2018 National Formulary - Southern Scripts, LLC Rx National Formulary... · 2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for

2018 National Formulary

Effective 01/01/2018

The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing.

For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.

Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs

Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options

2018

Preferred Non-Preferred / Excluded * Drug Class

ANALGESICS

EUFLEXXA, GEL-ONE, HYALGAN, MONOVISC, ORTHOVISC

GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE

ANTIARTHRITICS

ABSTRAL, EMBEDA, KADIAN, ZOHYDRO ER fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, FENTORA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

NARCOTICS

ANTI-INFECTIVES

REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS

DAKLINZA*, EPCLUSA*, HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK*

MAVYRET, ZEPATIER HEPATITIS C

DOXYCYCLINE IR-DR ORACEA TETRACYCLINES

CARDIAC

BENICAR HCT, EDARBI, EDARBYCLOR candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

ANGIOTENSIN RECEPTOR BLOCKER

PRADAXA clopidogrel, ELIQUIS, XARELTO ANTICOAGULANTS

LIVALO, VYTORIN atorvastatin calcium, rosuvastatin calcium, simvastatin

STATINS

CNS

ADDERALL XR dextroamphetamine-amphet er, dextroamphetamine-amphetamine

ADHD

PEXEVA, SARAFEM citalopram hbr, escitalopram oxalate, escitalopram oxalate, fluoxetine hcl, fluvoxamine maleate, paroxetine er, paroxetine hcl, sertraline hcl, trazodone hcl, VIIBRYD

ANTIDEPRESSANTS

FANAPT, INVEGA, REXULTI aripiprazole, olanzapine, olanzapine odt, quetiapine fumarate, quetiapine fumarate er, LATUDA, SAPHRIS

ANTI-PSYCHOTIC

ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er, BELSOMRA, ROZEREM

SLEEP

DIABETES

ALOGLIPTIN, KAZANO, KOMBIGLYZE XR, NESINA, ONGLYZA, OSENI

JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA

DPP-4

BYDUREON PEN, BYETTA, TANZEUM TRULICITY, VICTOZA INCRETINS

AFREZZA, APIDRA HUMALOG, HUMALOG MIX 50-50, HUMALOG MIX 75-25, HUMULIN 70-30, HUMULIN N, HUMULIN R, NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30

INSULIN

BASAGLAR KWIKPEN U-100 LANTUS, LANTUS SOLOSTAR, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-200

INSULIN: LONG ACTING

GLUMETZA, RIOMET metformin hcl OTHER

INVOKAMET, INVOKANA FARXIGA, JARDIANCE, SYNJARDY, XIGDUO XR

SGLT-2


DIABETES

ACCU-CHEK AVIVA CONNECT, ACCU-CHEK AVIVA PLUS, ADVOCATE BLOOD GLUCOSE MONITOR, ASCENSIA BREEZE 2, CONTOUR, EMBRACE, PRODIGY, TRUETEST TEST STRIPS, TRUETRACK SMART SYSTEM, UNISTRIP1

FREESTYLE TEST STRIPS, ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TESTING

ENDOCRINE

ESTRING estradiol, DIVIGEL, PREMARIN ESTROGENS

GANIRELIX ACETATE, PREGNYL CETROTIDE, NOVAREL GONADOTROPIN

BRAVELLE clomiphene citrate, FOLLISTIM AQ, FOLLISTIM AQ, GONAL-F, MENOPUR

OVULATORY STIMULANTS

CRINONE, ENDOMETRIN PROGESTINS

FORTESTA, NATESTO, STRIANT, TESTIM, VOGELXO

ANDROGEL, AXIRON TESTOSTERONE

GASTROINTESTINAL

PANCREAZE, PERTZYE CREON, VIOKACE, ZENPEP DIGESTIVE ENZYMES

DIPENTUM, LIALDA balsalazide disodium, AMITIZA, APRISO, ASACOL HD, DELZICOL, LINZESS, PENTASA

OTHER

DEXILANT, ZEGERID RX lansoprazole, omeprazole, pantoprazole sodium

PROTON PUMP INHIBITORS

GROWTH HORMONES

GENOTROPIN, HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, ZOMACTON, ZORBTIVE

NORDITROPIN FLEXPRO

HEMATOLOGY

ARANESP, EPOGEN, MIRCERA PROCRIT

MUSCULOSKELETAL

ACTEMRA, CIMZIA, OTEZLA, REMICADE, SIMPONI, STELARA, TALTZ AUTOINJECTOR, TALTZ SYRINGE, XELJANZ

COSENTYX 150MG, COSENTYX 300MG, ENBREL, ENTYVIO, HUMIRA, ORENCIA, SILIQ

ANTI-INFLAMMATORY **

** Trial of ONE First Line Product and ONE Second Line Product is Required before any Non-Preferred Products.

Required Second Line Required First Line Indication

HUMIRA or ORENCIA HUMIRA or ORENCIA Rheumatoid Arthritis

Juvenille Idiopathic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA

COSENTYX or HUMIRA or ORENCIA HUMIRA or ORENCIA Ankylosing Spondylitis

Psoriatic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA

COSENTYX or SILIQ COSENTYX or HUMIRA Plaque Psoriasis

ENBREL Pediatric Plaque Psoriasis

ENTYVIO HUMIRA Crohn's Disease

HUMIRA Pediatric Crohn's

ENTYVIO HUMIRA Ulcerative Colitis

HUMIRA Hidradentis Supperativa

HUMIRA Uvelitis

OPHTHALMIC

COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, latanoprost, AZOPT, COMBIGAN, TRAVATAN Z

GLAUCOMA

ACUVAIL bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA

NSAIDS


OTIC

CETRAXAL ciprofloxacin hcl MISCELLANEOUS

RESPIRATORY

DULERA, INCRUSE ELLIPTA ADVAIR DISKUS, ANORO ELLIPTA, BREO ELLIPTA, SPIRIVA, STIOLTO RESPIMAT, SYMBICORT, TUDORZA PRESSAIR

ARCAPTA NEOHALER, FORADIL, PROVENTIL HFA, XOPENEX HFA

PERFOROMIST, PROAIR HFA, SEREVENT DISKUS, VENTOLIN HFA

BETA AGONISTS

ALVESCO, ASMANEX ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR

INHALED STEROIDS

BECONASE AQ, NASONEX, OMNARIS, QNASL, ZETONNA

flunisolide, DYMISTA NASAL STEROIDS

TOPICAL

ATRALIN, AVAGE, AZELEX, BENZACLIN, VELTIN

adapalene, clindamycin phos-tretinoin, clindamycin-benzoyl peroxide, erythromycin, metronidazole, tretinoin, ACANYA, EPIDUO, FINACEA, TAZORAC

ACNE

ALDARA, FLUOROURACIL, ZYCLARA fluorouracil, imiquimod, PICATO MISCELLANEOUS

UROLOGICAL

ENABLEX, GELNIQUE, TOVIAZ oxybutynin chloride, tolterodine tartrate, MYRBETRIQ, VESICARE

ANTISPASMODICS

LEVITRA, STAXYN, STENDRA, VIAGRA sildenafil citrate, CIALIS ERECTILE DYSFUNCTION

Please Note: Drugs Marked with * are Excluded

CARDIAC

ACE INHIBITORS

CAPSULE

amlodipine besylate-benazepril 1

TABLET

benazepril hcl 1

TABLET

benazepril hcl-hctz 1

TABLET

captopril 1

TABLET

captopril/hydrochlorothiazide 1

TABLET

enalapril maleate 1

TABLET

fosinopril sodium 1

TABLET

fosinopril-hydrochlorothiazide 1

TABLET

lisinopril 1

TABLET

lisinopril-hctz 1

TABLET

moexipril hcl 1

TABLET

moexipril-hydrochlorothiazide 1

TABLET

perindopril erbumine 1

TABLET

quinapril 1

TABLET

quinapril-hydrochlorothiazide 1

CAPSULE

ramipril 1

TABLET

trandolapril 1

TABLET

ACCUPRIL 3

CAPSULE

ALTACE 3

SOLUTION, ORAL

EPANED 3

TABLET

LOTENSIN 3

TABLET

MAVIK 3

TABLET

PRINIVIL 3

SOLUTION, ORAL

QBRELIS 3

TABLET,IMMED AND EXTEND REL BIPHASE 24HR

TARKA 3

TABLET

VASOTEC 3

TABLET

ZESTRIL 3

ANTICOAGULANTS

TABLET

cilostazol 1

TABLET

clopidogrel 1

TABLET

dipyridamole 1

SYRINGE (ML)

enoxaparin sodium SP 1

SYRINGE (ML)

fondaparinux sodium SP 1

VIAL (ML)

heparin sodium 1

TABLET

jantoven 1

TABLET, EXTENDED RELEASE

pentoxifylline 1

TABLET

ticlopidine hcl 1

TABLET

warfarin sodium 1

TABLET

BRILINTA 2

TABLET

COUMADIN 2

TABLET

EFFIENT 2

TABLET

ELIQUIS 2

SYRINGE (ML)

FRAGMIN SP 2

TABLET

MEPHYTON 2

TABLET

XARELTO SP 2

CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR

AGGRENOX 3

CAPSULE

PRADAXA 3

ANTIARRHYTHMIC

TABLET

amiodarone hcl 1

SOLUTION, ORAL

digoxin 1

TABLET

digoxin 1

CAPSULE

disopyramide phosphate 1

TABLET

flecainide acetate 1

CAPSULE

mexiletine hcl 1

TABLET

pacerone 1

VIAL (ML)

procainamide hcl 1

TABLET

propafenone hcl 1

Printed Date:11/1/2017

Page 5 | 2018 National Formulary Data Last Updated:10/30/2017

B4G Participant: N

CARDIAC

ANTIARRHYTHMIC

VIAL (ML)

quinidine gluconate 1


quinidine sulfate 1

TABLET

quinidine sulfate 1

TABLET

sorine 1

TABLET

sotalol 1

TABLET

sotalol af 1

TABLET

MULTAQ 2

CAPSULE, EXTENDED RELEASE

NORPACE CR 3

CAPSULE

TIKOSYN SP 3

OTHER

TABLET

ENTRESTO 2

TABLET, EXTENDED RELEASE 12 HR

RANEXA 2

TABLET

VECAMYL 3

ANGIOTENSIN RECEPTOR BLOCKER

TABLET

candesartan cilexetil 1

TABLET

candesartan-hydrochlorothiazid 1

TABLET

eprosartan mesylate 1

TABLET

irbesartan 1

TABLET

irbesartan-hydrochlorothiazide 1

TABLET

losartan potassium 1

TABLET

losartan-hydrochlorothiazide 1

TABLET

olmesartan medoxomil 1

TABLET

olmesartan medoxomil 1

TABLET

telmisartan 1

TABLET

telmisartan-amlodipine 1

TABLET

telmisartan-hydrochlorothiazid 1

TABLET

valsartan 1

TABLET

valsartan-hydrochlorothiazide 1

TABLET

TEKAMLO 2

TABLET

TEKTURNA 2

TABLET

TEKTURNA HCT 2

TABLET

ATACAND HCT 3

TABLET

AZOR 3

TABLET

BENICAR 3

TABLET

BENICAR HCT 3

TABLET

DIOVAN HCT 3

TABLET

EDARBI 3

TABLET

EDARBYCLOR 3

TABLET

EXFORGE 3

TABLET

EXFORGE HCT 3

TABLET

TRIBENZOR 3

BETA BLOCKERS

CAPSULE

acebutolol hcl 1

TABLET

atenolol 1

TABLET

atenolol w/chlorthalidone 1

TABLET

betaxolol hcl 1

TABLET

bisoprolol fumarate 1

TABLET

bisoprolol fumarate/hctz 1

TABLET

carvedilol 1

TABLET

labetalol hcl 1

TABLET

metoprolol tartrate 1

TABLET

nadolol 1

TABLET

nadolol-bendroflumethiazide 1

TABLET

pindolol 1

TABLET

propranolol hcl 1

SOLUTION, ORAL

propranolol hcl 1

TABLET

propranolol hcl-hctz 1



B4G Participant: N

CARDIAC

BETA BLOCKERS

TABLET

timolol maleate 1

TABLET

BYSTOLIC 2


COREG CR 2

TABLET

LEVATOL 3

CALCIUM CHANNEL BLOCKERS


afeditab cr 1

TABLET

amlodipine besylate 1

CAPSULE, EXT RELEASE 24 HR

cartia xt 1


diltiazem 24hr cd 1


diltiazem er 1

TABLET

diltiazem hcl 1


felodipine er 1

CAPSULE

isradipine 1

CAPSULE

nifedipine 1


nifedipine er 1

CAPSULE

nimodipine 1


nisoldipine 1

CAPSULE, EXTENDED RELEASE 24HR

taztia xt 1

CAPSULE,24HR EXTENDED RELEASE PELLET CT

verapamil er pm 1

TABLET

verapamil hcl 1

DIURETICS

TABLET

acetazolamide 1

TABLET

amiloride hcl 1

TABLET

amiloride hcl w/hctz 1

TABLET

bumetanide 1

TABLET

chlorothiazide 1

TABLET

eplerenone 1

SOLUTION, ORAL

furosemide 1

TABLET

hydrochlorothiazide 1

TABLET

indapamide 1

TABLET

methazolamide 1

TABLET

methyclothiazide 1

TABLET

metolazone 1

TABLET

spironolactone 1

TABLET

spironolactone w/hctz 1

TABLET

torsemide 1

TABLET

triamterene w/hctz 1

CAPSULE

DYRENIUM 3

OTHER ANTI-HYPERTENSIVES

TABLET

clonidine hcl 1

TABLET

clorpres 1

TABLET

doxazosin mesylate 1

TABLET

guanfacine hcl 1

TABLET

hydralazine hcl 1

TABLET

methyldopa 1

TABLET

methyldopa/hydrochlorothiazide 1

TABLET

minoxidil 1

CAPSULE

prazosin hcl 1

TABLET

reserpine 1

CAPSULE

terazosin hcl 1

TABLET

BIDIL 3


CARDURA XL 3

STATINS

TABLET

amlodipine-atorvastatin 1

TABLET

atorvastatin calcium 1

POWDER IN PACKET (EA)

cholestyramine 1

TABLET

colestipol hcl 1



B4G Participant: N

CARDIAC

STATINS

TABLET

fenofibrate 1

CAPSULE,DELAYED RELEASE (ENTERIC COATED)

fenofibric acid 1

CAPSULE

fluvastatin sodium 1

TABLET

gemfibrozil 1

TABLET

lovastatin 1


niacin er 1

TABLET

pravastatin sodium 1


prevalite 1

TABLET

rosuvastatin calcium 1

TABLET

simvastatin 1

CAPSULE

JUXTAPID SP 2

CAPSULE

LIPOFEN 2

PEN INJECTOR (ML)

PRALUENT PEN SP 2

SYRINGE (ML)

PRALUENT SYRINGE SP 2

PEN INJECTOR (ML)

REPATHA SURECLICK SP 2

SYRINGE (ML)

REPATHA SYRINGE SP 2

CAPSULE

VASCEPA 2

TABLET

WELCHOL 2


WELCHOL 2


ALTOPREV 3

CAPSULE

ANTARA 3

TABLET

CRESTOR 3

TABLET

FENOGLIDE 3


LESCOL XL 3

TABLET

LIVALO 3

CAPSULE

LOVAZA 3

TABLET

NIACOR 3

TABLET

TRIGLIDE 3

TABLET

VYTORIN 3

TABLET

ZETIA 3

NITRATES

TABLET

isosorbide dinitrate 1

TABLET

isosorbide mononitrate 1

OINTMENT (GRAM)

nitro-bid 1

PATCH, TRANSDERMAL 24 HOURS

nitroglycerin 1

AEROSOL, SPRAY (GRAM)

nitroglycerin 1


DILATRATE-SR 2


MINITRAN 3


NITRO-DUR 3

TABLET, SUBLINGUAL

NITROSTAT 3

ANALGESICS

ANTIARTHRITICS

SYRINGE (ML)

GELSYN-3 SP 2

SYRINGE (ML)

SUPARTZ FX SP 2

SYRINGE (ML)

SYNVISC SP 2

SYRINGE (ML)

SYNVISC-ONE SP 2

SYRINGE (ML)

EUFLEXXA SP 3

SYRINGE (ML)

GEL-ONE SP 3

SYRINGE (ML)

GENVISC 850 SP 3

SYRINGE (ML)

HYALGAN SP 3

SYRINGE (ML)

HYMOVIS SP 3

SYRINGE (ML)

MONOVISC 3

SYRINGE (ML)

ORTHOVISC SP 3

HEADACHE

CAPSULE

apap/dichlphen/isometheptene 1

AEROSOL, SPRAY WITH PUMP (ML)

dihydroergotamine mesylate SP 1

TABLET

naratriptan hcl 1



B4G Participant: N

ANALGESICS

HEADACHE

TABLET

rizatriptan 1

TABLET

sumatriptan succinate 1

PEN INJECTOR (ML)

sumatriptan succinate SP 1

SPRAY, NON-AEROSOL (EA)

sumatriptan succinate SP 1

TABLET

zolmitriptan 1

TABLET,DISINTEGRATING

zolmitriptan odt 1

NEEDLE-FREE INJECTOR (ML)

SUMAVEL DOSEPRO 2

TABLET

TREXIMET 2


ZOMIG 2

TABLET

AXERT 3

TABLET

CAFERGOT 3

TABLET, SUBLINGUAL

ERGOMAR 3

TABLET

FROVA 3

TABLET

RELPAX 3

NARCOTIC ANTAGONISTS

TABLET, SUBLINGUAL

buprenorphine-naloxone 1

TABLET

naltrexone hydrochloride 1


NARCAN 2

FILM, MEDICATED (EA)

SUBOXONE 2

SUSPENSION, EXTENDED RELEASE, RECONST.

VIVITROL SP 2

TABLET, SUBLINGUAL

ZUBSOLV 2

NARCOTICS

SOLUTION, ORAL

acetaminophen w/codeine 1

TABLET

acetaminophen w/codeine 1

TABLET, SUBLINGUAL

buprenorphine hydrochloride 1

CAPSULE

butalbital compound 1

CAPSULE

butalbital compound w/codeine 1

TABLET

butalbital/apap/caffeine 1

CAPSULE

butalbital/caff/apap/codeine 1

TABLET

codeine sulfate 1

TABLET, SOLUBLE

diskets 1


fentanyl 1

LOZENGE ON A HANDLE

fentanyl citrate 1

TABLET

hydrocodone bit-ibuprofen 1

TABLET

hydrocodone w/acetaminophen 1

SOLUTION, ORAL

hydrocodone w/acetaminophen 1

TABLET

hydromorphone hcl 1

SOLUTION, ORAL

meperidine hcl 1

SOLUTION, ORAL

methadone hcl 1

SUPPOSITORY, RECTAL

morphine sulfate 1


morphine sulfate er 1

SOLUTION, ORAL

oxycodone hcl 1

TABLET

oxycodone hcl-ibuprofen 1

TABLET

oxycodone w/acetaminophen 1

TABLET

oxycodone w/aspirin 1

TABLET

oxymorphone hcl 1

PATCH, TRANSDERMAL WEEKLY

BUTRANS 2

TABLET, EFFERVESCENT

FENTORA 2

TABLET,ORAL ONLY,EXTENDED RELEASE 24 HR

HYSINGLA ER 2

TABLET

NUCYNTA 2


NUCYNTA ER 2

TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR

OXYCONTIN 2

TABLET, SUBLINGUAL

ABSTRAL 3

SUSPENSION, ORAL (FINAL DOSE FORM)

CAPITAL W/CODEINE 3

CAPSULE,ORAL ONLY, EXT. RELEASE PELLETS

EMBEDA 3

CAPSULE, EXTENDED RELEASE PELLETS

KADIAN 3



B4G Participant: N

ANALGESICS

NARCOTICS

TABLET

PRIMLEV 3


SUBSYS 3

CAPSULE,ORAL ONLY, EXTENDED RELEASE 12HR

ZOHYDRO ER 3

NSAIDS

CAPSULE

celecoxib 1

TABLET

diclofenac potassium 1


diclofenac sodium 1

TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE

diclofenac sodium-misoprostol 1

TABLET

etodolac 1

TABLET

fenoprofen calcium 1

TABLET

flurbiprofen 1

CAPSULE

indomethacin 1

CAPSULE

ketoprofen 1

TABLET

ketorolac tromethamine 1

CAPSULE

meclofenamate sodium 1

CAPSULE

mefenamic acid 1

TABLET

meloxicam 1


meloxicam 1

TABLET

nabumetone 1

TABLET

naproxen 1

TABLET

naproxen sodium 1

TABLET

oxaprozin 1

CAPSULE

piroxicam 1

TABLET

sulindac 1

CAPSULE

tolmetin sodium 1


FLECTOR 2

CAPSULE

ZORVOLEX 2

CAPSULE

CELEBREX 3

TABLET

DUEXIS 3

SUPPOSITORY, RECTAL

INDOCIN 3

CAPSULE

NALFON 3


SPRIX SP 3

TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE

VIMOVO 3

GEL (GRAM)

VOLTAREN 3

CAPSULE

ZIPSOR 3

MISCELLANEOUS

TABLET

diflunisal 1

TABLET

salsalate 1

TABLET

tramadol hcl 1


tramadol hcl er 1

TABLET

tramadol hcl-acetaminophen 1

CAPSULE,EXT.RELEASE 24 HR BIPHASIC 25-75

CONZIP 3

GROWTH HORMONES

PEN INJECTOR (ML)

NORDITROPIN FLEXPRO SP 2

VIAL (EA)

EGRIFTA SP 3

CARTRIDGE (EA)

GENOTROPIN SP 3

CARTRIDGE (EA)

HUMATROPE SP 3

PEN INJECTOR (ML)

NUTROPIN AQ NUSPIN SP 3

CARTRIDGE (ML)

OMNITROPE SP 3

CARTRIDGE (EA)

SAIZEN SP 3

VIAL (EA)

SEROSTIM SP 3

VIAL (EA)

ZOMACTON SP 3

VIAL (EA)

ZORBTIVE SP 3

HEMATOLOGY

SYRINGE (ML)

NEULASTA SP 2

VIAL (ML)

PROCRIT SP

2

SYRINGE (ML)

ZARXIO SP 2



B4G Participant: N

HEMATOLOGY

VIAL (ML)

ARANESP SP 3

* ST: Must try and fail Procrit.

SYRINGE (ML)

ARANESP SP 3

* ST: Must try and fail Procrit.

VIAL (ML)

EPOGEN SP 3

SYRINGE (ML)

MIRCERA SP 3

SYRINGE (ML)

NEUPOGEN SP 3

ONCOLOGY

TABLET

anastrozole SP 1

TABLET

bicalutamide SP 1

VIAL (ML)

cytarabine SP 1

TABLET

exemestane SP 1

CAPSULE

flutamide SP 1

CAPSULE

hydroxyurea 1

TABLET

imatinib mesylate 1

TABLET

letrozole SP 1

TABLET

leucovorin calcium 1


megestrol acetate 1

TABLET

megestrol acetate 1

TABLET

mercaptopurine 1

TABLET

methotrexate 1

TABLET

tamoxifen citrate 1

CAPSULE

temozolomide SP 1

TABLET

AFINITOR SP 2

TABLET FOR SUSPENSION

AFINITOR DISPERZ SP 2

CAPSULE

ALECENSA SP 2

TABLET

BOSULIF SP 2

TABLET

CAPRELSA SP 2

CAPSULE

DROXIA 2

SYRINGE (EA)

ELIGARD SP 2

CAPSULE

EMCYT SP 2

TABLET

FARESTON SP 2

TABLET

GILOTRIF SP 2

CAPSULE

HYCAMTIN SP 2

TABLET

ICLUSIG SP 2

CAPSULE

IMBRUVICA SP 2

TABLET

INLYTA SP 2

TABLET

JAKAFI SP 2

TABLET

LEUKERAN SP 2

TABLET

LYSODREN SP 2

CAPSULE

MATULANE SP 2

TABLET

MEKINIST SP 2

TABLET

MESNEX SP 2

TABLET

NEXAVAR SP 2

CAPSULE

POMALYST SP 2

CAPSULE

REVLIMID SP 2

TABLET

SPRYCEL SP 2

TABLET

STIVARGA SP 2

CAPSULE

SUTENT SP 2

TABLET

TABLOID 2

CAPSULE

TAFINLAR SP 2

TABLET

TARCEVA SP 2

CAPSULE

TASIGNA SP 2

CAPSULE

THALOMID SP 2

TABLET

TREXALL 2

TABLET

TYKERB SP 2



B4G Participant: N

ONCOLOGY

TABLET

VOTRIENT SP 2

CAPSULE

XALKORI SP 2

TABLET

ZELBORAF SP 2

CAPSULE

ZOLINZA SP 2

TABLET

ZYTIGA SP 2

CAPSULE

COMETRIQ SP 3

TABLET

GLEEVEC SP 3


MEGACE ES 3

SOLUTION, ORAL

SOLTAMOX 3

CAPSULE

TEMODAR SP 3

VIAL (EA)

VIDAZA SP 3

CAPSULE

XTANDI SP 3

* ST: Must try and fail Zytiga.

IMMUNOSUPPRESSANTS

TABLET

azathioprine SP 1

CAPSULE

cyclosporine SP 1

SOLUTION, ORAL

cyclosporine SP 1

CAPSULE

gengraf SP 1

SOLUTION, ORAL

gengraf SP 1

CAPSULE

mycophenolate mofetil SP 1

TABLET

sirolimus SP 1

CAPSULE

tacrolimus SP 1

TABLET

AZASAN SP 2

CAPSULE

NEORAL SP 2

SOLUTION, ORAL

NEORAL SP 2

SOLUTION, ORAL

RAPAMUNE SP 2

SOLUTION, ORAL

SANDIMMUNE SP 2

CAPSULE

SANDIMMUNE SP 2

TABLET

ZORTRESS SP 2


ASTAGRAF XL SP 3

SUSPENSION, RECONSTITUTED, ORAL (ML)

CELLCEPT SP 3

TABLET

RAPAMUNE SP 3

INTERFERONS

VIAL (ML)

ACTIMMUNE SP 2

VIAL (ML)

ALFERON N SP 2

KIT

AVONEX ADMINISTRATION PACK SP 2

KIT

BETASERON SP 2

VIAL (EA)

INTRON A SP 2

SYRINGE (ML)

PEGASYS SP 2

SYRINGE (ML)

REBIF SP 2

KIT

SYLATRON SP 2

KIT

EXTAVIA SP 3

KIT

PEG-INTRON SP 3

PEN INJECTOR KIT (EA)

PEG-INTRON REDIPEN SP 3

OPHTHALMIC

ANTIBIOTICS

OINTMENT (GRAM)

bacitracin 1

OINTMENT (GRAM)

bacitracin 1

OINTMENT (GRAM)

bacitracin/polymyxin 1

DROPS

ciprofloxacin hcl 1

OINTMENT (GRAM)

erythromycin 1

DROPS

gatifloxacin 1

OINTMENT (GRAM)

gentamicin sulfate 1

DROPS

gentamicin sulfate 1

DROPS

levofloxacin hemihydrate 1

OINTMENT (GRAM)

neo/polymyxin/dexamethasone 1

SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

neo/polymyxin/dexamethasone 1



B4G Participant: N

OPHTHALMIC

ANTIBIOTICS

OINTMENT (GRAM)

neomycin/bacitracin/poly/hc 1

OINTMENT (GRAM)

neomycin/bacitracin/polymyxin 1

DROPS

neomycin/polymyxin/gramicidin 1

SOLUTION, NON-ORAL

neomycin/polymyxin/hc 1


neomycin/polymyxin/hc 1

DROPS

ofloxacin 1

DROPS

polymyxin b sul-trimethoprim 1

DROPS

sulfacetamide sodium 1

DROPS

sulfacetamide w/prednisolone 1

DROPS

tobramycin sulfate 1


tobramycin-dexamethasone 1

DROPS

AZASITE 2

DROPS

AZASITE 2


BESIVANCE 2


CIPRODEX 2

DROPS, VISCOUS (ML)

MOXEZA 2


NATACYN 2

OINTMENT (GRAM)

TOBRADEX 2


TOBRADEX ST 2


ZYLET 2

DROPS

BLEPH-10 3


BLEPHAMIDE 3

OINTMENT (GRAM)

BLEPHAMIDE S.O.P. 3

OINTMENT (GRAM)

CILOXAN 3


CIPRO HC 3


COLY-MYCIN S 3

OINTMENT (GRAM)

PRED-G 3

OINTMENT (GRAM)

TOBREX 3

BETA BLOCKERS

DROPS

betaxolol hcl 1

DROPS

carteolol hcl 1

DROPS

levobunolol hcl 1

DROPS

metipranolol 1

DROPS

timolol maleate 1

DROPS

BETIMOL 3


BETOPTIC S 3

DROPS, ONCE DAILY

ISTALOL 3

DROPPERETTE, SINGLE-USE DROP DISPENSER

TIMOPTIC 3

GLAUCOMA

DROPS

dorzolamide hcl 1

DROPS

dorzolamide-timolol 1

DROPS

latanoprost 1

DROPS

pilocarpine hcl 1


AZOPT 2

DROPS

COMBIGAN 2

DROPS

LUMIGAN 2

DROPS

TRAVATAN Z 2


COSOPT PF 3

KIT

MITOSOL 3


SIMBRINZA 3


ZIOPTAN 3

NSAIDS

DROPS

bromfenac sodium 1

DROPS

diclofenac sodium 1

DROPS

flurbiprofen sodium 1

DROPS

ketorolac tromethamine 1


ILEVRO 2



B4G Participant: N

OPHTHALMIC

NSAIDS


NEVANAC 2

DROPS

PROLENSA 2


ACUVAIL 3

STEROIDS

DROPS

dexamethasone sodium phosphate 1


fluorometholone 1


prednisolone acetate 1


ALREX 2


LOTEMAX 2


PRED MILD 2

DROPS

DUREZOL 3


FLAREX 3


FML FORTE 3


MAXIDEX 3

MYDRIATICS

DROPS

atropine sulfate 1

DROPS

cyclopentolate hcl 1

DROPS

homatropine hydrobromide 1

DROPS

tropicamide 1

DROPS

CYCLOGYL 3

DROPS

PAREMYD 3

VASOCONSTRICTOR

DROPS

CYCLOMYDRIL 3

MISCELLANEOUS

DROPS

apraclonidine hcl 1

DROPS

azelastine hcl 1

DROPS

brimonidine tartrate 1

DROPS

cromolyn sodium 1

DROPS

epinastine hcl 1

DROPS

flucaine 1

DROPS

fluorescein-benoxinate 1

DROPS

proparacaine hcl 1

DROPS

tetracaine hcl 1

DROPS

trifluridine 1

DROPS

ALPHAGAN P 2

DROPS

BEPREVE 2

DROPS

CYSTARAN SP 2


RESTASIS 2

DROPS

ALOCRIL 3

DROPS

EMADINE 3


IOPIDINE 3

DROPS

LASTACAFT 3

DROPS

PATADAY 3

DROPS

PATANOL 3

DROPPERETTE, VISCOUS

TETRAVISC 3

GEL (GRAM)

ZIRGAN 3

OTIC

MISCELLANEOUS

DROPS

acetasol hc 1

SOLUTION, NON-ORAL

acetic acid 1

DROPS

acetic acid/hydrocortisone 1


ciprofloxacin hcl 1


CETRAXAL 3

TOPICAL

CORTICOSTEROIDS VERY HIGH POTENCY

CREAM (GRAM)

clobetasol e 1

SHAMPOO

clobetasol propionate 1

OINTMENT (GRAM)


SOLUTION, NON-ORAL


OINTMENT (GRAM)

halobetasol propionate 1



B4G Participant: N

TOPICAL

CORTICOSTEROIDS VERY HIGH POTENCY

SPRAY, NON-AEROSOL (ML)

CLOBEX 3

ANESTHETICS

OINTMENT (GRAM)

lidocaine 1

CREAM (GRAM)

lidocaine-hc 1

CREAM (GRAM)

lidocaine-prilocaine 1

GEL (GRAM)

NOVACORT 3

CREAM (GRAM)

PLIAGLIS 3

MISCELLANEOUS

CREAM (GRAM)

fluorouracil 1

CREAM IN PACKET (EA)

imiquimod 1

SHAMPOO

lindane 1

LOTION (ML)

malathion 1

CREAM (GRAM)

permethrin 1

SOLUTION, NON-ORAL

podofilox 1

CREAM (GRAM)

silver sulfadiazine 1

CREAM (GRAM)

thermazene 1

CREAM (GRAM)

CARAC 2

CREAM (GRAM)

ELIDEL 2

GEL (EA)

PICATO 2

GEL (GRAM)

REGRANEX 2

OINTMENT (GRAM)

SANTYL 2


ALDARA 3

CREAM (GRAM)

BIONECT 3

GEL (GRAM)

BIONECT 3

CREAM (GRAM)

EURAX 3

CREAM (GRAM)

FLUOROURACIL 3

OINTMENT (GRAM)

PROTOPIC 3


ZYCLARA 3

CREAM IN METERED-DOSE PUMP

ZYCLARA 3

CORTICOSTEROIDS HIGH POTENCY

CREAM (GRAM)

amcinonide 1

OINTMENT (GRAM)

amcinonide 1

LOTION (ML)

amcinonide 1

CREAM (GRAM)

apexicon e 1

CREAM (GRAM)

betamethasone dipropionate 1

OINTMENT (GRAM)


LOTION (ML)


OINTMENT (GRAM)

betamethasone valerate 1

GEL (GRAM)

desoximetasone 1

CREAM (GRAM)

desoximetasone 1

OINTMENT (GRAM)

desoximetasone 1

CREAM (GRAM)

diflorasone diacetate 1

CREAM (GRAM)

fluocinonide 1

CREAM (GRAM)

fluocinonide 1

OINTMENT (GRAM)

fluocinonide 1

CREAM (GRAM)

fluocinonide-e 1

CREAM (GRAM)

triamcinolone acetonide 1

CREAM (GRAM)

HALOG 3

OINTMENT (GRAM)

HALOG 3

SPRAY, NON-AEROSOL (ML)

TOPICORT 3

TOPICAL CORTICOSTEROIDS MEDIUM POTENCY

CREAM (GRAM)


LOTION (ML)


CREAM (GRAM)

fluticasone propionate 1

LOTION (ML)


CREAM (GRAM)

hydrocortisone butyrate 1

SOLUTION, NON-ORAL

hydrocortisone butyrate 1



B4G Participant: N

TOPICAL

TOPICAL CORTICOSTEROIDS MEDIUM POTENCY

OINTMENT (GRAM)

mometasone furoate 1

SOLUTION, NON-ORAL

mometasone furoate 1

OINTMENT (GRAM)

prednicarbate 1

OINTMENT (GRAM)

trianex 1

CREAM (GRAM)

triderm 1

CREAM (GRAM)

CLODERM 3

CREAM (GRAM)

CORDRAN 3

AEROSOL (GRAM)

KENALOG 3

LOTION (ML)

LOCOID 3

OINTMENT (GRAM)

TOPICORT 3

TOPICAL CORTICOSTEROIDS LOW POTENCY

CREAM (GRAM)

alclometasone dipropionate 1

OINTMENT (GRAM)

alclometasone dipropionate 1

OINTMENT (GRAM)

desonide 1

LOTION (ML)

desonide 1

CREAM (GRAM)

fluocinolone acetonide 1

SOLUTION, NON-ORAL

fluocinolone acetonide 1

CREAM (GRAM)

hydrocortisone 1

SHAMPOO

CAPEX SHAMPOO 3

GEL (GRAM)

DESONATE 3

CREAM (GRAM)

SYNALAR 3

SOLUTION, NON-ORAL

TEXACORT 3

FOAM (GRAM)

VERDESO 3

ACNE

GEL (GRAM)

adapalene 1

CLEANSER (ML)

benzoyl peroxide 1

FOAM (GRAM)

benzoyl peroxide 1

CAPSULE

claravis SP 1

SWAB, MEDICATED

clindamycin phosphate 1

FOAM (GRAM)


SOLUTION, NON-ORAL


GEL (GRAM)


LOTION (ML)


GEL (GRAM)

clindamycin phos-tretinoin 1

GEL (GRAM)

clindamycin-benzoyl peroxide 1

GEL (GRAM)

erygel 1

GEL (GRAM)

erythromycin 1

SOLUTION, NON-ORAL

erythromycin 1

GEL (GRAM)

erythromycin-benzoyl peroxide 1

GEL (GRAM)

metronidazole 1

CREAM (GRAM)

metronidazole 1

LOTION (ML)

metronidazole 1

CAPSULE

myorisan SP 1

CREAM (GRAM)

rosadan 1

GEL (GRAM)

rosadan 1

LOTION (GRAM)

sodium sulfacetamide/sulfur 1

CLEANSER (ML)

sodium sulfacetamide/sulfur 1

CREAM (GRAM)

tretinoin 1

GEL (GRAM)

tretinoin 1

GEL (GRAM)

tretinoin microsphere 1

CAPSULE

ABSORICA SP 2

GEL WITH PUMP (GRAM)

ACANYA 2


EPIDUO 2

FOAM (GRAM)

FINACEA 2

GEL (GRAM)

MIRVASO 2

GEL (GRAM)

TAZORAC 2



B4G Participant: N

TOPICAL

ACNE

CREAM (GRAM)

TAZORAC 2

KIT

ACCUCAINE 3

GEL (GRAM)

ACZONE 3

GEL (GRAM)

ATRALIN 3

CREAM (GRAM)

AVAGE 3

PADS, MEDICATED (EA)

AVAR 3

CREAM (GRAM)

AZELEX 3


BENZACLIN 3

FOAM (GRAM)

BENZEFOAM 3

GEL (ML)

CLINDAGEL 3

LOTION (ML)

DIFFERIN 3

FOAM (GRAM)

FABIOR 3

COMBINATION PACKAGE (EA)

INOVA 3

CREAM (GRAM)

NORITATE 3

GEL (GRAM)

NUOX 3

PADS, MEDICATED (EA)

PACNEX HP 3

GEL (GRAM)

VELTIN 3

ANTIPSORIATIC

CAPSULE

acitretin 1

OINTMENT (GRAM)

calcipotriene 1

CREAM (GRAM)

calcipotriene 1

SOLUTION, NON-ORAL

calcipotriene 1

OINTMENT (GRAM)

calcitrene 1

CREAM (GRAM)

drithocreme hp 1

SHAMPOO

selenium sulfide 1

LOTION (ML)

selenium sulfide 1

CLEANSER (ML)

sodium sulfacetamide 1

SHAMPOO

sodium sulfacetamide 1

SUSPENSION, TOPICAL (GRAM)

TACLONEX 2

FOAM (GRAM)

EPIFOAM 3

SHAMPOO

OVACE PLUS 3

CREAM (GRAM)

PRAMOSONE 3

LOTION (ML)

PRAMOSONE 3

CREAM (GRAM)

PRAMOSONE E 3

FOAM (GRAM)

SORILUX 3

FOAM (GRAM)

TERSI FOAM 3

CREAM, RAPID RELEASE (GRAM)

ZITHRANOL-RR 3

ANTIFUNGALS

SUSPENSION, TOPICAL (ML)

ciclopirox 1

SHAMPOO

ciclopirox 1

GEL (GRAM)

ciclopirox 1

SOLUTION, NON-ORAL

clotrimazole 1

CREAM (GRAM)

clotrimazole 1

CREAM (GRAM)

clotrimazole/betamethasone 1

LOTION (ML)

clotrimazole/betamethasone 1

CREAM (GRAM)

econazole nitrate 1

SHAMPOO

ketoconazole 1

CREAM (GRAM)

ketoconazole 1

OINTMENT (GRAM)

nystatin 1

CREAM (GRAM)

nystatin w/triamcinolone 1

FOAM (GRAM)

ECOZA 3

CREAM (GRAM)

ERTACZO 3

SOLUTION, NON-ORAL

EXELDERM 3

LOTION (ML)

EXODERM 3

CREAM (GRAM)

MENTAX 3

CREAM (GRAM)

NAFTIN 3

GEL (GRAM)

NAFTIN 3



B4G Participant: N

TOPICAL

ANTIFUNGALS

CREAM (GRAM)

OXISTAT 3

LOTION (ML)

OXISTAT 3

ANTIBACTERIALS

OINTMENT (GRAM)

mupirocin 1

CREAM (GRAM)

SULFAMYLON 2

GEL IN PACKET (GRAM)

ALCORTIN A 3

OINTMENT (GRAM)

ALTABAX 3

OINTMENT (GRAM)

CENTANY 3

ANTIVIRALS

OINTMENT (GRAM)

acyclovir 1

CREAM (GRAM)

DENAVIR 3

CREAM (GRAM)

XERESE 3

UROLOGICAL

BPH

TABLET

finasteride 1

CAPSULE

RAPAFLO 2

CAPSULE

AVODART 3


JALYN 3

ANTISPASMODICS

TABLET

bethanechol chloride 1

TABLET

flavoxate hcl 1

TABLET

oxybutynin chloride 1

SYRUP

oxybutynin chloride 1


oxybutynin chloride er 1

TABLET

tolterodine tartrate 1


tolterodine tartrate er 1

TABLET

trospium chloride 1


MYRBETRIQ 2

TABLET

VESICARE 2


ENABLEX 3


GELNIQUE 3

PATCH, TRANSDERMAL SEMIWEEKLY

OXYTROL 3


TOVIAZ 3

ERECTILE DYSFUNCTION

TABLET

sildenafil citrate 1

TABLET

CIALIS 2

SUPPOSITORY, URETHRAL

MUSE 2

TABLET

LEVITRA 3


STAXYN 3

TABLET

STENDRA 3

TABLET

VIAGRA 3

DIABETES

INSULIN

VIAL (ML)

HUMALOG 2

VIAL (ML)

HUMALOG MIX 50-50 2

VIAL (ML)

HUMALOG MIX 75-25 2

VIAL (ML)

HUMULIN 70-30 2

VIAL (ML)

HUMULIN N 2

VIAL (ML)

HUMULIN R 2

VIAL (ML)

NOVOLIN 70-30 2

VIAL (ML)

NOVOLIN N 2

VIAL (ML)

NOVOLIN R 2

CARTRIDGE (ML)

NOVOLOG 2

INSULIN PEN (ML)

NOVOLOG FLEXPEN 2

VIAL (ML)

NOVOLOG MIX 70-30 2

CARTRIDGE WITH INHALER

AFREZZA 3

VIAL (ML)

APIDRA 3

INSULIN PEN (ML)

APIDRA SOLOSTAR 3


VIAL (ML)

LANTUS 2



B4G Participant: N

DIABETES


INSULIN PEN (ML)

LANTUS SOLOSTAR 2

VIAL (ML)

LEVEMIR 2

INSULIN PEN (ML)

TOUJEO SOLOSTAR 2

INSULIN PEN (ML)

TRESIBA FLEXTOUCH U-200 2

INSULIN PEN (ML)

BASAGLAR KWIKPEN U-100 3

INCRETINS

PEN INJECTOR (ML)

TRULICITY 2

PEN INJECTOR (ML)

VICTOZA SP 2

VIAL (EA)

BYDUREON SP 3

PEN INJECTOR (EA)

BYDUREON PEN SP 3

PEN INJECTOR (ML)

BYETTA SP 3

PEN INJECTOR (EA)

TANZEUM 3

DPP-4

TABLET

GLYXAMBI 2

TABLET

JANUMET 2

TABLET,EXTENDED RELEASE MULTIPHASE 24 HR

JANUMET XR 2

TABLET

JANUVIA 2

TABLET

JENTADUETO 2

TABLET

TRADJENTA 2

TABLET

ALOGLIPTIN 3

TABLET

ALOGLIPTIN-METFORMIN 3

TABLET

KAZANO 3


KOMBIGLYZE XR 3

TABLET

NESINA 3

TABLET

ONGLYZA 3

TABLET

OSENI 3

SULFONYLUREAS

TABLET

glimepiride 1


glipizide er 1

TABLET

glipizide-metformin 1

TABLET

glyburide 1

TABLET

glyburide micronized 1

TABLET

glyburide-metformin hcl 1

TZD

TABLET

pioglitazone hcl 1

TABLET

pioglitazone-glimepiride 1

TABLET

pioglitazone-metformin 1

OTHER

TABLET

acarbose 1

TABLET

metformin hcl 1


metformin hcl er 1

TABLET

nateglinide 1

TABLET

repaglinide 1

VIAL (EA)

GLUCAGEN 2

KIT

GLUCAGON EMERGENCY KIT 2

PEN INJECTOR (ML)

SYMLINPEN 120 2

TABLET

CYCLOSET 3

TABLET, ER GASTRIC RETENTION 24 HR

GLUMETZA SP 3

TABLET

GLYSET 3

SOLUTION, ORAL

RIOMET 3

SGLT-2

TABLET

FARXIGA 2

TABLET

JARDIANCE 2

TABLET

SYNJARDY 2

TABLET,IMMED AND EXTEND REL BIPHASE 24HR

XIGDUO XR 2

TABLET

INVOKAMET 3

TABLET

INVOKANA 3

TESTING

EACH

ACCU-CHEK 2



B4G Participant: N

DIABETES

TESTING

NEEDLE, DISPOSABLE

BD INSULIN PEN NEEDLE UF MINI 2

SYRINGE, EMPTY DISPOSABLE

B-D INSULIN SYRINGE 2

NEEDLE, DISPOSABLE

B-D NEEDLES 2

EACH

DEXCOM G4 2

EACH

DEXCOM G5 2

STRIP

FREESTYLE INSULINX 2

STRIP

FREESTYLE INSULINX TEST STRIPS 2

STRIP

FREESTYLE LITE STRIPS 2

STRIP

FREESTYLE TEST STRIPS 2

SYRINGE, EMPTY DISPOSABLE

INSULIN- SYRINGE 2

STRIP

ONE TOUCH ULTRA TEST STRIPS 2

STRIP

ONE TOUCH VERIO 2

STRIP

PRECISION XTRA 2

EACH

ACCU-CHEK AVIVA CONNECT 3

STRIP

ACCU-CHEK AVIVA PLUS 3

STRIP

ACCU-CHEK COMPACT 3

EACH

ACCU-CHEK NANO SMARTVIEW 3

STRIP

ACCU-CHEK SMARTVIEW 3

STRIP

ACCUTREND GLUCOSE 3

EACH

ADVOCATE BLOOD GLUCOSE MONITOR 3

STRIP

ASCENSIA BREEZE 2 3

STRIP

CONTOUR 3

STRIP

CONTOUR NEXT EZ 3

STRIP

EMBRACE 3

STRIP

OPTIUM 3

STRIP

OPTIUM EZ 3

STRIP

PRECISION PCX PLUS 3

STRIP

PRECISION Q-I-D 3

KIT

PRODIGY 3

STRIP

TRUETEST TEST STRIPS 3

KIT

TRUETRACK SMART SYSTEM 3

STRIP

UNISTRIP1 3

VACCINES

VIAL (ML)

BOOSTRIX 2

SYRINGE (ML)

CERVARIX 2

SYRINGE (ML)

ENGERIX-B 2

VIAL (ML)

GARDASIL 2

VIAL (ML)

HAVRIX 2

SYRINGE (ML)

INFANRIX 2

VIAL (ML)

PNEUMOVAX 23 2

SYRINGE (ML)

PREVNAR 13 2

VIAL (ML)

RECOMBIVAX HB 2

SOLUTION, ORAL

ROTATEQ 2

VIAL (ML)

TWINRIX 2

VIAL (EA)

ZOSTAVAX 2

VITAMINS/ELECTROLYTES

CAPSULE

calcium acetate 1

TABLET

dialyvite 1

TABLET

elite-ob 1

TABLET, CHEWABLE

fluoride 1

TABLET

folic acid 1

PACKET (EA)

klor-con 1

COMBINATION PACKAGE, TABLET AND DR CAP

obstetrix dha 1

LIQUID (ML)

potassium chloride 1


potassium chloride 1



B4G Participant: N

VITAMINS/ELECTROLYTES

TABLET

prenatabs rx 1

TABLET

prenatal plus 1


NASCOBAL 2


DUET DHA 3


K-TAB 3

TABLET

OB COMPLETE 3

SOLUTION, ORAL

PHOSLYRA 3

MISCELLANEOUS


bupropion sr 1


calcitonin-salmon 1

CAPSULE

cevimeline hcl 1

TABLET

disulfiram 1

TABLET

etidronate disodium 1

TABLET

midodrine hcl 1

TABLET

riluzole 1

TABLET, DISPERSIBLE

CARBAGLU SP 2

TABLET

CHANTIX 2

AUTO-INJECTOR (EA)

EPINEPHRINE 2

AUTO-INJECTOR (EA)

EPINEPHRINE 2

AUTO-INJECTOR (EA)

EPIPEN 2

AUTO-INJECTOR (EA)

EPIPEN JR. 2

TABLET, DISPERSIBLE

EXJADE SP 2

TABLET, CHEWABLE

FOSRENOL 2

AUTO-INJECTOR (EA)

ADRENACLICK 3

AUTO-INJECTOR (EA)

AUVI-Q 3

KIT

EPISNAP 3

GEL IN PACKET (ML)

GELCLAIR 3

TABLET

RENAGEL 3


RENVELA 3


SALIVAMAX 3

TABLET, CHEWABLE

VELPHORO 3

CNS

ANTIDEPRESSANTS

TABLET

amitriptyline hcl 1

TABLET

amitriptyline/chlordiazepoxide 1

TABLET

amitriptyline-perphenazine 1

TABLET

amoxapine 1

TABLET

bupropion hcl 1


bupropion hcl xl 1

SOLUTION, ORAL

citalopram hbr 1

TABLET

citalopram hbr 1

CAPSULE

clomipramine hcl 1

TABLET

desipramine hcl 1

CAPSULE

doxepin hcl 1

CONCENTRATE, ORAL

doxepin hcl 1


duloxetine hcl 1

SOLUTION, ORAL

escitalopram oxalate 1

TABLET

escitalopram oxalate 1

SOLUTION, ORAL

fluoxetine hcl 1

CAPSULE

fluoxetine hcl 1

TABLET

fluvoxamine maleate 1

TABLET

imipramine hcl 1

CAPSULE

imipramine pamoate 1

TABLET

maprotiline hcl 1

TABLET

mirtazapine 1

TABLET

nefazodone hcl 1



B4G Participant: N

CNS

ANTIDEPRESSANTS

CAPSULE

nortriptyline hcl 1

SOLUTION, ORAL

nortriptyline hcl 1


paroxetine er 1

TABLET

paroxetine hcl 1

TABLET

phenelzine sulfate 1

TABLET

protriptyline hcl 1

TABLET

sertraline hcl 1

TABLET

tranylcypromine sulfate 1

TABLET

trazodone hcl 1

TABLET

venlafaxine hcl 1


venlafaxine hcl er 1

CAPSULE

BRISDELLE 2

CAPSULE,EXTENDED RELEASE 24 HR DOSE PACK

FETZIMA 2

TABLET

VIIBRYD 2


APLENZIN SP 3


DESVENLAFAXINE ER 3


EMSAM 3


FORFIVO XL 3


KHEDEZLA 3

TABLET

MARPLAN 3

TABLET

PEXEVA 3


PRISTIQ 3

TABLET

SARAFEM 3

MISCELLANEOUS

TABLET

armodafinil 1


lithium carbonate 1

CAPSULE

lithium carbonate 1

SOLUTION, ORAL

lithium citrate 1

TABLET

modafinil 1

TABLET

BELVIQ 2

CAPSULE

NUEDEXTA 2


QSYMIA 2

PEN INJECTOR (ML)

SAXENDA 2

TABLET

XENAZINE SP 3

ANTICONVULSANTS


carbamazepine 1

TABLET

carbamazepine 1


carbamazepine er 1


carbamazepine er 1


clonazepam 1

TABLET

clonazepam 1

KIT

diazepam 1

TABLET, ENTERIC COATED

divalproex sodium 1


divalproex sodium er 1

TABLET

epitol 1

CAPSULE

ethosuximide 1

CAPSULE

ethosuximide 1

SOLUTION, ORAL

ethosuximide 1

TABLET

felbamate 1


felbamate 1

VIAL (ML)

fosphenytoin sodium 1

CAPSULE

gabapentin 1

TABLET

gabapentin 1

TABLET

lamotrigine 1

TABLET

levetiracetam 1

SOLUTION, ORAL

levetiracetam 1

TABLET

oxcarbazepine 1



B4G Participant: N

CNS

ANTICONVULSANTS


oxcarbazepine 1

ELIXIR

phenobarbital 1

TABLET

phenobarbital 1


phenytoin 1

CAPSULE

phenytoin sodium 1

TABLET

primidone 1

TABLET

tiagabine hcl 1

TABLET

topiramate 1

CAPSULE

valproic acid 1

SOLUTION, ORAL

valproic acid 1

CAPSULE

zonisamide 1

TABLET

BANZEL SP 2

TABLET

FYCOMPA 2

TABLET

GABITRIL 2

TABLET, EXTENDED RELEASE, DOSE PACK

LAMICTAL XR 2

CAPSULE

LYRICA 2


ONFI SP 2


OXTELLAR XR 2

TABLET

PEGANONE 2

TABLET

POTIGA 2

TABLET

SABRIL SP 2


TROKENDI XR 2

TABLET

VIMPAT 2

SOLUTION, ORAL

VIMPAT 2


DEPAKOTE ER 3


EQUETRO 3


HORIZANT 3


LAMICTAL ODT 3

ADHD

TABLET

dexmethylphenidate hcl 1

CAPSULE,EXTENDED RELEASE BIPHASIC 50-50

dexmethylphenidate hcl er 1

SOLUTION, ORAL

dextroamphetamine sulfate 1

TABLET

dextroamphetamine sulfate 1


dextroamphetamine-amphet er 1

TABLET

dextroamphetamine-amphetamine 1

TABLET

guanidine hcl 1


methylphenidate er 1

TABLET

methylphenidate hcl 1

SOLUTION, ORAL

methylphenidate hcl 1


methylphenidate hcl cd 1


DAYTRANA 2

TABLET,CHEW,IR AND ER BIPHASIC REL 24HR

QUILLICHEW ER 2

SUSPENSION,EXTENDED RELEASE,RECONST.24HR

QUILLIVANT XR 2

CAPSULE

VYVANSE 2


ADDERALL XR 3

TABLET,DISINTEGRATING,ER BIPHASIC 24 HR

ADZENYS XR-ODT 3


FOCALIN XR 3


INTUNIV 3

CAPSULE

STRATTERA 3

ANTI-PSYCHOTIC

TABLET

aripiprazole 1

TABLET

chlorpromazine hcl 1

TABLET

clozapine 1


clozapine odt 1

TABLET

fluphenazine hcl 1

CONCENTRATE, ORAL

fluphenazine hcl 1



B4G Participant: N

CNS

ANTI-PSYCHOTIC

TABLET

haloperidol 1

VIAL (ML)

haloperidol decanoate 1

CONCENTRATE, ORAL

haloperidol lactate 1

CAPSULE

loxapine succinate 1

TABLET

olanzapine 1


olanzapine odt 1

CAPSULE

olanzapine-fluoxetine hcl 1

TABLET

perphenazine 1

TABLET

quetiapine fumarate 1


quetiapine fumarate er 1

TABLET

risperidone 1


risperidone odt 1

TABLET

thioridazine hcl 1

CAPSULE

thiothixene 1

TABLET

trifluoperazine hcl 1

CAPSULE

ziprasidone hcl 1

SUSPENSION,EXTENDED RELEASE SYRINGE (EA)

ABILIFY MAINTENA SP 2

TABLET

LATUDA 2

SYRINGE (EA)

RISPERDAL CONSTA SP 2

TABLET, SUBLINGUAL

SAPHRIS 2

TABLET

ABILIFY 3

TABLET

FANAPT 3


FAZACLO 3


INVEGA SP 3

TABLET

ORAP 3

TABLET

REXULTI 3


SEROQUEL XR 3


VERSACLOZ 3

ANXIOLYTICS

TABLET

alprazolam 1


alprazolam er 1

CONCENTRATE, ORAL

alprazolam intensol 1


alprazolam odt 1


alprazolam xr 1

TABLET

buspirone hcl 1

CAPSULE

chlordiazepoxide hcl 1

TABLET

clorazepate dipotassium 1

CONCENTRATE, ORAL

diazepam 1

TABLET

diazepam 1

TABLET

lorazepam 1

CONCENTRATE, ORAL

lorazepam intensol 1

SYRUP

midazolam hcl 1

CAPSULE

oxazepam 1

ALZHEIMER'S

CAPSULE, EXTENDED RELEASE PELLETS 24 HR

galantamine er 1

CAPSULE

rivastigmine 1

CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR

NAMENDA XR 2


EXELON 3

SOLUTION, ORAL

NAMENDA 3

ANTIPARKINSONISM

TABLET

benztropine mesylate 1

TABLET

bromocriptine mesylate 1

TABLET

carbidopa/levodopa 1


carbidopa-levodopa er 1

TABLET

carbidopa-levodopa-entacapone 1

TABLET

entacapone 1

TABLET

ropinirole hcl 1



B4G Participant: N

CNS

ANTIPARKINSONISM

TABLET

selegiline hcl 1

ELIXIR

trihexyphenidyl hcl 1

TABLET

trihexyphenidyl hcl 1


NEUPRO 2


ZELAPAR 2

TABLET

AZILECT 3


MIRAPEX ER 3

TABLET

STALEVO 3

TABLET

TASMAR 3

MS


AMPYRA SP 2

TABLET

AUBAGIO SP 2

CAPSULE

GILENYA SP 2


TECFIDERA SP 2

SYRINGE (ML)

COPAXONE SP 3

SLEEP

TABLET

estazolam 1

TABLET

eszopiclone 1

CAPSULE

flurazepam hcl 1

TABLET

quazepam 1

CAPSULE

temazepam 1

CAPSULE

zaleplon 1

TABLET, EXTENDED RELEASE MULTIPHASE

zolpidem tartrate er 1

TABLET

BELSOMRA 2

TABLET

ROZEREM 2

TABLET

BUTISOL SODIUM 3

TABLET, SUBLINGUAL

INTERMEZZO 3


ZOLPIMIST 3

ENDOCRINE

CONTRACEPTIVES

TABLET

altavera 1

TABLET

alyacen 1

TABLET, DOSE PACK, 3 MONTHS

amethia 1

TABLET

amethyst 1

TABLET

apri 1

TABLET

aranelle 1

TABLET

aubra 1

TABLET

aviane 1

TABLET

azurette 1

TABLET

balziva 1

TABLET

briellyn 1


camrese 1

TABLET

caziant 1

TABLET

chateal 1

TABLET

cryselle 1

TABLET

cyclafem 1

TABLET

dasetta 1


daysee 1

TABLET

elinest 1

TABLET

emoquette 1

TABLET

enpresse 1

TABLET

enskyce 1

TABLET

estarylla 1

TABLET

falmina 1

TABLET

gianvi 1

TABLET

gildagia 1


introvale 1


jolessa 1



B4G Participant: N

ENDOCRINE

CONTRACEPTIVES

TABLET

junel 1

TABLET

kariva 1

TABLET

kelnor 1-35 1

TABLET

kurvelo 1

TABLET

larin fe 1

TABLET

leena 1

TABLET

lessina 1

TABLET

levonest 1

TABLET

levora 1

TABLET

lomedia 24 fe 1

TABLET

loryna 1

TABLET

low-ogestrel 1

TABLET

lutera 1

TABLET

marlissa 1

TABLET

microgestin 1

TABLET

mono-linyah 1

TABLET

mononessa 1

TABLET

myzilra 1

TABLET

necon 1

TABLET

nortrel 1

TABLET

ocella 1

TABLET

ogestrel 1

TABLET

orsythia 1

TABLET

philith 1

TABLET

pimtrea 1

TABLET

pirmella 1

TABLET

portia 1

TABLET

previfem 1


quasense 1

TABLET

reclipsen 1

TABLET

sprintec 1

TABLET

sronyx 1

TABLET

syeda 1

TABLET

tilia fe 1

TABLET

tri-estarylla 1

TABLET

tri-linyah 1

TABLET

trinessa 1

TABLET

tri-previfem 1

TABLET

tri-sprintec 1

TABLET

trivora 1

TABLET

velivet 1

TABLET

vestura 1

TABLET

viorele 1

TABLET

wera 1

TABLET, CHEWABLE

wymzya fe 1

TABLET

zarah 1

TABLET

zenchent 1

TABLET

zovia 1

TABLET

LO LOESTRIN FE 2

TABLET

NATAZIA 2

RING, VAGINAL

NUVARING 2

TABLET

SAFYRAL 2

INTRAUTERINE DEVICE

SKYLA SP 2

TABLET

BEYAZ 3

TABLET, CHEWABLE

GENERESS FE 3



B4G Participant: N

ENDOCRINE

CONTRACEPTIVES

TABLET

ORTHO TRI-CYCLEN LO 3


QUARTETTE 3

ESTROGENS


estradiol 1

TABLET

estradiol-norethindrone acetat 1

TABLET

estrogen & methyltestosterone 1

TABLET

jinteli 1


COMBIPATCH 2

GEL IN PACKET (EA)

DIVIGEL 2

TABLET

DUAVEE 2

CREAM WITH APPLICATOR

ESTRACE 2


MINIVELLE 2


PREMARIN 2

TABLET

PREMARIN 2

TABLET

PREMPHASE 2

TABLET

PREMPRO 2


ALORA 3

TABLET

ANGELIQ 3


CLIMARA PRO 3

RING, VAGINAL

ESTRING 3

GEL IN METERED-DOSE PUMP

ESTROGEL 3

TABLET

FEMHRT 3

TABLET

PREFEST 3

TABLET

VAGIFEM 3

PROGESTINS

TABLET

camila 1

TABLET

errin 1

TABLET

heather 1

TABLET

jencycla 1

TABLET

jolivette 1

TABLET

lyza 1

TABLET

nora-be 1

TABLET

norethindrone acetate 1

CAPSULE

progesterone 1

GEL WITH PREFILLED APPLICATOR (GRAM)

CRINONE SP 2

INSERT

ENDOMETRIN SP 2

OVULATORY STIMULANTS

TABLET

clomiphene citrate SP 1

VIAL (ML)

FOLLISTIM AQ SP 2

CARTRIDGE (ML)

FOLLISTIM AQ SP 2

VIAL (EA)

GONAL-F SP 2

VIAL (EA)

MENOPUR SP 2

VIAL (EA)

BRAVELLE SP 3

GONADOTROPIN

KIT

CETROTIDE SP 2

VIAL (EA)

NOVAREL SP 2

SYRINGE (ML)

GANIRELIX ACETATE SP 3

VIAL (EA)

PREGNYL SP 3

TESTOSTERONE

TABLET

androxy 1

CAPSULE

danazol 1

TABLET

oxandrolone 1

VIAL (ML)

testosterone cypionate 1


ANDROGEL 2


ANDROGEL 2

SOLUTION IN METERED-DOSE PUMP WITH APPL.

AXIRON 2


ANDRODERM 3

CAPSULE

ANDROID 3



B4G Participant: N

ENDOCRINE

TESTOSTERONE

VIAL (ML)

DEPO-TESTOSTERONE 3


FORTESTA 3


NATESTO 3

MUCOADHESIVE SYSTEM,EXTEND.RELEASE 12 HR

STRIANT 3

GEL (GRAM)

TESTIM 3

PELLET (EA)

TESTOPEL SP 3


TESTOSTERONE 3

GEL (GRAM)

TESTOSTERONE 3


TESTOSTERONE 3

CAPSULE

TESTRED 3

GEL (GRAM)

VOGELXO 3


VOGELXO 3


VOGELXO 3

ADRENAL HORMONES

TABLET

dexamethasone 1

TABLET

fludrocortisone acetate 1

TABLET

hydrocortisone 1

TABLET, DOSE PACK

methylprednisolone 1

VIAL (ML)

methylprednisolone acetate 1

SOLUTION, ORAL

prednisolone 1

TABLET

prednisone 1

VIAL (EA)

SOLU-CORTEF 2

VIAL (ML)

ACTHAR H.P. 3


ORAPRED ODT 3


RAYOS 3

THYROID

TABLET

levothyroxine sodium 1

TABLET

levoxyl 1

TABLET

liothyronine sodium 1

TABLET

methimazole 1

TABLET

nature-throid 1

TABLET

unithroid 1

TABLET

ARMOUR THYROID 2

SOLUTION, ORAL

SSKI 3

TABLET

THYROLAR 3

CAPSULE

TIROSINT 3

MISCELLANEOUS

TABLET

cabergoline 1

CAPSULE

calcitriol 1


desmopressin acetate 1

TABLET

desmopressin acetate 1

TABLET

ADDYI 3

GASTROINTESTINAL

H2 ANTAGONISTS

SOLUTION, ORAL

cimetidine 1

TABLET

cimetidine 1


famotidine 1

TABLET

famotidine 1

TABLET

misoprostol 1

CAPSULE

nizatidine 1

SYRUP

ranitidine hcl 1

TABLET

ranitidine hcl 1



lansoprazole 1


omeprazole 1

CAPSULE

omeprazole-sodium bicarbonate 1


pantoprazole sodium 1


rabeprazole sodium 1



B4G Participant: N

GASTROINTESTINAL


CAPSULE, DELAYED RELEASE, BIPHASIC

DEXILANT 3

SUSP FOR RECON,DELAYED REL. IN A PACKET

NEXIUM RX 3


NEXIUM RX 3

PACKET (EA)

ZEGERID RX 3

OTHER ULCER THERAPY


lansoprazol-amoxicil-clarithro 1

TABLET

sucralfate 1


CARAFATE 2

CAPSULE

PYLERA 2

ANTIEMETIC

CAPSULE

dronabinol SP 1

TABLET

granisetron hcl SP 1

TABLET

meclizine hcl 1

SOLUTION, ORAL

ondansetron hcl 1

TABLET

ondansetron hcl 1


ondansetron odt 1

SUPPOSITORY, RECTAL

prochlorperazine maleate 1

TABLET

prochlorperazine maleate 1

CAPSULE

trimethobenzamide hcl 1


SANCUSO SP 2

TABLET

ANZEMET SP 3

CAPSULE

EMEND SP 3

PATCH,TRANSDERMAL 3 DAY

TRANSDERM-SCOP 3

FILM, MEDICATED (EA)

ZUPLENZ 3

ANTIDIARRHEALS


anaspaz 1

CAPSULE

dicyclomine hcl 1

CAPSULE

dicyclomine hcl 1

TABLET

diphenoxylate w/atropine 1

LIQUID (ML)

diphenoxylate w/atropine 1

TABLET

glycopyrrolate 1

DROPS

hyoscyamine sulfate 1

CAPSULE

loperamide hcl 1

TABLET

methscopolamine bromide 1

SOLUTION, ORAL

CUVPOSA 3

TABLET

HOMAPIN 10 3

DIGESTIVE ENZYMES


CREON SP 2

SOLUTION, ORAL

SUCRAID SP 2

TABLET

VIOKACE SP 2


ZENPEP SP 2


PANCREAZE SP 3


PERTZYE SP 3

BOWEL EVACUANTS

SOLUTION, RECONSTITUTED, ORAL

SUPREP 2


COLYTE 3


MOVIPREP 3

TABLET

OSMOPREP 3

RECTAL

SUPPOSITORY, RECTAL

anucort-hc 1

ENEMA (ML)

colocort 1

ENEMA (ML)

mesalamine 1

SUPPOSITORY, RECTAL

CANASA 2

AEROSOL, FOAM WITH APPLICATOR (GRAM)

CORTIFOAM 2

OTHER

CAPSULE

balsalazide disodium 1

CAPSULE, DELAYED, AND EXTENDED RELEASE

budesonide ec 1

CAPSULE

clidinium w/chlordiazepoxide 1

SOLUTION, ORAL

constulose 1



B4G Participant: N

GASTROINTESTINAL

OTHER

SOLUTION, ORAL

lactulose 1

TABLET

metoclopramide hcl 1

SOLUTION, ORAL

metoclopramide hcl 1

TABLET

sulfasalazine 1


sulfasalazine dr 1

CAPSULE

ursodiol 1

CAPSULE

AMITIZA 2


APRISO 2


ASACOL HD SP 2

LIQUID (ML)

BELLADONNA 2

TABLET

CHENODAL SP 2

CAPSULE (WITH DELAYED RELEASE TABLETS)

DELZICOL 2

VIAL (EA)

KINEVAC 2

CAPSULE

LINZESS 2

TABLET

MOVANTIK 2


PENTASA 2

SYRINGE (ML)

RELISTOR SP 2

CAPSULE

DIPENTUM 3

CAPSULE

ENTEREG 3

TABLET

GIAZO 3

PACKET (EA)

KRISTALOSE 3


LIALDA SP 3

TABLET

LOTRONEX 3

MUSCULOSKELETAL

OSTEOPOROSIS

SOLUTION, ORAL

alendronate sodium 1

TABLET

alendronate sodium 1

TABLET

ibandronate sodium 1

PEN INJECTOR (ML)

FORTEO SP 2

TABLET

ACTONEL 3


ATELVIA 3

TABLET, EFFERVESCENT

BINOSTO 3

TABLET

FOSAMAX PLUS D 3

SYRINGE (ML)

PROLIA SP 3

MUSCLE RELAXANTS

TABLET

baclofen 1

TABLET

carisoprodol 1

TABLET

carisoprodol compound 1

TABLET

carisoprodol compound/codeine 1

TABLET

carisoprodol-aspirin 1

TABLET

chlorzoxazone 1

TABLET

cyclobenzaprine hcl 1

CAPSULE

dantrolene sodium 1

TABLET

meprobamate 1

TABLET

metaxalone 1

TABLET

methocarbamol 1


orphenadrine citrate 1

TABLET

tizanidine hcl 1


AMRIX 3

TABLET

LORZONE 3

GOUT THERAPY

TABLET

allopurinol 1

CAPSULE

COLCHICINE 1

TABLET

probenecid 1

TABLET

probenecid w/colchicine 1

TABLET

COLCRYS 2



B4G Participant: N

MUSCULOSKELETAL

GOUT THERAPY

CAPSULE

MITIGARE 2

TABLET

ULORIC 2

ANTI-INFLAMMATORY

PEN INJECTOR (ML)

COSENTYX 150MG SP 2

* PA: Coverage based on indication. See details in Major Drug Class Overview chart.

SYRINGE (ML)

COSENTYX 300MG SP 2


PEN INJECTOR (ML)

ENBREL SP 2


VIAL (EA)

ENTYVIO SP 2


PEN INJECTOR KIT (EA)

HUMIRA SP 2


SYRINGE (ML)

ORENCIA SP 2


AUTO-INJECTOR (ML)

ORENCIA CLICKJECT SP 2


AUTO-INJECTOR (ML)

OTREXUP SP 2

AUTO-INJECTOR (ML)

RASUVO SP 2

TABLET

SAVELLA 2


SYRINGE (ML)

SILIQ SP

2


SYRINGE (ML)

ACTEMRA SP 3


KIT

CIMZIA SP 3


SYRINGE KIT (EA)

CIMZIA SP 3


SYRINGE (ML)

KINERET SP 3


TABLET

OTEZLA SP 3


VIAL (EA)

REMICADE SP 3


TABLET

SAVELLA 3


PEN INJECTOR (ML)

SIMPONI SP 3


SYRINGE (ML)

STELARA SP 3


AUTO-INJECTOR (ML)

TALTZ AUTOINJECTOR SP 3


SYRINGE (ML)

TALTZ SYRINGE SP 3


TABLET

XELJANZ SP 3



XELJANZ XR SP 3


RESPIRATORY

AMPUL FOR NEBULIZATION (ML)

ipratropium-albuterol 1

GRANULES IN PACKET (EA)

montelukast sodium 1

TABLET

montelukast sodium 1

TABLET

sildenafil citrate SP 1

TABLET

zafirlukast 1

TABLET

ADCIRCA SP 2

TABLET

ADEMPAS 2

BLISTER, WITH INHALATION DEVICE

ADVAIR DISKUS 2



B4G Participant: N

RESPIRATORY

HFA AEROSOL WITH ADAPTER (GRAM)

ADVAIR HFA 2


ANORO ELLIPTA 2


ATROVENT HFA 2


BREO ELLIPTA 2

MIST INHALER (GRAM)

COMBIVENT RESPIMAT 2

TABLET

DALIRESP 2

TABLET

KALYDECO SP 2

TABLET

LETAIRIS SP 2

SOLUTION, NON-ORAL

PULMOZYME SP 2

CAPSULE, WITH INHALATION DEVICE

SPIRIVA 2

MIST INHALER (GRAM)

SPIRIVA RESPIMAT 2

MIST INHALER (GRAM)

STIOLTO RESPIMAT 2


SYMBICORT 2

TABLET

TRACLEER SP 2

AEROSOL POWDER, BREATH ACTIVATED (EA)

TUDORZA PRESSAIR 2

VIAL (EA)

XOLAIR SP 2


DULERA 3


INCRUSE ELLIPTA 3

TABLET

ZYFLO SP 3

INHALED STEROIDS

AMPUL FOR NEBULIZATION (ML)

budesonide 1


ARNUITY ELLIPTA 2


FLOVENT DISKUS 2

AEROSOL WITH ADAPTER (GRAM)

FLOVENT HFA 2


PULMICORT FLEXHALER 2

AEROSOL WITH ADAPTER (GRAM)

QVAR 2


ALVESCO 3


ASMANEX 3

NASAL STEROIDS

AEROSOL, SPRAY (ML)

flunisolide 1

SPRAY, SUSPENSION


AEROSOL, SPRAY WITH PUMP (GRAM)

DYMISTA 2

AEROSOL, SPRAY (GRAM)

BECONASE AQ 3


NASONEX 3


OMNARIS 3


QNASL 3


ZETONNA 3

BETA AGONISTS

SOLUTION, NON-ORAL

albuterol sulfate 1

TABLET

albuterol sulfate 1

SYRUP

albuterol sulfate 1

VIAL, NEBULIZER (ML)

levalbuterol hcl 1

SYRUP

metaproterenol sulfate 1

TABLET

metaproterenol sulfate 1

TABLET

terbutaline sulfate 1

VIAL, NEBULIZER (ML)

PERFOROMIST 2


PROAIR HFA 2


SEREVENT DISKUS 2

MIST INHALER (GRAM)

STRIVERDI RESPIMAT 2


VENTOLIN HFA 2


ARCAPTA NEOHALER 3


FORADIL 3


PROVENTIL HFA 3


XOPENEX HFA 3

ANTIHISTAMINES

TABLET

arbinoxa 1

TABLET

carbinoxamine 1

LIQUID (ML)

carbinoxamine 1



B4G Participant: N

RESPIRATORY

ANTIHISTAMINES

TABLET

clemastine fumarate 1

TABLET

cyproheptadine hcl 1

TABLET

desloratadine 1

ELIXIR

diphenhydramine hcl 1

SOLUTION, ORAL

hydroxyzine hcl 1

TABLET

hydroxyzine hcl 1

CAPSULE

hydroxyzine pamoate 1

CAPSULE

hydroxyzine pamoate 1

TABLET

levocetirizine dihydrochloride 1

TABLET

promethazine hcl 1

TABLET

r-tanna 1

SYRUP

CYPROHEPTADINE HCL 3

CAPSULE

SEMPREX-D 3

ANTITUSSIVE

CAPSULE

benzonatate 1

LIQUID (ML)

guaifenesin with codeine 1

TABLET

hydrocodone/homatropine 1

SUSPENSION, EXTENDED RELEASE 12 HR

hydrocodone-chlorpheniramine 1

SYRUP

promethazine vc w/codeine 1

SYRUP

promethazine w/dm 1

CAPSULE, EXTENDED RELEASE 12 HR

TUSSICAPS 2

SYRUP

BROMFED-DM 3


ZODRYL AC 35 3

OTHER


azelastine hcl 1

AEROSOL, SPRAY (ML)

ipratropium bromide 1


theophylline anhydrous 1

SOLUTION, ORAL

theophylline anhydrous 1

SPACER (EA)

AEROCHAMBER 2

SPACER (EA)

AEROCHAMBER PLUS 2


PATANASE 3

ANTI-INFECTIVES

PENICILLINS

TABLET

amoxicillin 1


amoxicillin 1


amoxicillin-clavulanate pot er 1

TABLET

amoxicillin-clavulanate potass 1


amoxicillin-clavulanate potass 1

CAPSULE

ampicillin trihydrate 1


ampicillin trihydrate 1

CAPSULE

dicloxacillin sodium 1

TABLET

penicillin v potassium 1


penicillin v potassium 1

HIV

TABLET

abacavir SP 1

TABLET

abacavir-lamivudine-zidovudine SP 1


didanosine SP 1

TABLET

lamivudine-zidovudine SP 1


nevirapine SP 1

TABLET

nevirapine SP 1

CAPSULE

stavudine SP 1


stavudine SP 1

TABLET

zidovudine 1

CAPSULE

zidovudine 1

SYRUP

zidovudine 1

SOLUTION, ORAL

APTIVUS SP 2

CAPSULE

APTIVUS SP 2

TABLET

ATRIPLA SP 2



B4G Participant: N

ANTI-INFECTIVES

HIV

TABLET

COMPLERA SP 2

CAPSULE

CRIXIVAN SP 2

TABLET

DESCOVY SP 2

TABLET

EDURANT SP 2

CAPSULE

EMTRIVA SP 2

SOLUTION, ORAL

EMTRIVA SP 2

TABLET

GENVOYA SP 2

TABLET

INTELENCE SP 2

TABLET

INVIRASE SP 2

TABLET

ISENTRESS SP 2

TABLET

KALETRA SP 2

TABLET

LEXIVA SP 2


LEXIVA SP 2

SOLUTION, ORAL

NORVIR SP 2

TABLET

NORVIR SP 2

TABLET

ODEFSEY 2

TABLET

PREZISTA SP 2


PREZISTA SP 2

TABLET

RESCRIPTOR SP 2

CAPSULE

REYATAZ SP 2

TABLET

SELZENTRY SP 2

TABLET

STRIBILD SP 2

CAPSULE

SUSTIVA SP 2

TABLET

TIVICAY SP 2

TABLET

TRUVADA SP 2


VIDEX SP 2

TABLET

VIRACEPT SP 2

TABLET

VIREAD SP 2

SOLUTION, ORAL

ZIAGEN 2

SOLUTION, ORAL

EPIVIR SP 3

TABLET

EPZICOM SP 3

SOLUTION, ORAL

KALETRA 3

ANTIVIRALS


acyclovir 1

CAPSULE

acyclovir 1

TABLET

acyclovir 1

CAPSULE

amantadine hcl 1

SOLUTION, ORAL

amantadine hcl 1

TABLET

famciclovir 1

TABLET

lamivudine SP 1

TABLET

moderiba SP 1

TABLET, DOSE PACK

ribapak SP 1

CAPSULE

ribasphere SP 1

TABLET

ribavirin SP 1

CAPSULE

ribavirin SP 1

TABLET

rimantadine hcl 1

TABLET

valacyclovir 1

SOLUTION, ORAL

EPIVIR HBV SP 2


TAMIFLU 2

TABLET

BARACLUDE SP 3

SOLUTION, ORAL

REBETOL SP 3

MUCO-ADHESIVE BUCCAL TABLET

SITAVIG SP 3

CAPSULE

TAMIFLU 3

TABLET

VALCYTE SP 3


VALCYTE SP 3

VAGINAL



B4G Participant: N

ANTI-INFECTIVES

VAGINAL



GEL WITH APPLICATOR (GRAM)

metronidazole 1

SUPPOSITORY, VAGINAL

miconazole 3 1


terconazole 1

SUPPOSITORY, VAGINAL

terconazole 1


AVC 3

CREAM WITH PREFILLED APPLICATOR

GYNAZOLE-1 3

MISCELLANEOUS

CAPSULE

clindamycin hcl 1


clindamycin palmitate hcl 1

TABLET

dapsone 1

TABLET

linezolid SP 1

TABLET

methenamine hippurate 1

TABLET

methenamine mandelate 1

CAPSULE

nitrofurantoin 1

CAPSULE

nitrofurantoin macrocrystal 1

TABLET

sulfadiazine 1

TABLET

sulfamethoxazole/trimethoprim 1


sulfamethoxazole/trimethoprim 1

TABLET

trimethoprim 1

CAPSULE

vancomycin hcl 1

CAPSULE

TOBI PODHALER SP 2

TABLET

XIFAXAN SP 2

PACKET (EA)

MONUROL 3

SOLUTION, ORAL

PRIMSOL 3

TABLET

SIVEXTRO SP 3

TABLET

ZYVOX SP 3

HEPATITIS C

TABLET

MAVYRET 2

TABLET

ZEPATIER SP 2

TABLET

DAKLINZA SP 4

TABLET

EPCLUSA SP 4

TABLET

HARVONI SP 4

CAPSULE

OLYSIO SP 4

TABLET

SOVALDI SP 4

TABLET

TECHNIVIE SP 4

TABLET, DOSE PACK

VIEKIRA PAK SP 4

CEPHALOSPORINS


cefaclor 1

CAPSULE

cefaclor 1

CAPSULE

cefadroxil 1


cefadroxil 1

CAPSULE

cefdinir 1


cefdinir 1


cefprozil 1

TABLET

cefprozil 1


ceftibuten 1

CAPSULE

ceftibuten 1

TABLET

cephalexin 1


cephalexin 1


CEFTIN 3


SUPRAX 3

ERYTHROMYCINS/MACROLIDS


azithromycin 1


clarithromycin 1

TABLET

clarithromycin 1


clarithromycin er 1



B4G Participant: N

ANTI-INFECTIVES

ERYTHROMYCINS/MACROLIDS


ery-tab 1

TABLET

erythromycin 1

TABLET

erythromycin ethylsuccinate 1

TABLET

DIFICID SP 3

TABLET, PARTICLES/CRYSTALS IN

PCE 3

TETRACYCLINES

TABLET

demeclocycline hcl 1

TABLET

doxycycline hyclate 1

CAPSULE

doxycycline monohydrate 1

CAPSULE

minocycline hcl 1

CAPSULE

morgidox 1

CAPSULE

tetracycline hcl 1

CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE

ORACEA 2


SOLODYN 2


DORYX 3

CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE

DOXYCYCLINE IR-DR 3

SYRUP

VIBRAMYCIN 3

QUINOLONES


ciprofloxacin er 1

TABLET

ciprofloxacin hcl 1

SOLUTION, ORAL


TABLET


ANTIFUNGAL

TROCHE

clotrimazole 1


fluconazole 1

TABLET

fluconazole 1

CAPSULE

flucytosine 1

TABLET

griseofulvin 1


griseofulvin 1

TABLET

griseofulvin ultramicrosize 1

CAPSULE

itraconazole 1

TABLET

ketoconazole 1

TABLET

nystatin 1


nystatin 1

TABLET

terbinafine 1


voriconazole 1

TABLET

voriconazole 1


NOXAFIL SP 2

SOLUTION, ORAL

SPORANOX 2

TABLET

ONMEL SP 3

ANTIMALARIALS

TABLET

atovaquone-proguanil hcl 1

TABLET

chloroquine phosphate 1

TABLET

hydroxychloroquine sulfate 1

TABLET

mefloquine hcl 1

CAPSULE

quinine sulfate 1

TABLET

COARTEM 2

TABLET

DARAPRIM 2

TABLET

PRIMAQUINE 2

ANTIMYCOBACTERIALS

TABLET

ethambutol hcl 1

TABLET

isoniazid 1

TABLET

pyrazinamide 1

CAPSULE

rifampin 1

TABLET

SIRTURO 2

CAPSULE

CYCLOSERINE 3

GRANULES DELAYED RELEASE FOR SUSP PACKET

PASER 3

TABLET

RIFATER 3



B4G Participant: N

ANTI-INFECTIVES

ANTIMYCOBACTERIALS

TABLET

TRECATOR 3

ANTIPARASITICS

TABLET

metronidazole 1

CAPSULE

paromomycin sulfate 1

TABLET

tinidazole 1

TABLET

ALBENZA SP 2

TABLET

ALINIA 2


ALINIA 2

TABLET

BILTRICIDE 2


FLAGYL ER 3


MEPRON 3

TABLET

STROMECTOL 3

Quick Reference Preferred Drug List



B4G Participant: N

Documents

2018 National Formulary - Southern Scripts, LLC Rx National Formulary... · 2018 National Formulary Effective 01/01/2018 The Formulary List is a guide providing tier designation for