3-Tier Formulary Guide

A nonprofit independent licensee of the Blue Cross Blue Shield Association

3-TIER FORMULARY GUIDEIncludes generic and brand-name medications

ExcellusBCBS.comB-1354 Y18 / 12291-18FLRX

January 2019

Dear Member,

The prescription drug benefit is one of the most important and frequently

utilized elements of health plan coverage. To help you identify which

medications are covered under your plan, we are pleased to provide the

3-Tier Formulary Guide. This booklet provides you with easy to understand

information about your prescription drug coverage including descriptions of

prescription drug safety and cost-saving programs.

The 3-Tier Formulary Guide lists commonly prescribed medications and their

tier classifications. The medications listed have been approved by the Food

and Drug Administration (FDA) as safe and effective and were selected in

consultation with a team of health care professionals because they meet our

criteria for safety, quality and value. We continually review and update

our formulary.

The drugs listed in the formulary and program descriptions may not apply to all plans.

This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.

The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.

If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.

How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.

How do I use the Formulary?There are two ways to find your drug within the formulary:

Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.

Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.

3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.

• Tier One drugs are typically generics and have the lowest copayment amount.

• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.

• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.

The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.

Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.

Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.

Generics Are Real MedicineGeneric drugs: safe, effective, affordable!

To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.

In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.

Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.

Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.

Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com

Mail Service PharmacyGet your prescriptions delivered right to your door!

When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer

opay savings for ordering prescriptions cthrough Express Scripts Home Delivery PharmacySM

or Wegmans® Home Delivery Pharmacy.

Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com

Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.

If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.

Coverage requirements or limits may include:

Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based

on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.

Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work, we will then cover Drug B.

Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.

Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com

Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.

Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.

Key:

UPPERCASE – Brand name medicationlowercase – generic medication

PA = Prior Authorization required

QL = Quantity Limit applies

ST = Step Therapy required

S = Specialty Drugs

MS = Drug must be purchased at a participating network specialty pharmacy for coverage

LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ANAPROX 3

ANAPROX DS 3

ARTHROTEC 50 3 QL

ARTHROTEC 75 3 QL

butalbital/aspirin/caffeine 50-325-40 capsule 1 QL

butalbital/aspirin/caffeine 50-325-40 tablet 1

CAMBIA 3

QL

ST

CELEBREX (50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE, 400MG CAPSULE)

3 QL

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL

choline salicylate/magnesium salicylate 1

DAYPRO 3 QL

diclofenac potassium 1

diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)

1

diclofenac sodium/misoprostol 1 QL

DICLOPR 3

QL

PA

diflunisal 1

DISALCID 3

DITHOL 3

QL

PA

DUEXIS 3

QL

PA

EC-NAPROSYN 3

etodolac 1

FELDENE 3

FENOPROFEN CALCIUM (200 MG CAPSULE, 400 MG CAPSULE) 3 PA

PAGE 5 LAST UPDATED 01/2019


fenoprofen calcium 600 mg tablet 1 PA

FENORTHO 3 PA

FIORINAL 3 QL

FLECTOR 3

QL

PA

flurbiprofen 1

IBU 1

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1

INDOCIN (25 MG/5 ML SUSPENSION, 50 MG SUPPOSITORY) 3

indomethacin 1

ketoprofen 1

ketorolac tromethamine 10 mg tablet 1 QL

LODINE 3

MECLOFENAMATE SODIUM 3

mefenamic acid 1

meloxicam (7.5 mg tablet, 15 mg tablet) 1

MELOXICAM 7.5 MG/5 ML ORAL SUSP 3

MOBIC (7.5 MG TABLET, 7.5 MG/5 ML SUSPENSION, 15 MG TABLET) 3

nabumetone (500 mg tablet, 750 mg tablet) 1 QL

NALFON 3 PA

NAPRELAN 3

NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500MG TABLET)

3

naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500mg tablet dr)

1

NAPROXEN 125 MG/5 ML ORAL SUSP 3

naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550mg tablet)

1

NUDROXIPAK 3

QL

PA

oxaprozin 600 mg tablet 1 QL

PENNSAID 2% PUMP 3

QL

PA



piroxicam 1

PONSTEL 3

PROFENO 1 PA

salsalate 1

SPRIX 3

QL

PA

S

sulindac 1

TIVORBEX 3

QL

PA

tolmetin sodium 1

VIMOVO 3

QL

PA

VIVLODEX 3 PA

VOLTAREN-XR 3

ZIPSOR 3

QL

PA

ZORVOLEX 3

QL

PA

OPIOID ANALGESICS, LONG-ACTING

ARYMO ER 3 PA

AVINZA 3 PA

BELBUCA 3 PA

BUPRENORPHINE PATCH 3 PA

BUTRANS 3 PA

CONZIP 3 PA

DOLOPHINE HCL 3

DURAGESIC 3 PA

EMBEDA 3 PA

EXALGO 3 PA



fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)

1 PA

FENTANYL (37.5MCG/HR PATCH TD72, 62.5MCG/HR PATCH TD72,87.5MCG/HR PATCH TD72)

1 PA

hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32mg tab er 24h)

1 PA

HYSINGLA ER 3 PA

KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE,ER 50 MG CAPSULE, ER 60 MG CAPSULE, ER 80 MG CAPSULE, ER 100MG CAPSULE)

3 PA

KADIAN (ER 40 MG CAPSULE, ER 200 MG CAPSULE) 3

PA

ST

levorphanol tartrate 1 PA

methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mg tablet sol)

1 PA

METHADONE INTENSOL 1 PA

METHADOSE 10 MG/ML ORAL CONC 3 PA

METHADOSE 40 MG TABLET DISPR 1 PA

MORPHABOND ER 3 PA

morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg cpmp 24hr, 30 mg tablet er, 40 mg cap er pel, 45 mg cpmp24hr, 50 mg cap er pel, 60 mg cap er pel, 60 mg cpmp 24hr, 60 mg tablet er, 75mg cpmp 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 100 mg cap er pel, 100 mgtablet er, 120 mg cpmp 24hr, 200 mg tablet er)

1 PA

MS CONTIN 3 PA

NUCYNTA ER 2 PA

OXYCODONE HCL ER 3 PA

OXYCONTIN 3 PA

oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mgtab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h)

1 PA

TRAMADOL ER CAPS 3 PA

tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200mg tbmp 24hr, 300 mg tab er 24h, 300 mg tbmp 24hr)

1 PA

ULTRAM ER 3 PA

XTAMPZA ER 2 PA

ZOHYDRO ER 3 PA

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 3

QL

PA



acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)

1

acetaminophen/caff/dihydrocod 320.5-30mg capsule 1

ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 TABLET 3

ACTIQ 3

QL

PA

ASCOMP WITH CODEINE 1

aspirin/caffeine/dihydrocodeine bitartrate 1

butalbital/acetaminophen/caffeine/codeine phosphate 1 QL

butorphanol tartrate 10 mg/ml spray 1 QL

CAPITAL W-CODEINE 3

carisoprodol/aspirin/codeine 200-325-16 tablet 1

codeine phosphate/butalbital/aspirin/caffeine 1

codeine sulfate 1

DEMEROL (50 MG TABLET, 100 MG TABLET) 3

DILAUDID (2 MG TABLET, 4 MG TABLET, 5 MG/5 ML ORAL LIQUID, 8 MGTABLET)

3

ENDOCET 1

fentanyl citrate 1

QL

PA

FENTORA 3

QL

PA

FIORICET WITH CODEINE 3 QL

FIORINAL WITH CODEINE #3 3

HYCET 3



hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-163/7.5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)

1

hydrocodone/ibuprofen 1

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)

1

IBUDONE 3

ibuprofen/oxycodone hcl 1

LAZANDA 3

QL

PA

LORCET 1

LORCET HD 1

LORCET PLUS 1

LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET) 1

LORTAB 10 MG-300 MG/15 ML ELXR 3

meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1

MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2

morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)

1

NALOCET 3

NORCO 3

NUCYNTA 2

OPANA (5 MG TABLET, 10 MG TABLET) 3

opium/belladonna alkaloids 1

OXAYDO 3

OXECTA 3

OXYCODONE 10MG/0.5ML ORAL SYRINGE 3

oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)

1



oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)

1

oxycodone hcl/aspirin 1

oxymorphone hcl (5 mg tablet, 10 mg tablet) 1

PANLOR 3 QL

pentazocine hcl/naloxone hcl 1

PERCOCET 3

PRIMLEV 3

REPREXAIN 1

ROXICODONE 3

ROXYBOND 3

SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)

3

QL

PA

SYNALGOS-DC 3

tramadol hcl 50 mg tablet 1

tramadol hcl/acetaminophen 1

TREZIX 3

TYLENOL-CODEINE NO.3 3


ULTRACET 3

ULTRAM 3

VERDROCET 1

VICODIN 1

VICODIN ES 1

VICODIN HP 1

XARTEMIS XR 3 PA

XODOL 10-300 3

XODOL 5-300 3

XODOL 7.5-300 3

XYLON 10 1

ZAMICET 3



ANESTHETICS

LOCAL ANESTHETICS

ANACAINE 3

ANASTIA 3

ANODYNE LPT 3

QL

PA

BUCALSEP 3

DERMACINRX EMPRICAINE 3 PA

DERMACINRX PRIZOPAK 1

QL

PA

DOLOTRANZ 3

QL

PA

EMLA 3

GLYDO 1

LIDO-K 1

LIDO-PRILO CAINE PACK 3

QL

PA

lidocaine (5 % adh. patch, 5 % oint. (g)) 1

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)

1

lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5kit)

1

LIDODERM 3

LIDOPAC 3

QL

PA

LIDOPIN 3% CREAM 1

LIDOPIN 3.25% CREAM 3

LIDOPRIL 3

QL

PA

LIDOPRIL XR 3

QL

PA

LIDOTRANS 5 PAK 3

QL

PA



LIPROZONEPAK 3 PA

MEDOLOR PAK 3 PA

NEURCAINE 3

QL

PA

NUMBONEX 3

PAINGO KFT 3

QL

PA

PRILOLID 3 PA

RELADOR PAK 3

QL

PA

SOLUPAK 3

QL

PA

ZTLIDO 3 QL

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 1 QL

ANTABUSE 3

disulfiram 1

naltrexone hcl 1

REVIA 3

OPIOID DEPENDENCE TREATMENTS

BUNAVAIL 3

buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1

buprenorphine hcl/naloxone hcl 1

LUCEMYRA 3 QL

SUBOXONE 2

ZUBSOLV 2

OPIOID REVERSAL AGENTS

naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1 mg/ml syringe) 1

NARCAN 4 MG NASAL SPRAY 2



SMOKING CESSATION AGENTS

BUPROBAN 1

bupropion hcl 150 mg tab er 12h 1

CHANTIX 3 QL

NICOTROL 3 QL

NICOTROL NS 3 QL

ZYBAN 3

ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 3

QL

PA

S

GENTAK 1

gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))

1

neomycin sulfate 1

paromomycin sulfate 1

tobramycin 1

TOBREX (DROP, OINTMENT) 3

ANTIBACTERIALS, OTHER

AKTIPAK 3

QL

ST

ALTABAX 3

bacitracin 500 unit/g oint. (g) 1

BACTROBAN (CREAM, OINTMENT) 3

BACTROBAN NASAL 3

BENZAMYCIN 3

CENTANY 3

CENTANY AT 3

QL

PA

CLEOCIN (2% CREAM, 100 MG OVULE) 3

CLEOCIN HCL 3

CLEOCIN PALMITATE 3



CLEOCIN T (T GEL, T LOTION, T PLEDGETS, T SOLUTION) 3 ST

CLINDACIN ETZ 1% PLEDGET 1

CLINDACIN ETZ KIT 3

QL

PA

CLINDACIN P 1

CLINDACIN PAC 3

QL

PA

CLINDAGEL 3 ST

clindamycin hcl 1

clindamycin palmitate hcl 75 mg/5 ml soln recon 1

clindamycin phosphate (1 % foam, 1 % gel (gram), 1 % lotion, 1 % med. swab,1 % solution, 2 % cream/appl)

1

clindamycin phosphate 1 % gel daily 3 ST

CLINDESSE 3

erythromycin base/benzoyl peroxide 1

EVOCLIN 3 ST

FIRVANQ 2

FLAGYL 3

FLAGYL ER 3

FURADANTIN 3

HIPREX 3

HYOPHEN 1

linezolid 100 mg/5ml susp recon 1

linezolid 600 mg tablet 1 QL

MACROBID 3

MACRODANTIN 3

methenamine hippurate 1

methenamine mandelate 1

methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1

METROGEL-VAGINAL 3

metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)

1

MONUROL 3



mupirocin 1

mupirocin calcium 1

nitrofurantoin 1

nitrofurantoin macrocrystal 1

nitrofurantoin monohydrate/macrocrystals 1

NUVESSA 3 QL

PHOSPHASAL 1

PRIMSOL 3

SIVEXTRO 200 MG TABLET 3 PA

SOLOSEC 3

SULFAMYLON (8.5% CREAM, POWDER PACKET) 3

TINDAMAX 3

tinidazole 1

trimethoprim 1

TRIMPEX 3

UR N-C 1

URAMIT MB 1

URELLE 3

URETRON D-S 1

URIBEL 3

URIMAR-T 1

URIN D.S. 1

URO-458 1

URO-MP 1

UROGESIC-BLUE 1

URYL 1

UTIRA-C 1

VANCOCIN HCL 3

vancomycin hcl (125 mg capsule, 250 mg capsule) 1

VANDAZOLE 1

ZYVOX 100 MG/5 ML SUSPENSION 3

ZYVOX 600 MG TABLET 3 QL



BETA-LACTAM, CEPHALOSPORINS

CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3

cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)

1

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5mlsusp recon)

1

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1

cefditoren pivoxil 1

cefixime 1

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)

1

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500mg tablet)

1

CEFTIBUTEN 3

CEFTIN (250 MG TABLET, 500 MG TABLET) 3

cefuroxime axetil 1

cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule)

1

DAXBIA 3

KEFLEX 3

SPECTRACEF 3

SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 ML SUSPENSION, 200MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 400 MG CAPSULE,500 MG/5 ML SUSPENSION)

3

BETA-LACTAM, PENICILLINS

amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susprecon, 500 mg capsule, 500 mg tablet, 875 mg tablet)

1

AMOXICILLIN ER 775 MG 3



amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)

1

ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susprecon, 500 mg capsule)

1

AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET)

3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

dicloxacillin sodium 1

MOXATAG 3 PA

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)

1

MACROLIDES

AZASITE 3

azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)

1

BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3

clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)

1

DIFICID 3 ST

E.E.S. 200 3

E.E.S. 400 3

ERY 1

ERY-TAB 1

ERYGEL 3

ERYPED 200 3

ERYPED 400 3

ERYTHROCIN STEARATE 1

erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)

1

erythromycin base in ethanol (in 2 % gel (gram), in 2 % med. swab, in 2 %solution)

1

erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet) 1

ILOTYCIN 3

PCE 3



ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MGTABLET)

3

ZITHROMAX TRI-PAK 3

ZMAX 3

QUINOLONES

AVELOX 3

AVELOX ABC PACK 3

BAXDELA 450 MG TABLET 3 QL

BESIVANCE 3

CETRAXAL 3 QL

CILOXAN (EYE DROPS, OINTMENT) 3

CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG TABLET, 500 MGTABLET)

3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)

1

ciprofloxacin hcl 0.2 % droperette 1 QL

ciprofloxacin/ciprofloxacin hcl 1

FACTIVE 3

FLOXIN 3

gatifloxacin 1

LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET, 500 MG TABLET, 750MG TABLET)

3

levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)

1

MOXEZA 2

moxifloxacin hcl (0.5 % drops, 400 mg tablet) 1

OCUFLOX 3

ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1

OTIPRIO 3

VIGAMOX 3

ZYMAXID 3

SULFONAMIDES

AVC 3

BACTRIM 3



BACTRIM DS 3

BLEPH-10 3

KLARON 3

SILVADENE 3

silver sulfadiazine 1

SSD 1

sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1

sulfadiazine 1

sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oralsusp, sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)

1

SULFATRIM 1

THERMAZENE 1

TETRACYCLINES

ACTICLATE 3 PA

ADOXA 3

AVIDOXY 1

demeclocycline hcl 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet, 50 mg tablet dr,75 mg tablet dr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tabletdr, 200 mg tablet dr)

1

doxycycline hyclate (75 mg tablet, 150 mg tablet) 1

QL

PA

doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mgtablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mgcapsule, 150 mg tablet)

1

DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3

QL

ST

MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3

minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 90 mg tab er 24h, 115mgtab er 24h, 135 mg tab er 24h)

1

QL

PA

minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100mg capsule, 100 mg tablet)

1

MINOLIRA ER 3

QL

PA



MONDOXYNE NL 1

MONODOX 3

MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3

QL

PA

MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

ORACEA 3

QL

ST

SOLODYN 3

QL

PA

TARGADOX 3

tetracycline hcl 1

VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3

XIMINO 3

QL

PA

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET, 100 MG TABLET)

3

QL

PA

EPIDIOLEX 3

QL

PA

S

MS

KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET)

3

KEPPRA XR (500 MG TABLET, 750 MG TABLET) 3 QL

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)

1

levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL

POTIGA 3

ROWEEPRA 1

ROWEEPRA XR 500 MG TABLET 1

ROWEEPRA XR 750 MG TABLET 1 QL



SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)

3

QL

PA

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 3

ethosuximide (250 mg capsule, 250 mg/5ml solution) 1

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3

ZONEGRAN 3

zonisamide 1

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam (10 mg tablet, 20 mg tablet) 1 QL

clobazam 2.5 mg/ml oral susp 1

DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLE 3

DIASTAT 3 QL

DIASTAT ACUDIAL 3 QL

diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1

divalproex sodium 1

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)

1

GABITRIL 3

GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

GRALISE 30-DAY STARTER PACK 3 PA

MYSOLINE 3

NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE,400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET)

3

ONFI (10 MG TABLET, 20 MG TABLET) 3 QL

ONFI 2.5 MG/ML SUSPENSION 3



phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)

1

primidone 1

SABRIL 3

QL

PA

S

MS

tiagabine hcl 1

valproic acid 1

valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution,500mg/10ml solution)

1

vigabatrin 1

QL

PA

S

MS

GLUTAMATE REDUCING AGENTS

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1

FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)

3 QL

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

3

LAMICTAL (BLUE) 3

LAMICTAL (GREEN) 3

LAMICTAL (ORANGE) 3

LAMICTAL ODT 3 QL

LAMICTAL XR 3

lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)

1 QL

lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)

1

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)

3

QL

PA

TOPAMAX 3

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)

1

TOPIRAMATE ER CAPS 3

QL

PA



TROKENDI XR 3

QL

PA

SODIUM CHANNEL AGENTS

APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)

3

QL

PA

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)

1

CARBATROL 3

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2

DILANTIN-125 2

EPITOL 1

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mgtablet)

1

OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3

QL

PA

PEGANONE 3

PHENYTEK 2

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1

phenytoin sodium extended 1

TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3

TEGRETOL XR 3

TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600MG TABLET)

3

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

2

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 1

CHOLINESTERASE INHIBITORS

ARICEPT 3

donepezil hcl 1

EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 13.3 MG/24HRPATCH)

3



galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

1

NAMZARIC 3

QL

PA

RAZADYNE 3

RAZADYNE ER 3

rivastigmine 1

rivastigmine tartrate 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)

1

memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)

1 QL

NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK,10 MG TABLET)

3

NAMENDA XR 3

QL

ST

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

amitriptyline hcl/chlordiazepoxide 1

APLENZIN 3

QL

ST

bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL

bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)

1

bupropion hcl 450 mg tab er 24h 3

QL

ST

FORFIVO XL 3

QL

ST

mirtazapine 1

olanzapine/fluoxetine hcl 1

perphenazine/amitriptyline hcl 1

REMERON 3

SYMBYAX 3

WELLBUTRIN 3

WELLBUTRIN SR 3



WELLBUTRIN XL (150 MG TABLET, 300 MG TABLET) 3 QL

MONOAMINE OXIDASE INHIBITORS

EMSAM 3

QL

ST

MARPLAN 3

NARDIL 3

PARNATE 3

phenelzine sulfate 1

tranylcypromine sulfate 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)

BRISDELLE 3

QL

PA

CELEXA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL

citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL

citalopram hydrobromide 10 mg/5 ml solution 1

DESVENLAFAXINE ER 3

QL

ST

DESVENLAFAXINE FUMARATE 3

QL

ST

desvenlafaxine succinate 1 QL

EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE, 150 MG CAPSULE) 3 QL

escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mgtablet)

1

FETZIMA 3 QL

fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)

1

fluoxetine hcl 90 mg capsule dr 1 QL

fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

KHEDEZLA 3

QL

ST

LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10 MG TABLET, 20 MGTABLET)

3



maprotiline hcl 1

nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1

nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL

OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3

QL

ST

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1

paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL

paroxetine mesylate 1

QL

PA

PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET)

3

PAXIL CR 3 QL

PEXEVA 3

QL

ST

PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET, ER 100 MG TABLET) 3 QL

PROZAC (10 MG, 40 MG) 3 QL

PROZAC 20 MG PULVULE 3

PROZAC WEEKLY 3 QL

SARAFEM 3

sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1

trazodone hcl 1

TRINTELLIX 3 QL

VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)

3

QL

ST

venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)

1

venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL

VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)

3 QL

VIIBRYD 10-20 MG STARTER PACK 3

ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET)

3

ZOLOFT 20 MG/ML ORAL SOLN 3



TRICYCLICS

amitriptyline hcl 1

amoxapine 1

ANAFRANIL 3

clomipramine hcl 1

desipramine hcl 1

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

1

imipramine hcl 1

imipramine pamoate 1

NORPRAMIN 3

nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1

nortriptyline hcl (10 mg/5 ml solution, 20 mg/10ml solution) 3

QL

PA

PAMELOR 3

protriptyline hcl 1

SURMONTIL 3

TOFRANIL 3

TOFRANIL-PM 3

trimipramine maleate 1

ANTIEMETICS

ANTIEMETICS, OTHER

BONJESTA 3

QL

PA

COMPAZINE (5 MG TABLET, 10 MG TABLET) 3

COMPAZINE 25 MG SUPPOSITORY 1

COMPRO 1

DICLEGIS 3

QL

PA

meclizine hcl (12.5 mg tablet, 25 mg tablet) 1

metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1 QL

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)

1

METOZOLV ODT 3 QL



perphenazine 1

PHENADOZ 1

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1

prochlorperazine 1

prochlorperazine maleate 1

promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)

1

PROMETHEGAN 1

REGLAN 3

scopolamine 1

TIGAN 300 MG CAPSULE 3

TRANSDERM-SCOP 3

trimethobenzamide hcl 1

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG CAPSULE 3 QL

ANZEMET (50 MG TABLET, 100 MG TABLET) 3

QL

ST

aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)

1 QL

CESAMET 3

dronabinol 1

EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE, 125 MGPOWDER PACKET, TRIPACK)

3 QL

granisetron hcl 1 mg tablet 1 QL

MARINOL 3

ondansetron 1

ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1

SANCUSO 3

QL

ST

SUSTOL 3

SYNDROS 3 PA

VARUBI 90 MG TABLET 3

ZOFRAN (4 MG TABLET, 4 MG/5 ML ORAL SOLN, 8 MG TABLET) 3

ZOFRAN ODT 3



ZUPLENZ 3

QL

ST

ANTIFUNGALS

ANCOBON 3

CICLODAN 0.77% CREAM 1

CICLODAN 8% SOLUTION 1 QL

ciclopirox (0.77 % gel (gram), 1 % shampoo) 1

ciclopirox 8 % solution 1 QL

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1

clotrimazole (1 % cream (g), 10 mg troche) 1

CRESEMBA 186 MG CAPSULE 3

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

3

econazole nitrate 1

ECOZA 3

QL

ST

ERTACZO 3 ST

EXELDERM (CREAM, SOLUTION) 3

EXTINA 3 ST

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mgtablet, 150 mg tablet, 200 mg tablet)

1

flucytosine 1

GRIFULVIN V 3

GRIS-PEG 3

griseofulvin ultramicrosize 1

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1

GYNAZOLE 1 3

itraconazole (10 mg/ml solution, 100 mg capsule) 1

JUBLIA 3

QL

PA

KERYDIN 3 PA

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1

KETODAN (FOAM, FOAM KIT) 1



LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3

QL

PA

LAMISIL 250 MG TABLET 3

LOPROX (0.77% CREAM, 0.77% TOPICAL SUSP, 1% SHAMPOO) 3

LOPROX (CREAM KIT, SUSPENSION KIT) 3

QL

PA

luliconazole 3 QL

LUZU 3

QL

ST

MENTAX 3 ST

miconazole nitrate 200 mg supp.vag 1

naftifine hcl 1 % cream (g) 1

naftifine hcl 2 % cream (g) 1 QL

NAFTIN (1% GEL, 2% GEL) 3 ST

NAFTIN 2% CREAM 3 QL

NATACYN 3

NIZORAL 3

NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3

NYAMYC 1

NYATA 3

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500k unit tablet,500mm unit powder(ea), 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)

1

nystatin/triamcinolone acetonide 1

NYSTOP 1

ONMEL 3

QL

PA

ORAVIG 3 PA

oxiconazole nitrate 1

OXISTAT 1% CREAM 3

OXISTAT 1% LOTION 3 ST

PENLAC 3 QL



SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3

TERAZOL 3 3

TERAZOL 7 3

terbinafine hcl 250 mg tablet 1

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1

VFEND (40 MG/ML SUSPENSION, 50 MG TABLET) 3

VFEND 200 MG TABLET 3 QL

voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1

voriconazole 200 mg tablet 1 QL

VUSION 3

XOLEGEL 3 ST

ANTIGOUT AGENTS

allopurinol 1

COLCHICINE 3 QL

COLCRYS 2 QL

DUZALLO 3

QL

PA

MITIGARE 3 QL

probenecid 1

probenecid/colchicine 1

ULORIC 2

QL

ST

ZURAMPIC 3

QL

PA

ZYLOPRIM 3

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG AUTOINJECTOR 2

QL

PA

AIMOVIG AUTOINJECTOR (2 PACK) 2

QL

PA



AJOVY 2

QL

PA

EMGALITY 2

QL

PA

ERGOT ALKALOIDS

CAFERGOT 3

D.H.E.45 3

dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1

DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL

ERGOMAR 3

ergotamine tartrate/caffeine 1

MIGERGOT 3

MIGRANAL 3 QL

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate 1 QL

AMERGE 3 QL

AXERT 3 QL

eletriptan hydrobromide 1 QL

FROVA 3 QL

frovatriptan succinate 1 QL

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 5 MGNASAL SPRAY, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6MG/0.5 ML VIAL, 20 MG NASAL SPRAY, 25 MG TABLET, 50 MG TABLET,100 MG TABLET)

3 QL

MAXALT 3 QL

MAXALT MLT 3 QL

naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL

ONZETRA XSAIL 3

QL

ST

RELPAX 3 QL

rizatriptan benzoate 1 QL

sumatriptan (5 mg spray, 20 mg spray) 1 QL



sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)

1 QL

sumatriptan succinate/naproxen sodium 1 QL

SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3

QL

ST

TREXIMET 3 QL

ZEMBRACE SYMTOUCH 3

QL

ST

zolmitriptan 1 QL

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3

QL

ST

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL

ZOMIG ZMT 3 QL

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 3

MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG TIMESPAN) 3

pyridostigmine bromide 1

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 1

MYCOBUTIN 3

rifabutin 1

ANTITUBERCULARS

cycloserine 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1

MYAMBUTOL 3

PASER 3

PRIFTIN 3

pyrazinamide 1

RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3



RIFAMATE 3

rifampin (150 mg capsule, 300 mg capsule) 1

RIFATER 3

SIRTURO 3

TRECATOR 3

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLET 3

CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50 MG CAPSULE) 1

GLEOSTINE 3

HEXALEN 3

LEUKERAN 2

lomustine 1

MATULANE 2 S

melphalan 1

MYLERAN 2

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MGCAPSULE, 180 MG CAPSULE, 250 MG CAPSULE)

3

S

MS

temozolomide 1

S

MS

VALCHLOR 3

QL

PA

S

MS

ANTIANDROGENS

bicalutamide 1

CASODEX 3

ERLEADA 3

QL

PA

S

MS

flutamide 1



NILANDRON 3

nilutamide 1

XTANDI 2

QL

PA

S

MS

YONSA 3

QL

PA

S

MS

ZYTIGA (250 MG TABLET, 500 MG TABLET) 2

QL

PA

S

MS

ANTIANGIOGENIC AGENTS

POMALYST 3

QL

PA

S

MS

REVLIMID 2

QL

PA

S

MS

THALOMID 3

QL

S

MS

ANTIESTROGENS/MODIFIERS

EMCYT 3

FARESTON 2

SOLTAMOX 3

QL

PA

tamoxifen citrate 1



ANTIMETABOLITES

capecitabine 1

S

MS

DROXIA 3

EFUDEX 3

fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1

HYDREA 3

hydroxyurea 1

mercaptopurine 1

PURIXAN 3

QL

PA

S

SIKLOS 100 MG TABLET 3

TABLOID 2

XELODA 3

S

MS

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)

3

QL

PA

S

MS

COPIKTRA 15 MG CAPSULE 3

QL

PA

S

COPIKTRA 25 MG CAPSULE 3

QL

PA

HEMANGEOL 3 S

IDHIFA 3

QL

PA

S

MS

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1



LONSURF 3

PA

S

MS

LYSODREN 2

NINLARO 3

PA

S

MS

RUBRACA (200 MG TABLET, 250 MG TABLET, 300 MG TABLET) 3

QL

PA

S

RYDAPT 3

QL

PA

S

MS

SYLATRON 3

PA

S

MS

TIBSOVO 3

QL

PA

VIZIMPRO 3

QL

PA

S

MS

ZOLINZA 3

QL

PA

S

MS

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1

ARIMIDEX 3

AROMASIN 3

exemestane 1

FEMARA 3



letrozole 1

ENZYME INHIBITORS

etoposide 50 mg capsule 1

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2

QL

PA

S

MS

MOLECULAR TARGET INHIBITORS

AFINITOR 2

QL

PA

S

MS

ALECENSA 3

PA

S

MS

BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3

QL

PA

S

MS

BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

S

CABOMETYX 3

QL

PA

S

MS

CALQUENCE 3

QL

PA

S

CAPRELSA (100 MG TABLET, 300 MG TABLET) 2

QL

PA

S



COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2

QL

PA

S

COTELLIC 3

PA

S

MS

ERIVEDGE 3

QL

PA

S

MS

FARYDAK 3

QL

PA

S

MS

GILOTRIF 3

QL

PA

S

MS

GLEEVEC (100 MG TABLET, 400 MG TABLET) 3

QL

ST

S

MS

IBRANCE 2

QL

PA

S

MS

ICLUSIG (15 MG TABLET, 45 MG TABLET) 3

QL

PA

S

imatinib mesylate (100 mg tablet, 400 mg tablet) 1

QL

S

MS



IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)

3

QL

PA

S

INLYTA (1 MG TABLET, 5 MG TABLET) 3

QL

PA

S

MS

IRESSA 3

QL

PA

S

MS

JAKAFI 2

QL

PA

S

MS

KISQALI 3

QL

PA

S

MS

KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3

QL

PA

S

MS

LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)

3

QL

PA

S

MS

LYNPARZA (100 MG TABLET, 150 MG TABLET) 3

QL

PA

S

MS

LYNPARZA 50 MG CAPSULE 3

PA

S

MS



MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3

QL

PA

S

MS

MEKTOVI 3

QL

PA

S

MS

NERLYNX 3

QL

PA

S

MS

NEXAVAR 2

QL

PA

S

MS

ODOMZO 3

PA

S

MS

SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)

2

QL

PA

S

MS

STIVARGA 2

QL

PA

S

MS

SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)

2

QL

PA

S

MS



TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

S

MS

TAGRISSO 3

PA

S

MS

TALZENNA (0.25 MG CAPSULE, 1 MG CAPSULE) 3

QL

PA

S

MS

TARCEVA 3

QL

PA

S

MS

TASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) 3

QL

PA

S

MS

TYKERB 2

QL

PA

S

MS

VENCLEXTA 3

QL

PA

S

VERZENIO 2

QL

PA

MS

VOTRIENT 2

QL

PA

S

MS



XALKORI 3

QL

PA

S

MS

ZEJULA 3

QL

PA

ZELBORAF 2

QL

PA

S

MS

ZYDELIG 3

QL

PA

S

MS

ZYKADIA 3

QL

PA

S

MS

RETINOIDS

bexarotene 1

QL

PA

S

MS

PANRETIN 3

TARGRETIN 1% GEL 3

PA

S

MS

TARGRETIN 75 MG CAPSULE 3

QL

PA

S

MS

tretinoin 10 mg capsule 1



TREATMENT ADJUNCTS

MESNEX 400 MG TABLET 3

ANTIPARASITICS

ANTIHELMINTHICS

albendazole 1

ALBENZA 3

benznidazole (12.5 mg tablet, 100 mg tablet) 3 QL

BILTRICIDE 3

EMVERM 3

QL

PA

ivermectin 1

praziquantel 1

SKLICE 3 QL

STROMECTOL 3

ANTIPROTOZOALS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3

atovaquone 1

atovaquone/proguanil hcl 1

chloroquine phosphate 1

COARTEM 3

DARAPRIM 3 S

hydroxychloroquine sulfate 1

IMPAVIDO 3

QL

PA

MALARONE 3

mefloquine hcl 1

MEPRON 3

NEBUPENT 3

PLAQUENIL 3

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3 PA

quinine sulfate 1 PA



PEDICULICIDES/SCABICIDES

CROTAN 1 QL

ELIMITE 3

EURAX 3 QL

lindane 1 QL

malathion 1

OVIDE 3

permethrin 5 % cream (g) 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1

ANTIPARKINSON AGENTS, OTHER

amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1

carbidopa/levodopa/entacapone 1

COMTAN 3

entacapone 1

GOCOVRI 3

QL

PA

OSMOLEX ER 3

QL

PA

STALEVO 3

TASMAR 3

tolcapone 1

DOPAMINE AGONISTS

APOKYN 3

S

MS

bromocriptine mesylate 1

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

QL

PA



PARLODEL 3

pramipexole di-hcl 1

REQUIP 3

REQUIP XL 3 QL

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet)

1

ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er24h, 12 mg tab er 24h)

1 QL

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 1

carbidopa/levodopa 1

LODOSYN 3

RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)

3

QL

PA

SINEMET 10-100 3

SINEMET 25-100 3

SINEMET 25-250 3

SINEMET CR 3

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT 3 QL

ELDEPRYL 3

rasagiline mesylate 1 QL

selegiline hcl 1

XADAGO (50 MG TABLET, 100 MG TABLET) 3

QL

ST

ZELAPAR 3

QL

PA

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE 3

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet,200 mg tablet)

1

fluphenazine decanoate 1



fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5mg/ml oral conc, 10 mg tablet)

1

haloperidol 1

haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1

loxapine succinate 1

molindone hcl 1

ORAP 3

pimozide 1

thioridazine hcl 1

thiothixene 1

trifluoperazine hcl 1

2ND GENERATION/ATYPICAL

ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20MG TABLET, 30 MG TABLET)

3 QL

ABILIFY DISCMELT 3 QL

aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mg tablet)

1 QL

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)

3

QL

ST

FANAPT TITRATION PACK 3 ST

GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE)

3

INVEGA 3 QL

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)

3

QL

ST

NUPLAZID (10 MG TABLET, 17 MG TABLET, 34 MG CAPSULE) 3

QL

PA

S

MS

olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet, 7.5 mg tablet, 10 mgtab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tab rapdis, 20mg tablet)

1

paliperidone 1 QL

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)

1



quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)

1 QL

REXULTI 3

QL

ST

RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 1 MG/MLSOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)

3

RISPERDAL M-TAB 3

risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mgtablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mgtablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)

1

SAPHRIS 3

QL

ST

SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET, 300 MG TABLET)

3

SEROQUEL 400 MG TABLET 3 QL

SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MGTABLET, 400 MG TABLET)

3 QL

VRAYLAR 3

QL

ST

ziprasidone hcl 1

ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MGTABLET, 15 MG TABLET, 20 MG TABLET)

3

ZYPREXA ZYDIS 3

TREATMENT-RESISTANT

clozapine 1

CLOZARIL 3

FAZACLO 3

VERSACLOZ 3

ANTISPASTICITY AGENTS

baclofen (10 mg tablet, 20 mg tablet) 1

baclofen 5 mg tablet 1

DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3

dantrolene sodium 1

tizanidine hcl 1

ZANAFLEX 3



ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS (240 MG TABLET, 480 MG TABLET) 3

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3

valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1

ZIRGAN 3

ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 1

BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL

entecavir 1 QL

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3

HEPSERA 3

lamivudine 100 mg tablet 1

TYZEKA 3 QL

VEMLIDY 3

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3

QL

PA

ST

S

MS

EPCLUSA 3

QL

PA

S

MS

HARVONI 3

QL

PA

S

MS

MAVYRET 3

QL

PA

S

MS



OLYSIO 3

QL

PA

ST

S

MS

SOVALDI 3

QL

PA

S

MS

TECHNIVIE 3

QL

PA

ST

S

MS

VIEKIRA PAK 3

QL

PA

ST

S

MS

VIEKIRA XR 3

QL

PA

ST

S

MS

VOSEVI 3

QL

PA

S

MS

ZEPATIER 3

QL

PA

ST

S

MS



ANTI-HEPATITIS C (HCV) AGENTS, OTHER

COPEGUS 3

PA

S

MS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLIONUNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)

3

S

MS

MODERIBA 1

PA

S

MS

PEGASYS 3

QL

PA

S

MS

PEGASYS PROCLICK 3

QL

PA

S

MS

PEGINTRON 3

QL

PA

S

MS

PEGINTRON REDIPEN 3

QL

PA

S

MS

REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3

PA

S

MS

RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1

PA

S

MS

RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3

PA

S

MS



RIBASPHERE RIBAPAK 3

PA

S

MS

RIBATAB 3

PA

MS

ribavirin (200 mg capsule, 200 mg tablet) 1

PA

S

MS

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY 2 S

GENVOYA 2 S

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 MGTABLET)

2

QL

S

ISENTRESS 100 MG POWDER PACKET 2 S

ISENTRESS HD 2

QL

S

STRIBILD 3

QL

S

TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3

QL

S

VITEKTA 150 MG TABLET 3

QL

S

VITEKTA 85 MG TABLET 3 S

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA 3

QL

ST

S

COMPLERA 3 S

DELSTRIGO 3

QL

S

EDURANT 3 S



efavirenz 1 S

INTELENCE 2 S

nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1 S

NEVIRAPINE 50 MG/5 ML ORAL SUSP 2 S

ODEFSEY 3 S

PIFELTRO 3

QL

S

RESCRIPTOR 2 S

SUSTIVA 3 S

SYMFI 2

QL

S

SYMFI LO 2

QL

S

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3 S

VIRAMUNE XR 3 S

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mg/ml solution 1

abacavir sulfate 300 mg tablet 1 S

abacavir sulfate/lamivudine 1 S

abacavir sulfate/lamivudine/zidovudine 1 S

CIMDUO 2

QL

S

COMBIVIR 3 S

didanosine 1 S

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3 S

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3 S

EPZICOM 3 S

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1 S

lamivudine/zidovudine 1 S



RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3 S

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule,40 mg capsule)

1 S

tenofovir disoproxil fumarate 1 S

TRIZIVIR 3 S

TRUVADA 2 S

VIDEX 2 S

VIDEX EC 3 S

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)

3 S

ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE)

3 S

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3 S

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1 S

ANTI-HIV AGENTS, OTHER

DESCOVY 2 S

JULUCA 3

QL

S

SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)

2

QL

S

SELZENTRY 20 MG/ML ORAL SOLN 2 S

TRIUMEQ 3 S

TYBOST 2

QL

S

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3 S

atazanavir sulfate 1 S

CRIXIVAN 3 S

EVOTAZ 3

QL

S

INVIRASE 3 S

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MGTABLET)

3 S



LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3 S

lopinavir/ritonavir 1 S

NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)

3 S

PREZCOBIX 3 S

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET,400 MG TABLET, 600 MG TABLET, 800 MG TABLET)

3 S

REYATAZ 3 S

ritonavir 1 S

SYMTUZA 3 QL

VIRACEPT 3 S

ANTI-INFLUENZA AGENTS

FLUMADINE 3

oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)

1 QL

RELENZA 3 QL

rimantadine hcl 1

TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75MG CAPSULE)

3 QL

ANTIHERPETIC AGENTS

acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1

acyclovir 5 % oint. (g) 1 QL

ALFERON N 3

DENAVIR 3 QL

famciclovir (125 mg tablet, 250 mg tablet) 1

famciclovir 500 mg tablet 1 QL

FAMVIR (125 MG TABLET, 250 MG TABLET) 3

FAMVIR 500 MG TABLET 3 QL

SITAVIG 3 PA

trifluridine 1

valacyclovir hcl 1

VALTREX 3

VIROPTIC 3



XERESE 3 PA

ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800MG TABLET)

3

ZOVIRAX (CREAM, OINTMENT) 3 QL

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 1

meprobamate 1

midazolam hcl 2 mg/ml syrup 1

BENZODIAZEPINES

alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)

1

ALPRAZOLAM INTENSOL 1

ATIVAN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3

chlordiazepoxide hcl 1

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)

1

clorazepate dipotassium 1

diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10mg tablet)

1

KLONOPIN 3

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1

LORAZEPAM INTENSOL 1

oxazepam 1

TRANXENE T-TAB 3

VALIUM 3

XANAX 3

XANAX XR 3

BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO 3

lithium carbonate 1

lithium citrate 1

LITHOBID 3



BLOOD GLUCOSE REGULATORS

DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:

ANTIDIABETIC AGENTS

acarbose 1

ACTOPLUS MET 3

ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL

ACTOS 3

ADLYXIN 3 QL

ALOGLIPTIN BENZOATE 3

QL

ST

ALOGLIPTIN BENZOATE/METFORMIN HCL 3

QL

ST

ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3

QL

ST

AMARYL 3

AVANDIA 3

BYDUREON 2 QL

BYDUREON BCISE 2 QL

BYDUREON PEN 2 QL

BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL

CHLORPROPAMIDE 3

CYCLOSET 3 QL

DIABETA 3

DUETACT 3 QL

FARXIGA 2

FORTAMET 3 ST

glimepiride 1

glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)

1

glipizide/metformin hcl 1

GLUCOPHAGE 3



GLUCOPHAGE XR 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUCOVANCE 3

GLUMETZA 3 ST

glyburide 1

glyburide,micronized 1

glyburide/metformin hcl 1

GLYNASE 3

GLYSET 3

GLYXAMBI 3 QL

INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)

2

INVOKAMET 50-500 MG TABLET 2 QL

INVOKAMET XR 2

INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL

JANUMET 2 QL

JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)

2 QL

JANUVIA 2 QL

JARDIANCE 10 MG TABLET 3 QL

JARDIANCE 25 MG TABLET 3

JENTADUETO 2 QL

JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL

KAZANO 3

QL

ST

KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3

QL

ST

metformin er 500mg & 1000mg tab (generic version of glumetza) 1 ST

metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)

1

metformin hcl 1000 mg tab er 24 1 ST

metformin hcl 500 mg tab er 24 1



metformin hcl 500 mg/5ml solution 3

miglitol 1

nateglinide 1

NESINA 3

QL

ST

ONGLYZA 3

QL

ST

OSENI 3

QL

ST

OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL

pioglitazone hcl 1

pioglitazone hcl/glimepiride 1 QL

pioglitazone hcl/metformin hcl 1

PRANDIN 3

PRECOSE 3

QTERN 3 QL

repaglinide 1

REPAGLINIDE/METFORMIN 3

RIOMET 3

SEGLUROMET 2 QL

STARLIX 3

STEGLATRO 2 QL

STEGLUJAN 3 QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)

3 QL

TANZEUM 30 MG PEN INJECT 3 QL

TANZEUM 50 MG PEN INJECT 3

tolazamide 1

tolbutamide 1



TRADJENTA 2 QL

TRULICITY 2 QL

VICTOZA 2-PAK 2 QL

VICTOZA 3-PAK 2 QL

XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)

2 QL

BLOOD GLUCOSE SUPPLIES

Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.

FREESTYLE FREEDOM LITE METER 2

FREESTYLE INSULINX GLUCOSE SYS 2

FREESTYLE INSULINX TEST STRIPS 2 QL

FREESTYLE LITE METER 2

FREESTYLE LITE TEST STRIPS 2 QL

FREESTYLE PREC NEO TEST STRIPS 2 QL

FREESTYLE PRECISION NEO METER 2

FREESTYLE TEST STRIPS 2 QL

ONETOUCH ULTRA TEST STRIP 2 QL

ONETOUCH ULTRA2 GLUCOSE SYST 2

ONETOUCH ULTRAMINI METER 2

ONETOUCH VERIO FLEX SYSTEM KIT 2

ONETOUCH VERIO IQ SYSTEM KIT 2

ONETOUCH VERIO METER SYSTEM 2

ONETOUCH VERIO SYNC SYST KIT 2

ONETOUCH VERIO TEST STRIP 2 QL

PRECISION XTRA MONITOR 2

PRECISION XTRA TEST STRIPS 2 QL

GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 2

GLUCAGON EMERGENCY KIT 2 QL

PROGLYCEM 3



INSULINS

ADMELOG 3

ADMELOG SOLOSTAR 3

AFREZZA 3

APIDRA 3

APIDRA SOLOSTAR 3

BASAGLAR KWIKPEN U-100 3

FIASP 3

FIASP FLEXTOUCH 3

HUMALOG 2

HUMALOG JUNIOR KWIKPEN 2

HUMALOG KWIKPEN U-100 2


HUMALOG MIX 50-50 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 2


HUMULIN 70-30 2

HUMULIN 70/30 KWIKPEN 2

HUMULIN N 2

HUMULIN N KWIKPEN 2

HUMULIN R 2

HUMULIN R U-500 2

HUMULIN R U-500 KWIKPEN 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70-30 2

NOVOLIN 70-30 FLEXPEN 2

NOVOLIN N 2

NOVOLIN R 2

NOVOLOG 2



NOVOLOG FLEXPEN 2

NOVOLOG MIX 70-30 2

NOVOLOG MIX 70-30 FLEXPEN 2

SOLIQUA 100-33 3 QL

TOUJEO MAX SOLOSTAR 2

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH U-100 2


XULTOPHY 100-3.6 3 QL

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

ARIXTRA 3 S

BEVYXXA 3 QL

COUMADIN 2

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL

ELIQUIS 5 MG STARTER PACK 2 QL

enoxaparin sodium 1 S

fondaparinux sodium 1 S

FRAGMIN 3 S

IPRIVASK 3 S

JANTOVEN 1

LOVENOX 3 S

PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 3

QL

ST

PRADAXA 110 MG CAPSULE 3 ST

SAVAYSA 3

QL

ST

warfarin sodium 1

XARELTO (2.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MGTABLET)

2 QL

XARELTO STARTER PACK 2



ZONTIVITY 3

QL

PA

BLOOD FORMATION MODIFIERS

AGRYLIN 3

anagrelide hcl 1

ARANESP 2

S

MS

DOPTELET 3

QL

PA

S

MS

EPOGEN 2

S

MS

FULPHILA 3

QL

S

MS

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML SYRINGE, 480MCG/0.8 ML SAFE SYR, 480 MCG/0.8 ML SYRINGE)

3

QL

PA

S

MS

LEUKINE 3

QL

S

MS

MOZOBIL 3

QL

PA

S

MS

MULPLETA 3

QL

PA

S

MS

NEULASTA 3

QL

S

MS



NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYR, 480 MCG/1.6 ML VIAL)

3

QL

PA

S

MS

NIVESTYM 3

PA

S

MS

PROCRIT 2

S

MS

PROMACTA 3

QL

PA

S

MS

RETACRIT 3

S

MS

TAVALISSE 3

QL

PA

S

ZARXIO 2

S

MS

HEMOSTASIS AGENTS

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3

aminocaproic acid (250 mg/ml solution, 500 mg tablet) 1

aminocaproic acid 1000 mg tablet 3

LYSTEDA 3 QL

MEPHYTON 3

phytonadione (vit k1) 5 mg tablet 1

tranexamic acid 650 mg tablet 1 QL

PLATELET MODIFYING AGENTS

ASPIRIN/DIPYRIDAMOLE 3

BRILINTA 60 MG TABLET 2

BRILINTA 90 MG TABLET 2 QL



cilostazol 1

clopidogrel bisulfate 300 mg tablet 1

clopidogrel bisulfate 75 mg tablet 1 QL

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1

EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL

PERSANTINE 3

PLAVIX 300 MG TABLET 3

PLAVIX 75 MG TABLET 3 QL

PLETAL 3

prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL

ticlopidine hcl 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES 3

CATAPRES-TTS 3 QL

clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)

1 QL

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1

guanfacine hcl (1 mg tablet, 2 mg tablet) 1

methyldopa 1

midodrine hcl 1

NORTHERA 3

QL

PA

S

MS

TENEX 3

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 3

DIBENZYLINE 3

doxazosin mesylate 1

MINIPRESS 3

phenoxybenzamine hcl 1



prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 3

AVAPRO 3

BENICAR 3

candesartan cilexetil 1

COZAAR 3

DIOVAN 3

EDARBI 3 ST

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

MICARDIS 3

olmesartan medoxomil 1

telmisartan 1

valsartan 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACCUPRIL 3

ACEON 3

ALTACE 3

benazepril hcl 1

captopril 1

enalapril maleate 1

EPANDED SOLUTION 3 PA

fosinopril sodium 1

lisinopril 1

LOTENSIN 3

MAVIK 3

moexipril hcl 1

perindopril erbumine 1

PRINIVIL 3



QBRELIS 3

QL

PA

quinapril hcl 1

ramipril 1

trandolapril 1

VASOTEC 3

ZESTRIL 3

ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1

BETAPACE 3

BETAPACE AF 3

CORDARONE 3

disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2 QL

NORPACE 3

NORPACE CR 3

PACERONE 1

propafenone hcl 1

quinidine gluconate 324 mg tablet er 1

quinidine sulfate 1

RYTHMOL 3

RYTHMOL SR 3

SORINE 1

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1

SOTYLIZE 3 PA

TIKOSYN 3

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 1

atenolol 1



betaxolol hcl (10 mg tablet, 20 mg tablet) 1

bisoprolol fumarate 1

BYSTOLIC 3

carvedilol 1

carvedilol phosphate 1 QL

COREG 3

COREG CR 3 QL

CORGARD 3

INDERAL LA 3

INDERAL XL 3

INNOPRAN XL 3

KAPSPARGO SPRINKLE 3

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

LEVATOL 3

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3

metoprolol succinate 1

metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)

1

nadolol 1

pindolol 1

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mgtablet, 120 mg cap sa 24h, 160 mg cap sa 24h)

1

SECTRAL 3

TENORMIN 3

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

TOPROL XL 3

ZEBETA 3

CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC 3

AFEDITAB CR 1

amlodipine besylate 1

CALAN 3

CALAN SR 3



CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

CARTIA XT 1

DILT-XR 1

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)

1

felodipine 1

isradipine 1

MATZIM LA 1

nicardipine hcl (20 mg capsule, 30 mg capsule) 1

NIFEDICAL XL 1

nifedipine 1

nimodipine 1

nisoldipine 1 QL

NORVASC 3

NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 ML SOLUTION) 3 QL

PROCARDIA 3

PROCARDIA XL 3

SULAR 3 QL

TAZTIA XT 1

TIAZAC 3

verapamil hcl 1

VERELAN 3

VERELAN PM 3

CARDIOVASCULAR AGENTS, OTHER

ACCURETIC 3

ALDACTAZIDE 3

amiloride hcl/hydrochlorothiazide 1

amlodipine besylate/atorvastatin calcium 1 QL



amlodipine besylate/benazepril hcl 1

amlodipine besylate/olmesartan medoxomil 1 QL

amlodipine besylate/valsartan 1

QL

PA

amlodipine besylate/valsartan/hydrochlorothiazide 1

QL

PA

ATACAND HCT 3

atenolol/chlorthalidone 1

AVALIDE 3

AZOR 3 QL

benazepril hcl/hydrochlorothiazide 1

BENICAR HCT 3

BIDIL 3 QL

bisoprolol fumarate/hydrochlorothiazide 1

BYVALSON 3 QL

CADUET 3 QL

candesartan cilexetil/hydrochlorothiazide 1

captopril/hydrochlorothiazide 1

CLORPRES (0.1-15 TABLET, 0.2-15 TABLET) 1

CLORPRES 0.3-15 TABLET 3

CORLANOR 3 QL

CORZIDE 3

DEMSER 3

DIGITEK 1

DIGOX 1

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1

DIOVAN HCT 3

DUTOPROL 3 QL

DYAZIDE 3

EDARBYCLOR 3 ST

enalapril maleate/hydrochlorothiazide 1



ENTRESTO 3

QL

ST

EXFORGE 3 QL

EXFORGE HCT 3 QL

fosinopril sodium/hydrochlorothiazide 1

HYZAAR 3

irbesartan/hydrochlorothiazide 1

isoxsuprine hcl 1

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250MCG TABLET)

2

lisinopril/hydrochlorothiazide 1

LOPRESSOR HCT 3

losartan potassium/hydrochlorothiazide 1

LOTENSIN HCT 3

LOTREL 3

MAXZIDE 3

MAXZIDE-25 MG 3

methyldopa/hydrochlorothiazide 1

METOPROLOL SUCCINATE/HYDROCHLOROTHIAZIDE 3 QL

metoprolol tartrate/hydrochlorothiazide 1

MICARDIS HCT 3

moexipril hcl/hydrochlorothiazide 1

nadolol/bendroflumethiazide 1

olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL

olmesartan medoxomil/hydrochlorothiazide 1

pentoxifylline 1

PRESTALIA (7 MG-5 MG TABLET, 14 MG-10 MG TABLET) 3 QL

PRESTALIA 3.5 MG-2.5 MG TABLET 3

propranolol hcl/hydrochlorothiazide 1

quinapril hcl/hydrochlorothiazide 1

RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL

RESERPINE 3



spironolactone/hydrochlorothiazide 1

TARKA 3 QL

TEKTURNA 3 QL

TEKTURNA HCT 3 QL

telmisartan/amlodipine besylate 1 QL

telmisartan/hydrochlorothiazide 1

TENORETIC 100 3

TENORETIC 50 3

trandolapril/verapamil hcl 1 QL

triamterene/hydrochlorothiazide 1

TRIBENZOR 3 QL

TWYNSTA 3 QL

valsartan/hydrochlorothiazide 1

VASERETIC 3

VECAMYL 3

ZESTORETIC 3

ZIAC 3

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide 1

DIAMOX SEQUELS 3

KEVEYIS 3

PA

S

DIURETICS, LOOP

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

DEMADEX 3

EDECRIN 3

ethacrynic acid 1

furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,80 mg tablet)

1

LASIX 3

torsemide 1



DIURETICS, POTASSIUM-SPARING

ALDACTONE 3

amiloride hcl 1

CAROSPIR 3 QL

DYRENIUM 3

eplerenone 1

INSPRA 3

spironolactone 1

DIURETICS, THIAZIDE

chlorothiazide 1

chlorthalidone 1

DIURIL 3

hydrochlorothiazide 1

indapamide 1

methyclothiazide 1

metolazone 1

MICROZIDE 3

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

ANTARA 3

fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL

fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1

fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL

fenofibrate,micronized 1

fenofibric acid 1

fenofibric acid (choline) 1 QL

FENOGLIDE 3 QL

FIBRICOR 3

gemfibrozil 1

LIPOCHOL PLUS 3

LIPOFEN 3

LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 200 MG CAPSULE) 3

LOFIBRA 160 MG TABLET 3 QL



LOFIBRA 54 MG TABLET 3

LOPID 3

TRICOR (48 MG TABLET, 145 MG TABLET) 3 QL

TRIGLIDE 3 QL

TRILIPIX 3 QL

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV 3 QL

atorvastatin calcium 1

CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL

FLOLIPID 3

fluvastatin sodium 1 QL

LESCOL 3 QL

LESCOL XL 3 QL

LIPITOR 3

LIVALO 3

QL

ST

lovastatin (10 mg tablet, 20 mg tablet) 1

lovastatin 40 mg tablet 1 QL

PRAVACHOL 3

pravastatin sodium 1

rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL

ZOCOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET, 80MG TABLET)

3 QL

ZYPITAMAG 3 ST

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1

cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)

1

colesevelam hcl 1

COLESTID (1 GM TABLET, FLAVORED GRANULES, GRANULES,GRANULES PACKET)

3

colestipol hcl 1



ezetimibe 1

ezetimibe/simvastatin 1

JUXTAPID 3

QL

PA

S

KYNAMRO 3

PA

S

MS

LOVAZA 3 QL

niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL

NIACOR 3

NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL

omega-3 acid ethyl esters 1 QL

PRALUENT 2

QL

PA

S

MS

PREVALITE (PACKET, POWDER) 1

QUESTRAN (PACKET, POWDER) 3

QUESTRAN LIGHT 3

REPATHA 2

QL

PA

S

MS

VASCEPA 0.5 GM CAPSULE 3

VASCEPA 1 GM CAPSULE 3 QL

VYTORIN 3

WELCHOL 3

ZETIA 3

VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1

minoxidil (2.5 mg tablet, 10 mg tablet) 1



VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 3

GONITRO 3 PA

ISORDIL 3

ISORDIL TITRADOSE 3

isosorbide dinitrate 1

isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1

isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)

1

MINITRAN 1

NITRO-BID 3

NITRO-DUR 3

NITRO-TIME 1

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)

1

nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1

nitroglycerin 400mcg/spr spray 1

QL

PA

NITROLINGUAL 3 QL

NITROMIST 3

QL

PA

NITROSTAT 3

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

ADDERALL 3

ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE)

3 QL

ADZENYS ER 3

QL

PA

ADZENYS XR-ODT 3

QL

PA

amphetamine sulfate 1

DESOXYN 3

DEXEDRINE (SPANSULE 5 MG, SPANSULE 10 MG, SPANSULE 15 MG) 3



DEXEDRINE 10 MG TABLET 1

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h)

1 QL

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)

1

dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)

1

DYANAVEL XR 3

QL

PA

EVEKEO 3

methamphetamine hcl 1

MYDAYIS 3

QL

ST

PROCENTRA 3

VYVANSE 2 QL

ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 30 MG TABLET)

3

ZENZEDI (5 MG TABLET, 10 MG TABLET) 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)

3

QL

ST

atomoxetine hcl 1

clonidine hcl 0.1 mg tab er 12h 1 QL

CONCERTA 3 QL

COTEMPLA XR-ODT 3

QL

PA

DAYTRANA 3

QL

ST

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1



dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)

1 QL

FOCALIN 3

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MGCAPSULE)

3 QL

guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er24h)

1 QL

INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3 MG TABLET, ER 4 MGTABLET)

3 QL

KAPVAY 3 QL

METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)

3 QL

METADATE ER 1

METHYLIN (2.5 MG CHEWABLE TAB, 5 MG CHEWABLE TABLET, 5 MG/5ML SOLUTION, 10 MG CHEWABLE TABLET, 10 MG/5 ML SOLUTION)

3

methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70,20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 40 mg cpbp 30-70,40 mg cpbp 50-50)

1 QL

methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)

1 QL

methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)

1

methylphenidate hcl 72 mg tab er 24 3 QL

QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)

3

QL

PA

QUILLIVANT XR 3

QL

PA

RELEXXII 3 QL

RITALIN 3

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE)

3 QL

STRATTERA 3

CENTRAL NERVOUS SYSTEM, OTHER

ADIPEX-P 3

ALLZITAL 3

AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3

QL

PA

S

MS



BELVIQ 3

QL

PA

BELVIQ XR 3

QL

PA

benzphetamine hcl 1

BONTRIL PDM 3

BUPAP 3 QL

butalbital/acetaminophen (butalbital/acetaminophen capsule,butalbital/acetaminophen tablet)

1 QL

butalbital/acetaminophen 50mg-325mg tablet 1

butalbital/acetaminophen/caffeine 1

CAPACET 1

CONTRAVE 3

QL

PA

diethylpropion hcl 1

ESGIC 50-325-40 MG TABLET 3

ESGIC CAPSULE 1

FIORICET 3

HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

INGREZZA 3

QL

PA

S

LOMAIRA 3

MARTEN-TAB 1

NUEDEXTA 3

QL

PA

phendimetrazine tartrate 1

phentermine hcl 1

QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)

3

QL

PA

REGIMEX 3

RILUTEK 3



riluzole 1

SUPRENZA ODT 3

QL

PA

TEGSEDI 3

QL

PA

S

MS

TENCON 3

tetrabenazine (12.5 mg tablet, 25 mg tablet) 1

QL

PA

S

MS

TIGLUTIK 3 QL

VANATOL LQ 3

XENAZINE (12.5 MG TABLET, 25 MG TABLET) 3

QL

S

MS

ZEBUTAL 1

FIBROMYALGIA AGENTS

CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60 MG CAPSULE) 3 QL

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL

duloxetine hcl 40 mg capsule dr 1

IRENKA 3

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)

2

LYRICA 20 MG/ML ORAL SOLUTION 2 QL

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)

3

QL

PA

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET, TITRATION PACK)

3

QL

ST



MULTIPLE SCLEROSIS AGENTS

AMPYRA 3

QL

PA

S

MS

AUBAGIO 3

QL

ST

S

MS

AVONEX 2

QL

S

MS

BETASERON 3

QL

ST

S

MS

COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2

QL

S

MS

dalfampridine 1

QL

PA

S

MS

EXTAVIA 3

PA

S

MS

GILENYA 0.5 MG CAPSULE 2

QL

S

MS

glatiramer acetate (20 mg/ml syringe, 40 mg/ml syringe) 1

QL

S

MS



GLATOPA 20 MG/ML SYRINGE 1

QL

ST

S

MS

GLATOPA 40 MG/ML SYRINGE 1

QL

S

MS

PLEGRIDY 2

QL

S

MS

PLEGRIDY PEN 2

QL

S

MS

REBIF 2

QL

S

MS

TECFIDERA 2

QL

S

MS

ZINBRYTA 3

QL

ST

S

DENTAL AND ORAL AGENTS

cevimeline hcl 1

chlorhexidine gluconate 0.12 % mouthwash 1

EVOXAC 3

ORALONE 1

PAROEX 1

PERIDEX 3

PERIOGARD 1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

SALAGEN 3

triamcinolone acetonide 0.1 % paste (g) 1



DERMATOLOGICAL AGENTS

8-MOP 3

ABSORICA 3 PA

ACANYA 3

QL

PA

acitretin 1 QL

ACZONE 3

QL

ST

adapalene (0.1 % cream (g), 0.1 % gel (gram), 0.3 % gel (gram), 0.3 % gelw/pump)

1

adapalene 0.1 % solution 1

QL

ST

ADAPALENE 0.1% LOTION 3 ST

adapalene/benzoyl peroxide 1 QL

ALDARA 3

ALEVICYN PLUS 3

ALTRENO 3 QL

AMELUZ 3

ammonium lactate 1

AMNESTEEM 1

ANA-LEX 3

ANALPRAM E 3

ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE,2.5%-1% LOTION)

3

ATRALIN 3

ATRAPRO DERMAL SPRAY 3

AVAR CLEANSER 1

AVAR-E 3

AVAR-E GREEN 3

AVITA 1

AZELEX 3

BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 QL

BENZEPRO 6% FOAMING CLOTHS 1 QL



BENZEPRO 7% CREAMY WASH 1

benzoyl peroxide 7 % cleanser 1

BPO (4% GEL, 8% GEL) 1

BPO 6% FOAMING CLOTHS 1 QL

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1

calcipotriene/betamethasone dipropionate 1

CALCITRENE 1

CALCITRIOL 3 MCG/G OINTMENT 3

CARAC 3 PA

CLARAVIS 1

clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1

QL

PA

clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram),phos/benzoyl 1 % gel w/pump)

1 QL

clindamycin phosphate/tretinoin 1 PA

clotrimazole/betamethasone dipropionate (clotrimazole/betamethasone 1 %cream (g), clotrimazole/betamethasone 1 % lotion)

1

CONDYLOX (GEL, TOPICAL SOLN) 3

CORTISPORIN (CREAM, OINTMENT) 3

COSENTYX 2

QL

PA

ST

S

MS

dapsone 5 % gel (gram) 1 QL

DERMACINRX CLORHEXACIN 3

QL

PA

DERMACINRX LEXITRAL 3

QL

PA

DERMACINRX SURGICAL PHARMAPAK 3

QL

PA

DERMACINRX THERAZOLE PAK 3

QL

PA



DICLO GEL 3

QL

PA

DICLO GEL-XRYLIX SHEET 3

QL

PA

diclofenac sodium 1 % gel (gram) 1 QL

diclofenac sodium 3 % gel (gram) 1 PA

DICLOZOR 3

QL

PA

DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL PUMP) 3

DIFFERIN 0.1% LOTION 3 ST

DOVONEX 3

DOXEPIN HCL 5 % CREAM (G) 3

DRITHOCREME HP 3

DRYSOL 3

DUAC 3

DUPIXENT 200 MG/1.14 ML SYRING 3

QL

PA

S

MS

ELIDEL 3 QL

ENSTILAR 3

QL

PA

EPIDUO 3 QL

EPIDUO FORTE 3 QL

EPIFOAM 3

EUCRISA 3 ST

FABIOR 3

QL

PA

FINACEA 3

FLUOROPLEX 3

FLUOROURACIL 0.5% CREAM 3 PA



GORDON'S UREA 3

hydrocortisone acetate/iodoquinol/aloe vera 1

hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2 %-2 % kit,hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)

1

hydrocortisone acetate/pramoxine hcl 1

hydroquinone microspheres 1

imiquimod 3.75 % crm md pmp 3

imiquimod 5 % cream pack 1

lactic acid 10 % lotion 1

LEVULAN 3

LEXIXRYL 3

QL

PA

lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)

1

LOTRISONE 3

methoxsalen 10 mg cap lq rap 1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)

1

MICORT HC 2.5% CREAM 3

MICROCYN 3

MICROCYN HYDROGEL 3

MYORISAN 1

NATROBA 3

NEO-SYNALAR 0.5%-0.025% CREAM 3

NEUAC GEL 1

NORITATE 3 ST

NOVACORT 3

NUDICLO SOLUPAK 3

QL

PA

NUOX 3



ONEXTON GEL PUMP 3

QL

PA

OVACE 3

OVACE PLUS (9.8% FOAM, 10% CREAM, 10% SHAMPOO, 10% WASH) 3

OVACE PLUS WASH 3

OXSORALEN-ULTRA 3

PACNEX 3

PACNEX HP 3

PACNEX LP 3

PICATO (0.015% GEL, 0.05% GEL) 2 QL

PLEXION (CLNSING CLOTH, CREAM, LOTION) 3

PLIXDA 3

QL

ST

podofilox 1

PR BENZOYL PEROXIDE 1

PRAMCORT 1

PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1%CREAM, 2.5%-1% LOTION, 2.5%-1% OINTMENT)

3

PRAMOSONE E 3

PROCORT 3

PROCTOFOAM-HC 3

PROTOPIC 3 QL

PRUDOXIN 3

QBREXZA 3

QL

ST

REA LO 39 1

REA LO 40 (40 CM, 40 TION) 1

RECTIV 3 QL

REGRANEX 3 QL

RETIN-A 3

RETIN-A MICRO 3

RETIN-A MICRO PUMP 3



ROSADAN (CREAM KIT, GEL KIT) 3

QL

PA

ROSADAN (CREAM, GEL) 1

ROSANIL 3

ROSULA 10%-5% CLOTHS 3

SANTYL 3

SEB-PREV 1

selenium sulfide 1

SELRX 3

SILIQ 3

QL

PA

ST

S

MS

silver nitrate/potassium nitrate 1

SOLARAZE 3 PA

SOOLANTRA 3

QL

ST

SORIATANE 3 QL

SORILUX 3

QL

PA

SPINOSAD 3

SSS 10-5 CREAM 1

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2

QL

PA

S

MS

STELARA 45 MG/0.5 ML VIAL 2

PA

S

MS

sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1



sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)

1

TACLONEX 0.005%-0.064% SUSPENS 3

QL

PA

TACLONEX OINTMENT 3

tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL

TALTZ 3

QL

PA

ST

S

MS

tazarotene 1

TAZORAC 3

TOLAK 2

TREMFYA 3

QL

PA

ST

S

MS

TRETIN-X (0.025% CREAM COMB PCK, 0.05% COMBO PACK, 0.1%COMBO PACK)

3

TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3

QL

PA

tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.05 % gel (gram), 0.1 % cream (g))

1

tretinoin microspheres 1

tretinoin/emollient base 1 PA

TRI-CHLOR 1

ULESFIA 3

VECTICAL 3

VELTIN 3 PA

VEREGEN 3

VOLTAREN 3 QL

VYTONE 3



XELITRAL 3

QL

PA

XEPI 3 QL

XRYLIX 3

QL

PA

ZENATANE 1

ZEYOCAINE 3

QL

PA

ZIANA 3 PA

ZITHRANOL-RR 3

ZONALON 3

ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75% CREAM PUMP) 3

ZYPRAM 3

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

CARBAGLU 3

PA

S

MS

CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3

CARNITOR SF 3

CLINPRO 5000 1

CYTRA-K CRYSTALS PACKET 1

DENTA 5000 PLUS 1

DENTAGEL 1

EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3

EFFER-K 25 MEQ TABLET EFF 1

ENDARI 3

QL

PA

ICAR-C PLUS 3

K EFFERVESCENT 1

K-SOL 1

K-TAB ER 3



KLOR-CON 10 1

KLOR-CON 20 MEQ PACKET 1

KLOR-CON 25 MEQ PACKET 3

KLOR-CON 8 1

KLOR-CON M10 1

KLOR-CON M15 1

KLOR-CON M20 1

KLOR-CON SPRINKLE 1

KLOR-CON-EF 1

levocarnitine (with sugar) 1

levocarnitine 330 mg tablet 1

NESTABS ONE 3

NUTRESTORE 3 PA

ORACIT 3

potassium bicarbonate/citric acid 1

potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meqtablet er, 20meq/15ml liquid, 40meq/15ml liquid)

1

potassium chloride/potassium bicarbonate/citric acid 1

potassium citrate 1

potassium citrate/citric acid 3300-1002 packet 1

PREVIDENT (0.2%, DENTAL) 1

PREVIDENT (1.1% GEL, 5000 BOOSTER PLUS) 3

PREVIDENT 5000 3

PREVIDENT 5000 ENAMEL PROTECT 3

PREVIDENT 5000 PLUS 3

PREVIDENT 5000 SENSITIVE 3

SF 1

SF 5000 PLUS 1

TL G-FOL OS 1

UROCIT-K 3

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 3

CUPRIMINE 3 PA



EXJADE 3

S

MS

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3 S

GALZIN 3

JADENU 3

S

MS

JYNARQUE 3

QL

PA

S

KAYEXALATE 3

KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1

RADIOGARDASE 3

SAMSCA 3

QL

S

MS

sodium polystyrene sulfonate 1

SPS 1

SYPRINE 3 PA

trientine hcl 1 PA

DEPEN 2

PHOSPHATE BINDERS

AURYXIA 3 QL

calcium acetate 1

ELIPHOS 1

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MGTABLET CHEW)

3 QL

FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3

lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL

PHOSLO 3

PHOSLYRA 3

RENAGEL 3

RENVELA 3



sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1

sevelamer carbonate 0.8 g powd pack 1 QL

VELPHORO 3 QL

VELTASSA 3 ST

VITAMINS

BRAND RX PRENATAL VITAMINS ARE T3 AND GENERIC RX PRENATALVITAMINS ARE T1

3

cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1

ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.

3 PA

folic acid 1 mg tablet 1

NASCOBAL 3

OB COMPLETE PETITE 3

POTABA 3

XURIDEN 3

QL

PA

S

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

ANASPAZ 3

BENTYL (10 MG CAPSULE, 20 MG TABLET) 3

chlordiazepoxide/clidinium bromide 1

CUVPOSA 3

QL

PA

dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1

ED-SPAZ 1

GLYCATE 3

QL

PA

glycopyrrolate (1 mg tablet, 2 mg tablet) 1

glycopyrrolate 1.5 mg tablet 1

QL

PA



hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet,0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir)

1

HYOSYNE 1

LEVBID 3

LEVSIN 0.125 MG TABLET 3

LEVSIN-SL 3

LIBRAX 3

methscopolamine bromide 1

NULEV 1

OSCIMIN 1

OSCIMIN SL 1

OSCIMIN SR 1

propantheline bromide 1

ROBINUL 1 MG TABLET 3

ROBINUL FORTE 3

SYMAX 1

SYMAX DUOTAB 3

SYMAX-SL 1

SYMAX-SR 1

GASTROINTESTINAL AGENTS, OTHER

ACTIGALL 3

CHENODAL 3 S

cromolyn sodium 20 mg/ml oral conc 1

diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)

1

ENTEREG 3

FULYZAQ 3

QL

PA

GASTROCROM 3

GATTEX 3

QL

PA

S

MS

lansoprazole/amoxicillin trihydrate/clarithromycin 1



LOMOTIL 3

MOTOFEN 3

MOVANTIK 2 QL

MYALEPT 3

PA

S

MS

MYTESI 3

QL

PA

OMECLAMOX-PAK 3

QL

PA

opium tincture 1

paregoric 1

PREVPAC 3

PYLERA 3

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL, 150 MG TABLET)

3

SYMPROIC 3

QL

ST

URSO 3

URSO FORTE 3

ursodiol 1

XENICAL 3 PA

XIFAXAN 200 MG TABLET 3

XIFAXAN 550 MG TABLET 3 QL

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 1

cimetidine hcl 1

famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1

nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) 1

PEPCID (40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg capsule,300 mg tablet)

1

ZANTAC 300 MG TABLET 3



IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 1 QL

AMITIZA 3

QL

ST

LINZESS 2 QL

LOTRONEX 3 QL

TRULANCE 3

QL

ST

VIBERZI 3

LAXATIVES

CLENPIQ 3

COLYTE WITH FLAVOR PACKETS 3

CONSTULOSE 1

ENULOSE 1

GAVILYTE-C 1

GAVILYTE-G 1

GAVILYTE-H AND BISACODYL 1

GAVILYTE-N 1

GENERLAC 1

GIALAX 3

GOLYTELY (PACKET, SOLUTION) 3

KRISTALOSE 3 PA

lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1

lactulose 10 g packet 1

QL

PA

MOVIPREP 3 QL

NULYTELY WITH FLAVOR PACKS 3

OSMOPREP 3

peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 1

PEG-PREP 1

PLENVU 3



polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 1

PREPOPIK 2

sodium chloride/sodium bicarbonate/potassium chloride/peg 1

SUPREP 2

TRILYTE WITH FLAVOR PACKETS 1

PROTECTANTS

CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3

CYTOTEC 3

misoprostol 1

sucralfate 1

PROTON PUMP INHIBITORS

ACIPHEX 3 QL

ACIPHEX SPRINKLE 3

QL

PA

DEXILANT 3

QL

ST

ESOMEP-EZS 3

QL

PA

esomeprazole magnesium 1 QL

ESOMEPRAZOLE STRONTIUM 3 PA

lansoprazole (15 mg capsule dr, 30 mg capsule dr) 1 QL

lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1

QL

ST

NEXIUM 3

QL

ST

omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) 1 QL

omeprazole/sodium bicarbonate 1

QL

ST

pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 QL

PREVACID (30 MG SOLUTAB, DR 30 MG CAPSULE) 3 QL

PRILOSEC 3 QL



PROTONIX 3 QL

rabeprazole sodium 1 QL

ZEGERID (20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) 3

QL

ST

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

BUPHENYL (500 MG TABLET, POWDER) 3

CERDELGA 3

PA

S

MS

CHOLBAM 3

PA

S

CREON 2

CYSTADANE 3 S

CYSTAGON 2 S

GALAFOLD 3

QL

PA

S

MS

KUVAN 3

PA

S

MS

miglustat 1

QL

PA

S

MS

NITYR 3

PA

S

OCALIVA 3

QL

PA

S

MS

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG CAPSULE, 10MG CAPSULE, 20 MG CAPSULE)

3

PA

S



PALYNZIQ 3

PA

S

MS

PANCREAZE 3

PANCRELIPASE 5,000 1

PERTZYE 3

PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3

QL

PA

S

MS

RAVICTI 3

QL

PA

S

MS

sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1

STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)

3

QL

PA

S

SUCRAID 3

PA

S

MS

ULTRESA 3

VIOKACE 3

ZAVESCA 3

QL

PA

S

MS

ZENPEP 2

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide 1 QL

DETROL 3 QL



DETROL LA 3 QL

DITROPAN XL 3

ENABLEX 3 QL

flavoxate hcl 1

GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)

3

QL

ST

MYRBETRIQ 2 QL

oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)

1

OXYTROL 3 ST

tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL

TOVIAZ 2 QL

trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL

VESICARE 2 QL

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl 1 QL

AVODART 3 QL

CARDURA XL 3

CIALIS (2.5 MG TABLET, 5 MG TABLET) 3

QL

ST

dutasteride 1 QL

dutasteride/tamsulosin hcl 1 QL

finasteride 5 mg tablet 1

FLOMAX 3 QL

JALYN 3 QL

PROSCAR 3

RAPAFLO 3

QL

ST

tadalafil (2.5 mg tablet, 5 mg tablet) 1 QL

tamsulosin hcl 1 QL



UROXATRAL 3 QL

GENITOURINARY AGENTS, OTHER

ADDYI 3 PA

bethanechol chloride 1

CAVERJECT 3 QL

CIALIS (10 MG TABLET, 20 MG TABLET) 3

QL

ST

CONCEPTROL 0 C Covered in full

EDEX 3 QL

ELMIRON 3

FEM PH 3

GYNOL II 0 C Covered in full

K-PHOS NO.2 3

K-PHOS ORIGINAL 3

LEVITRA 3

QL

ST

LITHOSTAT 3

MUSE 3 QL

phenazopyridine hcl 1

PYRIDIUM 3

RELAGARD 3

RIMSO-50 3

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL

STAXYN 3

QL

ST

STENDRA 3

QL

ST

tadalafil 10 mg tablet 1 QL

tadalafil 20 mg tablet 1

QL

PA

S

MS



THIOLA 3

QL

S

TODAY CONTRACEPTIVE SPONGE 0 C Covered in full

URECHOLINE 3

UROQID-ACID NO.2 3

VCF (FILM, FOAM, GEL) 0 C Covered in full

VIAGRA 3 QL

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ALA-CORT 1

ALA-SCALP 3

alclometasone dipropionate 1

amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1

ANUCORT-HC 1

ANUSOL-HC 25 MG SUPPOSITORY 3

APEXICON E 3

betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))

1

betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05% cream (g), betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))

1

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 %foam)

1

CAPEX SHAMPOO 3

clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05% lotion, 0.05 % oint. (g), 0.05 % shampoo, 0.05 % solution, 0.05 % spray)

1

clobetasol propionate/emollient base (propionate/emoll 0.05 % cream (g),propionate/emoll 0.05 % foam)

1

CLOBEX 3

CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST

CLODAN 0.05% KIT 3

QL

PA

CLODAN 0.05% SHAMPOO 1

CLODERM 3 ST

CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION, 0.05%OINTMENT)

3 ST

CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL

CORMAX 1



CORTEF 3

cortisone acetate 1

CUTIVATE (CREAM, LOTION) 3

DECADRON 0.5 MG/5 ML ELIXIR 1

DELTASONE 1

DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3

DERMACINRX CINLONE-I CPI 3

QL

PA

DERMACINRX SILAPAK 3

QL

PA

DERMACINRX SILAZONE 3

QL

PA

DERMATOP 3

DERMAZONE 3

QL

PA

DESONATE 3 ST

desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1

DESOWEN (CREAM, LOTION) 3

desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 %cream (g), 0.25 % oint. (g), 0.25 % spray)

1

dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1

QL

PA

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mgtablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

1

DEXAMETHASONE INTENSOL 3

DIFLORASONE DIACETATE 3

DIPROLENE (LOTION, OINTMENT) 3

DIPROLENE AF 3

ELLZIA PAK 3

QL

PA

ELOCON (CREAM, LOTION, OINTMENT) 3

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 30MG TABLET, 36 MG TABLET)

3

QL

PA

S



fludrocortisone acetate 1

fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 %cream (g), 0.025 % oint. (g))

1

fluocinolone acetonide/shower cap 1

fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 %solution, 0.1 % cream (g))

1

fluocinonide/emollient base 1

flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1

fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1

H.P. ACTHAR 3

QL

PA

S

MS

halobetasol propionate 1

HALOG 3 ST

HEMMOREX-HC 1

hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g),2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mgtablet)

1

hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1

hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

hydrocortisone butyrate 0.1 % lotion 1 ST

hydrocortisone butyrate/emoll 0.1 % cream (g) 1

hydrocortisone valerate 1

hydrocortisone/mineral oil/petrolatum,white 1

IMPOYZ 3 ST

KENALOG 3 ST

KORLYM 3

QL

PA

S

LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 ST

LOCOID LIPOCREAM 3 ST

LUXIQ 3

MEDROL 3

methylprednisolone 1



MICORT-HC 2.5% CREAM 3

MIFEPREX 3

MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3

MILLIPRED DP 3

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1

NOLIX 0.05% CREAM 1

NUCORT 3

NUTRIARX 3

QL

PA

OLUX 3

OLUX-E 3

ORAPRED ODT 3

PANDEL 3 ST

PEDIADERM HC 3

QL

PA

PEDIAPRED 3

prednicarbate 1

prednisolone 15 mg/5 ml solution 1

prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 mlsolution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5ml solution, 30 mg tab rapdis)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)

1

PREDNISONE INTENSOL 1

PROCTO-MED HC 1

PROCTO-PAK 1

PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3

PROCTOSOL-HC 1

PROCTOZONE-HC 1

PSORCON 3

RAYOS 3 PA

SANADERMRX 3

QL

PA

SCALACORT 1



SERNIVO 3

QL

ST

SILALITE PAK 3

QL

PA

SILAZONE-II 3

QL

PA

SYNALAR (0.01% SOLUTION, 0.025% CREAM, 0.025% OINTMENT) 3

SYNALAR TS 3

QL

PA

TAPERDEX 3

QL

PA

TEMOVATE 3

TEXACORT 3

TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM,0.25% OINTMENT, 0.25% SPRAY)

3

TRI-SILA 3

QL

PA

triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.147mg/g aerosol, 0.5 % cream(g), 0.5 % oint. (g))

1

TRIANEX 3

TRIDERM 1

TRIDESILON 3

ULTRAVATE (CREAM, OINTMENT) 3

ULTRAVATE 0.05% LOTION 3

QL

ST

ULTRAVATE X 3

QL

PA

VANOS 3 ST

VERDESO 3 ST

VERIPRED 20 3

WHYTEDERM TRILASIL PAK 3

QL

PA

ZODEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 3

QL

PA



HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

BRAVELLE 3

QL

PA

S

MS

chorionic gonadotropin, human 1

QL

PA

S

MS

DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3

DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3

S

MS

DDAVP 0.01% NASAL SPRAY 3

desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet,10/spray spray/pump)

1

desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1

S

MS

desmopressin acetate (non-refrigerated) 1

EGRIFTA (1 MG VIAL, 2 MG VIAL) 3

QL

PA

S

FOLLISTIM AQ (75 VIAL, 300 CARTRIDG, 600 CARTRIDG, 900 CARTRIDG) 3

QL

PA

ST

S

MS

GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG,MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MG CARTRIDGE)

3

PA

ST

S

MS

GONAL-F 2

QL

PA

S

MS



HUMATROPE 3

PA

ST

S

MS

INCRELEX 3

PA

S

MS

MENOPUR 3

PA

S

MS

NOCDURNA 3 QL

NOCTIVA 3

QL

S

NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5, 30 MG/3 ML) 3

PA

ST

S

MS

NOVAREL 10,000 UNITS VIAL 1

QL

PA

S

MS

NUTROPIN AQ 3

PA

ST

S

MS

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2

PA

S

MS

OVIDREL 3

PA

S

MS



PREGNYL 1

QL

PA

S

MS

SAIZEN 3

QL

PA

ST

S

MS

SEROSTIM 3

QL

PA

S

MS

STIMATE 3 S

ZOMACTON 3

QL

PA

S

MS

ZORBTIVE 3

QL

PA

S

MS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 3

OXANDRIN 3

oxandrolone 1

ANDROGENS

ANDRODERM 2 PA

ANDROGEL 2 PA

ANDROID 3 PA

ANDROXY 1 PA



AXIRON 3 PA

danazol 1

DEPO-TESTOSTERONE 3

FORTESTA 3 PA

METHITEST 1 PA

methyltestosterone 1 PA

NATESTO 3

QL

PA

STRIANT 3 PA

TESTIM 3 PA

testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel packet, 20.25/1.25 gel mdpmp, 25mg(1%) gel packet, 30mg/1.5ml sol md pmp)

1 PA

TESTOSTERONE (10 MG (2%) GEL MD PMP, 12.5/1.25G GEL MD PMP, 50MG (1%) GEL (GRAM)

3 PA

TESTOSTERONE (50 MG (1%) GEL PACKET). SOME MANUFACTURERSARE T3 AND OTHERS T1

3 PA

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1

testosterone enanthate 200 mg/ml vial 1

TESTRED 3 PA

VOGELXO 3 PA

ESTROGENS

ACTIVELLA 3

AFTERA 0 C Covered in full

ALORA 3 QL

ALTAVERA 0 C Covered in full

ALYACEN 0 C Covered in full

AMABELZ 1

AMETHIA 0 C Covered in full

AMETHIA LO 0 C Covered in full

AMETHYST 0 C Covered in full

ANGELIQ 3

APRI 0 C Covered in full



ARANELLE 0 C Covered in full

ASHLYNA 0 C Covered in full

AUBRA 0 C Covered in full

AUBRA EQ 0 C Covered in full

AVIANE 0 C Covered in full

AZURETTE 0 C Covered in full

BALCOLTRA 0 C Covered in full

BALZIVA 0 C Covered in full

BEKYREE 0 C Covered in full

BEYAZ 3

BLISOVI 24 FE 0 C Covered in full

BLISOVI FE 0 C Covered in full

BREVICON 3

BRIELLYN 0 C Covered in full

CAMRESE 0 C Covered in full

CAMRESE LO 0 C Covered in full

CAZIANT 0 C Covered in full

CHATEAL 0 C Covered in full

CHATEAL EQ 0 C Covered in full

CLIMARA 3 QL

CLIMARA PRO 2

COMBIPATCH 3

COVARYX 1

COVARYX H.S. 1

CRYSELLE 0 C Covered in full

CYCLAFEM 0 C Covered in full

CYCLESSA 3

CYRED 0 C Covered in full



DASETTA 0 C Covered in full

DAYSEE 0 C Covered in full

DELESTROGEN 3

DELYLA 0 C Covered in full

DEPO-ESTRADIOL 3

DESOGEN 3

desogestrel-ethinyl estradiol 0 C Covered in full

desogestrel-ethinyl estradiol/ethinyl estradiol 0 C Covered in full

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL PACKET) 3

drospirenone/ethinyl estradiol/levomefolate calcium 0 C Covered in full

ECONTRA ONE-STEP 0 C Covered in full

EEMT 1

EEMT H.S. 1

ELESTRIN 3

ELINEST 0 C Covered in full

EMOQUETTE 0 C Covered in full

ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)

3 QL

ENPRESSE 0 C Covered in full

ENSKYCE 0 C Covered in full

ESTARYLLA 0 C Covered in full

ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3

ESTRACE 0.01% CREAM 2

estradiol (.025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patchtdsw, .0375mg/24 patch tdwk, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,0.06mg/24h patch tdwk, .075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk)

1 QL

estradiol (0.01 % cream/appl, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 10 mcgtablet)

1

estradiol valerate 1

estradiol/norethindrone acetate 1

ESTRING 3

ESTROGEL 3

estrogens,esterified/methyltestosterone 1



estropipate 1

ESTROSTEP FE 3

ethinyl estradiol/drospirenone 0 C Covered in full

ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 0 C Covered in full

ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 0 C Covered in full

EVAMIST 3

FALMINA 0 C Covered in full

FAYOSIM 0 C Covered in full

FEMCON FE 3

FEMHRT 3

FEMRING 3

FEMYNOR 0 C Covered in full

FYAVOLV 1

GENERESS FE 3

GIANVI 0 C Covered in full

GILDAGIA 0 C Covered in full

GILDESS 24 FE 0 C Covered in full

IMVEXXY 3

INTROVALE 0 C Covered in full

ISIBLOOM 0 C Covered in full

JEVANTIQUE LO 1

JINTELI 1

JOLESSA 0 C Covered in full

JULEBER 0 C Covered in full

JUNEL 0 C Covered in full

JUNEL FE 0 C Covered in full

JUNEL FE 24 0 C Covered in full

KAITLIB FE 0 C Covered in full

KARIVA 0 C Covered in full



KELNOR 1-35 0 C Covered in full

KELNOR 1-50 0 C Covered in full

KIMIDESS 0 C Covered in full

KURVELO 0 C Covered in full

l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 0 C Covered in full

LARIN 0 C Covered in full

LARIN 24 FE 0 C Covered in full

LARIN FE 0 C Covered in full

LARISSIA 0 C Covered in full

LAYOLIS FE 0 C Covered in full

LEENA 0 C Covered in full

LESSINA 0 C Covered in full

LEVONEST 0 C Covered in full

levonorgestrel 0 C Covered in full

levonorgestrel-ethinyl estradiol 0 C Covered in full

levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)

0 C Covered in full

LEVORA-28 0 C Covered in full

LILLOW 0 C Covered in full

LO LOESTRIN FE 0 C Covered in full

LOESTRIN 3

LOESTRIN FE 3

LOMEDIA 24 FE 0 C Covered in full

LOPREEZA 1

LORYNA 0 C Covered in full

LOSEASONIQUE 3

LOW-OGESTREL 0 C Covered in full

LUTERA 0 C Covered in full

MARLISSA 0 C Covered in full



MELODETTA 24 FE 0 C Covered in full

MENEST 3

MENOSTAR 3 QL

MIBELAS 24 FE 0 C Covered in full

MICROGESTIN 0 C Covered in full

MICROGESTIN 24 FE 0 C Covered in full

MICROGESTIN FE 0 C Covered in full

MILI 0 C Covered in full

MIMVEY 1

MIMVEY LO 1

MINASTRIN 24 FE 3

MINIVELLE 3 QL

MIRCETTE 3

MONO-LINYAH 0 C Covered in full

MONONESSA 0 C Covered in full

MY CHOICE 0 C Covered in full

MY WAY 0 C Covered in full

MYZILRA 0 C Covered in full

NATAZIA 0 C Covered in full

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, 7-7-7-28TABLET, 10-11-28 TABLET)

0 C Covered in full

NEW DAY 0 C Covered in full

NIKKI 0 C Covered in full

norethindrone ac-eth estradiol 1mg-20mcg tablet 0 C Covered in full

norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 1

norethindrone acetate-ethinyl estradiol/ferrous fumarate 0 C Covered in full

norethindrone-ethinyl estradiol/ferrous fumarate 0 C Covered in full

norgestimate-ethinyl estradiol 0 C Covered in full

NORINYL 1-35 3



NORTREL 0 C Covered in full

NUVARING 0 C Covered in full

OCELLA 0 C Covered in full

OGESTREL 0 C Covered in full

ORSYTHIA 0 C Covered in full

ORTHO TRI-CYCLEN 3

ORTHO TRI-CYCLEN LO 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 3

OVCON-35 3

PHILITH 0 C Covered in full

PIMTREA 0 C Covered in full

PIRMELLA 0 C Covered in full

PLAN B ONE-STEP 0 C Covered in full

PORTIA 0 C Covered in full

PREFEST 3

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)

2

PREMPHASE 2

PREMPRO 2

PREVIFEM 0 C Covered in full

QUARTETTE 3

QUASENSE 0 C Covered in full

RAJANI 0 C Covered in full

RECLIPSEN 0 C Covered in full

RIVELSA 0 C Covered in full

SAFYRAL 3

SEASONIQUE 3

SETLAKIN 0 C Covered in full

SPRINTEC 0 C Covered in full



SRONYX 0 C Covered in full

SYEDA 0 C Covered in full

TAKE ACTION 0 C Covered in full

TARINA FE 0 C Covered in full

TAYTULLA 0 C Covered in full

TILIA FE 0 C Covered in full

TRI FEMYNOR 0 C Covered in full

TRI-ESTARYLLA 0 C Covered in full

TRI-LEGEST FE 0 C Covered in full

TRI-LINYAH 0 C Covered in full

TRI-LO-ESTARYLLA 0 C Covered in full

TRI-LO-MARZIA 0 C Covered in full

TRI-LO-SPRINTEC 0 C Covered in full

TRI-MILI 0 C Covered in full

TRI-NORINYL 3

TRI-PREVIFEM 0 C Covered in full

TRI-SPRINTEC 0 C Covered in full

TRI-VYLIBRA 0 C Covered in full

TRINESSA 0 C Covered in full

TRINESSA LO 0 C Covered in full

TRIVORA-28 0 C Covered in full

TYDEMY 0 C Covered in full

VAGIFEM 3

VELIVET 0 C Covered in full

VESTURA 0 C Covered in full

VIENVA 0 C Covered in full

VIORELE 0 C Covered in full

VIVELLE-DOT 3 QL



VYFEMLA 0 C Covered in full

VYLIBRA 0 C Covered in full

WERA 0 C Covered in full

WYMZYA FE 0 C Covered in full

XULANE 0 C Covered in full

YASMIN 28 3

YAZ 3

YUVAFEM 1

ZARAH 0 C Covered in full

ZENCHENT 0 C Covered in full

ZENCHENT FE 0 C Covered in full

ZOVIA 1-35E 0 C Covered in full

ZOVIA 1-50E 0 C Covered in full

PROGESTERONE AGONISTS/ANTAGONISTS

ELLA 0 C Covered in full

PROGESTINS

AYGESTIN 3

CAMILA 0 C Covered in full

CRINONE 4% GEL 3

CRINONE 8% GEL 3 S

DEBLITANE 0 C Covered in full

DEPO-SUBQ PROVERA 104 0 C Covered in full

ECONTRA EZ 0 C Covered in full

ENDOMETRIN 3

PA

S

ERRIN 0 C Covered in full

FALLBACK SOLO 0 C Covered in full

HEATHER 0 C Covered in full

INCASSIA 0 C Covered in full



JENCYCLA 0 C Covered in full

JOLIVETTE 0 C Covered in full

KYLEENA 0 C Covered in full as medicalbenefit

LILETTA 0 C Covered in full as medicalbenefit

LYZA 0 C Covered in full

medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 0 C Covered in full

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1

MEGACE 3

MEGACE ES 3

megestrol acetate (20 mg tablet, 40 mg tablet) 1

megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1

MIRENA 0 C Covered in full as medicalbenefit

NEXPLANON 0 C Covered in full as medicalbenefit

NEXT CHOICE ONE DOSE 0 C Covered in full

NOR-Q-D 3

NORA-BE 0 C Covered in full

norethindrone 0 C Covered in full

norethindrone acetate 5 mg tablet 1

NORLYDA 0 C Covered in full

NORLYROC 0 C Covered in full

OPCICON ONE-STEP 0 C Covered in full

OPTION 2 0 C Covered in full

ORTHO MICRONOR 3

progesterone 1

S

MS

progesterone, micronized 1

PROMETRIUM 3

PROVERA 3

SHAROBEL 0 C Covered in full



SKYLA 0 C Covered in full as medicalbenefit

TULANA 0 C Covered in full

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

clomiphene citrate 1

DUAVEE 2

EVISTA 3

OSPHENA 3 ST

raloxifene hcl 1

SEROPHENE 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 3

CYTOMEL 3

LEVO-T 1

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)

1

LEVOXYL 1

liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1

NATURE-THROID 3

NP THYROID 1

SYNTHROID 3

THYROLAR-1 3

THYROLAR-1/2 3

THYROLAR-1/4 3

THYROLAR-2 3

THYROLAR-3 3

TIROSINT 3

UNITHROID 1

WESTHROID 3

WP THYROID 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 1



CETROTIDE 3

PA

S

MS

GANIRELIX ACETATE 3

PA

S

MS

leuprolide acetate 1

PA

S

LUPANETA PACK 3

S

MS

octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)

1

S

MS

ORILISSA (150 MG TABLET, 200 MG TABLET) 3

QL

PA

SANDOSTATIN 3

S

MS

SANDOSTATIN LAR 3

S

MS

SANDOSTATIN LAR DEPOT 3

S

MS

SIGNIFOR 3

PA

S

MS

SOMATULINE DEPOT 3

QL

S

MS

SOMAVERT 3

PA

S

MS

SYNAREL 3



HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

SSKI 3

TAPAZOLE 3

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT 3

QL

PA

S

MS

CINRYZE 3

QL

PA

S

MS

FIRAZYR 3

QL

PA

S

MS

HAEGARDA 3

QL

PA

S

MS

RUCONEST 3

QL

PA

S

MS

TAKHZYRO 3

QL

PA

S

MS



IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3

QL

PA

S

AZASAN 3

ST

S

azathioprine 1 S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 3 S

CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) 3

QL

PA

ST

S

MS

cyclosporine (25 mg capsule, 100 mg capsule) 1 S

cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100mg/ml solution)

1 S

ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2

QL

PA

S

MS

ENBREL MINI 2

QL

PA

S

MS

ENBREL SURECLICK 2

QL

PA

S

MS

ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3

QL

PA

S

GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)

1 S



HUMIRA 2

QL

PA

S

MS

IMURAN 3 S

KINERET 3

QL

PA

ST

S

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1

methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1 S

mycophenolate sodium 1 S

MYFORTIC 3 S

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100MG/ML SOLUTION)

3 S

OLUMIANT 3

QL

PA

S

MS

ORENCIA 3

QL

PA

ST

S

MS

OTREXUP 3 PA

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3 S

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)

3 S

RASUVO 3 PA

RHEUMATREX 3

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLN) 3 S



SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/MLPEN INJECTOR, 100 MG/ML SYRINGE)

3

QL

PA

ST

S

MS

sirolimus 1 S

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1 S

TREXALL 3

XATMEP 3 PA

XELJANZ 10 MG TABLET 2

QL

PA

S

MS

XELJANZ 5 MG TABLET 2

PA

S

MS

XELJANZ XR 2

QL

PA

S

MS

ZORTRESS 3 S

IMMUNOMODULATORS

ACTEMRA 162 MG/0.9 ML SYRINGE 2

QL

PA

S

MS

ACTIMMUNE 3

PA

S

MS

ARAVA 3

ARCALYST 3

PA

S

MS



BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3

QL

PA

S

MS

DUPIXENT 300 MG/2 ML SAFE SYRG 3

QL

PA

S

MS

GRASTEK 3 QL

KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 ML SYRINGE, 200MG/1.14 ML PEN INJ, 200 MG/1.14 ML SYRINGE)

3

QL

PA

ST

S

MS

leflunomide 1

ORALAIR 3

QL

S

OTEZLA 2

QL

PA

S

MS

RAGWITEK 3 QL

RIDAURA 3

VACCINES

XOFLUZA 3 QL

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 3 QL

ASACOL HD 3

balsalazide disodium 1

CANASA 3

COLAZAL 3



DELZICOL 2

DIPENTUM 3

GIAZO 3

QL

PA

LIALDA 3

mesalamine (1.2 g tablet dr, 4 g/60 ml enema) 1

MESALAMINE 800 MG TABLET DR 1

mesalamine with cleansing wipes 1

QL

PA

PENTASA 2

ROWASA 4 GM/60 ML ENEMA KIT 3

QL

PA

SFROWASA 3

GLUCOCORTICOIDS

budesonide 3 mg capdr - er 1

budesonide 9 mg tabdr - er 1

QL

PA

COLOCORT 1

CORTENEMA 3

CORTIFOAM 3

ENTOCORT EC 3

hydrocortisone 100mg/60ml enema 1

UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3

QL

PA

SULFONAMIDES

AZULFIDINE 3

sulfasalazine 1

METABOLIC BONE DISEASE AGENTS

ACTONEL (5 MG TABLET, 30 MG TABLET, 35 MG TABLET, 150 MGTABLET)

3 QL

alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70mg tablet)

1 QL

alendronate sodium 70 mg/75ml solution 1

ATELVIA 3 QL



BINOSTO 3 QL

BONIVA 150 MG TABLET 3 QL

calcitonin,salmon,synthetic 1

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1

DRISDOL 3

ergocalciferol (vitamin d2) 50000 unit capsule 1

etidronate disodium 1

FORTEO 3

PA

S

MS

FORTICAL 3

FOSAMAX 3 QL

FOSAMAX PLUS D 3 QL

HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 3

ibandronate sodium 150 mg tablet 1 QL

MIACALCIN 200 UNIT NASAL SPRAY 3

NATPARA 3

QL

PA

S

MS

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1

RAYALDEE 3

risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)

1 QL

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORALSOLN)

3

SENSIPAR 3

TRIXYLITRAL 3

QL

PA

TYMLOS 3

QL

PA

S

MS



ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3

MISCELLANEOUS THERAPEUTIC AGENTS

BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2

cervical cap 0 C Covered in full

CETYLEV 3

COMFORT PAC-MELOXICAM 3

QL

PA

COMFORT PAC-NAPROXEN 3

QL

PA

condoms, female 0 C Covered in full

diaphragms, contoured 0 C Covered in full

diaphragms, wide seal 0 C Covered in full

FLEXIPAK 3

QL

PA

foam/gauze bandage/lidocaine/chlorhexidine/isopropyl alcohol 3

QL

PA

INFLAMMACIN 3

QL

PA

INTRAROSA 3 QL

isometheptene mucate/dichloralphenazone/acetaminophen 1

LOKELMA (5 POWDER PACKET, 10 POWDER PACKET) 2 QL

METHERGINE 1 QL

methylergonovine maleate 0.2 mg tablet 1 QL

NODOLOR 1

NUDICLO TABPAK 3

QL

PA

NUDROXIPAK DSDR-50 3

QL

PA




QL

PA

NUDROXIPAK E-400 3

QL

PA

NUDROXIPAK I-800 3

QL

PA

NUDROXIPAK N-500 3

QL

PA

ODACTRA 3 QL

PARAGARD T 380-A 0 C Covered in full as medicalbenefit

PREVIDOLRX PLUS ANALGESIC PAK 3

QL

PA

SAXENDA 3

QL

PA

silver/bandage/foam/gauze/lidocaine/chlorhexidin/isopropanol 3

QL

PA

syringe, insulin u-500 with needle, disposable, 0.5 ml 3

XENAFLAMM 3

QL

PA

XERMELO 3

QL

PA

MODIFIED SOLID FOODS

All modified solid foods are covered as brands with Prior Authorization

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

AKTEN 3

ALCAINE 3

atropine sulfate (1 % drops, 1 % oint. (g)) 1

bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 3



cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1

CYSTARAN 3

PA

S

ISOPTO ATROPINE 1% EYE DROP 3

ISOPTO ATROPINE 1% EYE DROPS 3

LACRISERT 3

MAXITROL (DROPS, OINTMENT) 3

MITOSOL 3

NAPHAZOLINE 0.1% 3

NEO-POLYCIN 1

NEO-POLYCIN HC 1

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1

neomycin sulfate/bacitracin/polymyxin b 1

neomycin sulfate/polymyxin b sulfate/gramicidin d 1

neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))

1

neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1

NEOSPORIN EYE DROPS 3

PAREMYD 3

phenylephrine hcl (2.5 % drops, 10 % drops) 1

POLYCIN 1

polymyxin b sulfate/trimethoprim 1

POLYTRIM 3

PRED-G (1% DROPS, S.O.P. OINTMENT) 3

proparacaine hcl 1

RESTASIS 2 QL

RESTASIS MULTIDOSE 2 QL

sulfacetamide sodium/prednisolone sodium phosphate 1

TETRAVISC 3

TETRAVISC FORTE 3

TOBRADEX (DROPS, OINTMENT) 3

TOBRADEX ST 3



tobramycin/dexamethasone 1

tropicamide (0.5 % drops, 1 % drops) 1

XIIDRA 2 QL

ZYLET 3

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 3

ALOMIDE 3

azelastine hcl 0.05 % drops 1

BEPREVE 3

cromolyn sodium 4 % drops 1

ELESTAT 3

EMADINE 3

epinastine hcl 1

LASTACAFT 3

olopatadine hcl (0.1 % drops, 0.2 % drops) 1

PATADAY 3

PATANOL 3

PAZEO 3

OPHTHALMIC ANTI-INFLAMMATORIES

ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 3

bromfenac sodium 1

BROMSITE 3 QL

dexamethasone sodium phosphate 0.1 % drops 1

diclofenac sodium 0.1 % drops 1

DUREZOL 3

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 3



FML FORTE 3

FML S.O.P. 3

ILEVRO 3

ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1

LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2

MAXIDEX 3

NEVANAC 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

prednisolone acetate 1

prednisolone sod phosphate 1 % drops 1

PROLENSA 3 QL

VEXOL 3

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 2

apraclonidine hcl 1

AZOPT 3

BETAGAN 3

betaxolol hcl 0.5 % drops 1

BETIMOL 3

BETOPTIC S 3

brimonidine tartrate 1

carteolol hcl 1

COMBIGAN 2 QL

COSOPT 3

COSOPT PF 3 QL

dorzolamide hcl 1

dorzolamide hcl/timolol maleate 1

dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL

IOPIDINE (0.5% DROPS, 1% DROPS) 3



ISOPTO CARPINE 3

ISTALOL 3

levobunolol hcl 1

methazolamide 1

metipranolol 1

NEPTAZANE 3

PHOSPHOLINE IODIDE 3

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1

RESCULA 3

RHOPRESSA 3

QL

ST

SIMBRINZA 3 QL

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drop daily, 0.5 % drops,0.5 % sol-gel)

1

TIMOPTIC (0.25% DROP, 0.5% DROP) 3

TIMOPTIC (0.25% DROPS, 0.5% DROPS) 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE (0.25% EYE GEL-SOLN, 0.5% GEL-SOLUTION) 3

TIMOPTIC-XE (0.25% SOLN, 0.5% SOLN) 3

TRUSOPT 3

VYZULTA 3 ST

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2

latanoprost 1 QL

LUMIGAN 2

TRAVATAN Z 2

XALATAN 3 QL

ZIOPTAN 3

QL

ST

OTIC AGENTS

ACETASOL HC 1

acetic acid 2 % solution 1



acetic acid/aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

DERMOTIC 3

fluocinolone acetonide oil 1

hydrocortisone/acetic acid 1

neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)

1

OTOVEL 3 QL

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

AEROSPAN 3

QL

ST

ALVESCO (80 MCG INHALER, 160 MCG INHALER) 3

QL

ST

ARMONAIR RESPICLICK 2 QL

ARNUITY ELLIPTA 2 QL

ASMANEX 2 QL

ASMANEX HFA 2 QL

BECONASE AQ 3 QL

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)

1 QL

FLOVENT DISKUS 2 QL

FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)

2 QL

flunisolide 1 QL

fluticasone propionate 50 mcg spray susp 1

mometasone furoate 50 mcg spray/pump 1

NASONEX 3

OMNARIS 3 QL

PULMICORT 3 QL



PULMICORT FLEXHALER (90 MCG, 180 MCG) 3

QL

ST

QNASL 2 QL

QNASL CHILDREN 2 QL

QVAR 2 QL

QVAR REDIHALER 2 QL

RHINOCORT AQUA 3

TICANASE 3

QL

PA

TICASPRAY 3

QL

PA

triamcinolone acetonide 55 mcg spray 1

VERAMYST 3 QL

XHANCE 3

QL

PA

ZETONNA 3 QL

ANTIHISTAMINES

ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1

ASTEPRO 3 QL

azelastine hcl 137 mcg spray/pump 1

azelastine hcl 205.5 mcg spray/pump 1 QL

carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1

carbinoxamine maleate 6 mg tablet 1

QL

PA

cetirizine hcl 1 mg/ml solution 1

CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET) 3

clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup) 1

QL

PA

cyproheptadine hcl 4 mg tablet 1



desloratadine 1

diphenhydramine hcl 12.5mg/5ml elixir 1

hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)

1

hydroxyzine pamoate 1

KARBINAL ER 3 QL

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL

levocetirizine dihydrochloride 5 mg tablet 1

olopatadine hcl 0.6 % spray/pump 1 QL

PATANASE 3 QL

promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1

RYCLORA 3 QL

RYVENT 3

QL

PA

VISTARIL 3

XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET) 3

ANTILEUKOTRIENES

ACCOLATE 3

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)

1 QL

SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG TABLET CHEW,10 MG TABLET)

3 QL

zafirlukast 1

zileuton 1 QL

ZYFLO 3 QL

ZYFLO CR 3 QL

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT 3

ATROVENT HFA 2

INCRUSE ELLIPTA 3 QL

ipratropium bromide 1

LONHALA MAGNAIR REFILL 3

QL

ST



LONHALA MAGNAIR STARTER 3

QL

ST

SEEBRI NEOHALER 3

SPIRIVA 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3 QL

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK 3 QL

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)

1

ARCAPTA NEOHALER 3 QL

AUVI-Q (0.15 MG, 0.3 MG) 3

QL

PA

BROVANA 3

epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1

epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1 QL

EPIPEN 2 QL

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

FORADIL 2 QL

levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)

1

levalbuterol tartrate 1

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1

PERFOROMIST 3 QL

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROVENTIL HFA 3 QL

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 2 QL

terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1



VENTOLIN HFA 2 QL

VOSPIRE ER 3

XOPENEX 3

XOPENEX CONCENTRATE 3

XOPENEX HFA 3

CYSTIC FIBROSIS AGENTS

BETHKIS 3

QL

S

MS

CAYSTON 3

S

MS

KALYDECO 3

QL

PA

S

MS

KITABIS PAK 3

S

MS

ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)

3

QL

PA

S

MS

PULMOZYME 3

S

MS

SYMDEKO 3

QL

PA

S

MS

TOBI PODHALER 3

QL

S

tobramycin/nebulizer 1

S

MS



MAST CELL STABILIZERS

cromolyn sodium 20 mg/2 ml ampul-neb 1

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate 60 mg/3 ml solution 1

DALIRESP (250 MCG TABLET, 500 MCG TABLET) 3

QL

ST

ELIXOPHYLLIN 3

THEO-24 3

THEOCHRON 1

theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)

1

PULMONARY ANTIHYPERTENSIVES

ADCIRCA 3

QL

PA

S

MS

ADEMPAS 3

QL

PA

S

MS

LETAIRIS 3

QL

PA

S

MS

OPSUMIT 3

QL

PA

S

MS

ORENITRAM ER 3

PA

S

MS



REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3

QL

PA

S

MS

sildenafil citrate 20 mg tablet 1

QL

PA

S

MS

TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3

PA

S

MS

TRACLEER 32 MG TABLET FOR SUSP 3

QL

PA

S

MS

TYVASO 3

QL

PA

S

MS

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400 MCG TABLET,600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)

3

QL

PA

S

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2

QL

PA

S

MS

OFEV 2

QL

PA

S

MS

RESPIRATORY TRACT AGENTS, OTHER

acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1



ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

AIRDUO RESPICLICK 3

QL

ST

ANORO ELLIPTA 2 QL

benzonatate 1

BEVESPI AEROSPHERE 2 QL

BREO ELLIPTA 100-25 MCG INH 2 QL

BREO ELLIPTA 200-25 MCG INH 2

BROMFED DM 1

brompheniramine/pseudoephed/dm 2-30-10/5 syrup 1

CENTERGY DM 1

CLARINEX-D 12 HOUR 3

COMBIVENT RESPIMAT 2 QL

CUROSURF 3

DULERA 3 QL

DYMISTA 3

QL

PA

FLOWTUSS 3 QL

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 2 QL

guaifenesin/hydrocodone bitartrate 3

QL

PA

HYCOFENIX 3

hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1

hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)

1

hydrocodone polistirex/chlorpheniramine polistirex 1 QL

HYDROMET 1

ipratropium bromide/albuterol sulfate 1

NEBUSAL 3% VIAL 1

OBREDON 3 QL



phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1

promethazine hcl/codeine 1

promethazine/dextromethorphan 6.25-15/5 syrup 1

promethazine/phenyleph/codeine 6.25-5-10 syrup 1

REZIRA 3

ribavirin 6 g vial-neb 1 MS

SEMPREX-D 3

sodium chloride for inhalation 1

STIOLTO RESPIMAT 2 QL

SYMBICORT 2 QL

TESSALON PERLE 3

TICALAST 3

QL

PA

TOBI 3 S

tobramycin in 0.225 % sodium chloride 1 S

TRELEGY ELLIPTA 3

QL

ST

TUSSICAPS 3

TUSSIGON 1

TUSSIONEX 3

QL

ST

TUZISTRA XR 3 ST

TYZINE 3

UTIBRON NEOHALER 2

VIRAZOLE 3

VITUZ 3 QL

ZUTRIPRO 3

SKELETAL MUSCLE RELAXANTS

AMRIX 3

QL

PA

carisoprodol 250 mg tablet 1

QL

PA



carisoprodol 350 mg tablet 1

carisoprodol/aspirin 200-325 mg tablet 1

chlorzoxazone 250 mg tablet 1

QL

PA

chlorzoxazone 500 mg tablet 1 QL

COMFORT PAC-CYCLOBENZAPRINE 3

QL

PA

COMFORT PAC-TIZANIDINE 3

QL

PA

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1

cyclobenzaprine hcl 7.5 mg tablet 1

QL

PA

FEXMID 3

QL

PA

LORZONE 3

QL

PA

METAXALL 1 QL

metaxalone 400 mg tablet 1

metaxalone 800 mg tablet 1 QL

methocarbamol (500 mg tablet, 750 mg tablet) 1

orphenadrine citrate 100 mg tablet er 1

PARAFON FORTE DSC 3 QL

ROBAXIN 500 MG TABLET 3

ROBAXIN-750 3

SKELAXIN 3 QL

SOMA 250 MG TABLET 3

QL

PA

SOMA 350 MG TABLET 3



SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

AMBIEN (5 MG TABLET, 10 MG TABLET) 3 QL

AMBIEN CR 3 QL

DORAL 3

EDLUAR 3

QL

ST

estazolam 1

eszopiclone 1 QL

flurazepam hcl 1

HALCION 3

INTERMEZZO 3

QL

ST

LUNESTA 3 QL

quazepam 1

RESTORIL 3

SONATA (5 MG CAPSULE, 10 MG CAPSULE) 3 QL

temazepam 1

triazolam 1

zaleplon (5 mg capsule, 10 mg capsule) 1 QL

zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)

1 QL

ZOLPIMIST 3

QL

ST

SLEEP DISORDERS, OTHER

armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL

BELSOMRA 3

QL

ST

BUTISOL SODIUM 3

HETLIOZ 3

QL

PA

S

MS



modafinil 1 QL

NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 250 MGTABLET)

3 QL

PROVIGIL 3 QL

ROZEREM 3

QL

ST

SECONAL SODIUM 3

SILENOR 3

QL

ST

XYREM 3

QL

PA

S


Index of covered drugs

88-MOP 84

Aabacavir sulfate 54

abacavir sulfate/lamivudine 54

abacavir sulfate/lamivudine/zidovudine 54

ABILIFY 48

ABILIFY DISCMELT 48

ABSORICA 84

ABSTRAL 8

acamprosate calcium 13

ACANYA 84

acarbose 58

ACCOLATE 138

ACCUPRIL 67

ACCURETIC 70

acebutolol hcl 68

ACEON 67

acetaminophen with codeine phosphate 9

ACETAMINOPHEN/CAFF/DIHYDROCOD 325-

30-16 TABLET 9

acetaminophen/caffeine/dihydrocodeine

bitartrate 9

ACETASOL HC 135

acetazolamide 73

acetic acid 135

acetic acid/aluminum acetate 136

acetylcysteine 142

ACIPHEX 98

ACIPHEX SPRINKLE 98

acitretin 84

ACTEMRA 126

ACTICLATE 20

ACTIGALL 95

ACTIMMUNE 126

ACTIQ 9

ACTIVELLA 111

ACTONEL 128

ACTOPLUS MET 58

ACTOPLUS MET XR 58

ACTOS 58

ACULAR 133

ACULAR LS 133

ACUVAIL 133

acyclovir 56

ACZONE 84

ADALAT CC 69

adapalene 84

ADAPALENE 0.1% LOTION 84

adapalene/benzoyl peroxide 84

ADASUVE 47

ADCIRCA 141

ADDERALL 77

ADDERALL XR 77

ADDYI 102

adefovir dipivoxil 50

ADEMPAS 141

ADIPEX-P 79

ADLYXIN 58

ADMELOG 62

ADMELOG SOLOSTAR 62

ADOXA 20

ADRENACLICK 139

ADVAIR DISKUS 143

ADVAIR HFA 143

ADZENYS ER 77

ADZENYS XR-ODT 77

AEROSPAN 136

AFEDITAB CR 69

AFINITOR 39

AFREZZA 62

AFTERA 111

AGRYLIN 64

AIMOVIG AUTOINJECTOR 32

AIMOVIG AUTOINJECTOR (2 PACK) 32

AIRDUO RESPICLICK 143

AJOVY 33

AKTEN 131

AKTIPAK 14

AKYNZEO 29

ALA-CORT 103

ALA-SCALP 103

albendazole 45

ALBENZA 45

albuterol sulfate 139

ALCAINE 131

alclometasone dipropionate 103

ALDACTAZIDE 70

ALDACTONE 74

ALDARA 84

ALECENSA 39

alendronate sodium 128

ALEVICYN PLUS 84

ALFERON N 56

alfuzosin hcl 101

ALINIA 45

ALKERAN 35

allopurinol 32

ALLZITAL 79

almotriptan malate 33

ALOCRIL 133

ALOGLIPTIN BENZOATE 58

alogliptin benzoate/metformin hcl 58

alogliptin benzoate/pioglitazone hcl 58

ALOMIDE 133

ALORA 111

alosetron hcl 97

ALPHAGAN P 134

alprazolam 57

ALPRAZOLAM INTENSOL 57

ALREX 133

ALTABAX 14

ALTACE 67

ALTAVERA 111

ALTOPREV 75

ALTRENO 84

ALUNBRIG 37

ALVESCO 136

ALYACEN 111

AMABELZ 111

amantadine hcl 46


AMARYL 58

AMBIEN 146

AMBIEN CR 146

amcinonide 103

AMELUZ 84

AMERGE 33

AMETHIA 111

AMETHIA LO 111

AMETHYST 111

AMICAR 65

amiloride hcl 74

amiloride hcl/hydrochlorothiazide 70

aminocaproic acid 65

amiodarone hcl 68

AMITIZA 97

amitriptyline hcl 28

amitriptyline hcl/chlordiazepoxide 25

amlodipine besylate 69

amlodipine besylate/atorvastatin calcium 70

amlodipine besylate/benazepril hcl 71

amlodipine besylate/olmesartan medoxomil 71

amlodipine besylate/valsartan 71

amlodipine

besylate/valsartan/hydrochlorothiazide 71

ammonium lactate 84

AMNESTEEM 84

amoxapine 28

amoxicillin 17

AMOXICILLIN ER 775 MG 17

amoxicillin/potassium clavulanate 18

amphetamine sulfate 77

ampicillin trihydrate 18

AMPYRA 82

AMRIX 144

ANA-LEX 84

ANACAINE 12

ANADROL-50 110

ANAFRANIL 28

anagrelide hcl 64

ANALPRAM E 84

ANALPRAM HC 84

ANAPROX 5

ANAPROX DS 5

ANASPAZ 94

ANASTIA 12

anastrozole 38

ANCOBON 30

ANDRODERM 110

ANDROGEL 110

ANDROID 110

ANDROXY 110

ANGELIQ 111

ANODYNE LPT 12

ANORO ELLIPTA 143

ANTABUSE 13

ANTARA 74

ANUCORT-HC 103

ANUSOL-HC 103

ANZEMET 29

APEXICON E 103

APIDRA 62

APIDRA SOLOSTAR 62

APLENZIN 25

APOKYN 46

apraclonidine hcl 134

aprepitant 29

APRI 111

APRISO 127

APTENSIO XR 78

APTIOM 24

APTIVUS 55

ARANELLE 112

ARANESP 64

ARAVA 126

ARBINOXA 137

ARCALYST 126

ARCAPTA NEOHALER 139

ARICEPT 24

ARIKAYCE 14

ARIMIDEX 38

aripiprazole 48

ARIXTRA 63

armodafinil 146

ARMONAIR RESPICLICK 136

ARMOUR THYROID 121

ARNUITY ELLIPTA 136

AROMASIN 38

ARTHROTEC 50 5

ARTHROTEC 75 5

ARYMO ER 7

ASACOL HD 127

ASCOMP WITH CODEINE 9

ASHLYNA 112

ASMANEX 136

ASMANEX HFA 136

aspirin/caffeine/dihydrocodeine bitartrate 9

ASPIRIN/DIPYRIDAMOLE 65

ASTAGRAF XL 124

ASTEPRO 137

ATACAND 67

ATACAND HCT 71

atazanavir sulfate 55

ATELVIA 128

atenolol 68

atenolol/chlorthalidone 71

ATIVAN 57

atomoxetine hcl 78

atorvastatin calcium 75

atovaquone 45

atovaquone/proguanil hcl 45

ATRALIN 84

ATRAPRO DERMAL SPRAY 84

ATRIPLA 53

atropine sulfate 131

ATROVENT 138

ATROVENT HFA 138

AUBAGIO 82

AUBRA 112

AUBRA EQ 112

AUGMENTIN 18

AUGMENTIN ES-600 18

AUGMENTIN XR 18

AURYXIA 93


AUSTEDO 79

AUVI-Q 139

AVALIDE 71

AVANDIA 58

AVAPRO 67

AVAR 84

AVAR-E 84

AVAR-E GREEN 84

AVC 19

AVELOX 19

AVELOX ABC PACK 19

AVIANE 112

AVIDOXY 20

AVINZA 7

AVITA 84

AVODART 101

Avonex 82

AXERT 33

AXIRON 111

AYGESTIN 119

AZASAN 124

AZASITE 18

azathioprine 124

azelastine hcl 133,137

AZELEX 84

AZILECT 47

azithromycin 18

AZOPT 134

AZOR 71

AZULFIDINE 128

AZURETTE 112

Bbacitracin 14

bacitracin/polymyxin b sulfate 131

baclofen 49

BACTRIM 19

BACTRIM DS 20

BACTROBAN 14

BACTROBAN NASAL 14

BALCOLTRA 112

balsalazide disodium 127

BALZIVA 112

BANZEL 24

BARACLUDE 50

BASAGLAR KWIKPEN U-100 62

BAXDELA 19

BD Pen Needles T2. All other manufacturers

T3. 130

BECONASE AQ 136

BEKYREE 112

BELBUCA 7

BELSOMRA 146

BELVIQ 80

BELVIQ XR 80

benazepril hcl 67

benazepril hcl/hydrochlorothiazide 71

BENICAR 67

BENICAR HCT 71

BENLYSTA 127

BENTYL 94

BENZACLIN 84

BENZAMYCIN 14

BENZEPRO 84,85

benznidazole 45

benzonatate 143

benzoyl peroxide 85

benzphetamine hcl 80

benztropine mesylate 46

BEPREVE 133

BERINERT 123

BESIVANCE 19

BETAGAN 134

betamethasone dipropionate 103

betamethasone dipropionate/propylene

glycol 103

betamethasone valerate 103

BETAPACE 68

BETAPACE AF 68

BETASERON 82

betaxolol hcl 69,134

bethanechol chloride 102

140

134

134

143

63

44

112

18

35

71

53

45

135

129

69

71

20

131

131

112

112

129

28

80

39

85

39

94

108

143

112

112

65

BETHKIS

BETIMOL

BETOPTIC S

BEVESPI AEROSPHERE

BEVYXXA

bexarotene

BEYAZ

BIAXIN

bicalutamide

BIDIL

BIKTARVY

BILTRICIDE

bimatoprost 0.03 % drops (into the eye for

glaucoma)

BINOSTO

bisoprolol fumarate

bisoprolol fumarate/hydrochlorothiazide

BLEPH-10

BLEPHAMIDE

BLEPHAMIDE S.O.P.

BLISOVI 24 FE

BLISOVI FE

BONIVA

BONJESTA

BONTRIL PDM

BOSULIF

BPO

BRAFTOVI

BRAND RX PRENATAL VITAMINS ARE T3

AND GENERIC RX PRENATAL VITAMINS

ARE T1

BRAVELLE

BREO ELLIPTA

BREVICON

BRIELLYN

BRILINTA

brimonidine tartrate 134


BRISDELLE 26

BRIVIACT 21

BROMFED DM 143

bromfenac sodium 133

bromocriptine mesylate 46

brompheniramine maleate/pseudoephedrine

hcl/dextromethorphan 143

BROMSITE 133

BROVANA 139

BUCALSEP 12

budesonide 128,136

bumetanide 73

BUNAVAIL 13

BUPAP 80

BUPHENYL 99

buprenorphine hcl 13

buprenorphine hcl/naloxone hcl 13

BUPRENORPHINE PATCH 7

BUPROBAN 14

bupropion hcl 14,25

buspirone hcl 57

butalbital/acetaminophen 80

butalbital/acetaminophen/caffeine 80

butalbital/acetaminophen/caffeine/codeine

phosphate 9

butalbital/aspirin/caffeine 5

BUTISOL SODIUM 146

butorphanol tartrate 9

BUTRANS 7

BYDUREON 58

BYDUREON BCISE 58

BYDUREON PEN 58

BYETTA 58

BYSTOLIC 69

BYVALSON 71

Ccabergoline 121

CABOMETYX 39

CADUET 71

CAFERGOT 33

caffeine citrate 141

CALAN 69

CALAN SR 69

calcipotriene 85

calcipotriene/betamethasone dipropionate 85

calcitonin,salmon,synthetic 129

CALCITRENE 85

calcitriol 129

CALCITRIOL 3 MCG/G OINTMENT 85

calcium acetate 93

CALQUENCE 39

CAMBIA 5

CAMILA 119

CAMRESE 112

CAMRESE LO 112

CANASA 127

candesartan cilexetil 67

candesartan cilexetil/hydrochlorothiazide 71

CAPACET 80

capecitabine 37

CAPEX SHAMPOO 103

CAPITAL W-CODEINE 9

CAPRELSA 39

captopril 67

captopril/hydrochlorothiazide 71

CARAC 85

CARAFATE 98

CARBAGLU 91

carbamazepine 24

CARBATROL 24

carbidopa 47

carbidopa/levodopa 47

carbidopa/levodopa/entacapone 46

carbinoxamine maleate 137

CARDIZEM 70

CARDIZEM CD 70

CARDIZEM LA 70

CARDURA 66

CARDURA XL 101

carisoprodol 144,145

carisoprodol/aspirin 145

carisoprodol/aspirin/codeine phosphate 9

CARNITOR 91

CARNITOR SF 91

CAROSPIR 74

carteolol hcl 134

CARTIA XT 70

carvedilol 69

carvedilol phosphate 69

CASODEX 35

CATAPRES 66

CATAPRES-TTS 66

CAVERJECT 102

CAYSTON 140

CAZIANT 112

CEDAX 17

cefaclor 17

cefadroxil 17

cefdinir 17

cefditoren pivoxil 17

cefixime 17

cefpodoxime proxetil 17

cefprozil 17

CEFTIBUTEN 17

CEFTIN 17

cefuroxime axetil 17

CELEBREX 5

celecoxib 5

CELEXA 26

CELLCEPT 124

CELONTIN 22

CENTANY 14

CENTANY AT 14

CENTERGY DM 143

cephalexin 17

CERDELGA 99

cervical cap 130

CESAMET 29

cetirizine hcl 137

CETRAXAL 19

CETROTIDE 122

CETYLEV 130


cevimeline hcl 83

CHANTIX 14

CHATEAL 112

CHATEAL EQ 112

CHEMET 92

CHENODAL 95

chlordiazepoxide hcl 57

chlordiazepoxide/clidinium bromide 94

chlorhexidine gluconate 83

chloroquine phosphate 45

chlorothiazide 74

chlorpromazine hcl 47

CHLORPROPAMIDE 58

chlorthalidone 74

chlorzoxazone 145

CHOLBAM 99

cholestyramine (with sugar) 75

cholestyramine/aspartame 75

choline salicylate/magnesium salicylate 5

chorionic gonadotropin, human 108

CIALIS 101,102

CICLODAN 30

ciclopirox 30

ciclopirox olamine 30

cilostazol 66

CILOXAN 19

CIMDUO 54

cimetidine 96

cimetidine hcl 96

CIMZIA 124

CINRYZE 123

CIPRO 19

CIPRO HC 136

CIPRO XR 19

CIPRODEX 136

ciprofloxacin 19

ciprofloxacin hcl 19

ciprofloxacin/ciprofloxacin hcl 19

citalopram hydrobromide 26

CLARAVIS 85

CLARINEX 137

CLARINEX-D 12 HOUR 143

clarithromycin 18

clemastine fumarate 137

CLENPIQ 97

CLEOCIN 14

CLEOCIN HCL 14

CLEOCIN PALMITATE 14

CLEOCIN T 15

CLIMARA 112

CLIMARA PRO 112

CLINDACIN ETZ 15

CLINDACIN P 15

CLINDACIN PAC 15

CLINDAGEL 15

clindamycin hcl 15

clindamycin palmitate hcl 15

clindamycin phosphate 15

clindamycin phosphate/benzoyl peroxide 85

clindamycin phosphate/tretinoin 85

CLINDESSE 15

CLINPRO 5000 91

clobazam 22

clobetasol propionate 103

clobetasol propionate/emollient base 103

CLOBEX 103

CLOCORTOLONE PIVALATE 0.1 %

CREAM(G) 103

CLODAN 103

CLODERM 103

clomiphene citrate 121

clomipramine hcl 28

clonazepam 57

clonidine 66

clonidine hcl 66,78

clopidogrel bisulfate 66

clorazepate dipotassium 57

CLORPRES 71

clotrimazole 30

clotrimazole/betamethasone dipropionate 85

clozapine 49

CLOZARIL 49

COARTEM 45

codeine phosphate/butalbital/aspirin/caffeine 9

codeine sulfate 9

COLAZAL 127

COLCHICINE 32

COLCRYS 32

colesevelam hcl 75

COLESTID 75

colestipol hcl 75

COLOCORT 128

COLY-MYCIN S 136

COLYTE WITH FLAVOR PACKETS 97

COMBIGAN 134

COMBIPATCH 112

COMBIVENT RESPIMAT 143

COMBIVIR 54

COMETRIQ 40

COMFORT PAC-CYCLOBENZAPRINE 145

COMFORT PAC-MELOXICAM 130

COMFORT PAC-NAPROXEN 130

COMFORT PAC-TIZANIDINE 145

COMPAZINE 28

COMPLERA 53

COMPRO 28

COMTAN 46

CONCEPTROL 102

CONCERTA 78

condoms, female 130

CONDYLOX 85

CONSTULOSE 97

CONTRAVE 80

CONZIP 7

COPAXONE 82

COPEGUS 52

COPIKTRA 37

CORDARONE 68

CORDRAN 103

COREG 69

COREG CR 69

CORGARD 69

CORLANOR 71


CORMAX 103

CORTEF 104

CORTENEMA 128

CORTIFOAM 128

cortisone acetate 104

CORTISPORIN 85

CORTISPORIN-TC 136

CORZIDE 71

COSENTYX 85

COSOPT 134

COSOPT PF 134

COTELLIC 40

COTEMPLA XR-ODT 78

COUMADIN 63

COVARYX 112

COVARYX H.S. 112

COZAAR 67

CREON 99

CRESEMBA 30

CRESTOR 75

CRINONE 119

CRIXIVAN 55

cromolyn sodium 95,133,141

CROTAN 46

CRYSELLE 112

CUPRIMINE 92

CUROSURF 143

CUTIVATE 104

CUVPOSA 94

cyanocobalamin (vitamin b-12) 94

CYCLAFEM 112

CYCLESSA 112

cyclobenzaprine hcl 145

cyclopentolate hcl 132

CYCLOPHOSPHAMIDE (25 mg CAPSULE, 50

mg CAPSULE) 35

cycloserine 34

CYCLOSET 58

cyclosporine 124

cyclosporine, modified 124

CYMBALTA 81

cyproheptadine hcl 137

CYRED 112

CYSTADANE 99

CYSTAGON 99

CYSTARAN 132

CYTOMEL 121

CYTOTEC 98

CYTRA-K 91

DD.H.E.45 33

DAKLINZA 50

dalfampridine 82

DALIRESP 141

danazol 111

DANTRIUM 49

dantrolene sodium 49

dapsone 34,85

DARAPRIM 45

darifenacin hydrobromide 100

DASETTA 113

DAXBIA 17

DAYPRO 5

DAYSEE 113

DAYTRANA 78

DDAVP 108

DEBLITANE 119

DECADRON 104

DELESTROGEN 113

DELSTRIGO 53

DELTASONE 104

DELYLA 113

DELZICOL 128

DEMADEX 73

demeclocycline hcl 20

DEMEROL 9

DEMSER 71

DENAVIR 56

DENTA 5000 PLUS 91

DENTAGEL 91

DEPAKENE 22

DEPAKOTE 22

DEPAKOTE ER 22

DEPAKOTE SPRINKLE 22

DEPEN 93

DEPO-ESTRADIOL 113

DEPO-SUBQ PROVERA 104 119

DEPO-TESTOSTERONE 111

DERMA-SMOOTHE-FS 104

DERMACINRX CINLONE-I CPI 104

DERMACINRX CLORHEXACIN 85

DERMACINRX EMPRICAINE 12

DERMACINRX LEXITRAL 85

DERMACINRX PRIZOPAK 12

DERMACINRX SILAPAK 104

DERMACINRX SILAZONE 104

DERMACINRX SURGICAL PHARMAPAK 85

DERMACINRX THERAZOLE PAK 85

DERMATOP 104

DERMAZONE 104

DERMOTIC 136

DESCOVY 55

desipramine hcl 28

desloratadine 138

desmopressin acetate 108

desmopressin acetate (non-refrigerated) 108

DESOGEN 113

desogestrel-ethinyl estradiol 113

desogestrel-ethinyl estradiol/ethinyl

estradiol 113

DESONATE 104

desonide 104

DESOWEN 104

desoximetasone 104

DESOXYN 77

DESVENLAFAXINE ER 26

DESVENLAFAXINE FUMARATE 26

desvenlafaxine succinate 26

DETROL 100

DETROL LA 101

dexamethasone 104

DEXAMETHASONE INTENSOL 104


dexamethasone sodium phosphate 133

DEXEDRINE 77,78

DEXILANT 98

dexmethylphenidate hcl 78,79

dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate 78

dextroamphetamine sulfate 78

DIABETA 58

DIAMOX SEQUELS 73

diaphragms, contoured 130

diaphragms, wide seal 130

DIASTAT 22

DIASTAT ACUDIAL 22

diazepam 22,57

DIBENZYLINE 66

DICLEGIS 28

DICLO GEL 86

DICLO GEL-XRYLIX SHEET 86

diclofenac potassium 5

diclofenac sodium 5,86,133

diclofenac sodium/misoprostol 5

DICLOPR 5

dicloxacillin sodium 18

DICLOZOR 86

dicyclomine hcl 94

didanosine 54

diethylpropion hcl 80

DIFFERIN 86

DIFICID 18

diflorasone diacetate 104

DIFLUCAN 30

diflunisal 5

DIGITEK 71

DIGOX 71

digoxin 71

dihydroergotamine mesylate 33

dihydroergotamine mesylate 0.5mg/spry

spray/pump 33

DILANTIN 24

DILANTIN-125 24

DILATRATE-SR 77

DILAUDID 9

DILT-XR 70

diltiazem hcl 70

DIOVAN 67

DIOVAN HCT 71

DIPENTUM 128

diphenhydramine hcl 138

diphenoxylate hcl/atropine sulfate 95

DIPROLENE 104

DIPROLENE AF 104

dipyridamole 66

DISALCID 5

disopyramide phosphate 68

disulfiram 13

DITHOL 5

DITROPAN XL 101

DIURIL 74

divalproex sodium 22

DIVIGEL 113

dofetilide 68

DOLOPHINE HCL 7

DOLOTRANZ 12

donepezil hcl 24

DOPTELET 64

DORAL 146

DORYX 20

DORYX MPC 20

dorzolamide hcl 134

dorzolamide hcl/timolol maleate 134

dorzolamide hcl/timolol maleate/pf 134

DOVONEX 86

doxazosin mesylate 66

doxepin hcl 28

doxepin hcl 5 % cream (g) 86

doxercalciferol 129

doxycycline hyclate 20

doxycycline monohydrate 20

DOXYCYCLINE MONOHYDRATE 40 mg CAP

IR DR 20

DRISDOL 129

DRITHOCREME HP 86

dronabinol 29

drospirenone/ethinyl estradiol/levomefolate

calcium 113

DROXIA 37

DRYSOL 86

DUAC 86

DUAVEE 121

DUETACT 58

DUEXIS 5

DULERA 143

duloxetine hcl 81

DUPIXENT 86,127

DURAGESIC 7

DUREZOL 133

dutasteride 101

dutasteride/tamsulosin hcl 101

DUTOPROL 71

DUZALLO 32

DYANAVEL XR 78

DYAZIDE 71

DYMISTA 143

DYRENIUM 74

EE.E.S. 200 18

E.E.S. 400 18

EC-NAPROSYN 5

econazole nitrate 30

ECONTRA EZ 119

ECONTRA ONE-STEP 113

ECOZA 30

ED-SPAZ 94

EDARBI 67

EDARBYCLOR 71

EDECRIN 73

EDEX 102

EDLUAR 146

EDURANT 53

EEMT 113

EEMT H.S. 113

efavirenz 54


EFFER-K 91

EFFEXOR XR 26

EFFIENT 66

EFUDEX 37

EGRIFTA 108

ELDEPRYL 47

ELESTAT 133

ELESTRIN 113

eletriptan hydrobromide 33

ELIDEL 86

ELIMITE 46

ELINEST 113

ELIPHOS 93

ELIQUIS 63

ELIXOPHYLLIN 141

ELLA 119

ELLZIA PAK 104

ELMIRON 102

ELOCON 104

EMADINE 133

EMBEDA 7

EMCYT 36

EMEND 29

EMFLAZA 104

EMGALITY 33

EMLA 12

EMOQUETTE 113

EMSAM 26

EMTRIVA 54

EMVERM 45

ENABLEX 101

enalapril maleate 67

enalapril maleate/hydrochlorothiazide 71

ENBREL 124

ENBREL MINI 124

ENBREL SURECLICK 124

ENDARI 91

ENDOCET 9

ENDOMETRIN 119

ENJUVIA 113

enoxaparin sodium 63

ENPRESSE 113

ENSKYCE 113

ENSTILAR 86

entacapone 46

entecavir 50

Enteral Formula Requires Prior Authorization.

Brands are Tier 3 & generics are Tier 1. 94

ENTEREG 95

ENTOCORT EC 128

ENTRESTO 72

ENULOSE 97

ENVARSUS XR 124

EPANDED SOLUTION 67

EPCLUSA 50

EPIDIOLEX 21

EPIDUO 86

EPIDUO FORTE 86

EPIFOAM 86

epinastine hcl 133

epinephrine 139

EPIPEN 139

EPIPEN 2-PAK 139

EPIPEN JR 2-PAK 139

EPITOL 24

EPIVIR 54

EPIVIR HBV 50

eplerenone 74

EPOGEN 64

eprosartan mesylate 67

EPZICOM 54

EQUETRO 57

ergocalciferol (vitamin d2) 129

ergoloid mesylates 24

ERGOMAR 33

ergotamine tartrate/caffeine 33

ERIVEDGE 40

ERLEADA 35

ERRIN 119

ERTACZO 30

ERY 18

ERY-TAB 18

ERYGEL 18

ERYPED 200 18

ERYPED 400 18

ERYTHROCIN STEARATE 18

erythromycin base 18

erythromycin base in ethanol 18

erythromycin base/benzoyl peroxide 15

erythromycin ethylsuccinate 18

ESBRIET 142

escitalopram oxalate 26

ESGIC 80

ESOMEP-EZS 98

esomeprazole magnesium 98

esomeprazole strontium 98

ESTARYLLA 113

estazolam 146

ESTRACE 113

estradiol 113

estradiol valerate 113

estradiol/norethindrone acetate 113

ESTRING 113

ESTROGEL 113

estrogens,esterified/methyltestosterone 113

estropipate 114

ESTROSTEP FE 114

eszopiclone 146

ethacrynic acid 73

ethambutol hcl 34

ethinyl estradiol/drospirenone 114

ethosuximide 22

ethynodiol diacetate-ethinyl estradiol 114

etidronate disodium 129

etodolac 5

etoposide 39

EUCRISA 86

EURAX 46

EVAMIST 114

EVEKEO 78

EVISTA 121

EVOCLIN 15

EVOTAZ 55


EVOXAC 83

EXALGO 7

EXELDERM 30

EXELON 24

exemestane 38

EXFORGE 72

EXFORGE HCT 72

EXJADE 93

EXTAVIA 82

EXTINA 30

ezetimibe 76

ezetimibe/simvastatin 76

FFABIOR 86

FACTIVE 19

FALLBACK SOLO 119

FALMINA 114

famciclovir 56

famotidine 96

FAMVIR 56

FANAPT 48

FARESTON 36

FARXIGA 58

FARYDAK 40

FAYOSIM 114

FAZACLO 49

felbamate 23

FELBATOL 23

FELDENE 5

felodipine 70

FEM PH 102

FEMARA 38

FEMCON FE 114

FEMHRT 114

FEMRING 114

FEMYNOR 114

fenofibrate 74

fenofibrate nanocrystallized 74

fenofibrate,micronized 74

fenofibric acid 74

fenofibric acid (choline) 74

FENOGLIDE 74

fenoprofen calcium 6

FENOPROFEN CALCIUM (200 mg CAPSULE,

400 mg CAPSULE) 5

FENORTHO 6

fentanyl 8

FENTANYL (37.5mcg/hr patch td72,

62.5mcg/hr patch td72, 87.5mcg/hr patch

td72) 8

fentanyl citrate 9

FENTORA 9

FERRIPROX 93

FETZIMA 26

FEXMID 145

FIASP 62

FIASP FLEXTOUCH 62

FIBRICOR 74

FINACEA 86

finasteride 101

FIORICET 80

FIORICET WITH CODEINE 9

FIORINAL 6

FIORINAL WITH CODEINE #3 9

FIRAZYR 123

FIRVANQ 15

FLAGYL 15

FLAGYL ER 15

FLAREX 133

flavoxate hcl 101

flecainide acetate 68

FLECTOR 6

FLEXIPAK 130

FLOLIPID 75

FLOMAX 101

FLOVENT DISKUS 136

FLOVENT HFA 136

FLOWTUSS 143

FLOXIN 19

fluconazole 30

flucytosine 30

fludrocortisone acetate 105

FLUMADINE 56

flunisolide 136

fluocinolone acetonide 105

fluocinolone acetonide oil 136

fluocinolone acetonide/shower cap 105

fluocinonide 105

fluocinonide/emollient base 105

fluorometholone 133

FLUOROPLEX 86

fluorouracil 37

FLUOROURACIL 0.5% CREAM 86

fluoxetine hcl 26

fluphenazine decanoate 47

fluphenazine hcl 48

flurandrenolide 105

flurazepam hcl 146

flurbiprofen 6

flurbiprofen sodium 133

flutamide 35

fluticasone propionate 105,136

fluticasone propionate/salmeterol xinafoate 143

fluvastatin sodium 75

fluvoxamine maleate 26

FML 133

FML FORTE 134

FML S.O.P. 134

foam/gauze

bandage/lidocaine/chlorhexidine/isopropyl

alcohol 130

FOCALIN 79

FOCALIN XR 79

folic acid 94

FOLLISTIM AQ 108

fondaparinux sodium 63

FORADIL 139

FORFIVO XL 25

FORTAMET 58

FORTEO 129

FORTESTA 111

FORTICAL 129


FOSAMAX 129

FOSAMAX PLUS D 129

fosinopril sodium 67

fosinopril sodium/hydrochlorothiazide 72

FOSRENOL 93

FRAGMIN 63

FREESTYLE FREEDOM LITE METER 61

FREESTYLE INSULINX GLUCOSE SYS 61

FREESTYLE INSULINX TEST STRIPS 61

FREESTYLE LITE METER 61

FREESTYLE LITE TEST STRIPS 61

FREESTYLE PREC NEO TEST STRIPS 61

FREESTYLE PRECISION NEO METER 61

FREESTYLE TEST STRIPS 61

FROVA 33

frovatriptan succinate 33

FULPHILA 64

FULYZAQ 95

FURADANTIN 15

furosemide 73

FYAVOLV 114

FYCOMPA 23

Ggabapentin 22

GABITRIL 22

GALAFOLD 99

galantamine hbr 25

GALZIN 93

GANIRELIX ACETATE 122

GASTROCROM 95

gatifloxacin 19

GATTEX 95

GAVILYTE-C 97

GAVILYTE-G 97

GAVILYTE-H AND BISACODYL 97

GAVILYTE-N 97

GELNIQUE 101

gemfibrozil 74

GENERESS FE 114

GENERLAC 97

GENGRAF 124

GENOTROPIN 108

GENTAK 14

gentamicin sulfate 14

GENVOYA 53

GEODON 48

GIALAX 97

GIANVI 114

GIAZO 128

GILDAGIA 114

GILDESS 24 FE 114

GILENYA 82

GILOTRIF 40

glatiramer acetate 82

GLATOPA 83

GLEEVEC 40

GLEOSTINE 35

glimepiride 58

glipizide 58

glipizide/metformin hcl 58

GLUCAGEN 61

GLUCAGON EMERGENCY KIT 61

GLUCOPHAGE 58

GLUCOPHAGE XR 59

GLUCOTROL 59

GLUCOTROL XL 59

GLUCOVANCE 59

GLUMETZA 59

glyburide 59

glyburide,micronized 59

glyburide/metformin hcl 59

GLYCATE 94

glycopyrrolate 94

GLYDO 12

GLYNASE 59

GLYSET 59

GLYXAMBI 59

GOCOVRI 46

GOLYTELY 97

Gonal-f 108

GONITRO 77

GORDON'S UREA 87

GRALISE 22

granisetron hcl 29

GRANIX 64

GRASTEK 127

GRIFULVIN V 30

GRIS-PEG 30

griseofulvin ultramicrosize 30

griseofulvin, microsize 30

guaifenesin/hydrocodone bitartrate 143

guanfacine hcl 66,79

GUANIDINE HCL 34

GYNAZOLE 1 30

GYNOL II 102

HH.P. ACTHAR 105

HAEGARDA 123

HALCION 146

halobetasol propionate 105

HALOG 105

haloperidol 48

haloperidol lactate 48

HARVONI 50

HEATHER 119

HECTOROL 129

HEMANGEOL 37

HEMMOREX-HC 105

HEPSERA 50

HETLIOZ 146

HEXALEN 35

HIPREX 15

HORIZANT 80

HUMALOG 62

HUMALOG JUNIOR KWIKPEN 62



HUMALOG MIX 50-50 62


HUMALOG MIX 75-25 62



HUMATROPE 109

Humira 125

HUMULIN 70-30 62

HUMULIN 70/30 KWIKPEN 62

HUMULIN N 62

HUMULIN N KWIKPEN 62

HUMULIN R 62

HUMULIN R U-500 62

HUMULIN R U-500 KWIKPEN 62

HYCAMTIN 39

HYCET 9

HYCOFENIX 143

hydralazine hcl 76

HYDREA 37

hydrochlorothiazide 74

hydrocodone bitart/chlorpheniramine

maleate/pseudoephedrine 143

hydrocodone bitartrate/acetaminophen 10

hydrocodone bitartrate/homatropine

methylbromide 143

hydrocodone polistirex/chlorpheniramine

polistirex 143

hydrocodone/ibuprofen 10

hydrocortisone 105,128

hydrocortisone acetate 105

hydrocortisone acetate/iodoquinol/aloe vera 87

hydrocortisone acetate/lidocaine hcl/aloe

vera 87

hydrocortisone acetate/pramoxine hcl 87

hydrocortisone butyrate 105

hydrocortisone butyrate/emollient base 105

hydrocortisone valerate 105

hydrocortisone/acetic acid 136

hydrocortisone/mineral oil/petrolatum,white 105

HYDROMET 143

hydromorphone hcl 8,10

hydroquinone microspheres 87

hydroxychloroquine sulfate 45

hydroxyurea 37

hydroxyzine hcl 138

hydroxyzine pamoate 138

HYOPHEN 15

hyoscyamine sulfate 95

HYOSYNE 95

HYSINGLA ER 8

HYZAAR 72

Iibandronate sodium 129

IBRANCE 40

IBU 6

IBUDONE 10

ibuprofen 6

ibuprofen/oxycodone hcl 10

ICAR-C PLUS 91

ICLUSIG 40

IDHIFA 37

ILEVRO 134

ILOTYCIN 18

imatinib mesylate 40

IMBRUVICA 41

imipramine hcl 28

imipramine pamoate 28

imiquimod 87

IMITREX 33

IMPAVIDO 45

IMPOYZ 105

IMURAN 125

IMVEXXY 114

INCASSIA 119

INCRELEX 109

INCRUSE ELLIPTA 138

indapamide 74

INDERAL LA 69

INDERAL XL 69

INDOCIN 6

indomethacin 6

INFLAMMACIN 130

INGREZZA 80

INLYTA 41

INNOPRAN XL 69

INSPRA 74

INTELENCE 54

INTERMEZZO 146

INTRAROSA 130

INTRON A 52

INTROVALE 114

INTUNIV 79

INVEGA 48

INVIRASE 55

INVOKAMET 59

INVOKAMET XR 59

INVOKANA 59

IOPIDINE 134

ipratropium bromide 138

ipratropium bromide/albuterol sulfate 143

IPRIVASK 63

irbesartan 67

irbesartan/hydrochlorothiazide 72

IRENKA 81

IRESSA 41

ISENTRESS 53

ISENTRESS HD 53

ISIBLOOM 114

isometheptene

mucate/dichloralphenazone/acetaminophen 13

0

isoniazid 34

ISOPTO ATROPINE 132

ISOPTO CARPINE 135

ISORDIL 77

ISORDIL TITRADOSE 77

isosorbide dinitrate 77

isosorbide mononitrate 77

isoxsuprine hcl 72

isradipine 70

ISTALOL 135

itraconazole 30

ivermectin 45

JJadenu 93

JAKAFI 41


JALYN 101

JANTOVEN 63

JANUMET 59

JANUMET XR 59

JANUVIA 59

JARDIANCE 59

JENCYCLA 120

JENTADUETO 59

JENTADUETO XR 59

JEVANTIQUE LO 114

JINTELI 114

JOLESSA 114

JOLIVETTE 120

JUBLIA 30

JULEBER 114

JULUCA 55

JUNEL 114

JUNEL FE 114

JUNEL FE 24 114

JUXTAPID 76

JYNARQUE 93

KK EFFERVESCENT 91

K-PHOS NO.2 102

K-PHOS ORIGINAL 102

K-SOL 91

K-TAB ER 91

KADIAN 8

KAITLIB FE 114

KALETRA 55

KALYDECO 140

KAPSPARGO SPRINKLE 69

KAPVAY 79

KARBINAL ER 138

KARIVA 114

KAYEXALATE 93

KAZANO 59

KEFLEX 17

KELNOR 1-35 115

KELNOR 1-50 115

KENALOG 105

KEPPRA 21

KEPPRA XR 21

KERYDIN 30

ketoconazole 30

KETODAN 30

ketoprofen 6

ketorolac tromethamine 6,134

KEVEYIS 73

KEVZARA 127

KHEDEZLA 26

KIMIDESS 115

KINERET 125

KIONEX 93

KISQALI 41

KISQALI FEMARA CO-PACK 41

KITABIS PAK 140

KLARON 20

KLONOPIN 57

KLOR-CON 92

KLOR-CON 10 92

KLOR-CON 8 92

KLOR-CON M10 92

KLOR-CON M15 92

KLOR-CON M20 92

KLOR-CON SPRINKLE 92

KLOR-CON-EF 92

KOMBIGLYZE XR 59

KORLYM 105

KRISTALOSE 97

KURVELO 115

KUVAN 99

KYLEENA 120

KYNAMRO 76

Llabetalol hcl 69

LACRISERT 132

lactic acid 87

lactulose 97

LAMICTAL 23

LAMICTAL (BLUE) 23

LAMICTAL (GREEN) 23

LAMICTAL (ORANGE) 23

LAMICTAL ODT 23

LAMICTAL XR 23

LAMISIL 31

lamivudine 50,54

lamivudine/zidovudine 54

lamotrigine 23

LANOXIN 72

lansoprazole 98

lansoprazole/amoxicillin

trihydrate/clarithromycin 95

lanthanum carbonate 93

LANTUS 62

LANTUS SOLOSTAR 62

LARIN 115

LARIN 24 FE 115

LARIN FE 115

LARISSIA 115

LASIX 73

LASTACAFT 133

latanoprost 135

LATUDA 48

LAYOLIS FE 115

LAZANDA 10

LEENA 115

leflunomide 127

LENVIMA 41

LESCOL 75

LESCOL XL 75

LESSINA 115

LETAIRIS 141

letrozole 39

leucovorin calcium 37

LEUKERAN 35

LEUKINE 64

leuprolide acetate 122

levalbuterol hcl 139

levalbuterol tartrate 139

LEVAQUIN 19


LEVATOL 69

LEVBID 95

LEVEMIR 62

LEVEMIR FLEXTOUCH 62

levetiracetam 21

LEVITRA 102

LEVO-T 121

levobunolol hcl 135

levocarnitine 92

levocarnitine (with sugar) 92

levocetirizine dihydrochloride 138

levofloxacin 19

LEVONEST 115

levonorgestrel 115

levonorgestrel-ethinyl estradiol 115

levonorgestrel/ethinyl estradiol and ethinyl

estradiol 115

LEVORA-28 115

levorphanol tartrate 8

levothyroxine sodium 121

LEVOXYL 121

LEVSIN 95

LEVSIN-SL 95

LEVULAN 87

LEXAPRO 26

LEXIVA 56

LEXIXRYL 87

LIALDA 128

LIBRAX 95

LIDO-K 12

LIDO-PRILO CAINE PACK 12

lidocaine 12

lidocaine hcl 12

lidocaine hcl/hydrocortisone acetate 87

lidocaine/prilocaine 12

LIDODERM 12

LIDOPAC 12

LIDOPIN 12

LIDOPRIL 12

LIDOPRIL XR 12

LIDOTRANS 5 PAK 12

LILETTA 120

LILLOW 115

lindane 46

linezolid 15

LINZESS 97

liothyronine sodium 121

LIPITOR 75

LIPOCHOL PLUS 74

LIPOFEN 74

LIPROZONEPAK 13

lisinopril 67

lisinopril/hydrochlorothiazide 72

lithium carbonate 57

lithium citrate 57

LITHOBID 57

LITHOSTAT 102

LIVALO 75

LO LOESTRIN FE 115

LOCOID 105

LOCOID LIPOCREAM 105

LODINE 6

LODOSYN 47

LOESTRIN 115

LOESTRIN FE 115

LOFIBRA 74,75

LOKELMA 130

LOMAIRA 80

LOMEDIA 24 FE 115

LOMOTIL 96

lomustine 35

LONHALA MAGNAIR REFILL 138

LONHALA MAGNAIR STARTER 139

LONSURF 38

LOPID 75

lopinavir/ritonavir 56

LOPREEZA 115

LOPRESSOR 69

LOPRESSOR HCT 72

LOPROX 31

lorazepam 57

LORAZEPAM INTENSOL 57

LORCET 10

LORCET HD 10

LORCET PLUS 10

LORTAB 10

LORYNA 115

LORZONE 145

losartan potassium 67

losartan potassium/hydrochlorothiazide 72

LOSEASONIQUE 115

LOTEMAX 134

LOTENSIN 67

LOTENSIN HCT 72

LOTREL 72

LOTRISONE 87

LOTRONEX 97

lovastatin 75

LOVAZA 76

LOVENOX 63

LOW-OGESTREL 115

loxapine succinate 48

LUCEMYRA 13

luliconazole 31

LUMIGAN 135

LUNESTA 146

LUPANETA PACK 122

LUTERA 115

LUXIQ 105

LUZU 31

LYNPARZA 41

LYRICA 81

LYRICA CR 81

LYSODREN 38

LYSTEDA 65

LYZA 120

MMACROBID 15

MACRODANTIN 15

MALARONE 45

malathion 46

maprotiline hcl 27


MARINOL 29

MARLISSA 115

MARPLAN 26

MARTEN-TAB 80

MATULANE 35

MATZIM LA 70

MAVIK 67

MAVYRET 50

MAXALT 33

MAXALT MLT 33

MAXIDEX 134

MAXITROL 132

MAXZIDE 72

MAXZIDE-25 MG 72

meclizine hcl 28

MECLOFENAMATE SODIUM 6

MEDOLOR PAK 13

MEDROL 105

medroxyprogesterone acetate 120

mefenamic acid 6

mefloquine hcl 45

MEGACE 120

MEGACE ES 120

megestrol acetate 120

MEKINIST 42

MEKTOVI 42

MELODETTA 24 FE 116

meloxicam 6

MELOXICAM 7.5 MG/5 ML ORAL SUSP 6

melphalan 35

memantine hcl 25

MENEST 116

MENOPUR 109

MENOSTAR 116

MENTAX 31

meperidine hcl 10

MEPHYTON 65

meprobamate 57

MEPRON 45

mercaptopurine 37

mesalamine 128

MESALAMINE 800 MG TABLET DR 128

mesalamine with cleansing wipes 128

MESNEX 45

MESTINON 34

METADATE CD 79

METADATE ER 79

metaproterenol sulfate 139

METAXALL 145

metaxalone 145

metformin er 500mg & 1000mg tab (generic

version of glumetza) 59

metformin hcl 59,60

methadone hcl 8

METHADONE INTENSOL 8

METHADOSE 8

methamphetamine hcl 78

methazolamide 135

methenamine hippurate 15

methenamine mandelate 15

methenamine/sod

phosph,monobasic/methylene

blue/hyoscyamine 15

METHERGINE 130

methimazole 123

METHITEST 111

methocarbamol 145

methotrexate sodium 125

methotrexate sodium/pf 125

methoxsalen 87

methscopolamine bromide 95

methyclothiazide 74

methyldopa 66

methyldopa/hydrochlorothiazide 72

methylergonovine maleate 130

METHYLIN 79

methylphenidate hcl 79

methylprednisolone 105

methyltestosterone 111

metipranolol 135

metoclopramide hcl 28

metolazone 74

metoprolol succinate 69

metoprolol succinate/hydrochlorothiazide 72

metoprolol tartrate 69

metoprolol tartrate/hydrochlorothiazide 72

METOZOLV ODT 28

METROCREAM 87

METROGEL 87

METROGEL-VAGINAL 15

METROLOTION 87

metronidazole 15,87

mexiletine hcl 68

MIACALCIN 129

MIBELAS 24 FE 116

MICARDIS 67

MICARDIS HCT 72

miconazole nitrate 31

MICORT-HC 87,106

MICROCYN 87

MICROCYN HYDROGEL 87

MICROGESTIN 116

MICROGESTIN 24 FE 116

MICROGESTIN FE 116

MICROZIDE 74

midazolam hcl 57

midodrine hcl 66

MIFEPREX 106

MIGERGOT 33

miglitol 60

miglustat 99

MIGRANAL 33

MILI 116

MILLIPRED 106

MILLIPRED DP 106

MIMVEY 116

MIMVEY LO 116

MINASTRIN 24 FE 116

MINIPRESS 66

MINITRAN 77

MINIVELLE 116

MINOCIN 20

minocycline hcl 20


MINOLIRA ER 20

minoxidil 76

MIRAPEX 46

MIRAPEX ER 46

MIRCETTE 116

MIRENA 120

mirtazapine 25

misoprostol 98

MITIGARE 32

MITOSOL 132

MOBIC 6

modafinil 147

MODERIBA 52

moexipril hcl 67

moexipril hcl/hydrochlorothiazide 72

molindone hcl 48

mometasone furoate 106,136

MONDOXYNE NL 21

MONO-LINYAH 116

MONODOX 21

MONONESSA 116

montelukast sodium 138

MONUROL 15

MORGIDOX 21

MORPHABOND ER 8

morphine sulfate 8,10

morphine sulfate (15 mg tablet, 30 mg tablet)

10

MOTOFEN 96

MOVANTIK 96

MOVIPREP 97

MOXATAG 18

MOXEZA 19

moxifloxacin hcl 19

MOZOBIL 64

MS CONTIN 8

MULPLETA 64

MULTAQ 68

mupirocin 16

mupirocin calcium 16

MUSE 102

MY CHOICE 116

MY WAY 116

MYALEPT 96

MYAMBUTOL 34

MYCOBUTIN 34

mycophenolate mofetil 125

mycophenolate sodium 125

MYDAYIS 78

MYFORTIC 125

MYLERAN 35

MYORISAN 87

MYRBETRIQ 101

MYSOLINE 22

MYTESI 96

MYZILRA 116

Nnabumetone 6

nadolol 69

nadolol/bendroflumethiazide 72

naftifine hcl 31

NAFTIN 31

NALFON 6

NALOCET 10

naloxone hcl 13

naltrexone hcl 13

NAMENDA 25

NAMENDA XR 25

NAMZARIC 25

NAPHAZOLINE 0.1% 132

NAPRELAN 6

NAPROSYN 6

naproxen 6

NAPROXEN 125 MG/5 ML ORAL SUSP 6

naproxen sodium 6

naratriptan hcl 33

NARCAN 13

NARDIL 26

NASCOBAL 94

NASONEX 136

NATACYN 31

NATAZIA 116

nateglinide 60

NATESTO 111

NATPARA 129

NATROBA 87

NATURE-THROID 121

NEBUPENT 45

NEBUSAL 143

NECON 116

nefazodone hcl 27

NEO-POLYCIN 132

NEO-POLYCIN HC 132

NEO-SYNALAR 87

neomycin sulfate 14

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 132

neomycin sulfate/bacitracin/polymyxin b 132

neomycin sulfate/polymyxin b

sulfate/gramicidin d 132

neomycin sulfate/polymyxin b

sulfate/hydrocortisone 132,136

neomycin/polymyxin b

sulfate/dexamethasone 132

NEORAL 125

NEOSPORIN 132

NEPTAZANE 135

NERLYNX 42

NESINA 60

NESTABS ONE 92

NEUAC 87

NEULASTA 64

NEUPOGEN 65

NEUPRO 46

NEURCAINE 13

NEURONTIN 22

NEVANAC 134

nevirapine 54

NEVIRAPINE 50 MG/5 ML ORAL SUSP 54

NEW DAY 116

NEXAVAR 42

NEXIUM 98


NEXPLANON 120

NEXT CHOICE ONE DOSE 120

niacin 76

NIACOR 76

NIASPAN 76

nicardipine hcl 70

NICOTROL 14

NICOTROL NS 14

NIFEDICAL XL 70

nifedipine 70

NIKKI 116

NILANDRON 36

nilutamide 36

nimodipine 70

NINLARO 38

nisoldipine 70

NITRO-BID 77

NITRO-DUR 77

NITRO-TIME 77

nitrofurantoin 16

nitrofurantoin macrocrystal 16

nitrofurantoin monohydrate/macrocrystals 16

nitroglycerin 77

NITROLINGUAL 77

NITROMIST 77

NITROSTAT 77

NITYR 99

NIVESTYM 65

nizatidine 96

NIZORAL 31

NOCDURNA 109

NOCTIVA 109

NODOLOR 130

NOLIX 106

NOR-Q-D 120

NORA-BE 120

NORCO 10

NORDITROPIN FLEXPRO 109

norethindrone 120

norethindrone acetate 120

norethindrone acetate-ethinyl estradiol 116

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 116

norethindrone-ethinyl estradiol/ferrous

fumarate 116

norgestimate-ethinyl estradiol 116

NORINYL 1-35 116

NORITATE 87

NORLYDA 120

NORLYROC 120

NORPACE 68

NORPACE CR 68

NORPRAMIN 28

NORTHERA 66

NORTREL 117

nortriptyline hcl 28

NORVASC 70

NORVIR 56

NOVACORT 87

NOVAREL 109

NOVOLIN 70-30 62

NOVOLIN 70-30 FLEXPEN 62

NOVOLIN N 62

NOVOLIN R 62

NOVOLOG 62

NOVOLOG FLEXPEN 63

NOVOLOG MIX 70-30 63

NOVOLOG MIX 70-30 FLEXPEN 63

NOXAFIL 31

NP THYROID 121

NUCORT 106

NUCYNTA 10

NUCYNTA ER 8

NUDICLO 87,130

NUDROXIPAK 6



NUDROXIPAK E-400 131

NUDROXIPAK I-800 131

NUDROXIPAK N-500 131

NUEDEXTA 80

NULEV 95

NULYTELY WITH FLAVOR PACKS 97

NUMBONEX 13

NUOX 87

NUPLAZID 48

NUTRESTORE 92

NUTRIARX 106

NUTROPIN AQ 109

NUVARING 117

NUVESSA 16

NUVIGIL 147

NYAMYC 31

NYATA 31

NYMALIZE 70

nystatin 31

nystatin/triamcinolone acetonide 31

NYSTOP 31

OOB COMPLETE PETITE 94

OBREDON 143

OCALIVA 99

OCELLA 117

octreotide acetate 122

OCUFEN 134

OCUFLOX 19

ODACTRA 131

ODEFSEY 54

ODOMZO 42

OFEV 142

ofloxacin 19

OGESTREL 117

olanzapine 48

olanzapine/fluoxetine hcl 25

OLEPTRO ER 27

olmesartan medoxomil 67

olmesartan medoxomil/amlodipine

besylate/hydrochlorothiazide 72

olmesartan medoxomil/hydrochlorothiazide 72

olopatadine hcl 133,138

OLUMIANT 125

OLUX 106


OLUX-E 106

OLYSIO 51

OMECLAMOX-PAK 96

omega-3 acid ethyl esters 76

omeprazole 98

omeprazole/sodium bicarbonate 98

OMNARIS 136

OMNIPRED 134

OMNITROPE 109

ondansetron 29

ondansetron hcl 29

ONETOUCH ULTRA TEST STRIP 61

ONETOUCH ULTRA2 GLUCOSE SYST 61

ONETOUCH ULTRAMINI METER 61

ONETOUCH VERIO FLEX SYSTEM KIT 61

ONETOUCH VERIO IQ SYSTEM KIT 61

ONETOUCH VERIO METER SYSTEM 61

ONETOUCH VERIO SYNC SYST KIT 61

ONETOUCH VERIO TEST STRIP 61

ONEXTON 88

ONFI 22

ONGLYZA 60

ONMEL 31

ONZETRA XSAIL 33

OPANA 10

OPCICON ONE-STEP 120

opium tincture 96

opium/belladonna alkaloids 10

OPSUMIT 141

OPTION 2 120

ORACEA 21

ORACIT 92

Oralair 127

ORALONE 83

ORAP 48

ORAPRED ODT 106

ORAVIG 31

ORENCIA 125

ORENITRAM ER 141

ORFADIN 99

ORILISSA 122

ORKAMBI 140

orphenadrine citrate 145

ORSYTHIA 117

ORTHO MICRONOR 120

ORTHO TRI-CYCLEN 117

ORTHO TRI-CYCLEN LO 117

ORTHO-CYCLEN 117

ORTHO-NOVUM 117

OSCIMIN 95

OSCIMIN SL 95

OSCIMIN SR 95

oseltamivir phosphate 56

OSENI 60

OSMOLEX ER 46

OSMOPREP 97

OSPHENA 121

OTEZLA 127

OTIPRIO 19

OTOVEL 136

OTREXUP 125

OVACE 88

OVACE PLUS 88

OVACE PLUS WASH 88

OVCON-35 117

OVIDE 46

OVIDREL 109

OXANDRIN 110

oxandrolone 110

oxaprozin 6

OXAYDO 10

oxazepam 57

oxcarbazepine 24

OXECTA 10

oxiconazole nitrate 31

OXISTAT 31

OXSORALEN-ULTRA 88

OXTELLAR XR 24

oxybutynin chloride 101

OXYCODONE 10MG/0.5ML ORAL

SYRINGE 10

oxycodone hcl 10

OXYCODONE HCL ER 8

oxycodone hcl/acetaminophen 11

oxycodone hcl/aspirin 11

OXYCONTIN 8

oxymorphone hcl 8,11

OXYTROL 101

OZEMPIC 60

PPACERONE 68

PACNEX 88

PACNEX HP 88

PACNEX LP 88

PAINGO KFT 13

paliperidone 48

PALYNZIQ 100

PAMELOR 28

PANCREAZE 100

PANCRELIPASE 5,000 100

PANDEL 106

PANLOR 11

PANRETIN 44

pantoprazole sodium 98

PARAFON FORTE DSC 145

PARAGARD T 380-A 131

paregoric 96

PAREMYD 132

paricalcitol 129

PARLODEL 47

PARNATE 26

PAROEX 83

paromomycin sulfate 14

paroxetine hcl 27

paroxetine mesylate 27

PASER 34

PATADAY 133

PATANASE 138

PATANOL 133

PAXIL 27

PAXIL CR 27

PAZEO 133


PCE 18

PEDIADERM HC 106

PEDIAPRED 106

peg 3350/sod sulf/sod bicarb/sod

chloride/potassium chloride 97

PEG-PREP 97

PEGANONE 24

PEGASYS 52

PEGASYS PROCLICK 52

PEGINTRON 52

PEGINTRON REDIPEN 52

penicillin v potassium 18

PENLAC 31

PENNSAID 6

PENTASA 128

pentazocine hcl/naloxone hcl 11

pentoxifylline 72

PEPCID 96

PERCOCET 11

PERFOROMIST 139

PERIDEX 83

perindopril erbumine 67

PERIOGARD 83

permethrin 46

perphenazine 29

perphenazine/amitriptyline hcl 25

PERSANTINE 66

PERTZYE 100

PEXEVA 27

PHENADOZ 29

phenazopyridine hcl 102

phendimetrazine tartrate 80

phenelzine sulfate 26

PHENERGAN 29

phenobarbital 23

phenoxybenzamine hcl 66

phentermine hcl 80

phenylephrine hcl 132

phenylephrine hcl/promethazine hcl 144

PHENYTEK 24

phenytoin 24

phenytoin sodium extended 24

PHILITH 117

PHOSLO 93

PHOSLYRA 93

PHOSPHASAL 16

PHOSPHOLINE IODIDE 135

phytonadione (vit k1) 65

PICATO 88

PIFELTRO 54

pilocarpine hcl 83,135

pimozide 48

PIMTREA 117

pindolol 69

pioglitazone hcl 60

pioglitazone hcl/glimepiride 60

pioglitazone hcl/metformin hcl 60

PIRMELLA 117

piroxicam 7

PLAN B ONE-STEP 117

PLAQUENIL 45

PLAVIX 66

PLEGRIDY 83

PLEGRIDY PEN 83

PLENVU 97

PLETAL 66

PLEXION 88

PLIXDA 88

podofilox 88

POLYCIN 132

polyethylene glycol 3350 98

polymyxin b sulfate/trimethoprim 132

POLYTRIM 132

POMALYST 36

PONSTEL 7

PORTIA 117

POTABA 94

potassium bicarbonate/citric acid 92

potassium chloride 92

potassium chloride/potassium bicarbonate/citric

acid 92

potassium citrate 92

potassium citrate/citric acid 92

POTIGA 21

PR BENZOYL PEROXIDE 88

PRADAXA 63

PRALUENT 76

PRAMCORT 88

pramipexole di-hcl 47

PRAMOSONE 88

PRAMOSONE E 88

PRANDIN 60

prasugrel hcl 66

PRAVACHOL 75

pravastatin sodium 75

praziquantel 45

prazosin hcl 67

PRECISION XTRA MONITOR 61

PRECISION XTRA TEST STRIPS 61

PRECOSE 60

PRED FORTE 134

PRED MILD 134

PRED-G 132

prednicarbate 106

prednisolone 106

prednisolone acetate 134

prednisolone sod phosphate 106,134

prednisone 106

PREDNISONE INTENSOL 106

PREFEST 117

PREGNYL 110

PREMARIN 117

PREMPHASE 117

PREMPRO 117

PREPOPIK 98

PRESTALIA 72

PREVACID 98

PREVALITE 76

PREVIDENT 92

PREVIDENT 5000 92

PREVIDENT 5000 ENAMEL PROTECT 92

PREVIDENT 5000 PLUS 92

PREVIDENT 5000 SENSITIVE 92


PREVIDOLRX PLUS ANALGESIC PAK 131

PREVIFEM 117

PREVPAC 96

PREVYMIS 50

PREZCOBIX 56

PREZISTA 56

PRIFTIN 34

PRILOLID 13

PRILOSEC 98

PRIMAQUINE PHOSPHATE 45

primidone 23

PRIMLEV 11

PRIMSOL 16

PRINIVIL 67

PRISTIQ 27

PROAIR HFA 139

PROAIR RESPICLICK 139

probenecid 32

probenecid/colchicine 32

PROCARDIA 70

PROCARDIA XL 70

PROCENTRA 78

prochlorperazine 29

prochlorperazine maleate 29

PROCORT 88

PROCRIT 65

PROCTO-MED HC 106

PROCTO-PAK 106

PROCTOCORT 106

PROCTOFOAM-HC 88

PROCTOSOL-HC 106

PROCTOZONE-HC 106

PROCYSBI 100

PROFENO 7

progesterone 120

progesterone, micronized 120

PROGLYCEM 61

PROGRAF 125

PROLENSA 134

PROMACTA 65

promethazine hcl 29,138

promethazine hcl/codeine 144

promethazine hcl/dextromethorphan hbr 144

promethazine/phenylephrine hcl/codeine 144

PROMETHEGAN 29

PROMETRIUM 120

propafenone hcl 68

propantheline bromide 95

proparacaine hcl 132

propranolol hcl 69

propranolol hcl/hydrochlorothiazide 72

propylthiouracil 123

PROSCAR 101

PROTONIX 99

PROTOPIC 88

protriptyline hcl 28

PROVENTIL HFA 139

PROVERA 120

PROVIGIL 147

PROZAC 27

PROZAC WEEKLY 27

PRUDOXIN 88

PSORCON 106

PULMICORT 136

PULMICORT FLEXHALER 137

PULMOZYME 140

PURIXAN 37

PYLERA 96

pyrazinamide 34

PYRIDIUM 102

pyridostigmine bromide 34

QQBRELIS 68

QBREXZA 88

QNASL 137

QNASL CHILDREN 137

QSYMIA 80

QTERN 60

QUALAQUIN 45

QUARTETTE 117

QUASENSE 117

quazepam 146

QUDEXY XR 23

QUESTRAN 76

QUESTRAN LIGHT 76

quetiapine fumarate 48,49

QUILLICHEW ER 79

QUILLIVANT XR 79

quinapril hcl 68

quinapril hcl/hydrochlorothiazide 72

quinidine gluconate 68

quinidine sulfate 68

quinine sulfate 45

QVAR 137

QVAR REDIHALER 137

Rrabeprazole sodium 99

RADIOGARDASE 93

RAGWITEK 127

RAJANI 117

raloxifene hcl 121

ramipril 68

RANEXA 72

ranitidine hcl 96

RAPAFLO 101

RAPAMUNE 125

rasagiline mesylate 47

RASUVO 125

RAVICTI 100

RAYALDEE 129

RAYOS 106

RAZADYNE 25

RAZADYNE ER 25

REA LO 39 88

REA LO 40 88

REBETOL 52

Rebif 83

RECLIPSEN 117

RECTIV 88

REGIMEX 80

REGLAN 29


REGRANEX 88

RELADOR PAK 13

RELAGARD 102

RELENZA 56

RELEXXII 79

RELISTOR 96

RELPAX 33

REMERON 25

RENAGEL 93

RENVELA 93

repaglinide 60

REPAGLINIDE/METFORMIN 60

REPATHA 76

REPREXAIN 11

REQUIP 47

REQUIP XL 47

RESCRIPTOR 54

RESCULA 135

RESERPINE 72

RESTASIS 132

RESTASIS MULTIDOSE 132

RESTORIL 146

RETACRIT 65

RETIN-A 88

RETIN-A MICRO 88

RETIN-A MICRO PUMP 88

RETROVIR 55

REVATIO 142

REVIA 13

REVLIMID 36

REXULTI 49

REYATAZ 56

REZIRA 144

RHEUMATREX 125

RHINOCORT AQUA 137

RHOPRESSA 135

RIBASPHERE 52

RIBASPHERE RIBAPAK 53

RIBATAB 53

ribavirin 53,144

RIDAURA 127

rifabutin 34

RIFADIN 34

RIFAMATE 35

rifampin 35

RIFATER 35

RILUTEK 80

riluzole 81

rimantadine hcl 56

RIMSO-50 102

RIOMET 60

risedronate sodium 129

RISPERDAL 49

RISPERDAL M-TAB 49

risperidone 49

RITALIN 79

RITALIN LA 79

ritonavir 56

rivastigmine 25

rivastigmine tartrate 25

RIVELSA 117

rizatriptan benzoate 33

ROBAXIN 145

ROBAXIN-750 145

ROBINUL 95

ROBINUL FORTE 95

ROCALTROL 129

ropinirole hcl 47

ROSADAN 89

ROSANIL 89

ROSULA 89

rosuvastatin calcium 75

ROWASA 128

ROWEEPRA 21

ROWEEPRA XR 21

ROXICODONE 11

ROXYBOND 11

ROZEREM 147

RUBRACA 38

RUCONEST 123

RYCLORA 138

RYDAPT 38

RYTARY 47

RYTHMOL 68

RYTHMOL SR 68

RYVENT 138

SSABRIL 23

SAFYRAL 117

SAIZEN 110

SALAGEN 83

salsalate 7

SAMSCA 93

SANADERMRX 106

SANCUSO 29

SANDIMMUNE 125

SANDOSTATIN 122

SANDOSTATIN LAR 122

SANDOSTATIN LAR DEPOT 122

SANTYL 89

SAPHRIS 49

SARAFEM 27

SAVAYSA 63

SAVELLA 81

SAXENDA 131

SCALACORT 106

scopolamine 29

SEASONIQUE 117

SEB-PREV 89

SECONAL SODIUM 147

SECTRAL 69

SEEBRI NEOHALER 139

SEGLUROMET 60

selegiline hcl 47

selenium sulfide 89

SELRX 89

SELZENTRY 55

SEMPREX-D 144

SENSIPAR 129

SEREVENT DISKUS 139

SERNIVO 107

SEROPHENE 121


SEROQUEL 49

SEROQUEL XR 49

SEROSTIM 110

sertraline hcl 27

SETLAKIN 117

sevelamer carbonate 94

SF 92

SF 5000 PLUS 92

SFROWASA 128

SHAROBEL 120

SIGNIFOR 122

SIKLOS 37

SILALITE PAK 107

SILAZONE-II 107

sildenafil citrate 102,142

SILENOR 147

SILIQ 89

SILVADENE 20

silver nitrate/potassium nitrate 89

silver sulfadiazine 20

silver/bandage/foam/gauze/lidocaine/chlorhexid

in/isopropanol 131

SIMBRINZA 135

SIMPONI 126

simvastatin 75

SINEMET 10-100 47

SINEMET 25-100 47

SINEMET 25-250 47

SINEMET CR 47

SINGULAIR 138

sirolimus 126

SIRTURO 35

SITAVIG 56

SIVEXTRO 16

SKELAXIN 145

SKLICE 45

SKYLA 121

sodium chloride for inhalation 144

sodium chloride/sodium bicarbonate/potassium

chloride/peg 98

sodium phenylbutyrate 100

sodium polystyrene sulfonate 93

SOLARAZE 89

SOLIQUA 100-33 63

SOLODYN 21

SOLOSEC 16

SOLTAMOX 36

SOLUPAK 13

SOMA 145

SOMATULINE DEPOT 122

SOMAVERT 122

SONATA 146

SOOLANTRA 89

SORIATANE 89

SORILUX 89

SORINE 68

sotalol hcl 68

SOTYLIZE 68

SOVALDI 51

SPECTRACEF 17

SPINOSAD 89

SPIRIVA 139

SPIRIVA RESPIMAT 139

spironolactone 74

spironolactone/hydrochlorothiazide 73

SPORANOX 32

SPRINTEC 117

SPRITAM 22

SPRIX 7

SPRYCEL 42

SPS 93

SRONYX 118

SSD 20

SSKI 123

SSS 10-5 89

STALEVO 46

STARLIX 60

stavudine 55

STAXYN 102

STEGLATRO 60

STEGLUJAN 60

STELARA 89

STENDRA 102

STIMATE 110

STIOLTO RESPIMAT 144

STIVARGA 42

STRATTERA 79

STRENSIQ 100

STRIANT 111

STRIBILD 53

STRIVERDI RESPIMAT 139

STROMECTOL 45

SUBOXONE 13

SUBSYS 11

SUCRAID 100

sucralfate 98

SULAR 70

sulfacetamide sodium 20,89

sulfacetamide sodium/prednisolone sodium

phosphate 132

sulfacetamide sodium/sulfur 90

sulfadiazine 20

sulfamethoxazole/trimethoprim 20

SULFAMYLON 16

sulfasalazine 128

SULFATRIM 20

sulindac 7

sumatriptan 33

sumatriptan succinate 34

sumatriptan succinate/naproxen sodium 34

SUMAVEL DOSEPRO 34

SUPRAX 17

SUPRENZA ODT 81

SUPREP 98

SURMONTIL 28

SUSTIVA 54

SUSTOL 29

SUTENT 42

SYEDA 118

SYLATRON 38

SYMAX 95

SYMAX DUOTAB 95

SYMAX-SL 95


SYMAX-SR 95

SYMBICORT 144

SYMBYAX 25

SYMDEKO 140

SYMFI 54

SYMFI LO 54

SYMLINPEN 120 60

SYMLINPEN 60 60

SYMPROIC 96

SYMTUZA 56

SYNALAR 107

SYNALAR TS 107

SYNALGOS-DC 11

SYNAREL 122

SYNDROS 29

SYNJARDY 60

SYNJARDY XR 60

SYNTHROID 121

SYPRINE 93

syringe, insulin u-500 with needle, disposable,

0.5 ml 131

TTABLOID 37

TACLONEX 90

tacrolimus 90,126

tadalafil 101,102

TAFINLAR 43

TAGRISSO 43

TAKE ACTION 118

TAKHZYRO 123

Taltz 90

TALZENNA 43

TAMIFLU 56

tamoxifen citrate 36

tamsulosin hcl 101

TANZEUM 60

TAPAZOLE 123

TAPERDEX 107

TARCEVA 43

TARGADOX 21

TARGRETIN 44

TARINA FE 118

TARKA 73

TASIGNA 43

TASMAR 46

TAVALISSE 65

TAYTULLA 118

tazarotene 90

TAZORAC 90

TAZTIA XT 70

TECFIDERA 83

TECHNIVIE 51

TEGRETOL 24

TEGRETOL XR 24

TEGSEDI 81

TEKTURNA 73

TEKTURNA HCT 73

telmisartan 67

telmisartan/amlodipine besylate 73

telmisartan/hydrochlorothiazide 73

temazepam 146

TEMODAR 35

TEMOVATE 107

temozolomide 35

TENCON 81

TENEX 66

tenofovir disoproxil fumarate 55

TENORETIC 100 73

TENORETIC 50 73

TENORMIN 69

TERAZOL 3 32

TERAZOL 7 32

terazosin hcl 67

terbinafine hcl 32

terbutaline sulfate 139

terconazole 32

TESSALON PERLE 144

TESTIM 111

testosterone 111

TESTOSTERONE (10 mg (2%) gel md pmp,

12.5/1.25g gel md pmp, 50 mg (1%) gel

(gram) 111

TESTOSTERONE (50 mg (1%) gel packet).

SOME MANUFACTURERS ARE T3 AND

OTHERS T1 111

testosterone cypionate 111

testosterone enanthate 111

TESTRED 111

tetrabenazine 81

tetracycline hcl 21

TETRAVISC 132

TETRAVISC FORTE 132

TEXACORT 107

THALOMID 36

THEO-24 141

THEOCHRON 141

theophylline anhydrous 141

THERMAZENE 20

THIOLA 103

thioridazine hcl 48

thiothixene 48

THYROLAR-1 121

THYROLAR-1/2 121

THYROLAR-1/4 121

THYROLAR-2 121

THYROLAR-3 121

tiagabine hcl 23

TIAZAC 70

TIBSOVO 38

TICALAST 144

TICANASE 137

TICASPRAY 137

ticlopidine hcl 66

TIGAN 29

TIGLUTIK 81

TIKOSYN 68

TILIA FE 118

timolol maleate 69,135

TIMOPTIC 135

TIMOPTIC OCUDOSE 135


TIMOPTIC-XE 135

TINDAMAX 16

tinidazole 16

TIROSINT 121

TIVICAY 53

TIVORBEX 7

tizanidine hcl 49

TL G-FOL OS 92

TOBI 144

TOBI PODHALER 140

TOBRADEX 132

TOBRADEX ST 132

tobramycin 14

tobramycin in 0.225 % sodium chloride 144

tobramycin/dexamethasone 133

tobramycin/nebulizer 140

TOBREX 14

TODAY CONTRACEPTIVE SPONGE 103

TOFRANIL 28

TOFRANIL-PM 28

TOLAK 90

tolazamide 60

tolbutamide 60

tolcapone 46

tolmetin sodium 7

tolterodine tartrate 101

TOPAMAX 23

TOPICORT 107

topiramate 23

TOPIRAMATE ER CAPS 23

TOPROL XL 69

torsemide 73

TOUJEO MAX SOLOSTAR 63

TOUJEO SOLOSTAR 63

TOVIAZ 101

TRACLEER 142

TRADJENTA 61

TRAMADOL ER CAPS 8

tramadol hcl 8,11

tramadol hcl/acetaminophen 11

trandolapril 68

trandolapril/verapamil hcl 73

tranexamic acid 65

TRANSDERM-SCOP 29

TRANXENE T-TAB 57

tranylcypromine sulfate 26

TRAVATAN Z 135

trazodone hcl 27

TRECATOR 35

TRELEGY ELLIPTA 144

TREMFYA 90



TRETIN-X 90

tretinoin 44,90

tretinoin microspheres 90

tretinoin/emollient base 90

TREXALL 126

TREXIMET 34

TREZIX 11

TRI FEMYNOR 118

TRI-CHLOR 90

TRI-ESTARYLLA 118

TRI-LEGEST FE 118

TRI-LINYAH 118

TRI-LO-ESTARYLLA 118

TRI-LO-MARZIA 118

TRI-LO-SPRINTEC 118

TRI-MILI 118

TRI-NORINYL 118

TRI-PREVIFEM 118

TRI-SILA 107

TRI-SPRINTEC 118

TRI-VYLIBRA 118

triamcinolone acetonide 83,107,137

triamterene/hydrochlorothiazide 73

TRIANEX 107

triazolam 146

TRIBENZOR 73

TRICOR 75

TRIDERM 107

TRIDESILON 107

trientine hcl 93

trifluoperazine hcl 48

trifluridine 56

TRIGLIDE 75

trihexyphenidyl hcl 46

TRILEPTAL 24

TRILIPIX 75

TRILYTE WITH FLAVOR PACKETS 98

trimethobenzamide hcl 29

trimethoprim 16

trimipramine maleate 28

TRIMPEX 16

TRINESSA 118

TRINESSA LO 118

TRINTELLIX 27

TRIUMEQ 55

TRIVORA-28 118

TRIXYLITRAL 129

TRIZIVIR 55

TROKENDI XR 24

tropicamide 133

trospium chloride 101

TRULANCE 97

TRULICITY 61

TRUSOPT 135

TRUVADA 55

TUDORZA PRESSAIR 139

TULANA 121

TUSSICAPS 144

TUSSIGON 144

TUSSIONEX 144

TUZISTRA XR 144

TWYNSTA 73

TYBOST 55

TYDEMY 118

TYKERB 43



TYMLOS 129

Tyvaso 142

TYZEKA 50


TYZINE 144

UUCERIS 128

ULESFIA 90

ULORIC 32

ULTRACET 11

ULTRAM 11

ULTRAM ER 8

ULTRAVATE 107

ULTRAVATE X 107

ULTRESA 100

UNITHROID 121

UPTRAVI 142

UR N-C 16

URAMIT MB 16

URECHOLINE 103

URELLE 16

URETRON D-S 16

URIBEL 16

URIMAR-T 16

URIN D.S. 16

URO-458 16

URO-MP 16

UROCIT-K 92

UROGESIC-BLUE 16

UROQID-ACID NO.2 103

UROXATRAL 102

URSO 96

URSO FORTE 96

ursodiol 96

URYL 16

UTIBRON NEOHALER 144

UTIRA-C 16

VVAGIFEM 118

valacyclovir hcl 56

VALCHLOR 35

VALCYTE 50

valganciclovir hcl 50

VALIUM 57

valproic acid 23

valproic acid (as sodium salt) (valproate

sodium) 23

valsartan 67

valsartan/hydrochlorothiazide 73

VALTREX 56

VANATOL LQ 81

VANCOCIN HCL 16

vancomycin hcl 16

VANDAZOLE 16

VANOS 107

VARUBI 29

VASCEPA 76

VASERETIC 73

VASOTEC 68

VCF 103

VECAMYL 73

VECTICAL 90

VELIVET 118

VELPHORO 94

VELTASSA 94

VELTIN 90

VEMLIDY 50

VENCLEXTA 43

VENLAFAXINE ER TAB (TIER DEPENDENT

ON MANUFACTURER. UCB T3, OTHERS

T1) 27

venlafaxine hcl 27

VENTOLIN HFA 140

VERAMYST 137

verapamil hcl 70

VERDESO 107

VERDROCET 11

VEREGEN 90

VERELAN 70

VERELAN PM 70

VERIPRED 20 107

VERSACLOZ 49

VERZENIO 43

VESICARE 101

VESTURA 118

VEXOL 134

VFEND 32

VIAGRA 103

VIBERZI 97

VIBRAMYCIN 21

VICODIN 11

VICODIN ES 11

VICODIN HP 11

VICTOZA 2-PAK 61

VICTOZA 3-PAK 61

VIDEX 55

VIDEX EC 55

VIEKIRA PAK 51

VIEKIRA XR 51

VIENVA 118

vigabatrin 23

VIGAMOX 19

VIIBRYD 27

VIMOVO 7

VIMPAT 24

VIOKACE 100

VIORELE 118

VIRACEPT 56

VIRAMUNE 54

VIRAMUNE XR 54

VIRAZOLE 144

VIREAD 55

VIROPTIC 56

VISTARIL 138

VITEKTA 53

VITUZ 144

VIVELLE-DOT 118

VIVLODEX 7

VIZIMPRO 38

VOGELXO 111

VOLTAREN 90

VOLTAREN-XR 7

voriconazole 32

VOSEVI 51

VOSPIRE ER 140


VOTRIENT 43

VRAYLAR 49

VUSION 32

VYFEMLA 119

VYLIBRA 119

VYTONE 90

VYTORIN 76

VYVANSE 78

VYZULTA 135

Wwarfarin sodium 63

WELCHOL 76

WELLBUTRIN 25

WELLBUTRIN SR 25

WELLBUTRIN XL 26

WERA 119

WESTHROID 121

WHYTEDERM TRILASIL PAK 107

WP THYROID 121

WYMZYA FE 119

XXADAGO 47

XALATAN 135

XALKORI 44

XANAX 57

XANAX XR 57

XARELTO 63

XARTEMIS XR 11

XATMEP 126

XELITRAL 91

XELJANZ 126

XELJANZ XR 126

XELODA 37

XENAFLAMM 131

XENAZINE 81

XENICAL 96

XEPI 91

XERESE 57

XERMELO 131

XHANCE 137

XIFAXAN 96

XIGDUO XR 61

XIIDRA 133

XIMINO 21

XODOL 10-300 11

XODOL 5-300 11

XODOL 7.5-300 11

XOFLUZA 127

XOLEGEL 32

XOPENEX 140

XOPENEX CONCENTRATE 140

XOPENEX HFA 140

XRYLIX 91

XTAMPZA ER 8

XTANDI 36

XULANE 119

XULTOPHY 100-3.6 63

XURIDEN 94

XYLON 10 11

XYREM 147

XYZAL 138

YYASMIN 28 119

YAZ 119

YONSA 36

YUVAFEM 119

Zzafirlukast 138

zaleplon 146

ZAMICET 11

ZANAFLEX 49

ZANTAC 96

ZARAH 119

ZARONTIN 22

ZARXIO 65

ZAVESCA 100

ZEBETA 69

ZEBUTAL 81

ZEGERID 99

ZEJULA 44

ZELAPAR 47

ZELBORAF 44

ZEMBRACE SYMTOUCH 34

ZEMPLAR 130

ZENATANE 91

ZENCHENT 119

ZENCHENT FE 119

ZENPEP 100

ZENZEDI 78

ZEPATIER 51

ZERIT 55

ZESTORETIC 73

ZESTRIL 68

ZETIA 76

ZETONNA 137

ZEYOCAINE 91

ZIAC 73

ZIAGEN 55

ZIANA 91

zidovudine 55

zileuton 138

ZINBRYTA 83

ZIOPTAN 135

ziprasidone hcl 49

ZIPSOR 7

ZIRGAN 50

ZITHRANOL-RR 91

ZITHROMAX 19

ZITHROMAX TRI-PAK 19

ZMAX 19

ZOCOR 75

ZODEX 107

ZOFRAN 29

ZOFRAN ODT 29

ZOHYDRO ER 8

ZOLINZA 38

zolmitriptan 34

ZOLOFT 27

zolpidem tartrate 146


ZOLPIMIST 146

ZOMACTON 110

ZOMIG 34

ZOMIG ZMT 34

ZONALON 91

ZONEGRAN 22

zonisamide 22

ZONTIVITY 64

ZORBTIVE 110

ZORTRESS 126

ZORVOLEX 7

ZOVIA 1-35E 119

ZOVIA 1-50E 119

ZOVIRAX 57

ZTLIDO 13

ZUBSOLV 13

ZUPLENZ 30

ZURAMPIC 32

ZUTRIPRO 144

ZYBAN 14

ZYCLARA 91

ZYDELIG 44

ZYFLO 138

ZYFLO CR 138

ZYKADIA 44

ZYLET 133

ZYLOPRIM 32

ZYMAXID 19

ZYPITAMAG 75

ZYPRAM 91

ZYPREXA 49

ZYPREXA ZYDIS 49

ZYTIGA 36

ZYVOX 16


Documents

3-Tier Formulary Guide