2018 Health Choice Utah Formulary€¦ · Product Selection Criteria The Health Choice Pharmacy ... prescribed brand name product. An important consideration for generic ... compared

2018 Health Choice Utah Formulary

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Familia! Updated January 2018

What is the Health Choice Utah Formulary/Preferred Drug List (PDL)?

A Formulary / Preferred Drug List (PDL) is a list of drugs chosen by Health Choice Utah and a team of doctors and pharmacists. Health Choice will cover the drugs listed in our PDL as long as they are medically necessary and appropriate. All Health Choice member prescriptions must be filled at a Health Choice network pharmacy, and other plan rules must be followed.

What if a drug is not on the Formulary/ PDL? If a drug you want to prescribe for your patient is not on this Formulary / PDL, the prescriber can:

Prescribe a similar drug that is Formulary / PDL covered, or Ask Health Choice to make an exception and cover the medically necessary, non-formulary

drug through the prior authorization process.

Can the Formulary / PDF change? Yes, Health Choice may add or take off drugs during the year. To get the latest information about covered drugs, go to our website at www.HealthChoiceUtah.com or call Health Choice Member Services at 877-358-8797.

Product Selection Criteria The Health Choice Pharmacy & Therapeutics Committee will consider and advise Health Choice on all new-to-market drugs and will continually review and evaluate existing market drugs for formulary/PDL inclusion. The committee’s evaluation includes a current literature review. Expert external opinion may also be sought. Formal reviews are prepared that typically address the following information:

Safety Efficacy Comparison studies Approved indications Adverse effects Contraindications, warnings and precautions Pharmacokinetics Cost-effectiveness Patient administration and compliance considerations

When a new drug is considered for formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion of one or more drugs in a particular therapeutic class in an effort to continually promote the most clinically useful and cost- effective agents. The entire formulary / PDL is reviewed and approved annually. Prior authorization (PA) is required for two groups of medications and for two clinical formulary/ PDL override conditions:

Medication Groups Medications noted with a PA in the formulary / PDL. All unlisted medications.

i

ii

Clinical Override Conditions To override a Step Therapy (ST) edit. To override a Quantity Limit (QL) edit.

Health Choice anticipates that requests for an unlisted medication will be infrequent and providers will be able to prescribe a formulary / PDL medication for the vast majority of therapeutic needs. Providers are encouraged to use this formulary / PDL when prescribing medications for Health Choice members to avoid unnecessary delays in therapy.

Off label drugs may be prior authorized when the use of the drug has proven to be the community standard. Health Choice providers may formally request the Health Choice Pharmacy & Therapeutics Committee consider a medication be considered for addition to the formulary / PDL. The instructions and required submission form(s) which indicate how to submit a formulary / PDL medication consideration request are detailed in the Health Choice Provider Manual. The instructions and materials are also available on the Health Choice website. All the information in the Health Choice formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

Formulary Product Descriptions

To assist in understanding which specific strengths and dosage forms are on the formulary, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are on formulary.

Generic drugs are identified in lower case type, whereas brand drugs are identified in all caps

allopurinol is a generic drug ULORIC is a brand drug

The brand name products shown are for reference only; a different brand or a generic version may be dispensed.

simvastatin ZOCOR

Extended-release and delayed-release products require their own entry. Identified below, both propranolol and propranolol SR are on the formulary.

propranolol INDERAL propranolol SR INDERAL LA

Dose forms on formulary will be consistent with the category and use where listed. Identified below from Otic group, the otic solution and ophthalmic ointment are on the formulary, and the ophthalmic products and topical cream cannot be assumed to be on formulary unless there are entries for these products in the OPHTHALMIC and DERMATOLOGY sections of the formulary.

neomycin/polymyxin B/hydrocortisone CORTISPORIN

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Generic Substitution

Utah Medicaid health plans are required to utilize a mandatory generic drug substitution policy. Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand name product.

To gain FDA approval:

1. The generic drug must contain the same active ingredient(s), be the same strength and the

same dosage form as the brand name product. 2. The FDA has given the generic an "A" rating compared to the brand name product indicating

bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand name product. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book).

When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the healthcare practitioner to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the practitioner are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product.

It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange Book and carry a "B" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. It is also recommended that generic substitution not be undertaken for any unrated multisource products that might be considered narrow therapeutic index, or maintenance drugs where it is known that unrated products from different labelers are not bioequivalent. State law or regulations may dictate the ability to practice generic substitution for selected products or categories of drugs.

Drug Efficacy Study Implementation Drugs Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products.

Utah Medicaid and Health Choice will not pay for DESI "less than fully effective" drug products.

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Pharmacy Benefit Manager (PBM)

Health Choice Utah uses EnvisionRx to process our prescription drug claims

LEGEND

Boldface Indicates generic availability

OTC Over-the-Counter

PA Prior Authorization Required

QL Quantity Level Limit

ST Step Therapy through prerequisite drug required

Editor

Your comments and suggestions regarding the Health Choice Formulary are encouraged. Your input is vital to this clinical formulary’s continued success. All responses will be reviewed and considered. Please send comments to: Pharmacy Services Department Health Choice Utah 410 N 44th Street, Suite 405 Phoenix, AZ 85008

Notice

The information contained in this document is proprietary information. The information may not be copied in whole or in part without written permission of Health Choice Utah. © Copyright 2013. All rights reserved. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Health Choice. These trademarked brand names are included for informational purposes only and are not intended to imply or suggest any affiliation between Health Choice and such third-party pharmaceutical companies.

PA: Prior Authorization Required, ST: Step Therapy Required, QL: Quantity Limit applies to drug, SP: Specialty Drug

1

Health Choice Utah Formulary Effective January 1, 2018

Product Reference Brand-

Generic Requirements/Limits

*ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

modafinil oral tablet 100 mg, 200 mg Provigil G PA

*Aminoglycosides*

BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML

B

KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 MG/5ML

B

SP

neomycin sulfate oral tablet 500 mg G

paromomycin sulfate oral capsule 250 mg G

*Analgesics - Anti-Inflammatory*

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

CeleBREX G

PA

diclofenac potassium oral tablet 50 mg G

diclofenac sodium er oral tablet extended release 24 hour 100 mg

G

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

G

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML

B

PA; SP; QL (4.08 ML per28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML

B


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG

B

PA; SP; QL (8 EA per 28 days)

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

B


ENBREL MINI CARTRIDGE SUBCUTANEOUS SOLUTION 50 MG/ML

B PA; SP; QL (3.92 ML per28 days)

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg

G

etodolac oral capsule 200 mg, 300 mg G

etodolac oral tablet 400 mg Lodine G

etodolac oral tablet 500 mg G

fenoprofen calcium oral tablet 600 mg ProFeno G

flurbiprofen oral tablet 100 mg, 50 mg G


2

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

B



3

Product Reference Brand- Generic

Requirements/Limits

HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML

B


HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

B


HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

B


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML

B


ibuprofen childrens oral suspension 100 mg/5ml

Ibuprofen Childrens G

OTC

ibuprofen junior strength oral tablet chewable 100 mg

Advil Junior Strength G

OTC

ibuprofen oral capsule 200 mg Advil Migraine G OTC

ibuprofen oral tablet 200 mg Motrin IB G OTC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg G

INDOCIN ORAL SUSPENSION 25 MG/5ML B

INDOCIN RECTAL SUPPOSITORY 50 MG B

indomethacin er oral capsule extended release 75 mg

G

indomethacin oral capsule 25 mg, 50 mg G

infants ibuprofen oral suspension 50 mg/1.25ml

Medi-Profen G

OTC

ketoprofen oral capsule 50 mg, 75 mg G

leflunomide oral tablet 10 mg, 20 mg Arava G

meloxicam oral tablet 15 mg, 7.5 mg Mobic G

nabumetone oral tablet 500 mg, 750 mg G

naproxen dr oral tablet delayed release 375 mg, 500 mg

EC-Naprosyn G

naproxen oral suspension 125 mg/5ml Naprosyn G

naproxen oral tablet 250 mg, 500 mg Naprosyn G

naproxen oral tablet 375 mg G

naproxen sodium oral tablet 220 mg Flanax Pain Relief G OTC

naproxen sodium oral tablet 275 mg G

oxaprozin oral tablet 600 mg Daypro G

piroxicam oral capsule 10 mg, 20 mg Feldene G

RIDAURA ORAL CAPSULE 3 MG B

ibuprofen jr oral tablet 100 mg Advil Junior Strength G OTC

sulindac oral tablet 150 mg, 200 mg G

*Analgesics - Nonnarcotic*

acetaminophen er oral tablet extended release 650 mg

Tylenol 8 Hour G

OTC


4


Requirements/Limits

acetaminophen extra strength oral liquid 500 mg/15ml

Chloraseptic Sore Throat G

OTC

acetaminophen extra strength oral tablet 500 mg

Tylenol Extra Strength G

OTC

acetaminophen junior strength oral tablet dispersible 160 mg

G

OTC

acetaminophen oral capsule 500 mg G OTC

acetaminophen oral elixir 160 mg/5ml Medi-Tabs Childrens G OTC

acetaminophen oral liquid 160 mg/5ml Little Remedies for Fever G OTC

acetaminophen oral solution 160 mg/5ml G OTC

acetaminophen oral tablet 325 mg Tylenol G OTC

acetaminophen oral tablet chewable 80 mg Childrens Medi-Tabs G OTC

adult aspirin ec low strength oral tablet delayed release 81 mg

Ecotrin Low Strength G

OTC

aspirin childrens oral tablet chewable 81 mg Bayer Low Dose G OTC

aspirin ec oral tablet delayed release 325 mg Bayer Aspirin Regimen G OTC

aspirin oral tablet 325 mg Bayer Advanced Aspirin Reg St

G

OTC

aspirin rectal suppository 300 mg, 600 mg G OTC

bayer advanced aspirin ex st oral tablet 500 mg

G

OTC

buffered aspirin oral tablet 325 mg Bufferin G OTC

butalbital-acetaminophen oral tablet 50-325 mg

Tencon G

butalbital-apap-caffeine oral capsule 50-300- 40 mg

Fioricet G

butalbital-apap-caffeine oral capsule 50-325- 40 mg

Zebutal G

butalbital-apap-caffeine oral tablet 50-325-40 mg

Esgic G

butalbital-asa-caffeine oral capsule 50-325-40 mg

Fiorinal G

butalbital-aspirin-caffeine oral tablet 50-325- 40 mg

G

childrens acetaminophen oral tablet dispersible 80 mg

Mapap Childrens G

OTC

choline & mag trisalicylate oral tablet 1000 mg, 500 mg, 750 mg

G

choline-mag trisalicylate oral liquid 500 mg/5ml

G

diflunisal oral tablet 500 mg G

acetaminophen adults rectal suppository 650 mg

Feverall G OTC

acetaminophen childrens rectal suppository 120 mg

Feverall G OTC


5

acetaminophen junior strength rectal suppository 325 mg

Feverall G

OTC


6


Requirements/Limits

headache formula oral tablet 250-250-65 mg Excedrin Migraine G OTC

infants pain reliever oral suspension 80 mg/0.8ml

G

OTC

infants silapap oral solution 100 mg/ml G OTC

non-aspirin jr strength oral tablet chewable 160 mg

Medi-Tabs Junior Strength G

OTC

pain & fever childrens oral suspension 160 mg/5ml

PediaCare Children G

OTC

promacet oral tablet 50-650 mg G

salsalate oral tablet 500 mg, 750 mg G

*Analgesics - Opioid*

acetaminophen-codeine #2 oral tablet 300-15 mg

G

PA Required for Day Supply Greater than 7; QL (180 EA per 30 days)


Tylenol with Codeine #3 G



Tylenol with Codeine #4 G


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

G

PA Required for Day Supply Greater than 7

butalbital-apap-caff-cod oral capsule 50-300- 40-30 mg

Fioricet/Codeine G


butalbital-apap-caff-cod oral capsule 50-325- 40-30 mg

G


butalbital-asa-caff-codeine oral capsule 50- 325-40-30 mg

Fiorinal/Codeine #3 G


BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR

B

PA

codeine sulfate oral tablet 30 mg, 60 mg

G


fentanyl transdermal patch 72 hour 100 mcg/hr

Duragesic-100 G



Duragesic-25 G



Duragesic-50 G



Duragesic-75 G



5


Requirements/Limits

hydrocodone-acetaminophen oral solution 10- 325 mg/15ml

Zamicet G PA Required for Day Supply Greater than 7

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

Hycet G PA Required for Day Supply Greater than 7

hydrocodone-acetaminophen oral tablet 10- 300 mg

Vicodin HP G

QL (180 EA per 30 days)

hydrocodone-acetaminophen oral tablet 10- 325 mg

Norco G


hydrocodone-acetaminophen oral tablet 2.5- 325 mg

Verdrocet G


hydrocodone-acetaminophen oral tablet 5-300 mg

Vicodin G


hydrocodone-acetaminophen oral tablet 5-325 mg

Lorcet G



Vicodin ES G



Norco G


hydrocodone-ibuprofen oral tablet 10-200 mg

Xylon G


hydrocodone-ibuprofen oral tablet 5-200 mg

Ibudone G


hydrocodone-ibuprofen oral tablet 7.5-200 mg

G


hydromorphone hcl oral liquid 1 mg/ml

Dilaudid G PA Required for Day Supply Greater than 7

hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg

Dilaudid G


meperidine hcl oral tablet 100 mg, 50 mg

Demerol G


methadone hcl oral concentrate 10 mg/ml Methadose G

methadone hcl oral solution 10 mg/5ml, 5 mg/5ml

G

methadone hcl oral tablet 10 mg, 5 mg Dolophine G QL (180 EA per 30 days)

methadone hcl oral tablet soluble 40 mg Methadose G

morphine sulfate (concentrate) oral solution 100 mg/5ml

G


morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg

B

PA; QL (30 EA per 30 days)


6


Requirements/Limits

morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

Kadian G


morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg

MS Contin G


morphine sulfate injection solution 2 mg/ml, 4 mg/ml, 8 mg/ml

G


morphine sulfate intravenous solution 1 mg/ml, 25 mg/ml

G


morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml

G


morphine sulfate oral tablet 15 mg, 30 mg

G


oxycodone hcl er oral tablet er 12 hour abuse- deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg

OxyCONTIN G


oxycodone hcl oral capsule 5 mg

G


oxycodone hcl oral concentrate 100 mg/5ml

G PA Required for Day Supply Greater than 7

oxycodone hcl oral solution 5 mg/5ml


oxycodone hcl oral tablet 10 mg, 20 mg

G


oxycodone hcl oral tablet 15 mg, 30 mg, 5 mg

Roxicodone G


oxycodone-acetaminophen oral tablet 10-325 mg

Endocet G


oxycodone-acetaminophen oral tablet 2.5-325 mg

Percocet G


oxycodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg

Endocet G


oxycodone-aspirin oral tablet 4.8355-325 mg

G


oxycodone-ibuprofen oral tablet 5-400 mg

G


oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

G



7


Requirements/Limits

oxymorphone hcl oral tablet 10 mg, 5 mg

Opana G


ROXICET ORAL SOLUTION 5-325 MG/5ML


tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

G

tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

G

tramadol hcl oral tablet 50 mg

Ultram G


tramadol-acetaminophen oral tablet 37.5-325 mg

Ultracet G PA Required for Day Supply Greater than 7

*Androgens-Anabolic*

danazol oral capsule 100 mg, 200 mg, 50 mg G

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Depo-Testosterone G

PA

testosterone enanthate intramuscular solution 200 mg/ml

G

PA

*Anorectal Agents*

CORTIFOAM RECTAL FOAM 10 % B

hydrocortisone ace-pramoxine rectal cream 1- 1 %

Analpram-HC G

hydrocortisone rectal enema 100 mg/60ml Cortenema G

lidocaine-hydrocortisone ace rectal cream 3- 0.5 %

G

lidocaine-hydrocortisone ace rectal kit 2-2 % Ana-Lex G

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %, 3-2.5 %

G

pramoxine hcl rectal foam 1 % Proctofoam G OTC

PROCTOFOAM HC RECTAL FOAM 1-1 % B

procto-pak rectal cream 1 % G

proctozone-hc rectal cream 2.5 % G

*Antacids*

aluminum hydroxide gel oral suspension 320 mg/5ml

G

OTC

antacid calcium extra strength oral tablet chewable 750 mg

Tums Smoothies G

OTC

antacid calcium oral tablet chewable 500 mg Tums G OTC

antacid extra strength oral tablet chewable 675-135 mg

Rolaids Extra Strength G

OTC

antacid oral tablet chewable 420 mg Titralac G OTC


8


Requirements/Limits

antacid oral tablet chewable 550-110 mg Rolaids G OTC

calcium antacid ultra strength oral tablet chewable 1000 mg

Tums Ultra 1000 G

OTC

calcium carbonate (antacid) ORAL TABLET CHEWABLE 400 MG

Childrens Soothe G

OTC

geri-lanta supreme (calcium carbonate-mag hydroxide) oral suspension 400-135 mg/5ml

G

OTC

foaming antacid oral suspension 95-358 mg/15ml

Gaviscon G

OTC

heartburn antacid ex st oral tablet chewable 160-105 mg

Acid Gone G

OTC

magnesium oxide oral tablet 250 mg, 400 mg G OTC

magnesium oxide oral tablet 420 mg Maox G OTC

calcium carbonate-mag hydroxide chew tab 700-300 mg

MI‐Acid G OTC

aluminum hydroxide – magnesium trisilicate antacid oral tablet chewable 80- 20 mg

G

OTC

sodium bicarbonate oral tablet 325 mg, 650 mg

G

OTC

antacid oral tablet chewable 1000 mg Tums Ultra 1000 G OTC

*Anthelmintics*

ALBENZA ORAL TABLET 200 MG B

BILTRICIDE ORAL TABLET 600 MG B

ivermectin oral tablet 3 mg Stromectol G

pyrantel pamoate oral suspension 50 mg/ml Pin‐x G OTC

pyrantel pamoate oral suspension 144 mg/ml Reeses Pinworm Medicine G

OTC

*Antianginal Agents*

isosorbide dinitrate er oral tablet extended release 40 mg

G

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg

G

isosorbide dinitrate oral tablet 5 mg Isordil Titradose G

isosorbide dinitrate sublingual tablet sublingual 2.5 mg, 5 mg

G

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

G

isosorbide mononitrate oral tablet 10 mg, 20 mg

G

NITRO-BID TRANSDERMAL OINTMENT 2 % B

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr

Nitro-Dur G

nitroglycerin transdermal patch 24 hour 0.4 mg/hr

Minitran G


9

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

G


10


Requirements/Limits

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG

B

PA

*Antianxiety Agents*

hydroxyzine hcl oral syrup 10 mg/5ml G

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

G

hydroxyzine pamoate oral capsule 100 mg G

hydroxyzine pamoate oral capsule 25 mg, 50 mg

Vistaril G

*Antiarrhythmics*

amiodarone hcl oral tablet 100 mg, 200 mg Pacerone G

disopyramide phosphate oral capsule 100 mg, 150 mg

Norpace G

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

Tikosyn G

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

G

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

G

MULTAQ ORAL TABLET 400 MG B

NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG

B

pacerone oral tablet 100 mg, 200 mg G

propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg

Rythmol SR G

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

G

quinidine gluconate er oral tablet extended release 324 mg

G

quinidine sulfate oral tablet 200 mg, 300 mg G

*Antiasthmatic And Bronchodilator Agents*

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

B

ADVAIR HFA INHALATION AEROSOL 115- 21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

B

AEROSPAN INHALATION AEROSOL SOLUTION 80 MCG/ACT

B

albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

VoSpire ER G

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

G


11


Requirements/Limits

albuterol sulfate oral syrup 2 mg/5ml G

albuterol sulfate oral tablet 2 mg, 4 mg G

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

B

ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

B

ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

B

ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

B

QL (26 GM per 30 days)

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

Pulmicort G

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

B

cromolyn sodium inhalation nebulization solution 20 mg/2ml

B

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT

B

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

B

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

B

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH

B

ipratropium bromide inhalation solution 0.02 % G

ipratropium-albuterol inhalation solution 0.5- 2.5 (3) mg/3ml

G

metaproterenol sulfate oral syrup 10 mg/5ml G

metaproterenol sulfate oral tablet 10 mg, 20 mg

G

montelukast sodium oral packet 4 mg Singulair G

montelukast sodium oral tablet 10 mg Singulair G

montelukast sodium oral tablet chewable 4 mg, 5 mg

Singulair G

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

B


PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

B

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

B


12


Requirements/Limits

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

B


SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

B

SYMBICORT INHALATION AEROSOL 160- 4.5 MCG/ACT, 80-4.5 MCG/ACT

B

QL (10.2 GM per 30 days)

terbutaline sulfate oral tablet 2.5 mg, 5 mg G

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

Theochron G

theophylline er oral tablet extended release 12 hour 450 mg

G

theophylline er oral tablet extended release 24 hour 400 mg, 600 mg

G

theophylline oral solution 80 mg/15ml G

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

B

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

B

XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT

B

zafirlukast oral tablet 10 mg, 20 mg Accolate G ST

*Anticoagulants*

ELIQUIS ORAL TABLET 2.5 MG, 5 MG B QL (60 EA per 30 days)

enoxaparin sodium injection solution 300 mg/3ml

Lovenox G

QL (20 ML per 10 days)

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

Lovenox

G


heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

G

SP

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml

G

SP

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 7.5 mg

Jantoven G

warfarin sodium oral tablet 5 mg, 6 mg Coumadin G

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

B


XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

B


*Antidiabetics*

acarbose oral tablet 100 mg, 25 mg, 50 mg Precose G


13


Requirements/Limits

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG, 30-1000 MG

B

APIDRA INJECTION SOLUTION 100 UNIT/ML

B


APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

B


AVANDIA ORAL TABLET 2 MG, 4 MG B

chlorpropamide oral tablet 100 mg, 250 mg G

glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl G

glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

Glucotrol XL G

glipizide oral tablet 10 mg, 5 mg Glucotrol G

glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg

G

GLUCAGON EMERGENCY INJECTION KIT 1 MG

B

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

Glynase G

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg G

glyburide-metformin oral tablet 1.25-250 mg G

glyburide-metformin oral tablet 2.5-500 mg, 5- 500 mg

Glucovance G

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

B

PA; QL (60 ML per 30 days)

INVOKANA ORAL TABLET 100 MG, 300 MG B

JANUMET ORAL TABLET 50-1000 MG, 50- 500 MG

B

PA

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG

B

PA

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG

B

PA

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

B


LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

B


LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

B


LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML

B


metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg

Glucophage XR G

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

Glucophage G

nateglinide oral tablet 120 mg, 60 mg Starlix G


14


Requirements/Limits

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

B

OTC

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

B

OTC

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML

B

OTC

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML

B

OTC

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML

B

OTC

NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML

B

OTC; QL (60 ML per 30 days)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

B


NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML

B


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

B


NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

B


NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

B


pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg

Actos G

pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg

Duetact G

pioglitazone hcl-metformin hcl oral tablet 15- 500 mg, 15-850 mg

Actoplus Met G

repaglinide oral tablet 0.5 mg G

repaglinide oral tablet 1 mg, 2 mg Prandin G

TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG

B

PA

tolazamide oral tablet 250 mg, 500 mg G

tolbutamide oral tablet 500 mg G

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

B


VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML

B

PA

*Antidiarrheals*

bismuth subsalicylate oral tablet chewable 262 mg

Pepto-Bismol InstaCool G

OTC

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

G

diphenoxylate-atropine oral tablet 2.5-0.025 mg

Lomotil G


15


Requirements/Limits

FULYZAQ ORAL TABLET DELAYED RELEASE 125 MG

B


IMODIUM A-D ORAL TABLET CHEWABLE 2 MG

B

OTC

loperamide a-d oral tablet 2 mg G OTC

loperamide hcl oral capsule 2 mg Imodium A-D G

loperamide hcl oral liquid 1 mg/5ml G OTC

loperamide hcl oral suspension 1 mg/7.5ml Imodium A-D G OTC

pink bismuth maximum strength oral suspension 525 mg/15ml

Kaopectate Extra Strength G

OTC

pink bismuth oral suspension 262 mg/15ml Pepto-Bismol G OTC

bismuth subsalicylate oral tablet 262 mg G OTC

*Antidotes*

naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml

G

NARCAN NASAL LIQUID 4 MG/0.1ML B

*Antiemetics*

ANZEMET ORAL TABLET 100 MG, 50 MG B PA

aprepitant oral capsule 125 mg Emend G

aprepitant oral capsule 40 mg, 80 mg Emend G QL (6 EA per 30 days)

aprepitant oral capsule 80 & 125 mg Emend Tri-Pack G

dimenhydrinate oral tablet 50 mg Dramamine G

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Marinol G

granisetron hcl oral tablet 1 mg G

meclizine hcl oral tablet 12.5 mg G

meclizine hcl oral tablet 25 mg Dramamine Less Drowsy G

meclizine hcl oral tablet chewable 25 mg G OTC

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

G

SP

ondansetron hcl oral solution 4 mg/5ml Zofran G

ondansetron hcl oral tablet 24 mg G QL (30 EA per 30 days)

ondansetron hcl oral tablet 4 mg, 8 mg Zofran G QL (30 EA per 30 days)

ondansetron oral tablet dispersible 4 mg, 8 mg Zofran ODT G QL (30 EA per 30 days)

trimethobenzamide hcl oral capsule 300 mg Tigan G

*Antifungals*

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

Diflucan G

fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Diflucan G

flucytosine oral capsule 250 mg, 500 mg Ancobon G


16


Requirements/Limits

griseofulvin microsize oral suspension 125 mg/5ml

G

griseofulvin microsize oral tablet 500 mg G

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

Gris-PEG G

itraconazole oral capsule 100 mg Sporanox Pulsepak G PA

ketoconazole oral tablet 200 mg G

NOXAFIL ORAL SUSPENSION 40 MG/ML B PA

nystatin oral tablet 500000 unit G

SPORANOX ORAL SOLUTION 10 MG/ML B PA

terbinafine hcl oral tablet 250 mg LamISIL G QL (90 EA per 365 days)

voriconazole oral suspension reconstituted 40 mg/ml

Vfend G

voriconazole oral tablet 200 mg, 50 mg Vfend G

*Antihistamines*

carbinoxamine maleate oral solution 4 mg/5ml G

carbinoxamine maleate oral tablet 4 mg G

cetirizine hcl oral solution 1 mg/ml ZyrTEC Childrens G

cetirizine hcl oral tablet 10 mg ZyrTEC Allergy G OTC

cetirizine hcl oral tablet 5 mg G OTC

cetirizine hcl oral tablet chewable 10 mg, 5 mg ZyrTEC Childrens G OTC

chlorpheniramine maleate er oral tablet extended release 12 mg

Chlor-Trimeton Allergy G

OTC

chlorpheniramine maleate oral tablet 4 mg G OTC

clemastine fumarate oral syrup 0.67 mg/5ml G

clemastine fumarate oral tablet 1.34 mg Dayhist Allergy 12 Hour Relief

G

OTC

clemastine fumarate oral tablet 2.68 mg G

cyproheptadine hcl oral syrup 2 mg/5ml G

cyproheptadine hcl oral tablet 4 mg G

diphenhydramine oral tablet chewable 12.5 mg Benadryl Allergy Childrens G OTC

diphenhydramine hcl oral capsule 25 mg G

diphenhydramine hcl oral capsule 50 mg Banophen G

diphenhydramine hcl oral elixir 12.5 mg/5ml G

diphenhydramine hcl oral liquid 12.5 mg/5ml Scot-Tussin Allergy Relief G OTC

diphenhydramine oral solution 12.5 mg/5ml Benadryl G OTC

diphenhydramine hcl oral tablet 25 mg Banophen G OTC

doxylamine succinate tablet G OTC

ed chlorped jr oral syrup 2 mg/5ml Diabetic Tussin Allergy G OTC

ED CHLORPED (chlorpheniramine maleate) ORAL LIQUID 2 MG/ML

B OTC


17


Requirements/Limits

fexofenadine hcl childrens oral suspension 30 mg/5ml

Allegra Allergy Childrens G

OTC

fexofenadine hcl oral tablet 180 mg Allegra Allergy G OTC

fexofenadine hcl oral tablet 60 mg Allegra Allergy G OTC

levocetirizine dihydrochloride oral solution 2.5 mg/5ml

Xyzal G

levocetirizine dihydrochloride oral tablet 5 mg Xyzal G

loratadine allergy relief oral tablet dispersible 10 mg

Claritin G

OTC

loratadine oral tablet 10 mg Claritin G OTC

promethazine hcl injection solution 25 mg/ml, 50 mg/ml

Phenergan G

promethazine hcl oral syrup 6.25 mg/5ml G

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

G

promethazine hcl rectal suppository 12.5 mg, 50 mg

Phenergan G

promethazine hcl rectal suppository 25 mg Promethegan G

TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG

B

OTC

*Antihyperlipidemics*

atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Lipitor G


cholestyramine light oral packet 4 gm Prevalite G

cholestyramine light oral powder 4 gm/dose Prevalite G

cholestyramine oral packet 4 gm Questran G

cholestyramine oral powder 4 gm/dose Questran G

colestipol hcl oral granules 5 gm Colestid Flavored G

colestipol hcl oral packet 5 gm Colestid G

colestipol hcl oral tablet 1 gm Colestid G

ezetimibe oral tablet 10 mg Zetia G

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Lofibra G

fenofibrate oral tablet 145 mg, 48 mg Tricor G

fenofibrate oral tablet 160 mg Triglide G

fenofibrate oral tablet 54 mg Lofibra G

fenofibric acid oral capsule delayed release 135 mg, 45 mg

Trilipix G

FENOFIBRIC ACID ORAL TABLET 105 MG, 35 MG

Fibricor B

fluvastatin sodium oral capsule 20 mg Lescol G

fluvastatin sodium oral capsule 40 mg G

gemfibrozil oral tablet 600 mg Lopid G


18


Requirements/Limits

JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 5 MG, 60 MG

B


JUXTAPID ORAL CAPSULE 20 MG

B PA; QL (90 EA per 30 days)

lovastatin oral tablet 10 mg, 20 mg G QL (30 EA per 30 days)

lovastatin oral tablet 40 mg Mevacor G QL (30 EA per 30 days)

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

Niaspan G

omega-3-acid ethyl esters oral capsule 1 gm Lovaza G

pravastatin sodium oral tablet 10 mg G QL (30 EA per 30 days)

pravastatin sodium oral tablet 20 mg, 40 mg, 80 mg

Pravachol G


simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

Zocor G


*Antihypertensives*

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg

Lotrel G

amlodipine besy-benazepril hcl oral capsule 2.5-10 mg, 5-40 mg

G

atenolol-chlorthalidone oral tablet 100-25 mg Tenoretic 100 G

atenolol-chlorthalidone oral tablet 50-25 mg Tenoretic 50 G

benazepril hcl oral tablet 10 mg, 20 mg, 40 mg Lotensin G

benazepril hcl oral tablet 5 mg G

bisoprolol-hydrochlorothiazide oral tablet 10- 6.25 mg, 2.5-6.25 mg, 5-6.25 mg

Ziac G

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

G

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

G

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

Catapres G

clonidine hcl transdermal patch weekly 0.1 mg/24hr

Catapres-TTS-1 G


Catapres-TTS-2 G


Catapres-TTS-3 G

doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

Cardura G

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Vasotec G

enalapril-hydrochlorothiazide oral tablet 10-25 mg

Vaseretic G

enalapril-hydrochlorothiazide oral tablet 5-12.5 mg

G

eplerenone oral tablet 25 mg, 50 mg Inspra G


19


Requirements/Limits

eprosartan mesylate oral tablet 600 mg G

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg

G

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

G

guanfacine hcl oral tablet 1 mg, 2 mg G

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

G

irbesartan oral tablet 150 mg, 300 mg, 75 mg Avapro G

irbesartan-hydrochlorothiazide oral tablet 150- 12.5 mg, 300-12.5 mg

Avalide G

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

Zestril G

lisinopril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg, 20-25 mg

Zestoretic G

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

Cozaar G

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

Hyzaar G

methyldopa oral tablet 250 mg, 500 mg G

methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

G

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg

G

metoprolol-hydrochlorothiazide oral tablet 50- 25 mg

Lopressor HCT G

minoxidil oral tablet 10 mg, 2.5 mg G

moexipril hcl oral tablet 15 mg, 7.5 mg G

moexipril-hydrochlorothiazide oral tablet 15- 12.5 mg, 15-25 mg, 7.5-12.5 mg

G

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

Corzide G

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

Benicar G

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

Benicar HCT G

perindopril erbumine oral tablet 2 mg G

perindopril erbumine oral tablet 4 mg, 8 mg Aceon G

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg Minipress G

propranolol-hctz oral tablet 40-25 mg, 80-25 mg

G

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Accupril G

quinapril-hydrochlorothiazide oral tablet 10- 12.5 mg, 20-12.5 mg, 20-25 mg

Accuretic G


20


Requirements/Limits

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

Altace G

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

G

trandolapril oral tablet 1 mg, 2 mg G

trandolapril oral tablet 4 mg Mavik G

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Diovan G

valsartan-hydrochlorothiazide oral tablet 160- 12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

Diovan HCT G

*Anti-Infective Agents - Misc.*

atovaquone oral suspension 750 mg/5ml Mepron G

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

Cleocin G

clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml

Cleocin G

dapsone oral tablet 100 mg, 25 mg G

linezolid oral suspension reconstituted 100 mg/5ml

Zyvox G

PA

linezolid oral tablet 600 mg Zyvox G PA

metronidazole oral capsule 375 mg Flagyl G

metronidazole oral tablet 250 mg, 500 mg Flagyl G

PRIMSOL ORAL SOLUTION 50 MG/5ML B

SIVEXTRO ORAL TABLET 200 MG B PA; SP

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

Sulfatrim Pediatric G

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

Bactrim G

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

Bactrim DS G

tinidazole oral tablet 250 mg G

tinidazole oral tablet 500 mg Tindamax G

trimethoprim oral tablet 100 mg G

vancomycin hcl oral capsule 125 mg, 250 mg Vancocin HCl G

XIFAXAN ORAL TABLET 200 MG, 550 MG B PA

*Antimalarials*

atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg

Malarone G

chloroquine phosphate oral tablet 250 mg, 500 mg

G

COARTEM ORAL TABLET 20-120 MG B

hydroxychloroquine sulfate oral tablet 200 mg Plaquenil G

mefloquine hcl oral tablet 250 mg G


21


Requirements/Limits

quinine sulfate oral capsule 324 mg Qualaquin G

*Antimyasthenic Agents*

pyridostigmine bromide er oral tablet extended release 180 mg

Mestinon G

pyridostigmine bromide oral tablet 60 mg Mestinon G

*Antimyasthenic/Cholinergic Agents*

pyridostigmine bromide er oral tablet extended release 180 mg

Mestinon G

pyridostigmine bromide oral tablet 60 mg Mestinon G

*Antimycobacterial Agents*

ethambutol hcl oral tablet 100 mg, 400 mg Myambutol G

isonarif oral capsule 150-300 mg G

isoniazid oral syrup 50 mg/5ml G

isoniazid oral tablet 100 mg, 300 mg G

pyrazinamide oral tablet 500 mg G

rifampin oral capsule 150 mg, 300 mg Rifadin G

SIRTURO ORAL TABLET 100 MG B

*Antineoplastics And Adjunctive Therapies*

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

B

PA; SP

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

B

PA

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

B

PA

anastrozole oral tablet 1 mg Arimidex G PA

bexarotene oral capsule 75 mg Targretin G PA; SP

bicalutamide oral tablet 50 mg Casodex G

CAPRELSA ORAL TABLET 100 MG, 300 MG B PA; SP

cyclophosphamide oral capsule 25 mg, 50 mg Cytoxan G PA

ELIGARD SUBCUTANEOUS KIT 7.5 MG B PA; SP

ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

B

PA

etoposide oral capsule 50 mg G SP


22


Requirements/Limits

exemestane oral tablet 25 mg Aromasin G PA

FARESTON ORAL TABLET 60 MG B PA; SP

flutamide oral capsule 125 mg G

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

B

PA; SP

HEXALEN ORAL CAPSULE 50 MG B PA; SP

hydroxyurea oral capsule 500 mg Hydrea G

ICLUSIG ORAL TABLET 15 MG, 45 MG

B PA; SP; QL (60 EA per 30 days)

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

B

PA; SP

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

B

PA; SP

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

B

PA

letrozole oral tablet 2.5 mg Femara G

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

G

PA

LEUKERAN ORAL TABLET 2 MG B

leuprolide acetate injection kit 1 mg/0.2ml G SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG

B

PA; SP

LYSODREN ORAL TABLET 500 MG B

MATULANE ORAL CAPSULE 50 MG B PA; SP

megestrol acetate oral suspension 40 mg/ml G

megestrol acetate oral tablet 20 mg, 40 mg G

melphalan oral tablet 2 mg Alkeran G SP

mercaptopurine oral tablet 50 mg G

methotrexate oral tablet 2.5 mg G


23


Requirements/Limits

methotrexate sodium (pf) injection solution 50 mg/2ml

G

methotrexate sodium injection solution 50 mg/2ml

G

methotrexate sodium injection solution reconstituted 1 gm

G

MYLERAN ORAL TABLET 2 MG B

TABLOID ORAL TABLET 40 MG B

tamoxifen citrate oral tablet 10 mg, 20 mg G

TARGRETIN ORAL CAPSULE 75 MG B PA

tretinoin oral capsule 10 mg G SP

VESANOID B PA (for > 26 years old)

ZELBORAF ORAL TABLET 240 MG B PA

ZOLINZA ORAL CAPSULE 100 MG B PA

*Antiparkinson Agents*

amantadine hcl oral capsule 100 mg G

amantadine hcl oral syrup 50 mg/5ml G

amantadine hcl oral tablet 100 mg G

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

G

bromocriptine mesylate oral capsule 5 mg Parlodel G

bromocriptine mesylate oral tablet 2.5 mg Parlodel G

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

Sinemet CR G

carbidopa-levodopa oral tablet 10-100 mg, 25- 100 mg, 25-250 mg

Sinemet G

carbidopa-levodopa oral tablet dispersible 10- 100 mg, 25-100 mg, 25-250 mg

G

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg

Stalevo 50 G


Stalevo 75 G

carbidopa-levodopa-entacapone oral tablet 25-100-200 mg

Stalevo 100 G


Stalevo 125 G


24


Requirements/Limits


Stalevo 150 G

carbidopa-levodopa-entacapone oral tablet 50-200-200 mg

Stalevo 200 G

entacapone oral tablet 200 mg Comtan G

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

Mirapex G

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

Requip G

selegiline hcl oral capsule 5 mg Eldepryl G

selegiline hcl oral tablet 5 mg G

trihexyphenidyl hcl oral elixir 0.4 mg/ml G

trihexyphenidyl hcl oral tablet 2 mg, 5 mg G

*Antipsychotics/Antimanic Agents*

prochlorperazine rectal suppository 25 mg Compro G

*Antiretrovirals Adjuvants***

TYBOST ORAL TABLET 150 MG B

*Antivirals*

abacavir sulfate oral solution 20 mg/ml Ziagen G

abacavir sulfate oral tablet 300 mg Ziagen G

abacavir sulfate-lamivudine oral tablet 600- 300 mg

Epzicom G

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

Trizivir G

acyclovir oral capsule 200 mg Zovirax G

acyclovir oral suspension 200 mg/5ml Zovirax G

acyclovir oral tablet 400 mg, 800 mg Zovirax G

adefovir dipivoxil oral tablet 10 mg Hepsera G PA; SP

APTIVUS ORAL CAPSULE 250 MG B

APTIVUS ORAL SOLUTION 100 MG/ML B

ATRIPLA ORAL TABLET 600-200-300 MG B

BARACLUDE ORAL SOLUTION 0.05 MG/ML B PA; SP

COMPLERA ORAL TABLET 200-25-300 MG B

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

B

DESCOVY ORAL TABLET 200-25 MG B SP

didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg

Videx EC G

EDURANT ORAL TABLET 25 MG B

EMTRIVA ORAL CAPSULE 200 MG B

EMTRIVA ORAL SOLUTION 10 MG/ML B

entecavir oral tablet 0.5 mg, 1 mg Baraclude G PA; SP

EPIVIR HBV ORAL SOLUTION 5 MG/ML B SP


25


Requirements/Limits

EVOTAZ ORAL TABLET 300-150 MG B SP

famciclovir oral tablet 125 mg, 250 mg G

famciclovir oral tablet 500 mg Famvir G

fosamprenavir calcium oral tablet 700 mg Lexiva G

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

B

PA; SP

GENVOYA ORAL TABLET 150-150-200-10 MG

B

SP

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

B

INVIRASE ORAL CAPSULE 200 MG B

INVIRASE ORAL TABLET 500 MG B

ISENTRESS ORAL TABLET 400 MG B

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

B

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

B

lamivudine oral solution 10 mg/ml Epivir G

lamivudine oral tablet 100 mg Epivir HBV G SP

lamivudine oral tablet 150 mg, 300 mg Epivir G

lamivudine-zidovudine oral tablet 150-300 mg Combivir G

LEXIVA ORAL SUSPENSION 50 MG/ML B

lopinavir-ritonavir oral solution 400-100 mg/5ml

Kaletra G

MODERIBA ORAL 200 & 400 MG G PA; SP

MODERIBA ORAL 400 & 600 MG G PA

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

Viramune XR G

NEVIRAPINE ORAL SUSPENSION 50 MG/5ML

Viramune B

nevirapine oral tablet 200 mg Viramune G

NORVIR ORAL CAPSULE 100 MG B

NORVIR ORAL SOLUTION 80 MG/ML B

NORVIR ORAL TABLET 100 MG B

ODEFSEY ORAL TABLET 200-25-25 MG B SP

oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg

Tamiflu G


oseltamivir oral suspension reconstituted 6 MG/ML

Tamiflu G QL (10 ML per 365 days)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

B

PA; SP

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

B

PA; SP


26

PEG-INTRON PAK 4 SUBCUTANEOUS KIT 120 MCG/0.5ML

B

PA; SP


27


Requirements/Limits

PEG-INTRON SUBCUTANEOUS KIT 150 MCG/0.5ML

B

PA; SP

PEG-INTRON SUBCUTANEOUS KIT 50 MCG/0.5ML, 80 MCG/0.5ML

B

SP

PREZCOBIX ORAL TABLET 800-150 MG B

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

B

REBETOL ORAL SOLUTION 40 MG/ML B PA; SP

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

B


RESCRIPTOR ORAL TABLET 100 MG, 200 MG

B

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

B

ribasphere oral capsule 200 mg G PA; SP

ribasphere oral tablet 200 mg G PA; SP

ribasphere oral tablet 400 mg, 600 mg G PA; SP

RIBASPHERE RIBAPAK ORAL TABLET 200 & 400 MG

G

PA; SP

RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG

B

PA

RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG

B

PA; SP

ribavirin oral capsule 200 mg Rebetol G PA; SP

ribavirin oral tablet 200 mg Moderiba G PA; SP

rimantadine hcl oral tablet 100 mg Flumadine G

SELZENTRY ORAL TABLET 150 MG, 300 MG

B

SOVALDI ORAL TABLET 400 MG B PA; SP

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

Zerit G

stavudine oral solution reconstituted 1 mg/ml Zerit G

STRIBILD ORAL TABLET 150-150-200-300 MG

B

SUSTIVA ORAL CAPSULE 200 MG, 50 MG B

SUSTIVA ORAL TABLET 600 MG B

TIVICAY ORAL TABLET 50 MG B SP

TRIUMEQ ORAL TABLET 600-50-300 MG B SP

TRUVADA ORAL TABLET 200-300 MG B PA; SP

TYZEKA ORAL TABLET 600 MG B PA; SP

valacyclovir hcl oral tablet 1 gm, 500 mg Valtrex G


28


Requirements/Limits

valganciclovir hcl oral solution reconstituted 50 mg/ml

Valcyte G

valganciclovir hcl oral tablet 450 mg Valcyte G

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

B

VIRACEPT ORAL TABLET 250 MG, 625 MG B

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG

B

VITEKTA ORAL TABLET 150 MG, 85 MG B SP

zidovudine oral capsule 100 mg Retrovir G

zidovudine oral syrup 50 mg/5ml Retrovir G

zidovudine oral tablet 300 mg G

*Assorted Classes*

CUPRIMINE ORAL CAPSULE 250 MG B

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

B

PA; SP

sodium polystyrene sulfonate oral suspension 15 gm/60ml

Kionex G

sodium polystyrene sulfonate rectal suspension 50 gm/200ml

G

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

B

PA; SP

*Beta Blockers*

acebutolol hcl oral capsule 200 mg, 400 mg G

atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin G

betaxolol hcl oral tablet 10 mg, 20 mg G

bisoprolol fumarate oral tablet 10 mg, 5 mg G

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

Coreg G

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg

G

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Toprol XL G

metoprolol tartrate oral tablet 100 mg, 50 mg Lopressor G

metoprolol tartrate oral tablet 25 mg G

nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard G

pindolol oral tablet 10 mg, 5 mg G

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

Inderal LA G

propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml

G

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

G


29


Requirements/Limits

sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg

Betapace AF G

sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg

Sorine G

timolol maleate oral tablet 10 mg, 20 mg, 5 mg G

*Calcium Channel Blockers*

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

Norvasc G


CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

B


diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 360 mg, 420 mg

Tiazac G


diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 240 mg, 300 mg

Taztia XT G


diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 300 mg

Cartia XT G


diltiazem hcl er coated beads oral capsule extended release 24 hour 180 mg, 240 mg, 360 mg

Cardizem CD G


diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 360 mg, 420 mg

Cardizem LA G

diltiazem hcl er coated beads oral tablet extended release 24 hour 240 mg, 300 mg

Matzim LA G

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

G

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

G

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg Cardizem G

diltiazem hcl oral tablet 90 mg G

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

G

isradipine oral capsule 2.5 mg, 5 mg G

nicardipine hcl oral capsule 20 mg, 30 mg G

nifedipine er oral tablet extended release 24 hour 30 mg, 90 mg

Adalat CC G

nifedipine er oral tablet extended release 24 hour 60 mg

Afeditab CR G

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 90 mg

Procardia XL G

nifedipine er osmotic release oral tablet extended release 24 hour 60 mg

Nifedical XL G

nifedipine oral capsule 10 mg Procardia G

nifedipine oral capsule 20 mg G

nimodipine oral capsule 30 mg G


30


Requirements/Limits

nisoldipine er oral tablet extended release 24 hour 17 mg, 34 mg, 8.5 mg

Sular G

nisoldipine er oral tablet extended release 24 hour 20 mg, 25.5 mg, 30 mg, 40 mg

G

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

Verelan PM G


verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

Verelan G


verapamil hcl er oral tablet extended release 120 mg, 180 mg

Calan SR G


verapamil hcl er oral tablet extended release 240 mg

Isoptin SR G


verapamil hcl oral tablet 120 mg, 80 mg Calan G

verapamil hcl oral tablet 40 mg G

*Cardiotonics*

digoxin oral solution 0.05 mg/ml G

digoxin oral tablet 125 mcg, 250 mcg Lanoxin G

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG

B

*Cardiovascular Agents - Misc.*

ADCIRCA ORAL TABLET 20 MG B PA; SP

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg

Caduet G

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg

G

LETAIRIS ORAL TABLET 10 MG, 5 MG B PA; SP

sildenafil citrate oral tablet 20 mg Revatio G PA

TRACLEER ORAL TABLET 125 MG, 62.5 MG

B

PA; SP

TYVASO INHALATION SOLUTION 0.6 MG/ML

B

PA; SP

TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML

B

SP

TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML

B

PA; SP

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

B

PA; SP

*Cephalosporins*

cefaclor er oral tablet extended release 12 hour 500 mg

G

cefaclor oral capsule 250 mg, 500 mg G

cefadroxil oral capsule 500 mg G

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

G


29


Requirements/Limits

cefadroxil oral tablet 1 gm G

cefdinir oral capsule 300 mg G

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

G

CEFDITOREN PIVOXIL ORAL TABLET 200 MG

B

CEFDITOREN PIVOXIL ORAL TABLET 400 MG

Spectracef B

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Suprax G

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

G

cefpodoxime proxetil oral tablet 100 mg, 200 mg

G

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

G

cefprozil oral tablet 250 mg, 500 mg G

CEFTIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML

B

cefuroxime axetil oral tablet 250 mg, 500 mg Ceftin G

cephalexin oral capsule 250 mg, 500 mg, 750 mg

Keflex G

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

G

cephalexin oral tablet 250 mg, 500 mg G

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

B

*Chemicals*

HYDROXYPROGESTERONE CAPROATE POWDER

B

PA

*Contraceptives*

altavera oral tablet 0.15-30 mg-mcg G

alyacen 1/35 oral tablet 1-35 mg-mcg Pirmella 1/35 G

alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg- mcg

Dasetta 7/7/7 G

amethia lo oral tablet 0.1-0.02 & 0.01 mg G

amethia oral tablet 0.15-0.03 &0.01 mg G QL (91 EA per 91 days)

amethyst oral tablet 90-20 mcg G

apri oral tablet 0.15-30 mg-mcg G

aranelle oral tablet 0.5/1/0.5-35 mg-mcg G

ashlyna oral tablet 0.15-0.03 &0.01 mg G

aubra oral tablet 0.1-20 mg-mcg G

aviane oral tablet 0.1-20 mg-mcg G


30


Requirements/Limits

azurette oral tablet 0.15-0.02/0.01 mg (21/5) G

bekyree oral tablet 0.15-0.02/0.01 mg (21/5) G

blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg G

blisovi fe 1/20 oral tablet 1-20 mg-mcg G

briellyn oral tablet 0.4-35 mg-mcg Philith G

camila oral tablet 0.35 mg G

camrese lo oral tablet 0.1-0.02 & 0.01 mg G QL (91 EA per 91 days)

camrese oral tablet 0.15-0.03 &0.01 mg G

caziant oral tablet 0.1/0.125/0.15 -0.025 mg G

cesia oral tablet 0.1/0.125/0.15 -0.025 mg G

chateal oral tablet 0.15-30 mg-mcg G

cryselle-28 oral tablet 0.3-30 mg-mcg G

cyclafem 1/35 oral tablet 1-35 mg-mcg G

cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg- mcg

G

cyred oral tablet 0.15-30 mg-mcg G

dasetta 1/35 oral tablet 1-35 mg-mcg G

dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg G

daysee oral tablet 0.15-0.03 &0.01 mg G

deblitane oral tablet 0.35 mg G

delyla oral tablet 0.1-20 mg-mcg G

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION 104 MG/0.65ML

B

desogestrel-ethinyl estradiol oral tablet 0.15- 0.02/0.01 mg (21/5)

Kimidess G

desogestrel-ethinyl estradiol oral tablet 0.15- 30 mg-mcg

Isibloom G

drospirenone-ethinyl estradiol oral tablet 3- 0.02 mg

Loryna G

drospirenone-ethinyl estradiol oral tablet 3- 0.03 mg

Syeda G

levonorgestrel oral tablet 1.5 mg G OTC

elinest oral tablet 0.3-30 mg-mcg G

ella oral tablet 30 mg G

emoquette oral tablet 0.15-30 mg-mcg G

enpresse-28 oral tablet G

enskyce oral tablet 0.15-30 mg-mcg G

errin oral tablet 0.35 mg G

estarylla oral tablet 0.25-35 mg-mcg G

falmina oral tablet 0.1-20 mg-mcg G

gianvi oral tablet 3-0.02 mg G


31


Requirements/Limits

gildagia oral tablet 0.4-35 mg-mcg G

gildess 1.5/30 oral tablet 1.5-30 mg-mcg G

gildess 1/20 oral tablet 1-20 mg-mcg G

gildess fe 1.5/30 oral tablet 1.5-30 mg-mcg G

gildess fe 1/20 oral tablet 1-20 mg-mcg G

heather oral tablet 0.35 mg G

introvale oral tablet 0.15-0.03 mg G QL (91 EA per 91 days)

jencycla oral tablet 0.35 mg G

jolessa oral tablet 0.15-0.03 mg G

jolivette oral tablet 0.35 mg G

juleber oral tablet 0.15-30 mg-mcg G

junel 1.5/30 oral tablet 1.5-30 mg-mcg G

junel 1/20 oral tablet 1-20 mg-mcg G

junel fe 1.5/30 oral tablet 1.5-30 mg-mcg G

junel fe 1/20 oral tablet 1-20 mg-mcg G

junel fe 24 oral tablet 1-20 mg-mcg(24) G

kaitlib fe oral tablet chewable 0.8-25 mg-mcg G

kariva oral tablet 0.15-0.02/0.01 mg (21/5) G

kelnor 1/35 oral tablet 1-35 mg-mcg G

kimidess oral tablet 0.15-0.02/0.01 mg (21/5) G

kurvelo oral tablet 0.15-30 mg-mcg G

larin 1.5/30 oral tablet 1.5-30 mg-mcg G

larin 1/20 oral tablet 1-20 mg-mcg G

larin 24 fe oral tablet 1-20 mg-mcg(24) G

larin fe 1.5/30 oral tablet 1.5-30 mg-mcg G

larin fe 1/20 oral tablet 1-20 mg-mcg G

layolis fe oral tablet chewable 0.8-25 mg-mcg G

leena oral tablet 0.5/1/0.5-35 mg-mcg G

lessina oral tablet 0.1-20 mg-mcg G

levonest oral tablet G

levonorgest-eth estrad 91-day oral tablet 0.1- 0.02 & 0.01 mg

LoSeasonique G

levonorgest-eth estrad 91-day oral tablet 0.15- 0.03 &0.01 mg

Camrese G

levonorgest-eth estrad 91-day oral tablet 0.15- 0.03 mg

Quasense G

levonorgestrel oral tablet 1.5 mg My Way G

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg

Aubra G

levonorgestrel-ethinyl estrad oral tablet 0.15- 30 mg-mcg

Chateal G

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

G


32


Requirements/Limits

levonorg-eth estrad triphasic oral tablet Myzilra G

levora 0.15/30 (28) oral tablet 0.15-30 mg- mcg

G

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG

B

lomedia 24 fe oral tablet 1-20 mg-mcg(24) G

loryna oral tablet 3-0.02 mg G

low-ogestrel oral tablet 0.3-30 mg-mcg G

lutera oral tablet 0.1-20 mg-mcg G

lyza oral tablet 0.35 mg G

marlissa oral tablet 0.15-30 mg-mcg Chateal G

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

Depo-Provera G


microgestin 1.5/30 oral tablet 1.5-30 mg-mcg G

microgestin 1/20 oral tablet 1-20 mg-mcg G

microgestin 24 fe oral tablet 1-20 mg-mcg G

microgestin fe 1.5/30 oral tablet 1.5-30 mg- mcg

G

microgestin fe 1/20 oral tablet 1-20 mg-mcg G

mono-linyah oral tablet 0.25-35 mg-mcg G

mononessa oral tablet 0.25-35 mg-mcg G

my way oral tablet 1.5 mg G

myzilra oral tablet G

NATAZIA ORAL TABLET 3/2-2/2-3/1 MG B

necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg G

necon 1/35 (28) oral tablet 1-35 mg-mcg G

NECON 1/50 (28) ORAL TABLET 1-50 MG- MCG

B

NECON 10/11 (28) ORAL TABLET 35 MCG G

necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg G

next choice one dose oral tablet 1.5 mg G

nikki oral tablet 3-0.02 mg G

nora-be oral tablet 0.35 mg G

norethin ace-eth estrad-fe oral tablet 1-20 mg- mcg

Loestrin Fe 1/20 G

norethin ace-eth estrad-fe oral tablet 1-20 mg- mcg(24)

Larin 24 FE G

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

Microgestin 1/20 G

norethindrone oral tablet 0.35 mg Lyza G

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

Kaitlib Fe G

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Mono-Linyah G


33


Requirements/Limits

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg

Tri-Lo-Marzia G

norlyroc oral tablet 0.35 mg G

nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg G

nortrel 1/35 (21) oral tablet 1-35 mg-mcg G

nortrel 1/35 (28) oral tablet 1-35 mg-mcg G

nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg G

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

B

ocella oral tablet 3-0.03 mg G

ogestrel oral tablet 0.5-50 mg-mcg G

orsythia oral tablet 0.1-20 mg-mcg G

philith oral tablet 0.4-35 mg-mcg G

pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) G

pirmella 1/35 oral tablet 1-35 mg-mcg G

pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg- mcg

G

portia-28 oral tablet 0.15-30 mg-mcg G

previfem oral tablet 0.25-35 mg-mcg G

quasense oral tablet 0.15-0.03 mg G

reclipsen oral tablet 0.15-30 mg-mcg G

setlakin oral tablet 0.15-0.03 mg G

sharobel oral tablet 0.35 mg G

solia oral tablet 0.15-30 mg-mcg G

sprintec 28 oral tablet 0.25-35 mg-mcg G

sronyx oral tablet 0.1-20 mg-mcg G

syeda oral tablet 3-0.03 mg G

tarina fe 1/20 oral tablet 1-20 mg-mcg G

tilia fe oral tablet 1-20/1-30/1-35 mg-mcg G

tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg

G

tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg G

tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg

G

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg- 25 mcg

G

tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg

G

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg- 25 mcg

G


34


Requirements/Limits

trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg

G

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

G

tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg

G

tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg

G

trivora (28) oral tablet G

velivet oral tablet 0.1/0.125/0.15 -0.025 mg G

vestura oral tablet 3-0.02 mg G

vienva oral tablet 0.1-20 mg-mcg G

viorele oral tablet 0.15-0.02/0.01 mg (21/5) Kimidess G

vyfemla oral tablet 0.4-35 mg-mcg G

wera oral tablet 0.5-35 mg-mcg G

wymzya fe oral tablet chewable 0.4-35 mg- mcg

G

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24HR

G

zarah oral tablet 3-0.03 mg G

zenchent fe oral tablet chewable 0.4-35 mg- mcg

G

zenchent oral tablet 0.4-35 mg-mcg G

zovia 1/35e (28) oral tablet 1-35 mg-mcg G

*Corticosteroids*

budesonide oral capsule delayed release particles 3 mg

Entocort EC G

DELTASONE ORAL TABLET 20 MG G

dexamethasone oral elixir 0.5 mg/5ml G

dexamethasone oral solution 0.5 mg/5ml G

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

G

fludrocortisone acetate oral tablet 0.1 mg G

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Cortef G

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

Medrol G

prednisolone oral solution 15 mg/5ml G

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml

G

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

Pediapred G

prednisone oral solution 5 mg/5ml G

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg, 50 mg

G


35


Requirements/Limits

prednisone oral tablet therapy pack 10 mg (21), 5 mg (21)

G

*Cough/Cold/Allergy*

benzonatate oral capsule 100 mg Tessalon Perles G

benzonatate oral capsule 200 mg G

brotapp oral liquid 1-15 mg/5ml G OTC

cetirizine-pseudoephedrine er oral tablet extended release 12 hour 5-120 mg

ZyrTEC D G

OTC

coricidin hbp congestion/cough oral capsule 10-200 mg

G

OTC

dm-guaifenesin er oral tablet extended release 12 hour 60-1200 mg

Mucinex DM Maximum Strength

G

OTC

phenylephrine-guaifenesin oral liquid 5-100 mg/5ml

G OTC

chlorpheniramine / pseudoephedrine oral syrup 1-15 mg/5ml

G

OTC

fexofenadine-pseudoephed er oral tablet extended release 12 hour 60-120 mg

G

OTC

fexofenadine-pseudoephed er oral tablet extended release 24 hour 180-240 mg

Allegra-D Allergy & Congestion

G

OTC

FLU & SORE THROAT (PHENIRAMINE – PHENYLEPHRINE WITH ACETAMINOPHEN) ORAL packet 20-10-650 mg

B

OTC

dextromethorphan - guaifenesin oral liquid 10-200 mg/15ml

Vicks DayQuil Mucus Control DM

G

OTC

guaiatussin ac oral syrup 100-10 mg/5ml

G

PA Required for Day Supply Greater than 7; OTC

guaifenesin dm oral tablet 400-20 mg TabTussin DM G OTC

guaifenesin er oral tablet extended release 12 hour 600 mg

EQ Mucus ER G

guaifenesin oral solution 300 mg/15ml Mucinex Chest Congestion Child

G

OTC

hydrocodone-homatropine oral syrup 5-1.5 mg/5ml

G


hydrocodone-homatropine oral tablet 5-1.5 mg

Tussigon G PA Required for Day Supply Greater than 7

intense cough reliever oral liquid 20-300 mg/5ml

Double-Tussin DM G

OTC

j-max oral syrup 5-200 mg/5ml G OTC

J-TAN D PD ORAL LIQUID 1-7.5 MG/ML B OTC

liquituss gg oral liquid 200 mg/5ml G OTC

LOHIST-D ORAL LIQUID 2-30 MG/5ML G OTC

loratadine-d 12hr oral tablet extended release 12 hour 5-120 mg

Claritin G

OTC


36

loratadine-d 24hr oral tablet extended release 24 hour 10-240 mg

Claritin D-24HR G

OTC


37


Requirements/Limits

medi-tussin dm double strength oral liquid 30- 200 mg/5ml

G

OTC

mucus relief dm max oral liquid 5-100 mg/5ml Mucinex Fast-Max DM Max G OTC

mucus-dm oral tablet extended release 12 hour 30-600 mg

Mucinex DM G

OTC

nasal mist inhalation aerosol solution 0.9 % Broncho Saline G OTC

pedia relief cough/cold oral liquid 15-1-5 mg/5ml

G

OTC

pedi-atric nightrest oral liquid 15-1-7.5 mg/5ml G OTC

promethazine vc oral syrup 6.25-5 mg/5ml G

promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml

G


promethazine-codeine oral syrup 6.25-10 mg/5ml

G


pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml

Bromfed DM G

relcof c oral solution 100-6.3 mg/5ml G OTC

siltussin-dm alcohol free oral syrup 100-10 mg/5ml

G

OTC

sodium chloride inhalation nebulization solution 0.9 %, 10 %

G

sodium chloride inhalation nebulization solution 3 %

Nebusal G

sodium chloride inhalation nebulization solution 7 %

HyperSal G

sudogest sinus/allergy oral tablet 4-60 mg G OTC

tri-afed allergy & head cold oral tablet 2.5-60 mg

G

OTC

trip-pse oral liquid 0.938-10 mg/ml G OTC

trymine cg oral liquid 225-7.5 mg/5ml

Mar-Cof CG Expectorant G

PA Required for Day Supply Greater than 7; OTC

tusnel diabetic oral liquid 10-100 mg/5ml Tolu-Sed DM G OTC

phenylephrine w/ DM-GG oral liquid 5-10-200 mg/5ml

Tussin CF Max Multi-Symptom

G

OTC

tussin chest congestion oral syrup 100 mg/5ml Diabetic Tussin EX G OTC

tussin dm max adult oral liquid 10-200 mg/5ml Diabetic Tussin Max St G OTC

*Cystic Fibrosis Agent - Combinations***

ORKAMBI ORAL TABLET 200-125 MG, 100-125

B PA; SP

*Dermatologicals*

ABREVA EXTERNAL CREAM 10 % B OTC

acne maximum strength external pad 2 % Stri-Dex Maximum Strength G OTC

acne treatment external bar 10 % G OTC


38


Requirements/Limits

acne wash external liquid 2 % Clean & Clear Acne Cleanser

G

OTC

acyclovir external ointment 5 % Zovirax G QL (15 GM per 30 days)

adapalene external cream 0.1 % Differin G

adapalene external gel 0.1 %, 0.3 % Differin G

alclometasone dipropionate external cream 0.05 %

G

alclometasone dipropionate external ointment 0.05 %

G

amcinonide external cream 0.1 % G

amcinonide external lotion 0.1 % G

amcinonide external ointment 0.1 % G

ammonium lactate external cream 12 % Geri-Hydrolac 12 G

ammonium lactate external lotion 12 % Lac-Hydrin Twelve G

antibiotic plus pain relief external cream 3.5- 10000-10

Neosporin Plus Pain Relief MS

G

OTC

anti-dandruff external shampoo 1 % Selsun Blue Moisturizing G OTC

antifungal external cream 1 % Tinactin Jock Itch G OTC

anti-fungal external powder 1 % Odor Eaters Antifungal G OTC

athletes foot powder spray external aerosol powder 2 %

Lotrimin AF Powder G

OTC

athletes foot spray external aerosol 1 % Tinactin G OTC

bacitracin external ointment 500 unit/gm Baciguent G OTC

bacitracin zinc external ointment 500 unit/gm G OTC

bacitracin-polymyxin b external ointment 500- 10000 unit/gm

Polysporin B

OTC

BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 %

G

benzoyl peroxide cream 2.5% G OTC

benzoyl peroxide cleanser external lotion 6 % Oscion Cleanser G

benzoyl peroxide external foam 5.3 % BenzePrO G

benzoyl peroxide external foam 9.8 % BenzePrO Short Contact G

benzoyl peroxide external gel 10 % Clean & Clear Persa-Gel Max St

G

benzoyl peroxide external gel 5 % G

benzoyl peroxide wash external kit 4 & 5 %, 8 & 5 %

G

OTC

benzoyl peroxide wash external liquid 10 % PanOxyl Wash G

benzoyl peroxide wash external liquid 5 % Benzac AC Wash G OTC

benzoyl peroxide-erythromycin external gel 5- 3 %

Benzamycin G

beta care betamide external lotion 25 % G OTC

betamethasone dipropionate aug external cream 0.05 %

Diprolene AF G


39


Requirements/Limits

betamethasone dipropionate aug external gel 0.05 %

G


betamethasone dipropionate aug external lotion 0.05 %

Diprolene G

betamethasone dipropionate aug external ointment 0.05 %

Diprolene G


betamethasone dipropionate external cream 0.05 %

G

betamethasone dipropionate external lotion 0.05 %

G

betamethasone dipropionate external ointment 0.05 %

G

betamethasone valerate external cream 0.1 % G

betamethasone valerate external lotion 0.1 % G

betamethasone valerate external ointment 0.1 %

G

bp 10-1 external emulsion 10-1 % Cerisa Wash G

bp cleansing wash external emulsion 10-4 % G

bp wash external liquid 2.5 % PanOxyl G

bpo external gel 4 % G

bpo foaming cloths external 6 % BenzePrO Foaming Cloths G

calcipotriene external cream 0.005 % Dovonex G

calcipotriene external solution 0.005 % G

CALCITRENE EXTERNAL OINTMENT 0.005 %

G

CALCITRIOL EXTERNAL OINTMENT 3 MCG/GM

Vectical B

CENTANY AT EXTERNAL KIT 2 % B

CICLODAN EXTERNAL CREAM 0.77 % G

ciclopirox external solution 8 % Ciclodan G

ciclopirox olamine external suspension 0.77 % Loprox G

CLEAN & CLEAR ADVANTAGE 3-IN-1 EXTERNAL LOTION 5 %

B

OTC

clean & clear advantage relief external lotion 0.5 %

G

OTC

CLEAN & CLEAR BLACKHEAD ERASER EXTERNAL CREAM 2 %

B

OTC

CLEAN & CLEAR BLACKHEAD ERASER EXTERNAL GEL 0.5 %

B

OTC

CLEAN & CLEAR OIL ABSORBING EXTERNAL CREAM 0.5 %

B

OTC

clindamycin phos-benzoyl perox external gel 1-5 %

BenzaClin G

clindamycin phosphate external foam 1 % Evoclin G

clindamycin phosphate external gel 1 % Cleocin-T G


40


Requirements/Limits

clindamycin phosphate external lotion 1 % Cleocin-T G

clindamycin phosphate external solution 1 % Cleocin-T G

clindamycin phosphate external swab 1 % Clindacin-P G

clobetasol propionate emulsion external foam 0.05 %

Olux-E G QL (100 GM per 30 days)

clobetasol propionate external foam 0.05 %

Olux G QL (100 GM per 30 days)

clobetasol propionate external gel 0.05 % Temovate G QL (60 GM per 30 days)

clobetasol propionate external lotion 0.05 % Clobex G QL (118 ML per 30 days)

clobetasol propionate external shampoo 0.05 %

Clodan G

clobetasol propionate external solution 0.05 % Cormax Scalp Application G

clotrimazole anti-fungal external cream 1 % Lotrimin AF G

clotrimazole external solution 1 % FungiCure Intensive/NailGuard

G

clotrimazole-betamethasone external cream 1-0.05 %

Lotrisone G

clotrimazole-betamethasone external lotion 1- 0.05 %

G

CNL8 NAIL EXTERNAL KIT 8 % B

complete lice treatment combination kit 0.33- 4-0.5 %

RID Complete Lice Elimination

G

OTC

corn remover one-step external strip 40 % Compound W One Step Invisible

G

OTC

corn removers external pad 40 % Mediplast G OTC

corn/callus remover external solution 12.6 % G OTC

salicylic acid external gel 2 % Clean & Clear Acne Treatment

G

OTC

hydrocortisone external gel 1 % Corticool G OTC

desenex spray external aerosol 2 % G OTC

desonide external cream 0.05 % Tridesilon G

desonide external lotion 0.05 % DesOwen G

desonide external ointment 0.05 % G

diclofenac sodium transdermal gel 1 % Voltaren G PA

dry skin treatment adv therapy external ointment

Daily Conditioning Treatment

G

OTC

DRYSOL EXTERNAL SOLUTION 20 % B

DUOFILM EXTERNAL SOLUTION 17 % G OTC

ELIDEL EXTERNAL CREAM 1 %

B PA; QL (30 GM per 30 days)

elta tar external cream 2 % G OTC

elta tar external ointment 2 % G OTC

erythromycin external gel 2 % Erygel G


41


Requirements/Limits

erythromycin external pad 2 % G

erythromycin external solution 2 % G

EURAX EXTERNAL CREAM 10 % B PA

EURAX EXTERNAL LOTION 10 % B PA

fluocinolone acetonide body external oil 0.01 %

Derma-Smoothe/FS Body G

fluocinolone acetonide external cream 0.01 % G

fluocinolone acetonide external cream 0.025 %

Synalar G

fluocinolone acetonide external ointment 0.025 %

Synalar G

fluocinolone acetonide external solution 0.01 %

Synalar G

fluocinolone acetonide scalp external oil 0.01 %

Derma-Smoothe/FS Scalp G

fluocinonide external cream 0.05 % G

fluocinonide external cream 0.1 % Vanos G

fluocinonide external gel 0.05 % G QL (60 GM per 30 days)

fluocinonide external ointment 0.05 % G QL (60 GM per 30 days)

fluocinonide external solution 0.05 % G

fluocinonide-e external cream 0.05 % G

FLUOROPLEX EXTERNAL CREAM 1 % B

fluorouracil external cream 5 % Efudex G

fluorouracil external solution 2 %, 5 % G

fluticasone propionate external cream 0.05 % Cutivate G

fluticasone propionate external lotion 0.05 % Cutivate G

fluticasone propionate external ointment 0.005 %

G

gentamicin sulfate external cream 0.1 % G

gentamicin sulfate external ointment 0.1 % G

GERI-HYDROLAC 5 EXTERNAL LOTION 5 %

G

OTC

zinc oxide external ointment 10% Cottontails Diaper Rash Creamy

G

OTC

permethrin aerosol 0.5 % Licide G OTC

salicylic acid external liquid 3 % Psoriasin G OTC

halac external kit 0.05 & 12 % G

halobetasol propionate external cream 0.05 % Ultravate G

halobetasol propionate external ointment 0.05 %

Ultravate G

hydrocortisone acetate external cream 1 % Lanacort 10 G OTC

hydrocortisone acetate-aloe external gel 2 % G

hydrocortisone butyrate external cream 0.1 % Locoid G


42


Requirements/Limits

hydrocortisone butyrate external ointment 0.1 %

Locoid G

hydrocortisone butyrate external solution 0.1 %

Locoid G

hydrocortisone external cream 0.5 % G OTC

hydrocortisone external cream 1 % Preparation H Hydrocortisone

G

hydrocortisone external cream 2.5 % G

hydrocortisone external lotion 1 % Aquanil HC G OTC

hydrocortisone external lotion 2.5 % G

hydrocortisone external ointment 0.5 % G OTC

hydrocortisone external ointment 1 % Cortizone-10 G

hydrocortisone external ointment 2.5 % G

hydrocortisone valerate external cream 0.2 % G

hydrocortisone valerate external ointment 0.2 %

Westcort G

imiquimod external cream 5 % Aldara G

invisible acne treatment external cream 10 % Clearskin G OTC

KERALYT EXTERNAL GEL 3 % B OTC

KERALYT SCALP EXTERNAL KIT 6 % B

ketoconazole external cream 2 % G

ketoconazole external shampoo 2 % Nizoral G

lactic acid external lotion 10 % G

LATRIX XM EXTERNAL EMULSION 45 % G

lice killing external shampoo 4-0.33 % Licide G OTC

lice treatment external liquid 0.33-4 % Licide Maximum Strength G OTC

lice treatment external liquid 1 % Nix Creme Rinse G OTC

lice treatment external lotion 1 % G OTC

nit remover gel Liceout G OTC

lidocaine external cream 4 % AneCream G OTC

lidocaine external patch 5 % Lidoderm G QL (60 EA per 30 days)

lidocaine hcl external gel 2 % Regenecare HA G

lidocaine hcl external solution 4 % Xylocaine G

lidocaine-prilocaine external cream 2.5-2.5 % G

lindane external shampoo 1 % G

malathion external lotion 0.5 % Ovide G

metronidazole external cream 0.75 % Rosadan G

metronidazole external gel 0.75 % Rosadan G

metronidazole external lotion 0.75 % MetroLotion G

MG217 PSORIASIS MULTI-SYMPTOM EXTERNAL CREAM 3 %

B

OTC


43


Requirements/Limits

miconazole nitrate external cream 2 % Remedy Antifungal G OTC

miconazorb af external powder 2 % Lotrimin AF G OTC

mometasone furoate external cream 0.1 % Elocon G

mometasone furoate external ointment 0.1 % Elocon G

mometasone furoate external solution 0.1 % G

mupirocin external ointment 2 % Centany G QL (30 GM per 30 days)

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG

G

myorisan oral capsule 30 mg G

NEUTROGENA CLEAR PORE EXTERNAL LIQUID 3.5 %

B

OTC

nystatin external cream 100000 unit/gm G

nystatin external ointment 100000 unit/gm G

nystatin external powder 100000 unit/gm Nystop G

OC8 EXTERNAL GEL 7 % B OTC

one step callus remover external pad 40 % G OTC

one-step wart remover external pad 40 % Mediplast G OTC

pc-tar external shampoo 1 % Theraplex T G OTC

permethrin external cream 5 % Elimite G

podofilox external solution 0.5 % G

pr benzoyl peroxide wash external liquid 7 % G

PRAMOSONE EXTERNAL CREAM 1-1 % B

prednicarbate external cream 0.1 % Dermatop G

prednicarbate external ointment 0.1 % Dermatop G

permethrin spray & pyrethins-piperonyl butoxide shampoo combination kit 0.5-0.33-4 %

G OTC

coal tar shampoo 2.5 % Betatar Gel G OTC

RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 %

B

OTC

salicylic acid external cream 6 % Salacyn G

salicylic acid external foam 6 % Salvax G

salicylic acid external gel 6 % Keralyt G

salicylic acid external liquid 26 % G

salicylic acid external lotion 6 % Salacyn G

salicylic acid external shampoo 6 % Salex G

salicylic acid wart remover external liquid 27.5 %

Virasal G

salicylic acid-cleanser external kit 6 % (cream), 6 % (lotion)

Salex G

triple antibiotic plus lidocaine 4% external ointment

ProCoMycin G OTC

scalacort external lotion 2 % Ala Scalp G


44

scalp relief maximum strength external solution 1 %

Noble Formula HC G

OTC


45


Requirements/Limits

selenium sulfide external lotion 2.5 % G

selenium sulf-pyrithione-urea external shampoo 2.25 %

G

silver sulfadiazine external cream 1 % Thermazene G

SKLICE EXTERNAL LOTION 0.5 % B PA

SPINOSAD EXTERNAL SUSPENSION 0.9 % Natroba B

sss 10-5 external foam 10-5 % G

sulfacetamide sodium (acne) external lotion 10 %

Klaron G

sulfacetamide sodium external liquid 10 % Ovace Plus Wash G

sulfacetamide sodium-sulfur external cream 10-2 %

Avar-e LS G

sulfacetamide sodium-sulfur external cream 10-5 %

Avar-e Emollient G

sulfacetamide sodium-sulfur external emulsion 10-5 %

Avar Cleanser G

sulfacetamide sodium-sulfur external liquid 10-2 %

Avar LS Cleanser G

sulfacetamide sodium-sulfur external liquid 9- 4 %

Sumaxin Wash G

sulfacetamide sodium-sulfur external liquid 9- 4.5 %

Sumadan Wash G

sulfacetamide sodium-sulfur external lotion 10-5 %

G

sulfacetamide sodium-sulfur external pad 10-4 %

Sumaxin G

sulfacetamide sodium-sulfur external suspension 8-4 %

SulfaCleanse 8/4 G

sulfacetamide-sulfur in urea external emulsion 10-5 %

G

SULFACETAMIDE-SULFUR IN UREA EXTERNAL GEL 10-5 %

B

SULFAMYLON EXTERNAL PACKET 5 % B

tacrolimus external ointment 0.03 %, 0.1 %

Protopic G PA; QL (30 GM per 30 days)

tazarotene external cream 0.1 % Tazorac G

TAZORAC EXTERNAL CREAM 0.05 % B

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % B

tera-gel tar external shampoo 0.5 % G OTC

tetterine external ointment 2 % G OTC

tolnaftate external aerosol powder 1 % LamISIL AF Defense G OTC

tolnaftate external solution 1 % The Treatment Formula 3 G OTC

tretinoin external cream 0.025 % Avita G

tretinoin external cream 0.05 %, 0.1 % Retin-A G

tretinoin external gel 0.01 %, 0.025 % Retin-A G


46


Requirements/Limits

tretinoin external gel 0.05 % Atralin G

triamcinolone acetonide external cream 0.025 %

G

triamcinolone acetonide external cream 0.1 %, 0.5 %

Triderm G

triamcinolone acetonide external lotion 0.025 %, 0.1 %

G

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

G

triple antibiotic pain relief external ointment 1 %

Neosporin + Pain/Itch/Scar G

OTC

umecta mousse external foam 40 % G

urea external cream 10 %

Atrac-Tain G OTC; QL (85 GM per 30 days)


G OTC; QL (85 GM per 30 days)

urea external cream 45 % Uramaxin G QL (85 GM per 30 days)


Remeven G QL (142 GM per 30 days)

urea external emulsion 50 % G

urea external gel 40 % G

urea external lotion 10 % Nutraplus G OTC

urea external lotion 40 % Rea Lo 40 G

urea external lotion 45 % Uramaxin G

urea external suspension 50 % Latrix G

urea nail external gel 45 % Uramaxin G

urea nail film external suspension 40 % G

wart remover maximum strength external gel 17 %

Compound W Maximum Strength

G

OTC

wart remover maximum strength external liquid 17 %

Gets-It Corn/Callus Remover

G

OTC

*Diagnostic Products*

CHEMSTRIP K IN VITRO STRIP B OTC

CHEMSTRIP UGK IN VITRO STRIP B OTC

FREESTYLE LITE TEST IN VITRO STRIP

B

QL: #500/90 days for members on insulin; #200/90 days for members not on insulin; OTC

FREESTYLE TEST IN VITRO STRIP

B



47


Requirements/Limits

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

B


*Digestive Aids*

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000- 76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

B


SUCRAID ORAL SOLUTION 8500 UNIT/ML B

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000 UNIT, 40000 UNIT, 5000 UNIT

B


*Direct-Acting P2y12 Inhibitors***

BRILINTA ORAL TABLET 60 MG B QL (60 EA per 30 days)

BRILINTA ORAL TABLET 90 MG

B

QL (60 EA per 30 days); Maximum duration of therapy of 365 days

*Diuretics*

acetazolamide er oral capsule extended release 12 hour 500 mg

Diamox Sequels G

acetazolamide oral tablet 125 mg, 250 mg G

amiloride hcl oral tablet 5 mg G

amiloride-hydrochlorothiazide oral tablet 5-50 mg

G

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex G

chlorothiazide oral tablet 250 mg, 500 mg G

chlorthalidone oral tablet 25 mg, 50 mg G

furosemide oral solution 10 mg/ml, 8 mg/ml G

furosemide oral tablet 20 mg, 40 mg, 80 mg Lasix G

hydrochlorothiazide oral capsule 12.5 mg Microzide G

hydrochlorothiazide oral tablet 25 mg, 50 mg G

indapamide oral tablet 1.25 mg, 2.5 mg G

methazolamide oral tablet 25 mg, 50 mg Neptazane G

methyclothiazide oral tablet 5 mg G

metolazone oral tablet 10 mg, 2.5 mg, 5 mg G

spironolactone oral tablet 100 mg, 25 mg, 50 mg

Aldactone G

spironolactone-hctz oral tablet 25-25 mg Aldactazide G

torsemide oral tablet 10 mg, 20 mg Demadex G

torsemide oral tablet 100 mg, 5 mg G

triamterene-hctz oral capsule 37.5-25 mg Dyazide G

triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 G


48


Requirements/Limits

triamterene-hctz oral tablet 75-50 mg Maxzide G

*Endocrine And Metabolic Agents - Misc.*

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg

G


alendronate sodium oral tablet 35 mg G QL (4 EA per 28 days)

alendronate sodium oral tablet 70 mg Fosamax G QL (4 EA per 28 days)

cabergoline oral tablet 0.5 mg G

calcitonin (salmon) nasal solution 200 unit/act Miacalcin G

calcitriol intravenous solution 1 mcg/ml G

calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol G QL (30 EA per 30 days)

calcitriol oral solution 1 mcg/ml Rocaltrol G

desmopressin ace rhinal tube nasal solution 0.01 %

DDAVP Rhinal Tube G

PA

desmopressin ace spray refrig nasal solution 0.01 %

G

PA

desmopressin acetate oral tablet 0.1 mg, 0.2 mg

DDAVP G

desmopressin acetate spray nasal solution 0.01 %

DDAVP G

PA

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

Hectorol G

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

B

PA; SP

ibandronate sodium oral tablet 150 mg Boniva G

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

B

PA; SP

levocarnitine oral tablet 330 mg Carnitor G

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

B

SP

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

B

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

B

PA; SP

raloxifene hcl oral tablet 60 mg Evista G

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

B

PA; SP

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

B

PA; SP; QL (60 ML per 30 days)

sodium phenylbutyrate oral powder 3 gm/tsp Buphenyl G

STIMATE NASAL SOLUTION 1.5 MG/ML B SP


49


Requirements/Limits

ZOMACTON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 5 MG

B

PA; SP

*Estrogens*

ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

B

CENESTIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

B

CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/DAY

B

estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace G

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.075 mg/24hr

Vivelle-Dot G

estradiol transdermal patch twice weekly 0.05 mg/24hr

Alora G

estradiol transdermal patch twice weekly 0.1 mg/24hr

Minivelle G

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

Climara G

estradiol-norethindrone acet oral tablet 0.5-0.1 mg

Mimvey Lo G

estradiol-norethindrone acet oral tablet 1-0.5 mg

Mimvey G

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg G

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG

B

MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

B

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg

Femhrt Low Dose G

norethindrone-eth estradiol oral tablet 1-5 mg- mcg

Fyavolv G

PREFEST ORAL TABLET 1/1-0.09 MG (15/15)

B

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

B

PREMPHASE ORAL TABLET 0.625-5 MG B

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45- 1.5 MG, 0.625-2.5 MG, 0.625-5 MG

B

*Fluoroquinolones*

ciprofloxacin hcl oral tablet 100 mg, 750 mg G

ciprofloxacin hcl oral tablet 250 mg, 500 mg Cipro G

levofloxacin oral solution 25 mg/ml G


50


Requirements/Limits

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

Levaquin G

ofloxacin oral tablet 400 mg G

*Gastrointestinal Agents - Misc.*

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG B PA

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM

B

ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG

B

balsalazide disodium oral capsule 750 mg Colazal G

calcium acetate (phos binder) oral capsule 667 mg

PhosLo G

calcium acetate (phos binder) oral tablet 667 mg

Eliphos G

CANASA RECTAL SUPPOSITORY 1000 MG B

cromolyn sodium oral concentrate 100 mg/5ml Gastrocrom G

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

B

DIPENTUM ORAL CAPSULE 250 MG B

gas relief extra strength oral capsule 125 mg Gas-X Extra Strength G OTC

gas relief extra strength oral tablet chewable 125 mg

Gas-X Extra Strength G

OTC

gas relief oral liquid 40 mg/0.6ml Gas-X Infant Drops G OTC

gas relief oral tablet chewable 80 mg Gas-X G OTC

gas relief ultra strength oral capsule 180 mg Gas-X Ultra Strength G OTC

infants gas relief oral suspension 20 mg/0.3ml PediaCare Infants Gas Relief

G

OTC

lactulose encephalopathy oral solution 10 gm/15ml

G

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg

Fosrenol G

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

B

PA

mesalamine oral tablet delayed release 1.2 gm

Lialda G

MESALAMINE ORAL TABLET DELAYED RELEASE 800 MG

Asacol HD B

mesalamine rectal enema 4 gm G

metoclopramide hcl oral solution 5 mg/5ml G

metoclopramide hcl oral tablet 10 mg, 5 mg Reglan G

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG

B

RENAGEL ORAL TABLET 400 MG, 800 MG B

sevelamer carbonate oral packet 0.8 gm, 2.4 gm

Renvela G


51


Requirements/Limits

sevelamer carbonate oral tablet 800 mg Renvela G

simethicone oral capsule 125 mg Gas-X Extra Strength G OTC

simethicone oral capsule 180 mg Gas-X Ultra Strength G OTC

simethicone oral tablet chewable 125 mg Gas-X Extra Strength G OTC

simethicone oral tablet chewable 80 mg Gas-X G OTC

sulfasalazine oral tablet 500 mg Sulfazine G

sulfasalazine oral tablet delayed release 500 mg

Azulfidine EN-tabs G

ursodiol oral capsule 300 mg Actigall G

ursodiol oral tablet 250 mg Urso 250 G

ursodiol oral tablet 500 mg Urso Forte G

*Genitourinary Agents - Miscellaneous*

dutasteride oral capsule 0.5 mg Avodart G PA

ELMIRON ORAL CAPSULE 100 MG B

finasteride oral tablet 5 mg Proscar G

phenazopyridine hcl oral tablet 100 mg Pyridium G

phenazopyridine hcl oral tablet 200 mg Phenazo G

phenazopyridine hcl oral tablet 95 mg Phenazo G OTC

potassium citrate er oral tablet extended release 10 meq (1080 mg)

Urocit-K 10 G


Urocit-K 15 G


Urocit-K 5 G

sod citrate-citric acid oral solution 500-334 mg/5ml

Shohls Modified G

tamsulosin hcl oral capsule 0.4 mg Flomax G

urinary pain relief oral tablet 97.5 mg AZO Urinary Pain Relief G OTC

*Gout Agents*

allopurinol oral tablet 100 mg, 300 mg Zyloprim G

COLCHICINE ORAL CAPSULE 0.6 MG Mitigare B

COLCHICINE ORAL TABLET 0.6 MG Colcrys B

colchicine-probenecid oral tablet 0.5-500 mg G

COLCRYS ORAL TABLET 0.6 MG B

probenecid oral tablet 500 mg G

ULORIC ORAL TABLET 40 MG, 80 MG B

*Hematological Agents - Misc.*

anagrelide hcl oral capsule 0.5 mg Agrylin G

anagrelide hcl oral capsule 1 mg G

BRILINTA ORAL TABLET 60 MG B QL (60 EA per 30 days)


52


Requirements/Limits

BRILINTA ORAL TABLET 90 MG

B

QL (60 EA per 30 days); Maximum duration of therapy of 365 days

cilostazol oral tablet 100 mg, 50 mg G

clopidogrel bisulfate oral tablet 300 mg, 75 mg Plavix G

dipyridamole oral tablet 25 mg, 50 mg, 75 mg G

pentoxifylline er oral tablet extended release 400 mg

G

*Hematopoietic Agents*

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

B

PA; SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML

B

PA; SP

slow release iron oral tablet extended release 143 (45 fe) mg

G

OTC

cyanocobalamin injection solution 1000 mcg/ml

G

fabb oral tablet 2.2-25-1 mg Folgard RX G

fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25- 0.5 mg

G

ferrous gluconate oral tablet 240 (27 fe) mg Fergon G OTC

ferrous gluconate oral tablet 324 (37.5 fe) mg, 325 (36 fe) mg

G

OTC

FERROUS SULFATE GRANULES B

ferrous sulfate oral elixir 220 (44 fe) mg/5ml FeroSul G OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml Fer-In-Sol G OTC

ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg

G

OTC

ferrous sulfate oral tablet delayed release 325 (65 fe) mg

G

OTC

folic acid oral tablet 1 mg G

folic acid oral tablet 400 mcg G OTC

folic acid oral tablet 800 mcg FA-8 G OTC

iron oral tablet 200 (65 fe) mg Feosol G OTC

high potency iron oral tablet 134 mg G OTC

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

B

PA

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

B

PA; SP


53


Requirements/Limits

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

B

PA; SP

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

B

PA; SP

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

B

PA; SP

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

B

PA; SP

PROCRIT INJECTION SOLUTION 40000 UNIT/ML

B

PA

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

B

PA; SP

slow release iron oral tablet extended release 47.5 mg, 50 mg

G

OTC

slow release iron oral tablet extended release 143 (45 fe) mg

Slow Fe G

OTC

virt-vite oral tablet 2.5-25-1 mg NuFol G

*Hemostatics*

AMICAR ORAL TABLET 1000 MG, 500 MG B

tranexamic acid oral tablet 650 mg Lysteda G

*Hepatitis C Agent - Combinations***

MAVYRET B PA; SP; QL (84 EA per 28 days)

*Hypnotics*

diphenhydramine hcl (sleep) oral capsule 25 mg

ZzzQuil G OTC

diphenhydramine hcl (sleep) oral tablet 50 mg Nytol Maximum Strength G OTC

diphenhydramine oral liquid 50 mg/30ml ZzzQuil G OTC

estazolam oral tablet 1 mg, 2 mg G QL (30 EA per 30 days)

flurazepam hcl oral capsule 15 mg, 30 mg G QL (30 EA per 30 days)

ROZEREM ORAL TABLET 8 MG B PA

sleep aid (diphenhydramine) oral tablet 25 mg Restfully Sleep G OTC

sleep-aid maximum strength oral capsule 50 mg

Unisom Sleepgels G

OTC

temazepam oral capsule 15 mg, 30 mg Restoril G QL (30 EA per 30 days)

TRIAZOLAM ORAL TABLET 0.125 MG B

triazolam oral tablet 0.25 mg Halcion G

doxylamine succinate (sleep) oral tablet dispersible 25 mg

Unisom SleepMelts G OTC

zaleplon oral capsule 10 mg, 5 mg Sonata G QL (30 EA per 30 days)

zolpidem tartrate oral tablet 10 mg Ambien G QL (30 EA per 30 days)


54


Requirements/Limits

zolpidem tartrate oral tablet 5 mg Ambien G QL (60 EA per 30 days)

*Laxatives*

bisacodyl ec oral tablet delayed release 5 mg Feenamint G OTC

bisacodyl laxative rectal suppository 10 mg Dulcolax G OTC

chocolated laxative oral tablet chewable 15 mg

Ex-Lax G

OTC

diocto oral syrup 60 mg/15ml G OTC

docusate calcium oral capsule 240 mg Kao-Tin G OTC

docusate sodium oral capsule 100 mg Correctol Extra Gentle G OTC

docusate sodium oral capsule 250 mg DOK G OTC

docusate sodium oral capsule 50 mg

docusate sodium oral liquid 50 mg/5ml G OTC

docusate sodium oral tablet 100 mg Promolaxin G OTC

docusol mini rectal enema 283 mg G OTC

enema rectal enema 7-19 gm/118ml Fleet Pediatric G OTC

epsom salt oral granules G OTC

fiber laxative oral capsule 0.52 gm Medi-Mucil G OTC

gavilyte-c oral solution reconstituted 240 gm G

gavilyte-g oral solution reconstituted 236 gm G

geri-mucil oral powder 68 % Reguloid G OTC

lactulose oral solution 10 gm/15ml G

laxative oral tablet 25 mg Ex-Lax Maximum Strength G OTC

magnesium citrate oral solution 1.745 gm/30ml

Citroma G

OTC

milk of magnesia oral suspension 400 mg/5ml Phillips Milk of Magnesia G OTC

natural fiber laxative oral powder 28.3 % Metamucil Smooth Texture G OTC

natural fiber laxative oral powder 30.9 % Konsyl G OTC

psyllium powder 100%

G

OTC

natural psyllium seed oral powder 100 % Konsyl G OTC

NATURAL SENNA LAXATIVE ORAL TABLET 64.8-324 MG

B

OTC

OSMOPREP ORAL TABLET 1.102-0.398 GM B

peg 3350 oral packet ClearLax G OTC

peg 3350 oral powder ClearLax G OTC

peg 3350/electrolytes oral solution reconstituted 240 gm

Colyte with Flavor Packs G

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

Nulytely with Flavor Packs G

peg-3350/electrolytes oral solution reconstituted 236 gm

Golytely G

natural vegetable (psyllium) oral powder 95 % Hydrocil G OTC

sennosides laxative extra strength oral tablet 17.2 mg

Senokot Extra Strength G OTC


55


Requirements/Limits

saline laxative oral solution 0.9-2.4 gm/5ml G OTC

senna laxative oral tablet 8.6 mg Senokot G OTC

senna oral capsule 8.6 mg G OTC

senna oral syrup 8.8 mg/5ml G OTC

senna smooth oral tablet 15 mg G OTC

senna-docusate sodium oral tablet 8.6-50 mg Doc-Q-Lax G OTC

stool softener oral capsule 100 mg Correctol Extra Gentle G OTC

stool softener oral capsule 240 mg Kao-Tin G OTC

stool softener oral capsule 250 mg DOK G OTC

stool softener oral tablet 100 mg Promolaxin G OTC

trilyte oral solution reconstituted 420 gm G

*Leptin Analogues***

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG

B

PA; SP

*Macrolides*

azithromycin oral packet 1 gm Zithromax G

azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

Zithromax G

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Zithromax G

clarithromycin er oral tablet extended release 24 hour 500 mg

Biaxin XL Pac G

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

G

clarithromycin oral tablet 250 mg, 500 mg Biaxin G

DIFICID ORAL TABLET 200 MG B PA

ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML

B

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml

EryPed 200 G

*Medical Devices*

ALCOHOL PREP PAD BD Swab Single Use Regular

B

OTC

BD AUTOSHIELD DUO 30G X 5 MM B OTC

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML

B

OTC

BD INSULIN SYRINGE 27G X 1/2" 1 ML B OTC

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML

B

OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML

B

OTC

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 1 ML

B

OTC


56


Requirements/Limits

BD INSULIN SYRINGE ULTRAFINE 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML

B

OTC

CAYA VAGINAL DIAPHRAGM B

CONDOMS LifeStyles Ribbed B OTC

EASIVENT B

FC FEMALE CONDOM B OTC

FREESTYLE LANCETS B OTC

FREESTYLE SYSTEM KIT B OTC

INSULIN SYRINGE 29G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML

BD Insulin Syringe Ultrafine B

OTC

INSULIN SYRINGE 29G X 1/2" 0.5 ML UltiCare Insulin Syringe B OTC

INSULIN SYRINGE 29G X 1/2" 1 ML Sure-Ject Insulin Syringe B OTC

INSULIN SYRINGE 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Ultilet Insulin Syringe B

OTC

INSULIN SYRINGE 31G X 5/16" 0.5 ML BD Insulin Syr Ultrafine II B OTC

INSULIN SYRINGE 31G X 5/16" 1 ML ReliOn Insulin Syringe B OTC

INSULIN SYRINGE/NEEDLE 27G X 1/2" 0.5 ML

Easy Touch Insulin Syringe B

OTC

INSULIN SYRINGE/NEEDLE 28G X 1/2" 0.5 ML

Monoject Insulin Syringe B

OTC

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM

B

ORTHO DIAPHRAGM ALL-FLEX VAGINAL DIAPHRAGM 75 MM

B

ORTHO DIAPHRAGM COIL VAGINAL KIT 100 MM, 105 MM, 50 MM

B

ORTHO DIAPHRAGM FLAT VAGINAL KIT 55 MM, 60 MM, 65 MM, 70 MM, 75 MM, 80 MM, 85 MM, 90 MM, 95 MM

B

PRECISION GLUCOSE/KETONE CONTR IN VITRO LIQUID

B

OTC

PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML

B

OTC

PREMIUM CONDOMS LUBRICATED Reality Latex/Ultra Thin B OTC

RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML

B

OTC

RELION INSULIN SYRINGE 29G X 1/2" 1 ML B OTC

RELION INSULIN SYRINGE 30G X 5/16" 1 ML

B

OTC

RELION INSULIN SYRINGE 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML

B

OTC

SURE COMFORT INSULIN SYRINGE 30G X 1/2" 0.3 ML

Ultilet Insulin Syringe Short B

OTC

TROJAN REGULAR B OTC


57


Requirements/Limits

TRUEPLUS INSULIN SYRINGE 30G X 5/16" 0.5 ML

B

OTC

ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML

B

OTC

WIDE-SEAL DIAPHRAGM VAGINAL DIAPHRAGM 2 %

B

*Migraine Products*

CAFERGOT ORAL TABLET 1-100 MG B

ergot/caffen tab 1-100 mg G

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

B

rizatriptan benzoate oral tablet 10 mg, 5 mg Maxalt G QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

Maxalt-MLT G


sumatriptan nasal solution 20 mg/act, 5 mg/act

Imitrex G


sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

Imitrex G


sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml

Imitrex STATdose Refill G


sumatriptan succinate subcutaneous solution 6 mg/0.5ml

Imitrex G


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

Imitrex STATdose System G


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

G


*Minerals & Electrolytes*

calcium 500 + d3 oral tablet 500-600 mg-unit Os-Cal Extra D3 G OTC

calcium 600 + minerals oral tablet 600-200 mg-unit

G

OTC

calcium 600 oral tablet 1500 (600 ca) mg Caltrate 600 G OTC


58


Requirements/Limits

calcium 600+d plus minerals oral tablet 600- 400 mg-unit

G

OTC

calcium 600+d3 oral tablet 600-200 mg-unit G OTC

calcium 600+d3 oral tablet 600-800 mg-unit Pronutrients Calcium+D3 G OTC

calcium 600+d3 plus minerals oral tablet 600- 800 mg-unit

Caltrate 600+D Plus Minerals

G

OTC

calcium 600+d3 plus minerals oral tablet chewable 600-800 mg-unit

Caltrate 600+D Plus Minerals

G

OTC

calcium carbonate oral suspension 1250 (500 ca) mg/5ml

G

OTC

calcium carbonate oral tablet 1250 (500 ca) mg

Cal-Carb Forte G

OTC

calcium carbonate oral tablet 600 mg High Potency Calcium G OTC

calcium carbonate-vitamin d3 oral tablet 600- 400 mg-unit

G

OTC

calcium oral tablet 600 mg G OTC

calcium oral tablet chewable 500 mg, 500-100 mg-unit

G

OTC

calcium-vitamin d oral tablet 500-125 mg-unit, 600-200 mg-unit

G

OTC

effervescent pot chloride oral tablet effervescent 25 meq

G

ELITE CALCIUM ORAL TABLET (calcium) 150 MG

B OTC

fluoritab oral solution 0.275 (0.125 f) mg/drop Flura-Drops G

fluoritab oral tablet chewable 2.2 (1 f) mg Ludent G

KLOR-CON ORAL PACKET 25 MEQ B

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ

B

magnesium oral capsule 500 mg G OTC

magnesium oxide -mg supplement oral tablet 250 mg

G

OTC

magnesium oxide oral tablet 400 (240 mg) mg, 500 mg

G

OTC

magnesium oxide oral tablet 400 (241.3 mg) mg

MAGnesium-Oxide G

OTC

oyster shell calcium + d3 oral tablet 500-400 mg-unit

Oystercal-D G

OTC

oyster shell calcium plus d oral tablet 500-125 mg-unit

G

OTC

oyster shell calcium plus d oral tablet 500-200 mg-unit

Oysco 500+D G

OTC

oyster shell calcium/vitamin d oral tablet 250- 125 mg-unit

G

OTC

oyster-cal 500 oral tablet 500 mg G OTC

pediatric electrolyte oral solution G OTC


59


Requirements/Limits

potassium bicarbonate oral tablet effervescent 25 meq

Effer-K G

potassium chloride crys er oral tablet extended release 10 meq

Klor-Con M10 G

potassium chloride crys er oral tablet extended release 20 meq

Klor-Con M20 G

potassium chloride er oral capsule extended release 10 meq, 8 meq

Micro-K G

potassium chloride er oral tablet extended release 10 meq, 20 meq

K-Tab G

potassium chloride er oral tablet extended release 8 meq

Klor-Con G

potassium chloride oral packet 20 meq G

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

G

sodium fluoride oral solution 1.1 (0.5 f) mg/ml G

sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

Ludent G

*Mouth/Throat/Dental Agents*

cevimeline hcl oral capsule 30 mg Evoxac G

chlorhexidine gluconate mouth/throat solution 0.12 %

Paroex G

clinpro 5000 dental paste 1.1 % G

clotrimazole mouth/throat lozenge 10 mg G

sodium fluoride dental cream 1.1 % Denta 5000 Plus G

sodium fluoride dental gel 1.1 % Dentagel G

fluoride mouth rinse mouth/throat solution 0.0221 (0.01 f) %

Listerine Smart Rinse G

OTC

stannous fluoride dental gel 0.4 % Gel‐Tin G OTC

lidocaine hcl mouth/throat solution 4 % B

lidocaine viscous mouth/throat solution 2 % G

neutral sodium fluoride mouth/throat solution 0.2 %

PreviDent G

nystatin mouth/throat suspension 100000 unit/ml

G

stannous fluoride concentrate 0.63 % Periomed G OTC

pilocarpine hcl oral tablet 5 mg, 7.5 mg Salagen G

carbamide peroxide solution 10 %

Cankaid G

OTC

sodium fluoride rinse solution 0.05 %

Fluorigard G

OTC

triamcinolone acetonide mouth/throat paste 0.1 %

Oralone G

*Multivitamins*


60

b complex vitamins oral capsule G OTC


61


Requirements/Limits

b-complex balanced oral tablet Milco-B-Forte G OTC

b-complex high potency oral tablet extended release

G

OTC

b-complex/b-12 sublingual liquid G OTC

CENTRUM SPECIALIST PRENATAL ORAL 27-0.8 & 200 MG

B

OTC

child chewable vitamins/iron oral tablet chewable

Flintstones Plus Iron G

OTC

childrens chewable multi vits oral tablet chewable

Flintstones Plus Calcium G

OTC

CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG

B

PRENATAL GUMMY ORAL TABLET CHEWABLE 0.4-113.5 MG

B

OTC

multi vitamin/fluoride oral tablet chewable 0.25 mg, 1 mg

MVC-Fluoride G

multi-vit/fluoride oral solution 0.5 mg/ml Quflora Pediatric G

multi-vitamin/fluoride oral solution 0.25 mg/ml Floriva Plus G

multi-vitamin/fluoride oral tablet chewable 0.5 mg

MVC-Fluoride G

multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml

G

MYNATAL ORAL TABLET 90-1 MG B

MYNATAL PLUS ORAL TABLET Vitafol-OB B

O-CAL PRENATAL ORAL TABLET B

ONE-A-DAY WOMENS PRENATAL ORAL 28-0.8 & 440 MG

B

OTC

one-daily multi vitamins oral tablet Tab-A-Vite/Beta Carotene G OTC

polyvitamin oral solution 35 mg/ml Poly-Vi-Sol G OTC

poly-vitamin/iron oral solution 10 mg/ml BProtected Pedia Poly- Vite/Fe

G

OTC

PRENATA ORAL TABLET CHEWABLE 29-1 MG

B

prenatabs fa oral tablet Co-Natal FA B

PRENATAL 19 ORAL TABLET 29-1 MG B

prenatal 19 oral tablet chewable B

PRENATAL COMPLETE ORAL TABLET 14- 0.4 MG

B

OTC

prenatal low iron oral tablet 27-1 mg TheraNatal Core Nutrition B

PRENATAL MULTI +DHA ORAL CAPSULE 27-0.8-228 MG

B

OTC

PRENATAL MULTIVITAMIN + DHA ORAL 28- 0.8 & 200 MG

B

OTC

PRENATAL ORAL TABLET 27-0.8 MG Right Step Prenatal B

prenatal plus iron oral tablet 29-1 mg Prenatabs Rx B


62


Requirements/Limits

PRENATAL VITAMINS ORAL TABLET 28-0.8 MG

B

OTC

PRENATAL+DHA ORAL 28-0.975 & 200 MG B OTC

PRENATAL-U ORAL CAPSULE 106.5-1 MG B

PREQUE 10 ORAL TABLET 15-25-0.5-50 MG B

RENAL MULTIVITAMIN FORMULA ORAL TABLET

G

OTC

rena-vite rx oral tablet 1 mg Nephro-Vite Rx G

SIMILAC PRENATAL EARLY SHIELD ORAL 27-0.8 & 200 MG

B

OTC

triple-vitamin/fluoride oral solution 0.25 mg/ml G

tri-vit/fluoride/iron oral solution 0.25-10 mg/ml G

tri-vitamin oral solution 1500-400-35 BProtected Pedia Tri-Vite G OTC

tri-vitamin/fluoride oral solution 0.5 mg/ml G

VIRT NATE ORAL TABLET 28-1 MG Trinate B

virt-vite plus oral tablet 5 mg G

vitamin b complex oral tablet G OTC

vitamin e/folic acid/b-6/b-12 oral capsule Ze-Plus G OTC

*Musculoskeletal Therapy Agents*

baclofen oral tablet 10 mg, 20 mg G

chlorzoxazone oral tablet 500 mg Parafon Forte DSC G

cyclobenzaprine hcl oral tablet 10 mg, 5 mg G

dantrolene sodium oral capsule 100 mg G

dantrolene sodium oral capsule 25 mg, 50 mg Dantrium G

methocarbamol oral tablet 500 mg Robaxin G

methocarbamol oral tablet 750 mg Robaxin-750 G

tizanidine hcl oral tablet 2 mg G

tizanidine hcl oral tablet 4 mg Zanaflex G

*Nasal Agents - Systemic And Topical*

azelastine hcl nasal solution 0.1 % G QL (30 ML per 30 days)

budesonide nasal suspension 32 mcg/act Rhinocort Aqua G

pseudoephedrine hcl oral liquid 15 mg/5ml Sudafed Childrens G OTC

cromolyn sodium nasal aerosol solution 5.2 mg/act

NasalCrom G OTC; QL (13 ML per 30 days)

flunisolide nasal solution 25 mcg/act (0.025%) G QL (50 ML per 30 days)

fluticasone propionate nasal suspension 50 mcg/act

Flonase Allergy Relief G

ipratropium bromide nasal solution 0.03 %, 0.06 %

G

phenylephrine nasal decongestant nasal solution 1 %

G OTC


63

pseudoephedrine hcl er oral tablet extended release 12 hour 120 mg

Sudafed G

OTC


64


Requirements/Limits

pseudoephedrine hcl oral tablet 30 mg, 60 mg Sudafed G

saline nasal spray nasal solution 0.65 % Humist G OTC

oxymetazoline hcl 12 hour nasal solution 0.05%

Afrin NoDrip Original G

OTC

triamcinolone acetonide nasal aerosol 55 mcg/act

Nasacort Allergy 24HR G

ZEPHREX-D ORAL TABLET ABUSE- DETERRENT 30 MG

G

OTC

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

B

PA

*Neurogenic Orthostatic Hypotension (Noh) - Agents***

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

B

PA; SP

*Neuromuscular Agents*

riluzole oral tablet 50 mg Rilutek G

*Nutrients*

fish oil concentrate oral capsule 435 mg G OTC

fish oil oral capsule 645 mg G OTC

omega-3 fish oil oral capsule 1200 mg Theragran-M Fish Oil Conc G OTC

omega-3 fish oil oral capsule 300 mg Fish Oil Pearls G OTC

omega-3 fish oil oral capsule 500 mg Super Omega 3 G OTC

*Ophthalmic Agents*

allergy eye ophthalmic solution 0.025-0.3 % Naphcon-A G OTC

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

B

apraclonidine hcl ophthalmic solution 0.5 % Iopidine G

artificial tears ophthalmic solution 0.1-0.3 % Bion Tears G OTC

artificial tears ophthalmic solution 0.2-0.2-1 % Visine Tears G OTC

artificial tears ophthalmic solution 1.4 % G OTC

artificial tears ophthalmic solution 1-0.3 % Moisture Eyes G OTC

artificial tears ophthalmic solution 5-6 mg/ml Murine Tears for Dry Eyes G OTC

atropine sulfate ophthalmic ointment 1 % G

atropine sulfate ophthalmic solution 1 % G

azelastine hcl ophthalmic solution 0.05 % G QL (30 ML per 30 days)

AZOPT OPHTHALMIC SUSPENSION 1 % B PA

bacitracin ophthalmic ointment 500 unit/gm G QL (3.5 GM per 7 days)

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Polycin G

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

Neo-Polycin HC G


65


Requirements/Limits

betaxolol hcl ophthalmic solution 0.5 % G

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

B

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

B

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

B

BLINK TEARS OPHTHALMIC SOLUTION (polyethylene glycol 400) 0.25 %

B

OTC

brimonidine tartrate ophthalmic solution 0.15 %

Alphagan P G

brimonidine tartrate ophthalmic solution 0.2 % G

carteolol hcl ophthalmic solution 1 % G

ciprofloxacin hcl ophthalmic solution 0.3 % Ciloxan G

COSOPT PF OPHTHALMIC SOLUTION 22.3- 6.8 MG/ML

B

PA

cromolyn sodium ophthalmic solution 4 % G

lubricant drops ophthalmic gel 0.25-0.3 % GenTeal G OTC

lubricant drops ophthalmic gel 1 % G OTC

cyclopentolate hcl ophthalmic solution 1 %, 2 %

Cyclogyl G

dexamethasone sodium phosphate ophthalmic solution 0.1 %

G

diclofenac sodium ophthalmic solution 0.1 % G

dorzolamide hcl ophthalmic solution 2 % Trusopt G

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

Cosopt G

epinastine hcl ophthalmic solution 0.05 % Elestat G

erythromycin ophthalmic ointment 5 mg/gm G

naphazoline-pheniramine ophthalmic solution 0.027-0.315 %

Opcon-A G

OTC

naphazoline-pheniramine ophthalmic solution 0.05-0.25 %

Visine-AC G

OTC

fluorometholone ophthalmic suspension 0.1 % FML Liquifilm G

flurbiprofen sodium ophthalmic solution 0.03% G

gentamicin sulfate ophthalmic ointment 0.3 % Gentak G

gentamicin sulfate ophthalmic solution 0.3 % G

homatropine hbr ophthalmic solution 5 % Homatropaire G

ketotifen fumarate ophthalmic solution 0.025% Alaway G

latanoprost ophthalmic solution 0.005 % Xalatan G

levobunolol hcl ophthalmic solution 0.5 % Betagan G

levofloxacin ophthalmic solution 0.5 % G


66


Requirements/Limits

lubricant eye drops ophthalmic solution 0.4- 0.3 %

Systane G

OTC

lubricant eye drops ophthalmic solution 0.5 % Refresh Tears G OTC

lubricant eye drops ophthalmic solution 0.6 % Systane Balance G OTC

metipranolol ophthalmic solution 0.3 % G

moxifloxacin hcl ophthalmic solution 0.5 % Vigamox G PA

NATACYN OPHTHALMIC SUSPENSION 5 % B

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

Neo-Polycin G

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

Maxitrol G

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Maxitrol G

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Neosporin G

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

G

ofloxacin ophthalmic solution 0.3 % Ocuflox G

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

Altafrin G

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Isopto Carpine G

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

Polytrim G

PRED-G OPHTHALMIC SUSPENSION 0.3-1 %

B

PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 %

B

prednisolone acetate ophthalmic suspension 1 %

Omnipred G

prednisolone sodium phosphate ophthalmic solution 1 %

G

proparacaine hcl ophthalmic solution 0.5 % Alcaine G

RESTASIS OPHTHALMIC EMULSION 0.05% B

PA

SOOTHE OPHTHALMIC SOLUTION (propylene glycol – glycerin) 0.6-0.6 %

B

OTC

sulfacetamide sodium ophthalmic solution 10%

Bleph-10 G

sulfacetamide-prednisolone ophthalmic solution 10-0.23 %

G

SYSTANE OPHTHALMIC GEL 0.4-0.3 % B OTC

tetracaine hcl ophthalmic solution 0.5 % Altacaine G


67


Requirements/Limits

LUBRICANT EYE DROPS OPHTHALMIC SOLUTION 0.95 %

G

OTC

timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %

Timoptic-XE G

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Timoptic G

TOBRADEX OPHTHALMIC OINTMENT 0.3- 0.1 %

B

QL (3.5 GM per 7 days)

tobramycin ophthalmic solution 0.3 % Tobrex G

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

TobraDex G

travatan ophthalmic solution 0.004% G

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

B

PA

travoprost ophthalmic solution 0.004 % G PA

trifluridine ophthalmic solution 1 % Viroptic G

tropicamide ophthalmic solution 0.5 % G

tropicamide ophthalmic solution 1 % Mydriacyl G

VEXOL OPHTHALMIC SUSPENSION 1 % B

ZIOPTAN OPHTHALMIC SOLUTION 0.0015% B

PA

*Otic Agents*

acetic acid otic solution 2 % G

acetic acid-aluminum acetate otic solution 2 % G

antipyrine-benzocaine otic solution 5.4-1.4 %, 5.5-1.4 %

G

CIPRODEX OTIC SUSPENSION 0.3-0.1 % B

ciprofloxacin hcl otic solution 0.2 % Cetraxal B

ear wax removal system otic solution 6.5 % E-R-O Ear Drops G OTC

fluocinolone acetonide otic oil 0.01 % DermOtic G

hydrocortisone-acetic acid otic solution 1-2 % Acetasol HC G

neomycin-polymyxin-hc otic solution 1 % Cortisporin G

neomycin-polymyxin-hc otic suspension 3.5- 10000-1

G

ofloxacin otic solution 0.3 % Floxin Otic G

*Oxytocics*

methylergonovine maleate oral tablet 0.2 mg Methergine G

*Passive Immunizing Agents*

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5ML

B

PA; SP

*Penicillins*

amoxicillin oral capsule 250 mg, 500 mg G


68


Requirements/Limits

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

G

amoxicillin oral tablet 500 mg, 875 mg G

amoxicillin oral tablet chewable 125 mg, 250 mg

G

amoxicillin-pot clavulanate er oral tablet extended release 12 hour 1000-62.5 mg

Augmentin XR G

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml

G

amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml

Augmentin G

amoxicillin-pot clavulanate oral suspension reconstituted 600-42.9 mg/5ml

Augmentin ES-600 G

amoxicillin-pot clavulanate oral tablet 250-125 mg

G

amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg

Augmentin G

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

G

ampicillin oral capsule 250 mg, 500 mg G

ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

G

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

B

dicloxacillin sodium oral capsule 250 mg, 500 mg

G

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

G

penicillin v potassium oral tablet 250 mg, 500 mg

G

*Potassium Removing Agents***

sodium polystyrene sulfonate oral suspension 15 gm/60ml

Kionex G

sodium polystyrene sulfonate rectal suspension 50 gm/200ml

G

*Progestins*

MAKENA INTRAMUSCULAR OIL 250 MG/ML B PA

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

Provera G


norethindrone acetate oral tablet 5 mg Aygestin G


69


Requirements/Limits

progesterone micronized oral capsule 100 mg, 200 mg

Prometrium G

*Psychotherapeutic And Neurological Agents - Misc.*

AVONEX INTRAMUSCULAR KIT 30 MCG B PA; SP

AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML

B

PA; SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

B

PA; SP

BETASERON SUBCUTANEOUS KIT 0.3 MG B PA; SP

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

Zyban G

QL (84 days per 180 days)

CHANTIX ORAL TABLET 0.5 MG, 1 MG B QL (84 days per 180 days)

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

B


COPAXONE SUBCUTANEOUS SOLUTION PREFILLED syringe 20 MG/ML, 40 MG/ML

B

PA; SP

donepezil hcl oral tablet 10 mg, 23 mg, 5 mg Aricept G PA

donepezil hcl oral tablet dispersible 10 mg, 5 mg

G

PA

ergoloid mesylates oral tablet 1 mg G

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg

Razadyne ER G

PA

galantamine hydrobromide oral solution 4 mg/ml

B

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

Razadyne G

PA

GILENYA ORAL CAPSULE 0.5 MG B PA; SP

glatopa subcutaneous solution prefilled syringe 20 mg/ml

G

PA; SP

memantine hcl oral solution 2 mg/ml B

memantine hcl oral tablet 10 mg, 5 mg Namenda G PA

memantine hcl oral tablet 5 (28)-10 (21) mg Namenda Titration Pak G PA

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

B

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21

B

nicotine polacrilex mouth/throat gum 2 mg, 4 mg

Nicorette Starter Kit G OTC; QL (84 days per 180 days)

nicotine polacrilex mouth/throat lozenge 2 mg

Nicorette G OTC; QL (84 days per 180 days)

nicotine polacrilex mouth/throat lozenge 4 mg

Nicorette Mini G OTC; QL (84 days per 180 days)


70


Requirements/Limits

nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr

Nicoderm CQ G


NICOTROL INHALATION INHALER 10 MG B QL (84 days per 180 days)

NICOTROL NS NASAL SOLUTION 10 MG/ML

B


PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN- INJECTOR 63 & 94 MCG/0.5ML

B

PA; SP

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML

B

PA; SP

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 125 MCG/0.5ML

B

PA; SP

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML

B

PA; SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

B

PA; SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 6X8.8 & 6X22 MCG

B

PA; SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

B

PA; SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG

B

PA; SP

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

G

PA

rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

Exelon G

PA

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

B


SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG

B

TECFIDERA ORAL 120 & 240 MG B PA; SP

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG

B

PA; SP

*Pulmonary Fibrosis Agents***

ESBRIET ORAL CAPSULE 267 MG B PA; SP

*Respiratory Agents - Misc.*

PULMOZYME INHALATION SOLUTION 1 MG/ML

B

PA; SP

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb***

INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

B


71


Requirements/Limits

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG

B

*Sulfonamides*

sulfadiazine oral tablet 500 mg G

*Tetracyclines*

demeclocycline hcl oral tablet 150 mg, 300 mg G

doxycycline hyclate oral capsule 100 mg Vibramycin G

doxycycline hyclate oral capsule 50 mg Morgidox G

doxycycline hyclate oral tablet 100 mg, 20 mg G

doxycycline monohydrate oral capsule 100 mg Monodox G

doxycycline monohydrate oral capsule 150 mg Adoxa G

doxycycline monohydrate oral capsule 50 mg Mondoxyne NL G

doxycycline monohydrate oral suspension reconstituted 25 mg/5ml

Vibramycin G

doxycycline monohydrate oral tablet 100 mg G

minocycline hcl oral capsule 100 mg, 50 mg Minocin G

minocycline hcl oral capsule 75 mg G

*Thyroid Agents*

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG

B

ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG

B

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Unithroid Direct G

levothyroxine sodium oral tablet 137 mcg Levoxyl G

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

Cytomel G

methimazole oral tablet 10 mg, 5 mg Tapazole G

NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 162.5 MG, 260 MG, 325 MG, 48.75 MG, 81.25 MG

B

np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg

Armour Thyroid G

propylthiouracil oral tablet 50 mg G

WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 97.5 MG

B

WESTHROID ORAL TABLET 65 MG B

WP THYROID ORAL TABLET 16.25 MG B

*Ulcer Drugs*

CARAFATE ORAL SUSPENSION 1 GM/10ML

B

cimetidine hcl oral solution 300 mg/5ml G


72


Requirements/Limits

cimetidine oral tablet 200 mg Tagamet HB G

cimetidine oral tablet 300 mg, 400 mg, 800 mg G

dicyclomine hcl oral capsule 10 mg Bentyl G

dicyclomine hcl oral solution 10 mg/5ml G

dicyclomine hcl oral tablet 20 mg Bentyl G

famotidine oral suspension reconstituted 40 mg/5ml

Pepcid G

famotidine oral tablet 10 mg Pepcid AC G OTC

famotidine oral tablet 20 mg Pepcid AC Maximum Strength

G

famotidine oral tablet 40 mg Pepcid G

FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML

B

FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML

B

glycopyrrolate oral tablet 1 mg Robinul G

glycopyrrolate oral tablet 2 mg Robinul-Forte G

hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

Symax-SR G

hyoscyamine sulfate oral elixir 0.125 mg/5ml G

hyoscyamine sulfate oral solution 0.125 mg/ml G

hyoscyamine sulfate oral tablet 0.125 mg Levsin G

hyoscyamine sulfate oral tablet dispersible 0.125 mg

Anaspaz G

hyoscyamine sulfate sublingual tablet sublingual 0.125 mg

Levsin/SL G

lansoprazole oral capsule delayed release 15 mg, 30 mg

Prevacid G

methscopolamine bromide oral tablet 2.5 mg Pamine G

methscopolamine bromide oral tablet 5 mg Pamine Forte G

misoprostol oral tablet 100 mcg, 200 mcg Cytotec G

NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE 20 MG

B

OTC

omeprazole magnesium oral capsule delayed release 20.6 (20 base) mg

G

OTC

omeprazole oral capsule delayed release 10 mg, 40 mg

G

omeprazole oral capsule delayed release 20 mg

PriLOSEC G

OMEPRAZOLE ORAL TABLET DELAYED RELEASE 20 MG

B

OTC

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

Protonix G


propantheline bromide oral tablet 15 mg G

ranitidine acid reducer oral tablet 75 mg Zantac 75 G OTC


73


Requirements/Limits

ranitidine hcl oral capsule 150 mg, 300 mg G

ranitidine hcl oral syrup 15 mg/ml G

ranitidine hcl oral tablet 150 mg Zantac

G

ranitidine hcl oral tablet 300 mg Zantac G

sucralfate oral tablet 1 gm Carafate G

*Urinary Anti-Infectives*

methenamine hippurate oral tablet 1 gm Hiprex G

methenamine mandelate oral tablet 1 gm G

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Macrodantin G

nitrofurantoin monohyd macro oral capsule 100 mg

Macrobid G

nitrofurantoin oral suspension 25 mg/5ml Furadantin G

uroav-81 oral tablet 81 mg Hyolev MB G

uro-mp oral capsule 118 mg Uribel G

ustell oral capsule 120 mg G

utira-c oral tablet 81.6 mg G

*Urinary Antispasmodics*

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

Urecholine G

flavoxate hcl oral tablet 100 mg G

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG

B

ST

oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

Ditropan XL G

oxybutynin chloride oral syrup 5 mg/5ml G

oxybutynin chloride oral tablet 5 mg G

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg

Detrol LA G

ST

tolterodine tartrate oral tablet 1 mg, 2 mg Detrol G ST

trospium chloride oral tablet 20 mg G

*Vaccines*

AFLURIA INTRAMUSCULAR SUSPENSION B

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

B

FLUARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B


74


Requirements/Limits

FLUBLOK INTRAMUSCULAR SOLUTION B

FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION

B

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLUMIST QUADRIVALENT NASAL SUSPENSION

B

FLUVIRIN INTRAMUSCULAR SUSPENSION B

FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

B

FLUZONE QUADRIVALENT INTRADERMAL SUSPENSION PEN-INJECTOR 9 MCG/STRAIN

B

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

B

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML

B

medical provider ez flu pf intramuscular prefilled syringe kit 0.5 ml

B

medical provider ez flu shot intramuscular kit 0.5 ml

B

MEDICAL PROVIDER EZ FLUVIRIN INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

B

PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML

B

PREVNAR 13 INTRAMUSCULAR SUSPENSION

B

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

B

ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED 19400 UNT/0.65ML

B

*Vaginal Products*

AVC VAGINAL VAGINAL CREAM 15 % B

clindamycin phosphate vaginal cream 2 % Cleocin G

clotrimazole 3 vaginal cream 2 % Gyne-Lotrimin 3 G OTC

clotrimazole vaginal cream 1 % Gyne-Lotrimin G OTC


75


Requirements/Limits

ESTRACE VAGINAL CREAM 0.1 MG/GM B

ESTRING VAGINAL RING 2 MG B

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

B

PA

FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG

B


B


B


B

metronidazole vaginal gel 0.75 % MetroGel-Vaginal G

miconazole 1 vaginal kit 1200 & 2 mg & % Monistat 1 Combo Pack G OTC

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)

Monistat 3 Combination Pack

G

OTC

miconazole 3 vaginal cream 4 % Monistat 3 G OTC

miconazole 3 vaginal suppository 200 mg G

miconazole 7 vaginal cream 2 % Monistat 7 Simply Cure G OTC

miconazole nitrate vaginal suppository 100 mg G OTC

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL 3 %

B

OTC

PREMARIN VAGINAL CREAM 0.625 MG/GM B

terconazole vaginal cream 0.4 % Terazol 7 G

terconazole vaginal cream 0.8 % G

terconazole vaginal suppository 80 mg G

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 %

B

OTC

vcf vaginal contraceptive vaginal gel 4 % G OTC

YUVAFEM VAGINAL TABLET 10 MCG G

*Vasopressors*

epinephrine injection solution auto-injector 0.15 mg/0.3ml

EpiPen Jr 2-Pak G

epinephrine injection solution auto-injector 0.3 mg/0.3ml

EpiPen 2-Pak G

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg G

*Vitamins*

aqueous vitamin d oral liquid 400 unit/ml Just D G OTC

aqueous vitamin e oral solution 15 unit/0.3ml G OTC

LIQUI-E ORAL LIQUID 400 UNIT/15ML G OTC


76


Requirements/Limits

niacin er oral capsule extended release 250 mg, 500 mg

G

OTC

niacin er oral tablet extended release 1000 mg B OTC

niacin er oral tablet extended release 250 mg, 500 mg, 750 mg

Slo-Niacin G

OTC

niacin oral tablet 100 mg, 250 mg, 500 mg G OTC

niacin-50 oral tablet 50 mg G OTC

pyridoxine (vitamin B6) G OTC

vitamin d (ergocalciferol) oral capsule 50000 unit

Drisdol G

vitamin d oral capsule 2000 unit G OTC

vitamin d oral tablet 2000 unit Thera-D Rapid Repletion G OTC

vitamin d-3 oral capsule 1000 unit Pronutrients Vitamin D3 G OTC

vitamin d3 oral capsule 10000 unit Maximum D3 G OTC

vitamin d3 oral capsule 400 unit G OTC

vitamin d3 oral capsule 5000 unit Dialyvite Vitamin D 5000 G OTC

vitamin d3 oral capsule 50000 unit Decara G OTC

vitamin d3 oral liquid 5000 unit/ml G OTC

vitamin d3 oral tablet 1000 unit Vitamin D-1000 Max St G OTC

vitamin d3 oral tablet 400 unit, 5000 unit G OTC

vitamin e blend oral capsule 200 unit G OTC

vitamin e oral capsule 100 unit, 1000 unit, 600 unit

G

OTC

vitamin e oral capsule 400 unit Formula E 400 G OTC

vitamin e oral oil 100 unt/0.25ml G OTC

vitamin e oral tablet 400 unit E-Pherol G OTC

73

Index abacavir sulfate ............................... 23 abacavir sulfate-lamivudine ............. 23 abacavir-lamivudine-zidovudine ...... 23 ABREVA .......................................... 36 acarbose ..........................................11 acebutolol hcl ...................................26 acetaminophen .................................. 3 acetaminophen er ..............................2 acetaminophen extra strength ........... 3 acetaminophen junior strength .......... 3 acetaminophen-codeine .................... 4 acetaminophen-codeine #2 ............... 4 acetaminophen-codeine #3 ............... 4 acetaminophen-codeine #4 ............... 4 acetazolamide ................................. 45 acetazolamide er ............................. 45 acetic acid ........................................63 acetic acid-aluminum acetate .......... 63 acne maximum strength .................. 36 acne treatment .................................36 acne wash ....................................... 37 ACTIMMUNE ...................................20 ACTOPLUS MET XR .......................12 acyclovir .....................................23, 37 adapalene ........................................37 ADCIRCA ........................................ 28 adefovir dipivoxil .............................. 23 ADRENACLICK ............................... 71 adult aspirin ec low strength .............. 3 ADVAIR DISKUS ...............................9 ADVAIR HFA ..................................... 9 AEROSPAN .......................................9 AFINITOR ........................................20 AFINITOR DISPERZ ....................... 20 AFLURIA ......................................... 69 AFLURIA PRESERVATIVE FREE .. 69 aftera ............................................... 29 ALBENZA .......................................... 8 albuterol sulfate ........................... 9, 10 albuterol sulfate er ............................. 9 alclometasone dipropionate .............37 ALCOHOL PREP .............................53 alendronate sodium ......................... 46 all day allergy ...................................15 allergy eye ....................................... 60 allopurinol ........................................ 49 ALORA ............................................ 47 ALPHAGAN P ..................................60 ALSUMA ..........................................55 altaryl ............................................... 15 altavera ............................................29 aluminum hydroxide gel .....................7 alyacen 1/35 .................................... 29 alyacen 7/7/7 ................................... 29 amantadine hcl ................................ 22 amcinonide ...................................... 37 amethia ............................................29 amethia lo ........................................ 29

amethyst .......................................... 29 AMICAR ...........................................51 amiloride hcl .................................... 45 amiloride-hydrochlorothiazide ..........45 amiodarone hcl .................................. 9 AMITIZA .......................................... 48 amlodipine besy-benazepril hcl ....... 17 amlodipine besylate .........................27 amlodipine-atorvastatin ................... 28 ammonium lactate ........................... 37 amoxicillin .................................. 63, 64 amoxicillin-pot clavulanate ...............64 amoxicillin-pot clavulanate er .......... 64 ampicillin ..........................................64 anagrelide hcl .................................. 49 ANALPRAM E ................................... 7 anastrozole ...................................... 20 ANDROXY .........................................7 antacid ........................................... 7, 8 antacid calcium ..................................7 antacid calcium extra strength ........... 7 antacid extra strength ........................ 7 antibiotic plus pain relief .................. 37 anti-dandruff .................................... 37 antifungal ......................................... 37 anti-fungal ........................................37 antipyrine-benzocaine ..................... 63 ANZEMET ....................................... 14 APIDRA ........................................... 12 APIDRA SOLOSTAR .......................12 apraclonidine hcl ..............................60 aprepitant .........................................14 apri ...................................................29 APRISO ........................................... 48 APTIVUS ......................................... 23 aqueous vitamin d ........................... 71 aqueous vitamin e ........................... 71 aranelle ............................................29 ARANESP (ALBUMIN FREE) ......... 50 ARMOUR THYROID ....................... 67 artificial tears ................................... 60 ASACOL HD ....................................48 ashlyna ............................................ 29 ASMANEX 120 METERED DOSES 10 ASMANEX 30 METERED DOSES .. 10 ASMANEX 60 METERED DOSES .. 10 aspirin ................................................ 3 aspirin childrens .................................3 aspirin ec ........................................... 3 atenolol ............................................ 26 atenolol-chlorthalidone .................... 17 athletes foot powder spray .............. 37 athletes foot spray ........................... 37 atorvastatin calcium .........................16 atovaquone ......................................19 atovaquone-proguanil hcl ................ 19 ATRIPLA ..........................................23 atropine sulfate ................................ 60

ATROVENT HFA .............................10 aubra ............................................... 29 AUGMENTIN ................................... 64 AVANDIA .........................................12 AVC VAGINAL .................................70 aviane .............................................. 29 AVONEX ..........................................65 AVONEX PEN ................................. 65 AVONEX PREFILLED ..................... 65 azelastine hcl .............................59, 60 azithromycin .................................... 53 AZOPT .............................................60 azurette ............................................30 b complex vitamins .......................... 57 bacitracin ................................... 37, 60 bacitracin zinc ..................................37 bacitracin-polymyxin b ............... 37, 60 bacitra-neomycin-polymyxin-hc ....... 60 baclofen ........................................... 59 balsalazide disodium ....................... 48 BARACLUDE ...................................23 bayer advanced aspirin ex st .............3 b-complex balanced ........................ 58 b-complex high potency ...................58 b-complex/b-12 ................................58 BD AUTOSHIELD DUO ...................53 BD INSULIN SYRINGE ................... 53 BD INSULIN SYRINGE MICROFINE .................................... 53 BD INSULIN SYRINGE ULTRAFINE ...............................53, 54 bekyree ............................................30 benazepril hcl .................................. 17 BENZEPRO CREAMY WASH .........37 benzonatate .....................................35 benzoyl peroxide ............................. 37 benzoyl peroxide cleanser ...............37 benzoyl peroxide wash .................... 37 benzoyl peroxide-erythromycin ........37 benztropine mesylate ...................... 22 beta care betamide ..........................37 betamethasone dipropionate ........... 38 betamethasone dipropionate aug ................................................... 37, 38 betamethasone valerate .................. 38 BETASERON .................................. 65 betaxolol hcl ...............................26, 61 bethanechol chloride ....................... 69 BETHKIS ........................................... 1 BETOPTIC-S ................................... 61 bexarotene .......................................20 bicalutamide .................................... 20 BILTRICIDE .......................................8 bisacodyl ec .....................................52 bisacodyl laxative ............................ 52 bismuth subsalicylate ...................... 13 bisoprolol fumarate .......................... 26 bisoprolol-hydrochlorothiazide ......... 17

74

BLEPHAMIDE ................................. 61 BLEPHAMIDE S.O.P. ......................61 BLINK TEARS ................................. 61 blisovi fe 1.5/30 ................................30 blisovi fe 1/20 ...................................30 BOSULIF ......................................... 20 bp 10-1 ............................................ 38 bp cleansing wash ........................... 38 bp wash ........................................... 38 bpo ...................................................38 bpo foaming cloths .......................... 38 briellyn ............................................. 30 BRILINTA ............................ 45, 49, 50 brimonidine tartrate ..........................61 bromocriptine mesylate ................... 22 brotapp ............................................ 35 budesonide .......................... 10, 34, 59 buffered aspirin ..................................3 bumetanide ......................................45 bupropion hcl er (smoking det) ........ 65 butalbital-acetaminophen .................. 3 butalbital-apap-caff-cod ..................... 4 butalbital-apap-caffeine ..................... 3 butalbital-asa-caff-codeine ................ 4 butalbital-asa-caffeine ....................... 3 butalbital-aspirin-caffeine ...................3 BUTRANS ......................................... 4 cabergoline ...................................... 46 CAFERGOT .....................................55 calcipotriene .................................... 38 calcitonin (salmon) ...........................46 CALCITRENE ..................................38 CALCITRIOL ................................... 38 calcitriol ............................................46 calcium ............................................ 56 calcium 500 + d3 ............................. 55 calcium 600 ..................................... 55 calcium 600 + minerals ....................55 calcium 600+d plus minerals ........... 56 calcium 600+d3 ............................... 56 calcium 600+d3 plus minerals ......... 56 calcium acetate (phos binder) ......... 48 calcium antacid ultra strength ............8 calcium carbonate ........................... 56 calcium carbonate-vitamin d3 .......... 56 calcium-vitamin d .............................56 camila .............................................. 30 camrese ...........................................30 camrese lo ....................................... 30 CANASA ..........................................48 CAPRELSA ..................................... 20 captopril ........................................... 17 captopril-hydrochlorothiazide ...........17 CARAFATE ..................................... 67 carbidopa-levodopa ......................... 22 carbidopa-levodopa er .....................22 carbidopa-levodopa-entacapone ................................................... 22, 23 carbinoxamine maleate ................... 15 CARDIZEM LA ................................ 27

carteolol hcl ..................................... 61 carvedilol ......................................... 26 CAYA ...............................................54 caziant ............................................. 30 cefaclor ............................................ 28 cefaclor er ........................................28 cefadroxil ................................... 28, 29 cefdinir ............................................. 29 CEFDITOREN PIVOXIL .................. 29 cefixime ........................................... 29 cefpodoxime proxetil ........................29 cefprozil ........................................... 29 CEFTIN ............................................29 cefuroxime axetil ..............................29 celecoxib ............................................1 CENESTIN ...................................... 47 CENTANY AT ..................................38 CENTRUM SPECIALIST PRENATAL ......................................58 cephalexin ....................................... 29 cesia ................................................ 30 cetirizine hcl .....................................15 cetirizine-pseudoephedrine er ......... 35 cevimeline hcl .................................. 57 CHANTIX .........................................65 CHANTIX STARTING MONTH PAK65 chateal ............................................. 30 CHEMSTRIP K ................................ 44 CHEMSTRIP UGK ...........................44 child chewable vitamins/iron ............ 58 childrens acetaminophen ...................3 childrens chewable multi vits ........... 58 childrens silfedrine ...........................59 CHILDRENS SOOTHE ......................8 chlorhexidine gluconate ...................57 chloroquine phosphate .................... 19 chlorothiazide .................................. 45 chlorpheniramine maleate ............... 15 chlorpheniramine maleate er ........... 15 chlorpropamide ................................12 chlorthalidone .................................. 45 chlorzoxazone ................................. 59 chocolated laxative .......................... 52 cholestyramine ................................ 16 cholestyramine light .........................16 choline & mag trisalicylate ................. 3 choline-mag trisalicylate .................... 3 CICLODAN ...................................... 38 ciclopirox ..........................................38 ciclopirox olamine ............................ 38 cilostazol ..........................................50 cimetidine ........................................ 68 cimetidine hcl ...................................67 CIPRODEX ......................................63 ciprofloxacin hcl ................... 47, 61, 63 clarithromycin .................................. 53 clarithromycin er .............................. 53 CLEAN & CLEAR ADVANTAGE 3- IN-1 ..................................................38 clean & clear advantage relief ......... 38

CLEAN & CLEAR BLACKHEAD ERASER ..........................................38 CLEAN & CLEAR OIL ABSORBING ................................... 38 clemastine fumarate ........................ 15 CLIMARA PRO ................................47 clindamycin hcl ................................ 19 clindamycin palmitate hcl .................19 clindamycin phos-benzoyl perox ..... 38 clindamycin phosphate ........ 38, 39, 70 clinpro 5000 ..................................... 57 clobetasol propionate ...................... 39 clobetasol propionate emulsion ....... 39 clonidine hcl .....................................17 clopidogrel bisulfate .........................50 clotrimazole ......................... 39, 57, 70 clotrimazole 3 .................................. 70 clotrimazole anti-fungal ....................39 clotrimazole-betamethasone ........... 39 CNL8 NAIL ...................................... 39 COARTEM .......................................19 codeine sulfate .................................. 4 COLCHICINE .................................. 49 colchicine-probenecid ......................49 COLCRYS ....................................... 49 colestipol hcl .................................... 16 COMBIVENT RESPIMAT ................ 10 COMETRIQ (100 MG DAILY DOSE) ............................................. 20 COMETRIQ (140 MG DAILY DOSE) ............................................. 20 COMETRIQ (60 MG DAILY DOSE) 20 COMPLERA .................................... 23 complete lice treatment ................... 39 CONCEPT DHA .............................. 58 CONDOMS ......................................54 COPAXONE .................................... 65 coricidin hbp congestion/cough ....... 35 corn remover one-step .................... 39 corn removers ..................................39 corn/callus remover ......................... 39 CORTIFOAM ..................................... 7 COSOPT PF ....................................61 COTELLIC ....................................... 20 CREON ............................................45 CRIXIVAN ........................................23 cromolyn sodium ........... 10, 48, 59, 61 cryselle-28 ....................................... 30 CUPRIMINE .................................... 26 cvs acne spot treatment .................. 39 cvs allergy childrens ........................ 15 cvs cortisone cooling relief .............. 39 cvs lubricant drops ...........................61 CVS PRENATAL GUMMY .............. 58 cvs prenatal gummy ........................ 64 CVS SLOW RELEASE IRON .......... 50 cvs targeted acne spot .................... 39 cyanocobalamin ...............................50 cyclafem 1/35 .................................. 30 cyclafem 7/7/7 ................................. 30

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cyclobenzaprine hcl ......................... 59 cyclopentolate hcl ............................ 61 cyclophosphamide ...........................20 cyproheptadine hcl .......................... 15 cyred ................................................30 danazol .............................................. 7 dantrolene sodium ........................... 59 dapsone ...........................................19 dasetta 1/35 .....................................30 dasetta 7/7/7 ....................................30 daysee ............................................. 30 deblitane .......................................... 30 DELTASONE ...................................34 delyla ............................................... 30 DELZICOL ....................................... 48 demeclocycline hcl .......................... 67 denta 5000 plus ............................... 57 dentagel ...........................................57 DEPO-SUBQ PROVERA 104 ......... 30 DESCOVY ....................................... 23 desenex spray ................................. 39 desmopressin ace rhinal tube ..........46 desmopressin ace spray refrig ........ 46 desmopressin acetate ..................... 46 desmopressin acetate spray ............46 desogestrel-ethinyl estradiol ............30 desonide .......................................... 39 dexamethasone ............................... 34 dexamethasone sodium phosphate .61 DICLEGIS ........................................14 diclofenac potassium ......................... 1 diclofenac sodium ..................1, 39, 61 diclofenac sodium er ..........................1 dicloxacillin sodium ..........................64 dicyclomine hcl ................................ 68 didanosine ....................................... 23 DIFICID ............................................53 diflunisal .............................................3 digoxin ............................................. 28 diltiazem hcl .....................................27 diltiazem hcl er .................................27 diltiazem hcl er beads ......................27 diltiazem hcl er coated beads .......... 27 dimenhydrinate ................................ 14 diocto ............................................... 52 DIPENTUM ......................................48 diphenhydramine hcl ....................... 15 diphenhydramine hcl (sleep) ........... 51 diphenoxylate-atropine .................... 13 dipyridamole .................................... 50 disopyramide phosphate ................... 9 dm-guaifenesin er ............................35 docusate calcium .............................52 docusate sodium ............................. 52 docusol mini .....................................52 dofetilide ............................................ 9 donepezil hcl ....................................65 dorzolamide hcl ............................... 61 dorzolamide hcl-timolol mal ............. 61 doxazosin mesylate ......................... 17

doxercalciferol ................................. 46 doxycycline hyclate ..........................67 doxycycline monohydrate ................ 67 dronabinol ........................................14 drospirenone-ethinyl estradiol ......... 30 dry skin treatment adv therapy ........ 39 DRYSOL ..........................................39 DULERA .......................................... 10 DUOFILM ........................................ 39 dutasteride .......................................49 ear wax removal system .................. 63 EASIVENT .......................................54 econtra ez ........................................30 ed bron gp ....................................... 35 ED CHLORPED ...............................15 ed chlorped jr ...................................15 EDURANT ....................................... 23 effervescent pot chloride ................. 56 ELIDEL ............................................ 39 ELIGARD .........................................20 elinest .............................................. 30 ELIQUIS .......................................... 11 ELITE CALCIUM ............................. 56 ella ................................................... 30 ELMIRON ........................................ 49 elta tar ..............................................39 emoquette ........................................30 EMTRIVA .........................................23 enalapril maleate ............................. 17 enalapril-hydrochlorothiazide ...........17 ENBREL ............................................ 1 ENBREL SURECLICK .......................1 enema ..............................................52 ENGERIX-B .....................................69 enoxaparin sodium .......................... 11 enpresse-28 .....................................30 enskyce ........................................... 30 entacapone ......................................23 entecavir .......................................... 23 ENTRESTO ..................................... 60 EPCLUSA ........................................51 epinastine hcl ...................................61 epinephrine ......................................71 EPIVIR HBV .................................... 23 eplerenone .......................................17 eprosartan mesylate ........................ 18 epsom salt ....................................... 52 eq allergy relief childrens ................. 15 eq sleep-aid nighttime ..................... 51 eq triacting cold/allergy ....................35 ergoloid mesylates ...........................65 errin ................................................. 30 ERYPED 400 ...................................53 erythromycin ........................ 39, 40, 61 erythromycin ethylsuccinate ............ 53 ESBRIET ......................................... 66 estarylla ........................................... 30 estazolam ........................................ 51 ESTRACE ........................................71 estradiol ........................................... 47

estradiol-norethindrone acet ............47 ESTRING .........................................71 estropipate .......................................47 ethambutol hcl ................................. 20 etodolac ............................................. 1 etodolac er .........................................1 ETOPOPHOS ..................................20 etoposide ......................................... 20 EURAX ............................................ 40 EVOTAZ .......................................... 24 exemestane ..................................... 21 eye allergy relief .............................. 61 eye drops allergy relief .................... 61 ezetimibe ......................................... 16 fabb ..................................................50 fallback solo .....................................30 falmina ............................................. 30 famciclovir ........................................24 famotidine ........................................ 68 FARESTON ..................................... 21 fa-vitamin b-6-vitamin b-12 .............. 50 FC FEMALE CONDOM ................... 54 felodipine er ..................................... 27 FEMRING ........................................ 71 fenofibrate ........................................16 fenofibrate micronized ..................... 16 fenofibric acid .................................. 16 FENOFIBRIC ACID ......................... 16 fenoprofen calcium ............................ 1 fentanyl .............................................. 4 ferrous gluconate .............................50 FERROUS SULFATE ...................... 50 ferrous sulfate ..................................50 feverall adults .................................... 3 feverall childrens ................................3 feverall junior strength ....................... 3 fexofenadine hcl .............................. 16 fexofenadine hcl childrens ............... 16 fexofenadine-pseudoephed er .........35 fiber laxative .................................... 52 finasteride ........................................ 49 FIRST-LANSOPRAZOLE ................ 68 FIRST-OMEPRAZOLE .................... 68 FIRST-PROGESTERONE VGS 100 ...................................................71 FIRST-PROGESTERONE VGS 200 ...................................................71 FIRST-PROGESTERONE VGS 400 ...................................................71 FIRST-PROGESTERONE VGS 50 . 71 fish oil .............................................. 60 fish oil concentrate ...........................60 flavoxate hcl .....................................69 flecainide acetate ...............................9 FLOVENT DISKUS ..........................10 FLOVENT HFA ................................10 flu & sore throat ............................... 35 FLUARIX ......................................... 69 FLUARIX QUADRIVALENT ............ 69 FLUBLOK ........................................ 70

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FLUCELVAX ....................................70 fluconazole ...................................... 14 flucytosine ........................................14 fludrocortisone acetate .................... 34 FLULAVAL QUADRIVALENT ..........70 FLUMIST QUADRIVALENT ............ 70 flunisolide .........................................59 fluocinolone acetonide ...............40, 63 fluocinolone acetonide body ............ 40 fluocinolone acetonide scalp ........... 40 fluocinonide ..................................... 40 fluocinonide-e .................................. 40 fluoride mouth rinse ......................... 57 fluoritab ............................................56 fluorometholone ...............................61 FLUOROPLEX ................................ 40 fluorouracil ....................................... 40 flurazepam hcl ................................. 51 flurbiprofen .........................................1 flurbiprofen sodium .......................... 61 flutamide .......................................... 21 fluticasone propionate ............... 40, 59 fluvastatin sodium ............................16 FLUVIRIN ........................................ 70 FLUVIRIN PRESERVATIVE FREE . 70 FLUZONE HIGH-DOSE .................. 70 FLUZONE QUADRIVALENT ........... 70 folic acid ...........................................50 FORTEO ..........................................46 fosamprenavir calcium .....................24 fosinopril sodium ..............................18 fosinopril sodium-hctz ......................18 FREESTYLE LANCETS .................. 54 FREESTYLE LITE TEST .................44 FREESTYLE SYSTEM ....................54 FREESTYLE TEST ......................... 44 FULYZAQ ........................................ 14 furosemide .......................................45 FUZEON ..........................................24 galantamine hydrobromide .............. 65 galantamine hydrobromide er ..........65 gas relief .......................................... 48 gas relief extra strength ................... 48 gas relief ultra strength .................... 48 gavilyte-c ......................................... 52 gavilyte-g ......................................... 52 gel-tin ...............................................57 gemfibrozil ....................................... 16 gentamicin sulfate ......................40, 61 GENVOYA .......................................24 GERI-HYDROLAC 5 ........................40 geri-lanta supreme .............................8 geri-mucil ......................................... 52 gianvi ............................................... 30 gildagia ............................................ 31 gildess 1.5/30 .................................. 31 gildess 1/20 ..................................... 31 gildess fe 1.5/30 .............................. 31 gildess fe 1/20 ................................. 31 GILENYA ......................................... 65

GILOTRIF ........................................ 21 glatopa .............................................65 GLEOSTINE .................................... 21 glimepiride ....................................... 12 glipizide ............................................12 glipizide er ....................................... 12 glipizide-metformin hcl ..................... 12 GLUCAGON EMERGENCY ............ 12 glyburide .......................................... 12 glyburide micronized ........................12 glyburide-metformin ......................... 12 glycopyrrolate .................................. 68 gnp day time mucus relief dm ..........35 gnp diaper rash creamy ...................40 gnp foaming antacid .......................... 8 gnp iron ............................................50 gnp lice bedding .............................. 40 gnp scalp relief ................................ 40 granisetron hcl ................................. 14 griseofulvin microsize ...................... 15 griseofulvin ultramicrosize ............... 15 guaiatussin ac ..................................35 guaifenesin ...................................... 35 guaifenesin dm ................................ 35 guaifenesin er .................................. 35 guanfacine hcl ................................. 18 halac ................................................ 40 halobetasol propionate .................... 40 HARVONI ........................................ 51 headache formula ..............................4 heartburn antacid ex st ...................... 8 heather ............................................ 31 heparin sodium (porcine) ................. 11 heparin sodium (porcine) pf ............. 11 HEXALEN ........................................21 high potency iron ............................. 50 hm z-sleep ....................................... 51 homatropine hbr .............................. 61 HUMIRA ............................................ 2 HUMIRA PEDIATRIC CROHNS START ...............................................1 HUMIRA PEN .................................... 2 HUMIRA PEN-CROHNS STARTER . 2 HUMIRA PEN-PSORIASIS STARTER ..........................................2 HUMULIN R U-500 (CONCENTRATED) ........................ 12 hydralazine hcl .................................18 hydrochlorothiazide ......................... 45 hydrocodone-acetaminophen ............ 5 hydrocodone-homatropine ...............35 hydrocodone-ibuprofen ......................5 hydrocortisone ....................... 7, 34, 41 hydrocortisone ace-pramoxine .......... 7 hydrocortisone acetate .................... 40 hydrocortisone acetate-aloe ............ 40 hydrocortisone butyrate ............. 40, 41 hydrocortisone valerate ................... 41 hydrocortisone-acetic acid ............... 63 hydrocortisone-iodoquinol ............... 41

hydromorphone hcl ............................5 hydroxychloroquine sulfate ..............19 HYDROXYPROGESTERONE CAPROATE .....................................29 hydroxyurea .....................................21 hydroxyzine hcl ..................................9 hydroxyzine pamoate ........................ 9 hyoscyamine sulfate ........................ 68 hyoscyamine sulfate er ....................68 ibandronate sodium ......................... 46 ibuprofen ............................................2 ibuprofen childrens ............................ 2 ibuprofen junior strength ....................2 ICLUSIG .......................................... 21 imiquimod ........................................ 41 IMODIUM A-D ................................. 14 INCRELEX .......................................46 INCRUSE ELLIPTA ......................... 10 indapamide ...................................... 45 INDOCIN ........................................... 2 indomethacin ..................................... 2 indomethacin er ................................. 2 infants gas relief .............................. 48 infants ibuprofen ................................ 2 infants pain reliever ........................... 4 infants silapap ....................................4 INSULIN SYRINGE ......................... 54 INSULIN SYRINGE/NEEDLE .......... 54 INTELENCE .................................... 24 intense cough reliever ..................... 35 INTRON A ....................................... 21 introvale ........................................... 31 INVIRASE ........................................24 invisible acne treatment ...................41 INVOKAMET ................................... 66 INVOKAMET XR ............................. 67 INVOKANA ...................................... 12 ipratropium bromide ...................10, 59 ipratropium-albuterol ........................10 irbesartan .........................................18 irbesartan-hydrochlorothiazide ........ 18 ISENTRESS .................................... 24 ISONARIF ........................................20 isoniazid ...........................................20 isosorbide dinitrate ............................ 8 isosorbide dinitrate er ........................ 8 isosorbide mononitrate ...................... 8 isosorbide mononitrate er .................. 8 isradipine ......................................... 27 itraconazole ..................................... 15 ivermectin .......................................... 8 JAKAFI ............................................ 21 JANUMET ........................................12 JANUMET XR ..................................12 JANUVIA ......................................... 12 jencycla ............................................31 j-max ................................................35 jolessa ............................................. 31 jolivette ............................................ 31 J-TAN D PD .....................................35

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juleber ..............................................31 junel 1.5/30 ...................................... 31 junel 1/20 ......................................... 31 junel fe 1.5/30 .................................. 31 junel fe 1/20 ..................................... 31 junel fe 24 ........................................ 31 JUXTAPID ....................................... 17 kaitlib fe ........................................... 31 KALETRA ........................................ 24 kariva ............................................... 31 kelnor 1/35 .......................................31 KERALYT ........................................ 41 KERALYT SCALP ........................... 41 ketoconazole ............................. 15, 41 ketoprofen ..........................................2 ketotifen fumarate ............................61 kimidess ...........................................31 KITABIS PAK .....................................1 KLOR-CON ......................................56 K-TAB .............................................. 56 kurvelo ............................................. 31 labetalol hcl ......................................26 lactic acid .........................................41 lactulose .......................................... 52 lactulose encephalopathy ................ 48 lamivudine ....................................... 24 lamivudine-zidovudine ..................... 24 LANOXIN .........................................28 lansoprazole .................................... 68 lanthanum carbonate .......................48 LANTUS .......................................... 12 LANTUS SOLOSTAR ......................12 larin 1.5/30 .......................................31 larin 1/20 ..........................................31 larin 24 fe .........................................31 larin fe 1.5/30 ...................................31 larin fe 1/20 ......................................31 latanoprost .......................................61 LATRIX XM ......................................41 laxative ............................................ 52 layolis fe ...........................................31 leena ................................................31 leflunomide ........................................ 2 LENVIMA 10 MG DAILY DOSE ...... 21 LENVIMA 14 MG DAILY DOSE ...... 21 LENVIMA 18 MG DAILY DOSE ...... 21 LENVIMA 20 MG DAILY DOSE ...... 21 LENVIMA 24 MG DAILY DOSE ...... 21 LENVIMA 8 MG DAILY DOSE ........ 21 lessina ............................................. 31 LETAIRIS .........................................28 letrozole ........................................... 21 leucovorin calcium ........................... 21 LEUKERAN ..................................... 21 LEUKINE ......................................... 50 leuprolide acetate ............................ 21 LEVEMIR .........................................12 LEVEMIR FLEXTOUCH .................. 12 levobunolol hcl .................................61 levocarnitine .................................... 46

levocetirizine dihydrochloride .......... 16 levofloxacin ..........................47, 48, 61 levonest ........................................... 31 levonorgest-eth estrad 91-day .........31 levonorgestrel .................................. 31 levonorgestrel-ethinyl estrad ........... 31 levonorg-eth estrad triphasic ........... 32 levora 0.15/30 (28) .......................... 32 levothyroxine sodium .......................67 LEXIVA ............................................ 24 lice killing ......................................... 41 lice treatment ................................... 41 LICEOUT ......................................... 41 lidocaine .......................................... 41 lidocaine hcl ...............................41, 57 lidocaine viscous ............................. 57 lidocaine-hydrocortisone ace ............. 7 lidocaine-prilocaine ..........................41 lindane ............................................. 41 linezolid ............................................19 LINZESS ..........................................48 liothyronine sodium ..........................67 LIQUI-E ............................................71 liquituss gg .......................................35 lisinopril ............................................18 lisinopril-hydrochlorothiazide ........... 18 LO LOESTRIN FE ........................... 32 LOHIST-D ........................................35 lomedia 24 fe ................................... 32 loperamide a-d .................................14 loperamide hcl ................................. 14 lopinavir-ritonavir ............................. 24 loratadine .........................................16 loratadine allergy relief .................... 16 loratadine-d 12hr ............................. 35 loratadine-d 24hr ............................. 35 loryna ...............................................32 losartan potassium .......................... 18 losartan potassium-hctz ...................18 lovastatin ......................................... 17 low-ogestrel ..................................... 32 lubricant eye drops .......................... 62 LUPRON DEPOT (1-MONTH) ........ 21 LUPRON DEPOT-PED (1-MONTH) 46 lutera ................................................32 LYSODREN .....................................21 lyza .................................................. 32 magnesium ...................................... 56 magnesium citrate ........................... 52 magnesium oxide ........................ 8, 56 magnesium oxide -mg supplement ..56 MAKENA ......................................... 64 malathion ......................................... 41 marlissa ........................................... 32 MATULANE ..................................... 21 meclizine hcl .................................... 14 medical provider ez flu pf .................70 medical provider ez flu shot ............. 70 MEDICAL PROVIDER EZ FLUVIRIN ........................................ 70

medi-tussin dm double strength ...... 36 medroxyprogesterone acetate ...32, 64 mefloquine hcl ................................. 19 megestrol acetate ............................ 21 meloxicam ......................................... 2 melphalan ........................................ 21 memantine hcl ................................. 65 MENEST ..........................................47 meperidine hcl ................................... 5 mercaptopurine ................................21 mesalamine ..................................... 48 MESALAMINE ................................. 48 metaproterenol sulfate .....................10 metformin hcl ................................... 12 metformin hcl er ...............................12 methadone hcl ................................... 5 methazolamide ................................ 45 methenamine hippurate ...................69 methenamine mandelate ................. 69 methimazole .................................... 67 methocarbamol ................................59 methotrexate ....................................21 methotrexate sodium ....................... 22 methotrexate sodium (pf) .................22 methscopolamine bromide .............. 68 methyclothiazide ..............................45 methyldopa ...................................... 18 methyldopa-hydrochlorothiazide ......18 methylergonovine maleate .............. 63 methylprednisolone ......................... 34 metipranolol ..................................... 62 metoclopramide hcl ......................... 48 metolazone ...................................... 45 metoprolol succinate er ................... 26 metoprolol tartrate ........................... 26 metoprolol-hydrochlorothiazide ....... 18 metronidazole ...................... 19, 41, 71 mexiletine hcl .....................................9 MG217 PSORIASIS MULTI- SYMPTOM ...................................... 41 MIACALCIN ..................................... 46 mi-acid ............................................... 8 miconazole 1 ................................... 71 miconazole 3 ................................... 71 miconazole 3 combo pack ............... 71 miconazole 7 ................................... 71 miconazole nitrate ..................... 42, 71 miconazorb af .................................. 42 microgestin 1.5/30 ........................... 32 microgestin 1/20 .............................. 32 microgestin 24 fe ............................. 32 microgestin fe 1.5/30 ....................... 32 microgestin fe 1/20 .......................... 32 midodrine hcl ................................... 71 MIGERGOT ..................................... 55 milk of magnesia ..............................52 MINIVELLE ......................................47 minocycline hcl ................................ 67 minoxidil ...........................................18 misoprostol ...................................... 68

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modafinil ............................................ 1 MODERIBA ..................................... 24 moexipril hcl .....................................18 moexipril-hydrochlorothiazide .......... 18 mometasone furoate ........................42 mono-linyah ..................................... 32 mononessa ...................................... 32 montelukast sodium .........................10 morphine sulfate ................................ 6 morphine sulfate (concentrate) ..........5 morphine sulfate er ............................6 morphine sulfate er beads ................. 5 moxifloxacin hcl ............................... 62 mucus relief dm max ....................... 36 mucus-dm ........................................36 MULTAQ ............................................9 multi vitamin/fluoride ........................58 multi-vit/fluoride ............................... 58 multi-vitamin/fluoride ........................58 multi-vitamin/fluoride/iron .................58 mupirocin ......................................... 42 my way ............................................ 32 MYALEPT ........................................53 MYLERAN ....................................... 22 MYNATAL ........................................58 MYNATAL PLUS ............................. 58 MYORISAN ..................................... 42 myorisan .......................................... 42 MYRBETRIQ ................................... 69 myzilra ............................................. 32 nabumetone .......................................2 nadolol ............................................. 26 nadolol-bendroflumethiazide ........... 18 naloxone hcl .................................... 14 NAMENDA XR .................................65 NAMENDA XR TITRATION PACK .. 65 naproxen ............................................2 naproxen dr ....................................... 2 naproxen sodium ............................... 2 NARCAN ......................................... 14 nasal decongestant ......................... 59 nasal mist ........................................ 36 NATACYN ....................................... 62 NATAZIA ......................................... 32 nateglinide ....................................... 12 natural fiber laxative ........................ 52 natural psyllium seed .......................52 NATURAL SENNA LAXATIVE ........ 52 NATURE-THROID ........................... 67 necon 0.5/35 (28) ............................ 32 necon 1/35 (28) ............................... 32 NECON 1/50 (28) ............................ 32 NECON 10/11 (28) .......................... 32 necon 7/7/7 ......................................32 neomycin sulfate ................................1 neomycin-bacitracin zn-polymyx ..... 62 neomycin-polymyxin-dexameth ....... 62 neomycin-polymyxin-gramicidin ...... 62 neomycin-polymyxin-hc ............. 62, 63 NEULASTA ......................................51

NEULASTA ONPRO ....................... 50 NEUPOGEN .................................... 51 neutral sodium fluoride .................... 57 NEUTROGENA CLEAR PORE ....... 42 NEVIRAPINE ...................................24 nevirapine ........................................ 24 nevirapine er ....................................24 NEXIUM 24HR ................................ 68 next choice one dose .......................32 niacin ............................................... 72 niacin er ........................................... 72 niacin er (antihyperlipidemic) ........... 17 niacin-50 .......................................... 72 nicardipine hcl ..................................27 nicotine ............................................ 66 nicotine polacrilex ............................ 65 NICOTROL ...................................... 66 NICOTROL NS ................................ 66 nifedipine ......................................... 27 nifedipine er ..................................... 27 nifedipine er osmotic release ........... 27 nikki ................................................. 32 nimodipine ....................................... 27 NINLARO .........................................22 nisoldipine er ................................... 28 NITRO-BID ........................................ 8 nitrofurantoin ....................................69 nitrofurantoin macrocrystal .............. 69 nitrofurantoin monohyd macro ......... 69 nitroglycerin ....................................... 8 NITROSTAT ...................................... 8 non-aspirin jr strength ........................4 nora-be ............................................ 32 NORDITROPIN FLEXPRO ..............46 norethin ace-eth estrad-fe ............... 32 norethindrone .................................. 32 norethindrone acetate ......................64 norethindrone acet-ethinyl est ......... 32 norethindrone-eth estradiol ..............47 norethin-eth estradiol-fe ...................32 norgestimate-eth estradiol ............... 32 norgestim-eth estrad triphasic ......... 33 norlyroc ............................................33 NORPACE CR ...................................9 NORTHERA .................................... 60 nortrel 0.5/35 (28) ............................ 33 nortrel 1/35 (21) ............................... 33 nortrel 1/35 (28) ............................... 33 nortrel 7/7/7 ..................................... 33 NORVIR ...........................................24 NOVOLIN 70/30 .............................. 13 NOVOLIN 70/30 RELION ................ 13 NOVOLIN N .....................................13 NOVOLIN N RELION ...................... 13 NOVOLIN R .....................................13 NOVOLIN R RELION ...................... 13 NOVOLOG ...................................... 13 NOVOLOG FLEXPEN ..................... 13 NOVOLOG MIX 70/30 ..................... 13 NOVOLOG MIX 70/30 FLEXPEN ....13

NOVOLOG PENFILL .......................13 NOXAFIL ......................................... 15 np thyroid .........................................67 NUVARING ......................................33 nystatin ................................ 15, 42, 57 OC8 ................................................. 42 O-CAL PRENATAL ..........................58 ocella ............................................... 33 ODEFSEY ....................................... 24 ofloxacin .............................. 48, 62, 63 ogestrel ............................................33 olmesartan medoxomil .................... 18 olmesartan medoxomil-hctz .............18 omega-3 fish oil ............................... 60 omega-3-acid ethyl esters ............... 17 omeprazole ......................................68 OMEPRAZOLE ................................68 omeprazole magnesium .................. 68 OMNIFLEX DIAPHRAGM ............... 54 ondansetron .....................................14 ondansetron hcl ............................... 14 one step callus remover .................. 42 ONE-A-DAY WOMENS PRENATAL ......................................58 one-daily multi vitamins ................... 58 one-step wart remover .....................42 opcicon one-step ............................. 33 OPTIONS GYNOL II CONTRACEPTIVE .......................... 71 ORKAMBI ........................................ 36 orsythia ............................................ 33 ORTHO DIAPHRAGM ALL-FLEX ... 54 ORTHO DIAPHRAGM COIL ........... 54 ORTHO DIAPHRAGM FLAT ........... 54 oseltamivir phosphate ......................24 OSMOPREP ....................................52 oxaprozin ........................................... 2 oxybutynin chloride ..........................69 oxybutynin chloride er ......................69 oxycodone hcl ....................................6 oxycodone hcl er ............................... 6 oxycodone-acetaminophen ............... 6 oxycodone-aspirin ............................. 6 oxycodone-ibuprofen ......................... 6 oxymorphone hcl ............................... 7 oxymorphone hcl er ........................... 6 oyster shell calcium + d3 ................. 56 oyster shell calcium plus d ...............56 oyster shell calcium/vitamin d .......... 56 oyster-cal 500 .................................. 56 pacerone ............................................9 pain & fever childrens ........................ 4 pantoprazole sodium ....................... 68 paromomycin sulfate ......................... 1 pc-tar ............................................... 42 pedia relief cough/cold .....................36 pediatric electrolyte ..........................56 pedi-atric nightrest ........................... 36 peg 3350 ..........................................52 peg 3350/electrolytes ...................... 52

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peg 3350-kcl-na bicarb-nacl ............ 52 peg-3350/electrolytes ...................... 52 PEGASYS ....................................... 24 PEGASYS PROCLICK .................... 24 PEG-INTRON REDIPEN ................. 25 PEG-INTRON REDIPEN PAK 4 ...... 24 penicillin v potassium .......................64 PENTASA ........................................48 pentoxifylline er ................................50 perindopril erbumine ........................18 periomed ..........................................57 permethrin ....................................... 42 phenazopyridine hcl .........................49 phenylephrine hcl ............................ 62 philith ............................................... 33 pilocarpine hcl ............................57, 62 pimtrea .............................................33 pindolol ............................................ 26 pink bismuth .................................... 14 pink bismuth maximum strength ...... 14 pin-x ...................................................8 pioglitazone hcl ................................13 pioglitazone hcl-glimepiride ............. 13 pioglitazone hcl-metformin hcl ......... 13 pirmella 1/35 .................................... 33 pirmella 7/7/7 ................................... 33 piroxicam ........................................... 2 PLEGRIDY ...................................... 66 PLEGRIDY STARTER PACK .......... 66 PNEUMOVAX 23 .............................70 podofilox .......................................... 42 polymyxin b-trimethoprim ................ 62 polyvitamin .......................................58 poly-vitamin/iron .............................. 58 POMALYST ..................................... 22 portia-28 .......................................... 33 potassium bicarbonate .................... 57 potassium chloride ...........................57 potassium chloride crys er ............... 57 potassium chloride er ...................... 57 potassium citrate er ......................... 49 pr benzoyl peroxide wash ................42 pramipexole dihydrochloride ............23 PRAMOSONE ................................. 42 pramoxine hcl .................................... 7 pravastatin sodium .......................... 17 prazosin hcl ..................................... 18 PRECISION GLUCOSE/KETONE CONTR ............................................54 PRECISION SURE-DOSE SYRINGE ........................................ 54 PRECISION XTRA BLOOD GLUCOSE ....................................... 45 PRED-G ...........................................62 PRED-G S.O.P. ............................... 62 prednicarbate ...................................42 prednisolone .................................... 34 prednisolone acetate ....................... 62 prednisolone sodium phosphate 34, 62 prednisone .................................34, 35

PREFEST ........................................ 47 PREMARIN ................................47, 71 PREMIUM CONDOMS LUBRICATED ..................................54 PREMPHASE .................................. 47 PREMPRO ...................................... 47 PRENATA ........................................58 prenatabs fa .....................................58 PRENATAL ......................................58 PRENATAL 19 .................................58 prenatal 19 .......................................58 PRENATAL COMPLETE ................. 58 prenatal low iron .............................. 58 PRENATAL MULTI +DHA ............... 58 PRENATAL MULTIVITAMIN + DHA 58 prenatal plus iron ............................. 58 PRENATAL VITAMINS ....................59 PRENATAL+DHA ............................ 59 PRENATAL-U ..................................59 PREQUE 10 .................................... 59 previfem ...........................................33 PREVNAR 13 .................................. 70 PREZCOBIX ....................................25 PREZISTA ....................................... 25 PRIMSOL ........................................ 19 PROAIR HFA ...................................10 probenecid .......................................49 prochlorperazine ..............................23 PROCRIT ........................................ 51 PROCTOFOAM HC ...........................7 procto-pak ..........................................7 proctozone-hc ....................................7 progesterone micronized ................. 65 promacet ............................................4 PROMACTA .................................... 51 promethazine hcl ............................. 16 promethazine vc .............................. 36 promethazine vc/codeine .................36 promethazine-codeine ..................... 36 propafenone hcl .................................9 propafenone hcl er .............................9 propantheline bromide .....................68 proparacaine hcl .............................. 62 propranolol hcl ................................. 26 propranolol hcl er .............................26 propranolol-hctz ...............................18 propylthiouracil ................................ 67 pseudoeph-bromphen-dm ............... 36 pseudoephedrine hcl ....................... 60 pseudoephedrine hcl er ................... 59 PULMICORT FLEXHALER ............. 10 PULMOZYME ..................................66 PURE & GENTLE LUBRICANT ...... 62 pyrazinamide ................................... 20 pyridostigmine bromide ................... 20 pyridostigmine bromide er ............... 20 qc natural vegetable ........................ 52 quasense ......................................... 33 quinapril hcl ..................................... 18 quinapril-hydrochlorothiazide ...........18

quinidine gluconate er ....................... 9 quinidine sulfate .................................9 quinine sulfate ................................. 20 QVAR .............................................. 10 ra antiseptic mouth cleanser ............57 ra col-rite ..........................................52 ra hydrocortisone plus ..................... 42 ra laxative extra strength ................. 52 ra lice solution ..................................42 ra therapeutic ...................................42 raloxifene hcl ................................... 46 ramipril .............................................19 RANEXA ............................................9 ranitidine acid reducer ..................... 68 ranitidine hcl .................................... 69 react .................................................33 REBETOL ........................................25 REBIF .............................................. 66 REBIF REBIDOSE .......................... 66 REBIF REBIDOSE TITRATION PACK ...............................................66 REBIF TITRATION PACK ............... 66 reclipsen .......................................... 33 RECOMBIVAX HB ...........................70 reeses pinworm medicine .................. 8 relcof c ............................................. 36 RELENZA DISKHALER ...................25 RELION INSULIN SYRINGE ........... 54 RELI-ON INSULIN SYRINGE ..........54 RENAGEL ....................................... 48 RENAL MULTIVITAMIN FORMULA 59 rena-vite rx .......................................59 repaglinide ....................................... 13 RESCRIPTOR ................................. 25 RESTASIS .......................................62 REVLIMID ........................................26 REYATAZ ........................................ 25 ribasphere ........................................25 RIBASPHERE RIBAPAK .................25 ribavirin ............................................ 25 RID ESSENTIAL LICE ELIMINATION ..................................42 RIDAURA .......................................... 2 rifampin ............................................20 riluzole ............................................. 60 rimantadine hcl ................................ 25 rivastigmine ..................................... 66 rivastigmine tartrate ......................... 66 rizatriptan benzoate ......................... 55 ropinirole hcl .................................... 23 ROXICET ...........................................7 ROZEREM .......................................51 salicylic acid .....................................42 salicylic acid wart remover ...............42 salicylic acid-cleanser ...................... 42 saline laxative .................................. 53 saline nasal spray ............................60 salsalate ............................................ 4 SAVELLA .........................................66 SAVELLA TITRATION PACK .......... 66

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sb triple antibiotic .............................42 scalacort .......................................... 42 scalp relief maximum strength ......... 42 selegiline hcl .................................... 23 selenium sulfide ...............................43 selenium sulf-pyrithione-urea .......... 43 SELZENTRY ................................... 25 senna ...............................................53 senna laxative ..................................53 senna smooth .................................. 53 senna-docusate sodium .................. 53 SENSIPAR ...................................... 46 SEREVENT DISKUS .......................11 setlakin ............................................ 33 sevelamer carbonate ................. 48, 49 sharobel ...........................................33 SIGNIFOR ....................................... 46 sildenafil citrate ................................28 siltussin-dm alcohol free .................. 36 silver sulfadiazine ............................ 43 simethicone ..................................... 49 SIMILAC PRENATAL EARLY SHIELD ............................................59 simvastatin .......................................17 sinus nasal spray 12 hour ................60 SIRTURO ........................................ 20 SIVEXTRO ...................................... 19 SKLICE ............................................43 sleep aid (diphenhydramine) ........... 51 sleep-aid maximum strength ........... 51 slow release iron ..............................51 anticavity fluoride rinse .............. 57 foaming antacid ........................... 8 ibuprofen jr ...................................2 slow release iron ........................51 sod citrate-citric acid ........................49 sodium bicarbonate ........................... 8 sodium chloride ............................... 36 sodium fluoride ................................ 57 sodium phenylbutyrate .................... 46 sodium polystyrene sulfonate .... 26, 64 solia ................................................. 33 soothe ..............................................14 SOOTHE ......................................... 62 sotalol hcl .........................................27 sotalol hcl (af) .................................. 27 SOVALDI ......................................... 25 SPINOSAD ...................................... 43 SPIRIVA RESPIMAT ....................... 11 spironolactone ................................. 45 spironolactone-hctz ......................... 45 SPORANOX .................................... 15 sprintec 28 ....................................... 33 sronyx .............................................. 33 sss 10-5 ........................................... 43 stavudine ......................................... 25 STIMATE ......................................... 46 STIVARGA ...................................... 22 stool softener ................................... 53 STRIBILD ........................................ 25

SUCRAID ........................................ 45 sucralfate ......................................... 69 sudogest sinus/allergy ..................... 36 sulfacetamide sodium ................43, 62 sulfacetamide sodium (acne) ...........43 sulfacetamide sodium-sulfur ............ 43 sulfacetamide-prednisolone .............62 sulfacetamide-sulfur in urea ............ 43 SULFACETAMIDE-SULFUR IN UREA ...............................................43 sulfadiazine ......................................67 sulfamethoxazole-trimethoprim ....... 19 SULFAMYLON ................................ 43 sulfasalazine ....................................49 sulindac ............................................. 2 sumatriptan ......................................55 sumatriptan succinate ......................55 sumatriptan succinate refill .............. 55 SUPRAX ..........................................29 SURE COMFORT INSULIN SYRINGE ........................................ 54 SUSTIVA ......................................... 25 syeda ............................................... 33 SYMBICORT ................................... 11 SYNAGIS .........................................63 SYNRIBO ........................................ 22 SYSTANE ........................................62 TABLOID ......................................... 22 tacrolimus ........................................ 43 take action ....................................... 33 TAMIFLU ......................................... 25 tamoxifen citrate .............................. 22 tamsulosin hcl ..................................49 TANZEUM ....................................... 13 TARGRETIN ....................................22 tarina fe 1/20 ....................................33 tazarotene ........................................43 TAZORAC ....................................... 43 TECFIDERA .................................... 66 temazepam ......................................51 tera-gel tar ....................................... 43 terazosin hcl .................................... 19 terbinafine hcl .................................. 15 terbutaline sulfate ............................ 11 terconazole ...................................... 71 testosterone cypionate ...................... 7 testosterone enanthate ......................7 tetracaine hcl ................................... 62 tetterine ............................................43 tgt antacid .......................................... 8 TGT LUBRICANT EYE DROPS ...... 63 THALOMID ...................................... 26 theophylline ..................................... 11 theophylline er ................................. 11 tilia fe ............................................... 33 timolol maleate .......................... 27, 63 tinidazole ......................................... 19 TIVICAY ...........................................25 tizanidine hcl ....................................59 TOBRADEX .....................................63

tobramycin ....................................... 63 tobramycin-dexamethasone ............ 63 tolazamide ....................................... 13 tolbutamide ...................................... 13 tolnaftate ..........................................43 tolterodine tartrate ........................... 69 tolterodine tartrate er ....................... 69 torsemide .........................................45 TOUJEO SOLOSTAR ..................... 13 TRACLEER ..................................... 28 tramadol hcl ....................................... 7 tramadol hcl er ...................................7 tramadol hcl er (biphasic) .................. 7 tramadol-acetaminophen ...................7 trandolapril .......................................19 tranexamic acid ............................... 51 TRAVATAN ..................................... 63 TRAVATAN Z .................................. 63 travoprost .........................................63 tretinoin ................................22, 43, 44 tri-afed allergy & head cold ..............36 triamcinolone acetonide .......44, 57, 60 TRIAMINIC COUGH/RUNNY NOSE .............................................. 16 triamterene-hctz .........................45, 46 TRIAZOLAM .................................... 51 triazolam .......................................... 51 tri-estarylla ....................................... 33 trifluridine ......................................... 63 trihexyphenidyl hcl ........................... 23 tri-legest fe .......................................33 tri-linyah ........................................... 33 tri-lo-estarylla ................................... 33 tri-lo-marzia ......................................33 tri-lo-sprintec ....................................33 trilyte ................................................ 53 trimethobenzamide hcl .................... 14 trimethoprim .....................................19 trinessa (28) .....................................34 trinessa lo ........................................ 34 triple antibiotic pain relief ................. 44 triple-vitamin/fluoride ....................... 59 trip-pse .............................................36 tri-previfem .......................................34 tri-sprintec ........................................34 TRIUMEQ ........................................ 25 tri-vit/fluoride/iron ............................. 59 tri-vitamin ......................................... 59 tri-vitamin/fluoride ............................ 59 trivora (28) ....................................... 34 TROJAN REGULAR ........................ 54 tropicamide ...................................... 63 trospium chloride ............................. 69 TRUEPLUS INSULIN SYRINGE ..... 55 TRUVADA ....................................... 25 trymine cg ........................................ 36 TUDORZA PRESSAIR .................... 11 tusnel diabetic ..................................36 tussin cf max multi-symptom ........... 36 tussin chest congestion ................... 36

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tussin dm max adult .........................36 TYBOST .......................................... 23 TYVASO .......................................... 28 TYVASO REFILL .............................28 TYVASO STARTER ........................ 28 TYZEKA ...........................................25 ULORIC ........................................... 49 ULTICARE INSULIN SYRINGE ...... 55 umecta mousse ............................... 44 urea ................................................. 44 urea nail ...........................................44 urea nail film .................................... 44 urinary pain relief ............................. 49 uroav-81 .......................................... 69 uro-mp ............................................. 69 ursodiol ............................................ 49 ustell ................................................ 69 utira-c ...............................................69 valacyclovir hcl ................................ 25 valganciclovir hcl ............................. 26 valsartan .......................................... 19 valsartan-hydrochlorothiazide ..........19 vancomycin hcl ................................ 19 VCF VAGINAL CONTRACEPTIVE . 71 vcf vaginal contraceptive ................. 71 velivet .............................................. 34 VENTAVIS .......................................28 VENTOLIN HFA .............................. 11 verapamil hcl ................................... 28 verapamil hcl er ............................... 28 vestura .............................................34 VEXOL .............................................63 vh essentials uti relief ...................... 49 VICTOZA ......................................... 13 VIDEX ..............................................26 vienva .............................................. 34 viorele .............................................. 34 VIRACEPT .......................................26 VIREAD ........................................... 26 VIRT NATE ......................................59 virt-vite ............................................. 51 virt-vite plus ..................................... 59 vitamin b complex ............................59 vitamin d .......................................... 72 vitamin d (ergocalciferol) ................. 72 vitamin d3 ........................................ 72 vitamin d-3 ....................................... 72 vitamin e .......................................... 72 vitamin e blend ................................ 72 vitamin e/folic acid/b-6/b-12 .............59 VITEKTA ..........................................26 voriconazole .................................... 15 vyfemla ............................................ 34 wal-som ........................................... 51 warfarin sodium ............................... 11 wart remover maximum strength ..... 44 wera .................................................34 WESTHROID ...................................67 WIDE-SEAL DIAPHRAGM 60 ......... 55 WIDE-SEAL DIAPHRAGM 65 ......... 55

WIDE-SEAL DIAPHRAGM 70 ......... 55 WIDE-SEAL DIAPHRAGM 75 ......... 55 WIDE-SEAL DIAPHRAGM 80 ......... 55 WIDE-SEAL DIAPHRAGM 85 ......... 55 WIDE-SEAL DIAPHRAGM 90 ......... 55 WIDE-SEAL DIAPHRAGM 95 ......... 55 WP THYROID ..................................67 wymzya fe ........................................34 XARELTO ........................................11 XARELTO STARTER PACK ........... 11 XIFAXAN ......................................... 19 XOPENEX HFA ............................... 11 XTANDI ........................................... 22 XULANE .......................................... 34 YUVAFEM ....................................... 71 zafirlukast ........................................ 11 zaleplon ........................................... 51 zarah ................................................34 ZELBORAF ......................................22 zenchent .......................................... 34 zenchent fe ...................................... 34 ZENPEP .......................................... 45 ZEPHREX-D ....................................60 zidovudine ....................................... 26 ZIOPTAN ......................................... 63 ZOLINZA ......................................... 22 zolpidem tartrate ........................51, 52 ZOMACTON .................................... 47 ZOSTAVAX ..................................... 70 zovia 1/35e (28) ...............................34

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2018 Health Choice Utah Formulary€¦ · Product Selection Criteria The Health Choice Pharmacy ... prescribed brand name product. An important consideration for generic ... compared