 22

imipramine hcl ....................... 35

imipramine pamoate .............. 35

imiquimod .............................. 66

IMLYGIC .............................. 28

IMOGAM RABIES-HT (PF) 80

IMOVAX RABIES VACCINE

(PF) .................................... 82

INCRELEX ........................... 78

indapamide............................. 60

indomethacin ......................... 16

indomethacin sodium ............. 16

INFANRIX (DTAP) (PF) ...... 82

INLYTA ................................ 28

INSULIN SYRINGE-NEEDLE

U-100 ................................. 70

INTELENCE ......................... 46

INTRALIPID ......................... 53

INTRON A ............................ 48

INVANZ ................................ 22

INVEGA ................................ 44

INVEGA SUSTENNA .... 44, 45

INVEGA TRINZA ................ 45

INVIRASE............................. 47

INVOKAMET ....................... 36

INVOKANA .......................... 36

IONOSOL-B IN D5W ........... 90

IONOSOL-MB IN D5W........ 90

IPOL ....................................... 82

ipratropium bromide .............. 71

IPRIVASK ............................. 50

irbesartan ................................ 54

irbesartan-hydrochlorothiazide

............................................ 54

IRESSA .................................. 28

ISENTRESS ........................... 47

ISOLYTE M IN 5 %

DEXTROSE ....................... 90

ISOLYTE-H IN 5 %

DEXTROSE ....................... 90

ISOLYTE-P IN 5 %

DEXTROSE ....................... 90

ISOLYTE-S ........................... 90

isoniazid ................................. 41

isosorbide dinitrate ................. 61

isosorbide mononitrate ........... 61

isotretinoin ............................. 66

isradipine ................................ 59

itraconazole ............................ 39

ivermectin .............................. 42

IXEMPRA.............................. 28

IXIARO (PF) ......................... 82

J JAKAFI .................................. 28

JALYN ................................... 87

jantoven .................................. 50

JANUMET ............................. 36

JANUMET XR ...................... 36

JANUVIA .............................. 36

JARDIANCE ......................... 36

JENTADUETO ...................... 36

juleber .................................... 64

junel fe 24 .............................. 64

JUXTAPID ............................ 61

K KABIVEN.............................. 53

KALETRA ............................. 47

I-8




KALYDECO .......................... 94

KANUMA .............................. 70

KEDBUMIN .......................... 52

ketoconazole ........................... 39

ketoprofen............................... 16

ketorolac ........................... 16, 73

KEVEYIS ............................... 87

KEYTRUDA .......................... 28

kimidess (28) .......................... 64

KINERET ............................... 80

KINRIX (PF) .......................... 82

klor-con 10 ............................. 90

klor-con m10 .......................... 90

klor-con m15 .......................... 90

klor-con m20 .......................... 90

klor-con sprinkle .................... 90

KORLYM............................... 37

KRYSTEXXA ........................ 70

KUVAN ................................. 70

KYNAMRO ........................... 61

KYPROLIS ............................ 28

L l norgest/e.estradiol-e.estrad ... 64

labetalol .................................. 56

LACRISERT .......................... 71

LACTATED RINGERS ......... 85

lactulose .................................. 74

LAMICTAL ........................... 33

lamivudine .............................. 47

lamivudine-zidovudine ........... 47

lamotrigine ............................. 33

LANOXIN .............................. 59

lansoprazole ............................ 74

LANTUS ................................ 37

LANTUS SOLOSTAR .......... 37

larin 24 fe ............................... 64

larin fe 1/20 (28) ..................... 64

latanoprost .............................. 89

LATUDA ............................... 45

LAZANDA............................. 14

leflunomide............................. 80

LEMTRADA .......................... 87

LENVIMA ............................. 28

LETAIRIS ............................. 96

letrozole ................................. 29

leucovorin calcium ................ 87

LEUKERAN .......................... 29

LEUKINE .............................. 50

leuprolide ............................... 29

levetiracetam .......................... 33

levobunolol ............................ 89

levocarnitine .......................... 87

levocarnitine (with sugar) ...... 87

levocetirizine ......................... 40

levofloxacin ..................... 24, 72

levofloxacin in d5w ............... 24

levonorgestrel ........................ 64

levonorgestrel-ethin estradiol 64

levonorgestrel-ethinyl estrad . 64

levothyroxine ......................... 79

LEXIVA ................................ 47

lidocaine................................. 17

lidocaine (pf) .................... 17, 55

lidocaine hcl ........................... 17

lidocaine in 5 % dextrose (pf) 55

lidocaine-prilocaine ............... 17

linezolid ................................. 19

LINZESS ............................... 74

liothyronine ............................ 79

lipase-protease-amylase ......... 70

LIPOSYN II ........................... 53

LIPOSYN III ......................... 53

lisinopril ................................. 55

lisinopril-hydrochlorothiazide 55

lithium carbonate ................... 62

lithium citrate ......................... 63

l-norgest-eth estr/ethin estra .. 64

lomustine ............................... 29

LONSURF ............................. 29

loperamide ............................. 74

lorazepam ............................... 18

losartan................................... 54

losartan-hydrochlorothiazide . 54

LOTEMAX ............................ 73

LOTRONEX .......................... 74

lovastatin ................................ 61

loxapine succinate .................. 45

LUMIGAN ............................. 89

LUPRON DEPOT .................. 29

LUPRON DEPOT (3 MONTH)

............................................ 29


............................................ 29


............................................ 29

LUPRON DEPOT-PED ......... 78

LUPRON DEPOT-PED (3

MONTH)............................ 78

LYNPARZA .......................... 29

LYRICA ................................. 33

LYSODREN .......................... 29

M magnesium chloride ............... 90

magnesium sulf in 0.45% nacl90

magnesium sulfate ................. 90

magnesium sulfate in d5w ..... 90

magnesium sulfate in water ... 90

malathion................................ 69

maprotiline ............................. 35

MARPLAN ............................ 35

MATULANE ......................... 29

matzim la ................................ 57

meclizine ................................ 41

medroxyprogesterone ............. 79

mefenamic acid ...................... 16

mefloquine ............................. 42

MEFOXIN IN DEXTROSE

(ISO-OSM) ........................ 22

MEGACE ES ......................... 79

megestrol .......................... 29, 79

MEKINIST ............................ 29

meloxicam .............................. 16

memantine .............................. 34

MENACTRA (PF) ................. 82

MENEST................................ 77

MENHIBRIX (PF) ................. 82

I-9




MENOMUNE - A/C/Y/W-135

(PF) ..................................... 83

MENVEO A-C-Y-W-135-DIP

(PF) ..................................... 83

MENVEO MENA

COMPONENT (PF) ........... 83

MENVEO MENCYW-135

COMPNT (PF) ................... 83

mercaptopurine ....................... 29

meropenem ............................. 22

mesna ...................................... 87

MESNEX ............................... 87

MESTINON ........................... 87

MESTINON TIMESPAN ...... 87

metaproterenol ........................ 94

metaxall .................................. 95

metaxalone ............................. 95

metformin ............................... 37

methadone .............................. 14

methadone hcl ........................ 14

methazolamide ....................... 89

methenamine hippurate .......... 19

methenamine mandelate ......... 19

methimazole ........................... 79

methocarbamol ....................... 95

methotrexate sodium .............. 29

methotrexate sodium (pf) ....... 29

methoxsalen rapid .................. 66

methscopolamine .................... 74

methyclothiazide .................... 60

methylphenidate ..................... 63

methylprednisolone ................ 78

methylprednisolone acetate .... 78

methylprednisolone sodium succ

............................................ 78

metipranolol ........................... 89

metoclopramide hcl .......... 74, 75

metolazone ............................. 60

metoprolol succinate .............. 56

metoprolol ta-hydrochlorothiaz

............................................ 56

metoprolol tartrate .................. 56

metronidazole ............ 19, 40, 67

metronidazole in nacl (iso-os) 19

mexiletine .............................. 55

MIACALCIN......................... 85

miconazole nitrate .................. 39

midodrine ............................... 54

milrinone ................................ 59

milrinone in 5 % dextrose ...... 59

minitran .................................. 61

minocycline ........................... 25

minoxidil ................................ 61

MIRCERA ............................. 50

mirtazapine ............................ 35

misoprostol ............................ 74

mitoxantrone .......................... 29

M-M-R II (PF) ....................... 83

moexipril ................................ 55

moexipril-hydrochlorothiazide

........................................... 55

molindone .............................. 45

mometasone ........................... 69

montelukast ............................ 93

morphine .......................... 14, 15

MORPHINE .......................... 15

morphine (pf) in 0.9 % nacl ... 14

morphine concentrate ............ 14

morphine in dextrose 5 % ...... 14

morrhuate sodium .................. 87

MOVANTIK ......................... 75

MOVIPREP ........................... 75

MOXEZA .............................. 72

moxifloxacin .......................... 24

MOZOBIL ............................. 50

MULTAQ .............................. 55

mupirocin ............................... 67

mupirocin calcium ................. 67

mycophenolate mofetil .......... 80

mycophenolate sodium .......... 80

MYOZYME........................... 70

MYRBETRIQ ........................ 76

N nabumetone ............................ 16

nadolol.................................... 56

nafcillin .................................. 23

NAGLAZYME ...................... 70

naloxone ................................. 18

naltrexone ............................... 18

NAMENDA XR..................... 34

NAMZARIC .......................... 34

naphazoline ............................ 71

naproxen ........................... 16, 17

naproxen sodium .................... 17

naratriptan .............................. 40

NATACYN ............................ 72

nateglinide .............................. 37

NATPARA ............................. 85

NEBUPENT ........................... 42

nefazodone ............................. 35

neomy sulf-bacitrac zn-poly-hc

............................................ 72

neomycin ................................ 19

neomycin-bacitracin-poly-hc . 72

neomycin-bacitracin-polymyxin

............................................ 72

neomycin-polymyxin b gu ..... 67

neomycin-polymyxin b-

dexameth ............................ 72

neomycin-polymyxin-

gramicidin .......................... 72

neomycin-polymyxin-hc ........ 72

neo-polycin ............................ 72

NEPHRAMINE 5.4 % ........... 53

NEULASTA .......................... 50

NEUMEGA............................ 51

NEUPOGEN .......................... 51

NEUPRO................................ 43

NEVANAC ............................ 73

nevirapine ............................... 47

NEXAVAR ............................ 29

niacin ...................................... 61

nicardipine.............................. 59

NICOTROL ........................... 18

nifedipine ............................... 59

NILANDRON ........................ 29

I-10




NINLARO .............................. 29

NITRO-BID ........................... 61

nitrofurantoin macrocrystal .... 20

nitrofurantoin monohyd/m-cryst

............................................ 20

nitroglycerin ........................... 62

nitroglycerin in 5 % dextrose . 62

NITROSTAT .......................... 62

NORDITROPIN FLEXPRO .. 78

norelgestromin/ethin.estradiol 64

norepinephrine bitartrate ........ 59

norethindrone ......................... 64

norethindrone (contraceptive) 64

norethindrone acetate ............. 79

norethindrone ac-eth estradiol 64

norethindrone-e.estradiol-iron 64

norethindrone-ethinyl estrad .. 65

norethindrone-mestranol ........ 65

norgestimate-ethinyl estradiol 65

norgestrel-ethinyl estradiol ..... 65

NORMOSOL-M IN 5 %

DEXTROSE ....................... 91

NORMOSOL-R PH 7.4 ......... 91

NORTHERA .......................... 54

nortriptyline ............................ 35

NORVIR................................. 47

NOVOLIN 70/30.................... 37

NOVOLIN N .......................... 37

NOVOLIN R .......................... 37

NOVOLOG ............................ 37

NOVOLOG FLEXPEN.......... 37

NOVOLOG MIX 70-30 ......... 37

NOVOLOG MIX 70-30

FLEXPEN .......................... 37

NOVOLOG PENFILL ........... 37

NOXAFIL .............................. 39

NUCALA ............................... 95

NUCYNTA ............................ 15

NUCYNTA ER ...................... 15

NUEDEXTA .......................... 63

NULOJIX ............................... 81

NUTRESTORE ...................... 75

NUTRILIPID ......................... 53

NUTRILYTE ......................... 91

NUTRILYTE II ..................... 91

NUVARING .......................... 65

NUVIGIL............................... 95

nystatin................................... 39

NYSTATIN (BULK) ............. 39

nystatin-triamcinolone ........... 39

O OCTAGAM ........................... 81

octreotide acetate ................... 79

ODOMZO .............................. 29

OFEV ..................................... 95

ofloxacin .......................... 24, 72

olanzapine .............................. 45

olanzapine-fluoxetine ............ 35

olopatadine............................. 71

OLYSIO................................. 48

omega-3 acid ethyl esters ...... 61

omeprazole ............................. 74

ONCASPAR .......................... 29

ondansetron ............................ 41

ondansetron hcl ...................... 41

ondansetron hcl (pf) ............... 41

ONFI ................................ 18, 69

OPDIVO ................................ 30

OPSUMIT .............................. 96

ORAP..................................... 45

ORENCIA ............................. 81

ORENCIA (WITH MALTOSE)

........................................... 81

ORENITRAM ....................... 96

ORFADIN ............................. 70

ORKAMBI ............................ 95

OTEZLA ................................ 87

OTEZLA STARTER ............. 88

OTREXUP (PF) ..................... 88

oxacillin ........................... 23, 24

oxacillin in dextrose(iso-osm) 23

oxandrolone ........................... 77

oxcarbazepine ........................ 33

OXTELLAR XR.................... 33

oxybutynin chloride ............... 76

oxycodone .............................. 15

oxycodone hcl-acetaminophen

............................................ 15

oxycodone hcl-aspirin ............ 15

oxycodone-acetaminophen .... 15

oxycodone-aspirin .................. 15

OXYCONTIN ........................ 15

oxymorphone ......................... 15

P paliperidone............................ 45

PANRETIN ............................ 66

pantoprazole ........................... 74

papaverine .............................. 59

paricalcitol.............................. 85

paromomycin ......................... 42

paroxetine hcl ................... 35, 36

PASER ................................... 41

PATADAY ............................ 71

PAXIL .................................... 36

pedi m.vit no.17 with fluoride 97

PEDIARIX (PF) ..................... 83

PEDVAX HIB (PF) ............... 83

peg 3350-electrolytes ............. 75

PEG 3350-GRX ..................... 75

peg 3350-na sulf,bicarb,cl-kcl 75

PEGANONE .......................... 33

PEGASYS .............................. 48

PEGASYS PROCLICK ......... 48

peg-electrolyte soln ................ 75

PEGINTRON ......................... 48

PEN NEEDLE, DIABETIC ... 70

penicillin g pot in dextrose ..... 24

penicillin g potassium ............ 24

penicillin g procaine ............... 24

penicillin v potassium ............ 24

PENTACEL (PF) ................... 83

PENTACEL ACTHIB

COMPONENT (PF)........... 83

PENTAM ............................... 42

pentoxifylline ......................... 51

PERIKABIVEN ..................... 53

I-11




perindopril erbumine .............. 55

permethrin .............................. 69

perphenazine........................... 45

perphenazine-amitriptyline..... 36

phenelzine............................... 36

phenobarbital .......................... 33

phenobarbital sodium ............. 33

phenylephrine hcl ............. 54, 71

phenytoin ................................ 33

phenytoin sodium ................... 33

phenytoin sodium extended .... 33

PHOSLYRA ........................... 75

PHOSPHOLINE IODIDE ...... 89

phosphorus #1 ........................ 91

PICATO ................................. 66

pilocarpine hcl .................. 65, 89

pimozide ................................. 45

pindolol................................... 56

pioglitazone ............................ 37

pioglitazone-glimepiride ........ 37

pioglitazone-metformin .......... 37

piperacillin-tazobactam .......... 24

piroxicam ................................ 17

PLASBUMIN 25 % ............... 52

PLASBUMIN 5 % ................. 52

PLASMA-LYTE 148 ............. 91

PLASMA-LYTE A ................ 91

PLASMA-LYTE-56 IN 5 %

DEXTROSE ....................... 91

PLEGRIDY ............................ 88

podofilox ................................ 66

podophyllum resin .................. 66

polyethylene glycol 3350 ....... 75

polymyxin b sulfate ................ 20

polymyxin b sulf-trimethoprim

............................................ 72

POMALYST .......................... 30

PORTRAZZA ........................ 30

potassium acetate.................... 91

potassium bicarb and chloride 91

potassium bicarb-citric acid ... 91

potassium bicarbonate-cit ac .. 91

potassium chlorid-d5-0.45%nacl

........................................... 91

potassium chloride ........... 91, 92

potassium chloride in 0.9%nacl

........................................... 91

potassium chloride in 5 % dex91

potassium chloride in lr-d5 .... 91

potassium chloride-0.45 % nacl

........................................... 92


........................................... 92


........................................... 92


........................................... 92

potassium citrate .................... 92

potassium citrate-citric acid ... 92

potassium hydroxide .............. 66

potassium phosphate m-/d-basic

........................................... 92

POTIGA................................. 33

PRADAXA ............................ 50

PRALUENT PEN .................. 61

PRALUENT SYRINGE ........ 61

pramipexole ........................... 43

PRANDIMET ........................ 37

pravastatin .............................. 61

prazosin .................................. 54

prednicarbate ......................... 69

prednisolone acetate .............. 73

prednisolone sodium phosphate

..................................... 73, 78

prednisone .............................. 78

PREMARIN........................... 77

PREMASOL 10 %................. 53

PREMASOL 6 %................... 53

PREMPHASE ........................ 77

PREMPRO............................. 77

prenatal vitamins.................... 97

PREZCOBIX ......................... 47

PREZISTA............................. 47

PRIFTIN ................................ 41

PRIMAQUINE ...................... 42

primidone ............................... 33

PRISTIQ ................................ 36

PRIVIGEN ............................. 81

PROAIR HFA ........................ 94

PROAIR RESPICLICK ......... 94

probenecid .............................. 88

procainamide .......................... 55

PROCALAMINE 3% ............ 54

prochlorperazine .................... 41

prochlorperazine edisylate ..... 42

prochlorperazine maleate ....... 42

PROCRIT ............................... 51

PROCYSBI ............................ 88

progesterone ........................... 79

progesterone micronized ........ 79

PROGLYCEM ....................... 62

PROGRAF ............................. 81

PROLASTIN-C...................... 95

PROLENSA ........................... 73

PROLEUKIN ......................... 30

PROLIA ................................. 85

PROMACTA ......................... 51

promethazine .................... 40, 42

promethazine hcl .................... 42

propafenone...................... 55, 56

propantheline.......................... 32

proparacaine ........................... 71

proparacaine hcl ..................... 71

proparacaine-fluorescein sod . 71

propranolol ............................. 56

propranolol-hydrochlorothiazid

............................................ 56

propylthiouracil ...................... 79

PROQUAD (PF) .................... 83

PROSOL 20 % ....................... 54

protamine ............................... 51

protriptyline............................ 36

PULMOZYME ...................... 70

PURIXAN .............................. 30

pyrazinamide .......................... 41

pyridostigmine bromide ......... 88

I-12




Q QUADRACEL (PF) ............... 83

quetiapine ............................... 45

QUILLIVANT XR ................. 63

quinapril ................................. 55

quinapril-hydrochlorothiazide 55

quinidine gluconate ................ 56

quinidine sulfate ..................... 56

quinine sulfate ........................ 42

QVAR..................................... 93

R RABAVERT (PF) .................. 83

raloxifene ................................ 77

ramipril ................................... 55

RANEXA ............................... 59

ranitidine hcl ........................... 74

RAPAMUNE ......................... 81

RASUVO (PF) ....................... 88

RAVICTI ................................ 75

REBIF (WITH ALBUMIN) ... 88

REBIF REBIDOSE ................ 88

REBIF TITRATION PACK .. 88

RECOMBIVAX HB (PF) 83, 84

RELADOR PAK .................... 17

RELENZA DISKHALER ...... 48

RELISTOR ............................. 75

REMICADE ........................... 88

REMODULIN ........................ 96

RENAGEL ............................. 76

RENVELA ............................. 76

repaglinide .............................. 37

repaglinide-metformin ............ 37

REPATHA SURECLICK ...... 61

REPATHA SYRINGE ........... 61

RESCRIPTOR ........................ 47

RESTASIS ............................. 73

RETROVIR ............................ 47

REVLIMID ............................ 30

REXULTI ............................... 45

REYATAZ ............................. 47

ribavirin .................................. 49

RIDAURA .............................. 81

rifabutin ................................. 41

rifampin ................................. 41

RIFATER............................... 41

riluzole ................................... 63

rimantadine ............................ 48

ringers .............................. 85, 92

risedronate ............................. 86

RISPERDAL CONSTA ........ 45

risperidone ....................... 45, 46

RITUXAN ............................. 30

rivastigmine ........................... 34

rivastigmine tartrate ............... 34

rizatriptan ............................... 40

ropinirole ............................... 43

ROTARIX ............................. 84

ROTATEQ VACCINE .......... 84

ROZEREM ............................ 95

S SABRIL ................................. 34

SAIZEN ................................. 79

SAIZEN CLICK.EASY......... 79

salsalate .................................. 17

SANDOSTATIN LAR DEPOT

........................................... 79

SANTYL ............................... 66

SAPHRIS (BLACK CHERRY)

........................................... 46

SAVELLA ............................. 63

selegiline hcl .......................... 43

selenium sulfide ..................... 67

SELZENTRY ........................ 47

SENSIPAR ............................ 88

SEREVENT DISKUS ........... 94

SEROSTIM ........................... 79

sertraline ................................ 36

setlakin ................................... 65

SIGNIFOR ............................. 88

sildenafil ................................ 96

SILENOR .............................. 36

silver nitrate ........................... 67

silver nitrate applicators ......... 67

silver sulfadiazine .................. 67

SIMBRINZA.......................... 89

SIMPONI ............................... 88

SIMPONI ARIA .................... 88

simvastatin ............................. 61

sirolimus ................................. 81

SIRTURO .............................. 41

sodium acetate ........................ 92

sodium bicarbonate ................ 92

sodium chloride ................ 85, 92

sodium chloride 0.45 % ......... 92

sodium chloride 0.9 % ........... 92

sodium chloride 3 % .............. 92

sodium chloride 5 % .............. 92

sodium chloride-nahco3-kcl-peg

............................................ 75

sodium citrate-citric acid........ 92

sodium fluoride ................ 65, 97

sodium lactate ........................ 92

sodium phosphate................... 92

sodium polystyrene sulfonate 74,

75

sodium thiosulfate .................. 76

sod-pot-k cit-sod cit-cit acid .. 92

SOLTAMOX ......................... 30

SOLU-CORTEF (PF) ............ 78

SOMATULINE DEPOT ........ 79

SOMAVERT.......................... 79

sorbitol ................................... 85

sorbitol-mannitol .................... 85

sotalol ..................................... 56

sotalol hcl ............................... 56

SOVALDI .............................. 48

SPIRIVA RESPIMAT ........... 94

SPIRIVA WITH

HANDIHALER ................. 94

spironolactone ........................ 61

spironolacton-hydrochlorothiaz

............................................ 61

SPRYCEL .............................. 30

stavudine ................................ 47

STELARA.............................. 88

STERILE PADS .................... 88

I-13




STIOLTO RESPIMAT .......... 32

STIVARGA ............................ 30

STRATTERA ......................... 63

STRENSIQ ............................. 70

streptomycin ........................... 19

STRIBILD .............................. 47

STRIVERDI RESPIMAT ...... 94

sucralfate ................................ 74

sulfacetamide sodium ............. 72

sulfacetamide sodium (acne) .. 67

sulfacetamide-prednisolone .... 72

sulfadiazine............................. 24

sulfamethoxazole-trimethoprim

............................................ 24

sulfasalazine ........................... 25

sulfatrim ................................. 25

sulfazine ec ............................. 25

sulindac................................... 17

sumatriptan ............................. 40

sumatriptan succinate ............. 40

SUPPRELIN LA .................... 79

SUPRAX ................................ 22

SURMONTIL......................... 36

SUSTIVA ............................... 47

SUTENT................................. 30

SYLATRON........................... 48

SYLVANT ............................. 30

SYMLINPEN 120 .................. 37

SYMLINPEN 60 .................... 37

SYNAGIS............................... 48

SYNAREL ............................. 88

SYNERCID ............................ 20

SYNJARDY ........................... 37

SYNRIBO .............................. 30

SYPRINE ............................... 76

T TABLOID .............................. 30

tacrolimus ......................... 69, 81

TAFINLAR ............................ 30

TAGRISSO ............................ 30

TAMIFLU .............................. 48

tamoxifen ................................ 30

tamsulosin .............................. 76

TARCEVA ............................ 30

TARGRETIN......................... 30

tarina fe 1/20 (28) .................. 65

TASIGNA .............................. 30

TAZORAC ............................ 69

taztia xt .................................. 57

TECFIDERA ......................... 88

TECHNIVIE .......................... 48

TEFLARO ............................. 22

telmisartan ............................. 54

telmisartan-hydrochlorothiazid

........................................... 54

TEMODAR ........................... 30

TENIVAC (PF)...................... 84

terazosin ................................. 76

terbinafine hcl ........................ 39

terbutaline .............................. 94

terconazole ............................. 40

testosterone ............................ 77

testosterone cypionate ............ 77

testosterone enanthate ............ 77

TETANUS

TOXOID,ADSORBED (PF)

........................................... 84

TETANUS,DIPHTHERIA TOX

PED(PF)............................. 84

TETANUS-DIPHTHERIA

TOXOIDS-TD ................... 84

tetrabenazine .......................... 63

tetracaine hcl (pf) ................... 71

tetracycline ............................. 25

THALOMID .......................... 88

theophylline ........................... 94

theophylline anhydrous.......... 94

theophylline in dextrose 5 % . 94

thioridazine ............................ 46

thiotepa .................................. 31

thiothixene ............................. 46

tiagabine................................. 34

TICE BCG ............................. 81

TIKOSYN .............................. 56

timolol maleate................. 56, 89

TIVICAY ............................... 47

tizanidine ................................ 95

TOBI PODHALER ................ 19

TOBRADEX .......................... 72

TOBRADEX ST .................... 72

tobramycin ............................. 72

tobramycin in 0.225 % nacl ... 19

tobramycin in 0.9 % nacl ....... 19

tobramycin sulfate .................. 19

tobramycin-dexamethasone ... 72

TOLAK .................................. 66

tolazamide .............................. 38

tolbutamide ............................ 38

tolmetin .................................. 17

tolterodine .............................. 76

topiramate .............................. 34

toposar .................................... 31

torsemide ................................ 60

TOUJEO SOLOSTAR ........... 38

TOVIAZ ................................. 76

TPN ELECTROLYTES......... 92

TPN ELECTROLYTES II ..... 93

TRACLEER ........................... 96

TRADJENTA ........................ 37

tramadol ................................. 15

tramadol-acetaminophen ........ 15

trandolapril ............................. 55

tranexamic acid ...................... 51

TRANSDERM-SCOP............ 42

tranylcypromine ..................... 36

TRAVASOL 10 % ................. 54

TRAVATAN Z ...................... 89

travoprost (benzalkonium) ..... 89

trazodone ................................ 36

TREANDA ............................ 31

TRECATOR .......................... 41

TRELSTAR ........................... 31

tretinoin .................................. 69

tretinoin (chemotherapy) ........ 31

tretinoin microspheres ............ 69

TREXALL ............................. 31

I-14




triamcinolone acetonide .. 65, 69,

78

triamterene-hydrochlorothiazid

............................................ 60

TRIBENZOR ......................... 54

trifluoperazine ........................ 46

trifluridine............................... 73

trihexyphenidyl....................... 43

tri-lo-estarylla ......................... 65

tri-lo-marzia ............................ 65

tri-lo-sprintec .......................... 65

trimethoprim ........................... 20

trimipramine ........................... 36

TRIUMEQ .............................. 47

TROKENDI XR ..................... 34

TROPHAMINE 10 % ............ 54

TROPHAMINE 6% ............... 54

trospium .................................. 76

TRULICITY ........................... 37

TRUMENBA ......................... 84

TRUVADA ............................ 47

TUDORZA PRESSAIR ......... 94

TWINRIX (PF) ...................... 84

TYBOST ................................ 88

TYGACIL .............................. 25

TYKERB ................................ 31

TYPHIM VI ........................... 84

TYSABRI ............................... 81

TYVASO ................................ 96

TYVASO REFILL KIT ......... 96

TYVASO STARTER KIT ..... 96

TYZEKA ................................ 49

U ULORIC ................................. 88

UNITUXIN ............................ 31

UPTRAVI......................... 96, 97

ursodiol ................................... 75

V VAGIFEM .............................. 77

valacyclovir ............................ 49

VALCHLOR .......................... 66

valganciclovir ......................... 49

valproate sodium.................... 34

valproic acid .......................... 34

valproic acid (as sodium salt) 34

valsartan ................................. 54

valsartan-hydrochlorothiazide 54

VALSTAR ............................. 31

vancomycin ............................ 20

vancomycin in d5w ................ 20

VAQTA (PF) ......................... 84

VARIVAX (PF) ..................... 84

VASCEPA ............................. 61

VELCADE............................. 31

venlafaxine ............................. 36

VENTOLIN HFA .................. 94

verapamil ............................... 57

VERSACLOZ ........................ 46

VGO 40.................................. 70

VIBERZI ............................... 75

VICTOZA 3-PAK ................. 37

VIDEX 2 GRAM PEDIATRIC

........................................... 47

VIDEX 4 GRAM PEDIATRIC

........................................... 47

VIEKIRA PAK ...................... 48

vienva..................................... 65

VIGAMOX ............................ 73

VIIBRYD............................... 36

VIMIZIM ............................... 70

VIMPAT ................................ 34

vinorelbine ............................. 31

VIRACEPT ............................ 47

VIRAMUNE XR ................... 47

VIRAZOLE ........................... 49

VIREAD ................................ 47

VITAFOL FE+ (WITH

DOCUSATE)..................... 97

VITEKTA .............................. 47

VOLTAREN .......................... 17

voriconazole ........................... 39

VOTRIENT ........................... 31

VPRIV ................................... 70

VRAYLAR ............................ 46

W warfarin .................................. 50

water for irrigation, sterile ..... 85

X XALKORI.............................. 31

XARELTO ............................. 50

XELJANZ .............................. 88

XENAZINE ........................... 63

XIFAXAN.............................. 20

XOLAIR ................................ 95

XTANDI ................................ 31

xylon 10 ................................. 15

XYREM ................................. 95

Y YERVOY ............................... 31

YF-VAX (PF) ........................ 84

YONDELIS............................ 31

Z zafirlukast ............................... 93

zaleplon .................................. 95

ZARXIO ................................ 51

ZAVESCA ............................. 70

ZELBORAF ........................... 31

ZEMPLAR ............................. 86

ZENPEP ................................. 70

ZEPATIER ............................. 48

ZETIA .................................... 61

ZIAGEN ................................. 47

zidovudine .............................. 47

ziprasidone hcl ....................... 46

ZIRGAN ................................ 73

ZOLADEX ............................. 31

zoledronic acid ....................... 86


............................................ 86

ZOLINZA .............................. 31

zolmitriptan ............................ 40

zolpidem ................................. 96

ZOMETA ............................... 86

zonisamide ............................. 34

ZORTRESS............................ 81

ZOSTAVAX (PF) .................. 84

I-15




ZOVIRAX .............................. 66

ZUBSOLV ............................. 18

ZYDELIG............................... 32

ZYKADIA ............................. 32

ZYLET................................... 73

ZYPREXA RELPREVV ....... 46

ZYTIGA ................................. 32

ZYVOX.................................. 20

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