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2017 Healthy Premier Formulary
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PRODUCT SELECTION CRITERIA
When a new drug is considered for Formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on Formulary. In
addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion or non-Formulary (NF) status of drug(s) in
a particular therapeutic class, in an effort to continually promote the most clinically useful and cost-effective agents.
A central factor in successful management of the Formulary is the review and evaluation of the drug products available in the consumer market and a
means to make changes to the Formulary in response to changing therapies and economic factors. The P&T Committee utilizes the following criterion in
the evaluation of product selection for the Formulary:
a) The drug product must demonstrate unequivocal safety for medical use.
b) The drug product must be efficacious and be medically necessary for the treatment, maintenance, or prophylaxis of a medical condition.
c) The drug product does not have alternative/similar agents on the Formulary that could be substituted.
d) The drug product must demonstrate a therapeutic outcome.
e) The medical community must accept the drug product for use.
f ) The drug product must have an equitable cost ratio for the treatment of the medical condition.
FOUR-TIER FORMULARY CO-PAYMENT STRUCTURE
This Formulary is divided into four tiers and the tier is easily identified in the second column on the Formulary. Generic drugs offer an excellent value to
the consumer because they are chemically identical to brand drugs but are priced at a fraction of the cost of the corresponding brand drug. The U.S.
Food and Drug Administration (FDA) requires that generic drugs provide the same effectiveness and safety as their brand name counterparts. The FDA
requires drug manufacturers to show that the generic version enters the bloodstream the same way, contains the same amount of active ingredient,
comes in the same dosage form and is taken the same way as the brand name drug. Members will pay the lowest co-payment for 1st tier medications.
These agents can be easily identified in the Formulary as the agents with a "1" in the second column. The P&T Committee has reviewed these
medications and found them to be therapeutically equivalent to their brand counterparts. Refer to your benefit materials, or call the PTI/NPS Help Desk
telephone number on your ID card, to determine what level of coverage you have for your prescription drugs.
PREVENTIVE DRUGS
Certain medications are recommended to prevent certain disease states and are covered at a different benefit than other drugs. These drugs are listed
below. Coverage of these drugs may be limited based on age, quantity dispensed or other limitations.
ADACEL AFLURIA AFLURIA PF AFLURIA QUADRIVALENT AFTERA ALTAVERA ALYACEN 1/35 ALYACEN 7/7/7 AMETHIA AMETHIA LO APRI ARANELLE ASHLYNA ASPIRIN CHW81MG ASPIRIN TAB81MG ASPIRIN TAB81MG EC AUBRA AVIANE AZURETTE BALZIVA BEKYREE BEXSERO BLISOVI 24 FE BLISOVI FE 1.5/30 BLISOVI FE 1/20 BOOSTRIX BRIELLYN BUPROPION HCL TAB CAMILA CAMRESE CAMRESE LO CERVARIX CHATEAL CYCLAFEM 1/35 CYCLAFEM 7/7/7 CYRED DAPTACEL DASETTA 1/35 DASETTA 7/7/7 DAYSEE DEBLITANE DELYLA DESO/ETHINYLTABEST-28
DROSPIRENONE/ETHINYL ESTR EMOQUETTE ENGERIX-B ENSKYCE ERRIN ESTARYLLA FA-8 FALMINA FEMYNOR FLUAD FLUARIX QUADRIVALENT FLUBLOK FLUCELVAX FLULAVAL QUADRIVALENT FLUORABON FLUOR-A-DAY FLUORIDE CHW0.5MG FLUORIDE CHW1MG FLUORITAB FLURA-DROPS FLUVIRIN FLUZONE HIGH-DOSE FLUZONE QUADRIVALENT FOLIC ACID TAB400MCG FOLIC ACID TAB800MCG GARDASIL GARDASIL 9 GAVILYTE-C GAVILYTE-G GAVILYTE-N/FLAVOR PACK GIANVI GILDAGIA HAVRIX HEATHER HIBTITER INFANRIX INTROVALE IPOL INACTIVATED IPV JENCYCLA JOLESSA JULEBER JUNEL 1.5/30 JUNEL 1.5/30TAB
JUNEL 1/20 JUNEL FE 1.5/30 JUNEL FE 1/20 JUNEL FE 24 KAITLIB FE KARIDIUM KARIVA KIMIDESS KINRIX KURVELO LARIN 1.5/30 LARIN 1/20 LARIN 24 FE LARIN FE 1.5/30 LARIN FE 1/20 LARISSIA LAYOLIS FE LEENA LESSINA LESSINA-28 TAB LEVONORGESTREL LEVONORGESTREL AND ETHINY LEVONORGESTREL/ETHINYL ES LEVORA-28 TAB0.15/30 LOMEDIA 24 FE LORYNA LUDENT LUTERA LYZA MARLISSA MEDROXYPR ACINJ150MG/ML MENACTRA MENOMUNE-A/C/Y/W-135 MENVEO MICROGESTIN 1.5/30 MICROGESTIN 1/20 MICROGESTIN 24 FE MICROGESTIN FE MICROGESTIN FE 1.5/30 MIRCETTE M-M-R II MONO-LINYAH MY WAY
NAFRINSE NAFRINSE DROPS NECON TAB0.5/35 NECON 1/35 NELOVA TAB.5/35-28 NELOVA TAB1/35-21 NELOVA TAB1/35-28 NEXT CHOICE NIKKI NORETHINDRONE 0.35MG NORGESTIMATE/ETHINYL ESTR NORLYROC NORTREL (28) TAB1/35 NORTREL 0.5/35 (28) NORTREL 1/35 NORTREL 7/7/7 NUVARING OCELLA OPCICON ONE-STEP ORSYTHIA PEDIARIX PEDVAX HIB PEDVAX HIB INJ PEG 3350/ELECTROLYTES PEG-PREP PENTACEL PHILITH PIMTREA PIRMELLA 1/35 PIRMELLA 7/7/7 PNEUMOVAX 23 PORTIA-28 PREVIFEM PREVNAR 13 PROQUAD QUADRACEL QUASENSE RALOXIFENE HYDROCHLORIDE REACT RECLIPSEN RECOMBIVAX HB ROTARIX ROTATEQ
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SETLAKIN SHAROBEL SOD FLOURIDEDRO0.5MG/ML SOD FLOURIDEDRO1.1MG/ML SOD FLUORIDECHW0.25MG SOD FLUORIDECHW0.5MG SOD FLUORIDECHW1.1MG SOD FLUORIDECHW1MG SOD FLUORIDECHW2.2MG SPRINTEC 28 SRONYX
SYEDA TAKE ACTION TAMOXIFEN CITRATE TARINA FE 1/20 TENIVAC TGT ASPIRIN TGT CHILDRENS ASPIRIN TRI-ESTARYLLA TRI-LINYAH TRI-LO-ESTARYLLA TRI-LO-MARZIA
TRI-LO-SPRINTEC TRILYTE TRINESSA TRINESSA LO TRI-PREVIFEM TRI-SPRINTEC TRUMENBA TWINRIX VAQTA VARIVAX VESTURA
VIENVA VIORELE VYFEMLA WERA WYMZYA FE XULANE ZARAH ZENCHENT ZENCHENT FE ZOSTAVAX
OFF-LABEL USE OF MEDICATIONS
The Food and Drug Administration (FDA) has required that drugs used in the United States be both safe and effective. The label information or the
package insert of a medication indicates drug use only in certain "approved" doses and routes of administration for a particular condition or disease
state. The use of a drug for a disease state or condition not listed on the label, or in a dose or by a route not listed on the label, is considered to be a
"non-approved" or "un-labeled" or "off-label" use of the drug. A prior authorization is required when a medication is used outside of its FDA approved
route of administration, dosage, or indication. Coverage will be determined in the same manner and subject to the same conditions and limitations as
any other prescription drug. Prior authorizations for unlabeled uses of medications may be granted provided that: a) the medication is approved by the
FDA; and b) two or more peer-reviewed professional medical journals have recognized, based on scientific medical criteria, the safety and effectiveness
of the medication or combination of medications, for treatment of the indication for which the medication has been prescribed unless two articles from
major peer-reviewed professional medical journals have concluded, based on scientific or medical criteria, that the drug or combination of drugs is
unsafe or ineffective or the safety and effectiveness of the drug or combination of drugs cannot be determined for the treatment of the indication for
which the drug or combination of drugs has been prescribed.
EXPERIMENTAL MEDICATIONS
Any medication or drug that has not been approved by the FDA to be both safe and effective for use in the United States will not be covered. This
includes both FDA approved and non-approved medications that are in experimental or investigational trials to determine new indications, new routes of
administration, or new dosage forms.
PRIOR AUTHORIZATION
To promote appropriate utilization, selected high-risk or high-cost medications may require prior authorization to be eligible for coverage under the
member’s prescription drug benefit. The P&T Committee has established prior authorization criteria. In order for a member to receive coverage for a
medication requiring prior authorization, the member’s physician should contact the customer service center at 1-800-546-5677 to obtain a prior
authorization request form. Your physician may then be required to document the reason why a Formulary medication is not acceptable for treatment of
your disease state or medical condition. Your physician will want to include in his/her letter your diagnosis and previous therapies that have failed.
NEW DRUGS INTRODUCED INTO THE CONSUMER MARKET
As the U.S. Food and Drug Administration (FDA) approves new drugs and therapies available to the consumer market after the Plan Summary
Documents have been distributed, the Drug Benefit Plan reserves the right to extend or deny coverage to these medications after the printing of this
document. The Drug Benefit Plan also reserves the right to assign a unique co-pay or coinsurance to these medications and/or limit the quantities of
these medications.
Members will receive notices regarding any Drug Benefit Plan modifications concerning drugs or therapies at such time that they present a prescription
that is impacted by modifications to the Formulary. Network pharmacies are charged to communicate these updates or changes to the program which
may impact a member. The P&T Committee will review new drugs approved by the FDA on a monthly basis. New products with an FDA designation of
1P (FDA priority review – therapeutic advance over currently-marketed drugs) will automatically be considered for addition to the Formulary, even if not
requested by a plan. New products with an FDA designation of 1S (FDA standard review – no therapeutic gain over currently marketed drugs) will not
generally be considered for addition to the Formulary, unless requested by a plan, or the drug class is currently under review by the P&T Committee.
Members wanting to have newly approved therapies considered by the plan may write and/or call the company servicing the plan or may contact the
plan administrator.
STEP THERAPY
Step Therapy is a program especially designed for people who take prescription drugs regularly to treat an ongoing medical condition. The program
helps you get the prescription drugs you need, with safety, cost and—most importantly—your health in mind. In Step Therapy, the covered drugs you
take are organized in a series of “steps,” with your doctor approving and writing your prescriptions. The program usually starts with generic drugs in the
“first step.” These generics—rigorously tested and approved by the U.S. Food & Drug Administration (FDA)—allow you to begin or continue treatment
with safe, effective drugs that are also affordable: Your co-payment is usually the lowest with a first-step drug. More expensive brand-name drugs are
usually covered in the “second step,” even though the generics covered have been proven to be effective in treating medical conditions. Your doctor is
consulted for approval and writes your prescriptions based on the list of Step Therapy drugs covered by the formulary. Step Therapy is developed under
the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. They review the most current research on
thousands of drugs tested and approved by the Food and Drug Administration for safety and effectiveness. Then they recommend appropriate
prescription drugs for the Step Therapy program. The first time you submit a prescription that isn’t for a first-step drug, your pharmacist will tell you
there’s a note on the computer system indicating that our plan uses Step Therapy. This simply means that if you’d rather not pay full price for your
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prescription drug, your doctor needs to write you a new prescription for a first-step drug. With Step Therapy, more expensive brand-name drugs are
usually covered in a later step in the program if you’ve already tried the “first-step,” generic drugs covered in the program, you can’t take the “first-step”
drug (because of an allergy, for instance), or your doctor decides you need a brand-name drug, for medical reasons. If any one of these applies to you,
your doctor can ask for a “prior authorization” for you to take a second-step prescription drug. Once the prior authorization is approved, you pay the
appropriate co-payment for this formulary-approved drug. If the prior authorization is not approved, you will need to pay the full price for the drug.
SPECIALTY PHARMACY
The following list contains drugs that are deemed specialty drugs that treat medical conditions that are more complex, require more intensive patient
monitoring and are limited to dispensing at specialty pharmacies. Healthy Premier requires the drugs noted as specialty to be filled primarily at
University of Utah network of specialty pharmacies. In cases where drugs are available through a limited distribution from the manufacturer, these
drugs may be filled at Walgreens Specialty Pharmacy or for certain drugs, other specialty pharmacies.
PAPER CLAIMS FILING LIMITS Point-of-sale claims are generally submitted electronically at the time of dispensing. However, there may be mitigating reasons that require a claim to be submitted via a paper claim after being dispensed. The timely filing limit for paper claims is 90 days from the date of service for all original claims.
DISPENSING LIMITATION LIST
The following list represents the P&T Committee recommendations for dispensing or quantity limitations per a specific amount of time. Quantity limit
programming has become an acceptable pharmacy plan practice that may be appropriate to place on some medications. The intentions are to safeguard
members’ health and save plan benefit dollars. This program ensures members do not receive a prescription for a quantity that exceeds recommended
plan limits. Limits are set because some medications have the potential to be abused, misused, shared, or have a manufacturer’s limit on the maximum
dose. These limits have been reviewed by our clinical and medical staff, and the Pharmacy and Therapeutics Committee. The quantity limits are based
on FDA approved dosing schedules, current medical practices, evidence based clinical guidelines, and peer-reviewed medical literature related to that
particular drug. The inclusion of a medication on this list does not imply coverage under all plans, nor does the inclusion of a dispensing limitation imply
that your specific benefit plan also has the same limitation. Plans may elect their own limitations. Members should consult their prescription drug
benefit manual or contact a customer service representative to determine specific coverage and/or inclusion of a medication in the
dispensing limitations list, as the list is subject to change. A separate listing of all drugs subject to quantity limits is noted below.
DRUG NAME LIMITATION
ABACA/LAMIVUTAB600-300 30 per 30 days
ABACAV/LAMIVTAB/ZIDOVUD 60 per 30 days
ABACAVIR TAB300MG 60 per 30 days
ARIPIPRAZOLE SOL1MG/ML 900 per 30 days
ABSTRAL SUB100MCG 120 per 30 days
ABSTRAL SUB200MCG 120 per 30 days
ABSTRAL SUB300MCG 120 per 30 days
ABSTRAL SUB400MCG 120 per 30 days
ABSTRAL SUB600MCG 120 per 30 days
ABSTRAL SUB800MCG 120 per 30 days
ACARBOSE TAB100MG 90 per 30 days
ACARBOSE TAB25MG 90 per 30 days
ACARBOSE TAB50MG 90 per 30 days
ACYCLOVIR OIN5% 30 per 30 days
ADCIRCA TAB20MG 60 per 30 days
ADEMPAS TAB0.5MG 90 per 30 days
ADEMPAS TAB1.5MG 90 per 30 days
ADEMPAS TAB1MG 90 per 30 days
ADEMPAS TAB2.5MG 90 per 30 days
ADEMPAS TAB2MG 90 per 30 days
ADRENACLICK INJ0.15MG 2 per 30 days
ADVAIR DISKUAER100/50 60 per 30 days
ADVAIR DISKUAER250/50 60 per 30 days
ADVAIR DISKUAER500/50 60 per 30 days
ADVAIR HFA AER115/21 12 per 30 days
ADVAIR HFA AER230/21 12 per 30 days
ADVAIR HFA AER45/21 12 per 30 days
AFINITOR TAB10MG 60 per 30 days
AFINITOR TAB2.5MG 60 per 30 days
AFINITOR TAB5MG 60 per 30 days
AFINITOR TAB7.5MG 60 per 30 days
AFINITOR DISTAB2MG 150 per 30 days
AFINITOR DISTAB3MG 90 per 30 days
AFINITOR DISTAB5MG 60 per 30 days
AGGRENOX CAP25-200MG 60 per 30 days
ALBUTEROL NEB0.083% 360 per 30 days
ALBUTEROL NEB0.5% 60 per 30 days
ALBUTEROL NEB0.63MG/3 360 per 30 days
DRUG NAME LIMITATION
ALBUTEROL NEB1.25MG/3 360 per 30 days
ALENDRONATE TAB10MG 120 per 30 days
ALENDRONATE TAB35MG 5 per 30 days
ALENDRONATE TAB40MG 30 per 30 days
ALENDRONATE TAB5MG 240 per 30 days
ALENDRONATE TAB70MG 5 per 30 days
ALFUZOSIN TAB10MG 30 per 30 days
ALINIA SUS100/5ML 180 per 3 days
ALORA DIS0.025MG 8 per 28 days
ALORA DIS0.05MG 8 per 28 days
ALORA DIS0.075MG 8 per 28 days
ALORA DIS0.1MG 8 per 28 days
ALOSETRON 0.5 MG TAB 60 per 30 days
ALOSETRON 1 MG TAB 60 per 30 days
AMLODIPINE TAB10MG 30 per 30 days
AMLODIPINE TAB2.5MG 30 per 30 days
AMLODIPINE TAB5MG 30 per 30 days
ALMOTRIPTAN TAB 12 per 30 days
AMPHETAMINE CAP10MG ER 180 per 30 days
AMPHETAMINE CAP15MG ER 120 per 30 days
AMPHETAMINE CAP20MG ER 90 per 30 days
AMPHETAMINE CAP25MG ER 60 per 30 days
AMPHETAMINE CAP30MG ER 60 per 30 days
AMPHETAMINE CAP5MG ER 360 per 30 days
AMPHETAMINE TAB10MG 180 per 30 days
AMPHETAMINE TAB12.5MG 120 per 30 days
AMPHETAMINE TAB15MG 120 per 30 days
AMPHETAMINE TAB20MG 90 per 30 days
AMPHETAMINE TAB30MG 60 per 30 days
AMPHETAMINE TAB5MG 360 per 30 days
ANASTROZOLE TAB1MG 30 per 30 days
ANDRODERM DIS2MG/24HR 30 per 30 days
ANDRODERM DIS4MG/24HR 30 per 30 days
ANZEMET TAB100MG 30 per 30 days
ANZEMET TAB50MG 30 per 30 days
APLENZIN TAB174MG 30 per 30 days
APLENZIN TAB348MG 30 per 30 days
APLENZIN TAB522MG 30 per 30 days
APRISO CAP0.375GM 120 per 30 days
DRUG NAME LIMITATION
APTIOM TAB200MG 180 per 30 days
APTIOM TAB400MG 90 per 30 days
APTIOM TAB600MG 60 per 30 days
APTIOM TAB800MG 45 per 30 days
APTIVUS CAP250MG 120 per 30 days
APTIVUS SOL 300 per 30 days
ARCAPTA CAP75MCG 30 per 30 days
ASACOL HD TAB800MG 180 per 30 days
ASMANEX 120 AER220MCG 2 per 30 days
ASMANEX 14 AER220MCG 2 per 30 days
ASMANEX 30 AER110MCG 2 per 30 days
ASMANEX 30 AER220MCG 2 per 30 days
ASMANEX 60 AER220MCG 2 per 30 days
ASMANEX 7 AER110MCG 2 per 30 days
ATORVASTATINTAB10MG 30 per 30 days
ATORVASTATINTAB20MG 30 per 30 days
ATORVASTATINTAB40MG 30 per 30 days
ATORVASTATINTAB80MG 30 per 30 days
AVANDIA TAB2MG 60 per 30 days
AVANDIA TAB4MG 30 per 30 days
AVANDIA TAB4MG 60 per 30 days
AVANDIA TAB8MG 60 per 30 days
AVONEX KIT30MCG 4 per 28 days
AVONEX PREFLKIT30MCG 4 per 28 days
AZELASTINE SPR0.1% 30 per 30 days
AZELASTINE SPR0.15% 30 per 30 days
AZITHROMYCINSUS100/5ML 30 per 5 days
AZITHROMYCINSUS200/5ML 90 per 5 days
AZITHROMYCINTAB250MG 6 per 5 days
AZITHROMYCINTAB500MG 6 per 5 days
AZITHROMYCINTAB600MG 6 per 5 days
BANZEL SUS40MG/ML 2400 per 30 days
BANZEL TAB200MG 240 per 30 days
BANZEL TAB400MG 240 per 30 days
BENICAR TAB20MG 30 per 30 days
BENICAR TAB40MG 30 per 30 days
BENICAR TAB5MG 30 per 30 days
BETASERON INJ0.3MG 15 per 30 days
BICALUTAMIDETAB50MG 30 per 30 days
DRUG NAME LIMITATION
BREO ELLIPTA 60 per 30 days
BREO ELLIPTAINH100-25 60 per 30 days
BRILINTA TAB90MG 60 per 30 days
BUDEPRION TAB100MG SR 60 per 30 days
BUDEPRION TAB150MG SR 90 per 30 days
BUDESONIDE SUS0.25MG/2 120 per 30 days
BUDESONIDE SUS0.5MG/2 120 per 30 days
BUPRENORPHINSUB2MG 120 per 30 days
BUPRENORPHINSUB8MG 120 per 30 days
BUPREN/NALOXONE SUB 90 per 30 days
BUPROBAN TAB150MG 90 per 30 days
BUPROPION TAB100MG 120 per 30 days
BUPROPION TAB100MG 60 per 30 days
BUPROPION TAB100MG SR 60 per 30 days
BUPROPION TAB150MG SR 90 per 30 days
BUPROPION TAB200MG SR 30 per 30 days
BUPROPION TAB75MG 180 per 30 days
BUPROPN HCL TAB150MG XL 30 per 30 days
BUPROPN HCL TAB300MG XL 45 per 30 days
BUT/APAP/CAFCAPCODEINE 120 per 30 days
BUTORPHANOL SOL10MG/ML 10 per 30 days
BUTRANS DIS 4 per 28 days
BUTRANS DIS10MCG/HR 4 per 28 days
BUTRANS DIS15MCG/HR 4 per 28 days
BUTRANS DIS20MCG/HR 4 per 28 days
BUTRANS DIS5MCG/HR 4 per 28 days
BYDUREON INJ 4 per 28 days
BYETTA INJ10MCG 2 per 30 days
BYETTA INJ5MCG 2 per 30 days
CALCIPOTRIENCRE0.005% 120 per 30 days
CALCIPOTRIENSOL0.005% 60 per 30 days
CANDESARTAN TAB16MG 60 per 30 days
CANDESARTAN TAB32MG 30 per 30 days
CANDESARTAN TAB8MG 30 per 30 days
CANDESARTAN TAB4MG 30 per 30 days
CAPRELSA TAB100MG 60 per 30 days
CAPRELSA TAB300MG 30 per 30 days
CARISOPRODOLTAB250MG 120 per 30 days
CARISOPRODOLTAB350MG 120 per 30 days
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DRUG NAME LIMITATION
CARDURA XL TAB4MG 30 per 30 days
CARDURA XL TAB8MG 30 per 30 days
CARVEDILOL TAB12.5MG 60 per 30 days
CARVEDILOL TAB25MG 60 per 30 days
CARVEDILOL TAB3.125MG 60 per 30 days
CARVEDILOL TAB6.25MG 60 per 30 days
CELECOXIB 400MG 60 per 30 days
CESAMET CAP1MG 30 per 5 days
CHANTIX PAK0.5& 1MG 1 kit per 365 days
CHANTIX PAK1MG 60 per 30 days
CHANTIX TAB0.5MG 60 per 30 days
CHANTIX TAB1MG 60 per 30 days
CHLORPROPAM TAB100MG 120 per 30 days
CHLORPROPAM TAB250MG 90 per 30 days
CIMZIA KIT 6 per 28 days
CIMZIA PREFLKIT200MG/ML 6 per 28 days
CITALOPRAM SOL10MG/5ML 600 per 30 days
CITALOPRAM TAB10MG 30 per 30 days
CITALOPRAM TAB20MG 30 per 30 days
CITALOPRAM TAB40MG 30 per 30 days
CLARITHROMYCTAB500MG 28 per 14 days
CLARITHROMYCTAB500MG ER 28 per 14 days
CLONAZEP ODTTAB0.125MG 90 per 30 days
CLONAZEP ODTTAB0.25MG 90 per 30 days
CLONAZEP ODTTAB0.5MG 90 per 30 days
CLONAZEPAM TAB0.5MG 90 per 30 days
CLONAZEPAM TAB1MG 90 per 30 days
CLONAZEPAM TAB2MG 90 per 30 days
CLOZAPINE TAB100MG 120 per 30 days
CLOZAPINE TAB200MG 120 per 30 days
CLOZAPINE TAB25MG 120 per 30 days
CLOZAPINE TAB25MG ODT 1080 per 30 days
CLOZAPINE TAB50MG 120 per 30 days
COMPRO SUP25MG 30 per 30 days
CONCERTA TAB18MG 30 per 30 days
CONCERTA TAB27MG 30 per 30 days
CONCERTA TAB36MG 60 per 30 days
CONCERTA TAB54MG 30 per 30 days
CORDRAN 80X3TAP4MCG/CM 900 per 30 days
COREG CR CAP10MG 30 per 30 days
COREG CR CAP20MG 30 per 30 days
COREG CR CAP40MG 30 per 30 days
COREG CR CAP80MG 30 per 30 days
CRIXIVAN CAP200MG 360 per 30 days
CRIXIVAN CAP400MG 180 per 30 days
CROMOLYN SODNEB20MG/2ML 240 per 30 days
DALIRESP TAB500MCG 30 per 30 days
DESVENLAFAX TAB100MG ER 30 per 30 days
DESVENLAFAX TAB50MG ER 240 per 30 days
DEXMETHYLPH CAP15MG ER 30 per 30 days
DEXMETHYLPH CAP30MG ER 30 per 30 days
DEXMETHYLPH CAP40MG ER 30 per 30 days
DEXMETHYLPH TAB10MG 90 per 30 days
DEXMETHYLPH TAB2.5MG 90 per 30 days
DEXMETHYLPH TAB5MG 90 per 30 days
DEXTROAMPHETCAP10MG ER 120 per 30 days
DEXTROAMPHETCAP15MG ER 120 per 30 days
DEXTROAMPHETCAP5MG ER 120 per 30 days
DEXTROAMPHETTAB10MG 180 per 30 days
DEXTROAMPHETTAB5MG 90 per 30 days
DIDANOSINE CAP125MG 90 per 30 days
DIDANOSINE CAP200MG 60 per 30 days
DIDANOSINE CAP250MG 30 per 30 days
DIDANOSINE CAP400MG 30 per 30 days
DIPHEN/ATROPINE 2.5MGTAB 80 per 10 days
DIVIGEL GEL1MG/GM 30 per 30 days
DONEPEZIL TAB10MG 30 per 30 days
DONEPEZIL TAB10MG ODT 30 per 30 days
DONEPEZIL TAB5MG 30 per 30 days
DRUG NAME LIMITATION
DONEPEZIL TAB5MG ODT 30 per 30 days
DOVONEX CRE0.005% 120 per 1 days
DOXAZOSIN TAB1MG 30 per 30 days
DOXAZOSIN TAB2MG 30 per 30 days
DOXAZOSIN TAB4MG 30 per 30 days
DOXAZOSIN TAB8MG 60 per 30 days
DRONABINOL CAP10MG 60 per 30 days
DRONABINOL CAP2.5MG 60 per 30 days
DRONABINOL CAP5MG 60 per 30 days
DULERA AER100-5MCG 13 per 30 days
DULERA AER200-5MCG 13 per 30 days
DULOXETINE CAP20MG 180 per 30 days
DULOXETINE CAP30MG 120 per 30 days
DULOXETINE CAP60MG 60 per 30 days
EDURANT TAB25MG 30 per 30 days
EFFIENT TAB10MG 30 per 30 days
EFFIENT TAB5MG 30 per 30 days
ELIDEL CRE1% 30 per 30 days
ELIQUIS TAB2.5MG 60 per 30 days
ELIQUIS TAB5MG 60 per 30 days
EMEND CAP125MG 30 per 30 days
EMEND CAP40MG 30 per 30 days
EMEND CAP80MG 30 per 30 days
EMEND PAK80 & 125 30 per 30 days
EMSAM DIS12MG/24H 30 per 30 days
EMSAM DIS6MG/24HR 30 per 30 days
EMSAM DIS9MG/24HR 30 per 30 days
EMTRIVA CAP200MG 30 per 30 days
EMTRIVA SOL10MG/ML 850 per 30 days
ENBREL INJ25/0.5ML 8 per 28 days
ENBREL INJ25MG 16 per 28 days
ENBREL INJ50MG/ML 8 per 28 days
ENBREL SURECLICK 8 per 28 days
ENOXAPARIN INJ100MG/ML 28 per 30 days
ENOXAPARIN INJ120/0.8 22 per 30 days
ENOXAPARIN INJ150MG/ML 28 per 30 days
ENOXAPARIN INJ30/0.3ML 8 per 30 days
ENOXAPARIN INJ300/3ML 84 per 30 days
ENOXAPARIN INJ40/0.4ML 11 per 30 days
ENOXAPARIN INJ60/0.6ML 16 per 30 days
ENOXAPARIN INJ80/0.8ML 22 per 30 days
ENTACAPONE TAB200MG 270 per 30 days
ENTECAVIR TAB0.5MG 30 per 30 days
ENTECAVIR TAB1MG 30 per 30 days
EPINEPHRINE INJ0.15MG 2 per 30 days
EPINEPHRINE INJ0.3MG 2 per 30 days
EPROSART MESTAB600MG 30 per 30 days
EPZICOM TAB600-300 30 per 30 days
EQUETRO CAP100MG 480 per 30 days
EQUETRO CAP200MG 240 per 30 days
EQUETRO CAP300MG 180 per 30 days
ERIVEDGE CAP150MG 30 per 30 days
ESOMEPRA MAGCAP20MG DR 60 per 30 days
ESCITALOPRAMSOL5MG/5ML 620 per 30 days
ESCITALOPRAMTAB10MG 60 per 30 days
ESCITALOPRAMTAB20MG 60 per 30 days
ESCITALOPRAMTAB5MG 120 per 30 days
ESTRADIOL DIS0.025MG 4 per 28 days
ESTRADIOL DIS0.0375MG 4 per 28 days
ESTRADIOL DIS0.05MG 4 per 28 days
ESTRADIOL DIS0.06MG 4 per 28 days
ESTRADIOL DIS0.075MG 4 per 28 days
ESTRADIOL DIS0.1MG 4 per 28 days
ESTRING MIS2MG 1 per 90 days
EVAMIST SPR1.53MG 16 per 30 days
EXEMESTANE TAB25MG 60 per 30 days
EXTAVIA INJ0.3MG 15 per 30 days
EZETIM/SIMVATAB10-10MG 30 per 30 days
EZETIM/SIMVATAB10-20MG 30 per 30 days
DRUG NAME LIMITATION
EZETIM/SIMVATAB10-40MG 30 per 30 days
EZETIM/SIMVATAB10-80MG 30 per 30 days
FAMCICLOVIR TAB125MG 60 per 30 days
FAMCICLOVIR TAB250MG 60 per 30 days
FAMCICLOVIR TAB500MG 60 per 30 days
FANAPT PAK 60 per 30 days
FANAPT TAB10MG 90 per 30 days
FANAPT TAB12MG 60 per 30 days
FANAPT TAB1MG 720 per 30 days
FANAPT TAB2MG 360 per 30 days
FANAPT TAB4MG 180 per 30 days
FANAPT TAB6MG 120 per 30 days
FANAPT TAB8MG 90 per 30 days
FARESTON TAB60MG 30 per 30 days
FAZACLO TAB12.5/ODT 2160 per 30 days
FAZACLO TAB150MG 180 per 30 days
FAZACLO TAB200MG 120 per 30 days
FENOFIBRATE CAP130MG 30 per 30 days
FENOFIBRATE CAP134MG 30 per 30 days
FENOFIBRATE CAP200MG 30 per 30 days
FENOFIBRATE CAP43MG 30 per 30 days
FENOFIBRATE CAP67MG 30 per 30 days
FENOFIBRATE TAB145MG 30 per 30 days
FENOFIBRATE TAB160MG 30 per 30 days
FENOFIBRATE TAB48MG 30 per 30 days
FENOFIBRATE TAB54MG 30 per 30 days
FENTANYL DIS100MCG/H 30 per 30 days
FENTANYL DIS12MCG/HR 30 per 30 days
FENTANYL DIS25MCG/HR 30 per 30 days
FENTANYL DIS50MCG/HR 30 per 30 days
FENTANYL DIS75MCG/HR 30 per 30 days
FENTANYL OT LOZ1200MCG 120 per 30 days
FENTANYL OT LOZ1600MCG 120 per 30 days
FENTANYL OT LOZ200MCG 120 per 30 days
FENTANYL OT LOZ400MCG 120 per 30 days
FENTANYL OT LOZ600MCG 120 per 30 days
FENTANYL OT LOZ800MCG 120 per 30 days
FENTORA TAB400MCG 112 per 28 days
FINASTERIDE TAB5MG 30 per 30 days
FLOVENT DISKAER100MCG 120 per 30 days
FLOVENT DISKAER250MCG 120 per 30 days
FLOVENT DISKAER50MCG 120 per 30 days
FLOVENT HFA AER110MCG 24 per 30 days
FLOVENT HFA AER220MCG 24 per 30 days
FLOVENT HFA AER44MCG 21 per 30 days
FLUCONAZOLE TAB150MG 180 per 30 days
FLUNISOLIDE SPR0.025% 50 per 30 days
FLUOXETINE CAP10MG 30 per 30 days
FLUOXETINE CAP20MG 30 per 30 days
FLUOXETINE CAP40MG 60 per 30 days
FLUOXETINE CAP90MG DR 5 per 30 days
FLUOXETINE SOL20MG/5ML 600 per 30 days
FLUOXETINE TAB10MG 240 per 30 days
FLUOXETINE TAB20MG 120 per 30 days
FLUOXETINE TAB20MG 30 per 30 days
FLUOXETINE 60MG 30 per 30 days
FLUTICASONE SPR50MCG 16 per 30 days
FLUVASTATIN CAP20MG 60 per 30 days
FLUVASTATIN CAP40MG 60 per 30 days
FLUVASTATIN ER TAB 30 per 30 days
FLUVOXAMINE TAB100MG 90 per 30 days
FLUVOXAMINE TAB25MG 360 per 30 days
FLUVOXAMINE TAB50MG 180 per 30 days
FONDAPARINUXSOL10/0.8 20 per 30 days
FONDAPARINUXSOL2.5/0.5 15 per 30 days
FONDAPARINUXSOL5.0/0.4 20 per 30 days
FONDAPARINUXSOL7.5/0.6 20 per 30 days
FORADIL CAPAEROLIZE 60 per 30 days
FORFIVO XL TAB450MG 30 per 30 days
DRUG NAME LIMITATION
FORTEO SOL600/2.4 3 per 28 days
FOSAMAX + D TAB70-2800 4 per 28 days
FOSAMAX + D TAB70-5600 4 per 28 days
FREESTYLE LANCETS 150 per 30 days
FREESTYLE TEST STRIPS 150 per 30 days
FYCOMPA TAB10MG 30 per 30 days
FYCOMPA TAB12MG 30 per 30 days
FYCOMPA TAB2MG 120 per 30 days
FYCOMPA TAB4MG 90 per 30 days
FYCOMPA TAB6MG 60 per 30 days
FYCOMPA TAB8MG 30 per 30 days
GABAPENTIN CAP100MG 360 per 30 days
GABAPENTIN CAP300MG 360 per 30 days
GABAPENTIN CAP400MG 270 per 30 days
GABAPENTIN SOL250/5ML 2160 per 30 days
GABAPENTIN TAB600MG 180 per 30 days
GABAPENTIN TAB800MG 120 per 30 days
GALANTAMINE CAP16MG ER 30 per 30 days
GALANTAMINE CAP24MG ER 30 per 30 days
GALANTAMINE CAP8MG ER 30 per 30 days
GALANTAMINE SOL4MG/ML 180 per 30 days
GALANTAMINE TAB12MG 60 per 30 days
GALANTAMINE TAB4MG 60 per 30 days
GALANTAMINE TAB8MG 60 per 30 days
GELNIQUE GEL10% 30 per 30 days
GILENYA CAP0.5MG 30 per 30 days
GILOTRIF TAB20MG 30 per 30 days
GILOTRIF TAB30MG 30 per 30 days
GILOTRIF TAB40MG 30 per 30 days
GLIMEPIRIDE TAB1MG 60 per 30 days
GLIMEPIRIDE TAB2MG 60 per 30 days
GLIMEPIRIDE TAB4MG 60 per 30 days
GLIPIZIDE TAB10MG 120 per 30 days
GLIPIZIDE TAB5MG 240 per 30 days
GLIPIZIDE ERTAB10MG 60 per 30 days
GLIPIZIDE ERTAB2.5MG 240 per 30 days
GLIPIZIDE ERTAB5MG 120 per 30 days
GLIPIZIDE ERTAB5MG 60 per 30 days
GLUCAGEN INJHYPOKIT 30 per 30 days
GLUCAGON KIT1MG 2 per 30 days
GLYBURID MCRTAB1.5MG 120 per 30 days
GLYBURID MCRTAB3MG 60 per 30 days
GLYBURID MCRTAB6MG 30 per 30 days
GLYBURIDE TAB1.25MG 480 per 30 days
GLYBURIDE TAB2.5MG 240 per 30 days
GLYBURIDE TAB5MG 120 per 30 days
GRANISETRON TAB1MG 30 per 30 days
HUMALOG INJ100/ML 60 per 30 days
HUMALOG KWIKPEN 60 per 30 days
HUMALOG MIX INJ50/50 60 per 30 days
HUMALOG MIX INJ50/50KWP 60 per 30 days
HUMALOG MIX INJ75/25KWP 60 per 30 days
HUMALOG MIX SUS75/25 60 per 30 days
HUMIRA INJ10MG/0.2 6 per 28 days
HUMIRA INJ40MG/0.8 8 per 28 days
HUMIRA KIT20MG/0.4 8 per 28 days
HUMIRA PEDIATRIC CROHNS D 8 per 28 days
HUMIRA PEN INJCROHNS 8 per 28 days
HUMULIN INJ70/30 30 per 30 days
HUMULIN N INJU-100 30 per 30 days
HUMULIN R INJU-100 30 per 30 days
HUMULIN R INJU-500 30 per 30 days
HYDROCO/APAP 10-325MG 120 per 30 days
HYDROCO/APAP TAB 10-325MG 120 per 30 days
HYDROCO/APAP TAB 7.5-325MG 120 per 30 days
HYDROCO/APAP TAB 5-325MG 120 per 30 days
HYDROMORPHONTAB32MG ER 120 per 30 days
HYDROMORPHONTAB4MG 120 per 30 days
HYDROMORPHONTAB8MG 120 per 30 days
6
DRUG NAME LIMITATION
HYDROMORPHONTAB8MG ER 120 per 30 days
IBANDRONATE TAB150MG 1 per 28 days
ICLUSIG TAB15MG 90 per 30 days
IMBRUVICA CAP140MG 120 per 30 days
INDOMETHACINCAP25MG 120 per 30 days
INTELENCE TAB100MG 120 per 30 days
INTELENCE TAB200MG 60 per 30 days
INTELENCE TAB25MG 480 per 30 days
INVIRASE CAP200MG 300 per 30 days
INVIRASE TAB500MG 120 per 30 days
IPRATROPIUM SPR0.03% 30 per 30 days
IPRATROPIUM SPR0.06% 30 per 30 days
IRBESARTAN TAB150MG 30 per 30 days
IRBESARTAN TAB300MG 30 per 30 days
IRBESARTAN TAB75MG 30 per 30 days
ISENTRESS CHW100MG 180 per 30 days
ISENTRESS CHW25MG 720 per 30 days
ISENTRESS POW100MG 300 per 30 days
ISENTRESS TAB400MG 120 per 30 days
JAKAFI TAB10MG 60 per 30 days
JAKAFI TAB15MG 60 per 30 days
JAKAFI TAB20MG 60 per 30 days
JAKAFI TAB25MG 60 per 30 days
JAKAFI TAB5MG 60 per 30 days
JANUVIA TAB100MG 30 per 30 days
JANUVIA TAB25MG 30 per 30 days
JANUVIA TAB50MG 30 per 30 days
JARDIANCE TAB10MG 30 per 30 days
JARDIANCE TAB25MG 30 per 30 days
KALYDECO TAB150MG 60 per 30 days
KETOROLAC TAB10MG 20 per 30 days
KINERET INJ 28 per 28 days
LAMIVUD/ZIDOTAB150-300 60 per 30 days
LAMIVUDINE TAB150MG 60 per 30 days
LAMIVUDINE TAB300MG 30 per 30 days
LANSOPRAZOLECAP30MG DR 60 per 30 days
LANTUS INJ100/ML 30 per 30 days
LANTUS INJSOLOSTAR 30 per 30 days
LATANOPROST SOL0.005% 5 per 30 days
LATUDA TAB120MG 30 per 30 days
LATUDA TAB20MG 120 per 30 days
LATUDA TAB40MG 60 per 30 days
LATUDA TAB60MG 60 per 30 days
LATUDA TAB80MG 30 per 30 days
LAZANDA SPR100MCG 30 per 30 days
LAZANDA SPR400MCG 30 per 30 days
LEFLUNOMIDE TAB10MG 30 per 30 days
LEFLUNOMIDE TAB20MG 30 per 30 days
LETAIRIS TAB10MG 30 per 30 days
LETAIRIS TAB5MG 60 per 30 days
LETROZOLE TAB2.5MG 30 per 30 days
LEVALBUTEROLNEB0.31MG 270 per 30 days
LEVALBUTEROLNEB0.63MG 540 per 30 days
LEVALBUTEROLNEB1.25/0.5 270 per 30 days
LEVEMIR INJ 30 per 30 days
LEVEMIR INJFLEXPEN 30 per 30 days
LEVETIRACETATAB500MG ER 180 per 30 days
LEVETIRACETATAB750MG ER 120 per 30 days
LEVOCETIRIZITAB5MG 30 per 30 days
LEVOFLOXACINTAB250MG 14 per 14 days
LEVOFLOXACINTAB500MG 14 per 14 days
LEVOFLOXACINTAB750MG 14 per 14 days
LEXIVA SUS50MG/ML 1800 per 30 days
LEXIVA TAB700MG 120 per 30 days
LIDOCAINE PAD5% 90 per 30 days
LORCET TAB5-325MG 120 per 30 days
LORCET HD TAB10-325MG 120 per 30 days
LORCET PLUS TAB7.5-325 120 per 30 days
LORTAB TAB10-325MG 120 per 30 days
DRUG NAME LIMITATION
LORTAB TAB5-325MG 120 per 30 days
LORTAB TAB7.5-325 120 per 30 days
LOSARTAN POTTAB100MG 30 per 30 days
LOSARTAN POTTAB25MG 30 per 30 days
LOSARTAN POTTAB50MG 30 per 30 days
LOVASTATIN TAB10MG 30 per 30 days
LOVASTATIN TAB20MG 30 per 30 days
LOVASTATIN TAB40MG 60 per 30 days
LUMIGAN SOL0.01% 7 per 30 days
LUMIGAN SOL0.03% 7 per 30 days
LYRICA CAP100MG 120 per 30 days
LYRICA CAP150MG 120 per 30 days
LYRICA CAP200MG 120 per 30 days
LYRICA CAP225MG 120 per 30 days
LYRICA CAP25MG 120 per 30 days
LYRICA CAP300MG 120 per 30 days
LYRICA CAP50MG 120 per 30 days
LYRICA CAP75MG 120 per 30 days
LYRICA SOL20MG/ML 900 per 30 days
MAPROTILINE TAB25MG 270 per 30 days
MAPROTILINE TAB50MG 135 per 30 days
MEKINIST TAB0.5MG 120 per 30 days
MEKINIST TAB2MG 30 per 30 days
MELOXICAM TAB15MG 30 per 30 days
MELOXICAM TAB7.5MG 30 per 30 days
MENOSTAR DIS14MCG 4 per 28 days
METADATE TAB20MG ER 90 per 30 days
METFORMIN TAB1000MG 90 per 30 days
METFORMIN TAB500MG 150 per 30 days
METFORMIN TAB500MG ER 120 per 30 days
METFORMIN TAB500MG ER 150 per 30 days
METFORMIN TAB750MG ER 90 per 30 days
METFORMIN TAB850MG 90 per 30 days
METHADONE SOL10MG/5ML 600 per 30 days
METHADONE SOL5MG/5ML 1200 per 30 days
METHADONE TAB10MG 120 per 30 days
METHADONE TAB5MG 120 per 30 days
METHYLPHENIDCAP20MG ER 60 per 30 days
METHYLPHENIDCAP30MG ER 60 per 30 days
METHYLPHENIDCAP40MG ER 30 per 30 days
METHYLPHENIDCAP40MG ER 60 per 30 days
METHYLPHENIDTAB10MG 90 per 30 days
METHYLPHENIDTAB10MG ER 90 per 30 days
METHYLPHENIDTAB18MG ER 30 per 30 days
METHYLPHENIDTAB20MG 90 per 30 days
METHYLPHENIDTAB20MG ER 90 per 30 days
METHYLPHENIDTAB27MG ER 30 per 30 days
METHYLPHENIDTAB36MG ER 60 per 30 days
METHYLPHENIDTAB54MG ER 30 per 30 days
METHYLPHENIDTAB5MG 90 per 30 days
METOPROLOL TAB100MG ER 30 per 30 days
METOPROLOL TAB200MG ER 60 per 30 days
METOPROLOL TAB25MG ER 30 per 30 days
METOPROLOL TAB50MG ER 30 per 30 days
MIGRANAL SPR4MG/ML 16 per 30 days
MINITRAN DIS0.1MG/HR 30 per 30 days
MINITRAN DIS0.2MG/HR 30 per 30 days
MINITRAN DIS0.4MG/HR 30 per 30 days
MINITRAN DIS0.6MG/HR 30 per 30 days
MINIVELLE DIS0.025 MG 8 per 28 days
MINIVELLE DIS0.0375MG 8 per 28 days
MINIVELLE DIS0.05MG 8 per 28 days
MINIVELLE DIS0.075MG 8 per 28 days
MINIVELLE DIS0.1MG 8 per 28 days
MIRTAZAPINE TAB15MG 30 per 30 days
MIRTAZAPINE TAB15MG ODT 30 per 30 days
MIRTAZAPINE TAB30MG 30 per 30 days
MIRTAZAPINE TAB30MG ODT 30 per 30 days
MIRTAZAPINE TAB45MG 30 per 30 days
DRUG NAME LIMITATION
MIRTAZAPINE TAB45MG ODT 30 per 30 days
MIRTAZAPINE TAB7.5MG 30 per 30 days
MODAFINIL TAB100MG 30 per 30 days
MODAFINIL TAB200MG 60 per 30 days
MONTELUKAST CHW4MG 30 per 30 days
MONTELUKAST CHW5MG 30 per 30 days
MONTELUKAST GRA4MG 30 per 30 days
MONTELUKAST TAB10MG 30 per 30 days
MORPHINE SULCAP100MG ER 60 per 30 days
MORPHINE SULCAP10MG ER 60 per 30 days
MORPHINE SULCAP120MG ER 60 per 30 days
MORPHINE SULCAP20MG ER 60 per 30 days
MORPHINE SULCAP30MG ER 60 per 30 days
MORPHINE SULCAP45MG ER 60 per 30 days
MORPHINE SULCAP50MG ER 60 per 30 days
MORPHINE SULCAP60MG ER 60 per 30 days
MORPHINE SULCAP75MG ER 60 per 30 days
MORPHINE SULCAP80MG ER 60 per 30 days
MORPHINE SULCAP90MG ER 60 per 30 days
MORPHINE SULSOL10MG/5ML 1800 per 30 days
MORPHINE SULSOL20MG/5ML 900 per 30 days
MORPHINE SULSOL20MG/ML 180 per 30 days
MORPHINE SULTAB100MG ER 120 per 30 days
MORPHINE SULTAB15MG 120 per 30 days
MORPHINE SULTAB15MG ER 120 per 30 days
MORPHINE SULTAB200MG ER 120 per 30 days
MORPHINE SULTAB30MG 120 per 30 days
MORPHINE SULTAB30MG ER 120 per 30 days
MORPHINE SULTAB60MG ER 120 per 30 days
MULTAQ TAB400MG 60 per 30 days
MYRBETRIQ TAB25MG 30 per 30 days
MYRBETRIQ TAB50MG 30 per 30 days
NAMENDA XR CAP14MG 30 per 30 days
NAMENDA XR CAP21MG 30 per 30 days
NAMENDA XR CAP28MG 30 per 30 days
NAMENDA XR CAP7MG 30 per 30 days
NAMENDA XR CAPTITRATIO 28 per 365 days
NARATRIPTAN TAB1MG 9 per 30 days
NARATRIPTAN TAB2.5MG 9 per 30 days
NATEGLINIDE TAB120MG 90 per 30 days
NATEGLINIDE TAB60MG 90 per 30 days
NEFAZODONE TAB100MG 180 per 30 days
NEFAZODONE TAB150MG 120 per 30 days
NEFAZODONE TAB200MG 90 per 30 days
NEFAZODONE TAB250MG 72 per 30 days
NEFAZODONE TAB50MG 360 per 30 days
NEVIRAPINE SUS50MG/5ML 1200 per 30 days
NEVIRAPINE TAB200MG 60 per 30 days
NEVIRAPINE TAB400MG ER 30 per 30 days
NEXAVAR TAB200MG 120 per 30 days
NIACIN ER 1000MG 60 per 30 days
NICOTINE POLGUM2MG 720 per 30 days
NICOTINE POLGUM4MG 720 per 30 days
NICOTINE DIS21MG/24 30 per 30 days
NICOTINE DIS14MG/24 30 per 30 days
NICOTINE DIS7MG/24 30 per 30 days
NICOTINE LOZ2MG 720 per 30 days
NICOTINE LOZ4MG 720 per 30 days
NITROGLYCER DIS0.4MG/HR 30 per 30 days
NITROGLYCERIDIS0.6MG/HR 30 per 30 days
NORTHERA CAP100MG 14 per 1 days
NORTHERA CAP200MG 14 per 1 days
NORTHERA CAP300MG 14 per 1 days
NORVIR CAP100MG 360 per 30 days
NORVIR SOL80MG/ML 480 per 30 days
NORVIR TAB100MG 360 per 30 days
NOVOLIN INJ70/30 30 per 30 days
NOVOLIN N INJU-100 30 per 30 days
NOVOLIN R INJU-100 30 per 30 days
DRUG NAME LIMITATION
NOVOLOG INJ100/ML 60 per 30 days
NOVOLOG FLEXPEN 60 per 30 days
NOVOLOG MIX INJ70/30 60 per 30 days
NOVOLOG MIX INJFLEXPEN 60 per 30 days
NUCYNTA TAB100MG 180 per 30 days
NUCYNTA TAB50MG 180 per 30 days
NUCYNTA TAB75MG 180 per 30 days
NUCYNTA ER TAB100MG 60 per 30 days
NUCYNTA ER TAB150MG 60 per 30 days
NUCYNTA ER TAB200MG 60 per 30 days
NUCYNTA ER TAB250MG 60 per 30 days
NUCYNTA ER TAB50MG 60 per 30 days
OLANZAPINE TAB10MG 60 per 30 days
OLANZAPINE TAB10MG ODT 60 per 30 days
OLANZAPINE TAB15MG 60 per 30 days
OLANZAPINE TAB15MG ODT 60 per 30 days
OLANZAPINE TAB2.5MG 240 per 30 days
OLANZAPINE TAB20MG 30 per 30 days
OLANZAPINE TAB20MG ODT 30 per 30 days
OLANZAPINE TAB5MG 120 per 30 days
OLANZAPINE TAB5MG ODT 120 per 30 days
OLANZAPINE TAB7.5MG 90 per 30 days
OLMESA MEDOXTAB20MG 30 per 30 days
OLMESA MEDOXTAB40MG 30 per 30 days
OLMESA MEDOXTAB5MG 30 per 30 days
OMEPRAZOLE CAP10MG 60 per 30 days
OMEPRAZOLE CAP20MG 60 per 30 days
OMEPRAZOLE CAP40MG 60 per 30 days
ONDANSETRON SOL4MG/5ML 150 per 5 days
ONDANSETRON TAB24MG 30 per 30 days
ONDANSETRON TAB4MG 12 per 5 days
ONDANSETRON TAB4MG ODT 12 per 5 days
ONDANSETRON TAB8MG 12 per 5 days
ONDANSETRON TAB8MG ODT 12 per 5 days
ONFI SUS2.5MG/ML 480 per 30 days
ONGLYZA TAB2.5MG 30 per 30 days
ONGLYZA TAB5MG 30 per 30 days
OPANA ER TAB10MG 90 per 30 days
OPANA ER TAB20MG 90 per 30 days
OPANA ER TAB30MG 90 per 30 days
OPANA ER TAB40MG 90 per 30 days
OPANA ER TAB5MG 90 per 30 days
OPSUMIT TAB10MG 30 per 30 days
OTEZLA 60 per 30 days
OTEZLA TAB10/20/30 60 per 30 days
OTEZLA TAB30MG 60 per 30 days
OXANDROLONE TAB10MG 60 per 30 days
OXANDROLONE TAB2.5MG 120 per 30 days
OXYBUTYNIN SYP5MG/5ML 600 per 30 days
OXYBUTYNIN TAB5MG 120 per 30 days
OXYCOD/IBU TAB5-400MG 120 per 30 days
OXYCOD/APAP TAB 10-325MG 360 per 30 days
OXYCOD/APAP TAB 2.5-325MG 360 per 30 days
OXYCOD/APAP TAB 5-325MG 360 per 30 days
OXYCOD/APAP TAB 7.5-325MG 360 per 30 days
OXYCODONE TAB20MG 180 per 30 days
OXYCODONE TAB30MG 180 per 30 days
OXYCODONE TAB5MG 180 per 30 days
OXYCONTIN TAB10MG CR 90 per 30 days
OXYCONTIN TAB15MG CR 90 per 30 days
OXYCONTIN TAB20MG CR 90 per 30 days
OXYCONTIN TAB30MG CR 90 per 30 days
OXYCONTIN TAB40MG CR 90 per 30 days
OXYCONTIN TAB60MG CR 90 per 30 days
OXYCONTIN TAB80MG CR 90 per 30 days
OXYTROL DIS3.9MG/24 8 per 28 days
PALIPERIDONE 1.5MG ER 240 per 30 days
PALIPERIDONE 3MG ER 120 per 30 days
PALIPERIDONE 6MG ER 60 per 30 days
7
DRUG NAME LIMITATION
PALIPERIDONE 9MG ER 60 per 30 days
PANTOPRAZOLETAB20MG 60 per 30 days
PANTOPRAZOLETAB40MG 60 per 30 days
PAROXETIN ERTAB12.5MG 150 per 30 days
PAROXETIN ERTAB37.5MG 60 per 30 days
PAROXETINE TAB10MG 90 per 30 days
PAROXETINE TAB20MG 60 per 30 days
PAROXETINE TAB25MG ER 90 per 30 days
PAROXETINE TAB30MG 60 per 30 days
PAROXETINE TAB40MG 45 per 30 days
PAXIL SUS10MG/5ML 900 per 30 days
PEGASYS INJ 2 per 28 days
PEGASYS PROCLICK 2 per 28 days
PEXEVA TAB10MG 30 per 30 days
PEXEVA TAB20MG 60 per 30 days
PEXEVA TAB30MG 60 per 30 days
PEXEVA TAB40MG 30 per 30 days
PIOGLITAZONETAB15MG 30 per 30 days
PIOGLITAZONETAB30MG 30 per 30 days
PIOGLITAZONETAB45MG 30 per 30 days
POMALYST CAP1MG 120 per 30 days
POMALYST CAP2MG 60 per 30 days
POMALYST CAP3MG 30 per 30 days
POMALYST CAP4MG 30 per 30 days
POTIGA TAB200MG 180 per 30 days
POTIGA TAB300MG 120 per 30 days
POTIGA TAB400MG 90 per 30 days
POTIGA TAB50MG 720 per 30 days
PRADAXA CAP150MG 60 per 30 days
PRADAXA CAP75MG 60 per 30 days
PRAMIPEXOLE TAB0.125MG 90 per 30 days
PRAMIPEXOLE TAB0.25MG 90 per 30 days
PRAMIPEXOLE TAB0.5MG 90 per 30 days
PRAMIPEXOLE TAB0.75MG 90 per 30 days
PRAMIPEXOLE TAB1.5MG 90 per 30 days
PRAMIPEXOLE TAB1MG 90 per 30 days
PRAVASTATIN TAB10MG 30 per 30 days
PRAVASTATIN TAB20MG 30 per 30 days
PRAVASTATIN TAB40MG 60 per 30 days
PRAVASTATIN TAB80MG 30 per 30 days
PRECISION TEST STRIPS 150 per 30 days
PREZISTA SUS100MG/ML 400 per 30 days
PREZISTA TAB150MG 180 per 30 days
PREZISTA TAB600MG 60 per 30 days
PREZISTA TAB75MG 300 per 30 days
PRISTIQ TAB100MG 30 per 30 days
PRISTIQ TAB50MG 240 per 30 days
PROAIR HFA AER 13.4 per 30 days
PROCHLORPER SUP25MG 30 per 30 days
PROMACTA TAB12.5MG 90 per 30 days
PROMACTA TAB25MG 90 per 30 days
PROMACTA TAB50MG 90 per 30 days
PROMACTA TAB75MG 90 per 30 days
PROVENTIL AERHFA 17 per 30 days
PULMICORT INH180MCG 2 per 30 days
PULMICORT INH90MCG 2 per 30 days
QUETIAPINE TAB100MG 240 per 30 days
QUETIAPINE TAB200MG 120 per 30 days
QUETIAPINE TAB25MG 960 per 30 days
QUETIAPINE TAB300MG 90 per 30 days
QUETIAPINE TAB400MG 60 per 30 days
QUETIAPINE TAB50MG 480 per 30 days
QUETIAPINE TAB400MG ER 60 per 30 days
QVAR AER40MCG 34.8 per 30 days
QVAR AER80MCG 18 per 30 days
RABEPRAZOLE TAB20MG 60 per 30 days
RALOXIFENE TAB60MG 30 per 30 days
RAMIPRIL CAP1.25MG 30 per 30 days
RAMIPRIL CAP10MG 60 per 30 days
DRUG NAME LIMITATION
RAMIPRIL CAP2.5MG 30 per 30 days
RAMIPRIL CAP5MG 30 per 30 days
RANEXA TAB1000MG 120 per 30 days
RANEXA TAB500MG 120 per 30 days
REBIF INJ22/0.5 12 per 30 days
REBIF INJ44/0.5 12 per 30 days
REBIF TITRTNSOLPACK 6 per 30 days
RELENZA MISDISKHALE 60 per 180 days
RENVELA PAK0.8GM 180 per 30 days
RENVELA PAK2.4GM 90 per 30 days
RESCRIPTOR TAB100 MG 360 per 30 days
RESCRIPTOR TAB200MG 180 per 30 days
REVLIMID CAP10MG 60 per 30 days
REVLIMID CAP15MG 30 per 30 days
REVLIMID CAP2.5MG 30 per 30 days
REVLIMID CAP20MG 30 per 30 days
REVLIMID CAP25MG 30 per 30 days
REVLIMID CAP5MG 150 per 30 days
REYATAZ CAP150MG 60 per 30 days
REYATAZ CAP200MG 60 per 30 days
REYATAZ CAP300MG 30 per 30 days
RISPERIDONE SOL1MG/ML 480 per 30 days
RISPERIDONE TAB0.25 ODT 1920 per 30 days
RISPERIDONE TAB0.25MG 1920 per 30 days
RISPERIDONE TAB0.5MG 960 per 30 days
RISPERIDONE TAB0.5MG OD 960 per 30 days
RISPERIDONE TAB1MG 480 per 30 days
RISPERIDONE TAB1MG ODT 480 per 30 days
RISPERIDONE TAB2MG 240 per 30 days
RISPERIDONE TAB2MG ODT 240 per 30 days
RISPERIDONE TAB3MG 180 per 30 days
RISPERIDONE TAB3MG ODT 180 per 30 days
RISPERIDONE TAB4MG 120 per 30 days
RISPERIDONE TAB4MG ODT 120 per 30 days
RITALIN LA CAP10MG 60 per 30 days
RIVASTIGMINECAP1.5MG 60 per 30 days
RIVASTIGMINECAP3MG 60 per 30 days
RIVASTIGMINECAP4.5MG 60 per 30 days
RIVASTIGMINECAP6MG 60 per 30 days
RIZATRIPTAN TAB10MG 12 per 30 days
RIZATRIPTAN TAB10MG ODT 12 per 30 days
RIZATRIPTAN TAB5MG 12 per 30 days
SABRIL POW500MG 180 per 30 days
SABRIL TAB500MG 180 per 30 days
SAMSCA TAB15MG 60 per 30 days
SAMSCA TAB30MG 60 per 30 days
SANCUSO DIS3.1MG 1 per 7 days
SANTYL OIN250/GM 30 per 30 days
SAPHRIS SUB10MG 60 per 30 days
SAPHRIS SUB5MG 120 per 30 days
SARAFEM TAB10MG 35 per 14 days
SARAFEM TAB20MG 140 per 14 days
SEREVENT DISAER50MCG 60 per 30 days
SEROQUEL XR TAB150MG 30 per 30 days
SEROQUEL XR TAB200MG 30 per 30 days
SEROQUEL XR TAB300MG 60 per 30 days
SEROQUEL XR TAB400MG 60 per 30 days
SEROQUEL XR TAB50MG 60 per 30 days
SERTRALINE CON20MG/ML 300 per 30 days
SERTRALINE TAB100MG 60 per 30 days
SERTRALINE TAB25MG 240 per 30 days
SERTRALINE TAB50MG 120 per 30 days
SILDENAFIL TAB20MG 90 per 30 days
SIMPONI INJ100MG/ML 1 per 28 days
SIMPONI INJ50/0.5ML 1 per 28 days
SIMVASTATIN TAB10MG 30 per 30 days
SIMVASTATIN TAB20MG 30 per 30 days
SIMVASTATIN TAB40MG 30 per 30 days
SIMVASTATIN TAB5MG 30 per 30 days
DRUG NAME LIMITATION
SIMVASTATIN TAB80MG 30 per 30 days
SPIRIVA CAPHANDIHLR 90 per 30 days
SPIRIVA SPRRESPIMAT 4 per 30 days
SPRYCEL TAB100MG 30 per 30 days
SPRYCEL TAB140MG 30 per 30 days
SPRYCEL TAB20MG 30 per 30 days
SPRYCEL TAB50MG 30 per 30 days
SPRYCEL TAB70MG 30 per 30 days
SPRYCEL TAB80MG 30 per 30 days
STAVUDINE CAP15MG 120 per 30 days
STAVUDINE CAP20MG 120 per 30 days
STAVUDINE CAP30MG 60 per 30 days
STAVUDINE CAP40MG 60 per 30 days
STAVUDINE SOL1MG/ML 2400 per 30 days
STIVARGA TAB40MG 84 per 28 days
STRATTERA CAP100MG 60 per 30 days
STRATTERA CAP10MG 60 per 30 days
STRATTERA CAP18MG 60 per 30 days
STRATTERA CAP25MG 60 per 30 days
STRATTERA CAP40MG 60 per 30 days
STRATTERA CAP60MG 60 per 30 days
STRATTERA CAP80MG 60 per 30 days
STRIBILD TAB 30 per 30 days
SUBSYS SPR100MCG 120 per 30 days
SUBSYS SPR200MCG 120 per 30 days
SUBSYS SPR400MCG 120 per 30 days
SUBSYS SPR600MCG 120 per 30 days
SUBSYS SPR800MCG 120 per 30 days
SUMATRIPTAN INJ6MG/0.5 6 per 30 days
SUMATRIPTAN INJ6MG/0.5 8 per 28 days
SUMATRIPTAN SPR20MG/ACT 18 per 28 days
SUMATRIPTAN SUCCINATE REF 8 per 28 days
SUMATRIPTAN TAB100MG 9 per 30 days
SUMATRIPTAN TAB25MG 9 per 30 days
SUMATRIPTAN TAB50MG 9 per 30 days
SUSTIVA CAP200MG 120 per 30 days
SUSTIVA CAP50MG 360 per 30 days
SUSTIVA TAB600MG 30 per 30 days
SUTENT CAP12.5MG 90 per 30 days
SUTENT CAP25MG 30 per 30 days
SUTENT CAP37.5MG 30 per 30 days
SUTENT CAP50MG 30 per 30 days
SYMLINPEN 60INJ1000MCG 10 per 30 days
SYMLNPEN 120INJ1000MCG 10 per 30 days
TAFINLAR CAP50MG 180 per 30 days
TAFINLAR CAP75MG 120 per 30 days
TAMIFLU CAP30MG 84 per 180 days
TAMIFLU CAP45MG 42 per 180 days
TAMIFLU CAP75MG 42 per 180 days
TAMIFLU SUS6MG/ML 900 per 180 days
TAMSULOSIN CAP0.4MG 60 per 30 days
TARCEVA TAB100MG 30 per 30 days
TARCEVA TAB150MG 30 per 30 days
TARCEVA TAB25MG 90 per 30 days
TASIGNA CAP150MG 120 per 30 days
TASIGNA CAP200MG 120 per 30 days
TEKTURNA TAB150MG 30 per 30 days
TEKTURNA TAB300MG 30 per 30 days
TERAZOSIN CAP10MG 60 per 30 days
TERAZOSIN CAP1MG 30 per 30 days
TERAZOSIN CAP2MG 30 per 30 days
TERAZOSIN CAP5MG 30 per 30 days
TERBINAFINE TAB250MG 30 per 30 days
TERCONAZOLE SUP80MG 3 per 3 days
THALOMID CAP100MG 30 per 30 days
THALOMID CAP150MG 60 per 30 days
THALOMID CAP200MG 60 per 30 days
THALOMID CAP50MG 30 per 30 days
TICLOPIDINE TAB250MG 60 per 30 days
DRUG NAME LIMITATION
TIVICAY TAB50MG 60 per 30 days
TOLTERODINE CAP2MG ER 30 per 30 days
TOLTERODINE CAP4MG ER 30 per 30 days
TOLTERODINE TAB1MG 60 per 30 days
TOLTERODINE TAB2MG 60 per 30 days
TOPIRAMATE TAB100MG 480 per 30 days
TOPIRAMATE TAB200MG 240 per 30 days
TOPIRAMATE TAB25MG 1920 per 30 days
TOPIRAMATE TAB50MG 960 per 30 days
TOUJEO SOLO INJ300IU/ML 21 per 30 days
TOVIAZ TAB4MG 30 per 30 days
TOVIAZ TAB8MG 30 per 30 days
TRACLEER TAB125MG 60 per 30 days
TRACLEER TAB62.5MG 120 per 30 days
TRAMADOL HCLTAB50MG 240 per 30 days
TRANDOLAPRILTAB1MG 30 per 30 days
TRANDOLAPRILTAB2MG 30 per 30 days
TRANDOLAPRILTAB4MG 60 per 30 days
TRANSDERM-SCDIS1.5MG 24 per 30 days
TRAVATAN Z DRO0.004% 5 per 30 days
TRETINOIN 45 per 30 days
TRETINOIN CRE0.025% 45 per 30 days
TRETINOIN CRE0.05% 45 per 30 days
TRETINOIN CRE0.1% 45 per 30 days
TRETINOIN GEL0.01% 45 per 30 days
TRETINOIN GEL0.025% 45 per 30 days
TRETIN-X CRE0.0375% 45 per 30 days
TRETIN-X CRE0.075% 45 per 30 days
TRIAMCINOLONAER55MCG/AC 33 per 30 days
TRIUMEQ TAB 30 per 30 days
TRUVADA TAB200-300 30 per 30 days
TYKERB TAB250MG 180 per 30 days
ULORIC TAB40MG 30 per 30 days
ULORIC TAB80MG 30 per 30 days
VALACYCLOVIRTAB1GM 30 per 1 days
VALACYCLOVIRTAB500MG 30 per 1 days
VALSARTAN TAB160MG 60 per 30 days
VALSARTAN TAB320MG 30 per 30 days
VALSARTAN TAB40MG 90 per 30 days
VALSARTAN TAB80MG 90 per 30 days
VANCOMYCIN CAP125MG 40 per 30 days
VANCOMYCIN CAP250MG 80 per 30 days
VANDETANIB TAB100MG 60 per 30 days
VANDETANIB TAB300MG 30 per 30 days
VENLAFAXINE CAP150MG ER 60 per 30 days
VENLAFAXINE CAP37.5 ER 180 per 30 days
VENLAFAXINE CAP75MG ER 90 per 30 days
VENLAFAXINE TAB100MG 90 per 30 days
VENLAFAXINE TAB150MG ER 60 per 30 days
VENLAFAXINE TAB225MG ER 30 per 30 days
VENLAFAXINE TAB25MG 270 per 30 days
VENLAFAXINE TAB37.5 ER 180 per 30 days
VENLAFAXINE TAB37.5MG 180 per 30 days
VENLAFAXINE TAB50MG 150 per 30 days
VENLAFAXINE TAB75MG 150 per 30 days
VENLAFAXINE TAB75MG ER 90 per 30 days
VENTOLIN HFAAER 36 per 30 days
VERAMYST SPR27.5MCG 20 per 30 days
VESICARE TAB10MG 30 per 30 days
VESICARE TAB5MG 30 per 30 days
VICTOZA INJ18MG/3ML 9 per 30 days
VIDEX SOL2GM 1200 per 30 days
VIIBRYD TAB10MG 120 per 30 days
VIIBRYD TAB20MG 60 per 30 days
VIIBRYD TAB40MG 30 per 30 days
VIMPAT SOL10MG/ML 1200 per 30 days
VIMPAT TAB100MG 60 per 30 days
VIMPAT TAB150MG 60 per 30 days
VIMPAT TAB200MG 60 per 30 days
8
DRUG NAME LIMITATION
VIMPAT TAB50MG 60 per 30 days
VIREAD POW40MG/GM 240 per 30 days
VIREAD TAB150MG 30 per 30 days
VIREAD TAB200MG 30 per 30 days
VIREAD TAB250MG 30 per 30 days
VIREAD TAB300MG 30 per 30 days
VORICONAZOLETAB200MG 60 per 30 days
VORICONAZOLETAB50MG 120 per 30 days
VOTRIENT TAB200MG 120 per 30 days
XALKORI CAP200MG 60 per 30 days
XALKORI CAP250MG 60 per 30 days
XARELTO TAB10MG 30 per 30 days
XARELTO TAB15MG 51 per 30 days
DRUG NAME LIMITATION
XARELTO TAB20MG 30 per 30 days
XARELTO STARTAB15/20MG 51 per 30 days
XIFAXAN TAB550MG 60 per 30 days
XOPENEX HFA AER 30 per 30 days
ZAFIRLUKAST TAB10MG 60 per 30 days
ZAFIRLUKAST TAB20MG 60 per 30 days
ZALEPLON CAP10MG 60 per 30 days
ZALEPLON CAP5MG 30 per 30 days
ZETIA TAB10MG 30 per 30 days
ZIAGEN SOL20MG/ML 960 per 30 days
ZIDOVUDINE CAP100MG 180 per 30 days
ZIDOVUDINE SYP50MG/5ML 1920 per 30 days
ZIDOVUDINE TAB300MG 60 per 30 days
DRUG NAME LIMITATION
ZIPRASIDONE CAP20MG 240 per 30 days
ZIPRASIDONE CAP40MG 120 per 30 days
ZIPRASIDONE CAP40MG 60 per 30 days
ZIPRASIDONE CAP60MG 90 per 30 days
ZIPRASIDONE CAP80MG 60 per 30 days
ZMAX SUS2GM 60 per 30 days
ZOLINZA CAP100MG 120 per 30 days
ZOLPIDEM TAB10MG 30 per 30 days
ZOLPIDEM TAB5MG 30 per 30 days
ZOLPIDEM ER TAB12.5MG 30 per 30 days
ZOLPIDEM ER TAB6.25MG 30 per 30 days
ZOMIG TAB2.5MG 6 per 30 days
ZOMIG TAB5MG 6 per 30 days
DRUG NAME LIMITATION
ZOMIG NASAL SPR5MG 6 per 30 days
ZOMIG ZMT TAB2.5 MG 6 per 30 days
ZOMIG ZMT TAB5MG 6 per 30 days
ZORTRESS TAB0.25MG 120 per 30 days
ZORTRESS TAB0.5MG 120 per 30 days
ZORTRESS TAB0.75MG 60 per 30 days
ZYDELIG TAB100MG 90 per 30 days
ZYDELIG TAB150MG 60 per 30 days
ZYKADIA CAP150MG 150 per 30 days
ZYTIGA TAB250MG 120 per 30 days
9
DRUG LISTING Tier 1 - Preferred Generics Tier 2 - Non-Preferred Generics and Preferred Brands Tier 3 - Non-Preferred Brands Tier 4 - Preferred Specialty Products The cost of your prescription depends on:
Which tier your drug is on
Whether you fill your prescription at a network pharmacy
Your current drug payment stage - please read your Evidence of Coverage (EOC) for more information If the product has a limitation on the medication, this is noted in the LIMITS section. The following abbreviations apply to the LIMITS section: QL: Quantity Limitation. This medication is subject to limits on the amount of medication per prescription. PA: Prior Authorization. This medication requires you or your physician to get prior authorization prior to the medication being dispensed form a pharmacy. ST: Step Therapy. This medication requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we would require drug A be tried before Drug B can be utilized. SP: Specialty Pharmacy. This medication is required to be dispensed in a specialty pharmacy as the medication requires more intensive patient monitoring and are limited to dispensing at specialty pharmacies. Healthy Premier requires the drugs noted as specialty to be filled primarily at University of Utah network of specialty pharmacies. In cases where drugs are available through a limited distribution from the manufacturer, these drugs may be filled at Walgreens Specialty Pharmacy or for certain drugs, other specialty pharmacies.
DRUG NAME TIER LIMITS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
AMPHETAMINE CAP10MG ER 2 QL
AMPHETAMINE CAP15MG ER 2 QL
AMPHETAMINE CAP20MG ER 2 QL
AMPHETAMINE CAP25MG ER 2 QL
AMPHETAMINE CAP30MG ER 2 QL
AMPHETAMINE CAP5MG ER 2 QL
AMPHETAMINE TAB10MG 2 QL
AMPHETAMINE TAB12.5MG 2 QL
AMPHETAMINE TAB15MG 2 QL
AMPHETAMINE TAB20MG 2 QL
AMPHETAMINE TAB30MG 2 QL
AMPHETAMINE TAB5MG 2 QL
ARMODAFINIL TAB150MG 2 PA
ARMODAFINIL TAB250MG 2 PA
ARMODAFINIL TAB50MG 2 PA
CONCERTA TAB18MG 3 QL
CONCERTA TAB27MG 3 QL
CONCERTA TAB36MG 3 QL
CONCERTA TAB54MG 3 QL
DAYTRANA DIS10MG/9HR 3
DAYTRANA DIS15MG/9HR 3
DAYTRANA DIS20MG/9HR 3
DAYTRANA DIS30MG/9HR 3
DEXMETHYLPH CAP15MG ER 2 QL
DEXMETHYLPH CAP30MG ER 2 QL
DEXMETHYLPH CAP40MG ER 2 QL
DEXMETHYLPH TAB10MG 2 QL
DEXMETHYLPH TAB2.5MG 2 QL
DEXMETHYLPH TAB5MG 2 QL
DEXTROAMPHETCAP10MG ER 2 QL
DEXTROAMPHETCAP15MG ER 2 QL
DEXTROAMPHETCAP5MG ER 2 QL
DEXTROAMPHETTAB10MG 2 QL
DEXTROAMPHETTAB5MG 2 QL
GUANFACINE TAB1MG ER 2
GUANFACINE TAB2MG ER 2
GUANFACINE TAB3MG ER 2
GUANFACINE TAB4MG ER 2
METADATE TAB20MG ER 2 QL
METHYLIN CHW10MG 3
METHYLIN CHW2.5MG 3
METHYLIN CHW5MG 3
METHYLPHENIDCAP10MG 2
METHYLPHENIDCAP20MG ER 2 QL
METHYLPHENIDCAP30MG ER 2 QL
METHYLPHENIDCAP40MG ER 2 QL
METHYLPHENIDCAP40MG ER 2 QL
METHYLPHENIDCAP50MG 2
METHYLPHENIDCAP60MG 2
METHYLPHENIDSOL10MG/5ML 2
METHYLPHENIDSOL5MG/5ML 2
METHYLPHENIDTAB10MG 2 QL
METHYLPHENIDTAB10MG ER 2 QL
DRUG NAME TIER LIMITS
METHYLPHENIDTAB18MG ER 3 QL
METHYLPHENIDTAB20MG 2 QL
METHYLPHENIDTAB20MG ER 2 QL
METHYLPHENIDTAB27MG ER 3 QL
METHYLPHENIDTAB36MG ER 3 QL
METHYLPHENIDTAB54MG ER 3 QL
METHYLPHENIDTAB5MG 2 QL
MODAFINIL TAB100MG 1 QL
MODAFINIL TAB200MG 1 QL
QUILLIVANT SUSXR 3
RITALIN LA CAP10MG 3 QL
STRATTERA CAP100MG 2 QL
STRATTERA CAP10MG 2 QL
STRATTERA CAP18MG 2 QL
STRATTERA CAP25MG 2 QL
STRATTERA CAP40MG 2 QL
STRATTERA CAP60MG 2 QL
STRATTERA CAP80MG 2 QL
VYVANSE CAP20MG 3
VYVANSE CAP30MG 3
VYVANSE CAP40MG 3
VYVANSE CAP50MG 3
VYVANSE CAP60MG 3
VYVANSE CAP70MG 3
AMINOGLYCOSIDES
NEOMYCIN TAB500MG 1
PAROMOMYCIN CAP250MG 2
TOBRAMYCIN NEB300/5ML 4 PA SP
ANALGESICS - ANTI-INFLAMMATORY
ACTEMRA INJ162/0.9 4 PA SP
CELECOXIB 50 MG 1
CELECOXIB 100 MG 1
CELECOXIB 200 MG 1
CELECOXIB 400 MG 1 QL
DICLOFEN POTTAB50MG 1
DICLOFENAC TAB100MG ER 1
DICLOFENAC TAB25MG DR 1
DICLOFENAC TAB50MG DR 1
DICLOFENAC TAB75MG DR 1
ENBREL INJ25/0.5ML 4 QL PA SP
ENBREL INJ25MG 4 QL PA SP
ENBREL INJ50MG/ML 4 QL PA SP
ENBREL SURECLICK 4 QL PA SP
ETODOLAC CAP200MG 1
ETODOLAC CAP300MG 1
ETODOLAC TAB400MG 1
ETODOLAC TAB500MG 1
ETODOLAC ER TAB400MG 1
ETODOLAC ER TAB500MG 1
ETODOLAC ER TAB600MG 1
FENOPROFEN TAB600MG 2
FENOPROFEN CALCIUM 3
FLURBIPROFENTAB100MG 1
FLURBIPROFENTAB50MG 1
10
DRUG NAME TIER LIMITS
HUMIRA INJ10MG/0.2 4 QL PA SP
HUMIRA INJ40MG/0.8 4 QL PA SP
HUMIRA KIT20MG/0.4 4 QL PA SP
HUMIRA PEDIATRIC CROHNS D 4 QL PA SP
HUMIRA PEN INJCROHNS 4 QL PA SP
IBUPROFEN TAB400MG 1
IBUPROFEN TAB600MG 1
IBUPROFEN TAB800MG 1
INDOCIN SUS25MG/5ML 3
INDOMETHACINCAP25MG 1
INDOMETHACINCAP50MG 1
INDOMETHACINCAP75MG ER 1
KETOPROFEN CAP50MG 1
KETOPROFEN CAP75MG 1
KETOROLAC TAB10MG 1 QL
KINERET INJ 4 QL PA SP
LEFLUNOMIDE TAB10MG 1 QL
LEFLUNOMIDE TAB20MG 1 QL
MECLOFEN SODCAP100MG 2
MECLOFEN SODCAP50MG 2
MEFENAM ACIDCAP250MG 2
MELOXICAM TAB15MG 1 QL
MELOXICAM TAB7.5MG 1 QL
NABUMETONE TAB500MG 1
NABUMETONE TAB750MG 1
NALFON CAP200MG 3
NALFON CAP400MG 3
NAPROXEN SUS125/5ML 1
NAPROXEN TAB250MG 1
NAPROXEN TAB375MG 1
NAPROXEN TAB500MG 1
NAPROXEN DR TAB375MG 1
NAPROXEN DR TAB500MG 1
NAPROXEN SODIUM CR 2
NAPROXEN SODTAB275MG 1
NAPROXEN SODTAB500MG CR 2
NAPROXEN SODTAB550MG 1
ORENCIA 4 PA SP
OTEZLA 4 QL PA SP
OTEZLA TAB10/20/30 4 QL PA SP
OTEZLA TAB30MG 4 QL PA SP
OXAPROZIN TAB600MG 2
PIROXICAM CAP10MG 1
PIROXICAM CAP20MG 1
RHEUMATREX 3 PA
RHEUMATREX TAB2.5MG 3 PA
RIDAURA CAP3MG 4 PA SP
SIMPONI INJ100MG/ML 4 QL PA SP
SIMPONI INJ50/0.5ML 4 QL PA SP
SPRIX SPR15.75MG 3 PA
SULINDAC TAB150MG 1
SULINDAC TAB200MG 1
TOLMETIN SODCAP400MG 2
TOLMETIN SODTAB200MG 2
TOLMETIN SODTAB600MG 2
XELJANZ TAB5MG 4 PA SP
XELJANZ XR TAB11MG 4 PA SP
ZIPSOR CAP25MG 3
ANALGESICS - NonNarcotic
DIFLUNISAL TAB500MG 1
TENCON TAB50-325MG 1
ZEBUTAL CAP 1
ANALGESICS - OPIOID
ABSTRAL SUB100MCG 4 QL PA SP
ABSTRAL SUB200MCG 4 QL PA SP
ABSTRAL SUB300MCG 4 QL PA SP
ABSTRAL SUB400MCG 4 QL PA SP
ABSTRAL SUB600MCG 4 QL PA SP
ABSTRAL SUB800MCG 4 QL PA SP
BUNAVAIL MIS2.1-0.3 3 PA
BUNAVAIL MIS4.2-0.7 3 PA
BUNAVAIL MIS6.3-1MG 3 PA
BUPRENORPHINSUB2MG 1 QL
BUPRENORPHINSUB8MG 1 QL
BUPRENOR/NALOXONE SUB 1 QL
BUT/APAP/CAFCAPCODEINE 2 QL
BUTORPHANOL SOL10MG/ML 2 QL
BUTRANS DIS G 2 QL PA
BUTRANS DIS10MCG/HR 2 QL PA
BUTRANS DIS15MCG/HR 2 QL PA
DRUG NAME TIER LIMITS
BUTRANS DIS20MCG/HR 2 QL PA
BUTRANS DIS5MCG/HR 2 QL PA
CODEINE SULFTAB30MG 2
CODEINE SULFTAB60MG 2
EMBEDA CAP100-4MG 3 PA
EMBEDA CAP20-0.8MG 3 PA
EMBEDA CAP30-1.2MG 3 PA
EMBEDA CAP50-2MG 3 PA
EMBEDA CAP60-2.4MG 3 PA
EMBEDA CAP80-3.2MG 3 PA
ENDOCET TAB2.5-325 1
FENTANYL DIS100MCG/H 2 QL PA
FENTANYL DIS12MCG/HR 2 QL PA
FENTANYL DIS25MCG/HR 2 QL PA
FENTANYL DIS50MCG/HR 2 QL PA
FENTANYL DIS75MCG/HR 2 QL PA
FENTANYL OT LOZ1200MCG 4 QL PA SP
FENTANYL OT LOZ1600MCG 4 QL PA SP
FENTANYL OT LOZ200MCG 4 QL PA SP
FENTANYL OT LOZ400MCG 4 QL PA SP
FENTANYL OT LOZ600MCG 4 QL PA SP
FENTANYL OT LOZ800MCG 4 QL PA SP
FENTORA TAB400MCG 4 QL PA SP
HYDROCO/APAP TAB 10-325MG 1 QL
HYDROCO/APAP TAB 7.5-325MG 1 QL
HYDROCO/APAP TAB 5-325MG 1 QL
HYDROMORPHONLIQ1MG/ML 2
HYDROMORPHONTAB12MG ER 2 PA
HYDROMORPHONTAB16MG ER 2 PA
HYDROMORPHONTAB2MG 2 QL
HYDROMORPHONTAB32MG ER 2 QL PA
HYDROMORPHONTAB4MG 2 QL
HYDROMORPHONTAB8MG 2 QL
HYDROMORPHONTAB8MG ER 2 QL PA
LAZANDA SPR100MCG 4 QL PA SP
LAZANDA SPR400MCG 4 QL PA SP
LORCET TAB5-325MG 1 QL
LORCET HD TAB10-325MG 1 QL
LORCET PLUS TAB7.5-325 1 QL
LORTAB ELX10-300MG 2
LORTAB TAB10-325MG 1 QL
LORTAB TAB5-325MG 1 QL
LORTAB TAB7.5-325 1 QL
METHADONE CON10MG/ML 1 PA
METHADONE SOL10MG/5ML 1 QL PA
METHADONE SOL5MG/5ML 1 QL PA
METHADONE TAB10MG 1 QL PA
METHADONE TAB5MG 1 QL PA
MORPHINE SULCAP100MG ER 2 QL PA
MORPHINE SULCAP10MG ER 2 QL PA
MORPHINE SULCAP120MG ER 2 QL PA
MORPHINE SULCAP20MG ER 2 QL PA
MORPHINE SULCAP30MG ER 2 QL PA
MORPHINE SULCAP45MG ER 2 QL PA
MORPHINE SULCAP50MG ER 2 QL PA
MORPHINE SULCAP60MG ER 2 QL PA
MORPHINE SULCAP75MG ER 2 QL PA
MORPHINE SULCAP80MG ER 2 QL PA
MORPHINE SULCAP90MG ER 2 QL PA
MORPHINE SULSOL10MG/5ML 2 QL
MORPHINE SULSOL20MG/5ML 2 QL
MORPHINE SULSOL20MG/ML 2 QL
MORPHINE SULTAB100MG ER 2 QL PA
MORPHINE SULTAB15MG 2 QL
MORPHINE SULTAB15MG ER 2 QL PA
MORPHINE SULTAB200MG ER 2 QL PA
MORPHINE SULTAB30MG 2 QL
MORPHINE SULTAB30MG ER 2 QL PA
MORPHINE SULTAB60MG ER 2 QL PA
NALTREXONE TAB50MG 2
NUCYNTA TAB100MG 3 QL
NUCYNTA TAB50MG 3 QL
NUCYNTA TAB75MG 3 QL
NUCYNTA ER TAB100MG 2 QL PA
NUCYNTA ER TAB150MG 2 QL PA
NUCYNTA ER TAB200MG 2 QL PA
NUCYNTA ER TAB250MG 2 QL PA
NUCYNTA ER TAB50MG 2 QL PA
OXECTA TAB5MG 3
OXECTA TAB7.5MG 3
11
DRUG NAME TIER LIMITS
OXYCOD/APAP TAB 10-325MG 1 QL
OXYCOD/APAP TAB 2.5-325MG 1 QL
OXYCOD/APAP TAB 5-325MG 1 QL
OXYCOD/APAP TAB 7.5-325MG 1 QL
OXYCOD/IBU TAB5-400MG 2 QL
OXYCODONE TAB10MG 2 QL
OXYCODONE TAB10MG 2 QL
OXYCODONE TAB15MG 2 QL
OXYCODONE TAB20MG 2 QL
OXYCODONE TAB20MG 2 QL
OXYCODONE TAB30MG 2 QL
OXYCODONE TAB5MG 2 QL
OXYCONTIN TAB10MG CR 2 QL PA
OXYCONTIN TAB15MG CR 2 QL PA
OXYCONTIN TAB20MG CR 2 QL PA
OXYCONTIN TAB30MG CR 2 QL PA
OXYCONTIN TAB40MG CR 2 QL PA
OXYCONTIN TAB60MG CR 2 QL PA
OXYCONTIN TAB80MG CR 2 QL PA
OXYMORPHONE TAB10MG ER 2 PA
OXYMORPHONE TAB15MG ER 2 PA
OXYMORPHONE TAB20MG ER 2 PA
OXYMORPHONE TAB30MG ER 2 PA
OXYMORPHONE TAB40MG ER 2 PA
OXYMORPHONE TAB5MG ER 2 PA
OXYMORPHONE TAB7.5MG ER 2 PA
OXYMORPHONE TABHCL 10MG 2
OXYMORPHONE TABHCL 5MG 2
SUBSYS SPR100MCG 4 QL PA SP
SUBSYS SPR200MCG 4 QL PA SP
SUBSYS SPR400MCG 4 QL PA SP
SUBSYS SPR600MCG 4 QL PA SP
SUBSYS SPR800MCG 4 QL PA SP
TRAMADOL HCLTAB50MG 2 QL
XYLON TAB10-200MG 2
ANDROGENS-ANABOLIC
ANADROL-50 TAB50MG 3
ANDRODERM DIS2MG/24HR 2 QL
ANDRODERM DIS4MG/24HR 2 QL
ANDROGEL 3
ANDROGEL PUMP 3
ANDROID CAP10MG 3 PA
ANDROXY TAB10MG 3
AXIRON 3
DANAZOL CAP100MG 2
DANAZOL CAP200MG 2
DANAZOL CAP50MG 2
DEPO-TESTOSTINJ100MG/ML 2
DEPO-TESTOSTINJ200MG/ML 2
FORTESTA 3
METHITEST TAB10MG 2
OXANDROLONE TAB10MG 2 QL
OXANDROLONE TAB2.5MG 2 QL
STRIANT MIS30MG 3
TESTIM 3
TESTOST CYP INJ100MG/ML 2
TESTOST CYP INJ200MG/ML 2
TESTOST ENANINJ200MG/ML 2
TESTOSTERONE 3
TESTOSTERONE PUMP 3
TESTRED CAP10MG 3 PA
VOGELXO 3
VOGELXO PUMP 3
ANORECTAL AGENTS
COLOCORT ENE100MG 2
HYDROCORT CRE2.5% 1
HYDROCORT ENE100MG 2
PROCTOCREAM CREHC 2.5% 1
PROCTO-KIT CRE2.5% 1
PROCTO-PAK CRE1% 1
PROCTOSOL HCCRE2.5% 1
PROCTOZONE CRE-HC 2.5% 1
RECTIV OIN0.4% 3
ANTHELMINTICS
ALBENZA TAB200MG 3
BILTRICIDE TAB600MG 3
MEBENDAZOLE CHW100MG 1
ANTIANGINAL AGENTS
IMDUR TAB60MG ER 1
ISOCHRON TAB40MG CR 1
DRUG NAME TIER LIMITS
ISODITRATE TAB40MG ER 1
ISOSORB DIN SUB2.5MG 1
ISOSORB DIN SUB5MG 1
ISOSORB DIN TAB10MG 1
ISOSORB DIN TAB20MG 1
ISOSORB DIN TAB30MG 1
ISOSORB DIN TAB40MG ER 1
ISOSORB DIN TAB5MG 1
ISOSORB MONOTAB10MG 1
ISOSORB MONOTAB120MG ER 1
ISOSORB MONOTAB20MG 1
ISOSORB MONOTAB30MG ER 1
ISOSORB MONOTAB60MG ER 1
MINITRAN DIS0.1MG/HR 1 QL
MINITRAN DIS0.2MG/HR 1 QL
MINITRAN DIS0.4MG/HR 1 QL
MINITRAN DIS0.6MG/HR 1 QL
NITRO-BID OIN2% 1
NITROGLYCER DIS0.1MG/HR 1 QL
NITROGLYCER DIS0.2MG/HR 1 QL
NITROGLYCER DIS0.4MG/HR 1 QL
NITROGLYCERIDIS0.6MG/HR 1 QL
NITROGLYCRN SPR0.4MG 3
NITROLINGUALSPRPUMPSPRA 3
NITROMIST AER400MCG 3
NITROSTAT SUB0.3MG 2
NITROSTAT SUB0.4MG 2
NITROSTAT SUB0.6MG 2
RANEXA TAB1000MG 2 QL
RANEXA TAB500MG 2 QL
ANTIANXIETY AGENTS
ALPRAZOLAM 2
ALPRAZOLAM ODT 2
ALPRAZOLAM XR 2
BUSPIRONE TAB10MG 1
BUSPIRONE TAB15MG 1
BUSPIRONE TAB30MG 1
BUSPIRONE TAB5MG 1
BUSPIRONE TAB7.5MG 1
CLONAZEP ODTTAB0.125MG 1 QL
CLONAZEP ODTTAB0.25MG 1 QL
CLONAZEP ODTTAB0.5MG 1 QL
CLONAZEPAM TAB0.5MG 1 QL
CLONAZEPAM TAB1MG 1 QL
CLONAZEPAM TAB2MG 1 QL
DIAZEPAM 2
DIAZEPAM INTENSOL 2
HYDROXYZ HCLSOL10MG/5ML 1
HYDROXYZ HCLTAB10MG 1
HYDROXYZ HCLTAB25MG 1
HYDROXYZ HCLTAB50MG 1
HYDROXYZ PAMCAP100MG 1
HYDROXYZ PAMCAP25MG 1
HYDROXYZ PAMCAP50MG 1
LORAZEPAM 2
LORAZEPAM INTENSOL 2
MEPROBAMATE TAB200MG 2
MEPROBAMATE TAB400MG 2
ANTIARRHYTHMICS
AMIODARONE TAB100MG 1
AMIODARONE TAB200MG 1
AMIODARONE TAB400MG 2
DISOPYRAMIDECAP100MG 2
DISOPYRAMIDECAP150MG 2
FLECAINIDE TAB100MG 2
FLECAINIDE TAB150MG 2
FLECAINIDE TAB50MG 2
MEXILETINE CAP150MG 2
MEXILETINE CAP200MG 2
MEXILETINE CAP250MG 2
MULTAQ TAB400MG 3 QL
NORPACE CAP100MG CR 3
NORPACE CAP150MG CR 3
PACERONE TAB100MG 1
PACERONE TAB200MG 1
PACERONE TAB400MG 1
PROPAFENONE CAP225MG ER 1
PROPAFENONE CAP325MG ER 1
PROPAFENONE CAP425MG SR 1
PROPAFENONE TAB150MG 1
12
DRUG NAME TIER LIMITS
PROPAFENONE TAB225MG 1
PROPAFENONE TAB300MG 1
QUINIDINE GLTAB324MG CR 2
QUINIDINE SUTAB200MG 2
QUINIDINE SUTAB300MG 2
QUINIDINE SUTAB300MG ER 2
TIKOSYN CAP125MCG 4 PA SP
TIKOSYN CAP250MCG 4 PA SP
TIKOSYN CAP500MCG 4 PA SP
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ADVAIR DISKUAER100/50 2 QL
ADVAIR DISKUAER250/50 2 QL
ADVAIR DISKUAER500/50 2 QL
ADVAIR HFA AER115/21 2 QL
ADVAIR HFA AER230/21 2 QL
ADVAIR HFA AER45/21 2 QL
ALBUTEROL NEB0.083% 1 QL
ALBUTEROL NEB0.5% 1 QL
ALBUTEROL NEB0.63MG/3 1 QL
ALBUTEROL NEB1.25MG/3 1 QL
ALBUTEROL SYP2MG/5ML 1
ALBUTEROL TAB2MG 1
ALBUTEROL TAB4MG 1
ALBUTEROL TAB8MG ER 1
ANORO ELLIPTAER62.5-25 2
ARCAPTA CAP75MCG 3 QL
ASMANEX 120 AER220MCG 3 QL
ASMANEX 14 AER220MCG 3 QL
ASMANEX 30 AER110MCG 3 QL
ASMANEX 30 AER220MCG 3 QL
ASMANEX 60 AER220MCG 3 QL
ASMANEX 7 AER110MCG 3 QL
ASMANEX HFA AER100 MCG 3
ASMANEX HFA AER200 MCG 3
BREO ELLIPTAINH200-25 2 QL
BREO ELLIPTAINH100-25 2 QL
BROVANA NEB15MCG 3
BUDESONIDE SUS0.25MG/2 2 QL
BUDESONIDE SUS0.5MG/2 2 QL
CROMOLYN SODNEB20MG/2ML 2 QL
DALIRESP TAB500MCG 3 QL
DULERA AER100-5MCG 2 QL
DULERA AER200-5MCG 2 QL
ELIXOPHYLLINELX80/15ML 2
EPINEPHRINE INJ0.1MG/ML 2
FLOVENT DISKAER100MCG 2 QL
FLOVENT DISKAER250MCG 2 QL
FLOVENT DISKAER50MCG 2 QL
FLOVENT HFA AER110MCG 2 QL
FLOVENT HFA AER220MCG 2 QL
FLOVENT HFA AER44MCG 2 QL
FORADIL CAPAEROLIZE 2 QL
IPRATROPIUM SOL0.02%INH 2
LEVALBUTEROLNEB0.31MG 1 QL
LEVALBUTEROLNEB0.63MG 1 QL
LEVALBUTEROLNEB1.25/0.5 1 QL
LUFYLLIN TAB200MG 2
LUFYLLIN TAB400MG 2
METAPROTERENSYP10MG/5ML 1
METAPROTERENTAB10MG 1
METAPROTERENTAB20MG 1
MONTELUKAST CHW4MG 1 QL
MONTELUKAST CHW5MG 1 QL
MONTELUKAST GRA4MG 1 QL
MONTELUKAST TAB10MG 1 QL
PERFOROMIST NEB20MCG 3
PROAIR HFA AER 3 QL
PROAIR RESPICLICK 3
PROVENTIL AERHFA 3 QL
PULMICORT INH180MCG 2 QL
PULMICORT INH90MCG 2 QL
QVAR AER40MCG 2 QL
QVAR AER80MCG 2 QL
SEREVENT DISAER50MCG 3 QL
SPIRIVA CAPHANDIHLR 2 QL
SPIRIVA SPRRESPIMAT 2 QL
SPIRIVA RESPIMAT 2
STRIVERDI AERRESPIMAT 2
TERBUTALINE TAB2.5MG 1
TERBUTALINE TAB5MG 1
DRUG NAME TIER LIMITS
THEOCHRON TAB100MG CR 1
THEOCHRON TAB200MG CR 1
THEOCHRON TAB300MG CR 1
THEOPHYLLINETAB100MG CR 1
THEOPHYLLINETAB200MG CR 1
THEOPHYLLINETAB300MG ER 1
THEOPHYLLINETAB400MG ER 1
THEOPHYLLINETAB450MG ER 1
THEOPHYLLINETAB600MG ER 1
VENTOLIN HFAAER 3 QL
VOSPIRE ER TAB8MG 1
XOPENEX HFA AER 3 QL
ZAFIRLUKAST TAB10MG 2 QL
ZAFIRLUKAST TAB20MG 2 QL
ANTICOAGULANTS
ELIQUIS TAB2.5MG 2 QL
ELIQUIS TAB5MG 2 QL
ENOXAPARIN INJ100MG/ML 2 QL
ENOXAPARIN INJ120/0.8 2 QL
ENOXAPARIN INJ150MG/ML 2 QL
ENOXAPARIN INJ30/0.3ML 2 QL
ENOXAPARIN INJ300/3ML 2 QL
ENOXAPARIN INJ40/0.4ML 2 QL
ENOXAPARIN INJ60/0.6ML 2 QL
ENOXAPARIN INJ80/0.8ML 2 QL
FONDAPARINUXSOL10/0.8 4 QL PA SP
FONDAPARINUXSOL2.5/0.5 4 QL PA SP
FONDAPARINUXSOL5.0/0.4 4 QL PA SP
FONDAPARINUXSOL7.5/0.6 4 QL PA SP
HEPARIN LOCKINJ100/ML 1
HEPARIN SOD INJ1000/ML 1
HEPARIN SOD INJ10000/ML 1
HEPARIN SOD INJ5000/ML 1
HEPARIN SODIUM 1
JANTOVEN TAB10MG 1
JANTOVEN TAB1MG 1
JANTOVEN TAB2.5MG 1
JANTOVEN TAB2MG 1
JANTOVEN TAB3MG 1
JANTOVEN TAB4MG 1
JANTOVEN TAB5MG 1
JANTOVEN TAB6MG 1
JANTOVEN TAB7.5MG 1
PRADAXA CAP110MG 3 QL
PRADAXA CAP150MG 3 QL
PRADAXA CAP75MG 3 QL
WARFARIN TAB10MG 1
WARFARIN TAB1MG 1
WARFARIN TAB2.5MG 1
WARFARIN TAB2MG 1
WARFARIN TAB3MG 1
WARFARIN TAB4MG 1
WARFARIN TAB5MG 1
WARFARIN TAB6MG 1
WARFARIN TAB7.5MG 1
XARELTO TAB10MG 3 QL
XARELTO TAB15MG 3 QL
XARELTO TAB20MG 3 QL
XARELTO STARTAB15/20MG 3 QL
ANTICONVULSANTS
APTIOM TAB200MG 3 QL
APTIOM TAB400MG 3 QL
APTIOM TAB600MG 3 QL
APTIOM TAB800MG 3 QL
BANZEL SUS40MG/ML 3 QL
BANZEL TAB200MG 3 QL
BANZEL TAB400MG 3 QL
CARBAMAZEPINCAP100MG ER 1
CARBAMAZEPINCAP200MG ER 1
CARBAMAZEPINCAP300MG ER 1
CARBAMAZEPINCHW100MG 1
CARBAMAZEPINSUS100/5ML 1
CARBAMAZEPINTAB200MG 1
CARBAMAZEPINTAB200MG ER 1
CARBAMAZEPINTAB400MG ER 1
CELONTIN CAP300MG 2
DILANTIN CAP30MG 3
DIVALPROEX CAP125MG 2
DIVALPROEX TAB125MG DR 2
DIVALPROEX TAB250MG DR 2
13
DRUG NAME TIER LIMITS
DIVALPROEX TAB250MG ER 2
DIVALPROEX TAB500MG DR 2
DIVALPROEX TAB500MG ER 2
EPITOL TAB200MG 1
ETHOSUXIMIDECAP250MG 2
ETHOSUXIMIDESOL250/5ML 2
FELBAMATE SUS600/5ML 2
FELBAMATE TAB400MG 2
FELBAMATE TAB600MG 2
FYCOMPA TAB10MG 3 QL
FYCOMPA TAB12MG 3 QL
FYCOMPA TAB2MG 3 QL
FYCOMPA TAB4MG 3 QL
FYCOMPA TAB6MG 3 QL
FYCOMPA TAB8MG 3 QL
GABAPENTIN CAP100MG 2 QL
GABAPENTIN CAP300MG 2 QL
GABAPENTIN CAP400MG 2 QL
GABAPENTIN SOL250/5ML 2 QL
GABAPENTIN TAB600MG 2 QL
GABAPENTIN TAB800MG 2 QL
GABITRIL TAB12MG 3
GABITRIL TAB16MG 3
LAMOTRIGINE CHW25MG 2
LAMOTRIGINE CHW5MG 2
LAMOTRIGINE ER 2
LAMOTRIGINE TAB100MG 2
LAMOTRIGINE TAB150MG 2
LAMOTRIGINE TAB200MG 2
LAMOTRIGINE TAB25MG 2
LEVETIRACETASOL100MG/ML 2
LEVETIRACETATAB1000MG 2
LEVETIRACETATAB250MG 2
LEVETIRACETATAB500MG 2
LEVETIRACETATAB500MG ER 2 QL
LEVETIRACETATAB750MG 2
LEVETIRACETATAB750MG ER 2 QL
LYRICA CAP100MG 2 QL
LYRICA CAP150MG 2 QL
LYRICA CAP200MG 2 QL
LYRICA CAP225MG 2 QL
LYRICA CAP25MG 2 QL
LYRICA CAP300MG 2 QL
LYRICA CAP50MG 2 QL
LYRICA CAP75MG 2 QL
LYRICA SOL20MG/ML 2 QL
ONFI SUS2.5MG/ML 3 QL PA
OXCARBAZEPINSUS300MG/5M 2
OXCARBAZEPINTAB150MG 2
OXCARBAZEPINTAB300MG 2
OXCARBAZEPINTAB600MG 2
PEGANONE TAB250MG 3
PHENYTEK CAP200MG 1
PHENYTEK CAP200MG 2
PHENYTEK CAP300MG 1
PHENYTEK CAP300MG 2
PHENYTOIN CHW50MG 1
PHENYTOIN SUS125/5ML 1
PHENYTOIN EXCAP100MG 1
PHENYTOIN EXCAP200MG 1
PHENYTOIN EXCAP300MG 1
PIMOZIDE TAB1MG 1
PIMOZIDE TAB2MG 1
POTIGA TAB200MG 3 QL
POTIGA TAB300MG 3 QL
POTIGA TAB400MG 3 QL
POTIGA TAB50MG 3 QL
PRIMIDONE TAB250MG 1
PRIMIDONE TAB50MG 1
QUDEXY XR CAP100/24HR 3
QUDEXY XR CAP150/24HR 3
QUDEXY XR CAP200/24HR 3
QUDEXY XR CAP25/24HR 3
QUDEXY XR CAP50/24HR 3
SABRIL POW500MG 4 PA QL SP
SABRIL TAB500MG 4 PA QL SP
SPRITAM TAB 250MG 3
SPRITAM TAB 500MG 3
SPRITAM TAB 1000MG 3
SPRITAM TAB 750MG 3
DRUG NAME TIER LIMITS
TIAGABINE TAB2MG 2
TIAGABINE TAB4MG 2
TOPIRAMATE CAPER 100MG 3
TOPIRAMATE CAPER 150MG 3
TOPIRAMATE CAPER 200MG 3
TOPIRAMATE CAPER 25MG 3
TOPIRAMATE CAPER 50MG 3
TOPIRAMATE TAB100MG 1 QL
TOPIRAMATE TAB200MG 1 QL
TOPIRAMATE TAB25MG 1 QL
TOPIRAMATE TAB50MG 1 QL
VALPROIC ACDCAP250MG 1
VALPROIC ACDSYP250/5ML 1
VIMPAT SOL10MG/ML 2 QL ST
VIMPAT TAB100MG 2 QL ST
VIMPAT TAB150MG 2 QL ST
VIMPAT TAB200MG 2 QL ST
VIMPAT TAB50MG 2 QL ST
ZONISAMIDE CAP100MG 2
ZONISAMIDE CAP25MG 2
ZONISAMIDE CAP50MG 2
ANTIDEPRESSANTS
AMITRIPTYLINTAB100MG 2
AMITRIPTYLINTAB10MG 2
AMITRIPTYLINTAB150MG 2
AMITRIPTYLINTAB25MG 2
AMITRIPTYLINTAB50MG 2
AMITRIPTYLINTAB75MG 2
AMOXAPINE TAB100MG 2
AMOXAPINE TAB150MG 2
AMOXAPINE TAB25MG 2
AMOXAPINE TAB50MG 2
APLENZIN TAB174MG 3 QL ST
APLENZIN TAB348MG 3 QL ST
APLENZIN TAB522MG 3 QL ST
BUDEPRION TAB100MG SR 1 QL
BUDEPRION TAB150MG SR 1 QL
BUPROPION TAB100MG 1 QL
BUPROPION TAB100MG 1 QL
BUPROPION TAB100MG SR 1 QL
BUPROPION TAB150MG SR 1 QL
BUPROPION TAB200MG SR 1 QL
BUPROPION TAB75MG 1 QL
BUPROPN HCL TAB150MG XL 1 QL
BUPROPN HCL TAB300MG XL 1 QL
CITALOPRAM SOL10MG/5ML 1 QL
CITALOPRAM TAB10MG 1 QL
CITALOPRAM TAB20MG 1 QL
CITALOPRAM TAB40MG 1 QL
CLOMIPRAMINECAP25MG 1
CLOMIPRAMINECAP50MG 1
CLOMIPRAMINECAP75MG 1
DESIPRAMINE TAB100MG 1
DESIPRAMINE TAB10MG 1
DESIPRAMINE TAB150MG 1
DESIPRAMINE TAB25MG 1
DESIPRAMINE TAB50MG 1
DESIPRAMINE TAB75MG 1
DESVENLAFAX TAB100MG ER 2 QL
DESVENLAFAX TAB50MG ER 2 QL
DOXEPIN HCL CAP100MG 1
DOXEPIN HCL CAP10MG 1
DOXEPIN HCL CAP150MG 1
DOXEPIN HCL CAP25MG 1
DOXEPIN HCL CAP50MG 1
DOXEPIN HCL CAP75MG 1
DOXEPIN HCL CON10MG/ML 1
DULOXETINE CAP20MG 2 QL
DULOXETINE CAP30MG 2 QL
DULOXETINE CAP60MG 2 QL
EMSAM DIS12MG/24H 4 QL PA SP
EMSAM DIS6MG/24HR 4 QL PA SP
EMSAM DIS9MG/24HR 4 QL PA SP
ESCITALOPRAMSOL5MG/5ML 2 QL
ESCITALOPRAMTAB10MG 2 QL
ESCITALOPRAMTAB20MG 2 QL
ESCITALOPRAMTAB5MG 2 QL
FLUOXETINE CAP10MG 1 QL
FLUOXETINE CAP20MG 1 QL
FLUOXETINE CAP40MG 1 QL
14
DRUG NAME TIER LIMITS
FLUOXETINE CAP90MG DR 1 QL
FLUOXETINE SOL20MG/5ML 1 QL
FLUOXETINE TAB10MG 1 QL
FLUOXETINE TAB20MG 1 QL
FLUOXETINE TAB20MG 1 QL
FLUOXETINE TAB60MG 2 QL
FLUVOXAMINE TAB100MG 2 QL
FLUVOXAMINE TAB25MG 2 QL
FLUVOXAMINE TAB50MG 2 QL
FLUVOXAMINE CAP 100 MG ER 2
FLUVOXAMINE CAP 150 MG ER 2
FORFIVO XL TAB450MG 3 QL ST
IMIPRAM HCL TAB10MG 2
IMIPRAM HCL TAB25MG 2
IMIPRAM HCL TAB50MG 2
IMIPRAM PAM CAP100MG 1
IMIPRAM PAM CAP125MG 3
IMIPRAM PAM CAP150MG 1
IMIPRAM PAM CAP75MG 1
MAPROTILINE TAB25MG 2 QL
MAPROTILINE TAB50MG 2 QL
MAPROTILINE TAB75MG 2
MARPLAN TAB10MG 3
MIRTAZAPINE TAB15MG 2 QL
MIRTAZAPINE TAB15MG ODT 2 QL
MIRTAZAPINE TAB30MG 2 QL
MIRTAZAPINE TAB30MG ODT 2 QL
MIRTAZAPINE TAB45MG 2 QL
MIRTAZAPINE TAB45MG ODT 2 QL
MIRTAZAPINE TAB7.5MG 2 QL
NEFAZODONE TAB100MG 2 QL
NEFAZODONE TAB150MG 2 QL
NEFAZODONE TAB200MG 2 QL
NEFAZODONE TAB250MG 2 QL
NEFAZODONE TAB50MG 2 QL
NORTRIPTYLINCAP10MG 2
NORTRIPTYLINCAP25MG 2
NORTRIPTYLINCAP50MG 2
NORTRIPTYLINCAP75MG 2
NORTRIPTYLINSOL10MG/5ML 2
OLEPTRO TAB24HR150 3
OLEPTRO TAB24HR300 3
PAROXETIN ERTAB12.5MG 2 QL
PAROXETIN ERTAB37.5MG 2 QL
PAROXETINE SUS10MG/5ML 2
PAROXETINE TAB10MG 2 QL
PAROXETINE TAB20MG 2 QL
PAROXETINE TAB25MG ER 2 QL
PAROXETINE TAB30MG 2 QL
PAROXETINE TAB40MG 2 QL
PAXIL SUS10MG/5ML 3 QL
PEXEVA TAB10MG 3 QL
PEXEVA TAB20MG 3 QL
PEXEVA TAB30MG 3 QL
PEXEVA TAB40MG 3 QL
PHENELZINE TAB15MG 2
PRISTIQ TAB100MG 3 PA QL
PRISTIQ TAB50MG 3 PA QL
PROTRIPTYLINTAB10MG 2
PROTRIPTYLINTAB5MG 2
SERTRALINE CON20MG/ML 1 QL
SERTRALINE TAB100MG 1 QL
SERTRALINE TAB25MG 1 QL
SERTRALINE TAB50MG 1 QL
TRANYLCYPROMTAB10MG 2
TRAZODONE TAB100MG 2
TRAZODONE TAB150MG 2
TRAZODONE TAB300MG 2
TRAZODONE TAB50MG 2
TRIMIPRAMINECAP100MG 2
TRIMIPRAMINECAP25MG 2
TRIMIPRAMINECAP50MG 2
VENLAFAXINE CAP150MG ER 2 QL
VENLAFAXINE CAP37.5 ER 2 QL
VENLAFAXINE CAP75MG ER 2 QL
VENLAFAXINE TAB100MG 2 QL
VENLAFAXINE TAB150MG ER 2 QL
VENLAFAXINE TAB225MG ER 2 QL ST
VENLAFAXINE TAB25MG 2 QL
VENLAFAXINE TAB37.5 ER 2 QL
DRUG NAME TIER LIMITS
VENLAFAXINE TAB37.5MG 2 QL
VENLAFAXINE TAB50MG 2 QL
VENLAFAXINE TAB75MG 2 QL
VENLAFAXINE TAB75MG ER 2 QL
VIIBRYD KIT 3 ST
VIIBRYD TAB10MG 3 QL ST
VIIBRYD TAB20MG 3 QL ST
VIIBRYD TAB40MG 3 QL ST
ANTIDIABETICS
ACARBOSE TAB100MG 1 QL
ACARBOSE TAB25MG 1 QL
ACARBOSE TAB50MG 1 QL
AVANDIA TAB2MG 3 QL
AVANDIA TAB4MG 3 QL
AVANDIA TAB8MG 3 QL
BASAGLAR INJ100UNIT 2
BYDUREON INJ 2 QL ST
BYDUREON INJ 2 QL ST
BYETTA INJ10MCG 2 QL PA ST
BYETTA INJ5MCG 2 QL PA ST
CHLORPROPAM TAB100MG 1 QL
CHLORPROPAM TAB250MG 1 QL
FARXIGA TAB10MG 2 ST
FARXIGA TAB5MG 2 ST
GLIMEPIRIDE TAB1MG 1 QL
GLIMEPIRIDE TAB2MG 1 QL
GLIMEPIRIDE TAB4MG 1 QL
GLIPIZIDE TAB10MG 1 QL
GLIPIZIDE TAB5MG 1 QL
GLIPIZIDE ERTAB10MG 1 QL
GLIPIZIDE ERTAB2.5MG 1 QL
GLIPIZIDE ERTAB5MG 1 QL
GLIPIZIDE ERTAB5MG 1 QL
GLUCAGEN INJHYPOKIT 2 QL
GLUCAGON KIT1MG 2 QL
GLYBURID MCRTAB1.5MG 1 QL
GLYBURID MCRTAB3MG 1 QL
GLYBURID MCRTAB6MG 1 QL
GLYBURIDE TAB1.25MG 1 QL
GLYBURIDE TAB2.5MG 1 QL
GLYBURIDE TAB5MG 1 QL
HUMALOG INJ100/ML 2 QL
HUMALOG KWIKPEN 2 QL
HUMALOG MIX INJ50/50 2 QL
HUMALOG MIX INJ50/50KWP 2 QL
HUMALOG MIX INJ75/25KWP 2 QL
HUMALOG MIX SUS75/25 2 QL
HUMULIN INJ70/30 2 QL
HUMULIN N INJU-100 2 QL
HUMULIN R INJU-100 2 QL
HUMULIN R INJU-500 3 PA QL
INVOKAMET TAB150-1000 3 ST
INVOKAMET TAB150-500 3 ST
INVOKAMET TAB50-1000 3 ST
INVOKAMET TAB50-500MG 3 ST
INVOKANA TAB100MG 3 ST
INVOKANA TAB300MG 3 ST
JANUVIA TAB100MG 2 QL
JANUVIA TAB25MG 2 QL
JANUVIA TAB50MG 2 QL
JARDIANCE TAB10MG 3 QL ST
JARDIANCE TAB25MG 3 QL ST
LANTUS INJ100/ML 2 QL
LANTUS INJSOLOSTAR 2 QL
LEVEMIR INJ 2 QL
LEVEMIR INJFLEXPEN 2 QL
METFORMIN TAB1000MG 1 QL
METFORMIN TAB500MG 1 QL
METFORMIN TAB500MG ER 1 QL
METFORMIN TAB500MG ER 1 QL
METFORMIN TAB750MG ER 1 QL
METFORMIN TAB850MG 1 QL
MIGLITOL TAB100MG 2 QL
MIGLITOL TAB50MG 2 QL
MIGLITOL TAB25MG 2 QL
NATEGLINIDE TAB120MG 2 QL
NATEGLINIDE TAB60MG 2 QL
NOVOLIN INJ70/30 2 QL
NOVOLIN N INJU-100 2 QL
NOVOLIN R INJU-100 2 QL
15
DRUG NAME TIER LIMITS
NOVOLOG INJ100/ML 2 QL
NOVOLOG FLEXPEN 2 QL
NOVOLOG MIX INJ70/30 2 QL
NOVOLOG MIX INJFLEXPEN 2 QL
ONGLYZA TAB2.5MG 2 QL
ONGLYZA TAB5MG 2 QL
PIOGLITAZONETAB15MG 2 QL
PIOGLITAZONETAB30MG 2 QL
PIOGLITAZONETAB45MG 2 QL
REPAGLINIDE TAB0.5MG 1
REPAGLINIDE TAB1MG 1
REPAGLINIDE TAB2MG 1
RIOMET SOL 3
SYMLINPEN 60INJ1000MCG 3 QL PA
SYMLNPEN 120INJ1000MCG 3 QL PA
TANZEUM INJ30MG 2 ST
TANZEUM INJ50MG 2 ST
TOLAZAMIDE TAB250MG 1
TOLAZAMIDE TAB500MG 1
TOLBUTAMIDE TAB500MG 1
TOUJEO SOLO INJ300IU/ML 2 QL PA
TRADJENTA TAB5MG 2
TRULICITY INJ0.75/0.5 3 ST
TRULICITY INJ1.5/0.5 3 ST
VICTOZA INJ18MG/3ML 3 QL ST
ANTIDOTES
CHEMET CAP100MG 3
JADENU TAB180MG 4 PA SP
JADENU TAB360MG 4 PA SP
JADENU TAB90MG 4 PA SP
FERRIPROX TAB500MG 4 PA SP
NALOXONE INJ0.4MG/ML 1
NARCAN SPRAY 2
NALTREXONE TAB50MG 2
ANTIEMETICS
ANZEMET TAB100MG 3 QL
ANZEMET TAB100MG 3 QL SP
ANZEMET TAB50MG 3 QL
CESAMET CAP1MG 3 QL
DRONABINOL CAP10MG 2 QL
DRONABINOL CAP2.5MG 2 QL
DRONABINOL CAP5MG 2 QL
EMEND CAP125MG 3 QL
EMEND CAP40MG 3 QL
EMEND CAP80MG 3 QL
EMEND PAK80 & 125 3 QL
GRANISETRON TAB1MG 2 QL
GRANISOL SOL2MG/10ML 2
MECLIZINE TAB12.5MG 2
MECLIZINE TAB25MG 2
ONDANSETRON INJ4MG/2ML 2
ONDANSETRON SOL4MG/5ML 2 QL
ONDANSETRON TAB24MG 2 QL
ONDANSETRON TAB4MG 1 QL
ONDANSETRON TAB4MG ODT 1 QL
ONDANSETRON TAB8MG 1 QL
ONDANSETRON TAB8MG ODT 1 QL
SANCUSO DIS3.1MG 3 QL PA
TRANSDERM-SCDIS1.5MG 3 QL
TRIMETHOBENZCAP300MG 1
ANTIFUNGALS
FLUCONAZOLE SUS10MG/ML 2
FLUCONAZOLE SUS40MG/ML 2
FLUCONAZOLE TAB100MG 2
FLUCONAZOLE TAB150MG 2 QL
FLUCONAZOLE TAB200MG 2
FLUCONAZOLE TAB50MG 2
FLUCYTOSINE CAP250MG 2
FLUCYTOSINE CAP500MG 2
GRISEOFULVINSUS125/5ML 2
GRISEOFULVINTABMICR 500 2
GRISEOFULVINTABULTR 125 2
GRISEOFULVINTABULTR 250 2
ITRACONAZOLECAP100MG 2 PA
KETOCONAZOLETAB200MG 2
LAMISIL GRA125MG 3
LAMISIL GRA187.5MG 3
NYSTATIN SUS100000 1
NYSTATIN TAB500000 1
SPORANOX CAP PULSEPAK 3 PA
DRUG NAME TIER LIMITS
SPORANOX SOL10MG/ML 3 PA
TERBINAFINE TAB250MG 2 QL
VORICONAZOLETAB200MG 2 QL PA
VORICONAZOLETAB50MG 2 QL PA
ANTIHISTAMINES
ARBINOXA SOL4MG/5ML 1
ARBINOXA TAB4MG 1
CARBINOXAMINSOL4MG/5ML 1
CARBINOXAMINTAB4MG 1
CLEMASTINE SYP0.5/5ML 2
CLEMASTINE TAB2.68MG 2
CYPROHEPTAD SYP2MG/5ML 2
CYPROHEPTAD TAB4MG 2
DESLORATADINTAB2.5 ODT 2
DESLORATADINTAB5MG 2
DESLORATADINTAB5MG ODT 2
DEXCHLORPHENSYP2MG/5ML 2
LEVOCETIRIZISOL2.5/5ML 2
LEVOCETIRIZITAB5MG 2 QL
PALGIC SOL4MG/5ML 1
PHENADOZ SUP12.5MG 1
PHENADOZ SUP25MG 1
PHENERGAN SUP12.5MG 1
PHENERGAN SUP25MG 1
PROMETHAZINESUP12.5MG 1
PROMETHAZINESUP25MG 1
PROMETHAZINESUP50MG 1
PROMETHAZINESYP6.25/5ML 2
PROMETHAZINETAB12.5MG 2
PROMETHAZINETAB25MG 2
PROMETHAZINETAB50MG 1
PROMETHAZINETAB50MG 2
PROMETHEGAN SUP12.5MG 1
PROMETHEGAN SUP25MG 1
PROMETHEGAN SUP50MG 1
ANTIHYPERLIPIDEMICS
ANTARA CAP30MG 3
ANTARA CAP90MG 3
ATORVASTATINTAB10MG 1 QL
ATORVASTATINTAB20MG 1 QL
ATORVASTATINTAB40MG 1 QL
ATORVASTATINTAB80MG 1 QL
CHOLESTYRAM POW4GM LITE 1
COLESTIPOL GRA5GM 2
COLESTIPOL TAB1GM 2
EZETIM/SIMVATAB10-10MG 2 QL
EZETIM/SIMVATAB10-20MG 2 QL
EZETIM/SIMVATAB10-40MG 2 QL
EZETIM/SIMVATAB10-80MG 2 QL
FENOFIBRATE CAP130MG 1 QL
FENOFIBRATE CAP134MG 1 QL
FENOFIBRATE CAP200MG 1 QL
FENOFIBRATE CAP43MG 1 QL
FENOFIBRATE CAP67MG 1 QL
FENOFIBRATE TAB145MG 1 QL
FENOFIBRATE TAB160MG 1 QL
FENOFIBRATE TAB48MG 1 QL
FENOFIBRATE TAB54MG 1 QL
FENOFIBRIC TAB105MG 3
FENOFIBRIC TAB35MG 3
FENOFIBRIC CAP135MG DR 2
FENOFIBRIC CAP45MG DR 2
FENOGLIDE TAB120MG 3
FENOGLIDE TAB40MG 3
FIBRICOR TAB105MG 3
FIBRICOR TAB35MG 3
FLUVASTATIN CAP20MG 1 QL
FLUVASTATIN CAP40MG 1 QL
FLUVASTATIN ER TAB 2 QL
GEMFIBROZIL TAB600MG 1
LIPOFEN CAP150MG 3
LIPOFEN CAP50MG 3
LOVASTATIN TAB10MG 1 QL
LOVASTATIN TAB20MG 1 QL
LOVASTATIN TAB40MG 1 QL
NIACIN ER TAB1000MG 2 QL
NIACIN ER TAB500MG 2
NIACIN ER TAB750MG 2
NIACOR TAB500MG 1
OMEGA-3 ACID CAP 1 GM 2
16
DRUG NAME TIER LIMITS
PRAVASTATIN TAB10MG 1 QL
PRAVASTATIN TAB20MG 1 QL
PRAVASTATIN TAB40MG 1 QL
PRAVASTATIN TAB80MG 1 QL
PREVALITE POW4GM 1
QUESTRAN POW4GM 1
ROSUVASTATINTAB10MG 1 QL
ROSUVASTATINTAB20MG 1 QL
ROSUVASTATINTAB40MG 1 QL
ROSUVASTATINTAB5MG 1 QL
SIMVASTATIN TAB10MG 1 QL
SIMVASTATIN TAB20MG 1 QL
SIMVASTATIN TAB40MG 1 QL
SIMVASTATIN TAB5MG 1 QL
SIMVASTATIN TAB80MG 1 QL
TRIGLIDE TAB160MG 3
VASCEPA CAP1GM 3
ZETIA TAB10MG 2 QL
ANTIHYPERTENSIVES
BENAZEP/HCTZTAB10-12.5 2
BENAZEP/HCTZTAB20-12.5 2
BENAZEP/HCTZTAB20-25MG 2
BENAZEP/HCTZTAB5-6.25 2
BENAZEPRIL TAB10MG 1
BENAZEPRIL TAB20MG 1
BENAZEPRIL TAB40MG 1
BENAZEPRIL TAB5MG 1
BENICAR TAB20MG 3 QL
BENICAR TAB40MG 3 QL
BENICAR TAB5MG 3 QL
CANDESARTAN 4 MG 1 QL
CANDESARTAN 8 MG 1 QL
CANDESARTAN TAB16MG 1 QL
CANDESARTAN TAB32MG 1 QL
CAPTOPRIL TAB100MG 1
CAPTOPRIL TAB12.5MG 1
CAPTOPRIL TAB25MG 1
CAPTOPRIL TAB50MG 1
CLONIDINE DIS0.1/24HR 2 QL
CLONIDINE DIS0.2/24HR 2 QL
CLONIDINE DIS0.3/24HR 2 QL
CLONIDINE TAB0.1MG 1
CLONIDINE TAB0.2MG 1
CLONIDINE TAB0.3MG 1
DIBENZYLINE CAP10MG 4 PA SP
DOXAZOSIN TAB1MG 1 QL
DOXAZOSIN TAB2MG 1 QL
DOXAZOSIN TAB4MG 1 QL
DOXAZOSIN TAB8MG 1 QL
EDARBI TAB40MG 3
EDARBI TAB80MG 3
ENALAPRIL TAB10MG 1
ENALAPRIL TAB2.5MG 1
ENALAPRIL TAB20MG 1
ENALAPRIL TAB5MG 1
EPLERENONE TAB25MG 2
EPLERENONE TAB50MG 2
EPROSART MESTAB600MG 1 QL
FOSINOPRIL TAB10MG 1
FOSINOPRIL TAB20MG 1
FOSINOPRIL TAB40MG 1
GUANFACINE TAB1MG 1
GUANFACINE TAB2MG 1
HYDRALAZINE TAB100MG 1
HYDRALAZINE TAB10MG 1
HYDRALAZINE TAB25MG 1
HYDRALAZINE TAB50MG 1
IRBESARTAN TAB150MG 1 QL
IRBESARTAN TAB300MG 1 QL
IRBESARTAN TAB75MG 1 QL
LISINOP/HCTZTAB10-12.5 1
LISINOP/HCTZTAB20-12.5 1
LISINOP/HCTZTAB20-25MG 1
LISINOPRIL TAB10MG 1
LISINOPRIL TAB2.5MG 1
LISINOPRIL TAB20MG 1
LISINOPRIL TAB30MG 1
LISINOPRIL TAB40MG 1
LISINOPRIL TAB5MG 1
DRUG NAME TIER LIMITS
LOSARTAN POTTAB100MG 1 QL
LOSARTAN POTTAB25MG 1 QL
LOSARTAN POTTAB50MG 1 QL
LOSARTAN/HCTTAB100-12.5 1
LOSARTAN/HCTTAB100-25 1
LOSARTAN/HCTTAB50-12.5 1
METHYLDOPA TAB250MG 1
METHYLDOPA TAB500MG 1
MINOXIDIL TAB10MG 1
MINOXIDIL TAB2.5MG 1
MOEXIPRIL TAB15MG 1
MOEXIPRIL TAB7.5MG 1
OLMESA MEDOXTAB20MG 2 QL
OLMESA MEDOXTAB40MG 2 QL
OLMESA MEDOXTAB5MG 2 QL
PERINDOPRIL TAB2MG 1
PERINDOPRIL TAB4MG 1
PERINDOPRIL TAB8MG 1
PRAZOSIN HCLCAP1MG 1
PRAZOSIN HCLCAP2MG 1
PRAZOSIN HCLCAP5MG 1
QUINAPRIL TAB10MG 1
QUINAPRIL TAB20MG 1
QUINAPRIL TAB40MG 1
QUINAPRIL TAB5MG 1
RAMIPRIL CAP1.25MG 1 QL
RAMIPRIL CAP10MG 1 QL
RAMIPRIL CAP2.5MG 1 QL
RAMIPRIL CAP5MG 1 QL
TEKTURNA TAB150MG 3 QL
TEKTURNA TAB300MG 3 QL
TELMISARTAN TAB20MG 2
TELMISARTAN TAB40MG 2
TELMISARTAN/HCTZ 40/12.5MG 2
TELMISARTAN/HCTZ 80/12.5MG 2
TELMISARTAN/HCTZ 80/25MG 2
TELMISARTAN TAB80MG 2
TERAZOSIN CAP10MG 1 QL
TERAZOSIN CAP1MG 1 QL
TERAZOSIN CAP2MG 1 QL
TERAZOSIN CAP5MG 1 QL
TEVETEN TAB400MG 3
TRANDOLAPRILTAB1MG 1 QL
TRANDOLAPRILTAB2MG 1 QL
TRANDOLAPRILTAB4MG 1 QL
VALSARTAN TAB160MG 1 QL
VALSARTAN TAB320MG 1 QL
VALSARTAN TAB40MG 1 QL
VALSARTAN TAB80MG 1 QL
VALSART/HCTZTAB160-12.5 1
VALSART/HCTZTAB160-25MG 1
VALSART/HCTZTAB320-12.5 1
VALSART/HCTZTAB320-25MG 1
VALSART/HCTZTAB80-12.5 1
ANTI-INFECTIVE AGENTS - MISC
ALINIA SUS100/5ML 3 QL
ALINIA TAB500MG 3
ATOVAQUONE SUS750/5ML 2
CAYSTON INH75MG 4 PA SP
CLINDAMYCIN CAP150MG 2
CLINDAMYCIN CAP300MG 2
CLINDAMYCIN CAP75MG 2
CLINDAMYCIN SOL75MG/5ML 1
DAPSONE TAB100MG 1
DAPSONE TAB25MG 1
KETEK TAB300MG 3
KETEK TAB400MG 3
LINEZOLID INJ2MG/ML 4 PA SP
LINEZOLID SUSP100/5ML 2
LINEZOLID TAB600MG 2
METRONIDAZOLCAP375MG 2
METRONIDAZOLTAB250MG 2
METRONIDAZOLTAB500MG 2
PRIMSOL SOL50MG/5ML 2
SIVEXTRO TAB200MG 4 PA SP
SMZ/TMP DS TAB800-160 1
SMZ-TMP SUS200-40/5 1
SMZ-TMP TAB400-80MG 1
SULFATRIM PDSUS200-40/5 1
SYANGIS INJ 4 PA SP
17
DRUG NAME TIER LIMITS
TRIMETHOPRIMTAB100MG 1
VANCOMYCIN CAP125MG 2 QL PA
VANCOMYCIN CAP250MG 2 QL PA
XIFAXAN TAB200MG 3 PA
XIFAXAN TAB550MG 3 QL PA
ANTIMALARIALS
ATOVAQ/PROGUTAB250-100 2
ATOVAQ/PROGUTAB62.5-25 2
CHLOROQUINE TAB250MG 1
CHLOROQUINE TAB500MG 1
COARTEM TAB20-120MG 2
DARAPRIM TAB25MG 4 PA SP
HYDROXYCHLORTAB200MG 1
MEFLOQUINE TAB250MG 2
PRIMAQUINE TAB26.3MG 3
QUININE SULFCAP324MG 2
ANTIMYASTHENIC AGENTS
GUANIDINE TAB125MG 2
MESTINON SYP60MG/5ML 3
MYTELASE TAB10MG 3
PYRIDOSTIGM TAB60MG 2
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE CAP250MG 2
ETHAMBUTOL TAB100MG 2
ETHAMBUTOL TAB400MG 2
ISONIAZID SYP50MG/5ML 2
ISONIAZID TAB100MG 2
ISONIAZID TAB300MG 2
PASER GRA4GM 2
PRIFTIN TAB150MG 3
PYRAZINAMIDETAB500MG 2
RIFABUTIN CAP150MG 2
RIFAMATE CAP 3
RIFAMPIN CAP150MG 2
RIFAMPIN CAP300MG 2
RIFATER TAB 3
RIMACTANE CAP300MG 2
SEROMYCIN CAP250MG 2
SIRTURO TAB100MG 4 PA SP
TRECATOR TAB250MG 3
ANTINEOPLASTICS
AFINITOR TAB10MG 4 QL PA SP
AFINITOR TAB2.5MG 4 QL PA SP
AFINITOR TAB5MG 4 QL PA SP
AFINITOR TAB7.5MG 4 QL PA SP
AFINITOR DISTAB2MG 4 QL PA SP
AFINITOR DISTAB3MG 4 QL PA SP
AFINITOR DISTAB5MG 4 QL PA SP
ANASTROZOLE TAB1MG 1 QL
BEXAROTENE CAP75MG 4 PA SP
BICALUTAMIDETAB50MG 1 QL
CABOMETYX TAB 20MG 4 PA SP
CABOMETYX TAB 40MG 4 PA SP
CABOMETYX TAB 60MG 4 PA SP
CAPECITABINETAB150MG 4 PA SP
CAPECITABINETAB500MG 4 PA SP
CAPRELSA TAB100MG 4 QL PA SP
CAPRELSA TAB300MG 4 QL PA SP
COMETRIQ KIT 4 PA SP
CYCLOPHOSPH TAB25MG 4 PA SP
CYCLOPHOSPH TAB50MG 4 PA SP
EMCYT CAP140MG 4 PA SP
ERIVEDGE CAP150MG 4 QL PA SP
EXEMESTANE TAB25MG 2 QL
FARESTON TAB60MG 3 QL
FLUTAMIDE CAP125MG 2
GILOTRIF TAB20MG 4 QL PA SP
GILOTRIF TAB30MG 4 QL PA SP
GILOTRIF TAB40MG 4 QL PA SP
GLEOSTINE CAP100MG 4 PA SP
GLEOSTINE CAP10MG 4 PA SP
GLEOSTINE CAP40MG 4 PA SP
HEXALEN 4 PA SP
HYDROXY CAPRINJ1.25/5ML 4 PA SP
HYDROXYUREA CAP500MG 2
ICLUSIG TAB15MG 4 QL PA SP
IMATINIB MESTAB100MG 4 QL PA SP
IMATINIB MESTAB400MG 4 QL PA SP
IMBRUVICA CAP140MG 4 QL PA SP
INTRON A INJ18MU 4 PA SP
DRUG NAME TIER LIMITS
INTRON A INJ50MU 4 PA SP
INTRON-A INJ10MU 4 PA SP
INTRON-A INJ18MU 4 PA SP
JAKAFI TAB10MG 4 QL PA SP
JAKAFI TAB15MG 4 QL PA SP
JAKAFI TAB20MG 4 QL PA SP
JAKAFI TAB25MG 4 QL PA SP
JAKAFI TAB5MG 4 QL PA SP
LENVIMA 8MG CAP 4 PA SP
LENVIMA 18MG CAP 4 PA SP
LETROZOLE TAB2.5MG 1 QL
LEUCOVOR CA TAB10MG 2
LEUCOVOR CA TAB15MG 2
LEUCOVOR CA TAB25MG 2
LEUCOVOR CA TAB5MG 2
LEUKERAN TAB2MG 2
LEUPROLIDE INJ1MG/0.2 4 PA SP
LONSURF TAB15-6.14 4 PA SP
LONSURF TAB20-8.19 4 PA SP
LYSODREN 4 PA SP
MATULANE 4 PA SP
MEGESTROL ACSUS40MG/ML 2
MEGESTROL ACSUS625MG/5ML 2
MEGESTROL ACTAB20MG 2
MEGESTROL ACTAB40MG 2
MEKINIST TAB0.5MG 4 QL PA SP
MEKINIST TAB2MG 4 QL PA SP
MERCAPTOPUR TAB50MG 1
METHOTREXATE SODIUM INJ PF 1000MG/40ML 1
METHOTREXATEINJ1GM 1
METHOTREXATETAB2.5MG 1
NEXAVAR TAB200MG 4 QL PA SP
NILANDRON TAB150MG 4 QL PA SP
POMALYST CAP1MG 4 QL PA SP
POMALYST CAP2MG 4 QL PA SP
POMALYST CAP3MG 4 QL PA SP
POMALYST CAP4MG 4 QL PA SP
PURIXAN SUS20MG/ML 4 PA SP
SPRYCEL TAB100MG 4 QL PA SP
SPRYCEL TAB140MG 4 QL PA SP
SPRYCEL TAB20MG 4 QL PA SP
SPRYCEL TAB50MG 4 QL PA SP
SPRYCEL TAB70MG 4 QL PA SP
SPRYCEL TAB80MG 4 QL PA SP
STIVARGA TAB40MG 4 QL PA SP
SUTENT CAP12.5MG 4 QL PA SP
SUTENT CAP25MG 4 QL PA SP
SUTENT CAP37.5MG 4 QL PA SP
SUTENT CAP50MG 4 QL PA SP
TABLOID TAB40MG 3
TAFINLAR CAP50MG 4 QL PA SP
TAFINLAR CAP75MG 4 QL PA SP
TARCEVA TAB100MG 4 QL PA SP
TARCEVA TAB150MG 4 QL PA SP
TARCEVA TAB25MG 4 QL PA SP
TASIGNA CAP150MG 4 QL PA SP
TASIGNA CAP200MG 4 QL PA SP
TEMOZOLOMIDECAP100MG 4 PA SP
TEMOZOLOMIDECAP140MG 4 PA SP
TEMOZOLOMIDECAP180MG 4 PA SP
TEMOZOLOMIDECAP20MG 4 PA SP
TEMOZOLOMIDECAP250MG 4 PA SP
TEMOZOLOMIDECAP5MG 4 PA SP
TRETINOIN CAP10MG 4 PA SP
TREXALL TAB10MG 2
TREXALL TAB15MG 2
TREXALL TAB5MG 2
TREXALL TAB7.5MG 2
TYKERB TAB250MG 4 QL PA SP
VANDETANIB TAB100MG 4 QL PA SP
VANDETANIB TAB300MG 4 QL PA SP
VOTRIENT TAB200MG 4 QL PA SP
XALKORI CAP200MG 4 QL PA SP
XALKORI CAP250MG 4 QL PA SP
ZOLINZA CAP100MG 4 QL PA SP
ZYDELIG TAB100MG 4 QL PA SP
ZYDELIG TAB150MG 4 QL PA SP
ZYKADIA CAP150MG 4 QL PA SP
ZYTIGA TAB250MG 4 QL PA SP
ANTIPARKINSON AGENTS
18
DRUG NAME TIER LIMITS
AMANTADINE CAP100MG 2
AMANTADINE SYP50MG/5ML 2
AMANTADINE TAB100MG 2
AZILECT TAB0.5MG 3
AZILECT TAB1MG 3
BENZTROPINE TAB0.5MG 1
BENZTROPINE TAB1MG 1
BENZTROPINE TAB2MG 1
BROMOCRIPTINCAP5MG 1
BROMOCRIPTINTAB2.5MG 1
CARB/LEVO TAB10-100MG 1
CARB/LEVO TAB25-100MG 1
CARB/LEVO TAB25-250MG 1
CARB/LEVO ERTAB25-100MG 1
CARB/LEVO ERTAB50-200MG 1
ENTACAPONE TAB200MG 2 QL
PRAMIPEXOLE TAB0.125MG 2 QL
PRAMIPEXOLE TAB0.25MG 2 QL
PRAMIPEXOLE TAB0.5MG 2 QL
PRAMIPEXOLE TAB0.75MG 2 QL
PRAMIPEXOLE TAB1.5MG 2 QL
PRAMIPEXOLE TAB1MG 2 QL
PRAMIPEXOLE TAB0.375MG ER 2
PRAMIPEXOLE TAB0.75 ER 2
PRAMIPEXOLE TAB1.5MG ER 2
PRAMIPEXOLE TAB2.25MG ER 2
PRAMIPEXOLE TAB3MG ER 2
PRAMIPEXOLE TAB4.5MG ER 2
ROPINIROLE TAB0.25MG 1
ROPINIROLE TAB0.5MG 1
ROPINIROLE TAB12MG ER 2
ROPINIROLE TAB1MG 1
ROPINIROLE TAB2MG 1
ROPINIROLE TAB2MG ER 2
ROPINIROLE TAB3MG 1
ROPINIROLE TAB4MG 1
ROPINIROLE TAB4MG ER 2
ROPINIROLE TAB5MG 1
ROPINIROLE TAB6MG ER 2
ROPINIROLE TAB8MG ER 2
SELEGILINE CAP5MG 2
SELEGILINE TAB5MG 2
TOLCAPONE TAB100MG 2
TRIHEXYPHEN ELX0.4MG/ML 1
TRIHEXYPHEN TAB2MG 1
TRIHEXYPHEN TAB5MG 1
ZELAPAR TAB1.25MG 3
ANTIPSYCHOTICS
ARIPIPRAZOLE SOL1MG/ML 3 QL
ARIPIPRAZOLE TAB10MG 3
ARIPIPRAZOLE TAB15MG 3
ARIPIPRAZOLE TAB30MG 3
CHLORPROMAZ TAB100MG 1
CHLORPROMAZ TAB10MG 1
CHLORPROMAZ TAB200MG 1
CHLORPROMAZ TAB25MG 1
CHLORPROMAZ TAB50MG 1
CLOZAPINE TAB100/ODT 2 QL
CLOZAPINE TAB100MG 2 QL
CLOZAPINE TAB200MG 2 QL
CLOZAPINE TAB25MG 2 QL
CLOZAPINE TAB25MG ODT 2 QL
CLOZAPINE TAB50MG 2 QL
COMPRO SUP25MG 2 QL
EQUETRO CAP100MG 3 QL
EQUETRO CAP200MG 3 QL
EQUETRO CAP300MG 3 QL
FANAPT PAK 3 QL
FANAPT TAB10MG 3 QL
FANAPT TAB12MG 3 QL
FANAPT TAB1MG 3 QL
FANAPT TAB2MG 3 QL
FANAPT TAB4MG 3 QL
FANAPT TAB6MG 3 QL
FANAPT TAB8MG 3 QL
FAZACLO TAB12.5/ODT 3 QL
FAZACLO TAB150MG 3 QL
FAZACLO TAB200MG 3 QL
FLUPHENAZINECON5MG/ML 1
FLUPHENAZINEELX2.5/5ML 1
DRUG NAME TIER LIMITS
FLUPHENAZINETAB10MG 1
FLUPHENAZINETAB1MG 1
FLUPHENAZINETAB2.5MG 1
FLUPHENAZINETAB5MG 1
HALOPERIDOL CON2MG/ML 2
HALOPERIDOL TAB0.5MG 2
HALOPERIDOL TAB10MG 2
HALOPERIDOL TAB1MG 2
HALOPERIDOL TAB20MG 2
HALOPERIDOL TAB2MG 2
HALOPERIDOL TAB5MG 2
LATUDA TAB120MG 3 QL
LATUDA TAB20MG 3 QL
LATUDA TAB40MG 3 QL
LATUDA TAB60MG 3 QL
LATUDA TAB80MG 3 QL
LITHIUM SOL8MEQ/5ML 2
LITHIUM CARBCAP150MG 1
LITHIUM CARBCAP300MG 1
LITHIUM CARBTAB300MG 1
LITHIUM CARBTAB300MG ER 1
LITHIUM CARBTAB450MG ER 1
LOXAPINE CAP10MG 2
LOXAPINE CAP25MG 2
LOXAPINE CAP50MG 2
LOXAPINE CAP5MG 2
OLANZAPINE TAB10MG 2 QL
OLANZAPINE TAB10MG ODT 2 QL
OLANZAPINE TAB15MG 2 QL
OLANZAPINE TAB15MG ODT 2 QL
OLANZAPINE TAB2.5MG 2 QL
OLANZAPINE TAB20MG 2 QL
OLANZAPINE TAB20MG ODT 2 QL
OLANZAPINE TAB5MG 2 QL
OLANZAPINE TAB5MG ODT 2 QL
OLANZAPINE TAB7.5MG 2 QL
PALIPERIDONE 1.5 MG ER 2 QL
PALIPERIDONE 3 MG ER 2 QL
PALIPERIDONE 6 MG ER 2 QL
PALIPERIDONE 9MG ER 2 QL
PERPHENAZINETAB16MG 1
PERPHENAZINETAB2MG 1
PERPHENAZINETAB4MG 1
PERPHENAZINETAB8MG 1
PROCHLORPER SUP25MG 2 QL
PROCHLORPER TAB10MG 2
PROCHLORPER TAB5MG 2
QUETIAPINE TAB100MG 2 QL
QUETIAPINE TAB200MG 2 QL
QUETIAPINE TAB25MG 2 QL
QUETIAPINE TAB300MG 2 QL
QUETIAPINE TAB400MG 2 QL
QUETIAPINE TAB50MG 2 QL
QUETIAPINE TAB400MG ER 2 QL
RISPERIDONE SOL1MG/ML 2 QL
RISPERIDONE TAB0.25 ODT 2 QL
RISPERIDONE TAB0.25MG 2 QL
RISPERIDONE TAB0.5MG 2 QL
RISPERIDONE TAB0.5MG OD 2 QL
RISPERIDONE TAB1MG 2 QL
RISPERIDONE TAB1MG ODT 2 QL
RISPERIDONE TAB2MG 2 QL
RISPERIDONE TAB2MG ODT 2 QL
RISPERIDONE TAB3MG 2 QL
RISPERIDONE TAB3MG ODT 2 QL
RISPERIDONE TAB4MG 2 QL
RISPERIDONE TAB4MG ODT 2 QL
SAPHRIS SUB10MG 3 QL
SAPHRIS SUB5MG 3 QL
SEROQUEL XR TAB150MG 3 QL
SEROQUEL XR TAB200MG 3 QL
SEROQUEL XR TAB300MG 3 QL
SEROQUEL XR TAB400MG 3 QL
SEROQUEL XR TAB50MG 3 QL
THIORIDAZINETAB100MG 1
THIORIDAZINETAB10MG 1
THIORIDAZINETAB25MG 1
THIORIDAZINETAB50MG 1
THIOTHIXENE CAP10MG 1
THIOTHIXENE CAP1MG 1
19
DRUG NAME TIER LIMITS
THIOTHIXENE CAP2MG 1
THIOTHIXENE CAP5MG 1
TRIFLUOPERAZTAB10MG 1
TRIFLUOPERAZTAB1MG 1
TRIFLUOPERAZTAB2MG 1
TRIFLUOPERAZTAB5MG 1
VRAYLAR 3
ZIPRASIDONE CAP20MG 2 QL
ZIPRASIDONE CAP40MG 2 QL
ZIPRASIDONE CAP40MG 2 QL
ZIPRASIDONE CAP60MG 2 QL
ZIPRASIDONE CAP80MG 2 QL
ANTISEPTICS & DISINFECTANTS
PHISOHEX LIQ3% 3
ANTIVIRALS
ABACA/LAMIVUTAB600-300 4 QL SP
ABACAV/LAMIVTAB/ZIDOVUD 4 QL SP
ABACAVIR TAB300MG 4 QL SP
ACYCLOVIR CAP200MG 2
ACYCLOVIR SUS200/5ML 2
ACYCLOVIR TAB400MG 2
ACYCLOVIR TAB800MG 2
APTIVUS CAP250MG 4 QL SP
APTIVUS SOL 4 QL SP
ATRIPLA TAB 4 SP
COMPLERA TAB 4 SP
CRIXIVAN CAP200MG 4 QL SP
CRIXIVAN CAP400MG 4 QL SP
DESCOVY TAB200/25 4 SP
DIDANOSINE CAP125MG 4 QL SP
DIDANOSINE CAP200MG 4 QL SP
DIDANOSINE CAP250MG 4 QL SP
DIDANOSINE CAP400MG 4 QL SP
EDURANT TAB25MG 4 QL SP
EMTRIVA CAP200MG 4 QL SP
EMTRIVA SOL10MG/ML 4 QL SP
ENTECAVIR TAB0.5MG 4 QL PA SP
ENTECAVIR TAB1MG 4 QL PA SP
EPCLUSA TAB 4 PA SP
EPZICOM TAB600-300 4 QL SP
EVOTAZ 4 SP
FAMCICLOVIR TAB125MG 2 QL
FAMCICLOVIR TAB250MG 2 QL
FAMCICLOVIR TAB500MG 2 QL
GENVOYA TAB 4 SP
INTELENCE TAB100MG 4 QL SP
INTELENCE TAB200MG 4 QL SP
INTELENCE TAB25MG 4 QL SP
INVIRASE CAP200MG 4 QL SP
INVIRASE TAB500MG 4 QL SP
ISENTRESS CHW100MG 4 QL SP
ISENTRESS CHW25MG 4 QL SP
ISENTRESS POW100MG 4 QL SP
ISENTRESS TAB400MG 4 QL SP
LAMIVUD/ZIDOTAB150-300 4 QL SP
LAMIVUDINE TAB100MG 4 QL SP
LAMIVUDINE TAB150MG 4 QL SP
LAMIVUDINE TAB300MG 4 QL SP
LEXIVA SUS50MG/ML 4 QL SP
LEXIVA TAB700MG 4 QL SP
NEVIRAPINE SUS50MG/5ML 4 QL SP
NEVIRAPINE TAB200MG 4 QL SP
NEVIRAPINE TAB400MG ER 4 QL SP
NORVIR CAP100MG 4 QL SP
NORVIR SOL80MG/ML 4 QL SP
NORVIR TAB100MG 4 QL SP
ODEFSEY TAB 4 SP
PEGASYS INJ 4 QL PA SP
PEGASYS PROCLICK 4 QL PA SP
PEG-INTRON KIT 4 PA SP
PREZCOBIX 4 SP
PREZISTA SUS100MG/ML 4 QL SP
PREZISTA TAB150MG 4 QL SP
PREZISTA TAB400MG 4 QL SP
PREZISTA TAB600MG 4 QL SP
PREZISTA TAB75MG 4 QL SP
RELENZA MISDISKHALE 3 QL
RESCRIPTOR TAB100 MG 4 QL SP
RESCRIPTOR TAB200MG 4 QL SP
REYATAZ CAP150MG 4 QL SP
DRUG NAME TIER LIMITS
REYATAZ CAP200MG 4 QL SP
REYATAZ CAP300MG 4 QL SP
RIBAPAK PAK1000/DAY 4 PA SP
RIBAPAK PAK1200/DAY 4 PA SP
RIBAPAK PAK800/DAY 4 PA SP
RIBASPHERE CAP200MG 4 PA SP
RIBASPHERE TAB200MG 4 PA SP
RIBASPHERE TAB400MG 4 PA SP
RIBASPHERE TAB600MG 4 PA SP
RIBATAB PAK1000/DAY 4 PA SP
RIBATAB TAB400MG 4 PA SP
RIBATAB TAB600MG 4 PA SP
RIBATAB TAB800/DAY 4 PA SP
RIBAVIRIN CAP200MG 4 PA SP
RIBAVIRIN TAB200MG 4 PA SP
RIBAVIRIN TAB400MG 4 PA SP
RIBAVIRIN TAB600MG 4 PA SP
SELZENTRY TAB150MG 4 PA SP
SELZENTRY TAB300MG 4 PA SP
STAVUDINE CAP15MG 4 QL SP
STAVUDINE CAP20MG 4 QL SP
STAVUDINE CAP30MG 4 QL SP
STAVUDINE CAP40MG 4 QL SP
STAVUDINE SOL1MG/ML 4 QL SP
STRIBILD TAB 4 QL SP
SUSTIVA CAP200MG 4 QL SP
SUSTIVA CAP50MG 4 QL SP
SUSTIVA TAB600MG 4 QL SP
TAMIFLU CAP30MG 2 QL
TAMIFLU CAP45MG 2 QL
TAMIFLU CAP75MG 2 QL
TAMIFLU SUS6MG/ML 2 QL
TIVICAY TAB50MG 4 QL SP
TRIUMEQ TAB 4 QL SP
TRUVADA TAB200-300 4 QL PA SP
VALACYCLOVIRTAB1GM 2 QL
VALACYCLOVIRTAB500MG 2 QL
VALGANCICLOVIRTAB450MG 4 PA SP
VIDEX SOL2GM 4 QL SP
VIREAD POW40MG/GM 4 QL SP
VIREAD TAB150MG 4 QL SP
VIREAD TAB200MG 4 QL SP
VIREAD TAB250MG 4 QL SP
VIREAD TAB300MG 4 QL SP
ZEPATIER TABLET 4 PA SP
ZIDOVUDINE CAP100MG 4 QL SP
ZIDOVUDINE SYP50MG/5ML 4 QL SP
ZIDOVUDINE TAB300MG 4 QL SP
ASSORTED CLASSES
ASTAGRAF XL CAP0.5MG 4 SP
ASTAGRAF XL CAP1MG 4 SP
ASTAGRAF XL CAP5MG 4 SP
AZASAN TAB100MG 3
AZASAN TAB75 MG 3
AZATHIOPRINETAB50MG 1
CYCLOSPORINECAP100MG 2
CYCLOSPORINECAP100MG MD 1
CYCLOSPORINECAP25MG 1
CYCLOSPORINECAP25MG MOD 1
CYCLOSPORINECAP50MG MOD 1
CYCLOSPORINESOLMODIFIED 2
DICLEGIS TAB 3
GENGRAF CAP100MG 1
GENGRAF CAP25MG 1
GENGRAF SOL100MG/ML 2
IVERMECTIN TAB3MG 1
KIONEX POW 1
MYCOPHENOLATCAP250MG 2
MYCOPHENOLATTAB500MG 2
MYCOPHENOLICTAB180MG DR 2
MYCOPHENOLICTAB360MG DR 2
NEORAL CAP100MG 4 PA SP
NEORAL CAP25MG 4 PA SP
NEORAL SOL100MG/ML 4 PA SP
PHYSIOLYTE SOL 3
PHYSIOSOL SOLIRRIGAT 3
REVLIMID CAP10MG 4 QL PA SP
REVLIMID CAP15MG 4 QL PA SP
REVLIMID CAP2.5MG 4 QL PA SP
REVLIMID CAP20MG 4 QL PA SP
20
DRUG NAME TIER LIMITS
REVLIMID CAP25MG 4 QL PA SP
REVLIMID CAP5MG 4 QL PA SP
SIROLIMUS TAB0.5MG 4 PA SP
SOD POLY SULSUS15GM/60 1
SOD CHLORIDEINJ3% 1
SOD CHLORIDEINJ5% 1
SYPRINE CAP250MG 4 SP
TACROLIMUS CAP0.5MG 2
TACROLIMUS CAP1MG 2
TACROLIMUS CAP5MG 2
THALOMID CAP100MG 4 QL PA SP
THALOMID CAP150MG 4 QL PA SP
THALOMID CAP200MG 4 QL PA SP
THALOMID CAP50MG 4 QL PA SP
ZORTRESS TAB0.25MG 4 QL SP
ZORTRESS TAB0.5MG 4 QL SP
ZORTRESS TAB0.75MG 4 QL SP
BETA BLOCKERS
ACEBUTOLOL CAP200MG 2
ACEBUTOLOL CAP400MG 2
ATENOLOL TAB100MG 1
ATENOLOL TAB25MG 1
ATENOLOL TAB50MG 1
BETAXOLOL TAB10MG 1
BETAXOLOL TAB20MG 1
BISOPROL FUMTAB10MG 1
BISOPROL FUMTAB5MG 1
BYSTOLIC TAB10MG 3
BYSTOLIC TAB2.5MG 3
BYSTOLIC TAB20MG 3
BYSTOLIC TAB5MG 3
CARVEDILOL TAB12.5MG 1 QL
CARVEDILOL TAB25MG 1 QL
CARVEDILOL TAB3.125MG 1 QL
CARVEDILOL TAB6.25MG 1 QL
COREG CR CAP10MG 3 QL
COREG CR CAP20MG 3 QL
COREG CR CAP40MG 3 QL
COREG CR CAP80MG 3 QL
ESTRADIOL TAB0.5MG 1
LABETALOL TAB100MG 1
LABETALOL TAB200MG 1
LABETALOL TAB300MG 1
LEVATOL TAB20MG 3
METOPROL TARTAB100MG 1
METOPROL TARTAB25MG 1
METOPROL TARTAB50MG 1
METOPROL TARTAB37.5MG 1
METOPROL TARTAB75MG 1
METOPROLOL TAB100MG ER 1 QL
METOPROLOL TAB200MG ER 1 QL
METOPROLOL TAB25MG ER 1 QL
METOPROLOL TAB50MG ER 1 QL
NADOLOL TAB20MG 1
NADOLOL TAB40MG 1
NADOLOL TAB80MG 1
PINDOLOL TAB10MG 1
PINDOLOL TAB5MG 1
PRAVASTATIN TAB40MG 1 QL
PROPRANOLOL CAP120MG ER 1
PROPRANOLOL CAP160MG ER 1
PROPRANOLOL CAP60MG ER 1
PROPRANOLOL CAP80MG ER 1
PROPRANOLOL SOL20MG/5ML 1
PROPRANOLOL SOL40MG/5ML 1
PROPRANOLOL TAB10MG 1
PROPRANOLOL TAB20MG 1
PROPRANOLOL TAB40MG 1
PROPRANOLOL TAB60MG 1
PROPRANOLOL TAB80MG 1
SORINE TAB120MG 1
SORINE TAB160MG 1
SORINE TAB240MG 1
SORINE TAB80MG 1
SOTALOL AF TAB120MG 1
SOTALOL HCL TAB160MG 1
SOTALOL HCL TAB240MG 1
SOTALOL HCL TAB80MG 1
TIMOLOL MAL TAB10MG 1
TIMOLOL MAL TAB20MG 1
DRUG NAME TIER LIMITS
TIMOLOL MAL TAB5MG 1
CALCIUM CHANNEL BLOCKERS
AFEDITAB TAB30MG CR 2
AFEDITAB TAB60MG CR 2
AMLODIPINE TAB10MG 1 QL
AMLODIPINE TAB2.5MG 1 QL
AMLODIPINE TAB5MG 1 QL
CARTIA XT CAP120/24HR 1
CARTIA XT CAP180/24HR 1
CARTIA XT CAP240/24HR 1
CARTIA XT CAP300/24HR 1
COVERA-HS TAB180MG 3
COVERA-HS TAB240MG 3
DILT-CD CAP300MG 1
DILTIA XT CAP120MG/24 1
DILTIA XT CAP180MG/24 1
DILTIA XT CAP240MG/24 1
DILTIAZEM CAP120MG CD 1
DILTIAZEM CAP120MG ER 1
DILTIAZEM CAP180MG/24 1
DILTIAZEM CAP240MG CD 1
DILTIAZEM CAP300MG ER 1
DILTIAZEM CAP360MG/24 1
DILTIAZEM CAP420MG/24 1
DILTIAZEM CAP60MG ER 1
DILTIAZEM CAP90MG ER 1
DILTIAZEM TAB120MG 1
DILTIAZEM TAB30MG 1
DILTIAZEM TAB60MG 1
DILTIAZEM TAB90MG 1
DILT-XR CAP120MG 1
DILT-XR CAP180MG 1
DILT-XR CAP240MG 1
DYNACIRC CR TAB5MG 2
FELODIPINE TAB10MG ER 2
FELODIPINE TAB2.5MG ER 2
FELODIPINE TAB5MG ER 2
ISRADIPINE CAP2.5MG 1
ISRADIPINE CAP5MG 1
MATZIM LA TAB180MG/24 1
MATZIM LA TAB240MG/24 1
MATZIM LA TAB300MG/24 1
MATZIM LA TAB360MG/24 1
MATZIM LA TAB420MG/24 1
NICARDIPINE CAP20MG 2
NICARDIPINE CAP30MG 2
NIFEDIAC CC TAB90MG ER 1
NIFEDICAL XLTAB30MG 1
NIFEDICAL XLTAB60MG 1
NIFEDIPINE CAP10MG 2
NIFEDIPINE CAP20MG 2
NIFEDIPINE TAB30MG ER 1
NIFEDIPINE TAB60MG ER 1
NIFEDIPINE TAB90MG ER 1
NIMODIPINE CAP30MG 2
NISOLDIPINE TAB17MG ER 3
NISOLDIPINE TAB20MG 3
NISOLDIPINE TAB25.5MG 3
NISOLDIPINE TAB30MG 3
NISOLDIPINE TAB34MG ER 3
NISOLDIPINE TAB40MG 3
NISOLDIPINE TAB8.5MG ER 3
TAZTIA XT CAP120MG/24 1
TAZTIA XT CAP180MG/24 1
TAZTIA XT CAP240MG/24 1
TAZTIA XT CAP300MG/24 1
TAZTIA XT CAP360MG/24 1
VERAPAMIL CAP100MG ER 1
VERAPAMIL CAP120MG ER 1
VERAPAMIL CAP180MG ER 1
VERAPAMIL CAP200MG ER 1
VERAPAMIL CAP240MG ER 1
VERAPAMIL CAP300MG ER 1
VERAPAMIL CAP360MG SR 1
VERAPAMIL TAB120MG 1
VERAPAMIL TAB180MG ER 1
VERAPAMIL TAB240MG ER 1
VERAPAMIL TAB40MG 1
VERAPAMIL TAB80MG 1
VERAPAMIL HCL ER 1
21
DRUG NAME TIER LIMITS
CARDIOTONICS
DIGOX TAB0.125MG 1
DIGOX TAB0.25MG 1
DIGOXIN SOL50MCG/ML 3
DIGOXIN TAB0.125MG 1
DIGOXIN TAB0.25MG 1
LANOXIN TAB0.0625MG 3
LANOXIN TAB 0.25MG 1
LANOXIN TAB0.1875MG 3
CARDIOVASCULAR AGENTS - MISC
ADCIRCA TAB20MG 4 QL PA SP
ADEMPAS TAB0.5MG 4 QL PA SP
ADEMPAS TAB1.5MG 4 QL PA SP
ADEMPAS TAB1MG 4 QL PA SP
ADEMPAS TAB2.5MG 4 QL PA SP
ADEMPAS TAB2MG 4 QL PA SP
CIALIS TAB2.5MG 3
CIALIS TAB5MG 3
LETAIRIS TAB10MG 4 QL PA SP
LETAIRIS TAB5MG 4 QL PA SP
OPSUMIT TAB10MG 4 QL PA SP
ORENITRAM TAB0.125MG 4 PA SP
ORENITRAM TAB0.25MG 4 PA SP
ORENITRAM TAB1MG 4 PA SP
ORENITRAM TAB2.5MG 4 PA SP
SILDENAFIL TAB20MG 4 QL PA
TRACLEER TAB125MG 4 QL PA SP
TRACLEER TAB62.5MG 4 QL PA SP
VENTAVIS SOL10MCG/ML 4 PA SP
CEPHALOSPORINS
CEDAX CAP400MG 3
CEFACLOR CAP250MG 2
CEFACLOR CAP500MG 2
CEFACLOR SUS125/5ML 2
CEFACLOR SUS250/5ML 2
CEFACLOR SUS375/5ML 2
CEFACLOR ER TAB500MG 2
CEFADROXIL CAP500MG 2
CEFADROXIL SUS250/5ML 2
CEFADROXIL SUS500/5ML 2
CEFADROXIL TAB1GM 2
CEFDINIR CAP300MG 1
CEFDINIR SUS125/5ML 1
CEFDINIR SUS250/5ML 1
CEFDITOREN TAB200MG 2
CEFIXIME SUS100/5ML 2
CEFIXIME SUS200/5ML 2
CEFPODO PROXSUS100/5ML 2
CEFPODO PROXSUS50MG/5ML 2
CEFPODOXIME TAB100MG 2
CEFPODOXIME TAB200MG 2
CEFPROZIL SUS125/5ML 2
CEFPROZIL SUS250/5ML 2
CEFPROZIL TAB250MG 2
CEFPROZIL TAB500MG 2
CEFTIN SUS125/5ML 3
CEFTIN SUS250/5ML 3
CEFUROXIME SUS125/5ML 2
CEFUROXIME TAB250MG 1
CEFUROXIME TAB500MG 1
CEPHALEXIN CAP250MG 1
CEPHALEXIN CAP500MG 1
CEPHALEXIN SUS125/5ML 1
CEPHALEXIN SUS250/5ML 1
CEPHALEXIN TAB250MG 1
CEPHALEXIN TAB500MG 1
CHLORZOXAZONTAB500MG 2
SUPRAX TAB400MG 3
CONTRACEPTIVES
ELLA TAB30MG 3
MIBELAS 24 CHWFE 1
NORETH/ETHINCHWFE 1/20 1
TAYTULLA 3
CORTICOSTEROIDS
BAYCADRON ELX0.5/5ML 1
BUDESONIDE CAP3MG/24HR 2
CORTISONE ACTAB25MG 1
DEXAMETHASONCON1MG/ML 1
DEXAMETHASONELX0.5/5ML 1
DRUG NAME TIER LIMITS
DEXAMETHASONTAB0.5MG 1
DEXAMETHASONTAB0.75MG 1
DEXAMETHASONTAB1.5MG 1
DEXAMETHASONTAB1MG 1
DEXAMETHASONTAB2MG 1
DEXAMETHASONTAB4MG 1
DEXAMETHASONTAB6MG 1
DEXPAK PAK13 DAY 3
DEXPAK PAK6 DAY 3
FLUDROCORT TAB0.1MG 2
HYDROCORT TAB10MG 1
HYDROCORT TAB20MG 1
HYDROCORT TAB5MG 1
METHYLPRED PAK4MG 1
METHYLPRED TAB16MG 1
METHYLPRED TAB32MG 1
METHYLPRED TAB4MG 1
METHYLPRED TAB8MG 1
MILLIPRED SOL10MG/5ML 2
MILLIPRED TAB5MG 2
MILLIPRED DPPAK5MG 2
ORAPRED ODT TAB10MG 3
ORAPRED ODT TAB15MG 3
ORAPRED ODT TAB30MG 3
PRED SOD PHOSOL5MG/5ML 2
PREDNISOLONESOL15MG/5ML 2
PREDNISOLONESOL25MG/5ML 2
PREDNISOLONE ODT TAB10MG 2
PREDNISOLONE ODT TAB15MG 2
PREDNISOLONE ODT TAB30MG 2
PREDNISONE CON5MG/ML 1
PREDNISONE PAK10MG 1
PREDNISONE PAK5MG 1
PREDNISONE SOL5MG/5ML 1
PREDNISONE TAB10MG 1
PREDNISONE TAB1MG 1
PREDNISONE TAB2.5MG 1
PREDNISONE TAB20MG 1
PREDNISONE TAB50MG 1
PREDNISONE TAB5MG 1
RAYOS TAB1MG 3
RAYOS TAB2MG 3
RAYOS TAB5MG 3
VERIPRED 20 SOL20MG/5ML 2
COUGH/COLD/ALLERGY
ACETYLCYST SOL10% 2
ACETYLCYST SOL20% 2
DERMATOLOGICALS
8-MOP CAP10MG 4 PA SP
ACANYA GEL1.2-2.5% 3
ACITRETIN CAP10MG 2
ACITRETIN CAP17.5MG 2
ACITRETIN CAP25MG 2
ACTICIN CRE5% 1
ACYCLOVIR OIN5% 2 QL
ADAPALENE CRE0.1% 2
ADAPALENE GEL0.1% 2
ADAPALENE GEL0.3% 2
AKNE-MYCIN OIN2% 3
ALCLOMETASONCRE0.05% 2
ALCLOMETASONOIN0.05% 2
ALTABAX OIN1% 3
AMCINONIDE CRE0.1% 2
AMCINONIDE LOT0.1% 2
AMCINONIDE OIN0.1% 2
AMNESTEEM CAP10MG 2
AMNESTEEM CAP20MG 2
AMNESTEEM CAP40MG 2
APEXICON OIN0.05% 2
APEXICON E CRE0.05% 2
AUG BETAMET CRE0.05% 2
AUG BETAMET GEL0.05% 2
AUG BETAMET LOT0.05% 2
AUG BETAMET OIN0.05% 2
AZELEX CRE20% 3
BETAMETH DIPCRE0.05% 2
BETAMETH DIPLOT0.05% 2
BETAMETH DIPOIN0.05% 2
BETAMETH VALAER 0.12% 2
BETAMETH VALCRE0.1% 2
22
DRUG NAME TIER LIMITS
BETAMETH VALLOT0.1% 2
BETAMETH VALOIN0.1% 2
BP CLEANSINGEMU10-4% 1
CALCIPOTRIENCRE0.005% 2 QL
CALCIPOTRIENOINBETAMETH 2
CALCIPOTRIENSOL0.005% 2 QL
CALCITRIOL OIN3MCG/GM 2
CAPEX SHA0.01% 3
CICLODAN CRE0.77% 2
CICLODAN SOL8% 2
CICLOPIROX CRE0.77% 2
CICLOPIROX GEL0.77% 2
CICLOPIROX SHA1% 2
CICLOPIROX SOL8% 2
CICLOPIROX SUS0.77% 2
CLARAVIS CAP10MG 2
CLARAVIS CAP20MG 2
CLARAVIS CAP30MG 2
CLARAVIS CAP40MG 2
CLINDACIN KITPAC 1% 2
CLINDAGEL 3
CLINDAMAX GEL1% 2
CLINDAMAX LOT10MG/ML 2
CLINDAMY/BENGEL1-5% 2
CLINDAMYCIN AER1% 2
CLINDAMYCIN GEL1% 2
CLINDAMYCIN LOT1% 2
CLINDAMYCIN PAD1% 1
CLINDAMYCIN SOL1% 1
CLINDETS PAD1% 1
CLOBETASOL AER0.05% 2
CLOBETASOL GEL0.05% 2
CLOBETASOL LOT0.05% 2
CLOBETASOL OIN0.05% 2
CLOBETASOL SHA0.05% 2
CLOBETASOL SOL0.05% 2
CLOBETASOL ECRE0.05% 2
CLOCORTOLONECREPIV 0.1% 3
CLODAN SHA0.05% 2
CLODERM CRE0.1% PMP 3
CLOTRIM/BETACREDIPROP 2
CLOTRIM/BETALOTDIPROP 2
CONDYLOX GEL0.5% 3
CORDRAN LOT0.05% 3
CORDRAN 80X3TAP4MCG/CM 3 QL
CORMAX OIN0.05% 2
CORTISPORIN CRE0.5% 3
CORTISPORIN OIN1% 3
COSENTYX INJ150MG/ML 4 PA SP
DESONATE GEL0.05% 3
DESONIDE CRE0.05% 2
DESONIDE LOT0.05% 2
DESONIDE OIN0.05% 2
DESOXIMETAS CRE0.25% 2
DESOXIMETAS GEL0.05% 2
DESOXIMETAS OIN0.25% 2
DICLOFENAC SOL1.5% 1
DICLOFENAC GEL 3% 2
DIFLORASONE CRE0.05% 2
DIFLORASONE OIN0.05% 2
DOVONEX CRE0.005% 3 QL
ECONAZOLE CRE1% 2
ELIDEL CRE1% 3 QL
EPIDUO GEL0.1-2.5% 3
ERTACZO CRE2% 3 ST
ERY PAD2% 1
ERYTHROMYCINGEL/BENZOYL 2
ERYTHROMYCINGEL2% 2
ERYTHROMYCINPAD2% 1
ERYTHROMYCINSOL2% 1
EURAX CRE10% 2
EURAX LOT10% 2
EXELDERM CRE1% 3 ST
EXELDERM SOL1% 3 ST
FABIOR AER0.1% 3
FINACEA GEL15% 3
FLUOCIN ACETCRE0.01% 2
FLUOCIN ACETCRE0.025% 2
FLUOCIN ACETOILBODY 2
FLUOCIN ACETOIN0.025% 2
DRUG NAME TIER LIMITS
FLUOCIN ACETSOL0.01% 2
FLUOCINONIDECRE0.1% 2
FLUOCINONIDECRE-E 0.05% 2
FLUOCINONIDEGEL0.05% 2
FLUOCINONIDEOIN0.05% 2
FLUOCINONIDESOL0.05% 2
FLUOROPLEX CRE1% 2
FLUOROURACILCRE5% 2
FLUOROURACILSOL2% 2
FLUOROURACILSOL5% 2
FLUTICASONE CRE0.05% 2
FLUTICASONE LOT0.05% 2
FLUTICASONE OIN0.005% 2
GENTAMICIN CRE0.1% 1
GENTAMICIN OIN0.1% 1
GLYDO GEL2% 2
HALOBETASOL CRE0.05% 2
HALOBETASOL OIN0.05% 2 ST
HALOG CRE0.1% 3
HALOG OIN0.1% 3
HC BUTYRATE CRE0.1% 2
HC BUTYRATE OIN0.1% 2
HC BUTYRATE SOL0.1% 2
HC VALERATE CRE0.2% 2
HC VALERATE OIN0.2% 2
HYDROCORT CRE2.5% 1
HYDROCORT LOT2.5% 2
HYDROCORT OIN2.5% 1
IMIQUIMOD CRE5% 1
JUBLIA SOL10% 3 ST
KENALOG AERSPRAY 3
KERYDIN SOL5% 3 ST
KETOCONAZOLEAER2% 2
KETOCONAZOLECRE2% 2
KETOCONAZOLESHA2% 2
KETODAN KIT2% 2
KURIC CRE2% 2
LIDOCAINE GEL2% JELLY 2
LIDOCAINE OIN5% 2
LIDOCAINE PAD5% 2 QL
LIDOCAINE SOL4% 2
LIDO/PRILOCNCRE2.5-2.5% 1
LINDANE LOT1% 2
LINDANE SHA1% 2
LOCOID LOT0.1% 3
LOKARA LOT0.05% 2
MENTAX CRE1% 3 ST
METRONIDAZOLCRE0.75% 2
METRONIDAZOLGEL0.75% 2
METRONIDAZOLGEL1% 2
METRONIDAZOLLOT0.75% 2
MOMETASONE CRE0.1% 2
MOMETASONE OIN0.1% 2
MOMETASONE SOL0.1% 2
MUPIROCIN OIN2% 2
MYORISAN 2
MYORISAN CAP10MG 2
MYORISAN CAP20MG 2
MYORISAN CAP40MG 2
NAFTIFINE 1%CRE 3 ST
NAFTIFINE 2%CRE 3
NORITATE CRE1% 3
NYAMYC POW100000 1
NYSTAT/TRIAMCRE 2
NYSTAT/TRIAMOIN 1
NYSTATIN CRE100000 1
NYSTATIN OIN100000 1
NYSTATIN POW100000 1
NYSTOP POW100000 1
ORACEA CAP40MG 3
METHOXSALEN CAP10MG 2
PANDEL CRE0.1% 2
PEDI-DRI POW100000 1
PENNSAID SOL2% 3
PERMETHRIN CRE5% 1
PICATO GEL0.015% 2
PICATO GEL0.05% 2
PODOFILOX SOL0.5% 2
PREDNICARBATCRE0.1% 2
PREDNICARBATOIN0.1% 2
23
DRUG NAME TIER LIMITS
PRUDOXIN CRE5% 3
REFISSA CRE0.05% 2
REGRANEX GEL0.01% 2
RETIN-A MICRGEL0.08% 3
ROSADAN CRE0.75% 2
ROSADAN GEL0.75% 2
SANTYL OIN250/GM 3 QL
SCALACORT 2% 1
SELENIUM SULLOT2.5% 2
SELENIUM SULSHA2.25% 1
SILVER SULFACRE1% 1
SKLICE LOT0.5% 3
SOTRET CAP10MG 2
SOTRET CAP20MG 2
SOTRET CAP40MG 2
SSD CRE1% 1
STELARA INJ45MG/0.5 4 PA SP
STELARA INJ90MG/ML 4 PA SP
SULFACETAMIDSUS10% 2
SULFAMYLON CRE85MG/GM 3
SYNERA DIS70-70MG 3
TACLONEX OIN 3
TACLONEX SUS 3
TACROLIMUS OIN0.03% 2
TACROLIMUS OIN0.1% 2
TAZORAC CRE0.05% 3
TAZORAC CRE0.1% 3
TAZORAC GEL0.05% 3
TAZORAC GEL0.1% 3
TOPICORT OIN0.05% 3
TOPICORT SPR0.25% 3
TRETINOIN 2 QL
TRETINOIN CRE0.025% 2 QL
TRETINOIN CRE0.05% 2 QL
TRETINOIN CRE0.1% 2 QL
TRETINOIN GEL0.01% 2 QL
TRETINOIN GEL0.025% 2 QL
TRETINOIN GEL0.1% 2 QL
TRETIN-X CRE0.0375% 2 QL
TRETIN-X CRE0.075% 2 QL
TRETIN-X CREKIT0.025% 2
TRETIN-X CREKIT0.05% 2
TRETIN-X CREKIT0.1% 2
TRIAMCINOLONCRE0.025% 2
TRIAMCINOLONCRE0.1% 2
TRIAMCINOLONCRE0.5% 2
TRIAMCINOLONLOT0.025% 2
TRIAMCINOLONLOT0.1% 2
TRIAMCINOLONOIN0.025% 2
TRIAMCINOLONOIN0.1% 2
TRIAMCINOLONOIN0.5% 2
TRIDERM CRE0.1% 2
U-CORT CRE1% 1
ULESFIA LOT5% 3
VECTICAL OIN3MCG/GM 2
VELTIN GEL 3
VERDESO AER0.05% 3
VEREGEN OIN15% 3
XOLEGEL GEL2% 3 ST
ZENATANE 2
ZENATANE CAP10MG 2
ZENATANE CAP20MG 2
ZENATANE CAP40MG 2
ZIANA GEL 3
ZONALON CRE5% 3
ZYCLARA CRE3.75% 3
ZYCLARA PUMPCRE2.5% 3
DIAGNOSTIC PRODUCTS
FREESTYLE LANCETS 2 QL
FREESTYLE TEST STRIPS 2 QL
PRECISION TEST STRIPS 2 QL
GLUCAGEN INJHYPOKIT 2 QL
DIGESTIVE AIDS
CREON CAP12000UNT 2 PA
CREON CAP24000UNT 2 PA
CREON CAP3000UNIT 2 PA
CREON CAP36000UNT 2 PA
CREON CAP6000UNIT 2 PA
PANCREAZE CAP10500UNT 3 PA
PANCREAZE CAP16800UNT 3 PA
DRUG NAME TIER LIMITS
PANCREAZE CAP21000UNT 3 PA
PANCREAZE CAP4200UNIT 3 PA
PERTZYE CAP 3 PA
ZENPEP CAP10000UNT 3 PA
ZENPEP CAP15000UNT 3 PA
ZENPEP CAP20000UNT 3 PA
ZENPEP CAP25000UNT 3 PA
ZENPEP CAP3000UNIT 3 PA
ZENPEP CAP40000UNT 3 PA
ZENPEP CAP5000UNIT 3 PA
DIURETICS
ACETAZOLAMIDCAP500MG ER 2
ACETAZOLAMIDTAB125MG 2
ACETAZOLAMIDTAB250MG 2
AMILORIDE TAB5MG 1
BUMETANIDE INJ0.25/ML 1
BUMETANIDE TAB0.5MG 1
BUMETANIDE TAB1MG 1
BUMETANIDE TAB2MG 1
CHLOROTHIAZ TAB250MG 1
CHLOROTHIAZ TAB500MG 1
CHLORTHALID TAB100MG 1
CHLORTHALID TAB25MG 1
CHLORTHALID TAB50MG 1
DIURIL SUS250/5ML 3
DYRENIUM CAP100MG 3
DYRENIUM CAP50MG 3
EDECRIN TAB25MG 3
FUROSEMIDE SOL10MG/ML 1
FUROSEMIDE SOL8MG/ML 1
FUROSEMIDE TAB20MG 1
FUROSEMIDE TAB40MG 1
FUROSEMIDE TAB80MG 1
HYDROCHLOROTCAP12.5MG 1
HYDROCHLOROTTAB12.5MG 1
HYDROCHLOROTTAB25MG 1
INDAPAMIDE TAB1.25MG 1
INDAPAMIDE TAB2.5MG 1
METHAZOLAMIDTAB25MG 1
METHAZOLAMIDTAB50MG 1
METHYCLOTHIATAB5MG 2
METOLAZONE TAB10MG 1
METOLAZONE TAB2.5MG 1
METOLAZONE TAB5MG 1
SPIRONOLACT TAB100MG 1
SPIRONOLACT TAB25MG 1
SPIRONOLACT TAB50MG 1
THALITONE TAB15MG 3
TORSEMIDE TAB100MG 1
TORSEMIDE TAB10MG 1
TORSEMIDE TAB20MG 1
TORSEMIDE TAB5MG 1
ENDOCRINE AND METABOLIC AGENTS - MISC
ALENDRONATE TAB10MG 1 QL
ALENDRONATE TAB35MG 1 QL
ALENDRONATE TAB40MG 1 QL
ALENDRONATE TAB5MG 1 QL
ALENDRONATE TAB70MG 1 QL
CABERGOLINE TAB0.5MG 2
CALCITONIN SPR200/ACT 2
CALCITRIOL CAP0.25MCG 1
CALCITRIOL CAP0.5MCG 1
CALCITRIOL SOL1MCG/ML 1
CARBAGLU TAB200MG 4 PA SP
DESMOPRESSINSOL0.01% 2
DESMOPRESSINSPR0.01% 2
DESMOPRESSINTAB0.1MG 2
DESMOPRESSINTAB0.2MG 2
DOXERCALCIF CAP0.5MCG 2
DOXERCALCIF CAP1MCG 2
DOXERCALCIF CAP2.5MCG 2
ETIDRON DISDTAB200MG 2
ETIDRON DISDTAB400MG 2
FORTEO SOL600/2.4 4 QL PA SP
FORTICAL SPR200/ACT 4 PA SP
FOSAMAX + D TAB70-2800 3 QL
FOSAMAX + D TAB70-5600 3 QL
GENOTROPIN INJ0.2MG 4 PA SP
GENOTROPIN INJ0.4MG 4 PA SP
GENOTROPIN INJ0.6MG 4 PA SP
24
DRUG NAME TIER LIMITS
GENOTROPIN INJ0.8MG 4 PA SP
GENOTROPIN INJ1.2MG 4 PA SP
GENOTROPIN INJ1.4MG 4 PA SP
GENOTROPIN INJ1.6MG 4 PA SP
GENOTROPIN INJ1.8MG 4 PA SP
GENOTROPIN INJ12MG 4 PA SP
GENOTROPIN INJ1MG 4 PA SP
GENOTROPIN INJ2MG 4 PA SP
GENOTROPIN INJ5MG 4 PA SP
HUMATROPE INJ12MG 4 PA SP
HUMATROPE INJ24MG 4 PA SP
HUMATROPE INJ5MG 4 PA SP
HUMATROPE INJ6MG 4 PA SP
IBANDRONATE TAB150MG 1 QL
INCRELEX INJ40MG/4ML 4 PA SP
MIACALCIN INJ200/ML 4 PA SP
NORDITROPIN INJ10/1.5ML 4 PA SP
NORDITROPIN INJ15/1.5ML 4 PA SP
NORDITROPIN INJ30/3ML 4 PA SP
NORDITROPIN INJ5/1.5ML 4 PA SP
NUTROPIN AQ INJ10MG/2ML 4 PA SP
NUTROPIN AQ INJ20MG/2ML 4 PA SP
NUTROPIN AQ INJNUSPIN 5 4 PA SP
PROLIA 4 PA SP
RISEDRONATE TAB150MG 2
SAMSCA TAB15MG 4 QL PA SP
SAMSCA TAB30MG 4 QL PA SP
SEROSTIM INJ4MG 4 PA SP
SEROSTIM INJ5MG 4 PA SP
SEROSTIM INJ6MG 4 PA SP
SEROSTIM INJ8.8MG 4 PA SP
SIGNIFOR INJ0.3MG/ML 4 PA SP
SIGNIFOR INJ0.6MG/ML 4 PA SP
SIGNIFOR INJ0.9MG/ML 4 PA SP
SOMAVERT INJ10MG 4 PA SP
SOMAVERT INJ15MG 4 PA SP
SOMAVERT INJ20MG 4 PA SP
ZORBTIVE INJ8.8MG 4 PA SP
ESTROGENS
ALORA DIS0.025MG 2 QL
ALORA DIS0.05MG 2 QL
ALORA DIS0.075MG 2 QL
ALORA DIS0.1MG 2 QL
CENESTIN TAB0.3MG 3
CENESTIN TAB0.45MG 3
CENESTIN TAB0.625MG 3
CENESTIN TAB0.9MG 3
CENESTIN TAB1.25MG 3
DELESTROGEN INJ10MG/ML 3
DEPO-ESTRADIINJ5MG/ML 3
DIVIGEL GEL1MG/GM 3 QL
ELESTRIN GEL0.06% 3
ENJUVIA TAB0.3MG 3
ENJUVIA TAB0.45MG 3
ENJUVIA TAB0.625MG 3
ENJUVIA TAB0.9MG 3
ENJUVIA TAB1.25MG 3
ESTRAD VAL INJ10MG/ML 2
ESTRAD VAL INJ20MG/ML 2
ESTRAD VAL INJ40MG/ML 2
ESTRADIOL DIS0.025MG 1 QL
ESTRADIOL DIS0.0375MG 1 QL
ESTRADIOL DIS0.05MG 1 QL
ESTRADIOL DIS0.06MG 1 QL
ESTRADIOL DIS0.075MG 1 QL
ESTRADIOL DIS0.1MG 1 QL
ESTRADIOL TAB0.5MG 1
ESTRADIOL TAB1MG 1
ESTRADIOL TAB2MG 1
ESTROPIPATE TAB0.75MG 1
ESTROPIPATE TAB1.5MG 1
ESTROPIPATE TAB3MG 2
EVAMIST SPR1.53MG 3 QL
MENEST TAB0.3MG 2
MENEST TAB0.625MG 2
MENEST TAB1.25MG 2
MENEST TAB2.5MG 2
MENOSTAR DIS14MCG 3 QL
MIMVEY LO TAB0.5-0.1 1
MINIVELLE DIS0.025 MG 2 QL
DRUG NAME TIER LIMITS
MINIVELLE DIS0.0375MG 2 QL
MINIVELLE DIS0.05MG 2 QL
MINIVELLE DIS0.075MG 2 QL
MINIVELLE DIS0.1MG 2 QL
PREMARIN TAB0.3MG 2
PREMARIN TAB0.45MG 2
PREMARIN TAB0.625MG 2
PREMARIN TAB0.9MG 2
PREMARIN TAB1.25MG 2
PREMPRO 3
FLUOROQUINOLONES
CIPROFLOXACNSUS250MG/5 2
CIPROFLOXACNSUS500MG/5 2
CIPROFLOXACNTAB1000MG 1
CIPROFLOXACNTAB100MG 1
CIPROFLOXACNTAB250MG 1
CIPROFLOXACNTAB500MG 1
CIPROFLOXACNTAB500MG ER 1
CIPROFLOXACNTAB750MG 1
FACTIVE TAB320MG 3
LEVAQUIN TABLEVA-PAK 3
LEVOFLOXACINSOL25MG/ML 2
LEVOFLOXACINTAB250MG 2 QL
LEVOFLOXACINTAB500MG 2 QL
LEVOFLOXACINTAB750MG 2 QL
MOXIFLOXACINTAB400MG 2
OFLOXACIN TAB200MG 2
OFLOXACIN TAB300MG 2
OFLOXACIN TAB400MG 2
GASTROINTESTINAL AGENTS - MISC
ALOSETRON 0.5 MG TAB 2 QL
ALOSETRON 1 MG TAB 2 QL
APRISO CAP0.375GM 3 QL
ASACOL TAB400MG DR 2
ASACOL HD TAB800MG 2 QL
BALSALAZIDE CAP750MG 2
CALC ACETATECAP667MG 2
CALC ACETATETAB667MG 2
CANASA SUP1000MG 3
CIMZIA KIT 4 QL PA SP
CIMZIA PREFLKIT200MG/ML 4 QL PA SP
CROMOLYN SODCON100/5ML 1
DELZICOL CAP400MG 2
DIPENTUM CAP250MG 3
DIPHEN/ATROPINE 2.5MGTAB 1 QL
ELIPHOS TAB667MG 2
FOSRENOL CHW1000MG 3
FOSRENOL CHW500MG 3
FOSRENOL CHW750MG 3
GENERLAC SOL10GM/15 2
GIAZO TAB1.1GM 3
LACTULOSE SOL10GM/15 1
MESALAMINE KIT4GM 2
METOCLOPRAM SOL5MG/5ML 1
METOCLOPRAM TAB10MG 1
METOCLOPRAM TAB5MG ODT 2
METOCLOPRAM TAB5MG 1
METOZOLV ODTTAB10MG 3
PARICALCITOLCAP1 MCG 2
PARICALCITOLCAP2 MCG 2
PARICALCITOLCAP4 MCG 2
PENTASA CAP250MG CR 2
PENTASA CAP500MG CR 2
PHOSLYRA SOL 3
RENAGEL TAB400MG 3
RENAGEL TAB800MG 3
RENVELA PAK0.8GM 3 QL
RENVELA PAK2.4GM 3 QL
SFROWASA ENE4GM 3
SULFASALAZINTAB500MG 2
SULFAZINE TAB500MG 2
SULFAZINE ECTAB500MG 2
URSODIOL CAP300MG 2
URSODIOL TAB250MG 2
URSODIOL TAB500MG 2
GENITOURINARY AGENTS - MISCELLANEOUS
ALFUZOSIN TAB10MG 2 QL
AVODART CAP0.5MG 1
CARDURA XL TAB4MG 3 QL
CARDURA XL TAB8MG 3 QL
25
DRUG NAME TIER LIMITS
CYPROHEPTAD TAB4MG 2
CYSTAGON CAP150MG 4 PA SP
CYSTAGON CAP50MG 4 PA SP
FINASTERIDE TAB5MG 1 QL
POT CITRATE TAB1080MG 2
POT CITRATE TAB1620MG 2
POT CITRATE TAB540MG ER 2
RAPAFLO CAP4MG 3
RAPAFLO CAP8MG 3
TAMSULOSIN CAP0.4MG 1 QL
GOUT AGENTS
ALLOPURINOL TAB100MG 1
ALLOPURINOL TAB300MG 1
COLCHICINE CAP0.6MG 3
MITIGARE CAP0.6MG 3
PROBEN/COLCHTAB500-0.5 1
PROBENECID TAB500MG 1
ULORIC TAB40MG 2 QL
ULORIC TAB80MG 2 QL
HEMATOLOGICAL AGENTS - MISC
AGGRENOX CAP25-200MG 2 QL
ANAGRELIDE CAP0.5MG 1
ANAGRELIDE CAP1MG 1
BRILINTA TAB90MG 2 QL
CILOSTAZOL TAB100MG 1
CILOSTAZOL TAB50MG 1
CLOPIDOGREL TAB300MG 1 QL
CLOPIDOGREL TAB75MG 1 QL
DIPYRIDAMOLETAB25MG 1
DIPYRIDAMOLETAB50MG 1
DIPYRIDAMOLETAB75MG 1
EFFIENT TAB10MG 3 QL
EFFIENT TAB5MG 3 QL
FIRAZYR 4 PA SP
PENTOXIFYLLITAB400MG ER 1
PENTOXIL TAB400MG CR 1
TICLOPIDINE TAB250MG 1 QL
ZONTIVITY TAB2.08MG 3
HEMATOPOIETIC AGENTS
CERDELGA CAP84MG 4 PA SP
DROXIA CAP200MG 3
DROXIA CAP300MG 3
DROXIA CAP400MG 3
PROMACTA TAB12.5MG 4 QL PA SP
PROMACTA TAB25MG 4 QL PA SP
PROMACTA TAB50MG 4 QL PA SP
PROMACTA TAB75MG 4 QL PA SP
ZAVESCA CAP100MG 4 PA SP
HEMOSTATICS
TRANEXAMIC ACID 1
HYPNOTICS
ESZOPICLONE TAB1MG 2
ESZOPICLONE TAB2MG 2
ESZOPICLONE TAB3MG 2
TEMAZEPAM 2
ZALEPLON CAP10MG 2 QL
ZALEPLON CAP5MG 2 QL
ZOLPIDEM TAB10MG 2 QL
ZOLPIDEM TAB5MG 2 QL
ZOLPIDEM SUB 1.75MG 2 QL
ZOLPIDEM SUB 3.5MG 2 QL
ZOLPIDEM ER TAB12.5MG 2 QL
ZOLPIDEM ER TAB6.25MG 2 QL
LAXATIVES
CONSTULOSE SOL10GM/15 2
KRISTALOSE PAK10GM 1
KRISTALOSE PAK20GM 1
LACTULOSE SOL10GM/15 1
OSMOPREP TAB1.5GM 3
VISICOL TAB1.5GM 3
MACROLIDES
AZITHROMYCINPOW1GM PAK 1
AZITHROMYCINSUS100/5ML 1 QL
AZITHROMYCINSUS200/5ML 1 QL
AZITHROMYCINTAB250MG 1 QL
AZITHROMYCINTAB500MG 1 QL
AZITHROMYCINTAB600MG 1 QL
CLARITHROMYCSUS125/5ML 2
CLARITHROMYCSUS250/5ML 2
DRUG NAME TIER LIMITS
CLARITHROMYCTAB500MG 2 QL
CLARITHROMYCTAB500MG ER 2 QL
DIFICID TAB200MG 4 PA SP
E.E.S. 400 TAB400MG 2
E.E.S. GRAN SUS200/5ML 3
ERYPED SUS200/5ML 3
ERYPED SUS400/5ML 3
ERY-TAB TAB250MG EC 1
ERY-TAB TAB333MG EC 1
ERY-TAB TAB500MG EC 1
ERYTHROCIN TAB250MG 1
ERYTHROM ETHTAB400MG 2
ERYTHROMYCINTAB250MG BS 1
ERYTHROMYCINTAB500MG BS 1
PCE TAB333MG EC 3
PCE TAB500MG EC 3
ZITHROMAX POW1GM PAK 3
ZMAX SUS2GM 3 QL
MIGRAINE PRODUCTS
ALMOTRIPTAN TAB 2 QL
ALSUMA INJ6MG/0.5 3
DIHYDROERGOTINJ1MG/ML 2
ERGOMAR SUB2MG 1
FROVATRIPTAN TAB 2.5MG 2 QL
MIGRANAL SPR4MG/ML 2 QL
NARATRIPTAN TAB1MG 2 QL
NARATRIPTAN TAB2.5MG 2 QL
RELPAX TAB20MG 3
RELPAX TAB40MG 3
RIZATRIPTAN TAB10MG 2 QL
RIZATRIPTAN TAB10MG ODT 2 QL
RIZATRIPTAN TAB5MG 2 QL
SUMATRIPTAN INJ6MG/0.5 1 QL
SUMATRIPTAN SPR20MG/ACT 2
SUMATRIPTAN SPR20MG/ACT 2 QL
SUMATRIPTAN SPR5MG/ACT 2
SUMATRIPTAN SUCCINATE REF 2 QL
SUMATRIPTAN TAB100MG 2 QL
SUMATRIPTAN TAB25MG 2 QL
SUMATRIPTAN TAB50MG 2 QL
SUMAVEL DOSEINJ4MG/0.5 3
SUMAVEL DOSEINJ6MG/0.5 3
ZOLMITRIPTAN TAB2.5MG 1 QL
ZOLMITRIPTAN TAB5MG 1 QL
ZOLMITRIPTAN TAB2.5MG ODT 1 QL
ZOLMITRIPTAN TAB5MG ODT 1 QL
ZOMIG TAB2.5MG 3 QL
ZOMIG TAB5MG 3 QL
ZOMIG NASAL SPR5MG 3 QL
ZOMIG ZMT TAB2.5 MG 3 QL
ZOMIG ZMT TAB5MG 3 QL
MINERALS & ELECTROLYTES
KLOR-CON 10 TAB10MEQ ER 1
KLOR-CON 8 TAB8MEQ ER 1
KLOR-CON M15TAB 1
KLOR-CON M20TAB20MEQ ER 1
KLOR-CON SPRINKLE 1
K-TAB TAB20MEQ 1
POT CHLORIDECAP10MEQ ER 1
POT CHLORIDECAP8MEQ ER 1
POT CHLORIDETAB8MEQ ER 1
POT CL MICROTAB10MEQ ER 1
POT CL MICROTAB20MEQ ER 1
MISCELLANOUS DIABETIC PRODUCTS
INSULIN SYRINGES 2
INSULIN PEN NEEDLES 2
MOUTH/THROAT/DENTAL AGENTS
APHTHASOL PST5% 3
CEVIMELINE CAP30MG 3
CHLORHEX GLUSOL0.12% 1
CLOTRIMAZOLETRO10MG 2
LIDOCAINE SOL2% VISC 1
NYSTATIN SUS100000 1
ORAVIG TAB50MG 3
PAROEX SOL0.12% 1
PERIOGARD SOL0.12% 1
PILOCARPINE TAB5MG 1
PILOCARPINE TAB7.5MG 1
TRIAMCIN/ORAPST0.1% 1
26
DRUG NAME TIER LIMITS
MUSCULOSKELETAL THERAPY AGENTS
BACLOFEN TAB10MG 2
BACLOFEN TAB20MG 2
CARISOPRODOLTAB250MG 1
CARISOPRODOLTAB350MG 1
CHLORZOXAZONTAB500MG 1
CYCLOBENZAPRCAP15MG ER 1
CYCLOBENZAPRCAP30MG ER 1
CYCLOBENZAPRTAB10MG 1
CYCLOBENZAPRTAB5MG 1
CYCLOBENZAPRTAB7.5MG 1
DANTROLENE CAP100MG 2
DANTROLENE CAP25MG 2
DANTROLENE CAP50MG 2
LORZONE TAB375MG 1
LORZONE TAB750MG 1
METAXALONE TAB800MG 2
METHOCARBAM TAB500MG 1
METHOCARBAM TAB750MG 1
ORPHENADRINETAB100MG ER 1
TIZANIDINE CAP2MG 2
TIZANIDINE CAP4MG 2
TIZANIDINE CAP6MG 2
TIZANIDINE TAB2MG 2
TIZANIDINE TAB4MG 2
NASAL AGENTS - SYSTEMIC AND TOPICAL
AZELASTINE SPR0.1% 1 QL
AZELASTINE SPR0.15% 1 QL
BACTROBAN OINNASAL 2% 3
BUDESONIDE SUS32MCG 2
FLUNISOLIDE SPR0.025% 1 QL
FLUTICASONE SPR50MCG 1 QL
IPRATROPIUM SPR0.03% 1 QL
IPRATROPIUM SPR0.06% 1 QL
OLOPATADINE SPR0.6% 3
TRIAMCINOLONAER55MCG/AC 2 QL
TYZINE SOL0.1% 2
TYZINE PED DRO0.05% 2
VERAMYST SPR27.5MCG 3 QL ST
OPHTHALMIC AGENTS
ACUVAIL SOL0.45% 3
ALOCRIL SOL2% 2
ALOMIDE SOL0.1% OP 2
ALPHAGAN P SOL0.1% 2
ALREX SUS0.2% 2
APRACLONIDINSOL0.5% OP 2
AZASITE SOL1% 3
AZELASTINE DRO0.05% 2
AZOPT SUS1% OP 3
BACITRACIN OINOP 2
BEPREVE DRO1.5% 2
BESIVANCE SUS0.6% 3
BETAXOLOL SOL0.5% OP 2
BETIMOL SOL0.25% 3
BETIMOL SOL0.5% 3
BETOPTIC-S SUS0.25% OP 3
BRIMONIDINE SOL0.15% 2
BRIMONIDINE SOL0.2% OP 2
BROMDAY SOL0.09% 3
BROMFENAC SOL0.09% OP 2
CARTEOLOL SOL1% OP 2
CILOXAN OIN0.3% OP 3
CIPRO HC SUSOTIC 2
CIPROFLOXACNSOL0.3% OP 2
COMBIGAN SOL0.2/0.5% 3
CROMOLYN SODSOL4% OP 2
CYCLOPENTOLATE SOL OP 2
CYSTARAN SOL0.44% 4 PA SP
DEXAMETH PHOSOL0.1% OP 1
DICLOFENAC SOL0.1% OP 2
DORZOL/TIMOLSOL2-0.5%OP 2
DORZOLAMIDE SOL2% OP 2
DUREZOL EMU0.05% 3
EMADINE SOL0.05% OP 2
EPINASTINE DRO0.05% 2
ERYTHROMYCINOINOP 1
FLAREX SUS0.1% OP 3
FLUOROMETHOLSUS0.1% OP 2
FLURBIPROFENSOL0.03% OP 2
FML OIN0.1% OP 2
DRUG NAME TIER LIMITS
FML FORTE SUS0.25% OP 2
GATIFLOXACINSOL0.5% 1
GENOPTIC SOL0.3% OP 1
GENTAK OIN0.3% OP 2
GENTAMICIN OIN0.3% OP 2
GENTAMICIN SOL0.3% OP 1
GENTASOL SOL0.3% OP 1
ILEVRO DRO0.3% OP 3
ILOTYCIN OINOP 1
IOPIDINE SOL1% OP 3
ISTALOL SOL0.5% OP 3
KETOROLAC SOL0.4% 2
KETOROLAC SOL0.5% 2
LACRISERT MIS5MG OP 3 PA
LASTACAFT SOL0.25% 3
LATANOPROST SOL0.005% 2 QL
LEVOBUNOLOL SOL0.5% OP 1
LEVOFLOXACINSOL0.5% 2
LOTEMAX GEL0.5% 2
LOTEMAX OIN0.5% 2
LOTEMAX SUS0.5% 2
LUMIGAN SOL0.01% 2 QL ST
LUMIGAN SOL0.03% 2 QL ST
MAXIDEX SUS0.1% OP 3
METIPRANOLOLSOL0.3% OPH 2
MOXEZA SOL0.5% 3
NAPHAZOLINE SOL0.1% OP 1
NATACYN SUS5% OP 3
NEVANAC SUS0.1% 3
OFLOXACIN DRO0.3% OP 2
OLOPATADINE HCL OPH SOL 1
PHOSPHOLINE SOL0.125%OP 2
PILOCARPINE SOL1% OP 1
PILOCARPINE SOL2% OP 1
PILOCARPINE SOL4% OP 1
PILOPINE HS GEL4% OP 3
PRED MILD SUS0.12% OP 3
PRED SOD PHOSOL1% OP 2
PREDNISOLONE ACETATE 2
PREDNISOLONESUS1% OP 1
PROPINE SOL0.1% OP 3
ROMYCIN OINOP 1
SIMBRINZA SUS1-0.2% 3
SOD SULFACETSOL10% OP 2
TIMOLOL GEL SOL0.25% OP 2
TIMOLOL GEL SOL0.5% OP 2
TIMOLOL MAL SOL0.25% OP 2
TIMOLOL MAL SOL0.5% OP 2
TIMOPTIC OCUSOL0.25% OP 3
TIMOPTIC OCUSOL0.5% OP 3
TOBRADEX OIN0.3-0.1% 2
TOBRAMYCIN SOL0.3% OP 1
TRAVATAN Z DRO0.004% 3 QL ST
TRIFLURIDINESOL1% OP 2
TROPICAMIDE SOL0.5% OP 2
VEXOL SUS1% OP 3
VIGAMOX DRO0.5% 3
XIIDRA 5% 3
ZIOPTAN DRO0.0015% 3 ST
ZIRGAN GEL0.15% 3
OTIC AGENTS
ACETASOL HC SOLOTIC 2
ACETIC ACID SOL2% OTIC 2
CIPRO HC SUSOTIC 2
CIPRODEX SUS0.3-0.1% 2
COLY-MYCIN SSUSOTIC 3
CORTISPORIN SUS-TC OTIC 3
CORTOMYCIN SUS1% OTIC 1
FLUOCIN ACETOIL0.01% 2
HC/ACET ACIDSOLOTIC 2
NEO/POLY/HC SOL1% OTIC 1
NEO/POLY/HC SUS1% OTIC 1
OFLOXACIN DRO0.3%OTIC 2
PENICILLINS
AMOX/K CLAV CHW200MG 2
AMOX/K CLAV CHW400MG 2
AMOX/K CLAV SUS200/5ML 2
AMOX/K CLAV SUS250/5ML 2
AMOX/K CLAV SUS400/5ML 2
AMOX/K CLAV SUS600/5ML 2
27
DRUG NAME TIER LIMITS
AMOX/K CLAV TAB250MG 2
AMOX/K CLAV TAB500MG 2
AMOX/K CLAV TAB875MG 2
AMOXICILLIN CAP250MG 1
AMOXICILLIN CAP500MG 1
AMOXICILLIN CHW125MG 1
AMOXICILLIN CHW250MG 1
AMOXICILLIN SUS125/5ML 1
AMOXICILLIN SUS200/5ML 1
AMOXICILLIN SUS250/5ML 1
AMOXICILLIN SUS400/5ML 1
AMOXICILLIN TAB500MG 1
AMOXICILLIN TAB875MG 1
AMOXIL CAP500MG 1
AMOXIL SUS125/5ML 1
AMOXIL SUS250/5ML 1
AMOX-POT CLATABER 2
AMPICILLIN CAP250MG 1
AMPICILLIN CAP500MG 1
AMPICILLIN SUS125/5ML 1
AMPICILLIN SUS250/5ML 1
AUGMENTIN SUS125/5ML 3
DICLOXACILL CAP250MG 2
DICLOXACILL CAP500MG 2
MOXATAG TAB775MG 3
PENICILLN VKSOL125/5ML 1
PENICILLN VKSOL250/5ML 1
PENICILLN VKTAB250MG 1
PENICILLN VKTAB500MG 1
PROGESTINS
MEDROXYPR ACTAB10MG 1
MEDROXYPR ACTAB2.5MG 1
MEDROXYPR ACTAB5MG 1
NORETHIN ACETAB5MG 2
PROGESTERONECAP100MG 2
PROGESTERONECAP200MG 2
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -
MISC
ACAMPROSATE 333 MG TAB 1
AMPYRA TAB10MG 4 PA SP
AUBAGIO TAB14MG 4 PA SP
AUBAGIO TAB7MG 4 PA SP
AVONEX KIT30MCG 4 QL PA SP
AVONEX PREFLKIT30MCG 4 QL PA SP
BETASERON INJ0.3MG 4 QL PA SP
BUPROBAN TAB150MG 1 QL
BUPROPION TAB150MG SR 1 QL
DISULFIRAM TAB250MG 2
DISULFIRAM TAB500MG 2
DONEPEZIL TAB10MG 1 QL
DONEPEZIL TAB10MG ODT 1 QL
DONEPEZIL TAB5MG 1 QL
DONEPEZIL TAB5MG ODT 1 QL
ERGOLOID MESTAB1MG ORAL 1
EXELON SOL2MG/ML 3
EXTAVIA INJ0.3MG 4 QL PA SP
FLUOXETINE CAP10MG 1 QL
FLUOXETINE CAP20MG 1 QL
GALANTAMINE CAP16MG ER 2 QL
GALANTAMINE CAP24MG ER 2 QL
GALANTAMINE CAP8MG ER 2 QL
GALANTAMINE SOL4MG/ML 2 QL
GALANTAMINE TAB12MG 2 QL
GALANTAMINE TAB4MG 2 QL
GALANTAMINE TAB8MG 2 QL
GILENYA CAP0.5MG 4 QL PA SP
GLATOPA INJ 20MG/ML 4 PA SP
HORIZANT TAB300MG 3
HORIZANT TAB600MG 3
MEMANTINE HCL 5 MG TAB 2
MEMANTINE HCL 10MG TAB 2
MEMANTINE HCSOL2MG/ML 2 PA
NAMENDA XR CAP14MG 3 QL
NAMENDA XR CAP21MG 3 QL
NAMENDA XR CAP28MG 3 QL
NAMENDA XR CAP7MG 3 QL
NAMENDA XR CAPTITRATIO 3 QL
PLEGRIDY INJ 4 PA SP
PLEGRIDY PENINJSTARTER 4 PA SP
REBIF INJ22/0.5 4 QL PA SP
DRUG NAME TIER LIMITS
REBIF INJ44/0.5 4 QL PA SP
REBIF TITRTNSOLPACK 4 QL PA SP
RILUZOLE TAB50MG 2
RIVASTIGMINECAP1.5MG 2 QL
RIVASTIGMINECAP3MG 2 QL
RIVASTIGMINECAP4.5MG 2 QL
RIVASTIGMINECAP6MG 2 QL
SARAFEM TAB10MG 3 QL
SARAFEM TAB20MG 3 QL
TECFIDERA CAP120MG 4 PA SP
TECFIDERA CAP240MG 4 PA SP
TECFIDERA MISSTARTER 4 PA SP
TETRABENAZINETAB12.5MG 4 PA SP
TETRABENAZINETAB25MG 4 PA SP
RESPIRATORY AGENTS - MISC
KALYDECO TAB150MG 4 QL PA SP
PULMOZYME SOL 1MG/ML 4 PA SP
SODIUM CHLORNEB7% 1
SMOKING CESSATION
CHANTIX PAK0.5& 1MG 1 PA QL
CHANTIX PAK1MG 1 PA QL
CHANTIX PAK0.5MG 1 PA QL
CHANTIX TAB0.5MG 1 PA QL
CHANTIX TAB1MG 1 PA QL
NICOTINE POLGUM2MG 1 QL
NICOTINE POLGUM4MG 1 QL
NICOTINE DIS21MG/24 1 QL
NICOTINE DIS14MG/24 1 QL
NICOTINE DIS7MG/24 1 QL
NICOTINE LOZ2MG 1 QL
NICOTINE LOZ4MG 1 QL
SULFONAMIDES
SULFADIAZINETAB500MG 1
TETRACYCLINES
AVIDOXY TAB100MG 2
DEMECLOCYCL TAB150MG 2
DEMECLOCYCL TAB300MG 2
DOXYCYCL HYCTA2100MG DR 2
DOXYCYCL HYCTAB100MG DR 2
DOXYCYCL HYCTAB150MG DR 2
DOXYCYCL HYCTAB75MG DR 2
DOXYCYCLINE 2
DOXYCYCLINE CAP150MG 2
DOXYCYCLINE CAP75MG 2
DOXYCYCLINE MONOHYDRATE 2
DOXYCYCLINE TAB20MG 2
MINOCYCLINE CAP100MG 2
MINOCYCLINE CAP50MG 2
MINOCYCLINE CAP75MG 2
MINOCYCLINE TAB100MG 2
MINOCYCLINE TAB135MG ER 2
MINOCYCLINE TAB45MG ER 2
MINOCYCLINE TAB50MG 2
MINOCYCLINE TAB75MG 2
MINOCYCLINE TAB90MG ER 2
MONDOXYNE NLCAP100MG 2
MONDOXYNE NLCAP75MG 2
MORGIDOX CAP1X100MG 1
TETRACYCLINECAP250MG 2
TETRACYCLINECAP500MG 2
VIBRAMYCIN SYP50MG/5ML 3
THYROID AGENTS
LEVOTHYROXINTAB100MCG 1
LEVOTHYROXINTAB112MCG 1
LEVOTHYROXINTAB125MCG 1
LEVOTHYROXINTAB137MCG 1
LEVOTHYROXINTAB150MCG 1
LEVOTHYROXINTAB175MCG 1
LEVOTHYROXINTAB200MCG 1
LEVOTHYROXINTAB25MCG 1
LEVOTHYROXINTAB300MCG 1
LEVOTHYROXINTAB50MCG 1
LEVOTHYROXINTAB75MCG 1
LEVOTHYROXINTAB88MCG 1
LIOTHYRONINETAB25MCG 1
LIOTHYRONINETAB50MCG 1
LIOTHYRONINETAB5MCG 1
METHIMAZOLE TAB10MG 2
METHIMAZOLE TAB5MG 2
28
DRUG NAME TIER LIMITS
NP THYROID TAB15MG 1
NP THYROID TAB30MG 1
NP THYROID TAB60MG 1
NP THYROID TAB90MG 1
PROPYLTHIOURTAB50MG 2
SYNTHROID TAB100MCG 3
SYNTHROID TAB112MCG 3
SYNTHROID TAB125MCG 3
SYNTHROID TAB137MCG 3
SYNTHROID TAB150MCG 3
SYNTHROID TAB175MCG 3
SYNTHROID TAB200MCG 3
SYNTHROID TAB25MCG 3
SYNTHROID TAB50MCG 3
SYNTHROID TAB75MCG 3
SYNTHROID TAB88MCG 3
THYROLAR-1 TAB60MG 1
THYROLAR-1/2TAB30MG 1
THYROLAR-1/4TAB15MG 1
THYROLAR-2 TAB120MG 1
THYROLAR-3 TAB180MG 1
UNITHROID TAB100MCG 1
UNITHROID TAB112MCG 1
UNITHROID TAB125MCG 1
UNITHROID TAB150MCG 1
UNITHROID TAB175MCG 1
UNITHROID TAB200MCG 1
UNITHROID TAB25MCG 1
UNITHROID TAB300MCG 1
UNITHROID TAB50MCG 1
UNITHROID TAB75MCG 1
UNITHROID TAB88MCG 1
ULCER DRUGS
CANTIL TAB25MG 3
CARAFATE SUS1GM/10ML 3
CIMETIDINE SOL300/5ML 2
CUVPOSA SOL1MG/5ML 3
DICYCLOMINE CAP10MG 1
DICYCLOMINE SOL10MG/5ML 1
DICYCLOMINE TAB20MG 1
ESOMEPRA MAGCAP20MG DR 2 QL
ESOMEPRA MAGCAP40MG DR 2
FAMOTIDINE TAB20MG 2
FAMOTIDINE TAB40MG 2
FAMOTIDINESUS40MG/5ML 2
FIRST-OMEPRASUS2MG/ML 2
GLYCATE TAB1.5MG 2
GLYCOPYRROL TAB1MG 2
GLYCOPYRROL TAB2MG 2
LANSOPRAZOLECAP30MG DR 2 QL
METHSCOPOLAMTAB2.5MG 2
METHSCOPOLAMTAB5MG 2
MISOPROSTOL TAB100MCG 2
MISOPROSTOL TAB200MCG 2
OMEPRAZOLE CAP10MG 1 QL
OMEPRAZOLE CAP20MG 1 QL
OMEPRAZOLE CAP40MG 1 QL
PANTOPRAZOLETAB20MG 1 QL
PANTOPRAZOLETAB40MG 1 QL
RABEPRAZOLE TAB20MG 1 QL
RANITIDINE SYP15MG/ML 2
RANITIDINE CAP150MG 2
RANITIDINE CAP300MG 2
RANITIDINE TAB150MG 2
RANITIDINE TAB300MG 2
SUCRALFATE SUS1GM/10ML 3
SUCRALFATE TAB1GM 1
URINARY ANTI-INFECTIVES
METHENAM HIPTAB1GM 1
METHENAM HIPTAB1GM 3
MONUROL PAKGRANULES 3
NITROFUR MACCAP50MG 1
NITROFURANTNSUS25MG/5ML 2
NITROFURANTOIN MACROCRYST 1
NITROFURANTOIN MONOHYDRAT 1
URINARY ANTISPASMODICS
BETHANECHOL TAB10MG 1
BETHANECHOL TAB25MG 1
BETHANECHOL TAB50MG 1
BETHANECHOL TAB5MG 1
DRUG NAME TIER LIMITS
DARIFENACIN ER TAB 15MG 1
DARIFENACIN ER TAB 7.5MG 1
FLAVOXATE TAB100MG 1
GELNIQUE GEL10% 3 QL
GELNIQUE GEL3% 3
MYRBETRIQ TAB25MG 3 QL
MYRBETRIQ TAB50MG 3 QL
OXYBUTYNIN SYP5MG/5ML 1 QL
OXYBUTYNIN TAB5MG 1 QL
OXYTROL DIS3.9MG/24 3 QL
TOLTERODINE CAP2MG ER 1 QL
TOLTERODINE CAP4MG ER 1 QL
TOLTERODINE TAB1MG 1 QL
TOLTERODINE TAB2MG 1 QL
TOVIAZ TAB4MG 3 QL
TOVIAZ TAB8MG 3 QL
TROSPIUM CHLCAP60MG ER 2
VESICARE TAB10MG 2 QL
VESICARE TAB5MG 2 QL
VAGINAL PRODUCTS
CLEOCIN CRE2% VAG 3
CLEOCIN SUP100MG 3
CLINDAMAX CRE2% VAG 1
CLINDAMYCIN CRE2% VAG 1
CRINONE GEL4% VAG 4 PA SP
CRINONE GEL8% VAG 4 PA SP
ENDOMETRIN SUP100MG 3
ESTRACE VAG CRE0.1MG/GM 3
ESTRING MIS2MG 2 QL
FEMRING MIS0.05/24H 3
FEMRING MIS0.1MG/24 3
METRONIDAZOLGEL0.75%VAG 2
PREMARIN VAGCRE0.625MG 2
PROCHIEVE GEL4% 4 PA SP
TERCONAZOLE CRE0.4% 2
TERCONAZOLE CRE0.8% 2
TERCONAZOLE SUP80MG 2 QL
VAGIFEM TAB10MCG 2
ZAZOLE CRE0.4% 2
VASOPRESSORS
ADRENACLICK INJ0.15MG 3 QL PA
EPINEPHRINE INJ0.15MG 2 QL
EPINEPHRINE INJ0.3MG 2 QL
MIDODRINE TAB10MG 2
MIDODRINE TAB2.5MG 2
MIDODRINE TAB5MG 2
NORTHERA CAP100MG 4 QL PA SP
NORTHERA CAP200MG 4 QL PA SP
NORTHERA CAP300MG 4 QL PA SP
29
30
31
INDEX
8-MOP CAP10MG 21 ABACA/LAMIVUTAB600-300 4 ABACAV/LAMIVTAB/ZIDOVUD 4, 19 ABACAVIR TAB300MG 19 ABSTRAL SUB100MCG 10 ABSTRAL SUB200MCG 10 ABSTRAL SUB300MCG 10 ABSTRAL SUB400MCG 10 ABSTRAL SUB600MCG 10 ABSTRAL SUB800MCG 10 ABSTRAL SUB100MCG 4 ABSTRAL SUB200MCG 4 ABSTRAL SUB300MCG 4 ABSTRAL SUB400MCG 4 ABSTRAL SUB600MCG 4 ABSTRAL SUB800MCG 4 ACAMPROSATE 333 MG TAB 27 ACANYA GEL1.2-2.5% 21 ACARBOSE TAB100MG 14 ACARBOSE TAB25MG 14 ACARBOSE TAB50MG 14 ACARBOSE TAB100MG 4 ACARBOSE TAB25MG 4 ACARBOSE TAB50MG 4 ACEBUTOLOL CAP200MG 20 ACEBUTOLOL CAP400MG 20 ACETASOL HC SOLOTIC 26 ACETAZOLAMIDCAP500MG ER 23 ACETAZOLAMIDTAB125MG 23 ACETAZOLAMIDTAB250MG 23 ACETIC ACID SOL2% OTIC 26 ACETYLCYST SOL10% 21 ACETYLCYST SOL20% 21 ACITRETIN CAP10MG 21 ACITRETIN CAP17.5MG 21 ACITRETIN CAP25MG 21 ACTEMRA INJ162/0.9 9 ACTICIN CRE5% 21 ACUVAIL SOL0.45% 26 ACYCLOVIR CAP200MG 19 ACYCLOVIR OIN5% 21 ACYCLOVIR SUS200/5ML 19 ACYCLOVIR TAB400MG 19 ACYCLOVIR TAB800MG 19 ACYCLOVIR OIN5% 4 ADACEL 2
ADAPALENE CRE0.1% 21 ADAPALENE GEL0.1% 21 ADAPALENE GEL0.3% 21 ADCIRCA TAB20MG 21 ADCIRCA TAB20MG 4 ADEMPAS TAB0.5MG 21 ADEMPAS TAB1.5MG 21 ADEMPAS TAB1MG 21 ADEMPAS TAB2.5MG 21 ADEMPAS TAB2MG 21 ADEMPAS TAB0.5MG 4 ADEMPAS TAB1.5MG 4 ADEMPAS TAB1MG 4 ADEMPAS TAB2.5MG 4 ADEMPAS TAB2MG 4 ADRENACLICK INJ0.15MG 4, 28 ADVAIR DISKUAER100/50 4, 12 ADVAIR DISKUAER250/50 4, 12
ADVAIR DISKUAER500/50 4, 12 ADVAIR HFA AER115/21 4, 12 ADVAIR HFA AER230/21 4, 12 ADVAIR HFA AER45/21 4, 12 AFEDITAB TAB30MG CR 20 AFEDITAB TAB60MG CR 20 AFINITOR TAB10MG 17 AFINITOR TAB2.5MG 17 AFINITOR TAB5MG 17 AFINITOR TAB7.5MG 17 AFINITOR DISTAB2MG 4, 17 AFINITOR DISTAB3MG 4, 17 AFINITOR DISTAB5MG 4, 17 AFINITOR TAB10MG 4 AFLURIA 2
AFLURIA PF 2
AFLURIA QUADRIVALENT 2
AFTERA 2
AGGRENOX CAP25-200MG 25 AGGRENOX CAP25-200MG 4 AKNE-MYCIN OIN2% 21 ALBENZA TAB200MG 11 ALBUTEROL NEB0.083% 12 ALBUTEROL NEB0.5% 12 ALBUTEROL NEB0.63MG/3 12 ALBUTEROL NEB1.25MG/3 12 ALBUTEROL SYP2MG/5ML 12 ALBUTEROL TAB2MG 12 ALBUTEROL TAB4MG 12 ALBUTEROL TAB8MG ER 12 ALCLOMETASONCRE0.05% 21 ALCLOMETASONOIN0.05% 21 ALENDRONATE TAB10MG 4, 23 ALENDRONATE TAB35MG 4, 23 ALENDRONATE TAB40MG 4, 23 ALENDRONATE TAB5MG 4, 23 ALENDRONATE TAB70MG 4, 23 ALFUZOSIN TAB10MG 24 ALINIA SUS100/5ML 16 ALINIA TAB500MG 16 ALLOPURINOL TAB100MG 25 ALLOPURINOL TAB300MG 25 ALMOTRIPTAN TAB 25 ALOCRIL SOL2% 26 ALOMIDE SOL0.1% OP 26 ALORA DIS0.025MG 24 ALORA DIS0.05MG 24 ALORA DIS0.075MG 24 ALORA DIS0.1MG 24 ALOSETRON 0.5 MG TAB 4, 24 ALOSETRON 1 MG TAB 24 ALPHAGAN P SOL0.1% 26 ALPRAZOLAM 11 ALPRAZOLAM ODT 11 ALPRAZOLAM XR 11 ALREX SUS0.2% 26 ALSUMA INJ6MG/0.5 25 ALTABAX OIN1% 21 ALTAVERA 2
ALYACEN 1/35 2
ALYACEN 7/7/7 2
AMANTADINE CAP100MG 18 AMANTADINE SYP50MG/5ML 18
AMANTADINE TAB100MG 18 AMCINONIDE CRE0.1% 21 AMCINONIDE LOT0.1% 21 AMCINONIDE OIN0.1% 21 AMETHIA 2
AMETHIA LO 2
AMILORIDE TAB5MG 23 AMIODARONE TAB100MG 11 AMIODARONE TAB200MG 11 AMIODARONE TAB400MG 11 AMITRIPTYLINTAB100MG 13 AMITRIPTYLINTAB10MG 13 AMITRIPTYLINTAB150MG 13 AMITRIPTYLINTAB25MG 13 AMITRIPTYLINTAB50MG 13 AMITRIPTYLINTAB75MG 13 AMLODIPINE TAB10MG 20 AMLODIPINE TAB2.5MG 20 AMLODIPINE TAB5MG 20 AMNESTEEM CAP10MG 21 AMNESTEEM CAP20MG 21 AMNESTEEM CAP40MG 21 AMOX/K CLAV CHW200MG 26 AMOX/K CLAV CHW400MG 26 AMOX/K CLAV SUS200/5ML 26 AMOX/K CLAV SUS250/5ML 26 AMOX/K CLAV SUS400/5ML 26 AMOX/K CLAV SUS600/5ML 26 AMOX/K CLAV TAB250MG 27 AMOX/K CLAV TAB500MG 27 AMOX/K CLAV TAB875MG 27 AMOXAPINE TAB100MG 13 AMOXAPINE TAB150MG 13 AMOXAPINE TAB25MG 13 AMOXAPINE TAB50MG 13 AMOXICILLIN CAP250MG 27 AMOXICILLIN CAP500MG 27 AMOXICILLIN CHW125MG 27 AMOXICILLIN CHW250MG 27 AMOXICILLIN SUS125/5ML 27 AMOXICILLIN SUS200/5ML 27 AMOXICILLIN SUS250/5ML 27 AMOXICILLIN SUS400/5ML 27 AMOXICILLIN TAB500MG 27 AMOXICILLIN TAB875MG 27 AMOXIL CAP500MG 27 AMOXIL SUS125/5ML 27 AMOXIL SUS250/5ML 27 AMOX-POT CLATABER 27 AMPHETAMINE CAP10MG ER 4, 9 AMPHETAMINE CAP15MG ER 4, 9 AMPHETAMINE CAP20MG ER 4, 9 AMPHETAMINE CAP25MG ER 4, 9 AMPHETAMINE CAP30MG ER 4, 9 AMPHETAMINE CAP5MG ER 4, 9 AMPHETAMINE TAB10MG 4, 9 AMPHETAMINE TAB12.5MG 4, 9 AMPHETAMINE TAB15MG 4, 9 AMPHETAMINE TAB20MG 4, 9 AMPHETAMINE TAB30MG 4, 9 AMPHETAMINE TAB5MG 4, 9 AMPICILLIN CAP250MG 27 AMPICILLIN CAP500MG 27 AMPICILLIN SUS125/5ML 27
32
AMPICILLIN SUS250/5ML 27 AMPYRA TAB10MG 27 ANADROL-50 TAB50MG 11 ANAGRELIDE CAP0.5MG 25 ANAGRELIDE CAP1MG 25 ANASTROZOLE TAB1MG 4, 17 ANDRODERM DIS2MG/24HR 11 ANDRODERM DIS4MG/24HR 11 ANDROGEL 11 ANDROGEL PUMP 11 ANDROID CAP10MG 11 ANDROXY TAB10MG 11 ANORO ELLIPTAER62.5-25 12 ANTARA CAP30MG 15 ANTARA CAP90MG 15 ANZEMET TAB100MG 15 ANZEMET TAB50MG 15 APEXICON OIN0.05% 21 APEXICON E CRE0.05% 21 APHTHASOL PST5% 25 APLENZIN TAB174MG 13 APLENZIN TAB348MG 13 APLENZIN TAB522MG 13 APRACLONIDINSOL0.5% OP 26 APRI 2
APRISO CAP0.375GM 24 APTIOM TAB200MG 12 APTIOM TAB400MG 12 APTIOM TAB600MG 12 APTIOM TAB800MG 12 APTIVUS CAP250MG 19 APTIVUS SOL 19 ARANELLE 2
ARBINOXA SOL4MG/5ML 15 ARBINOXA TAB4MG 15 ARCAPTA CAP75MCG 12 ARIPIPRAZOLE SOL1MG/ML 18 ARIPIPRAZOLE TAB15MG 18 ARIPIPRAZOLE TAB30MG 18 ARIPIPRAZOLE SOL1MG/ML 4 ARIPIPRAZOLE TAB10MG 18 ARMODAFINIL TAB150MG 9 ARMODAFINIL TAB250MG 9 ARMODAFINIL TAB50MG 9 ASACOL TAB400MG DR 24 ASACOL HD TAB800MG 24 ASHLYNA 2
ASMANEX 120 AER220MCG 4, 12 ASMANEX 14 AER220MCG 12 ASMANEX 30 AER110MCG 12 ASMANEX 30 AER220MCG 12 ASMANEX 60 AER220MCG 12 ASMANEX 7 AER110MCG 12 ASMANEX HFA AER100 MCG 12 ASMANEX HFA AER200 MCG 12 ASPIRIN CHW81MG 2
ASPIRIN TAB81MG 2
ASPIRIN TAB81MG EC 2
ASTAGRAF XL CAP0.5MG 19 ASTAGRAF XL CAP1MG 19 ASTAGRAF XL CAP5MG 19 ATENOLOL TAB100MG 20 ATENOLOL TAB25MG 20 ATENOLOL TAB50MG 20 ATORVASTATINTAB10MG 4, 15 ATORVASTATINTAB20MG 4, 15
ATORVASTATINTAB40MG 4, 15 ATORVASTATINTAB80MG 4, 15 ATOVAQ/PROGUTAB250-100 17 ATOVAQ/PROGUTAB62.5-25 17 ATOVAQUONE SUS750/5ML 16 ATRIPLA TAB 19 AUBAGIO TAB14MG 27 AUBAGIO TAB7MG 27 AUBRA 2
AUG BETAMET CRE0.05% 21 AUG BETAMET GEL0.05% 21 AUG BETAMET LOT0.05% 21 AUG BETAMET OIN0.05% 21 AUGMENTIN SUS125/5ML 27 AVANDIA TAB2MG 14 AVANDIA TAB4MG 14 AVANDIA TAB8MG 14 AVIANE 2
AVIDOXY TAB100MG 27 AVODART CAP0.5MG 24 AVONEX KIT30MCG 27 AVONEX PREFLKIT30MCG 4, 27 AXIRON 11 AZASITE SOL1% 26 AZATHIOPRINETAB50MG 19 AZELASTINE DRO0.05% 26 AZELASTINE SPR0.1% 26 AZELASTINE SPR0.15% 26 AZELEX CRE20% 21 AZILECT TAB0.5MG 18 AZILECT TAB1MG 18 AZITHROMYCINPOW1GM PAK 25 AZITHROMYCINSUS100/5ML 4, 25 AZITHROMYCINSUS200/5ML 4, 25 AZITHROMYCINTAB250MG 4, 25 AZITHROMYCINTAB500MG 4, 25 AZITHROMYCINTAB600MG 4, 25 AZOPT SUS1% OP 26 AZURETTE 2
BACITRACIN OINOP 26 BACLOFEN TAB10MG 26 BACLOFEN TAB20MG 26 BACTROBAN OINNASAL 2% 26 BALSALAZIDE CAP750MG 24 BALZIVA 2
BANZEL SUS40MG/ML 12 BANZEL TAB200MG 12 BANZEL TAB400MG 12 BAYCADRON ELX0.5/5ML 21
BEKYREE 2
BENAZEP/HCTZTAB10-12.5 16 BENAZEP/HCTZTAB20-12.5 16 BENAZEP/HCTZTAB20-25MG 16 BENAZEP/HCTZTAB5-6.25 16 BENAZEPRIL TAB10MG 16 BENAZEPRIL TAB20MG 16 BENAZEPRIL TAB40MG 16 BENAZEPRIL TAB5MG 16 BENICAR TAB20MG 16 BENICAR TAB40MG 16 BENICAR TAB5MG 16 BENZTROPINE TAB0.5MG 18 BENZTROPINE TAB1MG 18 BENZTROPINE TAB2MG 18 BEPREVE DRO1.5% 26 BESIVANCE SUS0.6% 26
BETAMETH DIPCRE0.05% 21 BETAMETH DIPLOT0.05% 21 BETAMETH DIPOIN0.05% 21 BETAMETH VALAER 0.12% 21 BETAMETH VALCRE0.1% 21 BETAMETH VALLOT0.1% 22 BETAMETH VALOIN0.1% 22 BETASERON INJ0.3MG 27 BETAXOLOL SOL0.5% OP 26 BETAXOLOL TAB10MG 20 BETAXOLOL TAB20MG 20 BETHANECHOL TAB10MG 28 BETHANECHOL TAB25MG 28 BETHANECHOL TAB50MG 28 BETHANECHOL TAB5MG 28 BETIMOL SOL0.25% 26 BETIMOL SOL0.5% 26 BETOPTIC-S SUS0.25% OP 26 BEXAROTENE CAP75MG 17 BEXSERO 2
BICALUTAMIDETAB50MG 4, 17 BILTRICIDE TAB600MG 11 BISOPROL FUMTAB10MG 20 BISOPROL FUMTAB5MG 20 BLISOVI 24 FE 2
BLISOVI FE 1.5/30 2
BLISOVI FE 1/20 2
BOOSTRIX 2
BP CLEANSINGEMU10-4% 22 BREO ELLIPTA 4, 12 BREO ELLIPTAINH100-25 4, 12 BRIELLYN 2
BRILINTA TAB90MG 25 BRIMONIDINE SOL0.15% 26 BRIMONIDINE SOL0.2% OP 26 BROMDAY SOL0.09% 26 BROMFENAC SOL0.09% OP 26 BROMOCRIPTINCAP5MG 18 BROMOCRIPTINTAB2.5MG 18 BROVANA NEB15MCG 12 BUDEPRION TAB100MG SR 13 BUDEPRION TAB150MG SR 13 BUDESONIDE CAP3MG/24HR 21 BUDESONIDE SUS0.25MG/2 12 BUDESONIDE SUS0.5MG/2 12 BUDESONIDE SUS32MCG 26 BUMETANIDE TAB0.5MG 23 BUMETANIDE TAB1MG 23 BUMETANIDE TAB2MG 23 BUMETANIDE INJ0.25/ML 23 BUNAVAIL MIS2.1-0.3 10 BUNAVAIL MIS4.2-0.7 10 BUNAVAIL MIS6.3-1MG 10 BUPRENOR/NALOXONE 10 BUPRENORPHINSUB2MG 4, 10 BUPRENORPHINSUB8MG 4, 10 BUPROBAN 4, 27
BUPROBAN TAB150MG 27 BUPROPION TAB100MG 13 BUPROPION TAB100MG SR 13 BUPROPION TAB150MG SR 13, 27 BUPROPION TAB200MG SR 13 BUPROPION TAB75MG 13 BUPROPION HCL TAB 2
BUPROPN HCL TAB150MG XL 4, 13 BUPROPN HCL TAB300MG XL 4, 13
33
BUSPIRONE TAB10MG 11 BUSPIRONE TAB15MG 11 BUSPIRONE TAB30MG 11 BUSPIRONE TAB5MG 11 BUSPIRONE TAB7.5MG 11 BUT/APAP/CAFCAPCODEINE 4, 10 BUTORPHANOL SOL10MG/ML 4, 10 BUTRANS DIS 10 BUTRANS DIS10MCG/HR 10 BUTRANS DIS15MCG/HR 10 BUTRANS DIS20MCG/HR 10 BUTRANS DIS5MCG/HR 10 BYDUREON INJ 14 BYETTA INJ10MCG 14 BYETTA INJ5MCG 14 BYSTOLIC TAB10MG 20 BYSTOLIC TAB2.5MG 20 BYSTOLIC TAB20MG 20 BYSTOLIC TAB5MG 20 CABERGOLINE TAB0.5MG 23 CABOMETYX TAB 20MG 17 CABOMETYX TAB 40MG 17 CABOMETYX TAB 60MG 17 CALC ACETATECAP667MG 24 CALC ACETATETAB667MG 24 CALCIPOTRIENCRE0.005% 4, 22 CALCIPOTRIENOINBETAMETH 22 CALCIPOTRIENSOL0.005% 4, 22 CALCITONIN SPR200/ACT 23 CALCITRIOL CAP0.25MCG 23 CALCITRIOL CAP0.5MCG 23 CALCITRIOL OIN3MCG/GM 22 CALCITRIOL SOL1MCG/ML 23 CAMILA 2
CAMRESE 2
CAMRESE LO 2
CANASA SUP1000MG 24 CANDESARTAN 4 MG 16 CANDESARTAN 8 MG 16 CANDESARTAN TAB16MG 4, 16 CANDESARTAN TAB32MG 4, 16 CANTIL TAB25MG 28 CAPECITABINETAB150MG 17 CAPECITABINETAB500MG 17 CAPEX SHA0.01% 22 CAPRELSA TAB100MG 17 CAPRELSA TAB300MG 17 CAPTOPRIL TAB100MG 16 CAPTOPRIL TAB12.5MG 16 CAPTOPRIL TAB25MG 16 CAPTOPRIL TAB50MG 16 CARAFATE SUS1GM/10ML 28 CARB/LEVO TAB10-100MG 18 CARB/LEVO TAB25-100MG 18 CARB/LEVO TAB25-250MG 18 CARB/LEVO ERTAB25-100MG 18 CARB/LEVO ERTAB50-200MG 18 CARBAGLU TAB200MG 23 CARBAMAZEPINCAP100MG ER 12 CARBAMAZEPINCAP200MG ER 12 CARBAMAZEPINCAP300MG ER 12 CARBAMAZEPINCHW100MG 12 CARBAMAZEPINSUS100/5ML 12 CARBAMAZEPINTAB200MG 12 CARBAMAZEPINTAB200MG ER 12 CARBAMAZEPINTAB400MG ER 12 CARBINOXAMINSOL4MG/5ML 15
CARBINOXAMINTAB4MG 15 CARDURA XL TAB4MG 24 CARDURA XL TAB8MG 24 CARDURA XL TAB4MG 5 CARDURA XL TAB8MG 5 CARISOPRODOLTAB250MG 4, 26 CARISOPRODOLTAB350MG 4, 26 CARTEOLOL SOL1% OP 26 CARTIA XT CAP120/24HR 20 CARTIA XT CAP180/24HR 20 CARTIA XT CAP240/24HR 20 CARTIA XT CAP300/24HR 20 CARVEDILOL TAB12.5MG 20 CARVEDILOL TAB25MG 20 CARVEDILOL TAB3.125MG 20 CARVEDILOL TAB6.25MG 20 CARVEDILOL TAB12.5MG 5 CARVEDILOL TAB25MG 5 CAYSTON INH75MG 16 CEDAX CAP400MG 21 CEFACLOR CAP250MG 21 CEFACLOR CAP500MG 21 CEFACLOR SUS125/5ML 21 CEFACLOR SUS250/5ML 21 CEFACLOR SUS375/5ML 21 CEFACLOR ER TAB500MG 21 CEFADROXIL CAP500MG 21 CEFADROXIL SUS250/5ML 21 CEFADROXIL SUS500/5ML 21 CEFADROXIL TAB1GM 21 CEFDINIR CAP300MG 21 CEFDINIR SUS125/5ML 21 CEFDINIR SUS250/5ML 21 CEFDITOREN TAB200MG 21 CEFIXIME SUS100/5ML 21 CEFIXIME SUS200/5ML 21 CEFPODO PROXSUS100/5ML 21 CEFPODO PROXSUS50MG/5ML 21 CEFPODOXIME TAB100MG 21 CEFPODOXIME TAB200MG 21 CEFPROZIL SUS125/5ML 21 CEFPROZIL SUS250/5ML 21 CEFPROZIL TAB250MG 21 CEFPROZIL TAB500MG 21 CEFTIN SUS125/5ML 21 CEFTIN SUS250/5ML 21 CEFUROXIME SUS125/5ML 21 CEFUROXIME TAB250MG 21 CEFUROXIME TAB500MG 21 CELECOXIB 100 MG 9 CELECOXIB 200 MG 9 CELECOXIB 400 MG 9 CELECOXIB 50 MG 9 CELONTIN CAP300MG 12 CENESTIN TAB0.3MG 24 CENESTIN TAB0.45MG 24 CENESTIN TAB0.625MG 24 CENESTIN TAB0.9MG 24 CENESTIN TAB1.25MG 24 CEPHALEXIN CAP250MG 21 CEPHALEXIN CAP500MG 21 CEPHALEXIN SUS125/5ML 21 CEPHALEXIN SUS250/5ML 21 CEPHALEXIN TAB250MG 21 CEPHALEXIN TAB500MG 21 CERDELGA CAP84MG 25 CERVARIX 2
CESAMET CAP1MG 15 CEVIMELINE CAP30MG 25 CHANTIX PAK0.5& 1MG 5, 27 CHANTIX PAK1MG 5, 27 CHANTIX TAB0.5MG 5, 27 CHANTIX TAB1MG 5, 27 CHATEAL 2
CHEMET CAP100MG 15 CHLORHEX GLUSOL0.12% 25 CHLOROQUINE TAB250MG 17 CHLOROQUINE TAB500MG 17 CHLOROTHIAZ TAB250MG 23 CHLOROTHIAZ TAB500MG 23 CHLORPROMAZ TAB100MG 18 CHLORPROMAZ TAB10MG 18 CHLORPROMAZ TAB200MG 18 CHLORPROMAZ TAB25MG 18 CHLORPROMAZ TAB50MG 18 CHLORPROPAM TAB100MG 5, 14 CHLORPROPAM TAB250MG 5, 14 CHLORTHALID TAB100MG 23 CHLORTHALID TAB25MG 23 CHLORTHALID TAB50MG 23 CHLORZOXAZONTAB500MG 21, 26 CHOLESTYRAM POW4GM LITE 15 CIALIS TAB2.5MG 21 CIALIS TAB5MG 21 CICLODAN CRE0.77% 22 CICLODAN SOL8% 22 CICLOPIROX CRE0.77% 22 CICLOPIROX GEL0.77% 22 CICLOPIROX SHA1% 22 CICLOPIROX SOL8% 22 CICLOPIROX SUS0.77% 22 CILOSTAZOL TAB100MG 25 CILOSTAZOL TAB50MG 25 CILOXAN OIN0.3% OP 26 CIMETIDINE SOL300/5ML 28 CIMZIA KIT 24 CIMZIA PREFLKIT200MG/ML 5, 24 CIPRO HC SUSOTIC 26 CIPRODEX SUS0.3-0.1% 26 CIPROFLOXACNSOL0.3% OP 26 CIPROFLOXACNSUS250MG/5 24 CIPROFLOXACNSUS500MG/5 24 CIPROFLOXACNTAB1000MG 24 CIPROFLOXACNTAB100MG 24 CIPROFLOXACNTAB250MG 24 CIPROFLOXACNTAB500MG 24 CIPROFLOXACNTAB500MG ER 24 CIPROFLOXACNTAB750MG 24 CITALOPRAM SOL10MG/5ML 13 CITALOPRAM TAB10MG 13 CITALOPRAM TAB20MG 13 CITALOPRAM TAB40MG 13 CLARAVIS CAP10MG 22 CLARAVIS CAP20MG 22 CLARAVIS CAP30MG 22 CLARAVIS CAP40MG 22 CLARITHROMYCSUS125/5ML 25 CLARITHROMYCSUS250/5ML 25 CLARITHROMYCTAB500MG 5, 25 CLARITHROMYCTAB500MG ER 5, 25 CLEMASTINE SYP0.5/5ML 15 CLEMASTINE TAB2.68MG 15 CLEOCIN CRE2% VAG 28 CLEOCIN SUP100MG 28
34
CLINDACIN KITPAC 1% 22 CLINDAGEL 22 CLINDAMAX CRE2% VAG 28 CLINDAMAX GEL1% 22 CLINDAMAX LOT10MG/ML 22 CLINDAMY/BENGEL1-5% 22 CLINDAMYCIN AER1% 22 CLINDAMYCIN CAP150MG 16 CLINDAMYCIN CAP300MG 16 CLINDAMYCIN CAP75MG 16 CLINDAMYCIN CRE2% VAG 28 CLINDAMYCIN GEL1% 22 CLINDAMYCIN LOT1% 22 CLINDAMYCIN PAD1% 22 CLINDAMYCIN SOL1% 22 CLINDAMYCIN SOL75MG/5ML 16 CLINDETS PAD1% 22 CLOBETASOL AER0.05% 22 CLOBETASOL GEL0.05% 22 CLOBETASOL LOT0.05% 22 CLOBETASOL OIN0.05% 22 CLOBETASOL SHA0.05% 22 CLOBETASOL SOL0.05% 22 CLOBETASOL ECRE0.05% 22 CLOCORTOLONECREPIV 0.1% 22 CLODAN SHA0.05% 22 CLODERM CRE0.1% PMP 22 CLOMIPRAMINECAP25MG 13 CLOMIPRAMINECAP50MG 13 CLOMIPRAMINECAP75MG 13 CLONAZEP ODTTAB0.125MG 5, 11 CLONAZEP ODTTAB0.25MG 5, 11 CLONAZEP ODTTAB0.5MG 5, 11 CLONAZEPAM TAB0.5MG 5, 11 CLONAZEPAM TAB1MG 5, 11 CLONAZEPAM TAB2MG 5, 11 CLONIDINE DIS0.1/24HR 16 CLONIDINE DIS0.2/24HR 16 CLONIDINE DIS0.3/24HR 16 CLONIDINE TAB0.1MG 16 CLONIDINE TAB0.2MG 16 CLONIDINE TAB0.3MG 16 CLOPIDOGREL TAB300MG 25 CLOPIDOGREL TAB75MG 25 CLOTRIM/BETACREDIPROP 22 CLOTRIM/BETALOTDIPROP 22 CLOTRIMAZOLETRO10MG 25 CLOZAPINE TAB100/ODT 18 CLOZAPINE TAB100MG 18 CLOZAPINE TAB200MG 18 CLOZAPINE TAB25MG 18 CLOZAPINE TAB25MG ODT 18 CLOZAPINE TAB50MG 18 CLOZAPINE TAB100MG 5 CLOZAPINE TAB200MG 5 CLOZAPINE TAB25MG 5 CLOZAPINE TAB50MG 5 COARTEM TAB20-120MG 17 CODEINE SULFTAB30MG 10 CODEINE SULFTAB60MG 10 COLCHICINE CAP0.6MG 25 COLESTIPOL GRA5GM 15 COLESTIPOL TAB1GM 15 COLOCORT ENE100MG 11 COLY-MYCIN SSUSOTIC 26 COMBIGAN SOL0.2/0.5% 26 COMETRIQ KIT 17
COMPLERA 19 COMPRO SUP25MG 18 CONCERTA TAB18MG 9 CONCERTA TAB27MG 9 CONCERTA TAB36MG 9 CONCERTA TAB54MG 9 CONDYLOX GEL0.5% 22 CONSTULOSE SOL10GM/15 25 CORDRAN LOT0.05% 22 CORDRAN 80X3TAP4MCG/CM 5, 22 COREG CR CAP10MG 20 COREG CR CAP20MG 20 COREG CR CAP40MG 20 COREG CR CAP80MG 20 COREG CR CAP10MG 5 COREG CR CAP20MG 5 COREG CR CAP40MG 5 COREG CR CAP80MG 5 CORMAX OIN0.05% 22 CORTISONE ACTAB25MG 21 CORTISPORIN CRE0.5% 22 CORTISPORIN OIN1% 22 CORTISPORIN SUS-TC OTIC 26 CORTOMYCIN SUS1% OTIC 26 COSENTYX INJ150MG/ML 22 COVERA-HS TAB180MG 20 COVERA-HS TAB240MG 20 CREON CAP12000UNT 23 CREON CAP24000UNT 23 CREON CAP3000UNIT 23 CREON CAP36000UNT 23 CREON CAP6000UNIT 23 CRINONE GEL4% VAG 28 CRINONE GEL8% VAG 28 CRIXIVAN CAP200MG 19 CRIXIVAN CAP400MG 19 CRIXIVAN CAP200MG 5 CRIXIVAN CAP400MG 5 CROMOLYN SODCON100/5ML 24 CROMOLYN SODNEB20MG/2ML 5, 12 CROMOLYN SODSOL4% OP 26 CUVPOSA SOL1MG/5ML 28 CYCLAFEM 1/35 2
CYCLAFEM 7/7/7 2
CYCLOBENZAPRCAP15MG ER 26 CYCLOBENZAPRCAP30MG ER 26 CYCLOBENZAPRTAB10MG 26 CYCLOBENZAPRTAB5MG 26 CYCLOBENZAPRTAB7.5MG 26 CYCLOPENTOLATE SOL OP 26 CYCLOPHOSPH TAB25MG 17 CYCLOPHOSPH TAB50MG 17 CYCLOSERINE CAP250MG 17 CYCLOSPORINECAP100MG 19 CYCLOSPORINECAP100MG MD 19 CYCLOSPORINECAP25MG 19 CYCLOSPORINECAP25MG MOD 19 CYCLOSPORINECAP50MG MOD 19 CYCLOSPORINESOLMODIFIED 19 CYPROHEPTAD SYP2MG/5ML 15 CYPROHEPTAD TAB4MG 15, 25 CYRED 2
CYSTAGON CAP150MG 25 CYSTAGON CAP50MG 25 CYSTARAN SOL0.44% 26 DALIRESP 5, 12 DALIRESP TAB500MCG 12
DANAZOL CAP100MG 11 DANAZOL CAP200MG 11 DANAZOL CAP50MG 11 DANTROLENE CAP100MG 26 DANTROLENE CAP25MG 26 DANTROLENE CAP50MG 26 DAPSONE TAB100MG 16 DAPSONE TAB25MG 16 DAPTACEL 2
DARAPRIM TAB25MG 17 DARIFENACIN ER TAB 15MG 28 DARIFENACIN ER TAB 7.5MG 28 DASETTA 1/35 2
DASETTA 7/7/7 2
DAYSEE 2
DAYTRANA DIS10MG/9HR 9 DAYTRANA DIS15MG/9HR 9 DAYTRANA DIS20MG/9HR 9 DAYTRANA DIS30MG/9HR 9 DEBLITANE 2
DELESTROGEN INJ10MG/ML 24 DELYLA 2
DELZICOL CAP400MG 24 DEMECLOCYCL TAB150MG 27 DEMECLOCYCL TAB300MG 27 DEPO-ESTRADIINJ5MG/ML 24 DEPO-TESTOSTINJ100MG/ML 11 DEPO-TESTOSTINJ200MG/ML 11 DESCOVY TAB200/25 19 DESIPRAMINE TAB100MG 13 DESIPRAMINE TAB10MG 13 DESIPRAMINE TAB150MG 13 DESIPRAMINE TAB25MG 13 DESIPRAMINE TAB50MG 13 DESIPRAMINE TAB75MG 13 DESLORATADINTAB2.5 ODT 15 DESLORATADINTAB5MG 15 DESLORATADINTAB5MG ODT 15 DESMOPRESSINSOL0.01% 23 DESMOPRESSINSPR0.01% 23 DESMOPRESSINTAB0.1MG 23 DESMOPRESSINTAB0.2MG 23 DESO/ETHINYLTABEST-28 2
DESONATE GEL0.05% 22 DESONIDE CRE0.05% 22 DESONIDE LOT0.05% 22 DESONIDE OIN0.05% 22 DESOXIMETAS CRE0.25% 22 DESOXIMETAS GEL0.05% 22 DESOXIMETAS OIN0.25% 22 DESVENLAFAX TAB100MG ER 5, 13 DESVENLAFAX TAB50MG ER 5, 13 DEXAMETH PHOSOL0.1% OP 26 DEXAMETHASONCON1MG/ML 21 DEXAMETHASONELX0.5/5ML 21 DEXAMETHASONTAB0.5MG 21 DEXAMETHASONTAB0.75MG 21 DEXAMETHASONTAB1.5MG 21 DEXAMETHASONTAB1MG 21 DEXAMETHASONTAB2MG 21 DEXAMETHASONTAB4MG 21 DEXAMETHASONTAB6MG 21 DEXCHLORPHENSYP2MG/5ML 15 DEXMETHYLPH CAP15MG ER 5, 9 DEXMETHYLPH CAP30MG ER 5, 9 DEXMETHYLPH CAP40MG ER 5, 9
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DEXMETHYLPH TAB10MG 5, 9 DEXMETHYLPH TAB2.5MG 5, 9 DEXMETHYLPH TAB5MG 5, 9 DEXPAK PAK13 DAY 21 DEXPAK PAK6 DAY 21 DEXTROAMPHETCAP10MG ER 5, 9 DEXTROAMPHETCAP15MG ER 5, 9 DEXTROAMPHETCAP5MG ER 5, 9 DEXTROAMPHETTAB10MG 5, 9 DEXTROAMPHETTAB5MG 5, 9 DIAZEPAM 11 DIAZEPAM INTENSOL 11 DIBENZYLINE CAP10MG 16 DICLEGIS TAB 19 DICLOFEN POTTAB50MG 9 DICLOFENAC GEL 3% 22 DICLOFENAC SOL0.1% OP 26 DICLOFENAC SOL1.5% 22 DICLOFENAC TAB100MG ER 9 DICLOFENAC TAB25MG DR 9 DICLOFENAC TAB50MG DR 9 DICLOFENAC TAB75MG DR 9 DICLOXACILL CAP250MG 27 DICLOXACILL CAP500MG 27 DICYCLOMINE CAP10MG 28 DICYCLOMINE SOL10MG/5ML 28 DICYCLOMINE TAB20MG 28 DIDANOSINE CAP125MG 19 DIDANOSINE CAP200MG 19 DIDANOSINE CAP250MG 19 DIDANOSINE CAP400MG 19 DIFICID TAB200MG 25 DIFLORASONE CRE0.05% 22 DIFLORASONE OIN0.05% 22 DIFLUNISAL TAB500MG 10 DIGOX TAB0.125MG 21 DIGOX TAB0.25MG 21 DIGOXIN SOL50MCG/ML 21 DIGOXIN TAB0.125MG 21 DIGOXIN TAB0.25MG 21 DIHYDROERGOTINJ1MG/ML 25 DILANTIN CAP30MG 12 DILT-CD CAP300MG 20 DILTIA XT CAP120MG/24 20 DILTIA XT CAP180MG/24 20 DILTIA XT CAP240MG/24 20 DILTIAZEM CAP120MG CD 20 DILTIAZEM CAP120MG ER 20 DILTIAZEM CAP180MG/24 20 DILTIAZEM CAP240MG CD 20 DILTIAZEM CAP300MG ER 20 DILTIAZEM CAP360MG/24 20 DILTIAZEM CAP420MG/24 20 DILTIAZEM CAP60MG ER 20 DILTIAZEM CAP90MG ER 20 DILTIAZEM TAB120MG 20 DILTIAZEM TAB30MG 20 DILTIAZEM TAB60MG 20 DILTIAZEM TAB90MG 20 DILT-XR CAP120MG 20 DILT-XR CAP180MG 20 DILT-XR CAP240MG 20 DIPENTUM CAP250MG 24 DIPHEN/ATROPINE 2.5MGTAB 5, 24 DIPYRIDAMOLETAB25MG 25 DIPYRIDAMOLETAB50MG 25 DIPYRIDAMOLETAB75MG 25
DISOPYRAMIDECAP100MG 11 DISOPYRAMIDECAP150MG 11 DISULFIRAM TAB250MG 27 DISULFIRAM TAB500MG 27 DIURIL SUS250/5ML 23 DIVALPROEX CAP125MG 12 DIVALPROEX TAB125MG DR 12 DIVALPROEX TAB250MG DR 12 DIVALPROEX TAB250MG ER 13 DIVALPROEX TAB500MG DR 13 DIVALPROEX TAB500MG ER 13 DIVIGEL GEL1MG/GM 24 DONEPEZIL TAB10MG 27 DONEPEZIL TAB10MG ODT 27 DONEPEZIL TAB5MG 27 DONEPEZIL TAB5MG ODT 27 DORZOL/TIMOLSOL2-0.5%OP 26 DORZOLAMIDE SOL2% OP 26 DOVONEX CRE0.005% 22 DOXAZOSIN TAB1MG 16 DOXAZOSIN TAB2MG 16 DOXAZOSIN TAB4MG 16 DOXAZOSIN TAB8MG 16 DOXEPIN HCL CAP100MG 13 DOXEPIN HCL CAP10MG 13 DOXEPIN HCL CAP150MG 13 DOXEPIN HCL CAP25MG 13 DOXEPIN HCL CAP50MG 13 DOXEPIN HCL CAP75MG 13 DOXEPIN HCL CON10MG/ML 13 DOXERCALCIF CAP0.5MCG 23 DOXERCALCIF CAP1MCG 23 DOXERCALCIF CAP2.5MCG 23 DOXYCYCL HYCTA2100MG DR 27 DOXYCYCL HYCTAB100MG DR 27 DOXYCYCL HYCTAB150MG DR 27 DOXYCYCL HYCTAB75MG DR 27 DOXYCYCLINE 27 DOXYCYCLINE CAP150MG 27 DOXYCYCLINE CAP75MG 27 DOXYCYCLINE MONOHYDRATE 27 DOXYCYCLINE TAB20MG 27 DRONABINOL CAP10MG 15 DRONABINOL CAP2.5MG 15 DRONABINOL CAP5MG 15 DROSPIRENONE/ETHINYL ESTR 2
DROXIA CAP200MG 25 DROXIA CAP300MG 25 DROXIA CAP400MG 25 DULERA AER100-5MCG 5, 12 DULERA AER200-5MCG 5, 12 DULOXETINE CAP20MG 13 DULOXETINE CAP30MG 13 DULOXETINE CAP60MG 13 DULOXETINE CAP30MG 5 DUREZOL EMU0.05% 26 DYNACIRC CR TAB5MG 20 DYRENIUM CAP100MG 23 DYRENIUM CAP50MG 23 E.E.S. 400 TAB400MG 25 E.E.S. GRAN SUS200/5ML 25 ECONAZOLE CRE1% 22 EDARBI TAB40MG 16 EDARBI TAB80MG 16 EDECRIN TAB25MG 23 EDURANT TAB25MG 19 EFFIENT TAB10MG 25
EFFIENT TAB5MG 25 EFFIENT TAB10MG 5 ELESTRIN GEL0.06% 24 ELIDEL CRE1% 22 ELIDEL CRE1% 5 ELIPHOS TAB667MG 24 ELIQUIS TAB2.5MG 12 ELIQUIS TAB5MG 12 ELIQUIS TAB2.5MG 5 ELIQUIS TAB5MG 5 ELIXOPHYLLINELX80/15ML 12 ELLA TAB30MG 21 EMADINE SOL0.05% OP 26 EMBEDA CAP100-4MG 10 EMBEDA CAP20-0.8MG 10 EMBEDA CAP30-1.2MG 10 EMBEDA CAP50-2MG 10 EMBEDA CAP60-2.4MG 10 EMBEDA CAP80-3.2MG 10 EMCYT CAP140MG 17 EMEND CAP125MG 15 EMEND CAP40MG 15 EMEND CAP80MG 15 EMEND PAK80 & 125 15 EMEND CAP125MG 5 EMEND CAP40MG 5 EMEND CAP80MG 5 EMEND PAK80 & 125 5 EMOQUETTE 2
EMSAM DIS12MG/24H 13 EMSAM DIS6MG/24HR 13 EMSAM DIS9MG/24HR 13 EMTRIVA CAP200MG 19 EMTRIVA SOL10MG/ML 19 ENALAPRIL TAB10MG 16 ENALAPRIL TAB2.5MG 16 ENALAPRIL TAB20MG 16 ENALAPRIL TAB5MG 16 ENBREL INJ25/0.5ML 9 ENBREL INJ25MG 9 ENBREL INJ50MG/ML 9 ENBREL SURECLICK 5, 9 ENDOCET TAB2.5-325 10 ENDOMETRIN SUP100MG 28 ENGERIX-B 2
ENJUVIA TAB0.3MG 24 ENJUVIA TAB0.45MG 24 ENJUVIA TAB0.625MG 24 ENJUVIA TAB0.9MG 24 ENJUVIA TAB1.25MG 24 ENOXAPARIN INJ100MG/ML 12 ENOXAPARIN INJ120/0.8 12 ENOXAPARIN INJ150MG/ML 12 ENOXAPARIN INJ30/0.3ML 12 ENOXAPARIN INJ300/3ML 12 ENOXAPARIN INJ40/0.4ML 12 ENOXAPARIN INJ60/0.6ML 12 ENOXAPARIN INJ80/0.8ML 12 ENSKYCE 2
ENTACAPONE TAB200MG 18 ENTECAVIR TAB0.5MG 19 ENTECAVIR TAB1MG 19 EPCLUSA TAB 19 EPIDUO GEL0.1-2.5% 22 EPINASTINE DRO0.05% 26 EPINEPHRINE INJ0.15MG 5, 28 EPINEPHRINE INJ0.1MG/ML 12
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EPINEPHRINE INJ0.3MG 5, 28 EPITOL TAB200MG 13 EPLERENONE TAB25MG 16 EPLERENONE TAB50MG 16 EPROSART MESTAB600MG 5, 16 EPZICOM TAB600-300 19 EPZICOM TAB600-300 5 EQUETRO CAP100MG 18 EQUETRO CAP200MG 18 EQUETRO CAP300MG 18 EQUETRO CAP100MG 5 EQUETRO CAP200MG 5 EQUETRO CAP300MG 5 ERGOLOID MESTAB1MG ORAL 27 ERGOMAR SUB2MG 25 ERIVEDGE CAP150MG 17 ERIVEDGE CAP150MG 5 ERRIN 2
ERTACZO CRE2% 22 ERY PAD2% 22 ERYPED SUS200/5ML 25 ERYPED SUS400/5ML 25 ERY-TAB TAB250MG EC 25 ERY-TAB TAB333MG EC 25 ERY-TAB TAB500MG EC 25 ERYTHROCIN TAB250MG 25 ERYTHROM ETHTAB400MG 25 ERYTHROMYCINGEL/BENZOYL 22 ERYTHROMYCINGEL2% 22 ERYTHROMYCINOINOP 26 ERYTHROMYCINPAD2% 22 ERYTHROMYCINSOL2% 22 ERYTHROMYCINTAB250MG BS 25 ERYTHROMYCINTAB500MG BS 25 ESCITALOPRAMSOL5MG/5ML 5, 13 ESCITALOPRAMTAB10MG 5, 13 ESCITALOPRAMTAB20MG 5, 13 ESCITALOPRAMTAB5MG 5, 13 ESOMEPRA MAGCAP20MG DR 5, 28 ESOMEPRA MAGCAP40MG DR 28
ESTARYLLA 2
ESTRACE VAG CRE0.1MG/GM 28 ESTRAD VAL INJ10MG/ML 24 ESTRAD VAL INJ20MG/ML 24 ESTRAD VAL INJ40MG/ML 24 ESTRADIOL DIS0.025MG 24 ESTRADIOL DIS0.0375MG 24 ESTRADIOL DIS0.05MG 24 ESTRADIOL DIS0.06MG 24 ESTRADIOL DIS0.075MG 24 ESTRADIOL DIS0.1MG 24 ESTRADIOL TAB0.5MG 20, 24 ESTRADIOL TAB1MG 24 ESTRADIOL TAB2MG 24 ESTRADIOL DIS0.025MG 5 ESTRADIOL DIS0.0375MG 5 ESTRING MIS2MG 28 ESTROPIPATE TAB0.75MG 24 ESTROPIPATE TAB1.5MG 24 ESTROPIPATE TAB3MG 24 ESZOPICLONE TAB1MG 25 ESZOPICLONE TAB2MG 25 ESZOPICLONE TAB3MG 25 ETHAMBUTOL TAB100MG 17 ETHAMBUTOL TAB400MG 17 ETHOSUXIMIDECAP250MG 13 ETHOSUXIMIDESOL250/5ML 13
ETIDRON DISDTAB200MG 23 ETIDRON DISDTAB400MG 23 ETODOLAC CAP200MG 9 ETODOLAC CAP300MG 9 ETODOLAC TAB400MG 9 ETODOLAC TAB500MG 9 ETODOLAC ER TAB400MG 9 ETODOLAC ER TAB500MG 9 ETODOLAC ER TAB600MG 9 EURAX CRE10% 22 EURAX LOT10% 22 EVAMIST SPR1.53MG 24 EVOTAZ 19 EXELDERM CRE1% 22 EXELDERM SOL1% 22 EXELON SOL2MG/ML 27 EXEMESTANE TAB25MG 17 EXJADE TAB125MG 15 EXJADE TAB250MG 15 EXJADE TAB500MG 15 EXTAVIA INJ0.3MG 27 EZETIM/SIMVATAB10-10MG 5, 15 EZETIM/SIMVATAB10-20MG 5, 15 EZETIM/SIMVATAB10-40MG 5, 15 EZETIM/SIMVATAB10-80MG 5, 15 FA-8 2
FABIOR AER0.1% 22 FACTIVE TAB320MG 24 FALMINA 2
FAMCICLOVIR TAB125MG 5, 19 FAMCICLOVIR TAB250MG 5, 19 FAMCICLOVIR TAB500MG 5, 19 FAMOTIDINE SUS40MG/5ML 28 FAMOTIDINE TAB20MG 28 FAMOTIDINE TAB40MG 28 FANAPT PAK 18 FANAPT TAB10MG 18 FANAPT TAB12MG 18 FANAPT TAB1MG 18 FANAPT TAB2MG 18 FANAPT TAB4MG 18 FANAPT TAB6MG 18 FANAPT TAB8MG 18 FARESTON TAB60MG 17 FARXIGA TAB10MG 14 FARXIGA TAB5MG 14 FAZACLO TAB12.5/ODT 18 FAZACLO TAB150MG 18 FAZACLO TAB200MG 18 FELBAMATE SUS600/5ML 13 FELBAMATE TAB400MG 13 FELBAMATE TAB600MG 13 FELODIPINE TAB10MG ER 20 FELODIPINE TAB2.5MG ER 20 FELODIPINE TAB5MG ER 20 FEMRING MIS0.05/24H 28 FEMRING MIS0.1MG/24 28 FEMYNOR 2
FENOFIBRATE CAP130MG 5, 15 FENOFIBRATE CAP134MG 5, 15 FENOFIBRATE CAP200MG 5, 15 FENOFIBRATE CAP43MG 5, 15 FENOFIBRATE CAP67MG 5, 15 FENOFIBRATE TAB145MG 5, 15 FENOFIBRATE TAB160MG 5, 15 FENOFIBRATE TAB48MG 5, 15 FENOFIBRATE TAB54MG 5, 15
FENOFIBRIC CAP135MG DR 15 FENOFIBRIC CAP45MG DR 15 FENOFIBRIC TAB105MG 15 FENOFIBRIC TAB35MG 15 FENOGLIDE TAB120MG 15 FENOGLIDE TAB40MG 15 FENOPROFEN TAB600MG 9 FENOPROFEN CALCIUM 9 FENTANYL DIS100MCG/H 10 FENTANYL DIS12MCG/HR 10 FENTANYL DIS25MCG/HR 10 FENTANYL DIS50MCG/HR 10 FENTANYL DIS75MCG/HR 10 FENTANYL OT LOZ1200MCG 5, 10 FENTANYL OT LOZ1600MCG 5, 10 FENTANYL OT LOZ200MCG 5, 10 FENTANYL OT LOZ400MCG 5, 10 FENTANYL OT LOZ600MCG 5, 10 FENTANYL OT LOZ800MCG 5, 10 FENTORA TAB400MCG 10 FERRIPROX TAB500MG 15 FIBRICOR TAB105MG 15 FIBRICOR TAB35MG 15 FINACEA GEL15% 22 FINASTERIDE TAB5MG 5, 25 FIRAZYR 25 FIRST-OMEPRASUS2MG/ML 28 FLAREX SUS0.1% OP 26 FLAVOXATE TAB100MG 28 FLECAINIDE TAB100MG 11 FLECAINIDE TAB150MG 11 FLECAINIDE TAB50MG 11 FLOVENT DISKAER100MCG 5, 12 FLOVENT DISKAER250MCG 5, 12 FLOVENT DISKAER50MCG 5, 12 FLOVENT HFA AER110MCG 5, 12 FLOVENT HFA AER220MCG 5, 12 FLOVENT HFA AER44MCG 5, 12 FLUAD 2
FLUARIX 2
FLUARIX QUADRIVALENT 2
FLUBLOK 2
FLUCELVAX 2
FLUCONAZOLE SUS10MG/ML 15 FLUCONAZOLE SUS40MG/ML 15 FLUCONAZOLE TAB100MG 15 FLUCONAZOLE TAB150MG 5, 15 FLUCONAZOLE TAB200MG 15 FLUCONAZOLE TAB50MG 15 FLUCYTOSINE CAP250MG 15 FLUCYTOSINE CAP500MG 15 FLUDROCORT TAB0.1MG 21 FLULAVAL 2
FLULAVAL QUADRIVALENT 2
FLUNISOLIDE SPR0.025% 5, 26 FLUOCIN ACETCRE0.01% 22 FLUOCIN ACETCRE0.025% 22 FLUOCIN ACETOIL0.01% 26 FLUOCIN ACETOILBODY 22 FLUOCIN ACETOIN0.025% 22 FLUOCIN ACETSOL0.01% 22 FLUOCINONIDECRE0.1% 22 FLUOCINONIDECRE-E 0.05% 22 FLUOCINONIDEGEL0.05% 22 FLUOCINONIDEOIN0.05% 22 FLUOCINONIDESOL0.05% 22
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FLUORABON 2
FLUOR-A-DAY 2
FLUORIDE CHW0.5MG 2
FLUORIDE CHW1MG 2
FLUORITAB 2
FLUOROMETHOLSUS0.1% OP 26 FLUOROPLEX CRE1% 22 FLUOROURACILCRE5% 22 FLUOROURACILSOL2% 22 FLUOROURACILSOL5% 22 FLUOXETINE CAP10MG 13, 27 FLUOXETINE CAP20MG 13, 27 FLUOXETINE CAP40MG 13 FLUOXETINE CAP90MG DR 14 FLUOXETINE SOL20MG/5ML 14 FLUOXETINE TAB10MG 14 FLUOXETINE TAB20MG 14 FLUOXETINE TAB60MG 14 FLUPHENAZINECON5MG/ML 18 FLUPHENAZINEELX2.5/5ML 18 FLUPHENAZINETAB10MG 18 FLUPHENAZINETAB1MG 18 FLUPHENAZINETAB2.5MG 18 FLUPHENAZINETAB5MG 18 FLURA-DROPS 2
FLURBIPROFENSOL0.03% OP 26 FLURBIPROFENTAB100MG 9 FLURBIPROFENTAB50MG 9 FLUTAMIDE CAP125MG 17 FLUTICASONE CRE0.05% 22 FLUTICASONE LOT0.05% 22 FLUTICASONE OIN0.005% 22 FLUTICASONE SPR50MCG 5, 26 FLUVASTATIN CAP20MG 5, 15 FLUVASTATIN CAP40MG 5, 15 FLUVASTATIN ER TAB 15 FLUVIRIN 2
FLUVOXAMINE CAP 100 MG ER 14 FLUVOXAMINE CAP 150 MG ER 14 FLUVOXAMINE TAB100MG 5, 14 FLUVOXAMINE TAB25MG 5, 14 FLUVOXAMINE TAB50MG 5, 14 FLUZONE HIGH-DOSE 2
FLUZONE QUADRIVALENT 2
FML OIN0.1% OP 26 FML FORTE SUS0.25% OP 26 FOLIC ACID TAB400MCG 2
FOLIC ACID TAB800MCG 2
FONDAPARINUXSOL10/0.8 5, 12 FONDAPARINUXSOL2.5/0.5 5, 12 FONDAPARINUXSOL5.0/0.4 5, 12 FONDAPARINUXSOL7.5/0.6 5, 12 FORADIL CAPAEROLIZE 12 FORFIVO XL TAB450MG 14 FORTEO SOL600/2.4 23 FORTESTA 11 FORTICAL SPR200/ACT 23 FOSAMAX + D TAB70-2800 5, 23 FOSAMAX + D TAB70-5600 5, 23 FOSINOPRIL TAB10MG 16 FOSINOPRIL TAB20MG 16 FOSINOPRIL TAB40MG 16 FOSRENOL CHW1000MG 24 FOSRENOL CHW500MG 24 FOSRENOL CHW750MG 24 FREESTYLE LANCETS 5, 23
FREESTYLE TEST STRIPS 5, 23 FROVATRIPTAN TAB 2.5MG 25 FUROSEMIDE SOL10MG/ML 23 FUROSEMIDE SOL8MG/ML 23 FUROSEMIDE TAB20MG 23 FUROSEMIDE TAB40MG 23 FUROSEMIDE TAB80MG 23 FYCOMPA TAB10MG 13 FYCOMPA TAB12MG 13 FYCOMPA TAB2MG 13 FYCOMPA TAB4MG 13 FYCOMPA TAB6MG 13 FYCOMPA TAB8MG 13 GABAPENTIN CAP100MG 13 GABAPENTIN CAP300MG 13 GABAPENTIN CAP400MG 13 GABAPENTIN SOL250/5ML 13 GABAPENTIN TAB600MG 13 GABAPENTIN TAB800MG 13 GABITRIL TAB12MG 13 GABITRIL TAB16MG 13 GALANTAMINE CAP16MG ER 5, 27 GALANTAMINE CAP24MG ER 5, 27 GALANTAMINE CAP8MG ER 5, 27 GALANTAMINE SOL4MG/ML 5, 27 GALANTAMINE TAB12MG 5, 27 GALANTAMINE TAB4MG 5, 27 GALANTAMINE TAB8MG 5, 27 GARDASIL 2
GARDASIL 9 2
GATIFLOXACINSOL0.5% 26 GAVILYTE-C 2
GAVILYTE-G 2
GAVILYTE-N/FLAVOR PACK 2
GELNIQUE GEL10% 28 GELNIQUE GEL3% 28 GEMFIBROZIL TAB600MG 15 GENERLAC SOL10GM/15 24 GENGRAF CAP100MG 19 GENGRAF CAP25MG 19 GENGRAF SOL100MG/ML 19 GENOPTIC SOL0.3% OP 26 GENORA TAB1/35-28 2
GENOTROPIN INJ0.2MG 23 GENOTROPIN INJ0.4MG 23 GENOTROPIN INJ0.6MG 23 GENOTROPIN INJ0.8MG 24 GENOTROPIN INJ1.2MG 24 GENOTROPIN INJ1.4MG 24 GENOTROPIN INJ1.6MG 24 GENOTROPIN INJ1.8MG 24 GENOTROPIN INJ12MG 24 GENOTROPIN INJ1MG 24 GENOTROPIN INJ2MG 24 GENOTROPIN INJ5MG 24 GENTAK OIN0.3% OP 26 GENTAMICIN CRE0.1% 22 GENTAMICIN OIN0.1% 22 GENTAMICIN OIN0.3% OP 26 GENTAMICIN SOL0.3% OP 26 GENTASOL SOL0.3% OP 26 GIANVI 2
GIAZO TAB1.1GM 24 GILDAGIA 2
GILENYA CAP0.5MG 27 GILOTRIF TAB20MG 17
GILOTRIF TAB30MG 17 GILOTRIF TAB40MG 17 GLATOPA INJ 20MG/ML 27 GLEOSTINE CAP100MG 17 GLEOSTINE CAP10MG 17 GLEOSTINE CAP40MG 17 GLIMEPIRIDE TAB1MG 5, 14 GLIMEPIRIDE TAB2MG 5, 14 GLIMEPIRIDE TAB4MG 5, 14 GLIPIZIDE TAB10MG 14 GLIPIZIDE TAB5MG 14 GLIPIZIDE ERTAB10MG 5, 14 GLIPIZIDE ERTAB2.5MG 5, 14 GLIPIZIDE ERTAB5MG 5, 14 GLUCAGEN INJHYPOKIT 14, 23 GLUCAGON KIT1MG 14 GLYBURID MCRTAB1.5MG 5, 14 GLYBURID MCRTAB3MG 5, 14 GLYBURID MCRTAB6MG 5, 14 GLYBURIDE TAB1.25MG 14 GLYBURIDE TAB2.5MG 14 GLYBURIDE TAB5MG 14 GLYCATE TAB1.5MG 28 GLYCOPYRROL TAB1MG 28 GLYCOPYRROL TAB2MG 28 GLYDO GEL2% 22 GRANISETRON TAB1MG 5, 15 GRANISOL SOL2MG/10ML 15 GRISEOFULVINSUS125/5ML 15 GRISEOFULVINTABMICR 500 15 GRISEOFULVINTABULTR 125 15 GRISEOFULVINTABULTR 250 15 GUANFACINE TAB1MG 9, 16 GUANFACINE TAB1MG ER 9 GUANFACINE TAB2MG 9, 16 GUANFACINE TAB2MG ER 9 GUANFACINE TAB3MG ER 9 GUANFACINE TAB4MG ER 9 GUANIDINE TAB125MG 17 HALOBETASOL CRE0.05% 22 HALOBETASOL OIN0.05% 22 HALOG CRE0.1% 22 HALOG OIN0.1% 22 HALOPERIDOL CON2MG/ML 18 HALOPERIDOL TAB0.5MG 18 HALOPERIDOL TAB10MG 18 HALOPERIDOL TAB1MG 18 HALOPERIDOL TAB20MG 18 HALOPERIDOL TAB2MG 18 HALOPERIDOL TAB5MG 18 HAVRIX 2
HC BUTYRATE CRE0.1% 22 HC BUTYRATE OIN0.1% 22 HC BUTYRATE SOL0.1% 22 HC VALERATE CRE0.2% 22 HC VALERATE OIN0.2% 22 HC/ACET ACIDSOLOTIC 26
HEATHER 2
HEPARIN LOCKINJ100/ML 12 HEPARIN SOD INJ1000/ML 12 HEPARIN SOD INJ10000/ML 12 HEPARIN SOD INJ5000/ML 12 HEPARIN SODIUM 12 HIBTITER 2
HORIZANT TAB300MG 27 HORIZANT TAB600MG 27 HUMALOG INJ100/ML 14
38
HUMALOG KWIKPEN 5, 14 HUMALOG MIX INJ50/50 5, 14 HUMALOG MIX INJ50/50KWP 5, 14 HUMALOG MIX INJ75/25KWP 5, 14 HUMALOG MIX SUS75/25 5, 14 HUMATROPE INJ12MG 24 HUMATROPE INJ24MG 24 HUMATROPE INJ5MG 24 HUMATROPE INJ6MG 24 HUMIRA INJ10MG/0.2 10 HUMIRA INJ40MG/0.8 10 HUMIRA KIT20MG/0.4 10 HUMIRA PEDIATRIC CROHNS D 5, 10 HUMIRA PEN INJCROHNS 10 HUMULIN INJ70/30 14 HUMULIN N INJU-100 14 HUMULIN R INJU-100 14 HUMULIN R INJU-500 14 HYDRALAZINE TAB100MG 16 HYDRALAZINE TAB10MG 16 HYDRALAZINE TAB25MG 16 HYDRALAZINE TAB50MG 16 HYDROCHLOROTCAP12.5MG 23 HYDROCHLOROTTAB12.5MG 23 HYDROCHLOROTTAB25MG 23 HYDROCO/APAP 10-325MG 5 HYDROCO/APAP TAB 10-325MG 5, 10 HYDROCO/APAP TAB 5-325MG 5, 10 HYDROCO/APAP TAB 7.5-325MG 5, 10 HYDROCORT CRE2.5% 11, 22 HYDROCORT ENE100MG 11 HYDROCORT LOT2.5% 22 HYDROCORT OIN2.5% 22 HYDROCORT TAB10MG 21 HYDROCORT TAB20MG 21 HYDROCORT TAB5MG 21 HYDROMORPHONLIQ1MG/ML 10 HYDROMORPHONTAB12MG ER 10 HYDROMORPHONTAB16MG ER 10 HYDROMORPHONTAB2MG 10 HYDROMORPHONTAB32MG ER 5, 10 HYDROMORPHONTAB4MG 5, 10 HYDROMORPHONTAB8MG 5, 6, 10 HYDROMORPHONTAB8MG ER 6, 10 HYDROXY CAPRINJ1.25/5ML 17 HYDROXYCHLORTAB200MG 17 HYDROXYUREA CAP500MG 17 HYDROXYZ HCLSOL10MG/5ML 11 HYDROXYZ HCLTAB10MG 11 HYDROXYZ HCLTAB25MG 11 HYDROXYZ HCLTAB50MG 11 HYDROXYZ PAMCAP100MG 11 HYDROXYZ PAMCAP25MG 11 HYDROXYZ PAMCAP50MG 11 IBANDRONATE TAB150MG 6, 24 IBUPROFEN TAB400MG 10 IBUPROFEN TAB600MG 10 IBUPROFEN TAB800MG 10 ICLUSIG TAB15MG 17 ILEVRO DRO0.3% OP 26 ILOTYCIN OINOP 26 IMATINIB MESTAB100MG 17 IMATINIB MESTAB400MG 17 IMBRUVICA CAP140MG 17 IMDUR TAB60MG ER 11 IMIPRAM HCL TAB10MG 14 IMIPRAM HCL TAB25MG 14
IMIPRAM HCL TAB50MG 14 IMIPRAM PAM CAP100MG 14 IMIPRAM PAM CAP125MG 14 IMIPRAM PAM CAP150MG 14 IMIPRAM PAM CAP75MG 14 IMIQUIMOD CRE5% 22 INCRELEX INJ40MG/4ML 24 INDAPAMIDE TAB1.25MG 23 INDAPAMIDE TAB2.5MG 23 INDOCIN SUS25MG/5ML 10 INDOMETHACINCAP25MG 6, 10 INDOMETHACINCAP50MG 10 INDOMETHACINCAP75MG ER 10 INFANRIX 2
INSULIN PEN NEEDLES 25 INSULIN SYRINGES 25 INTELENCE TAB100MG 19 INTELENCE TAB200MG 19 INTELENCE TAB25MG 19 INTRON A INJ18MU 17 INTRON A INJ50MU 17 INTRON-A INJ10MU 17 INTRON-A INJ18MU 17
INTROVALE 2
INVIRASE CAP200MG 19 INVIRASE TAB500MG 19 INVOKAMET TAB150-1000 14 INVOKAMET TAB150-500 14 INVOKAMET TAB50-1000 14 INVOKAMET TAB50-500MG 14 INVOKANA TAB100MG 14 INVOKANA TAB300MG 14 IOPIDINE SOL1% OP 26 IPOL INACTIVATED IPV 2
IPRATROPIUM SOL0.02%INH 12 IPRATROPIUM SPR0.03% 6, 26 IPRATROPIUM SPR0.06% 6, 26 IRBESARTAN TAB150MG 16 IRBESARTAN TAB300MG 16 IRBESARTAN TAB75MG 16 ISENTRESS CHW100MG 19 ISENTRESS CHW25MG 19 ISENTRESS POW100MG 19 ISENTRESS TAB400MG 19 ISOCHRON TAB40MG CR 11 ISODITRATE TAB40MG ER 11 ISONIAZID SYP50MG/5ML 17 ISONIAZID TAB100MG 17 ISONIAZID TAB300MG 17 ISOSORB DIN SUB2.5MG 11 ISOSORB DIN SUB5MG 11 ISOSORB DIN TAB10MG 11 ISOSORB DIN TAB20MG 11 ISOSORB DIN TAB30MG 11 ISOSORB DIN TAB40MG ER 11 ISOSORB DIN TAB5MG 11 ISOSORB MONOTAB10MG 11 ISOSORB MONOTAB120MG ER 11 ISOSORB MONOTAB20MG 11 ISOSORB MONOTAB30MG ER 11 ISOSORB MONOTAB60MG ER 11 ISRADIPINE CAP2.5MG 20 ISRADIPINE CAP5MG 20 ISTALOL SOL0.5% OP 26 ITRACONAZOLECAP100MG 15 IVERMECTIN TAB3MG 19 JAKAFI TAB10MG 17
JAKAFI TAB15MG 17 JAKAFI TAB20MG 17 JAKAFI TAB25MG 17 JAKAFI TAB5MG 17 JANTOVEN TAB10MG 12 JANTOVEN TAB1MG 12 JANTOVEN TAB2.5MG 12 JANTOVEN TAB2MG 12 JANTOVEN TAB3MG 12 JANTOVEN TAB4MG 12 JANTOVEN TAB5MG 12 JANTOVEN TAB6MG 12 JANTOVEN TAB7.5MG 12 JANUVIA TAB100MG 14 JANUVIA TAB25MG 14 JANUVIA TAB50MG 14 JARDIANCE TAB10MG 14 JARDIANCE TAB25MG 14 JENCYCLA 2
JOLESSA 2
JUBLIA SOL10% 22 JULEBER 2
JUNEL 1.5/30 2
JUNEL 1.5/30TAB 2
JUNEL 1/20 2
JUNEL FE 1.5/30 2
JUNEL FE 1/20 2
JUNEL FE 24 2
KAITLIB FE 2
KALYDECO TAB150MG 27 KARIDIUM 2
KARIVA 2
KENALOG AERSPRAY 22 KERYDIN SOL5% 22 KETEK TAB300MG 16 KETEK TAB400MG 16 KETOCONAZOLEAER2% 22 KETOCONAZOLECRE2% 22 KETOCONAZOLESHA2% 22 KETOCONAZOLETAB200MG 15 KETODAN KIT2% 22 KETOPROFEN CAP50MG 10 KETOPROFEN CAP75MG 10 KETOROLAC SOL0.4% 26 KETOROLAC SOL0.5% 26 KETOROLAC TAB10MG 10 KIMIDESS 2
KINERET INJ 10 KINRIX 2
KIONEX POW 19 KLOR-CON 10 TAB10MEQ ER 25 KLOR-CON 8 TAB8MEQ ER 25 KLOR-CON M15TAB 25 KLOR-CON M20TAB20MEQ ER 25 KLOR-CON SPRINKLE 25 KRISTALOSE PAK10GM 25 KRISTALOSE PAK20GM 25 K-TAB TAB20MEQ 25 KURIC CRE2% 22 KURVELO 2
LABETALOL TAB100MG 20 LABETALOL TAB200MG 20 LABETALOL TAB300MG 20 LACRISERT MIS5MG OP 26 LACTULOSE SOL10GM/15 24, 25 LAMISIL GRA125MG 15
39
LAMISIL GRA187.5MG 15 LAMIVUD/ZIDOTAB150-300 6, 19 LAMIVUDINE TAB100MG 19 LAMIVUDINE TAB150MG 19 LAMIVUDINE TAB300MG 19 LAMOTRIGINE CHW25MG 13 LAMOTRIGINE CHW5MG 13 LAMOTRIGINE ER 13 LAMOTRIGINE TAB100MG 13 LAMOTRIGINE TAB150MG 13 LAMOTRIGINE TAB200MG 13 LAMOTRIGINE TAB25MG 13 LANOXIN TAB0.0625MG 21 LANOXIN TAB0.1875MG 21 LANOXIN TAB 0.25MG 21 LANSOPRAZOLECAP30MG DR 6, 28 LANTUS INJ100/ML 14 LANTUS INJSOLOSTAR 14 LARIN 1.5/30 2
LARIN 1/20 2
LARIN 24 FE 2
LARIN FE 1.5/30 2
LARIN FE 1/20 2
LARISSIA 2
LASTACAFT SOL0.25% 26 LATANOPROST SOL0.005% 6, 26 LATUDA TAB120MG 18 LATUDA TAB20MG 18 LATUDA TAB40MG 18 LATUDA TAB60MG 18 LATUDA TAB80MG 18 LAYOLIS FE 2
LAZANDA SPR100MCG 10 LAZANDA SPR400MCG 10 LEENA 2
LEFLUNOMIDE TAB10MG 6, 10 LEFLUNOMIDE TAB20MG 6, 10 LENVIMA 18MG CAP 17 LENVIMA 8MG CAP 17 LESSINA 2
LESSINA-28 TAB 2
LETAIRIS TAB10MG 21 LETAIRIS TAB5MG 21 LETROZOLE TAB2.5MG 17 LEUCOVOR CA TAB10MG 17 LEUCOVOR CA TAB15MG 17 LEUCOVOR CA TAB25MG 17 LEUCOVOR CA TAB5MG 17 LEUKERAN TAB2MG 17 LEUPROLIDE INJ1MG/0.2 17 LEVALBUTEROLNEB0.31MG 6, 12 LEVALBUTEROLNEB0.63MG 6, 12 LEVALBUTEROLNEB1.25/0.5 6, 12 LEVAQUIN TABLEVA-PAK 24 LEVATOL TAB20MG 20 LEVEMIR INJ 14 LEVEMIR INJFLEXPEN 14 LEVETIRACETASOL100MG/ML 13 LEVETIRACETATAB1000MG 13 LEVETIRACETATAB250MG 13 LEVETIRACETATAB500MG 6, 13 LEVETIRACETATAB500MG ER 6, 13 LEVETIRACETATAB750MG 6, 13 LEVETIRACETATAB750MG ER 6, 13 LEVOBUNOLOL SOL0.5% OP 26 LEVOCETIRIZISOL2.5/5ML 15
LEVOCETIRIZITAB5MG 6, 15 LEVOFLOXACINSOL0.5% 26 LEVOFLOXACINSOL25MG/ML 24 LEVOFLOXACINTAB250MG 6, 24 LEVOFLOXACINTAB500MG 6, 24 LEVOFLOXACINTAB750MG 6, 24 LEVONORGESTREL 2
LEVONORGESTREL AND ETHINY 2
LEVONORGESTREL/ETHINYL ES 2
LEVORA-28 TAB0.15/30 2
LEVOTHYROXINTAB100MCG 27 LEVOTHYROXINTAB112MCG 27 LEVOTHYROXINTAB125MCG 27 LEVOTHYROXINTAB137MCG 27 LEVOTHYROXINTAB150MCG 27 LEVOTHYROXINTAB175MCG 27 LEVOTHYROXINTAB200MCG 27 LEVOTHYROXINTAB25MCG 27 LEVOTHYROXINTAB300MCG 27 LEVOTHYROXINTAB50MCG 27 LEVOTHYROXINTAB75MCG 27 LEVOTHYROXINTAB88MCG 27 LEXIVA SUS50MG/ML 19 LEXIVA TAB700MG 19 LIDO/PRILOCNCRE2.5-2.5% 22 LIDOCAINE GEL2% JELLY 22 LIDOCAINE OIN5% 22 LIDOCAINE PAD5% 22 LIDOCAINE SOL2% VISC 25 LIDOCAINE SOL4% 22 LINDANE LOT1% 22 LINDANE SHA1% 22 LINEZOLID INJ2MG/ML 16 LINEZOLID SUSP100/5ML 16 LINEZOLID TAB600MG 16 LIOTHYRONINETAB25MCG 27 LIOTHYRONINETAB50MCG 27 LIOTHYRONINETAB5MCG 27 LIPOFEN CAP150MG 15 LIPOFEN CAP50MG 15 LISINOP/HCTZTAB10-12.5 16 LISINOP/HCTZTAB20-12.5 16 LISINOP/HCTZTAB20-25MG 16 LISINOPRIL TAB10MG 16 LISINOPRIL TAB2.5MG 16 LISINOPRIL TAB20MG 16 LISINOPRIL TAB30MG 16 LISINOPRIL TAB40MG 16 LISINOPRIL TAB5MG 16 LITHIUM SOL8MEQ/5ML 18 LITHIUM CARBCAP150MG 18 LITHIUM CARBCAP300MG 18 LITHIUM CARBTAB300MG 18 LITHIUM CARBTAB300MG ER 18 LITHIUM CARBTAB450MG ER 18 LOCOID LOT0.1% 22 LOKARA LOT0.05% 22 LOMEDIA 24 FE 2
LORAZEPAM 11 LORAZEPAM INTENSOL 11 LORCET TAB5-325MG 10 LORCET HD TAB10-325MG 10 LORCET PLUS TAB7.5-325 6, 10 LORTAB ELX10-300MG 10 LORTAB TAB10-325MG 10 LORTAB TAB5-325MG 10
LORTAB TAB7.5-325 10 LORYNA 2
LORZONE TAB375MG 26 LORZONE TAB750MG 26 LOSARTAN POTTAB100MG 6, 16 LOSARTAN POTTAB25MG 6, 16 LOSARTAN POTTAB50MG 6, 16 LOSARTAN/HCTTAB100-12.5 16 LOSARTAN/HCTTAB100-25 16 LOSARTAN/HCTTAB50-12.5 16 LOTEMAX GEL0.5% 26 LOTEMAX OIN0.5% 26 LOTEMAX SUS0.5% 26 LOVASTATIN TAB10MG 15 LOVASTATIN TAB20MG 15 LOVASTATIN TAB40MG 15 LOXAPINE CAP10MG 18 LOXAPINE CAP25MG 18 LOXAPINE CAP50MG 18 LOXAPINE CAP5MG 18 LUDENT 2
LUFYLLIN TAB200MG 12 LUFYLLIN TAB400MG 12 LUMIGAN SOL0.01% 26 LUMIGAN SOL0.03% 26 LUTERA 2
LYRICA CAP100MG 13 LYRICA CAP150MG 13 LYRICA CAP200MG 13 LYRICA CAP225MG 13 LYRICA CAP25MG 13 LYRICA CAP300MG 13 LYRICA CAP50MG 13 LYRICA CAP75MG 13 LYRICA SOL20MG/ML 13 LYZA 2
MAPROTILINE TAB25MG 6, 14 MAPROTILINE TAB50MG 6, 14 MAPROTILINE TAB75MG 14 MARLISSA 2
MARPLAN TAB10MG 14 MATZIM LA TAB180MG/24 20 MATZIM LA TAB240MG/24 20 MATZIM LA TAB300MG/24 20 MATZIM LA TAB360MG/24 20 MATZIM LA TAB420MG/24 20 MAXIDEX SUS0.1% OP 26 MEBENDAZOLE CHW100MG 11 MECLIZINE TAB12.5MG 15 MECLIZINE TAB25MG 15 MECLOFEN SODCAP100MG 10 MECLOFEN SODCAP50MG 10 MEDROXYPR ACTAB10MG 27 MEDROXYPR ACTAB2.5MG 27 MEDROXYPR ACTAB5MG 27 MEFENAM ACIDCAP250MG 10 MEFLOQUINE TAB250MG 17 MEGESTROL ACSUS40MG/ML 17 MEGESTROL ACSUS625MG/5ML 17 MEGESTROL ACTAB20MG 17 MEGESTROL ACTAB40MG 17 MEKINIST TAB0.5MG 17 MEKINIST TAB2MG 17 MELOXICAM TAB15MG 10 MELOXICAM TAB7.5MG 10 MEMANTINE HCL 10MG TAB 27
40
MEMANTINE HCL 5 MG TAB 27 MEMANTINE HCSOL2MG/ML 27 MENACTRA 2
MENEST TAB0.3MG 24 MENEST TAB0.625MG 24 MENEST TAB1.25MG 24 MENEST TAB2.5MG 24 MENOMUNE-A/C/Y/W-135 2
MENOSTAR DIS14MCG 24 MENTAX CRE1% 22 MENVEO 2
MEPROBAMATE TAB200MG 11 MEPROBAMATE TAB400MG 11 MERCAPTOPUR TAB50MG 17 MESALAMINE KIT4GM 24 MESTINON SYP60MG/5ML 17 METADATE TAB20MG ER 9 METAPROTERENSYP10MG/5ML 12 METAPROTERENTAB10MG 12 METAPROTERENTAB20MG 12 METAXALONE TAB800MG 26 METFORMIN TAB1000MG 14 METFORMIN TAB500MG 14 METFORMIN TAB500MG ER 14 METFORMIN TAB750MG ER 14 METFORMIN TAB850MG 14 METHADONE CON10MG/ML 10 METHADONE SOL10MG/5ML 10 METHADONE SOL5MG/5ML 10 METHADONE TAB10MG 10 METHADONE TAB5MG 10 METHAZOLAMIDTAB25MG 23 METHAZOLAMIDTAB50MG 23 METHENAM HIPTAB1GM 28 METHIMAZOLE TAB10MG 27 METHIMAZOLE TAB5MG 27 METHITEST TAB10MG 11 METHOCARBAM TAB500MG 26 METHOCARBAM TAB750MG 26 METHOTREXATE SODIUM 17 METHOTREXATEINJ1GM 17 METHOTREXATETAB2.5MG 17 METHOXSALEN CAP10MG 22 METHSCOPOLAMTAB2.5MG 28 METHSCOPOLAMTAB5MG 28 METHYCLOTHIATAB5MG 23 METHYLDOPA TAB250MG 16 METHYLDOPA TAB500MG 16 METHYLIN CHW10MG 9 METHYLIN CHW2.5MG 9 METHYLIN CHW5MG 9 METHYLPHENIDCAP10MG 9 METHYLPHENIDCAP20MG ER 6, 9 METHYLPHENIDCAP30MG ER 6, 9 METHYLPHENIDCAP40MG ER 6, 9 METHYLPHENIDCAP50MG 9 METHYLPHENIDCAP60MG 9 METHYLPHENIDSOL10MG/5ML 9 METHYLPHENIDSOL5MG/5ML 9 METHYLPHENIDTAB10MG 6, 9 METHYLPHENIDTAB10MG ER 6, 9 METHYLPHENIDTAB18MG ER 6, 9 METHYLPHENIDTAB20MG 6, 9 METHYLPHENIDTAB20MG ER 6, 9 METHYLPHENIDTAB27MG ER 6, 9 METHYLPHENIDTAB36MG ER 6, 9 METHYLPHENIDTAB54MG ER 6, 9
METHYLPHENIDTAB5MG 6, 9 METHYLPRED PAK4MG 21 METHYLPRED TAB16MG 21 METHYLPRED TAB32MG 21 METHYLPRED TAB4MG 21 METHYLPRED TAB8MG 21 METIPRANOLOLSOL0.3% OPH 26 METOCLOPRAM SOL5MG/5ML 24 METOCLOPRAM TAB10MG 24 METOCLOPRAM TAB5MG 24 METOCLOPRAM TAB5MG ODT 24 METOLAZONE TAB10MG 23 METOLAZONE TAB2.5MG 23 METOLAZONE TAB5MG 23 METOPROL TARTAB100MG 20 METOPROL TARTAB25MG 20 METOPROL TARTAB37.5MG 20 METOPROL TARTAB50MG 20 METOPROL TARTAB75MG 20 METOPROLOL TAB100MG ER 20 METOPROLOL TAB200MG ER 20 METOPROLOL TAB25MG ER 20 METOPROLOL TAB50MG ER 20 METOZOLV ODTTAB10MG 24 METRONIDAZOLCAP375MG 16 METRONIDAZOLCRE0.75% 22 METRONIDAZOLGEL0.75% 22, 28 METRONIDAZOLGEL0.75%VAG 28 METRONIDAZOLGEL1% 22 METRONIDAZOLLOT0.75% 22 METRONIDAZOLTAB250MG 16 METRONIDAZOLTAB500MG 16 MEXILETINE CAP150MG 11 MEXILETINE CAP200MG 11 MEXILETINE CAP250MG 11 MIACALCIN INJ200/ML 24 MIBELAS 24 CHWFE 21 MICROGESTIN 1.5/30 2
MICROGESTIN 1/20 2
MICROGESTIN 24 FE 2
MICROGESTIN FE 2
MICROGESTIN FE 1.5/30 2
MIDODRINE TAB10MG 28 MIDODRINE TAB2.5MG 28 MIDODRINE TAB5MG 28 MIGLITOL TAB100MG 14 MIGLITOL TAB25MG 14 MIGLITOL TAB50MG 14 MIGRANAL SPR4MG/ML 25 MILLIPRED SOL10MG/5ML 21 MILLIPRED TAB5MG 21 MILLIPRED DPPAK5MG 21 MIMVEY LO TAB0.5-0.1 24 MINITRAN DIS0.1MG/HR 11 MINITRAN DIS0.2MG/HR 11 MINITRAN DIS0.4MG/HR 11 MINITRAN DIS0.6MG/HR 11 MINIVELLE DIS0.025 MG 24 MINIVELLE DIS0.0375MG 24 MINIVELLE DIS0.05MG 24 MINIVELLE DIS0.075MG 24 MINIVELLE DIS0.1MG 24 MINOCYCLINE CAP100MG 27 MINOCYCLINE CAP50MG 27 MINOCYCLINE CAP75MG 27 MINOCYCLINE TAB100MG 27
MINOCYCLINE TAB135MG ER 27 MINOCYCLINE TAB45MG ER 27 MINOCYCLINE TAB50MG 27 MINOCYCLINE TAB75MG 27 MINOCYCLINE TAB90MG ER 27 MINOXIDIL TAB10MG 16 MINOXIDIL TAB2.5MG 16 MIRCETTE 2
MIRTAZAPINE TAB15MG 6, 14 MIRTAZAPINE TAB15MG ODT 6, 14 MIRTAZAPINE TAB30MG 6, 14 MIRTAZAPINE TAB30MG ODT 6, 14 MIRTAZAPINE TAB45MG 6, 14 MIRTAZAPINE TAB45MG ODT 6, 14 MIRTAZAPINE TAB7.5MG 6, 14 MISOPROSTOL TAB100MCG 28 MISOPROSTOL TAB200MCG 28 MITIGARE CAP0.6MG 25 M-M-R II 2
MODAFINIL TAB100MG 9 MODAFINIL TAB200MG 9 MODAFINIL TAB100MG 6 MODAFINIL TAB200MG 6 MOEXIPRIL TAB15MG 16 MOEXIPRIL TAB7.5MG 16 MOMETASONE CRE0.1% 22 MOMETASONE OIN0.1% 22 MOMETASONE SOL0.1% 22 MONDOXYNE NLCAP100MG 27 MONDOXYNE NLCAP75MG 27 MONO-LINYAH 2
MONTELUKAST CHW4MG 6, 12 MONTELUKAST CHW5MG 6, 12 MONTELUKAST GRA4MG 6, 12 MONTELUKAST TAB10MG 6, 12 MONUROL PAKGRANULES 28 MORGIDOX CAP1X100MG 27 MORPHINE SULCAP100MG ER 6, 10 MORPHINE SULCAP10MG ER 6, 10 MORPHINE SULCAP120MG ER 6, 10 MORPHINE SULCAP20MG ER 6, 10 MORPHINE SULCAP30MG ER 6, 10 MORPHINE SULCAP45MG ER 6, 10 MORPHINE SULCAP50MG ER 6, 10 MORPHINE SULCAP60MG ER 6, 10 MORPHINE SULCAP75MG ER 6, 10 MORPHINE SULCAP80MG ER 6, 10 MORPHINE SULCAP90MG ER 6, 10 MORPHINE SULSOL10MG/5ML 6, 10 MORPHINE SULSOL20MG/5ML 6, 10 MORPHINE SULSOL20MG/ML 6, 10 MORPHINE SULTAB100MG ER 6, 10 MORPHINE SULTAB15MG 6, 10 MORPHINE SULTAB15MG ER 6, 10 MORPHINE SULTAB200MG ER 6, 10 MORPHINE SULTAB30MG 6, 10 MORPHINE SULTAB30MG ER 6, 10 MORPHINE SULTAB60MG ER 6, 10 MOXATAG TAB775MG 27 MOXEZA SOL0.5% 26 MOXIFLOXACINTAB400MG 24 MULTAQ TAB400MG 11 MUPIROCIN OIN2% 22 MY WAY 2
MYCOPHENOLATCAP250MG 19 MYCOPHENOLATTAB500MG 19
41
MYCOPHENOLICTAB180MG DR 19 MYCOPHENOLICTAB360MG DR 19 MYORISAN 22 MYORISAN CAP10MG 22 MYORISAN CAP20MG 22 MYORISAN CAP40MG 22 MYRBETRIQ TAB25MG 28 MYRBETRIQ TAB50MG 28 MYTELASE TAB10MG 17 NABUMETONE TAB500MG 10 NABUMETONE TAB750MG 10 NADOLOL TAB20MG 20 NADOLOL TAB40MG 20 NADOLOL TAB80MG 20
NAFRINSE 2
NAFRINSE DROPS 2
NAFTIFINE 1%CRE 22 NAFTIFINE 2%CRE 22 NALFON CAP200MG 10 NALFON CAP400MG 10 NALOXONE INJ0.4MG/ML 15 NALTREXONE TAB50MG 10, 15 NAMENDA XR CAP14MG 27 NAMENDA XR CAP21MG 27 NAMENDA XR CAP28MG 27 NAMENDA XR CAP7MG 27 NAMENDA XR CAPTITRATIO 27 NAPHAZOLINE SOL0.1% OP 26 NAPROXEN SUS125/5ML 10 NAPROXEN TAB250MG 10 NAPROXEN TAB375MG 10 NAPROXEN TAB500MG 10 NAPROXEN DR TAB375MG 10 NAPROXEN DR TAB500MG 10 NAPROXEN SODIUM CR 10 NAPROXEN SODTAB275MG 10 NAPROXEN SODTAB500MG CR 10 NAPROXEN SODTAB550MG 10 NARATRIPTAN TAB1MG 6, 25 NARATRIPTAN TAB2.5MG 6, 25 NARCAN SPRAY 15 NATACYN SUS5% OP 26 NATEGLINIDE TAB120MG 6, 14 NATEGLINIDE TAB60MG 6, 14 NECON 1/35 2
NECON TAB0.5/35 2
NEFAZODONE TAB100MG 14 NEFAZODONE TAB150MG 14 NEFAZODONE TAB200MG 14 NEFAZODONE TAB250MG 14 NEFAZODONE TAB50MG 14 NEFAZODONE TAB100MG 6 NEFAZODONE TAB150MG 6 NEFAZODONE TAB200MG 6 NEFAZODONE TAB250MG 6 NEFAZODONE TAB50MG 6 NELOVA TAB.5/35-28 2
NELOVA TAB1/35-21 2
NELOVA TAB1/35-28 2
NEO/POLY/HC SOL1% OTIC 26 NEO/POLY/HC SUS1% OTIC 26 NEOMYCIN TAB500MG 9 NEORAL CAP100MG 19 NEORAL CAP25MG 19 NEORAL SOL100MG/ML 19 NEVANAC SUS0.1% 26
NEVIRAPINE SUS50MG/5ML 19 NEVIRAPINE TAB200MG 19 NEVIRAPINE TAB400MG ER 19 NEVIRAPINE SUS50MG/5ML 6 NEVIRAPINE TAB200MG 6 NEVIRAPINE TAB400MG ER 6 NEXAVAR TAB200MG 17 NEXAVAR TAB200MG 6 NEXT CHOICE 2
NIACIN ER 1000MG 6 NIACIN ER TAB1000MG 15 NIACIN ER TAB500MG 15 NIACIN ER TAB750MG 15 NIACOR TAB500MG 15 NICARDIPINE CAP20MG 20 NICARDIPINE CAP30MG 20 NICOTINE DIS14MG/24 27 NICOTINE DIS21MG/24 27 NICOTINE DIS7MG/24 6, 27 NICOTINE LOZ2MG 6, 27 NICOTINE LOZ4MG 6, 27 NICOTINE POLGUM2MG 27 NICOTINE POLGUM4MG 27 NICOTROL DIS15MG/16 6 NICOTROL INH 6 NICOTROL RFLDIS15MG/DIS 6 NIFEDIAC CC TAB90MG ER 20 NIFEDICAL XLTAB30MG 20 NIFEDICAL XLTAB60MG 20 NIFEDIPINE CAP10MG 20 NIFEDIPINE CAP20MG 20 NIFEDIPINE TAB30MG ER 20 NIFEDIPINE TAB60MG ER 20 NIFEDIPINE TAB90MG ER 20 NIKKI 2
NILANDRON TAB150MG 17 NIMODIPINE CAP30MG 20 NISOLDIPINE TAB17MG ER 20 NISOLDIPINE TAB20MG 20 NISOLDIPINE TAB25.5MG 20 NISOLDIPINE TAB30MG 20 NISOLDIPINE TAB34MG ER 20 NISOLDIPINE TAB40MG 20 NISOLDIPINE TAB8.5MG ER 20 NITRO-BID OIN2% 11 NITROFUR MACCAP50MG 28 NITROFURANTNSUS25MG/5ML 28 NITROFURANTOIN MACROCRYST 28 NITROFURANTOIN MONOHYDRAT 28 NITROGLYCER DIS0.1MG/HR 11 NITROGLYCER DIS0.2MG/HR 11 NITROGLYCER DIS0.4MG/HR 6, 11 NITROGLYCERIDIS0.6MG/HR 6, 11 NITROGLYCRN SPR0.4MG 11 NITROLINGUALSPRPUMPSPRA 11 NITROMIST AER400MCG 11 NITROSTAT SUB0.3MG 11 NITROSTAT SUB0.4MG 11 NITROSTAT SUB0.6MG 11 NORDITROPIN INJ10/1.5ML 24 NORDITROPIN INJ15/1.5ML 24 NORDITROPIN INJ30/3ML 24 NORDITROPIN INJ5/1.5ML 24 NORETH/ETHINCHWFE 1/20 21 NORETHIN ACETAB5MG 27
NORETHINDRONE 0.35 MG 2
NORGESTIMATE/ETHINYL ESTR 2
NORITATE CRE1% 22 NORLYROC 2
NORPACE CAP100MG CR 11 NORPACE CAP150MG CR 11 NORTHERA CAP100MG 28 NORTHERA CAP200MG 28 NORTHERA CAP300MG 28 NORTREL (28)TAB1/35 2
NORTREL 0.5/35 (28) 2
NORTREL 1/35 2
NORTREL 7/7/7 2
NORTRIPTYLINCAP10MG 14 NORTRIPTYLINCAP25MG 14 NORTRIPTYLINCAP50MG 14 NORTRIPTYLINCAP75MG 14 NORTRIPTYLINSOL10MG/5ML 14 NORVIR CAP100MG 19 NORVIR SOL80MG/ML 19 NORVIR TAB100MG 19 NOVOLIN INJ70/30 14 NOVOLIN N INJU-100 14 NOVOLIN R INJU-100 14 NOVOLOG INJ100/ML 15 NOVOLOG FLEXPEN 6, 15 NOVOLOG MIX INJ70/30 6, 15 NOVOLOG MIX INJFLEXPEN 6, 15 NP THYROID TAB15MG 28 NP THYROID TAB30MG 28 NP THYROID TAB60MG 28 NP THYROID TAB90MG 28 NUCYNTA TAB100MG 10 NUCYNTA TAB50MG 10 NUCYNTA TAB75MG 10 NUCYNTA ER TAB100MG 10 NUCYNTA ER TAB150MG 10 NUCYNTA ER TAB200MG 10 NUCYNTA ER TAB250MG 10 NUCYNTA ER TAB50MG 10 NUCYNTA ER TAB100MG 6 NUCYNTA ER TAB150MG 6 NUCYNTA ER TAB200MG 6 NUCYNTA ER TAB250MG 6 NUCYNTA ER TAB50MG 6 NUCYNTA TAB100MG 6 NUCYNTA TAB50MG 6 NUCYNTA TAB75MG 6 NUTROPIN AQ INJ10MG/2ML 24 NUTROPIN AQ INJ20MG/2ML 24 NUTROPIN AQ INJNUSPIN 5 24 NUVARING 2 NYAMYC POW100000 22 NYSTAT/TRIAMCRE 22 NYSTAT/TRIAMOIN 22 NYSTATIN CRE100000 22 NYSTATIN OIN100000 22 NYSTATIN POW100000 22 NYSTATIN SUS100000 15, 25 NYSTATIN TAB500000 15 NYSTOP POW100000 22 OCELLA 2
OFLOXACIN DRO0.3% OP 26 OFLOXACIN DRO0.3%OTIC 26 OFLOXACIN TAB200MG 24 OFLOXACIN TAB300MG 24 OFLOXACIN TAB400MG 24
42
OLANZAPINE TAB10MG 18 OLANZAPINE TAB10MG ODT 18 OLANZAPINE TAB15MG 18 OLANZAPINE TAB15MG ODT 18 OLANZAPINE TAB2.5MG 18 OLANZAPINE TAB20MG 18 OLANZAPINE TAB20MG ODT 18 OLANZAPINE TAB5MG 18 OLANZAPINE TAB5MG ODT 18 OLANZAPINE TAB7.5MG 18 OLANZAPINE TAB10MG 6 OLANZAPINE TAB15MG 6 OLANZAPINE TAB2.5MG 6 OLANZAPINE TAB20MG 6 OLANZAPINE TAB5MG 6 OLANZAPINE TAB5MG ODT 6 OLANZAPINE TAB7.5MG 6 OLEPTRO TAB24HR150 14 OLEPTRO TAB24HR300 14 OLMESA MEDOXTAB20MG 6, 16 OLMESA MEDOXTAB40MG 6, 16 OLMESA MEDOXTAB5MG 6, 16 OLOPATADINE HCL OPH SOL 26 OLOPATADINE SPR0.6% 26 OMEGA-3 ACID CAP 1 GM 15 OMEPRAZOLE CAP10MG 28 OMEPRAZOLE CAP40MG 28 OMEPRAZOLE CAP10MG 6 OMEPRAZOLE CAP20MG 6, 28 OMEPRAZOLE CAP40MG 6 ONDANSETRON INJ4MG/2ML 15 ONDANSETRON SOL4MG/5ML 6, 15 ONDANSETRON TAB24MG 6, 15 ONDANSETRON TAB4MG 6, 15 ONDANSETRON TAB4MG ODT 6, 15 ONDANSETRON TAB8MG 6, 15 ONDANSETRON TAB8MG ODT 6, 15 ONFI SUS2.5MG/ML 13 ONGLYZA TAB2.5MG 15 ONGLYZA TAB5MG 15 OPCICON ONE-STEP 2
OPSUMIT TAB10MG 21 ORACEA CAP40MG 22 ORAPRED ODT TAB10MG 21 ORAPRED ODT TAB15MG 21 ORAPRED ODT TAB30MG 21 ORAVIG TAB50MG 25 ORENCIA 10 ORENITRAM TAB0.125MG 21 ORENITRAM TAB0.25MG 21 ORENITRAM TAB1MG 21 ORENITRAM TAB2.5MG 21 ORPHENADRINETAB100MG ER 26 ORSYTHIA 2
OSMOPREP TAB1.5GM 25 OTEZLA 6, 10 OTEZLA TAB10/20/30 10 OTEZLA TAB30MG 10 OXANDROLONE TAB10MG 6, 11 OXANDROLONE TAB2.5MG 6, 11 OXAPROZIN TAB600MG 10 OXCARBAZEPINSUS300MG/5M 13 OXCARBAZEPINTAB150MG 13 OXCARBAZEPINTAB300MG 13 OXCARBAZEPINTAB600MG 13 OXECTA TAB5MG 10 OXECTA TAB7.5MG 10
OXYBUTYNIN SYP5MG/5ML 28 OXYBUTYNIN TAB5MG 28 OXYCOD/APAP TAB 10-325MG 6, 11 OXYCOD/APAP TAB 2.5-325MG 6, 11 OXYCOD/APAP TAB 5-325MG 6, 11 OXYCOD/APAP TAB 7.5-325MG 6, 11 OXYCOD/IBU TAB5-400MG 11 OXYCODONE TAB10MG 11 OXYCODONE TAB15MG 11 OXYCODONE TAB20MG 11 OXYCODONE TAB30MG 11 OXYCODONE TAB5MG 11 OXYCONTIN TAB10MG CR 11 OXYCONTIN TAB15MG CR 11 OXYCONTIN TAB20MG CR 11 OXYCONTIN TAB30MG CR 11 OXYCONTIN TAB40MG CR 11 OXYCONTIN TAB60MG CR 11 OXYCONTIN TAB80MG CR 11 OXYMORPHONE TAB10MG ER 11 OXYMORPHONE TAB15MG ER 11 OXYMORPHONE TAB20MG ER 11 OXYMORPHONE TAB30MG ER 11 OXYMORPHONE TAB40MG ER 11 OXYMORPHONE TAB5MG ER 11 OXYMORPHONE TAB7.5MG ER 11 OXYMORPHONE TABHCL 10MG 11 OXYMORPHONE TABHCL 5MG 11 OXYTROL DIS3.9MG/24 28 PACERONE TAB100MG 11 PACERONE TAB200MG 11 PACERONE TAB400MG 11 PALGIC SOL4MG/5ML 15 PALIPERIDONE 1.5 MG ER 18 PALIPERIDONE 3 MG ER 18 PALIPERIDONE 6 MG ER 18 PALIPERIDONE 9MG ER 18 PANCREAZE CAP10500UNT 23 PANCREAZE CAP16800UNT 23 PANCREAZE CAP21000UNT 23 PANCREAZE CAP4200UNIT 23 PANDEL CRE0.1% 22 PANTOPRAZOLETAB20MG 7, 28 PANTOPRAZOLETAB40MG 7, 28 PARICALCITOLCAP1 MCG 24 PARICALCITOLCAP2 MCG 24 PARICALCITOLCAP4 MCG 24 PAROEX SOL0.12% 25 PAROMOMYCIN CAP250MG 9 PAROXETIN ERTAB12.5MG 7, 14 PAROXETIN ERTAB37.5MG 7, 14 PAROXETINE SUS10MG/5ML 14 PAROXETINE TAB10MG 14 PAROXETINE TAB20MG 14 PAROXETINE TAB25MG ER 14 PAROXETINE TAB30MG 14 PAROXETINE TAB40MG 14 PASER GRA4GM 17 PAXIL SUS10MG/5ML 14 PCE TAB333MG EC 25 PCE TAB500MG EC 25 PEDIARIX 2
PEDI-DRI POW100000 22 PEDVAX HIB 2
PEDVAX HIB INJ 2
PEG 3350/ELECTROLYTES 2
PEGANONE TAB250MG 13 PEGASYS INJ 19 PEGASYS PROCLICK 7, 19 PEG-INTRON KIT 19 PEG-PREP 2
PENICILLN VKSOL125/5ML 27 PENICILLN VKSOL250/5ML 27 PENICILLN VKTAB250MG 27 PENICILLN VKTAB500MG 27 PENNSAID SOL2% 22 PENTACEL 2
PENTASA CAP250MG CR 24 PENTASA CAP500MG CR 24 PENTOXIFYLLITAB400MG ER 25 PENTOXIL TAB400MG CR 25 PERFOROMIST NEB20MCG 12 PERINDOPRIL TAB2MG 16 PERINDOPRIL TAB4MG 16 PERINDOPRIL TAB8MG 16 PERIOGARD SOL0.12% 25 PERMETHRIN CRE5% 22 PERPHENAZINETAB16MG 18 PERPHENAZINETAB2MG 18 PERPHENAZINETAB4MG 18 PERPHENAZINETAB8MG 18 PERTZYE CAP 23 PEXEVA TAB10MG 14 PEXEVA TAB20MG 14 PEXEVA TAB30MG 14 PEXEVA TAB40MG 14 PHENADOZ SUP12.5MG 15 PHENADOZ SUP25MG 15 PHENELZINE TAB15MG 14 PHENERGAN SUP12.5MG 15 PHENERGAN SUP25MG 15 PHENYTEK CAP200MG 13 PHENYTEK CAP300MG 13 PHENYTOIN CHW50MG 13 PHENYTOIN SUS125/5ML 13 PHENYTOIN EXCAP100MG 13 PHENYTOIN EXCAP200MG 13 PHENYTOIN EXCAP300MG 13 PHILITH 2
PHISOHEX LIQ3% 19 PHOSLYRA SOL 24 PHOSPHOLINE SOL0.125%OP 26 PHYSIOLYTE SOL 19 PHYSIOSOL SOLIRRIGAT 19 PICATO GEL0.015% 22 PICATO GEL0.05% 22 PILOCARPINE SOL1% OP 26 PILOCARPINE SOL2% OP 26 PILOCARPINE SOL4% OP 26 PILOCARPINE TAB5MG 25 PILOCARPINE TAB7.5MG 25 PILOPINE HS GEL4% OP 26 PIMOZIDE TAB1MG 13 PIMOZIDE TAB2MG 13 PIMTREA 2
PINDOLOL TAB10MG 20 PINDOLOL TAB5MG 20 PIOGLITAZONETAB15MG 7, 15 PIOGLITAZONETAB30MG 7, 15 PIOGLITAZONETAB45MG 7, 15 PIRMELLA 1/35 2
PIRMELLA 7/7/7 2
43
PIROXICAM CAP10MG 10 PIROXICAM CAP20MG 10 PLEGRIDY INJ 27 PLEGRIDY PENINJSTARTER 27 PNEUMOVAX 23 2
PODOFILOX SOL0.5% 22 POMALYST CAP1MG 17 POMALYST CAP2MG 17 POMALYST CAP3MG 17 POMALYST CAP4MG 17 PORTIA-28 2
POT CHLORIDECAP10MEQ ER 25 POT CHLORIDECAP8MEQ ER 25 POT CHLORIDETAB8MEQ ER 25 POT CITRATE TAB1080MG 25 POT CITRATE TAB1620MG 25 POT CITRATE TAB540MG ER 25 POT CL MICROTAB10MEQ ER 25 POT CL MICROTAB20MEQ ER 25 POTIGA TAB200MG 13 POTIGA TAB300MG 13 POTIGA TAB400MG 13 POTIGA TAB50MG 13 PRADAXA CAP110MG 12 PRADAXA CAP150MG 12 PRADAXA CAP75MG 12 PRAMIPEXOLE TAB0.125MG 7, 18 PRAMIPEXOLE TAB0.25MG 7, 18 PRAMIPEXOLE TAB0.375MG ER 18 PRAMIPEXOLE TAB0.5MG 7, 18 PRAMIPEXOLE TAB0.75 ER 18 PRAMIPEXOLE TAB0.75MG 7, 18 PRAMIPEXOLE TAB1.5MG 7, 18 PRAMIPEXOLE TAB1.5MG ER 18 PRAMIPEXOLE TAB1MG 7, 18 PRAMIPEXOLE TAB2.25MG ER 18 PRAMIPEXOLE TAB3MG ER 18 PRAMIPEXOLE TAB4.5MG ER 18 PRAVASTATIN TAB10MG 7, 16 PRAVASTATIN TAB20MG 7, 16 PRAVASTATIN TAB40MG 7, 16, 20 PRAVASTATIN TAB80MG 7, 16 PRAZOSIN HCLCAP1MG 16 PRAZOSIN HCLCAP2MG 16 PRAZOSIN HCLCAP5MG 16 PRECISION TEST STRIPS 7, 23 PRED MILD SUS0.12% OP 26 PRED SOD PHOSOL1% OP 26 PRED SOD PHOSOL5MG/5ML 21 PREDNICARBATCRE0.1% 22 PREDNICARBATOIN0.1% 22 PREDNISOLONE ACETATE 26 PREDNISOLONE ODT TAB10MG 21 PREDNISOLONE ODT TAB15MG 21 PREDNISOLONE ODT TAB30MG 21 PREDNISOLONESOL15MG/5ML 21 PREDNISOLONESOL25MG/5ML 21 PREDNISOLONESUS1% OP 26 PREDNISONE CON5MG/ML 21 PREDNISONE PAK10MG 21 PREDNISONE PAK5MG 21 PREDNISONE SOL5MG/5ML 21 PREDNISONE TAB10MG 21 PREDNISONE TAB1MG 21 PREDNISONE TAB2.5MG 21 PREDNISONE TAB20MG 21 PREDNISONE TAB50MG 21
PREDNISONE TAB5MG 21 PREMARIN TAB0.3MG 24 PREMARIN TAB0.45MG 24 PREMARIN TAB0.625MG 24 PREMARIN TAB0.9MG 24 PREMARIN TAB1.25MG 24 PREMARIN VAGCRE0.625MG 28 PREMPRO 24 PREVALITE POW4GM 16 PREVIFEM 2
PREVNAR 2
PREVNAR 13 2
PREZCOBIX 19 PREZISTA SUS100MG/ML 19 PREZISTA TAB150MG 19 PREZISTA TAB400MG 19 PREZISTA TAB600MG 19 PREZISTA TAB75MG 19 PRIFTIN TAB150MG 17 PRIMAQUINE TAB26.3MG 17 PRIMIDONE TAB250MG 13 PRIMIDONE TAB50MG 13 PRIMSOL SOL50MG/5ML 16 PRISTIQ TAB100MG 14 PRISTIQ TAB50MG 14 PROAIR HFA AER 12 PROAIR RESPICLICK 12 PROBEN/COLCHTAB500-0.5 25 PROBENECID TAB500MG 25 PROCHIEVE GEL4% 28 PROCHLORPER SUP25MG 7, 18 PROCHLORPER TAB10MG 18 PROCHLORPER TAB5MG 18 PROCTOCREAM CREHC 2.5% 11 PROCTO-KIT CRE2.5% 11 PROCTO-PAK CRE1% 11 PROCTOSOL HCCRE2.5% 11 PROCTOZONE CRE-HC 2.5% 11 PROGESTERONECAP100MG 27 PROGESTERONECAP200MG 27 PROLIA 24 PROMACTA TAB12.5MG 25 PROMACTA TAB25MG 25 PROMACTA TAB50MG 25 PROMACTA TAB75MG 25 PROMETHAZINESUP12.5MG 15 PROMETHAZINESUP25MG 15 PROMETHAZINESUP50MG 15 PROMETHAZINESYP6.25/5ML 15 PROMETHAZINETAB12.5MG 15 PROMETHAZINETAB25MG 15 PROMETHAZINETAB50MG 15 PROMETHEGAN SUP12.5MG 15 PROMETHEGAN SUP25MG 15 PROMETHEGAN SUP50MG 15 PROPAFENONE CAP225MG ER 11 PROPAFENONE CAP325MG ER 11 PROPAFENONE CAP425MG SR 11 PROPAFENONE TAB150MG 11 PROPAFENONE TAB225MG 12 PROPAFENONE TAB300MG 12 PROPINE SOL0.1% OP 26 PROPRANOLOL CAP120MG ER 20 PROPRANOLOL CAP160MG ER 20 PROPRANOLOL CAP60MG ER 20 PROPRANOLOL CAP80MG ER 20 PROPRANOLOL SOL20MG/5ML 20
PROPRANOLOL SOL40MG/5ML 20 PROPRANOLOL TAB10MG 20 PROPRANOLOL TAB20MG 20 PROPRANOLOL TAB40MG 20 PROPRANOLOL TAB60MG 20 PROPRANOLOL TAB80MG 20 PROPYLTHIOURTAB50MG 28 PROQUAD 2
PROTRIPTYLINTAB10MG 14 PROTRIPTYLINTAB5MG 14 PROVENTIL AERHFA 12 PRUDOXIN CRE5% 23 PULMICORT INH180MCG 12 PULMICORT INH90MCG 12 PULMOZYME SOL 1MG/ML 27 PURIXAN 17 PYRAZINAMIDETAB500MG 17 PYRIDOSTIGM TAB60MG 17 QUADRACEL 2
QUASENSE 2
QUDEXY XR CAP100/24HR 13 QUDEXY XR CAP150/24HR 13 QUDEXY XR CAP200/24HR 13 QUDEXY XR CAP25/24HR 13 QUDEXY XR CAP50/24HR 13 QUESTRAN POW4GM 16 QUETIAPINE TAB100MG 18 QUETIAPINE TAB200MG 18 QUETIAPINE TAB25MG 18 QUETIAPINE TAB300MG 18 QUETIAPINE TAB400MG 18 QUETIAPINE TAB50MG 18 QUETIAPINE TAB100MG 7 QUETIAPINE TAB200MG 7 QUETIAPINE TAB25MG 7 QUETIAPINE TAB300MG 7 QUETIAPINE TAB400MG 7, 18 QUETIAPINE TAB400MG ER 7, 18 QUETIAPINE TAB50MG 7 QUILLIVANT SUSXR 9 QUINAPRIL TAB10MG 16 QUINAPRIL TAB20MG 16 QUINAPRIL TAB40MG 16 QUINAPRIL TAB5MG 16 QUINIDINE GLTAB324MG CR 12 QUINIDINE SUTAB200MG 12 QUINIDINE SUTAB300MG 12 QUINIDINE SUTAB300MG ER 12 QUININE SULFCAP324MG 17 QVAR AER40MCG 12 QVAR AER80MCG 12 RABEPRAZOLE TAB20MG 7, 28 RALOXIFENE HYDROCHLORIDE 2
RAMIPRIL CAP1.25MG 16 RAMIPRIL CAP10MG 16 RAMIPRIL CAP2.5MG 16 RAMIPRIL CAP5MG 16 RANEXA TAB1000MG 11 RANEXA TAB500MG 11 RANITIDINE SYP15MG/ML 28 RANITIDINE CAP150MG 28 RANITIDINE CAP300MG 28 RANITIDINE TAB150MG 28 RANITIDINE TAB300MG 28 RAPAFLO CAP4MG 25 RAPAFLO CAP8MG 25
44
RAYOS TAB1MG 21 RAYOS TAB2MG 21 RAYOS TAB5MG 21 REACT 2
REBIF INJ22/0.5 27 REBIF INJ44/0.5 27 REBIF TITRTNSOLPACK 7, 27 RECLIPSEN 2
RECOMBIVAX HB 2
RECTIV OIN0.4% 11 REFISSA CRE0.05% 23 REGRANEX GEL0.01% 23 RELENZA MISDISKHALE 19 RELPAX TAB20MG 25 RELPAX TAB40MG 25 RENAGEL TAB400MG 24 RENAGEL TAB800MG 24 RENVELA PAK0.8GM 24 RENVELA PAK2.4GM 24 REPAGLINIDE TAB0.5MG 15 REPAGLINIDE TAB1MG 15 REPAGLINIDE TAB2MG 15 RESCRIPTOR TAB100 MG 19 RESCRIPTOR TAB200MG 19 RETIN-A MICRGEL0.08% 23 REVLIMID CAP10MG 19 REVLIMID CAP15MG 19 REVLIMID CAP2.5MG 19 REVLIMID CAP20MG 19 REVLIMID CAP25MG 20 REVLIMID CAP5MG 20 REYATAZ CAP150MG 19 REYATAZ CAP200MG 19 REYATAZ CAP300MG 19 RHEUMATREX 10 RHEUMATREX TAB2.5MG 10 RIBAPAK PAK1000/DAY 19 RIBAPAK PAK1200/DAY 19 RIBAPAK PAK800/DAY 19 RIBASPHERE CAP200MG 19 RIBASPHERE TAB200MG 19 RIBASPHERE TAB400MG 19 RIBASPHERE TAB600MG 19 RIBATAB PAK1000/DAY 19 RIBATAB TAB400MG 19 RIBATAB TAB600MG 19 RIBATAB TAB800/DAY 19 RIBAVIRIN CAP200MG 19 RIBAVIRIN TAB200MG 19 RIBAVIRIN TAB400MG 19 RIBAVIRIN TAB600MG 19 RIDAURA CAP3MG 10 RIFABUTIN CAP150MG 17 RIFAMATE CAP 17 RIFAMPIN CAP150MG 17 RIFAMPIN CAP300MG 17 RIFATER TAB 17 RILUZOLE TAB50MG 27 RIMACTANE CAP300MG 17 RIOMET SOL 15 RISEDRONATE TAB150MG 24 RISPERIDONE SOL1MG/ML 7, 18 RISPERIDONE TAB0.25 ODT 7, 18 RISPERIDONE TAB0.25MG 7, 18 RISPERIDONE TAB0.5MG 7, 18 RISPERIDONE TAB0.5MG OD 7, 18 RISPERIDONE TAB1MG 7, 18
RISPERIDONE TAB1MG ODT 7, 18 RISPERIDONE TAB2MG 7, 18 RISPERIDONE TAB2MG ODT 7, 18 RISPERIDONE TAB3MG 7, 18 RISPERIDONE TAB3MG ODT 7, 18 RISPERIDONE TAB4MG 7, 18 RISPERIDONE TAB4MG ODT 7, 18 RITALIN LA CAP10MG 9 RIVASTIGMINECAP1.5MG 7, 27 RIVASTIGMINECAP3MG 7, 27 RIVASTIGMINECAP4.5MG 7, 27 RIVASTIGMINECAP6MG 7, 27 RIZATRIPTAN TAB10MG 7, 25 RIZATRIPTAN TAB10MG ODT 7, 25 RIZATRIPTAN TAB5MG 7, 25 ROMYCIN OINOP 26 ROPINIROLE TAB0.25MG 18 ROPINIROLE TAB0.5MG 18 ROPINIROLE TAB12MG ER 18 ROPINIROLE TAB1MG 18 ROPINIROLE TAB2MG 18 ROPINIROLE TAB2MG ER 18 ROPINIROLE TAB3MG 18 ROPINIROLE TAB4MG 18 ROPINIROLE TAB4MG ER 18 ROPINIROLE TAB5MG 18 ROPINIROLE TAB6MG ER 18 ROPINIROLE TAB8MG ER 18 ROSADAN CRE0.75% 23 ROSADAN GEL0.75% 23 ROSUVASTATINTAB10MG 16 ROSUVASTATINTAB20MG 16 ROSUVASTATINTAB40MG 16 ROSUVASTATINTAB5MG 16 ROTARIX 2
ROTATEQ 2
SABRIL POW500MG 13 SABRIL TAB500MG 13 SAMSCA TAB15MG 24 SAMSCA TAB30MG 24 SANCUSO DIS3.1MG 15 SANTYL OIN250/GM 23 SAPHRIS SUB10MG 18 SAPHRIS SUB5MG 18 SARAFEM TAB10MG 27 SARAFEM TAB20MG 27 SCALACORT 2% 23 SELEGILINE CAP5MG 18 SELEGILINE TAB5MG 18 SELENIUM SULLOT2.5% 23 SELENIUM SULSHA2.25% 23 SEREVENT DISAER50MCG 7, 12 SEROMYCIN CAP250MG 17 SEROQUEL XR TAB150MG 7, 18 SEROQUEL XR TAB200MG 7, 18 SEROQUEL XR TAB300MG 7, 18 SEROQUEL XR TAB400MG 7, 18 SEROQUEL XR TAB50MG 7, 18 SEROSTIM INJ4MG 24 SEROSTIM INJ5MG 24 SEROSTIM INJ6MG 24 SEROSTIM INJ8.8MG 24 SERTRALINE CON20MG/ML 14 SERTRALINE TAB100MG 14 SERTRALINE TAB25MG 14 SERTRALINE TAB50MG 14 SETLAKIN 3
SFROWASA ENE4GM 24 SHAROBEL 3
SIGNIFOR INJ0.3MG/ML 24 SIGNIFOR INJ0.6MG/ML 24 SIGNIFOR INJ0.9MG/ML 24 SILDENAFIL TAB20MG 21 SILVER SULFACRE1% 23 SIMBRINZA SUS1-0.2% 26 SIMPONI INJ100MG/ML 10 SIMPONI INJ50/0.5ML 10 SIMVASTATIN TAB10MG 7, 16 SIMVASTATIN TAB20MG 7, 16 SIMVASTATIN TAB40MG 7, 16 SIMVASTATIN TAB5MG 7, 16 SIMVASTATIN TAB80MG 7, 16 SIROLIMUS TAB0.5MG 20 SIRTURO TAB100MG 17 SIVEXTRO TAB200MG 16 SKLICE LOT0.5% 23 SMZ/TMP DS TAB800-160 16 SMZ-TMP SUS200-40/5 16 SMZ-TMP TAB400-80MG 16 SOD CHLORIDEINJ3% 20 SOD CHLORIDEINJ5% 20 SOD FLOURIDEDRO0.5MG/ML 3
SOD FLOURIDEDRO1.1MG/ML 3
SOD FLUORIDECHW0.25MG 3
SOD FLUORIDECHW0.5MG 3
SOD FLUORIDECHW1.1MG 3
SOD FLUORIDECHW1MG 3
SOD FLUORIDECHW2.2MG 3
SOD POLY SULSUS15GM/60 20 SOD SULFACETSOL10% OP 26 SODIUM CHLORNEB7% 27 SOMAVERT INJ10MG 24 SOMAVERT INJ15MG 24 SOMAVERT INJ20MG 24 SORINE TAB120MG 20 SORINE TAB160MG 20 SORINE TAB240MG 20 SORINE TAB80MG 20 SOTALOL AF TAB120MG 20 SOTALOL HCL TAB160MG 20 SOTALOL HCL TAB240MG 20 SOTALOL HCL TAB80MG 20 SOTRET CAP10MG 23 SOTRET CAP20MG 23 SOTRET CAP40MG 23 SPIRIVA CAPHANDIHLR 12 SPIRIVA SPRRESPIMAT 12 SPIRIVA RESPIMAT 12 SPIRONOLACT TAB100MG 23 SPIRONOLACT TAB25MG 23 SPIRONOLACT TAB50MG 23 SPORANOX CAP PULSEPAK 15 SPORANOX SOL10MG/ML 15 SPRINTEC 28 3
SPRITAM TAB 1000MG 13 SPRITAM TAB 250MG 13 SPRITAM TAB 500MG 13 SPRITAM TAB 750MG 13 SPRIX SPR15.75MG 10 SPRYCEL TAB100MG 17 SPRYCEL TAB140MG 17 SPRYCEL TAB20MG 17 SPRYCEL TAB50MG 17
45
SPRYCEL TAB70MG 17 SPRYCEL TAB80MG 17 SRONYX 3
SSD CRE1% 23 STAVUDINE CAP15MG 19 STAVUDINE CAP20MG 19 STAVUDINE CAP30MG 19 STAVUDINE CAP40MG 19 STAVUDINE SOL1MG/ML 19 STELARA INJ45MG/0.5 23 STELARA INJ90MG/ML 23 STIVARGA TAB40MG 17 STRATTERA CAP100MG 9 STRATTERA CAP10MG 9 STRATTERA CAP18MG 9 STRATTERA CAP25MG 9 STRATTERA CAP40MG 9 STRATTERA CAP60MG 9 STRATTERA CAP80MG 9 STRIANT MIS30MG 11 STRIBILD TAB 19 STRIVERDI AERRESPIMAT 12 SUBSYS SPR100MCG 11 SUBSYS SPR200MCG 11 SUBSYS SPR400MCG 11 SUBSYS SPR600MCG 11 SUBSYS SPR800MCG 11 SUCRALFATE SUS1GM/10ML 28 SUCRALFATE TAB1GM 28 SULFACETAMIDSUS10% 23 SULFADIAZINETAB500MG 27 SULFAMYLON CRE85MG/GM 23 SULFASALAZINTAB500MG 24 SULFATRIM PDSUS200-40/5 16 SULFAZINE TAB500MG 24 SULFAZINE ECTAB500MG 24 SULINDAC TAB150MG 10 SULINDAC TAB200MG 10 SUMATRIPTAN INJ6MG/0.5 7, 25 SUMATRIPTAN SPR20MG/ACT 7, 25 SUMATRIPTAN SPR5MG/ACT 25 SUMATRIPTAN SUCCINATE REF 7, 25 SUMATRIPTAN TAB100MG 7, 25 SUMATRIPTAN TAB25MG 7, 25 SUMATRIPTAN TAB50MG 7, 25 SUMAVEL DOSEINJ4MG/0.5 25 SUMAVEL DOSEINJ6MG/0.5 25 SUPRAX TAB400MG 21 SUSTIVA CAP200MG 19 SUSTIVA CAP50MG 19 SUSTIVA TAB600MG 19 SUTENT CAP12.5MG 17 SUTENT CAP25MG 17 SUTENT CAP37.5MG 17 SUTENT CAP50MG 17 SYANGIS INJ 16 SYEDA 3
SYMLINPEN 60INJ1000MCG 7, 15 SYMLNPEN 120INJ1000MCG 7, 15 SYNERA DIS70-70MG 23 SYNTHROID TAB100MCG 28 SYNTHROID TAB112MCG 28 SYNTHROID TAB125MCG 28 SYNTHROID TAB137MCG 28 SYNTHROID TAB150MCG 28 SYNTHROID TAB175MCG 28 SYNTHROID TAB200MCG 28
SYNTHROID TAB25MCG 28 SYNTHROID TAB50MCG 28 SYNTHROID TAB75MCG 28 SYNTHROID TAB88MCG 28 SYPRINE CAP250MG 20 TABLOID TAB40MG 17 TACLONEX OIN 23 TACLONEX SUS 23 TACROLIMUS CAP0.5MG 20 TACROLIMUS CAP1MG 20 TACROLIMUS CAP5MG 20 TACROLIMUS OIN0.03% 23 TACROLIMUS OIN0.1% 23 TAFINLAR CAP50MG 17 TAFINLAR CAP75MG 17 TAKE ACTION 3 TAMIFLU CAP30MG 19 TAMIFLU CAP45MG 19 TAMIFLU CAP75MG 19 TAMIFLU SUS6MG/ML 19 TAMOXIFEN CITRATE 3
TAMSULOSIN CAP0.4MG 25 TANZEUM INJ30MG 15 TANZEUM INJ50MG 15 TARCEVA TAB100MG 17 TARCEVA TAB150MG 17 TARCEVA TAB25MG 17 TARINA FE 1/20 3
TASIGNA CAP150MG 17 TASIGNA CAP200MG 17 TAYTULLA 21 TAZORAC CRE0.05% 23 TAZORAC CRE0.1% 23 TAZORAC GEL0.05% 23 TAZORAC GEL0.1% 23 TAZTIA XT CAP120MG/24 20 TAZTIA XT CAP180MG/24 20 TAZTIA XT CAP240MG/24 20 TAZTIA XT CAP300MG/24 20 TAZTIA XT CAP360MG/24 20 TECFIDERA CAP120MG 27 TECFIDERA CAP240MG 27 TECFIDERA MISSTARTER 27 TEKTURNA TAB150MG 16 TEKTURNA TAB300MG 16 TELMISARTAN TAB20MG 16 TELMISARTAN TAB40MG 16 TELMISARTAN TAB80MG 16 TELMISARTAN/HCTZ 40/12.5MG 16 TELMISARTAN/HCTZ 80/12.5MG 16 TELMISARTAN/HCTZ 80/25MG 16 TEMAZEPAM 25 TEMOZOLOMIDECAP100MG 17 TEMOZOLOMIDECAP140MG 17 TEMOZOLOMIDECAP180MG 17 TEMOZOLOMIDECAP20MG 17 TEMOZOLOMIDECAP250MG 17 TEMOZOLOMIDECAP5MG 17 TENCON TAB50-325MG 10 TENIVAC 3
TERAZOSIN CAP10MG 16 TERAZOSIN CAP1MG 16 TERAZOSIN CAP2MG 16 TERAZOSIN CAP5MG 16 TERBINAFINE TAB250MG 7, 15 TERBUTALINE TAB2.5MG 12 TERBUTALINE TAB5MG 12
TERCONAZOLE CRE0.4% 28 TERCONAZOLE CRE0.8% 28 TERCONAZOLE SUP80MG 7, 28 TESTIM 11 TESTOST CYP INJ100MG/ML 11 TESTOST CYP INJ200MG/ML 11 TESTOST ENANINJ200MG/ML 11 TESTOSTERONE 11 TESTOSTERONE PUMP 11 TESTRED CAP10MG 11 TETRABENAZINETAB12.5MG 27 TETRABENAZINETAB25MG 27 TETRACYCLINECAP250MG 27 TETRACYCLINECAP500MG 27 TEVETEN TAB400MG 16 TGT ASPIRIN 3
TGT CHILDRENS ASPIRIN 3
THALITONE TAB15MG 23 THALOMID CAP100MG 20 THALOMID CAP150MG 20 THALOMID CAP200MG 20 THALOMID CAP50MG 20 THEOCHRON TAB100MG CR 12 THEOCHRON TAB200MG CR 12 THEOCHRON TAB300MG CR 12 THEOPHYLLINETAB100MG CR 12 THEOPHYLLINETAB200MG CR 12 THEOPHYLLINETAB300MG ER 12 THEOPHYLLINETAB400MG ER 12 THEOPHYLLINETAB450MG ER 12 THEOPHYLLINETAB600MG ER 12 THIORIDAZINETAB100MG 18 THIORIDAZINETAB10MG 18 THIORIDAZINETAB25MG 18 THIORIDAZINETAB50MG 18 THIOTHIXENE CAP10MG 18 THIOTHIXENE CAP1MG 18 THIOTHIXENE CAP2MG 19 THIOTHIXENE CAP5MG 19 THYROLAR-1 TAB60MG 28 THYROLAR-1/2TAB30MG 28 THYROLAR-1/4TAB15MG 28 THYROLAR-2 TAB120MG 28 THYROLAR-3 TAB180MG 28 TIAGABINE TAB2MG 13 TIAGABINE TAB4MG 13 TICLOPIDINE TAB250MG 7, 25 TIKOSYN CAP125MCG 12 TIKOSYN CAP250MCG 12 TIKOSYN CAP500MCG 12 TIMOLOL GEL SOL0.25% OP 26 TIMOLOL GEL SOL0.5% OP 26 TIMOLOL MAL SOL0.25% OP 26 TIMOLOL MAL SOL0.5% OP 26 TIMOLOL MAL TAB10MG 20 TIMOLOL MAL TAB20MG 20 TIMOLOL MAL TAB5MG 20 TIMOPTIC OCUSOL0.25% OP 26 TIMOPTIC OCUSOL0.5% OP 26 TIVICAY TAB50MG 19 TIZANIDINE CAP2MG 26 TIZANIDINE CAP4MG 26 TIZANIDINE CAP6MG 26 TIZANIDINE TAB2MG 26 TIZANIDINE TAB4MG 26 TOBRADEX OIN0.3-0.1% 26 TOBRAMYCIN NEB300/5ML 9
46
TOBRAMYCIN SOL0.3% OP 26 TOLAZAMIDE TAB250MG 15 TOLAZAMIDE TAB500MG 15 TOLBUTAMIDE TAB500MG 15 TOLCAPONE TAB100MG 18 TOLMETIN SODCAP400MG 10 TOLMETIN SODTAB200MG 10 TOLMETIN SODTAB600MG 10 TOLTERODINE CAP2MG ER 7, 28 TOLTERODINE CAP4MG ER 7, 28 TOLTERODINE TAB1MG 7, 28 TOLTERODINE TAB2MG 7, 28 TOPICORT OIN0.05% 23 TOPICORT SPR0.25% 23 TOPIRAMATE CAPER 100MG 13 TOPIRAMATE CAPER 150MG 13 TOPIRAMATE CAPER 200MG 13 TOPIRAMATE CAPER 25MG 13 TOPIRAMATE CAPER 50MG 13 TOPIRAMATE TAB100MG 13 TOPIRAMATE TAB200MG 13 TOPIRAMATE TAB25MG 13 TOPIRAMATE TAB50MG 13 TORSEMIDE TAB100MG 23 TORSEMIDE TAB10MG 23 TORSEMIDE TAB20MG 23 TORSEMIDE TAB5MG 23 TOUJEO SOLO INJ300IU/ML 7, 15 TOVIAZ TAB4MG 28 TOVIAZ TAB8MG 28 TRACLEER TAB125MG 21 TRACLEER TAB62.5MG 21 TRADJENTA TAB5MG 15 TRAMADOL HCLTAB50MG 7, 11 TRANDOLAPRILTAB1MG 7, 16 TRANDOLAPRILTAB2MG 7, 16 TRANDOLAPRILTAB4MG 7, 16 TRANEXAMIC ACID 25 TRANSDERM-SCDIS1.5MG 7, 15 TRANYLCYPROMTAB10MG 14 TRAVATAN Z DRO0.004% 26 TRAZODONE TAB100MG 14 TRAZODONE TAB150MG 14 TRAZODONE TAB300MG 14 TRAZODONE TAB50MG 14 TRECATOR TAB250MG 17 TRETINOIN 7, 17, 23 TRETINOIN CAP10MG 17 TRETINOIN CRE0.025% 23 TRETINOIN CRE0.05% 23 TRETINOIN CRE0.1% 23 TRETINOIN GEL0.01% 23 TRETINOIN GEL0.025% 23 TRETINOIN GEL0.1% 23 TRETIN-X CRE0.0375% 23 TRETIN-X CRE0.075% 23 TRETIN-X CREKIT0.025% 23 TRETIN-X CREKIT0.05% 23 TRETIN-X CREKIT0.1% 23 TREXALL TAB10MG 17 TREXALL TAB15MG 17 TREXALL TAB5MG 17 TREXALL TAB7.5MG 17 TRIAMCIN/ORAPST0.1% 25 TRIAMCINOLONAER55MCG/AC 7, 26 TRIAMCINOLONCRE0.025% 23 TRIAMCINOLONCRE0.1% 23
TRIAMCINOLONCRE0.5% 23 TRIAMCINOLONLOT0.025% 23 TRIAMCINOLONLOT0.1% 23 TRIAMCINOLONOIN0.025% 23 TRIAMCINOLONOIN0.1% 23 TRIAMCINOLONOIN0.5% 23 TRIDERM CRE0.1% 23 TRI-ESTARYLLA 3
TRIFLUOPERAZTAB10MG 19 TRIFLUOPERAZTAB1MG 19 TRIFLUOPERAZTAB2MG 19 TRIFLUOPERAZTAB5MG 19 TRIFLURIDINESOL1% OP 26 TRIGLIDE TAB160MG 16 TRIHEXYPHEN ELX0.4MG/ML 18 TRIHEXYPHEN TAB2MG 18 TRIHEXYPHEN TAB5MG 18 TRI-LINYAH 3
TRI-LO-ESTARYLLA 3
TRI-LO-MARZIA 3
TRI-LO-SPRINTEC 3
TRILYTE 3
TRIMETHOBENZCAP300MG 15 TRIMETHOPRIMTAB100MG 17 TRIMIPRAMINECAP100MG 14 TRIMIPRAMINECAP25MG 14 TRIMIPRAMINECAP50MG 14 TRINESSA 3
TRINESSA LO 3
TRI-PREVIFEM 3
TRI-SPRINTEC 3
TRIUMEQ TAB 19 TROPICAMIDE SOL0.5% OP 26 TROSPIUM CHLCAP60MG ER 28 TRULICITY INJ0.75/0.5 15 TRULICITY INJ1.5/0.5 15 TRUMENBA 3
TRUVADA TAB200-300 19 TWINRIX 3
TYKERB TAB250MG 17 TYZINE SOL0.1% 26 TYZINE PED DRO0.05% 26 U-CORT CRE1% 23 ULESFIA LOT5% 23 ULORIC TAB40MG 25 ULORIC TAB80MG 25 UNITHROID TAB100MCG 28 UNITHROID TAB112MCG 28 UNITHROID TAB125MCG 28 UNITHROID TAB150MCG 28 UNITHROID TAB175MCG 28 UNITHROID TAB200MCG 28 UNITHROID TAB25MCG 28 UNITHROID TAB300MCG 28 UNITHROID TAB50MCG 28 UNITHROID TAB75MCG 28 UNITHROID TAB88MCG 28 URSODIOL CAP300MG 24 URSODIOL TAB250MG 24 URSODIOL TAB500MG 24 VAGIFEM TAB10MCG 28 VALACYCLOVIRTAB1GM 7, 19 VALACYCLOVIRTAB500MG 7, 19 VALGANCICLOVIRTAB450MG 19 VALPROIC ACDCAP250MG 13 VALPROIC ACDSYP250/5ML 13
VALSART/HCTZTAB160-12.5 16 VALSART/HCTZTAB160-25MG 16 VALSART/HCTZTAB320-12.5 16 VALSART/HCTZTAB320-25MG 16 VALSART/HCTZTAB80-12.5 16 VALSARTAN TAB160MG 16 VALSARTAN TAB320MG 16 VALSARTAN TAB40MG 16 VALSARTAN TAB80MG 16 VANCOMYCIN CAP125MG 17 VANCOMYCIN CAP250MG 17 VANDETANIB TAB100MG 17 VANDETANIB TAB300MG 17 VAQTA 3
VARIVAX 3
VASCEPA CAP1GM 16 VECTICAL OIN3MCG/GM 23 VELTIN GEL 23 VENLAFAXINE CAP150MG ER 7, 14 VENLAFAXINE CAP37.5 ER 7, 14 VENLAFAXINE CAP75MG ER 7, 14 VENLAFAXINE TAB100MG 7, 14 VENLAFAXINE TAB150MG ER 7, 14 VENLAFAXINE TAB225MG ER 7, 14 VENLAFAXINE TAB25MG 7, 14 VENLAFAXINE TAB37.5 ER 7, 14 VENLAFAXINE TAB37.5MG 7, 14 VENLAFAXINE TAB50MG 7, 14 VENLAFAXINE TAB75MG 7, 14 VENLAFAXINE TAB75MG ER 7, 14 VENTAVIS SOL10MCG/ML 21 VENTOLIN HFAAER 7, 12 VERAMYST SPR27.5MCG 26 VERAPAMIL CAP100MG ER 20 VERAPAMIL CAP120MG ER 20 VERAPAMIL CAP180MG ER 20 VERAPAMIL CAP200MG ER 20 VERAPAMIL CAP240MG ER 20 VERAPAMIL CAP300MG ER 20 VERAPAMIL CAP360MG SR 20 VERAPAMIL TAB120MG 20 VERAPAMIL TAB180MG ER 20 VERAPAMIL TAB240MG ER 20 VERAPAMIL TAB40MG 20 VERAPAMIL TAB80MG 20 VERAPAMIL HCL ER 20 VERDESO AER0.05% 23 VEREGEN OIN15% 23 VERIPRED 20 SOL20MG/5ML 21 VESICARE TAB10MG 28 VESICARE TAB5MG 28 VESTURA 3
VEXOL SUS1% OP 26 VIBRAMYCIN SYP50MG/5ML 27 VICTOZA INJ18MG/3ML 15 VIDEX SOL2GM 19 VIENVA 3
VIGAMOX DRO0.5% 26 VIIBRYD KIT 14 VIIBRYD TAB10MG 14 VIIBRYD TAB20MG 14 VIIBRYD TAB40MG 14 VIMPAT SOL10MG/ML 13 VIMPAT TAB100MG 13 VIMPAT TAB150MG 13 VIMPAT TAB200MG 13
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VIMPAT TAB50MG 13 VIORELE 3
VIREAD POW40MG/GM 19 VIREAD TAB150MG 19 VIREAD TAB200MG 19 VIREAD TAB250MG 19 VIREAD TAB300MG 19 VISICOL TAB1.5GM 25 VOGELXO 11 VOGELXO PUMP 11 VORICONAZOLETAB200MG 8, 15 VORICONAZOLETAB50MG 8, 15 VOSPIRE ER TAB8MG 12 VOTRIENT TAB200MG 17 VRAYLAR 19 VYFEMLA 3
VYVANSE CAP20MG 9 VYVANSE CAP30MG 9 VYVANSE CAP40MG 9 VYVANSE CAP50MG 9 VYVANSE CAP60MG 9 VYVANSE CAP70MG 9 WARFARIN TAB10MG 12 WARFARIN TAB1MG 12 WARFARIN TAB2.5MG 12 WARFARIN TAB2MG 12 WARFARIN TAB3MG 12 WARFARIN TAB4MG 12 WARFARIN TAB5MG 12 WARFARIN TAB6MG 12 WARFARIN TAB7.5MG 12 WERA 3
WYMZYA FE 3
XALKORI CAP200MG 17 XALKORI CAP250MG 17 XARELTO TAB10MG 12 XARELTO TAB15MG 12 XARELTO TAB20MG 12 XARELTO STARTAB15/20MG 8, 12
XELJANZ TAB5MG 10 XELJANZ XR TAB11MG 10 XIFAXAN TAB200MG 17 XIFAXAN TAB550MG 17 XIIDRA 5% 26 XOLEGEL GEL2% 23 XOPENEX HFA AER 8, 12 XULANE 3
XYLON TAB10-200MG 11 ZAFIRLUKAST TAB10MG 8, 12 ZAFIRLUKAST TAB20MG 8, 12 ZALEPLON CAP10MG 25 ZALEPLON CAP5MG 25 ZARAH 3
ZAVESCA CAP100MG 25 ZAZOLE CRE0.4% 28 ZEBUTAL CAP 10 ZELAPAR TAB1.25MG 18 ZENATANE 23 ZENATANE CAP10MG 23 ZENATANE CAP20MG 23 ZENATANE CAP40MG 23 ZENCHENT 3
ZENCHENT FE 3
ZENPEP CAP10000UNT 23 ZENPEP CAP15000UNT 23 ZENPEP CAP20000UNT 23 ZENPEP CAP25000UNT 23 ZENPEP CAP3000UNIT 23 ZENPEP CAP40000UNT 23 ZENPEP CAP5000UNIT 23 ZEPATIER TABLET 19 ZETIA TAB10MG 16 ZIANA GEL 23 ZIDOVUDINE CAP100MG 19 ZIDOVUDINE SYP50MG/5ML 19 ZIDOVUDINE TAB300MG 19 ZIOPTAN DRO0.0015% 26 ZIPRASIDONE CAP20MG 8, 19
ZIPRASIDONE CAP40MG 8, 19 ZIPRASIDONE CAP60MG 8, 19 ZIPRASIDONE CAP80MG 8, 19 ZIPSOR CAP25MG 10 ZIRGAN GEL0.15% 26 ZITHROMAX POW1GM PAK 25 ZMAX SUS2GM 25 ZOLINZA CAP100MG 17 ZOLMITRIPTAN TAB2.5MG 25 ZOLMITRIPTAN TAB2.5MG ODT 25 ZOLMITRIPTAN TAB5MG 25 ZOLMITRIPTAN TAB5MG ODT 25 ZOLPIDEM SUB 1.75MG 25 ZOLPIDEM SUB 3.5MG 25 ZOLPIDEM TAB10MG 25 ZOLPIDEM TAB5MG 25 ZOLPIDEM ER TAB12.5MG 8, 25 ZOLPIDEM ER TAB6.25MG 8, 25 ZOMIG TAB2.5MG 25 ZOMIG TAB5MG 25 ZOMIG NASAL SPR5MG 8, 25 ZOMIG ZMT TAB2.5 MG 25 ZOMIG ZMT TAB5MG 25 ZONALON CRE5% 23 ZONISAMIDE CAP100MG 13 ZONISAMIDE CAP25MG 13 ZONISAMIDE CAP50MG 13 ZONTIVITY TAB2.08MG 25 ZORBTIVE INJ8.8MG 24 ZORTRESS TAB0.25MG 20 ZORTRESS TAB0.5MG 20 ZORTRESS TAB0.75MG 20 ZOSTAVAX 3
ZYCLARA CRE3.75% 23 ZYCLARA PUMPCRE2.5% 23 ZYDELIG TAB100MG 17 ZYDELIG TAB150MG 17 ZYKADIA CAP150MG 17 ZYTIGA TAB250MG 17
