2018 FORMULARY - Blue Cross Blue Shield of … FORMULARY (List of Covered Drugs) Note to existing members: This formulary has changed since last year. Please review this document to

Medicare Advantage Group

2018 FORMULARY(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANThis formulary was updated on 07/01/2018. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross Blue Shield of Massachusetts. When it refers to “plan” or “our plan,” it means Medicare HMO Blue or Medicare PPO Blue.This document includes a list of the drugs (formulary) for our plan which is current as of 07/01/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on 01/01/2019, and from time to time during the year.

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What is Medicare Advantage Group Plan Formulary?A formulary is a list of covered drugs selected by our Medicare Advantage Group plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Medicare HMO Blue or Medicare PPO Blue plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Advantage - plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 07/01/2018.

To get updated information about the drugs covered by our Medicare Advantage Group plans, please contact us. Our contact information appears on the front and back cover pages.

If we have a mid-year non-maintenance formulary change, we will provide a notice in the monthly Explanation of Benefits and on our website, www.bluecrossma.com/medicare. You may ask for a copy of the most recent formulary by contacting us. Our contact information appears on the front and back cover pages.

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How do I use the Formulary?There are two ways to find your drug within the formulary:• Medical Condition. The formulary begins on page 8. The drugs in this formulary

are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug.

• Alphabetical Listing. If you are not sure what category to look under, you should look for your drug in the Index that begins on page 99. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?Our Medicare Advantage Group plans cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:• Prior Authorization: Your Medicare Advantage Group plan requires you or your

physician to get prior authorization for certain drugs. This means that you will need to get approval from your Medicare Advantage Group plan before you fill your prescriptions. If you don’t get approval, your Medicare Advantage Group plan may not cover the drug.

• Quantity Limits: For certain drugs, your Medicare Advantage Group plan limits the amount of the drug that your Medicare Advantage Group plan will cover. For example, your Medicare Advantage Group plan provides up to 30 capsules per 30 days per prescription for Omeprazole 10 mg capsules. This may be in addition to a standard one-month or three-month supply.

• Morphine Equivalent Dosing: For certain drugs or combinations of drugs, there may be a safety limit applied to prevent opioid overutilization. The limit on these medications may be cumulative with other similar medications that you may be taking in the same class. A dosage adjustment by your physician or an exception may be required if you exceed the safety limit.

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• Step Therapy: In some cases, your Medicare Advantage Group plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, your Medicare Advantage Group plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, your Medicare Advantage Group plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Medicare HMO Blue or Medicare PPO Blue formulary?” on page 4 for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Member Service and ask if your drug is covered.

If you learn that your Medicare Advantage Group plan does not cover your drug, you have two options:• You can ask Member Service for a list of similar drugs that are covered by your

Medicare Advantage Group plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your Medicare Advantage Group plan.

• You can ask your Medicare Advantage Group plan to make an exception and cover your drug. See below for information about how to request an exception.

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How do I request an exception to the Medicare Advantage Group plans’ Formulary?You can ask your Medicare Advantage Group plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

• You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• Y ou can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, your Medicare Advantage Group plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our Medicare Advantage Group plans will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91-day supply and may be up to a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan’s exception process.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that might be covered under Medicare Part B.

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For more informationFor more detailed information about your Medicare Advantage Group plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our Medicare Advantage Group plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov.

Medicare Advantage Group Plans’ FormularyThe formulary that begins on Page 8 provides coverage information about the drugs covered by our Medicare Advantage Group plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 99.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AMOXIL®´) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Requirements/Limits column tells you if your Medicare Advantage Group plan has any special requirements for coverage of your drug.

The abbreviations you may see in the formulary (list of covered drugs) include: Quantity Limits (QL): To help ensure that the quantity and dosage of your medications remains consistent with manufacturer, clinical, and Food and Drug Administration (FDA) recommendations, we maintain a list of medications subject to QL. When you fill a prescription for a medication subject to QL, your prescription is reviewed for:

• Dose Consolidation. Dose consolidation checks to see whether you’re taking two or more daily doses of medicine that could be replaced with one daily dose providing the same total amount of medication.

• Recommended Monthly Dosing Level. This process checks to see that your monthly dosage of medication is consistent with both the manufacturer’s and the FDA’s monthly dosing recommendations and clinical information. Your doctor can also apply for an exception to QL guidelines when medically necessary.

Mail Order (MO): These prescription drugs are available through mail-order.

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Home Infusion (HI): This prescription drug may be covered under our medical benefit. For more information, call us. Our contact information appears on the front and back cover pages.

Medical Benefit (MB): These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmacies or mail-order service.*

Prior Authorization (PA): These prescription drugs require prior authorization from the plan.

Step Therapy (ST): These prescription drugs require you to first try another drug to treat your medical condition.

Limited Pharmacy Availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call us. Our contact information appears on the front and back cover pages.

Medicare Part B or D (B/D): This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

* Coverage for diabetic test strips and blood glucose monitors at a participating retail or mail order pharmacy is limited to those listed on our formulary and provided at no cost to you. There is no coverage for other brand test strips and blood glucose monitors that are not listed on our formulary when purchased at a retail or mail order pharmacy.

ANTI - INFECTIVES: ANTIFUNGALAGENTSDrug Name Tier Requirements/

LimitsAMBISOME 2 B/D PA, MO, HIamphotericin b 1 B/D PA, MO, HICANCIDAS 2 B/D PA, MO, HIcaspofungin 1 B/D PA, HIclotrimazole mucous 1 MOmembrane

CRESEMBA 2 HIINTRAVENOUS

CRESEMBA ORAL 2 MOfluconazole 1 MOfluconazole in 1 HIdextrose(iso-o)

fluconazole in nacl 1 MO, HI(iso-osm) intravenouspiggyback 200mg/100 ml

fluconazole in nacl 1 HI(iso-osm) intravenouspiggyback 400mg/200 ml

flucytosine 1 MOgriseofulvin microsize 1 MOgriseofulvinultramicrosize

1 MO

itraconazole 1 MO, QL (120 per30 days)

ketoconazole oral 1 MOMYCAMINE 2 MO, HINOXAFIL 2 HIINTRAVENOUS

NOXAFIL ORAL 2 MOnystatin oralsuspension

1 MO

nystatin oral tablet 1 MO

ANTI - INFECTIVES: ANTIFUNGALAGENTS (continued)Drug Name Tier Requirements/

Limitsterbinafine hcl oral 1 MO, QL (30 per

30 days)voriconazole 1 MO, HIintravenous

voriconazole oral 1 MO

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7.8

ANTI - INFECTIVES: ANTIVIRALSDrug Name Tier Requirements/

Limitsabacavir 1 MOabacavir-lamivudine 1 MOabacavir-lamivudine- 1 MOzidovudine

acyclovir oral capsule 1 MOacyclovir oralsuspension 200 mg/5ml

1 MO

acyclovir oral tablet 1 MOacyclovir sodiumintravenous recon

1 B/D PA, HI

soln 500 mgacyclovir sodiumintravenous solution

1 B/D PA, MO, HI

adefovir 1 MOamantadine hcl 1 MOAPTIVUS ORAL 2 MOCAPSULE

APTIVUS ORAL 2SOLUTION

atazanavir 1 MOATRIPLA 2 MOBARACLUDE ORAL 2 MOSOLUTION

BIKTARVY 2 MOcidofovir 1 B/D PA, MO, HICIMDUO 2 MOCOMPLERA 2 MOCRIXIVAN ORAL 2 MOCAPSULE 200 MG,400 MG

DAKLINZA ORALTABLET 30 MG

3 PA, MO, QL (90per 30 days)

DAKLINZA ORALTABLET 60 MG, 90MG


ANTI - INFECTIVES: ANTIVIRALS(continued)Drug Name Tier Requirements/

LimitsDESCOVY 2 MOdidanosine oralcapsule,delayedrelease(dr/ec) 200mg, 250 mg, 400 mg

1 MO

EDURANT 2 MOefavirenz 1 MOEMTRIVA 2 MOentecavir 1 MOEPCLUSA 2 PA, MO, QL (28

per 28 days)EPIVIR HBV ORALSOLUTION

2 MO

EVOTAZ 2 MOfamciclovir 1 MOfosamprenavir 1 MOFUZEONSUBCUTANEOUSRECON SOLN

2 MO

ganciclovir sodiumintravenous reconsoln

1 B/D PA, MO, HI

ganciclovir sodiumintravenous solution

1 B/D PA, MO, HI

GENVOYA 2 MOHARVONI 2 PA, MO, QL (28

per 28 days)INTELENCE 2 MOINVIRASE 2 MOISENTRESS 2 MOISENTRESS HD 2 MOJULUCA 2 MOKALETRA ORALTABLET

2 MO

lamivudine 1 MO

You can find information on what the symbols and abbreviations on this tablemean by going to page(s) 6 and 7. 9


Limitslamivudine-zidovudine 1 MOLEXIVA ORALSUSPENSION

2 MO

lopinavir-ritonavir 1 MOMAVYRET 3 PA, MO, QL (90

per 30 days)moderiba 1 MOmoderiba dose packoral tablets,dosepack 200 mg (28)-400 mg (28), 400-400mg (28)-mg (28),600-400 mg (28)-mg(28), 600-600 mg(28)-mg (28)

1 MO

moderiba dose packoral tablets,dosepack 400 mg (7)- 400mg (7), 600 mg (7)-600 mg (7)

1

nevirapine oral tablet 1 MOnevirapine oral tabletextended release 24hr

1 MO

NORVIR ORALCAPSULE

2

NORVIR ORALPOWDER INPACKET

2 MO

NORVIR ORALSOLUTION

2 MO

NORVIR ORALTABLET

2 MO

ODEFSEY 2 MOOLYSIO 3 PA, MO, QL (30

per 30 days)oseltamivir oralcapsule 30 mg

1 MO, QL (84 per180 days)


Limitsoseltamivir oralcapsule 45 mg, 75mg


oseltamivir oralsuspension forreconstitution


PREVYMISINTRAVENOUS

2 HI

PREVYMIS ORAL 2 MOPREZCOBIX 2 MOPREZISTA ORALSUSPENSION

2 MO

PREZISTA ORALTABLET 150 MG,600 MG, 75 MG, 800MG

2 MO

RELENZADISKHALER


RESCRIPTOR 2 MORETROVIRINTRAVENOUS

2 MO, HI

REYATAZ ORALCAPSULE 150 MG,200 MG, 300 MG

2 MO

REYATAZ ORALPOWDER INPACKET

2 MO

ribasphere 1 MOribasphere ribapakoral tablets,dosepack 200 mg (28)-400 mg (28), 400-400mg (28)-mg (28),600-400 mg (28)-mg(28), 600-600 mg(28)-mg (28)

1 MO



Limitsribasphere ribapakoral tablets,dosepack 200 mg (7)- 400mg (7), 400 mg (7)-400 mg (7), 600 mg(7)- 400 mg (7), 600mg (7)- 600 mg (7)

1

ribavirin oral capsule 1 MOribavirin oral tablet200 mg

1 MO

rimantadine 1 MOritonavir 1 MOSELZENTRY 2 MOSOVALDI 3 PA, MO, QL (30

per 30 days)stavudine oral capsule 1 MOSTRIBILD 2 MOSUSTIVA ORALCAPSULE 200 MG

2 MO

SUSTIVA ORALTABLET

2 MO

SYMFI 2 MOSYMFI LO 2 MOSYNAGIS 3 MO, LATECHNIVIE 3 PA, MO, QL (60

per 30 days)tenofovir disoproxilfumarate

1 MO

TIVICAY 2 MOTRIUMEQ 2 MOTROGARZO 2 MOTRUVADA 2 MOTYBOST 2 MOvalacyclovir 1 MO


Limitsvalganciclovir oralrecon soln

1 MO

valganciclovir oraltablet

1 MO

VEMLIDY 2 MOVIDEX 2 GRAMPEDIATRIC

2 MO

VIDEX 4 GRAMPEDIATRIC

2 MO

VIDEX EC ORALCAPSULE,DELAYEDRELEASE(DR/EC)125 MG

2 MO

VIEKIRA PAK 3 PA, MO, QL(112 per 28days)

VIEKIRA XR 3 PA, MO, QL (84per 28 days)

VIRACEPT ORALTABLET

2 MO

VIRAMUNE ORALSUSPENSION

2 MO

VIREAD 2 MOVOSEVI 2 PA, MO, QL (30

per 30 days)ZEPATIER 2 PA, MO, QL (30

per 30 days)ZERIT ORAL RECONSOLN

2 MO

ZIAGEN ORALSOLUTION

2 MO

zidovudine 1 MO


ANTI - INFECTIVES:CEPHALOSPORINSDrug Name Tier Requirements/

Limitscefaclor oral capsule 1 MOcefaclor oralsuspension forreconstitution 125mg/5 ml, 250 mg/5 ml

1 MO

cefaclor oralsuspension forreconstitution 375mg/5 ml

1

cefaclor oral tabletextended release 12hr

1 MO

cefadroxil oral capsule 1 MOcefadroxil oralsuspension forreconstitution 250mg/5 ml, 500 mg/5 ml

1 MO

cefadroxil oral tablet 1 MOcefazolin in dextrose(iso-os) intravenouspiggyback 1 gram/50ml, 2 gram/50 ml

1 MO, HI

cefazolin injectionrecon soln 1 gram,500 mg

1 MO, HI

cefazolin injectionrecon soln 10 gram

1 HI

cefazolin injectionrecon soln 100 gram,20 gram, 300 g

1 HI

cefazolin intravenous 1 HIcefdinir 1 MOcefepime 1 MO, HIcefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50ml

1

ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefepime in dextrose,iso-osm intravenouspiggyback 2gram/100 ml

1 MO

cefixime 1 MOcefotaxime injectionrecon soln 1 gram, 2gram, 500 mg

1 HI

cefotaxime injectionrecon soln 10 gram

1 HI

cefotetan injection 1 HIcefotetan intravenous 1 HIcefoxitin in dextrose,iso-osm

1

cefoxitin intravenousrecon soln 1 gram, 2gram

1 MO, HI

cefoxitin intravenousrecon soln 10 gram

1 HI

cefpodoxime 1 MOcefprozil 1 MOceftazidime injectionrecon soln 1 gram, 2gram

1 MO, HI

ceftazidime injectionrecon soln 6 gram

1 HI

ceftriaxone indextrose,iso-os

1 MO

ceftriaxone injectionrecon soln 1 gram, 2gram, 250 mg, 500mg

1 MO, HI

ceftriaxone injectionrecon soln 10 gram

1 HI

ceftriaxoneintravenous

1 MO, HI


ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefuroxime axetil oraltablet

1 MO

cefuroxime sodiuminjection recon soln750 mg

1 MO, HI

cefuroxime sodiumintravenous reconsoln 1.5 gram

1 MO, HI

cefuroxime sodiumintravenous reconsoln 7.5 gram

1 HI

cephalexin 1 MOSUPRAX ORALCAPSULE

2 MO

SUPRAX ORALTABLET,CHEWABLE

2 MO

TEFLARO 3 MO, HIZERBAXA 2 HI

ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDESDrug Name Tier Requirements/

Limitsazithromycinintravenous

1 MO, HI

azithromycin oral 1 MOclarithromycin oralsuspension forreconstitution

1 MO

clarithromycin oraltablet

1 MO

clarithromycin oraltablet extended

1 MO

release 24 hrDIFICID 3 MOe.e.s. 400 oral tablet 1 MOery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1 MO

ERY-TAB ORAL 2 MOTABLET,DELAYEDRELEASE (DR/EC)500 MG

erythrocin (asstearate) oral tablet250 mg

1 MO

ERYTHROCININTRAVENOUS

2 MO, HI

RECON SOLN 500MG

erythromycinethylsuccinate oralsuspension forreconstitution

1 MO

erythromycinethylsuccinate oraltablet

1 MO

erythromycin oralcapsule,delayedrelease(dr/ec)

1 MO


ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDES (continued)Drug Name Tier Requirements/

Limitserythromycin oraltablet

1 MO

ANTI - INFECTIVES:MISCELLANEOUS ANTDrug Name Tier

ALBENZA 2ALINIA 2amikacin injection 1solution 1,000 mg/4ml

amikacin injection 1solution 500 mg/2 ml

atovaquone 1atovaquone-proguanil 1AZACTAM 2AZACTAM IN 2DEXTROSE (ISO-OSM)

aztreonam injection 1recon soln 1 gram

aztreonam injection 1recon soln 2 gram

baciim 1bacitracin 1intramuscular

BENZNIDAZOLE 2BETHKIS 3CAPASTAT 2CAYSTON 2chloramphenicol sod 1succinate

chloroquine 1phosphate

cleocin intravenous 1solution 300 mg/2 ml

clindamycin hcl 1clindamycin in 5 % 1dextrose

clindamycin palmitate 1hcl

IINFECTIVESRequirements/Limits

MOMOMO, HI

MO, HI

MOMOMO, HIHI

MO, HI

MO, HI

MO

B/D PA, MOHIMO, LAHI

MO

MOMO, HI

MO


ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVES(continued)Drug Name Tier Requirements/

Limitsclindamycin pediatric 1 MOclindamycinphosphate injection

1 MO, HI

clindamycinphosphateintravenous solution300 mg/2 ml, 900mg/6 ml

1 HI

clindamycinphosphateintravenous solution600 mg/4 ml

1 HI

COARTEM 2 MOcolistin (colistimethatena)

1 MO, HI

CYCLOSERINE 2 MODALVANCE 2 MO, HIdapsone oral 1 MOdaptomycin 1 MO, HIDARAPRIM 3DORIPENEMINTRAVENOUSRECON SOLN 250MG

2 HI

DORIPENEMINTRAVENOUSRECON SOLN 500MG

2 HI

EMVERM 3 MOethambutol 1 MOgentamicin in nacl(iso-osm) intravenouspiggyback 100mg/100 ml, 60 mg/50ml, 80 mg/50 ml

1 MO, HI


Limitsgentamicin in nacl(iso-osm) intravenouspiggyback 70 mg/50ml, 90 mg/100 ml

1 HI

gentamicin in nacl(iso-osm) intravenouspiggyback 80 mg/100ml

1 HI

gentamicin injectionsolution 20 mg/2 ml

1 MO, HI

gentamicin injectionsolution 40 mg/ml

1 MO, HI

gentamicin sulfate(ped) (pf)

1 MO

gentamicin sulfate (pf)intravenous solution100 mg/10 ml

1 MO, HI

hydroxychloroquine 1 MOimipenem-cilastatin 1 MO, HIIMPAVIDO 2 MOINVANZ INJECTION 2 MO, HIINVANZINTRAVENOUS

2 HI

isoniazid injection 1isoniazid oral 1 MOivermectin 1 MOlincomycin 1 HIlinezolid 1 MOlinezolid in dextrose5%

1 HI

linezolid-0.9% sodiumchloride

1

mefloquine 1 MOmeropenem 1 MO, HImetro i.v. 1 MO, HI



Limitsmetronidazole in nacl(iso-os)

1 MO, HI

metronidazole oral 1 MONEBUPENT 2 B/D PA, MOneomycin 1 MOORBACTIV 2 MO, HIparomomycin 1 MOPASER 2 MOPENTAM 3 MO, HIpolymyxin b sulfate 1 MO, HIpraziquantel 1 MOPRIFTIN 2 MOPRIMAQUINE 3 MOpyrazinamide 1 MOquinine sulfate 1 MOrifabutin 1 MOrifampin intravenous 1 MO, HIrifampin oral 1 MORIFATER 3 MOSIRTURO 2 MO, LASIVEXTROINTRAVENOUS

2 HI

SIVEXTRO ORAL 2 MOSTREPTOMYCIN 2 MOSYNERCID 3 HItigecycline 1 HItinidazole 1 MOTOBI PODHALERINHALATIONCAPSULE

3


LimitsTOBI PODHALERINHALATIONCAPSULE, W/INHALATIONDEVICE

3 MO

tobramycin in 0.225 %nacl

1 B/D PA, MO

tobramycin sulfateinjection recon soln

1 HI

tobramycin sulfateinjection solution

1 MO, HI

TRECATOR 2 MOTYGACIL 2 MO, HIXIFAXAN ORALTABLET 550 MG

2 MO


ANTI - INFECTIVES: PENICILLINSDrug Name Tier Requirements/

Limitsamoxicillin oralcapsule

1 MO

amoxicillin oralsuspension forreconstitution

1 MO

amoxicillin oral tablet 1 MOamoxicillin oral tablet,chewable 125 mg,250 mg

1 MO

amoxicillin-potclavulanate oralsuspension forreconstitution

1 MO

amoxicillin-potclavulanate oraltablet

1 MO

amoxicillin-potclavulanate oraltablet extendedrelease 12 hr

1 MO

amoxicillin-potclavulanate oraltablet,chewable

1 MO

ampicillin oral capsule 1 MOampicillin sodiuminjection recon soln 1gram, 10 gram, 125mg

1 MO, HI

ampicillin sodiuminjection recon soln 2gram, 250 mg, 500mg

1 MO, HI

ampicillin sodiumintravenous

1 HI

ampicillin-sulbactaminjection recon soln1.5 gram, 3 gram

1 MO, HI

ampicillin-sulbactaminjection recon soln15 gram

1 HI

ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsampicillin-sulbactamintravenous reconsoln 1.5 gram

1 HI

ampicillin-sulbactamintravenous reconsoln 3 gram

1 MO, HI

BICILLIN L-A 3 MOdicloxacillin 1 MOnafcillin in dextroseiso-osm intravenouspiggyback 1 gram/50ml

1 HI

nafcillin in dextroseiso-osm intravenouspiggyback 2gram/100 ml

1 MO, HI

nafcillin injection reconsoln 1 gram, 10 gram

1 MO, HI

nafcillin injection reconsoln 2 gram

1 MO, HI

nafcillin intravenousrecon soln 1 gram

1 MO, HI

nafcillin intravenousrecon soln 2 gram

1 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50ml

1 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50ml

1 MO, HI

oxacillin injectionrecon soln 1 gram

1 HI


1 HI


1 MO, HI


ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitspenicillin g potassiuminjection recon soln20 million unit

1 MO, HI

penicillin g potassiuminjection recon soln 5million unit

1 MO, HI

penicillin g procaineintramuscular syringe1.2 million unit/2 ml

1 MO

penicillin g procaineintramuscular syringe600,000 unit/ml

1

penicillin g sodium 1 MO, HIpenicillin v potassium 1 MOpfizerpen-g 1 HIpiperacillin-tazobactamintravenous reconsoln 2.25 gram,3.375 gram, 4.5gram, 40.5 gram

1 MO, HI

ANTI - INFECTIVES: QUINOLONESDrug Name Tier Requirements/

LimitsBAXDELA 2 HIINTRAVENOUS

BAXDELA ORAL 2 MOciprofloxacin 1ciprofloxacin (mixture)oral tablet, er

1 MO

multiphase 24 hrciprofloxacin hcl oral 1 MOciprofloxacin in 5 %dextrose intravenous

1 MO, HI

piggyback 200mg/100 ml

ciprofloxacin in 5 %dextrose intravenous

1 MO, HI

piggyback 400mg/200 ml

ciprofloxacin lactateintravenous solution

1 HI

400 mg/40 mllevofloxacin in d5w 1 HIintravenouspiggyback 250 mg/50ml

levofloxacin in d5w 1 MO, HIintravenouspiggyback 500mg/100 ml, 750mg/150 ml

levofloxacin 1 MO, HIintravenous

levofloxacin oral 1 MOmoxifloxacin in nacl 1 HI(iso-osm)

moxifloxacin oral 1 MOofloxacin oral tablet 1300 mg

ofloxacin oral tablet 1 MO400 mg


ANTI - INFECTIVES: SULFA'S /RELATED AGENTSDrug Name Tier Requirements/

Limitssulfadiazine 1 MOsulfamethoxazole-trimethoprimintravenous

1 MO, HI

sulfamethoxazole-trimethoprim oral

1 MO

sulfatrim 1 MO

ANTI - INFECTIVES:TETRACYCLINESDrug Name Tier Requirements/

Limitscoremino oral tabletextended release 24hr

1

demeclocycline 1 MOdoxy-100 1 MO, HIdoxycycline hyclateoral capsule

1 MO

doxycycline hyclateoral tablet 100 mg,150 mg, 20 mg, 75mg

1 MO

doxycycline hyclateoral tablet 50 mg

1

doxycycline hyclateoral tablet,delayedrelease (dr/ec)

1 MO

doxycyclinemonohydrate oralcapsule

1 MO

doxycyclinemonohydrate oralsuspension forreconstitution

1 MO

doxycyclinemonohydrate oraltablet

1 MO

minocycline oralcapsule

1 MO

minocycline oral tablet 1 MOminocycline oral tabletextended release 24hr

1 MO

mondoxyne nl 1 MOmorgidox 1 MOokebo oral capsule 75mg

1 MO

soloxide 1


ANTI - INFECTIVES:TETRACYCLINES (continued)Drug Name Tier Requirements/

Limitstetracycline 1 MO

ANTI - INFECTIVES: URINARYTRACT AGENTSDrug Name Tier Requirements/

Limitsmethenaminehippurate

1 MO

methenaminemandelate

1 MO

nitrofurantoin 1 MOnitrofurantoinmacrocrystal

1 MO

nitrofurantoinmonohyd/m-cryst

1 MO

trimethoprim 1 MO

ANTI - INFECTIVES: VANCOMYCINDrug Name Tier Requirements/

LimitsVANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 1GRAM/200 ML(BRAND)

2 MO

VANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 500MG/100 ML, 750MG/150 ML (BRAND)

2

VANCOMYCIN INDEXTROSE ISO-OSM (BRAND)

2

VANCOMYCININJECTION(BRAND)

2

vancomycinintravenous reconsoln 1,000 mg, 10gram, 500 mg

1 MO, HI

vancomycinintravenous reconsoln 5 gram, 750 mg

1 MO, HI

vancomycin oralcapsule

1 MO

VIBATIVINTRAVENOUSRECON SOLN 750MG

2


ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS:ADJUNCTIVE AGENTSDrug Name Tier Requirements/

Limitsamifostine crystalline 1 MOdexrazoxane hcl 1 HIintravenous reconsoln 250 mg

dexrazoxane hcl 1 MO, HIintravenous reconsoln 500 mg

ELITEK 2 MO, HIKEPIVANCE 2 MO, HIleucovorin calcium 1 MO, HIinjection recon soln100 mg, 350 mg

leucovorin calcium 1 MO, HIinjection recon soln200 mg, 50 mg

leucovorin calcium 1 HIinjection recon soln500 mg

leucovorin calcium 1 MOoral

LEVOLEUCOVORIN 2 HIINTRAVENOUSRECON SOLN 175MG (BRAND)

levoleucovorin 1 HIintravenous reconsoln 50 mg

levoleucovorin 1 HIintravenous solution

mesna 1 MO, HIMESNEX ORAL 2 MOVISTOGARD 2 MOXGEVA 3 PA, MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSDrug Name Tier Requirements/

LimitsABRAXANE 2 MO, HIadriamycinintravenous solution

1 HI

10 mg/5 ml, 2 mg/ml,50 mg/25 ml

adriamycinintravenous solution

1 HI

20 mg/10 mladrucil intravenoussolution 2.5 gram/50ml

1 B/D PA, HI

adrucil intravenoussolution 5 gram/100ml

1 B/D PA, MO, HI

adrucil intravenoussolution 500 mg/10ml

1 B/D PA, MO, HI

AFINITOR 2 MOAFINITOR DISPERZ 2 MOALECENSA 2 MOALIMTA 2 MOINTRAVENOUSRECON SOLN 100MG

ALIMTAINTRAVENOUS

2 MO, HI

RECON SOLN 500MG

ALIQOPA 2 MO, HI, LAALUNBRIG 2 MOanastrozole 1 MOARRANON 2 HIARZERRA 2 B/D PA, MO, HIASTAGRAF XL 3 B/D PA, MOAVASTIN 2 MO, HIazacitidine 1 MO, HI


ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS(continued)Drug Name Tier Requirements/

Limitsazathioprine 1 B/D PA, MOazathioprine sodium 1 B/D PA, HIBAVENCIO 2 MO, HI, LABELEODAQ 2 MO, HIBENDEKA 2 MOBESPONSA 2 MO, HIbexarotene 1 MObicalutamide 1 MOBICNU 2 MO, HIbleomycin injectionrecon soln 15 unit

1 B/D PA, MO, HI

bleomycin injectionrecon soln 30 unit

1 B/D PA, MO, HI

BLINCYTOINTRAVENOUS KIT

2 B/D PA, MO

BORTEZOMIB 2 MO, HIBOSULIF 2 MObusulfan 1 HICABOMETYX 2 MO, LACALQUENCE 2 MO, LAcapecitabine MB MOCAPRELSA 2 MO, LAcarboplatinintravenous solution

1 MO, HI

CELLCEPTINTRAVENOUS

2 B/D PA, MO, HI

cisplatin 1 MO, HIcladribine 1 B/D PA, MO, HIclofarabine 1 HICOMETRIQ 2 MOCOTELLIC 2 MO, LA


Limitscyclophosphamideintravenous

1 MO

cyclophosphamideoral capsule

1 B/D PA, MO

cyclosporineintravenous

1 B/D PA, HI

cyclosporine modified 1 B/D PA, MOcyclosporine oralcapsule

1 B/D PA, MO

CYRAMZA 2 B/D PA, MO, HIcytarabine 1 B/D PA, MO, HIcytarabine (pf)injection solution 100mg/5 ml (20 mg/ml)

1 B/D PA, MO, HI

cytarabine (pf)injection solution 2gram/20 ml (100 mg/ml)

1 B/D PA, MO, HI

cytarabine (pf)injection solution 20mg/ml

1 B/D PA, HI

dacarbazineintravenous reconsoln 100 mg

1 MO, HI

dacarbazineintravenous reconsoln 200 mg

1 MO, HI

dactinomycin 1 HIDARZALEX 2 MO, HI, LAdaunorubicinintravenous solution

1 HI

decitabine 1 MO, HIdocetaxel intravenoussolution 160 mg/16ml (10 mg/ml)

1 HI



Limitsdocetaxel intravenoussolution 160 mg/8 ml(20 mg/ml), 20 mg/ml(1 ml), 80 mg/8 ml(10 mg/ml)

1 MO, HI

docetaxel intravenoussolution 20 mg/2 ml(10 mg/ml)

1 HI

DOCETAXELINTRAVENOUSSOLUTION 20 MG/ML (BRAND)

2 HI

docetaxel intravenoussolution 80 mg/4 ml(20 mg/ml)

1 MO, HI

doxorubicinintravenous reconsoln 10 mg

1 HI

doxorubicinintravenous reconsoln 50 mg

1 MO, HI

doxorubicinintravenous solution10 mg/5 ml, 2 mg/ml,20 mg/10 ml

1 MO, HI

doxorubicinintravenous solution50 mg/25 ml

1 MO, HI

doxorubicin, peg-liposomal

1 MO, HI

ELIGARD 2 MOELIGARD (3 MONTH) 2 MOELIGARD (4 MONTH) 2 MOELIGARD (6 MONTH) 2 MOEMCYT 2 MOEMPLICITI 2 B/D PA, MO, HIENVARSUS XR 3 B/D PA, MO


Limitsepirubicin intravenoussolution 200 mg/100ml

1 MO, HI

epirubicin intravenoussolution 50 mg/25 ml

1 MO, HI

ERBITUXINTRAVENOUSSOLUTION 100MG/50 ML

2 MO, HI

ERBITUXINTRAVENOUSSOLUTION 200MG/100 ML

2 MO, HI

ERIVEDGE 2 MOERLEADA 2 MOERWINAZE 2 MO, HIETOPOPHOS 2 MO, HIetoposide intravenous 1 MO, HIetoposide oral MB MOexemestane 1 MOFARESTON 2 MOFARYDAK 2 MOFASLODEX 2 MOFIRMAGON KIT WDILUENT SYRINGE

2 MO

floxuridine 1 B/D PAfludarabineintravenous reconsoln

1 MO, HI

fludarabineintravenous solution

1 HI



Limitsfluorouracilintravenous solution1 gram/20 ml, 2.5gram/50 ml, 500mg/10 ml

1 B/D PA, MO, HI

fluorouracilintravenous solution5 gram/100 ml

1 B/D PA, MO, HI

flutamide 1 MOFOLOTYNINTRAVENOUSSOLUTION 20 MG/ML (1 ML)

2 MO, HI

FOLOTYNINTRAVENOUSSOLUTION 40 MG/2ML (20 MG/ML)

2 MO, HI

GAZYVA 2 MOgemcitabineintravenous reconsoln 1 gram

1 MO, HI

gemcitabineintravenous reconsoln 2 gram

1 HI

gemcitabineintravenous reconsoln 200 mg

1 MO, HI

gemcitabineintravenous solution1 gram/26.3 ml (38mg/ml), 200 mg/5.26ml (38 mg/ml)

1 MO, HI

gemcitabineintravenous solution2 gram/52.6 ml (38mg/ml)

1 HI

gengraf oral capsule100 mg, 25 mg

1 B/D PA, MO


Limitsgengraf oral solution 1 B/D PA, MOGILOTRIF 2 MOGLEOSTINE 2 MOHALAVEN 2 MO, HIHERCEPTIN 2 MO, HIHEXALEN 2 MOHYCAMTIN ORAL MB MOhydroxyurea 1 MOIBRANCE 2 PA, MOICLUSIG ORALTABLET 15 MG

2

ICLUSIG ORALTABLET 45 MG

2 MO

idarubicin 1 HIIDHIFA 2 MO, LAifosfamide intravenousrecon soln 1 gram

1 MO, HI

ifosfamide intravenousrecon soln 3 gram

1 MO, HI

ifosfamide intravenoussolution

1 HI

imatinib 1 MOIMBRUVICA 2 PA, MOIMFINZI 2 MO, HI, LAINLYTA 2 MOIRESSA 2 MOirinotecan intravenoussolution 100 mg/5 ml

1 MO, HI

irinotecan intravenoussolution 40 mg/2 ml

1 MO, HI

irinotecan intravenoussolution 500 mg/25ml

1 HI



LimitsISTODAX 2 MO, HIIXEMPRA 2 MO, HIJAKAFI 2 PA, MOJEVTANA 2 MO, HIKADCYLA 2 MO, HIKEYTRUDAINTRAVENOUSSOLUTION

2 MO, HI

KISQALI 2 PA, MOKISQALI FEMARACO-PACK

2 PA, MO

KYPROLIS 2 MO, HILARTRUVO 2 MO, HI, LALENVIMA 2 MOletrozole 1 MOLEUKERAN 2 MOleuprolidesubcutaneous kit

1 MO

LONSURF 2 MOLUPRON DEPOT 2 MOLUPRON DEPOT (3MONTH)

2 MO

LUPRON DEPOT (4MONTH)

2 MO

LUPRON DEPOT (6MONTH)

2 MO

LUPRON DEPOT-PED

2 MO

LUPRON DEPOT-PED (3 MONTH)

2 MO

LYNPARZA 2 MOLYSODREN 2 MOMATULANE 2 MO


Limitsmegestrol oralsuspension 400mg/10 ml (10 ml)

1 PA

megestrol oralsuspension 400mg/10 ml (40 mg/ml),625 mg/5 ml

1 PA, MO

megestrol oral tablet 1 PA, MOMEKINIST 2 MOmelphalan 1 B/D PA, MOmelphalan hcl 1 HImercaptopurine 1 MOmethotrexate sodium(pf) injection reconsoln

1 B/D PA, HI

methotrexate sodium(pf) injection solution

1 B/D PA, MO, HI

methotrexate sodiuminjection

1 B/D PA, MO, HI

methotrexate sodiumoral

1 B/D PA, MO

mitomycin intravenous 1 MO, HImitoxantrone 1 MO, HIMUSTARGEN 2 MO, HImycophenolate mofetil 1 B/D PA, MOmycophenolate mofetilhcl

1 B/D PA, HI

mycophenolatesodium oral tablet,delayed release (dr/ec)

1 B/D PA, MO

MYLERAN MB MOMYLOTARG 2 MO, HI, LANERLYNX 2 PA, MO, LANEXAVAR 2 MO, LA



Limitsnilutamide 1 MONINLARO 2 MONULOJIX 3 B/D PA, MO, HIoctreotide acetate 1 MOODOMZO 2 MO, LAONCASPAR 2 MOONIVYDE 2 MOOPDIVOINTRAVENOUSSOLUTION 100MG/10 ML, 40 MG/4ML

2 MO, HI

OPDIVOINTRAVENOUSSOLUTION 240MG/24 ML

2 MO, HI

oxaliplatin intravenousrecon soln 100 mg

1 MO, HI

oxaliplatin intravenousrecon soln 50 mg

1 HI

oxaliplatin intravenoussolution 100 mg/20ml

1 MO, HI

oxaliplatin intravenoussolution 50 mg/10 ml(5 mg/ml)

1 MO, HI

paclitaxel 1 MO, HIPERJETA 2 MO, HIPOMALYST 2 PA, MO, LAPORTRAZZA 2 B/D PA, MOPROGRAFINTRAVENOUS

2 B/D PA, MO, HI

PURIXAN 2 MORAPAMUNE ORALSOLUTION

2 B/D PA, MO


LimitsREVLIMID 2 PA, MO, LARITUXAN 2 PA, MO, HIRITUXAN HYCELA 2 MOROMIDEPSIN 2RUBRACA 2 MO, LARYDAPT 2 MOSANDOSTATIN LARDEPOTINTRAMUSCULARSUSPENSION,EXTENDED RELRECON

2 MO

SIGNIFOR 2 MOSIGNIFOR LAR 2 MOSIMULECTINTRAVENOUSRECON SOLN 10MG

2 B/D PA, HI

SIMULECTINTRAVENOUSRECON SOLN 20MG

2 B/D PA, MO, HI

sirolimus 1 B/D PA, MOSOLTAMOX 3 MOSOMATULINEDEPOT

2 MO

SPRYCEL 2 MOSTIVARGA 2 MOSUTENT 2 MOSYLVANT 2 MO, HISYNRIBO 2 MOTABLOID 2 MOtacrolimus oral 1 B/D PA, MOTAFINLAR 2 MO



LimitsTAGRISSO 2 MO, LAtamoxifen 1 MOTARCEVA 2 MOTARGRETIN 1% GEL 2 MOTASIGNA 2 MOTECENTRIQ 2 MO, HI, LATEMODARINTRAVENOUS

2 MO

TEMODAR ORAL MB MOtemozolomide MB MOTHALOMID 2 MOthiotepa 1 MOtoposar 1 MO, HItopotecan intravenousrecon soln

1 HI

topotecan intravenoussolution

1 MO, HI

TORISEL 2 MO, HITREANDAINTRAVENOUSRECON SOLN

2 MO, HI

TRELSTAR 2 MOtretinoin(chemotherapy)

1 MO

TRISENOXINTRAVENOUSSOLUTION 2 MG/ML

2 MO, HI

TYKERB 2 MO, LAUNITUXIN 2 MOVALSTAR 2 MOVANTAS 2 MO


LimitsVECTIBIXINTRAVENOUSSOLUTION 100MG/5 ML (20 MG/ML)

2 B/D PA, MO, HI

VECTIBIXINTRAVENOUSSOLUTION 400MG/20 ML (20 MG/ML)

2 B/D PA, MO, HI

VELCADE 2 MO, HIVENCLEXTA 2 MO, LAVENCLEXTASTARTING PACK

2 MO, LA

VERZENIO 2 MO, LAvinblastineintravenous solution

1 B/D PA, MO, HI

vincasar pfsintravenous solution1 mg/ml

1 B/D PA, HI

vincasar pfsintravenous solution2 mg/2 ml

1 B/D PA, MO, HI

vincristine intravenoussolution 1 mg/ml

1 B/D PA, MO, HI

vincristine intravenoussolution 2 mg/2 ml

1 B/D PA, MO, HI

vinorelbineintravenous solution10 mg/ml

1 MO, HI

vinorelbineintravenous solution50 mg/5 ml

1 MO, HI

VOTRIENT 2 MOVYXEOS 2 B/D PA, MO, HIXALKORI 2 MO



LimitsXATMEP 2 B/D PA, MOXELODA MB MOXERMELO 2 MO, LAXTANDI 2 PA, MOYERVOYINTRAVENOUSSOLUTION 200MG/40 ML (5 MG/ML)

2 MO, HI

YERVOYINTRAVENOUSSOLUTION 50MG/10 ML (5 MG/ML)

2 MO, HI

YONDELIS 2 MO, HIZALTRAPINTRAVENOUSSOLUTION 100MG/4 ML (25 MG/ML)

2 MO, HI

ZALTRAPINTRAVENOUSSOLUTION 200MG/8 ML (25 MG/ML)

2 MO, HI

ZANOSAR 2 MO, HIZEJULA 2 MO, LAZELBORAF 2 MOZOLADEX 2 MOZOLINZA 2 MOZORTRESS 2 B/D PA, MOZYDELIG 2 MOZYKADIA 2 MOZYTIGA 2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTSDrug Name Tier Requirements/

LimitsAPTIOM 2 MOBANZEL 2 MOBRIVIACT 2 HIINTRAVENOUS

BRIVIACT ORAL 2 MOcarbamazepine oralcapsule, ermultiphase 12 hr

1 MO

carbamazepine oralsuspension 100 mg/5ml

1 MO

carbamazepine oraltablet

1 MO

carbamazepine oraltablet extended

1 MO

release 12 hrcarbamazepine oraltablet,chewable

1 MO

CELONTIN ORAL 2 MOCAPSULE 300 MG

clonazepam oral tablet 1 PA, MOclonazepam oraltablet,disintegrating

1 PA, MO

DIASTAT 3 MODIASTAT ACUDIAL 3 MOdiazepam rectal 1 MODILANTIN 30 MG 2 MOdivalproex oralcapsule, sprinkle

1 MO

divalproex oral tabletextended release 24

1 MO

hrdivalproex oral tablet,delayed release (dr/ec)

1 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTS (continued)Drug Name Tier Requirements/

Limitsepitol 1 MOethosuximide 1 MOfelbamate 1 MOfosphenytoin injectionsolution 100 mg pe/2ml

1 MO, HI

fosphenytoin injectionsolution 500 mgpe/10 ml

1 MO, HI

FYCOMPA ORALSUSPENSION

3 MO

FYCOMPA ORALTABLET

3 MO

gabapentin oralcapsule

1 MO

gabapentin oralsolution 250 mg/5 ml

1 MO

gabapentin oralsolution 250 mg/5 ml(5 ml), 300 mg/6 ml(6 ml)

1

gabapentin oral tablet600 mg, 800 mg

1 MO

GABITRIL ORALTABLET 12 MG, 16MG

2 MO

lamotrigine oral tablet 1 MOlamotrigine oral tabletdisintegrating, dosepk

1 MO

lamotrigine oral tabletextended release24hr

1 MO

lamotrigine oral tablet,chewable dispersible

1 MO


Limitslamotrigine oral tablet,disintegrating

1 MO

lamotrigine oraltablets,dose pack

1 MO

levetiracetam in nacl(iso-os) intravenouspiggyback 1,000mg/100 ml, 1,500mg/100 ml

1 HI

levetiracetam in nacl(iso-os) intravenouspiggyback 500mg/100 ml

1 MO, HI

levetiracetamintravenous

1 MO, HI

levetiracetam oralsolution 100 mg/ml

1 MO

levetiracetam oralsolution 500 mg/5 ml(5 ml)

1

levetiracetam oraltablet

1 MO

levetiracetam oraltablet extendedrelease 24 hr

1 MO

LYRICA 3 PA, MOONFI ORALSUSPENSION

3 PA, MO

ONFI ORAL TABLET10 MG, 20 MG

3 PA, MO

oxcarbazepine 1 MOOXTELLAR XR 3 MOPEGANONE 2 MOphenobarbital 1 PA, MO



Limitsphenobarbital sodiuminjection solution 130mg/ml

1 MO

phenobarbital sodiuminjection solution 65mg/ml

1

phenytoin oralsuspension 100 mg/4ml

1

phenytoin oralsuspension 125 mg/5ml

1 MO

phenytoin oral tablet,chewable

1 MO

phenytoin sodiumextended

1 MO

phenytoin sodiumintravenous solution

1 MO, HI

phenytoin sodiumintravenous syringe

1 HI

primidone 1 MOQUDEXY XR 3 PA, MOroweepra 1 MOroweepra xr 1SABRIL ORALTABLET

3 MO, LA

SPRITAM 3 MOtiagabine 1 MOtopiramate oralcapsule, sprinkle

1 PA, MO

topiramate oral tablet 1 PA, MOTROKENDI XR 3 PA, MOvalproate sodium 1 MO, HIvalproic acid 1 MO


Limitsvalproic acid (assodium salt) oralsolution 250 mg/5 ml

1 MO

valproic acid (assodium salt) oralsolution 250 mg/5 ml(5 ml), 500 mg/10 ml(10 ml)

1

vigabatrin 1 MO, LAVIMPATINTRAVENOUS

2 HI

VIMPAT ORALSOLUTION

2 MO

VIMPAT ORALTABLET

2 MO

zonisamide 1 PA, MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTSDrug Name Tier Requirements/

LimitsAPOKYN 2 MO, LAbenztropine injection 1 MO, HIbenztropine oral 1 MObromocriptine 1 MOcarbidopa 1 MOcarbidopa-levodopa 1 MOoral tablet

carbidopa-levodopa 1 MOoral tablet extendedrelease

carbidopa-levodopa 1 MOoral tablet,disintegrating

carbidopa-levodopa- 1 MOentacapone

entacapone 1 MONEUPRO 3 MOpramipexole oral 1 MOtablet

pramipexole oral 1 MOtablet extendedrelease 24 hr

rasagiline 1 MOropinirole oral tablet 1 MOropinirole oral tablet 1 MOextended release 24hr

selegiline hcl 1 MOtolcapone 1 MOtrihexyphenidyl 1 MOZELAPAR 3 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPYDrug Name Tier Requirements/

Limitsalmotriptan malateoral tablet 12.5 mg


almotriptan malateoral tablet 6.25 mg


dihydroergotamineinjection

1 MO

dihydroergotaminenasal


eletriptan 1 MO, QL (12 per30 days)

ergotamine-caffeine 1 MOfrovatriptan 1 MO, QL (27 per

30 days)migergot 1 MOnaratriptan 1 MO, QL (9 per

30 days)rizatriptan oral tablet 1 MO, QL (18 per

30 days)rizatriptan oral tablet,disintegrating


sumatriptan nasalspray,non-aerosol 20mg/actuation


sumatriptan nasalspray,non-aerosol 5mg/actuation


sumatriptan succinateoral


sumatriptan succinatesubcutaneouscartridge


sumatriptan succinatesubcutaneous peninjector



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPY(continued)Drug Name Tier Requirements/

Limitssumatriptan succinatesubcutaneoussolution


sumatriptan-naproxen 1 MOzolmitriptan oral tablet2.5 mg


zolmitriptan oral tablet5 mg


zolmitriptan oral tablet,disintegrating 2.5 mg


zolmitriptan oral tablet,disintegrating 5 mg


ZOMIG NASAL 2 MO, QL (18 per30 days)

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPYDrug Name Tier Requirements/

LimitsAMPYRA 3 PA, MO, LA, QL

(60 per 30days)

AUBAGIO 2 PA, MOAUSTEDO 2 MO, LAdonepezil oral tablet 1 MOdonepezil oral tablet,disintegrating

1 MO

galantamine oralcapsule,ext rel.pellets 24 hr

1 MO

galantamine oralsolution

1 MO

galantamine oraltablet

1 MO

GILENYA ORALCAPSULE 0.5 MG

2 PA, MO

glatiramersubcutaneoussyringe 20 mg/ml


glatiramersubcutaneoussyringe 40 mg/ml


glatopa subcutaneoussyringe 20 mg/ml


glatopa subcutaneoussyringe 40 mg/ml


HORIZANT 3 MOINGREZZA 2 MO, LAKEVEYIS 2 MOLEMTRADA 2 MOmemantine oral 1 MOcapsule,sprinkle,er24hr


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

Limitsmemantine oral 1 PA, MOsolution

memantine oral tablet 1 PA, MONUEDEXTA 2 PA, MOOCREVUS 2 MORADICAVA 2 MO, HIrivastigmine tartrate 1 MOrivastigminetransdermal

1 MO

TECFIDERA 2 PA, MO, LAtetrabenazine 1 MOTYSABRI 2 PA, MO, HI, LA

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPYDrug Name Tier Requirements/

Limitsanectine 1baclofen oral tablet 10 1 MOmg, 20 mg

carisoprodol 1 PA, MOcarisoprodol-asa-codeine

1 PA, MO

carisoprodol-aspirin 1 PA, MOchlorzoxazone oral 1 PAtablet 250 mg

chlorzoxazone oral 1 PA, MOtablet 500 mg

cyclobenzaprine oraltablet

1 PA, MO

dantrolene 1 MOmeprobamate 1 MOMESTINON ORAL 2 MOSYRUP

metaxall 1 PAmetaxalone 1 PA, MOmethocarbamol 1 PA, HIinjection

methocarbamol oral 1 PA, MOneostigminemethylsulfateintravenous solution

1 MO

0.5 mg/mlneostigminemethylsulfateintravenous solution

1

1 mg/mlorphenadrine citrateinjection

1 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPY (continued)Drug Name Tier Requirements/

Limitsorphenadrine citrateoral tablet extended

1 PA, MO

releasepyridostigminebromide oral tablet

1 MO

pyridostigminebromide oral tablet

1 MO

extended releaseregonol 1revonto 1tizanidine 1 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICSDrug Name Tier Requirements/

Limitsacetaminophen-caff-dihydrocod oralcapsule

1 MO

acetaminophen-codeine oral solution

1

120 mg-12 mg /5 ml(5 ml), 300 mg-30 mg/12.5 ml

acetaminophen-codeine oral solution

1 MO

120-12 mg/5 mlacetaminophen-codeine oral tablet

1 MO

ascomp with codeine 1 PA, MObuprenorphine hclinjection solution

1 MO, HI

buprenorphine hclinjection syringe

1 HI

buprenorphine hclsublingual

1 MO

butalbital compoundw/codeine

1 PA, MO

butalbital-acetaminop-caf-cod

1 PA, MO

butalbital- 1 PA, MOacetaminophen

butalbital- 1 PA, MOacetaminophen-cafforal capsule

butalbital- 1 PA, MOacetaminophen-cafforal tablet 50-325-40mg

butalbital-aspirin-caffeine oral capsule

1 PA, MO

butalbital-aspirin-caffeine oral tablet

1 MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICS (continued)Drug Name Tier Requirements/

Limitscapacet 1 PA, MOcodeine sulfate oral 1 MOtablet

codeine-butalbital- 1 PAasa-caff

demerol (pf) injection 1 B/D PA, MOsolution 100 mg/ml

duramorph (pf) 1 MO, HIinjection solution 0.5mg/ml

duramorph (pf) 1 HIinjection solution 1mg/ml

endocet oral tablet 1 MO10-325 mg, 2.5-325mg, 5-325 mg,7.5-325 mg

fentanyl citrate (pf) 1 MOinjection

fentanyl citrate (pf) 1intravenous syringe100 mcg/2 ml (50mcg/ml)

fentanyl citrate buccal 1 PA, MOlozenge on a handle

fentanyl transdermal 1 MOpatch

hydrocodone- 1 MOacetaminophen oralsolution 7.5-325mg/15 ml

hydrocodone- 1 MOacetaminophen oraltablet 10-300 mg,10-325 mg, 2.5-325mg, 5-300 mg, 5-325mg, 7.5-300 mg,7.5-325 mg


Limitshydrocodone-ibuprofen oral tablet10-200 mg, 5-200mg, 7.5-200 mg

1 MO

hydromorphone (pf) 1 MOhydromorphoneinjection solution 1mg/ml

1

hydromorphoneinjection solution 2mg/ml, 4 mg/ml

1 MO

hydromorphoneinjection syringe 1mg/ml, 2 mg/ml

1

hydromorphoneinjection syringe 4mg/ml

1 MO

hydromorphone oralliquid

1 MO

hydromorphone oraltablet

1 MO

hydromorphone oraltablet extended

1 MO

release 24 hribuprofen-oxycodone 1 MOlevorphanol tartrate 1 MOlorcet (hydrocodone) 1 MOlorcet hd 1 MOlorcet plus oral tablet7.5-325 mg

1 MO

meperidine (pf)injection solution 100mg/ml, 50 mg/ml

1 B/D PA, MO

meperidine (pf)injection solution 25mg/ml

1 B/D PA



Limitsmeperidine injectioncartridge

1 B/D PA

meperidine oral 1 MOmethadone injectionsolution

1 HI

methadone intensol 1 MOmethadone oral 1 MOconcentrate

methadone oral 1 MOsolution

methadone oral tablet 1 MOmethadose oral 1 MOconcentrate

morphine (pf) injectionsolution 0.5 mg/ml

1

morphine (pf) injectionsolution 1 mg/ml

1 MO

morphine (pf)intravenous patientcontrol.analgesiasoln 150 mg/30 ml

1 B/D PA, MO

morphine (pf)intravenous patientcontrol.analgesiasoln 30 mg/30 ml

1 B/D PA

morphine concentrateoral solution

1 MO

MORPHINE 2INJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND)

morphine injectionsolution 8 mg/ml

1


Limitsmorphine injectionsyringe 10 mg/ml, 2mg/ml, 4 mg/ml

1 MO

morphine injectionsyringe 5 mg/ml, 8mg/ml

1

morphine intravenouscartridge 10 mg/ml, 2mg/ml, 4 mg/ml

1

MORPHINE 2INTRAVENOUSCARTRIDGE 8 MG/ML (BRAND)

morphine intravenoussolution 10 mg/ml

1 MO

MORPHINE 2 MOINTRAVENOUSSOLUTION 4 MG/ML, 8 MG/ML(BRAND)

MORPHINE 2INTRAVENOUSSYRINGE 10 MG/ML, 8 MG/ML(BRAND)

morphine intravenoussyringe 2 mg/ml, 4mg/ml

1

morphine oralcapsule, ermultiphase 24 hr

1 MO

morphine oralcapsule,extend.release pellets

1 MO

morphine oral solution 1 MOmorphine oral tablet 1 MOmorphine oral tabletextended release

1 MO



Limitsoxycodone oralcapsule

1 MO

oxycodone oral 1 MOconcentrate

oxycodone oralsolution

1 MO

oxycodone oral tablet 1 MOOXYCODONE ORAL 2 MOTABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 20 MG, 40 MG,80 MG (BRAND)

OXYCODONE ORAL 2TABLET,ORAL ONLY,EXT.REL.12 HR 15MG, 30 MG, 60 MG(BRAND)

oxycodone-acetaminophen oraltablet 10-325 mg,2.5-325 mg, 5-325mg, 7.5-325 mg

1 MO

oxycodone-aspirin 1 MOOXYCONTIN ORAL 2 MOTABLET,ORAL ONLY,EXT.REL.12 HR

oxymorphone oraltablet

1 MO

oxymorphone oraltablet extended

1 MO

release 12 hrpanlor(acetam-caff-dihydrocod)

1

phrenilin forte(withcaffeine)

1 PA

tencon oral tablet 1 PA, MO50-325 mg


Limitsvicodin 1 MOvicodin es 1 MOvicodin hp 1 MOxylon 10 1zebutal oral capsule50-325-40 mg

1 PA, MO


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICSDrug Name Tier Requirements/

Limitsbuprenorphine-naloxone

1 MO

butorphanol tartrateinjection

1 MO, HI

butorphanol tartratenasal

1 MO

celecoxib 1 PA, MO, QL (60per 30 days)

clonidine (pf) epiduralsolution 5,000

1

mcg/10 mldiclofenac potassium 1 MOdiclofenac sodium oral 1 MOtablet extendedrelease 24 hr

diclofenac sodium oral 1 MOtablet,delayedrelease (dr/ec)

diclofenac sodium 1 MOtopical drops

diclofenac sodium 1 MOtopical gel 1 %

diclofenac-misoprostoloral tablet,ir,delayedrel,biphasic

1 MO

diflunisal 1 MODUROLANE MB MOetodolac oral capsule 1 MOetodolac oral tablet 1 MOetodolac oral tablet 1 MOextended release 24hr

EUFLEXXA MB MOfenoprofen oral tablet 1 MOflurbiprofen 1 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICS (continued)Drug Name Tier Requirements/

LimitsGEL-ONE MB MOGELSYN-3 MB MOGENVISC 850 MB MOHYALGAN MB MOHYMOVIS MBibu 1 MOibuprofen lysine (pf) 1ibuprofen oralsuspension

1 MO

ibuprofen oral tablet400 mg, 600 mg, 800

1 MO

mgindomethacin oral 1 MOcapsule

indomethacin oral 1 MOcapsule, extendedrelease

indomethacin sodium 1ketoprofen oralcapsule

1 MO

ketoprofen oralcapsule,ext rel.pellets 24 hr 200 mg

1 MO

ketorolac injectioncartridge 15 mg/ml

1

ketorolac injectioncartridge 30 mg/ml

1 MO

ketorolac injectionsolution 15 mg/ml, 30mg/ml (1 ml)

1 MO

ketorolac injectionsyringe

1

ketorolac 1 MOintramuscularcartridge


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICS (continued)Drug Name Tier Requirements/

Limitsketorolac 1 MOintramuscularsolution

ketorolac 1intramuscular syringe

ketorolac oral 1 MOmeclofenamate 1 MOmefenamic acid 1 MOmeloxicam oral 1 MOsuspension

meloxicam oral tablet 1 MO, QL (30 per30 days)

MONOVISC MB MOnabumetone 1 MOnalbuphine 1 MO, HInaloxone 1 MOnaltrexone 1 MOnaproxen oralsuspension

1 MO

naproxen oral tablet 1 MOnaproxen oral tablet,delayed release (dr/ec)

1 MO

naproxen sodium oraltablet 275 mg, 550

1 MO

mgnaproxen sodium oraltablet, er multiphase24 hr

1 MO

ORTHOVISC MB MOoxaprozin 1 MOpentazocine-naloxone 1 MOpiroxicam 1 MOprofeno 1

AUTONOMIC / CNS DRUGS,EUROLOGY / PSYCH: NON-ARCOTIC ANALGESICS (continued)rug Name Tier Requirements/

Limitsalsalate 1 MOUBOXONE 2 MOulindac 1 MOUPARTZ FX MB MOYNVISC MB MOYNVISC-ONE MB MO

olmetin 1 MOramadol oral tablet 1 MOramadol oral tablet 1 MOextended release 24hrramadol oral tablet, er 1 MOmultiphase 24 hrramadol- 1 MOacetaminophenISCO-3 MB MO

NND

sSsSSSttt

t

t

V


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGSDrug Name Tier Requirements/

LimitsABILIFY MAINTENA 2 MOADASUVE 3alprazolam intensol 1 PA, MOalprazolam oral tablet 1 PA, MOalprazolam oral tabletextended release 24

1 PA, MO

hralprazolam oral tablet,disintegrating

1 PA, MO

amitriptyline 1 PA, MOamitriptyline-chlordiazepoxide

1 PA, MO

amoxapine 1 MOaripiprazole oralsolution

1 MO

aripiprazole oral tablet 1 MOaripiprazole oraltablet,disintegrating

1 MO

ARISTADA 2 MOarmodafinil 1 PA, MOatomoxetine oralcapsule 10 mg, 100mg, 18 mg, 25 mg,80 mg


atomoxetine oralcapsule 40 mg, 60


mgbupropion hcl oraltablet

1 MO

bupropion hcl oraltablet extended

1 MO

release 12hrbupropion hcl oraltablet extended

1 MO

release 24hr

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGS(continued)Drug Name Tier Requirements/

Limitsbuspirone 1 MOchlordiazepoxide hcl 1 PA, MOchlorpromazineinjection

1 MO, HI

chlorpromazine oral 1 MOcitalopram oralsolution

1 MO

citalopram oral tablet 1 MOclomipramine 1 PA, MOclonidine hcl oral 1 MOtablet extendedrelease 12 hr

clorazepatedipotassium

1 PA, MO

clozapine oral tablet 1 MOclozapine oral tablet,disintegrating 100mg, 12.5 mg, 25 mg

1

CLOZAPINE ORAL 3TABLET,DISINTEGRATING150 MG, 200 MG(BRAND)

desipramine 1 MOdesvenlafaxine 1 MOsuccinate oral tabletextended release 24hr

dexmethylphenidateoral capsule,erbiphasic 50-50 10mg, 20 mg, 30 mg,40 mg, 5 mg




Limitsdexmethylphenidateoral capsule,erbiphasic 50-50 15mg, 25 mg, 35 mg


dexmethylphenidateoral tablet

1 MO

dextroamphetamineoral capsule,extended release

1 MO

dextroamphetamineoral solution

1 MO

dextroamphetamineoral tablet

1 MO

dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr 10 mg,15 mg, 25 mg, 5 mg


dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr 20 mg,30 mg


dextroamphetamine-amphetamine oraltablet

1 MO

diazepam injectionsolution

1 PA

diazepam injectionsyringe

1 PA, MO

diazepam intensol 1 PA, MOdiazepam oral 1 PA, MOconcentrate

diazepam oral solution5 mg/5 ml (1 mg/ml)

1 PA, MO

diazepam oral tablet 1 PA, MO


Limitsdoxepin oral 1 PA, MOduloxetine oral 1 MOcapsule,delayedrelease (dr/ec)

EMSAM 3 ST, MOergoloid 1 MOescitalopram oxalateoral solution

1 MO

escitalopram oxalateoral tablet

1 MO

estazolam 1 PA, MOeszopiclone 1 MO, QL (30 per

30 days)FANAPT 3 MOFAZACLO ORAL 3TABLET,DISINTEGRATING150 MG, 200 MG

FETZIMA 3 ST, MOflumazenil 1 MOfluoxetine 1 MOfluphenazinedecanoate

1 MO

fluphenazine hcl 1 MOflurazepam 1 PA, MOfluvoxamine oral 1 MOcapsule,extendedrelease 24hr

fluvoxamine oral tablet 1 MOFORFIVO XL 3 MOGEODON 2 MOINTRAMUSCULAR



Limitsguanfacine oral tabletextended release 24

1 MO

hrguanidine 1 MOhaloperidol 1 MOhaloperidol decanoate 1 MOhaloperidol lactateinjection

1 MO

haloperidol lactateintramuscular

1

haloperidol lactate oral 1 MOHETLIOZ 2 PA, MO, QL (30

per 30 days)imipramine hcl 1 PA, MOimipramine pamoate 1 PA, MOINVEGA SUSTENNA 3 MOINVEGA TRINZA 3 MOKHEDEZLA 3 ST, MOLATUDA 3 MOlithium carbonate oral 1 MOcapsule

lithium carbonate oral 1 MOtablet

lithium carbonate oral 1 MOtablet extendedrelease

lithium citrate oral 1 MOsolution 8 meq/5 ml

lorazepam injectionsolution

1 PA, MO

lorazepam injectionsyringe

1 PA

lorazepam intensol 1 PA, MO


Limitslorazepam oral 1 PA, MOloxapine succinate 1 MOmaprotiline 1 MOMARPLAN 2 MOmetadate er oral tabletextended release


methamphetamine 1 PA, MOmethylphenidate hcloral capsule, erbiphasic 30-70 10mg, 20 mg


methylphenidate hcloral capsule, erbiphasic 30-70 30mg, 40 mg, 50 mg,60 mg


methylphenidate hcloral capsule,erbiphasic 50-50 10mg, 20 mg


methylphenidate hcloral capsule,erbiphasic 50-50 30mg, 40 mg, 60 mg


methylphenidate hcloral solution

1 MO

methylphenidate hcloral tablet

1 MO

methylphenidate hcloral tablet extendedrelease 10 mg


methylphenidate hcloral tablet extendedrelease 20 mg




Limitsmethylphenidate hcl 1 MO, QL (30 peroral tablet extended 30 days)release 24hr 18 mg,27 mg, 54 mg

methylphenidate hcl 1 MO, QL (60 peroral tablet extended 30 days)release 24hr 36 mg

methylphenidate hcl 1 MOoral tablet,chewable

midazolam (pf) 1injection

midazolam injection 1midazolam oral syrup 1 MO2 mg/ml

mirtazapine oral tablet 1 MOmirtazapine oral 1 MOtablet,disintegrating

modafinil 1 PA, MOnefazodone 1 MOnortriptyline 1 MONUPLAZID 2 MOolanzapine 1 MOintramuscular reconsoln

olanzapine oral tablet 1 MOolanzapine oral tablet, 1 MOdisintegrating

olanzapine-fluoxetine 1 MOoxazepam 1 PA, MOpaliperidone oral 1 MOtablet extendedrelease 24hr

paroxetine hcl oral 1 MOtablet


Limitsparoxetine hcl oral 1 MOtablet extendedrelease 24 hr

paroxetine mesylate 1 MO(menop.sym)

PAXIL ORAL 3 MOSUSPENSION

pentobarbital sodium 1injection solution

perphenazine 1 MOperphenazine- 1 PA, MOamitriptyline

phenelzine 1 MOpimozide 1 MOprocentra 1 MOprotriptyline 1 MOquetiapine oral tablet 1 MOquetiapine oral tablet 1 MOextended release 24hr

REXULTI 3 MORISPERDAL CONSTA 2 MOrisperidone oral 1 MOsolution

risperidone oral tablet 1 MOrisperidone oral tablet, 1 MOdisintegrating

SAPHRIS (BLACK 3 MOCHERRY)

seconal sodium 1 PAsertraline oral 1 MOconcentrate

sertraline oral tablet 1 MO



Limitstemazepam 1 PA, MOthioridazine 1 MOthiothixene 1 MOtranylcypromine 1 MOtrazodone 1 MOtriazolam 1 PA, MOtrifluoperazine 1 MOtrimipramine 1 PA, MOTRINTELLIX 3 ST, MOvenlafaxine oral 1 MOcapsule,extendedrelease 24hr

venlafaxine oral tablet 1 MOvenlafaxine oral tablet 1 MOextended release24hr 150 mg, 37.5mg, 75 mg

VENLAFAXINE ORAL 3 MOTABLET EXTENDEDRELEASE 24HR 225MG (BRAND)

VERSACLOZ 2VIIBRYD ORAL 3 ST, MOTABLET

VIIBRYD ORAL 3 ST, MOTABLETS,DOSEPACK 10 MG (7)- 20MG (23)

VRAYLAR 3 MOXYREM 2 PA, MO, LAzaleplon 1 MO, QL (30 per

30 days)zenzedi oral tablet 10 1 MOmg, 5 mg


LimitsZENZEDI ORAL 3 MOTABLET 15 MG, 2.5MG, 20 MG, 30 MG,7.5 MG (BRAND)

ziprasidone hcl 1 MOzolpidem oral tablet 1 MO, QL (30 per

30 days)zolpidem oral tablet,ext releasemultiphase


zolpidem sublingual 1 MO, QL (30 per30 days)

ZYPREXA 3 MORELPREVV


CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIARRHYTHMIC AGENTSDrug Name Tier Requirements/

Limitsadenosine 1amiodaroneintravenous solution

1 B/D PA, MO, HI

amiodaroneintravenous syringe

1 B/D PA, HI

amiodarone oral 1 MOdisopyramidephosphate oralcapsule

1 MO

dofetilide 1 MOflecainide 1 MOibutilide fumarate 1 MOlidocaine (pf) in d7.5w 1 MOlidocaine (pf)intravenous solution

1 MO, HI

lidocaine (pf)intravenous syringe

1 HI

lidocaine in 5 % 1dextrose (pf)intravenousparenteral solution 4mg/ml (0.4 %), 8 mg/ml (0.8 %)

mexiletine 1 MOMULTAQ 3 MOpacerone oral tablet100 mg, 200 mg, 400

1 MO

mgprocainamide injectionsolution 100 mg/ml

1 MO, HI

procainamide injectionsolution 500 mg/ml

1 HI

propafenone oralcapsule,extendedrelease 12 hr

1 MO

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIARRHYTHMIC AGENTS(continued)Drug Name Tier Requirements/

Limitspropafenone oraltablet

1 MO

quinidine gluconateinjection

1 MO, HI

quinidine gluconateoral tablet extended

1 MO

releasequinidine sulfate oraltablet

1 MO

sorine oral tablet 120 1 MOmg, 160 mg, 80 mg

sorine oral tablet 240 1mg

sotalol af 1 MOsotalol oral 1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIHYPERTENSIVE THERAPYDrug Name Tier Requirements/

Limitsacebutolol 1 MOafeditab cr oral tablet 1 MOextended release

amiloride 1 MOamiloride- 1 MOhydrochlorothiazide

amlodipine 1 MOamlodipine-benazepril 1 MOamlodipine-olmesartan

1 MO

amlodipine-valsartan 1 MOamlodipine-valsartan-hcthiazid

1 MO

atenolol 1 MOatenolol-chlorthalidone 1 MObenazepril 1 MObenazepril-hydrochlorothiazide

1 MO

betaxolol oral 1 MObisoprolol fumarate 1 MObisoprolol-hydrochlorothiazide

1 MO

bumetanide injection 1 MO, HIbumetanide oral 1 MOcandesartan 1 MOcandesartan- 1 MOhydrochlorothiazid

captopril 1 MOcaptopril-hydrochlorothiazide

1 MO

cartia xt oral capsule,extended release

1 MO

24hr

CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIHYPERTENSIVETHERAPY (continued)Drug Name Tier Requirements/

Limitscarvedilol 1 MOcarvedilol phosphateoral capsule, ermultiphase 24 hr

1 MO

chlorothiazide 1 MOchlorothiazide sodium 1 MO, HIchlorthalidone oral 1 MOtablet 25 mg, 50 mg

clonidine (pf) epiduralsolution 1,000

1

mcg/10 ml (100 mcg/ml)

clonidine hcl oral 1 MOtablet

clonidine transdermal 1 MODEMSER 2 MOdiltiazem hcl 1 HIintravenous

diltiazem hcl oral 1 MOcapsule, extendedrelease

diltiazem hcl oral 1 MOcapsule,ext releasedegradable

diltiazem hcl oral 1 MOcapsule,extendedrelease 12 hr

diltiazem hcl oral 1 MOcapsule,extendedrelease 24hr

diltiazem hcl oral 1 MOtablet

diltiazem hcl oral 1 MOtablet extendedrelease 24 hr



Limitsdilt-xr oral capsule,ext 1 MOrelease degradable

doxazosin 1 MOenalapril maleate 1 MOenalaprilat intravenous 1solution

enalapril- 1 MOhydrochlorothiazide

eplerenone 1 MOepoprostenol (glycine) 1 B/D PA, MOeprosartan 1 MOesmolol intravenous 1solution

ethacrynate sodium 1 HIethacrynic acid 1 MOfelodipine oral tablet 1 MOextended release 24hr

fosinopril 1 MOfosinopril- 1 MOhydrochlorothiazide

furosemide injection 1 MO, HIfurosemide oral 1 MOsolution 10 mg/ml, 40mg/5 ml (8 mg/ml)

furosemide oral tablet 1 MOguanfacine oral tablet 1 MOhydralazine injection 1 MO, HIhydralazine oral 1 MOhydrochlorothiazide 1 MOindapamide 1 MOirbesartan 1 MO


Limitsirbesartan- 1 MOhydrochlorothiazide

isradipine 1 MOlabetalol intravenous 1 MO, HIsolution

labetalol intravenous 1 HIsyringe 20 mg/4 ml (5mg/ml)

labetalol oral 1 MOlisinopril 1 MOlisinopril-hydrochlorothiazide

1 MO

losartan 1 MOlosartan- 1 MOhydrochlorothiazide

mannitol 20 % 1mannitol 25 % 1 MOintravenous solution

matzim la oral tablet 1 MOextended release 24hr

methyclothiazide 1 MOmethyldopa 1 MOmethyldopa-hydrochlorothiazide

1 MO

methyldopate 1 HImetolazone 1 MOmetoprolol succinateoral tablet extended

1 MO

release 24 hrmetoprolol ta-hydrochlorothiaz

1 MO

metoprolol tartrateintravenous solution

1 MO, HI



Limitsmetoprolol tartrateintravenous syringe

1

metoprolol tartrate oraltablet

1 MO

minoxidil oral 1 MOmoexipril 1 MOmoexipril-hydrochlorothiazide

1 MO

nadolol 1 MOnadolol- 1 MObendroflumethiazide

nicardipineintravenous solution

1 HI

nicardipine oral 1 MOnifedipine oral capsule 1 MOnifedipine oral tabletextended release

1 MO

nifedipine oral tabletextended release

1 MO

24hrnimodipine 1 MOnisoldipine oral tabletextended release 24

1 MO

hrolmesartan 1 MOolmesartan-amlodipin-hcthiazid

1 MO

olmesartan- 1 MOhydrochlorothiazide

ORENITRAM ORALTABLET EXTENDED

2 PA, MO

RELEASEosmitrol 15 % 1osmitrol 20 % 1


Limitsperindopril erbumine 1 MOphenoxybenzamine 1 MOphentolamine injectionrecon soln

1

pindolol 1 MOprazosin 1 MOpropranololintravenous

1 HI

propranolol oralcapsule,extendedrelease 24 hr

1 MO

propranolol oralsolution

1 MO

propranolol oral tablet 1 MOpropranolol-hydrochlorothiazid

1 MO

quinapril 1 MOquinapril-hydrochlorothiazide

1 MO

ramipril 1 MOREMODULIN 2 PA, MO, HI, LAspironolactone 1 MOspironolacton-hydrochlorothiaz

1 MO

taztia xt oral capsule,extended release

1 MO

TEKTURNA 2 MOTEKTURNA HCT 2 MOtelmisartan 1 MOtelmisartan-amlodipine 1 MOtelmisartan- 1 MOhydrochlorothiazid

terazosin 1 MO



Limitstimolol maleate oral 1 MOtorsemide oral 1 MOtrandolapril 1 MOtrandolapril-verapamiloral tablet, ir - er,

1 MO

biphasic 24hrtriamterene- 1 MOhydrochlorothiazid

UPTRAVI 2 PA, MO, LAvalsartan 1 MOvalsartan- 1 MOhydrochlorothiazide

veletri 1 B/D PA, MOverapamil intravenoussolution

1 MO, HI

verapamil intravenoussyringe

1 HI

verapamil oralcapsule, 24 hr erpellet ct

1 MO

verapamil oralcapsule,ext rel.pellets 24 hr

1 MO

verapamil oral tablet 1 MOverapamil oral tabletextended release

1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: CARDIACGLYCOSIDESDrug Name Tier Requirements/

Limitsdigitek 1 MOdigox 1 MOdigoxin injectionsolution

1 MO, HI

digoxin oral solution50 mcg/ml

1 MO

digoxin oral tablet 1 MO


CARDIOVASCULAR,HYPERTENSION / LIPIDS:COAGULATION THERAPYDrug Name Tier Requirements/

Limitsaminocaproic acidintravenous

1 MO

aspirin-dipyridamoleoral capsule, ermultiphase 12 hr

1 MO

BEVYXXA 2 QL (43 per 180days)

BRILINTA 3 MOcilostazol 1 MOclopidogrel 1 MOdipyridamoleintravenous

1

dipyridamole oral 1 MOELIQUIS 2 MOenoxaparinsubcutaneoussolution


enoxaparinsubcutaneoussyringe 100 mg/ml,150 mg/ml


enoxaparinsubcutaneoussyringe 120 mg/0.8ml, 80 mg/0.8 ml


enoxaparinsubcutaneoussyringe 30 mg/0.3 ml






fondaparinuxsubcutaneoussyringe 10 mg/0.8 ml


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsfondaparinuxsubcutaneoussyringe 2.5 mg/0.5 ml


fondaparinuxsubcutaneoussyringe 5 mg/0.4 ml


fondaparinuxsubcutaneoussyringe 7.5 mg/0.6 ml


hep flush-10 (pf) MB MOheparin (porcine) in5 % dex intravenous

1 HI

parenteral solution12,500 unit/250 ml

heparin (porcine) in5 % dex intravenous

1 HI

parenteral solution20,000 unit/500 ml(40 unit/ml)

heparin (porcine) in5 % dex intravenous

1 MO, HI

parenteral solution25,000 unit/250 ml(100 unit/ml), 25,000unit/500 ml (50 unit/ml)

heparin (porcine) innacl (pf)

1

heparin (porcine)injection cartridge

1 MO, HI

heparin (porcine)injection solution

1 MO, HI

heparin (porcine)injection syringe5,000 unit/ml

1 MO, HI

heparin flush(porcine)-0.9nacl

MB MO

heparin lock flush MB MO


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsheparin lock flush(porcine) intravenoussolution

MB MO

heparin lockflush(porcine)(pf)

MB MO

heparin(porcine) in0.45% nacl

1 MO

intravenousparenteral solution25,000 unit/250 ml,25,000 unit/500 ml

heparin, porcine (pf)injection

1 MO

heparin, porcine (pf)intravenous syringe 1unit/ml

MB

heparin, porcine (pf)intravenous syringe10 unit/ml, 100 unit/ml

MB MO

jantoven 1 MONPLATE 2 MOpentoxifylline oraltablet extended

1 MO

releasePRADAXA 3 MOprasugrel 1 MOPRAXBIND 2PROMACTA 2 MO, LAprotamine 1tranexamic acid 1 MO, HIintravenous

warfarin 1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: LIPID/CHOLESTEROL LOWERINGAGENTSDrug Name Tier Requirements/

Limitsamlodipine-atorvastatin

1 MO

atorvastatin 1 MO, QL (30 per30 days)

cholestyramine (withsugar)

1 MO

cholestyramine light 1 MOcolesevelam 1 MOcolestipol 1 MOezetimibe 1 MO, QL (30 per

30 days)ezetimibe-simvastatin 1 MO, QL (30 per

30 days)fenofibrate micronized 1 MOfenofibrate 1 MOnanocrystallized

FENOFIBRATE ORAL 2 MOCAPSULE (BRAND)

fenofibrate oral tablet 1 MOfenofibric acid 1 MOfenofibric acid 1 MO(choline) oralcapsule,delayedrelease(dr/ec)

fluvastatin oralcapsule 20 mg


fluvastatin oralcapsule 40 mg


fluvastatin oral tabletextended release 24hr


gemfibrozil 1 MOJUXTAPID 3 PA, MO, LAKYNAMRO 3 PA, MO, LA


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: LIPID/CHOLESTEROLLOWERING AGENTS (continued)Drug Name Tier Requirements/

Limitslovastatin oral tablet10 mg


lovastatin oral tablet20 mg, 40 mg


niacin oral tablet 1 MOextended release 24hr

omega-3 acid ethyl 1 MOesters

PRALUENT PENSUBCUTANEOUSPEN INJECTOR 150


MG/MLPRALUENT PENSUBCUTANEOUSPEN INJECTOR 75


MG/MLpravastatin 1 MO, QL (30 per

30 days)prevalite 1 MOREPATHA 2 PA, MO, QL (3

per 30 days)REPATHAPUSHTRONEX

2 PA, MO, QL (3.5per 30 days)

REPATHASURECLICK


rosuvastatin 1 MO, QL (30 per30 days)

simvastatin 1 MO, QL (30 per30 days)

triklo 1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:MISCELLANEOUSCARDIOVASCULAR AGENTSDrug Name Tier Requirements/

Limitscardioplegic soln 1CORLANOR 2 PA, MOdobutamine 1 B/D PAdobutamine in d5wintravenous

1 B/D PA, MO

parenteral solution1,000 mg/250 ml(4,000 mcg/ml)

dobutamine in d5wintravenous

1 B/D PA

parenteral solution250 mg/250 ml (1mg/ml), 500 mg/250ml (2,000 mcg/ml)

dopamine in 5 %dextrose intravenous

1 B/D PA

solution 200 mg/250ml (800 mcg/ml), 400mg/250 ml (1,600mcg/ml), 400 mg/500ml (800 mcg/ml), 800mg/500 ml (1,600mcg/ml)

dopamine in 5 %dextrose intravenous

1 B/D PA, MO

solution 800 mg/250ml (3,200 mcg/ml)

dopamine intravenoussolution 200 mg/5 ml(40 mg/ml), 800mg/10 ml (80 mg/ml),800 mg/5 ml (160mg/ml)

1 B/D PA

dopamine intravenoussolution 400 mg/10ml (40 mg/ml), 400mg/5 ml (80 mg/ml)

1 B/D PA, MO


CARDIOVASCULAR, HYPERTENSION/ LIPIDS: MISCELLANEOUSCARDIOVASCULAR AGENTS(continued)Drug Name Tier Requirements/

LimitsENTRESTO 2 PA, MO, QL (60

per 30 days)isoproterenol hcl 1milrinone 1 B/D PA, MOmilrinone in 5 %dextrose

1 B/D PA, MO

norepinephrinebitartrate

1

RANEXA 2 MOsodium nitroprusside 1VECAMYL 3

CARDIOVASCULAR,HYPERTENSION / LIPIDS: NITRATESDrug Name Tier Requirements/

Limitsisosorbide dinitrate 1 MOoral tablet

isosorbide dinitrate 1oral tablet extendedrelease

isosorbide 1 MOmononitrate oraltablet

isosorbide 1 MOmononitrate oraltablet extendedrelease 24 hr

nitro-bid 1 MOnitroglycerin in 5 %dextrose intravenous

1 B/D PA

solution 100 mg/250ml (400 mcg/ml), 200mg/500 ml (400 mcg/ml), 50 mg/250 ml(200 mcg/ml), 50mg/500 ml (100 mcg/ml)

nitroglycerin in 5 %dextrose intravenous

1 B/D PA, MO

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

nitroglycerinintravenous

1 B/D PA, HI

nitroglycerin oralcapsule, extendedrelease

1

nitroglycerinsublingual

1 MO

nitroglycerintransdermal patch 24hour

1 MO

nitroglycerintranslingual spray,non-aerosol

1 MO


DERMATOLOGICALS/TOPICALTHERAPY: ANTIPSORIATIC /ANTISEBORRHEICDrug Name Tier Requirements/

Limitsacitretin 1 MOcalcipotriene 1 MOcalcipotriene-betamethasone

1 MO

calcitrene 1 MOcalcitriol topical 1 MOCOSENTYX 3 PA, MOCOSENTYX (2SYRINGES)

3 PA, MO

COSENTYX PEN 3 PA, MOCOSENTYX PEN (2PENS)

3 PA, MO

selenium sulfide 1 MOtopical lotion

STELARAINTRAVENOUS

3 PA, MO, HI

STELARASUBCUTANEOUS

3 PA, MO

DERMATOLOGICALS/TOPICALTHERAPY: BURN THERAPYDrug Name Tier Requirements/

Limitssilver sulfadiazine 1 MOssd 1 MO

DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALSDrug Name Tier Requirements/

Limitsammonium lactate 1 MOCONDYLOX 2 MOTOPICAL GEL

diclofenac sodium 1 MOtopical gel 3 %

doxepin topical 1 MODUPIXENT 2 PA, MOFLUOROURACIL 2 MOTOPICAL CREAM0.5 % (BRAND)

fluorouracil topicalcream 5 %

1 MO

fluorouracil topicalsolution

1 MO

imiquimod 1 MOmethoxsalen 1 MOPANRETIN 2 MOpodofilox 1 MOprudoxin 1 MOREGRANEX 2 MOtacrolimus topical 1 PA, MOUVADEX 2VALCHLOR 2 MO


DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNEDrug Name Tier Requirements/

Limitsadapalene topical 1 PA, MOcream

adapalene topical gel 1 PA, MOadapalene topical gelwith pump

1 PA, MO

adapalene-benzoylperoxide

1 PA, MO

amnesteem 1 MOavita topical cream 1 PA, MOclaravis 1 MOclindacin etz topicalswab

1 MO

clindacin p 1 MOclindamycinphosphate topical

1 MO

clindamycin-benzoylperoxide

1 MO

clindamycin-tretinoin 1 PA, MOdapsone topical 1 MOery pads 1 MOerygel 1 MOerythromycin withethanol

1 MO

erythromycin-benzoylperoxide

1 MO

FABIOR 3 MOisotretinoin 1metronidazole topical 1 MOmyorisan oral capsule10 mg, 20 mg, 40 mg

1 MO

myorisan oral capsule30 mg

1

neuac 1 MOrosadan topical cream 1 MO

DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNE(continued)Drug Name Tier Requirements/

Limitsrosadan topical gel 1 MOtazarotene 1 PA, MOTAZORAC TOPICALCREAM 0.05 %

3 PA, MO

TAZORAC TOPICALGEL

3 PA, MO

tretinoin microspheres 1 PA, MOtretinoin topical 1 PA, MOzenatane 1 MO


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICSDrug Name Tier Requirements/

Limitsbupivacaine 1 MObupivacaine (pf)injection solution0.25 % (2.5 mg/ml),0.5 % (5 mg/ml)

1 MO

bupivacaine (pf)injection solution0.75 % (7.5 mg/ml)

1

bupivacaine-epinephrine (pf)

1

bupivacaine-epinephrine injectionsolution

1

0.25 %-1:200,000bupivacaine-epinephrine injectionsolution

1 MO

0.5 %-1:200,000carbocaine (pf)injection solution 15mg/ml (1.5 %)

1

chloroprocaine (pf) 1glydo 1 MOlidocaine (pf) injectionsolution 10 mg/ml(1 %), 20 mg/ml(2 %), 40 mg/ml(4 %)

1 MO

lidocaine (pf) injectionsolution 15 mg/ml(1.5 %)

1 HI

lidocaine (pf) injectionsolution 5 mg/ml(0.5 %)

1 MO, HI

lidocaine hcl injectionsolution 10 mg/ml(1 %), 5 mg/ml(0.5 %)

1 MO, HI

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICS(continued)Drug Name Tier Requirements/

Limitslidocaine hcl injectionsolution 20 mg/ml(2 %)

1 MO, HI

lidocaine hcl 1 MOlaryngotracheal

lidocaine hcl mucous 1 MOmembrane jelly

lidocaine hcl mucous 1 MOmembrane jelly inapplicator

lidocaine hcl mucous 1 MOmembrane solution4 % (40 mg/ml)

lidocaine topicaladhesive patch,medicated

1 PA, MO

lidocaine topicalointment

1 MO

lidocaine viscous 1 MOlidocaine-epinephrineinjection solution0.5 %-1:200,000,

1

1.5 %-1:200,000,2 %-1:200,000

lidocaine-epinephrineinjection solution1 %-1:100,000,

1 MO

2 %-1:100,000lidocaine-prilocainetopical cream

1 MO

marcaine (pf) injectionsolution 0.75 % (7.5mg/ml)

1

polocaine injectionsolution 1 % (10 mg/ml)

1

polocaine-mpf 1


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANESTHETICS(continued)Drug Name Tier Requirements/

Limitsropivacaine (pf)injection solution

1

sensorcaine injectionsolution 0.5 % (5 mg/ml)

1 MO

sensorcaine/epinephrine

1

sensorcaine-mpfinjection solution0.5 % (5 mg/ml)

1

xylocaine dental-epinephrine

1

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALANTIBACTERIALSDrug Name Tier Requirements/

Limitsgentamicin topical 1 MOmafenide acetate 1 MOmupirocin 1 MOmupirocin calcium 1 MOsulfacetamide sodium 1 MO(acne)

SULFAMYLON 2 MOTOPICAL CREAM

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIFUNGALSDrug Name Tier Requirements/

Limitsciclodan 1 MOciclopirox 1 MOclotrimazole topical 1 MOclotrimazole- 1 MObetamethasone

econazole 1 MOketoconazole topical 1 MOLUZU 3 MOnaftifine 1 MOnyamyc 1 MOnystatin topical 1 MOnystatin-triamcinolone 1 MOnystop 1 MOoxiconazole 1 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIVIRALSDrug Name Tier Requirements/

Limitsacyclovir topical 1 MODENAVIR 2 MOZOVIRAX TOPICAL 2 MOCREAM


DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDSDrug Name Tier Requirements/

Limitsala-cort topical cream 1 MOalclometasone 1 MOamcinonide topical 1 MOcream

amcinonide topicallotion

1 MO

amcinonide topicalointment

1

apexicon e 1 MObetamethasone 1 MOdipropionate

betamethasone 1 MOvalerate

betamethasone, 1 MOaugmented

clobetasol 1 MOclobetasol-emollient 1 MOclodan 1 MOdesonide 1 MOdesoximetasone 1 MOdiflorasone 1 MOfluocinolone 1 MOfluocinolone and 1 MOshower cap

fluocinonide 1 MOfluocinonide-e 1 MOfluocinonide-emollient 1flurandrenolide 1 MOfluticasone topical 1 MOhalobetasol 1 MOpropionate

hydrocortisonebutyrate

1 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDS (continued)Drug Name Tier Requirements/

Limitshydrocortisone butyr-emollient

1 MO

hydrocortisone topicalcream 1 %, 2.5 %

1 MO

hydrocortisone topicallotion 2.5 %

1 MO

hydrocortisone topicalointment 1 %, 2.5 %

1 MO

hydrocortisonevalerate

1 MO

hydrocortisone-minoil-wht pet

1 MO

mometasone topical 1 MOnolix topical cream 1nolix topical lotion 1 MOprednicarbate 1 MOtriamcinolone 1 MOacetonide topicalaerosol

triamcinolone 1 MOacetonide topicalcream

triamcinolone 1 MOacetonide topicallotion

triamcinolone 1 MOacetonide topicalointment 0.025 %,0.1 %, 0.5 %

trianex 1 MOtriderm topical cream0.1 %

1 MO

triderm topical cream0.5 %

1


DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ENZYMESDrug Name Tier Requirements/

LimitsSANTYL 2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL SCABICIDES /PEDICULICIDESDrug Name Tier Requirements/

Limitslindane topicalshampoo

1 MO

malathion 1 MOpermethrin topical 1 MOcream

DIAGNOSTICS / MISCELLANEOUSAGENTS: ANTIDOTESDrug Name Tier Requirements/

Limitsacetylcysteineintravenous

1 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: IRRIGATING SOLUTIONSDrug Name Tier Requirements/

Limitslactated ringersirrigation

1 MO

neomycin-polymyxin b 1 MOgu

ringer's irrigation 1 MOSORBITOL 2IRRIGATION

tis-u-sol pentalyte 1 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsacamprosate oraltablet,delayedrelease (dr/ec)

1 MO

acetic acid irrigation 1 MOADAGEN 2 MOalendronate oral tablet40 mg


anagrelide 1 MOARALAST NPINTRAVENOUS

2 PA, MO, HI, LA

RECON SOLN 1,000MG

ARALAST NPINTRAVENOUS

2 PA, MO, HI, LA

RECON SOLN 500MG

bacteriostatic water MB(parabens)

bd pre-filled normalsaline

MB MO

BUPHENYL ORAL 2 MOTABLET

bupivacaine-dextrose-water(pf)

1

caffeine citrate 1intravenous

caffeine citrate oral 1 MOCARBAGLU 3 MO, LAcevimeline 1 MOCHEMET 2 MOCLINIMIX 4.25%/D5WSULFIT FREE

3 B/D PA, HI

CLINIMIX E 2.75%/D10W SUL FREE

3 B/D PA, HI


DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUS AGENTS(continued)Drug Name Tier Requirements/

LimitsCLINIMIX E 2.75%/D5W SULF FREE

3 B/D PA, HI

CLINIMIX N9G20E2.75%-D10W(SF)

3 B/D PA, HI

d10 %-0.45 % sodium 1 HIchloride

d2.5 %-0.45 % sodium 1 HIchloride

d5 % and 0.9 % 1 MO, HIsodium chloride

d5 %-0.45 % sodium 1 MO, HIchloride

deferoxamine 1 MOdextrose 10 % and 1 HI0.2 % nacl

dextrose 10 % in 1 MO, HIwater (d10w)

dextrose 20 % in 1water (d20w)




dextrose 5 % in water 1 MO, HI(d5w) intravenousparenteral solution

dextrose 5 % in water 1 MO, HI(d5w) intravenouspiggyback

dextrose 5 %-lactated 1 MO, HIringers

dextrose 5%-0.2 % 1 HIsod chloride


Limitsdextrose 5%-0.3 % 1 HIsod.chloride

dextrose 50 % in 1 MOwater (d50w)intravenousparenteral solution

dextrose 50 % in 1water (d50w)intravenous syringe

dextrose 70 % in 1 MOwater (d70w)

dextrose with sodium 1 HIchloride

disulfiram 1 MOetidronate disodium 1 MOEXJADE 2 MO, LAFERRIPROX ORAL 2SOLUTION

FERRIPROX ORAL 2 MOTABLET

GLASSIA 3 PA, MO, HI, LAINCRELEX 2 PA, MO, LAJADENU 2 MOJADENU SPRINKLE 2 MOkionex 1 MOkionex (with sorbitol) 1 MOlanthanum oral tablet, 1 MOchewable

levocarnitine (withsugar)

1 MO

levocarnitine oral 1 MOtablet

lmd 10 % in 0.9 % 1sodium chlor



Limitslmd 10 % in 5 % 1dextrose

midodrine 1 MOmonoject 0.9%sodium chloride

MB

monoject prefilladvanced ns

MB MO

monoject prefill salineflush

MB

normal saline flush MB MONORTHERA 3 MOORFADIN ORAL 2 LACAPSULE 10 MG, 2MG, 5 MG

ORFADIN ORAL 2 MOCAPSULE 20 MG

ORFADIN ORALSUSPENSION

2 MO, LA

pilocarpine hcl oral 1 MOPROLASTIN-CINTRAVENOUS

2 PA, HI, LA

RECON SOLNPROLASTIN-CINTRAVENOUS

2 PA, MO, HI, LA

SOLUTIONRAVICTI 3 MOriluzole 1 MOrisedronate oral tablet30 mg


sevelamer carbonate 1 MOoral powder in packet

sevelamer carbonate 1 MOoral tablet

sodium benzoate-sod 1phenylacet


Limitssodium chlor 0.9% MBbacteriostat

sodium chloride 0.9 % MBinjection solution

sodium chloride 0.9 % MB MOinjection syringe

sodium chloride 0.9 % 1 MO, HIintravenousparenteral solution

sodium chloride 0.9 % 1 MO, HIintravenouspiggyback

sodium chloride 1 MOirrigation

sodium phenylbutyrate 1 MOsodium polystyrene(sorb free)

1 MO

sodium polystyrenesulfonate oral

1 MO

sodium polystyrenesulfonate rectal

1

enema 30 gram/120ml

sps (with sorbitol) oral 1 MOsps (with sorbitol)rectal

1

SYPRINE 2 MOsyrex sodium chloride0.9 %

MB

THIOLA 2 MOtrientine 1 MOVELTASSA 3 MOwater for inject,bacteriostat

MB



Limitswater for irrigation,sterile

1 MO

XURIDEN 2 MOzoledronic acid- 1 MO, HImannitol-water

DIAGNOSTICS / MISCELLANEOUSAGENTS: SMOKING DETERRENTSDrug Name Tier Requirements/

Limitsbupropion hcl(smoking deter) oraltablet extended

1 MO

releaseCHANTIX 2 MOCHANTIX 2 MOCONTINUINGMONTH BOX

CHANTIX STARTING 2 MOMONTH BOX

NICOTROL 2 MONICOTROL NS 2 MO

EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsazelastine nasal 1 MO, QL (60 per

30 days)chlorhexidine 1 MOgluconate mucousmembrane

denta 5000 plus 1 MOdentagel 1 MOipratropium bromidenasal spray,non-aerosol 0.03 %


ipratropium bromidenasal spray,non-aerosol 42 mcg(0.06 %)


olopatadine nasal 1 MO, QL (30.5per 30 days)

oralone 1 MOparoex oral rinse 1 MOperiogard 1 MOsf 1 MOsf 5000 plus 1 MOtriamcinolone 1 MOacetonide dental


EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSOTIC PREPARATIONSDrug Name Tier Requirements/

Limitsacetic acid otic (ear) 1 MOciprofloxacin hcl otic(ear)

1 MO

floxin otic (ear) drops 1fluocinolone acetonide 1 MOoil

hydrocortisone-aceticacid

1 MO

ofloxacin otic (ear) 1 MO

EAR, NOSE / THROATMEDICATIONS: OTIC STEROID /ANTIBIOTICDrug Name Tier Requirements/

LimitsCIPRODEX 2 MOneomycin-polymyxin-hc otic (ear)

1 MO

ENDOCRINE/DIABETES: ADRENALHORMONESDrug Name Tier Requirements/

Limitsa-hydrocort 1 MObetamethasone acet, 1 MOsod phos

cortisone 1 MOdecadron 1deltasone oral tablet20 mg

1 B/D PA, MO

dexamethasone 1 MOdexamethasone 1 MOintensol

dexamethasone 1 MOsodium phos (pf)

dexamethasone 1 MO, HIsodium phosphateinjection solution 10mg/ml

dexamethasone 1 MOsodium phosphateinjection solution 4mg/ml

dexamethasone 1 MOsodium phosphateinjection syringe

fludrocortisone 1 MOhydrocortisone oral 1 MOmethylprednisolone 1 MOacetate

methylprednisoloneoral tablet

1 B/D PA, MO

methylprednisoloneoral tablets,dose

1 MO

packmethylprednisolonesodium succ injectionrecon soln 125 mg,40 mg

1 MO, HI


ENDOCRINE/DIABETES: ADRENALHORMONES (continued)Drug Name Tier Requirements/

Limitsmethylprednisolonesodium succ

1 MO, HI

intravenousmillipred dp 1 MOmillipred oral tablet 1 B/D PA, MOprednisolone oralsolution 15 mg/5 ml

1 MO

prednisolone sodiumphosphate oralsolution 10 mg/5 ml,15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml(5 mg/ml), 5 mgbase/5 ml (6.7 mg/5ml)

1 MO

prednisolone sodiumphosphate oral tablet,disintegrating

1 B/D PA, MO

prednisone intensol 1 B/D PA, MOprednisone oralsolution

1 MO

prednisone oral tablet 1 B/D PA, MOprednisone oraltablets,dose pack

1 MO

RAYOS 3 B/D PA, MOtriamcinolone 1 MOacetonide injection

veripred 20 1 MO

ENDOCRINE/DIABETES:ANTITHYROID AGENTSDrug Name Tier Requirements/

Limitsmethimazole oral 1 MOtablet 10 mg, 5 mg

propylthiouracil 1 MO


ENDOCRINE/DIABETES: DIABETESTHERAPYDrug Name Tier Requirements/

Limitsacarbose 1 MOACCU-CHEK AVIVAPLUS TEST STRIP

MB MO, QL (300 per30 days)

ACCU-CHEK BLOODGLUCOSE METERS

MB QL (1 per 365days)

ACCU-CHEKCOMPACT PLUSTEST STRIP


ACCU-CHEK GUIDETEST STRIP


ACCU-CHEKSMARTVIEW TESTSTRIP


ACCUTRENDGLUCOSE TESTSTRIP


ALCOHOL PADS 2 MOAVANDIA ORAL 3 MOTABLET 2 MG, 4 MG

BYDUREON 2 MO, QL (4 per28 days)

BYDUREON BCISE 2 MO, QL (3.4 per30 days)

BYETTASUBCUTANEOUSPEN INJECTOR 10

2 MO, QL (2.4 per30 days)

MCG/DOSE(250MCG/ML) 2.4 ML

BYETTASUBCUTANEOUSPEN INJECTOR 5


MCG/DOSE (250MCG/ML) 1.2 ML

chlorpropamide 1 MOCYCLOSET 3 MOFARXIGA 2 MOGAUZE PADS 2 X 2 2 MO

ENDOCRINE/DIABETES: DIABETESTHERAPY (continued)Drug Name Tier Requirements/

Limitsglimepiride 1 MOglipizide oral tablet 1 MOglipizide oral tabletextended release

1 MO

24hrglipizide-metformin 1 MOGLUCAGEN 2 MOHYPOKIT

GLUCAGON 2 MOEMERGENCY KIT(HUMAN)

glyburide 1 MOglyburide micronized 1 MOglyburide-metformin 1 MOGLYXAMBI 3 MOHUMALOG JUNIOR 2 MOKWIKPEN U-100

HUMALOG KWIKPEN 2 MOINSULIN

HUMALOG MIX 50-50 2 MOINSULN U-100

HUMALOG MIX 50-50 2 MOKWIKPEN

HUMALOG MIX 75-25 2 MOKWIKPEN

HUMALOG MIX 75-25 2 MO(U-100)INSULN

HUMALOG U-100 2 MOINSULIN

HUMULIN 70/30U-100 INSULIN

2 MO

HUMULIN 70/30U-100 KWIKPEN

2 MO

HUMULIN N NPH 2 MOINSULIN KWIKPEN



LimitsHUMULIN N NPH 2 MOU-100 INSULIN

HUMULIN R 2 MOREGULAR U-100INSULN

HUMULIN R U-500 2 MO(CONC) INSULIN

INPEN (FORHUMALOG)

2 QL (1 per 365days)

INSULIN PEN 2 MONEEDLE

INSULIN SYRINGE 2 MO(DISP) U-100 0.3 ML

INSULIN SYRINGE 2 MO(DISP) U-100 1 ML

INSULIN SYRINGE 2 MO(DISP) U-100 1/2 ML

INVOKAMET 3 MOINVOKAMET XR 3 MOINVOKANA 2 MOJANUMET 2 MOJANUMET XR 2 MOJANUVIA 2 MOJARDIANCE 2 MOKOMBIGLYZE XR 2 MOLANTUS SOLOSTAR 2 MOU-100 INSULIN

LANTUS U-100 2 MOINSULIN

metformin oral tablet 1 MOmetformin oral tablet 1 MOextended release(osm) 24hr

metformin oral tablet 1 MOextended release 24hr


Limitsmetformin oral tablet, 1 MOer gast.retention 24hr

miglitol 1 MOnateglinide 1 MONEEDLES, INSULINDISP.,SAFETY

2 MO

ONETOUCH BLOODGLUCOSE METERS

MB QL (1 per 365days)

ONETOUCH ULTRABLUE TEST STRIP


ONETOUCH VERIOTEST STRIP


ONGLYZA 2 MOOZEMPICSUBCUTANEOUSPEN INJECTOR 0.25

3 ST, MO, QL (1.5per 28 days)

MG OR 0.5 MG(2MG/1.5 ML)

OZEMPICSUBCUTANEOUSPEN INJECTOR 1

3 ST, MO, QL (3per 28 days)

MG/0.75 ML (2MG/1.5 ML)

pioglitazone 1 MOpioglitazone-glimepiride

1 MO

pioglitazone-metformin

1 MO

PROGLYCEM 2 MOrepaglinide 1 MOrepaglinide-metformin 1 MOSYMLINPEN 120 2 MOSYMLINPEN 60 2 MOSYNJARDY 3 MOSYNJARDY XR 3 MO



Limitstolazamide 1 MOtolbutamide 1 MOTOUJEO MAX 2 MOSOLOSTAR

TOUJEO SOLOSTAR 2 MOU-300 INSULIN

TRULICITY 2 MO, QL (2 per28 days)

XIGDUO XR 3 MO

ENDOCRINE/DIABETES:MISCELLANEOUS HORMONESDrug Name Tier Requirements/

LimitsALDURAZYME 2 MO, HIANADROL-50 3 PA, MOcabergoline 1 MOcalcitonin (salmon) 1 MOcalcitriol intravenous 1 MO, HIsolution 1 mcg/ml

calcitriol oral 1 MOCERDELGA 2 MOCEREZYMEINTRAVENOUS

2 PA, MO, HI

RECON SOLN 400UNIT

CHORIONICGONADOTROPIN,HUMAN

2 PA, MO

clomiphene citrate 1 MOdanazol 1 MOdesmopressininjection

1 MO, HI

desmopressin nasalsolution

1

desmopressin nasalspray with pump

1 MO

desmopressin nasalspray,non-aerosol

1 MO

desmopressin oral 1 MOdoxercalciferol 1intravenous

doxercalciferol oral 1 MOELELYSO 2 MO, HIFABRAZYME 2 MO, HIJYNARQUE 2 MOKANUMA 2 MO, HIKORLYM 3 PA, MO


ENDOCRINE/DIABETES:MISCELLANEOUS HORMONES(continued)Drug Name Tier Requirements/

LimitsKUVAN 2 MOMETHITEST 2 MOmethyltestosteroneoral capsule

1 MO

MIACALCIN 3 MOINJECTION

miglustat 1 MOMYALEPT 2 MO, LANAGLAZYME 2 MO, HI, LANATPARA 3 PA, MO, LANOVAREL 2 PA, MOoxandrolone 1 PA, MOpamidronateintravenous recon

1 MO, HI

solnpamidronateintravenous solution

1 MO, HI

PARICALCITOL 2HEMODIALYSISPORT INJECTION

paricalcitolintravenous

1 HI

PARICALCITOL 2 HIINTRAVENOUSSOLUTION 2 MCG/ML (BRAND)

PARICALCITOLINTRAVENOUS

2 MO, HI

SOLUTION 5 MCG/ML (BRAND)

paricalcitol oral 1 MOPARSABIV 2 MOSAMSCA 2 MOSENSIPAR 2 MOSOMAVERT 2 MO

ENDOCRINE/DIABETES:MISCELLANEOUS HORMONES(continued)Drug Name Tier Requirements/

LimitsSTIMATE 2 MOSTRENSIQ 2 MO, LASYNAREL 2 MOtestosterone cypionate 1 MOtestosterone 1 MOenanthate

testosterone 1 MOtransdermal gel(generic)

testosterone 1 MOtransdermal gel inmetered-dose pump12.5 mg/ 1.25 gram(1 %) (Androgelgeneric)

testosterone 1 MOtransdermal gel inpacket (Androgelgeneric)

testosterone 1 MOtransdermal solutionin metered pump w/app (Axiron generic)

VIMIZIM 2 MOZAVESCA 2 MO, LAzoledronic acid 1 MO, HIintravenous solution

ZOMETAINTRAVENOUS

2 MO, HI

PIGGYBACK


ENDOCRINE/DIABETES: THYROIDHORMONESDrug Name Tier Requirements/

Limitslevothyroxineintravenous recon

1 MO

soln 200 mcg, 500mcg

levothyroxine oral 1 MOlevoxyl oral tablet 100mcg, 112 mcg, 125mcg, 137 mcg, 150mcg, 175 mcg, 200mcg, 25 mcg, 50mcg, 75 mcg, 88 mcg

1 MO

liothyronineintravenous

1 MO, HI

liothyronine oral 1 MOnp thyroid 1 MOthyroid (pork) oraltablet 30 mg, 60 mg

1

thyroid (pork) oraltablet 90 mg

1 MO

unithroid 1 MO

GASTROENTEROLOGY:ANTIDIARRHEALS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsatropine injectionsyringe 0.05 mg/ml,0.1 mg/ml

1

chlordiazepoxide-clidinium

1

CUVPOSA 3 MOdicyclomineintramuscular

1 MO

dicyclomine oralcapsule

1 MO

dicyclomine oralsolution

1 MO

dicyclomine oral tablet 1 MOdiphenoxylate-atropine

1 MO

glycopyrrolateinjection

1 MO

glycopyrrolate oraltablet 1 mg, 2 mg

1 MO

loperamide oralcapsule

1 MO

methscopolamine 1 MOMYTESI 2 MOopium tincture 1 MOparegoric 1 MOpropantheline 1 MO


GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTSDrug Name Tier Requirements/

Limitsalosetron 1 MO, QL (60 per

30 days)AMITIZA 2 MO, QL (60 per

30 days)aprepitant 1 B/D PA, MObalsalazide 1 MObudesonide oral 1 MOcapsule,delayed,extend.release

CHOLBAM 2 MOCIMZIA 3 PA, MO, QL (3

per 28 days)CIMZIA POWDER 3 PA, MO, QL (1FOR RECONST per 28 days)

CIMZIA STARTER KIT 3 PA, MO, QL (3per 28 days)

CINVANTI 2 HIcolocort 1 MOcompro 1 MOconstulose 1 MOCREON ORAL 2 MOCAPSULE,DELAYEDRELEASE(DR/EC)

cromolyn oral 1 MOCYSTADANE 2 MOdimenhydrinate 1 MOinjection solution

DIPENTUM 3 MOdronabinol 1 B/D PA, MOdroperidol injection 1 MOsolution

EMEND 2 MO, HI(FOSAPREPITANT)

GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTS(continued)Drug Name Tier Requirements/

LimitsEMEND ORALSUSPENSION FOR

2 B/D PA, MO

RECONSTITUTIONENTYVIO 2 MOenulose 1 MOGATTEX 30-VIAL 3 PA, MOGATTEX ONE-VIAL 3 PA, MOgavilyte-c 1 MOgavilyte-g 1 MOgavilyte-n 1 MOgenerlac 1 MOgranisetron (pf)intravenous solution

1 MO, HI

1 mg/ml (1 ml)granisetron (pf)intravenous solution

1 HI

100 mcg/mlgranisetron hclintravenous

1 MO, HI

granisetron hcl oral 1 B/D PA, MOhydrocortisone rectal 1 MOhydrocortisone topicalcream with perinealapplicator

1 MO

hydrocortisone-pramoxine rectalcream 1-1 %

1 MO

INFLECTRA 2 PA, MO, HIlactulose 1 MOLINZESS 2 MO, QL (30 per

30 days)meclizine oral tablet 1 MO12.5 mg, 25 mg



Limitsmesalamine oral 1 MOtablet,delayedrelease (dr/ec) 1.2gram

mesalamine rectal 1 MOmetoclopramide hclinjection solution

1 MO, HI

metoclopramide hclinjection syringe

1 HI

metoclopramide hcloral solution

1 MO

metoclopramide hcloral tablet

1 MO

metoclopramide hcloral tablet,

1 MO

disintegratingOCALIVA 3 MO, LA, QL (30

per 30 days)ondansetron hcl (pf) 1 MO, HIondansetron hcl 1 MOintravenous

ondansetron hcl oralsolution

1 B/D PA, MO

ondansetron hcl oraltablet 24 mg

1 B/D PA

ondansetron hcl oraltablet 4 mg, 8 mg

1 B/D PA, MO

ondansetron oraltablet,disintegrating

1 B/D PA, MO

OSMOPREP 3 MOpalonosetronintravenous solution

1 MO

0.25 mg/5 ml


Limitspeg 3350-electrolytesoral recon soln

1 MO

236-22.74-6.74 -5.86gram

peg 3350-electrolytesoral recon soln

1

240-22.72-6.72 -5.84gram

peg-electrolyte 1PENTASA 2 MOpolyethylene glycol3350

1 MO

prochlorperazine 1 MOprochlorperazineedisylate injectionsolution 10 mg/2 ml(5 mg/ml)

1 MO

prochlorperazinemaleate oral

1 MO

procto-med hc 1 MOprocto-pak 1 MOproctosol hc topical 1 MOproctozone-hc 1 MORECTIV 3 MORELISTOR ORAL 2 MORELISTOR 2 MOSUBCUTANEOUSSOLUTION

RELISTOR 2 MOSUBCUTANEOUSSYRINGE

REMICADE 2 PA, MO, HIRENFLEXIS 2 PA, MO, HIscopolamine base 1 MO



LimitsSUCRAID 2 MOsulfasalazine oral 1 MOtablet

sulfasalazine oral 1 MOtablet,delayedrelease (dr/ec)

SYNDROS 3 B/D PA, MOtrilyte with flavorpackets

1 MO

trimethobenzamideoral

1 B/D PA, MO

UCERIS 3 MOursodiol 1 MOVARUBI 2INTRAVENOUS

VARUBI ORAL 2 B/D PA, MOZENPEP ORAL 2 MOCAPSULE,DELAYEDRELEASE(DR/EC)10,000-32,000 -42,000UNIT,10,000-34,000 -55,000UNIT,15,000-51,000 -82,000UNIT, 20,000-63,000-84,000 UNIT,25,000-79,000-105,000 UNIT,25,000-85,000-136,000 UNIT,3,000-10,000- 16,000UNIT,40,000-126,000-


LimitsZENPEP ORAL 2CAPSULE,DELAYEDRELEASE(DR/EC)15,000-47,000 -63,000UNIT,3,000-10,000 -14,000-UNIT


GASTROENTEROLOGY: ULCERTHERAPYDrug Name Tier Requirements/

Limitsamoxicil-clarithromy-lansopraz

1 MO

CARAFATE ORAL 2 MOSUSPENSION

cimetidine 1 MOcimetidine hcl oral 1 MOesomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 20 mg


esomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 40 mg


esomeprazole sodiumintravenous recon

1 HI

soln 20 mgesomeprazole sodiumintravenous recon

1 MO, HI

soln 40 mgfamotidine (pf) 1 MO, HIfamotidine (pf)-nacl(iso-os)

1 MO, HI

famotidine intravenous 1 MO, HIsolution

famotidine oral 1 MOsuspension

famotidine oral tablet 1 MO20 mg, 40 mg

lansoprazole oralcapsule,delayedrelease(dr/ec) 15 mg


lansoprazole oralcapsule,delayedrelease(dr/ec) 30 mg


lansoprazole oraltablet,disintegrat,delay rel

1 MO

GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitsmisoprostol 1 MOnizatidine 1 MOomeppi oral capsule20-1.1 mg-gram


omeppi oral capsule40-1.1 mg-gram


omeprazole oralcapsule,delayedrelease(dr/ec) 10 mg


omeprazole oralcapsule,delayedrelease(dr/ec) 20 mg,40 mg


omeprazole-sodiumbicarbonate oralcapsule 20-1.1 mg-


gramomeprazole-sodiumbicarbonate oralcapsule 40-1.1 mg-


gramomeprazole-sodiumbicarbonate oralpacket 20-1,680 mg


omeprazole-sodiumbicarbonate oralpacket 40-1,680 mg


pantoprazoleintravenous

1 MO, HI

pantoprazole oraltablet,delayedrelease (dr/ec) 20 mg


pantoprazole oraltablet,delayedrelease (dr/ec) 40 mg


rabeprazole oraltablet,delayedrelease (dr/ec)



GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitsranitidine hcl injectionsolution 25 mg/ml

1 MO, HI

ranitidine hcl injectionsolution 50 mg/2 ml(25 mg/ml)

1 MO, HI

ranitidine hcl oral 1 MOcapsule

ranitidine hcl oral 1 MOsyrup

ranitidine hcl oral 1 MOtablet 150 mg, 300mg

sucralfate oral tablet 1 MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGSDrug Name Tier Requirements/

LimitsACTIMMUNE 2 PA, MOARCALYST 2 MOAVONEX (WITHALBUMIN)


AVONEXINTRAMUSCULARPEN INJECTOR KIT


AVONEXINTRAMUSCULARSYRINGE KIT


GRANIX 2 MOHUMATROPE 2 PA, MOILARIS (PF)SUBCUTANEOUS

2 PA, MO, LA

SOLUTIONINTRON AINJECTION

2 PA, MO

LEUKINE INJECTIONRECON SOLN

2 MO, HI

MOZOBIL 2 MONEULASTA 2 MO, QL (1.2 per

30 days)NEUPOGENINJECTIONSOLUTION 300


MCG/MLNEUPOGENINJECTIONSOLUTION 480


MCG/1.6 MLNEUPOGENINJECTIONSYRINGE 300


MCG/0.5 ML


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsNEUPOGENINJECTIONSYRINGE 480


MCG/0.8 MLOMNITROPE 2 PA, MOPEGASYSPROCLICK


PEGASYSSUBCUTANEOUSSOLUTION


PEGASYSSUBCUTANEOUSSYRINGE


PEGINTRONSUBCUTANEOUSKIT 50 MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 125


MCG/0.5 MLPLEGRIDYSUBCUTANEOUSPEN INJECTOR 63


MCG/0.5 ML- 94MCG/0.5 ML

PLEGRIDYSUBCUTANEOUSSYRINGE 125


MCG/0.5 MLPLEGRIDYSUBCUTANEOUSSYRINGE 63


MCG/0.5 ML- 94MCG/0.5 ML

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsPROCRIT INJECTIONSOLUTION 10,000UNIT/ML, 2,000UNIT/ML, 20,000UNIT/2 ML, 20,000UNIT/ML, 3,000UNIT/ML, 4,000UNIT/ML


PROCRIT INJECTIONSOLUTION 40,000UNIT/ML


PROLEUKIN 2 PA, MO, HIREBIF (WITHALBUMIN)


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR 22


MCG/0.5 ML, 44MCG/0.5 ML

REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR


8.8MCG/0.2ML-22MCG/0.5ML (6)

REBIF TITRATIONPACK


SEROSTIMSUBCUTANEOUS

2 PA, MO

RECON SOLN 4 MG,5 MG, 6 MG

SYLATRON 2 MOZARXIO INJECTIONSYRINGE 300MCG/0.5 ML


ZARXIO INJECTIONSYRINGE 480MCG/0.8 ML


ZORBTIVE 2 PA, MO


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALSDrug Name Tier Requirements/

LimitsACTHIB (PF) 2 MOADACEL(TDAPADOLESN/ADULT)(PF)

2 MO

AFLURIA 2017-2018 MBAFLURIA 2017-2018 MB MO(PF)

AFLURIA QUAD2017-2018

MB

AFLURIA QUAD2017-2018 (PF)

MB

BCG VACCINE, LIVE(PF)

2 MO

BEXSERO 2 MOBOOSTRIX TDAP 2 MOBOTOX 3 PA, MODAPTACEL (DTAPPEDIATRIC) (PF)

2 MO

DYSPORT 3 PA, MOENGERIX-B (PF) 2 B/D PA, MOENGERIX-BPEDIATRIC (PF)INTRAMUSCULAR

2 B/D PA, MO

SYRINGEFLUAD 2017-2018 (65YR UP)(PF)

MB MO

FLUARIX QUAD2017-2018 (PF)

MB MO

FLUBLOK 2017-2018 MB MO(PF)

FLUBLOK QUAD2017-2018 (PF)

MB

FLUCELVAX QUAD2017-2018

MB

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALS (continued)Drug Name Tier Requirements/

LimitsFLUCELVAX QUAD2017-2018 (PF)

MB MO

FLULAVAL QUAD2017-2018

MB

FLULAVAL QUAD2017-2018 (PF)

MB MO

FLUMIST QUAD2017-2018

MB

FLUVIRIN 2017-2018 MBFLUVIRIN 2017-2018 MB MO(PF)

FLUZONE HIGH- MB MODOSE 2017-18 (PF)

FLUZONE MBINTRADERM QUAD2017-18

FLUZONE QUAD2017-2018

MB

FLUZONE QUAD2017-2018 (PF)INTRAMUSCULAR

MB

SUSPENSIONFLUZONE QUAD2017-2018 (PF)INTRAMUSCULAR

MB MO

SYRINGEFLUZONE QUADPEDI 2017-18 (PF)

MB

fomepizole 1 HIGAMASTAN S/D 2 MOGAMMAGARDLIQUID

2 PA, MO, HI

GAMMAGARD S-D 2 PA, MO, HI(IGA < 1 MCG/ML)



LimitsGAMUNEX-CINJECTION

2 PA, MO, HI

SOLUTION 1GRAM/10 ML (10 %)

GAMUNEX-CINJECTION

2 PA, MO, HI

SOLUTION 10GRAM/100 ML(10 %), 2.5 GRAM/25ML (10 %), 20GRAM/200 ML(10 %), 40GRAM/400 ML(10 %), 5 GRAM/50ML (10 %)

GARDASIL 9 (PF) 2 MOGRASTEK 3 MOHAVRIX (PF)INTRAMUSCULAR

2 MO

SUSPENSIONHAVRIX (PF)INTRAMUSCULAR

2 MO

SYRINGE 1,440ELISA UNIT/ML

HAVRIX (PF)INTRAMUSCULAR

2

SYRINGE 720 ELISAUNIT/0.5 ML

HIBERIX (PF) 2 MOHYPERRAB (PF) 2HYPERRAB S/D (PF) 2IMOVAX RABIES 2 MOVACCINE (PF)

INFANRIX (DTAP)(PF)

2 MO

IPOL 2 MO

IMMUNOLOGY, VACCINES /IOTECHNOLOGY: VACCINES /BISCELLANEOUSMMUNOLOGICALS (continued)IM

rug NameD Tier Requirements/Limits

IARO (PF)IX 2 MOINRIX (PF)KNTRAMUSCULARI

2

USPENSIONSINRIX (PF)KNTRAMUSCULARI

2 MO

YRINGESENACTRA (PF)MNTRAMUSCULARI

2 MO

OLUTIONSENVEO A-C-Y-M 2 MO-135-DIP (PF)W

-M-R II (PF)M 2 MORALAIRO 2 MOUBLINGUALSABLET 300 INDXTEACTIVITYR

EDIARIX (PF)P 2 MOEDVAX HIB (PF)P 2 MOENTACEL (PF)P 2 MONEUMOVAX 23P MB MOREVNAR 13 (PF)P MB MOROQUAD (PF)P 2 MOUADRACEL (PF)Q 2 MOABAVERT (PF)R 2 MOAGWITEKR 3ECOMBIVAX HBRPF)(NTRAMUSCULARI

2 B/D PA, MO

USPENSIONSECOMBIVAX HBRPF)(NTRAMUSCULARI

2 B/D PA, MO

YRINGE 10 MCG/SLM



LimitsRECOMBIVAX HB(PF)INTRAMUSCULAR

2 B/D PA

SYRINGE 5 MCG/0.5ML

ROTARIX 2ROTATEQ VACCINE 2 MOSHINGRIX (PF) 2 MOSTAMARIL (PF) 2TENIVAC (PF) 2 MOTETANUS,DIPHTHERIA TOX

2 MO

PED(PF)TETANUS- 2 MODIPHTHERIATOXOIDS-TD

TICE BCG 2 MOTRUMENBA 2 MOTWINRIX (PF)INTRAMUSCULAR

2 MO

SYRINGETYPHIM VI 2INTRAMUSCULARSOLUTION

TYPHIM VI 2 MOINTRAMUSCULARSYRINGE

VAQTA (PF) 2 MOVARIVAX (PF) 2 MOVARIZIG 2 MOINTRAMUSCULARSOLUTION

XEOMIN 3 PA, MOYF-VAX (PF) 2 MO


LimitsZINPLAVA 2 PA, MO, HIZOSTAVAX (PF) 2 MO

MUSCULOSKELETAL /RHEUMATOLOGY: GOUT THERAPYDrug Name Tier Requirements/

Limitsallopurinol 1 MOallopurinol sodium 1 HIaloprim 1 HICOLCHICINE ORAL 2 MOTABLET

COLCRYS 2 MOKRYSTEXXA 3 MOprobenecid 1 MOprobenecid-colchicine 1 MOULORIC 3 MOZURAMPIC 3 MO


MUSCULOSKELETAL /RHEUMATOLOGY: OSTEOPOROSISTHERAPYDrug Name Tier Requirements/

Limitsalendronate oralsolution


alendronate oral tablet10 mg, 5 mg


alendronate oral tablet35 mg, 70 mg


FORTEO 2 PA, MO, QL (2.4per 28 days)

ibandronate 1 MOintravenous

ibandronate oral 1 MO, QL (1 per30 days)

PROLIA 3 PA, MOraloxifene 1 MOrisedronate oral tablet150 mg


risedronate oral tablet35 mg, 35 mg (12pack), 35 mg (4pack)


risedronate oral tablet5 mg


risedronate oral tablet,delayed release (dr/ec)


TYMLOS 2 PA, MO, QL(1.56 per 30days)

MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALSDrug Name Tier Requirements/

LimitsACTEMRAINTRAVENOUS

3 PA, MO, HI

ACTEMRASUBCUTANEOUS

3 PA, MO

BENLYSTAINTRAVENOUS

2 MO, HI

BENLYSTA 2 MOSUBCUTANEOUS

CUPRIMINE 2 MODEPEN TITRATABS 3 MOENBREL MINI 2 PA, MO, QL (8

per 28 days)ENBRELSUBCUTANEOUSRECON SOLN


ENBRELSUBCUTANEOUSSYRINGE


ENBREL SURECLICK 2 PA, MO, QL (8per 28 days)

HUMIRA PEDIATRICCROHN'S START


HUMIRA PEN 2 PA, MO, QL (6per 30 days)

HUMIRA PENCROHN'S-UC-HSSTART


HUMIRA PENPSORIASIS-UVEITIS


HUMIRASUBCUTANEOUSSYRINGE KIT 10


MG/0.1 ML, 10MG/0.2 ML, 20MG/0.4 ML, 40MG/0.4 ML, 40MG/0.8 ML


MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsHUMIRASUBCUTANEOUSSYRINGE KIT 20


MG/0.2 MLKEVZARASUBCUTANEOUS

3 PA, MO

SYRINGEKINERET 2 PA, MOleflunomide 1 MO, QL (30 per

30 days)ORENCIA 2 PA, MOORENCIA (WITHMALTOSE)

2 PA, MO, HI

ORENCIACLICKJECT

2 PA, MO

OTEZLA 3 PA, MO, QL (60per 30 days)

OTEZLA STARTERORAL TABLETS,DOSE PACK 10 MG


(4)-20 MG (4)-30 MG(47)

RIDAURA 2 MOSIMPONI ARIA 3 PA, MO, HISIMPONISUBCUTANEOUSPEN INJECTOR 100


MG/MLSIMPONISUBCUTANEOUSPEN INJECTOR 50


MG/0.5 MLSIMPONISUBCUTANEOUSSYRINGE 100 MG/ML


MUSCULOSKELETAL /HEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Rrug NameD Tier Requirements/

LimitsIMPONISSUBCUTANEOUSSYRINGE 50 MG/0.5ML



OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINSDrug Name Tier Requirements/

Limitsamabelz 1 MOcamila 1 MOdeblitane 1 MOerrin 1 MOESTRACE VAGINAL 2 MOestradiol 1 MOestradiol valerate 1 MOintramuscular oil 20mg/ml, 40 mg/ml

estradiol- 1 MOnorethindrone acet

estropipate 1 MOfyavolv 1 MOheather 1 MOhydroxyprogesterone 1 MOcaproate

jencycla 1 MOjevantique lo 1 MOjinteli 1 MOjolivette 1 MOlopreeza 1 MOlyza 1 MOMAKENA 3 MOMAKENA (PF) 3 MOmedroxyprogesterone 1 MOmimvey 1 MOmimvey lo 1 MOnora-be 1 MOnorethindrone 1 MO(contraceptive)

norethindrone acetate 1 MO

OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINS(continued)Drug Name Tier Requirements/

Limitsnorethindrone ac-eth 1 MOestradiol oral tablet0.5-2.5 mg-mcg, 1-5mg-mcg

norlyda 1 MOnorlyroc 1PREMARIN 3 MO, HIINJECTION

progesterone 1 MOprogesterone in oil 1 MOprogesterone 1 MOmicronized

sharobel 1 MOtulana 1yuvafem 1 MO


OBSTETRICS / GYNECOLOGY:MISCELLANEOUS OB/GYNDrug Name Tier Requirements/

LimitsCLEOCIN VAGINAL 2 MOSUPPOSITORY

clindamycinphosphate vaginal

1 MO

GYNAZOLE-1 3 MOLUPANETA PACK (1MONTH)

3 MO

LUPANETA PACK (3MONTH)

3 MO

metronidazole vaginal 1 MOmiconazole-3 vaginalsuppository

1 MO

terconazole 1 MOtranexamic acid oral 1 MOvandazole 1 MOxulane 1 MO

OBSTETRICS / GYNECOLOGY:ORAL CONTRACEPTIVES /RELATED AGENTSDrug Name Tier Requirements/

Limitsaltavera (28) 1 MOalyacen 1/35 (28) 1 MOalyacen 7/7/7 (28) 1 MOamethia 1 MOamethia lo 1 MOamethyst 1 MOapri 1 MOaranelle (28) 1 MOashlyna 1 MOaubra 1 MOaviane 1 MOazurette (28) 1 MObalziva (28) 1 MObekyree (28) 1 MOblisovi 24 fe 1 MOblisovi fe 1.5/30 (28) 1 MOblisovi fe 1/20 (28) 1 MObriellyn 1 MOcamrese 1 MOcamrese lo 1 MOcaziant (28) 1 MOchateal 1 MOcryselle (28) 1 MOcyclafem 1/35 (28) 1 MOcyclafem 7/7/7 (28) 1 MOcyred 1 MOdasetta 1/35 (28) 1 MOdasetta 7/7/7 (28) 1 MOdaysee 1 MOdelyla (28) 1


OBSTETRICS / GYNECOLOGY: ORALCONTRACEPTIVES / RELATEDAGENTS (continued)Drug Name Tier Requirements/

Limitsdesog-e.estradiol/e. 1 MOestradiol

desogestrel-ethinyl 1estradiol

drospirenone-e. 1 MOestradiol-lm.fa

drospirenone-ethinyl 1 MOestradiol

elinest 1 MOELLA 2emoquette 1 MOenpresse 1 MOenskyce 1 MOestarylla 1 MOethynodiol diac-eth 1estradiol

falmina (28) 1 MOfayosim 1 MOfemynor 1 MOgianvi (28) 1 MOintrovale 1 MOisibloom 1 MOjolessa 1 MOjuleber 1 MOjunel 1.5/30 (21) 1 MOjunel 1/20 (21) 1 MOjunel fe 1.5/30 (28) 1 MOjunel fe 1/20 (28) 1 MOjunel fe 24 1 MOkaitlib fe 1 MOkariva (28) 1 MOkelnor 1/35 (28) 1 MO


Limitskelnor 1-50 1 MOkimidess (28) 1 MOkurvelo 1 MOl norgest/e.estradiol-e.estrad oral tablets,

1 MO

dose pack,3 month0.10 mg-20 mcg(84)/10 mcg (7), 0.15mg-30 mcg (84)/10mcg (7)

l norgest/e.estradiol-e.estrad oral tablets,

1

dose pack,3 month0.15 mg-20 mcg/0.15 mg-25 mcg

larin 1.5/30 (21) 1 MOlarin 1/20 (21) 1 MOlarin 24 fe 1 MOlarin fe 1.5/30 (28) 1 MOlarin fe 1/20 (28) 1 MOlarissia 1 MOlayolis fe 1 MOleena 28 1 MOlessina 1 MOlevonest (28) 1 MOlevonorgestrel-ethinylestrad

1 MO

levonorg-eth estradtriphasic

1 MO

levora-28 1 MOlillow 1 MOloryna (28) 1 MOlow-ogestrel (28) 1 MOlutera (28) 1 MO



Limitsmarlissa 1 MOmelodetta 24 fe 1 MOmibelas 24 fe 1 MOmicrogestin 1.5/30(21)

1 MO

microgestin 1/20 (21) 1 MOmicrogestin fe 1.5/30(28)

1 MO

microgestin fe 1/20(28)

1 MO

mili 1mono-linyah 1 MOmononessa (28) 1 MOmyzilra 1 MOnecon 0.5/35 (28) 1 MOnecon 7/7/7 (28) 1 MOnikki (28) 1 MOnoreth-ethinylestradiol-iron

1 MO

norethindrone ac-eth 1 MOestradiol oral tablet1-20 mg-mcg

norethindrone-e. 1 MOestradiol-iron

norgestimate-ethinylestradiol

1 MO

nortrel 0.5/35 (28) 1 MOnortrel 1/35 (21) 1 MOnortrel 1/35 (28) 1 MOnortrel 7/7/7 (28) 1 MOocella 1 MOogestrel (28) 1 MOorsythia 1 MO

OBSTETRICS / GYNECOLOGY: ORALONTRACEPTIVES / RELATEDCGENTS (continued)Arug NameD Tier Requirements/

Limitshilithp 1 MOimtrea (28)p 1 MOirmellap 1 MOortiap 1 MOrevifemp 1 MOuasenseq 1 MOajanir 1 MOeclipsen (28)r 1 MOivelsar 1 MOetlakins 1 MOprintec (28)s 1 MOronyxs 1 MOyedas 1 MOarina fe 1/20 (28)t 1 MOilia fet 1 MOri femynort 1 MOri-estaryllat 1 MOri-legest fet 1 MOri-linyaht 1 MOri-lo-estaryllat 1 MOri-lo-marziat 1 MOri-lo-sprintect 1 MOri-milit 1rinessa (28)t 1 MOrinessa lot 1 MOri-previfem (28)t 1 MOri-sprintec (28)t 1 MOrivora (28)t 1 MOri-vylibrat 1ydemyt 1 MO



Limitsvelivet triphasicregimen (28)

1 MO

vestura (28) 1 MOvienva 1 MOviorele (28) 1 MOvyfemla (28) 1 MOvylibra 1wera (28) 1 MOwymzya fe 1 MOzarah 1 MOzenchent (28) 1 MOzovia 1/35e (28) 1 MOzovia 1/50e (28) 1 MO

OBSTETRICS / GYNECOLOGY:OXYTOCICSDrug Name Tier Requirements/

Limitsmethergine 1methylergonovineinjection

1

methylergonovine oral 1 MOoxytocin injectionsolution

1 MO

OPHTHALMOLOGY: ANTIBIOTICSDrug Name Tier Requirements/

Limitsak-poly-bac 1 MObacitracin ophthalmic(eye)

1 MO

bacitracin-polymyxin bophthalmic (eye)

1 MO

ciprofloxacin hclophthalmic (eye)

1 MO

erythromycinophthalmic (eye)

1 MO

gatifloxacin 1 MOgentak ophthalmic(eye) ointment

1 MO

gentamicin ophthalmic(eye) drops

1 MO

levofloxacin 1 MOophthalmic (eye)

moxifloxacin 1 MOophthalmic (eye)

NATACYN 2 MOneomycin-bacitracin-polymyxin

1 MO

neomycin-polymyxin-gramicidin

1 MO

neo-polycin 1 MOofloxacin ophthalmic(eye)

1 MO

polycin 1 MOpolymyxin b sulf-trimethoprim

1 MO

tobramycin 1 MO


OPHTHALMOLOGY: ANTIVIRALSDrug Name Tier Requirements/

Limitstrifluridine 1 MOZIRGAN 3 MO

OPHTHALMOLOGY: BETA-BLOCKERSDrug Name Tier Requirements/

Limitsbetaxolol ophthalmic(eye)

1 MO

carteolol 1 MOlevobunolol 1 MOophthalmic (eye)drops 0.5 %

metipranolol 1timolol maleate 1 MOophthalmic (eye)

OPHTHALMOLOGY:CHOLINESTERASE INHIBITORMIOTICSDrug Name Tier Requirements/

LimitsPHOSPHOLINE 2 MOIODIDE

OPHTHALMOLOGY: CYCLOPLEGICMYDRIATICSDrug Name Tier Requirements/

Limitsatropine ophthalmic(eye) drops

1 MO

OPHTHALMOLOGY: DIRECT ACTINGMIOTICSDrug Name Tier Requirements/

Limitspilocarpine hclophthalmic (eye)drops 1 %, 2 %, 4 %

1 MO

OPHTHALMOLOGY:MISCELLANEOUSOPHTHALMOLOGICSDrug Name Tier Requirements/

Limitsazelastine ophthalmic(eye)

1 MO

balanced salt 1bss 1 MOcromolyn ophthalmic(eye)

1 MO

CYSTARAN 2 MOepinastine 1 MOLACRISERT 2 MOolopatadineophthalmic (eye)

1 MO

RESTASIS 2 MO, QL (60 per30 days)

RESTASISMULTIDOSE



OPHTHALMOLOGY: NON-STEROIDAL ANTI-INFLAMMATORYAGENTSDrug Name Tier Requirements/

Limitsbromfenac 1 MOdiclofenac sodium 1 MOophthalmic (eye)

flurbiprofen sodium 1 MOketorolac ophthalmic(eye)

1 MO

OPHTHALMOLOGY: ORAL DRUGSFOR GLAUCOMADrug Name Tier Requirements/

Limitsacetazolamide oral 1 MOcapsule, extendedrelease

acetazolamide oral 1 MOtablet

acetazolamide sodium 1 MO, HImethazolamide 1 MO

OPHTHALMOLOGY: OTHERGLAUCOMA DRUGSDrug Name Tier Requirements/

Limitsbimatoprostophthalmic (eye)

1 MO

dorzolamide 1 MOdorzolamide-timolol 1 MOlatanoprost 1 MOmiostat 1TRAVATAN Z 2 MO

OPHTHALMOLOGY: STEROID-ANTIBIOTIC COMBINATIONSDrug Name Tier Requirements/

Limitsneomycin-bacitracin-poly-hc

1 MO

neomycin-polymyxinb-dexameth

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

1 MO

neo-polycin hc 1 MOtobramycin-dexamethasone

1 MO

OPHTHALMOLOGY: STEROIDSDrug Name Tier Requirements/

Limitsdexamethasone 1 MOsodium phosphateophthalmic (eye)

fluorometholone 1 MOFML S.O.P. 2 MOPRED MILD 2 MOprednisolone acetate 1 MOprednisolone sodiumphosphateophthalmic (eye)

1 MO

OPHTHALMOLOGY: STEROID-SULFONAMIDE COMBINATIONSDrug Name Tier Requirements/

LimitsBLEPHAMIDE 3 MOBLEPHAMIDE S.O.P. 3 MOsulfacetamide- 1 MOprednisolone


OPHTHALMOLOGY:SULFONAMIDESDrug Name Tier Requirements/

Limitssulfacetamide sodiumophthalmic (eye)

1 MO

OPHTHALMOLOGY:SYMPATHOMIMETICSDrug Name Tier Requirements/

Limitsapraclonidinebrimonidine

11

MOMO

RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTSDrug Name Tier Requirements/

Limitsadrenalin injection 1carbinoxamine 1 MOmaleate oral liquid

carbinoxamine 1 MOmaleate oral tablet 4mg

carbinoxamine 1maleate oral tablet 6mg

cetirizine oral solution 1 MO1 mg/ml

clemastine oral tablet 1 MO2.68 mg

cyproheptadine 1 MOdesloratadine oral 1 MOtablet

desloratadine oral 1 MOtablet,disintegrating

diphenhydramine hclinjection solution 50mg/ml

1 MO, HI

diphenhydramine hclinjection syringe

1 MO, HI

diphenhydramine hcloral elixir

1 PA

EPINEPHRINE 3 MOINJECTION AUTO-INJECTOR 0.15MG/0.15 ML, 0.3MG/0.3 ML(ADRENACLICK)

EPINEPHRINE 2 MOINJECTION AUTO-INJECTOR 0.15MG/0.3 ML, 0.3MG/0.3 ML (EPIPEN)

EPIPEN 2 MO


RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTS (continued)Drug Name Tier Requirements/

LimitsEPIPEN 2-PAK 2 MOEPIPEN JR 2 MOEPIPEN JR 2-PAK 2 MOhydroxyzine hclintramuscular

1 MO

hydroxyzine hcl oralsolution 10 mg/5 ml

1 PA, MO

hydroxyzine hcl oraltablet

1 PA, MO

hydroxyzine pamoate 1 PA, MOlevocetirizine oral 1 MOsolution

levocetirizine oral 1 MOtablet

phenadoz 1 MOphenergan rectal 1promethazine injectionsolution

1 MO

promethazine oral 1 PA, MOpromethazine rectalsuppository 12.5 mg,25 mg

1 MO

promethazine rectalsuppository 50 mg

1

promethegan 1 MO

RESPIRATORY AND ALLERGY:PULMONARY AGENTSDrug Name Tier Requirements/

Limitsacetylcysteine 1 B/D PA, MOADCIRCA 2 PA, MOADEMPAS 2 PA, MO, LAADVAIR DISKUS 3 PA, MO, QL (60

per 30 days)ADVAIR HFA 3 PA, MO, QL (24

per 30 days)albuterol sulfateinhalation solution for

1 B/D PA, MO

nebulizationalbuterol sulfate oral 1 MOsyrup

albuterol sulfate oral 1 MOtablet

albuterol sulfate oral 1 MOtablet extendedrelease 12 hr

aminophyllineintravenous solution

1 HI

250 mg/10 mlaminophyllineintravenous solution

1 HI

500 mg/20 mlANORO ELLIPTA 2 MO, QL (60 per

30 days)ARCAPTANEOHALER


ARNUITY ELLIPTAINHALATIONBLISTER WITH


DEVICE 100 MCG/ACTUATION, 200MCG/ACTUATION

ARNUITY ELLIPTAINHALATIONBLISTER WITH


DEVICE 50 MCG/ACTUATION


RESPIRATORY AND ALLERGY:PULMONARY AGENTS (continued)Drug Name Tier Requirements/

LimitsATROVENT HFA 2 MO, QL (38.7

per 30 days)BEVESPIAEROSPHERE

2 MO, QL (10.7per 30 days)

BROVANA 2 B/D PA, MObudesonide inhalation 1 B/D PA, MOCINRYZE 2 MO, HICOMBIVENTRESPIMAT


cromolyn inhalation 1 B/D PA, MODALIRESP 2 MODULERA 2 MO, QL (26 per

30 days)ESBRIET 2 PA, MOFASENRA 2 PA, MOFIRAZYR 2 MOFLOVENT DISKUS 2 MO, QL (120 per

30 days)FLOVENT HFAAEROSOL INHALER110 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER220 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER44 MCG/ACTUATION

2 MO, QL (21.2per 30 days)

flunisolide nasal spray,non-aerosol 25 mcg(0.025 %)


fluticasone nasal 1 MO, QL (32 per30 days)

HYPER-SAL MB MO


LimitsINCRUSE ELLIPTA 2 MO, QL (30 per

30 days)ipratropium bromideinhalation

1 B/D PA, MO

ipratropium-albuterol 1 B/D PA, MOKALYDECO 2 PA, MOLETAIRIS 2 PA, MO, LAlevalbuterol hcl 1 B/D PA, MOmetaproterenol 1 MOmometasone nasal 1 MO, QL (34 per

30 days)montelukast 1 MOnebusal inhalation MB MOsolution fornebulization 3 %

NEBUSAL MB MOINHALATIONSOLUTION FORNEBULIZATION 6 %(BRAND)

NUCALA 2 PA, MO, LAOFEV 2 PA, MOOPSUMIT 2 PA, MO, LAORKAMBI 2 PA, MO, QL

(112 per 28days)

PROAIR HFA 2 MO, QL (25.5per 30 days)

PROAIR RESPICLICK 2 MO, QL (3 per30 days)

pulmosal MB MOPULMOZYME 2 B/D PA, MOREVATIO ORALSUSPENSION FOR

2 PA, MO

RECONSTITUTIONRUCONEST 2 MO, HI



LimitsSEREVENT DISKUS 2 MO, QL (60 per

30 days)sildenafil (pulmonaryarterial hypertension)intravenous solution

1 PA, HI

10 mg/12.5 mlsildenafil (pulmonaryarterial hypertension)oral tablet 20 mg

1 PA, MO

sodium chloride MB MOinhalation

SPIRIVA RESPIMAT 2 MO, QL (4 per30 days)

SPIRIVA WITHHANDIHALER


STIOLTO RESPIMAT 2 MO, QL (4 per30 days)

STRIVERDIRESPIMAT


SYMBICORT 2 MO, QL (20.4per 30 days)

terbutaline 1 MOtheophylline indextrose 5 %

1

intravenousparenteral solution200 mg/100 ml, 200mg/50 ml, 400mg/250 ml, 400mg/500 ml, 800mg/250 ml

theophylline oral elixir 1theophylline oralsolution

1 MO

theophylline oral tabletextended release 12

1 MO

hr

RESPIRATORY AND ALLERGY:ULMONARYP AGENTS (continued)rug NameD Tier Requirements/

Limitseophylline oral tabletth

extended release 241 MO

hrRACLEERT 2 PA, MO, LAYVASOT 2 B/D PA, MOYVASOTINSTITUTIONAL

2 B/D PA

START KITYVASO REFILL KITT 2 B/D PA, MOYVASO STARTERTKIT

2 B/D PA, MO

ENTAVISV 2 B/D PA, MOOLAIRX 2 PA, MO, LAafirlukastz 1 MOileuton oral tablet,z 1 MOextended release12hr mphase


UROLOGICALS:ANTICHOLINERGICS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsdarifenacin oral tablet 1 MOextended release 24hr

flavoxate 1 MOoxybutynin chlorideoral syrup

1 MO

oxybutynin chlorideoral tablet

1 MO

oxybutynin chlorideoral tablet extended

1 MO

release 24hrtolterodine oral 1 MOcapsule,extendedrelease 24hr

tolterodine oral tablet 1 MOtrospium oral capsule,extended release

1 MO

24hrtrospium oral tablet 1 MO

UROLOGICALS: BENIGNPROSTATIC HYPERPLASIA(BPH)THERAPYDrug Name Tier Requirements/

Limitsalfuzosin oral tablet 1 MOextended release 24hr

dutasteride 1 MOdutasteride-tamsulosin 1 MOoral capsule, ermultiphase 24 hr

finasteride oral tablet 1 MO5 mg

tamsulosin oral 1 MOcapsule,extendedrelease 24hr

UROLOGICALS: CHOLINERGICSTIMULANTSDrug Name Tier Requirements/

Limitsbethanechol chloride 1 MO


UROLOGICALS: MISCELLANEOUSUROLOGICALSDrug Name Tier Requirements/

Limitsalprostadil 1 MOCIALIS ORALTABLET 2.5 MG, 5MG


CYSTAGON 2 MO, LAELMIRON 2 MOglycine urologic 1glycine urologicsolution

1

potassium citrate oraltablet extended

1 MO

releasePROCYSBI 2 MO

VITAMINS, HEMATINICS /ELECTROLYTES: BLOODDERIVATIVESDrug Name Tier Requirements/

Limitsalbumin, human 25 % 1albuminar 25 % 1 MOalbuminar 5 % 1alburx (human) 25 % 1 MOalburx (human) 5 % 1albutein 25 % 1albutein 5 % 1buminate 5 % 1plasbumin 25 % 1 MOplasbumin 5 % 1

VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTESDrug Name Tier Requirements/

Limitscalcium acetate oral 1 MOcapsule

calcium acetate oral 1 MOtablet 667 mg

calcium chloride 1calcium gluconateintravenous

1 MO

effer-k oral tablet, 1 MOeffervescent 25 meq

eliphos 1 MOGLYCOPHOS 2k-effervescent 1 MOklor-con 10 oral tablet 1 MOextended release

klor-con 20 meqpacket

1 MO

klor-con 8 oral tablet 1 MOextended release

klor-con m10 oral 1 MOtablet,er particles/crystals



klor-con sprinkle oralcapsule, extendedrelease

1 MO

klor-con/ef 1 MOk-tab oral tablet 1 MOextended release 8meq

lactated ringersintravenous

1 MO, HI


VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTES(continued)Drug Name Tier Requirements/

Limitsmagnesium chlorideinjection

1 MO

magnesium sulfate inwater intravenous

1

parenteral solutionmagnesium sulfate inwater intravenous

1

piggyback 2 gram/50ml (4 %), 4 gram/50ml (8 %)

magnesium sulfate inwater intravenous

1 MO

piggyback 4gram/100 ml (4 %)

magnesium sulfateinjection solution

1 MO, HI

magnesium sulfateinjection syringe

1 HI

NORMOSOL-R 3NORMOSOL-R IN 3 HI5 % DEXTROSE

potassium acetateintravenous solution

1

2 meq/mlpotassium bicarb andchloride

1 MO

potassium bicarb-citricacid

1 MO

potassium chlorid-d5-0.45%nacl

1 HI

intravenousparenteral solution 10meq/l, 30 meq/l, 40meq/l


Limitspotassium chlorid-d5-0.45%nacl

1 MO, HI

intravenousparenteral solution 20meq/l

potassium chloride in0.9%nacl intravenous

1 HI

parenteral solution 20meq/l, 40 meq/l

potassium chloride in5 % dex intravenous

1 HI

parenteral solution 20meq/l, 40 meq/l

potassium chloride in5 % dex intravenous

1 HI

parenteral solution 30meq/l

potassium chloride inlr-d5 intravenous

1 MO, HI


potassium chloride inlr-d5 intravenous

1 HI


potassium chloride inwater intravenous

1 MO, HI

piggyback 10meq/100 ml


1 MO, HI

piggyback 10 meq/50ml


1 HI

piggyback 20meq/100 ml, 40meq/100 ml



Limitspotassium chloride inwater intravenous

1 HI

piggyback 20 meq/50ml, 30 meq/100 ml

potassium chlorideintravenous

1 MO, HI

potassium chlorideoral capsule,extended release

1 MO

potassium chlorideoral liquid

1 MO

potassium chlorideoral packet

1 MO

potassium chlorideoral tablet extended

1 MO

releasepotassium chlorideoral tablet,er

1 MO

particles/crystalspotassiumchloride-0.45 % nacl

1 HI

potassium chloride-d5-0.2%nacl

1 MO, HI



1 HI

intravenousparenteral solution 30meq/l, 40 meq/l


1 HI



Limitspotassium chloride-d5-0.9%nacl

1 MO, HI



1 HI


potassium phosphatem-/d-basic

1

ringer's intravenous 1 HIsodium acetate 1sodium bicarbonate 1 MOintravenous solution

sodium bicarbonate 1 MOintravenous syringe10 meq/10 ml(8.4 %), 7.5 % (0.9meq/ml)

sodium bicarbonate 1intravenous syringe4.2 % (0.5 meq/ml),8.4 % (1 meq/ml)

sodium chloride 1 MO, HI0.45 % intravenousparenteral solution

sodium chloride 1 HI0.45 % intravenouspiggyback

sodium chloride 3 % 1 MO, HIsodium chloride 5 % 1 HIsodium chloride 1 MO, HIintravenousparenteral solution2.5 meq/ml



Limitssodium chloride 1 MO, HIintravenousparenteral solution 4meq/ml

sodium lactate 1 HIintravenous

sodium phosphate 1 MO

VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTSDrug Name Tier Requirements/

LimitsAMINOSYN 10 % 3 B/D PA, HIAMINOSYN 7 %WITH

3 B/D PA, HI

ELECTROLYTESAMINOSYN 8.5 % 3 B/D PA, HIAMINOSYN 8.5 %-ELECTROLYTES

3 B/D PA, HI

AMINOSYN II 10 % 3 B/D PA, HIAMINOSYN II 15 % 3 B/D PA, HIAMINOSYN II 7 % 3 B/D PA, HIAMINOSYN II 8.5 % 3 B/D PA, HIAMINOSYN II 8.5 %-ELECTROLYTES

3 B/D PA, HI

AMINOSYN M 3.5 % 3 B/D PA, HIAMINOSYN-HBC 7% 3 B/D PA, HIAMINOSYN-PF 10 % 3 B/D PA, HIAMINOSYN-PF 7 %(SULFITE-FREE)

3 B/D PA, HI

AMINOSYN-RF 5.2 % 3 B/D PA, HICLINIMIX 5%/D15WSULFITE FREE

3 B/D PA, HI

CLINIMIX 5%/D25WSULFITE-FREE

3 B/D PA, HI

CLINIMIX 2.75%/D5WSULFIT FREE

3 B/D PA, HI

CLINIMIX 4.25%/D10W SULF FREE

3 B/D PA, HI

CLINIMIX 4.25%-D20W SULF-FREE

3 B/D PA, HI

CLINIMIX 4.25%-D25W SULF-FREE

3 B/D PA, HI

CLINIMIX 5%-D20W(SULFITE-FREE)

3 B/D PA, HI


VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

LimitsCLINIMIX E 4.25%/D10W SUL FREE

3 B/D PA, HI

CLINIMIX E 4.25%/D25W SUL FREE

3 B/D PA, HI

CLINIMIX E 4.25%/D5W SULF FREE

3 B/D PA, HI

CLINIMIX E 5%/D15WSULFIT FREE

3 B/D PA, HI


3 B/D PA, HI


3 B/D PA, HI

CLINIMIX N14G30E4.25%-D15W SF

3 B/D PA, HI

CLINIMIX N9G15E2.75%-D7.5W SF

3 B/D PA, HI

cysteine (l-cysteine)intravenous solution

1 B/D PA

electrolyte-48 in d5w 1FREAMINE HBC6.9 %

3 B/D PA, HI

freamine iii 10 % 1 B/D PAHEPATAMINE 8% 3 B/D PA, HIhetastarch 6 % in 10.9 % nacl

intralipid intravenousemulsion 20 %

1 B/D PA, HI

INTRALIPIDINTRAVENOUS

3 B/D PA, HI

EMULSION 30 %NEPHRAMINE 5.4 % 3 B/D PA, HINORMOSOL-M IN 3 HI5 % DEXTROSE

NORMOSOL-R PH 3 HI7.4

VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

Limitsplasmanate 1plenamine 1 B/D PA, HIpremasol 10 % 1 B/D PA, MO, HIPREMASOL 6 % 3 B/D PA, HIPROCALAMINE 3% 3 B/D PA, HIPROSOL 20 % 3 B/D PA, MO, HISMOFLIPID 3 B/D PA, HItravasol 10 % 1 B/D PA, MO, HITROPHAMINE 10 % 3 B/D PA, MO, HITROPHAMINE 6% 3 B/D PA, HI


VITAMINS, HEMATINICS /ELECTROLYTES: VITAMINS /HEMATINICSDrug Name Tier Requirements/

Limitsfluoride (sodium) oraldrops

1 MO

fluoride (sodium) oraltablet

1 MO

fluoride (sodium) oraltablet,chewable 0.25

1 MO

mg(0.55 mg sod.fluoride), 0.5 mg (1.1mg sodium fluorid)

fluoritab oral tablet, 1 MOchewable 0.5 mg (1.1mg sodium fluorid)

ludent fluoride oral 1 MOtablet,chewable 0.25mg(0.55 mg sod.fluoride), 0.5 mg (1.1mg sodium fluorid)

multi-vit with fluoride- 1 MOiron

multivitamin with 1 MOfluoride

multi-vitamin with 1 MOfluoride oral drops

multivitamins with 1 MOfluoride

multivit-fluor (vit eacetate)

1 MO

mvc-fluoride 1 MOprenatal vitamin oraltablet

1 MO

tri-vitamin with fluoride 1 MOvitamins a,c,d and 1fluoride


Index of DrugsAa-hydrocort. . . . . . . . . . . . . . . . . . . . . . . . . . . 63abacavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9abacavir-lamivudine. . . . . . . . . . . . . . . . . . . . . 9abacavir-lamivudine-zidovudine. . . . . . . . . . . 9ABILIFY MAINTENA. . . . . . . . . . . . . . . . . . . 40ABRAXANE. . . . . . . . . . . . . . . . . . . . . . . . . . 21acamprosate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

acarbose. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65ACCU-CHEK AVIVA PLUS TEST STRIP. . . . 65ACCU-CHEK BLOOD GLUCOSE METERS. 65ACCU-CHEK COMPACT PLUS TEST STRIP 65ACCU-CHEK GUIDE TEST STRIP. . . . . . . . 65ACCU-CHEK SMARTVIEW TEST STRIP. . . 65ACCUTREND GLUCOSE TEST STRIP. . . . 65acebutolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46acetaminophen-caff-dihydrocod oral capsule 34acetaminophen-codeine oral solution 120 mg-12mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml. . . 34

acetaminophen-codeine oral solution 120-12mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

acetaminophen-codeine oral tablet. . . . . . . . 34acetazolamide oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

acetazolamide oral tablet. . . . . . . . . . . . . . . . 87acetazolamide sodium. . . . . . . . . . . . . . . . . . 87acetic acid irrigation. . . . . . . . . . . . . . . . . . . . 59acetic acid otic (ear). . . . . . . . . . . . . . . . . . . . 63acetylcysteine. . . . . . . . . . . . . . . . . . . . . . . . . 89acetylcysteine intravenous. . . . . . . . . . . . . . . 59acitretin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54ACTEMRA INTRAVENOUS. . . . . . . . . . . . . . 79ACTEMRA SUBCUTANEOUS. . . . . . . . . . . . 79ACTHIB (PF). . . . . . . . . . . . . . . . . . . . . . . . . 76ACTIMMUNE. . . . . . . . . . . . . . . . . . . . . . . . . 74acyclovir oral capsule. . . . . . . . . . . . . . . . . . . 9acyclovir oral suspension 200 mg/5 ml. . . . . . 9acyclovir oral tablet. . . . . . . . . . . . . . . . . . . . . 9

acyclovir sodium intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

acyclovir sodium intravenous solution. . . . . . . 9acyclovir topical. . . . . . . . . . . . . . . . . . . . . . . 57ADACEL(TDAP ADOLESN/ADULT)(PF). . . . 76ADAGEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59adapalene topical cream. . . . . . . . . . . . . . . . 55adapalene topical gel. . . . . . . . . . . . . . . . . . . 55adapalene topical gel with pump. . . . . . . . . . 55adapalene-benzoyl peroxide. . . . . . . . . . . . . 55ADASUVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 40ADCIRCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89adefovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ADEMPAS. . . . . . . . . . . . . . . . . . . . . . . . . . . 89adenosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45adrenalin injection. . . . . . . . . . . . . . . . . . . . . 88adriamycin intravenous solution 10 mg/5 ml, 2mg/ml, 50 mg/25 ml. . . . . . . . . . . . . . . . . . . 21

adriamycin intravenous solution 20 mg/10 ml 21adrucil intravenous solution 2.5 gram/50 ml. 21adrucil intravenous solution 5 gram/100 ml. . 21adrucil intravenous solution 500 mg/10 ml. . 21ADVAIR DISKUS. . . . . . . . . . . . . . . . . . . . . . 89ADVAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 89afeditab cr oral tablet extended release. . . . . 46AFINITOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21AFINITOR DISPERZ. . . . . . . . . . . . . . . . . . . 21AFLURIA 2017-2018. . . . . . . . . . . . . . . . . . . 76AFLURIA 2017-2018 (PF). . . . . . . . . . . . . . . 76AFLURIA QUAD 2017-2018. . . . . . . . . . . . . 76AFLURIA QUAD 2017-2018 (PF). . . . . . . . . 76ak-poly-bac. . . . . . . . . . . . . . . . . . . . . . . . . . 85ala-cort topical cream. . . . . . . . . . . . . . . . . . 58ALBENZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14albumin, human 25 %. . . . . . . . . . . . . . . . . . 93albuminar 25 %. . . . . . . . . . . . . . . . . . . . . . . 93albuminar 5 %. . . . . . . . . . . . . . . . . . . . . . . . 93alburx (human) 25 %. . . . . . . . . . . . . . . . . . . 93alburx (human) 5 %. . . . . . . . . . . . . . . . . . . . 93albutein 25 %. . . . . . . . . . . . . . . . . . . . . . . . . 93albutein 5 %. . . . . . . . . . . . . . . . . . . . . . . . . . 93

99

albuterol sulfate inhalation solution fornebulization. . . . . . . . . . . . . . . . . . . . . . . . . . 89

albuterol sulfate oral syrup. . . . . . . . . . . . . . . 89albuterol sulfate oral tablet. . . . . . . . . . . . . . . 89albuterol sulfate oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

alclometasone. . . . . . . . . . . . . . . . . . . . . . . . 58ALCOHOL PADS. . . . . . . . . . . . . . . . . . . . . . 65ALDURAZYME. . . . . . . . . . . . . . . . . . . . . . . . 67ALECENSA. . . . . . . . . . . . . . . . . . . . . . . . . . 21alendronate oral solution. . . . . . . . . . . . . . . . 79alendronate oral tablet 10 mg, 5 mg. . . . . . . 79alendronate oral tablet 35 mg, 70 mg. . . . . . 79alendronate oral tablet 40 mg. . . . . . . . . . . . 59alfuzosin oral tablet extended release 24 hr. 92ALIMTA INTRAVENOUS RECON SOLN 100MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

ALIMTA INTRAVENOUS RECON SOLN 500MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

ALINIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14ALIQOPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21allopurinol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78allopurinol sodium. . . . . . . . . . . . . . . . . . . . . 78almotriptan malate oral tablet 12.5 mg. . . . . 31almotriptan malate oral tablet 6.25 mg. . . . . 31aloprim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78alosetron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70alprazolam intensol. . . . . . . . . . . . . . . . . . . . 40alprazolam oral tablet. . . . . . . . . . . . . . . . . . 40alprazolam oral tablet extended release 24 hr 40alprazolam oral tablet,disintegrating. . . . . . . 40alprostadil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93altavera (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82ALUNBRIG. . . . . . . . . . . . . . . . . . . . . . . . . . . 21alyacen 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 82alyacen 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . 82amabelz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81amantadine hcl. . . . . . . . . . . . . . . . . . . . . . . . 9AMBISOME. . . . . . . . . . . . . . . . . . . . . . . . . . . 8amcinonide topical cream. . . . . . . . . . . . . . . 58amcinonide topical lotion. . . . . . . . . . . . . . . . 58amcinonide topical ointment. . . . . . . . . . . . . 58amethia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

amethia lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 82amethyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82amifostine crystalline. . . . . . . . . . . . . . . . . . . 21amikacin injection solution 1,000 mg/4 ml. . . 14amikacin injection solution 500 mg/2 ml. . . . 14amiloride. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46amiloride-hydrochlorothiazide. . . . . . . . . . . . 46aminocaproic acid intravenous. . . . . . . . . . . 50aminophylline intravenous solution 250 mg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

aminophylline intravenous solution 500 mg/20ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

AMINOSYN 10 %. . . . . . . . . . . . . . . . . . . . . 96AMINOSYN 7 % WITH ELECTROLYTES. . . 96AMINOSYN 8.5 %. . . . . . . . . . . . . . . . . . . . . 96AMINOSYN 8.5 %-ELECTROLYTES. . . . . . 96AMINOSYN II 10 %. . . . . . . . . . . . . . . . . . . . 96AMINOSYN II 15 %. . . . . . . . . . . . . . . . . . . . 96AMINOSYN II 7 %. . . . . . . . . . . . . . . . . . . . . 96AMINOSYN II 8.5 %. . . . . . . . . . . . . . . . . . . 96AMINOSYN II 8.5 %-ELECTROLYTES. . . . . 96AMINOSYN M 3.5 %. . . . . . . . . . . . . . . . . . . 96AMINOSYN-HBC 7%. . . . . . . . . . . . . . . . . . . 96AMINOSYN-PF 10 %. . . . . . . . . . . . . . . . . . . 96AMINOSYN-PF 7 % (SULFITE-FREE). . . . . 96AMINOSYN-RF 5.2 %. . . . . . . . . . . . . . . . . . 96amiodarone intravenous solution. . . . . . . . . . 45amiodarone intravenous syringe. . . . . . . . . . 45amiodarone oral. . . . . . . . . . . . . . . . . . . . . . . 45AMITIZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70amitriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . 40amitriptyline-chlordiazepoxide. . . . . . . . . . . . 40amlodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 46amlodipine-atorvastatin. . . . . . . . . . . . . . . . . 51amlodipine-benazepril. . . . . . . . . . . . . . . . . . 46amlodipine-olmesartan. . . . . . . . . . . . . . . . . 46amlodipine-valsartan. . . . . . . . . . . . . . . . . . . 46amlodipine-valsartan-hcthiazid. . . . . . . . . . . 46ammonium lactate. . . . . . . . . . . . . . . . . . . . . 54amnesteem. . . . . . . . . . . . . . . . . . . . . . . . . . 55amoxapine. . . . . . . . . . . . . . . . . . . . . . . . . . . 40amoxicil-clarithromy-lansopraz. . . . . . . . . . . 73

100

amoxicillin oral capsule. . . . . . . . . . . . . . . . . 1amoxicillin oral suspension for reconstitution 1amoxicillin oral tablet. . . . . . . . . . . . . . . . . . . 1amoxicillin oral tablet,chewable 125 mg, 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

amoxicillin-pot clavulanate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 1

amoxicillin-pot clavulanate oral tablet. . . . . . 1amoxicillin-pot clavulanate oral tablet extendedrelease 12 hr. . . . . . . . . . . . . . . . . . . . . . . . 1

amoxicillin-pot clavulanate oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 1

amphotericin b. . . . . . . . . . . . . . . . . . . . . . . . . ampicillin oral capsule. . . . . . . . . . . . . . . . . . 1ampicillin sodium injection recon soln 1 gram,10 gram, 125 mg. . . . . . . . . . . . . . . . . . . . . 1

ampicillin sodium injection recon soln 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 1

ampicillin sodium intravenous. . . . . . . . . . . . 1ampicillin-sulbactam injection recon soln 1.5gram, 3 gram. . . . . . . . . . . . . . . . . . . . . . . . 1

ampicillin-sulbactam injection recon soln 15gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ampicillin-sulbactam intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ampicillin-sulbactam intravenous recon soln 3gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

AMPYRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3ANADROL-50. . . . . . . . . . . . . . . . . . . . . . . . 6anagrelide. . . . . . . . . . . . . . . . . . . . . . . . . . . 5anastrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . 2anectine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3ANORO ELLIPTA. . . . . . . . . . . . . . . . . . . . . 8apexicon e. . . . . . . . . . . . . . . . . . . . . . . . . . . 5APOKYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3apraclonidine. . . . . . . . . . . . . . . . . . . . . . . . . 8aprepitant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7apri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8APTIOM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2APTIVUS ORAL CAPSULE. . . . . . . . . . . . . . . APTIVUS ORAL SOLUTION. . . . . . . . . . . . . . ARALAST NP INTRAVENOUS RECON SOLN1,000 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 5

777

7

77

7

787

7

77

7

7

7

727913981802899

9

ARALAST NP INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

aranelle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82ARCALYST. . . . . . . . . . . . . . . . . . . . . . . . . . . 74ARCAPTA NEOHALER. . . . . . . . . . . . . . . . . 89aripiprazole oral solution. . . . . . . . . . . . . . . . 40aripiprazole oral tablet. . . . . . . . . . . . . . . . . . 40aripiprazole oral tablet,disintegrating. . . . . . . 40ARISTADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 40armodafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . 40ARNUITY ELLIPTA INHALATION BLISTERWITH DEVICE 100 MCG/ACTUATION, 200MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 89

ARNUITY ELLIPTA INHALATION BLISTERWITH DEVICE 50 MCG/ACTUATION. . . . . 89

ARRANON. . . . . . . . . . . . . . . . . . . . . . . . . . . 21ARZERRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 21ascomp with codeine. . . . . . . . . . . . . . . . . . . 34ashlyna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82aspirin-dipyridamole oral capsule, er multiphase12 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

ASTAGRAF XL. . . . . . . . . . . . . . . . . . . . . . . 21atazanavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9atenolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46atenolol-chlorthalidone. . . . . . . . . . . . . . . . . . 46atomoxetine oral capsule 10 mg, 100 mg, 18mg, 25 mg, 80 mg. . . . . . . . . . . . . . . . . . . . 40

atomoxetine oral capsule 40 mg, 60 mg. . . . 40atorvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 51atovaquone. . . . . . . . . . . . . . . . . . . . . . . . . . 14atovaquone-proguanil. . . . . . . . . . . . . . . . . . 14ATRIPLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9atropine injection syringe 0.05 mg/ml, 0.1mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

atropine ophthalmic (eye) drops. . . . . . . . . . 86ATROVENT HFA. . . . . . . . . . . . . . . . . . . . . . 90AUBAGIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32aubra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82AUSTEDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 32AVANDIA ORAL TABLET 2 MG, 4 MG. . . . . 65AVASTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21aviane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82avita topical cream. . . . . . . . . . . . . . . . . . . . . 55

101

AVONEX (WITH ALBUMIN). . . . . . . . . . . . . . 74AVONEX INTRAMUSCULAR PEN INJECTORKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

AVONEX INTRAMUSCULAR SYRINGE KIT. 74azacitidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 21AZACTAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 14AZACTAM IN DEXTROSE (ISO-OSM). . . . . 14azathioprine. . . . . . . . . . . . . . . . . . . . . . . . . . 22azathioprine sodium. . . . . . . . . . . . . . . . . . . . 22azelastine nasal. . . . . . . . . . . . . . . . . . . . . . . 62azelastine ophthalmic (eye). . . . . . . . . . . . . . 86azithromycin intravenous. . . . . . . . . . . . . . . . 13azithromycin oral. . . . . . . . . . . . . . . . . . . . . . 13aztreonam injection recon soln 1 gram. . . . . 14aztreonam injection recon soln 2 gram. . . . . 14azurette (28). . . . . . . . . . . . . . . . . . . . . . . . . 82

Bbaciim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14bacitracin intramuscular. . . . . . . . . . . . . . . . . 14bacitracin ophthalmic (eye). . . . . . . . . . . . . . 85bacitracin-polymyxin b ophthalmic (eye). . . . 85baclofen oral tablet 10 mg, 20 mg. . . . . . . . . 33bacteriostatic water(parabens). . . . . . . . . . . 59balanced salt. . . . . . . . . . . . . . . . . . . . . . . . . 86balsalazide. . . . . . . . . . . . . . . . . . . . . . . . . . . 70balziva (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82BANZEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28BARACLUDE ORAL SOLUTION. . . . . . . . . . . 9BAVENCIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BAXDELA INTRAVENOUS. . . . . . . . . . . . . . 18BAXDELA ORAL. . . . . . . . . . . . . . . . . . . . . . 18BCG VACCINE, LIVE (PF). . . . . . . . . . . . . . 76bd pre-filled normal saline. . . . . . . . . . . . . . . 59bekyree (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82BELEODAQ. . . . . . . . . . . . . . . . . . . . . . . . . . 22benazepril. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46benazepril-hydrochlorothiazide. . . . . . . . . . . 46BENDEKA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BENLYSTA INTRAVENOUS. . . . . . . . . . . . . 79BENLYSTA SUBCUTANEOUS. . . . . . . . . . . 79BENZNIDAZOLE. . . . . . . . . . . . . . . . . . . . . . 14

benztropine injection. . . . . . . . . . . . . . . . . . . 31benztropine oral. . . . . . . . . . . . . . . . . . . . . . . 31BESPONSA. . . . . . . . . . . . . . . . . . . . . . . . . . 22betamethasone acet,sod phos. . . . . . . . . . . . 63betamethasone dipropionate. . . . . . . . . . . . . 58betamethasone valerate. . . . . . . . . . . . . . . . 58betamethasone, augmented. . . . . . . . . . . . . 58betaxolol ophthalmic (eye). . . . . . . . . . . . . . . 86betaxolol oral. . . . . . . . . . . . . . . . . . . . . . . . . 46bethanechol chloride. . . . . . . . . . . . . . . . . . . 92BETHKIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14BEVESPI AEROSPHERE. . . . . . . . . . . . . . . 90BEVYXXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 50bexarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 22BEXSERO. . . . . . . . . . . . . . . . . . . . . . . . . . . 76bicalutamide. . . . . . . . . . . . . . . . . . . . . . . . . . 22BICILLIN L-A. . . . . . . . . . . . . . . . . . . . . . . . . 17BICNU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22BIKTARVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9bimatoprost ophthalmic (eye). . . . . . . . . . . . 87bisoprolol fumarate. . . . . . . . . . . . . . . . . . . . 46bisoprolol-hydrochlorothiazide. . . . . . . . . . . . 46bleomycin injection recon soln 15 unit. . . . . . 22bleomycin injection recon soln 30 unit. . . . . . 22BLEPHAMIDE. . . . . . . . . . . . . . . . . . . . . . . . 87BLEPHAMIDE S.O.P.. . . . . . . . . . . . . . . . . . 87BLINCYTO INTRAVENOUS KIT. . . . . . . . . . 22blisovi 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 82blisovi fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . 82blisovi fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 82BOOSTRIX TDAP. . . . . . . . . . . . . . . . . . . . . 76BORTEZOMIB. . . . . . . . . . . . . . . . . . . . . . . . 22BOSULIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22BOTOX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76briellyn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82BRILINTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50brimonidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 88BRIVIACT INTRAVENOUS. . . . . . . . . . . . . . 28BRIVIACT ORAL. . . . . . . . . . . . . . . . . . . . . . 28bromfenac. . . . . . . . . . . . . . . . . . . . . . . . . . . 87bromocriptine. . . . . . . . . . . . . . . . . . . . . . . . . 31BROVANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 90

102

bss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86budesonide inhalation. . . . . . . . . . . . . . . . . . 90budesonide oralcapsule,delayed,extend.release. . . . . . . . . . 70

bumetanide injection. . . . . . . . . . . . . . . . . . . 46bumetanide oral. . . . . . . . . . . . . . . . . . . . . . . 46buminate 5 %. . . . . . . . . . . . . . . . . . . . . . . . . 93BUPHENYL ORAL TABLET. . . . . . . . . . . . . . 59bupivacaine. . . . . . . . . . . . . . . . . . . . . . . . . . 56bupivacaine (pf) injection solution 0.25 % (2.5mg/ml), 0.5 % (5 mg/ml). . . . . . . . . . . . . . . . 56

bupivacaine (pf) injection solution 0.75 % (7.5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

bupivacaine-dextrose-water(pf). . . . . . . . . . . 59bupivacaine-epinephrine (pf). . . . . . . . . . . . . 56bupivacaine-epinephrine injection solution0.25 %-1:200,000. . . . . . . . . . . . . . . . . . . . . 56

bupivacaine-epinephrine injection solution0.5 %-1:200,000. . . . . . . . . . . . . . . . . . . . . . 56

buprenorphine hcl injection solution. . . . . . . 34buprenorphine hcl injection syringe. . . . . . . . 34buprenorphine hcl sublingual. . . . . . . . . . . . . 34buprenorphine-naloxone. . . . . . . . . . . . . . . . 38bupropion hcl (smoking deter) oral tabletextended release. . . . . . . . . . . . . . . . . . . . . 62

bupropion hcl oral tablet. . . . . . . . . . . . . . . . 40bupropion hcl oral tablet extended release12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

bupropion hcl oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

buspirone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40busulfan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22butalbital compound w/codeine. . . . . . . . . . . 34butalbital-acetaminop-caf-cod. . . . . . . . . . . . 34butalbital-acetaminophen. . . . . . . . . . . . . . . . 34butalbital-acetaminophen-caff oral capsule. . 34butalbital-acetaminophen-caff oral tablet50-325-40 mg. . . . . . . . . . . . . . . . . . . . . . . . 34

butalbital-aspirin-caffeine oral capsule. . . . . 34butalbital-aspirin-caffeine oral tablet. . . . . . . 34butorphanol tartrate injection. . . . . . . . . . . . . 38butorphanol tartrate nasal. . . . . . . . . . . . . . . 38BYDUREON. . . . . . . . . . . . . . . . . . . . . . . . . . 65BYDUREON BCISE. . . . . . . . . . . . . . . . . . . . 65

BYETTA SUBCUTANEOUS PEN INJECTOR 10MCG/DOSE(250 MCG/ML) 2.4 ML. . . . . . . 65

BYETTA SUBCUTANEOUS PEN INJECTOR 5MCG/DOSE (250 MCG/ML) 1.2 ML. . . . . . . 65

Ccabergoline. . . . . . . . . . . . . . . . . . . . . . . . . . . 67

ABOMETYX. . . . . . . . . . . . . . . . . . . . . . . . . 22affeine citrate intravenous. . . . . . . . . . . . . . 59affeine citrate oral. . . . . . . . . . . . . . . . . . . . 59alcipotriene. . . . . . . . . . . . . . . . . . . . . . . . . . 54alcipotriene-betamethasone. . . . . . . . . . . . . 54alcitonin (salmon). . . . . . . . . . . . . . . . . . . . . 67alcitrene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54alcitriol intravenous solution 1 mcg/ml. . . . . 67alcitriol oral. . . . . . . . . . . . . . . . . . . . . . . . . . 67alcitriol topical. . . . . . . . . . . . . . . . . . . . . . . 54alcium acetate oral capsule. . . . . . . . . . . . . 93alcium acetate oral tablet 667 mg. . . . . . . . 93alcium chloride. . . . . . . . . . . . . . . . . . . . . . . 93alcium gluconate intravenous. . . . . . . . . . . 93ALQUENCE. . . . . . . . . . . . . . . . . . . . . . . . . 22amila. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81amrese. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82amrese lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 82ANCIDAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8andesartan. . . . . . . . . . . . . . . . . . . . . . . . . . 46andesartan-hydrochlorothiazid. . . . . . . . . . . 46apacet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35APASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . 14apecitabine. . . . . . . . . . . . . . . . . . . . . . . . . . 22APRELSA. . . . . . . . . . . . . . . . . . . . . . . . . . 22aptopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46aptopril-hydrochlorothiazide. . . . . . . . . . . . . 46ARAFATE ORAL SUSPENSION. . . . . . . . . 73ARBAGLU. . . . . . . . . . . . . . . . . . . . . . . . . . 59arbamazepine oral capsule, er multiphase 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28arbamazepine oral suspension 100 mg/5 ml 28arbamazepine oral tablet. . . . . . . . . . . . . . . 28arbamazepine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28arbamazepine oral tablet,chewable. . . . . . . 28

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c

103

carbidopa. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31carbidopa-levodopa oral tablet. . . . . . . . . . . 31carbidopa-levodopa oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

carbidopa-levodopa oral tablet,disintegrating 31carbidopa-levodopa-entacapone. . . . . . . . . . 31carbinoxamine maleate oral liquid. . . . . . . . . 88carbinoxamine maleate oral tablet 4 mg. . . . 88carbinoxamine maleate oral tablet 6 mg. . . . 88carbocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

carboplatin intravenous solution. . . . . . . . . . 22cardioplegic soln. . . . . . . . . . . . . . . . . . . . . . 52carisoprodol. . . . . . . . . . . . . . . . . . . . . . . . . . 33carisoprodol-asa-codeine. . . . . . . . . . . . . . . 33carisoprodol-aspirin. . . . . . . . . . . . . . . . . . . . 33carteolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86cartia xt oral capsule,extended release 24hr. 46carvedilol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46carvedilol phosphate oral capsule, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

caspofungin. . . . . . . . . . . . . . . . . . . . . . . . . . . 8CAYSTON. . . . . . . . . . . . . . . . . . . . . . . . . . . 14caziant (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82cefaclor oral capsule. . . . . . . . . . . . . . . . . . . 12cefaclor oral suspension for reconstitution 125mg/5 ml, 250 mg/5 ml. . . . . . . . . . . . . . . . . . 12

cefaclor oral suspension for reconstitution 375mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

cefaclor oral tablet extended release 12 hr. . 12cefadroxil oral capsule. . . . . . . . . . . . . . . . . . 12cefadroxil oral suspension for reconstitution 250mg/5 ml, 500 mg/5 ml. . . . . . . . . . . . . . . . . . 12

cefadroxil oral tablet. . . . . . . . . . . . . . . . . . . . 12cefazolin in dextrose (iso-os) intravenouspiggyback 1 gram/50 ml, 2 gram/50 ml. . . . 12

cefazolin injection recon soln 1 gram, 500 mg 12cefazolin injection recon soln 10 gram. . . . . . 12cefazolin injection recon soln 100 gram, 20gram, 300 g. . . . . . . . . . . . . . . . . . . . . . . . . 12

cefazolin intravenous. . . . . . . . . . . . . . . . . . . 12cefdinir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12cefepime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

cefepime in dextrose,iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 12

cefepime in dextrose,iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 12

cefixime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12cefotaxime injection recon soln 1 gram, 2 gram,500 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

cefotaxime injection recon soln 10 gram. . . . 12cefotetan injection. . . . . . . . . . . . . . . . . . . . . 12cefotetan intravenous. . . . . . . . . . . . . . . . . . 12cefoxitin in dextrose, iso-osm. . . . . . . . . . . . 12cefoxitin intravenous recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

cefoxitin intravenous recon soln 10 gram. . . 12cefpodoxime. . . . . . . . . . . . . . . . . . . . . . . . . . 12cefprozil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ceftazidime injection recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ceftazidime injection recon soln 6 gram. . . . . 12ceftriaxone in dextrose,iso-os. . . . . . . . . . . . 12ceftriaxone injection recon soln 1 gram, 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 12

ceftriaxone injection recon soln 10 gram. . . . 12ceftriaxone intravenous. . . . . . . . . . . . . . . . . 12cefuroxime axetil oral tablet. . . . . . . . . . . . . . 13cefuroxime sodium injection recon soln 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

cefuroxime sodium intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

cefuroxime sodium intravenous recon soln 7.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

celecoxib. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38CELLCEPT INTRAVENOUS. . . . . . . . . . . . . 22CELONTIN ORAL CAPSULE 300 MG. . . . . 28cephalexin. . . . . . . . . . . . . . . . . . . . . . . . . . . 13CERDELGA. . . . . . . . . . . . . . . . . . . . . . . . . . 67CEREZYME INTRAVENOUS RECON SOLN400 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 67

cetirizine oral solution 1 mg/ml. . . . . . . . . . . 88cevimeline. . . . . . . . . . . . . . . . . . . . . . . . . . . 59CHANTIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62CHANTIX CONTINUING MONTH BOX. . . . 62CHANTIX STARTING MONTH BOX. . . . . . . 62chateal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

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CHEMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59chloramphenicol sod succinate. . . . . . . . . . . 14chlordiazepoxide hcl. . . . . . . . . . . . . . . . . . . 40chlordiazepoxide-clidinium. . . . . . . . . . . . . . . 69chlorhexidine gluconate mucous membrane. 62chloroprocaine (pf). . . . . . . . . . . . . . . . . . . . . 56chloroquine phosphate. . . . . . . . . . . . . . . . . 14chlorothiazide. . . . . . . . . . . . . . . . . . . . . . . . . 46chlorothiazide sodium. . . . . . . . . . . . . . . . . . 46chlorpromazine injection. . . . . . . . . . . . . . . . 40chlorpromazine oral. . . . . . . . . . . . . . . . . . . . 40chlorpropamide. . . . . . . . . . . . . . . . . . . . . . . 65chlorthalidone oral tablet 25 mg, 50 mg. . . . . 46chlorzoxazone oral tablet 250 mg. . . . . . . . . 33chlorzoxazone oral tablet 500 mg. . . . . . . . . 33CHOLBAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 70cholestyramine (with sugar). . . . . . . . . . . . . . 51cholestyramine light. . . . . . . . . . . . . . . . . . . . 51CHORIONIC GONADOTROPIN, HUMAN. . 67CIALIS ORAL TABLET 2.5 MG, 5 MG. . . . . . 93ciclodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57ciclopirox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57cidofovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9cilostazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CIMDUO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9cimetidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73cimetidine hcl oral. . . . . . . . . . . . . . . . . . . . . 73CIMZIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70CIMZIA POWDER FOR RECONST. . . . . . . . 70CIMZIA STARTER KIT. . . . . . . . . . . . . . . . . . 70CINRYZE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90CINVANTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70CIPRODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 63ciprofloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . 18ciprofloxacin (mixture) oral tablet, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

ciprofloxacin hcl ophthalmic (eye). . . . . . . . . 85ciprofloxacin hcl oral. . . . . . . . . . . . . . . . . . . 18ciprofloxacin hcl otic (ear). . . . . . . . . . . . . . . 63ciprofloxacin in 5 % dextrose intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . 18

ciprofloxacin in 5 % dextrose intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . 18

ciprofloxacin lactate intravenous solution 400mg/40 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 18

cisplatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22citalopram oral solution. . . . . . . . . . . . . . . . . 40citalopram oral tablet. . . . . . . . . . . . . . . . . . . 40cladribine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22claravis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55clarithromycin oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 13

clarithromycin oral tablet. . . . . . . . . . . . . . . . 13clarithromycin oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

clemastine oral tablet 2.68 mg. . . . . . . . . . . . 88cleocin intravenous solution 300 mg/2 ml. . . 14CLEOCIN VAGINAL SUPPOSITORY. . . . . . 82clindacin etz topical swab. . . . . . . . . . . . . . . 55clindacin p. . . . . . . . . . . . . . . . . . . . . . . . . . . 55clindamycin hcl. . . . . . . . . . . . . . . . . . . . . . . 14clindamycin in 5 % dextrose. . . . . . . . . . . . . 14clindamycin palmitate hcl. . . . . . . . . . . . . . . . 14clindamycin pediatric. . . . . . . . . . . . . . . . . . . 15clindamycin phosphate injection. . . . . . . . . . 15clindamycin phosphate intravenous solution 300mg/2 ml, 900 mg/6 ml. . . . . . . . . . . . . . . . . . 15

clindamycin phosphate intravenous solution 600mg/4 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

clindamycin phosphate topical. . . . . . . . . . . . 55clindamycin phosphate vaginal. . . . . . . . . . . 82clindamycin-benzoyl peroxide. . . . . . . . . . . . 55clindamycin-tretinoin. . . . . . . . . . . . . . . . . . . 55CLINIMIX 5%/D15W SULFITE FREE. . . . . . 96CLINIMIX 5%/D25W SULFITE-FREE. . . . . 96CLINIMIX 2.75%/D5W SULFIT FREE. . . . . . 96CLINIMIX 4.25%-D20W SULF-FREE. . . . . . 96CLINIMIX 4.25%-D25W SULF-FREE. . . . . . 96CLINIMIX 4.25%/D10W SULF FREE. . . . . . 96CLINIMIX 4.25%/D5W SULFIT FREE. . . . . . 59CLINIMIX 5%-D20W(SULFITE-FREE). . . . . 96CLINIMIX E 2.75%/D10W SUL FREE. . . . . . 59CLINIMIX E 2.75%/D5W SULF FREE. . . . . . 60CLINIMIX E 4.25%/D10W SUL FREE. . . . . . 97

105

CLINIMIX E 4.25%/D25W SUL FREE. . . . . . 97CLINIMIX E 4.25%/D5W SULF FREE. . . . . . 97CLINIMIX E 5%/D15W SULFIT FREE. . . . . . 97CLINIMIX E 5%/D20W SULFIT FREE. . . . . . 97CLINIMIX E 5%/D25W SULFIT FREE. . . . . . 97CLINIMIX N14G30E 4.25%-D15W SF. . . . . . 97CLINIMIX N9G15E 2.75%-D7.5W SF. . . . . . 97CLINIMIX N9G20E 2.75%-D10W(SF). . . . . . 60clobetasol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 58clobetasol-emollient. . . . . . . . . . . . . . . . . . . . 58clodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58clofarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . 22clomiphene citrate. . . . . . . . . . . . . . . . . . . . . 67clomipramine. . . . . . . . . . . . . . . . . . . . . . . . . 40clonazepam oral tablet. . . . . . . . . . . . . . . . . . 28clonazepam oral tablet,disintegrating. . . . . . 28clonidine (pf) epidural solution 1,000 mcg/10 ml(100 mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . 46

clonidine (pf) epidural solution 5,000 mcg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

clonidine hcl oral tablet. . . . . . . . . . . . . . . . . 46clonidine hcl oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

clonidine transdermal. . . . . . . . . . . . . . . . . . . 46clopidogrel. . . . . . . . . . . . . . . . . . . . . . . . . . . 50clorazepate dipotassium. . . . . . . . . . . . . . . . 40clotrimazole mucous membrane. . . . . . . . . . . 8clotrimazole topical. . . . . . . . . . . . . . . . . . . . 57clotrimazole-betamethasone. . . . . . . . . . . . . 57clozapine oral tablet. . . . . . . . . . . . . . . . . . . . 40clozapine oral tablet,disintegrating 100 mg, 12.5mg, 25 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 40

CLOZAPINE ORAL TABLET,DISINTEGRATING150 MG, 200 MG (BRAND). . . . . . . . . . . . . 40

COARTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . 15codeine sulfate oral tablet. . . . . . . . . . . . . . . 35codeine-butalbital-asa-caff. . . . . . . . . . . . . . . 35COLCHICINE ORAL TABLET. . . . . . . . . . . . 78COLCRYS. . . . . . . . . . . . . . . . . . . . . . . . . . . 78colesevelam. . . . . . . . . . . . . . . . . . . . . . . . . . 51colestipol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51colistin (colistimethate na). . . . . . . . . . . . . . . 15colocort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

COMBIVENT RESPIMAT. . . . . . . . . . . . . . . . 90COMETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . . 22COMPLERA. . . . . . . . . . . . . . . . . . . . . . . . . . . 9compro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70CONDYLOX TOPICAL GEL. . . . . . . . . . . . . 54constulose. . . . . . . . . . . . . . . . . . . . . . . . . . . 70coremino oral tablet extended release 24 hr. 19CORLANOR. . . . . . . . . . . . . . . . . . . . . . . . . . 52cortisone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63COSENTYX. . . . . . . . . . . . . . . . . . . . . . . . . . 54COSENTYX (2 SYRINGES). . . . . . . . . . . . . 54COSENTYX PEN. . . . . . . . . . . . . . . . . . . . . . 54COSENTYX PEN (2 PENS). . . . . . . . . . . . . 54COTELLIC. . . . . . . . . . . . . . . . . . . . . . . . . . . 22CREON ORAL CAPSULE,DELAYEDRELEASE(DR/EC). . . . . . . . . . . . . . . . . . . . 70

CRESEMBA INTRAVENOUS. . . . . . . . . . . . . 8CRESEMBA ORAL. . . . . . . . . . . . . . . . . . . . . 8CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 9cromolyn inhalation. . . . . . . . . . . . . . . . . . . . 90cromolyn ophthalmic (eye). . . . . . . . . . . . . . . 86cromolyn oral. . . . . . . . . . . . . . . . . . . . . . . . . 70cryselle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 82CUPRIMINE. . . . . . . . . . . . . . . . . . . . . . . . . . 79CUVPOSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 69cyclafem 1/35 (28). . . . . . . . . . . . . . . . . . . . . 82cyclafem 7/7/7 (28). . . . . . . . . . . . . . . . . . . . 82cyclobenzaprine oral tablet. . . . . . . . . . . . . . 33cyclophosphamide intravenous. . . . . . . . . . . 22cyclophosphamide oral capsule. . . . . . . . . . . 22CYCLOSERINE. . . . . . . . . . . . . . . . . . . . . . . 15CYCLOSET. . . . . . . . . . . . . . . . . . . . . . . . . . 65cyclosporine intravenous. . . . . . . . . . . . . . . . 22cyclosporine modified. . . . . . . . . . . . . . . . . . 22cyclosporine oral capsule. . . . . . . . . . . . . . . 22cyproheptadine. . . . . . . . . . . . . . . . . . . . . . . . 88CYRAMZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22cyred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82CYSTADANE. . . . . . . . . . . . . . . . . . . . . . . . . 70CYSTAGON. . . . . . . . . . . . . . . . . . . . . . . . . . 93CYSTARAN. . . . . . . . . . . . . . . . . . . . . . . . . . 86cysteine (l-cysteine) intravenous solution. . . 97

106

cytarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22cytarabine (pf) injection solution 100 mg/5 ml(20 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 22

cytarabine (pf) injection solution 2 gram/20 ml(100 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 22

cytarabine (pf) injection solution 20 mg/ml. . 22

Dd10 %-0.45 % sodium chloride. . . . . . . . . . . 6d2.5 %-0.45 % sodium chloride. . . . . . . . . . . 6d5 % and 0.9 % sodium chloride. . . . . . . . . . 6d5 %-0.45 % sodium chloride. . . . . . . . . . . . 6dacarbazine intravenous recon soln 100 mg. 2dacarbazine intravenous recon soln 200 mg. 2dactinomycin. . . . . . . . . . . . . . . . . . . . . . . . . 2DAKLINZA ORAL TABLET 30 MG. . . . . . . . . . DAKLINZA ORAL TABLET 60 MG, 90 MG. . . DALIRESP. . . . . . . . . . . . . . . . . . . . . . . . . . . 9DALVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 1danazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6dantrolene. . . . . . . . . . . . . . . . . . . . . . . . . . . 3dapsone oral. . . . . . . . . . . . . . . . . . . . . . . . . 1dapsone topical. . . . . . . . . . . . . . . . . . . . . . . 5DAPTACEL (DTAP PEDIATRIC) (PF). . . . . . 7daptomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 1DARAPRIM. . . . . . . . . . . . . . . . . . . . . . . . . . 1darifenacin oral tablet extended release 24 hr 9DARZALEX. . . . . . . . . . . . . . . . . . . . . . . . . . 2dasetta 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 8dasetta 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 8daunorubicin intravenous solution. . . . . . . . . 2daysee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8deblitane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8decadron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6decitabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2deferoxamine. . . . . . . . . . . . . . . . . . . . . . . . . 6deltasone oral tablet 20 mg. . . . . . . . . . . . . . 6delyla (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 8demeclocycline. . . . . . . . . . . . . . . . . . . . . . . . 1demerol (pf) injection solution 100 mg/ml. . . 3DEMSER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4DENAVIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

0000222990573556552222221320329567

denta 5000 plus. . . . . . . . . . . . . . . . . . . . . . . 62dentagel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62DEPEN TITRATABS. . . . . . . . . . . . . . . . . . . 79DESCOVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9desipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 40desloratadine oral tablet. . . . . . . . . . . . . . . . 88desloratadine oral tablet,disintegrating. . . . . 88desmopressin injection. . . . . . . . . . . . . . . . . 67desmopressin nasal solution. . . . . . . . . . . . . 67desmopressin nasal spray with pump. . . . . . 67desmopressin nasal spray,non-aerosol. . . . . 67desmopressin oral. . . . . . . . . . . . . . . . . . . . . 67desog-e.estradiol/e.estradiol. . . . . . . . . . . . . 83desogestrel-ethinyl estradiol. . . . . . . . . . . . . 83desonide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58desoximetasone. . . . . . . . . . . . . . . . . . . . . . . 58desvenlafaxine succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 40

dexamethasone. . . . . . . . . . . . . . . . . . . . . . . 63dexamethasone intensol. . . . . . . . . . . . . . . . 63dexamethasone sodium phos (pf). . . . . . . . . 63dexamethasone sodium phosphate injectionsolution 10 mg/ml. . . . . . . . . . . . . . . . . . . . . 63

dexamethasone sodium phosphate injectionsolution 4 mg/ml. . . . . . . . . . . . . . . . . . . . . . 63

dexamethasone sodium phosphate injectionsyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

dexamethasone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

dexmethylphenidate oral capsule,er biphasic50-50 10 mg, 20 mg, 30 mg, 40 mg, 5 mg. . 40

dexmethylphenidate oral capsule,er biphasic50-50 15 mg, 25 mg, 35 mg. . . . . . . . . . . . . 41

dexmethylphenidate oral tablet. . . . . . . . . . . 41dexrazoxane hcl intravenous recon soln 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

dexrazoxane hcl intravenous recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

dextroamphetamine oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

dextroamphetamine oral solution. . . . . . . . . . 41dextroamphetamine oral tablet. . . . . . . . . . . 41

107

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 25 mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 30 mg. . . . . 41

dextroamphetamine-amphetamine oral tablet 41dextrose 10 % and 0.2 % nacl. . . . . . . . . . . . 60dextrose 10 % in water (d10w). . . . . . . . . . . 60dextrose 20 % in water (d20w). . . . . . . . . . . 60dextrose 25 % in water (d25w). . . . . . . . . . . 60dextrose 30 % in water (d30w). . . . . . . . . . . 60dextrose 40 % in water (d40w). . . . . . . . . . . 60dextrose 5 % in water (d5w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 60

dextrose 5 % in water (d5w) intravenouspiggyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 60

dextrose 5 %-lactated ringers. . . . . . . . . . . . 60dextrose 5%-0.2 % sod chloride. . . . . . . . . . 60dextrose 5%-0.3 % sod.chloride. . . . . . . . . . 60dextrose 50 % in water (d50w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 60

dextrose 50 % in water (d50w) intravenoussyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

dextrose 70 % in water (d70w). . . . . . . . . . . 60dextrose with sodium chloride. . . . . . . . . . . . 60DIASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28DIASTAT ACUDIAL. . . . . . . . . . . . . . . . . . . . 28diazepam injection solution. . . . . . . . . . . . . . 41diazepam injection syringe. . . . . . . . . . . . . . 41diazepam intensol. . . . . . . . . . . . . . . . . . . . . 41diazepam oral concentrate. . . . . . . . . . . . . . 41diazepam oral solution 5 mg/5 ml (1 mg/ml). 41diazepam oral tablet. . . . . . . . . . . . . . . . . . . 41diazepam rectal. . . . . . . . . . . . . . . . . . . . . . . 28diclofenac potassium. . . . . . . . . . . . . . . . . . . 38diclofenac sodium ophthalmic (eye). . . . . . . 87diclofenac sodium oral tablet extended release24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

diclofenac sodium oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

diclofenac sodium topical drops. . . . . . . . . . . 38diclofenac sodium topical gel 1 %. . . . . . . . . 38diclofenac sodium topical gel 3 %. . . . . . . . . 54

diclofenac-misoprostol oral tablet,ir,delayedl,biphasic. . . . . . . . . . . . . . . . . . . . . . . . . . 38loxacillin. . . . . . . . . . . . . . . . . . . . . . . . . . . 17yclomine intramuscular. . . . . . . . . . . . . . . 69yclomine oral capsule. . . . . . . . . . . . . . . . 69yclomine oral solution. . . . . . . . . . . . . . . . 69yclomine oral tablet. . . . . . . . . . . . . . . . . . 69anosine oral capsule,delayed release(dr/ec)0 mg, 250 mg, 400 mg. . . . . . . . . . . . . . . . 9ICID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

orasone. . . . . . . . . . . . . . . . . . . . . . . . . . . 58unisal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38itek. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49oxin injection solution. . . . . . . . . . . . . . . . 49oxin oral solution 50 mcg/ml. . . . . . . . . . . 49oxin oral tablet. . . . . . . . . . . . . . . . . . . . . . 49ydroergotamine injection. . . . . . . . . . . . . . 31ydroergotamine nasal. . . . . . . . . . . . . . . . 31ANTIN 30 MG. . . . . . . . . . . . . . . . . . . . . . 28-xr oral capsule,ext release degradable. . 47iazem hcl intravenous. . . . . . . . . . . . . . . . 46iazem hcl oral capsule, extended release. 46iazem hcl oral capsule,ext releasegradable. . . . . . . . . . . . . . . . . . . . . . . . . . 46iazem hcl oral capsule,extended release 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46iazem hcl oral capsule,extended releasehr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46iazem hcl oral tablet. . . . . . . . . . . . . . . . . 46iazem hcl oral tablet extended release 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46enhydrinate injection solution. . . . . . . . . . 70ENTUM. . . . . . . . . . . . . . . . . . . . . . . . . . 70

henhydramine hcl injection solution 50g/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88henhydramine hcl injection syringe. . . . . . 88henhydramine hcl oral elixir. . . . . . . . . . . 88henoxylate-atropine. . . . . . . . . . . . . . . . . 69yridamole intravenous. . . . . . . . . . . . . . . . 50yridamole oral. . . . . . . . . . . . . . . . . . . . . . 50opyramide phosphate oral capsule. . . . . . 45ulfiram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

redicdicdicdicdicdid20

DIFdifldifldigdigdigdigdigdihdihDILdiltdiltdiltdiltde

dilthr

dilt24

diltdilthr

dimDIPdipm

dipdipdipdipdipdisdis

108

divalproex oral capsule, sprinkle. . . . . . . . . . 28divalproex oral tablet extended release 24 hr 28divalproex oral tablet,delayed release (dr/ec) 28dobutamine. . . . . . . . . . . . . . . . . . . . . . . . . . 52dobutamine in d5w intravenous parenteralsolution 1,000 mg/250 ml (4,000 mcg/ml). . 52

dobutamine in d5w intravenous parenteralsolution 250 mg/250 ml (1 mg/ml), 500 mg/250ml (2,000 mcg/ml). . . . . . . . . . . . . . . . . . . . 52

docetaxel intravenous solution 160 mg/16 ml(10 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 22

docetaxel intravenous solution 160 mg/8 ml (20mg/ml), 20 mg/ml (1 ml), 80 mg/8 ml (10mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

docetaxel intravenous solution 20 mg/2 ml (10mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

DOCETAXEL INTRAVENOUS SOLUTION 20MG/ML (BRAND). . . . . . . . . . . . . . . . . . . . . 23

docetaxel intravenous solution 80 mg/4 ml (20mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

dofetilide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45donepezil oral tablet. . . . . . . . . . . . . . . . . . . . 32donepezil oral tablet,disintegrating. . . . . . . . 32dopamine in 5 % dextrose intravenous solution200 mg/250 ml (800 mcg/ml), 400 mg/250 ml(1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml),800 mg/500 ml (1,600 mcg/ml). . . . . . . . . . 52

dopamine in 5 % dextrose intravenous solution800 mg/250 ml (3,200 mcg/ml). . . . . . . . . . 52

dopamine intravenous solution 200 mg/5 ml (40mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml(160 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 52

dopamine intravenous solution 400 mg/10 ml(40 mg/ml), 400 mg/5 ml (80 mg/ml). . . . . . 52

DORIPENEM INTRAVENOUS RECON SOLN250 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

DORIPENEM INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

dorzolamide. . . . . . . . . . . . . . . . . . . . . . . . . . 87dorzolamide-timolol. . . . . . . . . . . . . . . . . . . . 87doxazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47doxepin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 41doxepin topical. . . . . . . . . . . . . . . . . . . . . . . . 54doxercalciferol intravenous. . . . . . . . . . . . . . 67doxercalciferol oral. . . . . . . . . . . . . . . . . . . . . 67

doxorubicin intravenous recon soln 10 mg. . 23doxorubicin intravenous recon soln 50 mg. . 23doxorubicin intravenous solution 10 mg/5 ml, 2mg/ml, 20 mg/10 ml. . . . . . . . . . . . . . . . . . . 23

doxorubicin intravenous solution 50 mg/25 ml 23doxorubicin, peg-liposomal. . . . . . . . . . . . . . 23doxy-100. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19doxycycline hyclate oral capsule. . . . . . . . . . 19doxycycline hyclate oral tablet 100 mg, 150 mg,20 mg, 75 mg. . . . . . . . . . . . . . . . . . . . . . . . 19

doxycycline hyclate oral tablet 50 mg. . . . . . 19doxycycline hyclate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

doxycycline monohydrate oral capsule. . . . . 19doxycycline monohydrate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 19

doxycycline monohydrate oral tablet. . . . . . . 19dronabinol. . . . . . . . . . . . . . . . . . . . . . . . . . . 70droperidol injection solution. . . . . . . . . . . . . . 70drospirenone-e.estradiol-lm.fa. . . . . . . . . . . . 83drospirenone-ethinyl estradiol. . . . . . . . . . . . 83DULERA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90duloxetine oral capsule,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

DUPIXENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 54duramorph (pf) injection solution 0.5 mg/ml. . 35duramorph (pf) injection solution 1 mg/ml. . . 35DUROLANE. . . . . . . . . . . . . . . . . . . . . . . . . . 38dutasteride. . . . . . . . . . . . . . . . . . . . . . . . . . . 92dutasteride-tamsulosin oral capsule, ermultiphase 24 hr. . . . . . . . . . . . . . . . . . . . . . 92

DYSPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Ee.e.s. 400 oral tablet. . . . . . . . . . . . . . . . . . . 13econazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57EDURANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9efavirenz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9effer-k oral tablet, effervescent 25 meq. . . . . 93electrolyte-48 in d5w. . . . . . . . . . . . . . . . . . . 97ELELYSO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67eletriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ELIGARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

109

ELIGARD (3 MONTH). . . . . . . . . . . . . . . . . . 2ELIGARD (4 MONTH). . . . . . . . . . . . . . . . . . 2ELIGARD (6 MONTH). . . . . . . . . . . . . . . . . . 2elinest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8eliphos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ELIQUIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5ELITEK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2ELLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ELMIRON. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9EMCYT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2EMEND (FOSAPREPITANT). . . . . . . . . . . . . 7EMEND ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 7

emoquette. . . . . . . . . . . . . . . . . . . . . . . . . . . 8EMPLICITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 2EMSAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4EMTRIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . EMVERM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1enalapril maleate. . . . . . . . . . . . . . . . . . . . . . 4enalapril-hydrochlorothiazide. . . . . . . . . . . . . 4enalaprilat intravenous solution. . . . . . . . . . . 4ENBREL MINI. . . . . . . . . . . . . . . . . . . . . . . . 7ENBREL SUBCUTANEOUS RECON SOLN. 7ENBREL SUBCUTANEOUS SYRINGE. . . . . 7ENBREL SURECLICK. . . . . . . . . . . . . . . . . . 7endocet oral tablet 10-325 mg, 2.5-325 mg,5-325 mg, 7.5-325 mg. . . . . . . . . . . . . . . . . 3

ENGERIX-B (PF). . . . . . . . . . . . . . . . . . . . . . 7ENGERIX-B PEDIATRIC (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 7

enoxaparin subcutaneous solution. . . . . . . . 5enoxaparin subcutaneous syringe 100 mg/ml,150 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 5

enoxaparin subcutaneous syringe 120 mg/0.8ml, 80 mg/0.8 ml. . . . . . . . . . . . . . . . . . . . . . 5

enoxaparin subcutaneous syringe 30 mg/0.3ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5



enpresse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8enskyce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

33333013330

0331957779999

56

60

0

0

0

0

033

entacapone. . . . . . . . . . . . . . . . . . . . . . . . . . 31ecavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9TRESTO. . . . . . . . . . . . . . . . . . . . . . . . . . 53TYVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70lose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

VARSUS XR. . . . . . . . . . . . . . . . . . . . . . . 23CLUSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9nastine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86INEPHRINE INJECTION AUTO-INJECTOR5 MG/0.15 ML, 0.3 MG/0.3 ML

DRENACLICK). . . . . . . . . . . . . . . . . . . . . 88INEPHRINE INJECTION AUTO-INJECTOR5 MG/0.3 ML, 0.3 MG/0.3 ML (EPIPEN). 88

IPEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88IPEN 2-PAK. . . . . . . . . . . . . . . . . . . . . . . 89IPEN JR. . . . . . . . . . . . . . . . . . . . . . . . . . 89IPEN JR 2-PAK. . . . . . . . . . . . . . . . . . . . . 89rubicin intravenous solution 200 mg/100. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23rubicin intravenous solution 50 mg/25 ml. 23tol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29IVIR HBV ORAL SOLUTION. . . . . . . . . . . . 9erenone. . . . . . . . . . . . . . . . . . . . . . . . . . . 47prostenol (glycine). . . . . . . . . . . . . . . . . . 47osartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 47BITUX INTRAVENOUS SOLUTION 100

/50 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 23BITUX INTRAVENOUS SOLUTION 200

/100 ML. . . . . . . . . . . . . . . . . . . . . . . . . 23oloid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41otamine-caffeine. . . . . . . . . . . . . . . . . . . . 31IVEDGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 23LEADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 23n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81WINAZE. . . . . . . . . . . . . . . . . . . . . . . . . . 23 pads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55-tab oral tablet,delayed release (dr/ec) 250, 333 mg. . . . . . . . . . . . . . . . . . . . . . . . . 13

Y-TAB ORAL TABLET,DELAYED RELEASER/EC) 500 MG. . . . . . . . . . . . . . . . . . . . . 13gel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55throcin (as stearate) oral tablet 250 mg. . 13YTHROCIN INTRAVENOUS RECON SOLN0 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

entENENenuENEPepiEP0.1(A

EP0.1

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erythromycin ethylsuccinate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 1

erythromycin ethylsuccinate oral tablet. . . . . 1erythromycin ophthalmic (eye). . . . . . . . . . . . 8erythromycin oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 1

erythromycin oral tablet. . . . . . . . . . . . . . . . . 1erythromycin with ethanol. . . . . . . . . . . . . . . 5erythromycin-benzoyl peroxide. . . . . . . . . . . 5ESBRIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9escitalopram oxalate oral solution. . . . . . . . . 4escitalopram oxalate oral tablet. . . . . . . . . . . 4esmolol intravenous solution. . . . . . . . . . . . . 4esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 20 mg. . . . . . . . . . . . . . . . . . 7

esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 40 mg. . . . . . . . . . . . . . . . . . 7

esomeprazole sodium intravenous recon soln20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

esomeprazole sodium intravenous recon soln40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8estazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4ESTRACE VAGINAL. . . . . . . . . . . . . . . . . . . 8estradiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8estradiol valerate intramuscular oil 20 mg/ml, 40mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

estradiol-norethindrone acet. . . . . . . . . . . . . 8estropipate. . . . . . . . . . . . . . . . . . . . . . . . . . . 8eszopiclone. . . . . . . . . . . . . . . . . . . . . . . . . . 4ethacrynate sodium. . . . . . . . . . . . . . . . . . . . 4ethacrynic acid. . . . . . . . . . . . . . . . . . . . . . . . 4ethambutol. . . . . . . . . . . . . . . . . . . . . . . . . . . 1ethosuximide. . . . . . . . . . . . . . . . . . . . . . . . . 2ethynodiol diac-eth estradiol. . . . . . . . . . . . . 8etidronate disodium. . . . . . . . . . . . . . . . . . . . 6etodolac oral capsule. . . . . . . . . . . . . . . . . . . 3etodolac oral tablet. . . . . . . . . . . . . . . . . . . . 3etodolac oral tablet extended release 24 hr. . 3ETOPOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 2etoposide intravenous. . . . . . . . . . . . . . . . . . 2etoposide oral. . . . . . . . . . . . . . . . . . . . . . . . 2EUFLEXXA. . . . . . . . . . . . . . . . . . . . . . . . . . 3

335

34550117

3

3

3

33111

11117759308883338

EVOTAZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9exemestane. . . . . . . . . . . . . . . . . . . . . . . . . . 23EXJADE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60ezetimibe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ezetimibe-simvastatin. . . . . . . . . . . . . . . . . . 51

FFABIOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55FABRAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 67falmina (28). . . . . . . . . . . . . . . . . . . . . . . . . . 83famciclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9famotidine (pf). . . . . . . . . . . . . . . . . . . . . . . . 73famotidine (pf)-nacl (iso-os). . . . . . . . . . . . . 73famotidine intravenous solution. . . . . . . . . . . 73famotidine oral suspension. . . . . . . . . . . . . . 73famotidine oral tablet 20 mg, 40 mg. . . . . . . 73FANAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41FARESTON. . . . . . . . . . . . . . . . . . . . . . . . . . 23FARXIGA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65FARYDAK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23FASENRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 90FASLODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 23fayosim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83FAZACLO ORAL TABLET,DISINTEGRATING150 MG, 200 MG. . . . . . . . . . . . . . . . . . . . . 41

felbamate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29felodipine oral tablet extended release 24 hr. 47femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83fenofibrate micronized. . . . . . . . . . . . . . . . . . 51fenofibrate nanocrystallized. . . . . . . . . . . . . . 51FENOFIBRATE ORAL CAPSULE (BRAND). 51fenofibrate oral tablet. . . . . . . . . . . . . . . . . . . 51fenofibric acid. . . . . . . . . . . . . . . . . . . . . . . . . 51fenofibric acid (choline) oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 51

fenoprofen oral tablet. . . . . . . . . . . . . . . . . . . 38fentanyl citrate (pf) injection. . . . . . . . . . . . . . 35fentanyl citrate (pf) intravenous syringe 100mcg/2 ml (50 mcg/ml). . . . . . . . . . . . . . . . . . 35

fentanyl citrate buccal lozenge on a handle. . 35fentanyl transdermal patch. . . . . . . . . . . . . . 35FERRIPROX ORAL SOLUTION. . . . . . . . . . 60

111

FERRIPROX ORAL TABLET. . . . . . . . . . . . . 60FETZIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41finasteride oral tablet 5 mg. . . . . . . . . . . . . . 92FIRAZYR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90FIRMAGON KIT W DILUENT SYRINGE. . . . 23flavoxate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92flecainide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45FLOVENT DISKUS. . . . . . . . . . . . . . . . . . . . 90FLOVENT HFA AEROSOL INHALER 110MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 90

FLOVENT HFA AEROSOL INHALER 220MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 90

FLOVENT HFA AEROSOL INHALER 44MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 90

floxin otic (ear) drops. . . . . . . . . . . . . . . . . . . 63floxuridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23FLUAD 2017-2018 (65 YR UP)(PF). . . . . . . 76FLUARIX QUAD 2017-2018 (PF). . . . . . . . . 76FLUBLOK 2017-2018 (PF). . . . . . . . . . . . . . 76FLUBLOK QUAD 2017-2018 (PF). . . . . . . . . 76FLUCELVAX QUAD 2017-2018. . . . . . . . . . . 76FLUCELVAX QUAD 2017-2018 (PF). . . . . . . 76fluconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8fluconazole in dextrose(iso-o). . . . . . . . . . . . . 8fluconazole in nacl (iso-osm) intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . . 8

fluconazole in nacl (iso-osm) intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . . 8

flucytosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8fludarabine intravenous recon soln. . . . . . . . 23fludarabine intravenous solution. . . . . . . . . . 23fludrocortisone. . . . . . . . . . . . . . . . . . . . . . . . 63FLULAVAL QUAD 2017-2018. . . . . . . . . . . . 76FLULAVAL QUAD 2017-2018 (PF). . . . . . . . 76flumazenil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41FLUMIST QUAD 2017-2018. . . . . . . . . . . . . 76flunisolide nasal spray,non-aerosol 25 mcg(0.025 %). . . . . . . . . . . . . . . . . . . . . . . . . . . 90

fluocinolone. . . . . . . . . . . . . . . . . . . . . . . . . . 58fluocinolone acetonide oil. . . . . . . . . . . . . . . 63fluocinolone and shower cap. . . . . . . . . . . . . 58fluocinonide. . . . . . . . . . . . . . . . . . . . . . . . . . 58fluocinonide-e. . . . . . . . . . . . . . . . . . . . . . . . 58

fluocinonide-emollient. . . . . . . . . . . . . . . . . . 58uoride (sodium) oral drops. . . . . . . . . . . . . . 98uoride (sodium) oral tablet. . . . . . . . . . . . . . 98uoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodiumfluorid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98uoritab oral tablet,chewable 0.5 mg (1.1 mgsodium fluorid). . . . . . . . . . . . . . . . . . . . . . . 98uorometholone. . . . . . . . . . . . . . . . . . . . . . . 87uorouracil intravenous solution 1 gram/20 ml,2.5 gram/50 ml, 500 mg/10 ml. . . . . . . . . . . 24uorouracil intravenous solution 5 gram/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24LUOROURACIL TOPICAL CREAM 0.5 %(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 54uorouracil topical cream 5 %. . . . . . . . . . . . 54uorouracil topical solution. . . . . . . . . . . . . . 54uoxetine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41uphenazine decanoate. . . . . . . . . . . . . . . . . 41uphenazine hcl. . . . . . . . . . . . . . . . . . . . . . . 41urandrenolide. . . . . . . . . . . . . . . . . . . . . . . . 58urazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . 41urbiprofen. . . . . . . . . . . . . . . . . . . . . . . . . . . 38urbiprofen sodium. . . . . . . . . . . . . . . . . . . . 87utamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24uticasone nasal. . . . . . . . . . . . . . . . . . . . . . 90uticasone topical. . . . . . . . . . . . . . . . . . . . . 58uvastatin oral capsule 20 mg. . . . . . . . . . . . 51uvastatin oral capsule 40 mg. . . . . . . . . . . . 51uvastatin oral tablet extended release 24 hr 51LUVIRIN 2017-2018. . . . . . . . . . . . . . . . . . 76LUVIRIN 2017-2018 (PF). . . . . . . . . . . . . . 76uvoxamine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41uvoxamine oral tablet. . . . . . . . . . . . . . . . . . 41LUZONE HIGH-DOSE 2017-18 (PF). . . . . 76LUZONE INTRADERM QUAD 2017-18. . . 76LUZONE QUAD 2017-2018. . . . . . . . . . . . 76LUZONE QUAD 2017-2018 (PF)INTRAMUSCULAR SUSPENSION. . . . . . . 76LUZONE QUAD 2017-2018 (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 76LUZONE QUAD PEDI 2017-18 (PF). . . . . . 76ML S.O.P.. . . . . . . . . . . . . . . . . . . . . . . . . . . 87

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FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML). . . . . . . . . . . . . . . . . . . . . . . . . . . 24

FOLOTYN INTRAVENOUS SOLUTION 40MG/2 ML (20 MG/ML). . . . . . . . . . . . . . . . . 24

fomepizole. . . . . . . . . . . . . . . . . . . . . . . . . . . 76fondaparinux subcutaneous syringe 10 mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

fondaparinux subcutaneous syringe 2.5 mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

fondaparinux subcutaneous syringe 5 mg/0.4ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

fondaparinux subcutaneous syringe 7.5 mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

FORFIVO XL. . . . . . . . . . . . . . . . . . . . . . . . . 41FORTEO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79fosamprenavir. . . . . . . . . . . . . . . . . . . . . . . . . . 9fosinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47fosinopril-hydrochlorothiazide. . . . . . . . . . . . 47fosphenytoin injection solution 100 mg pe/2ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

fosphenytoin injection solution 500 mg pe/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

FREAMINE HBC 6.9 %. . . . . . . . . . . . . . . . . 97freamine iii 10 %. . . . . . . . . . . . . . . . . . . . . . 97frovatriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 31furosemide injection. . . . . . . . . . . . . . . . . . . . 47furosemide oral solution 10 mg/ml, 40 mg/5 ml(8 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . 47

furosemide oral tablet. . . . . . . . . . . . . . . . . . 47FUZEON SUBCUTANEOUS RECON SOLN. 9fyavolv. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81FYCOMPA ORAL SUSPENSION. . . . . . . . . 29FYCOMPA ORAL TABLET. . . . . . . . . . . . . . . 29

Ggabapentin oral capsule. . . . . . . . . . . . . . . . . 29gabapentin oral solution 250 mg/5 ml. . . . . . 29gabapentin oral solution 250 mg/5 ml (5 ml), 300mg/6 ml (6 ml). . . . . . . . . . . . . . . . . . . . . . . 29

gabapentin oral tablet 600 mg, 800 mg. . . . . 29GABITRIL ORAL TABLET 12 MG, 16 MG. . . 29galantamine oral capsule,ext rel. pellets 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

galantamine oral solution. . . . . . . . . . . . . . . . 32

galantamine oral tablet. . . . . . . . . . . . . . . . . 32AMASTAN S/D. . . . . . . . . . . . . . . . . . . . . . 76AMMAGARD LIQUID. . . . . . . . . . . . . . . . . 76AMMAGARD S-D (IGA < 1 MCG/ML). . . . . 76AMUNEX-C INJECTION SOLUTION 1

GRAM/10 ML (10 %). . . . . . . . . . . . . . . . . . 77AMUNEX-C INJECTION SOLUTION 10

GRAM/100 ML (10 %), 2.5 GRAM/25 ML(10 %), 20 GRAM/200 ML (10 %), 40GRAM/400 ML (10 %), 5 GRAM/50 ML (10%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77anciclovir sodium intravenous recon soln. . . 9anciclovir sodium intravenous solution. . . . . 9ARDASIL 9 (PF). . . . . . . . . . . . . . . . . . . . . 77atifloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 85ATTEX 30-VIAL. . . . . . . . . . . . . . . . . . . . . . 70ATTEX ONE-VIAL. . . . . . . . . . . . . . . . . . . . 70AUZE PADS 2 X 2. . . . . . . . . . . . . . . . . . . 65avilyte-c. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70avilyte-g. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70avilyte-n. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70AZYVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EL-ONE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ELSYN-3. . . . . . . . . . . . . . . . . . . . . . . . . . . 38emcitabine intravenous recon soln 1 gram. 24emcitabine intravenous recon soln 2 gram. 24emcitabine intravenous recon soln 200 mg. 24emcitabine intravenous solution 1 gram/26.3ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml). 24emcitabine intravenous solution 2 gram/52.6ml (38 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . 24emfibrozil. . . . . . . . . . . . . . . . . . . . . . . . . . . 51enerlac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70engraf oral capsule 100 mg, 25 mg. . . . . . . 24engraf oral solution. . . . . . . . . . . . . . . . . . . 24entak ophthalmic (eye) ointment. . . . . . . . . 85entamicin in nacl (iso-osm) intravenouspiggyback 100 mg/100 ml, 60 mg/50 ml, 80mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 15entamicin in nacl (iso-osm) intravenouspiggyback 70 mg/50 ml, 90 mg/100 ml. . . . 15entamicin in nacl (iso-osm) intravenouspiggyback 80 mg/100 ml. . . . . . . . . . . . . . . 15entamicin injection solution 20 mg/2 ml. . . . 15

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gentamicin injection solution 40 mg/ml. . . . . 15gentamicin ophthalmic (eye) drops. . . . . . . . 85gentamicin sulfate (ped) (pf). . . . . . . . . . . . . 15gentamicin sulfate (pf) intravenous solution 100mg/10 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 15

gentamicin topical. . . . . . . . . . . . . . . . . . . . . 57GENVISC 850. . . . . . . . . . . . . . . . . . . . . . . . 38GENVOYA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9GEODON INTRAMUSCULAR. . . . . . . . . . . . 41gianvi (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 83GILENYA ORAL CAPSULE 0.5 MG. . . . . . . 32GILOTRIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24GLASSIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60glatiramer subcutaneous syringe 20 mg/ml. . 32glatiramer subcutaneous syringe 40 mg/ml. . 32glatopa subcutaneous syringe 20 mg/ml. . . . 32glatopa subcutaneous syringe 40 mg/ml. . . . 32GLEOSTINE. . . . . . . . . . . . . . . . . . . . . . . . . . 24glimepiride. . . . . . . . . . . . . . . . . . . . . . . . . . . 65glipizide oral tablet. . . . . . . . . . . . . . . . . . . . . 65glipizide oral tablet extended release 24hr. . 65glipizide-metformin. . . . . . . . . . . . . . . . . . . . . 65GLUCAGEN HYPOKIT. . . . . . . . . . . . . . . . . 65GLUCAGON EMERGENCY KIT (HUMAN). . 65glyburide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65glyburide micronized. . . . . . . . . . . . . . . . . . . 65glyburide-metformin. . . . . . . . . . . . . . . . . . . . 65glycine urologic. . . . . . . . . . . . . . . . . . . . . . . 93glycine urologic solution. . . . . . . . . . . . . . . . . 93GLYCOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 93glycopyrrolate injection. . . . . . . . . . . . . . . . . 69glycopyrrolate oral tablet 1 mg, 2 mg. . . . . . . 69glydo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56GLYXAMBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 65granisetron (pf) intravenous solution 1 mg/ml (1ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

granisetron (pf) intravenous solution 100mcg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

granisetron hcl intravenous. . . . . . . . . . . . . . 70granisetron hcl oral. . . . . . . . . . . . . . . . . . . . 70GRANIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74GRASTEK. . . . . . . . . . . . . . . . . . . . . . . . . . . 77

griseofulvin microsize. . . . . . . . . . . . . . . . . . . 8griseofulvin ultramicrosize. . . . . . . . . . . . . . . . 8guanfacine oral tablet. . . . . . . . . . . . . . . . . . 47guanfacine oral tablet extended release 24 hr 42guanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42GYNAZOLE-1. . . . . . . . . . . . . . . . . . . . . . . . 82

HHALAVEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24halobetasol propionate. . . . . . . . . . . . . . . . . 58haloperidol. . . . . . . . . . . . . . . . . . . . . . . . . . . 42haloperidol decanoate. . . . . . . . . . . . . . . . . . 42haloperidol lactate injection. . . . . . . . . . . . . . 42haloperidol lactate intramuscular. . . . . . . . . . 42haloperidol lactate oral. . . . . . . . . . . . . . . . . . 42HARVONI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9HAVRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 77

HAVRIX (PF) INTRAMUSCULAR SYRINGE1,440 ELISA UNIT/ML. . . . . . . . . . . . . . . . . 77

HAVRIX (PF) INTRAMUSCULAR SYRINGE720 ELISA UNIT/0.5 ML. . . . . . . . . . . . . . . . 77

heather. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81hep flush-10 (pf). . . . . . . . . . . . . . . . . . . . . . . 50heparin (porcine) in 5 % dex intravenousparenteral solution 12,500 unit/250 ml. . . . . 50

heparin (porcine) in 5 % dex intravenousparenteral solution 20,000 unit/500 ml (40unit/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

heparin (porcine) in 5 % dex intravenousparenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml). . . . . . . 50

heparin (porcine) in nacl (pf). . . . . . . . . . . . . 50heparin (porcine) injection cartridge. . . . . . . 50heparin (porcine) injection solution. . . . . . . . 50heparin (porcine) injection syringe 5,000unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

heparin flush(porcine)-0.9nacl. . . . . . . . . . . . 50heparin lock flush. . . . . . . . . . . . . . . . . . . . . . 50heparin lock flush (porcine) intravenoussolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin lockflush(porcine)(pf). . . . . . . . . . . . 51

114

heparin(porcine) in 0.45% nacl intravenousparenteral solution 25,000 unit/250 ml, 25,000unit/500 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin, porcine (pf) injection. . . . . . . . . . . . 51heparin, porcine (pf) intravenous syringe 1unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 51

HEPATAMINE 8%. . . . . . . . . . . . . . . . . . . . . 97HERCEPTIN. . . . . . . . . . . . . . . . . . . . . . . . . 24hetastarch 6 % in 0.9 % nacl. . . . . . . . . . . . . 97HETLIOZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42HEXALEN. . . . . . . . . . . . . . . . . . . . . . . . . . . 24HIBERIX (PF). . . . . . . . . . . . . . . . . . . . . . . . 77HORIZANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 32HUMALOG JUNIOR KWIKPEN U-100. . . . . 65HUMALOG KWIKPEN INSULIN. . . . . . . . . . 65HUMALOG MIX 50-50 INSULN U-100. . . . . 65HUMALOG MIX 50-50 KWIKPEN. . . . . . . . . 65HUMALOG MIX 75-25 KWIKPEN. . . . . . . . . 65HUMALOG MIX 75-25(U-100)INSULN. . . . . 65HUMALOG U-100 INSULIN. . . . . . . . . . . . . . 65HUMATROPE. . . . . . . . . . . . . . . . . . . . . . . . . 74HUMIRA PEDIATRIC CROHN'S START. . . . 79HUMIRA PEN. . . . . . . . . . . . . . . . . . . . . . . . 79HUMIRA PEN CROHN'S-UC-HS START. . . 79HUMIRA PEN PSORIASIS-UVEITIS. . . . . . . 79HUMIRA SUBCUTANEOUS SYRINGE KIT 10MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.4 ML, 40MG/0.4 ML, 40 MG/0.8 ML. . . . . . . . . . . . . . 79

HUMIRA SUBCUTANEOUS SYRINGE KIT 20MG/0.2 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 80

HUMULIN 70/30 U-100 INSULIN. . . . . . . . . 65HUMULIN 70/30 U-100 KWIKPEN. . . . . . . . 65HUMULIN N NPH INSULIN KWIKPEN. . . . . 65HUMULIN N NPH U-100 INSULIN. . . . . . . . 66HUMULIN R REGULAR U-100 INSULN. . . . 66HUMULIN R U-500 (CONC) INSULIN. . . . . . 66HYALGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 38HYCAMTIN ORAL. . . . . . . . . . . . . . . . . . . . . 24hydralazine injection. . . . . . . . . . . . . . . . . . . 47hydralazine oral. . . . . . . . . . . . . . . . . . . . . . . 47hydrochlorothiazide. . . . . . . . . . . . . . . . . . . . 47

hydrocodone-acetaminophen oral solution-325 mg/15 ml. . . . . . . . . . . . . . . . . . . . . 35rocodone-acetaminophen oral tablet 10-300, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325, 7.5-300 mg, 7.5-325 mg. . . . . . . . . . . . 35rocodone-ibuprofen oral tablet 10-200 mg,00 mg, 7.5-200 mg. . . . . . . . . . . . . . . . . 35rocortisone butyr-emollient. . . . . . . . . . . . 58rocortisone butyrate. . . . . . . . . . . . . . . . . 58rocortisone oral. . . . . . . . . . . . . . . . . . . . 63rocortisone rectal. . . . . . . . . . . . . . . . . . . 70rocortisone topical cream 1 %, 2.5 %. . . 58rocortisone topical cream with perinealplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 70rocortisone topical lotion 2.5 %. . . . . . . . 58rocortisone topical ointment 1 %, 2.5 %. . 58rocortisone valerate. . . . . . . . . . . . . . . . . 58rocortisone-acetic acid. . . . . . . . . . . . . . . 63rocortisone-min oil-wht pet. . . . . . . . . . . . 58rocortisone-pramoxine rectal cream 1-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70romorphone (pf). . . . . . . . . . . . . . . . . . . . 35romorphone injection solution 1 mg/ml. . 35romorphone injection solution 2 mg/ml, 4/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35romorphone injection syringe 1 mg/ml, 2/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35romorphone injection syringe 4 mg/ml. . . 35romorphone oral liquid. . . . . . . . . . . . . . . 35romorphone oral tablet. . . . . . . . . . . . . . . 35romorphone oral tablet extended release 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35roxychloroquine. . . . . . . . . . . . . . . . . . . . 15roxyprogesterone caproate. . . . . . . . . . . 81roxyurea. . . . . . . . . . . . . . . . . . . . . . . . . . 24roxyzine hcl intramuscular. . . . . . . . . . . . 89roxyzine hcl oral solution 10 mg/5 ml. . . . 89roxyzine hcl oral tablet. . . . . . . . . . . . . . . 89roxyzine pamoate. . . . . . . . . . . . . . . . . . . 89MOVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38PER-SAL. . . . . . . . . . . . . . . . . . . . . . . . . 90PERRAB (PF). . . . . . . . . . . . . . . . . . . . . . 77PERRAB S/D (PF). . . . . . . . . . . . . . . . . . 77

7.5hydmgmg

hyd5-2

hydhydhydhydhydhydap

hydhydhydhydhydhyd%.

hydhydhydmg

hydmg

hydhydhydhydhr.

hydhydhydhydhydhydhydHYHYHYHY

115

Iibandronate intravenous. . . . . . . . . . . . . . . . 7ibandronate oral. . . . . . . . . . . . . . . . . . . . . . . 7IBRANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2ibu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3ibuprofen lysine (pf). . . . . . . . . . . . . . . . . . . . 3ibuprofen oral suspension. . . . . . . . . . . . . . . 3ibuprofen oral tablet 400 mg, 600 mg, 800mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ibuprofen-oxycodone. . . . . . . . . . . . . . . . . . . 3ibutilide fumarate. . . . . . . . . . . . . . . . . . . . . . 4ICLUSIG ORAL TABLET 15 MG. . . . . . . . . . 2ICLUSIG ORAL TABLET 45 MG. . . . . . . . . . 2idarubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2IDHIFA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2ifosfamide intravenous recon soln 1 gram. . . 2ifosfamide intravenous recon soln 3 gram. . . 2ifosfamide intravenous solution. . . . . . . . . . . 2ILARIS (PF) SUBCUTANEOUS SOLUTION. 7imatinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2IMBRUVICA. . . . . . . . . . . . . . . . . . . . . . . . . . 2IMFINZI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2imipenem-cilastatin. . . . . . . . . . . . . . . . . . . . 1imipramine hcl. . . . . . . . . . . . . . . . . . . . . . . . 4imipramine pamoate. . . . . . . . . . . . . . . . . . . 4imiquimod. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5IMOVAX RABIES VACCINE (PF). . . . . . . . . 7IMPAVIDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 1INCRELEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 6INCRUSE ELLIPTA. . . . . . . . . . . . . . . . . . . . 9indapamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 4indomethacin oral capsule. . . . . . . . . . . . . . . 3indomethacin oral capsule, extended release 3indomethacin sodium. . . . . . . . . . . . . . . . . . . 3INFANRIX (DTAP) (PF). . . . . . . . . . . . . . . . . 7INFLECTRA. . . . . . . . . . . . . . . . . . . . . . . . . . 7INGREZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 3INLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2INPEN (FOR HUMALOG). . . . . . . . . . . . . . . 6INSULIN PEN NEEDLE. . . . . . . . . . . . . . . . . 6INSULIN SYRINGE (DISP) U-100 0.3 ML. . . 6

994888

855444444444445224750078887024666

INSULIN SYRINGE (DISP) U-100 1 ML. . . . 66INSULIN SYRINGE (DISP) U-100 1/2 ML. . . 66INTELENCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 9intralipid intravenous emulsion 20 %. . . . . . . 97INTRALIPID INTRAVENOUS EMULSION 30%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

INTRON A INJECTION. . . . . . . . . . . . . . . . . 74introvale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83INVANZ INJECTION. . . . . . . . . . . . . . . . . . . 15INVANZ INTRAVENOUS. . . . . . . . . . . . . . . . 15INVEGA SUSTENNA. . . . . . . . . . . . . . . . . . . 42INVEGA TRINZA. . . . . . . . . . . . . . . . . . . . . . 42INVIRASE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9INVOKAMET. . . . . . . . . . . . . . . . . . . . . . . . . 66INVOKAMET XR. . . . . . . . . . . . . . . . . . . . . . 66INVOKANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 66IPOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77ipratropium bromide inhalation. . . . . . . . . . . 90ipratropium bromide nasal spray,non-aerosol0.03 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

ipratropium bromide nasal spray,non-aerosol 42mcg (0.06 %). . . . . . . . . . . . . . . . . . . . . . . . 62

ipratropium-albuterol. . . . . . . . . . . . . . . . . . . 90irbesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47irbesartan-hydrochlorothiazide. . . . . . . . . . . 47IRESSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24irinotecan intravenous solution 100 mg/5 ml. 24irinotecan intravenous solution 40 mg/2 ml. . 24irinotecan intravenous solution 500 mg/25 ml 24ISENTRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . 9ISENTRESS HD. . . . . . . . . . . . . . . . . . . . . . . 9isibloom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83isoniazid injection. . . . . . . . . . . . . . . . . . . . . . 15isoniazid oral. . . . . . . . . . . . . . . . . . . . . . . . . 15isoproterenol hcl. . . . . . . . . . . . . . . . . . . . . . 53isosorbide dinitrate oral tablet. . . . . . . . . . . . 53isosorbide dinitrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

isosorbide mononitrate oral tablet. . . . . . . . . 53isosorbide mononitrate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 53

isotretinoin. . . . . . . . . . . . . . . . . . . . . . . . . . . 55isradipine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

116

ISTODAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25itraconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 8ivermectin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15IXEMPRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25IXIARO (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 77

JJADENU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60JADENU SPRINKLE. . . . . . . . . . . . . . . . . . . 60JAKAFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25jantoven. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51JANUMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66JANUMET XR. . . . . . . . . . . . . . . . . . . . . . . . 66JANUVIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66JARDIANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 66jencycla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81jevantique lo. . . . . . . . . . . . . . . . . . . . . . . . . . 81JEVTANA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25jinteli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81jolessa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83jolivette. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81juleber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83JULUCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9junel 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 83junel 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . 83junel fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 83junel fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . 83junel fe 24. . . . . . . . . . . . . . . . . . . . . . . . . . . 83JUXTAPID. . . . . . . . . . . . . . . . . . . . . . . . . . . 51JYNARQUE. . . . . . . . . . . . . . . . . . . . . . . . . . 67

Kk-effervescent. . . . . . . . . . . . . . . . . . . . . . . . 93k-tab oral tablet extended release 8 meq. . . 93KADCYLA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25kaitlib fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83KALETRA ORAL TABLET. . . . . . . . . . . . . . . . 9KALYDECO. . . . . . . . . . . . . . . . . . . . . . . . . . 90KANUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67kariva (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 83kelnor 1-50. . . . . . . . . . . . . . . . . . . . . . . . . . . 83kelnor 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 83

KEPIVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 21ketoconazole oral. . . . . . . . . . . . . . . . . . . . . . . 8ketoconazole topical. . . . . . . . . . . . . . . . . . . 57ketoprofen oral capsule. . . . . . . . . . . . . . . . . 38ketoprofen oral capsule,ext rel. pellets 24 hr 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

ketorolac injection cartridge 15 mg/ml. . . . . . 38ketorolac injection cartridge 30 mg/ml. . . . . . 38ketorolac injection solution 15 mg/ml, 30 mg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

ketorolac injection syringe. . . . . . . . . . . . . . . 38ketorolac intramuscular cartridge. . . . . . . . . . 38ketorolac intramuscular solution. . . . . . . . . . 39ketorolac intramuscular syringe. . . . . . . . . . . 39ketorolac ophthalmic (eye). . . . . . . . . . . . . . . 87ketorolac oral. . . . . . . . . . . . . . . . . . . . . . . . . 39KEVEYIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32KEVZARA SUBCUTANEOUS SYRINGE. . . 80KEYTRUDA INTRAVENOUS SOLUTION. . . 25KHEDEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . 42kimidess (28). . . . . . . . . . . . . . . . . . . . . . . . . 83KINERET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80KINRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 77

KINRIX (PF) INTRAMUSCULAR SYRINGE. 77kionex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60kionex (with sorbitol). . . . . . . . . . . . . . . . . . . 60KISQALI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25KISQALI FEMARA CO-PACK. . . . . . . . . . . . 25klor-con 10 oral tablet extended release. . . . 93klor-con 20 meq packet. . . . . . . . . . . . . . . . . 93klor-con 8 oral tablet extended release. . . . . 93klor-con m10 oral tablet,er particles/crystals. 93klor-con m15 oral tablet,er particles/crystals. 93klor-con m20 oral tablet,er particles/crystals. 93klor-con sprinkle oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

klor-con/ef. . . . . . . . . . . . . . . . . . . . . . . . . . . 93KOMBIGLYZE XR. . . . . . . . . . . . . . . . . . . . . 66KORLYM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67KRYSTEXXA. . . . . . . . . . . . . . . . . . . . . . . . . 78kurvelo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83KUVAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

117

KYNAMRO. . . . . . . . . . . . . . . . . . . . . . . . . . . 51KYPROLIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ll norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),0.15 mg-30 mcg (84)/10 mcg (7). . . . . . . . . 83

l norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.15 mg-20 mcg/ 0.15 mg-25mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

labetalol intravenous solution. . . . . . . . . . . . 47labetalol intravenous syringe 20 mg/4 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

labetalol oral. . . . . . . . . . . . . . . . . . . . . . . . . 47LACRISERT. . . . . . . . . . . . . . . . . . . . . . . . . . 86lactated ringers intravenous. . . . . . . . . . . . . . 93lactated ringers irrigation. . . . . . . . . . . . . . . . 59lactulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70lamivudine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9lamivudine-zidovudine. . . . . . . . . . . . . . . . . . 10lamotrigine oral tablet. . . . . . . . . . . . . . . . . . 29lamotrigine oral tablet disintegrating, dose pk 29lamotrigine oral tablet extended release 24hr 29lamotrigine oral tablet, chewable dispersible. 29lamotrigine oral tablet,disintegrating. . . . . . . 29lamotrigine oral tablets,dose pack. . . . . . . . . 29lansoprazole oral capsule,delayed release(dr/ec) 15 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 73

lansoprazole oral capsule,delayed release(dr/ec) 30 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 73

lansoprazole oral tablet,disintegrat, delay rel 73lanthanum oral tablet,chewable. . . . . . . . . . . 60LANTUS SOLOSTAR U-100 INSULIN. . . . . 66LANTUS U-100 INSULIN. . . . . . . . . . . . . . . . 66larin 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 83larin 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . . 83larin 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83larin fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 83larin fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . . 83larissia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83LARTRUVO. . . . . . . . . . . . . . . . . . . . . . . . . . 25latanoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . 87LATUDA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

layolis fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83leena 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83leflunomide. . . . . . . . . . . . . . . . . . . . . . . . . . . 80LEMTRADA. . . . . . . . . . . . . . . . . . . . . . . . . . 32LENVIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25lessina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83LETAIRIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90letrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25leucovorin calcium injection recon soln 100 mg,350 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

leucovorin calcium injection recon soln 200 mg,50 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

leucovorin calcium injection recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

leucovorin calcium oral. . . . . . . . . . . . . . . . . 21LEUKERAN. . . . . . . . . . . . . . . . . . . . . . . . . . 25LEUKINE INJECTION RECON SOLN. . . . . . 74leuprolide subcutaneous kit. . . . . . . . . . . . . . 25levalbuterol hcl. . . . . . . . . . . . . . . . . . . . . . . . 90levetiracetam in nacl (iso-os) intravenouspiggyback 1,000 mg/100 ml, 1,500 mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml. . . . . . . . . . . . . . 29

levetiracetam intravenous. . . . . . . . . . . . . . . 29levetiracetam oral solution 100 mg/ml. . . . . . 29levetiracetam oral solution 500 mg/5 ml (5ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

levetiracetam oral tablet. . . . . . . . . . . . . . . . . 29levetiracetam oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

levobunolol ophthalmic (eye) drops 0.5 %. . . 86levocarnitine (with sugar). . . . . . . . . . . . . . . . 60levocarnitine oral tablet. . . . . . . . . . . . . . . . . 60levocetirizine oral solution. . . . . . . . . . . . . . . 89levocetirizine oral tablet. . . . . . . . . . . . . . . . . 89levofloxacin in d5w intravenous piggyback 250mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 18

levofloxacin in d5w intravenous piggyback 500mg/100 ml, 750 mg/150 ml. . . . . . . . . . . . . . 18

levofloxacin intravenous. . . . . . . . . . . . . . . . 18levofloxacin ophthalmic (eye). . . . . . . . . . . . 85levofloxacin oral. . . . . . . . . . . . . . . . . . . . . . . 18

118

LEVOLEUCOVORIN INTRAVENOUS RECONSOLN 175 MG (BRAND). . . . . . . . . . . . . . . 21

levoleucovorin intravenous recon soln 50 mg 21levoleucovorin intravenous solution. . . . . . . . 21levonest (28). . . . . . . . . . . . . . . . . . . . . . . . . 83levonorg-eth estrad triphasic. . . . . . . . . . . . . 83levonorgestrel-ethinyl estrad. . . . . . . . . . . . . 83levora-28. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83levorphanol tartrate. . . . . . . . . . . . . . . . . . . . 35levothyroxine intravenous recon soln 200 mcg,500 mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

levothyroxine oral. . . . . . . . . . . . . . . . . . . . . . 69levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,137 mcg, 150 mcg, 175 mcg, 200 mcg, 25mcg, 50 mcg, 75 mcg, 88 mcg. . . . . . . . . . . 69

LEXIVA ORAL SUSPENSION. . . . . . . . . . . . 10lidocaine (pf) in d7.5w. . . . . . . . . . . . . . . . . . 45lidocaine (pf) injection solution 10 mg/ml (1 %),20 mg/ml (2 %), 40 mg/ml (4 %). . . . . . . . . 56

lidocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine (pf) injection solution 5 mg/ml (0.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine (pf) intravenous solution. . . . . . . . . 45lidocaine (pf) intravenous syringe. . . . . . . . . 45lidocaine hcl injection solution 10 mg/ml (1 %), 5mg/ml (0.5 %). . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine hcl injection solution 20 mg/ml (2%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine hcl laryngotracheal. . . . . . . . . . . . . 56lidocaine hcl mucous membrane jelly. . . . . . 56lidocaine hcl mucous membrane jelly inapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine hcl mucous membrane solution 4 %(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine in 5 % dextrose (pf) intravenousparenteral solution 4 mg/ml (0.4 %), 8 mg/ml(0.8 %). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

lidocaine topical adhesive patch,medicated. 56lidocaine topical ointment. . . . . . . . . . . . . . . 56lidocaine viscous. . . . . . . . . . . . . . . . . . . . . . 56lidocaine-epinephrine injection solution0.5 %-1:200,000, 1.5 %-1:200,000, 2 %-1:200,000. . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine-epinephrine injection solution-1:100,000, 2 %-1:100,000. . . . . . . . . . 56aine-prilocaine topical cream. . . . . . . . . 56. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83mycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 15ne topical shampoo. . . . . . . . . . . . . . . . 59olid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15olid in dextrose 5%. . . . . . . . . . . . . . . . . 15olid-0.9% sodium chloride. . . . . . . . . . . 15ESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

yronine intravenous. . . . . . . . . . . . . . . . . 69yronine oral. . . . . . . . . . . . . . . . . . . . . . . 69opril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47opril-hydrochlorothiazide. . . . . . . . . . . . . 47m carbonate oral capsule. . . . . . . . . . . . 42m carbonate oral tablet. . . . . . . . . . . . . . 42m carbonate oral tablet extendedase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42m citrate oral solution 8 meq/5 ml. . . . . 42

10 % in 0.9 % sodium chlor. . . . . . . . . . . 60 10 % in 5 % dextrose. . . . . . . . . . . . . . . 61SURF. . . . . . . . . . . . . . . . . . . . . . . . . . . 25ramide oral capsule. . . . . . . . . . . . . . . . . 69avir-ritonavir. . . . . . . . . . . . . . . . . . . . . . 10

eeza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81zepam injection solution. . . . . . . . . . . . . 42zepam injection syringe. . . . . . . . . . . . . . 42zepam intensol. . . . . . . . . . . . . . . . . . . . . 42zepam oral. . . . . . . . . . . . . . . . . . . . . . . . 42et (hydrocodone). . . . . . . . . . . . . . . . . . . 35et hd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35et plus oral tablet 7.5-325 mg. . . . . . . . . 35na (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 83rtan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47rtan-hydrochlorothiazide. . . . . . . . . . . . . 47statin oral tablet 10 mg. . . . . . . . . . . . . . 52statin oral tablet 20 mg, 40 mg. . . . . . . . 52ogestrel (28). . . . . . . . . . . . . . . . . . . . . . 83pine succinate. . . . . . . . . . . . . . . . . . . . . 42nt fluoride oral tablet,chewable 0.25 mg

55 mg sod. fluoride), 0.5 mg (1.1 mg sodiumrid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98ANETA PACK (1 MONTH). . . . . . . . . . . 82

1 %lidoclillowlincolindalinezlinezlinezLINZliothliothlisinlisinlithiulithiulithiurele

lithiulmdlmdLONlopelopinloprloraloraloraloralorclorclorclorylosalosalovalovalow-loxalude(0.fluo

LUP

119

LUPANETA PACK (3 MONTH). . . . . . . . . . . 82LUPRON DEPOT. . . . . . . . . . . . . . . . . . . . . . 25LUPRON DEPOT (3 MONTH). . . . . . . . . . . . 25LUPRON DEPOT (4 MONTH). . . . . . . . . . . . 25LUPRON DEPOT (6 MONTH). . . . . . . . . . . . 25LUPRON DEPOT-PED. . . . . . . . . . . . . . . . . 25LUPRON DEPOT-PED (3 MONTH). . . . . . . 25lutera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 83LUZU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57LYNPARZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25LYRICA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29LYSODREN. . . . . . . . . . . . . . . . . . . . . . . . . . 25lyza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

MM-M-R II (PF). . . . . . . . . . . . . . . . . . . . . . . . . 77mafenide acetate. . . . . . . . . . . . . . . . . . . . . . 57magnesium chloride injection. . . . . . . . . . . . 94magnesium sulfate in water intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 94

magnesium sulfate in water intravenouspiggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

magnesium sulfate in water intravenouspiggyback 4 gram/100 ml (4 %). . . . . . . . . . 94

magnesium sulfate injection solution. . . . . . . 94magnesium sulfate injection syringe. . . . . . . 94MAKENA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81MAKENA (PF). . . . . . . . . . . . . . . . . . . . . . . . 81malathion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59mannitol 20 %. . . . . . . . . . . . . . . . . . . . . . . . 47mannitol 25 % intravenous solution. . . . . . . . 47maprotiline. . . . . . . . . . . . . . . . . . . . . . . . . . . 42marcaine (pf) injection solution 0.75 % (7.5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

marlissa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84MARPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 42MATULANE. . . . . . . . . . . . . . . . . . . . . . . . . . 25matzim la oral tablet extended release 24 hr. 47MAVYRET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10meclizine oral tablet 12.5 mg, 25 mg. . . . . . . 70meclofenamate. . . . . . . . . . . . . . . . . . . . . . . . 39medroxyprogesterone. . . . . . . . . . . . . . . . . . 81

mefenamic acid. . . . . . . . . . . . . . . . . . . . . . . 39efloquine. . . . . . . . . . . . . . . . . . . . . . . . . . . 15egestrol oral suspension 400 mg/10 ml (10

ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25egestrol oral suspension 400 mg/10 ml (40

mg/ml), 625 mg/5 ml. . . . . . . . . . . . . . . . . . 25egestrol oral tablet. . . . . . . . . . . . . . . . . . . 25EKINIST. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25elodetta 24 fe. . . . . . . . . . . . . . . . . . . . . . . 84eloxicam oral suspension. . . . . . . . . . . . . . 39eloxicam oral tablet. . . . . . . . . . . . . . . . . . . 39elphalan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25elphalan hcl. . . . . . . . . . . . . . . . . . . . . . . . . 25emantine oral capsule,sprinkle,er 24hr. . . . 32emantine oral solution. . . . . . . . . . . . . . . . . 33emantine oral tablet. . . . . . . . . . . . . . . . . . 33ENACTRA (PF) INTRAMUSCULAR

SOLUTION. . . . . . . . . . . . . . . . . . . . . . . . . . 77ENVEO A-C-Y-W-135-DIP (PF). . . . . . . . . 77eperidine (pf) injection solution 100 mg/ml, 50

mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35eperidine (pf) injection solution 25 mg/ml. . 35eperidine injection cartridge. . . . . . . . . . . . 36eperidine oral. . . . . . . . . . . . . . . . . . . . . . . 36eprobamate. . . . . . . . . . . . . . . . . . . . . . . . . 33ercaptopurine. . . . . . . . . . . . . . . . . . . . . . . 25eropenem. . . . . . . . . . . . . . . . . . . . . . . . . . 15esalamine oral tablet,delayed release (dr/ec)

1.2 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71esalamine rectal. . . . . . . . . . . . . . . . . . . . . 71esna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ESNEX ORAL. . . . . . . . . . . . . . . . . . . . . . . 21ESTINON ORAL SYRUP. . . . . . . . . . . . . . 33etadate er oral tablet extended release. . . 42etaproterenol. . . . . . . . . . . . . . . . . . . . . . . . 90etaxall. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33etaxalone. . . . . . . . . . . . . . . . . . . . . . . . . . . 33etformin oral tablet. . . . . . . . . . . . . . . . . . . 66etformin oral tablet extended release (osm)

24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66etformin oral tablet extended release 24 hr 66etformin oral tablet,er gast.retention 24 hr. 66ethadone injection solution. . . . . . . . . . . . . 36

mm

m

mMmmmmmmmmM

Mm

mmmmmmm

mmMMmmmmmm

mmm

120

methadone intensol. . . . . . . . . . . . . . . . . . . . 36methadone oral concentrate. . . . . . . . . . . . . 36methadone oral solution. . . . . . . . . . . . . . . . 36methadone oral tablet. . . . . . . . . . . . . . . . . . 36methadose oral concentrate. . . . . . . . . . . . . 36methamphetamine. . . . . . . . . . . . . . . . . . . . . 42methazolamide. . . . . . . . . . . . . . . . . . . . . . . . 87methenamine hippurate. . . . . . . . . . . . . . . . . 20methenamine mandelate. . . . . . . . . . . . . . . . 20methergine. . . . . . . . . . . . . . . . . . . . . . . . . . . 85methimazole oral tablet 10 mg, 5 mg. . . . . . . 64METHITEST. . . . . . . . . . . . . . . . . . . . . . . . . . 68methocarbamol injection. . . . . . . . . . . . . . . . 33methocarbamol oral. . . . . . . . . . . . . . . . . . . . 33methotrexate sodium (pf) injection recon soln 25methotrexate sodium (pf) injection solution. . 25methotrexate sodium injection. . . . . . . . . . . . 25methotrexate sodium oral. . . . . . . . . . . . . . . 25methoxsalen. . . . . . . . . . . . . . . . . . . . . . . . . . 54methscopolamine. . . . . . . . . . . . . . . . . . . . . . 69methyclothiazide. . . . . . . . . . . . . . . . . . . . . . 47methyldopa. . . . . . . . . . . . . . . . . . . . . . . . . . . 47methyldopa-hydrochlorothiazide. . . . . . . . . . 47methyldopate. . . . . . . . . . . . . . . . . . . . . . . . . 47methylergonovine injection. . . . . . . . . . . . . . 85methylergonovine oral. . . . . . . . . . . . . . . . . . 85methylphenidate hcl oral capsule, er biphasic30-70 10 mg, 20 mg. . . . . . . . . . . . . . . . . . . 42

methylphenidate hcl oral capsule, er biphasic30-70 30 mg, 40 mg, 50 mg, 60 mg. . . . . . . 42

methylphenidate hcl oral capsule,er biphasic50-50 10 mg, 20 mg. . . . . . . . . . . . . . . . . . . 42

methylphenidate hcl oral capsule,er biphasic50-50 30 mg, 40 mg, 60 mg. . . . . . . . . . . . . 42

methylphenidate hcl oral solution. . . . . . . . . 42methylphenidate hcl oral tablet. . . . . . . . . . . 42methylphenidate hcl oral tablet extendedrelease 10 mg. . . . . . . . . . . . . . . . . . . . . . . 42

methylphenidate hcl oral tablet extendedrelease 20 mg. . . . . . . . . . . . . . . . . . . . . . . 42

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg, 27 mg, 54 mg. . . . . . . 43

methylphenidate hcl oral tablet extendedease 24hr 36 mg. . . . . . . . . . . . . . . . . . . 43hylphenidate hcl oral tablet,chewable. . . 43hylprednisolone acetate. . . . . . . . . . . . . . 63hylprednisolone oral tablet. . . . . . . . . . . . 63hylprednisolone oral tablets,dose pack. . 63hylprednisolone sodium succ injection reconln 125 mg, 40 mg. . . . . . . . . . . . . . . . . . . 63hylprednisolone sodium succ intravenous 64hyltestosterone oral capsule. . . . . . . . . . 68ipranolol. . . . . . . . . . . . . . . . . . . . . . . . . . 86oclopramide hcl injection solution. . . . . . 71oclopramide hcl injection syringe. . . . . . . 71oclopramide hcl oral solution. . . . . . . . . . 71oclopramide hcl oral tablet. . . . . . . . . . . . 71oclopramide hcl oral tablet,disintegrating 71olazone. . . . . . . . . . . . . . . . . . . . . . . . . . . 47oprolol succinate oral tablet extendedease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 47oprolol ta-hydrochlorothiaz. . . . . . . . . . . 47oprolol tartrate intravenous solution. . . . . 47oprolol tartrate intravenous syringe. . . . . 48oprolol tartrate oral tablet. . . . . . . . . . . . . 48ro i.v.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15ronidazole in nacl (iso-os). . . . . . . . . . . . 16ronidazole oral. . . . . . . . . . . . . . . . . . . . . 16ronidazole topical. . . . . . . . . . . . . . . . . . . 55ronidazole vaginal. . . . . . . . . . . . . . . . . . 82iletine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45CALCIN INJECTION. . . . . . . . . . . . . . . . 68elas 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . 84onazole-3 vaginal suppository. . . . . . . . . 82rogestin 1.5/30 (21). . . . . . . . . . . . . . . . . 84rogestin 1/20 (21). . . . . . . . . . . . . . . . . . . 84rogestin fe 1.5/30 (28). . . . . . . . . . . . . . . 84rogestin fe 1/20 (28). . . . . . . . . . . . . . . . . 84azolam (pf) injection. . . . . . . . . . . . . . . . . 43azolam injection. . . . . . . . . . . . . . . . . . . . 43azolam oral syrup 2 mg/ml. . . . . . . . . . . . 43odrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61ergot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31litol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

relmetmetmetmetmetso

metmetmetmetmetmetmetmetmetmetrel

metmetmetmetmetmetmetmetmetmexMIAmibmicmicmicmicmicmidmidmidmidmigmig

121

miglustat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84millipred dp. . . . . . . . . . . . . . . . . . . . . . . . . . 64millipred oral tablet. . . . . . . . . . . . . . . . . . . . . 64milrinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53milrinone in 5 % dextrose. . . . . . . . . . . . . . . 53mimvey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81mimvey lo. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81minocycline oral capsule. . . . . . . . . . . . . . . . 19minocycline oral tablet. . . . . . . . . . . . . . . . . . 19minocycline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

minoxidil oral. . . . . . . . . . . . . . . . . . . . . . . . . 48miostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87mirtazapine oral tablet. . . . . . . . . . . . . . . . . . 43mirtazapine oral tablet,disintegrating. . . . . . . 43misoprostol. . . . . . . . . . . . . . . . . . . . . . . . . . . 73mitomycin intravenous. . . . . . . . . . . . . . . . . . 25mitoxantrone. . . . . . . . . . . . . . . . . . . . . . . . . 25modafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43moderiba. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10moderiba dose pack oral tablets,dose pack 200mg (28)- 400 mg (28), 400-400 mg (28)-mg(28), 600-400 mg (28)-mg (28), 600-600 mg(28)-mg (28). . . . . . . . . . . . . . . . . . . . . . . . . 10

moderiba dose pack oral tablets,dose pack 400mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) 10

moexipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48moexipril-hydrochlorothiazide. . . . . . . . . . . . 48mometasone nasal. . . . . . . . . . . . . . . . . . . . 90mometasone topical. . . . . . . . . . . . . . . . . . . . 58mondoxyne nl. . . . . . . . . . . . . . . . . . . . . . . . 19mono-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . 84monoject 0.9% sodium chloride. . . . . . . . . . . 61monoject prefill advanced ns. . . . . . . . . . . . . 61monoject prefill saline flush. . . . . . . . . . . . . . 61mononessa (28). . . . . . . . . . . . . . . . . . . . . . . 84MONOVISC. . . . . . . . . . . . . . . . . . . . . . . . . . 39montelukast. . . . . . . . . . . . . . . . . . . . . . . . . . 90morgidox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19morphine (pf) injection solution 0.5 mg/ml. . . 36morphine (pf) injection solution 1 mg/ml. . . . 36

morphine (pf) intravenous patient control.algesia soln 150 mg/30 ml. . . . . . . . . . . . 36rphine (pf) intravenous patient control.algesia soln 30 mg/30 ml. . . . . . . . . . . . . 36rphine concentrate oral solution. . . . . . . . 36RPHINE INJECTION SOLUTION 10 MG/

L, 2 MG/ML, 4 MG/ML, 5 MG/MLRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 36rphine injection solution 8 mg/ml. . . . . . . 36rphine injection syringe 10 mg/ml, 2 mg/ml, 4g/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36rphine injection syringe 5 mg/ml, 8 mg/ml 36rphine intravenous cartridge 10 mg/ml, 2 mg/l, 4 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 36RPHINE INTRAVENOUS CARTRIDGE 8

G/ML (BRAND). . . . . . . . . . . . . . . . . . . . . 36rphine intravenous solution 10 mg/ml. . . . 36RPHINE INTRAVENOUS SOLUTION 4 MG/

L, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 36RPHINE INTRAVENOUS SYRINGE 10 MG/

L, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 36rphine intravenous syringe 2 mg/ml, 4g/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36rphine oral capsule, er multiphase 24 hr. . 36rphine oral capsule,extend.release pellets 36rphine oral solution. . . . . . . . . . . . . . . . . . 36rphine oral tablet. . . . . . . . . . . . . . . . . . . . 36rphine oral tablet extended release. . . . . 36xifloxacin in nacl (iso-osm). . . . . . . . . . . . 18xifloxacin ophthalmic (eye). . . . . . . . . . . . 85xifloxacin oral. . . . . . . . . . . . . . . . . . . . . . 18ZOBIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74LTAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45lti-vit with fluoride-iron. . . . . . . . . . . . . . . . 98lti-vitamin with fluoride oral drops. . . . . . . 98ltivit-fluor (vit e acetate). . . . . . . . . . . . . . . 98ltivitamin with fluoride. . . . . . . . . . . . . . . . 98ltivitamins with fluoride. . . . . . . . . . . . . . . 98pirocin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57pirocin calcium. . . . . . . . . . . . . . . . . . . . . 57STARGEN. . . . . . . . . . . . . . . . . . . . . . . . . 25c-fluoride. . . . . . . . . . . . . . . . . . . . . . . . . . 98ALEPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68CAMINE. . . . . . . . . . . . . . . . . . . . . . . . . . . 8

anmoan

moMOM(B

momom

momom

MOM

moMOM

MOM

mom

momomomomomomomoMOMUmumumumumumumuMUmvMYMY

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mycophenolate mofetil. . . . . . . . . . . . . . . . . . 25mycophenolate mofetil hcl. . . . . . . . . . . . . . . 25mycophenolate sodium oral tablet,delayedrelease (dr/ec). . . . . . . . . . . . . . . . . . . . . . . 25

MYLERAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 25MYLOTARG. . . . . . . . . . . . . . . . . . . . . . . . . . 25myorisan oral capsule 10 mg, 20 mg, 40 mg. 55myorisan oral capsule 30 mg. . . . . . . . . . . . . 55MYTESI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69myzilra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Nnabumetone. . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48nadolol-bendroflumethiazide. . . . . . . . . . . . . 48nafcillin in dextrose iso-osm intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 17

nafcillin in dextrose iso-osm intravenouspiggyback 2 gram/100 ml. . . . . . . . . . . . . . . 17

nafcillin injection recon soln 1 gram, 10 gram 17nafcillin injection recon soln 2 gram. . . . . . . . 17nafcillin intravenous recon soln 1 gram. . . . . 17nafcillin intravenous recon soln 2 gram. . . . . 17naftifine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57NAGLAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 68nalbuphine. . . . . . . . . . . . . . . . . . . . . . . . . . . 39naloxone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39naltrexone. . . . . . . . . . . . . . . . . . . . . . . . . . . 39naproxen oral suspension. . . . . . . . . . . . . . . 39naproxen oral tablet. . . . . . . . . . . . . . . . . . . . 39naproxen oral tablet,delayed release (dr/ec). 39naproxen sodium oral tablet 275 mg, 550 mg 39naproxen sodium oral tablet, er multiphase 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

naratriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 31NATACYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85nateglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 66NATPARA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68NEBUPENT. . . . . . . . . . . . . . . . . . . . . . . . . . 16nebusal inhalation solution for nebulization 3%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

NEBUSAL INHALATION SOLUTION FORNEBULIZATION 6 % (BRAND). . . . . . . . . . 90

necon 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . . 84necon 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . . 84NEEDLES, INSULIN DISP.,SAFETY. . . . . . . 66nefazodone. . . . . . . . . . . . . . . . . . . . . . . . . . 43neo-polycin. . . . . . . . . . . . . . . . . . . . . . . . . . 85neo-polycin hc. . . . . . . . . . . . . . . . . . . . . . . . 87neomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16neomycin-bacitracin-poly-hc. . . . . . . . . . . . . 87neomycin-bacitracin-polymyxin. . . . . . . . . . . 85neomycin-polymyxin b gu. . . . . . . . . . . . . . . 59neomycin-polymyxin b-dexameth. . . . . . . . . 87neomycin-polymyxin-gramicidin. . . . . . . . . . . 85neomycin-polymyxin-hc ophthalmic (eye). . . 87neomycin-polymyxin-hc otic (ear). . . . . . . . . 63neostigmine methylsulfate intravenous solution0.5 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 33

neostigmine methylsulfate intravenous solution1 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

NEPHRAMINE 5.4 %. . . . . . . . . . . . . . . . . . . 97NERLYNX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25neuac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55NEULASTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 74NEUPOGEN INJECTION SOLUTION 300MCG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

NEUPOGEN INJECTION SOLUTION 480MCG/1.6 ML. . . . . . . . . . . . . . . . . . . . . . . . . 74

NEUPOGEN INJECTION SYRINGE 300MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 74

NEUPOGEN INJECTION SYRINGE 480MCG/0.8 ML. . . . . . . . . . . . . . . . . . . . . . . . . 75

NEUPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31nevirapine oral tablet. . . . . . . . . . . . . . . . . . . 10nevirapine oral tablet extended release 24 hr 10NEXAVAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25niacin oral tablet extended release 24 hr. . . . 52nicardipine intravenous solution. . . . . . . . . . 48nicardipine oral. . . . . . . . . . . . . . . . . . . . . . . 48NICOTROL. . . . . . . . . . . . . . . . . . . . . . . . . . . 62NICOTROL NS. . . . . . . . . . . . . . . . . . . . . . . 62nifedipine oral capsule. . . . . . . . . . . . . . . . . . 48nifedipine oral tablet extended release. . . . . 48nifedipine oral tablet extended release 24hr. 48nikki (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

123

nilutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nimodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 48NINLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nisoldipine oral tablet extended release 24 hr 48nitro-bid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53nitrofurantoin. . . . . . . . . . . . . . . . . . . . . . . . . 20nitrofurantoin macrocrystal. . . . . . . . . . . . . . 20nitrofurantoin monohyd/m-cryst. . . . . . . . . . . 20nitroglycerin in 5 % dextrose intravenoussolution 100 mg/250 ml (400 mcg/ml), 200mg/500 ml (400 mcg/ml), 50 mg/250 ml (200mcg/ml), 50 mg/500 ml (100 mcg/ml). . . . . . 53

nitroglycerin in 5 % dextrose intravenoussolution 25 mg/250 ml (100 mcg/ml). . . . . . 53

nitroglycerin intravenous. . . . . . . . . . . . . . . . 53nitroglycerin oral capsule, extended release. 53nitroglycerin sublingual. . . . . . . . . . . . . . . . . 53nitroglycerin transdermal patch 24 hour. . . . . 53nitroglycerin translingual spray,non-aerosol. 53nizatidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73nolix topical cream. . . . . . . . . . . . . . . . . . . . . 58nolix topical lotion. . . . . . . . . . . . . . . . . . . . . 58nora-be. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81norepinephrine bitartrate. . . . . . . . . . . . . . . . 53noreth-ethinyl estradiol-iron. . . . . . . . . . . . . . 84norethindrone (contraceptive). . . . . . . . . . . . 81norethindrone ac-eth estradiol oral tablet 0.5-2.5mg-mcg, 1-5 mg-mcg. . . . . . . . . . . . . . . . . . 81

norethindrone ac-eth estradiol oral tablet 1-20mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

norethindrone acetate. . . . . . . . . . . . . . . . . . 81norethindrone-e.estradiol-iron. . . . . . . . . . . . 84norgestimate-ethinyl estradiol. . . . . . . . . . . . 84norlyda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81norlyroc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81normal saline flush. . . . . . . . . . . . . . . . . . . . . 61NORMOSOL-M IN 5 % DEXTROSE. . . . . . . 97NORMOSOL-R. . . . . . . . . . . . . . . . . . . . . . . 94NORMOSOL-R IN 5 % DEXTROSE. . . . . . . 94NORMOSOL-R PH 7.4. . . . . . . . . . . . . . . . . 97NORTHERA. . . . . . . . . . . . . . . . . . . . . . . . . . 61nortrel 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . 84nortrel 1/35 (21). . . . . . . . . . . . . . . . . . . . . . . 84

nortrel 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 84nortrel 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 84nortriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 43NORVIR ORAL CAPSULE. . . . . . . . . . . . . . 10NORVIR ORAL POWDER IN PACKET. . . . . 10NORVIR ORAL SOLUTION. . . . . . . . . . . . . . 10NORVIR ORAL TABLET. . . . . . . . . . . . . . . . 10NOVAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 68NOXAFIL INTRAVENOUS. . . . . . . . . . . . . . . . 8NOXAFIL ORAL. . . . . . . . . . . . . . . . . . . . . . . . 8np thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69NPLATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51NUCALA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90NUEDEXTA. . . . . . . . . . . . . . . . . . . . . . . . . . 33NULOJIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26NUPLAZID. . . . . . . . . . . . . . . . . . . . . . . . . . . 43nyamyc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57nystatin oral suspension. . . . . . . . . . . . . . . . . 8nystatin oral tablet. . . . . . . . . . . . . . . . . . . . . . 8nystatin topical. . . . . . . . . . . . . . . . . . . . . . . . 57nystatin-triamcinolone. . . . . . . . . . . . . . . . . . 57nystop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

OOCALIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71ocella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84OCREVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . 33octreotide acetate. . . . . . . . . . . . . . . . . . . . . 26ODEFSEY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ODOMZO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26OFEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90ofloxacin ophthalmic (eye). . . . . . . . . . . . . . . 85ofloxacin oral tablet 300 mg. . . . . . . . . . . . . . 18ofloxacin oral tablet 400 mg. . . . . . . . . . . . . . 18ofloxacin otic (ear). . . . . . . . . . . . . . . . . . . . . 63ogestrel (28). . . . . . . . . . . . . . . . . . . . . . . . . . 84okebo oral capsule 75 mg. . . . . . . . . . . . . . . 19olanzapine intramuscular recon soln. . . . . . . 43olanzapine oral tablet. . . . . . . . . . . . . . . . . . . 43olanzapine oral tablet,disintegrating. . . . . . . 43olanzapine-fluoxetine. . . . . . . . . . . . . . . . . . . 43olmesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 48

124

olmesartan-amlodipin-hcthiazid. . . . . . . . . . . 48olmesartan-hydrochlorothiazide. . . . . . . . . . . 48olopatadine nasal. . . . . . . . . . . . . . . . . . . . . . 62olopatadine ophthalmic (eye). . . . . . . . . . . . . 86OLYSIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10omega-3 acid ethyl esters. . . . . . . . . . . . . . . 52omeppi oral capsule 20-1.1 mg-gram. . . . . . 73omeppi oral capsule 40-1.1 mg-gram. . . . . . 73omeprazole oral capsule,delayed release(dr/ec)10 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

omeprazole oral capsule,delayed release(dr/ec)20 mg, 40 mg. . . . . . . . . . . . . . . . . . . . . . . . 73

omeprazole-sodium bicarbonate oral capsule20-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 73

omeprazole-sodium bicarbonate oral capsule40-1.1 mg-gram. . . . . . . . . . . . . . . . . . . . . . 73

omeprazole-sodium bicarbonate oral packet20-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 73

omeprazole-sodium bicarbonate oral packet40-1,680 mg. . . . . . . . . . . . . . . . . . . . . . . . . 73

OMNITROPE. . . . . . . . . . . . . . . . . . . . . . . . . 75ONCASPAR. . . . . . . . . . . . . . . . . . . . . . . . . . 26ondansetron hcl (pf). . . . . . . . . . . . . . . . . . . . 71ondansetron hcl intravenous. . . . . . . . . . . . . 71ondansetron hcl oral solution. . . . . . . . . . . . . 71ondansetron hcl oral tablet 24 mg. . . . . . . . . 71ondansetron hcl oral tablet 4 mg, 8 mg. . . . . 71ondansetron oral tablet,disintegrating. . . . . . 71ONETOUCH BLOOD GLUCOSE METERS. 66ONETOUCH ULTRA BLUE TEST STRIP. . . 66ONETOUCH VERIO TEST STRIP. . . . . . . . . 66ONFI ORAL SUSPENSION. . . . . . . . . . . . . . 29ONFI ORAL TABLET 10 MG, 20 MG. . . . . . . 29ONGLYZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 66ONIVYDE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26OPDIVO INTRAVENOUS SOLUTION 100MG/10 ML, 40 MG/4 ML. . . . . . . . . . . . . . . . 26

OPDIVO INTRAVENOUS SOLUTION 240MG/24 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 26

opium tincture. . . . . . . . . . . . . . . . . . . . . . . . 69OPSUMIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90ORALAIR SUBLINGUAL TABLET 300 INDXREACTIVITY. . . . . . . . . . . . . . . . . . . . . . . . . 77

oralone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

ORBACTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 16ORENCIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80ORENCIA (WITH MALTOSE). . . . . . . . . . . . 80ORENCIA CLICKJECT. . . . . . . . . . . . . . . . . 80ORENITRAM ORAL TABLET EXTENDEDRELEASE. . . . . . . . . . . . . . . . . . . . . . . . . . . 48

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

ORFADIN ORAL CAPSULE 20 MG. . . . . . . . 61ORFADIN ORAL SUSPENSION. . . . . . . . . . 61ORKAMBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90orphenadrine citrate injection. . . . . . . . . . . . . 33orphenadrine citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

orsythia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84ORTHOVISC. . . . . . . . . . . . . . . . . . . . . . . . . 39oseltamivir oral capsule 30 mg. . . . . . . . . . . 10oseltamivir oral capsule 45 mg, 75 mg. . . . . 10oseltamivir oral suspension for reconstitution 10osmitrol 15 %. . . . . . . . . . . . . . . . . . . . . . . . . 48osmitrol 20 %. . . . . . . . . . . . . . . . . . . . . . . . . 48OSMOPREP. . . . . . . . . . . . . . . . . . . . . . . . . . 71OTEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80OTEZLA STARTER ORAL TABLETS,DOSEPACK 10 MG (4)-20 MG (4)-30 MG (47). . . 80

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 17

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50 ml. . . . . . . . . . . . . . . . 17

oxacillin injection recon soln 1 gram. . . . . . . 17oxacillin injection recon soln 10 gram. . . . . . 17oxacillin injection recon soln 2 gram. . . . . . . 17oxaliplatin intravenous recon soln 100 mg. . . 26oxaliplatin intravenous recon soln 50 mg. . . . 26oxaliplatin intravenous solution 100 mg/20 ml 26oxaliplatin intravenous solution 50 mg/10 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

oxandrolone. . . . . . . . . . . . . . . . . . . . . . . . . . 68oxaprozin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39oxazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43oxcarbazepine. . . . . . . . . . . . . . . . . . . . . . . . 29oxiconazole. . . . . . . . . . . . . . . . . . . . . . . . . . 57OXTELLAR XR. . . . . . . . . . . . . . . . . . . . . . . 29

125

oxybutynin chloride oral syrup. . . . . . . . . . . . 92oxybutynin chloride oral tablet. . . . . . . . . . . . 92oxybutynin chloride oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

oxycodone oral capsule. . . . . . . . . . . . . . . . . 37oxycodone oral concentrate. . . . . . . . . . . . . . 37oxycodone oral solution. . . . . . . . . . . . . . . . . 37oxycodone oral tablet. . . . . . . . . . . . . . . . . . . 37OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg. . . . 37

oxycodone-aspirin. . . . . . . . . . . . . . . . . . . . . 37OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR. . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxymorphone oral tablet. . . . . . . . . . . . . . . . 37oxymorphone oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxytocin injection solution. . . . . . . . . . . . . . . 85OZEMPIC SUBCUTANEOUS PEN INJECTOR0.25 MG OR 0.5 MG(2 MG/1.5 ML). . . . . . . 66

OZEMPIC SUBCUTANEOUS PEN INJECTOR1 MG/0.75 ML (2 MG/1.5 ML). . . . . . . . . . . 66

Ppacerone oral tablet 100 mg, 200 mg, 400mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

paclitaxel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26paliperidone oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

palonosetron intravenous solution 0.25 mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

pamidronate intravenous recon soln. . . . . . . 68pamidronate intravenous solution. . . . . . . . . 68panlor(acetam-caff-dihydrocod). . . . . . . . . . . 37PANRETIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 54pantoprazole intravenous. . . . . . . . . . . . . . . 73pantoprazole oral tablet,delayed release (dr/ec)20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

pantoprazole oral tablet,delayed release (dr/ec)40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

45

paregoric. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69ICALCITOL HEMODIALYSIS PORT

CTION. . . . . . . . . . . . . . . . . . . . . . . . . . 68alcitol intravenous. . . . . . . . . . . . . . . . . 68ICALCITOL INTRAVENOUS SOLUTION 2

/ML (BRAND). . . . . . . . . . . . . . . . . . . . 68ICALCITOL INTRAVENOUS SOLUTION 5

/ML (BRAND). . . . . . . . . . . . . . . . . . . . 68alcitol oral. . . . . . . . . . . . . . . . . . . . . . . . 68ex oral rinse. . . . . . . . . . . . . . . . . . . . . . 62momycin. . . . . . . . . . . . . . . . . . . . . . . . . 16xetine hcl oral tablet. . . . . . . . . . . . . . . . 43xetine hcl oral tablet extended release 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43xetine mesylate(menop.sym). . . . . . . . . 43SABIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 68

R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16L ORAL SUSPENSION. . . . . . . . . . . . . 43IARIX (PF). . . . . . . . . . . . . . . . . . . . . . . 77VAX HIB (PF). . . . . . . . . . . . . . . . . . . . . 77350-electrolytes oral recon soln

-22.74-6.74 -5.86 gram. . . . . . . . . . . . . 71350-electrolytes oral recon soln

-22.72-6.72 -5.84 gram. . . . . . . . . . . . . 71electrolyte. . . . . . . . . . . . . . . . . . . . . . . . 71ANONE. . . . . . . . . . . . . . . . . . . . . . . . . . 29ASYS PROCLICK. . . . . . . . . . . . . . . . . 75ASYS SUBCUTANEOUS SOLUTION. . 75ASYS SUBCUTANEOUS SYRINGE. . . 75INTRON SUBCUTANEOUS KIT 50

/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 75illin g potassium injection recon soln 20on unit. . . . . . . . . . . . . . . . . . . . . . . . . . 18illin g potassium injection recon soln 5on unit. . . . . . . . . . . . . . . . . . . . . . . . . . 18illin g procaine intramuscular syringe 1.2on unit/2 ml. . . . . . . . . . . . . . . . . . . . . . 18illin g procaine intramuscular syringe

,000 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 18illin g sodium. . . . . . . . . . . . . . . . . . . . . 18illin v potassium. . . . . . . . . . . . . . . . . . . 18

TACEL (PF). . . . . . . . . . . . . . . . . . . . . . 77TAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16TASA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

PARINJE

paricPARMCG

PARMCG

paricparoparoparoparohr. .

paroPARPASEPAXIPEDPEDpeg 3236

peg 3240

peg-PEGPEGPEGPEGPEGMCG

penicmilli

penicmilli

penicmilli

penic600

penicpenicPENPENPEN

126

pentazocine-naloxone. . . . . . . . . . . . . . . . . . 39pentobarbital sodium injection solution. . . . . 43pentoxifylline oral tablet extended release. . . 51perindopril erbumine. . . . . . . . . . . . . . . . . . . 48periogard. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62PERJETA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26permethrin topical cream. . . . . . . . . . . . . . . . 59perphenazine. . . . . . . . . . . . . . . . . . . . . . . . . 43perphenazine-amitriptyline. . . . . . . . . . . . . . . 43pfizerpen-g. . . . . . . . . . . . . . . . . . . . . . . . . . . 18phenadoz. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89phenelzine. . . . . . . . . . . . . . . . . . . . . . . . . . . 43phenergan rectal. . . . . . . . . . . . . . . . . . . . . . 89phenobarbital. . . . . . . . . . . . . . . . . . . . . . . . . 29phenobarbital sodium injection solution 130mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

phenobarbital sodium injection solution 65mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

phenoxybenzamine. . . . . . . . . . . . . . . . . . . . 48phentolamine injection recon soln. . . . . . . . . 48phenytoin oral suspension 100 mg/4 ml. . . . 30phenytoin oral suspension 125 mg/5 ml. . . . 30phenytoin oral tablet,chewable. . . . . . . . . . . 30phenytoin sodium extended. . . . . . . . . . . . . . 30phenytoin sodium intravenous solution. . . . . 30phenytoin sodium intravenous syringe. . . . . 30philith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84PHOSPHOLINE IODIDE. . . . . . . . . . . . . . . . 86phrenilin forte(with caffeine). . . . . . . . . . . . . . 37pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,4 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

pilocarpine hcl oral. . . . . . . . . . . . . . . . . . . . . 61pimozide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43pimtrea (28). . . . . . . . . . . . . . . . . . . . . . . . . . 84pindolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48pioglitazone. . . . . . . . . . . . . . . . . . . . . . . . . . 66pioglitazone-glimepiride. . . . . . . . . . . . . . . . . 66pioglitazone-metformin. . . . . . . . . . . . . . . . . 66piperacillin-tazobactam intravenous recon soln2.25 gram, 3.375 gram, 4.5 gram, 40.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

pirmella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84piroxicam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

plasbumin 25 %. . . . . . . . . . . . . . . . . . . . . . . 93bumin 5 %. . . . . . . . . . . . . . . . . . . . . . . . 93manate. . . . . . . . . . . . . . . . . . . . . . . . . . . 97GRIDY SUBCUTANEOUS PEN INJECTOR

5 MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . 75GRIDY SUBCUTANEOUS PEN INJECTOR

MCG/0.5 ML- 94 MCG/0.5 ML. . . . . . . . 75GRIDY SUBCUTANEOUS SYRINGE 125G/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 75GRIDY SUBCUTANEOUS SYRINGE 63G/0.5 ML- 94 MCG/0.5 ML. . . . . . . . . . . 75amine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97UMOVAX 23. . . . . . . . . . . . . . . . . . . . . . 77

ofilox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54caine injection solution 1 % (10 mg/ml). 56caine-mpf. . . . . . . . . . . . . . . . . . . . . . . . 56cin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85ethylene glycol 3350. . . . . . . . . . . . . . . . 71myxin b sulf-trimethoprim. . . . . . . . . . . . 85myxin b sulfate. . . . . . . . . . . . . . . . . . . . 16ALYST. . . . . . . . . . . . . . . . . . . . . . . . . . 26

ia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84TRAZZA. . . . . . . . . . . . . . . . . . . . . . . . . 26ssium acetate intravenous solution 2q/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94ssium bicarb and chloride. . . . . . . . . . . . 94ssium bicarb-citric acid. . . . . . . . . . . . . . 94ssium chlorid-d5-0.45%nacl intravenous

renteral solution 10 meq/l, 30 meq/l, 40q/l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94ssium chlorid-d5-0.45%nacl intravenous

renteral solution 20 meq/l. . . . . . . . . . . . . 94ssium chloride in 0.9%nacl intravenous

renteral solution 20 meq/l, 40 meq/l. . . . . 94ssium chloride in 5 % dex intravenous

renteral solution 20 meq/l, 40 meq/l. . . . . 94ssium chloride in 5 % dex intravenous

renteral solution 30 meq/l. . . . . . . . . . . . . 94ssium chloride in lr-d5 intravenous

renteral solution 20 meq/l. . . . . . . . . . . . . 94ssium chloride in lr-d5 intravenous

renteral solution 40 meq/l. . . . . . . . . . . . . 94ssium chloride in water intravenousgyback 10 meq/100 ml. . . . . . . . . . . . . . 94

plasplasPLE12

PLE63

PLEMC

PLEMC

plenPNEpodpolopolopolypolypolypolyPOMportPORpotame

potapotapotapame

potapa

potapa

potapa

potapa

potapa

potapa

potapig

127

potassium chloride in water intravenouspiggyback 10 meq/50 ml. . . . . . . . . . . . . . . 94

potassium chloride in water intravenouspiggyback 20 meq/100 ml, 40 meq/100 ml. 94

potassium chloride in water intravenouspiggyback 20 meq/50 ml, 30 meq/100 ml. . 95

potassium chloride intravenous. . . . . . . . . . . 95potassium chloride oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

potassium chloride oral liquid. . . . . . . . . . . . 95potassium chloride oral packet. . . . . . . . . . . 95potassium chloride oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

potassium chloride oral tablet,erparticles/crystals. . . . . . . . . . . . . . . . . . . . . . 95

potassium chloride-0.45 % nacl. . . . . . . . . . . 95potassium chloride-d5-0.2%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 95

potassium chloride-d5-0.2%nacl intravenousparenteral solution 30 meq/l, 40 meq/l. . . . . 95

potassium chloride-d5-0.3%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 95



potassium citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

potassium phosphate m-/d-basic. . . . . . . . . . 95PRADAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 51PRALUENT PEN SUBCUTANEOUS PENINJECTOR 150 MG/ML. . . . . . . . . . . . . . . . 52

PRALUENT PEN SUBCUTANEOUS PENINJECTOR 75 MG/ML. . . . . . . . . . . . . . . . . 52

pramipexole oral tablet. . . . . . . . . . . . . . . . . 31pramipexole oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

prasugrel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51pravastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 52PRAXBIND. . . . . . . . . . . . . . . . . . . . . . . . . . . 51praziquantel. . . . . . . . . . . . . . . . . . . . . . . . . . 16prazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48PRED MILD. . . . . . . . . . . . . . . . . . . . . . . . . . 87prednicarbate. . . . . . . . . . . . . . . . . . . . . . . . . 58prednisolone acetate. . . . . . . . . . . . . . . . . . . 87

prednisolone oral solution 15 mg/5 ml. . . . . . 64ednisolone sodium phosphate ophthalmiceye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87ednisolone sodium phosphate oral solution 10g/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4g/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml

6.7 mg/5 ml). . . . . . . . . . . . . . . . . . . . . . . . 64ednisolone sodium phosphate oralablet,disintegrating. . . . . . . . . . . . . . . . . . . . 64ednisone intensol. . . . . . . . . . . . . . . . . . . . 64ednisone oral solution. . . . . . . . . . . . . . . . . 64ednisone oral tablet. . . . . . . . . . . . . . . . . . 64ednisone oral tablets,dose pack. . . . . . . . . 64REMARIN INJECTION. . . . . . . . . . . . . . . . 81emasol 10 %. . . . . . . . . . . . . . . . . . . . . . . . 97REMASOL 6 %. . . . . . . . . . . . . . . . . . . . . . 97enatal vitamin oral tablet. . . . . . . . . . . . . . . 98evalite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52evifem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84REVNAR 13 (PF). . . . . . . . . . . . . . . . . . . . 77REVYMIS INTRAVENOUS. . . . . . . . . . . . . 10REVYMIS ORAL. . . . . . . . . . . . . . . . . . . . . 10REZCOBIX. . . . . . . . . . . . . . . . . . . . . . . . . 10REZISTA ORAL SUSPENSION. . . . . . . . . 10REZISTA ORAL TABLET 150 MG, 600 MG, 75

G, 800 MG. . . . . . . . . . . . . . . . . . . . . . . . . 10RIFTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16RIMAQUINE. . . . . . . . . . . . . . . . . . . . . . . . 16imidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ROAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 90ROAIR RESPICLICK. . . . . . . . . . . . . . . . . . 90obenecid. . . . . . . . . . . . . . . . . . . . . . . . . . . 78obenecid-colchicine. . . . . . . . . . . . . . . . . . 78ocainamide injection solution 100 mg/ml. . 45ocainamide injection solution 500 mg/ml. . 45ROCALAMINE 3%. . . . . . . . . . . . . . . . . . . 97ocentra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43ochlorperazine. . . . . . . . . . . . . . . . . . . . . . 71ochlorperazine edisylate injection solution 10g/2 ml (5 mg/ml). . . . . . . . . . . . . . . . . . . . 71

ochlorperazine maleate oral. . . . . . . . . . . . 71

pr(

prmm(

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prprprprPprPprprprPPPPPPM

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128

PROCRIT INJECTION SOLUTION 10,000UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,20,000 UNIT/ML, 3,000 UNIT/ML, 4,000UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

PROCRIT INJECTION SOLUTION 40,000UNIT/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

procto-med hc. . . . . . . . . . . . . . . . . . . . . . . . 71procto-pak. . . . . . . . . . . . . . . . . . . . . . . . . . . 71proctosol hc topical. . . . . . . . . . . . . . . . . . . . 71proctozone-hc. . . . . . . . . . . . . . . . . . . . . . . . 71PROCYSBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 93profeno. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39progesterone. . . . . . . . . . . . . . . . . . . . . . . . . 81progesterone in oil. . . . . . . . . . . . . . . . . . . . . 81progesterone micronized. . . . . . . . . . . . . . . . 81PROGLYCEM. . . . . . . . . . . . . . . . . . . . . . . . . 66PROGRAF INTRAVENOUS. . . . . . . . . . . . . 26PROLASTIN-C INTRAVENOUS RECONSOLN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

PROLASTIN-C INTRAVENOUS SOLUTION 61PROLEUKIN. . . . . . . . . . . . . . . . . . . . . . . . . 75PROLIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79PROMACTA. . . . . . . . . . . . . . . . . . . . . . . . . . 51promethazine injection solution. . . . . . . . . . . 89promethazine oral. . . . . . . . . . . . . . . . . . . . . 89promethazine rectal suppository 12.5 mg, 25mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

promethazine rectal suppository 50 mg. . . . . 89promethegan. . . . . . . . . . . . . . . . . . . . . . . . . 89propafenone oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

propafenone oral tablet. . . . . . . . . . . . . . . . . 45propantheline. . . . . . . . . . . . . . . . . . . . . . . . . 69propranolol intravenous. . . . . . . . . . . . . . . . . 48propranolol oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

propranolol oral solution. . . . . . . . . . . . . . . . 48propranolol oral tablet. . . . . . . . . . . . . . . . . . 48propranolol-hydrochlorothiazid. . . . . . . . . . . 48propylthiouracil. . . . . . . . . . . . . . . . . . . . . . . . 64PROQUAD (PF). . . . . . . . . . . . . . . . . . . . . . . 77PROSOL 20 %. . . . . . . . . . . . . . . . . . . . . . . . 97protamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

protriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 43prudoxin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54pulmosal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90PULMOZYME. . . . . . . . . . . . . . . . . . . . . . . . 90PURIXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26pyrazinamide. . . . . . . . . . . . . . . . . . . . . . . . . 16pyridostigmine bromide oral tablet. . . . . . . . . 34pyridostigmine bromide oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

QQUADRACEL (PF). . . . . . . . . . . . . . . . . . . . . 77quasense. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84QUDEXY XR. . . . . . . . . . . . . . . . . . . . . . . . . 30quetiapine oral tablet. . . . . . . . . . . . . . . . . . . 43quetiapine oral tablet extended release 24 hr 43quinapril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48quinapril-hydrochlorothiazide. . . . . . . . . . . . . 48quinidine gluconate injection. . . . . . . . . . . . . 45quinidine gluconate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

quinidine sulfate oral tablet. . . . . . . . . . . . . . 45quinine sulfate. . . . . . . . . . . . . . . . . . . . . . . . 16

RRABAVERT (PF). . . . . . . . . . . . . . . . . . . . . . 77rabeprazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

RADICAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 33RAGWITEK. . . . . . . . . . . . . . . . . . . . . . . . . . 77rajani. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84raloxifene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79ramipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48RANEXA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53ranitidine hcl injection solution 25 mg/ml. . . . 74ranitidine hcl injection solution 50 mg/2 ml (25mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

ranitidine hcl oral capsule. . . . . . . . . . . . . . . 74ranitidine hcl oral syrup. . . . . . . . . . . . . . . . . 74ranitidine hcl oral tablet 150 mg, 300 mg. . . . 74RAPAMUNE ORAL SOLUTION. . . . . . . . . . . 26rasagiline. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31RAVICTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

129

RAYOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64REBIF (WITH ALBUMIN). . . . . . . . . . . . . . . . 75REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 22 MCG/0.5 ML, 44 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML(6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

REBIF TITRATION PACK. . . . . . . . . . . . . . . 75reclipsen (28). . . . . . . . . . . . . . . . . . . . . . . . . 84RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 77

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 10 MCG/ML. . . . . . . . . . . . . . . . . 77

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 5 MCG/0.5 ML. . . . . . . . . . . . . . . 78

RECTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71regonol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REGRANEX. . . . . . . . . . . . . . . . . . . . . . . . . . 54RELENZA DISKHALER. . . . . . . . . . . . . . . . . 10RELISTOR ORAL. . . . . . . . . . . . . . . . . . . . . 71RELISTOR SUBCUTANEOUS SOLUTION. . 71RELISTOR SUBCUTANEOUS SYRINGE. . . 71REMICADE. . . . . . . . . . . . . . . . . . . . . . . . . . 71REMODULIN. . . . . . . . . . . . . . . . . . . . . . . . . 48RENFLEXIS. . . . . . . . . . . . . . . . . . . . . . . . . . 71repaglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 66repaglinide-metformin. . . . . . . . . . . . . . . . . . 66REPATHA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52REPATHA PUSHTRONEX. . . . . . . . . . . . . . . 52REPATHA SURECLICK. . . . . . . . . . . . . . . . . 52RESCRIPTOR. . . . . . . . . . . . . . . . . . . . . . . . 10RESTASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 86RESTASIS MULTIDOSE. . . . . . . . . . . . . . . . 86RETROVIR INTRAVENOUS. . . . . . . . . . . . . 10REVATIO ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 90

REVLIMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 26revonto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REXULTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43REYATAZ ORAL CAPSULE 150 MG, 200 MG,300 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

REYATAZ ORAL POWDER IN PACKET. . . . 10ribasphere. . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ribasphere ribapak oral tablets,dose pack 200g (28)- 400 mg (28), 400-400 mg (28)-mg8), 600-400 mg (28)-mg (28), 600-600 mg8)-mg (28). . . . . . . . . . . . . . . . . . . . . . . . . 10asphere ribapak oral tablets,dose pack 200g (7)- 400 mg (7), 400 mg (7)- 400 mg (7),0 mg (7)- 400 mg (7), 600 mg (7)- 600 mg). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11avirin oral capsule. . . . . . . . . . . . . . . . . . . 11avirin oral tablet 200 mg. . . . . . . . . . . . . . . 11DAURA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80butin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16mpin intravenous. . . . . . . . . . . . . . . . . . . 16mpin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 16

FATER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16zole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61antadine. . . . . . . . . . . . . . . . . . . . . . . . . . . 11ger's intravenous. . . . . . . . . . . . . . . . . . . . 95ger's irrigation. . . . . . . . . . . . . . . . . . . . . . 59edronate oral tablet 150 mg. . . . . . . . . . . . 79edronate oral tablet 30 mg. . . . . . . . . . . . . 61edronate oral tablet 35 mg, 35 mg (12 pack), mg (4 pack). . . . . . . . . . . . . . . . . . . . . . . 79

edronate oral tablet 5 mg. . . . . . . . . . . . . . 79edronate oral tablet,delayed releaser/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

SPERDAL CONSTA. . . . . . . . . . . . . . . . . . 43peridone oral solution. . . . . . . . . . . . . . . . . 43peridone oral tablet. . . . . . . . . . . . . . . . . . 43peridone oral tablet,disintegrating. . . . . . . 43navir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

TUXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TUXAN HYCELA. . . . . . . . . . . . . . . . . . . . 26astigmine tartrate. . . . . . . . . . . . . . . . . . . . 33astigmine transdermal. . . . . . . . . . . . . . . . 33elsa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84atriptan oral tablet. . . . . . . . . . . . . . . . . . . 31atriptan oral tablet,disintegrating. . . . . . . . 31MIDEPSIN. . . . . . . . . . . . . . . . . . . . . . . . 26inirole oral tablet. . . . . . . . . . . . . . . . . . . . 31inirole oral tablet extended release 24 hr. 31ivacaine (pf) injection solution. . . . . . . . . 57adan topical cream. . . . . . . . . . . . . . . . . . 55

m(2(2

ribm60(7

ribribRIrifarifarifaRIrilurimrinrinrisrisris35

risris(d

RIrisrisrisritoRIRIrivrivrivrizrizROropropropros

130

rosadan topical gel. . . . . . . . . . . . . . . . . . . . . 55rosuvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . 52ROTARIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 78ROTATEQ VACCINE. . . . . . . . . . . . . . . . . . . 78roweepra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30roweepra xr. . . . . . . . . . . . . . . . . . . . . . . . . . 30RUBRACA. . . . . . . . . . . . . . . . . . . . . . . . . . . 26RUCONEST. . . . . . . . . . . . . . . . . . . . . . . . . . 90RYDAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

SSABRIL ORAL TABLET. . . . . . . . . . . . . . . . . 30salsalate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39SAMSCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68SANDOSTATIN LAR DEPOTINTRAMUSCULAR SUSPENSION,EXTENDED REL RECON. . . . . . . . . . . . . . 26

SANTYL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59SAPHRIS (BLACK CHERRY). . . . . . . . . . . . 43scopolamine base. . . . . . . . . . . . . . . . . . . . . 71seconal sodium. . . . . . . . . . . . . . . . . . . . . . . 43selegiline hcl. . . . . . . . . . . . . . . . . . . . . . . . . 31selenium sulfide topical lotion. . . . . . . . . . . . 54SELZENTRY. . . . . . . . . . . . . . . . . . . . . . . . . . 11SENSIPAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 68sensorcaine injection solution 0.5 % (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

sensorcaine-mpf injection solution 0.5 % (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

sensorcaine/epinephrine. . . . . . . . . . . . . . . . 57SEREVENT DISKUS. . . . . . . . . . . . . . . . . . . 91SEROSTIM SUBCUTANEOUS RECON SOLN4 MG, 5 MG, 6 MG. . . . . . . . . . . . . . . . . . . . 75

sertraline oral concentrate. . . . . . . . . . . . . . . 43sertraline oral tablet. . . . . . . . . . . . . . . . . . . . 43setlakin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84sevelamer carbonate oral powder in packet. 61sevelamer carbonate oral tablet. . . . . . . . . . 61sf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62sf 5000 plus. . . . . . . . . . . . . . . . . . . . . . . . . . 62sharobel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81SHINGRIX (PF). . . . . . . . . . . . . . . . . . . . . . . 78SIGNIFOR. . . . . . . . . . . . . . . . . . . . . . . . . . . 26

SIGNIFOR LAR. . . . . . . . . . . . . . . . . . . . . . . 26nafil (pulmonary arterial hypertension)avenous solution 10 mg/12.5 ml. . . . . . . 91nafil (pulmonary arterial hypertension) orallet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 91r sulfadiazine. . . . . . . . . . . . . . . . . . . . . 54PONI ARIA. . . . . . . . . . . . . . . . . . . . . . . 80PONI SUBCUTANEOUS PEN INJECTOR MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 80

PONI SUBCUTANEOUS PEN INJECTORMG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . 80PONI SUBCUTANEOUS SYRINGE 100/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80PONI SUBCUTANEOUS SYRINGE 50/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 80ULECT INTRAVENOUS RECON SOLN 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ULECT INTRAVENOUS RECON SOLN 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26astatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 52

limus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TURO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16EXTRO INTRAVENOUS. . . . . . . . . . . . . 16EXTRO ORAL. . . . . . . . . . . . . . . . . . . . . 16

FLIPID. . . . . . . . . . . . . . . . . . . . . . . . . . 97ium acetate. . . . . . . . . . . . . . . . . . . . . . . 95ium benzoate-sod phenylacet. . . . . . . . . 61ium bicarbonate intravenous solution. . . 95ium bicarbonate intravenous syringe 10q/10 ml (8.4 %), 7.5 % (0.9 meq/ml). . . . 95ium bicarbonate intravenous syringe 4.2 %5 meq/ml), 8.4 % (1 meq/ml). . . . . . . . . . 95ium chlor 0.9% bacteriostat. . . . . . . . . . . 61ium chloride 0.45 % intravenous parenteralution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ium chloride 0.45 % intravenousgyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 95ium chloride 0.9 % injection solution. . . . 61ium chloride 0.9 % injection syringe. . . . . 61ium chloride 0.9 % intravenous parenteralution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61ium chloride 0.9 % intravenous piggyback 61ium chloride 3 %. . . . . . . . . . . . . . . . . . . 95ium chloride 5 %. . . . . . . . . . . . . . . . . . . 95

sildeintr

sildetab

silveSIMSIM100

SIM50

SIMMG

SIMMG

SIMMG

SIMMG

simvsiroSIRSIVSIVSMOsodsodsodsodme

sod(0.

sodsodsol

sodpig

sodsodsodsol

sodsodsod

131

sodium chloride inhalation. . . . . . . . . . . . . . . 91sodium chloride intravenous parenteral solution2.5 meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 95

sodium chloride intravenous parenteral solution4 meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 96

sodium chloride irrigation. . . . . . . . . . . . . . . . 61sodium lactate intravenous. . . . . . . . . . . . . . 96sodium nitroprusside. . . . . . . . . . . . . . . . . . . 53sodium phenylbutyrate. . . . . . . . . . . . . . . . . . 61sodium phosphate. . . . . . . . . . . . . . . . . . . . . 96sodium polystyrene (sorb free). . . . . . . . . . . 61sodium polystyrene sulfonate oral. . . . . . . . . 61sodium polystyrene sulfonate rectal enema 30gram/120 ml. . . . . . . . . . . . . . . . . . . . . . . . . 61

soloxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19SOLTAMOX. . . . . . . . . . . . . . . . . . . . . . . . . . 26SOMATULINE DEPOT. . . . . . . . . . . . . . . . . . 26SOMAVERT. . . . . . . . . . . . . . . . . . . . . . . . . . 68SORBITOL IRRIGATION. . . . . . . . . . . . . . . . 59sorine oral tablet 120 mg, 160 mg, 80 mg. . . 45sorine oral tablet 240 mg. . . . . . . . . . . . . . . . 45sotalol af. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45sotalol oral. . . . . . . . . . . . . . . . . . . . . . . . . . . 45SOVALDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11SPIRIVA RESPIMAT. . . . . . . . . . . . . . . . . . . 91SPIRIVA WITH HANDIHALER. . . . . . . . . . . . 91spironolacton-hydrochlorothiaz. . . . . . . . . . . 48spironolactone. . . . . . . . . . . . . . . . . . . . . . . . 48sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . . . 84SPRITAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30SPRYCEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26sps (with sorbitol) oral. . . . . . . . . . . . . . . . . . 61sps (with sorbitol) rectal. . . . . . . . . . . . . . . . . 61sronyx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84ssd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54STAMARIL (PF). . . . . . . . . . . . . . . . . . . . . . . 78stavudine oral capsule. . . . . . . . . . . . . . . . . . 11STELARA INTRAVENOUS. . . . . . . . . . . . . . 54STELARA SUBCUTANEOUS. . . . . . . . . . . . 54STIMATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68STIOLTO RESPIMAT. . . . . . . . . . . . . . . . . . . 91STIVARGA. . . . . . . . . . . . . . . . . . . . . . . . . . . 26

STRENSIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 68STREPTOMYCIN. . . . . . . . . . . . . . . . . . . . . . 16STRIBILD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11STRIVERDI RESPIMAT. . . . . . . . . . . . . . . . . 91SUBOXONE. . . . . . . . . . . . . . . . . . . . . . . . . . 39SUCRAID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72sucralfate oral tablet. . . . . . . . . . . . . . . . . . . 74sulfacetamide sodium (acne). . . . . . . . . . . . . 57sulfacetamide sodium ophthalmic (eye). . . . 88sulfacetamide-prednisolone. . . . . . . . . . . . . . 87sulfadiazine. . . . . . . . . . . . . . . . . . . . . . . . . . 19sulfamethoxazole-trimethoprim intravenous. 19sulfamethoxazole-trimethoprim oral. . . . . . . . 19SULFAMYLON TOPICAL CREAM. . . . . . . . 57sulfasalazine oral tablet. . . . . . . . . . . . . . . . . 72sulfasalazine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

sulfatrim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19sulindac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39sumatriptan nasal spray,non-aerosol 20mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan nasal spray,non-aerosol 5mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate oral. . . . . . . . . . . . . . . 31sumatriptan succinate subcutaneouscartridge. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate subcutaneous peninjector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate subcutaneous solution 32sumatriptan-naproxen. . . . . . . . . . . . . . . . . . 32SUPARTZ FX. . . . . . . . . . . . . . . . . . . . . . . . . 39SUPRAX ORAL CAPSULE. . . . . . . . . . . . . . 13SUPRAX ORAL TABLET,CHEWABLE. . . . . 13SUSTIVA ORAL CAPSULE 200 MG. . . . . . . 11SUSTIVA ORAL TABLET. . . . . . . . . . . . . . . . 11SUTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26syeda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84SYLATRON. . . . . . . . . . . . . . . . . . . . . . . . . . 75SYLVANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26SYMBICORT. . . . . . . . . . . . . . . . . . . . . . . . . 91SYMFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11SYMFI LO. . . . . . . . . . . . . . . . . . . . . . . . . . . 11SYMLINPEN 120. . . . . . . . . . . . . . . . . . . . . . 66

132

SYMLINPEN 60. . . . . . . . . . . . . . . . . . . . . . . 66SYNAGIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11SYNAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 68SYNDROS. . . . . . . . . . . . . . . . . . . . . . . . . . . 72SYNERCID. . . . . . . . . . . . . . . . . . . . . . . . . . . 16SYNJARDY. . . . . . . . . . . . . . . . . . . . . . . . . . . 66SYNJARDY XR. . . . . . . . . . . . . . . . . . . . . . . 66SYNRIBO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26SYNVISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39SYNVISC-ONE. . . . . . . . . . . . . . . . . . . . . . . 39SYPRINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61syrex sodium chloride 0.9 %. . . . . . . . . . . . . 61

TTABLOID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26tacrolimus oral. . . . . . . . . . . . . . . . . . . . . . . . 26tacrolimus topical. . . . . . . . . . . . . . . . . . . . . . 54TAFINLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 26TAGRISSO. . . . . . . . . . . . . . . . . . . . . . . . . . . 27tamoxifen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27tamsulosin oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

TARCEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27TARGRETIN 1% GEL. . . . . . . . . . . . . . . . . . 27tarina fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 84TASIGNA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27tazarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 55TAZORAC TOPICAL CREAM 0.05 %. . . . . . 55TAZORAC TOPICAL GEL. . . . . . . . . . . . . . . 55taztia xt oral capsule, extended release. . . . 48TECENTRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 27TECFIDERA. . . . . . . . . . . . . . . . . . . . . . . . . . 33TECHNIVIE. . . . . . . . . . . . . . . . . . . . . . . . . . 11TEFLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13TEKTURNA. . . . . . . . . . . . . . . . . . . . . . . . . . 48TEKTURNA HCT. . . . . . . . . . . . . . . . . . . . . . 48telmisartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 48telmisartan-amlodipine. . . . . . . . . . . . . . . . . . 48telmisartan-hydrochlorothiazid. . . . . . . . . . . . 48temazepam. . . . . . . . . . . . . . . . . . . . . . . . . . 44TEMODAR INTRAVENOUS. . . . . . . . . . . . . 27TEMODAR ORAL. . . . . . . . . . . . . . . . . . . . . 27

temozolomide. . . . . . . . . . . . . . . . . . . . . . . . . 27encon oral tablet 50-325 mg. . . . . . . . . . . . . 37ENIVAC (PF). . . . . . . . . . . . . . . . . . . . . . . . 78

enofovir disoproxil fumarate. . . . . . . . . . . . . 11erazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48erbinafine hcl oral. . . . . . . . . . . . . . . . . . . . . . 8erbutaline. . . . . . . . . . . . . . . . . . . . . . . . . . . 91erconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 82estosterone cypionate. . . . . . . . . . . . . . . . . . 68estosterone enanthate. . . . . . . . . . . . . . . . . 68estosterone transdermal gel (generic). . . . . 68estosterone transdermal gel in metered-dosepump 12.5 mg/ 1.25 gram (1 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68estosterone transdermal gel in packet(Androgel generic). . . . . . . . . . . . . . . . . . . . 68estosterone transdermal solution in meteredpump w/app (Axiron generic). . . . . . . . . . . . 68ETANUS,DIPHTHERIA TOX PED(PF). . . . 78ETANUS-DIPHTHERIA TOXOIDS-TD. . . . 78

etrabenazine. . . . . . . . . . . . . . . . . . . . . . . . . 33etracycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 20HALOMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 27

heophylline in dextrose 5 % intravenousparenteral solution 200 mg/100 ml, 200 mg/50ml, 400 mg/250 ml, 400 mg/500 ml, 800mg/250 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 91heophylline oral elixir. . . . . . . . . . . . . . . . . . 91heophylline oral solution. . . . . . . . . . . . . . . . 91heophylline oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91heophylline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91HIOLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

hioridazine. . . . . . . . . . . . . . . . . . . . . . . . . . . 44hiotepa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27hiothixene. . . . . . . . . . . . . . . . . . . . . . . . . . . 44hyroid (pork) oral tablet 30 mg, 60 mg. . . . . 69hyroid (pork) oral tablet 90 mg. . . . . . . . . . . 69iagabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ICE BCG. . . . . . . . . . . . . . . . . . . . . . . . . . . 78

igecycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 16ilia fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84imolol maleate ophthalmic (eye). . . . . . . . . . 86

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133

timolol maleate oral. . . . . . . . . . . . . . . . . . . . 49tinidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16tis-u-sol pentalyte. . . . . . . . . . . . . . . . . . . . . . 59TIVICAY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11tizanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34TOBI PODHALER INHALATION CAPSULE. 16TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 16

tobramycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 85tobramycin in 0.225 % nacl. . . . . . . . . . . . . . 16tobramycin sulfate injection recon soln. . . . . 16tobramycin sulfate injection solution. . . . . . . 16tobramycin-dexamethasone. . . . . . . . . . . . . 87tolazamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 67tolbutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 67tolcapone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31tolmetin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39tolterodine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

tolterodine oral tablet. . . . . . . . . . . . . . . . . . . 92topiramate oral capsule, sprinkle. . . . . . . . . . 30topiramate oral tablet. . . . . . . . . . . . . . . . . . . 30toposar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27topotecan intravenous recon soln. . . . . . . . . 27topotecan intravenous solution. . . . . . . . . . . 27TORISEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27torsemide oral. . . . . . . . . . . . . . . . . . . . . . . . 49TOUJEO MAX SOLOSTAR. . . . . . . . . . . . . . 67TOUJEO SOLOSTAR U-300 INSULIN. . . . . 67TRACLEER. . . . . . . . . . . . . . . . . . . . . . . . . . 91tramadol oral tablet. . . . . . . . . . . . . . . . . . . . 39tramadol oral tablet extended release 24 hr. 39tramadol oral tablet, er multiphase 24 hr. . . . 39tramadol-acetaminophen. . . . . . . . . . . . . . . . 39trandolapril. . . . . . . . . . . . . . . . . . . . . . . . . . . 49trandolapril-verapamil oral tablet, ir - er, biphasic24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

tranexamic acid intravenous. . . . . . . . . . . . . 51tranexamic acid oral. . . . . . . . . . . . . . . . . . . . 82tranylcypromine. . . . . . . . . . . . . . . . . . . . . . . 44travasol 10 %. . . . . . . . . . . . . . . . . . . . . . . . . 97TRAVATAN Z. . . . . . . . . . . . . . . . . . . . . . . . . 87

trazodone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44TREANDA INTRAVENOUS RECON SOLN. 27TRECATOR. . . . . . . . . . . . . . . . . . . . . . . . . . 16TRELSTAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 27tretinoin (chemotherapy). . . . . . . . . . . . . . . . 27tretinoin microspheres. . . . . . . . . . . . . . . . . . 55tretinoin topical. . . . . . . . . . . . . . . . . . . . . . . . 55tri femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-legest fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-lo-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . 84tri-lo-marzia. . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-lo-sprintec. . . . . . . . . . . . . . . . . . . . . . . . . 84tri-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84tri-previfem (28). . . . . . . . . . . . . . . . . . . . . . . 84tri-sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . 84tri-vitamin with fluoride. . . . . . . . . . . . . . . . . . 98tri-vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84triamcinolone acetonide dental. . . . . . . . . . . 62triamcinolone acetonide injection. . . . . . . . . . 64triamcinolone acetonide topical aerosol. . . . . 58triamcinolone acetonide topical cream. . . . . 58triamcinolone acetonide topical lotion. . . . . . 58triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %. . . . . . . . . . . . . . . . . 58

triamterene-hydrochlorothiazid. . . . . . . . . . . 49trianex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58triazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44triderm topical cream 0.1 %. . . . . . . . . . . . . . 58triderm topical cream 0.5 %. . . . . . . . . . . . . . 58trientine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61trifluoperazine. . . . . . . . . . . . . . . . . . . . . . . . . 44trifluridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86trihexyphenidyl. . . . . . . . . . . . . . . . . . . . . . . . 31triklo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52trilyte with flavor packets. . . . . . . . . . . . . . . . 72trimethobenzamide oral. . . . . . . . . . . . . . . . . 72trimethoprim. . . . . . . . . . . . . . . . . . . . . . . . . . 20trimipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 44trinessa (28). . . . . . . . . . . . . . . . . . . . . . . . . . 84trinessa lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 84

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TRINTELLIX. . . . . . . . . . . . . . . . . . . . . . . . . . 44TRISENOX INTRAVENOUS SOLUTION 2MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

TRIUMEQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11trivora (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 84TROGARZO. . . . . . . . . . . . . . . . . . . . . . . . . . 11TROKENDI XR. . . . . . . . . . . . . . . . . . . . . . . 30TROPHAMINE 10 %. . . . . . . . . . . . . . . . . . . 97TROPHAMINE 6%. . . . . . . . . . . . . . . . . . . . . 97trospium oral capsule,extended release 24hr 92trospium oral tablet. . . . . . . . . . . . . . . . . . . . 92TRULICITY. . . . . . . . . . . . . . . . . . . . . . . . . . . 67TRUMENBA. . . . . . . . . . . . . . . . . . . . . . . . . . 78TRUVADA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11tulana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81TWINRIX (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 78

TYBOST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11tydemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84TYGACIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16TYKERB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27TYMLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79TYPHIM VI INTRAMUSCULAR SOLUTION. 78TYPHIM VI INTRAMUSCULAR SYRINGE. . 78TYSABRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33TYVASO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91TYVASO INSTITUTIONAL START KIT. . . . . 91TYVASO REFILL KIT. . . . . . . . . . . . . . . . . . . 91TYVASO STARTER KIT. . . . . . . . . . . . . . . . . 91

UUCERIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72ULORIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78unithroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69UNITUXIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 27UPTRAVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ursodiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72UVADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Vvalacyclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 11VALCHLOR. . . . . . . . . . . . . . . . . . . . . . . . . . 54

valganciclovir oral recon soln. . . . . . . . . . . . . 11valganciclovir oral tablet. . . . . . . . . . . . . . . . . 11valproate sodium. . . . . . . . . . . . . . . . . . . . . . 30valproic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 30valproic acid (as sodium salt) oral solution 250mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

valproic acid (as sodium salt) oral solution 250mg/5 ml (5 ml), 500 mg/10 ml (10 ml). . . . . 30

valsartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49valsartan-hydrochlorothiazide. . . . . . . . . . . . 49VALSTAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 1 GRAM/200 ML (BRAND). . 20

VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 500 MG/100 ML, 750 MG/150ML (BRAND). . . . . . . . . . . . . . . . . . . . . . . . 20

VANCOMYCIN IN DEXTROSE ISO-OSM(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

VANCOMYCIN INJECTION (BRAND). . . . . . 20vancomycin intravenous recon soln 1,000 mg,10 gram, 500 mg. . . . . . . . . . . . . . . . . . . . . 20

vancomycin intravenous recon soln 5 gram, 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

vancomycin oral capsule. . . . . . . . . . . . . . . . 20vandazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 82VANTAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27VAQTA (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 78VARIVAX (PF). . . . . . . . . . . . . . . . . . . . . . . . 78VARIZIG INTRAMUSCULAR SOLUTION. . . 78VARUBI INTRAVENOUS. . . . . . . . . . . . . . . . 72VARUBI ORAL. . . . . . . . . . . . . . . . . . . . . . . . 72VECAMYL. . . . . . . . . . . . . . . . . . . . . . . . . . . 53VECTIBIX INTRAVENOUS SOLUTION 100MG/5 ML (20 MG/ML). . . . . . . . . . . . . . . . . 27

VECTIBIX INTRAVENOUS SOLUTION 400MG/20 ML (20 MG/ML). . . . . . . . . . . . . . . . 27

VELCADE. . . . . . . . . . . . . . . . . . . . . . . . . . . 27veletri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49velivet triphasic regimen (28). . . . . . . . . . . . . 85VELTASSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 61VEMLIDY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11VENCLEXTA. . . . . . . . . . . . . . . . . . . . . . . . . 27VENCLEXTA STARTING PACK. . . . . . . . . . 27

135

venlafaxine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

venlafaxine oral tablet. . . . . . . . . . . . . . . . . . 44venlafaxine oral tablet extended release 24hr150 mg, 37.5 mg, 75 mg. . . . . . . . . . . . . . . 44

VENLAFAXINE ORAL TABLET EXTENDEDRELEASE 24HR 225 MG (BRAND). . . . . . . 44

VENTAVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 91verapamil intravenous solution. . . . . . . . . . . 49verapamil intravenous syringe. . . . . . . . . . . . 49verapamil oral capsule, 24 hr er pellet ct. . . . 49verapamil oral capsule,ext rel. pellets 24 hr. . 49verapamil oral tablet. . . . . . . . . . . . . . . . . . . 49verapamil oral tablet extended release. . . . . 49veripred 20. . . . . . . . . . . . . . . . . . . . . . . . . . . 64VERSACLOZ. . . . . . . . . . . . . . . . . . . . . . . . . 44VERZENIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 27vestura (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85VIBATIV INTRAVENOUS RECON SOLN 750MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

vicodin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37vicodin es. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37vicodin hp. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37VIDEX 2 GRAM PEDIATRIC. . . . . . . . . . . . . 11VIDEX 4 GRAM PEDIATRIC. . . . . . . . . . . . . 11VIDEX EC ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 125 MG. . . . . . . . . . . . . 11

VIEKIRA PAK. . . . . . . . . . . . . . . . . . . . . . . . . 11VIEKIRA XR. . . . . . . . . . . . . . . . . . . . . . . . . . 11vienva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85vigabatrin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30VIIBRYD ORAL TABLET. . . . . . . . . . . . . . . . 44VIIBRYD ORAL TABLETS,DOSE PACK 10 MG(7)- 20 MG (23). . . . . . . . . . . . . . . . . . . . . . 44

VIMIZIM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68VIMPAT INTRAVENOUS. . . . . . . . . . . . . . . . 30VIMPAT ORAL SOLUTION. . . . . . . . . . . . . . 30VIMPAT ORAL TABLET. . . . . . . . . . . . . . . . . 30vinblastine intravenous solution. . . . . . . . . . . 27vincasar pfs intravenous solution 1 mg/ml. . . 27vincasar pfs intravenous solution 2 mg/2 ml. 27vincristine intravenous solution 1 mg/ml. . . . 27vincristine intravenous solution 2 mg/2 ml. . . 27

vinorelbine intravenous solution 10 mg/ml. . . 27vinorelbine intravenous solution 50 mg/5 ml. 27viorele (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 85VIRACEPT ORAL TABLET. . . . . . . . . . . . . . . 11VIRAMUNE ORAL SUSPENSION. . . . . . . . . 11VIREAD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11VISCO-3. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VISTOGARD. . . . . . . . . . . . . . . . . . . . . . . . . 21vitamins a,c,d and fluoride. . . . . . . . . . . . . . . 98voriconazole intravenous. . . . . . . . . . . . . . . . . 8voriconazole oral. . . . . . . . . . . . . . . . . . . . . . . 8VOSEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11VOTRIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 27VRAYLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44vyfemla (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85VYXEOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Wwarfarin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51water for inject, bacteriostat. . . . . . . . . . . . . . 61water for irrigation, sterile. . . . . . . . . . . . . . . 62wera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 85wymzya fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 85

XXALKORI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XATMEP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XELODA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28XEOMIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78XERMELO. . . . . . . . . . . . . . . . . . . . . . . . . . . 28XGEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21XIFAXAN ORAL TABLET 550 MG. . . . . . . . . 16XIGDUO XR. . . . . . . . . . . . . . . . . . . . . . . . . . 67XOLAIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91XTANDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28xulane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82XURIDEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62xylocaine dental-epinephrine. . . . . . . . . . . . . 57xylon 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37XYREM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

136

YYERVOY INTRAVENOUS SOLUTION 200MG/40 ML (5 MG/ML). . . . . . . . . . . . . . . . . 28

YERVOY INTRAVENOUS SOLUTION 50MG/10 ML (5 MG/ML). . . . . . . . . . . . . . . . . 28

YF-VAX (PF). . . . . . . . . . . . . . . . . . . . . . . . . 78YONDELIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 28yuvafem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Zzafirlukast. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91zaleplon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ZALTRAP INTRAVENOUS SOLUTION 100MG/4 ML (25 MG/ML). . . . . . . . . . . . . . . . . 28

ZALTRAP INTRAVENOUS SOLUTION 200MG/8 ML (25 MG/ML). . . . . . . . . . . . . . . . . 28

ZANOSAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 28zarah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85ZARXIO INJECTION SYRINGE 300 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

ZARXIO INJECTION SYRINGE 480 MCG/0.8ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

ZAVESCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68zebutal oral capsule 50-325-40 mg. . . . . . . . 37ZEJULA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZELAPAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ZELBORAF. . . . . . . . . . . . . . . . . . . . . . . . . . . 28zenatane. . . . . . . . . . . . . . . . . . . . . . . . . . . . 55zenchent (28). . . . . . . . . . . . . . . . . . . . . . . . . 85ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 10,000-32,000 -42,000UNIT, 10,000-34,000 -55,000 UNIT,15,000-51,000 -82,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-79,000- 105,000 UNIT,25,000-85,000- 136,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-126,000-. . . . . . . . . . . 72

ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 15,000-47,000 -63,000UNIT, 3,000-10,000 -14,000-UNIT. . . . . . . . 72

zenzedi oral tablet 10 mg, 5 mg. . . . . . . . . . . 44ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20MG, 30 MG, 7.5 MG (BRAND). . . . . . . . . . . 44

ZEPATIER. . . . . . . . . . . . . . . . . . . . . . . . . . . 11ZERBAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 13

ZERIT ORAL RECON SOLN. . . . . . . . . . . . . 11ZIAGEN ORAL SOLUTION. . . . . . . . . . . . . . 11zidovudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 11zileuton oral tablet,extended release 12hrmphase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

ZINPLAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 78ziprasidone hcl. . . . . . . . . . . . . . . . . . . . . . . . 44ZIRGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ZOLADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 28zoledronic acid intravenous solution. . . . . . . 68zoledronic acid-mannitol-water. . . . . . . . . . . 62ZOLINZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28zolmitriptan oral tablet 2.5 mg. . . . . . . . . . . . 32zolmitriptan oral tablet 5 mg. . . . . . . . . . . . . . 32zolmitriptan oral tablet,disintegrating 2.5 mg. 32zolmitriptan oral tablet,disintegrating 5 mg. . 32zolpidem oral tablet. . . . . . . . . . . . . . . . . . . . 44zolpidem oral tablet,ext release multiphase. . 44zolpidem sublingual. . . . . . . . . . . . . . . . . . . . 44ZOMETA INTRAVENOUS PIGGYBACK. . . . 68ZOMIG NASAL. . . . . . . . . . . . . . . . . . . . . . . 32zonisamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZORBTIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 75ZORTRESS. . . . . . . . . . . . . . . . . . . . . . . . . . 28ZOSTAVAX (PF). . . . . . . . . . . . . . . . . . . . . . 78zovia 1/35e (28). . . . . . . . . . . . . . . . . . . . . . . 85zovia 1/50e (28). . . . . . . . . . . . . . . . . . . . . . . 85ZOVIRAX TOPICAL CREAM. . . . . . . . . . . . . 57ZURAMPIC. . . . . . . . . . . . . . . . . . . . . . . . . . 78ZYDELIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYKADIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ZYPREXA RELPREVV. . . . . . . . . . . . . . . . . 44ZYTIGA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

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135

Nondiscrimination NoticeBlue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

Blue Cross Blue Shield of Massachusetts provides:• Free aids and services to people with disabilities to communicate effectively with us, such as

qualified sign language interpreters and written information in other formats (large print or other formats).

• Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Laureen Corey, Medicare Advantage Appeals and Grievance Manager.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Laureen Corey, Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from February 15 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through February 14, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711).

If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at www.hhs.gov.

136XX

Translation ResourcesProficiency of Language Assistance Services

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

English: ATT ENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711). Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711)

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

Mon-Khmer, Cambodian/ : 1-800-200-4255 (TTY: 711).

Arabic/خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 4255-200-800-1 (رقم :ةيبرعلا ھاتف الصم والبكم: 711).ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن

Chinese/繁體中文: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。

請致電 1-800-200-4255 (TTY: 711)..

Translation Resources Proficiency of Language Assistance Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

Chinese/繁體中文: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/االعربية: ملحوظة: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-200-4255

.(هاتف الصم والبكم: 711)

Mon-Khmer, Cambodian/ : 1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711). 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).Hindi/1-800-200-4255 (TTY: 711)Gujarati/ : 1-800-200-4255 (TTY: 711)

This formulary was updated on 07/01/2018. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit www.bluecrossma.com/medicare.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.The Formulary may change at any time. You will receive notice when necessary. ®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of the medications listed are the property of their respective manufacturers. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

175281-7 55-0184-18 (7/18)

Documents

2018 FORMULARY - Blue Cross Blue Shield of … FORMULARY (List of Covered Drugs) Note to existing members: This formulary has changed since last year. Please review this document to